There is a growing need for effective, large-scale interventions that can tackle noncommunicable diseases (NCD) that lead to global mortality and morbidity. Cardiovascular disease (CVD), cancers, diabetes, and chronic respiratory diseases that are addressed by the World Health Organization (WHO) global action plan for NCD prevention and control are largely caused by 4 shared behavioral risk factors: tobacco use, physical inactivity, unhealthy diet, and harmful alcohol use. The highest burden of these diseases is experienced in low- and middle-income countries (LMIC) where preventive programs are scarce.[2–5] The United Nations political declaration on NCD prevention and control emphasized a comprehensive approach to achieve the global target of 25% reduction in premature mortality by the year 2025. This approach goes beyond the health system and needs strong intersectoral collaboration between governmental agencies, private sector, academia, civil society, and other related sectors.
According to the WHO and some large multicentric studies, the modifiable risk factors of CVD like smoking, elevated blood pressure, and hypercholesterolemia account for over 70% of the CVD burden. However, the vision of CVD prevention through modifying these risk factors by 70% seems to be unrealistic specifically in LMIC, given their multiple challenges against prevention whether in public health structure or in clinical practice.[8,9] There are only a few successful multisectoral programs that have been implemented anywhere in the world. The North Karelia Project in Finland was 1 of the first intervention programs that was successful in leading to decreased NCD risk factors, prevalence, and mortality, and this model has been replicated in other countries.[10–12]
The Isfahan Healthy Heart Program (IHHP) was a 6-year multisectoral community-based integrated program, launched in 1999 and implemented from 2000 to 2001 to 2007 as a response to the growing epidemic of NCD and their determinants in Iran. The IHHP design was based on the North Karelia model and consisted of multidisciplinary intervention strategies using both population and high risk approaches.[13,14] Extensive evaluation of the implementation of interventions in the real life of the population was performed. The North Karelia and IHHP models are good examples of implementation and knowledge utilization toward the reduction of NCD burden in developed and developing countries.
Implementation research refers to understanding why and how evidence-based interventions in targeted settings lead to sustainable improvements in population health, or do not. Implementation research creates evidence about how to put a program into practice in 1 community that can be adapted and used by other communities thus promoting dissemination.[16,17] Implementation science has the potential to accelerate translation of research into practice and policy, while considering the complexity, dynamics, and adaptation of the environment in which the results will be implemented. Knowledge utilization that addresses the gap between research and practice may cover knowledge brokering and translation and can be strong facilitator or barrier of implementation. Diffusion and dissemination are other processes used to spread the evidence in communication in passive and active ways, respectively, however, both can play role as implementation barriers or facilitators.
Due to the lack of previous reports about program implementation in developing countries, this article provides a description of the ways that some of the IHHP interventions were implemented, disseminated, and translated into practice or policy, and the factors that facilitated or impeded their adoption.
Setting and target population
The IHHP was an action-oriented demonstration program that targeted the general population consisting of adults aged more than 18 years, adolescents and children aged 2–18 years and their parents, health professionals, and high-risk groups. The high-risk groups consisted of patients and their families with cardiac disease, stroke, diabetes, dyslipidemia, obesity and metabolic syndrome, and/or hypertension. Interventions aimed to promote healthy lifestyle behaviors including healthy nutrition, tobacco control, physical activity, and stress management, with the aim of ultimately preventing CVD and NCD more generally. The program’s methodology, target groups sampling procedures, interventions, and evaluation have been published previously.[13,14,20]
The intervention was carried out in Isfahan and Najafabad, whereas Arak served as a control (reference) area.[13,14] All these areas are industrial areas located in central Iran with similar socio-economic, demographic, and health profiles. Arak is located 375 km northwest of Isfahan with no mass media coverage or other types of contamination (Fig 1).
