COMMUNITY HEALTH STUDIES VOLUME XIII. NUMBER 2, 1989

IMPLEMENTING A PUBLIC CHOLESTEROL SCREENING CAMPAIGN THE NORTH COAST EXPERIENCE

Ray James, Colin Tyler, Eric van Beurden, Denise Henrikson

Heart Heahh Program, North Coast Health Region, 31 Uralba Slreet. Lismore, 2480

Abstract Several community-based interventions in the

United States have indicated that it is possible to economically screen the blood cholesterol levels of large numbers of the population and to assist those with elevated levels to reduce their blood cholesterol. The North Coast Cholesterol Check Campaign was designed to involve existing community health staff and community volunteers in a Health Promotion Campaign to: increase community awareness of the importance of cholesterol levels in relation to coronary heart disease; to offer participants immediate blood cholesterol analysis; and to offer dietary advice to those participants who were above the recommended 5.5 mmol/L level

Fifty-two Cholesterol Check Points were conducted on the North Coast of NSW between 1 September and 15 December, 1987. Each Check Point featured a rapid cholesterol analysis with a finger-prick procedure on the Boehringer- Mannheim Reflotron System and immediate dietary counselling by trained staff for participants with elevated levels. A total of 12,067 persons participated in the Campaign: 43 per cent were found to have cholesterol levels that exceeded the recommended desirable levels set by the Australian National Heart Foundation. A 4-5 month follow up of 61 per cent (3,164) of these individuals indicates that 72 per cent lowered their blood cholesterol levels and 65 per cent reduced their BMI. Mean cholesterol change was 0.65 mmol/L and mean BMI change was 0.5 1.

‘The results indicate the potential for similar community-based nutrition education programmes to reduce cholesterol levels in Australia. This paper details the rationale for the North Coast Cholesterol Check Campaign and the issues concerned with implementation of the campaign.

Introduction Cardiovascular disease (CVD) accounted for 48

per cent of the deaths in Australia in 1986 and 29 per cent of these may be classified ‘premature’.’ Although the death rates from CVD have fallen steadily during the last 40 years the total deaths from

JAMES et a1 130

CVD are still nearly twice those from cancer (24 per Cent of total deaths) and 18 times those from traffic accidents (3 per cent of total). CVD is also the greatest cause of permanent disability and accounts for more days of hospitalization than any other disease. Fifty-eight per cent of all cardiovascular deaths are due to coronary heart disease(CHD) and 23 per cent to stroke.’ These two comprise 80 per cent of the CVD deaths.

The economic burden of CVD takes a large portion of the total health care budget: direct medical costs for CVD were $2,147 million in 1984/85 with at least $480 million spent on coronary heart disease alone.* The total economic cost of CHD was close to $1,280 million. The additional $800 million represents the value of wages lost due to premature disability or mortality and the lost productivity from diminished capacity*.

The economic, social and personal costs of CVD led the Better Health Commission to make the reduction of cardiovascular disease the number-one health priority for Australia during the next decade.3 Since nearly 60 per cent of all cardiovascular deaths are due to C H D and Australia ranks 9th amongst developed countries for CHD we will concentrate our discussion on the reduction of heart disease.

Epidemiological explanations for the prevalence of C H D focus on the concept of ‘risk factors’. Population studies, animal experiments and clinical trials indicate that the major risk factors are high blood cholesterol, smoking and high blood

Davis reports that nearly 30 national or international expert committees have generally agreed on the part played by each of these risk factors and the likely benefits to be gained from modifying them.8

While the majority of scientific evidence indicates that elevated blood cholesterol is the major risk factor for CHD, the public’s perception is that this is the least important and the most difficult to change.9 We believe we must increase the public’s awareness of the importance of blood cholesterol levels and assist those with elevated levels to immediately reduce them to safer levels.

