Behavioural counselling in general practice for the promotion of healthy behaviour among adults at increased risk of coronary heart disease: randomised trial. Reduction of coronary heart disease risk factors in the German cardiovascular prevention study. The multifactor primary prevention trial in Göteborg, Sweden. Primary prevention of chronic disease in childhood: changes in risk factors after one year of intervention. Coronary heart disease prevention in childhood: one-year results of a randomized intervention study. Multiple risk factor intervention trial. Risk factor changes and mortality results. Multiple Risk Factor Intervention Trial Research Group. The efficacy of multiple risk factor intervention in treated hypertensive men during long-term follow up. Risk Factor Intervention Study Group. Implementing clinical guidelines in the treatment of hypertension in general practice. Work-site cardiovascular risk reduction: a randomized trial of health risk assessment, education, counseling, and incentives. WHO European Collaborative Trial of multifactorial prevention of coronary heart disease. The impact of increasing intensity of health promotion intervention on risk reduction. Promoting physical activity in a low-income multiethnic district: effects of a community intervention study to reduce risk factors for type 2 diabetes and cardiovascular disease: a community intervention reducing inactivity. Promotion of health in older people: a randomised controlled trial of health risk appraisal in British general practice. Effectiveness of two preventive interventions for coronary heart disease in primary care. Influence on lifestyle measures and five-year coronary risk by a comprehensive lifestyle intervention programme in patients with coronary heart disease. A cost effective, community based heart health promotion project in England: prospective comparative study. The impact of a decision aid about heart disease prevention on patients' discussions with their doctor and their plans for prevention: a pilot randomized trial. The Heartfile Lodhran CVD prevention project--end of project evaluation. Effectiveness of multidisciplinary lifestyle intervention for hypertension: a randomised controlled trial. Shifting the distribution of risk: results of a community intervention in a Swedish programme for the prevention of cardiovascular disease. Effectiveness of counselling patients on physical activity in general practice: cluster randomised controlled trial. The Otsego-Schoharie healthy heart program: prevention of cardiovascular disease in the rural US. Effect of nurse counselling on metabolic risk factors in patients with mild hypertension: a randomised controlled trial. Evaluation of a structured teaching and treatment programme for type 2 diabetes in general practice in a rural area of Austria. Evaluation of a multicomponent workplace health promotion program conducted in Japan for improving employees' cardiovascular disease risk factors. Advising people to take more exercise is ineffective: a randomized controlled trial of physical activity promotion in primary care. Integrated tobacco cessation counseling in a diabetes self-management training program: a randomized trial of diabetes and reduction of tobacco. Community-based primary prevention of cardiovascular disease in Switzerland: methods and results of the National Research Program (NRP 1A). Rational prescribing in primary care (RaPP): a cluster randomized trial of a tailored intervention. A randomized trial of effects of health risk appraisal combined with group sessions or home visits on preventive behaviors in older adults. A randomised controlled trial of senior Lay Health Mentoring in older people with ischaemic heart disease: The Braveheart Project. Secondary prevention of cardiovascular disease: a randomised trial of training in information management, evidence-based medicine, both or neither: the PIER trial. Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial. Implementing clinical guidelines in the treatment of hypertension in general practice. Evaluation of patient outcome related to implementation of a computer-based clinical decision support system. Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomised controlled trial. The Finnmark Intervention Study: is it possible to change CVD risk factors by community-based intervention in an Arctic village in crisis? Effects of a structured health education programme by a diabetic education nurse on cardiovascular risk factors in Chinese Type 2 diabetic patients: a 1-year prospective randomized study. Randomised controlled trial of follow up care in general practice of patients with myocardial infarction and angina: final results of the Southampton heart integrated care project (SHIP). The SHIP Collaborative Group. The relative effectiveness of educational and behavioral instruction programs for patients with NIDDM: a randomized trial. Hypertension improvement project: randomized trial of quality improvement for physicians and lifestyle modification for patients. Multifactorial primary prevention of cardiovascular diseases in middle-aged men. Risk factor changes, incidence, and mortality. Community-based intervention: the Coronary Risk Factor Study (CORIS). Systematic risk factor screening and education: a community-wide approach to prevention of coronary heart disease. Change in cardiovascular risk factors during a 10-year community intervention program. Reducing the risk of cardiovascular disease: effects of a community-based campaign on knowledge and behavior. Efficacy of an intensive prevention program in coronary patients in primary care, a randomised clinical trial. The impact of behavioral counseling on stage of change in fat intake, physical activity, and cigarette smoking in adults at increased risk of coronary heart disease.
To measure the effect of behaviourally oriented counselling in general practice on healthy behaviour and biological risk factors in patients at increased risk of coronary heart disease.
                Cluster randomised controlled trial.
                883 men and women selected for the presence of one or more modifiable risk factors: regular cigarette smoking, high serum cholesterol concentration (6.5-9.0 mmol/l), and high body mass index (25-35) combined with low physical activity.
                Brief behavioural counselling, on the basis of the stage of change model, carried out by practice nurses to reduce smoking and dietary fat intake and to increase regular physical activity.
                Questionnaire measures of diet, exercise, and smoking habits, and blood pressure, serum total cholesterol concentration, weight, body mass index, and smoking cessation (with biochemical validation) at 4 and 12 months.
                Favourable differences were recorded in the intervention group for dietary fat intake, regular exercise, and cigarettes smoked per day at 4 and 12 months. Systolic blood pressure was reduced to a greater extent in the intervention group at 4 but not at 12 months. No differences were found between groups in changes in total serum cholesterol concentration, weight, body mass index, diastolic pressure, or smoking cessation.
                Brief behavioural counselling by practice nurses led to improvements in healthy behaviour. More extended counselling to help patients sustain and build on behaviour changes may be required before differences in biological risk factors emerge. In six regions of former West Germany, a community-oriented prevention program for coronary heart disease (CHD) was conducted over a 7-year period.
                In the intervention regions, CHD prevention activities were performed with special emphasis on healthy nutrition, increased physical activity, and reduction of smoking, hypertension, and hypercholesterolemia. The impact of these activities on CHD risk factor trends was observed in three independent samples of the intervention regions. Three independent representative samples of the total West German population were used as a reference. Linear regression models with interaction terms to represent the intervention effects were used to test for differences in risk factor trends.
                In the pooled intervention regions, a net reduction in mean values of systolic (-2.0%) and diastolic (-2.0%) blood pressure, total serum cholesterol (-1.8%), as well as the percentage of smokers (-6.7%) was observed compared with the nationwide trend. From the major CHD risk factors, only body mass index was not influenced in the intervention population.
