The Dutch Heart Health Community Intervention 'Hartslag Limburg': effects on smoking behaviour

BACKGROUND AND METHODS: A pretest-posttest control group design with two posttests was used to evaluate the effects of a regional Dutch Heart Health Community Intervention on smoking behaviour and its determinants. At baseline, a cohort research population of 1,200 smokers was recruited in the intervention region and in a control region. Data was gathered by means of short structured telephone interviews. RESULTS: No significant differences were found between the intervention region and the control region on smoking behaviour and its determinants. CONCLUSION: It is concluded that the regional intervention was unable to exceed secular trends in smoking cessation.     

Twelve year follow-up of a school-based health education programme: The Oslo Youth Study

The Oslo Youth Study (1979–1981) was designed to evaluatethe impact of a school-based health education programme targetingstudents' eating patterns, physical activity levels and cigarettesmoking. The study was implemented with participants from 6combined elementary and junior high schools, half of whom receivedthe educational programme. In the autumn of 1991, students enrolledas part of the Oslo Youth Study grade cohorts in 1981 were invitedto participate in a follow-up study. The purpose of this studywas to investigate the potential long-term impact of the OsloYouth Study health education programme. A total of 711 subjectscompleted a questionnaire in 1991 (an overall participationrate of 75.1%). Analysing the cross-sectional data obtainedin 1991, we observed no overall long-term positive impact ofeither the smoking, nutrition or physical education programmes.Among the 1979–1991 cohort participants, we found thatsubjects exposed to the educational programme reported a significantlyhigher prevalence of regular vigorous exercise than did subjectsfrom comparison schools (49 versus 40%; p=0.01). No similareffect was seen with smoking or eating behaviour. The resultsfrom this 12 year follow-up study seem to confirm findings fromprevious studies indicating that school-based education canhave a positive short-term impact on health-related behaviours,but that these effects tend to disappear over time.     

Twenty year smoking trends in a community-based cardiovascular diseases prevention programme: Results from the North Karelia Project

Objectives: to evaluate long-term changes associated with acommunity-based cardiovascular disease prevention programmeon smoking. Methods: the North Karelia Project was started in1972 to carry out a comprehensive community-based programmeto reduce the exceptionally high rates of cardiovascular diseases(CVD) in North Karelia, an eastern province in Finland. Amongthe main intermediate objectives was the reduction of smokingrates, particularly among the male population. The programmewas evaluated by standardized examinations of large representativecross-sectional population samples in 1972, 1977, 1982, 1987and 1992 in North Karelia and in the Kuopio province, anotherprovince in eastern Finland, which was initially chosen as referencearea for the first project period. Results: in men the percentageof current smokers decreased during the 20 years from 52 to32% in North Karelia and from 50 to 37% in the initial referencearea (p<0.05). Smoking declined faster in the first 10 years(from 1972 to 1982) than in the last 10 years. During the first10 years the decline was more remarkable in North Karelia thanin the reference area. The main reason for the decline in smokingduring the first 10 years was smoking cessation and during thelast 10 years the increase in the number of people who had neversmoked regularly. Among women the proportion of smokers increasedin both areas from approximately 10 to approximately 20%. Thisincrease was greatest in the youngest age group. Conclusions:the community-based cardiovascular disease prevention programmewas an effective way to reduce smoking in the general populationin men and sustained decline could be achieved.     

Health demonstration projects: Evaluating a community-based health intervention programme to improve young people's sexual health

There has been criticism of systematic reviews and meta-analyses that have shown little evidence of effect of interventions to improve teenage sexual health. Moreover, there is considerable controversy surrounding the validity of outcomes and rigour of design in evaluation methods for community-based programmes. In this climate, Scotland launched Healthy Respect, one of four community-based national Demonstration Projects, to address teenage sexual health. Healthy Respect is a complex and multi-stranded intervention in Lothian Region that includes education and health-promotion activities and alternative ways to provide sexual health services for young people. A multidisciplinary research team at the University of Aberdeen was appointed to undertake an independent evaluation of this demonstration project. Challenging some aspects of theory-based evaluation, it is argued that adopting both quantitative and qualitative methods will provide an understanding of both the context and process of this Health Demonstration Project, as well as tracking outcomes, including behavioural change, in the target population. The authors’ evaluation includes: examining the process of implementation; comparative regional mapping of the service context including inter-agency partnership working; and assessing effectiveness using a quasi-experimental design and adjusted, population-based, behavioural and sexual health outcomes. Evaluation from these key perspectives contributes to a balanced appraisal of a complex, community-based health promotion and service delivery intervention.     

