Dr Abdel Rahim Mutwakel Gaffar, MBBS, DPH, FCM Nizwa Healthy Lifestyle Project, Planning and Implementation Experience

Contents Background information Background information Milestones of NHLP Milestones of NHLP Prevalence of NCDs and common RFs Prevalence of NCDs and common RFs Strategic plan Strategic plan IHHP Role IHHP Role Interventions re-planning and implementation Interventions re-planning and implementation Resources available Resources available Challenges and issues Challenges and issues

Background information… Sultanate of Oman Population: 2,331,391 (1,779,318 Omani) Population: 2,331,391 (1,779,318 Omani) Area: 309,500 square kilometers Area: 309,500 square kilometers Population settlement:5051 Population settlement:5051 The Sultanate of Oman borders Saudi Arabia and United Arab Emirates (U.A.E.) in the West, the Republic of Yemen in the South, the Strait of Hormuz in the North and the Arabian Sea in the East (map) The Sultanate of Oman borders Saudi Arabia and United Arab Emirates (U.A.E.) in the West, the Republic of Yemen in the South, the Strait of Hormuz in the North and the Arabian Sea in the East (map)

Background information… Willayat Nizwa (project Area) Location: In Ad Dakhliyah region about 175 Km from Muscat (the capital) Location: In Ad Dakhliyah region about 175 Km from Muscat (the capital) Population: 68,785 Population: 68,785 Population settlement: about 77 village including Nizwa center. Population settlement: about 77 village including Nizwa center.

Milestones of NHLP… (1) 1996:The idea to implement a community-Based programme for prevention of NCDs emerged. 1996:The idea to implement a community-Based programme for prevention of NCDs emerged. May 1997: Wali Nizwa (governor) express the willingness of the community to host the pilot project. May 1997: Wali Nizwa (governor) express the willingness of the community to host the pilot project. February 1999: Minister of health decree; appointment of a local project committee headed by Wali. February 1999: Minister of health decree; appointment of a local project committee headed by Wali. April – July 2001: Implementation of the Baseline survey. April – July 2001: Implementation of the Baseline survey.

Milestones of NHLP …(2) March 2002: Presentation of the preliminary survey results. March 2002: Presentation of the preliminary survey results. November 2003: Preparation of the Five years intervention strategic plan completed. November 2003: Preparation of the Five years intervention strategic plan completed. March 2004: Implementation of the intervention started. March 2004: Implementation of the intervention started.

Prevalence of NCDs and common RFs

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

Prevalence of IFG and Hypercholesterolemia in Nizwa and national level

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

Causes of unhealthy dietary habits! Lack of awareness Low availability of healthy choices at: At food stuff stores At restaurants. At schools.

Why people physically inactive? Lack of awareness regarding the of physical activity for health fitness and prevention of diseases Lack of awareness regarding the of physical activity for health fitness and prevention of diseases Social values and traditions regarding physical exercise (women, restriction). Social values and traditions regarding physical exercise (women, restriction). Non-availability public places suitable for physical activity (walking and cycling path, gymnasium). Non-availability public places suitable for physical activity (walking and cycling path, gymnasium). Modernization of life that reduce physical activity (sedentary life, TV, Computers, tel, cars). Modernization of life that reduce physical activity (sedentary life, TV, Computers, tel, cars).

Why 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 shops, even the small ones. Availability of tobacco in most of the shops, even the small ones. Lack of fruitful activities/hobbies for Leisure time. Lack of fruitful activities/hobbies for Leisure time.

Development of the strategic Plan The strategic intervention plan was developed mainly by the MOH in consultation with the other government sectors, CBO and WHO. The strategic intervention plan was developed mainly by the MOH in consultation with the other government 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 Plan Activities for each intervention area were identified, and broad action plan was developed indicating the responsibilities and inputs, process, out puts and outcome indicators. Activities for each intervention area were identified, and broad action plan was developed indicating the responsibilities and inputs, process, out puts and outcome indicators. The strategic plan describe the documentation process, evaluation mechanism, follow up activities..ect. The strategic plan describe the documentation process, evaluation mechanism, follow up activities..ect. It was strategic plan which need operational planning. It was strategic plan which need operational planning.

Objectives…(1) Ultimate goal: The main goal of the project is to improve the health of people in Nizwa by the implementation of a Community based project for primary prevention of non-communicable diseases and healthy lifestyle. The main goal of the project is to improve the health of people in Nizwa by the implementation of a Community based project for primary prevention of non-communicable diseases and healthy lifestyle.

Objectives…(2) Main objectives: To map the emerging epidemics of NCDs and to analyze the social, economic, behavioral and political determinants of the disease. To map the emerging epidemics of NCDs and to analyze the social, economic, behavioral and political determinants of the disease. To reduce the exposure of individuals and populations to the major determinants of NCDs and to prevent the emergence of preventable common risk factors. To reduce the exposure of individuals and populations to the major determinants of NCDs and to prevent the emergence of preventable common risk factors. To strengthen health care for people with NCDS by supporting effective interventions. To strengthen health care for people with NCDS by supporting effective interventions.

Strategies Promotion of development of supportive policies, legislation. Promotion of development of supportive policies, 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 interventions. Development of guidelines/protocols for preventive 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 project WHO NCDC/MOH Local project committee

The implementation of the project was started in March 2004, The activities in the first year was like an advocacy campaign. Thanks for the internet and IHHP

Operational planning From IHHP web site we learn how to prepare the intervention plan. We prepare intervention plan for 2006 based IHHP experience and our strategic plan. From IHHP web site we learn how to prepare the intervention plan. We prepare intervention plan for 2006 based IHHP experience and our strategic plan. BUT the questions was “ how to do it? ” BUT the questions was “ how to do it? ” The answer was in Isfahan 5 th International seminar, thanks to their support to attend that activity. The answer was in Isfahan 5 th International seminar, thanks to their support to attend that activity.

