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UBC Theses and Dissertations

Diet and cardiovascular disease : interrelationships among nutrition attitudes, knowledge, practice,.. Sullivan, Ann Dolores 1980

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DIET AND CARDIOVASCULAR DISEASE: INTERRELATIONSHIPS AMONG NUTRITION ATTITUDES', KNOWLEDGE, PRACTICE, 'AND BIODEMOGRAPHIC CHARACTERISTICS OF ADULT MEMBERS OF COMMUNITY CENTRES b y ANN DOLORES SULLIVAN B . S c , S t . F r a n c i s X a v i e r U n i v e r s i t y , Nova S c o t i a , 1 9 6 4 - B . E d . , S t . Thomas U n i v e r s i t y , New B r u n s w i c k , 1 § 6 6 M . S c , The U n i v e r s i t y o f M a n i t o b a , 1 9 7 1 A DISSERTATION SUBMITTED I N PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR-THE DEGREE OF \ DOCTOR OF PHILOSOPHY " - i n THE D I V I S I O N OF HUMAN NUTRITION SCHOOL OF HOME ECONOMICS We a c c e p t t h i s d i s s e r t a t i o n as c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF B R I T I S H COLUMBIA MAY, 1 9 8 0 © A n n D o l o r e s S u l l i v a n , I 9 8 O In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the require- ments for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y a v a i l - able f o r reference and study. I further agree that permission for extensive copying of th i s thesis f o r scholarly purposes may be granted by the Head of my Department or by his representatives. I t i s understood that copying or publication of t h i s thesis f o r f i n a n c i a l gain s h a l l not be allowed without my written permis- sion. D i v i s i o n of Human Nutrition, School of Home Economics The University of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 ABSTRACT A study was designed to investigate the attitudes, know- ledge, and practice regarding diet and cardiovascular disease (CVD) among adult members attending selected community centres. The relationships among attitudes, knowledge, and practice and the influence of s p e c i f i c biodemographic variables on these three dependent variables were determined. The independent v a r i ables, non-manipulative i n nature, were age, gender, l i v i n g ar- rangement, family history of CVD, personal history of CVD, phys- i c a l exercise pattern, smoking habit, education l e v e l , and obesity r i s k . Data were coll e c t e d by a self-administered ques- tionnaire that had been validated and pretested i n a p i l o t study In May 1979> questionnaires were dis t r i b u t e d by random day to adult members of 11 community centres i n the c i t y of Van- couver. Each centre was represented by a random sample or by volunteers i n attendance at each class on the chosen day. The f i n a l sample size was 281, y i e l d i n g an o v e r a l l response rate of 7^•7%. Data were analyzed by computer and a l l analyses were con- ducted at the .05 l e v e l of si g n i f i c a n c e . Expressed as percent- ages of possible scores, the mean scores f o r the two attitude subtests and t o t a l test were quite high (83%) with standard deviations of 8 to 9%. The mean scores f o r the three knowledge subtests and t o t a l test revealed tests of medium d i f f i c u l t y (48 to 53f°) with standard deviations of 12 to 17%. Practice scores, e x p r e s s e d as r a t i o s o f r e c o m m e n d e d v a l u e s , w e r e e q u a l t o o r e x - c e e d e d t h e C a n a d i a n D i e t a r y S t a n d a r d a n d t h e N u t r i t i o n Recom- m e n d a t i o n s f o r C a n a d i a n s f o r n i n e o f t h e 11 n u t r i e n t s e x a m i n e d ; a l l w e r e g r e a t e r t h a n 67% o f t h e r e c o m m e n d e d v a l u e s . R e l i a b i l i t i e s d e t e r m i n e d b y i n t e r n a l c o n s i s t e n c y , t e s t - r e t e s t , a n d c o n g r u e n c y c h e c k p r o c e d u r e s f o r a t t i t u d e s a n d k n o w - l e d g e , b i o d e m o g r a p h i c , a n d p r a c t i c e i n s t r u m e n t s , r e s p e c t i v e l y , w e r e c o n s i d e r e d a d e q u a t e f o r t h e p u r p o s e o f t h e s t u d y . C o r r e l a t i o n a n a l y s i s r e v e a l e d t h a t a t t i t u d e s a n d k n o w l e d g e w e r e m o d e r a t e l y c o r r e l a t e d ( r a n g e .38 t o .56) b u t p r a c t i c e a n d b o t h a t t i t u d e s a n d k n o w l e d g e w e r e w e a k l y c o r r e l a t e d ( r a n g e .00 t o .2^-). O n e - w a y m u l t i v a r i a t e a n a l y s e s o f v a r i a n c e r e v e a l e d t h a t l i v i n g a r r a n g e m e n t , d e g r e e o f o b e s i t y , a n d p o s i t i v e f a m i l y h i s t o r y o f CVD d i d n o t a p p e a r t o h a v e a n e f f e c t o n a n y o f t h e d e p e n d e n t v a r i a b l e s . S m o k i n g h a b i t was n o t f o u n d t o i n f l u e n c e e i t h e r a t t i t u d e s o r k n o w l e d g e . M u l t i v a r i a t e a n a l y s e s o f v a r i a n c e r e v e a l e d t h a t r e s p o n d e n t s w i t h a p o s i t i v e p e r s o n a l h i s t o r y o f CVD h a d s i g n i f i c a n t l y d i f - f e r e n t a t t i t u d e s t o w a r d t h e use o f d i e t i n p r e v e n t i o n o f CVD a n d p e r f o r m e d s i g n i f i c a n t l y b e t t e r o n t h e s u b t e s t a b o u t t h e a f f e c t o f f o o d s t h a n t h o s e w i t h o u t a p o s i t i v e h i s t o r y . A d u l t s u n d e r 50 y e a r s o f age h a d s i g n i f i c a n t l y more p o s i t i v e a t t i t u d e s t o w a r d t h e r o l e o f d i e t i n h e a r t d i s e a s e a n d s c o r e d s i g n i f i c a n t l y h i g h e r o n s u b t e s t o f f a c t s v e r s u s f a l l a c y t h a n a d u l t s o v e r 50 y e a r s o f a g e . F e m a l e s h a d s i g n i f i c a n t l y more p o s i t i v e a t t i t u d e s a n d p e r f o r m e d s i g n i f i c a n t l y b e t t e r o n a l l k n o w l e d g e s u b t e s t s t h a n m a l e s . The e d u c a t i o n g r o u p w i t h l e s s t h a n g r a d e 12 h a d s i g n i f i c a n t l y l e s s p o s i t i v e a t t i t u d e s t o w a r d t h e r o l e o f d i e t ' i n h e a r t d i s e a s e a n d s i g n i f i c a n t l y l o w e r k n o w l e d g e r e l a t e d t o f o o d c o m p o s i t i o n t h a n a l l o t h e r e d u c a t i o n g r o u p s ; a n d s i g n i f - i c a n t l y l o w e r s c o r e s o n f a c t s v e r s u s f a l l a c y t h a n t h e one t o t h r e e y e a r s u n i v e r s i t y g r o u p . No s i g n i f i c a n t d i f f e r e n c e s i n k n o w l e d g e o r p r a c t i c e w e r e o b s e r v e d b e t w e e n g r o u p s who v a r i e d i n e x e r c i s e p a t t e r n , h o w e v e r , t h e s e d e n t a r y g r o u p h a d s i g n i f i - c a n t l y l e s s p o s i t i v e a t t i t u d e s t o w a r d t h e r o l e o f d i e t i n h e a r t d i s e a s e t h a n t h o s e who w e r e c l a s s i f i e d as h i g h m o d e r a t e o r v i g - o r o u s . W h i l e s i g n i f i c a n t d i f f e r e n c e s i n p r a c t i c e w e r e o b s e r v e d f o r a n u m b e r o f b i o d e m o g r a p h i c v a r i a b l e s , no p a r t i c u l a r g r o u p was c h a r a c t e r i z e d b y a d e f i c i e n t o r e x c e s s i n t a k e o f a n y o f t h e 1 1 n u t r i e n t s e x a m i n e d . S e v e r a l i m p l i c a t i o n s f o r n u t r i t i o n e d u c a t i o n w e r e i n f e r r e d f r o m i n t e r p r e t a t i o n o f r e s u l t s . R e s e a r c h S u p e r v i s o r V TABLE OF CONTENTS Page ABSTRACT 1 1 LIST OF TABLES x ACKNOWLEDGEMENTS x i i i CHAPTER I INTRODUCTION 1 Background to the Problem 1 Statement of the Problem 4 Hypotheses 5 D e f i n i t i o n of Terms 7 Assumptions 10 Organization of the Study 11 II REVIEW OF THE LITERATURE 12 N u t r i t i o n and Cardiovascular Disease (CVD) ... 12 Risk factors 12 Strategies f o r prevention of CVD 13 Dietary recommendations f o r prevention of CVD 16 N u t r i t i o n Attitudes, Knowledge, and Practice . 19 Models f o r the i n t e r a c t i o n of attitudes, knowledge, and practice 20 Research on n u t r i t i o n attitudes, knowledge, and practice 25 Survey Research 40 Questionnaire versus interview 41 Response bias 44 Response format 45 Attitude and knowledge measurement 47 Practice measurement 53 Conclusion 63 v i CHAPTER Page I I I PRELIMINARY AND PILOT TESTING OF INSTRUMENTS . . . . 65 P u r p o s e 65 P r e l i m i n a r y T e s t i n g 65 N u t r i t i o n a t t i t u d e i n s t r u m e n t 66 N u t r i t i o n k n o w l e d g e i n s t r u m e n t 73 B i o d e m o g r a p h i c s e c t i o n 79 N u t r i t i o n p r a c t i c e i n s t r u m e n t 80 P i l o t S t u d y 83 The s a m p l e 83 H y p o t h e s e s 83 D a t a c o l l e c t i o n p r o c e d u r e 84 D a t a a n a l y s i s 85 R e s u l t s a n d d i s c u s s i o n 86 R e v i s i o n s o f t h e I n s t r u m e n t s 97 A t t i t u d e i n s t r u m e n t 97 K n o w l e d g e i n s t r u m e n t 98 B i o d e m o g r a p h i c s e c t i o n 99 P r a c t i c e i n s t r u m e n t 99 I V METHOD 100 I n s t r u m e n t s 100 N u t r i t i o n a t t i t u d e s 100 N u t r i t i o n k n o w l e d g e 101 B i o d e m o g r a p h i c s e c t i o n 101 D i e t a r y p r a c t i c e 102 P o p u l a t i o n 103 Samp le 105 D a t a C o l l e c t i o n P r o c e d u r e s 106 Q u e s t i o n n a i r e d i s t r i b u t i o n 106 I n t e r v i e w s a m p l e 107 D a t a A n a l y s i s 109 P r e p a r a t i o n o f d a t a 109 S c o r i n g 110 S t a t i s t i c a l a n a l y s i s 113 v i i CHAPTER Page V RESULTS AND DISCUSSION 120 I n t r o d u c t i o n 120 R a t e o f R e s p o n s e 121 C o m p a r i s o n o f e a r l y a n d l a t e r e s p o n d e n t s . . 121 P r e l i m i n a r y A n a l y s e s 123 D e s c r i p t i o n o f t h e S a m p l e 129 C h a r a c t e r i s t i c s o f t h e M e a s u r i n g I n s t r u m e n t s . 140 A t t i t u d e s c a l e 140 K n o w l e d g e s c a l e 142 P r a c t i c e i n s t r u m e n t 147 H y p o t h e s e s T e s t i n g 150 R e l a t i o n s h i p s among a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e 150 The r e l a t i o n s h i p o f b i o d e m o g r a p h i c v a r i - a b l e s t o a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e 153 V I SUMMARY AND IMPLICATIONS I 6 3 Summary 163 P u r p o s e I 6 3 P r o c e d u r e 164 A n a l y s i s 165 P s y c h o m e t r i c p r o p e r t i e s o f t h e i n s t r u m e n t s . 165 R e s u l t s 166 L i m i t a t i o n s 170 I m p l i c a t i o n s 171 F u t u r e R e s e a r c h 175 LITERATURE CITED 177 APPENDIX A DATA COLLECTION INSTRUMENTS AND COVER LETTERS . . . 190 A . l . P r e l i m i n a r y Q u e s t i o n n a i r e 191 A . 2 . P i l o t S t u d y Q u e s t i o n n a i r e 199 A . 3 . M a i n R e s e a r c h I n s t r u m e n t 212 v i i i APPENDIX Page B PROCEDURES FOR NUTRITION PRACTICE INTERVIEWS . . . . 225 B . l . P r e l i m i n a r y I n s t r u c t i o n s 226 B . 2 . A n t h r o p o m e t r i c M e a s u r e m e n t s 228 B. 3 . I n t e r v i e w S c h e d u l e 230 C COMMUNITY CENTRE CORRESPONDENCE 237 C l . C o v e r L e t t e r t o R e c r e a t i o n C o o r d i n a t o r . 238 C. 2 . A u t h o r i z a t i o n Fo rm f o r C o m m u n i t y C e n t r e P a r t i c i p a t i o n 239 C. 3 . C o n s e n t F o r m f o r t h e P a r t i c i p a n t s . . . . . . 240 D SCORING PROCEDURE FOR THE PRACTICE INSTRUMENT . . . 2 4 l D . l . P r o c e d u r e 2 ^ 2 D . 2 . C o d i n g I n s t r u c t i o n s f o r A l c o h o l 2^3 D . 3 . C o d i n g I n s t r u c t i o n s f o r U n s p e c i f i e d I t e m s a n d / o r Q u a n t i t i e s 2 ^ 4 E MEAN AND STANDARD D E V I A T I O N FOR EACH ATTITUDE AND KNOWLEDGE SUBTEST AND PRACTICE SCORE BY CENTRE, SEPARATELY AND COMBINED 246 E . I . A t t i t u d e a n d K n o w l e d g e S u b t e s t S c o r e s . . 247 E . 2 . P r a c t i c e R a t i o S c o r e s 249 F ITEM ANALYSIS DATA FOR ATTITUDE SCALE 251 G KNOWLEDGE SCORING SYSTEM 255 G . l . Summary T e s t S t a t i s t i c s f o r A l t e r n a t e S c o r i n g S y s t e m s 256 G. 2 . I t e m A n a l y s i s D a t a f o r 2 , 1 , 0 S c o r i n g S y s t e m 257 H SUMMARY OF DISCRIMINANT ANALYSIS 2 6 l H. l . F o r m a t i o n o f P r a c t i c e G r o u p s 262 H . 2 . R e s u l t s a n d D i s c u s s i o n 264 i x APPENDIX Page I SUMMARY TABLES AND DISCUSSION OF HOMOGENEITY OF VARIANCE-GOVARIANCE FOR EACH BIODEMOGRAPHIC VARIABLE 268 J MEAN AND STANDARD DEVIAT ION FOR EACH ATTITUDE AND KNOWLEDGE SUBTEST AND PRACTICE SCORE BY B I O - DEMOGRAPHIC GROUP 273 J . l . A t t i t u d e a n d K n o w l e d g e S u b t e s t S c o r e s . . 27^ J . 2 . P r a c t i c e R a t i o S c o r e s 277 K SUMMARY TABLES OF MULTIVARIATE AND UNIVARIATE ANALYSES OF VARIANCE FOR EACH BIODEMOGRAPHIC VARIABLE 283 X L I S T OF TABLES TABLE Page 1 S c o r i n g S y s t e m f o r t h e A t t i t u d e I n s t r u m e n t 69 2 A t t i t u d e I n s t r u m e n t : D i s t r i b u t i o n o f J u d g e s ' R a t i n g f o r I t e m R e l e v a n c e t o C o n t e n t D o m a i n . . . 71 3 A g r e e m e n t o f V a l i d a t o r s o n Q u e s t i o n s C o n c e r n i n g C o n t e n t V a l i d a t i o n o f t h e A t t i t u d e I n s t r u - m e n t 72 4 S c o r i n g S y s t e m f o r t h e K n o w l e d g e I n s t r u m e n t 75 5 K n o w l e d g e I n s t r u m e n t : D i s t r i b u t i o n o f J u d g e s ' R a t i n g f o r I t e m R e l e v a n c e t o C o n t e n t D o m a i n . . 77 6 A g r e e m e n t o f V a l i d a t o r s o n Q u e s t i o n s c o n c e r n i n g C o n t e n t V a l i d a t i o n o f t h e - K n o w l e d g e I n s t r u - m e n t a n d t h e Key t o t h e S t a t e m e n t s 78 7 Summary T e s t S t a t i s t i c s f o r t h e A t t i t u d e I n s t r u m e n t 87 8 Mean S c o r e s f o r A t t i t u d e S u b t e s t s b y G r o u p 89 9 One-Way A n a l y s i s o f V a r i a n c e f o r A t t i t u d e S u b - t e s t s a n d T o t a l T e s t 89 10 D i f f e r e n c e s among G r o u p Mean S c o r e s f o r A t t i - t u d e S u b t e s t s 90 11 Summary T e s t S t a t i s t i c s f o r t h e K n o w l e d g e I n s t r u m e n t 93 12 Mean S c o r e s f o r K n o w l e d g e S u b t e s t s b y G r o u p 94 13 One-Way A n a l y s i s o f V a r i a n c e f o r K n o w l e d g e S u b - t e s t s a n d T o t a l T e s t 94 14 D i f f e r e n c e s among G r o u p Mean S c o r e s f o r K n o w l e d g e S u b t e s t s 95 15 D i s t r i b u t i o n o f R e s p o n s e b y C o m m u n i t y C e n t r e , X S e p a r a t e l y a n d C o m b i n e d 122 16 T e s t o f H o m o g e n e i t y o f V a r i a n c e a n d D i f f e r e n c e b e t w e e n Means o n A t t i t u d e , K n o w l e d g e , a n d P r a c t i c e S c o r e s o f E a r l y a n d L a t e R e s p o n d - e n t s 124 x i TABLE Page 17 MANOVA L i k e l i h o o d R a t i o T e s t o f D i f f e r e n c e s among Mean A t t i t u d e , K n o w l e d g e , a n d P r a c t i c e S c o r e s o f C o m m u n i t y C e n t r e s 125 18 B a r t l e t t - B o x H o m o g e n e i t y o f D i s p e r s i o n T e s t among A t t i t u d e s , K n o w l e d g e , a n d P r a c t i c e S c o r e s o f C o m m u n i t y C e n t r e s 125 19 Summary o f C e n t r e A n a l y s e s f o r H o m o g e n e i t y o f V a r i a n c e - C o v a r i a n c e a n d D i f f e r e n c e s among Mean P r a c t i c e S c o r e s 128 20 B i o d e m o g r a p h i c C h a r a c t e r i s t i c s , P e r c e n t i n S a m p l e 130 21 T y p e s a n d F r e q u e n c y o f S u p p l e m e n t 134 22 S o u r c e s o f C a r d i o v a s c u l a r N u t r i t i o n I n f o r m a t i o n R e p o r t e d b y Samp le 135 23 P r a c t i c e C h a r a c t e r i s t i c s o f t h e S a m p l e 138 24 Summary T e s t S t a t i s t i c s f o r t h e A t t i t u d e I n s t r u - m e n t 1 4 1 25 Summary T e s t S t a t i s t i c s f o r t h e K n o w l e d g e I n s t r u m e n t 144 26 P a i r e d t T e s t o f P r a c t i c e S c o r e s f r o m Q u e s t i o n - n a i r e a n d I n t e r v i e w 148 27 P e a r s o n P r o d u c t - M o m e n t C o r r e l a t i o n s b e t w e e n Q u e s t i o n n a i r e a n d I n t e r v i e w R e s p o n s e s t o B i o d e m o g r a p h i c Q u e s t i o n s 149 28 P e a r s o n P r o d u c t - M o m e n t C o r r e l a t i o n s b e t w e e n A t t i t u d e a n d K n o w l e d g e S c o r e s 150 29 P e a r s o n P r o d u c t - M o m e n t C o r r e l a t i o n s b e t w e e n P r a c t i c e a n d A t t i t u d e a n d K n o w l e d g e S c o r e s . . . 152 30 Summary o f t h e B i o d e m o g r a p h i c V a r i a b l e s ' E f f e c t o n A t t i t u d e , K n o w l e d g e , a n d P r a c t i c e S c o r e s . . 159 31 Summary f o r D i s c r i m i n a n t A n a l y s i s o f A t t i t u d e a n d K n o w l e d g e S c o r e s w i t h P r a c t i c e 265 32 Mean S c o r e s a n d P e r c e n t a g e s f o r P r e d i c t o r B a t t e r y among P r a c t i c e L e v e l s 267 33 B a r t l e t t - B o x H o m o g e n e i t y T e s t f o r A t t i t u d e S c o r e s w i t h O b e s i t y R i s k 270 x i i TABLE Page 34 B a r t l e t t - B o x H o m o g e n e i t y o f D i s p e r s i o n T e s t f o r A t t i t u d e , K n o w l e d g e , a n d P r a c t i c e S c o r e s w i t h t h e B i o d e m o g r a p h i c V a r i a b l e s E x e r c i s e P a t t e r n , L e v e l o f E d u c a t i o n , G e n d e r , a n d P e r s o n a l H i s - t o r y o f CVD 272 35 One-Way A n a l y s i s o f V a r i a n c e S t a t i s t i c s f o r A t t i - t u d e , K n o w l e d g e , a n d P r a c t i c e S c o r e s w i t h Age 285 36 One-Way A n a l y s i s o f V a r i a n c e S t a t i s t i c s f o r A t t i t u d e , K n o w l e d g e , a n d P r a c t i c e S c o r e s w i t h G e n d e r 286 37 One-Way A n a l y s i s o f V a r i a n c e S t a t i s t i c s f o r A t t i t u d e , K n o w l e d g e , a n d P r a c t i c e S c o r e s w i t h L i v i n g A r r a n g e m e n t 287 38 One-Way A n a l y s i s o f V a r i a n c e S t a t i s t i c s f o r A t t i t u d e , K n o w l e d g e , a n d P r a c t i c e S c o r e s w i t h F a m i l y H i s t o r y o f CVD 288 39 One-Way A n a l y s i s o f V a r i a n c e S t a t i s t i c s f o r A t t i t u d e , K n o w l e d g e , a n d P r a c t i c e S c o r e s w i t h P e r s o n a l H i s t o r y o f CVD 289 40 One-Way A n a l y s i s o f V a r i a n c e S t a t i s t i c s f o r A t t i t u d e , K n o w l e d g e , a n d P r a c t i c e S c o r e s w i t h P h y s i c a l E x e r c i s e P a t t e r n 290 4 1 One-Way A n a l y s i s o f V a r i a n c e S t a t i s t i c s f o r A t t i t u d e , K n o w l e d g e , a n d P r a c t i c e S c o r e s w i t h O b e s i t y R i s k 291 4 2 One-Way A n a l y s i s o f V a r i a n c e S t a t i s t i c s f o r A t t i t u d e , K n o w l e d g e , a n d P r a c t i c e S c o r e s w i t h L e v e l o f E d u c a t i o n 292 43 One-Way A n a l y s i s o f V a r i a n c e S t a t i s t i c s f o r A t t i t u d e , K n o w l e d g e , a n d P r a c t i c e S c o r e s w i t h S m o k i n g H a b i t 293 x i i i ACKNOWLEDGEMENTS The author expresses sincere gratitude to Dr. Nancy' Schwartz, her major advisor, and Dr. Todd Rogers, a member of the supervisory committee, for t h e i r guidance, encouragement, and generous contribution of expertise and time throughout the period of thi s research and i n preparation of the manuscript. The other members of my committee, Dr. Harriet Kuhnlein and Dr. Indra Desai are g r a t e f u l l y acknowledged fo r t h e i r assistance. Appreciation i s also expressed to Dr. Jean H. Sabry of the University of Guelph f o r serving as external examiner. Special thanks are extended to Jean Pieterinen and Eva Villeneuve f o r conducting the interviews; V i r g i n i a Green and Louis James f o r assistance i n computer programming; Bernice G i l f o y f o r typing this manuscript; and the many students, d i e t i - tians, recreation coordinators, and, i n p a r t i c u l a r , the adult members of the community centres who participated i n the various phases of the study. F i n a l l y , the author wishes to express s p e c i a l gratitude to her family whose encouragement and support made this experience possible. 1 CHAPTER I INTRODUCTION B a c k g r o u n d t o t h e P r o b l e m Few a r e a s o f r e s e a r c h i n c l i n i c a l n u t r i t i o n h a v e r e c e i v e d as much a t t e n t i o n i n r e c e n t y e a r s as t h e r e l a t i o n s h i p o f d i e t t o c a r d i o v a s c u l a r d i s e a s e ( C V D ) . H o w e v e r , l i t t l e c o n c l u s i v e e v i d e n c e h a s r e s u l t e d . I n C a n a d a , CVD i s t h e m a j o r c a u s e o f m o r t a l i t y a n d m o r b i d i t y as w e l l as a m a j o r s o u r c e o f e c o n o m i c d r a i n f r o m l o s s o f p r o d u c t i v i t y ( C a n a d a , 1974a; C a n a d i a n H e a r t F o u n d a t i o n , 1977). These f a c t s , c o m b i n e d w i t h t h e i n c r e a s e d i n c i d e n c e o f p r e m a t u r e h e a r t a t t a c k s among a d u l t s u n d e r 4 0 , have b e e n r e s p o n s i b l e f o r a n i n t e n s i f i c a t i o n o f r e s e a r c h o n e t i o l o g y a n d p r e v e n t i o n o f CVD, i n c l u d i n g t h e r o l e o f d i e t . The f i r s t e v i d e n c e o f a l i n k b e t w e e n h a b i t u a l d i e t a n d CVD was p r o v i d e d b y A n c e l K e y s ( K e y s e t a l . , 1955) who i n t r o d u c e d t h e d i e t a r y f a t h y p o t h e s i s b a s e d i n i t i a l l y o n a c o r r e l a t i o n b e t w e e n CVD a n d a v a i l a b l e f o o d f a t i n s e v e n c o u n t r i e s ( K e y s , 1970). S u b s e q u e n t l y , n u m e r o u s r e s e a r c h e r s (McGandy e t a l . , 1972; Kummerow e t a l . , 1977; T r u s w e l l , 1976; V e r g r o e s e n , 1977; E a t o n , 1978) c o n t r i b u t e d i n f o r m a t i o n o n t h e e f f e c t o f f a t a n d o t h e r n u t r i e n t s o n t h e d e v e l o p m e n t o f CVD w h i c h s u p p o r t e d t h e r e l a t i o n - s h i p o f d i e t t o CVD. H o w e v e r , s e v e r a l y e a r s o f r e s e a r c h h a v e f a i l e d t o p r o v i d e c o n s i s t e n t r e s u l t s o r s u f f i c i e n t e v i d e n c e t o 2 e s t a b l i s h a c a u s a l r e l a t i o n s h i p b e t w e e n a n y s p e c i f i c d i e t a r y f a c t o r a n d CVD. D e s p i t e i n c o n s i s t e n t a n d o f t e n c o n t r o v e r s i a l r e s e a r c h f i n d - i n g s , a n u m b e r o f c o u n t r i e s h a v e a d o p t e d n a t i o n a l d i e t a r y g u i d e - l i n e s f o r p r e v e n t i o n o f h e a r t d i s e a s e . T h e s e r e c o m m e n d a t i o n s f o r d i e t a r y m o d i f i c a t i o n a r e b a s e d u p o n t h e c o n c e p t o f r i s k f a c t o r s a n d k n o w l e d g e o f t h e i n f l u e n c e o f d i e t o n t h e s e f a c t o r s . R i s k f a c t o r s a r e " f a c t o r s ( h a b i t s , t r a i t s o r a b n o r m a l i t i e s ) t h a t a r e a s s o c i a t e d w i t h a n i n c r e a s e d l i k e l i h o o d o f h e a r t a t t a c k " ( K u l l e r , 1976, p . 4 2 5 ) . A l t h o u g h r i s k f a c t o r s may be g e n e t i c o r e n v i r o n m e n t a l , s t r a t e g i e s f o r p r e v e n t i o n o f CVD h a v e f o c u s e d o n t h o s e f a c t o r s t h a t may be c o n t r o l l e d . D i e t a r y g u i d e l i n e s f o r p r e v e n t i o n o f CVD, s u c h as t h e N u t r i t i o n R e c o m m e n d a t i o n s f o r C a n a d i a n s (NRC) ( C a n a d a , 1977)» a r e a i m e d a t r e d u c i n g t w o m a j o r r i s k f a c t o r s , h y p e r l i p i d e m i a a n d h y p e r t e n s i o n , as w e l l as o b e s - i t y . R e l e a s e o f NRC was a c c o m p a n i e d b y a d d i t i o n a l r e c o m m e n d a - t i o n s t o G o v e r n m e n t , A g r i c u l t u r e , a n d I n d u s t r y s t r e s s i n g t h e i m p o r t a n c e o f e s t a b l i s h i n g v i g o r o u s c a m p a i g n s t o p r o m o t e t h e r e c o m m e n d e d d i e t a r y c h a n g e s . T h i s r e q u i r e d t h a t r e s e a r c h be d i r e c t e d a t t h e d e v e l o p m e n t o f t h e m o s t e f f e c t i v e m e t h o d s f o r m a k i n g u s e f u l k n o w l e d g e a v a i l a b l e t o C a n a d i a n s . A c c o m p l i s h m e n t o f t h i s g o a l may be g r e a t l y f a c i l i t a t e d b y p r i o r a s s e s s m e n t o f t h e p o p u l a t i o n ' s c u r r e n t n u t r i t i o n a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e . B a s e d o n r e s u l t s o f s u c h a n a s s e s s m e n t , a p p r o p r i a t e n u t r i t i o n e d u c a t i o n p r o g r a m s may be d e v e l o p e d . A s e a r c h o f t h e l i t e r a t u r e r e v e a l e d a n u m b e r o f s t u d i e s t h a t have assessed a t t i t u d e s , knowledge, and p r a c t i c e r e l a t e d to g e n e r a l n u t r i t i o n but a p a u c i t y of r e s e a r c h r e l a t e d to the assessment of c a r d i o v a s c u l a r n u t r i t i o n a t t i t u d e s , knowledge, and p r a c t i c e . I n a d d i t i o n , few of the data c o l l e c t i o n i n s t r u - ments developed to measure these three v a r i a b l e s have been empir- i c a l l y and c r i t i c a l l y assessed f o r v a l i d i t y and r e l i a b i l i t y . T h i s f i n d i n g i n d i c a t e d a need to develop sound instruments f o r measuring n u t r i t i o n a t t i t u d e s , knowledge, and p r a c t i c e so t h a t n u t r i t i o n e d u c a t i o n programs co u l d be planned, based upon ac- c u r a t e b a s e l i n e i n f o r m a t i o n . Once the data are a v a i l a b l e , i n v e s t i g a t i o n of r e l a t i o n s h i p s among n u t r i t i o n a t t i t u d e s , knowledge, and p r a c t i c e i s r e q u i r e d , s i n c e the development of an e f f e c t i v e n u t r i t i o n e d u c a t i o n s t r a t - egy assumes a p a r t i c u l a r sequence of events- p r i o r to the adop- t i o n of a b e h a v i o u r a l change such as d i e t a r y p r a c t i c e . The t r a d i t i o n a l l y accepted model, the KAP or c o n s i s t e n c y model, pree 1- d i e t e d that knowledge would be f o l l o w e d by change i n a t t i t u d e which would l e a d to change i n behaviour (Swanson, 1972). T h i s a l l e g e d sequence of change has been s e r i o u s l y c o n t r a d i c t e d by r e s e a r c h f i n d i n g s . As a r e s u l t , s e v e r a l a l t e r n a t e models have been proposed to e x p l a i n the i n t e r r e l a t i o n s h i p s among a t t i t u d e s , knowledge, and p r a c t i c e which, a c c o r d i n g to McGuire ( 1 967 ) 1 are complimentary t o , r a t h e r than mutually e x c l u s i v e of, one another. Researchers have attempted to r e s o l v e these c o g n i t i v e i n - c o n s i s t e n c i e s and to p r e d i c t how i n c o n s i s t e n c y r e d u c t i o n might occur. One outcome ( F i s h b e i n , I967) i n d i c a t e d t h a t behaviour 4 i s a f u n c t i o n o f many v a r i a b l e s i n c l u d i n g : s i t u a t i o n a l v a r i a b l e s , n o r m s , a n d m o t i v a t i o n as w e l l as a t t i t u d e ; a n d t h a t a n y f a c t o r w h i c h i n f l u e n c e d one o r m o r e o f t h e s e d i r e c t d e t e r m i n a n t s was a l s o a n i m p o r t a n t , a l b e i t i n d i r e c t d e t e r m i n a n t . The p r a c t i c a l a p p l i c a b i l i t y o f t h e s e f i n d i n g s t o t h e c o m - p r e h e n s i o n o f how h e a l t h y b e h a v i o u r m i g h t be p r o m o t e d i s o b s c u r e . C l e a r l y , k n o w l e d g e i s a n e c e s s a r y f a c t o r i n t h e t o t a l p r o c e s s b u t i t may n o t be t h e d e t e r m i n i n g f a c t o r i n b e h a v i o u r a l c h a n g e . I n - d e e d , a c o n s i d e r a b l e a m o u n t o f v a r i a t i o n m i g h t be e x p e c t e d i n t h e r e l a t i o n s h i p b e t w e e n d i f f e r e n t f a c t o r s ( a t t i t u d e s , k n o w - l e d g e , o r b i o d e m o g r a p h i c c h a r a c t e r i s t i c s ) a n d b e h a v i o u r . W h i l e i t i s i m p o r t a n t t o d e l i n e a t e t h e m o d e l t h a t b e s t r e p - r e s e n t s t h e o b s e r v e d r e s u l t s , i d e n t i f i c a t i o n o f t h e s p e c i f i c f a c t o r s r e s p o n s i b l e f o r t h e d i e t a r y p r a c t i c e i s p a r a m o u n t . R e c - o g n i t i o n o f m i s c o n c e p t i o n s a n d i n a d e q u a c i e s i n k n o w l e d g e r e l a t e d t o d i e t a n d CVD, n e g a t i v e a t t i t u d e s t h a t m i g h t i n t e r f e r e w i t h a d e s i r a b l e c h a n g e , a n d b i o d e m o g r a p h i c s u b g r o u p s o f t h e p o p u l a t i o n t h a t r e q u i r e s p e c i a l a t t e n t i o n , w o u l d p r o v i d e t h e f o u n d a t i o n o n w h i c h t o b u i l d a p p r o p r i a t e c a r d i o v a s c u l a r n u t r i t i o n e d u c a t i o n p r o g r a m s . S t a t e m e n t o f t h e P r o b l e m A n a n a l y t i c a l s u r v e y was c o n d u c t e d t o d e t e r m i n e i n t e r r e - l a t i o n s h i p s among c a r d i o v a s c u l a r n u t r i t i o n a t t i t u d e s , k n o w l e d g e , p r a c t i c e , a n d b i o d e m o g r a p h i c c h a r a c t e r i s t i c s . D a t a w e r e c o l - l e c t e d among a d u l t members o f c o m m u n i t y c e n t r e s t o a d d r e s s t h e 5 f o l l o w i n g q u e s t i o n s : 1. What are c u r r e n t a t t i t u d e s , knowledge, and p r a c t i c e r e l a t e d to d i e t and CVD? 2. What i s the nature of the r e l a t i o n s h i p s among a t t i - tudes, knowledge, and p r a c t i c e ? 3. Is there a s i g n i f i c a n t d i f f e r e n c e i n n u t r i t i o n a t t i - tudes, knowledge, and p r a c t i c e among groups d e f i n e d i n terms of the f o l l o w i n g biodemographic v a r i a b l e s : (a) age gender (c) l i v i n g arrangement (d) f a m i l y h i s t o r y of CVD (e) p e r s o n a l h i s t o r y of CVD (f) p h y s i c a l e x e r c i s e p a t t e r n (g) smoking h a b i t (h) e d u c a t i o n l e v e l , and ( i ) o b e s i t y r i s k ? Hypotheses Based on review of the l i t e r a t u r e , i t was p o s t u l a t e d t h a t there would be a s i g n i f i c a n t r e l a t i o n s h i p among a t t i t u d e , know- ledge, and p r a c t i c e s c o r e s o f a d u l t s . Consequently, the f o l l o w - i n g t hree n u l l hypotheses were t e s t e d among a d u l t s a t t e n d i n g community c e n t r e s : There i s no s i g n i f i c a n t c o r r e l a t i o n 6 1. b e t w e e n a t t i t u d e a n d k n o w l e d g e s c o r e s , 2 . b e t w e e n a t t i t u d e a n d p r a c t i c e s c o r e s , a n d 3. b e t w e e n k n o w l e d g e a n d p r a c t i c e s c o r e s . G i v e n s i g n i f i c a n t r e l a t i o n s h i p s w e r e f o u n d among t h e t h r e e v a r i a b l e s , i t was h y p o t h e s i z e d t h a t one o f t h e f o l l o w i n g t w o p l a u s i b l e c a u s a l m o d e l s w o u l d a c c o u n t f o r t h e o b s e r v e d r e l a t i o n s : 1, K n o w l e d g e " c a u s e s " a t t i t u d e s w h i c h l e a d t o p r a c t i c e . 2 . A t t i t u d e s " c a u s e " k n o w l e d g e w h i c h l e a d s t o p r a c t i c e . A t h i r d s e t o f h y p o t h e s e s was e x a m i n e d i n w h i c h a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e o f v a r i o u s s u b g r o u p s w e r e c o m p a r e d : 1. T h e r e a r e no s i g n i f i c a n t d i f f e r e n c e s i n mean a t t i t u d e , k n o w l e d g e , a n d p r a c t i c e s c o r e s among y o u n g , m i d - , o r o l d - a g e d a d u l t s . 2 . T h e r e a r e no s i g n i f i c a n t d i f f e r e n c e s i n mean a t t i t u d e , k n o w l e d g e , a n d p r a c t i c e s c o r e s b e t w e e n m a l e a n d f e m a l e a d u l t s . 3. T h e r e a r e no s i g n i f i c a n t d i f f e r e n c e s i n mean a t t i t u d e , k n o w l e d g e , a n d p r a c t i c e s c o r e s b e t w e e n a d u l t s who l i v e w i t h f a m i l y a n d t h o s e who do n o t . 4 . T h e r e a r e no s i g n i f i c a n t d i f f e r e n c e s i n mean a t t i t u d e , k n o w l e d g e , a n d p r a c t i c e s c o r e s b e t w e e n a d u l t s who h a v e a p o s i t i v e f a m i l y h i s t o r y o f CVD a n d t h o s e who do n o t . 7 5. There are no s i g n i f i c a n t differences i n mean attitude, knowledge, and practice scores between adults who have a positive personal history of CVD and those who do not. 6. There are no s i g n i f i c a n t differences i n mean attitude, knowledge, and practice scores between adults who follow sedentary, low moderate, high moderate, or vigorous physical exercise patterns. 7 . There are no s i g n i f i c a n t differences i n mean attitude, knowledge, and practice scores among adults who are non- smokers, past smokers, l i g h t smokers, moderate smokers, heavy smokers, or very heavy smokers. 8 . There are no s i g n i f i c a n t differences i n mean attitude, knowledge, and practice scores among adults who have less than grade 12 , grade 12 , one to three years uni- v e r s i t y , or four or more years university education. 9 . There are no s i g n i f i c a n t differences i n mean attitude, knowledge, and practice scores among adults who are at low, moderate, or high r i s k f o r obesity. D e f i n i t i o n of Terms The following terms were operationally defined f o r the pur- pose of t h i s study: Adults: members of community centres who were 19 years of age or older. P a r t i c i p a n t s : a d u l t members o f c o m m u n i t y c e n t r e s who w e r e r e g i s t e r e d f o r p r o g r a m s o f f e r e d d u r i n g t h e S p r i n g 1979 s e s s i o n a n d who a g r e e d t o p a r t i c i p a t e i n t h e s t u d y . C o m m u n i t y c e n t r e : t h e 11 c o m m u n i t y c e n t r e s i n t h e c i t y o f V a n c o u v e r t h a t a g r e e d t o p a r t i c i p a t e a n d t h a t f u l f i l l e d t h e c r i t e r i a f o r i n c l u s i o n i n t h e s t u d y ( s e e p .104). A c o m m u n i t y c e n t r e i s a m u l t i - p u r p o s e n e i g h b o u r h o o d f a c i l i t y o p e r a t e d b y t h e V a n c o u v e r P a r k B o a r d t o p r o - v i d e s p a c e f o r c u l t u r a l , s p o r t s , e d u c a t i o n a l , p h y s i c a l f i t n e s s , a n d s o c i a l a c t i v i t i e s ( V a n c o u v e r , 1977)• N u t r i t i o n a t t i t u d e s : p a r t i c i p a n t ' s o p i n i o n s o f t h e i m p o r t a n c e o f d i e t i n CVD as m e a s u r e d b y s c o r e s r e f l e c t i n g r e - s p o n s e s t o t h e a t t i t u d e i n s t r u m e n t ( s c a l e ) d e v e l o p e d f o r t h i s s t u d y . N u t r i t i o n k n o w l e d g e : p a r t i c i p a n t ' s c o m p r e h e n s i o n o f b a s i c c o n - c e p t s o f d i e t a n d CVD a s m e a s u r e d b y s c o r e s o b t a i n e d o n t h e k n o w l e d g e t e s t ( s c a l e ) d e v e l o p e d f o r t h i s s t u d y . N u t r i t i o n - p r a c t i c e : p a r t i c i p a n t ' s u s u a l d i e t a r y i n t a k e as m e a s u r e d b y s c o r e s o b t a i n e d i n t h r e e s t e p s : e s t i m a - t i o n o f u s u a l i n t a k e o f s p e c i f i c f o o d s u s i n g a m o u n t s o r s e r v i n g s i z e s r e p o r t e d i n t h e p r a c t i c e i n s t r u m e n t d e v e l o p e d f o r t h i s s t u d y , c h a n g e t o n u t r i e n t v a l u e s b a s e d o n c o m p u t e r f o o d c o m p o s i t i o n d a t a b a n k , a n d c o n - v e r s i o n t o n u t r i e n t r a t i o s c o r e s b a s e d o n t h e C a n a d i a n D i e t a r y S t a n d a r d ( C a n a d a , 1975a) f o r age a n d g e n d e r , a n d t h e N u t r i t i o n R e c o m m e n d a t i o n f o r C a n a d i a n s ( C a n a d a , 1977)• C a r d i o v a s c u l a r d i s e a s e ( C V D ) : a t h e r o s c l e r o s i s a n d h y p e r t e n s i o n . L i v i n g a r r a n a g e m e n t : one o f t h e f o l l o w i n g modes o f l i v i n g : w i t h f a m i l y , r o o m m a t e ( s ) , c o m m u n a l , a l o n e , o t h e r . F a m i l y h i s t o r y o f CVD: p r i o r h i s t o r y o f h y p e r t e n s i o n , h y p e r - l i p i d e m i a a n d / o r h e a r t a t t a c k b y a n y member o f t h e i m m e d i a t e f a m i l y ( p a r e n t , s i b l i n g , s p o u s e , c h i l d ) . P e r s o n a l h i s t o r y o f CVD: p r i o r t r e a t m e n t f o r one o r more o f t h e f o l l o w i n g c o n d i t i o n s : h y p e r t e n s i o n , h y p e r l i p i d e m i a , h e a r t a t t a c k , a n g i n a , d i a b e t e s . P h y s i c a l e x e r c i s e p a t t e r n : one o f t h e f o u r c a t e g o r i e s d e f i n e d b y t h e H e a l t h H a z a r d A p p r a i s a l M a n u a l ( C a n a d a , 1974b ) : s e d e n t a r y ( w o r k a n d l e i s u r e , u n d e r f i v e f l i g h t s o f s t a i r s o r h a l f a m i l e o f w a l k i n g p e r d a y ) ; l o w m o d e r a t e (some a c t i v i t y w o r k a n d l e i s u r e ; b e t w e e n f i v e a n d 15 f l i g h t s o f s t a i r s o r 0 .5 t o 1.5 m i l e s w a l k i n g o r c o m - p a r a b l e d a i l y e x e r c i s e ) ; h i g h m o d e r a t e ( p r o g r a m m e d e x e r c i s e f o u r t i m e s p e r week o r 1.5 t o t w o m i l e s o f w a l k i n g o r 15 t o 20 f l i g h t s o f s t a i r s o r c o m p a r a b l e d a i l y e x e r c i s e ) ; v i g o r o u s ( g r e a t e r t h a n t h a t o f h i g h m o d e r a t e ) . S m o k i n g h a b i t : one o f s i x c a t e g o r i e s o f r i s k r a n g i n g f r o m l o w t o h i g h : n o n s m o k e r ( n e v e r smoked o r n o t smoked f o r f i v e y e a r s ) ; former smoker (not smoked f o r l e s s than f i v e y e a r s ) ; l i g h t smoker ( c i g a r s or p i p e s only: l e s s than f i v e per day not i n h a l e d ) ; moderate smoker ( c i g a r s or p i p e s only: f i v e or more per day or any amount i n - haled; and c i g a r e t t e s : l e s s than 10 per day); heavy smoker ( c i g a r e t t e s : 10 to 19 per day); very heavy smoker ( c i g a r e t t e s : 20 or more per day). These c a t e - g o r i e s were m o d i f i e d from the H e a l t h Hazard A p p r a i s a l Manual (Canada, 1974b) and the h e a l t h r i s k index (Fam- i l y H e a l t h M e d i c a l Datamation, 1 9 7 8 ) . L e v e l of education: one of f o u r c l a s s i c a l groupings f o r y e a r s of e d u c a t i o n completed: l e s s than grade 12 , grade 12 , one to t h r e e years u n i v e r s i t y , f o u r or more years of u n i v e r s i t y . O b e sity r i s k : low, moderate, or h i g h r i s k a c c o r d i n g to Thomas* nomograph method f o r d i a g n o s i n g o b e s i t y (Thomas et a l . , 1976) and based on body mass index. Body mass index (BMI): r a t i o of weight i n kilograms to h e i g h t i n meters squared (Keys et a l . , 1 9 7 2 ) . Assumptions Assumptions u n d e r l y i n g t h i s study are: 1. P a r t i c i p a n t s i n the study are r e p r e s e n t a t i v e of the a d u l t membership of community centres i n the c i t y of Vancouver. 2. Each q u e s t i o n n a i r e r e c e i v e d from p a r t i c i p a n t s i n t h e s t u d y was completed i n good f a i t h , by the i n d i v i d u a l t o whom i t was d i s t r i b u t e d , w i t h o u t a s s i s t a n c e f rom r e f e r e n c e s o u r c e s o r o t h e r i n d i v i d u a l s . O r g a n i z a t i o n o f the Study T h i s s t u d y b e g i n s w i t h background i n f o r m a t i o n r e l a t i n g t o c a r d i o v a s c u l a r n u t r i t i o n and t h e need f o r r e s e a r c h t o determine c u r r e n t a t t i t u d e s , knowledge, and p r a c t i c e among t h e g e n e r a l p u b l i c . A r e v i e w o f p e r t i n e n t l i t e r a t u r e i s p r e s e n t e d i n Chap- t e r I I . The p i l o t s t u d y , conducted t o e s t a b l i s h r e l i a b i l i t y and v a l i d i t y o f d a t a c o l l e c t i o n i n s t r u m e n t s d e v e l o p e d f o r t h i s r e - s e a r c h , i s summarized i n Chapter I I I . C h apter IV i n c l u d e s a d e s c r i p t i o n of the methodology em- p l o y e d f o r t h i s r e s e a r c h . The r e s u l t s and a d i s c u s s i o n o f t h e major f i n d i n g s a re p r e s e n t e d i n Ch a p t e r V. The s i x t h and f i n a l c h a p t e r , c o n t a i n s a summary o f the s t u d y , l i m i t a t i o n s , and im- p l i c a t i o n s based on i n t e r p r e t a t i o n o f t h e f i n d i n g s . Appendices c o n t a i n m a t e r i a l p e r t i n e n t t o the i n v e s t i g a t i o n and a r e a p p r o p r i a t e l y i d e n t i f i e d i n the s e c t i o n s o f the r e p o r t to w h i c h t h e y a p p l y . 12 CHAPTER I I REVIEW OF THE LITERATURE I n t h e f i r s t s e c t i o n o f t h i s c h a p t e r t h e c u r r e n t p o s i t i o n r e g a r d i n g n u t r i t i o n ' s r o l e i n c a r d i o v a s c u l a r d i s e a s e (CVD) i n - c l u d i n g t h e c o n c e p t o f r i s k f a c t o r s , s t r a t e g i e s f o r p r e v e n t i o n , a n d r e c o m m e n d a t i o n s f o r C a n a d i a n s , i s d i s c u s s e d . The s e c o n d s e c - t i o n e x a m i n e s b o t h t h e t r a d i t i o n a l a n d a l t e r n a t e m o d e l s f o r t h e i n t e r r e l a t i o n s h i p s among a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e as w e l l a s c o n t r i b u t i o n s o f r e s e a r c h o n g e n e r a l a n d c a r d i o v a s c u l a r n u t r i t i o n a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e . The f i n a l s e c t i o n i s a c r i t i q u e o f m e t h o d s f o r a s s e s s i n g a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e i n c l u d i n g i n s t r u m e n t s , p r o c e d u r e s f o r d a t a c o l l e c t i o n , a n d t e c h n i q u e s f o r d e t e r m i n i n g v a l i d i t y a n d r e l i a b i l i t y . N u t r i t i o n a n d C a r d i o v a s c u l a r D i s e a s e (CVD) R i s k F a c t o r s C u r r e n t k n o w l e d g e o f t h e r o l e o f n u t r i t i o n i n CVD has e v o l v e d f r o m e p i d e m i o l o g i c a l , e x p e r i m e n t a l , a n d c l i n i c a l i n - v e s t i g a t i o n s t h a t h a v e e s t a b l i s h e d a n u m b e r o f " r i s k f a c t o r s " a s s o c i a t e d w i t h s u s c e p t i b i l i t y t o CVD ( K e y s e t a l . , 1955; S h e r - w i n , 197^; O l i v e r , I 9 7 6 ) . These r i s k f a c t o r s , d e f i n e d as f a c t o r s a s s o c i a t e d w i t h a n i n c r e a s e d l i k e l i h o o d o f h e a r t a t t a c k ( K u l l e r , 1976), may be g e n e t i c i n o r i g i n o r a c q u i r e d f r o m o n e ' s e n v i r o n m e n t . T h e y h a v e b e e n c l a s s i f i e d as p r i m a r y , i n c l u d i n g h y p e r c h o l e s t e r o l e m i a , h y p e r t e n s i o n , a n d c i g a r e t t e s m o k i n g o r s e c o n d a r y , i n c l u d i n g a g e , g e n d e r , h e r e d i t y , h y p e r t r i g l y c e r i d e m i a , d i a b e t e s m e l l i t u s , p h y s i c a l i n a c t i v i t y , s t r e s s , a n d p e r s o n a l i t y t y p e ( G o t t o e t a l . , 1976; K u l l e r , 1976; B l a c k b u r n , 1 976 ) . B e c a u s e g e n e t i c m a n i p u l a t i o n i s n o t p o s s i b l e a t p r e s e n t , r e - s e a r c h h a s b e e n f o c u s e d o n e n v i r o n m e n t a l l y p r o d u c e d r i s k f a c t o r s t h o u g h t t o be a m e n a b l e t o p r e v e n t i v e a c t i o n s u c h as l i f e s t y l e a n d d i e t a r y m o d i f i c a t i o n . S t r a t e g i e s f o r P r e v e n t i o n o f CVD F u n d a m e n t a l t o t h e c o n c e p t o f p r e v e n t i o n o f CVD i s t h e b e - l i e f t h a t CVD i s n o t a n i n e v i t a b l e c o n s e q u e n c e o f a g i n g o r a f f l u e n c e a n d t h a t i t s d e v e l o p m e n t may be r e t a r d e d o r r e v e r s e d . One a p p r o a c h t o t h e p r e v e n t i o n o r r e v e r s a l o f CVD i s t o i n t e r - v e n e o n r i s k f a c t o r s . Two t y p e s o f i n t e r v e n t i o n t r i a l s f o r CVD have b e e n c o n d u c t e d : p r i m a r y p r e v e n t i o n t r i a l s d e s i g n e d t o p r e v e n t CVD among s u b j e c t s a t h i g h r i s k b u t f r e e o f c l i n i c a l CVD; a n d s e c o n d a r y p r e v e n t i o n t r i a l s d e s i g n e d t o p r e v e n t d e a t h o r r e c u r r i n g h e a r t a t t a c k i n p a t i e n t s w i t h CVD. A l t h o u g h v a l u a b l e i n f o r m a t i o n has r e s u l t e d f r o m b o t h t y p e s o f t r i a l s , s e c o n d a r y p r e v e n t i o n t r i a l s , b y t h e i r v e r y d e f i n i - t i o n , p r o v i d e d l i m i t e d i n f o r m a t i o n r e g a r d i n g t h e f e a s i b i l i t y o f l i f e s t y l e m o d i f i c a t i o n f o r t h e g e n e r a l p u b l i c as a means o f p r e - v e n t i n g CVD. The m a i n t h r u s t o f t h e s e t r i a l s has b e e n t h e r a - p e u t i c u s e o f d i e t w h i c h m i g h t be so s e v e r e l y m o d i f i e d t h a t i t w o u l d n o t be t o l e r a t e d b y o r a d v i s a b l e f o r t h e g e n e r a l p o p u l a - t i o n . A c l a s s i c e x a m p l e o f a p r i m a r y p r e v e n t i o n t r i a l was t h e New Y o r k A n t i - C o r o n a r y C l u b S t u d y d e s i g n e d t o l o w e r b l o o d c h o - l e s t e r o l l e v e l s among a g r o u p o f a d u l t men ( C h r i s t a k i s e t a l . , 1 9 6 6 ) . A c o n t r o l g r o u p m a i n t a i n e d n o r m a l e a t i n g h a b i t s b u t a n e x p e r i m e n t a l g r o u p f o l l o w e d a s t u d y d i e t w i t h 30 -33$ o f t h e t o t a l c a l o r i e s as f a t a n d a p o l y u n s a t u r a t e d f a t t y a c i d (PUFA) t o s a t u r a t e d f a t t y a c i d (SFA) r a t i o o f 1 . 2 5 - 1 . 50 t o 1 . 0 . I f t h e s u b j e c t s w e r e o v e r w e i g h t , t o t a l f a t i n t a k e was r e d u c e d t o 19% a n d e n e r g y , t o 1900 k i l o c a l o r i e s . When n o r m a l w e i g h t was r e a c h - e d , t h e s t u d y d i e t was b e g u n . A t t h e e n d o f s e v e n y e a r s , t h e e x p e r i m e n t a l g r o u p h a d s i g n i f i c a n t l y l o w e r s e r u m l e v e l s a n d a s i g n i f i c a n t l y l o w e r i n c i d e n c e o f CVD, t h u s s u p p o r t i n g t h e r o l e o f d i e t f o r p r i m a r y p r e v e n t i o n o f CVD. S h a p e r (1976) a d v i s e d c a u t i o n i n i n t e r p r e t i n g t h i s d a t a s i n c e t h e c o n t r o l g r o u p was s e l e c t e d t w o y e a r s a f t e r t h e o n s e t o f t h e s t u d y , f r o m a p o p u l a - t i o n o t h e r t h a n t h a t o f t h e e x p e r i m e n t a l g r o u p . A l s o , i n f o r m a - t i o n o n c h a r a c t e r i s t i c s o f l i f e s t y l e s u c h a s p h y s i c a l a c t i v i t y w e r e n o t r e p o r t e d . S i m i l a r f i n d i n g s h a v e b e e n r e p o r t e d b y o t h e r p r i m a r y p r e v e n t i o n t r i a l s t h a t i n v o l v e d v e t e r a n s , m e n t a l p a t i e n t s ( M i e t t i n e n s e t a l . , 1 972 ) , o r i n t e r n a t i o n a l g r o u p s ( M u l t i n a t i o n c o l l a b o r a t i o n s t u d i e s ) . Y e t , s t u d y l i m i t a t i o n s i n c l u d i n g l a c k o f c o n t r o l o v e r s u b j e c t s , i n a b i l i t y t o d e t e r m i n e a l l p e r t i n e n t i n f o r m a t i o n b e c a u s e o f t i m e c o n s i d e r a t i o n s , o r t h e n e c e s s i t y o f u s i n g p a t i e n t s w i t h o u t CVD h a v e r e s u l t e d i n m i n i m a l k n o w l e d g e g a i n s . 