Health Promotion International, Vol. 14, No. 3, 221-230,
September 1999
© Oxford University Press 1999
Feasibility of a lifestyle cardiovascular health promotion programme for 8—15-year-olds in Irish general practice: results of the Galway Health Project
Department of Health Promotion, Clinical Sciences Institute, National University of Ireland, Galway, Ireland
Address for correspondence: C. Cecily Kelleher Department of Health Promotion Clinical Sciences Institute National University of Ireland Galway Ireland E-mail: cecily.kelleher{at}nuigalway.ie
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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Health promotion initiatives in general practice suggest moderate benefit for adults, but little evidence in children. This study assessed the feasibility of a cardiovascular programme for 8—15-year-olds targeted at smoking, exercise and diet. Following an initial needs assessment of 56 general practitioners (response rate 69%), 12 practices were randomized to a 1-year factorial intervention study based on nurse- or doctor-led clinics offered opportunistically at surgery attendance or by recall from age—sex register. A purpose-designed information programme was used by both doctors and nurses at a 10-min appointment session. All participants completed a baseline questionnaire and were followed up 1 year later. As part of the intervention, 516 people were seen; half to nurse-led recall clinics (15% attendance rate). Doctors reported lack of time to organize recall clinics, though attendance at both types of opportunistic clinics was similar. Families from higher socio-economic groups were significantly over-represented among attenders (Chi square 31.64, p < 0.0001); 29% of adults and 16% of 12—15-year-olds were current smokers at baseline. There were high satisfaction levels (98%) among attendees with the educational materials. There were significant gains in several nutrition and exercise knowledge indicators at follow-up among both children and adults. A survey of a 10% sample of non-attenders revealed that inconvenience of appointment was the largest obstacle to attendance (71%). A survey of 35 local schools in the catchment area revealed that the target topics were covered in the curriculum, but no concerted life skills programme was in place. For programmes to have an impact, nurse clinic resources and an adequate age—sex register are needed; there are considerable economic implications. Association with skills-based schools programmes would facilitate action on advice received in line with a multi-sectoral approach.
Key words: cardiovascular risk factors; general practice; schools; young people
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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Cardiovascular disease is multi-factorial, lifestyle related and associated with a number of risk factors that commence in childhood, particularly obesity, hypertension and smoking (Webber et al., 1983
; Boreham et al., 1993). There is great potential in theory for reducing risk factors in young people by means of supportive environment and lifestyle health education. Two key settings are schools and primary care. The CATCH (Webber et al., 1996), CHIC (Harrell et al., 1996) and Heart Smart programmes (Arbeit et al., 1991) are all school-based cardiovascular-based intervention programmes in the USA. Though many such health programmes exist, there are in fact few programmes for young people in primary care. In the UK there have been two large-scale, family-oriented randomized controlled trials in adults, the Oxcheck (ICRF, 1996) and the Family Heart Study (Family Heart Study Group, 1994). The Family Heart Study achieved a change in risk factors consistent with a 12% reduction in coronary disease, but stressed the need for a cross-sectoral approach. The Oxcheck study, on 11 090 adults, showed a significant reduction in total cholesterol concentration and self-reported saturated fat consumption. General practitioners in many countries are supportive of lifestyle education programmes, particularly smoking cessation, but they prefer to offer advice linked to the presenting complaint, and are concerned about the time and resource implications (Bruce and Burnett, 1991; Moser et al., 1991; Coleman and Wilson, 1996; Jessup and Harrell, 1996). Despite the advantages of co-ordinating their efforts with other services, we found no examples of collaborative studies between schools and general practices.
In Ireland, health promotion is part of public policy, and a number of specific lifestyle targets have been set in relation to smoking, diet and exercise (Department of Health, 1994, 1995). Likewise, in the UK there is a public strategy for health promotion (Secretary of State for Health, 1992), and until recently health promotion activity was a compulsory part of general practitioners' contracts. Though there are many common factors in the Irish and British health care systems, a key difference is that Ireland has a two-tiered health care structure so that only about a third of the population are entitled, according to means testing, to free primary care services known as the General Medical Services (GMS), while two-thirds must pay a fee (currently £15—20 per consultation). There are no comprehensive patient registration systems, only the GMS patients are registered and confined to one general practitioner. Those paying a fee, private patients, may attend more than one GP at any one time and are normally not formally registered and therefore amenable to easy recall. This study arose at the instigation of the local faculty of the Irish College of General Practitioners who wished to put in place some kind of health education programme for young people. We planned to establish first what existing arrangements and facilities were in local general practices and schools, what kind of programme could be developed and whether it was feasible to deliver an effective programme in the context of Irish general practice.
