Leeds Health Education Database 2015

Database entries with complete fields

15. Chronic diseases, disability, mental health and substance abuse

November 2015

15.1 Diabetes

15.2 Disability and mental health

15.3 Drugs and substance abuse

15.4 Cancer

15.5 Cardiovascular health


Click on the link for details of the Leeds Health Education Database Project, a complete listing of papers included and a listing of papers on chronic diseases etc. reviewed but not included in the database

15.1 Diabetes

Fernando, D.J. Knowledge about diabetes and metabolic control in diabetic patients. Ceylon.Med.J. 38(1):18-21, 1993.. Ref ID : 7348

Target Group/Country Diabetic patients Sri Jayawardenepura General Hospital, Talapathpitiya, Nugegoda, Sri Lanka

Intervention Methodology The educational session consisted of didactic lectures by trained nurses, individual instruction, information leaflets and group discussions. This was reinforced at 23 month intervals by repeat attendance at nurse education sessions.

Evaluation Method A randomised controlled clinical trial in patient education was conducted at a diabetic and general medical clinic in Sri Jayawardenepura General Hospital. Two groups of diabetic patients matched for age, gender and duration of diabetes were allocated randomly to conventional care at general medical clinics or to a diabetes clinic where specific educational objectives were defined and patients trained to achieve these objectives. The doctors treating these patients were not 'blinded' to treatment groups. Diabetes knowledge was assessed using a diabetes knowledge scale and metabolic control assessed by mean fasting blood glucose. 80 patients were initially enrolled and final number was reduced to 61 with drop-outs due to death, going away, difficulty of tracing and exclusion due to development of acute myocardial infarcation.

Impact Achieved The patients attending the diabetic clinic showed significant improvement in both knowledge scores (67% vs 34%, p < 0.01) and mean fasting blood glucose 6.38 +/- 0.85 mmol/l vs 9.7 +/- 1.7 mmol/l, p < 0.01) at 6 months.

Goldhaber-Fiebert, J. D., Goldhaber-Fiebert, S. N., Tristan, M. L. and Nathan, D. M. (2013) Randomized controlled community-based nutrition and exercise intervention improves glycemia and cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica. Diabetes Care, 26, 24-29. Ref ID: 9294

Target Group/Country Type 2 Diabetic patients in Costa Rica

Intervention Methodology A community-based, group-centered public health intervention addressing nutrition and exercise delivered through 11 weekly nutrition classes (90 min each session). Subjects for whom exercise was deemed safe also participated in triweekly walking groups (60 min each session).
Before random assignment to the treatment groups, all volunteers received standard diabetes education in the form of a lecture that reviewed type 2 diabetes and its symptoms, treatment, and associated complications. After randomization, the subjects in the intervention group began the 12-week lifestyle intervention, and the subjects in the control group were informed that they would be offered a similar program at the end of the study. The lifestyle intervention included 11 weekly nutrition classes (90 min each session) in centrally located community centers. The classes were taught by three nutritionists who were enrolled in a nutrition Master's degree program at the University of San Jose´. They received instruction in the specific dietary curriculum that was used in the study and helped to refine it to conform to local customs. Each class was offered twice per week in each community to enhance attendance. The classes were limited to 15 individuals per class; subjects were encouraged to bring family members. The course focused on portion control for weight reduction and use of healthier food substitutes (electronic copies of the Spanish- language curriculum are available upon request from the corresponding author). Because the concept of counting calories is less common in Costa Rica, specific suggestions were made for portion the saturated fat content in foods such as chicharrones (fried pork sausages). To harness the benefits of peer support, subjects set weekly goals for specific changes in their eating behaviors to decrease portion sizes and make healthier food choices. These goals were shared with the group at the end of class, and progress was reported at the beginning of the next class. Emphasis was placed on the importance of nutritional health for all family members, regardless of diabetes status. Each participant was given written handouts and a notebook to take notes and record food diaries. Those who were not able to read or write were assisted during the class and were encouraged to ask a family member for assistance at home. Each participant was also given a measuring cup and taught how to use it for portion control. The subjects in the intervention group were invited to participate in 60- min walking group sessions three times per week for 12 weeks.

Evaluation Method A total of 75 adults with type 2 diabetes, mean age 59 years, were randomly assigned to the intervention group or the control group. All participants received basic diabetes education. Glycosylated hemoglobin, fasting plasma glucose, total cholesterol, triglycerides, HDL and LDL cholesterol, height, weight, BMI, and blood pressure were measured at baseline and the end of the study (after 12 weeks).

