A multilevel ecological approach to promoting walking in rural communities. Effectiveness of a multi-disciplinary family-based programme for treating childhood obesity (the Family Project). Effects of "10,000 steps Ghent": a whole-community intervention. Improving quality of prevention of mother-to-child HIV transmission services in Ukraine: a focus on provider communication skills and linkages to community-based non-governmental organizations. Clinic-based support to help overweight patients with type 2 diabetes increase physical activity and lose weight. Wheeling walks: evaluation of a media-based community intervention. Effect of school based physical activity programme (KISS) on fitness and adiposity in primary schoolchildren: cluster randomised controlled trial. A community-based approach to promoting walking in rural areas. Promoting physical activity in middle school girls: Trial of Activity for Adolescent Girls. Methodological challenges of multiple-component intervention: lessons learned from a randomized controlled trial of functional recovery after hip fracture. Pathways: a school-based, randomized controlled trial for the prevention of obesity in American Indian schoolchildren. The Heartfile Lodhran CVD prevention project--end of project evaluation. Tai Chi and health-related quality of life in nursing home residents. An advocacy intervention program for women with abusive partners: initial evaluation. A community-wide Responsible Beverage Service program in three communities: early findings. Population tobacco control interventions and their effects on social inequalities in smoking: placing an equity lens on existing systematic reviews. Do lifestyle interventions work in developing countries? Findings from the Isfahan Healthy Heart Program in the Islamic Republic of Iran. A randomized trial of medical care management for community mental health settings: the Primary Care Access, Referral, and Evaluation (PCARE) study.
Walking is a key focus of public health interventions yet is particularly uncommon in rural residents. This study's purpose was to determine whether a multilevel community intervention affected rates of moderate physical activity, in particular walking.
                A quasi-experimental design examined changes in walking in six rural intervention communities in Missouri and six comparison communities in Arkansas and Tennessee in 2003-2004. Interventions were developed with community input and included individually tailored newsletters; interpersonal activities that stressed social support and health provider counseling; and community-wide events such as fun walks. A dose variable estimated exposure to intervention activities. Primary outcomes were rates of walking and moderate physical activity in the past week.
                At follow-up (n = 1531), the percentage of respondents who met the recommendation for walking was the same across the intervention and comparison areas. Among the dependent variables, walking showed some evidence of a positive linear trend across dose categories (P = 0.090). After adjusting for covariates and baseline rates, intervention participants in the moderate and high dose categories were about three times more likely to meet recommended guidelines for walking.
                Some evidence of effectiveness was shown for a multilevel intervention approach to promote walking. To determine if a multi-component family focused education package is more effective than a waiting list control group in treating overweight and obese children.
                A 2-year randomised controlled trial; 65 overweight and obese children aged 6-14 years were allocated to active intervention in either the first or second year, with body composition monitoring alone in the control period. Anthropometric measurements were undertaken at six monthly intervals and a 7-day food and activity diary were issued.
                Over the 2 years of the study body mass index (BMI) SDS (z score) fell significantly in the intervention/control (I/C) group, but not in the control/intervention (C/I) group. The difference between groups was 0.3, which was borderline significant (95% confidence interval (95% CI) -0.62 to 0.02, P=0.06) before adjusting for potential confounding factors. Thirty-three percent of the I/C group and 12% of the C/I group achieved the target reduction of 0.5 BMI SDS. The I/C group had a significantly greater reduction in the percentage with a BMI above the 99.6th centile at 24 months (P=0.04) and gained 5.7 kg less over the time of the study. There were no significant differences between groups for mean percentage attendance at physical activity sessions (I/C group=24.1%, 95% CI, 15.4-32.9; C/I group=31.7%, 95% CI, 22.4-41.1, P=0.229).
                Children given active intervention followed by body composition monitoring alone reduced their BMI SDS, and fewer children were classified as grossly overweight by the end of the study. If these findings are true, there are important implications for the provision of services managing overweight in the community. Currently there is a great deal of interest in multistrategy community-based approaches to changing physical activity or health behaviors. The aim of this article is to describe the effectiveness of the physical activity promotion project "10,000 Steps Ghent" after 1 year of intervention.
