CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
ADOLESCENT HEALTH EDUCATION TO REDUCE
\\
HYPERTENSION
A thesis submitted in partial satisfaction
of the requirements for the degree of
Master of Science in
Health Science
by
Patricia J. Newell
June, 1980
The Thesis of Patricia J. Newell is approved:
California State University, Northridge
ii
ACKNONLEDGEMENTS
I wish to acknowledge with sincere appreciation
the help and patience of Dr. Waleed Alkhateeb, my thesis
committee chairman.
His assistance and support has been
a positive asset in completing this study.
Sincere
thanks also to Dr. Seymour Eiseman and Mrs. Lillian
Casady, P.H.N., who also served on my thesis committee.
I wish to sincerely thank the Health Education
Instructors who permitted their classes to be employed
in conducting this study.
-
iii
----
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TABLE OF CONTENTS
Page
. . . . ..
ACKN01tJLEDGEMENTS
LIST OF TABLES .
ABSTRACT • .
•
iii
vi
•
vii
CHAPTER
I.
II.
III.
IV.
v.
INTRODUCTION
1
Purpose of the Study
2
Null Hypothesis • • •
2
Definition of Terms .
3
REVI~~
OF THE LITERATURE
4
Cardiovascular Disease
4
Relationship of Childhood
Hypertension to Adult
Hypertension . . • • . • .
7
Secondary Hypertension
11
Essential Hypertension
12
Hypertension Treatment
16
Summary • •
20
METHODOLOGY • •
21
ANALYSIS AND RESULTS
25
SUMMARY, CONCLUSIONS AND
RECOW~ENDATIONS
31
Summary • •
31
Conclusions •
32
Recommendations •
33
iv
Page
Chapter
VI.
BIBLIOGRAPHY .
34
APPENDICES
A.
STANDARDS FOR CHILDRENS' BLOOD PRESSURE
36
B.
ADOLESCENT HEALTH EDUCATION TO REDUCE
HYPERTENSION . . • • • .
. • .
38
c.
LESSON PLAN I
40
D.
LESSON PLAN II .
46
E.
LESSON PLAN III
48
F.
LESSON PLAN IV •
50
G.
LESSON PLAN V
57
H.
SEI'tlANTIC DIFFERENTIAL QUESTIONNAIRE
59
I.
HEALTH QUESTIONNAIRE •
63
J.
RAW SCORES OF STUDENTS TESTS •
69
v
LIST OF TABLES
Table
Page
1.
Study Research Design
2.
Frequencies in Groups by Sex and Ethnic
Background • • • . • • • • • • . • . • • • 26
3.
T-Tests for Significance of Change in
Paired Observation Results Between Control
and Test Groups for Physical Measurements • 27
4.
T-Tests for Significance of Change in
Paired Observation Results Between Control
and Test Groups for Knowledge Test • • • . 29
5.
T-Tests for Significance of Change in
Paired Observation Results Between Control
and Test Groups for Semantic Differential
Scores
. . • • • • • . . • • • . • . • • • 30
vi
•
• 23
ABSTRACT
ADOLESCENT HEALTH EDUCATION TO REDUCE
HYPERTENSION
By
Patricia J. Newell
Master of Science in Health Science
The purpose of this study was to determine
whether and to what extent health education can increase
knowledge levels, and influence the diet of teenagers to
minimize the tendency toward essential hypertension.
The study population consisted of 112 tenth grade
health education students in four classes assigned to one
teacher.
The study population was randomly assigned into
an experimental group, and into a control group to aid in
the statistical evaluation of the study.
A health questionnaire was developed to measure
changes in levels of knowledge about heart disease and
hypertension.
A semantic differential questionnaire was
employed to determine changes in student attitude toward
vii
hypertension and diet.
These questionnaires were
administered to each student as pre and post tests.
The blood pressure and the weight of each student
were taken before and at the conclusion of the study.
The experimental group attended health education classes
conducted by the investigator.
These classes consisted
of two 50 minute sessions followed by a series of 10
minute sessions spaced throughout the semester.
Teaching
took place over a four-month interval to reinforce the
need for diet change over an extended period of time.
Neither group was informed that any tests would
be given to them.
The class instructor covered the same
health information in all four classes, except for the
study information which was taught by the investigator.
Analysis of the results showed the following:
1) the systolic pressure of the experimental group was
lowered significantly as compared to the control group
(a<.04), 2) the experimental group showed a significant
gain in level of knowledge compared to that held by the
control group (a<.04), 3) there was a significant change
in attitude towards diet control between the experimental
and control group (a<.Ol).
viii
CHAPTER I
INTRODUCTION
Heart disease is the leading cause of death in
the United States.
Undetected, uncontrolled, and un-
treated hypertension is a high risk factor in heart disease, strokes and renovascular disease.
K'-;
The medical pro-
~,
fession and associated agencies sucl).·as the American
Heart Association have extensive programs for the detection and treatment of the disease in adults.
The study
of hypertension in children and adolescents during the
last few years showed a definite need to include them as
part of a sustained health care system to minimize the
effects of hypertension.
The recommended programs for
children and adolescents are somewhat different than
adults in both physical and psychological aspects.
The
treatment of adolescent hypertension includes drug therapy, dynamic exercises and diet alternation.
Because of
the possible long term effects of drug therapy, the conservative treatment is one which minimizes their use (10) .
Diet changes, including the reduction of salt
intake, is one of the simplest treatments that is often
effective, if followed on a long· term basis.
Sodium is
the critical ingredient in salt that affects hypertension.
The salt intake of the American diet is too high (some
1
2
estimates are as high as 20 times the required daily
intake which is the equivalent of two teaspoons of salt).
High salt intake adversely affects at least 20 percent
of Americans who develop high blood pressure.
Hyperten-
sion is a silent disease that, if not detected and controlled, develops symptoms about 15 years after onset.
This means that health education and diet changes should
reach susceptible individuals as early as possible to
minimize the long term affects (13).
It is reasonable
to assume that education in the high school can meet part,
of this requirement.
Purpose of the Study
The purpose of this study was to determine
whether health education can increase knowledge levels
and influence the diet of teenagers to minimize the tendency toward essential hypertension.
Null Hypothesis
Health education on hypertension will have no
significant effect on knowledge levels or diet control
for the students in this study.
3
Definition of Terms
The following terms are defined to insure a
common interpretation of the study material.
ADRENERGIC - Applied to agents stimulating the
sympathetic nervous system.
ARTERIOSCLEROSIS - A degeneration and hardening of the
walls of arteries, capillaries, or veins, due to
chronic inflammation and resulting in fibrous
tissue formation.
CARDIOVASCULAR - Pertaining to the heart and blood
vessels.
