What can India do about disease?

The number of non-communicable diseases (NCDs) is rising at an alarming rate across the world. India now faces a growing burden of NCDs due to rapid industrialization, socio-economic development, urbanization, demographic transition and changing lifestyles. According to a 2014 profile by the World Health Organization, NCDs account for about 60% of total deaths and 26% of premature deaths in India. It is estimated that this will pose a substantial threat to India’s socio-economic development, with a potential loss of more than $6 trillion by 2030, which is much higher than the nation’s current GDP. India needs to address this growing burden through health-promoting partnerships, policies and programmes.

Evidence from developed countries confirms that prevention and early diagnosis of NCDs is most cost-effective. Most NCDs are preventable and share common behavioural risk factors: harmful consumption of alcohol, tobacco use, physical inactivity and an unhealthy diet, which are deep-rooted yet modifiable social determinants.Exposure to behavioural risk factors can be reduced through policy interventions that have been labelled “best buys” as they require low investment and are also easy to implement. They constitute measures such as increased taxes and advertising bans on tobacco and alcohol, the replacement of trans fats with polyunsaturated fats, and restricted access to these harmful products.

Concurrent with healthy policies, it is also vital to provide an enabling environment so that people can sustain their lifestyle changes. Health promotion interventions in different settings have shown benefits in India, around risk-factor reduction and prevention. School-based interventions can reach a large population in a cost-effective manner. In the Indian context, Project MYTRI (Mobilizing Youth for Tobacco-Related Initiatives in India), conducted between 2004 and 2006, showed a successful implementation of a school-based intervention to reduce tobacco-use rates among urban adolescents in New Delhi and Chennai. The multi-component intervention consisted of classroom curricula, school posters, a parental-involvement component, and peer-led activism based on the social cognitive theory of behaviour change.

HRIDAY-CATCH was a cardio-vascular disease prevention intervention conducted with children in seventh grade, from 30 schools in Delhi between 1996 and 1998. The intervention involved awareness and advocacy messages by teachers and peer leaders in schools, and home-based programmes that encouraged the use of activity-based booklets to positively inculcate behaviours promoting healthy lifestyles through family involvement. The intervention was successful: fewer students tried tobacco or had intentions to use it in the future. It demonstrated that a systematic and coordinated health-promotion programme can bring about a desired outcome.

Arogya World, in collaboration with HRIDAY (Health Related Information Dissemination Amongst Youth), carried out a one-year diabetes awareness project among nearly 2,000 middle-school students (9-13 years of age) in six schools in Delhi in 2011. The goal was to encourage children to adopt healthy lifestyles – increasing physical activity and good eating habits, with the overall goal of helping them to prevent (or at least delay) the onset of diabetes, heart disease and obesity later in life. The results were extremely positive: awareness of diabetes and its seriousness increased, and positively influenced behaviour change at an early age. There were significant changes noted in the dietary and physical activity habits of the children, a decrease in consumption of carbonated drinks, an increase in consumption of fruits, an increase in physical activity levels and use of stairs.

Worksite interventions around influencing cardiovascular risk factors were carried out by CCDC (Centre for Chronic Disease Control). This included implementation of a multi-component cardiovascular disease prevention programme, including advocacy to increase consumption of fruits and vegetables, reduce intake of salt and oils, promote physical activity, reduce tobacco use and maintain a healthy weight. The results were a significant decline in cardiovascular risk indicators and increased fruit and vegetable intake, as well as more physical activity.

Social marketing campaigns that utilize mass media are feasible and effective interventions for tobacco control in India. Mass-media efforts can reach a larger population. A national television and radio media campaign was initiated and aired for six weeks during November and December 2009. It focused on creating awareness about the harms of smokeless tobacco, as this is the most prevalent form of tobacco use in India. The impact of the campaign was positive, with 63% of users of smokeless tobacco and 72% of users of both smokeless and smoking forms remembered the advertisements, primarily via television, and recalled the campaign making them anxious about their habit. Campaign awareness was associated with better knowledge, more negative attitudes towards smokeless tobacco and greater cessation-oriented intentions and behaviours among smokeless tobacco users.

Use of mHealth has a growing potential due to its ability to provide access to high-quality healthcare information at a lower cost to large numbers of users. Also, the high mobile usage rates in India, coupled with fast-improving healthcare management, makes it an ideal intervention for disseminating awareness and influencing behaviour change. A population-level mHealth intervention was developed by Arogya World in partnership with HRIDAY, to send out text messages about prevention of diabetes and increasing physical activity twice a week for six months. Evaluation revealed that the test group’s awareness ofthe complications of diabetes increased by 25%. There was also an 11% increase in physical-activity levels versus the control group, which showed no change. In addition, the test group showed an 8% increase in intake of fruit and vegetables.

Recent estimates from the Global Adult Tobacco Survey highlighted a significant increase in smokeless tobacco (SLT) use among Indians. Taking cognizance of this growing NCD threat and realizing India’s current status as “oral cancer capital of the world”, the Indian government introduced a ban on SLT products across all states in 2011. This policy initiative is a step towards the tobacco endgame, as it will prevent fresh uptake among adolescents, who initiate tobacco use at an early age and become addicted to it as adults.

Given India’s high expenditure on health to treat NCDs, top of the priority list should be prevention and early diagnosis of these diseases, from a public health perspective. Combating NCDs also requires addressing the social determinants that influence health. This would require developing and implementing a comprehensive, nationwide, multi-sector action plan that focuses on prevention and control of NCDs. Investment in health promotion will bear long-term benefits for the country and for population health.

Read our report: Economics of Non-Communicable Diseases in India 

Author: Monika Arora, Public Health Foundation of India

Image: Commuters stand at an open doorway of a suburban train during the morning rush hour in Kolkata September 22, 2014. REUTERS/Rupak De Chowdhuri