Engaging local governments in health promotion and chronic disease prevention activities: the case of Local Health Security Funds in Thailand

The study protocol was approved by the Institutional Review Board, Faculty of Medicine, Chulalongkorn University (approval No. 248/55). We collected data from local governments who have participated in LHSFs in Thailand. The calculated sample size of the study was 780 respondents. Data regarding the LHSF activities were sought from all chiefs or vice-chiefs of the local governments who participated in the Annual Conference of the Local Governments in 2014. The chief of a local government is the highest decision makers of the local government who also serves as the LHSF secretary to administer and manage a LHSF to achieve its objectives. These chiefs or vice-chiefs are considered suitable respondents for our questionnaire survey because they can provide answers to our questionnaire that reflect community-related situations.

The questionnaire or survey instrument was developed based on an extensive review of health promotion theories and studies of community participatory approaches conducted both in Thailand and abroad. We also conducted an additional review of the literature regarding health promotion and prevention of DM and HBP in communities from the following countries: the United States of America, Switzerland, Australia, Japan, and Singapore. A group of local government chiefs from 4 communities that had been awarded LHSFs and 4 additional local government chiefs from communities in the same province that had not been awarded LHSFs were also interviewed, and the elicited information was used to draft the questionnaire. A panel of experts who had studied LHSFs evaluated the questionnaire to ensure content validity. We designed all questions in accordance with the framework to promote health and prevent disease based on the Ottawa Charter.

The self-administered questionnaire was distributed on the first day of the conference. There were at least 2,300 participants at the conference from a total of 7,776 local governments in the country. As an incentive to participate in the study, an appropriate lucky draw was conducted for the respondents if they had returned a completed questionnaire to the researchers within the specified time.

Microsoft Excel and SPSS for Windows were used to analyze the data. Data regarding demographic characteristics of the participants were analyzed in terms of frequency, proportion, mean, and standard deviation. A factor analysis was conducted for group related questions. A Chi-square test was employed to determine the association between the characteristics of local governments and their activities to promote health as based on the Ottawa Charter. We also analyzed the completeness of activities conducted by these LHSFs to promote health as based on the Ottawa Charter.

Of the 2,300 conference participants, 1,159 (50.4%) were willing to respond to the questionnaire. Of these respondents 1,149 (98.4%) provided completed answers. Among those respondents that provided completed answers, 1,072 (93.7%) already joined LHSFs and had conducted health promotion activities.

Among the 1,149 respondents who provided completed answers, the ratio of men to women was almost 1 to 1. The mean age of the respondents was 43 years. About 77% had graduated with a Bachelor degree. The duration of work experience with the community was up to 13 years, with a mean duration of 8 years.

Almost half, or 47%, of the respondents, came from the northeastern region of Thailand. When classifying the size of local governments, 79.9% came from Subdistrict Administration Organizations (SAOs), the smallest size of local government in Thailand. The remaining came from urban or rural municipalities. The characteristics of the respondents and their local governments are shown in Table 1 below.

Overview of activities to promote health supported by LHSFs

Local governments conducted many types of activities aimed to promote health and prevent NCDs. When classifying these activities according to the Ottawa Charter, we found that most local governments conducted activities aimed to promote health according to almost all categories of the Ottawa Charter. For example, 90 percent of local governments conducted activities to strengthen community development, including setting up community plans, increasing community strength, and establishing community networks. About 70% initiated health education programs, and about 60% provided support to local health officers to improve activities aimed to promote health. Finally, >60% implemented environmental change programs to facilitate health promotion. However, about 30% of all local governments did not use regulations or policy development to facilitate the promotion of health in their communities. The prevalence of each category of health promotion activities according to the Ottawa Charter is shown in Figure 1 A description of activities to promote health aimed to prevent DM and HBP is provided in Table 2.

Figure 1

Table 2

Health promotion and disease prevention activities for diabetes and high blood pressure in community

