AASSS:~i~lrheD~~~~~;dof Card i ovascularHearth Education Program
for Adolescents
by
Sandra Pike, R.N.,B.N.
Schoo l of Nursing
A thesis submi tted to the Schoo l of Graduate Studies
in partial fulfillment of the requirements for the Degree of Masterof Nursing
School of Nursing Me mori al University of Newfoundland
De c e mb@r 1990
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of his/herthesis byanymeansandIn any formOfformat,makingthisttlesIs8V'lI1abIe to Interestedpersons," ...Theauthorretainsownership ofthecopyright in hisJherthesis.Neithel"the ttlesisnor substantialextracts fromitmaybeprintedOf otherwisereproducedwithoottisnlerper- mission .
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TO WHOMrrMAY CONCERN
The64lwr.e 011:page35 06my .thIlA.u.,.iJ,an adap.ta.t.loll06 .tIleOJl.t!lillal copy«gh.t06.the P.R.E.C.E.V.E .F!tamel\l:l1Lf~.(IIIUch1lQLlgivel1 pe/U11-<A-6.wtl.cause alt(( a..:{allta-6.iJuU.ca.t edby thete.tt eJL~1LOmthe May&i el d PubWh.infjComlXlI1!1.
Thank You.
StUldJraPike
ABSTRACT
The purpose ofth i s study was to assessth e impact of a s1:'gciallydesigned Cardiovascular He alt h Education Prog ram(C.H.E.P.),onthecardiovascularhealth knowledge of juniorhigh school adolescents.The program cons i s t ed of seveneeuceetcnef ncc ur e e implementedwithin sevenofthe healthclassesin one gradeeightclass of junior highschool adolescents.The impact of the program was assessed using the CardiovascularHealthKnowledge Que stionna i r e(C. H. K.Q. ) with anexperi nle nta l groupand control group.The C.H .K.Q.was administeredprior to the implementationof theC.H.E .P. (pretest), immed ia t ely after its implementation, (pos t test1)andfou rmonths later(posttest 2).
Both the experimental and controlgroupsscored poorlyon the pretest.The experimental group si g n i fica ntl yimp ro ve d theirmean scores on the post test I (p<.05) and this improvementwa s maintained on the post test:2. Theco ntro l grouphowever didnot demonstrateany signifi cantimprovement on any of the post tests.
The findings ofthi s study demonstra tethat a specially de sign ed ecnccr-easeccardiovascular health educationprogram can ha ve an impa c t on adolescent ca r d i ova s c u lar heal thknowledge.Further research is warranted to replicatethe stUdy with a larger sample and to assessthe impact ofthe programon adolescent cardiovascu larhea l thattitudesand behaviors.
L
ACKNOWLEDGEMENTS
I wish to express my sincere gratitude to my thesis committee chairperson, Dr. S. Banoub-Baddour. Special thanks are alsoextended to my other committee members, Dr.M.J.Trapp-BUlbrook and Ms.D.S.Martin.!would also like to thank Dr. D. Bryant for his assistance in the data analysis phase of this study.
I gratefully acknowledge the assistance of the junior high schoolprincipal who gave his consent for me to implement this study.My thanks also to the adolescents who participated in this study.
Finally, ath a nk you to my fami1.y and especially cordon,Their enccaracemene and unfailing support have been constant throughout the thesisprogram.
iL
iii.
TABLEOFCONTEN"l'S
ABSTRA CT
ACKNOWLEDGEMENTS •••.•••... .••• ..••. .• . . •••..•
TABLEOF CONTENTS••••• •••••••••••••• • ••••••• • • LIST OFTABLES•.••••• •..•.• • .• ..•... •... ... •. • LISTOFFIGURES •• • ••••••••••••••••• •• • ••• • •• • LIS TOFAPPE NDIC ES ••• •••• •• ••••• • • ••••• • • ••••
CHAPl'ER 1- THEPROBLEMANDPURPOSE
Introduction•.••••..••.•• • .••• . ....••. ...•.•
TheProblem..• ...•... . ... . ....•. . . Purpose.... . ..•..• ... •. ... . ... ... .•...
aesea e ct,Questi ons ..•.•....•.•••. •... •••• ..
ope r atio na l De tinitions.• •.. ••....••.... .•..
Assumpt i o ns •.•..•. ...•. ..••.•.• •.•.••. . . .• ••
PAGE i.
li.
Iv, vi.
vi i.
viii.
CHAPTER 2- LITERATUREREVIEW
Int roduct ion .•••• •.. .. • ••. .• •.. ..•.•..•.•.
Hea l th Educ a t i onPlanning••• . •••••.••... • .• pathophysioloqyof Cardiova s cularDi s e ase.• 13 Adoles c entRis ktor Ca rdio va s cular Dise ase . 16 Adole scentCardiovascularHeal th Knowle dge . 21 Expe r i e nti al Learningtor Adolescents••. ••. 23 School Ba s ed Cardiovascu larHealth Educat i on Programs•. . ...• .. ••. ..•... ... ...•.. ...•... 28 Summaryof LiteratureReview ... .. .• 32 conceptu a l Fr a mewo rk.... ..•• •.••.•• ••...••.. 34
tv.
CHAPTER 3 - METHODOLOGY
ResearchDesign ••••• ••••••• ••••• •• • • ••••••• 38 The Setting •• ••••••••••••• ••••• ••••••••• • • • 39 Th e sample ••••• •••••••• •• •••• ••• ••••••••••• 39 Pr o cedu r e •• • • •••.•••••••••.•• •• •.•.••..•••• 40 Instrumentation •••••••••• •• •..••••• ••• • •••• 43
va l id ity and Reliabili ty 44
EthicalConsiderations •••• ••••••• •• ••••••• • 46 Data Analy sis ••• ••••• •• ••••••••••••••••• ••• 46
Limitations of the St u dy 4.8
CHAPI'ER 4 - FINDINGSANDDIS CUSS ION Selected Cbaracteri st i c s of st Udied
Adolescent s •••••• ••••••.•••.••••••.••• ••.• 49 Ad o l e s c e nt Cardiov a s cul a rHeal thKnowledge . 55 Cha nge in Car di ova s c u larHeal t h Knowledge ... 58 Retentionof Cardiov a scul arHealthKnowledge 61
CHAPTER5- IMPLICATIONSAND RECOMMENDATIONS Summary andconclusions.... ... ... ... 66 Implicati onsfo r Nu rs i n g Pract ice •• •••• •• •• 69 Implicationsfor Nurs ingResearch.. ..•• ••••• 71
REFERENCES •••••• •• ••• • •••••• ••• ••••••• ••••••• ••• 73
Table1
Table2
Table 3
Table 4
Table5
Table 6
Tab le 7
LISTOF TABLES
PAGE
C.H. K.Q.Means an dSt an d a r d Dev i ations on Pretest(Bo t h Group s ) .••.•.. ..• ... .. 56 C. H.K .Q. Means and Stan d ard Deviat i o ns on Pretest and PostTest 1
(Expe rimenta lGr ou p) 58
C.H.K.Q. MeansandSt a nd a rd Deviationson PrQtestand PostTest 1 (Control Gr o u p ) . 59 C.H .K .Q.Meansand Sta nd a r d Devi ationson PostTest1 and Pos t Te st 2
(Expe r i mental Groups ).: . .... .... . ... . ... 62
vi.
LIST OF FIGURES
PAGE
Figu r e1 The P.R.E.C. E.D.E. FrameworkotHealth Educat ion Pl a nn ing ••••.•••••••.• ••.. • ••
Figur e2 The Ca rdiovascular HealthEducationProgram (C.H.E.P.) Conce ptual lo·ramework.. . ... 35
vi i.
LIST OF APPENDICES
PAGE Ap p e nd i x A. Permission to useth e P.R.E.C.E.D. E.
Framework •• •••.•..••• ••••.• • • • • • 77 AppendixB.The Ca r di ov a scu l ar Healt h
Educa tionProgram (C.H.E.P.)••••• 78 AppendixC.The Cardiovascu la r He a l t h Knowledge
Questionnaire(C.H .K.Q.) •...•• 113 Ap pendixD.Pe rm i s s i o n to use theCa r di o v a s c u l a r
Health Knowledge Qu estionnaire ..•• 116 AppendixE.Letter 1.:.0the Principal •••• •••• • 117 Append ixF.Info rma t i o n for Parentsof
~g~l~~~~~~;. pa~~~7~~~~~~? ~~... ....
