Dr Abdel Rahim Mutwakel Gaffar, Dr Abdel Rahim Mutwakel Gaffar, MBBS, DPH, FCMMBBS, DPH, FCM

Nizwa Healthy Lifestyle Project, Nizwa Healthy Lifestyle Project, Planning and Implementation Planning and Implementation

ExperienceExperience 19991999 - - 20082008

ContentsContents Background informationBackground information

Milestones of NHLPMilestones of NHLP

Prevalence of NCDs and common RFsPrevalence of NCDs and common RFs

Strategic planStrategic plan

IHHP Role IHHP Role

Interventions re-planning and implementation Interventions re-planning and implementation

Resources available Resources available

Challenges and issuesChallenges and issues

Background information…Background information…Sultanate of OmanSultanate of Oman

Population: Population: 2,331,391 (1,779,318 Omani)2,331,391 (1,779,318 Omani)

Area: 309,500 square kilometers Area: 309,500 square kilometers

Population settlement:Population settlement:50515051

The Sultanate of Oman borders Saudi Arabia and The Sultanate of Oman borders Saudi Arabia and United Arab Emirates (U.A.E.) in the West, the United Arab Emirates (U.A.E.) in the West, the Republic of Yemen in the South, the Strait of Republic of Yemen in the South, the Strait of Hormuz in the North and the Arabian Sea in the Hormuz in the North and the Arabian Sea in the East (map) East (map)

Background information…Background information…Willayat Nizwa (project Area)Willayat Nizwa (project Area)

Location: In Ad Dakhliyah region about 175 Location: In Ad Dakhliyah region about 175 Km from Muscat (the capital)Km from Muscat (the capital)

Population: 68,785Population: 68,785

Population settlement: about 77 village Population settlement: about 77 village including Nizwa center.including Nizwa center.

Milestones of NHLP… (1)Milestones of NHLP… (1)

1996:1996:The idea to implement a community-Based The idea to implement a community-Based programme for prevention of NCDs emerged.programme for prevention of NCDs emerged.

May 1997:May 1997: Wali Nizwa (governor) express the Wali Nizwa (governor) express the

willingness of the community to host the pilot willingness of the community to host the pilot project.project.

February 1999:February 1999: Minister of health decree; Minister of health decree; appointment of a local project committee headed appointment of a local project committee headed by Wali.by Wali.

April April –– July 2001: July 2001: Implementation of the Baseline Implementation of the Baseline

survey.survey.

Milestones of NHLP …(2)Milestones of NHLP …(2)

March 2002:March 2002: Presentation of the preliminary Presentation of the preliminary survey results.survey results.

November 2003:November 2003: Preparation of the Five years Preparation of the Five years intervention strategic plan completed.intervention strategic plan completed.

March 2004:March 2004: Implementation of the intervention Implementation of the intervention started.started.

Prevalence of NCDs and common Prevalence of NCDs and common RFsRFs

Prevalence of Diabetes Mellitus, Hypertension and Prevalence of Diabetes Mellitus, Hypertension and Metabolic syndrome in Nizwa and national levelMetabolic syndrome in Nizwa and national level

9.5

16.2

19.5

9.88.5

23

9.7

12.1

21

11.6

15.2

21

0

5

10

15

20

25

DM Hypertension MetabolicSyndrom

%

Male Female Total National

Prevalence of IFG and Hypercholesterolemia in Nizwa Prevalence of IFG and Hypercholesterolemia in Nizwa and national leveland national level

7.7

36

4.4

34.6

5.9

35.3

6.1

40.6

0

5

10

15

20

25

30

35

40

45

IFG Hyperchlestrolemia

%

Male Female Total National

Prevalence of Obesity, Physical Inactivity and Tobacco Prevalence of Obesity, Physical Inactivity and Tobacco use in Nizwa and national leveluse in Nizwa and national level

8.6

30.9

48

9.6

17

25.3

73

0

13.1

28.4

60.5

9.6

19.1

28.9

10.6

0

10

20

30

40

50

60

70

80

Obesity Overweight PhysicalInactivity

Tobacco use

%

Male Female Total National

Causes of unhealthy dietary Causes of unhealthy dietary habitshabits!!

Lack of awarenessLack of awareness

Low availability of healthy choices at: Low availability of healthy choices at: • At food stuff storesAt food stuff stores• At restaurants.At restaurants.• At schools.At schools.

Why people physically inactiveWhy people physically inactive?? Lack of awareness regarding the of physical Lack of awareness regarding the of physical

activity for health fitness and prevention of activity for health fitness and prevention of diseasesdiseases

Social values and traditions regarding Social values and traditions regarding

physical exercise (women, restriction).physical exercise (women, restriction).