15 The a b o v e e x a m p l e s f o c u s e d o n a s i n g l e r i s k f a c t o r . R e c o g - n i z i n g m a n ' s e n v i r o n m e n t i s m u l t i f a c e t e d , i n t e r e s t i n m u l t i - f a c t o r r i s k r e d u c t i o n l e d t o t h e e s t a b l i s h m e n t o f a c o m m u n i t y i n t e r v e n t i o n a p p r o a c h . I n t h e e a r l y 1 9 7 0 ' s , t h r e e t r i a l s d i - r e c t e d t h e i r a t t e n t i o n t o t h e m a j o r r i s k f a c t o r s : c i g a r e t t e s m o k i n g , h i g h s e r u m c h o l e s t e r o l l e v e l , a n d h y p e r t e n s i o n . The S t a n f o r d p r o j e c t a n d t h e F i n l a n d p r o j e c t i n N o r t h K a r e l i a f o c u s - ed o n e n t i r e c o m m u n i t i e s w h i l e t h e m u l t i p l e r i s k f a c t o r i n t e r - v e n t i o n t r i a l ( M R F I T ) c o n c e n t r a t e d i n t e n s i v e e f f o r t s o n h i g h r i s k i n d i v i d u a l s o n l y , c i g a r e t t e s m o k e r s w i t h h y p e r t e n s i o n a n d h i g h s e r u m c h o l e s t e r o l l e v e l s . The S t a n f o r d T h r e e C o m m u n i t y S t u d y u s e d mass m e d i a t o t e a c h s p e c i f i c b e h a v i o u r a l s k i l l s a n d was r e p o r t e d t o l e a d t o f a v o u r a b l e d i e t a r y c h a n g e s i n t h e g e n - e r a l p o p u l a t i o n ( S t e r n e t a l . , 1 9 7 6 ) . I n c o n t r a s t , t h e N o r t h K a r e l i a p r o j e c t o f E a s t e r n F i n l a n d i n t e g r a t e d t h e p r o j e c t o b - j e c t i v e i n t o t h e e x i s t i n g s e r v i c e s t r u c t u r e a n d s o c i a l o r g a n i z a - t i o n o f t h e c o u n t r y . T h i s r e q u i r e d i m p l e m e n t a t i o n o f a s t r a t e g y w h e r e b y w i d e s p r e a d p a r t i c i p a t i o n o f t h e F i n n i s h p e o p l e , t h e i r o r g a n i z a t i o n s , a n d t h e i r i n s t i t u t i o n s w o u l d be i n s u r e d . F i v e y e a r s l a t e r , r e s u l t s i n d i c a t e d s u c c e s s ( B r e s l o w , 1978)• The MRFIT p r o j e c t d i f f e r e d f r o m t h e S t a n f o r d a n d F i n n i s h p r o j e c t s i n t h a t i t f i r s t s e l e c t e d h i g h r i s k i n d i v i d u a l s who w e r e w i l l i n g t o p a r t i c i p a t e i n a s i x y e a r p r o g r a m . H a l f o f t h e g r o u p w e r e f o l l o w e d - u p b y t h e i r u s u a l s o u r c e s o f m e d i c a l c a r e a n d t h e r e m a i n d e r i n t r o d u c e d t o a s p e c i f i c i n t e r v e n t i o n p r o g r a m w i t h i n t e n s i v e g r o u p s e s s i o n s . The g r o u p s e s s i o n s e m p h a s i z e d f a c t u a l e d u c a t i o n , p r i n c i p l e s o f b e h a v i o u r m o d i f i c a t i o n , a n d t h e u s e o f g r o u p p r o c e s s t o f a c i l i t a t e c h a n g e ( B r e s l o w , 1 9 7 8 ) . Once t h e r i s k f a c t o r g o a l s w e r e a c h i e v e d , a m a i n t e n a n c e p r o - g r a m was i n t r o d u c e d . To d a t e , p r e l i m i n a r y r e s u l t s f o r t h e MRFIT p r o j e c t a r e e n c o u r a g i n g b u t c o n c l u s i v e f i n d i n g s p e r t i n e n t t o t h e s t u d y o b j e c t i v e s a w a i t c o m p l e t i o n o f t h e p r o j e c t . The common c o m p o n e n t i n t h e s e t h r e e p r o j e c t s i s t h e c h a n g e i n l i f e s t y l e w i t h p a r t i c u l a r e m p h a s i s o n d i e t . Any d i e t a r y r e c o m m e n d a t i o n t o t h e p u b l i c a i m e d a t r e d u c i n g t h e r i s k o f CVD m u s t be s p e c i f i c , c l e a r , a n d b r i e f ( S h a p e r a n d M a r r , 1 977 ) . The n u t r i t i o n e d u c a t i o n p r o g r a m s h o u l d t r y t o p r o v i d e some l e a d e r s h i p a n d a n s w e r t h e q u e s t i o n s o f how m u c h s u g a r , s a l t , c h o l e s t e r o l , f a t , o r k i n d o f f a t i s d e s i r a b l e i n t h e d i e t ( H e g s t e d , 1 978 ) . The h i g h i n c i d e n c e o f o v e r w e i g h t i n t h e U n i t e d S t a t e s h a s b e e n a t t r i b u t e d t o f a i l u r e o f t h e p u b l i c t o u n d e r s t a n d a n d a p p l y e n e r g y c o n c e p t s ( M c N u t t , 1 9 7 8 ) . A s i m i l a r r e a s o n may e x i s t i n C a n a d a . M c N u t t s u g g e s t e d t h e f a u l t l i e s w i t h p r o g r a m s t h a t move t o o q u i c k l y o v e r b a s i c c o n c e p t s b e c a u s e n u t r i t i o n e d u c a t o r s a r e m i s l e d b y t h e a b i l i t y o f p e o p l e t o d e a l w i t h r a t h e r s o p h i s - t i c a t e d n u t r i t i o n t e r m i n o l o g y a n d h a v e t h u s i n c o r r e c t l y assumed t h a t p e o p l e w e r e e q u a l l y a b l e t o i m p l e m e n t s i m p l e n u t r i t i o n a l c o n c e p t s . D i e t a r y R e c o m m e n d a t i o n s f o r P r e v e n t i o n o f CVD The a c t u a l r o l e o f d i e t i n r e d u c i n g t h e r i s k o f CVD h a s b e e n e x t e n s i v e l y d e b a t e d . Some i n v e s t i g a t o r s ( M a n n , 1977; R e i s e r , 1978; H a r p e r , 1978) f a v o u r e d a b a n d o n m e n t o f t h e c o n c e p t t h a t d i e t a r y m o d i f i c a t i o n w o u l d p r e v e n t o r d e l a y a t h e r o s c l e r o s i s a n d t h e r e s u l t i n g CVD. A s e c o n d g r o u p o f i n v e s t i g a t o r s a r g u e d t h a t r e s e a r c h , w h i l e n o t p r o v i n g a d i r e c t r e l a t i o n s h i p b e t w e e n p l a s m a c h o l e s t e r o l c o n c e n t r a t i o n i n a n i n d i v i d u a l a n d a p a r t i c u l a r n u t r i e n t o r f o o d i n t h e c u r r e n t d i e t , h a d d e m o n s t r a t e d t h e a b i l i t y t o a l t e r p l a s B ma c h o l e s t e r o l c o n c e n t r a t i o n s i n a p r e d i c t a b l e way b y s p e c i f i c c h a n g e s i n d i e t a r y c o m p o s i t i o n ( N a t i o n a l D i e t - H e a r t S t u d y , 1 9 6 8 ) . A l t h o u g h s u g g e s t i v e b u t n o t u n e q u i v o c a l p r o o f e x i s t e d t h a t d i e t a r y m o d i f i c a t i o n w o u l d a m e l i o r a t e o r p r e v e n t CVD i n m a n , t h e s e i n v e s t i g a t o r s ( S h a p e r a n d M a r r , 1977; T r u s w e l l , 1978; G l u e c k a n d C o n n o r , 1978; H e g s t e d , 1978) r e c o m m e n d e d c h a n g e s i n d i e t as a p r e v e n t i v e m e a s u r e t o r e d u c e CVD i n c i d e n c e . E n c o u r a g i n g r e s u l t s h a v e b e e n p r e s e n t e d i n a r e c e n t r e v i e w o f r e s e a r c h i n a t h e r o s c l e r o s i s a n d r i s k f a c t o r s ( G o t t o , 1 9 7 9 ) . R e g r e s s i o n o f CVD h a d b e e n r e p o r t e d i n p i g e o n s , c h i c k e n s , d o g s , a n d n o n - h u m a n p r i m a t e s a n d , i n t h e c a s e o f m a n , p r e l i m i n a r y s t u d y r e s u l t s s u p p o r t e d t h e h y p o t h e s i s t h a t a t h e r o s c l e r o s i s i n man i s r e v e r s i b l e . A r e c e n t p o l l o f i n t e r n a t i o n a l e x p e r t s i n a t h e r o s c l e r o s i s a n d l i p i d s r e v e a l e d a c o n s e n s u s among t h e s e e x p e r t s t h a t s u f - f i c i e n t i n f o r m a t i o n d i d e x i s t u p o n w h i c h t o b a s e d i e t a r y r e c - o m m e n d a t i o n s f o r t h e p u b l i c ( N o r u m , 1 9 7 8 ) . The p o l l a l s o p o i n t e d o u t d i f f e r e n c e s among t h e e x p e r t s i n t e r m s o f p r i o r i t y f o r t h e r e c o m m e n d a t i o n s . D e s p i t e t h e c o n t r o v e r s y a n d t h e many u n a n s w e r e d q u e s t i o n s a b o u t t h e r o l e o f d i e t as a r i s k f a c t o r i n CVD, many W e s t e r n c o u n t r i e s i n c l u d i n g C a n a d a , U n i t e d S t a t e s , W e s t G e r m a n y , t h e N e t h e r l a n d s , S w e d e n , F i n l a n d , A u s t r a l i a , N o r w a y , U n i t e d K i n g d o m a n d New Z e a l a n d h a v e r e c o m m e n d e d d i e t a r y g u i d e l i n e s f o r t h e g e n e r a l p u b l i c ( T r u s w e l l , 1976; U . S . S e n a t e , 1977; U . S . S e n a t e 2nd e d . , 1977; C a n a d a , 1977). N u t r i t i o n r e c o m m e n d a t i o n s f o r C a n a d i a n s I n C a n a d a , a c o m p r e h e n s i v e r e v i e w o f l i t e r a t u r e o n t h e r e l a t i o n s h i p o f d i e t t o CVD was u n d e r t a k e n b y a s p e c i a l e x p e r t c o m m i t t e e a p p o i n t e d b y H e a l t h a n d W e l f a r e C a n a d a i n 1973. The c o m m i t t e e c o n c l u d e d t h a t t h e r e was a d e q u a t e b a s i s f o r recommend i n g some c h a n g e s i n t h e d i e t a r y h a b i t s a n d l i f e s t y l e o f C a n a d i a n s a n d s u b m i t t e d a r e p o r t t o t h e M i n i s t e r o f H e a l t h a n d W e l f a r e i n D e c e m b e r 1976. F o l l o w i n g f u r t h e r c l a r i f i c a t i o n , t h e ammended r e c o m m e n d a t i o n s o f t h i s c o m m i t t e e w e r e a d o p t e d b y t h e D e p a r t m e n t o f N a t i o n a l H e a l t h a n d W e l f a r e i n J u n e 1977 ( C a n a d a , 1977)• I t was s t r e s s e d t h a t t h e r e c o m m e n d a t i o n s w e r e f o r t h e g e n e r a l p u b l i c a n d n o t f o r p a t i e n t s o n t h e r a p e u t i c d i e t s p r e - s c r i b e d b y p h y s i c i a n s , n o r c h i l d r e n u n d e r t w o y e a r s o f a g e . I n s u m m a r y , t h e d i e t a r y r e c o m m e n d a t i o n s w e r e : 1. Consume a n u t r i t i o n a l l y a d e q u a t e d i e t , as o u t l i n e d i n C a n a d a ' s F o o d G u i d e . 2. Reduce c a l o r i e s f r o m f a t t o a maximum o f 35$ o f t o t a l c a l o r i e s . I n c l u d e a s o u r c e o f p o l y u n s a t u r a t e d f a t t y a c i d s ( l i n o l e i c a c i d ) i n t h e d i e t . 3 . Consume a d i e t w h i c h e m p h a s i z e s w h o l e g r a i n p r o d u c t s a n d f r u i t s a n d v e g e t a b l e s , a n d m i n i m i z e s a l c o h o l , s a l t , a n d r e f i n e d s u g a r . 4. P r e v e n t a n d c o n t r o l o b e s i t y b y r e d u c i n g e x c e s s c o n s u m p - t i o n o f c a l o r i e s a n d i n c r e a s i n g p h y s i c a l a c t i v i t y . P r e - c a u t i o n s s h o u l d be t a k e n t h a t no d e f i c i e n c y o f v i t a m i n s a n d m i n e r a l s o c c u r s w h e n t o t a l c a l o r i e s a r e r e d u c e d ( C a n a d a , 1978). The r e l e a s e o f t h e r e c o m m e n d a t i o n s s t i m u l a t e d d i s c u s s i o n r e g a r d i n g t h e m o s t a p p r o p r i a t e m e t h o d s f o r i m p l e m e n t a t i o n a t b o t h p u b l i c a n d p r o f e s s i o n a l l e v e l s . The o u t c o m e was t h e r e a l i z a t i o n t h a t t h e r e c o m m e n d a t i o n s p r o v i d e t h e f o u n d a t i o n f o r g e n e r a l h e a l t h p r o m o t i o n a n d d i s e a s e p r e v e n t i o n o t h e r t h a n j u s t p r e v e n - t i o n o f CVD. S u b s e q u e n t l y , t h e r e c o m m e n d a t i o n s w e r e r e n a m e d N u t r i t i o n R e c o m m e n d a t i o n s f o r C a n a d i a n s ( C a n a d a , 1979b). N u t r i t i o n A t t i t u d e s , K n o w l e d g e , a n d P r a c t i c e I t i s g e n e r a l l y a c c e p t e d t h a t a n e f f e c t i v e n u t r i t i o n e d u c a - t i o n p r o g r a m m u s t a c k n o w l e d g e c u r r e n t l y h e l d c o n c e p t s , b u i l d - i n g u p o n t h o s e t h a t a r e a c c u r a t e a n d c o r r e c t i n g t h o s e t h a t a r e i n e r r o r . Kow t h i s m i g h t be a c h i e v e d m o s t e f f e c t i v e l y r e m a i n s u n c l e a r . One a p p r o a c h h a s b e e n t o e x a m i n e n u t r i t i o n a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e i n c l u d i n g t h e i r i n t e r r e l a t i o n s h i p s . S u c h a n e x a m i n a t i o n o f t h e r e l a t i o n s h i p s among t h e t h r e e v a r i - a b l e s i s e s s e n t i a l s i n c e d e v e l o p m e n t o f a n u t r i t i o n e d u c a t i o n 20 strategy assumes a p a r t i c u l a r sequence of events prior to the adoption of a behavioural change such as dietary practice. Models f o r the Interaction of Attitudes, Knowledge, and Practice The t r a d i t i o n a l l y accepted model, termed the KAP or con- sistency model, predicted that the accumulation or introduction of knowledge would be followed by changes i n attitudes which would lead to changes i n behaviour (Swanson, 1972; Steuart, 1 9 7 5 ) . Past health education programs have confirmed this model with the end point adoption of a p a r t i c u l a r health p r a c t i c e . However, most research findings have f a i l e d to support t h i s alleged sequence of change. Reported inconsistencies with the KAP model have resulted i n several alternatives being proposed to explain the effects of knowledge upon attitudes and practice. Craft (1978) questioned whether improvements i n knowledge or attitudes toward dental health always lead to desirable changes i n preventive dental practices, or whether change i n dental be- haviour could precede improvement i n attitudes and knowledge. Using a sample of general dental p r a c t i t i o n e r s and t h e i r pa- t i e n t s , Craft compared attitudes and reported behaviour to de- si r a b l e preventive dental practice. He had hypothesized that the parental behaviour of dentists acted as a motivation model which was responsible f o r better oral health of t h e i r children, compared to that of t h e i r patients' children. Results showed that the dentists made no cognitive d i s t i n c t i o n i n the importance of dental health f o r patients and family but, i n practice, "behaved i n d i f f e r e n t ways. The dentists, by p r a c t i c i n g stand- ards of o r a l health i n keeping with t h e i r profession, served as "an example" f o r t h e i r children thus providing an adjunct to the routine check up period f o r giving information and know- ledge. Craft proposed that this model supports the p o s s i b i l i t y that behaviour can precede attitudes and knowledge as had been suggested by Steuart (1975) and Rayner ( 1 970 ) . The KAP model was further challenged by a committee of the World Health Organization (WHO, 1 9 7 8 ) . They suggested that the model might be workable f o r certain situations but, i n a s o c i a l - l y and c u l t u r a l l y diverse world characterized by an immense variety of circumstances, i t would be doomed to f a i l u r e unless due consideration was given to a l l intervening forces. The WHO report further emphasized that the ultimate change i n any attitude was not due to knowledge per se but to the re- lated values which would ultimately determine the p r a c t i c e . Young's review (1967) of health education research supported the necessity of considering e x i s t i n g value systems by suggest- ing that e f f e c t i v e information; that i s , knowledge, would only lead to desired practice i f the recommended practice did not c o n f l i c t with one's motives, b e l i e f s , values, or existing s o c i a l group norms. Lack of precise d i r e c t i o n as to how one's health behaviour can be altered has led to numerous studies exploring the a t t i - tude-to-practice r e l a t i o n s h i p . Fishbein (1963) attempted to refine the KAP model by dealing with ways i n which evaluative, mediating responses combined to produce the o v e r a l l a t t i t u d e . 22 He postulated that b e l i e f s led to attitudes which led to prac- t i c e . This extension of the model offered no contradiction to the consistency theory since he defined b e l i e f as "the informa- t i o n a person has about the object" (Fishbein and Ajzen, 1975 , p. 1 2 ) . The source of information does not necessarily imply an education s i t u a t i o n but encompasses a l l external information. Later Fishbein and Ajzen (1975) presented conceptual d i s t i n c t i o n between attitude, b e l i e f , and behavioural intention. These di s - t i n c t i o n s appear to be more important f o r t h e o r e t i c a l discussion of attitudes since the existing methods of measurement generally combine a l l three i n a single attitude score (Gross and Niman, 1 9 7 5 ) . The inconsistencies of reported relationships between a t t i - tudes and practice have been explained as the r e s u l t of f a i l u r e to appreciate attitudes as but one of several variables which influence behaviour (Gross and Niman, 1975)• Previously Wicker (1971) concluded that measured attitudes by themselves were r e l a t i v e l y poor predictors of overt behaviour. However, i f "other variables" were taken into account along with attitudes, he suggested that behaviour might be predicted i n some cases. In 1 9 6 9 , Wicker proposed that several factors could influence the attitude-practice relationship; namely, personal factors, s i t u a t i o n a l f a c t o r s , s o c i a l norms, and role requirements as well as expected consequences. He stressed that most of these factors had not been systematically studied. Fishbein and Ajzen (1975) endeavoured to unify the a t t i t u d e t h e o r i e s b y d e - e m p h a s i z i n g t h e d i s t i n c t i o n b e t w e e n b e h a v i o u r a n d c o n s i s t e n c y t h e o r i e s o f t h e d a y . E a c h t h e o r y was e x a m i n e d i n t e r m s o f t h e r e l a t i o n s among b e l i e f s , a t t i t u d e s , i n t e n t i o n s , a n d b e h a v i o u r . T h e y c o n c l u d e d t h a t t h e c o n s i s t e n c y t h e o r i e s u s i n g t h e c o g n i t i v e a p p r o a c h f o c u s e d o n i n f o r m a t i o n p r o c e s s i n g , l e a d i n g t o a t t i t u d e f o r m a t i o n a n d r e s u l t i n g c h a n g e . I n o t h e r w o r d s , k n o w l e d g e may l e a d t o t h e f o r m a t i o n o f a n a t t i - t u d e o r a c h a n g e i n a n e x i s t i n g a t t i t u d e . F e s t i n g e r ' s 1957 c o g n i t i v e d i s s o n a n c e t h e o r y f o l l o w e d t h i s s c h o o l o f t h o u g h t s i n c e i t d e a l t w i t h t h e e f f e c t s o f i n c o n s i s t e n t b e l i e f s , a n d a t t e m p t s a t r e d u c i n g t h e d i s s o n a n c e w h i c h l e d t o c h a n g e s i n a t t i t u d e o r p r a c t i c e . T h i s i n t e r p r e t a t i o n c o u l d be u s e d t o e x - p l a i n r e p o r t e d i n c o n s i s t e n c i e s i n t h e KAP m o d e l w h i c h s u g g e s t e d t h a t p r a c t i c e p r e l e e d e d a t t i t u d e s .or ' k n o w l e d g e . I f a p a r t l c u - „ l a r p r a c t i c e i s e n f o r c e d a n d l e a d s t o " c o g n i t i v e d i s s o n a n c e " b e c a u s e t h e p r a c t i c e i s n o t c o n s i s t e n t w i t h t h e i n f o r m a t i o n k n o w n o r a t t i t u d e h e l d , t h e p e r s o n ' s m i n d may s h i f t t h e e x i s t - i n g a t t i t u d e t o b r i n g i t more i n l i n e w i t h t h e b e h a v i o u r e x - p r e s s e d . I n t h i s c a s e , i t c o u l d be s t a t e d t h a t t h e p r a c t i c e p r e c e d e d t h e a t t i t u d e . The s e c o n d s c h o o l o f t h o u g h t i s b a s e d o n b e h a v i o u r t h e o r y w h i c h u t i l i z e s t h e s t i m u l u s - r e s p o n s e a p p r o a c h m o s t c h a r a c t e r i s t i c o f v a r i o u s l e a r n i n g t h e o r i e s c o n c e r n i n g a t t i t u d e . I t d i f f e r s f r o m t h e c o n s i s t e n c y t h e o r y i n t h a t i t p o s t u l a t e s a d y n a m i c , r a t h e r t h a n a f o r m a t i v e p r o c e s s . T h a t i s , i t f o c u s e s o n c h a n g e w i t h l i t t l e c o n c e r n f o r f o r m a t i o n o f a t t i t u d e s o r b e l i e f s . Osgood a n d T a n n e n b a u m ' s 1955 c o n g r u i t y t h e o r y e x e m p l i f i e s t h i s viewpoint since i t i s concerned with changes i n attitude or b e l i e f produced by incongruity or lack of agreement between exist i n g attitudes or attitude and p r a c t i c e . The state of i n - congruity leads to evaluation with r e s u l t i n g change i n attitude to achieve congruity. From the previous discussion, i t i s evident that p r a c t i c a l a p p l i c a b i l i t y of these theories to the comprehension of how healthy behaviour might be promoted i s obscure. Clearly know- ledge i s a necessary factor i n the t o t a l process but i t may not be the determining factor i n behavioural change. I f knowledge i s not s u f f i c i e n t i n i t s e l f , i t would seem l o g i c a l that a t t i - tudes must mediate the process of behavioural change. However, evidence suggests that special circumstances such as s o c i a l norms which determine one's behaviour, can produce changes i n attitude as a r e s u l t of the modeling of the behaviour. This viewpoint has been suggested by numerous researchers (Rayner, 1970; Swanson, 1972; Salancik, 1976; Craft, 1978) and may be considered as support for the WHO health education concept that * education should be considered as a process which enlarges one's capacities (perhaps by broadening attitudes, b e l i e f s , intentions, and/or behaviour) as well as one's knowledge (WHO, 1978). This discussion has provided background f o r the succeeding section which w i l l examine the contributions and l i m i t a t i o n s of s p e c i f i c research i n n u t r i t i o n attitudes, knowledge, and prac- t i c e . The "other variable" e f f e c t w i l l be considered with reference to biodemographic f a c t o r s . 25 R e s e a r c h o n N u t r i t i o n A t t i t u d e s , K n o w l e d g e , a n d P r a c t i c e A t t i t u d e s a n d k n o w l e d g e B e c a u s e o f t h e c o n t i n u a l e x p a n s i o n o f n u t r i t i o n , a y o u n g s c i e n c e , b y r e s e a r c h f i n d i n g s , t h e n e c e s s i t y o f p r o v i d i n g n u t r i - t i o n k n o w l e d g e f o r t h e p u b l i c i s n o t i n d i s p u t e . I n d e e d , i t n e c e s s i t a t e s t h e i n t e g r a t i o n o f t h e s e f i n d i n g s w i t h t h e e x i s t i n g c o n c e p t s a n d t h e i r d i s s e m i n a t i o n t o t h e p u b l i c . A m a j o r c o n c e r n among n u t r i t i o n e d u c a t o r s i s t h e a p p a r e n t l a c k o f a p p l i c a t i o n o f n u t r i t i o n k n o w l e d g e g a i n e d f r o m v a r i o u s s o u r c e s ( P o o l t o n , 1972) . I n o r d e r t o e s t a b l i s h t h e r a t i o n a l e f o r n o n - a p p l i c a t i o n o f n u t r i t i o n k n o w l e d g e , a n u m b e r o f s t u d i e s w e r e c o n d u c t e d w h i c h i n v e s t i g a t e d a t t i t u d e s t o w a r d n u t r i t i o n as w e l l as k n o w l e d g e o f n u t r i t i o n . I n 1 9 7 6 , S ims r e p o r t e d r e s u l t s o f a s u r v e y o n k n o w l e d g e a n d a t t i t u d e s o f m o t h e r s o f p r e s c h o o l c h i l d r e n . The d e s i g n u t i l i z e d a c o m b i n a t i o n o f m a i l q u e s t i o n n a i r e a n d p e r s o n a l i n t e r - v i e w . I t was f o u n d t h a t t h e h i g h e s t k n o w l e d g e s c o r e s w e r e a c h i e v e d b y m o t h e r s who f e l t p r o p e r n u t r i t i o n was i m p o r t a n t f o r t h e c h i l d . The a u t h o r s u g g e s t e d t h a t h e r r e s u l t s c o n f i r m e d p r e v i o u s r e s e a r c h w h i c h i n d i c a t e d t h a t a t t i t u d e s e x e r t e d a c o n - s i s t e n t i n f l u e n c e o n n u t r i t i o n k n o w l e d g e s c o r e s . S c h w a r t z ' s (1976) m a i l s u r v e y o f p u b l i c h e a l t h n u r s e s d e t e r - m i n e d t h a t a s i g n i f i c a n t r e l a t i o n s h i p (P < . 0 5 ) e x i s t e d b e t w e e n s c o r e s f o r n u t r i t i o n k n o w l e d g e a n d a t t i t u d e s . S i m i l a r f i n d i n g s (P< . 0 0 1 a n d P<.05» r e s p e c t i v e l y ) w e r e r e p o r t e d f o r f e m a l e 26 a t h l e t e s ( W e r b l o w e t a l . , 1978) a n d e i g h t h g r a d e s t u d e n t s ( T h o m p s o n a n d S c h w a r t z , 1 9 7 7 ) . H o w e v e r , G r o t k o w s k i a n d S ims (1978) r e p o r t e d t h a t n u t r i t i o n k n o w l e d g e o f t h e e l d e r l y was s i g n i f i c a n t l y r e l a t e d t o t h r e e o f f o u r a t t i t u d e s a s s e s s e d (P<-.-05,, 0 . 0 1 , a n d 0 . 0 0 1 , r e s p e c t i v e l y ) . The c o r r e l a t i o n b e t w e e n k n o w l e d g e a n d t h e f o u r t h a t t i t u d e ( v i t a m i n / m i n e r a l s u p p l e m e n t s a r e n e c e s - s a r y ) was r e p o r t e d t o be i n v e r s e ( P e a r s o n " r " , - . 3 0 ) , a l t h o u g h n o t s t a t i s t i c a l l y s i g n i f i c a n t . K n o w l e d g e a n d p r a c t i c e On c o n s i d e r i n g t h e r e l a t i o n s h i p o f k n o w l e d g e a n d p r a c t i c e , v a r y i n g r e s u l t s w e r e f o u n d . A B e i r u t s t u d y ( A l - l s i e t a l . , - 1975) t h a t a s s e s s e d k n o w l e d g e a n d p r a c t i c e among m o t h e r s o f p r e - s c h o o l e r s r e p o r t e d t h a t a l t h o u g h t h e m o t h e r s as a w h o l e w e r e v e r y d e f i c i e n t i n k n o w l e d g e a n d p o o r i n p r a c t i c e r e l a t e d t o i n - f a n t f e e d i n g s , t h e r e l a t i o n s h i p b e t w e e n t h e v a r i a b l e s was s i g - n i f i c a n t ( P < . 0 0 1 ) . The c o r r e l a t i o n b e t w e e n k n o w l e d g e a n d p r a c - t i c e was f o u n d t o be v e r y l o w a n d n o n s i g n i f i c a n t f o r e i g h t h g r a d e s t u d e n t s ( T h o m p s o n a n d S c h w a r t z , 1 977 ) , s i g n i f i c a n t (P<.05) f o r p u b l i c h e a l t h n u r s e s ( S c h w a r t z , 1 9 7 6 ) , l a c t a t i n g women ( r v a l u e s o f .25 t o . 4 1 ) ( S i m s , 1978b ) , a n d a c o m b i n a t i o n i . e . , s i g n i f i c a n t o r n o n s i g n i f i c a n t d e p e n d i n g o n t h e s p e c i f i c f o o d p a t t e r n , f o r f e m a l e a t h l e t e s ( W e r b l o w e t a l . , 1 9 7 8 ) . W e r b l o w ' s g r o u p (1978) r e p o r t e d a s i g n i f i c a n t r e l a t i o n s h i p (P<.05) b e - t w e e n k n o w l e d g e a n d f o o d p a t t e r n s a s s o c i a t e d w i t h t r a i n i n g - w e i g h t c o n t r o l d i e t s a n d p r e - e v e n t - w e i g h t c o n t r o l d i e t s ( r v a l u e s o f . 2 4 a n d .25) b u t no s i g n i f i c a n t c o r r e l a t i o n b e t w e e n k n o w l e d g e a n d t h e r e m a i n i n g f o o d p a t t e r n s a s s e s s e d : g e n e r a l - w e i g h t c o n - t r o l , g e n e r a l - p r e - e v e n t , g e n e r a l - t r a i n i n g , a n d t r a i n i n g - p r e - e v e n t d i e t s . I n a s u r v e y o f t h e e l d e r l y , t h e a s s o c i a t i o n b e - t w e e n k n o w l e d g e a n d n u t r i e n t i n t a k e was r e p o r t e d p o s i t i v e b u t n o t s t a t i s t i c a l l y s i g n i f i c a n t ( G r o t k o w s k i a n d S i m s , 1978) . I n t h i s l a t t e r s t u d y , i t s h o u l d be n o t e d t h a t a t o t a l d i e t s c o r e was n o t d e t e r m i n e d . I n s t e a d , q u a n t i t i e s f o r t e n m a j o r n u t r i e n t s p l u s e n e r g y w e r e c o m p u t e d . A t t i t u d e s a n d p r a c t i c e The r e l a t i o n s h i p b e t w e e n a t t i t u d e s a n d p r a c t i c e p r o v e d t o be m o r e d i v e r s e . S a n j u r (197^0 r e v i e w e d t h r e e s t u d i e s w h i c h e x - a m i n e d t h e e f f e c t o f a t t i t u d e s o n p r a c t i c e . H e r d e f i n i t i o n o f a t t i t u d e s was c u l t u r e - d e p e n d e n t a n d i n c l u d e d b e l i e f s , c u s t o m s , a n d t a b o o s . The s a m p l e s w e r e composed o f m o t h e r s o f L a t i n A m e r i c a n d e s c e n t who l i v e d i n t h r e e e n v i r o n m e n t s : a v e r y s m a l l v i l l a g e i n S o u t h w e s t M e x i c o , a l a r g e u r b a n c e n t r e i n S o u t h A m e r i c a , a n d i n t h e l o w - s o c i o e c o n o m i c a r e a o f E a s t H a r l e m , New Y o r k . The a u t h o r n o t e d t h a t i n a l l t h r e e c a s e s , a number o f f o o d b e l i e f s e x i s t e d w h i c h m i g h t s u g g e s t n e g a t i v e n u t r i t i o n a l i m p l i c a t i o n s . She s t r e s s e d t h a t a n y m o d i f i c a t i o n i n f o o d b e - h a v i o u r m u s t i n v o l v e c h a n g e s t h a t a r e c o m p a t i b l e w i t h e x i s t i n g b e l i e f s a n d a t t i t u d e s . T h i s a p p r o a c h h a d b e e n s u g g e s t e d b y F r a n k l e a n d H e u s s e n - stamm (197^) f o r d e a l i n g w i t h v a r i o u s c o u n t e r c u l t u r e g r o u p s i n W e s t e r n s o c i e t y . The i m p o r t a n c e o f a s k i n g t h e o p i n i o n s o f t h e p e r s o n b e f o r e a t t e m p t i n g t o r e c o m m e n d a c h a n g e i n t h e i r e a t i n g p r a c t i c e was s t r e s s e d w i t h t h e a d m o n i t i o n t h a t " S e n s i t i v i t y t o a n d r e c o g n i t i o n o f t h e e m o t i o n a l s i g n i f i c a n c e o f f o o d o n t h e p a r t o f p r o f e s s i o n a l s . . - . . I t i s c r u c i a l t o u n d e r s t a n d t h e s o c i a l p s y c h o l o g y i n v o l v e d i n t h e use o f t h e s e f o o d s " ( F r a n k l e a n d Heussens tamm, , . 1974, p . 1 6 ) . A s i g n i f i c a n t c o r r e l a t i o n (P< . 0 5 ) b e t w e e n s c o r e s f o r a t t i - t u d e s a n d p r a c t i c e was r e p o r t e d ( S c h w a r t z , 1976; T h o m p s o n a n d S c h w a r t z , 1977) among C a n a d i a n p u b l i c h e a l t h n u r s e s a n d e i g h t h g r a d e s t u d e n t s , b u t no s i g n i f i c a n t a s s o c i a t i o n was f o u n d b e t w e e n a t t i t u d e s a n d p r a c t i c e o f f e m a l e a t h l e t e s ( W e r b l o w e t a l . , 1978); l a c t a t i n g women ( r v a l u e s . 0 3 t o .25) ( S i m s , 19781)) , o r t h e e l d e r l y ( G r o t k o w s k i a n d S i m s , 1978) e x c e p t (P<.05) b e t w e e n c e r - t a i n n u t r i e n t s a n d t w o o f t h e f o u r a t t i t u d e s a s s e s s e d ( r v a l u e s r a n g i n g f r o m . 0 0 t o . 3 8 ) . O t h e r v a r i a b l e e f f e c t o n a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e The r e l a t i o n s h i p b e t w e e n n u t r i t i o n a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e a n d s p e c i f i c v a r i a b l e s was a l s o r e v i e w e d . A g e , g e n d e r , a n d e d u c a t i o n l e v e l h a v e b e e n s h o w n t o i n f l u e n c e a t t i - t u d e s , k n o w l e d g e , a n d p r a c t i c e . R e s e a r c h r e s u l t s s u g g e s t e d t h a t m o t h e r s ' e d u c a t i o n a l l e v e l a p p e a r e d t o a f f e c t t h e i r c h i l - d r e n ' s n u t r i t i o n a l s t a t u s ( A l - l s i e t a l . , 1975)» a t l e a s t w i t h - i n a l o w s o c i o e c o n o m i c c l a s s i n L e b a n o n . A s i g n i f i c a n t d i f - f e r e n c e i n k n o w l e d g e a n d p r a c t i c e s c o r e s b e t w e e n women w i t h f i v e o r l e s s y e a r s o f s c h o o l i n g c o m p a r e d w i t h s e v e n - t o - n i n e y e a r s was r e p o r t e d . H o w e v e r , no s i g n i f i c a n t d i f f e r e n c e was f o u n d among women o f n o , o n e - t o - t h r e e , a n d f i v e y e a r s o f s c h o o l - i n g . I n c o n t r a s t , S h e k e l l e a n d L i u (1978) r e p o r t e d p o o r n u t r i - t i o n k n o w l e d g e r e l a t e d t o CVD among b o t h m a l e s a n d f e m a l e s , 20 t o 59 y e a r s o f a g e , a n d w i t h v a r y i n g e d u c a t i o n b a c k g r o u n d ( f r o m n o t a h i g h s c h o o l g r a d u a t e , t o a h i g h s c h o o l g r a d u a t e , t o a c o l l e g e g r a d u a t e ) . S ims (1976) r e p o r t e d m o t h e r s o f p r e s c h o o l e r s who s c o r e d h i g h e s t i n n u t r i t i o n k n o w l e d g e w e r e f r o m a h i g h e r s o c i o e c o n o m i c l e v e l (SES) t h a n t h o s e who s c o r e d l o w . No age i n f o r m a t i o n was r e p o r t e d b u t o l d e r f a m i l i e s w e r e o b s e r v e d t o be l e s s k n o w l e d g e - a b l e a b o u t n u t r i t i o n . The same h i g h s c o r e r s i n k n o w l e d g e w e r e o b s e r v e d ±0 r a n k h i g h i n t h e a t t i t u d e " n u t r i t i o n i s i m p o r t a n t " . To d e t e r m i n e w h e t h e r age i s a n i n f l u e n c e o n o n e ' s a t t i t u d e s a n d p r a c t i c e , s e v e r a l s t u d i e s w i t h t h e e l d e r l y h a v e b e e n r e p o r t e d . G r o t k o w s k i a n d S ims (1978) f o u n d a p o s i t i v e c o r r e l a t i o n b e t w e e n SES a n d k n o w l e d g e . . - a n d w i t h a t t i t u d e s a n d k n o w l e d g e i n t h i s g r o u p . SES was a l s o p o s i t i v e l y r e l a t e d t o t h e a d e q u a c y o f n u t r i e n t i n - t a k e . The g r o u p was composed o f 77$ f e m a l e s a n d c o m p r i s e d 64 s u b j e c t s i n t o t a l so t h e e f f e c t o f g e n d e r was n o t d e t e r m i n e d . J a l s o e t a l . (I965) h a d p r e v i o u s l y r e p o r t e d t h a t e d u c a t i o n was d i r e c t l y r e l a t e d t o v a l i d n u t r i t i o n o p i n i o n s a n d t h a t p r a c t i c e o b s e r v e d r e f l e c t e d t h e i n f l u e n c e o f a g e , n o t e d u c a t i o n . Cho a n d F r y e r (1974) s t u d i e d n u t r i t i o n k n o w l e d g e o f p h y s i c a l e d u c a - t i o n m a j o r s a t K a n s a s S t a t e U n i v e r s i t y . Women w e r e f o u n d t o s c o r e h i g h e r t h a n men a n d g r a d u a t e s t u d e n t s a t t a i n e d h i g h e r s c o r e s t h a n u n d e r g r a d u a t e s . T h i s s u g g e s t e d a d i f f e r e n c e i n k n o w l e d g e due t o g e n d e r a n d t o e d u c a t i o n l e v e l . 3 0 S o u r c e s o f n u t r i t i o n i n f o r m a t i o n h a v e a l s o b e e n r e p o r t e d t o i n f l u e n c e a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e , h o w e v e r , t h e p a r t i c u l a r s o u r c e o f i n f o r m a t i o n d i f f e r s w i d e l y . Cho a n d F r y e r (1974) r e p o r t e d a p r o g r e s s i v e d e c r e a s e i n n u t r i t i o n k n o w - l e d g e as t h e p r i m a r y s o u r c e o f n u t r i t i o n i n f o r m a t i o n moved f r o m c o l l e g e c o u r s e s , t o h i g h s c h o o l c o u r s e s , t o o t h e r s o u r c e s ( s u c h as d o c t o r ) , t o p a r e n t s , a n d c o a c h e s . A s i g n i f i c a n t d i f f e r e n c e was f o u n d b e t w e e n t h e s c o r e s o f t h o s e who r a n k e d c o l l e g e as t h e p r i m a r y s o u r c e o f i n f o r m a t i o n a n d t h o s e who r a n k e d p a r e n t s a n d c o a c h e s as p r i m a r y s o u r c e s . T h i s s u g g e s t e d t h e c a l i b e r o f t h e i n f o r m a t i o n r e c e i v e d l e d t o h i g h e r s c o r e s . Women a t h l e t e s w e r e a l s o s t u d i e d b y W e r b l o w e t a l . (1978), a n d a g e n e r a l p o s i t i v e i n f l u e n c e o f n u t r i t i o n e d u c a t i o n f r o m h i g h s c h o o l o r c o l l e g e o n k n o w l e d g e a n d a t t i t u d e s was r e p o r t e d . J a l s o e t a l . (1965) d e t e r - m i n e d m a g a z i n e s , n e w s p a p e r s , a n d b o o k s r a n k e d h i g h e s t as s o u r c e s o f n u t r i t i o n i n f o r m a t i o n among homemakers i n t h e i r s t u d y . L a - b e l s ( B r o w n a n d S l o a n , 1978), m a g a z i n e s , n e w s p a p e r s , r a d i o , a n d t e l e v i s i o n t a l k s h o w s , a n d d i e t b o o k s ( M c N u t t , 1978) , h a v e b e e n e a r m a r k e d as s o u r c e s o f n u t r i t i o n i n f o r m a t i o n f o r t h e p u b - l i c . IGndeed, m e d i c a l s t u d e n t s a n d p h y s i c i a n s , l i k e t h e g e n e r a l p u b l i c , w e r e r e p o r t e d t o r e l y o n n o n p r o f e s s i o n a l l i t e r a t u r e f o r t h e i r n u t r i t i o n i n f o r m a t i o n ( P o d e l l e t a l . , 1975a). B e c a u s e , s u r v e y s o f d i f f e r e n t p o p u l a t i o n s h a v e r e p o r t e d t h a t p h y s i c i a n s a r e a m a j o r s o u r c e o f n u t r i t i o n i n f o r m a t i o n ( C o s p e r a n d W a k e f i e l d , 1975; S i m s , 1978a), t h e n e c e s s i t y o f a s s e s s i n g p h y s i c i a n s ' a t t i t u d e s a n d p r a c t i c e i s c l e a r . T h i s e f f e c t o f p h y s i c i a n s ' a t t i t u d e s a n d p r a c t i c e h a d b e e n d e m o n s t r a t e d i n a 31 B r i t i s h C o l u m b i a s t u d y o f m o t h e r s * a t t i t u d e s a n d p r a c t i c e t o - w a r d i n f a n t n u t r i t i o n ( S c h w a r t z a n d B a r r , 1977). I n f o r m a t i o n o b t a i n e d f r o m a s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e a n d a n i n t e r - v i e w i n d i c a t e d t h a t t h e a t t i t u d e s o f t h e s e m o t h e r s p a r a l l e l e d t h e a t t i t u d e s a n d c o u n s e l l i n g p r a c t i c e o f t h e p h y s i c i a n s ( J o h n s t o n a n d S c h w a r t z , 1978), a n d t h a t p h y s i c i a n s w e r e a n i m - p o r t a n t s o u r c e o f i n f o r m a t i o n o n b o t h p r e n a t a l a n d i n f a n t n u t r i t i o n . The n e c e s s i t y o f f o r m a l n u t r i t i o n t r a i n i n g f o r s p e c i f i c p o p u l a t i o n s u b g r o u p s s u c h as p h y s i c i a n s becomes m o r e a p p a r e n t w i t h t h e i n c r e a s i n g i n v o l v e m e n t o f h e a l t h p r o f e s s i o n a l s i n c o u n s e l l i n g p a t i e n t s o n n u t r i t i o n . P o d e l l e t a l . (1975a) a s s e s s - ed t h e c l i n i c a l n u t r i t i o n k n o w l e d g e o f f o u r g r o u p s o f m e d i c a l v o l u n t e e r s composed o f p r a c t i c i n g p h y s i c i a n s , ' i n t e r n i s t s a n d p e d i a t r i c i a n s , t w o t h i r d - y e a r m e d i c a l s t u d e n t g r o u p s , a n d one f o u r t h - y e a r m e d i c a l s t u d e n t g r o u p . The r e p r e s e n t a t i v e n e s s o f t h e p a r t i c i p a n t s was n o t d e t e r m i n e d so d a t a w e r e n o t s t a t i s t i c - a l l y a n a l y z e d . F i n d i n g s o f t h e s u r v e y i n d i c a t e d t h a t k n o w l e d g e o f c l i n i c a l n u t r i t i o n was p o o r f o r a l l f o u r g r o u p s a n d r e m a r k - a b l e v a r i a t i o n s w i t h i n a r e a s o f n u t r i t i o n w e r e o b s e r v e d . V e r y h i g h k n o w l e d g e s c o r e s w e r e a t t a i n e d o n t o p i c s o f c u r r e n t p o p u - l a r i t y i n t h e p r e s s a n d n o n p r o f e s s i o n a l j o u r n a l s s u g g e s t i n g t o t h e a u t h o r s t h a t l e a r n i n g o f n u t r i t i o n was v e r y h a p h a z a r d a n d d e p e n d e n t o n n o n p r o f e s s i o n a l l i t e r a t u r e . R e c e n t l y K r a u s e a n d F o x (1977) s t u d i e d t h e n u t r i t i o n k n o w - l e d g e a n d a t t i t u d e s o f N e b r a s k a p h y s i c i a n s b y a m a i l s u r v e y . No s i g n i f i c a n t r e l a t i o n s h i p was f o u n d b e t w e e n n u t r i t i o n k n o w l e d g e a n d a t t i t u d e s . H o w e v e r , w i t h a 22$ r e s p o n s e r a t e (292 o u t o f 1350 p h y s i c i a n s ) , t h e r e p r e s e n t a t i v e n e s s o f t h e d a t a i s q u e s t i o n a b l e . I n a d d i t i o n , p r e c i s e i n f o r m a t i o n o n t h e d e v e l o p m e n t o f i n s t r u m e n t s , - r e l i a b i l i t y , a n d v a l i d i t y p r o c e d u r e s w e r e n o t r e p o r t e d o t h e r t h a n t o n o t e t h a t t h e b a s i s o f t h e q u e s t i o n n a i r e was t h e r e c o m m e n d a t i o n s o f 20 n u t r i t i o n i s t s a n d d i e t i t i a n s , a n d a s t a t i s t i c i a n who h a d r e v i e w e d t h e i r d r a f t q u e s t i o n n a i r e . P h y s i c i a n s i n B r i t i s h C o l u m b i a w e r e s u r v e y e d b y m a i l r e - g a r d i n g t h e i r o p i n i o n s a n d c o u n s e l l i n g p r a c t i c e i n m a t e r n a l a n d i n f a n t n u t r i t i o n ( J o h n s t o n a n d S c h w a r t z , 1978). C o n t e n t v a l i d i t y o f t h e t e s t i n s t r u m e n t s was d e t e r m i n e d b y a p a n e l o f 16 n u t r i t i o n e x p e r t s i n C a n a d a a n d t h e U n i t e d S t a t e s ( J o h n s t o n , 1975)• The o v e r a l l r e s p o n s e r a t e was 43$ o f a l l p r a c t i c i n g g e n e r a l p r a c t i t i o n e r s , p e d i a t r i c i a n s , a n d o b s t e t r i c i a n s r e g i s - t e r e d w i t h t h e B r i t i s h C o l u m b i a M e d i c a l A s s o c i a t i o n . S i g n i f i - c a n t l y h i g h e r o p i n i o n a n d p r a c t i c e t e s t s c o r e s w e r e o b t a i n e d b y g e n e r a l p r a c t i t i o n e r s who w e r e f e m a l e , h a d a d d i t i o n a l t r a i n i n g , a t t e n d e d c o n t i n u i n g e d u c a t i o n p r o g r a m s , a n d h a d r e c e i v e d n u t r i - t i o n i n s t r u c t i o n d u r i n g m e d i c a l s c h o o l . Those p h y s i c i a n s w i t h more t h a n 10 y e a r s i n p r a c t i c e w e r e f o u n d t o s c o r e s i g n i f i c a n t l y l o w e r (P< . 0 0 1 ) . None o f t h e v a r i a b l e s m e n t i o n e d h a d a c o n s i s t - e n t , s i g n i f i c a n t e f f e c t o n t h e n u t r i t i o n o p i n i o n a n d p r a c t i c e s c o r e s o f o b s t e t r i c i a n s o r p e d i a t r i c i a n s . C o m p a r i s o n w i t h t h e t w o p r e v i o u s l y c i t e d s t u d i e s ( P o d e l l e t a l . , 1975a; K r a u s e a n d F o x , 1977) i s n o t p o s s i b l e as d i f f e r e n t i n s t r u m e n t s , s a m p l e c h a r a c t e r i s t i c s , a n d p r o c e d u r e s w e r e u s e d t o a s s e s s t h e 33 n u t r i t i o n a t t i t u d e s a n d k n o w l e d g e . I n t e r r e l a t i o n s h i p s o f a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e S c h w a r t z (1975) s u r v e y e d a r a n d o m s a m p l e o f 1000 O h i o h i g h s c h o o l g r a d u a t e s t o a s c e r t a i n t h e i r n u t r i t i o n a t t i t u d e s , k n o w - l e d g e , a n d p r a c t i c e , a n d t o d e t e r m i n e t h e n a t u r e o f t h e r e l a t i o n - s h i p o f n u t r i t i o n k n o w l e d g e t o a t t i t u d e s a n d p r a c t i c e a n d t h e i n t e r r e l a t i o n s h i p o f k n o w l e d g e a n d a t t i t u d e s w i t h p r a c t i c e . A m a i l q u e s t i o n n a i r e was e m p l o y e d a n d a 31•3% r e s p o n s e r a t e o b - t a i n e d . The a t t i t u d e a n d k n o w l e d g e i n s t r u m e n t s w e r e a d a p t e d f r o m a p r e v i o u s l y d e v e l o p e d a n d v a l i d a t e d q u e s t i o n n a i r e ( E p p r i g h t e t a l . , 1970) b u t t h e p r a c t i c e i n s t r u m e n t was d e v e l o p e d e s p e c i a l - l y f o r t h i s s t u d y . A s e p a r a t e p h a s e o f t h e s t u d y d e t e r m i n e d a n d c o n f i r m e d c o n t e n t v a l i d i t y a n d r e l i a b i l i t y o f t h e d a t a c o l l e c t i o n i n s t r u m e n t a n d m e t h o d f o r q u a n t i t a t i v e e v a l u a t i o n o f n u t r i t i o n a l p r a c t i c e ( R u d g e , 1973) • The KAP m o d e l d e s c r i b e d p r e v i o u s l y ( s e e p . 2 0 ) was e m p l o y e d b y S c h w a r t z (1975) a n d f o u r p o s s i b l e v a r i a t i o n s o f t h e m u l t i - v a r i a t e i n t e r r e l a t i o n s h i p w e r e c o n s i d e r e d ! KAP m o d e l 1 . K <—» A < — > P KAP m o d e l 2 . KAP m o d e l 3 . KAP m o d e l 4 . S i g n i f i c a n t c o r r e l a t i o n c o e f f i c i e n t s w e r e r e p o r t e d b e t w e e n n u t r i t i o n k n o w l e d g e a n d a t t i t u d e s a n d b e t w e e n n u t r i t i o n a t t i - t u d e s a n d p r a c t i c e b u t t h e c o r r e l a t i o n b e t w e e n n u t r i t i o n k n o w - l e d g e a n d p r a c t i c e was n o n s i g n i f i c a n t . The a u t h o r i n t e r p r e t e d t h i s r e s u l t as s u p p o r t f o r t h e KAP m o d e l 1. (K<H>A <—>P) t o d e s - c r i b e t h e i n t e r r e l a t i o n s h i p o f n u t r i t i o n k n o w l e d g e , a t t i t u d e s , a n d p r a c t i c e o f t h e s e h i g h s c h o o l g r a d u a t e s . I n c o n t r a s t t o S c h w a r t z ' s (1975) c o n c l u s i o n , S ims (1978b) p r o p o s e d k n o w l e d g e as t h e m e d i a t o r b e t w e e n a t t i t u d e s a n d p r a c - t i c e t h u s q u e s t i o n i n g t h e t r a d i t i o n a l s e q u e n c e o f t h e KAP m o d e l . H e r s t u d y p o p u l a t i o n c o n s i s t e d o f 6l l a c t a t i n g women i n I n d i a n a a n d P e n n s y l v a n i a who h a d b e e n s o l i c i t e d t h r o u g h c o n t a c t w i t h t h e l o c a l La L e c h e L e a g u e , b y p e r s o n o r b y f o l l o w - u p o f b i r t h a n - n o u n c e m e n t s i n l o c a l p a p e r s . Q u e s t i o n n a i r e s a n d t h r e e o n e - d a y f o o d r e c o r d s w e r e d i s t r i b u t e d b y m a i l o r i n p e r s o n , w i t h t e l e - p h o n e f o l l o w - u p a n d c l a r i f i c a t i o n o f r e s p o n s e as n e c e s s a r y . The c o e f f i c i e n t s o f r e l i a b i l i t y ( a l p h a ) w e r e .77 f o r t h e n u t r i t i o n k n o w l e d g e i n s t r u m e n t a n d .71 t o .83 f o r t h e f o u r a t t i t u d e s m e a s u r e d . N u t r i e n t d a t a f r o m t h e f o o d r e c o r d s w e r e e x p r e s s e d as p e r c e n t a g e s o f t h e A m e r i c a n r e c o m m e n d e d d i e t a r y a l l o w a n c e ( R D A ) . V a l u e s f o r e n e r g y a n d t e n m a j o r n u t r i e n t s w e r e t h e n f o r m u l a t e d i n t o f o u r g r o u p i n d i c e s : p r o t e i n g r o u p i n d e x , e n e r g y g r o u p i n d e x , d a i r y g r o u p i n d e x , a n d a s c o r b i c a c i d i n d e x . The l a t t e r r e p r e s e n t e d a s i n g l e n u t r i e n t . R e l i a b i l i t y a n a l y s e s o f t h e t h r e e g r o u p i n d i c e s r e s u l t e d i n s c o r e s r a n g i n g f r o m .83 t o .87. U n l i k e t h e p r e v i o u s s t u d y , S ims (1978b) e x p l o r e d t h e u n d e r l y i n g c a u s a l n a t u r e o f t h e r e l a t i o n s h i p s b e t w e e n n u t r i t i o n k n o w l e d g e , a t t i t u d e s , a n d n u t r i e n t i n t a k e u s i n g t h e p a t h a n a l - y s i s t e c h n i q u e . Two m o d e l s w e r e e x a m i n e d : (1) K — » A — > P a n d (2) A — » K >P. The one way a r r o w r e p r e s e n t s t h e c a u s a l r e l a t i o n s h i p b e t w e e n e a c h d e t e r m i n i n g v a r i a b l e a n d e a c h v a r i a b l e d e p e n d e n t o n i t . V a l u e s , t h a t i s , p a t h c o e f f i c i e n t s w e r e c a l c u - l a t e d f o r e a c h c a u s a l a r r o w a n d a n o n s i g n i f i c a n t p a t h c o e f f i - c i e n t r e s u l t e d i n d e l e t i o n o f t h e c a u s a l a r r o w f r o m t h e p a t h a n a l y s i s d i a g r a m . S ims r e p o r t e d a s i g n i f i c a n t c o r r e l a t i o n b e - t w e e n k n o w l e d g e a n d a t t i t u d e s , k n o w l e d g e a n d e d u c a t i o n , a n d k n o w l e d g e a n d e a c h d i e t a r y f a c t o r . O n l y one o f t h e f o u r a t t i - t u d e m e a s u r e s was f o u n d t o be s i g n i f i c a n t l y r e l a t e d t o one o f t h e f o u r n u t r i e n t - i n d i c e s . T h e s e r e p o r t e d c o r r e l a t i o n s among k n o w l e d g e , a t t i t u d e s , a n d p r a c t i c e ( d e f i n e d as n u t r i e n t i n t a k e ) d i f f e r f r o m h e r p r e v i o u s o b s e r v a t i o n o f a l a c k o f s t a t i s t i c a l c o r r e l a t i o n b e t w e e n n u t r i t i o n a l k n o w l e d g e a n d n u t r i e n t i n t a k e s o f t h e e l d e r l y ( G r o t k o w s k i a n d S i m s , 1978). . The r e s u l t s o f t h e p a t h a n a l y s i s t e s t p r o c e d u r e w e r e r e - p o r t e d ( S i m s , 1978b) t o s u p p o r t t h e s e q u e n c e o f A — » K >P (P<.05)« O n l y one a t t i t u d e o u t o f f o u r was f o u n d t o e x e r t a s i g n i f i c a n t e f f e c t f o r i n c l u s i o n i n t h e p a t h a n a l y s i s d i a g r a m . The s e c o n d . m o d e l , K — * A — > P was n o t s u p p o r t e d b y t h e d a t a . C o m p a r i s o n o f t h e r e s u l t s o f t h e s e t w o m a j o r i n v e s t i g a - t i o n s ( S c h w a r t z , 1975; S i m s , 1978b) m u s t be made w i t h c a u t i o n . The u s e o f s p e c i f i c o v e r a l l a t t i t u d e m e a s u r e m e n t s , r a n d o m l y s e l e c t e d v e r s u s j u d g e m e n t a l s a m p l e s , a f o o d f r e q u e n c y c h e c k l i s t o f 17 f o o d s u b g r o u p s e x p r e s s e d as a s i n g l e c u m u l a t i v e s c o r e v e r s u s f o o d r e c o r d d a t a e x p r e s s e d as f o u r n u t r i e n t i n d i c e s , as w e l l as d i f f e r i n g p r o c e d u r e s f o r a d m i n i s t r a t i o n o f t h e i n s t r u - m e n t s a n d a n a l y s i s o f d a t a , l i m i t s t h e l i k e l i h o o d o f m e a n i n g - f u l c o m p a r i s o n s . F u r t h e r e m p i r i c a l t e s t i n g o f t h e KAP m o d e l a n d i t s v a r i a t i o n s w o u l d a p p e a r w a r r a n t e d . C a r d i o v a s c u l a r n u t r i t i o n a t t i t u d e s , k n o w l e d g e , a n d - p r a c t i c e P o d e l l e t a l . ( 1975b, 1978) c o n d u c t e d a t w o - y e a r i n v e s t i - g a t i o n t o e v a l u a t e t h e e f f e c t i v e n e s s o f a c a r d i o v a s c u l a r n u t r i - t i o n e d u c a t i o n p r o g r a m . The s t u d y p o p u l a t i o n was t e n t h g r a d e b i o l o g y s t u d e n t s f r o m t w o s i m i l a r s c h o o l s , d e s i g n a t e d t e s t a n d c o n t r o l . The t e s t g r o u p c o m p l e t e d a q u e s t i o n n a i r e t o a s s e s s t h e i r c a r d i o v a s c u l a r n u t r i t i o n a t t i t u d e s , k n o w l e d g e , a n d p r a c - t i c e p r i o r t o t h e p r o g r a m a n d s e v e n m o n t h s a f t e r c o m p l e t i o n . The c o n t r o l g r o u p was n o t s u r v e y e d f o r t h e i r c a r d i o v a s c u l a r a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e . A l l s t u d e n t s w e r e s c r e e n e d f o r f a s t i n g c h o l e s t e r o l a n d t r i g l y c e r i d e (TG) l e v e l s . I n t e r p r e t a t i o n o f t h e r e s u l t s was s e n t t o a l l p a r e n t s o f t h e s e s t u d e n t s . One y e a r l a t e r , b o t h g r o u p s w e r e r e t e s t e d f o r s e r u m c h o l e s t e r o l a n d TG l e v e l s (64 a n d 83$ o f t h e t e s t a n d c o n t r o l g r o u p s , r e s p e c t i v e l y ) . R e s u l t s o f p r e t e s t - p o s t t e s t c h a n g e i n d i c a t e d a s i g n i f i c a n t (P<.001) i m p r o v e m e n t i n k n o w l e d g e a n d f i v e o f t h e s i x a t t i t u d e p a r a n m e t e r s m e a s u r e d ( P < . 0 0 1 e x c e p t f o r o n e , P < . 0 1 ) . S t u d e n t s who w e r e f e m a l e (P<.01) a n d h a d h i g h i n i t i a l c h o l e s t e r o l l e v e l s (P< . 