Fortmann S P, Flora J A, Winkleby M A, Schooler C, Taylor C B, Farquhar J W
Center for Research in Disease Prevention, Stanford University School of Medicine, Palo Alto, CA 94304-1825, USA.
Am J Epidemiol. 1995 Sep 15;142(6):576-86. doi: 10.1093/oxfordjournals.aje.a117678.
In the past two decades several community intervention studies designed to lower the risk of cardiovascular disease in populations have been completed. These trials shared the rationale that the community approach was the best way to address the large population attributable risk of mild elevations of multiple risk factors, the interrelation of several health behaviors, and the potential efficiency of large-scale interventions not limited to the medical care system. These trials also shared several threats to internal validity, especially the small number of intervention units (usually cities) that could be studied. The purpose of this paper is to reflect on the lessons learned in one of the studies, the Stanford Five-City Project, which began in 1978. The anticipated advantages were observed, including the generalizability of the intervention components, the potential for amplification of interventions through diffusion in the community, and the efficiency of the mass media and other community programs for reaching the entire population. Numerous components of the intervention proved effective when evaluated individually, as was true in other community studies. However, the design limitations proved difficult to overcome, especially in the face of unexpectedly large, favorable risk factor changes in control sites. As a result, definitive conclusions about the overall effectiveness of the communitywide efforts were not always possible. Nevertheless, in aggregate, these studies support the effectiveness of communitywide health promotion, and investigators in the field should turn to different questions. The authors have learned how little they know of the determinants of population-level change and the characteristics that separate communities that change quickly in response to general health information from those that do not. Future studies in communities must elucidate these characteristics, while improving the effectiveness of educational interventions and expanding the role of environmental and health policy components of health promotion.
在过去二十年里，已经完成了几项旨在降低人群心血管疾病风险的社区干预研究。这些试验基于这样一个基本原理：社区方法是应对多种风险因素轻度升高所导致的大量人群归因风险、几种健康行为之间的相互关系以及不限于医疗保健系统的大规模干预措施潜在效率的最佳方式。这些试验在内部效度方面也面临一些共同的威胁，尤其是可研究的干预单位（通常是城市）数量较少。本文的目的是反思在其中一项始于1978年的研究——斯坦福五城市项目中所吸取的经验教训。研究观察到了预期的优势，包括干预组成部分的可推广性、通过在社区中传播来扩大干预效果的潜力，以及大众媒体和其他社区项目覆盖全体人群的效率。正如其他社区研究一样，当对干预的众多组成部分进行单独评估时，许多部分都证明是有效的。然而，事实证明设计上的局限性很难克服，尤其是面对对照地点出现意外的、有利的风险因素变化时。因此，关于整个社区层面努力的总体有效性并不总是能够得出明确结论。尽管如此，总体而言，这些研究支持社区层面健康促进的有效性，该领域的研究人员应该转向不同的问题。作者们认识到他们对人群层面变化的决定因素以及能够迅速响应一般健康信息的社区与不能迅速响应的社区之间的差异特征了解甚少。未来的社区研究必须阐明这些特征，同时提高教育干预的有效性，并扩大健康促进中环境和健康政策组成部分的作用。