Impact Achieved The intervention group lost 1.0 +/- 2.2 kg compared with a weight gain in the control group of 0.4 +/- 2.3 kg (P = 0.028). Fasting plasma glucose decreased 19 +/- 55 mg/dl in the intervention group and increased 16 +/- 78 mg/dl in the control group (P = 0.048). Glycosylated hemoglobin decreased 1.8 +/- 2.3% in the intervention group and 0.4 +/- 2.3% in the control group (P = 0.028). Authors concluded that glycemic control of type 2 diabetic patients can be improved through community-based, group-centered public health interventions addressing nutrition and exercise


15.2 Disability and mental health

Adamolekun, B., Mielke, J.K. and Ball, D.E. (1999) An evaluation of the impact of health worker and patient education on the care and compliance of patients with epilepsy in Zimbabwe. Epilepsia 40, 507-511.Ref ID : 8458

Target Group/Country Community in Zvimba district in Zimbabwe

Intervention Methodology The use of primary health care nurses in the diagnosis and management of epilepsy patient-information pamphlets to promote drug compliance and clinic attendance. Primary health care workers from 24 clinics  attended a workshop to improving their knowledge in the diagnosis and management of generalized tonic-clonic seizures. An illustrated leaflet was produced containing information on the nature of epilepsy, the importance of drug therapy and good drug compliance and the emergency management of seizures.

Evaluation Method Half of the clinics (experimental group) subsequently received patient-information pamphlets for distribution to patients and relatives, whereas the other half (control group) did not. Frequency of clinic attendance, mean seizure frequencies, and mean serum levels of phenobarbitone were compared at baseline and at 6 months after intervention in patients within each group, and at 6 months after intervention between both groups.  Patients who missed two consecutive clinic appointments were regarded as defaulters

Impact Achieved 296 patients with epilepsy were on the epilepsy registers of the 245 clinics at the beginning of the study and 400 at the end - an increase of 74% (204®270 cases in the clinic receiving the pamphlet and 92® 130 in the group not receiving a pamphlet). There was an overall marked improvement in patient drug compliance over the 6-month study period. The group receiving patient patient-information pamphlets showed a marked reduction in patient default from clinic follow-up (p<0.01) but there was no increase in drug compliance or seizure frequency for the group receiving the leaflet. The authors concluded that oral communication by health workers might have a greater impact than printed materials in a community with a low level of literacy.  Note that the investigation did not attempt to ascertain whether the pamphlets, once received by the patients in the experimental group, were actually read and understood by them. Their reasons were that they were keeping their intervention simple and capable of replication elsewhere so such a study would have added to the complexity of the intervention. However, this argument confuses the generalisable intervention from the separate research component which is needed to evaluate the intervention but would not form part of the model of change being investigated.  

Mitchell, R.A., Zhou, D., Lu, Y. and Watts, G. (1993) Community-based rehabilitation: does it change community attitudes towards people with disability? Disability and Rehabilitation 15, 179-183. Ref ID : 4622

Target Group/Country Urban population in Jin Hua Street Local Govenrment Area in Gangzhou City, China.

Intervention Methodology A pilot community-based rehabilitation  (CBR) project

Evaluation Method Post hoc measurement of attitudes towards people with disabilities was carried out in a community in which CBR had been established (n=250) and in a control community (n=250) with equal numbers of males and females. Measurement of attitudes used the "Attitude towards the Disable People Scale" of Yuker, block and Campbell - taking care in translation the terms into Chinese.

Impact Achieved Both groups scored below 'ideal' score of 180 but the community exposed to CBR obtained a mean attitude score of 108.0 ±4.88 significantly (p < 0.001) closer to the positive end of the scale than did the control community 95.4±3.79. The authors themselves comment on the problems of "translating complex, abstract and possible socially and culturally biased terms into another language and culture". While achieving a shift in attitude in a more positive direction, it is not clear from the study how CBR method used might be improved to reach the desired level of 180.

Rahman, A., Mubbashar, M.H., Gater, R. and Goldberg, D. (1998) Randomised trial of impact of school mental-health programme in rural Rawalpindi, Pakistan. Lancet 352, 1022-1025. Ref ID : 8427

Target Group/Country Secondary school children in Rawalpindi, Pakistan

Intervention Methodology A school mental-health programme has been developed as a component of the community mental-health programme in Rawalpindi, Pakistan. The objectives were to improved the understanding of mental-health disorders and increase awareness of treatment facilities that were being integrated within the primary health care services. The intervention was carried out by a doctor, a psychologist and a social worker from the Institute of Psychiatry, Rawalpindi. Teachers were given a short training and with support from the team the educational programme  was developed to be presented by teachers with various participatory methods which were incorporated into regular activities of the school curriculum . Activities include inputs at annual speeches, drama productions, essay-writing and poster painting competitions, involvement or parent-teachers associations. Teachers were supported through weekly school visits by the mental health team.