0 5 ) w e r e r e p o r t e d t o h a v e s i g n i f i c a n t l y g r e a t e r c h a n g e i n e a t i n g p r a c t i c e . S t u d e n t s w i t h a p o s i t i v e f a m i l y h i s t o r y o f e l e v a t e d , c h o l e s t e r o l a l s o s h o w e d a s i g n i f i c a n t (P<.01) p o s i t i v e c h a n g e i n a t t i t u d e s t o w a r d a c h o l e s t e r o l - l o w e r i n g d i e t c o m p a r e d i t o t h o s e w i t h no f a m i l y h i s t o r y . D e s p i t e t h e s e c h a n g e s i n a t t i t u d e , k n o w l e d g e , a n d p r a c t i c e , no s i g n i f i c a n t c h a n g e i n s e r u m c h o l e s t e r o l a n d TG l e v e l s w e r e r e p o r t e d . A c o m m u n i t y - b a s e d s t u d y o f 35 t o 59 y e a r o l d m a l e a n d f e - m a l e a d u l t s a s s e s s e d t h e i r c a r d i o v a s c u l a r n u t r i t i o n k n o w l e d g e a n d p r a c t i c e ( S t e r n e t a l . , 1976; F a r q u h a r e t a l . , 1977) as p a r t o f t h e S t a n f o r d T h r e e C o m m u n i t y S t u d y d i s c u s s e d e a r l i e r i n t h i s c h a p t e r ( B r e s l o w , 1 9 7 8 ) . R e s i d e n t s o f t h e t w o c o m m u n i t i e s , w h e r e a t w o y e a r m a s s - m e d i a h e a l t h e d u c a t i o n c a m p a i g n was c o n - d u c t e d , w e r e c o m p a r e d t o r e s i d e n t s o f a c o n t r o l c o m m u n i t y . A d i e t a r y q u e s t i o n n a i r e w h i c h e s t i m a t e d p a r t i c i p a n t s ' c o n s u m p t i o n o f c h o l e s t e r o l , s a t u r a t e d f a t , a n d p o l y u n s a t u r a t e d f a t was u s e d t o a s s e s s p r a c t i c e b o t h b e f o r e a n d a f t e r t h e c a m p a i g n ( S t e r n e t a l . , 1976) ./ K n o w l e d g e was m e a s u r e d b y a 2 5 - i t e m t e s t o f f a c t o r s a s s o c i a t e d w i t h CVD ( F a r q u h a r e t a l . , 1 9 7 7 ) • R e s u l t s o f s u b j e c t s who p a r t i c i p a t e d i n t h e i n i t i a l s u r v e y a n d i n t w o s u b s e q u e n t f o l l o w - u p s u r v e y s i n d i c a t e d a s i g n i f i c a n t r e d u c t i o n i n c h o l e s t e r o l a n d s a t u r a t e d f a t c o n s u m p t i o n among b o t h men a n d women ( S t e r n e t a l . , 1 9 7 6 ) , as w e l l as a n i n c r e a s e i n k n o w l e d g e r e l a t e d t o CVD ( F a r q u h a r e t a l . , 1 9 7 7 ) . A s i m i l a r a d u l t p o p u l a t i o n , a g e d 20 t o 59 y e a r s , was s u r - v e y e d o n t h e i r k n o w l e d g e , b e l i e f s , a n d a t t i t u d e s r e l a t e d t o CVD, e s p e c i a l l y c a u s e s a n d p r e v e n t i o n o f h e a r t a t t a c k . T e l e p h o n e i n t e r v i e w s w e r e c o n d u c t e d w i t h a r a n d o m s a m p l e o f 617 r e s i d e n t s o f C o o k , Du P a g e , a n d L a k e c o u n t i e s , I l l i n o i s ( S h e k e l l e a n d L i u , 1 9 7 8 ) . O v e r h a l f (58%) o f t h e r e s p o n d e n t s w e r e h i g h s c h o o l g r a d u a t e s . W h i l e 76%. o f a l l p a r t i c i p a n t s i n d i c a t e d " b e l i e f i n t h e p o s s i b i l i t y o f h e a r t a t t a c k p r e v e n t i o n i n p e o p l e u n d e r 60 y e a r s o f a g e , a s u b s t a n t i a l d i f f e r e n c e i n r e s p o n s e a c c o r d i n g t o e d u c a t i o n l e v e l was a p p a r e n t ( c o l l e g e g r o u p , 88%; n o t h i g h s c h o o l g r a d u a t e , 62%). When a s k e d t o name t h e m a j o r c a u s a t i v e a g e n t o f h e a r t a t t a c k , " c i g a r e t t e s m o k i n g " , " h i g h b l o o d p r e s s u r e " , a n d " c h o l e s t e r o l o r f a t i n t h e d i e t o r b l o o d " w e r e i n d i c a t e d b y 28 , 2 1 , a n d 13% o f t h e r e s p o n d e n t s , r e s p e c t i v e - l y . I f f o r m a l e d u c a t i o n o f t h e r e s p o n d e n t s w e r e c o n s i d e r e d , t h e s e p e r c e n t a g e s i n c r e a s e d w i t h a n i n c r e a s e i n e d u c a t i o n ; h o w - e v e r , e v e n among c o l l e g e g r a d u a t e s o n l y 1% w e r e a b l e t o name t h r e e m a j o r r i s k f a c t o r s a n d 4 1 % o f t h e m d i d n o t name a n y . The a u t h o r s c o n c l u d e d t h a t t h e r e was a common, e x t e n s i v e l a c k o f i n f o r m a t i o n among t h e g e n e r a l a d u l t p o p u l a t i o n c o n c e r n - i n g p o s s i b l e c a u s e s o f CVD e v e n t h o u g h a p o s i t i v e a t t i t u d e t o - w a r d p r e v e n t i o n o f h e a r t a t t a c k was i n d i c a t e d b y 75% o f t h e r e s p o n d e n t s . No s p e c i f i c d i e t a r y p r a c t i c e s w e r e r e c o r d e d i n t h i s s u r v e y b u t r e s p o n s e s c o n c e r n i n g o v e r w e i g h t , h i g h f a t m e a l s , p r o p e r d i e t , c h o l e s t e r o l , a n d f a t c o n t e n t o f t h e d i e t w e r e r e - p o r t e d i n d i c a t i n g , p e r h a p s , a n a s s o c i a t i o n o f d i e t w i t h h e a r t a t t a c k i n c i d e n c e . D e s p i t e t h e s t u d y l i m i t a t i o n s , n a m e l y , b r e v i t y o f t h e i n t e r v i e w (15 t o 20 m i n u t e s ) , l a c k o f f a c e - t o - f a c e c o n t a c t , n o n r e s p o n s e r a t e (27 .6%), a n d r e s t r i c t e d l o c a l e , t h e r e s u l t s seem t o s u p p o r t t h e n e e d f o r l a r g e - s c a l e p r o g r a m s i n c a r d i o v a s c u l a r n u t r i t i o n e d u c a t i o n f o r t h e p u b l i c . A r e c e n t C a n a d i a n s t u d y ( C a n a d a , 1979t>) > was d e s i g n e d t o 39 i n v e s t i g a t e among a s a m p l e f r o m t h e g e n e r a l p u b l i c : p e r c e p t i o n o f a n d a t t i t u d e t o w a r d b a s i c n u t r i t i o n c o n c e p t s i n c l u d i n g i n t e r - p r e t a t i o n o f " s e n s i b l e " , " b a l a n c e d " , o r " a d e q u a t e " d i e t ; p e r - c e p t i o n o f C a n a d i a n s ' w i l l i n g n e s s t o f o l l o w t h e N u t r i t i o n Recom- m e n d a t i o n s ( C a n a d a , 1 9 7 7 ) ; a n d s o u r c e s o f n u t r i t i o n i n f o r m a t i o n . R e s u l t s w e r e i n t e n d e d t o p r o v i d e g o v e r n m e n t a n d n o n g o v e r n m e n t s e r v i c e s w i t h d i r e c t i o n f d J r r t h e d e v e l o p m e n t o f f u t u r e c a r d i o - v a s c u l a r n u t r i t i o n e d u c a t i o n a n d h e a l t h p r o m o t i o n p r o g r a m s f o r C a n a d i a n s . The s t u d y u s i n g a m u l t i - s t a g e r a n d o m s a m p l e o f 6 7 6 I a d u l t s f r o m B r i t i s h C o l u m b i a , t h e P r a i r i e s , O n t a r i o , a n d t h e A t l a n t i c r e g i o n s , c o l l e c t e d d a t a b y q u e s t i o n n a i r e d u r i n g a n i n t e r v i e w . A l l f o u r a r e a s r e s p o n d e d s i m i l a r l y . O v e r 80$ f e l t a s e n s i b l e d i e t was i m p o r t a n t a n d t h a t b e t t e r h e a l t h , g e n e r a l w e l l - b e i n g , a n d w e i g h t c o n t r o l w e r e t h e t h r e e m a j o r b e n e f i t s o f s u c h a n e a t i n g p a t t e r n . T h i s was i n t e r p r e t e d t o i n d i c a t e p o s - s i b l e t o p i c s o f i m p o r t a n c e f o r f u t u r e p r o g r a m s . Use o f a w i d e v a r i e t y o f n u t r i t i o n s o u r c e s was c o n s i d e r e d t o e m p h a s i z e t h e n e e d f o r e x t e n d e d use o f t h e m e d i a . Of t h e c o n c e p t s e x a m i n e d , p o l y u n s a t u r a t e d f a t t y a c i d s (PUFA) was c o n s i d e r e d t o be m i s u n d e r - s t o o d b y 40 t o 45$ o f t h e s a m p l e d e s p i t e t h e f a c t t h a t t h e m a j o r i t y h a d a m i n i m u m o f 12 y e a r s o f e d u c a t i o n . The s t u d y g r o u p was f o u n d t o p e r c e i v e C a n a d i a n s as more l i k e l y t o i n c l u d e t h a n l i m i t o r a v o i d c e r t a i n f o o d s , s u g g e s t i n g t h a t a p o s i t i v e a p p r o a c h m i g h t be m o r e s u c c e s s f u l i n n u t r i t i o n e d u c a t i o n p r o - g r a m s . The r e p r e s e n t a t i v e n e s s o f t h e f i n d i n g s may be q u e s t i o n - ed s i n c e p e o p l e i n Q u e b e c , t h e T e r r i t o r i e s , a n d a l l c i t i e s o f l e s s t h a n 5000 p e o p l e w e r e n o t s a m p l e d . I n a d d i t i o n , a l o w r e s p o n s e r a t e ( r a n g i n g f r o m 22 t o 36%) f o r t h e f o u r a r e a s s u g - g e s t e d a n o n r e s p o n s e "b ias t h a t was n o t e x a m i n e d . R e s u l t s o f t h e p r e v i o u s l y c i t e d s t u d i e s m u s t be c o m p a r e d a n d g e n e r a l i z e d c a u t i o u s l y , as e a c h s t u d y i n v o l v e d w i d e l y d i f - f e r i n g r e s e a r c h d e s i g n s , s a m p l i n g t e c h n i q u e s , p o p u l a t i o n s , d a t a c o l l e c t i o n i n s t r u m e n t s , a n d p r o c e d u r e s . A n e x a m i n a t i o n o f t h e m e a s u r e m e n t i n s t r u m e n t s i n p a r t i c u l a r r e v e a l e d t h e n e e d f o r n u t r i t i o n e d u c a t i o n r e s e a r c h e r s t o e m p l o y s o u n d t e c h n i q u e s <3f m e a s u r e m e n t . C a r r u t h a n d A n d e r s o n (1977) s u g g e s t e d t h a t more r e s e a r c h be d e v o t e d t o t h e d e v e l o p m e n t o f i n s t r u m e n t s f o r m e a s - u r i n g n u t r i t i o n k n o w l e d g e a n d a t t i t u d e s . F u t u r e r e s e a r c h o n t h e c o m p l e x r e l a t i o n s h i p s among a t t i - t u d e s , k n o w l e d g e , a n d p r a c t i c e n e c e s s i t a t e s s c r u t i n y o f t h e m e t h o d o l o g y a v a i l a b l e f o r a s s e s s i n g t h e s e v a r i a b l e s . The f o l l o w - i n g s e c t i o n w i l l r e v i e w a d v a n t a g e s a n d l i m i t a t i o n s o f m e t h o d s r e l e v a n t t o t h e p r e s e n t s t u d y . S u r v e y R e s e a r c h I n c o n t r a s t t o l a b o r a t o r y r e s e a r c h , s u r v e y s a r e g e n e r a l l y c o n d u c t e d o n a f a i r l y l a r g e s c a l e e m p l o y i n g one o f s e v e r a l m e t h o d s f o r d a t a c o l l e c t i o n : p e r s o n a l i n t e r v i e w , q u e s t i o n n a i r e , v a r i a t i o n s i n c l u d i n g p a n e l a n d t e l e p h o n e , a n d o b s e r v a t i o n a l t e c h n i q u e s ( M o u l y , 1970; K e r l i n g e r , 1 9 7 3 ) • The i n t e r v i e w a n d q u e s t i o n n a i r e w e r e u s e d i n t h e p r e s e n t s t u d y t o a s s e s s t h e c a r d i o v a s c u l a r n u t r i t i o n a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e o f c o m m u n i t y c e n t r e a d u l t m e m b e r s . C o n s e q u e n t l y , t h e f o l l o w i n g d i s c u s s i o n w i l l f o c u s o n t h e s e t w o m e t h o d s . 41 Q u e s t i o n n a i r e v e r s u s I n t e r v i e w B e c a u s e t h e t e r m q u e s t i o n n a i r e i s o f t e n u s e d t o d e s i g n a t e a n y k i n d o f i n s t r u m e n t t h a t h a s i t e m s o r q u e s t i o n s t o w h i c h i n d i v i d u a l s r e s p o n d , t h e s u c c e e d i n g d i s c u s s i o n w i l l use t h e t e r m " s c h e d u l e " t o r e f e r t o t h e d a t a c o l l e c t i o n i n s t r u m e n t u s e d i n t h e p e r s o n a l i n t e r v i e w , a n d " q u e s t i o n n a i r e " t o r e f e r t o t h e s e l f - a d m i n i s t e r e d d a t a c o l l e c t i o n i n s t r u m e n t u s e d t o m e a s u r e a t t i t u d e s , k n o w l e d g e , a n d d i e t a r y p r a c t i c e . B o t h t h e s c h e d u l e a n d t h e q u e s t i o n n a i r e a r e c l a s s i f i e d as d i r e c t i n s t r u m e n t s w i t h t h e i r a d v a n t a g e b e i n g t h a t a g r e a t d e a l o f i n f o r m a t i o n c a n be r e c e i v e d f r o m r e s p o n d e n t s b y d i r e c t q u e s t i o n i n g . The m a i n d i s a d v a n t a g e i s t h a t r e s p o n d e n t s may be u n w i l l i n g , r e l u c t a n t , o r u n a b l e t o a n s w e r some q u e s t i o n s r e a d i l y a n d d i r e c t l y . A l l m e t h o d s f o r d a t a c o l l e c t i o n h a v e s t r e n g t h s a n d w e a k n e s s e s t h a t m u s t be w e i g h e d so t h a t t h e m o s t a p p r o p r i a t e m e t h o d i s c h o s e n b a s e d o n t h e p u r p o s e o f t h e s t u d y . A c c o r d i n g t o B e n n e t t a n d R i t c h i e , " t h e s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e i s c o m p l e t e d b y t h e r e s p o n d e n t w i t h o u t t h e a s s i s t a n c e o r i n t e r - f e r e n c e o f a n i n t e r v i e w e r " ( 1975 , p . 5 2 ) . I t i s g e n e r a l l y t h e m e t h o d o f c h o i c e f o r k n o w l e d g e a n d a t t i t u d e a s s e s s m e n t . The i t e m s o f t h e q u e s t i o n n a i r e may be " o p e n q u e s t i o n s " w h i c h r e q u i r e t h e r e s p o n d e n t t o r e p l y i n h i s own w o r d s o r " c l o s e d q u e s t i o n s " w h i c h p r o v i d e t h e r e s p o n d e n t w i t h r e a d y - m a d e a l t e r n a t i v e s . G r e a t e r u n i f o r m i t y a n d r e l i a b i l i t y c a n be a c h i e v e d b y u s e o f c l o s e d q u e s t i o n s ( K e r l i n g e r , 1 9 7 3 ) • M o u l y (1970) s u g g e s t e d t h a t t h e u s e o f c l o s e d q u e s t i o n s h a d t h e a d d e d a d v a n t a g e o f k e e p i n g t h e l e n g t h r e a s o n a b l e , t h u s e n c o u r a g i n g r e s p o n s e a n d t h e r e f o r e 42 v a l i d i t y , i n t e r m s o f r e p r e s e n t a t i v e n e s s o f t h e r e t u r n s . B e n n e t t a n d R i t c h i e (1975) s u g g e s t e d t h a t t h e c l o s e d - t y p e q u e s - t i o n s e r v e d t o r e f i n e t h e q u e s t i o n n a i r e m e t h o d w i t h t h e c h i e f a d v a n t a g e b e i n g t h a t i t i n s u r e d s t a n d a r d i z a t i o n o f m e a s u r e m e n t b e c a u s e a l l s u b j e c t s a r e a s k e d p r e c i s e l y t h e same q u e s t i o n . The a b i l i t y t o p r o v i d e a n o n y m i t y , t o i n c r e a s e t h e s a m p l e s i z e , a n d t o u s e t h e p o s t a l s y s t e m , i f d e s i r e d , w e r e a d d i t i o n a l a d v a n - t a g e s o f t h e q u e s t i o n n a i r e t o c o n s i d e r ( K e r l i n g e r , 1973; H e n e r s o n e t a l . , 1978) a l o n g w i t h t h e r e m o v a l o f t h e i n t e r v i e w e r b i a s , l o w e r c o s t , a n d a b i l i t y t o r e s p o n d a t o n e ' s c o n v e n i e n c e . D i s a d v a n t a g e s o f t h e s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e w e r e l a c k o f f l e x i b i l i t y a n d t h e p r o b l e m o f t h o s e p e o p l e who h a v e l e s s a b i l i t y t o e x p r e s s v i e w s i n w r i t i n g c o m p a r e d t o o r a l l y ( H e n e r s o n e t a l . , 1978) . B e n n e t t a n d R i t c h i e (1975) c o n s i d e r e d t h i s m e t h o d t o be a p p r o p r i a t e o n l y w h e n s i m p l e a n d s t r a i g h t f o r - w a r d q u e s t i o n s w e r e p o s s i b l e a n d u n d e r s t a n d a b l e w i t h t h e a i d o f w r i t t e n i n s t r u c t i o n s . T h i s r e s t r i c t i o n w o u l d e l i m i n a t e i t s u s e f o r p e r s o n s o f l o w i n t e l l i g e n c e o r p o o r r e a d i n g a b i l i t y , p e r - h a p s due t o f a i l i n g e y e s i g h t . The p h y s i c a l l y h a n d i c a p p e d may a l s o be e l i m i n a t e d as r e s p o n d e n t s t o t h e s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e . K e r l i n g e r (1973) s t a t e d t h a t t h e m a i n d i s a d - v a n t a g e was l a c k o f o p p o r t u n i t y t o p r o b e f o r u n c e r t a i n r e s p o n s e s , as t h e r e s p o n s e s a r e f i n a l . He a l s o c i t e d l o w p e r c e n t a g e o f r e t u r n s ( e s p e c i a l l y i f m a i l e d ) a n d u n e x p e c t e d l a c k o f u n i f o r m i t y as d i s a d v a n t a g e s t h a t c o u l d be a v o i d e d i n t h e s t r u c t u r e d i n t e r - v i e w . Some o f t h e s e d i s a d v a n t a g e s c a n be o v e r c o m e . M o u l y (1970) s u g g e s t e d f o l l o w - u p as t h e m a j o r w a y t o p r o m o t e h i g h r e t u r n r a t e s . T h i s m i g h t i n v o l v e a s e r i e s o f f o l l o w - u p m a i l i n g s . F i n a l l y , p e r h a p s a s h o r t e n e d v e r s i o n o f t h e q u e s t i o n n a i r e o r a n i n t e r v i e w w i t h a r a n d o m s a m p l e o f t h e n o n r e s p o n d e n t s m i g h t be n e c e s s a r y b e f o r e r e t u r n s r e a c h a n a c c e p t a b l e l e v e l . I n c o n t r a s t t o . t h e q u e s t i o n n a i r e , t h e i n t e r v i e w i s a " f a c e - t o - f a c e i n t e r p e r s o n a l r o l e s i t u a t i o n i n w h i c h one p e r s o n , t h e i n t e r v i e w e r , a s k s a p e r s o n b e i n g i n t e r v i e w e d , t h e r e s p o n d e n t , q u e s t i o n s d e s i g n e d t o o b t a i n a n s w e r s p e r t i n e n t t o t h e r e s e a r c h p r o b l e m " ( K e r l i n g e r , 1973, p . 4 8 1 ) . The i n t e r v i e w s c h e d u l e i s " r e a d o u t b y a n i n t e r v i e w e r , t o w h i c h t h e r e s p o n d e n t r e p l i e s o r a l l y a n d t h e r e s p o n s e i s n o t e d down b y t h e i n t e r v i e w e r " ( B e n n e t t a n d R i t c h i e , 1975 , p . 3 8 ) . The s c h e d u l e may be s t a n d a r d - i z e d so t h a t t h e q u e s t i o n s , t h e i r o r d e r , a n d t h e i r w o r d i n g a r e f i x e d . R e l a t i v e l y l i t t l e l i b e r t y i n a s k i n g q u e s t i o n s i s p e r - m i t t e d a n d t h i s m u s t be s p e c i f i e d i n a d v a n c e . The u n s t a n d a r d - i z e d i n t e r v i e w d i f f e r s i n t h a t i t i s f l e x i b l e , o p e n , u n o r d e r e d , a n d o r d i n a r i l y l a c k i n g a s c h e d u l e . S i m i l a r i t i e s b e t w e e n t h e s t r u c t u r e d s c h e d u l e a n d t h e s e l f - a d m i n i s t e r e d c l o s e d - t y p e q u e s t i o n n a i r e a r e o b v i o u s , h o w e v e r , some d i f f e r e n c e s a r e e v i d e n t . The m a i n a d v a n t a g e o f t h e s c h e d - u l e o v e r t h e q u e s t i o n n a i r e i s i t s g r e a t e r f l e x i b i l i t y w h i c h p e r m i t s p u r s u i t o f l e a d s , e l a b o r a t i o n o f p o i n t s , o r c l a r i f i c a - t i o n o f q u e s t i o n s a p p a r e n t l y m i s u n d e r s t o o d , t h u s , e n a b l i n g t h e i n v e s t i g a t o r t o r e m a i n i n command o f t h e s i t u a t i o n t h r o u g h o u t t h e i n v e s t i g a t i o n . M o u l y (1970) c o n s i d e r e d a d v a n t a g e s o f t h e s c h e d u l e t o be e s t a b l i s h m e n t o f g r e a t e r r a p p o r t w h i c h w o u l d l e a d t o m o r e c o m p l e t e a n d v a l i d r e s p o n s e s ; i n c l u s i o n o f r e s p o n d e n t s 44 o t h e r w i s e e l i m i n a t e d s u c h as t h e i l l e r a t e ; a n d p r o m o t i o n o f h i g h e r r e t u r n s . The i n t e r v i e w e r may be a b l e t o a p p r a i s e t h e s i t u a t i o n , p e r h a p s r e d u c e r e l u c t a n c e o r r e s i s t a n c e , a n d t h u s i m p r o v e t h e q u a l i t y o f t h e r e s u l t s . T h e m a j o r w e a k n e s s o f t h e s c h e d u l e i s i n t e r v i e w e r b i a s w h i c h may be e x p r e s s e d b y t h e r e s p o n d e n t s g i v i n g t h e s o c i a l l y a c c e p t e d a n s w e r , r a t h e r t h a n t h e t r u t h i n a n a t t e m p t t o p l e a s e , o r e v a d i n g t h e q u e s t i o n due t o a n n o y a n c e w i t h t h e i n t e r v i e w e r . The i n t e r v i e w m e t h o d i s a l s o more e x p e n s i v e , i n t i m e , e f f o r t , a n d m o n e y . A l a r g e s a m p l e w i l l r e q u i r e more t h a n one i n t e r - v i e w e r . D i f f e r e n c e s i n r e s u l t s among i n t e r v i e w e r s may be due t o i n d i v i d u a l p e r s o n a l c h a r a c t e r i s t i c s o r d e v i a t i o n s f r o m t h e s t a n d a r d i z e d p r o c e d u r e . B o t h o f t h e s e p r o b l e m s c a n be m i n i m i z e d i f n o t o v e r c o m e , b y c a r e i n t h e s e l e c t i o n o f i n t e r v i e w e r s a n d i n t h e i r t r a i n i n g ( B e n n e t t a n d R i t c h i e , 1 9 7 5 ) - R e s p o n s e B i a s A s e c o n d t y p e o f b i a s , r e s p o n s e b i a s , i s c o n c e r n e d w i t h p o s s i b l e d i f f e r e n c e s i n s t u d y r e s u l t s due t o t h e f a c t t h a t a l l s u b j e c t s d i d n o t r e t u r n t h e q u e s t i o n n a i r e . Two m e t h o d s o f c o n - t r o l l i n g r e s p o n s e b i a s , p r e v e n t i o n a n d c o r r e c t i o n , h a v e b e e n s u g g e s t e d ( B e n n e t t a n d R i t c h i e , 1975) • P r e v e n t i o n as a means o f c o n t r o l l i n g r e s p o n s e b i a s c o n - c e r n s c o n s t r u c t i o n o f t h e q u e s t i o n n a i r e i n a m a n n e r t h a t w i l l i n d u c e r e s p o n s e . B e n n e t t a n d R i t c h i e (1975) s u g g e s t e d t h a t c o l o u r o f p a p e r , q u e s t i o n n a i r e l e n g t h , t y p e d v e r s u s h a n d w r i t t e n e n v e l o p e s , t o n e o f t h e c o v e r l e t t e r , l a y o u t , m e t h o d o f r e c o r d i n g , a n d t i m i n g w e r e a l l f a c t o r s t h a t i n f l u e n c e d r e s p o n s e . I n a d d i t i o n t o a f o l l o w - u p l e t t e r , M o u l y (1970) s u g g e s t e d t h e i n - c l u s i o n o f a s e c o n d c o p y o f t h e q u e s t i o n n a i r e w i t h t h e r e m i n d e r , i n c a s e t h e r e s p o n d e n t h a d d i s c a r d e d t h e f i r s t . C o r r e c t i o n o f r e s p o n s e b i a s i n v o l v e s h y p o t h e s i z i n g why n o n r e s p o n s e o c c u r r e d . To s t u d y t h i s , r e t u r n d a t e s f o r e a c h q u e s t i o n n a i r e a r e r e c o r d e d so t h a t e a r l y a n d l a t e r e s p o n d e n t s c a n be i d e n t i f i e d . A c c e p t i n g t h a t l a t e r e s p o n d e n t s p e r f o r m s i m i l a r l y t o n o n r e s p o n d e n t s ( O p p e n h e i m , I 9 6 6 ) , a c o m p a r i s o n o f t h e a n s w e r s g i v e n i n e a r l y a n d l a t e r e t u r n s c a n be u s e d t o j u d g e t h e r e s p o n s e b i a s . R e s p o n s e F o r m a t C o n s t r u c t i o n o f t h e q u e s t i o n n a i r e may i n v o l v e c l o s e d - o r o p e n - t y p e i t e m f o r m a t s . C l o s e d q u e s t i o n n a i r e s a r e s t r u c t u r e d so t h a t t h e r i s k o f m i s i n t e r p r e t a t i o n o f t h e c o n c e p t u n d e r s t u d y i s m i n i m i z e d , a n d t a b u l a t i o n a n d i n t e r p r e t a t i o n o f r e s u l t s a r e e a s i e r . W h i l e t h e o p e n - t y p e p o s s e s s e s g r e a t e r f l e x i b i l i t y , t h e f o r m a t p r o d u c e s m o r e d e t a i l e d r e s p o n s e s , a l e n g t h e n e d r e s p o n s e t i m e r e q u i r e m e n t , a n d p r o b l e m s w i t h s t a t i s t i c a l a n a l y s i s . I f i n t e r p r e t a t i v e , j u d g e m e n t a l p r o c e d u r e s a r e u s e d , t h e p r i o r c l a s s i f i c a t i o n o f r e s p o n s e s may r e s u l t i n e r r o r ( B e n n e t t a n d R i t c h i e , 1975)• The c l o s e d q u e s t i o n n a i r e i s n o t w i t h o u t p r o b - l e m s . I t m u s t a l l o w f o r a l l p o s s i b l e a n s w e r s ( M o u l y , 1970) . T h e r e i s l o s s o f s p o n t a n e i t y a n d e x p r e s s i v e n e s s a n d , p o s s i b l y , a n i n t r o d u c t i o n o f b i a s b y f o r c i n g r e s p o n d e n t s t o c h o o s e b e - t w e e n g i v e n a l t e r n a t i v e s w h i c h m i g h t n o t h a v e o c c u r r e d t o t h e m ( O p p e n h e i m , ± 9 6 6 ) . H e n e r s o n e t a l . (1978) s u g g e s t e d t h a t a c l o s e d - r e s p o n s e f o r m a t be u s e d i f t h e s a m p l e s i z e was g r e a t e r t h a n 20 t o 3 0 . H o w e v e r , t h e a d v a n t a g e s o f p e r m i t t i n g e x p r e s - s i o n o f f e e l i n g , p r o v i d i n g f o r u n a n t i c i p a t e d o u t c o m e s , o r o b - t a i n i n g u n p r o m p t e d r e s p o n s e s may s u g g e s t t h e u s e o f b o t h o p e n - a n d c l o s e d - r e s p o n s e f o r m a t s . I f t h e c l o s e d - r e s p o n s e f o r m a t i s u s e d , s e v e r a l o p t i o n s a r e a v a i l a b l e , n a m e l y : (1) c h e c k l i s t , (2) t w o - w a y q u e s t i o n s , (3) m u l t i p l e - c h o i c e q u e s t i o n s , a n d (4) r a n k i n g s c a l e s . A b i o - d e m o g r a p h i c d a t a c o l l e c t i o n q u e s t i o n n a i r e w i l l o f t e n u s e a n y o r a l l o f t h e f i r s t t h r e e o p t i o n s , d e p e n d i n g o n t h e t y p e o f a n s w e r r e q u i r e d . A c h e c k l i s t may v e r i f y t h e p r e s e n c e o r a b s e n c e o f some s i t u a t i o n , t h e m a i n c r i t e r i o n b e i n g t h a t t h e c h e c k l i s t c o n - t a i n a l l r e l e v a n t o p t i o n s ( H e n e r s o n e t a l . , 1 9 7 8 ) . The t w o - way q u e s t i o n p r e s e n t s d i c h o t o m o u s a l t e r n a t i v e s t h a t m u s t p r e s e n t a r e a l i s t i c c h o i c e . The l i m i t a t i o n o f t h i s t y p e o f r e s p o n s e f o r m a t i s t h a t a s i n g l e m i s i n t e r p r e t a t i o n o f t h e q u e s t i o n o r e r r o r i n r e c o r d i n g t h e r e s p o n s e , r e s u l t s i n a c o m p l e t e r e v e r s a l o f t h e a n s w e r ( B e n n e t t a n d R i t c h i e , 1 9 7 5 ) . A t h i r d o p t i o n , t h e m u l t i p l e - c h o i c e q u e s t i o n , i s f a v o u r e d b y m o s t q u e s t i o n n a i r e d e v e l o p e r s . I t a t t e m p t s t o o v e r c o m e t h e l i m i t a t i o n s o f t h e d i c h o t o m o u s t y p e o f r e s p o n s e f o r m a t b y p e r m i t t i n g a g r e a t e r v a r i e t y o f r e s p o n s e s . I t i s p a r t i c u l a r l y u s e f u l f o r s i t u a t i o n s w h e r e i t i s n e c e s s a r y t o e n s u r e a w a r e n e s s o f a l l p o s s i b l e r e s p o n s e s t o a q u e s t i o n ( H e n e r s o n e t a l . , 1 9 7 8 ) . A s p e c i a l f o r m o f t h e m u l t i p l e - c h o i c e q u e s t i o n i s t h e r a t i n g s c a l e w h i c h a l l o w s f o r q u a n t i f i c a t i o n o f t h e r e s p o n s e s . A t t i t u d e r a t i n g s c a l e s may be c o n s i d e r e d as a s p e c i a l k i n d o f q u e s t i o n n a i r e ( H e n e r s o n e t a l . , 1978) d e v e l o p e d a c c o r d i n g t o s t r i c t p r o c e d u r e s w h i c h e n s u r e t h a t s e v e r a l r e s p o n s e s c a n be summed t o y i e l d a s i n g l e s c o r e r e p r e s e n t i n g one a t t i t u d e . A t t i t u d e a n d K n o w l e d g e M e a s u r e m e n t The c o n s t r u c t i o n o f a n a t t i t u d e s c a l e i n v o l v e s e v a l u a t i n g e a c h i t e m t o d e t e r m i n e t h e e x t e n t t o w h i c h i t c a n d i f f e r e n t i a t e t h o s e r e s p o n d e n t s w i t h a p o s i t i v e a t t i t u d e f r o m t h o s e w i t h a n e g a t i v e a t t i t u d e . The s i n g l e s c o r e o b t a i n e d i n d i c a t e s t h e d i r e c t i o n a n d i n t e n s i t y o f t h e r e s p o n d e n t ' s a t t i t u d e t o w a r d t h e o b j e c t . T h e r e a r e t h r e e m a j o r t y p e s o f a t t i t u d e s c a l e s ( K e r l i n g e r , 1 9 7 3 ) : (1) L i k e r t ' s s u m m a t e d r a t i n g s c a l e s , (2) T h u r s t o n e s ' s e q u a l - a p p e a r i n g i n t e r v a l s c a l e , a n d (3) G u t t m a n ' s c u m u l a t i v e s c a l e s . K e r l i n g e r d e s c r i b e s a L i k e r t - t y p e summated r a t i n g s c a l e as " a s e t o f a t t i t u d e i t e m s , a l l o f w h i c h a r e c o n s i d e r e d o f a p p r o x i m a t e l y e q u a l ' a t t i t u d e v a l u e * , a n d t o e a c h o f w h i c h s u b j e c t s r e s p o n d w i t h d e g r e e s o f a g r e e m e n t o r d i s a g r e e m e n t ( i n t e n s i t y ) . The s c o r e s o f t h e i t e m s o f s u c h a s c a l e a r e s u m - m e d , o r summed a n d a v e r a g e d , t o y i e l d a n i n d i v i d u a l ' s a t t i t u d e s c o r e " ( p . 4 9 6 ) . The T h u r s t o n e e q u a l - a p p e a r i n g i n t e r v a l s c a l e a l s o a s s i g n s a t t i t u d e s c o r e s t o i n d i v i d u a l s b u t d i f f e r s i n t h a t i t " a c c o m p l i s h e s t h e i m p o r t a n t p u r p o s e o f s c a l i n g t h e a t t i t u d e i t e m s . E a c h i t e m i s a s s i g n e d a s c a l e v a l u e a n d t h e s c a l e v a l u e i n d i c a t e s t h e s t r e n g t h o f a t t i t u d e o f a n a g r e e m e n t r e s p o n s e t o t h e i t e m " ( K e r l i n g e r , 1973 , p .4 - 9 7 ) . The f i n a l t y p e o f s c a l e , t h e G u t t m a n s c a l e , i s d e f i n e d "by K e r l i n g e r as " a r e l a t i v e l y s m a l l s e t o f homogeneous i t e m s t h a t a r e u n i d i m e n s i o n a l " ( p . 4 9 7 ) . The r e s u l t i n g c u m u l a t i v e r e l a t i o n "be tween i t e m s a n d t h e t o t a l s c o r e s o f i n d i v i d u a l s makes i t p o s s i b l e t o p r e d i c t a n i n d i v i d - u a l ' s p a t t e r n o f r e s p o n s e f r o m i n f o r m a t i o n o n t h e t o t a l s c o r e . W h i l e t h e p u r p o s e o f a n y a t t i t u d e s c a l e i s t o p l a c e a n i n d i v i d - u a l somewhere o n a n a g r e e m e n t c o n t i n u u m o f t h e a t t i t u d e u n d e r e x a m i n a t i o n , e a c h s c a l e i s v e r y d i f f e r e n t . The L i k e r t - t y p e s c a l e f o c u s e s o n t h e s u b j e c t s a n d t h e i r p l a c e m e n t w h e r e a s t h e T h u r s t o n e s c a l e c o n c e n t r a t e s o n t h e i t e m s a n d t h e i r p l a c e o n t h e s c a l e . G u t t m a n ' s c u m u l a t i v e s c a l e d i f f e r s i n t h a t i t f o c u s e s o n s c a l a b i l i t y o f s e t s o f i t e m s a n d o n s c a l e p o s i t i o n s o f i n d i v i d u a l s . A c c o r d i n g t o K e r l i n g e r (1973) . "the L i k e r t - t y p e s c a l e i s e a s i e r t o d e v e l o p , y i e l d s r e s u l t s c o m p a r a b l e t o t h e more l a b o r i o u s l y c o n s t r u c t e d T h u r s t o n e s c a l e , a n d c a n be a d a p t e d t o many n e e d s o f b e h a v i o u r a l r e s e a r c h . B e c a u s e t h e L i k e r t s c a l e d o e s n o t i n c l u d e i t e m s t h a t r e p r e s e n t g r a d a t i o n s o f t h e a t t i t u d e b u t o n e s t h a t embody e x t r e m e s , t h e r e s p o n d e n t s a r e a s k e d t o i n d i c a t e t h e i r a g r e e m e n t w i t h e a c h s t a t e m e n t c o m - m o n l y u s i n g a f i v e - p o i n t s c a l e . The s c a l e r e s p o n s e a l t e r n a t i v e s r a n g e f r o m s t r o n g l y a g r e e t o s t r o n g l y d i s a g r e e . T h i s r e s p o n s e f o r m a t i s u s e d i n a v a r i e t y o f m e a s u r e s ( H e n e r s o n e t a l . , 1978) i n c l u d i n g k n o w l e d g e t e s t s . C o n s t r u c t i o n o f L i k e r t - t y p e s c a l e s t o m e a s u r e a t t i t u d e s a n d k n o w l e d g e f o l l o w p a r a l l e l p r o c e d u r e s d e s c r i b e d i n d e t a i l b y s e v e r a l i n v e s t i g a t o r s ( E d w a r d s , 1957; L i k e r t , 1967; T h o r n d i k e a n d H a g e n , 1977; H e n e r s o n e t a l . , 1 9 7 8 ) . The m a i n d i s t i n c t i o n b e t w e e n t h e t w o s c a l e s i s t h e t y p e o f i t e m u s e d . A t t i t u d e i t e m s m u s t be e x p r e s s i o n s o f d e s i r e d b e h a v i o u r ( L i k e r t , 19^7) a n d n o t be s t a t e m e n t s o f f a c t , as a r e k n o w l e d g e i t e m s . B o t h may u s e t h e f i v e p o i n t c o n t i n u u m r a n g i n g f r o m 1= s t r o n g l y d i s a g r e e o r d e f i n i t e l y f a l s e t o 5 = s t r o n g l y a g r e e o r d e f i n i t e l y t r u e . B e s i d e s t h e u s e o f s i m i l a r p r o c e d u r e s f o r c o n s t r u c t i o n , a t t i t u d e s a n d k n o w l e d g e i n s t r u m e n t s may a l s o be e x a m i n e d b y s i m i l a r t e c h n i q u e s f o r v a l i d i t y a n d r e l i a b i l i t y . V a l i d i t y a n d r e l i a b i l i t y o f a t t i t u d e a n d k n o w l e d g e i n s t r u m e n t s The i m p o r t a n c e o f d e t e r m i n i n g v a l i d i t y a n d r e l i a b i l i t y o f t e s t i n s t r u m e n t s h a s b e e n c o n s i s t e n t l y e m p h a s i z e d i n t h e l i t e r - a t u r e . T h i s n e e d f o r e s t a b l i s h i n g q u a l i t y s t a n d a r d s f o r t e s t c o n s t r u c t i o n l e d t o t h e 1966 p u b l i c a t i o n o f " S t a n d a r d s f o r e d u c a t i o n a l a n d p s y c h o l o g i c a l t e s t s " b y t h e A m e r i c a n P s y c h o - l o g i c a l A s s o c i a t i o n (APA, 1 9 7 4 ) . The r e c o m m e n d a t i o n s o f t h i s r e v i s e d d o c u m e n t f o r m t h e b a s i s o f q u a l i t y t e s t c o n s t r u c t i o n t o d a y . T r a d i t i o n a l l y , v a l i d i t y o f a n i n s t r u m e n t has b e e n d e f i n e d as " t h e e x t e n t t o w h i c h a t e s t m e a s u r e s w h a t i t i s s u p p o s e d t o m e a s u r e " ( S t a n l e y a n d H o p k i n s , 1972, p . 4 5 9 ) b u t S t a n l e y a n d H o p k i n s s u g g e s t t h a t a more a p p r o p r i a t e d e f i n i t i o n i s " t h e e x t e n t t o w h i c h a t e s t does t h e j o b f o r w h i c h i t i s u s e d " ( 1 9 7 2 , p.4 -58) . T h i s l a t t e r d e f i n i t i o n r e g a r d s v a l i d i t y as a m u l t i - f a c e t e d c o n c e p t w h i c h i s i m p l i e d b y t h e A P A ' s c l a s s i f i c a t i o n o f v a l i d i t y i n t o t h r e e t y p e s : (1) c o n t e n t , (2) c o n s t r u c t , a n d (3) c r i t e r i o n - r e l a t e d v a l i d i t i e s (APA, 1 9 7 4 ) . C o n t e n t v a l i d i t y i s d e f i n e d as t h e " r e p r e s e n t a t i v e n e s s o r s a m p l i n g a d e q u a c y o f t h e c o n t e n t — t h e s u b s t a n c e , t h e m a t t e r , t j i e t o p i c s - - o f a m e a s u r i n g i n s t r u m e n t " ( K e r l i n g e r , 1973* p . 4 5 8 ) . V a l i d a t i o n o f c o n t e n t i n v o l v e s j u d g e m e n t o f t h e r e p r e - s e n t a t i v e n e s s o f t h e i t e m s as d e t e r m i n e d b y e x p e r t s i n t h e f i e l d o f s t u d y (APA, 1 9 7 4 ) . B e c a u s e t h i s m e t h o d o f v a l i d a t i n g i s p r i m a r i l y a p r o c e s s o f l o g i c a l a n a l y s i s ( S t a n l e y a n d H o p k i n s , 1 9 7 2 ) , i t i s n e c e s s a r y t h a t t h e e x p e r t s be c a r e f u l l y s e l e c t e d i n t e r m s o f r e l e v a n t p r o f e s s i o n a l e x p e r i e n c e a n d q u a l i f i c a t i o n s (APA, 1 9 7 4 ) . By i t s e l f , c o n t e n t v a l i d i t y u t i l i z i n g l o g i c a l a n a l y s i s c a n n o t d i s p r o v e a v a l i d i t y c l a i m b u t r e q u i r e s e m p i r i c a l v e r i f i c a t i o n ( C r o n b a c h , 1 9 7 1 ) . T h u s , t h e r e i s a n e e d t o d e t e r - m i n e c o n s t r u c t v a l i d i t y o f t h e t e s t i n s t r u m e n t . I n c o n t r a s t t o c o n t e n t v a l i d i t y , c o n s t r u c t v a l i d i t y i s a n a n a l y s i s o f t h e p r o p e r t y b e i n g m e a s u r e d , n o t t h e t e s t i t s e l f ( K e r l i n g e r , 1 9 7 3 ) • C r o n b a c h (1971) s u g g e s t s t h a t c o n s t r u c t v a l i d a t i o n i s a t h r e e p a r t p r o c e s s b e g i n n i n g w i t h t h e c l a i m t h a t a g i v e n t e s t m e a s u r e s a c e r t a i n c o n s t r u c t , d e v e l o p i n g a n h y p o t h - e s i s a b o u t t h e c o n s t r u c t a n d , f i n a l l y , s y s t e m a t i c a l l y t e s t i n g t h e t h e o r y . T h i s e m p i r i c a l a n a l y s i s p r o c e d u r e i s e x e m p l i f i e d b y t h e k n o w n g r o u p s m e t h o d ( K e r l i n g e r , 1973) w h e r e i n g r o u p s o f p e o p l e w i t h k n o w n c h a r a c t e r i s t i c s a r e a d m i n i s t e r e d t h e i n s t r u - m e n t . The r e s u l t s a r e t h e n e m p i r i c a l l y s t u d i e d a n d , i f t h e t e s t has c o n s t r u c t v a l i d i t y , t h e h y p o t h e s i z e d d i r e c t i o n o f d i f f e r - e n c e s w i l l be c o n f i r m e d . The t h i r d t y p e o f v a l i d i t y , c r i t e r i o n - r e l a t e d v a l i d i t y , i s s t u d i e d b y c o m p a r i n g t e s t s o r s c a l e s c o r e s w i t h one o r m o r e e x t e r n a l c r i t e r i a a n d i s a p p l i e d w h e n one w i s h e s t o i n f e r f r o m a t e s t s c o r e o n e ' s p r o b a b l e s t a n d i n g o n some o t h e r v a r i a b l e o r c r i t e r i o n (APA, 1 9 7 4 ) . The q u a l i t y o f t h e c r i t e r i o n , as w e l l as t h e t e s t , i s i n v o l v e d i n t h i s p r o c e d u r e s i n c e t h e c r i t e r i o n u s e d m u s t be r e l i a b l e ( S t a n l e y a n d H o p k i n s , 1 9 7 2 ) . A c c o r d i n g t o K e r l i n g e r ( 1 9 7 3 )» t h e s i n g l e g r e a t e s t d i f f i c u l t y o f c r i t e r i o n - r e l a t e d v a l i d a t i o n i s t h e c r i t e r i o n s i n c e a r e l i a b l e c r i t e r i o n i s f r e q u e n t l y n o t a v a i l a b l e . B e c a u s e t h i s was t h e s i t u a t i o n f o r t h e p r e s e n t s t u d y , t h e r e w i l l be no f u r t h e r d i s c u s s i o n o f c r i t e r i o n - r e l a t e d v a l i d a t i o n . W h i l e v a l i d i t y i s a l w a y s a m a j o r c o n s i d e r a t i o n i n t e s t c o n s t r u c t i o n , r e l i a b i l i t y i s a l s o a c r u c i a l p r e r e q u i s i t e . A c - c o r d i n g t o t h e APA, " r e l i a b i l i t y r e f e r s t o t h e d e g r e e t o w h i c h t h e r e s u l t s o f t e s t i n g a r e a t t r i b u t a b l e t o s y s t e m a t i c s o u r c e s o f v a r i a n c e " ( 1 9 7 4 , p . 4 8 ) , t h a t i s , " t h e a c c u r a c y a n d p r e c i s i o n o f t h e m e a s u r e m e n t t a k e n b y t h e t e s t p r o c e d u r e " ( T h o r n d i k e a n d H a g e n , 1977» p « 5 6 ) . I n d i c e s o f r e l i a b i l i t y i n d i c a t e t h e e x t e n t t o w h i c h a p a r t i c u l a r m e a s u r e m e n t i s c o n s i s t e n t a n d r e p r o d u c i b l e a n d may be d e t e r m i n e d b y t h r e e p r o c e d u r e s : (1) t e s t - r e t e s t , (2) p a r a l l e l - f o r m s , a n d (3) s p l i t - h a l f o r i n t e r n a l c o n s i s t e n c y m e t h o d s . The t e s t - r e t e s t m e t h o d r e q u i r e s r e t e s t i n g w i t h t h e i d e n t i - c a l t e s t t h u s i n t r o d u c i n g a p r a c t i c e e f f e c t t h a t may c a u s e a s p u r i o u s l y h i g h c o r r e l a t i o n o f t h e t w o s e t s o f s c o r e s . To o v e r - come t h i s p r o b l e m , p a r a l l e l s e t s o f i t e m s , t h a t i s , t h e p a r a l l e l - f o r m s m e t h o d , c a n be u s e d . T h i s may be i m p r a c t i c a l i n s i t u a t i o n s w h e r e o n l y one t e s t i n g p e r i o d i s r e q u i r e d o r l i m i t e d f u n d s a r e a v a i l a b l e . To a v o i d t w o t e s t a d m i n i s t r a t i o n s o f u n s p e e d e d t e s t s , m e t h o d s w h i c h e s t i m a t e t h e i n t e r n a l c o n s i s t e n c y o f t h e t e s t a r e e m p l o y e d . A c c o r d i n g t o t h e APA ( 1 9 7 4 ) , e s t i m a t e s o f i n t e r n a l c o n s i s t e n c y s h o u l d be d e t e r m i n e d b y t h e s p l i t - h a l f m e t h o d o r b y a n a l y s i s o f v a r i a n c e p r o c e d u r e s . The f o r m e r m e t h o d may a s s e m b l e t h e t e s t i n t o h a l f - t e s t s b y m a t c h i n g , t h a t i s , u s i n g e x p e r t j u d g e m e n t t o b a l a n c e t h e c o n t e n t a n d d i f f i c u l t y l e v e l o r b y a l t e r n a t i n g i t e m s , t h a t i s , p u t t i n g a l l o d d - n u m b e r e d i t e m s i n one h a l f - t e s t a n d a l l t h e e v e n - n u m b e r e d i t e m s i n t h e o t h e r ( T h o r n d i k e a n d H a g e n , 1 9 7 7 ) • The o b t a i n e d s c o r e s f o r e a c h h a l f - t e s t c a n t h e n be c o r r e l a t e d t o s e c u r e a s p l i t - h a l f c o e f f i c i e n t o f r e l i a b i l i t y ( S t a n l e y a n d H o p k i n s , 1 9 7 2 ) . The a n a l y s i s o f v a r i a n c e p r o c e d u r e f o r e s t i m a t i n g i n t e r n a l c o n s i s t e n c y i s t h e H o y t r e l i a b i l i t y p r o c e d u r e t h a t d e f i n e s a v a r i a b l e e r r o r i n a s l i g h t l y d i f f e r e n t way t h a n t h e o t h e r p r o c e d u r e s . B e c a u s e a n y t e s t i s a s a m p l e f r o m a p o p u l a t i o n o f i t e m s , m o s t p r o c e d u r e s c o n s i d e r a n o b t a i n e d s c o r e t o be a c o m b i n a t i o n o f t h e " t r u e " s c o r e p l u s a r a n d o m e r r o r o f m e a s u r e m e n t . The H o y t p r o c e d u r e d i f f e r s i n t h a t v a r i a t i o n i n t h e p e r f o r m a n c e o f a n i n d i v i d u a l f r o m i t e m t o i t e m i s n o t c o n s i d e r e d t o be a n e r r o r b u t a r e a l ( n o n e r r o r ) d i f f e r e n c e . T h u s , t h e t o t a l v a r i a t i o n o b s e r v e d i s d i v i d e d i n t o t h r e e , n o t t w o p a r t s : t r u e i n t e r i n d i v i d u a l d i f - f e r e n c e s , i n t r a i n d i v i d u a l d i f f e r e n c e s , a n d e r r o r i n t e r i n d i v i d u a l d i f f e r e n c e s . T h i s c o n c e p t i s e x p r e s s e d i n t e r m s o f a m a t h e - m a t i c a l l y d e r i v e d H o y t r e l i a b i l i t y f o r m u l a w h i c h c a n be e s t i - m a t e d b y a n a n a l y s i s o f v a r i a n c e p r o c e d u r e ( H e l m s t a d t e r , 1 9 7 0 ) . A n o t h e r p r o c e d u r e t h a t d o e s n o t r e q u i r e s p l i t t i n g t h e t e s t i n t o t w o h a l v e s was s u g g e s t e d b y T h o r n d i k e a n d H a g e n ( 1 9 7 7 ) . I t d e p e n d s u p o n t h e c o n s i s t e n c y o f t h e i n d i v i d u a l ' s p e r f o r m a n c e f r o m i t e m t o i t e m a n d i s b a s e d o n t h e s t a n d a r d d e v i a t i o n o f t h e t e s t a n d t h e s t a n d a r d d e v i a t i o n o f t h e s e p a r a t e i t e m s . The e s t i m a t e o f r e l i a b i l i t y f o r m e d , t e r m e d C r o n b a c h ' s c o e f f i c i e n t " a l p h a " , e s t i m a t e s t h e d e g r e e t o w h i c h a l l o f t h e i t e m s m e a s u r e a common c h a r a c t e r i s t i c ( T h o r n d i k e a n d H a g e n , 1 9 7 7 ) . T h a t i s , i t " t e l l s how w e l l s c o r e s o b t a i n e d b y t e s t i n g u n d e r j u s t one c o n d i t i o n r e p r e s e n t u n i v e r s e s c o r e s " ( C r o n b a c h , 1970, p . 1 6 0 ) . P r a c t i c e M e a s u r e m e n t The l i t e r a t u r e c o n t a i n s s e v e r a l r e v i e w s o f d i e t a r y d a t a c o l l e c t i o n m e t h o d s f o r i n d i v i d u a l d i e t a r y i n t a k e s ( P e k k a r i n e n , 1970; M a r r , 1 9 7 1 , C h r i s t a k i s , 1973; B a z z a r r e a n d M y e r s , 1 9 7 9 ) . A l l a g r e e t h a t t h e r e i s no s i n g l e m e t h o d p r e s e n t l y a v a i l a b l e w h i c h i s f r e e f r o m e r r o r a n d l i m i t a t i o n s . H o w e v e r , e a c h m e t h o d p r o v i d e s c e r t a i n a d v a n t a g e s w h i c h m i g h t make i t more s u i t e d t o t h e p u r p o s e o f a p a r t i c u l a r s t u d y . Any d e c i s i o n r e g a r d i n g t h e m o s t a p p r o p r i a t e m e t h o d f o r a s s e s s i n g i n d i v i d u a l d i e t c o n s u m p - t i o n i n v o l v e s a c o n s i d e r a t i o n o f t h e p r o s p e c t i v e m e t h o d s b a s e d o n f o o d r e c o r d s , n a m e l y , f o o d i n v e n t o r y a n d w e i g h e d f o o d i n t a k e a n d t h e m o r e r e c e n t r e t r o s p e c t i v e m e t h o d s b a s e d o n d i e t a r y r e - c a l l . The l a t t e r f o c u s o n a c t u a l i n t a k e , u s u a l i n t a k e , o r f o o d f r e q u e n c y a n d u t i l i z e t h e i n t e r v i e w s c h e d u l e a n d / o r s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e . 54 P r o s p e c t i v e methods Although the p r o s p e c t i v e methods, e s p e c i a l l y f o o d r e c o r d s by d i r e c t weighing, p r o v i d e the most ac c u r a t e food i n t a k e data (Bazzarre and Myers, 1 9 7 9 ) , t h e i r many disadvantages r e s u l t e d i n t h e i r replacement w i t h the r e c a l l method f o r l a r g e s c a l e n u t r i t i o n s u r v e y s . The main l i m i t a t i o n s of the p r o s p e c t i v e methods are the n e c e s s i t y f o r a h i g h degree of c o o p e r a t i o n by the p a r t i c i p a n t s over a s u f f i c i e n t time i n t e r v a l , the i n a b i l i t y to determine i f the record-keeping of food consumed caused a change i n the normal e a t i n g h a b i t s , and the i n a b i l i t y to assess l a r g e numbers, p a r t i c u l a r l y i f d i r e c t weighing i s u t i l i z e d be- cause of p r o h i b i t i v e time, p e r s o n n e l , and monetary requirements. The a l t e r n a t i v e to p r o s p e c t i v e methods, r e t r o s p e c t i v e methods, attempts to q u a n t i f y a c t u a l i n t a k e , usual i n t a k e , or frequency of use of s p e c i f i c f o o d s . Chapter IV, Method, w i l l d i s c u s s d e t a i l s of the method chosen. The present d i s c u s s i o n w i l l summarize the advantages and l i m i t a t i o n s of the three v a r i a n t s of d i e t a r y r e c a l l as background f o r the study d e c i s i o n d e t a i l e d i n Chapter IV. R e t r o s p e c t i v e methods Pekkarinen ( 1 9 7 0 ) s t a t e d t h a t the major advantages of r e t r o s p e c t i v e methods i n g e n e r a l were r e p r e s e n t a t i v e n e s s and l a r g e s i z e of the sample, two f a c t o r s not always p o s s i b l e w i t h p r o s p e c t i v e methods. She a l s o i n c l u d e d l e s s cost r e l a t i v e to the p r o s p e c t i v e methods, no i n t e r f e r e n c e w i t h the normal d i e t , a n d s h o r t e r t i m e r e q u i r e m e n t as a d v a n t a g e s . The 2 4 — h o u r r e c a l l . The m o s t w i d e l y u s e d r e c a l l m e t h o d t h a t d e t e r m i n e s t h e a c t u a l a m o u n t s a n d t y p e s o f f o o d consumed i s t h e 24—hour r e c a l l . F o r l a r g e g r o u p s , i t i s c o n s i d e r e d t o p r o v i d e e s t i m a t e s o f g r o u p a v e r a g e i n t a k e s c o m p a r a b l e t o t h o s e o b t a i n e d w i t h m o r e cumbersome t e c h n i q u e s ( B e a t o n e t a l . , 1 9 7 9 ) . The m a j o r d i s a d v a n t a g e o f t h i s m e t h o d i s t h a t t h e d a t a do n o t p r o v i d e a r e l i a b l e e s t i m a t e o f t h e u s u a l i n t a k e s i n c e t h e d a y r e p r e s e n t e d may be a t y p i c a l . D i e t a r y h i s t o r y m e t h o d . The s e c o n d t y p e o f r e c a l l i s t h e d i e t a r y h i s t o r y m e t h o d w h i c h d e t e r m i n e s t h e i n d i v i d u a l ' s u s u a l i n t a k e . B e a l (1967) s u g g e s t e d t h a t u s u a l i n t a k e i s p r e f e r a b l e t o a c t u a l i n t a k e f o r c o r r e l a t i o n w i t h a l l i e d d a t a o n t h e i n d i - v i d u a l . M o s t d i e t a r y h i s t o r y m e t h o d s f o l l o w o r a r e m o d i f i c a - t i o n s o f t h e B u r k e m e t h o d ( B u r k e , 194-7) a n d c o n s i s t o f d a t a o n t h e o v e r a l l e a t i n g p a t t e r n i n c l u d i n g a 24—hour r e c a l l , a c r o s s - c h e c k , a n d s o m e t i m e s a 3 - d a y m e n u . The c o m p l e t e d i e t a r y h i s t o r y p r o c e d u r e r e q u i r e s f r o m one t o one a n d o n e - h a l f h o u r s ( B a z z a r r e a n d M y e r s , 1979) so t h e 3 - d a y menu i s f r e q u e n t l y o m i t t e d i n t h e i n t e r e s t o f t i m e . A r a n g e o f t i m e r e q u i r e m e n t s f r o m a n a v e r a g e o f 30 m i n u t e s ( A b r a m s o n e t a l . , 1 9 6 3 ) , 30 t o 4-5 m i n u t e s ( Y o u n g , 1959) t o a p p r o x i m a t e l y 60 m i n u t e s ( B u r k e , 194-<7) h a v e b e e n r e - p o r t e d . A l l a g r e e d t h a t t h e t i m e c o u l d v a r y d e p e n d i n g o n t h e t y p e o f h i s t o r y u s e d . Use o f g r a d u a t e d f o o d m o d e l s i n t h e i n t e r v i e w i s a d e c i d e d a d v a n t a g e as i t i s r e p o r t e d t o l e s s e n t h e i n t e r v i e w t i m e r e q u i r e m e n t , g r e a t l y r e d u c e t h e f r u s t r a t i o n o f r e s p o n d e n t s , a n d p e r h a p s c o n t r i b u t e t o t h e q u a n t i t a t i v e a c c u r a c y o f t h e r e - p o r t e d i n t a k e s ( M o o r e e t a l . , I 9 6 7 ) • The i n f o r m a t i o n o b t a i n e d i s t r a n s l a t e d i n t o u s u a l i n t a k e b y a n u t r i t i o n i s t who d e t e r m i n e s t h e a v e r a g e i n t a k e o n t h e b a s i s o f t h e u s u a l p a t t e r n a n d c r o s s - c h e c k . B e c a u s e t h e v a l u e s a r e n u t r i e n t i n t a k e e s t i m a t e s , B u r k e (1947) p r o p o s e d t h e use o f a r a t i n g s c a l e t o a n a l y z e a n d i n t e r p r e t t h e v a l u e s . I n C a n a d a , t h e m o s t w i d e l y u s e d s t a n d a r d f o r r a t i n g n u t r i e n t v a l u e s , i s t h e C a n a d i a n D i e t a r y S t a n d a r d (CDS) ( C a n a d a , 1975a). The d i s a d v a n t a g e s o f t h e d i e t a r y h i s t o r y a r e t h e d e p e n d e n c y o n t h e i n t e r v i e w e r ' s s k i l l a n d t h e p a r t i c i - p a n t ' s memory a n d d e g r e e o f c o o p e r a t i o n . P e k k a r i n e n (1970) v i e w e d t h e d e p e n d e n c y o n p e r s o n a l c h a r a c t e r i s t i c s o f t h e i n t e r - v i e w e r as t h e m a i n d i s a d v a n t a g e o f t h e i n t e r v i e w t e c h n i q u e u s e d i n a n y r e c a l l m e t h o d . She s t a t e d t h a t " t h e a t t i t u d e o f t h e i n t e r v i e w e r t o w a r d s t h e r e s p o n d e n t s may be d e c i s i v e f o r t h e s u c c e s s o f t h e s u r v e y i n some c a s e s " ( p . l 6 2 ) . D i f f e r e n c e s b e - t w e e n i n t e r v i e w e r s w e r e n o t c o n s i d e r e d t o a l t e r a p p r e c i a b l y t h e r e s u l t s o f t h e s u r v e y p r o v i d e d t h a t t h e i n t e r v i e w e r s h a d s i m i - l a r b a c k g r o u n d s a n d t r a i n i n g ( C h u r c h e t a l . , 1954). I n a d d i t i o n t o t h e c o n c e r n a b o u t t h e i n t e r v i e w , t h e d i e t - a r y h i s t o r y g e n e r a l l y i n v o l v e s m o r e t i m e , c o s t , a n d - p r o f e s s i o n a l p e r s o n n e l t h a n t h e o t h e r v a r i a t i o n s o f r e c a l l . The a d v a n t a g e s may c o m p e n s a t e f o r t h e a d d i t i o n a l c o s t . L i n u s s o n e t a l . (1974) a d v o c a t e d t h e u s e o f t h e d i e t a r y h i s t o r y o v e r t h e 2 4 - h o u r r e c a l l as a m e t h o d o f p r o v i d i n g q u a n t i t a t i v e i n f o r m a t i o n as o p p o s e d t o m o r e q u a l i t a t i v e e s t i m a t e s , e s p e c i a l l y i f t h e s u r v e y p o p u l a t i o n c o n s u m e d a v a r i e d d i e t . I n f a c t , a o n e - w e e k r e c a l l s u r v e y may n o t he s u f f i c i e n t t o p r o v i d e r e l i a b l e d a t a o n n o r m a l f o o d c o n s u m p t i o n i f t h e s a m p l e f o l l o w s a v a r i e d d i e t ( P e k k a r i n e n , 1970) . F o o d f r e q u e n c y . The t h i r d t y p e o f r e c a l l , f o o d f r e q u e n c y , c o l l e c t s s e m i - q u a n t i t a t i v e d a t a o n f r e q u e n c y o f c o n s u m p t i o n o f f o o d i t e m s s u b d i v i d e d i n t o s p e c i f i c f o o d g r o u p s ( B a z z a r r e a n d M y e r s , 1 9 7 9 ) • The l i s t o f f o o d i t e m s c a n be s h o r t o r v e r y l o n g r e q u i r i n g as m u c h a s t w o h o u r s f o r c o m p l e t i o n . D a t a , e x p r e s s e d as t h e n u m b e r o f t i m e s a s p e c i f i c f o o d t y p e i s consumed p e r u n i t o f t i m e ( d a y o r w e e k ) , may be a n a l y z e d d i r e c t l y o r be c o n v e r t e d t o a f o o d s c o r e , a more q u a n t i t a t i v e e s t i m a t e o f t h e f o o d c o n - s u m e d . The a d v a n t a g e s o f t h e f o o d f r e q u e n c y m e t h o d a r e t h a t i t f o c u s e s o n s p e c i f i c f o o d s , n o t n u t r i e n t s , a n d t h e r e f o r e e l i m i n - a t e s t h e e r r o r s i n h e r e n t i n f o o d c o m p o s i t i o n t a b l e s . D i s a d - v a n t a g e s a r e t h e l a c k o f q u a n t i t a t i v e d a t a as w e l l as r e l i a n c e o n p a r t i c i p a n t ' s a b i l i t y t o r e c a l l f o o d , t h e a m o u n t c o n s u m e d , a n d t h e f r e q u e n c y o f i t s c o n s u m p t i o n . B a z z a r r e a n d M y e r s (1979) s u g g e s t e d t h a t t h e f r e q u e n c y m e t h o d m i g h t r e d u c e t h e c h a n c e o f s h o w i n g t r u e d i f f e r e n c e s among g r o u p s due t o f a i l u r e o f t h e s u b j e c t t o r e m e m b e r d i f f e r e n t f o o d s , e s p e c i a l l y i f t h e f o o d s w e r e " l o w e s t e e m " f o o d s n e c e s s a r y f o r t h e p u r p o s e o f t h e s t u d y . B a l o g h e t a l . ( I 9 6 8 ) , o n t h e o t h e r h a n d , r e p o r t e d s u c c e s s w i t h a f r e q u e n c y q u e s t i o n n a i r e d e v e l o p e d as p a r t o f a c a r d i o v a s c u l a r d i s e a s e s u r v e y . 