                A multistrategy community-based intervention was implemented in 2005 with follow-up measurements in 2006 to promote physical activity to adults. A local media campaign, environmental approaches, the sale and loan of pedometers, and several local physical activity projects were concurrently implemented. In 2005, 872 randomly selected subjects (aged 25 to 75), from the intervention community Ghent and 810 from a comparison community, participated in the baseline measurements. Of these, 660 intervention subjects and 634 comparison subjects completed the follow-up measurements in 2006. Statistical analyses were performed in 2006.
                After one year there was an increase of 8% in the number of people reaching the "10,000 steps" standard in Ghent, compared with no increase in the comparison community. Average daily steps increased by 896 (95% CI=599-1192) in the intervention community, but there was no increase in the comparison community (mean change -135 [95% CI= -432 to 162]) (F time x community=22.8, p<0.001). Results are supported by self-reported International Physical Activity Questionnaire (IPAQ) data.
                The "10,000 steps/day" message reached the Ghent population and the project succeeded in increasing pedometer-determined physical activity levels in Ghent, after 1 year of intervention. Ukraine has the highest rate of HIV infection in Europe, with an estimated adult prevalence of 1.6 percent. The epidemic in Ukraine remains largely driven by injection drug use, and women of reproductive age are being increasingly affected. Prior research has highlighted the need to improve the quality of services for prevention of mother-to-child transmission (PMTCT) and to address other issues related to HIV counseling, testing, and care, especially in the context of antenatal and obstetric services.
                From 2004 to 2007, PATH led a collaborative effort to improve the quality of PMTCT services in Ukraine. Initial assessments included focus groups with Ukrainian women and review of existing educational materials. Interventions focused on training providers to improve skills in communication and referral to community-based support; they also addressed the underlying issue of stigma.
                Observational data demonstrated that providers who participated in the training intervention delivered PMTCT counseling of a consistently higher quality than did providers who did not undergo training. Exit interviews with clients confirmed these findings.
                An intervention focused on strengthening voluntary counseling and testing for HIV, forging partnerships with local organizations, and undoing HIV-related stigma can help to improve access to and quality of PMTCT services in antenatal care clinics. Our objective was to test the effect of physicians providing brief health lifestyle counseling to patients with type 2 diabetes mellitus during usual care visits.
                We conducted a randomized controlled trial of a 12-month intervention at 2 large community health centers, enrolling 310 patients with a body mass index (calculated as weight in kilograms divided by height in meters squared) of 25 or greater. In the intervention group, self-management goals for nutrition and physical activity were set using a tailored computer program. Goals were then reviewed at each clinic visit by physicians. The control group received only printed health education materials. The main outcome measures included change in physical activity and body weight.
                In the intervention group, recommended levels of physical activity increased from 26% at baseline to 53% at 12 months (P< .001) compared with controls (30% to 37%; P= .27), and 32% of patients in the intervention group lost 6 or more pounds at 12 months compared with 18.9% of controls (odds ratio, 2.2; P= .006).
                A brief intervention to increase the dialogue between patients and health care providers about behavioral goals can lead to increased physical activity and weight loss. Mass media community-wide physical activity intervention to promote and sustain changes in walking was assessed using a 2-community longitudinal design. The intervention targeted sedentary 50- to 65-year-old residents of Wheeling, West Virginia. Telephone surveys of a probability sample followed cohorts at baseline and at 3-, 6-, and 12-month post-intervention with comparison communities. The intervention, consisting of paid advertisements, public relations, and community participatory planning, attained high levels of awareness and effected significant sustained population-wide changes among the most sedentary in Wheeling. To assess the effectiveness of a school based physical activity programme during one school year on physical and psychological health in young schoolchildren.
                Cluster randomised controlled trial.
                28 classes from 15 elementary schools in Switzerland randomly selected and assigned in a 4:3 ratio to an intervention (n=16) or control arm (n=12) after stratification for grade (first and fifth grade), from August 2005 to June 2006.