Assessing the knowledge and skill needs of community-based health promoters

Community-based health promoters require a range of complexskills. As part of its ongoing support to five community-basedhealth promotion programs, the Health Promotion Branch of theOntario (Canada) Ministry of Health, commissioned a study toidentify knowledge and skills needs in these programs and assesswhether resources were available to meet these needs. A NeedsAnalysis Questionnaire was developed and administered to coordinators,staff board members, and volunteers at 23 health promotion sites.Key informant interviews with site coordinators and focus groupinterviews of site staff board members and volunteers were carriedout. The needs analysis process is presented, as are illustrativefindings. Potential applications of the needs analysis proceduresare considered.     

Towards a framework for outcome assessment of health intervention: Conceptual and methodological considerations

We provide a framework for assessing the outcome of community-basedintervention programmes for the promotion of cardiovascularhealth at local level. Particular attention is therefore givento conceptual components connected with community participationin health programmes and to methodological approaches in theevaluation of cardiovascular disease (CVD)-prevention programmes.In a search of the literature covering more than 20 years (1966–1988)in 2 databases (MEDLINE and SOCA), we found that the conceptsof ‘community participation’ and ‘communityinvolvement’ have mainly been used during the latter halfof the study period. The concepts were often used interchangeablyand with no statement as to their precise meanings. The methodologicalexamination of 2 well-known community-based CVO-preventive programmesrevealed that most of the scientific papers from these programmesdealt with health behavioural and/or medical effects. The suggestedframework presented in this study is designed as a longitudinalprocess analysis focusing on critical key steps along the pathfrom input to output. The suggested research strategy is problem-orientated,inter-disciplinary and based on a multi-method approach.     

Promoting physical activity in women: evaluation of a 2-year community-based intervention in Sydney, Australia

Women are less likely than men to reach recommended levels of physical activity and have unequal access to active leisure time. Studies in Australia have consistently found that women are only half as likely as men to be adequately active. A community-based multi-strategic health promotion intervention, 'Concord, A Great Place to be Active', was implemented from 1997 to 1999. It aimed to increase the physical activity levels of women aged 20-50 years living in the Concord Local Government Area (LGA), an inner-western region of Sydney, Australia. A key feature of this intervention was a partnership between Concord Council (the local government) and the Central Sydney Health Promotion Unit (CSHPU). The project was evaluated using qualitative and quantitative methods. Key informant interviews and focus groups were conducted to inform the development of the intervention and to assess the impact of the project on Concord Council. Pre- and post-intervention telephone surveys of the target group were also conducted. Following the intervention, there was a statistically significant (6.4%) reduction in the proportion of sedentary women. Further, there were a number of positive enhancements in the Council's capacity to promote physical activity in the community. These findings demonstrate that a community-based intervention targeting a specific population can achieve positive changes in physical activity and that a local government has the capacity to be involved in and sustain physical activity interventions.     

The Ghana community-based health planning and services initiative for scaling up service delivery innovation

Research projects demonstrating ways to improve health services often fail to have an impact on what national health programmes actually do. An approach to evidence-based policy development has been launched in Ghana which bridges the gap between research and programme implementation. After nearly two decades of national debate and investigation into appropriate strategies for service delivery at the periphery, the Community-based Health Planning and Services (CHPS) Initiative has employed strategies tested in the successful Navrongo experiment to guide national health reforms that mobilize volunteerism, resources and cultural institutions for supporting community-based primary health care. Over a 2-year period, 104 out of the 110 districts in Ghana started CHPS. This paper reviews the development of the CHPS initiative, describes the processes of implementation and relates the initiative to the principles of scaling up organizational change which it embraces. Evidence from the national monitoring and evaluation programme provides insights into CHPS' success and identifies constraints on future progress.     

