Open Access Research BMJ Open: first published as 10.1136/bmjopen-2017-015943 on 26 December 2017. Downloaded from Comprehensive assessment of health education and health promotion in five non-communicable disease demonstration districts in China: a cross-sectional study Qiaohua Xu, Yuelong Huang, Biyun Chen To cite: Xu Q, Huang Y, ABSTRACT Strengths and limitations of this study Chen B. Comprehensive Objectives This study aims to develop assessment assessment of health education indicators of health education and promotion for non- ► To the best of the authors’ knowledge, this study is and health promotion in communicable disease (NCD) demonstration districts in five non-communicable the first to build assessment indicators for health China and to identify significant factors associated with disease demonstration education and promotion in non-communicable NCD health education and promotion work. districts in China: a cross- disease (NCD) demonstration districts in China. Methods Three complementary techniques were used to sectional study. BMJ Open ► This study used three popular assessment tools conduct this study in Hunan Province, China, between late 2017;7:e015943. doi:10.1136/ (Delphi, rank sum ratio and technique for order of 2013 and 2015. The Delphi technique was used to develop bmjopen-2017-015943 preference by similarity to ideal solution) that are weighted assessment indicators, followed by the rank Prepublication history and both qualitative and quantitative and hence provide ► sum ratio (RSR) to normalise the weights through rank additional material for this a methodological reference for similar future studies. conversion. Lastly, the technique for order of preference paper are available online. To ► One limitation of this study was that fewer NCD by similarity to ideal solution was conducted to assess view these files, please visit demonstration districts were selected as evaluation five randomly selected NCD demonstration districts the journal online (http:// dx. doi. samples and thus failed to fully reflect the whole representing five different orientations in the province. org/ 10. 1136/ bmjopen- 2017- situation in China. 015943). Results A total of 24 assessment indicators were ► Another limitation was the cross-sectional design constructed covering the following sections: organisational Received 25 January 2017 and lack of control data from either the history of management, fund support, personnel supplies, health http://bmjopen.bmj.com/ those districts or non-NCD demonstration districts. Revised 3 October 2017 education and promotion, people’s awareness of NCDs, Accepted 19 October 2017 management and control of patients with NCD, satisfaction with health education and promotion and health literacy of residents. Five districts were selected as samples for spectrum of people’s diseases is dominated evaluation (Furong District, Ziyang District, Shaodong by non-communicable diseases (NCDs) (also County, Shuangfeng County and Luxi County). Performance known as chronic diseases), such as cardiovas- varied among the sites, with Furong District greatly cular diseases, lung cancer, chronic obstruc- surpassing the other sites, especially in fund support, 1 media promotion, technical support for publicity materials, tive pulmonary disease and road injuries, on September 28, 2021 by guest. Protected copyright. community promotion and supportive environment instead of infectious diseases. This transition supplies. The latter four factors were also much greater in has resulted in a rapid increase in the inci- the second-ranked Luxi County site than those in the other dence of these diseases and a heavy disease sites (except Furong District). burden. Currently, approximately 260 million Conclusions There were gaps in health education Chinese accounting for 19% of the nation’s and promotion work in NCD demonstration districts in population suffer from NCDs, which Hunan Province. The districts that performed better had contribute to 85% of the mortality rate and obvious advantages in fund support, media promotion, 70% of the disease burden.2 Thus, China is technical support, community promotion and supportive facing great challenges from NCDs. environment supplies. Our study provided both a The National Health and Family Planning Department of Chronic Disease methodological reference and an assessment indicator Control and Prevention, Hunan framework for similar future studies. Commission of China (NHFPC, the former Provincial Centre for Diseases Ministry of Health) launched a nationwide Control and Prevention, NCD demonstration district (or county) Changsha, China programme in late 2010 that was similar Correspondence to INTRODUCTION to the widely known health cities that were Dr Qiaohua Xu; China has