Community and Public Health Intervention Strategies

1
Community and Public Health Intervention
Strategies

• The Psychology of Physical Activity
• KINE 2000
• Sherry Grace, PhD

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Outline

• Site-based Community Interventions
• School
• Work
• Health system
• Policy, Legislation, Environment
• Mass Media
• Multiple Risk Factor Interventions
• Assessing Impact RE-AIM

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Why?

• Increases in routine and lifestyle forms of PA
  than can be incorporated naturally throughout a
  persons day may provide the most effective means
  of increasing PA in the population at large
• Phys inactivity is population-wide problem

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Community Level Interventions

• DEFN Population-based prevention strategies
  that assist entire communities to reduce their
  level of risk factors for cardiovascular disease
  and that will ultimately result in a reduction of
  illness and early death

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Site-Based Interventions Schools

• Elementary, middle, and high schools have
  traditionally offered physical education (PE)
  classes ability to reach virtually all kids
• Schools are offering fewer, and shorter duration
  PE, and have even eliminated them completely is
  some cases ()
• Also, kids are sedentary majority of PE class
  time

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Site-Based Interventions Schools

• Two Areas of Focus
• Increasing physical activity during physical
  education classes
• Increasing out-of-school physical activity

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Typical Interventions in Schools

• Curriculum changes more info about health
  aspects of PA
• Implementing PA activities b4 after school
• Training of personnel in schools to deliver new
  curriculum
• Grade school, high school, post-secondary

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Site-Based Interventions Schools

• The Child and Adolescent Trial for Cardiovascular
  Health (CATCH)
• 96 elementary schools in California, Louisiana,
  Minnesota, and Texas
• CATCH targeted increasing physical activity
  during PE classes, and outside of school time
• Multi-site RCT
• Control schools

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CATCH Study - School

• 5,106 ethnically diverse 3rd graders
• Policy interventions such as the provision of
  space, equipment and supervision during
  non-school hours
• Curricula in PE classes
• Outcome measured number of minutes of PA in PE
  classes
• Also total daily activity

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CATCH Study - Results

• Students in intervention schools engaged in more
  moderate vigorous PA during PE lessons than
  controls
• 51.9 vs. 42.3
• Intervention students also reported sig more
  vigorous total daily activity

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CATCH Cohort Tracking Maintenance of PA??

• Assess PA through 8th grade (6, 7, 8)
• 3 yr F/U (no further intervention) showed that
  behl changes were maintained through early
  adolescence
• diff for vigorous activity b/w grps maintained,
  but actual minutes of PA declined in both groups
• Intervention grp 8 min more PA/day than controls
  3 yrs after intervention

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Schools Review of 14 Interventions

• Interventions often successful at improving
  knowledge attitudes towards PA
• Interventions typically successful at increasing
  PA during PE classes
• Interventions generally unsuccessful at
  increasing out-of-school PA

Stone et al., 1998
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Site-Based Interventions Worksites

• Targeted due to suspected link between fitness
  and work productivity
• Potential to reach large of adult popn

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Site-Based Interventions Worksites

• Dishman and associates (1998) conducted a
  meta-analysis on 26 studies examining worksite
  interventions
• The results of the meta-analysis revealed a
  small, but insignificant, effect for worksite
  interventions

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Site-Based Interventions Health Care Settings
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PAL Study

• Patient completes assessment in waiting room to
  determine stage of motivational readiness,
  baseline PA
• Brief physician-delivered intervention matched to
  stage, 3-5 min
• Given ex prescription booklet
• F/U postcard

Goldstein et al., 1999
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Site-Based Interventions Health Care Settings

• Systematic review of health care setting physical
  activity interventions
• Primary Prevention PA for apparently healthy
  individuals
• Secondary Prevention PA promotion for
  individuals with established disease (e.g., CVD)

Simons-Morton and colleagues (1998)
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Health Care Settings - Primary

