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~iir{~~lZt~; .iit SECOND ' , NATIONAL CONFERENCE ON CARDIOV'ASC6ULAkDISEASES onimiizzity 'Service and Bdiscation WASHINGTON, D. C. 1964 I

.•:_e:rsentation and innovation for the offering v.C s:vz w.ces for individuals,l groups and cosmunities tua 4u..wipass the growing edge of social work 1:uo:rle.T;,c,. in fawily, counseling, , group treatment, L0 t i-disciplinary practice.--- 5'ha p.orisionuof op~portuuities" both within and c~atsid: the social agency or,'social eervice dep:.rtr.-nt for the development of advanced ccmpetency in surial~work'practice: .- Crnainnc.4 {experiaientatiou by: social-- agencies in: a =s`:~taffing patterns,; J. on and b. ' ct~c _scleeti ~ use of case ~ aides.'or social vc» k ':'a'ssistarits, c:` t~..t.'differentia'tion betweenXthe less trained anJ the`"fully~°trained worker~. ra mcstion; Frac•ace and Research - rroiessfwi.i;courage to,scrap services,,methods"and cvcn pbilosopLicx'that no"ionger meet,human needa. in favor of those'serviccs; metbods"and philosophies ~iAaC Qo.~ ' REFERENCES 1. Eoc:ks, Warner W.:''Qbjectives 'of 'the Curriculum of the Yuta.ere, Vol. I, New York: Council on Social Work Educatiou, 7959, p. 54 :." 2. U.S. Department of Health, Education, and Welfare: Co,'is for Coasunitv Services, Washington, U.S. Govern- sicnt Priatiug OfficeyJ963, p.. L 3. Itocbncr, Dwsyac:, A Reaoaessment'of the Curriculum, Editor's Preface,_Nev York:.Teache:a College, Columbia University, 1964, 'p.` 5. ,• 4. Begensbarg, Jeanette:_::Unpublished Manuscript, New York: Couocil on Social Work Educatiod;_,:>, ` ,., National Association: of SocialyWorkers, Inc.: Regional ` Tnstitute Program: NeYork," '1964: . 50327 306? EDUCATION OF THE IAY PUDLIC Division Chairman: George M. Wheatley, M. DJ Third Vice-President and Medical Director Health and Welfare Division Metropolitan Life Insurance Company One Madison Avenue New York 10, New York Granville W. Larimore, M. D. First Deputy Commissioner New York State Department of Health 84 Holland Avenue Albany 8, New York Fred V. Hein, Ph.D. . Director Community Health and Health Education American Medical Association 535 North Dearborn Street Chicago, Illinois 60610 ~ Mrs. Frances U. Everett (Consultant) Health and Welfare Division Metropolitan Life Insurance Company One Madison Avenue New York 10, New York I 493

lutrs,.tuction ` _ i.2y' iLb l i c:.1950-1964 ` u:YU1oi..ents in Education of the 2he Early Fifties , : '1tie-;l.ate_Fifties ?.:. •The' Sixties " `` Statusr,of,Public Education,1964', lir IItUUUl:L1Ud ror` tb~ purpaaes of etiiaL.paper; *tlie4ls~Mnblic has been : defi+~ d as tl_q =;Que'reof schoo ~populitionrincluding patients, •bi~b;xial., f~xtiviauaYs~actd~the steneral_oitblic ''' The educatien" i+f tl.e^ i;, =.c~laic rc~gaidibtg cardiovaseular"diseases has been vie~recl in urciad tarms ~,1. as a vadt and~complex effort in- . ~,.. vclvi.&g scientif,Tc, ,professionai".nd Jay: personnel; '2.' as an enkavar dcwandibg'Y`vartetv:of inedica],; public' health and cvcational know3edge'and~skills; 'and 3~,,:as'a' national` effort rcqnfriag,'tt«e~'cooperatioAofTmsserous organized groups includ- -iog;chc.ted`rol,~~state`'an~,local governments,;boluntary asso-- ciattotu.,->'professional'organizations; and':aelected foundations and private-e~nte'rprises..~l•lhirthermo`re;~-professional , 'educat ion • lus been considcred by'!the.'Comsnittee'as'a primary prerequisite for lay edncation,°and:the cffectiveness of the latter is due in .a;or part-to:>tlie' qnality of the: foraier: """`Nevertheless for , tbc `parposes, of .`chis'`paper, =the role`°of professional education bas'becn cwitied-except.by:`inference`or='occasional reference. Finally, education of theilay public has been reviewed as an integral component of coemnmity services and patient care. The intent'of this paper is to provide an overview of significant developments in cardiovascular disease education of the public since 1950, to evaluate the progress that has becn aa3e, and to present key Issues and reco®endations for the future. The Coisittee has not attempted an exploration of the fuadaaentals of education as a teaching-learning pro- cess, nor does it intend this paper to be a definitive report on lay education. 2isie has not permitted such analyses. Ex- cept for examples to illustrate specific points, the paper deals witb activities generated on the national level. Studies. 494 - Bcca& I avndatioris Appcw3ix; ''~t . , 50327 3083 495 articles, educational materials, etc. are cited only for ` illustrative purposes. The Committee hopes, however, that the findings here pre- sented will serve as appropriate stimuli to fruitful Conference deliberations and will lead the Conferencc to the formulation of recommendations that will serve as fresh guidelines for future educational efforts. In 1950, the Section on Lay Education and Preventiori, First National Conference on Cardiovascular Diseases, focused its discussion on three major aspects of the problem: "1. What known facts about cardiovascular diseases can be transmitted to the lay public? 