Nurses are the experts in this field but even they are not very effective in reducing coronary risk. In the community-based OXCHECK randomized trial (N = 6124, aged 35-64) serum cholesterol fell by only 0.08-0.2mmol/L and there was no significant difference in rates of giving up smoking, or in body mass index. Systolic (and diastolic) BP fell by ~2.5% in the intervention group receiving dietary and lifestyle advice. Blanket health promotion may not be a complete waste of resources, but it is certainly expensive for rather limited gains. Similar results have been obtained by the Family Heart Study Group. Depending on the assumed duration of risk reduction, the programme cost per discounted life year gained ranges from 34,800 if interventional benefits last for 1 year, compared with 1500 for 20-year duration. Corresponding OXCHECK figures are 29,300 and 900. These figures exclude broader long-term cost effects other than coronary mortality.
The conclusion may be that energies are best spent on those with highest risk as determined in routine consultations by a fewsimple questions about smoking, family history, etc. One trouble is that these questions are not always innocuous. It is not necessarily a good thing to bring upstrokes and heart attacks in the family in, for example, consultations about tension headaches. OXCHECK is not the last word and there is evidence that if lipid-lowering drugs were used very much more extensively, cholesterol (and cardiac events) could fall by 30%.
Novel ways of delivering health education messages
- For those who have difficulty in accessing health services, eg those in rural areas, videoconferencing and the internet may be a good way forward. Sustainability of these programmes depends upon the following issues: cost, delivery style, and availability of appropriate technology and patient-friendly internet sites.61
- Traditionally, health education has been given by experts, partly because they can answer questions authoritatively. But this authority is itself a problem. Risk-takers are unlikely to listen to the prim and proper. So peer-education has been developed as a tool to reach certain groups, and evidence suggests that this is a promising way forward.
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