Non-availability public places suitable for Non-availability public places suitable for physical activity (walking and cycling path, physical activity (walking and cycling path, gymnasium).gymnasium).

Modernization of life that reduce physical Modernization of life that reduce physical activity (sedentary life, TV, Computers, tel, activity (sedentary life, TV, Computers, tel, cars). cars).

Why people use tobaccoWhy people use tobacco?? Peers pressure.Peers pressure.

Lack of awareness among youth.Lack of awareness among youth.

Media and advertisement.Media and advertisement.

Availability of tobacco in most of the Availability of tobacco in most of the shops, even the small ones.shops, even the small ones.

Lack of fruitful activities/hobbies for Lack of fruitful activities/hobbies for Leisure time.Leisure time.

Development of the strategic PlanDevelopment of the strategic Plan

The strategic intervention plan was The strategic intervention plan was developed mainly by the MOH in developed mainly by the MOH in consultation with the other government consultation with the other government sectors, CBO and WHO.sectors, CBO and WHO.

The plan intervention areas:The plan intervention areas:• Healthy nutrition promotion,Healthy nutrition promotion,• Promotion of physical activity,Promotion of physical activity,• Tobacco control and prevention,Tobacco control and prevention,• Road Traffic and domestic accident control. Road Traffic and domestic accident control.

Development of the strategic PlanDevelopment of the strategic Plan

Activities for each intervention area were Activities for each intervention area were identified, and broad action plan was identified, and broad action plan was developed indicating the responsibilities developed indicating the responsibilities and inputs, process, out puts and outcome and inputs, process, out puts and outcome indicators.indicators.

The strategic plan describe the The strategic plan describe the documentation process, evaluation documentation process, evaluation mechanism, follow up activities ..ect.mechanism, follow up activities ..ect.

It was strategic plan which need It was strategic plan which need operational planning. operational planning.

Objectives…(1)Objectives…(1)

Ultimate goal:Ultimate goal:

The main goal of the project is to improve the The main goal of the project is to improve the health of people in Nizwa by the implementation health of people in Nizwa by the implementation of a Community based project for primary of a Community based project for primary prevention of non-communicable diseases and prevention of non-communicable diseases and healthy lifestyle. healthy lifestyle.

Objectives…(2)Objectives…(2)

Main objectives:Main objectives: To map the emerging epidemics of NCDs and to To map the emerging epidemics of NCDs and to

analyze the social, economic, behavioral and analyze the social, economic, behavioral and political determinants of the disease.political determinants of the disease.

To reduce the exposure of individuals and To reduce the exposure of individuals and populations to the major determinants of NCDs populations to the major determinants of NCDs and to prevent the emergence of preventable and to prevent the emergence of preventable common risk factors.common risk factors.

To strengthen health care for people with NCDS To strengthen health care for people with NCDS by supporting effective interventions.by supporting effective interventions.

StrategiesStrategies Promotion of development of supportive policies, Promotion of development of supportive policies,

legislation.legislation.

Inter-sectoral collaboration.Inter-sectoral collaboration.

Community involvement.Community involvement.

Health education and information.Health education and information.

Development of guidelines/protocols for preventive Development of guidelines/protocols for preventive interventions. interventions.

Training of medical professionals.Training of medical professionals.

Research, monitoring and evaluation.Research, monitoring and evaluation.

International cooperation.International cooperation.

Organization structure of the projectOrganization structure of the project

Central CBI unitPHCD/MOH

Project Executive Office

Dietary style committee

Physical activity and Environment committee

Smoking and accident control committee

WHONCDC/MOH

Local project committee

The implementation of the project The implementation of the project was started in March 2004,was started in March 2004,

The activities in the first year was The activities in the first year was like an advocacy campaign.like an advocacy campaign.

Thanks for the internet and IHHPThanks for the internet and IHHP

Operational planningOperational planning From IHHP web site we learn how to From IHHP web site we learn how to

prepare the intervention plan. We prepare the intervention plan. We prepare intervention plan for 2006 prepare intervention plan for 2006 based IHHP experience and our based IHHP experience and our strategic plan.strategic plan.

BUT the questions was BUT the questions was ““how to do it?how to do it?””

The answer was in Isfahan 5The answer was in Isfahan 5thth International seminar, thanks to their International seminar, thanks to their support to attend that activity. support to attend that activity.

