AWARENESS ATTITUDE AND PRACTICES REGARDING PREVENTION

AND CONTROL OF NON COMMUNICABLE DISEASES AND

RISK FACTORS AMONG PANCHAYAT MEMBERS OF

A NORTHERN DISTRICT OF KERALA, INDIA

VEENA.P

Dissertation submitted in partial fulfilment of the

requirement for the award of the degree of

Master of Public Health

ACHUTHA MENON CENTRE FOR HALTH SCIENCE STUDIES

SREE CHITRA TIRUNAL INSTITURE FOR MEDICAL SCIENCES AND

TECHNOLOGY, TRIVANDRUM

Thiruvananthapuram, Kerala. India-695011

October-2017

Dedicated to my parents

ACKNOWLEDGEMENTS

First and foremost, I thank God almighty for his blessings. I am grateful to him for the

strength he provided to undertake this journey.

I would like to express my sincere gratitude to my guide Dr Manju Nair R. I am extremely

thankful and indebted to her for sharing her expertise, and sincere and valuable guidance and

encouragement throughout the time of research and writing this thesis. Without her

supervision and constant help this dissertation would not have been possible.

I thank all the faculty members of AMCHSS, Dr. KR Thankappan, Dr. V Raman Kutty, Dr.

PS Sharma, Dr. TK Sundari Ravindran, Dr Mala Ramanathan, Dr. Srinivasan Kannan, Dr.

Biju Soman, Dr. Ravi Prasad Varma, Dr. Jissa VT and Dr. Jeemon P. for their valuable

suggestions and guidance during the course.

My special thanks to all students of MPH 2015 and MPH 2016 batch who helped me to sail

through the journey of research and thesis. I would like to acknowledge Mr. Ragind for his

extreme support for transportation during my data collection.

I am grateful to the study participants who were part of the study, without whom, I would not

have been able to conduct this research. And finally, I thank my parents and brother for

everything they did to support me throughout this course.

CERTIFICATE

Certified that the dissertation titled “Awareness attitude and practices regarding

prevention and control of non communicable diseases and risk factors among

panchayat members of a northern district of Kerala, India” is a record of the research

work undertaken by Ms. VEENA.P in partial fulfilment of the requirements for the award of

the degree of “Master of Public Health” under my guidance and supervision.

GUIDE

Dr. MANJU NAIR R

Scentist C

Achutha Menon Centre for Health Science Studies

Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum

Thiruvananthapuram, Kerala. India -695011

October 2017.

DECLARATION

I hereby declare that this dissertation titled Awareness attitude and practices regarding

prevention and control of non-communicable diseases and risk factors among

panchayat members of a northern district of Kerala, India-is the bona fide record of my

original research. It has not been submitted to any other university or institution for the award

of any degree or diploma. Information derived from the published or unpublished work of

others has been duly acknowledged in the text.

VEENA.P

Achutha Menon Centre for Health Science Studies

Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum

Thiruvananthapuram, Kerala. India -695011

October 2017

TABLE OF CONTENTS

List of tables………………………………………………………………….

Glossary and abbreviations…………………………………………………..

Abstract……………………………………………………………………….

Section Content Page No.

CHAPTER 1- INTRODUCTION

1.1 Background 1

1.2 Rationale 2

1.3 Objectives of the study

3

CHAPTER 2- LITERATURE REVIEW

2.1 Role of decentralization in policy making 4-6

2.2 Decentralization in the health sector 6-7

2.2.1 World scenario 6

2.2.2 Indian scenario 6

2.2.3 Kerala scenario 7

2.3 Kerala- challenges of demographic and epidemiological

transition

7-8

2.4 Epidemiological transition 8

2.5 Non communicable diseases 9

2.6 Non communicable diseases control measures

9-11

CHAPTER 3- METHODOLOGY

3.1 Study design 12

3.2 Study setting 12

3.3 Study population 12

3.4 Sample size estimation 13

3.5 Sample selection procedure 13

3.6 Inclusion criteria 15

3.7 Exclusion criteria 15

3.8 Data collection technique 15

3.9 Study tool 15

3.10 Plan for data collection and analysis 15

3.10.1 Gant chart 16

3.11 Variables under study 16-17

3.11.1 Dependent variables 16

3.11.2 Independent variables 17

3.12 Operationalisation of variables 17-18

3.13 Ethical considerations 19

3.13.1 Informed consent 19

3.13.2 Confidentiality 19

3.13.3 Beneficence 19

3.13.4 Risks

19

CHAPTER 4- RESULTS

4.1 Sample characteristics 20

4.2 Professional experience of the respondents as elected

members

21-22

4.2.1 Current designation 21

4.2.1 Training on NCD prevention and control 22

4.2.2 Experience as panchayat members 22

4.3 Awareness about non communicable diseases among

panchayat members

23

4.3.1 Perceptions about the burden of NCDs in their

constituencies

23

4.3.2 Awareness among panchayat members about specific

chronic disease conditions

24-25

4.4 Awareness among panchayat members about major risk

factors of non-communicable diseases

26

4.4.1 Perceptions among panchayat members about the harmful

effects of tobacco

26

4.4.2 Awareness among panchayat members about the

provisions of anti-tobacco legislations

27-28

4.4.3 Perceptions of panchayat members about harmful effects

of alcohol

28-29

4.4.4 Perceptions among panchayat members about fruits and

vegetables consumption

30

4.4.5 Perception among panchayat members regarding physical

activity and health

31-32

4.5 NCD related behavioural risk factors among panchayat

members

32-34

4.5.1 Tobacco use among panchayat members 32-33

4.5.2 Alcohol use among panchayat members 33

4.5.3 Physical activity among panchayat members 34

4.6 Bivariate analysis 34-36

4.6.1 Association between training received and awareness

regarding provisions of COTPA

35-36

4.6.2 Association between training received and awareness

legal restriction related to sale of alcohol

36

4.7 Analysis of panchayat budgets-Expenditure on schemes

related to prevention of NCDs

37-42

4.7.1 Projects of allied structure impacts on control of NCDs

42-44

CHAPTER 5- DISCUSSION

5.1 Awareness about burden of non-communicable diseases 45

5.2 Awareness regarding specific non-communicable

diseases

46-47

5.3 Awareness regarding major risk factors 47-48

5.4 Practices in daily life of panchayat members 48-49

5.5 Training on NCDs and its effect on knowledge regarding

NCD risk factors

49

5.6 Analysis of budget expenditure of panchayats-

Expenditure on schemes related to prevention and control

of NCDs

50-51

5.7 Limitations of the study 51

5.8 Conclusion

51-52

REFERENCES 53-56

ANNEXURE I Institutional ethics committee clearance

ANNEXURE II Interview schedule - English

ANNEXURE III Consent form - English

ANNEXURE IV Interview schedule - Malayalam

ANNEXURE V Consent form – Malayalam

ANNEXURE VI Budget expenditure details of study settings 2015-16

ANNEXURE VII Budget expenditure details of study settings 2016-17

LIST OF TABLES

Sl no Content Page no.

3.1

List of selected district, blocks and grama panchayats

14

4.1a Characteristics of sample population 21

4.1b Socio demographic of sample population 21

4.2 Professional experience of respondents as elected members 22

4.3 Perception regarding the burden of non-communicable and

communicable diseases in their ward

23

4.4 Awareness among panchayat members about specific

chronic diseases conditions

24-25

4.5 Perceptions among panchayat members about the harmful

effects of tobacco

26

4.6 Awareness among panchayat members about provisions of

anti-tobacco legislations

27

4.7 Awareness among panchayat members about all provisions

of COTPA

28

4.8 Perceptions among panchayat members regarding harmful

effects of alcohol

29

4.9 Perceptions among panchayat members regarding fruit and

vegetable consumption

30

4.10 Perceptions among panchayat members regarding physical

activity

31-32

4.11 Tobacco use among panchayat members 33

4.12 Alcohol use among panchayat members 33

4.13 Physical activity among panchayat members 34

4.14 Association between awareness of panchayat members

regarding provisions of COTPA and their training on

NCDs

35-36

4.15 Association between awareness of panchayat members

regarding legal restrictions on sale of alcohol with their

training on NCDs

36

4.16 Nature of projects undertaken under the four sub heads of

health sector

38

4.17 Proportion of expenditure on sub category projects from

total health sector expenditure 2015-16

39

4.18 Proportion of expenditure on sub category projects from

total health sector expenditure 2016-17

40

4.19 Type of projects under the health sector related to chronic

diseases control

40

4.20 Total expenditure and health expenditure as percent 41

expenditure in the panchayat-

2015-16 &2016-17

4.21 Type of projects in allied sectors of agriculture and sports

with implication for prevention of chronic NCDs

42

4.22 No. and type of projects undertaken by PRIs to encourage

sports

42

4.23 Proportion of expenditure on sub category projects from

total allied sector expenditure 2015-16

43

4.24 Proportion of expenditure on sub category projects from

total allied sector expenditure 2016-17

44

LIST OF FIGURES

Sl no. Content Page no.

