Research in Cardiovascular Health Education Darwin Dendson, EdD
INTRODUCTION
Morbidity and mortality associated with cardiovascular disease has reached epidemic proportions in the United States. One man in five will develop symptoms, and one man in three will have some form of arterial disease before the age of 65.’ An even more disturbing fact is that precursors to cardiovascular disease, known as risk factors, have been considerably prevalent among youth. To date, no conclusive evidence indicates that the modification of risk factors will reduce cardiovascular morbidity and mortality. But, some evidence suggests the medical profession’s efforts (earlier identification and diagnosis, improvements in technology and advancements in therapeutic management) have reached a peak of programmatic and practical effectiveness. I This evidence indicates most deaths occur outside the hospital and too rapidly for medical care. Many times, the sudden death is the first and last manifestation. However, strong evidence indicates risk factors have been positively correlated with cardiovascular disease. The American Heart Association, the Inter-Society Commission for Heart Disease, 198
and the National Heart, Lung and Blood Institute 5 have recommended national programs of cardiovascular disease education to reduce risk factors with the underlying assumption there will be a later decline in cardiovascular morbidity and mortality. The purpose of this paper is to report the current status of research in cardiovascular disease education. Because of the recency of cardiovascular disease education, only 11 studies were selected for inclusion in the paper. The selected studies meet the following criteria: (1) the research was initiated or completed during the 1970s, (2) the independent variable was an intervention or education program and its impact was measured, (3) the dependent measures were self-report inventories and biomedical indices, and (4) the education program had a multifactoral design, ie, two or more risk factors were intervened. Three studies had exceptions to the above criteria but were included because they contained a unique or significant contribution. Some studies were reviewed but not included in the paper because the research design was not organized with sufficient rigor to accept the findings as valid. For organizational
THE JOURNAL OF SCHOOL HEALTH
APRIL 1979
purposes, the cardiovascular disease education research is sectioned into the population studied, asymptomatic youth or symptomatic adults, and a section is included on ongoing efforts. ASYMPTOMATIC YOUTH The School Health Curriculum Project (SHCP), known as the Berkeley Project, provided a multiplicity of learning experiences that emphasized health problems affecting the digestive tract, lungs, heart and brain in 4th-7th The actual instruction of the students was preceded by a @-hour training workshop for the teachers, their principal, and one or two support persons such as a school nurse, a health educator or a curriculum specialist. Research on the effects of the project indicate that students’ cardiovascular health knowledge improved and the teacher training workshops were Other research indicated that students developed positive attitudes against smoking. Another study Iz reported inconsistent findings regarding the impact of the project on students’ reported health behavior. This study followed up the students who were in the fifth, sixth, and seventh grades when the project was
introduced and who were in the ninth and tenth grades at the time of the evaluation. The students exposed to the SHCP were compared with a matched sample of control students. Results indicated that cigarette smoking behavior was reported to be significantly reduced in some students at one grade level but not in other students at another grade level. A questionable aspect of this study was that smoking behavior was measured by self-report responses to two questions which were not subjected to external verification or reliability. No biomedical data were reported; but the National Center for Health Education, the current grantee, has stated that a new evaluation program will be conducted. A study of the effects of a Heart Health Instructional Model (HHIM) upon the heart health behavior of asymptomatic university students was conducted at two SUNY campuses in Western New York.I3 Experimental groups at both campuses received instruction related to nutrition, exercise, smoking and relaxation while control groups at both campuses received instruction in non-heart health areas. Major risk factors were evaluated by a Heart Health Profile, l4 a biomedia l l y validated self-report inventory administered before, immediately after, and one month following the study period. Although data collected on exercise, smoking and relaxation changed in the expected direction, only the nutritional hypothesis was supported. However, when a comparison of data was conducted on students “at risk,” those students subjected to the HHIM were significantly different in reduced smoking behavior than the students in the control groups. The effects of a cardiovascular nutrition education program upon high school biology students’ nutritional behavior was evaluated by an analysis of before and after program data. 1s Improvements were ob-