IHHP LessonsIHHP Lessons

Leadership;Leadership; organization and personal, organization and personal,

Project design;Project design; clear plan, monitoring and clear plan, monitoring and evaluation indicators ,evaluation indicators ,

Partnership & inter-sectoral collaboration;Partnership & inter-sectoral collaboration; create ownership create ownership

Team work;Team work; multidisciplinary, committed and multidisciplinary, committed and motivated,motivated,

Strong international co-operation;Strong international co-operation; open open opportunities for exchange of experienceopportunities for exchange of experience

NHLP InterventionsNHLP Interventions n Population approach Population approach School Programs School Programs (school health, Education)(school health, Education) Community Empowerment Community Empowerment (CSG, OWA, Scouts, (CSG, OWA, Scouts,

sport teams,)sport teams,) Supportive Environment Supportive Environment (municipality)(municipality) Public Education Public Education (CSG, OWA, Scouts, sport teams, (CSG, OWA, Scouts, sport teams,

Education, PHC, ..ect)Education, PHC, ..ect) RTA prevention and control RTA prevention and control (Police, NGO)(Police, NGO)

n High-Risk Approach High-Risk Approach Lifestyle Clinic Lifestyle Clinic (NPC, nutrition department)(NPC, nutrition department) Health professionals education and involvement Health professionals education and involvement

(NPC)(NPC) Obesity screening and management at PHC Obesity screening and management at PHC (NPC, (NPC,

nutrition department)nutrition department)

Population approach Population approach School ProgramsSchool Programs

1. NHLP Friendly Schools 1. NHLP Friendly Schools competition:competition:

Schools implement activities Schools implement activities (Group education, Events and (Group education, Events and contests) to raise the contests) to raise the awareness of children and awareness of children and parents regarding Healthy parents regarding Healthy diet, physical activity, tobacco diet, physical activity, tobacco control and road safety.control and road safety.

The activities evaluated The activities evaluated against special criteria by against special criteria by joint NHLP and Education joint NHLP and Education team. team.

Winners schools were Winners schools were selected and appraised in selected and appraised in major public event. major public event.

Population approach Population approach School ProgramsSchool Programs

2. Alharaka Baraka (Move for Health):2. Alharaka Baraka (Move for Health): Programme to promote physical activity Programme to promote physical activity

among children in Gulf area. For the first time among children in Gulf area. For the first time to be implemented in Oman.to be implemented in Oman.

Population approach Population approach Community EmpowermentCommunity Empowerment

In collaboration with the community organizations:In collaboration with the community organizations: Community Support Groups.Community Support Groups. Omani Women Association.Omani Women Association. Scouts (Jawalat Nizwa)Scouts (Jawalat Nizwa)

Training workshops for community members to work as Training workshops for community members to work as health promoters in their local community settings.health promoters in their local community settings.

Supportive Environment Supportive Environment Promotion of establishment of female gymnasium in Promotion of establishment of female gymnasium in

collaboration with OWA.collaboration with OWA. Plan to establish walking pathPlan to establish walking path Competition between supermarket to made high fiber, Competition between supermarket to made high fiber,

low fat, low sugar choices available. low fat, low sugar choices available.

Population approach Population approach Public EducationPublic Education

Group and direct education; schools, mosques, Group and direct education; schools, mosques, sablat, majalis and health institutions.sablat, majalis and health institutions.

Brochures and leaflets.Brochures and leaflets.

Events and contests (World health, Heart, DM, Events and contests (World health, Heart, DM, Tobacco Tobacco ……ect).ect).

Walkathons.Walkathons.

Screenings campaigns (Obesity, BP, DM).Screenings campaigns (Obesity, BP, DM).

Street Boards.Street Boards.

High risk approach High risk approach Lifestyle ClinicLifestyle Clinic

Provide Lifestyle Change therapy Provide Lifestyle Change therapy (counseling) for individuals with:(counseling) for individuals with:

Obesity and overweight,Obesity and overweight, DM,DM, Hypertension,Hypertension, Dyslipidemia,Dyslipidemia, Smoking cessation counseling. Smoking cessation counseling.

High risk approach High risk approach Health professionals education Health professionals education

and involvementand involvement

Workshops and events (WHD, tobacco day) to Workshops and events (WHD, tobacco day) to sensitize health professionals regarding risk sensitize health professionals regarding risk factors assessment and management as a key factors assessment and management as a key step for primary prevention of non-step for primary prevention of non-communicable disease. communicable disease.

Training program for 3Training program for 3rdrd year nursing student year nursing student at Nizwa nursing institute.at Nizwa nursing institute.

High risk approach High risk approach Obesity screening and Obesity screening and

management at PHC levelmanagement at PHC level ObjectivesObjectives To introduce a program for the detection and To introduce a program for the detection and

management of overweight and obesity in the primary management of overweight and obesity in the primary health care system.health care system.

To study the prevalence of obesity and overweight in To study the prevalence of obesity and overweight in adults >20 years of age who attend the health centers.adults >20 years of age who attend the health centers.