2. How do lay people react with respect to cardiovascular diseases and why do they act as they do? 3. How can we develop a sound vigorous action program through which lay people will have opportunities to acquire needed knowledge and understanding and"to de- velop the'kinds of educational programs, facilities and services which they need?"1 In its summary, the Section on Lay Education and Preven- tion outlined six general concepts about cardiovascular.disease that should be stressed in a' lsy education program and mention- ed specific information in connection wich congenital, rheuma- tic, and syphilitic heart disease and with adult cardiovascular diseases. The Section further recommended research and atGdies to determine what various population-groups know and believe about cardiovascular disease. Finally, the Section defined the objectives of any education program on heart disease and identified those aspects of a program necessary to success including the appraisal of health needs in the community, the involvement of volunteers and professionals on the iocal lcvel, the development of educational materials, and the conduct of research in education methods.1 In gathering information and organizing this paper, the Camaittee has similarly focussed its study on the following points: 1. Philosophy and purpose of educational efforts 2. Shifting emphases and trends 3. Significant developments including specific probrams . and approaches, and their effectiveness '

50327 30G# 497 <i. ,a'tti;tudcs :and `practices=of, the public' ~ " `.. la:a+c s aritt.'QUebtions :.: y , l.:1& been c,ollected through the corilial cooperation of r i,. J, r; t: n Hceart Association,' the 1leart Disease Control Y.-.:~r:n., of.d tiee. National Heart Institute of, the Public Health S<..i_., Sc~cc Commissioners of Health; and through correspon- d.-.kv vitt', n.weroua;;physicians,' public;;health educators and. lay ;..•ptc vl:o havc bcen`actively"engaged'in cardiovascular dis,•:.n.- scs ~~;rch or in ucart disease education programs. The of the First Nationali Conference and the recommen- drtions oi tbe Section on Lay Education and Prevention have a.-v,6.*d as ihe yardstick"to measure progress and to make value 74c C.,...uttec wishes to aeknowledge with gratitude the s. r.i :.t aure :i .•ccived • from. busy professional and lay people whose ;w~.tiat~ a,wt responsive concern for,;!!education of the lay puLlic" hr,s in itself, demonstrated the vital role of education in the solution of`thr cardiovascular:diaease problem. (See Appct.dix fa.r the nau~es"'of.'those, ilndividuals•who were consulted iWtiio piaPZxation'of this docvment.),, . 1950-1964~ ~ Ti~1~ 1 er1S }`i Ct'ipsi" "Cresting a Clfmate of ~•Understanding nL1%LOPNlEMTS IN EDUCATION OF:'THE:.LAY PUBLIC 9Lo,ev.nts, one"izi11947 and"the"other-in 1948, made way for the dcv.a opment'and4advancement<of lay education in the cardiovascular_diseases during the decade of the fifties. y'tsea,~- wcre the:reorganization of the~American Heart Asso- ciation from essentially a professional"society to a voluntary organization with broad nblic purposes, and 2. the passage of the 22atio«1 Heart Act "to amend the Public Health Service Act to support`research and training'3n'diseases of the heart and circulation and to aid the States in the development of cor.ounity programs for.the control of these diseases, and for other purposes." Out"of these tvo'eventa grew the organized educational activities of the Public'liealth Service (PAS) through the Heart Disease'Coritrol Programr (HDCP) and the Itationa.l Scart Institute (NHI)•vith its Heart Information Center, and the Departments on-Coaninnity Service and Education and Public Information of the American Heart Association (AHA). .. ;..,,.. Fdacational Coals In;1950;='thc First National Conference on Cardiovascular Diseases '(FNC);'recognizing the fundamental iraportacxc of'lay education, developed.three broad educational ,:- . . _ . _ . ., goals;l "1. To develop public interest in the problem and pulilic desire to do something about it. 2. To develop public recognition that cardiovascular disease is part and parcel•.of the total health pro- gram of the people, and that use should be m:.dc of all health agencies, official and non-official, aud facilities available in the community in orde-r to integrate a heart program into a total corz,u,nity ~ program. .3. To encourage every cowaun i t y to have a(a) f u i l t imr• health department, and (b) a planning body co:,ipos.:d of representatives of official and voluntary ag.:ncies and interested individuals." In the ensuing years these objectives have served as isa- portant guides in the development of heart information y+robran:s and public education services. A review of efforts in the early '50's indicates that they were primarily informational.* , Public messages were designcd to create a climate of understanding about cardiovascular dis- eases as a national economic and social problem, as well as one of personal and community health; to reduce public fears and misconceptions about heart and circulatory diseases; and to 'encourage early diagnosis and treatment. Six general concc,ts about cardiovascular diseases spe}led out at the FNC provided the core of educational programs: 1. Cardiovascular diseases include many diseases of the heart and circulation. i 2. Some cardiovascular diseases are prevcntable; for example, the heart conditions which fo:luw acutc communicable diseases. 3. All types of cardiovascular diseases can be handlcd *By informational we mean activities utilizing the mass media of press, television, radio, pamphlets, and exhibits. Infor- mation is a vital part of "public education" which refers to a continuous learning process combiniug information and the indi- vidual's personal experiences. ,

