School Component: Early Heart Attack Care Program Development and Evaluation
Helen Stemler, PhD, CHESCurriculum Coordinator
Bermuda Ministry of Education
Hamilton, Bermuda
Quick Overview
A review of the Comprehensive School Health literature indicates that the rationale for utilizing schools as sites to implement community-based approaches to prevention and early intervention initiatives is based on at least four criteria: (1) prevention and early intervention efforts are cost-effective; (2) education and health are interrelated; (3) a more comprehensive approach to health education is needed; and (4) health promotion should be centered in and around schools (see Table 1).
A Comprehensive School Health Program (CSHP) is designed to utilize the
school as a center for community health initiatives that focus on the prevention
and early intervention of identified risk factors associated with the health
status of our children and youth. It also recognizes the role that school
health can potentially play in healthcare reform. Our vision in school health
is to create a system that contributes to the attainment of at least one
third of the nation's health objectives and all of its education objectives.
Among the numerous goals in the 1991 edition of Healthy People 2000: National
Health Promotion and Disease Prevention Objectives, (1) the two overriding
ones relative to everyone interested in supporting an Early Heart Attack
Care (EHAC) strategy are that by the year 2000 we should (1) increase to
75% the proportion of the nation's schools that provide planned and sequential
quality health education, and (2) have a definitive heart attack prevention
strategy in use in the community setting. Basic to this health education
is a foundation of knowledge about the interrelationship of behavior and
health, interactions within the human body, and the prevention of diseases
and other health problems. (2) For children and youth, and the future of
our nation, education and health must be seen as interdependent systems.
If EHAC's goal is to have a chest pain center in every U.S. hospital, in
order to provide the penetration and hospital connection necessary to reach
patients with acute myocardial infarction (AMI) and acute myocardial ischemia
early enough to intervene, school-based EHAC programs, which can reach a
vast segment of the public, are critical. These programs can teach individuals
to behave differently and to present with earlier symptoms. (3)
Beginning in 1990, a school-based EHAC program was developed, implemented,
and evaluated in Maryland and is currently being replicated in several states
and in Bermuda. The EHAC program was offered during required health education
classes of approximately 45 minutes in length and instructed by certified
health educators. This initiative was designed to discuss other risk factors
of heart attacks, and provided numerous opportunities for young people to
practice assertiveness, persistence, and communication skills. Additionally,
schools were encouraged to provide employee-wellness and PTA (parent/families)
EHAC programs to adults. (4)
Background
During the 1990-1991 school year, a 2-day EHAC mini-unit of instruction
was designed and implemented in the Howard County Public School System,
Maryland. This EHAC program was sponsored under a formal school/business
partnership with The Paul Dudley White Coronary Care System, St. Agnes HealthCare.
In cooperation, staff from St. Agnes HealthCare and the school systems Office
of Health Education organized materials and teacher training, and requested
teachers to implement this new initiative as part of middle school curriculum
implementation linking disease prevention and control concepts with first
responder issues in emergency medical services units. Whereas it was felt
that this program could be successfully implemented with a wide age range
of young people or adults, the school system chose the seventh grade (age,
12 years) as a time when students would be developmentally ready for this
instruction and this initiative would support existing health education
curriculum. During the first 2 years of implementation, teacher observation
and feedback were positive; however, a need to redesign the EHAC unit of
instruction from a 2- to a 5-day period was identified. Once redesigned,
a need to assess the program's effectiveness was recognized.
