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A continuing medical education program which linked primary care physicians to a source of needed appropriate clinical knowledge at a relatively low cost has been demonstrated. Chronic obstructive pulmonary disease was identified as the health problem; the reference patient population was comprised of coal miner health fund beneficiaries living in a 10-county region. Primary care physicians treating beneficiaries in this region were the eligible program participants. Content of the program was based on multiple sources of information about actual practice needs. Several educational techniques were used in combination to convey the knowledge identified as appropriate in the diagnostic stage. A quasi-experimental program evaluation indicated significant changes in physician knowledge, judgment, and self-reported behavior related to diagnosis and treatment of chronic obstructive pulmonary disease.

Three health education interventions for urban poor hypertensive patients were introduced sequentially in a randomized factorial design: 1) an exit interview to increase understanding of and compliance with the prescribed regimen; 2) a home visit to encourage a family member to provide support for the patient's regimen; and 3) invitations to small group sessions to increase the patient's confidence and ability to manage his/her problem. Previous evaluation of the initial two-year experience demonstrated a positive effect of the educational program on compliance with the medical treatment and blood pressure control. Data accumulated over an additional three years, including mortality analysis, are now presented. The study group consisted of the same cohort of 400 ambulatory hypertensive outpatients in the eight experimental and control groups. The five-year analysis shows a continuing positive effect on appointment keeping, weight control, and blood pressure control. All-cause life table mortality rate was 57.3 per cent less for the experimental group compared to the control group (12.9/100 vs 30.2/100, p less than .05), while the hypertension-related mortality rate was 53.2 per cent less (8.9/100 vs 19.0/100, p less than .01). The results from this longitudinal study provide evidence to encourage health practitioners to utilize such educational programs in the long-term management and control of high blood pressure.

Graduate Turkish midwives were trained in triage rules for determining family planning home visit frequency based on risk of couples. In a sample of 542 couples followed for six months, modern contraceptive use increased 22 per cent among high-risk and about 15 per cent among moderate- and low-risk couples. After making assumptions about the fecundity, contraceptive success, and pregnancy complications, the estimated average cost per complication averted was $61 for high-risk, $177 for moderate-risk and $526 for low-risk couples.

Survey content is necessarily limited by the investigators' foresight and by prior research on their subject of inquiry. Clinical data must supplement statistical data whenever the prior research is insufficient to delineate exactly what problems to expect. The differing perspectives on needs of patients sometimes set up competing demands. This calls for strategies based on a programmatic or population perspective that identifies the commonalities in patients educational needs from the statistical profiles, while at the same time allowing for the development of interventions that provide for as much tailoring of the educational experience based on clinical judgments as possible. By combining the community health education perspective with a clinical perspective, we were able to design interventions that responded to the educational needs of a population of low-income, black hypertensive patients. A needs assessment process that combined these perspectives began with a historical and community assessment of the problem in its most general terms. A second phase focused on the most important behavioral and organizational points for intervention. A third phase required formal assessment of predisposing, enabling, and reinforcing factors that may be determining the priority behaviors of health care organizational problems. Finally, clinical and administrative judgment sharpened and supplemented the educational interventions that were suggested by statistical data from formal surveys. Behavioral sciences theory was applied usefully in all these phases.

The School Health Curriculum Project (SHCP), initiated over a decade ago to provide a health education curriculum package for elementary students, has been widely and variously evaluated. In analyzing studies designed to assess the effectiveness of the SHCP, it was recognized that the measured impact of this project (or any health education intervention) would derive from the adequacy of the theory upon which the program is based, the adequacy of its implementation, and the adequacy of its measurement. Hence, an examination of the theoretical base of the SHCP and its variance in practice was conducted. In addition, a metaevaluation of 24 studies designed to access the effectiveness of the SHCP was completed. Results suggest that the project is effective in influencing health-related knowledge and attitudes. A rationale for future evaluation efforts in school health education is subsequently outlined.

