Understanding the variability in the effectiveness of community heart health programs: a meta-analysis

Long-term effectiveness of a lifestyle intervention on the prevention of type 2 diabetes in a middle-income country

This study aims to assess the effects of a community-based lifestyle intervention program on the incidence of type 2 diabetes (T2D). For this purpose, three communities in Tehran were chosen; one community received a face-to-face educational session embedded in a long-term community-wide lifestyle intervention aimed at supporting lifestyle changes. We followed up 9,204 participants (control: 5,739, intervention: 3,465) triennially from 1999 to 2015 (Waves 1-5). After a median follow-up of 3.5 years (wave 2), the risk of T2D was 30% lower in the intervention community as compared with two control communities by (Hazard-ratio: 0.70 [95% CI 0.53; 0.91]); however, the difference was not statistically significant in the following waves. After a median follow-up of 11.9 years (wave 5), there was a non-significant 6% reduction in the incidence of T2D in the intervention group as compared to the control group (Hazard-ratio: 0.94 [0.81, 1.08]). Moreover, after 11.9 years of follow-up, the intervention significantly improved the diet quality measured by the Dietary Approaches to Stop Hypertension concordance (DASH) score. Mean difference in DASH score in the intervention group versus control group was 0.2 [95% CI 0.1; 0.3]. In conclusion, the intervention prevented T2D by 30% in the short-term (3.5 years) but not long-term; however, effects on improvement of the diet maintained in the long-term.Registration: This study is registered at IRCT, a WHO primary registry ( https://irct.ir ). The registration date 39 is 2008-10-29 and the IRCT registration number is IRCT138705301058N1.

Mass media campaigns to reduce unnecessary caesarean sections: a systematic review

Introduction

The worldwide increase in unnecessary caesarean sections (CSs) is a major global health issue. Mass media campaigns have been used in several countries to reduce this trend. The objectives of this systematic review were to identify, critically appraise and synthesise the findings, including the barriers and enablers, of mass media campaigns directed at lay people to reduce unnecessary CS.

Methods

We included any study design that reported health communication mass media campaigns directed at lay people with the specific objective of reducing unnecessary CS, created by any agent, in any format. We searched seven electronic databases without language restrictions, from inception to February 2019. Experts in the field were contacted.

Results

The search yielded 14 320 citations; 50 were selected for full-text reading; and one was included. Six other reports were included. The seven campaigns were conducted in 2009–2017, mostly in Latin America. Most campaigns were independent efforts by non-governmental or activist organisations. Only one campaign conducted formative research and pretested the intervention. All campaigns used indirect communication, mostly through internet channels; two campaigns also used direct communication with the public. None assessed their effects on CS rates. Only two campaigns measured their impacts on participants’ knowledge, attitudes and birth preferences but only in the short term. The main barriers were lack of financial and human resources. The main enablers were the enthusiasm of volunteers, the participation of famous persons/celebrities and the involvement of communication professionals.

Conclusions

There are few mass media campaigns directed at lay people to reduce CS. Most campaigns did not use key principles recommended for the creation and implementation of health communication interventions, and none assessed their effects in reducing CS rates. If media campaigns can play a role in modifying population views towards CS, there is a need for more rigorous studies including impact assessment.

PROSPERO registration number

CRD42019120314.

Hot Topic: Global Burden of Treating Hypertension-What is the Role of the Emergency Department?

Hypertension (HTN) is the most common modifiable risk factor for cardiovascular disease (CVD) morbidity and mortality worldwide. Lower- and middle-income countries (LMICs) are projected to bear the vast majority of this disease burden, but local and regional health care delivery systems in these countries are ill equipped to meet this need. Emergency care is receiving increased recognition as a crucial component of public and community health. The rapid evolution of emergency care in LMICs provides a unique opportunity to develop innovative strategies, incorporating existing strengths of emergency departments, to address this paradigm shift in the disease burden associated with HTN on a global scale.

A systematic review of published interventions for primary and secondary prevention of ischaemic heart disease (IHD) in rural populations of Australia

BACKGROUND

Rural Australians are known to experience a higher burden of ischaemic heart disease (IHD) than their metropolitan counterparts and the reasons for this appear to be highly complex and not well understood. It is not clear what interventions and prevention efforts have occurred specifically in rural Australia in terms of IHD. A summary of this evidence could have implications for future action and research in improving the health of rural communities. The aim of this study was to review all published interventions conducted in rural Australia that were aimed at the primary and/or secondary prevention of ischaemic heart disease (IHD) in adults.

METHODS

Systematic review of the peer-reviewed literature published between January 1990 and December 2015. Search terms were derived from four major topics: (1) rural; (2) ischaemic heart disease; (3) Australia and; (4) intervention/prevention. Terms were adapted for six databases and three independent researchers screened results. Studies were included if the published work described an intervention focussed on the prevention or reduction of IHD or risk factors, specifically in a rural population of Australia, with outcomes specific to participants including, but not limited to, changes in diet, exercise, cholesterol or blood pressure levels.