Type of activities	Number (n = 1,072)	Percentage (%)
Build healthy public policy
Creating community policies & regulations to support health	358	33.4
promotion
Identification of community role models	247	69.0
Awards for successful guideline follower	146	40.8
Punishment for violation of rules	53	14.8
Environment improvement to facilitate health promoting
behavior
Facility development or improvement	874	81.5
Sports or exercise areas	775	88.7
Public parks	287	32.8
Learning centers	274	31.4
Community areas for herb gardens	221	25.3
Healthy markets	68	7.8
Swimmingpools	5	0.5
Creating community space or areas for health	628	58.6
Designation of smoke-free areas	436	69.4
Designation of alcohol-free areas	251	40.0
Requirement of public places such as temples and schools to be equipped with health risk assessment tools	242	38.5
Requirements of restaurants in the community to have a healthy menu	103	16.4
Strengthen community actions through group or network formation
Community action plans	1049	97.9
Community strengthening development	1032	96.3
Community networking	974	90.9
Types of groups
Exercise groups	694	71.3
Women’s groups	638	65.5
Youth groups	414	42.5
Alcohol drinking cessation group	151	15.5
Smoking cessation group	85	8.7
Types of support
Budget	890	88.9
Supplies	530	52.9
Study visits	359	35.9
Personnel	286	28.6
Organizing contests	281	28.1
Monitoring, evaluation, and support	221	22.1
Search and promotion of role models	120	12.0
Develop personal skills through health education	814	75.9
Target population
General population	674	82.8
Elderly persons	454	55.8
Overweight persons	282	34.6
Alcohol drinkers	183	22.5
Smokers	171	19.8
Channels of health education
Workshops/seminars/lectures	498	46.5
Leaflets/brochures	486	44.3
Counselling	373	34.8
Community news broadcast	313	29.2
Billboards in the community	251	23.4
Training camps	142	13.2
Contents of health education in relation to NCDs
General knowledge	829	77.3
Risk factors	798	74.4
Severity and complications of diseases	728	67.9
Behavior and practice
Diet	842	78.5
Exercise	829	77.3
Alcohol drinking cessation	817	76.2
Smoking cessation	815	76.0
Stress management	770	71.8
Self-care practice during illness	747	69.7
Self-monitoring or screening
Blood glucose screening	731	68.2
Monthly blood pressure monitoring	705	65.8
Monthly waist measurement	636	59.3
Weekly weight measurement	602	56.2
Reorient health services to facilitate health promotion activities against NCDs
Type of activities or support to health facilities or health staff	887	82.7
Provision of financial support to carry out health promotion activities
Provide data on vulnerable groups e.g. people with	662	74.6
diabetes and hypertension	606	68.3
Provision of supplies for use in health promotion activities	424	47.8
Registration of vulnerable groups	361	40.7
Hiring more staff to work at the healthcare settings	168	18.9
Methods of implementation	667	62.2
Health promoting activities while waiting for services at the hospital	595	89.2
Relaxation activities while waiting for services at the hospital	191	28.6
Integration of health promotion activities into home visits	845	78.8
Blood sugar screening	714	84.5
Blood pressure screening	751	88.9
Weight measurement	648	76.7
Waist circumference measurement	531	62.8

To improve the environment for encouraging activities to promote health, most of the communities (88.7%) prepared specific areas for sport activities or exercise, public parks, and learning centers where people could gather to participate in health promoting activities with one another. In addition, public places in the communities were designated as smoke-free areas (69.4%) and alcohol-free areas (40.0%) to accommodate the policy regarding health promotion. About 38.5% of the local governments made equipment and tools to assess health risks available in public places. Collaboration was sought from local restaurants to prepare a healthy menu as an alternative for people in the community in only 16.4% of the LHSFs.

Public policies for community health promotion and disease prevention were implemented by only about 30% of LHSFs. The most common methods were identifying and promoting role models in health behavior for others (69.0%), offering an award to persons who had successfully followed the health promotion guidelines (40.8%), and imposing means of punishment such as collecting a fine when health promotion rules or regulations were violated (14.8%).

Many LHSFs supported the establishment of and activities by health promotion groups or networks in the community. Most common group support by various LHSFs was for elderly people (77.7%). These were followed by the exercise groups and local housewife societies. Only few local governments supported the formation of smoking cessation groups or no alcohol support groups (8.7% and 15.5%, respectively). These group and networks were mainly supported through provision of budgets (88.9%), followed by site study visits to areas with best practices for benchmarking (12%).

Our study shows that the majority of local governments joined the LHSF program by the NHSO. Many types and forms of health promotion activities have been implemented. The most common area of LHSF activities according to the Ottawa Charter classification was strengthening of community actions such as devising community plans, increasing community participation in community actions, and establishing community networks and groups for health promotion actions. The second most common area was to reorient health services towards health promotion. This includes supporting local health care providers and community health officers to conduct health promotion activities, and to integrate them into

Table 3. Diversity of 5 main categories of health promotion activities routine health service provision. The third common area was environment improvement to facilitate health-promoting behaviors. For example, many LHSFs supported regulations on smoking areas and alcohol drinking restriction areas in the communities. In terms of personal skill development, this study mainly focused on health education. Several types and channels of health education activities were conducted for various target groups. However, it was not as common as the other 3 areas, because only about 75% of LHSFs had health education interventions for NCDs. Least common area of activities was development of healthy public policies or regulations in the community.