Unemployment and health in Spain: The influence of socio-economic environment

We present the results of a study on the association betweenunemployment and health and the use of health services, exploringthe influence of the socio-economic environment on these relationships.With this aim, data from the Spanish National Health Survey(SNHS) were used. Health was measured by subjective health status,presence of chronic illnesses and psychological symptoms. Theuse of health services was measured by drug consumption (overthe counter and/or prescribed drugs), doctor consultation, hospitaladmission and casualty attendance. A total of 13,344 individualsaged between 16 and 65 years were included. Results were analysedfor all of Spain and for 3 regions with different socio-economiclevels: Andalusia, Catalonia and the Basque Country. Althoughin Spain as a whole there was a relationship between unemployment,ill health and more use of health services, this relationshipvaried for the selected regions. Thus, in Catalonia and theBasque Country, where unemployment rates have dramatically increasedin recent years, this relationship was maintained, while inAndalusia, where high unemployment rates have been a long-standingphenomenon, the relationship was less clear. It is suggestedthat the economic and social environment might be critical indetermining the relationship between unemployment and health.     

SMOCC: Design of a Representative Cohort-study of Live-born Infants in the Netherlands

The Social Medical Survey of Children attending Child HealthClinics (SMOCC) was initiated to obtain reference data on morbidityin children in their first two years of life. During 1988 and1989, the staff of 21 Child Health Clinics recorded data onthe pre- and perinatal period, and on the first two years oflife, of infants born in the geographically defined catchmentareas of these clinics. The cohort is representative of thenewborn population of the Netherlands with respect to mother'sage at delivery, parity and, to a somewhat lesser extent thelevel of maternal education and degree of urbanization of residentialarea. The incidence of preterm birth and of very preterm birthin the sample was 6.8% and 0.66%, respectively. Incidence oflow birthweight and of very low birthweight was 6.0% and 0.71%,respectively. Birthweights of singleton infants were in accordancewith the national standard (the Amsterdam intrauterine growthcharts).     

Lessons for health strategies in Europe: The evaluation of a national health strategy in England

Objectives: To determine the impact of the national health strategyfor England, ‘Health of the Nation’ (HOTN) at thelocal level; the mechanisms by which this was achieved; andto provide lessons for the new strategy, ‘Saving lives:our healthier nation’. Design: Case studies. Semi-structuredInterviews with key actors across a range of organisations (n=133),analysis of documents (n=189), and analysis of expenditure forthe period 1991/1992 – 1996/1997. Setting: Eight randomlyselected English health authorities. Main outcome measures:Perceptions and documentary evidence of the impact of HOTN onlocal policy and changes In expenditure. Results: Three modelsof implementation were Identified: strategies based directlyon HOTN; HOTN plus additional elements (‘HOTN plus’);and strategies under another label such as healthy cities orurban regeneration. There was clear commitment to Intersectoralwork and some support for joint appointments of directors ofpublic health by health and local authorities. HOTN was seenas failing to address underlying determinants of health, reducingcredibility with key partners. Views were divided on whetherto adopt a population- or disease-based model. Consistency incentral government policies and communication of the strategywere criticised. HOTN was universally perceived as increasinghealth promotion activities, particularly in the key areas.HOTN received few mentions in corporate contracts and generalpractice reports. Expenditure on health promotion activitiesIncreased slightly then declined, and HOTN appears to have hadonly limited influence on resource allocation. Conclusions:Central government, In England, should enable rather than prescribestrategy implementation. It should ensure appropriate structuresare in place and that national polices are consistent with thestrategy. There is a debate about where the responsibility forhealth strategy should lie, whether with the NHS or local authorities.The new strategy should address different audiences: local government;the NHS; the voluntary sector; the private sector; and the public.One model is the matrix approach of the European Commissionhealth promotion programme. HOTN failed to engage three groups:the public, primary care, and the private sector. This studyhas important implications for the monitoring of the new strategy.It needs to be firmly embedded in the work of those who mustimplement it. It should be incorporated into the NHS performancemanagement framework. The current financial reporting mechanismspreclude monitoring expenditure on a health strategy. Ring-fencingsome resources for the new strategy should be considered, ifonly to give it the high priority it requires. This study, bothin terms of the methods used to evaluate the strategy and thelessons learned, could be used by other European countries developingand evaluating their own health strategies.     