RESULTS

Of 791 papers identified in the search, seven studies met the inclusion criteria, and one further study was retrieved from searching reference lists of screened abstracts. Typically, excluded studies focused on cardiovascular diseases without specific reference to IHD, or presented intervention results without stratification by rurality. Larger trials that included metropolitan residents without stratification were excluded due to differences in the specific needs, characteristics and health service access challenges of rural populations. Six interventions were primary prevention studies, one was secondary prevention only and one included both primary and secondary intervention strategies. Two interventions were focussed exclusively on Aboriginal and Torres Strait Islander (Australian Indigenous) populations.

CONCLUSIONS

Few interventions were identified that exclusively focussed on IHD prevention in rural communities, despite these populations being at increased risk of IHD in Australia, and this is consistent with comparable countries, internationally. Although limited, available evidence shows that primary and secondary interventions targeted at IHD and related risk factors can be effective in a rural setting.

Impact of a 3-year multi-centre community-based intervention on risk factors for chronic disease and obesity among free-living adults: the Healthy Alberta Communities study

BACKGROUND

Healthy Alberta Communities (HAC) was a 3-year community-based intervention to reduce lifestyle-related risk factors for chronic disease and obesity at a population-level. The current paper examines changes in blood pressure (BP) and anthropometric indicators within HAC communities compared to secular trends.

METHODS

Between 2006 and 2009, this community-academic partnership sought to create environments supportive of healthier dietary and physical activity behaviours within four diverse communities in Alberta, Canada. Height, weight, waist and hip circumference and BP were measured among 1554 and 1808 community residents at baseline (2006) and follow-up (2009), respectively. A comparison sample was drawn from a representative national survey. Samples were stratified by age and change between pre- and post-intervention was assessed using t-tests. Changes in parameters over time between groups were compared using meta-analysis. The net difference in change in outcomes (change in intervention communities minus change in comparison group) represented the effect of the intervention.

RESULTS

Adjusted systolic (SBP) and diastolic (DBP) BP declined within most age groups in HAC communities from pre- to post-intervention. The net decline in SBP was 1 mmHg in 20-39 year olds (p = 0.006) and 2 mmHg in 40-59 year olds (p = 0.001), while the net decline in DBP was 3 mmHg in 20-39 year olds (p < 0.001), 2 mmHg in 40-59 year olds (p < 0.001) and 3 mmHg in 60-79 year olds (p < 0.001). The net increase in the proportion of individuals with normal BP was 5.9 % (p < 0.001), while the net decline in the proportion of individuals with stage 1 hypertension was 4.5 % (p < 0.001). BMI and body weight were unchanged. There was a significant net increase in waist and hip circumference among 20-39 year olds within intervention communities.

CONCLUSIONS

Findings suggest HAC succeeded in shifting the population distribution of BP in a leftward direction. By contrast, anthropometric parameters remained unchanged or worsened within intervention communities. Therefore, while improvements in some clinical risk factors can be achieved through relatively diffuse and shorter-term community-level environmental changes, improvements in others may require interventions of greater intensity and duration. Evaluating the success of community-based interventions based on their efficacy in changing individual-level clinical indicators may, however, underestimate their potential.

Effectiveness of multifactorial interventions in primary health care settings for primary prevention of cardiovascular disease: A systematic review of systematic reviews

OBJECTIVE

To evaluate the effectiveness of multifactorial interventions carried out in the community setting to decrease cardiovascular risk in healthy patients.

METHODS

Systematic review of the MEDLINE (via PubMed), Web of Science and Cochrane Library databases from January 1980 to January 2014. Identified for inclusion were systematic reviews of clinical trials that included multifactorial interventions carried out in primary care or community settings, targeting more than one cardiovascular risk factor, and implementing more than one type of intervention. The methodological quality of the included articles was evaluated using the AMSTAR tool.

RESULTS

Eight systematic reviews were selected, including 219 studies. All of these reviews provided information about the effectiveness of multifactorial interventions in reducing mortality and morbidity due to cardiovascular diseases. Four reviews reported moderate effectiveness and four showed limited effectiveness.

CONCLUSION

Multifactorial community interventions improve cardiovascular risk factors and have a small but potentially important effect on mortality. These interventions seem to be more effective in the at-risk population and when they are carried out at a high level of intensity.

Cost effective interventions for the prevention of cardiovascular disease in low and middle income countries: a systematic review

BACKGROUND

While there is good evidence to show that behavioural and lifestyle interventions can reduce cardiovascular disease risk factors in affluent settings, less evidence exists in lower income settings.This study systematically assesses the evidence on cost-effectiveness for preventive cardiovascular interventions in low and middle-income settings.

METHODS

DESIGN

Systematic review of economic evaluations on interventions for prevention of cardiovascular disease.

DATA SOURCES

PubMed, Web of Knowledge, Scopus and Embase, Opensigle, the Cochrane database, Business Source Complete, the NHS Economic Evaluations Database, reference lists and email contact with experts.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

we included economic evaluations conducted in adults, reporting the effect of interventions to prevent cardiovascular disease in low and middle income countries as defined by the World Bank. The primary outcome was a change in cardiovascular disease occurrence including coronary heart disease, heart failure and stroke.

