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.

Impact of a community health promotion program on existing organizations: the Minnesota Heart Health Program.

A community organization strategy was used in the delivery of health education programs by the Minnesota Heart Health Program (MHHP). The effectiveness of the approach was evaluated to determine whether an enhanced health promotion delivery system had developed in MHHP communities by the end of the intervention period or whether the intervention had suppressed community efforts. 'Social connectedness' among providers, as measured by health promotion network size, also was expected to be higher in intervention communities. Six Midwestern communities were studied: the MHHP communities of Mankato, MN and Fargo, ND--Moorhead, MN with two matched comparison communities for each (Winona, MN, St Cloud, MN and Eau Claire, WI, Sioux Falls, SD). Nine areas of health promotion were assessed, including the five heart disease risk factor areas where education campaigns had been implemented (smoking cessation, weight loss, eating patterns, exercise, and heart disease education and screening) and four other areas where community programs are common (chemical dependency; home, personal and drivers' safety; stress management; and cancer education and screening). Indicators of the health promotion delivery system were developed (program options and program participation), and data were collected in separate surveys of 438 community organization providers and 320 larger worksites in the six communities. Results showed no suppression of health promotion delivery systems in MHHP communities. Instead, the survey of larger worksites showed that there was greater participation in heart disease health promotion and greater 'social connectedness' among worksites in both intervention communities. Also, there were more heart disease health promotion programs in the larger intervention community of Fargo-Moorhead. In the community organization survey, results favored the larger intervention community over its comparison communities in heart disease health promotion program options and in 'social connectedness' but not in program participation. However, survey results favored one of the comparison communities (Winona) over the smaller intervention community (Mankato) on all indicators in this survey. The greater impact of the MHHP intervention at worksites suggests that institutionalization may be more likely in stable organizations whose current needs and interests fit the goals of the intervention activity.

Current status of health promotion activities in four midwest cities.

Community-wide surveys were conducted in Winona and St. Cloud, MN, Eau Claire, WI, and Sioux Falls, SD, in 1986 and 1987 to determine the current status of the supply and demand of health promotion activities in nine categories. Supply and demand indicators were conceptualized and defined as program options (different activities in a coded list) and participation (registrations). An annual inventory of all health promotion activities in each community was complied from interviews with providers of such activities. Interviews of probable community providers was followed by a nomination process to identify others. Providers at worksites were interviewed in a separate study with matching data endpoints. Results show that exercise programs have the highest levels of options and participation in all four cities. On the supply side of total programs offered, there was similarity in rates among three of the cities, with only Winona offering more health promotion opportunities. There was similarity also in the areas of health where most programs are offered, favoring exercise, followed by the heart disease risk factor areas of screening, smoking cessation, and nutrition education. On the demand side of participation, there was similarity in total participation rates among three of the four cities with Sioux Falls showing substantially higher demand. Exercise showed the highest participation in all cities, but there was little similarity among the cities in ranking participation in the other areas of health promotion. In the four cities combined, high levels of program options with low participation were characteristic of smoking cessation. In contrast, low levels of program options and high participation were shown in chemical dependency. Worksites are the main providers of health promotion programs for adults, with schools and colleges also major program providers. Educational organizations account for the largest percentage of total participation in health promotion.

The social nature of chronic disease and disability.

Recent epidemiologic data on the changing scope and distribution of chronic illness and disability in the United States is analyzed in terms of medical, social, and economic costs. Research findings regarding current gaps in health and social service delivery systems for patients and their families are reviewed. Implications and recommendations for public policy and program changes are discussed, including practice directions for social workers.

Use of community analysis methods in community-wide intervention programs.