                The community-oriented German Cardiovascular Prevention program can effectively be used to reduce CHD risk factors in a broad population. The effect of a multifactorial intervention programme on coronary heart disease (CHD), stroke incidence and total mortality was determined in a random sample of men, 47-55 years old at entry. The intervention group comprised 10 004 men, and the two control groups were of similar size. The intervention consisted of antihypertensive treatment in subjects with screening blood pressure above 175 mmHg systolic or 115 mmHg diastolic, dietary advice to men with serum cholesterol levels above 260 mg per 100 ml (= 6.8 mMol l-1), advice to stop smoking to subjects who smoked more than 15 cigarettes per day. The intervention was applied for 10 years during which time CHD and stroke incidence and mortality were followed by means of special registers. Participation rate at first screening examination was 75%. The risk factor levels, i.e. blood pressure, serum cholesterol and smoking decreased markedly during 10 years in the intervention group, but also among the control groups. Total mortality, stroke and CHD incidence did not differ significantly between the intervention group and any of the two control groups. We conclude that a decrease has taken place in all three major risk factors for CHD in the general male population in Göteborg, Sweden. Strategies other than intervention on high-risk individuals must be chosen if a major impact on disease incidence is to be achieved in the general population. A five-year intervention study of the feasibility and effectiveness of a program aimed at the primary prevention of chronic disease was initiated in 1980 among children in 22 elementary schools in the Bronx, New York. Schools randomly were assigned either to the intervention program or to a control group. The intervention program consists of a curriculum focusing on nutrition, physical fitness, and cigarette smoking prevention. The study population at baseline comprised 2,283 fourth-graders. Subjects were eligible at baseline and at one-year follow-up for participation in a medical examination in which the following target risk factors were measured: systolic and diastolic blood pressures, plasma total and high-density lipoprotein (HDL) cholesterol, serum thiocyanate, ponderosity index, triceps skinfold thickness, and postexercise pulse recovery rate. After one year of intervention, systolic pressure increased less in the intervention group than among controls. Diastolic pressure decreased in both groups, but more in the intervention subjects than in controls. Total cholesterol decreased in the intervention group while increasing among controls. Significant net changes in the favorable direction also were observed for total cholesterol/HDL cholesterol ratio and for thiocyanate. These observations indicate that it is feasible to implement a school-based program aimed at the primary prevention of chronic disease. The intervention program appears to have had a favorable effect on several target risk factors. Although the effects were relatively small, intervention programs in schools may prove to be effective in lowering chronic disease risk. A six-year intervention study of the feasibility and effectiveness of a program aimed at the primary prevention of coronary heart disease (CHD) has been initiated among children in six school districts in Westchester County, New York. Schools randomly were assigned either to the intervention program or to a control group. The intervention program consists of a curriculum focusing on nutrition, physical fitness, and cigarette smoking prevention. The study population at baseline comprised 1,822 fourth-graders. This paper presents the findings at baseline and at one-year follow-up for the following target risk factors: systolic and diastolic blood pressure, plasma total and high-density lipoprotein (HDL) cholesterol, serum thiocyanate, ponderosity index, triceps skinfold thickness, and postexercise pulse recovery rate. After one year of intervention, the program was found to be acceptable to school administrators, teachers, parents, and children. Small net changes in the favorable direction were observed for diastolic blood pressure and thiocyanate. Intervention programs in schools may, after sufficient duration, prove to be effective in lowering CHD risk. The Multiple Risk Factor Intervention Trial was a randomized primary prevention trial to test the effect of a multifactor intervention program on mortality from coronary heart disease (CHD) in 12,866 high-risk men aged 35 to 57 years. Men were randomly assigned either to a special intervention (SI) program consisting of stepped-care treatment for hypertension, counseling for cigarette smoking, and dietary advice for lowering blood cholesterol levels, or to their usual sources of health care in the community (UC). Over an average follow-up period of seven years, risk factor levels declined in both groups, but to a greater degree for the SI men. Mortality from CHD was 17.9 deaths per 1,000 in the SI group and 19.3 per 1,000 in the UC group, a statistically nonsignificant difference of 7.1% (90% confidence interval, -15% to 25). Total mortality rates were 41.2 per 1,000 (SI) and 40.4 per 1,000 (UC). Three possible explanations for these findings are considered: (1) the overall intervention program, under these circumstances, does not affect CHD mortality; (2) the intervention used does affect CHD mortality, but the benefit was not observed in this trial of seven years' average duration, with lower-than-expected mortality and with considerable risk factor change in the UC group; and (3) measures to reduce cigarette smoking and to lower blood cholesterol levels may have reduced CHD mortality within subgroups of the SI cohort, with a possibly unfavorable response to antihypertensive drug therapy in certain but not all hypertensive subjects. This last possibility was considered most likely, needs further investigation, and lends support to some preventive measures while requiring reassessment of others. To examine the feasibility and efficacy of a multifactorial intervention programme directed towards hypercholesterolaemia, smoking, and diabetes mellitus in treated hypertensive patients after more than 3 years' follow-up and to describe the incidence of cardiovascular complications.
                Open, randomized, parallel-group study with allocation either to a comprehensive multiple risk factor modification programme or to usual care.
                Outpatient clinic in a city hospital.
                A total of 508 male patients with treated hypertension, aged 50-72 years, with at least one of the following: serum cholesterol > or = 6.5 mmol L-1, smoking or diabetes mellitus.
                Individually given advice and group meetings based on nutritional advice and behavioral treatment principles. Drug therapy could be instituted to achieve the treatment goals in the intervention group: serum total cholesterol below 6.0 mmol L-1, no smoking, and HbA1c below 6.0%. Diastolic blood pressure below 90 mmHg was the treatment goal in both groups.
                Serum cholesterol, HbA1c, diastolic blood pressure, smoking. Cardiovascular end-points were recorded.
                The net changes were (change intervention--change usual care): serum cholesterol -5.0% (95% confidence interval, -7.6 to -2.3%), 17.6% more stopped smoking (P = 0.04); diastolic blood pressure and HbA1c remained unchanged. The incidence of stroke was lower in the intervention group compared with the usual-care group: 2.0 and 6.7%, respectively (P = 0.017).
                The intervention programme was comparatively successful with regards to the effects on hypercholesterolaemia and smoking habits. An unexpected decrease in the stroke incidence was observed in the intervention group compared with the usual-care group. Discrepancies between clinical guidelines and clinical practice call for practical implementation strategies. This study evaluates the implementation of clinical guidelines for hypertension in general practice with a specific computer-based clinical decision support system (CDSS) as part of the intervention. We carried out a randomized study of general practice health centres in Sør- and Nord-Trøndelag counties in Norway (population 380000). A total of 17 health centres were included, with 24 doctors and 984 patients in the intervention group. Data from 887 patients was used in the analyses. There were 12 health centres with 29 doctors and 1255 patients in the control group. Data from 1127 control patients was used in the analyses. The main outcome measures were doctor's behaviour, measured by adherence to registration of recommended variables in the Norwegian clinical guidelines for hypertension. The aim of the intervention was to lower the fractions of patients without registrations. However, there were no clinically significant differences between the intervention group and the control group for fractions of patients without registration of blood pressure (intervention group 14.3%, control group 14.2%) or serum cholesterol (62.3% vs. 56.8%) during 12 months, nor, during 18 months, for fractions of patients without a registration of cigarette smoking (82.9% vs. 87.1%), cardiovascular inheritance (79.5% vs. 73.4%) and body mass index (81.5% vs. 89.2%). One or several variables necessary for calculation of risk score for myocardial infarction were missing in 91.7% of patients in the intervention group and 91.9% of patients in the control group. Large centre variations were shown for all variables. Implementation of clinical guidelines in the treatment of hypertensive patients in general practice, by means of a CDSS and several procedures for implementation did not result in clinically significant changes in the doctors' behaviour. Of importance are both the lack of user-friendliness of the specific CDSS and problems in performing time-consuming multidimensional procedures. This study reports an efficacy trial of four work-site health promotion programs. It was predicted that strategies making use of behavioral counseling would produce a greater reduction in cardiovascular disease risk factors than screening and educational strategies.
                Twenty-eight work sites were randomly allocated to a health risk assessment, risk factor education, behavioral counseling, or behavioral counseling plus incentives intervention. Participants were assessed before the intervention and at 3, 6, and 12 months.
                Compared with the average of the health risk assessment and risk factor education conditions, there were significantly higher validated continuous smoking cessation rates and smaller increases in body mass index and estimated percentage of body fat in the two behavioral counseling conditions. The behavioral counseling condition was associated with a greater reduction in mean blood pressure than was the behavioral counseling plus incentives condition. On average among all groups, there was a short-term increase in aerobic capacity followed by a return to baseline levels.
                Work-site interventions that use behavioral approaches can produce lasting changes in some cardiovascular risk factors and, if implemented routinely, can have a significant public health impact. Results are reported from a trial of multifactorial prevention of coronary heart disease (CHD) in occupational groups, involving randomization of 66 factories to intervention and control (49,781 men ages 40 to 59) in the United Kingdom, Belgium, Italy, and Poland. Net average reductions in the intervention factors were 1.2% (plasma cholesterol), 8.9% (daily cigarettes), 0.4% (weight), 2% (systolic blood pressure), and 11% for a combined risk estimate. Reductions were larger in high-risk men (19% for the combined estimate). Red blood cell fatty acid profiles were substantially changed. There was a net overall reduction of 7.4% in fatal CHD and 2.7% in total deaths. Benefits were larger in centers achieving larger risk factor reductions, and in one country--Belgium--the net decreases in CHD incidence and total deaths were significant at the 5% level. Benefit was at least as great in men with established ECG abnormality. It is concluded that CHD risk in middle-aged men seems to be reducible by simple and cost-effective means. The HealthWise Stepped Intervention Study (1988-1990) at Pacific Gas and Electric was conducted to evaluate how a health promotion program affects behavior change and whether increasing levels of preventive interventions improve health status. The basic intervention components consisted of health risk assessment and health newsletter (Levels 1, 2, 3, and 4). Additional interventions were health resource center and self-care books (Levels 2, 3, and 4), behavioral change workshops and Division Healthwise team (Levels 3 and 4), and case management and environmental policy (Level 4). The study employed a quasi-experimental design with nonequivalent control groups. The overall risk status has significantly improved at all four intervention levels. The comparison across the four intervention levels found that Level 4, combining environmental policy with "high risk" targeting, showed the most impressive performance. Participants in Level 4 consistently showed significantly greater improvement in life-style factors, and their overall risk status also showed the greatest improvement. The aim was to assess the net effects on risk factors for type 2 diabetes and cardiovascular disease of a community-based 3-year intervention to increase physical activity.
