Implications of the results of community intervention trials

Worksite tobacco control programs: the role of occupational health

Worksite tobacco control initiatives face a crucial challenge: the growing occupational disparity in smoking prevalence. Blue-collar workers are more likely to be smokers than workers are in white-collar jobs. Blue-collar workers also experience a high prevalence of hazardous exposures on the job. Given these multiple risks, it is imperative that successful comprehensive programs be developed to promote and protect the health of blue-collar workers. Although evidence is still accruing about the efficacy of workplace interventions integrating tobacco control and occupational health, it is possible to identify promising intervention strategies by drawing on the preliminary evidence on effective worksite interventions. The effectiveness of worksite tobacco control interventions will be enhanced when coordinated interventions aim to promote cessation among individual smokers, build social support for quitting and social norms that support non-smoking, engage management in assuring a healthy work environment, involve workers' families in non-smoking initiatives, and provide links to community and public policy initiatives that support tobacco control as well as a broader effort promoting worker health.

Susceptibility of youth to tobacco: a social ecological framework for prevention

For most smokers, tobacco dependence begins in childhood or adolescence. This review summarizes the state of social science with respect to the prevention of tobacco use. Social ecology is introduced as a theoretical framework useful for organizing prevention approaches. In recent years, the field has shifted from approaches directed at individuals, towards appreciation of additional, more comprehensive social and environmental influences on initiation. These range from intra-individual factors (including physiological responses to nicotine and the psychology of use) to individual, interpersonal, organizational, community, and population factors affecting access and demand. This review highlights prevention approaches that address social and societal influences, from school programs that attempt to change susceptibility of individual youth to tobacco, to community projects, media campaigns, restrictive policies, and tobacco pricing. The most promising approaches are those designed with input based on extensive formative research including studies with youth, directed at multiple levels of the social ecology, and sustained over time with significant resources and ongoing, multi-sector inputs.

Effect of health lifestyle pattern on dietary change

PURPOSE

To examine the effect of lifestyle on the effectiveness of a low-intensity dietary intervention.

DESIGN

A secondary data analysis was performed using data from the Eating Patterns Study, a randomized controlled trial that found that self-help materials with physician advice was effective in changing dietary intake and behavior.

SETTING

Primary care clinics in a large health maintenance organization.

SUBJECTS

A total of 2111 patients with a routine scheduled appointment with their primary care physicians.

MEASURES

Participants were grouped into one of six health lifestyle patterns based on similarities in baseline measures of alcohol intake, smoking, diet quality, and exercise. Within each lifestyle pattern, changes from baseline in usual fat and fiber intake (based on a food frequency) and a fat and fiber behavior score were compared at 3 months and 12 months for intervention vs. control participants.

INTERVENTION

Self-help materials delivered by a physician with advice to change diet.

RESULTS

Intervention participants in the fitness lifestyle group made the largest changes relative to controls for each dietary outcome at 3 and 12 months. For intervention participants defined by their alcohol intake or current smoking, either no changes in diet were observed compared with controls, or early changes were not sustained over time. Intervention-control comparisons within the remaining lifestyle patterns showed smaller dietary changes compared with the fitness lifestyle. This finding was similar to previously published results.

CONCLUSIONS

This randomized controlled trial had limited power to detect subgroup differences; however, these results suggest that lifestyle patterns may be useful in the development of effective, targeted interventions to change behavior.

A community participatory oral health promotion program in an inner-city Latino community

OBJECTIVES

This paper reports the planning, implementation, process evaluation, and refinement of an oral health community participatory project in Mount Pleasant, an inner-city Latino neighborhood of Washington, DC. The main goal was to explore the feasibility of implementing such a project.

METHODS

The PRECEDE-PROCEED model was used to guide the planning and process evaluation of this project, in conjunction with community organizational methods. A steering committee, which met periodically, was formed to assist in program planning, implementation, and evaluation. The needs assessment of the community identified extensive dental health problems among children and deficiencies in their parents' oral health knowledge, opinions, and practices. In response, culturally appropriate health education and promotion activities were planned and implemented in collaboration with local community organizations, volunteers, and local practitioners. Process evaluation was used to provide feedback into the refinement of the community approach, which included record keeping and an inventory approach to activities completed and resources used. The overall impact and usefulness of this program were assessed informally using an anonymous open-ended questionnaire directed to members of the steering committee, and an outreach survey using a convenience sample at a local Latino health fair.