118
Appendix G. Consent Form For ParentsofAdo l e s c e nt s Parti c ipatingin tho C.H.E .P. ••• ••• 119 AppendixH. Information for ParentsofAd ol e s c e nt s
Participating intheStudy 120
Appendix I.Cons e nt Form for Parent sof Adolescents Participating inth e Study ••• •.. Appendix J. Inf o rma t i o n and Consent Form for
Adolesce ntsParticipating
inthe C.H.E.P. ••••.••• ••••• •.••• • 122 Appendi xK. In f o rmat io n and Consent Form for
Ad o lesce ntsParticipating
in th e Study •••••••• .•••• •• •.•..•. 124 Append ix L.Pe rm i s r;o io n to Use"Yo u r Risk ForHe a r t
Disease ". ... ... . . ... ... .... 125 Appendix M.You rRisk For Heart Disease •• •••. . 126
viii.
CHAPTER 1 THE PRO(\LEM AND PURPOSE
Introduction
Identifying new and effective strat~gies for preventing chronic diseases, such as cardiovascular disease, and their resulting disabilities,1lo>an exciting challenge for health care professionals in the nineties (Epp, 1986)• Traditionally nurses have designed, implemented and evaluat.edhealth education programs ir.
hospital settings, but recent emphasis has shifted attention towards preventive community baaed settings (Edeleman t MandIe, 1986). The reae of the nurse as heal th educator is widely recognizer! and nurses are now being encouraged to promote health in specific populations such as adolescence (Pender, 1987; Rarden, 1987; Smith, 1987).
Cardiovascular health promotion programs can have a major impact on future society through the imp r ov e d quality of life and reduced mortality and morbidity rates from cardLo-rascufax disease particularly when started early. It has been suggested that there is a urgent need to maintair. an optimum state of well being in the pediatric popuLat.Lcn , through strategies designed to screen for and prevent cardiovascular disease (Balram, 1982; Public Health Branch, 1986;Weinberg, carbonari, &
Laufman, 1984).
The Problem
Cardi ova scular disease is the leading cause of pxemaxur-e death and disability in most indu strialized ccunta-LesincludingCanada (Heyden, 19821OINeil,1984 ). It has been associated with angina, congestive heart failure,nyeeare...al infarction and sudden death (Lewis&
collier,19 8 7 ).In1981,th e Canadianmalemortalityrate fo r coronary heart disease was 30 2per100..000men aged 35to69years (OINe il , 19 8 4;statisticsCanada, 1984).
In that same year, the Newfoundlandmale mortality rate for coronary hl1artdiseasewas 298 per100,000men aged 35 to69years of age (Balr am, 1982) . These statistics indicate thatcardiovascular disease is a major health problemfor Newfoundlandand Canada as a whole.
Canadian health professionals have responsibility to address this major health proble mby promoti ng healthy li f e s t yl e s to reduce the severityof certain.caretcvaecu rec ri s k factors (Heyden, 19821 Frase r, 1986; Watkins & strong,19 8 4 ). In particular, hypertension, smoking and obesity have been identified in school-aged children and are causing a great concern (Balram, 1982; Berenson, 1980). Thereforeit has been recommended that cardiovascularheal th education programs be designed for the pa e d i a t ric population, if adult mortality rates from cardiovascular disease are to declinein the future (Berenson,1980;Williams&carter , 1980; wynder, Wi l l i a ms, Laakso, & Levenstein, 19 81 ) .
Ideally ,mosthe alth educa tionprogram s shouldbegin as ear ly as the pr e-s c hool years, however it has been recommend ed tha t adolescence is the most appropriat e targetgro up fo rcard iovascularhea l theducatio n(Balram, 1982; Pub licHealth Branch,1986;we i nbe r g et al., 1984). At the ti me of thi s study, there were few card iov a s c ularhe a lth educat ionprogramsdesignedfor the pediatric populatio n , none of which appeared to be amenable to replicationwithlimi tedfinancial and human resources .Two programs weredesignedforthe youngerage groupof primary and elementaryschool children (Butcher et al.,19S8; aesruccw, Or landi,Vaccaro,&Wynder,1989) and only one prog ram addressedthe junior high school adolesr:ent (Williams, Carter, Ar nold, &wynder, 1979). That last program requireda complex medical screening proceduretorchronicdiseases other than cardiovascular diseaseandhenceco u ld not beimple me nt e d by one nurse.
The otherprogramsaddressed onlyone risk fact o rsuch as stress (Petosa & Oldfield, 1985) and exe rcise (Leon, 1979 ) , and werethere for e li mite d in their design. Only one program hadbeenevaluated attheti me of this study (Wi lliamset al., 1979 ). Thatevaluationindicated the need for adi ff erent approachto cardiovascular health promotionamon gteens (Taggart, Bush,ZUkerman, &Theiss, 1989) •
Because of the paucity of available and tested heart educat ion progra ms for adolescents , this investigato rdesignedthe Ca rdiovascular He al t h Edu cation
Program (C.H.E.P.).In an effort to assess the impact of the program on adolescent cardiovascular health kno ....ledge, this present research study was designed.
Purpose
The purpose of this research study was to assess the impact of the C.H.E.P. on the cardiovascular health knowledge of one sample of Newfoundland junior high school adolescents.
Research Questions
The following research questions were addressed:
1.What is the cardiovascular health knowledge of adolescents participating in this study?
2. Does participation in the Cardiovascular Health Education Program (C.H.E.P)have an impact on adolescent cardiovascular health knOWledge?
3. If there is a change in cardiovascular health knowledge, is that change retained over a foO\:
month period?
4. How does the cardiovascular health knowledge of the adolescents who paz:ticipated in the C.H.E .P.
compare with that of adolescentswho did not participate?
OperationalDefinitions
Adol esc e nt:Anyperson whose age is between thirteen and sixteen years inclusiveand who attends a junior high school.
Ca r d iovasc u l ar He a l t h bowledge: Knowledge ot general nutrition, cardiovascular fitness, cholesterol and plaque formation, saturated and unsaturated ta t s, tobacco hazards and cardiovasculardisease risk factors (Weinberg, Carbonari, &Lautman,1984).
Health Education : A process with intellectual , psychological and social dimensions relating to activitiesthat increase the abilities of people to make informed decisions affecting their health (Ross&Mico, 1980).
He a l t h EducationProgram: A planned and organized series of health education activities or procedures implementedwith a he a lth education specialist and integra tedset of objectives (Ross&Mico, 19 8 0 ) .
Parti c ipaUoD: To take part in, and sha re the experiencesof the C.H .E .P.with others.
change:To pr og ressfromone levelof cardiovascular healthknowledgeto another.
Impact: The imm'i'!d i a t e and short-term in flue nc eof the C.H.E.P . on participa nt::;l cardiovascular health knowledge.
Assumptions
The fol lowingare the two assumptions upon which this studyis based:
1.Adolescentsare capable of makingind ep e ndent decisions regarding theirhe a lthbe ha v iou r,and 2. KnOWledge of cardiovascularhealthis an
antecedent to positive cardiovascularhealth be ha v i ours.
The basis for th ese assumptio ns will be fo und in both thelit e r atu r e reviewandtheconceptualframework .
CHAPTER 2 LIT ERATURE REVIEW
Introduction
The fo llo wi ng lit eratu r e review exaadnee the background,rationale for , and the various approaches to cardiovascularhealth educationprograms for adolescents.
The first section describes a systematic approach for planning andevaluating health education programs. The second section reviews the pathophysiology of cardiovascular disease, and in the third section , the incidenceandpr eval e n c e of cardiovasculardisease risk factors in the adolescent population is examined. Th e forth section addresses cardiovascular health knowledge among adolescents, while the fifth sectiondescribes one selected health educational strategy, that of experiential learning. The last section examines availableschool - based cardiovascular health education programs for adolescents.
Health Education Planning
Healtheducation can be defined as "an educationally oriented process of planned change which focusses on those behaviors or problems that directly or indirectly affect people'shealth It (Ross&Mi c e , 1980, p, 7). In order for health education programs to have a direct impact on health choices, they must provide a broad
perspective on the mu ltifacetedelementswhichinfl uenc e health.Thepr e d i s pos i ng,ReinforcingandEnabl ingCauses in Educationa l Diagnosis and Eval uation Fram ework (P.R.E.C.E.D.E .) can assistwi t h ope rat i o nali z i ng the critical elements which need to be addressed when designi ng heal th ed uc a t i on interventions . The P.R.E.C.E.D.E. fr a me wo r k has been used byhu nd r e ds of authors in a wide variety of sit uations including nu r s i ng , medicine, pharmacy, and social work, (Green, Kreuter, Deeds, &.pa r t r i dge, 1980).It has been designed to help unde rs tand "th e nature of andthe relat ionships among indep en d e nt variables that influence health behaviour" (Kol be etaL , 1981,p.25).
