The Dutch Heart Health Community Intervention 'Hartslag Limburg': effects on smoking behaviour.

Abstract

A pretest-posttest control group design with two posttests was used to evaluate the effects of a regional Dutch Heart Health Community Intervention on smoking behaviour and its determinants. At baseline, a cohort research population of 1,200 smokers was recruited in the intervention region and in a control region. Data was gathered by means of short structured telephone interviews.
No significant differences were found between the intervention region and the control region on smoking behaviour and its determinants.
It is concluded that the regional intervention was unable to exceed secular trends in smoking cessation.

Full text

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The Dutch Heart Health Community
Intervention ‘Hartslag Limburg’
Effects on smoking behaviour
GABY RONDA, PATRICIA VAN ASSEMA, MATH CANDEL, ERIK RULAND, MIEKE STEENBAKKERS,
JAN VAN REE, JOHANNES BRUG *
Background and Methods: A pretest–posttest control group design with two posttests was used to evaluate the effects of a
regional Dutch Heart Health Community Intervention on smoking behaviour and its determinants. At baseline, a cohort research
population of 1,200 smokers was recruited in the intervention region and in a control region. Data was gathered by means of
short structured telephone interviews. Results: No significant differences were found between the intervention region and the
control region on smoking behaviour and its determinants. Conclusion: It is concluded that the regional intervention was unable
to exceed secular trends in smoking cessation.
Keywords: cardiovascular diseases, community-based prevention, effect study, evaluation, smoking behaviour
In 1998, a regional cardiovascular diseases (CVD) prevention
programme, integrating a community strategy and a high-risk
strategy, was started in the Maastricht region of the province of
Limburg, called ‘Hartslag Limburg’ (Dutch for Heartbeat
Limburg). Hartslag Limburg is a joint project of the municipal
authorities of the Maastricht region, the Maastricht Regional
Public Health Institute (RPHI), community social work
organizations, the regional community health care organization,
general practitioners, Maastricht University, the University
Hospital, and various local organizations, clubs and companies.
In January 2001, the World Health Organisation (WHO)
selected Hartslag Limburg as one of twelve so-called ‘field
projects’, based on its potential to meet pre-established criteria
of the WHO project ‘Towards Unity for Health’.1 The major
goal of community intervention is to reduce CVD risk among
the 180,000 inhabitants of the region by encouraging
behavioural change, i.e. dietary fat reduction, increased physical
activity, and smoking cessation. The project is to continue at
least until 2003.
The implementation of the Hartslag Limburg community inter-
vention in the Maastricht region involved several smoking
cessation activities. The most important was the regional mass
media-led smoking cessation campaign ‘Proficiat’ (‘Congratula-
tions’) implemented in January and February 2000 and 2001.2
This campaign, organised by the RPHI, consisted of radio com-
mercials, advertisements and messages in papers, billboards along
roads, and posters and postcards in waiting rooms and public
buildings. Additionally, there were smaller local activities,
organised by working groups consisting of representatives of local
organizations, such as a non-smoking campaign for the parents
of children in playgroups.2 It was supposed that the inhabitants
of the Maastricht region would feel more involved with these
regional activities than with a national mass media-led smoking
cessation campaign ‘Dat kan ik ook’ (‘I can do that too’) that was
implemented around the turn of the century in the Netherlands.
This national campaign consisted of various television pro-
grammes, an info line, non-smoking courses, mailings to various
organizations, billboards in bus shelters, brochures, posters, etc.
This report presents the effects of the Hartslag community
intervention on smoking behaviour. A description of the full
project has been published elsewhere.3
METHODS
Design and sample
To assess differences between the Maastricht and a control
region (where there was no community intervention), a pretest–
posttest control group design was used, with two posttests.4 The
baseline measurement was conducted in April 1998, the first
posttest in April 2000, and the second posttest in April 2001. At
baseline, a cohort research population of 1,200 smokers (age 18
and over) was recruited in each region by taking a stratified
random sample of 6,500 inhabitants in each region from the
computerized telephone registers, based on the number of in-
habitants in each municipality included in the region.
The control region was comparable with respect to the incidence
and prevalence of CVD, number of inhabitants, number of
municipalities, and degree of urbanisation.