58 R e g a r d l e s s o f t h e t y p e o f i n s t r u m e n t t h a t i s c h o s e n , i t m u s t he e v a l u a t e d b y v a l i d a t i o n a n d r e l i a b i l i t y p r o c e d u r e s p r i o r t o i t s a d m i n i s t r a t i o n i n t h e f i e l d . V a l i d i t y a n d r e l i a b i l i t y o f d i e t a r y p r a c t i c e i n s t r u m e n t s The a c t u a l v a l i d a t i o n o f a d i e t a r y i n t a k e i n s t r u m e n t u t i l - i z e s t h e same p r i n c i p l e s a n d p r o c e d u r e s as v a l i d a t i o n o f a n y i n s t r u m e n t o f t e s t i n g a n d m e a s u r e m e n t . The p r e s e n t s t a t e o f l i m i t e d k n o w l e d g e r e g a r d i n g d i e t b e h a v i o u r i n t h e g e n e r a l p o p u l a - t i o n p r e s e n t s u n i q u e p r o b l e m s . The m o s t d e s i r a b l e m e t h o d f o r v a l i d m e a s u r e m e n t o f f o o d i n t a k e i s c o n s i d e r e d t o be t h e p r e c i s e w e i g h i n g t e c h n i q u e ( B a l o g h e t a l . , 1968; P e k k a r i n e n , 1970; M a r r , 1971).- Due t o i t s h i g h c o s t a n d t i m e r e q u i r e m e n t , i t i s i m - p r a c t i c a l f o r s u r v e y s o f t h e g e n e r a l p o p u l a t i o n ( B u r k e , 19^7). R e s e a r c h e r s h a v e a t t e m p t e d t o v a l i d a t e t h e r e t r o s p e c t i v e m e t h o d s a g a i n s t t h e f o o d r e c o r d o r o n e - w e e k w e i g h e d r e c o r d t e c h n i q u e s b u t h a v e a c h i e v e d l i t t l e s u c c e s s ( Y o u n g e t a l . , 1952; P e k k a r - i n e n , 1970; M a r r , 1971). P a r t o f t h e d i f f i c u l t y may be a t t r i - b u t e d t o t h e l a c k o f c o n t r o l l e d c o n d i t i o n s f o r w e i g h i n g o r m e a s u r i n g , a n d t o t h e d i s a d v a n t a g e o f c r e a t i n g a n a r t i f i c i a l s i t u a t i o n w h i c h may a l t e r t h e n o r m a l e a t i n g p a t t e r n o f t h e i n d i v i d u a l ( B u r k e , 1 9 ^ 7 ) . Y o u n g e t a l . (1952) c o n c l u d e d t h a t i t was i m p o s s i b l e t o p r e d i c t a n i n d i v i d u a l ' s f o o d i n t a k e as e s t i m a t e d b y one m e t h o d ( d i e t a r y h i s t o r y ) b y p r o j e c t i n g v a l u e s f o r a n o t h e r m e t h o d ( s e v e n - d a y r e c o r d ) w i t h a n y p r a c t i c a l d e g r e e o f a c c u r a c y . D a w b e r e t a l . (I962) s t a t e d t h e i m p o r t a n t c o n - s i d e r a t i o n i s t h a t t h e " m e a s u r e m e n t o f t h e v a r i a b l e ( d i e t a r y 59 i n t a k e ) be s u f f i c i e n t l y a c c u r a t e t o p l a c e a s u b j e c t i n a s u b - g r o u p w i t h r e a s o n a b l e c e r t a i n t y a n d t h a t t h e s u b g r o u p s d i f f e r s i g n i f i c a n t l y , one f r o m t h e o t h e r " ( p . 2 2 ? ) . T h e y c o n c l u d e d t h a t a s u i t a b l e m e t h o d f o r e s t a b l i s h i n g v a l i d i t y o f d i e t a r y e v a l u a - t i o n d i d n o t e x i s t . M a r r (1971) e m p h a s i z e d t h e n e e d t o a s c e r - t a i n t o w h a t e x t e n t v a l i d i t y i s i n f l u e n c e d b y t h e p r a c t i c a l n e c e s s i t y o f r e p l a c i n g t h e p r e c i s e w e i g h i n g t e c h n i q u e w i t h a d e s c r i p t i v e m e a s u r e m e n t s u c h as t h e m o d i f i e d d i e t a r y h i s t o r y u s i n g t h e i n t e r v i e w t e c h n i q u e . A n y l o s s o f v a l i d i t y m u s t be b a l a n c e d a g a i n s t t h e u s e f u l n e s s o f t h e d a t a f r o m s a m p l e s o f a f r e e - l i v i n g p o p u l a t i o n . To i m p r o v e v a l i d i t y l o s t b y d a t a r e c o r d e d i n d e s c r i p t i v e e s t i m a t e s , M a r r (1971) s u g g e s t e d t h e i n c l u s i o n o f b o t h a 2 4 - h o u r r e c a l l a n d a c u r r e n t r e c o r d i n t h e h i s t o r y m e t h o d . D e s p i t e t h e s h o r t c o m i n g s o f t h e d i e t a r y h i s t o r y m e t h o d , many r e s e a r c h e r s c o n s i d e r " t h e d i e t a r y d a t a t o be a r e a s o n a b l e a p p r o x i m a t i o n o f t h e t r u t h " ( P a u l e t a l . , I 9 6 3 , p . 2 8 ) . P r o g r e s s i n t h i s a r e a o f v a l i d a t i o n o f d i e t a r y i n t a k e m e a s u r e m e n t s h a s b e e n m i n i m a l i n t h e l a s t s e v e r a l d e c a d e s . As a r e s u l t , c r i t e r i o n - r e l a t e d v a l i d a t i o n i s n o t f e a s i b l e n o r i s c o n s t r u c t v a l i d a t i o n ; t h e f o r m e r , b e c a u s e o f l a c k o f a v a l i d c r i t e r i o n a n d t h e l a t t e r , b e c a u s e o f l a c k o f i n f o r m a t i o n c o n - c e r n i n g t h e c o n s t r u c t ( d i e t a r y i n t a k e ) . S i n c e t h e r e q u i r e m e n t , d e v e l o p m e n t o f a n h y p o t h e s i s a b o u t t h e c o n s t r u c t ( C r o n b a c h , 1971)» i s n o t c r e d i b l e as a r e s u l t o f t h e p r e s e n t s t a t e o f k n o w l e d g e r e g a r d i n g d i e t b e h a v i o u r o f t h e g e n e r a l p o p u l a t i o n , a s y s t e m a t i c t e s t i n g o f t h e h y p o t h e s i s b y p r o c e d u r e s s u c h a s t h e k n o w n g r o u p s m e t h o d i s n o t f e a s i b l e a t p r e s e n t . C o n t e n t v a l i d a t i o n i s p o s s i b l e , h o w e v e r , a n d c a n be d e t e r m i n e d b y a n e x p e r t p a n e l o f j u d g e s u s i n g l o g i c a l a n a l y s i s . E a c h q u e s t i o n o f t h e s t r u c t u r e d i n t e r v i e w m u s t be r e l a t e d t o t h e t o p i c o f t h e s u r v e y , m u s t a d e q u a t e l y c o v e r t h e o v e r a l l t o p i c , a n d m u s t be c l e a r a n d u n a m b i g u o u s ( M o u l y , 1970) . S i n c e t h e v a l i d i t y o f t h e i n t e r v i e w m e t h o d h a s b e e n r e p o r t e d t o be d i r e c t l y p r o p o r t i o n a l t o t h e c o m p e t e n c e o f t h e i n t e r v i e w e r ( M o u l y , 1 9 7 0 ) , r i g o r o u s s e l e c t i o n a n d i n t e n s i v e t r a i n i n g o f t h e i n t e r v i e w e r s w i l l a s s u r e q u a l i t y c o n t r o l o f t h e d i e t a r y a s s e s s m e n t p r o c e d u r e a n d i m p r o v e v a l i d i t y ( B a l o g h e t a l . , 1 9 6 8 ) . C o n t e n t v a l i d a t i o n o f t h e p r a c - t i c e q u e s t i o n n a i r e w o u l d f o l l o w t h e same p r o c e d u r e s as t h e i n t e r v i e w s c h e d u l e . R e l i a b i l i t y o f t h e i n t e r v i e w m e t h o d may be d e t e r m i n e d i n v a r i o u s w a y s . The m o d i f i e d d i e t a r y h i s t o r y a s k s q u e s t i o n s o n t h e g e n e r a l f o o d p a t t e r n s a n d h a b i t s o f t h e i n d i v i d u a l o v e r a r e l a t i v e l y l o n g p e r i o d o f t i m e . . The o b t a i n e d d a t a may be c r o s s - c h e c k e d ( B u r k e , 19^7) b y w e i g h i n g d i f f i c u l t i t e m s o r r e c o r d i n g d a i l y a n d w e e k l y f o o d p u r c h a s e s . T h i s t y p e o f c r o s s - c h e c k i s r e s t r i c t e d t o t h o s e i n t e r v i e w s h e l d a t h o m e . I f t h e i n t e r v i e w i s h e l d away f r o m home, c r o s s - c h e c k i n g c a n c o n s i s t o f a s k i n g a d d i t i o n a l q u e s t i o n s c o n c e r n i n g g e n e r a l f o o d h a b i t s ( P e k k a r i n e n , 1970) o r c o n c e r n i n g t h e u s u a l i n t a k e o f f o o d s f r o m a c h e c k l i s t o f f o o d g r o u p s ( Y o u n g e t a l . , 1 9 5 2 ) . The u s e o f f o o d m o d e l s a n d q u a l i t y c o n t r o l o f t h e p r o c e d u r e i t s e l f h a v e a l s o b e e n s u g g e s t e d a s a n a i d e i n p r o m o t i n g r e l i a b l e d a t a ( Y o u n g e t a l . , 1952; B a l o g h e t a l . , 1 9 6 8 ) . B u r k e (19^7) s u g g e s t e d t h a t c a r e f u l q u e s t i o n i n g as t o e a c h f o o d g r o u p l i s t e d i n r e l a t i o n t o t h e a m o u n t g i v e n as u s u a l i n t a k e , was e s s e n t i a l t o i m p r o v e t h e a c c u r a c y o f t h e h i s t o r y . I n t h i s w a y , i t i s p o s s i b l e t o c l a r i f y a n d v e r i f y t h e d a t a . B e c a u s e some i n a c c u r a c i e s o f d i e t a r y h i s - t o r y a r e i n e v i t a b l e , B u r k e s u g g e s t e d t h e u s e o f r a t i n g s c a l e s r a t h e r t h a n p r e c i s e q u a n t i t i e s f o r e x p r e s s i n g d i e t a r y i n t a k e so t h a t t h e r a n g e w o u l d a b s o r b t h e i n a c c u r a c i e s a n d p r o m o t e r e l i - a b i l i t y . R e l i a b i l i t y o f t h e m o d i f i e d d i e t a r y h i s t o r y q u e s t i o n n a i r e d a t a c a n be d e t e r m i n e d b y a c o n g r u e n c y c h e c k m e t h o d . A c o m p a r i - s o n o f t h e r e s p o n s e s b y p e r s o n a l i n t e r v i e w u s i n g a s c h e d u l e d e v e l o p e d as a p a r a l l e l f o r m o f a m o d i f i e d d i e t a r y h i s t o r y s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e c a n s u p p o r t t h e r e l i a b i l i t y o f t h e u s u a l i n t a k e d a t a p r o v i d e d t h a t no s i g n i f i c a n t d i f f e r e n c e s a r e f o u n d b e t w e e n t h e t w o r e s p o n s e s b y a p a i r e d t t e s t . R e c e n t s t u d i e s i n v e s t i g a t e d t h e e f f e c t o f i n t r a i n d i v i d u a l s o u r c e s o f v a r i a t i o n i . e . , day b y d a y v a r i a t i o n i n i n t a k e , o n t h e r e l i a b i l i t y o f t h e e s t i m a t e s o f mean c o n s u m p t i o n ( L i u e t a l . , 1 9 7 8 ; B e a t o n e t a l . , 1 9 7 9 ) a n d t h e a u t h o r s s u g g e s t e d p o s s i b l e p r o c e d u r e s f o r d i m i n i s h i n g t h e e f f e c t o f t h i s i n t r a i n d i v i d u a l v a r i a t i o n t o i m p r o v e t h e v a l i d i t y o f t h e g r o u p mean e s t i m a t e s . L i u e t a l . ( 1 9 7 8 ) c o n c l u d e d a s i n g l e 2 4 — h o u r r e c a l l was a v e r y l i m i t e d t o o l t o r e p r e s e n t a n i n d i v i d u a l ' s t r u e i n t a k e due t o t h e i n f l u e n c e o f t h e i n t r a i n d i v i d u a l v a r i a t i o n . T h e y f u r t h e r s t a t e d t h e p r e s e n c e o f a h i g h d e g r e e o f i n t r a i n d i v i d u a l v a r i a - t i o n i n f o o d i n t a k e d a t a b a s e d o n a s i n g l e d a y ' s i n t a k e m i g h t be t h e e x p l a n a t i o n f o r t h e r e p o r t e d l a c k o r weak r e l a t i o n s h i p b e t w e e n n u t r i e n t s a n d v a r i o u s r i s k f a c t o r s ( F r a n k e t a l . , 1978) I n c o n t r a s t , B e a t o n e t a l . (1979) c o n c l u d e d t h a t g o o d e s t i m a t e s o f g r o u p a v e r a g e i n t a k e s c o u l d be o b t a i n e d w i t h one d a y d a t a f o r a r e a s o n a b l e - s i z e d g r o u p p r o v i d e d t h a t t h e g r o u p s w e r e f o r m ed b y u s i n g a v a r i a b l e k n o w n t o h a v e a s m a l l i n t r a i n d i v i d u a l v a r i a t i o n . T h u s , t h e c h o i c e o f a p p r o a c h t o d a t a a n a l y s i s may r e d u c e t h e i m p a c t o f a l a r g e i n t r a i n d i v i d u a l v a r i a t i o n i n d i e t - a r y d a t a p e r m i t t i n g t h e c o n t i n u e d u s e o f t h e 2 4 - h o u r r e c a l l . B e a t o n e t a l . (1979) f u r t h e r s u g g e s t e d t h a t t h e d a t a be a n a - l y z e d u s i n g n u t r i e n t c o n c e n t r a t i o n s ( i n p r o p o r t i o n t o e n e r g y ) r a t h e r t h a n a b s o l u t e n u t r i e n t i n t a k e . I n t h e B o g a l u s a H e a r t S t u d y , F r a n k e t a l . (1978) r e p o r t e d a s i m i l a r a p p r o a c h t o a n a l - y s i s i n w h i c h c h i l d r e n w e r e g r o u p e d a c c o r d i n g t o r i s k f a c t o r l e v e l . A p r e v i o u s g r o u p i n g b y i n t a k e l e v e l o f s e l e c t e d n u t r i - e n t s h a d f a i l e d t o r e s u l t i n o b s e r v a b l e d i f f e r e n c e s i n a n y r i s k f a c t o r l e v e l s t r e s s i n g t h e i m p o r t a n c e o f c h o o s i n g t h e m o s t a p p r o p r i a t e g r o u p i n g v a r i a b l e . M o d i f i c a t i o n s o f t h e d i e t a r y h i s t o r y m e t h o d h a v e b e e n u s e d i n d i e t - C V D s t u d i e s ( P a u l e t a l . , 1 9 6 3 ; K a n n e t a l . , 1969; N i c h o l s e t a l . , 1 9 7 6 ) . The u s e o f t h i s m e t h o d assumes t h e i n t r a i n d i v i d u a l v a r i a t i o n h a s b e e n a c c o u n t e d f o r b y t h e i n d i - v i d u a l r e p o r t i n g h i s u s u a l h a b i t o v e r a s p e c i f i e d t i m e p e r i o d ( L i u e t a l . , - 1 9 7 8 ) . Dawber e t a l . (1962) e x p r e s s e d c o n c e r n a b o u t t h e a b i l i t y o f a p e r s o n t o d i r e c t l y e s t i m a t e h i s own t r u e mean f o r d i e t a r y i n t a k e . B e a l ( 1 9 6 7 ) , b a s e d o n r e s u l t s f r o m a 1 2 - y e a r l o n g i t u d i n a l s t u d y , c o n c l u d e d i n d i v i d u a l s w e r e n o t a b l e t o g i v e a d e q u a t e d a t a u s i n g t w i c e - y e a r l y h i s t o r i e s b u t w e r e a b l e t o g i v e a d e q u a t e d a t a f o r m o n t h l y h i s t o r i e s . She a l s o 63 s t r e s s e d t h a t a f t e r one y e a r , t h e i n t e r v a l p e r i o d c o u l d be e x t e n d e d t o t h r e e m o n t h s w i t h o u t a f f e c t i n g t h e q u a l i t y o f t h e d a t a . L i u e t a l . (1978) s u g g e s t e d a n y c o r r e l a t i o n s t u d y t e s t - i n g t h e r e l a t i o n s h i p b e t w e e n d i e t p a t t e r n s a n d some o t h e r v a r i - a b l e e . g . , s e r u m c h o l e s t e r o l , s h o u l d u s e d i e t r e c a l l o r c o n - s e c u t i v e d a i l y f o o d r e c o r d m e t h o d s , p r o v i d e d t h e e f f e c t o f i n t r a i n d i v i d u a l v a r i a t i o n was c o n s i d e r e d , b u t t h a t t h e d i e t a r y h i s t o r y m e t h o d was c l e a r l y i n a p p r o p r i a t e . W h i l e no r e a s o n f o r r e j e c t i n g t h e d i e t a r y h i s t o r y m e t h o d was o f f e r e d , t h e f a c t t h a t , i t i s a s i n g l e m e a s u r e m e n t ( a s e r i e s o f h i s t o r i e s a r e a s s u m e d t o m e a s u r e c h a n g e i n p a t t e r n ) w h i c h does n o t p e r m i t t h e i d e n t - i f i c a t i o n o f i n t r a i n d i v i d u a l v a r i a t i o n , may be t h e c a u s e . S i n c e b o t h r e p e a t e d r e c a l l a n d d a i l y f o o d r e c o r d m e t h o d s a l l o w t h e i d e n t i f i c a t i o n o f i n t r a i n d i v i d u a l v a r i a t i o n , L i u e t a l . (1978) c o n s i d e r e d t h e m m o r e s u i t a b l e . C o n c l u s i o n T h i s r e v i e w o f t h e l i t e r a t u r e i l l u s t r a t e s t h e s c o p e o f o u r p r e s e n t u n d e r s t a n d i n g o f c a r d i o v a s c u l a r n u t r i t i o n as w e l l a s t h e c o n s e n s u s among i n t e r n a t i o n a l e x p e r t s i n a t h e r o s c l e r o s i s a n d l i p i d s t h a t t h e r e i s a n a d e q u a t e b a s i s f o r r e c o m m e n d i n g d i e t a r y c h a n g e s . The r e c o m m e n d a t i o n s a r e i n t e n d e d as a p r e - v e n t i v e m e a s u r e d e s i g n e d t o r e d u c e t h e r i s k o f CVD among t h e g e n e r a l p o p u l a t i o n ( T r u s w e l l , 1976; C a n a d a , 1977; U . S . S e n a t e , 1977; S h a p e r a n d M a r r , 1977; T u r n e r , 1 9 7 8 ) . As a p r e r e q u i s i t e t o t h e d e v e l o p m e n t o f e f f e c t i v e e d u c a t i o n s t r a t e g i e s t o a s s i s t a d u l t s i n i m p l e m e n t i n g t h e r e c o m m e n d a t i o n s , b a s e l i n e d a t a a r e r e q u i r e d . C u r r e n t r e s e a r c h o n t h e r e l a t i o n s h i p s among n u t r i t i o n a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e i s r e v i e w e d t o e x p o s e a r e a s r e q u i r i n g f u r t h e r i n v e s t i g a t i o n . A n o v e r v i e w o f t h e a v a i l a b l e m e t h o d s f o r a s s e s s i n g t h e s e t h r e e v a r i a b l e s ( a t t i t u d e s , k n o w - l e d g e , a n d p r a c t i c e ) p r o v i d e s b a c k g r o u n d f o r d e c i s i o n - m a k i n g o f t h e p r e s e n t s t u d y . The f o l l o w i n g c h a p t e r p r e s e n t s t h e p r e l i m i - . n a r y a n d p i l o t t e s t i n g o f i n s t r u m e n t s w h i c h v a l i d a t e d t h e a t t i - t u d e , k n o w l e d g e , a n d p r a c t i c e i n s t r u m e n t s a n d p r e t e s t e d t h e t o t a l q u e s t i o n n a i r e d e v e l o p e d f o r u s e i n t h e m a i n s t u d y . CHAPTER I I I PRELIMINARY AND PILOT TESTING OF INSTRUMENTS P u r p o s e P r e l i m i n a r y a n d p i l o t t e s t i n g was c o n d u c t e d t o : (1) v a l i - d a t e t h e a t t i t u d e a n d k n o w l e d g e i n s t r u m e n t s s p e c i f i c a l l y d e v e l - o p e d f o r t h e p r e s e n t s t u d y , a n d (2) p r e t e s t t h e d a t a c o l l e c t i o n p r o c e d u r e . The t e s t i n g i n v o l v e d s e v e r a l s t a g e s : p r e p a r a t i o n o f a d r a f t q u e s t i o n n a i r e , v a l i d a t i o n o f t h e i n s t r u m e n t a t i o n , p r e t e s t i n g , r e v i s i n g t h e q u e s t i o n n a i r e f o r p i l o t t e s t i n g , a n a l y z - i n g t h e r e s u l t s o f t h e s t u d y , a n d r e f i n e m e n t o f t h e q u e s t i o n - n a i r e f o r l a t e r use i n t h e m a i n s t u d y . P r e l i m i n a r y T e s t i n g P r i o r t o c o n s t r u c t i o n o f t h e q u e s t i o n n a i r e , r a t i n g s c a l e s w e r e c h o s e n t o m e a s u r e a t t i t u d e s a n d k n o w l e d g e . The use o f s i m i l a r s c o r i n g p r o c e d u r e s a n d f o r m a t s was d e s i r e d f o r ease i n r e s p o n d i n g a n d f a m i l i a r i t y o f t h e c a t e g o r i e s u s e d . The a t t i t u d e , k n o w l e d g e , a n d p r a c t i c e d a t a w e r e c o l l e c t e d b y means o f a s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e . T h i s q u e s t i o n - n a i r e c o n s i s t e d o f f o u r s e c t i o n s r e l a t e d , r e s p e c t i v e l y , t o n u t r i t i o n a t t i t u d e s , n u t r i t i o n k n o w l e d g e , b i o d e m o g r a p h i c i n f o r - m a t i o n , a n d n u t r i t i o n p r a c t i c e . A l l p a r t s o f t h e q u e s t i o n n a i r e w e r e c o m p l e t e d b y a l l p a r t i c i p a n t s . N u t r i t i o n A t t i t u d e I n s t r u m e n t S i n c e t h e p u r p o s e o f t h e a t t i t u d e i n s t r u m e n t was t o a s - c e r t a i n t h e a t t i t u d e s o r f e e l i n g s r e g a r d i n g d i e t as a means o f p r o m o t i n g h e a r t h e a l t h a n d i n t e r v e n i n g a g a i n s t h e a r t d i s e a s e , t h r e e s u b - s c a l e s w e r e c h o s e n t o r e p r e s e n t t h i s d o m a i n . F o l l o w i n g p r o c e d u r e s o u t l i n e d b y E d w a r d s (1957)» t h r e e s u b t e s t s o f f i v e i t e m s e a c h w e r e f o r m e d . The f i r s t s u b d o m a i n f o c u s e d o n a t t i - t u d e s t o w a r d t h e g e n e r a l r o l e o f d i e t i n h e a r t d i s e a s e (A : GEN R O L E ) . B e c a u s e t h e C a n a d i a n g u i d e l i n e s ( C a n a d a , 1977) r e c o m - mended some c h a n g e s i n d i e t a r y h a b i t s , a t t i t u d e s r e g a r d i n g c h a n g i n g o r m a n i p u l a t i n g t h e d i e t w e r e i n c l u d e d as t h e s e c o n d s u b d o m a i n ( A : MANAGE) o f t h e a t t i t u d e i n s t r u m e n t . F i n a l l y , b e c a u s e t h e r e c o m m e n d a t i o n s w e r e d e s i g n e d t o h e l p t h e p u b l i c t a k e some p e r s o n a l r e s p o n s i b i l i t y f o r h e a l t h (Rae a n d M u r r a y , 1 9 7 8 ) , t h e t h i r d s e c t i o n o f t h e i n s t r u m e n t was d e v e l o p e d t o d e t e r m i n e t h e a t t i t u d e s t o w a r d s e l f - r e s p o n s i b i l i t y ( A : RESPON) f o r h e a r t h e a l t h . I t e m s t h a t e x p r e s s e d a g r e e m e n t w i t h t h e C a n a d i a n r e c o m m e n d a t i o n s o r t h e i n t e n t i o n s o f t h e r e c o m m e n d a - t i o n s (Rae a n d M u r r a y , 1978) w e r e c o n s i d e r e d f a v o u r a b l e o f p o s i t i v e a n d t h o s e t h a t d i s a g r e e d , u n f a v o u r a b l e o r n e g a t i v e . The s c o r i n g s y s t e m , v a l i d a t e d i n p r e v i o u s r e s e a r c h ( T h o m p - s o n a n d S c h w a r t z , 1977) p r o v i d e d f o r t w o r e s p o n s e s t o e a c h s t a t e m e n t ; t h e f i r s t , a d e s i g n a t i o n o f a g r e e m e n t o r d i s a g r e e - m e n t a n d t h e s e c o n d , a d e s i g n a t i o n o f one o f f o u r d e g r e e s o f c e r t a i n t y f o r t h e r e s p o n s e r a n g i n g f r o m v e r y d o u b t f u l t o v e r y c e r t a i n . E a c h s t a t e m e n t was t h e n s c o r e d f r o m one t o e i g h t , w i t h a s c o r e o f one r e p r e s e n t i n g a n e g a t i v e a t t i t u d e w i t h t h e h i g h e s t d e g r e e o f c e r t a i n t y a n d a s c o r e o f e i g h t r e p r e s e n t i n g a p o s i t i v e a t t i t u d e w i t h t h e h i g h e s t d e g r e e o f c e r t a i n t y . A p a n e l o f s e v e n n u t r i t i o n e x p e r t s f a m i l i a r w i t h t h e s u b - j e c t m a t t e r a n d a c t i v e l y i n v o l v e d i n c o m m u n i t y n u t r i t i o n s e r v - i c e s i n B r i t i s h C o l u m b i a i n d e p e n d e n t l y v a l i d a t e d t h e i n s t r u m e n t . I n a d d i t i o n , p r i o r t o p r e l i m i n a r y t e s t i n g , s e v e n g r a d u a t e s t u - d e n t s i n human n u t r i t i o n a n d f i v e a d u l t s w i t h l i t t l e o r no p r e v i o u s e x p o s u r e t o f o r m a l n u t r i t i o n p r e t e s t e d t h e i n s t r u m e n t . F rom t h e v a l i d a t i o n a n d p r e t e s t r e s u l t s , m i n o r c h a n g e s w e r e made t o t h e w o r d i n g o f s e v e r a l i t e m s . The a t t i t u d e q u e s t i o n - n a i r e was t h e n p r e p a r e d f o r p r e l i m i n a r y t e s t i n g d u r i n g t h e Summer 1978 w i t h 4 1 p e o p l e o f t h e same n a t u r e as t h o s e who w o u l d r e c e i v e t h e f i n a l d r a f t , n a m e l y , m a l e a n d f e m a l e a d u l t members o f c o m m u n i t y c e n t r e s . I t e m a n a l y s i s was p e r f o r m e d o n e a c h s u b t e s t u s i n g LERTAP ( N e l s o n , 1974), a c o m p u t e r p r o g r a m , t o d e t e r m i n e i f t h e i t e m - s u b t e s t c o r r e l a t i o n s w e r e p o s i t i v e . P o s i t i v e c o r r e l a t i o n s f o r f i v e , t h r e e , a n d t h r e e i t e m s , r e s p e c t i v e l y , w e r e f o u n d . R e - s u l t s o f a n a l y s i s f o r i n t e r n a l c o n s i s t e n c y o f t h e t h r e e s u b - t e s t s i n d i c a t e d t h a t t h e a t t i t u d e i n s t r u m e n t , i n i t s p r e l i m - i n a r y f o r m , h a d l o w r e l i a b i l i t y ( r = .60, .10, a n d .00, r e s p e c t t i v e l y ) . The r e v i s e d a t t i t u d e i n s t r u m e n t B a s e d u p o n t h e s e o b s e r v a t i o n s , s e v e r a l c h a n g e s w e r e i n t r o - d u c e d : 68 (1) The i t e m s w e r e r e - e x a m i n e d a n d r e f i n e d f o r i m p r o v e - m e n t i n c l a r i t y . The c o n s t r u c t i o n o f t h e i t e m s was s u c h t h a t , as f a r as p o s s i b l e , e a c h s u b t e s t c o n t a i n e d e q u a l n u m b e r s o f i t e m s t h a t r e f l e c t e d p o s i t i v e a n d n e g a t i v e a t t i t u d e s . The i t e m s w e r e t h e n r a n d o m l y o r d e r e d w i t h i n t h e s c a l e . (2) B e c a u s e t h e r e l i a b i l i t y c o e f f i c i e n t i n c r e a s e s w i t h l e n g t h o f t h e t e s t a n d s p r e a d o r v a r i a n c e o f s c o r e s ( T h o r n d i k e a n d H a g e n , 1977)» t h e t o t a l n u m b e r o f i t e m s was i n c r e a s e d t o 26 b y i n c l u d i n g m o r e i t e m s t o r e f l e c t e a c h s u b t e s t a r e a r e l a t e d t o d i e t a n d h e a r t d i s e a s e . The n u m b e r o f i t e m s a d d e d t o e a c h s u b t e s t was f o u r , f o u r , a n d t h r e e , r e s p e c t i v e l y . (3) To a v o i d t h e p o s s i b i l i t y t h a t t h e r e s p o n s e f o r m a t h a d b e e n t o o c o m p l i c a t e d f o r t h e g r o u p t e s t e d , t h e s c o r i n g s y s t e m was c h a n g e d t o a L i k e r t - t y p e summated s c a l e w i t h a f i v e c a t e g o r y c o n t i n u u m r a n g i n g f r o m 1= s t r o n g l y d i s a g r e e t o 5~ s t r o n g l y a g r e e . R e s p o n d e n t s were- r e q u e s t e d t o c i r c l e t h e n u m b e r t h a t b e s t i n d i c a t - ed how c l o s e l y t h e y a g r e e d o r d i s a g r e e d w i t h e a c h i t e m . To s c o r e t h e i n s t r u m e n t , e a c h s t a t e m e n t was r a t e d f r o m one t o f i v e w i t h a s c o r e o f one r e p r e s e n t - i n g a n e g a t i v e a t t i t u d e w i t h t h e h i g h e s t d e g r e e o f c e r t a i n t y a n d a s c o r e o f f i v e s i g n i f y i n g a p o s i t i v e a t t i t u d e w i t h t h e h i g h e s t d e g r e e o f c e r t a i n t y . T h u s t h e p o s s i b l e a t t i t u d e s c o r e r a n g e f o r t h e i n s t r u m e n t c o u l d r a n g e b e t w e e n 26 a n d 1 3 0 . The s c o r i n g s y s t e m f o r t h e a t t i t u d e i n s t r u m e n t i s i l l u s t r a t e d i n T a b l e 1. TABLE 1 S c o r i n g S y s t e m f o r t h e A t t i t u d e I n s t r u m e n t W o r d i n g o f I t e m S t r o n g l y D i s a g r e e 1 D i s a g r e e 2 U n d e c i d e d 3 A g r e e 4 S t r o n g l y A g r e e 5 P o s i t i v e 1 2 3 4 5 N e g a t i v e 5 4 3 2 1 V a l i d a t i o n o f t h e a t t i t u d e i n s t r u m e n t A f t e r c a r e f u l c o n s t r u c t i o n a n d e d i t i n g o f t h e 26 s t a t e m e n t s , t h e a t t i t u d e i n s t r u m e n t was s u b m i t t e d t o a p a n e l o f f i v e i n d e - p e n d e n t j u d g e s who w e r e members o f t h e C a n a d i a n D i e t e t i c A s s o c - i a t i o n , B r i t i s h C o l u m b i a D i e t e t i c A s s o c i a t i o n , a n d B r i t i s h C o l u m b i a N u t r i t i o n C o u n c i l , a n d w e r e e m p l o y e d i n c o m m u n i t y n u t r i t i o n s e r v i c e i n B . C . e i t h e r w i t h g o v e r n m e n t s e r v i c e s , c o m m u n i t y a g e n c i e s a n d o r g a n i z a t i o n s , o r i n h o s p i t a l c l i n i c a l s e r v i c e s . I n a d d i t i o n , e a c h member o f t h e p a n e l was a n a c t i v e p a r t i c i p a n t i n n u t r i t i o n c o n t i n u i n g e d u c a t i o n p r o g r a m s a n d h a d e x p e r i e n c e i n c o u n s e l l i n g a d u l t s o n d i e t and" h e a r t d isease . - . The j u d g e s w e r e i n s t r u c t e d t o i n d e p e n d e n t l y f o l l o w t h e j u d g i n g p r o c e d u r e s as o u t l i n e d , s i n c e a- f o l l o w - u p i n t e r v i e w w o u l d be c o n d u c t e d i f c l a r i f i c a t i o n o f comments was n e c e s s a r y . . . . The a t t i t u d e d o m a i n was d e f i n e d a n d t h e t h r e e s u b d o m a i n s u s e d t o d e s c r i b e t h e d o m a i n l i s t e d . The p r o c e d u r e d e a l t w i t h e a c h s u b d o m a i n s e p a r a t e l y a n d a s k e d q u e s t i o n s , a l l o p e n - e n d e d a b o u t : (1) w h e t h e r t h e s u b d o m a i n was r e p r e s e n t a t i v e , (2) w h e t h e r e a c h i t e m b e l o n g e d t o t h e s u b d o m a i n , a n d (3) w h e t h e r a l l c o n c e p t s w e r e p r e s e n t r e g a r d i n g t h e s u b d o m a i n . I n a d d i t i o n , t h e v a l i d a t - o r s w e r e a s k e d t o r a t e , o n a n i n e p o i n t . s c a l e , r e l e v a n c y o f e a c h i t e m t o t h e a t t i t u d e d o m a i n ( 9 , e x t r e m e l y r e l e v a n t ; 1, e x t r e m e l y i r r e l e v a n t ) . A f i n a l q u e s t i o n a s k e d w h e t h e r , as a s e t , t h e i t e m s p r o v i d e d a n a d e q u a t e a m o u n t o f i n f o r m a t i o n f o r v a l i d l y e s t i m a t i n g t h e a t t i t u d e s o f a d u l t s t o w a r d d i e t a n d c a r d i o - v a s c u l a r d i s e a s e ( C V D ) . T a b l e 2 r e p o r t s t h e a g r e e m e n t o f t h e p a n e l r e g a r d i n g t h e r e l e v a n c e o f t h e i t e m s t o t h e d o m a i n t o w h i c h e a c h was r e f e r e n c e d . D e f i n i n g c o n s e n s u s as a r a t i n g o f s e v e n o r g r e a t e r b y a t l e a s t f o u r v a l i d a t o r s , c o n s e n s u s was a c h i e v e d f o r 19 o f t h e 26 a t t i t u d e s t a t e m e n t s . T a b l e 3 p r e s e n t s v a l i d a t i o n r e s u l t s r e g a r d i n g r e p r e s e n t - a t i v e n e s s o f t h e i n d i v i d u a l s u b d o m a i n s , a p p r o p r i a t e n e s s o f e a c h s t a t e m e n t t o i t s s u b d o m a i n , a n d p r e s e n c e o f a l l c o n c e p t s r e g a r d i n g t h e s u b d o m a i n . I n a d d i t i o n , j u d g e m e n t o f t h e o v e r - a l l r e p r e s e n t a t i v e n e s s o f t h e i n s t r u m e n t t o d i e t a n d h e a r t d i s e a s e , a n d a d e q u a c y o f i n f o r m a t i o n a r e i n c l u d e d . C o n s e n s u s ( a t l e a s t f o u r o u t o f f i v e ) was a c h i e v e d among t h e v a l i d a t o r s f o r r e p r e s e n t a t i v e n e s s o f e a c h s t a t e m e n t t o i t s s u b d o m a i n , a p p r o p r i a t e n e s s o f e a c h s t a t e m e n t t o i t s s u b d o m a i n ( w i t h t h e e x c e p t i o n o f i t e m s 15 a n d 16 w h i c h r e c e i v e d a g r e e m e n t TABLE 2 A t t i t u d e I n s t r u m e n t : D i s t r i b u t i o n o f J u d g e s ' R a t i n g f o r I t e m R e l e v a n c e t o C o n t e n t D o m a i n I t e m D i s t r i b u t i o n o f r a t i n g s a Mean N o . 9 8 7 6~~ 5 4~ 3 2 1 R a t i n g 1 3 2 8 . 6 2 3 2 8 . 6 3 2 1 1 1 7 . 2 1 2 1 1 7 . 6 5 2 1 1 1 7 . 2 6 4 1 7 . 4 7 3 1 1 7 . 4 8 2 2 1 8 . 2 9 3 2 8 . 6 10 4 1 8 . 5 11 3 2 8 . 2 12 2 2 1 8 . 2 13 1 2 1 1 7 . 6 14 3 1 1 7 . 4 15 1 2 1 1 6 . 2 16 1 1 1 1 1 6 . 2 17 4 1 8 . 4 18 2 2 1 . 8 . 2 19 4 1 8 . 8 20 2 1 1 1 7 . 2 21 2 2 1 8 . 0 22 2 1 1 1 6 . 8 23 3 1 1 8 . 2 24 2 2 1 7 . 6 25 3 1 1 8 . 2 26 2 2 1 7 . 8 N o t e . Number o f J u d g e s = 5 . 9 •= e x t r e m e l y r e l e v a n t ; 1 = e x t r e m e l y i r r e l e v a n t . TABLE 3 A g r e e m e n t o f V a l i d a t o r s o n Q u e s t i o n s C o n c e r n i n g C o n t e n t V a l i d a t i o n o f t h e A t t i t u d e I n s t r u m e n t C o n t e n t D o m a i n : A t t i t u d e s o r f e e l i n g s t o w a r d d i e t as a means o f p r o m o t i n g h e a r t h e a l t h a n d i n t e r v e n i n g a g a i n s t h e a r t d i s e a s e . A g r e e m e n t o f J u d g e s 1. G e n e r a l r o l e o f d i e t i n h e a r t d i s e a s e a ) r e p r e s e n t a t i v e o f C o n t e n t D o m a i n 5 b ) e a c h s t a t e m e n t b e l o n g s ( 1 - 9 ) ^ c ) a l l c o n c e p t s p r e s e n t 5 2 . C h a n g i n g / m a n i p u l a t i n g t h e d i e t t o p r o m o t e a h e a l t h y h e a r t a ) r e p r e s e n t a t i v e o f C o n t e n t D o m a i n 5 b ) e a c h s t a t e m e n t b e l o n g s ( 1 0 - 1 8 ) 5 c ) a l l c o n c e p t s p r e s e n t 4- 3 . S e l f - r e s p o n s i b i l i t y f o r o n e ' s h e a r t h e a l t h a ) r e p r e s e n t a t i v e o f C o n t e n t D o m a i n 5 b ) e a c h s t a t e m e n t b e l o n g s ( 1 9 - 2 6 ) 5 c ) a l l c o n c e p t s p r e s e n t 5 S t a t e m e n t s o v e r a l l r e p r e s e n t a d e q u a t e v a r i e t y o f t o p i c s o n d i e t a n d h e a r t d i s e a s e 5 S t a t e m e n t s c o v e r a d e q u a t e amoun t o f i n f o r m a t i o n t o o b t a i n a v a l i d e s t i m a t e o f a t t i t u d e s o f a d u l t s as r e l a t e t o d i e t a n d h e a r t d i s e a s e 5 N o t e . Number o f v a l i d a t o r s = 5« a E x c e p t i t e m s 15 a n d 16 ( a g r e e m e n t 3 / 5 ) • "by t h r e e o u t o f f i v e j u d g e s ) , a n d p r e s e n c e o f a l l c o n c e p t s r e - g a r d i n g e a c h s u b d o m a i n . I n a d d i t i o n , t h e r e was c o m p l e t e a g r e e - m e n t among t h e v a l i d a t o r s t h a t t h e s t a t e m e n t s o v e r a l l r e p r e s e n t - ed a n a d e q u a t e v a r i e t y o f t o p i c s o n d i e t a n d h e a r t d i s e a s e , a n d t h a t t h e y w o u l d p r o v i d e a n a d e q u a t e amoun t o f i n f o r m a t i o n t o o b t a i n a v a l i d e s t i m a t e o f a d u l t s ' a t t i t u d e s r e l a t e d t o d i e t a n d h e a r t d i s e a s e . N u t r i t i o n K n o w l e d g e I n s t r u m e n t N u t r i t i o n k n o w l e d g e r e l a t e d t o d i e t a n d CVD was m e a s u r e d b y a q u e s t i o n n a i r e d e v e l o p e d f o r t h i s s t u d y a n d b a s e d o n t h e 1977 r e c o m m e n d a t i o n s o f H e a l t h a n d W e l f a r e Canada ( C a n a d a , 1977) a n d c u r r e n t k n o w l e d g e r e g a r d i n g d i e t a n d CVD. A t h o r o u g h r e v i e w o f t h e C a n a d i a n r e c o m m e n d a t i o n s a n d a s s o c i a t e d l i t e r a t u r e p o i n t e d o u t t h r e e g e n e r a l a r e a s o f s i g n i f i c a n c e . U s i n g c r i t e r i a s u g g e s t e d b y O p p e n h e i m (1966) a n d M o u l y ( 1 9 7 0 ) , 23 i t e m s w e r e d e v e l o p e d t o t e s t t h r e e s u b d o m a i n s : (1) how f o o d a f f e c t s t h e h e a r t ( K : A F F E C T S ) , (2) t h e i m p o r t a n c e o f f o o d c o m p o s i t i o n ( K : COMP), a n d (3) f a c t s v e r s u s f a l l a c y ( K : F A C T S ) . The f i r s t s u b d o m a i n , how f o o d a f f e c t s t h e h e a r t , t e s t e d r e s p o n d e n t s ' k n o w l e d g e r e g a r d i n g f o o d a n d i t s a s s o c i a t i o n w i t h t h e h e a r t . The s e c o n d s u b d o m a i n t e s t e d r e s p o n d e n t s ' k n o w l e d g e o f f o o d c o m p o s i t i o n c o n s i d e r e d e s s e n t i a l f o r m a k i n g s u b s t i t u t i o n s o r m o d i f i c a t i o n s i n d i e t a r y p r a c t i c e . The t h i r d s u b d o m a i n , f a c t s v e r s u s f a l l a c y , t e s t e d r e s p o n d e n t s ' k n o w l e d g e i n v o l v i n g t h e d i f f e r e n t i a t i o n b e t w e e n f a c t s a n d f i c t i o n o r m y t h s r e l a t e d t o d i e t a n d CVD. Common t o p i c s o f f a d d i s m o r m i s i n f o r m a t i o n t h a t a r e p r o m o t e d b y t h e p o p u l a r p r e s s b u t n o t s u p p o r t e d b y s c i e n - t i f i c e v i d e n c e w e r e i n c l u d e d . F o r b r e v i t y , t h e p a r e n t h e s i z e d a b b r e v i a t i o n s f o r b o t h a t t i t u d e a n d k n o w l e d g e s u b t e s t s w i l l be u s e d i n a l l s u b s e q u e n t d i s c u s s i o n a n d t a b l e s . A t w o r e s p o n s e s c o r i n g s y s t e m was u s e d w i t h t h e f i r s t r e s p o n s e s p e c i f y i n g t r u e o r f a l s e a n d t h e s e c o n d , t h e d e g r e e o f c e r t a i n t y r a n g i n g f r o m v e r y d o u b t f u l t o v e r y c e r t a i n . A g a i n , e a c h i t e m was s c o r e d f r o m one t o e i g h t w i t h one s i g n i f y i n g a n i n c o r r e c t r e s p o n s e made w i t h t h e h i g h e s t d e g r e e o f c e r t a i n t y a n d e i g h t s i g n i f y i n g a c o r r e c t r e s p o n s e w i t h t h e h i g h e s t d e g r e e o f c e r t a i n t y . I n t h e i r p r e l i m i n a r y f o r m , t h e k n o w l e d g e i t e m s w e r e v a l i - d a t e d a n d p r e t e s t e d a t t h e same t i m e as t h e a t t i t u d e i t e m s ( s e e p . 6 7 ) . R e s p o n s e s f r o m t h i s p r e l i m i n a r y t e s t i n g w e r e a n a l y z e d u s i n g LERTAP ( N e l s o n , 1974), t o d e t e r m i n e i f t h e i t e m s w e r e b e h a v i n g i n t h e c o r r e c t d i r e c t i o n , t h a t i s , i f t h e r e was a p o s i t i v e p o i n t b i s e r i a l c o r r e l a t i o n f o r e a c h c o r r e c t o p t i o n . R e s u l t s s h o w e d t h a t s e v e r a l i t e m s w e r e n e g a t i v e l y c o r r e l a t e d . As w e l l , t h e t o p s c o r e r s d i d n o t c o n s i s t e n t l y h a v e m o r e c o r r e c t r e s p o n s e s , as w o u l d be e x p e c t e d . E s t i m a t e s o f i n t e r n a l c o n - s i s t e n c y r e v e a l e d t h a t t h e i n s t r u m e n t i n i t s p r e l i m i n a r y f o r m , h a d l o w r e l i a b i l i t y ( r = . 0 0 , . 0 4 , a n d .72, r e s p e c t i v e l y ) . The r e v i s e d k n o w l e d g e i n s t r u m e n t B a s e d u p o n t h e s e o b s e r v a t i o n s , t h e i t e m s w e r e r e v i s e d . Two i t e m s e a c h w e r e t r a n s f e r r e d f r o m t h e s u b t e s t K:AFFECTS t o K:C0MP a n d K :FACTS, r e s p e c t i v e l y . The t o t a l number o f knowledge items was i n c r e a s e d to 32 by adding t h r e e , s i x , and thre e items, r e s p e c t i v e l y to the three knowledge s u b t e s t s . The items were c o n s t r u c t e d so th a t a balance was maintained, as f a r as p o s s i b l e , between t r u e and f a l s e items f o r each of the sub- t e s t s . Once completed, the items were randomly ordered i n the t e s t . A l s o , the response format was r e p l a c e d . Again, the change to a f i v e category continuum ranging from 1= d e f i n i t e l y f a l s e to 5~ d e f i n i t e l y t r u e was made and the respondents r e - quested to c i r c l e the number that best i n d i c a t e d t h e i r knowledge of each item. To score the t e s t , each statement was r a t e d from one to f i v e as shown i n Table k. TABLE 4 S c o r i n g System f o r the Knowledge Instrument D e f i n i t e l y Probably Do Not Probably D e f i n i t e l y F a l s e F a l s e Know True True KEY 1 2 3 5 True 1 2 '3 5 F a l s e 5 4 3 2 1 Content v a l i d a t i o n of the knowledge instrument Judgement packets c o n t a i n i n g the 32 items were prepared f o r " v a l i d a t i o n by the same p a n e l of f i v e judges used to v a l i - date the a t t i t u d e instrument. The l o g i c a l a n a l y s i s method ( K e r l i n g e r , 1973) and s i m i l a r i n s t r u c t i o n format were f o l l o w e d . An a d d i t i o n a l q u e s t i o n asked about the c o r r e c t n e s s of the item k e y . R e s u l t s f o r r e l e v a n c e r a t i n g a r e p r e s e n t e d i n T a b l e 5. A g a i n , d e f i n i n g c o n s e n s u s as a r a t i n g o f s e v e n o r g r e a t e r b y a t l e a s t f o u r v a l i d a t o r s , c o n s e n s u s was a c h i e v e d f o r a l l b u t t w o o f t h e k n o w l e d g e s t a t e m e n t s . T a b l e 6 p r e s e n t s v a l i d a t i o n r e s u l t s r e g a r d i n g r e p r e s e n t a - t i v e n e s s o f t h e i n d i v i d u a l s u b d o m a i n s t o t h e c o n t e n t d o m a i n , a p p r o p r i a t e n e s s o f e a c h s t a t e m e n t t o i t s s u b d o m a i n , p r e s e n c e o f a l l c o n c e p t s r e g a r d i n g t h e s u b d o m a i n , a n d a g r e e m e n t o f t h e p a n e l w i t h t h e k e y f o r e a c h i t e m . I n a d d i t i o n , j u d g e m e n t o f t h e o v e r - a l l r e p r e s e n t a t i v e n e s s o f t h e i n s t r u m e n t t o d i e t a n d CVD, a n d a d e q u a c y o f i n f o r m a t i o n a r e a l s o i n c l u d e d . W i t h t h e e x c e p t i o n o f one i t e m ( n u m b e r 2 ) , c o n s e n s u s ( a t l e a s t f o u r o u t o f f i v e ) was a c h i e v e d among t h e v a l i d a t o r s f o r r e p r e s e n t a t i v e n e s s o f t h e i n d i v i d u a l s u b d o m a i n t o c o n t e n t d o - m a i n , a p p r o p r i a t e n e s s o f e a c h s t a t e m e n t t o i t s s u b d o m a i n , a n d a g r e e m e n t o f t h e p a n e l w i t h t h e k e y . F o u r o u t o f f i v e j u d g e s a g r e e d t h a t a l l c o n c e p t s w e r e p r e s e n t r e g a r d i n g t h e s u b d o m a i n s "how f o o d a f f e c t s t h e h e a r t " a n d " f a c t s v e r s u s f a l l a c y " . The s u b d o m a i n " i m p o r t a n c e o f f o o d c o m p o s i t i o n " was j u d g e d t o c o n - t a i n a l l c o n c e p t s b y one v a l i d a t o r o n l y . H o w e v e r , t h e m e t h o d o f a g r e e m e n t was a y e s - n o r e s p o n s e w i t h t h e r e q u e s t t h a t t h e m i s s i n g c o n c e p t ( s ) be r e c o r d e d . One v a l i d a t o r s u g g e s t e d f u r t h e r c l a r i f i c a t i o n o f t h e d i f f e r e n c e b e t w e e n p o l y u n s a t u r a t e d f a t t y a c i d a n d s a t u r a t e d f a t t y a c i d . T h i s was c o n s i d e r e d t o c o n t r a d i c t t h e p u r p o s e o f t h e t e s t a n d was n o t i m p l e m e n t e d . Two o f t h e f i v e v a l i d a t o r s s u g g e s t e d i n c l u s i o n o f i t e m s t h a t t e s t e d k n o w l e d g e o f t h e TABLE 5 Knowledge Instrument: D i s t r i b u t i o n of Judges' Rating f o r Item Relevance to Content Domain j%em D i s t r i b u t i o n of ratings M e a n No. 9 8 7 6 5 4 3 2 1 Rating 1 3 1 1 8 . 4 2 3 1 1 6 . 4 3 4 1 8.2 4 2 2 1 8.0 5 2 2 1 7.6 6 3 1 1 8.0 7 3 2 8.2 8 3 1 1 8.2 9 3 1 1 8 . 4 10 3 1 1 8.0 11 3 1 1 8 . 4 12 3 1 1 7.8 13 3 2 8.6 14 3 1 1 8.2 15 3 1 1 8 . 4 16 2 2 1 8.0 17 4 1 8.8 18 3 1 1 8 . 4 19 2 1 2 8.0 20 3 2 8.6 21 2 2 1 7 . 4 22 2 1 2 8.0 23 4 1 8 . 4 24 3 1 1 8 . 4 25 3 1 1 8.2 26 2 1 1 6 . 4 27 2 2 1 8.2 28 3 1 1 8.0 29 2 1 1 1 7-8 30 3 1 1 8 . 4 31 3 1 1 8 . 4 32 3 1 1 8 . 4 Note. Number of Judges = 5. a 9 = extremely relevant; 1 = extremely i r r e l e v a n t . 7 8 TABLE 6 A g r e e m e n t o f V a l i d a t o r s o n Q u e s t i o n s C o n c e r n i n g C o n t e n t V a l i d a t i o n o f t h e K n o w l e d g e I n s t r u m e n t a n d t h e Key t o t h e S t a t e m e n t s C o n t e n t D o m a i n : N u t r i t i o n k n o w l e d g e r e l a t e d t o t h e h e a r t . A g r e e m e n t o f J u d g e s 1. How f o o d a f f e c t s t h e h e a r t a ) r e p r e s e n t a t i v e o f C o n t e n t D o m a i n 5 a b ) e a c h s t a t e m e n t b e l o n g s ( 1 - 9 ) 4 c ) a l l c o n c e p t s p r e s e n t , i f n o , s u g g e s t w h a t i s m i s s i n g 4^ d) a g r e e w i t h t h e k e y f o r 1-9 5 2 . I m p o r t a n c e o f f o o d c o m p o s i t i o n a ) r e p r e s e n t a t i v e o f C o n t e n t D o m a i n 5 C b ) e a c h s t a t e m e n t b e l o n g s ( 10-21) 5 c ) a l l c o n c e p t s p r e s e n t , i f n o , s u g g e s t w h a t d i s m i s s i n g 1 d) a g r e e w i t h t h e k e y f o r 1 0 - 2 1 5 3 . F a c t s v e r s u s f a l l a c y a ) r e p r e s e n t a t i v e o f C o n t e n t D o m a i n 5 b ) e a c h s t a t e m e n t b e l o n g s ( 2 2 - 3 2 ) 5 c ) a l l c o n c e p t s p r e s e n t , i f n o , s u g g e s t w h a t i s m i s s i n g 4 d ) a g r e e w i t h t h e k e y f o r 2 2 - 3 2 5 S t a t e m e n t s o v e r a l l r e p r e s e n t a n a d e q u a t e v a r i e t y o f t o p i c s o n d i e t a n d h e a r t d i s e a s e 5 S t a t e m e n t s g i v e a n a d e q u a t e a m o u n t o f i n f o r m a t i o n t o o b t a i n a v a l i d e s t i m a t e o f n u t r i t i o n k n o w l e d g e as r e l a t e s t o d i e t a n d h e a r t d i s e a s e 5 N o t e . Number o f V a l i d a t o r s = 5 . ^ E x c e p t i t e m 2 ( a g r e e m e n t 2 / 5 ) . E x c e p t i t e m 9 ( a g r e e m e n t 4 / 5 ) . , E x c e p t i t e m 12 ( a g r e e m e n t 4 / 5 ) . 1/5 s u g g e s t e d t h e d i f f e r e n c e b e t w e e n p o l y u n s a t u r a t e d a n d s a t u r - a t e d f a t be c l a r i f i e d ( c o n t r a d i c t s p u r p o s e o f t h e i n s t r u m e n t ) . 2/5 s u g g e s t e d s o d i u m c o n t e n t o f f o o d s a n d s n a c k s be i n c l u d e d ( t o o s p e c i a l i z e d a q u e s t i o n i n l i g h t o f t h e r e c o m m e n d a t i o n r e g a r d i n g s a l t ) . 