"Land and Food Systems, Faculty of"@en . "DSpace"@en . "UBCV"@en . "Sullivan, Ann Dolores"@en . "2010-03-23T19:48:46Z"@en . "1980"@en . "Doctor of Philosophy - PhD"@en . "University of British Columbia"@en . "A study was designed to investigate the attitudes, knowledge,\r\nand 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 specific biodemographic variables on these three dependent variables were determined. The independent vari ables, non-manipulative in nature, were age, gender, living arrangement,\r\nfamily history of CVD, personal history of CVD, physical\r\nexercise pattern, smoking habit, education level, and obesity risk. Data were collected by a self-administered questionnaire\r\nthat had been validated and pretested in a pilot study\r\nIn May 1979, questionnaires were distributed by random day to adult members of 11 community centres in the city of Vancouver.\r\nEach centre was represented by a random sample or by volunteers in attendance at each class on the chosen day. The final sample size was 281, yielding an overall response rate of 74.7%.\r\nData were analyzed by computer and all analyses were conducted\r\nat the .05 level of significance. Expressed as percentages\r\nof possible scores, the mean scores for the two attitude subtests and total test were quite high (83%) with standard deviations of 8 to 9%. The mean scores for the three knowledge subtests and total test revealed tests of medium difficulty (48 to 53%) with standard deviations of 12 to 17%. Practice scores, expressed as ratios of recommended values, were equal to or exceeded\r\nthe Canadian Dietary Standard and the Nutrition Recommendations\r\nfor Canadians for nine of the 11 nutrients examined; all were greater than 67% of the recommended values.\r\nReliabilities determined by internal consistency, test-retest, and congruency check procedures for attitudes and knowledge,\r\nbiodemographic, and practice instruments, respectively, were considered adequate for the purpose of the study.\r\n\r\nCorrelation analysis revealed that attitudes and knowledge were moderately correlated (range .38 to .56) but practice and both attitudes and knowledge were weakly correlated (range .00 to .24). One-way multivariate analyses of variance revealed that living arrangement, degree of obesity, and positive family history of CVD did not appear to have an effect on any of the dependent variables. Smoking habit was not found to influence either attitudes or knowledge.\r\nMultivariate analyses of variance revealed that respondents with a positive personal history of CVD had significantly different\r\nattitudes toward the use of diet in prevention of CVD and performed significantly better on the subtest about the affect of foods than those without a positive history. Adults under 50 years of age had significantly more positive attitudes toward the role of diet in heart disease and scored significantly higher on subtest of facts versus fallacy than adults over 50 years of age. Females had significantly more positive attitudes and performed significantly better on all knowledge subtests than males. The education group with less than grade 12 had significantly less positive attitudes toward the role of diet' in heart disease and significantly lower knowledge related to food composition than all other education groups; and significantly\r\nlower scores on facts versus fallacy than the one to three years university group. No significant differences in knowledge or practice were observed between groups who varied in exercise pattern, however, the sedentary group had significantly\r\nless positive attitudes toward the role of diet in heart disease than those who were classified as high moderate or vigorous.\r\nWhile significant differences in practice were observed for a number of biodemographic variables, no particular group was characterized by a deficient or excess intake of any of the 11 nutrients examined.\r\nSeveral implications for nutrition education were inferred from interpretation of results."@en . "https://circle.library.ubc.ca/rest/handle/2429/22370?expand=metadata"@en . "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 \u00C2\u00A7 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 \u00C2\u00A9 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^\u00E2\u0080\u00A27%. 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\u00C2\u00B0) 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 - 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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)\u00C2\u00BB 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)\u00E2\u0080\u00A2 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)\u00E2\u0080\u00A2 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)\u00E2\u0080\u00A2 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)\u00E2\u0080\u00A2 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)\u00E2\u0080\u00A2 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 - \u00E2\u0080\u009E 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\u00C2\u00BB 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)\u00C2\u00BB 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 \u00C2\u00B10 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)\u00E2\u0080\u00A2 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\u00E2\u0080\u00A23% 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) \u00E2\u0080\u00A2 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 <\u00E2\u0080\u0094\u00C2\u00BB A < \u00E2\u0080\u0094 > 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. (KA <\u00E2\u0080\u0094>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 \u00E2\u0080\u0094 \u00C2\u00BB A \u00E2\u0080\u0094 > P a n d (2) A \u00E2\u0080\u0094 \u00C2\u00BB 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 \u00E2\u0080\u0094 \u00C2\u00BB K >P (P<.05)\u00C2\u00AB 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 \u00E2\u0080\u0094 * A \u00E2\u0080\u0094 > 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 ) \u00E2\u0080\u00A2 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 ) \u00E2\u0080\u00A2 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 ) \u00E2\u0080\u00A2 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) \u00E2\u0080\u00A2 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)\u00E2\u0080\u00A2 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 , \u00C2\u00B1 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 \u00E2\u0080\u0094 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 ) \u00E2\u0080\u00A2 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 )\u00C2\u00BB 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\u00C2\u00BB p \u00C2\u00AB 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 ) \u00E2\u0080\u00A2 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 \u00E2\u0080\u0094 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\u00E2\u0080\u0094hour 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\u00E2\u0080\u0094hour 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 ) \u00E2\u0080\u00A2 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 ) \u00E2\u0080\u00A2 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)\u00C2\u00BB 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 \u00E2\u0080\u0094 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)\u00C2\u00BB 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)\u00C2\u00BB 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 \u00E2\u0080\u00A2= 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\u00C2\u00AB 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 ) \u00E2\u0080\u00A2 \"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)\u00C2\u00BB 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) \u00E2\u0080\u00A2 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\u00C2\u00BB 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 \u00E2\u0080\u00A2 \u00E2\u0080\u00A2 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 \u00E2\u0080\u00A2\u00E2\u0080\u00A2 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 \u00E2\u0080\u00A2 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: MANAGE8\" 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 \u00E2\u0080\u00A2 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 \u00E2\u0080\u00A2 71 .74 \u00E2\u0080\u00A2 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)\u00E2\u0080\u00A2 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) \u00E2\u0080\u00A2 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\u00C2\u00BB 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)\u00E2\u0080\u00A2 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 \u00E2\u0080\u0094 V A \u00E2\u0080\u0094 > P a n d A \u00E2\u0080\u0094 > K \u00E2\u0080\u0094 \u00C2\u00BB 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 \u00E2\u0080\u00A2 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 \u00E2\u0080\u00A2 95 .02 \u00E2\u0080\u00A2 558 .577 1 . 0 8 8 .629 FAT .83 .02 .82 .02 \u00E2\u0080\u00A2 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 ) \u00C2\u00AB 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 ) \u00C2\u00BB 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 \u00E2\u0080\u00A2 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)\u00C2\u00BB 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\u00C2\u00AB7$ 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 ) \u00E2\u0080\u00A2 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) \u00E2\u0080\u00A2\u00E2\u0080\u00A2 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\u00E2\u0080\u00A25 N u r s e 11 .7 N o n p r o f e s s i o n a l 77\u00E2\u0080\u00A29 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 \u00E2\u0080\u00A2 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 - \u00C2\u00B0 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\u00E2\u0080\u00A29% 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$) . I n t h e N u t r i t i o n C a n a d a s u r v e y , a l c o h o l was i n c l u d e d w i t h CHO TABLE 23 P r a c t i c e C h a r a c t e r i s t i c s o f t h e Samp le N u t r i e n t 3 \" S c o r e s P e r c e n t o f S a m p l e 3 , X S . D . D e f i c i e n t * 3 A c c e p t a b l e 1 3 E x c e s s KCAL .94 . 2 6 1 4 . 6 7 9 . 7 5-7 PROT I . 7 6 . 5 2 1.1 1 7 . 8 8 1 . 1 CA 1 . 1 4 . 5 4 1 6 . 4 5 5 . 5 2 8 . 1 FE 1 . 0 4 . 4 9 2 3 . I 55-5 2 1 . 4 VA 2 . 3 9 2 . 7 8 1 4 . 2 2 9 . 2 5 6 . 5 T H I 1.12 . 6 1 1 6 . 4 5 8 . 4 2 5 . 3 RIBO 1 .61 1 . 4 6 5 . 3 5 0 . 5 4 4 . 1 NIA 1 . 3 9 c . 6 1 ' c 6 . 0 4 8 . 4 4 5 . 6 VC 4 . 1 9 2 . 5 5 1.1 5 . 0 9 4 . 0 FAT 1.12 . 2 2 2 . 1 8 2 . 6 1 5 . 3 CHO .85 . 1 8 1 3 . 9 8 5 . 4 .7 N o t e . S a m p l e s i z e = 2 8 1 . a E x p r e s s e d as 1977) \u00E2\u0080\u00A2 r a t i o o f r e c o m m e n d e d v a l u e s ( C a n a d a , 1975a; D e f i c i e n t , <67%; a c c e p t a b l e , 67-133%; e x c e s s , >133% ( e x c e p t VC, >200%) o f r e c o m m e n d e d v a l u e s . c E x p r e s s e d as mg NIA i n t a k e / C D S b a s e d o n age a n d g e n d e r . w h i c h may a c c o u n t f o r t h e d i f f e r e n c e . When t h e s a m p l e i s s e p a r a t e d i n t o t h r e e p r a c t i c e c a t e -g o r i e s , t h e p e r c e n t a g e w i t h n u t r i e n t s c o r e s l e s s t h a n 67$ ( 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)\u00E2\u0080\u00A2 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\u00C2\u00AB7%) 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 \u00E2\u0080\u00A2 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 ) \u00E2\u0080\u00A2 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 ta 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 \u00E2\u0080\u00A2 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 \u00E2\u0080\u0094 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)\u00C2\u00BB 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)\u00E2\u0080\u00A2 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\u00C2\u00BB787)=1.92; P<.05)\u00C2\u00AB 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 sa 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\u00C2\u00AB4% 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 * , ; . \u00E2\u0080\u00A2 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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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 , 1977, 1, 169-172. S h a p e r , A . G . P r i m a r y 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 i n 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 a l J o u r n a l , 1976, 52, 464-469. S h a p e r , A . G . , & M a r r , J . W . 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 c o m -m u n i t y t o w a r d s t h e p o s t p o n e m e n t o f c o r o n a r y h e a r t d i s e a s e . B r i t i s h M e d i c a l J o u r n a l , 1977, 1, 867-871. S h e k e l l e , R . B . , & L i u , S . C . P u b l i c b e l i e f s a b o u t 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 s . 