RESULTS

The implementation of such a community participatory approach was feasible and useful for building upon existing local resources and addressing oral health concerns in a community not reached by traditional dental care and health promotion initiatives. Individuals in this community showed a substantial interest in oral health matters and participated in a variety of oral health prevention activities. The community approach adhered to community-based research principles.

Selected statistical issues in group randomized trials

Group randomized trials (GRTs) in public health research typically use a small number of randomized groups with a relatively large number of participants per group. Two fundamental features characterize GRTs: a positive correlation of outcomes within a group, and the small number of groups. Appropriate consideration of these fundamental features is essential for design and analysis. This paper presents the fundamental features of GRTs and the importance of considering these features in design and analysis. It also reviews and contrasts the main analytic methods proposed for GRTs, emphasizing the assumptions required to make these methods valid and efficient. Also discussed are various design issues, along with guidelines for choosing among them. A real data example illustrates these issues and methods.

Privatization of local health department services: effects on the practice of health education

Local health departments (LHDs) are changing service delivery mechanisms to accommodate changes in health care financing and decreased public support for governmental services. This study examined the extent to which North Carolina LHDs privatized and contracted out services and the effects on the time spent on core functions of public health and activities of health educators. Questionnaires were mailed to the senior health educators in all LHDs. Sixty-nine responded, and 68% of LHDs had not privatized any services other than laboratory and home health. Clinical services were more commonly privatized than nonclinical services. Respondents perceived that privatization produces more time for LHDs to address the core public health functions and for health educators to engage in appropriate professional activities. Health educators in LHDs that had not privatized were more likely to be concerned about potential negative effects. This study suggests that privatization has generally had a positive effect on the roles of health educators in North Carolina LHDs.

A review of collaborative partnerships as a strategy for improving community health

Collaborative partnerships (people and organizations from multiple sectors working together in common purpose) are a prominent strategy for community health improvement. This review examines evidence about the effects of collaborative partnerships on (a) community and systems change (environmental changes), (b) community-wide behavior change, and (c) more distant population-level health outcomes. We also consider the conditions and factors that may determine whether collaborative partnerships are effective. The review concludes with specific recommendations designed to enhance research and practice and to set conditions for promoting community health.

Health promotion in the city: a review of current practice and future prospects in the United States

To achieve its health goals, the United States must reduce the disproportionate burden of illness and poor health borne by urban populations. In the 20th century, patterns of immigration and migration, changes in the global economy, increases in income inequality, and more federal support for suburbanization have made it increasingly difficult for cities to protect the health of all residents. In the last 25 years, epidemics of human immunodeficiency virus infections and substance abuse and increases in homelessness, lack of health insurance, rates of violence, and concentrations of certain pollutants have also damaged the health of urban residents. Several common strategies for health promotion are described, and their relevance to the unique characteristics of urban populations is assessed. To identify ways to strengthen health promotion practices in U.S. cities, lessons have been taken from five related fields of endeavor: human rights, church- and faith-based social action, community economic development, youth development, and the new social movements. By integrating lessons from these areas into their practice, public health professionals can help to revitalize the historic mission of public health, contribute to creating healthier cities, and better achieve national health objectives.

Motivational interviewing in health care settings. Opportunities and limitations

Motivational interviewing (MI) has been well studied in specialist settings. There has been considerable interest in applying MI to community health care settings. Such settings represent a significant departure from the more traditional, specialist settings in which MI has been developed and tested. The purpose of this paper is to provide a brief overview of MI and to identify and discuss the key issues that are likely to arise when adapting this approach to health care and public health settings. This paper provides an overview of important issues to consider in adapting an effective counseling strategy to new settings, and is intended to begin a dialogue about the use of MI in community health care settings.

