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NICE Coronary heart disease


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  • 1. Coronary Heart Disease Guidance for implementing the preventive aspects of the National Service Framework
  • 2. The Health Development Agency The Health Development Agency (HDA) is a special health authority with a remit to improve the health of people in England and in particular, to reduce inequalities in health. It achieves this by: • Working with key statutory and non-statutory organisations at national, regional and local level • Finding out what works and maintaining this evidence base • Turning the evidence into action by building up the skills and capacity of those working to improve the public’s health • Advising on the setting of standards for public health planning and practice.
  • 3. Contents iii INTRODUCTION Methods used to develop the guidance 1 Focusing on coronary risk factors 3 PREVENTION OF CHD THROUGH PROMOTING HEALTHIER LIFESTYLES 5 Chapter 1: REDUCING SMOKING PREVALENCE 7 1.1 Introduction 7 1.1.1 The National Service Framework for coronary heart disease 7 1.1.2 Benefits of smoking cessation for CHD 8 1.1.3 Trends in smoking 8 1.2 Objectives of interventions to reduce smoking 9 1.3 Features of effective interventions 9 1.4 Components of a local strategy 10 1.4.1 Develop smoking cessation services 10 1.4.2 Reduce smoking in public places including workplaces 12 1.4.3 Support national media campaigns 13 1.4.4 Use media advocacy 13 1.4.5 Monitor the voluntary advertising ban 14 1.4.6 Reduce sales of cigarettes to children under 16 years old 14 1.4.7 Encourage the introduction of smoking policies in schools 14 1.5 Reducing inequity 15 1.5.1 Black and minority ethnic groups 15 1.6 Tables of suggested activities to support local action Intervention, Evidence, Outcome, Who could be involved?, Skills and resources, Points to consider, Further information 17 1.7 References 21 Contents
  • 4. Coronary heart disease: guidance for implementing the preventive aspects of the NSF iv Chapter 2: IMPROVING DIET AND NUTRITION 25 2.1 Introduction 25 2.2 Objectives of nutritional interventions 25 2.2.1 Professional knowledge and expertise 26 2.3 Features of effective interventions 27 2.4 Components of a local strategy 27 2.4.1 Schools 27 2.4.2 Local/community projects 28 2.4.3 Workplace 28 2.4.4. Healthcare 29 2.5 Reducing inequity 29 2.5.1 Black and minority ethnic groups 30 2.5.2 Children 30 2.6 Tables of suggested activities to support local action Intervention, Evidence, Outcome, Who could be involved?, Skills and resources, Points to consider, Further information 31 2.7 References 40 Chapter 3: INCREASING PHYSICAL ACTIVITY 43 3.1 Introduction 43 3.2 Objectives of physical activity interventions 43 3.3 Features of effective interventions 44 3.4 Components of a local strategy 44 3.4.1 Healthcare interventions 44 3.4.2 Exercise referral schemes 44 3.4.3 Workplaces 44 3.4.4 Mass media 45 3.4.5 Schools 45 3.4.6 Older people 45 3.4.7. Physically active transport 46 3.5 Reducing inequity 46 3.6 Useful sources of information about community based programmes 47 3.7 Tables of suggested activities to support local action Intervention, Evidence, Outcome, Who could be involved?, Skills and resources, Points to consider, Further information 48 3.8 References 54
  • 5. Contents v Chapter 4: REDUCING OVERWEIGHT AND OBESITY 57 4.1 Introduction 57 4.2 Objectives of weight management 58 4.2.1 Definitions of ‘lifestyle’ weight management interventions 58 4.3 Features of effective interventions 59 4.3.1 Skills 60 4.4 Reducing inequity 60 4.5 Further information 61 4.6 Tables of suggested activities to support local action Intervention, Evidence, Outcome, Who could be involved?, Skills and resources, Points to consider, Further information 63 4.7 References 68 STRATEGY DEVELOPMENT 71 Chapter 5: DEVELOPING A LOCAL STRATEGY 73 5.1 Establishing a local CHD implementation team 73 5.1.1 Milestones and goals 73 5.2 Developing local delivery plans 73 5.3 Building effective partnerships 74 5.3.1 New freedoms to promote and support joint working 74 5.3.2 Making the partnership effective 75 5.4 Involving local communities 75 5.4.1 Consulting local communities 76 5.4.2 Developing capacity 77 5.4.3 Engaging ‘excluded’ groups 77 5.5 Health needs assessment 77 5.6 Community profiling 77 5.7 Equity profiling 78 5.7.1 Audit of current provision 78 5.7.2 Personal and professional development audit 78 5.8 Monitoring progress 79 5.8.1 Developing local targets 80 5.8.2 Monitoring frameworks 82 5.9 Illustrative monitoring frameworks 5.10 Further sources of information 87 5.11 References 90 Appendix 91 Contributors 91 Glossary 93
  • 6. Coronary heart disease is the biggest killer of men and women in this country. More than 111,000 people die from this condition, and about 300,000 have heart attacks every year. The national service framework for coronary heart disease (NSF CHD), which the government published in March 2000, is our blueprint for tackling this chronic disease. This document is a key component of that blueprint. The framework and The NHS plan describe a range of strategies to diagnose, treat and care for people who suffer from heart disease, and also how to prevent it occurring in the first place. The health service must give people who want to make changes to their lifestyles, the support and advice that they need. Effective interventions at an early stage will not only reduce the immediate risks, but also slow down the progression of the disease, identify the early symptoms and limit the incidence of death and long term incapacity. This document explains how this is possible at local level. It provides evidence-based examples of effective interventions for dealing with all the primary risk factors for heart disease – smoking, poor nutrition, physical inactivity, overweight and obesity. It is, in effect, an early warning system for tackling heart disease. I am confident that the document will help to transform prevention services throughout the NHS. Alan Milburn Secretary of State for Health Foreword by the Secretary of State for Health i
  • 7. The prevention of coronary heart disease (CHD) is a government priority. The white paper Saving lives: our healthier nation [Department of Health (DH) 1999] set a target of reducing the death rate from heart disease, stroke and related conditions by 40% in those aged under 75 years by the year 2010. CHD is common, frequently fatal and largely preventable. The burden of heart disease is higher, and has fallen less in the UK than many other countries. It is the leading cause of death, killing over 110,000 people in England in 1998, including more than 41,000 under the age of 75 years (DH 2000a). The recently published NHS plan reinforces CHD as a clinical priority and focuses on preventive aspects of the disease. The Plan emphasises the importance of the NHS role of working in partnership with others to address health inequalities (DH 2000b). The plan highlights the importance of the NSF CHD which, for the first time, sets out national quality standards for preventive and clinical services. The HDA, at the request of the DH, has developed this guidance. It is intended to assist local implementation teams [health authorities (HAs), primary care groups (PCGs) and primary care trusts (PCTs), local authorities (LAs) and other local stakeholders] in developing their approaches to addressing the preventive aspects of the NSF CHD. It therefore relates to Standards 1, 2, 3, 4 and 12 (see Box on the next page). The guidance should be read in conjunction with the NSF CHD main report (DH 2000c), Chapter 1 of the NSF (DH 2000a) and relevant sections of Chapter 2 (DH 2000d) and Chapter 12 (DH 2000e). The HDA’s Health update: coronary heart disease and stroke provides useful information on trends and risk factors (HDA 2000). The guidance covers strategy development and interventions to promote CHD-related healthier lifestyles (smoking, nutrition, physical activity and weight management). In the strategy section, approaches that should underpin all health improvement work are covered briefly and further information is signposted where available. In the sections on risk factors, key objectives are presented that will contribute to CHD prevention together with an overview of effective approaches that will promote healthier lifestyles. In addition to CHD, the risk factors and the strategies listed in this resource will also have a significant impact on other initiatives in public health, such as The cancer plan, the forthcoming NSF for older people and the NSF on diabetes. A range of interventions to be developed locally is suggested, involving a range of players in a variety of settings, which could link with other local initiatives. This work is evolving and represents the first stage of support for those working on preventive aspects of the NSF CHD at a local level (see box on next page). The HDA welcomes comment on this document and suggestions on how to improve the guidance. Please contact Karen Ford ( or Hilary Whent ( at the HDA. Methods used to develop the guidance A range of research and expert opinion has been drawn upon in preparing this report. Systematic reviews and literature reviews have been scanned, and literature searches and consultation with expert informants have been carried out. Some 65 critical readers were sent a first draft of this document and amendments were made in the light of their comments. Introduction Introduction 1
  • 8. The HDA takes a broad approach to evidence, valuing a range of research methods, which contribute to the multidisciplinary nature of health improvement work. Implications from the research evidence have been drawn out and recommendations for local action are made. Gaps in the evidence base have been highlighted. A broad front approach: upstream and downstream The government recognises the socio-economic influences on population health. In its strategy to improve public health, it identifies the complex interaction of causes of poor health, and recommends action right across government to reduce social inequalities in health (DH 1999). The government’s strategy is informed by the evidence from the Independent Inquiry into Inequalities in Health, chaired by Sir Donald Acheson (Acheson 1998). This recommended that a broad front approach be taken to tackle the underlying, root causes of inequalities in health. The inquiry reported that policies to improve health are needed both ‘upstream’ and ‘downstream’. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 2 Preventive aspects of the National Service Framework Reducing heart disease in the population Standard 1 The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of coronary risk factors in the population, and reduce inequalities in risks of developing heart disease. Standard 2 The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the general population. Milestones: pages 20–21 of NSF CHD (DH 2000c) Prevention of coronary heart disease in high risk patients in primary care Standard 3 GPs and primary care teams should identify all people with established cardiovascular disease and offer them comprehensive advice and appropriate treatment to reduce their risks. Standard 4 GPs and primary care teams should identify all people at significant risk of cardiovascular disease but who have not yet developed symptoms and offer them appropriate advice and treatment to reduce their risks. Milestones: pages 25–26 of NSF CHD (DH 2000c) Cardiac rehabilitation Standard 12 NHS trusts should put in place agreed protocols/systems of care so that, prior to leaving hospital, people admitted to hospital suffering from coronary heart disease have been invited to participate in a multidisciplinary programme of secondary prevention and cardiac rehabilitation. The aim of the programme will be to reduce their risk of subsequent cardiac problems and to promote their return to a full and normal life. Milestones: pages 54–55 of NSF CHD (DH 2000c)
  • 9. 3 ‘For instance, a policy which reduces inequalities in income and improves the income of the less well off, and one which provides pre-school education for all four year olds are examples of “upstream” policies which are likely to have a wide range of consequences, including benefits to health. Policies such as providing nicotine replacement therapy on prescription, or making better facilities for taking physical exercise, are “downstream” interventions which have a narrower range of benefits’ (Acheson 1998). This guidance document fully endorses this approach to improving health. Where evidence is available on the impact of upstream policies, it is reported. However, for the most part, there is greater evidence of the impact of downstream policies. There are more reported studies of interventions aimed at individuals (lifestyle and health related behaviours) than there are of policies that seek to influence the broader determinants of CHD. This preponderance of research aimed at assessing the effectiveness of downstream policies should not be seen as evidence that downstream policies are more effective than upstream policies. It simply reflects the fact that downstream policies tend to be more amenable to research efforts that seek to assess the effectiveness of interventions. Focusing on coronary risk factors ‘... by April 2001 all NHS bodies, working closely with local authorities will have agreed and be contributing to the delivery of local programmes of effective policies on: a) reducing smoking b) promoting healthy eating c) increasing physical activity d) reducing overweight and obesity’ (DH 2000c, page 57; DH 2000a, page 18) The NSF CHD focuses on three main lifestyle behaviours that are associated with risk of CHD: smoking, physical activity and diet. It also focuses on obesity, which is associated with both these last two factors, and is also independently associated with some increase in CHD risk. In addition, there is now strong evidence that a moderate intake of alcohol reduces the risk of CHD, but an excessive alcohol intake increases the risk. Quantifying the impact of risk factors on CHD It is hard to give figures for the proportion of CHD that could be prevented if lack of physical activity, poor diet (high fat, low fruit and vegetables) and smoking were successfully eliminated. This is because many people with heart disease have multiple risk factors, and it is hard to disentangle the separate effects. The American Public Health Association did make an attempt at such an estimate (Smith and Pratt 1993) and the results are shown in the box below. A similar modelling exercise in the UK would be expected to produce slightly different findings because more of the UK population are smokers, while fewer are obese. However, the information is useful in giving some indication of the relative importance of these risk factors in terms of the potential for making an impact on CHD rates. In the following sections, information is presented about effective interventions, which aim to bring about change in these risk factors. Implications are drawn from the evidence and suggestions are made for local action at a number of levels, involving a range of players and linking to other local initiatives. Further information sources are also signposted. The gaps have been identified in the evidence base. There is an urgent need for more and better designed evaluations of interventions aiming to improve health and well being and the dissemination of results. Evaluation is Introduction Proportion of CHD attributable to various modifiable risk factors in the USA Risk factor Best estimate Range % % Cholesterol >200 mg/dl 43 39–47 Physical inactivity 35 23–46 Cigarette smoking 22 17–25 Obesity 17 7–32 Source: Smith and Pratt (1993)
  • 10. a planned set of activities, which helps people to see how work is progressing and whether or not it is effective. It should be seen as an integral part of projects and programmes. Evaluation requires relevant skills and it is worth considering making links with local researchers (within the NHS, LAs and academic institutions). There are many approaches to evaluation and sources of support are listed on p89. References Acheson, D., 1998. Independent inquiry into inequalities in health. London: The Stationery Office. DH, 1999. Saving lives: our healthier nation. London: The Stationery Office. DH, 2000a. National service framework for coronary heart disease: Chapter 1. Reducing heart disease in the population. London: DH. DH, 2000b. The NHS plan. A plan for investment. A plan for reform. London: The Stationery Office. DH, 2000c. National service framework for coronary heart disease: main report. London: DH. DH, 2000d. National service framework for coronary heart disease, Chapter 2. Preventing coronary heart disease in high risk patients. London: DH. DH, 2000e. National service framework for coronary heart disease: Chapter 12. Cardiac rehabilitation. London: DH. HDA, 2000. Health update: coronary heart disease and stroke. London: HDA. Smith, C. and Pratt, M., 1993. Cardiovascular disease. In: R. Brownson, P. Remington and J. Davis, eds. Chronic disease epidemiology and control. Washington: American Public Health Association. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 4
  • 11. 1.1 Introduction Smoking is the cause of one out of every seven deaths from heart disease (nearly one in four deaths among men and one in 10 among women). Nine in 10 deaths from lung cancer among men and nearly three in four among women are estimated to have been caused by smoking – 84% of all lung cancer deaths. Among those aged under 65 years, two in five deaths from stroke were caused by smoking. Smoking is also linked to many other serious conditions, including asthma and other respiratory illnesses, cataracts, peripheral vascular disease, periodontal disease and brittle bone disease (Callum 1998). Treating the illnesses and diseases caused by smoking is estimated to cost the NHS up to £1.7 billion every year (Raw et al. 1998). Passive smoking – breathing in other people’s tobacco smoke – is also a major cause of mortality and morbidity. It contributes to death from heart disease and a range of other health problems (Royal College of Physicians 1992). In December 1998, the Government’s first-ever white paper on tobacco, Smoking kills, set three targets, for adults smoking, smoking during pregnancy and children smoking (DH 1998a). • To reduce adult smoking in all social classes so that the overall rate falls from 28% to 24% or less by 2010, with a fall to 26% by the year 2005. In terms of today’s population, this would mean 1.5 million fewer smokers in England. • To reduce the percentage of women who smoke during pregnancy from 23% to 15% by the year 2010, with a fall to 18% by the year 2005. This will mean approximately 55,000 fewer women in England who smoke during pregnancy. • To reduce smoking among children from 13% to 9% or less by the year 2010, with a fall to 11% by the year 2005. This will mean approximately 110,000 fewer children smoking in England by the year 2010. The cancer plan published in September 2000 introduces new national and local targets to address inequalities in smoking rates between socio-economic groups. At a national level the target is: • To reduce smoking rates among manual groups from 32% in 1998 to 26% by 2010 (DH 2000a). 1.1.1 The National Service Framework for coronary heart disease The NSF CHD (DH 2000b) states that ‘by October 2000 HAs, LAs, PCGs/PCTs and NHS trusts will have set up, or have firm plans in place [for a range of NHS smoking cessation services which will enable national and regional targets for the numbers of smokers quitting to be met]. By April 2001, HAs, LAs, PCGs/PCTs and NHS trusts will have agreed and be contributing to the delivery of the local programme of effective policies on reducing smoking; as an employer, have implemented a policy on smoking and be able to refer clients/service users to specialist smoking cessation services, including clinics …’ The immediate priorities for implementing the smoking cessation area of the NSF CHD are: • By April 2001, health authorities will introduce specialist smoking cessation clinics, helping 150,000 people Chapter 1 Reducing smoking prevalence Reducing smoking prevalence 7
  • 12. • Delivering the early milestones set out in Chapter 1 of NSF CHD: Reducing heart disease in the population (DH 2000b). The requirements of smoking cessation are detailed in Appendix A, Chapter 1 of NSF CHD: Reducing heart disease in the population (DH 2000b). 1.1.2 Benefits of smoking cessation for CHD The costs and benefits of smoking cessation are well established (Raw et al. 1998). • Reductions in smoking prevalence are guaranteed to bring population health gains (Raw et al. 1998; US Department of Health and Human Services 1990). • Smoking cessation reduces the risk of dying from smoking related diseases. Smokers have about twice the risk of dying from CHD compared with lifetime non-smokers. This excess risk is reduced by about half among ex- smokers after only one year of abstinence and declines gradually thereafter. After 15 years of abstinence, the risk of CHD is similar to that of people who have never smoked (Tang et al. 1992). Smoking cessation is particularly important in the secondary prevention of CHD. In smokers with existing CHD, the risk of premature CHD mortality can be reduced by 50% or more on giving up (US Department of Health and Human Services 1990). • Reductions in smoking prevalence will produce sizeable reductions in common hospitalised events and costs (Naidoo et al. 1999). • The cost savings that can be made through moderate success in smoking cessation programmes are significant and cumulative (Naidoo et al. 1999). 1.1.3 Trends in smoking Adults The prevalence of smoking in the UK over the past 20 years or so has fallen. In 1998, 27% of adults aged 16 years and over smoked cigarettes compared with 40% in 1978. However, most of this decline occurred in the 1970s and 1980s. In the 1990s, the decline in smoking prevalence among adults levelled off (DH 2000c). The prevalence of smoking is higher among people in manual than non-manual social classes (32% compared with 21% in 1998). The widening of this gap over the past 20 years reflects a steeper decline in smoking prevalence among non-manual classes compared with manual classes (DH 2000c). The social class differentials in smoking are reflected in the social gradients of deaths caused by smoking. The percentage of deaths from ischaemic heart disease caused by smoking ranges from 39% for men aged 35–64 years in social classes I–II to 49% of those in classes IV–V. For women aged 35–64 years the figures range between 35% for classes I–II to 46% for classes IV–V (Callum 1998). Pregnant women The proportion of women who smoke during pregnancy has fluctuated over the past eight years (Owen et al. 1998; Owen and Penn 1999). In 1999 nearly a third of women (30%) smoked during pregnancy compared with 27% in 1992. Among young pregnant women (aged 16–24 years) from social groups C2DE (similar to manual and unemployed classes), the percentage is even higher, with 51% smoking during pregnancy in 1999 (Owen and Penn 1999). Teenagers In 1999, an estimated 9% of children aged 11–15 years smoked cigarettes (DH 2000c). This figure has varied considerably over time, showing a low of 8% in 1988 and a high of 13% in 1996 (DH 2000b). As the majority of smokers take up the habit in their teens, any increases in the rates of young smokers will eventually feed through into adult smoking rates. Black and minority ethnic groups Cigarette smoking among minority ethnic groups is generally less than among the UK population as a whole (28%1). However, a more detailed examination reveals important differences between and within groups. The smoking rate among Bangladeshi men is very high (49%). Coronary heart disease: guidance for implementing the preventive aspects of the NSF 8 1Differences between the HEA (1999a) and DH (2000c) surveys in timing and methodology most likely account for the 1% difference in the estimates of the percentage of adults who smoke.
  • 13. This same group of men also has high rates of chewing tobacco products. Smoking rates are even higher among middle-aged and older Bangladeshi men (54% and 70% for men aged between 30–49 and 50–74 years, respectively). Smoking rates among African-Caribbean men and women resemble, and sometimes exceed, the rates for the UK population as a whole. Smoking rates among African-Caribbean women are higher for younger women [Health Education Authority (HEA) 1999a]. Poverty and smoking Traditional measures of social class tend to underplay the extent to which smoking has become concentrated in the poorest sections of society. Recent studies have shown that smoking levels have remained virtually unchanged among those in the poorest groups, and among lone mothers smoking levels have risen (Marsh and McKay 1994; Dorsett and Marsh 1998; Jarvis 1998). In a detailed study, lone parents living in rented accommodation and relying on social security benefits were found to have smoking levels in excess of 75% (Dorsett and Marsh 1998). 1.2 Objectives of interventions to reduce smoking The importance of a comprehensive approach has long been recognised (WHO 1979). As well as approaches aimed at the individual, there has been a recognition of the need for policy and legislative measures and social and environmental initiatives as essential components of any strategy to reduce tobacco use (WHO 1998). Ideally, each component of such a comprehensive strategy would encompass the following objectives: • Promote quitting (not cutting down) among adults and young people • Reduce exposure to environmental tobacco smoke • Create a social environment that is supportive of non-smoking and cessation. In the context of reducing smoking among adults, a secondary objective could include strategies to prevent the uptake of smoking among young people. However, it is important to note that there is little evidence that teenage strategies, especially in the absence of adult strategies, have any impact on the uptake of smoking among children (Reid 1996; Hill 1999). Local strategies to reduce smoking prevalence should reflect the policies and population groups set out in the white paper on tobacco Smoking kills (DH 1998a), The NHS plan (DH 2000d, Chapter 13), NSF CHD (DH 2000b) and The cancer plan (DH 2000a). Local strategies should also include an alliance of NHS, local government, education and commercial interests, as well as voluntary agencies, to help reduce smoking and to provide information on smoking by using local media, creating local activities and promoting debate to generate interest. Some areas of the country already have smoking alliances. These cover about 60% of the population of England and are supported by the DH. 1.3 Features of effective interventions A comprehensive approach – combining community wide approaches with economic and regulatory measures – was identified by the US Surgeon General as the strategy most likely to have the greatest long-term, population impact (US Department of Health and Human Services 2000). Educational and clinical approaches were considered to be of greater importance in helping individuals resist or abandon the use of tobacco. Community wide approaches typically involve a range of agencies including health services, voluntary agencies, the media (paid and unpaid), as well as government and local authorities (see 5.3, Building effective partnerships, p74). Together, they undertake a range of activities such as direct smoking cessation, helplines, training and resources for health professionals, development of policies to reduce smoking in public places, media campaigns and advocacy, reducing sales to minors and work in schools. Overall, community interventions seek to influence both individual behaviour and the environmental, social and cultural conditions that affect tobacco use (Lantz et al. 2000). The impact of a comprehensive approach is difficult to evaluate, especially given the potential for individual components to work synergistically to produce combined effects (Chapman 1993; US Department of Health and Human Services 2000). For example, the effectiveness of school based programmes appears to be enhanced when they are included in broad based community interventions (Lantz et al. 2000). Nevertheless, Reducing smoking prevalence 9
  • 14. studies that have sought to measure the effects of a comprehensive approach have yielded encouraging results (US Department of Health and Human Services 2000; Lantz et al. 2000; Sowden and Arblaster, 2000a,b; Wakefield and Chaloupka 2000). It is accepted that population-wide approaches should aim to reduce both adult and teenage smoking. But where should the emphasis lie? Experts agree that teenage smoking rates are unlikely to decline in the absence of a fall in adult rates. The view that smoking among adults should therefore be tackled ahead of teenagers was discussed by Hill (1999) in a recent article. His argument is fivefold: • First, reducing smoking among adults will lead to a quicker and bigger reduction of tobacco related harm, because there is a higher level of smoking related mortality and morbidity among adults than teenagers • Second, reducing smoking among adults will provide protection to the unborn and recently born against exposure to direct and indirect tobacco smoke • Third, quitting by adults (especially by parents) reduces the likelihood of children taking up smoking • Fourth, while there are clear ethical reasons for educating children about what is the largest preventable cause of death, beyond this, the methods of delivering interventions are fraught with practical problems and the evidence of effectiveness of interventions aimed at young people is poor • Finally, the fact that the tobacco industry itself supports antismoking campaigns targeted at teenagers should be taken as a warning signal: ‘Even Phillip Morris was confident that [antismoking] youth campaigns could do them little damage’ (Hill 1999). 1.4 Components of a local strategy 1.4.1 Develop smoking cessation services • The health improvement programme (HImP) should emphasise the importance of an integrated service including primary care advice, specialist smoking cessation clinics, one-to-one cessation advice [Health Service Circular (HSC) 1998, 1999; Action on Smoking and Health (ASH) 2000a,b]. The requirements for smoking cessation are detailed in Appendix A, Chapter 1 of NSF CHD: Reducing heart disease in the population (DH 2000b). • Build upon and develop these guidelines for local cessation services. • Provide special services for pregnant women. The NHS plan (DH 2000d) states that ’the specialist smoking cessation services will focus on heavily dependent smokers needing intensive support, and on pregnant smokers as part of antenatal care. Primary care groups will take the lead in commissioning – and where appropriate providing – these services’. In support of the smoking cessation treatments bupropion is now available on prescription and The NHS plan recommends that nicotine replacement therapy (NRT) should also be made available on prescription. These services followed evidence based guidelines for smoking cessation published in December 1998 (Raw et al. 1998). These guidelines have been updated and will be available in December 2000. The Committee on Safety of Medicines will consider whether NRT can be made available for general sale. An evaluation of the first year of the development of the national cessation services has recently been published (Adams et al. 2000). At a meeting of smoking cessation experts held in July 2000, it was agreed that the smoking cessation services should offer support to all people who request it. The focus on particular groups could be achieved through recruitment to the services – for example by engaging midwives or promoting the services at antenatal classes (ASH 2000a,b; The meeting, with representation from the DH, identified a model approach to smoking cessation services in primary care, which also sought to provide clarification on the role of intermediate cessation services. Discrepancies in the guidelines concerning intermediate services had caused confusion in some health action zones (HAZs) (Adams et al. 2000). Both intermediate services and specialist clinics have been subsumed in the model by the term ‘qualifying specialist services’ for which a minimum standard of service to the smoker has been set and for which the centrally provided smoking cessation budget may be used. The model of the service is set out in Figure 1 on facing page. For full details and further guidance see: Coronary heart disease: guidance for implementing the preventive aspects of the NSF 10
  • 15. Model of the service to the smoker Each smoker contacting the NHS should be offered a package of both pharmaceutical aids and behavioural support that meets their particular needs and circumstances. Given restrictions on who can prescribe drugs, and limitations on the extent to which those who may prescribe are able to offer support, it will not always be possible to provide a ‘one-stop shop’. The aim must be to make access to drugs and support as straightforward as possible. The elements of the support package include: • Influences on smokers’ motivations to quit, including advice from primary care professionals, national campaigns, No Smoking Day and manufacturers’ advertising • Brief opportunistic interventions by the GP and other primary care professionals • Prescribing pharmacotherapies: NRT and bupropion (Zyban) • Behavioural support. This will need to be tailored to match the circumstances of the smoker, but the range of options includes: Referral to a ‘qualifying’ specialist service – these would qualify for funding from the smoking cessation budgets if they offered a certain minimum service standard Discussion of other support options (eg telephone, self-help) that the smoker could consider, if he/she chose not to attend a qualifying specialist service. Reducing smoking during pregnancy For pregnant women, pregnancy specific materials are more cost effective than less specific, cheaper, standard information because of their greater effectiveness (Buck and Godfrey 1994). The intensity of the intervention also affects outcome. While there is some evidence of the effectiveness of advice when literature is coupled with follow up, more intensive interventions (eg a structured Reducing smoking prevalence 11 Figure 1. Configuration of smoking cessation support services.
