Abstract
Non-communicable diseases (NCDs) are a leading cause of death in India, creating the need to research strategies for preventing and recognising these diseases.
Objectives:
The purpose of this study was to develop and research an interactive health education programme on NCDs in a rural subpopulation of Bengaluru and to build ‘health champions’ among young people to contribute to the prevention of NCDs in India.
Design:
A descriptive qualitative approach was used to develop and evaluate an interactive educational programme. Students, aged 12–16, from a rural secondary school took part in the study.
Method:
Participants were separated into five focus groups covering different NCDs including hypertension, diabetes mellitus, otitis media, oral cancer and malnutrition. Each focus group was interviewed face-to-face before, during and after all activities. Content analysis was conducted using a directed approach.
Results:
Findings were organised into themes that described aspects of learning that enhanced or detracted from student understanding about NCDs.
Conclusion:
Findings from this study show that creative methods have a positive impact on educating students, aged 12–16, on NCDs.
Background
Those living in rural communities comprise about 70% of India’s population; however, research and disease prevention strategies have largely been concentrated on urban populations (Little et al., 2016). The significant increase in unhealthy lifestyle behaviours such as physical inactivity and smokeless tobacco use in rural communities has increased these communities’ risks for disease (Sathish et al., 2017). Patients in rural areas are subject to a ‘triple burden’ of lack of education, financial insecurity and poor access to health care and tend to delay seeking treatment (Swaminathan et al., 2017). The burden of non-communicable diseases (NCDs) in India ‘exceeds global increases’ due to a lack of preventive measures (Swaminathan et al., 2017). Chronic conditions like diabetes are no longer ‘confined to urban areas of India’ and have become a burden in rural communities as well (Little et al., 2016).
NCDs such as type 2 diabetes mellitus and hypertension have a profound impact on global health (World Health Organization [WHO], 2016). The International Diabetes Federation (IDF) (2017) has stated that diabetes affects upwards of 425 million people and is projected to affect 693 million by 2045, with most cases occurring in low- and middle-income countries. The IDF has also predicted the number of adults with pre-diabetes will increase to 472 million by 2030 (Hu, 2011). In the impoverished areas of Bengaluru, India, NCDs such as malnutrition, diabetes, hypertension, oral cancer and otitis media have been noted as ‘top health priorities’ by community health officials (Abdi et al., 2018). However, precise data of disease prevalence are lacking for NCDs in India (Arokiasamy, 2018). With a high prevalence of smoking, heavy alcohol use and increased intake of refined carbohydrates, coupled with declining levels of physical activity, India has seen an increase in NCDs such as type 2 diabetes and hypertension (Gupta, 2016; Little et al., 2016; WHO, 2016).
The burden of NCDs is on the rise in India. The diabetes prevalence, as found by a large-scale study, has reached 7.8% with the rate of pre-diabetes trailing at 7.1% in rural India (Little et al., 2016). Although it varies by region, the national rural prevalence of diabetes in India has quadrupled over the last quarter century (Little et al., 2016). The prevalence of diabetes in Karnataka has been estimated at 16% (Sheeladevi et al., 2014). Globally, hypertension was estimated to effect 1.3 billion people in 2010 and is continuing to grow (Bloch, 2019). The prevalence of hypertension in India has been established as a quarter of rural adults (Gupta, 2016). Hypertension has caused about 170,000 deaths in India every year, and an estimated 140 million people are living with high blood pressure in India currently (Johnson et al., 2014). Furthermore, the WHO (n.d.) reports that 15.2% of the Indian population consumes less than the minimum level of dietary requirement or are malnourished. India has been declared a ‘Low-Income Food-Deficit Country’ (WHO, n.d.). However, epidemiologic studies have shown that NCDs are mostly preventable through diet and lifestyle modifications (Hu, 2011).
