OUTCOME (SUMMATIVE) EVALUATION

The major outcome evaluation component focussed on the overall impact of the Newfoundland Heart Health Program, according to the primary goals of the NLHHP as noted above:

3.1 Reduction in Mortality, Morbidity, and the Prevalence of Controllable Cardiovascular Disease Risk Factors.

Trends in morbidity, mortality and prevalence of cardiovascular risk factors were not examined for the following reasons:

1. Experience from other programs (such as the North Karelia Project) suggest that a time frame of 10-15 years is required to observe any discernable impact of interventions on morbidity and mortality. Furthermore, the time lag in publication of data did not permit a reasonable review of trends post the NLHHP.
2. Data regarding morbidity are not readily available in this province, with the exception of information on bed days and length of stay (which is only available up to 1992-93 at this time). Data on utilization of hospital outpatient clinics, community health agencies and physician offices are not accessible at this time.
3. A repeat of the Newfoundland Heart Health study has not yet been carried out in this province. Between November 1988 and 1989, the Newfoundland Heart Health Survey was carried out by the Community Health Branch of the Department of Health, Government of Newfoundland and Labrador, in collaboration with the Health Services and Promotion Branch of the Department of National Health and Welfare. The survey (which consisted of home interview and clinic visit) was conducted by specially trained community health staff (Public Health Nurses, Nutritionists and Health Educators). A total of 2412 non-institutionalized residents of Newfoundland (male and female between the ages of 18 and 74 years) participated in the survey. Participants were randomly selected from the province's Medical Care Plan File and were representative of both urban and rural areas.

The survey provided the baseline data on the prevalence and distribution patterns of cardiovascular disease risk factors, including hypertension, elevated blood lipids, smoking and obesity in the province. It also assessed how much residents of the province knew about those factors and their relationship to heart disease and stroke. A repeat of this survey is necessary, as it would permit in-depth assessment of changes in heart health behaviour and knowledge in this province.

3.2 Diffusion of Intervention Strategies to Address Cardiovascular Risk Factors Throughout the Community Health System of the Province.

The existing community health system was originally envisioned as the primary diffusion channel for Heart Health activities in the province and the project successfully achieved this major goal. In January 1997, the Provincial Department of Health circulated the standard guidelines for core programming in the 6 community health regions of the province. The document was a collaborative endeavour of Provincial and Regional Community Health Representatives. The impact of the NLHHP was evident throughout the document, Technical Report Appendix A. The Guiding Principles statement embraced (1) a population health approach (2) a community development model for working with communities (3) the creation of healthy public policy (4) intersectoral cooperation and (5) public education. Four areas of programming were clarified and objectives established for the year 2000. These areas included: (1) promotion and support of health and wellbeing (2) promotion of a healthy environment; (3) prevention and control of communicable diseases; and (4) provision of health services. Heart Health objectives were stated in all areas (except communicable diseases). Furthermore, an explicit strategy related to the "promotion and support of health and wellbeing" outlined the relationship between the regional community health system and the promotion of heart health (including linkages with the NLHHP), as described below:

Technical Report, Appendix B contains detailed reports of heart health activities undertaken in the different community health regions of the province, 1995-1997. To date, an extensive array of heart health activities has been generated and diffused across the province. These activities include (1) lifestyle clinics, (2) Heart-Smart Restaurant Programs (3) media promotion (4) public information sessions and displays, (5) targeted promotion to women, the workplace and the schools, (6) participation in health fairs, (7) use and promotion of tools developed for public education through the NLHHP (such as The Community Television Kit) and (8) participation in Regional Heart Health Coalitions.

The regional community health personnel spearheaded the formation of the Regional Heart Health Coalitions, another major vehicle for sustaining and diffusing heart health activities across the province. Technical Report, Appendix C provides details about the extensive activities of these coalitions.

To date, 7 of the nine original community projects have successfully sustained aspects of their projects. Furthermore, activities sponsored by the Public Education and Public Policy Sub-Committees of the Coordinating Committee are maintaining their profile on the provincial scene. Only one subcommittee activity encountered substantial problems in successfully initiating and sustaining a project, the Professional Education Committee. Factors contributing to variable degrees of success in terms of sustainability are offered in the discussion of process/implementation which follows.