                A pseudo-experimental cohort design was used to compare changes in risk factors from an intervention and a control district with similar socioeconomic status in Oslo, Norway, using a baseline investigation of 2,950 30- to 67-year-old participants and a follow-up investigation of 1,776 (67% of those eligible, 56% women, 18% non-Western immigrants) participants. A set of theory-based activities to promote physical activity were implemented and tailored toward groups with different psychosocial readiness for change. All results reported are net changes (the difference between changes in the intervention and control districts). At both surveys, the nonfasting serum levels of lipids and glucose were adjusted for time since last meal.
                The increase in physical activity measured by two self-reported questionnaires was 9.5% (P = 0.008) and 8.1% (P = 0.02), respectively. The proportion who increased their body mass was 14.2% lower in the intervention district (P < 0.001), implying a 50% relative reduction compared with the control district, and was lower across subgroups. Beneficial effects were seen for triglyceride levels (0.16 mmol/l [95% CI 0.06-0.25], P = 0.002), cholesterol-to-HDL cholesterol ratio (0.12 [0.03-0.20], P = 0.007), systolic blood pressure (3.6 mmHg [2.2-4.8], P < 0.001), and for men also in glucose levels (0.35 mmol/l [0.03-0.67], P = 0.03). The net proportion who were quitting smoking was 2.9% (0.1-5.7, P = 0.043).
                Through a theory-driven, low-cost, population-based intervention program, we observed an increase in physical activity levels, reduced weight gain, and beneficial changes in other risk factors for type 2 diabetes and cardiovascular disease. there is inadequate evidence to support currently formulated NHS strategies to achieve health promotion and preventative care in older people through broad-based screening and assessment in primary care. The most extensively evaluated delivery instrument for this purpose is Health Risk Appraisal (HRA). This article describes a trial using HRA to evaluate the effect on health behaviour and preventative-care uptake in older people in NHS primary care.
                a randomised controlled trial was undertaken in three London primary care group practices. Functionally independent community-dwelling patients older than 65 years (n = 2,503) received a self-administered Health Risk Appraisal for Older Persons (HRA-O) questionnaire leading to computer-generated individualised written feedback to participants and general practitioners (GPs), integrated into practice information-technology (IT) systems. All primary care staff received training in preventative health in older people. The main outcome measures were self-reported health behaviour and preventative care uptake at 1-year follow-up.
                of 2,503 individuals randomised, 2,006 respondents (80.1%) (intervention, n = 940, control n = 1,066) were available for analysis. Intervention group respondents reported slightly higher pneumococcal vaccination uptake and equivocal improvement in physical activity levels compared with controls. No significant differences were observed for any other categories of health behaviour or preventative care measures at 1-year follow-up.
                HRA-O implemented in this way resulted in minimal improvement of health behaviour or uptake of preventative care measures in older people. Supplementary reinforcement involving contact by health professionals with patients over and above routine clinical encounters may be a prerequisite to the effectiveness of IT-based delivery systems for health promotion in older people. 1. To compare a patient-centred, self-directive intervention with conventional care; 2. To evaluate longitudinal within-group changes of coronary heart disease risk.
                Risk factor changes were evaluated in 110 men with high coronary heart disease risk attending a one year intervention study in general practice. The 22 participating general practice centres were randomly allocated to follow either a patient-centred, self-directive intervention or a conventional approach.
                No significant between-group differences were found in any single risk factor or in the combined risk of coronary heart disease. The improvement of total risk from screening time to conclusion of the study corresponded with changes of relative risks of CHD to 0.64 (95% CI: 0.54-0.77) and 0.65 (0.54-0.77) in the patient-centred, self-directive and the conventional care group respectively (p < 0.0001 in both groups).
                Everyday general practice clinical work seems as efficacious as a specific intervention method based on currently advocated behaviour change principles. Lifestyle measures of coronary heart disease (CHD) prevention have been overshadowed by the efficacy of drug treatments. This is particularly the case in the setting of secondary prevention where the benefits of lipid lowering, anti-platelet and anti-hypertensive drugs have been emphasised in numerous trials. Lifestyle measures address several CHD risk factors at once and are generally free of serious side effects.
                The objective of the present study was to determine whether a comprehensive programme of lifestyle modification could favourably influence dietary and exercise habits in addition to smoking cessation over two years. In addition, an attempt was made to evaluate if this programme could favourably influence the five-year CHD-risk in the male population included in the study.
                A total of 197 patients with proven coronary heart disease were included and randomised to a lifestyle intervention programme or to usual care. Follow-up was after a period of two years.
                Intervention comprised a low fat diet, regular exercise, smoking cessation, psychosocial support and education, delivered by nurses on the rationale for pharmacological and lifestyle measures. Usual care comprised follow-up in the routine outpatient clinic. Both groups were given the same comprehensive medication according to recent guidelines.
                Patients in the lifestyle intervention group reduced the intake of saturated fat, sugar and cholesterol (P<0.001), increased their exercise level (P<0.01) and stopped smoking (P<0.05) when compared with the usual care group. A sub-analysis of the influence of five-year CHD calculated risk in males resulted in a relative risk reduction of 22% (95% confidence intervals 9-35). Although significant, this result must be interpreted with caution due to poor statistical power and reproducibility of the method.
                In the presence of modern drug treatments for secondary cardiovascular disease prevention it remains possible through a favourable diet, exercise and smoking cessation to show an additional reduction in the five-year risk for CHD in males. To determine whether a community based coronary heart disease health promotion project, undertaken over four years, was associated with changes in the prevalence in adults of lifestyle risk factors known to affect the development of coronary heart disease, and to estimate whether such an approach was cost effective.
                Prospective, comparative study of the effects of a health promotion intervention on coronary heart disease lifestyle risk factors, assessed by postal questionnaire sent to a randomly chosen sample, both at baseline and after four years.
                Intervention and control populations of adults aged 18-64 in Rotherham, both from areas with a high incidence of coronary heart disease and similar socioeconomic composition.
                Changes in prevalence of lifestyle risk factors between the control and intervention communities from 1991 to 1995. The effect of the intervention on certain lifestyle behaviours was evaluated using multiple logistic regression to model the proportion with a particular behaviour in the study communities as a function of age (18-40 or 41-64 years), sex, the year of observation (1991 or 1995), and area (intervention of control).
                6.9% fewer people smoked and 8.7% more drank low fat milk in the intervention area, but no other statistically significant changes between the areas were detected. The estimated cost per life year gained was pounds 31.
                It is possible to have a cost effective impact on coronary heart disease lifestyle risk factors in a population of adults over four years using only modest resources. Low utilization of effective coronary heart disease (CHD) prevention strategies may be due to many factors, but chief among them is the lack of patient involvement in prevention decisions. We undertook this study to test the effectiveness of an individually-tailored, computerized decision aid about CHD on patients' discussions with their doctor and their plans for CHD prevention.
                We conducted a pilot randomized trial in a convenience sample of adults with no previous history of cardiovascular disease to test the effectiveness of an individually-tailored, computerized decision aid about CHD prevention against a risk factor list that patients could present to their doctor.