Promoting health: intervention strategies from social and behavioral research

This report, released by the Division of Health Promotion and Disease Prevention within the Institute of Medicine at the National Academy of Sciences, asserts that behavioral and social interventions such as health promotion and disease prevention offer great promise to reduce disease morbidity and mortality in the United States, but as yet their potential has not been recognized or tapped by the federal government. Two overarching recommendations are the need to address generic social and behavioral determinants of health rather than the clinical causes of disease and death, and the need to intervene at multiple levels of influence including the individual, interpersonal, institutional, community, and policy levels. Seven recommendations for intervention strategies, nine recommendations for research, and three recommendations for funding are offered.

Assessing community change at multiple levels: the genesis of an evaluation framework for the California Healthy Cities Project

More than 40 cities have participated in the California Healthy Cities Project since its inception in 1988. Because Healthy Cities efforts are community driven, these cities address diverse health and social issues using a wide variety of strategies. This complexity, in addition to the usual difficulties associated with evaluating community interventions, creates many challenges for evaluation. Given the community building and process orientation of Healthy Cities, it may be most appropriate to measure intermediate community changes that have been linked to health outcomes in previous research or, at a minimum, theoretically. The California Healthy Cities evaluation framework conceptualizes change at five levels: individual, civic participation, organizational, interorganizational, and community. The framework, developed collaboratively with Healthy Cities participants, attempts to synthesize current thinking and practice on evaluation of community projects by applying concepts from community capacity/competence, social ecology, and urban planning.

A social-ecologic approach to assessing support for disease self-management: the Chronic Illness Resources Survey

We report on the development and validation of an instrument to assess support and resources for chronic illness management (the Chronic Illness Resources Survey; CIRS). The 64-item full instrument and the 29-item Brief CIRS are based on a social-ecologic model, designed to apply across chronic diseases, and assess support and resources at each of seven levels (e.g., family and friends, physician and health care team, neighborhood/community). A prospective evaluation with 123 patients having heart disease, arthritis, diabetes, and/or COPD revealed that the overall instrument, as well as subscales and the brief instrument, had acceptable internal consistency, moderate to high test-retest reliability, good construct validity, and moderate concurrent and prospective criterion validity. We discuss potential uses of the CIRS for assessment, feedback, tailoring intervention, and evaluation and make recommendations for future research.

Community-based parenting and family support interventions and the prevention of drug abuse

This paper presents a model for the development of a comprehensive, multilevel, preventively-oriented parenting and family support strategy to reduce family risk factors associated with drug abuse in young people. If parenting interventions are to make a significant impact at a population level on the prevalence of dysfunctional parenting practices, there is a need for an ecological approach to parenting support. Such an approach needs to target a variety of social contexts that are in a position to provide parents with access to evidence-based parenting interventions. The Triple P-Positive Parenting Program is discussed as an example of such an approach to illustrate the distinguishing features of a population level strategy. The core constructs underpinning the Triple P system include the promotion of parental self-regulation (self-sufficiency, self-efficacy, self-management, personal agency, and problem solving), through making parenting programs of adequate intensity widely available in the community through flexible delivery modalities (individual, group, telephone assisted and self-directed). The system comprises a tiered continuum of increasingly intensive parenting interventions ranging from media interventions with wide reach, to intensive behavioural family interventions with narrow reach for high-risk families where parenting problems are complicated by other factors including marital conflict, parental mood disturbance, and lack of social support. The scientific basis of the system of intervention and possible directions for future research is discussed.

The Australian National Workplace Health Project: design and baseline findings

BACKGROUND

This paper describes the study design, recruitment, measurement, and initial recruitment outcomes of Australia's largest workplace intervention trial, the National Workplace Health Project.

METHODS

This was a cluster-randomized trial of socio-behavioral and environmental interventions focusing on key behaviors of physical activity, healthy food choices, cigarette smoking, and alcohol consumption, as well as motivational readiness for change. Twenty worksites were randomized separately for each intervention using a two-by-two factorial design. All participants underwent a health risk appraisal and measurements were made at baseline and at 1 and 2 years.