COMMUNITY HEALTH STUDIES

A review of the scientific literature on the role of blood cholesterol and the risk of C H D by Grundy confirms that blood cholesterol levels are “correlated significantly with the prevalence ofCHD”. IOGrundy further suggests that this is not a strict threshold concept. Data from the Multiple Risk Factor Intervention Trial indicate that the relationship is curvilinear.’! As concentrations of cholesterol increase, the atherogenic process progresses and the risk of C H D is compounded. Thus when blood cholesterol levels are near 5.17 mmol/L (and no other risk factors are present) a critical degree of atherosclerosis is reached by many people by the age of 70. If the cholesterol level is 6.47 mmol/L the same degree of sclerosis would be attained by age 60. It thus behoves an individual to maintain cholesterol levels as low as possible. Pyorala recommends a population mean blood cholesterol level less than 5.2 mmol/L as a long term goal.12 At present about half of all adults in Australia have levels above 5.5 mmol/L and 20 per cent have unacceptably high cholesterol concentrations of 6.5 mmoljL or more. The current mean blood cholesterol for the Australian population is 5.65 mmol/L.I3Each 1 per cent decrease in blood cholesterol levels is associated with a 2 per cent reduction in CHD risk.14”’

Animal, metabolic and clinical studies cited by Ernst and Cleeman have all shown that it is possible to increase or lower blood cholesterol levels through drug and dietary interventions.16 The Lipid Research Clinics Coronary Primary Prevention Trial reported conclusively, in 1984, that lowering high blood cholesterol levels reduced the risk of CHD.14 The study indicated &hat a 9 per cent decrease in total cholesterol was associated with a 19 per cent reduction in CHD deaths. Data from the 1987 Cholesterol Lowering Atherosclerosis Study showed that drug and dietary interventions to lower blood cholesterol actually produced regression of coronary atherosclerosis in men with coronary bypass grafts. 17

The prevalence of CHD and the high costs to the community have led to the development of a range of lipid-lowering drugs. Nestel has recently provided a detailed guide to the pharmacological treatment of hypercholesterolaemia.18 Due to the costs and undesirable side effects of many of these drugs, however, drug therapy is only recommended for those individuals who are ‘high risk‘, or have two or more risk factors, and then only after a dietary i n t e r v e n t i ~ n . ~ ~ ’ ~ ~ This dietary intervention is basically a reduction in saturated fats and an increase in complex carbohydrates. A person who receives appropriate counselling and adheres to the dietary regime can expect to lower their cholesterol level by 10-15 per cent in 3 months.16

The high prevalence of CHD in Australia and

JAMES et a1 131

the direct relationship with cholesterol levels has promoted an increased interest in a population approach to reducing cholesterol through nutrition education. McNeil contends that the best strategy for a reduction in the incidence of CHD in Australia is for the majority of the population to adopt life style changes that affect all coronary risk factors favorably. The adoption of a diet that is substantially lower in saturated fat is a key component of this strategy.20

Recent population-based studies have shown the potential for nutrition education to assist people to reduce blood cholesterol levels. Farquhar’s early work at Stanford in the 1970’s indicated the potential for mass-media educational campaigns to reduce the risk of cardiovascular disease in the community.21 More recently, the Pawtucket Heart Health Program has demonstrated that public campaigns can result in significant changes in cholesterol levels for a substantial number of people within two months following ‘a screening and educational intervention.22 Walter et al. have shown that screening and educational programs in primary schools can have a favorable effect on blood cholesterol levels of children.23

The advantage of a population-based intervention is the potential for reducing the risk of coronary disease in the mid-range of the population distribution of cholesterol levels. As Rose pointed out in 1981, =a large number of peopleexposed to a low risk are more likely to produce more cases than a small number of people exposed to a high risk”.24 In Australia the greatest number of CHD episodes occur in persons whose cholesterol levels would not be considered significantly elevated.20

Recently developed dry chemistry analyzers, which permit the quick measurement of cholesterol levels at low cost, have made it possible to screen and educate large numbers of clients, in a short time, in easily accessible venues. The American Health Foundation was able to screen over 12,000 participants in five days; a team at the University of Rochester School of Medicine and Dentistry screened 1,OS 1 peo le in 10 hours for an average cost of $3.00 per test?” Studies conducted in Australia have shown these ‘dry analyzers’ to be portable, easy to use, reliable, and as accurate as commonly used laboratory te~hniques.~’’~