Brief description of interventions
Fig 2 shows IHHP’s theoretical framework that consists of planning, implementing and evaluating interventions after an initial assessment. Evaluation started with implementing the interventions, thus some interventions continued as it was planned or even disseminated while some were modified or failed. Healthy nutrition, increased physical activity, tobacco control, and coping with stress were the primary types of interventions that were implemented on the entire population and high risk groups within the intervention areas. However, the high-risk population received specific interventions that targeted their disease or risk factors. Key strategies for intervention activities included public education through mass media, intersectoral collaboration, professional education and involvement, social marketing, organizational development, legislation and policy enforcement or development, and research and evaluation. All interventions were planned and performed considering differences between men and women, age groups, literacy, socioeconomic situation, and cultural beliefs.
Based on data from the baseline surveys and needs assessment, IHHP interventions were implemented in the form of 10 projects, each targeted at different audiences. These projects included Healthy Food for Healthy Community, Isfahan Exercise Project, Heart Health Promotion from Childhood, Youth Intervention Project, Women’s Healthy Heart Project, Worksite Intervention Project, Non-Governmental Organization and Volunteer Intervention Project, Health Professional Education Project, Healthy Lifestyles for High risk Populations, and Healthy Lifestyles for Cardiac Patients (Table 1). All these intervention projects operated simultaneously. In terms of sex equity, women were included, in most projects, not only in the “Women’s Healthy Heart Project.”
A brief description of the educational, environmental, and legislative activities within each project is provided in Table 1 and can be seen in detail on the IHHP website at www.ihhp.ir. Interventions could target individuals, populations, and/or the environment. Community mobilization was achieved through a “train the trainers” approach, and activities to improve the knowledge and behavior of the people in gatherings in parks, gymnasiums, mosques, shops, restaurants, schools, kindergartens, universities, garrisons, factories, and offices. Community health and religious leaders were actively involved, including a group of health professionals who received regular training sessions and transferred IHHP messages to the target population. Each project was supervised by a steering committee that consisted of academics, health care providers, stakeholders or beneficiaries of the interventions, and decision makers. A representative of each project’s steering committee served on the IHHP overall executive steering committee that was responsible for planning all strategies and policies of the program overall.
We were guided by a social marketing approach in conducting and implementing some of our interventions. We considered some aspects of social marketing like identifying target and segmenting audiences, identifying the objectives of targeted behavior changes, tailoring messages to specific groups, using appropriate preexisting settings, adapting strategies like branding, and using mass media or competing for attention. Practical examples of social marketing in IHHP include creating specific learning materials for illiterate people or children; branding some restaurants whose owners agreed to serve healthy food and use healthy cooking methods as heart healthy restaurants; and using preexisting policy that all young people who intend to marry should attend health education classes to integrate our healthy lifestyle messages within their education agenda or volunteers who cooperate with health workers, and finally Continuous Medical Education to train health professionals.
An underlying principle in all the projects was to develop and maintain close contact with representatives of relevant community organizations. Teams worked intensively and closely with representatives of the mass media (television, radio, newspapers); health professionals (physicians, nurses, health workers, volunteers, social workers, school health care providers, and occupational medicine specialists in worksites); business and market leaders (food industry, supermarkets, restaurants, bakeries, nuts shops, confectionaries); related nongovernmental organizations; and local political decision makers like district, municipal and provincial leaders.
In addition to a general regular television program, which was broadcast on a weekly basis for 4 years, each intervention project had various target-oriented programs that lasted for 3–4 years. Routine national health programs were continued in both intervention and control areas during the study.
Brief description of IHHP evaluation
The IHHP was evaluated using a quasi-experimental design with a variety of embedded substudies (Fig 3). The IHHP included a control community, given the lack of evidence from developing countries about the impact of a comprehensive community-based NCD programs. Another reason for having a control area was that this study design would provide convincing scientific evidence that could increase the possibility that the Ministry of Health would support future national NCD prevention programs. Impact and outcome evaluations were conducted in both intervention and control areas, whereas the process evaluation was performed in the intervention areas only. Impact evaluation was based on changes in lifestyle behaviors as assessed by annual questionnaire-based surveys in independent random samples from both communities. Process evaluation comprised both qualitative and quantitative methods and was based on small samples in the intervention areas to test the implementation of intervention activities. Outcome evaluation was based on changes in metabolic risk factors in independent samples in intervention and control areas between baseline (2000 to 2001) and at the end of the program (2007), using multi-stage random sampling.[3,24–26] Sampling methods, sample size calculations, and changes in lifestyle behaviors and metabolic risk factors for different target groups have been described elsewhere.[3,27]
The quality of data collection procedure was maximized through rigorous training and ongoing quality assurance programs, and evaluation was an integral component of the program.