  • 16. cessation course based on self-help booklets) provide stronger evidence (Raw et al. 1998). Public education campaigns may be effective in shifting pregnant women’s attitudes and behaviour (Campion et al. 1994). The difficulties of advising outright cessation in pregnancy has led some health professionals to suggest cutting down as an alternative. However, there is little evidence to show that cutting down is of any health benefit (Raw et al. 1998). Thus quitting as opposed to cutting down needs to be emphasised. Many women who do stop smoking in pregnancy go back to smoking after the birth of the baby. In one American study over half (56%) of women who stopped during pregnancy were smoking within one month of the birth (Secker-Walker et al. 1995). Relapse prevention interventions with pregnant women and women who have recently given birth are needed. • All those responsible for providing antenatal care should ensure that relapse prevention is included as a component in the smoking cessation service. The lower rate of cessation associated with mothers from lower socio-economic groups, led the Scientific Advisory Group on Inequalities to conclude that ‘interventions that target the individual behaviour alone may not be sufficient ... broader policies to combat inequality are also required’ (Acheson 1998). Further information on smoking and pregnancy can be obtained in the following reports: • Smoking and pregnancy: a survey of knowledge, attitudes and behaviour 1992–1999 (Owen and Penn 1999) • Smoking and pregnancy: guidance for purchasers and providers (HEA 1994a) • Helping pregnant smokers quit: training for health professionals (HEA 1994b) • Smoking and pregnancy: developing a communications strategy for cessation (Owen and Bolling 1996) • Smoking and pregnancy: a growing problem (HEA 1996a). Mechanisms for delivering cessation services for young people are outlined in the document Smoking cessation in young people: should we do more to help young people quit? (HDA 2000a). 1.4.2 Reduce smoking in public places including workplaces Restricting smoking is important not only for limiting the public’s exposure to toxins in sidestream smoke, but also for broader policy reasons. First, it puts smoking in a broader context than one of personal choice and personal risk and legitimises it as a social problem; second, it may be the source of litigation against employers or businesses; and third, the spread of smoking restrictions reduces the opportunities to smoke and thus reduces consumption (Borland et al. 1991; Brenner and Mielck 1992; Marcus et al. 1992; Wakefield et al. 1992; Jeffery et al. 1994; Glasgow et al. 1997; Brauer and Mannetje 1998). The Health and Safety Executive (HSE) has been examining current practice on restricting smoking at work with a view to issuing an Approved Code of Practice (ACoP). There are potential legal liabilities for employers who do not address passive smoking in the workplace. Employees have recourse to civil law, contract and employment law and the general provisions of the Health and Safety at Work Act (1974). The ACoP will clarify the legal position for both employers and employees, and enable LA environmental health officers (EHOs) to intervene. Local plans should include objectives to: • Ensure that all local hospitals have smoking policies (DH 1998a; HEA 1999b), and that these are fully implemented • Implement policies to restrict smoking in public places [Scientific Committee on Tobacco and Health (SCOTH) 1998] • Encourage restaurants, bars and other leisure facilities to provide smoke free areas. Many employers now find an advantage in smoking restrictions through savings on sickness absences, increased productivity, lower insurance and cleaning costs. The checklist in Box 1.1 will help managers of workplaces to develop an effective strategy on smoking. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 12
  • 17. Further information For examples of case studies of effective practice within the NHS see Tobacco control policies within the NHS: case studies of effective practice (HDA 2000b). For further information on developing, reviewing and amending tobacco control policies, see Been there, done that: revisiting tobacco control policies in the NHS (HEA 1999b). Sample policies and consultation questionnaires can be found in Smoking policy for the workplace: an update (HEA 1999c) and Towards tobacco-free environments: guidelines for local authorities (HEA 1999d). Also see the ASH website: 1.4.3 Support national media campaigns Mass media campaigns can influence smoking behaviour (DH 1998a; Lantz et al. 2000; Sowden and Arblaster 2000a,b) and may be especially appropriate for reaching those who are less educated (Mackaskill et al. 1992) and those in poor communities (Jenkins et al. 1997). Message content and the intensity and duration over which the messages are delivered appear to be important factors in determining the impact of mass media campaigns (Grey et al. 2000; Lantz et al. 2000). Media campaigns should focus predominantly on adults, since the majority of cigarettes (>95%) are consumed by adults and adult smokers are a major factor influencing the uptake of smoking by minors. Local media may be used to raise the profile of national campaigns (No Smoking Day). For ideas in planning local media campaigns see: Tel: 020 7916 8070. • Local plans should include links to the network of local smoking control alliances in England. 1.4.4 Use media advocacy There is some evidence that the use of media advocacy (see Box 1.2) may affect tobacco consumption (Buck and Godfrey 1994), but its major role is in social marketing. This involves shaping the media agenda, prompting policy changes and influencing the social norms around smoking (Reid et al. 1992). Media advocacy techniques Reducing smoking prevalence Box 1.1 Management checklist for a smoking policy • Review current situation. • Assess need, capacity to change. • Make sure you consult with everyone. • Seek feedback, not permission. • Decide on the policy details. • Decide on a total or partial ban. • Decide what restrictions to impose if a total ban is not possible. • Communicate final decisions clearly to all staff. • Label smoking and smoke-free areas. • Monitor and review the policy. Source: HEA (1999c) Box 1.2 Checklist for setting up local media advocacy work First think about the following points: • What you hope to achieve • Who your campaign is aimed at • How much you think it will cost • How it will be supported by local activity and action • How you plan to evaluate it (have you achieved what you hoped?). Create a media plan: • What stories or angles will attract the media? • What information is needed for a newsworthy press release? • Draw up a media list – names and contact numbers of relevant journalists • Find out the deadlines for media you are targeting • Find out how media contacts want you to communicate with them (press release, direct contact) • Decide who will act as spokespersons • Coordinate media schedules with partners who may also be using the media • If the campaign is a long one, create a media calendar to ensure a constant supply of news items. 13
  • 18. may be especially effective with poor communities (Jernigan and Wright 1993) since low income groups, including smokers, are high consumers of TV. For further guidance on media advocacy and factors that influence its effectiveness, see An investigation into the potential of media advocacy as a health promotion strategy (HDA in press). 1.4.5 Monitor the voluntary advertising ban Indirect marketing of cigarette brands is the growing and preferred marketing strategy of the tobacco industry, perhaps in response to threats of advertising restrictions. Until legislation is introduced, the existing ‘voluntary agreements’ on tobacco promotion should continue to be monitored locally, not so much because these restrictions have been found to be effective in preventing uptake of smoking, but because infringement of the rules offers opportunities for media advocacy. Those provisions include, for example, banning advertising on billboards near schools and promotions in magazines for young people. People working locally should be vigilant in monitoring any new marketing strategies, for example, using events at discos, student functions and the Internet to promote brands. 1.4.6 Reduce sales of cigarettes to children under 16 years old Combining regular test purchasing with a high profile media approach has been found to be successful in reducing the incidents of reported sales of cigarettes to people under 16 years of age. Overall, the evidence of effectiveness of sales restrictions suggests that vigorous local enforcement of the law forbidding sale of tobacco to under-16s can reduce sales (Stead and Lancaster 2000). This strategy has also been shown to have a small delaying effect on the uptake of smoking among children. There is little evidence, however, to suggest that it has any effect on the uptake of smoking among children. Considerable resources are required, both in terms of trading standards officers’ and court time. The existing law is not being applied effectively (DH 1998a). The Local Government Association and Local Authorities Co-ordinating Body on Food and Trading are developing a new enforcement protocol to address this. Features of the protocol are listed in Box 1.3. Proof-of-age card schemes have been developed, but the government recommends that a single system be agreed. The vending machine trade association, the National Association of Cigarette Machine Operators, has produced a new, stricter code for its members to clarify siting arrangements and monitoring for vending machines (DH 1998a). 1.4.7 Encourage the introduction of smoking policies in schools A formal, well publicised school policy on smoking reinforces non-smoking as the norm in society, supports health messages in the curriculum and may have positive effects on smoking levels among pupils, staff and all adult users of the premises (see Box 1.4). Additional potential benefits include reduced absenteeism, reduced costs and elimination of the harmful effects of passive smoking. • Provide support to schools to introduce no smoking policies. The National Curriculum Science Order recommends that teaching the harmful effects of tobacco, alcohol and other drugs should begin at Key Stage 2 (age 7–11 years). The Office of Fair Standards and Training in Education (OFSTED) 1999 report Drug education in schools and the Department for Education and Employment (DfEE 1998) report Protecting young people: good practice in drug education in schools and the youth Coronary heart disease: guidance for implementing the preventive aspects of the NSF Box 1.3 Enforcement protocol • Local authorities should publish a clear statement on underage tobacco sales. • Ensure that all shops and vending machines display notices stating the law. • Use test purchases to assess local compliance by retailers. Gather information about premises likely to be breaching the law. • Use media advocacy to raise the profile locally. • Educate to increase compliance. • Detail enforcement action taken, prosecutions and fines, to act as a deterrent. 14
  • 19. service recommend teaching young people from the age of five years upwards about the risks and consequences of tobacco, alcohol and drug use, together with teaching the life skills needed to resist the pressure to misuse these substances. Teaching should clearly cover issues relevant to the child’s age and experience. This frequently entails tackling smoking and alcohol-related issues first, as these are the substances that young people will generally be exposed to first. 1.5 Reducing inequity With little or no decline in the lowest income groups, smoking has become concentrated in Britain’s poorest households. For example, among lone parents on benefits and living in council housing, more than three-quarters smoke (Dorsett and Marsh 1998). Moreover, recent research suggests that nicotine dependence is higher in people experiencing disadvantage (Jarvis and Wardle 1999). In keeping with these findings, the Independent Inquiry into Inequalities in Health recommended a short- term strategy to reduce nicotine dependence, which is likely to be stronger in disadvantaged smokers, through the provision of free NRT. A complementary, longer-term strategy aims at removing the cultural and environmental barriers that disadvantaged people face. Community based interventions, brief advice from a GP and specialised smoking clinics are also recommended as effective settings in which to provide NRT (Acheson 1998). Attempts to set up community based projects to promote smoking cessation have met with mixed success. In a report of initiatives set up in low income communities in Scotland, the authors concluded that: ‘small grant funding for time limited projects can promote work on smoking amongst women living or working in low income communities. Although reducing smoking was a long term goal for the majority of the initiatives most did not perceive themselves as a cessation group. As a result they did not measure success by the numbers quitting. Changes in individual smoking behaviours were noted and these ranged from extending the period of smoke free time, to restricting smoking to a specific room or location and trying nicotine replacement therapy’ (ASH Scotland and HEBS 1999). Examples of other community based projects funded through small grants schemes can be found in Empowering smokers to quit: success principles for community stop-smoking projects (HEA 1996b). The use of mass media, especially TV, may be particularly appropriate for reaching less educated and/or disadvantaged smokers. This reflects the tendency for the less educated to receive information from TV more often than those who are more educated (Buck and Godfrey 1994). Indeed, research has shown that mass media antismoking campaigns can have a significant impact on low income and low educational groups (Macaskill et al. 1992; Jenkins et al. 1997). 1.5.1 Black and minority ethnic groups Little has been published on the impact of smoking cessation interventions in reducing tobacco use among black and minority ethnic groups in England. However, studies from the USA suggest that they can be effective Reducing smoking prevalence 15 Box 1.4 Checklist for a school’s smoking policy • Put the development of a smoking policy on the agenda. • Review the current situation. • Identify staff with sufficient skill and seniority to take responsibility for developing a new policy if necessary. • Form a working party involving key people from the school and community, if appropriate. • Establish a rationale for the policy. • Identify educational, health and economic reasons for introducing a policy or improving existing conditions. • Draft the policy. • Evaluate the draft policy by consulting with all relevant parties, identify potential constraints and problems. • Inform everyone about the policy before it is implemented. • Allow sufficient time for implementation of the new policy – three to six months is considered a reasonable time between initiating and implementing the policy. • Monitor the operation of the new policy.
  • 20. (Botvin et al. 1992; Elder et al. 1993; Lillington et al. 1995; Elder et al. 1996). In the absence of UK studies, patterns of tobacco use (HEA 1999a) and research into the role of tobacco within and between black and minority ethnic groups (Maltby et al. 2000) can provide some pointers for the way forward. Examples of these are highlighted below (HEA 1999a; Maltby et al. 2000). • The high rates of tobacco chewing, especially among Bangladeshis, suggests that this practice should be included in interventions aimed at reducing tobacco use. • Sensitivity to gender issues is vital. • Literature should be multi-lingual and in a style that is culturally familiar (eg use of vignettes to highlight health risks associated with tobacco use). • Information campaigns should be developed to redress misperceptions about tobacco use (eg belief that tobacco use can relieve indigestion; belief that healthy practice in other areas such as diet and exercise will offset the detrimental effects of smoking). • Ethnic differences in attitudes and beliefs about cigarette smoking should be incorporated into smoking cessation interventions. Thus, to be successful, a tobacco cessation campaign must take account of the culture, tradition and religion of the particular target group. In so doing it will need to involve community groups, religious groups, smoking cessation coordinators, local tobacco alliances, primary health care (PHC) teams, culturally relevant local and national media as well as key individuals within different ethnic groups. In response to ethnic health inequalities, the government has announced that £1,000,000 will be made available to help reduce the high rates of smoking among certain ethnic groups. Further information on black and minority ethnic groups DH, 1996. Directory of ethnic minority initiatives, G60/008 3934 1P 5K May 96 (23). London: DH. Gervais, M. and Jovchelovitch, S., 1998. The health beliefs of the Chinese community in England: a qualitative research study. London: HEA. HEA, 1999. Black and minority ethnic groups and tobacco use in England: a practical resource for health professionals. London: HEA. HEA, 2000. Black and minority ethnic groups in England: the second health and lifestyles survey. London: HEA. McKeigue, P. and Sevak, L. 1994. Coronary heart disease in South Asian communities. London: HEA. Sproston, K., Pitson, L., Whitfield, G. and Walker E., 1999. Health and Lifestyles of the Chinese population in England. London: HEA. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 16
  • 21. Reducing smoking prevalence 17 Dependsontheparticular interventionunder consideration(seebelow). Candoubletheeffectiveness ofanintervention,beitbrief advicefromaGPorintensive supportthroughaspecialist clinicorwill-poweralone. Intervention Smokingcessation Nicotine replacement therapy Bupropion(Zyban) Evidence Effectivenessandcosteffectiveness arewellestablished(Fioreetal. 1996;Rawetal.1998).Updated guidelines(Dec2000). Doubleschanceofsuccessof smokerswishingtostop(Fioreetal. 1996;Rawetal.1998). JustlaunchedintheUK.An effectivepharmacotherapy(Hurtet al.1997;Jorenbyetal.1999),itwill beavailableonprescription. Whocouldbe involved? Healthprofessionals, LAs,specialist smokingcessation coordinators, voluntarysector, HAZs,localsmoking alliance. PHC,pharmacists, healthpromotion specialists. GPsandthose approvedfor prescribingthrough thePatientGroup Directive, PHC,pharmacists, healthpromotion specialists. Skillsandresources Smokingcessationskills, carbonmonoxidemonitor, leaflets.Althoughtraining schemesareavailable nationally,accreditedcourses shouldbeestablished. Demonstratecultural sensitivity. Smokingcessationskills, accesstoNRTproducts. Smokingcessationskills. Pointstoconsider Majorcomponentof governmentstrategyto reducesmokinginEngland. HSC(1999)hassetout guidelinesonmonitoringfor thenewservices. Theavailabilityand accessibilityofservicesshould takeaccountofcultural differences. Currently,someareavailable onprescriptionaswellas beingavailableoverthe counter(OTC).Nasalsprayis OTCand2mggumisalso availableonthegeneralsales list(GSL). Prescriptiononly. Furtherinformation HSC(1998,1999),DH (1998a),Acheson(1998). CochraneLibrarywebsite: http://www.update- clib.htm Evaluationofyearoneof nationalcessationstrategy (Adamsetal.2000).ASH (2000a). Seeabove. Outcome Table1.6Suggestedactivitiestosupportlocalaction
  • 22. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 18 BriefadviceinNHS andprimarycare Verybriefadvice(three minutes)canresultina2% increaseinnumberof smokersabstinentforsix monthsorlongercompared withnoadvice.Briefadvice (10minutes)canresultina 3%increase.AddingNRTto briefadvicecanresultina 6%increase. Comparedwithno interventionintensivesupport canresultinan8%increase inthenumberofsmokers abstinentforsixmonthsor longer. Resultina5%increaseinthe numberofsmokersabstinent forsixmonthsorlonger. Resultina7%increaseinthe numberofsmokersabstinent forsixmonthsorlonger. Quitrateof15.6%(adjusted) reportedinEnglandwith massmediacampaign(Owen 2000). Intensivesupport (egsmokers’clinics) Cessationadvice andsupportfor hospitalpatients Cessationadvice andsupportfor pregnantsmokers Telephone helplines Fioreetal.1996;Rawetal.1998; updatedguidelines(Dec2000). Fioreetal.1996;Rawetal.1998; updatedguidelines(Dec2000). Rawetal.1998;Fioreetal.1996; updatedguidelines(Dec2000). Evidencebaseforeffectivenessis growingandThoraxguidelines indicatethattheymayprovidean effectiveservice(Rawetal.1998). Ameta-analysisreportsasignificant effect(Fioreetal.1996). Seeabove. Providersof(national andlocal)helplines, workplace,public places,NHS, communitygroups, cessationservices. InterventionEvidence Fioreetal.1996;Rawetal.1998; updatedguidelines(December 2000). Whocouldbe involved? PHCteam,linkwith othersupport servicesif appropriate [eghealthyliving centres(HLCs), hospitalstaff, doctors,nurses, midwives]. Skillsandresources Smokingcessationskills. Smokingcessationskills. Smokingcessationskills. Smokingcessationskills. Smokingcessationskills, trainedstaffrequired. Pointstoconsider Reachlowerthanthatfor briefadvice,butassociated withahighersuccessrate; resourceintensive;easeof access(egconvenience,safe location,timing)andcost (ifany)areimportant considerations. Massreach,easyand convenientforsmoker. Guidelinesareavailablefor thosewantingtosetuplocal helplines.Alternatively, activitiesandliteraturecould beundertakentoraisepublic awarenessofanduseof existinghelplines.Canbe usedtopromoteother cessationsupportservicesin locality. Furtherinformation Asabove. Asabove.TheMaudsley smokers’clinicisanexample ofgoodpracticehighlighted inthetobaccowhitepaper (DH1998a). Lichtensteinetal.(1996), NHSDirectHelpline 08001690169, Quit(Charity) 02073885775, Quitline0800002200. Outcome
  • 23. Reducing smoking prevalence 19 Likelyimpactuncertain. AUSstudyofemployees reportedareductionof5% insmokingprevalenceand 10%inconsumptionafter theintroductionofworkplace bans.Otherbenefitsinclude recognitionofnon-smoking asnorm,protectionofnon- smokers,increasedpublic awarenessandacceptanceof healthrisks.Mayencourage adolescentsnottostart. Quitrange0–5%foradult interventions(Reid1996), directinfluenceonclimateof publicopinion. Reducesmokingin publicandwork places Massmedia campaigns Associatedwithreduced consumption,possiblereductionsin prevalenceinthelongerterm (BrennerandMielck1992;Buck andGodfrey1994;Reid1996). Canenhancenaturalquitrateand mayreducerelapse(Reid1996; McVeyandStapletoninpress);may alsoreduceuptakeofsmokingin youngpeople(Sowdenand Arblaster2000a). BritishHospitality Association,The Restaurant Association,British Instituteof Innkeeping,Brewers andLicensed RetailersAssociation, Associationof LicensedMultiple Retailers,employers andemployees,NHS. Nationalandlocal media,community settingsand activities,workplaces andpublicplaces. Intervention Othertreatments Evidence Insufficientevidenceofeffectiveness forhypnotherapyandacupuncture, etc.(Abbotetal.2000;Whiteetal. 2000). Whocouldbe involved? Privatesector,links withothersmoking cessationproviders. Inviewoflackof evidencebase, considercontacting recognised professional associationsfor trainedindividuals. Skillsandresources Costly;requiresminimallevel ofexposureanddevelopment ofnewmessagestoavoid consumerburn-out. Pointstoconsider Smokersshouldbegiven informationaboutother treatmentstoenablethemto makeaninformedchoice withoutdiscouraging attemptstostop.Levelof traininglikelytovaryfrom nonetosufficienttojustify membershipofaprofessional body(Rawetal.1998). Charteragreedbetween governmentandlicensed hospitalitytrade.TheHSEis producinganewACoPon smokingintheworkplace, whichwillprovidepractical adviceonhowtocomply withthelaw. Highreach;workswellwith otherinterventionssuchas taxincreases;cansupport localcessationservices;focus shouldbeonadults. Furtherinformation BritishHypnotherapy Association(BHA),1 WythburnPlace,London W1H5WLTel:0207723 4443,email: BritishSocietyof Hypnotherapists(BSH),37 OrbainRoad,LondonSW6 7JZTel:02073851166 AssociationofGeneral PractitionersofNatural Medicine(AGPNM),38Nigel House,PortpoolLane, LondonEC1N7UR Tel:02074052781. InstituteofComplementary Medicine(ICM),POBox194, LondonSE161QZ Tel:02072375165. DH(1998a),HEA(1999c,d). TheNationalHSE(NHSE)is developingatoolkittohelp withtheimplementationof itspolicies. DHsmokingpolicyteam, DHcommunicationsteam, reviewofuseofmassmedia campaignsinEngland availablefromHDA(Greyet al.2000).CochraneLibrary websitehttp://www.update- Outcome
  • 24. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 20 Oneyearnetquitrates estimated0.3–0.5%(Reidet al.,1992;BuckandGodfrey 1994);influenceonpublic opinion;providesbasisfor otherinitiatives;may contributetoimpactofmass mediacampaign; extendsdebateabout smoking. Impactofmonitoringlocal infringementofvoluntary agreementnotknown,but doesofferopportunitiesfor mediaadvocacy. Localactivitycanreduce sales;usefulformedia advocacy;mayhaveasmall delayingeffectonchildren’s uptake. Implementationvariessothat outcomeisunclear;reinforces non-smokingasthenorm; otherpotentialbenefits includereducedabsenteeism, reducedcostsandelimination ofpassivesmoking. Advertisingban Reduceillegalsales Smokingpoliciesin schools Possibleeffectonadult consumptionandteenage prevalence(Reidetal.1992; SowdenandArblaster,2000a). Localactivitycanreducesales.This mayhaveasmalldelayingeffecton children’suptakeofsmoking. Impactonuptakeofsmoking uncertain. Government,health promotionspecialists, tobaccoadvocates andotherscan monitorexisting voluntary agreements. Magistrates,retailers, localtrading standardsofficers, schools,parents, localgovernment association,LAs, NationalAssociation ofCigaretteMachine Operators. Schoolteachers, governors,heads, parents,pupils,local community(for policiesthatinvolve non-smokingin schoolpremisesfor communityactivities). Intervention Mediaadvocacy andNoSmoking Day Evidence Effectivenesslowerthanmore intensiveinterventionsbuthighly cost-effectivebecausethereachis muchgreater(Reidetal.,1992; BuckandGodfrey1994). Whocouldbe involved? NHS,local government, commercialinterests, voluntaryagencies. Skillsandresources Cheaperthanpaid advertisingbutsubstantial resourcesrequiredfor generatingstories; goodcontactswithlocal mediaandtheleisureand hospitalitytrade.Trainingin mediaadvocacyneeded. Requiressubstantial resources. Pointstoconsider Reliesongoodlinkswith otheragencies(egvoluntary sector,localgovernment, hospitalitytrade)tocreate localactivities. Localactivitycouldinclude monitoringinfringementsto voluntaryagreements(eg advertisingonbillboardsnear schools,promotionsin magazinesaimedatyoung people). Existinglawstatesthatitis illegaltoselltobacco productstounder16s,but enforcementisproblematic. Possiblyaddstoperception thatsmokingisaforbidden fruit(KayScottAssociates 2000). Supportshealthmessagesin thenationalcurriculum. Furtherinformation Exampleofgoodpractice: RoyCastleGoodAirAwards DH(1992).IssuedwithDH circularEL(92)71. NationalAssociationof CigaretteMachineOperators hasproducedacodefor members.LocalGovernment Association(LGA)andLocal AuthoritiesCoordinating BodyonFoodandTrading haveproducedanLA enforcementprotocol. HEA(1993,1999e). Outcome
  • 25. 1.7 References Abbot, N.C., Stead, L.F., White, A.R., Barnes, J. and Ernst, E., 2000. Hypnotherapy for smoking cessation, Cochrane Review. In: Cochrane Library, Issue 3. Oxford: Update Software. Acheson, D., 1998. Independent inquiry into inequalities in health report. London: The Stationery Office. Adams, C., Bauld, L. and Judge, K., 2000. Baccy to front. Health Service Journal, 110 (5713), 28–31. ASH, 2000a. Smoking cessation in primary care: how to spend NHS money much more effectively. London: ASH. ( ASH, 2000b. Smoking cessation services: Implementing the NHS National Plan. London: ASH. ASH Scotland and HEBS, 1999. Women, low income and smoking: breaking down the barriers. Edinburgh: Action on Smoking and Health Scotland and Health Education Board for Scotland. Borland, R., Owen, N., Hill, D. and Schofield, P., et al., 1991. Predicting attempts and sustained cessation of smoking after the introduction of workplace smoking bans. Health Psychology, 10 (5), 336–342. Botvin, G.J., Dusenbury, L., Baker, E., Ortiz, S., Botvin, E.M. and Kerner, J., 1992. Smoking prevention among urban minority youth: assessing effects on outcome and mediating variables. Health Psychology, 11 (5), 290–299. Brauer, M. and Mannetje, A., 1998. Restaurant smoking restrictions and environmental tobacco smoke exposure. American Journal of Public Health, 88 (12), 1834–1836. Brenner, H. and Mielck, A., 1992. Restrictions to smoking at the workplace and smoking habits: a literature review. Soz Praventivmed, 37 (4), 162–167. Buck, D. and Godfrey, C., 1994. Helping smokers give up: guidance for purchasers on cost effectiveness. London: HEA. Callum, C., 1998. The UK smoking epidemic: deaths in 1995. London: HEA. Campion, P., Owen, L., McNeill, A. and McGuire, C., 1994. Evaluation of a mass media campaign on smoking and pregnancy. Addiction, 89 (10), 1245–1254. Chapman, S., 1993. Unravelling gossamer with boxing gloves: problems in explaining the decline in smoking. British Medical Journal, 307, 429–432. DFEE, 1998. Protecting young people: good practice in drug education in schools and the youth service. Sudbury, Suffolk: DfEE Publications. DH, 1992. Effect of tobacco advertising on tobacco consumption: a discussion document reviewing the evidence (C. Smee, Chair, Department of Health Economics and Operational Research Division). London: DH [issued with DH EL(92)71]. DH, 1998a. Smoking kills, white paper on tobacco. London: The Stationery Office. DH, 1998b. Directory of African Caribbean initiatives. Birmingham: N Films Ltd. DH, 2000a. The cancer plan. London: The Stationery Office. DH, 2000b. National service framework for coronary heart disease. London: DH. DH, 2000c. Statistics on smoking: England, 1978 onwards. London: DH Statistical Bulletin. DH, 2000d. The NHS plan. A plan for investment. A plan for reform. London: The Stationery Office. Dorsett, R. and Marsh, A., 1998. The health trap: poverty, smoking and lone parenthood. London: Policy Studies Institute. Elder, J P., Wildey, M., de Moor, C., Sallis, J.F., Jr., Eckhardt, L., Edwards, C., Erickson, A., Golbeck, A., Hovell, M., Johnston, D., Levitz, M.D., Molgard, C., Young, R., Vito, D. and Woodruff, S.I., 1993. The long-term prevention of tobacco use among junior high school students: classroom and telephone interventions. American Journal of Public Health, 83 (9), 1239–1244. Elder, J.P., Edwards, C.C., Conway, T.L., Kenney, E., Johnson, C.A. and Bennett, E.D., 1996. Independent evaluation of the California Tobacco Education Program. Public Health Report, 111 (4), 353–358. Fiore, M.C., Bailey, W.C., Cohen, S.J., Dorfman, S.F., Goldstein, M.G., Gritz, E.R., Heyman, R.B., Holbrook, J., Jaen, C.R., Kottke, T.E., Lando, H.A., Mecklenburg, R., Mullen, P.D., Nett, L.M., Robinson, L., Stitzer, M.L., Tommasello, A.C., Villejo, L. and Wewers, M.E., 1996. Smoking cessation, Clinical Practice Guideline No. 18. Rockville: Agency for Health Care Policy and Research, US Department of Health and Human Services, Publication No. 96-0692. Glasgow, R.E., Cummings, K.M. and Hyland, A., 1997. Relationship of worksite smoking policy to changes in employee tobacco use: findings from COMMIT. Community Intervention Trial for Smoking Cessation. Tobacco Control, 6 (suppl 2), S44–S48. Reducing smoking prevalence 21
