How can the results of a qualitative process evaluation be applied in management, improvement and modification of a preventive community trial? The IHHP Study

BACKGROUND: This study reports the results of the qualitative process evaluation (PE) of the Isfahan Healthy Heart Program (IHHP), an integrated community-based trial for prevention and control of non-communicable diseases in Iran. METHODS: The study explored the overall quality of program implementation. The participants, including designers of IHHP, stakeholders and community members (n = 60) were purposefully recruited from the intervention areas. Data collected from semi-structured interviews and field notes were analyzed using a modified thematic analysis. RESULTS: Four main themes were identified. Our findings highlighted the key role of the resources as both facilitating and hindering factors. IHHP directors faced incompatibilities arising from negative perceptions/attitudes which resulted in decreased adherence to the program. Hence various strategies were used to motivate, strengthen and organize the human workforce implementing the program. CONCLUSION: Recommendations arising from evaluation of the program were used in subsequent stages of implementation. Qualitative research is an important component of community trials which can improve their implementation

Gender Differences in Obesogenic Behaviour, Socioeconomic and Metabolic Factors in a Population-based Sample of Iranians: The IHHP Study

This study investigated the gender differences in association of some behavioural and socioeconomic factors with obesity indices in a population-based sample of 12,514 Iranian adults. The mean body mass index (BMI), waist circumference (WC), and the waist-to-hip ratio (WHR) were significantly higher in women than in men. Current and passive smoking had an inverse association with BMI among males whereas current smoking, transportation by a private car, and longer duration of watching television (TV) had a positive association with BMI among females. Current and passive smoking, cycling, and Global Dietary Index (GDI) had an inverse association with WC among males. Higher consumption of fruits and vegetables, current and passive smoking, duration of daily sleep, and GDI had an inverse association with WC among females. Using a private car for transportation had a significant positive association with WHR among both males and females. Living in an urban area, being married, and having a higher education level increased the odds ratio of obesity among both the genders. Non-manual work also increased this risk among males whereas watching TV and current smoking increased this risk among females. Such gender differences should be considered for culturally-appropriate interventional strategies to be implemented at the population level for tackling obesity and associated cardiometabolic risk factors

Differences in the prevalence of metabolic syndrome in boys and girls based on various definitions

BACKGROUND: The prevalence of metabolic syndrome (MetS) is increasing among children and adolescents. However, the prevalence of this disorder varies based on its different definitions. This study aimed to determine the prevalence of MetS in Iranian adolescents in junior high and high schools according to the definitions provided by the International Diabetes Federation (IDF) and De Ferranti. METHODS: Overall, 1039 junior high school and 953 high school students were selected using multistage random sampling. Demographic data was collected using validated questionnaires. Fasting blood sugar, total cholesterol, triglyceride, high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) levels were determined. Waist circumference and blood pressure were measured by trained individuals. Subjects with MetS were selected according to two definitions provided by the IDF and De Ferranti. Chi-square and Fisher&rsquo;s exact tests were used to compare the prevalence of MetS and its components based on sex, school level, and the two definitions. RESULTS: The mean age of junior high and high school students was 13.11 &plusmn; 1.21ad 15.93 &plusmn; 1.07 years old, respectively. The prevalence of MetS among all participants was 4.8% and 12.7% according to the definitions by the IDF and De Ferranti, respectively. It was significantly higher among boys compared to girls. According to the IDF definition, low HDL-C and hypertension were the most frequent components. Based on the De Ferranti, abdominal obesity and hypertriglyceridemia were the most frequent components. CONCLUSION: The prevalence of MetS was higher in both groups of students based on De Ferranti definition compared to the IDF definition. The prevalence was not significantly different in boys and girls. Further studies to investigate the most suitable definition of MetS for Iranian adolescents are necessary. &nbsp; Keywords: Metabolic Syndrome, Adolescence, International Diabetes Federation and De Ferranti</div

