Target audience penetration by a healthy lifestyle promotion programme: results from the Kilkenny Health Project

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The Economic and Social Review, Vol. 26, No. 3, April, 1995, pp. 261-282

Target Audience Penetration by a Healthy

Lifestyle Promotion Programme:

Results F r o m The Kilkenny Health Project*

P E T E R M U R R A Y

The Economic and Social Research Institute E M E R S H E L L E Y

Department of Epidemiology and Preventive Medicine, Royal College of Surgeons in Ireland

L E S L I E D A L Y

Department of Public Health Medicine and Epidemiology, University College, Dublin

C L A I R E C O L L I N S R O N A N C O N R O Y I A N G R A H A M

Department of Epidemiology and Preventive Medicine, Royal College of Surgeons in Ireland

Abstract: Between 1985 and 1992 County K i l k e n n y was the site of a n evaluated programme of community intervention w h i c h aimed to reduce the population's h e a r t disease b u r d e n by promoting the adoption of a healthy lifestyle. T h i s paper analyses data on public awareness of the K i l k e n n y H e a l t h Project's activities collected in a 1990-91 evaluation survey. T h e implic ations of the findings for healthy lifestyle promotion programmes supporting the achievement of the targets set i n the recently unveiled national health strategy are discussed.

I I N T R O D U C T I O N

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p i d e m i o l o g i c a l r e s e a r c h h a s s h o w n t h a t t h e r i s k of d e v e l o p i n g h e a r t d i s e a s e or c a n c e r — w h i c h , a l o n g w i t h a c c i d e n t s , a r e t h e m a j o r c a u s e s of p r e m a t u r e d e a t h i n I r e l a n d — i s c l o s e l y r e l a t e d to t h e c o m p o s i t i o n o f a

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p o p u l a t i o n ' s d i e t , i t s s m o k i n g p r e v a l e n c e , i t s a l c o h o l c o n s u m p t i o n a n d i t s l e v e l s of p h y s i c a l e x e r c i s e . T h u s h e a l t h - e n h a n c i n g c h a n g e s i n c u r r e n t l y p r e v a i l i n g l i f e s t y l e s h o l d out t h e p r o s p e c t of a s i g n i f i c a n t r e d u c t i o n i n t h e p r e s e n t b u r d e n of l i m i t i n g i l l n e s s a n d p r e m a t u r e d e a t h . T h e a c h i e v e m e n t of s u c h p o t e n t i a l h e a l t h g a i n s i s t h e o v e r a l l objective of t h e r e c e n t l y u n v e i l e d n a t i o n a l h e a l t h s t r a t e g y ( D e p a r t m e n t of H e a l t h , 1 9 9 4 ) , w h i c h s e t s m e d i u m -t e r m -t a r g e -t s for r e d u c -t i o n s i n -t h e r a -t e s of -t h e -t h r e e m a i n c a u s e s of p r e m a -t u r e m o r t a l i t y a n d i d e n t i f i e s s i x k e y a r e a s — s m o k i n g ; alcohol; n u t r i t i o n a n d diet; c h o l e s t e r o l a n d b l o o d p r e s s u r e ; e x e r c i s e ; c a u s e s of a c c i d e n t s — o n w h i c h h e a l t h p r o m o t i o n p r o g r a m m e s w i l l focus.

W h i l e s o m e c h a n g e s i n t h e s o c i a l e n v i r o n m e n t — s u c h a s i n c r e a s e d r e s t r i c t i o n of s m o k i n g i n t h e w o r k p l a c e — a r e e n v i s a g e d , t h e s u c c e s s f u l a c h i e v e m e n t of t h e n a t i o n a l h e a l t h strategy's t a r g e t s a p p e a r s to be p r i m a r i l y d e p e n d e n t o n t h e w i d e s p r e a d a d o p t i o n of a m o r e h e a l t h y l i f e s t y l e w i t h i n t h e p o p u l a t i o n i n r e s p o n s e to t h e s t i m u l u s of p u b l i c c o m m u n i c a t i o n c a m p a i g n s . T h e t h e o r y , p r a c t i c e a n d e v a l u a t i o n of s u c h c a m p a i g n s h a s g i v e n r i s e to a n e x t e n s i v e i n t e r n a t i o n a l l i t e r a t u r e . B u t , w h i l e t h i s i s u n d o u b t e d l y a v a l u a b l e s o u r c e of g e n e r a l i s e d g u i d a n c e for c a m p a i g n p l a n n i n g i n a n I r i s h c o n t e x t , p l a n n e r s a l s o n e e d to t a k e i n t o a c c o u n t t h e specificity of t h e n a t i o n a l - s t a t e s t r u c t u r e s t h r o u g h w h i c h c o m m u n i c a t i o n w i l l be c h a n n e l l e d to a n I r i s h p u b l i c . T h e p a t t e r n of h e a l t h p r o m o t i o n i n i t i a t i v e s i n t h e U S A , for i n s t a n c e , s t r o n g l y r e f l e c t s t h e a v a i l a b i l i t y of P u b l i c S e r v i c e A n n o u n c e m e n t t i m e o n r a d i o a n d t e l e v i s i o n w h i c h s t a t i o n s a r e obliged to d o n a t e free of c h a r g e i n o r d e r to m e e t t h e l i c e n s i n g r e q u i r e m e n t s of t h e F e d e r a l C o m m u n i c a t i o n s C o m m i s s i o n : I r i s h h e a l t h p r o m o t i o n e n j o y s no s i m i l a r f a c i l i t y . V i r t u a l l y u n i  v e r s a l r e g i s t r a t i o n a n d a h i g h l e v e l of r e g u l a r c o n s u l t a t i o n w i t h g e n e r a l p r a c t i t i o n e r s ( G P s ) p r o v i d i n g m e d i c a l c a r e free of c h a r g e to a l l u n d e r l i e s t h e s t r o n g U K e m p h a s i s o n g e n e r a l p r a c t i c e a s a b a s e for h e a l t h p r o m o t i o n i n i t i a t i v e s . I n t h e R e p u b l i c of I r e l a n d t h e p o p u l a t i o n i s s e g m e n t e d into t h o s e e n t i t l e d to free G P c a r e a n d t h o s e w h o a r e not: t h e two groups v a r y m a r k e d l y i n c o n s u l t a t i o n f r e q u e n c y a n d o n l y t h e f o r m e r a r e a c c o u n t e d for b y a r e g i s  t r a t i o n s y s t e m . T h e school s y s t e m s of different c o u n t r i e s a l l c o n t a i n a poten t i a l c a p t i v e a u d i e n c e for h e a l t h e d u c a t i o n b u t b e t w e e n t h e s e s y s t e m s t h e r e a r e m a j o r d i f f e r e n c e s i n m a n a g e m e n t s t r u c t u r e , c u r r i c u l u m c o n t e n t a n d v a l u e o r i e n t a t i o n w h i c h m a y f a c i l i t a t e or r e s t r i c t o p p o r t u n i t i e s for h e a l t h c o m m u n i c a t i o n w i t h p u p i l s .

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c o u n t y b e t w e e n 1985 a n d 1992. D a t a collected i n t h e c o u r s e of i t s e v a l u a t i o n p r o v i d e a n o p p o r t u n i t y to e x a m i n e h o w p u b l i c a w a r e n e s s of t h e o u t p u t of h e a l t h p r o m o t i o n m e s s a g e s t h e p r o j e c t d i s s e m i n a t e d t h r o u g h t h e s i m u l  t a n e o u s u s e of a r a n g e of c h a n n e l s of c o m m u n i c a t i o n w a s c r e a t e d . I n t h i s a r t i c l e t h e s e d a t a a r e a n a l y s e d a n d t h e i m p l i c a t i o n s of t h e f i n d i n g s for t h e t a r g e t i n g of t h e c o m m u n i c a t i o n c a m p a i g n s t h a t s u p p o r t t h e c u r r e n t n a t i o n a l s t r a t e g y a r e d i s c u s s e d .

I I T H E K I L K E N N Y H E A L T H P R O J E C T : E V A L U A T I O N D E S I G N A N D C H A N G E P R O C E S S M O D E L

T h e K i l k e n n y H e a l t h P r o j e c t w a s d e s i g n e d a s a q u a s i - e x p e r i m e n t i n w h i c h a "treatment" c o m m u n i t y r e c e i v i n g a n i n t e r v e n t i o n p r o g r a m m e ( K i l k e n n y ) i s c o m p a r e d w i t h a s i m i l a r "control" c o m m u n i t y w h i c h w a s n o t e x p o s e d to t h e i n t e r v e n t i o n (Offaly). D a t a w e r e collected i n b o t h of t h e c o m m u n i t i e s , p r i n  c i p a l l y t h r o u g h d i s e a s e r e g i s t e r s a n d t h r o u g h b a s e l i n e ( p r e - p r o g r a m m e ) a n d t e r m i n a t i o n ( p o s t - p r o g r a m m e ) s u r v e y s . A p e r i o d of five y e a r s i n t e r v e n e d b e t w e e n t h e b a s e l i n e a n d t h e t e r m i n a t i o n s u r v e y s ( O ' M a h o n y , C o n r o y , S h e l l e y , et al, 1991; S h e l l e y , D a l y , G r a h a m , et al., 1991; M u r r a y , 1992).