DATA EXTRACTION

After selection of the studies, data were extracted by two independent investigators using a previously constructed tool and quality was evaluated using Drummond's quality assessment score.

RESULTS

From 9731 search results we found 16 studies, which presented economic outcomes for interventions to prevent cardiovascular disease in low and middle income settings, with most of these reporting positive cost effectiveness results.When the same interventions were evaluated across settings, within and between papers, the likelihood of an intervention being judged cost effective was generally lower in regions with lowest gross national income. While population based interventions were in most cases more cost effective, cost effectiveness estimates for individual pharmacological interventions were overall based upon a stronger evidence base.

CONCLUSIONS

While more studies of cardiovascular preventive interventions are needed in low and mid income settings, the available high-level of evidence supports a wide range of interventions for the prevention of cardiovascular disease as being cost effective across all world regions.

Increasing physical activity of high intensity to reduce the prevalence of chronic diseases and improve public health

High incidence and prevalence of chronic diseases, increasing obesity and inactivity as well as rising health expenditure represent a set of developments that cannot be considered sustainable, and will have dire long-term consequences given the increasing proportion of elderly people in our society. Based on a review of the experiences from previous large scale population-based prevention programs and the documented effects of increased physical activity and cardiorespiratory fitness on chronic diseases and its risk factors, we argue that increased physical activity, especially vigorous physical activity, is a major way to reduce the prevalence of chronic diseases and improve public health. We conclude that a coordinated population-based intervention program for improved health through increased physical activity in the entire population, with a special focus on high intensity exercise, urgently needs to be implemented nationally and internationally.

Population-based intervention for cardiovascular diseases related knowledge and behaviours in Asian Indian women

BACKGROUND & OBJECTIVES

There is poor knowledge and behaviors regarding chronic diseases related nutritional and lifestyle factors among women in low income countries. To evaluate efficacy of a multilevel population-based intervention in improving knowledge and practices for related factors we performed a study in India.

METHODS

Population based study among women 35-70 years was performed in four urban and five rural locations. Stratified sampling was performed and we enrolled 4624 (rural 2616, urban 2008) of eligible 8000 women (58%). Demographic details, medical history, diet, physical activity and anthropometry were recorded and blood hemoglobin, glucose and total cholesterol determined. Knowledge and behaviors regarding diet in chronic diseases were inquired in a randomly selected 100 women at each site (n = 900). A systematic multilevel population based intervention (using posters, handouts, street plays, public lectures, group lectures and focused group discussions) was administered over 6 months at each site. The questionnaire was re-administered at the end in random 100 women (n = 900) and differences determined. Descriptive statistics are reported. Comparison of parameters before and after intervention was assessed using Mann Whitney test.

RESULTS

Prevalence (%) of chronic disease related lifestyles and risk factors in rural/urban women, respectively, was illiteracy in 63.6/29.4, smoking/tobacco use 39.3/18.9, high fat intake 93.6/93.4, high salt intake 18.2/12.6, low physical activity 59.5/70.2, overweight/obesity 22.5/45.6, truncal obesity 13.0/44.3, hypertension 31.6/48.2, hypercholesterolemia 13.5/27.7, and diabetes in 4.3/15.1 percent. Composite chronic diseases knowledge at baseline vs after intervention increased significantly in overall (32.0 vs 62.0), rural (29.0 vs 63.5) and urban (39.5 vs 60.5) groups (p < 0.001). Significant increase in knowledge regarding diet in hypertension, diabetes, heart disease and anemia as well as importance of dietary proteins, fats, fibres and fruits was observed (p < 0.001). There was insignificant change in most of the practices regarding intake of low fat, high protein, high fibre diet except sieving the flour which declined significantly (80.1 vs 53.6, p < 0.001).

CONCLUSIONS

A short-term multilevel population-wide intervention among women in rural and urban locations in India increased chronic disease knowledge but failed to influence practices.

Type 2 diabetes in Asians: prevalence, risk factors, and effectiveness of behavioral intervention at individual and population levels

This review summarizes the current data on diabetes risk factors, prevalence, and prevention efforts in Asia and Asian migrant populations. Studies indicate that type 2 diabetes mellitus is a large and growing threat to public health in Asian populations. Furthermore, Asian subgroups (e.g., South Asians/Asian Indians, Chinese) have unique risk factor profiles for developing diabetes, which differ from other populations and between Asian ethnic groups. Lifestyle intervention programs are effective in preventing diabetes in Asians, as with other ethnicities. The strength of these findings is lessened by the lack of systematically collected data using objective measurements. Large epidemiologic studies of diabetes prevalence and risk factor profiles and translational trials identifying sustainable and culturally acceptable lifestyle programs for Asian subgroups are needed.

How explicable are differences between reviews that appear to address a similar research question? A review of reviews of physical activity interventions

BACKGROUND

Systematic reviews are promoted as being important to inform decision-making. However, when presented with a set of reviews in a complex area, how easy is it to understand how and why they may differ from one another?

