Why this case study?

This illustrates how a situational analysis was carried out in the state of Kerala, India in order to assess the need to implement a diabetes prevention programme.

The situational analysis laid the foundation for the adaptation of diabetes prevention programmes from Europe, the USA and Australia to the local context.

Title

Carrying out a situational analysis for the implementation of NCD prevention and control policies and interventions

Source

Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India

Health issue

Type 2 diabetes mellitus

Setting

Trivandrum region in Kerala, India

Target population

Men and women at high risk of developing diabetes

Background

India has approximately 65 million individuals with type 2 diabetes mellitus (T2DM) – the second-largest number for a single country in the world. This number is expected to double by 2030.^(1,2) Studies estimate that T2DM affects between 9% and 20% of the country’s adult population.^(3,4)

Kerala has the highest prevalence of T2DM, with up to 20% of adults estimated to have the disease in parts of the state.^(5,6)

Description of policy or intervention

The Kerala Diabetes Prevention Program (KDPP) is a lifestyle intervention aimed at individuals in rural areas of Kerala at high risk of developing diabetes. The programme is designed to reduce the risk of developing diabetes through a series of peer-led sessions held within local communities. Following training on diabetes prevention and group facilitation, peer leaders identified from within the community conduct small group sessions focused on increasing knowledge about diabetes and on prevention strategies. Sessions are supplemented with community-wide activities such as yoga, walking and gardening which help participants to put into practice the learning from the group sessions.

What took place?

A situational analysis was carried out prior to the development of the KDPP by triangulating evidence from:

1. previous research on the prevalence and control of diabetes in India and elsewhere;
2. policy and other programme documents relevant to diabetes prevention specific to Kerala or India and
3. a collection of novel qualitative data in Kerala through engagement with local stakeholders (including consumers).⁽⁷⁾

Relevant published research was retrieved following PubMed searches using medical subject heading (MeSH) terms related to diet, physical activity, tobacco and health pro-motion interventions conducted in India.

The search engines of relevant government department websites (e.g. of the Ministry of Health & Family Welfare) were used to retrieve relevant policy and programme documents (including guidelines at both the state and national level on NCD prevention and control, diet, physical activity and tobacco and alcohol use).

The qualitative research component consisted of focus groups (with pre-diabetic individuals from rural areas of Kerala, identified from the database of an earlier survey⁽⁸⁾ that explored perceptions and attitudes towards T2DM and its prevention). These group discussions helped to identify specific needs for cultural adaptation and for delivery of the programme to target communities.

What was learnt?

The National Programme for Prevention and Control of Diabetes Cardiovascular Dis- eases and Stroke (NPDCS) – with recommendations on diet and physical activity – only launched recently in India. This contrasts to the situation in high income countries (HICs), where most diabetes prevention programmes were implemented almost a decade ago.

Despite the large burden of NCDs in the state and across the country, the situational analysis revealed gaps in NCD research and policy in Kerala/India. A review of epidemiological studies revealed a higher prevalence of risk factors for T2DM in Kerala than in the rest of the country,⁽⁴⁾ with some risk behaviours (such as smoking) higher than the national average. Adult physical inactivity during leisure time was also high (9).

The focus groups highlighted the important role of families and cultural norms in making lifestyle choices in India. This underpinned the importance of developing a more integrated approach to behaviour change interventions than used in HICs. Multiple strategies involving family and community empowerment were called for – as corroborated by other studies in India.^{(7, 10-11)}

References:

1. Shaw, J.E., R.A. Sicree, and P.Z. Zimmet, Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract, 2010. 87(1): p. 4-14.
2. Ramachandran, A., R.C. Wan Ma, and C. Snehalatha, Diabetes in Asia. Lancet, 2009. 375(9712): p. 408-18.
3. Thankappan, K.R., et al., Risk factor profile for chronic non-communicable diseases: Results of a community-based study in Kerala, India. Indian Journal of Medical Research, 2010. 131: p. 53-63.
4. Menon, V.U., et al., Prevalence of known and undetected diabetes and associated risk factors in central Kerala – ADEPS. Diabetes Research and Clinical Practice, 2006. 74(3): p. 289-94.
5. Raman, K.V., A. Joseph, and C.R. Soman, High prevalence of type 2 diabetes in an urban settlement in Kerala, India. Ethnicity and Health, 1999. 4(4): p. 231-9.
6. Daivadanam, M., et al., Lifestyle change in Kerala, India: needs assessment and planning for a community-based diabetes prevention trial. BMC Public Health, 2013. 13: p. 95.
7. Soman, C.R., et al., Cohort profile: the PROLIFE study in Kerala, India. Int J Epidemiol, 2011. 40(1): p. 10-4.
8. Sugathan, T.N., C.R. Soman, and S. K, Behavioural risk factors for non communicable diseases among adults in Kerala, India. The Indian Journal of Medical Research, 2008. 127(6): p. 555- 63.
9. Krishnan, A., et al., Evaluation of community-based interventions for non-communicable diseases: Experiences from India and Indonesia. Health Promotion International, 2011. 26(3): p. 276-89.
10. Kumar, M.S., P.S. Sarma, and K.R. Thankappan, Community-based group intervention for tobacco cessation in rural Tamil Nadu, India: A cluster randomized trial. Journal of Substance Abuse Treatment, 2012. 43(1): p. 53-60.
11. Mohan, V., et al., Community empowerment – A successful model for prevention of noncommunicable diseases in India – The Chennai Urban Population Study (CUPS-17). The Journal of the Association of Physicians of India, 2006. 54(858-62).