                We enrolled 75 adults. Mean age was 53. 59% were female, 73% white, and 23% African-American. 66% had some college education. 43% had a 10-year CHD risk of 0-5%, 25% a risk of 6-10%, 24% a risk of 11-20%, and 5% a risk of > 20%. 78% had at least one option to reduce their CHD risk, but only 45% accurately identified the strategies best supported by evidence. 41 patients received the decision aid, 34 received usual care. In unadjusted analysis, the decision aid increased the proportion of patients who discussed CHD risk reduction with their doctor from 24% to 40% (absolute difference 16%; 95% CI -4% to +37%) and increased the proportion who had a specific plan to reduce their risk from 24% to 37% (absolute difference 13%; 95% CI -7% to +34%). In pre-post testing, the decision aid also appeared to increase the proportion of patients with plans to intervene on their CHD risk (absolute increase ranging from 21% to 47% for planned medication use and 5% to 16% for planned behavioral interventions).
                Our study confirms patients' limited knowledge about their CHD risk and effective risk reduction options and provides preliminary evidence that an individually-tailored decision aid about CHD prevention might be expected to increase patients' discussions about CHD prevention with their doctor and their plans for CHD risk reduction. These findings should be replicated in studies with a larger sample size and patients at overall higher risk of CHD. Mainstream preventive interventions often fail to reach poor populations with a high risk of cardiovascular diseases (CVDs) in Pakistan. A community-based CVD primary prevention project aimed at developing approaches to reduce risk factors in such populations was established by Heartfile in collaboration with the National Rural Support Program in the district of Lodhran. The project implemented a range of activities integrated with existing social and health service mechanisms during a three year intervention period 2000/01-03/04. These were targeted in 4 key settings: community health education, mass media interventions, training of health professionals and health education through Lady Health Workers. The project received support from the Department for International Development, U.K. At the community level, a pre-test-post-test quasi-experimental design was used for examining project outcomes related to the community component of the intervention. Pre and post-intervention (training) evaluations were conducted involving all health care providers in randomly selected workshops in order to determine baseline levels of knowledge and the impact of training on knowledge level. In order to assess practices of physician and non-physician health care providers patient interviews, with control comparisons were conducted at each health care facility. Significant positive changes were observed in knowledge levels at a community level in the district of intervention compared with baseline knowledge levels particularly in relation to a heart healthy diet, beneficial level of physical activity, the causes of high blood pressure and heart attack and the effects of high blood pressure and active and passive smoking on health. Significant changes in behaviors at a practice level were not shown in the district of intervention. However the project played a critical role in spurring national action for the prevention and control of non-communicable diseases and introducing sustainable public health interventions for poor communities in Pakistan. Lifestyle factors like weight, alcohol consumption, salt intake and physical activity have shown to be important in treating hypertension. There have been made some randomised trials about the effects of lifestyle interventions, but the numbers of patients have been relatively small and the durations of follow-ups have been short. No controlled trials assessing the effects of lifestyle intervention in a rehabilitation setting have been reported. In this study, the effects of multidisciplinary lifestyle intervention in rehabilitation centres among middle-aged hypertensive employees were described. A total of 731 hypertensives from 45 worksites were randomised to lifestyle intervention in a rehabilitation centre or to usual care in an occupational or primary health-care centre for 12 months. Standard measurements were conducted before the intervention and 1-year later. Blood pressure (BP) levels were clearly reduced in the intervention group, while only minor changes were observed in the control group. The net changes between the two groups both for systolic and diastolic BPs were -2.1 mmHg (95% confidence intervals (CI) -4.0 to -0.1) and -1.5 mmHg (95% CI -2.6 to -0.4), respectively. The net changes were greater among men than women. The multidisciplinary lifestyle intervention in a rehabilitation centre setting produced significant reductions in BP among middle-aged employees with hypertension. To examine the impact of a systematic risk factor screening and counselling carried out by family physicians and family nurses within the larger framework of a community intervention programme for the prevention of cardiovascular disease (CVD).
                Quasi-experimental study comparing trends in an intervention area with those in a reference area.
                A Northern Sweden municipality (5500 inhabitants) constituted the intervention area while the Northern Sweden region (510,000 inhabitants) served as the reference area.
                All 30, 40, 50, and 60 year old inhabitants were invited each year from 1985 to 1992. Among 2046 eligible 1893 participated (92.5%), which formed eight independent cross sections. One cross section, 1986, was re-surveyed forming a panel.
                In the cross sections, mean total cholesterol was reduced from 7.09 to 6.27 mmol/l for men (p < 0.001) and from 7.13 to 5.89 mmol/l for women (p < 0.001) and mean systolic blood pressure from 132.2 to 123.7 mm Hg for men (p < 0.05) and from 129.2 to 122.0 mm Hg for women (p < 0.001) during the eight years. Body mass index (BMI) increased from 25.6 to 26.2 for men (p < 0.05) and from 25.0 to 25.5 for women (NS). A corresponding reduction in cholesterol and blood pressure (for women) occurred in the panel, while BMI was unchanged. The risk for CVD, using the Framingham equation, was estimated to be reduced overall by 19% (p = 0.0021) when comparing early cross sections (1985/86) with the later cross sections (1990/91).
                It was concluded that a long term community based CVD prevention programme that combines population and individual strategies can substantially promote a health shift in CVD risk in a high risk rural population. The individual attention and evaluation provided by the health provider survey seem to accelerate, but not increase the amount of, risk reduction. To assess the long term effectiveness of the "green prescription" programme, a clinician based initiative in general practice that provides counselling on physical activity.
                Cluster randomised controlled trial. Practices were randomised before systematic screening and recruitment of patients.
                42 rural and urban general practices in one region of New Zealand.
                All sedentary 40-79 year old patients visiting their general practitioner during the study's recruitment period.
                General practitioners were prompted by the patient to give oral and written advice on physical activity during usual consultations. Exercise specialists continued support by telephone and post. Control patients received usual care.
                Change in physical activity, quality of life (as measured by the "short form 36" (SF-36) questionnaire), cardiovascular risk (Framingham and D'Agostino equations), and blood pressure over a 12 month period.
                74% (117/159) of general practitioners and 66% (878/1322) of screened eligible patients participated in the study. The follow up rate was 85% (750/878). Mean total energy expenditure increased by 9.4 kcal/kg/week (P=0.001) and leisure exercise by 2.7 kcal/kg/week (P=0.02) or 34 minutes/week more in the intervention group than in the control group (P=0.04). The proportion of the intervention group undertaking 2.5 hours/week of leisure exercise increased by 9.72% (P=0.003) more than in the control group (number needed to treat=10.3). SF-36 measures of self rated "general health," "role physical," "vitality," and "bodily pain" improved significantly more in the intervention group (P<0.05). A trend towards decreasing blood pressure became apparent but no significant difference in four year risk of coronary heart disease.
                Counselling patients in general practice on exercise is effective in increasing physical activity and improving quality of life over 12 months. To describe a rural, hospital-based public health intervention program and to evaluate its effectiveness in cardiovascular disease (CVD) risk reduction using cross-sectional studies and a panel study.
                A rural population of 158,000 located in New York state comprised the intervention population. A similar but separate population was used for reference. A multifaceted, multimedia 5-year program provided health promotion and education initiatives to increase physical activity, decrease smoking, improve nutrition, and identify hypercholesterolemia and hypertension. To evaluate the effectiveness of the intervention, surveys were conducted at baseline in 1989 (cross-sectional) and at follow-up in 1994-95 (cross-sectional and panel). For cross-sectional studies, a random sample of adults was obtained using a three-stage cluster design. Self-reported and objective risk factor measurements were obtained. Comparison of pre- to post- changes in intervention versus reference populations was done using 2 x 2 randomized block ANOVA, 2 x 2 mixed ANOVA. and extension of the McNemar test.
                Smoking prevalence declined (from 27.9% to 17.6%) in the intervention population. Significant adverse trends were observed for high-density lipoprotein cholesterol and triglycerides. Systolic blood pressure was reduced while diastolic blood pressure remained stable. Body mass index increased significantly in both populations.
                This rural. 5-year CVD community intervention program decreased smoking. The risk reduction may be attributable to tailoring of a multifaceted approach (multiple risk factors, multiple messages, and multiple population subgroups) to a target rural population. The study period was too short to identify changes in CVD morbidity and mortality. Hypertension often clusters with metabolic risk factors and its optimal treatment may involve a number of changes in lifestyle. Nurse-led care regarding lifestyle change may improve outcomes in cardiovascular disease prevention involving.