• 12 primary prevention studies
• Based on patient counseling
• No interventions included structured physical
  activity programs
• 75 implemented by doctors
• The results of these studies were generally
  positive in the short term
• Effects decreased over time

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Health Care Settings - Secondary

• Only 13 of the 24 studies reported significant
  changes in PA
• Effective Interventions
• supervised exercise
• with behaviour modification techniques
• or the provision of home equipment

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Summary

• Sufficient data to promote use of interventions
  in health care settings
• Offer continuing maintenance or booster sessions
• To offer a sufficiently intense behl
  intervention, have docs provide advice, and other
  health care professionals provide more in depth
  counselling, supervision, f/u

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Mass Media
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Mass Media

• Television, radio, newspapers, the use of
  telephones, internet technology, and postal
  services
• Using some medium other than personal contact
• Offer means of reaching larger number of people
  at less expense

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4 Roles of Mass Media

• Educator to introduce new ideas
• Supporter to reinforce old messages or maintain
  change
• Promoter to attract attention to existing
  programs
• Supplement to community-based interventions

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Social Marketing

• Like advertising in the business world But
  instead of pushing a product, social marketers
  push ideas
• Uses the principles of market analysis, planning,
  competitive assessment, ongoing evaluation,
  models of consumer behaviour.
• Focuses on communication and persuasion toward
  target groups e.g., sedentary, older

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National PA Campaigns in Canada

• ParticipACTION has demonstrated increased
  awareness of and interest in exercising during
  time when campaign was running
• E.g., 70 of participants surveyed recall
  campaign messages

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ParticipACTION

• After nearly 30 years of encouraging Canadians to
  get up and get fit, ParticiPACTION called in
  quits in 2001. The federal government has said no
  to the fitness agency's 2.5 million funding
  request. There will be no further money for the
  non-profit's famous fitness drives and
  information campaigns. In 1972, then-prime
  minister Pierre Trudeau set up the program to
  battle exorbitant health costs.

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Body Break

• PARTICIPaction was looking for a new approach to
  promote active living across the nation, and when
  they met Hal and Joanne, they found the
  tailor-made combination that they needed. They
  contracted Hal Johnson and Joanne to produce and
  host a series of 90 shows, and "Body Break " was
  born. The series has been very successful.

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Policy Interventions

• Legislation refers to formal legal structures at
  the local, state, or federal levels of
  government.
• Policy is the formal or informal rules that
  provide structure to a governing organization.

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Recent Examples with Smoking

• Implementation of laws to prohibit sales to
  minors
• No smoking in workplaces, restaurants, public
  spaces (TTC)
• Obligatory inclusion of messages regarding health
  risks of smoking on packaging
• Taxes / cost

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Examples of Env / Policy Interventions

• Increasing daily commuting to work by foot or
  bike through provision of showers and changing
  facilities
• Opening new leisure centers in low-SES
  neighbourhoods (e.g., Belfast)
• Bike paths, sex-segregated gyms, release time for
  PA, extend hours for gym

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Cdn PA Legislation

• In 1961, Bill C-131, or the Fitness and Amateur
  Sport Act was passed by the Parliament of Canada.
  
• The act committed 5,000,000 for the development
  of sport
• Over the next three decades several reports were
  commissioned, increasing amounts of money were
  committed, a National Sport Administration Centre
  was developed to house national sport governing
  bodies.
• We had federal government funding, a minister and
  a bureaucracy to help meet the challenges, three
  new fitness research centers, and scholarships to
  enable Canadians to pursue advanced degrees in
  the field of physical education, health, and
  exercise physiology

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Community-Wide Campaigns Using Multiple Methods
to TargetMultiple Behaviours
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Interventions for Multiple Risk Factors

• Campaign Stanford 5-City Project
• Sample 4 cities in California
• Design 2 pairs matched, 1 surveillance only
• Activity target leisure and lifestyle activity
  as part of CVD risk reduction
• Walking, taking stairs

Young et al., 1996
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Stanford 5-City Project