Evaluation Method Two secondary schools for boys and two for girls were chosen that were similar in terms of size, staff-pupil ratio, and drop-out rates. 100 children aged 12-16 years (25 girls and 25 boys in each of the study and control groups), 100 parents (one for each child), 100 friends who did not attend school (one for each child), and 100 neighbours (one for each child) were given a 19-item questionnaire before and after the study group had had a 4-month programme of mental- health education. The maximum score for the questionnaire was 16 points.

Impact Achieved Before the school mental-health programme the awareness of mental-health issues was poor (mean score 5.7-7.6) in the four groups of participants. In the study group there was a significant improvement in the mean scores after the school programme in the schoolchildren (mean improvement 7.6 [95% CI 6.7-8.5], p<0.01), their parents (5.3 [4.5-6.1], p<0.01), friends (5.1 [4.1-6.1], p<0.01), and neighbours (3.4 [2.6-4.2], p<0.01). In the control group the difference in awareness was significant only in schoolchildren (1.5 [0.5-2.3], p=0.01) and their friends (0.8 [0.3-1.3], p<0.01).  Before the intervention there was no significant difference in scores between the intervention and control school pupils, after the intervention the scores at the intervention school were higher than that of the control (p<0.01). This study is important as it shows that a school-based intervention can tackle issues of prejudice and stigma. Details of the cost in money and time are not provided of the intervention which would have been helpful in assessing the feasibility of disseminating this model.

Russell,P..S., al John,J.K. and Lakshmanan,J.L. (1999)  Family intervention for intellectually disabled children. Randomised controlled trial.  Br. J. Psychiatry  174:254-258. Ref ID: 8583

Target Group/Country Parents of children with learning difficulties

Intervention Methodology Interactive group psycho-education (IGP) in the form of closed group sessions conducted twice a week by psychologists and special educators to one parent (either male of female) of 26 children who were below 13 yrs and IQ<70 but who showed no signs of co-morbidity (either physical or psychiatric) and whose parents spoke the language of training. Each one hour session was on the aspects of child-rearing skills, developmental milestones and delays, common causes of intellectual disability, co-morbidities, skill deficit, problem behavior, behavioural techniques, sexuality and marriage and legal and social support systems for the intellectually disabled in India. Each session alternated between information dissemination, discussion among parents and with therapist and problem solving tasks. For the control group, classes which were only for information dissemination were conducted on the same topics and for the same period as the didactic lecture but without the discussion. The children entering the therapy programme in both groups were given training in self-care skills, social skills, pre-vocational skills, control of problem behaviour using special education and behavioural techniques irrespective of their being in the experimental or control group.

Evaluation Method Fifty-seven parents randomized to 10 weeks of experimental (n=26) and control therapy (n=26) were assessed in the first and 10th week using the Parental Attitude Scale towards the Management of Intellectual Disability. The pre- and post-intervention measurements were done by a single-blinded rater and compared.

Impact Achieved The intervention group of parents had a statistically significant increase in the outcome scores and clinical improvement in the total parental attitude score (p=0.0007), orientation towards child-rearing  (p=0.003) knowledge towards intellectual disability (p=0.0001) and attitude towards management of intellectual disability (p=0.05) but no change in attitude towards the intellectual disability subscale. Limitations of the study are lack of long term follow-up. It is also not stated what proportion of the parents were fathers or mothers.

Wessels,C., Van Kradenberg,J., Mbanga,I., Emsley,R.A. and Stein,D.J. (1999)  Television as a medium for psycho-education in South Africa: analysis of calls to a mental health information centre after screening of a TV series on psychiatric disorders.  Cent. Afr. J. Med.  45, 1-3. Ref ID: 8584 (Borderline for inclusion in database)

Target Group/Country General public in South Africa

Intervention Methodology The South African Broadcasting Corporation (SABC) recently screened a TV series in 1996/7that focused on the signs and symptoms of the main psychiatric disorders.The TV series "Improve Your Frames of Mind" was developed by an independent producer in collaboration with the Society of Psychiatrists of South Africa, and was screened by the SABC. At the end of each show, the telephone number of our Mental Health Information Centre was given to viewers.

Evaluation Method All calls to the centre were received by three psychiatric nurses at the Mental Health Information Centre who completed a questionnaire during the conversation with the caller and entered the information onto a database for analysis.

Impact Achieved Almost 3,000 calls were taken. Calls related to each of the major psychiatric disorders, particularly the mood and anxiety disorders. Callers expressed satisfaction with the information that they received from the Centre. Callers were particularly interested in anxiety and mood disorders. This evaluation showed that a television programme can encourage people to call in for help.


