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 Table of Contents  
Year : 2012  |  Volume : 56  |  Issue : 3  |  Page : 180-186  

Health promotion for prevention and control of non-communicable diseases: Unfinished agenda

Secretary General, Indian Public Health Association and Director - Professor (Public Health), All India Institute of Hygiene and Public Health, Kolkata, India

Date of Web Publication3-Dec-2012

Correspondence Address:
Madhumita Dobe
Director - Professor (Public Health), All India Institute of Hygiene and Public Health, Kolkata
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-557X.104199

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The magnitude of Non Communicable diseases demands urgent attention. Common, preventable risk factors underlie most NCDs. These include behavioural risk factors and metabolic risk factors. The prevalence of these, varies between income groups and differs with gender. Majority of events occur in individuals with modest elevations of multiple risks rather than with significant elevation of a single risk factor. The need of the hour is to adopt a process which addresses the upstream determinants through enabling people, to increase control over their health and its determinants, thereby promoting and sustaining good health The answer lies in Health Promotion which involves changing behaviour at multiple levels. In order to change, there is need to understand and apply the models which have been widely used to empower people to make healthy choices. These include the Health Belief, Self-Efficacy, Social Learning and Self-empowerment models.Changing behaviour, however, is a process, not an event. Different strategies are most effective at different Stages of Change. The contextual determinants of health and health behaviouralso significantly influence the risks of NCDs.Till date, there has been limited focus on these issues. We urgently, need aclose look at policies and their impact on health. With increasing burden of NCDs, the Health Sector will face strain on services delivery and budgets. Special policies and programs are necessary for the disadvantaged poor to address their differential vulnerabilities and risks. The unfinished agenda of NCD prevention and control needs to be addressed urgently with an integrated comprehensive framework of Health Promotion

Keywords: Health promotion, Non-communicable diseases, Upstream determinants, Behaviour change models

How to cite this article:
Dobe M. Health promotion for prevention and control of non-communicable diseases: Unfinished agenda. Indian J Public Health 2012;56:180-6

How to cite this URL:
Dobe M. Health promotion for prevention and control of non-communicable diseases: Unfinished agenda. Indian J Public Health [serial online] 2012 [cited 2023 Mar 27];56:180-6. Available from:

   Noncommunicable Diseases Demand Urgent Attention Top

The World Health Organization (WHO) Global Status Report (GSR 2010) on Noncommunicable Diseases (NCDs) 2010 showed that NCDs are the biggest cause of death worldwide. More than 36 million people died from NCDs in 2008, mainly from cardiovascular diseases (48%), cancers (21%), chronic respiratory diseases (12%), and diabetes (3%). More than nine million of these deaths occurred before the age of 60 and could have largely been prevented. Premature deaths from NCDs range from 22% among men to 35% among women in low-income countries.

In India, the situation is very grim. It is estimated that NCDs accounted for 53% of the total mortality and 44% of disability-adjusted life-years (DALYs) lost, in 2005, with projections indicating a rise to 67% of the total mortality by 2030. Cardiovascular disease is the major contributor to this burden and accounts for 52% of NCD-associated mortality and 29% of total mortality.

Notably, in India, NCDs disproportionately impact people at younger ages, causing premature loss of life.

   The Concept of Risk Top

Common, preventable risk factors underlie most NCDs. The risk factors can be categorized as:

Behavioral risk factors

  • Use of tobacco

    Smokers have a markedly increased risk of multiple cancers, particularly lung cancer, and are at a far greater risk for heart disease, stroke, and chronic obstructive pulmonary disease (COPD). People who chew tobacco risk cancers of the lip, tongue, and mouth. Nonsmokers exposed to second-hand smoke have a 25 to 35% increased risk of suffering acute coronary diseases and increased frequency of chronic respiratory conditions.
  • Excessive intake of alcohol

    Excessive use of alcohol causes about 20 to 30% cases each of esophageal cancer, liver disease, and motor vehicle accidents worldwide. The proportion of disease burden attributable to the use of alcohol in the developing world is between 2.6 and 9.8% of the total burden for men and between 0.5 and 2.0% of the total burden for women. Heavy use of alcohol increases the risk of cardiovascular disease and stroke.
  • Lack of physical activity