The impact of obesity on hypertension and diabetes control following healthy Lifestyle Intervention Program in a developing country setting

Background: The aim of this study was to evaluate the impact of obesity and overweight on diabetes mellitus (DM) and hypertension (HTN) control in a healthy lifestyle intervention program in Iran. Methods: Within the framework of the Isfahan Healthy Heart Program (IHHP), a community trial that was conducted to prevent and control cardiovascular disease and its risk factors, two intervention counties (Isfahan and Najafabad) and one reference county (Arak) were selected. Demographic information, medical history, anti-diabetic and anti-hypertensive medications use were asked by trained interviewers in addition to physical examination and laboratory tests for 12514 adults aged more than 19 years in 2001 and were repeated for 9572 adults in 2007. Results: In women, the frequency of HTN control change significantly neither in normal weight nor in those with high body mass index (BMI), waist circumference (WC) or waist to hip ratio (WHR). In men, the frequency of HTN control was only significant among those with high WHR, whereas the interaction between changes in intervention compared to reference area from 2001 to 2007 was significant in men with normal or high WC or WHR. In intervention area, the number of women with high BMI who controlled their DM increased significantly from 2001 to 2007 (p = 0.008), however, this figure decreased in men. In reference area, obesity indices had no significant association with DM control. The percentage of diabetic subjects with high WC who controlled their DM decreased non-significantly in intervention area compared to reference area in 2007. A non-significant increase in controlled DM among men and women with high WHR was observed between intervention and reference areas. Conclusions: Our lifestyle interventions did not show any improving effect on HTN or DM control among obese subjects based on different obesity indices. Other lifestyle intervention strategies are suggested

The sustainability of interventions of a community-based trial on children and adolescents’ healthy lifestyle

BACKGROUND: Sustainability is the core of a successful health-related intervention program. This study was conducted to evaluate the sustainability of interventions of the Heart Health Promotion from Childhood (HHPC) project, one of the 10 interventional projects of the Isfahan Healthy Heart Program. METHODS: The evaluation of HHPC included administrating surveys to 500 elementary and middle, and 500 high school students. The study participants were randomly selected from all schools in Isfahan. The questionnaires were administered by interviews to evaluate the sustainability of interventions. RESULTS: The results of interviews showed that interventions were sustainable in 100% of elementary school, 99% of middle school, and 87% of high school students. Training of healthy lifestyle behaviors was significantly higher in all-girls middle schools (P &lt; 0.001). Daily morning exercise was more frequent in girls high schools (P &lt; 0.001), while selling unhealthy food was more frequent in boys high schools (P &lt; 0.001). The participants attributed the success of the program mostly to students&rsquo; agreement and cooperation. CONCLUSION: Even though 5 years have passed since the end of the HHPC project, many of the interventions have been continued at the schools, often because healthy behaviors have become institutionalized in the target population. However, now all schools have the same level of sustainability, especially the middle and high schools, and all-boys schools. Therefore, it is important for future projects to place additional emphasis on these institutions for future school-based interventions. &nbsp; Keywords: Behavior, Community Health Planning, Institutionalization, Schools, Sustainability&nbsp;</div