The questionnaire
Data on smoking behaviour and its determinants was gathered
by means of short structured telephone interviews. Smoking
behaviour was assessed by asking respondents whether they had
smoked in the last seven days (yes/no). Only smokers were
further questioned at baseline. Smokers were asked if they had
made quit attempts in the past year. Measurements of a selection
of psychosocial determinants of smoking behaviour were in-
cluded in order to assess intermediate intervention effects. The
selection of these psychosocial factors was based on the Theory
of Planned Behaviour and the Transtheoretical Stages of
Change.5,6 Smokers were asked to evaluate their attitudes
towards smoking cessation on a ‘bad–good’ scale, and on an
‘unpleasant–pleasant’ scale. Furthermore, smokers were asked if
they intended to stop smoking in the future (intention),
how confident they were about their ability to stop smoking
(self-efficacy), and if they experienced support from important
others to stop smoking (perceived social support). All items, with
EUROPEAN JOURNAL OF PUBLIC HEALTH 2004; 14: 191–193
© European Public Health Association 2004; all rights reserved
* G. Ronda1, P. Van Assema1, M. Candel2, E. Ruland3, M. Steenbakkers3,
J. Van Ree4, J. Brug1,5
1 Department of Health Education and Promotion, Maastricht University,
The Netherlands
2 Department of Methodology and Statistics, Maastricht University,
The Netherlands
3 Department of Public Health of the Regional Public Health Institute
Maastricht, The Netherlands
4 Department of General Practice, Maastricht University, The Netherlands
5 Department of Public Health, Erasmus Medical Center Rotterdam,
Rotterdam, The Netherlands
Correspondence: Gaby Ronda, PhD, Department of Health Education and
Promotion, Maastricht University, P.O. Box 616, 6200 MD Maastricht,
The Netherlands, tel. +31 43 3882447, fax +31 43 3671032,
e-mail: G.Ronda@GVO.unimaas.nl
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the exception of perceived social support (yes/no), could be
answered on bipolar five-point scales.
Smokers were also asked if they intended to stop smoking within
the next six months (yes/no) and, if so, whether they planned to
do this within the next 30 days (yes/no). Afterwards, they were
classified into three stages of change: ‘in preparation’ if they
reported the intention to stop smoking within 30 days, ‘in
contemplation’ if they intended to stop smoking within six
months but not within 30 days, and ‘in precontemplation’ if they
had no intentions to stop smoking.
Furthermore, the posttests included questions measuring
respondents’ familiarity with smoking cessation campaigns.
Finally, respondents were questioned about their age and
education.
STATISTICAL ANALYSIS
A multiple logistic regression analysis was conducted to identify
potential dropout bias (with attendance versus dropout as the
dependent variable and baseline values for gender, age,
education, and condition as the independent variables).
Further multiple logistic regression analysis was used to identify
potential baseline differences between the Maastricht region and
the control region. The independent variables in this analysis
were the baseline values for gender, age and education. Only
respondents who completed all surveys were included. These
preliminary analyses were performed using the SPSS 10.0
statistical package.7
Differences in smoking behaviour and its psychosocial deter-
minants between the Maastricht region and the control region
at posttests were studied with multilevel regression analysis,
using the MlwiN statistical package.8 Multilevel regression
analysis was used to take into account possible dependencies
among individuals within the same municipality.9 If the multi-
level analysis revealed that individuals within municipalities
could be regarded as independent, analyses were repeated using
‘ordinary’ regression within the SPSS statistical package.7
The main independent variable included in all effect analyses
was condition. In addition, the pre-intervention score of the
outcome variable, gender, age, and education were included as
independent variables in all analyses. The intention at baseline
to quit smoking in the future was included as a further in-
dependent variable in the analyses of behavioural change.
Differences were considered to be statistically significant if
p<0.05.
RESULTS
Respondents
Overall, 8,939 inhabitants (4,242 in the Maastricht region and
4,697 in the control region) were reached by telephone. The
proportion of current smokers in this group was 34.6% (35.4%
in the Maastricht region and 34.0% in the control region). Of
those who smoked 21.6% refused the interview (19.1% in the
Maastricht region and 24.0% in the control region). Attrition
rate from baseline (T0) to second posttest (T2) was 37.9%.
The net attrition rate (after the exclusion of unreachable
respondents) from T0 to T2 was 18.7%. Overall, 1,508
respondents completed all three questionnaires: 772 in the
experimental region and 736 in the control region. Attrition did
not differ between the two regions. Moreover, there were no
significant differences between dropouts and those who parti-
cipated in all three measurements with respect to age, gender and
education. Respondents from the Maastricht region were signi-
ficantly older, more often female, and were more highly educated
than respondents from the control region (table 1).
Familiarity with the regional smoking cessation campaign in the
Maastricht region was much higher in 2001 (T2) than in 2000
(T1) (χ2 (1) = 38.46; p=0.000). Familiarity with the national
smoking cessation campaign, which was only measured at T1,
was high in both regions (table 1).
Differences between the Maastricht and the control region
There were no overall condition effects on smoking behaviour
and its determinants, although some indications of a minor
intervention effect on social support (OR=1.23; p=0.099) and
stage of change (OR=1.28; p=0.084) were present at T2 (table 2).