The major health problems confronting most countries require interdisciplinary approaches to the provision of service, teaching, and investigation. Past research indicates difficulty in role relations between various types of health professionals and the importance of the interaction of selection, educational processes and work experiences in affecting long-term professional behaviour in collaborative directions. This paper applies these concepts to the analysis of the first five years of experience in a pre- and post-doctoral research training programme at the Johns Hopkins Medical Institutions concerned with educational and behavioural approaches to cardiovascular risk reduction. Concepts or processes specifically incorporated into the programme to increase the likelihood of graduates conducting their subsequent career activities from an interdisciplinary approach are described and analyzed. These include appropriate recruitment and selection; early interdisciplinary learning experiences; reinforcing socialization and professionalization processes; active faculty role model team approaches; and reinforcing research experiences. To date the programme has provided training to 14 post-doctoral and 16 predoctoral fellows. Analysis of the effect of the programme on the cardiovascular fellows in regard to their performance, interdisciplinary approach, subsequent career patterns and performance, as well as on other students not supported by the programme, and upon faculty, recommends this format for research training in health education and behavioural sciences.

A protocol for the stepped education and support of patients is derived from the cumulative experience of more than 200 clinical trials of patient education and behavioral change interventions. The recommended procedure entails assessing a patient's educational needs by asking a sequence of "diagnostic" questions to assure patient motivation, skill and resources and to reinforce adherence to the prescribed medical regimen or life-style modifications. The sequence of questions and interventions is also designed to minimize a physician's time commitment and to maximize the medical benefit to the patient.

The literatures on both behavior modification and behavioral development have engendered innovations in public health programs, addressing problems of patient adherance to preventive and therapeutic regimens, delay in seeking diagnosis of illness symptoms, risk-taking behavior, and other aspects of lifestyle associated with health. Because most of this literature derives from psychology, there has been a distinct bias in the construction of interventions, pointing them directly at individuals, usually in a counseling or small group mode of delivery. These developments served public health well enough during a decade or so when the preoccupation was with utilization of health services and medical management of chronic diseases. With the publication of the Lalonde Report in Canada in 1974, the passage of Public Law 94-317 in 1976 in the United States, and similar initiatives in other English-speaking and European countries, the recognition of the greater complexities of lifestyle development and modification in the absence of symptoms has taken hold. Policy makers and public health workers seek a more efficient and equitable set of strategies to meet the behavioral health challenges of modern society without placing the entire weight of responsibility for behavior on the individual or on therapeutic practitioners. Concurrently, on a more global scale and in the developing countries, a concern has emerged for strategies that give individuals, families, and communities a greater role in deciding their own health priorities. The convergence of these two trends--one seeking to distribute responsibility for lifestyle more equitably and the other seeking to distribute responsibility for planning health programs more equitably --calls for policies, strategies, and interventions that will place similar emphasis on health education and organizational, economic, and environmental supports for health behavior. The combination of these elements of support for behavior calls, in turn, for research and more inventive applications of theory from sociology, political science, economics, and anthropology. Public health workers will need to become more conversant and facile in these social sciences, as they have in psychology and its applications in the recent past.

Three educational interventions for the control of essential hypertension in ambulatory patients were based on analyses of the educational needs of patients and providers. The educational program increased reported compliance with medication, improved the proportion of patients losing weight, and improved appointment keeping. Most important, there was a favorable effect on blood pressure (BP) control. The proportion of patients with BP under control in the group assigned to all three interventions increased by 28% (from 38% to 66%), while the proportion in the control group receiving standard medical therapy with no educational interventions remained unchanged at 42%.

A cost-benefit analysis of preparticipation sports exams of 763 adolescents was based on data from parallel programs conducted on affluent white and indigent black populations. After initial exams, 16 athletes (2.1%) were referred for further evaluation before participation was allowed; 15 of 16 reported their problems on the history form. Two were disqualified and one was treated. The cost of identifying the three athletes with significant problems was $4,537 per athlete. An additional 163 athletes (21.6%) had significant medical problems unrelated to safe sports participation and 89% of students sought routine health care only to obtain permission to play sports. Preparticipation sports exams have an unfavorable cost-benefit ratio even if costs are carefully controlled. The ratio might be improved if significant health problems not relevant to safe sports participation are sought or if exams are limited to athletes with positive responses on a preliminary history form.

Guidelines are presented for specifying objectives, identifying resources, selecting methods and evaluating the health education component for maternal and child health programmes. Examples of the application of the principles are integrated with the Guidelines. Diagnostic, planning, organizational, administrative and evaluative procedures are presented around a model of health education which emphasizes: a) the careful delineation of the health problem; b) the specification of behaviours influencing the health problem; c) setting priorities among target behaviours on the basis of their relative epidemiological importance and their changeability; and d) the identification of factors that predispose, enable and reinforce the behaviour.