1 Epidemiological transition in India 8

2 Kannur district 12

3 Sampling frame 14

4 Proportion of panchayat members who are aware of

individual provisions of COTPA

28

LIST OF ABBREVIATIONS

AFR Agenda For Reform

CD Communicable diseases

CHC Community Health Centre

CHP Comprehensive Health Planning

COTPA Cigarette and Other Tobacco Products Act

CVD Cardio Vascular Diseases

DM Diabetes Mellitus

GOI Government of India

NCD Non-communicable diseases

NPCDCS National Programme for prevention and control of Cancer,

Diabetes, CVD and Stroke

PA Physical Activity

PRI Panchayat Raj Institutions

TAC Technical Advisory Committee

WHO World Health organization

ABSTRACT:

Background:

Kerala state is faced with the challenges of a growing burden of non-communicable diseases

(NCD). The presence of an effective local self-government system offers the state, a unique

opportunity to plan and implement programmes that is context specific and sustainable. This

study was undertaken to explore the awareness, attitudes and practices of panchayat members

regarding non-communicable diseases and their risk factors and the nature and extent of

budget expenditure of the panchayats for their prevention and control

Methods:

A cross sectional study was conducted among 300 panchayat members selected by multi

stage random sampling from Kannur district. Information on the awareness, attitudes and

practices were collected using a structured interview schedule along with an analysis of the

budget expenditure of the panchayats

Results:

The panchayat members who took part in the study were well aware of the harmful effects of

smoking (98%) and passive smoking (96.7%). More than 80% of them knew about smoking

ban in public space and ban of tobacco sale near schools. 82% of them are aware about the

recommended levels of physical activity. Panchayat members who received training were

significantly more aware of the provisions of Cigarettes and Other Tobacco Products Act

(COTPA) than those who did not. Analysis of the budget expenditure of panchayats showed

that there were no schemes or funds allotted specifically for NCD prevention and control.

Conclusion:

The awareness among panchayat members regarding most of the non-communicable disease

risk factors was high and those who had received training were better informed than the

others. But knowledge alone does not seem to translate itself into community level action as

suggested by the absence of funds and initiatives for the prevention and control of NCDs

Guidance from the state government regarding potential schemes and ear marked along with

continued training of panchayat members may be required improve the prevention and

control of non-communicable disease in the communities.

1

CHAPTER 1

INTRODUCTION

1.1 Background:

Legislators have an important role in policy making, their attitude towards

particular policies especially about tobacco control has been documented in Canada,

USA and the Netherlands (A de Guia et al., 2003). Implementation of effective

policies are facilitated by the knowledge of the need of particular policies and its

pros and cons. Legislators may always support policies which is good for the

majority of the society. It has been observed that if the legislators are aware about the

larger benefits that the society might gain through the enhancement of a certain

policy, they are most likely to support it. The support of the legislators in the

formation of the Canadian tobacco policy is often cites as an example (Cohen et al.,

2002).

Political ideology also has an important role in adapting policies. It influences

certain assumptions about whether the ultimate responsibility of health lies in

individual or with society, and whether government has a responsibility to regulate

individuals behaviour and activity to protect the public good (Cohen, 2000). An

understanding of each political ideology and their interpretation of the extent of the

government‟s role in its enhancement of challenging policies of larger social interest

is considered as an important factor to bring out the effective policy implementation

strategies. The analysis of the course of Canadian tobacco legislation, indicate that

irrespective of political allegiance, legislators who believed that the government had

2

some responsibility in promoting health were its key allies (Cohen et al., 2002). The

process of adoption of a new policy is especially not easy in a politically strong

environment. Public perception and attitude to a policy is also considered important

in such cases and novel ways to create key support groups in the society has proved

successful as in the case of tobacco control in Malaysia (Rashid et al., 2014).

1.2 Rationale for the study

A study conducted in Ratnagiri district of Maharashtra discuss about how

agricultural practices improved by knowledge. The women representatives who had

good knowledge were initiated the villagers for ensuring conservations of manorial

resources, preparing compost and sale it. The study evidenced that increase level of

awareness can improve the performance of panchayats (D.M. Mankar, 2005).

In Kerala context, Non-communicable diseases are at high level, so the awareness

about non-communicable diseases can influence the health sector project planning at

panchayat level. Kannur is purposively selected because of early experiments carried

out in Kalyasseri panchayat during early 90s.

Palliative care programmes were got emerge in Northern districts of Kerala

especially Calicut and Kannur, which is effectively carried out with community

participation.

This study is trying to explore the extent of projects plans in the area of prevention

and control of Non-communicable diseases and its risk factors.

3

1.3 Objectives of the study

Major objective

o To assess the awareness regarding non-communicable diseases

and its risk factors among panchayat members of Kannur district

Minor objectives

o To study the practices followed by the panchayat members for

prevention and control of non-communicable diseases and risk

factors.

o To understand the extend of fund allocation for prevention and

control of non-communicable diseases and risk factors in the

annual budget plans during the years 2015-2017.

4

CHAPTER 2

LITERATURE REVIEW

2.1 Role of decentralisation in policy making

Policy making is highly influenced by the political ideology as well as the attitude

of the legislators. The process of decentralization in governance has made policy

making process more simple as well as challenging. A process of decentralization

that started in Latin America and Africa in the 1980s and 90s respectively has spread

to several port of the world more recently(Ali and Kumar, 2015). It is defined as

“transfer of authority and power in planning, management and decision making from

higher to lower of organizational control”(Saltman, 2007). Decentralization of

governance processes are believed to be effective in addressing poverty, gender

inequality, environmental concerns, the improvement of health care, education and

access to technology better than a centralised policy environment(Robertson Work,

2002). The type of decentralization is selected according to the political structure and

administrative issues of the country.

Decentralisation in governance can be;

Political decentralization: - aims to give citizens or their elected

representatives more power in public decision making.

Administrative decentralization: - it is the transfer of authority and

responsibility for the planning financing and management of certain public

functions to lower level of governance.

5

Fiscal decentralization: - for carrying out decentralization process in an

effective manner, the local government and private organizations need to

have adequate revenue which is either raised by themselves or transferred

from central government.

Economic or market decentralization:- most complete form of

decentralization, which is from a government‟s perspective are privatization

and deregulation, that is, they shift responsibility functions from public to the

privat (Ine, 2003).

The aim of decentralization is to bring decision making close to the people and

therefore yields programmes and services that better address local needs(Robertson

Work, 2002). In order to address local needs in planning the citizen level control of

planning process is the effective choice(Sherry Arstein, 1969). De Vries(2000),

argued that decentralization enhances civil participation, neutralizes entrenched local

elites and increased political stability(Vries, 2000).

In India, since 1950s followed the Government of India Act which constituted

popularly elected provincial governments and that gave the key opportunity for the

growth of local self-governments (Franke R and T M Thomas Isaac, 2000). The 64th

and 65th

constitutional amendments were made in 1990 and in 1993 the crucial 73rd

and 74th

amendments were passed. That provided a uniform three tier Panchayati raj

institutions system; district, block/taluk, and village level in the rural and town

panchayats in the smaller and urban areas (Franke R and T M Thomas Isaac,2000).