The evidence gathered by the Better Health Commission and by the National Heart Foundation indicating the economic, social and personal costs of CHD; the research supporting the benefit of reducing blood cholesterol levels, and the results of several large scale cholesterol education programs indicate the need for a national cholesterol reduction program in Australia. The availability of the technology for rapid screening, combined with

COMMUNITY HEALTH STUDIES

current knowledge regardin dietary modification, makes now the time to act. 8 2 0 10

The North Coast Cholesterol Check Campaign The North Coast Cholesterol Check Campaign

(NCCCC) was initiated in April 1987 as a community-based demonstration and research project designed to assist the public to lower their blood cholesterol levels. The North Coast Health Region (NCHR) is situated in the northern corner of New South Wales. In 1987 the regionstretched from Tweed Heads in the North to Taree in the South, a dis tance of 600 kilometres, compris ing approximately 424,000 people. The Regional population is predominantly Anglo-Saxon with 6 per cent of the population Aboriginal, mean education level is 9 years of schoolingand the mean age is 41 with 50 per cent of the population between the ages of 25 and 65. While the average income is between $12,000 and $15,000 p.a., 34 per cent of the population is below the $9,000 p.a. poverty level.

In 1987 the North Coast Health Region had 23 hospitals and 20 Community Health Centres and employed approximately 3,000 staff with over 300 of these working in community-based centres. The Region's staff development officers, media and library resources are located in acentral unit (Health Education Services) in Lismore.

In April 1987, a small Heart Health Unit (3 people) was formed by the North Coast Health Region to plan campaigns to improve the health status of residents of the Region following priorities set by the Better Health Commission.29 The first priority of the Heart Health Unit was to reduce the incidence of cardiovascular disease in the Region. While the major focus of the Unit was to translate heart disease prevention research into effective programs it was also deemed necessary to conduct a thorough evaluation of the campaign interventions. The Heart Health Unit was attached to Health Education Services in order to give it the media, library, and secretarial support it needed. Given its small number of staff, and the large geographical area for which it was responsible, several key decisions were made by the team.

The team elected to focus its resources. for the first two years, on the issue of cholesterol; in subsequent years it would address the topics of weight control, exercise and blood pressure. There arc concurrent stopsmoking initiatives already in place in the Region and these would continue. The purpose of the Cholesterol Check Campaign was to increase community awareness of the relationship between cholesterol and coronary heart disease and of the importance of reducing fat in the diet. Participants with elevated cholesterol levels (above 5.5 mmol/L) would be targeted for an educational

JAMES et al I32

intervention, referrJ and follow-up assessment. The team decided to concentrate on a basic and simple educational message 'eat less fat' rather than the more complicated 'reduce saturated fat and eat more carbohydrates' due to research showing the effectiveness of the former in studies conducted in Western Australia and the problems of delivering messages that contained a large amount of factual information or were complicated.'' "

The Campaign team also decided to utilize existing health staff and community volunteers to run the screening, education and referral events (SCORES) .~~ We believed that the success of the campaign would be determined by our capacity to mobilize these people. This would enable a small central team with limited financial resources to interact with at least 5 per cent of the adult population ( I 2,000) in each of the first two years of the program. The ultimate target was to reach 20-25 per cent of the adult population of the Region.

After reviewing the literature and field testing two portable blood analyzers (the Kodak Ektachem DT60 and the Boehringer-Mannheim Reflotron) a decision was made to utilize the Reflotron System because of its ease of use, cost and 3 minute analysis time. The Heart Health Unit then acquired four of these machines: one for training, two for the screening events and one machine for back-up purposes. An agreement was then made with the Boehringer-Mannheim Distributor in Sydney NSW to provide technical support and assistance with training in the proper use of the Reflotron System.?" These key decisions shaped the North Coast Cholesterol Check Campaign.