Results are reported of a quantitative synthesis of 70 published evaluations of educational programs for people with long-term health problems and regimens that include drugs. Study methods and interventions are rated according to methodological and educational principles, respectively. The differential effects achieved by seven types of educational techniques are compared. The largest effect-size values (in standard deviation units) for knowledge were in three empirically distinct and homogeneous groups of studies--those testing one-to-one counseling, group education, and one or both of these strategies in combination with audiovisual materials (range = 0.73-1.13). Homogeneous subgroups of behavioral studies (grouped according to type of intervention) were found within the studies measuring drug utilization errors, but the overall group was homogeneous. The absence of significant differences among the subgroups precluded subgroup comparison. The overall effect size was 0.37, indicating substantially decreased drug errors. Analyses of study and other intervention characteristics found the educational rating score to be the strongest predictor of effect size for both knowledge and drug errors. Patient package inserts were predictors of lower effect sizes.

Successful implementation of clinical preventive care programs is a shared responsibility of patients and health care professionals. The physician often laments patient failure to follow directions while the same patient complains that instructions were never given. Health care professionals should strive to "practice as they preach." They need to assure that their patients have clearly understood the recommendations and that patient concerns are assessed and addressed. Similarly, patients need to participate more actively in their own health care and to assume greater initiative in getting their questions answered and their concerns addressed. To increase the likelihood of these actions and their intended health behavior changes, a set of principles derived from theory and research can be followed. These principles represent a way to understand and influence the health behavior of physicians and patients. The principles are interactive and complementary and are based on the elements that appear to be associated with successful educational programs. Consideration of these principles in the conduct of educational diagnoses, interventions, and health education programs increases the incidence and durability of behavior change.

Emergence of consumer health self-care is a reflection of the increased commitment of health professionals to patient education, growing consumer awareness that they are capable of sophisticated self-help, and a variety of social, economic and technological currents. These currents are reviewed and a survey of existing medical self-care programs is summarized. The attempts and potentials to evaluate these programs are critically examined. A number of important research and demonstration issues are raised including the determination of behavioral outcomes, technical limits, and manpower implications. A federal program of replicative studies on such issues would provide substantive knowledge in the self-care field, generalizable to the larger field of health education, but the hazards of undermining the voluntaristic and non-establishment character of the programs must be considered in designing evaluative studies.

The Reagan Administration has adopted the policy guidelines developed over the previous few years in the disease prevention and health promotion initiative of the Carter Administration. Broad national consensus had been sought in the formulation of 226 measurable objectives for the decade. We classify the prevention objectives according to their position in an implied causal chain: 1) improved programs, 2) increased public and professional awareness, 3) reduced risk factors, and 4) improved health status. Prior to 1980, the data systems and periodic surveys sponsored by federal agencies and national organizations covered only four of the 42 objectives in the public and professional awareness category, whereas at least half of the objectives in each of the other three categories were covered by available national data sources, mostly federal. Sample surveys are needed to measure the majority of the currently unmeasured objectives in all four categories. Private and state health interview surveys are needed to supplement the federal capacity, especially in the face of federal cutbacks in survey capacity.

Large-scale, integrated programs--as distinct from multiple and widespread replications of small-scale programs--require for their planning, implementation and evaluation a qualitatively different set of concepts, methods, and procedures. They are not merely the sum of the parts making up numerous applications of the same health education messages and objectives in various organizations or communities. This review of theory, research and the experience of national and community-based studies in mass media and community development for health, family planning and cardiovascular risk reduction identifies some distinctions between micro- and macrointerventions, as well as between the uses of mass media in commercial marketing and those in health promotion.

Seven dilemmas of evaluation and measurement posed by the nature of health education are presented, together with suggestions for their resolution. These include the dilemmas of : 1) rigor of experimental design vs significance or program adaptability; 2) internal validity or "true" effectiveness vs external validity or feasibility; 3) experimental vs placebo effectsl 4) effectiveness vs economy of scale; 5) risk vs payoff; 6) measurement of long-term vs short-term out-comon. Emphasis is placed on the need to develop a more cumulative data base through standardization of measures, replication of experiments in different settings, and better documentation, reporting, and diffusion of experiences in practice.

