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Overall, 7 of the top 10 fatal diseases in the world are chronic noncommunicable diseases (NCDs) (1). Approximately 89% of deaths in China were attributed to NCDs in 2018 (2). In order to mitigate the effects of NCDs in China, it is necessary to establish a system for comprehensive NCDs control, carry out comprehensive health education and promotion, and advocate the adoption of a healthy lifestyle by the public (3). Therefore, multiple national departments launched the China Healthy Lifestyle for All (CHLA) campaign to promote and disseminate information on a healthy lifestyle, promote technical measures and support tools, and carry out various national activities in 2007. To evaluate the implementation and intervention of CHLA, we applied the RE-AIM model (4). Overall, the CHLA has shown an upward growth trend and actions taken under the CHLA in multiple domains have shown great progress. To further promote the CHLA, measures were tailored to local conditions.
This study contains a literature review, systematic review, and meta-analysis and applied the RE-AIM model to evaluate the process and results of the CHLA project. The relevant literature was retrieved from both Chinese and English databases as well as other publicly available platforms, including the VIP Chinese Journal Service Platform, the China National Knowledge Infrastructure (CNKI), and the United States National Library of Medicine (PubMed) with the key words of CHLA and its related activities. A mixed research approach combining qualitative and quantitative methods was used to collect and analyze the data. Annual progress data for CHLA comes from the work information management system of CHLA, which includes CHLA activities’ data from 31 provincial-level administrative divisions (PLADs) and Xinjiang Production and Construction Corps (XPCC) in the mainland of China. The evaluation dimensions are described inTable 1.
Dimension Definition Index Reach
Obtain service propagation or effective coverageCoverage and mass participation Efficacy Behavioral consequences of intervention Awareness rate, utilization rate of health tools, changes in life behavior; mass satisfaction Adoption Organizational support and participation in policy implementation Departments involved in the action Implementation Whether the implementation is carried out as planned, the content and depth of implementation; the compliance of the participants The construction of propaganda and education activities, training activities and health support environment Maintenance The extent to which the action is maintained or institutionalized (policy, legislation) Measures to ensure the sustainability of the action Abbreviation: RE-AIM=reach, efficacy-adoption, implementation, maintenance. Table 1.RE-AIM evaluation dimensions.
In the “Reach” dimension, the coverage and mass participation in the CHLA actions were shown inTable 2. In our study, up to December 31, 2015, a total of 2,507 counties (districts) across the country had launched the CHLA, a launch rate of 80.90%. Up to December 31, 2020, a total of 2,817 counties (districts) across the country had launched the CHLA action, a launch rate of 95.20%. The rates in the eastern, central, and western regions were 97.36%, 97.73%, and 91.36%, respectively. The launch rate of each region has increased in the two phases with the fastest expansion in the western region. In general, the launch rate of the western region, as compared with the eastern and central regions, was still at a low level.
Region Phase 1 Phase 2 Number of counties (districts) under their jurisdiction Number of counties (districts) launching CHLA Proportion (%) Number of counties (districts) under their jurisdiction Number of counties (districts) launching CHLA Proportion (%) Eastern region 912 849 93.09 909 885 97.36 Central region 922 888 96.31 927 906 97.73 Western region 1,265 770 60.87 1,123 1,026 91.36 Total 3,099 2,507 80.90 2,959 2,817 95.20 Note: For phase 1: Data was updated on December 31, 2015; for phase 2: Data was updated on December 31, 2020.
Abbreviation: CHLA=China Healthy Lifestyle for All.Table 2.Launch of CHLA in the eastern, central, and western regions.
