The effectiveness of stress management intervention in a community-based program: Isfahan Healthy Heart Program Hamidreza Roohafza(1), Nizal Sarrafzadegan(2), Masoumeh Sadeghi(3), Mohammad Talaei(4), Mehrdad Talakar(5), Masoud Mahvash(4). Abstract BACKGROUND: This study was designed to assess the effectiveness of stress management training in improving the ability of coping with stress in a large population. METHODS: Five cross-sectional studies using multistage cluster random sampling were performed on adults aged ≥ 19 years between 2000 to 2005 in Isfahan and Najafabad (Iran) as intervention cities and Arak, Iran as the control city within the context of Isfahan Healthy Heart Program. Stress management training was adapted according to age and education levels of the target groups. In a 45-minute home interview, demographic data, General Health Questionnaire (GHQ) and stress management questionnaires were collected. Data was analyzed by t-test, linear regression and general linear model. RESULTS: Trends of both adaptive and maladaptive coping skills and GHQ scores from baseline to the last survey were statistically significant in both intervention and reference areas (P < 0.001). While adaptive coping skills increased significantly, maladaptive coping skills decreased significantly in the intervention areas. Furthermore, stress levels decreased significantly in the intervention compared to the reference area. CONCLUSION: Stress management programs could improve coping strategies at the community level and can be considered in designing behavioral interventions Keywords: Stress Management, Community, Intervention, Coping Strategies. ARYA Atherosclerosis Journal 2012, 7 (4): 176-183 Date of submission: 2011 Oct 11, Date of acceptance: 2012 Jan 24 techniques and lifestyle improvement.4 Recent clinical Introduction trials have reported the effectiveness of training stress Various definitions have been offered for the concept management techniques in various disease states, of stress. Stress is defined as "the nonspecific result of which act through physiological mechanisms or any demand upon the body, be the effect mental or lifestyle modification.5,6 Therefore, it may be effective somatic".1 Several studies, both in molecular science for NCD primary preventive interventions. Moreover, field and in clinical setting, have shown deleterious few studies have been performed on the effect of effects of stress on healthy people and various groups stress and stress management interventions in the of patients with non-communicable diseases (NCDs) community level.4 such as cancers, cardiovascular diseases and diabetes. In Iran, a recent study showed that 36.5% of the However, the underlying mechanisms of these studied populations had experienced a high level of conditions are not clear.2,3 stress.7 Therefore, strategies and plans to reduce Stress management techniques, which have been stress level and to increase the population skills on developed to prevent, reduce and cope with stress, how to cope with stresses in the Iranian community emphasized on adaptive techniques and reducing are required. The purpose of the present study was to maladaptive behaviors. These techniques include investigate the effectiveness of a multi-component problem solving, relaxation, time management stress management training program to develop the 1. Assistant Professor, Isfahan Cardiovascular Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran 2. Professor, Cardiovascular Research Center, Isfahan Cardiovascular Research Institute , Isfahan University of Medical Sciences, Isfahan, Iran 3. Associate Professor, Psychosomatic Research Centre, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran 4. MSc, Cardiac Rehabilitation Research Center, Isfahan Cardiovascular Research Institute , Isfahan University of Medical Sciences, Isfahan, Iran 5. MSc, Psychosomatic Research Centre, Isfahan University of Medical Sciences, Isfahan, Iran Correspondence To: Hamidreza Roohafza, Email: [email protected] 176 ARYA Atherosclerosis Journal 2012 (Winter); Volume 7, Issue 4 H Roohafza, N Sarrafzadegan, M Sadeghi, M Talaei, M Talakar, M Mahvash coping strategies at the community level, as part of a somatic symptoms of stress; 4) psychological comprehensive interventional study named "Isfahan symptoms of stress; 5) behavioral symptoms of stress; Healthy Heart Program" (IHHP),8 and to offer a 6) stress and illness; 7) stress management techniques; model for including such trainings in health 8) improvement of adaptive (positive) coping skills; promotion programs for improving lifestyle behaviors and 9) reducing maladaptive (negative) coping skills. in the population. The educational core was formed by