CIH presentations OxHA summit 09 - Oxford Health Alliance

Confronting the Epidemic of Chronic Disease 

The Oxford Health Alliance 


CIH Framework and Preliminary 

Baseline Results 

Denise Stevens and Fiona Wong 

CIH Director and CIH Coordinator 

KR Thankappan 

Principal Investigator CIH Kerala 

www.oxha.org



Chronic Disease Risk Factors 

• Three risk factors cause four chronic diseases 

that cause over half of deaths worldwide. 

• The risk factors are: 

Lack of physical activity 

Unhealthy diet 

Tobacco use 

www.oxha.org



CIH: Part of the Solution 

• CIH – Community Interventions for Health –is the action 

arm of the Oxford Health Alliance. 

– CIH addresses both the risk factors for chronic disease and 

the barriers to change. 

– It is a multinational collaborative (developing and 

developed countries). 

– Researchers globally are working together to implement 

and evaluate interventions to address unhealthy 

diet, physical inactivity and tobacco use. 

‘Without knowledge action is useless and 

knowledge without action is futile’ 

(Abu Bakr, c.573–674) 

www.oxha.org



CIH – Focus 

On the individual level the focus will be changes in 

knowledge, attitude, and behaviour as well as changes in 

physical/biological risk factors. 

On the local level, the focus will be on changes in policies and 

environments. 

Targeting structural (policy, environment, economic) changes 

as part of a comprehensive approach in 

neighbourhoods, schools, workplaces, and health centres is a 

primary strength of the CIH study. 

www.oxha.org



CIH Settings & Strategies 

• Four settings for a comprehensive intervention programme 

– School 

– Workplaces 

– Health centres 

– Neighbourhoods 

• Four strategies for change 

– Structural interventions (e.g. 

policy, environmental, economic) 

– Health education 

– Community coalition‐building 

– Media 

www.oxha.org



Comprehensive Approach 

CIH is about individual behavioural change through policy and environmental changes. 

Making the healthy choices the easy choices. 

www.oxha.org



CIH: Ecological Model 

www.oxha.org



www.oxha.org

• Community 



Types of Structural Interventions 

– Health assessments at community 

events 

– Affordable and accessible fruit and 

vegetables 

– Smoke‐free policies 

– Healthy food choices at 

stores, restaurants and at events 

salt & fats & sugar 

– Safe routes for walking and bicycling 

(addressing active transport) 

Including addressing the built 

environment for where people shop, eat 

and play 

www.oxha.org




• Schools 

– Affordable healthy food 

and drink in cafeterias and 

vending machines 


– 30 minutes of physical 

activity a day, three times 

per week 

– Advertisement‐free schools 

– Enhanced health curricula 

www.oxha.org




• Healthcare settings 

– Smoke‐free hospitals with 

healthy food options 

– Lifestyle‐tracking for 

patients 

– Incentives and training for 

providers to screen for and 

prevent chronic disease 

• Media 

– Information provided to 

families and children via 

radio and TV 

– Billboards, signs, posters to 

encourage healthy lifestyles 

www.oxha.org




• Workplace 

– Healthy and affordable food in 

vending machines and cafeterias 


– Use of healthier oils in food 

preparation 

– Health risk assessments and 

smoking‐cessation programmes 

– Incentives for participation in on‐ 

site and off‐site physical activity 

– Point‐of‐contact prompts 

– Smoke‐free workplaces 

www.oxha.org

LEGEND 

Site: Sousse Tunisia 

University Hospital Farhat 

Hached 

Site: New Haven USA 

Yale University 

Site: Andover UK 

Oxford University 

Site: New Delhi India 

Centre for Chronic Disease 

CIH pilot sites 

Emerging CIH sites 



Site: A Delegacion in 

Mexico City 

InterAmerican Heart 

Foundation 

CIH Globally 

Site: Leicester, United 

Kingdom 

De Montefort University 

Site: Trivandrum District 

in the State of 

Kerala, India 

Centre for Health Science 

Studies of Sree Chitra 

Site: Hangzhou China 

Peking Univ. School of 

Public Health and 

Hangzhou CDC 

www.oxha.org

CIH EVALUATION METHODOLOGY 



www.oxha.org

Evaluation Methodology 

Process & Outcome Evaluation Design 

1. Intervention and Comparison Communities 

Intervention units selected as similar to comparison units on: SES, 

rural/urban status, and cultural/ethnic factors 

2. Pre‐ and Post Assessments (of individual and community) )(N~12,000/site) 

Individual Change & Impact of Structural Change 

– Surveys for behaviours as they relate to RFs, KAB, prevalence 

– Standard international survey translated and back‐translated 

– Site‐specific surveys allow the integration of important site questions 

– Physical and biological measurements 

3. Community Change: changes in policy and environment 

– Document review 

– Environmental scans 

– Key informant interviews 

– GIS mapping 

Implementation process evaluation (on‐going) 