To evaluate the effectiveness of the intervention To evaluate the effectiveness of the intervention program.program.

Finalization of the practical guidelines (first of its kind in Finalization of the practical guidelines (first of its kind in Oman) Oman)

Status of implementation…(1)Status of implementation…(1)

162

79

27

131111123

2532

17

0

20

40

60

80

100

120

140

160

180

No

.

Nizwa Healthy Lifestyle Project total activities 2004-2006

Status of implementation…(2)Status of implementation…(2)

24

45488

340

40

8

79

237

0255

27

18

3

59

11

16

51331

1414

6

0

10

20

30

40

50

60

70

80

90

No

.

Nizwa Healthy Lifestyle project activities per year, 2004-2006

2004 2005 2006*

Training and capacity buildingTraining and capacity building

Nizwa Healthy Lifestyle Project Capacity Building and Training activities, 2003-2006

1

4

2

7

1

0

5

9

2

0000

1

2

3

4

5

6

7

8

9

10

2003200420052006

No

.

Training workshops or courses held Participation in regional and international events Field visits

Percent of population who attend HE activity Percent of population who attend HE activity about PA or healthy diet or tobacco control, about PA or healthy diet or tobacco control,

2001 - 20062001 - 2006

68

90.9

0

10

20

30

40

50

60

70

80

90

100

2001 2006

Research and studiesResearch and studiesAbdelrahim M Belal, Raha Alsalmi, Zahir Alanqudi, Patterns of Abdelrahim M Belal, Raha Alsalmi, Zahir Alanqudi, Patterns of

Physical activity and levels of inactivity among school children in Physical activity and levels of inactivity among school children in Willayat Nizwa, Oman, 2006. In: School Children and Adolescent Willayat Nizwa, Oman, 2006. In: School Children and Adolescent Nutrition in Gulf. Arab Center for Nutrition, Bahrain 2006; 1st ed.: Nutrition in Gulf. Arab Center for Nutrition, Bahrain 2006; 1st ed.: 223-242.223-242.

Zahir Alanqoudi, Nagi Zaki, Abdelrahim M Belal, Diabetes Care Zahir Alanqoudi, Nagi Zaki, Abdelrahim M Belal, Diabetes Care Clinical Outcome in Ad Dakhliya Region, Oman (presented in Gulf Clinical Outcome in Ad Dakhliya Region, Oman (presented in Gulf Group for study of diabetes).Group for study of diabetes).

Reports:Reports:Evaluation of Nizwa Healthy Lifestyle Project activities, 2004-2006 Evaluation of Nizwa Healthy Lifestyle Project activities, 2004-2006 Nutrition Clinic Annual Report and weight management outcome, Nutrition Clinic Annual Report and weight management outcome,

20062006Manuscripts: Manuscripts: Abdelrahim M Belal, Halima G Alhinai, Community-Based Initiatives Abdelrahim M Belal, Halima G Alhinai, Community-Based Initiatives

for prevention and control of non-communicable diseases: Nizwa for prevention and control of non-communicable diseases: Nizwa Healthy Lifestyle Project planning experience in Oman.Healthy Lifestyle Project planning experience in Oman.

Abdelrahim M Belal, Raha Alsalmi, Zahra Alabri, Availability of Abdelrahim M Belal, Raha Alsalmi, Zahra Alabri, Availability of nutrition choices in schools' food stores and their role in nutrition choices in schools' food stores and their role in promotion of healthy eating habits. promotion of healthy eating habits.

Resources available for the projectResources available for the project Human resources:Human resources:

• Available full time staff in the HLP Office as follows:Available full time staff in the HLP Office as follows: Doctor; working as regional CBI coordinator.Doctor; working as regional CBI coordinator. Nurse; project coordinator.Nurse; project coordinator. Project secretary.Project secretary.

• Part time (4);Part time (4); Head of non-communicable disease Head of non-communicable disease control section (2 days/week), the community control section (2 days/week), the community participation coordinator of the region, staff nurse participation coordinator of the region, staff nurse from Hypertension study (one day/week) and the from Hypertension study (one day/week) and the nutritionist in Nizwa Poly clinic (3 days/week). nutritionist in Nizwa Poly clinic (3 days/week).

• Supportive staff;Supportive staff; administrative and financial administrative and financial superintendent.superintendent.

IssuesIssues..…..…

Number and capacity of staff (human Number and capacity of staff (human resources).resources).

The delay in the starting of the The delay in the starting of the interventions (2001 2004)!!!!interventions (2001 2004)!!!!

No reference area for the project … No reference area for the project …

The design and evaluation issue!The design and evaluation issue!