W i t h i n t h i s d e s i g n n e t c h a n g e — t h a t i s , t h e c h a n g e i n t h e t r e a t m e n t c o m m u n i t y over t h e p e r i o d of t h e p r o g r a m m e n e t of t h e c h a n g e i n t h e c o n t r o l c o m m u n i t y o v e r t h e s a m e p e r i o d — i s t h e k e y o u t c o m e e v a l u a t i o n m e a s u r e . C h a n g e w i t h i n t h e c o n t r o l c o m m u n i t y r e p r e s e n t s t h e a m o u n t of c h a n g e o c c u r r i n g w i t h o u t a n y s p e c i a l i n t e r v e n t i o n b e i n g u n d e r t a k e n : t h e a d d i t i o n a l c h a n g e ( i f a n y ) t h a t r e m a i n s i n t h e t r e a t m e n t c o m m u n i t y after t h i s "secular" c o m p o n e n t i s n e t t e d out c o n s t i t u t e s w h a t c a n be s p e c i f i c a l l y a t t r i b u t e d to t h e i n t e r v e n t i o n p r o g r a m m e . E f f e c t i v e i n t e r v e n t i o n i s e x p e c t e d to s h o w a p a t t e r n of s t a t i s t i c a l l y s i g n i f i c a n t n e t c h a n g e a c r o s s i t s e v a l u a t e d outcomes.

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I n t h i s a r t i c l e t h e focus i s o n a w a r e n e s s g e n e r a t i o n a n d t h e c h a n n e l s t h r o u g h w h i c h t h e s p e c i a l s t i m u l u s of t h e i n t e r v e n t i o n p r o g r a m m e w a s c o m m u n i c a t e d . T h e d a t a p r e s e n t e d t h e r e f o r e r e f e r o n l y to t h e t r e a t m e n t c o m m u n i t y , K i l k e n n y . O t h e r d a t a f r o m t h e e v a l u a t i o n s u r v e y s p r o v i d e t h e b a s i s for n e t c h a n g e c o m p a r i s o n s to be m a d e b e t w e e n K i l k e n n y a n d O f f a l y i n r e l a t i o n to p u b l i c k n o w l e d g e c o n c e r n i n g c o r o n a r y h e a r t d i s e a s e , l i f e s t y l e b e h a v i o u r s a n d m a j o r c o r o n a r y h e a r t d i s e a s e r i s k factor l e v e l s . P r e l i m i n a r y d e s c r i p t i v e c o m p a r i s o n s b e t w e e n t h e c o u n t i e s a c r o s s t h i s r a n g e of o u t c o m e s h a v e b e e n p u b l i s h e d a n d a p a p e r w h i c h t a k e s t h e p e n u l t i m a t e s t a g e i n t h e e n v i s a g e d c h a n g e p r o c e s s — s h i f t s i n r i s k factor l e v e l s — a s i t s a n a l y t i c a l focus i s i n p r e s s ( K i l k e n n y H e a l t h P r o j e c t , 1992; S h e l l e y , D a l y , C o l l i n s , et al., f o r t h c o m i n g ) . A l t h o u g h a n i n i t i a l s t a g e outcome, a w a r e n e s s g e n e r a t i o n i s one t h a t a l s o m e r i t s s e r i o u s a t t e n t i o n . A n i n t e r v e n t i o n ' s f e a s i b i l i t y s h o u l d be d e m o n s t r a t e d r a t h e r t h a n p r e s u m e d a n d t h e r e i s a s t r o n g e m p h a s i s i n r e c e n t c o n t r i b u t i o n s to t h e l i t e r a t u r e o n c o m m u n i t y h e a l t h p r o m o t i o n p r o g r a m m e e v a l u a t i o n s o n t h e n e e d for "dose" of i n t e r v e n t i o n e x p o s u r e i n f o r m a t i o n to p r o v i d e t h e c o n t e x t w i t h i n w h i c h a t r e a t m e n t c o m m u n i t y ' s r e s p o n s e i s a p p r a i s e d ( W H O R e g i o n a l Office for E u r o p e , 1 9 8 8 , p. 24; F l o r a , L e f e b v r e , M u r r a y , etal., 1993; P i r i e , S t o n e , A s s a f , etal., 1994).

I l l T H E K I L K E N N Y H E A L T H P R O J E C T : C O M M U N I C A T I O N I N I T I A T I V E S

S u p p o r t e d b y f u n d i n g f r o m g o v e r n m e n t s o u r c e s a n d from t h e I r i s h H e a r t F o u n d a t i o n , t h e K i l k e n n y H e a l t h P r o j e c t w a s i n i t i a t e d w i t h t h e a i m of r e d u c i n g h e a r t d i s e a s e a m o n g t h e people of C o u n t y K i l k e n n y b y p r o m o t i n g c o m m u n i t y - w i d e a d o p t i o n of a h e a l t h y lifestyle. T h e choice of K i l k e n n y a s t h e i n t e r v e n t i o n p r o g r a m m e ' s h o s t w a s i n f l u e n c e d b y a n u m b e r of factors. T h e c o u n t y h a s a h i s t o r y of c o m m u n i t y d e v e l o p m e n t a n d i s w e l l k n o w n for i t s c i v i c s p i r i t a n d c o u n t y p r i d e . T h e r e i s a m i x t u r e o f u r b a n a n d r u r a l c o m m u n i t i e s i n t h e c o u n t y . I t w a s a c c e s s i b l e to t h e a c a d e m i c a n d o t h e r n a t i o n a l i n s t i t u t i o n s w h o s e s u p p o r t for t h e d e v e l o p m e n t a n d e v a l u a t i o n of p r o g r a m m e s w a s n e e d e d . T h e S o u t h E a s t e r n H e a l t h B o a r d , w i t h i n w h o s e r e g i o n K i l k e n n y i s located, w e r e w i l l i n g to collaborate w i t h t h e P r o j e c t .

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co-o r d i n a t e d a p r co-o g r a m m e co-of free h e a l t h c h e c k - u p s c a r r i e d co-o u t b y g e n e r a l p r a c t i t i o n e r s w h i c h w a s i n i t i a l l y offered to a l l K i l k e n n y r e s i d e n t s i n t h e i r 4 0 s a n d w a s e x t e n d e d , after two y e a r s i n o p e r a t i o n , to t h o s e i n t h e i r 30s.

T w o r o u n d s of v i s i t s to a l l of t h e c o u n t y ' s p r i m a r y s c h o o l s d i s t r i b u t i n g i n f o r m a t i v e g a m e s a n d p o s t e r s w e r e u n d e r t a k e n b y t h e P r o j e c t ' s E d u c a t i o n Officer a n d i t s m a s c o t , B e n j y t h e cat. T h e P r o j e c t also a d a p t e d a U S p r i m a r y s c h o o l p r o g r a m m e Race to Health a n d f a c i l i t a t e d i t s i n t r o d u c t i o n i n t o K i l  k e n n y schools. A t second l e v e l i t offered s u p p o r t for t h e p r o v i s i o n i n K i l k e n n y s c h o o l s of a n I r i s h - d e v i s e d , j u n i o r c y c l e l i f e s k i l l s p r o g r a m m e , Learning for Life. C o o k e r y d e m o n s t r a t i o n s o r g a n i s e d by P r o j e c t s t a f f w e r e i n i t i a l l y offered a s p a r t of t h e a d u l t e d u c a t i o n p r o g r a m m e of t h e K i l k e n n y V o c a t i o n a l E d u c a t i o n C o m m i t t e e ( V E C ) : l a t e r t h e P r o j e c t d e v e l o p e d Look Good, Feel Good c l a s s e s , c o m b i n i n g a n e x e r c i s e s e s s i o n w i t h d i s c u s s i o n of a h e a l t h -r e l a t e d topic, a n d i n t -r o d u c e d t h e s e a s a p -r o g -r a m m e option. D u -r i n g t h e c o u -r s e of t h e P r o j e c t s p e a k e r s g a v e l e c t u r e s a n d t a l k s to a w i d e r a n g e of K i l k e n n y c o m m u n i t y groups. I n c o n j u n c t i o n w i t h t h e I r i s h C o u n t r y w o m e n ' s A s s o c i a t i o n ( I C A ) m e e t i n g s w e r e h e l d for a l l t h e p a r i s h e s i n t h e c o u n t y d u r i n g t h e Project's f i r s t t w o y e a r s .