With the decentralization, the local administration department has given an important

role in the formulation of policies and implementation of developmental works at the

grass root level. Supremacy of the elected body, the elected heads of the local

6

governments were declared as the executive authority(Bihar Gram Swaraj Yojana

Society, 2013).

Decentralisation in Kerala

Decentralization planning process in Kerala, like rest of the country, started in the

early 1970s, with establishment of District Planning Offices and identification of

district scheme(Franke R and T M Thomas Isaac, 2000); but made a pioneering

attempt in 1996 followed 73rd

constitutional amendment act of India(Joe Varghese,

2007); through which significant devolution of powers, both administrative and

financial was made to the local governments.

2.2 Decentralization in the health sector:

2.2.1 World scenario

The idea of health sector decentralization is one of the policy reform discussed in

the Agenda for Reform(AFR) of World Bank (1987). AFR discusses

decentralization in the context of structural adjustment programme and the squeeze

on government expenditure. And it is one of the four policy recommendations

discussed by world bank and also which is the difficult and least tried policy

recommendations(World Bank, 1987).

Decentralization demands more community participation and provides the “decision

space” and spurs- “innovation” and “directed change” in health sector. However the

decision space could be limited or wide depending on the extent and range of

functions over which the local administration have autonomy(Thomas Bossert,

1998).

7

2.2.2 Indian scenario

Political and bureaucratic commitment to reforms was found to be the most

important facilitating factor for health sector decentralization in India(Kaur et al.,

2012). Based on the national and international discourse and experiences related to

this, a participatory planning approach was set with panchayathi raj institutions being

given responsibility of functioning of peripheral health institutions(Kaur et al., 2012).

However decentralization in health sector has to move beyond being de jure to

become de facto, and this required political will to devolve fund and power to lower

levels of governments(Seshadri et al., 2016).

2.2.3 Kerala scenario:

Kerala state is a pioneer in terms of decentralisation in the health sector through an

innovative, comprehensive health planning process(CHP). In the year 2011 the

government of Kerala has accepted the recommendation of fourth finance

commission that to devolve 30 percent of the state plan fund to local self-government

and 20 percent of this fund earmarked exclusively for health and education sector(Ali

and Kumar, 2015).

2.3 Kerala- challenges of demographic transition

Kerala has achieved through a gamut of historical, social and political

movements high levels of development indicators including a state of population

stabilisation with a near zero population growth (Government of India, 2011). It is

faced with the challenges of demographic and epidemiological transition as a result

of changes in fertility and mortality rates.

8

2.4 Epidemiological Transition:

In India, chronic diseases contribute to an estimated 53 percent of total death and 44

percent of disability adjusted life years lost(Murray et al., 2012).

Figure 1 Epidemiological transition in India

Source: K S Reddy. Lancet 1998.

Studies also indicate high incidence and prevalence of risk factors of CVDs among

the young and show rapid transition(Huffman et al., 2011).

Kerala is in the third stage of epidemiologic transition and therefore faces has high

level of coronary artery disease in the both urban and rural areas (rural prevalence of

7 percent and urban prevalence of 12 percent) (Krishnan et al., 2016)

Globally over 33 million people die due to chronic non-communicable diseases.

By 2020, it is estimated that 70 percent of disease burden will be related to non-

communicable diseases(Beaglehole and Yach, 2003). Several surveys on risk factor

conducted across south Asian countries shows high rates of overweight, central

obesity, diabetes, high blood pressure and dyslipidemia in urban population and

lesser magnitude in rural population(WHO, 2002).

9

2.5 Non-communicable diseases

Changing patterns of food consumption with growing choice and increasing

consumption from „away-from-home‟ sources are some of the factors leads to rise in

prevalence of obesity, blood pressure, total cholesterol and diabetes(Nag and Ghosh,

2013).

Lifestyle changes like unhealthy dietary habits, physical inactivity, sedentary

lifestyle, smoking etc. are leading causes for the rising burden of non-communicable

diseases(Daivadanam et al., 2013). The situation in Kerala was described as a „low

mortality high morbidity state where, though mortality rates are low, morbidity is

high compared to other Indian states(Nayar, 1989). In Kerala NCDs account for

more than half total death occurring in the age group between 30 and 60, with 27

percent of males and 9 percent of females being diabetic(Daivadanam et al., 2013).

2.6 Non-communicable disease control measures

Consistent efforts of the GOI, WHO, research institutions as well as national and

international experts to formulate health policies for prevention of NCDs in India led

to major non-communicable diseases control programmes in the country(Srivastava

and Bachani, 2011).

During 11th

five-year plan there was considerable focus on prevention and control

non-communicable diseases. Public awareness programme, integrated management

and strong monitoring were stressed for successful implementation of the

programmes. Aa result in 2010 government of India started National Programme for

prevention and control of Cancer, Diabetes, CVD and Stroke(NPCDCS). The

NPCDCS program has two components Cancer and on Diabetes, CVDs and Stroke.

10

These two components have been integrated at different levels as far as possible for

optimal utilization of the resources. The activities at State, Districts, CHC and Sub

Centre level have been planned under the programme and will be closely monitored

through NCD cell at different levels(Government of India, 2011).

NPCDCS was introduced in selected districts of Kerala in 2010 and NCD control

programme (Amrutham Arogyam) was introduced by the department of health

covering all 14 districts with activities planned up to sub centre level(Government of

Kerala, 2013) and all the primary healthcare institutions have been transferred to the

three tier PRIs. A major financial devolution was also carried out with 40 percent of

the state‟s plan fund of various sectors including that of health sector was transferred

to these institutions(Government of Kerala, 2013).

At the panchayat level each sector including health has a working group headed by

an elected member and the health sector working group is convened by the medical

officer of the concerned primary health institution. This committee‟s mandate is to

generate project ideas and formulate draft from the community level through village

meetings or grama sabhas; presented in grama sabha for discussions and corrections

and submitted to the Technical advisory committee of district planning committees.

The TAC provide technical inputs to the projects and is then submitted to state level

for approval (Joe Varghese, 2007; Udaya S Mishra, 2012; Viayanand, 2009).

Effectiveness of health sector decentralization and the relate planning and

implementation depends on the vision, attitude and abilities if the administrative and

political leadership at the lower level. Utilisation of united funds has been found to

11

be significantly correlate with greater involvement and use of the available decision

space at the panchayat level (B Ekbal, 1997).

This study is proposed in the current context of Kerala where it faces a growing

burden of non-communicable diseases; and at the same time has an effective self-

government set up that has a tremendous potential to plan and implement locally

relevant and context specific initiatives for the prevention and control of non-

communicable diseases.

12

CHAPTER 3

METHODOLOGY

3.1 Study design:

A cross sectional survey.

3.2 Study setting:

District, block and grama panchayats of Kannur district.

Figure 2 Kannur district

http://www.mapsofindia.com/maps/kerala/districts/kannur-district-

map.jpg

3.3 Sample population:

All the current panchayat members of the selected panchayats

13

3.4 Sample size estimation

Sample size is estimated using Open Epi version 3.03, with an estimated awareness

level 42.3 percent(D.M. Mankar, 2005) from one of the earlier study, and-

5%(absolute precision) at 95% confidence interval, design effect 1 and 20percent

non-response rate. Sample size adjusted for finite population correction factor as the

population of panchayat members in the district was finite (1500) and rounded off to

340.

3.5 Sample selection procedure

Kannur district is selected purposively since the earliest experiment in 1990s, the

Kallyasseri panchayat had carried out experiment in participatory planning for local

level development, activities like, resource mapping, repair work of canals and

building Vellanchira-Paraparam road had got wide felicitation. Kallyasseri

illustrated the importance of developing comprehensive village plan even if their

immediate operational potential was low. Later in1996 Kallyasseri experiment was

accepted to implement at state level.