50327 3085 499 if diagnosed early and treaFedi~properly. 4. lk•_.i cardiovascular.diseases -can be Joaterially im- pr„v~:, by:proper'treatment and management:- ; 5. G+rdiovascular'diseases do not.necessarily'prevent' uu.: f:om living comfortably and earning a living, pro- v,'.iin„ the;type of'vork:is-:`selected"according to the Iiwicatiens'of' the individual.` Recreational and avc.,:a:ional'interest and activities, should be planned with an understanding•of the physical capacities of the ;..dividaal. - G. S;%ui+taos and sfgna suggesting cardiovascular diseases d., not neccasarily..mean a diseased.`heart. This can cm,ly ioc deterincd.;by a' physician..; ` A S~aflcf entitled "Five Facts You'Stiouid Know About Heart pis~a:.c"- -h.cKi Efvcu iridc distribution.by the AHA summarized tlovs.: iwr.ortant concepts for the publTr• in;,1952. ii•vcl, i,r.rut of 'Materiaia, : To` further ,interpret this fun- 3a:utal infv:wation for<the public,`;the AHA..began to develop a bro.:d spectrwa`of mat ria'Ys on the heart sind circulatory sYstv.a and on ,uany specific.aspects of`'cardiovascular disease, in tt,r forw of publications, films and`other visual materials. FactualTncuIICent,'but;frequently.general'in nature,.many of . tt,..st .ateriala were-desxgned primarfly for a: patiest-family aa.licucc; :urE. as:"How to i.ive'jJith Heart' Trouble," prepared joi.uly`bp A1l%'and thet Public.Affairs Cocmi'ttee. Physicians Wrc iuforeK~d of the~'availability of.:`'these materials and en- couraged"tc,'use thea'st~ 15ie:`ABA`also developed two.lay quarter- lies: -"2t,e Ame-rican`• Heart; !;.which, reports on all phases of d,. AtiA. program, and "Heart"Research:Hewsletter,"•which keeps the hublic.informed about;developments in cardiovascular , researcn: - Rhei.mat ic; fever: sras an:, early foccus for materials and public inforstion prepared`by 1~tHLrsnd AHA ~ A pamphlet, "Heart Discase;and Pregnancy' ! 3 v s'd'p bl sti d D 'AHA , ~ , ,a u ~ S e y in 1953. The Itichiganwart%Associatioa developed"a;film; "Take"It Easy" 3 , " „ on uork,;iipIi ffcstion~for atie`:cardia¢ hou'sevife in 1954. Lifor>aationaI ~sterYals~for,'`the~publie:'were' also'designed to '- interpret the program`.an3 activities';of NHI and AHA. NHI coraneneed ttu important taak"of='provtdirig'special information for the +executivexaad lcgi'slative branches of government:in coan~:ction with appropriationsother`Congressional hearings. . As research programs were established and other cardio- vascular disease activities developed, the breadth and'co.a- plexity of the task of collecting, interpreting, analyzing, and disseminating information for all kinds of lay audiences during these years of growth can hardly be exaggerated., The Mass Media. The early involt+ement of the mass wedia in reporting on developments in heart research and the activi- ties of NHI and AHA both reinforced and give additional iwpc,tus to the broad'campaign to alert the public to the possibility of controlling the cardiovascular diseases and to the promises of research. In this decade science writing emerged as n specialty - a reflection of the age and the times, but also testimony to the fact that the public had become responsi.ve to matters of health including the cardiovascular disease problem. Countless magazine articles have been prepared to satisfy the public's growing search for knowledge and under- standing, and similarly books on many aspects of heart disease have come from press. One of the earliest was Dr. H. H. Marvin's You and Your Heart published by Random House in 1950, and later in 1952 published in an inexpensive paper-covcred edition by New American Library. A current example is the recently published Episode by Eric Hodgins describing his personal experiences as a stroke victim. Radio was used frequently as a resource for communicating general information emphasis•,ing early diagnosis, proper treat- ment and thorough rehabilitation. Sustained public service messages have been sponsored by local Heart Associations, h1tl, and such private enterprises as the Metropolitan Life Insurance Company. The emergence of television offered new opportunities to bring educational heart disease films before a mass audience. Special TV privileges were obtained as early rs 1952 by the AHA to show the film "Guard Your Heart".3 Several pioneering Heart Associations in various parts of the country taok advantage of the then new medium to tell their coaauunities about their program and the latest scientific advances in fighting heart disease. Reaching the Public. In short of five years, by the mid- fifties, the first educational goal of arousing public interest in the cardiovascular disease problem and influencing public attitudes to want to do something about it was being reached. This outcome is assessed not only through public demand for information through the mass media, but also through direct ~ ,

