1. No category

A clustered quasi-experimental health promotion study in China’s rural areas
Xiangyang Tian, MD, M.M.Sc;1 Liping Yan, PhD;1* Genming Zhao, MD;2 Liang Wang, MD, DrPH, MPH;3 Yulan Cheng, MPH; 1 Yong Lu,
MPH 1
1 Chinese Center for Health Education, Beijing, China 100011
2 School of Public Health, Fudan University, Shanghai, China 200032
3 Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, Tennessee
37209-1561
* Joint first author.
Correspondence to: Xiangyang Tian, MD, M.M.Sc
Chinese Center for Health Education, Building 12, Block 1st, Anhua Xili, Chaoyang District, Beijing China 100011, Email: [email protected],
Tel: +86 10 6426 3018
1
Abstract
Background: There is an urgent need to develop effective strategies for health improvement in China rural population with lower health status.
Methods: A total of 36 rural villages were randomly selected from three provinces with 18 villages in the intervention group and 18 as control.
A clustered quasi-experimental trial had been conducted using health promotion strategies for two years. Data on two-week morbidity and
lifestyles were collected before and after the intervention respectively, to estimate the effectiveness by comparing the intervention and control
groups.
2
Results: All intervention villages had developed healthy policies addressed prioritized health issues. After the intervention, the two-week
morbidity rate decreased to 13.4% from 18.5% (P=0.009), and the incidence of diarrhea decreased to 9.5% from 13.0% (P=0.038). The
knowledge of Hepatitis B and rabies, risk factors of hypertension and diabetes, and the practice of hand washing and food processing safety were
improved for both of the intervention and control villages (P<0.05).
Conclusions: The implementation of holistic health promotion strategies improved the health status, and assisted the rural communities to be
informed and make sensible decisions to protect their own health.
Key words: Quasi-experimental study, rural population, health promotion.
3
INTRODUCTION AND BACKGROUND
Health promotion is a process of empowering individuals and communities to take action and exert control over the determinants of health
by way of participation and partnership (WHO, 1986; Gillies, 1997). Health promotion devotes to improving health through efforts on areas of
healthy public policy, supportive environment, community action, personal skills, and re-orientation of health care services by implementation of
strategies of empowerment, mediation and advocacy (Epp, 1986). Hundreds of health promotion programs have been developed in the rural
areas since 1970s globally, and obtained significant effects in tackling rural health problems including environment risk factors reduction, health
behavior improvement, and disease prevention (Puska, 1998; Vartimnen et al., 1994; Sandy, 1997; Roberts, 1997).
As an extension of Healthy Cities project which is advocated by WHO, dozens of healthy village programs had been initiated since 1980s
over the world, especially in the developing countries(Kenzer, 2000; Harpham et al., 2001; Khosh-Chashm, 1995.), using health promotion
strategies in combination(Howard et al., 2002; WHO, 2014). These projects were considered successful in disease prevention, improvement of
health accessibility and infrastructure, hygienic condition, healthy lifestyles and social status(Kumpusalo et al., 1991, 1996; Johnson et al., 1993;
WHO, 2007; Allahyari et al., 2010; Kiyu et al., 2006; Staykova, 2006; ).
4
Overall, 54.3% of Chinese population lives in the rural areas (NBS, 2009). Compared to the urban residents, the health status of their rural
counterparts, especially in the central and western regions of China, is still under a lower level with inadequate health infrastructure and
facilities(Tao, 2009; Wei et al., 2001; Yao et al., 2009), healthcare service providing, and health human resources. The rural residents have a
double burden of infectious and non-communicable chronic diseases(Chen et al, 2010; Liang et al., 2005; Wang, 2012), higher mortality rate for
children under 5 years(NHFPC, 2012), lower health awareness, and poor healthy lifestyles(MOH, 2009; XXX;). These problems have a serious
impact on the rural residents’ health, quality of life, and sustainable socio-economic development, and there is an urgent need to develop
effective strategies for health improvement in the rural population.
A dozen of rural health education and promotion studies have been conducted in China’s rural areas so far. However, most of the studies
only used the methods and strategies of health communication with reports in health related knowledge and behavioral changes, and few used
holistic strategies of health promotion and epidemiological method of quasi-experiment, and reported changes of health status, healthy policy
development, and environment improvement(Li et al., 2006; Hu and Fan, 2007; Shen et al., 2007; Pan et al., 2007; Gong et al., 2010; Zhu et al.,
2004; Li et al., 2005; He and Huang, 2010; Huang et al., 2008; Ma et al., 2000; Wang et al., 2007; Hou and Hou, 1999). From 2010 to 2012, we
conducted a health promotion project in the rural areas of China’s three provinces using a quasi-experimental method, and this paper reported
5
and discussed the outcome of the two-year health promotion intervention campaign.
METHODS
Study design
This study was quasi-experimentally designed(DiNardo, 2008). 36 villages were randomly selected from provinces of Jiangsu, Henan and
Shaanxi in representing China’s Eastern, Central and Western regions, geographically, and socio-economic development levels of optimistic,
average and low, respectively, with 18 villages being as the intervention group and the other 18 as the control. Health promotion strategies such
as capacity building, partnership, community participation, advocacy, empowerment, skills development, health supportive policies development,
and environment improvement were implemented in the 18 intervention villages and only spread health communication materials in the control
villages. Community diagnoses were undertaken in both intervention and control villages to collect baseline data. After two years, a similar
procedure was performed to collect the post-intervention data and estimate the effectiveness of intervention by comparing the data between preand post-intervention, and between intervention and control villages, respectively.