served in nutritional knowledge, nutritional attitudes and reported eating behavior. However, these improvements, although significant, were not sufficient to produce changes in serum cholesterol levels. In fact, cholesterol levels increased at both study and control schools during the one-year study period. Since significant changes in diet reduce serum cholesterol, the authors assumed that the reported dietary changes did not reflect actual diet change or the actual diet change was not enough to counter the maturational increase in serum cholesterol. SYMPTOMATIC ADULTS
A study was conducted at the Varian Corporation l6 to examine the effects of behavior modification, individual counseling and singletime physician visits on 36 employees who were identified as being at high risk. The 20-minute physician visit served as a control condition in that all subjects received this treatment. The individual counseling group met for nine 15-minute sessions over the ll-week study period. The behavior modification group met for twelve 2-3% hour sessions. Self-report and biomedical data were collected before and after treatment and three months later. As predicted, behavior modification and individual counseling produced greater change on both criteria than single-time physician visits. Data supported, but do not confirm, that behavior modification techniques will produce behavior change which will be maintained more effectively than the other treatments. In view of the marked time differential among treatment groups (20 minutes for physician visits versus 135 minutes for counseling versus approximately 1800 minutes for behavior modification), the results may be more a factor of the amount of individual attention received than the instructional method utilized. APRIL 1979
The Stanford Three-Community Study was conducted to evaluate the effects of a health education campaign in three similar agricultural towns in northern California. The mass media campaign (TV spots and programs, newspaper spots and stories, posters and direct mail) was directed at two communities while the third community served as acontrol. In one of the mass media communities, health counseling consisting of group classes and home visits for a 10-week period was provided to a small subset of high-risk individuals from the original sample. Self-report and biomedical data related to cardiovascular risk factors were collected before the campaign and one and two years afterwards. Both the media and media plus counseling communities had significant effects on all variables except relative weight after the two-year study period. The media plus counseling community improved in the expected direction significantly greater than the mass media community alone and the control community. This significance was maintained for the two-year period although the mass media community closed the gap during the second year. Thus, it appears that health counseling accelerates change, but less direct health education may be as effective after a few years. The Nutrition Education Project, 18 a cooperative venture of the Chicago Heart Association, the Chicago Board of Health and St. Joseph Hospital, was designed to teach high-risk individuals to modify their dietary intake. The project assigned hypercholesterolemic men and women to one of four instructional groups including individual, small group, self and a combination of all three. An additional group serving as the control received usual medical care. Comparisons between groups were made from data obtained from self-reported three-day food records during 6 to 9 month follow-up visits after the instruction.
THE JOURNAL OF SCHOOL HEALTH
199
An analysis of these data yielded no significant differences in nutrient intake by instructional method, but those individuals in the instructional groups were statistically different from the usual medical care group in caloric intake, percent of calories from fat and high fat food groups. An unexplained aspect of this study was that an initial significant difference in cigarette smokers in the control group was reported. This difference may have influenced or biased outcome data. Biomedical data were collected but not reported in terms of differences between treatment groups.
ONGOING EFFORTS The most comprehensive, ongoing research project in cardiovascular disease education is the Multiple Risk Factor Intervention Trial. l9 This six-year primary prevention program sponsored by the National Heart, Lung and Blood Institute was organized to determine whether symptomatic men exposed to intervention programs will produce a significant reduction in mortality from coronary heart disease. Participant recruitment began in 1974 at 20 clinical centers throughout the United States and was completed on November 1, 1975. Half of the 12,866 selected subjects were randomly assigned to intervention groups, and the other half were referred to their usual sources of medical care. 19 Only baseline data were available at this time. Another ongoing effort is the Cardiovascular Curriculum Education Project (CCEPT). This project was designed at the National Heart and Blood Vessel Research and Demonstration Center, Baylor College of Medicine, for asymptomatic youth. CCEPT integrated clinical research with education programs and includes a curriculum guidebook of specific risk factor units. Research on the effectiveness of this project is planned and a teacher’s needs assessment has been reported.
