Patient delay in seeking care for heart attack symptoms: findings from focus groups conducted in five U.S. regions.

BACKGROUND: Patient delay in seeking health care for heart attack symptoms is a continuuing problem in the United States. METHODS: Investigators conducted focus groups (N = 34; 207 participants) in major U.S. regions (NE, NW, SE, SW, MW) as formative evaluation to develop a multi-center randomized community trial (the REACT Project). Target groups included adults with previous heart attacks, those at higher risk for heart attack, and bystanders to heart attacks. There were also subgroups reflecting gender and ethnicity (African-American, Hispanic-American, White). FINDINGS: Patients, bystanders, and those at higher risk expected heart attack symptoms to present as often portrayed in the movies, that is, as sharp, crushing chest pain rather than the more common onset of initially ambiguous but gradually increasing discomfort. Patients and those at higher risk also unrealistically judge their personal risk as low, understand little about the benefits of rapid action, are generally unaware of the benefits of using EMS/9-1-1 over alternative transport, and appear to need the "permission" of health care providers or family to act. Moreover, participants reported rarely discussing heart attack symptoms and appropriate responses in advance with health care providers, spouses, or family members. Women often described heart attack as a "male problem," an important aspect of their underestimation of personal risk. African-American participants were more likely to describe negative feelings about EMS/9-1-1, particularly whether they would be transported to their hospital of choice. CONCLUSIONS: Interventions to reduce patient delay need to address expectations about heart attack symptoms, educate about benefits and appropriate actions, and provide legitimacy for taking specific health care-seeking actions. In addition, strategy development must emphasize the role of health care providers in legitimizing the need and importance of taking rapid action in the first place.

Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: The Rapid Early Action for Coronary Treatment (REACT) Trial.

CONTEXT: Delayed access to medical care in patients with acute myocardial infarction (AMI) is common and increases myocardial damage and mortality. OBJECTIVE: To evaluate a community intervention to reduce patient delay from symptom onset to hospital presentation and increase emergency medical service (EMS) use. DESIGN AND SETTING: The Rapid Early Action for Coronary Treatment Trial, a randomized trial conducted from 1995 to 1997 in 20 US cities (10 matched pairs; population range, 55,777-238,912) in 10 states. PARTICIPANTS: A total of 59,944 adults aged 30 years or older presenting to hospital emergency departments (EDs) with chest pain, of whom 20,364 met the primary population criteria of suspected acute coronary heart disease on admission and were discharged with a coronary heart disease-related diagnosis. INTERVENTION: One city in each pair was randomly assigned to an 18-month intervention that targeted mass media, community organizations, and professional, public, and patient education to increase appropriate patient actions for AMI symptoms (primary population, n=10,563). The other city in each pair was randomly assigned to reference status (primary population, n=9801). MAIN OUTCOME MEASURES: Time from symptom onset to ED arrival and EMS use, compared between intervention and reference city pairs. RESULTS: General population surveys provided evidence of increased public awareness and knowledge of program messages. Patient delay from symptom onset to hospital arrival at baseline (median, 140 minutes) was identical in the intervention and reference communities. Delay time decreased in intervention communities by -4.7% per year (95% confidence interval [CI], -8.6% to -0.6%), but the change did not differ significantly from that observed in reference communities (-6. 8% per year; 95% CI, -14.5% to 1.6%; P=.54). EMS use by the primary study population increased significantly in intervention communities compared with reference communities, with a net effect of 20% (95% CI, 7%-34%; P<.005). Total numbers of ED presentations for chest pain and patients with chest pain discharged from the ED, as well as EMS use among patients with chest pain released from the ED, did not change significantly. CONCLUSIONS: In this study, despite an 18-month intervention, time from symptom onset to hospital arrival for patients with chest pain did not change differentially between groups, although increased appropriate EMS use occurred in intervention communities. New strategies are needed if delay time from symptom onset to hospital presentation is to be decreased further in patients with suspected AMI. JAMA. 2000;284:60-67

Adolescent alcohol use and the community health agenda: a study of leaders' perceptions in 28 small towns.