    Physically inactive persons have a 20 to 30% increased risk of all-cause mortality as compared to those who adhere to 30 minutes of moderately intense physical activity on most days of the week. Globally, physical inactivity accounts for 21.5% of ischemic heart disease, 11% of ischemic stroke, 14% of diabetes, 16% of colon cancer, and 10% of breast cancer. Physical inactivity is a major risk factor for obesity, which itself is a risk factor for other NCDs [Table 1].
  • Unhealthy diet

    Overall, 2.7 million lives would be saved each year worldwide if consumption of fruits and vegetables was increased. Adequate consumption of fruit and vegetables reduces the risk for cardiovascular diseases, stomach cancer, and colorectal cancer.
Table 1: Proportion (%) of population inactive in various domains

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Metabolic Risk Factors

  • Obesity

    Twenty percent of India's population is overweight and 4% is obese. Risks of coronary heart disease, ischemic stroke, and type 2 diabetes mellitus increase with increasing body mass index (BMI). A raised BMI also increases the risks of cancer of the breast, colon, prostate, endometrium, kidney, and gall bladder. Waist circumference serves as a proxy indicator of intra-abdominal fat mass and total body fat. Waist circumference or waist-to-hip ratio is a more powerful determinant of a subsequent risk for type 2 diabetes than BMI [Table 2]. A large number of obese and overweight Indians are based in states with a high literacy and high per capita income, with Punjab, Kerala, and Delhi, topping the list. Urban India also comes up short in the consumption of fiber-rich food. High-income groups derive 32% of their energy intake from fats alone. As an outcome of increasing cultural liberalism, 64% Indians now eat nonvegetarian food compared to 40% in the early 1990s. Cultural liberalism leading to an increase in nonvegetarian diet and the proliferation of fast food outlets are definitely contributing to obesity and subsequent diabetes.
  • Hypertension

    Raised blood pressure is a major risk factor for coronary heart disease and stroke. The risk of cardiovascular disease doubles for each increment of 20/10 mmHg of blood pressure, starting as low as 115/75.
  • Dyslipidemia

    A raised level of total cholesterol is also a major cause of ischemic heart disease and stroke. A 10% reduction in serum cholesterol in men aged 40 years results in a 50% reduction in heart disease and a 20% reduction in heart disease occurs in men aged 70 years within five years. A 4.6% reduction in the population mean of total cholesterol level had the greatest impact of all risk factors in decreasing the coronary heart disease mortality in Ireland; a full 30% reduction in mortality was attributable to this reduction alone.
  • Impaired glucose tolerance
    Table 2: Mean body mass index (BMI) and waist circumference

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    The age-adjusted mortality, mostly due to coronary heart disease, is two to four times higher in diabetics in comparison with the nondiabetic population. People with diabetes have a two-fold increased risk for stroke.

The overall picture of risk factors for mortality is raised blood pressure (responsible for 13% of deaths globally), followed by the use of tobacco (9%), raised blood glucose (6%), physical inactivity (6%), and overweight and obesity (5%). The prevalence of these risk factors varies between income groups and differs with gender.

It is however, important to note that 'risk' operates across a continuum, not thresholds. More events occur from the body of the distribution of risk factors rather than from the upper tail. Risk is multiplicative, when risk factors coexist and cluster together as is often the case. The majority of events occur in individuals with modest elevations of multiple behavioral and metabolic risks rather than with significant elevation of a single risk factor.

The need of the hour is to adopt a process which addresses not only individual unhealthy behavior but also the upstream determinants/cause of causes through enabling people, individually and collectively to increase control over their health and its determinants, and thereby promote and sustain good health. Promotion of health relies strongly on mediation and advocacy for these 'enabling environments' , which are very much essential for the prevention and control of NCDs.

A look at the stages of the disease continuum replicated below identifies the different levels in which approaches to health promotion can be applied [Figure 1].
Figure 1: Health promotion in different level of prevention

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Prime attention has been and still needs to be given to universal and targeted approaches of health education for the promotion of healthy behaviors and environments throughout the course of life, particularly for the prevention and modification of risk behavior.

   Promotion of Health Means Change in Behavior at Multiple Levels Top

To change behavior, however, there is need to understand and apply the models which have been widely used to predict health behavior. However, people have limited knowledge about which behaviors are health threatening and how these behaviors develop as these health-threatening behaviors start developing at a time when there is little immediate incentive to practice health-enhancing behaviors, for example, effects of smoking are felt in later life rather than when people start smoking.