External evaluation was undertaken by university and international experts with a comprehensive report submitted to university officials, the Ministry of Health, and the WHO office in Iran.
National and regional dissemination.
Many of the ideas related to planning, interventions, evaluation, and implementation in any of the 10 projects were quite new in Iran or the Eastern Mediterranean region at the time the program was ongoing. The IHHP served as a demonstration study potentially to be later scaled up to the national level or even to some other countries in the region. Following their emergence as global priorities, NCD prevention and promoting healthy lifestyles became subjects of interest at the national level. Recently, the WHO published the HEARTS Technical Package for CVD management and integration in primary health care. This package provides a set of effective, practical interventions for strengthening the management of risk factors for CVD in primary health care. The HEARTS package covers 6 elements including healthy lifestyle, evidence-based treatment protocol, access to essential medicines and technology, risk-based management, team care and task-sharing, and systems for monitoring. In these guidelines, the IHHP is included as a model for a healthy lifestyle component that includes counseling on tobacco cessation, healthy diet, physical activity, alcohol use, and self-care.
IHHP leaders were often asked whether and how the whole program could be implemented in other provinces or even at the national level. Implementation of the entire intervention at a single point in time is not likely to be feasible due to the complexity and varying start up times for different components of such programs. However, IHHP leaders believe that the widespread implementation of some of the IHHP interventions has gradually occurred in many areas based on diffusion and dissemination. In many cases, diffusion happened in passive way without previous planning with other provinces starting community-based interventions, mostly on a smaller scale.
IHHP investigators laid the groundwork for local and national dissemination by organizing training courses for health professionals from other provinces based on the requests and support of the Ministry of Health. They shared mass media programs with the national broadcasting organization, provided IHHP educational materials to other provinces, and organized workshops with the Ministry of Health support with field visits for health professionals from other provinces to show them how interventions were planned and implemented. They had extensive contacts with the Ministry of Health-related offices to implement feasible and successful interventions. Other governmental and nongovernmental organizations were asked to consider using successful IHHP interventions in their ongoing work and to publish related brief reports on their experiences in their own newsletters. IHHP investigators published many articles and books and presented the program at national or international meetings to support dissemination.
As IHHP was well known at the national level, and because of continuous contacts of its leaders with the Ministry of health officials, it was used as a reference for policy planning, especially in the field of nutrition. In addition, after the IHHP ended, other intervention activities were initiated in Isfahan and Najafabad to achieve expected outcomes that had not been achieved by IHH. This included a number of programs: “Isfahan Tobacco Use Prevention Program,”[33,34] “Evaluating the Implementation of Framework Convention on Tobacco Control (FCTC) in Iran,” “Obesity Prevention and Control, does a self-care model works” entitled TABASSOM,[36–38] “The Sustainability of IHHP Interventions,” “Studying IHHP interventions Facilitators and Barriers,” “Determining the trend of salt intake” and other action-oriented studies on increasing the population awareness on how to combat air pollution.[41,42] Some of these studies’ results were used by the local authorities and some by related offices in the Ministry of Health.