15.3 Drugs/substance abuse

Abolfotouh, M.A., Aziz, M.A., Badawi, I.A., and Alakija, W. Smoking intervention programme for male secondary-school students in south-western Saudi Arabia. Eastern Mediterranean Health Journal 3(1):90-99, 1997.  Ref ID : 7833

Target Group/Country Secondary school pupils in Abha, Saudi Arabia

Intervention Methodology A one day antismoking programme was conducted for 289 students in a male secondary school. Methods used included lectures, group discussion , role-play of peer pressure, demonstrations, poetry, an exhibition with posters, pamphlets, booklets and video-tapes and the contribution of an ex-smoker

Evaluation Method The one group pretest (n=270) /post-test (n=240) design to evaluate the programme was based on an Arabic version of the WHO standard questionnaire for young people. As the questionnaire was anonymous the data from the pre- and post-test were unlinked. There were no controls.

Impact Achieved The results showed that the prevalence rate of self-reported regular smoking at pre-test  was 14.5% (data on smoking on pre-test not reported). The students showed marked variability in correct responses to various factual items. There was a significant increase in knowledge of nonsmokers (p<0.01) but not smokers.  With the exception of smokers, the students showed an overall positive attitude toward public action. The lack of impact of the programme on smokers provides a classic example of selective perception showing the need to move beyond a one day programme in order to address the problem.

Barrett,M.E. and de Palo,M.P. (1999)  Community-based intervention to reduce demand for drugs in Northern Thai tribal villages.  Subst. Use. Misuse.  34, 1837-1879. Ref ID: 8639 (Borderline for inclusion in database)

Target Group/Country Population of 85 tribal villages located in Northern Thailand.

Intervention Methodology The Integrated Drug Abuse Prevention (IDAP) Project was conducted from 1995 to 1997 to reduce the demand for and use of opium, heroin, and other drugs. It used a community-based  empowerment approach which included innovative methods such as multimedia awareness raising campaigns, networking between villages and local government agencies, and village-based drug detoxification and treatment to assist villages in solving their drug problems.

Evaluation Method The evaluation was a process evaluation such as those commonly used in project evaluations. The first phase of the evaluation was at the termination of the project in December 1999 and consisted of examination of project documents and key informant interviews, records of reported drug addicts (determined through head counts by village leaders) and visits to 11 villages. The second phase was 6 months after termination of the project collecting similar data.

Impact Achieved There were very few new cases of drug addiction reported in the 85 project villages during the duration of the project (10 new cases over the two years 1996-7). The model was successfully implemented in most villages and demonstrated very good results in improving awareness, decreasing the number of active drug users living in the villages, and preventing new cases of addiction. The addict population had decreased substantially from 1,142 persons in June 1995 to only 397 in November 1997 (65% decrease) and 6 of the 11 sample villages were reported to be drug free. However, the evaluation was not able to determine what proportion of this decline was due to migration out of the area by addicts. Data presented showed that villages were able to detoxify about two-thirds of the addicts who had enrolled for treatment in the field study villages. A follow-up study at 6 months after project termination indicated problems with sustainability of demand reduction activities and outcomes. These problems were attributed in part to a lack of empowerment among village leaders to continue activities without assistance from project staff. Also, village leaders expressed problems in resisting drug dealers who returned to the area, which suggested that support from law enforcement is critical to the viability of drug demand reduction programs. Although this evaluation is limited by lack of base line data and limited presentation of data, it contains valuable insights into the problems of conducting drug education in a demanding environment. It also provides a very good example of a process evaluation.

Hunter, S.M., Steyn, K., Yach, D. and Sipamla, N. (1991) Smoking prevention in black schools: a feasibility study. South African Journal of Education 11, 137-141.Ref ID : 8281

Target Group/Country An anti-smoking intervention among Xhosa-speaking primary school children in the black townships of Guguletu and Langa near Cape Town in the Republic of South Africa.

Intervention Methodology Training concepts derived from Social Cognitive Theory were used to 'inoculate' children against chronic self-doubt or learned helplessness. The programme consisted of four one-hour lessons aimed at increasing self-confidence in children's ability to choose healthy life-styles. Key features were the promotion of : mastery experiences, modelling, transfer of factual information, physiological feedback and booster sessions.

Evaluation Method Thirty-one children were pre- and post-tested in the intervention school, 40 children in the control school A and 40 children post-tested only in control school B. The evaluation consisted of self-administered questionnaires. In addition, reactions of the parents, principal and teachers were recorded and a video programme of the intervention was evaluated by health and educational authorities

Impact Achieved During the intervention, children increased their self-confidence (p=0.0001). The only significant decline in tobacco consumption in the intervention group was for snuff (23%®0%) which had been the most prevalent form of tobacco use (to the surprise of the investigators).