                540 children, of whom 502 consented and presented at baseline.
                Children in the intervention arm (n=297) received a multi-component physical activity programme that included structuring the three existing physical education lessons each week and adding two additional lessons a week, daily short activity breaks, and physical activity homework. Children (n=205) and parents in the control group were not informed of an intervention group. For most outcome measures, the assessors were blinded.
                Primary outcome measures included body fat (sum of four skinfolds), aerobic fitness (shuttle run test), physical activity (accelerometry), and quality of life (questionnaires). Secondary outcome measures included body mass index and cardiovascular risk score (average z score of waist circumference, mean blood pressure, blood glucose, inverted high density lipoprotein cholesterol, and triglycerides).
                498 children completed the baseline and follow-up assessments (mean age 6.9 (SD 0.3) years for first grade, 11.1 (0.5) years for fifth grade). After adjustment for grade, sex, baseline values, and clustering within classes, children in the intervention arm compared with controls showed more negative changes in the z score of the sum of four skinfolds (-0.12, 95 % confidence interval -0.21 to -0.03; P=0.009). Likewise, their z scores for aerobic fitness increased more favourably (0.17, 0.01 to 0.32; P=0.04), as did those for moderate-vigorous physical activity in school (1.19, 0.78 to 1.60; P<0.001), all day moderate-vigorous physical activity (0.44, 0.05 to 0.82; P=0.03), and total physical activity in school (0.92, 0.35 to 1.50; P=0.003). Z scores for overall daily physical activity (0.21, -0.21 to 0.63) and physical quality of life (0.42, -1.23 to 2.06) as well as psychological quality of life (0.59, -0.85 to 2.03) did not change significantly.
                A school based multi-component physical activity intervention including compulsory elements improved physical activity and fitness and reduced adiposity in children. Trial registration Current Controlled Trials ISRCTN15360785. Ecologic models are often recommended to promote physical activity, yet sparse data exist on their effectiveness.
                A quasi-experimental design examined changes in walking behavior in six rural intervention communities in the Missouri "bootheel" region and in six comparison communities in Arkansas and Tennessee.
                The communities ranged in population from 2399 to 17,642; interventions focused on adults aged >/=18 years.
                Interventions were developed with community input and included individually tailored newsletters, interpersonal activities that stressed social support, and community-wide events such as walk-a-thons.
                Primary outcomes were rates of walking-trail use, total number of minutes walked in the past week, and total minutes walked for exercise.
                Among persons who used trails at baseline (16.9% of the total population), 32.1% reported increases in physical activity since they began using the trail. From community-wide samples, two subgroups indicated a positive net change in rates of 7-day total walking: people with high school degrees or less and people living in households with annual incomes of <==$20,000. However, no studied group showed a statistically significant net intervention effect.
                Although there was an increase in the rate of walking-trail use, a community-wide change in walking rates in rural communities was not documented. Results of this study should provide guidance for future projects. Physical activity is important for weight control and good health; however, activity levels decline in the adolescent years, particularly in girls.
                Group randomized controlled trial.
                Middle school girls with English-speaking skills and no conditions to prevent participation in physical activity in 36 schools in six geographically diverse areas of the United States. Random, cross-sectional samples were drawn within schools: 6th graders in 2003 (n=1721) and 8th graders in 2005 (n=3504) and 2006 (n=3502).
                A 2-year study-directed intervention (fall 2003 to spring 2005) targeted schools, community agencies, and girls to increase opportunities, support, and incentives for increased physical activity. Components included programs linking schools and community agencies, physical education, health education, and social marketing. A third-year intervention used school and community personnel to direct intervention activities.
                The primary outcome, daily MET-weighted minutes of moderate-to-vigorous physical activity (MET-weighted MVPA), was assessed using accelerometry. Percent body fat was assessed using anthropometry.