several members of each target group in each intervention site who Materials and Methods acted as tutors of the group and as role models (Table1). Workshops were held to train members of Data was available as part of the IHHP. The IHHP the educational core. Various methods, including was a comprehensive integrated community-based written materials like booklets, posters, and program aiming to prevent NCDs through wallpapers, were used to train the target groups. Face- improvement of the lifestyle behaviors. It was designed to-face and group education sessions including by Isfahan Cardiovascular Research Center and Deputy lectures, seminars and workshops were also of Health in Isfahan University of Medical Sciences, organized. A booklet named "stress recognition and Iran. The details of the program have been described management techniques" was presented in three by Sarrafzadegan et al. previously.8,9 levels for physicians, the educational core and the The IHHP started with a baseline survey in public. Annual meetings and seminars were held to 2000-2001 in intervention (Isfahan and Najafabad) review and present continuing education and to offer and reference (Arak) regions which finished in 2007. new topics (Table 1). Four annual evaluations were performed on Female health volunteers collaborated effectively in independent samples from 2002 to 2005. A total of public education.12 They were committed to offering 32271 subjects were studied. Multistage cluster education to their family, relatives and neighbors. They random sampling method was conducted to stratify underwent monthly training courses by physicians of the studied population according to their distribution provincial deputy of health that reviewed educational in the community. Written informed consents were topics with members and updated them. Mass media obtained from all persons who contributed to the programs were also offered to the public by the evaluation studies every year. provincial TV network, radio stations and newspapers Because of the importance of the IHHP, Isfahan covering a large number of audiences. The last two University of Medical Sciences carried out external specifically covered housewives and those not exposed evaluations of this program by international experts. to other programs and extensively increased the External evaluations assessed the implementation of number of people receiving educations (Table 1). interventions and research components.10 Measurements Intervention strategies All adults over 19 years old underwent a home The IHHP conducted integrated activities in health interview by trained health professionals to record promotion, disease prevention, and rehabilitation. In demographic characteristics, socioeconomic status, all, the program comprised 10 distinct projects each lifestyle behavior and medical histories. Although targeting different groups.11 Main intervention general health questionnaire (GHQ) was added in strategies of the IHHP were categorized in three 2002, due to financial limitations, not all groups of educational, environmental and legislative measurements were performed in the reference areas strategies. The rationales underlying these strategies in the fourth evaluation.9 included simplicity, feasibility, sustainability, possibility GHQ is a 12-item questionnaire that assesses of integration into the current health system, psychological distress. Each item is rated on a four- applicability to a large population, and possibility of point scale, with the 0-0-1-1 method yielding in scores being evaluated. between 0 and 12.13,14 A scientific committee consisted of a Stress management questionnaire was also multidisciplinary team, who were expert in different fields including psychiatry, psychology and health employed. It is a multicomponent 30-item self education, designed the stress management courses administered questionnaire that assesses adaptive and with cooperation of principal investigators of each maladaptive cognitive and behavioral coping skills.15 project. Although interventions had some differences The questionnaire includes 20 adaptive and 10 according to target groups and sites of intervention, maladaptive coping skills. Examples of adaptive items educational topics based on cognitive behavioral include positive self-instructions, situation control, theme were similar. The topics included: 1) definition humor, social support, relaxation, and referring to a of stress and stressors; 2) good and bad stress; 3) consultant, psychologist or psychiatrist. Examples of ARYA Atherosclerosis Journal 2012 (Winter); Volume 7, Issue 4 177 Stress management intervention in a community Table 1. Stress management educational activities of Isfahan