                To examine if lifestyle guidance given by a nurse improved components of the metabolic syndrome including blood pressure, lipids and waist circumference.
                Subjects that participated in a health screening with systolic blood pressure 140-169 mm Hg and diastolic blood pressure 90-99 mm Hg at a minimum of three separate readings treated or not treated with antihypertensive drugs were randomly allocated either to monthly nurse-led lifestyle counselling (intervention group, N=31) or to conventional primary care (control group, N=20) to be followed by lifestyle counselling.
                The mean (S.D.) baseline and end of study blood pressure was 157 (9)/94 (6) mm Hg and 147 (9)/91 (8) mm Hg, respectively, in the intervention group versus 153 (9)/94 (4) and 143 (10)/92 (8) mm Hg, respectively, in the control group (NS between the groups). Waist circumference increased significantly between baseline and 6 months in the control but not in the intervention (mean difference between the groups, 3.1 cm [95% CI 1.2-5.0], p=0.04) and serum triglyceride concentrations were reduced in the intervention compared with the control group (mean difference, 0.56 mmol/l [95% CI 0.22-0.90], p=0.03). The number of risk factors of the metabolic syndrome was 2.1 (S.D. 1.1) at baseline and 2.6 (S.D. 1.2) at 6 months in the control group versus 2.2 (S.D. 1.1) and 1.9 (S.D. 1.0), respectively, in the intervention group (p=0.01). Change in triglycerides was correlated with change in weight (Pearson's correlation coefficient=0.73, p=0.001) and waist circumference (Pearson's correlation coefficient=0.63, p=0.009) in the control group.
                Nurse counselling did not reduce blood pressure but was associated with a lesser gain in waist circumference and reduced triglyceride concentrations. Metabolic risk factors may worsen rapidly in patients with mild hypertension in the waiting period for lifestyle intervention. The efficacy of a treatment and teaching programme for non-insulin-treated Type 2 diabetic patients in general practice was evaluated in a prospective, controlled study. In a rural area in southern Austria, 53 patients from seven general practices participated in a structured programme (intervention group) and 55 patients from seven general practices without the programme served as the control group. After 6 months the weight reduction in the intervention group was 2.6 kg (1.6-3.7 kg, p < 0.001) and the difference in HbA1c between the groups was 0.92% (0.23-1.61%, p < 0.01) at follow-up. Systolic (-16.6 mmHg) and diastolic (-11.1 mmHg) blood pressure, serum triglycerides (-0.63 mmol I-1), and serum cholesterol (-0.40 mmol I-1) were reduced significantly in the intervention group (p < 0.006). The number of patients with callus formation and poor nail care decreased significantly after participating in the teaching programme (p < 0.001). In the control group no reduction in body weight, metabolic control or in risk factors for diabetic foot complications were observed. Calculated health care costs per patient and year decreased in the intervention group (-33 pounds) and increased in the control group (+ 30 pounds) mainly due to changes in prescription of oral hypoglycaemic agents in both groups. This programme may be an efficient and helpful model to increase overall quality of diabetes care according to the St Vincent Declaration. The long-term effectiveness of multicomponent worksite health promotion programs targeting cardiovascular disease risk factors remains unclear in Japan. This study was conducted to evaluate the effectiveness of such a health promotion program consisting of a main program provided over 4 days and a follow-up program provided over 1 year.
                The subjects of this randomized controlled trial were male employees working for a building maintenance company in Japan. The intervention group (n = 152) and the control group (n = 150) consisted of employees having abnormal findings in at least one of the following items at baseline health examination: body mass index (BMI), systolic (SBP) or diastolic blood pressure, total cholesterol, HDL cholesterol, triglycerides, and fasting blood glucose. Evaluation was conducted at 18 months after the main program.
                BMI, SBP, total cholesterol, and triglycerides improved significantly in the intervention group compared with the control group (P < 0.05). When comparisons were limited to those who showed abnormality at baseline, BMI, total cholesterol, and triglycerides improved significantly in the intervention group (P < 0.05).
                The multicomponent health promotion program provided to employees was shown to be effective in improving obesity, high blood pressure, and hyperlipidemia when evaluated 18 months after the main intervention program.
                Copyright 2001 American Health Foundation and Elsevier Science. Over the last 10 years 'exercise referral schemes' have been popular even though the evidence for effectiveness of any one-to-one intervention in primary care is deficient. We report the results of a primary care based one-to-one intervention that compared the effect of two communication styles with a no-intervention control group on self-reported physical activity at 12 months.
                In all, 1658 middle-aged men and women were randomly assigned to 30 minutes of brief negotiation or direct advice in primary care or a no-intervention control group. The main outcome was self-reported physical activity at 12 months. Secondary outcome measures included change in blood pressure and body mass index.
                Intention-to-treat analysis revealed no significant differences in physical activity between groups. Brief negotiation group participants who completed the study increased their physical activity significantly more than controls. There was no change in body mass index in any group. The brief negotiation group produced a greater reduction in diastolic blood pressure than direct advice.
                If patients whose health may benefit from increased physical activity seek advice in primary care, 20-30 minutes of brief negotiation to increase physical activity is probably more effective than similar attempts to persuade or coerce. However, blanket physical activity promotion in primary care is not effective. The most effective way of increasing physical activity in primary care has yet to be determined. The purpose of this study was to evaluate the impact of a tobacco cessation intervention using motivational interviewing on smoking cessation rates during diabetes self-management training (DSMT).
                A randomized controlled trial was conducted with subjects recruited from an ongoing type 2 diabetes adult education program at a large diabetes center. A total of 114 subjects were randomized to intervention (n = 57; face-to-face motivational interviewing plus telephone counseling and offering of medication) or standard care (n = 57). Outcome measures included tobacco cessation rates, mean number of cigarettes smoked, A1C, weight, blood pressure, and lipids.
                Intensive intervention using motivational interviewing integrated into a standard DSMT program resulted in a trend toward greater abstinence at 3 months of follow-up in those receiving the intervention. However, this same trend was not observed at 6 months. The addition of this structured smoking cessation intervention did not negatively affect either diabetes education or other measures of diabetes management, including A1C values.
                Structured tobacco cessation efforts can be readily integrated into established diabetes education programs without a negative impact on diabetes care or delivery of diabetes education. However, an intervention of moderate intensity for smoking cessation was no more effective than usual care in assisting patients with tobacco cessation after 6-month follow-up. Whether a more intensive intervention, targeting patients expressing a readiness to discontinue tobacco use, and/or a longer duration or a more cumulative effect of treatment will be more effective must be evaluated. The National Research Program 1A on Primary Prevention of Cardiovascular Disease in Switzerland was designed to determine whether community health education can reduce cardiovascular risk factors in whole population groups. Two towns (12,000 inhabitants each) in the French-speaking and two (16,000 inhabitants each) in the German-speaking part of the country were selected for either intervention or comparison. Following baseline screening in 1977 (stratified random samples) and the community intervention program (1978-1980), a final assessment on the initial participants was made at the end of 1980. In intervention towns, 26.2% of the regular smokers quit during this period compared with 18.1% in the reference towns. In addition, a significant net increase in the proportion of hypertensive patients under effective control was observed. A reduction in cholesterol levels was noted in both the intervention and the reference towns, with no difference between them. However, cholesterol levels in a subgroup of women participating in program activities as compared with those not participating were significantly reduced. The program, with extensive involvement of a diversity of community groups, has enjoyed continued support, even after the end of the research experience, thus demonstrating the viability and acceptability of community-oriented preventive action. A gap exists between evidence and practice regarding the management of cardiovascular risk factors. This gap could be narrowed if systematically developed clinical practice guidelines were effectively implemented in clinical practice. We evaluated the effects of a tailored intervention to support the implementation of systematically developed guidelines for the use of antihypertensive and cholesterol-lowering drugs for the primary prevention of cardiovascular disease.