www.oxha.org



Process Evaluation 

• What is the program intended to be? 

• What is delivered, in reality? 

• Where are the gaps between program design and delivery? 

• Examining factors such as…….. 

Who: the program clients/recipients and staff 

What: activities, behaviors, materials 

When: frequency and length of the contact or intervention 

Where: the community context and physical setting 

How: strategies for operating the program or intervention 

*keeps sites on target and comprehensive 

www.oxha.org

• Height 

• Weight 



Physical & Biological Measures 

• Waist circumference 

• Hip circumference 

• Heart rate 

• Skin‐fold (if possible); 

and 

• Blood pressure 

• Fasting glucose 

• Random glucose 

• Total cholesterol 

• HDL 

• LDL 

• Triglycerides 

• Total cholesterol/HDL 

ratio 

www.oxha.org



Community Profile 

Component What tools will be used What information will it 

add? 

Current Policy 

Environmental scans Degree of policy 

Implementation and 

Practices 

Key Informant short 

surveys 

implementation and 

practices implemented 

without policy enactment 

Key informant 

interviews 

Media review 

Physical Aspects GIS mapping Representation of the 

community to assess 

relationships with physical 

and geographic attributes 

Policy Review Document review 

Key Informant short 

surveys 

Key informant 

interviews 

Current policies 

implemented, enforced, or 

being considered 

www.oxha.org

Schematic of Neighbourhood Assessment 



0.25 mile (or 400m) radius 

www.oxha.org



www.oxha.org



Evaluation Indicators 

• Intervention versus control and pre‐post: 

– Δ Behavioural determinants 

• e.g. consumption patterns 

– Δ Biometric measures 

• e.g. BMI, blood pressure 

– Δ Behavioural risk factor prevalence (self‐reported) 

• Policy implementation 

– e.g. environmental changes within community settings 

• Economic factors 

– e.g. affordability/availability/accessibility of healthy 

options 

www.oxha.org

End Products: 



End Products of CIH 

– A comprehensive international database of 

intervention processes and outcomes 

– A best‐practice ‘roadmap’ of guidance to address 

chronic disease risk factors with adaptations for 

different settings 

– Research articles to further the field in risk factor 

reduction and chronic disease prevention 

www.oxha.org



Importance of CIH 

• Comprehensive community interventions are rare 

(particularly in developing countries) 

• Structural interventions work 

• Need for best practice research 

• CIH includes an extensive evaluation component 

including both process and outcome evaluation 

• Cross cultural comparisons 

www.oxha.org



CIH Investigators: Pilot Initiative 

• OxHA Board & Stig Pramming, MD, Executive Director of the Oxford Health Alliance 

• Christine Hancock, RN, Administrative Director, Oxford Health Alliance 

• Beatriz Champagne, PhD, Executive Director of the InterAmerican Heart Foundation 

• KR Thankappan, MD, Additional Professor and Head of Achutha Menon Centre for Health Science Studies 

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

• Liming Lee ,MD, Vice President for Chinese Academy of Medical Science & Peking Union Medical College 

and Professor at Peking University School of Public Health 

• Jorge Ramírez Hernández, MD, PhD, Coordinator of Social and Economic Studies for Latin 

America, InterAmerican Heart Foundation, Mexico 

• Robert Baggott, Ph.D., Professor of Public Policy and Director Health Policy Research Unit, deMontefort 

University, Leicester, United Kingdom 

• Denise Stevens, PhD, Director of CIH Evaluation, President, MATRIX PHS (Evaluation Team) 

• Kathleen O’Connor, M.Ed, Co‐Director of CIH Evaluation (PhD candidate) Yale University School of 