Diabetes has been declared a ‘global public health crisis’ and is fuelled by poor diet and sedentary lifestyles (Hu, 2011). Due to the rapid rise of NCDs, such as hypertension, WHO has begun to implement nutrition modifications in the form of a salt reduction programme (Johnson et al., 2014). Lifestyle modifications concerning personal, dietary and exercise habits need to be taught to the youth of the community (Kini et al., 2016). The epidemic of NCDs can be curbed through the advocating of healthy diets and lifestyles (Hu, 2011). Therefore, it is essential to engage with local communities and better understand their perceptions of health and priorities to develop future interventions based on their needs (Abdi et al., 2018).
Building health champions among youth
Health professionals and researchers in the United Kingdom (UK) have advocated for children and youth to become ‘health champions’ or integral members of the community who serve as change agents to promote health (Altogether Better, 2018; White et al., 2010). Health champions are defined as individuals who have been trained and supported to ‘voluntarily bring their ability to relate to people and their own life experience to transform health and well-being in their communities’ (Altogether Better, 2018). Their value comes by ‘unlocking the assets and resources of individuals and communities’ and in turn ‘create healthier communities’ and better knowledge of health services (NHS Confederation, 2012). Health education and promotion have the ability to cross social boundaries and influence social norms and behaviours (Lwin et al., 2018). Researchers have found that meaningful engagement with the community has resulted in better health and well-being, improved self-care of chronic illnesses and healthier lifestyles (NHS Confederation, 2012).
Researchers in the UK found that building health champions among youth transformed young people into becoming stakeholders in improving the type of wellness activities they co-designed and implemented (NHS Confederation, 2012). It also has the power to change the lives of people in the community experiencing the ‘poorest of health’ (NHS Confederation, 2012). Sustainable, cost-effective programmes are necessary to counteract the impact of ‘breadwinner[s] [being] unable to work’ (Sheeladevi et al., 2014). Research suggests that there have been improved health outcomes for the children and youth involved, as well as improved health outcomes in their local communities. Through the Altogether Better UK project, children had improved self-efficacy in their role as change agents to improve community health and valued their communities more (Altogether Better, 2018; White et al., 2010). However, we could find no research on the incidence or effectiveness of youth serving as health champions in India (Altogether Better, 2018; White et al., 2010). At the individual level, the outcome goal of health champions is to use their social skills and training to engage the community and ‘increase their knowledge and awareness of health issues’ (Altogether Better, 2018). Per the NHS Confederation (2012), there is ‘untapped potential’ in these communities, and we cannot afford to lose it.
Learning styles of youth in India
Gandhi believed in an education system that centred around the use of crafts as a teaching and learning strategy and stated that it would become ‘a bridge’ between the school and home environment of the child (Gaur, 2018). The use of crafts in school became a source of dialogue at home, spun by students themselves (Gaur, 2018). Research has shown that if teachers use a variety of teaching methods, such as making posters, puppets, gardening and weaving, the students are exposed to both the familiar and unfamiliar in a way that provides ‘both tension and comfort’ during the process (Kamboj and Singh, 2015: 289). The variety of teaching methods provides the students with more than one way to excel in their learning (Kamboj and Singh, 2015). It has been found that ‘abstract learning, artistic and aesthetic interest’ tend to achieve ‘higher academic marks’, especially in those children with a strong preference for imaginative thinking (Kamboj and Singh, 2015: 292).
Students in the sciences tend to reject school that is ‘disconnected from their own lives’, where they are not free to explore and incorporate their imagination into the process (United Nations Educational, Scientific and Cultural Organization, 2010). Despite many attempts to revamp science education in India, it has remained a stagnant collection of facts and theories that student’s rote memory will be evaluated on throughout the term; typically, it lacks creativity and discourages imagination (Mahajan, 2018). However, crafting products leads to an early understanding of how the pieces of a concept fit together to create the desired end (Gaur, 2018). Students tend to ‘watch and then try to do’, and they learn best ‘through exploration’ (Kamboj and Singh, 2015: 306–307). Evidence suggests that students like to design, create and build to remember items rather than by writing down notes (Kamboj and Singh, 2015). Students can remember pictures and images better than words and names (Kamboj and Singh, 2015). Students who are given freedom to think and imagine score higher than those ‘who are given a “cookbook” approach to class’ (Mahajan, 2018: 129).