DIASTOLIC PRESSURE - The point of greatest relaxation
normally measured as a pressure.
DIURETIC - An agent which increases secretion of urine.
HYPERTENSION - A condition in which a patient has a
higher blood pressure than normal for his age.
RENAL - Pertaining to the kidney.
SYSTOLIC PRESSURE - The greatest force exerted by the
heart and the highest degree of resistance put
forth by the arterial walls.
URIC ACID - A crystalline acid in the urine, a
metabolism product of nuclein.
CHPATER II
REVIffi~
OF THE LITERATURE
This chapter presents a review of the literature
pertaining to hypertension and treatment.
Hypertension
is a condition in which a patient has a higher blood
pressure than is normal for his age.
The adult population
in the United States has a high prevalence toward hypertension and a good portion of cases are undiagnosed.
A
continued elevated blood pressure over a period of years
causes untoward effects on the heart, blood vessels, and
associated organs (10).
The review discusses in order:
cardiovascular
risk factors and how hypertension affects an individual's
life, the relationship of childhood hypertension to adult
hypertension to show what correlation can be made, secondary hypertension which relates to other primary anomalies that cause hypertension and often are curable,
essential hypertension which deals with hypertension
other than secondary, and hypertensive treatment.
Cardiovascular Disease
This nation faces a major public health problem
from the affects of coronary heart disease and cardiovascular complications of hypertension (6).
4
Authorities
'~'~":-.·
i-'
5
in the field have estimated that five to twenty percent
of the adult population have hypertension (5,16,11).
Studies by the National Heart, Lung, and Blood
Institute's Task Force on Blood Pressure Control in Children (NHLBI-Task Force, 13) revealed that hypertension
was more prevalent and more severe in black Americans
than among whites.
Further, the mortality rate for black
patients was approximately twice that of white patients
and deaths related to hypertension occurred at a relatively younger age.
The Task Force also pointed out that
racial differences may also cause different target organ
complications such as the documented susceptibility of
the Japanese to cerebral hemorrhage.
Additionally the
Task Force data have shown a positive correlation between
hypertension and increased weight for height, both in
adults and children.
Relative weight accounts for about
ten percent of the variation in blood pressure among the
population (13).
In the case of hypertension, early identification
has been disappointing in terms of the motivation for
follow-up treatment and blood pressure control.
An indi-
vidual feels well with high blood pressure, but may exper-;
ience side effects from hypertensive medications.
These
side effects can range from dizziness, muscle weakness,
and nausea to sexual impotence and psychological
depression (19).
6
Approximately seventy to eighty percent of the
American adult population that had hypertension, demon; strated diastolic blood pressures less than 105 mm.Hg.,
and are often referred to as mild or borderline.
These
people have an increased risk of heart attacks or
strokes, but the benefits of therapy have not been conelusively proved.
One of medicine's great dilemmas is
whether or not to treat mild hypertension (18).
Finner (3) associated family history with the
future development of high blood pressure.
This was
related to both borderline as well as definite elevation.
Tracking, maintaining the same percentile value
of blood pressure at varying ages in an individual's
life, was studied by Finner (3) and preliminary data suggested that it was present from early childhood.
The
statistical correlation with tracking improves with age
reaching the adult level by about the age of 20 years.
A number of prospective studies conducted by
Henderson (6) during the last decade have indicated a
relationship between a number of physical and behavioral
characteristics and cardiovascular disease.
Hypertension,
cigarette smoking, diet, obesity, lack of exercise, and
various life stresses contributed to the risk status.
The nation as a whole may be at higher risk due to cultural and social norms, e.g., high fat convenience foods,
cigarette smoking, sedentary physical
behavio~:--~~~-~
___
I
7
time-pressure life style.
Persons "at risk" may be
asymptomatic and ignorant of any future danger to their
hearts.
Also, one may not be motivated to alter behav-
ioral and life styles (6).
The annual cost of treatment on a national scale
for people with diastolic pressures of 105 mm.Hg. or
greater was estimated at $1.4 billion.
If mild hyper-
tensives were also treated, the annual cost would rise
to $4.8 billion.
Inclusion in treatment of persons with
mild hypertension has serious cost as well as medical
ramifications (18).
Relationship of Childhood Hypertension
to Adult Hypertension
Lieberman (10) stated that adolescent
hypertension has received increased attention in the past
few years.
This has been caused, to a large extent, by
an increased awareness of the problem.
The correlation
of hypertension in childhood or as young adult by contrast to the same person as a mature adult has no,t been
adequately demonstrated.
This may be due to the lack of
long term studies in this area.
The past decade, accord-:
ing to Lieberman, has seen a flowering of clinical, community, and research programs to reduce the morbidity
and mortality associated with uncontrolled hypertension.
Investigations of individuals less than 20 years old
8
have been made as part of this research study.
The
techniques and data base to adequately study and measure
hypertension in small children and diminutive stature
have been obtained.
Standards for children's blood pres-
sure have been developed as part of this effort (see
Appendix A) .
Until 1970, hypertension in children had been
categorized secondary to underlying physical disorders.
However, primary or essential hypertension in children
has been diagnosed with increasing frequency as more detailed studies using better diagnostic methods have been
made (2).
The treatment of children with essential hyper-'
tension has been difficult to formulate because the longterm implications of elevated blood pressure levels in
childhood are not known.
The long-term effects of treat-
ment have not been studied (10).
The cause of hyperten-
sion in at least 90 percent of adults is not known, so
the disease is categorized as primary hypertension (10).
According to McClain (11), the two basic
questions that need to be answered relative to childhood
vs. adult hypertension are:
1) Do a significant percentage of these children
develop essential hypertension as an adult?
2) Does treatment of these children have a
significant effect in reducing the morbidity
that is associated with untreated hypertension in adults?
9
Most of the available data is on young adults.
Perera (15) followed 30 young adults with essential hypertension for 20 years.
Eight patients of the 50 studied
died while 15 experienced hypertensive complications.
Diehl and Hesfordder, as reported by McClain (11),
discussed men who several years earlier had hypertension
in college.
They found them more likely to have elevated
systolic pressures than those who initially had normal
hypertension.
Julius and his associates, as reported by McClain
(11), compared the blood pressures of 200 male college
students with blood pressures of the students taken 20
years later and found that the incidence of hypertension
was the same.
The correlation between initial and final
blood pressure readings of an individual subject was
poor, but there appeared to be a relationship between
hypertension and obesity.
Heyden and his associates (7) studied a group of
435 adolescents to determine whether they had hypertension.
Eleven percent or 50 people had elevated blood
pressures.
Thirty of these persons were re-evaluated
seven years later and 12 percent had lower blood pressures, 23 percent had the same pressure and 37 percent
had either high blood pressure or cardiovascular complications.