Why this case study?

This showcases knowledge synthesis in preparation for the implementation of tobacco plain packaging policies and interventions in India.

The case study also illustrates that, although there may be evidence for a policy or intervention’s effectiveness, it is important to take account of local context.

Title

Knowledge synthesis on plain packaging to assess existing evidence to promote the selection of evidence-based policies and interventions for implementation in India

Source

Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia

Health issue

Respiratory diseases and other NCDs caused by tobacco

Setting

India

Target population

Individuals who use tobacco products

Background

Tobacco is responsible for 25% of deaths from respiratory diseases in India,⁽¹⁾ which is the world’s second largest consumer of tobacco (smoking and smokeless forms).⁽²⁾ The prevalence of tobacco use is 48% in males and 20% in females, with many others exposed to second-hand smoke.^(3,4) Tobacco attributable deaths in India are expected to rise to 1.5 million annually by 2020.⁽⁵⁾ It has been suggested that the cost of respiratory diseases attributable to tobacco in India in 2011 was US$ 600 million⁽⁶⁾

In 2003 the Indian government, consistent with the WHO Framework Convention on Tobacco Control (FCTC),⁽⁷⁾ passed The Cigarettes and Other Tobacco Products Act (COTPA). This prohibited tobacco-related advertising and sponsorship and specified health warnings on tobacco packs.⁽⁸⁾ However, the impact of these measures was limited,⁽⁹⁾ prompting the Indian Government to consider larger, more effective pictorial health warnings.^(10-15) The next step would be plain packaging, for which there is growing international evidence.

Description of policy or intervention

Plain packaging entails the removal of all branding (colours, imagery, corporate logos and trademarks), with brand names mandated a uniform size and font and placed together with current or enhanced graphic health warnings on the tobacco packaging.

Plain packaging would apply to packaging of all forms of tobacco; in India this includes beedis and chewed forms of tobacco as well as conventional cigarettes.

The aim of plain packaging is to decrease the attractiveness of the package, enhance the effect of pictorial health warnings on the package, increase thoughts about quit- ting and promote negative attitudes towards tobacco use.

Plain packaging of tobacco products has a significant evidence base from a number of countries^{(13, 16-19)} – especially from Australia where it was first introduced. However, evidence on such packaging in rapidly developing countries such as India is relatively scant.^(20,21)

What took place?

A joint Indian and Australian taskforce was convened with support from a small grant from the Australia India Institute. Following a comprehensive knowledge synthesis project, the taskforce produced a report on the possibility of plain packaging in India.⁽¹⁹⁾

The report included evidence from other jurisdictions, local market research on plain packages⁽²²⁾ and results from a stakeholder analysis undertaken with legal experts, policy-makers and tobacco control experts. It summarized all the behavioural, political and legal evidence and provided graded recommendations as to the way forward.

The report was launched at a high level event attended by politicians from India, WHO representatives, leading tobacco control experts and legal experts. In response, a private members bill on plain packaging was introduced to the Indian parliament in 2013 and a follow up international conference was also held at which the Indian health minister and health secretary gave presentations.

However, a number of contextual barriers have slowed progress on plain packaging. These include a change of government and health ministers, a demand for local evidence and opposition from a significant tobacco farming industry in India. Further research is planned to respond to these concerns and produce additional local evidence.

What have we learnt?

While external (international) evidence and the input of international experts is a helpful start in formulating policies, it is not sufficient for successful policy change.

To increase the chances of the knowledge synthesis leading to a change in policy, the following points are useful:

• It is important to know the specific audience for whom the knowledge synthesis is being undertaken.
• Research needs to take account of the policy-making timetable – e.g. regulatory committee meetings or election cycles.
• A mechanism is needed to ensure the knowledge synthesis is fed to the appropriate groups to inform debate and policy. In particular, a clear communication strategy is needed to reach decision-makers.
• The knowledge synthesis team need to involve credible figures to maximize the likelihood of evidence reaching decision-makers. (In this example, two coinvestigators sat on government advisory committees).
• Contextual information can often result in a need to include and/or produce unique evidence in addition to that available from other jurisdictions. (For example, in this case the tobacco products and industries of Australia and India were very different, so further information was needed).