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METHODS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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The study comprised needs assessment, intervention, process and impact evaluation phases. First, following several meetings with local GPs and teacher groups, all members of the city and county faculties (branches) of the Irish College of General Practitioners were surveyed for information on practice organization, frequency of contact with the target age group and willingness to undertake health promotion activities. An initial questionnaire and two reminders were sent. Arising from the results of this survey, a randomized, factorial intervention study was designed comprising four groups, either opportunistic or recall clinics to be run by a doctor or nurse. A pilot study was first undertaken in four practices over a 3-month period to develop an intervention protocol. Practices associated with the Galway General Practice Unit (originally established to audit drug prescription budgets) in the local Western health board were asked to participate. Practices had to agree to be randomized to one of the four groups. Fifteen initially agreed and 12 ultimately took part in the study, giving three practices in each intervention group. In so-called opportunistic practices, where it was planned to offer the lifestyle session as families visited the surgery for other reasons, the notes of all children aged 8—15 years on a specified date were tagged in advance by the research nurse for the attention of the secretary or general practitioner when they were seen. These children were then either invited back for a special session or given the consultation at the time. In so-called recall practices, a full list of names and addresses of children in the specified age group was drawn up by the research nurse in half of the practices and the GPs undertook to do so in the other half. Though offered the services of a nurse they preferred to undertake this themselves. Invitation to an appointment was issued by letter with a contact number if they wished to change the time. The children and any accompanying parent were asked to complete a baseline questionnaire before seeing either GP or nurse. The questions concerned demographic data and lifestyle practice in relation to diet, smoking and exercise. Though purpose designed for this study, all questions were used in previous studies and the final instrument was piloted. A 10-min interview for each family was planned; both doctor and nurse agreed a checklist of topics to be covered and background educational materials were provided. The community nutritionist (MOD) designed a special accordion-style information card/wallchart for young people which could be taken home; information on diet, smoking and exercise was included based on current national guidelines for health promotion, a balanced diet based on the food pyramid is suggested and any level of exercise encouraged. Training in use of the tool was provided for both nurses and all the GPs. Process evaluation of the tool was undertaken separately by means of follow-up postal and telephone surveys with participants, a focus group session and discussion with health professionals (O'Donnell, 1996
). Finally, after 1 year, all participant families in the 12 general practices received a follow-up lifestyle questionnaire, and a 10% sample of non-attenders in the three practices where a note search was undertaken by the research nurse was surveyed to try to identify reasons for non-participation. A survey of all post-primary (18) and half the primary schools (30) within an 8-mile catchment area of participating practices was also undertaken to assess their level of health promotion activity, for two reasons: one to establish to what programmes children in the catchment area of practices were exposed; and secondly as a baseline, should a full-scale initiative be developed. The questionnaire was designed for completion by the principal or a designated responsible teacher. Schools were asked whether health education on the topics of smoking, exercise or nutrition was in place, if so, whether these were defined programmes or cross-curricular. Schools were also asked if they had policies on these topics, perceived barriers or incentives in offering such programmes, and interest in further teacher training.
Data were pre-coded. The Irish social class scale was used to record the occupation of the head of the household (O'Hare, 1982). Statistical analysis was undertaken using the WHO Epi Info package, categorical comparisons were by means of Chi square tests as appropriate.
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RESULTS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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Questionnaire survey in general practices
Fifty-six out of 81 actively practising general practitioners responded to the questionnaire (69%); 46% of these worked single-handed. Practice characteristics are presented in Table 1
. Ninety-six per cent had health education literature in their surgeries, most were from the National Health Promotion Unit in the Department of Health or voluntary organizations. The general practitioners were generally supportive of health promotion activities, with virtually everyone agreeing on the need for intervention (Table 2). Though they felt recall clinics were optimal, they were sceptical about the feasibility of such appointment arrangements for health promotion, mainly because of the lack of a comprehensive age—sex register. The main perceived barriers to a more active health education role were practical, including lack of incentive in their service contract with Health Boards.
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Intervention programme in general practice
The average number of doctors in the 12 practices ranged from 2 to 2.3 whole-time equivalents, and was not different across the four intervention groups. Total numbers of children and adults seen in each category are presented in Table 3
. Most (87%) of the adults were mothers, but the children's groups were more balanced with nearly half overall being boys. The social class distribution of attenders' male parent [middle class (SC 1, 2, 3) 40%, working class (SC 4, 5, 6) 35%, farmers 22%, unknown 3%] was highly significantly skewed towards the higher socio-economic groups (p = 0.0001). Because of the voluntary nature of private patient attenders and therefore general practice registration, exact numbers of registered clients are difficult to assess, and a comprehensive note search was undertaken in only three practices, but we estimate an average of 292 children per practice. The best attendance rates were in nurse recall practices where over half the children in the study were seen; of 732 families invited, 160 children attended from 111 families, a response of 15%. Attendance in the other groups was obviously lower giving an overall attendance rate of 9%, but the opportunistic clinic groups were comparable. Only one general practitioner was able to comply with the full protocol stipulations, and no doctor practice recalled the full client group as the nurses did. Average consultation contact time by nurses was 12 min in opportunistic clinics and 10 min in recall clinics. Additional administration time by nurses was 7.5 min per child seen. Doctors did not report their duration of consultation time.