I n t h e c o m m u n i c a t i o n s m e d i a field t h e P r o j e c t from t h e o u t s e t e s t a b l i s h e d l i n k s w i t h t h e l o c a l p r e s s . I n N o v e m b e r 1 9 8 5 a " H e a l t h y People" c o l u m n w a s i n i t i a t e d i n t h e w e e k l y Kilkenny People n e w s p a p e r . A r t i c l e s o n h e a l t h y e a t i n g w e r e also r e g u l a r l y p l a c e d i n t h e Kilkenny Standard after i t s a p p e a r a n c e on t h e s c e n e i n 1989. I n M a y 1986 t h e P r o j e c t l a u n c h e d i t s o w n free n e w s l e t t e r CATCH, of w h i c h t h r e e i s s u e s w e r e u s u a l l y p r o d u c e d e a c h y e a r . CATCH w a s d i s t r i b u t e d w i t h t h e Kilkenny People a n d w a s a l s o a v a i l a b l e t h r o u g h o u t l e t s s u c h a s d o c t o r s ' s u r g e r i e s a n d l o c a l h e a l t h c e n t r e s . W i t h t h e a d v e n t of l i c e n s e d l o c a l r a d i o b r o a d c a s t i n g , P r o j e c t s t a f f b e c a m e r e g u l a r c o n t r i b u t o r s to a l u n c h t i m e c h a t s h o w on Radio Kilkenny. T h e P r o j e c t a l s o d e v i s e d a s e r i e s of i n f o r m a t i o n l e a f l e t s o n c o r o n a r y h e a r t d i s e a s e r i s k f a c t o r s , p r o d u c e d videos o n h o w to m a k e h e a l t h y food choices a n d p u b l i s h e d i t s o w n cookbook. C o m p e t i t i o n s a n d f e a t u r e s i n CATCH d o v e t a i l e d w i t h t h e d i s t r i b u t i o n of m a t e r i a l s i n schools w h i l e video s h o w i n g s s t r u c t u r e d a second r o u n d of i n t e n  s i v e c o n t a c t s w i t h c o m m u n i t y groups d u r i n g t h e f i n a l t w o y e a r s of t h e e v a l u  a t i o n p e r i o d . C o m m u n i c a t i n g i n t e r v e n t i o n p r o g r a m m e m e s s a g e s t h r o u g h c h a n n e l s a c c e s s i b l e to both K i l k e n n y a n d O f f a l y r i s k e d " c o n t a m i n a t i n g " t h e q u a s i - e x p e r i m e n t b y e x p o s i n g t h e c o n t r o l c o m m u n i t y to t h e i n t e r v e n t i o n . T h i s c o n s i d e r a t i o n l e d t h e P r o j e c t to i n i t i a l l y a d o p t a p o l i c y of n o t a c t i v e l y s e e k i n g t h e a t t e n t i o n o f t h e n a t i o n a l l e v e l b r o a d c a s t i n g a n d p r i n t m e d i a .

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I V T H E I M P A C T O F T H E C O M M U N I C A T I O N I N I T I A T I V E S I N C O U N T Y K I L K E N N Y : S U R V E Y M E T H O D S

A s e t of q u e s t i o n s a b o u t k n o w l e d g e of t h e P r o j e c t a n d t h e c h a n n e l s t h r o u g h w h i c h t h i s h a d b e e n a c q u i r e d w e r e i n c l u d e d i n t h e t e r m i n a t i o n s u r v e y c a r r i e d o u t i n C o u n t y K i l k e n n y i n 1 9 9 0 - 9 1 . T h e s a m p l i n g f r a m e , f r o m w h i c h a s a m p l e of n a m e s a n d a d d r e s s e s w a s d r a w n , w a s t h e R e g i s t e r of E l e c t o r s . T h i s i s a n a n n u a l l y r e v i s e d l i s t i n g of a l l t h o s e eligible to vote i n l o c a l , n a t i o n a l or E u r o p e a n e l e c t i o n s . T h e s a m p l i n g w a s p e r f o r m e d u s i n g t h e R A N S A M " c o m p u t e r p r o g r a m m e (see W h e l a n ( 1 9 7 9 ) for a d e t a i l e d d e s c r i p t i o n ) w h i c h i m p l e m e n t s a m u l t i - s t a g e r a n d o m s a m p l e i n c o r p o r a t i n g b o t h s t r a t i f i c a t i o n a n d c l u s t e r i n g , a n d g i v i n g e a c h i n d i v i d u a l o n t h e r e g i s t e r a n e q u a l p r o b a b i l i t y of b e i n g selected. A d e t a i l e d s t u d y of t h e q u a l i t y of t h e R e g i s t e r a s a s a m p l i n g f r a m e ( K e o g h a n d W h e l a n , 1986) f o u n d t h a t i t w a s i n r e a s o n a b l e c o n c o r d a n c e w i t h t h e p o p u l a t i o n a s m e a s u r e d b y t h e C e n s u s .

T h e m a i n d e f i c i e n c i e s i d e n t i f i e d i n t h a t s t u d y , u n d e r - r e p r e s e n t a t i o n of y o u n g s i n g l e p e r s o n s a n d n e w l y - f o r m e d h o u s e h o l d s h a v e l i t t l e r e l e v a n c e i n t h e p r e s e n t c o n t e x t a s i n c l u s i o n w a s r e s t r i c t e d to t h o s e a g e d b e t w e e n 3 5 a n d 6 4 . T h i s r e s t r i c t i o n i s a n o r m a l f e a t u r e of h e a r t d i s e a s e p r e v e n t i o n p r o j e c t e v a l u a t i o n s u r v e y s a n d d e r i v e s f r o m a c o n c e r n to t r y a n d m e a s u r e t h e effects of i n t e r v e n t i o n o n m o r t a l i t y , w h i c h i s t h a n k f u l l y r a r e a m o n g t h e y o u n g a n d r e g r e t t a b l y u n c e r t a i n i n t h e q u a l i t y of i t s c e r t i f i c a t i o n a m o n g t h e o l d ( M u r r a y , 1 9 9 2 ) . - T h e e x a c t p r o c e d u r e s u s e d to d r a w t h i s a g e - r e s t r i c t e d s a m p l e for t h e t e r m i n a t i o n s u r v e y w e r e s i m i l a r to t h o s e u s e d i n t h e e a r l i e r b a s e l i n e s u r v e y w h i c h h a v e b e e n d e s c r i b e d e l s e w h e r e ( S h e l l e y , D a l y , K i l c o y n e , et al., 1 9 9 1 ) . I n a l l , 8 0 2 i n d i v i d u a l s p a r t i c i p a t e d i n t h e K i l k e n n y t e r m i n a t i o n s u r v e y . P a r t i c i p a t i o n i n v o l v e d a v i s i t to a h e a l t h c e n t r e a n d t h e t a k i n g of b i o m e d i c a l m e a s u r e m e n t s a n d s a m p l e s a s w e l l a s t h e c o m p l e t i o n of t w o q u e s t i o n n a i r e s , one s e l f - a d m i n i s t e r e d a n d t h e o t h e r a d m i n i s t e r e d b y a s u r v e y n u r s e (the q u e s t i o n s a b o u t a w a r e n e s s of t h e P r o j e c t a n d t h e m e a n s b y w h i c h t h i s w a s a c q u i r e d f o r m e d p a r t of t h e s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e ) . W h i l e i n c r e a s i n g a s s u r a n c e t h a t t h e d a t a c o l l e c t e d w o u l d be r e l i a b l e a n d of h i g h q u a l i t y , t h e s e s u r v e y a r r a n g e m e n t s m i g h t be e x p e c t e d to d e p r e s s i t s r e s p o n s e r a t e . T h e r a t e a c h i e v e d w a s o v e r 7 0 p e r c e n t i n b o t h t h e b a s e l i n e a n d t e r m i n a t i o n s u r v e y s , h o w e v e r . T h i s c o m p a r e s q u i t e f a v o u r a b l y w i t h t h o s e r e p o r t e d b y s o c i a l s u r v e y s c a r r i e d out v i a t h e s t a n d a r d m e t h o d of h o m e v i s i t s .

V T H E I M P A C T O F T H E C O M M U N I C A T I O N I N I T I A T I V E S I N C O U N T Y K I L K E N N Y : R E S U L T S

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c a t e g o r i e s w e r e u s e d i n t h e q u e s t i o n s a b o u t r e a d e r s h i p of t h e " H e a l t h y People" c o l u m n i n t h e Kilkenny People n e w s p a p e r a n d a b o u t r e a d e r s h i p of CATCH: t h e d i s t r i b u t i o n s of r e s p o n s e s to t h e s e i t e m s a r e s h o w n i n T a b l e s 1 a n d 2.

Table 1: "Have you Read the Articles in the Kilkenny People Newspaper which are Written by the Kilkenny Health Project?"

Response Per Cent

Do not read the Kilkenny People newspaper 13

Did not see any articles written by the Kilkenny Health Project 5 Saw Kilkenny Health Project articles but did not read them 12

Read Kilkenny Health Project articles sometimes 47

Read Kilkenny Health Project articles regularly 23

Total 100

Table 2: "The Kilkenny Health Project's Magazine is called CATCH. Did you Read CATCH?"

Response Per Cent

Never saw C A T C H 21

Saw occasional C A T C H but did not read it 13

Read C A T C H sometimes 38

Read C A T C H two or three times a year 28

Total 100

T h e o t h e r q u e s t i o n s u s e d a "Yes", "No", " U n s u r e or don't k n o w " r e s p o n s e f o r m a t . T h e s e q u e s t i o n s , a n d t h e d i s t r i b u t i o n s of r e s p o n s e s to t h e m , a r e s h o w n i n T a b l e 3.