The P.R.E .C.E.D.E. framework suggestsa six phase, sequentialprocess for the planningof healtheducation pr ograms (Figure 1). In phase one of the framework, the
"quality of life" of a commun i t y or an ind i v i dua l is assessed and specific healthproblemsar e ident ifiedand subjectively defi ned .Phase two examines epidemiological studiesand further de f i ne sthe health problemusing suc h fa ctors as socialindicators,vi t a l indicators (mortali ty rate s ) anddimensions (incidence and preva lence) of the problem. This data, plus scientific or th e oret i c a l lite rature on the co ur s e and etiology of the healt h problemis used to suppo rt the educationaldiagnosis.
The th ird phase of the P.R.E.C.E.D. E. framework involvessystematically identifyingthe behavioural and non-beha v i ou r al heal th causes that are linked to th e
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10 healthpro bl e m. Non-b e h avi o ura l hea l thca u s e s include such fact ors illS heredity or en v i r onme n t a l st re s s ors. Behavioural causes include other ind i c a t o r s such as preve ntiveactionsllnd consumptionpatterns.These ca us e s ar e also considered wh en setti ng priorities for th e planning ofthe program .
In phas e s four and fiv e, be havioural cau s e s further differentiated according to three di s ti nct ca tegor ies of factors known as the pr ed ispos i ng, ena b ling. andreinforcing fa ctors . predispos i ng fact ors are ant ecedents to he alth behav i our s and pro v i de the rational e or motivation for the healthbehaviour. They inc l ude knowledge , at titudes, beliefs, val ue s and percep tions of the he alth behaviours. Predisposing fa c t ors canhi nd e ror facilitatepers onal mo tivati o n for change.
Theenabl ing fa c t o rsarealso antecedentsto health behaviour and they inc l ude personal skills and the availability ofre s our c e s. Reinforcingfactorsarethose fac tors which reinforce the behavi our byproviding a rewardor punishment.Reinforcingfactorscan includethe atti tudesand behavioursof hea l thand other pers onn el, peers, pare nt s and te a c h ers (Gree net. a1.,19 8 0 ;Mann, 1989;Ros s ' xree, 198 0).
Phas e six of the P.R.E. C.E.D.E. frame....ork invol v e s an analys i s ofthedata colle c tedin theotherphases.It is the last pha se where the pr ogra m is dev elop e d, impl emented and evaluated. The health education
11 compo ne nt softhe he a lthprogramare identifiedaccor ding to the characte r i sti c s of the hea lth probl emand the targeted popul a tion. In thi s ph ase, budge ting is cons i de red andthere is an anal ys is ofcnetact o r s that elln in fl ue nce implementa tio n . Learning objQ c t i v es are de ve l o pe d and the program evaluati on is designed.
Evaluationcanbe simpl y defined asthe compari s o n of an object of int e r Post aga i ns t a standardotacc e pt a b ilit y (Gr e e n et al., 1980). Objects of in te res t includ e the quality oflife,be h avioralor non-behavioral cau s e s, and predispos ing . reinf orcing and/or enab l i ng tactors as dep ictedin the P.R.E. C.E.D.E fra me wor k (Fi qure1).
Health educat ion programs ca nalsobe evaluatedon thre ele ve ls : prpcess ; impac t, and outcome.At thefirst le v el otprocessevaluation, the quality of the program ismo n i t ore d by va r i ous mea n s such aspe er reviewand aud it i ng. Theseco nd levelofimpact evalua tionrefe rs to the immf"diate impact ot the pr og r am on kno....ledge, at ti t u d es and/or behav i o r s.Quit eoftenkno....ledg e isthe onl y factorexa mi ne dat this levelbecausean eva l ua tio n of the impac t ofa prog r amonat t i tudes and beha v i ors requires a long term project. At the th ird level of outcome evaluatio n, the object ot inte re st is the mortalityand morbidity rates. This level of evaluation als o requires long term projects with large sample populat ions (Greenat al. , 1980) .
The P. R.E.C.E .O.E frame work has been used by hundredsof authors, includi ng gradu a te students inthe
12 fielcis (,If nursing, me d i c i ne and social work, todesign health educationproqrams for specific populations.For example,the P.R.E.C.E.D.E . framework helpedto address the problem of inadequate use of the local health services in the state of Maryland (Green et a1., 1980). Through the use of the framework,i twas identifiedthat the enabling factor of inadequate communication of services was the most significant factor influ(!ncinq the problem.An educationalprogram was designedto broaden the perceptionand understanding of county residents.
re ga r d ing the use ofloc a l healthservices.Theprogram was only evaluated in relation to its impact on the accessibility and us e of available resources. The ina dequate commurrdcatiLcn of services was not directly addressed in the evaluation.
Another study presentedan instructional model for treatment adherence related activities in hypertensive clients, whichen c o rp or a t e d the P.R.E.C.E.D.E.framework (Mann, 1989). The author used the frame....ork to demonstratehow to address thecriticalelements that are needed in such an educatiol".alprogram.She identified the factors that could modify the relationship bet....een educational programs and the adherence to the medical regime for hypertension.Mann (1989 ) conc lud e dtha t the use of the P.R.E .C.E.D.E. framework ....ouldenable one to:
(1) systematicallyassess all of the relevantfactors for ind ivi d u a l client learning; (2) develop and imp l e me nt educationalplans , and (3) encorporatestrategiestohelp
13 clients achieve the educational goals. Sh e did not however. design any instructionalprogram.
As the literature indicates, the P.R.E. C.E .D.E . fr ame wo r kha s ass istedin thedesignofhea l t h education programs for a wide variety of popu lat i o n s. Althou gh there is limiteddocumentation of it s spe c i f ic use in planning cardiovascular health educationprograms,ithas been ci t e d asaneffective, systematicapproa chtoheal t h education planni ng in general. As sugge s ted in the framework,thefi r stphaseintheplan ning ofany health education programis to identifyand def ine a pr i ori ty healthproblem.For the purposes ofthepresent study, the health pr obl e m identified here is that of ca r diov ascul a r disease.
pathophys i ologyof Cardi ov a s cular Oiseas e
Car diovascula r disease is the leading ca us e of premature death an d dis a b i lity in most industrialized countries(Statis tics Ca na d a, 1984;Heyden,1982; O' Ne il , 1984).It'.ismost oftena resultofat h e ro sc l e rosis which isaIfp o l ye t i o l ogi c a l ,polypat h og e ni c family of cl osely related vascular lesion s" (MCMi l l a n , 1973,p.542).These lesions colftlDo nl y form on the arterialint ima, or the inner lini ngofthe arterial wa l l s andmayvary insi ze and locat ion throughoutlargeand even the small blood ve ssels. One common type of lesion whi ch ari s es from fattyflecksorst rea ks, usu a lly conta i nsexcesslipids
14 and cholesterol and has been found in cbildhoodat sites wherele s i o n s of theadulttype are themost common and severe (McMillan,1973 ; Mitchell&Jesse, 19 73).
Fatty flecksand streakscan be found in the aorta, within the first few years of life and may be fai rly uniform throughouttheci r cu l a t o ry systembythe end of the first decade (Mitchell, 1973). The fatty streak is of universal appearance in humans within the first two decades of life, but th e mere presence of the fatty streakis not necessaril y apredictorof the adulttype of cardiovascular disea.se (Mitchell & Jesse, 197 3 j. However, a great ma j o r ity of mature atherosclerotic lesions do evolve fromthese fatty streaks which then evol ve into fibrous ecae r csca e roc rcplaques (McMil la n , 1973).
From a chronological poi ntof view, the first gross atheroscleroticcha ng esin the form of "fattystreaks"in the aorta can be evidentwithinthe firstfewmo nt hs of birth.Although thesefa t t y streaksmay be the precursor to disease, they are seldom identified in children becausetheydo notcauseany clinicalsignsor symptoms.