  • 26. Grey, A., Owen, L. and Bolling, K., 2000. A breath of fresh air: tackling smoking through the media. London: HDA. HDA, 2000a. Smoking cessation in young people: should we do more to help young people quit? London: HDA. HDA, 2000b. Tobacco control policies within the NHS: case studies of effective practice. London: HDA. HDA, in press. An investigation into the potential of media advocacy as a health promotion strategy. London: HDA. HEA, 1993. Smoking policies in schools: guidelines for policy development. London: HEA. HEA, 1994a. Smoking and pregnancy: guidance for purchasers and providers. London: HEA. HEA, 1994b. Helping pregnant smokers quit: training for health professionals. London: HEA. HEA, 1996a. Smoking and pregnancy: a growing problem. London: HEA. HEA, 1996b. Empowering smokers to quit: success principles for community stop-smoking projects. London: HEA. HEA, 1999a. Black and minority ethnic groups in England: health and lifestyles. London: HEA. HEA, 1999b. Been there, done that: revisiting tobacco control policies in the NHS. London: HEA. HEA, 1999c. Smoking policy for the workplace: an update. London: HEA. HEA, 1999d. Towards tobacco-free environments: guidelines for local authorities. London: HEA. HEA, 1999e. Smoke-free schools: seven steps to success. London: HEA. HSC, 1998. Tobacco white paper, HSC 1998/234. London: NHS Executive. HSC, 1999. New NHS smoking cessation services, HSC 1999/087. London: NHS Executive. Hill, D., 1999. Why we should tackle adult smoking first. Tobacco Control, 8, 333–335. Hurt, R.D, Sachs, D.P.L., Glover, E.D., Offord, M.S., Johnston, J.A., Lowell, P.D., Khayrallah, M.A., Schroeder, D.R., Glover, P.N., Sullivan, C.R., Croghan, I.T. and Sullivan, P.M., 1997. A comparison of sustained-release Buproprion and placebo for smoking cessation. New England Journal of Medicine, 337, 1195–1002. Jarvis, M., 1998. Extra analyses of the General Household Survey commissioned by the Health Education Authority. London: HEA. Jarvis, M. and Wardle, J., 1999. Social patterning of health behaviours: the case of cigarette smoking. In: M. Marmott and R. Wilkinson, eds. Social determinants of health. Oxford: Oxford University Press, 1999, 240–255. Jeffery, R.W., Kelder, S.H., Forster, J.L., French, S.A., Lando, H.A., Baxter J.E., 1994. Restrictive smoking policies in the workplace: effects on smoking prevalence and cigarette consumption. Preventive Medicine, 23 (1), 78–82. Jenkins, C.N., McPhee S.J., Le, A., Pham, G.Q., Ha, N.T., Steward, S., 1997. The effectiveness of a media-led intervention to reduce smoking among Vietnamese-American men. American Journal of Public Health, 87 (6), 1031–1034. Jernigan, D. and Wright, P., eds., 1993. Making news: changing policy. Case studies of media advocacy on alcohol and tobacco use. Bethesda, MD: Center for Substance Abuse Prevention. Jorenby, D.E., Leischow, S.J., Nides, M.A., Rennard, S.I., Johnston, J.A., Hughes, A.R., Smith, S.S., Muramoto, M.L., Daughton, D.M., Doan, K., Fiore, M.C. and Baker, T.B., 1999. A controlled trial of sustained-release buproprion, a nicotine patch, or both for smoking cessation. New England Journal of Medicine, 340, 685–691. Kay Scott Associates, 2000. Need a fag, need a fag. Smoking and young people, Report on six qualitative discussion groups. London: ASH. Lantz, P.M., Jacobson, P.D., Warner, K.E., Wasserman, J., Pollack, H.A. and Ahlstrom, A., 2000. Investing in youth tobacco control: a review of smoking prevention and control strategies. Tobacco Control, 9, 47–63. Lichtenstein, E., Glasgow, R.E., Lando, H.A., Ossip-Klein, D.J. and Boles, S.M., 1996. Telephone counselling for smoking cessation: rationales and meta-analytic review of evidence. Health Education Research, 11, 243–257. Lillington, L., Royce, J., Novak, D., Ruvalcaba, M. and Chlebowski, R., 1995. Evaluation of a smoking cessation program for pregnant minority women. Cancer Practice, 3 (3), 157–163. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 22
  • 27. Macaskill, P., Pierce, J.P., Simpson, J.M. and Lyle, D.M., 1992. Mass media-led antismoking campaign can remove the education gap in quitting behaviour. American Journal of Public Health, 82 (1), 96–98. Maltby, S., Simmons, R., Choudry, S., Warrant, M. and Haggett, C., 2000. Research on tobacco use among black and minority ethnic groups. London: HDA. Marcus, B.H., Emmons, K.M. and Abrams D.B., 1992. Restrictive workplace smoking policies: impact on non-smokers’ tobacco exposure. Journal of Public Health Policy, 13 (1), 42–51. Marsh, A. and McKay, S., 1994. Poor smokers. London: Policy Studies Institute. Naidoo, B., Stevens, W. and McPherson, K., 1999. A report for the Health Education Authority on modelling the short-term consequences of smoking cessation in England on the hospitalisation rates for acute myocardial infarction and stroke. London: London School of Hygiene and Tropical Medicine. OFSTED, 1997. Drug education in schools. London: The Stationery Office. Owen, L., 2000. Impact of a telephone helpline for smokers who called during a mass media campaign. Tobacco Control, 9, 148–154. Owen, L. and Penn, G., 1999. Smoking and pregnancy: a survey of knowledge, attitudes and behaviour 1992–1999. London: HEA. Owen, L., McNeill, A. and Callum, C., 1998. Trends in smoking during pregnancy in England, 1992–7: quota sampling surveys. British Medical Journal, 317, 728. Owen, L. and Bolling, K., 1996. Smoking and pregnancy: developing a communications strategy for cessation. London: HEA. Raw, M., McNeill, A., and West, R., 1998. Smoking cessation guidelines for health professionals. Thorax, 53 (suppl 5). Reid, D., 1996. Tobacco control: overview. British Medical Bulletin, 52 (1), 108–120. Reid, D., Killoran, A., McNeill, A. and Chambers, J., 1992. Choosing the most effective health promotion options for reducing a nation’s smoking prevalence. Tobacco Control, 1, 185–197. Royal College of Physicians, 1992. Smoking and the young. London: Royal College of Physicians. SCOTH, 1998. Report of the Scientific Committee on Tobacco and Health. London: The Stationery Office. Secker-Walker, R.H., Solomon, L.J., Flynn, B.S., Skelly, J.M., 1995. Smoking relapse prevention counselling during prenatal and early postnatal care. American Journal of Preventive Medicine, 11, 86–93. Sowden, A.J. and Arblaster, L., 2000a. Mass media interventions for preventing smoking in young people, Cochrane Review. In: Cochrane Library, Issue 2. Oxford: Update Software. Sowden, A. and Arblaster, L., 2000b. Community interventions for preventing smoking in young people, Cochrane Review. In: Cochrane Library, Issue 2. Oxford: Update Software. Stead, L. and Lancaster, T., 2000. A systematic review of interventions for preventing tobacco sales to minors. Tobacco Control, 9, 169–176. Tang, J.L., Cook, D.G. and Shaper, A.G., 1992. Giving up smoking: how rapidly does the excess risk of ischaemic heart disease disappear? Journal of Smoking-Related Diseases, 3, 203–215. US Department of Health and Human Services, 1990. The health benefits of smoking cessation, a report of the Surgeon General, DHHS Publication No. CDC 90-8416. Rockville, MD: National Centers for Disease Control and Prevention, Office on Smoking and Health. US Department of Health and Human Services, 2000. Reducing tobacco use, a report of the Surgeon General, DHHS Publication No. CDC20402, S/N017-001-00544-4. Rockville, MD: National Centers for Disease Control and Prevention, Office on Smoking and Health. Wakefield, M. and Chaloupka, F., 2000. Effectiveness of comprehensive tobacco control programmes in reducing teenage smoking in the USA. Tobacco Control, 9, 177–186. Wakefield, M.A., Wilson, D., Owen, N., Esterman, A. and Roberts, L., 1992. Workplace smoking restrictions, occupational status, and reduced cigarette consumption. Journal of Occupational Medicine, 34 (7), 693–697. White, A.R., Rampes, H. and Ernst E., 2000. Acupuncture for smoking cessation, Cochrane Review. In: Cochrane Library, Issue 3. Oxford: Update Software. WHO, 1979. Controlling the smoking epidemic, WHO Technical Report Series No. 636. Geneva: WHO. WHO, 1998. Guidelines for controlling and monitoring the tobacco epidemic. Geneva: WHO. Reducing smoking prevalence 23
  • 28. Box 2.1 Identification of barriers to healthy eating and interventions to address them: an example Chapter 2 Improving diet and nutrition Improving diet and nutrition 25 2.1 Introduction Diet plays a fundamental role in the development of CHD. The type and amount of fat and its relationship to blood cholesterol levels have been recognised for some time as being particularly influential. Salt intake has been implicated in relation to blood pressure and, more recently, an increased intake of fruit and vegetables has been identified as an important factor in reducing the rates of both heart disease and some cancers (DH 1994, 1998). The promotion of healthy eating is important in reducing the risk not only of CHD but also of other chronic conditions, such as obesity and diet related cancers. Effective strategies to promote healthy eating are generally those that work at several levels. It is important to identify the barriers to dietary change in the local population and then select interventions to address them (see Box 2.1). 2.2 Objectives of nutritional interventions Diet is one of the key modifiable risk factors in the prevention of CHD. The government’s Committee on the Medical Aspects of Food and Nutrition Policy (COMA; DH 1994) recommended a reduction in fat (particularly saturated fat), a reduction in salt and an increase in complex carbohydrates. In addition, fruit and vegetable consumption should be increased by at least 50% (to at least five portions per day). The recommendations are summarised in nutrition briefing papers produced by the HEA (1992, 1996). Also, it has been estimated that around one-third of all cancers might be influenced by diet. In 1998, COMA reviewed the evidence on diet and cancer in the UK (DH 1998). The working group recommendations were consistent with other dietary recommendations made for the prevention of obesity, diabetes and cardiovascular disease. Barrier • Belief that the family is already eating enough fruit and vegetables • Dislike of taste of vegetables and lack of confidence in cooking and preparing them; fear of waste and of rejection by the family • Difficulty in finding affordable, good quality fruit and vegetables locally Intervention • Information about five portions a day and portion sizes • Set up cooking skills clubs and tasting sessions, or develop cooking sessions as part of the activities of existing groups (eg women’s groups, youth groups) • Set up community owned retailing and food cooperatives to introduce affordable supplies
  • 29. 26 In promoting a healthy balanced diet to reduce the risk of cardiovascular disease and diet related cancers in the population, interventions should focus on the following: • Reducing the amount of fat, and in particular, the amount of saturated fat It has been estimated that a 10% reduction in saturated fat intake within the UK population would be associated with a reduction in CHD mortality of between 20% and 30% (Marmot 1994). Therefore, to help achieve a healthy diet, people should be encouraged to use reduced fat spreads and dairy products in place of full fat versions, to replace oils and fats high in saturates with those high in monounsaturates, to reduce the amount of fat used in cooking, to trim fat from meat and to reduce the amount of products such as biscuits, pastries, cakes, and crisps in the diet. • Increasing the amount of fruit and vegetables eaten to at least five portions each day Apart from being rich sources of carbohydrate, dietary fibre, antioxidants and other bioactive factors, fruit and vegetables are also rich sources of potassium, which is associated with lower blood pressure and a lower risk of stroke (Joshipura et al. 1999). For many people, this will mean almost doubling their intake. It will mean having fruit and vegetables at most meals, and as snacks between meals. Access to affordable, good quality supplies of fruit and vegetables must be ensured and skills and confidence to prepare and cook fruit and vegetables should be developed [National Heart Forum (NHF) 1997]. • Increasing the intake of fibre rich, starchy foods, such as bread, potatoes, pasta and rice, by half as much again Make these foods the main part of most meals, and replace fattier snacks. • Reducing the average salt intake by around a third There is now a consensus that dietary sodium is a factor in the development of high blood pressure (DH 1994). People should be encouraged to gradually reduce the salt they add to food, both in cooking and at the table. Also, people should be more aware of low-salt alternatives to processed foods if available and should recognise the salt content of processed foods by reading food labels. • Increasing the amount of fish eaten to at least two portions each week, one of which should be an oily fish Encourage people to eat fish more often: this may mean working with communities to develop their cooking skills and confidence to cook fish. A useful tool to support health promoters in promoting a balanced diet is The balance of good health [HEA, DH and Ministry of Agriculture, Fisheries and Foods (MAFF) 1994]. It shows what proportion of the diet should come from the different food groups and could provide a consistent and easily understood message about a balanced diet1. The balance of good health has also been modified for use with black and minority ethnic groups. The British Dietetic Association and Sainsburys have developed an African-Caribbean version and the British Nutrition Foundation has produced a model suitable for use with the Chinese community. Dietitians at Wandsworth Community Health Trust, with support from Spillers Milling, formed a healthy alliance and produced a version suitable for use with South Asian groups. 2.2.1 Professional knowledge and expertise Identifying the barriers and developing an integrated programme of complementary activities will require the input of staff with a range of skills. While most areas have access to a community dietitian, it is quite common for clinical duties to interfere with the dietitian’s ability to spend time in the community. In planning the resources needed to implement the strategy, it may be worth considering ring fencing a block of dietitian time to devote to community work. Public health nutritionists can provide the expertise to develop and implement a public health nutrition strategy and to work on other nutrition issues at a population level. In recent years, the Nutrition Society has introduced a registration system for public health nutritionists (RPH Nutr). In addition, the Nutrition Society has recently developed an associate registration Coronary heart disease: guidance for implementing the preventive aspects of the NSF 1The balance of good health does not apply to children under two years of age, who need a diet that is higher in fat and lower in fibre rich, starchy foods, to children aged between two and five years (a gradual transition towards a diet consistent with The balance of good health is needed here) or to people with special dietary requirements or those under medical supervision.
  • 30. • Clear goals were set, based on theories of behavioural change, rather than relying on the provision of information alone • There was personal contact with individuals or small groups sustained over time • Participants received personalised feedback on any changes in their behaviour and risk factors • Changes in the local environment were promoted, for example in shops and catering outlets to help people choose a healthy diet. Providing information alone is not a solution. Improving people’s knowledge about diet does not necessarily lead to behaviour change. Improvements in knowledge should be accompanied by the development of skills and provide the opportunity to put the knowledge into practice. For example, there is little point in encouraging people to eat more fish, in particular oily fish, if access to these foods is not available, and if people lack the skills and confidence to prepare and cook fish. Integrated programmes of activity could be more effective if they first identify the barriers to dietary change, and then provide the information, skills and opportunities to put the suggestion into practice (NHF 1999). 2.4 Components of a local strategy 2.4.1 Schools A meta-analysis of 12 intervention studies to promote heart-healthy eating behaviour in schools concluded that they can have a significant effect (McArthur 1998). Two reviews have identified the following features of an effective school intervention (Contento 1995; Roe et al. 1997): • Nutrition education interventions are more likely to be effective when they employ educational strategies that are directly relevant to a particular behaviour (eg diet or physical activity) and are derived from appropriate theory and research • Interventions need adequate time and intensity to be effective Improving diet and nutrition 27 scheme for newly qualified public health nutrition professionals who have not yet accumulated the three years’ experience required for full registration as a public health nutritionist. The Register of Public Health Nutritionists can be found on or contact Jackie Landman at the Nutrition Society (020 7602 0228) for further information on the associate scheme. Local people are an important addition to this skill base. Research suggests that the efficiency and effectiveness of community based interventions can be improved by using local people to complement the work of health professionals. McGlone et al. (1999) suggested that ‘if local food projects are to work, then they must genuinely involve local people’. Services provided by local people are often considered more appropriate and more accessible for the health needs of the community. Such services foster self-reliance, community participation and can help overcome barriers. They also allow access to groups that are typically hard to reach and can be particularly beneficial for black and minority ethnic groups. These benefits are two way, as local people have the opportunity to develop their own skills. Exploratory work with this peer education approach (Hodgson et al. 1995; Kennedy et al. 1999) showed that it was possible to achieve both significant increases in nutrition knowledge and potentially beneficial changes in the dietary practices of low income families. The best approach appears to be one in which guided ‘hands on’ food preparation/cooking sessions allow the participants to acquire knowledge and skills. However, it was noted that this approach was resource intensive, particularly in professional staff time, and there is little evidence of effectiveness in terms of dietary change. This approach may result in potential health, social and economic benefits and therefore warrants further study. 2.3 Features of effective interventions A meta-analysis of randomised controlled trials shows that dietary interventions can be effective in reducing CHD risk factors (Brunner et al. 1997). A systematic review of the effectiveness of interventions to promote healthy eating found that characteristics of a successful intervention had the following features (Roe et al. 1997): • It focused on diet alone, or diet plus physical activity rather than tackled a range of risk factors
  • 31. • Family involvement enhances the effectiveness of programmes for younger children • Incorporation of a self-evaluation or self-assessment and feedback is effective in interventions for older children • Effective nutrition education includes consideration of the whole school environment and community • Interventions in the larger community can enhance school nutrition education • The most effective interventions focus on diet alone or diet and physical activity. 2.4.2 Local/community projects This section includes a range of interventions from small-scale local projects to well funded community interventions. Little rigorous evaluation of the effectiveness of the small scale projects has been carried out. Roe et al. (1997) concluded that intensive, smaller scale projects generally resulted in positive changes in diet and blood cholesterol, at least in the short term. However, many large community-wide studies failed to show a similar effect because they were conducted in the 1980s, a time when awareness of CHD risk factors had increased in the population. Therefore, in one study, the reduction in blood cholesterol observed in the intervention communities was also found in the comparison community. In addition, there was a diversity of other informational and educational interventions; therefore, the investigators were unable to attribute any change to their specific intervention. Effective community interventions appear to: • Focus on diet or diet plus physical activity • Use a theoretical model • Use diverse multiple interventions at individual, group, community and environmental level • Include small-group interventions (Contento 1995; Roe et al. 1997). McGlone et al. (1999) identified the characteristics of projects that appear to have been ‘successful’ using a range of criteria: • Flexibility needed by agencies to respond to the needs of particular communities • Access to secure, and ongoing, funds • Professionals work in partnership with a community • Projects need to involve local people, and ensure equal respect • Evaluation should not be confined to narrow clinical and behavioural measures. Include food purchasing patterns, structural changes and social outcomes, for example • Strike a balance between partnerships and local ownership • Local and national networks should enable sharing of experiences • Training for professionals and members of the community to acquire skills for a new way of working • Government policies that do not deter volunteers (eg social welfare benefits) • Provide incentives for local projects and small businesses, such as tax relief • Allow time for community projects to develop, on the basis that there is no ‘quick fix’ and that local policy should support realistic time frames for community food projects. However, to date, there has been no systematic evaluation of the effectiveness of local projects. 2.4.3 Workplace Three out of four good-quality interventions showed positive effects of nutrition workplace interventions, with decreases in blood cholesterol of between 2.5% and 10% (Roe et al. 1997). An HEA review of the effectiveness of health promotion interventions in the workplace (Peersman et al. 1998) identified four studies Coronary heart disease: guidance for implementing the preventive aspects of the NSF 28
  • 32. Another systematic review (Roe et al. 1997) included interventions in the primary healthcare setting. Four ‘good quality’ studies were identified in the past 10 years. Modest and sustained effects on both blood cholesterol and dietary fat intake were achieved for dietary interventions only, or for multifactorial interventions. Characteristics of an effective healthcare intervention include: • Small group or one to one counselling sessions • Targeting higher risk groups, which is also more cost- effective (Van der Weidjen 1998; Wood et al. 1998) • Family counselling and education for those at increased risk • Tailoring to the personal characteristics of individuals • Educational and behavioural frameworks which are client centred • Staff training and development (topic based knowledge and counselling skills) • Low intensity interventions, such as mailed, computer generated, personalised, nutrition education material for well-motivated groups (Roe et al. 1997). 2.5 Reducing inequity There are inequalities in diet between those on higher and lower incomes (Acheson 1998). The most striking difference is that people in lower socio-economic groups tend to eat less fruit and vegetables. The 1997 National Food Survey (MAFF 1998) found that consumption of fruit and vegetables by those in the upper socio-economic groups was a third higher than that of those in lower groups. This social class difference has also been reported in children (Gregory et al. 2000). Studies have shown that people on a low income can describe a healthy diet as well as those on higher incomes (Lobstein 1997). Food poverty, affordability and access to a healthy and varied diet have been identified as possible barriers (Lobstein 1997; DH 1996). Improving diet and nutrition 29 on healthy eating with adequate methodologies. Three showed positive effects on fat, fruit and vegetable intake, intention to change the diet and self-efficacy. Characteristics of an effective workplace intervention include: • Visible and enthusiastic support and involvement from management • Involvement by employees at all levels in the planning and implementation phases • A focus on definable and modifiable risk factors rather than multiple risk factor interventions • Screening and/or individual counselling • Changes to the composition of best selling foods provided in canteens and vending machines • Tailoring to the characteristics and needs of the employees • Use of local resources in organisation and implementation of the intervention • Combine population based policy initiatives with intensive individual and group oriented interventions • Built-in sustainability. 2.4.4 Healthcare In a meta-analysis by Brunner et al. (1997), the study participants were well motivated. Most studies were conducted in either a healthcare or an institutional setting. Interventions included dietary advice to reduce fat or sodium and to increase fibre. The authors estimated that, if changes in dietary behaviour were sustained, they could lead to a reduction in the incidence of CHD by 14% and the incidence of stroke by 9%. A meta-analysis by Yu-Poth (1999) reported a 10% reduction in plasma total cholesterol with a low intensity intervention, and a 13% reduction with the high intensity intervention. Tang et al. (1998) reported reductions in blood cholesterol following individual dietary advice to modify fat intake: 8.5% at three months and 5.5% at 12 months.
  • 33. raised by the recent National Diet and Nutrition Surveys, of children aged 11⁄2 to 41⁄2 years (Gregory et al. 1995) and 4 to 18 years (Gregory et al. 2000). Acheson (1998) concluded that ‘pre-school education or day care may be especially effective in improving the achievement and health of the most disadvantaged children’. A recent review by Tedstone et al. (1998) of the effectiveness of interventions to promote healthy eating in pre-school children aged 1–5 years found that pre-school and day care centres were likely to be appropriate settings for interventions, and that parental involvement may enhance the effectiveness of interventions and should be facilitated. In more detail, the review reported that: • Traditional, video or computer-based teaching methods were successful at increasing nutrition knowledge and the effectiveness was enhanced by the inclusion of parents • Behavioural modification techniques using repeated exposure to initially novel foods were successful in increasing willingness to consume the foods only if tasting was facilitated as part of the exposure • The use of reward to encourage consumption of foods was not successful once the reward had been removed • One to one diet counselling that was ‘needs focused’ was successful at bringing about improvements in UK mothers. Acknowledgement Information in Table 2.6 concerning some of the local community interventions was drawn in part from Making Links – a toolkit for local food projects (Sustain 2000). 30 The Acheson report (Acheson 1998) recommended further development of policies that will ensure adequate retail provision of food to those who are disadvantaged. A report by Policy Action Team (PAT) 13 (1999) confirmed that accessing affordable, good quality fruit and vegetables within some local areas might be difficult. However, access should not be seen purely in terms of physical proximity, and other kinds of access need to be considered, for example, financial access, knowledge and information (HEA 1998a). In areas where a large proportion of the population is unemployed, on low income or in receipt of benefits, interventions to improve people’s access to a healthier diet are likely to be a key priority. 2.5.1 Black and minority ethnic groups Improving the health of minority ethnic groups is also a priority in the government’s drive to reduce social exclusion and inequalities in health. Further impetus was provided by Acheson (1998), who recommended that the needs of black and minority ethnic groups be considered specifically. The HEA (2000) found that among black and minority ethnic groups, understanding of healthy eating messages varied widely across groups and knowledge of foods high in complex carbohydrates, fibre, fat and saturated fat was often poor across all ethnic groups. There is, therefore, a need to raise awareness of the links between diet and CHD among these groups and to promote culturally relevant messages. 2.5.2 Children Early childhood experiences strongly influence dietary preference and good eating habits. While they may not have an immediate effect on the rates of CHD, strategies to promote healthy eating among children will benefit in the longer term. They will help to address the concerns Coronary heart disease: guidance for implementing the preventive aspects of the NSF
  • 34. Improving diet and nutrition 31 Outcome Compliancewithlegal requirement;givesasound basistoawholeschool approach;willcontributeto achievingtheNational HealthySchoolsStandard (NHSS);clearguidanceand frameworkformonitoring willbeprovided;willensure goodnutritionalstandardsfor freemeals. Intervention Nutritional standardsfor schoollunches FromApril2001, newlegislationwill requireschool lunchestomeet minimumnutritional standards. Evidence Roeetal.(1997)identifiedtwo goodqualitystudiesrelevantto schoolmeals.Ellisonetal.(1989, 1990)showedthatpassive manipulationoffatcontentreduced saturatedfatintakeby2%witha similarincreaseinpolyunsaturated fatintake.Whitakeretal.(1994) showeda3%increaseinlowfat choiceswhenpromoted. Whocouldbe involved? Localeducation authority(LEA),direct serviceorganisation; contractcaterersand in-housedietitians; LocalAuthority Caterers’Association (LACA):http://www. SchoolsNutrition ActionGroup(SNAG) initiativecanhelp schoolsindeveloping aschoolfoodpolicy. Localhealthyschools programme. ChildPovertyAction Group: uk Skillsandresources Supportforcaterersfrom communitydietitianorpublic healthnutritionistintraining inhealthiercateringpractices andinmonitoringcompliance withthestandards. Pointstoconsider Pricingofhealthierchoices– andcaterers’perceptionsof thehigherproductioncosts; introducingaschoolfood policytosupportadoptionof thestandards;opportunityto reviewsnackprovisionsat sametime,aswellas breakfastclubsandvending machines. Meetingandmonitoring standardswillbealegal requirement. Furtherinformation DepartmentforEducation andtheEnvironment(DfEE) http://www.nutritional.stand NationalStandardsfor SchoolLunches,England. Regulations2000.Statutory Instrumentnumber1777. TheStationeryOffice.£1.50. Eatingwellatschool:dietary guidanceforschoolmeal providers(1997).DfEE Publications,POBox5050, Annesley,Nottingham, NG150DJ.Tel:0845 602260.Freeofcharge. SchoolMealsAssessment Pack(SMAP;computer packageassessingthe nutritionalqualityof secondaryschoolmeals) producedbytheNHF. SMAP,POBox7,London W52GQ.£45.00,cheques payabletoBSS. Schoolfoodpolicyguide producedbySNAG. ContactJoeHarvey,Health EducationTrust(tel/fax: 01789773915). Nutritionguidelinesfor schoolmeals(1992)available fromTheCarolineWalker Trust,22KindersleyWay, AbbotsLangley,Herts,WD5 0DQ.Cost£10including postageandpacking(p&p). Whataretoday’schildren eating?TheGardnerMerchant SchoolMealsSurvey2000. GardnerMerchant (tel:01793512112). Table2.6Suggestedactivitiestosupportlocalaction
  • 35. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 32 Addressesarangeofrisk factorsforCHDaspartof wholeschoolapproach.Has aformalisedsupport network.Couldbeusedto formaliseandsecurefunding foranyschoolbased initiatives.Allowsaflexible approachtomeeting standardcriteria. NHSSsupportmaterialswill facilitatestrategic connectionsandhelpidentify localpartnersaswellas providecasestudyexamples ofgoodpractice. Evaluationofpilotsites(Riversetal. 2000)foundconflictbetween healthyeatingcriteriaandschool mealscontracts.Newlegal minimumstandardsforschool lunchesshouldovercomethis. Notyetevaluatednationally. Localhealthyschools programme coordinatorsbasedin LEAsorHAs. OutcomeInterventionEvidenceWhocouldbe involved? Skillsandresources Localprogramme coordinatorswillwelcome theinvolvementof communitydietitians,public healthnutritionists,health promotionspecialists,in meetingthestandard. Pointstoconsider Schoolsagreeprioritieswith coordinatorsoflocalhealthy schoolprogrammes.Healthy eatingmaynotbethefirst priority. Thisisanopportunityto becomeinvolvedinthe strategicplanningtomeet thehealthyeatingstandard. Legalrequirementsforschool luncheswillincreasethe priorityforhealthyeating. AllLEAshavenowsignedup toachievetheNHSS. Furtherinformation Futureoffoodinschools report(1998).Availablefree ofchargefromPennyRolfe, Chartwells,IcknieldHouse, 40WestStreet,Dunstable, BedsLU61TA. McMahon,W.andMarsh, T.,1999.Fillingthegap. ChildPovertyActionGroup. Cost£5.00, 94WhiteLionStreet, LondonW19PF.Tel:020 78377979.Theirwebsite alsocontainsbriefingpapers onschoolmealsandhealthy eatingandschoolmealsin Scotland. NationalHealthySchool Standardguidance. DfEE(1999).Availablefree fromDfEEPublications,PO Box5050,Annesley, NottinghamNG150DJ. The‘Yourhealthyschool’ sectionof http://www.wiredforhealth. Food–afactoflife:range ofteachingresource materialforprimaryand secondaryschools(British NutritionFoundation). Contact02074046504or Nationalhealthy schoolstandard (NHSS) Criteriaforhealthy eating,toinform implementationof wholeschool approach.