Epidemiology & Public Health (Evaluation Team) 

Evaluation Team (additional) 

• Fiona Wong, MIH, Research Coordinator CIH, MATRIX PHS (Evaluation Team) 

• Brenda Fenton, Ph.D. Director of Research and Evaluation, MATRIX PHS (Evaluation Team) 

• Monika Doshi, MPH, Field Researcher, MATRIX PHS (Evaluation Team) 

• Karen Siegel, MPH, previously Data Manager CIH (currently Oxford University Research Fellow) 

www.oxha.org

CIH Advisory Board and Expert Panel 

Advisory Board Intervention Committee 

Diane Finegood, Executive Director, The CAPTURE Project, Canadian Samira Asma, Associate Director, Global Tobacco Control, CDC (US) 

Partnership Against Cancer (Canada) 

Diane Finegood, Executive Director, The CAPTURE Project, Canadian 

Martin McKee, Professor, London School of Hygiene and Tropical Partnership Against Cancer (Canada) 

Medicine (UK) 

William Haskell, Stanford University (US) 

K.M. Venkat Narayan, Professor, Emory University School of Public 

Health (US) 

Victor Matsudo, Agita Sao Paulo (Brazil) 

Pekka Puska, Director, Finland National Public Health Institute (Finland) 

Mark Woodward Professor of Medicine and Director, Biostatistics Core 

Department of Medicine The Mount Sinai Medical Center (US) 

OxHA Board Members Participating 

David Matthews, Oxford Centre for Diabetes, Endocrinology & Metabolism, 

UK 

Derek Yach, Director of Global Policy, PepsiCo, US 



Martin McKee, Professor, London School of Hygiene and Tropical 

Medicine (UK) 

Rachel Nugent, Center for Global Development (US) 

Michael Pratt, Centres for Disease Control and Prevention (US) 

Nigel Unwin, Institute of Health and Society (UK) 

Mark Woodward Professor of Medicine and Director, Biostatistics Core 

Department of Medicine The Mount Sinai Medical Center (US) 

www.oxha.org

Mexico 

India 

China 

United 

Kingdom 



CIH Baseline Progress 

Community 

Surveys 

(I) (C) 

School Surveys 

(I) (C) 

√ √ √ 

Health Centres 

(I) (C) 

√ √ √ √ √ √ 

√ √ √ √ √ √ √ 

I=Intervention C=Control 

baseline begins September 2009 

Work Places 

(I) (C) 

www.oxha.org



ENVIRONMENTAL SCAN 

www.oxha.org



Example of a Community Scan 

www.oxha.org



Mexico Baseline: 2008 Intervention Site 

What was scanned 

• 10 radii scan intervention and control 

• 293 stores/kiosk/fixed cart/mobile cart 

• 103 Restaurants or food services 

• Additional facility: 

– Street vendors, recreational facilities, parks and cultural 

house 

Student data 

• 2288 school children 

• Students were mostly 12 and 14 years 

www.oxha.org

FOOD ENVIRONMENT = shopping + eating 



www.oxha.org

Student Data: Fruit & Vegetable Consumption 



www.oxha.org



Example Radius: Places to Shop 

Mostly Sell fruits sell & high‐fat/salt/sugar 

Veg 

foods Other stores 

Other stores 

www.oxha.org



Opportunities for Structural Change 

Common store type 

Local stores (38%) 

Kiosks/stalls/ carts (25%) 

Convenience stores (14%) 

Mostly sell 

high‐fat/salt/sugar foods 


Kiosks/stalls/carts (37%) 


Opportunities 

↑ availability healthy 

food options 

www.oxha.org



Opportunities for Structural change 

Common store type Sell fruits and vegetables Opportunities 


Kiosks/stalls/ carts (25%) 



Kiosks/stalls/carts (60%) 


• Encourage vendors 

to promote sale of 

fruits and vegetables 

www.oxha.org



Combining Scan & School Data 

• Students were more likely to eat vegetables 

5+ days/wk in radii with more shopping 

opportunities for F+V 

• There was no relationship between students 

consumption of fruits 5+ days/wk by shopping 

opportunities. 

www.oxha.org

What Do We Know About the Food Environment? 



www.oxha.org



Opportunities For Eating (N=103) 