METHODS

An analysis of eight reviews reporting evidence on effectiveness of community interventions to promote physical activity. We assessed review quality and investigated overlap of included studies, citation of relevant reviews, consistency in reporting, and reasons why specific studies may be excluded.

RESULTS

There were 28 included studies. The majority (n = 22; 79%) were included only in one review. There was little cross-citation between reviews (n = 4/28 possible citations; 14%). Where studies appeared in multiple reviews, results were consistently reported except for complex studies with multiple publications. Review conclusions were similar. For most reviews (n = 6/8; 75%), we could explain why primary data were not included; this was usually due to the scope of the reviews. Most reviews tended to be narrow in focus, making it difficult to gain an understanding of the field as a whole.

CONCLUSIONS

In areas where evaluating impact is known to be difficult, review findings often relate to uncertainty of data and methodologies, rather than providing substantive findings for policy and practice. Systematic 'maps' of research can help identify where existing research is robust enough for multiple in-depth syntheses and also show where new reviews are needed. To ensure quality and fidelity, review authors should systematically search for all publications from complex studies. Other relevant reviews should be searched for and cited to facilitate knowledge-building.

Implementing a hypertension management programme in a rural area: local approaches and experiences from Ba-Vi district, Vietnam

BACKGROUND

Costly efforts have been invested to control and prevent cardiovascular diseases (CVD) and their risk factors but the ideal solutions for low resource settings remain unclear. This paper aims at summarising our approaches to implementing a programme on hypertension management in a rural commune of Vietnam.

METHODS

In a rural commune, a programme has been implemented since 2006 to manage hypertensive people at the commune health station and to deliver health education on CVD risk factors to the entire community. An initial cross-sectional survey was used to screen for hypertensives who might enter the management programme. During 17 months of implementation, other people with hypertension were also followed up and treated. Data were collected from all individual medical records, including demographic factors, behavioural CVD risk factors, blood pressure levels, and number of check-ups. These data were analysed to identify factors relating to adherence to the management programme.

RESULTS

Both top-down and bottom-up approaches were applied to implement a hypertension management programme. The programme was able to run independently at the commune health station after 17 months. During the implementation phase, 497 people were followed up with an overall regular follow-up of 65.6% and a dropout of 14.3%. Severity of hypertension and effectiveness of treatment were the main factors influencing the decision of people to adhere to the management programme, while being female, having several behavioural CVD risk factors or a history of chronic disease were the predictors for deviating from the programme.

CONCLUSION

Our model showed the feasibility, applicability and future potential of a community-based model of comprehensive hypertension care in a low resource context using both top-down and bottom-up approaches to engage all involved partners. This success also highlighted the important roles of both local authorities and a cardiac care network, led by an outstanding cardiac referral centre.

Coronary heart disease in Indians: implications of the INTERHEART study

Coronary heart diseases (CHD) have reached epidemic proportions among Indians. The recently concluded INTERHEART study emphasizes the role of behavioural and conventional risk factors in the prediction of CHD risk among Indians. These findings have implication for the health care providers and policy makers in the country due to the fact that all these conventional risk factors are potentially modifiable and are good starting points for prevention. The policy measures by means of legislation and regulatory approaches on agriculture and food industry or tobacco or physical activity will have large impact on CHD risk factor reduction in the population. In addition, the health system needs to focus on: (i) providing information for increasing awareness and an enabling environment for adoption of healthy living habits by the community; (ii) early detection of persons with risk factors and cost-effective interventions for reducing risk; and (iii) early detection of persons with clinical disease and cost-effective secondary prevention measures to prevent complications. The evidence from INTERHEART provides rationale for developing treatment algorithms and treatment guidelines for CHD at various levels of health care. In addition, INTERHEART provides answer for the quest for a single reliable biomarker, Apo B/ApoA 1 ratio that can predict the future CHD risk among individuals. Further to this, the INTERHEART study also opens up several unanswered questions on the pathobiology of the premature onset of myocardial infarction among Indians and calls for the need to developing capacity in clinical research in CHD in India.

Comparative Effectiveness Research: Using Systematic Reviews and Meta-Analyses to Synthesize Empirical Evidence

The increased demand for evidence-based health care practices calls for comparative effectiveness research (CER), namely the generation and synthesis of research evidence to compare the benefits and harms of alternative methods of care. A significant contribution of CER is the systematic identification and synthesis of available research studies on a specific topic. The purpose of this article is to provide an overview of methodological issues pertaining to systematic reviews and meta-analyses to be used by investigators with the purpose of conducting CER. A systematic review or meta-analysis is guided by a research protocol, which includes (a) the research question, (b) inclusion and exclusion criteria with respect to the target population and studies, © guidelines for obtaining relevant studies, (d) methods for data extraction and coding, (e) methods for data synthesis, and (f ) guidelines for reporting results and assessing for bias. This article presents an algorithm for generating evidence-based knowledge by systematically identifying, retrieving, and synthesizing large bodies of research studies. Recommendations for evaluating the strength of evidence, interpreting findings, and discussing clinical applicability are offered.