  • 36. Improving diet and nutrition 33 Outcome Offerbroaderbenefits (egpre-andafter-school care). Opportunitytoencouragethe intakeoffruitoncereal,as juiceorafterschoolas snacks.Mayalsohelpto addresslowintakesofiron andothermicronutrients (Gregoryetal.2000). HEAYoungPeopleand HealthSurvey(1999)revealed thatalmostoneinfive(18%) youngpeopleaged11–16 yearsnever(orhardlyever) hadbreakfastbeforeschool (males13%,females23%). InterventionEvidence 34breakfastclubs;breakfastclub evaluationscurrentlyunderway. Whocouldbe involved? LEADirectService Organisations;school caterers;head teachers,school governorsandPTAs; regionalandlocal coordinatorsofthe healthyschools programmes;schools nutritionaction groups(SNAGs); Kellogg’s http://www.breakfast Localhealthyschools programme. Skillsandresources Paidstafftopreparefood andsupervisechildren; venue,facilitiesand equipmentforthesafeand hygienicpreparationand storageoffood;activities/ resourcestooccupythe children;researchsupportto evaluatesuccessof programme. Pointstoconsider Couldformpartofawhole schoolapproachtoimproving diet. Breakfastsandsnacksoffered needtoreflectThebalance ofgoodhealth(HEA,DHand MAFF1994)(egwholegrain cerealswithsemiskimmed milkandfruit). FreeEUinterventionstocksof fruitcouldbeuseful.Fruitis availabletoschoolsbutthis mustbeinadditiontonormal suppliesandnotusedaspart ofschoolcanteenmeals. Currently,governmentis fundingbreakfastclubsin areasofdeprivation, includingHAZs,education actionzones(EAZs)andSure Startareas,tohelptackle healthinequalities. Furtherinformation BreakfastClubs.Ahow to…guide.Kellogg’sNew PolicyInstituteand Kellogg’s.Availablefrom http://www.breakfast- Street,C.andKenway,P., 1998.Fitforschool–how breakfastclubsmeethealth educationandchildcare needs.NewPolicyInstitute. Cost£12.50. Donovan,N.andStreet,C., 1999.Foodforthought– breakfastclubsandtheir challenges.NewPolicy Institute.Cost£7.50. Reportsavailablefrom: NewPolicyInstitute,109 CoopergateHouse,16 BruneStreet,LondonE17NJ (tel:02077218421). ScottishCommunityDiet Project,c/oScottish ConsumerCouncil,Royal ExchangeHouse,100Queen Street,GlasgowG13DN (tel01412265261). Email Website: InformationonEU interventionstocksoffruit fromtheIntervention Board’sfruitandvegetable withdrawalsection (tel:01189531694).An informationsheetforschools isavailable(formHOR18). Schoolfoodpolicyguide producedbySNAG. ContactJoeHarvey,Health EducationTrust(tel/fax: 01789773915). Breakfastandafter schoolclubs Governmenthas recentlyfunded230 schoolbreakfast clubsaspartofits drivetotackle inequalitiesinhealth.
  • 37. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 34 Clubscanstimulateinterest andconfidencetodevelop cookingskillsoutofthe schoolsetting;Cookingfor Kidsreportsopportunitiesto reinforcenutritionandfood hygienelessontaughtin class,aheadstartinYear7 foodtechnology;gettingto knownewschool/teacherin advance;opportunitytobuild interestandenthusiasmfor cookingskills. Partofa‘wholeschool’ approachtohealthyeating; reinforcesthetaught curriculumonhealthyeating andoralhealth;complements thenewnutritionalstandards forschoollunches;provides idealopportunitytoincrease fruitandvegetableintakes andpromotesnackssafefor teeth. Healthytuckshops, breaktimesand vending Foodanddrinks availableatbreak timesarean importantpartofa wholeschool approachtohealthy eatingandarean idealopportunityto increasechildren’s fruitandvegetable intakes. FoodStandardsAgencyhasfunded threestudiespromotingfruitand vegetablesinschools (Andersonetal.,Universityof Dundee;Barkeretal.,Universityof Sheffield;Mooreetal.,Universityof Bristol). Localgrowers, markets, greengrocers,food cooperativesand supermarkets;LEAs; schoolcaterers,local andregionalNHSS programme coordinators;head teachersandschool governors;SNAGs; community development workers. OutcomeIntervention Cookingskills clubs Cookingandfood preparationskills compulsorywithin NationalCurriculum FoodTechnology (KeyStage1and2, optionalatKeyStage 3and4). NationalInitiativeson cookingskillsinclude CookingforKids (DfEE)forYears6 and7andFocuson Foodcookingskills bus,RetailServices Association(RSA) andWaitrose. Evidence Langetal.1999showedageneral dearthofcookingskillsinthe populationandthatschoolsarea keysettingforlearningsuchskills. FocusonFoodisbeingevaluatedby theUniversityofReading,results due2001. CookingforKidsreportedarange ofbenefitsatendoffirstyear, socialaswellaseducational (Waldon1999,unpublishedreport). Whocouldbe involved? DfEE’sCookingfor Kids;RSAand WaitroseFocuson Food;LEAs;head teachers,parentsand schoolgovernors, schoolcaterers, teachersoffood technology;local chefsrestaurateurs andshopswhomay bewillingto help/donate ingredients. Localhealthyschools programme. Skillsandresources Accesstoschoolkitchensor communitykitchens equippedforthesafeand hygienicpreparationand storageoffood;teaching staff/schoolmealsstaff willingtoparticipateoutof hours;parentsorvolunteers toassistwithsupervision; ingredientsandequipment; fundingsources(eg EducationExtra;The FoundationforAfterSchool Clubs). Adedicatedpersonto manageorderingand preparationof fruit/vegetables;facilitiesfor thesafeandhygienic storage,washingand preparationoffruitand vegetables;fortuck shops/vendingmachines, someonetomanagethe money;apricingpolicy wherefruitispurchased; stockrotationand temperatureinvending machines. Pointstoconsider Clubstakeplaceoutof schoolhoursorinholidays andformostchildrenthisisa onedayexperience. Notareplacementforregular teachingofcookingskills; canbeausefulpartofa wholeschoolapproach;for somechildrenthismaybe oneofveryfewopportunities tocook. NewNationalPlanforthe NHShasannounceda NationalSchoolFruitScheme whereeverychildinnursery andagedfourtosixyearsin infantschoolswillbeentitled toafreepieceoffruitevery schoolday(seeBreakfastand afterschoolclubs). NationalDietandNutrition Surveyofyoungpeople (Gregoryetal.2000)showed lowintakesoffruitand vegetablesandhighintakes ofconfectioneryandsoft drinks. Fruitandvegetableintakes arelowestinhouseholdson lowincomeandreceiving benefits. Furtherinformation http://www.wiredforhealth. CookingforKidsproject manual.Availablefreefrom JoeMonksatthe DepartmentofHealthtel 02079722000. FocusonFoodscampaign: focusonfood/ Tel:01422383191. BritishDieteticAssociation GiveMe5Pack Tel:01216339555. InformationonEU interventionstocksoffruit (seeBreakfastandafter schoolclubs). Schoolfoodpolicyguide producedbySNAG. ContactJoeHarvey,Health EducationTrust (tel/fax:01789773915).
  • 38. Improving diet and nutrition 35 Cookandeat Sessions Mainlylocal initiatives,some basedoriginallyon theformerGet cooking! programme. Canhelppeopleaccess affordablemeals;mayreduce socialisolation; empowermentofproject workersanddevelopmentof theirskillsbase;mayprovide pointofaccesstoother healthandsocialservices. Communitycafes Runonalocaland ‘notforprofit’basis, oftenpartofawider communitycentre offeringother services;aimto provideaffordable (notnecessarily healthy)mealsina sociableatmosphere, toreducesocial isolation. Notwelldocumented;anevaluation ofacommunitycaféinsoutheast England(Kaduskaretal.1999) couldnotdeterminewhetherthe cafewassuccessfulinitsaimof providingcheap,goodqualityfood. Outcome Sustain(2000)reportedthat suchprojectscouldincrease nutritionalknowledgeand improveskillsaslongasthe approachwasrelevantto participants’culturaland socio-economic circumstances. Evaluationsalsoreportwider healthbenefitssuchas reducingsocialisolation,and buildingselfconfidence. Mayprovideaforumin whichtodiscussotherhealth issues. InterventionEvidence Caraheretal.(1999)suggestedthat redesignedcookingandfood classeschangeddietsofyoung peopleandtheirfamilies. Agenerallackofcookingskillsin thepopulationwasfoundand confidencetocookvariedwithage andgender(Langetal.1999). Increasedselfconfidenceand esteemfoundinGetCookingin Wales(CaraherandLang1995). SaffronFoodandHealthProject (Dobsonetal.2000)suggeststhat theaimofcommunityfoodprojects mustbetogetpeopleinterested andimproveconfidenceandbasic cookingskills. Whocouldbe involved? Sessionscouldberun ingroupssuchas women’sgroups, youthclubs;church, templesorreligious settings;local cateringcolleges, andhomeeconomics teachers;LACA;local retailersorgardening andallotment schemesforproduce andingredients; healthvisitors. Skillsandresources Venue,facilitiesand equipmentforthesafeand hygienicpreparationand storageoffood;funding; ingredients;aprojectleader withpracticalfood preparationskills,food hygieneandnutritional knowledge;linkworkers/ peereducators,particularly forworkwithminorityethnic groupsoryoungpeople; budgetmanagementskills. Venue,facilitiesand equipmentforthesafeand hygienicpreparationof foods;aprojectleaderwith foodpreparationandbook keepingskills;trainingin foodpreparationandfood hygieneforvolunteersand paidstaff. Pointstoconsider Couldbeusedtoencourage intakesoffruitand vegetablesbyproviding opportunitytotastenew varieties.Mayprovideaway intoworkingwithcertain audiences(egSouthAsian women)asasocially acceptableactivity. Cafesreliantonexternal funding,andsosustainability maybeanissue;involving thecommunityin developmentseemstolead togreatersustainability; shouldberunasaproper business,complyingwith environmentalhealth(EH) andtradingstandards;local circumstancesimportant: particularlygoodforpeople whoarehomeless,lack cookingfacilitiesorare elderly/singleonlowincome. Furtherinformation Foodandlowincome(FLI) database (, ourhealthiernationin practice(OHNiP),HAZnet. SouthAsiancookingclubin LutonHAZisaBeaconSite andcanbevisitedat:http:// SaffronFoodandHealth Project: Getcookingandget shoppingpackfromSustain, £14(tel:02078371228). OK!Let’scook,Healthy Norfolk2000,£2 (tel:01603487990). Nodoshgoodnoshfrom Nightsafe,Blackburn,£1 (tel:01254587687). FLIdatabase;OHNiP; HAZnet. Justforstartersfromthe HealthEducationBoardfor Scotland(tel:0131536 5500)‘startingup’advice andrecipes. CommunityCatering Initiativesconferencereport and‘howto’information, fromCommunityHealthUK, £7.50+£1.75(p&p) (tel:01225462680). HeartbeatAwardcaterers’ guide(see‘Catering awards’). LA,EHOandtrading standards;funding couldbeavailable fromregeneration relatedinitiatives (egNewDealfor Communitiesand SingleRegeneration Budget);linkswith localsupermarkets, retailers,community ownedretailing(food cooperatives)and growingschemes; localcateringcolleges, LACA(investigatepeer educationoflocal volunteers);job centresforcaterers seekingwork.
  • 39. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 36 Community growingschemes Mayvaryfromcity farmstoallotments orschemessetupon wasteland;can increasesuppliesof affordablevegetables andfruitlocally;can belinkedtofood cooperatives; sometimessetup withan environmentalrather thanhealthagenda. Bradford‘GardeningforHealth’ project,runwithBangladeshi women.Participantsreported eatingmorefruitandvegetables, beingmoreactive,losingweight andfeelingmoreconfidenttogo outalone(HussainandRobinson 2000). Outcome Likelytobebroaderthan increasingtheavailabilityof fruitandvegetablesalone (egprovidingasocial meetingplaceinthelocal community);empowerment oflocalcommunityandskills developmentinthose runningit;BoltonFood cooperativedevelopedspin- offs,supplyingfruit tuckshopsinschoolsand deliverytotheelderly.The TowerHamletscooperative hassubsequentlydevelopeda localfarmers’market. Intervention Communityowned retailing(food cooperatives) Locallyorganised initiativesthatcan improveaccessibility tofoodssuchasfruit andvegetablesin areasthatlacklocal affordablesupplies. Insomeareasitis difficulttoaccess affordablegood qualityfruitand vegetables(PAT13 1999). Evidence EvaluationsinBoltonandinTower HamletsandStepney(Priceand Sephton1995;Ostasiewicz1997) showedincreasedavailabilityoffruit andvegetables.Itallowedpeopleto trynewfoodsataffordableprices; increasedtheconfidence,self esteemanddevelopednewskillsin thoserunningthecooperative. Whocouldbe involved? LAEHOandtrading standards;funding couldbeavailable fromregeneration- relatedinitiatives (egNewDealfor Communitiesand SingleRegeneration Budget);suppliers suchaslocal wholesalers,farmers’ marketsor communityallotment andgrowing schemes. Increasebuying powerbylinking withotherlocalfood cooperatives. Mayincreasephysicalactivity, reducesocialisolation,and buildconfidence. ParticipantsintheBradford Projectinitiallygrewfamiliar Asianvegetablesbutthen grewandstartedtoeat Britishvegetablevarieties whicharecheaper;also developedmarketable gardeningskills. Skillsandresources Venue,includinghygienic storagespaceandtransport; equipmentsuchastill,scales, float;startupcostsandfuel costs;staff,includingdrivers andabookkeeper. Startupcosts;land, equipment,storage,water supply,seeds;projectleaders withexperienceingardening/ horticulturewhowillneedto bepaid;abookkeeper;if workingwithblackand minorityethnicgroupsmay needalinkworker. Pointstoconsider Foodcooperativesarelegal entitiesandhavetorunona membershipbasis.Feesfor membershipcanhelpwith startupcosts. Commitmentofthestaffis essentialtoensuresurvival. Paymentfortheirtimemay help. Thereisaneedtocomply withtradingstandardsand EHregulations,andtosupply culturallyappropriatefoods. Foodcooperativesarenot viewedasalong-term solutionbutcanbeused alongsideotherregeneration initiativestoimproveaccess. TheNHSPlanstatesthatthe governmentwillworkwith industrytoincreaseprovision offruitandvegetablesand wherenecessarytoestablish localfoodcooperatives. Gettingaccesstolandand settingupanagreementfor itsuseoverasuitableperiod oftime;possible contaminationoflandin someareas;sharingout producebetweenparticipants and/orsellingitontofood cooperatives,farmers’ markets,communitycafes; maybeusefulinareasof regenerationwhereaccessto affordablefruitand vegetablesarepoor. Mayhelpmeetprioritiesof LA21. Furtherinformation Startyourownfoodco-op videoBoltonco-op,£15(tel: 01204360094/360095). Foodforthoughtreportand video.WolverhamptonFood Co-opsUmbrellaGroupLtd, £1(tel:01902304851). Theco-opstartuppack CWS.Availablefree(tel: 01618275349). CWSsmallgrants CommunityDividend Scheme (tel:01618275950). FLIdatabase,OHNiP, HAZnet. SandwellBeaconsite uk/ FLIdatabase. Sustainpublications: Growingfoodincities(£10); Cityharvest(£30fullreport, summary£5); tel:02078371228. FederationofCityFarmsand CommunityGardens,Starter pack(tel01179231800). LocalAgenda21 (LA21)coordinators; LAleisureor environmental services;local horticulturalcolleges. Fundingcouldbe availablefrom regenerationrelated initiatives(egNew DealforCommunities andSingle RegenerationBudget). NationalSocietyof AllotmentandLeisure GardenersLtd (tel:01536266576).
  • 40. Improving diet and nutrition 37 Communityshops andsimilarschemes Setupinresponseto closureoflocalshops onhousingestatesor inruralareas;maybe runona‘notfor profit’basis,usually byvolunteers. Communityshopsarearecent innovation,whichhavenotyet beenevaluated. Outcome Improvedaccesstoaffordable fruitandvegetables;retail outletforcommunity growingschemes; environmentalbenefitsin thatproduceisnot transportedgreatdistances; increasedsocialcapital. Intervention Farmers’markets Marketsthatallow farmersandgrowers toselldirectlyto consumers,thereby reducingtheprice. Theyareoftensetup asenvironmental initiativesandrequire producetobegrown withinacertain radiusofthemarket. Somefocuson organicproduce. Evidence Farmers’marketsoffergoodvalue formoney;provideanopportunity tobuyfresh,localproduce;give localpeopleasenseofwellbeing andbelonging;provideasocial meetingplace;andalsoplayarole inrevitalisingthelocalrural economy(Buretal.1999;Bullock 2000). Whocouldbe involved? LAandtrading standards;anylocal growers’ associations; LA21coordinator; NationalAssociation ofFarmers’Markets (tel:01225787914); SoilAssociationlocal foodlinks department (tel:01179142426). Improvedaccesstofoods suchasfruitandvegetables; usefulinruralareaswhere publictransportispoor;shop staffcandevelopmarketable skillsandgainwork experience;canbepartof neighbourhoodrenewal initiatives. Skillsandresources Staff(paidorvoluntary)to liaisewithlocalcouncil, growersandconsumers; suitablevenueinproximityto areaofneed;accessto growerswillingtoparticipate withinthelocality. Projectleaderswithretail experienceand/orbook keepingskills;driverand transporttotravelto wholesalers;fundingfrom grantsorsubsidies;suitable premiseswithstorage facilitiesandequipmentin thelocality,whichcomplies withEHandhealthand safetyregulations. Pointstoconsider Needshelpandsupportfrom LA;needtoencourage growerstoparticipate;needs publicity;anaccessiblevenue notrequiringcostlypublic transport;ensurebonafide growersonlyparticipate;may improveaccesstoretail servicesandincreasesupply ofaffordablefruitand vegetables;mayaffecttrade inlocalsmallshops. MeetsprioritiesofLA21. ‘Notforprofit’,therefore dependentongrantsor subsidies;membershipfees canhelpstartupcosts:must complywithtrading standards,EHregulations;in someareasmoreappropriate totakepeopletoshops ratherthanshopstopeople (PAT131999);couldhelp improveaccesstofruitand vegetables;maycontributeto neighbourhoodrenewal strategies. Furtherinformation TheNationalAssociationof Farmers’Marketshasalist offarmers’markets (tel:01225787914) http://www.farmersmarkets. net ‘Eco-logic’publicationson farmers’markets (tel:01225484472). TheSoilAssociationprovides trainingonsettingupand runningafarmers’market: (tel:01179142426). Howtomakeyour communityshopsucceed. CommunityEnterpriseLtd (tel:01314752345). Villageshopsandpost offices:aguideto deploymentofvillage investmenttorescue,sustain andrevive.VIRSA,£15(tel: 01305259383). Ifthevillageshopcloses… ahandbookoncommunity shops.OxfordRural CommunityCouncil,£3.50 (tel:01865883488). LA,EHdepartment andtrading standards;Village RetailServices Association(VIRSA; tel:01305259383); fundingcouldbe availablefrom regeneration-related initiatives(egNew Dealfor Communitiesand SingleRegeneration Budget). CommunityOwned Retailing:training andsupportin settingup neighbourhood shops (tel:01435883005) http://www.communi
  • 41. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 38 Supermarkettours Usuallyledbya dietitianor nutritionistwithsmall groupsofconsumers. Mayfocuson interpretingfood labelsandhealth claimsandon selectingfoodsand discussinghealthier preparationmethods. Sometimesusedwith groupswitha particularareaof interest(egdiabetes). Cateringawards Forexample, HeartbeatAwardisa nationallyrecognised butlocallyrunaward madetocaterers whoadopthealthier practices,havegood standardsoffood hygieneandoffer nonsmokingseating. UsuallyrunbyLA EHOsinpartnership withdietitiansand healthpromotion specialists. Increaseinselfreported‘healthy’ purchasesandbehaviourcompared withcontrols,onemonthafter two-hourtour,butstudywasof poorquality(Silzeretal.1994). Oneofsixschemesevaluatedby HEAin1998showedsignificantly greateruseofhealthiercatering practicesinawardholdingpremises (Patersonetal.,inpreparation). AquarterofHeartbeatAward premisesreportedincreasesinsales ofsomehealthieritemsbutsalesof lesshealthychoicestendedto remainthesame(Holdsworthetal. 1999). Greaterprovisionofsomehealthier foods,healthieroptionsandgreater commitmenttohealthyeating (Warmetal.1997). Outcome Accesstomainstreamshops andservices(PAT131999). Overcomedifficulties experiencedbypeoplein carryingheavyfruitand vegetablesfromshops. Intervention Transporttoshops schemes Canberunonalocal basisorbylinking withsupermarket chainsorlocal retailers. Evidence Casestudy HackneyCommunitytransport developedtoincreaseaccessto localactivitiesfordisabledand elderlypeople.‘Plusbuses’nowrun every30minutesonafixedroute whichlinksupthelocalhospital, daycentres,schools,shopsand othertransportinterchanges. Whocouldbe involved? Localsupermarkets andlocalchamberof commerceortrade. Maybeusefulaspartofa widerprogrammeofhealthy eatingsupermarketinitiatives, butmostneedtobe coordinatednationallyrather thanlocally. Roeetal.(1997)foundfour goodqualitysupermarket studies:threepointof purchaselabelling,onevideo feedbackwhichshowed increasesinsalesof promotedproductswhilethe studywasrunning. Betterrelationshipsbetween caterersandEHdepartment; goodpublicrelations(PR)for caterers,acommitmentto customercareandtofood hygienetraining;difficultto demonstratetheeffectofthe schemeontheoveralldietof consumers. Skillsandresources Drivers,vehiclesandfunding tosupportrunningcosts; insuranceandcompliance withsafetyregulations. Dietitian/publichealth nutritionist;goodrelationship withlocalsupermarketand abilitytoidentifyandusePR opportunities. EH,dieteticsandhealth promotionexpertiseon smokingpolicies;partnership workingskills;evaluation skills;timeforprocessing annualrenewalsinaddition tonewapplications;funding tosupportscheme;PR support. Pointstoconsider Areasthatneedtobelinked, frequencyofservices;linking withlocalretailersbus schemes. Schemesmaybeveryuseful inincreasingaccessto affordablesuppliesoffruit andvegetables. Usefulwithgroupswitha particularfocus(egdiabetics); usefultobasethetouron Thebalanceofgoodhealth (HEA,DHandMAFF1994); opportunitytomakelinks withlocalretailers. Tomaximiseimpactmaybe bestconcentratedinvenues wherethesamepeopleeat everyday(egworkplaces, prisons);needstohaveboth dieteticandEHOinput, requiresagoodworking relationshipbetweenthetwo departments;couldhelpto supportHImPsasrequiresjoint workingbetweenLAandHA trusts.Evaluationisvital,as fundersmayseekevidenceof benefitsbeforecommitting resourcestocontinuethe scheme.Thiswillalsohelpto buildevidencebasenationally. Furtherinformation CommunityTransport Association(tel:0161367 8780). FerguslieParkAccessto Shoppingprojectreport (tel:01418879650). Retailers’ownmaterials basedonThebalanceof goodhealth(HEA,DHand MAFF1994)couldbeused asaresource. HeartbeatAwardStarterpack; Acaterer’sguidetothe HeartbeatAward(packs5); HeartbeatAwardflyers(packs 50). Heartbeatawardcertificates andwindowstickers(packs 10each). Aguidetoevaluatingthe HeartbeatAward.(HEA 1998). TheHeartbeatAward:Making themostofthemedia(HEA 1996). AllHEApublicationsavailable fromMarstonBookServices (tel:01235465565). Supermarkets, nutritionistsbasedin headoffice;local press;groupswith particularinterest (egdiabetics, mothersofyoung children). Caterers,catering trainers,employers, occupationalhealth nurses;health promotionspecialists withaninterestin evaluation.
  • 42. Improving diet and nutrition 39 Promotinghealthy eatinginpre- schools,suchas familycentresrun bysocialservicesor privateday nurseries Pre-schoolanddaycarecentres werelikelytobeappropriate settingsforinterventions(Tedstone etal.1998b). Outcome Aroundaneighthofenergy, fat,andsaturatedfatinthe dietisfromthefoodeaten awayfromhome. Workplacecaterersmay prepareasignificant proportionofmealsfor regularcustomersandso haveanimportantinfluence ontheoveralldiet. Intervention Adoptionof healthiercatering practicesin workplacecatering andhighlighting ‘healthier‘choices Evidence Positiveeffectonfoodchoicesfor thedurationofinterventions modifyingrecipesorhighlighted healthierchoicesinvarietyof settings;nogoodqualitystudiesin aworkplacesetting(Roeetal. 1997);increaseinsalesoflowfat mealsintheworkplacewhen highlightedwithsymbolsonmenus andposters(Levin1996). Makingsmallchangestobest sellingdishescanbeeffectivein promotinghealthierchoices,and presentationisimportant. Promotingmenuitemsissuccessful whereparallelchoicesareonoffer (HEA1998b). Whocouldbe involved? Caterers,service staff,catering managers,chef trainers;workplace management,human resources, occupationalhealth; contractcaterers dietitians/inhouse cheftrainers; communitydietitians, PublicHealth Nutritionists, workplacehealth promotionspecialists. Increasechildcarers,children andparents’nutritional knowledge;improvemain mealprovisionandbetween mealsnacksanddrinks. Skillsandresources Sometrainingofcaterersand servicestaff;basicresearch skillstocarryoutneeds assessmentamong customers. Communitydentalstaffand communitydietitianscan providespecialistknowledge andlocaldata(egonoral healthofunderfives). Pointstoconsider Workplaceoffersamajor opportunitytogainaccessto, andcommunicatewith,a largeproportionoftheadult population;acknowledgedby governmentasauseful settingforgeneralhealth promotion. Covertchangestothemenu overallhavepotentialto benefitallcustomers, promotinghealthieroptions onlybenefitscustomersthat choosethem. Shouldextendtovending andsnackprovisionandto hospitalitycatering. Mayhelpcatererqualifyfor anHBA. Acomprehensivehealthy eatingpolicyshouldinclude allmeals,shouldconsider childrenwithspecial requirementsandshould fostergoodeatingskillsand tablemanners. Amorelimitedpolicymay notcoverbetweenmeal snacks. Furtherinformation Tippingthebalancevideo andworkshopnotes,HEA; Acaterer’sguidetothe HeartbeatAward,HEA;Dine outeatwell,leaflet,DH; Thenationalcatering initiative:promoting healthierchoices,HEA; Frameworkforaction. HealthatworkintheNHS, HEA. Thesepublicationsare availablefreefromMarston BookServices (tel:01235465565). Website: home.cfmonSureStart includesacomprehensive contactlistforunder5s agenciesandweblinks. CarolineWalkerTrust (1998).Eatingwellfor under-5sinchildcare. Practicalandnutritional guidelines.22Kindersley Way,AbbotsLangley, Hertfordshire,WD50DQ. Cost£12.95(includingp&p). Watt,R.,ed.,1999.Oral healthpromotion:aguideto effectiveworkinginpre- schoolsettings.London: HEA.Availablefreefrom MarstonBookServices (tel:01235465565). Healthpromotion specialists;LAearly yearsadviser; voluntarysector (egPre-School LearningAlliance, National Childminding Association);local SureStart programmesworking inpartnershipwith parents.