Fa t t y streakscan rapidly progress insi z e sothat by the age of fifteen years, fift e e n percent of the aortic intima may be aff ected . Fatty streaks have beenfoundin the coronary arteriesbe t we e n the ages of 10to20 ye a r s and inthe cerebralarteriesbetween theages of30 to40 years (Fr a s e r , 1986 ) .
Fatty streakscanevolve int o the fibr ot icplaques
15 whic h constitute the adult type of athe r osclero t ic le s i on s. Fibr ot ic plaques ha ve be en ident ifi e d in th e coronaryarteries as ear lyas twentyyears ofage . These plaques may inc r ea s e in size and number and became calcifiedwi t h incr easing age . Once tt'l calci fication occurs, the plaqu es areof such a siz e as to cause a varietyof clinicalsignsandsymptom$;indic a tingdisease of the circulat orysystem.Th e s e symptoms arise dueto haemor r hage,ulceratio nand throl'lCosisof majorarteries.
Fi nally"the plaques maycr i t i cally interfardwith thenorma l functioningof the circulatory sys tem throu gh weakening of bl ood vessel walls and the occlusion of major ar teries. Myocardial infarction , cerebra l infarc tion and abdominal aortic aneurysms may occur.
Epidemiological studies of adult victims of ca rdiovascular di s ea s e have re ve a l e d that certai n cardiovascular di s ea s e riskfactorsare associated with the development of thes e atherosclerotic plaques . Unfortunately ,these ris k factorshavebeen iden t ified in thepae di at r i c popUlationand are cau s i ng grea tconcern.
As suggest ed in phases2-3at the P.R.E .C.E.D.E.
fra mework , the behavioral and non-behaviora l causesof the priori tyhealth pr obl elll must also be defined when pla nning ahe al th educationprogram.Thehe a l th pract ices tha t appea rtobe causallylinkedto the healthpr ob l e m of cardiovascular disease must be syst ematical ly ident ifi ed and encorporated into the design of the program.
16 Adolescent Risk for Cardiovascular Disease
A cardiovascular disease risk factor can be defined as an identifiable characteristicwhich when presentis associatedwith an increased susceptibilityto developing cardiovascular di s ea s e (FraserI 19 8 6 ; Watkins&Strong, 1984). Certain ris k fa c t ors which contribute to the developmentofcardi ov a s cul ar disease include: (1)diets high in saturatedfats; (2) sedentary lifesty!es; (3) smoking: (4) psychosocial tension or st ress; (5) heredity; (6) obesity; (7) hypercholesterolemia; (8) hypertension, and (9) hyperglycaemia (Fraser, 1984; Watkins&St r ong, 1984 ).
In order to appreciatetheimp a c t of risk factorson the development of cardiovascular disease, it is necessary to understandthe studieson whichthey are based. These studies have identified the presence of certain characte ristics or "r i s k factors" in adults Which ,When present,can help topr e d i c t an individual's ris k for developing the disease (Heyden, 1982). It is important to remember that the s e risk factors do not actual ly "c a us e " the disease, rather they alter the
"probability"of the disease'scccazrence in a particular individual (~Iitchell, 1973)
Cardiovascular disease risk factors be classified into IIinterventionable" and "non- interventiollable"risk factors.The non-interventionable cardiovascular diseasa risk factors incl ude: (1)
17 lipoprotein profile; (2) coronary anatomy; (3)sex; (4) age , and (5) metabo licfactors. These traits cannot be mod ified . The interventionable cardiovascu lar disease risk factors involve: (1) smoking; (2) diets hi g h in saturatedfats, and(3)sedentary lifestyles. These risk facto rscanbemodified tore du c e personal riskfor the developmentof cardiovasculardisease (the s e are furthe r elaborateduponin "The CardiovascularHealth Education Program " ,Appendix B).
One of the more impor t a nt considerations of cardiovascular disease risk factors is their paediatric origin. The phenomenon of "t r a c ki ng" , which has been observed in long itUd i na l studies paediatric popUlations, tends to ind i c a t e that once children are id e nt i f i e d as"a t ris k "th e y "roughlytendto mainta inin that positionrelativeto otherindividuals (i n te rms of risk factors) as th e y grow" (Fraser,1986, p, 220). Adeyan ju and Cresswell (198 7) monitored trends in the cardiovascularhealth attitudesand behavioursof ninety- threeado lescents...ho,accordingto clinicalmeasures, were identified as "at risk" for the development of cardiovasCUlar disease. Data collected included biomedical measures and self-reported he a l t h attitudes and behaviours. The researchers determined that after four years, the risk factors identified in the adolescentswerestill present. These findingsclec rly documentedthatcardiovasculardisease risk factors do track with time.
re One of the pr oblemsfacedbythe ea rlyinv e s ti g a t ors ofthe paediatricoriginsof cardi ovasculardi s e a s e WIlS the lack of establ ished. screening protocols and stan da rdized tools .Berens on(198 0) attempt e d toadd r es s thisco n c e rn byscree ni nq 3.524Ameri c anschool ch ild r e n age d 5 to 14 years for cardiova s cul ar disease ris k factors in the Bolqa lusaHeartStudy . A tour ye ar plan was dev e loped to r examining children in two cr os s sectio na lstudieslinke d withfou r longitudinal studies . The examina t ions incl uded triceps skinfolds thickness, height. weight, lip o prot e i n profile ,blood pressure and nutrit io nalscreening.
An int e rest i ng find i ng fromtha t st u d y inc lude d observ at i on s on th e cha nge s in serum lipid and lipoproteinle v e ls inthe studie dpopulation. Ac cordi ng to Ber e nson (1980 ) pae d iatric lipopro tein le ve lsbegi n app r oachi ng ad u l t le ve l s by the age of 2 to 3yea r s. These le ve ls usually remainstable unt il ado l e s c e nc e, Whe n they decre ase slightl y before retu rn i ng to adul t levels. That studyde monstratedthatlipo proteinlevels are at the ir lowest duri ng adole s c e n c e. 'l'he Bogalus a Heart StUdy al s o id e nt i f i e d that ot he r cardiovascular disease risk factorssuch asobe s itywere presentin the paediat ricpopulation.specificscreeningprotocolswere documentedand st anda r d i z edinst ruments wer e ident ified for measuring cardiovasc ula r ri s k in the paediatric population.
In1981, 17, 150 children ranging in age fromten to
19 fifteenyears from variouscountries ,were screened for cardiovascu lar disease risk facto rs . That study also measured thechi ldren 'shealthknowledge with a 50 item true false questionnaire (Williams et al., 197 7) . Part icipatIngcountriesinc luded th e FederalRepUblicof Germany, Finland, France , Gr e e c e , Italy, Japan, Kenya, Kuwait , TheNet h e r l an d s, Nigeria. Norway, Thailand, the Unite d Sta tesandYugoslavia (wynder,Williams, Laakso,
&Levens tein,19 8 1 ) .wynder et aL (198 1) concludedthat
cardiovascular disease risk factors were present to varying deg r e es in each of the above coun t r ies. The pre v ale nc e of cardiovasculardisease riskfactors inthis young age gro up le d the investigators to concl ude tha t school-based health education pr ogr a ms should be initi a t e d in the paecHatric po pUl a t ion in order to preventthe developmentof ch roniccardio vasculardisease in early adult life. The findings from the kncwjedqe questionnaire were not reportedintha t study.
In19 8 2,a cross sectionalepidemiologicalstUdy was carried out to investigated the distribution of cardiovascular di s e a s e risk factors in 2,305 ch ild r e n rangingin age fr om eightto sixteenyears re s i d i ng in two majo r re gio ns of Newfoundland; a high mortal ity region (HMRj and a lo w lllortalityregion (LMR) (Bal ram, 1982).The age adjustedcoronaryheart dis e a s e mortality rates for malesand females inthe HMR were 298 and131 per 100,000 res p e c t i v e l y , compa red to 198 and 85 per 100,000 for malesand females respectively inthe LMR.
20 Theres ults of th a t studyindica tedtha tthe adolescents resid i ng a high llIor t a lityre gio n (HMR)wereat greate r ri sk fo r the development of coronaryhea r t diseasethan the adol escents res idi ng inalow mortalityregion(LMR).