Study population and sampling
6
A three-staged stratified cluster sampling method was utilized to select the study villages. Firstly, one county was selected from each of the
three provinces, representing the average level of the provincial socio-economic development. Secondly, in each selected county, three towns
were sampled representing optimistic, average and lower levels of local socio-economic development, respectively. Thirdly, from each selected
town, four villages were extracted at random using systematic sampling methods, and two villages were chosen randomly as the intervention
group with the other 2 villages as control. In total, 18 villages were thus assigned to the intervention group while the remaining 18 villages
served as the controls (Table 1). All villagers of the 18 intervention villages were taken as target population.
INTERVENTIONS
Social mobilization
An initiating meeting was held with the participants from the Chinese Ministry of Agriculture, Environment Protection and Health, Chinese
Center for Disease Control and Prevention (CDC), and province and county level related organizations. The participants discussed and reviewed
the research plan, methods of baseline survey and community diagnoses, and intervention strategies.
As a key strategy of health promotion, cross-sectoral collaboration and partnership were formed among the grassroots organizations
including county and township level government departments of agriculture, education, health, broadcasting, movie and TV administration,
7
county CDC, hospitals, and township health centers. The leaders of these organizations, the chairmen of intervention village board, health
workers of village clinics and villager representatives (always key informants or opinion leaders) were organized to an initiating workshop. After
the initiation workshop, training sessions were arranged on basic knowledge of health, environment sanitation, healthy lifestyles and disease
prevention. Separate interviews were conducted to chairmen of villager’s board, health workers and villager’s representatives of each
intervention village to communicate the study plan specifically.
Capacity building and training
A tailored three-tiered capacity building approach was employed in terms of the study needs and needed skills of different participants of
provincial, county and village level. Totally, 28 leaders of government departments, health workers and representatives on the county level, 200
leaders and health workers from township health centers and village clinics, and the chairmen of the intervention villages were trained by
lectures, workshops and face-to-face interviews.
A guiding book of rural health education and promotion was developed and delivered to the leaders of the intervention villages for
reference. Based on the principles of empowerment, the contents of the guiding book were purposely designed to strengthen and promote the
recognition of significance, knowledge, and skills of health promotion, and fostering of the villager’s health-related values and health behaviors.
8
Healthy policies development
Based on the prioritization of major health problems and risk factors by the intervention villages, healthy policies were firstly proposed by
the villager’s board, and then a general assembly with participation of most villagers was convened to discuss the feasibility, implementation,
and enforcement. Policies adopted by the village general assembly would be validated and publicized by the villager’s board. All intervention
villages were encouraged to institutionalize the development procedure to be a sustainable mechanism.
Clean-up Day
The environmental hygienic conditions were assessed and mapped with the help of county health inspectors. All intervention villages were
motivated to clean up the public places and household spaces periodically, and to beautify household garden. A monthly “clean-up day” was
advocated and established by the villager’s board, and on the day, at least one member of each family was required to join the cleaning activities.
According to the related standards made by the Chinese Ministry of Health (MOH)(MOH, 2003), all household and livestock excreta were
required to be disposed harmlessly before drainage or being utilized as fertilizer for farmland. Household living wastes were required to be
classified and collected daily by special cleaning team and treated collectively at the government-designated sites. Recommendations for sanitary
conditions improvement of household kitchen and toilet were also given by professionals from county CDC in terms of the standards made by
the NHFPC(NHFPC, 2013).
9
Health education and behavioral intervention
Health Belief Model (HBM) (Janz and Becker, 1984) was applied in the health education campaign development. And according to the
factors affecting health behavioral change recommended by HBM, the severity and susceptibility of the health problems in the intervention
villages such as eating before washing hands, open defecation, and smoking, were reiterated, and the villagers were supported to identify the
barriers to practice health-promoting behaviors. Peer education, volunteerism, and family members support were encouraged.
In consideration of the subjective needs of the local people, major health problems, and outcomes of community diagnoses, professionals
from county CDC, health education institutes, hospitals, and maternal and children’s health institutes were invited to give health lectures in the
intervention villages (Table 1).
All villagers aged 35 years or older were screened for hypertension and diabetes by village clinics, and all patients with non-communicable
diseases (NCDs) were registered, treated properly and followed. Villagers with high risk factors such as overweight/obesity, cigarette smoking
or sedentary life-styles were interviewed at least once every three month by health workers of village clinics, and recommendations were given.
Health communication activities
10
In view of the Diffusion of Innovation Theory (Rogers and Everett, 1983), firstly, inner-village wired broadcasting, booklets, pictorials,
posters and slogans were used to communicate health messages (Table 1) to increase the coverage of health communication and raise the health
awareness of the villagers on health issues. Then, the health workers of village clinics were invited to give home visit and family health
proposals. The intervention villagers were organized and encouraged to join participatory health and recreational activities such as fitness
gymnastics, singing group, calligraphy, chess competitions, Taiji exercises, and basketball teams. Members of grassroots women’s federation,
retired health workers, and elder villagers as opinion leaders were mobilized to form volunteer groups to supervise environment sanitation,
garbage disposal and health practice of the villagers.