                After the staff-directed intervention (pre-stated primary outcome), there were no differences (mean= -0.4, 95% CI= -8.2 to 7.4) in adjusted MET-weighted MVPA between 8th-grade girls in schools assigned to intervention or control. Following the Program Champion-directed intervention, girls in intervention schools were more physically active than girls in control schools (mean difference 10.9 MET-weighted minutes of MVPA, 95% CI=0.52-21.2). This difference is about 1.6 minutes of daily MVPA or 80 kcal per week. There were no differences in fitness or percent body fat at either 8th-grade timepoint.
                A school-based, community-linked intervention modestly improved physical activity in girls. We conducted a randomized controlled trial to assess the efficacy and safety of a multiple-component intervention designed to improve functional recovery after hip fracture. One hundred seventy-six patients who underwent surgery for a primary unilateral hip fracture were assigned randomly to receive usual care (control arm, n = 86) or a brief motivational videotape, supportive peer counseling, and high-intensity muscle-strength training (intervention arm, n = 90). Between-group differences on the physical functioning, role-physical, and social functioning domains of the SF-36 were assessed postoperatively at 6 months. At the end of the trial, 32 intervention and 27 control patients (34%) completed the 6-month outcome assessment. Although patient compliance with all three components of the intervention was uneven, over 90% of intervention patients were exposed to the motivational videotape. Intervention patients experienced a significant (P = 0.03) improvement in the role-physical domain (mean change, -11 +/- 33) compared to control patients (mean change, -37 +/- 41). Change in general health (P = 0.2) and mental health (P = 0.1) domain scores was also directionally consistent with the study hypothesis. Although our findings are consistent with previous reports of comprehensive rehabilitation efforts for hip fracture patients, the trial was undermined by high attrition and the possibility of self-selection bias at 6-month follow-up. We discuss the methodological challenges and lessons learned in conducting a randomized controlled trial that sought to implement and assess the impact of a complex intervention in a population that proved difficult to follow up once they had returned to the community. Childhood obesity is a major public health problem in the United States, particularly among American Indian communities.
                The objective was to evaluate the effectiveness of a school-based, multicomponent intervention for reducing percentage body fat in American Indian schoolchildren.
                This study was a randomized, controlled, school-based trial involving 1704 children in 41 schools and was conducted over 3 consecutive years, from 3rd to 5th grades, in schools serving American Indian communities in Arizona, New Mexico, and South Dakota. The intervention had 4 components: 1) change in dietary intake, 2) increase in physical activity, 3) a classroom curriculum focused on healthy eating and lifestyle, and 4) a family-involvement program. The main outcome was percentage body fat; other outcomes included dietary intake, physical activity, and knowledge, attitudes, and behaviors.
                The intervention resulted in no significant reduction in percentage body fat. However, a significant reduction in the percentage of energy from fat was observed in the intervention schools. Total energy intake (by 24-h dietary recall) was significantly reduced in the intervention schools but energy intake (by direct observation) was not. Motion sensor data showed similar activity levels in both the intervention and control schools. Several components of knowledge, attitudes, and behaviors were also positively and significantly changed by the intervention.
                These results document the feasibility of implementing a multicomponent program for obesity prevention in elementary schools serving American Indian communities. The program produced significant positive changes in fat intake and in food- and health-related knowledge and behaviors. More intense or longer interventions may be needed to significantly reduce adiposity in this population. Mainstream preventive interventions often fail to reach poor populations with a high risk of cardiovascular diseases (CVDs) in Pakistan. A community-based CVD primary prevention project aimed at developing approaches to reduce risk factors in such populations was established by Heartfile in collaboration with the National Rural Support Program in the district of Lodhran. The project implemented a range of activities integrated with existing social and health service mechanisms during a three year intervention period 2000/01-03/04. These were targeted in 4 key settings: community health education, mass media interventions, training of health professionals and health education through Lady Health Workers. The project received support from the Department for International Development, U.K. At the community level, a pre-test-post-test quasi-experimental design was used for examining project outcomes related to the community component of the intervention. Pre and post-intervention (training) evaluations were conducted 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 at a community level 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. Significant changes in behaviors at a practice level were not shown in the district of intervention. However 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. Health-related quality of life (HRQOL) that is good is regarded as the goal of elderly residential care. However, limited evidence exists indicating a promising intervention that can achieve this goal. The aim of this study is to examine the effect of Tai Chi on HRQOL in nursing home residents.