Successful implementation of large scale health intervention programs aimed at heart disease or cancer prevention require prior analysis and understanding of community structure, organization and influence networks. Systematic sociological analysis facilitates the health program entry process. Survey results are used to build acceptance, participation and to design educational programs. Specific methods used to assess the community's social configuration, organizational resources, and leadership patterns are described. Local leader identification process and participation in community advisory boards is presented. Approaches to the study of community are reviewed in the context of the Minnesota Heart Health Project, a ten year research and demonstration program to reduce risk of cardiovascular disease in three U.S.A. cities.

Collaboration between schools of social work and university medical centers.

Although the interface involving social work, medicine, and the other health professions occurs primarily in the day-to-day world of practice in hospitals and other health agencies, an equally important opportunity exists for interaction at the university level between schools of social work and schools for health professionals. This artice analyzes one school's effort to build effective interdisciplinary linkages.

Community fieldwork collaboration between medical and social work students.

This article describes an educational demonstration in interdisciplinary community field experiences between social work and medical students at the University of Kentucky Medical school, the hospital social service department, the school of social work, and community social and health agencies. The pilot program in which students from different professions lived for 6 weeks in outling rural communities served by the medical center, provided an opportunity: (a) to study the feasibility of combining a borad community health study experimence with casework services in a hospital-based educational program and (b) to assess the benefits of early interdisciplinary community and clinical work between future doctors and social workers. Students saw the advantages of cooperative teamwork in studying community problems, and were able to apply classroom theory about community organization to real community situations. The organizational structure and staff resources required to carry out such a demonstration are described, and the implications of the training project are discussed.

Worksite health promotion in four Midwest cities.

A survey of worksite health promotion activities in nine areas of health was conducted in four Midwest cities--Winona and St. Cloud, MN; Eau Claire, WI and Sioux Falls, SD to determine how many worksites are involved in these activities; how many different kinds of programs they offer; and whether or not worksite involvement is growing in these areas of health. All worksites with over 100 employees were surveyed with a completion rate of 96% for eligible worksites. Comparing program offerings at worksites with such offerings by other community providers, we find worksites provide 40% of the total of such programs to adults. They tend to operate most programs independently of other community providers. Exercise and smoking cessation programs are most commonly offered. Worksites in the four communities significantly differed in the number of exercise program options offered and in the prevalence of worksite involvement in home, personal and drivers' safety programs. Compared to national survey results, worksites in these Midwest cities show a lower level of participation in heart disease and cancer screening activities. There is a high rate of dropout among current providers of heart disease screening activities and few nonproviders are initiating programs. Program initiation among nonproviders is highest in smoking cessation, weight loss and nutrition. Program growth among current providers is high in the areas of chemical dependency, exercise and personal, home and drivers' safety.

Social work and nursing in hospital settings: a study of interprofessional experiences.

Social workers and nurses in hospitals often work together on interdisciplinary health care teams. Collaboration between these two professions can be enhanced through a better understanding of each other's roles, skills, and practice expectations. One way to acquire knowledge in these areas is through opportunities to interact with individuals from the other discipline. This article reports the findings of a study that investigated the kinds of interprofessional experiences occurring between hospital social workers and nurses during their educational preparation and clinical practice.

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.

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.

Community education for cardiovascular disease prevention: risk factor changes in the Minnesota Heart Health Program.

OBJECTIVES: The Minnesota Heart Health Program is a 13-year research and demonstration project to reduce morbidity and mortality from coronary heart disease in whole communities. METHODS: Three pairs of communities were matched on size and type; each pair had one education site and one comparison site. After baseline surveys, a 5- to 6-year program of mass media, community organization, and direct education for risk reduction was begun in the education communities, whereas surveys continued in all sites. RESULTS: Many intervention components proved effective in targeted groups. However, against a background of strong secular trends of increasing health promotion and declining risk factors, the overall program effects were modest in size and duration and generally within chance levels. CONCLUSIONS: These findings suggest that even such an intense program may not be able to generate enough additional exposure to risk reduction messages and activities in a large enough fraction of the population to accelerate the remarkably favorable secular trends in health promotion activities and in most coronary heart disease risk factors present in the study communities.

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.

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.