tt, ` the Heart Infoxmation Service of AHA and to the ion Center of' r'HI. Physicians reported, too, ti. •: k, .; c i.-cal_'conaunity `groups began `to seek them as speakers t.µ .•i,n ,t ~cs~:;l mcetings. and` that esierging.'questions ref lected , ia, r,-: -ia~ sc~,•~!tisticatiAlso` the;is}crqasing support of - • ' cTth `leiitia°oicd 1 the;id -n-•cevAsa.gsaove..7.,nterests an trends exantple,- in 1950 Congressional appro- pr;.aus wAIIil.alooe rrere-$10,T25,000:,,;:Yn 1955, this sum o`$16,668,000~ " The 'tretid for` support of N11I has k couz 6,911..•.t ttie, sixties"vith:'apgropriitiona at $62,237;000. .iti:.K, rartic~t on~ Of•significanco in developing a fav..•,~i~1c y.uLlic•opinion;during,the ear~°fifties was citizen ~: t i, i p.,ti'uu `~'As' recaaoended,.by, the FNC; ;lay and professional p.ro;.l.: .Ki e bi ought 'together; in' program planning. . Within the A1it, :. rublac"'F:ducation`Committee:,of ptiysicians and laymen was fc.,c.•,1. At tlt~start;' fhis:cosmiittee w~asrlargely concerned .,itc. the'dcv..lopwentVof~'acciirate'and"reliable publications and oth:-r c3ucatiix~al "tools"~~ S`oon;"tios+ever; the'very nature of the cducatYOna l:r,process- stiaouIated`this group to question how . tlir r-:zteriala `rrere being dtsseminatedand;used particularly ~ , ~, ie l.rc7;ra~s o: `aocal1 Heart Associations '.<.~Recognition was 's1c..:ly beIug given•to'the'premise;that,education does not be- giu noc camf with the;?dissemination of;information. Hence the fuiictioas `of ~this'.conmittee 'videned iii` order to explore and l'vulu<lte the .ffective use.of'educational,tools and to give dircction to thoughtful, program planning..- Similar committees ia loc„1 H,art Associations have been developed in more recent y~ur .s Citi.en support vas also stimulated through the or- fu,&.i raising of AHA. The increasing size of the Heart Fu«T ove- the ycars is one measure of public..involvement in ti.: r;,rdiovac.cular disease problem. Between 1950 and 1955, thC tVA ii.creased from $4,104,485. to $13,575,963. In the ly4S drivu, the Heart Fund raised $27,900,383.. camusaitv Services. The early fifties also saw thee be- ginnittda of increased and expanded cammunity services. Into m.zny of tLesc programs have been woven planned educational activitics. Ia 1954 the first full time health educator was br.K,ZLt to tue' Central Office Staff of the PCP as a consul- t:.nt. Today there are two Yn'the Central Office and seven in the iic6ld, three'scrvirig`at a7'State level; and four at a county lcvcl. Thesc>individuals have contributed significantly to th.• growing concept of:ithe team approach in the planning and iaplc-%uentat;on of heart{:diseasQ control programs. With the dewelopvent of cor,munity..,serviees -,,home care programs, car- diac clinics, rehabilitation centers, work evaluation units, 50327 3006 501 for example - grew special educational activities for the cardiac homemaker, the stroke patient, the child with rheuatatic fever and so on. Coordinated community planning developed in many local situations as the need was recognized, and increascd cooperation among official and voluntary health and,welfarc agencies, medical societies, and other groups bc:camc rr.andatnry. As the Heart Information Service of local lleart Associations become better known, it has played an important rolc in rcfcr- ring individuals in need of help to find appropriate medical care or community services. During the early fifties, too, there was continual scnrrl, for further definition of the cardiovascular disease problem and how best to bring not only scientific information to the public, but also information about available community scrviccs and future community needs. In 1954, Congress amended the llos- pital•Survey and Construction Act7 to provide funds to statcs for constructing nursing homes, diagnostic and treatment cen- ters, rehabilitation facilities and chronic disease ho::pitals. Frequently referred to as the Hill-Burton program, this legis- latipn stimulated the expansion and development of public health centers from 468 in 1948 to 1,204 in 1963.8 Au>:iliary public health fa%ilities increased from 722 to 1,062 dtiring the same peribd. Hence the second and third broad goals of the FNC were beginning to be realized. By the mid-fifties, however, those individuals responsi- rc_o~nizia•~ ble for educational innovation and programming were that creating a favorable climate of understanding was not enough. Efforts had to be made to influence behavior and reach the individual in his home or community. The Iate Fifties: Influencing Public Attitudes and Bflovinr. / In summary, the early fifties have been characterized as years which established and reached for broad educatiunal goals, stimulated citizen participation, began the devvlopmcu: of educational tools, and fostered educational activities as an integral part of total community health planning and ser- vices. Out of the early fifties emerged the specialty of ' science writing and the growth of the mass media as an in- fluential stimulus of public opinion. From these ever,ts de- veloped a greater public awareness of the cardiovascular dis- ease problGm and an atmosphere of understanding favoraLle to further progress in the late fifties.