‘’
200
The Johns Hopkins Pediatric Hypertension Project 2’ is an ongoing study with symptomatic youth. This study was designed to identify selected intervention strategies which have the greatest potential for lowering the blood pressure of 10-19 year-olds. Various health education methodologies and biofeedback learning experiences will be examined. The “Know Your Body Program” developed by the American Health Foundation in New York was designed to determine the effectiveness of a multifactoral program of risk factor identification and intervention. The program is ongoing in middle schools of New York City and Westchester County. Information available at this time includes the study design ” and baseline data. ” The Heart Attack Prevention Program (HAPP) of the Chicago Heart Association contains well-developed modules utilizing a humanistic approach. This recently refunded project proposes to refine and implement a cardiovascular disease education program in the sixth grade of the City of Chicago schools. HAPP” has an inner-city orientation and the evaluation protocol plans to analyze longitudinal data.
DISCUSSION The cardiovascular disease education curriculum reported in nine of the eleven studies is multifactoral. Cardiovascular diseases are multiple in terms of clinical conditions and behavioral etiology. In some instances, programs directed at two or three risk factors found improvements in the third factor. For example, a program that establishes adequate nutritional intake and activity levels may be more effective in reducing cigarette smoking than a single risk factor program on smoking prevention. Another important consideration is that asymptomatic, free-living individuals may have positive behaviors in some risk
THE JOURNAL OF SCHOOL HEALTH
APRIL 1979
factors and negative behaviors on other risk factors. Thus, it seems reasonable to assume that curriculum directed at various risk factors is more powerful than curriculum directed at a single risk factor. The medical community indicates the lipid hypothesis (ie, the level of serum cholesterol) is related to the incidence of heart disease, and reducing the level of cholesterol to reduce the incidence of cardiovascular disease is the most viable to determine program effectiveness. Many risk factors (obesity, inactivity, and improper nutrition) have strong causal links to elevated lipid levels. Therefore, the inclusion of biomedical data, especially cholesterol and lipid levels, to evaluate the impact of cardiovascular disease education has greater credibility than self-report and/or other data. This may be due to noted discrepancies between self-report data and actual behavior change. It has been suggested that, in certain situations, individuals report to the researchers what the individual presumes the researcher wants. To counter this situation, most of the included studies utilized biomedical and selfreport data; and it seems logical that future evaluation efforts should include both types of data. In general, the studies using symptomatic adults as subjects were more sophisticated in terms of research methodology and evaluation. But, the studies using asymptomatic youth had more advanced educational programs. The symptomatic adult studies confirmed more hypotheses than asymptomatic youth studies. This may be explained by (1) the initial positive behaviors of many asymptomatic individuals and (2) the greater urgency of symptomatic persons to reduce risks. To evaluate asymptomatic youth studies, researchers must then either factor out asymptomatic persons or utilize maintenance criteria. Programs for both asymptomatic and symptomatic individuals are
necessary and should be interrelated for maximum impact upon the community.
LIMITATIONS Most of the studies reported in this paper have certain inherent limitations. For example, in health education, it is difficult to design “blind” studies. The health educators and the study participants would have to know who was in the experimental and control groups because the management of these groups is clearly different. It is also difficult to control for the natural placebo of health education. Health education relies on principles of motivation and persuasion and thus could be defined as “controlled placebo.” Other limitations common to application studies are present. CONCLUSION Recognizing the noted problems of curriculum organization, evaluation and design, the cardiovascular health education research reported herein represents a major step in developing national and community programs of primary prevention. The ongoing projects represent more effort and dollars directed at this endeavor than at any other time. And, if we can coordinate our planning and develop realistic expectations, cardiovascular health education will assist in the reduction of morbidity and mortality of other diseases associated with the cardiovascular system. Appreciation is expressed to James Wolfgang, research assistant, Department of Health Education, who assisted in the review of literature for this pzper.
