The Heartfile Lodhran CVD Prevention Project - End of Project Evaluation

Published in the journal Promotion & Education (Vol. XIV, No. 1, pp. 17-27), this report examines a community-based cardiovascular disease (CVD) project carried out in Pakistan in an effort to increase knowledge about CVDs and their prevention. Motivated by data indicating that mainstream preventive interventions often fail to reach economically poor populations with a high risk of CVDs, the non-governmental organisation (NGO)/think tank Heartfile partnered with the National Rural Support Program (NRSP) to undertake a 3-year-long, low-resource, setting-sensitive communication project in the district of Lodhran. The project received support from the Department for International Development (DFID).

As detailed in the report, in January 2000, organisers began implementing a range of activities, which they integrated with existing social and health service mechanisms. Designed to reach communities and health care providers, these activities included:

1. Community health education - partnership with the NRSP enabled access to a district-wide network of organised grassroots-level community-based organisations (CBOs). Structured health education sessions, lasting approximately 3 hours, were used to impart health-related knowledge during community organisation meetings. Illustrated posters were used; these and accompanying pamphlets were given away to participants to take with them. No incentive was given to villagers to participate in the sessions, which were conducted in the village in what organisers describe as a culturally acceptable manner. A trained officer delivered the talk in local language, and also facilitated interactive debates around issues raised. A total of 182 community sessions were held in 45 villages, involving 5,667 individuals - who were then expected to disseminate this message within their villages.
2. Mass media interventions - public service announcements (PSAs) were broadcast daily on local radio stations during one year of the project.
3. Training of health professionals - through collaboration with the District Health Department, organisers held one-day workshops for 40 physicians (and 60 non-physicians; separate workshops and tools were developed for these latter participants). Health care providers engaged in interactive training that featured "locally adapted, validated and resource sensitive risk management and assessment protocols (WHO, 2003)". Doctors received signs with the Heartfile logo and the inscription "have you had your blood pressure checked?" after the training.
4. Health education through Lady Health Workers (LHWs) - LHWs deliver services in the field. As part of this project, 31 6-hour-long training sessions were held for 703 LHWs. A Heartfile officer took the role of the lead trainer and conducted interactive training in the local language, emphasising the role of LHWs in advocating healthy life styles and stressing the need for blood pressure screening. The objective of training was to create awareness about the role of lifestyle changes in preventing CVDs and aimed at equipping them with the necessary knowledge and tools to disseminate this message in the communities.

Researchers carried out pre- and post-intervention (training) evaluations involving all health care providers in randomly selected workshops in order to determine baseline levels of knowledge and the impact of training on knowledge level. In order to assess practices of physician and non-physician health care providers, patient interviews (with control comparisons) were conducted at each health care facility.

Significant positive changes were observed in knowledge levels in the district of intervention compared with baseline knowledge levels - particularly in relation to a heart-healthy diet, beneficial level of physical activity, the causes of high blood pressure and heart attack, and the effects of high blood pressure and active and passive smoking on health. While no significant changes in behaviours at a practice level were found, researchers indicate that "the project played a critical role in spurring national action for the prevention and control of non-communicable diseases and introducing sustainable public health interventions for poor communities in Pakistan." To elaborate, they explain that the increase in knowledge levels is a prerequisite to decreasing health risk and improving community health status - that is, "raising awareness, is the first stage of community readiness. It is well established that change in practices that are new occurs in stages: the user must be aware of a need for improving a practice, search for methods for improvement, select one method from alternatives, gather the necessary resources to initiate the practice, implement the practice and sustain it."