502 T.i~--:,i),r.:,rer lleart Attack. The heart attack of Presi- dvmt t't r in September of 1955 was an event of singular i,."Lhe `educatiori of the public :about cardiovascular disw.,:`.•::. t+l` tbcdia:• of 'cossnunication devoted.-their resources so• ew.•linE ri:r p+,t,lic` demand for inforwation, "and terms such as ", it.~.scy ti~ro,obosia" and-''Sayocardial;;'ijfai{ction"• were.in- tcrj. .L.t i.,r.o t:be'.pub2ie•s.'vocabulary. ;Ths.'press published acc...... t. c.f .w.eic.atrdcscript*-ons'of a heart attack; magazines d...•L.p.•d 1vit),tt,y`.'and comprehensive articles:oh both the sc i, ec i fic wiJ,rehabilitative' aspects of"the",problem. And the lia:.ilitics c.f i,eart disease to the national welfare became s.or.- app:,r.nt-- ~ . _ T'ts Ei sea,oi~rer'. heatt attack "and . the sub'sequent ly pub 1 i- t.cart att.-ck"°of :the then Senator Lyndon B. Johnson in 1~5? did m,cih to'arouse-public interest'-in what could be done to Yz.:r:•ct the i+cart and what could be done to lead a near aor.:;O l ife aft.•r injury to the Cardtovascular system had oc- curces. Tf1e successful medical recoveries of both these men dc.;on:crated dr::matically,for the public that a "heart attack" no 1ou;or sti,ulu be looked upon as necessarily fatal or even pc, w.:ucut ly di K bling. • 1:•;„ratic+w+1 ProRramminit. Educational programming began to f•4:us nor. x••lectivcly on special. problems '- heart attack, l,ypcrtension, a:berosclerosis, rheumatic fever, etc. - and on ap~i;-l i,ctcc•e:;t`groups ='-the executive, the farmer,'children, and ::o forth. t:ducational tools became more sophisticated for a s,s:+- sol.his.ticated public, and messages were designed to aa:.:sc the y.:ai.at or his family to know what to do (the application of research developments and prophylactic measures), and w:,eve to Zo (using commanity resources) for help. The joint campaign of NHI and AHA to make rheumatic fever a rare discase iss a useful example. Traditionally AHA's edu- cational programing has been designed.primarily to aid phy- sicians ia their care of patients and to help in prevention of ill hrealth..,Ia 1955 efforts were sade.to reach practicing pbysicians (110,000:tbrough;direct svail,alone) and other pro- fessional:peksonnel ws vell~as'thetilay.c:`pablic with the infor- s,ation thac a'preceding:`streptococcalffnfe`ctioa Sa the initia- tiag agcnt of'first"-'attacks¢and;rheueoatic:feYar recurrences. In k ssages to the-public;'especiallyapareata, emphasis was placed on'early diagaosis`of atreptoeoccal infection and on tt,e use of antibiotics to wipe out;-infection before rheumatic fevcr developed.-•A wide va•riety of materials was pr,epared and dissminated.g. . 50327 3087 503 Rheumatic fever education has consistently been an in- tegral component of overall cardiovascular disease education for the public. It represents one of the few known areas of the cardiovascular problem where prevention of occurence is possible. Yet, rheumatic heart disease continues to be a problem and as such demands further attention in profession:,l education (importance of taking throat swabs and utilization of laboratories employing the Fluorescent Antibody Technique to identify group A streptococci) and in public education (to seek and secure up-to-date diagnostic and preventive meaaurus). As with rheumatic heart disease prevention of occurence is possible in•syphilitic heart disease. During the fifties, educational emphasis on this cardiovascular disease deciined with the decrease in reported cases of syphilis fran 1950 to 1958. Since 1959, thtOreported case rate of syphilis has been on the increase suggesting that on-going medical and educational vigilance is a public health necessity if there is to be venereal disease control and a continued reduction in the incidence of syphilitic heart disease. For patients with congestive heart failure, educational efforts have slowly been built into some hospital and homc care projectsb. The nurse, for example, who works with the congestive heart patient does a tremendous amount of ed„cation, not only in nursing care, but also in specific areas such as nutrition, and in the overa'1 management of the case. e•!hen nutritionists are availa4le, they may assist the patient in selecting and preparing a special diet. Manuals on sodium restricted diet and fat restricted diet were groduced jointly by AHA and HDCP for the use of the physician. A pub'_icaci.on, "A Guide for the Congestive }leart Failure Patient" was dev--l- oped by HDCP, as were other materials prepared by AIiA. Despite the availability of useful teaching materials and the demon- strated value of planned patient education, th: vast majority of the 2,000,000 Americans suffering from congestive heart failure leave the hospital unprepared to cope with their problem. During the late fifties, public information and education programs also focussed on the stroke problem and rehabilitative techniques for stroke patients. The HDCP began in 1957 to assist in the solution of this community problem through the education of professional and lay groups, by preparing ruch needed literature, program guides, exhibits and other materials for both groups and by providing consultation to states and communities for program planning. The AHA in 1958 publishod • 3