Swaddiwudhipong, W., Chaovakiratipong, C., Nguntra, P., Khumklam, P. and Silarug, N. (1993) A Thai monk: an agent for smoking reduction in a rural population. International Journal of Epidemiology 22, 660-665. Ref ID : 6125

Target Group/Country Rural community in Thailand

Intervention Methodology Monks in a rural community in northern Thailand were observed to conduct anti-smoking activities.

Evaluation Method A survey of adults > or = 15 years of age in this village (intervention village sample) and a randomly selected village (control village sample) in the same sub-district. Between March and April 1991, 372 individuals in the intervention village and 664 in the control village were interviewed. The two villages were of similar socioeconomic status.

Impact Achieved The proportion of ever smokers who had tried to quit was greater in the intervention sample (79.6%) than in the control sample (72.0%) (P = 0.048). The proportion of former smokers who had stopped smoking for > or = 1 year was significantly greater in the intervention sample (25.5% of ever smokers) than in the control sample (16.6%) (P = 0.011). Of current smokers in the intervention village, 45.8% reported smoking less tobacco during the year preceding the survey than in the previous 1-year period compared with 35.2% in the control village (P = 0.034). Many former smokers (80.3%) in the intervention village cited the suggestion of a monk as one important reason for quitting compared with 25.6% in the control village (P = 0.000). The proportion of individuals who were well aware of the harmful effects of smoking on health was greater in the intervention village than in the control village.

Wu,Z., Detels,R., Zhang,J., Li,V. and Li,J. (2015) Community-based trial to prevent drug use among youths in Yunnan, China. American Journal of Public Health 92, 1952-1957. Reference ID: 9041

Intervention Methodology Four overlapping educational strategies were used to encourage each group to play a significant role in the prevention effort: a school approach, a family approach, a community approach, and a clinic approach.
In January 1997, Longchuan government and department leaders, village leaders, health workers, and schoolteachers were involved in the intervention planning. Three meetings were initially organized: the first with leaders from the different county government sectors involved in public health and drug problems, the second with village leaders from all 19 villages in the intervention area, and the third with the director of
the Longchuan County Education Department and rectors from schools in the intervention area. Workshops and regular meetings for village leaders and others were organized, games and videos with drug prevention messages were provided, and classes to improve literacy and agricultural yield were conducted. School programs were implemented, including didactic work, visits to detoxification centers, and participation in drug intervention activities

Evaluation Method A survey carried out in the localaity in The unblinded, matched community-based trial to prevent initiation of drug use was implemented in 1997. Thirty-eight villages were selected from the 83 included in their previous study conducted in 1994.4 The selected villages had a high incidence of new drug users in the earlier study. Nineteen villages and 10 schools in one cluster were allocated randomly to the intervention group and 19 villages and 9 schools to the comparison cluster (control area). Both clusters were close to main roads but were separated by a distance of at least 15 miles; between them were uninvolved villages and mountains. Villages close to roads were selected because (1) they had higher rates of drug use and HIV infection and (2) the presence of roads facilitated the initiation and monitoring of intervention activities. Villages were matched only for the prevalence of drug use, based their previous study,4 and for the number of drug users
In October 1998, all males aged 15 to 49 years in both the intervention and control areas were invited to participate in the evaluation survey. The questionnaire was anonymous. The interviewers were not from the villages and had not been involved in the Intervention. Information collected included personal background, knowledge of and attitudes towards drugs and AIDS, previous and current drug use and previous and current sexual behaviours. Additional data about drug use in each village were collected from village heads and youth leaders to verify the survey data. 559 males in the control villages nad 748 males in the intervention villages were interviewed with a response rage of 91% in the intervention villages and 88% in the control villages. There was no baseline study but the single study was used to determine the incidence rate of new drug users during the 17 month period from October 1995 and from May 1997 where were considered the pre- and post intervention periods.

Impact Achieved The incidence of new users decreased in the intervention area from 3.47% to 1.88% and in the control area from 2.10% to 1.50%, a 2.7-fold greater decrease in the intervention villages than in the control villages. The attributable risk reduction was 0.99% for the intervention vs control villages (P= .048). Major decreases were observed in the 15- to 19-year age groups (attributable risk reduction=4.79%, P<.001; a 1.8-fold relative reduction), among single men (attributable risk reduction=2.98%, P<.001; a 42.6- fold relative reduction), among the Jingpo ethnic group (attributable risk reduction= 3.01%, P<.001; a 2.9-fold relative reduction), and among the illiterate/semiliterate men (attributable risk reduction=6.16%, P< .001; a 616-fold relative reduction). For each, the incidence increased in the control villages and decreased in the intervention villages. The incidence dropped to zero among the Han group, the major Chinese ethnicity, in both the intervention and control areas. After the intervention, the intervention group had a significantly greater perception of the problems of drug use and the AIDS epidemic in every category and a greater willingness to participate in activities to prevent drug use and AIDS transmission than in the control areas (P<.01). Individuals in the intervention area also had a greater knowledge about risk factors for drug use and knowledge of HIV transmission routes and prevention measures (P<.001). The inputs used existing field staff to keep the cost of the intervention as low as possible. An unusual feature of this study is the use of a single post-intervention survey to infer incidence of new drug users before and after the intervention. The interpretation of the differences in knowledge between the control and intervention communities is based on the assumption that the original communities had similar knowledge levels - that is based on an earlier survey not reported on in this paper. The authors comment that this evaluation is dependent on the validity of the self-reported data and it is possible that the higher knowledge in the intervention communities could have lead to a greater concealment of their true drug use behaviour.


