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Assessment of Mortality and Smoking Rates Before and After Reduction in Community-wide Prevention Programs in Rural Maine.

ABSTRACT: Importance:It is unclear whether effective population-wide interventions that reduce risk factors and improve health result in sustained benefits to a community's health. If benefits do persist after a program is ended, interventions could be brief rather than maintained long term. Objective:To measure mortality and smoking rates in a rural community over decades before, during, and after prevention program reductions. Design, Setting, and Participants:This cross-sectional study compared smoking and mortality rates in a rural Maine county with other Maine counties over time by 5-year intervals. Multiple changes occurred between 2001 and 2015 in the physiological and behavioral risk factor reduction programs offered in the county. They included reductions in leadership, staff, institutional resources, data monitoring, and the programs themselves. Data were analyzed from May 2018 to March 2019. Intervention:Previous multifaceted interventions and outcome monitoring were withdrawn or diminished in the past decade. Main Outcomes and Measures:Smoking and age-adjusted mortality rates vs household income. Results:Reduced mortality rates in Franklin County in 1986 to 2005 reverted to those predicted by household incomes, relative to other Maine counties, by 2006 to 2015 (1986-1990 T score?=?-2.86 [P?=?.01] and 2001-2005 T score?=?-3.00 [P?=?.01] to 2006 to 2010 T score?=?-0.43 [P?=?.67] and 2011-2015 T score?=?-0.72 [P?=?.48]). Analysis of County Health Rankings data from 2010 to 2018 also showed that Franklin County's outcomes have reverted to no better than predicted by socioeconomic status. The county's T scores increased from -3.62 (P?=?.003) in 2010 to -0.41 (P?=?.69) in 2015 to 0.13 (P?=?.90) in 2018. Statewide association of income with mortality by analyses of variance showed that the R2 values have increased from the decades preceding 2000 (1976-1980, R2?=?0.21; P?=?.08; 1986-1990, R2?=?0.32; P?=?.02) to 2006 to 2010 (R2?=?0.73; P?

SUBMITTER: Onion DK

PROVIDER: S-EPMC6575143 | biostudies-literature | 2019 Jun

REPOSITORIES: biostudies-literature

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Assessment of Mortality and Smoking Rates Before and After Reduction in Community-wide Prevention Programs in Rural Maine.

Onion Daniel K DK Prior Roderick E RE Record N Burgess NB Record Sandra S SS Cayer Gerald R GR Amos Christopher I CI Pearson Thomas A TA

JAMA network open 20190605 6

<h4>Importance</h4>It is unclear whether effective population-wide interventions that reduce risk factors and improve health result in sustained benefits to a community's health. If benefits do persist after a program is ended, interventions could be brief rather than maintained long term.<h4>Objective</h4>To measure mortality and smoking rates in a rural community over decades before, during, and after prevention program reductions.<h4>Design, setting, and participants</h4>This cross-sectional ...[more]

PMID: 31199453

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Project description:IntroductionWe compared smoking cessation outcomes between those who used a pharmacist-led community-based smoking cessation intervention and those who did not, prior to total joint replacement (TJR) surgery. Also, we examined intervention characteristics (e.g. number/duration of sessions attended, recommended therapy) and smoking cessation outcomes.MethodsThis prospective evaluation was nested within a comparative study from a centralized clinic that prepares over 3000 patients annually for TJR and focused on participants referred to the community-based smoking cessation program preoperatively. Pharmacists offered an individualized evidence-based intervention and collected visit, duration and intervention data. Smoking cessation, the primary outcome, was ascertained independently of participating pharmacists at 6 weeks post-operative using exhaled CO monitoring and at 6 months post-recruitment via telephone interview.ResultsOf 286 eligible candidates, 104 agreed to participate, with one subsequently withdrawing (n=103). At 6 weeks post-operatively, 66/103 (64%) participants returned for study re-assessment while 63/103 (61%) participants completed the post-recruitment interview at 6 months; non-respondents to study follow-up were considered smokers. Of 103 participants, 58 (56%) consulted with a pharmacist; those who did not consult a pharmacist (n=45) were slightly younger (p=0.02) with significantly higher CO level (p=0.02) on study entry. Validated 7-day point prevalence abstinence (PPA) at 6 weeks post-operative was 11/58 (19%) in pharmacist-compliant participants compared to 2/45 (4%) in non-compliant participants (p=0.04). At 6 months post-recruitment, 19/58 (33%) pharmacistcompliant participants self-reported a 7-day PPA compared to 2/45 (4%) by non-compliant participants (p<0.001). For pharmacist-compliant participants, 33/58 (54%) saw the pharmacist 4 times; the mean overall pharmacist time was 71.8±24.4 minutes/patient with 26/58 (45%) and 19/58 (33%) prescribed nicotine replacement therapy and varenicline, respectively, and 13/58 (22%) not using medication; post hoc analysis suggested varenicline was marginally more effective for smoking cessation than no medication (p=0.04).ConclusionsCommunity-based pharmacist-led smoking cessation programs are an effective addition to usual preoperative care for smokers awaiting elective TJR. Using existing community resources led to higher smoking cessation rates in smokers waiting for TJR relative to those not using these resources.