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Follow-up questionnaires were received from 332 people (65% of participants). Lifestyle characteristics of adults and children at baseline and follow-up are given in Tables 4 and 5
. There were a number of changes compared with baseline. Though self-reported adult smoking rates and number of cigarettes smoked per day had fallen slightly, these changes were not significant. There continued to be very high non-smoking rates in both groups of children.
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The number of adults who knew that the diet should contain no more than 35% energy as fat was significantly improved. Knowledge levels in children aged 12—15 about the role of saturated fat also improved. Younger children showed positive changes in selection of the healthier food option in all six categories, reaching significance in the case of pizza, baked potato and fish.
The rates of adults participating in exercise and knowledge about exercise were unchanged, though those taking no exercise at all declined significantly. This may be explained in part by the increase in non-responders to this question. Among adults, correct identification of aerobic activities was significantly improved in the case of cycling (from 72 to 88%, p < 0.0001), swimming (from 85 to 91%, p = 0.027) and running (from 56 to 73%, p < 0.0001), and they were significantly less likely to think there should be an arbitrary exercise threshold of at least three times weekly. The 12—15-year-olds also recognized that playing video games and snooker or pool were not aerobic activities (p = 0.04 and p = 0.019, respectively). Knowledge levels about aerobic activities were unchanged in the 8—11-year-olds.
Adult participants reported themselves either satisfied (48%) or very satisfied (49%) with the intervention. Nearly 94% of children enjoyed the visit. About a third of 8—11-year-old children reported use of the wallchart to record diet and half to measure height. The rates of utilization in older children were much lower, 12 and 22%, respectively. Two-thirds of children felt it made them more aware of health issues; the main reason for disliking the session was the need to cut back on sweets. There were no notable differences in results from nurse or doctor clinics.
Questionnaires were sent to 10% (n = 110 children in 70 families) of non-attenders in the three practices where the nurse had done a complete practice note search. Eight families were found to have moved away, and of the remainder, 32 adults (52%) and 33 of their children completed the questionnaire. Follow-up by telephone revealed a further six families with no phone, six who could not remember the invitation, 10 who incorrectly stated they returned the questionnaire and eight who were not interested. The main reason for non-attendance among responders was inconvenience of appointment time (71%), mainly either because of other commitments (35%) or because the time did not suit (32%). Though numbers were small, there were no significant differences between attenders at baseline and non-participants in behaviours and knowledge about lifestyle.
Questionnaire survey in schools
Twenty-two primary schools (73%) and 13 post-primary schools responded (72%). The type of programmes available in schools varied; materials used were mainly from available Government health education packages. Issues addressed are given in Table 6. In primary schools, topics were covered as part of social and environmental studies, followed by religion and physical education. In post-primary schools, home economics and religion were the main areas, followed by science. Because two of these are optional subjects, less students would have been exposed than the tables imply. Two-thirds of the schools in the catchment area (62%) claimed to have a health education programme, but only 17% of schools had a dedicated health education co-ordinator. One primary school was part of the pilot Health Promoting Schools project. Two post-primary schools had a life skills programme. The main constraint was perceived as lack of time (89%), followed by need for teacher training (74%). Though a subsequent teacher training programme was offered on the topics of exercise, smoking and diet, this was poorly attended; the main reasons being time constraints, including the fact that it could only be offered out of hours and lack of in-service accreditation by the Department of Education.
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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This was a health services research project to assess the feasibility of mounting a community programme in a region where neither a concerted primary care nor schools health education programme previously existed. The surveys of general practitioners and schools indicated positive support, though both groups would like to see Government policy providing more practical incentives. There were two aspects to the general practice intervention, first to see whether a nurse-led or doctor-led intervention would be more efficient and whether a practice register search with nurse support would help, and secondly to see whether such an intervention had any beneficial impact. The randomized design removed the bias of self-selection and the practices were comparable in resource terms. The nurse recall clinic was obviously most efficient, though with attendance levels well below rates in UK studies (Family Heart Study Group, 1994
; ICRF Oxcheck Study, 1996; Baxter et al., 1997a,b). Opportunistic clinic attendance rates were comparable for both doctors and nurses, suggesting both a real effect and low utilization by the target group of services generally. The doctor recall group did not prove feasible. Unfortunately, doctors did not report their duration of consultation time, but this is known to influence quality of contact (Howie et al., 1991).