Healthy Heart Program (IHHP) Activities Provider Frequency Schools (876 in Isfahan, 351 in Najafabad): No. of school health workers: 1306 No. of students: 196326  Training students school health workers weekly  Training parents (Recognition of stressors of children) school health workers monthly (parents and teachers meetings)  Making wallpapers students Monthly Universities (3 in Isfahan, 0 in Najafabad):  Training pupils to be a role model (workshop) educational core at the beginning of every educational year  designing pamphlets and posters students bimonthly  Training students about stress (of exams) and managing it role models every semester Military training garrisons (3 in Isfahan, 1 in Najafabad):  Training military recruits and personnel health worker 14 hours for each course Iranian Red Crescent Society (IRC) No. of divisions: Isfahan: 2; Najafabad: 1 No. of members of educational core: 50; Frequency of training courses: 500/yr; Frequency of trainers: ~ 14000/yr  Training volunteers of aid and rescue educational core 6 hours in a 45-hour course  Authorizing a multimedia package about healthy lifestyle cooperation of IHHP regular educational and IRC programs Hospitals (13 in Isfahan, 1 in Najafabad):  Training physicians and nurses IHHP scientific annually committee  Training patients and their families physicians and nurses during hospitalization  Authorizing a booklet named Healthy Heart and handing to educational core continuous patients at discharge Worksite No. of workshops/factories: Isfahan: 224; Najafabad: 56 No. of organizations: Isfahan:120; Najafabad: 25  Training workers health worker monthly  Seminars for workers and their families health worker seasonal Medical Health Centers (241 in Isfahan, 53 in Najafabad): No of referees: 417925 in the past year  Providing a checklist of educational topics for families IHHP scientific committee  Training one topic of the checklist in every visit (face to face) health professional continuous  Training newly engaged couples (in pre-marriage health professional continuous counseling centers) Mass media No. of provincial TV channels: 1; No. of provincial radio stations:1; No. of local newspapers: 3  Radio programs - Morning and life 15 minutes monthly - Question and answer program 30 minutes weekly  Television programs - a 26-part series program named In the house, a family program with cultural, 60 minutes weekly educational and recreational parts - a 52-part series program named Health Path (Gozare Tandorosti) 30 minutes weekly  Local newspapers - scientific column continuous - advertisement sections Health volunteers (2710 in Isfahan, 1479 in Najafabad) No. of covered families: Isfahan:118300; Najafabad:36745  Training families, friends and neighbors health volunteers continuous  Recognition and referring cases needing consultation health volunteers continuous 178 ARYA Atherosclerosis Journal 2012 (Winter); Volume 7, Issue 4 Stress management intervention in a community maladaptive items are drug abuse, passive avoidance, univariate general linear model (GLM) for each coping rumination, aggression, more sleeping, and more skill score as dependent variable including the smoking. Participants report frequency of using each demographic factors (sex, educational level and age strategy in a three item scale (never, sometimes, and category), separately, and stages of study (baseline often). Two scores are reported for adaptive and survey and annual evaluations; 5 time points totally) as maladaptive coping skills. For scoring, number of items fixed factors. GLM was computed to test the effects of marked as "often" is divided by the sum of items time point and demographic factors (group) and their marked as "often" and "sometimes". The final score is interaction (stage × group) with coping skills scores. P expressed as percent.15 of 0.05 or less were considered statistically significant Statistical analysis for all analyses. Data entry was performed by Epi InfoTM (Centers for Disease Control and Prevention; Atlanta, GA). The Results SPSS software version 11.5 (SPSS Inc, Chicago, IL) Demographic characteristics of the studied population was used for data analysis. Scores of GHQ and in baseline survey and four evaluation phases are adaptive and maladaptive coping skills were reported presented in table 2. as mean ± SD. Trends of the adaptive and Figure 1 demonstrates the trend of adaptive maladaptive coping skills and GHQ scores of the coping skills scores in the intervention (df = 4; baseline survey and four annual evaluations were F = 73.77; P < 0.001) and reference (df = 3; analyzed as continuous variables with analysis of F = 159.33; P < 0.001) areas, as well as maladaptive variance (ANOVA). Student t-test