504. "Ct~,,:. :, A C..ide for the Fasiily"3,and through its Coordinating l2,filon\tidC,;.StrOke~hrogramhas continued to urge E..r,:: i v 4•u*. i i, attitudes _ about thn possibility of full, or i.-rt ;:., from strokes.., "llnwng the publications of the Alt :..•, i, "u.rt line for a Public Education Program on Strokes" i.,. ,:. ..."t 1..:.x iations, and'the Stroke Program of the Chicago K••i. t t. :•.,: iai.inn. is an illustrtc tion of howe the, educational t.il " r h > ii ied - t, .•, .:vL r a ca r ou tiw~se' few.examples it, can be Qtoted that education- al •fi,rthcr"devclopcd during the late fifties as an 1*:.: t oi co"aity services - hatne caje pro jects, re- tsbititc::iocc_p~aLraus,~ctc focussing on`cardiovascular disc~ce c:ait;:a ~cre=putient'attitudesAand behavior needed. suppor4~~; Hogever, as' ha"s~been noted, effective Lati.:nt c.Sdcatian-is still in4ts•.infsnc_y;;the~`attitudes of cLc r. ,ical ; au.l allied_.h alth,~professions ~st' be shaped to ` 'see t.. ;.. . i c,rrc of acute~eoiiditions to bc, concerned about futurc carc, rc:wbilitation, and prevention ', iG•: lth u. tyrtrents: For'the most part,:, the activities of sta+c•, rouqty; a,ld local.health, departmecits' in public education rrg..rJic,6 c+er.ti.;v$scuLaic' disease's have b•e'en minimal over the ycn~ s, (k.TY' iN the last:; fetir°'years, ;mainly : through formula graut.,iJ froin.the •A1S 'and'vith ,ttie',; ass~'atance of health r,t..:•: rars fr.cw;; t he°IiDCP,, have•''several : state ,health departments cc+~, :,: e.2 `ststc-wi8e planning~,arid `programning:r . - 2 of lay I:or tAfs_paper, ttie;Caamittee.~undertook a survey1 cduc;,tiun activities'iin''the`card.iovascular field which have becu cp,„luct.~3 by:"state;'and`territorialahealth departments. Infu.~ •t i.an Was requcsted°on three basic`;'components of lay csorati.•n pr..g::..as:, studies, materials;';'and group projects. Forcy-v+,c statt:s and four territories responded. 1'hc data collected in the survey indicate that the role of scatv and teiritorial health departments in the education of tiwe goncral public has not been standardized. Over half of thasr reporting stated that they either did not provide e.iucationaI activities for the laity or they did it only thr.wr,h tt,c production and distribution of informational ma- tcrials, such as pamphlets and films. Many respondents felt that t-.turatic.c of the general public should be the responsf- t.ility of voluutary heart associations and their local chap- ters. l:ithin a numbec of state and territorial health de- partwcs,ts, various cardiovascular education activities are dissil...t.-,t anong operating units 'other than heart disease con- trol, such as ssaternal,and child health, nursing, nutrition, 50327 3083 505 accident prevention and dental health. In a few instances, responsibility for heart disease education is shared with various official agencies, such as dcpartments of vocatioi»1 rehabilitation. The degree of sophistication of state and territorisl programs runs the gamut from the distribution of a heart asso- ciation pamphleG to the undertaking of a complex, sociologic:,l study of lay knowledge levels and attitudes concerning cardiu- vascular disease. Public education activities, for the most part, were concentrated in four major areas: rheumatic fuver and rheumatic heart disease, primary and secondary prevention programs; stroke rehabilitation programs; congestive heart failure programs; and cardiopulmonary resuscitation programs. Some significant developments are evident from thc survey material. Exploratory studies are being conducted by a few states into witat the public knows about heart disease and how this knowledge affects their attitudes and behavior toward it; why patients with rheumatic fever and congestive heart disease fail to follow prescribed procedures; and what barriers affect the employment of cardiacs. Where programs exist, emphasi.s is being placed on the education of selected groups, such as patients and their family members, rather than populations en masse. Techniques of education are being considered with some experimentation in the use of television and the "teaching machine." Following are a few examples of informational and educa- tional activities conducted by states: In Tennessee, the State Department of Health, in coop- eration with the Tennessee Heart Association under con- tract with the Tennessee Association of Broadcasters, has produced a series of radio and television spots on general cardiovasctlar diseasc. During oae month, 3,407 spot announcements were carried over sixty radio and nine television stations. In Pennsylvania, the State Department of Health, in cooperation with other agencies, craated a large "walk- through model of a human heart made largely of papor mache. The exhibit was lighted to show the inner structure of the heart and wired so that the heart sound appropriate to the chamber is heard as one walks through • it. In 1962, 496,000 persons "walked through".

