American Journal of Epidemiology Vol. 142, No. 6: 576-586
Copyright © 1995 by The Johns Hopkins University School of Hygiene and Public Health
research-article |
Community Intervention Trials: Reflections on the Stanford Five-City Project Experience
1Center for Research in Disease Prevention, Stanford University School of Medicine Stanford, CA
2Division of General Internal Medicine, Stanford University School of Medicine Stanford, CA
3Department of Communication, Stanford University Stanford, CA
4Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine Stanford, CA.
*Reprint requests to Dr. Stephen P. Fortmann, Center for Re-search in Disease Prevention, Stanford University School of Medi-cine, 1000 Welch Road, Palo Alto, CA 94304-1825.
In the past two decades several community intervention studies designed to lower the risk of cardiovascular disease in populations have been completed. These trials shared the rationale that the community approach was the best way to address the large population attributable risk of mild elevations of multiple risk factors, the interrelation of several health behaviors, and the potential efficiency of large-scale interventions not limited to the medical care system. These trials also shared several threats to internal validity, especially the small number of intervention units (usually cities) that could be studied. The purpose of this paper is to reflect on the lessons learned in one of the studies, the Stanford Five-City Project, which began in 1978. The anticipated advantages were observed, including the generalizability of the intervention components, the potential for amplification of interventions through diffusion in the community, and the efficiency of the mass media and other community programs for reaching the entire population. Numerous components of the intervention proved effective when evaluated individually, as was true in other community studies. However, the design limitations proved difficult to overcome, especially in the face of unexpectedly large, favorable risk factor changes in control sites. As a result, definitive conclusions about the overall effectiveness of the communitywide efforts were not always possible. Nevertheless, in aggregate, these studies support the effectiveness of communitywide health promotion, and investigators in the field should turn to different questions. The authors have learned how little they know of the determinants of population-level change and the characteristics that separate communities that change quickly in response to general health information from those that do not. Future studies in communities must elucidate these characteristics, while improving the effectiveness of educational interventions and expanding the role of environmental and health policy components of health promotion. Am J Epidemiol 1995; 142:576–86.
cardiovascular diseases; health behavior; health education; health promotion
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