Previous research into youth health champions was conducted in the UK through the All Together Better Program (Altogether Better, 2018; White et al., 2010). However, a gap in the literature exists concerning the effectiveness of health champions in India. Previous research with a focus on health champions has been conducted in different cultures with different customs for health care and prevention of disease. Alternative measures to address challenges related to culture in India are needed. Therefore, to evaluate the effectiveness of youth health champions, further research is necessary for a non-western country such as India.
Purpose
Health promotion and education play an essential role in the prevention and management of NCDs. According to WHO (2016), the probability of dying from the four major NCDs is 26% in India. WHO (2016) also states that the emergence of NCDs is responsible for 67% of India’s mortality burden. The higher probability of dying from a preventable disease justifies the need for enhanced health education from a young age. Thus, the school that participates in the recommended approach of nominating and building health champions in each grade will be able to advocate for those in their communities at risk or affected by these diseases. The overarching purpose of this study was to develop and research an interactive health education programme on type 2 diabetes and hypertension in a high school in a rural subpopulation in Bengaluru, to build youth health champions and to contribute to the prevention of NCDs in India. Specifically, the aim was to identify and evaluate aspects of learning that enhanced or detracted from youth understanding of NCDs.
Methods
Design
A descriptive qualitative approach was used to develop and evaluate an interactive educational programme on type 2 diabetes and hypertension in a high school in a rural subpopulation in Bengaluru, India, to build health champions among the students. The project encompassed the development and research of an interactive education programme, including various craft activities that provided health and nutrition education to youth to build health champions towards prevention of hypertension, diabetes, otitis media, malnutrition and oral cancer in Bengaluru, India. While the disease topics primarily focused on NCDs, it is acknowledged that otitis media can be infectious or non-infectious. This topic was specifically requested by the school because it had been problematic among the students, therefore was included. The interactive health education programme focused on providing students at a rural secondary school in Bangalore, India, with the means necessary to become health champions to educate their own families, peers and other stakeholders to improve health outcomes in their community. The choice of schools resulted from collaboration with the Community Health Director and social worker who had both already begun education on ‘life skills’ in the school previously.
Participants and procedures
Convenience sampling was employed to recruit rural secondary students from a subpopulation attending school in Karnataka, India. Inclusion criteria were as follows: (1) enrolled as a student, teacher or administrator in the selected middle or high school in the DJ Halli Slum or other Bangalore Baptist Hospital partner school in Bengaluru, India; (2) being a youth participant recommended or nominated by a primary school teacher or administrator and (3) speaking and understanding at least one of three languages spoken by the translators (English, Hindi or Kannada). Exclusion criteria included as follows: (1) those who did not meet inclusion criteria and (2) those who did not provide consent. This study took place in a government high school in the Bangalore Rural District, where 20 students attended 2 days of education on NCDs in June of 2018. Young women comprised 70% of the student sample population. The majority of the students were between 14 and 16 years of age with only 5% being younger, at age 12. All the participants were fluent in Kannada with only one student able to speak some English.
Human participant protection
Informed assent was obtained from each student participant and informed consent was obtained from each teacher participant before beginning the NCD education intervention. The study received exempt status from the Institutional Review Board (IRB) at Baylor University in Waco, Texas (IRB Reference #1185311) and was approved by the Bangalore Baptist Hospital Institutional Review Board in India. All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional research committee approving the study and the 1964 Helsinki Declaration and its later amendments.
Measures
Data were collected through face-to-face semi-structured, in-depth, focus group interviews before, during and after students were engaged in educational strategies focused on building health champion and preventing NCDs in India. Student and faculty interview questions are outlined in Tables 1 and 2. Research questions were designed to identify the student’s base knowledge of diseases and nutrition as it relates to disease prevention, as well as their current education practices. The student and faculty interviews lasted 48 and 19 minutes, respectively. The student focus group was led by the principal investigator and two translators. There were 20 students who had been nominated by their teachers to become health champions for their schools. There was only one student who did not attend both days of the workshop due to conflicts with other school activities. Students were excited to get started and were laughing and telling stories throughout the interview process. The faculty focus group was led by two faculty mentors without translators. The discussion revolved around curriculum and resources the school provided to the children such as hot lunches and bicycles.