Estimation of the burden of cardiovascular disease attributable to modifiable risk factors and cost-effectiveness analysis of preventative interventions to reduce this burden in Argentina

BACKGROUND

Cardiovascular disease (CVD) is the primary cause of mortality and morbidity in Argentina representing 34.2% of deaths and 12.6% of potential years of life lost (PYLL). The aim of the study was to estimate the burden of acute coronary heart disease (CHD) and stroke and the cost-effectiveness of preventative population-based and clinical interventions.

METHODS

An epidemiological model was built incorporating prevalence and distribution of high blood pressure, high cholesterol, hyperglycemia, overweight and obesity, smoking, and physical inactivity, obtained from the Argentine Survey of Risk Factors dataset. Population Attributable Fraction (PAF) of each risk factor was estimated using relative risks from international sources. Total fatal and non-fatal events, PYLL and Disability Adjusted Life Years (DALY) were estimated. Costs of event were calculated from local utilization databases and expressed in international dollars (I$). Incremental cost-effectiveness ratios (ICER) were estimated for six interventions: reducing salt in bread, mass media campaign to promote tobacco cessation, pharmacological therapy of high blood pressure, pharmacological therapy of high cholesterol, tobacco cessation therapy with bupropion, and a multidrug strategy for people with an estimated absolute risk > 20% in 10 years.

RESULTS

An estimated total of 611,635 DALY was lost due to acute CHD and stroke for 2005. Modifiable risk factors explained 71.1% of DALY and more than 80% of events. Two interventions were cost-saving: lowering salt intake in the population through reducing salt in bread and multidrug therapy targeted to persons with an absolute risk above 20% in 10 years; three interventions had very acceptable ICERs: drug therapy for high blood pressure in hypertensive patients not yet undergoing treatment (I$ 2,908 per DALY saved), mass media campaign to promote tobacco cessation amongst smokers (I$ 3,186 per DALY saved), and lowering cholesterol with statin drug therapy (I$ 14,432 per DALY saved); and one intervention was not found to be cost-effective: tobacco cessation with bupropion (I$ 59,433 per DALY saved)

CONCLUSIONS

Most of the interventions selected were cost-saving or very cost-effective. This study aims to inform policy makers on resource-allocation decisions to reduce the burden of CVD in Argentina.

Community programs for the prevention of cardiovascular disease: a systematic review

In this systematic review, the authors aimed to assess the effectiveness of community programs for prevention of cardiovascular disease (CVD). They searched numerous electronic databases (CDSR, DARE, HTA, EED, and CENTRAL via the Cochrane Library, MEDLINE, MEDLINE In Process, EMBASE, CINAHL, PsycINFO, HMIC, and ASSIA) and relevant Web sites from January 1970 to mid-July 2008. Controlled studies of community programs for the primary prevention of CVD were included. Net changes in CVD risk factors were used to generate an overall index for net change in 10-year CVD risk. The authors identified 36 relevant community programs that took place between 1970 and 2008. These programs were multifaceted interventions employing combinations of media, screening, and counseling activities and environmental changes and were primarily evaluated using controlled before-after studies. In 7 studies, investigators reported changes in CVD/total mortality rates, and in 5 they reported net changes. In all cases, these net changes were positive but were largely nonsignificant. In 22 studies, investigators reported changes in physiologic CVD risk factors, and there was a positive trend in the calculated CVD risk score. The average net reduction in 10-year CVD risk was 0.65%. Community programs for CVD prevention appear to have generally achieved favorable changes in overall CVD risk and, with adaptation to current circumstances, deserve continued consideration as possible approaches to preventing CVD.

Impact of a Positive Deviance Approach to Improve the Effectiveness of an Iron-Supplementation Program to Control Nutritional Anemia among Rural Senegalese Pregnant Women

Background

Iron supplementation through prenatal care remains the most widespread strategy to control anemia during pregnancy, but its effectiveness is only partial, showing the need to address other approaches.

Objective

This study was conducted to measure the impact of a positive deviance approach to improve an iron-supplementation program among pregnant women in a rural Senegalese area.

Methods

A positive deviance approach (PD Micah) was compared with an ongoing integrated nutrition and health program intervention (Micah) in a rural Senegalese area. A pre-post evaluation was conducted using independent cross-sectional samples with a total of 371 pregnant women. A sociodemographic questionnaire was administered, and biologic and anthropometric measurements were performed.

Results

After 9 months of activities, the mean hemoglobin level rose from 93.9 to 100.7 g/L in the PD Micah group. Distribution of iron supplements through community volunteers and implementation of healthy pregnancy promotion sessions on a monthly basis improved the accessibility to 23.3% in the PD Micah group. No significant change was observed in the Micah group. Logistic regression analysis showed a significantly reduced risk of anemia in the PD Micah area (adjusted odds ratio, 0.25; 95% confidence interval, 0.12 to 0.53).

Conclusions

This intervention shows that a community-based strategy, such as the positive deviance approach, can contribute to improving the effectiveness of iron supplementation during pregnancy.