‘Americanized' Fast Food vs 

Others 

Americanized' fast food 

Mixed 

Other 

87% 

8% 5% 

www.oxha.org



Opportunities For Structural Change 

Consider focusing on non‐chain/local 

(“mom and pop”) restaurants to 

increase healthy food options 

CIH work with local restaurant associations 

Influence “demand” (e.g. address healthy 

alternatives e.g. Jicama with chili sauce) 

Is Americanized fast foods part of the 

story? 

www.oxha.org

Physical Activity Environment 



www.oxha.org



Student Data: Perception Of Physical 

Activity Environment 

www.oxha.org



Student Data: Active Transport 

• 49% of students walked or biked to school 

daily 

• in distance from school was associated 

with frequency of walking to 

school/bike 

• Students who live more than 30 minutes 

still walked or biked to school on some 

days. 

∴Feasible and acceptable for children to 

walk or ride bicycle to school (87% at least 

1+ days per week) 

www.oxha.org



Student Data: Sedentary Behaviour 

• 17% student have 7+ hours of sedentary 

habits (homework, screen time, and other 

sitting activities) during weekdays 

• 24% students have 7+ hours of sedentary 

habits during weekends (homework, screen 

time, and other sitting activities) 

www.oxha.org



Opportunities For Physical Activity 

• Places for physical activity 

– 6 parks 

– 17 recreational facilities (diverse types: gyms, dance 

studios, basketball courts, etc.) 

– 1 bike trail (ciclopista) 

– 1 large forest park (bosque) 

• Most indoor facilities have associated fees 

• Majority of facilities within 500 meters of public transport 

www.oxha.org



Opportunities For Structural Change 

•↑opportunities for 

physical activity both indoor/ 

outdoors 

•↑ availability of free or low 

cost facilities 

www.oxha.org




Develop school policies and support to: 

• Increase the amount of time spent engaged in 

physical activity 

• Use play grounds, equipment and space after‐ 

school hours (e.g. team sports) 

www.oxha.org

TOBACCO ENVIRONMENT=Shopping and smoking 



www.oxha.org



Student Data About Tobacco Use 

•16% of students reported 

smoking in the past 30 days 

•Stores and “other people” were 

most common sources of 

cigarettes (~30% each) 

www.oxha.org



Opportunities to Purchase Tobacco 

58% 

Availability of Tobacco in Stores 

Has tobacco No tobacco 

Has "no sale to minors" sign Does not have "no sale to minor" sign 

42% 

34% 

66% 

www.oxha.org



Where Tobacco is Sold 

Stores selling tobacco 

Store selling tobacco 

with “no sale to minor” 

signs 

Other stores 

www.oxha.org



Opportunities For Tobacco Control 

Tobacco‐free environments 

•Of the 96 restaurants 16% had “no 

smoking” signs 

This varied across radii with 0%‐40% 

of restaurants having “no smoking” 

signs 

•No outdoor recreational facilities were 

designated as smoke‐free 

www.oxha.org




Stores selling tobacco No sale to minor sign Opportunities 

•42 % sell tobacco •34% of stores that sell 

tobacco 

↑of stores with “no 

sale to minor” signs 

www.oxha.org

What Do We Know About the Tobacco Environment? 



www.oxha.org

Snap Shot: Availability of Tobacco vs F&V 



www.oxha.org



What Have We Learned? 

www.oxha.org



Summary Points 

• Important differences occur across radii with 

respect to the risk factors therefore targeted 

interventions are needed 

• More opportunities occur to buy unhealthy 

foods and tobacco than F&V 

• Students are sedentary therefore strategies 

are needed to encourage active transport and 

promote use of the built environment 

www.oxha.org

Benefits of the Environmental Scan 

• Environmental scan is value‐added in that it 

will: 

1. ↑ intervention effectiveness by identifying 

specific targets in the built environment; 

2. ↑ intervention efficiency through simultaneous 

assessment & planned interventions for the built 

environment to address multiple risk factors; 

3. capture the continuum of environments that 

people go through in their daily lives (home 

community, school, workplace, health care) 



www.oxha.org

Environmental Scan Operationalizes the 

Multifactorial Nature of Chronic Disease 

It Describes & Suggests Opportunities to Impact 

• Built environment 

• Healthy food options & physical activity 

(balancing the energy In = energy out 

equation) 