That is, the adolescents in the HMR had a hi ghe r incidence of cardiovasculardi s e a s e ris k factors. Fo r examp le,12.3 \ of adolescents in the HMR had a diastolic bloodpressuregreater th a n 140nunHg, as comparedto only 4.8% of adolescents in the lMR. Also, 33.7% of the Ne wf o undla nd adolascents res iding in the HMRsmo ked as compa r e dto 25\ in the LMR. It is interesting to note, tha t 15 . 2% of the adolescents 1n the urn ha d a total blood cholesterol leve l of greater than 200 mgt as compared to only 9.8\ of the adolescents in the HMR. Balram (1982) concludedthat cardiovasculardisease risk factors wer e pre s e nt to varying degrees in the Ne wf o u nd l an d adolescen ts residing in the HMR and therefo repreventionprog ramsshouldbe started wi ththis population.
In addi tionto their beingobviously at risk for the development of cardiovascular disease , there are several other reasons fo r choosing the adolescen t
populat i on appropriate target grou p for
cardiovascularhealth te a c hi ng.Firstly ,adolescentsare ope n to positive and negative infl uences and theymay acquire attitude and behavioral changeswhichmayla s t a lifet ime (Leventha l, 1973).Also , adolescents are ata developmental levelwhenthe irca pac i tyfor hypotheti ca l
21 thinki ng andreasoningbylo g i c enab les themtoper c e i v e the reality of he alth. The y oft e n se e k scient ific explanat i o ns andask serious andpenetratingquest ions andtherefore needti me totalk with healthprofessionals (Pidgeon, 198 3 ) .
Thir d ly, th e adolescent'scognitive de v elopme nt is nea rl y equivalent tothat of anadult ; the re f orehe alth teac hi ng can be unl i mi t e d . The health educator can exploremany topicswithth e adolescent,includingstress management and nut r i t io n (Pidgeon, 1983) . Lastly, ado lescentsare capableofabs t r a c t thinking requiredto competently make informed decisions regarding their cardiovascularhealth.They areab l e toconsider allof the possibilit ies in problem-solvingand can understand the consequences of plannedactions (Kolbeat al., 1981) For thesere asons, it is thisinvestigator 'sbelief that adolescence is the most appropriate target gro up for cardiovascular heal t heducationpr ograms.
AdolescentCardiovascul a r Heal thKnowledge
One of the bar r iers to desi gning cardiovascular health education programs for ado lescents is that so li t t le datais available rela t e d to their current le vel of ca rdiovascu la r he al t h knowledge,. In an effort to address this paucit y of re s e a r c h, Wh ite, Albanese , Ande rson , and Caplan (1977) developed the .I2n
~i9vascUlar He alt h Knowledge Test (I CHKT) and
22 administeredit to 2,675students from grades 6, 7, and 8. They at tempted to determine the status of the cardiovascularhealthknowledge among adolescents and to ascertain the rate at ....hich cardiovascular health knowledge increased as comparedto other sUbject areas.
Although the ins trument was developed by a panel of cardiologyexperts,it was not suitableto an adolescent cognitive level. One of the problems inherent in the ICHKT was its complex medical terminology (i.e.
"ventricularfibrillationand syncope").
The findings from that questionnaire demonstrated that the averagestudentin the sixth ,seventh and eighth grades answe red 37.9 ± .04, 41.2± 0.3and 43.7 ± .0 4 percent of the items correctly. Although the scores increased minimally «1 item/grade) as grade levels increased,that increase was 75% slower than the increase in scores in other SUbjects tested. Those results documented a deficiency in cardiovascular he a l t h knowledge and provided a model for use in educational assessmentprograms in health disciplines.
Other studies onadolescentcardiovascularhealth knowledgereported similar findings.weinberg, Carbonari, and Laufman (1984) developed a questionnaire to assess what grade eight , nine and ten adolescents did not know about cardiovasculardisease and its prevention. That135 item questionnairewas distributedto 3,000students and responses were analysed by general knowledge area and le v el of knowledgerequired to answerthe questions.
23 Despitethe tact thatth e questionnai rewasdesi gn e d for adol e s cents , the fi nd i ng s from that study again demons trated thattheadole sc ent s' cardiova scula rhealth knowledgewas detlcient and composedof simpl e fact ual info rmation abo ut the cardi ovascular system, relat e d di seases and prevention. Re s ul tswe r e di s cu s s ed inte rms of guidelines for cardiov a s c u lar he al t h ed uc a tion prog r a ms. We inberg at a1. (1984) re c omme nded that such progr a msshou l d beusedto improvecardiova s cularhealth educ a tionclassroom te a ch ing.They also re c ommendedth at he alth educ ators dev e l op not-e comprehens ive and exp e r i en t ia lly based car d iovascula r he alth education curriculumunitsfor adolescentswhIch couldper1llit th e translation of fact ual knowledge into re al-l i f e decisions.
ExperientialLearning fo r Adolescents
The mastery of health education facts for the purpos e ofhe al th teaching may not be the sameas the mast eryof subject mat te r tobe use d ineveryday life (Weinberget al.,1984 ).These aut ho rsrecommende d that he althedu ca t orsde v elop mor e experie nt i all y based health edu c ation cur ricul um units tha t could supplem e nt the regular health education cur ric ulumin schools. These experiential educa t ional uni tscoul d als o encou rage the adolescent student to take a deeper look at th e func tions , processes andimp lications ofca rd i ova s c ul a r
24 disease .
Expe r i en t i a l learninqca nbedefinedas .. a seque nce of eve ntswithone orlIlore iden tifiedlearningobjectives requir i ng'active involv e mentby partici pants at one or morepoints in the sequence" (Wal t er ' Harks , 198 1., p, 1). The theory ot experi e ntia l le arn i ng has be en descri b ed as "stude nt cent e red " educatio n becaus e it focuses on st ude nt "experiences" as a prer equisite to learning (Boyer , 1984). Expe r ientia l le arninghas also beentermed "tot a l pers o n" learni ng asitenc ompa s sess theint e llectual , emotio na l and physiologic alself into thelearningproc e s s.Thetheoryof experientia l learni ng isappropr i a t e in most env i ronments and for all age s. Every le arner, young or old, usually has amp le prior expe rie ncefor slgnit1cantlearning tota ke plac e. The main focus ot experiential le a rn i ng is the changing nature of the world and the human experience (Boyer, 19 8 4 ) •
The experiential appro a c h to le arning is especia lly useful in des igni ng individual learn i ng experiences.The thr ee essent i a leleme ntsof a climatein which experi ential learning ta ke s pl a c e are: (1) the perception of a "real" health pro blem, such as sus c e pt ib il i t y to the devel op ment of card i ov a s cu l a r disease; (2 ) the perceptionof thehe alth ed uc a to r as a
"rea l " pe r s on in the ir interactionswith the students, and (3) the util iza t i on of va ried resource s - audi o, visual, technica l and creative - to stimu late the
25 st ude nt s to experie nce learning within their en v ironment (Biehlar , 19 7 1).
There are als o tou r primary chara c teri sti c s ot:
experi e n tia l learning an d these are: (1)involvemen t ; (2 ) relevance, (3) re s ponsibility, and (4) flex ibi l it y (Walter&Marks, 198 1 ).The participants' invol vementin the learning proces s is int e g r al to experiential le arn i ng. Inv o lve me nt usually include s enga ging in a partiCUlar activity which promotes at t itUd e change, growthand/or sk illdevelopmen t.Involve ment canincrease motivation on the pa rt of the st uden ts. A ·s e c o nd cha r act e r istic of experiential learning.Lsrel evanceof thetop i c tothe indiv iduaL The in f o rma tion presented during the learni ng ex pe ri en c e must be linked to individual be hav io r lind ha ve Hpr act icalMapp lication to real life.
The thirdch aracterist i c of experie ntialle a rn i ng, as sugge ste d by Walt e r and Marks (1981).isthe fos t e ri ng of respons ibi lity on the part of the participants . Responsibility ispromoted byallowi ng pa rt i cipa n t s to choose the aMount of energy they wil l ne ed to inv est in the exp erience andhow they wi l l re spo ndto partiCUlar ac t i v iti e s . Finally,experientiallearningis flexiblein relatio n to set t i ngs, par ticipants lind activ ities.
Set tingscanrange frompreschool to graduatestud iesand caneven includechurches , ind u s t ryand healthclinics.
Thiskindof le arn ing can be used wi th a wideva r i ety of students from pre-sc ho o l to university. Act ivities can
2 .
range from the simple sharing of information t.o the learningofvery specificski l ls.