Generalized cost-effectiveness analysis of a package of interventions to reduce cardiovascular disease in Buenos Aires, Argentina

BACKGROUND

Chronic diseases, represented mainly by cardiovascular disease (CVD) and cancer, are increasing in developing countries and account for 53% of chronic diseases in Argentina. There is strong evidence that a reduction of 50% of the deaths due to CVD can be attributed to a reduction in smoking, hypertension and hypercholesterolemia. Generalized cost-effectiveness analysis (GCE) is a methodology designed by WHO to inform decision makers about the extent to which current or new interventions represent an efficient use of resources. We aimed to use GCE analysis to identify the most efficient interventions to decrease CVD.

METHODS

Six individual interventions (treatment of hypertension, hypercholesterolemia, smoking cessation and combined clinical strategies to reduce the 10 year CVD Risk) and two population-based interventions (cooperation between government, consumer associations and bakery chambers to reduce salt in bread, and mass education strategies to reduce hypertension, hypercholesterolemia and obesity) were selected for analysis. Estimates of effectiveness were entered into age and sex specific models to predict their impact in terms of age-weighted and discounted DALYs saved (disability-adjusted life years). To translate the age- and sex-adjusted incidence of CVD events into health changes, we used risk model software developed by WHO (PopMod). Costs of services were measured in Argentine pesos, and discounted at an annual rate of 3%. Different budgetary impact scenarios were explored.

RESULTS

The average cost-effectiveness ratio in argentine pesos (ARS$) per DALY for the different interventions were: (i) less salt in bread $151; (ii) mass media campaign $547; (iii) combination drug therapy provided to subjects with a 20%, 10% and 5% global CVD risk, $3,599, $4,113 and $4,533, respectively; (iv) high blood pressure (HBP) lowering therapy $7,716; (v) tobacco cessation with bupropion $ 33,563; and (iv) high-cholesterol lowering therapy with statins $ 70,994.

CONCLUSION

Against a threshold of average per capita income in Argentina, the two selected population-based interventions (lowering salt intake and health education through mass-media campaigns) plus the modified polypill strategy targeting people with a 20% or greater risk were cost-effective. Use of this methodology in developing countries can make resource-allocation decisions less intuitive and more driven by evidence.

Population-level interventions for coronary heart disease prevention: what have we learned since the North Karelia project?

PURPOSE OF REVIEW

The prevalence of coronary heart disease (CHD) risk factors in the population necessitates investment in the design and delivery of effective population-level interventions to prevent and enhance the management of CHD. This review examines the approaches that have been central to the design and delivery of previous, seminal population-level CHD prevention programs; it offers recommendations for the design and evaluation of the next generation of population-level CHD prevention trials.

RECENT FINDINGS

Almost 50% of the decline in the rates of CHD mortality in the developed world can be attributed to population-level declines in CHD risk factors, including cholesterol, hypertension, and smoking. There is evidence that community-based CHD prevention interventions can have a positive impact on these risk factors within a distinct population. More recent community-based CHD trials have focused on discrete populations including the socioeconomically deprived, ethnic minorities, and rural communities.

SUMMARY

There has been large variability in the success experienced by population-level CHD prevention trials. Best practices have emerged which may be used to inform the design of future trials. These include the need for multisectoral partnerships, coordination of multi-level interventions (programs and policy), and delivering a sufficient intervention dose to targeted populations.

Impact of lifestyle intervention on physical activity and diet of Japanese workers

OBJECTIVE

To evaluate the effectiveness of the Life Style Modification Program for Physical Activity and Diet (LiSM-PAN) in comparison to a conventional healthcare program.

METHOD

Subjects with risk factor(s) for chronic disease were allocated as a cluster to the LiSM group (n=92) or the Control group (n=85). The LiSM-PAN program consisted of counseling plus social and environment support, and the Control program consisted of written feedback for changing physical activity and dietary practice. Intervention was conducted for 6 months during 2001-2002 and with data analysis during 2003-2004 in Tokyo, Japan. The main outcomes were leisure time exercise energy expenditure (L.E.E.E.), maximum oxygen uptake (VO2max), dietary habits, body mass index (BMI), blood pressure, blood glucose, and lipid parameters.

RESULTS

The LiSM group showed a significantly greater increase in L.E.E.E. than the Control group at the end of the intervention (mean inter-group difference: 400.6 kcal/week, 95% CI: 126.1, 675.0 kcal/week). No significant mean inter-group differences were observed in dietary habits. The LiSM group showed significantly greater decreases in BMI, systolic blood pressure, and LDL-cholesterol than the Control group.

CONCLUSION

The LiSM-PAN program produced greater positive changes in L.E.E.E., dietary habits, and risk factors for cardiovascular diseases in high-risk middle-aged male workers compared to the Control program.

