Thomas M. Lasater

The Pawtucket Heart Health Program: community changes in cardiovascular risk factors and projected disease risk.

OBJECTIVES Whether community-wide education changed cardiovascular risk factors and disease risk in Pawtucket, RI, relative to a comparison community was assessed. METHODS Random-sample, cross-sectional surveys were done of people aged 18 through 64 years at baseline, during, and after education. Baseline cohorts were reexamined. Pawtucket citizens of all ages participated in multilevel education, screening, and counseling programs. RESULTS The downward trend in smoking was slightly greater in the comparison city. Small, insignificant differences favored Pawtucket in blood cholesterol and blood pressure. In the cross-sectional surveys, body mass index increased significantly in the comparison community; a similar change was not seen in cohort surveys. Projected cardiovascular disease rates were significantly (16%) less in Pawtucket during the education program. This difference lessened to 8% posteducation. CONCLUSIONS The hypothesis that projected cardiovascular disease risk can be altered by community-based education gains limited support from these data. Achieving cardiovascular risk reduction at the community level was feasible, but maintaining statistically significant differences between cities was not. Accelerating risk factor changes will likely require a sustained community effort with reinforcement from state, regional, and national policies and programs.

Theory and delivery of health programming in the community: The Pawtucket Heart Health Program☆

The Pawtucket Heart Health Program is one of the community studies examining whether population-based efforts to lower cardiovascular risk factors will reduce cardiovascular morbidity and mortality. The Pawtucket Heart Health Program intervention is based on a blend of social learning theory, community organization models, community psychology tenets, and diffusion research. This model allows for multifaceted programs that target individuals, groups, organizations, and the entire community to alter their cardiovascular risk through managing blood pressure, lowering blood cholesterol, quitting smoking, increasing fitness, and maintaining desirable weight levels. A dominant feature of the intervention is the emphasis that it places on volunteers for program delivery. The role of volunteers in providing direct services to help citizens lower their blood pressure and lose weight is highlighted to demonstrate the feasibility and effectiveness of these services. In addition, church-based programming which utilizes volunteers to manage and direct programs is also presented as an example of community-based health promotion efforts that promote collective efficacy.

Dietary differences in smokers and nonsmokers from two southeastern New England communities

OBJECTIVE Previous studies based on 24-hour dietary recall data have shown that smokers tend to consume less healthful diets than nonsmokers. We tested this hypothesis using data from food frequency questionnaires (FFQs) in a group of men and women. DESIGN Characteristics of smokers and nonsmokers were compared using data collected from a cross-sectional household health survey. SUBJECTS Adults aged 18 through 64 years from two communities in southeastern New England were randomly selected for the study and interviewed in their homes by trained personnel. The interview included questions on demographic and behavioral characteristics. Height, weight, blood pressure, and serum lipids were measured using standard protocols. The Willett FFQ was completed by 1,608 of 2,531 eligible respondents who made up our study sample. STATISTICAL ANALYSES PERFORMED Respondents were categorized as current cigarette smokers or nonsmokers. Demographic, behavioral, physiologic, and dietary characteristics were compared between smokers and nonsmokers by analysis of covariance with age as the covariate. RESULTS Eligible respondents who did not complete the FFQ differed from respondents with respect to age, gender, smoking prevalence, and several other demographic characteristics. Smokers consumed more energy, fat, alcohol, and caffeine than nonsmokers. Smoking status was inversely associated with intake of vitamins A and C, dietary fiber, folate, and iron among women, whereas differences were smaller and not significant among men. Women who smoked consumed fewer servings of fruits and vegetables than nonsmokers, but this trend was not noted in men. The association between diet and smoking was only slightly diminished by multivariate adjustment for age, income, regular exercise, marital status, and working status but most clinically relevant associations remained. The interaction between gender and smoking was not statistically significant for most dietary variables. CONCLUSIONS These results suggest that health promotion messages targeted to smokers should include dietary instructions, especially for women.

Dietary factors in relation to weight change among men and women from two southeastern New England communities.

OBJECTIVE: Dietary factors, independent of total energy, may be important in promoting obesity. We examined prospectively the relationship between baseline diet composition and weight gain among adult men and women from southeastern New England. DESIGN: The prospective association of nutrient consumption and weight change was examined in a randomly selected cohort examined four years apart. SUBJECTS: Adults aged 18 through 64 years from two communities in Southeastern New England were randomly selected for the study after being interviewed in their homes. The present investigation is based on a subgroup of 465 individuals who completed a food-frequency questionnaire in 1986 or 1987 and were reinterviewed four years later. STATISTICAL ANALYSES: Multiple regression analyses were used to determine the association of weight change with different nutrients and food groups after adjusting for age, smoking status, baseline body mass index, physical activity level, and total energy. RESULTS: Total energy was positively associated with weight gain and age was inversely associated with weight gain. None of the nutrients or food groups were significantly related to weight gain. CONCLUSIONS: These findings indicate that weight gain increased with increasing baseline total energy intake, particularly in the young. Future research is required to determine ways of decreasing energy intake in younger individuals.

Organizational and community approaches to community-wide prevention of heart disease: The first two years of the pawtucket heart health program☆☆☆

The Pawtucket Heart Health program (PHHP) is a federally funded research and demonstration project for the primary prevention of coronary heart disease (CHD) in a community. This article presents a discussion of the first 26 months of this intervention, divided into its three phases. PHHP staff initially approached the intervention city through local organizations to accomplish risk-factor behavior change in the population. After 11 months, PHHP complemented its programs in organizations with activities open to all city residents, in order to accelerate participation by the population. Seven months into this phase, it was decided that community activities should be the major focus of the intervention approach to assure a level of participation adequate to make a measurable impact. The third has shown the greatest percentage of public participation, demonstrating the complementary nature of organization and community interventions and of the translation of social learning theory into principles for primary prevention in a community.