The three essential elements(Bl e h Ia r , 1971) and the fou r primary charecteristics (Walter&Marks,198 1) must be consideredwh e n designing educationalstrategies fo r health educationprograms basedonexp e r ient i a l learning . Se veral st r a t e g i e s either central to ex pe r i e nt i al learn ing, or bo r r o we d from the "clas sical" te a ch ing strategies ha ve been propo sed . Three such central educational strat egies ar e su ggested by Green et aa . (198 0 ) and Walter and Hark s (1981 ); th ese inc l u de simu l a tio ns, games and peer group disc uss i o ns. Simulations are attempts to reproduce some aspec t of re a l ity in a simp ler form. The y require a supp ortive cl ima t e with a sup po r tiveeducato r who iswa rm, caring, an d authen tic . Game sareusuall y compe t itiveactiv i t ies withrules andspe cifi c goal s.Both simulati onsand ga mes rep rese nt someasp ect of expe r ienc eas theycan re flect and duplic atea real life eve nt or co nd i t i o n.Peergroup discussions can involve small gr o up processes. The interaction s or discussions are the focus of the experience , or the medium through which a parti cu l ar ex pe r i e nceocc urs.
Two other meth ods tha t ar ecen t r a l to expe rie nt i a l l£".arning are exerc ises, and bod y mov ement (Wa lter &
Marks,1981).Exe rcise sareact iv i t i e s de signedto enga ge participants di rectlywiththe content of the exp e r i e nce or with eachother.Theyar est e p - by - stepprocedures
28 Educators using audio visual aids must haveth e skill to locate or developthe necessarymaterial and they must also be able to operate the equipment (Walter&Harks, 1981)•
When developinghealth educationprograms, previous efforts mustalso be examined.At present there area few cardiovascular he a l t h educationprograms designed for the pediatric pcpu.LatLcn, and only one that has been opeciallydes.Lqned for adolescents has been identified.
School Based CardiovascularHealth Education Programs
Specialcardiovascular disease prevention programs have been recommended by numerous researchers for the paediatric population (Ade ya n j u & Cresswell, 1987 ; Balram, 1982; Berenson, 1980; Butcher at al., 1988 I Fraser, 19 8 6 1 Kolbe & Newman, 1981; Watkins &strong, 1984; Williams& Carter, 1980; Weinberg et al.,1984). Yet few comprehensive and practical programs have been developed . Many of those programs require a team of health care professionals during the implementation phase, including nurses, physicians, health teachers and other aids .
The Know Your Body Program (K.'l.B.) was a chronic disease pr ev e nt i o n program designed to improve health re l a t e d behaviour inschool-agedchildrenaged 11 to 14 years (Williams, Arnold, &Wynder, 1977). That program also involved teaching the students to know their own
27 that presentan opportun i tytobec ome familiar withand prac tice sk ills.The y can height en aware nessand creat e feelings. The me thod ot bodymov e me nt involves a wide rangeof acti vitiesfrollphys i cal exercises to relaxa t i o n te chniques. Body moveme ntsar e ge n e r all yus e dto develop and enhance perso na l awa r en ess and the y pr o vide an alternative to verbal expression. When usin g bod y move me nt as an educ a tional strategy. ed ucators should knowthe technique swell, and"pers onal expe rienc e with the technique s is a near prerequisite" (Wal te r&Marks, 1981, p. 17).
other strateg i e s of experientia l le arn ing bo r rowed fromthe"classica l"educationalst r ate9 ies ,arele c ture s and the us e of aud i o vi s ua l aids. Lecturing. as the world'5 oldest formal teaching meth od , illparts in f o rmat i on , influencesopinions, st imulatesthought and davelope s critica l thinking (Gree net al., 1980). As a component of experiential learning, teeeures sh o u ld engageparticipan tsincreativethin k i ng an dlistenin gby st a t ing problems and pr e s e nting guid e l ine s for the i r sol u t i o n. The le cture r must be credi b le , obse rvab ly knowledga b leand commit t edtothe mate rial.
Audio vis ual aids also impor t a nt for expe r i e n t ial le ar ningand canhelp to clar ifyconc e p t s and id e a s. Suc h aids may include; (1) graphic presentat ions :(2)flip charts; (3)blackboard s ; (4)wall diagrams; (5 ) models; (6) real life demo ns trat ions ; (7) sti ll andmoving pr oj e c t e daids, and (8) audiosystems.
29 body, in an attemp t to assist them to adopt a sense of responsibility towards thei r ownhe a l th . The children par tici patingin theprogram were taughtthe impo rtance of behavioral modification, the dangers of smoking, alcohol and drug abuse and th e importance of physical fitness.In order to promote awarenessof healthandthe prevention of chronicdisease,thechildren we r e sc reened forhe a r t diseaseand othe rdiseases ofthe circulatol.~
system, as well as diseases ofthe lungsand respiratory tr a c t, and cancer.
The medical screening (\f the K.Y.B. incl uded a
nonfa~ting blood sample for cholesterol , and a measurement of height weight and blood pressure. The results were returned to participants in C\ "Health Pass"9ort"and the findings were discussed individually . Following the screening and return of results, a multidimensiona l hl.!alth education curriculum implemented by school he alth teachers. That curriculum was designedto enhanceknowledgeof personal riskand major interventio ngoals weredirected toward re d ucing cigarette smoking and modifying dietary habi tsto reduce th e i r intakeof saturatedfats and cholestero l(Williams ,
Arnold,&wynder, 1977).
In198 9 , a process evaluation was cond uctedon the effectivenessof the KYB curriculum,as implementedamong ju n i or high school studentsin the Districtof colombia.
Taggart, Bush, Zukerman, and Theiss (1989) re v e a l e d that school healthteacherswereins uf f i cie nt role mode ls to
30 te ach that prr 'Jra m. One of th e maj or ....eaknesses ide n t i fied by that process eval ua tion wa s a lack of effectiveimp leme n tationofth e pr ogra m.Tagg art et al. (1989) rec o mmende d th at scho o l heal theducato rsreceive extensivetr a i ning in the compon ents of heal theeu e e eden before impleme nting a heal thprogramsuch astheK. Y.B.
Anothe r widely reco gn i z e d scho o l based cardiovascular he alth education program for younger groups is the "Heart Smart" Program, which has been designed for North American elementary school -aged child ren(Brtich e z-et a1., 1988). Thi s pr ogra m encompasses kindergarten to gra de six and addresses th.!areas of fluoridation and dental health, smoking, misuse of alcoho land drugs,physicalfitness, exerciseandco ntrol of stressand violence. The objectives of the program inc lude ena b lingst ude nts to adoptheal thybehavioursin the are as of cardiovascula r heal th, disease and riSk facto rspreventio n. It includes a classroom cur ricu lum Which is not iso lated fromregular healthclas ses , an aerobic fitr.ess program, a school lunc h progr amand a teacher-staffdevelopmentprogram.Al s o integraltothe programis riskfactor scree ning. This programhas not ye t bee nevaluated .
ot he rcar diovascula rheal theducationprogramshave be endevelo pedforth e paediat ric po pul a t i on , butaddress only oneor twocar di ova s c ul a r diseaseriskfactors. Leon (1979) desi g nedan exercise prog ram to addretJactivity levels and ob~sity in six sedenta ryyoung men aged 19
ai years andol de r .That pr og r a m involveda 16 week vigorous walking regime. Afterthe program, ai l of the sUbjects demonstrated a re duc t i on in "body fat stores ", a re duct i on in food intake and impr ov e d capacity to do exercise and improved cardiorespi ra toryfitness.Although that program included the age group of19 years, it was not particularlydesigned for young adolescents.
Anothe r program developed by Petosa and Oldfield (1985) addressed one cardiovasculardisease risk factor;
that of stress in elementary school children. A post test-only cont rol group design was employed and 12 studen tswererandomly assigned to treatment andcont rol groups.Th a t pilotstudydemonstratedthat chil d rencan le a rnstressmanagementtechniquesthat can mediate the impact ofst r ess on their physical and mentalheal th.Th e findings alsosupportedthe concept,that the acquisition ofsuchskills canenhance children's ab il i ty to attend to classroomact ivities. The findings of that research may have been compromised because the control and experimen talgroupswere not matched priortothe study.