Project description:Few comprehensive cardiovascular risk reduction programs, particularly those in rural, low-income communities, have sustained community-wide interventions for more than 10 years and demonstrated the effect of risk factor improvements on reductions in morbidity and mortality.To document health outcomes associated with an integrated, comprehensive cardiovascular risk reduction program in Franklin County, Maine, a low-income rural community.Forty-year observational study involving residents of Franklin County, Maine, a rural, low-income population of 22,444 in 1970, that used the preceding decade as a baseline and compared Franklin County with other Maine counties and state averages.Community-wide programs targeting hypertension, cholesterol, and smoking, as well as diet and physical activity, sponsored by multiple community organizations, including the local hospital and clinicians.Resident participation; hypertension and hyperlipidemia detection, treatment, and control; smoking quit rates; hospitalization rates from 1994 through 2006, adjusted for median household income; and mortality rates from 1970 through 2010, adjusted for household income and age.More than 150,000 individual county resident contacts occurred over 40 years. Over time, as cardiovascular risk factor programs were added, relevant health indicators improved. Hypertension control had an absolute increase of 24.7% (95% CI, 21.6%-27.7%) from 18.3% to 43.0%, from 1975 to 1978; later, elevated cholesterol control had an absolute increase of 28.5% (95% CI, 25.3%-31.6%) from 0.4% to 28.9%, from 1986 to 2010. Smoking quit rates improved from 48.5% to 69.5%, better than state averages (observed?-?expected [O?-?E], 11.3%; 95% CI, 5.5%-17.7%; P?<?.001), 1996-2000; these differences later disappeared when Maine's overall quit rate increased. Franklin County hospitalizations per capita were less than expected for the measured period, 1994-2006 (O?-?E, -17 discharges/1000 residents; 95% CI -20.1 to -13.9; P?<?.001). Franklin was the only Maine county with consistently lower adjusted mortality than predicted over the time periods 1970-1989 and 1990-2010 (O?-?E, -60.4 deaths/100,000; 95% CI, -97.9 to -22.8; P?<?.001, and -41.6/100,000; 95% CI, -77.3 to -5.8; P?=?.005, respectively).Sustained, community-wide programs targeting cardiovascular risk factors and behavior changes to improve a Maine county's population health were associated with reductions in hospitalization and mortality rates over 40 years, compared with the rest of the state. Further studies are needed to assess the generalizability of such programs to other US county populations, especially rural ones, and to other parts of the world.

Project description:IntroductionFall rates and fall-related injuries among community-dwelling older adults (≥65 years) are expected to increase rapidly, due to the aging population worldwide. Fall prevention programs (FPPs), consisting of strength and balance exercises, have been proven effective in reducing fall rates among older adults. However, these FPPs have not reached their full potential as most programs are under-enrolled. Therefore, this study aims to identify promising strategies that promote participation in FPPs among community-dwelling older adults.MethodsThis is an exploratory qualitative study. Previously, barriers and facilitators for participation in FPPs by older adults had been identified. Next, six strategies had been designed using the Intervention Mapping approach: (1) reframing; (2) informing about benefits; (3) raising awareness of risks; (4) involving social environment; (5) offering tailored intervention; (6) arranging practicalities. Strategies were validated during semi-structured interviews with community-dwelling older adults (n = 12) at risk of falling. Interviews were audio-recorded, transcribed, and analyzed following a qualitative thematic methodology, with a hybrid approach.ResultsAll strategies were considered important by at least some of the respondents. However, two strategies stood out: (1) reframing 'aging' and 'fall prevention': respondents preferred to be approached differently, taking a 'life course' perspective about falls, and avoiding confronting words; and (2) 'informing about benefits' (e.g., 'living independently for longer'); which was mentioned to improve the understanding of the relevance of participating in FPPs. Other strategies were considered important to take into account too, but opinions varied more strongly.DiscussionThis study provides insight into potential strategies to stimulate older adults to participate in FPPs. Results suggest that reframing 'aging' and 'fall prevention' may facilitate the dialogue about fall prevention, by communicating differently about the topic, for example 'staying fit and healthy', while focusing on the benefits of participating in FPPs. Gaining insight into the strategies' effectiveness and working mechanisms is an area for future research. This could lead to practical recommendations and help professionals to enhance older adults' participation in FPPs. Currently, the strategies are further developed to be applied and evaluated for effectiveness in multiple field labs in a central Dutch region (Utrecht).