EVALATION
Community diagnoses and baseline survey
Before intervention, both intervention and control villages were investigated to collect the data of the socio-economic development,
environment, health status, health welfare, health infrastructure, facilities and services, and behavioral risk factors as the baseline. Villager’s
health needs and status quo of existing health education and promotion programs were also investigated and reviewed by key informant
interview and outpatient file retrieval of the village health clinics.
11
Household and family member survey with questionnaire
A total of 10 families were sampled at random from each of 36 villages using a systematic sampling method. From each of the sampled
family, one family member was selected as a representative to complete the household survey using pre-constructed questionnaire, which
included questions of household socio-economic status, environment health condition, and utilization of health services. All the family members
aged 12 years or older were selected to be interviewed separately by researchers to complete another questionnaire to collect the information of
personal social-demographic characteristics, two-week morbidity, incidence of clinically diagnosed diarrhea, health knowledge, health behavior
and life-styles. At least 35 villagers were required to be surveyed from each village.
Final research
After the 2-year’s intervention, a similar method and procedure which was used in the baseline survey was taken to conduct the final
research, and to estimate the impact of intervention by comparing the data collected from the baseline and final investigation respectively. The
comparisons were completed horizontally between intervention and control villages, and vertically between the baseline and final survey.
Statistical methods
All quantitative data obtained were coded and recorded using Excel, and statistical analysis was performed using SAS 8.1 (SAS Institute,
12
Cary, NC, USA). Chi-square test was conducted for the rates, and t-tests and one-way ANOVA analysis were conducted for means comparison
at a 0.05 significant level of alpha. Qualitative data was gathered from personal interviews, document reviews, and on-site observations.
Ethical Consideration
This study was approved by the Ethical Committee of Chinese Center for Health Education. Informed consent was obtained from the
leaders of three selected counties and chairmen of villager’s boards of the 18 intervention groups. Oral and written consent was obtained from all
sampled respondents before administering the questionnaire or interview. Confidentiality assurance was indicated on the questionnaire or before
the interview.
RESULTS
Profile of the study villages and socio-economic status (SES) of the selected households
At baseline, no significant differences were found between the intervention and control villages in average area, population size, proportion
of residents aged 60 years or older, annual income per capita, and service population of every village clinic (Table 2). Key informant interviews
revealed that no intensified health education and communication programs had been implemented in the 36 villages during the past two years.
13
In total, 196 and 205 households were sampled from the intervention and control villages at baseline, respectively. There was no statistically
significant difference in average family size (number of family members), medical expenditure, proportion of households being assisted with
minimum living guarantee, New Rural Cooperative Medical System usage, centralized water supply coverage, and sanitary latrine usage
between the intervention and control villages (P>0.05) except for the proportion of collective garbage disposal (65.8% vs. 48.8%, P<0.01) (Table
2).
Healthy policies developed by the intervention villages
All the intervention villages developed and implemented health policies on captivity raised livestock, designated disposal of garbage, no
littering in the public places, and villager’s duty of public places cleaning. 17 villages made the policies of financial support for the families with
lower income than the average, 12 villages implemented the smoke-free policies in public places, and 10 villages promulgated the policy of
drinking water protection.
Self-reported health status
The self-reported clinically diagnosed 2-week morbidity rate of the intervention and control population at baseline was 18.5% and 12.0%,
14
respectively. After the intervention, the rate was significantly decreased to 13.4% for the intervention group (P=0.009), and there was no
significant change for the control group. The incidence of clinically diagnosed diarrhea in the past year among the intervention group was 13.0%
at baseline and dropped to 9.5% at the final research (P=0.038), while there was no significant change found for the control villages (Table 3).
Health knowledge
Table 3 shows that 27.5% of the intervention respondents could identify all the three transmission ways of Hepatitis B virus correctly at
baseline and the proportion increased to 34.4% (P<0.05) after the intervention. The proportion of those who could identify all the possible
transmission ways of rabies increased among the intervention population (12.0% vs. 24.6%, P<0.0001) but there was no significant change
between the baseline and final survey among the control population. After intervention, although statistically significant increase was found in
the health knowledge of correct treatment of dog bites, identification of standard of normal blood tension value and recommended upper limit of
daily sodium intake for both of the intervention and control populations, all the increase ranges of changes of the three indicators for the
intervention group were larger than that of the control group.
Health behavior and lifestyles
15
Among both intervention and control groups, the proportion of hand washing before eating and correct chopping board use increased
significantly (all P<0.01). Additionally, the proportion of physical exercise less than 2 times per week and alcohol drinking at least 3 times per
week decreased at the final survey for both the intervention and control villages ( P<0.05). However, the ranges of all above changes for the
intervention group were larger than that for the control except for the proportion of those who do physical exercise less than 2 times per week.
Although it was quite low, the female current smoking rate of the control villagers had increased by 8.4 times at the final research (Table 3).