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Table 3: Awareness of the Kilkenny Health Project Through Other Forms of its Output of Activity

Per Cent

Question Yes Alb

Unsure or Don't Know "Before you were asked to take part i n this survey,

h a d you heard of the Kilkenny Health Project?" 93 6 1 "Have you seen a Kilkenny Health Project leaflet about

diet or smoking or heart disease?" 67 26 7

"Have you, or has someone i n your household, seen the

Kilkenny Health Project cookery book?" 29 57 14 "Have you, or has someone i n your household, seen a

Kilkenny Health Project video about choosing or

cooking healthy food?" 6 88 6

"Did you ever hear someone from the Kilkenny Health

Project on R T E radio?" 29 64 7

"Did you ever see anything about the Kilkenny

Health Project on television?" 28 60 12

"Did you hear anything about the Kilkenny Health

Project on Radio Kilkenny or on any other local radio?" 46 48 6 "Have you ever attended a n I C A meeting, a V E C lecture

or had any other meeting where someone from Kilkenny Health Project was speaking about the Project or about

Health lifestyles and preventing heart disease?" 12 87 1 "Did you see any of the leaflets or posters or other materials

which were distributed i n schools by the Kilkenny Health

Project?" 49 46 5

c e n t of t h e p o t e n t i a l a u d i e n c e a t some t i m e or a n o t h e r w h i l e t h e videos, w h i c h w e r e u s e d i n c o n j u n c t i o n w i t h s u c h m e e t i n g s i n t h e l a t e r p a r t of t h e Project's e v a l u a t i o n p e r i o d , w e r e s e e n b y 6 p e r cent.

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p e r c e n t of f e m a l e r e s p o n d e n t s r e a d t h e Kilkenny People a r t i c l e s a n d CATCH a t l e a s t "sometimes" w h i l e 19 p e r c e n t h a d a t t e n d e d a m e e t i n g o r l e c t u r e a t w h i c h a P r o j e c t r e p r e s e n t a t i v e spoke.

D i f f e r e n t i a l i m p a c t s b y a r e a of r e s i d e n c e , s o c i a l c l a s s a n d a g e f i n i s h e d s c h o o l i n g w e r e a l s o a p p a r e n t . A r e a o f r e s i d e n c e w a s c o d e d i n t o t h r e e c a t e g o r i e s — K i l k e n n y C i t y a n d e n v i r o n s , O t h e r U r b a n , R u r a l — a n d for 9 o f t h e 11 a w a r e n e s s i t e m s f r e q u e n c y of c o n t a c t i s g r e a t e s t i n t h e c a s e of c i t y r e s i d e n t s . T h e e x c e p t i o n s w e r e t h e i n t e r l i n k e d "seen a K i l k e n n y H e a l t h P r o j e c t video" a n d "attended a n I C A ... or a n y o t h e r m e e t i n g " i t e m s w h e r e c o n t a c t w a s h i g h e s t a m o n g t h o s e r e s i d e n t i n O t h e r U r b a n a r e a s . I n r e l a t i o n to t h e I r i s h S o c i a l C l a s s s c a l e , a p a t t e r n of t h e t h r e e n o n - m a n u a l c l a s s e s a t t h e top a n d t h e t h r e e m a n u a l c l a s s e s a t t h e bottom p r e v a i l e d for 9 of t h e 11 a w a r e n e s s i t e m s . M a n u a l c l a s s e s r e p o r t e d g r e a t e r a w a r e n e s s t h a n t h e n o n -m a n u a l o n e s for t h e "ever see a n y t h i n g on t e l e v i s i o n " a n d t h e "see a n y of t h e l e a f l e t s . . . or o t h e r m a t e r i a l s w h i c h w e r e d i s t r i b u t e d i n schools" q u e s t i o n s . A g e left school or f u l l - t i m e s t u d y s h o w s a c l e a r t e n d e n c y for t h o s e w i t h m o r e s c h o o l i n g to h a v e h a d m o r e a w a r e n e s s of t h e P r o j e c t . A g e a n d m a r i t a l s t a t u s b r e a k d o w n s do n o t p r o d u c e a c l e a r p a t t e r n . I n t h e c a s e of c u r r e n t e m p l o y  m e n t s t a t u s , a w a r e n e s s i s c o n s i s t e n t l y h i g h e s t a m o n g t h o s e on h o m e d u t i e s ( a n a l m o s t 100 p e r c e n t f e m a l e group) a n d a m o n g t h e s m a l l ( s i n c e people o v e r 6 5 w e r e not s a m p l e d ) r e t i r e d category.

M o v i n g on to m u l t i v a r i a t e a n a l y s i s of project a w a r e n e s s , a w i d e r r a n g e o f i n d e p e n d e n t v a r i a b l e s w a s e x p l o r e d . I t h a s b e e n a r g u e d t h a t m o t i v a t i o n to a c q u i r e i n f o r m a t i o n about subjects l i k e c a r d i o v a s c u l a r h e a l t h a r i s e s p r i m a r i l y o u t o f p a r t i c u l a r life s i t u a t i o n s i n w h i c h i n d i v i d u a l s f i n d t h e m s e l v e s . " S i t u -a t i o n -a l l y s e n s i t i v e " v -a r i -a b l e s m -a y therefore be b e t t e r p r e d i c t o r s of m o t i v -a t i o n to a c q u i r e s u c h i n f o r m a t i o n t h a n c r o s s - s i t u a t i o n a l v a r i a b l e s of t h e socio-d e m o g r a p h i c k i n socio-d ( E t t e m a , B r o w n a n socio-d L u e p k e r , 1983). S i t u a t i o n a l s e n s i t i v i t y w o u l d s u g g e s t t h a t people w h o h a v e b e e n m e d i c a l l y t r e a t e d for h e a r t d i s e a s e s or e x p e r i e n c e s y m p t o m s or h a v e a h i s t o r y of s u c h d i s e a s e s i n t h e i r f a m i l y b a c k g r o u n d w o u l d s h o w g r e a t e r r e c e p t i v i t y to m e s s a g e s a b o u t p r e v e n t i o n . H e r e t h i s w a s probed t h r o u g h t h r e e d u m m y v a r i a b l e s :

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v a s c u l a r d i s e a s e , d y s p n o e a or p o s s i b l e i n f a r c t i o n . W h e r e t h e s y m p t o m s of n o n e of t h e s e c o n d i t i o n s w e r e i n d i c a t e d , t h e v a l u e of t h i s v a r i a b l e w a s 0.

F a m i l y H i s t o r y of H e a r t D i s e a s e took t h e v a l u e 1 w h e r e a n y n e a r r e l a t i v e — p a r e n t , s i b l i n g or c h i l d — of t h e r e s p o n d e n t h a d a h e a r t a t t a c k or c o r o n a r y t h r o m b o s i s . W h e r e n e a r r e l a t i v e s h a d not e x p e r i  e n c e d s u c h i l l n e s s , t h e v a l u e of t h i s v a r i a b l e w a s 0.

T h e c u r r e n t l i f e s t y l e p a t t e r n of r e s p o n d e n t s w a s a l s o i n t r o d u c e d . T h e s u r v e y a s k e d a b o u t e x e r c i s e , i n t a k e of f r u i t a n d v e g e t a b l e s , s u g a r i n t a k e , a r a n g e of o t h e r h e a l t h y e a t i n g i n d i c a t o r s , s m o k i n g a n d d r i n k i n g a s w e l l a s c a r r y i n g o u t h e i g h t a n d w e i g h t m e a s u r e m e n t s from w h i c h B o d y M a s s I n d e x c a n be c a l c u l a t e d . A h e a l t h y p a t t e r n w a s d e f i n e d a s : e n g a g i n g i n v i g o r o u s p h y s i c a l a c t i v i t y for a t l e a s t 2 0 m i n u t e s once a w e e k or m o r e often; e a t i n g f r e s h f r u i t s e v e n t i m e s w e e k l y a n d a l s o e a t i n g v e g e t a b l e s o t h e r t h a n potatoes s e v e n t i m e s w e e k l y ; a d d i n g no m o r e t h a n two teaspoonfuls of s u g a r to d r i n k s or c e r e a l s p e r d a y ; h a v i n g a p o s i t i v e r a t h e r t h a n a n e g a t i v e r a t i n g on a t l e a s t 7 o u t of t h e 10 o t h e r h e a l t h y e a t i n g i n d i c a t o r s ; b e i n g i n t h e "acceptable" r a n g e for B o d y M a s s I n d e x ; n o t s m o k i n g a n d h a v i n g a n alcohol i n t a k e w i t h i n t h e r e c o m m e n d e d " s e n s i b l e d r i n k i n g limits".