was used to coping skills scores in the intervention (df = 4; compare mean differences in time points between the F = 14.84; P < 0.001) and reference (df = 3; intervention and reference populations. Multiple F = 33.59; P < 0.001) areas. As shown, the trend of linear regression models were performed between adaptive and maladaptive coping skills had GHQ scores as dependent variables and coping skills statistically significant differences. Figure 1 verifies scores as independent variables. that in the baseline survey, adaptive and maladaptive The second part of the analysis was performed on scores in the intervention and reference areas were data of the intervention area. Analysis consisted of statistically significant (P < 0.001). Mean differences Table 2. Demographic characteristics of subjects in the reference and intervention area according to phases of program Baseline 1stevaluation 2ndevaluation 3rd evaluation 4th evaluation Int. N = 6175 N =2994 N = 2400 N = 3013 N = 3011 Ref. N =6339 N =2897 N =2393 N =3069 N = ----* Int. 3167 (51.3) 1497(50.0) 1207(50.3) 1524 ( 50.6) 1548(51.4) Female Ref. 3220 (50.8) 1477(51.0) 1208(50.5) 1568 (51.1) --- Sex (%) Int. 3007 (48.7) 1497(50.0) 1195(49.8) 1488 (49.4) 1463(48.6) Male Ref. 3119 (49.2) 1419(49.0) 1184(49.5) 1501 (48.9) --- Int. 4872 (78.9) 2437(81.4) 1951(81.3) 2401(79.7) 2650(88.0) Urban Ref. 4222 (66.6) 1932(66.7) 1555(65.0) 2108 (68.7) --- Residency (%) Int. 1303 (21.1) 557(18.6) 451(18.8) 612 (20.3) 361(12.0) Rural Ref. 2117 (33.4) 965(33.3) 837(35.0) 960 (31.3) --- Int. 2735 (44.3) 1317(44.0) 1042(43.4) 1413 (46.9) 1454(48.3) 0-5 y Ref. 3658 (57.7) 1718(59.3) 1204(50.3) 1768 (57.6) --- Educational Int. 2705 (43.8) 1221(40.8) 1042(43.4) 1187 (39.4) 1186(39.4) 6-12 y Level (%) Ref. 2119 (33.3) 973(33.6) 926(38.7) 1000 (32.6) --- Int. 735 (11.9) 455(15.2) 319(13.3) 416 (13.8) 373(12.4) > 12 y Ref. 570 (9.0) 206(7.1) 263(11.0) 301 ( 9.8) --- Int. 1130 (18.3) 599(20.0) 482(20.1) 476 (19.6) 427(17.4) 19-25y Ref. 1179 (18.6) 576(19.9) 483(20.2) 494 (19.4) --- Int. 1846 (29.9) 611(20.4) 475(19.8) 512 (21.1) 538(22.0) 26-35 y Ref. 1813 (28.6) 591(20.4) 492(20.6) 528 (20.4) --- Age category Int. 1365 (22.1) 611(20.4) 482(20.1) 506 (20.8) 511(20.8) 36-45 y (%) Ref. 1350 (21.3) 591(20.4) 476(19.9) 519 (20.4) --- Int. 821 (13.3) 584(19.5) 472(19.7) 521(20.4) 509(20.7) 46-55 y Ref. 811 (12.8) 553(19.1) 474(19.8) 509 (20.0) --- Int. 1013 (16.4) 593(19.8) 488(20.3) 413 (17.0) 496(19.1) 56≤ y Ref. 1179 (18.6) 585(20.2) 464(19.4) 495(19.4) --- Int.: intervention area, Ref.: Reference area * Measurements were not performed in the reference area in fourth evaluation due to financial limitations ARYA Atherosclerosis Journal 2012 (Winter); Volume 7, Issue 4 179 H Roohafza, N Sarrafzadegan, M Sadeghi, M Talaei, M Talakar, M Mahvash 90 70 %) s( kill s g n 50 pi o C 30 10 base 1st evaluation 2nd evaluation 3rd evaluation 4th evaluation Evaluation stage (Adaptive coping skills ) intervention (Adaptive coping skills )reference (Maladaptive coping skills )intervention (Maladaptive coping skills )reference Figure 1. Trend of adaptive and maladaptive coping skills in the intervention and reference areas from baseline (2000-2001) until the 4th evaluation (2005) 5 4 e or 3 c S Q 2 H G 1 0 1st evaluation 2nd evaluation 3rd evaluation 4th evaluation Evaluation stages intervention reference Figure 2. Trend of GHQ scores in the intervention and reference areas from baseline (2000-2001) until 4th evaluation (2005) of adaptive and maladaptive coping skills differed (t = -4.951; P = 0.042). Inversely, for each percent significantly for each evaluation in the intervention and decrease in maladaptive coping skills score, the GHQ reference areas (all P ≤ 0.05). score decreased by 0.644 (t = 25.049; P < 0.001). The Figure 2 shows the trend of GHQ scores in the adaptive and maladaptive coping skills scores explained years of study from the first to the fourth evaluation in 40.4% of variance in GHQ score, i.e. they accounted both the intervention (df = 3; F = 101.37; P < 0.001) for 40.4% improvement in the model. and reference areas (df = 2; F = 32.90; P ≤ 0.001). table 3 shows coping skills in the intervention area Comparison of mean differences of GHQ scores in by demographic characteristics and stage. Generally, the intervention and reference areas showed a the difference in adaptive and maladaptive coping skills significant difference (all P ≤ 0.05). scores was insignificant between women and men. Both adaptive and maladaptive coping skills scores Adaptive coping skills scores were higher in higher contributed to the model for predicting GHQ score educational levels, and maladaptive coping skills were significantly. According to multiple linear