Table 1 Baseline demographic characteristics, smoking behaviour, and familiarity with smoking cessation campaigns in the Maastricht
region (n=772) and the control region (n=736)
Variable
Age (mean and SD in years)a
Group
Maastricht
Control
T0T1 T2
49.8
45.7
(13.6)
(14.1)
Gender (% and number)a
Male Maastricht
Control
Maastricht
Control
39.2 (303)
46.6 (343)
60.8 (469)
53.4 (393)
Female
Education (% and number)a
LowMaastricht
Control
Maastricht
Control
Maastricht
Control
Maastricht
Control
Maastricht
Maastricht
Control
35.5 (274)
36.7 (270)
47.2 (364)
50.3 (370)
17.4 (134)
13.0
100.0 (772)
100.0 (736)
Intermediate
High
(96)
Smoking behaviour (% and number of smokers)87.7 (677)
85.7 (631)
16.8 (130)
70.7 (546)
76.2 (561)
81.3 (628)
81.4 (599)
42.4 (327)Familiarity with regional campaign (% and number familiar)
Familiarity with national campaign (% and number familiar)b
a: Significant baseline (T0) differences between Maastricht and control region (logistic regression analysis).
b: Only measured at T1.
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DISCUSSION
The present study found no significant differences between the
Maastricht region and a control region on smoking behaviour
and its determinants. A possible explanation for the lack of
intervention effects are secular trends, i.e. there may not have
been enough additional exposure in the Maastricht region to
exceed secular trends like the national smoking cessation
campaign or spontaneous abstinence. Secular trends are
frequently mentioned as a possible explanation for modest or
absent intervention effects in community CVD prevention pro-
grammes.10,11 Process data of the Hartslag Limburg Community
Intervention revealed that the focus of the intervention had
mostly been on intervention activities aimed at nutrition and
physical activity. Fewer activities for smoking cessation were
developed and implemented.
Furthermore, the (reported) participation in smoking cessation
activities was greater in the control region than in the Maastricht
region. The multiple risk factor approach in Hartslag Limburg
may have reduced the potential effect on smoking behaviour
because intermediaries as well as the target population may have
preferred diet or physical activity as more attractive targets for
behaviour change.
The present study had some limitations. First, the results are
based on self-reports. Further, the psychological factors were
measured with single items. Finally, although the regions were
matched on several characteristics, the study included only one
intervention and one control region, and there were differences
in gender, age and education. In an attempt to overcome this
design weakness to some extent, the pre-intervention score of
the outcome variables, gender, age, and education were included
as independent variables in the effect analyses.
In conclusion, the results of the present study do not show a
significant impact of the Hartslag Limburg intervention on
smoking, i.e. the regional intervention could not accelerate the
secular trend.
This study was financially supported by the Netherlands Heart
Foundation.
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3 Ruland E, Harting J, Van Limpt P, et al. Hartslag Limburg:
a united approach in preventive care. Maastricht: GGD-ZZL, 1999.
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7 SPSS for Windows. Rel. 10.0. Chicago: SPSS Inc, 2000.
8 Rasbash J, Browne W, Goldstein H, et al. A user’s guide to
MlwiN. London: Institute of Education, 1999.
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to basic and advanced multilevel modelling. London: Sage, 1999.
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Received 29 August 2002, accepted 19 December 2002
Table 2 Smoking behaviour, and psychological determinants (only smokers included in analyses) at T1 and T2; parameter estimatesa
(binary and ordinal logistic regression estimates)
Variable
(measurement
level)
Smokingb
(dichotom)d
T1
Quit
attemptsc
(dichotom)
T1
1.505
(p=
0.000)
Attitude
(good)c
(ordinal)
T1
0.856
(p=
0.000)
Attitude
(pleasant)c
(ordinal)
T1
0.426
(p=
0.000)
Social
supportc
(dichotom)
T1
1.308
(p=
0.000)
Self-efficacyc
(ordinal)
T1
0.758
(p=
0.000)
Intentionc
(ordinal)
T1
0.866
(p=
0.000)
Stagec
(ordinal)
T1
1.275
(p=
0.000)
T2T2
1.105
(p=
0.000)
T2
0.808
(p=
0.000)
T2
0.491
(p=
0.000)
T2
1.324
(p=
0.000)
T2
0.835
(p=
0.000)
T2
0.706
(p=
0.000)
T2
1.271
(p=
0.000)
Pre-inter-
vention
score
Condition
(Maastricht
region=1,
control
region=0)
Age
0.203
(p=
0.099)
–0.015
(p=
0.001)
0.243
(p=
0.084)
0.015
(p=
0.003)
–0.016
(p=
0.001)
–0.015
(p=
0.001)
0.325
(p=
0.016)
–0.011
(p=
0.010)
–0.011
(p=
0.004)
–0.010
(p=
0.003)
–0.016
(p=
0.000)
Gender
(female=1,
male=0)
Education 1
(low=1,
high=0)
Education 2
(inter-
mediate=1,
high=0)
Intention
(T0)
–0.230
(p=
0.039)
–0.242
(p=
0.032)
0.393
(p=
0.039)
–0.492
(p=
0.004)
0.380
(p=
0.040)
–0.374
(p=
0.023)
–0.356
(p=
0.000)
–0.178
(p=
0.000)
0.393
(p=
0.000)
0.363
(p=
0.000)
a: Positive parameter estimates reflect a positive association between the dependent and the independent variables.
b: Lower score indicates less smoking.
c: Higher score indicates more quit attempts or more positive determinants.
d: dichotom = dichotomous
Heart Health Community Intervention
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