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Improving cardiovascular health at population level: 39 community cluster randomised trial of Cardiovascular Health Awareness Program (CHAP)

BMJ 2011; 342 doi: (Published 07 February 2011) Cite this as: BMJ 2011;342:d442

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  1. Janusz Kaczorowski, professor123,
  2. Larry W Chambers, president and chief scientist4,
  3. Lisa Dolovich, associate professor256,
  4. J Michael Paterson, scientist7,
  5. Tina Karwalajtys, assistant professor2,
  6. Tracy Gierman, director8,
  7. Barbara Farrell, scientist49,
  8. Beatrice McDonough, public health nurse10,
  9. Lehana Thabane, associate professor5,
  10. Karen Tu, scientist7,
  11. Brandon Zagorski, analyst7,
  12. Ron Goeree, associate professor5,
  13. Cheryl A Levitt, professor2,
  14. William Hogg, professor4911,
  15. Stephanie Laryea, research assistant2,
  16. Megan Ann Carter, research associate11,
  17. Dana Cross, acting director8,
  18. Rolf J Sabaldt, associate clinical professor6
  1. 1Department of Family Practice, University of British Columbia, 320-5950 University Boulevard, Vancouver, BC, Canada V6T 1Z3
  2. 2Department of Family Medicine, McMaster University, Hamilton, ON, Canada
  3. 3Child & Family Research Institute, Vancouver
  4. 4Institut de recherche Élisabeth-Bruyère Research Institute, Bruyère Continuing Care and University of Ottawa, Ottawa, ON, Canada
  5. 5Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton
  6. 6Department of Medicine, McMaster University, Hamilton
  7. 7Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
  8. 8Academic Health Council, University of Ottawa, Ottawa
  9. 9Department of Family Medicine, University of Ottawa
  10. 10Public Health Services, City of Hamilton, Hamilton
  11. 11Institute of Population Health, University of Ottawa
  1. Correspondence to: J Kaczorowski Janusz.kaczorowski{at}
  • Accepted 20 October 2010


Objective To evaluate the effectiveness of the community based Cardiovascular Health Awareness Program (CHAP) on morbidity from cardiovascular disease.

Design Community cluster randomised trial.

Setting 39 mid-sized communities in Ontario, Canada, stratified by location and population size.

Participants Community dwelling residents aged 65 years or over, family physicians, pharmacists, volunteers, community nurses, and local lead organisations.

Intervention Communities were randomised to receive CHAP (n=20) or no intervention (n=19). In CHAP communities, residents aged 65 or over were invited to attend volunteer run cardiovascular risk assessment and education sessions held in community based pharmacies over a 10 week period; automated blood pressure readings and self reported risk factor data were collected and shared with participants and their family physicians and pharmacists.

Main outcome measure Composite of hospital admissions for acute myocardial infarction, stroke, and congestive heart failure among all community residents aged 65 and over in the year before compared with the year after implementation of CHAP.

Results All 20 intervention communities successfully implemented CHAP. A total of 1265 three hour long sessions were held in 129/145 (89%) pharmacies during the 10 week programme. 15 889 unique participants had a total of 27 358 cardiovascular assessments with the assistance of 577 peer volunteers. After adjustment for hospital admission rates in the year before the intervention, CHAP was associated with a 9% relative reduction in the composite end point (rate ratio 0.91, 95% confidence interval 0.86 to 0.97; P=0.002) or 3.02 fewer annual hospital admissions for cardiovascular disease per 1000 people aged 65 and over. Statistically significant reductions favouring the intervention communities were seen in hospital admissions for acute myocardial infarction (rate ratio 0.87, 0.79 to 0.97; P=0.008) and congestive heart failure (0.90, 0.81 to 0.99; P=0.029) but not for stroke (0.99, 0.88 to 1.12; P=0.89).

Conclusions A collaborative, multi-pronged, community based health promotion and prevention programme targeted at older adults can reduce cardiovascular morbidity at the population level.

Trial registration Current controlled trials ISRCTN50550004.


  • We thank all members of the participating communities: all volunteer peer health educators, family physicians, pharmacists, public health nurses, and local coordinators, as well as the local lead organisations: CHATS—Community Home Assistance to Seniors (Aurora), Leamington District Memorial Hospital (Leamington), Community Care Access Centre of Wellington—Dufferin (Orangeville), PrimaCare Family Health Team (Paris), Stratford Meals on Wheels and Neighbourly Services (Stratford), VON Middlesex/Elgin (Strathroy), VON Niagara (Thorold), Tillsonburg Community Centre (Tillsonburg), VHA Home HealthCare (Wallaceburg), VON Oxford (Woodstock), Community Care Northumberland (Port Hope), Pembroke Regional Hospital (Pembroke), Orillia Soldiers’ Memorial Hospital (Orillia), Community Care City of Kawartha Lakes (Lindsay), New Horizons Seniors Centre (Kenora), VON Eastern Counties Branch (Cornwall), Bayshore Home Health (Elliot Lake), The Friends (Gravenhurst), YMCA of Collingwood (Collingwood), and The Friends (Collingwood).

  • Contributors: JK wrote the Initial draft of the paper. All other authors provided feedback on drafts of the paper. JK, LWC, and LD were responsible for the conception of the study and primarily responsible for the overall supervision and implementation of the trial. TK, TG, SL, MAC, and DC were responsible for implementation of the programme. LT, KT, BZ, and JMP did the quantitative analyses. BF, BMcD, CAL, RG, RJS, and WH provided clinical and technical inputs to programme development and implementation. JK and JMP are the guarantors.

  • Funding: The study was funded in part by the Canadian Stroke Network and the Ontario Ministry of Health Promotion—Ontario Stroke System. The Canadian Stroke Network is a part of the federal government supported “Networks of Centres of Excellence,” whose purpose is to mobilise and support the best stroke research talent in Canada. The Government of Ontario, Ministry of Health Promotion, provided support for the mobilisation and implementation of CHAP, including salaries of the local CHAP coordinators in each of the 20 intervention communities. This study was supported by the Institute for Clinical Evaluative Sciences (ICES), a non-profit research corporation funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results, and conclusions are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare that none of the authors has financial interests that may be relevant to the submitted work

  • Ethical approval: The study protocol was approved by the research ethics boards at Bruyère Continuing Care in Ottawa, Sunnybrook Health Sciences Centre in Toronto, and McMaster University in Hamilton.

  • Data Sharing: No additional data available.

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