DISCUSSIONS
This study implemented interventions in randomly sampled rural villages of China’s three provinces, using a quasi-experimental method and
a holistic approach of health promotion, addressing health issues of the rural population, by way of policy development, empowerment, capacity
building, cross-sectoral partnership, community participation, social mobilization, and health communication. The results indicated, after 2 years
intervention, a variety of health policies had been developed in the intervention villages involving diverse health-related subjects prioritized by
the villagers, and the 2-week morbidity rate and prevalence of diagnosed diarrhea of the intervention population decreased significantly. After
intervention, although most of the health knowledge and behaviors were significantly improved for both of the intervention and control group,
16
most of the ranges of changes for the intervention group were better than that for the control group.
Many studies reported that health education and promotion interventions aimed at improving personal hygiene and environment sanitation
were proved to be effective in reducing respiratory and gastrointestinal infections, including diarrhea (Rabie and Curtis, 2006; Curtis and
Cairncross, 2003; Borghi et al., 2002; Madhu and Beinum, 2012;). In the current study, the hand washing behavior of the intervention
respondents was improved, and the diarrhea incidence of the intervention villagers declined, though some studies found no significant difference
in the diarrhea incidence between intervention and control communities while notable hand washing behavioral change had been seen (Haggerty
et al., 1994; Luby et al., 2004). To evaluate the short-term effectiveness of the rural health education and promotion, incidence of diarrhea might
be a sensitive and proper indicator besides the health knowledge and behavior.
Trainings were taken as an efficient way of capacity building for the community leaders and health workers in identifying and prioritizing
health needs, solving health problems, and managing potential environmental risk factors（Evans and Dowling, 2002; Andrus and Bennett, 2006;
Perez et al., 2006; Flowers and Waddell, 2004）. As an important component of intervention, capacity building played a key role in the current
study in fostering local government and intervention villagers’ awareness, motivation, self-efficacy and capacity to deal positively and
17
effectively with health related issues.
As formed to benefit from the synergy of working together to achieve a shared objective (Sindall, 1997), collaborative partnerships have
been increasingly recognized as an essential strategy of health promotion, and played an important role in community intervention (WHO, 1997;
Armstrong et al., 2006; Roussos and Fawcett, 2000; Sanchez et al., 2005; Khandekar et al., 2006). In the present study, a variety of non-health
sectors were mobilized and involved in resource pooling and service providing. All of the three study counties established a coordinating group
teamed by the leaders of government bureaus, township organizations, and intervention villages. They strived for policy support, resource
allocation to intervention villages, and implementing community mobilization. Local health professionals and workers were invited to form
working teams to provide training and technical support and to carry out environmental health monitoring, water and sanitation improving, and
health communication activities. The cross-sectoral cooperation mechanism could be a generalizable prototype for Chinese rural health
education and promotion.
The Organic Law of the Villagers Committee, which was promulgated in China in 1998, ruled that the villager’s board member should be
responsible for management of public affairs, social security, dispute mediation, public health and family planning, and that all villagers should
18
directly elect the chairman and vice-chairman of the board (SCNPC, 1998). The informed chairmen of the villager’s board are the key persons in
implementing health intervention strategies, mobilizing villagers, and coordinating resources. The interventions of this study involved all the
villager’s board members in the collaborative action (Pearson et al., 2001), and the village chairmen were taken as not only the intervention
target population but also the facilitators and partners throughout the study.
This study adopted a non-prescriptive approach as guiding principle to motivate, inform, and empower the villagers and rural communities
to make sensible decisions within their own contexts to protect their health (Rotem et al., 1994), and to facilitate the emergence of effective
processes for making improvements in village health conditions. Almost all intervention villages had formed a mechanism of healthy policy
development, and a series of healthy policies had been made based on their own process. This would be especially significant for the solid basis
it laid for sustainability.
HBM (Janz and Becker, 1984) and Diffusion of Innovation Theory (Rogers and Everett, 1983) were applied throughout all the intervention
campaigns, and all key messages were refined to be simple, practicable, and culturally appropriate. As we all know, although it's rather difficult
to alter the long-standing habits of the rural people, we found that the application of the HBM not only raised the awareness of health but also
19
inspired the self-efficacy of intervention villagers to enhance better health-related practices. During the intervention, the volunteers played an
important role in modeling health concepts, persuading adoption of healthy life-styles, and facilitating health skills, being as the early adopter,
medium, and catalyst. Additionally, the unexplainable increase of the female current smoking of the control villages might be due to the
Hawthorne effect (McCarney et al., 2007; Fox et al., 2008).
LIMITATIONS
Firstly, contamination may occur due to the occasional interaction between the intervention and control villages through opportunities of
social mixing, local cultural happenings, travel or migration, direct participation of residents from control villages in health communication and
education activities, township fairs, and other social events. Furthermore, the leaders of the villager’s board of the control villages could develop
health education and communication activities by themselves due to possible learning the benefits gained in the intervention villages. The
effectiveness of intervention might have been neutralized and underestimated by this contamination (Hayes and Moulton, 2009). Contrary to this,
however, the Hawthorne effect (McCarney et al., 2007; Fox et al., 2008) could have exaggerated the response of the villagers and positive
outcomes of intervention, for that the intervention villages had not experienced such in-depth interventions before this study, and most of the
20
villagers expressed strong interests. Thirdly, the intervention duration was too short for having lasted for only two years, hence, the showed
effects should be accepted in caution. Finally, the epidemiological historical context factors, such as county TV station’s broadcasting of health
related programs during the intervention period, could not be excluded, and this might have led to the effectiveness overestimation.