                We conducted a cluster-randomized trial comparing a tailored intervention to passive dissemination of guidelines in 146 general practices in two geographical areas in Norway. Each practice was randomized to either the tailored intervention (70 practices; 257 physicians) or control group (69 practices; 244 physicians). Patients started on medication for hypertension or hypercholesterolemia during the study period and all patients already on treatment that consulted their physician during the trial were included. A multifaceted intervention was tailored to address identified barriers to change. Key components were an educational outreach visit with audit and feedback, and computerized reminders linked to the medical record system. Pharmacists conducted the visits. Outcomes were measured for all eligible patients seen in the participating practices during 1 y before and after the intervention. The main outcomes were the proportions of (1) first-time prescriptions for hypertension where thiazides were prescribed, (2) patients assessed for cardiovascular risk before prescribing antihypertensive or cholesterol-lowering drugs, and (3) patients treated for hypertension or hypercholesterolemia for 3 mo or more who had achieved recommended treatment goals. The intervention led to an increase in adherence to guideline recommendations on choice of antihypertensive drug. Thiazides were prescribed to 17% of patients in the intervention group versus 11% in the control group (relative risk 1.94; 95% confidence interval 1.49-2.49, adjusted for baseline differences and clustering effect). Little or no differences were found for risk assessment prior to prescribing and for achievement of treatment goals.
                Our tailored intervention had a significant impact on prescribing of antihypertensive drugs, but was ineffective in improving the quality of other aspects of managing hypertension and hypercholesterolemia in primary care. To explore effects of a health risk appraisal for older people (HRA-O) program with reinforcement, we conducted a randomized controlled trial in 21 general practices in Hamburg, Germany.
                Overall, 2,580 older patients of 14 general practitioners trained in reinforcing recommendations related to HRA-O-identified risk factors were randomized into intervention (n = 878) and control (n = 1,702) groups. Patients (n = 746) of seven additional matched general practitioners who did not receive this training served as a comparison group. Patients allocated to the intervention group, and their general practitioners, received computer-tailored written recommendations, and patients were offered the choice between interdisciplinary group sessions (geriatrician, physiotherapist, social worker, and nutritionist) and home visits (nurse).
                Among the intervention group, 580 (66%) persons made use of personal reinforcement (group sessions: 503 [87%], home visits: 77 [13%]). At 1-year follow-up, persons in the intervention group had higher use of preventive services (eg, influenza vaccinations, adjusted odds ratio 1.7; 95% confidence interval 1.4-2.1) and more favorable health behavior (eg, high fruit/fiber intake, odds ratio 2.0; 95% confidence interval 1.6-2.6), as compared with controls. Comparisons between intervention and comparison group data revealed similar effects, suggesting that physician training alone had no effect. Subgroup analyses indicated favorable effects for HRA-O with personal reinforcement, but not for HRA-O without reinforcement.
                HRA-O combined with physician training and personal reinforcement had favorable effects on preventive care use and health behavior. to examine the effects and feasibility of educating and empowering older people with ischaemic heart disease using trained senior lay health mentors.
                randomised controlled trial with blinded evaluation.
                Falkirk and District Royal Infirmary. Participants: inpatients and outpatients aged 60 or over attending secondary care with a diagnosis of angina or acute myocardial infarction. Three-hundred and nineteen entered and 289 completed exit assessments. The intervention group took part in mentoring groups for 1 year, meeting monthly for 2 hours, each led by two trained lay health mentors in addition to standard care.
                primary outcome measures were changes in coronary risk factors, medication usage and actual use of secondary care health services. Secondary outcomes were total and cardiovascular events; changes in medication compliance, non-medical support requirement, health status and psychological functioning, and social inclusion.
                there were significant improvements in a reported current exercise score (mean +0.33, +0.02 to +0.52), in the average time spent walking per week by 72 minutes (+1 to +137 minutes), and in the SF36 Physical Functioning Score (+6.1, +2.4 to +9.5). There was a 1.0% reduction in total fat (95% CI -3.0% to -0.6%) and a 0.6% reduction in saturated fat (95% CI -1.5% to -0.03%). The intervention group showed reduced outpatient attendance for coronary heart disease (-0.25 appointments, -0.61 to -0.08). Attendance rates were high. Socio-economic grouping did not affect participation.
                Lay Health Mentoring is feasible, practical and inclusive, positively influencing diet, physical activity, and health resource utilisation in older subjects with ischaemic heart disease without causing harm. Sub-optimal management of cardiovascular disease (CVD) patients is widespread in primary and secondary care, with risk factors frequently unrecorded or untreated.
                To investigate the effectiveness of educational interventions developed in primary care, on recording, prescribing and control of risk factors among all patients recorded by their general practitioner as having CVD.
                Factorial, duster-randomised controlled trial.
                Primary care teams representing the range of practice development in a geographically defined area in inner London.
                Participating practices were randomly allocated to one of the four intervention groups: information, evidence, both or neither. Interventions were tailored to suit individual practice needs. At a mean of 19 months after baseline, and three months after the end of intervention, practices carried out the follow-up assessment of recording, treatment, and control of risk factors in the same CVD patients.
                Adequate recording of all three risk factors, found inapproximately a third of patients at baseline, increased non-significantly by 10.5% (95% confidence interval [CI] = 3.9 to 24.9) in the information (versus not information) group and by 6.6% (95% [CI] = 8.9 to 22.0) in the evidence (versus not evidence) group. Factorial improvements in prescribing and control of risk factors tended not to be significant. Adequate recording of an three risk factors showed the greatest improvement in the information plus evidence group (19.9% increase, P for heterogeneity across the four groups < or = 0.001). Mean change from baseline to follow-up within the four intervention groups suggested improvements in the combined information plus evidence group in cholesterol recording (22.5% increase), prescribing of lipid lowering drugs (4.4% increase) and mean cholesterol (0.7 mmol/l decrease).
                Adequate risk factor recording did not differ between the information (versus not information) or the evidence (versus not evidence) intervention groups. Combined training in information systems and evidence-based medicine should be considered in the design of future interventions, to improve secondary prevention of CVD. Depression and anxiety disorders are common mental disorders worldwide. The MANAS trial aimed to test the effectiveness of an intervention led by lay health counsellors in primary care settings to improve outcomes of people with these disorders.
                In this cluster randomised trial, primary care facilities in Goa, India, were assigned (1:1) by computer-generated randomised sequence to intervention or control (enhanced usual care) groups. All adults who screened positive for common mental disorders were eligible. The collaborative stepped-care intervention offered case management and psychosocial interventions, provided by a trained lay health counsellor, supplemented by antidepressant drugs by the primary care physician and supervision by a mental health specialist. The research assessor was masked. The primary outcome was recovery from common mental disorders as defined by the International Statistical Classification of Diseases and Related Health Problems-10th revision (ICD-10) at 6 months. This study is registered with ClinicalTrials.gov, number NCT00446407.
                24 study clusters, with an equal proportion of public and private facilities, were randomised equally between groups. 1160 of 1360 (85%) patients in the intervention group and 1269 of 1436 (88%) in the control group completed the outcome assessment. Patients with ICD-10-confirmed common mental disorders in the intervention group were more likely to have recovered at 6 months than were those in the control group (n=620 [65·0%] vs 553 [52·9%]; risk ratio 1·22, 95% CI 1·00-1·47; risk difference=12·1%, 95% CI 1·6%-22·5%). The intervention had strong evidence of an effect in public facility attenders (369 [65·9%] vs 267 [42·5%], risk ratio 1·55, 95% CI 1·02-2·35) but no evidence for an effect in private facility attenders (251 [64·1%] vs 286 [65·9%], risk ratio 0·95, 0·74-1·22). There were three deaths and four suicide attempts in the collaborative stepped-care group and six deaths and six suicide attempts in the enhanced usual care group. None of the deaths were from suicide.
                A trained lay counsellor-led collaborative care intervention can lead to an improvement in recovery from CMD among patients attending public primary care facilities.
                The Wellcome Trust.
                Copyright © 2010 Elsevier Ltd. All rights reserved. To evaluate the implementation of clinical guidelines for hypertension in general practice by use of a computer-based clinical decision support system (CDSS) and a specific implementation strategy. Evaluation of patient outcome.
                Randomised study with health centres as units. The intervention group had the CDSS installed and made ready for use, doctors and assistants were trained and received a user-manual, the doctors were offered telephone repetitions, a seminar in risk intervention and, at the same seminar, further demonstration of the CDSS. The doctors received baseline registrations with information of how they treated their own hypertensive patients, and use of the CDSS was checked repeatedly.
                General practice in Sør- and Nord-Trøndelag counties in Norway, 380,000 inhabitants.