The Campaign Strategy The North Coast Cholesterol Check Campaign

was organized as a Regional Health Promotion event which focused on cholesterol screening, with a nutrition education intervention component, leading to a reduction of fat in the diet. The principal goal of this campaign was to make the community aware of the importance of maintaining a safe level of cholesterol in the blood by reducing their overall intake of fat. The main objectives were: 0 to assist local Area Health Services to sponsor

co-ordinated Health Promotion Activities; 0 to assist local Area Health Services to promote

themselves in the community; to provide each local Area Health Service with information regarding nutrition and diet needs in the community:

0 to provide an in-service training for health staff and selected community members on the importance of cholesterol in coronary heart disease; to screen the non-fasting blood cholesterol levels

COMMUNITY H E A L T H STUDIES

of 5 per cent of the NCHR’s adult population. t o provide a brief nutrition education intervention regarding fat in the diet to those who presented with elevated cholesterol levels; to provide a follow-up test for those participants who had elevated cholesterol levels; to collect a general health data base on 5 per cent of the NCHR population; to evaluate the impact of this type of screening/education intervention on community behaviours regarding cholesterol, weight, Body Mass Index (BMI) and dietary change.

The campaign strategy was to implement a number of screening ‘events’ in community venues throughout the Region from I September to I5 December, 1987. Each of these events would include data collection, cholesterol screening, nutrition advice and referral, and they were to be run in a uniform, standardized manner as described in the Methodology and Protocol training manual developed by the campaign team.35

Implementation Each of the 10 Planning Areas in the Region had

responsibility for selecting a local supervisor, a team for the delivery of the event, venues and screening dates. Each Planning Area was allocated a maximum of six consecutive days to conduct the cholesterol screening event and each Area was asked to screen at least 5 per cent of their adult population. Screening events were to be conducted in an enclosed venue that was easily accessible to the public. Two pilot studies conducted in the- region indicated that it was not necessary to publicise the screening event in the local media. In fact, any comment on the radio or newspapers usually brought out more people than the team could screen in a day.

The screening team was selected from existing health staff (the majority from the community-based staff) and community volunteers. These people were then trained by the project officer and a nutrition consultant in a threehour training program approximately one week before implementing the SCORE in their local community. The training program had four components:

the rationale for a comprehensive campaign to prevent coronary heart disease and the importance of cholesterol as a risk factor, discussion of the nutrition education message‘eat less fat’ that would be used in the campaign and the training of the ‘cholesterol advisors’; training on the Reflotron System; an explanation of the protocol for running the

JAMES et al I33

event, including screening the population and offering nutrition advice to those with elevated cholesterol levels. A Cholesterol Event ‘package’ consisting of two

Reflotron Dry Chemistry Analyzers, display stands, tables and chairs, promotional material, handouts and cholesterol information was designed to fit into a one tonne, E series, Mazda panel van. Thcvan was delivered to the local team at the beginning of the time they had allocated for screening. A team of eight staff, with two Reflotrons, could screen and educate approximately 200 clients in 7 hours. Community Volunteers were used to distribute the data card, collect a $2.00 fee, and take height and weight measurements. Members of the health staff and selected community members (community educators or weight control leaders) were used as ‘cholesterol advisors’ and only trained nurses were used on the Reflotron.

Participants moved from a waiting area to the blood screening stations as openings became available. The whole screening process averaged 15-20 minutes; waiting time was between 5 minutes and 2 hours, depending on the size ofthecrowd. The education component took approximately 10 minutes and followed guidelines set forth in a ‘fact sheet’. Screening usually ran from 10 am to 5 or 6 pm; some Areas also did screening in conjunction with late-night shopping. Several screening events were also conducted in worksites.

All participants were required to fill in a data card which included their name, address, information on age, sex, education and previous cholesterol readings. Participants then paid‘a $2.00 fee for the cholesterol test and had their height and weight recorded. AH participants were given NHF information on cholesterol, heart disease, and the importance of maintaining a low fat diet. Those participants who were screened as under 5.5 mmol/L were given a red heart (sticker) that said ‘I’m Desirable’ and were encouraged to maintain a low fat diet. Participants whose cholesterol levels were above 5.5 mmol/L were asked to speak with the cholesterol adviser. All of these people were given the ‘fact sheet’ and a brief consultation on ‘five ways to reduce fat in the diet’. Those participants between 5.5 mmol/L and 6.5 mmol/L were encouraged to go to their family doctor for a second test; those above 6.5 mmol/ L were strongly urged to see their family doctor for a fasting cholesterol test including HDLs.