Kannur district consists of 1 district panchayat, 11 block panchayats and 71 grama

panchayats. All the 11 blocks and 71 panchayats list obtain from official website of

Kannur district. 5 block panchayats were randomly selected by using Microsoft

excel. Then all the panchayats in the selected blocks were listed. 15 panchayats were

selected by lottery method. All the members of the selected panchayats were

interviewed. If any member is not available at the first visit, prior appointment was

obtained by phone call. Substitution cannot be possible if any member is not willing

to participate in the study.

14

Figure 3 Sampling frame

Table3.1 List of selected District, blocks and panchayats:

n – number of members in the selected panchayats

Sl no Block Panchayat

I Kannur district panchayat (n=24)

Randomly selected 5 blocks

1 Thalasseri (n=14) Anjarakandy (n=15)

Pinarayi (n=19)

New mahe (n=13)

Vengad (n=21)

Muzhappilangad(18)

2 Kuthuparamb (n=13) Kottayam (n=14)

Mangattidam (n=19)

Chittariparamb(n=16)

3 Edakkad (n=13) Chembilode (n=23)

Munderi (n=20)

Peralasseri (n=18)

Sl no Block Panchayat

4 Peravoor (n=13) Kelakam (n=13)

Malur (n=15)

Peravoor (n=16)

5 Kannur (n=13) Valapattanam (n=13)

Total = 66 Total = 253

1 district

panchayat

(Number of

members=24)

Randomly select

5 block

panchayats

(Number of

block

members=66)

Randomly

select 15 grama

panchayats

from selected

blocks

(Number of

panchayat

members=253)

All members of

selected

panchayat

levels

24+66+253=343

15

3.6 Inclusion criteria:

- Panchayat members.

3.7 Exclusion criteria;

- Members who are not willing to participate.

3.8 Data collection technique:

Data was collected using an interview schedule in Malayalam by principal

investigator. Other information like budget estimates was collected separately for

each panchayat from their annual report. The interview was conducted at the

member‟s home with minimal distractions and discomfort for the member.

3.9 Study tool:

Structured interview schedule

Template prepared for collecting budget details of each panchayat

3.10 Plan for data collection and analysis:

The data collection period was from June to August 2017. The data collection has

been done by Principal Investigator. The participants were selected as per described

in the section of sample selection procedure. A written informed consent was

obtained prior to the interview. Privacy and confidentiality were taken care. The data

were entered in Epi data manager and Microsoft excel. The data were analysed for

the proportion of members who are aware about non-communicable diseases and its

risk factors, member‟s practices for prevention and control of non-communicable

diseases, budget analysis will be separately carried out. Bivariate (if needed

16

multivariate) analysis will be done to identify the factors affecting the member‟s

awareness regarding prevention and control of non-communicable diseases and its

risk factors. Data was analysed using IBM SPSS Statistics for Windows, version

20.0. Armonk, NY: IBM Corp.

3.10.1 Gant chart:

April May June July August September October

TAC

IEC

Data

collection

Data entry

Data

analysis

Submission

3.11 Variables under study:

3.11.1 Dependent variables:

- Awareness and attitude about NCDs and its risk factors like

. Tobacco use

. Alcohol use

. Physical Activity

17

. Diet

. High blood pressure

. Diabetes

. Heart diseases

. Cancer

. Stroke

- Practices of prevention and control of NCDs and its risk factors

3.11.2 Independent variable:

- Demographic variables like age, sex

- Socio economic variables like position in the panchayat, years of experience,

trainings received, administrative level (grama panchayat, block panchayat,

district panchayat).

3.12 Operationalization of variables:

Non-communicable diseases: Non-communicable diseases (NCDs), also known

as chronic diseases, tend to be of long duration and are the result of a combination

of genetic, physiological, environmental and behaviours factors. The main types

of NCDs are cardiovascular diseases (like heart attacks and stroke), cancers,

chronic respiratory diseases (such as chronic obstructive pulmonary disease and

asthma) and diabetes.

Communicable diseases: Infectious diseases are caused by pathogenic

microorganisms, such as bacteria, viruses, parasites or fungi; the diseases can be

18

spread, directly or indirectly, from one person to another, e.g. malaria, tuberculosis,

dengue fever etc.

Panchayat member: Elected member of any administrative level of panchayati raj

system

Standing committee: A permanent committee that meets regularly for discussion of

concerned areas

Budget: A estimate of income and expenditure for a particular period of time

Awareness: Awareness is the ability to directly know and perceive, to feel, or to be

cognizant of events

Attitude: A settled way of thinking or feeling about something.

Practice: The actual application or use of an idea, belief, or method, as opposed to

theories relating to it

Risk factors: A risk factor is any attribute, characteristic or exposure of an

individual that increases the likelihood of developing a disease or injury.

Diabetes: a particular quality or disposition regarded as adversely affecting a person

or group of people.

High blood pressure: Blood pressure is created by the force of blood pushing

against the walls of blood vessels (arteries) as it is pumped by the heart. High blood

pressure is when systolic BP>140mmHg and diastolic BP> 100mmHg

Physical activity: Physical activity is defined as any bodily movement produced by

skeletal muscles that requires energy expenditure

19

3.13 Ethical considerations:

3.13.1 Informed consent:

Written informed consent was obtained from the subjects prior to the start of

interview. The member who were not able to give written consent then verbal

consent were obtained in such case, witness signature also obtained. Participants

were given freedom to withdraw their participation at any time during the interview

schedule without giving any explanation.

3.13.2 Confidentiality:

The identity of the participants was kept anonymous. Each participant was given a

unique identification number. Their demographic details or any other information

will not be used for identifying the individual. The information given by the

members will not be disclosed with anybody else other than principal investigator.

3.13.3 Beneficence:

There will not be any direct benefit for any of the participants by participating in

this study. The information collected will be used for making health policy regarding

non-communicable diseases and its risk factors.

3.13.4 Risks:

There will not be any risks for members by participating in this study. Questions

related to behavioural practices may be slight discomfort. Participants have the

option to skip the questions if they are not interested to answer.

20

CHAPTER 4

RESULTS

The results of the analysis of the data from the cross sectional descriptive study

among panchayat members is presented in this chapter. A total of 340 panchayat

members were contacted for the survey among whom 40 members refused to take

part. The final study sample was thus 300 with a response rate of 88.2 percent. The

main reasons for non-response were, inconvenience to spend time for the survey

(n=20), refusal to sign the consent(n=5), quitting the interview in between (n=5) and

not filling the questionnaire completely (n=10). Among the non-respondents,

majority of them were males (65.5%) and the remaining females (34.5%). Data was

analysed using IBM SPSS Statistics for Windows, version 20.0. Armonk, NY: IBM

Corp.

The sample characteristics are presented first followed by results of univariate and

bivariate analysis. The results of the expenditure of panchayats are then presented

under a separate heading.

4.1 Sample characteristics

A total of 300 respondents were interviewed; 41.3 percent were males and 58.7

percent were females. The median age was 48 years; and it was 54 years among

males and 46 years among females. And the median period in office in the current

was 20 months.

21

Table 4.1a Characteristics of the sample population

Category

Median (N) Total N

Age

Males 54 yrs. 284

Females 46 yrs.

Period in office

(current term)

20 months

299

Among the participants interviewed, half of them were educated till higher secondary

or above level, and about 14 percent had only primary schooling.

Table 4.1b Socio demographic of sample population

Category N (%)

Total N

Sex Males 124 (41.3)

299 Females 176(58.7)

Education Primary school 41(13.7)

299 Secondary school 108(36)

Higher secondary

and above 150(50)

4.2 Professional experience of the respondents as elected members

4.2.1 Current designation

Among the participants seven percent served as panchayat presidents, seven percent

as vice- presidents and 86 percent as panchayat members.