RESULTS

The overall response rate for the baseline survey was 73% with 61% attending the health risk appraisal. The sample was predominantly male, English-speaking, married, blue-collar workers. Overall, 12% reported unsafe alcohol consumption, 26% were current smokers, 44% were physically inactive, 74% ate at most one piece of fruit per day, and 26% ate at most one serving of vegetables per day. Intervention and control conditions were similar at baseline for the primary outcomes, except that a higher proportion of the sociobehavioral intervention condition was more physically active (59%) than the corresponding control condition (53%).

CONCLUSIONS

This study will permit the rigorous evaluation of the efficacy of sociobehavioral and environ mental intervention approaches to workplace health promotion. Although participants were randomized by worksite, intervention and control conditions were similar at baseline; any differences in the primary out come variables will be controlled for in the analysis.

A brief smoking cessation intervention for women in low-income planned parenthood clinics

OBJECTIVES

The purpose of this study was to evaluate a brief smoking cessation intervention for women 15 to 35 years of age attending Planned Parenthood clinics.

METHODS

Female smokers (n = 1154) were randomly assigned either to advice only or to a brief intervention that involved a 9-minute video, 12 to 15 minutes of behavioral counseling, clinician advice to quit, and follow-up telephone calls.

RESULTS

Seventy-six percent of those eligible participated. Results revealed a clear, short-term intervention effect at the 6-week follow-up (7-day self-reported abstinence: 10.2% vs 6.9% for advice only, P < .05) and a more ambiguous effect at 6 months (30-day biochemically validated abstinence: 6.4% vs 3.8%, NS).

CONCLUSIONS

This brief, clinic-based intervention appears to be effective in reaching and enhancing cessation among female smokers, a traditionally underserved population.

Occurrence of hip fractures and socioeconomic position

OBJECTIVES

The purpose of this study was to determine hip fracture incidence in the older U.S. White population as a function of their socioeconomic position.

METHODS

A sample of 5,161 White, hip fracture cases, 50 years and older, was selected using data from the National Hospital Discharge Survey for 1989-91. Median annual household income by ZIP Code of residence based on the 1990 Census was used as the measure of socioeconomic position. Fracture rates were calculated by age, sex, and income groups ranging from under $20,000 to $40,000 and more.

RESULTS

A weighted, least squares analysis found a significant linear decrease in rates with increasing income after controlling for age and sex.

CONCLUSIONS

The results indicate that hip fracture incidence varies as a function of the income level of the ZIP Code area where the population resides. Implications for targeting prevention programs within local areas with low median income are discussed.

Results of employee involvement in planning and implementing the Treatwell 5-a-Day work-site study

When work-site health promotion programs incorporate theories of community organization, it is likely that employee ownership and participation are enhanced. This article reports quantitative indicators of involvement of Employee Advisory Board (EAB) members in the Treatwell 5-a-Day work-site study and examines relationships between EAB member time spent on project activities and work-site size, with indicators of the extent of implementation and variables associated with behavior change and work-site support. The results reported here indicate that a greater number of EAB member hours spent on program activities was associated with a greater number of events implemented. Smaller work-site size was associated with greater employee awareness of the program and greater participation in project activities as reported on the employee survey. These results suggest that the number of hours employee representatives devote to project activities might be an important consideration in planning employee involvement in work-site health promotion programming.

External collaboration and performance: North Carolina local public health departments, 1996

OBJECTIVES

This study examined the extent to which local public health departments in North Carolina collaborated with other groups and organizations, the health problems on which they worked together, and the effect of external collaboration on health departments' performance on core public health functions.

METHODS

The author mailed a questionnaire asking about interactions with city and county government agencies, boards of health, schools, nonprofits, physicians/private clinics, community health centers/migrant clinics, community members, citizens' groups, state and federal agencies, and universities to all of the directors of local public health departments in North Carolina. Sixty-four directors returned the questionnaire, for a response rate of 74.4%.

RESULTS

Local public health departments most frequently interacted with boards of health, state agencies, community members, schools, city and county government agencies, and nonprofit agencies. Large majorities reported productive relationships with boards of health, state agencies, city and county government agencies, schools, nonprofit agencies, and hospitals. Greater frequency of interaction with several types of partners was associated with better performance.