Community interventions for cardiovascular disease

Review of the community-based CVD intervention programs suggests that a number of components have been successful using varying methods and materials for CVD risk reduction. It should be noted, however, that in multi-intervention programs it is often difficult to determine which components of the intervention were responsible for the overall success of the study. The community-based approach to CVD prevention is generalizable, cost-effective (because of the use of mass communication methods), and has the potential for modifying the environment and influencing health policies. Based on the experiences and successes of a number of community projects, recommendations have been proposed for developing future programs. Although they are not totally comprehensive, it has been suggested that a community-based intervention program should consider the following recommendations: 1) An understanding of the community: the needs and priorities of the community should be assessed, and close collaboration with individuals from the community, including community leaders, opinion leaders, community health care providers, and community organizations from various sectors of the community, should be consulted. Efforts should be focused on underserved and vulnerable populations. 2) Inclusion of community activities: these activities should be integrated within the context of the community environment, including primary health care services, voluntary organizations, grocery stores, restaurants, work sites, schools, and local media. 3) Inclusion mass media messages: the mass media can provide information and reinforcement of the behavior change. 4) Develop cost-effective interventions to assure that the community is exposed to an effective dose of the intervention. 5) Work with community organizations to help change social and physical environments to make them more conducive to health and healthy life-styles changes. 6) Develop a reliable monitoring and evaluation system: monitor the change process and conduct summary evaluations. 7) Disseminate the results to ensure that the benefits from the community program reach all communities. 8) For national implementation, the intervention program should work closely with national policy makers throughout the project.

A public health framework for chronic disease prevention and control

Chronic noncommunicable diseases are leading causes of death and disability in many developing countries. Several low-income countries lack mortality and morbidity data and do not yet know their burden of noncommunicable diseases. Cost studies are scarce, but in middle-income countries such as those of Latin America and the Caribbean, the cost of illness not only represents much of the direct costs of medical care, but also has an impact on family disposable income. Studies have reported that in low-resource settings, given incomplete health coverage and partial insurance, out-of-pocket expenses are high. Persons with chronic conditions, in many instances, have to forego care because of their inability to pay. Poverty and chronic noncommunicable diseases have a two-way interaction. These conditions warrant attention from poverty-reduction programs. Evidence shows that to have an impact on the burden of chronic diseases, action must occur at three levels: population-wide policies, community activities, and health services. The latter includes both preventive services and appropriate care for persons with chronic conditions. A public health approach embodies a systems perspective, containing the continuum of prevention and control, from determinants to care. In this framework it is critical to identify and address interactions and interventions that connect between and among the three levels of action.

Primary prevention of cardiovascular disease by an occupational health service

BACKGROUND

Worksites are considered to be a key channel for the delivery of interventions to prevent cardiovascular disease. The aim of this study was to evaluate the effect on the blood cholesterol levels of an intervention program offered by an occupational health service.

METHODS

The intervention group consisted of 95 employees and the reference group consisted of 74 employees, in all, 169 subjects, with a serum cholesterol > or = 5.2 mmol/l. Both groups completed a standardized questionnaire. Occupational health nurses carried out the blood sampling before and after the program. The intervention group was then offered counseling on physical activity and a dietician offered individual counseling on healthy food habits. The reference group was not the subject of the intervention program.

RESULTS

The mean cholesterol level decreased by 0.3 mmol/l (5%) in the intervention group and for the men the decrease was 0.5 mmol/l, while the mean level of the reference group was unchanged. Furthermore, there was a nonsignificant decrease of the mean triglyceride level in the intervention group.

CONCLUSION

The results of this controlled trial indicates that risk factors for cardiovascular disease can be reduced by interventions at the worksite. Even modest reductions of cholesterol levels may reduce the risk to a tangible degree.

The economics of smoking and cardiovascular disease

The direct medical cost of cardiovascular and circulatory diseases was $151 billion in 1995, approximately 17% of all direct medical care costs in the United States. Incidence and prevalence based estimates indicate that smoking is a major contributing factor for cardiovascular disease and associated costs. Statewide smoking control programs and workplace and public area smoking bans are effective in reducing smoking prevalence. Smoking cessation therapies are very cost-effective interventions for the prevention of cardiovascular disease. Incidence based estimates indicate that smoking cessation control expenditures in the United States have been a cost effective method for reducing the direct medical costs of cardiovascular disease in the past, and may be cost saving in the future. The expected cost of producing an additional ex-smoker has been estimated to be approximately $1,000 to $1,500. Most or all of this cost can be recovered in the short run from savings in avoided heart attacks and strokes alone in healthy quitters. Observational studies of the direct medical costs following cessation in those observed to quit show a reduction utilization, but which may occur only after a lag of three to five years.

Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk

BACKGROUND

Cardiovascular disease accounts for much morbidity and mortality in developed countries and is becoming increasingly important in less developed regions. Systolic blood pressure above 115 mm Hg accounts for two-thirds of strokes and almost half of ischaemic heart disease cases, and cholesterol concentrations exceeding 3.8 mmol/L for 18% and 55%, respectively. We report estimates of the population health effects, and costs of selected interventions to reduce the risks associated with high cholesterol concentrations and blood pressure in areas of the world with differing epidemiological profiles.