This study suggested that hypertension at a
j
-·~·-
·-----·--------
10
younger age can be indicative of future or more severe
hypertension.
McClain (11), Lieberman (10), and the Task Force
on Blood Pressure Control in Children (Task Force - BPCC,
13) stated that the evidence was conflicting making it
difficult to formalize a proper treatment.
In fact, the
suggested treatment of primary hypertension for children
tended toward a conservative approach that minimized
medication because of possible long-term side effects.
In summary, it would appear that the best
predictor of hypertension is the level of blood pressure
at some earlier date, as in childhood, or its presence
in the parents.
Weight and heart rate have been observed
to make modest, independent contributions to the risk of
hypertension developing in children: the importance of
other factors (e.g., plasma postload glucose and serum
uric acid) can only be extrapolated from observations
made on adults (13).
The Task Force suggested that these observations,
though requiring further study, lend support to the possibility that hygienic measures, such as control of
weight and avoidance of abuse of salt intake, may have
great potential for primary prevention of hypertension in
those identified as being at increased risk at an early
age ( 13) .
11
Secondary Hypertension
According to the NHLBI-Task Force (13), most
juvenile hypertension has traditionally been related to
some identifiable cause, for example, renal disease.
These identifiable causes were often associated with
clinical findings that focus on a particular organ and
system including renal, cardiovascular, endocrine, and
central nervous system.
In prepubertal children, con-
genital or acquired renal disorders were associated with
clear cut elevations of blood pressure which must be considered as secondary hypertension.
chemicals have caused hypertension.
Drugs, toxins, and
In most cases, dis-
continuation of the agent has eliminated the problem.
Drugs in this category include:
and corticosteroids.
ephendrine, amphetamine,
Acute poisoning and certain anti-
biotics have caused renal damage resulting in hypertension.
Kaplin (9), stated that there was little doubt
that hypertension can be related to oral contraceptives.
Agents that are predominantly estrogenic can lead to salt
and water retention as well as changes to the blood constituents.
Many young girls that have used these oral
contraceptives have developed hypertension within weeks
of initiation of use.
By removing the medication, the
hypertension disappeared in from three to six months.
12
Essential Hypertension
According to Tobian (21), continuing research in
hypertension demonstrated that the kidney plays an ever
important role.
Early studies showed that small,
shrunken kidneys were associated with a thickened left
ventricle.
Then experiments of narrowing the renal ar-
teries and producing hypertension clearly linked hypertension to the kidney in specific cases.
Tobian stated
increased hypertension was created by removing animal
adrenal glands, by the addition of salt in food to rats,
or by narrowing the renal artery in dogs.
In fact, many
secondary hypertensive cases have some problem with the
renal system.
Additional studies on rats have shown that
when kidneys are transplanted in rats, the hypertensive
condition follows each kidney.
This led to the concept
that the kidneys control the long term level of arterial
hypertension.
Further, Tobian noted that arterial pressures
have been related in many cases to the kidney.
The kid-
ney can regulate the pressure by adjusting blood volume·
and extra-cellular fluid or by regulating various renal
hormones such as renin.
The excess fluid could affect
almost any system related to the heart and blood flow.
Thus, the kidney has the capacity to affect and control
arterial pressure (21).
13
Vertes (22) noted that essential hypertension
has strong familial aspects.
Studies of twins for hyper-
tension suggested that there was a strong heredity clustering trait.
The author noted in early hypertension in
men aged 15 to 25, there is often an elevation of cardiac
output above normal.
Peripheral resistance may be normal
at rest, but it is still elevated in relation to cardiac
output.
During exercise, these young hypertensives al-
ways have abnormally high peripheral vascular resistance.
As the person ages to say 30, he develops an established
high level of arterial pressure.
The continuous high
pressure produces excessive stress on the arterial walls.
This extra stress leads to increased levels of cerebral
and coronary atherosclerosis, increased numbers of microaneuryisms in the cerebral arteries and premature arteriosclerosis in the renal and general systemic arterioles.
This increased resistance makes the left ventricle work
harder, which may ultimately lead to its failure.
Vertes
noted that the precise mechanism of these events was not
well understood (22).
Vertes goes on to note that arterial pressure is
regulated by the resistance encountered to distribute the
flow of blood throughout the system and the body can
operate very efficiently at widely varying pressures.
a bit of hypertension would be harmless except for the
added strain on the heart and blood vessels causing
So
14
--~---~--
premature aging.
The question has revolved around what
sets the arterial pressure.
The kidney has been shown to
be one such regulator, possibly by adjusting the volume
of blood and extra cellular fluid or by regulating the
rate of secretion of renal hormones such as renin.
These
hormones and fluids affect many parts of the body related
to blood pressure according to the QUthor (22).
The role of salt (sodium) in hypertension has
been of increasing interest since Arnbard and Braujard
first proclaimed a relationship between lowering hypertension and low sodium chloride diets (21).
William Kempaer, as reported by Tobian (21),
introduced the rice diet which basically was low in sodium.
Tobian reported that McQuarrie showed that a high
sodium intake produced hypertension in a 13 year old boy,
and that normal sodium intake would bring the blood pressure back to normal.
He continued that Meneely's classic '
experiment varied diets of rats containing salt in small,
moderate, and high amounts over a nine month period.
Each increment of salt showed an increase in blood pressure.
Rats eating ten percent salt developed hyperten-
sion.
At two to five percent salt, mild hypertension was
noted along with shortened life span.
Potassium feeding
reduced the hypertension for concomitant salt feeding
and also increased the life span.
-
---------------------------------------------
--·····
-------------'
15
Tobian went on to note that salt and
' environmental studies have also been made, such as
Madocks & Prior, who noted that natives in small villages
in New Guinea had virtually no hypertension and that
blood pressures in older men were no higher than in
younger men.
This demonstrated that hypertension is not
necessarily age dependent.
In addition, natives of sirn-
ilar genetic backgrounds that move into modern cities,
developed their share of hypertension.
Salt was suspected
as the cause of this change (21).
Observations in the Solomon Islands by Page (14),
showed that natives in one area had no hypertension independent of age.
Similar natives on an offshore island,
had significant amounts of hypertension and blood pressure
that increased with age.
The main difference in these
two groups was that the natives on the island cooked their
food in salty sea water.
The food acquired about three
percent salt in this process.
Another study was conducted
on a group of Japanese farmers who ate large amounts of
i
salt (20 to 35 grams per day} as part of their diet.
This:
may be due to the method of preserving their food.
i
i;
Eighty-four percent of the farmers showed systolic blood
pressures over 140 mrn.Hg.