Doctors in each Planning Area of the Region were contacted by the NSW State branch of the National Heart Foundation approximately one week before the screening event was to occur in their Area. These doctors received a letter encouraging them to support the campaign and a copy of the National Heart Foundation publication. The

COMMUNITY HEALTH STUDIES

Fami!)! Doctor’s Coronary Risk Handbook, which describes the protocol for dealing with hypercholesterolaemia. T w o seminars on cholesterol and heart disease were conducted for medical officers in the Region by the State branch of the National Heart Foundation during the Campaign. (A separate analysis of GP support for the program is described elsewhere.36)

A booster letter that encouraged participants to continue to reduce the fat in their diets and offered more assistance in the form of books on diet,

exercise and nutrition, which could be purchased from the Campaign team, was sent out four weeks after the initial screening. A separate analysis of the effectiveness of the booster letter is described elsewhere.3’

Four weeks prior to the date for the second test a recall letter was sent to all participants who had cholesterol levels above 5.5 mmol/L. Potential participants were asked to contact the local Health Service to make an appointment for the retest. There was no charge for this test. Only cholesterol

TABLE I

Characteristics of Screened Population

Number Percent

Sex Male 4832 40%

Female 7235 60%

TOTAL 12,067

Age Range 18-98

Mean Age 49

Cholesterol (mmol/ L)

<5.5 6862

5.5 - 6.5 3237

>6.5 1968

Mean Cholesterol 5.42

BMI >25 555 I

Mean BMI 25.08

High Blood Pressure (Treated) 2655

Family History Of Heart Disease 4465

Previous Cholesterol Test 3620

Current Smokers I689

Number per Day (mean) 16

Exercise (Never/ Rarely) 7964

57%

27%

16%

46%

22%

37%

30%

14%

66%

JAMES et a1 134 COMMUNITY HEALTH STUDIES

TABLE 2

Age, Sex, mean Cholesterol and Mean BMI Whole Sample

n = 12,067

Age Male Female SubTotal

Mean Mean Mean Choles- Mean Choles- Mean Choles- Mean

N terol BMI N terol BMI N terol BMI (mmol/L) (mmol/L) (mmol/L)

<35 720 4.57 24.27 1173 4.66 22.64 1893 4.62 23.25

35-54 1944 5.35 25.81 2941 5.20 24.56 4885 5.27 25.06

>54 2174 5.50 26.18 3115 6.07 25.42 5289 5.84 25.88

Sub Totals 4838 5.31 25.77 7229 5.49 24.62 12067 5.42 25.07

levels and weight were measured at this time. All data collected were recorded and analyzed by the Heart Health Unit. A report was then sent to each local Planning Area on the results of their screening events. This information was then disseminated by the screening team to the local media.

Results Fifty-two Cholesterol Check points were

conducted on the North Coast between I September and 15 December by 160 health staff and 150 community volunteers; 12,067 people were screened, 43 per cent (5,205) of these were over 5.5 mmol/L and 16 per cent (1,968) were over 6.5 mmol/L. The mean age of the group was 49 (18-98) with 60 per cent females. The average cholesterol level was 5.42 mmol/L. Thirty per cent of the sample indicated they had previously had a cholesterol test but only I I per cent could say what the result was. Twenty-two per cent of the sample population said they were being treated for high blood pressure but only 12 per cent could say what their current level was. Fourteen per cent of the sample were smokers (average 16 per day), 66 per cent indicated they never or rarely exercised and 46 per cent were over the recommended BMI of 25. Thirty-seven per cent of the sample had a family history of heart disease (see Table I). Table 2 shows an age by sex analysis of the mean cholesterol and BMI levels for the entire sample.

The 6,862 participants who had levels below the recommended 5.5 mmol/L were told that their cholesterol levels were within the ‘desirable’ zone and they were encouraged to maintain a healthy diet and have another test in two years. The 5,205 participants who were over 5.5 mrnol/L were offered a free second test 4-5 months later. A computerized register maintained by the Heart Health Unit allows for a systematic follow up of these individuals. Recall letters were sent out to all of these people four weeks before the second test dates. Of the 5,205 participants who were over 5.5 mmol/L a total of 3,164 (60.8 per cent) returned for the second test; 72.5 per cent of these subjects reduced their cholesterol and 65 percent reduced their BMI. Mean cholesterol change for the retest group was a 0.65mmol/L, a 10 per cent reduction, and mean BMI change was 0.51, a 2 per cent reduction. Analysis by paired t test indicates that these reductions were significant for both males and females (P<.OOl) .