METHODS

Effect sizes were derived from systematic reviews or meta-analyses, and the effect on health outcomes projected over time for populations with differing age, sex, and epidemiological profiles. Incidence data from estimates of burden of disease were used in a four-state longitudinal population model to calculate disability-adjusted life years (DALYs) averted and patients treated. Costs were taken from previous publications, or estimated by local experts, in 14 regions.

FINDINGS

Non-personal health interventions, including government action to stimulate a reduction in the salt content of processed foods, are cost-effective ways to limit cardiovascular disease and could avert over 21 million DALYs per year worldwide. Combination treatment for people whose risk of a cardiovascular event over the next 10 years is above 35% is also cost effective leading to substantial additional health benefits by averting an additional 63 million DALYs per year worldwide.

INTERPRETATION

The combination of personal and non-personal health interventions evaluated here could lower the global incidence of cardiovascular events by as much as 50%.

Curtailing tobacco use among youth: evaluation of project 4-health

This article reports the development and evaluation of Project 4-Health, a theory-driven, research-based program to prevent tobacco use among youth enrolled in 4-H clubs throughout California. Additional goals were to involve youth in discouraging others' tobacco use and to develop youth leadership for tobacco control. To assess program effectiveness, 72 clubs were matched and randomly assigned to the program or control condition. Of 1,853 eligible club members, 88.6% completed the pretest. Of these, 79.5% completed a posttest 4 months after conclusion of program delivery, and 77.6% completed a second posttest 2 years later.Short-term effects were found on 7 of 24 outcome measures, indicating changes in knowledge, attitudes, and behavioral intention, but not in social influence variables or behaviors. No long-term effects were observed. Discussion considers how the challenges of designing, delivering, and evaluating the intervention influenced results and implications for preventing tobacco use through community-based youth groups.

Issues in the meta-analysis of cluster randomized trials

Meta-analyses involving the synthesis of evidence from cluster randomization trials are being increasingly reported. These analyses raise challenging methodologic issues beyond those raised by meta-analyses which include only individually randomized trials. In this paper we review and comment on a selected number of these issues, including problems of study heterogeneity, difficulties in estimating design effects from individual trials and the choice of statistical methods.

Can a sustainable community intervention reduce the health gap?--10-year evaluation of a Swedish community intervention program for the prevention of cardiovascular disease

OBJECTIVES

This paper evaluates the 10-year outcomes of a Northern Sweden community intervention program for the prevention of cardiovascular disease (CVD), with special reference to the social patterning of risk development.

METHODS

Using a quasi-experimental design, trends in risk factors and predicted mortality in an intervention area (Norsjö municipality) are compared with those in a reference area (Northern Sweden region) by repeated independent cross-sectional surveys.

RESULTS

There were significant differences in changes in total cholesterol level and systolic blood pressure between the intervention and reference populations. The predicted coronary heart disease mortality (based on the North Karelia risk equation). after adjustment for age and education, was reduced by 36% in the intervention area and by 1% in the reference area.

CONCLUSIONS

We conclude that a long-term community-based CVD prevention program which combines population and individual strategies can substantially promote a health shift in CVD risk in a high risk rural population. When evaluated for different social strata, we found no signs of an increasing health gap between socially privileged and less privileged groups. Socially less-privileged groups benefited the most from the present prevention program.

Community interventions for reducing smoking among adults

BACKGROUND

Since smoking behaviour is determined by social context, the best way to reduce the prevalence of smoking may be to use community-wide programmes which use multiple channels to provide reinforcement, support and norms for not smoking.

OBJECTIVES

To assess the effectiveness of community interventions for reducing the prevalence of smoking.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group specialised register, MEDLINE (1966-August 2001) and EMBASE (1980-August 2001) and reference lists of articles.

SELECTION CRITERIA

Controlled trials of community interventions for reducing smoking prevalence in adult smokers. The primary outcome was smoking behaviour.

DATA COLLECTION AND ANALYSIS

Data were extracted by one person and checked by a second.

MAIN RESULTS

Thirty two studies were included, of which seventeen included only one intervention and one comparison community. Only four studies used random assignment of communities to either the intervention or comparison group. The population size of the communities ranged from a few thousand to over 100,000 people. Change in smoking prevalence was measured using cross-sectional follow-up data in 27 studies. The estimated net decline ranged from -1.0% to 3.0% for men and women combined (10 studies). For women, the decline ranged from -0.2% to + 3.5% per year (n=11), and for men the decline ranged from -0.4% to +1.6% per year (n=12). Cigarette consumption and quit rates were only reported in a small number of studies. The two most rigorous studies showed limited evidence of an effect on prevalence. In the US COMMIT study there was no differential decline in prevalence between intervention and control communities, and there was no significant difference in the quit rates of heavier smokers who were the target intervention group. In the Australian CART study there was a significantly greater quit rate for men but not women.

REVIEWER'S CONCLUSIONS

The failure of the largest and best conducted studies to detect an effect on prevalence of smoking is disappointing. A community approach will remain an important part of health promotion activities, but designers of future programmes will need to take account of this limited effect in determining the scale of projects and the resources devoted to them.