Studies in the United States
by Dahl, as reported by Meneely (12), found that employees of Brookhaven National Laboratory who did not salt
their food had significantly lower incidence of
-----~--------~---~-· ~-
~~
··---~-~- --~
-
~---
_ _ _ _ _ _ _ _ _ _ __ j
'
16
hypertension than employees which salted their food
heavily.
Dahl (1), studied the resistance and sensitivity
of rats to salt induced hypertension by differential
breeding.
He took a single strain of rats and bred them
to develop two races of rats; one was highly susceptible
to salt hypertension.
Nhen these rats were fed small
amounts of salt, their blood pressures were similar.
Whereas, a high intake of salt developed hypertension in
the salt-sensitive rats and not the other strain.
Studies
of human beings have shown similar relationships.
Tobian (21), hypothesized that early man probably
was a sodium deficient herbivore, desperate for dietary
sodium in order to survive.
This may have caused the de-
velopment of the taste receptors in the human tongue.
So,
evolution has equipped humans to cope with sodium deficiency rather than an excess.
Therefore, our current diets
quite logically cause some medical problems like hypertension.
Hypertension Treatment
Treatment for children and adolescents with
hypertension is well stated by the Task Force on BPCC
(13)
as:
Only children who manifest persistent
hypertension, documented by multiple observations, should be considered for initiation of
17
treatment.
Such treatment is not limited to
the administration of drugs. Children and
adolescents with borderline pressure elevation
may not require antihypertensive drugs, but
they should have annual re-evaluation, should
receive counseling on weight control and avoidance of salt abuse, and should be encouraqed to
be physically active. They should receive advice concerning other atherosclerosis risk factors, including abstaining from the use of
cigarettes.
The Task Force commented further on physical
activity and recommended supervised, dynamic exercises
such as calisthenics, swimming, running, baseball, or
basketball playing which improve cardiovascular fitness.
On the other hand, exercises such as weight lifting,
wrestling, and isometrics, raises both systolic and diastolic pressure and markedly stresses the heart.
Behav-
ioral methods to lower blood pressure, including biofeedback, relaxation, psycho-therapy, suggestion, and
placebo, have been tried, but insufficient information
has been available to adequately judge their effects.
Freis (4), stated that drugs are the other main
method of hypertensive control and are usually required
for moderate to severe hypertension.
For children, major
questions still exist about unanticipated consequences of
prolonged drug administration.
High incidence of serious
adverse reactions has not been reported, however, long
term studies have not been made.
The Task Force on BPCC (13) position was that it
is not unreasonable to expect that drugs that influence
18
the peripheral autonomic nervous system may also affect
the central nervous system and potentially modify cognitive as well as behavioral development.
Also, compounds
that modify the electrolyte status and fluid composition
of the body could conceivably exert long-term influence
on the growth of a variety of systems.
Adherence to any therapeutic regimen is one of
the more critical problems for persons of all ages.
Young children can achieve adherence through parental
influence.
As the individual assumes some autonomy and
participates in his own care, increasing failures in
adherence occur (13}.
In children and adults, the management of
chronically elevated blood pressure is generally appreached in a step care type treatment:
first a diuretic,
•.
then an adrenergic blocker is added, and finally, a vasodilator is added to the first two drugs.
These anti-
hypertensive drugs act by resetting blood pressure
mechanisms by controlling:
1.
Extracellular Fluid Volume (ECF)
Controlled by kidney
ECF reset downward about 2 liters by
continuous administration of diuretics.
2.
Sympatho-Adrenergic System
Resetting beta-adrenergic activity
downward causing reduced cardiac rate
and output - (Propranolol)
Resetting alpha-adrenergic activity
downward causing vasodilation with
19
postural hypotension etc. , prazos in)
(phentolamine,
Inhibiting both alpha and beta peripheral
action - (Reserpine, quanethidine) central
action - {Alpha methyldopa, cloridine)
3.
Arteriolar Tone
Resetting smooth muscle tone downward (Hydralazine, dizoxide, and sodium
nitroprusside, Prazosin} (4)
Smith (17) and Henderson (6) noted that the
disadvantage of drugs are the side effects.
There are
disturbing, unacceptable aspects of some side effects
such as dry mouth, lethargy, weakness, sexual dysfunction,
sleep disturbances, and altered intellectual function or
effect.
They interfere with efforts to achieve and main-
tain control of blood pressure.
of the patient who is
tions.
This is especially true
asymptomatic, without complica-
For many of these patients, it requires changing
their life.
Perhaps a more critical problem is the lack of
information on the potentially harmful consequences of
drug induced chronic changes in the potassium, uric acid,
and glucose tolerance of the body.
effects are gout and diabetes.
Other possible side
Experimental studies of
large populations have not been made, but the concern is
somewhat ameliorated by reflecting on the fact that millions of people have used the most commonly prescribed
drugs over the last two decades and no excess of chronic
20
diseases, gout, diabetes, or sudden death has been
noted (17).
Summary
This review has discussed hypertension slanted
toward the adolescent.
Discussions on risk factors, the
correlation between adolescent and adult hypertension,
the two types of hypertension, and hypertension treatment
were presented.
The Task Force on BPCC states the issue
as:
In summary, it would appear that the best
predictor of later hypertension is the level
of blood pressure at some earlier date, as in
childhood, or its presence in the parents.
Overweight and heart rate have been observed
to make modest independent contributions to the
risk of hypertension developing in children;
the importance of other factors, e.g., plasma
postload glucose and serum uric acid, can only
be extrapolated from observations made on adults.
These observations, though requiring
further study, lend support to the possibility
that relatively simple hygienic measures, such
as control of weight and avoidance of abuse of
salt intake, may have great potential for primary prevention of hypertension in those identified as being at increased risk at an early age
(13) •
~--
~~--
~~
-~----~
-----~----
CHAPTER III
METHODOLOGY
The purpose of this study was to determine
whether health education could influence the diet of
teenagers to minimize the tendency toward essential
hypertension.
The evaluation of this premise was done in a
local high school during the 1979 Spring semester.
Ap-
proval was obtained from the Director of District Nursing
Services and the Director of Health Education for the Los
Angeles Unified School System.
Permission was then ob-
tained from the California State University, Northridge,
Health Science Department Human Subjects Committee to
conduct the research.
The population was selected in the
following manner to minimize statistical evaluation bias:
1.
A large enough group of students so that the
sample size does not significantly affect the
confidence interval.
2.
Concurrent comparison of both groups.
3.
Insuring that both groups have the same
health education, except for this study,
by using classes taught by the same health
education teacher.
4.
The demographic distribution is typical of
a lOth grade high school class.
a.
b.
c.
Male and Female
Mixed ethnic groups
Mixed education achievement
--------~--
21
22
The evaluation was made from demographic, physical
information, health and semantic differential questionnaire.