REFERENCES 1. Turner R, Ball K: The cardiologist’s responsibility for preventive coronary heart
disease. Am Heart J 119:139, 1976. 2. Boyer JL: Coronary heart disease as a pediatric problem. Am J Cardiol 33:784, 1974. 3. Gordon T, Kannel WB: Coronary R b k Handbook. New York, American Heart Association, 1973. 4. Inter-society commission for heart disease resources: primary prevention of the atherosclerotic diseases. Circulation 42:5595, 1970. 5 . National Heart & Lung Institute Task Force on Arteriosclerosis: Arteriosclerosis. US Dept HEW Pub. No. (NIH) 72-137, June 1971. 6. Heit P: The Berkeley model. Health Ed 8(1):2-3, 1977. 7. David RL: Making health education relevant and exciting in elementary and junior high school. Health Services Reports 88(2):99-105, 1973. 8. American Lung Association: Background and description of elementary school health curriculum project - Berkeley model and primary grades health curriculum project - Seattle model including program suggestions. Meeting proceedings, November 12, 1976. 9. Cook RJ, Olsen LK: Assessment of the cognitive effect of a prototype health education unit on sixth grade students. J Sch Health 45(7):390-393, 1975. 10. Redican KJ, Olsen LK, Stone DB: Health knowledge assessment of selected lower socioeconomic elementary school students. Paper presented at the Research Council, ASHA Annual convention, October 1976. 11. Caramanica VP, Feiler EG, Olsen LK: Evaluation of the effects of performance based teacher education on the health knowledge and attitudes of fifth grade students. J Sch Health 44(8):449-454, 1974. 12. Milne AN, Marshall-Mies J, Colmen JG: A study of impact of the school health curriculum project on knowledge, attitude and behavior of teenage students. Dept HEW, Contract #CDC 21-74-508. 13. Affleck M, Greenberg JS, Dennison D: The effects of a heart instructional model on heart related behavior. Paper presented at ASHA 52nd annual convention, October 14, 1978. 14. Golaszewski T: An instrument to measure the tendency toward heart disease risk in an adolescent population: the heart health profile. Unpublished doctoral dissertation, State University of New York at Buffalo, 1978.
APRIL 1979
15. Podell RN, Keller H, Mulvihill MN, et al: Evaluation of the effectiveness of a high school course in cardiovascular nutrition. Am J Pub Health 68(6):573-576, 1978. 16. Meyer AJ, Henderson JB: Multiple risk factor reduction in the prevention of cardiovascular disease. Preventive Med 3:225-236, 1974. 17. Stern MP, Taylor CB: Response of dietary patterns to a two-year cardiovascular health education campaign: the Stanford three-community study, in Proceedings ofthe Nutritional Behavior Research Conference, Bethesda, MD, April 29-30, 1975, DHEW Pub. NO. (NIH) 76-978, pp 21-31. 18. Hall Y, Mojonnier L: Summary of the Chicago Heart Association nutrition education project, in Proceedings of the National Behavior Research Conference, Bethesda, MD, April 29-30, 1975, DHEW Pub. No. (NIH) 76-978, pp 33-40. 19. The multiple risk factor intervention trial (MRFIT): a national study of primary prevention of coronary heart disease. JAMA 235(8):825-827, 1976. 20. White RC, Weinberg AD, Spiker CA, et al: Cardiovascular disease education in Texas: health education classes, a needs assessment. J Sch Health 48(6):341-349, 1978. 21. Fors S, Kreuter M: Heart health education in a patient care setting. Paper presented at ASHA 52nd Annual convention, October 1978. 22. Williams CL, Arnold CB, Wynder EL: Primary prevention of chronic disease beginning in childhood: the know your body program design of study. Preventive Med 6:344-357, 1977. 23. Williams CL, Synder EL: A blind spot in preventive medicine. JAMA 236:21%2197, 1976. 24. Sunseri AJ: Unpublished abstract of the heart attack prevention program, Chicago, Chicago Heart Association. 25. Green LW: Evaluation and measurement: some dilemmas for health education. Am J Pub Health (67(2):155-161, Feb 1977.
Darwin Dennison, EdD, b Associate Professor, Department of Health Education and Health Sciences Education, State University of New York at Buffalo, Buffalo, NY 14214. Member, AHA Subcommittee on Heart Health Education in the Young.