CONCLUSIONS
In summary, the two-year’s health promotion interventions in China’s rural areas assisted and facilitated rural communities to be informed,
and to make sensible decisions within their own contexts to protect their own health. The health status and healthy lifestyles of the rural
population were improved significantly, and healthy policies and sustainable development mechanisms were formed for diverse health problems
prioritized by the rural residents. The findings and experiences of this study might be referred and spread across China for health improvement
policy making and planning for the rural populations.
21
REFERENCES
1. Allahyari MS, Alipour H, Chbok RG. (2010) Healthy village cooperative: An approach towards rural development. Scientific Research and Essays, 5 (19):
2867–2874.
2. Armstrong R, Doyle J, Lamb C, Waters E. (2006) Multi-sectoral health promotion and public health: the role of evidence. J Public Health (Oxf), 28(2):
168–172.
3. Andrus NC, Bennett NM. (2006) Developing an interdisciplinary, community based education program for health professionals students: the Rochester
experience. Acad Med., 81(4): 326–331.
4. Borghi J, Guinness L, Ouedraogo J, Curtis V. (2002) Is hygiene promotion cost-effective? A case study in Burkina Faso. Trop Med Int Health, 7:
960–969.
5. Chen YP, Feng L, Wu HT. (2010) A review of researches on prevalence of diseases in the rural areas of China. J. of Wuhan Uni. of Sci. & Tech. (Social
Science Edition), 12(6): 54–58.
6. Curtis V, Cairncross S. (2003) Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. Lancet Infect Dis., 3(5):
275–281.
7. DiNardo J. (2008) "Natural experiments and quasi-natural experiments". In Durlauf, Steven N.; Blume, Lawrence E. The New Palgrave Dictionary of
Economics (Second edition). Palgrave Macmillan.
8. Du SS, Cai JM, Liu YS. (2010) Growth diversity and evolution pattern analysis of net income of farmers in the counties of Henan. Economic Geography,
22
30(12): 2091–2096.
9. Epp J. (1986) "Achieving health for all. A framework for health promotion" (PDF). Health Promot., 1 (4): 419–28. PMID 10302169.
10. Evans D, Dowling S. (2002) Developing a multidisciplinary public health specialist workforce: training implications of current UK policy. J Epidemiol
Community Health, 56(10): 744–747.
11. Flowers R, Waddell D. (2004) Community Leadership Development Handbook. Center for Population Education UTS, Broadway NSW.
12. Fox NS, Brennan JS, Chasen ST. (2008) Clinical estimation of fetal weight and the Hawthorne effect. Eur J Obstet Gynecol Reprod Biol., 141 (2):
111–114.
13. Gillies PA. (1997) The Effectiveness of Alliances or Partnerships for Health Promotion, WHO Working Paper. Fourth International Conference on Health
Promotion. WHO, Geneva.
14. Gong SY, Zhao GF, Shen LW, Zhou YH, Wang SZ. (2010) Effect of HIV/AIDS Health Education on Rural Women. Chinese Journal of Family Planning,
18(2): 94–96.
15. Harpham T, Burton S, Blue I. (2001) Healthy city projects in developing countries: the first evaluation. Health Promot Int., 16(2):111–125.
16. Howard G, Bogh C, Prüss A, Goldstein G, Shaw R, Morgan J, et al. (2002) Healthy Villages: A guide for communities and community health workers.
World Health Organization, Geneva. ISBN 9241545534 (NLM Classification: WA 390.)
17. Hu HF, Fan LQ. (2007) An evaluation report of the health promotion in the prosperous rural community. Chinese Rural Health Service Administration,
23
27(8): 608–610.
18. He JQ, Huang XS. (2010) A study on hyperlipidemia through community health intervention. Chinese Community Doctors, 12(19): 248–250.
19. Huang Y, Li Y, Qian WC, zhao JK, Wu YL, Zhou J, et al. (2008) Evaluation on the effects of community-based intervention on hypertension among rural
women. Chin J Public Health, 24(6): 645–647.
20. Hou YM, Hou XH. (1999) A study report on rural health education. Chin J Rural Health Service Administration, l9(4): 36–37.
21. Haggerty PA, Muladi K, Kirkwood BR, Ashworth A, Manunebo M. (1994) Community-based hygiene education to reduce diarrhoeal disease in rural
Zaire: Impact of the intervention on diarrhoeal morbidity. Int J Epidemiol., 23: 1050–1059.
22. Hayes RJ, Moulton LH. (2009) Cluster randomized trials. London: CRC Press.
23. Johnson Z, Howell F, Molloy B. (1993) Community mothers' program: randomised controlled trial of nonprofessional intervention in parenting. BMJ,
306(6890): 1449–1452.