Approaches to behavior change aim to bring about changes in individual behavior through changes in cognitions of individuals through provision of information about health risks and hazards, assuming that humans are rational decision makers whose cognitions inform their actions.

One approach which is used commonly in this regard is based on the health belief model (HBM). The HBM has been applied to a wide range of health behaviors including risk behaviors (e.g., use of seatbelts, healthy diets, etc.).

Let us consider how the issue of smoking can be dealt with by the HBM.

Smokers deciding whether to give up smoking would be expected to consider:

  • How susceptible they are to lung cancer and other smoking-related conditions.
  • How serious these conditions are.
  • The extent and value of the benefits of giving up smoking.
  • The potential negative consequences of giving up smoking.

In addition, there exists the role of cues to action, internal (e.g., a symptom such as a smoker's cough) and external (e.g., information, advice, or meeting someone with lung cancer), as well as motivation, and the importance of health to the individual.

Each key variable of the HBM tends to be significantly correlated with the particular behavior under study. A literature review of all HBM studies published from 1974 to 1984 identified, across study designs and populations, perceived barriers as the most influential variable for predicting and explaining health-related behaviors, for example, cultural norms and lack of information regarding the harmful effects of tobacco are perceived barriers for quitting use of tobacco and perceived severity has been identified as the least significant variable [Figure 2].
Figure 2: Health Belief Model

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More recently, though, researchers are suggesting that an individual's 'self-efficacy', that is, the perceived ability to successfully carry out a 'healthy behavior' such as quitting tobacco greatly influences his/her decision and ability to enact and sustain a changed behavior. There is evidence that most people want to quit when informed of the health risks but support/cessation services are very scarce and self-efficacy becomes low.

Interaction of individual factors, social environment, and experience-social learning-is also influential in shaping behavior. If we consider the spread for a traditional Indian marriage reception, the amount of visible and invisible saturated fat and sweets in the repast is surely unhealthy. The theory of reasoned action and its revised version, the theory of planned behavior proposes that behavior is formed by attitudes as well as subjective norms about the behavior, that is, what significant others think one should do. Our choice of food in such social functions is determined similarly by what significant others do and what they think one should do, despite awareness about the unhealthiness of the food served.

Attitudes and subjective norms are based upon beliefs held by the individual. So, the belief that friends and relatives would not approve of a menu in a marriage reception without these items are thought to generate a negative attitude, as well as social pressure, thus giving rise to the intention to serve unhealthy food. Unfortunately, correlations between the intention to behave and actual behavior are not perfect. They tend to range between 0.45 and 0.62.

To help individuals act upon their intentions to adopt healthy behaviors, the 'self-empowerment' approach can be used to empower people to make healthy choices by examining their own values and beliefs and explore the extent to which socialization and social location affect the choices they make. Self-empowerment is particularly popular for young people, as peer pressure has been identified as a powerful obstacle to the adoption of healthy practices by young people.

Success of population-based interventions by addressing multiple risk factors common to most NCDs through lifestyle-linked community programs have been demonstrated in developed and developing countries. Changing behavior, however, is a process, not an event. At any given point of time, individuals are at different levels of change through which they pass, when change occurs. The stages are:

  1. Precontempation (not ready to change)
  2. Contemplation (thinking of changing)
  3. Preparation (ready to change): Individuals are suitable for action-oriented programs, for example, smoking cessation, weight loss, or exercise programs.
  4. Action (making change): At this stage, measures should be taken against relapse.
  5. Maintenance (staying on track): Here, the focus is on ongoing, active work to maintain changes made and prevention of relapse.
  6. Relapse: Falling back to the old behaviors after going through other stages.

This 'Stages of Change' model has been applied to a wide variety of unhealthy behaviors like smoking cessation, exercise, low fat diet, alcohol abuse, weight control, and so on.

Different strategies are most effective at different stages of change. Hence, interventions must be geared to the level of change. Tailoring matters, and programs that are tailored have been proved to do better.