THE JOURNAL OF SCHOOL HEALTH
201
INTRODUCTION
Morbidity and mortality associated with cardiovascular disease has reached epidemic proportions in the United States. One man in five will develop symptoms, and one man in three will have some form of arterial disease before the age of 65.’ An even more disturbing fact is that precursors to cardiovascular disease, known as risk factors, have been considerably prevalent among youth. To date, no conclusive evidence indicates that the modification of risk factors will reduce cardiovascular morbidity and mortality. But, some evidence suggests the medical profession’s efforts (earlier identification and diagnosis, improvements in technology and advancements in therapeutic management) have reached a peak of programmatic and practical effectiveness. I This evidence indicates most deaths occur outside the hospital and too rapidly for medical care. Many times, the sudden death is the first and last manifestation. However, strong evidence indicates risk factors have been positively correlated with cardiovascular disease. The American Heart Association, the Inter-Society Commission for Heart Disease, 198
and the National Heart, Lung and Blood Institute 5 have recommended national programs of cardiovascular disease education to reduce risk factors with the underlying assumption there will be a later decline in cardiovascular morbidity and mortality. The purpose of this paper is to report the current status of research in cardiovascular disease education. Because of the recency of cardiovascular disease education, only 11 studies were selected for inclusion in the paper. The selected studies meet the following criteria: (1) the research was initiated or completed during the 1970s, (2) the independent variable was an intervention or education program and its impact was measured, (3) the dependent measures were self-report inventories and biomedical indices, and (4) the education program had a multifactoral design, ie, two or more risk factors were intervened. Three studies had exceptions to the above criteria but were included because they contained a unique or significant contribution. Some studies were reviewed but not included in the paper because the research design was not organized with sufficient rigor to accept the findings as valid. For organizational
THE JOURNAL OF SCHOOL HEALTH
APRIL 1979
purposes, the cardiovascular disease education research is sectioned into the population studied, asymptomatic youth or symptomatic adults, and a section is included on ongoing efforts. ASYMPTOMATIC YOUTH The School Health Curriculum Project (SHCP), known as the Berkeley Project, provided a multiplicity of learning experiences that emphasized health problems affecting the digestive tract, lungs, heart and brain in 4th-7th The actual instruction of the students was preceded by a @-hour training workshop for the teachers, their principal, and one or two support persons such as a school nurse, a health educator or a curriculum specialist. Research on the effects of the project indicate that students’ cardiovascular health knowledge improved and the teacher training workshops were Other research indicated that students developed positive attitudes against smoking. Another study Iz reported inconsistent findings regarding the impact of the project on students’ reported health behavior. This study followed up the students who were in the fifth, sixth, and seventh grades when the project was
introduced and who were in the ninth and tenth grades at the time of the evaluation. The students exposed to the SHCP were compared with a matched sample of control students. Results indicated that cigarette smoking behavior was reported to be significantly reduced in some students at one grade level but not in other students at another grade level. A questionable aspect of this study was that smoking behavior was measured by self-report responses to two questions which were not subjected to external verification or reliability. No biomedical data were reported; but the National Center for Health Education, the current grantee, has stated that a new evaluation program will be conducted. A study of the effects of a Heart Health Instructional Model (HHIM) upon the heart health behavior of asymptomatic university students was conducted at two SUNY campuses in Western New York.I3 Experimental groups at both campuses received instruction related to nutrition, exercise, smoking and relaxation while control groups at both campuses received instruction in non-heart health areas. Major risk factors were evaluated by a Heart Health Profile, l4 a biomedia l l y validated self-report inventory administered before, immediately after, and one month following the study period. Although data collected on exercise, smoking and relaxation changed in the expected direction, only the nutritional hypothesis was supported. However, when a comparison of data was conducted on students “at risk,” those students subjected to the HHIM were significantly different in reduced smoking behavior than the students in the control groups. The effects of a cardiovascular nutrition education program upon high school biology students’ nutritional behavior was evaluated by an analysis of before and after program data. 1s Improvements were ob-