  • 43. Gregory, J.R., Collins, D.L., Davies, P.S.W., Hughes, J.M. and Clarke, P.C., 1995. National diet and nutrition survey: children aged 11⁄2 to 41⁄2 years. Vol. 1, Report of the diet and nutrition survey. London: The Stationery Office.. Gregory, J., Lowe, S., Bates, C. J., Prentice, A., Jackson, L. V., Smithers, G., Wenlock, R. and Farron, M., 2000. National diet and nutrition survey: young people aged 4 to 18 years. Vol. 1, Report of the diet and nutrition survey. London: The Stationery Office. HEA, 1992. Scientific basis of nutrition education: a synopsis of dietary reference values. London: HEA. HEA, 1996. Nutritional aspects of cardiovascular disease. London: HEA. HEA, 1998a. Deprived neighbourhoods and access to retail services: a report on work undertaken by the Health Education Authority on behalf of the Department of Health and the Social Exclusion Unit (unpublished). London: HEA. HEA, 1998b. The national catering initiative: promoting healthier choices. London: HEA. HEA, 1999. Young people and health: health behaviour in school-aged children. A report of the 1997 findings. London: HEA. HEA, 2000. Black and minority ethnic groups in England: the second health and lifestyles survey. London: HEA. HEA, DH and MAFF, 1994. The balance of good health. London: HEA. Hodgson, P., Wyles, D., Kennedy-Haynes, L. and Hunt, C., 1995. Friends with food: the development of a nutrition education programme for low income groups, 1990–1994. Huddersfield: Huddersfield Health Promotion Unit. Holdsworth, M., Haslam, C. and Raymond, N.T., 1999. An assessment of compliance with nutrition criteria and food purchasing trends in Heartbeat Award premises. Journal of Human Nutrition and Dietetics, 12, 327–335. Hussain, H. and Robinson, J., 2000. Gardening for health: evaluation. Bradford: Heartsmart and Bradford Community Environment Project. Joshipura, K.J., Ascherio, A., Manson, J.E. and Stampfer, M.J., 1999. Fruit and vegetable intake in relation to risk of ischemic stroke. Journal of the American Medical Association, 282, 1233–1239. 2.7 References Acheson, D., 1998. Independent inquiry into inequalities in health report. London: The Stationery Office. Brunner, E., White, I., Thorogood, M., Bristow, A., Curle, D. and Marmot, M., 1997. Can dietary interventions change diet and cardiovascular risk factors? A meta-analysis of randomised control trials. American Journal of Public Health, 87 (9), 1415–1422. Bullock, S., 2000. The economic benefits of farmers’ markets. London: Friends of the Earth. Bur, A.M., Jewell, T. and Rayner, K., 1999. Sussex Farmers’ Market: an evaluation of three pilot markets in Lewes. Lewes: Common Cause. Caraher, M. and Lang, T., 1995. Evaluating cooking skills classes: a report to Health Promotion Wales. Cardiff: Health Promotion Wales. Caraher, M. and Lang, T., 1999. Can’t cook, won’t cook: a review of cooking skills and their relevance to health promotion. International Journal of Health Promotion and Education, 37 (3), 89–100. Contento, I., 1995. The effectiveness of nutrition education and implications for nutrition education policy. Journal of Nutrition Education, 27, 279–418. DH, 1994. Nutritional aspects of cardiovascular disease: report of the cardiovascular review group of the Committee on Medical Aspects of Food Policy. London: The Stationery Office. DH, 1996. Low income, food, nutrition and health: report from the Nutrition Task Force. London: DH. DH, 1998. Nutritional aspects of the development of cancer: report of the working group on diet and cancer of the Committee on Medical Aspects of Food and Nutrition Policy. London: The Stationery Office. Dobson, B., Kellard, K. and Talbot, D., 2000. A recipe for success? An evaluation of a community food project. Loughborough: Centre for Research in Social Policy, Loughborough University. Ellison, R.C., Capper, A.L., Goldberg, R.J., Witschi, J.C. and Stare, F.J., 1989. The environment component changing school food service to promote cardiovascular health. Health Education Quarterly, 16, 285–297. Ellison, R.C., Goldberg, R.J., Witschi, J.C., Capper, A.L., Puleo, E.M. and Stare, F.J., 1990. Use of fat modified food products to change dietary fat intake of young people. American Journal of Public Health, 80, 1374–1376. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 40
  • 44. Improving diet and nutrition 41 Kaduskar, S., Boaz, A., Dowler, E., Meyrick, J. and Rayner, M., 1999. Evaluating the work of a community café in a town in the South East of England: reflections on methods, process and results. Health Education Journal, 58, 341–354. Kennedy, L. A., Ubido, J., Elhassan, S., Price, A. and Sephton, J., 1999. Dietetic helpers in the community: the Bolton Community Nutrition Assistants Project. Journal of Human Nutrition and Dietetics, 12, 501–512. Lang, T., Caraher, M., Dixon, P. and Carr-Hill, R., 1999. Cooking skills and health. London: HEA. Levin, S., 1996. Pilot study of a cafeteria program relying primarily on symbols to promote healthy choices. Journal of Nutrition Education, 28 (5), 282–285. Lobstein, T., 1997. If they don’t eat a healthy diet, it’s their own fault! Myths about food and low income. London: National Food Alliance. Lowe, F., 2000. The psychological determinants of children’s food preferences. Bangor: University of Wales (in press). Marmot, M., 1994. The cholesterol papers. British Medical Journal, 308, 351–352. McArthur, D., 1998. Heart-healthy eating behaviors of children following a school based intervention: a meta-analysis. Issues in Comprehensive Pediatric Nursing, 21, 35–48. McGlone, P., Dobson, B., Dowler, E. and Nelson, M., 1999. Food projects and how they work. London: Joseph Rowntree Foundation. MAFF, 1998. National food survey 1997, annual report on food expenditure, consumption and nutrient intakes. London: The Stationery Office. NHF, 1997. At least five a day – strategies to increase fruit and vegetable consumption. London: The Stationery Office/NHF. NHF, 1999. Looking to the future: making CHD an epidemic of the past. London: The Stationery Office. Ostasiewicz, L., 1997. Evaluation of Tower Hamlets food co-ops. London: Tower Hamlets Food Co-op. Paterson, K., Poulter, J., Swann, C. and Peploe, K., 2000. The effecitveness of the Heartbeat Award in England: a review. London (in preparation). PAT 13, 1999. Improving shopping access for people living in deprived neighbourhoods. London: Social Exclusion Unit. Peersman, G., Harden, A. and Oliver, S., 1998. Effectiveness of health promotion interventions in the workplace: a review. London: HEA. Price, S. and Sephton, J., 1995. Evaluation of Bolton’s food co-ops. Bolton: Community Healthcare. Rivers, K., Aggleton, P., Chase, E., Downie, A., Mulvihill, C., Sinkler, P., Tyrer, P. and Warwick, I., 2000. Setting the standard: research linked to the development of the national healthy school standard (NHSS). London: DH and DfEE. Roe, L., Hunt, P., Bradshaw, H. and Rayner, M., 1997. Health promotion interventions to promote healthy eating in the general population: a review. London: HEA. Silzer, J.S., Sheeska, J., Tomasik, H.H. and Woolcot, D.M., 1994. An evaluation of ‘Supermarket Safari’ nutrition education tours. Journal of the Canadian Dietetic Association, 55, 179–183. Sustain, 2000. Making links – a toolkit for local food projects. 2nd ed. London: Sustain: the alliance for better food and farming. Tang, J.L., Armitage, J.M., Lancaster, T., Silagy, C.A., Fowler, G.H. and Neil, H.A.W., 1998. Systematic review of dietary intervention trials to lower blood total cholesterol in free-living subjects. British Medical Journal, 316, 1213–1220. Tedstone, A.E., Aviles, M. Shetty, P. and Daniels, L.A., 1998. Effectiveness of interventions to promote healthy eating in pre-school children aged 1–5 years: a review. London: HEA. Van der Weijden, T., 1998. Economic evaluation of cholesterol related interventions in dietary practice: an appraisal of the evidence. Journal of Epidemiology and Community Health, 52, 586–594. Warm, D.L, Rushmere, A.E, Margetts, B.M, Kerridge, L. and Speller, V.M., 1997. The Heartbeat Award Scheme: an evaluation of catering practices. Journal of Human Nutrition and Dietetics, 10, 171–179. Whitaker, R.C., Wright, J.A., Koepsell, T.D., Finch, A.J. and Psaty, B.M., 1994. Randomized intervention to increase children’s selection of low-fat foods in school lunches. Journal of Paediatrics, 125, 535–540. Wood, D., Durrington, P., Poulter, N., McInnes, G., Rees, A. and Wray, R., on behalf of the British Cardiac Society, British Hyperlipidaemia
  • 45. Yu-Poth, S, 1999. Effects of the National Cholesterol Education Programs’ Step I and Step II dietary intervention programs on cardiovascular risk factors: a meta-analysis. American Journal of Clinical Nutrition, 69, 632–646. Association, British Hypertension Society and British Diabetic Association, 1998. Joint British recommendations on prevention of coronary heart disease in clinical practice. Heart, 80 (suppl 2). Coronary heart disease: guidance for implementing the preventive aspects of the NSF 42
  • 46. 3.1 Introduction There is international consensus that a physically active lifestyle is important for health and has great potential health gain (WHO/Federation of Sports Medicine 1995; US Department of Health and Human Services 1996). Physical activity has been shown to have the following benefits: • Regular physical activity or cardiorespiratory fitness decreases the risk of cardiovascular disease mortality in general and of CHD mortality in particular • The level of decreased risk of CHD attributable to regular physical activity is similar to that of other lifestyle factors, such as not smoking • Regular physical activity prevents or delays the development of high blood pressure, and exercise reduces blood pressure in people with hypertension • Physical activity is also important in controlling diabetes, regulating weight and reducing the risks of osteoporosis and colon cancer. Since there is a high rate of inactivity in the population, the majority of the population could benefit from increasing their activity. The attributable risk from inactivity for CHD is considerable. It has been estimated that in the US, 35% of CHD deaths could be attributed to inactivity (Powell and Blair 1994). Physical activity is an important element in controlling overweight and obesity (discussed in more detail in Chapter 4). 3.2 Objectives of physical activity interventions The current guideline is to achieve 30 minutes of moderate intensity activity (such as brisk walking, heavy gardening and heavy housework) on at least five days of the week (DH 1996). Walking and cycling are frequently cited as examples of how to achieve this recommendation (WHO/Federation of Sports Medicine 1995; US Department of Health and Human Services 1996). The overall prevalence of physical activity is low (see Box 3.1). Data from the 1998 Health Survey for England (Joint Surveys Unit 1999) showed that 37% of men and 25% of women met the current guidelines for activity (30 minutes of activity per day on at least five days of the Chapter 3 Increasing physical activity Increasing physical activity Box 3.1 Proportion of men and women in England meeting physical activity guidelines by age, 1998 Age (years) 16–24 25–34 35–44 45–54 55–64 65–74 75+ All ages Men 58 48 43 36 32 17 7 37 Women 32 31 32 30 21 12 4 25 Source: Joint Surveys Unit (1999) 43
  • 47. week). These levels drop with age. Participation is lower among many black and minority ethnic groups. An important step in the effective promotion of physical activity is developing strategies that encourage partnerships between a variety of professionals and community groups. Reviews of effective policy development emphasise the importance of a strong evidence base, ownership by a range of stakeholders, community involvement, needs analysis and evaluation (HEA 1995; NHF 1995; Foster 2000). For more data on the effectiveness of physical activity strategies, see Table 4.7 in Chapter 4: Reducing overweight and obesity. 3.3 Features of effective interventions A review of randomised controlled trials of physical activity promotion found some evidence that physical activity can be increased and maintained for up to two years. Interventions that encourage walking and do not require attendance at a facility appear most likely to lead to sustainable increases in physical activity (Hillsdon et al. 1999). Others have found that promoting lifestyle physical activity (eg walking) leads to similar changes in behaviour and CHD risk factors as does promoting structured, facility-based, interventions (Dunn et al. 1999). Hillsdon et al. (1999) also reported that brisk walking has the greatest potential for meeting current physical activity recommendations. Regular brisk walking can lead to the majority of health benefits associated with physical activity (Morris and Hardman 1997). Interventions aimed at modifying the environment, such as signs posted to increase stair climbing (Brownell et al. 1980; Blamey et al. 1995), have proved effective also over the short term. 3.4 Components of a local strategy 3.4.1 Healthcare interventions Interventions in healthcare settings can increase physical activity for both primary and secondary prevention (Simons-Morton et al. 1998). Long-term effects are more likely with continuing intervention and multiple intervention components such as supervised exercise, provision of equipment and behavioural approaches (Simons-Morton et al. 1998). Mixed results have been obtained on the effectiveness of primary care based interventions, but these have been shown to be moderately effective. A recent study did not find evidence of longer-term maintenance of increased levels of physical activity (Harland et al. 1999). A benefit of primary care based intervention is that it can reach a wide range of the population (Harland et al. 1999). 3.4.2 Exercise referral schemes These involve primary care staff (usually practice nurses or GPs) referring patients to leisure centres for advice and assistance in increasing physical activity. Although there is a lack of rigorous evaluation of these programmes, there is some evidence of short-term increases in the level of activity. However, there is no evidence of a sustained long-term behaviour change. Data from case studies suggest an impact on a range of parameters in a variety of people. The effectiveness of the schemes may be improved when: • Staff are trained in behaviour change strategies • Quality supervision is achieved by adequate practitioner–patient ratios • Liaison between health and leisure service personnel is established and maintained • Community based networks offer support beyond the referral period, incorporating sustained, active living (Riddoch et al. 1998). Some practitioners have expressed concerns about the amount of time and resources required to set up and run high quality referral schemes that address the needs of only a small section of the population. Targeting of appropriate referrals will be an important task where schemes are adopted. 3.4.3 Workplaces Workplaces provide an organisational structure for coordination of health programmes. However, existing research, although not conclusive, shows that it can lead to increases in physical activity (Shephard 1990; Bovell Coronary heart disease: guidance for implementing the preventive aspects of the NSF 44
  • 48. 1992; Dishman et al. 1998). A booklet is available with ideas for introducing workplace physical activity, giving examples of three case studies (Elder 1996). Some interventions to promote active commuting using written materials have shown increases in physical activity levels (Mutrie et al. 1999; see also section 3.4.7: Physically active transport). 3.4.4 Mass media In mass media interventions, the number of contacts and tailored interventions was important for increasing effectiveness but there was little impact on long-term physical activity behaviour (Marcus et al. 1998). 3.4.5 Schools Physical activity programmes in schools have been associated with a number of positive changes. Most interventions are developed as a result of collaboration between schools and external advisory and support services, in the context of local healthy schools programmes (HEA 1998a). Reviews of activity promotion in schools (Shephard et al. 1980; Simons-Morton et al. 1988; Pieron et al. 1996; Harris 1997; Sallis et al. 1990, 1993) have concluded that: • Appropriately designed, delivered and supported physical activity curriculum can enhance current levels of physical activity and can improve physical skill development • Young people benefit from access to suitable and accessible facilities and opportunities for physical activity • Interventions are likely to be more effective when young people are involved in planning programmes. A qualitative exploration of the views of young people (aged 11–15 years) shows clear gender differences, with young women less likely to engage in active pursuits. A flexible and differentiated approach to physical activity promotion may be required to meet the needs and preferences of this group (Mulvihill et al. 2000). Features of well-designed schemes [Department of Environment, Transport and the Regions (DETR) 1999] include: • Quality of teacher skills, knowledge and experience enhanced through professional education and training programmes • Differentiation in the design of interventions according to young people’s developmental and other needs • A range of enjoyable, health enhancing physical activities • A whole school approach to the promotion of physical activity, including – a physical and health education curriculum – extracurricular activities – links with the local community – safe transport routes to schools • The involvement and support of the local community • Provision of appropriate activities to meet the religious and cultural needs of people from minority ethnic groups • A mechanism to demonstrate how a school will measure increases in the levels of participation in regular physical activity. 3.4.6 Older people Physical activity promotion for older people (HEA 1995; Walters et al. 1999) should: • Provide opportunities for affordable, accessible physical activity (particularly for those least likely to take part) • Address psycho-social needs and combine fun and socialising with physical activity • Involve older people in the planning, implementation and evaluation of programmes • Address the specific needs of different groups • Address the political, social and economic barriers that discourage older people from participating Increasing physical activity 45
  • 49. • Ensure that the outdoor environment is safe and pleasant for taking exercise. Addressing the environmental and planning aspects that promote or deter physical activity is important in meeting the needs of older people. This includes factors that make older people feel unsafe, either from other people or hostile environments (Walters et al. 1999). A WHO (1996) consensus statement is available on levels of physical activity to improve health in older adults. 3.4.7 Physically active transport Transport offers potential for health enhancing physical activity. Cycling and walking can be of suitable intensity, and trips such as commuting or travel to school are regular, frequent and often of a suitable length (71% of journeys are less than five miles, and 45% less than two) (DETR 1996). Mutrie et al. (1999) found significant increases in walking to work when written interactive promotional material was used, but no increases in cycle commuting. Evidence suggests that promoting workplace based cycling requires attention to environmental factors, both in the workplace (eg cycle parking and showers) and to the road environment (eg safety). Walking and cycling to work have been shown to lead to improved health outcomes (Vuori and Oja 1999). 3.5 Reducing inequity Deprived groups are twice as likely to be sedentary as the most affluent groups (Gordon et al. 1999). A higher proportion of men in lower social classes participate in moderate or vigorous activity, but this is mainly due to occupational physical activity. The trend does not apply to women. However, a higher proportion of men and women in non-manual occupations participate in sports and leisure activities compared with those in manual occupations. The characteristics of good practice in work on physical activity and inequalities (HEA 1999a) include: • Proactive outreach work • A multidisciplinary approach • Involving the targeted communities • Developing new partnerships with professionals who have good access to ‘hard to reach’ groups. Barriers to participation in physical activity among black and minority ethnic groups tend to be similar to many of those in other groups, including lack of time and concerns about body shape. Additional barriers include racism, cultural inappropriateness (eg lack of single sex provision), the importance of family responsibilities and language issues (HEA 1997a). More single sex exercise facilities may encourage uptake among Asian women (HEA 2000). Participation in physical activity tends to be low among people with disabilities. A key issue is for people with disabilities to participate in activities that they enjoy, perceive as supportive in maintaining activities of daily living and are activities which can be incorporated easily into routine life. Activities must be: • Appropriate from a social, environmental and physiological perspective • Planned in close cooperation with the target group • Involve specialist advice where appropriate (HEA 1997b). Coronary heart disease: guidance for implementing the preventive aspects of the NSF 46
  • 50. Increasing physical activity 47 3.6 Useful sources of information about community based programmes The European Heart Network has produced a report Physical activity and cardiovascular disease prevention in the European Union. It summarises the evidence on the relationship between physical activity and cardiovascular health and provides recommendations to encourage a more active environment. ivity.pdf Europe on the move! is an information network of the European programme for the Promotion of Health-Enhancing Physical Activity (HEPA). There are many links on their website to European local initiatives with contact details. A guide for promoting walking in the community has been produced by the Finnish Rheumatism Association and links are available via this site. http://www.europe-on-the- Promotion of transport, walking and cycling in Europe: strategy directions is a web accessible document that includes useful and practical information on promoting transport walking and cycling. It suggests strategies, defines targets, and provides advice on funding, advocacy and lobbying, monitoring and evaluation. It can be accessed at the Europe on the Move site. http://www.europe-on-the- Looking to the future: making CHD an epidemic of the past (NHF 1999) reviews successes and failures of health policy in reducing high rates of CHD. Moving on: international perspectives on promoting physical activity is a report from a symposium in 1994 designed to support the Physical Activity Task Force in its role of developing a national strategy for promoting physical activity in England (Killoran et al. 1995). A community approach to behavioural change in the promotion of physical activity, published by the Center for Disease Control and Prevention (CDC), is aimed at all those interested in a community-wide strategy (central and local government, transport, health and community planners, exercise specialists and health professionals, community groups, businesses, schools, colleges and universities). pa/pahand.htm The CDC in the USA has a report entitled Physical activity and health which covers the promotion of physical activity in our daily lives. /summary.htm The CDC has also published a set of guidelines on the promotion of physical activity in children and adolescents, with guidance on the benefits and consequences of physical activity. h/physact.htm For helpful advice on active school travel projects the School Travel Advisory Group (STAG) report gives extensive recommendations for the development of active travel patterns in the school setting. These have been endorsed by DH, DETR and the DfEE. www.local-
  • 51. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 48 Table3.7Suggestedactivitiestosupportlocalaction Primarycare InterventionEvidenceOutcomeSkillsandresourcesPointstoconsiderFurtherinformation Individualpatient riskassessmentand advice Someevidenceforshort-term effectivenessbutnoevidenceof sustainability(BullandJamrozik 1998;Marcusetal.1998;Eakinet al.2000). Identificationoflevelsof activity,interventionsbased onpredictedrisk. Assessmentprotocols, tailoredadvice,responsiveto client’sneeds,knowledgeof healthimpactofphysical activityonhealth. NSFCHDrequirementto ‘identifyallpeopleat significantriskof cardiovasculardisease…and offerthemappropriateadvice andtreatmenttoreducetheir risks’(Standard4); knowledgeoflocalfacilities useful;knowledgeof messagesaboutphysical activitymaybelowamong PHCstaff;focusonactive livinglikelytobeappropriate formanypeople. Coatsetal.(1995). Counsellingfor behaviourchange Frequentprofessionalcontactis associatedwithadherence(Hillsdon etal.1999).Long-termeffectsare morelikelywithcontinuing interventionsandbehavioural approaches(Simons-Mortonetal. 1998). Sustainedbehaviourchange intargetgroup,possible reductioninriskfactors (eghypertension)intarget group. Motivationalinterviewing, goodknowledgeabout physicalactivityandlocal facilities. AvailabilityandtimeofPHC staff;mosteffectiveinthose activelycontemplating increasinglevelsofphysical activity. Harlandetal.(1999); Hillsdonetal.(1999). Physicalactivity referral Smallbutpossiblymeaningful improvementsachieved(Riddochet al.1998);noevidenceoflong-term impact. Effectivepartnershipbetween healthandleisureservices, identificationandreferralof appropriatepatients, sustainedbehaviourchanges. Collaborationwithleisure servicestrainedstaff, communitynetworksto supportpost-referral;costly, resourceintensive. Effectivenessimprovedwhen: staffaretrainedinbehaviour changestrategies,andquality supervisionisachievedby adequatepatient/practitioner ratios;opportunitiesfor targetinggroupswithclinical conditionsputtingthemat risk. Riddochetal.(1998). Whocouldbe involved? PHCstaff. PHCstaff, physiotherapists, leisureprofessionals. GP,PHCstaff,leisure servicepersonnel, HLCstaff.
  • 52. Increasing physical activity 49 Intervention Promotionofactive transport Thisincludeswalking toschool (egWalkingbuses) andwalking/cycling towork. Evidence Walkingisakeyinterventionto promoteactivelifestyles(Morrisand Hardman1997).Environmental changesareimportanttofacilitate itsuptake.Areasthatpromotethe needsofcyclistsandpedestrians haveaboveaverageuseofthese modes(egYorktransportpolicy: HouseofCommons1996). Outcome Reduceddangerto pedestrians/cyclistsby encouraginggreateractive transport;modalshift towardsthesetransport choices. Skillsandresources Crosssectionalfinancing throughHImPspossible;skills –jointworking,targetsetting andplanning. Pointstoconsider Productionofalocal transportplan(LTP)isa requirementforLAs; promotionofcyclingand walkingisencouraged,asis jointworkingwithHAs,HImP coordinatorsandothers. Schemesaddressingdanger fromvehicles(eg20mph zones)haveshowndramatic accidentreductionoutcomes (61%dropinpedestrian casualtiesanda67%dropin childpedestrianandcyclists casualties;Websterand Mackie1996). Furtherinformation HEA(1998c,1999b,c); DETR(1999,2000).Free copiesofthelatter(School travelstrategiesandplans.A bestpracticeguideforlocal authorities)areavailable,tel: 08701226236(quoting: 99ASCS0240A). WHO(1998);website: pamphlets Whocouldbe involved? Transport LAs,education services;business; nongovernmental organisations(NGOs); localroadsafety officers;police; LA21.
  • 53. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 50 Intervention NHSS,‘whole school’approach Schooltravelplans [includingSafer RoutestoSchool (SRTS)] Evidence Positiveoutcomeshavebeen reportedfollowingimplementation ofphysicalactivityprogrammesin schools. Casestudieshaveshownincreases incycling,walkingandbususe (egWalkingbuses)(DETR2000a). Outcome Suggestsallpupilsexperience twohoursofphysicalactivity aweek;encouragesstaff, pupils,parents/carersand otheradultstobecome involvedinpromoting physicalactivity. Skillsandresources In-servicetrainingofteachers. Mayinvolvephysicalchanges toroadlayoutorschool environment;provisionof safecycleparks. Pointstoconsider Physicalactivityparticipation mayenhanceacademic performanceandencourage lifelongphysicalactivity; providespositive environmentalimpact(eg reducedcartravel);helps fulfilNationalCurriculum requirementsforscienceand physicaleducationaswellas contributestothenational frameworkforpersonal, socialandhealtheducation (PSHE). Schooltravelplansare supportedbyIntegrated TransportWhitePaper(DETR 1998);canbeincorporated intoalocaltransportplan; linkstolocalenvironmental concerns(Community Strategy,LA21). Furtherinformation TheNHSSidentifiescriteria onphysicalactivitytoinform goodpracticeandthe implementationofa‘whole school’approach(NHSS 2000). NHSSsupportmaterialon physicalactivityforprimary andsecondaryschools; NHSSphysicalactivity,DH andDfEE(2000).London: HDA. BritishHeartFoundation (BHF)(2000). http://www.wiredforhealth. TheSTAGreportisavailable at:http://www.local- travel/index.htm#1998- 1999report DETRSchoolTravelPlanBest PracticeGuide: http://www.local- ravel/bpgla/index.htm SchoolTravelStrategiesand PlansCaseStudiesReport canbeaccessedat: http://www.local- travel/bpgla/casestudies/index .htmInthisguide,detailsare providedforurbanandrural schools. SustransSRTScanbe accessedat: f_srs.htm Whocouldbe involved? Staff,pupils,local educationauthority (LEA),healthyschools network,leisure services,transport department,NGOs (egSustrans). Schools Improvedenvironmentfor cyclingandwalking;changes inuseofmotorisedtravelto school;reducedroaddanger. Staff,pupils,parents, localtransport planners,NGOs (Sustrans),school governors.
  • 54. Increasing physical activity 51 Intervention ’Green‘transport plans(GTPs) Stairusepromotion Evidence Schemestopromotewalkingto workcanbeeffective(Walkinto workout,Mutrieetal.1999); changesintravelmodeswhenGTPs havebeenimplemented. Promotionofstairusewaseffective inGlasgow,usingposters(Blamey etal.1995). Outcome Percentageofemployerswith developedtransportplans; changesinworkplacetravel. Skillsandresources Providesafeparkingfor bicyclesandshowers. Pointstoconsider NSFCHDmilestone:‘ByApril 2002everylocalhealth communitywill…have developed“green”transport plans’(milestone3). PromotionofGTPsneednot beconfinedtohealthservice sites.Workplacecycling promotioninparticular requiresenvironmental changes(intheworkplace andontheroad). Cheapintervention; objectivesalliedwith environmentalconcerns (reductioninuseof electricity). Furtherinformation Transport2000(1998). DETRadviceforgovernment departments:‘green transportguide’ http://www.environment. gcont.htm DETR(1999,2000b).Free copiesofthelatter(School travelstrategiesandplans.A bestpracticeguideforlocal authorities)areavailable,tel: 08701226236(quoting: 99ASCS0240A). WHO(1998);website: pamphlets Whocouldbe involved? Staff,unions,local transportplanners, localpublictransport providers. Workplaceinterventions Stairusetobecomethe norm;increasedprominence ofstairsinbuildingdesign comparedtolifts/escalators; increaseduseofstairs. Staff,unions, employers,architects.
  • 55. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 52 Intervention Promotinguseof facilities Theseincludeleisure andsportscentres, communitycentres, andlocalcommunity interventionsfor minoritygroups. Evidence Accessandcostareimportant determinantsformanygroups. Involving‘hardtoreach’groupsis likelytoincreaseuptakeand appropriatenessofprojects. OutcomeSkillsandresources Auditandevaluationskills, translation,knowledgeof localfacilities;community developmentskills;separate changingareas;provisionof appropriatefacilities. Pointstoconsider Culturalandlanguageissues maybeimportant.‘Sporty’ connotationsofleisureand exercisecentrescanbeoff putting.HLCfundingis available.Projectsneedtobe additionaltostatutory provisionandinvolve communitiesindevelopment andmanagement. Furtherinformation HEA(1997a,b,1998b, 1999a). TheConfederationofIndian Organisationsrunsan exerciseprojecttoincrease levelsofwalkinginthe Asiancommunityin Leicester(contactSandeep Rohit,tel:01162259299, fordetails). Whocouldbe involved? Leisureactivities Identificationofgroupsnot participatinginlocal provision;increased participationby‘hardto reach’groups;involvementin designandrunningof projectsbyrepresentatives fromspecificlocalgroups, suchasolderpeople,black andminorityethnicgroups, youngpeople,peoplewith disabilities. Leisureservices, professionals/ communityleaders involvedwith’hard toreach‘groups, PHC,community groups,HLCs.
  • 56. Increasing physical activity 53 Intervention Healthwalksand othernon-facility basedphysical activity Integrationoflocal plans Evidence Uncertaintyaboutwhoparticipates andimpactsonotherphysically activebehaviours;11%ofthe SonningCommonpopulation;three timesmorewomenthanmen (Bartlett1998);someevidenceofa shiftfromcarjourneysto walking/cycling. Environmentimportantforinformal physicalactivity(egwalking,active play)butfrequentlynotformally evaluated. Outcome Localhealthwalks, partnershipswith transport/environment services;raisedprofileof physicalactivity;addresses somesafetyissues. Skillsandresources Mapsand/ormarkedroutes, trainedleaders. Skillsindeveloping partnershipsacrosssectors. Pointstoconsider Participantstendtobeolder andfromhighersocio- economicgroups.Consider communitygardening schemesorgardeningon prescription. LAswillhaverequirementto producecommunity strategiesandmanyhave LA21plans.Neighbourhood renewalconsultationwas publishedrecently.Supports severalsustainable developmentaims.Personal safetyisfrequentlyan importantconcernrestricting useofopenspaceandneeds tobeaddressed.Lottery funding(£125m)isavailable for‘Greenandsustainable communities’. Furtherinformation Bartlett,H.,1998.Walking thewaytohealth.BHF/ ConsumersAssociation(CA). SonningCommonHealth Walkprogrammean example(Bartlett1998). NewOpportunitiesFund (NOF)website: temp.cfm?content=envi_1 Communitystrategy consultationwebsite: http://www.local- lgbill99/pcsdraft/index.htm DETR(1999,2000b).Free copiesofthelatter(School travelstrategiesandplans.A bestpracticeguideforlocal authorities)areavailable,tel: 08701226236(quoting: 99ASCS0240A). WHO(1998);website: ment/pamphlets Whocouldbe involved? PHCstaff, environment, planningand transport professionals,leisure services,LA21. Communitystrategies/LA21/neighbourhoodrenewal Developmentofeffective intersectoralpartnerships; provisionofsafe, appropriatelybuiltdesignfor active,highqualitylifestyles. Communities,local planners,architects, developers,business, Regional Development Agencies(RDAs), governmentoffices, police.