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 \u00E2\u0080\u00A2 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\u00C2\u00A3, 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, \u00C2\u00A33_, 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 . \u00E2\u0080\u009E , , 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 (\u00E2\u0080\u00A2) 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. \u00E2\u0080\u0094' 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 be c l e a r l y l a b e l l e d as to the i r contribution to heart health. 21. My eating habits influence my heart health. 22. I f I pay attention to how my food i s cooked, I can reduce the amount of f a t I eat. 23. As long as I trim away the f a t , I can eat a l l the meat I want. 24. People of a l l ages should be concerned about eating f o r a healthy heart. 25. I think i t i s the job of industry to develop foods that are healthy for the heart. 26. I f e e l I should be concerned about the t o t a l amount of f a t I eat. PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED NUTRITION KNOWLEDGE Some true and f a l s e statements concerning n u t r i t i o n , d i e t and heart disease are below. Please c i r c l e the number which best indicates your knowledge of each statement. C i r c l e : 1 i f the statement i s DEFINITELY FALSE 2 i f the statement i s PROBABLY FALSE 3 i f you DO NOT KNOW 4 i f the statement i s PROBABLY TRUE 5 i f the statement i s DEFINITELY TRUE DEFIN: FALSE TELY PROBABLY DON'T PROBABLY DEFINITELY FALSE 27. A l c o h o l i c beverages add extra c a l o r i e s to the d i e t . 28. G a r l i c p u r i f i e s the blood thus protecting against heart disease. 29. Hardening of the a r t e r i e s can be slowed down by eating wisely. 30. I t i s unnecessary for healthy people to l i m i t their intake of ch o l e s t e r o l , a f a t t y substance found i n animal foods. 31. Non-dairy cream substitutes such as Coffee-Mate contain no f a t . 32. Low-cholesterol egg products such as Egg-Beaters are hea l t h i e r than eggs. 33. What one eats a f f e c t s the amount of fat i n the blood. 34. Being thin i s no guarantee against heart disease. 35. Hardening of the a r t e r i e s (athero-s c l e r o s i s ) i s caused by fa t i n the d i e t . 36. The more polyunsaturated f a t i n the di e t , the better protected one i s against heart disease. 37. Vitamin E supplements o f f e r no protection against heart disease. 38. High blood pressure i s the r e s u l t of high s a l t intake. 39. Normal weight people need not exercise to protect t h e i r heart. 40. Polyunsaturated f a t s are made up of polyunsaturated f a t t y acids, the most important of which i s l i n o l e i c a c i d . KNOW 3 3 3 TRUE 4 4 4 TRUE 5 5 5 CONTINUED ON BACK OF PAGE 41. Use of margarine i n place of butter protects against heart disease. 42. Just because no one i n your family has had heart problems does not mean you are protected against heart disease. 43. A good way to lose weight i s to eat a high meat d i e t . 44. Weight for weight, hamburger has the same energy value as white chicken breast meat. 45. Of a l l the vegetable o i l s , corn o i l contains the most polyunsaturated f a t . 46. Olive o i l contains less polyunsatur-ated f a t than safflower o i l . 47. Heart disease a f f e c t s only people who over eat. 48. L e c i t h i n , a fat t y substance i n animal tissue and eggs, prevents heart disease by cle a r i n g cholesterol from the a r t e r i e s . 49. Drinking hard water causes heart disease. 50. Obese people have a greater chance of a f a t a l heart attack than people of normal weight. 51. Vitamin C cures heart disease by removing fa t from the blood stream. 52. Processed meats l i k e sausage and salami are high i n saturated f a t . 53. People do not out grow the need for regular exercise. 54. Due to t h e i r high ch o l e s t e r o l content, eggs should be eliminated from the d i e t . 55. White f i s h such as cod and haddock i s lower i n fat content than beef. 56. The food we eat af f e c t s the develop-ment of heart disease. 57. F r u i t drinks such as Tang are a n u t r i -tious substitute for fresh f r u i t s . TELY PROBABLY DON'T PROBABLY DEFINITELY FALSE FALSE KNOW TRUE TRUE 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 '2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED 204 - 5 INFORMATION ABOUT YOU Please check \/ or f i l l i n the appropriate blanks below: 1. Your sex: Q Male \u00E2\u0080\u00A2 Female 2. Your age: Q19-24 \u00E2\u0080\u00A2 40-44 \u00E2\u0080\u00A2 60-64 P 25-29 \u00E2\u0080\u00A2 45-49 \u00E2\u0080\u00A2 64+ Q 30-34 \u00E2\u0080\u00A2 50-54 Q 35-39 \u00E2\u0080\u00A2 55-59 3. Do you l i v e : | | alone \u00E2\u0080\u00A2 with family Q communal Q other, please specify Q with roommate(s) 4. Highest l e v e l of education completed: College or University High School \u00E2\u0080\u00A2 4+ \u00E2\u0080\u00A2 * \u00E2\u0080\u00A2 3 \u00E2\u0080\u00A2 2 C h Q 1 Voc \u00E2\u0080\u00A2 3 \u00E2\u0080\u00A2 l Elementary [ J 6 & 5 \u00E2\u0080\u00A2 4 & 3 \u00E2\u0080\u00A2 2 & 1 | |None 5. Your present occupation ( i f you are a student, write your intended 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), please describe as c a r e f u l l y as possible: Were you born i n Canada? | | Yes - go to number 7 \u00E2\u0080\u00A2 No Where were you born? How long have you l i v e d i n Canada? CONTINUE ON BACK OF PAGE 2 0 5 7. What i s your regular exercise pattern? Check one. [*~| Sedentary: work and l e i s u r e . Under 5 f l i g h t s of s t a i r s or half a mile walking per day. | | Low moderate: some a c t i v i t y work and l e i s u r e ; between 5 and 15 f l i g h t s of s t a i r s or 0.5 to 1.5 miles walking or comparable d a i l y exercise. ] | High moderate: programmed exercise A times per week or 1.5 to 2 miles of walking or 15 to 20 f l i g h t s of s t a i r s or comparable d a i l y exercise. | | Vigorous: greater than that of high moderate. 8. What i s your height: f t . i n . (or cm.) What i s your present weight? l b s . (or kg.) 9. Do you have a history of previous weight gain? | | Yes FJ.No - go to number 10 How has your weight changed? [^increased Q decreased Why? Please specify 10. What i s your smoking habit? Check one. | | Nonsmoker: never smoked or not smoked for 5 years | | Past smoker: not smoked for les s than 5 years [ | Cigarettes: 20 or more per day | | Cigarettes: 10-19 per day \ | Cigarettes: less than 10 per day | | Cigars or pipes ONLY: 5 or more per day or any amount inhaled | | Cigars or pipes ONLY: less than 5 per day not inhaled 11. 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 fat l e v e l s and/or heart attack? | | Yes FJ] No Q Do not know 12. Have you ever been treated for any of the following (check as many as apply): | | High blood pressure \u00C2\u00A3 ^ Angina | | High blood f a t l e v e l s Q Diabetes | | High blood cholesterol l e v e l s Q None of the above \ | Heart attack 13. There are many sources from which one can obtain information about diet and heart disease. Check I y/1 the source(s) from which you have obtained information on d i e t and heart disease (check as many as apply): P Labels on foods | | Doctor | j Weight co n t r o l group | | Action B.C. [~\ Exhibits or displays | | Health food store | | Family | | Newspapers ] | Magazines | | Grocery store Q Books [ | Cookbooks [~| Friends | | T e l e v i s i o n | | 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 Q YM/YWCA [ | Radio r~~| Fitness i n s t r u c t o r [~~| Teacher [ | Drug store [ | Service club | | None | | Other, please specify below PLEASE CHECK TO BE SURE ALL THE QUESTIONS HAVE BEEN ANSWERED YOUR DIETARY PRACTICES We are interested i n determining your \"usual\" eating habits. To help you remember, three questions w i l l be asked. Question 1: What did you eat yesterday? Think of yesterday, hour by hour, and record on the back of thi s page EVERYTHING you ate and drank from the time you got up i n the morning u n t i l you went to bed at night and what you ate during the night. Mention meals, snacks, and drinks of a l l kinds taken at home, at work, and away from home. BE AS ACCURATE AS POSSIBLE. Record the KIND of food and AMOUNT that you ate. Use average household servings, sizes or portions and describe the food as completely as possible. Say i f i t d i f f e r e d from your \"usual\". SAMPLE: Food type/preparation Amount Va r i a t i o n from \"Usual\" MID DAY: F i s h , cod, f r i e d i n one tablespoon butter Pie, apple (2 crust) Beer, H i g h l i t e 4 oz. cooked 1/6 of 9\" pie 2 - 12oz. bottles Usually have cheese sandwich and tea CONTINUE ON BACK OF PAGE - 8 -FOOD TYPE/PREPARATION AMOUNT MORNING? VARIATION FROM \"USUAL\" \u00E2\u0080\u00A2 Yes \u00E2\u0080\u00A2 No If yes, what? LATE MORNING? MID DAY? \u00E2\u0080\u00A2 Yes \u00E2\u0080\u00A2 No If yes, what? \u00E2\u0080\u00A2 Yes \u00E2\u0080\u00A2 No If yes, what? AFTERNOON? \u00E2\u0080\u00A2 Yes \u00E2\u0080\u00A2 No If yes, what? EVENING MEAL? D Yes D No If yes, what? AFTER EVENING MEAL? CU Yes Zl No If yes, what? Question 2: What i s your GENERAL EATING PATTERN, including supplements? Please c h e c k j ^ j or f i l l i n the appropriate blanks below. A. Was your intake yesterday unusual i n any way? \u00E2\u0080\u00A2 Yes [_ No - go to B Why was your intake yesterday unusual? Please specify In what way was your intake yesterday unusual? Please specify Are you taking any food or nutrient supplement? [J Yes __] No - go to C When did you l a s t take a food or nutrient supplement? | [ within the past three months | | not within the past three months What kind? Check and write the name and amount below: | | Vitamin | | Mineral Q Both | | Don't know the name/kind but the amount i s On whose advice? | | Doctor/nurse \u00E2\u0080\u00A2 S e l f | | Other, please specify Do you currently (within the past year) drink a l c o h o l i c beverages? | | Yes | | No - go to D What type of a l c o h o l i c beverage(s) do you drink? | | wine, 4 oz. I | l i g h t beer (3.5 or less % al c o h o l ) , 12 oz. [ | ale/beer, 12 oz. j | s p i r i t s / h a r d l i q u o r , 1-1*5 oz. How much? (The amount beside each type of drink above equals one drink) [ | less than 2 drinks per week | | 2 to 10 drinks per week | | 10 to 25 drinks per week | | over 25 drinks per week CONTINUE ON BACK OF PAGE Do you use salt? (Check twice i f yes) 1) at the table \u00E2\u0080\u00A2 Yes Q No 2) i n cooking \u00E2\u0080\u00A2 Yes \u00E2\u0080\u00A2 No 3) before tast i n g \u00E2\u0080\u00A2 Yes \u00E2\u0080\u00A2 No 4) after t a s t i n g \u00E2\u0080\u00A2 Yes \u00E2\u0080\u00A2 No ALWAYS FREQUENTLY SOMETIMES NEVER Do you have any food d i s l i k e s ? | | No - go to F What food d i s l i k e ( s ) do you have? Please specify Do you eat the same on weekends as you do during the week? Q Y e s - go to G \u00E2\u0080\u00A2 No What i s the difference between your weekday and weekend eating practices? Please specify . . Do you usually skip or omit a meal? |~~] No - go to H \u00E2\u0080\u00A2 Ye Which meal(s)? | [Breakfast | |Lunch: noon meal \u00E2\u0080\u00A2 Dinner: evening meal How long have you followed your present pattern of eating? \u00E2\u0080\u00A2 Less than one month [ |A few months \u00E2\u0080\u00A2 Over one year Question 3: HOW FREQUENTLY do you eat each of the following common foods? This is only an estimate, but try to be as Please indicate by checking accurate as possible. Average serving sizes or portions are noted beside each food, to serve as a guide. (C. = cup; oz. = ounce; Tbsp. = tablespoon; Tsp. = teaspoon) AVERAGE PORTION , ALWAYS ! FREQUENTLY at least : not daily;more one/day j than one/week SOMETIMES less than once/week SELDOM/NEVER less than once/month Cream, whole 2 Tbsp. i t i Half & Half 1 Tbsp. 1 ; Milk (a l l forms) 1 C.(8oz.) 1 1 Cheese ( a l l types) 1 oz. 1 | Cottage cheese 2 Tbsp. j i Meat/fish/poultry 3 oz. 1 1 Ham : l oz. 1 l 1 1 j Bacon, side 1 strip i : i ! ; ! i Bacon, back ; 1 strip ; i i ; Organ meat (liver) . 3 oz. 1 i Weiners (hot dogs) 2 j i Dried beans/peas 1/2 C. | 1 ' Eggs, medium 1 ; : I Grapefruit (4) orange ' 1 ; ! ! : as iuice ' 1/2 C. ! ; 1 Tomato and/or iuice ; 1/2 C. \u00E2\u0080\u00A2 \u00E2\u0080\u00A2 ; Dried fruit ' 1/2 C. ! ! i i Other fruit 1 or 1 C. i I ! ! 1 Dk. green leafy veg-etables/deep yellow '. 1/2 C. j I ; j 1 i i i 1 1 ;-' 1 Potatoes, mashed 1/2 C. j ! 1 baked/boiled 1 French fried 1 C. i i i i Bread/roll/muffin/ biscuit ' 1 i i Bkfst. cereal, dry 1 C. i cooked 3/4 C. 1 Spaghetti/macaroni/ rice/noodles 3/4 C. j i Salty crackers 2 r i t z , 4 melba , 1 . ! CONTINUE ON BACK OF PAGE AVERAGE PORTION ALWAYS at least one/day FREQUENTLY not daily;more than one/week SOMETIMES less than once/week SELDOM/NEVER less than once/month Butter 2 pats 1 Tbsp. Margarine, soft 1 Tbsp. Q \u00C2\u00A3\u00E2\u0080\u0094. Margarine, regular 1 Tbsp. j Vegetable oils 1 Tbsp. | \" Lard 1 Tbsp. 1 ! i i Puddings 1 C. I i Pie/pastry 1/7 of 9\" LJL * Cake/doughnut 1 < j Candy, chocolate 3/4 oz. j % 25cbar 1 i i Candy, other (examples) 4 hard : 7caramels i ! Jam/ielly ' 2 Tbsp. i Syrup/molasses ' 2 Tbsp. i i \u00C2\u00A3 t\u00E2\u0080\u0094i Ice cream : 1/2 C. i 1 I Soft drinks 1 8 oz. i j Potato chips/corn chips \u00E2\u0080\u00A2 10 about i 2\"in size i Popcorn, plain : 1 C. i i Popcorn, buttered 1 1 C. I t Pizza, a l l kinds 1/8 of 14' t j Coffee, regular ; 1 C. S i ! Coffee, decaffeinated 1 C. ' i \u00E2\u0080\u00A2 Tea : 1 C. i If any food items that you usually eat have been omitted from the above table, please add and check the frequency. THANK YOU VERY MUCH FOR YOUR TIME AND COOPERATION 213 A.3. Main Research Instrument 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 immediate reaction to these statements. Please c i r c l e the number which best indicates how c l 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 t 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 at t h i s time. This person STRONGLY DISAGREES with the statement. (?) 