Project description:The purpose of this study was to reduce cardiovascular disease (CVD) risk in women by implementing a cardiovascular prevention health promotion program in faith- and community-based sites. The primary outcomes were reducing obesity and increasing physical activity. A longitudinal cohort of high-risk (age > 40, ethnic minority) women (n = 1,052) was enrolled at 32 sites across the USA. The pre- or post-educational intervention consisted of eight biweekly counseling sessions conducted over 4 months each addressing one of six of the major CVD risk factors (smoking, diabetes, hypertension, cholesterol, obesity, and physical inactivity) as well as signs and symptoms of a heart attack and stroke; plus 4-6 maintenance sessions over three additional months. A multifaceted approach delivered by lay and medically trained personnel involving medical screenings, health behavior counseling, risk behavior modification, and stage of change were determined at baseline and end of counseling or maintenance. Following list-wise deletion, data were analyzed on 423 women who completed all follow-up time-points. Overall, significant improvement was attained in most of 28 secondary outcomes but not in the primary outcomes. Knowledge and awareness of heart disease as the leading killer or women, all of the signs and symptoms of a heart attack, calling 911, and CVD risk factors increased significantly (p < 0.05) by 8.8%, 13.6%, 5.8%, and 10%, respectively. There was a 10% (p < 0.05) increase in participants attaining control for hypertension (blood pressure < 140/90) coupled with a significant reduction in mean blood pressure in the entire cohort. Knowledge of effective CVD risk modification strategies for all CVD risk factors increased significantly (p < 0.05), except for obesity. In addition, there were significant (p < 0.05) increases in forward movement in stage of change for each CVD risk factor (range +10% to +39%). Thus, a heart disease prevention intervention built around a model of community engagement, advocacy, self-efficacy, resource knowledge, and health promotion in faith- and community-based organizations is successful at improving cardiovascular knowledge and awareness outcomes in high-risk women. Limitations of our study include the high dropout rate, significant time demands on site coordinators, limited resources for program implementation, lack of morbidity and mortality endpoints, and failure to attain the primary outcomes of weight loss and physical activity. Future studies should not only assess the effect of community education interventions on lifestyle change and knowledge and awareness of participants but should also address program duration, cost, and resources required to attain improved outcomes.

Project description:ObjectiveSmoking cessation and relapse prevention during and after pregnancy reduces the risk of adverse maternal and infant health outcomes, but the economic evaluations of such programs have not been systematically reviewed. This study aims to critically assess economic evaluations of smoking cessation and relapse prevention programs for pregnant women.MethodsAll relevant English-language articles were identified using PubMed (January 1966-2003), the British National Health Service Economic Evaluation Database, and reference lists of key articles. Economic evaluations of smoking cessation and relapse prevention among pregnant women were reviewed. Fifty-one articles were retrieved, and eight articles were included and evaluated. A single reviewer extracted methodological details, study designs, and outcomes into summary tables. All studies were reviewed, and study quality was judged using the criteria recommended by the Panel on Cost-Effectiveness in Health and Medicine and the British Medical Journal (BMJ) checklist for economic evaluations.ResultsThe search retrieved 51 studies. No incremental cost-effectiveness studies or cost-utility studies were found. A narrative synthesis was conducted on the eight studies thatmet the inclusion criteria. Roughly one-third employed cost-benefit analyses (CBA). Those conducting CBA have found favorable benefit-cost ratios of up to 3:1; for every dollar invested $3 are saved in downstream health-related costs.ConclusionsCBA suggests favorable cost-benefit ratios for smoking cessation among pregnant women, although currently available economic evaluations of smoking cessation and relapse prevention programs for pregnant women provide limited evidence on cost-effectiveness to determine optimal resource allocation strategies. Although none of these studies had been performed in accordance with Panel recommendations or BMJ guidelines, they are, however, embryonic elements of a more systematic framework. Existing analyses suggest that the return on investment will far outweigh the costs for this critical population. There is significant potential to improve the quality of economic evaluations of such programs; therefore, additional analyses are needed. The article concludes with ideas on how to design and conduct an economic evaluation of such programs in accordance with accepted quality standards.

Dataset Information

Assessment of Mortality and Smoking Rates Before and After Reduction in Community-wide Prevention Programs in Rural Maine.

Publications

Assessment of Mortality and Smoking Rates Before and After Reduction in Community-wide Prevention Programs in Rural Maine.

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