15.4 Cancer

Attia, A.K., Rahman, D.A.M.A., and Kamel, L.I. Effect of an educational film on the Health Belief Model and breast self-examination practice. Eastern Mediterranean Health Journal 3(3):435-443, 1997.  Ref ID : 7793

Target Group/Country Second-year nursing students in Alexandria University.

Intervention Methodology Following an introduction a  10 minute educational film "Self examination of the breast " . the content include the importance of breast self examination, anatomy of the breast, methods of performing breast self examination. It was followed by a discussion and distribution of a summary handout. The study design was based on the Health Belief Model.

Evaluation Method A questionnaire was given to 87 2nd year nursing students who had voluntarily attended the film presentation before and 2 months after the film. The questionnaire was also given to a group of 3rd year nursing students who had seen the film 12 months earlier. The structured questionnaire was based on the health Belief Model a was designed to measure practices related to breast self examination, knowledge of risk factors related to breast cancer. Note that it is not clear from the report whether the questionnaire was self-completed or administered by an interviewer. There were no controls.

Impact Achieved Before the film 79.9% of the student felt they would be unable to perfom BSE effectively but this percentage decreased to 54% after the film (p<0.01). The % performing breast self examination increased from 57.5% to 77.0% after watching the film  (significance Z=2.745). An increase Of the 50 students who had seen the film 12 months previously 42 were practicing breast self examination. The study is limited by the lack of baseline data on the cohort who had seen the film 12 months previously and also the lack of discussion of the validity of self-reported behaviour change and also the use of a questionnaire for measurement of correct performance of breast self examination/palpitation (a significant increase in the correct method of palpitation was claimed). It should be noted that the sample were nursing students who might be receiving information on cancer from other parts of their course and who might be more motivated than general population to respond to a film.

Baric,L., Stevens,R.D., Karuppalyam,V. and Vadivelu,M. (1977)  Cancer education in Kancheepuram - a case against transferring health education approaches.  International Journal of Health Education  17, 32-42. Ref ID: 8377 (Borderline for inclusion in database)

Target Group/Country Women in rural Tamil Nadu, India

Intervention Methodology Pilot project to promote womens' uptake of cervical screening. A survey of the population was followed by house-to-house visits of 350 women who had already received two visits and had failed to attend for screening.  Two different approaches were tried out. The first explained facts about cancer and its dangers and offering the test as a means of preventing this danger. The other concentrated mainly on the preventive aspects of the test emphasizing its positive value for health with only brief reference to cancer.

Evaluation Method During the study screening facilities were arranged in a maternity center of the area staffed by two full time doctors. The 350 had been divided into two groups each of which received one of the appeals. screening clinic records were checked to see who had subsequently come for a test.

Impact Achieved Of the 350 women visited 133 (33%) said that they would go for test but only 14 (4%) returned for a test. A possible reason for the low uptake for screening is the low awareness of cancer as a potentially serious problem and that women were unaccustomed to go to health services when they are healthy and do not understand the value of prevention. This intervention is mainly of interest because it shows a difference between intention and action and produced such a poor result - demonstrating the difficulty of introducing screening for health in a traditional community.

Swaddiwudhipong, W., Chaovakiratipong, C., Nguntra, P., Mahasakpan, P., Lerdlukanavonge, P. and Koonchote, S. (1995) Effect of a mobile unit on changes in knowledge and use of cervical cancer screening among rural Thai women. Int. J. Epidemiol. 24, 493-498.. Ref ID : 4298

Target Group/Country Rural Thai women in Mae Sot District, Tak Province, Thailand

Intervention Methodology A cervical cancer screening programme using a mobile unit and targeted all adult women - especially those who had not been screened. Health information about cervical cancer and the importance of the screening was disseminated to the villages through radio, village loud speakers and leaflets. Health education thorough a group lecture and discussion was provided to the village health communicators and adult women in each village at night, a few days before the day allotted for taking smears. The village health communicators were asked to actively deliver the health message to other women who might not have received the health information and to invite them personally to the screening programme, Cervical smears were taken by trained public health nurses at no charge at the health centre or the village primary school.