In the “Efficacy” dimension, the CHLA action had achieved a remarkable intervention effect. In 2012, the National Action Office carried out a nationwide assessment of the CHLA, which mainly assessed its five aspects, including “awareness of the CHLA action,” “awareness of healthy lifestyles,” “awareness of health knowledge,” “use of health support tools,” and “changes in lifestyle and behavior.” It has been documented that specific knowledge on a healthy lifestyle, such as the recommended level of physical activity, recommended intake of oil and salt, and parameters for a healthy Body Mass Index were higher in the action groups than in the non-action groups, and higher in urban than rural populations (5). In addition, the proportion of conscious control of oil and salt intake in urban and rural action groups was higher than that in non-action groups (5). In this study, according to the inclusion and exclusion criteria, 42 pieces of literature (47 studies) were included in the meta-analysis. The results showed that the CHLA was effective. SeeTable 3for the results on lifestyle and behavior changes in the CHLA action group and the control group. In addition, it was notable that the CHLA was well accepted across the country. For example, in 2014, Shanghai carried out an evaluation of the effect of the yearly distribution of health gift packages to the city’s residents as part of the CHLA action, showing 82.1% satisfaction.
Item Region Quantity of study RR (95% CI) Conscious control of salt intake Eastern region 12 1.43 (1.22, 1.68) Central region 2 1.83 (0.85, 3.94) Western region 5 1.17 (1.13, 1.23) Total 19 1.39 (1.25, 1.54) Conscious control of edible oil intake Eastern region 12 1.59 (1.30, 1.94) Central region 2 1.89 (0.86, 4.13) Western region 5 1.24 (1.13, 1.36) Total 19 1.50 (1.32, 1.70) Conscious control of body weight Eastern region 11 1.51 (1.23, 1.86) Central region 2 1.36 (0.57, 3.23) Western region 5 1.23 (1.16, 1.30) Total 18 1.40 (1.23, 1.59) Daily intake of fresh fruits Eastern region 3 1.27 (0.89, 1.81) Central region 1 1.52 (1.43,1.61) Western region 5 1.36 (1.08, 1.70) Total 9 1.35 (1.16, 1.57) Daily intake of fresh vegetables Eastern region 3 1.16 (1.06, 1.27) Central region 1 1.59 (1.52, 1.67) Western region 5 1.34 (1.15, 1.57) Total 9 1.31 (1.16, 1.49) Abbreviations: CHLA=China Healthy Lifestyle for All; RR=relative risk; CI=confidence interval. Table 3.Meta-analysis of the behavior changes in the CHLA action group and the control group.
In the “Adoption” dimension, many departments were involved in the action. The first phase of the CHLA was jointly initiated by three departments and the second phase was jointly managed by five ministries and commissions. In light of local conditions and the advantages of multi-department collaboration, a working mechanism for the CHLA has been gradually formed under the leadership of the government and with the participation of various departments. For example, the Chongqing Municipal Education Commission, market regulatory departments, sports departments, municipal governments, propaganda unions, and other relevant departments actively issued policy documents conducive to the control of risk factors related to chronic NCDs.
In the “Implementation” dimension, the corresponding results were shown inTable 4. Increasing trends were seen in the number of trainees, on-site activities, health lectures, and so on since the launch of the CHLA actions in the eastern, central, and western regions. In the first phase of CHLA implementation, the eastern region made progress in all areas, while the western region lagged behind. In the second phase, progress was made in all regions.
Item Phase 1 Phase 2 Eastern region Central region Western region Total Eastern region Central region Western region Total Number of trainees 330,685 290,642 205,563 826,890 531,459 518,130 1,128,370 2,177,959 Number of on-site activities and health lectures 42,668 23,968 20,653 87,289 98,224 57,424 60,661 216,309 Frequency of media coverage 11,728 9,943 5,453 27,124 26,426 22,869 15,676 64,971 Supportive environment* 24,171 10,305 6,480 40,956 42,463 22,001 14,532 78,996 Smoke-free environment 17,690 7,942 6,544 32,176 21,420 12,643 11,047 45,110 Ten minutes of physical exercise at schools 1,063 843 383 2,289 1,388 1,058 621 3,067 Healthy lifestyle instructors 126,339 74,025 44,040 244,404 362,726 222,042 214,209 798,977 Abbreviation: CHLA=China Healthy Lifestyle for All.