2 3 4 5 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. Once an adult, i t i s too l a t e to protect your heart by changing your food habits. 5. There i s too much emphasis on eating for the heart 6. As long as the doctor does not say that I should cut down the amount I eat, I do not need to be concerned. 7. What I eat w i l l a f f e c t my heart. 8. 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 . 4 5 4 5 4 5 (8) (9) (10) (11) (12) (13) (14) (15) CONTINUE ON BACK OF PAGE 214 - 2 -STRONGLY STRONGLY DISAGREE DISAGREE UNDECIDED AGREE AGREE 9. If I am care f u l I can cut down the amount of f a t I eat. 10. As long as I eat properly, I can forget about exercising for my heart. 11. I am tr y i n g to eat for a healthy heart. 12. I f e e l i t i s impossible to change what I eat regardless of my heart health. 13. 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. 14. I think people should be advised to change the type of f a t they eat. 15. My eating habits influence my heart health. 16. I f I pay attention to how my food i s cooked, I can reduce the amount of f a t I eat. 17. As long as I trim away the f a t , I can eat a l l the meat I want. 18. People of a l l ages should be concerned about eating for a healthy heart. 19. I f e e l I should be concerned about the t o t a l amount of f a t I eat. (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED 215 3 -NUTRITION KNOWLEDGE Some true and false statements concerning nutrition, diet and heart disease are below. Please circle the number which best indicates your knowledge of each statement. Circle: 1 i f the statement is DEFINITELY FALSE 2 i f the statement is PROBABLY FALSE 3 i f you DO NOT KNOW 4 if the statement is PROBABLY TRUE 5 i f the statement is DEFINITELY TRUE DEFINITELY PROBABLY DON'T PROBABLY DEFINITELY FALSE FALSE KNOW TRUE TRUE 20. Alcoholic beverages add extra calories to the diet. 21. Garlic purifies the blood thus protecting against heart disease. 22. It is unnecessary for healthy people to limit their intake of cholesterol, a fatty substance found in animal foods. 23. Non-dairy cream substitutes such as Coffee-Mate contain fat. 24. What one eats affects the amount of fat in the blood. 25. Being thin is no guarantee against heart disease. 26. Hardening of the arteries (athero-sclerosis) is caused by fat in the diet. 27. The more polyunsaturated fat in the diet, the better protected one is against heart disease. 28. High blood pressure is caused by high salt intake. 29. Normal weight people need not exercise to protect their heart. 30. Polyunsaturated fats are made up of polyunsaturated fatty acids, the most important of which is linoleic acid. (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) CONTINUE ON BACK OF PAGE 216 - 4 -DEFINITELY PROBABLY DON'T PROBABLY DEFINITELY FALSE FALSE KNOW TRUE TRUE 31. Just because no one i n your family has had heart problems does not mean you are protected against heart disease. 32. A good way to lose weight i s to eat a high meat d i e t . 33. Weight for weight, hamburger has the same energy value as white chicken breast meat. 34. Of a l l the vegetable o i l s , corn o i l contains the most polyunsaturated f a t . 35. Olive o i l contains less polyun-saturated f a t than safflower o i l . 36. Heart disease a f f e c t s only people who over eat. 37. L e c i t h i n , a fat t y substance i n animal tissue and eggs, prevents heart disease by clearing c h o l e s t e r o l from the a r t e r i e s . 38. Drinking hard water causes heart disease. 39. Obese (very fat) people have a greater chance of a f a t a l heart attack than people of normal weight. 40. Vitamin C cures heart disease by removing f a t from the blood stream. 41. Processed meats l i k e sausage and salami are high i n saturated f a t . 42. People do not outgrow the need f o r regular exercise. 43. Due to th e i r high cholesterol content, eggs should be eliminated from the d i e t . 44. White f i s h such as cod and haddock i s lower i n f a t content than beef. 45. The food we eat af f e c t s the develop-ment of heart disease. 46. F r u i t drinks such as Tang are a n u t r i -tious substitute for fresh f r u i t s . (38) (39) (40) (41) (42) (43) (44) (45) (46) (47) (48) (49) (50) (51) (52) (53) PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED 217 5 -INFORMATION ABOUT YOU Please check O of f i l l in the appropriate blanks below: \u00E2\u0080\u00A2 60-66 \u00E2\u0080\u00A2 66+ 1. Your sex: \u00E2\u0080\u00A2 Male | | Female 2. Your age: \u00E2\u0080\u00A2 19-24 \u00E2\u0080\u00A2 40-44 \u00E2\u0080\u00A2 25-29 Q 45-50 \u00E2\u0080\u00A2 30-35 \u00E2\u0080\u00A2 51-54 \u00E2\u0080\u00A2 36-39 \u00E2\u0080\u00A2 55-59 3. You live: \u00E2\u0080\u00A2 alone \u00E2\u0080\u00A2 \u00E2\u0080\u00A2 communal \u00E2\u0080\u00A2 \u00E2\u0080\u00A2 with roomma te(s) Highest level of education completed: College or University High School \u00E2\u0080\u00A2 4+ \u00E2\u0080\u00A2 A \u00E2\u0080\u00A2 3 \u00E2\u0080\u00A2 1 Voc \u00E2\u0080\u00A2 * \u00E2\u0080\u00A2 3 \u00E2\u0080\u00A2 ^ \u00E2\u0080\u00A2 1 Elementary \u00E2\u0080\u00A2 \u00C2\u00AB \u00E2\u0080\u00A2 6 & 5 \u00E2\u0080\u00A2 4 & 3 \u00E2\u0080\u00A2 2 & 1 | | None Your present occupation (if you are a student, write your intended occupation; i f retired, your past one; i f unemployed, your usual one; i f a homemaker, write that of your spouse), please describe as carefully as possible: Were you born in Canada? [ jYes - go to number 7 \u00E2\u0080\u00A2 No Where were you born? How long have you lived in Canada? (8) (9,10) .(11.) (12,13) _(14,15) (16,17) (18,19) CONTINUE ON BACK OF PAGE 218 7, What is your regular exercise pattern? Check one. | | Sedentary: work and leisure. Under 5 flights of stairs or half a mile walking per day. | | Low moderate: some activity work and leisure; between 5 and 15 flights of stairs or 0.5 to 1.5 miles walking or comparable daily exercise. | | High moderate: programmed exercise 4 times per week or 1.5 to 2 miles of walking or 15 to 20 flights of stairs or comparable daily exercise. | | Vigorous: greater than that of high moderate. 8. What is your height? 10. 11. 12. f t . What is your present weight? lbs. (or (or _cm.) _kg.) Do you have a history of previous weight change? | | No-go to number 10 \u00E2\u0080\u00A2 Yes How has your weight changed? Q increased r___ decreased Why? Please specify What is your smoking habit? Check one. | | Nonsmoker: never smoked or not smoked for 5 years [ | Past smoker: not smoked for less than 5 years | | Cigarettes: 20 or more per day | [ Cigarettes: 10-19 per day | | Cigarettes: less than 10 per day [ | Cigars or pipes ONLY: 5 or more per day or any amount inhaled | | Cigars or pipes ONLY: less than 5 per day not inhaled Have you ever been treated for any of the following (check as many as apply): | | High blood pressure Q Angina | [ High blood fat levels \u00C2\u00A3j Diabetes | | High blood cholesterol levels None of the above | | Heart attack Has anyone in your immediate family (husband, wife, children or brother, sister, parent) ever had high blood pressure, stroke, high blood fat levels and/or heart attack? | | Yes [_ No [_] D o n o t k n o w _(20) (21,22,23) (24,25,26) (27) (28) _(29) _(30) _(31) _(32) _(33) _(34) _(35) (36) 219 - 7 -13. There are many sources from which one can obtain information about d i e t and heart disease. Check [\/| the source(s) from which you have obtained information on di e t and heart disease (check as many as apply): 37 \u00E2\u0080\u00A2 Doctor 50 \u00E2\u0080\u00A2 Labels on foods 38 \u00E2\u0080\u00A2 Weight control group 51 \u00E2\u0080\u00A2 N u t r i t i o n i s t , d i e t i t i a n 39 \u00E2\u0080\u00A2 Action B.C. 52 \u00E2\u0080\u00A2 Home economist, home ec teacher 40 \u00E2\u0080\u00A2 Exhibits or displays 53 \u00E2\u0080\u00A2 Nurse 41 \u00E2\u0080\u00A2 Health food store 54 \u00E2\u0080\u00A2 YM/YWCA 42 \u00E2\u0080\u00A2 Family 55 \u00E2\u0080\u00A2 Radio 43 \u00E2\u0080\u00A2 Newspapers 56 \u00E2\u0080\u00A2 Fitness i n s t r u c t o r 44 \u00E2\u0080\u00A2 Magazines 57 \u00E2\u0080\u00A2 Teacher 45 \u00E2\u0080\u00A2 Grocery store 58 \u00E2\u0080\u00A2 Drug store 46 \u00E2\u0080\u00A2 Books 59 \u00E2\u0080\u00A2 Service club 47 \u00E2\u0080\u00A2 Cookbooks 60 \u00E2\u0080\u00A2 None 48 \u00E2\u0080\u00A2 Friends 61 \u00E2\u0080\u00A2 Other, please specify below 49 \u00E2\u0080\u00A2 T e l e v i s i o n PLEASE CHECK TO BE SURE ALL THE QUESTIONS HAVE BEEN ANSWERED YOUR DIETARY PRACTICES We are interested i n determining your \"usual\" eating habits. To help you remember, three questions w i l l be asked. Question 1: What did you eat yesterday? Think of yesterday, hour by hour, and record on the back of t h i s page EVERYTHING you ate and drank from the time you got up i n the morning u n t i l you went to bed at night and what you ate during the night. Mention meals, snacks, and drinks of a l l kinds taken at home, at work, and away from home. BE AS ACCURATE AS POSSIBLE. Record the KIND of food and AMOUNT that you ate. Use average household servings, sizes or portions and describe the food as completely as possible. Say i f i t d i f f e r e d from your \"usual\". SAMPLE: Food type/preparation Amount Var i a t i o n from \"Usual\" MID DAY: Fish, cod, f r i e d i n one tablespoon butter Pie, apple (2 crust) Beer, H i g h l i t e 4 oz. cooked 1/6 of 9\" pie 2 - 12oz, bottles Usually have cheese sandwich and tea CONTINUE ON BACK OF PAGE 220 (8 ) (9) - 8 Did you eat i n the LATE MORNING? D No If yes, what? (10) Did you eat MID DAY? ( I D (12) D No If yes, what? Did you eat an EVENING MEAL? LZi No If yes, what? (13) Did you eat a f t e r the EVENING MEAL? \u00E2\u0080\u00A2 No If yes, what? 2 2 1 - 9 -Question 2: What is your GENERAL EATING PATTERN, including supplements? Please check \u00E2\u0080\u00A2 or f i l l in the appropriate blanks below. A. Was your intake yesterday unusual in any way? [ | No - go to B (14) \u00E2\u0080\u00A2 Yes Why was your intake yesterday unusual? Please specify In what way was your intake yesterday unusual? Please specify Are you taking any food or nutrient supplement? | | Yes \u00E2\u0080\u00A2 No - go to C When did you last take a food or nutrient supplement? \u00E2\u0080\u00A2 within the past three months | | not within the past three months What kind? Check and write the name below: | | Vitamin | | Mineral \u00E2\u0080\u00A2 Both _ \u00E2\u0080\u00A2 Food (15) (16,17) (18) On whose advice? | | Doctor/nurse \u00E2\u0080\u00A2 Self I |Other, please specify Do you currently (within the past year) drink alcoholic beverages? ! | Yes \u00E2\u0080\u00A2 No - go to D What type of alcoholic beverage(s) do you drink? | [ wine, 4 oz. \u00E2\u0080\u00A2 light beer (3.5 or less % alcohol), 12 oz. \u00E2\u0080\u00A2 j ale/beer (5% or more alcohol), 12 oz. \u00E2\u0080\u00A2 j spirits/hard liquor, 1-1*5 oz. How much? (The amount beside each type of drink above equals one drink) [ |less than 2 drinks per week | | 2 to 10 drinks per week | |10 to 25 drinks per week | | over 25 drinks per week _(19,20) (21) CONTINUE ON BACK OF PAGE 222 - 10 D. Do you use salt? 1) at the table Q No If yes, check: 2) in cooking _ j No If yes, check: 3) before tasting Q No If yes, check: A) after tasting Q No If yes, check: ALWAYS FREQUENTLY SOMETIMES SELDOM E. Do you have any food dislikes? \u00E2\u0080\u00A2 N\u00C2\u00B0 _(22) _(23) _(2A) _(25) (26) Yes go to F \u00E2\u0080\u00A2 What food dislike(s) do you have? Please specify F. Do you eat the same on weekends as you do during the week? Q Yes - go to G (27) What is the difference between your weekday and weekend eating practices? Please specify -\u00E2\u0080\u0094-\u00E2\u0080\u0094 G. Do you usually skip or omit a meal? | | No - go to H (28) \u00E2\u0080\u00A2 Yes Which meal(s)? | | Breakfast | j Lunch: Noon1 meal | | Dinner: evening meal How long have you followed your present pattern of eating? | [ Less than one month | j A few months | [ Over one year (29) 223 - 11 -Question 3: HOW FREQUENTLY do you eat each of the following common foods? Please indicate by checking [ y ] . This is only an estimate, but try to be as accurate as possible. Average serving sizes or portions are noted beside each food, to serve as a guide. (C. = cup; oz. = ounce; Tbsp. = tablespoon; Tsp. = teaspoon) ALWAYS FREQUENTLY SOMETIMES SELDOM/NEVER AVERAGE at least not daily;more less than less than PORTION one/day than one/week once/week once/month 4 (8) Cream, whole 2 Tbsp. Half & Half 1 Tbsp. (9) Milk ( a l l forms) lC.