Parental perceptions of weight status of their children

BACKGROUND: Understanding the knowledge, attitudes, and beliefs of parents is important for planning appropriately to control their children&rsquo;s weight. We aimed to study these variables in parents of normal, underweight, overweight, and obese children. METHODS: This cross-sectional study targeted the parents of normal, underweight, overweight, and obese children, who were selected using multistage random sampling method. The parents&rsquo; knowledge, attitudes, beliefs, and behaviors about the weight status of their children, weight management, obesity, diet, lifestyle, and related psychosocial factors were evaluated using a validated questionnaire. The questionnaire, which had been validated, consisted of 12 demographic, 8 knowledge, 19 attitude and beliefs, and 25 behavior questions. Mean knowledge, attitude and beliefs, and behavior scores were compared across three subgroups of parents. Student&rsquo;s independent t-test, ANOVA, and Kruskal-Wallis test were used to study the correlation between different demographic and socioeconomic factors, and the studied variables. RESULTS: 90% of parents were aware that obesity is a disease, and 92% knew that eating too much fast food would lead to obesity in children. Only 5% assumed that obese children are healthier than non-obese children. The mean scores of the three subgroups showed no significant difference in knowledge, attitude and beliefs, and behavior. Families with fathers, whose education level was higher than high school diploma, rated their children&rsquo;s weight status as overweight or obese significantly less than families with fathers, whose education level was high school diploma or lower (8.5% vs. 16.5%, respectively, P = 0.014). Only 12% of parents tried to help their children lose weight at least once, and only 6% arranged sport activities for the family members. In 57% and 41% of families, the child, respectively, decided how much time was enough to watch TV, and how much chocolates and sweets to eat. 46% of children watched TV for more than 2 hours/day, and 49% of children watched TV while eating meals. The mean total score of boys&rsquo; parents was significantly lower than that of girls&rsquo; parents (P &lt; 0.05). Families with low income, with no medical insurance, or not owning a house thought that the cost of registration in sport activities for children was too high (P &lt; 0.03). CONCLUSION: Some parents unreasonably rated the weight status of their children as overweight/obese. It is suggested that further studies be carried out to evaluate and improve parents&rsquo; knowledge, attitudes, and behaviors regarding their children&rsquo;s weight. &nbsp; Keywords: Children, Obesity, Overweight, Knowledge, Attitude, Belief, Behavior</div

The outcome of secondary prevention interventions in a community based interventional Program: Isfahan Healthy Heart program

Background : Healthy Life for Cardiovascular Patients(HLCP), one of the ten projects included in Isfahan Healthy Heart Program, was designed and performed based on high-risk and secondary prevention strategies and aimed to reduce cardiac recurrences, along with the risk factors, morbidity and mortality among cardiovascular patients. In this study we investigate the trend of changes of frequency of coronary patients’ medicine intake, aswell as the results of process evaluation. Materials and Methods: Five main strategies were designed to meet the project's goals. These interventions were designed based on education, legislation, and attracting inter-division and public cooperation. Process evaluation was performed in order to determine the project's successfulness. Prior to the project, the morbidity and medicine intake among the patients were also studied. These indices were again measured during the interventions and also after the project were completed. Results: Amongst all the interventions, educating the patients during the hospitalization period, at the time of release and also post-release educations were successful. Another success of the project in merging secondary prevention programs in the society was to attract public coordination and to establish a Non-Governmental Organization. The results also show an increase in the amount of aspirin, beta blockers, Angiotensin Converting Enzyme (ACE) Inhibitors, and statins taken by cardiovascular patients during the project. Conclusion: The results suggest that secondary prevention and cardiovascular patient care promotion interventions can be performed using available facilities

Metabolic syndrome and health-related quality of life in Iranian population

Background: To investigate the association between Metabolic syndrome (MetS) and Health related quality of life (QoL) in Iranian population. Methods: We used data from the post-intervention phase of Isfahan Healthy Heart Program (IHHP), a community trial for cardiovascular disease (CVD) prevention and control. We recruited 9570 healthy adults, aged ≥ 19 years who were randomly selected using multistage random sampling method. World Health Organization QoL questionnaire (WHOQOL-BREF) which contains 26 items was used to assess QoL. It assesses four domains of QoL; Physical health, Psychological health, Social relationship and Environmental issues. MetS was defined based on ATP III criteria. Results: The mean age of participants was 38.8±15.6 years (mean ± SD) and the prevalence of MetS was 22.5%. From all participant 18.2% were illiterate and 13.2% had university educational level. Two way multivariate analyses of covariance (MANCOVA) test after adjusting age showed significant difference between women with and without Mets in regard to physical health and social relations domains, while none of QoL domains was different in men with Mets in comparison to men without it. Conclusions: After adjusting the role of socio-demographic factors as components of QoL score, no association was observed between QoL domains and MetS in men, while only social relations and physical health scores were higher in women with Mets compared to those without Mets. Other variety of health-related QoL assessment tools or definitions of MetS may show different relationship in the Iranian socio-cultural context