Evaluation Method Health education and collection of Pap smears were carried out by the mobile unit throughout the 54, between January and February 1993. The study compared the results of two interview surveys of women 18-65 years old in the villages selected by systematic sampling for each survey, first in January 1991 and then in January 1994. A total of 1603 and 1369 women participated in each survey respectively. There was no control.

Impact Achieved The % of women who could indicated cervical cancer to be the most common cause of cancer in women increased from 20.8% to 66.4% (p<0.001)The proportion of women who knew of the Pap smear test increased from 20.8% in the first survey sample to 57.3% in the second survey sample (p<0.001). The proportion of those who had even been screened increased from 19.9% in the first survey sample to 58.1% in the second survey sample (p<0.001). These increases were observed solely among ever-married women and there were no significant changes among single women, most of whom remained unscreened. It is not clear whether the increase in screening was due to increased awareness through health education or increased access to a locally available screening service.


15.5 Cardiovascular health

Bach, J.F., Chalons, S., Forier, E., Elana, G., Jouanelle, J., Kayemba, S., Delbois, D., Mosser, A., Saint-Aime, C., and Berchel, C. 10-year educational programme aimed at rheumatic fever in two French Caribbean islands. Lancet 347:644-648, 1996.  Ref ID : 4095 (Borderline for inclusion indatabase)

Target Group/Country Health workers and general public in French Caribbean islands Martinique and Guadeloupe

Intervention Methodology The 10-year programme  was based in the community and in clinics and hospitals and was directed at the public and at health-care workers to reduce the incidence of rheumatic fever. The educational part of the programme targeted the public and health- care workers, including doctors, with written information distributed in schools or via radio and television broadcasts or videotapes. Pamphlets describing the clinical features and origin of cardiac complications of rheumatic fever were distributed to school children's parents and patients attending hospital clinics. Posters were produced in French and Creole and placed in schools and hospitals. A 30 min film was produced to shown to teachers, parents and pupils in schools. The public television channel gave regular time for advertisements and messages were regularly broadcast in public and private radio channels. In the content of the messages, the benign clinical presentation of the initial streptococcal infection was contrasted with the severity of later heart disease.

Evaluation Method The programme established a registry of all cases of primary and secondary rheumatic fever (diagnosed by Jones' modified criteria), with systematic hospital admission of children. They graded carditis as severe, mild, or subclinical, and acute glomerulonephritis was defined by oedema, proteinuria, and haematuria for less than 3 months. 1982 as the baseline year and data was collected up to 1992.

Impact Achieved  The first months of the programme led to a 10-20% increase in the number of rheumatic fever cases admitted to hospital, because of the renewed attention paid to the disease. .1982-83 the incidence of rheumatic fever was 19.6 per 100 000 inhabitants aged under 20 in Martinique. Disease frequency was highest in the poorest areas and families, a finding that persisted over time. The programme was associated with a progressive decline in the frequency of rheumatic fever: final reduction of 78% in Martinique and 74% in Guadeloupe. The frequency of carditis also fell. Apart from two outbreaks in one hospital, the frequency of acute glomerulonephritis also declined; 31% of cases had had sore throat, while 56% had skin infections. The cost of the programme during the 4 most intensive years was FFr 250 000 (US$ 44 500) in each island. The cost of childhood rheumatic fever, excluding late sequelae, was initially (in 1982) about FFr 7.8 million (US$ 1426 000). The cost fell to an average of Ffr 550 000 (US$ 100 000) per year in 1991-92.

The main limitations of this study are the lack of controls and the difficulty of ascribing importance to the different programme inputs.

Dowse, G.K., Gareeboo, H., Alberti, K.G.M.M., Zimmet, P., Tuomilehto, J., Purran, A., Fareed, D., Chitson, P., Collins, V.R. and Hemraj, F. (1995) Changes in population cholesterol concentrations and other cardiovascular risk factor levels after five years of the non-communicable disease intervention programme in Mauritius. British Medical Journal Clinical Research edition 311, 1255-1259. Ref ID : 6536 (Borderline for inclusion in database)

Target Group/Country General public in the island of Mauritius

Intervention Methodology Changes in the prevalence of risk factors for cardiovascular disease were examined following a 5-year population-wide ion

Evaluation Method intervention programme promoting a healthy lifestyle in Mauritius. Little information is provided on the intervention which included use of the mass media, fiscal and legislative measures and widespread community, school and workplace health education activities to promote healthy nutrition, increased exercise, smoking cessation and reduction in alcohol intake.