                A nonequivalent pretest-posttest control-group design.
                A convenience sample of 139 residents from six nursing homes in Hong Kong was used. The experimental group (n=66) joined a 26-week Tai Chi program, while the control group (n=73) continued with usual daily activities. The physical and mental components of HRQOL were designated as the dependent variables. Resident satisfaction was considered as a covariate. Doubly multivariate repeated measures analysis of covariance was done to examine the intervention effect.
                After adjusting for the confounding effect of resident satisfaction, a statistically significant difference (p<0.05) in the physical and mental components of HRQOL between the experimental and control groups was found. Findings showed significant improvement in HRQOL after residents practiced Tai Chi.
                These investigators contribute additional knowledge about the health benefits of Tai Chi among nursing home residents and indicates support for its use in this population to improve HRQOL.
                Tai Chi has unique characteristics as a health exercise that is particularly suitable for nursing home residents. The inclusion of Tai Chi exercise in elderly residential care practice is recommended. Experimentally tested the hypotheses that (1) battered women are in need of numerous community resources upon exit from a domestic violence shelter, (2) working with advocates increases women's effectiveness in obtaining needed resources and social support, and (3) success in obtaining resources and social support increases women's levels of life satisfaction and decreases their risk of further abuse. The initial findings of a short-term intervention project designed to provide postshelter advocacy services to women with abusive partners are presented. One-hundred forty-one battered women were interviewed immediately upon their exit from a domestic violence shelter as well as 10 weeks thereafter. Half the sample was randomly assigned to receive the services of trained advocates who assisted them in accessing needed community resources. Women who worked with advocates reported being more effective in accessing resources and had higher levels of social support and overall quality of life postintervention. Although all women reported some decrease in postshelter abuse, there were no differences between those with and those without advocates, and abuse continued to be a problem for many women. Evidence accumulating over the past 10 years or so suggests that commercial servers of alcoholic beverages will intervene to reduce levels of impairment among their patrons and will refuse service to intoxicated customers. While some Responsible Beverage Service (RBS) programs have had significant effects on server and patron behavior, others have not. This leads us to consider issues of implementation and program effectiveness. In the current paper, a community-wide RBS program is described in some detail. The program was comprised by a larger comprehensive community intervention project in three sites across California and South Carolina. Process evaluation data, to track program implementation and proximal effects, provide early findings. Expressed support for RBS principles was high for both the public and the hospitality industry in all sites. A telephone survey of managers also suggests that prevention policies at bars and restaurants are beginning to show up, but a direct measure of server intervention with heavy drinkers does not yet demonstrate a program effect. With smoking increasingly confined to lower socio-economic groups, the tobacco control community has been urged to identify which population-level tobacco control interventions work in order to help tackle smoking-related health inequalities. Systematic reviews have a crucial role to play in this task. This overview was therefore carried out in order to (i) summarise the evidence from existing systematic reviews of population-level tobacco control interventions, and (ii) assess the need for a new systematic review of primary studies, with the aim of assessing the differential effects of such interventions.
                Systematic review methods were used to evaluate existing systematic reviews that assessed a population-level tobacco control intervention and which reported characteristics of included participants in terms of at least one socio-demographic or socio-economic factor.
                Nineteen systematic reviews were included. Four reviews assessed interventions aimed at the population level alone, whilst fifteen included at least one primary study that examined this type of intervention. Four reviews assessed youth access restrictions, one assessed the effects of increasing the unit price of tobacco, and six assessed smoking bans or restrictions. Of the eight remaining reviews, six assessed multi-component community based interventions, in which the population-level interventions were part of a wider tobacco control programme, and two assessed the impact of smoking bans or restrictions in reducing exposure to environmental tobacco smoke. We found tentative evidence that the effect of increasing the unit price of tobacco products may vary between ethnic and socio-economic groups, and between males and females. However, differences in the context and the results of different reviews made it difficult to draw any firm conclusions. Few identified reviews explicitly attempted to examine differences in intervention effects between socio-demographic groups. Therefore on the basis of these reviews the potential for smoking bans, and youth access restrictions to decrease social inequalities in smoking remains unknown.
