THE PAWTUCKET HEART HEALTH PROGRAM

The Pawtucket Heart Health Program (PHHP) was a community-based research and demonstration project focused on modifying major risk factors for cardiovascular disease (CVD) among residents of Pawtucket, Rhode Island. Its main goals were to reduce cardiovascular morbidity and mortality using strategies that rely on community volunteers and to develop a framework of community organization capable of sustain-ing health enhancement programs. Individuals, groups, organizations, and the entire community joined forces to help people learn skills, build support systems, and develop strategies for initiating and maintaining healthy behaviors. Risk factors targeted included high blood cholesterol levels, high blood pressure, smoking, sedentary lifestyle, and obesity. The National Heart, Lung, and Blood Institute (NHLBI) and the National Institutes of Health (NIH) funded the program, which ran from 1980 to 1991. The PHHP, along with the Stanford Five-City Project and the Minnesota Heart Health Program, were part of a major initiative by the federal government to translate research on heart disease prevention into effective community-based health programs, with the ultimate goal of reducing the impact of heart disease on individuals and on the nation's health expenditures.

The PHHP originated in Pawtucket's Memorial Hospital with a decision by the Board of Directors to reduce the city's high rate of CVD. Grants from the Rhode Island Department of Health and from private foundations funded pilot research needed to apply for funding from NHLBI. With NHLBI funds, an intervention unit was formed to recruit and train volunteers to develop, deliver, evaluate, and eventually manage a program to change risk behaviors associated with CVD. The intervention unit was complemented by an evaluation unit, which conducted random household surveys, designed and implemented a complex process evaluation system, and monitored rele-vant changes in Pawtucket and a comparison city. A marketing strategy was developed to promote intervention programs, each focused on a single CVD risk factor. An education program based on social learning theory emphasized materials designed for people with low literacy levels. Interventions included a Lighten Up program focused on weight control; Know Your Cholesterol, which included screening, counsel-ing, and referrals aimed at reducing blood cholesterol levels; and Quit and Win, an incentive-based smoking cessation program. The PHHP also developed a software package (FPbase), for storing and retrieving data on participants; maintaining accu-rate information about community interventions; providing reports on program per-formance; and identifying populations for health promotion activities.

The complex design of PHHP interventions required a comprehensive approach to process and outcome evaluation. Process evaluation focused on replicability, delivery of programs, and other variables. An overall outcome evaluation was based in part on cross-sectional random sample surveys of 1,200 persons aged 18-65 in Pawtucket and an equal number in the comparison city. Surveys began in 1981 and were repeated every 2 years through 1993. Survey data showed no statistically significant effects of PHHP activities on cholesterol, blood pressure, and smoking; these risk factors declined in both intervention and control communities. Values for body mass index remained stable in Pawtucket but rose steadily over time in the control community to yield significant between-city differences. CVD rates were significantly (20 percent) less in Pawtucket than in the control community at the peak of intervention activities; 3 years postintervention, this difference decreased to 8 percent. Estimated between-city differences in CVD risk for changes between the first and last cross-sectional sur-veys were statistically different only for a less educated subpopulation. Risk factor-focused interventions were also evaluated individually. In a pilot study of the Weigh-In program, a mean weight loss of 8.2 pounds over 10 weeks was observed, as well as a large decrease in blood cholesterol levels. In the Know Your Cholesterol program, 600 of 1,040 participants had lowered their blood cholesterol by an average of 29 mg/dl at 2 months after intervention. Quit and Win produced a substantial self-reported quit rate of 23.7 percent.

Volunteers were probably the most important resource of the PHHP. Over a 7-year period, more than 3,600 people in the community and surrounding areas gave their time and energy, contributing a total of at least 200,000 hours to the program. The favorable effect on CVD risk among persons with less education suggests that PHHP interventions can effectively reach this underserved segment of society.

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