                Seventeen health centres with 24 doctors and 984 patients in the intervention group. Data from 879 patients used in the final analyses. Twelve health centres with 29 doctors and 1255 patients in the control group. Data from 1119 patients used in the final analyses.
                After an intervention period of 18 months, group differences in level of systolic and diastolic blood pressure, serum cholesterol, body mass index, and risk score for myocardial infarction were calculated, as well as group differences in fractions of smokers.
                Significant group difference in favour of intervention group: diastolic blood pressure 1 mmHg (95% CI -1.89, -0.17). However, a significant baseline difference in systolic blood pressure in favour of control group of 2.7 mmHg (95% CI 1.0, 4.5) had been reduced to 1.2 mmHg (95% CI -0.6, 3.0) after intervention.
                Implementation of clinical guidelines in the treatment of hypertensive patients in general practice by means of a CDSS and several other procedures for implementation did not affect patient outcome in any clinically significant way. To test the effectiveness of a complex intervention designed, within a theoretical framework, to improve outcomes for patients with coronary heart disease.
                Cluster randomised controlled multicentre trial.
                General practices in Northern Ireland and the Republic of Ireland, regions with different healthcare systems.
                903 patients with established coronary heart disease registered with one of 48 practices.
                Tailored care plans for practices (practice based training in prescribing and behaviour change, administrative support, quarterly newsletter), and tailored care plans for patients (motivational interviewing, goal identification, and target setting for lifestyle change) with reviews every four months at the practices. Control practices provided usual care.
                The proportion of patients at 18 month follow-up above target levels for blood pressure and total cholesterol concentration, and those admitted to hospital, and changes in physical and mental health status (SF-12).
                At baseline the numbers (proportions) of patients above the recommended limits were: systolic blood pressure greater than 140 mm Hg (305/899; 33.9%, 95% confidence interval 30.8% to 33.9%), diastolic blood pressure greater than 90 mm Hg (111/901; 12.3%, 10.2% to 14.5%), and total cholesterol concentration greater than 5 mmol/l (188/860; 20.8%, 19.1% to 24.6%). At the 18 month follow-up there were no significant differences between intervention and control groups in the numbers (proportions) of patients above the recommended limits: systolic blood pressure, intervention 98/360 (27.2%) v control, 133/405 (32.8%), odds ratio 1.51 (95% confidence interval 0.99 to 2.30; P=0.06); diastolic blood pressure, intervention 32/360 (8.9%) v control, 40/405 (9.9%), 1.40 (0.75 to 2.64; P=0.29); and total cholesterol concentration, intervention 52/342 (15.2%) v control, 64/391 (16.4%), 1.13 (0.63 to 2.03; P=0.65). The number of patients admitted to hospital over the 18 month study period significantly decreased in the intervention group compared with the control group: 107/415 (25.8%) v 148/435 (34.0%), 1.56 (1.53 to 2.60; P=0.03).
                Admissions to hospital were significantly reduced after an intensive 18 month intervention to improve outcomes for patients with coronary heart disease, but no other clinical benefits were shown, possibly because of a ceiling effect related to improved management of the disease.
                Current Controlled Trials ISRCTN24081411. Owing to high cardiovascular mortality, the Norwegian Government introduced the programme "Health and Inequalities in Finnmark" in 1988. One of the projects in this programme was aimed at changing cardiovascular risk factors through community-based intervention in a fishing community in the Norwegian Arctic.
                The intervention community Båtsfjord and the three control communities were selected from the same coastal area. The intervention was based on a quasi-experimental design, and evaluated by population surveys before (1987) and after (1993) the invention. The attending cohort was analysed. The intervention method was based on empowerment and cooperation between different organizations, and the primary healthcare system.
                From 1987 - 93, the male cohort in Båtsfjord had a more favourable development when compared with changes in the control communities regarding the 8.6% increase in physical activity (p = 0.047), the reduction in systolic blood pressure by 0.01 mmHg (p = 0.002), and the reduction in diastolic blood pressure by 2.1 mmHg (p < 0.001). The female cohort in Båtsfjord had a more favourable development when compared with changes in the control communities regarding the 11.2% increase in use of low-fat milk (p = 0.046), the increase in systolic blood pressure by 2.1 mmHg (p = 0.024), and the reduction in diastolic blood pressure by 2.1 mmHg (p < 0.001).
                Despite a difficult economic situation for the Arctic coastal communities, the study found it possible for voluntary organizations, local public administration, and local health personnel to promote change in lifestyle and blood pressure using a community intervention approach. To assess the effect of regular diabetic health education on cardiovascular risk factors in Chinese Type 2 diabetic patients.
                This was a 1-year prospective randomized study. One hundred and eighty Type 2 diabetic subjects were recruited from three regional diabetic centres in Hong Kong. Ninety received additional structured reinforcement of diabetic health education by a trained nurse after the doctors' consultations every 3 months (intervention group). The others received the same medical care except no nursing reinforcement (control group). Outcome measures included fasting plasma glucose, HbA(1c), body mass index, waist circumference, blood pressure and lipid profiles, which were assessed before the study and after 1 year.
                Two of the controls defaulted follow-up. The intervention group and controls had similar age and sex distribution. At the end of study, the intervention group had reducted their waist circumference, diastolic blood pressure, HbA(1c), total cholesterol and low-density lipoprotein cholesterol levels. The controls had reduced their total cholesterol and low-density lipoprotein cholesterol levels. Other cardiovascular risk factors were not significantly changed in the controls. Addition of drugs and/or dosage increment of anti-diabetic drugs, lipid-lowering agents and anti-hypertensive agents were similar between the two groups.
                Regular structured reinforcement with diabetic health education is useful. It helps to control more successfully some of the cardiovascular risk factors in Chinese Type 2 diabetic patients. To assess the effectiveness of a programme to coordinate and support follow up care in general practice after a hospital diagnosis of myocardial infarction or angina.
                Randomised controlled trial; stratified random allocation of practices to intervention and control groups.
                All 67 practices in Southampton and south west Hampshire, England.
                597 adult patients (422 with myocardial infarction and 175 with a new diagnosis of angina) who were recruited during hospital admission or attendance at a chest pain clinic between April 1995 and September 1996.
                Programme to coordinate preventive care led by specialist liaison nurses which sought to improve communication between hospital and general practice and to encourage general practice nurses to provide structured follow up.
                Serum total cholesterol concentration, blood pressure, distance walked in 6 minutes, confirmed smoking cessation, and body mass index measured at 1 year follow up.
                Of 559 surviving patients at 1 year, 502 (90%) were followed up. There was no significant difference between the intervention and control groups in smoking (cotinine validated quit rate 19% v 20%), lipid concentrations (serum total cholesterol 5.80 v 5.93 mmol/l), blood pressure (diastolic pressure 84 v 85 mm Hg), or fitness (distance walked in 6 minutes 443 v 433 m). Body mass index was slightly lower in the intervention group (27.4 v 28.2; P=0.08).