• DVs knowledge, attitudes
• Self-reported PA daily energy expenditure,
  moderate vig activity
• Intervention delivery Electronic print mass
  media, face to face community events
• 6 Years

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Stanford FCP - Results

• Little consistent evidence of tx effect on PA
  knowledge or attitudes
• Men in tx cities displayed modest ? in vigorous
  PA
• Women showed small ? in moderate PA
• Limitations focused more on other risk factors
  such as diet, smoking

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Minnesota Heart Health Program

• Sample 6 Midwestern communities, 400,000 people
• Design 3 matched pairs, 1 educ in each
• Activity target low-moderate intensity leisure
  activity
• DVs
• increase energy expenditure by 50 kcal/day
• Increase mod activity in 30 of individuals

Luepker et al., 1994
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Minnesota Heart Health Program

• Intervention Delivery Mass media, community
  events, businesses
• 6 yrs
• Results small but sig effects in first 3 yrs of
  program, but not maintained thereafter

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Conclusions

• Only modest improvements in PA, which generally
  declines across years of f/u assessment
• Better maintenance assoc w option for home-based
  PA, mediated delivery, self-management
  instruction, booster sessions

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Conclusions

• From evidence we have, provision of a variety of
  PA facilities by various community orgs does
  enable people to be more active
• Use of mass media appears to be successful in
  promoting awareness and interest in exercising,
  but not successful in actually changing exercise
  behaviour

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• Public Health Level
• Measuring the Impact of Interventions

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Improving Health in the Real World

• At the root of the rationale to promote physical
  activity is the necessity to improve public
  health
• Little is known about the translatability of
  physical activity programs from research into
  practice
• Do these things work in the real world?
• Will research be followed by practice?
• How can those people who evaluate physical
  activity interventions determine if they have had
  or could have a significant public health impact?
  

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The Public Health Impact Of Physical Activity
Interventions

• The concern of many health care professionals is
  the external validity of interventions developed
  and tested in very controlled environments
• Interventions that work in the environment of the
  randomized clinical trial (RCT) are often
  ineffective in real-world settings

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Why?

• Resources within real-world settings are
  different from those in the study
• , time, politics
• The trained professionals who offer the
  intervention in the study were more qualified,
  less busy than those that offer it in a
  real-world setting
• Research assistant versus nurse

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RE-AIM Framework Glasgow et al., 1999
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RE-AIM Reach

• The proportion of the target population that
  participated in the intervention
• Often times the reach of a randomized controlled
  trial can be determined by the participation rate
  of those contacted
• This calculation could overestimate the reach in
  real-world

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Reach - Examples
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RE-AIM Efficacy

• The success in promoting physical activity at the
  individual level
• Findings of meta-analyses report the impact of an
  intervention through effect sizes
• A higher effect size indicates a more efficacious
  intervention

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RE-AIM Adoption

• The proportion of settings that subsequently use
  the intervention
• Considered the missing link between research and
  practice
• PA researchers have generally neglected this
  aspect

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Mechanisms to increase adoption

• 1) Individuals from all major community groups
  and institutions should be consulted and informed
  throughout all stages of the research
• 2) Activities should be integrated with existing
  community activities
• 3) Summarize and disseminate the results of
  intervention programs to the participants,
  community leaders, and important organizations
  within the community

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RE-AIM Implementation

• Extent to which an intervention will be delivered
  as it was intended
• Practitioners fidelity to the interventions
  protocol
• May alter efficacy of intervention when delivered
  in real world
• Research assistant vs. nurse

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RE-AIM Maintenance

• The level of sustained use of the intervention
  over time
• Reflects both an individual and organizational
  level
• Typical relapse rates show the need to document
  the length of adherence
• Once a program is started in an organization, its
  length of existence is seldom reported

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Summary

• Need for multi-level interventions ind, group,
  community
• Need to assess their real-world impact and
  dissemination
• Long-term maintenance a problem
• Lots more to do! You are the next generation who
  can effect change!!