(8oz.) (10) Yoghurt, a l l types 6 oz. ( I D Cheese ( a l l types) 1 oz. (12) Cottage cheese 2 Tbsp. (13) Meat/fish/poultry 3 oz. (14) Ham 1 oz. (15) Bacon, side/back 1 strip (16) Organ meat (liver) 3 oz. (17) Weiners (hot dogs) 2 (18) Dried beans/peas 1/2 C. (19) Eggs, medium 1 (20) Grapefruit (h) orange 1 (21) as iuice 1/2 C. (22) Tomato and/or iuice 1/2 C. (23) Dried fruit 1/2 C. (24) Other fruit/canned/ frozen/cooked/raw 1 or 1 C. (25) Dk. green, yellow and/or orange vegetables 1/2 C. (26) Other vegetables 1/2 C. (27) Potatoes, mashed 1/2 C. (28) baked/boiled 1 (29) French fried 1 C. (30) Bread/roll/muffin/ biscuit 1 (31) Bkfst. cereal, dry 1 C. (32) cooked 3/4 C. (33) Spaghetti/macaroni/ rice/noodles 3/4 C. (34) CONTINUE ON BACK OF PAGE 224 - 12 -ALWAYS FREQUENTLY SOMETIMES SELDOM/NEVER AVERAGE at least not daily;more less than less than PORTION one/day than one/week once/week once/month (35) Salty crackers 2 Pl a i n crackers 2 (36) Butter 1 Tbsp. (37) Peanut butter 1 Tbsp. (38) Margarine, soft 1 Tbsp. (39) Margarine, regular 1 Tbsp. (40) Vegetable o i l s 1 Tbsp. (41) Mayonnaise or Salad Dressing 1 Tbsp. (42) Lard and/or shortening 1 Tbsp. (43) Puddings 1 C. (44) Pie/pastry l/6of 9\" (45) Cookies, a l l types l - 2 \" s i z e > (46) Cake/doughnut 1 (47) Candy, chocolate 3/4 oz. (48) Candy, other 1 oz. (49) Jam/ielly 2 Tbsp. (50) Syrup/molasses 2 Tbsp. (51) Ice cream 1/2 C. (52) Soft drinks 8 oz. (53) Potato chips/corn chips 10 about 2\" i n s i z (54) Pizza, a l l kinds 1/8 of 14\" (55) Nuts/peanuts 1/2 C. (56) Coffee, regular 1 C. (57) Coffee, decaffeinated 1 C. (58) Tea 1 C. (59) Other If any food items that you usually eat have been omitted from the above table, please add and check the frequency. THANK YOU VERY MUCH FOR YOUR TIME AND COOPERATION. APPENDIX B PROCEDURES FOR NUTRITION PRACTICE INTERVIEWS 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 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 B . 3 . I n t e r v i e w S c h e d u l e 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 Interview s c h e d u l i n g : Mr. X, I am , c a l l i n g about the d i e t and hea r t d i s e a s e survey i n which you p a r t i c i p a t e d a t community c e n t r e . You have been s e l e c t e d at random f o r an i n t e r v i e w about your food h a b i t s . A l l answers w i l l be t r e a t e d c o n f i d e n t i a l l y and no names w i l l be used i n the a n a l y s i s . Have you completed and mailed the q u e s t i o n n a i r e ? yes no. ( I f no, ... do you i n t e n d to complete i t ? Would you l i k e a second copy to r e p l a c e the one l o s t , \"etc.)? I f so, take the address. ( I f yes, ... I would l i k e to come and t a l k w i t h you about your food h a b i t s on (date) I t should take about 30 minutes. Please g i v e me the white f i l e card t h a t came w i t h the q u e s t i o n n a i r e , at t h a t time. TIME: What time i s most convenient? PLACE: S h a l l I c a l l a t your home? Address? or \"_ ? I f he h e s i t a t e s , at community centre.) Before s a y i n g good-bye, rep e a t \"I s h a l l see you a t \" ( i ) time ( i i ) p l a c e ( i i i ) day and date. 2 2 7 MEETING: ( i ) I d e n t i f y s e l f (may show i d e n t i f i c a t i o n f o r m ) . ( i i ) R e p e a t t h e s u r v e y name a n d UBC. ( i i i ) E m p h a s i z e a n s w e r s a r e c o n f i d e n t i a l . T h e n , p r o c e e d w i t h t h e i n t e r v i e w . 228 B . 2 . Anthropometric Measurements For both h e i g h t and weight measurement, the person should he i n s t r e e t c l o t h i n g ( l i g h t ) and without shoes. Ask him to remove outer j a c k e t , sweater, e t c . , i f necessary. Height measurement: taken w i t h the i n d i v i d u a l i n the p o s i t i o n as f o l l o w s : 1. Place board on f l o o r at r i g h t angles to a w a l l without a baseboard, or a door. 2. D i r e c t the person to stand on the board, as t a l l as p o s s i b l e , w i t h head, s h o u l d e r s , b u t t o c k s , and heels t o u c h i n g the w a l l . Arms should be s t r a i g h t at t h e i r s i d e s . 3. Place the wooden plaque so t h a t i t makes a r i g h t angle w i t h the w a l l and the crown of the person's head. 4. Hold the plaque a g a i n s t the w a l l and ask the person to come away from the w a l l , and to h o l d the plaque i n p o s i t i o n so you can measure the h e i g h t . 5. With the tab of the metal tape, connect over the wooden plaque and lower the tape u n t i l the case r e s t s f l a t on the board. Be sure the d i r e c t i o n i s s t r a i g h t down wit h no bend or r i p p l e i n the tape. Lock the tape i n p o s i -t i o n . 6. Record the r e a d i n g to the n e a r e s t 1/32\" (adjustment w i l l be made l a t e r , so note the s i d e of the plaque used i . e . , 3\" or | \" ) . 229 Weight measurement: 1. Ask the person to stand s t r a i g h t ; look ahead, not down at h i s f e e t ; a v o i d moving and f a c e the f r o n t of the s c a l e s . 2 . Record the weight to the nearest pound or k i l o g r a m . B.3- I n t e r v i e w Schedule Interview Schedule Code No. Date Sex Height no shoes Your age: 19-24 25-29 30-35 36-39 40-44 45-50 51-54 55-59 Present weight 60-66 60+ Your present occupation: (Give as complete a description as possible. If a student: intended; retired: past; unemployed: usual one; homemaker: spouse's) 1. Your regular exercise pattern: (a) How would you describe your activity pattern at work and leisure? (b) Do you follow any regular program of exercise? (c) What about your walking habits - how many miles might you walk per day? Do you climb stairs regularly? How many flights? Sedentary: work and leisure. Under 5 flights of stairs or half milk walking per day. Low moderate: some activity work.and leisure. Between 5 and 15 flights of stairs or 0.5 to 1.5 miles walking or comparable daily activity. High moderate: programmed exercise 4 times per week or 1.5 to 2 miles of walking or 15 to 20 flights of stairs or comparable daily activity. Vigorous: greater than high moderate 2. Your smoking habit: Check one. (Show card to help the participant remember the quantities). Nonsmoker; not smoked for 5 years or never smoked Past smoker; not smoked for less than 5 years Cigarettes; 20 or more per day Cigarettes; 10-19 per day Cigarettes; less than 10 per day Cigars/pipes ONLY; 5 or more per day or any amount inhaled Cigars/pipes ONLY; less than 5 per day not inhaled 3. Are you taking any food or nutrient supplement? yes no. Skip to question 4 Within past 3 months Not within the past 3 months Page What kind of food/nutrient supplement? Vitamin Mineral Both Food Other (e.g. yeast/tonic), please specify: Whose advice? Doctor/nurse Self Other, specify: Do you have a history of previous weight change? No Yes increased? decreased: Why? Please specify: Do you have any food dislikes? No Yes What? Do you have any food allergies? No Yes , please specify: Do you avoid eating any particular food(s)? No Yes , please specify: We are interested in determining your \"usual\" eating habits. Let us begin by looking at what you ate yesterday. Think of yesterday, hour by hour, from the time you got up in the morning until you went to bed at night and i f you ate during the night. Then we w i l l compare that day with your \"usual\" day. 232 Page 3 Food Kind/Preparation | Amount Var i a t i o n from \"usual\" Morning? Late Morning? Mid Day? Afternoon? Evening Meal? After Evening Meal? Page 4 Comments: (including variations on weekends, eating out etc.): 1. a) Do you eat the same on weekends as you do during the week? yes no Difference? b) Do you usually skip or omit a meal? If yes, which one(s)? Breakfast yes Lunch (noon) Dinner (evening) c) How long have you followed your present pattern of eating? Less than one week Over one year A few months d) Do you currently (within the past year) drink alcoholic beverages? yes (show card) no - go to (e). What type of alcoholic beverage(s) do you drink? wine, 4 oz. light beer (3.5 or less % alcohol), 12 oz. ale/beer, 12 oz. spirits/hard liquor, oz. How much? (The amount beside each type of drink above equals one drink) less than 2 drinks per week 2 to 10 drinks per week 10 to 25 drinks per week over 25 drinks per week e) Do you use salt? 1) at the table No 2) in cooking No 3) before tasting No 4) after tasting No If yes, how often? If yes, how often? If yes, how often? If yes, how often? ALWAYS FREQUENTLY SOMETIMES SELDOM Page 5 I would now l i k e to f i n d out how frequently you eat each of the following foods. (Show card) AVERAGE PORTION ALWAYS at lea s t one/day FREQUENTLY not daily;more than one/week SOMETIMES less than once/week SELDOM/NEVER less than once/month Cream, whole 2 Tbsp. Half & Half 1 Tbsp. Milk ( a l l forms) IC.(8oz.) Yogurt, a l l types 6 oz. Cheese ( a l l types) 1 oz. Cottage cheese 2 Tbsp. *-\"r? \u00E2\u0080\u0094 Meat/fish/poultry 3 oz. Ham 1 oz. Bacon, side/back 1 s t r i p Organ meat ( l i v e r ) 3 oz. Weiners (hot dogs) 2 Dried beans/peas h C. Eggs, medium 1 Grapefruit (h) orange 1 as i u i c e h C. Tomato and/or i u i c e h c. Dried f r u i t h c. Other fruit/canned/ frozen/cooked/raw 1 or IC. Dk. green, yellow and/or orange vegetables h c Other vegetables h c Potatoes, mashed 4 c baked/boiled l French f r i e d 1 C. Bread/roll/muffin/ b i s c u i t 1 Bkfst.cereal, dry 1 c. cooked 3/4 C. Spaghetti/macaroni/ rice/noodles 3/4 C. Page 6 ALWAYS FREQUENTLY SOMETIMES SELDOM/NEVER AVERAGE at least not daily;more less than less than PORTION\" one/day than one/week once/week once/month , : \u00C2\u00A3 , : 1 1 Salty crackers 2 , \u00E2\u0080\u0094 jPlain crackers 2 Butter 1 Tbsp. Peanut butter 1 Tbsp. Margarine, soft 1 Tbsp. Margarine, regular 1 Tbsp. Vegetable oils 1 Tbsp. Mayonnaise or Salad Dressing 1 Tbsp. Lard and/or shortening \u00E2\u0080\u00A21 Tbsp. Puddings 1 C. Pie/pastry l/6of 9\" Cookies, a l l types l-2\"size Cake/doughnut 1 Candy, chocolate 3/4 oz. Candy, other 1 oz. Jam/jelly 2 Tbsp. Syrup/molasses 2 Tbsp. Ice Cream h C. Soft drinks 8 oz. Potato chips/corn chips 10 about 2\"in size Pizza, a l l kinds l/8ofl4\" Nuts/peanuts 1/2 C. Coffee, regular 1 C. Coffee, decaffeinated 1 C. Tea 1 C. *Other \ *Are there any foods that I have missed but which you eat regularly? Page 7 As the interviewer, what is your impression of this interview? Acceptable Not acceptable Reason? How long did this interview take? 30-45 minutes 45-60 minutes Longer, please specify: Thank you very much for your time. Your cooperation is most appreciated, (or similar thank you). 237 APPENDIX C COMMUNITY CENTRE CORRESPONDENCE 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 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 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 238 THE UNIVERSITY OF BRITISH COLUMBIA 2075 WESBROOK MALL VANCOUVER, B.C., CANADA V6T 1W5 DIVISION OF H U M A N NUTRITION SCHOOL OF HOME ECONOMICS A p r i l 19\u00C2\u00BB 1979 D e a r As r e c r e a t i o n c o o r d i n a t o r o f C o m m u n i t y C e n t r e , we a r e e n l i s t i n g y o u r c o o p e r a t i o n i n a s u r v e y w h i c h we p l a n t o c o n d u c t d u r i n g May among a d u l t members 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 s . The s u r v e y i s e n d o r s e d b y t h e B . C . H e a r t F o u n d a t i o n a n d i i s d e s i g n e d t o i n v e s t i g a t e 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 a d u l t s w i t h r e s p e c t t o d i e t a n d h e a r t d i s e a s e . T h i s i n f o r m a t i o n w i l l p r o v i d e a v a l u a b l e b a s i s f o r h e a l t h e d u c a t o r s p l a n n i n g p r o g r a m s f o r s u c h a g e n c i e s as t h e B . C . H e a r t F o u n d a t i o n a n d t h e M i n i s t r y o f H e a l t h . T h i s p a s t y e a r , a q u e s t i o n n a i r e was d e v e l o p e d a n d p r e t e s t e d t h r o u g h t h e c o o p e r a t i o n o f t h e M a r p o l e - O a k r i d g e Com-m u n i t y C e n t r e . We a r e now a s k i n g f o r y o u r p e r m i s s i o n t o a p p r o a c h members o f y o u r c o m m u n i t y c e n t r e r e g i s t e r e d f o r s p e c i f i c p r o g r a m s t h i s S p r i n g . I f y o u a r e a b l e t o h e l p u s , p l e a s e s i g n t h e 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 a n d r e t u r n t o me a t y o u r e a r l i e s t c o n v e n i e n c e i n t h e e n v e l o p e p r o v i d e d . S h o u l d y o u be u n a b l e t o c o m p l y , we w o u l d a p p r e c i a t e y o u r i m m e d i a t e r e t u r n o f t h e f o r m i n d i c a t i n g y o u r i n a b i l i t y t o p a r t i c i p a t e . I hope t h i s e x p l a n a t i o n i s s u f f i c i e n t t o g i v e y o u a n a p p r e c i a t i o n o f t h e r e s e a r c h we w i s h t o c o n d u c t . S h o u l d y o u h a v e q u e s t i o n s c o n c e r n i n g t h i s r e q u e s t , I s h a l l be p l e a s e d t o a n s w e r t h e m w h e n I t e l e p h o n e y o u o n A p r i l 25. A c o p y o f t h e c o v e r l e t t e r u s e d f o r t h e M a r p o l e - O a k r i d g e C o m m u n i t y C e n t r e S u r -v e y a n d a s a m p l e c o n s e n t f o r m a r e e n c l o s e d f o r y o u r i n f o r m a t i o n . A s i m i l a r l e t t e r a n d c o n s e n t f o r m w o u l d a c c o m p a n y t h e q u e s t i o n -n a i r e t o be d i s t r i b u t e d t o y o u r c o m m u n i t y c e n t r e m e m b e r s . Y o u r s t r u l y , D o c t o r a l C a n d i d a t e D i v i s i o n o f Human 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 E n c l o s u r e s 239 THE UNIVERSITY OF BRITISH COLUMBIA 2075 WESBROOK MALL VANCOUVER, B.C., CANADA V6T 1W5 DIVISION OF HUMAN NUTRITION -SCHOOL OF HOME ECONOMICS TO COMMUNITY CENTRE COORDINATOR: I F YOU AGREE TO PARTICIPATE I N THE MAY SURVEY: 1 . YOU W I L L BE ASKED TO HELP COMPILE A L IST OF NAMES OF ADULT MEMBERS WHO PARTICIPATE I N CLASSES ON ONE SPECIF IC DAY OF THE WEEK. FORTY NAMES W I L L BE SELECTED AT RANDOM FROM THE L I S T . 