                Although the programme was effective in promoting follow up in general practice, it did not improve health outcome. Simply coordinating and supporting existing NHS care is insufficient. Ischaemic heart disease is a chronic condition which requires the same systematic approach to secondary prevention applied in other chronic conditions such as diabetes mellitus. In this randomized trial patients with non-insulin-dependent diabetes were allocated to one of four programs: a minimal instruction program (n = 59), and education program of individual visits (n = 57), an education program incorporating a group education course (n = 66), and a behavioral program (n = 59). Individual and group education programs had higher attrition rates than the behavioral and minimal programs. The four programs, which involved different amounts of patient contact time, delivery format, and instructional strategies, all produced reductions in HbA1 and BMI, with no significant differences between the programs. There were no differences between groups over three time periods in total cholesterol, HDL cholesterol, systolic blood pressure, or proportion of patients consulting an ophthalmologist. The behavioral program produced a greater reduction in diastolic blood pressure over 12 months than the education programs and a greater reduction in the cholesterol risk ratio over 3 months than the other programs. The behavioral program patients were more likely to have visited a podiatrist after 6 months and reported higher satisfaction. Despite widely publicized hypertension treatment guidelines for physicians and lifestyle recommendations for patients, blood pressure control rates remain low. In community-based primary care clinics, we performed a nested, 2 x 2 randomized, controlled trial of physician intervention versus control and/or patient intervention versus control. Physician intervention included internet-based training, self-monitoring, and quarterly feedback reports. Patient intervention included 20 weekly group sessions followed by 12 monthly telephone counseling contacts and focused on weight loss, Dietary Approaches to Stop Hypertension dietary pattern, exercise, and reduced sodium intake. The primary outcome was change in systolic blood pressure at 6 months. Eight primary care practices (32 physicians) were randomized to physician intervention or control groups. Within those practices, 574 patients were randomized to patient intervention or control groups. Patient mean age was 60 years, 61% were women, and 37% were black. Blood pressure data were available for 91% of patients at 6 months. The main effect of physician intervention on systolic blood pressure at 6 months, adjusted for baseline pressure, was 0.3 mm Hg (95% CI: 1.5 to 2.2; P=0.72). The main effect of the patient intervention was 2.6 mm Hg (95% CI: 4.4 to 0.7; P=0.01). The interaction of the 2 interventions was significant (P=0.03); the largest impact was observed with the combination of physician and patient intervention (9.7 +/- 12.7 mm Hg). Differences between treatment groups did not persist at 18 months. Combined physician and patient interventions lowers blood pressure; future research should focus on enhancing effectiveness and sustainability of these interventions. In a randomized five-year multifactorial primary prevention trial of vascular diseases, hyperlipidemias, hypertension, smoking, obesity, and abnormal glucose tolerance of the high-risk test group (n = 612 men) were treated with dietetic-hygienic measures and hypolipidemic (mainly probucol and clofibrate) and antihypertensive (mainly diuretics and beta-blockers) agents. A matched high-risk control group (n = 610) and a low-risk control group (n = 593) were not treated. The program markedly improved the risk factor status, yet the five-year coronary incidence tended to be higher in the intervention group than in the control group (3.1% vs 1.5%), while the stroke incidence was significantly reduced (1.3% vs 0%). The coronary events tended to be accumulated in subgroups treated with beta-blocking agents or clofibrate, but there were few in those receiving probucol or diuretics. Thus, the intervention program significantly reduced development of stroke, but the occurrence of cardiac events was not prevented. Possible adverse drug effects offsetting the probable benefit of improved risk profile are not excluded. The Coronary Risk Factor Study (CORIS) examined the feasibility and effectiveness of a multifactorial community intervention programme to reduce coronary heart disease (CHD) risk factor levels. Three Afrikaner communities were surveyed before and after a 4-year intervention in two of the communities, the third serving as a control (C). Intervention was primarily by small mass media (low-intensity intervention, LII) or by small mass media plus interpersonal intervention to high-risk individuals (high-intensity intervention, HII). After allowing for change in C, significant net reductions in blood pressure, smoking, and risk score were obtained in LII and HII alike. Though the total cholesterol (TC) fell by 10-12%, there was no net reduction in favour of the intervention communities. However, LII and HII resulted in significant increases in high-density lipoprotein cholesterol (HDL-C) levels and HDL-C/TC ratios in comparison to C. Overall, the LII community fared almost as well as the HII community, and high-risk individuals did not show a greater change in risk factors than others. We conclude that community-based intervention works, and that in these particular communities a media-based health education programme was more cost-effective than one which adds a greater degree of interpersonal intervention. Within a community-wide heart disease prevention effort, it was hypothesized that personalized risk factor screening and education would result in modified health behaviors and reduced risk factor levels for coronary heart disease. Adults from a population sample were randomized to a community-wide screening and education program or were excluded from that program for 1 year. At the end of that year, both groups were measured for risk factor levels and related health behaviors. Those who received the screening and education program had significantly lower risk factor levels and other evidence of health behavior change, including lower blood cholesterol (206.9 vs 211.5 mg/dl), lower diastolic blood pressure (68.7 vs 70.0 mm Hg), lower resting heart rate (71.4 vs 72.7 bpm), and increased selection of low-fat and low-sodium meals in local restaurants. These data suggest that systematic risk factor screening and education may result in lower population risk for coronary heart disease. The study describes changes in cardiovascular risk factors during 10 years of a community intervention program conducted in a rural area in Central Italy. Two areas were involved, one for treatment and one for reference. In 1983-84, 739 men and 859 women in the treatment area and 942 men and 1045 women in the control area, aged 20-69 years, were screened; total and HDL cholesterol, systolic and diastolic blood pressure, fasting blood glucose, smoking habit, weight and height were measured. Between 1983 and 1993 several intervention activities based on community medicine were carried out in the treatment area. They were based on interaction with the local socio-sanitary institutions and school system in order to influence individual persons, small groups and entire community. Major effort was addressed to mass health education, nutrition education, antismoking-propaganda and detection and treatment of hypertension, diabetes and hyperlipidemia. In 1972 the Stanford Heart Disease Prevention Program launched a three-community field study. A multimedia campaign was conducted for two years in two California communities (Watsonville and Gilroy), in one of which (Watsonville) it was supplemented by an intensive-instruction program with high-risk subjects. A third community (Tracy) was used as a control. The campaigns were designed to increase participants' knowledge of the risk factors for cardiovascular disease, to change such risk-producing behavior as cigarette smoking, and to decrease the participants' dietary intake of calories, salt, sugar, saturated fat, and cholesterol. Results of a sample survey indicate that substantial gains in knowledge, in behavioral modification, and in the estimated risk of cardiovascular disease can be produced by both methods of intervention. The intensive-instruction program, when combined with the mass-medica campaign, emerged as the most effective for those participants who were initially evaluated to be at high risk. The results after two years of intervention are reported for effects on knowledge and behavioral change for the total participant samples and for the high-risk subsamples in each of the three communities. Most studies that have analysed the effect of secondary prevention of coronary heart disease come from hospitals. Those that are community-based have been conducted mainly by nurses and follow-up was generally too short to show impact on cardiovascular events.
                This is a multi-centre randomised controlled clinical trial in which patients in the intervention group received periodic postal reminders to see their general practitioner every three months during a 3-year follow-up. General practitioners reinforced healthy lifestyle recommendations to patients and reviewed drug therapies at these quarterly intervals. Patients in the control group received usual care.
                A total of 983 patients aged 30-79 were included. During the 3-year follow-up, 67 patients died and 156 experienced a non-fatal cardiovascular event. The event rates and all-cause mortality were similar in the intervention and control groups (24.0% and 23.5%, and 8.1% and 9.9%, respectively). Improvement in quality of life was similar in both groups. Blood pressure and high-density lipoprotein cholesterol were more frequently within recommended levels in the intervention group than in controls: odds ratio 1.63, 95% confidence interval 1.05-2.51, and odds ratio 2.61, 95% confidence interval 1.32-5.18, respectively.
                Intensive secondary prevention conducted by general practitioners may improve long-term blood pressure control and increase high-density lipoprotein cholesterol in patients with stable coronary disease. This study assessed stages of change in fat intake, physical activity, and cigarette smoking during a randomized controlled trial of behavioral counseling.
                Twenty general practices (primary health care centers) were randomized to lifestyle counseling by behavioral methods or to usual health promotion. A total of 883 patients were selected for the presence of 1 or more of the following risk factors: cigarette smoking, high cholesterol, or a combination of a high body mass index and low physical activity. Stage of change (precontemplation, contemplation, preparation, and action/maintenance) was assessed at baseline and after 4 and 12 months.
                The odds of moving to action/maintenance for behavioral intervention vs control patients at 4 months were 2.15 (95% confidence interval [CI] = 1.30, 3.56) for fat reduction, 1.89 (95% CI = 1.07, 3.36) for increased physical activity, and 1.77 (95% CI = 0.76, 4.14) for smoking cessation. The likelihood of achieving action/maintenance was related to baseline stage for all 3 behaviors.
                Brief behavioral counseling based on advice matched to stage of readiness for change may be valuable in encouraging healthy lifestyles among patients in primary care at raised risk of cardiovascular disease.
Interventions using counselling and education aimed at behaviour change do not reduce total or CHD mortality or clinical events in general populations but may be effective in reducing mortality in high-risk hypertensive and diabetic populations. Risk factor declines were modest but owing to marked unexplained heterogeneity between trials, the pooled estimates are of dubious validity. Evidence suggests that health promotion interventions have limited use in general populations.