Questions/Answers

Sri Lanka Army has a strength of 171800 personnel and are located in establishments in all nine provinces of the country. The Healthy Army Healthy Nation (HAHN) program was initiated on 19th May 2014 with the aim to reduce the incidence of Chronic Non Communicable diseases(NCDs) and to reduce premature deaths and disability due to NCD amongst Army personnel in Sri Lanka. The HAHN program comprised three parts. First part of the HAHN was a campaign to raise awareness on prevention, risk factors and the impact of NCDs. We created a HAHN Health Education Center, with a trained team, for more effective coordination. The Centre is located in the main Army Hospital in Colombo, the capital of Sri Lanka. Though there were indications that over the years the NCD burden has increased among army personnel, particularly after the three decades of civil war evidence by way of data were not available. Therefore, the second part of HAHN was to survey among over thirty years olds for NCDS and for behavioral and metabolic risk factors. Among 70666 army personnel over 30 years, 47429 (67%) were screened over a period of 3 years. The results confirmed that prevalence of NCDs, obesity, abnormal lipid profiles and diabetes among the army personnel were higher than general populations. This evidence was the basis for the third part which was advocating for the necessary policy changes for primary and secondary preventive activities of HAHN as described in other sections. The third part was to implement activities for prevention of risk factors and to initiate treatment for newly diagnosed and defaulted and follow them up and to evaluate the impact of the program. The latest move is the introduction of Annual HAHN Health Excellence Award to the best unit of the Army which engaged in HAHN activities.

The overall objective is to prevent NCDs and reduce premature deaths and disability amongst Army personnel. With health education program we aim to empower the soldier and the families. The island wide survey indicated that soldiers’ physical activity was low and we introduced measures to increase physical activities. Soldier has to maintain a normal Body Mass Index to be eligible for promotions . Our analysis indicated that the food provide free of charge, were high in calorie and fat . We started regular training of army chefs on healthy cooking and initiated serving of healthy snacks at meetings. We arranged treatment for diagnosed patients and arranged a supply of 16 essential drugs to treat NCDs at peripheral army hospitals. We introduced a NCD record book to monitor treatment. We distributed packs containing a weighing scale, sphygmomanometer, stethoscope, measuring tape and glucometer to each peripheral unit to monitor the progress at their camp. We are providing psychological support through a helpline and education programs to help combat addiction to alcohol/cigarettes. We were successful in legislations to ban selling/smoking of cigarettes in Army restaurants and Alcohol ban on Mondays and Wednesdays and after 10 pm on other days.

Category 2 . The HAHN was designed and is being implemented by the Medical branch of the Sri Lanka Army. The programme took all steps to formalize it to each of the Regiment of the Army and to ensure the participation of the Army personnel in decision-making. In the past, adhoc measures to reduce NCDs were taken such as one-off awareness or screening programs but there wasn’t a holistic, multifaceted program like Healthy Army Healthy Nation (HAHN). All activities are conducted by the Army personnel. HAHN collected data regarding prevalence and risk factors for NCDs and evaluated key areas that needed to change. The initiative is geared towards educating personnel to modify their lifestyle and initiate treatment to prevent development and progression of NCDs. As they were unaware of the impact of NCDs in their lives we have initiated education and support around this. We recognized that a big motivating factor was their family life. We used real case studies demonstrating the effect of NCDS on personnel and their families. This had a big impact on lifestyle modifications. No similar program has been initiated in any of the Armed Forces so far.

The initiative improves the delivery of public services in many ways. Reaching all army personnel with the service and not leave anyone behind was the premise of the design of the program. Furthermore, through the army personnel we also reached their families. Many case studies where the HAHN is been cited as having ‘saved’ the lives of the solders and their families have been documented by us. This program is indeed an enhancement to the existing services in the health sector of the country. The underlying design is creating a health promoting setting in the Sri Lanka Army. HAHN has already been recognized as a valuable contribution to the health sector in the country. Reaching all with comprehensive program with both preventive and curative components is certainly in alignment with the 2030 SDG agenda.

The HAHN was designed specifically to cater for the Sri Lanka Army personnel and their families. Having a healthy army is a must for the country. HAHN served men and women army personnel equally. Through the soldiers it reached the families, comprising children and elders. Sri Lanka experienced a civil war for 30 years and high proportions of army personnel are left with disabilities. The HAHN had a particular focus on the disabled and included special features to cater for the disabled. The following significant issues related to the delivery of public services were addressed by HAHN. In the past, public services related to providing health care to Army personnel, especially awareness and screening programs were done in Colombo Army hospital . No coordinated national program existed and programs were not spread out to be delivered into the periphery. Patients with NCDs or complications were treated only if they presented to the main army hospital in Colombo as NCD medication were not available in the periphery. Patients would present late as they lacked awareness of symptoms and was further for them to travel for review .