The study assessed leaders' perceptions of adolescent alcohol use as a public health issue in 28 small communities in northern Minnesota, as part of formative evaluation for a community-based intervention to reduce adolescent alcohol access and consumption. One hundred and eighteen leaders from five key community sectors were interviewed about their perceptions of social, health and alcohol-related problems in their communities. Analyses indicated that school representatives and police chiefs perceived adolescent alcohol use and related problems to be serious; newspaper editors mentioned other social problems more often; and mayors and business representatives did not perceive adolescent alcohol problems to be as serious. In relation to efforts to affect local policy, the study suggested government and business sectors in these communities may need to be educated about the problem to build its importance on the community agenda of health issues. Thus community leaders in some sectors may comprise a key target audience for intervention.

REACT theory-based intervention to reduce treatment-seeking delay for acute myocardial infarction. Rapid Early Action for Coronary Treatment.

Coronary heart disease (CHD) remains the leading cause of mortality in the U.S. Innovations in reperfusion therapies can potentially reduce CHD morbidity and mortality associated with acute myocardial infarction (AMI) when treatment is initiated within the first few hours of symptom onset. However, delay in seeking treatment for AMI is unacceptably lengthy, resulting in most patients being ineligible for reperfusion therapies. The Rapid Early Action for Coronary Treatment (REACT) Trial is a four-year, 20-community, randomized trial to design and test the effectiveness of a multi-component intervention to reduce patient delay for hospital care-seeking for AMI symptoms. This manuscript describes the development and content of the theoretically-based REACT intervention and summarizes: (1) the research literature used to inform the intervention; (2) the behavioral theories used to guide the development, implementation, and evaluation of the intervention; (3) the formative research undertaken to understand better decision-making processes as well as barriers and facilitators to seeking medical care as perceived by AMI patients, their families, and medical professionals; (4) the intervention design issues that were addressed; (5) the synthesis of data sources in developing the core message content; (6) the conceptualization for determining the intervention target audiences and associated intervention components and strategies, their integration with guiding theoretical approaches and implementation theories for the study, and a description of major intervention materials developed to implement the intervention; and (7) the focus of the outcome, impact, and process measurement based on the intervention components and theories on which they were developed.

Mass media, secular trends, and the future of cardiovascular disease health promotion: an interpretive analysis.

Mass media roles in promoting cardiovascular health in the context of lessons learned from major U.S. community studies, changing media technology, and emergent models of media-community partnerships are discussed. Three principal issues are explored: (1) implications of the current expansion, convergence, and harmonization of mass media technology;(2) recent trends in media coverage of heart disease and population practices; and (3) implications for the future relationship between the media and public health in cardiovascular health promotion. It is concluded that classic campaign models focusing on individual-level change have evolved to recognize environmental-level influences on behavior. Emergent public health campaign models have moved toward "agenda-building," in which the focus is on a more unified approach to influencing public and community agendas for social, behavioral, and policy change. Recent developments among the commercial mass media may offer new opportunities for public health partnerships to promote cardiovascular health.

Rapid early action for coronary treatment: rationale, design, and baseline characteristics. REACT Research Group.

OBJECTIVE: Early reperfusion for acute myocardial infarction (AMI) can reduce morbidity and mortality, yet there is often delay in accessing medical care after symptom onset. This report describes the design and baseline characteristics of the Rapid Early Action for Coronary Treatment (REACT) community trial, which is testing community intervention to reduce delay. METHODS: Twenty U.S. communities were pair-matched and randomly assigned within pairs to intervention or comparison. Four months of baseline data collection was followed by an 18-month intervention of community organization and public, patient, and health professional education. Primary cases were community residents seen in the ED with chest pain, admitted with suspected acute cardiac ischemia, and discharged with a diagnosis related to coronary heart disease. The primary outcome was delay time from symptom onset to ED arrival. Secondary outcomes included delay time in patients with MI/unstable angina, hospital case-fatality rate and length of stay, receipt of reperfusion, and ED/emergency medical services utilization. Impact on public and patient knowledge, attitudes, and intentions was measured by telephone interviews. Characteristics of communities and cases and comparability of paired communities at baseline were assessed. RESULTS: Baseline cases are 46% female, 14% minorities, and 73% aged > or =55 years, and paired communities have similar demographics characteristics. Median delay time (available for 72% of cases) is 2.3 hours and does not vary between treatment conditions (p > 0.86). CONCLUSIONS: REACT communities approximate the demographic distribution of the United States and there is baseline comparability between the intervention and comparison groups. The REACT trial will provide valuable information for community educational programs to reduce patient delay for AMI symptoms.