T h e 10 o t h e r h e a l t h y e a t i n g i n d i c a t o r s u s e d w e r e t y p e of m i l k u s u a l l y d r u n k ; n u m b e r of eggs e a t e n p e r w e e k ; t y p e of s p r e a d u s u a l l y e a t e n o n b r e a d ; n u m b e r of t i m e s b o i l e d or b a k e d potatoes w e r e e a t e n p e r w e e k ; n u m b e r of t i m e s c h i p s or r o a s t potatoes w e r e e a t e n p e r w e e k ; t h e n u m b e r of t i m e s f i s h w a s e a t e n p e r w e e k ; t h e n u m b e r of t i m e s c h i c k e n w a s e a t e n p e r w e e k ; t h e n u m b e r of t i m e s o t h e r m e a t w a s e a t e n p e r w e e k ; t h e n u m b e r of t i m e s f r i e d foods w e r e e a t e n p e r w e e k a n d t h e n u m b e r of t i m e s c a r r y - o u t or t a k e - a w a y food w a s e a t e n p e r w e e k . A p o s i t i v e r a t i n g o c c u r r e d w h e r e w h o l e m i l k w a s not u s u a l l y d r u n k ; l e s s t h a n 7 eggs w e r e e a t e n p e r w e e k ; low fat s p r e a d or soft p o l y u n s a t u r a t e d m a r g a r i n e w a s u s e d ; b o i l e d or b a k e d p o t a t o e s w e r e e a t e n five or m o r e t i m e s p e r w e e k ; c h i p s or r o a s t potatoes w e r e e a t e n no m o r e t h a n t w i c e a w e e k ; f i s h w a s e a t e n once or m o r e t i m e s p e r w e e k ; c h i c k e n w a s e a t e n t w i c e or m o r e t i m e s p e r w e e k ; o t h e r m e a t w a s e a t e n no m o r e t h a n e i g h t t i m e s p e r w e e k ; f r i e d foods w e r e e a t e n no m o r e t h a n t h r e e t i m e s p e r w e e k a n d t a k e - a w a y food w a s e a t e n no m o r e t h a n once p e r w e e k .

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l i f e s t y l e i n f o r m a t i o n c o l l e c t e d i n t h e s u r v e y r a t h e r t h a n a n a t t e m p t to i d e n t i f y t h e s u b s e t of v a r i a b l e s t h a t m o s t e f f i c i e n t l y p r e d i c t s a h e a l t h y l i f e s t y l e p a t t e r n . W h i l e t h e t h r u s t of c u r r e n t a d v i c e o n h e a l t h y l i f e s t y l e p r o m o t i o n i s c e r t a i n l y r e f l e c t e d b y t h e H e a l t h H a b i t s S c o r e , t h e r e i s a l s o , i n e v i t a b l y , a d e g r e e of a r b i t r a r i n e s s i n t h e s e t t i n g of t h e c u t - o f f p o i n t s s e p a r a t i n g "good" from "bad" b e h a v i o u r .

I n d i c a t o r s of o v e r a l l h e a l t h s t a t u s s u c h a s t h e p r e s e n c e or a b s e n c e of a m a j o r c h r o n i c i l l n e s s or i n f i r m i t y or t h e r e s p o n d e n t ' s s e l f - r a t i n g of h i s or h e r h e a l t h a s "excellent, good, f a i r or poor c o m p a r e d w i t h s o m e o n e of y o u r o w n age" h a v e a good r e c o r d a s p r e d i c t o r s of m o r t a l i t y , a d j u s t m e n t to m a j o r i l l n e s s a n d u s a g e of h e a l t h s e r v i c e s ( B l a x t e r , 1990; N o l a n , 1 9 9 1 ) . R e c e p t i v e n e s s to h e a l t h p r o m o t i o n m e s s a g e s m i g h t a l s o be h y p o t h e s i s e d a s b e i n g p o s i t i v e l y or n e g a t i v e l y affected b y a t a r g e t a u d i e n c e m e m b e r ' s o v e r a l l h e a l t h s t a t u s . T h e t e r m i n a t i o n s u r v e y d i d not i n q u i r e into i t s r e s p o n d e n t s " o v e r a l l h e a l t h s t a t u s b u t i t d i d i n c l u d e a s e l f - r a t i n g of "your p r e s e n t p h y s i c a l condition" w h o s e five r e s p o n s e options r a n g e d from "very good" t h r o u g h "good", "fair", a n d "not v e r y good" to "bad". T h i s w a s i n t r o d u c e d i n t o t h e a n a l y s i s a s a c o n t i n u o u s v a r i a b l e .

F o r t h e m u l t i v a r i a t e a n a l y s i s t w o s o c i o - d e m o g r a p h i c v a r i a b l e s — age a n d s o c i a l c l a s s — w e r e e n t e r e d a s c o n t i n u o u s v a r i a b l e s . T h e r e m a i n i n g c a t e g o r i c a l s o c i o - d e m o g r a p h i c v a r i a b l e s w e r e t r a n s f o r m e d i n t o t h e f o l l o w i n g s e r i e s of d u m m i e s :

F e m a l e S e x : t a k i n g t h e v a l u e 1 w h e r e t h e r e s p o n d e n t i s f e m a l e ; o t h e r  w i s e zero.

C i t y R e s i d e n t : t a k i n g t h e v a l u e 1 w h e r e t h e r e s p o n d e n t i s a K i l k e n n y city r e s i d e n t ; o t h e r w i s e zero.

O t h e r U r b a n R e s i d e n t : t a k i n g t h e v a l u e 1 w h e r e t h e r e s p o n d e n t r e s i d e s i n a n O t h e r U r b a n a r e a ; o t h e r w i s e zero.

M a r r i e d : t a k i n g t h e v a l u e 1 w h e r e t h e r e s p o n d e n t i s m a r r i e d ; o t h e r w i s e zero.

W i d o w e d , D i v o r c e d or S e p a r a t e d : t a k i n g t h e v a l u e 1 w h e r e t h e r e s p o n d e n t i s w i d o w e d , d i v o r c e d or s e p a r a t e d ; o t h e r w i s e zero.

F u l l t i m e E m p l o y e d : t a k i n g t h e v a l u e 1 w h e r e t h e r e s p o n d e n t i s i n f u l l -t i m e e m p l o y m e n -t ; o -t h e r w i s e zero.

U n a b l e to W o r k : t a k i n g t h e v a l u e 1 w h e r e t h e r e s p o n d e n t i s u n a b l e to w o r k o w i n g to p e r m a n e n t s i c k n e s s or d i s a b i l i t y ; o t h e r w i s e z e r o .

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L e f t S c h o o l a t 14: t a k i n g t h e v a l u e 1 w h e r e t h e r e s p o n d e n t left school or

f u l l - t i m e s t u d y a t or before t h e age of 14; o t h e r w i s e zero.

f u l l - t i m e s t u d y a t or after t h e age of 15; o t h e r w i s e zero.

f u l l - t i m e s t u d y a t t h e age of 16; o t h e r w i s e zero.

B e c a u s e o f t h e m u l t i p l i c i t y o f c h a n n e l s t h r o u g h w h i c h t h e P r o j e c t ' s

m e s s a g e s w e r e t r a n s m i t t e d , a d e p e n d e n t v a r i a b l e of c e n t r a l i n t e r e s t i s t h e

n u m b e r o f d i f f e r e n t s o u r c e s w h i c h c o n t r i b u t e d to t h e c r e a t i o n of t h e

r e s p o n d e n t s " p r o j e c t a w a r e n e s s . T o m e a s u r e t h i s a n O v e r a l l A w a r e n e s s S c o r e

w a s c o m p u t e d . I n t h i s s c o r e , h a v i n g h e a r d of t h e P r o j e c t s c o r e d 1, a s d i d a

"yes" a n s w e r to a n y of t h e o t h e r q u e s t i o n s l i s t e d i n T a b l e 3, b e i n g e i t h e r a n

o c c a s i o n a l or a r e g u l a r r e a d e r of CATCH a n d b e i n g e i t h e r a n o c c a s i o n a l or a

r e g u l a r r e a d e r of t h e " H e a l t h y People" c o l u m n . P o s s i b l e v a l u e s of t h e O v e r a l l

A w a r e n e s s S c o r e t h e r e f o r e r a n g e d f r o m 0 to 1 1 , a n d a l l of t h e a w a r e n e s s

i t e m s c a r r y t h e s a m e w e i g h t w i t h i n t h i s o v e r a l l score.

A s t h e O v e r a l l A w a r e n e s s S c o r e i s a c o n t i n u o u s v a r i a b l e a l e a s t s q u a r e s

r e g r e s s i o n m o d e l i s a p p r o p r i a t e for r e g r e s s i n g t h i s a w a r e n e s s score o n t h e

f u l l s e t of i n d e p e n d e n t v a r i a b l e s d e s c r i b e d above. T h e m o d e l w a s fitted u s i n g

s t e p w i s e i n d e p e n d e n t v a r i a b l e s e l e c t i o n w i t h t h e c r i t e r i o n for e n t r y s e t a t a

p r o b a b i l i t y of F of .10 a n d t h e c r i t e r i o n for r e m o v a l set a t a p r o b a b i l i t y of F of

.15. T h e r e s u l t s a r e s h o w n i n T a b l e 4.