2. YOU W I L L BE ASKED TO ASSIST THE RESEARCHER I N S O L I C I T I N G VOLUNTEERS FROM THE FORTY SELECTED MEMBERS. I a g r e e t o a s s i s t A n n S u l l i v a n i n s e l e c t i n g f o r t y s u b j e c t s f r o m o u r C o m m u n i t y C e n t r e M e m b e r s h i p t o p a r t i c i p a t e i n 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 a n d f u r t h e r a u t h o r i z e h e r t o c o n t a c t t h o s e members i n t h e p r o g r a m s f o r w h i c h t h e y a r e r e g i s t e r e d . I u n d e r -s t a n d t h a t a l l i n f o r m a t i o n w i l l be h e l d i n c o n f i d e n c e a n d names w i l l n o t be i n c l u d e d i n t h e d a t a a n a l y s i s . S i g n a t u r e : D a t e : A r e y o u u n a b l e t o a u t h o r i z e t h i s May s u r v e y r e q u e s t ? YES S i g n a t u r e : D a t e : Do y o u w i s h t o m e e t t h e s u r v e y o r g a n i z e r f o r f u r t h e r i n f o r m a -t i o n : YES NO. I f y e s , y o u w i l l be c o n t a c t e d as s o o n as p o s s i b l e f o r a n a p p o i n t m e n t . 24 0 THE PURPOSE OF T H I S SURVEY I S TO GAIN A BETTER UNDERSTANDING OF FACTORS RELATED TO DIET AND HEART DISEASE AMONG ADULTS I N THE GREATER VANCOUVER AREA. I F YOU AGREE TO PARTICIPATE I N T H I S SURVEY: 1 . YOU W I L L BE ASKED TO COMPLETE A QUESTIONNAIRE INCLUDING INFORMATION RELATED TO YOUR D I E T , YOUR BELIEFS ABOUT THE ROLE THAT DIET PLAYS I N HEART D ISEASE, AND SOME INFORMATION ABOUT YOU AND YOUR F A M I L Y . THE QUESTIONNAIRE W I L L THEN BE RETURNED BY M A I L I N THE STAMPED, ADDRESSED ENVELOPE PROVIDED. 2 . YOU MAY BE ASKED TO TAKE PART I N ONE INTERVIEW CONCERNING YOUR DIETARY PRACTICES AND RELATED INFORMATION. 3 . A L L INFORMATION W I L L BE HELD I N CONFIDENCE AND NAMES W I L L NOT BE USED I N THE DATA ANALYSIS . 4 . THE RESULTS OF THE STUDY W I L L BE ANALYZED AND THE KNOWLEDGE OBTAINED USED TO DESIGN EFFECTIVE PUBLIC EDUCATION PROGRAMS ON D I E T AND HEART DISEASE. *************************** I , . h a v e h a d t h e s u r v e y e x p l a i n e d t o me (PLEASE PRINT) a n d a g r e e t o p a r t i c i p a t e . I u n d e r s t a n d t h a t I may d e c l i n e t o a n s w e r o r I may w i t h d r a w f r o m t h e s t u d y a t a n y t i m e . S i g n a t u r e : D a t e : __ T h i s s u r v e y has b e e n a p p r o v e d a n d a u t h o r i z e d b y t h e 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 s . Y o u r p a r t i c i p a t i o n o r l a c k t h e r e o f i n t h e s u r v e y w i l l i n no way i n f l u e n c e y o u r m e m b e r s h i p i n t h e C o m m u n i t y C e n t r e . APPENDIX D SCORING PROCEDURE FOR THE PRACTICE INSTRUMENT D . l . P r o c e d u r e 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 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 242 D . 1 . P r o c e d u r e A . Compare t h e r e c o r d e d i n t a k e ( y e s t e r d a y ' s 2 4 - h o u r r e c a l l ) w i t h t h e ' v a r i a t i o n f r o m u s u a l ' comments ( q u e s t i o n 1 o f t h e i n s t r u m e n t ) . Make a d j u s t m e n t s as n e c e s s a r y . B. C h e c k t h e r e s p o n s e s t o q u e s t i o n 2: g e n e r a l e a t i n g p a t t e r n . I f i n t a k e f o r y e s t e r d a y was u n u s u a l , c h e c k t h e comments a g a i n s t t h e ' v a r i a t i o n f r o m u s u a l * a n d make a d j u s t m e n t s as n e c e s s a r y . C. C h e c k t h e a l c o h o l c o n s u m p t i o n p a t t e r n f o r t y p e a n d a m o u n t . A d d t h e q u a n t i t i e s s t i p u l a t e d b y t h e p r e - e s t a b l i s h e d c h a r t ( s e e A p p e n d i x D . 2 . ) . D. Compare t h e f o o d s f r o m t h e 2 4 - h o u r r e c a l l a g a i n s t t h e f r e -q u e n c y c h e c k l i s t . F o r t h o s e i t e m s consumed a t l e a s t o n c e p e r d a y , b u t n o t i n c l u d e d i n t h e 24 - h o u r r e c a l l , a d d one p o r t i o n u n l e s s o t h e r w i s e i n d i c a t e d ; i f a n i t e m i s c h e c k e d ' f r e q u e n t l y ' , a d d _\u00E2\u0080\u00A2 p o r t i o n . E . T o g e t h e r , i t e m s A t o D p r o v i d e a l i s t o f s p e c i f i c f o o d s w i t h t h e a m o u n t u s u a l l y c o n s u m e d . T h i s g i v e s 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 f o r t h e i n d i v i d u a l . F . The s p e c i f i c f o o d s a r e t h e n c o d e d ( s e e 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 a m o u n t s , A p p e n d i x D . 3 \u00C2\u00AB ) , a c c o r d i n g t o t y p e a n d s e r v i n g s i z e , i n t o t h e f o o d r e c o r d b o o k l e t s f o r l a t e r c o n v e r s 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 f o r m e d o n t h e b a s i s o f c o m p o s i t i o n t a b l e s . 24-3 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 D r i n k s p e r week T y p e s A d d i t i o n s t o t h e ' u s u a l i n t a k e ' l e s s t h a n 2 a l l 4- 2 oz b e e r , _ oz w i n e w i n e 1.3 \u00C2\u00B0 z w i n e b e e r 4- oz b e e r s p i r i t s _ oz l i q u o r 2 t o 10 a l l 4 1 oz w i n e , 6 oz b e e r , .4- oz s p i r i t s w i n e ' 4- oz w i n e b e e r 12 oz b e e r s p i r i t s 1 oz l i q u o r 10 t o 25 a l l 4- 2 .5 oz w i n e , 14- oz b e e r , w i n e 10 oz w i n e b e e r 30 oz b e e r s p i r i t s 3 oz l i q u o r .9 oz s p i r i t s more t h a n 25 a l l 4- 3-5 oz w i n e , 20 oz b e e r , 1 oz l i q u o r w i n e 14 oz w i n e b e e r 42 oz b e e r s p i r i t s 4-.5 oz l i q u o r 244 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 A . C e r e a l , r e a d y t o e a t : c o d e as c o r n f l a k e s , K e l l o g g s . B. C e r e a l , a m o u n t o f m i l k u n s p e c i f i e d : code as \ C p e r 1 C c e r e a l . C . A m o u n t o f b u t t e r o r m a r g a r i n e a d d e d jto p a n c a k e s , w a f f l e , F r e n c h t o a s t : 1 t s p . D . A m o u n t o f b u t t e r o r m a r g a r i n e a d d e d ( o r c o o k e d i n ) t o v e g e -t a b l e s , u n k n o w n : code 1 t s p p e r 1 C v e g e t a b l e s . E . A m o u n t o f d r e s s i n g s o n s a l a d , u n k n o w n : c o d e 1 t b s p p e r C o f s a l a d . F . A m o u n t o f b u t t e r o r m a r g a r i n e s p r e a d o n b r e a d o r s a l t i n e : c o d e 1 t s p a n d _j t s p , r e s p e c t i v e l y . G. G r i l l e d s a n d w i c h e s : c o d e as r e g u l a r s a n d w i c h w i t h 1 t s p m a r g a r i n e p e r s l i c e o f b r e a d . H. Raw f r u i t , u n k n o w n s i z e : code as m e d i u m . I . B r e a d e d m e a t / f i s h / p o u l t r y : c o d e 1 t b s p b r e a d c r u m b s p e r 4 oz p o r t i o n . J . E g g s i z e u n k n o w n : code l a r g e . K. P e a n u t b u t t e r , amount u n s p e c i f i e d : code 1 t b s p p e r s a n d -w i c h ( 2 s l i c e s ) . L . Cheese o m e l e t , c h e e s e a m o u n t u n s p e c i f i e d : c o d e 1_- t b s p c h e e s e p e r e g g u s e d . M. I c e c r e a m s u n d a e , a m o u n t u n k n o w n : code -\u00C2\u00A7- C i c e c r e a m , 2 t b s p c h o c o l a t e s y r u p , i f c h o c o l a t e ; 2 t b s p p r e s e r v e s , e t c . N. M i l k , amoun t n o t s p e c i f i e d : code 1 C a n d w h o l e . 0 . C o c o a made w i t h e v a p o r a t e d m i l k : \ C e v a p o r a t e d m i l k p e r c u p . P. O l i v e s : c o d e as g r e e n o l i v e s . Q. V e g e t a b l e s e a t e n away f r o m home: assume 1 t s p f a t p e r C i s a d d e d . R. S u g a r o n c e r e a l , u n k n o w n : code 1 t s p p e r C, d r y o r 1 t s p p e r 1_- C, c o o k e d . 24-5 S . S y r u p a m o u n t u n k n o w n : c o d e 1 t b s p p e r p a n c a k e , w a f f l e , o r p i e c e o f F r e n c h t o a s t . T . W h i p p e d t o p p i n g o n d e s s e r t : c o d e as 1 t b s p t o p p i n g p e r C d e s s e r t . U. C h e e s e , u n s p e c i f i e d : c o d e Cheddar. V . C o o k i e s , u n s p e c i f i e d : c o d e s a n d w i c h - t y p e . W. C r e a m , u n k n o w n a m o u n t : c o d e 1 t s p p e r 6 oz c o f f e e ; 1 a n d 1 / 3 t s p p e r 8 oz C. APPENDIX E MEAN AND STANDARD DEVIAT ION FOR EACH ATTITUDE AND KNOWLEDGE SUBTEST AND PRACTICE SCORE BY CENTRE, SEPARATELY AND COMBINED E . 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 E . 2 . P r a c t i c e R a t i o S c o r e s E . l . Mean a n d S t a n d a r d D e v i a t i o n o f 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 a n d T o t a l T e s t s 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 . A: GEN ROLE A:MANAGE A:TOTAL K:AFFECTS KrCOMP K:FACTS K:TOTAL 1 (30) X S , D . 42 .73 3-57 38.30 3.60 81 .03 6.74 9.20 1.56 10.90 2.63 9-37 3.22 29.47 5.72 2 ( 2 8 ) X S . D . 4 1 . 1 4 4.15 37.57 3.44 78.71 6.92 8.75 I .60 9-79 3.25 9 . 46 2.73 28.00 5.31 3 (27) X S . D . 42 .63 5.29 37.74 3.10 80.37 7.86 8.44 1.91 9.37 2.65 8.78 2.98 26.59 6.23 4 (16) X S . D . 40 .12 3 . 8 1 36.94 3.94 77 .06 6.98 8.06 1.95 8.25 2.35 7-75 3.38 24 .06 6.57 5 (29) X S . D . 40 .72 4.56 36.83 3.32 77.55 7.20 7.52 2.05 9.52 3.55 8.69 3 . 6 4 25.72 7.68 6 (35) X S . D . 40.57 5 . 40 36.54 5.12 77.11 9.94 7.97 2.32 9.26 2.78 7.71 3.52 24 .94 7.21 7 ( 1 8 ) X S . D . 40 .67 5 . 28 37.44 3-87 78.11 8.66 8.72 2.22 9.22 2.98 7.89 3-38 25.83 6.62 8 (27) X S . D . 41 .33 3.68 37.52 3.97 78.85 7.16 8.26 1.83 9.52 3.67 8.07 2.67 25.85 7.12 9 (17) X S . D . \" 4 1 . 8 2 3 . 8 1 36.06 3.88 77-88 6.80 8.59 1.73 9-59 4.43 9.12 3.37 27.29 8.27 E.I. Mean and Standard Deviation of Attitude and Knowledge Subtests^and Total Tests by Community Centre, Separately and Combined (continued) Centre A: GEN 'SOLE A:MANAGE A:TOTAL K:AFFECTS K.C0MP K:FACTS K:TOTAL 10 (25) X S .D. 42.16 4.28 37.68 4.68 79.84 7.96 8.32 2.46 10.24 3.94 9.4o 3.71 27.96 8.47 11 (29) X S .D. 43.69 4.16 38.59 4.44 82.28 8.01 8.97 2.01 10.17 - 2.83 9.55 2.40 28.69 5.63 Combined (281) X S .D. 41.67 4.49 37.43 4.01 79.10 7.84 8.43 2.01 9.69 3.21 8.74 3.21 26.86 6.88 E . 2 . Mean a n d S t a n d a r d D e v i a t i o n o f P r a c t i c e R a t i o \" S c o r e s \" \" ( R a n g e 0 t o 1 ) 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 C e n t r e ( n ) KCAL PROT CA FE VA T H I 1 (SO) X . 7 3 . 9 5 . 8 4 \u00E2\u0080\u00A2 72 . 8 9 . 8 3 S .D . .19 . 1 1 . 2 0 . 2 2 . 1 8 . 2 1 2 ( 2 8 ) X . 7 9 . 9 7 . 7 8 \u00E2\u0080\u00A2 70 . 8 2 . 7 9 S . D . .16 . 0 8 . 2 2 . 2 0 . 2 4 . 2 1 3 (27) X .71 . 9 8 . 7 8 .71 . 8 5 . 8 0 S . D . . 1 8 .06 . 2 2 .19 . 20 . 2 1 4 (16) X .67 . 9 7 .62 .67 . 8 6 . 7 4 S .D . .17 .07 . 2 0 . 2 0 .26 .23 5 ( 2 9 ) X . 6 8 . 9 5 .76 \u00E2\u0080\u00A2 73 . 8 9 .72 S . D . .15 . 1 4 . 2 2 . 1 9 . 2 1 . 2 0 6 ( 3 5 ) X \u00E2\u0080\u00A2 74 . 9 9 \u00E2\u0080\u00A2 74 . 7 5 . 8 1 . 7 5 S .D . \u00E2\u0080\u00A2 17 .03 .23 . 2 4 .25 .19 7 ( 1 8 ) X .71 \u00E2\u0080\u00A2 96 . 7 4 . 7 5 .70 . 6 8 S .D . . 2 0 . 1 0 .25 .23 . 2 8 .25 8 ( 2 7 ) X . 6 6 . 9 5 \u00E2\u0080\u00A2 71 . 8 0 . 8 2 \u00E2\u0080\u00A2 -73 S . D . .19 . 1 2 .25 .25 .23 . 2 1 9 (17) X . 6 4 .96 \u00E2\u0080\u00A2 72 . 6 4 . 8 5 .69 S . D . . 1 6 .09 .23 . 2 2 .24 . 1 8 10 (25) X \u00E2\u0080\u00A2 71 . 9 8 . 8 3 .69 . 8 4 . 7 7 S . D . . 1 8 .05 . 2 0 . 2 0 . 2 2 .19 1 1 (29) X . 5 9 \u00E2\u0080\u00A2 93 \u00E2\u0080\u00A2 73 . 6 4 .76 . 6 4 S . D . . 1 8 . 1 4 .26 . 2 4 . 2 8 . 2 2 C o m b i n e d X .70 .96 .76 .71 . 8 3 . 7 4 ( 2 8 1 ) S . D . . 1 8 . 1 0 .23 . 2 2 . 2 4 . 2 1 250 E . 2 . Mean a n d S t a n d a r d D e v i a t i o n o f P r a c t i c e R a t i o S c o r e s (Range 0 t o l ) 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 C e n t r e ( n ) 1 (30) 2 ( 2 8 ) 3 (27) 4 (16) 5 (29) 6 (35) 7 ( 1 8 ) 8 (27) 9 (17) 10 (25) 11 (29) C o m b i n e d ( 2 8 1 ) RIBO NIA VC FAT CHO X . 9 4 .90 .96 . 8 5 . 5 9 S .D . . 1 4 .15 . 1 4 . 1 4 . 1 1 X .91 . 8 8 . 9 3 . 8 7 . 6 5 S . D . . 1 6 .16 .16 . 1 2 . 1 1 X . 8 8 . 9 2 . 9 9 \u00E2\u0080\u00A2 78 . 6 4 S .D . .15 . 1 4 .03 . 1 4 . 1 4 X .76 . 8 4 . 9 7 . 8 2 .63 S .D . . 1 8 . 1 9 . 1 2 .13 . 1 1 X . 8 3 .80 . 9 4 . 8 0 .69 S .D . .19 . 2 0 . 1 4 .16 .13 X . 8 0 .91 . 9 8 . 8 2 . 6 6 S . D . .19 . 1 4 .06 .16 .17 X . 8 2 . 8 6 . 8 9 . 8 6 . 6 1 S .D . . 2 1 . 2 2 . 2 0 . 0 9 . 1 0 X \u00E2\u0080\u00A2 85 . 8 5 . 9 4 . 8 6 .60 S . D . . 2 0 . 1 8 . 1 8 . 1 4 .17 X . 8 1 . 8 1 .96 . 8 0 . 6 6 S .D . .19 .19 .16 . 1 4 . 1 0 X . 8 8 .90 . 9 8 . 8 4 . 6 5 S . D . . 1 4 . 1 4 .07 . 1 4 .16 X . 8 2 . 8 0 .91 . 8 1 .62 S .D . . 2 2 . 2 2 . 2 0 . 1 4 . 1 1 X . 8 5 . 