Effects of Communitywide Education on Cardiovascular Disease Risk Factors The Stanford Five-City Project John W. Farquhar, MD; Stephen P. Fortmann, MD; June A. Flora, PhD; C. Barr Taylor, MD; William L. Haskell, PhD; Paul T. Williams, PhD; Nathan Maccoby, PhD; Peter D. Wood, DSc, PhD To test whether communitywide health education can reduce stroke and coro- nary heart disease, we compared two treatment cities (N = 122 800) and two control cities (N = 197 500) for changes in knowledge of risk factors, blood pressure, plasma cholesterol level, smoking rate, body weight, and resting pulse rate. Treatment cities received a 5-year, low-cost, comprehensive program using social learning theory, a communication\p=m-\behavior change model, commu- nity organization principles, and social marketing methods that resulted in about 26 hours of exposure to multichannel and multifactor education. Risk factors were assessed in representative cohort and cross-sectional surveys at baseline and in three later surveys. After 30 to 64 months of education, significant net reductions in community averages favoring treatment occurred in plasma cho- lesterol level (2%), blood pressure (4%), resting pulse rate (3%), and smoking rate (13%) of the cohort sample. These risk factor changes resulted in important decreases in composite total mortality risk scores (15%) and coronary heart disease risk scores (16%). Thus, such low-cost programs can have an impact on risk factors in broad population groups. (JAMA. 1990;264:359-365) CARDIOVASCULAR disease (CVD), the major cause of death and disability in industrialized countries,1 is related to hypertension, elevated plasma choles¬ terol, cigarette use, obesity, and seden¬ tary life-style.2 Communitywide pro¬ grams designed to decrease these risk factors have appeal because of their po¬ tential for synergism from using multi¬ ple education strategies (including changes in institutions) and from the use of inherently efficient channels, such as the mass media.3"5 This comprehensive approach also enhances the possibility of altering regulations, environmental factors, and behavioral norms to favor healthy life-styles.6"9 This report describes changes in CVD risk factors during the Stanford Five-City Multifactor Risk Reduction Project (FCP), a 14-year trial of commu¬ nitywide CVD risk reduction achieved through a comprehensive, integrated program of community organization and health education.2 We hypothesized that such a program would produce fa¬ vorable changes in knowledge, CVD risk factors, and fatal and nonfatal coro¬ nary heart disease (CHD) and stroke rates.2 We report changes in knowledge and in risk factors after 5 Vs years of education. Earlier efforts have suggest¬ ed the efficacy of such an approach,3"5 seeking to influence people, the social environment, and the media. Data are still being collected for future analyses of CHD and stroke morbidity and mor¬ tality and of the maintenance of risk factor changes. METHODS Community selection, assignment to treatment condition, and evaluation of the FCP have been described previous¬ ly2 and are reviewed only briefly here. Intervention Methods A program for organizing and educat¬ ing communities toward prevention of strokes and CHD was developed in col¬ laboration with existing community or¬ ganizations and was implemented in 1980. Two treatment cities received continual exposure to general education punctuated by four to five separate risk factor education campaigns per year. The program was amplified through use of volunteers and promoted (1) reduc¬ tions in plasma cholesterol levels through diet change; (2) reductions in blood pressure through encouraging regular blood pressure checks, reduced salt intake, reduced weight, increased physical activity, and use of antihyper¬ tensive medications; (3) reductions in cigarette use through both prevention and cessation programs; (4) weight con¬ trol through reduced intakes of fat and energy and increased physical activity; and (5) increases in physical activity appropriate to age and physical condi¬ tion. From the Center for Research in Disease Prevention, Stanford University School of Medicine, Palo Alto, Calif. Reprint requests to Center for Research in Disease Prevention, Stanford University School of Medicine, 1000 Welch Rd, Palo Alto, CA 94304 (Dr Farquhar). Downloaded From: http://jama.jamanetwork.com/ by a STANFORD Univ Med Center User on 03/02/2015