   Beyond Individual Knowledge, Attitudes and Behavior, The Contextual Determinants of Health and Health Behavior Have a Significant Influence on Risks of NCDs. Top

Change in 'consumer tastes' observable in India can be attributed to the growing emulation of the consumption patterns of affluent groups, exposure to new food items, influence of advertisement, and rising numbers of nuclear families with both spouses working. More money has meant spending more on food, especially processed and packaged foods which are aggressively marketed. In short, our booming economy has caused our waistlines to expand proportionately.

Some studies have noted the decline of a range of traditional foodstuffs in various parts of rural India, such as the growing scarcity of some vegetables due to recent changes in cropping patterns, the reduced availability of fish in rice fields due to the use of pesticides, and deprivation of forest products or common property resources due to environmental degradation. All this could have an adverse impact on food intake and nutritional status.

A significant proportion of global marketing is now targeted at children in developing economies and is a key contributor to unhealthy behavior.

Recognizing the close relationship between individual health and its social and material contexts, collective action is imperative toward improving health care by addressing socioeconomic and environmental causes of ill health. For example, in a German city, the community group identified weight as a health-care problem in the community and decided to approach butchers in the city with the request to develop a new low-fat sausage. Research into the impact of poor housing on health found that levels of mould in the air had a direct and independent effect upon the health of children living in the dwellings. The findings of this study were used to campaign for changes in housing conditions.

In the United Kingdom and the United States of America, processed foods and fast, takeaway foods have been found to be the main dietary sources of excess salt, saturated fats, trans fats, and excess calories. In 2001, the Food Standards Agency (FSA) of the United Kingdom began working with the industry to develop a range of healthy food strategies including voluntary product reformulation, clearer (traffic light) package labeling of nutrient levels, and media campaigns. The salt strategy of the FSA helped reduce the average daily salt intake by nearly 1 g between 2001 and 2008 (from 9.5 to 8.6 g, respectively). However, outside the United Kingdom, stricter regulatory policies have resulted in much greater reductions, for example, between 1979 and 2002, the daily average salt intake of Finland fell from 12 to 9 g.

Till date, there has been limited focus on health promotion for the prevention of NCDs in India. Despite the vast body of evidence, not enough has been done for policy development and action. What we need urgently is therefore a close look at policies and their impact on health, for example, food production, pricing, labeling, and marketing policies. Evidence-based healthy public policy formulation is the answer to these challenges, for example, a conducive transport policy which favors urban cycle lanes and curbs vehicular transport as well as provides facilities for leisure time exercise in community playgrounds, substitution of less energy-dense foods containing high salt and trans fats with more nutritious products by retail outlets, and so on.

Causal risk factors for NCDs are deeply entangled in the social and cultural framework, and there is thus a need to focus on controlling them in an integrated manner. An integrated, comprehensive NCD prevention program in line with the framework of health promotion action needs to be planned, implemented, monitored, and evaluated.

Schools, workplaces, hospitals, and other settings where people live, work, and play can be specially utilized to promote healthy lifestyles through empowerment and motivation for collective action. These will also serve as demonstration projects for emulation and scaling up.

A look at the NCD capacity profile of selected indicators by country, reproduced below, in the Southeast Asia region reveals the poor status of India [Table 3]:

Though NCD epidemics usually originate in the upper socioeconomic strata, they diffuse across the social spectrum, with the social gradient ultimately reversing and the poor becoming predominantly afflicted. Indeed, in the more mature stages of these epidemics, the poor are often the worst afflicted in terms of disease and usually the most marginalized in terms of care. The differential risks and vulnerabilities of the poor are a cause for special concern. The poor are more exposed to risk factors for NCDs, for example, smoking, poor diet, and harmful use of alcohol. They are born with greater vulnerability. They are at risk from within the intrauterine environment, compounding over the life course, and do much less well in terms of acute and long-term health-associated outcomes. There is evidence that people from disadvantaged backgrounds are less successful in achieving behavior change following participation in formal programs such as smokers' clinics. They begin with a lower chance of success because of their starting levels of behavior, and physical and/or social environments which undermine attempts at change. It has been found that significantly more poor are likely to fail to quit smoking compared to smokers in higher socioeconomic groups. Special policies and programs are thus necessary for the disadvantaged poor to address their differential vulnerabilities and risks.
Table 3: Countries in Southeast Asia region according to NCD capacity profile

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With an increasing burden of NCDs, the health-care sector will face a strain on delivery of services and stress budgets, for example, people with diabetes require at least two to three times the health-care resources than people who do not have diabetes; diabetes care accounts for up to 15% of national health-care budgets. If the incidence of sickness can be reduced by the promotion of health, the cost of present services will go down, or at least the rate of increase will diminish. Programs and services need to be urgently reoriented toward efficiently tackling prevention and control of NCDs along with retooling the infrastructure of the health-care system. To face the challenge of NCDs, health-care workforce will also need training and new skills.