Table 4: Factors Predicting Overall Awareness of Project Activities in 765 Respondents

Standardised

Regression Standard Regression

Variable Coefficient Standard Coefficient Significance

(B) Error ofB (Beta T-Statistic ofT

Female Sex .811190 .184074 .169597 4.407 .0000

Irish Social C l a s s -.145377 .053106 -.101165 -2.737 .0063

City Residence .672958 .194597 .121790 3.458 .0006

Health Habits Score .201709 .065796 .117015 3.066 .0083

Left School at 14 -.640445 .219763 -.112259 -2.914 .0037

Age .021993 .010520 .074800 2.091 .0369

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O u t of t h e 2 0 i n d e p e n d e n t v a r i a b l e s e x a m i n e d , 7 m e t t h e c r i t e r i o n for e n t r y i n t o a n d r e t e n t i o n w i t h i n t h e m o d e l . N o v a r i a b l e w h i c h h a d b e e n e n t e r e d w a s s u b s e q u e n t l y r e m o v e d . W i t h i n t h i s group of 7, t h e r e i s a m i x t u r e of p o s i t i v e l y a n d n e g a t i v e l y s i g n e d coefficients. T h e r e s u l t s i n d i c a t e t h a t t h e a w a r e n e s s s c o r e r o s e s i g n i f i c a n t l y w i t h a g e , f e m a l e s e x , K i l k e n n y c i t y r e s i d e n c e , a h i g h h e a l t h y h a b i t s score a n d l e a v i n g s c h o o l a g e d 17: i t f e l l s i g n i f i c a n t l y a s t h e c l a s s s p e c t r u m i s c r o s s e d f r o m h i g h e r p r o f e s s i o n a l to u n s k i l l e d m a n u a l w o r k e r a n d i f t h e r e s p o n d e n t left school a t or before t h e age of 14. T h e R2 f i g u r e , s h o w i n g t h e p r o p o r t i o n of v a r i a t i o n i n t h e O v e r a l l

A w a r e n e s s S c o r e e x p l a i n e d b y t h e m o d e l , i s a m o d e s t 12 p e r cent.

A m o n g t h e i n d i v i d u a l g e n e r a t o r s of a w a r e n e s s a g g r e g a t e d to f o r m t h e O v e r a l l A w a r e n e s s S c o r e , r e a d e r s h i p of t h e Kilkenny People c o l u m n a n d of CATCH w e r e of p a r t i c u l a r i n t e r e s t s i n c e b o t h t h e s e m e d i a h a d offered t h e P r o j e c t r e c u r r i n g o p p o r t u n i t i e s to c o m m u n i c a t e m e s s a g e s i t s o w n s t a f f h a d f r a m e d t h r o u g h o u t m o s t of t h e e v a l u a t i o n p e r i o d . T h e r e s p o n s e c a t e g o r i e s s h o w n i n T a b l e 1 a n d T a b l e 2 w e r e r e g r o u p e d , d i c h o t o m i s i n g r e s p o n d e n t s i n e a c h c a s e i n t o r e a d e r s or n o n - r e a d e r s .

L o g i s t i c r e g r e s s i o n i s t h e a p p r o p r i a t e m e t h o d o f a n a l y s i s h e r e s i n c e b o t h o f t h e s e d e p e n d e n t v a r i a b l e s a r e d i c h o t o m o u s , r a t h e r t h a n c o n t i n u o u s , i n n a t u r e . T h e r e s u l t s of r e g r e s s i n g r e a d e r s h i p of CATCH a n d r e a d e r s h i p of t h e Kilkenny People c o l u m n on t h e f u l l s e t of i n d e p e n d e n t v a r i a b l e s , a g a i n u s i n g t h e f o r w a r d s t e p w i s e i n d e p e n d e n t v a r i a b l e s e l e c t i o n m e t h o d a n d t h e s a m e s i g n i f i c a n c e l e v e l c r i t e r i a for e n t r y a n d r e t e n t i o n , a r e s h o w n i n T a b l e s 5 a n d 7 r e s p e c t i v e l y . E a c h of t h e s e t a b l e s i s a c c o m p a n i e d b y a n o t h e r e m p l o y i n g a m e t h o d c o m m o n l y u s e d to o v e r c o m e t h e difficulty a t t a c h e d to i n t e r p r e t i n g l o g i s t i c coefficients. T h i s t r a n s f o r m s t h e coefficients to p r o d u c e a p r e d i c t e d p r o b a b i l i t y , w h i c h v a r i e s b e t w e e n 0 a n d 1, of a n e v e n t — i n t h i s c a s e t h e r e a d i n g of CATCH or t h e Kilkenny People c o l u m n — o c c u r r i n g . T h e p r o c e d u r e i n v o l v e s c o n s t r u c t i n g a s e t of b a s e l i n e c a s e s , c a l c u l a t i n g t h e i r p r e d i c t e d p r o b a b i l i t i e s a n d e x a m i n i n g h o w t h e s e a r e affected b y i n t r o d u c i n g s p e c i f i c v a r i a t i o n s i n t o t h e b a s e l i n e s ( N o r u s i s , 1990, pp. 47-48).

Table 5: Logistic Regression of Readership of CATCH: Number of Respondents = 751

Regression Wold

Coefficient Standard Statistic Significance

Variable (B) Error ofB (ldf) of Wold

City Residence .7255 .2048 12.5431 .0004

Female Sex 1.1376 .1796 40.0995 .0000

Left School at 14 -.4283 .1939 4.8777 .0272

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Table 6: Predicted Impact of Different Variables on the Probability of Being a Reader ofCATCH

a) ® m (4)_ Baseline 0.88 0.66 0.60 0.32 Female — 0.86 — 0.60 Male 0.71 — 0.32 — City resident — — 0.75 0.49 Not city resident 0.79 0.48 — — 2 good health habits 0.82 0.60 — — 6 good health habits 0.93 0.80 0.80 0.56 Left school at or before 14 0.83 0.55 — — Left school at a n older age — — 0.69 0.42 (1) Baseline = woman, city resident, 4 good health habits, left school aged 15 or

older.

(2) Baseline = m a n , city resident, 3 good health habits, left school aged 15 or older. (3) Baseline = woman, not city resident, 2 good health habits, left school at or under

14.

(4) Baseline = m a n , not city resident, 2 good health habits, left school at or under 14.

Table 7: Logistic Regression of Readership of the Healthy People Column: Number of Respondents = 742

Regression Wald Coefficient Standard Statistic Significance Variable (B) Error of B (ldf) of Wald

I r i s h Social C l a s s -.0980 City Residence .7611 Female Sex .8705 Health Habits Score .2074

.0510 3.6872 .0548 .2153 12.4978 .0004 .1828 22.6654 .0000 .0651 10.1515 .0014

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t h e u n i n t e r e s t e d : t h o s e w h o h a v e t r i e d to m a k e positive c h a n g e s i n t h e p a s t 5 y e a r s w i t h r e g a r d to e x e r c i s e , w e i g h t a n d d i e t a r y c o m p o s i t i o n r a n g e f r o m one-t h i r d u p one-to one-t w o - one-t h i r d s of r e s p o n d e n one-t s .

Table 8: Predicted Impact of Different Variables on the Probability of Being a Reader of the Healthy Column People Column

(1) (2) (3) (4)

Baseline 0.88 0.70 0.63 0.44

Male Female 0.76 0.85 0.42 0.66 City resident

Not city resident 0.78 0.52

0.79 0.63

2 healthy habits 6 healthy habits

0.83 0.92

0.65

0.81 0.80 0.65

Unskilled manual class 0.84 0.66 — 0.42

Skilled manual class — 0.68 0.47

Higher professional class 0.90 0.76 0.74 0.54

(1) Baseline = woman, city resident, 4 healthy habits, other non-manual class. (2) Baseline = man, city resident, 3 healthy habits, skilled m a n u a l class.

(3) Baseline = woman, not city resident, 2 healthy habits, unskilled manual class. (4) Baseline = man, not city resident, 2 healthy habits, semi-skilled manual class.

Table 9: Lifestyle Components: Classification of Current State and Efforts at Change in the Past Five Years

Current State and Change Status

Lifestyle Component Healthy, No Change Attempted Healthy Change Attempted Unhealthy, Change Attempted Unhealthy, No Change Attempted Row Total Exercise % 7 % 8 % 34 % 51 % 100 F r u i t and Vegetable

Intake 15 27 28 30 100

Other Healthy E a t i n g

Indicators 18 51 15 16 100

Weight Range 28 7 36 29 100

Sugar Intake 42 23 13 22 100

Cigarette Smoking 66 10 16 8 100

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O r i e n t a t i o n to l i f e s t y l e c h a n g e w a s f u r t h e r e x p l o r e d b y t a k i n g t h e 7 life

s t y l e c o m p o n e n t s i n T a b l e 9 a n d , i n e a c h i n s t a n c e , d i c h o t o m i s i n g b e t w e e n

t h o s e w h o r e p o r t i n g a t t e m p t i n g c h a n g e ( s c o r e d 1) a n d t h o s e w h o d i d not

( s c o r e d 0 ) . C u r r e n t s t a t e w a s d i s r e g a r d e d for t h e p u r p o s e s of t h i s e x e r c i s e .

