Seminar 7: How environment influences behaviour

The seventh in C3’s series of International Breakfast Seminars was given by Dr Denise Stevens on 9 June 2011, on Community Interventions for Health: an exemplar for examining how environment influences behaviour. Denise is president of MATRIX Public Health Solutions (a ‘think-and-do’ organisation that gives technical assistance to government, NGOs etc.) and a lecturer at Yale University School of Medicine’s School of Public Health. She leads the evaluation of the Community Interventions for Health (CIH: www.cih.net) programme.

• Slides from the event are available here >> – warning: large file (6MB)
• A full précis of the event is available here >>

Community Interventions for Health is currently one of the largest community-based NCD-prevention studies in the world, taking place in Mexico, South India and China, with both implementation and comparison sites in each country. It has been in place for 18 months, and final data collection is under way, tracking interventions are neighbourhoods, schools, workplaces and health care settings. Sample sizes are large, and address biometric measures, behaviour change, policy changes and the environment.

Key to the project is the environmental scan, drawing a 400m radius around a school, and then assessing the options within that area for exercise and play, eating, media, shopping, etc.  Capturing the data was a comprehensive and time-consuming task, as there were up to 20 schools in each site, but the resulting map of where fresh fruit and vegetables, or fast food, or parks, or tobacco were found to be available starkly demonstrates the accessibility of healthy choices.

At the start of the project, each site was provided with the same set of evidence-based practices from which they could choose interventions, but each chose a different route to implementing the ideas:

China

• The China (Hangzhou) team worked closely with providers within the local Primary Health Care (PHC) system to implement initiatives. For example, a team of 80 people from the PHCs undertook health screenings in the local community (which reached approximately 2 million people), and PHCs were also trained in tobacco cessation. The broader, city-wide initiative is known as ‘Healthy Hangzhou’ – it is only the second city in China to be smoke-free (i.e. smoking is banned in workplaces etc.), physical activity equipment has been installed along the canal, and a new bicycle-hire scheme is in place.

Mexico

• In Mexico, partnership with local people was emphasised from the start. A major partnership has been with the national sports authority: 400 physical activity promoters were trained about the other risk factors (and local community residents are trained to continue the projects), with Zumba dance classes being held in communities – dance is a particularly strong cultural influence in the region. Street food vendors are also a particular target of interventions.

India

• The India CIH team in Kerala developed a partnership with the department of social welfare, focusing particularly on the ‘anganwadi’ workers (women who work in maternal and child health in poor communities), who were trained in the risk factors of diet, tobacco use and physical inactivity. This has proved a very cost-effective strategy, as their messages now reach 200,000 households.  A further important aspect of the work is shifting the cultural norms of young girls and women. For example, boys cycle but girls do not, so bike training has been organised for girls to encourage them to join in, and women’s yoga classes (which was a form of activity in which women were happy to take part) now include an aerobic component and are very popular.

Essential lessons learned include that:

• the importance of health education ‘cannot be overstated’;
• policy-level changes can be very successful and sustainable;
• there is a need to build partnerships with people on the ground.

The discussion that followed included:

• how the momentum of the project has grown over time – a ‘ricochet effect’;
• the importance of taking a ‘learning attitude’, and the influence this has on attitudes within local communities;
• the role of the food, pharmaceutical, insurance and other industries (including the use of digital technology); and
• plans for longer-term sustainability of the initiative.