Student interview excluding probing questions.
Faculty interview excluding probing questions.
In all, 2 days of education on NCDs were conducted in Karnataka, India. The education techniques included both didactic and hands-on crafting experiences. Didactic instruction was performed in five separate focus groups each containing four students. Each group was taught about a different NCD including hypertension, diabetes, otitis media, malnutrition and oral cancer. Each group of participants was then allowed to continue their learning through craft projects including sand art, puppet shows, colouring worksheets, bracelet making and chalk art.
The 2 days of education was facilitated by two nursing faculty from the USA, six nursing students from the USA, five nursing students from India, the Community Health Director from a local hospital and a social worker from a local hospital. The focus groups were led by five nursing students from the USA with translation from Kannada to English being facilitated by the Indian nursing students and the social worker.
Data analysis
The directed content analysis of quantitative data is indicated when prior research exists and allows for further exploration of the topic (Hsieh and Shannon, 2005). After data have been collected through interviews, directed content analysis is used to organise passages into predetermined codes related to the known phenomenon (Hsieh and Shannon, 2005). Our prior knowledge is based in the UK’s Altogether Better Campaign for Health Champions. Audio recordings were collected throughout the 2-day workshop and then transcribed. The verbatim transcripts were reviewed several times for familiarity. Using a directed content analysis approach, the principal investigator (M.B.) then identified meaningful texts and codes that appeared in research questions. A qualitative research expert then reviewed the data for validity. An open coding strategy was first used to determine broad concepts and create categories and subcategories of patterns within the data, specific to facilitators and barriers to health education on NCDs in India. After this, axial coding was used to explore and refine the properties and dimensions of categories and subcategories. Finally, selective coding was used to examine the relationships between them (Hsieh and Shannon, 2005). NVivo® qualitative software was used to sort and organise the data. This method of analysis allowed the researcher (M.B.) to shed more light on the need for implementation of health champion programmes to improve NCD-related health education in India.
Findings
Participants found a creative approach to be an effective method of delivering health education. The interest generated through the interview process remained throughout the 2-day workshop. Participants were engaged in the health education activities and were considering ways they could continue teaching about health in their community after the workshop.
Two distinct themes were identified and organised into themes that described aspects of education that (1) detracted from overall understanding of NCDs and (2) enhanced overall understanding of NCD (Table 3). By far, the most robust primary category concerned aspects of education that enhanced overall understanding. These captured the central objective of the study and comprised three subcategories: ‘previous creative experiences’ which reflects the impact that creative learning has already had on their understanding, ‘impact of translation on learning’ which demonstrates the necessity of accounting for native language when implementing education programmes and ‘implementation of the health champion’ which shows the impact that 2 days of health education through craft projects impacted their previous knowledge of NCDs.
Thematic interpretation.
Aspects of education that detracted from overall understanding
Lecture-based learning
The health education curriculum at the school is often dictated by what was available and accessible for the learners to use. The class lacked a diversity of teaching styles and were streamlined into lecture only sections. The students acknowledged that creative learning methods were not new; they found that lecture-based classes comprised a large portion of their schooling: Mostly, it’s the lectures and things going on, but then being taught certain things like cleanliness and using charts, posters, which they like. (Translator 2)
Responses to follow-up questions comparing lecture-based learning and creative learning revealed that although the students have exposure to other methods of education, it is a rare enough occurrence that they are unable to compare it to the effectiveness of their regular lectures: I think their exposure in general is mostly lecture. So, if you ask them, they are not able to say. If you give them options, they don’t have much things to compare. (Translator 1)
This limited view of other learning methods restricted our preliminary assessment of how creative learning strategies would affect the curriculum. Given the lack of experience with other forms of teaching, the majority of students acknowledged that lectures left them confused.