T h e s e v e n i t e m s w e r e t h e n a d d e d to c r e a t e a n o v e r a l l E f f o r t s a t C h a n g e

S c o r e . T h i s s c o r e w a s r e g r e s s e d o n t h e f u l l s e t of i n d e p e n d e n t v a r i a b l e s u s e d

i n t h e p r e v i o u s r e g r e s s i o n a n a l y s e s p l u s t h e O v e r a l l A w a r e n e s s S c o r e . A s

before, t h e m o d e l w a s f i t t e d u s i n g s t e p w i s e i n d e p e n d e n t v a r i a b l e s e l e c t i o n

w i t h t h e c r i t e r i o n for e n t r y set a t a p r o b a b i l i t y of F of .10 a n d t h e c r i t e r i o n for

r e m o v a l s e t a t a p r o b a b i l i t y of F of .15. T h e r e s u l t s a r e s h o w n i n T a b l e 10.

Table 10: Factors Predicting Efforts at Lifestyle Change in 802 Respondents

Standardised Regression Standard Regression

Variable

Coefficient (B)

Error ofB

Coefficient

(Beta) T-Statistic

Significance ofT

Overall Awareness Score .097883 .023484 .150029 4.168 .0000

Medical Treatment Related

to Heart Disease .710584 .139513 .189662 5.093 .0000

Left School at 18 .490229 .146872 .116635 3.338 .0009

City Residence .356320 .127266 .098840 2.800 .0053

Age -.021619 .007196 -.112698 -3.004 .0028

F u l l - t i m e Employed -.364341 .112831 -.116659 -3.229 .0013

Symptoms Suggestive of

Heart Disease .257330 .114548 .080053 2.246 .0250

Health Habits Score .078503 .041184 .069803 1.906 .0570

Widowed, Divorced or

Separated .438141 .234033 .066500 1.872 .0616

Model R2 = 0.133

T h e O v e r a l l A w a r e n e s s S c o r e i s a p r e d i c t o r of t h o s e w h o r e p o r t h a v i n g

a t t e m p t e d to c h a n g e h e a l t h h a b i t s i n t h e p a s t 5 y e a r s . A m o n g t h e o t h e r

p r e d i c t o r s , t h e a p p e a r a n c e of t h e s i t u a t i o n a l s e n s i t i v i t y v a r i a b l e s M e d i c a l

T r e a t m e n t r e l a t e d to H e a r t D i s e a s e a n d S y m p t o m s S u g g e s t i v e of H e a r t

D i s e a s e i s s t r i k i n g , a s t h e s e v a r i a b l e s d i d n o t e n t e r a n y of t h e m o d e l s

c o n s t r u c t e d i n t h e c o u r s e of r e g r e s s i n g t h e O v e r a l l A w a r e n e s s S c o r e , r e a d e r 

s h i p of CATCH or r e a d e r s h i p of t h e Kilkenny People c o l u m n . T h e i r p r e s e n c e

s u g g e s t s t h a t , i n a d d i t i o n to t h e p r i m a r y p r e v e n t i o n i n i t i a t i v e s of c o m m u n i t y

h e a l t h p r o m o t i o n , t h e s e c o n d a r y p r e v e n t i o n w o r k c a r r i e d o n w i t h p a t i e n t s

w i t h i n t h e m e d i c a l c a r e s y s t e m e x e r t s a n i m p o r t a n t i n f l u e n c e o v e r d e c i s i o n s

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V I D I S C U S S I O N

T h e b r o a d p a t t e r n of r e s u l t s i s c o n s i s t e n t a c r o s s t h e m u l t i v a r i a t e a n a l y s e s of a w a r e n e s s p r e d i c t o r s . K i l k e n n y c i t y r e s i d e n c e , f e m a l e s e x a n d m o r e good h e a l t h h a b i t s h a v e a s t r o n g positive r e l a t i o n s h i p to a w a r e n e s s of t h e P r o j e c t ' s m e s s a g e s w h i l e m a n u a l s o c i a l c l a s s m e m b e r s h i p a n d e a r l y s c h o o l l e a v i n g h a v e a n e g a t i v e r e l a t i o n s h i p .

A n i m b a l a n c e b e t w e e n i t s i m p a c t o n K i l k e n n y c i t y a n d o n o t h e r p a r t s of t h e c o u n t y h a d become a p p a r e n t from t h e Project's process e v a l u a t i o n d a t a b y t h e m i d - p o i n t of i t s e v a l u a t i o n period. I n a d d i t i o n to a v a i l i n g of n e w m e s s a g e d i s s e m i n a t i o n o p p o r t u n i t i e s a s t h e y a r o s e , ongoing m o d i f i c a t i o n of t h e m i x of c h a n n e l s u s e d to c o m m u n i c a t e P r o j e c t m e s s a g e s s o u g h t to s p e c i f i c a l l y a d d r e s s t h i s d i f f e r e n t i a l i m p a c t p r o b l e m ( W a l l a c e , 1 9 8 9 ; M u r r a y , S h e l l e y , D a l y , et al., 1 9 9 4 ) . T h u s , w h e n t h e P r o j e c t w a s p r e s e n t e d w i t h a R e f l o t r o n m a c h i n e i n D e c e m b e r 1988, a Kilkenny Health Project Roadshow f o r m a t w a s d e v i s e d offering blood c h o l e s t e r o l m e a s u r e m e n t a n d blood p r e s s u r e c h e c k s s u p p o r t e d b y d i e t i t i a n c o u n s e l l i n g a n d — w h e r e t h e r e s u l t s s u g g e s t e d i t to be a d v i s a b l e — r e f e r r a l to t h e p e r s o n ' s doctor. T h i s m o b i l e p r o g r a m m e w a s d e l i v e r e d i n v a r i o u s p a r t s of t h e c o u n t y i n c o l l a b o r a t i o n w i t h l o c a l P u b l i c H e a l t h N u r s e s . T h e s e efforts w e r e not, h o w e v e r , w h o l l y s u c c e s s f u l i n e l i m i n  a t i n g a n i m p a c t i m b a l a n c e w h o s e i m p l i c a t i o n s for i n t e r v e n t i o n s m o u n t e d i n s u p p o r t of t h e n e w n a t i o n a l h e a l t h s t r a t e g y a r e u n c l e a r . I t w o u l d be r a s h to a s s u m e t h a t t h e g r e a t e r u r b a n m e s s a g e r e c e p t i o n f o u n d i n K i l k e n n y ( w h e r e t h e M u n i c i p a l B o r o u g h a n d i t s E n v i r o n s h a d a c o m b i n e d p o p u l a t i o n of a r o u n d

1 7 , 5 0 0 i n t h e 1991 C e n s u s ) w o u l d be r e p e a t e d i n a c i t y t h e s i z e of D u b l i n w h e r e r e s e a r c h h a s i d e n t i f i e d "black-spot" a r e a s c h a r a c t e r i s e d b y b o t h h i g h m o r t a l i t y r a t e s a n d a h i g h p r e v a l e n c e of l i f e s t y l e r i s k f a c t o r s ( J o h n s o n a n d D a c k , 1989; J o h n s o n , J e n n i n g s , F o g a r t y , et al., 1 9 9 1 ) . A s t u d y t h a t d r e w i t s s a m p l e f r o m D u b l i n a n d f r o m a r u r a l p a r t of a n o t h e r L e i n s t e r c o u n t y ( M c C l u s k e y , 1 9 8 9 ) p r o v i d e s evidence t h a t h e a l t h beliefs a n d p r a c t i c e s do v a r y s i g n i f i c a n t l y b y t y p e of a r e a . M o r e effective i n t e r v e n t i o n p r o g r a m m i n g w i l l n e e d to t a k e t h e e x i s t e n c e of t h i s v a r i a t i o n i n t o a c c o u n t a n d to p r o c e e d i n t a n d e m w i t h r e s e a r c h t h a t explores i t i n g r e a t e r d e t a i l .

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f r i n g e b e n e f i t . T h e p r i v a t e h e a l t h i n s u r a n c e s y s t e m i n I r e l a n d does n o t o p e r a t e i n a w a y t h a t c r e a t e s s i g n i f i c a n t costs t h a t f a l l on e m p l o y e r s a n d t h e h e a l t h c a r e cost c o n t a i n m e n t c o n c e r n s t h a t h a v e h e l p e d s t i m u l a t e A m e r i c a n w o r k p l a c e i n i t i a t i v e s a r e l a r g e l y a b s e n t i n t h i s c o u n t r y , a l t h o u g h e n t e r p r i s e s m a y a v a i l of t h e s c r e e n i n g a n d c o u n s e l l i n g s e r v i c e s offered b y o r g a n i s a t i o n s s u c h a s t h e I r i s h H e a r t F o u n d a t i o n a n d costs a s s o c i a t e d w i t h a b s e n t e e i s m a r e a n i s s u e for m a n y e m p l o y e r s .