undergone a swift health transi- designated in many countries in the late xqh301717@ sina. com tion over the past two decades. Currently, the 1980s.3 The programme aimed to create Xu Q, et al. BMJ Open 2017;7:e015943. doi:10.1136/bmjopen-2017-015943 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2017-015943 on 26 December 2017. Downloaded from an exemplary effect of NCD demonstration districts for prevention; thus, these policies play important roles in other regions and to promote NCD control and preven- NCD demonstration district programmes. However, the tion across the country. In the principle of voluntary, step- work is relatively new in China, and only rare systematic by-step declaration, areas that wanted to become national assessments have been reported (ie, no assessment indi- NCD demonstration districts had to obtain a recom- cators are available). Thus, based on health education mendation from the provincial health administration and promotion in the districts, this study was conducted department and then pass an assessment organised by to develop assessment indicators, compare the perfor- the NHFPC. Similarly, the declaration of provincial NCD mances among districts and analyse important factors for demonstration districts went through a city-level recom- health education and promotion to provide a framework mendation first and then a provincial assessment. or methodological reference for other health studies. Health education is defined as a systematic social activity that helps people improve their health-related behaviours. For NCDs, health education often involves publicising METHODS a healthy lifestyle, such as non-smoking, a low-salt diet, Study design a proper diet, adequate physical activities and mental Three evaluation techniques were comprehensively health, using publicity materials, billboard, lectures and followed in the study. Figure 1 shows the flow diagram. A media promotion. Health promotion is the process of modified Delphi method originally developed by Kathryn enabling people to increase control over and improve Fitch5 was used in the following steps (conducted between their health.4 The Ottawa Charter for health promotion late 2013 and 2014): action includes the following five policies4: building a 1. Thirty-nine subsectional consultative items in seven healthy public policy (eg, raising the tobacco excise tax), sections were selected for the first Delphi round based creating supportive environments (eg, building a fitness on the work manuals of the NCD demonstration dis- trail), strengthening community actions, developing tricts developed by the Chinese Centre for Disease personal skills and reorienting health services. Integrated Control and Prevention (China CDC) and our own health education and promotion are the first priorities work experiences (see online supplementary appen- of the policy and the primary means of NCD control and dix table A1). http://bmjopen.bmj.com/ on September 28, 2021 by guest. Protected copyright. Figure 1 Study flow diagram. NCDs, non-communicable diseases; RSR, rank sum ratio; TOPSIS, technique for order of preference by similarity to ideal solution. 2 Xu Q, et al. BMJ Open 2017;7:e015943. doi:10.1136/bmjopen-2017-015943 Open Access BMJ Open: first published as 10.1136/bmjopen-2017-015943 on 26 December 2017. Downloaded from 2. Experts nationwide were invited if they met the fol- 5. The distance of each alternative to the ideal Di+ and lowing demands: worked in NCD control and pre- negative ideal Di solutions and the relative similar- vention, health education and promotion or other − ( ) ities of an alternative to the ideal solution Ci were public health professions, worked for provincial or ( ) calculated. national institutions with 5 years or more of work ex- ( ) 6. The alternatives were ranked based on Ci. A larger Ci perience and showed an interest in participating in indicated a greater alternative. the study. 3. A two-round Delphi process was conducted. In the Statistical analyses first round, experts were asked to judge whether items During the Delphi process, the assessment items were should be included and were free to add items or excluded unless they simultaneously reached expert make comments. The experts scored each item using agreement (%)≥70%,13–15 a median score ≥716–18 and a 9-point Likert scale (1–9: extremely unimportant to a coefficient of variation (CV) <0.25.19 20 The internal 6–8 extremely important). The data were summarised, consistency of the items was evaluated with Cronbach’s revised and sent to experts for a second round follow- α coefficient test. A Cronbach’s α of 0.7 or greater was ing the same format as the first round. Then, the as- regarded as reasonable reliability, and a value of 0.8 or sessment indicators