Effects of the Heartbeat Wales programme over five years on behavioural risks for cardiovascular disease: quasi-experimental comparison of results from Wales and a matched reference area

British Medical Journal, March 14, 1998 by Chris Tudor-Smith, Don Nutbeam, Laurence Moore, John Catford

Introduction

Cardiovascular disease remains one of the major causes of morbidity and premature mortality in the United Kingdom.[1] During the 1980s a consensus evolved on the need to reduce this toll of ill health and death through population-wide preventive measures (see, for example, papers by the World Health Organisation[2] and Rose et al[3]). The Welsh Office and the existing national agency for health education, the Health Education Council, agreed to establish a community based demonstration programme in Wales directed towards reducing modifiable behavioural risks for cardiovascular disease.

The programme was publicly launched in 1985 as Heartbeat Wales with three strategic aims: leadership--to coordinate, support, initiate, and monitor action at local and regional levels which would encourage improvements in modifiable behavioural risks for prevention of cardiovascular disease; demonstration--to stimulate, disseminate, and assist the development of strategies and programmes to promote health and prevent cardiovascular disease throughout the United Kingdom; and experimentation--to research, develop, and evaluate a range of new projects and initiatives for heart health promotion and provide feedback on their feasibility and impact.[4]

Heartbeat Wales drew on the experiences of other community based risk reduction programmes for cardiovascular disease, particularly those in Finland and the United States.[5-8] The programme used a range of established health promotion methods directed towards both changing health behaviours in individuals and achieving environmental, organisational, and policy changes that support healthy choices.[9] Among the resources developed and interventions undertaken by Heartbeat Wales were television series with BBC Wales and HTV such as Don't Break your Heart, Fit far Life, and the BBC Diet Programmer "Quit and Win," a smoking cessation project; food labelling and nutrition education with a major grocery retailer; "Heartbeat Awards," a restaurant and canteen scheme to increase the availability of healthy food choices and smoke free areas; and Make Health Your Business, a worksite health promotion programme with CBI Wales.

Further details of the Heartbeat Wales intervention have been published elsewhere.[9-13] To assess behavioural outcomes of the intervention a quasi-experimental evaluation design was adopted on the basis of comparison of change in modifiable behavioural risks for cardiovascular disease in Wales with that in a reference area in the United Kingdom closest in sociodemographic and health profile to Wales at the 1981 census. The reference area selected was north east England (Tyne and Wear, Cleveland, Durham, and North Yorkshire). The Health Education Council indicated that there would be no major additional resources in that area for heart health promotion between 1985 and 1990.

Two population surveys were conducted in 1985 and 1990 in Wales and the reference area. To assist with the interpretation of the findings from these surveys, a range of other studies described elsewhere[14] was also planned for Wales but not the reference area. These studies have suggested that Heartbeat Wales achieved its basic aim of establishing a region-wide approach to the prevention of cardiovascular disease and that many of the key elements of the programme have been taken up and used elsewhere both in the United Kingdom and overseas.[4, 10-13, 15-18] It has also been shown that there were significant reductions in prevalence of smoking and improvements in food choices between 1985 and 1990 in Wales.[19] This current paper compares these and other changes in modifiable behavioural risks for cardiovascular disease in Wales with those that took place in the reference area over the same time to assess net intervention effects of the Heartbeat Wales programme.

Subjects and methods

Data were collected in random sample, cross sectional surveys during the summer and autumn of 1985 and 1990. In each survey households were selected with a multistage cluster sampling design, within 10 strata defined by the nine Welsh district health authorities and the reference area. Sample size in the 1985 survey was determined ([Alpha] = 0.05, [Beta] = 0.2) to detect a 5% change in prevalence of smoking within each strata by using a two tailed significance test. In 1990 sample size in the reference area was increased to improve the power of analyses that compared Wales with the reference area. Brief interviews were undertaken at each household, and one self completion questionnaire was then left for each resident aged 18-64. Respondents to all three surveys were asked a set of identical questions covering key health related behaviours such as smoking, diet, and physical activity as well as health knowledge and beliefs. In Wales the response rate for the household interview was 88% in 1985 and 79% in 1990 and the self completion response was 67% and 61%, respectively. In the reference area the respective figures were 84% and 77% for the household interview and 64% and 61% for the self completion questionnaire. Altogether, 31 583 questionnaires (18 538 in 1985 and 13 045 in 1990) were returned over the two surveys in Wales, with 6017 (1483 and 4534, respectively) returned in the reference area. Data were weighted before analysis by sex, age group, social class, and population distribution within each strata to minimise bias due to differential response rates between groups. Further details of survey methodology and weighting are available elsewhere.[19]