The unfinished agenda of the prevention and control of NCDs needs to be addressed urgently with an integrated comprehensive framework of health promotion.[17]

   References Top

1.World Health Organization Noncommunicable Diseases Country Profiles 2011.   Back to cited text no. 1
2.World Health Organization. Global Status Report on Alcohol 2004. Geneva, 2004. Available from: [Last accessed on 2012 Jan 16].  Back to cited text no. 2
3.Rehm J, Room R, Monteiro M, Gmel G, Graham K, Rehn N, et al. Alcohol. In: Ezzati M, Alan D Lopez, Anthony Rogger and Aristopher J.L. Murray, editors. Comparative quantification of health risks: Global and regional burden of disease due to selected major risk factors. Geneva: World Health Organization; 2004.  Back to cited text no. 3
4.Bandura A. Self-efficacy mechanism in physiological activation and health-promoting behavior. In: Madden J IV, editor. Neurobiology of learning, emotion and affect. New York: Raven; 1991a. p. 229-70.  Back to cited text no. 4
5.Janz NK, Becker MH. The Health Belief Model: a decade later. Health Educ Q 1984 Spring;11:1-47.  Back to cited text no. 5
6.Ajzen I, Fishbein M. Attitudinal and normative variables as predictors of specific behavior. J Pers Soc Psychol 1973;27:41-57.   Back to cited text no. 6
7.Fishbein M, Ajzen I. Belief, attitude, intention, and behavior: An introduction to theory and research. Reading, Mass.; Don Mills, Ontario: Addison-Wesley Pub. Co.; 1975.  Back to cited text no. 7
8.Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: Application to addictive behaviors. Am Psychol 1992;47:1102-14.  Back to cited text no. 8
9.Noar SM, Benac CN, Harris MS. Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions. Psychol Bull 2007;4:673-93.  Back to cited text no. 9
10.Velicer WF, Prochaska JO, Fava JL, Norman GJ, Redding CA. Smoking cessation and stress management: Applications of the transtheoretical model of behavior change. Homeostasis 1998;38:216-33.  Back to cited text no. 10
11.Prochaska JO and DiClemente CC. The Transtheoretical Approach: Towards a Systematic Eclectic Framework. Dow Jones Irwin, Homewood, IL, USA 1984.  Back to cited text no. 11
12.Vartiainen E, Puska P, Pekkanen J, Tuomilehto J, Jousilahti P. Changes in risk factors explain changes in mortality from ischemic heart disease in Finland. Br Med J 1994;309:23-7.  Back to cited text no. 12
13.O Flaherty M, Flores-Mateo G, Nnoaham K, Lloyd-Williams F, Capewell S. Potential cardiovascular mortality reductions with stricter food policies in the United Kingdom of Great Britain and Northern Ireland. Bull World Health Organ 2012;90:522-31.   Back to cited text no. 13
14.Kristal AR, Shattuck AL, Henry HJ. Patterns of dietary behavior associated with selecting diets low in fat: Reliability and validity of behavioral approach to dietary assessment. J Am Diet Assoc 1990;90:214-20.  Back to cited text no. 14
15.Hunt S. Damp and mouldy housing: A holistic approach. In: Burridge R, Ormandy D, editors. Unhealthy Housing: Research, Remedies and Reform. New York, NY: Spon Press; 1993. p. 67-93.  Back to cited text no. 15
16.Michie S, Jochelson K, Markham WA, Bridle C. Low-income groups and behaviour change interventions: A review of intervention content, effectiveness and theoretical frameworks. J Epidemiol Community Health 2009;63: 610-22.   Back to cited text no. 16
17.Reddy KS. Prevention and control of non-communicable diseases: status and strategies July, 2003 Working paper no. 104. Indian Council for Research on International Economic Relations.  Back to cited text no. 17


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]

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