regression used more frequently by younger people. Throughout results, for each percent increase in adaptive coping the intervention, an increment in adaptive coping skills skills score, the GHQ score decreased by 0.13 and a decrement in using maladaptive coping skills 180 ARYA Atherosclerosis Journal 2012 (Winter); Volume 7, Issue 4 Table 3. Comparison of adaptive and maladaptive coping skills based on demographic factors and stage of evaluations in the intervention area Base 1st evaluation 2nd evaluation 3rd evaluation 4th evaluation P group × % Mean ± SD % Mean ± SD % Mean ± SD % Mean ± SD % Mean ± SD group stage stage Maladaptive coping skills Female 39.24 ± 29.14 36.88 ± 26.33 38.72 ± 24.88 38.00 ± 24.08 34.78 ± 20.06 0.390 < 0.001 0.069 Sex Male 40.73 ± 28.37 36.33 ± 26.28 39.06 ± 25.73 34.94 ± 22.56 34.16 ± 17.43 0-5 y 37.42 ± 28.52 35.53 ± 25.91 36.87 ± 24.63 35.52 ± 22.92 34.78 ± 19.26 < 0.001 < 0.001 0.011 Educational level 6-12 y 42.02 ± 29.05 38.63 ± 26.98 39.81 ± 25.65 37.99 ± 23.45 33.74 ± 18.53 > 12 y 41.90 ± 28.18 34.31 ± 25.39 42.42 ± 36.02 35.54 ± 24.54 35.67 ± 17.92 19-25 y 41.45 ± 28.18 37.80 ± 27.01 37.47 ± 24.24 36.72 ± 22.67 34.40 ± 18.64 0.004 < 0.001 0.507 26-35 y 39.34 ± 28.41 39.28 ± 26.31 40.51 ± 27.01 35.30 ± 22.96 34.50 ± 17.11 Age category 36-45 y 40.72 ± 28.95 36.14 ± 26.31 40.90 ± 25.01 39.82 ± 24.19 33.59 ± 19.60 46-55 y 39.82 ± 28.70 36.48 ± 26.25 39.64 ± 24.82 37.91 ± 24.22 36.78 ± 19.63 56≤ y 37.82 ± 28.45 33.83 ± 25.71 34.97 ± 24.63 35.24 ± 23.14 33.25 ± 18.51 Adaptive coping skills Female 46.86 ± 22.23 45.51 ± 21.82 40.83 ± 17.56 43.87 ± 17.86 51.79 ± 15.14 0.089 0.004 < 0.001 Sex Male 45.36 ± 21.67 41.57 ± 22.75 39.69 ± 18.21 38.15 ± 26.68 52.19 ± 16.03 0-5 y 43.06 ± 21.15 40.38 ± 21.45 36.60 ± 16.79 39.06 ± 17.36 48.64 ± 15.82 < 0.001 < 0.001 0.668 Educational level 6-12 y 47.98 ± 22.82 45.79 ± 23.40 42.27 ± 18.30 42.28 ± 16.68 54.65 ± 16.10 > 12 y 50.80 ± 20.69 46.55 ± 21.26 45.78 ± 18.55 44.27 ± 19.24 56.52 ± 14.60 19-25 y 45.94 ± 21.91 46.43 ± 21.41 41.79 ± 17.01 41.83 ± 17.37 56.68 ± 15.47 < 0.001 < 0.001 0.003 26-35 y 46.31 ± 21.82 46.96 ± 21.78 42.42 ± 18.20 45.11 ± 16.56 52.97 ± 15.31 Age Category 36-45 y 45.80 ± 22.09 41.66 ± 23.24 40.36 ± 17.91 44.53 ± 17.57 53.02 ± 16.53 46-55 y 46.63 ± 21.78 41.97 ± 22.78 40.13 ± 18.23 40.17 ± 17.96 51.30 ± 16.26 56 ≤ y 46.04 ± 21.15 42.37 ± 22.62 36.48 ± 16.70 37.99 ± 17.08 49.45 ± 15.53 H Roohafza, N Sarrafzadegan, M Sadeghi, M Talaei, M Talakar, M Mahvash based on sex, educational levels, and age categories the effectiveness of the intervention in the succeeding were observed. However, an interaction between sex evaluations. A second explanation could be the fact that and stage or age category and stage increased adaptive stress management strategies are culture bound and the coping skills significantly. The interaction of modification takes time. For obtaining persistent effects, educational level and stage was significant for intervention seems essential. maladaptive scores. Studies have shown that being female is a risk factor for impaired mental health.18 Women use Discussion emotion-focused coping skills and men use problem- In this study, adaptive coping skills showed a positive focused coping skills more frequently, but there is no trend and maladaptive coping skills showed a negative difference among genders regarding stress trend in the intervention area compared to the response.19,20 In the baseline survey, coping skills were reference area. A consequent decrease in GHQ score not significantly different in men and women and an was observed in the intervention area compared to the improvement in stress management skills was reference area. As the results indicated, the observed throughout the study. However, the effect interventions were comprehensive with enough of interventions in increasing the frequency of dimensions to affect genders, all age groups and all adaptive coping skills was more pronounced in men. educational levels. However, adaptive coping skills Due to underlying biological, cognitive, emotional were more promoted among men and younger people, and social context factors and type of stressors in and maladaptive coping skills showed more decrease in youth, maladaptive coping skills such as passive higher educational levels throughout the follow-up. avoidance, rumination, resignation, and aggression are These finding may support the effectiveness of this known to be more frequently used than adaptive integrated community-based interventional program in coping skills such as minimization and distraction, improving coping strategies and reducing stress levels. situation control, positive self-instructions, and Stress management interventions have