IHHP Lessons Leadership; organization and personal, Leadership; organization and personal, Project design; clear plan, monitoring and evaluation indicators, Project design; clear plan, monitoring and evaluation indicators, Partnership & inter-sectoral collaboration; create ownership Partnership & inter-sectoral collaboration; create ownership Team work; multidisciplinary, committed and motivated, Team work; multidisciplinary, committed and motivated, Strong international co-operation; open opportunities for exchange of experience Strong international co-operation; open opportunities for exchange of experience

NHLP Interventions n Population approach  School Programs (school health, Education)  Community Empowerment (CSG, OWA, Scouts, sport teams,)  Supportive Environment (municipality)  Public Education (CSG, OWA, Scouts, sport teams, Education, PHC,..ect)  RTA prevention and control (Police, NGO) n High-Risk Approach Lifestyle Clinic (NPC, nutrition department) Lifestyle Clinic (NPC, nutrition department) Health professionals education and involvement (NPC) Health professionals education and involvement (NPC) Obesity screening and management at PHC (NPC, nutrition department) Obesity screening and management at PHC (NPC, nutrition department)

Population approach School Programs 1. NHLP Friendly Schools competition: Schools implement activities (Group education, Events and contests) to raise the awareness of children and parents regarding Healthy diet, physical activity, tobacco control and road safety. Schools implement activities (Group education, Events and contests) to raise the awareness of children and parents regarding Healthy diet, physical activity, tobacco control and road safety. The activities evaluated against special criteria by joint NHLP and Education team. The activities evaluated against special criteria by joint NHLP and Education team. Winners schools were selected and appraised in major public event. Winners schools were selected and appraised in major public event.

Population approach School Programs 2. Alharaka Baraka (Move for Health): Programme to promote physical activity among children in Gulf area. For the first time to be implemented in Oman. Programme to promote physical activity among children in Gulf area. For the first time to be implemented in Oman.

Population approach Community 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 health promoters in their local community settings. Training workshops for community members to work as health promoters in their local community settings. Supportive Environment Promotion of establishment of female gymnasium in collaboration with OWA. Promotion of establishment of female gymnasium in collaboration with OWA. Plan to establish walking path Plan to establish walking path Competition between supermarket to made high fiber, low fat, low sugar choices available. Competition between supermarket to made high fiber, low fat, low sugar choices available.

Population approach Public Education Group and direct education; schools, mosques, sablat, majalis and health institutions. Group and direct education; schools, mosques, sablat, majalis and health institutions. Brochures and leaflets. Brochures and leaflets. Events and contests (World health, Heart, DM, Tobacco … ect). Events and contests (World health, Heart, DM, Tobacco … ect). Walkathons. Walkathons. Screenings campaigns (Obesity, BP, DM). Screenings campaigns (Obesity, BP, DM). Street Boards. Street Boards.

High risk approach Lifestyle Clinic Provide Lifestyle Change therapy (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 Health professionals education and involvement Workshops and events (WHD, tobacco day) to sensitize health professionals regarding risk factors assessment and management as a key step for primary prevention of non- communicable disease. Workshops and events (WHD, tobacco day) to sensitize health professionals regarding risk factors assessment and management as a key step for primary prevention of non- communicable disease. Training program for 3 rd year nursing student at Nizwa nursing institute. Training program for 3 rd year nursing student at Nizwa nursing institute.

High risk approach Obesity screening and management at PHC level Objectives Objectives To introduce a program for the detection and management of overweight and obesity in the primary health care system. To introduce a program for the detection and management of overweight and obesity in the primary health care system. To study the prevalence of obesity and overweight in adults >20 years of age who attend the health centers. To study the prevalence of obesity and overweight in adults >20 years of age who attend the health centers. To evaluate the effectiveness of the intervention program. To evaluate the effectiveness of the intervention program. Finalization of the practical guidelines (first of its kind in Oman) Finalization of the practical guidelines (first of its kind in Oman)

Status of implementation…(1)

Status of implementation…(2)

Training and capacity building

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

Research and studies Abdelrahim M Belal, Raha Alsalmi, Zahir Alanqudi, Patterns of Physical activity and levels of inactivity among school children in Willayat Nizwa, Oman, In: School Children and Adolescent Nutrition in Gulf. Arab Center for Nutrition, Bahrain 2006; 1st ed.: Zahir Alanqoudi, Nagi Zaki, Abdelrahim M Belal, Diabetes Care Clinical Outcome in Ad Dakhliya Region, Oman (presented in Gulf Group for study of diabetes). Reports: Evaluation of Nizwa Healthy Lifestyle Project activities, Nutrition Clinic Annual Report and weight management outcome, 2006 Manuscripts: Abdelrahim M Belal, Halima G Alhinai, Community-Based Initiatives for prevention and control of non-communicable diseases: Nizwa Healthy Lifestyle Project planning experience in Oman. Abdelrahim M Belal, Raha Alsalmi, Zahra Alabri, Availability of nutrition choices in schools' food stores and their role in promotion of healthy eating habits.

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

Issues….. Number and capacity of staff (human resources). Number and capacity of staff (human resources). The delay in the starting of the interventions ( )!!!! The delay in the starting of the interventions ( )!!!! No reference area for the project … No reference area for the project … The design and evaluation issue! The design and evaluation issue!