24. Janz NK, Becker MH. (1984) The Health Belief Model: A decade later. Health Educ Q. 1984; 11(1): 1–47.
25. Kenzer M. (2000) Healthy Cities: A guide to the literature. Public Health Rep., 115(2-3): 279-289.
26. Khosh-Chashm K. (1995) Healthy Cities and Healthy Villages: how to tackle health and environmental problems in urban and rural areas. Eastern
Mediterranean Health Journal, 1(2): 103–111.
27. Kumpusalo E, Neittaanmaki L, Pekkarinen H, Hanninen O, Parviainen M, Penttila I, et al. (1991) Finnish Healthy Village Study: health profile analysis
24
for local health promotion. Health Promot Int., 6(1): 3–12.
28. Kumpusalo E, Neittaanmaki L, Halonen P, Heikkipekkarinen, Penttila I, Parviainen M. (1996) Finnish Healthy Village Study: impact and outcomes of a
low-cost local health promotion programme. Health Promot Int., 11(2): 105–115.
29. Kiyu A, Steinkuehler AA, Hashim J, Hall J, Lee PF, Taylor R. (2006) Evaluation of the healthy village program in Kapit district, Sarawak, Malaysia.
Health Promot Int., 21(1):13–18.
30. Khandekar R, Ton TK, Do Thi P. (2006) Impact of face washing and environmental improvement on reduction of active trachoma in Vietnam—a public
health intervention study. Ophthalmic Epidemiol., 13(1): 43–52.
31. Liang XF, Chen YS, Wang XJ, He X, Chen LJ, Wang J, et al. (2005) A study on the sero-epidemiology of hepatitis B in Chinese population aged over 3
years old. Chin J Epidemiology, 26(9): 655–658.
32. Li JX, Xu XS, Duan XF, Xie BY, Chen JC, Qin FJ, et al. (2006) The impact of the 8 years health promotion on smoking knowledge, attitude and behavior
in the rural community of Fangshan County of Beijing. Chinese Journal of Prevention and Control of Chronic Non-communicable Disease, 14(4):
280–281.
33. Li L, Hu XY, Zhang CN, Li HF, Zheng XM, MEI CQ, et al. (2005) Effectiveness evaluation of health promotion of safe injection behavior among rural
doctors and nursing staff. Chinese Journal of Health Education, 21(10):782–784.
34. Luby SP, Agboatwalla M, Painter J, Altaf A, Billhimer WL, Hoekstra RM. (2004) Effect of Intensive Handwashing Promotion on Childhood Diarrhea in
High-Risk Communities in Pakistan, A Randomized Control Trial. JAMA, 291: 2547–2554.
35. Ministry of Health (MOH). (2009)Center for Health Statistics and Information and Physical examinations for People aged 35 and above. (Ⅴ)Major
25
Health Behaviors. Results of the Household Health Survey in China 2008 (Summary). Analysis Report of Health Service Survey. Available at:
http://www.moh.gov.cn/cmsresources/mohwsbwstjxxzx/cmsrsdocument/doc9912.pdf
36. Ma X, Li L, Wang DZ, Chen JY. (2000) A study rural health promotion with an application of social mobilization. Chinese Primary Health Care, 14(5):
3–7.
37. Ministry of Health (MOH). (2003) Document affiliation E. Alternating double pit latrines.
http://www.moh.gov.cn/cmsresources/zwgkzt/wsbz/hjwsbz/hjws/nclcwsbz/006.gif
38. Meng ZX, Meng HS, Li YP. (2010) Analysis of the Problem of the Farmers’ Income Structure and Growth in China's Central Region—Central Study in
Shaanxi. Chinese Agricultural Science Bulletin, 26(14):425–428.
39. Madhu R, Beinum AV. (2012) A systematic review of community hand washing interventions leading to changes in hygiene behavior in the developing
world. Global Journal of Medicine and Public Health, 1(4): 49–55.
40. McCarney R, Warner J, Iliffe S, van Haselen R, Griffin M, Fisher P. (2007) The Hawthorne Effect: a randomised, controlled trial. BMC Med Res
Methodol., 7: 30.
41. National Bureau of Statistics (NBS). (2009) Population. Statistical Data: Annual. Available at: http://www.stats.gov.cn/tjsj/ndsj/2009/indexeh.htm
42. National Health and Family Planning Commission (NHFPC). (2012) Mortality Rate of Maternal & Children Under 5-year in Surveillance Region. Health
Status of Population. Digest of China Health Statistics 2012. Available at: http://www.gov.cn/gzdt/att/att/site1/20110921/001e3741a4740fe3bdab01.pdf
43. National Health and Family Planning Commission (NHFPC). (2013) National Standard for Healthy Town. Available at:
http://www.moh.gov.cn/zhuzhan/wsbmgz/201304/110b523fbfc34caa89dd46508366ae75.shtml
26
44. Puska P, Vartiainen E, Tuomilehto J, Salomaa V, Nissinen A. (1998) Changes in premature deaths in Finland: Successful long-term prevention of
cardiovascular diseases. Bull World Health Organ, 76(4): 419–425.
45. Pang SH, Zheng CJ, Lv L, Tang XL, Zeng CQ, Dou XB. (2007) Effect evaluation of health education on acute infectious disease in Guangxi minority
area. Modern Preventive Medicine, 34(6):1004–1006.