D u r i n g t h e P r o j e c t ' s l i f e t i m e b u s i n e s s i n v o l v e m e n t t e n d e d to t a k e t h e f o r m of s p o n s o r s h i p of e v e n t s w i t h p a r t i c i p a t i o n b y t h e w i d e r K i l k e n n y c o m m u n i t y r a t h e r t h a n j u s t i t s o w n w o r k f o r c e s . N a t i o n a l l y r e c e n t w o r k s i t e i n i t i a t i v e s h a v e i n c l u d e d a h e a l t h a n d l i f e s t y l e p r o m o t i o n c a m p a i g n u n d e r t a k e n w i t h i n t h e c o n s t r u c t i o n i n d u s t r y a n d I r e l a n d ' s p a r t i c i p a t i o n i n a 7 c o u n t r y s t u d y of h e a l t h p r o m o t i o n i n w o r k p l a c e s s p o n s o r e d b y t h e E u r o p e a n F o u n d a t i o n for t h e I m p r o v e m e n t of W o r k i n g a n d L i v i n g C o n d i t i o n s ( C o n s t r u c t i o n I n d u s t r y F e d e r a t i o n , et al., 1 9 9 2 ; W y n n e , 1 9 9 2 ) . A l a r g e a g r i c u l t u r a l s e c t o r a n d t h e p r e v a l e n c e of s m a l l u n i t s i n t h e m a n u f a c t u r i n g a n d s e r v i c e s e c t o r s a r e f e a t u r e s of t h e I r i s h e c o n o m y w h i c h c r e a t e d i f f i c u l t i e s for t h e w i d e s p r e a d d i f f u s i o n of w o r k s i t e h e a l t h p r o m o t i o n p r o g r a m m i n g . P e r s i s t e n t l y h i g h u n e m p l o y m e n t r a t e s a n d r e l a t i v e l y l o w f e m a l e p a r t i c i p a t i o n i n t h e p a i d l a b o u r force a r e o t h e r f a c t o r s m i l i t a t i n g a g a i n s t t h e w o r k s i t e b e c o m i n g a s p r o m i n e n t a focal p o i n t of h e a l t h p r o m o t i o n s t r a t e g y i n I r e l a n d a s i t h a s i n s o m e o t h e r c o u n t r i e s .

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U n e v e n r e s p o n s e s f r o m d i f f e r e n t s o c i a l c l a s s e s a n d l e v e l s of e d u c a t i o n w o u l d t h e r e f o r e be e n v i s a g e d after l e s s t h a n 5 y e a r s i n t e r v e n t i o n b y i n n o  v a t i o n - d i f f u s i o n t h e o r y . A t s u c h a n e a r l y s t a g e , s u c c e s s i n i n f l u e n c i n g a c o m m u n i t y ' s o p i n i o n l e a d e r s to m a k e l i f e s t y l e c h a n g e s r a t h e r t h a n t h e i r a c r o s s - t h e - b o a r d a d o p t i o n w i t h i n t h e c o m m u n i t y i s w h a t t h i s t h e o r e t i c a l f r a m e w o r k w o u l d propose a s t h e a p p r o p r i a t e focus. H o w e v e r , a l e s s o p t i m i s t i c v i e w of r e s p o n s e u n e v e n n e s s m i g h t a l s o be p u t f o r w a r d . A c c o r d i n g to t h i s v i e w , s o m e g r o u p s do n o t m e r e l y l a g b e h i n d i n t h e a d o p t i o n of l i f e s t y l e i n n o v a t i o n b u t a r e i n d a n g e r of b e i n g a l t o g e t h e r left o u t of t h e p r o c e s s of c h a n g e . B y c o m p a r i s o n w i t h o t h e r c o u n t r i e s , a n d p a r t l y a s a r e s u l t of prob l e m s i n o b t a i n i n g t h e d a t a needed, t h e r e h a s b e e n r e l a t i v e l y l i t t l e a n a l y s i s of a n d d e b a t e a b o u t socio-economic h e a l t h d i f f e r e n t i a l s i n I r e l a n d ( C o o k , 1 9 9 0 ) . H o w e v e r , N o l a n ( 1 9 9 0 ) h a s overcome some of t h e d a t a difficulties a n d s h o w n t h e e x i s t e n c e of s i g n i f i c a n t d i f f e r e n t i a l s i n s t a n d a r d i s e d m o r t a l i t y r a t e s b e t w e e n t h o s e i n p r o f e s s i o n a l / m a n a g e r i a l o c c u p a t i o n a l g r o u p s a n d t h o s e i n s e m i - s k i l l e d or u n s k i l l e d m a n u a l o c c u p a t i o n a l g r o u p s for m e n a g e d 15 to 6 4 . D e t a i l e d s o c i a l c l a s s a n a l y s i s of t h e K i l k e n n y H e a l t h P r o j e c t d a t a b a s e i s o n g o i n g a n d w i l l c o n t r i b u t e a n e w d i m e n s i o n to o u r u n d e r s t a n d i n g of I r i s h socio-economic h e a l t h differentials w h e n i t i s completed.

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i f n e e d e d (see K i l k e n n y H e a l t h P r o j e c t ( 1 9 9 0 ) , p. 2 8 ) . N a t i o n a l l y , e n d o r s e  m e n t of t h e H e a l t h P r o m o t i n g S c h o o l concept by t h e 1992 E d u c a t i o n G r e e n P a p e r ( G o v e r n m e n t of I r e l a n d , 1 9 9 2 ) o u g h t to be t h e p r e l u d e for a m o r e e x t e n s i v e u s e of s c h o o l - h o m e c o m m u n i c a t i o n w i t h i n I r i s h h e a l t h p r o m o t i o n i n i t i a t i v e s .

V e r y l i t t l e u s e w a s a b l e to be m a d e of t e l e v i s i o n a s a c o m m u n i c a t i o n c h a n n e l i n K i l k e n n y d u r i n g t h e c o u r s e of t h e P r o j e c t . A s n o t e d above, one r e a s o n for t h i s w a s a c o n s t r a i n t a r i s i n g out of t h e Project's e v a l u a t i o n design: s i n c e t h e m e d i u m f u n c t i o n s i n I r e l a n d on a n a t i o n a l r a t h e r t h a n a l o c a l b a s i s , c o m m u n i c a t i n g i n t e r v e n t i o n p r o g r a m m e m e s s a g e s t h r o u g h c h a n n e l s a c c e s s  i b l e to b o t h t r e a t m e n t a n d c o n t r o l c o m m u n i t i e s r i s k e d " c o n t a m i n a t i n g " t h e q u a s i - e x p e r i m e n t . C o n t a m i n a t i o n t h r o u g h e x p o s u r e of a c o n t r o l c o m m u n i t y to t h e t e l e v i s i o n o u t p u t of a n i n t e r v e n t i o n p r o g r a m m e h a s i n fact r e c e n t l y o c c u r r e d i n t h e c a s e of t h e U K ' s H e a r t b e a t W a l e s , despite t h e s t r o n g e l e m e n t of r e g i o n a l i s a t i o n w i t h i n b o t h t h e B B C a n d the I n d e p e n d e n t t e l e v i s i o n sectors ( N u t b e a m , S m i t h , M u r p h y a n d C a t f o r d , 1993). T h e r i s k of d e s i g n c o n t a m i n  a t i o n l e d t h e P r o j e c t to i n i t i a l l y adopt a p o l i c y of n o t a c t i v e l y s e e k i n g t h e a t t e n t i o n of w h a t a n t i c i p a t e d c o m m u n i c a t i o n effectiveness w o u l d o t h e r w i s e h a v e m a d e a p r i m e t a r g e t — t h e n a t i o n a l l e v e l b r o a d c a s t i n g a n d p r i n t m e d i a . W h e n a m o r e p o s i t i v e a t t i t u d e to t h e p l a c e m e n t of m a t e r i a l s i n t h e n a t i o n a l m e d i a w a s s u b s e q u e n t l y a d o p t e d , d i f f i c u l t y i n a t t r a c t i n g c o v e r a g e w a s e x p e r i e n c e d a p p a r e n t l y b e c a u s e n a t i o n a l m e d i a g a t e k e e p e r s p e r c e i v e d t h e P r o j e c t to be a s u b j e c t of l i m i t e d , a n d l a r g e l y p r o v i n c i a l , i n t e r e s t . N a t i o n a l h e a l t h p r o m o t i o n p r o g r a m m i n g w i l l not be c o n s t r a i n e d w i t h r e g a r d to t e l e  v i s i o n u s a g e i n t h e s a m e w a y a s a pilot r e s e a r c h a n d d e m o n s t r a t i o n project w a s : b u t , a s l o n g a s p a i d a d v e r t i s i n g i s t h e o n l y d i r e c t f o r m of a c c e s s to t h e m e d i u m a v a i l a b l e , i t w i l l f i n d i t a v e r y e x p e n s i v e option.

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