One school-based heal t heducationinterventionfor primary school children was designed by Resni cow, orlandi, Vacca ro,andWynd er (1989) to address the risk factor of cholesterol in th e diet. The childr en who participated had beenident i f i e d withhigh to t a l serum cholesterol levels and were therefo reconside red to be
"a t risk" for the developmentof hear t disease .Thirty- fourst udentscompletedthe five sessionbehavioralgroup
32 interventio n. Fol lowing that intervention.the meanto t a l choles terol for the group dropped by9 \:. The results suggest ed that school site chol e s t erol reduction int erventions for high risk tnd i v i dua l s are feasible, cost ef f ectiveandpotential lyefficacious.
As thi s l ite rature revie w indicates there are seve r a lca rdiovascula rheal t h educ a t i on programs fo r the paediatric population but only one has be en desig ne d spe c ifica lly for jun i o r high sc hool adolescents. That prog r am re qu i r e s a team of heal t h care pr o f e ssion al inclUd i ng nurs e s, physicians, te a ch ers, and aids . The structured envir onme nt of a junio r hi gh sc ho o l, its health education cur riculum and the capabilities of today's junior high school adolescents, suggest tha t there is a need for more complex, experientiallybased health interventions, (I v e r s o n & Kolbe , 1983; Kolbe, Iv ers o n, Kreuter,Hochbaum, &Christensen, 19 8 1 ; Kolbe&
Ne wma n, 1984: Mroczek, 1976: Public Health Branch, 1986). Therefore. suc h programs should be developed. implemen tedand evaluated in an effort to address the he a lth pro b l e m of cardiovascular di s e a s e risk in the adolescent popu latio n .
Summary of Li t era t ure Review
The development of sch oo l-based health educ a t ion cur r icu l umunits is one impleme ntation st rategy tha t co uld be used by healthca re professionals to prC'mote
aa ind i v id ua landcommunity health towards"achieving he al t h fo r all "in th eni n e t i e s (Epp,1986).Th e P.R.E.C.E.D.E . framawork for healt heducationplanning can assist with this processby ope r a t l o na li zing the criticalelements thatneed to be addressedwhendevelopingheal t h progra ms tor specit'1c populations.
Adol e s c e nts areone of the most appropriate ta r g et groups for cardiovascu lar health education pr o g r a ms because the y are inthe process of establishing health habits and behaviors which may last a lifetime (Leventhal, 1977~ pi.d q e c n , 1983). Newfoundland adolescents in particular areat increasedrisk for the deve lopment of cardiovascular disease (Balram, 198 2 ). Also as this lite rature review indicates, adolescent cardiovascular heal th knowledge is le s s than adequate (Wh iteet al., 1977; weinberg et al., 1984).Althougha few pr ogra ms hav e be en designed for the adolescent popuLat.Lcn , they have not alwaysbeen fullyev a l u a t e d.
One particularevaluation ofa cardiovascularhealth educatio nprog ramfor adolescentsre c omme nd e dthatbe for e impl e me n ti n g healtheducatio nprograms,educatorsshould recieve extensivetrainin gin the multifacetedelements that influ~ncehealth(Tagga r tet al.,19 8 9).Nurseshave that required trainingand backgroundandcan effective ly design, imp lementandevaluate heal theducat ion prog r a ms for spe cific popUlations (Edeleman & MandIe, 1986;
Ro rden, 198 7 ; smith, 19 87 ) . Thereforenursingshou ld ta k e a leading role in cardiovascularhe a l t h educat ion for
34 adolescents.
Assu g g e s t e dbyWeinberg et a1. (198 4) suchpr og r ams should enco rpo r a te the principles of exper i en t i a l learningtoass ist adolesce nts withthe tr anslationof ta ctu a l knowl e dge int o real lite decis i ons. The developmentot experie ntiallybasedcardiova s cularhealth education programs targe ted at adole scents has been suppo r t ed by this litera tu re revi e w and the following concept ualframework outlinesthebasi s tor this eeudy.
cencepcu, Framework
Inth ispre s ent st u dy theP.R.E .C.E.D.E. framework of health educatio n planning ~a5 used to desig n, impl eme nt and ass es s the impa ct of the Cardiov ascula r Hea l th Educat ion Program(C.H.E.P.) on the car diov a scula r he a l t h knOWledge of one group of junior hig h school ado l e s ce nts . Based on selected concepts from the P.R.E.C .E.D.E. fr amework , combinedwiththe conc e pt s of experiential le arn i ng, the C.H.E .P. was des igned. The health problemident ified in pha s e s 1 and 2 of this study'S conceptual fr a me wo r k (Fi gure 2) ....as the adolescents' risk forthe developme nt ot ca r diov a s c ula r disease. The rationale for choosing cardiovascular di s e a s e ri s k as the health problem has been base d on epidemiological st udiesas ind i c a t e d in the literature review .
The behavioral and non - behavioral healthcauses
~.The cardiovascularHealth E'ducation Program Conceptual F%a:IreI;ork
Administrative Diagwsis
.1
I P!lASE 6C.H.E.P.
- SlMJUIl'ICNS -GAMES - PEER GIn1P
OISCUSSICNS -BCDYMJVEMEm
- EXm:=
- LECnlRFS -AUDIOvrsr.w.
AIDS
PHP.SE4 -5 Educational Diagnosis
I
P!lASE 3 Behavioral
Diagnosis
I '
- sroJdng -stress -diet -exeectsa
P8ASE 1 - 2 Ep!deoUological
Diagnosis"
. I
.llEl\LW PJ>:lBIDl
ADULT CARDIOJA&:l.JIAA·
DISEASE
-=allty rates - incidence - prevalenc e
of risk fac"-...orsin adolescents
Note.rrenHea!t..~EducationPla".ni.m (p . 1 4)byL.Gree..." M.xeeceee,S.De::s arxiK.par""..r.iC.S-e.1980, Pal o Alto,cal.:.::O-'"lli.a:Mayfield P'Jblishing cer.:-....any.
36 that werelinke dtothis healthprob l em included a group of .. int erven tio nable " and "no n - interventionab l e"
cardiova sculardiseaseris kfa ctors.The int ervention able ris k fac tors whic h can be modified to redu ce persona l ri sk for developingthe disease includeddi et, smoking , exe rcise and st ress. The non- i nte rventiona b l e ris k fac t o r s or the non-be h a vioral causes of the health problem includ e d age, sex , andheredi t y (Fr ase r , 198 6;
Watkins &Stron g , 1984 ).
Onemajor fa ctor ident ifiedinphases 4- 5 of the fra mewor kas ha vi ng an impa c t on cardiovascu l a r he a l th , was the pr ed isp osi ng factor of ca rd iova scu lar heal t h knowl edge.Al t hou ghsomeres e archersha v e contendedthat the acquisitionof know ledg emay ha ve lit tleimpact on act u al health beh avi ors. a more ba l an c ed persp ective sug ges ts tha t knowledge increases the decisio n-ma ki ng abili ties nee d e d to l iv e in today's comple x world (I ve rson&Portnoy , 1977; Gre e net~l., 1980) . Info rme d ind i vidua l s aremorelike l y toen g ag einbehaviours Wh ich are co nd u ci ve to health than individual s ....ne are not informe d (Kolbe et a1.. 1981 ).
Adol esc ents'kno....le dg e of the cardiova sc ularsystem . it s disease sand th e irpreve nt i onhasbeen re cognized to be la r g e ly su perf...ci al and compo sed of si mple factu a l in fo rm at i on (We inberg et a1.. 1984). The C.H .E.P.
at temp ted to ta ke a deeper look at the process es and implicati onsofcar d iovascu l a r di s eas ethrou ghthe use of experiential learn i ng tec hn ique s. It wa s believed th at
37 the adoptio nof the experi e nt i a lle arn i ng approach tothe C.H.E .P. woul d fac il i t ate the process of tr anslati ng fact ual knowl e dg e into re al life decisions about cardrevaec u ree health.
Encorporating the essential elements and primary Charac te r isticsofexp e r i ent ialle arn i ng,the educat iona l stra ·~egies most app ropriate for a primary prevention programfo r adolesce nts were selectedduri ng phase 5.
Th e s e Inc ku ded simulations and games, peer group discussions,lectures, audio-visua l aids, exercises and body movement activities (Greenet a1. , 198 0; Wal te r &
Marks, 19 8 1 ).