  • 57. 3.8 References Bartlett, H., Ashley, A. and Howells, K., 1998. Evaluation of the Sonning Common health walks scheme. Oxford: Brookes University. BHF, 2000. Active school resource pack. London: BHF. Blamey, A., Mutrie, N. and Aitchison, T., 1995. Health promotion by encouraging use of stairs. British Medical Journal, 311, 289–290. Bovell, V., 1992. The economic benefits of health promotion in the workplace. London: HEA. Brownell, K.D., Stunkard, A.J. and Albaum, J.M., 1980. Evaluation and modification of exercise patterns in the natural environment. American Journal of Psychiatry, 137, 1540–1545. Bull, F.C. and Jamrozik, K., 1998. Advice on exercise from a family physician can help sedentary patients to become active. American Journal of Preventive Medicine, 152, 85–94. Coats, A., McGee, H. and Stokes. H., eds., 1995. British Association of Cardiac Rehabilitation guidelines for cardiac rehabilitation. Oxford: Blackwell Science. DETR, 1996. Vulnerable road users, Transport Committee, third report. London: The Stationery Office. DETR, 1998. A new deal for transport: better for everyone. London: DETR. DETR, 1999. School travel: strategies and plans: a best practice guide for local authorities. London: DETR. DETR, 2000a. School travel strategies and plans: case study reports. London: DETR. DETR, 2000b. Encouraging walking: advice to local authorities. London: DETR. DH, 1996. Strategy statement on physical activity. London: DH. Dishman, R.K., Oldenburg, B., O’Neal, H. and Shephard R.J., 1998. Worksite physical activity interventions. American Journal of Preventive Medicine, 15, 344–361. Dunn, A., Marcus, B., Kampert, J., Garcia, M., Kohl, H. and Blair, S. 1999. Comparison of lifestyle and structured interventions to promote physical activity and cardiorespiratory fitness: a randomised trial. Journal of the American Medical Association, 281, 327–34. Eakin, E.G., Glasgow, R.E. and Riley, K.M., 2000. Review of primary care-based physical activity intervention effectiveness and implications for practice and future research. Journal of Family Practice, 49 (2), 158–168. Elder, P., 1996. Promoting physical activity in NHS workplaces. London: NHS Executive and HEA. Foster, C., 2000. Guidelines for health-enhancing physical activity promotion programmes. Oxford: BHF Health Promotion Research Group. Gordon, D., Shaw, M., Dorling, D. and Smith, G.D., eds., 1999. Inequalities in health: the evidence presented to the independent inquiry into inequalities in health, chaired by Sir Donald Acheson. Bristol: The Policy Press. Harland, J., White, M., Drinkwater, C., Chin, D., Farr, L. and Howel, D., 1999. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. British Medical Journal, 319, 828–832. Harris, J., 1997. Physical education: a picture of health? The implementation of health related exercise in the national curriculum in secondary schools in England and Wales, doctoral dissertation. Loughborough: Loughborough University. HEA, 1995. Promoting physical activity: guidance for commissioners, purchasers and providers. London: HEA. HEA, 1997a. Physical activity ‘from our point of view’: qualitative research among South Asian and black communities. London: HEA. HEA, 1997b. Guidelines: promoting physical activity with people with disabilities. London: HEA HEA, 1998a. Young and active? Young people and health enhancing physical activity: evidence and implications. London: HEA. HEA, 1998b. Guidelines: promoting physical activity with older people. London: HEA. HEA, 1998c. Transport and health: a briefing for health professionals and local authorities. London: HEA HEA, 1999a. Physical activity and inequality: a briefing paper. London: HEA. HEA, 1999b. Making THE links: integrating sustainable transport, health and environment policies: a guide for local authorities and health authorities. London: HEA. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 54
  • 58. HEA, 1999c. Active transport: a guide to the development of local initiatives to promote cycling and walking. London: HEA. HEA, 2000. Health and lifestyle survey. London: HEA. Hillsdon, M., Thorogood, M. and Foster, C., 1999. A systematic review of strategies to promote physical activity. In: D. MacAuley, ed. Benefits and hazards of exercise, Vol. 1. London: British Medical Journal Publications, 25–46. House of Commons, 1996. Risk reduction for vulnerable road users, Transport Committee, third report. London: The Stationery Office. Joint Surveys Unit, 1999. Health survey for England, 1998. London: The Stationery Office. Killoran, A., Fentem, P. and Caspersen, C., eds., 1995. Moving on: international perspectives on promoting physical activity. London: HEA. Marcus, B.H., Owen, N., Forsyth, L.H., Cavill, N.A. and Fridinger, F., 1998. Interventions to promote physical activity using mass media, print media and information technology. American Journal of Preventive Medicine, 15, 362–378. Morris, J. N. and Hardman, A. E., 1997. Walking to health. Sports Medicine, 23, 306–332. Mulvihill, C., Rivers, K. and Aggleton, P., 2000. Views of young people towards physical activity: determinants and barriers to involvement. Health Education, 100, 190–199. Mutrie, N., Blamey, A. and Whitelaw, A., 1999. A randomised controlled trial of a cognitive behavioural intervention aimed at increasing active commuting in a workplace setting. Edinburgh: Chief Scientist’s Office of the Scottish Executive. NHF, 1995. Physical activity: an agenda for action. London: NHF. NHF, 1999. Looking to the future: making CHD an epidemic of the past. London: The Stationery Office. NHSS, 2000. National Healthy Schools Standard: physical activity. London: HDA. Pieron, M., Cloes, M., Delfosse, C. and Ledent, M., 1996. An investigation of the effects of daily physical education in kindergarten and elementary schools. European Physical Education Review, 2, 116–132. Powell, K.E. and Blair, S.N., 1994. The public health burdens of sedentary living habits: theoretical but realistic estimates. Medicine and Science in Sports and Exercise, 26, 851–856. Riddoch, C., Puig-Ribera, A. and Cooper, A., 1998. Effectiveness of physical activity promotion schemes in primary care: a review. London: HEA. Sallis, J.F., Hovell, M.F., Hofstetter, C.R., Elder, J.P., Hackley, M., Casperson, C.J. and Powell, K.E., 1990. Distance between homes and exercise facilities related to frequency of exercise among San Diego residents. Public Health Reports, 105, 179–185 Sallis, J.F., Nader, P.R., Broyules, S.L., Berry, C.C., Elder, J.P., McKenzie, T.L. and Nelson, J.A., 1993. Correlates of physical activity at home in Mexican-American and Anglo-American pre-school children. Health Psychology, 12, 390–398. Shephard, R.J., Jequier, J.-C., Lavallee, H., La Barre, R. and Rajic, M., 1980. Habitual physical activity: effects of sex, milieu, season and required activity. Journal of Sports Medicine, 20, 55–66. Shephard, R.J., 1990. Costs and benefits of an exercising versus a non-exercising society. In: C. Bouchard, R.J. Shephard, T. Stephens, J.R. Sutton and B.D. McPherson, eds. Exercise, fitness and health. Champaign, IL: Human Kinetics, 1990, 49–60. Simons-Morton, D.G., Calfas, K.J., Oldenburg, B. and Burton, N., 1998. Effects of interventions in health care settings on physical activity or cardiorespiratory fitness. American Journal of Preventive Medicine, 15, 413–430. Transport 2000, 1998. Healthy transport toolkit. London: Transport 2000. US Department of Health and Human Services, 1996. Physical activity and health: a report of the Surgeon General. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention. Vuori, P. and Oja, P., 1999. The health potential of physical activity through transport by walking and cycling: a scientific review prepared for the charter on transport, environment and health. Copenhagen: WHO. Walters, R., Cattan, C., Speller, V. and Stuckelberger, A., 1999. Proven strategies to improve older people’s health: a Eurolink Age report for the European Commission. Brussels: Eurolink Age. Webster, D.C. and Mackie, A.M., 1996. TRL report 215: review of traffic calming schemes in 20mph zones. Wokingham: Transport and Road Research Laboratory. WHO/Federation of Sports Medicine, 1995. Exercise for health: WHO/FIMS committee on physical activity for health. Bulletin of the World Health Organization, 73 (2), 135–136. Increasing physical activity 55
  • 59. WHO, 1996. Guideline series for healthy ageing: No. 1. The Heidelberg Guidelines for promoting physical activity among older persons. Geneva: WHO. WHO, 1998. Walking and cycling in the city, LAs, health and environment briefing pamphlet series no. 35. Copenhagen: WHO Regional Office for Europe. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 56
  • 60. 4.1 Introduction The prevalence of overweight and obesity has increased in the United Kingdom in recent decades (see Box 4.1). The incidence of CHD is highest in obese men and women, especially in those under 50 years old. There is a graded, increased risk of cardiovascular and total mortality in people with a body mass index (BMI) over 25 kg/m2 (Nutrition and Physical Activity Task Forces 1995). Approximately 75% of non-insulin dependent diabetic patients are overweight (Jung 1997). In women, a weight gain of about 10 kg can lead to a threefold increased risk of developing diabetes (Jung 1997). Women with a BMI over 35kg/m2 (compared with a BMI of 22 kg/m2 ) have a 93 times higher risk of diabetes and men have a 42-fold increased risk (Jung,1997). Obesity in childhood is on the increase and predicts adolescent obesity and adult obesity (Parsons et al. 1999). Adolescent obesity is associated with an increased risk of adult mortality and morbidity (Epstein 1995). Children are more likely to be obese if they have an obese parent. There are critical periods in the life course where weight gain is more likely. In women these are between the ages of 15 and 19 years, after marriage, pregnancy, the menopause and retirement. In men the categories are between ages 35 and 40 years, after marriage and after retirement. Although the causes of obesity are varied, energy intake exceeds energy expenditure for weight gain to occur. Major weight gain tends not to occur over the short-term, and an energy imbalance of only 1–2% per day can lead to the trend towards overweight and obesity seen in the UK over the years. Daily energy consumption has decreased by approximately 20% since 1970, but obesity has increased over this period of time (Prentice and Jebb 1995). The number of hours spent watching TV has increased since the 1960s and a more automated lifestyle (domestic appliances, use of a motor car) eliminates the amount of physical activity incorporated into daily life. The population is more sedentary with the result that the amount of energy expended has reduced. The prevalence of obesity is Chapter 4 Reducing overweight and obesity Reducing overweight and obesity Box 4.1 Prevalence of overweight and obesity Men % Women % Overweight (BMI 25–29.9 kg/m2 ) 45% 33% Obese (BMI >30kg/m2 ) 17% 20% Overweight or obese aged 16–24 years 27% 28% Overweight or obese aged 55–64 years 74% 69% Over last 10 years, increase in obesity Increase by 50% Increase by 42% 25% of women in unskilled occupation are obese compared with 14% of women in professional jobs. Source: Petersen et al. (1999) 57
  • 61. increasing, despite decreasing energy intake (Barlow and Dietz 1998). Losing weight is in itself beneficial to reducing CHD risk but increased cardiorespiratory fitness should also be encouraged. Normal weight men with low cardiorespiratory fitness have a greater risk of cardiovascular disease mortality than overweight or obese men who do not have low cardiorespiratory fitness (Wei et al. 1999). See box 4.2. 4.2 Objectives of weight management Prevention, identification and treatment of obesity, and sustainability of weight loss after the intervention are all important in a weight management strategy. Specifically: • To prevent an increase in prevalence of obesity in children and adults • To promote a reduction of obesity in children and adults • To support weight maintenance in young children and weight loss in children and adults • To encourage weight maintenance and prevent increases of weight in individuals who have successfully reduced their body weight. The US National Heart, Lung and Blood Institute (1998) guidelines have suggested that weight loss programmes should aim initially to reduce body weight by 10% from baseline, at a rate of one or two pounds (approximately 0.5–1 kg) a week, for six months. The Scottish Intercollegiate Guidelines Network (SIGN 1996) recommend a period of 12 weeks of weight loss followed by 12 weeks of weight stabilisation in order for energy expenditure to readjust. US guidelines for the evaluation and treatment of obesity in children (Barlow and Dietz 1998) recommend that children with a BMI greater than or equal to the 85th percentile with complications of obesity or with a BMI greater than or equal to the 95th percentile, with or without complications, should undergo evaluation and possible treatment. Determinants of weight and weight gain are multifactorial (Sherwood et al. 2000). The Pound of Prevention study concluded that exercise, fat intake and total energy intake all contribute to successful long- term control of body weight (Sherwood et al. 2000). Energy consumption must be reduced. High calorie/low volume foods should be avoided and replaced with an increase in complex carbohydrates (such as whole grain foods) and an increase in fruit and vegetables. A reduced fat intake is also an important element of a balanced healthy diet. See the sections on promoting healthy eating (Chapter 2), and increasing physical activity (Chapter 3) in this document for further details on the effectiveness of interventions for those risk factors. 4.2.1 Definitions of ‘lifestyle’ weight management interventions Behavioural therapy Cognitive behaviour modification and behavioural skills training to modify eating and physical activity habits to prevent weight regain are often used with dietary therapy. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 58 Box 4.2 Health benefits of weight reduction A 10 kg reduction in body weight can lead to the following health benefits: Mortality >20% fall in total mortality >30% fall in diabetes related deaths >40% fall in obesity-related cancer deaths Hypertension Approximately 10 mmHg systolic and diastolic blood pressure Lipids 10% total cholesterol reduction 15% low density lipoprotein cholesterol reduction 30% triglycerides reduction 7% increase in high density lipoprotein cholesterol Diabetes Fall of 50% in fasting glucose Source: Jung (1997)
  • 62. Family therapy Behavioural therapy sessions involve all members of the family rather than individual counselling of the affected member (to be used in the prevention of obesity in children specifically). Dietary therapy Two main types of dietary therapy are a low calorie diet (800–1500 kcal daily), and a very low calorie diet (less than 800 kcal of energy daily), which usually consists of a protein-enriched liquid. Exercise therapy The primary goal is to move sedentary people into an active category (even if it is moderate levels of intensity) and to move moderate level individuals into more vigorous levels. Accumulation of daily physical activity should be the key if 30 minutes at least five times a week seems unobtainable. (See Chapter 3 on Increasing physical activity for further information.) 4.3 Features of effective interventions A number of themes are emerging on what strategies are the most effective in preventing obesity. These are: to reduce sedentary behaviour in obese children; to use diet, physical activity and behavioural strategies for adults, in combination where possible; and to use maintenance strategies such as continued therapist contact. A gradual, incremental stepwise approach seems to have the most beneficial long-term effect. Evidence for the effectiveness of obesity prevention and treatment is inconclusive (Harvey et al. 2000). Where possible, the intended target group or geographic area should be consulted to establish what strategies are most appropriate and it is important to monitor the impact. Accurate recording of baseline data at the local level and the establishment of clear objectives can aid this. It is impossible to measure the impact of an intervention where the aims and objectives are too vague and multi-faceted. The overwhelming evidence is that overweight and obese people should be encouraged to integrate changes to their lifestyle over a longer period of time to maintain the benefit of initial weight loss (Tremblay et al. 1999). A combination of decreased food intake and increased physical activity is more likely to lead to sustained weight loss (Sherwood et al. 2000). • A combination of diet and physical activity (in conjunction with behavioural counselling) is probably more effective in sustaining weight loss than diet or exercise alone in adults. The type of activity does not seem important. • Family therapy is more effective than conventional diet and exercise in preventing weight gain in children (but not necessarily in treatment of obesity). Family therapy is essential in treatment with younger children. • Small, sustainable modifications in diet, exercise and communication are more effective than restrictive strategies. With small steps, the family/individual can accommodate the required lifestyle modifications. • Maintenance of weight loss interventions (self-help peer groups, relapse prevention strategies and continued therapist contact by phone and mail) may require longer-term contact to promote sustainability of weight loss. Further information is available from Glenny et al. (1997), NHS Centre for Reviews and Dissemination (1997) and Edmunds and Waters (2000). More detail can be found in Table 4.7 at the end of this chapter. Modest, regular bouts of physical activity can lead to benefits. The type of exercise is not important and short bouts of walking can cumulatively be of much benefit. Walking a mile a day for a year is equivalent in energy to that stored in 3 kg of adipose tissue (DH 1994). Habitual physical activity can also help keep weight off after weight loss has been achieved, and can reduce the threat of the post-weight-loss seesaw effect (DH 1994). Generally, it is agreed that the cumulative effect of physical activity can benefit weight loss (DH 1994) although this view has been questioned by some (Sherwood et al. 2000). Very low calorie diets are not advisable in children (Epstein 1995) and they are not effective. In terms of increasing children’s physical activity, a more active daily lifestyle should be encouraged rather than structured aerobic exercise schedules (Epstein 1995). It appears to be more effective to promote less sedentary lifestyles (with less opportunity to eat excessively while watching TV, for example) than simply attempt to increase activity. Reducing overweight and obesity 59
  • 63. Potential barriers to effective obesity management may include lack of access to appropriate support services, lack of motivation by professionals due to negative perceptions of overweight and obese people or the efficacy of treatments (Harvey et al. 2000). There is still very little information about how clinical practice in a primary care setting or the organisation of care in this area might be improved (Harvey et al. 2000). A workbook has been published by the former HEA to guide health professionals in their weight management strategies (Cowburn and Foster 1998). It provides self-learning advice in counselling approaches. 4.3.1 Skills A local assessment of the provision of weight management services will be necessary. The PCGs will be carrying out a mapping/profiling exercise. If obesity management services are not considered, an equity profile (see p78) should be part of the local assessment. Groups at greater risk of obesity and related CHD illness should be identified and targeted. A local mapping exercise can help achieve this goal (population structure by age, ethnicity, employment and housing status as well as identification of food suppliers, access to parks/leisure facilities and specialist centres). There will be a need for training of the professionals who will be delivering the services (primary care, specialist exercise and nutrition staff). This will involve providing information about what options and services are available as well as equipping them with the skills to identify, treat and manage ‘at risk’ overweight or obese people. 4.4 Reducing inequity There are socioeconomic and ethnic differences in the prevalence of obesity. There is a higher level of obesity in the more deprived groups (Gordon et al. 1999). This should be considered when planning obesity prevention and treatment interventions. Studies have shown that weight loss and prevention of weight regain are less effective in lower income groups (Jeffery and French 1997; Hardeman et al. 2000). Epidemiological evidence suggests that there are a number of groups who are most at risk of gaining weight, and subsequently of suffering from co-morbidity associated with obesity. These groups are: • South Asians • African-Caribbeans • Those living in socially deprived areas • Smokers planning to stop (need to liaise with smoking cessation planners) • People with disabilities. Identification of individuals or groups who are at risk of associated obesity co-morbidities must be an essential element of a strategy to reduce the increased prevalence of overweight or obesity. Consideration must be given to disabled people who may suffer a range of additional barriers to managing their weight and participating in weight loss programmes. There is no evidence to suggest effective interventions in this area, but training in identifying and prescribing appropriate strategies must be considered. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 60
  • 64. Reducing overweight and obesity 61 4.5 Further information There is an obesity toolkit available from the Faculty of Public Health Medicine, Tackling obesity: a toolbox for local partnership action. A number of interventions are listed by setting (community, home, school and workplace). It is divided into prevention, and weight management in the treatment of obesity (Davis et al. 2000). A copy was sent out to all directors of public health and all health promotion units. Tel: 020 7935 0243; email: A comprehensive overview of obesity will shortly be available on the web as part of the Health Care Needs Assessment Series. It covers the epidemiological data, services available and the effectiveness of interventions of the prevention and treatment of obesity in adults and children. A directory of projects of weight management compiled by the DH is available in each regional office. Three main themes emerged: that weight loss is rarely maintained, that multicomponent programmes are more successful and that regular follow up is important (Hughes and Martin 1999) . The US National Institute of Health’s Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults (National Heart, Lung, and Blood Institute 1998) is available on the web. Useful information for healthcare professionals working in obesity treatment and prevention can be located on their website. nes/obesity/ob_gdlns.htm nes/obesity/ob_home.htm The appendices in the Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults list a number of useful strategies to help treat obesity. Examples of weight goal records, food substitution ideas and food preparation leaflets, guide to behavioural change strategies and exercise programmes for gradual build up of activity/fitness are included. Consideration should be given to making this available to health professionals. nes/obesity/practgde.htm An initiative Shape up America, designed for doctors, nurses, dietitians and other health professionals, has produced guidance on treating obesity. It includes ideas for weight gain prevention and weight loss. The appendices may be a useful practical toolkit for suggested approaches and include suggestions for walking (including safety considerations and food diaries). onal/index.html The US CDC has a report entitled Physical activity and health, which covers the promotion of physical activity in our daily lives (US Department of Health and Human Services 1996). /summary.htm CDC has published a set of guidelines on the promotion of physical activity in children and adolescents, with guidance on the benefits and consequences of physical activity. There is a separate set of guidelines for the promotion of healthy eating in schools. Physical activity: h/physact.htm Nutrition: h/nutraag.htm
  • 65. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 62 Further information (continued) WHO report Obesity: preventing and managing the global epidemic (1999). The executive summary can be viewed in the publications section at There are two Cochrane reviews in progress on the prevention and treatment of obesity in childhood. Campbell et al. (2000a,b). A community approach to behavioural change in the promotion of physical activity, published by the CDC, is aimed at all those interested in a community- wide strategy (central and local government, transport, health and community planners, exercise specialists and health professionals, community groups, businesses, schools, colleges and universities). Community physical activity approach: pa/pahand.htm The International Obesity Task Force (IOTF) has a web site with many links to obesity related sites.
  • 66. Reducing overweight and obesity 63 Table4.6Suggestedactivitiestosupportlocalaction Community InterventionEvidenceOutcomeSkillsandresourcesPointstoconsiderFurtherinformation Individualweight management integratedwith population interventions Individualstrategiesmaybemost effectivealongsidewider environmentalinterventions(Jeffery 1995;NestleandJacobson2000). Increaseinaccessibleand safesettingsforthe promotionofphysicalactivity; greateraccesstoaffordable andhealthyfoodoptions. Awarenessofthe complexitiesintheaetiology ofobesityandan understandingofthe multifactorialapproachto reducingobesity. Massmediahaslimited short-termimpactonphysical activityparticipationbutmay haveanimpactin encouragingaclimateof change(Cavill1998). Smallbutsteady changeindietand activity Weightlossabout1–2lb/weekfor aperiodofsixmonths.Inthe longerterm,weightlosscanbe maintained.Womenwhodidsome formofmoderateexerciseona regularbasisgainedweightmore slowlythanthosewhowereless active(Sherwoodetal.2000). Weightreductionbyabout 10%ofbaselineweight; preventionofrelapseto previousweightlevel. Skillinencouragingpatients whomaybecome disillusionedwithslowloss. Thereiscumulativebenefitin frequent,butshortspellsof physicalactivity. Combinediet, physicalactivity andbehavioural therapy Acombinationofinterventionsis mosteffective(ClinicalEvidence 2000).Evidencesuggeststhat effectsareshortterm. Improvedlinksbetween leisurefacilities,caterers,LAs andHAs. Regularmeetingsbetween differentsectorswillbe required.Identifyleadperson ororganisation. Frequentongoingcontactis suggestedtohelpmaintain thebenefits. Whocouldbe involved? HAs,education sector,local environment planners. Primarycareteam, dietitians, behavioural therapists. Nutritionand physicalactivity experts.
  • 67. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 64 Intervention Secondary preventionin schools Use‘wholeschool’ approach(Goranet al.1999;Story 1999). Primaryprevention inschools Use‘wholeschool’ approach. Supportiveand respectfulapproach Evidence Abouta10%meanreductionin overweightwasreported(Story 1999).Younger(pre-adolescent) interventionsweremoresuccessful. Thisresultwasbasedonashort- termfollowup(mostlylessthansix months). Approachshowntobeeffective (Story1999). QualitativeinterviewsofUSchildren (Story1999);increasedadherenceif approachedinasensitivemanner. Preventincreasesinweightin alreadyoverweightchildren. Preventbecomingoverweight orobese. Buildself-confidenceandself esteem. Skillsandresources Accesstogymsandplaying fields.Childrencaneatupto twomealsperdayinschools; familiesarenottoincurthe cost(Goranetal.1999). Willrequiretrainedyouth counsellors/dietitians. Pointstoconsider Needlonger-termdatatosee whetherweightlosscanbe sustained.Potentialharmful effects(stigmatisation,eating disorders,labelling)may result.Potentialframework forPSHE. Provideaculturally appropriateintervention; includeclassroomhealth educationclasses;potential frameworkforPSHE. Beawareofadverse psychologicalimpact. Furtherinformation Moreinformationonyoung people’sattitudestodiet, healthandexercisecanbe foundat: Pubs/yp98.html Asummaryoftheside effectsoftreatmentin childrencanbefoundin (Epsteinetal.1998). Asystematicreviewon healthpromotioninschools isavailable(Lister-Sharp etal.1999).Itcanalsobe accessedontheWeb: OutcomeWhocouldbe involved? Schoolnurses, teachers,counsellors, localhealthyschools programme. Schools LAs,foodsector, leisurefacilities managers,teachers, schoolbased counsellors,youth workers/youthclubs, parents,localhealthy schoolsprogramme. Teachers,school basedcounsellors, parents,localhealthy schoolsprogramme.
  • 68. Reducing overweight and obesity 65 Intervention The‘StoplightDiet’ fortreatmentof pre-adolescent children Ithas‘red’foodsfor bestavoided,‘amber’ forfoodsthatcanbe eateninmoderation and‘green’forplentiful. Regulardaily activityinchildren; combinedietand exercise Encourageless sedentaryleisure time Familygroup sessionswith dietaryadvice,and regularvisitstoGP Evidence Youngerchildrenachievedbetter weightloss,andmaintenanceof loss(Epsteinetal.1998). Integratingregularactivityintodaily lifeismoreeffectivethanstructured aerobicexercise.Theeffectwas maintainedatatwoyearfollowup (Epsteinetal.1998). TrialofreducingTVwatching resultedindecreasedadiposity (Robinson1999).Trialofareward systemfordecreasingsedentary behaviourshowedareductionin percentageoverweight(Epsteinet al.1995). Preventedprogressiontosevere obesityinadolescencein10-and 11-year-olds(Flodmarketal.1993), butnodifferenceatone-yearfollow up. Atrialwitha10-yearfollowup showedthatinvolvementofparent andchildwasmosteffective (Epsteinetal.1998).Inclusionof masteryelement(takingcontrolof ownbehaviours)anduseof rewardswerefoundtobemore effectiveinreducingweightin children. Weightloss;modificationof eatingandexercise behaviours. Regularphysicalactivityin dailylifebecomesthenorm. Increasedactivityandless ‘snacking’time. Encouragechangesin habituallifestylebyallfamily members. Skillsandresources Leafletsondiets. Educationforparentsand childrenwillberequired. Teacherstoexplainhowto beselectiveinchoiceofTV watching;leafletstoparents aboutrecordingchild’s activities;TVmonitoring boxescouldbeconsidered. Pointstoconsider Ensurethechildhas adequatenutritionfor growth.Monitor psychologicalimpacton children. Safetyissueswithlocalurban plannersandrecreational divisiontoensuresafeplay areas. Long-termoutcomenotyet known. Onestudyshowsthatifthe childandparentare counselledseparately,better weightlossisachieved.Both areinvolvedintheprocess, butareseenapart. Self-monitoringandgoal settingpraisearesuggested. Gradualbehaviouraltherapy overalongerperiodoftime hadabetterlong-termeffect thanintensesessions(Epstein etal.1998). Furtherinformation Epstein,L.H.andSquires, S.S.,1998.TheStoplight Dietforchildren.Boston, MA:Little,BrownandCo. BHFleafletsforparents:Get kidsonthego: ications/uploaded_pdfs/activ echildren.pdf OutcomeWhocouldbe involved? Schoolbasedhealth carers(dietitiansand schoolnurses),PE teachers,family. Children School,physical education(PE) teachers,exercise specialists,family, localparksand recreationareas; localhealthyschools programme. Parents,teachers, youthworkers,local healthyschools programme. Counsellingservices, dietitians,PCGs, schoolnurses.
  • 69. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 66 Intervention Individualised adviceandrisk assessment Provideregular followupcontact. Exerciseasintegral partof intervention Encouragefriends andfamilyto accompany participant(maybea buddyschemewhere participantscanlink upwithanother memberofthe group). Energy-restricted diet(1,000–2,000 kcal/day)rather thanfatrestricted diet(22–26g/day) Specialistweight lossclinicwithina GPpractice Evidence Groupsessionsappearedmore effective(HughesandMartin1999). Sustainedweightlossinprimary caresettingsisuncommon(Hughes andMartin1999). Moderate(short-term)effectsof primarycarebasedcounsellingand interventionstailoredtoparticular needswithwrittenmaterialshada strongereffect(Eakinetal.2000). Randomisedcontrolledtrial(RCT) showedgreaterweightlossinthe energyrestricteddiet,at18month followup(ClinicalEvidence2000). Aweeklyclinic(withahealth visitor)achievedweightlossevenat aone-yearfollowup;33% achieveda10%weightreduction and6%maintainedthislossatone year(Sleath1999). Appropriatelytailored interventionsforparticular groupsleadtobetter complianceandeffective outcomes;canbeusedfor higherriskgroupssuchas ethnicminorityordisabled groups. Increasedactivityaspartof everydayliving;better balanceofenergyintakeand expenditure. Maintenanceofweightloss throughregularfollowup. Skillsandresources Linkwithlocalcommunity groupsworkingwithethnic minorities;languageskills, recognitionofculturaland religiousrequirements;see Improvingdietandnutrition (Chapter2)forinterventions. Trainingforprimarycare teamsabouttheroleof physicalactivity;see Increasingphysicalactivity (Chapter3). Trainingforhealth professionals(seeImproving dietandnutrition, Chapter2). Roominthepractice;training forahealthvisitor(which couldbesharedbetween practicesinthearea). Pointstoconsider Assessingreadinessto changeisimportantwhen recommendingaweight reductionprogramme(Dietz 1999).Identifybarriers (accesstoaffordable, nutritiousfood,childcare arrangements,openinghours offacilities). Amotivatedcoordinatorand supportiveteammayimprove outcomes. Patientsshouldbegiven choiceofactivity(including homebased)(Hillsdon1998). Exercisereferralschemescan identifysuitablecandidates andestablishthe responsibilitieswithina programmebetweenthe parties(HughesandMartin 1999),butrecruitmentand adherencemaybefairlylow andnotreachthosewith mosttogain(Hillsdon1998) Furtherinformation Aframeworkhasbeen developedthatrunsthrough thestagesofpromoting exerciseforweight managementfromassessing readinesstochangetothe processofchangeand interventions(BiddleandFox 1998). SeeImprovingdietand nutrition(Chapter2). OutcomeWhocouldbe involved? Primarycareteams, GPs,community dietitians,community (ethnicgroup)link workers,health visitors. Primarycarelevel PCGs,practice nurses,leisurefacility personnel;some healthvisitorshave thisrole. Dietitians,practice nurses. PCG,healthvisitor, communitydietitian.