22

Table 4.2 Professional experience of the respondents as elected members

Category N(%) Total N

Current designation Members 258(86)

300

President 21(7)

Vice president 21(7)

Whether elected earlier Yes 186(62)

299 No 113(37.7)

First time elected members Males 79(42.5)

Females 107(57.5)

186

Previous experience

(No. of terms as elected

members)

One time 67(59.3)

113

Two times 37(32.7)

Three times

or more 9(8)

Whether member of ruling

party

Yes 263(87)

297

No 34(11.3)

Whether any training on

NCDs prevention received

Yes 242(82.9)

292 No 50(17.1)

4.2.2 Training on NCD prevention and control

Among the respondents,82.9 percent had received some kind of training regarding

NCDs and their risk factors and 17.1 percent had not.

4.2.3 Experience as panchayat members

More than half of the respondents were first time elected representatives (62%).

More than a third had previously been elected (37.7%). Among the women 60.2

23

percent had previous experience as an elected representative compared to 39.8

percent of men. Panchayat members who were serving their term for first time was

67 percent, for the second time was 32.7 and for the third time or more was 8

percent. Around 90 percent of the respondents belonged to the ruling party or front.

4.3 Awareness about non-communicable diseases among panchayat

members

4.3.1 Perceptions about the burden of NCDs in their constituencies

Around three fourth of the respondents (75.3%) opined that non-communicable

diseases were common in their constituency (panchayat ward). About one in two of

them felt that non-communicable diseases are less dangerous than communicable

diseases and about 56 percent believed that non-communicable diseases are easily

preventable.

Table 4.3 Perception regarding the burden of non-communicable diseases and

communicable diseases in their constituencies

Category Agree

N(%)

Disagree

N(%)

Don’t know

N(%)

Communicable diseases are common in

their ward

118(62) 104(34.7) 6(2)

Non-communicable diseases are common

in their ward

226(75.3) 61(20.3) 7(2.3)

Non-communicable diseases are less

dangerous than communicable diseases

152(50.7) 131(43.7) 13(4.3)

Non-communicable diseases are easily

preventable

167(55.7) 119(39.7) 11(3.7)

24

4.3.2 Awareness among panchayat members about specific chronic

disease conditions

Respondent‟s knowledge regarding specific chronic disease conditions were

explored and the results provided in Table no.4.4.

Three fourth of the respondents knew that diets high in salt content could cause

high blood pressure. About 14 percent did not know about this fact. Majority of the

participants were aware that high blood pressure causes various health disorders

(94.3%). About 70 percent of the respondents knew brain as an organ that could be

affected by hypertension and 60.3 percent of them knew about heart but only 14.7

percent knew that it could affect multiple other organs in the body.

Table 4.4 Awareness among panchayat members about specific chronic diseases

conditions

Category Yes

n(%)

No n(%) Don’t

know

n(%)

Total N

Hypertension

Salt rich diet causes high BP 225(75) 33(11) 40(13.3)

Hypertension causes health

disorders

283(94.3) 13(4.3) 3(1) 300

Hypertension affects heart 181(60.3) 109(36.3) 9(3)

Hypertension affects brain 213(71) 84(28) 20(6.7)

Hypertension affect multiple

organs including kidneys

44(14.7)

256(85.3)

Diabetes

steps to prevent Diabetes

Meditation/yoga 107(35.8) 165(55.2) 27(9)

Diet modification 260(87) 38(12.7) 1(0.3) 300

25

Category Yes

n(%)

No n(%) Don’t

know

n(%)

Total N

Exercise 228(76.3) 70(23.4) 1(0.3)

Weight reduction

166(55.5) 126(42.1) 7(2.3)

Cancer

Risk factors of Cancer

Obesity 42(14) 240(80) 18(6)

Diabetes 45(15) 231(77) 24(8)

Heredity 197(65.7) 100(33.3) 3(1) 300

Smoking 294(98) 5(1.7) 1(0.3)

Alcohol

253(84.3)

43(14.3) 4(1.3)

Heart diseases

Risk factors of heart diseases

Obesity 180(60.2) 110(14.3) 9(3)

Diabetes 207(69.2) 87(29.1) 4(1.3)

Smoking 191(63.9) 93(31.1) 15(5) 300

Alcohol 214(71.6) 73(24.4) 12(4)

Inadequate physical activity 261(87.3) 36(12) 2(0.7)

The respondents were asked about their opinion regarding the steps to prevent

diabetes. Majority of them knew about diet modification (87%) and physical activity

(76.3%) but more than sixty percent did not know or were incorrect regarding the

benefits of meditation or yoga and about half of them knew regarding the link

between reduction of body weight and diabetes.

Almost all the respondents knew that smoking would cause cancer (98%), and more

than 80 percent knew that alcohol was a risk factor for cancer. Close to ninety

26

percent of the panchayat leaders knew that lack of physical activity was a main risk

factor for developing heart diseases. More than sixty percent of the panchayat leaders

were also aware of the other main risk factors for heart diseases like obesity,

diabetes, smoking and alcohol.

4.4 Awareness among panchayat leaders about major risk factors of

non-communicable diseases

The four risk factors included were tobacco use, alcohol use, healthy diet and

physical activity.

4.4.1 Perceptions among panchayat members about the harmful

effects of Tobacco

Almost all (98%) the panchayat members knew that smoking and passive smoking

were harmful to health. More than 80 percent thought cigarette and smokeless

tobacco use such as Sambhu/ Hans as harmful tobacco products. Only 62.3 percent

considered beedi as harmful and less than half of the elected members thought snuff

powder was a harmful tobacco product.

Table 4.5 Perceptions among panchayat members about the harmful effects of

Tobacco

Category Yes n(%) No n(%) Don’t know

n(%)

Smoking is harmful to health 294(98) 1(0.3) 4(1.3)

Passive smoking is harmful to health 290(96.7) 6(2) 3(0.3)

Harmful tobacco products

Beedi 187(62.3) 108(36) 1(0.7)

Cigarette 235(84) 61(20.3) 2(0.7)

Sambhu/Hans 252(84.6) 45(15) 1(0.3)

Sniff powder 141(47) 141(47) 16(5.3)

27

4.4.2 Awareness among panchayat members about the provisions of

anti-tobacco legislation

The panchayat leaders were asked about major provisions of COTPA

(Cigarette and Other Tobacco Products Act 2003). More than eighty percent of the

respondents were aware that public smoking is banned in their ward. Similarly, more

than eighty percent of the elected leaders also knew that „no smoking‟ boards were in

place in their panchayat offices and schools. The third question related to COTPA

was regarding the distance from educational institutions (schools) within which

tobacco sales are banned.

Table 4.6 Awareness among panchayat members about the provisions of anti-tobacco

legislations

Category N (%)

Total N

Smoke ban in public places

Yes 250 (86)

292 No 41(13.7)

Don‟t know 1(0.3)

Whether „No smoking‟ board put up in

the office

Yes 239 (81)

295 No 56(19)

Whether „No smoking‟ board put up in

schools

Yes 219(81.1)

270 No 39 (14.4)

Don‟t know 12(4.4)

Distance from schools within which

tobacco sale is banned

90-100 meters 193(64.3)

300

Other than

90-100 meters

107(35.7)

About 64.3 percent of the respondents knew that the specified distance from the

educational institution within which tobacco sale was banned between 90-100

meters.

28

Only about 58 percent of the panchayat leaders were aware of all the four provisions

of COTPA.

Table 4.7 Awareness among panchayat members about all the provisions of COTPA

Category Total n(%) N

COTPA awareness

Yes 173(57.7)

No 127(42.3)

300

Fig 4 Proportion of panchayat members who were aware of the individual

provisions of COTPA

4.4.3 Perceptions of panchayat members regarding harmful effects

of alcohol

About three fourth of the participants thought any amount of alcohol was harmful to

health (74%) whereas 13 percent responded that only daily drinking was harmful.

86

%

81

%

81

.10

%

64

.30

%

S M O K E B A N I N P U B L I C P L A C E S

W H E T H E R ' N O S M O K I N G ' B O A R D

P R E S E N T I N O F F I C E

W H E T H E R ' N O S M O K I N G ' B O A R D

P R E S E N T I N S C H O O L S

D I S T A N C E F O R T O B A C C O S A L E

P R O H I B I T E D F R O M S C H O O L S I S

9 0 - 1 0 0 M E T E R S

PER

CEN

T

COMPONENTS OF COTPA

29

Only 28.3 percent panchayat leaders were aware that 200 meters is the distance from

educational institutions within which alcohol sale is banned as per the government of

Kerala guideline.