Strengthening of community actions in health promotion took many forms. Establishment and development of health promotion networks and interest groups is one popular mechanism among LHSFs in Thailand. Major methods to support establishment of networks and groups were provision of budgets, equipment, and other related necessities. This is likely because it is easy to operate and practical. Networks that were mainly supported by LHSF to prevent DM and HBP were groups for the elderly and for exercise. This could be the result of the existing formation of groups for the elderly in most communities, and because elderly individuals are easier to recruit. A survey conducted by the College of Population Studies, Chulalongkorn University, and the Foundation of Thai Gerontology Research and Development Institute in 2012 revealed that there were as many as 3,487 elderly clubs and exercise groups in the country [16]. By contrast, nonsmoking and no-alcohol groups did not receive as much support. Even though more support should be offered to these individuals in these categories in the community, latest scientific evidence suggests that networking of these risk groups may not be effective [17-19]. Other effective and worthwhile methods to shape their behaviors should be considered, such as creation of no-smoking areas in the community, skill development workshops to reduce or quit smoking and drinking, policies to increase taxes on tobaccos and alcohols, restriction of access to tobacco and alcohol, and a ban on tobacco-and alcohol-related advertising.

Many LHSFs provided support to health care providers and health officers to conduct health promotion and disease prevention activities. In theory, various measures could be used to encourage health officers to implement health promotion tasks [20]. For example, the health care providers should be engaged in policy planning and public health operations by local governments. They could work together in mutual goal-setting and LHSFs could provide resources and social support to attract these health care staff to do more health promotion and disease prevention. They should exchange health information and knowledge on a continuous and consistent basis. It is noteworthy that the results of this study show that LHSFs could increase their support to public health staff to conduct health promotion activities because currently they took less than 33% of the LHSF budget. Our survey also found that almost three quarters of the participants, or 72.4%, felt that there were not enough public health officers for health promotion activities.

Development and adjustment of the community environment to promote healthy behavior is found to be an effective health promotion measure that could be used by local governments. In our study, we found that LHSFs mainly focused on construction of sports stadiums, exercise fields, or public parks, which required a large budget. This may be a result of the political attractiveness of such programs, which show concrete and visible results to the voters in the community. However, there are other approaches to adjust and improve the environment in the community such as encouragement of healthy menus and options in community food stores or restaurants. This was not very common, probably because it was not considered as an option. Other settings for health promotion activities such as temple-based health promotion projects or school-based health promotion projects could also be implemented, but the current practice seems to be quite limited. This is an area where future health promotion advocacy could be implemented to persuade LHSFs and local governments to do more.

Personal skill development is an important area for health promotion. This study asked questions on health education activities, which was a relatively common approach in Thailand. We found that common health knowledge dissemination methods include training, seminars, lectures, and written documents that covered or related to DM and HBP including general information, severity, risk factors, and prevention guidelines. Although dissemination of health education is relatively easy, its effectiveness may be limited [14-15]. More active approaches such as self-risk assessment, especially weight measurement and waist circumference measurement are more likely to be more effective. Unfortunately, from our findings they were conducted less than other health education activities.

Devising public policies or regulations for community health promotion is another important approach that was recommended in the Ottawa Charter. However, according to our findings, community efforts to devise public policies or regulations were relatively insufficient. Policies developed at provincial or national level may not be implemented successfully at the community level [13]. For communities with close relationships between individuals, creating a law or regulation to enforce on others will not be easy nor acceptable, especially if people in the community did not have a chance to participate in its design and implementation. Therefore, a focus should be placed on community strengthening and socially driven measures with which local governments and people in the community have an opportunity to work together in order to make it successful and sustainable.

To support local governments to play a more active role of the supporter and promoter of health officers and other related agencies, further studies may be called for. The methodology such as community participation may be useful to help local governments and public health officers to identify and develop mechanisms to work collaboratively with community members towards better health promotion practices. It will also help create more conducive environment and policies for changes. In fact, there are many countries that have already utilized this method [21-23] with an objective to enable public health officers to adjust their work to integrate and operate health promotion activities to cover all major health risks. This could be employed to facilitate LHSFs to more actively and effectively fulfill their assigned roles and responsibilities in health promotion to prevent NCDs, especially DM and HBP.