The relationship between weight and CVD risk factors in a sample population from central Iran (based on IHHP)

&nbsp;&nbsp; BACKGROUND: Atherosclerosis is one of the leading causes of mortality all around the world. Obesity is an independent risk factor for atherosclerosis and cardiovascular diseases (CVD). In this respect, we decided to examine the effect of the subgroups of weight on cardiovascular risk factors. &nbsp;&nbsp; METHODS: This cross-sectional study was done in 2006 using the data obtained by the Iranian Healthy Heart Program (IHHP) and based on classification of obesity by the World Health Organization (WHO). In this study, the samples were tested based on the Framingham risk score, Metabolic Measuring Score (MMS) and classification of obesity. Chi-square and ANOVA were used for statistical analysis. &nbsp;&nbsp; RESULTS: 12514 people with a mean age of 38 participated in this study. 6.8% of women and 14% of men had university degrees (higher than diploma). Obesity was seen in women more than men: 56.4% of women and 40% of men had a Body Mass Index of (BMI) &ge; 25 Kg/m2. 13% of the subjects had FBS &gt; 110 and13.9% of them were using hypertensive drugs. In this study, we found that all risk factors, except HDL cholesterol in men, increased with an increase in weight. This finding is also confirmed by the Framingham flowchart for men and women. &nbsp;&nbsp; CONCLUSION: One of every two Americans, of any age and sex, has a Body Mass Index of (BMI) &ge; 25 Kg/m2. Obesity associated CVD and other serious diseases. Many studies have been done in different countries to find the relationship between obesity and CVD risk factors. For example, in the U.S.A and Canada they found that emteropiotic parameters, blood presser and lipids increased by age(of both sexes). Moreover, another study done in China, which is a country in Asia like Iran, shows that BMI has an indirect effect on HDL cholesterol, LDL cholesterol and triglyceride. This data is consistent with the results of the current study. However, In China they found that this relationship in men is stronger than women, but our study reveals the opposite. &nbsp; Keywords: Body Mass Index (BMI), Overweight, Cardiovascular Risk Factors, Framingham Risk Score, Metabolic Syndrome.</p

Familial Hypercholesterolemia (FH) in Iran: Findings from the Four-Year FH Registry

Background. Familial hypercholesterolemia (FH) is a common autosomal dominant disease. Its diagnosis in Iran was uncommon. Iran registry of FH (IRFH) has been started from 2017 from Isfahan. In this study, we report the four-year FH registry. Methods. The Iran FH registry is an ongoing study which is followed by a dynamic cohort. It has been started from 2017. The patients are selected from laboratories due to high cholesterol level and who have history of premature cardiovascular disease. The Dutch Lipid Clinic Network (DLCN) criteria are used for the detection of FH. Cascade screening is performed for detection of first-degree relative of patients. Results. Among the 997 individuals included in this registry, they were 522 (mean age 51.41±12.91 year), 141 (mean age 51.66±8.3 year), and 129 (mean age 41±16.5 year) patients from laboratories, premature cardiovascular disease, and relatives, respectively. In total, 263 patients were diagnosed with probable or definite FH, and others were in the possible group. Low-density lipoprotein cholesterol (LDL) level was 141.42±45.27 mg/dl in the laboratory group and 54.9% of patients were on LLT treatment. In patients with premature cardiovascular disease and FH, the LDL level was 91.93±32.58 and was on LLT treatment. The LDL concentration in the first relative of FH patients was 152.88±70.77 and 45.7% of them are on LLT therapy. Conclusions. Most of FH patients were underdiagnosed and undertreated before their inclusion in the IRFH. Cascade screening helps in the improvement of diagnosis