A randomized community trial to increase mammography utilization among low-income women living in public housing.

BACKGROUND: A randomized trial was conducted to evaluate the impact of a community-based intervention on mammography use among low-income women living in public housing. METHODS: All 41 public housing high-rise buildings were randomized to treatment and delayed treatment (control) conditions. After a cross-sectional baseline survey, an intervention called Friend to Friend was conducted in the treatment buildings by American Cancer Society and building resident volunteers. The intervention consisted of a health professional talk, small group discussions, and an opportunity to request assistance in obtaining a mammogram or mammogram reminder. A second cross-sectional survey was conducted to measure differences in screening rates between the study groups. RESULTS: Participation in the intervention averaged 27%. The study groups were equivalent at baseline. At follow-up, the proportion of women age 50-79 years who reported mammography screening in the previous 15 months was significantly higher in the treatment group (64%) than in the control group (52%). Breast cancer knowledge, attitudes, and beliefs did not differ between groups. CONCLUSIONS: These findings suggest that a multidimensional intervention which reaches women within their social environment and uses community volunteers can increase mammography utilization among women in public housing.

Project Northland: outcomes of a communitywide alcohol use prevention program during early adolescence.

OBJECTIVES: Project Northland is an efficacy trial with the goal of preventing or reducing alcohol use among young adolescents by using a multilevel, communitywide approach. METHODS: Conducted in 24 school districts and adjacent communities in northeastern Minnesota since 1991, the intervention targets the class of 1998 (sixth-grade students in 1991) and has been implemented for 3 school years (1991 to 1994). The intervention consists of social-behavioral curricula in schools, peer leadership, parental involvement/education, and communitywide task force activities. Annual surveys of the class of 1998 measure alcohol use, tobacco use, and psychosocial factors. RESULTS: At the end of 3 years, students in the intervention school districts report less onset and prevalence of alcohol use than students in the reference districts. The differences were particularly notable among those who were nonusers at baseline. CONCLUSIONS: The results of Project Northland suggest that multilevel, targeted prevention programs for young adolescents are effective in reducing alcohol use.

Community ownership and program continuation following a health demonstration project.

Community ownership and maintenance of heart health programs was a major study goal of the Minnesota Heart Health Program (MHHP), a community-based National Heart, Blood and Lung Institute (NIH)-funded demonstration project. A partnership between the University of Minnesota and three Upper Midwest intervention communities was initiated in 1981. Local citizen boards were instrumental in planning, implementing and incorporating programs. Through an 8 year process of community organization, training and volunteer involvement, MHHP educational program responsibility was transferred to existing community-based groups and organizations. In 1989, when federal funding was withdrawn, 70% of all heart health intervention programs initiated by MHHP were being continued by local sponsors and supported by local funds. By 1992, maintenance of programs had decreased to an average 60%. Differential results of program incorporation among the three intervention communities are presented including findings on community sectors that most frequently sponsored programs. Factors that facilitate or impede local ownership are discussed. Research on longer-term maintenance of heart health programs in the three communities continues.

Where and how adolescents obtain alcoholic beverages.

Patterns of acquisition of alcoholic beverages by underage youth were studied, using focus group methods with a sample of midwestern youth. Results showed that the alcohol initially used by those in their early teens is obtained from parents' stocks or from older siblings and friends. By the midteens, parties at which alcohol (usually beer) is readily available become the major source. In the mid to late teens, young people purchase alcohol from commercial alcohol outlets, despite the fact that 21 is the legal age for purchasing alcohol. Factors reported to increase the rate of successful alcohol purchases include female buyer, male seller, young seller, and convenience store outlet. Results of focus group interviews revealed the easy accessibility of alcoholic beverages to underage youth. Further investigation into patterns of underage access to alcohol is recommended, with results from the focus group study guiding the design of probability sample studies to assess their generalizability.

Background, conceptualization and design of a community-wide research program on adolescent alcohol use: Project Northland.