Two year cumulative incidence of trunk abnormalities in a schoolpopulation in Rotterdam, The Netherlands

We conducted a study of the 2 year cumulative incidence of trunkabnormalities in a cohort of 3,071 11 year old children (1,621boys, 1,450 girls). The following data were recorded: height,weight, signs of puberty and menarche. Trunk abnormality wasassessed in the erect child (asymmetry of shoulders and waistline,imbalance of the trunk, scoliosis, lordosis, kyphosis, swaybackand flexibility) and by the forward bending test (FBT) (ribhump or lumbar prominence, persisting scoliosis, kyphosis anddeviant lateral aspect). A normal FBT both at baseline and atfollow-up was found in 84% of the boys and in 79% of the girls.The 2 year cumulative incidence of an abnormal FBT was 10% inboys and 13% in girls.     

Governing through community allegiance: a qualitative examination of peer research in community-based participatory research

The disappointing results of many public health interventions have been attributed in part to the lack of meaningful community engagement in the planning, implementation, and evaluation of these initiatives. Community-based participatory research (CBPR) has emerged as an alternative research paradigm that directly involves community members in all aspects of the research process. Their involvement is often said to be an empowering experience that builds capacity. In this paper, we interrogate these assumptions, drawing on interview data from a qualitative study investigating the experiences of 18 peer researchers (PRs) recruited from nine CBPR studies in Toronto, Canada. These individuals brought to their respective projects experience of homelessness, living with HIV, being an immigrant or refugee, identifying as transgender, and of having a mental illness. The reflections of PRs are compared to those of other research team members collected in separate focus groups. Findings from these interviews are discussed with an attention to Foucault’s concept of ‘governmentality’, and compared against popular community-based research principles developed by Israel and colleagues. While PRs spoke about participating in CBPR initiatives to share their experience and improve conditions for their communities, these emancipatory goals were often subsumed within corporatist research environments that limited participation. Overall, this study offers a much-needed theoretical engagement with this popular research approach and raises critical questions about the limits of community engagement in collaborative public health research.     

The Cancer and Diet Intervention Project: a community-based intervention to reduce nutrition-related risk of cancer

This paper describes a community-based intervention programdesigned to lower diet-related risk of cancer. The program isone of the first to attempt to make operational cancer-relateddietary guidelines. It was designed as a feasibility study fora possible larger-scale multi-community study. The interventionwas structured in three parts: mass media, grocery store environmentmodification including point-of-purchase labelling and a home-basededucation course, and was undertaken in one rural midwest communitywith a similar community as a comparison. Formative evaluationwas undertaken to define and tune intervention strategies. Communityleaders were involved in the intervention from its inception.The initial intense program ran for 3 months with a maintenanceperiod of 12 months. The dietary intervention was focused onan eating pattern message (designed to reduce fat consumptionand increase fiber intake) for which criteria for specific foodswere developed. Outcome variables included knowledge, attitudesand practices related to diet and cancer. These were measuredin a series of cross-sectional samples in each community. Thestudy design allowed estimation of dose-response effects withinthe intervention community. Novel aspects of the evaluationdesign included a specific attempt to measure the effect ofself-selection into an intense information-giving interventioncomponent and two new ways of measuring community dietary change.Cost-effectiveness evaluation was included.     

Developing a community-based neonatal care intervention: a health facility assessment to inform intervention design

Community-based interventions are an important way of improving health in low-income countries. A necessary prerequisite for the design of such interventions is an understanding of the local health system. This will inform intervention design, help ensure the community-intervention forms part of a continuum of care, and provide information about health system strengthening activities that may be necessary for success. Such formative research processes, however, are seldom reported in the literature. We present the results of a health facility assessment used in the design stage of Newhints, a community-based intervention to improve neonatal survival in rural Ghana. We illustrate the methodology, findings and how these were used to inform the design and implementation of Newhints. The assessment involved key informant interviews with staff members at seven health facilities within the study area, including a brief inventory of available drugs and equipment. The key informant interviews identified that practices and health promotion messages at the health facilities were not consistent with one of the key target behaviours of the Newhints intervention - thermal care through delayed infant bathing. Health workers were bathing neonates soon after delivery and also advising women to do the same, which is a potential cause of hypothermia for the newborn. We found that health centres other than large district hospitals were ill-equipped to treat serious complications of labour or illness in the newborn, which had implications for advice on health seeking behaviour within the intervention. As a result of the health facility assessment, it was deemed necessary to undertake both health worker training and sensitisation activities. We demonstrate that important information can be yielded from a relatively simple health facility assessment involving key informant interviews.     