Previous knowledge of disease processes
Throughout our discussion with students and faculty, it became clear that a lack of understanding surrounding NCDs existed. While exploring how the students have previously learned about preventable diseases, students revealed their confusion associated with lectures: The lecture method, he’s saying he may not understand it. (Translator 1)
As we began to dive deeper into the assessment of the students’ knowledge of NCDs, the lack of understanding related to lecture-based lessons became evident. Although students showed evidence of some previous knowledge, they struggled to separate disease processes from one another, especially hypertension and diabetes mellitus. The students began to list off characteristics of diseases that were associated with something else: She said diabetes symptoms, like those were the symptoms. (Translator 2)
The faculty stated that although they knew that hypertension was high blood pressure, they did not truly understand it:
I know that term hypertension, high BP. (Male speaker 1) High BP. Like this, I know but- (Male speaker 1) He doesn’t know. (Male speaker 2)
Aspects of education that enhanced overall understanding
Previous creative experiences
The lesson plan gives the teacher a month to go over NCDs with their students. This small amount of time is spent going over a single chapter in their science textbooks: We have a chapter about that topic and noncommunicable disease. We have that in the chapter. It’s a month to teach. (Female speaker 3)
Although the teachers realise that using alternate forms of videos is more beneficial to the students, they can run into trouble with language barriers in the classroom. The children in the school speak Kannada, a language not commonly used in health education videos: Videos . . . because the language problem is there . . . Kannada the children. They have videos they can’t understand. (Female speaker 3)
When the teachers use these videos in the classroom they have to translate for their students: If you were going to show a video you would have to interpret kind of what’s going on for most of the children. (Female speaker 2)
Impact of translation on learning
During the implementation phase of the health education programme, this need for translation was underlined. Although many of the students had a basic understanding of English, their preferred language of instruction was Kannada. To address this issue, nursing students from Bangalore Baptist Hospital who were native speakers of the language were recruited to provide the active role of translators. Through the use of diagrams, illustrations and direct translation, students were able to interact with the material in a more efficiently and effectively: They were able to understand a lot especially because we had pictures to show them. The nursing student was a great help to understand the questions the students had. (Research assistant 6) Once the translating and teaching were in sync, things ran smoothly. (Research assistant 2)
It is important to note that while the students seemed to have a foundational knowledge of NCDs. Although they did not have a full understanding of the differences in disease processes or prevention techniques, they had been able to learn enough in their traditional classes to grasp the new content we shared with them in an effective way: The children knew more than I expected and supplemented what we taught them with past information they learned. They were very ready to interact and hear the information we had to give them. (Research assistant 6) It wasn’t difficult to transfer the knowledge because the students had a foundational knowledge. (Research assistant 3)
The students stated that most of their current knowledge of NCDs came from an animated video on NCDs developed in their native language Kannada. When we asked how they could share this knowledge with their peers, the students rejected the lecture-method, stating, They say even though they’re taught in lecture methods, that is fine. But when they want to teach somebody like their peers, lecture is not a good method. (Translator 2)
The students argued that to inform their peers or families about issues they needed to tell stories. They felt this would be more effective than just stating the facts: They like stories. Whatever they tell through stories, they will listen to it. (Translator 1)
After the students struggled to tell us the symptoms of hypertension, they asked if they could instead show us the issues associated with diabetes. Their love of story-telling came out as they began to role play a diabetic patient’s interaction with their health provider: One is gonna be the counselor and the other is gonna be a patient and they’re gonna talk about diabetes, say what they know. (Facilitator 2)
Implementation of the health champion
Students showed a strong desire to learn more about the conditions affecting their community. Four students championed one of these diseases, diabetes mellitus. They took on the task of absorbing all the information they could about the disorder including causes, symptoms and prevention techniques. After a short course on the disorder, the students began organising a puppet show for their classmates: The students were very receptive to crafts and teaching. My group made puppets and they really enjoyed making their own unique characters. They were able to give their characters individual personalities during the skit which makes it fun for the other students to watch and learn. (Research assistant 4)
Not only did students enjoy putting together the puppet show and performing for their peers, but they also exhibited a large amount of knowledge retention from the previous day’s discussions on the disorders. They were able to communicate a comprehensive description of diabetes to their classmates and school faculty: The students were able to meet the objectives I set for them. They were able to talk about diabetes and include all the material taught to them in their puppet show. (Research assistant 4)
The students were able to effectively deliver their learning and knowledge of the disorders through all five of the disease focus groups. Each of the groups took charge of the disease process assigned to them and showed pride in the presentation of their projects at the end of the workshop: I saw students take leadership which means they were confident and comfortable with the content. (Research assistant 3) The objective of the project was met; the students were able to learn the topics and teach back what they had learned from the craft activities. (Research assistant 5)
Discussion
Our study revealed different approaches to teaching that facilitated learning through the interactive health education programme on hypertension, diabetes, otitis media, malnutrition and oral cancer in middle and high schools in a rural subpopulation in Bengaluru, India to build ‘health champions’ among youth.