* There are nine main environments for health-oriented interventions: communities, public institutions, schools, canteens, restaurants (hotels), footpaths, cabins (gas stations), streets, and theme parks.Table 4.CHLA Progress in the eastern, central, and western regions.
In the “Maintenance” dimension, central and local governments took many measures to ensure the sustainability of the CHLA actions. For example, Shandong Province brought salt reduction interventions under the provincial basic public health service projects and grassroot medical and health service institutions carried out salt reduction interventions and follow-up for residents in areas under their jurisdiction. In addition, since the launch of the CHLA, many technical programs have been released, such as the Overall Program of Action on Healthy Lifestyles for All (2007–2015), the Implementation Program for Healthy Lifestyle Instructors, the Action Program on Healthy Lifestyles for All (2014–2025), and so on. These actions have also been incorporated into policy documents such as the Performance Evaluation Standard for Disease Prevention and Control (2012), the Outline of the “Healthy China 2030” Plan, and China’s Mid-and Long-term Plan for the Prevention and Treatment of Chronic Diseases (2017–2025) and so on.
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China’s top legislature approved the country’s 14th Five-Year Plan, the blueprint for high-level development for the next five years, and pointed out the need to “fully implement the healthy China Action.” Therefore, we applied the RE-AIM model to evaluate the actions to provide scientific advice for the formulation of population-based risk reduction strategies for chronic NCDs for the 14th Five-Year Plan.
In this study, the launch rate of the CHLA showed an upward trend in adoption at the county level. However, due to the vast differences in the level of economic growth among different regions, the development of CHLA was not balanced. Compared with the eastern and central regions, the start-up rate in the western region was the lowest. As for the progress on the actions themselves, the eastern region was generally in a leading position, while the western region was relatively slow. This suggests that the actions can be carried out by level management in the future (6). The Health Literacy Monitoring Report of Chinese Residents 2012–2020 showed that among the 3 aspects of health literacy levels, healthy lifestyle and behavioral literacy had the fastest average growth rate. Among the literacy levels of six types of health problems, NCDs prevention and control literacy had the fastest average growth rate. These metrics indicate the success of the CHLA. However, some of the CHLA’s goals and indicators have not been satisfactory. For example, the rate of obesity among urban and rural residents of all ages in China has been rising, with more than half of the adult residents being either overweight or obese (7). It is worth noting that the rate of being overweight or obese among 6- to 17-year-old children and adolescents is 19% (7). These problems indicate that the development of a healthy lifestyle requires continuous efforts and attention to all stages of the life cycle (8). Overall, it is important for the government to formulate strategies and measures with sustainable plans for their ensured and continued implementation.
Since the CHLA was launched in 2007, only one effective evaluation had been carried out nationwide in 2012. There had also been some evaluations in some PLADs, but the evaluation methods and content design varied. Since the initiation of the CHLA action, no scientific, comprehensive, and systematic evaluation has been conducted on the application of health-supported environments nor on the settings and work of healthy lifestyle instructors. In order to ensure the sustainability and scientific nature of this strategy, it is recommended that an action evaluation index system is developed, standardized, and adopted for the evaluation of content and implementation of the CHLA actions as soon as possible for regular evaluations.
This study was subject to several limitations. First of all, this study used publicly available data. Therefore, no unreleased or non-published data was included. Second, CHLA is a population-based intervention for NCDs in China. Therefore, it is unable to be used to develop scientific recommendations and strategies for individual-based intervention.
In the future, with improved strategies and more attention from the government, national healthy lifestyle actions can be effectively promoted, helping residents demonstrate the concept of “taking the first responsibilities for their own health.”
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No conflicts of interest.
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Experts who contributed to the project and the Office of China Healthy Lifestyles for All.
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