served in nutritional knowledge, nutritional attitudes and reported eating behavior. However, these improvements, although significant, were not sufficient to produce changes in serum cholesterol levels. In fact, cholesterol levels increased at both study and control schools during the one-year study period. Since significant changes in diet reduce serum cholesterol, the authors assumed that the reported dietary changes did not reflect actual diet change or the actual diet change was not enough to counter the maturational increase in serum cholesterol. SYMPTOMATIC ADULTS
A study was conducted at the Varian Corporation l6 to examine the effects of behavior modification, individual counseling and singletime physician visits on 36 employees who were identified as being at high risk. The 20-minute physician visit served as a control condition in that all subjects received this treatment. The individual counseling group met for nine 15-minute sessions over the ll-week study period. The behavior modification group met for twelve 2-3% hour sessions. Self-report and biomedical data were collected before and after treatment and three months later. As predicted, behavior modification and individual counseling produced greater change on both criteria than single-time physician visits. Data supported, but do not confirm, that behavior modification techniques will produce behavior change which will be maintained more effectively than the other treatments. In view of the marked time differential among treatment groups (20 minutes for physician visits versus 135 minutes for counseling versus approximately 1800 minutes for behavior modification), the results may be more a factor of the amount of individual attention received than the instructional method utilized. APRIL 1979
The Stanford Three-Community Study was conducted to evaluate the effects of a health education campaign in three similar agricultural towns in northern California. The mass media campaign (TV spots and programs, newspaper spots and stories, posters and direct mail) was directed at two communities while the third community served as acontrol. In one of the mass media communities, health counseling consisting of group classes and home visits for a 10-week period was provided to a small subset of high-risk individuals from the original sample. Self-report and biomedical data related to cardiovascular risk factors were collected before the campaign and one and two years afterwards. Both the media and media plus counseling communities had significant effects on all variables except relative weight after the two-year study period. The media plus counseling community improved in the expected direction significantly greater than the mass media community alone and the control community. This significance was maintained for the two-year period although the mass media community closed the gap during the second year. Thus, it appears that health counseling accelerates change, but less direct health education may be as effective after a few years. The Nutrition Education Project, 18 a cooperative venture of the Chicago Heart Association, the Chicago Board of Health and St. Joseph Hospital, was designed to teach high-risk individuals to modify their dietary intake. The project assigned hypercholesterolemic men and women to one of four instructional groups including individual, small group, self and a combination of all three. An additional group serving as the control received usual medical care. Comparisons between groups were made from data obtained from self-reported three-day food records during 6 to 9 month follow-up visits after the instruction.
THE JOURNAL OF SCHOOL HEALTH
199
An analysis of these data yielded no significant differences in nutrient intake by instructional method, but those individuals in the instructional groups were statistically different from the usual medical care group in caloric intake, percent of calories from fat and high fat food groups. An unexplained aspect of this study was that an initial significant difference in cigarette smokers in the control group was reported. This difference may have influenced or biased outcome data. Biomedical data were collected but not reported in terms of differences between treatment groups.
ONGOING EFFORTS The most comprehensive, ongoing research project in cardiovascular disease education is the Multiple Risk Factor Intervention Trial. l9 This six-year primary prevention program sponsored by the National Heart, Lung and Blood Institute was organized to determine whether symptomatic men exposed to intervention programs will produce a significant reduction in mortality from coronary heart disease. Participant recruitment began in 1974 at 20 clinical centers throughout the United States and was completed on November 1, 1975. Half of the 12,866 selected subjects were randomly assigned to intervention groups, and the other half were referred to their usual sources of medical care. 19 Only baseline data were available at this time. Another ongoing effort is the Cardiovascular Curriculum Education Project (CCEPT). This project was designed at the National Heart and Blood Vessel Research and Demonstration Center, Baylor College of Medicine, for asymptomatic youth. CCEPT integrated clinical research with education programs and includes a curriculum guidebook of specific risk factor units. Research on the effectiveness of this project is planned and a teacher’s needs assessment has been reported.