Table 3 shows the frequency of cholesterol risk reduction in the sample who attended the retest. Nearly 37 per cent of this sample shifted to the ‘desirable range’ with the greatest number shifting from the moderate to the desirable category.

Discussion The North Coast Cholesterol Check Campaign

has shown that it is possible to assist community

JAMES et al 135 COMMUNITY HEALTH STUDIES

TABLE 3

Frequency of Cholesterol Reductions in Retest Sample

(n = 3164)

Change n 9%

Moderate (5 .5-6.5)

(6.5-7.5)

P7.5)

High

V. High

To Desirable (<5.5)

(<5.5) To Desirable

To Desirable (<5.5)

Total

members to make dietary changes that lead to a significant reduction in total blood cholesterol and BMI. The campaign demonstrated also that this reduction can be achieved by utilizing existing health care resources. In effect, we did no more than focus the desire and intention of health care workers to reduce the burden of coronary heart disease into a structured and disciplined activity. This approach challenges the belief that we need to create new structures to deliver health promotion services and indicates how it is possible to access an extensive resource base in order to deliver a comprehensive campaign. By integrating with existing health care services (hospitals and community based staff), medical providers (G.P.s), and community members, it was possible to present this campaign as a part of the normal health service mix rather than as something superimposed by medical or ‘health promotion’ specialists.36

The major difficulty that we encountered was ensuring that the program was implemented exactly as planned. Quality control of the data collection, measurements and nutrition advice required specific training and direct supervision. We quickly learned that all staff recruited to the program must be trained and certified by our project officers and then placed under a trained local supervisor. We found it helpful to develop ‘quality assurance’ checklists and train the supervisor to use these to monitor the screening events.

The second largest problem was recruitment of Health Service staff. Although community-based staff in our Region are required, by Regional objectives, to spend at least 10 per cent of their time

JAMES et a1 I36

908 28.7

210 6.6

51 I .6

1 I69 36.9

in ‘health promotion’ activities, many staff members complained that the cholesterol screening events were added to their normal work routines. Naturally this created some resistance to participating in the campaign. We have discussed this matter with Senior staff in the Region and we have also decided that we would utilize more community volunteers in the future.

Our third problem was simply the volume of community members who wished to be screened. With minimal advertising, nearly every Cholesterol Check station had to turn people away at the end of the day. This created some difficulty for the local Area teams but it also indicated the tremendous interest in cholesterol testing. We suggested that people who were not able to be screened should visit their family doctor for a lipid panel and we also began to investigate ways to increase the number of people we could screen each day.

Our final problem occurred in the analysis of the results of the cholesterol measurements. Because we were not able to include a control group which did not receive an intervention, there is the possibility that some of the 10 per cent reduction in mean cholesterol levels is due to the phenomenon of ‘regression to the mean’. There is also some possibility that cholesterol measurements taken between January and February are systematically lower than those taken in July and August. We have done a separate analysis of the adult population between the ages of 25-64 which makes allowance for the first of these factors (regression towards the mean), and we still show a net improvement in mean cholesterol levels of 8 per cent.

COMMUNITY HEALTH STUDIES

Thanks to feedback from the local Supervisor of the Cholesterol Screeningevents(S0CC). the teams, and the public we have been able to modify the program in order to increase its efficiency and effectiveness. We are now implementing our third year of public cholesterol screening. We can screen over 200 people in 6 hours, guarantee within 5 per cent accuracy on all cholesterol measurements and minimize work for local Health Services.

The key factors in the success of this population- based nutrition education intervention were: accessibility; a trigger event; immediate feedback and counselling a goal; a simple, direct message on how to reach the goal; behavioural steps for success; a 'second chance'; and timing.

The NCCCC was conducted in venues that were accessible to the public; shopping centres, community health centres and worksites. The SCORE was presented in an attractive, 'upmarket' fashion that de-medicalized the screening intervention and encouraged participation by a wide range of the population. The 'trigger event' was the opportunity to have a cholesterol test conducted for a low cost, with results within three minutes.