The demographic and physical information included:
1.
Age
2.
Sex
3.
Race
4.
Weight
5.
Blood pressure
The health questionnaire was used to assess the level of
knowledge relative to Cardiovascular disease, especially
high blood pressure and associated salt restricted diets.
The semantic differential questionnaire was used to measure the students' attitudes and fee lings tmvard:
~'leight
1.
Dieting -
control
2.
Salt
3.
Smoking
4.
Hypertension control by minimizing salt intake
The demographic, physical information and the two tests
were given to both control and experimental groups.
The
health education program was presented only to the experimental group.
The health education program was devel-
oped by the investigator.
Since dieting and a change in
the taste for salt require long term efforts to produce
results, the program was conducted on a regular basis
throughout the semester.
The course consisted of two 50
minute classes followed by a series of 10 minute sessions
--------~-----··--·-
·--
23
to reinforce the education.
Weight and blood pressure
were measured and the two tests were given at the beginning and at the end of the investigation to both the control and experimental groups.
The study is a before -
after experimental design as shown in Table 1.
TABLE 1
Study Research Design
Experimental Group:
R
Control Group:
R
X
1
Statistical comparison
R
=
y"'
Y"'
2
with
(Y"' -
Y"')
2
1
indicates random assignment
indicates assessment of the dependent
variables before and after, respectively,
with the introduction of the program (X)
X
=
Experimental variable (Health Education Program)
indicates assessment of the dependent
variables before and after, respectively,
without the introduction of X.
In this design the experimental and control groups are
measured with respect to Y variables before and after
exposure of the experimental group to the X event.
Then
the hypothesis that X influences Y is evaluated by comparing the extent of the change from pre - to post
24
measure on the part of the experimental group with change
in the control group from pre - to post measure.
The
random assignment provides reasonable assurance of the
initial equivalence of the two groups.
Using the same
pre - post measure technique increases the sensitivity
of the experiment by accounting for the room for change
in the groups with respect to the variables (17).
CHAPTER IV
ANALYSIS AND RESULTS
The two study groups consisted of students from
four classes, two classes that had initially 62 students
for the experimental group and two classes with 66 students for the control group.
Each group lost and gained
students during the semester from transfers in and out of
the school rather than any reason associated with the
study.
Data were not included on any student that did
not obtain the total spectrum of testing and education.
The experimental group ended up with a sample size of
(n
=
55) and the control group with (n
=
57).
All
statistical tests were based on these sample sizes.
The
raw scores of the information obtained as part of the
study is included in Appendix J.
Table 2 summarizes the distribution of sex and
ethnic background in the two groups.
chosen had a diverse population.
The high school
The Anglo ethnic group
accounted for 63 percent of the sample, the Black ethnic
group for 13 to 16 percent, the Spanish ethnic group for
19 to 20 percent and the rest of the nationalities for
2 to 4 percent.
This ethnic distribution eliminated bias
from the study.
The classes were mixed sex groups with
25
26
the experimental group diverging the most f:rom a 50-50
~orm
with 44 percent females and 56 percent
T~.BLE
~ales.
2
Frequencies in Groups by Sex and
Ethnic Background
Test Group
Variable
Frequency
%
Frequency
%
Ethnic Background
Black
9
16
7
13
Anglo
36
63
35
63
Spanish
11
19
11
20
1
2
2
4
57
100
55
100
Hale
29
51
31
56
Female
28
49
24
44
57
100
55
100
Other
Total
Sex
Total
\The measurements of weight and blood pressure both significant risk measurements associated with essential hypertension - are presented in Table 3.
27
TABLE 3
T-Tests for Significance of Change in Paired
Observation Results Between Control and
Test Groups for Physical Measurements
Comparison
Group
ExE_erimental
b.
Weight
X
4.53
Control
S/lfl
x
s/ITI
t-Value
4.61
1.03
.06
b.
.787
Blood Pressure
Systolic
2.76
2.99
-4.96
1.91
2.17*
Diastolic
4.67
1.93
2. 53
1.15
.95
b.x - Mean Difference of Paired Observations,
(Pre-Education Score) - (Post-Education Score)
S/vn-- Standard Error of Paired Observation Data
n
=
55 for Experimental Group
n
=
57 for Control Group
*
t-value significant at (a<0.05)
The initial weights ranged from 103 to 223 lbs. for the
experimental group and 90 to 222 lbs. for the control
group.
Both groups lost approximately 4.5 lbs. yielding
no statistical difference for this parameter between
groups (a=.52).
The initial blood pressures for the experimental
group ranged from 54 to 88 rnrn.Hg. diastolic, and from 98
to 140 rnrn.Hg. systolic pressure.
For the control group
the same pressures are 48 to 96 mrn.Hg. and 96 to 142
I
--
-·-
--- -- - - - - - -
---
I
28
..
mm.Hg. respectively.
-- - - - - - -
--------------~-------
'
The diastolic pressure changes
were insufficient to be statistically significant, but
Ii
I
the change in systolic pressure between groups was a tvalue of 2.17 with statistical significance (a=.04).
indicated an association between the education and systolic blood pressure.
The health inventory test consisted of eleven
multiple choice questions associated with hypertension,
diet and salt intake.
Table 4 summarizes the statistical
parameters of these data.
In the questions directly re-
lated to foods high in salt the experimental group gained
significant knowledge change, t-value = 3.38 (a=.OOl).
The other question that showed an association
with the education was the one concerning the identification of hypertension risks that showed a t-value of 2.19
(a=.04).
Table 5 summarizes the statistically related
parameters of the semantic differential scores.
For each
concept eight to ten descriptive scales were used in
determining the concepts value.
Each descriptive scale
varied from one to seven to judge the concept.
A high
value relates to a good, valuable or healthy type of
judgment; whereas, a low value assigns a bad worthless
or sick type of judgment.
All four subjects showed a
positive change in attitude as a function of the education based on the mean difference.
-~
The concept of
~
---~ ~
~·-
-~
i
This!