Each army soldier over 30 years has been given a NCD record book with their health information data ,next clinic appointment, when to get their next blood test done and Cardio Vascular Risk Prediction Chart. We have empowered the soldier on an individual basis to take control of their health management. Our records show that they regularly attend their appointments. We introduced a compulsory annual fitness test for officers which includes blood pressure, blood sugar, cholesterol measurements, BMI and waist circumference. We introduced a marks system based on these readings. Our records indicate an increased initiative by the officers to maintain their BMI. Our Health Education Centre shows an increased number of attendance by family members of Army personnel who want to get dietary advice to reduce weight and get medicine for NCDs. They have been motivated by their relatives working in the Army.

Our multifaceted holistic approach of tackling NCDs – which includes awareness programs, nationwide screening, early detection and treatment, follow up and monitoring - is a new approach in the public sector , especially in the Armed Forces. Further we have implemented innovative policies such as banning the sale of cigarettes and smoking in Army camps to make camps a smoke-free workplace. Another policy implemented was to restrict the sale of alcohol after 10 pm in army restaurants to reduce alcohol consumption. Our screening indicated that the percentage of people with obesity and hyperlipidemia was higher than the national average. Therefore, with support of army management, we proposed an innovative idea to incorporate healthy options at Army camps to support dietary changes. We have started to train Army chefs on regular basis on healthy cooking methods. We have ensured that healthy snacks are now being served at meetings instead of deep fried snacks. Additionally, we identified that sugar consumption was high in particular because 56g of sugar was included and consumed by an Army personnel per day in their cups of tea. We have recently proposed that sugar quotas be reduced and that sugar be served separately with tea.

Our program is original and shaped primarily due to recognition of the impact of NCDs within the Army. We take into account feedback from ground level personnel when designing solutions and proposals for implementation of the program. The program deals with specific problems seen in Armed forces such as stress, living away from home in camps or peer pressure to smoke and drink. Due to the work commitments they are unable to attend awareness programs, screening programs or attend medical clinics in the Army hospital in Colombo to collect medication. Our program enables the delivery of preventive initiatives, treatment and follow up to be available in every camps around the island. Recently we have given the personnel 4 goals to achieve and given them a pneumonic to remember it which is the date that they won the civil war, 2009.05.19. Cholesterol level below 200mg/dl, diastolic blood pressure 90mmHg or below, HbA1C close to 5.6 and BMI between 18.5 to 24.9.

We approached the Commander of the Army and the directors to present our work, long term goals and proposals for our initiative. We gained their support and approval. We obtained funds, material, staff and other resources from the Army for the program. When we first started this program Prof .Shanthi Mendis from WHO gave her valuable advice. We obtained health education leaflets from the Non Communicable Diseases Unit in the Health Department and Nutrition unit. The WHO country office helped us with material resources, advice and guidance. All the invited lecturers for our health education programs helped voluntarily.

No

We have discussions with medical staff of other armed forces to initiate a similar program in their forces. All three parts of the HAHN program could be started by other forces

One of the key principles of this program is to give soldiers ownership of this project and enable them to take responsibility for their health. The program has been co-created by the people (Army personnel) to deal with their issues. We used their ideas to help design this program. We also started this program on a battalion by battalion basis so that the program could be localized as needed and so that the commanding officers of the battalions feel the responsibility to make their troops healthy. Additionally, we provide every soldier with a booklet following screening to empower them to be a part of the program, and an active part of monitoring their health. We also continually listen to personals ideas to help introduce new initiatives into the program, giving them the flexibility to change and adapt the program by providing them the processes to feedback any suggestions or changes needed on a regular basis. Therefore, they feel that they have and can inform us of the problems and challenges and that the solutions are more applicable to them, making them less resistant to these initiatives. We also ensure that we have educational programs for family members of soldiers on a regular basis so that soldier can get support needed from home to sustain behavior changes and lead a healthy life.