Regional replication of the program was attempted as part of the term of reference of the “Isfahan Cardiovascular Research Center,” which is a WHO collaborating center for research and training of CVD prevention and control in the Eastern Mediterranean Region. Seven short-term training courses were conducted, with support from WHO headquarters and/or the region. The National Institute for Health and Welfare in Finland supported all training courses, and the World Heart Federation helped with some. Participating fellows in these 5-day training courses were not only from the region but also from other developing countries. Some representatives attended more than once, and some countries sent fellows who spent 1–2 weeks in Isfahan to get familiar with all IHHP intervention activities. Representatives were health professionals either from academic or public health sector or from the Ministry of Health of these countries. IHHP leaders were also invited to other countries to present about the IHHP and to visit new NCD prevention programs in these countries like Oman, Emirates, Tunisia, Lebanon, and Pakistan.[43–45]
There is a big challenge to assess which intervention could bring the most benefit with the lowest cost in multisectorial programs, because in these kinds of programs, multiple interventions are performed simultaneously with possible multiplicative impacts, in that the programs may reinforce one another and boost the effects overall. Therefore, calculating the whole costs or studying the cost-effectiveness of such programs is not an easy task, given the complexity of calculating the indirect costs. The whole program, considered as a package of interventions or primary strategies, can be considered as a successful model. We did not consider our program as a “best buy” because by definition, “best buys” are those interventions that are the most effective with lowest costs. Other programs that do not meet the criteria of a best buy but still offer good value and have other attributes that recommend their use, can be characterized as “good buys.” For national scale-up, policy makers can consider best buys as core programs and good buys as expanded set of interventions to implement when resources are available. It is important to indicate that it is not usual to scale up the implementation of all elements of a feasibility study of a multisectoral NCD prevention program to the national level at 1 time because this process happens gradually, and it may take years to be disseminated.
For national implementation, IHHP’s primary investigators established the “IHHP national implementation committee.” The aim of this committee was to review the process of implementation of feasible and successful interventions in IHHP that could be implemented in other parts of the country. The ideas of the national officers in the NCD and other related units in the Ministry of Health were considered in the discussions and incorporated in the decisions. The committee ended up developing a questionnaire about each intervention that asked respondents to discuss the factors that affected how they implemented their intervention activities, specifically the facilitators and barriers. We also conducted a qualitative study by interviewing all project managers asking for the facilitators and barriers of performing their activities. The analysis of the results was conducted by summarizing the main points, categorizing, extracting important quotes, minimizing the facilitators’ biases in the interpretation of the findings.
Based on the findings obtained from the questionnaires and interviews, we classified the interventions as: (1) interventions that can be implemented at the national level as they are; (2) interventions that need some modifications before implementation at the national level; (3) interventions that are not feasible to be implemented at the national level. The third category did not rule out the possibility of implementing the intervention at local or provincial level as had been done in the IHHP intervention areas. At multiple meetings, the committee identified important issues including mechanisms of implementation, its barriers or facilitators, feasibility and practicality of specific interventions, tailoring the intervention according to socioeconomic status, and cultural beliefs. Major facilitators and barriers to IHHP implementation are discussed below.
Mechanisms of implementation
A comprehensive multisectoral approach that goes beyond education, training, and building capacity and includes fiscal and regulatory actions by policy makers at the local or national levels is required to achieve effective implementation of NCD prevention programs. Although multiple organizations contributed to the implementation of the IHHP interventions, information diffusion happened largely through media interest, which was high throughout the program.
There was also a clear need for active dissemination of health education. Public education that was provided as part of the IHHP gradually increased the interest of the all population groups in Isfahan and Najafabad in healthy products, specifically healthy food, and led to the involvement of the private sector. Food companies, restaurants, bakeries, and confectionaries were interested to cooperate and felt ownership in the Healthy Food for Healthy Community project, which was 1 of the program’s main strategies.[46–48] Starting contacts and involvement with big and well-known companies, factories, and restaurants led others to adopt similar policies and practices, either because of their interest in following them or for competitive reasons. Larger companies were more interested in looking for innovations than smaller ones to produce healthy new food products, for example, low salt as preservative in canned food, low sugar in sweets, free trans fatty acid, and low saturated fatty acid products and whole grain wheat in bakeries
Involving relevant stakeholders and policy makers in each of the 10 interventional projects in planning, implementing, and evaluating the intervention activities led them to be more involved and to consider the project as their own. The IHHP project managers included governmental and nongovernmental organization leaders such as the Nutrition Improvement Office in the Ministry of Health, Ministry of Industry, Mining and Commerce; the Governor of the Provinces, the Welfare Organization; National Iranian Broadcasting Corporation, religious leaders, the Flour and Bread Council, the Health, Food, and Drug Deputy and Treatment Deputy of the University of Medical Sciences, the Medical Education Development Center of University, Institute of Standard and Industrial Research, the unions of restaurants, bakeries, fast food and nuts, owners of food industries that produce healthy food products, and health professionals (physicians, nurses, health technicians, nutritionists). Ownership and leadership were among the most powerful mechanisms behind implementing IHHP interventions that also helped to sustain some of them after the program ended. Although implementation can be more meaningful if a program or policy is sustained, the process and mechanisms of sustainability need further study. We have continued to study the programs initiated during the IHHP after the conclusion of the formal program. IHHP interventions were considered sustainable and institutionalized if they currently exist in the same way that they were implemented during the program or if their process changed, but the intervention still exists or operates within its original organizational strategy. An example of a sustained intervention is the morning physical activity program that was started during IHHP and still exists in all primary and intermediate schools 7 years after IHHP ended. Another example is the educational reports about healthy lifestyle that were published in the IHHP-specific newsletter for workers and employees in factories and offices, which are now incorporated in the factories or office’s own newsletters.