Impact Achieved All adults (25-74 years old) residing in 11 geographically defined clusters were surveyed in 1987 (n=5892) and 1992 (n=5770). Response rates were 86.2% in 1987 and 89.5% in 1992. Subjects underwent a 2-h oral glucose (75 g) tolerance test. Body mass index, waist-hip ratio, serum lipid concentrations and blood pressure were examined and a lifestyle questionnaire was completed. There were significant decreases in the prevalence of hypertension (15.0 to 12.1% in men and 12.4 to 10.9% in women); tobacco smoking (58.2 to 47.2% and 6.9 to 3.7%, respectively); and heavy alcohol consumption (38.2 to 14.4% and 2.6 to 0.6%, respectively). Moderate leisure physical activity increased from 16.9 to 22.1% in men and from 1.3 to 2.7% in women. Mean population serum total cholesterol concentration decreased (5.5 to 4.7 mmol/litre; P<0.001). The prevalence of overweight or obesity increased. The rate of glucose intolerance was similar. The prevalence of cholesterol concentrations ?6.5 mmol/litre and triacylglycerol concentrations of ?2.0 mmol/litre decreased. The mean concentrations of fasting triacylglycerols, total cholesterol and uric acid decreased (P<0.001) and HDL cholesterol increased (P<0.001). The main limitations of this study is the lack of information on the interventions, the lack of a control and the fact that some of the change may be due to the government substituting coconut oil for soybean oil in the government issued ration oil,

Iyengar, S.D., Grover, A., Kumar, R., Ganguly, N.K., and Wahi, P.L. Participation of health workers, school teachers and pupils in the control of rheumatic fever: evaluation of a training programme. Indian Pediatr. 29:875-881. Ref ID 4713

Target Group/Country Teachers and pupils in rural Haryana State, North India

Intervention Methodology A programme for control of rheumatic fever and rheumatic heart disease (RF/RHD). This included a training campaign for all 74 health workers, 773 school teachers and 12,500 older pupils (class V to X) to enable them to suspect and refer cases of RF/RHD and counsel them about secondary prophylaxis. Training material was used by project staff, medical officers and teachers to convey that this serious disease with onset between 5 and 15 years can be recognized by four simple criteria: fever with joint pain or swelling; breathlessness and fatigue; involuntary face and limb movements.

Evaluation Method One year later after the intervention a self-completed questionnaire was given to 40 and 41 health workers, 75 and 54 teachers ; 187 and 12 pupils from intervention and control blocks respectively.

Impact Achieved Health workers, teachers and pupils of the intervention block were significantly better aware of the nature, severity and presentation of the disease (p<0.001).  13 teachers and 11 pupils in the intervention community compared with 2 and 0 in controls had reported recognizing a case of rheumatic heart disease (p< 0.05). Most of the teachers and half the pupils had referred suspected cases for treatment.  A limitation of this study is the lack of baseline information, however it does indicated that teachers and pupils can be motivated to take action on this condition.

Jinxiang, X., Jiguang, W. and Husheng, Y. (1998) Hypertension control improved through patient education. Chinese Medical Journal 111, 581-584 Ref ID : 8386

Target Group/Country Patients with mild hypertension

Intervention Methodology The education consisted of counseling on non-pharmacological treatment including : weight reduction, salt moderation, physical exercise, alcohol moderation, psychological relaxing assisted by biofeedback, medication adherence, monitoring of progress towards target blood pressure, other risk reduction (lipid, smoking) and keeping of appointment. Details are not provided of the frequency, duration and content of sessions.

Evaluation Method Of 169 eligible patients (systolic blood pressure 160 mmHg and/or diastolic Blood pressure 95 mmHg), 6O were assigned to educational group (group E, antihypertensive drug treatment with an addition of patient education) and 109 to routine group (group R, antihypertensive drug treatment alone). The average follow-up approximated to 3 years.

Impact Achieved The blood pressure was reduced from at baseline and sustained in the three year follow-up by 20/13 mmHg in group E and by 22/13 mm Hg in group R. For this similar blood pressure reduction, about 10 mg less of metoprolol and 6 mg less of nitrendipine were used in group E than in group R. The percentage of the patients in whom goal blood pressure (under 160/90 mmHg) was achieved during follow-up was higher and progressively increased in group E (1st year: 65%, 2nd year: 72%) in comparison with in group R (1st year: 45%; 2nd year: 55%). Body weight was significantly reduced by 1.36 and 1.81 kg from at baseline to at the 1st and 2nd year repeated measurements in group E. The significant reduction from at baseline to at the 2nd year was significantly different from that in group R ( P = 0.02). For 24-hour urinary sodium excretion, it was decreased in the group E, whereas it was increased in the group R. The cumulative rates of hypertension-related complications were 4.43% in group E and 7.02% in group R (absolute difference = 2. 59%, P = 0. 48). . Four patients lost to follow-up in group R (6.87%) and 1 patient in group E (1.74%, P=0.08). The study shows the value of patient education for persons with mild or moderate hypertension.


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