To the question on whether alcohol use was an issue in their panchayat wards 84.3

percent of the respondents reported that it was a problem in their ward. Around fifty

percent of them perceive it was one of the serious problems in the ward. Close to one

fifth of the members considered it as a minor problem in their wards.

Table 4.8 Perception among panchayat members regarding harmful effects of alcohol

Category Total n(%) N

Harmful amount of alcohol use

Any amount of alcohol is harmful

Drinking once a week

Daily drinking

Don‟t know

222(74)

13(4.3)

39(13)

24(8)

298

Distance from school within which alcohol

sale is banned

200 meters

Other than 200 meters

85(28.3)

215(71.5)

300

Whether alcohol use is a problem in the

ward

Yes

No

Don‟t know

253(84.3)

43(14.3)

3(1)

299

Severity of the problem in the ward

Most serious problem

One of the serious problems

One of many other problems

Only a minor problem

88(30.1)

51(17.5)

102(34.9)

51(17.5)

292

30

4.4.4 Perception among panchayat members about fruits and

vegetable consumption

Almost half of the respondents considered consumption of vegetables and fruits as

important. About 40 percent mentioned local dietary habits as a reason for people in

their ward not consuming enough fruits and vegetables. This was followed by 25

percent of the leaders citing cost and another 25 percent citing availability as factors

reducing fruits and vegetables intake locally.

Table 4.9 Perceptions among panchayat members regarding fruit and vegetable

consumption

Category n(%) Total N

Consumption of vegetables

Not important

Moderately important

Important

Most important

8(2.7)

54(18)

156(52) 300

82(27.3)

Consumption of fruits

Not important

Moderately important

Important

Most important

23(7.7)

77(25.7)

152(50.7) 300

48(16)

Reasons for people not consuming enough

fruits and vegetables

Cost

Availability

Local dietary practices

Do not know the benefits

No time to cook

76(25.3)

66(22)

120(40) 300

34(11.3)

2(0.7)

31

4.4.5 Perceptions among panchayat members regarding physical

activity and health

Slightly more than 80 percent of the respondents knew that 30 minutes per day more

than or equal to five days was the recommended level of physical activity. Half of

the panchayat leaders thought that adults in their ward were physically active. The

most common responses for why they thought people were inactive were lack of

interest, people‟s lack of awareness regarding the benefits and lack of time. One in

four panchayat leaders also mentioned lack of facilities as a reason. Regarding

children more than eighty percent believed that children in their area were physically

active and the main reason for lack of physical activity among children were that

they had too much to study, a lack of awareness regarding its benefits and a lack of

interest.

Table 4.10 Perception among panchayat members regarding physical activity

Category Total n (%) N

Recommended levels of physical activity

30 mts/day>=5days

10 mts/day for all days

Weekly one hour

Don‟t know

246(82)

39(13.3)

10(3.3)

5(1.7)

300

Whether adults in their ward were physically

active

Yes

No

Don‟t know

161(53.7)

78(26)

60(20)

299

Reasons for inadequate physical activity

among adults

No time

No facility

They don‟t know about it

They don‟t want to

85(28.3)

38(12.7)

68(22.7)

106(35.3)

297

32

Category Total n (%) N

Whether children in their ward were physically

active

Yes

No

Don‟t know

247(82.3)

33(10.9)

19(6.3)

299

Reasons for physical activity among children

No time

Too much to study

Schools not allow it

They don‟t know about it

They don‟t want to

47(15.4)

71(23.7)

24(8)

50(16.7)

53(17.7)

300

4.5 NCDs related behavioural risk factors among panchayat

members

4.5.1 Tobacco use among panchayat members

About 84.3 percent of the respondents reported that they have never smoked; among

whom about 70 percent were women and 30 percent were men. About 13percent of

them were ex-smokers and 0.6 percent participants were current smokers and they

were all males.

Around 80 percent participants reported that nobody within their home are current

smokes. But 20.1 percent of the participants had some person who was a current

smoker at home. Only about three percent had ever used smokeless tobacco and none

were current users.

33

Table 4.11 Tobacco use among panchayat members

Category Male

n

Female

n

Total

n(%)

N

History of smoking among the

members

Never smoked

Ever smoked

Current smoker

80

37

6

174

1

0

253(84.6)

38(12.7)

6(2)

299

Whether there was any current

smoker at home

Yes

No

13

111

47

128

60(20.1)

239(79.9)

299

History of smokeless tobacco use

among the members

Never user

Ever user

Current user

118

5

0

172

4

0

290(97)

9(3)

0(0)

299

4.5.2 Alcohol use among panchayat members

About 93 percent of the participants responded that they are not current users.

Among those who reported current alcohol use (6.4%), majority were males (68.5%)

and about 32 percent were females. Around 90 percent of the respondents that none

in their home were current users of alcohol

Table 4.12 Alcohol use among panchayat members

Category Male

n

Female

n

Total

n (%)

N

Current alcohol uses by self

Yes

No

Refused to answer

13

117

1

6

160

2

19(6.4)

277(92.6)

3(1)

299

Whether any family members

were current users of alcohol

Yes

No

Don‟t know

13

109

0

23

147

2

36(12)

256(85.6)

2(0.6)

299

34

4.5.3 Physical activity among panchayat members

About 20.7 percent of the panchayat members reported that they have vigorous

physical activity on more than or equal to five days in a week. About 80 percent

reported that they do moderate physical activity for more than or equal to five days in

a week. More than half of the participants responded that they spend 0-4hrs a day for

sitting or resting (59.5%). About 22.1 percent responded that they spend more than

9hrs for sitting or resting.

Table 4.13 Physical activity among panchayat members

Category Male

n

Female

n

Total n(%) N

Vigorous activity in a week

0-2 days

3-5 days

>5days

73

20

31

119

22

35

192(64)

46(15)

62(20.7)

300

Moderate physical activity in week

0-2 days

3-5 days

>5 days

13

25

86

10

14

182

23(7.7)

39(13)

238(79.3)

300

Hours spend for sitting/resting

0-4hrs

5-9hrs

>9hrs

69

20

34

109

35

32

178(59.5)

55(18.4)

66(22.1)

300

4.6 Bivariate analysis

In order to see whether panchayat leaders who had any kind of training regarding

non-communicable diseases and their control and their awareness are related, a

bivariate analysis was done to see the relation between awareness regarding

provisions of anti-tobacco legislation (COTPA) and legal restriction related to sale of

alcohol.

35

4.6.1 Association between training received and awareness

regarding provisions of COTPA

About 80 percent of the panchayat members had received some kind of training

related to non-communicable diseases and their control. Having received training

was significantly associated with two main provisions of COTPA namely ban of

public smoking in the panchayats (p 0.015) and the legal restriction on distance from

schools within which the sale of tobacco is banned (p 0.051).

Around 83 percent of the members who had received training were aware of the

public smoking ban compared to around 16 percent among those who had not

received any training. Almost78 percent of the participants who received training

knew that the legal restrictions for tobacco sale around the educational institution is

90-100 meters compared to 30 percent of the members who had not received any

training.

Table 4.14 Association between awareness of panchayat members regarding

provisions of COTPA and their training on NCDs

Variable Training

received

Training not

received

N P value

Public smoke is banned in

the ward

Yes

No

Don‟t know

209(83.6)

32(13.2)

0(0)

41(16.4)

9(18)

1(0.4)

250

41

1

0.015

Whether no smoking board

put up in the office

Yes

No

188(80.7)

51(21.3)

45(19.3)

3(6.2)

233

54

0.441

36

Variable Training

received

Training not

received

N P value

Whether no smoking board

put up in the schools

Yes

No

Don‟t know

174(81.3)

35(16.1)

9(4.1)

40(18.7)

4(8.7)

2(4.3)

214

39

11

0.320

Distance from schools

within which tobacco sale

is banned

90-100 meters

Other than 90-100 meters

81(77.1)

161(86.1)

24(22.9)

26(13.9)

105

187

0.051

4.6.2 Association between training received and awareness about

legal restriction related to sale of alcohol

The bivariate analysis to evaluate the association between the awareness of

panchayat members regarding the legal restriction related to sale of alcohol near

schools did not reveal any significant association.