CONCLUSIONS

While questions exist about whether performance on core functions improves the community's health status, the results suggest that it is important for local public health departments to continue to build relationships with other organizations in the community.

Process tracking results from the Treatwell 5-a-Day Worksite Study

PURPOSE

To report findings from Treatwell 5-a-Day process tracking.

DESIGN

Worksites were randomly assigned to a minimal intervention control, worksite-only condition, or worksite-plus-family condition.

SETTING

Twenty-two small community health centers in Massachusetts.

SUBJECTS

Employees of the community health centers.

INTERVENTION

Both intervention conditions included the formation of employee advisory boards; activities such as nutrition discussions and taste tests targeting individual behavior change; and point-of-purchase labeling as an environmental strategy. Worksite-plus-family sites incorporated activities such as family contests, campaigns, and picnics.

MEASURES

Documentation of the number and type of activities for extent of implementation; number of participants in activities for reach; program awareness and participation from the follow-up employee survey (n = 1306, representing 76% [range, 56%-100%] of the sample); change in fruit and vegetable consumption from a comparison between the follow-up and baseline surveys (n = 1359, representing 87% [range, 75%-100%] of the sample).

RESULTS

A higher number of activities per employee was significantly correlated with greater program awareness (.68; p = .006) and greater change in fruit and vegetable consumption (.55; p = .04). Greater participation in activities was significantly correlated with greater awareness (.67; p = .007), higher participation (.61; p = .02), and increase in fruit and vegetable consumption. (.55; p = .04).

CONCLUSIONS

These results provide quantitative indicators of a dose-response relationship between the number of intervention activities per employee and higher percentage of employee participation and observed increases in fruit and vegetable consumption.

A randomized community intervention trial to increase awareness and knowledge of the role of periconceptional folate in women of child-bearing age

OBJECTIVES: To determine the effect of a consumer-directed information campaign to increase knowledge of folate for the prevention of neural tube defects among women of child-bearing age, and to measure women's recall of sources of information and knowledge about folate. DESIGN: A community randomized trial. SETTING: Three matched pairs of geographically distinct Local Government Areas in the state of Victoria, Australia. INTERVENTION: Printed information recommending folate intake to decrease the risk of neural tube defects was disseminated to women of child-bearing age in three of the Local Government Areas selected randomly. MAIN OUTCOME MEASURE: The proportion of women aware of the association between folate and spina bifida. RESULTS: Of 1197 women interviewed prior to the intervention, 12.4% (adjusted for the cluster and population sampling unit) were aware of folate and neural tube defects. After the intervention, there was not only a significant background increase of 3.4% (P=0.02) in folate awareness since the pre-intervention survey (n=603), but also a significant additional increase of 4.0% (P=0.04) owing to the intervention itself (n=603). Only 70% of women who were aware of folate knew the correct timing. CONCLUSIONS: The provision of printed educational material can increase folate awareness among women of child-bearing age. A comprehensive, long-term and ongoing health promotion campaign including such material, together with initiatives by relevant health service providers and the food industry, could best address the current low levels of folate awareness among women of child-bearing age.

Specificity of developmental precursors to schizophrenia and affective disorders

Developmental precursors to adult disorder suggest that components of their causes operate in early life. Several birth cohort studies have relevant prospective data and are reporting results for schizophrenia and affective disorder. These studies suggest that developmental findings are not specific for schizophrenia, although the magnitude of effects tends to be greater compared with affective disorder. These findings are reviewed and some methodological issues discussed. Apparent lack of specificity may mask underlying unique mechanisms and causes. In terms of a future public health perspective involving prediction and prevention, a lack of specificity may be advantageous.

