Impact evaluation of a Dutch community intervention to improve health-related behaviour in deprived neighbourhoods
Introduction
Available data on socioeconomic inequalities in health in Europe show that inequalities in mortality and self-reported morbidity are substantial (Mackenbach and Bakker, 2002). Health-related behaviours are important determinants of health and are often differentially distributed across socioeconomic groups. Studies have shown that smoking (Cavelaars et al., 2000; Choiniere et al., 2000), consumption of a less healthy diet (Martikainen et al., 2003), lack of physical activity (Cauley et al., 1991; Ford et al., 1991) and obesity (Molarius et al., 2000; Lenthe van and Mackenbach, 2002) are more prevalent among lower socioeconomic groups. National advisory committees in several European countries have proposed comprehensive strategies to reduce health inequalities. One of the recommendations of the Dutch committee was to adapt health promotion programmes to the needs of lower socioeconomic groups (Mackenbach and Stronks, 2002). Community interventions are especially thought to be suitable for this purpose (Mackenbach and Bakker, 2003). Furthermore, the latest Dutch Public Health Status and Forecasts have shown that the increase of life expectancy in the Netherlands is lagging behind the increase of life expectancy in other European Union countries (Oers van, 2002). Unhealthy behaviour is seen as one of the major causes underlying this stagnation.
Community interventions are likely to be a promising approach to target disadvantaged populations, for several reasons. Firstly, lower socioeconomic groups are more likely to respond to information from their direct social environment instead of external sources like general (mass media) information campaigns (Weenig and Midden, 1997). Community participation creates the opportunity to reach residents through the social networks of involved community members. Secondly, the inclusion of multiple change tactics such as group programmes, publicity campaigns or school-based activities within the intervention programme creates the opportunity to reach participants through multiple information channels. Thirdly, preventive measures to improve risk behaviours are not always an important issue on the agenda of residents in deprived neighbourhoods because they also have to deal with problems like poverty, unemployment or housing. However, if health authorities plan and implement activities together with community members and also act upon these “competing problems” they are more likely to create support for health behaviour prevention goals.
Much of what we know about community interventions in deprived neighbourhoods comes from studies in the United States and Canada (Fisher et al., 1998; O’Loughlin et al., 1999). The Neighbours for Smoke Free North Side programme goals were directed at smoking cessation in predominantly African American neighbourhoods. The 2-year intervention programme reported a positive intervention effect on the prevalence of smoking in the intervention neighbourhoods (Fisher et al., 1998). The Coeur en Santé heart health promotion programme promoted heart-healthy behaviours in a disadvantaged neighbourhood. The 5-year programme reported only a small but positive intervention effect on the frequency of cholesterol checkups in the intervention neighbourhoods (O’Loughlin et al., 1999). In the Netherlands, a community intervention aimed at reducing socioeconomic health inequalities by targeting health-related problems defined by community members themselves showed no impact on improved perceived health or health-related problems (Abbema et al., 2004). Thus, these results raise questions about the effectiveness of community interventions in deprived neighbourhoods.
The programme “Wijkgezondheidswerk” (Dutch for Working on Healthy Neighbourhoods) is a community intervention to improve health-related behaviour among adults living in deprived neighbourhoods in the city of Eindhoven. The intervention was based on a theoretical framework that used community organization principles (Bracht et al., 1998; Thompson and Kinne, 1998) and two social cognition models, the Transtheoretical Model of Change (Prochaska et al., 1992) and the Attitude-Social influence-Efficacy model of behavioural change (Kok et al., 1991; Vries de et al., 1988), to achieve intervention implementation and changes in outcomes of health-related behaviour. The aim of this evaluation was to examine the impact of the programme “Wijkgezondheidswerk” on health-related behaviours and intermediate outcomes of health-related behaviour, including knowledge, attitudes (beliefs about a particular behaviour), self-efficacy expectations (a person's beliefs about their abilities to perform a particular behaviour) and awareness of one's own behaviour and the intention to change behaviour (stages of change).
Section snippets
Design and setting
Eindhoven is one of the 30 big cities in the Netherlands and therefore part of the Urban Policy system developed by the Dutch national government. The main objectives of the Urban Policy are to tackle urban problems in the economic, social and physical domains. To tackle health inequalities, the cities are advised to follow the interventions and policy measures recommended by the Dutch advisory committee on socioeconomic inequalities in health (Mackenbach and Stronks, 2002). In 1997, the city
Respondents
Two-year follow-up data were collected from 69% () of the respondents in the baseline survey. Logistic regression analyses showed that follow-up attrition did not differ between the intervention and comparison neighbourhoods. However, dropouts were more likely to be male, younger and smoker than respondents who participated in both surveys (results not shown). Table 2 shows the demographic characteristics and outcome measures at baseline and follow-up. At baseline, respondents in the
Discussion
After 2 years of implementing a wide range of health behaviour activities we found evidence for a small impact on fruit consumption and intermediate outcomes of fruit consumption including knowledge related to fruit and vegetable consumption, stages of change for fruit consumption and self-efficacy expectations for fruit consumption. The intervention also had a small impact on the awareness of one's own physical activity level. The intervention showed no impact on outcomes of vegetable
Acknowledgements
This research project was supported by a grant from the Dutch Health Research and Development Council (ZonMw) (No. 22000045) and the study protocol was approved by the Medical Ethical Committee of the Catharina Hospital, Eindhoven, The Netherlands.
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