  • 70. Reducing overweight and obesity 67 Intervention Frequentcontact overlongterm Provisionofhome exerciseequipment Alsosupervised exercisesessionswith simplebehavioural therapy(SBT)atone yearcomparedwith SBTandsimple exercise(Clinical Evidence2000). Commercialweight lossprogrammes Evidence Systematicreviewshowedthatany typeoffrequentcontactledtoless weightgain(ClinicalEvidence 2000).Interventionsshouldlastfor leastsixmonthsandincorporate continuingcontacttoprevent weightregain(NationalHeart,Lung andBloodInstitute1998).Faceto facecontact(housevisits)were showntobeeffectiveinreducing weightregaininoneRCT(moreso thanphoneorlettercontact) (ClinicalEvidence2000). Improvedweightlossachievedwith provisionofexerciseequipmentfor thehomecombinedwithadviceon continuousexercise(versus intermittent)(ClinicalEvidence 2000).Supervisedexercisesessions (threetimesaweekfor12weeks) plusSBTwasmoreeffectivein weightlossatoneyear,butanother foundthatsupervisedwalksora personaltrainerresultedinless weightlossthanSBTalone(Clinical Evidence2000). Evidencethatbetterweightlossis achievedingroupsettings(Davis etal.2000). Reduceweightgain. Cumulativedailyactivitycan beofbenefitinaweight controlprogrammeandcan improveadherence(Jacicic etal.1995). Improvepsychologicalwell- being.Maketheprocessof losingweightmore enjoyable. Skillsandresources Resourcestofollowupover longertimeperiodrequired (staff/phonecalls/letter); frequentorlong-termfollow upmayrequireextrapractice resources. Supervisedsessionsrequire extraresources.Liaisonwith leisurefacilitiesorlocal suppliersmaymakeiteasier toprovidehomebased equipment(considera rentingscheme?). Motivatedclassleadermay beimportant. Pointstoconsider Self-helppeergroups,self- managementtechniquesand familyorspousalinvolvement mayallbeofsomehelp (ClinicalEvidence2000). Approachcanencourage sedentarypeopletobecome moreactive.Smallerboutsof activitymayappearmore attainable.Aimto accumulateabout30minutes ofactivityperday(National Heart,LungandBlood Institute1998). Evaluationtoolsfor commercialweightloss programmesareneeded (Conley1998). FurtherinformationOutcomeWhocouldbe involved? GP,practicenurseor weightspecialist. Maintenanceofweightloss Physicalactivity advisor,counselling services.
  • 71. 4.7 References Barlow, S.E. and Dietz, W.H., 1998. Obesity evaluation and treatment: expert committee recommendations. Pediatrics, 102, E29. Biddle, S.J.H. and Fox, K.R., 1998. Motivation for physical activity and weight management. International Journal of Obesity and Related Metabolic Disorders, 22 (suppl 2), S39–S47. Campbell, K., Waters E., O'Meara, S. and Summerbell, C., 2000a. Interventions for preventing obesity in children, protocol for a Cochrane Review. In: Cochrane Library, Issue 3. Oxford: Update Software. Campbell, K., Summerbell, C., O'Meara, S. and Waters, E., 2000b. Interventions for treating obesity in children, protocol for a Cochrane Review. In: Cochrane Library, Issue 3. Oxford: Update Software. Cavill, N., 1998. National campaigns to promote physical activity: Can they make a difference? International Journal of Obesity and Related Metabolic Disorders, 22 (suppl 2), S48–S51. Clinical Evidence, 2000. Clinical evidence: a compendium of the best available evidence for effective health care. London: BMJ Books. Conley, R., 1998. The commercial sector: marketing and fitness responsibly. International Journal of Obesity and Related Metabolic Disorders, 22 (suppl 2), S55–S58. Cowburn, G. and Foster, C., 1998. Managing weight: a workbook for health and other professionals. London: HEA. Davis, A., Giles, A. and Rona, R., 2000. Tackling obesity: a toolbox for local partnership action. London: Faculty of Public Health Medicine. DH, 1994. Nutritional aspects of cardiovascular disease: report of the cardiovascular review group of the Committee on Medical Aspects of Food Policy. London: The Stationery Office. Dietz, W., 1999. How to tackle the problem early? The role of education in the prevention of obesity. International Journal of Obesity and Metabolic Disorders, 23 (suppl 4), S7–S9. Eakin, E.G., Glasgow, R.E. and Riley, K.M., 2000. Review of primary care-based physical activity intervention studies. The Journal of Family Practice, 49, 158–168. Edmunds, L. and Waters, E., 2000. Childhood obesity. In: V.A. Moyer, E.J. Elliot, R.L. Davis, R. Gilbert, T. Klassen, S. Logan, C. Mellis and K. Williams, eds. Evidence based pediatrics and child health. London: BMJ Books, 141–153. Epstein, L.H., 1995. Management of obesity in children. In: K.D. Brownell and Fairburn, C.G., eds. Eating disorders and obesity. New York: The Guilford Press, 516–519. Epstein, L.H., Valoski, A.M., Vara, L.S., McCurley, J., Wisniewski, L., Kalarchian, M.A., Klein, K.R. and Shrager, L.R., 1995. Effects of decreasing sedentary behavior and increasing activity on weight change in obese children. Health Psychology, 14, 109–115. Epstein, L.H., Myers, M.D., Raynor, H.A. and Saelens, B.E., 1998. Treatment of pediatric obesity. International Journal of Obesity and Related Metabolic Disorders, 101, 554–570. Flodmark, C.E., Ohlsson, T., Ryden, O. and Sveger, T., 1993. Prevention of progression to severe obesity in a group of obese schoolchildren treated with family therapy. Pediatrics, 91, 880–884. Glenny, A.M., O’Meara, S., Sheldon, T. A. and Wilson, C., 1997. The treatment and prevention of obesity: a systematic review of the literature. International Journal of Obesity and Related Metabolic Disorders, 21, 715–737. Goran, M.I., Reynolds, K.D. and Lindquist, C.H., 1999. Role of physical activity in the prevention of obesity in children. International Journal of Obesity and Related Metabolic Disorders, 23 (suppl 3), S18–S33. Gordon, D., Shaw, M., Dorling, D. and Davey Smith, G., eds., 1999. Inequalities in health: the evidence presented to the independent inquiry into inequalities in health, chaired by Sir Donald Acheson. Bristol: The Policy Press. Hardeman, W., Griffin, S., Johnston, M., Kinmonth, A.L. and Wareham, N.J., 2000. Interventions to prevent weight gain: a systematic review of psychological models and behavioural change methods. International Journal of Obesity and Related Metabolic Disorders, 24, 131–143. Harvey, E. L., Glenny, A., Kirk, S.F.L. and Summerbell, C.D., eds., 2000. Improving health professionals’ management and the organisation of care for overweight and obese people. Oxford: Update Software. Hillsdon, M., 1998. Promoting physical activity: issues in primary health care. International Journal of Obesity and Related Metabolic Disorders, 22 (suppl 2), S52–S54. Hughes, J. and Martin, S., 1999. The Department of Health’s project to evaluate weight management services. Journal of Human Nutrition and Dietetics, 12, 1–8. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 68
  • 72. Jacicic, J.M., Wing, R.R., Butler, B.A. and Robertson, R.J., 1995. Prescribing exercise in multiple short bouts versus one continuous bout: effects on adherence, cardiorespiratory fitness, and weight loss in overweight women. International Journal of Obesity and Related Metabolic Disorders, 19, 893–901. Jeffery, R.W., 1995. Public health approaches to the management of obesity. In: K.D. Brownell and C.G. Fairburn, eds. Eating disorders and obesity. New York: The Guilford Press, 558–563 Jeffery, R.W. and French, S.A., 1997. Preventing weight gain in adults: design, methods and one year results from the Pound of Prevention study. International Journal of Obesity and Related Metabolic Disorders, 21, 457–464. Jung, R.T., 1997. Obesity as a disease. British Medical Bulletin, 53, 307–321. Lister-Sharp, D., Chapman, S., Stewart-Brown, S. and Sowden, A., 1999. Health promoting schools and health promotion in schools: two systematic reviews. Health Technology Assessment, 3, 1–207. National Heart, Lung, and Blood Institute, 1998. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Bethesda, MD: The Evidence Report, National Institutes of Health. Nestle, M. and Jacobson, M.F., 2000. Halting the obesity epidemic: a public health policy approach. Public Health Reports, 115, 12–24. NHS Centre for Reviews and Dissemination, 1997. The prevention and treatment of obesity. Effective Health Care, 3, 1–12. Nutrition and Physical Activity Task Forces, 1995. Obesity: reversing the increasing problem of obesity in England. London: DH. Parsons, T.J., Power, C., Logan, S. and Summerbell, C.D., 1999. Childhood predictors of adult obesity: a systematic review. International Journal of Obesity and Related Metabolic Disorders, 23 (suppl 8), S1–S107. Petersen, S., Mockford, C. and Rayner, M., 1999. Coronary heart disease statistics. London: BHF. Prentice, A.M. and Jebb, S.A., 1995. Obesity in Britain: gluttony or sloth? British Medical Journal, 311, 437–439. Robinson, T.N., 1999. Reducing children’s television viewing to prevent obesity. Journal of the American Medical Association, 282, 1561–1567. Sherwood, N.E., Jeffery, R.W., French, S.A., Hannan, P.J. and Murray, D.M., 2000. Predictors of weight gain in the Pound of Prevention study. International Journal of Obesity, 24, 395–403. SIGN, 1996. Obesity in Scotland: integrating prevention with weight management, SIGN Publication No. 8. Edinburgh: SIGN. Sleath, C., 1999. Can clinically significant weight loss be achieved and sustained? An evaluation of a general practice based weight control clinic. Journal of Human Nutrition and Dietetics, 12, 28–31. Story, M., 1999. School based approaches for preventing and treating obesity. International Journal of Obesity and Related Metabolic Disorders, 23 (suppl 7), S43–S51. Tremblay, A., Doucet, E. and Imbeault, P., 1999. Physical activity and weight maintenance. International Journal of Obesity and Related Metabolic Disorders, 23 (suppl 3), S50–S54. US Department of Health and Human Services, 1996. Physical activity and health, a report of the Surgeon-General. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention. Wei, M., Kampert, J.B., Barlow, C.E., Nichaman, M.Z., Gibbons, L.W., Paffenbarger, R.S. and Blair, S.N., 1999. Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men. Journal of the American Medical Association, 282, 1547–1553. WHO, 1999. Obesity: preventing and managing the global epidemic, Technical Report Series. Geneva: WHO. Reducing overweight and obesity 69
  • 73. 5.1 Establishing a local CHD implementation team As outlined in the NSF CHD, every HA should make contact with all local NHS organisations, LAs and other partner agencies to establish an implementation team. This will work on behalf of the local health community with members representing relevant stakeholders, including users and carers (DH 2000a, Chapter 3.7, p63). Partnership working, both for strategy development and implementation will be crucial to success. 5.1.1 Milestones and goals Organisational and health promotion milestones and goals are set out on pp57–60 of the NSF CHD main report (DH 2000a). These include responsibilities for NHS organisations and LAs as employers (smoking policy, ‘green transport’ policies, and employee-friendly policies) and responsibilities for implementing the preventive aspects of the NSF. In particular, by April 2001 all NHS bodies, working closely with LAs, will have agreed and be contributing to the delivery of local programmes of effective policies (DH 2000a, p57; DH 2000b, p18) on: • Reducing smoking • Promoting healthy eating • Increasing physical activity • Reducing overweight and obesity. 5.2 Developing local delivery plans The local implementation team is responsible for producing a local delivery plan for implementing the NSF CHD. Local delivery plans should be in place and agreed by all the relevant players by October 2000 (DH 2000a, Chapter 3.38, p70). The key elements of NSF CHD delivery are: • Identifying service developments – what needs to be done differently? • Identifying organisational and systems developments – how will the service developments be delivered? • Professional and personal development – what skills are needed and who needs them? (DH 2000a, pp 64–65). The NSF CHD should be delivered within the context of the overall HImP and the National Priorities Guidance. The plan should be consistent with the development plan for clinical governance and be reflected within the service and financial frameworks. The plans should also link and be consistent with primary care investment plans (DH 2000c), and the emerging LA community strategies. Teams should identify other local strategies and plans to which the delivery plan should be linked and map the contribution that they currently make to CHD prevention. Chapter 5 Developing a local strategy Developing a local strategy 73
  • 74. 74 It will be important to consider local plans in the context of regional health strategies. Box 5.1 identifies local initiatives which are relevant to CHD prevention. In order to develop their local implementation plans, teams need to develop partnerships, involve their local communities and assess local needs. The planning process follows a number of key stages as outlined in Figure 1. 5.3 Building effective partnerships Local implementation of the NSF CHD is intended to be partnership based. There are three broad objectives for local partnerships to prevent CHD: • improving the coordination and integration of policies (eg integration of the CHD prevention strategy with relevant health and other policies such as health at work and healthy schools policies; environmental, regeneration and leisure policies) • developing innovative and high quality services by bringing together the contributions and expertise of all partners • increasing and maximising the financial and other resources available for local services by developing joint ventures between statutory organisations, the voluntary sector and the private sector (such as healthy living centre approaches, health at work initiatives). The development of effective policies and interventions to prevent CHD requires the involvement of the NHS, LAs, voluntary organisations, businesses and the local community in the strategic reshaping of service provision. In many areas this will mean building on alliances and partnerships, which already exist. Existing local partnerships should be reviewed. They may be able to take on this responsibility, or new partnerships may need to be formed to deliver the NSF locally. 5.3.1 New freedoms to promote and support joint working New powers to enable HAs and LAs to work together more effectively came into force on 1 April 2000 (DH 2000d). Pooled budgets, integrated provision and lead commissioning are operational flexibilities, which enable services to be developed according to need, irrespective of the boundaries between organisations. Coronary heart disease: guidance for implementing the preventive aspects of the NSF Figure 1. Suggested framework for local plans. Box 5.1 Local plans and initiatives linking to CHD prevention All areas should include: • HlmP • Primary care investment plans • Community strategy • LA 21/sustainable development/environment strategy • LTP. Those areas covered by the following (eg): • HAZ • Healthy cities/health for all • HLCs • School health plans • Sports and leisure strategies • Anti-poverty strategies • Existing health topic strategies • Secondary prevention strategies (including coronary rehabilitation services, open access chest pain clinics) • Regeneration initiatives and plans (eg New Deal for Communities).
  • 75. 5.3.2 Making the partnership effective Effective partnership working should include (Geddes 1998; Plamping et al. 2000; Watson et al. 2000): • Leadership and vision – the management and development of a shared realistic vision for the partnership’s work through the creation of common goals • Involvement and commitment – the commitment of local players and particularly the involvement of communities as equal partners. Senior level commitment and involvement from NHS, LAs and other partner organisations • Resources – the contribution and shared utilisation of information, financial, human and technical resources. LAs and HAs should report the proportion of their budgets to be given to health promotion, including heart health promotion (DH 2000b, p15). Box 5.2 provides examples of a range of people and organisations who could be involved in different aspects of CHD prevention. 5.4 Involving local communities A community development approach enables communities to make their own decisions about how to achieve better health for themselves, their families and the wider community. Professionals are required to act as facilitators, rather than imposing an agenda on the community. Community development projects do not usually have a focus on disease prevention; however, many address at least one of the lifestyle risk factors for CHD and/or its broader social determinants. The NSF requires that there is at least one community development project with a focus on CHD in one of the most deprived communities in every LA area. Health visitors will be a vital resource in securing successful community development (DH 2000a, p19). HLCs, which are funded through the NOF, can provide a focus for community development initiatives ( Consulting and involving communities is a key part of government policy which service providers are required Developing a local strategy 75 Box 5.2 Who could be involved in the CHD prevention partnership? From the NHS: • Community Health NHS Trusts • Community nurses, health visitors and midwives • Hospitals and staff • GPs (Local Medical Committee and/or GP Forum) • HAs • Health promotion • Nutrition and dietetic services • Occupational health • Physiotherapy • PCGs/PCTs • Public health • Smoking cessation services • Ambulance trusts • NHS Direct • Community pharmacists From LAs: • Community development • Education • Environmental health • Highways • Housing • Leisure • LA 21 • Regeneration and planning • Social care services • Schools • Transport, roads and highways • Youth and community services From the voluntary sector: • Local voluntary organisations with a remit for CHD prevention or which address relevant CHD risk factors • Local voluntary organisations who have links with local target groups (eg groups who work with older people, black and minority ethnic groups) From the local community: • Schools and colleges • Groups which work with relevant local target groups From private sector: • Food retailers and local businesses • Medium to large size local employers (for health at work policies) • Private sector leisure providers • Restaurateurs, caterers and other local food outlets • Private transport companies
  • 76. to implement and is a key part of many local initiatives (eg NHSE 1998, 1999; DETR 2000). Involving local communities in developing strategies and action plans improves the quality and effectiveness of programmes (Nichols 1999). Local communities should be actively involved in CHD partnerships at every stage to include strategy development, action planning, delivery and review and evaluation. Local people are able to provide insights into the nature of health and social issues and the appropriateness and acceptability of policies and strategies (Rogers et al. 1997). Actively involving local communities in needs assessment research processes, ensuring their representation within planning and management arrangements and providing training and resources for volunteers and local networks are key factors for success in initiatives to improve health and well being (Gillies 1998). 5.4.1 Consulting local communities The Audit Commission (1999) has identified principles of good practice in this area. Consultation should: • Be related to a decision that the organisations intend to take • Have clear objectives • Be competently carried out • Be inclusive • Be used in practice. Effective consultation is not easy to achieve. It needs to be carefully planned, effectively carried out and thoughtfully used. Communities contain many different interests and interest groups and it is important to try to establish whom a representative is representing, and to whom in the community the representative is accountable. Findings from community consultations have to be balanced with other factors such as other stakeholder priorities, available resources and statutory requirements. There are many different consultation methods, each with their own advantages and disadvantages. These include: meetings, surveys, focus groups, user groups, citizens’ juries, citizens’ panels, neighbourhood fora, youth councils, community visioning/mapping exercises, and participatory appraisal and participatory action research. A broad spectrum of approaches should be used and selection of those which are relevant to the purpose of the consultation, and suitable for those who are being consulted, is recommended. Public participation and consultation occurs at different levels, and the degree of control local people experience relates to the level of involvement (see Box 5.3). When planning community consultation it is important to: • Identify information from consultation that has already taken place through existing initiatives such as LA 21 • Work with other partners to agree a joint approach to consultation and to agree the most appropriate methods (this will avoid consultation overload, and make the best use of available resources) • Present the exercise realistically to avoid raising unrealistic expectations • Plan feedback to the participants. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 76 Box 5.3 Level of involvement Less involvement High involvement Source: Audit Commission (1999) One off polls (eg referendum, public opinion survey) Regular surveys of views (eg panel survey) One off deliberative exercises (eg citizens’ jury, community visioning events) Ongoing consultation groups (eg neighbourhood forum)
  • 77. Once the consultation is completed consider who else would find the results useful in planning and delivering their services, and disseminate the findings accordingly. 5.4.2 Developing capacity To support effective community development and involvement, consideration needs to be given to capacity building on three levels (Russell and Killoran 1999): • Individual development • Capacity building within local groups (eg through training, support workers, skills development, administrative resources) • Developing the local community infrastructure. Capacity building enables individuals in communities to develop knowledge, skills and self-efficacy that may help them to continue to be involved with prevention initiatives and to sustain programmes and activities within the community. 5.4.3 Engaging ‘excluded’ groups As a first step it is vital that the implementation team has a clear picture of those who take part. A participation profile may include: • Demographic analysis (age, ethnicity, gender, disability) • Geographical breakdown (town, ward, enumeration district) • Economic background (employment status, occupation). Comparing this with the profile of the whole population will enable the identification of those who are not yet involved, and allow efforts to be targeted to include them. A first step is to ascertain whether there are any specific reasons preventing participation, and to address them. Reasons may include: • Language barriers • Time • Lack of awareness of the consultation or project • A feeling that ‘it isn’t for us’. Implementation teams need to know the composition of their communities and have targets and strategies to ensure they are included in the process. Capacity building will be particularly important with groups who are less likely to be involved. A traditionally ‘excluded’ group may be an appropriate focus for a community development project. 5.5 Health needs assessment Assessing local need, and profiling the local community is the first step towards developing a local delivery plan. Different areas will be at different stages. As part of the HImP and Director of Public Health’s Annual Report, many places will have well developed local needs assessment for CHD and community profiles will already have been undertaken. In other places more work will need to be done. Local Public Health and Health Promotion experts provide an important resource for local implementation groups. This guidance concentrates on prevention activities only, but consideration should be given to needs assessment as part of planning the delivery of other parts of the NSF CHD. Needs assessment is intended to inform local plans: to look at unmet need for services and to provide information that will allow services to be tailored to local populations. Successful local strategies to address CHD risk will take a broad approach to needs assessment, involving a wide range of partners and ensuring community involvement. 5.6 Community profiling A community profile describes the local area in terms of local populations (eg ethnicity, age, gender) and characteristics of the local environment (eg employers and employment; parks and open spaces; housing and estates) of importance in planning local CHD prevention strategies. Assessing health needs of the local population involves: • Defining the different ’segments‘ or target groups within their local population Developing a local strategy 77
  • 78. • Describing these different groups according to their needs and preferences using a variety of data. Target groups can be distinguished in two ways: • Geographical groups bound together by locality • Social groups bound together by some other attribute, such as age, gender, ethnic origin, health status or socio-economic status (and combinations of these). Consultation with local communities will identify factors that local people consider are important, which should be included in the profile. A well developed community profile would include local data (qualitative and quantitative) on the burden of CHD disease, and on risk factors (smoking prevalence, physical activity, diet, and weight); perceptions of health, service and facility provision and use, socio-economic information. Examples of data items to include are presented on p82 on local indicators. Where local data do not exist, risk profiles may be derived from national data sets (by applying risk profiles based on the total population to a locality). Consideration should be given to collecting missing local data, relevant to the local action plan. Sources of local data can be found in Box 5.4. As part of the development plan, identify gaps in current data which need to be filled to enable better targeting and monitoring of local implementation. 5.7 Equity profiling The incidence of CHD is not uniformly distributed among the population. CHD risk is stratified by sex, age, social class, ethnic origin, and region of residence. The NSF highlights the importance of developing a local equity profile, with equity targets. Directors of public health are charged with producing the profile. The equity profile is intended to identify inequalities in heart health and in access to preventive and treatment services. It will concentrate on the needs of individuals and groups, especially those for whom special consideration is warranted (poorer people, children, pregnant women, women of childbearing age, minority ethnic groups, other vulnerable groups). The equity profile should identify the inequalities which exist locally in terms of CHD mortality and morbidity. The equity targets are local targets to reduce these inequalities. As part of the prevention strategy equity profiling should cover smoking, nutrition, physical activity and weight management, with associated targets. 5.7.1 Audit of current provision Local needs assessment requires a comprehensive audit of activity relevant to the four areas for prevention (smoking, physical activity, nutrition and overweight and obesity). An example for physical activity is presented in Box 5.5. This type of audit will allow the identification of gaps and in conjunction with the equity profile, will identify unmet need for interventions. 5.7.2 Personal and professional development audit A local skills audit is an important aspect of needs assessment. There will be a need for appropriate personal and professional development for a wide range of people. This will include not just health professionals, but other professional groups involved in planning and delivering services (eg LA officers, teachers, social workers, youth leaders, voluntary sector staff) and members of the public involved in needs assessment and in delivering community-based programmes. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 78 Box 5.4 Local sources of data • The annual reports of the Director of Public Health • HlmPs and other local plans and profiles (eg poverty profile) • LA data sets • Socio-economic data derived from the census • Neighbourhood statistics • Regional data sets (eg health and lifestyle surveys) • Public health observatories • Local surveys (eg by LAs, HAs and local colleges or universities)
  • 79. 5.8 Monitoring progress Monitoring is a review of progress towards goals. To do this it is important to set targets and related indicators. Targets are an expression of the goals of the programme and indicators track movement towards or away from them. The NSF CHD identifies priorities and uses milestones, which set out the time by which the recommendations should be implemented. These milestones should be used to set local targets and be reflected in HImPs and other local plans. The broad performance indicators for CHD fit within the areas of the national Performance Assessment Framework (PAF) and are designed to track progress. The PAF is summarised in the main NSF document (DH 2000a, p74). There will be additional performance indicators for CHD and these are also set out in the main NSF CHD (DH 2000a, pp81–82). Chapter 1 of the NSF CHD includes a framework for the preventive aspects of the programme, and highlights data items that should be collected locally (DH 2000b, p16). A technical supplement to follow the white paper Saving lives: our healthier nation (DH 1999) is currently being drafted and will set out the scientific basis for target setting and the indicators available for the assessment of progress at both national and local level. See further sources of information on p88. Developing a local strategy 79 Box 5.5 Audit of local provision of services and facilities for physical activity Group/locality How many? Where? How accessible to group? Facilities Swimming pools Sports facilities Health clubs School facilities Community facilities Conducive environments Cycle routes/tracks Walks Parks/playing fields Other open spaces Active local groups Sports clubs Sports promotion units Primary care Health promotion Local resources Workplace facilities NHS LA Local business Source: HEA (1995)
  • 80. 80 5.8.1 Developing local targets A target is usually expressed numerically (quantitative). Targets should be feasible in the timeframe and be revised according to changes in the policy environment. They should be measurable – that is, it must be possible to measure them and to collect the required data items. There is a national target for reducing the death rate from CHD: stroke and related diseases in people under 75 years should be reduced by at least two-fifths by 2010 (DH 1999). The NSF CHD emphasises the need for intervention with other sections of the population such as children and pregnant women that will have an impact on CHD long after the 2010 deadline. Local targets can be based on national targets for CHD risk factors, modified to take into account the population profile. They can be set in terms of long-term disease risk, risk factors or be focused on areas or groups at particular risk. Local targets need to take into account past trends and performance. Baseline measures for the target in question need to be collected (although initially, national data can be adapted while local data are collected). An example, focusing on physical activity, is presented in Box 5.6. Equity targets The government intends to set national targets for reducing inequalities in health (DH 2000c). However, as discussed above, local plans should include an equity Coronary heart disease: guidance for implementing the preventive aspects of the NSF Box 5.6 Example of local targets for physical activity *The recommendation is that adults build into their daily routine half an hour of moderate intensity physical activity. Note: For each target baseline values should be established. If data exist the trend over time should be looked at to help set achievable targets. Sources of data for measuring progress should be identified, and plans made to collect missing data items. Local targets for physical activity Description Example Long-term disease or health status Mortality and morbidity A reduction in CHD mortality rates by 32% by 2010 Risk factor Relating to physical activity An increase in the proportion of the population taking the recommended amount of physical activity* to 45% by 2003 (from 37% of men and 25% of women) Process/Intermediate Policy An increase in the number of employers with more than 100 employees with a workplace physical activity policy by 20% by 2003 Groups or areas at particular risk A decrease in the proportion of Bangladeshi people who are sedentary (from 52% men and 56% of women to 30% by 2005) Access and delivery An increase in young women from X locality accessing leisure services from 10% to 20% by 2004