‘’
200
The Johns Hopkins Pediatric Hypertension Project 2’ is an ongoing study with symptomatic youth. This study was designed to identify selected intervention strategies which have the greatest potential for lowering the blood pressure of 10-19 year-olds. Various health education methodologies and biofeedback learning experiences will be examined. The “Know Your Body Program” developed by the American Health Foundation in New York was designed to determine the effectiveness of a multifactoral program of risk factor identification and intervention. The program is ongoing in middle schools of New York City and Westchester County. Information available at this time includes the study design ” and baseline data. ” The Heart Attack Prevention Program (HAPP) of the Chicago Heart Association contains well-developed modules utilizing a humanistic approach. This recently refunded project proposes to refine and implement a cardiovascular disease education program in the sixth grade of the City of Chicago schools. HAPP” has an inner-city orientation and the evaluation protocol plans to analyze longitudinal data.
DISCUSSION The cardiovascular disease education curriculum reported in nine of the eleven studies is multifactoral. Cardiovascular diseases are multiple in terms of clinical conditions and behavioral etiology. In some instances, programs directed at two or three risk factors found improvements in the third factor. For example, a program that establishes adequate nutritional intake and activity levels may be more effective in reducing cigarette smoking than a single risk factor program on smoking prevention. Another important consideration is that asymptomatic, free-living individuals may have positive behaviors in some risk
THE JOURNAL OF SCHOOL HEALTH
APRIL 1979
factors and negative behaviors on other risk factors. Thus, it seems reasonable to assume that curriculum directed at various risk factors is more powerful than curriculum directed at a single risk factor. The medical community indicates the lipid hypothesis (ie, the level of serum cholesterol) is related to the incidence of heart disease, and reducing the level of cholesterol to reduce the incidence of cardiovascular disease is the most viable to determine program effectiveness. Many risk factors (obesity, inactivity, and improper nutrition) have strong causal links to elevated lipid levels. Therefore, the inclusion of biomedical data, especially cholesterol and lipid levels, to evaluate the impact of cardiovascular disease education has greater credibility than self-report and/or other data. This may be due to noted discrepancies between self-report data and actual behavior change. It has been suggested that, in certain situations, individuals report to the researchers what the individual presumes the researcher wants. To counter this situation, most of the included studies utilized biomedical and selfreport data; and it seems logical that future evaluation efforts should include both types of data. In general, the studies using symptomatic adults as subjects were more sophisticated in terms of research methodology and evaluation. But, the studies using asymptomatic youth had more advanced educational programs. The symptomatic adult studies confirmed more hypotheses than asymptomatic youth studies. This may be explained by (1) the initial positive behaviors of many asymptomatic individuals and (2) the greater urgency of symptomatic persons to reduce risks. To evaluate asymptomatic youth studies, researchers must then either factor out asymptomatic persons or utilize maintenance criteria. Programs for both asymptomatic and symptomatic individuals are
necessary and should be interrelated for maximum impact upon the community.
LIMITATIONS Most of the studies reported in this paper have certain inherent limitations. For example, in health education, it is difficult to design “blind” studies. The health educators and the study participants would have to know who was in the experimental and control groups because the management of these groups is clearly different. It is also difficult to control for the natural placebo of health education. Health education relies on principles of motivation and persuasion and thus could be defined as “controlled placebo.” Other limitations common to application studies are present. CONCLUSION Recognizing the noted problems of curriculum organization, evaluation and design, the cardiovascular health education research reported herein represents a major step in developing national and community programs of primary prevention. The ongoing projects represent more effort and dollars directed at this endeavor than at any other time. And, if we can coordinate our planning and develop realistic expectations, cardiovascular health education will assist in the reduction of morbidity and mortality of other diseases associated with the cardiovascular system. Appreciation is expressed to James Wolfgang, research assistant, Department of Health Education, who assisted in the review of literature for this pzper.