46. Perez M, Findley SE, Mejia,M, Martinez J. (2006) The impact of community health worker training and programs in New York City. J Health Care Poor
Underserved., 17(1 suppl): 26–43.
47. Pearson TA , Wall S, Lewis C, Jenkins PL, Nafziger A, Weinehall L. (2001) Dissecting the “black box” of community intervention: lessons from
communitywide cardiovascular disease prevention programs in the US and Sweden. Scand J Public Health, 29(suppl 56): 69–78.
48. Roberts G. (1997) The Kadavu health promotion model, Fiji. Health Promot Int., 12(4): 283–290.
49. Rogers, Everett M. (1983) Diffusion of Innovations. New York: Free Press. ISBN 978-0-02-926650-2.
50. Rabie T, Curtis V. (2006) Hand washing and risk of respiratory infections: a quantitative systematic review. Trop Med Int Health, 11(3): 258–267.
51. Roussos ST, Fawcett SB. (2000) A review of collaborative partnerships as a strategy for improving community health. Annu Rev Public Health, 21:
369–402.
52. Rotem A, Roberts G, Robertson S, McLachlan J. (1994) Practice based training in nurse management development: a case study. Aust Health Rev., 17(2):
40–53.
53. Sandy Angus. (1997) Promoting the health of aboriginal and Torres Strait Island Communities. Case studies and principals of good practice. Common
27
Wealth Australia. ISBN 0642272239. Available at: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/hp7.pdf
54. Staykova C. (2006) Water Supply and Sanitation Strategy Building on a solid foundation. Available at:
http://siteresources.worldbank.org/INTEAPINFRASTRUCT/Resources/Water.pdf
55. Shen YM, Yu SF , Cu MY, Shen QF, Qi XA. (2007) Health education and health promotion affecting farmers’ health in rural communities. Chinese Rural
Health Service Administration, 27(8): 603.
56. Statistics Information of Jiangsu Province (SIJP). (2011) Economic and Social Development Statistics Bulletin 2010 of Jiangsu Province. 12: people’s
living and social security. Available at: http://www.jssb.gov.cn/jstj/djgb/qsndtjgb/201104/t20110406_115078.htm
57. Sindall C. (1997) Inter-sectoral collaboration: the best of times, the worst of times. Health Promot Int., 12(1): 5–7.
58. Sanchez L, Perez D, Perez T, Sosa T, Cruz G, Kouri G, et al. (2005) Inter-sectoral coordination in Aedes aegypti control. A pilot project in Hanava City,
Cuba. Trop Med Int Health, 10(1): 82–91.
59. Standing Committee of the National People's Congress (SCNPC). (1998) Organic Law of the Villagers Committees of the People's Republic of China
[Revised]. Available at: http://www.lawinfochina.com/display.aspx?lib=law&id=988&CGid
60. Tao Y. (2009) China Rural Drinking Water and Sanitation Survey. J Environ Health, 26(1): 1–2.
61. XXX
62. Vartimnen E, Puska P, Pekkanen J, Tuomilehto J, Jousilahti P. (1994) Changes in risk factors explain changes in mortality from ischaemic heart disease in
Finland. BMJ, 309 (6946): 23–27.
28
63. WHO. (1986) The Ottawa Charter for Health Promotion. First International Conference on Health Promotion, Ottawa. Available at:
http://www.who.int/healthpromotion/conferences/previous/ottawa/en/
64. World Health Orgnization (WHO). (2014) Types of Healthy Settings. Healthy Settings. Available at:
http://www.who.int/healthy_settings/types/villages/en/
65. World Health Organization (WHO). (2007) Evaluation of the healthy village program in the Syrian Arab Republic［R］. Cairo: WHO. 2007. 111.
66. Wei X, Liu XL, Su Y. (2007) The Characteristics of environment pollution in the rural settlements. China Development, 7(4): 92-96.
67. Wang Y. (2012) Technical Guidance Group of the Fifth National TB Epidemiological Survey: the Office of the Fifth National TB Epidemiological Survey.
The Fifth national tuberculosis epidemiological survey in 2010. Chin J Anti-tuberculosis, 34(8): 485–508.
68. Wang J, Liu FY, Yang L, Wan Y, Zhang Y, Liu LD, et al. (2007) Analysis on the effect of prevention and treatment of reproductive tract infections ( RITs)
among rural women in Yunnan Province. Chin J of Reproductive Health, 18(5): 264–269.
69. World Health Organization (WHO). (1997) Jakarta Declaration on Leading Health Promotion into the 21st century. World Health Organization, Geneva.
70. Yao W, Qu XG, Li HX, Fu YF. (2009) Investigation of latrines improvement and excreta utilization in rural areas, China. J Environ Health, 26(1): 12–14.
71. Zhu Y, Song SC, Yan JS, Yan M. (2004) Effectiveness of Education on Reproduction and Relevant Health knowledge among Women of Child-bearing
Age in Poverty-stricken Rural Areas. Chinese Journal of Health Education, 20(11):1030–1032.