8 6 . 9 5 . 8 3 . 6 4 S .D . . 1 8 . 1 8 . 1 4 . 1 4 . 1 4 251 APPENDIX F ITEM ANALYSIS DATA FOR ATTITUDE SCALE 252 Summary I t e m S t a t i s t i c s f o r A t t i t u d e S u b t e s t s ( n = 2 8 1 ) S u b t e s t I t e m O p t i o n Wt P Mean S . D . C o r r e l a t i o n ST TT A: GEN R O L E a 1 1 5 31-7 3-99 .97 .38 .50 2 4 48.8 3 3 7.1 4 2 11.4 5 1 1.1 2 1 5 49 .8 4.21 1.03 .27 .35 2 4 35.6 3 3 3.2 4 2 8.9 5 1 2.5 3 1 5 30.6 4.02 .89 .51 .60 2 4 49.5 3 3 12.1 4 2 6.8 5 1 1.1 4 1 5 40 .6 4.21 .88 .43 .51 2 4 48.0 3 3 5.0 4 2 5-0 5 1 1.1 5 1 1 2.1 4.15 .85 .48 .59 2 2 3-2 3 3 7.5 4 4 51.6 5 5 35.6 6 1 5 48.8 4 .42 .66 .46 .53 2 4 46.6 3 3 3-2 4 2 \u00E2\u0080\u00A2 7 5 1 \u00E2\u0080\u00A2 7 7 1 1 1.4 3-72 .89 .16 .38 2 2 10.7 3 3 16.7 4 4 56.9 5 5 14.2 8 1 5 47.0 4.37 .74 .42 .50 2 4 48.0 3 3 1.1 4 2 2.8 5 1 1.1 253 Summary I t e m S t a t i s t i c s f o r A t t i t u d e S u b t e s t s ( c o n t i n u e d ) S u b t e s t I t e m O p t i o n Wt P Mean S .D . C o r r e l a t i o n ST TT A:GEN R0LE a 9 1 1 .4 4.16 \u00E2\u0080\u00A2 70 . 4 8 .61 2 2 1.8 3 3 7.1 4 4 61.6 5 5 28.8 10 l 1 .0 4 . 4 2 .62 . 4 1 .58 2 2 1.8 3 3 1.4 4 4 49.8 5 5 47.0 A : MANAGE1 3 1 1 1 3.6 3 . 6 4 1.12 .35 M 2 2 15.7 3 3 1 9 . 2 4 4 36.7 5 5 2 4 . 9 2 1 5 60.1 4 . 4 1 .97 .16 .45 2 4 31.7 3 3 1.8 4 2 2.8 5 1 2.8 3 1 1 1.8 4.55 .72 .29 .38 2 2 \u00E2\u0080\u00A2 7 3 3 .7 4- 4 34.5 5 5 62.3 4 1 1 1.1 4.35 .62 .38 .51 2 2 .0 3 3 1.4 4 4- 58.0 5 5 39-5 5 1 5 43.4 4.26 .86 .37 .52 2 4 47.3 3 3 3.2 4- 2 4.3 5 1 1.8 6 1 1 .7 3.89 .83 .37 .44 2 2 3.2 3 3 22.8 4 4 50.9 5 5 22.1 254 Summary I t e m S t a t i s t i c s f o r A t t i t u d e S u b t e s t s ( c o n t i n u e d ) S u b t e s t I t e m O p t i o n w t P Mean S . D . C o r r e l a t i o n ST TT A:MANAGE^ 7 1 l , .\u00E2\u0080\u00A24 4.31 .63 . 4 8 .56 2 2 1.4 3 3 2.5 4 4 58.4 5 5 37-4 8 1 5 22.1 3.79 .99 .34 .50 2 4 50.5 3 3 1 4 . 2 4 2 10.7 5 1 2.5 9 1 1 .4 4.23 .77 .51 .60 2 2 3-2 3 3 5-3 4 4 53.4 5 5 37-4 a I t e m s 1 t o 10 a r e n u m b e r e d i n t h e q u e s t i o n n a i r e as 2 , 3 , 5 , 6 ,7 , 1 0 , 1 1 , 1 2 , 1 5 a n d 1 8 , r e s p e c t i v e l y . b I t e m s 1 t o 9 a r e n u m b e r e d i n t h e q u e s t i o n n a i r e as 1 , 4 , 8 , 9 , 1 3 , 1 4 , 16, 17, a n d 19, r e s p e c t i v e l y . 255 APPENDIX G KNOWLEDGE SCORING SYSTEM 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 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 G . l . Summary T e s t S t a t i s t i c s f o r K n o w l e d g e S c a l e u s i n g 5 t o 1; 1,0; a n d 1,1,0 S c o r i n g S y s t e m s K: AFFECTS K:C0MP K:FACTS K: TOTAL N o . i t e m s 8 10 9 5 t o 1 S y s t e m Mean (fo) S . D . (fo) H o y t ' s r S .E . 29.11 2.57 .06 2.33 (72.78) ( 6.42) 38.03 3.70 .43 2.66 (76.10) ( 7.40) 33-53 4.20 .47 2.87 (74.5D ( 9.33) 100.67 (74.57) 7 . 62 A 5 .64) \u00E2\u0080\u00A2 52 a 4.77 l , 0 S y s t e m Mean (%) S . D . (%) H o y t ' s r S . E . 3.32 1.59 .59 .95 (41.50) (19.88) 3.67 1.95 .65 1.09 (36.70) (19.50) 3.36 1.91 .66 1.06 (37.33) (21.22) 10.35 (38.33) 4.62 (17.11) .80 a 1.88 l .1,0 S y s t e m Mean (fo) S . D . (f) H o y t ' s r S . E . 5 . H .82 .04 .75 (63.88) (10.25) 6.02 1.58 .45 1.11 (60.20) (15.80) 5.38 1.62 .47 1.11 (59-78) (18.00) 16.51 (61.15) 2.89 Q(10.70) . 4 6 a 1.83 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) . 257 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 Summary I t e m S t a t i s t i c s f o r K n o w l e d g e S u b t e s t s ( n = 2 8 l ) C o e f f i c i e n t s o f c o r r e l a t i o n Means S u b t e s t I t e m ) t i o n wt P PB-ST B-ST ST TT 1 0 5 9 . 8 .27 . 3 4 8 . 8 7 2 8 . 4 6 2 0 25 .6 -.27 -.36 7.51 24 .50 3 0 3 . 6 - . 1 2 - . 2 8 7 . 2 0 2 0 . 9 0 4 1 8 . 2 - . 0 4 -.07 8.17 25 .43 5 2 2 . 8 . 1 1 .29 9 . 7 5 26 .00 1 0 . 7 - . 0 2 - . 0 8 8 . 0 0 3 2 . 0 0 2 0 3 . 2 - . 1 6 - . 3 9 6.67 2 2 . 1 1 3 0 6 . 8 - . 2 8 - . 5 4 6.32 2 2 . 1 1 4 1 3 9 . 1 - . 4 3 - . 5 5 7 . 3 5 23 .93 5 2 50 .2 .62 . 7 8 9.67 30 .02 1 2 1 . 1 . 2 2 . 8 0 12 .67 3 7 . 3 3 2 1 6 . 4 .07 .13 8 . 9 4 28 .06 3 0 2 2 . 4 - . 1 4 -.19 7.92 24 .48 0 4 4 . 8 - . 1 0 - . 1 3 8 . 2 1 26 .84 5 0 25 .3 .16 . 2 1 8 . 9 7 2 8 . 2 7 1 2 9 . 3 . 3 8 . 6 6 1 0 . 8 1 32 .65 2 1 1 4 . 6 .15 . 2 3 9.17 27 .83 3 0 2 4 . 9 - . 3 7 -.50 7 . 1 4 2 2 . 6 6 0 3 5 . 6 - . 0 4 -.05 8 . 3 3 27 .22 5 0 15 .3 .05 . 0 8 8.67 2 8 . 4 0 1 2 7 9 . 7 .51 \u00E2\u0080\u00A2 72 8 . 9 5 2 8 . 4 1 2 1 15-7 - . 3 9 -.60 6 . 5 9 2 0 . 8 9 3 0 1 . 4 -.16 -.52 5 . 7 5 22 .50 4 0 1 . 4 -.16 -.52 5 . 7 5 16 .00 5 0 1 . 8 - . 1 8 - . 5 3 5 . 8 0 2 2 . 4 0 l 2 70 .1 . 4 8 .63 9.06 29.16 2 1 2 4 . 6 -.36 - . 4 9 7.17 2 1 . 8 7 3 0 1 . 1 - . 1 8 - . 6 5 5 . 0 0 16 .00 0 3 . 6 -.25 -.60 5 . 8 0 19 .80 5 0 . 7 . 0 0 . 0 1 8.50 2 4 . 0 0 1 0 2 . 1 -.17 - . 4 7 6.17 2 4 . 8 3 2 0 1 . 8 -.04 -.13 7 . 8 0 2 7 . 8 0 3 0 . 4 - . 0 1 -.07 8 . 0 0 3 8 . 0 0 1 32 .4 - . 5 5 -.71 6 . 8 5 2 1 . 8 2 5 2 6 3 - 3 . 5 9 .76 9 . 3 4 2 9 . 4 2 K:AFFECTS 1 3 4 Summary I t e m S t a t i s t i c s f o r K n o w l e d g e S u b t e s t s ( c o n t i n u e d ) S u b t e s t C o e f f i c i e n t s o f c o r r e l a t i o n Means ST TT I t e m O p t i o n wt P PB-ST B-ST 8 1 0 .7 -.06 -.26 2 0 1.8 -.19 -.57 3 0 4.3 - .21 -.47 4 1 37.4 -.47 -.60 5 2 55.9 .60 .76 1 l 0 .7 9 .01 -.02 2 0 .7 -.10 - . 4 1 3 0 1.4 -.19. - .61 4 1 6.8 -.25 - . 4 8 5 2 90.0 .33 \u00E2\u0080\u00A2 53 2 1 0 3.6 -.09 - .21 2 0 12.1 -.12 -.19 3 0 32.7 -.36 - . 4 6 1 29.2 .01 .01 5 2 22.1 .53 .74 3 1 0 .0 .00 .00 2 0 1.4 .02 .07 3 0 75.8 -.44 - .60 1 16.7 .26 .38 5 2 6.0 .38 .75 4 l 2 19.6 . 4 8 .70 2 1 29.2 . 0 4 .06 3 0 30.2 -.45 -.59 4 0 19.2 - . 0 4 - .06 5 0 1.8 . 0 8 . 2 4 5 l 2 6.4 .38 .75 2 1 10.0 .07 .12 3 0 4 2 . 7 -.23 -.29 0 34.5 -.03 - . 0 4 5 0 6.4 . 0 4 .08 6 1 0 9.3 .16 .28 2 0 15-3 - . 0 1 - .01 3 0 54.4 - . 4 0 - .51 1 1 4 . 9 .19 .29 5 2 5.7 . 4 0 . 8 1 7 1 0 .7 -.03 -.13 \u00E2\u0080\u00A22 0 2.1 ^ . 0 9 - . 2 4 3 0 6.4 -.33 -.65 1 43.1 -.36 - . 4 6 5 2 47-3 .56 .71 K:AFFECTS 6 -. 6 7 .00 24.50 5.60 2 1 . 4 0 6 . 4 2 2 1 . 4 2 7 . 2 1 23.59 9.51 29.67 K : C 0 M P b 1 . S . 0 1 - . 2 9-50 28 .50 6 . 0 0 23 .00 4.75 1 8 . 0 0 6.74 2 0 . 4 2 10 .04 27.56 8 . 2 0 25 .20 8 . 6 8 2 4 . 6 8 8 .05 2 4 . 2 0 9.73 26.62 1 2 . 8 7 3 2 . 7 4 . 0 0 . 0 0 10 .25 35 .00 8.89 25 .64 11 .53 28 .83 14 .47 34 .82 1 2 . 8 4 3 2 . 8 4 9 . 9 1 26 .73 7 . 4 9 22 .71 9.43 27.06 11 .60 3 1 . 8 0 14.39 34.56 IO .36 27 .36 8.85 25.37 9.57 26 .64 1 0 . 2 2 29 .56 (hi.27 29.50 9.63 27.79 8.50 24.73 1 1 . 1 4 29.07 14 .88 34.69 8.50 25 .00 7 . 83 2 2 . 8 3 5 . 6 1 19 .28 8 .35 23 .88 11 .59 3 0 . 8 9 Summary I t e m S t a t i s t i c s f o r K n o w l e d g e S u b t e s t s ( c o n t i n u e d ) C o e f f i c i e n t s o f c o r r e l a t i o n Means S u b t e s t I t e m K : C 0 M P b 8 10 K s F A C T S C 4 5 D p t i o n wt p PB-ST B-ST ST TT 1 2 47.7 .45 .57 11.21 29-89 2 1 \u00E2\u0080\u00A234.2 -.22 - . 2 8 8.73 2 4 . 6 4 3 0 5.3 -.23 -.47 6.60 20.20 4 0 9.6 -.26 -.45 7.15 23.26 5 0 3.2 .02 .06 10.11 27.44 1 0 1 . 8 -.05 -.16 8 .40 25.40 2 0 3-6 - . 0 8 - . 1 8 8 .40 25.40 3 0 8.9 -.36 - . 6 4 6.00 20.44 4 1 27.8 -.37 -.49 7.78 \u00E2\u0080\u00A2 22.95 5 2 57-7 .60 .75 11.33 29.96 1 2 64.8 . 4 6 .59 10.78 28.97 2 1 22.8 - .26 -.36 8.17 23.75 3 0 5.7 -.25 -.52 6.38 20.69 4 0 6.0 - .20 - . 4 0 7.18 22.82 5 0 .7 -.07 -.30 7.00 18.50 1 2 15-7 .49 .74 12.36 32.75 2 1 18.1 .23 .34 10.33 28.90 3 0 39-9 -.38 - . 4 8 7.26 2 4 . 4 0 4 0 21.0 -.15 -.21 7.83 25 .42 5 0 5.3 -.10 - .22 7.33 26.67 1 0 5.0 -.12 -.26 7.00 26.14 2 0 3-6 -.12 -.29 6.70 22.20 3 0 2.8 -.23 - .60 4.38 17.00 4 1 25.3 -.29 -.39 7.15 23.38 5 2 63.3 .44 .57 9 .82 29.01 1 2 5.0 \u00E2\u0080\u00A2 30 . 6 4 13.00 35-93 2 1 12.8 . 1 4 .22 9.89 28.25 3 0 29.2 -.25 -.34 7 .48 23.15 4 0 36.7 -.05 -.06 8.54 26.87 5 0 16.4 .07 .10 9 .24 29.61 1 0 10.7 -.16 -.27 7.23 25.53 2 0 5.0 -.21 -.44 5.86 20.43 3 0 1.1 -.01 -.05 8.33 24.33 4 1 21.4 -.33 -.47 6.68 21.72 5 2 61.6 .49 .62 9-98 29.45 1 2 42.3 .53 .66 10.71 30.77 2 1 30.6 -.17 - .22 7.94 24.45 3. 0 10.7 -.35 -.58 5.53 20.00 4 0 13.9 -.21 -.33 7.08 25.31 5 0 2.5 -.03 - . 0 8 8 .14 28.00 260 Summary I t e m S t a t i s t i c s f o r K n o w l e d g e S u b t e s t s , ( c o n t i n u e d ) C o e f f i c i e n t s o f c o r r e l a t i o n Means S u b t e s t I t e m O p t i o n Wt P PB-ST B-ST ST K : F A C T S 0 1 2 9.6 .33 .57 12.00 32.26 2 1 16.4 .11 .17 9-57 27.15 3 0 47.0 - . 1 8 -.22 8 .14 25.37 4 0 20.3 -.09 -.13 8 .14 26.61 5 0 6.8 -.05 -.10 8.11 29-58 1 2 30.2 .60 \u00E2\u0080\u00A2 79 11.65 32.09 2 1 35.6 -.13 -.16 8.20 25.70 3 0 30.2 - . 4 2 - . 5 5 6.7I 23.16 4 0 3.2 - . 1 4 - . 3 4 6 .33 23.67 5 0 .4 .02 .13 10.00 36.OO 1 2 25.3 .61 .83 12.11 32.92 2 1 31.0 .04 .05 8.91 27.20 3 0 33.5 - .51 -.66 6.43 22.48 0 \u00E2\u0080\u00A28.5 -.09 -.17 7.75 25.67 5 0 1.1 -.09 -.32 6.00 23.33 1 0 1.8 -.10 -.30 6 .40 26.20 2 0 2.8 -.19 - . 4 8 5.25 17-38 3 0 .4 -.05 -.29 6.00 13.00 4 1 11.7 -.36 - . 5 9 5.58 19.76 5 2 82.6 \u00E2\u0080\u00A2 .45 .65 9.40 28.34 a I t e m s 1 t o 8 a r e n u m b e r e d i n t h e q u e s t i o n n a i r e as 2 2 , 2 4 , 2 6 , 2 8 , 29,36,39,45. b I t e m s 1 t o 10 a r e n u m b e r e d i n t h e q u e s t i o n n a i r e as 20,23,30,33, 34 ,35 , 41 , 43 ,44 , 46 . c I t e m s 1 t o 9 a r e n u m b e r e d i n t h e q u e s t i o n n a i r e as 21,25,27,31, 32 ,37 ,38 , 4 0 , 4 2 . APPENDIX H SUMMARY OF DISCRIMINANT ANALYSIS 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 H . 2 . R e s u l t s a n d D i s c u s s i o n 262 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 I d e n t i f i c a t i o n o f g r o u p s b a s e d o n i n d i v i d u a l ' s n u t r i e n t p r o f i l e was c a r r i e d o u t u s i n g l o g i c a l a n a l y s i s . B e c a u s e a l l n u t r i e n t e x c e s s e s w e r e n o t o f n u t r i t i o n a l c o n c e r n i n t h e p r e s e n t s t u d y , a r a t i o o f 1.0 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, a n d c a r b o h y -d r a t e was j u d g e d t o be w i t h i n a c c e p t a b l e l i m i t s . F o r t h e v a r i -a b l e f a t a n d k i l o c a l o r i e , a r a t i o s c o r e o f 1.0 was c o n s i d e r e d t o be o f n u t r i t i o n a l c o n c e r n a n d u n a c c e p t a b l e . U s i n g t h e s e t w o r e s t r i c t i o n s , t h e g r o u p s w e r e f o r m e d b y e x a m i n i n g e a c h n u t r i e n t p r o f i l e a n d d e t e r m i n i n g s p e c i f i c n u t r i e n t d e f i c i e n c i e s a n d e x -c e s s e s o f f a t a n d k i l o c a l o r i e s . F o u r u n i q u e g r o u p s r e s u l t e d c h a r a c t e r i z e d b y d i s t i n c t i v e u n a c c e p t a b l e p r a c t i c e a n d one g r o u p w i t h a c c e p t a b l e p r a c t i c e . The p r a c t i c e g r o u p s w e r e d e f i n e d a s : 1. D e f i c i e n t i n t a k e : one o r more n u t r i e n t s l e s s t h a n 67% o f r e c o m m e n d e d v a l u e s (n=115). 2. E x c e s s f a t i n t a k e : c a s e s w i t h f a t i n t a k e g r e a t e r t h a n 133$ o f CVD g u i d e l i n e s b u t a l l o t h e r n u t r i e n t s w i t h i n a c c e p t a b l e l i m i t s (n=8). 3. E x c e s s k i l o c a l o r i e i n t a k e : c a s e s w i t h k i l o c a l o r i e i n -t a k e g r e a t e r t h a n 133$ o f CVD g u i d e l i n e s b u t a l l o t h e r n u t r i e n t s w i t h i n a c c e p t a b l e l i m i t s (n=9). 4. A d e q u a t e i n t a k e : c a s e s whose i n t a k e f o r a l l 11 n u t r -i e n t s was w i t h i n a c c e p t a b l e l i m i t s (n=113). 263 5. M u l t i p r a c t i c e p r o b l e m : c a s e s c h a r a c t e r i z e d b y o v e r l a p -p i n g o f 1 o r 2 o r 3 (n=36). To s u b s t a n t i a t e t h i s l o g i c a l p a r t i t i o n i n g , - a n a l y t i c a l a n a l -y s i s u s i n g m u l t i d i m e n s i o n a l s c a l o g r a m a n a l y s i s ( L i n g o e s , I 9 6 6 ) p r o g r a m c o m p u t e d a n d p l o t t e d G u t m a n n - L i n g o e s o u t e r - p o i n t s c a l o -g r a m a n a l y s i s c o o r d i n a t e s f o r t w o d i m e n s i o n s . The r e s u l t i n g p l o t s u g g e s t e d l i t t l e d i f f e r e n c e among t h e m a j o r i t y o f p r o f i l e s b u t d i d a s s i g n t h e same c a s e s t o g r o u p s p r e v i o u s l y e s t a b l i s h e d b y l o g i c a l a n a l y s i s . To t e s t t h e p r e d i c t i v e 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 s u b t e s t s c o r e s , t h e f i f t h g r o u p ( m u l t i p r a c t i c e p r o b l e m ) was e l i m -i n a t e d s i n c e t h e g r o u p s m u s t be f o r m e d so t h a t a n y i n d i v i d u a l who b e l o n g s s i m u l t a n e o u s l y t o m o r e t h a n one g r o u p i s r e m o v e d ( T a t s u s k a , 1970). B o t h l o g i c a l a n d a n a l y t i c a l a n a l y s i s i d e n t i -f i e d t h e m u l t i p r a c t i c e p r o b l e m g r o u p w h i c h was e l i m i n a t e d f r o m t h e s u b s e q u e n t d i s c r i m i n a n t a n a l y s i s . 264 H . 