been widely seeking for social support.21,22 Similarly, in our study, used in different studies but in different ways and maladaptive coping skills were more frequently used with different contents. This might explain different by young people. On the contrary, adaptive coping outcomes of various studies, and that the results are skills were more frequently used by older people. not easily comparable.165 Most of these interventions Obviously, all age groups, especially younger people have been secondary prevention strategies performed that are more compliant and ready for change,23,24 on small samples and with limited time period, while showed improvements in stress coping skills. large community-based interventions similar to our Low educational level has been shown to be a risk study are scarce.17 Although the present study did not factor of impaired mental health.18 We also found that compare different methods of stress management to those with high educational levels (> 12 years) used both recommend the most effective method, it seems that adaptive and maladaptive coping skills more frequently among different methods of stress management, compared to those with low educational levels. It seems coping skills training including multicomponent that due to a lack of adequate cognitive development cognitive-behavioral skills is a good option as a and correct perception of stressors, these people are not primary prevention intervention in the community able to benefit from coping skills. setting. This method is feasible, simple and flexible People who were not quite familiar with life enough to be implementable considering the stressors were more affected by them. Apparently, the differences in culture, demographic characteristics term "life stressor" is generally used by people to point and socioeconomic status of various target groups.15 to major events such as serious financial problems, In this study, for an appropriate understanding of natural disasters, divorce, imprisonment, dismissal community characteristics through the baseline and unemployment. Interestingly, the meaning of the survey, comprehensive interventions were designed to concept of stress among the population differed. cover the whole population. In order to maximize the From the authors' point of view, providing such educational efficacy and to attract people ranging insights is one of the factors that improved the from illiterates to university graduates, appropriate efficiency of this intervention. audiovisual and writing methods were used according Limitations of this study to educational level, interest and preferences of the target groups as well as their accessibility and jobs.12 In spite of the noticeable achievements in some Stress level indicated distinct improvement in the cooperative governmental and nongovernmental third and fourth years of the intervention. A possible organizations, similar to other community-based explanation could be the gradual increase in the number studies, the large sample size of the current study of people involved in the interventions which increased could have not been covered perfectly. The second 182 ARYA Atherosclerosis Journal 2012 (Winter); Volume 7, Issue 4 H Roohafza, N Sarrafzadegan, M Sadeghi, M Talaei, M Talakar, M Mahvash limitation of the present study was the baseline 9. Sarrafzadegan N, Baghaei A, Sadri GH, Kelishadi R, difference of stress levels and coping strategies Malekafzali H, Boshtam M, et al. Isfahan healthy heart program: Evaluation of comprehensive, community- between the intervention and reference groups. based interventions for non-communicable disease prevention. Prevention and Control 2006; 2(2): 73-84. Conclusion 10. Isfahan Healthy Heart Program (IHHP) External Primary prevention programs targeting definition of evaluation [Online]. 2009; Available from: URL: stress and improving coping strategies should be http://ihhp.ir/IHHP/display.aspxid=1656/ 11. Sarrafzadegan N, Kelishadi R, Esmaillzadeh A, promoted. This interventional program could have Mohammadifard N, Rabiei K, Roohafza H, et al. Do impacts on all educational levels, and the effect was lifestyle interventions work in developing countries? greater on higher educational levels due to better Findings from the Isfahan Healthy Heart Program in readiness and compliance of the target group. It the Islamic Republic of Iran. Bull World Health Organ provides support for further research and practice in 2009; 87(1): 39-50. primary preventions for recognition of underlying 12. Yasamy MT, Shahmohammadi D, Bagheri Yazdi SA, social and environmental risk factors that surely help Layeghi H, Bolhari J, Razzaghi EM, et al. 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