50327 3039 506 + l,o .;,.higaan,'d'pamphlet entitled "The Sportsmen's was distributed by the State Department of ic..ltt. to hunters and fishermen through licensing r; ,... ;.•s aud sporting goods stores. L, (r,.!,horra and California, the State Departments of lr.;,lti. arc-actively engaged in research projects invol- vikv. the use of "Leaching machines" for the instruction ef I.aicnis with congestive heart failure. - in rla:ida, the Bureau of Dental,liealth issues wallet- sized, chcck'list cards to physiqians, wh3ch are com- pl.acd by the physician and provided to patients. Each ca:d iadicates th'e"patient's cardiac status, alerts him to potcntial=`dental hazards,'?and`suggests that he show hfs:.ent:isv'"the card prior;to"aay operative procedure. Ovcr` °y,000 `caids~have already;tbee3v distributed. - In the Department'of . HealttY; in cooperation - with 'the li..wati' ticart Association and Electric Company, arr t, vaching:;_cardiaca how to simplify household tasks. - In lcnasylvania,„seminars"oa`cercbro-vascular disease are being conducted:for;clqrgy of`all faiths. The sauinars provide a description of strokes and their eficc:ts - physical, mental and`economic - and an over- view of ceasnunity facilities available to the patient and the`family. - In New York, the Department of Sociology, University of Syracuse, under contract with the State Department of Health, is initiating a study of the barriers which affect the employment of the cardiac. - In Minnesota, the State Department of Health, in coop- cratiou with other agencies, is involved in a project to determine whether or not patients who have congestive heart failure-understand and remember what their doctors advise.'. Fram thiweursory,sropling, it "is obvious that programs of state and territorial departments:of health are being con- ducted in coopcration,vith heart associations, universities aad other agencies. Since the problem of-•heart disease does not vary significa.itly from state to state, it seems equally obvious that each activity, therefore, should have some degree of al.propriatencss and applicability in all states. There is a nec+i for cach,state and territorial depar,tment of health to 507 not only monitor the status of disease within their own juris- dictions, but also to consider what is being done to prevent its occurrence, treat its.victims, nnd rehabilitate its pa- tients. This would help to ensure that current inowlcdl;e - educational, medical, social or economic - is being applied most effectively. The Physician and Tiedical Organizations. The American Medical Association (Alir1) and state and county medical socie- ties have made various efforts to both inform and educatc the lay public regarding cardiovascular diseases over the years. These have continued to develop during the late fifties. Since the vital role of the physician as educator has been recognized for centuries, the support and participation of the practicing physician and medical organizations in lay education programs have been of paramount importance. Although primarily concerned with professional education, the AMA, through its Departi,icnt of Community Hea;th and Uealth Education, Cocmunications Division and Special Councils and Committees, has endeavored to use every availc,ble mediun of communication to promote more healthful living including the .procurement of-timely and adequate medical care and the prac- tice of periodic health inventories. Various aspects of cardiovascular diseases have been given attention in Today's Health, the AMA's lay magazine. Through its National Speaker's Bureau the Association supplies speakers to non-medical groups. Increasingly during the olate fifties, county medical societies have been called upon to provide speakers for lay audiences. The Association has maintained an extensive question and answer service by mail for the lay public and has assisted writers in the preparation of manuscripts and other health materials plan- ned for the general public. An increasing number of individual physicians, through the efforts of,the AHA and medical organi- zations, have become more aware of the need fcr patient and family education in the management of a case. In a survey of physician's attitudes anL opinions about a booklet on stroke, most physicians found the booklet useful for a number of reasons: a.) it helped patients attain self- care; b.) it simplified the problem of teaching patients and their families how to give exercises; c.) it improved attitutc5 of patients and families by giving them something constructive to do; d.) it lessened the time the physician needed to spcnd with patients.l3 The continuing efforts to stimulate the physician,