Experiences of family caregivers regarding a community-based care- and case-management intervention. A qualitative study

Family caregivers play an essential role in healthcare for elderly people in primary care settings. The complexity of geriatric patients as well as the fragmentation of healthcare systems can lead to a burden for family caregivers, which can affect their physical and psychological health as well as social relationships, economic productivity and quality of caregiving. Care- and case-management offers a possibility to support, empower and navigate family caregivers through healthcare systems in order to reduce their own burden. The project RubiN (Continuous care in a regional network) was developed to provide regional care- and case-management for outpatient care of the elderly (age >70 years) in a primary care setting in Germany. The aim of this qualitative study was to explore experiences and attitudes of family caregivers of geriatric patients regarding the community-based care- and case-management intervention RubiN. Telephone interviews with a purposeful sample of 21 family caregivers enlisted in all RubiN networks were conducted between March and May 2020 and were followed by qualitative content analysis. The main categories, which emerged were namely: (1) current healthcare situation and (2) experiences with RubiN. Main findings suggest that participants in this study valued the provided support and experienced a sense of relief. However, some participants were disappointed with RubiN and the included support by care- and case-managers. A care- and case-management affected caregiving per se as well as the patient's and family caregiver's well-being. Important aspects contributing to these findings were a continuous relationship, training and expertise of the care- and case-managers. Establishing networks between the patients, family caregivers, care- and case-managers and healthcare providers were key components as well as a good explanation about RubiN itself for family caregivers. Therefore, a community-based care- and case-management can play an important role in detecting, facilitating and preventing family caregiver burden.     

Intervention on cardiovascular disease risk factors in Finnmark county: changes after a period of three years. The Cardiovascular Disease Study in Finnmark County, Norway

In Finnmark county in Norway, 12 329 males and females aged 20-49 years participated in two screening examinations with an interval of 3 years. The primary health service attempted, without receiving any extra resources, to reduce the risk of cardiovascular disease by means of a personal intervention programme among high-risk individuals and a health education programme directed at all residents in the county. During these 3 years the serum total-cholesterol (cross-sectionally) level decreased on average by about 0.3 mmol/l due to: firstly, a decrease among persons recommended a follow-up examination and secondly a decrease among household members of persons followed-up. The effect of a recommendation to attend a follow-up examination because of high blood pressure was doubtful. Cigarette consumption (cross-sectionally) decreased 12% for males and 4% for females. The joint decrease (improvement) in risk factors indicates a possible health benefit of about 20%, calculated in terms of myocardial infarction over 10 years.     

Evaluation of a community-based weight management program for overweight and obese adolescents: The Loozit study

Aim:  To evaluate a community-based weight management program for overweight and obese adolescents aged 13–16 years.
Methods:  The present study was a group-based intervention over five months conducted in Australian community health centres. Program evaluation questionnaires were completed by adolescents and their parents. Seven semi-structured group sessions were held for adolescents: weekly for four weeks and then at two, four and five months. The program sessions focused on healthy eating, increasing physical activity, decreasing sedentary behaviour and increasing self-esteem. Adolescents' anthropometry, blood pressure and fasting blood biochemistry were measured. Adolescents completed validated questionnaires on diet, physical activity and self-esteem.
Results:  Twenty-two overweight and obese adolescents were recruited with a median body mass index (BMI) z-score 2.30. Recruitment strategies were identified and a high retention rate (91%) was achieved. The program was well received by adolescents. Parents reported their adolescents were making healthier food choices and increasing physical activity. At treatment end there were clinically significant improvements in self-perception scores for physical appearance and romantic appeal ( P  < 0.05), waist circumference (median 100.1 cm vs 97.1 cm; P  < 0.0001) and HDL cholesterol (median 1.10 mmol/L vs 1.20 mmol/L; P  = 0.02), but not BMI or BMI z-score.
Conclusions:  The Loozit weight management intervention is one of the first to involve adolescents in the evaluation of the program and to operate at a sustainable intensity in an accessible community setting. The present study provides valuable insights into the elements of a program that is acceptable to adolescents.