Community-wide prevention of cardiovascular disease: education strategies of the Minnesota Heart Health Program.

The Minnesota Heart Health Program (MHHP) is a research and demonstration project of population-wide primary prevention of cardiovascular disease. Study goals are to achieve reductions in cardiovascular disease risk factors and morbidity and mortality in three education communities compared with three reference communities. The program in the first of the three intervention communities, Mankato, has been operating for 3 of the planned 5 years. Early objectives of the program have been achieved based on data obtained from population-based random samples surveyed in education and comparison communities. After 2 years of participation, Mankato was significantly more exposed to activities promoting cardiovascular disease prevention. In this town of 38,000 inhabitants, 190 community leaders were directly involved as program volunteers, 14,103 residents (over 60% of adults) attended a screening education center, 2,094 attended MHHP health education classes, 42 of 65 physicians and 728 other health professionals participated in continuing education programs offered by MHHP, and distribution of printed media averaged 12.2 pieces per household. These combined educational strategies have resulted in widespread awareness of MHHP and participation by the majority of the Mankato adult population in its education activities.

Community-wide prevention strategies: evaluation design of the Minnesota Heart Health Program.

The Minnesota Heart Health Program (MHHP) is a community-based research and demonstration program designed to accelerate population-wide changes in coronary risk factors and disease. MHHP is on-going in three pairs of communities in Minnesota, North and South Dakota. To strengthen inference of program effects, its basic design involves elements of control, repetition, sensitive trend measurements and evaluation of the effects of program components. Its evaluation design is presented here as a comprehensive measurement system for disease endpoints, risk factor levels and efficacy of specific educational programs. The MHHP design is able to compare risk factor levels and mortality rates between education and comparison communities. MHHP statistical power is sufficient to detect community-wide changes of public health import. Early results show comparability of education and comparison communities for most variables. Widespread community awareness of and participation in MHHP programs is reported.

Organization for a community cardiovascular health program: experiences from the Minnesota Heart Health Program.

The World Health Organization has emphasized the importance of community participation as a keystone of primary health care and in meeting their goal of health for all. This article reports on the first three years of experience in a community-based approach to cardiovascular health. The project involves three communities totaling almost a quarter of a million inhabitants with matched comparison communities. An extensive volunteer structure provides a dynamic partnership with the education research group in bringing learning opportunities and enabling situations for the practice of heart healthy life styles in the total community. The project goal is to demonstrate reduced mortality and morbidity from educational interventions. The participative intervention model suggests a feasible alternative for future public health practice.

Family planning field research projects: balancing internal against external validity.

This report discusses the experience of a two-year family planning and maternal/child health project in Nepal. Although the project was planned as an experimental field research endeavor, a series of unanticipated events repeatedly compromised the internal validity of the project and forced design changes. While unexpected events are common in the history of most field projects, they present the research evaluator with the fundamental dilemma of trying to maintain a high degree of internal validity without sacrificing external validity. Rigid research designs with tight control over the introduction and measurement of experimental variables may serve to increase internal validity but they may also create an atypical and artificial situation that fails to mirror real field conditions and thus threatens external validity.

PIP: This report discusses the experience of a 2-year family planning and maternal/child health project in Nepal. Although the project was planned as an experimental field research endeavor, a series of unanticipated events repeatedly compromised the internal validity of the project and forced design changes. While unexpected events are common in the history of most field projects, they present the research evaluator with the fundamental dilemma of trying to maintain a high degree of internal validity without sacrificing external validity. Rigid research designs with tight control over the introduction and measurement of experimental variables may serve to increase internal validity but they may also create an atypical and artificial situation that fails to mirror real field conditions and thus threatens external validity. Goals of this project, which ran from 1976 to 1978 in the Gorkha and Dhanusha district, were to: 1) test a new field based, experimental model of training for Nepal; 2) compare the work performance of panchayat (community) based workers against a similar category of clinic based workers; and 3) evaluate the effect, if any, that these workers had on the family planning knowledge and contraceptive practice of currently married women. The area had previously been included in a KAP survey (family planning knowledge, attitude, and practice). Evaluation methods were to include collection of service statistics for panchayat and clinic workers, and comparison of data from the KAP survey with current family planning knowledge, attitudes and practices for each worker's area, collected by personal interviews and panels of currently married women. Unanticipated events effecting the evaluation included: 1) selection of panchayats too remote or not coinciding with KAP sampled panchayats; 2) lack of full staffing; 3) 2 sterilization camps held during the project period; 4) some panchayat workers began to work in clinic worker areas; and 5) salary payments were stopped for 2 months. Instead of a quantitative outcome evaluation, the project problems resulted in a process evaluation for a service delivery field demonstration. The project showed that decentralized mobile units using local panchayat workers could perform well without constant supervision in remote areas.

Early childhood experience in Nepal: a study of sickness, treatment and mortality.

This article reports on a longitudinal study of almost 7,000 children under six years in selected villages in Nepal, giving their morbidity and mortality history, treatments given and costs involved. The study suggests that about two children out of three are defined as sick by their mothers in any given year and that treatment is sought for about 40 percent of sickness in small children. Three of four children treated are treated by scientific medicine, that is by physicians, nurses or pharmacists. The principal causes of death are fevers and diarrhea. Education of mothers in spacing of births, hygiene, nutrition and rehydration therapy would appear to be the most important primary health care service, along with increased access to potable water and to medical clinics.

Promoting health and preventing disease some thoughts for HMOs.

Many of the predisposing factors to current morbidity and mortality relate to societally approved behaviors. Attempts to intervene or change behavioral patterns after a chronic condition is clinically established are limited in effectiveness. Because health maintenance as a conceptual activity occurs outside the medical care delivery system, organizations committed to health maintenance must be active in the school, workplace, and the community if they are to be effective. The concept of prepaid health insurance has been extended in the HMO Act to include responsibility for the maintenance of health and the prevention of disease. This paper provides a three stage model for preventive and promotive activities in HMOs. The case is made that HMOs have a responsibility to provide health promotion and disease prevention services beyond the clinical setting.

Socio-educational influences on nepali women and their association with innovative values and behaviors.

The introduction of health and family planning services in developing countries often requires extensive changes in the values and behaviors of the women of those countries. A better understanding of the factors influencing change in rural women would provide a stronger scientific base for the introduction of health services.The authors gathered data from 1,417 rural women in Nepal. Indicators of social change were contraceptive use, desired family size and scientific treatment of sick children. Major influences associated with change were regionality, having children in school, ownership of money and access to media. However, the strength of association with the indices of change varied, suggesting that change in values and behaviors is meaning specific and not a general phenomenon.