1/5 s u g g e s t e d more i t e m s r e l a t e d t o s u g a r c o n t e n t o f f o o d s ( t h e r e c o m m e n d a t i o n s u g g e s t e d m o d e r a t i o n i n t h e use o f s u g a r t o a v o i d o v e r w e i g h t a n d d i s p l a c e m e n t o f e s s e n t i a l v i t a m i n s a n d / o r m i n e r a l s ) . s o d i u m c o n t e n t o f f o o d s a n d s n a c k s . A g a i n , t h i s s u g g e s t i o n was n o t i m p l e m e n t e d b e c a u s e o f i t s s p e c i a l i z e d n a t u r e a n d t h e f a c t t h a t t h e C a n a d i a n r e c o m m e n d a t i o n s do n o t a d v i s e a q u a n t i t a t i v e l i m i t o n t h e s o d i u m i n t a k e o f t h e g e n e r a l p o p u l a t i o n . The r e c o m m e n d a t i o n was t o r e d u c e t h e i n t a k e o f s a l t y f o o d s a n d e x e r t m o d e r a t i o n i n t h e u s e o f s a l t i n c o o k i n g a n d a t t a b l e (Rae a n d M u r r a y , 1 9 7 8 ) - - b o t h c o n c e r n e d w i t h t h e r e d u c t i o n o f a d d e d s a l t ( s o d i u m c h l o r i d e ) , n o t t h e s o d i u m c o n t e n t o f f o o d s p e r s e . The f i n a l s u g g e s t i o n b y t h e f o u r t h v a l i d a t o r was t o i n c l u d e i t e m s t o t e s t k n o w l e d g e o f t h e s u g a r c o n t e n t o f f o o d s . T h i s s u g g e s - t i o n was n o t c a r r i e d o u t e i t h e r s i n c e t h e C a n a d i a n g u i d e l i n e s d i d n o t a d v i s e a q u a n t i t a t i v e l i m i t o n s u g a r i n t a k e o f t h e g e n e r a l p o p u l a t i o n b u t r e c o m m e n d e d m o d e r a t i o n i n i t s u s e so as t o a v o i d o v e r w e i g h t a n d / o r d i s p l a c e m e n t o f e s s e n t i a l v i t a m i n s a n d m i n e r a l s . A l l members o f t h e p a n e l a g r e e d t h a t t h e s t a t e m e n t s o v e r - a l l r e p r e s e n t e d a n a d e q u a t e v a r i e t y o f t o p i c s o n d i e t a n d h e a r t d i s e a s e a n d w o u l d g i v e a n a d e q u a t e a m o u n t o f i n f o r m a t i o n t o o b t a i n a v a l i d e s t i m a t e o f c a r d i o v a s c u l a r n u t r i t i o n k n o w l e d g e . B e f o r e f u r t h e r a c t i o n b a s e d o n t h e s e v a l i d a t i o n r e s u l t s was t a k e n , i t was d e c i d e d t o t r y o u t a l l a t t i t u d e a n d k n o w l e d g e i t e m s w i t h t h e p i l o t s a m p l e . B i o d e m o g r a p h i c S e c t i o n I n t h e t h i r d s e c t i o n o f t h e q u e s t i o n n a i r e , r e s p o n d e n t s w e r e a s k e d t o p r o v i d e t h e f o l l o w i n g b i o d e m o g r a p h i c i n f o r m a t i o n : a g e , g e n d e r , o c c u p a t i o n , p h y s i c a l e x e r c i s e p a t t e r n , s m o k i n g h a b i t , h e i g h t a n d w e i g h t , l i v i n g a r r a n g e m e n t , e d u c a t i o n l e v e l , p l a c e o f b i r t h , f a m i l y h i s t o r y o f CVD, p e r s o n a l h i s t o r y o f CVD, a n d s o u r c e s f r o m w h i c h i n f o r m a t i o n o n d i e t a n d h e a r t d i s e a s e w e r e o b t a i n e d . The f o r m a t was a c h e c k l i s t o r s h o r t a n s w e r . Check l i s t q u e s t i o n s w e r e d e s i g n e d so t h a t , i f n e c e s s a r y , s h o r t a n s w e r s c o u l d be g i v e n t o a l l o w f o r r e s p o n d e n t s who d i d n o t f i n d a n y o f t h e a l t e r n a t i v e s s u i t a b l e . N u t r i t i o n P r a c t i c e I n s t r u m e n t P r a c t i c e was m e a s u r e d i n t h e f o u r t h a n d f i n a l s e c t i o n o f t h e q u e s t i o n n a i r e . - I t e m s w e r e d e v e l o p e d f o r t h i s s t u d y b y m o d i f y i n g a n u m b e r o f p r e v i o u s l y v a l i d a t e d d i e t a r y h i s t o r y a n d d i e t a r y r e c a l l q u e s t i o n n a i r e s ( D i e t M a n u a l C o m m i t t e e o f t h e B . C . D . A . , 1976; O h l s o n , 1?72; F r a n k l e a n d Owen, 1978; C a n a d a , 1973)» as w e l l as a f o o d f r e q u e n c y p r a c t i c e i n s t r u m e n t ( S c h w a r t z , 1973) • The p r a c t i c e i n s t r u m e n t was c o n s t r u c t e d as a p a r a l l e l i n s t r u m e n t t o t h e m o d i f i e d d i e t a r y h i s t o r y w h i c h u t i l i z e s a n i n t e r v i e w s i t u a t i o n f o r a m o r e c o m p r e h e n s i v e c o v e r a g e o f d i e t - a r y i n f o r m a t i o n . Due t o l o g i s t i c a l c o n s t r a i n t s , t h e s o l e u s e o f t h e i n t e r v i e w was n o t f e a s i b l e f o r t h e m a i n s t u d y . The p r a c t i c e q u e s t i o n n a i r e was f u r t h e r s u b d i v i d e d i n t o t h r e e s e c t i o n s c o r r e s p o n d i n g t o t h e f o l l o w i n g t h r e e g e n e r a l q u e s t i o n s : " W h a t d i d y o u e a t y e s t e r d a y ? " "Wha t i s y o u r g e n - e r a l e a t i n g p a t t e r n ? " , a n d "How f r e q u e n t l y do y o u e a t e a c h o f t h e f o l l o w i n g common f o o d s ? " Q u e s t i o n one i n v o l v e d r e c a l l o f a l l f o o d s a n d b e v e r a g e s c o n s u m e d o v e r t h e p r e v i o u s 2 4 - h o u r p e r i o d . R e s p o n d e n t s w e r e a s k e d t o r e p o r t t h e k i n d o f f o o d , t y p e a n d / o r p r e p a r a t i o n , a n d a m o u n t c o n s u m e d f o r s i x t i m e p e r i o d s : m o r n i n g , l a t e m o r n i n g , m i d d a y , a f t e r n o o n , e v e n i n g m e a l , a n d a f t e r e v e n i n g m e a l . A l s o , n e x t t o t h e i r r e p o r t , t h e y w e r e a s k e d t o i n d i c a t e how i t v a r i e d f r o m u s u a l f o r t h e c o r r e s - p o n d i n g p e r i o d . A s e r i e s o f q u e s t i o n s ( o p e n - a n d c l o s e - e n d e d ) f o l l o w e d t o d e t e r m i n e t h e a n s w e r t o t h e s e c o n d q u e s t i o n c o n - c e r n i n g g e n e r a l e a t i n g p a t t e r n . Comments o n v a r i a t i o n s o f t h e p r e v i o u s r e c a l l f r o m t h e u s u a l . p a t t e r n ; , use o f f o o d o r n u t r i e n t s u p p l e m e n t s , c u r r e n t a l c o h o l c o n s u m p t i o n , u s e o f s a l t , f o o d d i s - l i k e s , w e e k e n d f o o d p r a c t i c e , m e a l s k i p p i n g p r a c t i c e , a n d l e n g t h o f p r e s e n t e a t i n g p a t t e r n w e r e a l s o i n c l u d e d . The f i n a l s u b s e c t i o n o f t h e p r a c t i c e q u e s t i o n n a i r e c o n t a i n - ed a c o m p r e h e n s i v e f o o d f r e q u e n c y c h e c k l i s t w h i c h , t o g e t h e r w i t h t h e d a t a f r o m p r e v i o u s q u e s t i o n s , s e r v e d as a c r o s s - c h e c k o n t h e u s u a l f o o d i n t a k e a n d c o n t r i b u t e d t o t h e f i n a l e s t i m a t e o f t h e p a r t i c i p a n t s ' u s u a l d i e t a r y p r a c t i c e . B e c a u s e t h e c o m p o n e n t s o f t h e p r a c t i c e i n s t r u m e n t h a d b e e n p r e v i o u s l y v a l i d a t e d , t h e v a l i d i t y o f t h e p r a c t i c e i n s t r u m e n t was n o t d e t e r m i n e d b e f o r e p i l o t t e s t i n g . H o w e v e r , t h e t o t a l q u e s t i o n n a i r e , i n c l u d i n g a t t i t u d e , k n o w l e d g e , b i o d e m o g r a p h i c , a n d p r a c t i c e s e c t i o n s , was p r e t e s t e d b y n i n e g r a d u a t e s t u d e n t s i n human n u t r i t i o n , t h r e e o f whom h a d p r e v i o u s p r o f e s s i o n a l e x p e r i e n c e i n p u b l i c h e a l t h n u t r i t i o n a n d d i e t e t i c s i n C a n a d a . Two human n u t r i t i o n f a c u l t y members w i t h e x p e r i e n c e i n n u t r i t i o n s u r v e y r e s e a r c h a l s o e x a m i n e d t h e i n s t r u m e n t . B a s e d o n t h e r e - s u l t s o f t h i s p r e t e s t a n d t h e v a l i d a t i o n p r o c e d u r e , t h e q u e s t i o n - 8 2 n a i r e was p r e p a r e d f o r p i l o t t e s t i n g . P i l o t s t u d y f o r m . The f o u r s e c t i o n s d e s c r i b e d a b o v e w e r e a s s e m b l e d t o f o r m o n e q u e s t i o n n a i r e . E a c h s e c t i o n was c o l o u r - c o d e d t o f a c i l i t a t e t h e t r a n s i t i o n b e t w e e n s e c t i o n s f o r t h e r e s p o n d e n t s . G r e e n was c h o s e n f o r t h e a t t i t u d e s i n s t r u m e n t , b l u e f o r t h e k n o w l e d g e i n s t r u m e n t , a n d y e l l o w f o r t h e b i o d e m o - g r a p h i c a n d p r a c t i c e s e c t i o n s . The s e c t i o n s w e r e i n t r o d u c e d b y a b r i e f s t a t e m e n t o f c o n t e n t a n d d i r e c t i o n f o r r e s p o n d i n g . The f i r s t s e c t i o n , a t t i t u d e s , a l s o i n c l u d e d a n e x a m p l e o f t h e r e - s p o n s e p r o c e d u r e u s i n g a g e n e r a l i t e m u n r e l a t e d t o d i e t a n d h e a r t d i s e a s e . F i n a l l y , t o r e d u c e t h e b u l k o f t h e q u e s t i o n n a i r e , b o t h s i d e s o f t h e p a g e w e r e u t i l i z e d r e s u l t i n g i n a t o t a l o f s i x p a g e s ( o n e , o n e , a n d f o u r , r e s p e c t i v e l y ) f o r t h e p i l o t q u e s t i o n n a i r e . Q u e s t i o n s f o r a s h o r t i n t e r v i e w w e r e a l s o c o n s t r u c t e d t o d e a l w i t h s p e c i f i c p o i n t s n o t p o s s i b l e t o c o v e r i n t h e p r e t e s t q u e s t i o n n a i r e , s u c h a s , (1) how s p e c i f i c i t e m s w e r e i n t e r p r e t e d ; (2) i f a n y s t a t e m e n t s g a v e d i f f i c u l t y ; (3) w h e t h e r i t was d i f - f i c u l t t o s w i t c h f r o m a t t i t u d e s t o k n o w l e d g e ; (4) i f t h e r e w e r e a n y d i f f i c u l t i e s , p r o b l e m s , q u e s t i o n s , o r f r u s t r a t i o n s r e g a r d i n g t h e p r a c t i c e i n s t r u m e n t ; a n d (5) o v e r a l l i m p r e s s i o n o f t h e q u e s t i o n n a i r e . A c o p y o f b o t h t h e p r e l i m i n a r y q u e s t i o n n a i r e a n d t h e p i l o t s t u d y q u e s t i o n n a i r e a r e p r e s e n t e d i n A p p e n d i x A . P i l o t S t u d y P u r p o s e The p u r p o s e o f t h e p i l o t s t u d y was t w o f o l d : (1) t o d e t e r - m i n e i f t h e t o t a l q u e s t i o n n a i r e was a p p r o p r i a t e f o r t h e i n t e n d e d t a r g e t p o p u l a t i o n ; a n d (2) t o f u r t h e r u t i l i z e t h e d a t a t o d e t e r - m i n e t h e p s y c h o m e t r i c c h a r a c t e r i s t i c s o f t h e a t t i t u d e a n d k n o w - l e d g e i n s t r u m e n t s d e v e l o p e d f o r t h i s s t u d y . The S a m p l e The p i l o t s a m p l e c o n s i s t e d o f f i v e g r o u p s " k n o w n " t o d i f f e r i n n u t r i t i o n k n o w l e d g e . Two o f t h e g r o u p s w e r e u n i v e r s i t y s t u - d e n t s : o n e , a f o u r t h y e a r c l a s s o f n u t r i t i o n a n d d i e t e t i c s m a j o r s ( N U T R ) ; t h e o t h e r , a f o u r t h y e a r s e c o n d a r y e d u c a t i o n c l a s s ( E D U C ) . To a v o i d a p o s s i b l e u n i v e r s i t y e f f e c t o n s c o r e r e s u l t s , t w o n o n - u n i v e r s i t y g r o u p s w e r e i n c l u d e d as w e l l : a g r o u p o f n u t r i t i o n a n d d i e t e t i c s p r o f e s s i o n a l s e m p l o y e d i n t h e c o m m u n i t y ( D I E T ) , a n d a g r o u p o f a d u l t s who w e r e members o f a V a n c o u v e r c o m m u n i t y c e n t r e ( C C ) . Members o f t h e e d u c a t i o n c l a s s a n d t h e c o m m u n i t y c e n t r e g r o u p who r e p o r t e d p r i o r c o u r s e s i n n u t r i t i o n i n t h e d e b r i e f i n g q u e s t i o n n a i r e t h a t a c c o m p a n i e d t h e p i l o t p a c k e t , f o r m e d a f i f t h g r o u p ( M I X ) . H y p o t h e s e s I t was h y p o t h e s i z e d t h a t t h e r e w o u l d be a s i g n i f i c a n t d i f f e r e n c e i n mean k n o w l e d g e s c o r e s among t h e f i v e g r o u p s . I t was a s s u m e d t h a t , b e c a u s e t h e members o f NUTR g r o u p w e r e c u r r e n t l y e l e c t i n g n u t r i t i o n as t h e i r c h o i c e o f a f u t u r e p r o - f e s s i o n , t h e y w o u l d h a v e t h e m o s t k n o w l e d g e r e g a r d i n g d i e t a n d DVD. B e c a u s e t h e EDUC g r o u p w e r e p r e s u m e d t o h a v e l e s s a s s o c - i a t i o n w i t h i n f o r m a t i o n o n d i e t a n d CVD, t h e y w e r e p r e d i c t e d t o h a v e l e s s k n o w l e d g e t h a n a n y o f t h e g r o u p s w i t h p r i o r n u t r i - t i o n e x p o s u r e b u t e q u a l t o o r m o r e k n o w l e d g e t h a n t h e CC g r o u p . L i k e w i s e , i t was p r e d i c t e d t h a t t h e CC g r o u p w o u l d h a v e l o w e r mean k n o w l e d g e s c o r e s t h a n t h e D IET g r o u p i n t h e c o m m u n i t y , t h e MIX g r o u p , a n d t h e NUTR g r o u p . I t was f u r t h e r h y p o t h e s i z e d t h a t t h e r e w o u l d be no d i f f e r - e n c e i n mean a t t i t u d e s c o r e s b e t w e e n t h e t w o n u t r i t i o n g r o u p s (NUTR a n d D I E T ) ; no d i f f e r e n c e i n mean a t t i t u d e s c o r e s b e t w e e n t h e t w o n o n - n u t r i t i o n g r o u p s (EDUC a n d CC) b u t a s i g n i f i c a n t d i f f e r e n c e i n mean a t t i t u d e s c o r e s b e t w e e n t h e n u t r i t i o n g r o u p s a n d t h e n o n - n u t r i t i o n g r o u p s . D a t a C o l l e c t i o n P r o c e d u r e I n M a r c h 1979» a q u e s t i o n n a i r e p a c k e t c o n s i s t i n g o f a c o v e r l e t t e r , t h e s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e , a n d a s h o r t d e b r i e f i n g q u e s t i o n n a i r e was d i s t r i b u t e d t o e a c h p e r s o n i n t h e p i l o t t e s t s a m p l e . The u n i v e r s i t y g r o u p s a n d t h e p r o f e s s i o n a l c o m m u n i t y g r o u p w e r e b r i e f l y a d d r e s s e d b y t h e i n v e s t i g a t o r , t h e p u r p o s e o f t h e • • p i l o t . ' s t u d y was s t a t e d , a n d t h e p a c k e t d i s t r i b - u t e d . The q u e s t i o n n a i r e s w e r e i m m e d i a t e l y c o m p l e t e d a n d c o l - l e c t e d . The c o m m u n i t y c e n t r e g r o u p was a l s o a d d r e s s e d b y t h e 8 5 investigator, the purpose stated, and the packet including a self-addressed envelope, di s t r i b u t e d to those who agreed to p a r t i c i p a t e . The questionnaire was taken home, completed, and returned by mail or to the community centre within one week of d i s t r i b u t i o n . Data c o l l e c t i o n f o r a l l groups was completed within a two week period. Data Analysis In preparation f o r analysis by computer, the investigator coded the responses. Each questionnaire was given an i d e n t i - f i c a t i o n number that i d e n t i f i e d the person and the group to which she or he belonged. The coded questionnaires were key- punched d i r e c t l y and v e r i f i e d by the Key-punching Services of the Computer Centre at the University of B r i t i s h Columbia. The data were then placed on f i l e and hand-checked f o r punching errors by the investigator. Any errors were double-checked and corrected. A l l analyses were performed by an AMDAHL 4 7 0 V/ 6 Model II computer under the Michigan Terminal System. Item analysis was performed using the LERTAP (Nelson, 1 9 7 4 ) computer program i n order to determine the i n t e r n a l consistency (Hoyt, 1 9 4 1 ) of the knowledge and attitude instruments and to examine the performance of the items. One-way analysis of variance (AN0V11: University of Alberta, 1 9 & 9 ) was also per- formed to test the t e n a b i l i t y of the hypotheses followed by Scheffe's S method (Kirk, 1 9 6 8 ) to determine the source of any s i g n i f i c a n t e f f e c t . 86 Results and. Discussion Attitude instrument Item analysis. An examination of the item-subtest c o r r e l a - tions revealed that a l l item-test values for both A:GEN ROLE and A:MANAGE were pos i t i v e ; however, i n the case of A:RESP0NS, f i v e of the eight items were found to be negatively correlated with the subtest. An examination of the subtest :RESP0N for each of the f i v e groups showed that only two of the items were p o s i t i v e l y correlated with three or more groups; the remaining six items had negative or no co r r e l a t i o n for three or more groups. This indicated that the items were ambiguous for the majority of the groups. The i n t e r n a l consistency c o e f f i c i e n t s f o r the subtest and Cronbach's alpha f o r the t o t a l test are reported i n Table 7 together with the corresponding mean, standard deviation, and standard error. The mean scores indicated an apparent pos i t i v e attitude toward the role of diet i n promotion of heart health and i n t e r - vention against CVD f o r A:GEN ROLE and A:MANAGE (both means greater than 85% of t o t a l possible score). The mean score f o r A:RESPON was somewhat lower. The r e l i a b i l i t i e s f or A:GEN ROLE and A:MANAGE were accept- able (.72 and . 7 9 , respectively) but Hoyt's r f o r A:RESP0N- indicated that subtest was not r e l i a b l e , i n agreement with the item l e v e l analysis. The in t e r n a l consistency of the t o t a l TABLE ? Summary T e s t S t a t i s t i c s f o r t h e A t t i t u d e I n s t r u m e n t A:GEN ROLE A:MANAGE •• A:RESPON A : T O T A L No. o f i t e m s 9 9 8 26 Mean (fo) 3 8 . 9 5 ( 8 6 . 5 6 ) 3 8 . 5 4 ( 8 5 . 6 4 ) 2 9 . 3 8 ( 7 3 . 4 5 ) 1 0 6 . 8 7 ( 8 2 . 2 1 ) S . D . (fo) 3 .46( 7 . 6 9 ) 3 . 9 3 ( 8 . 7 3 ) 2 . 5 8 ( 6 . 4 5 ) 7 . 9 7 ( 6 . 1 3 ) H o y t 1 s r .72 • 79 . 0 0 . 7 0 a S .E . 1.72 1 .68 2 . 4 9 3 . 6 6 C r o n b a c h ' s c o m p o s i t e a l p h a ( C r o n b a c h , 1 9 5 1 ) . scale was acceptable ( . 7 0 ) . Given the lack of r e l i a b i l i t y of A:RESP0N, no further analysis was performed with t h i s subtest, the items of which are discussed under r e v i s i o n of the attitude instrument. Test of hypotheses. To tes t the hypotheses that there was no difference i n mean attitude scores between the two n u t r i t i o n groups (NUTR and DIET) or between the two non-nutrition groups (EDUC and CC) but that there was a s i g n i f i c a n t difference be- tween the n u t r i t i o n groups and the non-nutrition groups, a one- way analysis of variance was performed f o r A:GEN ROLE and A:MANAGE. Table 8 presents the mean attitude scores for the f i v e groups and Table 9 summarizes the analysis of variance r e s u l t s . In each case, the n u l l hypothesis was rejected. To deter- mine the source of the ef f e c t s , a l l pairwise comparisons among mean scores were tested using Scheffe's S method (Kirk, 1968) at the . 0 5 l e v e l of s i g n i f i c a n c e . Table 10 summarizes the r e s u l t s . As shown i n Table 10, f o r A:GEN ROLE, the mean attitude scores of the NUTR group were s i g n i f i c a n t l y higher (P<.05) than those of the CC group. A l l other pairwise comparisons were not found to be s i g n i f i c a n t l y d i f f e r e n t . For the second subtest (A:MANAGE.) , the NUTR group scored s i g n i f i c a n t l y (P<.05) higher than both non-nutrition groups. In addition, the DIET group scored s i g n i f i c a n t l y (P<.05) higher than the EDUC group. These r e s u l t s lend support to the conclusion that there was evidence f o r construct v a l i d i t y . TA3.LE 8 Mean S c o r e s f o r A t t i t u d e S u b t e s t s b y G r o u p G r o u p N A : GEN ROLE A: MANAGE 8" CC 11 36.64 36 .36 EDUC 25 37-96 36 . 24 MIX 10 39 .50 4 0 . 0 0 DIET 14 39.86 39-86 NUTR 16 40.94 41.56 O r d e r e d a c c o r d i n g t o p e r f o r m a n c e i n A:GEN ROLE. TABLE 9 One-Way A n a l y s i s o f V a r i a n c e f o r A t t i t u d e S u b t e s t s a n d T o t a l T e s t S o u r c e o f F V a r i a b i l i t y d f A:GEN ROLE A:MANAGE A :"T0TAL B e t w e e n 4 3 . 8 9 * 8 . 5 5 * 6 . 1 8 * W i t h i n 71 MSw 1 0 . 3 5 . 1 1 . 0 0 4 9 . 7 5 * p < . 0 5 . TABLE 10 D i f f e r e n c e s among G r o u p Mean S c o r e s f o r A t t i t u d e S u b t e s t s G r o u p A:GEN ROLE A:MANAGE a 2 3 4 5 2 3 4 5 1 CC 1 .32 2 . 8 6 3 . 2 2 4 . 3 0 * .12 3.64 3 . 5 0 5 . 2 0 2 EDUC 1 .54 1 . 9 0 2 . 9 8 3 . 7 6 3 . 6 2 * 5 . 3 2 * 3 MIX . 3 6 1 .44 .14 I . 5 6 4 D I E T 1 . 0 8 1 .70 5 NUTR a O r d e r b a s e d . o n p e r f o r m a n c e i n A:GEN ROLE. * P < . 0 5 . Knowledge i n s t r u m e n t Item a n a l y s i s . Items w h i c h behave i n the c o r r e c t d i r e c t i o n w i l l have a p o s i t i v e p o i n t b i s e r i a l c o r r e l a t i o n f o r t h e key response o p t i o n ; as w e l l , the more knowledgeable groups s h o u l d have more c o r r e c t r e s p o n s e s t h a n i n c o r r e c t . Items on the i n d i - v i d u a l s u b t e s t s were examined f o r the f i v e g r o u p s , s e p a r a t e l y and combined, i n o r d e r to i d e n t i f y t h o s e items t h a t behaved c o r - r e c t l y . A c o mparison o f t h e p r o p o r t i o n from each group t h a t responded c o r r e c t l y t o an i t e m i n d i c a t e d whether the i t e m d i s - c r i m i n a t e d between the n u t r i t i o n (NUTR and DIET) and n o n - n u t r i - t i o n (EDUC and CC) groups. E x a m i n a t i o n o f the p r o p o r t i o n c o r - r e c t l y r e s p o n d i n g f o r the combined group s u g g e s t e d the d i f f i - c u l t y l e v e l o f t h e i n d i v i d u a l i t e m . I n s u b t e s t K:AFFECTS, one i t e m was found t o have a c o r r e - l a t i o n o f .15 as w e l l as not d i s c r i m i n a t e between the n u t r i t i o n and n o n - n u t r i t i o n g roups. F o u r o t h e r i t e m s s u g g e s t e d t h a t t h e r e was c o n s i d e r a b l e g u e s s i n g . However, t h e p o i n t b i s e r i a l c o r r e - l a t i o n s were g r e a t e r t h a n . 2 3 and t h e h i g h e s t s c o r e r s c o r r e c t l y answered the f o u r i t e m s . The r e m a i n i n g items appeared t o behave c o r r e c t l y . Item a n a l y s i s r e s u l t s f o r K:C0MP r e v e a l e d t h r e e o f the 12 items were m i s b e h a v i n g i n t h a t major g u e s s i n g was s u g g ested f o r a l l f i v e groups i n d i c a t i n g l a c k o f d i s c r i m i n a t i o n between the n u t r i t i o n and n o n - n u t r i t i o n g roups. F o r K:FACTS, two o f 10 i t e m s w h i l e h a v i n g p o s i t i v e p o i n t b i s e r i a l c o r r e l a t i o n s g r e a t e r t h a n • 3 9 , d i d n o t d i s c r i m i n a t e between the n u t r i t i o n and t h e non- n u t r i t i o n g r o u p s . W i t h d a t a f r o m a l l f i v e g r o u p s , i n t e r n a l c o n s i s t e n c y o f s u b t e s t s a n d t o t a l t e s t was c o m p u t e d u s i n g a n a l y s i s o f v a r i a n c e ( s e e H o y t , 1 9 4 1 ) f o r s u b t e s t s a n d C r o n b a c h ' s c o m p o s i t e a l p h a f o r t h e t o t a l t e s t . M e a n , s t a n d a r d d e v i a t i o n , H o y t ' s r e l i a b i l i t y c o e f f i c i e n t , a n d s t a n d a r d e r r o r a r e s u m m a r i z e d f o r t h e k n o w - l e d g e i n s t r u m e n t i n T a b l e 11. The l o w r e l i a b i l i t y f o r K:AFFECTS (.36) may be p a r t i a l l y due t o t h e n a t u r e o f t h e s u b t e s t c o n t e n t , a m o r e g e n e r a l t o p i c t h a n e i t h e r f o o d c o m p o s i t i o n o r f a c t s v e r s u s f a l l a c y ; o r t o t h e m i s b e h a v i o u r o f f i v e o f t h e n i n e i t e m s . The r e l i a b i l i t y o f t h e r e m a i n i n g k n o w l e d g e s u b t e s t s a n d t h e t o t a l t e s t a l l e x c e e d e d .71, w i t h t h a t f o r t h e t o t a l t e s t ( C r o n b a c h ' s a l p h a ) a p p r o a c h - i n g t h e m o r e d e s i r e d v a l u e o f .80. T e s t o f h y p o t h e s e s . To t e s t t h e h y p o t h e s i s t h a t t h e r e was a s i g n i f i c a n t d i f f e r e n c e i n mean k n o w l e d g e s c o r e s among t h e f i v e g r o u p s , o n e - w a y a n a l y s i s o f v a r i a n c e was p e r f o r m e d . T a b l e 12 p r e s e n t s t h e mean k n o w l e d g e s c o r e s f o r e a c h g r o u p . T a b l e 13 s u m m a r i z e s - t h e r e s u l t s o f t h e a n a l y s i s . I n e a c h c a s e , t h e n u l l h y p o t h e s i s was r e j e c t e d a t t h e .05 l e v e l o f s i g n i f i c a n c e . To d e t e r m i n e t h e s o u r c e o f t h e ' e f f e c t s , a l l p a i r w i s e c o m p a r i s o n s among mean s c o r e s w e r e t e s t - ed u s i n g S c h e f f e ^ ' s S m e t h o d ( K i r k , 1968) . The r e s u l t s a r e s u m m a r i z e d i n T a b l e 1 4 . TABLE 11 Summary T e s t S t a t i s t i c s f o r t h e K n o w l e d g e I n s t r u m e n t K:AFFECTS K:COMP K:FACTS K:TOTAL N o . o f i t e m s 9 12 10 31 Mean (fo) 3 4 . 2 6 ( 7 6 . 1 3 ) 46 .91(78.18) 3 9 . 6 1 ( 7 9 . 2 2 ) 1 2 0 . 7 8 ( 7 7 . 9 2 ) S . D . (f) 3 . 1 9 ( 7 . 0 9 ) 6 . 2 1 ( 1 0 . 3 5 ) 5 . 1 3 ( 1 0 . 2 6 ) 1 2 . 5 9 ( 8 . 1 2 ) H o y t ' s r .36 • 71 .74 • 7 9 a S . E . 2.40 3 . 2 3 2.46 4 . 9 1 C r o n b a c h ' s c o m p o s i t e a l p h a ( C r o n b a c h , 1951)• TABLE 12 Mean S c o r e s f o r K n o w l e d g e S u b t e s t s b y G r o u p G r o u p N K:AFFECTS KrCOMP . K:FACTS cc 11 32 .27 40 . 36 34 .00 EDUC 25 32 .48 43 . 52 37 -12 MIX 10 34 .00 47 .30 40.50 DIET 14 36 . 57 50 .57 42.64 NUTR 16 36 . 56 53 .25 4 4 . 1 3 TABLE 13 One-Way A n a l y s i s o f V a r i a n c e f o r K n o w l e d g e S u b t e s t s - a n d T o t a l T e s t S o u r c e o f F _ V a r i a b i l i t y d f - - : K: AFFECTS rKYC0MP K: FACTS K :.T0TAL B e t w e e n 4 10 . 47* 21 . 70* 16 .94* 3 1 . 29* W i t h i n 71 MSw 6 .76 18.33 14.23 60 .58 * P<.05 . TABLE 14 D i f f e r e n c e s among Group Mean S c o r e s f o r K n o w l e d g e S u b t e s t s G r o u p K:AFFECTS K:COMP K:FACTS 2 3 4 5 2 3 4 5 2 3 4 5 1 CC .21 1.73 4 . 2 9 * 4 . 3 0 * 3.16 6.94* 10 .21* 12 .89* 3.12 6 . 5 0 * 8.64* 1 0 . 1 3 * 2 EDUC 1 .52 4.08* 4 .09* 3.78 7 . 0 5 * 9.73* 3-38 5 . 5 2 * 7.01* 3 MIX 2.56 2.57 3 .27 5-95* 2.14 3 . 6 3 4 DIET .01 2.68 1.49 5 NUTR * P < . 0 5 . NO As s h o w n i n T a b l e 1 4 , t h e mean s c o r e s f o r NUTR a n d D I E T g r o u p s w e r e s i g n i f i c a n t l y (P< . 0 5 ) g r e a t e r t h a n t h e EDUC a n d CC g r o u p s i n a l l t h r e e k n o w l e d g e s u b t e s t s . S i m i l a r l y , t h e CC g r o u p d i d n o t d i f f e r s i g n i f i c a n t l y (P< . 0 5 ) f r o m t h e EDUC g r o u p , n o r t h e NUTR g r o u p f r o m t h e DIET g r o u p f o r a l l t h r e e s u b t e s t s . S i n c e t h e s e r e s u l t s i n d i c a t e d t h a t t h e mean s c o r e s o f t h e n u t r i t i o n g r o u p s w e r e s i g n i f i c a n t l y (P< . 0 5 ) g r e a t e r t h a n t h o s e o f t h e n o n - n u t r i t i o n g r o u p s , b u t t h a t t h e mean s c o r e s o f t h e CC g r o u p d i d n o t d i f f e r s i g n i f i c a n t l y faoom - the EDUC g r o u p , t h i s c o n f i r m e d t h e r e q u i r e m e n t t h a t t h e t e s t d i s c r i m i n a t e b e t w e e n t h o s e w i t h a n d w i t h o u t s p e c i f i c k n o w l e d g e , t h u s p r o v i d i n g f u r t h e r e v i d e n c e o f t h e c o n t e n t v a l i d i t y o f t h e s e t e s t s . D e b r i e f i n g - q u e s t i o n n a i r e a n d i n t e r v i e w A s h o r t d e b r i e f i n g q u e s t i o n n a i r e a c c o m p a n i e d t h e p r e t e s t q u e s t i o n n a i r e . I t u s e d a c h e c k f o r m a t w i t h p r o v i s i o n f o r a d - d i t i o n a l c o m m e n t s . N i n e q u e s t i o n s d e a l t w i t h : (1) c l a r i t y o f t h e c o v e r l e t t e r , (2) d i r e c t i o n s , (3) u s e o f c o l o u r , ( 4 ) t i m e r e q u i r e m e n t f o r c o m p l e t i o n , (5) l e n g t h o f t h e q u e s t i o n n a i r e , (6) p r i o r a t t e n d a n c e a t f o r m a l n u t r i t i o n c o u r s e s , (7) w h e t h e r a n y s t a t e m e n t s w e r e r e g a r d e d a s a m b i g u o u s , r e p e t i t i o u s , b i a s e d , (8) w h e t h e r t h e q u e s t i o n n a i r e was i n t e r e s t i n g , a n d (9) t h e i r o v e r a l l i m p r e s s i o n o f t h e q u e s t i o n n a i r e . To d e t e r m i n e a n s w e r s t o q u e s t i o n s t h a t c o u l d n o t be c o v e r - ed i n t h e d e b r i e f i n g q u e s t i o n n a i r e , a s h o r t i n t e r v i e w (15 m i n - u t e s ) was a r r a n g e d w i t h r a n d o m l y c h o s e n r e p r e s e n t a t i v e s o f ; t h r e e 97 (NUTR, CC, EDUC) g r o u p s . I n t h e c a s e o f t h e p r o f e s s i o n a l n u t r i - t i o n g r o u p i n t h e c o m m u n i t y ( D I E T ) , t h e 14 d i e t i t i a n s w i t h e x - p e r i e n c e i n d i e t a r y h i s t o r y p r o c e d u r e s p a r t i c i p a t e d i n a r o u n d t a b l e d i s c u s s i o n . A t t h a t t i m e , t h e q u e s t i o n s p r e v i o u s l y d e - s c r i b e d w e r e a s k e d as w e l l as q u e s t i o n s r e g a r d i n g t h e p r a c t i c e i n s t r u m e n t i t s e l f . E a c h s e c t i o n o f t h e p r a c t i c e i n s t r u m e n t was e x a m i n e d f o r r e l e v a n c e t o t h e t o p i c ( u s u a l d i e t a r y p r a c t i c e ) , a d e q u a c y o f c o v e r a g e o f t h e t o p i c , c l a r i t y , a n d l a c k o f a m b i g u - i t y ( M o u l y , 1 9 7 0 ) . R e s u l t s a r e d e s c r i b e d b e l o w i n t h e d i s - c u s s i o n o f t h e r e v i s i o n s o f t h e i n s t r u m e n t s . R e v i s i o n s o f t h e I n s t r u m e n t s A t t i t u d e I n s t r u m e n t Comments o b t a i n e d f r o m t h e i n t e r v i e w a n d t h e d e b r i e f i n g q u e s t i o n n a i r e c o n f i r m e d t h e a m b i g u i t y o f t h e s i x i t e m s i n t h e A:RESPON s u b t e s t w h i c h c o r r e l a t e d n e g a t i v e l y w i t h t h e t o t a l s u b - t e s t s c o r e . C o n s e q u e n t l y , t h e s e s i x i t e m s w e r e d e l e t e d . The r e - m a i n i n g t w o i t e m s o f t h e s u b t e s t a p p e a r e d t o p e r f o r m c o r r e c t l y a n d w e r e t r a n s f e r r e d t o s u b t e s t A:GEN ROLE. A s e v e n t h i t e m was a l s o d e l e t e d f r o m s u b t e s t A:GEN ROLE as i t s c o r r e l a t i o n , w h i l e p o s i t i v e a n d v e r y l o w (.09) f o r t h e t o t a l g r o u p , was n e g a t i v e l y c o r r e l a t e d f o r t w o o f t h e f i v e g r o u p s , a n d was c o n - s i d e r e d a m b i g u o u s i n t h e d e b r i e f i n g r e s u l t s . The f i n a l r e v i s e d a t t i t u d e i n s t r u m e n t c o n s i s t e d o f t w o s u b t e s t s : (1) A:GEN ROLE a n d (2) A:MANAGE w i t h 10 a n d n i n e i t e m s , r e s p e c t i v e l y . 98 K n o w l e d g e I n s t r u m e n t The t w o c r i t e r i a u s e d f o r d e l e t i n g o r r e v i s i n g k n o w l e d g e i t e m s w e r e as f o l l o w s : ( 1 ) a p o i n t b i s e r i a l c o r r e l a t i o n l e s s t h a n . 2 ; a n d ( 2 ) t h e i n a b i l i t y o f a n i t e m t o d i s c r i m i n a t e b e - t w e e n t h e n u t r i t i o n a n d n o n - n u t r i t i o n g r o u p s as d e t e r m i n e d b y t h e p r o p o r t i o n o f e a c h g r o u p t h a t r e s p o n d e d c o r r e c t l y . F o r K :AFFECTS, o f t h e f i v e m i s b e h a v i n g i t e m s i d e n t i f i e d o n t h e b a s i s o f t h e i t e m a n a l y s i s r e s u l t s , f o u r w e r e r e t a i n e d . On e a c h , t h e t o p s c o r e r s f o r t h e t o t a l K:AFFECTS r e s p o n d e d c o r - r e c t l y . One o f t h e s e i t e m s was a l t e r e d t o i n c r e a s e t h e c l a r i t y o f t h e s t a t e m e n t b a s e d o n p r e t e s t c o m m e n t s . The f i f t h i t e m was d e l e t e d s i n c e b o t h n u t r i t i o n g r o u p s h a d n e g a t i v e c o r r e l a - t i o n s a n d t h e c o r r e l a t i o n f o r t h e t o t a l g r o u p , w h i l e p o s i t i v e , was o n l y .15. T h e t h r e e i t e m s t h a t m i s b e h a v e d i n K:C0MP w e r e r e - e x a m i n e d . One was r e t a i n e d d e s p i t e i t s d i f f i c u l t y l e v e l ( 3 0 % o f t e s t t a k e r s p i c k e d t h e c o r r e c t r e s p o n s e ) . W h i l e m o s t i t e m s s h o u l d be i n t h e 50 t o 80% d i f f i c u l t y r a n g e ( S t a n l e y a n d H o p k i n s , 1 9 7 2 , p p . 1 8 8 - I 8 9 ) i t h e i t e m was r e t a i n e d b e c a u s e o f i t s i m p o r t t a n c e t o t h e s t u d y as a w h o l e . The r e m a i n i n g t w o i t e m s w e r e d e l e t e d due t o c o n f i r m e d a m b i g u i t y f r o m t h e p r e t e s t c o m m e n t s . Two i t e m s f r o m t h e f i n a l s u b t e s t (K :FACTS) w e r e a l s o r e - e x a m i n e d . One was r e t a i n e d e v e n t h o u g h a l l g r o u p s a p p e a r e d t o be g u e s s i n g , b e c a u s e o f i t s i m p o r t a n c e r e g a r d i n g CVD. The s e c o n d i t e m was d e l e t e d s i n c e i t was j u d g e d t o r e f l e c t c u r r e n t p o p u l a r l i t e r a t u r e a n d f a i l e d t o d i s c r i m i n a t e b e t w e e n g r o u p s ( o v e r a l l p r o p o r t i o n who a n s w e r e d c o r r e c t l y was 1 9 . 7 % ) . The f i n a l k n o w l e d g e i n s t r u m e n t c o n s i s t e d o f t h r e e s u b t e s t s : K :AFFECTS, K:COMP, a n d K:FACTS w i t h e i g h t , 1 0 , a n d n i n e i t e m s , r e s p e c t i v e l y . B i o d e m o g r a p h i c S e c t i o n Two r e v i s i o n s w e r e made i n t h e b i o d e m o g r a p h i c s e c t i o n : t h e age c a t e g o r i e s w e r e a l t e r e d t o c o i n c i d e w i t h t h e C a n a d i a n D i e t - a r y S t a n d a r d c a t e g o r i e s , a n d t h e s e q u e n c e o f t h e q u e s t i o n s c o n - c e r n i n g h i s t o r i e s o f CVD was r e v e r s e d , t h a t i s , t h e p e r s o n a l h i s t o r y o f CVD now p r e c e e d e d t h e f a m i l y h i s t o r y o f CVD. P r a c t i c e I n s t r u m e n t The d i e t i t i a n s a g r e e d t h a t t h e q u e s t i o n s w e r e c l e a r , r e l e - v a n t t o u s u a l d i e t a r y p r a c t i c e , a n d p r o v i d e d a d e q u a t e c o v e r a g e o f t h e t o p i c e x c e p t f o r some m i n o r a d d i t i o n s . More d e s c r i p t i o n was a d d e d t o t h e " y e s t e r d a y ' s i n t a k e " f o r m a t a n d s e v e r a l f o o d s w e r e a d d e d t o t h e f o o d f r e q u e n c y c h e c k l i s t . The d e b r i e f i n g q u e s t i o n n a i r e e s t a b l i s h e d t h e t i m e r e q u i r e - m e n t f o r c o m p l e t i o n o f t h e q u e s t i o n n a i r e t o be a b o u t 30 m i n u t e s , a n d c o n f i r m e d t h e u s e o f t h e c o l o u r e d s e c t i o n s t o s e p a r a t e t h e a t t i t u d e , k n o w l e d g e , a n d t h e r e m a i n i n g s e c t i o n s ( b i o d e m o g r a p h i c a n d p r a c t i c e ) . The r e v i s i o n s m e n t i o n e d w e r e i m p l e m e n t e d ; t h e f i n a l q u e s t i o n n a i r e t y p e d , p r i n t e d , a n d c o l l a t e d i n p r e p a r a t i o n f o r t h e m a i n s u r v e y , t h e m e t h o d o l o g y o f w h i c h i s d e s c r i b e d i n t h e n e x t c h a p t e r . A c o p y o f t h e f i n a l q u e s t i o n n a i r e i s p r e s e n t e d i n A p p e n d i x A . CHAPTER I V METHOD A n a n a l y t i c a l s u r v e y was c o n d u c t e d t o d e t e r m i n e i n t e r - r e l a t i o n s h i p s among c a r d i o v a s c u l a r n u t r i t i o n a t t i t u d e s , k n o w - l e d g e , a n d p r a c t i c e a n d b i o d e m o g r a p h i c c h a r a c t e r i s t i c s o f a d u l t members o f c o m m u n i t y c e n t r e s . I n s t r u m e n t s C a r d i o v a s c u l a r n u t r i t i o n a t t i t u d e s , k n o w l e d g e , a n d p a s a c t i c d a t a w e r e c o l l e c t e d b y a s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e t h a t c o n s i s t e d o f f o u r s e c t i o n s c o r r e s p o n d i n g , r e s p e c t i v e l y , t o n u t r i t i o n a t t i t u d e s , n u t r i t i o n k n o w l e d g e , b i o d e m o g r a p h i c i n f o r m a t i o n , a n d d i e t a r y p r a c t i c e . N u t r i t i o n A t t i t u d e s The a t t i t u d e i n s t r u m e n t , v a l i d a t e d a n d p r e t e s t e d i n t h e p i l o t s t u d y d e s c r i b e d i n t h e p r e v i o u s c h a p t e r , c o n s i s t e d o f t w o s u b t e s t s : ( 1 ) A?GEN ROLE a n d ( 2 ) A:MANAGE w i t h 1 0 a n d n i n e i t e m s , r e s p e c t i v e l y . A:GEN ROLE m e a s u r e d a t t i t u d e s t o w a r d t h e g e n e r a l r o l e o f n u t r i t i o n i n h e a r t d i s e a s e . The s e c o n d s u b - t e s t , A:MANAGE, m e a s u r e d a t t i t u d e s r e g a r d i n g t h e c h a n g i n g o r m a n i p u l a t i n g o f t h e d i e t as a p r e v e n t i v e m e a s u r e a g a i n s t CVD. The o v e r a l l p u r p o s e o f t h e i n s t r u m e n t was t o m e a s u r e a t t i t u d e s t o w a r d d i e t as a means o f p r o m o t i n g h e a r t h e a l t h a n d i n t e r v e n - i n g a g a i n s t h e a r t d i s e a s e . N u t r i t i o n K n o w l e d g e The k n o w l e d g e i n s t r u m e n t , a l s o v a l i d a t e d a n d p r e t e s t e d i n t h e p i l o t s t u d y , c o n t a i n e d t h r e e s u b t e s t s : K :AFFECTS; K:COMP; a n d K :FACTS, w i t h e i g h t , 1 0 , a n d n i n e i t e m s , r e s p e c t i v e l y . The f i r s t s u b t e s t , K :AFFECTS, m e a s u r e d k n o w l e d g e o f how f o o d a f f e c t s t h e h e a r t . K n o w l e d g e o f f o o d c o m p o s i t i o n was m e a s u r e d b y t h e s u b t e s t K : C 0 M P , a n d k n o w l e d g e i n v o l v i n g t h e d i f f e r e n t i a t i o n b e t w e e n f a c t s a n d f a l l a c i e s r e l a t e d t o d i e t a n d CVD was a s s e s s - ed b y K :FACTS. B i o d e m o g r a p h i c S e c t i o n The b i o d e m o g r a p h i c s e c t i o n o f t h e s e l f - a d m i n i s t e r e d q u e s - t i o n n a i r e c o l l e c t e d d a t a o n t h e i n d e p e n d e n t v a r i a b l e s w h i c h w e r e n o n - m a n i p u l a t i v e i n n a t u r e a n d i n c l u d e d : ( 1 ) g e n d e r , (2) a g e , (3) l i v i n g a r r a n g e m e n t , (4) e d u c a t i o n l e v e l , (5) p h y s i c a l e x e r c i s e p a t t e r n , ( 6 ) h e i g h t , ( 7 ) b o d y w e i g h t , ( 8 ) s m o k i n g h a b i t , ( 9 ) p e r s o n a l h i s t o r y o f CVD, a n d ( 1 0 ) f a m i l y h i s t o r y o f CVD. I n a d d i t i o n , i n f o r m a t i o n t h a t r e l a t e d t o o c - c u p a t i o n , p l a c e o f b i r t h , h i s t o r y o f p r e v i o u s w e i g h t c h a n g e , a n d s o u r c e s f r o m w h i c h i n f o r m a t i o n o n d i e t a n d h e a r t d i s e a s e was o b t a i n e d , was c o l l e c t e d . A l l r e s p o n s e s r e q u i r e d s h o r t a n s w e r s o r c h e c k i n g . 102 D i e t a r y P r a c t i c e The p r a c t i c e i n s t r u m e n t , v a l i d a t e d b y 14 d i e t i t i a n s w i t h e x p e r i e n c e i n d i e t a r y h i s t o r y p r o c e d u r e s ( s e e C h a p t e r I I I , p . 9 7 ) , m e a s u r e d t h e u s u a l d i e t a r y p r a c t i c e o f t h e p a r t i c i p a n t s . I t c o n - s i s t e d o f t h r e e s e c t i o n s t h a t p r o v i d e d i n f o r m a t i o n o n y e s t e r - d a y ' s i n t a k e , g e n e r a l e a t i n g p a t t e r n , a n d f r e q u e n c y o f c o n s u m p - t i o n o f a n u m b e r o f common f o o d s . The c o m b i n e d i n f o r m a t i o n f r o m t h e t h r e e s e c t i o n s g a v e a n e s t i m a t e o f t h e u s u a l i n t a k e o f t h e i n d i v i d u a l . To a s c e r t a i n t h e r e l i a b i l i t y o f t h e p r a c t i c e d a t a , d i e t - a r y d a t a was a l s o o b t a i n e d f r o m p e r s o n a l i n t e r v i e w s w i t h a r a n - dom s u b s a m p l e o f t h o s e r e t u r n i n g t h e q u e s t i o n n a i r e s . The i n t e r v i e w s c h e d u l e was a p a r a l l e l f o r m t o t h e q u e s t i o n n a i r e a n d was p r e d o m i n a n t l y a c l o s e - e n d e d i n s t r u m e n t b a s e d o n t h e m e t h o d d e s c r i b e d b y B u r k e (1947) a n d Y o u n g (1959) • I"t u s e d a 2 4 - h o u r r e c a l l w i t h p r o b i n g t e c h n i q u e s f o r d e t e r m i n i n g - v a r i a t i o n s f r o m t h e u s u a l i n t a k e r e c o r d e d , q u e s t i o n s r e g a r d i n g t h e g e n e r a l e a t - i n g p a t t e r n , a n d . a f o o d f r e q u e n c y c h e c k l i s t t o c r o s s - c h e c k t h e u s u a l f o o d i n t a k e . The i n t e r v i e w s c h e d u l e a l s o c o l l e c t e d d a t a o n t h e p a r t i c i p a n t . ' s e x e r c i s e p a t t e r n , s m o k i n g h a b i t s , a g e , g e n d e r , a n d u s e o f s u p p l e m e n t s . A l l i n t e r v i e w s w e r e c o n d u c t e d b y t w o q u a l i f i e d n u t r i t i o n i s t s w i t h e x p e r i e n c e i n o b t a i n i n g d i e t a r y h i s t o r i e s . P r o b i n g q u e s t i o n s a n d f o o d m o d e l s w e r e u s e d t o a s s i s t t h e p a r t i c i p a n t i n r e c a l l i n g p o r t i o n s i z e s a n d a m o u n t s . Once t h e r e c o r d e d i n t a k e h a d b e e n c a r e f u l l y c r o s s - c h e c k e d , t h e f i n a l e s t i m a t e o f t h e p a r t i c i p a n t ' s d i e t a r y p r a c - t i c e was d e t e r m i n e d a c c o r d i n g t o t h e same p r o c e d u r e u s e d f o r 1 0 3 the s e l f - a d m i n i s t e r e d p r a c t i c e instrument. Because the v a l i d i t y of the i n t e r v i e w data i s a f f e c t e d "by the competence of the i n t e r v i e w e r , the two n u t r i t i o n i s t s r e - c e i v e d two or more hours of t r a i n i n g i n the i n t e r v i e w s p e c i f i c to t h i s study. I n s t r u c t i o n s i n c l u d e d the use of food models, probing, and r e c o r d i n g of data as w e l l as procedures f o r height and weight measurement, so t h a t the i n t e r v i e w p r o t o c o l was s t a n d a r d i z e d , between-interviewer d i f f e r e n c e s minimized, q u a l i t y c o n t r o l assured, and v a l i d i t y improved. W r i t t e n i n s t r u c t i o n s f o r s t a n d a r d i z i n g the i n t e r v i e w and measuring weight and height were p r o v i d e d (see Appendix B). To p r e t e s t the schedule, the i n t e r v i e w e r s conducted a taped p r a c t i c e i n t e r v i e w w i t h the same a d u l t , not a member of the survey sample. The tapes were l a t e r reviewed by both i n t e r v i e w e r s and any problems, q u e s t i o n s , or improvements c o l l e c t i v e l y r e s o l v e d . As a r e s u l t of the p r e t e s t , s e v e r a l minor changes i n the schedule were made. A copy of the f i n a l form of the schedule i s presented i n Appendix B. The f o u r s e c t i o n s of the q u e s t i o n n a i r e were assembled i n the same order used i n the p i l o t q u e s t i o n n a i r e : a t t i t u d e s , knowledge, biodemographic, and p r a c t i c e s e c t i o n s . Colour-coded s e c t i o n s were used and the pages p r i n t e d on both s i d e s . P o p u l a t i o n The p r e s e n t study was an a n a l y t i c a l f i e l d survey designed to i n v e s t i g a t e the c a r d i o v a s c u l a r n u t r i t i o n of a d u l t members of community cen t r e s w i t h r e s p e c t to the dependent v a r i a b l e s 104 a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e , a n d t h e r e l a t i o n s h i p s o f t h e s e t h r e e v a r i a b l e s t o t h e b i o d e m o g r a p h i c c h a r a c t e r i s t i c s o f t h e s a m p l e . I t was t h o u g h t t h a t a d u l t s who a t t e n d e d c o m m u n i t y c e n t r e p r o g r a m s w o u l d l i k e l y f o r m a n a u d i e n c e a p p r o p r i a t e f o r t h e t y p e o f c a r d i o v a s c u l a r n u t r i t i o n p r o g r a m t h a t m i g h t be p l a n n e d b a s e d o n t h e f i n d i n g s . T h e r e f o r e , t h e t a r g e t p o p u l a t i o n f o r t h i s s u r v e y was a d u l t s , 19 y e a r s o f age a n d o v e r , who p a r t i c i p a t e d i n p r o g r a m s o f f e r e d b y c o m m u n i t y c e n t r e s o p e r a t e d i n t h e c i t y o f V a n c o u v e r , B . C . S i n c e 1976, t h e c i t y h a d b e e n d i v i d e d i n t o f o u r r e c r e a t i o n a r e a s ( V a n c o u v e r , 1977) c o n t a i n i n g a t o t a l o f -21 c o m m u n i t y c e n t r e s ( V a n c o u v e r , 1978). I n f o r m a t i o n r e c e i v e d f r o m t h e h e a d o f f i c e s o f e a c h r e c r e a t i o n a r e a s u g g e s t e d t h a t d i f f e r - e n c e s e x i s t e d f r o m c e n t r e t o c e n t r e as w e l l as b e t w e e n r e c r e a - t i o n a r e a s , i n d i c a t i n g t h e i n a d v i s a b i l i t y o f u s i n g a n y one c o m m u n i t y c e n t r e t o r e p r e s e n t a p a r t i c u l a r a r e a . C o n s e q u e n t l y , i t was d e c i d e d t h a t e a c h c o m m u n i t y c e n t r e w o u l d be s a m p l e d i n o r d e r t o r e p r e s e n t t h e t o t a l p o p u l a t i o n o f V a n c o u v e r c o m m u n i t y c e n t r e a d u l t s . The r e q u i r e m e n t s f o r i n - c l u s i o n i n t h e s u r v e y w e r e t h a t t h e c o m m u n i t y c e n t r e c a t e r t o t h e w h o l e c o m m u n i t y a n d t h a t t h e members f l u e n t l y s p e a k a n d r e a d E n g l i s h . O f t h e 21 c e n t r e s , f o u r w e r e e l i m i n a t e d f r o m t h e s t u d y : one c e n t r e u s e d a l a n g u a g e t h a t was n o t E n g l i s h , t w o c e n t r e s c a t e r e d t o s p e c i f i c s u b g r o u p s o f t h e c o m m u n i t y , a n d a f o u r t h c e n t r e p a r t i c i p a t e d am b o t h p r e l i m i n a r y a n d p i l o t t e s t - i n g o f t h e i n s t r u m e n t s . Sample I n A p r i l 1 9 7 9 , l e t t e r s t h a t d e s c r i b e d t h e p u r p o s e o f t h e s t u d y , ..-asked f o r t h e i r c o o p e r a t i o n , a n d r e q u e s t e d c o m p l e t i o n a n d r e t u r n o f a n e n c l o s e d a u t h o r i z a t i o n f o r m w e r e s e n t t o t h e r e c - r e a t i o n c o o r d i n a t o r s o f t h e 17 c o m m u n i t y c e n t r e s ( s e e A p p e n d i x C ) . Of t h e 17 c e n t r e s a p p r o a c h e d , t h r e e c h o s e n o t t o p a r t i c i - p a t e i n t h e s t u d y a n d t w o w e r e u n a c c e p t a b l e b e c a u s e t h e y d i f f e r - ed i n o r i e n t a t i o n f r o m r e m a i n i n g c o m m u n i t y c e n t r e s i . e . , n o t c e n t r a l i z e d o r s c h o o l s r a t h e r t h a n a c t i v i t y c e n t r e s . One f i n a l c e n t r e a l l o w e d e n t r y o f t h e i n v e s t i g a t o r b u t d e c l i n e d p e r m i s s i o n f o r c o n d u c t i o n o f t h e r e s e a r c h p r o c e d u r e d e v i s e d f o r t h e s t u d y . To a v o i d i n t r o d u c i n g p o s s i b l e b i a s w i t h a d i f f e r e n t a p p r o a c h , t h i s c e n t r e was a l s o e l i m i n a t e d f r o m t h e s t u d y . The s i x n o n - p a r t i c i p a t i n g c e n t r e s r e p r e s e n t e d a l l f o u r r e c r e a t i o n a r e a s o f t h e c i t y o f V a n c o u v e r ; t w o e a c h f r o m t h e S o u t h a n d N o r t h a r e a s ; one e a c h f r o m t h e W e s t a n d E a s t a r e a s . The r e m a i n i n g c e n t r e s , 11 i n t o t a l , p a r t i c i p a t e d i n t h e s t u d y . The f o l l o w i n g s a m p l i n g p r o c e d u r e was u s e d f o r e a c h o f t h e c o m m u n i t y c e n t r e s s u r v e y e d . As t h e m a j o r i t y o f t h e c o m m u n i t y c e n t r e c l a s s e s o p e r a t e d o n a Monday t o T h u r s d a y b a s i s , one d a y f r o m among t h e s e f o u r was r a n d o m l y s e l e c t e d . T h e n , f r o m t h e o f f i c e ' s r e g i s t r a t i o n l i s t , a l i s t o f members f o r t h e p r o g r a m s o f t h e c h o s e n d a y was g e n e r a t e d a n d 4-0 names w e r e r a n d o m l y s e l e c t e d . B e c a u s e o f d i f f e r e n t c e n t r e a d m i n i s t r a t i v e p o l i c i e s , f i v e o f t h e 11 c e n t r e s w e r e n o t a b l e t o s u p p l y a . m e m b e r s h i p l i s t a n d / o r a c l a s s l i s t f o r t h e c h o s e n d a y . I n t h e s e f i v e i n s t a n c e s , t h e i n v e s t i g a t o r w i t h t h e c o o p e r a t i o n o f o f f i c i a l s o f t h e c e n t r e s c o n c e r n e d , m e t e a c h c l a s s o p e r a t i n g o n t h a t p a r t i c u l a r d a y . A f t e r i n t r o d u c i n g h e r s e l f , t h e i n v e s t i g a t o r s t a t e d : (1) t h e . p u r p o s e o f t h e s u r v e y , (2) t h a t t h e d a y h a d "been s e l e c t e d a t r a n d o m t o r e p r e s e n t t h e i r c e n t r e , (3) t h a t a l l c l a s s e s o p e r a t i n g o n t h a t p a r t i c u l a r d a y w o u l d be a p p r o a c h e d , (4) t h a t v o l u n t e e r s w e r e r e q u e s t e d f o r p a r t i c i p a t i o n i n t h e s t u d y , (5) t h a t t h e q u e s t i o n n a i r e r e q u i r e d a b o u t 30 m i n u t e s t o c o m p l e t e , (6) t h a t t h e y c o u l d t a k e i t home a n d m a i l i t b a c k i n t h e s t a m p e d e n v e l o p e p r o v i d e d , a n d (7) t h a t c o m p l e t e a n o n y m i t y w o u l d be m a i n t a i n e d a n d a l l a n s w e r s t r e a t e d c o n f i d e n t i a l l y . The r e m a i n i n g s i x c e n t r e s p r o v i d e d . . l i s t s f r o m w h i c h names w e r e r a n d o m l y s e l e c t e d . D a t a C o l l e c t i o n P r o c e d u r e s Q u e s t i o n n a i r e D i s t r i b u t i o n Once t h e d i s t r i b u t i o n d a y h a d b e e n a s s i g n e d t o e a c h p a r t i c - i p a t i n g c o m m u n i t y c e n t r e , a t i m e t a b l e f o r a d m i n i s t r a t i o n o f t h e q u e s t i o n n a i r e p a c k e t s d u r i n g May a n d J u n e 1979 was a r r a n g e d . T h i s n e c e s s i t a t e d s e v e r a l d i s t r i b u t i o n p e r i o d s p e r c e n t r e . E a c h t i m e , t h e i n v e s t i g a t o r b r i e f l y a d d r e s s e d t h e s e l e c t e d g r o u p , s t a t e d t h e p u r p o s e o f t h e s u r v e y , a n d r e q u e s t e d t h e i r p a r t i c i p a t i o n . B e f o r e r e c e i v i n g t h e s u r v e y p a c k e t w h i c h c o n - t a i n e d a c o v e r l e t t e r , t h e q u e s t i o n n a i r e , a n i d e n t i f i c a t i o n c a r d , a n d a n a d d r e s s e d , s t a m p e d , r e t u r n e n v e l o p e , t h e p a r t i c i - p a n t s s i g n e d a c o n s e n t f o r m . They w e r e a s s u r e d t h a t c o m p l e t e a n o n y m i t y w o u l d be m a i n t a i n e d a n d t h a t a l l r e s u l t s w o u l d be t r e a t e d c o n f i d e n t i a l l y . M a i l r e t u r n o f t h e c o m p l e t e d q u e s t i o n - n a i r e i n t h e e n v e l o p e p r o v i d e d was r e q u e s t e d w i t h i n one w e e k f r o m t h e d a t e o f d i s t r i b u t i o n . A t t h e t i m e o f d i s t r i b u t i o n , t h r e e o f t h e s i x c e n t r e s i n w h i c h r a n d o m s a m p l i n g h a d b e e n c o n - t e m p l a t e d w e r e f o u n d t o h a v e p r o b l e m s . Due t o c l a s s c a n c e l l a t - i o n o r r e p l a c e m e n t , o n l y h a l f o f t h e i n i t i a l c l a s s e s w e r e p r e s e n t . C o n s e q u e n t l y , t h e i n v e s t i g a t o r m e t w i t h t h e s u b s t i - t u t e d c l a s s e s a n d r e q u e s t e d p a r t i c i p a t i o n f r o m a l l p r e s e n t . U s i n g t h e s i g n e d c o n s e n t f o r m s , l i s t s o f p a r t i c i p a n t s f r o m e a c h c e n t r e w e r e made a n d r e m i n d e r s , o n c e t h e d e a d l i n e e l a p s e d , c o m m u n i c a t e d b y means o f t e l e p h o n e f o l l o w - u p . I n t e r v i e w Samp le W i t h t h e same l i s t o f p a r t i c i p a n t s who s i g n e d t h e c o n s e n t f o r m s , a s e c o n d s a m p l i n g p r o c e d u r e was f o l l o w e d t o s e l e c t a s u b s a m p l e f o r t h e i n t e r v i e w s e g m e n t o f t h e s t u d y . F rom t h e l i s t , s t r a t i f i e d b y g e n d e r , a r a n d o m s u b s a m p l e o f f o u r p e o p l e p e r c e n t r e was s e l e c t e d w i t h g e n d e r r e p r e s e n t e d i n p r o p o r t i o n t o t h e o r i g i n a l c e n t r e p a r t i c i p a t i o n . C o n t a c t b y t e l e p h o n e d e t e r m i n e d w h e t h e r t h e y h a d r e t u r n e d t h e q u e s t i o n n a i r e a n d , i f s o , w h e t h e r t h e y w e r e w i l l i n g t o p a r t i c i p a t e i n t h e i n t e r v i e w . I n t h i s w a y , a s u b s a m p l e o f 4 4 p e o p l e , r e p r e s e n t a t i v e o f t h e 1 1 c o m m u n i t y c e n t r e s , was i n t e r v i e w e d . I n t e r v i e w d a t a c o l l e c t i o n p r o c e d u r e The f i n a l s t a g e o f t h e d a t a c o l l e c t i o n , t h e i n t e r v i e w i n g o f t h e s u b s a m p l e , was s c h e d u l e d t w o w e e k s a f t e r t h e a d m i n i s t r a - t i o n o f t h e q u e s t i o n n a i r e . A p p o i n t m e n t s w e r e a r r a n g e d f o r i n t e r v i e w i n g a c c o r d i n g t o t h e c o n v e n i e n c e o f t h e members o f t h e s u b s a m p l e . The p r o c e d u r e was as f o l l o w s : t h e i n t e r v i e w e r s w e r e a s s i g n e d t o s u b j e c t s a c c o r d i n g t o a t i m e t a b l e e s t a b l i s h e d b y m u t u a l - * . / c o n v e n i e n c e . The i n t e r v i e w e r s t e l e p h o n e d t h e p r o s p e c t i v e p a r t i c i p a n t a n d s t a t e d " M r . X , I am . . . . c a l l i n g a b o u t t h e d i e t a n d h e a r t d i s e a s e s u r v e y i n w h i c h y o u p a r t i c i p a t e d a t . . . . c o m m u n i t y c e n t r e . " He was i n f o r m e d t h a t he h a d b e e n r a n d o m l y c h o s e n f o r t h e i n t e r v i e w a b o u t h i s f o o d h a b i t s , t h a t a l l a n s w e r s w e r e c o n - f i d e n t i a l , a n d t h a t no names w o u l d be u s e d i n t h e a n a l y s i s . He was t h e n a s k e d i f he h a d c o m p l e t e d a n d r e t u r n e d t h e q u e s t i o n - n a i r e . I f he r e s p o n d e d n e g a t i v e l y , he was a s k e d w h e t h e r he i n - t e n d e d t o c o m p l e t e i t o r w i s h e d a s e c o n d c o p y t o r e p l a c e t h e one l o s t . I f he r e s p o n d e d i n t h e a f f i r m a t i v e , ibhe i n t e r v i e w e r s t a t e d t h a t s h e w i s h e d t o come a n d t a l k w i t h h i m a b o u t h i s f o o d h a b i t s o n ( d a t e ) , a n d t h a t i t w o u l d t a k e a b o u t 3 0 m i n u t e s . He was r e m i n d e d t h a t he w o u l d be a s k e d a t t h a t t i m e t o s u b m i t t h e i d e n t i f i c a t i o n c a r d t h a t a c c o m p a n i e d t h e q u e s t i o n n a i r e . The c o n v e r s a t i o n c l o s e d w i t h t w o q u e s t i o n s : What t i m e i s m o s t c o n v e n i e n t f o r y o u , a n d s h a l l I c a l l a t y o u r home? o r . . . ( a d d r e s s t o be t a k e n ) . I f t h e p e r s o n h e s i t a t e d , t h e . . . . c o m m u n i t y c e n t r e was s u g g e s t e d . B e f o r e e n d i n g t h e t e l e p h o n e c o n v e r s a t i o n , t h e i n t e r v i e w e r r e v i e w e d t h e t i m e a n d p l a c e f o r t h e i n t e r v i e w . On t h e d a y o f t h e i n t e r v i e w , t h e i n t e r v i e w e r i d e n t i f i e d 109 h e r s e l f , s h o w e d t h e a u t h o r i z a t i o n f o r m , r e p e a t e d t h e s u r v e y name a n d U n i v e r s i t y o f B r i t i s h C o l u m b i a a f f i l i a t i o n , a n d em- p h a s i z e d t h a t a l l a n s w e r s w e r e c o n f i d e n t i a l . T h e n , s h e p r o - c e e d e d w i t h t h e i n t e r v i e w a c c o r d i n g t o t h e e s t a b l i s h e d p r o t o - c o l . A t t h e e n d , t h e p a r t i c i p a n t s w e r e r e m i n d e d t o s u b m i t t h e i r i d e n t i f i c a t i o n c a r d so c o m p a r i s o n w i t h t h e p a r a l l e l s e l f - a d - m i n i s t e r e d p r a c t i c e i n s t r u m e n t c o u l d be m a d e . D a t a A n a l y s i s P r e p a r a t i o n o f D a t a As q u e s t i o n n a i r e s w e r e r e c e i v e d , t h e i d e n t i f i c a t i o n n u m - b e r s w e r e r e c o r d e d a n d t h e d a t e o f t h e r e t u r n n o t e d . E a c h q u e s t i o n n a i r e was r e v i e w e d f o r c o m p l e t e n e s s a n d t h o s e w i t h i n - c o m p l e t e s e c t i o n s d e l e t e d . A l l b i o d e m o g r a p h i c d a t a w e r e c o n - v e r t e d t o n u m e r i c a l c o d e s , r e c o r d e d o n t h e q u e s t i o n n a i r e , a n d d o u b l e - c h e c k e d f o r a c c u r a c y . P r a c t i c e i n f o r m a t i o n was t r a n s f e r r e d b y t h e i n v e s t i g a t o r t o f o o d r e c o r d b o o k l e t s u s i n g t h e s c o r i n g p r o c e d u r e d e s c r i b e d b e l o w . D a t a w e r e k e y - p u n c h e d d i r e c t l y f r o m t h e q u e s t i o n n a i r e a n d p r a c t i c e c o d i n g b o o k l e t s ( t h e l a t t e r f r o m b o t h t h e q u e s t i o n n a i r e a n d i n t e r v i e w ) b y t h e s t a f f a t t h e U n i v e r s i t y o f B r i t i s h Columfe b i a C o m p u t e r C e n t r e . The b i o d e m o g r a p h i c i n f o r m a t i o n f r o m t h e i n t e r v i e w s c h e d u l e s was k e y - p u n c h e d b y t h e i n v e s t i g a t o r . B e - c a u s e o f t h e l a r g e v o l u m e o f d a t a , a l l r a w d a t a i n p u t w e r e p l a c e d o n f i l e s a n d h a n d - c h e c k e d f o r k e y - p u n c h i n g e r r o r s b y 110 t h e i n v e s t i g a t o r . Any e r r o r s w e r e d o u b l e - c h e c k e d a n d c o r r e c t e d . The i t e m s o f t h e a t t i t u d e a n d k n o w l e d g e s c a l e s w e r e a l s o r e - c h e c k e d f o r c o r r e c t c o d i n g a n d s c o r i n g k e y . S c o r i n g The same s c o r i n g p r o c e d u r e s f o r t h e a t t i t u d e a n d k n o w l e d g e s c a l e s u s e d i n t h e p r e v i o u s l y d e s c r i b e d p i l o t s t u d y ( s e e C h a p t e r I I I , p p . 