Women's Healthy Heart Project (WHHP) is a component of Isfahan Healthy Heart Program.10
It involved all women aged above 18 years in the counties of Isfahan and Najafabad (intervention areas) and Arak (control areas). Lifestyle characteristics and CVD risk factors of women were identified through situation analysis conducted in the first phase of the study in 2002. Lifestyle modification interventions were conducted using strategies geared towards education of the public, health personnel, and intersectoral collaboration involving women in the community. Lifestyle and CVD risk factors were assessed again in an independent sample after interventions lasting 5 years. In the control area, annual evaluation of independent samples of women was performed in the absence of any interventions. In the counties of intervention, all organizations that were linked to women in any form were targeted by the project.
The organizations collaborating with this project were as follows: Isfahan Provincial Government Commission for Women's Affairs, Imam Khomeini Relief Committee, the Literacy Campaign Organization, Women's Basij, non-governmental women's groups, Isfahan radio and television broad casting (IRIB), Women's Seminary, the Red Crescent Society, and the Center for Retirees’ Welfare. All women working in government organization, factories and workshops were reached via IHHP's Worksite Intervention Project (WIP). Different strategies were used in every organization. In the beginning, education content for each group was prepared according to level of literacy and age. This included pamphlets, books, and CDs addressing various aspects of healthy living, e.g. health eating, physical activity, coping with stress, and tobacco cessation, increase knowledge about CVD risk factors and control of them. What follows is a brief description of how WHHP interventions were implemented. The strategies and operations of this project fell in three categories, namely educational, environmental, and legislative.
A) Educational: e.g. face-to-face/group training of women, pamphlets, books, training the instructors and officers responsible for institutions involved in women's affairs, public education via mass media and IRIB, offering suitable models to encourage greater physical activity at home, and publishing a video CD teaching ways of keeping active in the family.
B) Environmental: Increasing the availability of physical space for women to exercise.
C) Legislative: Integration of lifestyle training classes with existing pre-marriage classes targeting young couples, publishing an educational book compatible with the curriculum of the Literacy Campaign Organization, advocating and following through enforcement of new legislation aimed at reducing the use of hookah in traditional cafes and teahouses of Isfahan.
The main interventions in Isfahan and Najafabad were as follows:
1) Training young women attending pre-marriage classes at health/treatment centers by health advisers; information was given to couples on non-communicable diseases and ways of avoiding them. These classes last 4 hours and are held on all weekdays. Half an hour was allocated to healthy lifestyle education. This intervention was efficiently integrated into the health system and did not involve any costs.
2) Training instructors of the Literacy Campaign Organization, as well as women attending literacy courses offered by the organization. Such women are usually middle-aged. This intervention required the initial raining of instructors, who would in turn pass their knowledge to learners. The educational material was integrated with the organization's existing curriculum. Every year, the Literacy Campaign instructors were required to attend a 2-3-day workshop (4 hours/daily). Also, a book entitled “The Healthy Heart” was published for use by instructors. The content was passed on to learners during the course of the educational year.
3) Training women calling on health/treatment centers; large numbers of women visit health/treatment centers to receive various services, such as advice on family planning, childcare, and vaccination. Hence health/treatment centers were ideal locations for offering women training on non-communicable diseases, their risk factors and ways of avoiding them. The training was offered by advisers at these centers. In addition to face-to-face training sessions lasting 5 minutes, 1-2-hour group training session was also dedicated to advice for lifestyle improvement weekly. Educational posters and pamphlets were also used. Women visiting health/treatment centers were also taught how to use an automated telephone health advice line to access information on non-communicable disease and ways of avoiding them. The latter chapter was added to a pre-existing service (known as Neda-ye-Behdasht) as an IHHP initiative.
4) Training female instructors of the Red Crescent Organization was another WHHP intervention. These instructors would in turn pass on their information to volunteers working for the Society. Every year, a two-day workshop (8 hours) as well as a re-education course (2 hours) was held for female instructors of the Red Crescent Society. This intervention has been integrated in the Society's curriculum. The Society's periodical educational curriculum now contains information on CVD prevention and control.
5) Educating women in the community using radio and television programming and educational aids. Radio and television enjoy a central role as media of mass communication in the Iranian society. Women are among the core audience of these media, hence WHHP attempted to employ them to the benefit of its interventions. A number of radio and television programs, themed on non-communicable diseases, their risk factors, and healthy living were made and broadcast. Group discussions and interviews on a range of related topics were also incorporated into other routine radio and television programming. These and many other similar projects were planned and carried out within memoranda of understanding signed with Isfahan Radio and Television authority (IRIB Isfahan)
In line with educating women in the community, more than 6 titles of educational pamphlets were also published in distributed in the society (health and treatment centers, the Red Crescent Society and other intervention sites).
In other organizations, such as Imam Khomeini Relief Committee, Women's Basij, Centers for Retirees’ Welfare, religious clerics, non-governmental organization, and especially for health volunteers, training was conducted by trained individuals on a periodical basis. The variables being investigated included nutrition, physical activity and major risk factors (obesity, hypertension, smoking status, diabetes disorders and lipid disorders) which were assessed in both the first and final phases. All stages of this project were periodically subjected to external and process evaluation.
For this study, initially in each phase (first and final of WHHP), a questionnaire obtaining demographic information and occupational status was completed.
Nutritional status was determined using a food frequency questionnaire and the global dietary index (GDI). This questionnaire obtained information about weekly consumption of seven food categories, namely frequency of using fast foods, fruit and vegetables, chicken, fish, cereals, soy protein, confections, hydrogenated fat, animal fat and hard margarine/butter, and olive oil. Each food category was given a score based on atherogenicity (maximum atherogenicity: 2, minimum atherogenicity: 0). Higher GDI indicated higher atherogenicity.11
Total Daily Physical Activity (TDPA) was assessed in MET (Metabolic Equivalent) per day, by considering 3 types of physical activity: transport, leisure time and working at home.12
To perform physical examination and biochemical tests in the first and final phases, the individuals were asked to present to designated centers after 12 hours of fasting. Body weight, height, waist, and circumference were measured according to international standards.13
Body weight and height were measured in light clothing without shoes by trained personnel. German Seca scales (± 0.5 kg) were used to measure body weight. Body height was measured using non-elastic tapes (± 0.5 cm). Body Mass Index (BMI) was calculated as weight (kg) divided by the square of height. Individuals with BMI>30 kg/m2
and/or those with waist-to-hip ratio greater than 0.8 were considered as obese.14
Waist and hip circumference were measured in standing position. Waist circumference was measured at the midpoint between the lower border of the rib cage and the iliac crest. Hip circumference was measured at the level of femur. Waist-to-hip ratio was calculated.15
Statistical Analysis; All data were analyzed using SPSS-15. The analytical methods included Student's t-test, chi-square test, General linear model of ANOVA, and logistic regression.