There are several likely explanations for these results. It must be remembered that this study was deliberately designed to reflect a real life situation. Despite the goodwill and support in principle of the local general practitioners and the schools, as evidenced by both surveys at baseline, in practice it proved time consuming to mount the programme in the calendar year allocated to the feasibility exercise. The target groups were difficult to reach due to several factors. Firstly, in all practices the process of identifying children was slow because no computerized database existed. The relative success of the nurse- led clinics was largely expected because both nurses were trained in health promotion (Hill and Becker, 1995) and had dedicated time to set up clinics. By contrast, the GPs would have had to make time in an existing schedule. These attendance rates are in line with other surveys through general practice in the region (Fallon et al., 1999; Sixsmith et al., 1998). Two studies on the issue of women's health had attendance rates of about a third of those invited, and in both cases the notes had been searched first by the doctor to identify people for whom the programmes were appropriate, and the uncorrected proportion of the age—sex register who attended was comparable with our present findings. Accordingly, this is likely to be a realistic reflection of response to either an opportunistic or recall approach unless a proper system of registration within practices is established. Were more substantial resources made available to practices in the future, a higher penetration rate might be reached. Our subsample of non-respondents indicates that about half the families would attend if the time was suitable, a fifth were not contactable and a third were uninterested. To achieve this, however, particularly if the recall option was to be used, the general practices would probably need the services of a trained health education nurse with appropriate facilities and the costs would need to be quantified. Our estimates are that the consultation time needed is at least equivalent to a routine visit. The daytime surgeries are not appropriate because so many gave this as a reason for not participating. There seems little evidence that GPs themselves could undertake this work without a review of their workload and protected time dedicated to health promotion, but if they were supportive and worked in conjunction with a schools programme there might be considerable gain.
Though only a short-term impact evaluation was undertaken, there were some beneficial changes which may be attributable to the programme. While some studies showed little effect (Baxter et al., 1997a), other concerted community studies have seen positive results (Baxter et al., 1997b), and the Oxcheck study also showed gains in dietary behaviour and total cholesterol concentration consistent with our findings (ICRF Oxcheck Study, 1996). The satisfaction ratings among those who did participate were very high. There were some positive changes in knowledge and behaviours in both children groups and adults, consistent with the content of the intervention. There is clearly a possibility of bias in an open study of this kind because the most interested were likely to respond at every stage of the programme, but the findings were encouraging nonetheless. Longer-term evaluation would be required to see what impact this would have on behaviours, and a life skills programme in conjunction with the schools would help to reinforce the programme. Should such programmes be confined to schools because the primary care option seems to demand a high resource investment for a modest return? Current health promotion strategies suggest that multi-sector approaches are likely to be the most effective in sustaining behaviour change (Nutbeam, 1997, 1998). Heath and education professionals may have different roles in supporting this process. As information on diet and exercise becomes more sophisticated, as exemplified in the recent dialogue on relative and total fat intake in the USA (Connor and Connor, 1997; Katan et al., 1997), increasingly high-quality specific information will be required by families. General practitioners, in conjunction with a nutrition service, might help to facilitate this. The class gradient seen among attenders, despite the fact that in Ireland the registration system for the lower socio-economic groups is better organized, merits particular attention. Again, there is considerable support now for the proposition that social inequalities must be tackled first if beneficial lifestyle changes are to occur in the economically disadvantaged (Ebrahim and Davey-Smith, 1997). The materials developed for this project are now being used nationally, and life skills programmes are likely to be introduced into Irish schools as part of curriculum reform. General practitioners could incorporate lifestyle education programmes as part of a concerted reorientation towards a health-promoting practice, provided they are trained and motivated (Cainan et al., 1986). This would reinforce the school strategy and provide a personalized approach for the children at highest risk who are more likely to be GMS patients. The potential health gain for young people is considerable. The resource and opportunity cost implications should not be underestimated, and lessons from this project could be useful for other countries in a similar start-up situation, particularly those without a full national health service with a registered population in primary care. Based on our findings, a proper economic analysis of cost effectiveness is warranted.
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ACKNOWLEDGEMENTS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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This project is part of a community intervention programme funded by the Western Health Board, the Health Promotion Unit, Department of Health, Croi the West of Ireland Cardiology Foundation and the Irish Heart Foundation through the Galway Health Project Steering Committee chaired by Professor James Ward. The educational materials were partly funded by Bristol Myers Squibb pharmaceutical company. We are grateful to the Galway Faculty of the Irish College of General Practitioners, particularly the medical and secretarial staff of 12 participating practices who so generously gave their time to participate and to the General Practice Unit. We thank Professor Bill Shannon, of the Department of General Practice, Royal College of Surgeons in Ireland, for helpful comments on an earlier draft of this paper.
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