6 8 a n d 75 a n d T a b l e s 1 a n d 4) w e r e u s e d i n t h e m a i n s t u d y . R e s p o n s e s t o t h e a t t i t u d e a n d k n o w l e d g e s u b t e s t s w e r e i t e m a n a l y z e d a n d t h e r e s u l t i n g s c o r e s s t o r e d o n f i l e . S c o r i n g o f t h e p r a c t i c e d a t a i n v o l v e d t h r e e s t e p s : (1) e s t i m a t i o n o f t h e u s u a l i n t a k e , (2) t r a n s f e r t o c o d i n g b o o k l e t s f o r t r a n s l a t i o n b y c o m p u t e r t o n u t r i e n t v a l u e s , a n d (3) c o n - v e r s i o n t o n u t r i e n t r a t i o s c o r e s . E s t i m a t i o n o f u s u a l i n t a k e To s c o r e t h e u s u a l e a t i n g p r a c t i c e o f t h e r e s p o n d e n t s , g u i d e l i n e s w e r e d e v e l o p e d t o s t a n d a r d i z e t h e s c o r i n g p r o c e d u r e f o r t h e p r a c t i c e i n s t r u m e n t ( s e e A p p e n d i x D ) . The u s u a l i n t a k e was e s t i m a t e d i n t e r m s o f s p e c i f i c f o o d s , u s i n g a m o u n t s o r s e r v - i n g s i z e s c o n s u m e d . T r a n s l a t i o n t o n u t r i e n t v a l u e s The u s u a l i n t a k e i n f o r m a t i o n was t r a n s f e r r e d t o d i e t a r y a n a l y s i s c o d i n g b o o k l e t s d e v i s e d b y t h e D i v i s i o n o f Human I l l N u t r i t i o n , S c h o o l o f Home E c o n o m i c s , U n i v e r s i t y o f B r i t i s h C o l u m b i a . E a c h f o o d i t e m was i d e n t i f i e d b y a s p e c i f i c code n u m b e r a n d r e c o r d e d a c c o r d i n g t o t h e s e r v i n g q u a n t i t y c o n s u m e d f o r l a t e r n u t r i e n t c o m p o s i t i o n d e t e r m i n a t i o n b y c o m p u t e r . A l l c o d i n g b o o k l e t s w e r e i d e n t i f i e d b y t h e r e s p o n d e n t ' s u n i q u e i d e n t i f i c a t i o n n u m b e r a n d p r a c t i c e d a t a w e r e c o n f i n e d t o one b o o k l e t p e r r e s p o n d e n t . A n u m b e r o f a d d i t i o n s t o t h e e x i s t i n g n u t r i e n t f o o d c o m p o - s i t i o n d a t a b a n k w e r e n e c e s s a r y . The f o o d c o m p o s i t i o n t a b l e s u s e d t o s u p p l e m e n t t h e GNA: G e n e r a l N u t r i e n t A n a l y s i s p r o g r a m ( s e e p.112) w e r e b a s e d o n t h e r e v i s e d p u b l i c a t i o n s NUTRIENT VALUES OF SOME COMMON FOODS ( C a n a d a , 1979a) a n d FOOD VALUES OF PORTIONS COMMONLY USED ( C h u r c h a n d C h u r c h , 1975). The n u t r i e n t c o m p o s i t i o n f o r one s p e c i f i e d s e r v i n g o f t h e new f o o d i t e m was e n t e r e d i n t o t h e n u t r i e n t a n a l y s i s f o o d c o m p o s i t i o n d a t a b a n k a n d s t o r e d f o r l a t e r u s e . F o r e a c h a d d i t i o n , a n i d e n t i f y i n g n i n e d i g i t c o d e was d e v i s e d f o l l o w i n g t h e p r o g r a m ' s o r i g i n a l p r o c e d u r e f o r c o d i n g f o o d i t e m s . T h a t i s , t h e f i r s t t h r e e d i g i t s w e r e u n i q u e f o r e a c h f o o d i t e m , t h e f o u r t h t o s i x t h d i g i t s r e p r e s e n t e d t h e f o o d g r o u p s e . g . , 130 r e f e r r e d t o c h e e s e , a n d t h e r e m a i n i n g t h r e e d i g i t s d e t e r m i n e d one s e r v i n g p o r t i o n , c o d e d i n g r a m s . The new f o o d i t e m s w e r e a d d e d t o t h e d i e t a r y a n a l y s i s c o d i n g b o o k l e t s w i t h t h e f i r s t s i x i d e n t i f y i n g code n u m b e r s o n l y . T h e n t h e t h r e e d i g i t s t o d e s i g n a t e t h e s e r v i n g p o r t i o n w e r e b a s e d o n t h e f r a c t i o n o f s e r v i n g p o r t i o n s p e c i f i e d ( o n e s e r v i n g p o r t i o n was c o d e d 010). . T h u s , t h e n u t r i e n t c o m p o s i t i o n 112 o f a f o o d i t e m was d e t e r m i n e d b y t h e f r a c t i o n o f s e r v i n g p o r - t i o n e n t e r e d i n t h e f o o d b o o k l e t . F o l l o w i n g t h e a b o v e p r o c e d u r e , t h e u s u a l i n t a k e was e n t e r e d , a c c o r d i n g t o t h e l i s t o f f o o d s a n d t h e s e r v i n g q u a n t i t i e s o f e a c h , b y t h e a p p r o p r i a t e f o o d c o d e s . The c o n v e r s i o n f r o m f o o d c o d e t o n u t r i e n t v a l u e was done b y c o m p u t e r . The GNA: G e n e r a l N u t r i e n t A n a l y s i s p r o g r a m , d e v e l o p e d b y R . D . M e l d r u m , r e v i s e d b y L o u i s J a m e s , 1979, a n d p a r t o f t h e N u t r i t i o n a l S t a t u s I n v e s t i g a t i o n C o m p u t e r P r o g r a m s o f t h e S c h o o l o f Home E c o n o m i c s , U . B . C . was u s e d . V a l u e s f o r t h e n u t r i e n t s ( p r o t e i n , c a l c i u m , i r o n , v i t a m i n A , t h i a m i n , r i b o f l a v i n , n i a c i n , v i t a m i n C, f a t , c a r b o h y d r a t e ) a n d e n e r g y ( k i l o c a l o r i e s ) w e r e d e t e r m i n e d . C o n v e r s i o n t o n u t r i e n t r a t i o s c o r e s S i n c e n u t r i e n t i n t a k e i n t e r m s o f t h e C a n a d i a n D i e t a r y S t a n d a r d (CDS) ( C a n a d a , 1975a) f o r a d u l t s b y age a n d g e n d e r a n d t h e d i e t a r y g u i d e l i n e s r e l e a s e d b y H e a l t h a n d W e l f a r e r e - g a r d i n g d i e t a n d CVD ( C a n a d a , 1977) w e r e o f m a j o r i n t e r e s t , n u t r i e n t r a t i o s c o r e s , t e r m e d p r a c t i c e s c o r e s , w e r e c o m p u t e d f o r e a c h i n t a k e v a l u e , i n c l u d i n g e n e r g y . T h i s a v o i d e d t h e c o n - f u s i o n o f d i f f e r e n t u n i t s f o r n u t r i e n t a n d e n e r g y m e a s u r e m e n t a n d c o n t r o l l e d f o r v a r i a t i o n i n r e q u i r e m e n t due t o age a n d g e n - d e r . The p r a c t i c e s c o r e f o r a g i v e n n u t r i e n t was t h e r a t i o o f t h e r e s p o n d e n t ' s i n t a k e t o t h e CDS f o r t h a t r e s p o n d e n t ' s g e n d e r a n d age c a t e g o r y , o r t o t h e r e c o m m e n d a t i o n r e g a r d i n g d i e t a n d CVD. F o r k i l o c a l o r i e s , p r o t e i n , c a l c i u m , ' . i r o n , v i t a m i n A , 113 thiamin, r i b o f l a v i n , n i a c i n , and vitamin C, the following form- ula was used: actual intake nutrient r a t i o score = CDS based on age and gender For the nutrients f a t and carbohydrate, the formula used was as follows: intake i n gx9 or 4 / k i l o c a l o r i e intake nutrient r a t i o score = ^ 7^ , . . Canadian recommendation The numerator i n the second formula computed the proportion of energy derived from f a t and carbohydrate, respectively. The gross nutrient values and the nutrient r a t i o scores were placed on f i l e . Data for the remaining items were un- altered. S t a t i s t i c a l Analysis Formation of variables Biodemographic variables. Univariate frequency d i s t r i - butions were computed f o r each biodemographic variable using the S t a t i s t i c a l Package f o r the S o c i a l Sciences (SPSS) sub- program FREQUENCIES (Nie et a l . , 1975). Based on these r e s u l t s , the number of categories f o r several of the variables were altered as follows: 114 (1) The 10 age groups were c o l l a p s e d i n t o t hree c a t e g o r i e s : young ( 1 9 - 3 5 y e a r s ) , mid- ( 3 6 - 5 0 y e a r s ) , and older-age (51 + years) group, the same grouping system employed by the CDS. (2) L i v i n g arrangement was c o l l a p s e d i n t o two c a t e g o r i e s : those who l i v e d w i t h f a m i l y and other. (3) For ed u c a t i o n l e v e l , f o u r c l a s s i c a l groups were formed: l e s s than grade 1 2 , grade 1 2 , 1-3 years u n i v e r s i t y , and 4 or more years of u n i v e r s i t y . ( 4 ) Place of b i r t h was expressed by two c a t e g o r i e s : Canada and o t h e r . (5) Height and weight were expressed as body mass index (BMI) d e f i n e d as the r a t i o of weight i n kilograms to height i n meters squared (Keys et a l . , 1 9 7 2 ) . A f t e r computing the BMI f o r each respondent (Wt/Ht ), Thomas' et a l . , (1976) nomograph method was used to e s t a b l i s h three o b e s i t y r i s k c a t e g o r i e s : low, moderate, and h i g h . The b a s i s of the nomograph method i s the use. of l i f e i nsurance t a b l e s ' d e s i r a b l e weights f o r men and women. Ranges were suggested to correspond to degree of r i s k f o r o b e s i t y . Men and women whose BMI f e l l w i t h i n ranges t h a t were equal to or l e s s than t h e i r d e s i r a b l e weight or g r e a t e r than 20% of the out- s i d e l i m i t f o r d e s i r a b l e weight a c c o r d i n g to gender were designated a t low or hig h r i s k , r e s p e c t i v e l y . 1 1 5 T h o s e who f e l l w i t h i n + 2 0 $ o f t h e i r d e s i r a b l e w e i g h t w e r e d e s i g n a t e d a t m o d e r a t e r i s k f o r o b e s i t y . (6) F a m i l y h i s t o r y o f CVD was e x p r e s s e d as t w o c a t e g o r i e s , p o s i t i v e a n d o t h e r . ( 7 ) The 24- i n f o r m a t i o n s o u r c e s w e r e g r o u p e d i n t o t h r e e c a t e g o r i e s : human p r o f e s s i o n a l , human n o n - p r o f e s s i o n a l , a n d m a t e r i a l s o u r c e . O r i g i n a l l y , s o c i o e c o n o m i c s t a t u s ( S E S ) , a c o m b i n a t i o n o f o c c u p a t i o n a n d e d u c a t i o n l e v e l d a t a , a n d l i f e s t y l e , a c o m b i n a - t i o n o f e x e r c i s e p a t t e r n , o b e s i t y r i s k , a n d s m o k i n g h a b i t , w e r e c o n s i d e r e d as p o s s i b l e i n d e p e n d e n t v a r i a b l e s . I n f o r m a t i o n o n e d u c a t i o n a t t a i n m e n t a n d o c c u p a t i o n w e r e t o be u s e d t o f o r m SES i n d i c e s a c c o r d i n g t o G r e e n ' s ( 1 9 7 0 ) m e t h o d d e v e l o p e d f o r r e - s e a r c h s p e c i f i c a l l y r e l a t e d t o h e a l t h b e h a v i o u r . T h i s was c o n - s i d e r e d somewha t r e d u n d a n t i n l i g h t o f a n a l y s i s f o l l o w i n g t h e c l a s s i c a l g r o u p i n g f o r e d u c a t i o n l e v e l . S i n c e m o s t i n d i c e s a r e b a s e d o n e d u c a t i o n a n d , as G r e e n ' s m e t h o d h a d no s e t s t a n d a r d f o r c a t e g o r i z i n g t h e SES l e v e l s , i t was d e c i d e d t o d r o p SES i n d e x a n d t o u s e e d u c a t i o n l e v e l o n l y as t h e i n d e p e n d e n t v a r i - a b l e . The u s u a l C a n a d i a n i n d e x ( B l i s h e n e t a l . , 1 9 7 1 ) i s a p p l i e d t o t h e m a l e a n d n o t f e m a l e s , a n d w a s , t h e r e f o r e , c o n - s i d e r e d i n a p p r o p r i a t e f o r t h e p r e s e n t s t u d y . L i k e w i s e , t h e v a r i a b l e l i f e s t y l e r i s k was d r o p p e d b e c a u s e o f c o n c e r n r e g a r d - i n g t h e s c o r i n g p r o c e d u r e a n d p o s s i b l e f a i l u r e t o r e p r e s e n t e a c h r i s k c o m p o n e n t e q u a l l y . I n s t e a d , t h e c o m p o n e n t v a r i a b l e s , p h y s i c a l e x e r c i s e p a t t e r n , s m o k i n g h a b i t , a n d o b e s i t y r i s k , w e r e u s e d i n t h e b i o d e m o g r a p h i c s e c t i o n o f t h e a n a l y s i s . P r a c t i c e s c o r e c a t e g o r i e s . P r a c t i c e n u t r i e n t r a t i o s c o r e s f o r i n t e r p r e t a t i v e p u r p o s e s , w e r e g r o u p e d i n t o t h r e e c a t e g o r i e s d e f i c i e n t , a c c e p t a b l e , a n d e x c e s s . The c u t - o f f p o i n t s w e r e l e s s t h a n 67, 67 t o 133» o r m o r e t h a n 133% o f t h e v a l u e s r e corns mended b y CDS, w i t h t h e e x c e p t i o n o f v i t a m i n C ( C a n a d a , 1975a), o r C a n a d i a n r e c o m m e n d a t i o n s ( C a n a d a , 1977)• The u p p e r l i m i t f o r v i t a m i n C was s e t a t 200% s i n c e a v a l u e o f 1.33 f e l l w i t h i n t h e A m e r i c a n Recommended D i e t a r y A l l o w a n c e (RDA, 1980) f o r t h a t n u t r i e n t . T r a d i t i o n a l l y , t h e l i t e r a t u r e r e p o r t e d i n t a k e s l e s s t h a n 2/3 i . e . , 67% o f t h e CDS, as d e f i c i e n t a n d o f c o n c e r n . C o n s u m p t i o n i n e x c e s s o f 100% o f t h e r e c o m m e n d e d v a l u e s r e - c e i v e d l i t t l e , i f a n y , a t t e n t i o n . S i n c e e x c e s s k i l o c a l o r i e s a n d f a t a r e b o t h o f n u t r i t i o n a l c o n c e r n i n CVD, t h e t h i r d c a t e - g o r y ( e x c e s s ) was d e f i n e d as i n t a k e t h a t was 133% o f t h e r e c o m - mended v a l u e s (200% f o r v i t a m i n C ) . U s i n g r a t i o n a l e s i m i l a r t o t h a t e m p l o y e d f o r d e f i n i n g t h e d e f i c i e n t c a t e g o r y , i t was j u d g e d t o be s u f f i c i e n t l y s t r i c t t o a s s u r e a n a r e a o f n u t r i - t i o n a l c o n c e r n y e t f l e x i b l e e n o u g h t o p r o v i d e a n a l l o w a n c e f o r i n d i v i d u a l d i f f e r e n c e s i n r e q u i r e m e n t . P r e l i m i n a r y a n a l y s i s o f c e n t r e d i f f e r e n c e s D e s c r i p t i v e s t a t i s t i c s ( m e a n , s t a n d a r d d e v i a t i o n , m i n i m u m a n d maximum s c o r e s , r a n g e , s k e w n e s s a n d k u r t o s i s ) w e r e c o m p u t e d f o r t h e a t t i t u d e , . - . know ledge , a n d p r a c t i c e s c o r e s f o r e a c h c e n t r e u s i n g t h e SPSS s u b p r o g r a m CONDESCRIPTIVE ( N i e e t a l . , 1975). Means a n d s t a n d a r d d e v i a t i o n s a r e r e p o r t e d i n A p p e n d i x E . A p r e l i m i n a r y a n a l y s i s was p e r f o r m e d t o t e s t f o r p o s s i b l e d i f f e r e n c e s among c e n t r e s f o r a t t i t u d e s , k n o w l e d g e , a n d p r a c - t i c e . OWMAR, a c o m p u t e r p r o g r a m ( m a i n t a i n e d b y t h e P s y c h o l o g y D e p a r t m e n t , U . B . C . ) was u s e d t o p e r f o r m m u l t i v a r i a t e t e s t o f d i f f e r e n c e s i n c e n t r a l t e n d e n c y among t h e c e n t r e s a n d t o t e s t t h e t e n a b i l i t y o f t h e a s s u m p t i o n o f h o m o g e n e i t y o f v a r i a n c e - c o v a r i a n c e . As d e s c r i b e d i n t h e n e x t c h a p t e r , p r e l i m i n a r y a n a l y s i s r e v e a l e d t h a t d a t a c o u l d be p o o l e d a c r o s s c o m m u n i t y c e n t r e s .v ( s e e pp .123-129) R e l i a b i l i t y I t e m a n a l y s i s a n d r e l i a b i l i t y a n a l y s i s w e r e p e r f o r m e d o n t h e r e s p o n s e s o f t h e a t t i t u d e a n d k n o w l e d g e i n s t r u m e n t s u s i n g t h e p r o g r a m LERTAP ( N e l s o n , 1 9 7 4 ) . R e l i a b i l i t y a n a l y s i s o f t h e p r a c t i c e i n s t r u m e n t was d e t e r m i n e d b y a c o n g r u e n c y c h e c k o f t h e mean i n t a k e f o r t h e q u e s t i o n n a i r e d a t a a g a i n s t t h e i n t e r v i e w d a t a . A p a i r e d t t e s t was u s e d t o t e s t t h e n u l l h y p o t h e s i s t h a t t h e mean d i f f e r e n c e b e t w e e n t h e t w o d a t a c o l l e c t i o n i n s t r u m e n t s was e q u a l t o z e r o . A c o m p a r i s o n o f s e l e c t e d b i o d e m o g r a p h i c d a t a f o r r e s p o n d e n t s who c o m p l e t e d b o t h i n s t r u m e n t s was p e r f o r m e d u s i n g t h e t e s t - r e t e s t p r o c e d u r e . C o r r e l a t i o n a l a n a l y s i s To d e t e r m i n e t h e r e l a t i o n s h i p among a t t i t u d e , k n o w l e d g e , a n d p r a c t i c e s c o r e s , a m a t r i x o f c o r r e l a t i o n s was f o r m e d u s i n g SPSS s u b p r o g r a m PEARSON CORR a n d SCATTERGRAM. The f i r s t p r o - g r a m c o m p u t e d P e a r s o n p r o d u c t - m o m e n t c o r r e l a t i o n s f o r a l l p a i r s o f t h e t h r e e v a r i a b l e s , w h i l e t h e l a t t e r p r o v i d e d s c a t t e r p l o t s w h i c h w e r e e x a m i n e d f o r s y s t e m a t i c d e p a r t u r e s f r o m l i n e a r i t y . A s s u m i n g a s t r o n g r e l a t i o n s h i p among t h e t h r e e v a r i a b l e s , t w o h y p o t h e s i z e d m o d e l s o f c a u s a l r e l a t i o n s h i p among a t t i t u d e , k n o w l e d g e , a n d p r a c t i c e s c o r e s w e r e t o be t e s t e d b y p a t h a n a l - y s i s . T h e two m o d e l s w e r e : K — V A — > P a n d A — > K — » P w i t h t h e o n e - w a y a r r o w r e p r e s e n t i n g t h e c a u s a l r e l a t i o n s h i p b e t w e e n e a c h d e t e r m i n i n g v a r i a b l e a n d e a c h v a r i a b l e d e p e n d e n t o n i t . F o r e a c h m o d e l , t h e s t r e n g t h o f t h e r e l a t i o n s h i p was d e f i n e d b y p a t h c o e f f i c i e n t s ( b e t a w e i g h t s ) d e t e r m i n e d b y m u l t i p l e r e g r e s s i o n a n a l y s i s u s i n g SPSS s u b p r o g r a m REGRESSION. I f t h e b e t a w e i g h t s w e r e s i g n i f i c a n t a t t h e . 0 5 l e v e l , t h e m o d e l b e i n g c o n s i d e r e d w o u l d be s u p p o r t e d . M o d e l s i n c o n s i s t e n t w i t h t h e d a t a w o u l d be r e j e c t e d . B i o d e m o g r a p h i c a n a l y s i s I n t h e p r e s e n t s t u d y , t h r e e o n e - w a y m u l t i v a r i a t e a n a l y s i s o f v a r i a n c e , OWMAR a n a l y s e s , c o r r e s p o n d i n g t o a t t i t u d e s , k n o w - l e d g e , a n d p r a c t i c e , w e r e p e r f o r m e d f o r e a c h o f t h e b i o d e m o - g r a p h i c v a r i a b l e s . B e c a u s e o f t h e u n e q u a l s a m p l e s i z e s , h o m o - g e n e i t y o f v a r i a n c e - c o v a r i a n c e was c h e c k e d u s i n g t h e B a r t l e t t - Box p r o c e d u r e d e s c r i b e d b y W i n e r ( 1971 , p . 5 9 5 ) . F o l l o w - u p u n i - v a r i a t e F - s t a t i s t i c s , as s u g g e s t e d b y Hummel a n d S l i g o (1971) a n d F i n n ( 1 9 7 ^ ) , w e r e c o m p u t e d f o l l o w i n g s i g n i f i c a n t m u l t i - v a r i a t e F r a t i o s ( F o x a n d G u i r e , 1 9 7 6 ) . A l l a n a l y s e s w e r e 1 1 9 t e s t e d a t t h e .05 l e v e l o f s i g n i f i c a n c e . The s o u r c e o f a n y s i g n i f i c a n t e f f e c t was t h e n d e t e r m i n e d u s i n g S c h e f f e ' s S m e t h o d ( K i r k , 1968). 120 CHAPTER V RESULTS AND DISCUSSION I n t r o d u c t i o n I n t h i s c h a p t e r , t h e r e s u l t s a n d i n t e r p r e t a t i o n o f a n a l - y s e s c o n d u c t e d " t o ' t e s t " t h e 1 h y p o t h e s e s ^ a r e p r e s e n t e d . R e s p o n s e r a t e a n d p r e l i m i n a r y a n a l y s e s t o a s c e r t a i n d i f f e r e n c e s among c o m m u n i t y c e n t r e s a r e g i v e n f i r s t , f o l l o w e d b y a d e s c r i p t i o n o f t h e s a m p l e . The p r o p e r t i e s o f t h e m e a s u r i n g d e v i c e s a r e t h e n r e p o r t e d . N e x t , t h e r e l a t i o n s h i p s among a t t i t u d e , k n o w l e d g e , a n d p r a c t i c e s c o r e s a r e e x a m i n e d . The c h a p t e r c o n c l u d e s w i t h r e s u l t s d e s c r i b i n g t h e e f f e c t o f b i o d e m o g r a p h i c v a r i a b l e s o n a t t i t u d e s , k n o w l e d g e , a n d d i e t a r y p r a c t i c e v a r i a b l e s . F o r r e a s o n s o f b r e v i t y , t h e a t t i t u d e a n d k n o w l e d g e s u b - t e s t s , t o t a l t e s t s , a n d t h e n u t r i e n t s w i l l be d e s i g n a t e d b y t h e f o l l o w i n g p a r e n t h e s i z e d a b b r e v i a t i o n s t h r o u g h o u t t h e d i s c u s s i o n a n d i n t h e t a b l e s : a t t i t u d e s u b t e s t 1 , g e n e r a l r o l e o f d i e t i n c a r d i o v a s c u l a r d i s e a s e (CVD) (A:GEN R O L E ) ; a t t i t u d e s u b t e s t 2 , c h a n g i n g o r m a n i p u l a t i n g t h e d i e t t o p r o m o t e a h e a l t h y h e a r t (A :MANAGE) ; t o t a l a t t i t u d e t e s t , a t t i t u d e t o w a r d d i e t as a means o f p r o m o t i n g h e a r t h e a l t h a n d i n t e r v e n i n g a g a i n s t h e a r t d i s e a s e ( A : T 0 T A L ) ; k n o w l e d g e s u b t e s t 1 , how f o o d a f f e c t s t h e h e a r t ( K : A F F E C T S ) ; k n o w l e d g e s u b t e s t 2 , i m p o r t a n c e o f f o o d c o m p o s i t i o n ( K : C 0 M P ) ; k n o w l e d g e s u b t e s t 3 , f a c t s v e r s u s f a l l a c y ( K : F A C T S ) ; t o t a l k n o w l e d g e t e s t , n u t r i t i o n k n o w l e d g e r e l a t e d t o 121 t h e h e a r t ( K : T O T A L ) ; k i l o c a l o r i e ( K C A L ) ; p r o t e i n ( P R O T ) ; c a l - c i u m ( C A ) ; i r o n ( F E ) ; v i t a m i n A ( V A ) ; r i b o f l a v i n ( R I B O ) ; n i a c i n ( N I A ) ; t h i a m i n ( T H I ) ; v i t a m i n C ( V C ) ; c a r b o h y d r a t e (CHO) . R a t e o f R e s p o n s e T a b l e 15 s u m m a r i z e s t h e d i s t r i b u t i o n o f r e s p o n s e s b y c o m m u n i t y c e n t r e . I n t o t a l , 391 q u e s t i o n n a i r e s w e r e d i s t r i b - u t e d . Of t h e 292 r e t u r n e d , o n l y 11 w e r e c o n s i d e r e d t o be n o n - u s a b l e ( s e e f o o t n o t e , T a b l e 1 5 ) . The o v e r a l l r a t e o f r e s p o n s e (7^.68%) a n d o v e r a l l p e r c e n t u s a b l e r e t u r n s (71.87%) c o m p a r e f a v o u r a b l y w i t h o t h e r r e p o r t e d s u r v e y r e s p o n s e s ( w h e r e a 40 t o 50% c o m p l e t i o n r a t e i s ' c o n s i d e r e d g o o d ( W a r w i c k a n d L i n i n g e r , 1975) ) . C o m p a r i s o n o f E a r l y a n d L a t e R e s p o n d e n t s B e c a u s e t h e m a i l q u e s t i o n n a i r e as a r e s e a r c h i n s t r u m e n t does n o t p r o v i d e f o r c o n t r o l o v e r who r e s p o n d s , t h e p r o b l e m a r i s e s o f a p o s s i b l e n o n r e s p o n s e b i a s . I f t h e n o n r e s p o n d e n t s d i f f e r e d s i g n i f i c a n t l y f r o m t h o s e who r e s p o n d e d t o t h e q u e s t i o n - n a i r e , t h e i n t e r p r e t a t i o n o f t h e s t u d y m i g h t be i n v a l i d . R e - s e a r c h e r s ( L a r s o n a n d C a t t o n , 1959; R o e h e r , 1 9 6 3 ; O p p e n h e i m , 1966) h a v e shown t h a t d i f f e r e n c e s b e t w e e n e a r l y a n d l a t e r e t u r n s w e r e i n d i c a t i v e o f d i f f e r e n c e s b e t w e e n r e t u r n s a n d n o n r e t u r n s . A c c e p t i n g t h e s e f i n d i n g s , l a c k o f a s i g n i f i c a n t d i f f e r e n c e b e - t w e e n e a r l y a n d l a t e r e s p o n d e n t s i n t h e p r e s e n t s t u d y may s u g - g e s t t h a t t h e s u r v e y r e s u l t s a r e r e p r e s e n t a t i v e o f a l l a d u l t TABLE 15 D i s t r i b u t i o n o f R e s p o n s e b y C o m m u n i t y C e n t r e , S e p a r a t e l y a n d C o m b i n e d No. o f Q u e s t i o n n a i r e R e t u r n s Q u e s t i o n n a i r e s C e n t r e D i s t r i b u t e d E a r l y (%) L a t e a {%) T o t a l {%) U s a b l e b w 1 32 21 (65 .62) 10 (31 .25) 31 ( 9 6 .88 ) 30 ( 9 3 . 7 5 ) 2 34 21 (61 .76) 9 (26 .47) 30 (88.24) ' 28 (82.35) 3 34 19 (55.88) 8 (23.53) 27 (79.41) 27 (79.41) 4 25 11 (44.00) 6 (24.00) 17 (68.00) 16 (64.00) 5 43 20 (46 .51) 9 (20.93) 29 (67 .44) 29 (67 .44) 6 44 20 (45.45) 16 ( 3 6 . 3 6 ) . 36 (81.82) 35 (79.55) 7 32 13 (40 .62) 7 (21.88) 20 ( 6 2 . 5 0 ) 18 (56 .25) 8 38 22 (57.89) 5 ( 1 3 . 1 6 ) 27 ( 7 1 . 0 5 ) 27 ( 7 1 . 0 5 ) 9 24 16 ( 6 6 . 6 7 ) 2 ( 8 . 3 3 ) 18 (75 -00) 17 (70.83) 10 43 19 (44.19) 8 (18 . 6 0 ) 27 ( 6 2 .79 ) 25 (58.14) 11 42 19 (45.24) 11 ( 2 6 .19 ) 30 (71.43) 29 ( 6 9 . 0 5 ) C o m b i n e d 391 201 (51 .54) 91 ( 2 3 . 2 7 ) 292 (74.68) 281 (71 .87) E a r l y : r e t u r n e d b y f i r s t d e a d l i n e ; l a t e : r e t u r n e d a f t e r t h e f i r s t d e a d l i n e a n d up t o c u t - o f f d a t e . E l e v e n q u e s t i o n n a i r e s w e r e c o n s i d e r e d u n a c c e p t a b l e : f i v e w e r e s u b s t a n t i a l l y i n c o m p l e t e , t h r e e w e r e u n m a r k e d , t w o w e r e r e t u r n e d a f t e r t h e c u t - o f f d a t e , a n d one was c o m p l e t e d b y a n u n d e r - a g e i n d i v i d u a l . F i v e o f t h e 11 u n a c c e p t a b l e q u e s t i o n n a i r e s w e r e e a r l y ; s i x w e r e l a t e . members o f t h e 11 c o m m u n i t y c e n t r e s s u r v e y e d . Of t h e 281 who r e t u r n e d u s a b l e q u e s t i o n n a i r e s , 196 d i d so by t h e f i r s t d e a d l i n e a n d w e r e d e s i g n a t e d as e a r l y r e s p o n d e n t s . The r e m a i n i n g 85 who r e t u r n e d t h e q u e s t i o n n a i r e b e f o r e t h e f i n a l c u t - o f f d a t e w e r e c o n s i d e r e d t o b e • l a t e r e s p o n d e n t s . R e s u l t s o f t t e s t a n d F t e s t a n a l y s i s f o r t e s t i n g d i f f e r e n c e s b e t w e e n means a n d h o m o g e n e i t y o f v a r i a n c e , r e s p e c t i v e l y , a r e r e p o r t e d i n T a b l e 16 f o r e a c h o f t h e v a r i a b l e s c o n s i d e r e d i n t h e s t u d y . T w o - t a i l e d t e s t s o f t h e h y p o t h e s e s t h a t t h e r e i s h o m o g e n e i t y o f v a r i a n c e b e t w e e n e a r l y a n d l a t e r e s p o n d e n t s ' a t t i t u d e , k n o w l e d g e , a n d p r a c t i c e s c o r e s a n d t h a t t h e r e i s no ' s i g n i f i c a n t d i f f e r e n c e b e t w e e n e a r l y a n d l a t e r e s p o n d e n t s ' mean a t t i t u d e , k n o w l e d g e , a n d p r a c t i c e s c o r e s w e r e n o t s i g n i f i c a n t a t t h e .05 l e v e l . Thus i t was c o n c l u d e d t h a t t h e d a t a c o u l d be p o o l e d f o r s u b s e q u e n t a n a l y s e s . P r e l i m i n a r y A n a l y s e s I n i t i a l o b s e r v a t i o n s s u g g e s t e d t h a t no s i g n i f i c a n t d i f f e r - e n c e s e x i s t e d among c e n t r e s f o r mean a t t i t u d e , k n o w l e d g e , a n d p r a c t i c e s c o r e s . F u r t h e r , s i n c e a n a l y s i s o f v a r i a n c e p r o c e - d u r e s w e r e t o be u s e d s u b s e q u e n t l y , t h e a s s u m p t i o n o f homo- g e n e i t y o f v a r i a n c e - c o v a r i a n c e among c e n t r e s was e x a m i n e d as t h e c e n t r e s d i f f e r e d a p p r e c i a b l y i n s i z e . B o t h t h e t e s t o f h o m o g e n e i t y o f v a r i a n c e - c o v a r i a n c e a n d t h e t e s t o f d i f f e r e n c e s among c e n t r e mean s c o r e s f o r a t t i t u d e , k n o w l e d g e , a n d p r a c t i c e w e r e c o m p l e t e d u s i n g t h e c o m p u t e r p r o g r a m OWMAR ( m a i n t a i n e d b y TABLE 16 Tests of Homogeneity of Variance and Difference between Means on Attitude, Knowledge, and Practice Scores of Early and Late Respondents Homogeneity of Early (n=196) Late (n=85) Difference Variance X S 2 X S 2 t(df 279) P F a ( d f 84,195) P Attitudes A:GEN ROLE 41.44 19 .36 42.18 22.00 -1 . 2 5 7 . 2 1 0 1 . 1 3 7 .470 A:MANAGE 37.26 15.86 3 7 . 8 3 16 .52 -1 . 1 0 5 . 2 7 0 1.041 .808 A:TOTAL 7 8 . 7 0 5 8 . 5 2 80.01 67.77 -1.286 .200 1 . 1 5 8 .408 lowledge*3 KiAFFECTS 8.33 3.95 8 . 67 4 .25. -1 . 3 1 8 . 1 8 9 1.074 . 6 8 0 KsCOMP 9.69 10.08 9 .68 10.96 . 0 2 8 .978 1.087 . 6 3 2 K:FACTS 8.54 10 .17 9.20 10.42 -1 . 5 8 6 .114 1 . 0 2 5 .874 K:TOTAL 26.56 47.46 27.55 47 .06 -1.110 . 2 6 8 1.008 .984 ractice* 3 KCAL .71 . 0 3 .67 . 0 3 1.394 .164 1 . 1 1 9 .561 PROT .96 .01 .97 .01 - .421 .674 1 . 0 2 5 .914 CA .75 . 0 5 .77 . 0 5 - .585 .559 1.070 .734 FE .71 . 0 5 .71 . 0 5 .076 .940 1.042 .804 VA .83 . 0 5 .82 . 0 6 .125 .901 1.072 . 6 8 9 THI .74 . 0 5 .75 .04 - .414 . 6 8 0 1 . 0 5 0 .812 RIBO .85 . 0 3 . 8 6 .04 - .394 .694 1 . 0 6 0 .731 NIA .86 . 0 3 .88 . 0 3 -1 . 2 0 1 . 2 3 1 1 . 0 5 1 .769 VC .95 .02 • 95 .02 • 558 .577 1 . 0 8 8 .629 FAT .83 .02 .82 .02 • 743 .458 1.224 . 2 9 1 CHO .64 .02 . 6 3 .01 .274 .784 1.428 . 0 6 3 The F represents the ratio of the larger of the two sample variances to the smaller. The computed attained significance level is one-sided. For the usual two-sided test, the MIDAS output value must be doubled ( S t a t i s t i c s Research Laboratory, University of Michigan, p.217, 1976). ^ Attitude and knowledge scores analyzed i n the raw form; practice scores analyzed using arc sine transformation of a practice ratio score with a range of 0 to 1. (see pp.126,127). * P< . 0 5 . 125 D e p a r t m e n t o f P s y c h o l o g y , U . B . C . ) ' The r e s u l t s o f t h e s e a n a l - y s e s a r e p r e s e n t e d i n T a b l e s 17 a n d 1 8 . TABLE 17 MANOVA L i k e l i h o o d R a t i o T e s t o f D i f f e r e n c e s among Mean A t t i t u d e , K n o w l e d g e , a n d P r a c t i c e S c o r e s o f C o m m u n i t y C e n t r e s V a r i a b l e s DF1 DF2 F-RAT10 PR0B C e n t r e s A t t i t u d e S c o r e s 20 538 K n o w l e d g e S c o r e s 30 787 P r a c t i c e S c o r e s 110 1959 1 . 1702 1.1363 1 .4479* .275 .282 . 0 0 2 * P<.05 . TABLE 18 B a r t l e t t - B o x H o m o g e n e i t y o f D i s p e r s i o n T e s t among A t t i t u d e , K n o w l e d g e , a n d P r a c t i c e S c o r e s o f C o m m u n i t y C e n t r e V a r i a b l e s DF1 DF2 F-RAT10 PR0B C e n t r e s A t t i t u d e S c o r e s 3 0 - 1 0 0 0 3 9 K n o w l e d g e S c o r e s 60 56662 .3 P r a c t i c e S c o r e s 660 4 l 4 4 l . 7 1 . 2385 1 . 0258 2 . 0 280* .173 . 4 2 0 . 0 0 0 * P<.05- The r e s u l t s i n d i c a t e d t h a t t h e n u l l h y p o t h e s e s o f no s i g n i f i c a n t d i f f e r e n c e s among c e n t r e s f o r mean a t t i t u d e a n d k n o w l e d g e s c o r e s a n d t h e n u l l h y p o t h e s e s o f h o m o g e n e i t y o f v a r i - a n c e - c o v a r i a n c e among c e n t r e s f o r a t t i t u d e s a n d k n o w l e d g e s c o r e s w e r e t e n a b l e a t . 0 5 l e v e l o f s i g n i f i c a n c e . S i g n i f i c a n t d i f f e r - e n c e s among c e n t r e means a n d among c e n t r e v a r i a n c e - c o v a r i a n c e w e r e o b s e r v e d f o r t h e p r a c t i c e s c o r e s ( P < . 0 5 ) « S t a n d a r d i z a t i o n w i t h i n c e n t r e t o mean 50 a n d s t a n d a r d d e - v i a t i o n 10 e l i m i n a t e d t h e v a r i a n c e d i f f e r e n c e s b u t n o t t h e c o - v a r i a n c e d i f f e r e n c e s . The s u s p e c t e d c a u s e o f t h e c o v a r i a n c e p r o b l e m was t h e p r e s e n c e o f o u t l i e r s i . e . , d i s p a r a t e c a s e s . S u b s e q u e n t l y , 47 o u t l i e r s w e r e i d e n t i f i e d b y UBC BMD10M p r o g r a m ( H a l m , 1976) w h i c h s c r e e n e d t h e 1 1 p r a c t i c e s c o r e s b y c o m p u t i n g t h e M a h a l a n o b i s d i s t a n c e o f e a c h c a s e f r o m t h e c e n t r e o f t h e d i s t r i b u t i o n o f t h e r e m a i n i n g c a s e s . I f t h e p r o b a b i l i t y o f t h e F - s t a t i s t i c c o r r e s p o n d i n g t o t h e g r e a t e s t d i s t a n c e was l e s s t h a n t h e s t i p u l a t e d p r o b a b i l i t y c u t - o f f (P< . 0 5 ) » t h e c a s e i n = v o l v e d was r e m o v e d a n d t h e p r o c e s s r e p e a t e d u n t i l a l l c a s e s me t t h e r e q u i r e m e n t . The r e m a i n i n g c a s e s (234) w e r e a n a l y z e d , b y c e n t r e , u s i n g OWMAR. A l t h o u g h a l o w e r F r a t i o r e s u l t e d , t h e s t a t i s t i c a l d e c i s i o n r e m a i n e d u n c h a n g e d i . e . , h o m o g e n e i t y was n o t t e n a b l e . T h e r e f o r e , t h e o u t l i e r s w e r e r e t u r n e d a n d t h e t o t a l s a m p l e u s e d f o r s u b s e q u e n t a n a l y s e s . The B a r t l e t t - B o x t e s t f o r h o m o g e n e i t y o f v a r i a n c e - c o v a r i - a n c e i s s e n s i t i v e t o f a i l u r e t o m e e t t h e n o r m a l i t y a s s u m p t i o n . To a v o i d p o s s i b l e c o n t a m i n a t i o n due t o n o n - n o r m a l i t y , w h e n t h e d a t a a r e p r o p o r t i o n s , a n a r c s i n e t r a n s f o r m a t i o n c a n be u t i l - i z e d t o n o r m a l i z e t h e d a t a a n d s t a b l i z e t h e v a r i a n c e ( N a t r e l l a , 1 9 6 3 ) . T h i s p a r t i c u l a r t r a n s f o r m a t i o n r e q u i r e s t h e r a n g e o f v a r i a b l e s t o be z e r o t o o n e . C o n s e q u e n t l y , t h e o r i g i n a l n u t r - i e n t r a t i o s c o r e s w e r e t r a n s f o r m e d i n t o p r o p o r t i o n s b y 1 2 7 e s t a b l i s h i n g a n u p p e r b o u n d a r y f o r t h e n u t r i e n t v a l u e s . D e f i n - i n g a n u p p e r l i m i t was j u d g e d t o be a p p r o p r i a t e f o r t h i s s t u d y s i n c e t h e p r a c t i c e s c o r e s w o u l d be i n t e r p r e t e d o n t h e b a s i s o f t h e i r b e i n g w i t h i n d e f i c i e n t , a c c e p t a b l e , o r e x c e s s i v e l i m i t s . E x c e s s was d e f i n e d as a n y a m o u n t t h a t e x c e e d e d 133% o f t h e C a n a d i a n D i e t a r y S t a n d a r d ( C a n a d a , 1975a) f o r a l l n u t r i e n t s b u t v i t a m i n C. The l a t t e r ' s u p p e r l i m i t was s e t a t 200% s i n c e a v a l u e o f 1 . 3 3 f e l l w i t h i n t h e A m e r i c a n Recommended D i e t a r y A l l o w a n c e (RDA, 1 9 8 0 ) f o r t h a t n u t r i e n t . The v a l u e s w e r e t h e n d i v i d e d b y t h e u p p e r l i m i t f o r t h a t n u t r i e n t t o g i v e r a t i o s c o r e s w i t h a r a n g e o f z e r o t o o n e . Means a n d s t a n d a r d d e v i a t i o n s o f t h e p r a c t i c e r a t i o s c o r e s a r e p r e s e n t e d i n A p p e n d i x E . As a l l r a t i o s w e r e g r e a t e r t h a n . 0 0 1 , t h e s e r a t i o s w e r e t h e n t r a n s f o r m e d u s i n g t h e a r c s i n e t r a n s f o r m a t i o n ( K i r k , 1968; W i n e r , 1971): ( i ) X = 2 a r c s i n Vx* f o r v a l u e s o f X b e t w e e n . 0 0 1 a n d .999 ( i i ) X1 = 2 a r c s i n 4 ' x - l / 2 n , f o r v a l u e s o f X>.999 a n d w h e r e n i s t h e n u m b e r o f o b s e r v a t i o n s o n w h i c h X I s b a s e d . A c c o r d i n g t o N a t r e l l a ( I 9 6 3 ) , one i m p o r t a n t c h a r a c t e r i s t i c o f t h i s t r a n s f o r - m a t i o n i s t h a t i t i s o r d e r p r e s e r v i n g i . e . , t h e r e l a t i v e r a n k o r d e r ( w i t h r e s p e c t t o m a g n i t u d e ) o f t h e o r i g i n a l v a l u e s i s s t r i c t l y p r e s e r v e d i n t h e i r t r a n s f o r m e d s t a t e . T h i s t r a n s f o r - m a t i o n o f p r a c t i c e s c o r e s was n o t c o n s i d e r e d t o d i s t o r t t h e i n t e r p r e t a t i o n o f t h e r e s u l t s , n o r t o j e o p a r d i z e t h e p u r p o s e o f t h e s t u d y . The t r a n s f o r m e d p r a c t i c e s c o r e s w e r e t h e n a n a l y z e d , b y c e n t r e , t o t e s t h o m o g e n e i t y o f v a r i a n c e - c o v a r i a n c e u s i n g 0WMAR. 128 The r e s u l t i n g B a r t l e t t - B o x F - s t a t i s t i c was r e d u c e d ( f r o m 2 . 0 2 8 t o 1 . 2 0 5 ) b u t s t i l l s i g n i f i c a n t a t t h e . 0 5 l e v e l . S i n c e m o d e r - a t e d e p a r t u r e s f r o m t h e a s s u m p t i o n o f h o m o g e n e i t y o f v a r i a n c e do n o t s e r i o u s l y a f f e c t t h e s a m p l i n g d i s t r i b u t i o n o f t h e F - s t a t i s t i c ( W i n e r , 1971* p . 2 0 5 ) , a n d i n l i g h t o f t h e s m a l l v a l u e f o r F ( 1 . 2 0 5 ) , i t w a s c o n c l u d e d t h a t t h e d e p a r t u r e s w e r e s u c h t h a t s u b s e q u e n t t e s t s o f mean d i f f e r e n c e s w o u l d n o t be a d v e r s e l y a f f e c t e d . The n u l l h y p o t h e s i s t h a t t h e r e w e r e no s i g n i f i c a n t d i f f e r - e n c e s among c e n t r e mean p r a c t i c e s c o r e s was a l s o r e j e c t e d ( T a b l e 1 9 ) . T h e r e f o r e , a l t h o u g h t h e s u b j e c t s w e r e p a r t o f i n t a c t g r o u p s , i t was a s s u m e d t h a t a n i n d i v i d u a l ' s p r a c t i c e s c o r e s w e r e n o t i n f l u e n c e d b y t h e ' c e n t r e t o w h i c h he b e l o n g e d . . TABLE 19 Summary o f C e n t r e A n a l y s e s f o r H o m o g e n e i t y o f V a r i a n c e - C o v a r i a n c e a n d D i f f e r e n c e s among Mean P r a c t i c e S c o r e s a T e s t DF1 DF2 F-RATIO PROB B a r t l e t t - B o x H o m o g e n e i t y o f D i s p e r s i o n T e s t 660 4 1 4 4 1 . 7 1 . 2 0 5 * . 0 0 0 2 MAN0VA L i k e l i h o o d R a t i o T e s t f o r D i f f e r e n c e s among Means 110 1959 1 . 4 8 4 * . 0 0 1 P r a c t i c e s c o r e s e x p r e s s e d as a r c s i n e t r a n s f o r m e d v a l u e s . * P < . 0 5 . T h e r e f o r e , a t t i t u d e , k n o w l e d g e , a n d t r a n s f o r m e d p r a c t i c e s c o r e s w e r e p o o l e d a c r o s s c e n t r e s a n d c e n t r e was n o t c o n s i d e r e d i n f u r t h e r a n a l y s e s . I n a l l s u b s e q u e n t a n a l y s e s , " p r a c t i c e s c o r e s w e r e a n a l y z e d u s i n g t h e p r a c t i c e r a t i o s c o r e s c o n v e r t e d t o a n a r c s i n e a c c o r d i n g t o t h e f o r m u l a p r e v i o u s l y d e s c r i b e d . D e s c r i p t i o n o f t h e S a m p l e The B i o d e m o g r a p h i c c h a r a c t e r i s t i c s o f t h e s a m p l e a r e s u m - m a r i z e d i n T a b l e 2 0 . Age The m a j o r i t y ( 5 7 . 7 $ ) o f p a r t i c i p a n t s w e r e y o u n g ( b e t w e e n 19 a n d 3.5 y e a r s o f a g e ) . The r e s t o f t h e s a m p l e was a b o u t e q u a l l y d i s t r i b u t e d b e t w e e n m i d - ( 3 6 - 5 0 y e a r s ) a n d o l d e r - g r e a t e r t h a n 50 y e a r s ) age ( 2 2 . 3 a n d 2 0 $ , r e s p e c t i v e l y ) . G e n d e r The g e n d e r c o m p o s i t i o n o f t h e s a m p l e was 79% f e m a l e a n d 21$ m a l e . P l a c e o f B i r t h When d e s c r i b e d b y p l a c e o f b i r t h , 6 2 . 7 $ o f t h e p a r t i c i p a n t w e r e b o r n i n C a n a d a , 1 4 . 9 $ i n t h e B r i t i s h I s l e s , w h i l e t h e r e - m a i n d e r w e r e d i s p e r s e d among 30 o t h e r c o u n t r i e s . TABLE 20 B i o d e m o g r a p h i c C h a r a c t e r i s t i c s , P e r c e n t i n S a m p l e Age P h y s i c a l E x e r c i s e 19-35 y e a r s 5 7 . 7 P a t t e r n 3 6 - 5 0 y e a r s 2 2 . 3 S e d e n t a r y 1 1 . 4 g r e a t e r t h a n 50 2 0 . 0 Low m o d e r a t e 4 4 . 8 y e a r s H i g h m o d e r a t e 3 2 . 0 V i g o r o u s 10 .0 G e n d e r M a l e 2 1 . 0 O b e s i t y R i s k F e m a l e 7 9 . 0 Low M o d e r a t e 7 4 . 7 1 9 . 6 P l a c e o f B i r t h H i g h 4 . 6 Canada 6 2 . 7 B r i t i s h I s l e s 1 4 . 9 L e v e l o f E d u c a t i o n O t h e r 2 2 . 4 L e s s t h a n g r a d e 12 G r a d e 12 20 .3 2 9 . 9 L i v i n g A r r a n g e m e n t 7 4 . 0 1-3 y e a r s u n i v e r s i t y 3 0 . 6 W i t h f a m i l y 4 o r m o r e y e a r s 1 9 . 2 A l o n e 1 6 . 4 u n i v e r s i t y S m o k i n g H a b i t O t h e r • 9 . 6 F a m i l y H i s t o r y o f N o n s m o k e r 6 6 . 2 C V D a F o r m e r s m o k e r 1 2 . 8 P o s i t i v e , 5 4 . 8 L i g h t s m o k e r c 7 . 1 O t h e r D 4 4 . 1 H e a v y s m o k e r V e r y h e a v y s m o k e r 8 . 2 5 . 3 P e r s o n a l H i s t o r y o f C V D a P o s i t i v e . , 1 9 . 2 O t h e r D 7 6 . 9 N o t e . Number i n s a m p l e = 2 8 1 . a CVD: c a r d i o v a s c u l a r d i s e a s e . O t h e r f o r F a m i l y H i s t o r y i n c l u d e d t h o s e r e p o r t i n g t h e y d i d n o t k n o w ; o t h e r f o r P e r s o n a l H i s t o r y r e f e r r e d t o t h o s e who h a d n e v e r r e c e i v e d t r e a t m e n t f o r c a r d i o v a s c u l a r - r e l a t e d c o n d i t i o n s . 0 L i g h t s m o k e r c a t e g o r y i n c l u d e d t h e m o d e r a t e c a t e g o r y b e c a u s e o n l y one p a r t i c i p a n t r e p o r t e d t h e y d i d n o t i n h a l e . 131 L i v i n g A r r a n g e m e n t The m a j o r i t y o f t h e s a m p l e ( 7 4 . 0 $ ) r e p o r t e d l i v i n g w i t h " f a m i l y . The r e m a i n d e r ( 2 6 . 0 $ ) e i t h e r l i v e d a l o n e o r n o t w i t h f a m i l y m e m b e r s . F a m i l y a n d P e r s o n a l H i s t o r y o f C a r d i o v a s c u l a r D i s e a s e (CVD) F a m i l y h i s t o r y o f CVD was r e p o r t e d p o s i t i v e f o r 5 4 . 8 $ o f t h e s a m p l e a n d n e g a t i v e o r u n k n o w n f o r 4 4 . 1 $ . When a s k e d a b o u t t h e i r p e r s o n a l h i s t o r y o f CVD, 7 6 . 9 $ o f t h e s a m p l e r e p o r t e d t h a t t h e y r e c e i v e d no p r e v i o u s t r e a t m e n t f o r a n y c a r d i o v a s c u l a r - r e l a t e d c o n d i t i o n ( i . e . , h i g h b l o o d p r e s s u r e , h i g h b l o o d f a t l e v e l s , h i g h b l o o d c h o l e s t e r o l l e v e l s , h e a r t a t t a c k , a n g i n a , d i a b e t e s ) w h i l e 1 9 . 2 $ r e p o r t e d r e c e i v i n g t r e a t m e n t f o r one o r m o r e o f t h e r e l a t e d c o n d i t i o n s . The h i g h p e r c e n t a g e r e p o r t i n g no p r e v i o u s t r e a t m e n t f o r c a r d i o v a s c u l a r - r e l a t e d c o n d i t i o n s may ' be e x p l a i n e d i n p a r t b y t h e p r e d o m i n a n c e o f p a r t i c i p a n t s l e s s t h a n 35 y e a r s o f age ( 5 7 . 7 $ ) a n d t h e f a c t t h a t CVD i s a n i n s i d i o u s c o n d i t i o n t h a t may n o t be m a n i f e s t e d u n t i l l a t e i n l i f e . P h y s i c a l E x e r c i s e P a t t e r n The r e g u l a r e x e r c i s e p a t t e r n r e p o r t e d b y r e s p o n d e n t s de^- s c r i b e d a b o u t 10$ o f t h e s a m p l e as w a l k i n g l e s s t h a n m i l e p e r d a y (SEDENTARY). The m a j o r i t y ( 4 4 . 8 $ ) r e p o r t e d , some a c t i v i t y d u r i n g w o r k a n d l e i s u r e c o m p a r a b l e t o w a l k i n g b e t w e e n _ t o l J r m i l e s p e r d a y (LOW MODERATE) a n d 32$ r e p o r t e d p r o g r a m m e d e x e r c i s e f o u r t i m e s a week o r d a i l y w a l k i n g f r o m 1-g- t o 2 m i l e s (HIGH MODERATE). W a l k i n g i n e x c e s s o f t w o m i l e s p e r d a y (VIGOROUS) was r e p o r t e d b y 10$ o f t h e s a m p l e . T h u s , o v e r 50$ o f t h e p a r t i c i p a n t s who r e s p o n d e d t o t h i s q u e s t i o n (n=276) d e - s c r i b e d t h e i r a c t i v i t y p a t t e r n as b e i n g o n t h e l o w end o f t h e a c t i v i t y s c a l e . S i n c e t h e p a r t i c i p a n t s w e r e members o f c o m - m u n i t y c e n t r e s t h a t o f f e r a w i d e r a n g e o f p h y s i c a l a c t i v i t i e s f o r members o f a l l a g e s , t h e r e p o r t e d l o w a c t i v i t y i s a m a t t e r f o r c o n c e r n . I t s u p p o r t s t h e n e e d t o s t r e s s p h y s i c a l a c t i v i t y a n d f i t n e s s p r o g r a m s p r o p o s e d by N u t r i t i o n C a n a d a (1973)» a s p a r t o f n u t r i t i o n e d u c a t i o n s i n c e t h e a v a i l a b i l i t y o f s p o r t a n d e x e r c i s e f a c i l i t i e s i n i t s e l f does n o t a p p e a r t o be s u f f i c i e n t . O b e s i t y R i s k O b e s i t y r i s k , c a l c u l a t e d o n t h e b a s i s o f p a r t i c i p a n t ' s b o d y mass i n d e x ( B M I : W t / H t .) a n d c o n t r o l l e d f o r g e n d e r (Thomas e t a l . 1976 ) , was f o u n d t o be l o w f o r 7 4 . 7 $ , m o d e r a t e f o r 1 9 . 6 $ , a n d h i g h f o r 4 . 6 $ o f t h e s a m p l e . U s i n g p o n d e r a l i n d e x ( P I ) , t h e r a t i o o f h e i g h t t o cube r o o t w e i g h t ( C a n a d a , 1 973 ) , o b e s i t y r i s k was f o u n d t o be l o w f o r 6 7 . 3 $ a n d h i g h f o r 3 2 . 7 $ o f t h e s a m p l e . F u r t h e r e x a m i n a t i o n o f t h e h i g h r i s k g r o u p , a s d e f i n e d i n s u b - s e q u e n t N u t r i t i o n Canada r e p o r t s ( C a n a d a , 1 975b ) , r e s u l t e d i n c l a s s i f y i n g 2 7 . 0 $ a t m o d e r a t e r i s k a n d 5«7$ a t h i g h r i s k . A c o m p a r i s o n o f t h e t w o i n d i c e s r e v e a l e d t h a t a l o w e r p e r c e n t a g e o f t h e s a m p l e was c l a s s i f i e d a t h i g h r i s k b y BMI t h a n b y P I . B o t h i n d i c e s i n d i c a t e d t h a t t h e p r e s e n t s a m p l e was a t l o w e r r i s k o f o b e s i t y t h a n t h e C a n a d i a n p o p u l a t i o n w h e r e h a l f o r m o r e w e r e r e p o r t e d t o be a t h i g h r i s k ( C a n a d a , 1 9 7 3 ) • S u b s e q u e n t a n a l y s e s u s e d BMI as t h e i n d e x o f c h o i c e b e - c a u s e BMI m e t t h e t w o r e q u i r e m e n t s f o r a n a p p r o p r i a t e i n d e x o f r e l a t i v e w e i g h t : (1) h i g h l y c o r r e l a t e d w i t h w e i g h t , a n d (2) r e l a t i v e l y i n d e p e n d e n t o f h e i g h t ( K e y s e t a l . , 1972). I n c o n t r a s t , P I h a d b e e n r e p o r t e d t o o v e r e s t i m a t e t h e a m o u n t o f o b e s i t y among t h e s h o r t as c o m p a r e d w i t h t h e t a l l women ( K h o s l a a n d L o w e , I967) •• T h i s b i a s i n r e l a t i o n t o h e i g h t made P I a l e s s s u i t a b l e c h o i c e , a n d may e x p l a i n t h e d i f f e r e n t p e r c e n t a g e s o b s e r v e d b e t w e e n i n d i c e s i n t h e p r e s e n t s t u d y . L e v e l o f E d u c a t i o n F o r t h e v a r i a b l e e d u c a t i o n , 2 0 . 3 % o f t h e p a r t i c i p a n t s h a d n o t c o m p l e t e d h i g h s c h o o l , 29.9% c o m p l e t e d g r a d e 12, 3 0 . 6 % c o m p l e t e d 1-3 y e a r s o f u n i v e r s i t y , a n d t h e r e m a i n d e r (19.2%) c o m p l e t e d f o u r o r more y e a r s o f u n i v e r s i t y t r a i n i n g . On t h e w h o l e , t h e s t u d y p o p u l a t i o n r e p r e s e n t e d a m o r e h i g h l y e d u c a t e d p o p u l a t i o n t h a n t h a t o f t h e c i t y o f V a n c o u v e r ( C a n a d a , 1976b) w h e r e a b o u t 40% a r e r e p o r t e d t o h a v e l e s s t h a n g r a d e 12 e d u c a - t i o n . S m o k i n g H a b i t S m o k i n g h a b i t s c l a s s i f i e d t h e s a m p l e a c c o r d i n g t o d e g r e e o f r i s k f o r CVD f r o m s m o k i n g . I n o r d e r o f i n c r e a s i n g r i s k , 66.2% r e p o r t e d t h e y n e v e r smoked o r n o t f o r f i v e y e a r s (NON- SMOKER); 12.8%, n o t smoked f o r l e s s t h a n f i v e y e a r s (FORMER 134 SMOKER); 7 . 1 $ , c i g a r s , p i p e s , o r l e s s t h a n 10 c i g a r e t t e s a d a y (L IGHT SMOKER); 8 . 2 $ , 10 t o 19 c i g a r e t t e s a d a y (HEAVY SMOKER); a n d 5 - 3 $ , 20 o r m o r e c i g a r e t t e s a d a y (VERY HEAVY SMOKER). The h i g h p e r c e n t a g e o f n o n s m o k e r s (79$) s u p p o r t s l i t e r a t u r e r e p o r t s o f a d e c l i n e i n s m o k i n g among C a n a d i a n a d u l t s (Game a n d D e v e n y i , 1971; M o r r i s o n , 1978) a l t h o u g h a s u b s t a n t i a l n u m b e r ( 2 0 . 6 $ ) s t i l l r e t a i n t h e h a b i t . S u p p l e m e n t s R e s p o n d e n t s w e r e a s k e d t o i n d i c a t e w h a t t y p e o f f o o d o r n u t r i e n t s u p p l e m e n t t h e y w e r e t a k i n g . As s h o w n i n T a b l e 2 1 , 5 1 . 6 $ o f t h e s a m p l e w e r e t a k i n g some t y p e o f s u p p l e m e n t w h i l e 4 7 - 7 $ w e r e n o t t a k i n g a n y k i n d o f s u p p l e m e n t . The m o s t p o p u l a r s u p p l e m e n t a p p e a r e d t o be v i t a m i n s . TABLE 21 T y p e s a n d F r e q u e n c y o f S u p p l e m e n t S u p p l e m e n t P e r c e n t i n Samp le V i t a m i n M i n e r a l V i t a m i n a n d m i n e r a l V i t a m i n , m i n e r a l , a n d f o o d V i t a m i n a n d f o o d F o o d None 2 1 . 0 1.1 1 7 . 8 5 . 3 5 - 0 1 .4 4 7 . 7 S o u r c e s o f N u t r i t i o n I n f o r m a t i o n T h e p a r t i c i p a n t s r e p o r t e d 24 s o u r c e s o f n u t r i t i o n i n f o r m a - t i o n o n d i e t a n d h e a r t d i s e a s e ( s e e T a b l e 2 2 ) . When g r o u p e d TABLE 22 S o u r c e s o f C a r d i o v a s c u l a r N u t r i t i o n I n f o r m a t i o n R e p o r t e d by S a m p l e P e r c e n t o f P e r c e n t o f S o u r c e Samp le S o u r c e S a m p l e P r o f e s s i o n a l 5 9 . 