----------
29
TABLE 4
T-Tests for Significance of Change in Paired
Observation Results Between Control and
Test Groups for Knowledge Test
Comparison
Group
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Experimental
~x-
s/lil
~x
Control
s/v'n
t-Value
Three Leading
Death Causes
-
.218
.109
-.105
.093
-
. 79
Exercises that
Stress Heart
-
.073
.057
-.0175 .059
-
. 68
Hypertension
Meaning
-
.127
.058
-.088
.052
-
. 51
.000
.064
-.158
.060
-1.80
Hypertension
Test
Hypertension
Symptoms
-
.073
-.018
.081
.053
-
Variables
that Help
Reduce Blood
Pressure
-
. 509
.192
-.193
.188
-1.17
Hypertension
Statements
-
• 40
.131
-.281
.103
-
.055
.084
.000
.094
Foods High
in Salt
-1.777
.296
-.579
.184
-3.38*
Seasonings
High in Salt
-
.218
-.386
.166
-1.51
Identify
Hypertension
Risks
-1.309
.250
-.474
.288
-2.19*
Salts Effect
on
Hypertension
~x
-
. 80
.72
•43
P~an difference of paired observations
(Pre score) - (Post score)
s/l:n - Standard error of paired observation data
n = 55 experimental group
n = 57 control group
* t-value significant at (a<0.05)
• 57
30
dieting showed a significant change in attitude based on
the education, t-value
=
4.03 {a<.Ol). With statistically ·
significant differences in all three types of testing physical, knowledge and attitude change - the null hypothesis that health education on hypertension will have no
significant effect on knowledge levels or diet control
for students in this study was rejected.
TABLE 5
T-Tests for Significance of Change in Paired
Observation Results Between Control and
Test Groups for Semantic
Differential Scores
Experimental
Comparison
Groups
6x
s/ln
.6x
Control
s/vn
t-Value
Controlling
Salt in Diet
3.03
2.31
-1.56
Dieting
1.45
1.12
-1.33
Smoking
.16
1.4R
3.16
1.52
-1.41
-4.84
1.42
-2.39
1.12
-1.36
Salt
.6x s/vn
1.48
2.07
.923
4.03*
Mean Difference of Paired Observations
(Pre-Education Score) - (Post-Education Score)
Standard Error of Paired Observation Data
Comparison Group Values Range from 1 to 7
From Good - Bad Type Pairings
*
t-value significant at a
= 0.01
CHAPTER V
SUMMARY, CONCLUSIONS
~~D
FE.COMMENDATIONS
Summary
The purpose of this study was to determine to
what extent health education can increase the knowledge
level and influence the diet of teenagers to minimize the '
tendency toward essential hypertension.
~_J,.j.._t.e_rature
re-
view
of hypertension with emphasis on the adolescent was
. - -----·---1
conducted.
Discussions on risk factors, the correlation
between adolescent and adult hypertension, the two types
of hypertension and treatment of hypertension were presented.
The basic conclusion on adolescent hypertension
was that simple hygienic measures, such as weight control
and the reduction of salt intake have a great potential
for prevention of hypertension (13).
The study population was composed of 112 tenth
grade health education students that were divided into
an experimental and control group.
Questionnaires were
developed to measure the change in knowledge and attitude
toward hypertension.
The weight and blood pressures were
also taken since these are significant risk factors in
hypertension.
A before-after experimental design was
used for the evaluation.
The statistical analysis
---------~
31
-~---
32
compared the extent of change from pre- to post measure
on the part of the experimental group with the change in
the control group from pre- to post measure.
The experimental groups hypertension education
consisted of two 50 minute classes followed by a series
of 10 minute sessions spaced throughout the semester.
The education was spread over the four-month interval
because of the need to reinforce the emphasis on diet
change.
Analysis of the results showed for the
experimental group that the systolic pressure was low·ered
significantly, the gain in knowledge related to foods
high in salt and hypertension risk factors was significant (a<.05).
Therefore, the null hypothesis that health
education on hypertension will have no significant effect
on knowledge levels or diet control for students in this
study was rejected.
Conclusions
The results of this study shows that health
education on diet does make a difference in the blood
pressures of high school students.
The students knowl-
edge related to foods high in salt improved and a positive
change in attitude towards diet control resulted.
33
Recommendations
This study showed that education on hypertension
and diet control should be considered in setting up a
high school health program.
Distributing the education
over an extended period of time is also important to allow
for reinforcement of the need to minimize salt intake.
The taste for salt is difficult to change (21).
The
earlier a student recognizes the need for control of salt
in the diet, the earlier he has the opportunity for control of this hypertension risk factor.
A study of junior
high school students is recommended to determine whether
similar results can be obtained in that age group.
Using
dual stethescopes to allow the student to participate in
measurement of blood pressure works well as an educational tool and is recommended as part of the instruction.
-----~--~·
VI.
BIBLIOGRAPHY
1.
Dahl, L.K., "Salt & Hypertension," American LTournal
of Clinical Nutrition. Vol. 25: 231-239, 1972.
2.
Dooley, Kenneth J., "Review of Hypertension &
Hypercholesterolemia in Children," Journal of
Medical of the Association, Georgia. Vol. 65:
427-429, Nov., 1976.
3.
Pinner, S.H., P.S. Levy, & E.H. Kass, "Familial
Aggregation of Blood Pressure in Childhood,"
New England Journal of Medicine.
4.
Freis, Edward D., "Treatment of the Hypertensive
Patient," Medical Times. May, 1978.
5.
Groover, M.E., Jr., M.D. Simpson, & M.D. Fulgham,
"The Early Detection & Treatment of Hypertension," Presented at the Twentieth Annual Meeting
of the American College of Angiology, Phoenix,
Arizona, pp. 15-24, Jan. 23-27, 1974.
6.
Henderson, J.B., & A.J. Enelow, "The Coronary Risk
Factor Problem: A Behavioral Perspective,"
Preventive Medicine. Vol. 5: 128-148, 1976.
7.
Heyden, S., et. al., "Elevated Blood Pressure Levels
in Adolescents, Evans County, Ga.," Journal of
the American Medical Association. Vol. 209:-1683-1689, 1969.
8.
Kannel, William B., "Further Findings from
Framingham," Medical Times . .r.-tay, 1978.
9.
Kaplan, Norman M., "A Guide to Curable Causes of
Hypertension," Medical Times. May, 1978.
10.
Lieberman, Ellin, "Hypertension in Childhood &
Adolescence," Clinical Symposium. Vol. 30,
No. 3: 3-43, March, 1978.
11.
McClain, Larry G., "Hypertension in Childhood: A
Review," American Heart Journal. Vol. 92, No. 5:
634-646.
34
35
12.
Meneely, G.R., & H.D. Battarbee, "Sodium &
Potassium," Nutrition Reviews. Vol. 36, No. 225233, August, 1976.
13.
National Heart, Lung, & Blood Institute's Task Force
on Blood Pressure Control in Children, "Report
of the Task Force on Blood Pressure Control in
Children," Pediatrics. Vol. 59, No. 5: 797-820,
1977.
14.
Page, I.H., "Arterial Hypertension in Retrospect,"
Circulation Research. No. 34: 133-140, 1974.
15.
Perera, G.A., "The Course of Primary Hypertension in
the Young," Annals of Internal Medicine. Vol.
49: 1348-1356, 1950-.-
16.
