NCD Prevention: Does it really work?

One of the bicycle routes organised by the Initiative Group in Bogushevsk has been adapted for Nordic walking practice in winter time. Photo: © Belarus Red Cross

Context: NCD risk factors for Belarus

For many of the former Soviet Union countries, independence was accompanied by a sharp decline in health outcomes. Despite the recent downward trend in some of the main causes of mortality, there remains a significant gap in life expectancy between these countries, including Belarus, and western European countries. Over half of this gap can be explained by circulatory disease mortality. According to the latest WHO NCD profile for Belarus, non-communicable diseases are responsible for the large majority (89%) of mortality in Belarus, with cardiovascular diseases accounting for the largest share (63%), followed by cancer (14%). Other main causes of mortality include injuries (9%) and other NCDs (9%) respiratory disease (2%) and communicable disease, maternal and child health and nutritional conditions (3%).

Key findings of the STEPS 2016 in Belarus reveal that:

• 40.5% of adults in Belarus have 3 or more NCD risk factors;
• more than 30% of population smoke with prevalence 3.8 times higher among males than females and higher among people in rural than urban settings;
• hypertension makes up more than 40% in men, and 38% in women
• 72.9% of adults do not eat the recommended 5 servings of fruit and/or vegetables per day, with prevalence higher among males;
• 60.6% of adults are overweight or obese and 25.4% are obese, with prevalence higher among females;
• Only 10.8% of the total population regularly take part in physical activity, while according to self-reporting, only 24% of population experience lack of physical activity

The overall context of the national health care system is also not very positive. The state health system can be described as an “inverted pyramid” (see the picture) when it is based not on strong primary health care with a solid prevention component, but on well-developed and further cultivated highly specialised tertiary level of health care. The situation is aggravated by the fact that primary prevention is often replaced by screening or highly formalised (“health schools” in outpatient clinics, formal lectures to pupils and students, etc.), which makes it extremely ineffective and inefficient.

Context: experience of community mobilisation

Since 2006, the Belarus Red Cross Society has been implementing participative community work approach working with vulnerable groups, including the elderly. Participative community work is aimed at involving people, especially socially excluded ones, in the process of identification of the needs and problems of the local community and their solution. This approach assumes the active role of people in improving their own lives and the situation within the community, as well as helps the participants to increase their confidence about their knowledge and skills. It was the Swiss Red Cross that shared this work model with the Belarus Red Cross.

Participatory community work (PCW) process

Positive results of applying PCW for decreasing vulnerability of older people and extending their activities to broader communities, as well as successful SRC progamme on Community Action for Health in Kyrgyzstan, established a basis for transferring existing knowledge and experience to the sphere of non-communicable disease (NCD) prevention.

Community action for health

In 2014-2017, Swiss Red Cross had been supporting a “Community Action for Health” project in Belarus. Directly implemented by the Belarus Red Cross, it was aimed at improving knowledge and changing attitudes and behaviour of the local population on such determinants of NCDs as physical activity (primarily) and healthy nutrition via establishing Initiative Groups (IGs) in the communities: 14 IGs in 2 pilot regions; more than 400 members and volunteers, 76,500 people in pilot communities covered by the IGs’ work. Key areas of the IGs’ work: interactive training sessions on NCDs prevention, mini-initiatives promoting physical activity and healthy eating in communities, individual peer-support for behaviour change.

Members of the IG in Zhirovichi conduct a training on NCD prevention in their community. Photo: © Belarus Red Cross

Base-line data on NCD related knowledge, attitudes and behaviour of people living in the pilot districts was collected in 2014. To identify effectiveness of the community mobilisation approach, a project end-line survey was done in March-July 2017. The end-line data collection was done using the quasi-experimental method. 1866 respondents were organised in three target groups (TGs): 417 IGs members and volunteers with full coverage; a sample of 385 from 76,500 people in pilot communities covered by the IGs’ work; a sample of 1,067 people not covered by the IGs’ work (multistage samplings with district stratification at the first stage, rural/urban stratification at the second stage) from 208,411 people living in the pilot districts. First two groups were considered as experimental, the third one – as a control group. The end-line results were also compared with the base-line data.

Unexpected "spill-over" effect

The 2017 survey results demonstrated effectiveness of the community mobilisation approach with a solid “spill-over” effect: not only people directly involved in the IGs – members and volunteers, - but also people “covered” by the IGs’ work are more physically active (ride a bicycle every day/few times a week 31.9% of “covered” population versus 19.2% of general population; go for a walk 71.4% versus 58.5% respectively). The IGs members/volunteers and the “covered” population reported switching to healthier diet (53.3% and 41.5% respectively) and weight loss (29.2% and 20.1%).

End-line survey: physical exercises

End-line survey results: drinking 1.5 liters of water a day

Effectiveness of the community mobilisation approach was appreciated by the local authorities, resulting in scaling up: new IGs will be established in the pilot regions and beyond, already outside of the SRC project. The approach was also presented to the state health system management and NCD prevention specialists via a series of training workshops to promote it nation-wide implementation.

There were a number of factors that contributed to the success of the community mobilisation work:

• Well thought through and designed training materials and trainers’ sets developed by the International Federation of the Red Cross and adopted and translated in Russian by the Belarus Red Cross improved effectiveness of the training and learning on NCD prevention.
• Partnership agreements with the local governmental partners as well as training of the local medical administrators and professionals ensured support to the Initiative Groups and promotion of their work within and beyond their communities.
• Advocacy at the level of the regional and national health care management/policy makers allowed for scaling up.
  
  

Individual behaviour change did work for some groups

Four years of project implementation allows to make some conclusions about effectiveness of the approach and its’ different elements:

• The approach works better for the rural communities where the whole concept of community is more developed than in urban areas. In the cities the model was implemented mostly at educational institutions – colleges and universities. 
• More narrow thematic focus of the interventions brings better results: targeting different types of interventions primarily on improving physical activity (and on healthy diet in selected communities) delivered a strong cumulative effect on behaviour change.
• Individual peer-support, when members of the Initiative Groups paired-up with interested in behaviour change members of communities, defined their goals and made the plan, led by example, implemented planned interventions together and provided continuous psycho-social support, has great potential and needs to be further formalised.
• Reaching to most vulnerable remains an issue as the Initiative Groups unite first and foremost the most active people. At the same time there were examples when strong Groups could reach out to the people with serious alcohol abuse problems and help to change their lives to the better. Thus the role of community is greater than the role of methodology.

The overall health system context plays an important role in any NCD/health promotion related initiative. While the implementation within the project approach has demonstrated impressive results, the level of innovation was too high for many health professionals and, thus, initially envisaged integration of the approach into the state health prevention system was not very successful. Nevertheless, routine work with the health system at different levels, provision of training and, - the most important –evidence-based advocacy allowed to make the first steps towards acceptance and support in scaling up the approach application.

For the Swiss Red Cross as an international organisation supporting health related interventions all over the world, Implementation of the project has also confirmed importance of proper knowledge transfer: with understanding differences in the contexts, flexibility in the process of implementation, checking for sustainability mechanisms at the very beginning of the process. Another important precondition for effective health programming is long-term planning with an adequate funding and strong evaluation methodologies that will bring evidence for further advocacy. Establishing a positive public discourse around the issue addressed by the programme through close work with the media should go in parallel with the advocacy work. Finally, international organisations together with the national partners should be wise to regularly monitor and assess effectiveness of the applied approaches and methods and strong enough to stop doing things that do not work in order to be able to allocate expertise, time and funds to interventions that bring results and change lives of people and communities to the better.