REFERENCES 1. Turner R, Ball K: The cardiologist’s responsibility for preventive coronary heart
disease. Am Heart J 119:139, 1976. 2. Boyer JL: Coronary heart disease as a pediatric problem. Am J Cardiol 33:784, 1974. 3. Gordon T, Kannel WB: Coronary R b k Handbook. New York, American Heart Association, 1973. 4. Inter-society commission for heart disease resources: primary prevention of the atherosclerotic diseases. Circulation 42:5595, 1970. 5 . National Heart & Lung Institute Task Force on Arteriosclerosis: Arteriosclerosis. US Dept HEW Pub. No. (NIH) 72-137, June 1971. 6. Heit P: The Berkeley model. Health Ed 8(1):2-3, 1977. 7. David RL: Making health education relevant and exciting in elementary and junior high school. Health Services Reports 88(2):99-105, 1973. 8. American Lung Association: Background and description of elementary school health curriculum project - Berkeley model and primary grades health curriculum project - Seattle model including program suggestions. Meeting proceedings, November 12, 1976. 9. Cook RJ, Olsen LK: Assessment of the cognitive effect of a prototype health education unit on sixth grade students. J Sch Health 45(7):390-393, 1975. 10. Redican KJ, Olsen LK, Stone DB: Health knowledge assessment of selected lower socioeconomic elementary school students. Paper presented at the Research Council, ASHA Annual convention, October 1976. 11. Caramanica VP, Feiler EG, Olsen LK: Evaluation of the effects of performance based teacher education on the health knowledge and attitudes of fifth grade students. J Sch Health 44(8):449-454, 1974. 12. Milne AN, Marshall-Mies J, Colmen JG: A study of impact of the school health curriculum project on knowledge, attitude and behavior of teenage students. Dept HEW, Contract #CDC 21-74-508. 13. Affleck M, Greenberg JS, Dennison D: The effects of a heart instructional model on heart related behavior. Paper presented at ASHA 52nd annual convention, October 14, 1978. 14. Golaszewski T: An instrument to measure the tendency toward heart disease risk in an adolescent population: the heart health profile. Unpublished doctoral dissertation, State University of New York at Buffalo, 1978.
APRIL 1979
15. Podell RN, Keller H, Mulvihill MN, et al: Evaluation of the effectiveness of a high school course in cardiovascular nutrition. Am J Pub Health 68(6):573-576, 1978. 16. Meyer AJ, Henderson JB: Multiple risk factor reduction in the prevention of cardiovascular disease. Preventive Med 3:225-236, 1974. 17. Stern MP, Taylor CB: Response of dietary patterns to a two-year cardiovascular health education campaign: the Stanford three-community study, in Proceedings ofthe Nutritional Behavior Research Conference, Bethesda, MD, April 29-30, 1975, DHEW Pub. NO. (NIH) 76-978, pp 21-31. 18. Hall Y, Mojonnier L: Summary of the Chicago Heart Association nutrition education project, in Proceedings of the National Behavior Research Conference, Bethesda, MD, April 29-30, 1975, DHEW Pub. No. (NIH) 76-978, pp 33-40. 19. The multiple risk factor intervention trial (MRFIT): a national study of primary prevention of coronary heart disease. JAMA 235(8):825-827, 1976. 20. White RC, Weinberg AD, Spiker CA, et al: Cardiovascular disease education in Texas: health education classes, a needs assessment. J Sch Health 48(6):341-349, 1978. 21. Fors S, Kreuter M: Heart health education in a patient care setting. Paper presented at ASHA 52nd Annual convention, October 1978. 22. Williams CL, Arnold CB, Wynder EL: Primary prevention of chronic disease beginning in childhood: the know your body program design of study. Preventive Med 6:344-357, 1977. 23. Williams CL, Synder EL: A blind spot in preventive medicine. JAMA 236:21%2197, 1976. 24. Sunseri AJ: Unpublished abstract of the heart attack prevention program, Chicago, Chicago Heart Association. 25. Green LW: Evaluation and measurement: some dilemmas for health education. Am J Pub Health (67(2):155-161, Feb 1977.
Darwin Dennison, EdD, b Associate Professor, Department of Health Education and Health Sciences Education, State University of New York at Buffalo, Buffalo, NY 14214. Member, AHA Subcommittee on Heart Health Education in the Young.
THE JOURNAL OF SCHOOL HEALTH
201