Among other facilitators that helped the implementation of IHHP were the interest and engagement of stakeholders and policy makers like the head of unions or managers of offices or factories, our feedback on the work progress to stakeholders and policy makers was effective too. In some interventions, political will played a major role as facilitator like implementing antismoking rules or promoting physical activity in big governmental factories by it’s managers. Furthermore, supportive formal or informal partnership or coalition between researchers and users devolved to frontline teams for, for example, we established a partnership between academics, food industry, and the community to provide technical advice to industries on how to produce healthy products and to support these products. Strategic climate of an organization, incentives and mandates, resetting the community or organizational norms, good managerial steps, dedicated human resources, internal communications and personal contacts, readiness of the community, provider and user acceptance and cooperation, external collaboration, and flexibility of interventions were among other facilitators of IHHP. We provided briefly some practical examples of most of the above-mentioned facilitator mechanisms in Table 2, with more details of Table 2 in Appendix 1.
There are multiple barriers that work against the implementation of multisectoral NCD prevention programs. IHHP barriers include the absence of universal health insurance coverage for NCD primary prevention strategies proposed in IHHP like risk factors screening and modifications, nonsupportive or unstable environment, for example, in Isfahan Exercise Project people were encouraged to use bicycles and public transportation, while using private cars was forbidden in 1 of the main streets in Isfahan once a week. This strategy was built on the old traditional way of transfer in Isfahan many years ago; however, the unsafe roads and limited availability of cycling pathways and heavy traffic were among the big barriers to this recommended intervention at that time. Years after the study and following providing essential infrastructure, the same strategy has been implemented by the provincial government, therefore, forbidding using private cars has restarted in the same street in Isfahan city on weekly basis. In addition, the number of inter-city bicycle paths and borrowing stations are growing in Isfahan.
Lack of political will played a major role in tobacco control interventions specially in the field of the growing water pipe use. Other barriers include lack of knowledge of the mechanisms of adapting the best buys as they are not applicable in different situations or cultures either because of high costs or time allocation, or are not customizable. Sometimes, the intervention setting, or adopter characteristics, doesn’t represent the general population. Among other barriers are the nonacceptance of interventions by provider or receiver, failure in social processes like communication, no capacity or readiness in the target community to change, sociopolitical and economic factors, and the lack of connection between researchers and knowledge users. Table 2 shows some practical examples of the barriers to the implementation of different IHHP interventions.
Several mechanisms, some that act as facilitators and some as barriers, were observed during the implementation of the IHHP. One of the most important facilitators was involving relevant stakeholders and policy makers as managers in different interventional projects, while low political support, particularly in the field of tobacco control, was among the most important barriers. Understanding the barriers and facilitators to program implementation is needed for better or large-scale implementation such as national scale up or its replication in other countries.
The authors are thankful to the team of ICRC and Isfahan Provincial Health Office and collaborators from both the Najafabad Health Office and Arak University of Medical Sciences.
The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by Progress in Preventive Medicine at the discretion of the Editor-in-Chief.
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Appendix: Table 2. Barriers and facilitators of the implementation of IHHP interventions