Synthesis of Findings and Issues from Religious ..Based Cardiovascular Disease Prevention Trials

Purpose: Widespread prevention of cardiovascular disease (CVD) requires significant aggregate lifestyle behavior changes. Extensive resources including money, time, access, facilities, materials, and programs are needed to bring about such behavior changes on a large scale. Over the past several decades, funds for large scale public health efforts and related CVD research have become more difficult to acquire, and prevention efforts have been shifting to state and community sites. Thus, large scale behavior modification for CVD prevention requires active efforts to access resources from partnerships with multiple private sector organizations. Methods: Religious organizations (ROs) are a potentially valuable channel with many advantages for undertaking behavior change programming in partnership with public health researchers. ROs have a broad, direct “reach” with people and provide social support structures, facilities, volunteers, communication channels and access to many sub-populations as well as a compatible mission and history of interest in health. In spite of the many advantages of partnerships between CVD health researchers and ROs, very few formal research studies have been conducted. Existing reports have emphasized the feasibility and powerful benefits of implementing RO-based health programs; however, little data or formal hypothesis testing have been reported. Very few formal CVD research projects have employed scientifically acceptable research designs with random assignment of intact groups to intervention and comparison conditions. Results: In this review, conducted by the current authors, only six projects have been identified that meet these more rigorous scientific criteria. In a discussion of these projects, we classify RO-based studies into four levels of involvement of the RO: 1) use of ROs as sites for recruitment and tracking of experimental subjects; 2) use of RO facilities to conduct interventions; 3) involvement of RO members in delivering behavior change programs; and 4) the addition of significant religious components as an integral part of the intervention. This paper discusses the design, results and implications of these studies including information on what we already know about conducting research with ROs, gaps in existing research and recommendations for future studies. Conclusions: There is enormous untapped potential for RO-based CVD prevention research, but considerably more work is required to achieve the level of research that is currently conducted in other channels such as worksites and schools. Health practitioners/researchers and ROs are increasingly seizing the opportunity for partnerships to improve health. The knowledge gained from these projects and their documented successes will hopefully encourage other components of the public health system such as hospitals, managed care organizations and departments of health to continue developing ways of including ROs in health research and behavior change programming.

Is a History of Depressive Symptoms Associated With an Increased Risk of Infertility in Women

Researchers have reported an association between self-reported antidepressant use and increased risk of ovulatory infertility but could not control for confounding by the drug indication. We evaluated the role of depressive symptoms in the development of infertility. We recontacted a population-based sample of Pawtucket Heart Health Program (PHHP) health survey respondents to perform this case-control study. Self-reported infertility was defined as an inability to conceive after 12 months of unprotected intercourse. Controls were women who reported at least one pregnancy. The index age for infertile women was the age at which they first experienced fertility problems, and for the fertile women it was the age of their first pregnancy. History of depressive symptoms was based on self-report before the index age. Women with a history of depressive symptoms were nearly twice as likely to report infertility relative to women without a history of depressive symptoms before the index age after controlling for potential confounders (90% confidence interval: 0.9-3.2). Our data suggest that depressive symptoms as well as the drugs used to treat these conditions may play an important role in the pathogenesis of infertility. The association between depressive symptoms and infertility should be explored further.

Physical activity, physical fitness, and coronary heart disease risk factors.

The relationships between physical activity, physical fitness, and coronary heart disease risk factors measured in a large community sample were evaluated. Self-reported physical activity using a single question, maximal oxygen consumption estimates derived from the Pawtucket Heart Health Step Test, blood pressure, nonfasting lipids, and body mass index were cross-sectionally evaluated in 381 men and 556 women. The correlation of estimated maximal oxygen consumption and self-reported physical activity was modest but statistically significant (r = 0.13 in men and r = 0.19 in women). Blood pressure, body mass index, and HDL cholesterol were correlated with physical fitness (r = 0.24-0.65) and correlated to self-reported physical activity (r = 0.09-0.14). Evaluation of coronary heart disease risk factors using both physical activity and physical fitness revealed a complex relationship that generally showed a stronger relationship with measures of physical fitness than with physical activity. This study suggests that simultaneous measurement of physical activity and physical fitness may be useful in epidemiologic studies of habitual physical activity and chronic disease.

The accuracy of self-reported smoking status assessed by cotinine test strips

We evaluated a new cotinine test strip to assess smoking status. Urine cotinine was measured using cotinine test strips and also by gas chromatographic techniques (GC) (as the reference criterion). Smoking status was assessed with a self-administered questionnaire. The cotinine test strip identified smokers with a very high level of agreement (97.3% using 100 ng/ml and 97.1% using 250 ng/ml for the cutoff point) and non-smokers with a fair-to-moderate level of agreement (74.5% using 100 ng/ml and 86.4% using 250 ng/ml for the cutoff point). These data suggest that the cotinine test strip appears to provide a reasonably accurate measure of smoking status. Since this was the first study to evaluate the cotinine test strip using the test strip prototype, larger clinical trials are needed to evaluate the validity of the cotinine test strip compared to GC measurements to confirm smoking status.

Methods in Program Evaluation The Process Evaluation System of the Pawtucket Heart Health Program

A methodology for a process evaluation system as applied to the Pawtucket Heart Health Program is described. The rationale, goals, and design of this system, which are suited to the documentation of community demonstration programs or other interventions, are discussed. Examples of data from the system are provided, including those from linked, computer-based files for the systematic tracking of program activities and the characteristics of program participants. Also discussed are approaches to maintaining such a system in a context of limited resources.