Nine population education workshops were held for city school teachers in Baltimore, Maryland during the 1972-73 academic year. The original program schedule was modified two times, at the end of the third workshop and the sixth. Each change resulted in fewer formal presentations, more teacher discussions and greater teacher involvement in the workshop program. From the ideas generated by the workshops, curriculum units suitable for elementary and secondary school students were produced. An evaluation of the program showed that teachers' knowledge of selected demographic concepts and facts increased between the pre-workshop period and the post-workshop period. The changes were greater in the later workshops. The changes in knowledge were statistically significant. While there was some regression to pre-test levels, the teachers retained a substantiol portion of the knowledge they received when measured a second time after the workshop. High school teachers showed greater effective changes in knowledge than lower grade teachers. However, interest in population education appears to be wide-spread among all teachers including lower grade teachers. It is suggested that in the future, programs in population education consider conducting separate workshops for teachers of the same or similar grade level.

Sustaining patient motivation for long-term adherence to drug therapies remains a substantial problem for physicians, other health care providers, the patients themselves, and their families. Other therapeutic requests such as dietary changes and weight control may be even more difficult to maintain than taking pills. As part of a controlled experimental design implemented in an outpatient teaching hospital, an educational program was implemented to improve family member support for medical compliance among hypertensive patients. Family members were interviewed, counseled, and provided with a booklet for the purpose of educating and involving them in the home management of high blood pressure. The booklet identified ways the family member could assist the patient with medication compliance, appointment keeping, as well as diet and weight control. These items were identified and recorded as behavioral objectives in the booklet. Patients were followed for three years to assess long-term outcomes. Results showed a strong statistically significant difference between the experimental and control groups, with the experimental group demonstrating higher levels of appointment-keeping behavior, weight control, and BP under control (all p values less than .001). Analysis of the main effects of the educational program demonstrated that the family member support intervention accounted for the greatest decrease in diastolic blood pressure variability, R2 = .20, p less than .001.

Adherence to the medical regimen continues to rank as a major clinical problem in the management of patients with essential hypertension, as in other conditions treated with drugs and life-style modification. This article reviews the psychometric properties and tests the concurrent and predictive validity of a structured four-item self-reported adherence measure (alpha reliability = 0.61), which can be easily integrated into the medical visit. Items in the scale address barriers to medication-taking and permit the health care provider to reinforce positive adherence behaviors. Data on patient adherence to the medical regimen were collected at the end of a formalized 18-month educational program. Blood pressure measurements were recorded throughout a 3-year follow-up period. Results showed the scale to demonstrate both concurrent and predictive validity with regard to blood pressure control at 2 years and 5 years, respectively. Seventy-five percent of the patients who scored high on the four-item scale at year 2 had their blood pressure under adequate control at year 5, compared with 47% under control at year 5 for those patients scoring low (P less than 0.01).

Studies relating stress and oral pathology have been limited to animal experiments or clinical studies of personality and psychological health that have ignored the role of specific life events. The present study related measurements of life events stress to measurements of periodontal disease. Subjects were fifty male volunteers recruited from a pool of dental patients from the Brooklyn VA Outpatient Dental Clinic. Oral examinations were given to determine the degree of periodontitis and gingivitis. Evidence of other somatic symptomatology was assessed by the somatization subscale of the Brief Symptom Inventory. The degree of life events stress was assessed with the Life Experience Survey. Measurements of life events stress were found to be significantly correlated with measures of periodontal disease. Periodontal disease was more severe and widespread as stressors increased. Subjects were found whose general physical health was unrelated to their life situation.

This article reviews 21 published evaluations of workplace smoking cessation programs. Its purpose is to assess the quality of these evaluations and outline recommendations that may benefit such smoking cessation efforts. Issues that should be considered during the planning and evaluation of these smoking cessation programs include research design, behavior measurement and verification, employee recruitment strategies, nonsmoking behavior maintenance, and ethics.

The future of cancer patient education, extrapolated from its mystified past through the promising recent developments reported elsewhere in this issue, would seem to be bright. Growing financial constraints on medical care in most countries, however, will retard the expansion and strengthening of patient education unless it can demonstrate both its effectiveness and its cost-containing potential. This can be accomplished by (1) emphasizing the potential benefits of patient education beyond the strictly medical; by (2) evaluating the effectiveness of patient education in achieving those benefits; and by (3) developing triage and step-by-step approaches to allocating scarce educational resources to the patients who will benefit most from them.