Pawtucket Heart Health Program

Background/Questions

This community prevention trial, begun in 1980, tested the effects of a community-wide education program on levels of CVD risk factors and risk and rates of CHD in an intervention city relative to a comparison one. The hypothesis was that population risk factor “intensity” and projected CHD risk would decrease more in Pawtucket, Rhode Island, the intervention site, than in a comparison city.

Method/Design

Approximately 71,000 individuals resided in Pawtucket versus 98,000 in the comparison town. The two communities represented a slightly older population than in the U.S. as a whole, along with lower average household income and higher rates of unemployment.

Evaluation of the Pawtucket Heart Health Program included biennial random household risk factor surveys and continuous surveillance for MI and stroke in 8 community hospitals. A formative and process evaluation assessed intervening variables along with operations of new or existing community risk modification programs.

The baseline survey was conducted during 1981/82 and field intervention efforts began in the spring of 1982. During the first 3 years, the Pawtucket Heart Health Program involved 15,000 persons directly in heart health behavior change programs through community activation in planning, implementation, evaluation, and management of the programs. The programs used a volunteer-based delivery system with target behaviors for control of blood pressure and serum cholesterol levels, smoking cessation, regular aerobic physical activity, and maintenance of desirable body weight using strategies consistent with the tenets of social learning theory.

Results

Six cross-sectional surveys of adults aged 18-64 years in Pawtucket and the comparison city were carried out between 1981 and 1993. Between 2000 and 3000 individuals responded to each survey in the 2 communities. There were no significant community differences in smoking, blood cholesterol or blood pressure changes between Pawtucket and the control city. Declines in cigarette smoking were observed in both sites, with no significant city differences.

A significantly lower rate of increase in body mass occurred in the intervention city. While there were small declines in both communities over the 12-year survey period in the projected rates of CVD, the greater decreases between the initial and final survey occurred in Pawtucket. Based on responses to a series of open-ended knowledge questions, knowledge of CVD prevention improved significantly over time in both cities and in each demographic subgroup examined. The increases in knowledge came primarily from increases in the identification of physical inactivity and blood cholesterol and a high fat diet as important CVD risk factors.

The percentage of respondents who thought that they could do something to prevent having a heart attack or stroke increased over time (87% at the initial survey to 93% at survey 6). Total (fatal plus non-fatal) CHD rates remained stable during this period. Increases in nonfatal CHD events, and concomitant decreases in in-hospital and out-of-hospital CHD deaths, contributed to these trends.

Conclusions/Discussion

The study strengths include the use of intensive community based risk factor intervention efforts, several cross-sectional surveys, and long-term study follow-up. Pawtucket developed particularly the strategy of community organization, that is, involvement of existing structures and institutions in health promotion. The limitations include the study of only 2 communities and lack of longitudinal (cohort) surveys to follow changes. The results of this study, as well as findings from other community-based intervention efforts, highlight the difficulties in implementing community-wide risk factor modification efforts and in outpacing population level changes in coronary risk factors that are occurring generally. (HB)