1/ Support of senior staff: The program is expected to be sustainable as we have ensured that we have continually secured support from the Commanders, decision makers and senior staff of the Army on a regular basis. We regularly present to Army senior staff and decision makers, as well to Army Commanders as soon as they are appointed, to demonstrate the impact of NCDs on the Army. We highlight the impact of personnel through statistics and case studies, as well as the impact on the overall army of the loss of manpower, in particular due to premature deaths and number of personnel unable to do normal army duties due to the development of complications due to NCDs, and the cost and economic burden to the army as a result of NCDs. We also engaged with management to help shape and change the program, as well as to implement wide scale policy changes (e.g. restriction of the sale of cigarettes in army shops). Through these presentations and engagement, we ensured that the management of the Army strongly supports the continuation of the project moving forward. 2/ Regular updates to materials of the program: We constantly introduce new materials and resources into the program to keep army personnel engaged with health messages. For example, the army media team supports us to make new short films with case studies to showcase the impact of NCDs as well as new posters and materials. 3/ Showcasing best practice and inspiring other personnel: We have recently introduced an annual Award to recognize personnel and battalions who have implemented good health practices to showcase success and motivating their peers to do the same. By regularly celebrating success and using this to inspire peers to make future changes, we believe this will help sustain the project moving forward.

Yes

We performed an analysis of the effectiveness of the programme based on the data over the past three years. The data on incidence of NCDs among army personnel and the premature deaths among Army personnel was compared over the period of three years. Every six months we have to present to army Advisory Board, evaluation of our data with regard to NCD deaths

Evaluation of the death records showed that number of people dying from NCDs have reduced since the commencement of the HAHN. In the year 2015 deaths due to NCDs among Army personnel under 55yeasrs was 63, whereas in 2017 deaths under 55yrs from NCDs was 48. The percentage of over 30 yrs old people who smoked was 69% in2015. It was 35% in 2017.It shows that reduction in exposure to major risk factor for cardio vascular deaths. The results of the evaluations have been presented at the Annual Scientific Sessions of the Sri Lanka Association of Military Medicine (SLAMM) in 2017 and was awarded a prize. A journal article on the results of the evaluation has been accepted and will be published in SLAMM journal in March 2018.

The main quantitative impact indicators used are • deaths due to NCDs among Army personnel under 55 yrs • percentage of over 30 yrs old Army personnel who smoked • percentage of over 30 yrs old Army personnel who had high cholesterol levels • percentage of over 30 yrs old Army personnel Who had high Blood pressure • percentage of over 30 yrs old Army personnel Who had high Blood Sugar • percentage of over 30 yrs old Army personnel Who had high – BMI Other than these, informal discussions with the medical staff of units are also used as qualitative indictors to inform the progress of the program

1. Ground-level army personnel: When designing HAHN program, and on a continual basis, we obtain views of ground-level army personnel through discussions and information from regular feedback questionnaires (e.g. after awareness events) 2. Management of the army: We have established cross-functional steering and advisory committees with senior officers from administrative staff, medical directorate, laboratory staff, psychiatrist and psychologists, medical officers, and staff from battalion medical units as well as staff from the IT department and publicity & media unit of SL Army. These committees have enabled us to engage with teams from across the military to guidance and help to conduct and implement this program. 3. We engaged with the Epidemiologist of the Medical School of Kotalawela Defence University, who has contributed in designing NCD patient monitoring book (a book given to every patient after screening to enable effective condition and treatment monitoring) 4. WHO Country Office: Medical and Administrative Officers from WHO country office, Colombo have worked closely with us from the start of this program, giving us their fullest cooperation and providing us with constructive guidance as well as equipment and materials. 5. Ministry of Health: We have engaged with a number of departments in the Ministry of Health such as NCD unit and Nutritional unit who have provided us educational leaflets on a regular basis. 6. Other civil and private sector organizations: Private sector organizations have supported us by providing us resources and logistical support to organize screening and health education programs for the family members of the army personnel in numerous districts outside Colombo. We have also engaged other civil / private organizations as needed during the course of the project – for example, we recently partnered with Sri Lanka Hotel School, who provided us volunteer chefs to train chefs in the Army in healthy food preparation.

1. We initially introduced BMI in the officers’ yearly fitness tests to be used as a measure of obesity. The use of this measure faced much opposition. This was because BMI could be impacted by not only fat but also by muscle mass and bone weight. Hence, next year we plan to purchase a body analyzer machine which will read bone weight muscle mass together with BMI which is likely to give a more holistic indication of health. 2. One of the biggest challenges of our initiatives has been influencing army personnel to unlearn their current wrong attitudes, misconceptions and unhealthy behavior and lifestyle choices. Therefore, we have initiated NCD prevention lectures in the curriculum of their introductory program of new recruits of the Army. A recent survey of new recruits revealed that only one in ten had some knowledge and understanding in NCDs and its prevention. Hence we believe that by equipping them with knowledge of NCDs and how to reduce their risk of these conditions at start of their army career, we will be able to instill behaviors in them to help reduce the impact of NCDs in the long term more easily and more sustainably.