2 . R e s u l t s a n d D i s c u s s i o n To t e s t w h e t h e r a t t i t u d e a n d k n o w l e d g e t e s t s c o r e s c o u l d p r e d i c t t h e f o u r p r a c t i c e c a t e g o r i e s , 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 was p e r f o r m e d w i t h p r a c t i c e , t h e g r o u p i n g v a r i a b l e , as d e p e n d e n t o r c r i t e r i o n v a r i a b l 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 as t h e i n d e p e n d e n t o r p r e d i c t o r v a r i a b l e s . D i s c r i m i n a n t a n a l y s i s was p e r f o r m e d u s i n g t h e f i v e s u b t e s t s (A:GEN ROLE, A:MANAGE, K:AFFECTS, K.COMP, K:FACTS) as i n d e p e n -d e n t v a r i a b l e s a n d t h e f o u r l e v e l s o f p r a c t i c e as d e p e n d e n t v a r i a b l e s . F o r t h e a n a l y s i s , v a l u e s o f 1.0 f o r maximum F t o e n t e r a n d maximum F t o r e m o v e w e r e u s e d . The r e s u l t s ( T a b l e 31) s u g g e s t e d t h a t , f o r t h e c o m b i n e d d i s c r i m i n a n t f u n c t i o n s , 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 (P<.05) among t h e f o u r g r o u p c e n t r o i d s o f t h e s e t o f f i v e v a r i a b l e s . Once t h e f i r s t f u n c t i o n was r e m o v e d , t h e s e c o n d f u n c t i o n was 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 . W h i l e t h e r e s u l t s i l l u s t r a t e d t h a t t h e f i r s t d i s c r i m i n a n t f u n c t i o n was s t a t i s t i c a l l y s i g n i f i c a n t (P<.05) a n d a c c o u n t e d f o r 84.84% o f t h e t o t a l d i s c r i m i n a t o r y p o w e r o f t h e f i v e s c a l e s , t h e s a m p l e s i z e was l a r g e (n=245) . T h e r e f o r e , t o d e t e r m i n e t h e d e -g r e e o f d i f f e r e n t i a t i o n t h e p r e d i c t o r b a t t e r y e x h i b i t e d among t h e f o u r p r a c t i c e l e v e l s , t h e t o t a l d i s c r i m i n a t o r y p o w e r was c a l c u l a t e d b y t h e f o r m u l a , a m u l t i v a r i a t e e x t e n s i o n o f t h e u n i -v a r i a t e e s t i m a t e d (0 ( s e e T a t s u o k a , 1970, p . 4 8 ) : TABLE 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 E i g e n - % o f C a n o n i c a l : A f t e r W i l k s 1 C h i -i c t i o n V a l u e V a r i a n c e C o r r e l a t i o n : F u n c t i o n Lambda S q u a r e d d f S i g n i f i c a n c e 1 .07022 84.84 .25616 2 .01255 15.16 .11134 0 .9228 19.36* 6 .0036 1 .9876 3-01 2 .2224 * P<.05. 266 ~ i N Cd = i (N-k) (1+ A| ) (1+A_ )...(!+ A,)+l where A s Ax , ..., are the e i g e n v a l u e s ; N, the t o t a l sample s i z e ; and k, the number of groups. The r e s u l t , .0655> suggest-ed o n l y about 7% of the t o t a l v a r i a b i l i t y of the two d i s c r i m i n a -t o r y f u n c t i o n s was a t t r i b u t a b l e to group d i f f e r e n c e s i . e . , the t o t a l d i s c r i m i n a t o r y power of the p r e d i c t o r b a t t e r y as a whole was very weak. Th i s may be p a r t i c a l l y e x p l a i n e d by the low o v e r a l l knowledge l e v e l e x h i b i t e d by each group. Mean scores and percentages f o r the f i v e p r e d i c t o r s c a l e s are r e p o r t e d i n Table 3 2 . The t a b l e shows t h a t the adequate group alone scor e d con-s i s t e n t l y h i g h e r than the t o t a l sample mean score f o r each of the f i v e s c a l e s , however, no one group s c o r e d more than S7f\u00C2\u00B0 on any of the knowledge t e s t s . TABLE-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 D e p e n d e n t V a r i a b l e ( n = 2 4 5 ) P r e d i c t o r V a r i a b l e s A : GEN ROLE A:MANAGE K:AFFECTS KtCOMP K:FACTS A d e q u a t e E x c e s s f a t D e f i c i e n t E x c e s s k i l o c a l o r i e T o t a l s a m p l e ( n = 2 8 1 ) 42.15(84 .30) 39.50(79.00) 41.16(82 .33) 41 .67(83 .33) 41 .67(83.34) 37 .64(83 .64) 34 .12(75.83) 37 .10(82 .45) 39-89(88.64) 37 .43(83 .18) 8.68(54.25) 9.00(56.25) 8.23(51 .41) 8.00(50.00) 8.43(52.69) 10.14(50 .71) 9.50(47.50) - 9 .14(45.70) 9.67(48.33) 9.69(48.45) 9.03(50.15) 7-38(40 .97) 8 .61 (47.83) 9.22(51.23) 8.74(48 .56) APPENDIX I SUMMARY TABLES AND DISCUSSION OF HOMOGENEITY OF VARIANCE-COVARIANCE FOR EACH BIODEMOGRAPHIC VARIABLE Summary T a b l e s a n d D i s c u s s 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 OWMAR, a 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 p r o g r a m was u s e d t o t e s t t h e 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 . The p r o -g r a m e m p l o y s t h e B a r t l e t t - B o x t e s t ( s e e W i n e r , 1971, p-595) f o r t h i s p u r p o s e . The r e s u l t s r e v e a l e d t h a t f o r 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 a g e , l i v i n g a r r a n g e m e n t , f a m i l y 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 ( C V D ) , a n d s m o k i n g h a b i t , 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 was t e n a b l e f o r e a c h o f t h e t h r e e s e t s o f 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 , a n d p r a c t i c e ) F o r t h e g r o u p s d e f i n e d i n t e r m s o f o b e s i t y , 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 was t e n a b l e f o r 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 u t n o t f o r mean a t t i t u d e . A u n i v a r i a t e F - s t a t i s t i c , s u g g e s t e d by B o x , was c o m p u t e d t o t e s t t h e h y p o t h -e s i s t h a t t h e s t r a t u m v a r i a n c e s w e r e e q u a l f o r e a c h o f t h e a t t i t u d e s u b t e s t s . R e s u l t s o f t h e u n i v a r i a t e F - s t a t i s t i c p i n -p o i n t e d s u b t e s t A:MANAGE as b e i n g r e s p o n s i b l e f o r l a c k o f homo-g e n e i t y . T a b l e 33 p r e s e n t s t h e r e s u l t s f o r t h e o b e s i t y r i s k v a r i a b l e a n d a t t i t u d e s c o r e s . I n s p e c t i o n o f means a n d s t a n d a r d d e v i a t i o n s f o r A:MANAGE ( s e e A p p e n d i x J ) r e v e a l e d t h a t t h e h i g h r i s k g r o u p h a d t h e h i g h e s t mean s c o r e b u t a l s o t h e g r e a t e s t v a r i a b i l i t y a n d l o w e s t n u m b e r o f c a s e s . A c c o r d i n g t o G l a s s a n d S t a n l e y (1970, p .372), t h e e f f e c t o f h e t e r o g e n o u s v a r i a n c e s w h e n t h e s a m p l e s i z e s a n d v a r i a n c e s a r e u n e q u a l , a n d f e w e r c a s e s a r e s a m p l e d f r o m t h e p o p u l a t i o n w i t h t h e l a r g e s t v a r i a n c e , i s t o s h i f t t h e F r a t i o t o t h e l e f t i . e . , i n c r e a s e t h e p r o b a b i l i t y o f a Type I e r r o r . TABLE 33 B a r t l e t t - \u00E2\u0080\u00A2Box 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 I n d e p e n d e n t V a r i a b l e M u l t i v a r i a t e T e s t D e p e n d e n t U n i v a r i a t e T e s t F ( d f ) V a r i a b l e F ( d f ) A : GEN ROLE 1.4-9 (2, 13573) O b e s i t y R i s k 2.22* (6, 7626.88) A:MANAGE 4.11* (2, 13573) * p<.05. 271 Thus, i t was concluded t h a t departures from homogeneity of v a r i a n c e - c o v a r i a n c e would he such t h a t i t would not a d v e r s e l y i n f l u e n c e the a t t i t u d e r e s u l t s o b t a i n e d . For the remaining v a r i a b l e s : e x e r c i s e p a t t e r n , e d u c a t i o n l e v e l , gender, and p e r s o n a l h i s t o r y of CVD, and a l l t h r e e de-pendent v a r i a b l e s , homogeneity of v a r i a n c e - c o v a r i a n c e was t e n -able f o r a t t i t u d e s and knowledge scores but not t e n a b l e f o r p r a c t i c e s c o r e s . I n s p e c t i o n of the v a r i a b l e s , shown i n Table 34, r e v e a l e d F - r a t i o s t h a t v a r i e d from 1.241 to I . 9 7 I . I f sample s i z e s are equal, t h e r e i s no reason f o r concern about v i o l a t i o n of the assumption of homogeneous v a r i a n c e s (Glass and S t a n l e y , 1970, p.306). In an attempt to assess the extent of t h i s v i o l a t i o n of homogeneity, s t a t i s t i c a l a n a l y s i s was performed i n which groups were made equal by random e l i m i n -a t i o n of cases from each group u n t i l a l l were equal. R e s u l t s , presented i n Table 34 f o r the v a r i a b l e e d u c a t i o n l e v e l , showed t h a t there was no change i n the s t a t i s t i c a l d e c i s i o n made. Thus, i t d i d not appear u s e f u l to randomly d e l e t e s u b j e c t s to achieve equal s i z e groups. Summary Indeed, the s i g n i f i c a n c e shown i s l i k e l y an a t t r i b u t e to the l a r g e number of degrees of freedom a s s o c i a t e d w i t h the F-v a l u e . In l i g h t of t h i s l a s t e s t i m a t i o n , the s m a l l F - r a t i o s , and the robustness of the m u l t i v a r i a t e t e s t (Olson, 1974), i t was decided t h a t the departures from homogeneity of v a r i a n c e -c o v a r i a n c e were such t h a t they would not a d v e r s e l y i n f l u e n c e the r e s u l t s o b t a i n e d . 2 7 2 TABLE 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 V a r i a b l e DF1 DF2 F - R a t i o E x e r c i s e P a t t e r 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 9 18 198 69600.5 4-0044.9 28119.7 1 . 2 6 4 . 4 6 0 1.241* E d u c a 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 9 18 198 4 9 3 9 7 6 . 0 1 9 4 8 8 1 . 0 1 2 3 9 8 5 - 0 1 . 6 6 2 1.145 1 . 2 8 2 * G e n d e r 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 3 6 66 1 6 2 1 9 9 . 0 6 6 5 6 9 . 5 3 7 3 9 6 . 0 I . 6 7 0 1 . 5 1 0 1.746* P e r s o n a l H i s t o r y o f CVD 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 3 6 66 1 3 0 7 6 8 . 0 5 4 5 5 1 . 8 3 0 7 7 2 . 5 1 . 7 8 3 .812 1 . 9 7 1 * EQUAL GROUPS E d u c a t i o n P r a c t i c e 1 9 8 9 6 7 I I . O 1 . 2 5 * * P < . 0 5 . APPENDIX J MEAN AND STANDARD DEVIAT ION FOR EACH ATTITUDE AND KNOWLEDGE SUBTEST AND PRACTICE SCORE BY BIODEMOGRAPHIC GROUP 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 J . 2 . P r a c t i c e R a t i o S c o r e s J . l . Mean a n d S t a n d a r d D e v i a t i o n 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 b y B i o d e m o g r a p h i c G r o u p B i o d e m o g r a p h i c Group ( n ) A:GEN ROLE A:MANAGE K:AFFECTS K.COMP K:FACTS G e n d e r M a l e F e m a l e {\u00E2\u0080\u00A259) (222) X S . D . X S .D . 39.54 3.96 42.23 4.47 36 .07 4.16 37.80 3.90 7.66 2.16 8 .64 1.93 8.80 3 .64 9-93 3.05 7-78 2.80 9.00 3.27 Age Y o u n g M i d O l d (162) ( 63) ( 56) X S . D . X S .D . X S ,D . 42.07 4.27 42.60 4.16 39.43 4.83 37.26 3.96 38.24 3.73 37.04 4.38 8 .46 2.09 8 .48 1.87 8.29 1.98 9.76 3.12 9.67 3.37 9.52 3.33 8.91 3.00 9.49 3.49 7.39 3.13 L i v i n g A r r a n g e m e n t F a m i l y (208) O t h e r ( 73) X S . D . X S . D . 41.98 4 .42 40.78 4.61 37.62 4.12 36.89 3.65 8.51 2.05 8.21 1.91 9.80 3 .04 9.38 3.66 8.85 3.28 8 .42 2.99 E d u c a t i o n L e v e l < g r a d e 12 ( 57) Grade 12 ( 84) 1-3 y r U n i v ( 86) > 4 y r U n i v ( 54) X S . D . X S . D . X S . D . X S . D . 39.33 4.76 41.92 4.69 42.69' 4.11 42.11 3 .64 36.32 4.67 37.86 3.65 37-80 3.79 37.37 4.01 7.79 I .96 8.52 2.02 8.67 2.00 8.57 1.99 8.65 3.06 9 .48 3.27 10.09 2.88 10.48 3.52 7.47 3.15 8.93 2.86 9.26 3.39 8.96 3 .24 J . l . Mean and Standard Deviation of Attitude and Knowledge Scores by Biodemographic Group (continued) Biodemographic Group (n) A: GEN ROLE A:MANAGE K:AFFECTS K:C0MP K:FACTS Personal History of CVD Positive ( 54) Negative (216) Family History of CVD Positive (154) Negative (124) Physical Exercise Pattern Sedentary Low Moderate High Moderate Vigorous Smoking Habit Very Heavy Heavy Light T32) (126) ( 90) ( 28) ( 15) ( 23) ( 20) X S .D. X S.D. X S.D. X S.D. X S .D. X S.D. X S .D. X S.D. X S.D. X S.D. X S .D . 41.75 4.34 41.02 5.08 41.58 4.54 41.84 4.39 39.50 5.59 41.58 4.16 42.39 4.25 43.00 3.93 4l.6o 3.64 43.09 3.46 40.35 4.17 37.25 4.06 38.00 3.82 37.51 4.08 37.42 3.92 36.84 4.62 37.^0 3.77 37.70 3.86 37-64 4.86 37.20 3.88 37.74 3.14 36.45 3.76 8.29 1.98 8.91 2.08 8.45 1.95 8.43 2.09 7.69 2.12 8.44 1.94 8.60 2.08 8.71 2.09 8.13 1.60 8.78 1.73 7^5 1.88 9-78 3.19 9.28 3.18 9.54 2.99 9.80 3.^5 8.62 3.71 9.66 3.06 10.08 3.16 9-93 3.25 9-73 2.66 9.39 2.71 8.60 1.85 8.80 3.18 8.35 3.31 8.76 3.30 8.69 3.13 8.41 3.70 8.81 3.22 8.74 3.11 9.25 3.04 9.00 3.16 8.48 3.69 8.00 2.27 J . l . Mean a n d S t a n d a r d D e v i a t i o n 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 b y B i o d e m o g r a p h i c G r o u p ( c o n t i n u e d ) B i o d e m o g r a p h i c Group ( n ) A:GEN ROLE A:MANAGE K:AFFECTS K.COMP K:FACTS S m o k i n g H a b i t F o r m e r ( 36) N o n s m o k e r (186) O b e s i t y R i s k H i g h ( 13) M o d e r a t e ( 55) Low (210) X S . D . X S . D . X S . D . X S . D . X S .D . 41.03 4.25 41.75 4/73 42.54 5.92 41.29 4 .11 41.76 4.48 36.89 4.00 37.63 4.16 38.54 5.61 37.33 4.63 37.45 3.71 8.36 9.44 8.11 1.99 3.10 3.00 8.53 9.88 8.96 2.08 3.44 3.28 9.08 9.08 9.08 2.40 3.30 3.75 8.47 10.24 8.35 2.19 3-37 3.22 8 .41 9.58 8 .84 1.93 3 .18 3.19 J . 2 . Mean a n d S t a n d a r d '. D e v i a t i o n o f P r a c t i c e R a t i o S c o r e s Group (Range 0 t o 1) b y B i o d e m o g r a p h i c B i o d e m o g r a p h i c Group ( n ) KCAL PROT CA FE VA T H I G e n d e r M a l e F e m a l e ( 59) (222) X S . D . X S . D . . 