The ability to have the results within three minutes made it possible to give dietary advice to those participants who had elevated cholesterol levels when they were in the 'teachable moment'. This might prove to be the single most important aspect of the total program. Counselling was provided to help participants achieve a goal: a desirable level of total cholesterol. The message was simple; to reduce your cholesterol 'Eat less Fat'. Cholesterol Advisors then discussed 5 behavioural steps to help participants reduce the amount of fat in their diet. Participants were then offered a second test in 4-5 months to check their progress. Sixty per cent of the original sample of participants who had elevated cholesterol levels returned for the second test.

A phone survey of 100 participants who had cholesterol levels over 6.5 mmol/L and did not return for the second test indicates that 30 per cent could not attend the second test because they were on holiday, 25 per cent were under supervision by their own doctor and did not think it was necessary, 16 per cent did not receive notification and for 28 per cent it was simply an inconvenient time for them. Only 1 per cent indicated that they did not attend the retest because they did not feel they had made any progress. An analysis of the retest group shows only small differences from the original portion of the sample who had elevated cholesterol levels when compared for sex, age and BMI. There was no significant difference for cholesterol (p=O. 144). It appears that people slightly older came for the second test and slightly heavier people were less

JAMES et al 137

likely to return. The timing of this intervention was a crucial

element in its success. The National Heart Foundation has been actively educating the public and the medical community regarding the CHD risk associated with elevated cholesterol levels since 1980 and the Better Health Commission has recently made CVD risk reduction the major public health priority for Australia, Although Pierce and associates reported in I985 that the public needed to be better informed regarding the importance of reducing cholesterol levels. it seems that successive media campaigns by the Heart Foundation in 1986 and 1987, the introduction of new cholesterol lowering drugs, and the development of low cost, accurate cholesterol testing machines have made cholesterol a household word and virtually a new lifestyle factor in Our pilot studies and qualitative research showed that the community knew what to do regarding elevated cholesterol levels, or could easily access that information, but they still had not made the necessary behaviour changes to their diet. We believe that community members require a'push', or a'cue to action'that will motivate them to modify their nutrition habits and they need an opportunity to demonstrate their ability to succeed.

Previous studies in the USA have shown that the population will respond to public cholesterol screening events and that dietary advice to reduce fat in the diet can significantly reduce cholesterol

It appears to be time to implement similar programs in Australia and the NCCCC offers one possible approach.

Research conducted by the Pawtucket Heart Health Program indicates that what is crucial to the success of any public cholesterol screening program aimed at assisting the public to lower their cholesterol levels, by making dietary changes, is the use of a campaign straregy that incorporates the above mentioned elements and presents them to the community in an organized and systematic manner.40 For community-based health promotion efforts to successfully reduce the economic and social burden of C H D in an effective and cost- efficient manner we must utilize the existing resources in the best possible way. A campaign strategy will allow us to set targets, monitor achievement, evaluate outcomes and adapt the intervention to suit the particular needs of the Australian population.

The North Coast Cholesterol Check Campaign has shown the positive effect such a campaign can have on the community. Further research now needs to be conducted to determine the most cost-effective manner of delivering the SCORE, the impact of the campaign on different target groups, the potential

levels.?? Qq/26

COMMUNITY HEALTH STUDIES

for replicating the campaign in other regions of New Acknowledgement South Wales and the cost benefit of public The authors thank The Health Staff and cholesterol screenings to reduce CHD. Community Volunteers who made this program

possible.

References

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2. Gross P. National Health policies: Thechallenge of heart disease. Part 2 The cost of heart disease. Medical Observer August, 1987.

3. Cardiovascular Disease: Preventing a n Unnecessary Way 'of Death; The Report of the Cardiovascular Disease Task Force of the Better Health Commission. Australian Government Publishing Service, 1987.

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17. Blankenhorn DH, Nessim SA, Johnson RL, et al. Beneficial effects of combined colestipol- niacin therapy on coronary venous bypass grafts. JAMA 1987; 256: 3233-3240.

18. Nestel P. Managing Hyperlipidaemia. Med J Aust 1988; 148: 29-31.

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