Evaluation
Overview
The evaluation of student achievement used a pretest-posttest two-group design of knowledge, attitudes, and skill-related items (product evaluation). All seventh graders (N=321) receiving EHAC instruction during the third or fourth quarter of the 1992-1993 school year in two divergent middle schools completed the instruments and were encouraged to communicate EHAC principles to their parents/families and request that their parents/families return the EHAC Parent/Family Appraisal Form. Additionally, teachers and administrators involved in the EHAC program were requested to provide feedback about EHAC program's implementation. The two middle schools were selected because of teacher interest and involvement in EHAC curriculum development and differences in their locations (one urban, the other more suburban). (5)Methodology
Five assessment instruments were used in this descriptive evaluation study of the Howard County Public School System's EHAC program for middle school students. Process evaluation was achieved through utilizing four instruments providing program appraisal feedback from students, teachers, administrators, and parents/families. Product evaluation of student learning outcomes utilized a three-part student learning outcomes instrument: a 10-item inventory assessing knowledge, a 14-item skills inventory, and a measuring scale rating students' attitudes about the value of the EHAC program and the citizen's role as a first responder. For the nine items of knowledge related to student learning outcome variables, results were transformed into a percentage of attainable points. Rating scales on a one-to-three basis were tabulated into scores for the 14-skill outcome variables and on a one-to-four basis for the two attitudinal outcome variables. Frequencies were tabulated and narrative comments were listed in the four process evaluation instruments.
Quick Overview
Findings
The EHAC unit of instruction was evaluated on the basis of seven factors considered important in the quality of such programs. On all seven of the criteria employed, the program was strong. On none was it judged average or weak. The results of the descriptive evaluation showed an overall 22-percentage point gain in knowledge, a 24-percentage point increase in skills, and a 34-percentage point improvement in attitudes. All students in both treatment and control (delayed treatment) classes completed the assessment of student achievement. Eighty-nine percent of students indicated that they told their parents or guardians about the importance of EHAC principles as learned in class. In terms of process evaluation, a strong degree of satisfaction with program implementation surfaced. Among the reported perceptions about the EHAC program of instruction, the following comments are a sampling of feedback from appraisals by students, teachers, administrators, and parents.
Students' perceptions:
"My grandmother had a heart attack last month; all schools should teach about this!"
"How do they treat patients who get help early and those who don't?"
"What does a chest pain center in an emergency department look like?"
"Can we have speakers who used a chest pain center and survived a heart attack tell us about their experience?"
Teachers' perceptions:
"Students stayed after class to relate personal stories of meaningful family discussions about early heart attack care."
"Students demonstrated a lot of interest in the lessons."
"Whereas students showed significant improvements in knowledge, skills, and attitudes, concepts are still somewhat abstract; the production of more multicultural visual aids could improve instruction."
"When feedback was received, parents indicated extreme appreciation of and support for this program."
Administrators' Perceptions:
"Administratively, I value this program for my staff and students. The written curriculum was specific and used a variety of teaching strategies."
"As part of our employee-wellness activities, our staff appreciated learning about EHAC. Thanks!"
"The program was well organized and provided a positive learning experience for students."
"I'm delighted that my school had the Governor and Dr. Bahr come in person to 'deputize' the students . . . It made the initiation of this program in our community very visible."
Parents' perceptions:
"I never really took the time to talk to my son about early intervention; this created an opportunity for intergenerational communication that was very meaningful among my mother, myself, and my son. He now wants his cholesterol level checked too."
"My daughter sat me down and taught me everything she learned in class during the last few days. She was very serious, not silly and giddy as she and her friends tend to be at this age. I was impressed with her new knowledge and caring attitude about being a 'deputy' in the battle against premature death and disability from heart attacks."
"My son liked learning about early heart attack care and tested his older brother's and my knowledge about it. He knew more than we did."
Recommendations
Program recommendations were made to:1. Investigate opportunities to increase the emphasis on home-school linkages; involvement of parents/families in their children's education should be expanded.
2. Continue implementation of the EHAC program unit of instruction at the middle school level and design new initiatives that could be used 2 years later at the high school level and also in required college health education classes as reinforcement and review. Continuity and progression in acquiring EHAC-related knowledge, skills, and attitudes would then be provided to millions of early, middle, and older adolescents for a 10-year duration between the ages of 12 and 22.
3. Develop more concrete and multicultural print, nonprint, and electronic EHAC materials of instruction through cooperative school-community hospital partnerships.
4. Provide increased effective education opportunities for students to value early heart attack care.
5. Replicate the study with tighter controls on sampling variables (statistically matched mean achievement and aptitude scores, socioeconomic levels, and other related factors).