508 ;•4•_: tf, ..iul as a part of a medical group, to utilize and .:. !.' th< ...•.•c,rtunities he has for teaching should become an i: •, •• 1-•iji t.•,:d in lay. education. Other professional medical t- 1, :,:c the American Academy of Pediatrics and the ~. o+ ta•;:cral Practice also support this trend throtiigh tt.• i, activities, journals and meetings. i•-a throuRh Industrial Programs. With the growth oi i+rtustri.•a s+edical- progras+s, the interest of industrial Nt,y:.[c~au. i+ti che cardiovascular disease problem has also g+..~~. lw"Lo.iness;'organizations where an employee medical c:ists,' early diagnosis'of a cardiovascular problem is :.cr.•ssol through periodic.health examinations and important h.alti. co.a+ssling is frequently.given to employees who may have he:t4t :isCs.: or whosc family history or medical examination m-+y its latent possibility.l`' '<In some companies, the c,~:,=2op: r w;t;,aztne may carry an" article on some aspect of car- di.x: :.cul:t. dGseasc,', and pamphlet tnateriaT is made available tcb i at rrested employceg rv`. 1t1c'?'K 3ica: Fonndatibn; Inc.; a voluntary organization 1-st'+t+t tiai+,_.t~,n~-1957'`l # has~developed •services to provide health .~w •,iva~.,-ams~pon~Zi~quest in"the~businesses' nd indus- tri. r oC;Ett.c gt'catcr-"Boston and Nev England areas:~6 A pro- Sr~tt La.,"1.,•.c+i available4ori*;!'Your Aeatt:: A'Perpetual Motion k..•,i: • that b.zs `involved botli management' and employee part ici- patic.n and t6- use"bf-a~variety;of!:teaching tools. There are oti..•rs scbedutcd dealing;with heart.di'sease as it relates to nutriticm an.+ physical fitness. ;Evaluation of these activities is• p.:rt of Ttio; Medical Foundationts responsibility, and ques- tiot.i..,ires',h;+vc been worked up as"baselines for pre and post ccst m.asure+~nts.' tTae of,the most-:valuable developtnents of the late fifties ks i..-en th; fiirther establishment and use of Cardiac Work Evaluation,;Ilnits.: The first-of_these_"clinics" was set up as carly as'.1941 -;:Today there are'about'36 Heart Association- sp..nsorcd Units'rrhose fundamental purpose is education - of the emi;,loyer as;well as'the employee-patient - to help pro- ductivelyin the rehabilitation'of 'the patient to full or part tiur useful employment. -Published evidence, however, sug,gosts that.these units are'not used sufficiently.17 It should be noted, too, that the AM''has continued to stiwnlate interest :n the nee:: and problems of the cardiac- in-industry through sponsorship of meetings and state wide conferences such as those held annually in Chicago coeanencing in 1952 and the one held in Harrisburg, Pennsylvania in 1960. R 50327 3090 509 Additional study of the problem is indicated, however, and the full cooperation of manage:ment, unions and the medical prufv:.- sion is needed. Other Organized Efforts. As has been noted, during thc late fifties educational efforts have focused on helping the heart patient and his family understan,•d the problem, scck pro- per care, and follow a regimen most conducive to normal wid intelligent daily living. The Health Insurance Plan of Crcater New York, frequently referred to as HIP, has carried out .+ program of health education for subscribers (approximately 700,000) which has often considered the heart and circulatory system, and the related role of doctor and patient.18 Worning through the 1,000 physicians organized into 32 medical groups affiliated with HIP, the program has been carried out maittly through subscriber group meetings using large group lectures (average reported attendance 250) and small group discussions. Summaries of these meetings and original articles by 1111' physicians and staff, pamphlet reviews and other cardiovascular items also appear in the quarterly health education bulletins mailed to all subscribers. The life,insurance industry has a well recognized stake in the cardiovascular disease problem. In the area of lay education, the Metropolitan Life Insurance Company has bc.•n a pioneer. For many years the Company has made available to the public and community agencies a comprehensive boolcl::t on the circulatory system and hi:art disease as well as sYecial leaflets on rheumatic fevck and coronary heart disease. "ilow to Control Your Weight" and "Your Guide to Good Health" have been two additional ublications used in urging intelligent 'health maintenance.l~ From 1950 to 1963, the Metropolita« placed 22 different public service messages on cardiovascular diseases alone in national magazines. During the same titnc period, similar niessages were carried over radio networks. In keeping with the general trend in cardiovascular intoru:ation for the public, the Company's messages included fPctuat in- formation about heart research, the circulatory system, and common misconceptions; and focused on such preventive measures as periodic check-ups, knowledge of warning signals, avoidance of stress, weight control, regular exercise, and a daily rou- tine of healthful living. Both the Prudential Insurance Company of America and the John Hancock Life Insurance Company are others in the insur- ance industry who have made heart disease informatioa avail- able to the public although on a much more limited scale than Metropolitan. The Prudential has published "It's Your Hcart"