Evaluating the public health impact of health promotion interventions: the RE-AIM framework

Progress in public health and community-based interventions has been hampered by the lack of a comprehensive evaluation framework appropriate to such programs. Multilevel interventions that incorporate policy, environmental, and individual components should be evaluated with measurements suited to their settings, goals, and purpose. In this commentary, the authors propose a model (termed the RE-AIM model) for evaluating public health interventions that assesses 5 dimensions: reach, efficacy, adoption, implementation, and maintenance. These dimensions occur at multiple levels (e.g., individual, clinic or organization, community) and interact to determine the public health or population-based impact of a program or policy. The authors discuss issues in evaluating each of these dimensions and combining them to determine overall public health impact. Failure to adequately evaluate programs on all 5 dimensions can lead to a waste of resources, discontinuities between stages of research, and failure to improve public health to the limits of our capacity. The authors summarize strengths and limitations of the RE-AIM model and recommend areas for future research and application.

The Working Healthy Project: a worksite health-promotion trial targeting physical activity, diet, and smoking

Worksites are a key channel for delivery of interventions designed to reduce chronic disease among adult populations. Although some evaluations of worksite physical-activity interventions have been conducted, to date very few randomized trials of worksite health promotion have included the goal of increasing physical-activity levels as part of a comprehensive multiple risk factor approach to worksite health promotion. This article presents the results regarding behavior change found among the cohort of 2055 individuals who completed three health-behavior assessments as part of their worksites' participation in The Working Healthy Project (WHP), a multiple risk factor intervention implemented in 26 manufacturing worksites. In this study, a randomized matched-pair design was used. Fifty-one percent (n = 2,761) of the employees who completed the baseline assessment also completed the interim survey. Eighty-three percent of those who completed the interim assessment also completed the final survey. The WHP intervention targeted smoking, nutrition, and physical activity. At baseline, 38% of the sample reported engaging in regular exercise, and subjects reported consuming an average of 2.7 servings of fruits and vegetables per day, 7.9 grams of fiber per 1000 kilocalories, and 35.4% calories from fat per day; 28% of the sample were smokers. By the time of both the interim (intervention midpoint) and final (end of intervention) assessments, participants in the intervention condition had significantly increased their exercise behavior, compared with the control condition. There was also increased consumption of fruits and vegetables and fiber in the intervention condition by the time of the final assessment, compared with the control condition. No differences by condition were found with regard to percentage of calories from fat consumed or smoking cessation. These results suggest that among a cohort of participants in a worksite health promotion study, there were significant health behavior changes across two risk factors over time. These data suggest that further investigation of multiple risk factor worksite health promotion is warranted, particularly with a focus on ways to increase participation in these programs and to diffuse intervention effects throughout the entire workforce.

Public health in the twentieth century: advances and challenges

Substantial advances in public health methods, practice, and the health of the public have occurred in the twentieth century. Some of the contributions most notable for their impact on mortality and longevity are vaccine development and widespread use, smallpox eradication, large reductions in communicable disease epidemics, and the rise and decline of several serious chronic diseases. Many methodological advances have facilitated better understanding of disease processes and opportunities for control. Epidemiological methods have advanced, but studies often ignore the determinants of health at the community level and above, leading to simplistic formulations of multiple risk factors contributing to chronic and other diseases and injuries. Occupational and environmental health developed as disciplines in this century, making significant contributions to current and future population health. The health care system became more organized, technologically sophisticated, and costly. New tools to assess health and the burden of ill health, to improve the effectiveness of interventions, and to measure economic effects of alternative investments promise greater efficiency and effectiveness for public health. An increasingly fragmented public health infrastructure must confront unprecedented challenges including dramatic global population growth, increased aging of the population associated with enhanced longevity, and possible irreversible changes in key environmental health determinants.

Triple P-Positive Parenting Program: towards an empirically validated multilevel parenting and family support strategy for the prevention of behavior and emotional problems in children

This paper outlines the theoretical and empirical foundations of a unique multilevel parenting and family support strategy designed to reduce the prevalence of behavioral and emotional problems in preadolescent children. The program known as Triple P-Positive Parenting Program is a multilevel system of family intervention, which provides five levels of intervention of increasing strength. These interventions include a universal population-level media information campaign targeting all parents, two levels of brief primary care consultations targeting mild behavior problems, and two more intensive parent training and family intervention programs for children at risk for more severe behavioral problems. The program aims to determine the minimally sufficient intervention a parent requires in order to deflect a child away from a trajectory towards more serious problems. The self-regulation of parental skill is a central construct in the program. The program uses flexible delivery modalities (including individual face-to-face, group, telephone assisted, and self-directed programs) to tailor the strength of the intervention to the requirements of individual families. Its multidisciplinary, preventive and community-wide focus gives the program wide reach, permitting the targeting of destigmatized access points through primary care services for families who are reluctant to participate in parenting skills programs. The available empirical evidence supporting the efficacy of the program is discussed and its implications for research on dissemination are discussed.