Rawes, L.K., & Associates, "Normal Blood Pressures
& the Evaluation of Sustained Blood Pressure
Elevation in Childhood: The Huscatine Study,"
Pediatrics. Vol. 61, No. 2: 245-251, February,
1978.
17.
Selltiz, Claire, and others. Research Methods in
Social Relations.
New York: Holt, Rinehart-and
Winston, 1976.
18.
Smith, W.M., "Hypertension: Who Should be Treated?"
Medical Times. May, 1978.
19.
Sub-Committee on Reduction of Risk of Heart Attack
& Strokes, "High Blood Pressure Control: A
Guide for Community Programs," American Heart
Association, Inc., New York, 1974.
(Mimeographed)
20.
Taber, Clarence T.\Tilbur, Taber's Cyclopedic Medical
Dictionary.
Sixth Edit1on, 1953.
21.
Tobian, L.
"What We Now Know About the Mechanisms
of Essential Hypertension," Medical Times. May,
1978.
22.
Vertes, Victor, "The Rationale for Individualized
Treatment of Essential Hypertension," Searle &
Co., San Juan, Puerto Rico.
1-15, 1977.
(Mimeographed)
i
_ _ _ _ _ _ _ _ _ _ _ _j
APPENDIX A
STANDARDS FOR
CHILDP~NS'
BLOOD PRESSURE
Charts of percentiles of blood pressure for
children, ages two to 18, were developed by the Task
Force on Blood Pressure Control in Children (13) from
three available studies.
Populations between the ages
of two to four and one half years, consisted of children,
two thirds of whom were black.
Statistically, both sex
and ethnicity showed no significant differences, and
all the data was pooled.
The population between the
ages of five and 18 years was almost exclusively white.
The distribution of blood pressure is displayed by
selected percentiles.
The position of an individual
child's blood pressure is plotted against those of a
larger group of children.
There was a considerable var-
iation in most children's pressures.
Therefore, a single
high reading does not mean an abnormal pressure.
These
charts provide a mechanism for a child's pressure to be
recorded so that a pattern over a period of time can be
observed.
36
PERCENT:LES OF B!.'JOD PRESf\_lPf: >~!=:-'l.~iJr1~MENT
PERCENTILES OF BLOOD. PRESSURE MEASUREMENT
·. • (RIGHT ARM. SEATED)
II
-rFEMALES
150
140
130
~20
01
'110
X
E 100
E
w
n:
:J
90
(f)
(/)
I !I
n:
Q.
0
0
0
.J
G)
I I 75
' .:..so
! I
I
SOl
I
'
·~~!
I
I 'I I
I
I
j
I
I I-I
.
18
I____._
The N•tlon•l Hun, lun~. >nil Blood lns&itu:c~ l>sk Fnrte on Bloocll'r•ssur• Conuol in
01ikircn~ .. .trl)ort of &h~ 1 t ,k force on Glou.i P:~...t•Jf4! Cvntrai. in 01ildren,.. P~Ji#trla.
Supplement. S9(S): 797·820,1.1>y 1977,
The N>&ion>llle>rt,lun,, >nd Blood IMtitutc't Ta•k Fc:tc on Blood Prnwrc CcnuO: In
Children: "Rtport or th•l••k fnrce on Blood l'r<KUrl Coni'oi in Ooildren,• Ptdi.tUicL
S..pplcment. S9(S): 7!17·120, ~loy 1977.
w
-...)
38
APPENDIX B
ADOLESCENT HEALTH EDUCATION TO REDUCE
HYPERTENSION
SUMMARY
Pre Test
2126179
2127179
Ia
Hypertension Background and Risk Factors
2127179
Ib
Sodium Restricted Diet
3112179
II
3127179
III
4110179
IV
51 Bl79
V
Blood Pressure Measurement Technique
Foods High in Salt
Heart Attack Risk Factors
Reducing the Risk of Cardiovascular
Disease
Post Test
5129180
Class I Instruction I Test
I.
Students from four classes of Health
Students taught by same teacher
A.
B.
II.
III.
classes Experimental
Two classes Control
T¥10
Education level lOth Grade
Semester Study
A.
B.
Two initial 50 minute classes
Remaining 10 minute classes to
reinforce education
I
39
IV.
Testing Addressed
A.
B.
C.
D.
Demographic information
Physical measurements - weight and
blood pressure
Knowledge gained - multiple choice
questions
Attitude change - Semantic
Differential
I
-------~----_j
'
APPENDIX C
LESSON PLAN I
(50 Minutes)
TOPIC A:
HYPERTENSION BACKGROUND AND RISK FACTORS
CONCEPT:
Hypertension is a highly prevalent disease that can be easily diagnosed
and controlled often bv minimizing risk factors.
,OBJECTIVES:
1) The student will be able to identify the causes of hypertension.
2) The student will be able to explain how risk factors such as
weight, smoking, drugs and diet affect hypertension.
\EVALUATION
CRITERIA:
1) The student will be required to state 2 out of 4 causes of
hypertension as part of written test.
2) Both in class and in written test the student will be asked to
identify risk factors for hypertension.
LEARNING OPPORTUNITIES
CONTENT
1.
Definition of Hypertension
1) Disease Related Hypertension
2) Essential Hypertension
L______ · - - - - - - - - - - · ·
1.
The teacher will query the class
about family members with hypertension to interest the class leading into a definition of hypertension. The information will be
summarized on the chalkboard for
later use in (4).
~
0
LESSON PLAN I - TOPIC A (Continued)
LEARNING OPPORTUNITIES
CONTENT
Risk factor related to other
diseases
2.
Risk factor in hardening of the
arteries, heart disease, kidney
damage and brain hemorrhage.
3.
Leading death causes Heart disease is first out of top
15 leading death causes
3.
The students will be asked to guess
how heart disease ranks to other
major death causes as a lead into
a discussion of leading death
causes. A view chart is used to
project the list.
4.
Diagnosis Methods
4.
The teacher will discuss how blood
pressure is measured using a blood
pressure cuff and stethoscope as a
visual aid. A chart of blood pres- .
sure vs age and percentile distri- ,
bution is used to relate normal vs
high blood pressure. The family
history data from (1} will be used
to lead into a teacher lead discus- i
sion on nationality, family and
individual health history related
to hypertension.
.2.
a.
b.
c.
i
I
!.
Blood pressure measurement using
cuff and stethoscope
Normal vs. high or low values vs.
age
Genetic-Health history relationship
1) Nationality
2} Family
3} Individual
ol::o
I-'
LESSON PLAN I - TOPIC A (Continued)
CONTENT
: 5.
Risk factors and how they affect
blood pressure
a.
b.
c.
d.
: 6.
b.
c.
5.