• The continuum of environments where risk 

factors coexist together in our communities 



www.oxha.org

LESSONS LEARNED CIH 

BASELINE 



www.oxha.org



Objectives of CIH Meeting 

• Share experiences of CIH baseline collection 

and intervention planning 

• Identify lessons learned 

• Strengthen partnerships across sites 

• Build linkages with global experts 

www.oxha.org



Lessons Learned I: Facilitators 

• The positive reputation of the 

university/PI’s research identity in 

the community made the 

introduction of the CIH study into 

the community smoother 

• Communities and schools very 

engaged in the process increased 

access to survey participants 

• Involvement of key government 

stakeholders in the project opened 

doors 

www.oxha.org



Lessons Learned II: Strengths 

• Use of and training on innovative technologies 

(e.g. environmental scan, fat analyzer) 

• Creation of new partnerships, “grafting” to 

existing partnerships, multiple university 

departments (including involvement of 

volunteers, students, community) 

• Educational opportunities provided for several 

Ph.D. students 

www.oxha.org



Lessons Learned III: Starting Up 

• Obtaining support & buy‐in from the key stakeholders 

(e.g. education, health, social welfare etc) 

– Example: Approximately 6 weeks of time invested 

to organize data collection (letters written, at least 

4 phone calls made for each setting and at least 3 

visits to each setting) 

• Giving stakeholders something they want (and which 

is within your realm of expertise to provide or 

leverage) in order to obtain buy‐in (e.g. One 

workplace requested EKGs in addition to the 

biomarker study). 

www.oxha.org

Lessons Learned IV: Starting Up (Cont.) 

• Organizing meeting with key stakeholders to make 

them “champions” for the project (Example; 2 

meetings with community leaders and important 

stakeholders (6 to 7 Panchayats) –with day long 

meetings of up to 50 ) 

• Doing the “legwork” to establish face‐to‐face contact 

and minimize burden to settings (Example: It took 

approximately 6 visits to each school to gather 

baseline data ‐ initial meeting to introduce, then 

meet with teachers, distribute consent forms, data 

collection days 



www.oxha.org



Lessons Learned V: Challenges 

• Poor response rates among clinicians 

• Identity of non‐responders (particularly work 

place setting) 

• Stakeholders identify priorities outside scope of 

CIH (e.g. request for water and sanitation 

interventions) 

• Language: 

• Not all people involved in the project are able to 

understand the international protocols 

• Translation issues (literal and intended meaning) 

• Ensuring there is strong mechanism for quality 

control 

www.oxha.org

Lessons Learned VI: Challenges (Cont.) 



• Cultural belief that obesity is 

a sign of health and beauty 

• Impact of the economic 

transition interacting with 

cultural norms (e.g. 

hospitality around 

food, walking/biking to work 

linked to social status) 

• Biophysical measures (weight 

circumference women; 

equipment functioning 

challenges due to heat) 

www.oxha.org

Evaluation Team Observations: Strengths 

1. Dedicated researchers and institutions 

2. Selection of sites important, based on 

qualifications, status of academic 

institution, ability to function in team 

environments, commitment to comprehensive 

focus of CIH, ability and interest in working with 

communities 

3. International study ‐‐ communicating with 

diverse cultures enriches understanding and 

appreciation both personally and professionally 

and will ultimately strengthen the study 



www.oxha.org

Evaluation Team Observations: Strengths 

(Cont.) 

1. Successful establishment of management structures 

to handle the comprehensive approach/multiple 

settings 

2. Capacity building in communities and among new 

researchers 

3. Sharing of innovation (e.g. evaluation team and the 

environmental scan; fat analyzer) and spin off 

studies (e.g. nutritional labeling) 

4. Educational opportunities ‐ at least 1 Ph.D. and 2 

master’s theses currently underway 



www.oxha.org

Evaluation Team Observations: Challenges 

1. Survey development ‐ over 2 years in 

development, major challenge was addressing 

the balance between comprehensiveness and 

feasibility (hard for the evaluation team who 

saw the value of questions and what would be 

lost) 

2. Adaptation – multiple viewpoints, time to build 

consensus 

3. Communication – working with different time 

zones, understanding accents, different styles 



www.oxha.org

CIH presentations OxHA summit 09 - Oxford Health Alliance

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