Finally, note that while the stages of knowledge synthesis outlined above will help to identify policies and interventions that may be pursued in the prevention and control of NCDs, they may not provide information about transferability of these to new and different contexts. Approaches to the assessment of suitability and adaptation of policies and interventions to new contexts are discussed later in the guide.

References:

1. World Health Organization, WHO global report: mortality attributable to tobacco, W. Press, Editor. 2012: Geneva.
2. Jhanjee, S., Tobacco Control in India – Where are we now? Delhi Psychiatry Journal, 2011. 14(1): p. 26.
3. Ministry of Health and Family Welfare India, Tobacco use among students and teachers. Findings from the Global Youth Tobacco Survey and Global School Personnel Survey India. 2010: New Delhi.
4. International Institute for Population Sciences & MoHFW India, Global Adult Tobacco Survey (GATS) India 2009-2010. New Delhi.
5. ITC Project, TCP India National Report. Findings from the Wave 1 Survey (2010-2011). 2013, University of Waterloo, Canada; Healis-Sekhsaria Institute for Public Health, India.
6. Ministry of Health and Family Welfare (Government of India), Economic Burden of Tobacco Related Diseases in India. Executive Summary. 2014, New Delhi: PHFI and WHO Country Office for India.
7. World Health Organization, WHO Framework Convention on Tobacco Control. 2003: Geneva.
8. Ministry of Health and Family Welfare India, The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003. 2009: New Delhi.
9. Arora, M., Tewari A, Nazar PN, Gupta K, Shrivastav R,, Ineffective pictorial health warnings on tobacco products: lessons learnt from India. Indian Journal of Public Health, 2012. 56(1): p. 61-64.
10. Yadav, A., India: New Warnings to Cover 85% of Packs. Tobacco Control, 2015. 24(1): p. 3.
11. Moodie, C., et al., Plain tobacco packaging: A systematic review. UK Centre for Tobacco Control Studies, 2012.
12. Wakefield, M.A., et al., Introduction effects of the Australian Plain Packaging policy on adult smokers: a cross-sectional study. BMJ open, 2013. 3(7): p. e003175.
13. Lok Sabha Secretariat, Fourth Report on the Cigarettes and other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003, C.o.S. Legislation, Editor. 2015, Government of India Press: New Delhi.
14. White V, Australian Secondary Students’ Alcohol and Drug (ASSAD), Centre for Behavioural Research in Cancer (CBRC), Editor. 2015, Department of Health Canberra.
15. Hammond D, Health warning messages on tobacco products: a review Tobacco Control, 2011. 20(327).
16. Arora M, T.A., Grills N, Nazar GP, Sonrexa J, Gupta VK, Moodie R, Reddy KS., Exploring perception of Indians about Plain Packaging of tobacco products. Frontiers in Public Health, 2013. 1: p. 35.
17. Dunlop, S., et al., Impact of Australia’s introduction of tobacco plain packs on adult smokers’ pack-related perceptions and responses. BMJ Open, 2014. 4: p. e005836.
18. Hammond, D., Standardized packaging of tobacco products: evidence review. 2014, Irish Department of Health.
19. Australia India Institute, Report of the AII Taskforce on Tobacco Control: Plain Packaging of tobacco products. 2012: Melbourne
20. Hughes N, Grills N, and Aurora M, Effect of plain packaging of tobacco products in low and middle income settings: A systematic review of the literature. Currently under reviewed, 2015.
21. Jann W and Werich K, Theories of policy change, in Handbook of Public Policy Analysis: Theory, Politics, and Methods, Fischer F and Miller GJ, Editors. 2007, Taylor and Francis group.
22. Henggeler, S.W., et al., Transporting efficacious treatments to field settings: The link between supervisory practices and therapist fidelity in MST programs. Journal of Clinical Child & Adolescent Psychology, 2002. 31(2): p. 155-67.

Why this case study?

This case illustrates the importance of adapting interventions to the local context and piloting them prior to scale up.

The case study also highlights some of the barriers and facilitators to the adaption and piloting process and proposes ways in which to address these.

Title

Adapting policies and interventions to new contexts

Source

The George Institute for Global Health, Sydney, Australia

Health issue

Hypertension and comorbidities

Setting

Mongolia

Target population

General population of Ulaanbaatar (Mongolia’s capital city)

Background

Population-wide salt reduction programmes are widely viewed as one of the most cost-effective interventions for the prevention of hypertension and associated NCDs.