As suggested in phase 6 of the framework, the C.H.E.P. evaluation was conceptualized as a short te rm impact evaluation. As dep icted by the bidirectional arrows betweenpha s e s 5 and6 in Figure 2, the C.H.E.P.
was to be evaluated by assessing the impact of the program on the predisposing factor of adolescentsI 1,;:ardiovascu lar he alth knowledge.This evaluationdidnot address the long term impact on their attitudes or behaviors .·Adeta ile d descriptionof the C.H .E.P. , its imp lementationand impact ,as ....ell as thedis cus sio n of relatedfind ingsare presen tedin the following chap ters.
38 CHAPI'ER 3
METHODOLOGY Re s e arch Desig n
Baeed onan iden ti fi e d ne e dsup portedby both the literatu re and thi s invest igat or 's cl inica l experience, the Ca rd i ovascular Heal t hEducat ion Progra m (C . H. E. P. )"'asdesigned during a pre liminarypha se (see AppendixBfor a comple t e descriptionot the C.H. E. P.).
Three nurse expe r ts: re vi e we d.the program for content va l i ditybe t orebei ng itDple ment e d by this inv estigator. In addition,onejunior hi g h scho olte a cher was consu l ted to esta bl i sh the approp r iateness of the selected educationalmaterials for theNewfouncUandadolescents. The imp l e men ta tion phase of th e C. H. E. P. is pri marily describedunder the section on"Procedure."
In order to assess the impact of theC.H.E .P. on ad olesce n t cardiovascula r health Jcnovledge, a "quasi- experi ment a l untrea ted control group design wit h a pretes t and post test"was used (Burns ' Groves, 1987, p.260). Twen ty-e ig ht junio r high scho ol adolesce nts partic ipated 1n this stud y and the i r car d iovascul a r heal t h knowledge wa s te sted us i ng the Cardiovasc u l a r Hea l t h KnOWledg e Questi on n a ire (C. H.I<.Q. Appe ndixC) as a pretest (beforetheC.H . E.P.),post test 1 (i mmedi ately following the C.H.E .P.) and post te st 2 (four months fo l lo wi ng th e C.H.E.P.).
3.
TheSetting
The sett i ng was one junior high school in st.
Jannts, Newfound land ,which had 600st udentsin grades7, 8 and 9.The res earch was implementedduring thehealth educ a t ionclasses of th e school .
The Sample
A conv eni encesample ofon eclass was selectedfrom the fourclassesofgradeeight he a l th education students inthat schoo l.Thatselectedclasswas comparable toth e other three grade eightclassesinre gar ds to itssize, and the students ' academic performance. Because of the needto minimize interru pt i on with there g Ul a r school sc he d ule ,th e principal chose onehealthclassth a t was usual lysplit into two equal groups for their re gula r healthclasses.In that way one group wouldparticipate in th e C.H.E.P. while the ot he rs would attend their regul arheal thclasses. Thehe alth educationteacherwas availab le totake thecon trol group Whilethe C.H.E.P.
wa s being implementated.
There were thi rty ado lescents in this class - sixteen fe male SUbjectsand fou rteenmale subjects.The thirty SUbjects randomly assigned to the experimenta l and controlgroups via the flipof a coin.
TwoSUbjec ts....ere lost during the courseofthe study.
One SUbject fr omthe control gro upleft theprov inceand
40 one sUbject from the experimental group moved to another school. Th i s left a total of fourteen sUbjects in each group.Thetotal remaining sample consisted of fifteen maleandthi rte e n female sUbjects.
Procedure
Approval of the school boardwas obtained through the principal of the junior high school (Appendix E). Meetings were arranged with the health education teacher of the selectedgrade eight class to explainthe study and to enlist assistance in Obtaining the studentsI
consent to participate.Atthat time, the researcher was assuredbythe health education teacher that all students were capableof reading at the grade eight level.
Two weeks prior to the implementation of the program, the health teacher distributedinformationand consent forms for the parents and students.The students wereinstructed tobr i ng the forms home and discussthem with their parents.They were then instructedto return the forms tothehe al t h teacher within one week.
Thepa r e nts of the experimenta l group were given the
"I n f o rma t io n for Parentsof Adolescents participating in the C.H.E. P." (Appendix F) which contained information on the stU dyand the program.They were also given a consent form "Consent Form for Parents of Adolescents Participating in the C.H.E.P." (Appendix G) which contained further d~tails on the program and the
41 confidentiality of the resu lts . The parents of the co nt r o l group were give n "Information for Parents of Ado l e s c e n t s Participating in the Study" (App e ndi x H) and
"Consent FOnDfor Parentsof Ad olesc entsParticipat ingin the study" (Ap p e nd ix I) which contained informatio non theC.H.K .Q .andth e consent form.
Theadolescentsin the experimenta l gr oup were given an informationand consent form, the "I nformati on and Co ns e nt Form for Adolescents Partic ipat i ng in the C. H. E. P. " (App e ndixJ). The ado l escen t s in the control group were givenan othe r information andconsent form
"Inform ation and Consent Form for Adolescents participating 1nthest udy "(Appe n dix K). All parents and stUde nts fr ee lycons e nt ed topa r t icipa t ionin thestudy . Al l inf o rmati o nandco ns en t forms referredtothe con fidentiality of the results. Pri or to the administration of the questionnaire,theadolescentswere remind ed that theycould withdraw fr om thestudy or the program atany time.Studentswe r e also remindedat that time that the results of the C.H.K. Q. would not be reflected in their scho ol ma r k s , nor would their attendance and ac a demi c performance at their regular health class be affected. Priorto theadmini stration of the pretest, alladolescents ve r ba lly confi rme d their consent to par tici p a te in the st u dy .
In order to impl el1entthe program, a schedul eof the health education clas s periods was obtained fr om the health teacher. The C.H.E.P. was implemented over a
42 period of approximately four weeks in seven modules (Appendix B) which cor responded to seven of the 45 minute-health education classes. The controlgroup did not participate in the C.H.E .P ., but rather received theirreg"llar healtheducation classes.
In order to assess the adoLescerrts ' baseline cardiovascular healthknowledge and any re l a t e d change afterthe implementationof the program ,theCoR.X.Q.was administered to the experimental group on three separate occasions: (1) during Module I (p r e t e s t ): (2) during ModuleVII (post test1)I and (3) four months after the completion of theC.H.E .P ., during a scheduled class (post test2).TheCoH.K .Q .vas also administeredon three separate occasions tothe controlgroup, on the same day as the experimental group, by the health education te a c he r . Both groups wer£ giventhi rty to forty minutes to completethe questionnaire.
During ModuleVI, the experimentalgroup completed the ri s k fa c t or grid "Your Risk for Heart Disease"
(li<l>nilton& Whitney, 198 2 ). Permission to use the grid was obtained from the LomaLind a University (Appendix L) .
·Thatgrid was designedto calculate anindividual's risk for developing heart disease. It provided a measure of cardiovascular risk from "below average" risk to
"dangerous " ri s k on a five point scale. The grid addressed the areas of heredity, smoking, exercise patterns, and dietaryhabits (Appendix M) and was used to provide adolescentswitha personalized experience with
43 the-r ea l-pr ob l emofcardiovascul.1.rdi sea seassuggested byBiehler , (1 97 1 )andRog e r s andSt evens , (1967).
Instrulllentation
The thirtyquestions from the Cardiovascula rHealth KnowledgeQuestionnaire (C.H.K.Q. )were borrowedfromthe KnowYour Body Health KnowledgeQuesti onna i r e(K. Y.B.).
The K. r. B. questionnaire (Williams et a1., 1977 ) was developedby a panel of heal thexperts in an effort to doc umentthelev el of health knowledgere l ate d to chronic di s e as e s , including cardiovascular dise~'se. in grade eight adolescents. Pe rmi s s i on to usethe questionnaire was obta i ne d thr ough the Canad i an Heart and Str oke Founda tio n,St.John' s bra nch (AppendixD).
Only th irty ques tion swer e chosen troll the X.Y.B.
tor their card iovascular cont en t.These que stions wer e notpilot testedtorthepresent st udyasthey we r e taken from an establishedtool.Thattoolhasbe e nadministered to many adolescents in dif ferent parts of the wo r l d in order to asse ss their ba s e line cardiova scular he a l t h knowledge (Williamset al.,1977 ; Willi a msetal ..1979;
wynderet al., 1981).
The questions which constitute the C.H.K.Q. consisted of thirty true and false sta teme nts. The r e were: (1) six questions on cardiovascular disease ris k fa ctors ; (2) eight que stion s on general nutrition and exerci se; (3)twelvequestions onchole s t e r o l and. plaque