Project Northland is a community-wide research program funded by the National Institute on Alcoholism and Alcohol Abuse, for a 5-year period (1990-95). The aim of the study is to prevent or delay onset of alcohol use among young adolescents, as well as to reduce use among those who are already drinkers. Twenty communities were recruited in northeastern Minnesota, an area referred to as the Northland, Arrowhead or Iron Range region, and then were randomly assigned to either Education or Delayed Program conditions. The 10 Education school districts have agreed to participate in 3 years of intervention programs in schools, with parents and in the community-at-large. One group of young adolescents, the Class of 1998 (sixth grade students in the 1991-92 school year), form the study cohort. Surveys (1991-94) of the Class of 1998, their parents, community leaders and alcohol merchants are the primary components of the program's evaluation. Many conceptual and methodological questions emerged during the development of the research protocols for Project Northland over the past 2 years. These questions are the impetus for this article. Specifically, the focus on young adolescents and alcohol use was selected, as contrasted with older adolescents or with multiple problem behaviors. The project was designed using a community-wide model that addresses both supply and demand issues, rather than limited to a school-based model. Intervention strategies and evaluation methods were chosen that could address community-level as well as individual-level behavior change, which required the development and application of new technologies. The rationale for these decisions may be useful to others considering community-wide health promotion efforts.

A community education monitoring system: methods from the Stanford Five-City Project, the Minnesota Heart Health Program and the Pawtucket Heart Health Program.

Understanding the process of behavior change interventions is critical to achieving campaign effectiveness and successful program replication. The present article presents a community education monitoring system (CEMS) using data from the Stanford Five-City Project (FCP), the Minnesota Heart Health Program (MHHP) and the Pawtucket Heart Health Program (PHHP). CEMS records the number and type of intervention activities, outcome objectives, targets of change (individual, organizational or environmental), channel(s) of dissemination and proportion of programs funded by the community. These data illustrate (1) the application of theory for each project, (2) data-based program administration, (3) feedback for revising programs and (4) type of reach or 'dose' information obtained from intervention monitoring. Process evaluations such as CEMS provide critical links between field realities and evaluation outcomes. This type of evaluation develops standards for measuring program reach and allows comparisons with other programs. CEMS also illustrates how programs enact theory. Validation studies are critical to the continued successful use of CEMS. The first step, however, is to develop a uniform way of describing complex multichannel behavior change programs. CEMS in a refined form should prove invaluable to health promotion program planners whether in research or service settings.

Process evaluation of a home-based program to reduce diet-related cancer risk: the "WIN at Home Series".

A random mailed survey (response N = 226; 75.3%) of participants in diet-related home-based learning evaluated exposure to recruitment channels and impact on salience, utility, level of participation, sharing the course with others, knowledge, and performing recommended behaviors. A post-only design, the study was conducted in a small Minnesota city (population = 20,000), part of the Cancer and Diet Intervention (CANDI) project. About 18.5% of residents (3,711) enrolled during an 8-week media campaign; women, college graduates, and those over 44 years old were overrepresented. Participants learned about the program through mass media (97%); small media (41.9%); and interpersonal sources (50%). Women were more likely to learn about the course through interpersonal sources. In analysis of variance (ANOVA) modeling, salience and utility predicted level of participation in course activities. Level of participation in turn predicted nutrition knowledge and with salience predicted performance of recommended behaviors. Although the course appealed to individuals who needed it less, there was evidence of diffusion to the unenrolled. About 57% of responding participants reported sharing it with spouses; about 67% reported sharing it with someone outside their households.

Measuring and tracking education program implementation: the Minnesota Heart Health Program experience.

In an overall framework uniting program planning and evaluation, process evaluation can assist community-based health promotion programs in establishing participation objectives, monitoring their achievement and the quality of interventions used, and translating these into useful information for managing and developing programs. This research reports on efforts by the Minnesota Heart Health Program to develop a system that permitted tracking educational program contacts, its implementation, and its use to make management decisions about program activities. The system was developed as part of a planning and evaluation framework with specific criteria for developing and tracking educational programs drawn from the social-learning literature. Overall, the system helped to make participation objectives more concrete, aided decision making about allocation of personnel and material resources, and encouraged the development of innovative programs.

Direct mail as a prompt for follow-up care among persons at risk for hypertension.

We undertook a direct mail campaign to urge persons identified as being at risk for hypertension to seek medical advice. Those who received a single mailing displayed a 28% increase in the proportion who subsequently discussed their blood pressure with a physician and a 12% increase in the proportion who had their blood pressure rechecked, while those persons who received six mailings reported an equivalent increase in physician discussions but a smaller increase in rechecking their blood pressure. These results support the use of inexpensive social marketing strategies as follow-up methods for blood pressure screening programs.