Challenges for the public in negotiating the health system in the 21st century

This paper addresses the challenges and opportunities that face the public in negotiating the health care system (both medicine and public health) in the 21st century. It addresses three issues: how consumers exercise choice, with special attention to the choice of health care coverage; how patients and communities interact with clinicians and public health professionals; and whether and how the public's "voice" is heard as health policy decisions, at the societal and institutional levels, are made. With respect to each of these issues, the paper describes the current status of public influence and articulates a vision for the future. These three related visions are (1) that empowered, informed, supported consumers make decisions about health plans, clinicians, treatments, and their own behavior; (2) that clinicians and public health professionals, working as partners with patients and communities, are in a position to "standardize the customization of care" so that all aspects of care are tailored to the needs of the individual, family, or community in question and social, economic, and cultural factors are taken into account in the day-to-day practice of medicine and public health; and (3) that the ability and willingness of the public to negotiate and shape the health care environment is supported by an independent infrastructure that permits enhanced public involvement in health policy making and governance. The paper identifies key elements of this vision, discusses challenges to pursuing and achieving each vision, and identifies opportunities that may support the pursuit of the vision.

Increasing fruit and vegetable consumption through worksites and families in the treatwell 5-a-day study

OBJECTIVES

We report on the results of the Treatwell 5-a-Day study, a worksite intervention aimed at increasing consumption of fruits and vegetables.

METHODS

Twenty-two worksites were randomly assigned to 3 groups: (1) a minimal intervention control group, (2) a worksite intervention, and (3) a worksite-plus-family intervention. The interventions used community-organizing strategies and were structured to target multiple levels of influence, following a socioecological model. Data were collected by self-administered employee surveys before and after the intervention; the response rate was 87% (n = 1359) at baseline and 76% (n = 1306) at follow-up. A process tracking system was used to document intervention delivery.

RESULTS

After control for worksite, gender, education, occupation, race/ethnicity, and living situation, total fruit and vegetable intake increased by 19% in the worksite-plus-family group, 7% in the worksite intervention group and 0% in the control group (P = .05). These changes reflect a one half serving increase among workers in the worksite-plus-family group compared with the control group (P = .018).

CONCLUSIONS

The worksite-plus-family intervention was more successful in increasing fruit and vegetable consumption than was the worksite intervention. Worksite interventions involving family members appear to be a promising strategy for influencing workers' dietary habits.

Women's oral health awareness and care-seeking characteristics: a pilot study

The authors designed a pilot study to examine issues that affect women's oral health. They found a substantial lack of awareness regarding important oral health issues, and that 44 percent of the participants reportedly did not have regular dental care. High perceived dental need was reported concurrently with low dental care attendance. Additionally, reported lack of dental insurance and self-perception of low income and of poor dental health were important explanatory factors for the women who reportedly did not have regular dental care.

Durability, dissemination, and institutionalization of worksite tobacco control programs: Results from the working well trial

Durability, dissemination and institutionalization o f tobacco control activities are reported, based on the Working Well worksite cancer control intervention study (n = 83 worksites). Tobacco control activities increased significantly in intervention worksites as a result of research-supported activities but were not sustained 2 years after the conclusion of the intervention. Intervention sites were more likely than control sites to initiate and maintain structures for institutionalizing programs, such as assigning a committee responsibility for health-promotion programs or providing a budget for health-promoting activities. Dissemination of the program to control worksites had little impact on the level of smoking control activities in control worksites. Although program durability was not a primary aim of this intervention study, these analyses provide an important assessment of program maintenance beyond a funded intervention and underscore the need for additional research to identify effective organizational strategies for institutionalization of worksite health-promotion programs.