6 4 .19 .71 . 1 8 .92 .16 .98 .07 .74 .24 .76 .22 .87 . 1 8 .67 .21 .80 .25 .83 .23 .71 .22 .75 .21 Age Y o u n g M i d O l d (162) ( 63) ( 56) X S . D . X S . D . X S . D . .68 .19 .68 .17 .76 .16 .97 .09 .95 .10 .96 .12 .78 .23 .71 .22 .75 .23 .68 .22 .65 .19 .87 .16 .82 . 2 4 .82 .22 . 8 4 .25 .74 .22 .74 .22 .75 .19 L i v i n g A r r a n g e m e n t F a m i l y C208) O t h e r ( 73 ) E d u c a t i o n L e v e l < g r a d e 12 ( 5 7 ) G r a d e 12 ( 8 4 ) 1 -3 y r U n i v ( 8 6 ) > 4 y r U n i v ( 5 4 ) X .69 \u00E2\u0080\u00A2 97 .76 . 7 0 . 8 2 .75 S . D . . 1 8 .09 . 2 2 . 2 2 . 2 4 . 2 1 X .71 .96 .75 .76 . 8 6 . 7 4 S . D . . 1 8 . 1 3 .25 .23 . 2 2 . 2 1 X .69 . 9 5 .70 .71 . 8 0 . 6 5 S . D . . 1 9 . 1 2 . 2 2 .25 .26 . 2 1 X . 6 8 . 9 7 .76 . 7 0 . 8 2 . 7 4 S . D . . 1 8 . 1 0 .23 . 2 2 . 2 4 .20 X .69 .96 .76 .70 . 8 3 . 7 7 S . D . .18 . 1 0 . 2 4 . 2 0 . 2 4 .23 X . 7 4 . 9 8 . 8 1 .75 . 8 6 . 8 0 S . D . . 1 8 .07 . 2 1 . 2 2 . 2 1 . 1 8 J . 2 . Mean a n d S t a n d a r d D e v i a t i o n o f P r a c t i c e R a t i o S c o r e s G r o u p ( c o n t i n u e d ) B i o d e m o g r a p h i c G r o u p ( n ) KCAL PROT P e r s o n a l H i s t o r y o f CVD _ P o s i t i v e ( 54) X .72 .95 S . D . . 1 9 . 1 4 N e g a t i v e (216) X .70 .97 S . D . . 1 8 .09 F a m i l y H i s t o r y o f CVD _ P o s i t i v e (154) X .69 .97 S . D . .18 . 0 9 N e g a t i v e ( 1 2 4 ) X .71 .96 S . D . . 1 8 . 1 1 P h y s i c a l E x e r c i s e P a t t e r n _ S e d e n t a r y ( 32) X .70 . 9 9 S . D . .16 .05 Low M o d e r a t e (126) X .72 .97 S . D . .17 .109 H i g h M o d e r a t e ( 90 ) X .67 .96 S . D . . 1 8 .10 V i g o r o u s ( 28) X .68 .93 S . D . . 2 2 .16 S m o k i n g H a h i t _ V e r y H e a v y ( 15 ) X .62 .96 S . D . .17 .09 H e a v y ( 23 ) X .66 .96 S . D . .16 .09 L i g h t ( 20 ) X .76 1.00 S . D . . 1 8 .00 (Range 0 t o 1) b y B i o d e m o g r a p h i c CA FE VA T H I .74 \u00E2\u0080\u00A2 77 .86 .73 .25 .20 .23 .20 .76 .70 .82 .75 .23 .22 . 2 4 .22 .75 .71 .83 .73 .23 .22 . 2 4 .22 .76 \u00E2\u0080\u00A2 72 . 8 2 .76 .23 .22 .23 .20 .69 .74 .88 \u00E2\u0080\u00A2 73 .22 .22 .20 .20 .78 \u00E2\u0080\u00A2 72 . 8 4 .74 .22 .21 .23 .21 .74 .68 .79 .75 .23 .23 .25 .22 .79 .76 .80 .76 . 2 4 .22 .26 .21 .70 .68 .68 . 6 4 .26 .26 .31 .25 .72 .66 .80 .74 .21 . 2 4 .23 .23 .73 .76 .83 .78 .22 .21 . 2 4 .20 ro 00 J . 2 . Mean a n d S t a n d a r d D e v i a t i o n o f P r a c t i c e R a t i o S c o r e s (Range 0 t o 1) b y B i o d e m o g r a p h i c Group ( c o n t i n u e d ) B i o d e m o g r a p h i c G r o u p ( n ) KCAL PROT CA FE VA T H I S m o k i n g H a b i t F o r m e r ~~ ( 36) N o n s m o k e r $186) O b e s i t y R i s k H i g h ( 13) M o d e r a t e ( 55) Low (210) X S . D . X S . D . X S . D . X S . D . X S . D . .70 .19 .70 .18 .58 .13 \u00E2\u0080\u00A2 72 .18 .70 .18 .95 .76 .76 .86 .12 .27 .22 .23 .21 .96 \u00E2\u0080\u00A2 77 .71 .83 .75 .10 .22 .21 .23 .21 .98 .05 .97 .08 .96 .11 \u00E2\u0080\u00A2 72 .21 .77 .22 .96 .23 .60 .65 .65 .22 .25 .20 \u00E2\u0080\u00A2 75 .82 .73 .22 .24 .21 .71 .84 .75 .22 .23 .21 J . 2 . Mean a n d S t a n d a r d D e v i a t i o n o f P r a c t i c e R a t i o S c o r e s (Range 0 t o 1 ) b y B i o d e m o g r a p h i c G r o u p B i o d e m o g r a p h i c G r o u p ( n ) RIBO NIA VC FAT CHO G e n d e r M a l e F e m a l e _ _ e Y o u n g M i d O l d ( 59) (222) (162) ( 63) ( 56) L i v i n g A r r a n g e m e n t F a m i l y T208) O t h e r ( 73) E d u c a t i o n L e v e l < g r a d e 12 ( 57 ) G r a d e 12 ( 8 4 ) 1-3 y r U n i v ( 86 ) _ 4 y r U n i v ( 54 ) X . 7 8 . 80 .92 . 8 4 . 6 4 S . D . . 2 2 . 2 2 . 18 .13 . 1 2 X . 8 7 .88 .96 . 8 2 . 64 S . D . .17 .16 .13 . 1 4 . 1 4 X . 8 6 . 8 7 .96 . 8 4 .63 S . D . . 18 .17 .13 . 1 4 .13 X . 8 4 . 86 .93 . 8 3 .62 S .D . . 1 9 . 1 8 . 1 8 . 1 2 . 14 X . 8 4 . 8 6 . 9 5 . 80 . 68 S .D . . 1 9 . 1 9 .13 .15 . 14 X .85 .87 .95 .83 . 6 4 S . D . . 1 8 .17 . 1 4 . 1 4 .13 X .86 .85 .96 .83 .63 S . D . .20 .19 . 1 4 . 1 4 . 1 4 X .76 . 8 1 .90 . 8 1 .67 S .D . .20 .21 . 1 8 .15 .15 X .86 .88 .97 .82 .63 S . D . . 1 8 .17 .11 . 1 4 .13 X .87 .87 .94 .83 .62 S . D . . 1 8 . 1 8 .16 . 1 4 .13 X .90 .89 .98 .86 .63 S . D . . 1 4 .15 .07 .13 .12 J . 2 . Mean a n d S t a n d a r d D e v i a t i o n o f P r a c t i c e R a t i o S c o r e s G r o u p ( c o n t i n u e d ) B i o d e m o g r a p h i c Group ( n ) RIBO P e r s o n a l H i s t o r y o f CVD _ P o s i t i v e ( 54) X .83 S . D . .21 N e g a t i v e (216) X . 8 6 S . D . . 1 8 F a m i l y H i s t o r y o f CVD P o s i t i v e (15%) X . 8 4 S.D_. . 1 8 N e g a t i v e ( 124 ) X .86 S . D . . 1 8 P h y s i c a l E x e r c i s e P a t t e r n _ S e d e n t a r y ( 32) X . 8 0 S . D . .17 Low M o d e r a t e (126) ' \"X .86 S . D . . 1 8 H i g h M o d e r a t e ( 90) X .85 S . D . .19 V i g o r o u s ( 2 8 ) X .86 S . D . .22 S m o k i n g H a b i t _ V e r y H e a v y ( 15 ) X .74 S . D . .21 H e a v y ( 23 ) X .90 S . D . . 1 4 L i g h t ( 20 ) X .86 S . D . . 1 8 (Range 0 t o 1 ) b y B i o d e m o g r a p h i c N I A VC FAT CHO .87 .99 . 8 1 . 6 4 .19 .07 .16 .15 .86 .94 .83 . 6 4 .18 .15 . 1 4 .13 .87 .95 . 8 1 . 6 4 .17 . 1 4 . 14 .13 .85 .95 .85 .62 .19 . 14 . 1 4 .13 .85 .95 .79 .67 .15 .13 .17 . 14 .88 .94 .83 . 6 4 . 1 8 .16 . 1 4 . 14 .86 .96 .83 .62 .17 .12 . 1 4 .13 . 8 4 .98 .87 .62 .21 .09 .13 .15 . 8 7 . 87 . 85 . 5 9 .15 .26 . 0 8 .15 . 8 5 . 9 3 . 8 2 . 5 6 . 1 9 . 1 4 .15 .16 .91 . 9 8 . 7 8 . 66 .15 .09 . 1 6 . 1 2 J . 2 . Mean a n d S t a n d a r d D e v i a t i o n o f P r a c t i c e R a t i o S c o r e s (Range 0 t o 1) b y B i o d e m o g r a p h i c G r o u p ( c o n t i n u e d ) B i o d e m o g r a p h i c G r o u p ( n ) RIBO NIA VC FAT CHO .94 .84 .62 .16 .14 .13 .96 .83 .65 .13 .14 .13 S m o k i n g H a b i t F o r m e r ~~ ( 36) N o n s m o k e r (186) X S .D . X S . D . .85 .22 .85 .18 .89 .17 .86 .18 O b e s i t y R i s k H i g h ( 13) M o d e r a t e ( 55) Low (210) X S . D . X S . D . X S . D . .84 .81 .94 .82 .59 .20 .23 .15 .16 .17 .86 .85 .96 .84 .64 .16 .20 .13 .13 .11 .85 .87 .95 .82 .64 .19 .17 .14 .14 .14 283 APPENDIX K SUMMARY TABLES OF MULTIVARIATE AND UNIVARIATE ANALYSES OF VARIANCE FOR EACH BIODEMOGRAPHIC VARIABLE Summary T a b l e 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 e 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 I n t h e f o l l o w i n g o n e - w a y 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 t a b l e s ( T a b l e s 35 t o 43) 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 b i o d e m o g r a p h i c v a r i a b l e s , t h e u n i v a r i a t e F , n u m b e r e d 1 t o 11 r e f e r s t o : ( i ) A t t i t u d e s : 1 (A :GEN ROLE) , 2 (A :MANAGE) ; ( i i ) K n o w l e d g e : 1 ( K : A F F E C T S ) , 2 ( K : C O M P ) , 3 ( K : F A C T S ) ; ( i i i ) P r a c t i c e : 1 ( K C A L ) , 2 ( P R O T ) , 3 ( C A ) , 4 ( F E ) , 5 ( V A ) , 6 ( T H I ) , 7 ( R I B O ) , 8 ( N I A ) , 9 ( V C ) , 10 ( F A T ) , 11 ( C H O ) . TABLE 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 S o u r c e o f V a r i -a b i l i t y A t t i t u d e s B e t w e e n W i t h i n M u l t i -v a r i a t e T e s t d f : F d f U n i v a r i a t e T e s t 5 4 7.62* 2 9.53* 1-71 554 278 MSw 19 .04 15-99 8 10 11 K n o w l e d g e B e t w e e n W i t h i n 6 3.03* 2 . 1 8 .12 7-21* 552 278 MSw 4.08 10.37 9-86 P r a c t i c e B e t w e e n W i t h i n 22 536 3.61* 278 MSw 3 . 4 1 1.03 2.53 22.18* .3^ -04 .39 .11 -59 .22 .12 . 4 1 .32 . 4 8 .37 .32 .31 . 1 8 1 . 2 4 3.25* . 1 9 . 0 9 *P<.05 CO Ul TABLE 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 S o u r c e o f V a r i -a h i l i t y M u l t i -v a r i a t e T e s t d f F U n i v a r i a t e T e s t d f 1 5\" 8 10 11 A t t i t u d e s B e t w e e n W i t h i n 2 8 . 8 1 * 1 17.66* 8.92* 278 279 MSw 19.06 15.63 K n o w l e d g e B e t w e e n W i t h i n 3 4.29* 1 11.31* 5.89* 6.83* 277 279 MSw 3.91 10.13 10.09 P r a c t i c e B e t w e e n W i t h i n 11 17.97* 1 5.83* 16.98* .09 47.37* .52 1.96 10.60* 10.20* 4.16* .06 .01 269 279 MSw .22 .11 . 4 2 .32 . 4 8 .37 .31 .30 . 1 8 .19 .10 * p<.05. ro co ON TABLE 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 S o u r c e o f V a r i -a b i l i t y M u l t i -v a r i a t e T e s t d f F d f U n i v a r i a t e T e s t 5 8 10 11 A t t i t u d e s B e t w e e n W i t h i n 2 1.92 1 3.86 1.82 278 279 MSw 19 .99 16.03 K n o w l e d g e B e t w e e n W i t h i n 3 0.52 1 1.23 -90 .95 277 279 MSw 4.05 10.31 10.30 P r a c t i c e B e t w e e n W i t h i n 11 269 I .63 279 MSw .38 .54 .01 4.62 2.00 .26 .73 .22 .12 .42 .36 .47 .37 .32 .32 .45 .12 .07 .31 .18 .19 -10 * P<.05\u00C2\u00AB 00 \u00E2\u0080\u00A2S3 TABLE 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 S o u r c e o f V a r i -a b i l i t y M u l t i -v a r i a t e T e s t . U n i v a r i a t e T e s t -F d f F d f 1 2 3 4 5 6 7 8 9 10 1 1 A t t i t u d e s B e t w e e n W i t h i n 2 275 .36 1 276 MSw . 2 2 2 0 . 0 4 .03 1 6 . 1 0 K n o w l e d g e B e t w e e n W i t h i n 3 274 . 2 8 1 276 MSw . 0 1 4 .06 . 4 5 1 0 . 2 7 .04 1 0 . 4 0 P r a c t i c e B e t w e e n W i t h i n 1 1 266 . 7 2 1 276 MSw 1 . 0 1 .23 . 0 2 . 1 2 . 4 4 . 4 2 . 1 0 .37 \u00E2\u0080\u00A2 31 . 4 8 .96 . 3 7 . 4 2 . 3 2 .30 . 3 1 . 1 4 . 1 9 4 .60 . 1 8 1 . 8 7 .09 a CVD: c a r d i o v a s c u l a r d i s e a s e . * P<.05. 00 00 TABLE 39 One-way Analysis of Variance S t a t i s t i c s f o r Attitude, Knowledge, and Practice Scores with Personal History of CVD Source M u l t i - Univariate Test of V a r i -a b i l i t y variaxe Test F df F df 1 2 3 4 5 6 7 8 9 10 11 Attitudes Between \u00E2\u0080\u00A2Within 2 267 4.56* 1 268 MSw 1.16 20.19 1.49 16.12 Knowledge Between Within 3 266 4.05* 1 268 MSw 4.08* 4.01 1.06 10.16 .83 10.30 Practice Between Within 11 258 2.12* 1 268 MSw .59 \u00E2\u0080\u00A2 23 .83 .12 .08 .42 3.68 .36 1 .18 .48 .57 .38 .76 \u00E2\u0080\u00A2 32 .01 .31 5.77* 2.02 .18 .19 .20 .10 a CVD: cardiovascular disease. P<.05. 00 M3 TABLE 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 S o u r c e nf M u l t i -v a r i a t e njPR-h ; l J n i ' v a r i a t e T e s t V a r i -a b i l i t y F d f F d f 1 2 3 4 5 6 7 8 9 10 11 A t t i t u d e s B e t w e e n W i t h i n 6 542 2.86* 3 ^-33* 272 MSw 18.96 .38 16.21 K n o w l e d g e B e t w e e n W i t h i n 9 657 1.00 3 272 MSw 1.84 4.08 1.68 10.20 \u00E2\u0080\u00A2 35 10.41 P r a c t i c e B e t w e e n W i t h i n 33 773 1.32 3 272 MSw .96 .22 2.17 .12 2.08 .41 1.02 1.47 .36 .48 .19 1.27 .37 -32 .73 .31 .59 ' .19 1.29 .19 1.15 .10 * p<.05. ro \o o TABLE 41 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 S o u r c e . M u l t i - U n i v a r i a t e T e s t o f V a r i -v a r i a x e T e s t F a b i l i t y d f F d f 1 2 3 4 5 6 7 8 9 10 11 A t t i t u d e s B e t w e e n W i t h i n 4 548 .39 2 275 MSw .48 20.14 .50 16.03 K n o w l e d g e B e t w e e n W i t h i n 6 546 1.50 2 275 MSw .68 4.03 1.16 10.39 .59 10.39 P r a c t i c e B e t w e e n W i t h i n 22 530 1.12 2 275 MSw 3.01 .22 .19 .12 .29 .42 2.08 .37 4.15 -.47 1.61 .37 .05 .32 .70 .31 115 .19 .45 .19 .57 .09 * p<.05. ro \o i\u00E2\u0080\u0094 1 TABLE 42 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 S o u r c e o f V a r i -a b i l i t y M u l t i -v a r i a t e T e s t d f F d f U n i v a r i a t e T e s t 3 10 11 A t t i t u d e s B e t w e e n W i t h i n 6 4.12* 552 3 7.32* 2.06 277 MSw 18.91 15.90 K n o w l e d g e B e t w e e n W i t h i n 9 2.08* 669 3 2.54 3.78* 4.01* 277 MSw 3.99 10.01 9-98 P r a c t i c e B e t w e e n W i t h i n 33 1.92* 3 1.44 1.05 2 .98* .74 .36 5 .64* 6.79* 2.07 4 .64* 1.19 2.59 787 277 MSw .22 .12 .41 .37 .48 .35 -31 -31 .18 .19 .09. * P<.05. tV) VO TABLE 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 S o u r c e o f V a r i -a b i l i t y . M u l t i -v a r i a t e T e s t U n i v a r i a t e T e s t d f F .df F 1 2 3 4 .5 6 7 8 9 10 11 A t t i t u d e s B e t w e e n 8 .80 4 1.20 .62 W i t h i n 548 275 MSw 20.19 16.22 K n o w l e d g e B e t w e e n 12 ,.88 4 1.58 .83 .88 W i t h i n 723 275 MSw 4.03 10.35 10.35 P r a c t i c e B e t w e e n 33 1.58* a 3 1.32 . 0 4 . 8 2 .89 2.30 .88 2 . 4 2 . 40 1.50 .08 3.60* W i t h i n 725 256 MSw .22 .13 .42 .37 .47 .37 .32 .32 .19 .19 .09 L i g h t s m o k e r s (n=20) g r o u p o m i t t e d f r o m a n a l y s i s f o r P r a c t i c e b e c a u s e t h e v a r i a n c e o f t h e g r o u p f o r VC was z e r o . U n i v a r i a t e a n a l y s e s u s i n g f u l l s a m p l e ( a l l 5 g r o u p s ) p r o v i d e d t h e same s t a t i s t i c a l d e c i s i o n s as t h e a b o v e . * P<.05. "@en . "Thesis/Dissertation"@en . "10.14288/1.0095224"@en . "eng"@en . "Human Nutrition"@en . "Vancouver : University of British Columbia Library"@en . "University of British Columbia"@en . "For non-commercial purposes only, such as research, private study and education. Additional conditions apply, see Terms of Use https://open.library.ubc.ca/terms_of_use."@en . "Graduate"@en . "Diet and cardiovascular disease : interrelationships among nutrition attitudes, knowledge, practice, and biodemographic characteristics of adult members of community centres"@en . "Text"@en . "http://hdl.handle.net/2429/22370"@en .