1 D o c t o r 4 4 . 8 A c t i o n B . C . 5-7 N u t r i t i o n i s t / D i e t i t i a n 2 2 . 1 Home E c o n o m i s t / T e a c h e r 13•5 N u r s e 11 .7 N o n p r o f e s s i o n a l 77•9 W e i g h t C o n t r o l G r o u p 1 6 . 7 F a m i l y 33-8 H e a l t h F o o d S t o r e 2 3 . 5 G r o c e r y S t o r e 7 .1 F r i e n d s 4 5 . 9 YM/YWCA 5 • 0 F i t n e s s I n s t r u c t o r 22,?.l T e a c h e r 1 5 . 3 D r u g S t o r e 8 . 2 S e r v i c e C l u b 1 .8 M a t e r i a l 8 8 . 3 E x h i b i t s / D i s p l a y s 2 8 . 1 N e w s p a p e r s 5 2 . 3 M a g a z i n e s B o o k s 6 1 - ° C o o k b o o k s 3 2 . 0 T e l e v i s i o n 4 9 . 5 F o o d L a b e l s 2 9 . 2 R a d i o 2 9 - 9 No S o u r c e U n r e p o r t e d 136 a c c o r d i n g t o w h e t h e r t h e s o u r c e was human ( p r o f e s s i o n a l o r n o n - p r o f e s s i o n a l ) o r m a t e r i a l , 59.1% o f t h e s a m p l e r e c e i v e d i n f o r - m a t i o n f r o m p r o f e s s i o n a l s ; 77•9% f r o m n o n p r o f e s s i o n a l s ; a n d 88.3% f r o m m a t e r i a l s o u r c e s . O n l y 4.3% r e p o r t e d r e c e i v i n g no p r e v i o u s i n f o r m a t i o n o n d i e t a n d h e a r t d i s e a s e . Of t h e m a t e r i a l s o u r c e s c i t e d , m a g a z i n e s , h o o k s , n e w s p a p e r s , a n d t e l e v i s i o n w e r e m o s t f r e q u e n t l y m e n t i o n e d . S i m i l a r s o u r c e s o f i n f o r m a t i o n o n n u t r i t i o n w e r e r e p o r t e d b y New Y o r k S t a t e a d u l t s ( J a l s o e t a l . , 1965), m e d i c a l s t u d e n t s a n d p h y s i c i a n s ( P o d e l l e t a l . , 1975a), a n d C a n a d i a n s 18 y e a r s a n d o l d e r ( C a n a d a , 1979b). O f t h e n o n - p r o f e s s i o n a l s o u r c e s c i t e d , r a n k e d s e c o n d i n i m p o r t a n c e , f r i e n d s a n d f a m i l y w e r e t h e c h i e f s o u r c e s . T h i s i s i n c o n t r a s t t o S i m s ' (1976) s t u d y o f m o t h e r s o f p r e s c h o o l c h i l d r e n i n w h i c h t e l e - v i s i o n a n d f r i e n d s r a n k e d l a s t . C o n s i s t e n t w i t h f i n d i n g s o f t h e C a n a d i a n s t u d y ( C a n a d a , 1979b), o t h e r m a j o r s o u r c e s r e p o r t - ed w e r e f a m i l y a n d d o c t o r . R e s u l t s o f t h e p r e s e n t s t u d y s t r o n g - l y s u p p o r t t h e C a n a d i a n r e c o m m e n d a t i o n ( C a n a d a , 1979b) t h a t t h e m e d i a i s m o s t i m p o r t a n t a s a c h a n n e l f o r n u t r i t i o n e d u c a t i o n . F u r t h e r , n u t r i t i o n e d u c a t o r s s h o u l d r e c o g n i z e t h e i m p o r t a n t r o l e t h a t d o c t o r s , f a m i l y , a n d f r i e n d s may p l a y as s o u r c e s o f i n f o r m a t i o n o n d i e t a n d h e a r t d i s e a s e . I n s u m m a r y , t h e s t u d y p o p u l a t i o n t e n d e d t o be y o u n g , f e m a l e , C a n a d i a n - b o r n , l i v i n g w i t h f a m i l y , c h a r a c t e r i z e d b y no p r e v i o u s t r e a t m e n t f o r c a r d i o v a s c u l a r - r e l a t e d d i s e a s e s , i n t h e l o w r i s k c a t e g o r y f o r o b e s i t y , a n d n o n s m o k e r s . E d u c a t i o n l e v e l a n d p h y s i c a l e x e r c i s e p a t t e r n w e r e a b o u t e q u a l l y r e p r e s e n t e d b e - t w e e n h i g h e r e d u c a t i o n ( o n e o r more y e a r s o f u n i v e r s i t y ) a n d 137 l o w e r e d u c a t i o n ( g r a d e 12 o r l e s s ) a n d b e t w e e n h i g h e r a c t i v i t y p a t t e r n s a n d l o w e r a c t i v i t y p a t t e r n s . S l i g h t l y more t h a n h a l f o f t h e p a r t i c i p a n t s r e p o r t e d h a v i n g f a m i l y h i s t o r i e s o f c a r d i o - v a s c u l a r - r e l a t e d c o n d i t i o n s . A b o u t 52$ o f t h e s a m p l e r e p o r t e d t a k i n g some t y p e o f s u p p l e m e n t a n d o v e r 95$ h a d r e c e i v e d some p r i o r e x p o s u r e t o c a r d i o v a s c u l a r n u t r i t i o n i n f o r m a t i o n . The m a i n i n f o r m a t i o n s o u r c e s m e n t i o n e d w e r e m a g a z i n e s , b o o k s , n e w s p a p e r s , t e l e v i s i o n , f r i e n d s , d o c t o r , a n d f a m i l y . B e f o r e p r o c e e d i n g t o a d i s c u s s i o n o f t h e m e a s u r i n g d e v i c e s u s e d i n t h e s t u d y , a b r i e f d e s c r i p t i o n o f t h e s a m p l e i n t e r m s o f t h e i r r e p o r t e d d i e t a r y p r a c t i c e s i s p r e s e n t e d . C h a p t e r I V ( s e e p p . 112,116 ) r e v i e w e d t h e m e t h o d f o r c o m p u t i n g t h e n u t r ^ i e n t v a l u e s a n d f o r i n t e r p r e t i n g t h e m a c c o r d i n g t o r e c o m m e n d e d s t a n d a r d s . T a b l e 23 p r e s e n t s t h e mean a n d s t a n d a r d d e v i a t i o n o f e a c h n u t r i e n t s c o r e , e x p r e s s e d as a r a t i o o f t h e r e c o m m e n d e d v a l u e , a n d t h e d i s t r i b u t i o n o f t h e s a m p l e b y p r a c t i c e c a t e g o r y . F o r t h e s a m p l e , t h e mean n u t r i e n t s c o r e s f o r PROT, VA, R I B O , a n d N I A e x c e e d e d 133$, a n d VC, 200$ o f t h e r e c o m m e n d e d v a l u e s ( C a n a d a , 1975a). None o f t h e mean n u t r i e n t s c o r e s w e r e l e s s t h a n 67$ o f t h e s t a n d a r d . The mean s c o r e s f o r FAT a n d CHO, w h i c h r e p r e s e n t p r o p o r - t i o n s o f t o t a l e n e r g y i n t a k e (39.2 a n d 4-2.5$, r e s p e c t i v e l y ) a r e v e r y s i m i l a r t o t h e v a l u e s f o r FAT (39 t o 4-0$) r e p o r t e d b y N u t r i t i o n Canada ( C a n a d a , 1976a, p.24-0) f o r t h e C a n a d i a n a d u l t p o p u l a t i o n b u t s o m e w h a t l o w e r f o r CHO v a l u e s (4-6 t o 47$) . I n t h e N u t r i t i o n C a n a d a s u r v e y , a l c o h o l was i n c l u d e d w i t h CHO TABLE 23 P r a c t i c e C h a r a c t e r i s t i c s o f t h e Samp le N u t r i e n t 3 " S c o r e s P e r c e n t o f S a m p l e 3 , X S . D . D e f i c i e n t * 3 A c c e p t a b l e 1 3 E x c e s s KCAL .94 . 2 6 1 4 . 6 7 9 . 7 5-7 PROT I . 7 6 . 5 2 1.1 1 7 . 8 8 1 . 1 CA 1 . 1 4 . 5 4 1 6 . 4 5 5 . 5 2 8 . 1 FE 1 . 0 4 . 4 9 2 3 . I 55-5 2 1 . 4 VA 2 . 3 9 2 . 7 8 1 4 . 2 2 9 . 2 5 6 . 5 T H I 1.12 . 6 1 1 6 . 4 5 8 . 4 2 5 . 3 RIBO 1 .61 1 . 4 6 5 . 3 5 0 . 5 4 4 . 1 NIA 1 . 3 9 c . 6 1 ' c 6 . 0 4 8 . 4 4 5 . 6 VC 4 . 1 9 2 . 5 5 1.1 5 . 0 9 4 . 0 FAT 1.12 . 2 2 2 . 1 8 2 . 6 1 5 . 3 CHO .85 . 1 8 1 3 . 9 8 5 . 4 .7 N o t e . S a m p l e s i z e = 2 8 1 . a E x p r e s s e d as 1977) • r a t i o o f r e c o m m e n d e d v a l u e s ( C a n a d a , 1975a; D e f i c i e n t , <67%; a c c e p t a b l e , 67-133%; e x c e s s , >133% ( e x c e p t VC, >200%) o f r e c o m m e n d e d v a l u e s . c E x p r e s s e d as mg NIA i n t a k e / C D S b a s e d o n age a n d g e n d e r . w h i c h may a c c o u n t f o r t h e d i f f e r e n c e . When t h e s a m p l e i s s e p a r a t e d i n t o t h r e e p r a c t i c e c a t e - g o r i e s , t h e p e r c e n t a g e w i t h n u t r i e n t s c o r e s l e s s t h a n 67$ ( d e f i c i e n t ) o f t h e r e c o m m e n d e d v a l u e s i n d i c a t e s p o s s i b l e d e f i - c i e n c i e s f o r a s m a l l s e g m e n t o f t h e s a m p l e . The p e r c e n t a g e d e f i c i e n t i n FE (23$) i s n o t s u r p r i s i n g as t h e m a j o r i t y o f t h e s a m p l e w e r e f e m a l e a n d i t h a d b e e n r e p o r t e d t h a t 75$ o f 20 t o 64 y e a r o l d f e m a l e s h a v e l e s s t h a n d e s i r a b l e FE i n t a k e s ( N u t r i - t i o n C a n a d a , 1973)• Those r e p o r t i n g d e f i c i e n t KCAL i n t a k e (14 .6$) m i g h t p o s s i b l y r e p r e s e n t a p o r t i o n o f t h e s a m p l e c o n - c e r n e d w i t h w e i g h t c o n t r o l r a t h e r t h a n one c h a r a c t e r i z e d b y c h r o n i c KCAL d e f i c i t . The p e r c e n t a g e ( 14 .2$) d e f i c i e n t i n VA i n t a k e i s o f c o n c e r n i f t h e d e f i c i e n t i n t a k e h a d o c c u r r e d f o r a n e x t e n d e d p e r i o d o f t i m e a n d d e p l e t e d l i v e r r e s e r v e s ; o t h e r - w i s e , VA r e q u i r e s no i m m e d i a t e a t t e n t i o n . The 6$ d e f i c i e n t i n N IA i s o f l i t t l e c o n c e r n s i n c e PROT l e v e l s a r e s u f f i c i e n t l y h i g h t o p r o v i d e t r y p t o p h a n f o r N IA s y n t h e s i s . The p e r c e n t a g e d e f i c i e n t i n T H I a n d RIBO may r e f l e c t t h e h i g h f e m a l e r e p r e - s e n t a t i o n s i n c e N u t r i t i o n Canada r e p o r t e d t h a t m o r e f e m a l e s consumed i n a d e q u a t e a m o u n t s o f T H I a n d RIBO t h a n m a l e s . The r e l a t i v e l y h i g h p e r c e n t a g e s (16.4$) d e f i c i e n t i n T H I a n d CA may s u g g e s t t h a t T H I a n d CA s h o u l d r e c e i v e s p e c i a l a t t e n t i o n . N u t r i t i o n Canada r e p o r t e d t h a t CA i n t a k e s w e r e i n a d e q u a t e f o r one o u t o f f i v e women i n t h e g e n e r a l p o p u l a t i o n a n d t h e p r e s e n t s t u d y c o n f i r m s t h i s f i n d i n g f o r 16$ o f t h e s a m p l e . I n t h e e x c e s s c a t e g o r y ( g r e a t e r t h a n 133$ o r f o r VC, 2 0 0 $ , o f r e c o m m e n d e d ) , p e r c e n t a g e s f o r t h e n u t r i e n t s PROT a n d .VC w e r e e x t r e m e l y h i g h . Many a u t h o r i t i e s c o n s i d e r n u t r i e n t i n t a k e s L t h a t a r e h i g h e r t h a n r e q u i r e d f o r h e a l t h , b u t n o t i m c o m p a t i b l e w i t h i t , t o be o f l i t t l e c o n c e r n . W i t h t h e e x c e p t i o n o f KCAL a n d F A T , i n t a k e s t h a t e x c e e d e d r e c o m m e n d e d v a l u e s f o r t h e r e m a i n i n g n u t r i e n t s e x a m i n e d w o u l d n o t be c o n s i d e r e d u n a c c e p t a b l e . C o n - s e q u e n t l y , t h e m a j o r i t y o f t h e s a m p l e c a n be d e s c r i b e d as h a v i n g a c c e p t a b l e p r a c t i c e s . A s m a l l p e r c e n t a g e o f t h e s a m p l e (5«7%) r e p o r t e d u n a c c e p t a b l y h i g h KCAL i n t a k e s . O f g r e a t e r c o n c e r n a r e t h o s e ( 1 5 0 % ) who r e p o r t e d e x c e s s FAT i n t a k e w h i c h i n d i c a t e s t h a t t h e y a r e c o n s u m i n g o v e r 46% o f t h e i r e n e r g y as F A T , a v a l u e f a r i n e x c e s s o f t h e r e c o m m e n d e d 35% m a x i m u m . O v e r a l l , n u t r i e n t i n t a k e s w e r e s a t i s f a c t o r y e x c e p t f o r FE w h e r e n e a r l y one q u a r t e r o f t h e s a m p l e w e r e c l a s s i f i e d a s h a v - i n g a d e f i c i e n t i n t a k e o f t h a t n u t r i e n t a n d FAT w h e r e o v e r 15% o f t h e s a m p l e r e p o r t e d c o n s u m i n g o v e r 133% o f t h e r e c o m m e n d e d maximum a m o u n t . C h a r a c t e r i s t i c s o f t h e M e a s u r i n g I n s t r u m e n t s A t t i t u d e S c a l e Summary s t a t i s t i c s f o r t h e a t t i t u d e s c a l e a r e p r e s e n t e d i n T a b l e 24. The mean s c o r e s f o r e a c h o f t h e s u b t e s t s (A:GEN ROLE, A:MANAGE) a n d t o t a l t e s t ( A : T O T A L ) w e r e q u i t e h i g h r e p r e s e n t i n g 83% o f t h e p o s s i b l e s c o r e . T h i s s u g g e s t e d t h e s a m p l e as a w h o l e r e p o r t e d a p o s i t i v e a t t i t u d e t o w a r d d i e t as a means o f p r o m o t i n g h e a r t h e a l t h a n d i n t e r v e n i n g a g a i n s t h e a r t d i s e a s e . I t e m a n a l y s i s d a t a f o r t h e a t t i t u d e s c a l e a r e r e p o r t e d i n A p p e n d i x F . TABLE 24 S ummary T e s t S t a t i s t i c s f o r t h e A t t i t u d e I n s t r u m e n t A t t i t u d e S u b t e s t A : GEN ROLE A:MANAGE A : TOTAL N o . i t e m s 10 9 19 Mean (fo) 41 .67 (83 .34 ) 37 .43 (83 . 18 ) 79 .10 (83 .26 ) S . D . (fo) 4 . 4 9 ( 8 .98) 4 . 01 ( 8 . 91 ) 7 . 84 ( 8 . 25 ) K u r t o s i s - .025 - .177 - .264 S k e w n e s s - .324 - .249 - .225 H o y t ' s r .73 .67 .82 a S . E . 2.22 2 .17 3 .20 C r o n b a c h ' s c o m p o s i t e a l p h a ( C r o n b a c h , 1 9 5 1 ) . The p o s i t i v e a t t i t u d e t o w a r d t h e r o l e o f d i e t i n h e a r t • d i s e a s e (A :GEN ROLE) i s s i m i l a r t o t h a t r e p o r t e d f o r a n o t h e r C a n a d i a n g r o u p ( C a n a d a , 1979b) w h e r e o v e r 80% f e l t t h a t t h e b e n e f i t s o f a s e n s i b l e d i e t i n c l u d e d b e t t e r h e a l t h a n d f e w e r h e a l t h p r o b l e m s . S t a n d a r d d e v i a t i o n s f o r e a c h s u b t e s t a n d t o t a l t e s t w e r e q u i t e a c c e p t a b l e r e p r e s e n t i n g e i g h t t o n i n e p e r c e n t o f t h e p o s s i b l e s c o r e . T h i s s u p p o r t s t h e p o s i t i v e a t t i t u d e o f t h e g r o u p s i n c e a p p r o x i m a t e l y 70% o f t h e a t t i t u d e s c o r e s w o u l d be g r e a t e r t h a n 75$ o f t h e p o s s i b l e s c o r e , i f t h e i r d i s t r i b u t i o n a p p r o x i m a t e d t h e n o r m a l . K u r t o s i s a n d s k e w n e s s v a l u e s s u p p o r t no m a r k e d d e v i a t i o n o f t h e s u b t e s t s o r t o t a l t e s t s c o r e s f r o m a n o r m a l d i s t r i b u t i o n . 142 The r e l i a b i l i t y c o e f f i c i e n t s a r e .73 a n d .67 ( H o y t ' s ANOVA i n t e r n a l c o n s i s t e n c y e s t i m a t e s ) f o r t h e s u b t e s t s a n d . 8 2 f o r t h e t o t a l t e s t ( C r o n b a c h ' s c o m p o s i t e a l p h a ) . T h e s e a r e c o n s i d e r e d a d e q u a t e f o r t h e p u r p o s e o f t h i s s t u d y . K n o w l e d g e S c a l e Summary s t a t i s t i c s f o r t h e k n o w l e d g e s c a l e r e v e a l e d t h a t r e l i a b i l i t i e s f o r t h e t h r e e s u b t e s t s (K :AFFECTS, K:COMP, K:FACTS) w e r e q u i t e l o w (.06, .43, .47, r e s p e c t i v e l y , s e e A p p e n d i x G ) . T h i s r a i s e d a q u e s t i o n r e g a r d i n g t h e s c o r i n g p r o - c e d u r e . S i n c e a l l t h e i t e m s h a d b e e n b a s e d o n c u r r e n t k n o w l e d g e r e g a r d i n g t h e r e l a t i o n s h i p o f d i e t a n d CVD a n d t h e k e y t o t h e i t e m s h a d b e e n a c c e p t e d b y a p a n e l o f e x p e r t s , a n a t t e m p t was made t o i m p r o v e t h e r e l i a b i l i t y o f t h e i n s t r u m e n t b y c h a n g i n g f r o m t h e 1 t o 5 s c o r i n g s y s t e m i n i t i a l l y a d o p t e d ( s e e T a b l e 4 , C h a p t e r I I I ) t o a s y s t e m r e f l e c t i n g a more c o n v e n t i o n a l r i g h t - w r o n g s c o r i n g . T h r e e a l t e r n a t i v e s y s t e m s w e r e e x p l o r e d : ( 1 ) Two p o i n t s f o r " d e f i n i t e l y c o r r e c t " , one f o r " p r o b - a b l y c o r r e c t " , a n d z e r o f o r t h e r e m a i n i n g r e s p o n s e s ( 2 , 1 , 0 s y s t e m ) ; ( 2 ) One p o i n t f o r " d e f i n i t e l y c o r r e c t " , one f o r " p r o b - a b l y c o r r e c t " , a n d z e r o f o r t h e r e m a i n i n g r e s p o n s e s ( 1 , 1 , 0 s y s t e m ) ; (3) One p o i n t f o r " d e f i n i t e l y c o r r e c t " r e s p o n s e a n d z e r o f o r t h e r e m a i n d e r ( 1 , 0 s y s t e m ) . 14-3 I n s p e c t i o n o f t h e t e s t s t a t i s t i c s f o r e a c h s y s t e m r e v e a l e d t h a t t h e 1 , 1 , 0 s y s t e m r e s u l t e d i n r e l i a b i l i t i e s f o r . t h e t h r e e s u b t e s t s as l o w as t h a t o f t h e 1 t o 5 s y s t e m ( . 0 4 , . 4 5 , a n d . 4 7 ) . A c o m p a r i s o n o f r e s u l t s u s i n g s c o r i n g s y s t e m s , r l , 0 w i t h t h a t o f 2 , 1 , 0 s h o w e d t h a t t h e r e l i a b i l i t i e s o f K:C0MP a n d K:FACTS w e r e v e r y s i m i l a r f o r t h e t w o s y s t e m s b u t t h a t t h e r e l i a b i l i t y f o r K:AFFECTS was somewhat l o w e r w i t h t h e 2 , 1 , 0 s y s t e m ( . 4 5 c o m p a r e d t o . 5 9 ) . As e x p e c t e d , C r o n b a c h ' s c o m p o s - i t e a l p h a was l o w e r f o r t h e 2 , 1 , 0 s y s t e m a l s o . A l t h o u g h t h e s c o r i n g s y s t e m s h o u l d r e f l e c t as c l o s e l y a s p o s s i b l e t h e p u r - p o s e o f t h e t e s t , w h i c h i n t h i s c a s e was i d e n t i f i c a t i o n o f s t a t e m e n t s as t r u e o r f a l s e , t h e 1 , 0 s y s t e m was deemed i n a p p r o - p r i a t e f o r t h e p r e s e n t s t u d y . I n s t e a d t h e 2 , 1 , 0 s y s t e m was c h o s e n s i n c e t h i s o p t i o n was j u d g e d t o m o r e c l e a r l y r e f l e c t t h e r e s p o n s e f o r m a t w h i c h i m p l i e d more t h a n one a p p r o p r i a t e r e s p o n s e . I n t h i s w a y , t h o s e r e s p o n d e n t s who knew t h e c o r r e c t r e s p o n s e b u t b e c a u s e o f t r a i t s o f c h a r a c t e r c i r c l e d " p r o b a b l y " r a t h e r t h a n " d e f i n i t e l y " w o u l d be i n c l u d e d . A summary o f t h e t e s t s t a t i s t i c s f o r t h e k n o w l e d g e s c a l e u s i n g t h e 2 , 1 , 0 s y s t e m i s p r e s e n t e d i n T a b l e 25. . - A p p e n d i x G r e p o r t s summary s t a t i s - t i c s f o r t h e o t h e r s c o r i n g s y s t e m s (1 t o 5 ; 1 , 0 ; 1 , 1 , 0 ) . I t e m a n a l y s i s d a t a f o r t h e 2 , 1 , 0 s y s t e m a r e a l s o r e p o r t e d i n A p p e n d i x The mean p e r c e n t a g e f o r e a c h s u b t e s t a n d t o t a l t e s t i n d i - c a t e t h e t e s t s w e r e o f med ium d i f f i c u l t y . K u r t o s i s a n d s k e w n e s s v a l u e s f o r t h e k n o w l e d g e s u b t e s t s a n d t o t a l t e s t i n d i c a t e t h a t t h e s c o r e s a p p r o x i m a t e d t h e n o r m a l d i s t r i b u t i o n . S t a n d a r d TABLE 25 Summary T e s t S t a t i s t i c s f o r t h e K n o w l e d g e I n s t r u m e n t K n o w l e d g e S u b t e s t s K:AFFECTS K:C0MP K:FACTS K: TOTAL N o . i t e m s 8 10 9 27 Mean (%) 8.43 (52.69) 9.69 (48.45) 8.74 (48 .56) 26.86 (49.74) S . D . (fo) 2.01 (12 .56) 3.21 (16 .05) 3.21 (17.83) 6.88 (12 .74) K u r t o s i s - .372 .439 - .333 - .358 S k e w n e s s - .320 .372 .211 - .033 H o y t ' s r .45 .64 .62 .72 h S .E . 1 .40 1 .84 1.86 3.12 2,1,0 s c o r i n g s y s t e m . C r o n b a c h ' s c o m p o s i t e a l p h a ( C r o n b a c h , 1951). d e v i a t i o n s f o r t h e s u b t e s t s r e v e a l g r e a t e r v a r i a b i l i t y o f k n o w - l e d g e f o r t h e s p e c i f i c t e s t s ( K : COMP-, a n d K: FACTS) t h a n t h e m o r e g e n e r a l t e s t ( K : A F F E C T S ) . The r e l i a b i l i t y c o e f f i c i e n t s ( T a b l e 25) a r e .45, .64, a n d .62 f o r K: AFFECTS, KtCOMP, a n d K: FACTS r e s p e c t i v e l y . A l t h o u g h t h e r v a l u e f o r K:AFFECTS i s r e l a t i v e l y l o w s u g g e s t i n g a l e s s homogeneous s u b t e s t , t h e m i s b e h a v i o u r o f t h r e e o f t h e e i g h t i t e m s may p a r t i a l l y e x p l a i n t h e r e s u l t . T h e s e i t e m s w e r e t h e same t h r e e o f f o u r i t e m s f o u n d t o m i s b e h a v e i n t h e p i l o t s t u d y b u t w e r e r e t a i n e d f o r t h e i r c o n t r i b u t i o n t o t h e p u r p o s e o f t h e t e s t ( s e e C h a p t e r I I I , p . 98). I n t h e p r e s e n t s t u d y , t h e t h r e e i t e m s w e r e a n s w e r e d c o r r e c t l y b y t h e h i g h e s t s c o r e r s a n d , i n t w o o f t h r e e c a s e s , h a d p o i n t b i s e r i a l c o r r e l a t i o n s g r e a t e r t h a n .22. The t h i r d i t e m , r e l a t e d t o c h o l e s t e r o l i n t h e d i e t , was i n c o r r e c t l y a n s w e r e d b y t h e m a j o r i t y (85%) o f t h e s a m p l e a n d h a d a l o w p o i n t b i s e r i a l c o r r e l a t i o n . The c o e f f i c i e n t f o r t h e c o m p o s i t e (.72) s u p p o r t e d t h e r e l i a b i l i t y o f t h e t e s t , t h u s i t was c o n c l u d e d t h a t t h e k n o w l e d g e s c a l e was r e l i a b l e f o r m e a s u r i n g k n o w l e d g e i n t h e p r e s e n t s t u d y . E x a m i n a t i o n o f t h e i t e m t e s t s t a t i s t i c s ( A p p e n d i x G) r e - v e a l e d t h e p r o p o r t i o n s o f t h e s a m p l e t h a t r e s p o n d e d t o t h e v a r - i o u s o p t i o n s f o r e a c h i t e m . F o r t h e s u b t e s t K :AFFECTS, i t e m s r e l a t e d t o o v e r w e i g h t , o b e s i t y , a n d o v e r e a t i n g i . e . , - w e i g h t c o n t r o l , w e r e a n s w e r e d c o r r e c t l y b y m o r e t h a n 8 0 % o f t h e s a m p l e . H o w e v e r , o v e r 65% s h o w e d l a c k o f k n o w l e d g e f o r i t e m s c o n c e r n i n g c h o l e s t e r o l a n d f a t , b o t h i t e m s o f p a r t i c u l a r i n t e r e s t i n CVD. O v e r a l l , s u b t e s t K:C0MP h a d a s l i g h t l y l o w e r mean p e r c e n t a g e 146 t h a n a n y o f t h e o t h e r s u b t e s t s y e t , m o r e t h a n 70$ o f t h e s a m p l e w e r e a b l e t o a n s w e r f i v e o f t h e 10 i t e m s c o r r e c t l y . I t e m s d e a l - i n g w i t h n u t r i e n t c o m p o s i t i o n o f m e a t , f i s h , f r u i t , e g g s , a n d a l c o h o l w e r e a n s w e r e d c o r r e c t l y more f r e q u e n t l y t h a n i t e m s t h a t r e l a t e d t o t h e c o m p o s i t i o n o f f o o d s u b s t i t u t e s o r o i l s a n d w h i c h r e q u i r e d a k n o w l e d g e o f t h e t e r m s s a t u r a t e d a n d u n s a t u r a t e d . F o r t h e l a t t e r g r o u p o f i t e m s , 30 t o 50$ o f t h e r e s p o n d e n t s r e p o r t e d t h e y d i d n o t know t h e c o r r e c t r e s p o n s e . The p o o r e s t r e s p o n s e ( o v e r 75$ r e p o r t i n g t h e y d i d n o t k n o w ) o c c u r r e d f o r t h e i t e m , d e f i n i n g p o l y u n s a t u r a t e d f a t t y a c i d s ( P U F A ) . T h i s f i n d i n g a g r e e s w i t h t h e C a n a d i a n O p i n i o n s t u d y ( C a n a d a , 1979b) r e p o r t t h a t 4-0 t o 4-5$ o f t h e i r r e s p o n d e n t s c o u l d n o t d e f i n e w h a t was m e a n t b y "make s u r e t h a t s o u r c e s o f PUFA a r e i n c l u d e d i n y o u r d i e t " ( p . 2 5 ) • The f i n a l s u b t e s t K:FACTS a g a i n p o i n t e d t o t h e l a c k o f k n o w l e d g e a b o u t PUFA i n t h e d i e t as o v e r 50$ o f t h e s a m p l e r e - p o r t e d t h e more PUFA i n t h e d i e t t h e b e t t e r a n d a b o u t 30$ s a i d t h e y d i d n o t k n o w . I t e m s o f n u t r i t i o n f a l l a c i e s c o n c e r n i n g t h i n n e s s , f a m i l y h i s t o r y , w e i g h t r e d u c t i o n m e t h o d s , a n d e x e r - c i s e w e r e c o r r e c t l y a n s w e r e d b y o v e r 70$ o f t h e s a m p l e . F o u r i t e m s t h a t w e r e r e l a t e d t o s p e c i a l f u n c t i o n s o f g a r l i c , l e c i - t h i n , h a r d w a t e r , a n d v i t a m i n C w e r e l e s s w e l l a n s w e r e d as 20 t o 4-0$ o f t h e s a m p l e r e s p o n d e d " d o n o t k n o w " a n d , 30 t o 4-7$, i n c o r r e c t l y . T h e s e p e r c e n t a g e s i n d i c a t e a p r e d o m i n a n c e o f i n - s u f f i c i e n t k n o w l e d g e r e g a r d i n g d i e t a n d CVD w h i c h may be f u r t h e r c o m p l i c a t e d b y t h e p r e s e n c e o f i n a c c u r a t e o r c o n f l i c t i n g i n f o r - m a t i o n a c c e p t e d as t r u e b y t h e r e s p o n d e n t s . T h i s l a t t e r c l a i m i s "based o n t h e a p p a r e n t a c c e p t a n c e o f s t a t e m e n t s r e g a r d i n g t h e s p e c i a l f u n c t i o n s o f f o o d c o m p o n e n t s e . g . , t h e l e c i t h i n i t e m c o n s i d e r e d a t r u e s t a t e m e n t "by 47% o f t h e s a m p l e . P r a c t i c e I n s t r u m e n t R e l i a b i l i t y a n a l y s i s o f t h e p r a c t i c e s c a l e was p e r f o r m e d u s i n g a s u b s a m p l e o f r e s p o n d e n t s who r e p o r t e d r e t u r n i n g q u e s - t i o n n a i r e s . As d e s c r i b e d i n C h a p t e r I V , a r a n d o m s a m p l e o f f o u r r e s p o n d e n t s p e r c e n t r e was i n t e r v i e w e d (15.7% o f t o t a l . , s a m p l e ) . F i v e i n t e r v i e w s w e r e r e j e c t e d due t o i n a d e q u a t e age o f one i n t e r v i e w e e , i n c o m p l e t e p r a c t i c e r e s p o n s e s , f a i l u r e t o r e t u r n t h e q u e s t i o n n a i r e , f a i l u r e t o r e t a i n t h e i d e n t i f i c a t i o n i n t e r v i e w c a r d , o r u n r e l i a b l e i n t e r v i e w as j u d g e d by t h e i n t e r - v i e w e r . I n t o t a l , 39 i n t e r v i e w s (13-9% o f s t u d y p o p u l a t i o n ) w e r e u s e d i n t h e a n a l y s i s . B e c a u s e t h e i n t e r v i e w s c h e d u l e was d e v e l o p e d as a p a r a l l e l f o r m t o t h e s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e , a c o n g r u e n c y c h e c k o f t h e mean p e r f o r m a n c e was u s e d t o v e r i f y t h e c o n s i s t e n c y o f t h e p r a c t i c e d a t a . A p a i r e d t t e s t was u s e d t o t e s t t h e n u l l h y p o t h e s i s t h a t t h e mean o f t h e d i f f e r e n c e b e t w e e n t h e t w o v a r i - a b l e s ( q u e s t i o n n a i r e a n d i n t e r v i e w ) was z e r o . R e s u l t s a r e p r e s e n t e d i n T a b l e 26. The r e s u l t s show t h a t , a t t h e .05 l e v e l o f s i g n i f i c a n c e , t h e r e was no s i g n i f i c a n t d i f f e r e n c e i n p r a c t i c e s c o r e s b e t w e e n q u e s t i o n n a i r e a n d i n t e r v i e w m e t h o d s f o r a l l n u t r i e n t s e x c e p t c a l c i u m . S i n c e i n s p e c t i o n o f t h e mean s c o r e s f o r c a l c i u m 148 TABLE 26 P a i r e d t T e s t o f P r a c t i c e S c o r e s f r o m Q u e s t i o n n a i r e a n d I n t e r v i e w V a r i a b l e Q u e s t i o n - n a i r e X ^ R a t i o I n t e r v i e w X 2 R a t i o X 1 " X 2 S . D . t - S t a t a S i g n i f - a i c a n c e KCAL .724 .720 .003 .194 . 2 0 4 . 8 4 0 PROT .987 .972 .015 .055 1.552 .129 CA • 763 .888 -.125 .189 - 3 . 6 8 1 * .001 FE .783 .774 .009 .190 . 2 8 6 .777 VA .839 .865 -.026 .298 - .574 .569 T H I . 8 1 4 . 8 0 0 . 0 1 4 .208 .443 .660 RIBO .872 . 9 1 8 — 046 .200 -1.351 .185 NIA .937 .901 .036 .158 1.396 .171 VC .952 .986 -.033 .152 -1.277 .209 FAT .802 .789 .013 .177 .496 .622 CHO .639 .671 -.033 .127 -1.617 . 1 1 4 N o t e . S i z e o f s a m p l e = 39. c o m p u t e d u s i n g a r c s i n e t r a n s f o r m e d d a t a . * P<.05. 149 r e v e a l e d b o t h g r o u p s w e r e w e l l w i t h i n t h e m i d t o u p p e r l e v e l s o f t h e a c c e p t a b l e r a n g e ( d i s c u s s e d i n C h a p t e r I V , p . l l 6 ) f o r c a l c i u m i n t a k e , t h e p r a c t i c e i n s t r u m e n t was j u d g e d t o p r o v i d e i n f o r m a t i o n o n d i e t a r y p r a c t i c e s as r e l i a b l e as t h a t o f t h e i n t e r v i e w . S e l f - r e p o r t o f t h e b i o d e m o g r a p h i c i n f o r m a t i o n was a l s o c h e c k e d f o r c o n s i s t e n c y u s i n g t h e t e s t - r e t e s t p r o c e d u r e . The c o r r e l a t i o n o f t h e r e s p o n s e s b e t w e e n q u e s t i o n n a i r e a n d i n t e r v i e w w e r e f o u n d t o v a r y b e t w e e n 1.00 a n d .58 ( T a b l e 27) c o m p a r i n g q u i t e f a v o u r a b l y w i t h t h e l i t e r a t u r e s u g g e s t i o n t h a t a c o r r e l a - t i o n o f .5 t o .8 i n d i c a t e s a n a c c e p t a b l e d e g r e e o f r e p r o d u c - a b i l i t y b e t w e e n d a t a c o l l e c t i o n i n s t r u m e n t s ( D a w b e r e t a l . , 1962; R e s h e f a n d E p s t e i n , 1972; S t e r n e t a l . , 1976). O n l y t w o v a r i a b l e s ( h e i g h t a n d w e i g h t ) w e r e o b j e c t i v e l y - m e a s u r e d a t t h e t i m e o f t h e i n t e r v i e w , t h e r e m a i n d e r w e r e r e p o r t e d . The h i g h c o r r e l a t i o n s (.83 a n d .99, r e s p e c t i v e l y ) o f t h e s e t w o v a r i a b l e s o f f e r a d d i t i o n a l s u p p o r t f o r t h e a c c u r a c y o f t h e q u e s t i o n n a i r e d a t a . TABLE 27 P e a r s o n P r o d u c t - M o m e n t C o r r e l a t i o n s b e t w e e n Q u e s t i o n n a i r e a n d I n t e r v i e w R e s p o n s e s t o B i o d e m o g r a p h i c Q u e s t i o n s V a r i a b l e C o e f f i c i e n t G e n d e r Age S m o k i n g H a b i t E x e r c i s e P a t t e r n H e i g h t W e i g h t Amoun t o f A l c o h o l 1.00 .997 .926 .580 .829 .986 .885 N o t e . S i z e o f s a m p l e = 39. 150 Hypotheses Testing Relationships among Attitudes, Knowledge, and Practice The f i r s t hypotheses to be tested were c o r r e l a t i o n a l i n nature focusing on the relationships among attitudes, knowledge, and p r a c t i c e . To ascertain the type of relationships among attitudes, knowledge, and practice, scatterplots f o r a l l combi- nations of attitude, knowledge, and practice scores were formed. On examining these scat t e r p l o t s , no nonlinear r e l a t i o n - ships were found. Thus, Pearson product-moment correlations were computed to r e f l e c t the magnitudes of l i n e a r r e l a t i o n s h i p among these varia b l e s . Table 28 presents the correlations f o r attitude and knowledge scores. TABLE 28 Pearson Product-Moment Correlations between Attitude and Knowledge Scores 2 3 4 5 6 7 1 A:GEN ROLE ..70* .93* .48* .40* .49* .56* 2 A:MANAGE .91* .44* .38* .38* .48* 3 A:TOTAL .50* .42* .47* .56* 4 K:AFFECTS .49* .50* .76* 5 K:C0MP .48* .83* 6 K:FACTS .84* 7 K:TOTAL p<.05. R e s u l t s confirmed,a moderate c o r r e l a t i o n between a t t i t u d e and knowledge sc o r e s (range .38 to .56) and r e j e c t e d the n u l l h ypothesis t h a t the c o r r e l a t i o n between a t t i t u d e and knowledge scores i s equal to zero. The high c o r r e l a t i o n observed between sub t e s t s and t o t a l t e s t f o r both a t t i t u d e and knowledge scores must be r e c o g n i z e d as s p u r i o u s l y h i g h s i n c e i t i s based p a r t l y on the p e r f e c t correspondence of i d e n t i c a l e r r o r s of measure- ment i n the s u b t e s t and i n the t o t a l t e s t (APA, 1974,p.53) . The degree of r e l a t i o n s h i p between p r a c t i c e and both a t t i t u d e and knowledge scores i s presented i n Table 29. The r e s u l t s r e v e a l e d a zero to weak r e l a t i o n s h i p between p r a c t i c e and both a t t i t u d e s and knowledge (range .00 to .24). Although s e v e r a l of the c o r r e l a t i o n s were s t a t i s t i c a l l y s i g n i f - i c a n t , the maximum shared v a r i a n c e between any p r a c t i c e score and a t t i t u d e or knowledge score was only 5-8% ( f o r , RIBO and A:GEN ROLE, o n l y 5.8$ of the v a r i a n c e of RIBO could be de t e r - mined by A:GEN ROLE s c o r e s ) . I n summary, while comparable c o r r e l a t i o n c o e f f i c i e n t s have been r e p o r t e d f o r the r e l a t i o n s h i p s among a t t i t u d e s , knowledge, and p r a c t i c e (see Chapter I I , pp. 26,28), s t r o n g e r c o r r e l a t i o n s than those found i n the present study have been r e p o r t e d f o r the r e l a t i o n s h i p between p r a c t i c e and both a t t i t u d e s and know- ledg e . A reason f o r the d i f f e r e n t f i n d i n g s may be due i n p a r t to the assessment of c a r d i o v a s c u l a r , not g e n e r a l , n u t r i t i o n a t t i t u d e s and knowledge or to the use of a d u l t members of community c e n t r e s , not s p e c i f i c segments of the p o p u l a t i o n i . e . , l a c t a t i n g females and women a t h l e t e s who might be expected to TABLE 29 P e a r s o n P r o d u c t - M o m e n t C o r r e l a t i o n s b e t w e e n P r a c t i c e a n d A t t i t u d e a n d K n o w l e d g e S c o r e s A:GEN ROLE A:MANAGE A:TOTAL K:AFFECTS K:COMP K:FACTS K:TOTAL KCAL . 0 4 .05 . 0 4 .13* .11 .07 .12* PROT ,08 . 0 4 .07 .03 .09 .06 .08 CA .20* .13* . 1 8 * .10 .15* . 0 8 . 1 4 * FE -.02 .05 .01 .00 .05 -.05 -.00 VA .05 .09 .07 .01 .01 .08 .05 T H I .15* .11 . 1 4 * .16* . 1 4 * .10 .16* RIBO . 2 4 * .16* .22* .12* .15* .10 .16* NIA .11 .12* .13* .11 .11 .09 .13* VC .05 .07 .06 .13* .10 .10 .13* FAT .00 -.07 -.03 .03 .06 -.04 .02 CHO -.04 -.01 - .02 - . 0 4 - .06 .03 -.03 * P<.05. 153 "be more i n v o l v e d w i t h r e s p e c t t o the s p e c i f i c p r a c t i c e i n v e s t i - g a t e d . Because o f the weak r e l a t i o n s h i p o b s e r v e d between p r a c t i c e s c o r e s and b o t h a t t i t u d e and knowledge s c o r e s , p a t h a n a l y s i s p r o c e d u r e s to t e s t the models: (1) P< A and (2) P < A t h a t knowledge causes a t t i t u d e s w h i c h cause p r a c t i c e o r a t t i - t u des cause knowledge w h i c h causes p r a c t i c e were judged i n - a p p r o p r i a t e and not a t t e m p t e d . An attempt was made to see i f w i t h i n the sample, p r a c t i c e groups d e f i n e d i n terms o f the e x t e n t o f d e f i c i e n c y and excess c o u l d be formed and membership s u b s e q u e n t l y p r e d i c t e d from a t t i t u d e and knowledge s c o r e s . The f o r m a t i o n o f p r a c t i c e groups i s d e s c r i b e d i n Appendix H. Use o f m u l t i p l e d i s c r i m i n a n t a n a l - y s i s c o n f i r m e d the weak r e l a t i o n s h i p and r e v e a l e d o n l y about 7% o f the t o t a l v a r i a b i l i t y o f the two d i s c r i m i n a n t f u n c t i o n s formed was a t t r i b u t a b l e t o group d i f f e r e n c e s (see Appendix H() . The t o t a l d i s c r i m i n a t o r y power o f the p r e d i c t o r b a t t e r y as a whole was v e r y weak. The R e l a t i o n s h i p o f Biodemographic V a r i a b l e s t o A t t i t u d e s , Knowledge, and P r a c t i c e B e f o r e e x a m i n i n g t h e mean a t t i t u d e , knowledge, and p r a c t i c e i n terms o f the biodemographic v a r i a b l e s l i s t e d i n T a b l e 20 ( w i t h t h e e x c e p t i o n o f p l a c e o f b i r t h ) , i t was n e c e s s a r y f i r s t t o t e s t t h e t e n a b i l i t y o f t h e a s s u m p t i o n o f h o m o g e n e i t y o f v a r i a n c e - c o v a r i a n c e f o r e a c h b i o d e m o g r a p h i c v a r i a b l e c o n s i d e r e d . Summary t a b l e s a n d a c c o m p a n y i n g d i s c u s s i o n a r e p r e s e n t e d i n A p p e n d i x I . B r i e f l y , t h e B a r t l e t t - B o x h o m o g e n e i t y t e s t r e v e a l e d t h a t t h i s a s s u m p t i o n was t e n a b l e f o r s i x o f t h e n i n e b i o d e m o - g r a p h i c v a r i a b l e s . F o r t h e r e m a i n i n g t h r e e , d e p a r t u r e s w e r e s u c h t h a t , g i v e n t h e r o b u s t n e s s o f t h e MANOVA ( O l s o n , 1974) a n d t h e l e v e l s o f s i g n i f i c a n c e a s s o c i a t e d w i t h t h e t e s t s , a n a l y s e s p r o c e e d e d w i t h t h e a s s u m p t i o n t h a t r e s u l t s o f t e s t s o f mean d i f f e r e n c e s w o u l d n o t be a d v e r s e l y i n f l u e n c e d . Means a n d s t a n d a r d d e v i a t i o n s o f a t t i t u d e , k n o w l e d g e , a n d p r a c t i c e s c o r e s f o r e a c h b i o d e m o g r a p h i c g r o u p a r e p r e s e n t e d i n A p p e n d i x J . T a b l e s t h a t s u m m a r i z e t h e r e s u l t s o f m u l t i v a r i a t e a n d u n i v a r i a t e a n a l y s i s o f v a r i a n c e f o r e a c h b i o d e m o g r a p h i c v a r i a b l e c o n s i d e r e d a r e p r e s e n t e d i n A p p e n d i x K. A g e R e s u l t s o f t h e m u l t i v a r i a t e a n a l y s i s o f v a r i a n c e f o r age s h o w e d t h a t s i g n i f i c a n t d i f f e r e n c e s w e r e f o u n d f o r a t t i t u d e s (F(4,554)=7.62; P< .05) , k n o w l e d g e (F(6,552=) = 3.03; P<.05), a n d p r a c t i c e (F(22,536)=3.6 l ; P<.05). The f o l l o w - u p u n i v a r i a t e t e s t s r e v e a l e d t h a t , f o r a t t i t u d e s , t h e y o u n g a n d m i d - a g e g r o u p s p o s s e s s e d a s i g n i f i c a n t l y (P<.05) more p o s i t i v e a t t i t u d e t o w a r d t h e g e n e r a l r o l e o f d i e t i n CVD (A:GEN ROLE) as c o m p a r e d t o t h e o l d e s t g r o u p (>50 y e a r s ) a n d t h a t t h e same t w o g r o u p s s c o r e d s i g n i f i c a n t l y (P<.05) h i g h e r o n t h e t e s t o f f a c t s v e r s u s f a l l a c y 155 (K:FACTS) than the o l d e s t group. I n the case of p r a c t i c e , the o l d e s t group was found to consume s i g n i f i c a n t l y (P<.05) higher amounts of FE (.87) than the young or mid-aged groups (.68 and .65, r e s p e c t i v e l y ) . However, a l l three groups were w i t h i n the a c c e p t a b l e range f o r t h i s n u t r i e n t . Gender The m u l t i v a r i a t e F r e s u l t s f o r gender were a l s o s i g n i f i c a n t f o r the three v a r i a b l e s : a t t i t u d e s (F(2,278)=8.8l; P<.05)» knowledge (F(3,277)=4.29; P<.05). and p r a c t i c e ( F ( l l , 2 6 9 ) = l ? . 9 7 ; P<.05)• U n i v a r i a t e analyses r e v e a l e d t h a t females possessed a s i g n i f i c a n t l y (P<.05) more p o s i t i v e a t t i t u d e toward both the g e n e r a l r o l e of d i e t i n CVD and the m a n i p u l a t i o n of d i e t to pro- mote heart h e a l t h (A:GEN ROLE, A:MANAGE) than males. In a d d i - t i o n , females were s i g n i f i c a n t l y (P<.05) more knowledgeable on a l l three knowledge s u b t e s t s than males. I n s p e c t i o n of the p r a c t i c e r e s u l t s of u n i v a r i a t e analyses showed the consumption of a number of n u t r i e n t s (KCAL, PROT, FE, RIBO, NIA, VC) d i f - f e r e d s i g n i f i c a n t l y (P<.05) between males and females. In a l l cases except FE, females scor e d higher than males. Again, how- ever, a l l mean scores f o r these s i x n u t r i e n t s were w i t h i n the acceptable range. L i v i n g Arrangement For l i v i n g arrangement, the m u l t i v a r i a t e a n a l y s i s of v a r i - ance r e s u l t s i n d i c a t e d no s i g n i f i c a n t (P<.05) d i f f e r e n c e s 156 "be tween a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e o f t h o s e who l i v e w i t h f a m i l y a n d t h o s e who do n o t . The t y p e o f l i v i n g a r r a n g e - m e n t a p p e a r e d n o t t o i n f l u e n c e p e o p l e s ' a t t i t u d e t o w a r d d i e t as a means o f p r o m o t i n g h e a r t h e a l t h a n d i n t e r v e n i n g a g a i n s t h e a r t d i s e a s e , k n o w l e d g e o f n u t r i t i o n r e l a t e d t o t h e h e a r t , n o r f o o d p r a c t i c e i n w h i c h t h e y e n g a g e d . I n s p e c t i o n o f t h e mean p r a c t i c e s c o r e s d i s c l o s e d t h a t a l l n u t r i e n t i n t a k e s w e r e w i t h i n t h e a c - c e p t a b l e r a n g e . F a m i l y H i s t o r y o f CVD T h e r e w e r e no s i g n i f i c a n t (P<.05) d i f f e r e n c e s b e t w e e n a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e o f r e s p o n d e n t s w i t h a p o s i - t i v e f a m i l y h i s t o r y o f CVD a n d t h o s e w i t h no f a m i l y h i s t o r y o f CVD. T h i s s u g g e s t s t h a t t h e p r e s e n c e o f f a m i l y p r o b l e m s w i t h CVD does n o t a c t as a d e t e r r e n t f o r t h e r e s t o f t h e f a m i l y - l e a d - i n g t o more p o s i t i v e a t t i t u d e s , g r e a t e r k n o w l e d g e , o r b e t t e r p r a c t i c e r e l a t e d t o CVD p r e v e n t i o n . P e r s o n a l H i s t o r y o f CVD A l t h o u g h m u l t i v a r i a t e F r a t i o s f o r p e r s o n a l h i s t o r y o f CVD w e r e s i g n i f i c a n t f o r a t t i t u d e s (F(2,267)=4.56; P<.05), k n o w l e d g e (F(3,266)=4.05; P<.05), a n d p r a c t i c e ( F ( l l ,258)=2 .12 ; P<.05), f o l l o w - u p a n a l y s i s w i t h i n s p e c t i o n o f means d i d n o t c l a r i f y t h e e f f e c t f o r a t t i t u d e s . S i n c e more c o n f i d e n c e c a n be p l a c e d i n t h e m u l t i v a r i a t e t e s t , t h e h y p o t h e s i s , t h a t t h e r e i s no s i g n i f - i c a n t d i f f e r e n c e i n a t t i t u d e s o f p e o p l e w i t h a p o s i t i v e p e r s o n a l h i s t o r y o f CVD a n d o t h e r s , was r e j e c t e d a t .05 l e v e l o f s i g n i f - i c a n c e . U n i v a r i a t e t e s t s i n d i c a t e d t h a t t h o s e w i t h a p o s i t i v e p e r - s o n a l h i s t o r y s c o r e d s i g n i f i c a n t l y (P<.05) h i g h e r o n g e n e r a l k n o w l e d g e o f how f o o d a f f e c t s t h e h e a r t h u t w e r e n o t s i g n i f i c a n t l y more k n o w l e d g e a b l e a b o u t f o o d c o m p o s i t i o n o r n u t r i t i o n f a c t s v e r s u s f a l l a c y t h a n t h e r e s t o f t h e s a m p l e . F o r p r a c t i c e , t h i s g r o u p ( p o s i t i v e p e r s o n a l h i s t o r y o f CVD) was f o u n d t o consume s i g n i f i c a n t l y (P<.05) h i g h e r a m o u n t s o f VC t h a n t h e o t h e r s , y e t , b o t h g r o u p s ' mean i n t a k e f o r VC was w i t h i n t h e a c c e p t a b l e r a n g e . P h y s i c a l E x e r c i s e P a t t e r n R e s u l t s o f t h e m u l t i v a r i a t e a n a l y s i s o f v a r i a n c e f o r p h y s - i c a l e x e r c i s e p a t t e r n r e v e a l e d s i g n i f i c a n t d i f f e r e n c e s o n l y f o r a t t i t u d e s (F(6,54-2)=2.86; P<.05). The f o l l o w - u p u n i v a r i a t e t e s t s i n d i c a t e d t h a t t h e s e d e n t a r y g r o u p h a d a s i g n i f i c a n t l y (P<.05) l e s s p o s i t i v e a t t i t u d e t o w a r d t h e g e n e r a l r o l e o f d i e t i n h e a r t d i s e a s e t h a n t h o s e who f o l l o w e d h i g h m o d e r a t e a n d v i g - o r o u s a c t i v i t y p a t t e r n s . The r e m a i n i n g g r o u p ( l o w m o d e r a t e ) d i d n o t d i f f e r s i g n i f i c a n t l y f r o m a n y o f t h e g r o u p s . O b e s i t y R i s k M u l t i v a r i a t e F r a t i o s f o r o b e s i t y r i s k i n d i c a t e d t h a t t h e r e w e r e no s i g n i f i c a n t (P<.05) d i f f e r e n c e s f o r a t t i t u d e s , k n o w l e d g e a n d p r a c t i c e . The d e g r e e o f r i s k f o r o b e s i t y a p p e a r e d n o t t o i n f l u e n c e p e o p l e s ' a t t i t u d e t o w a r d , k n o w l e d g e o f , o r p r a c t i c e r e g a r d i n g d i e t a n d CVD. 158 L e v e l o f E d u c a t i o n E x a m i n a t i o n o f t h e m u l t i v a r i a t e r e s u l t s f o r t h e i n d e p e n d e n t v a r i a b l e l e v e l o f e d u c a t i o n showed t h a t s i g n i f i c a n t d i f f e r e n c e s e x i s t e d among t h e g r o u p s f o r a t t i t u d e s (F(6,552)=4.12; P<.05), k n o w l e d g e (F(9,669)=2.08; P<.05), a n d p r a c t i c e (F(33»787)=1.92; P<.05)« F u r t h e r e x p l o r a t i o n r e v e a l e d t h a t t h o s e w i t h l e s s t h a n g r a d e 12 h a d s i g n i f i c a n t l y (P<.05) l e s s p o s i t i v e a t t i t u d e s t o - w a r d t h e g e n e r a l r o l e o f d i e t i n h e a r t d i s e a s e (A:GEN ROLE) t h a n a l l o t h e r g r o u p s ; a n d w e r e s i g n i f i c a n t l y (P<.05) l e s s i n - f o r m e d a b o u t f o o d c o m p o s i t i o n (KrCOMP) t h a n a l l o t h e r g r o u p s , as w e l l as s i g n i f i c a n t l y (P<.05) l e s s i n f o r m e d a b o u t n u t r i t i o n f a c t s v e r s u s f a l l a c y (K:FACTS) t h a n t h e one t o t h r e e y e a r u n i - v e r s i t y g r o u p . I n t e r m s o f p r a c t i c e , t h o s e w i t h l e s s t h a n g r a d e 12 r e p o r t e d s i g n i f i c a n t l y (P<.05) l e s s CA i n t a k e t h a n t h o s e w i t h f o u r o r more y e a r s o f u n i v e r s i t y ; l e s s T H I i n t a k e t h a n b o t h u n i v e r s i t y g r o u p s ; l e s s VC i n t a k e t h a n t h o s e w i t h g r a d e 12 a n d one t o t h r e e y e a r s o f u n i v e r s i t y ; a n d l e s s RIBO i n t a k e t h a n a l l g r o u p s . I t m u s t be e m p h a s i z e d t h a t a l l mean i n t a k e s f o r t h e f o u r e d u c a t i o n g r o u p s w e r e . w i t h i n t h e a c c e p t a b l e r a n g e . S m o k i n g H a b i t F o r t h e v a r i a b l e s m o k i n g h a b i t , m u l t i v a r i a t e r e s u l t s i n d i - c a t e d t h a t t h e r e w e r e no s i g n i f i c a n t (P<.05) d i f f e r e n c e s f o r a t t i t u d e s a n d k n o w l e d g e b u t a s i g n i f i c a n t d i f f e r e n c e was f o u n d f o r p r a c t i c e (F(33,725)=1.58; P<.05). U n i v a r i a t e t e s t s r e v e a l e d t h a t t h e n u t r i e n t CHO was t h e s o u r c e o f t h e e f f e c t , h o w e v e r , no p a i r w i s e c o m p a r i s o n was s i g n i f i c a n t f o r CHO u s i n g S c h e f f e " ' s S m e t h o d a t t h e .05 l e v e l o f s i g n i f i c a n c e . T h i s s u g g e s t e d a c o m - p l e x c o m p a r i s o n was r e s p o n s i b l e f o r t h e s i g n i f i c a n t e f f e c t . A summary o f t h e b i o d e m o g r a p h i c e f f e c t o n a t t i t u d e s , k n o w - l e d g e , a n d p r a c t i c e i s r e p o r t e d i n T a b l e 30. TABLE 30 Summary o f t h e B i o d e m o g r a p h i c V a r i a b l e s ' E f f e c t o n A t t i t u d e , K n o w l e d g e , a n d P r a c t i c e S c o r e s A t t i t u d e K n o w l e d g e P r a c t i c e Age s a S S G e n d e r S S S L i v i n g A r r a n g e m e n t N S b NS NS F a m i l y H i s t o r y o f CVD NS NS NS P e r s o n a l H i s t o r y o f CVD S S S P h y s i c a l E x e r c i s e P a t t e r n S NS NS O b e s i t y R i s k NS NS NS E d u c a t i o n L e v e l S S S S m o k i n g H a b i t NS NS S S : s i g n i f i c a n t a t P<.05. b NS: n o t s i g n i f i c a n t a t P<.05. E v a l u a t i o n o f t h e r e l a t i o n s h i p s b e t w e e n b i o d e m o g r a p h i c v a r i a b l e s a n d mean a t t i t u d e , k n o w l e d g e , a n d p r a c t i c e s c o r e s r e - v e a l e d t h a t t h e t y p e o f l i v i n g a r r a n g e m e n t , t h e p r e s e n c e o f a f a m i l y h i s t o r y o f CVD, a n d o n e ' s d e g r e e o f o b e s i t y r i s k h a d no a p p a r e n t i n f l u e n c e o n p e o p l e s ' a t t i t u d e s t o w a r d , k n o w l e d g e o f , 160 o r p r a c t i c e r e l a t e d t o d i e t a n d CVD. S m o k i n g h a b i t a l s o a p p e a r - ed t o h a v e no s i g n i f i c a n t e f f e c t o n p e o p l e s ' c a r d i o v a s c u l a r a t t i - t u d e a n d k n o w l e d g e b u t a s i g n i f i c a n t (P<.05) e f f e c t o n p r a c t i c e w h i c h was t r a c e d t o a c o m p l e x c o m p a r i s o n o f g r o u p s f o r t h e n u t r - i e n t CHO. F o r p h y s i c a l a c t i v i t y p a t t e r n , s e d e n t a r y p e o p l e h a d a s i g n i f i c a n t l y (P<.05) l e s s p o s i t i v e a t t i t u d e t o w a r d t h e g e n e r a l r o l e o f d i e t i n h e a r t d i s e a s e c o m p a r e d w i t h b o t h a c t i v e g r o u p s y e t , t h e a t t i t u d e f o r a l l g r o u p s r a n g e d f r o m 79 t o 86$ i n d i c a t - i n g t h a t t h e o v e r a l l a t t i t u d e was p o s i t i v e r e g a r d l e s s o f a c t i v - i t y p a t t e r n f o l l o w e d . The r e m a i n i n g , a g e , g e n d e r , p e r s o n a l h i s t o r y o f CVD, e d u c a - t i o n l e v e l , w e r e a l l f o u n d t o s i g n i f i c a n t l y (P<.05) i n f l u e n c e a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e . The o l d e s t g r o u p (>50 y e a r s ) h a d a s i g n i f i c a n t l y (P<.05) l e s s p o s i t i v e a t t i t u d e t o - w a r d t h e g e n e r a l r o l e o f d i e t i n CVD a n d w e r e s i g n i f i c a n t l y (P<;05) l e s s a b l e t o s e p a r a t e n u t r i t i o n f a c t s f r o m f a l l a c y t h a n t h e r e s t o f t h e s a m p l e . W h i l e t h e o l d e s t g r o u p d i d h a v e a s a t - i s f a c t o r y a t t i t u d e (78.9$ o f p o s s i b l e s c o r e ) , t h e mean p e r c e n t - age f o r t h e k n o w l e d g e t e s t was much more d e f i c i e n t f o r t h i s g r o u p ( 4 1 . 