The number of such national programmes has almost doubled between 2010 and 2014 and programmes are now being implemented in most regions of the world. However, to date, most of those that have demonstrated an impact are from HICs. There is some way to go to translate the lessons from these countries to low and medium income countries (LMICs).

Description of policy or intervention

Successful salt reduction programmes identify the main sources of salt in the diet and then develop a strategy to reduce them.

The Ministry of Health in Mongolia (MMoH) implemented a pilot intervention to reduce population salt intake in Ulaanbaatar during 2012–2013. The results of this pilot, combined with a series of other initiatives, informed the development of a National Salt Reduction Strategy.

What took place?

The MMoH established an intersectoral working party and organized a two-week national consultation and training programme on salt reduction. Actions arising included implementation of a pilot salt reduction intervention.

The main objective of the pilot intervention was to reduce salt intake of the employees of three factories, based on the notion that simply telling people what they should/should not eat does not work – the food environment also needs to change. Adapting this to the Mongolian context, implementation strategies included training employees on the negative health impact of salt and on consuming a healthy diet, as well as actually reducing salt levels in the food served in company canteens/kitchens.

Pre- and post-intervention monitoring showed that salt intake reduced between 2011 and 2013. The number of people that did not know which foods were high in salt also declined substantially during the same period.

These activities demonstrated the potential for action and helped to convince policy-makers to scale up the policy to national level, resulting in the Mongolian National Salt Reduction Strategy being endorsed by the government in 2015 – with the ultimate goal to reduce population salt intake in Mongolia by 30%.

What have we learnt?

Success of the pilot intervention and scaling up of the policy to national level was possible for a number of reasons:

• The importance of multisectoral action was recognized from the outset.
• The project emerged from consultation and training on salt reduction and raised awareness of the health impacts of salt.
• The approach started by trying to understand the main sources of salt in the diet and how best to reduce them (rather than simply replicating salt reduction initiatives from other countries).

Lessons for other countries:

• Do not just replicate other programmes. A good understanding of how consumption patterns are contributing to salt intake in the country of interest is also needed.
• Do ensure that your strategy is multifaceted, combining a change of the food environment together with programmes to change consumer behaviour.
• Do continue with advocacy programmes to ensure strong government support and adequate financing.
• Do establish effective multisectoral stakeholder engagement, community participation and training procedures from the outset.
• Do, where possible, implement pilot interventions.
• Do not leave evaluation until the end of the programme. Regular monitoring ensures programmes are on track to achieve targets.

Why this case study?

This illustrates the negative consequences of implementing an effective intervention without first assessing acceptability in a new context.

Title

The importance of establishing acceptability

Source

Beltramo T, Levine DI. The effect of solar ovens on fuel use, emissions and health: Results from a randomised controlled trial.⁽¹⁾

Health issue

Respiratory diseases

Setting

Senegal

Target population

Households where cooking is conducted using solid fuels

Background

Traditional stoves for cooking and heating in LMICs are frequently fuelled with dung, coal and wood. The smoke resulting from burning such solid fuels pollutes the air and has been linked to a range of respiratory and other diseases.

Improved stoves have the potential to reduce exposure to household air pollution and so improve health outcomes. One such improved stove is the solar oven. During laboratory testing in highly controlled contexts, solar ovens frequently show positive results and do not emit any emissions. However, studies in real-world contexts are far less promising.

Description of policy or intervention

A phased, randomized controlled trial to test the effects of a solar oven called ‘the HotPot’ was carried out in Senegal.

What took place?

The solar oven was provided to 465 households. After six months, the intervention group had just as high carbon monoxide exposure as the control group and there was no reduction in self-reported health symptoms.

In the laboratory these stoves were shown to be effective – so what went wrong?

The study showed poor levels of adoption of the HotPot, with households using the stove very infrequently. A major reason for this was that the solar oven was far too small for the majority of households in the study.

Other studies⁽²⁾ indicated additional reasons for solar oven unacceptability to communities: cooking could take longer, the ovens could not be used for heating and light, and the oven might need be used outdoors during sunlight.

What have we learnt?

Adoption of new technologies is challenging and interventions must be tailored to the needs and preferences of communities in order to succeed.⁽³⁾

References:

1. Beltramo, T. and D.I. Levine, The effect of solar ovens on fuel use, emissions and health: Results from a randomised controlled trial. Journal of Development Effectiveness, 2013. 5(2): p. 178-207.
2. Otte, P.P., Solar cookers in developing countries-What is their key to success? Energy Policy, 2013. 63: p. 375-381.
3. Thomas, E., et al., Improved stove interventions to reduce household air pollution in low and middle income countries: a descriptive systematic review. BMC Public Health, 2015. 15: p. 650.