Table 4.15 Association between awareness of panchayat members regarding legal

restrictions on sale of alcohol with their training on NCDs

Variable 200mtrs Other than

200mtrs

N P

value

Training received

Yes

No

70(28.9)

15(30)

14(28)

77(31.8)

50

242

0.879

Education level

Primary school

Secondary school

Higher secondary

and above

6(14.6)

32(29.6)

47(31.3)

35(85.4)

76(70.4)

103(68.7)

41

108

150

0.104

37

4.7 Analysis of panchayat budgets- Expenditure on schemes related

to prevention of NCDs

In general allocation of funds and nature of schemes vary between the district,

block and grama panchayats. The budget expenditure during the years 2015-16 and

2016-17 of eighteen panchayats were studied (14 grama panchayats, 3 block

panchayats and 1 district panchayat).

In addition to the expenditure in the health sector, expenditure in the allied sectors

that could indirectly help to prevent non-communicable diseases were also

considered separately.

This section is organised as follows: The details of the type of projects undertaken by

the panchayats under health sector (Table 4.16), total health sector expenditure and

expenditure on the four subheads - sanitation, hospital & clinics, public health and

others as a percentage of the health expenditure in the 2015-16 and 2016-17.

(Table 4.17 &4.18) * Health sector expenditure in this analysis has included only those

projects/expenditure related to modern medicine; since the alternate medical systems have

only curative role and no community based, public health prevention and promotion

activities.

38

Table 4.16 Nature of projects undertaken under the four subheads of health sector

SANITATION

Sanitary Unit

Pipe Compost

Ring Compost

Toilet/sanitation

Pre monsoon cleaning

Plastic waste management

HOSPITALS AND CLINICS-

ALLOPATHY

Renovation of hospital

Construction of new ward

Equipment for hospitals

Equipment for treatment of aged

Biomedical waste management

Machineries for district hospital

Pending bills of district hospital

Equipment for cancer detection

Machines- PHC/CHC

Maintenance PHC/Hospitals

PUBLIC HEALTH

Total poverty alleviation

Nutrition program for child centre

Development for women and children

Welfare of the aged

Control of communicable diseases

Gynec care

Medical camps

Public health programs

Balamanasam-child health

Nutrition and rehabilitation of AIDS patients

Nutrition for TB patients

New sanitary well

Pain & palliative

Stray do sterilization

Rabies control

Drinking water well

Public well maintenance

Anganwadi nutrition

OTHERS

Scholarship- mentally/physically challenged

Three wheeler/orthotics for physically

challenged

Buds rehabilitation centre fund

Camp for physically challenged

Arogyasree- NCD hand book

39

Table 4.17 Proportion of expenditure on sub category projects from total health

sector expenditure 2015-16

Settings

Total

expenditure on

health sector

Rs.

Sanitation

(%)

Hospitals

and clinics

(%)

Public health

(%)

Others

(%)

District and block panchayats

1

2

3

4

39304000

1432229

3669494

3762093

4.45

0

3.99

6.93

49.60

22.1

41.5

80.87

5.57

19.2

8.49

12.2

41.00

58.64

46.02

0

Grama panchayats

1

2

3

4

5

6

7

8

9

10

11

12

13

14

3163307

1141348

2896436

6182175

5841294

2476847

1066964

7536290

5500000

3121849

9637375

2878908

6069627

6354839

10.41

30.00

17.60

11.01

14.19

0

19.22

25.00

NA

10.60

NA

12.87

18.53

19.34

1.00

4.02

3.45

17.00

9.01

39.56

22.12

11.61

NA

7.02

NA

8.54

8.33

8.17

74.74

57.54

56.18

59.38

61.20

51.62

25.62

57.79

NA

74.37

NA

58.52

56.60

60.56

14.08

8.44

22.77

12.61

14.21

8.02

33.04

5.60

NA

8.01

NA

20.07

16.54

11.93

While analysing the tables, it is clear that the majority of the expenditure of district

and block panchayats were going to hospitals & clinics category, followed by the

category others in the both the years. And majority of expenditure of grama

panchayats were going to the category public health followed by sanitation.

Hospitals & clinics are the least funded areas by grama panchayats whereas

sanitation is the least funded area by district and block panchayats.

40

Table 4.18 Proportion of expenditure on sub category projects from total health

sector expenditure 2016-17

Settings

Total

expenditure on

health sector

Rs.

Sanitation

(%)

Hospitals

and clinics

(%)

Public health

(%)

Others

(%)

District and block panchayats

1

2

3

4

41138289

1756292

1872791

3772190

18.24

10.70

12.00

6.91

69.4

40.66

78.00

56.81

7.25

19.78

0

2.65

5.11

29.78

9.19

33.61

Grama panchayats

1

2

3

4

5

6

7

8

9

10

11

12

13

14

2198353

1814955

6120251

7461258

6190393

1599157

2762685

7096945

7999700

5982561

7499000

3239916

3170804

5700923

62.25

18.46

44.06

18.59

12.96

8.87

12.82

17.85

NA

42.95

NA

16.68

38.53

18.57

13.76

4.05

6.85

7.78

6.35

9.37

10.60

10.69

NA

8.42

NA

8.82

7.40

11.48

6.14

43.3

51.82

60.89

62.20

69.13

36.34

58.78

NA

41.22

NA

64.78

23.93

59.43

17.85

8.59

22.87

12.74

18.49

12.61

40.24

12.68

NA

8.21

NA

10.38

30.14

10.52

Table 4.19 Type of projects under the health sector related to chronic disease control

Medical camps

Pain and palliative

Anganwadi nutrition

Equipment for cancer detection

Equipment for treatment of aged

Balamanasam- child health

Total poverty alleviation

Nutrition program for child centre

Development for women and children (related to menopause,

healthy nutrition)

41

Table 4.20 Presents the health expenditure as a percent of total expenditure of the

panchayats and expenditure on chronic disease control as a percent of health sector

expenditure. On an average, the district and block panchayats expenditure for chronic

disease control was 11.3 percent in 2015-16 and was 27.7 percent in 2016-17. But

among the grama panchayats the proportion was 58.3 percent in 2015-16 and it has

decreased to 34.9 percent in 2016-17.

Table 4.20 Total expenditure and health expenditure as percent total expenditure in

the panchayats - 2015-16 & 2016-17

Settings

2015-2016

2016-2017

Total

expenditure

health sector

(Rs)

Health sector

expenditure as

percent total

expenditure(%)

Proportion of

NCD

prevention

and control

projects (%)

Total

expenditure

health

sector (Rs)

Health sector

expenditure as

percent total

expenditure(%)

Proportion

of NCD

prevention

and control

projects

(%)

District&block

panchayats

1

2

3

4

Mean

Grama

panchayats

1

2

3

4

5

6

7

8

9

10

11

12

13

14

Mean

39304000

3762093

1432229

3669494

100466954

3163307

1141348

2896436

6182175

5841294

2476847

106664

7536290

5500000

3121849

9637374

2878908

6069627

6354839

4493354.14

5.41

7.31

2.89

NA

5.20

9.61

11.62

7.76

16.29

14.93

13.44

3.38

8.22

26.53

8.57

17.81

14.63

16.34

13.14

13.02

0

14.49

27.92

2.72

11.28

75.86

73.59

8.13

58.03

61.74

54.54

35.14

55.73

NA

90.53

NA

60.43

61.69

64.06

58.28

41138289

1756292

1872791

3772190

12134890

2198353

1814955

6120251

7461258

6190393

1599157

2762685

7096945

7999700

5982561

7499000

3239916

3170804

5700923

4916921.5

9.01

5.22

6.91

NA

7.21

7.77

24.17

20.39

21.39

16.38

11.80

9.85

15.43

29.90

22.48

16.02

17.13

12.79

15.22

17.20

52.67

0

0

2.65

27.66

4.54

49.80

44.36

60.48

63.84

6.11

15.38

60.82

NA

46.27

NA

40.49

7.76

18.22

34.83

42

4.7.1 Projects of allied structure with potential impacts on control of

NCDs

An analysis of expenditure on projects carried out in the allied sectors indicated that

there were two sectors – agriculture and sports; where the type of projects undertaken

could indirectly lead to risk factor reduction and prevention of non-communicable

diseases. Table 4.19 indicate the type of such projects undertaken in those sectors