29
Table 1 Health communication activities developed in the intervention villages
Activities
Lectures
Contents
Health literacy one should have; Hypertension prevention and treatment;
Diabetes prevention and treatment; Smoking kills; Prevention of pesticides
poisoning.
Lectures
New health concept; Healthy life-styles.
Lectures
New health concept; Smoking kills. Prevention of gastro-intestinal infectious
diseases; First aid; Environment protection; Food poisoning prevention.
Wired
Prevention of common infectious diseases; Dieting and health;
broadcasting Non-communicable chronic disease prevention.
IEC
materials
spread
A public letter to villagers for promoting health; 66 health literacies one
should have; Shopping bags with slogans of key health message; Pokers with
key health messages; Movable health board.
Rural health (booklet); Health literacy one should have (leaflets); Nutrition
and health (foldings); Diabetes prevention (foldings); Hypertension
prevention (foldings); Smoking skills (foldings).
Free shopping bags with slogans of ‘Healthy village, Happy life’; Key health
messages; Cups with signs of key health messages; 66 health literacies one
should have (booklet); Anime DVDs; Prevention of cerebral-cardio-vascular
diseases (booklet).
Villages
Nantou, Wangyao (Jiangsu
province)
Coverage
360 PTs
Nancha, Xiaoci (Jiangsu province)
Huayang, Yiping (Jiangsu
province)
Dahuaishu, Jing-ao, Nantou,
Xiaxitou, Checun, Majiapu
(Shaaxi province)
Huanglongmiao, Mayao,
Donggaomei, Miaowan,
Shizhuang, Tiefusi (Henan
Province)
Nancha, Xiaoci, Qingzhen,
Wangyao, Huayang, Yiping
(Jiangsu province)
600 PTs
471 PTs
Dahuaishu, Jing-ao, Nantou,
Xiaxitou, Checun, Majiapu
(Jiangsu province)
-
20022
Copies/Items
28500
Copies/Items
26500
Copies/Items
30
Table 2 Profile of the sampled villages and socio-economic Status (SES) of the
selected households in three typical provinces of China, 2009
Indicators
Intervention
Control
Profile of the villages
N=18
N=18
5.1±4.9
2113.9±1801.8
14.2
3.5±2.3
1353.4±570.9
17.8
.203
.097
0.316
3920.5±2840.8
2238.3
4200.1±3177.2
1624.1
0.782
--
N=196
N=205
Average number of family members
5.1±1.5
5.2±1.5
0.932
Family medical expenditure last year
3158.4±5419.1
2886.6±4371.3
0.580
Assisted with minimum living
8.2%
11.7%
0.248
99%
100%
0.238
Centralized piped water supply
73.3%
75.5%
0.647
Household use of sanitary latrine
45.9%
44.4%
0.764
Collective garbage disposal
65.8%
48.8%
0.001
Average area(KM2) per village
Average population per village
Proportion of population above 60
yrs(%)
Average annual income per capita ¥
Average service population per
village clinic
Household SES
P Value
guarantee*
Registered user of New Rural
Cooperative Medical System
*The households would be subsidized by the government if the annual income per
capita of a family is lower than the rural standard of minimum living assistance (The
household annual income per capita of the 36 sampled villages well represented the
average economic conditions of rural residents of three provinces. In 2007, the
average annual income per capita of the rural dwellers was ¥7357, ¥4044, and ¥3665,
for rural Jiangsu (SIJP, 2011) , Henan(Du et al., 2010), and Shaanxi (Meng et al.,
2010), respectively. )
31
Table 3 Comparison of health status, knowledge and life-styles of the study
respondents between pre- and post-intervention and range of change after
intervention
Indicators
Intervention villages
Pre-
Post-
P Value
Range of
Change (%)
2-week morbidity rate
18.5(143/774)
13.4(87/651)
-27.6
0.009
12.0(
One-year incidence of diarrhea
13.0(101/775)
9.5(62/651)
-26.9
0.038
11.9(
Transmission way of Hepatitis B
27.5(213/775)
34.4(224/651)
+25.1
0.005
21.1(
Transmission way of rabies
12.0(93/775)
24.6(160/651)
+105.0
0.000
22.0(
Correct treatment of dog bites
23.5(182/775)
42.4(276/651)
+80.4
0.000
25.4(
Identification of standard of normal blood tension value
43.2(335/775)
67.6(40/651)
+56.5
0.000
45.2(
Identification of recommended upper limit of daily sodium intake
20.5(159/775)
42.2(275/651)
+105.9
0.000
23.9(
Physical exercise less than 2 times per week
79.5(616/775)
73.3(477/651)
-7.8
0.006
83.5(
Male
44.3(160/361)
42.5(135/318)
-4.1
0.624
42.4(
Female
0.7(3/414)
0.9(3/332)
+28.6
1.00*
0.5(2
Alcohol drinking at least 3 times per week
17.4(135/775)
3.5(23/651)
-79.9
0.000*
15.6(
Always washing hands before eating
71.0(550/775)
83.4(543/651)
+17.5
0.000
80.0(
Using chopping board separately for raw meat cut
6.7%(13/195)
27.4%(49/179
+309.0
0.000
11.2(
Current Smoking
)
*Fisher’s Exact Test (2-sided).
32