NCDs are one of the leading causes of death in India and have a higher tendency to be ignored due to lack of understanding. Currently, students are taught health education through lecture-based classes in secondary school. However, the majority of students interviewed demonstrated a lack of fundamental knowledge of NCD and how to prevent them. The mechanisms through which it is most effective to teach health education remain unclear. Identification of learning methods that enhance or detract from the understanding of NCDs will facilitate the development of novel and effective health education curriculum and may improve responses to disease in the community.
In this study, we implemented various teaching strategies to identify aspects of learning that enhanced students’ knowledge and understanding of NCD. Through a combination of interviews and focused teaching groups, we identified creative learning techniques as a significant enhancer for student understanding. The students were able to demonstrate a comprehensive understanding of the disease assigned to their focus group by teaching their classmates in other focus groups accurately and effectively. A previous study demonstrated that the implementation of youth health champions in the United Kingdom improved community engagement and understanding of disease (Altogether Better, 2018; White et al., 2010). This report is consistent with our finding that youth health champions are able to share their knowledge of disease through creative measures effectively. Based on these data, we suggest that creative learning strategies and the implementation of health champions are major influencers on community understanding of NCDs.
This study also revealed how young people perceive their current food choices in comparison to diets used for disease prevention. Through the interview process and discussions with the students, we identified that despite their common meals lacking fruits and vegetables and persisting of mostly grains and starches, the students believed their diets to be ‘healthy’. Previous studies have declared poor diets and sedentary lifestyles to be a catalyst for diseases such as diabetes (Hu, 2011). This argument along with our findings that young people lacked understanding of health-conscious diets confirmed that further education was needed on disease prevention. Based on these findings, lifestyle modifications such as dietary habits need to be addressed as part of the health education curriculum.
Strengths and limitations
There are several limitations to the study. The interviews and focus groups were delivered in English and then translated to the students in their native language. Although the students were receiving the questions and instruction in their primary language, Kannada, the need for translation could influence their understanding of the interview questions and information received in the focus groups. This was also the first time that a health champions approach has been implemented in India. In addition, sampling methods used limited the geographical location of participants to one village in south India. The small sample size and restricted geographical area may have limited the transferability of the results to other schools. Ideally, the workshops would have been conducted in different geographical locations in order that the results could be compared.
Conclusion
Study findings highlight the powerful influence of interactive and creative health education programmes on NCDs. This underlines the significance of creative science curriculum and emphasises the need to address how health champions can be established in other communities effectively. In the absence of strong health education, youth health champions are tasked with sharing their knowledge with their communities to prioritise NCD prevention. Targeting students who are recommended by their faculty or peers may be especially important, given their already established role in the community and their potential motivation to learn.
The findings also reinforce the importance of health education presented in the native language of the learner. This highlights the need for access to translators in order to support staff in implementing an effective learning environment. Given the limited availability of resources, organised games or activities that are common in the community should be utilised. Before implementing health champions in a school, researchers should establish what natural and cost-effective alternatives to craft supplies are available in the community. Future research should focus on developing and testing strategies to maximise implementation of health champions in nearby rural and urban community schools.