Table 4.21 Type of projects in allied sectors of agriculture and sports with

implications for prevention of chronic non communicable diseases

AGRICULTURE

Paddy farming

Plantain farming

Coconut farming

Pepper farming

Growbag vegetables

Organic vegetables

Kitchen garden

Fruit plants farming

Medicinal plants

Inter crop

SPORTS

Bicycle for SC/ST students

Indoor stadium

Foot path

Sports

Swimming pool

Yoga

Kalari payattu training for school

children

Mini stadium

Table 4.22 No. and type of projects undertaken by PRIs to encourage sports

Project 2015-16 (N) 2016-17 (N)

Bicycle for SC/ST students 3 8

Indoor stadium 0 1

Footpath 8 7

Kalari training 2 1

Yoga 0 1

Swimming pool 1 0

Mini stadium 1 0

43

Though these projects were undertaken to encourage sports under the sports subhead,

these were also considered due to the indirect benefits they provide in the prevention

of chronic non communicable diseases. Majority of the panchayats spent the money

under this sector to develop foot paths in both the years; however, this were also

included since it could increase people‟s access to better walkways and promote

physical activity.

Table 4.23 Proportion of expenditure on sub category projects from total allied sector

expenditure 2015-16

Settings Total

expenditure on

allied sectors

Rs.

Agriculture

(%)

Sports

(%)

District and block panchayats

1

2

3

4

7788037

500000

0

1701025

100

0

0

0

0

100

100

100

Grama panchayats

1

2

3

4

5

6

7

8

9

10

11

12

13

14

510300

218728

687000

594630

2273850

1772408

995400

454538

NA

856491

NA

843534

1686987

639648

74.07

100

0

80.72

100

2.53

97.9

67.26

NA

15.98

NA

55.20

82.74

88.83

25

0

100

19.28

0

97.46

2.1

32.72

NA

84.02

NA

44.8

17.26

11.17

44

Table 4.24 Proportion of expenditure on sub category projects from total allied sector

expenditure 2016-17

Settings Total

expenditure on

allied sectors

Rs.

Agriculture

(%)

Sports

(%)

District and block panchayats

1

2

3

4

808812

2212047

1653560

501476

100

57.05

100

0

0

42.95

0

100

Grama panchayats

1

2

3

4

5

6

7

8

9

10

11

12

13

14

1409113

866310

802635

653496

2060155

544904

1122494

989168

0

923380

0

445999

2390917

608390

99.68

40.20

55.56

56.50

94.07

10.72

64.72

73.44

NA

84.77

NA

84.09

100

93.53

0.32

59.80

44.44

43.50

5.93

89.28

35.28

26.56

NA

15.23

NA

15.91

0

6.47

In the year 2015-16, between agriculture and sports, the entire expenditure by the

district and block panchayats was in the subhead of sports and none in agriculture.

But in 2016-17 expenditure was higher in agriculture than in sports. But in both the

years, the major share of expenditure by the grama panchayats was in agriculture

sector. This may be because the large infrastructural development like stadia, foot

paths etc. would be at the district/block level

45

CHAPTER 5

DISCUSSION

This study aimed to explore the awareness, attitudes and practices related to chronic

non communicable diseases and their risk factors among panchayat members. In

addition, an analysis of the selected panchayats was analysed to assess the nature of

the projects/initiatives undertaken and the extent of fund allocation to prevent and

control NCDs and their risk factors

5.1 Awareness about the burden of non-communicable diseases

Majority (75.3%) of the panchayat members were aware that chronic non

communicable diseases were common in their constituencies. However slightly more

than fifty percent of them perceived NCDs as less dangerous than communicable

diseases and are easily preventable. This perception regarding non- communicable

diseases and its prevention among the panchayat leaders could effective and

proactive policy making, implementation and enforcement of key interventions and

regulation related to the control NCD control strategies at the local level. Studies

have found legislator attitudes towards issues and perceptions regarding its public

health impact and the extent of the government‟s role in its management to be crucial

in the case of tobacco control in the United States and Canada(Joanna E Cohen et al.,

1997).

46

5.2 Awareness regarding specific non-communicable diseases

About three fourths of the panchayat members were aware of the link between high

salt consumption and hypertension in comparison and this was far higher than 27

percent, that was reported by a study done in India among opinion leaders(Dongre et

al., 2008). A significant proportion of them also knew that hypertension could lead to

heart diseases and affect the brain. The high levels of awareness regarding the

specific chronic diseases and its health implications could be a positive factor for

policy makers in their attempt to gain legislative and political support to roll out long

term strategies for control of NCDs. Legislator support has been documented as a

key factor for public health advocates to legislation and enacting policies aimed at

tobacco control(Gottlieb et al., 2003). Similarly legislator‟s awareness regarding

addictiveness of tobacco were more supportive of tobacco control policies for the

youth(Goldstein et al., 1997).

About 87 percent of the panchayat members were also aware that healthy diet can

help to prevent diabetes. However only around three fourths of them were aware

about the benefits of physical activity in preventing diabetes; which is lower than that

reported by a recent study in Kerala among adults(Kurian, 2016).

Almost all the panchayat members were aware about the causes of cancer and about

being a risk factor for cancers and about three fourths of them were aware about the

risk of cancer from alcohol use which was much higher than that reported by a study

related to cancers in India, (Smoking-79.2% and alcohol 58.8%)(Raj T.P et al.,

2012).

47

Close to ninety percent of them also knew that lack of physical activity could lead to

heart diseases. More than sixty percent were also aware about the link between

diabetes, obesity, smoking and heart diseases. In contrast to an earlier study from

Kerala where only 13.1(Areekal et al., 2015) knew about the association between

alcohol misuse and heart diseases, 71.6 percent, of panchayat members in this study

were aware about it.

5.3 Awareness regarding major risk factors

The panchayat members who took part in the study were well aware of the fact that

smoking affects health (98%) and that passive smoking was also harmful (96.7%).

The high level of awareness regarding tobacco smoking in general and cancers and

heart diseases in particular may be due to the several training that they get during

their term as well as the general discourse in Kerala regarding the rising burden of

chronic diseases like cancers, diabetes and heart diseases. Kerala was the first state to

ban smoking in public spaces as well as a ban on the manufacture and sale of

chewable tobacco like gutka and pan masala in the state. This social context is also

the reason for such high awareness regarding harmful effects of tobacco.

It is especially notable that only around 60 percent of the panchayat leaders

perceived beedi as a harmful to health. This may be because the leftist party in power

had the largest beedi workers‟ cooperative society in the district and used to be a

major producer till two decades back and this history either prompted a lot of them to

answer or they assumed that beedi was not harmful. In addition, only less than 15

percent thought snuff as a harmful tobacco product. Therefore, public health

48

advocates may have to take steps to prevent people from associating tobacco use

exclusively with cigarettes.

More than 86 percent of our study participants responded that smoking in public

place was banned in their ward, which was lower than the response (94.2%) from

panchayat members in another study from Kerala (Mohan et al., 2013). However

only 81 percent participants knew whether “no smoking” boards were put up in their

office and schools in their constituencies. The COTPA act of 2003 restricts sale of

tobacco within 100 yards (91.4 metres) of educational institutions. About 64.3

percent of the panchayat leaders gave an answer between 90 and 100 (and all of them

in metres). It is much higher than that reported by a study among members of PRIs in

Haryana(Kumar and Misra, 2011), but much lower