1 c o m p a r e d t o 4-9.5 a n d 52.7$), s u g g e s t i n g a g e n e r a l i n a b i l i t y t o s e p a r a t e n u t r i t i o n f a c t s t h a t a r e t r u e f r o m s t a t e - m e n t s t h a t a r e i n a c c u r a t e . T h i s l a t t e r f i n d i n g i s o f p a r t i c u l a r i n t e r e s t t o n u t r i t i o n e d u c a t o r s s i n c e n u t r i t i o n s o u r c e s o f q u e s t i o n a b l e v a l i d i t y a r e so p r e v a l e n t i n t h e p o p u l a r p r e s s . F e m a l e s w e r e f o u n d t o c o n s i s t e n t l y p o s s e s s m o r e p o s i t i v e a t t i t u d e s t o w a r d a n d be more k n o w l e d g e a b l e a b o u t d i e t a n d CVD than males. While the attitudes f o r Doth were quite p o s i t i v e , i n the case of knowledge scores, the mean percentages f o r males ranged from 43 to 48% compared with 50 to 54% for females, with the lower percentages f o r males and females i n the more s p e c i f i c knowledge areas i . e . , related to food composition and the a b i l - i t y to i d e n t i f y n u t r i t i o n f a c t s . For personal h i s t o r y of CVD, both those who responded i n the affirmative and others were found to have po s i t i v e a t t i - tudes (attaining 82 to 84.4% of the possible score) although the multivariate t e s t indicated a s i g n i f i c a n t (P<.05) difference existed between the two groups when the o v e r a l l attitude was considered. F i n a l l y , those with less than grade 12 education consist- ently reported less p o s i t i v e attitudes toward diet as a means of promoting heart health and intervening against heart disease than the remaining groups, yet, t h e i r mean score was 78% of the possible score, a quite p o s i t i v e value. Only knowledge re- lated to facts versus f a l l a c y was found to d i f f e r s i g n i f i c a n t l y (P<.05) between those with less than grade 12 and those with one to three years of university. Mean scores f o r the four groups ranged from 41 .5 to 51«4% of the possible score i n d i - cating a deficiency i n cardiovascular n u t r i t i o n knowledge i s not confined just to the less educated. In addition, a number of s i g n i f i c a n t (P<.05) practice scores were reported f o r age, gender, education l e v e l , personal history of CVD, and smoking habit. It should be stressed once more that, while differences between groups were s t a t i s t i c a l l y 162 s i g n i f i c a n t , i n s p e c t i o n showed t h a t a l l g r o u p mean s c o r e s w e r e w i t h i n t h e a c c e p t a b l e r a n g e f o r t h e n u t r i e n t s c o n c e r n e d . T h i s s u g g e s t s t h a t no p a r t i c u l a r b i o d e m o g r a p h i c g r o u p i n g i s c h a r a c - t e r i z e d b y e i t h e r a d e f i c i e n t o r e x c e s s i v e i n t a k e o f a n y o f t h e 11 n u t r i e n t s e x a m i n e d . CHAPTER V I SUMMARY AND IMPLICATIONS A b r i e f r e v i e w o f t h e s t u d y , i t s o b j e c t i v e s a n d m a j o r f i n d i n g s a r e p r e s e n t e d i n t h i s c h a p t e r . L i m i t a t i o n s o f t h e s t u d y a n d i m p l i c a t i o n s i n f e r r e d f r o m i n t e r p r e t a t i o n o f t h e f i n d i n g s , as w e l l as s u g g e s t i o n s f o r f u t u r e r e s e a r c h , a r e a l s o d i s c u s s e d . S ummary P u r p o s e T h i s a n a l y t i c a l s t u d y was d e s i g n e d t o i n v e s t i g a t e t h e n u t r t i o n a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e o f a d u l t members o f com m u n i t y c e n t r e s r e g a r d i n g d i e t a n d c a r d i o v a s c u l a r d i s e a s e ( C V D ) . The r e l a t i o n s h i p s among n u t r i t i o n a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e w e r e d e t e r m i n e d as w e l l as t h e i n f l u e n c e o f s p e c i f i c b i o d e m o g r a p h i c v a r i a b l e s o n t h e t h r e e d e p e n d e n t v a r i a b l e s ( a t t i t u d e s , k n o w l e d g e , p r a c t i c e ) . The i n d e p e n d e n t v a r i a b l e s , n o n - m a n i p u l a t i v e i n n a t u r e , w e r e : (1) a g e , (2) g e n d e r , (3) l i v i n g a r r a n g e m e n t , (4) f a m i l y h i s t o r y o f CVD, (5) p e r s o n a l h i s t o r y o f CVD, (6) p h y s i c a l e x e r c i s e p a t t e r n , (7) s m o k i n g h a b i t , (8) e d u - c a t i o n l e v e l , a n d (9) o b e s i t y r i s k . The i n v e s t i g a t i o n was e x p l o r a t o r y i n n a t u r e s i n c e l i m i t e d r e s e a r c h d a t a w e r e a v a i l - a b l e o n c a r d i o v a s c u l a r n u t r i t i o n a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e r e l a t i o n s h i p s o f f r e e - l i v i n g a d u l t s , p a r t i c u l a r l y i n t e r m s 164 o f t h e i n f l u e n c e o f b i o d e m o g r a p h i c v a r i a b l e s . P r o c e d u r e D a t a c o l l e c t i o n i n s t r u m e n t s w e r e d e v e l o p e d f o r t h i s s t u d y a n d i n c l u d e d : (1) a n a t t i t u d e i n s t r u m e n t c o m p o s e d o f t w o s u b - t e s t s (A:GEN ROLE, A:MANAGE), ( 2 ) a k n o w l e d g e i n s t r u m e n t i n - c o r p o r a t i n g t h r e e s u b t e s t s (K :AFFECTS, K:COMP, K : F A C T S ) , (3) a b i o d e m o g r a p h i c s e c t i o n , a n d (4) a p r a c t i c e i n s t r u m e n t . The a t t i - t u d e i n s t r u m e n t m e a s u r e d a t t i t u d e s t o w a r d d i e t as a means o f p r o m o t i n g h e a r t h e a l t h a n d i n t e r v e n i n g a g a i n s t h e a r t d i s e a s e . C o m p r e h e n s i o n o f b a s i c c o n c e p t s o f d i e t a n d h e a r t d i s e a s e was m e a s u r e d b y t h e k n o w l e d g e i n s t r u m e n t . The b i o d e m o g r a p h i c s e c - t i o n c o l l e c t e d d a t a o n t h e i n d e p e n d e n t v a r i a b l e s . F i n a l l y , t h e u s u a l i n t a k e o f e l e v e n s p e c i f i c n u t r i e n t s was e s t i m a t e d b y t h e p r a c t i c e i n s t r u m e n t a n d d e f i n e d as p r a c t i c e s c o r e s . A l l f o u r s e c t i o n s o f t h e d a t a c o l l e c t i o n i n s t r u m e n t w e r e c o m p l e t e d b y a l l p a r t i c i p a n t s . D u r i n g May a n d J u n e 1979, t h e i n v e s t i g a t o r d i s t r i b u t e d t h e v a l i d a t e d q u e s t i o n n a i r e , b y r a n d o m d a y , t o a d u l t members o f 1 1 c o m m u n i t y c e n t r e s i n t h e c i t y o f V a n c o u v e r . E a c h c e n t r e was r e p r e s e n t e d b y a r a n d o m s a m p l e o r b y v o l u n t e e r s i n a t t e n d a n c e a t e a c h c l a s s o n t h e c h o s e n d a y . C o m p l e t e d q u e s t i o n n a i r e s w e r e r e t u r n e d b y m a i l i n a d d r e s s e d , s t a m p e d e n v e l o p e s p r o v i d e d . The f i n a l s a m p l e s i z e was 2 8 1 , y i e l d i n g a n o v e r a l l r e s p o n s e r a t e o f 74.7% A n a l y s i s The a t t i t u d e , k n o w l e d g e , a n d p r a c t i c e i n s t r u m e n t s w e r e v a l i d a t e d a n d p r e t e s t e d i n t h e p i l o t s t u d y ( s e e C h a p t e r I I I ) . R e l i a b i l i t y o f t h e a t t i t u d e a n d k n o w l e d g e i n s t r u m e n t s was d e t e r - m i n e d u s i n g LERTAP ( N e l s o n , 197^). A c o n g r u e n c y c h e c k e m p l o y i n g a p a i r e d t t e s t was u s e d t o d e t e r m i n e t h e r e l i a b i l i t y o f t h e p r a c t i c e d a t a a n d a t e s t - r e t e s t p r o c e d u r e , t o d e t e r m i n e t h e r e l i a b i l i t y o f s e l e c t e d b i o d e m o g r a p h i c d a t a . A l l a n a l y s e s w e r e t e s t e d a t t h e .05 l e v e l o f s i g n i f i c a n c e . C o r r e l a t i o n a n a l y s i s was u s e d t o t e s t t h e h y p o t h e s e s r e g a r d i n g t h e r e l a t i o n s h i p s among a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e . P e a r s o n p r o d u c t - m o m e n t c o r r e l a t i o n s w e r e c o m p u t e d f o r a l l p a i r s o f t h e t h r e e v a r i a b l e s . F u r t h e r a n a l y s i s t o t e s t t w o c a u s a l m o d e l s b y p a t h a n a l y s i s was j u d g e d i n a p p r o p r i a t e . The r e m a i n i n g n u l l h y p o t h e s e s r e g a r d i n g t h e i n f l u e n c e o f b i o d e m o g r a p h i c v a r i - a b l e s o n a t t i t u d e s , k n o w l e d g e , a n d p r a c t i c e w e r e t e s t e d b y o n e - way m u l t i v a r i a t e a n a l y s i s o f v a r i a n c e . Any s i g n i f i c a n t e f f e c t was f o l l o w e d b y u n i v a r i a t e a n a l y s i s o f v a r i a n c e , a n d t h e s o u r c e o f t h e e f f e c t . . w a s t h e n d e t e r m i n e d b y S c h e f f e " ' s S m e t h o d ( K i r k , 1968) . P s y c h o m e t r i c P r o p e r t i e s o f t h e I n s t r u m e n t s The mean s c o r e s f o r t h e a t t i t u d e s u b t e s t s a n d t o t a l t e s t (A :GEN ROLE, A:MANAGE, A : T O T A L ) w e r e q u i t e h i g h (83% o f t h e p o s s i b l e s c o r e ) w i t h s t a n d a r d d e v i a t i o n s r e p r e s e n t i n g 8-9% o f t h e p o s s i b l e s c o r e . The mean s c o r e s f o r t h e k n o w l e d g e s u b t e s t s a n d t o t a l t e s t ( K : AFFECTS', K-.COMP, K :FACTS, K: TOTAL) r e v e a l e d t e s t s of medium d i f f i c u l t y w i t h mean percents ranging from 4-8 to 53$ and standard d e v i a t i o n s r a n g i n g from 12 to 17$ of the p o s s i b l e s c o r e . K u r t o s i s and skewness values f o r both a t t i t u d e and knowledge s u b t e s t s and t o t a l t e s t s supported no marked de- p a r t u r e from a normal d i s t r i b u t i o n . R e l i a b i l i t y of the a t t i t u d e and knowledge instruments was co n s i d e r e d adequate f o r the purpose of t h i s study w i t h i n t e r n a l c o n s i s t e n c y r e l i a b i l i t y c o e f f i c i e n t s (Hoyt, 1941) f o r the sub- t e s t s of .73, .67, .45, .64 , and .62, r e s p e c t i v e l y . The r e l i - a b i l i t y of the p r a c t i c e instrument was determined by a congru- ency check of the data c o l l e c t e d by q u e s t i o n n a i r e and by i n t e r - view on a subsample of the survey respondents. As a r e s u l t of a p a i r e d t t e s t , the n u l l hypothesis t h a t the mean d i f f e r e n c e was zero between the p r a c t i c e scores c o l l e c t e d by q u e s t i o n n a i r e and by i n t e r v i e w was not r e j e c t e d . A t e s t - r e t e s t procedure determined the r e l i a b i l i t y of s e l e c t e d biodemographic data and r e s u l t e d i n c o r r e l a t i o n s r a n g i n g from .58 to 1.0. R e s u l t s No s i g n i f i c a n t d i f f e r e n c e was found between e a r l y and l a t e respondents* mean a t t i t u d e , knowledge, and p r a c t i c e s c o r e s , so the data were pooled and the a n a l y s i s conducted w i t h the t o t a l sample from each c e n t r e . P r e l i m i n a r y a n a l y s i s r e v e a l e d t h a t data c o u l d be c o l l a p s e d across community c e n t r e s . The major f i n d i n g s of t h i s study.were: 167 A t t i t u d e s The r e s p o n d e n t s ' a t t i t u d e s w e r e c o n s i s t e n t l y p o s i t i v e t o - w a r d s d i e t as a means o f p r o m o t i n g h e a r t h e a l t h a n d i n t e r v e n i n g a g a i n s t h e a r t d i s e a s e . K n o w l e d g e R e s p o n d e n t s ' c o m p r e h e n s i o n o f b a s i c c o n c e p t s o f d i e t a n d CVD was f o u n d t o be more d i v e r s e . O v e r 8 0 $ o f t h e s a m p l e c o u l d c o r r e c t l y a n s w e r i t e m s r e l a t e d t o b o d y w e i g h t a n d n u t r i e n t c o m - p o s i t i o n o f m e a t , f i s h , p o u l t r y , f r u i t s , e g g s , a n d a l c o h o l . A r e a s o f i n a d e q u a t e c o m p r e h e n s i o n w e r e r e l a t e d t o f a t , c h o l e s - t e r o l , a n d n u t r i e n t c o m p o s i t i o n o f s p e c i f i c p r o d u c t s s u c h as f o o d s u b s t i t u t e s a n d o i l s . O v e r a l l , t h e m o s t d i f f i c u l t i t e m c o n c e r n e d p o l y u n s a t u r a t e d f a t t y a c i d s ( P U F A ) . A g a i n , o v e r 8 0 $ o f t h e r e s p o n d e n t s c h o s e t h e i n c o r r e c t o p t i o n f o r t h e i t e m r e - l a t e d t o t h e a p p l i c a t i o n o f t h e c o n c e p t " i s m o r e b e t t e r ? " t o t h e u s e o f PUFA. A b i l i t y t o d i f f e r e n t i a t e n u t r i t i o n f a c t s f r o m f a l l a c i e s was v e r y p o o r as e x e m p l i f i e d b y r e s p o n s e s t o i t e m s a t t r i b u t i n g s p e c i a l b e n e f i t s f r o m g a r l i c , l e c i t h i n , h a r d w a t e r , o r v i t a m i n C. I n c o n t r a s t , r e s p o n s e s t o i t e m s r e l a t i n g f a m i l y h i s t o r y , b o d y w e i g h t , o r e x e r c i s e t o CVD i n d i c a t e d g o o d k n o w l e d g e i n t h e s e a r e a s . P r a c t i c e Mean v a l u e s f o r n i n e o f t h e 1 1 n u t r i e n t s e x a m i n e d w e r e 168 e q u a l t o o r e x c e e d e d t h e r e c o m m e n d e d v a l u e s o f t h e C a n a d i a n D i e t a r y S t a n d a r d (CDS) o r N u t r i t i o n R e c o m m e n d a t i o n s f o r C a n a d - i a n s ( N R C ) . K i l o c a l o r i e s a n d c a r b o h y d r a t e i n t a k e s , w h i l e l e s s t h a n r e c o m m e n d e d v a l u e s , w e r e w i t h i n a c c e p t a b l e l i m i t s . The l a t t e r , c a r b o h y d r a t e , r e p r e s e n t e d 42 .5% o f "the e n e r g y c o n s u m e d c o m p a r e d t o t h e s u g g e s t e d 50%, a n d was somewha t l o w e r t h a n t h e n a t i o n a l a v e r a g e r e p o r t e d b y N u t r i t i o n Canada ( C a n a d a , 1976a). A l t h o u g h no m o r e t h a n 35% o f t o t a l c a l o r i e s as f a t i s r e c - ommended, f a t i n t a k e i n e x c e s s o f 46% o f t h e t o t a l e n e r g y was r e p o r t e d b y 15-3% o f t h e s a m p l e . The mean f o r t h e s a m p l e (39%) was s i m i l a r t o t h a t o f t h e n a t i o n a l a v e r a g e as r e p o r t e d b y N u t r i t i o n C a n a d a . O n l y 5.7% o f t h e s a m p l e r e p o r t e d e n e r g y i n - t a k e i n e x c e s s (133% o f t h e CDS) w h i l e n e a r l y 25% o f t h e s a m p l e r e p o r t e d d e f i c i e n t ( l e s s t h a n 67% o f CDS) i r o n i n t a k e a n d a b o u t 16%, d e f i c i e n t i n t a k e o f t h i a m i n a n d c a l c i u m . R e l a t i o n s h i p s among a t t i t u d e s , k n o w l e d g e , a n d - p r a c t i c e W h i l e t h e c o r r e l a t i o n b e t w e e n a t t i t u d e s a n d k n o w l e d g e r e - l a t e d t o d i e t a n d CVD was m o d e r a t e ( r a n g e .38 t o .56), t h e c o r - r e l a t i o n b e t w e e n p r a c t i c e a n d b o t h a t t i t u d e s a n d k n o w l e d g e was weak ( r a n g e f r o m .00 t o .24). B i o d e m o g r a p h i c v a r i a b l e s No e f f e c t . T y p e o f l i v i n g a r r a n g e m e n t , d e g r e e o f o b e s i t y r i s k , a n d p o s i t i v e f a m i l y h i s t o r y o f CVD d i d n o t a p p e a r t o i n - f l u e n c e a t t i t u d e s , k n o w l e d g e , o r p r a c t i c e . I n a d d i t i o n , t h o s e 1 6 9 w i t h v a r y i n g s m o k i n g h a b i t s d i d n o t d i f f e r s i g n i f i c a n t l y i n a t t i t u d e s o r k n o w l e d g e . A t t i t u d e a n d k n o w l e d g e e f f e c t . A p o s i t i v e p e r s o n a l h i s t o r y o f CVD a p p e a r e d t o i n f l u e n c e a t t i t u d e s t o w a r d d i e t as a means o f p r o m o t i n g h e a r t h e a l t h a n d i n t e r v e n i n g a g a i n s t h e a r t d i s e a s e . T h o s e w i t h a p o s i t i v e p e r s o n a l h i s t o r y a l s o p e r f o r m e d s i g n i f - i c a n t l y b e t t e r o n t h e k n o w l e d g e s u b t e s t a b o u t t h e a f f e c t o f f o o d ( K : A F F E C T S ) . No s i g n i f i c a n t d i f f e r e n c e s w e r e n o t e d b e t w e e n t h e p e r f o r m a n c e o f t h o s e w i t h a n d w i t h o u t a p o s i t i v e p e r s o n a l h i s - t o r y o n s u b t e s t s r e l a t e d t o more s p e c i f i c k n o w l e d g e , n a m e l y , f o o d c o m p o s i t i o n a n d f a c t s v e r s u s f a l l a c y . Those who w e r e y o u n g o r m i d - a g e d h a d a s i g n i f i c a n t l y m o r e p o s i t i v e a t t i t u d e t o w a r d t h e r o l e o f d i e t i n h e a r t d i s e a s e , a n d w e r e s i g n i f i c a n t l y b e t t e r i n f o r m e d a b o u t f a c t s v e r s u s f a l l a c y t h a n t h o s e who w e r e o l d - a g e d . F e m a l e s w e r e a l s o . f o u n d c o n s i s t - e n t l y t o h a v e s i g n i f i c a n t l y more p o s i t i v e a t t i t u d e s a n d t o be s i g n i f i c a n t l y more i n f o r m e d a b o u t d i e t a n d CVD t h a n w e r e m a l e s . I n t e r m s o f e d u c a t i o n l e v e l , t h o s e w i t h l e s s t h a n 1 2 y e a r s o f e d u c a t i o n h a d s i g n i f i c a n t l y l e s s p o s i t i v e a t t i t u d e s t o w a r d t h e r o l e o f d i e t i n h e a r t d i s e a s e , a n d w e r e s i g n i f i c a n t l y l e s s k n o w l e d g e a b l e a b o u t f o o d c o m p o s i t i o n t h a n a l l o t h e r e d u c a t i o n g r o u p s . T h o s e w i t h one t o t h r e e y e a r s o f u n i v e r s i t y s c o r e d s i g n i f i c a n t l y h i g h e r o n t h e s u b t e s t f a c t s v e r s u s f a l l a c y t h a n t h o s e w i t h l e s s t h a n g r a d e 1 2 ; h o w e v e r , t h e r e was no s i g n i f i c a n t d i f f e r e n c e b e t w e e n a n y o t h e r p a i r w i s e c o m b i n a t i o n o f e d u c a t i o n g r o u p s f o r t h i s s u b t e s t . 170 A t t i t u d e e f f e c t . Those w i t h v a r y i n g p h y s i c a l e x e r c i s e p a t t e r n s d i d n o t d i f f e r i n k n o w l e d g e o r p r a c t i c e h u t t h e s e d e n - t a r y g r o u p was f o u n d t o h a v e a s i g n i f i c a n t l y l e s s p o s i t i v e a t t i - t u d e t o w a r d t h e r o l e o f d i e t i n h e a r t d i s e a s e t h a n t h o s e who r e g u l a r l y f o l l o w e d . a h i g h m o d e r a t e o r v i g o r o u s a c t i v i t y p a t t e r n . P r a c t i c e e f f e c t . W h i l e a n u m b e r o f d i f f e r e n c e s w e r e f o u n d t o be s i g n i f i c a n t w h e n t h e p r a c t i c e s c o r e s o f t h e d i f f e r e n t b i o - d e m o g r a p h i c g r o u p s ( a g e , g e n d e r , p e r s o n a l h i s t o r y o f CVD, e d u c a - t i o n l e v e l , a n d s m o k i n g h a b i t ) w e r e e x a m i n e d , no p a r t i c u l a r g r o u p was c h a r a c t e r i z e d b y a d e f i c i e n t o r e x c e s s i n t a k e o f a n y o f t h e 11 n u t r i e n t s e x a m i n e d . T h a t i s , a l l b i o d e m o g r a p h i c g r o u p s c o n s u m e d i n t a k e s w i t h i n t h e r a n g e c o n s i d e r e d a c c e p t a b l e f o r t h i s s t u d y . L i m i t a t i o n s The s t u d y was c o n d u c t e d w i t h a d u l t s o n l y , a g e d 19 y e a r s o r o v e r , i n M e t r o p o l i t a n V a n c o u v e r a n d was r e s t r i c t e d t o members o f 11 c o m m u n i t y c e n t r e s . No a t t e m p t was made t o a s s e s s r e s i d e n t s o f r u r a l o r s m a l l e r u r b a n a r e a s , o r a d u l t s who w e r e n o t c o m - m u n i t y c e n t r e m e m b e r s . T h i s r e s t r i c t e d s a m p l e may a c c o u n t f o r t h e l a c k o f v a r i a b i l i t y among b i o d e m o g r a p h i c s u b g r o u p s , i n p a r t i c u l a r r e g a r d i n g p r a c t i c e s c o r e s . Due t o c i r c u m s t a n c e s b e y o n d t h e c o n t r o l o f t h e i n v e s t i - g a t o r , r a n d o m s a m p l i n g was n o t f e a s i b l e f o r a l l c e n t r e s , r e - s u l t i n g i n t h e m a j o r i t y o f t h e p a r t i c i p a n t s b e i n g . v o l u n t e e r s * , ; . • 171 A l t h o u g h t h e r e s p o n s e r a t e was h i g h (74.7%), t h e n o n - r e s p o n d e n t s w e r e n o t c h e c k e d f o r p o s s i b l e n o n r e s p o n s e b i a s . I m p l i c a t i o n s S e v e r a l i m p l i c a t i o n s c a n be i n f e r r e d f r o m i n t e r p r e t a t i o n o f t h e r e s u l t s . The f i n d i n g s t h a t a t t i t u d e a n d k n o w l e d g e w e r e m o d - e r a t e l y c o r r e l a t e d b u t t h a t t h e c o r r e l a t i o n b e t w e e n p r a c t i c e a n d b o t h a t t i t u d e s a n d k n o w l e d g e 'was weak p r o v i d e s u p p o r t f o r t h e r e - l a t i o n s h i p o f a t t i t u d e s a n d k n o w l e d g e b u t does n o t s u p p o r t a d i - r e c t r e l a t i o n s h i p b e t w e e n p r a c t i c e a n d e i t h e r a t t i t u d e s o r k n o w - l e d g e . The l a t t e r f i n d i n g may be e x p l a i n e d b y t w o r e a s o n s : (1) d e f i c i e n c i e s i n t h e m e a s u r e m e n t i n s t r u m e n t s , o r (2) t h e r e i s no d i r e c t r e l a t i o n s h i p b e t w e e n c a r d i o v a s c u l a r n u t r i t i o n p r a c t i c e a n d e i t h e r a t t i t u d e s o r k n o w l e d g e . W i t h r e s p e c t t o t h e m e a s u r e m e n t i n s t r u m e n t s , a n o p e r a t i o n a l d e f i n i t i o n o f n u t r i t i o n a l p r a c t i c e l i m i t e d t o d i e t a r y r i s k f a c t o r s f o r CVD may h a v e b e e n more s u i t - a b l e . S i m i l a r l y , a r e s p o n s e f o r m a t f o r t h e k n o w l e d g e i n s t r u m e n t o t h e r t h a n t h a t e m p l o y e d i n t h e s t u d y may h a v e i m p r o v e d t h e r e - s u l t s . S i n c e t h e s a m p l e as a w h o l e r e p o r t e d p o s i t i v e a t t i t u d e s t o w a r d t h e r o l e o f d i e t i n CVD' p r e v e n t i o n y e t t h e s e a t t i t u d e s w e r e o n l y w e a k l y c o r r e l a t e d w i t h c a r d i o v a s c u l a r n u t r i t i o n p r a c - t i c e , t h i s w o u l d s u g g e s t t h e r e i s no d i r e c t r e l a t i o n s h i p b e - t w e e n c a r d i o v a s c u l a r n u t r i t i o n a t t i t u d e s a n d p r a c t i c e . I n t h e c a s e o f k n o w l e d g e , t h e ' m e a n s c o r e s f o r e a c h s u b t e s t w e r e a b o u t 50% o f t h e p o s s i b l e s c o r e . T h u s , f a i l u r e t o s u p p o r t a d i r e c t r e l a t i o n s h i p b e t w e e n c a r d i o v a s c u l a r p r a c t i c e a n d k n o w l e d g e may be t h e r e s u l t o f i n s u f f i c i e n t k n o w l e d g e o n t h e p a r t o f t h e 172 r e s p o n d e n t s a n d t h e r e f o r e i n a b i l i t y t o a p p l y k n o w l e d g e t o t h e i r p r a c t i c e . I f i n d e e d t h i s i s t h e c a s e , a n i m p r o v e m e n t i n c a r d i o - v a s c u l a r n u t r i t i o n k n o w l e d g e s h o u l d be r e f l e c t e d i n a n i m p r o v e - m e n t i n p r a c t i c e , w i t h a n a c c o m p a n y i n g i m p r o v e m e n t i n t h e c o r r e l a t i o n b e t w e e n t h e t w o . D e s p i t e f a i l u r e o f t h e s e f i n d i n g s t o s u p p o r t t h e c o n s i s t e n c y m o d e l (KAP m o d e l ) , r e s u l t s o f i t e m a n a l y s i s s u g g e s t e d a n e e d t o d e v e l o p c a r d i o v a s c u l a r n u t r i t i o n e d u c a t i o n p r o g r a m s f o r t h e g e n - e r a l p u b l i c w h i c h w o u l d p r o m o t e d i e t a r y m o d i f i c a t i o n . The f i n d - i n g s e m p h a s i z e n e e d f o r s p e c i f i c t o p i c s o f i n f o r m a t i o n i n c l u d i n g : 1. The m e a n i n g o f t e r m s s u c h as PUFA a n d l i n o l e i c a c i d . O v e r 75$ o f t h e r e s p o n d e n t s i n d i c a t e d t h a t t h e y d i d n o t know w h a t PUFA w a s . T h i s w o u l d h a v e t o be c l a r i f i e d b e f o r e t y p e s o f f a t s c o u l d be d i s c u s s e d o r m o d i f i c a t i o n o f d i e t i m p l e m e n t e d . 2. B a s i c n u t r i t i o n i n f o r m a t i o n o n t h e r o l e o f f a t , c h o l e s - t e r o l , a n d s a l t i n h e a r t d i s e a s e . T h i s s h o u l d i n c l u d e t h e c o n c e p t o f r i s k f a c t o r s , t h e r a t i o n a l e f o r t h e r e c o m m e n d a t i o n s r e g a r d i n g f a t a n d c h o l e s t e r o l , as w e l l a s i n f o r m a t i o n c o n c e r n i n g t h e u s e o f f a t . 3. C o m p o s i t i o n o f f o o d s , e s p e c i a l l y t h o s e r e l a t e d t o f a t , c h o l e s t e r o l , p r o t e i n , a n d c a r b o h y d r a t e . The r e p o r t e d h i g h p r o t e i n i n t a k e (1.76 o f C D S ) , f a t i n t a k e (4-0% o f t o t a l e n e r g y ) , a n d l e s s t h a n CDS a n d NRC r e c o m m e n d e d e n e r g y a n d c a r b o h y d r a t e i n t a k e s , r e s p e c t i v e l y , s u g g e s t t h e n e e d t o e m p h a s i z e p o s s i b l e h i d d e n f a t i n f o o d , p a r t i c u l a r l y " p r o t e i n f o o d s " , a n d t o i n t r o d u c e a p p r o - p r i a t e c h a n g e s i n t h e d i e t so t h a t r e d u c t i o n o f f a t i s a c c o m p a n i e d b y i n c r e a s e s i n c o m p l e x c a r b o h y d r a t e s t o m e e t t h e e n e r g y r e q u i r e m e n t s . I n f o r m a t i o n o n t h e c o m - p o s i t i o n o f n e w e r f o o d p r o d u c t s s u c h as f o o d s u b s t i t u t e s a n d t h e v a r i o u s o i l s was e m p h a s i z e d b y t h e i n a b i l i t y o f many r e s p o n d e n t s t o i d e n t i f y c o n s t i t u e n t s o f n o n - d a i r y c r e a m s u b s t i t u t e s o r d i f f e r e n t i a t e b e t w e e n o i l s . 4 . M i s c o n c e p t i o n s r e g a r d i n g s p e c i a l a t t r i b u t e s o f f o o d s a n d n u t r i e n t s . The n e e d f o r i n c l u s i o n o f t h i s a r e a o f i n - f o r m a t i o n i s e x e m p l i f i e d b y t h e a c c e p t a n c e o f g a r l i c , l e c i t h i n , a n d v i t a m i n C as p r o t e c t o r s a g a i n s t h e a r t d i s e a s e a n d o f h a r d w a t e r as a c a u s e o f h e a r t d i s e a s e . 5. F i n a l l y , a p p l i c a t i o n o f t h e a b o v e t o p i c s o f i n f o r m a t i o n i n t e r m s o f f o o d s e l e c t i o n . The a b i l i t y t o r e c i t e f a c t s r e l a t e d t o CVD i s o f no b e n e f i t u n l e s s i n f o r m a t i o n i s a l s o p r o v i d e d f o r t h e p r a c t i c a l a p p l i c a t i o n o f t h e i n - f o r m a t i o n t o d a i l y l i v i n g . I n t e r m s o f CVD p r e v e n t i o n , t h i s i n v o l v e s i n f o r m a t i o n o n how t o m o d i f y t h e p r e s e n t d i e t so t h a t t h e g u i d e l i n e s a r e i m p l e m e n t e d y e t t h e p e r s o n a l p r e f e r e n c e s o f t h e i n d i v i d u a l a r e r e c o g n i z e d a n d u t i l i z e d i n t h e m o s t a c c e p t a b l e m a n n e r . The f i n d i n g s f u r t h e r s u g g e s t t h a t t h e t a r g e t o f t h e p r o - g r a m s s h o u l d be t h e m a l e a u d i e n c e , s i n c e m a l e s a r e a t g r e a t e r r i s k t h a n f e m a l e s a n d w e r e f o u n d t o c o n s i s t e n t l y s c o r e s i g n i f - i c a n t l y l o w e r t h a n f e m a l e s o n a l l t h r e e k n o w l e d g e s u b t e s t s . 174 However, the f a c t t h a t the average percentage f o r both groups was 45 and 52%, r e s p e c t i v e l y , i n d i c a t e s need to reach the f e - male audience as w e l l . One method may be the e d u c a t i o n system i n i t s e n t i r e t y , i n c l u d i n g : primary, grade s c h o o l , h i g h s c h o o l , c o l l e g e , t r a d e , or u n i v e r s i t y , and c o n t i n u a t i o n s c h o o l , s i n c e poor performance was observed a c r o s s a l l e d u c a t i o n l e v e l s and a l l age groups, without e x c e p t i o n . Three major channels f o r d i s s e m i n a t i o n of c a r d i o v a s c u l a r n u t r i t i o n i n f o r m a t i o n were suggested by the study: (1) mass media, (2) d o c t o r s , and (3) f a m i l y and f r i e n d s . The p r i n c i p l e source of i n f o r m a t i o n on d i e t and heart d i s e a s e r e p o r t e d i n the study was mass media w i t h the main focus on magazines, books, newspapers, and t e l e v i s i o n . While these f o u r sources have been used f o r n u t r i t i o n e d u c a t i o n i n the past, u t i l i z a t i o n of t h e i r f u l l p o t e n t i a l may suggest a need f o r a m u l t i - d i s c i p l i n a r y approach to the development of f u t u r e c a r d i o v a s c u l a r n u t r i t i o n e d u c a t i o n programs. N u t r i t i o n educators working w i t h communi- c a t i o n experts may be able to devise a more e f f e c t i v e message f o r the g e n e r a l p u b l i c . A combination of sources would allow the reinf o rcement of the c e n t r a l theme i n more economical terms as w e l l as r e a c h those who do not come i n c o n t a c t w i t h a v a r i e t y of sources but r a t h e r r e s t r i c t themselves to s p e c i f i c forms of the mass media. I f the doctor, f a m i l y , and f r i e n d s are to be e f f e c t i v e , i n f o r m a t i o n s e r v i c e s t h a t provide the l a t e s t i n f o r m a t i o n must be e s t a b l i s h e d , i f they do not e x i s t ; or be promoted, i f they do e x i s t but are not e f f i c i e n t l y u t i l i z e d . T h i s l a t t e r p o i n t i n d i c a t e s a need to assess the present i n f o r m a t i o n s e r v i c e s f o r 175 the general public so that recommendations for t h e i r operation at f u l l p o t e n t i a l may be formulated and implemented. Future Research Results and implications of the study suggest several areas fo r future research: 1. Research should be undertaken to investigate the e f f e c t of a cardiovascular n u t r i t i o n education program on attitudes, knowledge, and practice of a large group of adults. Ran- dom assignment to experimental and control groups who are exposed or not exposed to the program, respectively, and the use of a pretest-posttest design should determine i f change has occurred and how much can be attributed to the pretesting or to the program. Such a study should provide valuable insight into the relationships among cardiovascu- l a r n u t r i t i o n attitudes, knowledge, and practice, i n pa r t i c u l a r , i f an improvement i n knowledge i s associated with an improvement i n practi c e . 2. Since the present study was r e s t r i c t e d to adult members / of community centres, further i n v e s t i g a t i o n of the public appears warranted. A study i n which the questionnaire i s distr i b u t e d to a large, random sample of adults who are not members of community centres i s desirable. The re- sul t s would establish the r e l i a b i l i t y of the instruments for assessing cardiovascular n u t r i t i o n attitudes, know- ledge, and practice of the general public. 3. Differences between groups based on the i r cardiovascular dietary practice should be investigated. A study using large groups of adults who are characterized as low f a t 176 o r h i g h f a t c o n s u m e r s s h o u l d be c o n d u c t e d t o d e t e r m i n e p o s s i b l e a t t i t u d e s a n d k n o w l e d g e d i f f e r e n c e s b e t w e e n t h e s e p r a c t i c e g r o u p s . P r i o r s c r e e n i n g t o e s t a b l i s h g r o u p m e m b e r s h i p i s n e c e s s a r y b e f o r e t h e q u e s t i o n n a i r e i s d i s t r i b u t e d . R e s u l t s s h o u l d r e v e a l t h e d i s c r i m i n a - t o r y p o w e r o f t h e a t t i t u d e a n d k n o w l e d g e i n s t r u m e n t s . I f t h e p o w e r i s a d e q u a t e , f u t u r e u s e o f t h e a t t i t u d e a n d k n o w l e d g e i n s t r u m e n t s a l o n e w o u l d p e r m i t a more e c o n o m - i c a l a n d l e s s t i m e c o n s u m i n g a s s e s s m e n t o f d i f f e r e n t g r o u p s i n t h e g e n e r a l p o p u l a t i o n . A s t u d y t o a s s e s s t h e f o o d p r a c t i c e o f a l a r g e n u m b e r o f a d u l t s w i t h s p e c i f i c e m p h a s i s o n f a t i n t a k e , i t s c o m p o s - i t i o n , a n d a n y a s s o c i a t e d p r a c t i c e t h a t m i g h t be m o d i f i e d t o r e d u c e CVD r i s k s h o u l d be u n d e r t a k e n . 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F o o d i d e o l o g y s y s t e m s as c o n d i t i o n e r s o f n u t r i t i o n a l p r a c t i c e s . A r c h i v o s L a t i n o a m e r i c a n o s de N u t r i c i o n , 1974, 24, 47-64. S c h w a r t z , N . E . The r e l a t i o n s h i p o f n u t r i t i o n e d u c a t i o n t o s u b - s e q u e n t n u t r i t i o n k n o w l e d g e , a t t i t u d e s , a n d p r a c t i c e s o f O h i o h i g h s c h o o l g r a d u a t e s . U n p u b l i s h e d d o c t o r a l d i s s e r t a - t i o n , O h i o S t a t e U n i v e r s i t y , 1973* S c h w a r t z , N . E . N u t r i t i o n k n o w l e d g e , a t t i t u d e s , a n d p r a c t i c e s o f h i g h s c h o o l g r a d u a t e s . J o u r n a l o f t h e A m e r i c a n D i e t e t i c A s s o c i a t i o n , 1975, 66, 28-31. S c h w a r t z , N . E . N u t r i t i o n k n o w l e d g e , a t t i t u d e s , a n d p r a c t i c e s o f C a n a d i a n p u b l i c h e a l t h n u r s e s . 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J o u r n a l o f t h e A m e r i c a n M e d i c a l A s s o c i a t i o n , 1978, glw, 75^-75%. S h e r w i n , R. The e p i d e m i o l o g y o f a t h e r o s c l e r o s i s a n d c o r o n a r y h e a r t d i s e a s e . P o s t g r a d u a t e M e d i c i n e , 1974, j_6, 81-88. S i m s , L . S . D e m o g r a p h i c a n d a t t i t u d i n a l c o r r e l a t e s o f n u t r i t i o n k n o w l e d g e . J o u r n a l o f N u t r i t i o n E d u c a t i o n , 1976, 8, 122-125. S i m s , L . S . D i e t a r y s t a t u s o f l a c t a t i n g w o m e n . I . N u t r i e n t i n t a k e f r o m f o o d a n d f r o m s u p p l e m e n t s . J o u r n a l o f t h e A m e r i c a n D i e t e t i c A s s o c i a t i o n , 1978a, 73~i 139-146. S i m s , L . S . D i e t a r y s t a t u s o f l a c t a t i n g w o m e n . I I . R e l a t i o n o f n u t r i t i o n k n o w l e d g e a n d a t t i t u d e s t o n u t r i e n t i n t a k e . J o u r n a l o f t h e A m e r i c a n D i e t e t i c A s s o c i a t i o n , 1978b, 73, 147-154. S t a n l e y , J . C . , & H o p k i n s , K . D . E d u c a t i o n a l a n d p s y c h o l o g i c a l m e a s u r e m e n t a n d e v a l u a t i o n . T o r o n t o : P r e n t i c e - H a l l o f C a n a d a L t d . , 1972. S t a t i s t i c a l R e s e a r c h L a b o r a t o r y , U n i v e r s i t y o f M i c h i g a n . E l e m e n t a r y s t a t i s t i c s u s i n g MIDAS (2nd e d . ) . U n i v e r s i t y o f M i c h - i g a n : S t a t i s t i c a l R e s e a r c h L a b o r a t o r y , 1976. S t e r n , M . P . , F a r q u h a r , J . W . , M a c c o b y , N . , & R u s s e l , S . H . R e - s u l t s o f a t w o - y e a r h e a l t h e d u c a t i o n c a m p a i g n o n d i e t a r y b e h a v i o u r - t h e S t a n f o r d t h r e e c o m m u n i t y s t u d y . C i r c u l a t i o n , 1976, 826-833. S t e u a r t , G.W. The p e o p l e : M o t i v a t i o n , e d u c a t i o n , a n d a c t i o n . B u l l e t i n New Y o r k Academy o f M e d i c i n e , 1975, i l , 174-185. Swanson, J . C . S e c o n d t h o u g h t s o n k n o w l e d g e a n d a t t i t u d e e f f e c t s u p o n b e h a v i o u r . J o u r n a l o f S c h o o l H e a l t h , 1972, 42, 363-365. T a t s u o k a , M . M . D i s c r i m i n a n t a n a l y s i s : The s t u d y o f g r o u p d i f - f e r e n c e s . C h a m p a i g n , 111.: I n s t i t u t e f o r P e r s o n a l i t y a n d A b i l i t y T e s t i n g , 1970. T h o m a s , A . E . , M c K a y , D . A . , & C u t l i p , M . B . A n o m o g r a p h m e t h o d f o r a s s e s s i n g b o d y w e i g h t . A m e r i c a n J o u r n a l o f C l i n i c a l N u t r i t i o n , 1976, 2__, 302-304. T h o m p s o n , J . K . , & S c h w a r t z , N . E . N u t r i t i o n k n o w l e d g e , a t t i t u d e s a n d p r a c t i c e s o f e i g h t h g r a d e s t u d e n t s . J o u r n a l o f t h e C a n a d i a n D i e t e t i c A s s o c i a t i o n , 1977, 18, 222 -228. 188 T h o r n d i k e , R . L . , & H a g e n , E . P . M e a s u r e m e n t a n d e v a l u a t i o n i n • p s y c h o l o g y a n d e d u c a t i o n ( 4 t h e d . ) . T o r o n t o : J o h n W i l e y a n d S o n s , I n c . , 1977. T r u s w e l l , A . S . D i e t i n t h e p a t h o g e n e s i s o f i s c h a e m i c h e a r t d i s e a s e . P o s t g r a d u a t e M e d i c a l J o u r n a l . 1976, j52 , 4 2 4 - 4 3 2 . T r u s w e l l , A . S . A n a t i o n a l f o o d p o l i c y f o r p r e v e n t i o n o f CHD? P o s t g r a d u a t e M e d i c a l J o u r n a l . 1978, j>4, 215 -220. T u r n e r , R . W . D . P e r s p e c t i v e s i n c o r o n a r y p r e v e n t i o n . P o s t - g r a d u a t e M e d i c a l J o u r n a l , 1978, ^4, 1 4 1 - 1 4 8 . U n i t e d S t a t e s S e n a t e S e l e c t C o m m i t t e e o n N u t r i t i o n a n d Human N e e d s . D i e t a r y g o a l s f o r t h e U n i t e d S t a t e s ( 2 n d e d . ) . W a s h i n g t o n , D . C : U . S . G o v e r n m e n t P r i n t i n g O f f i c e , D e c e m b e r , 1977- U n i v e r s i t y o f A l b e r t a E d u c a t i o n a l R e s e a r c h S e r v i c e s . A N 0 V 1 1 , 1 9 6 9 ( r e v i s e d ) . V a n c o u v e r . C i t y P l a n n i n g D e p a r t m e n t . U n d e r s t a n d i n g V a n c o u v e r . V a n c o u v e r : R. Spanman ( D i r e c t o r ) , 1977- V a n c o u v e r . D i r e c t o r y o f S e r v i c e s f o r G r e a t e r V a n c o u v e r ( 1 0 t h e d ) . G r e a t e r V a n c o u v e r I n f o r m a t i o n a n d R e f e r r a l S e r v i c e , A p r i l , 1 9 7 8 . V e r g r o e s e n , A . J . P h y s i o l o g i c a l e f f e c t s o f d i e t a r y l i n o l e i c a c i d . N u t r i t i o n R e v i e w s . 1977, 1£, 1 - 5 . W a r w i c k , D . P . , & L i n i n g e r , C . A . The s a m p l e s u r v e y : T h e o r y a n d p r a c t i c e . T o r o n t o : M c G r a w - H i l l , I n c . , 1975. W e r b l o w , J.A.. . , F o x , H . M . , & Henneman, A . N u t r i t i o n a l k n o w l e d g e , a t t i t u d e s , a n d f o o d p a t t e r n s o f women a t h l e t e s . J o u r n a l o f t h e A m e r i c a n D i e t e t i c A s s o c i a t i o n , 1978, £3_, 242 -245. WHO R e g i o n a l O f f i c e f o r t h e E a s t e r n M e d i t e r r a n e a n . H e a l t h e d u c a - t i o n w i t h s p e c i a l r e f e r e n c e t o t h e p r i m a r y h e a l t h c a r e a p p r o a c h . I n t e r n a t i o n a l J o u r n a l o f H e a l t h E d u c a t i o n , 1978, 2 1 , 1 - 1 8 . W i c k e r , A . W . A t t i t u d e s v e r s u s a c t i o n : The r e l a t i o n s h i p o f v e r b a l a n d o v e r t b e h a v i o u r a l r e s p o n s e s t o a t t i t u d e o b j e c t s . J o u r n a l o f S o c i a l I s s u e s , 1969, 2J5, 4 1 - 78 . W i c k e r , A . W . A n e x a m i n a t i o n o f t h e ' o t h e r v a r i a b l e s ' e x p l a n a - t i o n o f a t t i t u d e - b e h a v i o u r i n c o n s i s t e n c y . J o u r n a l o f P e r s o n a l i t y a n d S o c i a l P s y c h o l o g y , 1 9 7 1 , 19_, 1 8 - 3 0 . W i n e r , B . S t a t i s t i c a l p r i n c i p l e s i n e x p e r i m e n t a l d e s i g n ( 2 n d e d . ) . New Y o r k : M c G r a w - H i l l , 1971. 189 Y o u n g , C M . The i n t e r v i e w i t s e l f . J o u r n a l o f t h e A m e r i c a n D i e t e t i c A s s o c i a t i o n . 1959, 677-68I. Y o u n g , C M . , C h a l m e r s , F . W . , C h u r c h , H . N . , C l a y t o n , M . M . , T u c k e r , R . E . , W e r t s , A . W . , & F o s t e r , W . D . A c o m p a r i s o n o f d i e t a r y s t u d y m e t h o d s 1. D i e t a r y h i s t o r y v e r s u s s e v e n - d a y r e c o r d . J o u r n a l o f t h e A m e r i c a n D i e t e t i c A s s o c i a t i o n , 1952,. 28, 1 2 4 - 1 2 8 . Y o u n g , M . C R e s e a r c h a n d s t u d i e s r e l a t e d t o h e a l t h e d u c a t i o n c o m m u n i c a t i o n : M e t h o d s a n d m a t e r i a l s . H e a l t h E d u c a t i o n M o n o g r a p h s , 1967, 2 ^ ( 3 , p p . 7 - 1 8 ) . APPENDIX A DATA COLLECTION INSTRUMENTS AND COVER LETTERS A . l . P r e l i m i n a r y Q u e s t i o n n a i r e A . 2 . P i l o t S t u d y Q u e s t i o n n a i r e A . 3 . M a i n R e s e a r c h I n s t r u m e n t A . l . Preliminary Questionnaire NUTRITION OPINIONS No. Card Some statements concerning n u t r i t i o n , d i e t and heart disease are made below. We are interested i n your judgment of each statement, i n terms of how well i t r e f l e c t s your personal opinion or f e e l i n g s . I f the statement describes how you f e e l , c i r c l e "A" for agree; i f the statement does not describe how you f e e l , c i r c l e "D" for disagree. After you have made your decision, indicate how c e r t a i n you are about the decision. C i r c l e : 1 i f you are VERY DOUBTFUL about your decision (A or D) 2 i f you are MODERATELY DOUBTFUL about your decision 3 i f you are MODERATELY CERTAIN about your decision 4 i f you are VERY CERTAIN about your decision Please be sure to respond twice to each statement. Sample: N u t r i t i o n i s important to good health, (A) D This person i s MODERATELY CERTAIN that he/she agrees with the statement above. 2 (3) 4 As long as I have no symptoms of heart disease I guess I must be eating r i g h t . Agree or Disagree A D Eating for heart health i s necessary only for A overweight adults. D Children should be taught proper food habits that A w i l l help prevent heart disease i n l a t e r l i f e . D I think the government should remove products from A the market that are hazardous to the heart. D 3 4 2 3 4 1 2 3 4 2 3 4 5. Since heredity, age and stress have so much to do A with heart disease, i t doesn't r e a l l y matter what D I eat. 3 4 As long as I trim away the f a t , I can eat as much meat as I want. 2 3 4 As long as the doctor does not say that I should A cut down the amount I eat, I do not need to be D concerned. 1 2 3 4 8. Everyone should replace eggs with low-cholesterol A egg substitutes (eg. Egg-Beaters). D 9. I f e e l everyone should use polyunsaturated A margarine i n place of butter. D 2 3 4 1 2 3 4 CONTINUE ON BACK OF PAGE Card 10. As long as I eat properly, I don't have to worry about exercising. Agree or Disagree A D 11. I believe industry should develop more foods that A are good for our hearts. D 12. Labels should carry warnings i f the products are A harmful to the heart. D 13. If I eat baked, b r o i l e d , or steamed foods, I can A help reduce the amount of f a t i n my d i e t . D 14. I believe fats and o i l s should be c l e a r l y l a b e l l e d A as to t h e i r contribution to heart health. D 15. Females do not have to worry about eating for a A healthy heart. D 2 3 4 3 4 3 4 2 3 4 2 3 4 2 3 4 PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED NUTRITION KNOWLEDGE Some statements concerning n u t r i t i o n , d i e t and heart disease are made below. Indicate whether or not you think each statement i s true or f a l s e . C i r c l e "T" for true and "F" for f a l s e . After you have reached t h i s decision, indicate how c e r t a i n you are about your answer. C i r c l e : 1 i f you are VERY DOUBTFUL about your decision (T or F) ^ 2 i f you are MODERATELY DOUBTFUL about your decision 3 i f you are MODERATELY CERTAIN about your decision 4 i f you are VERY CERTAIN about your decision Please be sure to respond twice to each statement. True or False The food we eat a f f e c t s the development of heart disease. 1 2 3 4 2. Atherosclerosis (hardening of the a r t e r i e s ) i s T caused by f a t i n the d i e t . F 3. The more polyunsaturated f a t i n the di e t the better T protected one i s against heart disease. F 1 2 3 4 1 2 3 4 4. Heart disease a f f e c t s only people who eat too much and exercise too l i t t l e . 5. White f i s h i s lower i n fat content than beef. T 1 2 3 4 6. Hardening of the a r t e r i e s can be slowed down by T proper food habits. F i 7. Non-dairy cream substitutes do not contain any T saturated f a t . F 8. G a r l i c p u r i f i e s the blood thus protecting against T heart disease. F 9. Processed meats l i k e sausage and salami are high T i n saturated f a t . F a r t e r i e s . F 11. Vitamin C cures heart disease by clearing f a t T from the blood stream. F 13. Corn o i l contains more polyunsaturated fat than T does coconut o i l . F 14. Polyunsaturated fats are made up of polyunsaturated T fa t t y acids, the most important of which i s F l i n o l e i c a c i d . 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 10. L e c i t h i n prevents heart disease by softening the T 1 2 3 4 1 2 3 4 12. I t i s unnecessary for healthy people to l i m i t T 1 2 3 4 th e i r intake of c h o l e s t e r o l . F 1 2 3 4 1 2 3 4 15. Vitamin E supplements protect against heart T 1 2 3 4 disease. F 16. What one eats a f f e c t s the amount of f a t i n the T 1 2 3 4 blood. F 17. Overweight people are more l i k e l y to die of a T 1 2 3 4 heart attack. F 18. Due to t h e i r high cholesterol content, eggs should T 1 2 3 4 be eliminated from the diet of a l l adults. F 19. Drinking hard water causes heart disease. T . „ , , F 20. Use of margarine i n place of butter protects T 1 2 3 4 against heart disease. F PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED CONTINUED ON BACK OF PAGE - 4 - No. NUTRITIONAL PRACTICES Card We are interested i n the types of food that you eat during a period of three days. Indicate, by checking, HOW FREQUENTLY YOU ATE each of the foods l i s t e d below during the PAST THREE DAYS. This i s only an estimate but please try to be as accurate as possible. You may wish to r e c a l l your a c t i v i t i e s of the past three days which may help you to remember the foods you ate. Average serving sizes or portions are noted beside each food, to serve as a guide. Check (•) i n the appropriate blank: (1) the number of 'average' portions' of each food l i s t e d that you ate during the past three days (2) check under '0' i f you did not eat the food i n the past three days (3) check under 'never' i f you never consume the food Average Portion i 'imes eaten i n the Dast three c avs 10+ 8-9 6-7 4-5 2-3 1 1 0 Never 1. Milk as a beverage including flavoured milk drinks, cocoa made with milk 1 cup (8 oz) 2. Milk used on cereal, pudding, f r u i t *5 cup (4 oz) 3. Milk used i n cream soup, custard, pudding h cup 4. Ice cream, yoghurt, ic e milk h cup 5. Cottage cheese, Swiss, American &/or other types (except cream cheese) 1 oz 2 T 6. Eggs (except those used i n cooking and baking 1 7. Dried beans and/or peas h cup 8. Nuts and/or peanut butter 2 T 9. Meat, f i s h , poultry ( a l l v a r i e t i e s including weiners and luncheon meat) 3 oz 10. Orange (1), grapefruit Qi), orange j u i c e and/ or grapefruit j u i c e h cup 11. Tomato and/or tomato j uice h cup 12. Other f r u i t : one piece fresh f r u i t and/ or cooked, canned or frozen juice h cup 13. Dark green, yellow and/or orange vege- tables h cup 14. Other vegetables including potatoes h cup - 5 - No. Card Average Portion Times eaten i n the past three days 10+ 8-9 6-7 4-5 2-3 1 0 Never 15. Bread, r o l l , muffin, b i s c u i t 1/one s l i c e 16. Breakfast cereal ( a l l v a r i e t i e s ) *5-3/4 cup 17. Spaghetti, r i c e , macaroni, noodles %-3/4 cup Please underline the days which you chose to record i n the above table (three days) : MONDAY, TUESDAY, WEDNESDAY, THURSDAY, FRIDAY, SATURDAY, SUNDAY 1. Check (v) the types of milk used regularly f o r each of the following (check as many as apply) : Whole Milk 2% Milk Skim Fat-free Milk Canned Evaporated Milk Butter Milk Sweetened Condensed Milk Half and Half Whole Cream DISREGARD THIS COLUMN As beverage Cooking and baking On cereals and puddings 2. Check (O the types of fat used regularly for each of the following (check as many as apply): Bacon Fat Lard Butter Shortening Margarine Soft Margarine Veg. O i l Baking Cooking and fr y i n g As a spread on bread etc. CONTINUE ON BACK OF PAGE 197 - 6 No. INFORMATION ABOUT YOU Please check (v) or f i l l i n the appropriate blanks below: 1. Your sex: Male ( ) Female ( ) 19-24 ( ) 40-44 ( ) 25-29 ( ) 45-49 30-34 ( ) 50-54 35-39 ( ) 55-59 alone with family Card DISREGARD THIS COLUMN 2. Your age: Do you l i v e : ( ) ( ) ( ) 60-64 ( ) 64+ ( ) ( ) communal ( ) ( ) other ( ) with roommate(s) ( ) please specify Highest education received: College or University High School 4+ 4 3 2 1 1 Voc ( ) ( ) ( ) ( ) Elementary 8 ( 7 ( 6 & 5 ( 4 & 3 ( 2 & 1 ( Your present occupation ( i f you are a student, write your intendecj occupation; i f r e t i r e d , your past one; i f unemployed, your usual one; i f a homemaker, write that of your spouse): Check the one choice that best represents your personal habits: 6. Regular active exercise pattern: frequent (4-6X/week) ( ) infrequent (< lX/week) ( ) occasional (l-3X/week) ( ) none ( ) 7. Cigarette smoking: heavy (20+ per day) moderate (10-20 per day) l i g h t (1-9 per day) ex-smoker non-cigarette smoker 8. Your body weight: normal or less up to lOlbs. above normal 10+ lbs. above normal 198 No. Card 9. Has anyone i n your immediate family (husband, wife, children or brother, s i s t e r , parent) ever had high blood pressure, stroke, high blood f a t l e v e l s and/or heart attack? Yes No 10. Have you ever been treated for any of the following (check as many as apply): high blood pressure ( ) angina ( ) high blood f a t l e v e l s ( ) diabetes ( ) high blood c h o l e s t e r o l l e v e l s ( ) none of the above ( ) heart attack ( ) 11. There are many sources from which one can obtain information about d i e t and heart disease. Check (y) the source(s) from which you have obtained information on diet and heart disease (check as many as apply): labels on foods n u t r i t i o n i s t , d i e t i t i a n home economist/home ec teacher nurse YM/YWCA radio f i t n e s s instructor teacher drug store service club other, please specify DISREGARD THIS COLUMN doctor weight control group Action B.C. exhibits or displays health food store family newspapers magazines grocery store books cookbooks friends THANK YOU FOR YOUR TIME AND COOPERATION A.2. P i l o t Study Q u e s t i o n n a i r e - 1 - NUTRITION OPINIONS Some statements concerning n u t r i t i o n , d i e t , and heart disease are made below. We are interested i n your opinions of these statements. Please c i r c l e the number which best indicates how cl o s e l y you agree or disagree with the FEELING expressed i n each statement AS IT CONCERNS YOU. C i r c l e : 1 i f you STRONGLY DISAGREE with the statement 2 i f you DISAGREE with the statement 3 i f you are UNDECIDED, neither agree nor disagree 4 i f you AGREE with the statement 5 i f you STRONGLY AGREE with the statement SAMPLE: The premier of B r i t i s h Columbia should c a l l an e l e c t i o n ^ 2 3 4 5 at thi s time. —' This person STRONGLY DISAGREES with the statement. STRONGLY STRONGLY DISAGREE DISAGREE UNDECIDED AGREE AGREE 1. I am concerned about the amount of s a l t i n the foods that I buy. 2. With no signs of heart disease, I guess one i s eating r i g h t . 3. I t i s the doctor's job to make me eat for heart health. 4. There i s nothing I can do to prevent heart disease. 5. To help f i g h t heart disease, I f e e l only n u t r i t i o u s foods should be sold i n food stores. 6. Once an adult, i t i s too l a t e to protect your heart by changing your food habits. 7. There i s too much emphasis on eating for the heart. 8. As long as the doctor does not say that I should cut down the amount I eat, I do not need to be concerned. 9. I think I am the one who should decide what I eat. 10. What I eat w i l l a f f e c t my heart. 11. Labels should carry warnings i f the products are harmful to a healthy heart. 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 CONTINUED ON BACK OF PAGE 2 0 1 STRONGLY DISAGREE DISAGREE UNDECIDED AGREE STRONGLY AGREE 12. Children should be taught proper food habits that w i l l help prevent heart disease i n l a t e r l i f e . 13. I f I am ca r e f u l I can cut down the amount of f a t I eat. 14. As long as I eat properly, I can forget about exercising for my heart. 15. I am trying to eat for a healthy heart. 16. I f e e l i t i s impossible to change what I eat regardless of my heart health. 17. Since I can't control the amount of s a l t i n packaged foods, I can't cut down on the amount of s a l t I eat. 18. I think people should be advised to change the type of f a t they eat. 19. I think government can help us decide what i s best for a healthy heart. 20. I f e e l fats and o i l s should