                There is preliminary evidence that increases in the unit price of tobacco may have the potential to reduce smoking related health inequalities. There is a need for equity effects to be explicitly evaluated in future systematic reviews and in primary research assessing the effects of population tobacco control interventions. To assess the effects of a comprehensive, integrated community-based lifestyle intervention on diet, physical activity and smoking in two Iranian communities.
                Within the framework of the Isfahan Healthy Heart Program, a community trial was conducted in two intervention counties (Isfahan and Najaf-Abad) and a control area (Arak). Lifestyle interventions targeted the urban and rural populations in the intervention counties but were not implemented in Arak. In each community, a random sample of adults was selected yearly by multi-stage cluster sampling. Food consumption, physical exercise and smoking behaviours were quantified and scored as 1 (low-risk) or 0 (other) at baseline (year 2000) and annually for 4 years in the intervention areas and for 3 years in the control area. The scores for all behaviours were then added to derive an overall lifestyle score.
                After 4 years, changes from baseline in mean dietary score differed significantly between the intervention and control areas (+2.1 points versus -1.2 points, respectively; P < 0.01), as did the change in the percentage of individuals following a healthy diet (+14.9% versus -2.0%, respectively; P < 0.001). Daily smoking had decreased by 0.9% in the intervention areas and by 2.6% in the control area at the end of the third year, but the difference was not significant. Analysis by gender revealed a significant decreasing trend in smoking among men (P < 0.05) but not among women. Energy expenditure for total daily physical activities showed a decreasing trend in all areas, but the mean drop from baseline was significantly smaller in the intervention areas than in the control area (-68 metabolic equivalent task (MET) minutes per week versus -114 MET minutes per week, respectively; P < 0.05). Leisure time devoted to physical activities showed an increasing trend in all areas. A significantly different change from baseline was found between the intervention areas and the control area in mean lifestyle score, even after controlling for age, sex and baseline values.
                The results suggest that community-based lifestyle intervention programmes can be effective in a developing country setting. Poor quality of healthcare contributes to impaired health and excess mortality in individuals with severe mental disorders. The authors tested a population-based medical care management intervention designed to improve primary medical care in community mental health settings.
                A total of 407 subjects with severe mental illness at an urban community mental health center were randomly assigned to either the medical care management intervention or usual care. For individuals in the intervention group, care managers provided communication and advocacy with medical providers, health education, and support in overcoming system-level fragmentation and barriers to primary medical care.
                At a 12-month follow-up evaluation, the intervention group received an average of 58.7% of recommended preventive services compared with a rate of 21.8% in the usual care group. They also received a significantly higher proportion of evidence-based services for cardiometabolic conditions (34.9% versus 27.7%) and were more likely to have a primary care provider (71.2% versus 51.9%). The intervention group showed significant improvement on the SF-36 mental component summary (8.0% [versus a 1.1% decline in the usual care group]) and a nonsignificant improvement on the SF-36 physical component summary. Among subjects with available laboratory data, scores on the Framingham Cardiovascular Risk Index were significantly better in the intervention group (6.9%) than the usual care group (9.8%).
                Medical care management was associated with significant improvements in the quality and outcomes of primary care. These findings suggest that care management is a promising approach for improving medical care for patients treated in community mental health settings.
Although numerous studies have been undertaken, there is a noticeable inconsistency of the findings of the available studies and this is confounded by serious methodological issues within the included studies. The body of evidence in this review does not support the hypothesis that multi-component community wide interventions effectively increase population levels of physical activity. There is a clear need for well-designed intervention studies and such studies should focus on the quality of the measurement of physical activity, the frequency of measurement and the allocation to intervention and control communities.