  • 81. profile and equity targets. Equity targets should address the wider determinants of health and specify the need for levelling up (Kendall 1998). Those setting equity targets should be aware that differential targets may be required to take account of differential causes and effects in different population groups. Improving the potential for health amongst the most vulnerable could mean a reduction in services for other sections of the population. Objectives Objectives are the methods used to achieve the targets and are usually expressed in the form of desired changes. For example, if the aim were to increase access to leisure provision, objectives could include: to set up a special bus service to take people to facilities; to make facilities available more cheaply to certain groups; and to increase opening hours. Indicators Indicators measure the movement towards or away from objectives. They are used to assess progress against baselines and for comparative purposes. A small number of indicators will be collated nationally as part of the NSF CHD, but local implementation teams will need to assess performance using a wider range of appropriate local indicators. Indicators can be based on the input, process, output and outcome (Ziglio 1996). Input measures of resources and action Process also known as formative or intermediate indicators. These relate to the implementation of the actions defined in the delivery plan. Output also known as impact indicators. These measure the immediate impact of the work on its target group. Outcome also known as summative indicators. These focus on the end product and look at the extent to which the objectives have been achieved. It is a measure of the long-term goal, such as the improvement in health status. The NSF CHD notes that most local indicators will relate to inputs and processes where it will be important to assess the level of progress, and where data can be analysed at a local level. Output indicators can also be defined and assessed locally. Outcome measures, on the whole, can be assessed only regionally and nationally, where the numbers will be large enough to show trends over time (DH 2000a, p77). All performance indicators should relate to evidence- based changes towards the achievement of the desired outcomes. Not all will be quantifiable. Indicators can be quantitative or qualitative or a combination of the two. • Quantitative indicators can use standardised measuring instruments to collect data systematically over time. The size of the effect can be measured and compared over time with baselines (Hawe et al. 1990). A list of local sources of data is presented on p78. A CD-ROM resource, Health and lifestyles guide to sources (HEA 1997) is available, which provides an overview of quantitative health and lifestyle surveys of sound methodological design available at a national level. It presents details of these surveys, indicating information that could be usefully collected at a local level and used to support policy development and planning. • Qualitative indicators assess non-quantifiable aspects of the intervention that contributed to its impact. These indicators are generally assessed through questionnaires, observational studies, interview studies, focus groups and other forms of community consultation. Qualitative indicators can be a series of criteria that need to be fulfilled in order for the intervention or programme to be deemed a success or failure. See boxes 5.7 and 5.8 on p82. Challenges in setting indicators in public health • Limited data and resources (can lead to availability driving the indicator rather than the other way around) • Setting robust indicators for non-quantifiable outputs • Need to define short-, medium- and long-term goals (health promotion is usually evaluated in the short term but the objectives are often long-term) • Attributing cause and effect – interventions are often multi-agency and multi-intervention Developing a local strategy 81
  • 82. • Changes over time may occur for reasons independent of the intervention or there may be a long chain of events between intervention and effect. 5.8.2 Monitoring frameworks A series of monitoring frameworks could be developed as a management tool for project planning. The frameworks should: • Enable the identification of the local targets in relation to the national NSF CHD goal • Specify objectives set as a contribution to the target • Outline the interventions planned to achieve it • Derive indicators to monitor change. Illustrative monitoring frameworks are provided in Table 5.9 (pp83–86). Coronary heart disease: guidance for implementing the preventive aspects of the NSF 82 Box 5.7 Checklist for setting local indicators • Define target/problem/standard or criteria • Establish aim – defined by clients or institution concerned with needs/rights • Define who is responsible for the achievement of the move towards the target • Define whose interventions are you measuring • Set a timeframe – devise framework in which the indicator is to be targeted • Assess availability and quality of data • Formulate a monitoring system to collect data • Decide on form (eg a rate of change expressed as a proportion or the setting of a standard as a way of assessing the quality of a service or interaction) • Set baseline or reference data to standardise indicator • Test indicator, if possible, or set date for review Box 5.8 Examples of indicators used in public health • Shifts in policies or practices such as policy statements • Awareness among the public, NHS and LA employees • Access to services, equity • Participation or drop out rate • Levels of client satisfaction • Changes in individual knowledge, awareness and self efficacy • Changes in behaviour • Health status, quality of life (QOL) and quality adjusted life years (QALYs) • Community changes (eg decrease in fear of local crime, reduced levels of racial or sectarian violence) • Environmental changes (eg increase in the number of cycling routes) • Partnership working (eg evidence of partnerships with the community and evidence of increased involvement over time, equitable involvement of different community groups) • Advocacy (eg unpaid media coverage, policy setting and implementation) • Quality of services eg interaction between health professional and client • Quality of life and sustainability indicators (LA 21 indicators)
  • 83. Developing a local strategy 83 NSFCHDGOALandOHNTARGETContributetothetargetreductionofdeathsfromcirculatorydiseaseofupto200,000livesintotalby2010 LOCALTARGETbasedonCOMA(1991,1994) Toincreasethe availabilityof healthierfood productstothe localpopulation OBJECTIVE Comprehensiveandregular supplyoffruitandvegetablesto allsectionsofthepopulation withlocallyorganisedinitiatives andcommunityownedretailing (foodco-ops). INTERVENTION Toreducetheaveragepercentageoftotalfoodenergyderivedbythepopulationfromsaturatedfattyacids tonomorethan10%andtotalfattonomorethan35%by2005.Toincreasetheconsumptionoffruit andvegetablestofiveportionsadayby2005. Localsurvey2000 Observation/local survey Focusgroups SOURCE 2000:54% 2001:58% 2002:62% RESULT Percentageofpeoplewhoagreethattheycanfindfruit andvegetablesatanaffordablepricelocally. Increaseinawarenessandaccesstolocallygrown producefromcommunityallotmentandgrowing schemesby10%. Increaseinproportionofcommunityownedretailing schemesestablished(eg,baseline2000:oneinfive localities;2002:oneperlocality). Evidencethatpeopleonlowincomesfindfarmers’ marketsuseful. INDICATOR Table5.9Illustrativemonitoringframeworks Toencouragethe consumptionof tasty,healthy foods,including fruitand vegetables, amonglow incomegroups Betterprovisionofadequate nutritionmessages. Percentageofthelocalpopulationwhoareabletostate correctlyatleastthreeofthefollowingwaysof achievingahealthierdiet:(1)eatlotsoffruit,vegetables orsalad,(2)cutdownonfattyorfriedfoods,eatgrilled food,(3)eatlotsoffibre,cereals,wholemealfoodand (4)eatlotsofstarchyfoodssuchasbread,potatoes, pastaorrice. Increaseinconsumptionoffruitandvegetablesand starchyfoods,decreasedconsumptionoffatsamong socialclassesIVandV. Previousnational examples: HEMS(1996,1998) NationalFoodSurvey 1996:Males14% Females17% 1998:Males15% Females17% Base:16–74yearsold
  • 84. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 84 NSFCHDGOALandOHNTARGETContributetothetargetreductionofdeathsfromcirculatorydiseaseofupto200,000livesintotalby2010 LOCALTARGET Todevelopa ‘wholeschool’ approachto healthyeating OBJECTIVE Theschoolincludeseducation onhealthiereating,practical cookingskillsandbasicfood safetypracticesinthetaught curriculum. Policyguidelinesforeating healthysnacksinschools. Provisionofbreakfastclubsin selectedschools. INTERVENTION Toreducetheaveragepercentageoftotalfoodenergyderivedbythepopulationfromsaturatedfattyacids tonomorethan10%andtotalfattonomorethan35%by2005.Toincreasetheconsumptionoffruit andvegetablestofiveportionsadayby2005. Liaisonwithlocal healthyschools programme coordinator Audit Feedbackanddata fromteachingstaff, pupils,cateringstaff andparents Observation DatafromLEAsand schools Observation/audit SOURCERESULT Anincreaseinthenumberofschoolswithapolicyon healthyeating(includingsnacks)atschool. Evidenceofreviewandefficientuseofresources. Increaseinnumberofschoolssellingfruitintuckshops to6–11yearoldsand11–16yearolds;salesdata:fruit asaproportionofallsnackitemssoldinschools. Evidencethatinitiativesaresustainable. Anincreaseinthenumberofselectedschoolswho providebreakfastclubs;anincreaseinthenumberof schoolchildreninselectedschoolswhoeatbreakfast; percentageofschoolsaddressinghealthyeatingthrough a‘wholeschool’approach. Qualityofprovision INDICATOR
  • 85. Developing a local strategy 85 NSFCHDGOALandOHNTARGETContributetothetargetreductionofdeathsfromcirculatorydiseaseofupto200,000livesintotalby2010 LOCALTARGET Toreducethe impactofheart diseaseand stroke Toincrease awarenessofthe importanceof physicalactivity forolderpeople Topromote mentalaswell asphysical wellbeingand reduceisolation OBJECTIVE Improvecommunityinvolvement andrelationsbySupportYour Neighbourhoodscheme. Homebasedprogrammewith healthvisitorwithtelephone promptingtoencouragewalking (checkeffectiveness) INTERVENTION Toimprovethehealthofpeopleaged65–75yearsbyincreasingthelengthoftheirlivesandthenumberof yearsfreefromillnessby2010. HealthSurveyfor England(annual); localsurvey/ qualitativedatafrom neighbourhoodfora. Casestudies HealthSurveyfor England(annual) Localsurvey adaptationof questions; HEMS(1998). SOURCERESULT Involvementofolderpeopleinplanning;proportionof olderpeoplewhohelpoutwith: •Mealsonwheels •Daycentresfortheelderlyrunbycouncilorvoluntary organisations •Voluntaryorganisations •Helpatanotherservice. Qualityoflifemeasurement. Evidencethatolderpeoplefeelasenseofcontroland involvementwithinitiatives. Percentageofolderpeoplewhostatethattheyareable toenjoydaytodayactivities. Percentageofolderpeoplewhofinditdifficulttoget aroundthehouseontheirown. Percentageofolderpeoplewhohavewalksthatlastfor atleast15minutesbutlessthan30minutes. INDICATOR
  • 86. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 86 NSFCHDGOALandOHNTARGETContributetothetargetreductionofdeathsfromcirculatorydiseaseofupto200,000livesintotalby2010 LOCALTARGET Toincrease thelevelof awareness amonghealth professionalson theamountand typeofphysical activityneeded forabeneftto health Source:AdaptedfromMorgan,A.andFord,K.,1998.Aseriesofhealthpromotionmonitoringframeworksforuseindemonstratingcontributiontonationaltargets:adiscussion document.Unpublished. Toincreaselevels ofphysical activity OBJECTIVE Provisionofinformationand guidancetoprofessionals. Walkintoworkoutinitiative (Mutrieetal.1999). Reviewoflocalpolicies/facilities thatencouragephysicalactivity; recommendationsforaction. INTERVENTION Increasetheproportionofthelocalpopulationwhoarephysicallyactiveatamoderateintensitylevelforat least30minutesonfiveormoredaysoftheweek(fromalocalbaseline)by20%. Previousexample: HEAEvaluationof HealthandLeisure Professionals1995, 1996,1997. Localsurveydata Localsurveydata LA21indicator information Localsurveydata SOURCE %199519961997 GP304 Practice nurse237 Leisure workers334042 Health promotion345 RESULT Percentageofhealthprofessionalsandleisureservice workerswhocorrectlyidentifytherecommended physicalactivitymessage INDICATOR Percentageofthoseinvolvedintheprogrammewho continuedtowalktoworkaftersixmonths. Decreaseintheproportionofthesedentarylocal populationby5%frombaselineof27%(men)and 28%(women). Anincreaseinthepoliciessuchaspedestrianprecincts, allowingbicyclestobetakenontrains. Thenumberandqualityofphysicalfacilitiesavailablefor physicalactivitysuchasbiketracks,walkingpaths, publicswimmingpools;increaseinthepercentageof journeysmadebywalking.
  • 87. 5.10 Further sources of information Partnerships Advice and information is available from the Health and Social Care Joint Unit in the Department of Health and information is available at Audit Commission, 1998. A fruitful partnership: effective partnership working. London: Audit Commission (may be ordered on tel: 0800 50 20 30). Geddes, M., 1998. Achieving best value through partnership. London: DETR. NHSE, 1998. Health improvement programmes: planning for better health and better health care. HSC 1998/167 LAC 98(23). London: NHS. NHSE, 1999. Planning for health and health care: incorporating guidance on health improvement programmes, service and financial frameworks, joint investment plans and primary care investment plans. HSC 1999/244 LAC 99(39). London: NHS. Plamping, D., Pratt, J. and Gordon, P., 2000. Practical partnerships for health and local authorities. British Medical Journal, 320, 1723–1725. Pratt, J., Plamping, D. and Gordon, P., 1998. Partnerships: fit for purpose?. London: King’s Fund. Russell, H. and Killoran, A., 1999. Public health and regeneration: making the links. London: HEA. Watson, J., Speller, V., Markwell, S. and Platt, S., 2000. The Verona benchmark: applying evidence to improve the quality of partnership working. International Journal of Health Promotion and Education, 7, 17–23. Best value The Audit Commission publishes a number of reports on best value. Some of these can be directly accessed through their website: Local Government Improvement and Development Agency (IDeA) has placed many resources relating to best value on line: Community and public involvement Audit Commission, 1999. Listen up! Effective community consultation. London: Audit Commission (may be ordered on tel: 0800 50 20 30). Summary and management paper available from: Useful wallchart included in the main publication but can be obtained by tel: 020 7828 1212. Cohen, J. and Emanuel, J., 2000. Positive participation: consulting and involving young people in health-related work. A planning and training resource. London: HEA. DH, 1999. Patient and public involvement in the new NHS. London: DH. DETR, 2000. Preparing community strategies: draft guidance to local authorities from the Department of Environment, Transport and the Regions. London: DETR. Local Government Improvement and Development Agency (IDeA) has placed many resources relating to best value on line. This includes a document dealing with consultation: National Consumer Council, Consumer Congress and Service First Unit, 1999. Involving users: improving the delivery of healthcare. London: Cabinet Office. National Consumer Council, Consumer Congress and Service First Unit, 1999. Involving users: improving the delivery of local public services. London: Cabinet Office. Northern and Yorkshire Region NHS Executive, 1999. NHS primary care group’s public engagement toolkit. Durham: Northern and Yorkshire Region NHS Executive. Rifkin, S., Lewando-Hundt, G. and Draper, A., 2000. Participatory approaches in health promotion and health planning. London: HDA. Service First Unit, 1999. An introductory guide: how to consult your users. London: Cabinet Office. Service first publications can be found through the Cabinet Office website: http://www.cabinet- Developing a local strategy 87
  • 88. Health needs assessment HEA, 1999. Indicators of good practice: an organisational self- assessment tool. London: HEA. Sustain, 2000. Reaching the parts. Community mapping: working together to tackle social exclusion and food poverty. London: Sustain, in association with Oxfam’s UK Poverty Programme. Indicators and monitoring Bowling, A., 1991. Measuring health: a review of quality of life measurement. Milton Keynes: Open University Press. Buck, D., Godfrey, C. and Morgan, A., 1997. The contribution of health promotion to meeting health targets: questions of measurement, attribution and responsibility. Health Promotion International, 12 (3), 239–250. Cheadle, A., Sterling, T., Schmid, T. and Fawcett, S., 1995. Evaluating community based nutrition programmes: comparing grocery store and individual level survey measures of program impact. Preventive Medicine, 24 (1), 71–79. The indicators are shown on Funnell, R., Oldfield, K. and Speller, V., 1995. Towards healthier alliances: a tool for planning, evaluating and developing healthy alliances. London: HEA. Hawe, P., Degeling, D. and Hall, J., 1990. Evaluating health promotion. Sydney: Maclennan and Petty. Kendall, L., 1998. Local inequalities targets. London: Kings Fund. Macleod Clark, J., Latter, S., Maben, J. and Franks, H., 1997. Promoting health through primary health care nursing. London: HEA. Morgan, A., Buck, D. and Godfrey, C., 1996. Performance indicators and health promotion targets. York: Centre for Health Economics, University of York. Mutrie, N., Blamey, A. and Whitelaw, A., 1999. A randomised controlled trial of a cognitive behavioural intervention aimed at increasing active commuting in a workplace setting. Edinburgh: Chief Scientist’s Office of the Scottish Executive. Ziglio, E., 1996. Indicators of health promotion policy: directions for research. In: B. Bandura and I. Kickbush, eds. Health promotion research: towards a new social epidemiology. Copenhagen: WHO Regional Office for Europe. The HDA has commissioned the Office for National Statistics to develop and validate a module of questions to measure a range of components of social capital. These questions will be used to measure social capital at a national level in the General Household Survey 2000/2001. The questions will investigate areas such as the strength of voluntary organisations, norms of neighbourliness, reciprocity and trust and infrastructure resources, community networks and attitudes to community involvement. Some HAZs are using this questionnaire in their local surveys to enable them to make comparisons between their local area and the national average. Further information on this project can be obtained from Antony Morgan (antony.morgan@hda- or Caroline Mulvihill (caroline.mulvihill@hda- at the HDA. The National Centre for Health Outcomes Development ( provides relevant data and information on measurement tools for public health. It is a key source of information on assessment of health and outcomes of health interventions at individual, HA, Hospital and Community Trust, PCG/PCT and LA levels for the English NHS and the government. The website contains information on a range of indicators relevant to CHD, for example fat consumption, mean adult BMI and smoking statistics. HEA, 1997. Health and lifestyles: guide to sources. London: HEA. A technical supplement to follow the white paper, Saving lives: our healthier nation (DH, 1999), is currently being drafted. It will suggest some measures of progress to monitor the strategy, draw together information on data sources, and signpost relevant initiatives and references which may be helpful to those involved in monitoring progress at national or at local level. A short draft version is currently available on the OHN web site, situated at (look under ‘OHN’, then ‘Technical’), which will be regularly updated and supplemented with additional material as appropriate. StatBase ® StatBase ® is an on-line database which holds a large selection of Government statistics. It also provides descriptions of all the UK Government Statistical Service’s data sources, derived analyses, all its statistical products and services and all the relevant contact points. Social Exclusion Unit, 2000. Measuring deprivation: a review of indices in common use. This Working Paper was produced to inform, and support the work of the Social Exclusion Unit’s Policy Action Team (PAT) 18 on Better information. It reviews the most commonly used deprivation measures and highlights some of the issues surrounding their use. Social Exclusion Unit, 2000. Report of PAT 18: Better information. London: The Stationery Office. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 88
  • 89. OHN indicators Data to measure progress towards OHN indicators are collected by local directors of public health. Many of these are also applicable to the NSF CHD indicators. The OHNiP database: ( holds information on a wide range of projects and initiatives that in different ways contribute to the aims of the OHN health strategy. The database can be searched by health keyword, target audience, government initiative or zone and setting. The Health Survey for England has covered cardiovascular disease (1998) and ethnic minority groups (1999), published by The Stationery Office. The full text of the CHD survey is available at http://www.official- and information on the ethnic minority survey is at In 2000 the survey will focus on older people. Health Education Monitoring Survey (HEMS) The 1998 HEMS includes a measurement of social capital. The survey contains six questions whereby a neighbourhood social capital score can be calculated (Rainford L., Mason V., Hickman M. and Morgan, A., 2000. Health in England: investigating the links between social inequalities and health. London: The Stationery Office). HAZnet: Evidence is a key feature in the work of HAZs and HAZnet works towards creating and disseminating an evidence base for new ways of working. HAZnet has a database of area-based initiatives, local evaluation projects and other research specific to HAZs, which may also be of relevance as case studies for the NSF CHD. LA 21. Local indicators of sustainable development. The DETR has recently launched a handbook, Local quality of life counts, which offers ideas for measuring sustainable development and quality of life in local communities. The handbook gives a menu of 29 indicators from which local authorities may wish to consider using a selection for reporting in their LA 21 and community strategies. A number of these indicators are also applicable to the NSF CHD. These include 15 headline indicators that are intended to make up a ‘quality of life barometer’, which will be used to measure overall progress, including success in tackling poverty and social exclusion and expected years of healthy life. The handbook also provides advice on indicator development for: • Access to key services (i.e. medical services and shops) • Mode and average distance of travel to work • Percentage of school children travelling to and from school by different modes • Recorded crime per 1,000 population, fear of crime, social participation, community well being and social and community enterprises (social capital). Neighbourhood statistics Following the recommendations of the Social Exclusion Unit’s Policy action team 18: better information, a set of standard neighbourhood statistics covering the social exclusion characteristics of a neighbourhood will be collated annually. This work will be led by the Office for National Statistics and will be coordinated across Government departments and with local government and other public, private and voluntary sector organisations who collect relevant information so as to avoid duplication and minimise costs. It is envisaged that this information will be available down to ward level. Information will be collected within nine suggested domains which include access to services, community well being/social environment, crime, economic deprivation, education, skills and training, health, housing, physical environment and work deprivation. Evaluation The HDA has produced a practical toolkit on evaluation. It outlines the purpose and principles and describes the variety of approaches to evaluation. In addition it provides guidance on quantitative and qualitative research methods, developing recommendations and dissemination of findings. This toolkit will be available on Evidence Base 2000 on the HDA website ( in autumn 2000. Funnell, R., Oldfield, K. and Speller, V., 1995. Towards healthier alliances: a tool for planning, evaluating and developing healthy alliances. London: HEA. Meyrick, J. and Sinkler, P., 1999. An evaluation resource for healthy living centres. London: HEA. Thorogood, M and Coombes, Y., 2000. Evaluating health promotion: practice and methods. Oxford: Oxford University Press. 5.11 References Audit Commission, 1999. Listen up! Effective community consultation. London: Audit Commission. DETR, 2000. Preparing community strategies: draft guidance to local authorities from the Department of the Environment, Transport and Regions. London: DETR. Developing a local strategy 89
  • 90. DH, 1999. Saving lives: our healthier nation. London: The Stationery Office. DH, 2000a. National service framework for coronary heart disease: main report. London: DH. DH, 2000b. National service framework for coronary heart disease: Chapter 1. Reducing heart disease in the population. London: DH. DH, 2000c. The NHS plan. A plan for investment. A plan for reform. London: The Stationery Office. DH, 2000d. Implementation of Health Act partnership arrangements. HSC2000/10 LAC2000/09. London: DH. Geddes, M., 1998. Achieving best value through partnership. London: DETR. Gillies, P., 1998. Effectiveness of alliances and partnerships for health promotion. Health Promotion International, 13 (2), 99–121. Hawe, P., Degeling, D. and Hall, J., 1990. Evaluating health promotion. Sydney: Maclennan and Petty. HEA, 1995. Promoting physical activity: guidance for commissioners, purchasers and providers. London: HEA. HEA, 1997. Health and lifestyles: guide to sources. CD ROM. London: HEA. Kendall, L., 1998. Local inequalities targets. London: King’s Fund. NHSE, 1998. Health improvement programmes: planning for better health and better health care. HSC 1998/167 LAC 98(23). London: NHS. NHSE, 1999. Planning for health and health care: incorporating guidance on health improvement programmes, service and financial frameworks, joint investment plans and primary care investment plans. HSC 1999/244 LAC 99(39). London: NHS. Nichols, V., 1999. The role of community involvement in health needs assessment in London. London: HEA. Plamping, D., Pratt, J. and Gordon, P., 2000. Practical partnerships for health and local authorities. British Medical Journal, 320, 1723–1725. Rogers, A., Popay, J., Williams, G. and Latham, M., 1997. Inequalities in health and health promotion: insights from the qualitative research literature. London: HEA. Russell, H. and Killoran, A., 1999. Public health and regeneration: making the links. London: HEA. Watson, J., Speller, V., Markwell, S. and Platt, S., 2000. The Verona Benchmark: applying evidence to improve the quality of partnership working. International Journal of Health Promotion and Education, 7, 17–23. Ziglio, E., 1996. Indicators of health promotion policy: directions for research. In: B. Bandura and I. Kickbush, eds. Health promotion research: towards a new social epidemiology. Copenhagen: WHO Regional Office for Europe. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 90
  • 91. This guidance has been developed in consultation with a range of professionals through a workshop and critical review. The HDA would like to thank them for their cooperation. Researched and written by Health Development Agency Hugo Crombie Public health adviser, physical activity Karen Ford Head of public health advice and learning Caroline Mulvihill Research and development specialist Lesley Owen Public health adviser, smoking Karen Peploe Public health adviser, food and nutrition Hilary Whent Head of public health advice and learning Patti White Public health adviser, smoking Tricia Younger Head of action zone development London School of Hygiene and Tropical Medicine Dalya Marks Research fellow Margaret Thorogood Reader in public health and preventative medicine Freelance consultants Isobel Bowler Health policy consultant Lynn Stockley Nutrition consultant Appendix Contributors Appendix 91
  • 92. Reviewers Waqar Ahmad Professor of primary care research, Nuffield Institute, University of Leeds Danila Armstrong Health development manager, NHS Executive, London Amanda Avery Community dietitian, Community Nutrition Group, British Dietetic Association Janet Baker Deputy regional director of public health, NHS Executive, West Midlands Clive Bates Director, Action on Smoking and Health Yve Buckland Chair, Health Development Agency Jennie Carpenter Head of public health strategy and function in and through the NHS, DH Gill Cowburn Senior researcher, Health Promotion Research Group, BHF Adam Crosier Research and development specialist, HDA Aliya Darr Research fellow, Nuffield Institute, University of Leeds Mike De Silva Policy officer, DH Nick Dean Acting head, Health Strategy Branch, DH Elizabeth Dowler Public health nutritionist, University of Warwick Laurel Edmunds Senior researcher, Health Promotion Research Group, BHF Claudette Edwards Public health adviser, black and minority ethnic groups, HDA Carl Evans CHD/smoke prevention team, DH Charlie Foster Senior researcher, Health Promotion Research Group, BHF Mollie Foxall HAZ CHD lead, Manchester Health Authority Jeff French Director of planning, partnerships and communication, HDA Alison Giles Policy development officer, NHF Madeline Garraway Public health adviser, older people, HDA Lucy Hamer Development adviser, HImPs, HDA Lesley Hammond Health promotion officer, Environmental Services Division, Wycombe District Council Dominic Harrison Regional health development specialist, HDA (northwest region) Nick Hicks Strategy unit team member, DH Melvyn Hillsdon Lecturer in health promotion, London School of Hygiene and Tropical Medicine Jane Huntley Head of workplace health, HDA Paul Lincoln Director, NHF Richard Longbottom Senior planning manager, Bradford Health Authority Jeanette Longfield Coordinator, Sustain Susan Martin Deputy branch head PH2, DH Ann McNeill Freelance consultant Dawn Milner Senior medical officer, DH Antony Morgan Head of health information, HDA Mike Rayner Director, Health Promotion Research Group, BHF Sheela Reddy Nutrition division, Food Standards Agency Imogen Sharp Branch head, CHD/stroke prevention, DH Dave Shields Health development manager, Southampton City Council Viv Speller Director of health improvement, HDA Cathy Stillman-Lowe Public health adviser, oral health, HDA Carolyn Summerbell Reader in human nutrition, School of Health, University of Teeside Catherine Swann Research and development specialist, HDA Marilyn Toft Head of schools and young people, HDA Nikki Wade Health development specialist, Cambridgeshire Health Authority Sheila Webb Consultant in public health, Bradford Health Authority Jean Woodhouse Health promotion officer, Northumberland Health Authority Lynn Young Community health adviser, Royal College of Nursing Coronary heart disease: guidance for implementing the preventive aspects of the NSF 92
  • 93. ACoP Approved Code of Practice AGPNM Association of General Practitioners of Natural Medicine ASH Action on Smoking and Health BHA British Hypnotherapy Association BHF British Heart Foundation BMEG Black and minority ethnic groups BMI Body mass index BSH British Society of Hypnotherapists CA Consumers’ Association CDC Center for Disease Control and Prevention CHD Coronary heart disease COMA Committee on the Medical Aspects of Food and Nutrition Policy DETR Department of Environment, Transport and the Regions DfEE Department for Education and Employment DH Department of Health EAZ Education action zone EH Environmental health EHO Environmental health officer EU European Union FLI Food and low income (database) GP General practitioner GSL General sales list GTP ‘Green’ transport plan HA Health authority HAZ Health action zone HDA Health Development Agency HDL High density lipoprotein HEA Health Education Authority HEMS Health education monitoring survey HEPA Health-enhancing physical activity HLC Health living centre HlmP Health improvement programme HSC Health Services Circular HSE Health and Safety Executive ICM Institute of Complementary Medicine IDeA Improvement and Development Agency IOTF International Obesity Task Force LA Local authority LACA Local Authority Caterers’ Association LA 21 Local Agenda 21 LDL Low density lipoprotein LEA Local education authority LGA Local Government Association LTP Local transport plan MAFF Ministry of Agriculture, Fisheries and Food NGO Nongovernmental organisation NHF National Heart Forum NHS National Health Service NHSE National Health Service Executive NHSS National Healthy Schools Standard NOF New Opportunities Fund NRT Nicotine replacement therapy NSF National Service Framework NSF CHD National Service Framework for Coronary Heart Disease OFSTED Office of Fair Standards and Training in Education OHN Our Healthier Nation OHNiP Our healthier nation in practice (database) OTC Over the counter Glossary Glossary 93
  • 94. PAF Performance Assessment Framework p&p Postage and packing PAT Policy action team PCG Primary care group PCT Primary care trust PE Physical education PHC Primary health care PR Public relations PSHE Personal, social and health education PTA Parent–teacher association QALY Quality adjusted life year QOL Quality of life RCT Randomised controlled trial RDA Regional Development Agency RPHNutr Registered Public Health Nutritionist RSA Retail Services Association SACN Scientific Advisory Committee on Nutrition SBT Simple behavioural therapy SCOTH Scientific Committee on Tobacco and Health SIGN Scottish Intercollegiate Guidelines Network SMAP School Meals Assessment Pack SNAG Schools Nutrition Action Group SRTS Safer routes to school STAG School travel advisory group UK United Kingdom USA United States of America VIRSA Village Retail Services Association WHO World Health Organization Coronary heart disease: guidance for implementing the preventive aspects of the NSF 94