6. Continue to use data to monitor the process of ongoing EHAC program improvement.
Quick Overview
Summary and Conclusions
The EHAC program in schools has been viewed as successful since its inception in 1990 and as documented in the 1993 formal evaluation. The perceptions of students, teachers, administrators, and parents/families indicate that support for this program is positive. Substantial gains in the development of EHAC knowledge, skills, and attitudes, as measured by pretest and posttest instruments, indicate that program objectives were accomplished. CHSP's prepare young people to make responsible decisions and establish health practices that last a lifetime. As caring "EHAC deputies," motivated young people can spread the message to their families and neighbors. This pilot program documents this capability. In the study, the data demonstrate the initial sowing of the seeds. In the future, the bond among the home, the school, and the medical community should continue to sustain a unified effort to provide the penetration and hospital connection necessary to provide acute prevention of heart attacks in our communities.Appreciation is extended to the Medtronics Foundation and the Paul Dudley White Coronary Care System, St. Agnes HealthCare for sponsorship of this research.
References
1. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: Public Health Service; 1991. U.S. Dept of Health and Human Services publication PHS 91-50213.
2. Joint Committee on National Health Education Standards (Association for the Advancement of Health Education, American School Health Association and the American Public Health Association). National health education standards: achieving health literacy. American Cancer Society. May 1995:17.
3. Bahr RD. The EHAC strategy: citizens chart course for healthy people in the year 2000. J Cardiovasc Manag. 1995;4:40-43.
4. Bahr RD, Stemler HM. Early heart attack care in Maryland's schools. Maryland Association of Health Physical Education, Recreation and Dance Journal. Spring 1993;23:21-24.
5. Stemler HM. Early Heart Attack Care Program Evaluation: Howard County Public School System, Ellicott City, Maryland, December 1993. Report to the Board of Education and the Medtronics Foundation.
Return to Index of Articles for Clinician;
Volume 14.4
- Faculty Listing 3
- Introduction: Community Message in Acute Myocardial Ischemia 4
- Concept of Community Chest Pain Centers in Emergency Departments 5
- Reawakening Awareness of the Importance of Prodromal Symptoms in the Shifting Paradigm to Early Heart Attack Care (EHAC) 7
- The Role of Emergency Medicine in the Future of American Medical Care: A Summary of the Josiah Macy, Jr, Foundation Conference 12
- From ACC/AHA Guidelines to Best Practice: Can "Acute MI Report Cards" Save Lives?Measuring Quality of Care for Patients With Cardiovascular Disease 16
- Improving Lay Responses to Cardiovascular Emergencies and the Potential of Shifting the Paradigm to Early Heart Attack Care 18
- National Survey of Chest Pain Centers Rationale and Potential Results 21
- Outpatient Rule-Out Myocardial Infarction in Observation Units 22
- Reducing Time to Thrombolytic Treatment 24
- Intervention Programs to Reduce Patient Delays in Acute Myocardial Infarction 29
- Public Education Using the Early Heart Attack Care Program Shawnee Mission Medical Center 31
- School Component: Early Heart Attack Care Program Development and Evaluation 33
- Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction 36
- Precipitating Factors in Acute Cardiovascular Disease 41
- Use of Myocardial Perfusion Imaging in the Emergency Department for Risk Stratification 44
- The Evolution of Chest Pain Centers: The Impact of Technological Advances on the Evaluation of Patients With Possible Acute Ischemic Coronary Syndrome 47
- Critical Pathways for Triage and Treatment of Chest Pain Patients in the Emergency Department 53
- Chest Pain Centers: An Emerging Model for the Emergency Evaluation of Chest Pain and Treatment of Acute Myocardial Infarction 56
- The Key to Success in the Chest Pain Emergency Department: The Observational Role of theNurse 59
- Triage in Moderate Risk Patients With Chest Pain: The Emerging Role of Real-Time Continuous ECG Monitoring 61
- Diffusion of Innovations: The Introduction and Impact of the Chest Pain Emergency
- Department and its Comparison to the Coronary Care Unit Development 64
- Economics of Chest Pain Centers: What Really Matters? 68
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