Using the chalkboard, the teacher
will present the first risk factor
and its effects and ask for others
from the students. V.Ji th the
teachers help all primary factors
will be presented and discussed.
6.
The teacher will present
information to students.
Smoking and drinking
Exercise
Weight
Salt intake
Childhood and young adult prevalence
a.
LEARNING OPPORTUNITIES
Recent studies show all ages
affected
Lack of teenage diagnosis - no
measurements taken
Start treatment early
~
N
LESSON PLAN I
'TOPIC B:
SODIUM RESTRICTED DIET
·CONCEPT:
Reducing salt intake is one of the simplest and best treatments for
hypertension either for a person who has hypertension or may be susceptible based on known risk factors.
OBJECTIVE:
1) The student will become knowledgeable on salt restricted diets and
common foods that are high in salt and be able to list a representative group of foods.
2} All students but especially those susceptible to hypertension will
be motivated to change their diet to minimize salt intake.
EVALUATIVE
CRITERIA:
1) The student will be able to identify a majority of foods and
condiments from multiple choice questions on written test.
2) Blood pressure and weight changes will be correlated in pre and
post tests.
3) Attitude changes with respect to hypertension and risks will be
evaluated from Semantic differential pre and post tests.
CONTENT
1.
Salt (sodium) restriction related
to essential hypertension
LEARNING OPPORTUNITIES
1.
The teacher will discuss how salt
restrictions can affect essential
hypertension. The overall
~
w
LESSON PLAN I - TOPIC B (Continued)
2.
CONTENT
LEARNING OPPORTUNITIES
a.
b.
c.
d.
requirements to achieve life-long
change will be emphasized. The
student will be cautioned that a
severe salt restricted diet should
only be done as part of a doctors
treatment.
Sodium
a.
b.
c.
d.
3.
I___ _
2.
The teacher will list on the
chalkboard common food sources for
sodium and discuss why it is
difficult to reduce salt.
3.
The teacher will project a list
of foods with high salt content.
A class discussion on these foods
plus others suggested by the class
Common mineral
Everyone needs limited amount
Effects of high intake genetically
dependent.
(1) Some people can eat unlimited
amounts without problems
(2) Others get hypertension
Common Sources
(1) Foods - Salt (NACL),
Monosodium glutimate 0-'lSG)
(2) Water - Dependent on
geographic location
Difficulties related to accomplishing
salt reduction
a.
I
One of best and simplest treatments
Requires sodium reduction for life
Mild restriction - not elimination
"True" restricted diet a~-doctors
evaluation and treatment
Taste acquired in infancy
~
~
LESSON PLAN I - TOPIC B (Continued)
CONTENT
LEARNING OPPORTUNITIES
b.
as to their frequency of daily
intake will be held by the teacher.
c.
d.
!4.
High salt content foods
a.
b.
:5.
Severe reduction difficult to
follow
Slight reduction more realistic
Constant effort required for a
long period of time to change
desire for salt
Typical examples of high salt
foods
Read Food labels for salt
content
4.
The teacher will explain and
summarize on the chalkboard the
essence of a mild sodium restricted
diet that can be followed by the
students.
Limited Restriction
a.
b.
c.
Minimize intake of salty foods
Use salt and MSG sparingly at
table
Cut recipe amounts in half for
salt and MSC";
i
I
I___ .
.t::.
U1
APPENDIX D
LESSON PLAN II
(50 Hinutes)
TOPIC:
BLOOD PRESSURE MEASUREMENT TECHNIQUE
CONCEPT:
Blood pressure measurement is a simple test to identify hypertension.
The actual measurement can be heard and taken by anyone properly
trained.
OBJECTIVES:
1) The students will participate in taking their blood pressure to
eliminate confusion and the mystery of what is heard and done in
the measurement.
2) Reinforce the previous education on blood pressure and salt
restricted diets.
EVALUATION
CRITERIA:
The teacher will observe whether the student understands the technique
by having the student state his blood pressure reading as they take it.
CONTENT
1.
Review of hypertension, risk factors
LEARNING OPPORTUNITIES
1.
The teacher will summarize the
learning opportunities related to
hypertension and risk factors to
lead into blood pressure measurement.
~
"'
LESSON PLAN II (Continued)
LEARNING OPPORTUNITIES
CONTENT
2.
Blood pressure measurement
techniques
2.
The teacher will give a detailed
explanation of the physiology
associated with blood pressure
and how to take blood pressures
using the blood pressure cuff
and stethoscope.
3.
Review salt restricted diet need
3.
The class will be divided up into
groups of 4 or 5 students. The
teacher and assistants will individually demonstrate to the student blood pressure measurement.
Dual stethoscopes are utilized
that allows the students to hear
what the instructor hears.
4.
Questions and answers will be
informally handled as part of
the individual evaluation.
5.
The teacher will relate blood
pressure measurements, high blood
pressure and salt intake. The
need for a long term effort to
reduce salt intake is reiterated.
i
~
--------- ·- ----
----------- --------
-·.
-- -- --·-· -·-··-
. --- --·
- ----
-· ..
-------------
-...)
APPENDIX E
LESSON PLAN III
( 10 minutes)
TOPIC:
FOODS HIGH IN SALT
CONCEPT:
Knowing foods high in salt content is required to minimize salt intake ..
OBJECTIVES:
1) The student will be able to identify many of the common foods high
in salt.
2) Reinforce the need for a salt restricted diet.
I
EVALUATION
CRITERIA:
The student will choose from multiple choice questions on the written
test foods high in salt content.
LEARNING OPPORTUNITIES
CONTENT
1.
Review need for reducing salt in diet
1.
As a means of starting the class
the instructor will display a
chart questioning how many adults
out of a hundred will have hypertension. Students will be asked
for estimates.
2.
Canned Soups
2.
The teacher will discuss canned
soups as a typical convenience
food everyone is familiar with.
~----·-···--
""'
00
LESSON PLAN III (Continued)
CONTENT
LEARNING OPPORTUNITIES
a.
b.
c.
d.
e.
f.
Details of their high salt content
will be emphasized, with a final
note that homemade soup is better.
g.
3.
List typical soups (3 or 4)
Mainly convenience foods
Principle seasoning salt
High in MSG.
Major flavor characteristic salt
Salt content (typ. 1600 Mg.) vs
allowance for low sodium diet
(200 Mg.)
Typical content data
Salt content in typical foods
3.
The teacher will present typical
foods either as actual examples
in hand or as view graph pictures
and ask the students to guess how
much sodium per serving is in each ;
product. The list should include ·
items like corn flakes (260 Mg.), .
Peanuts (132 Mq.), Bread (117 Mg.)~
Potato chips (191 Mg.), Jello
\
(404 Mg.), Frozen chicken dinner
(1152 Mg.), Dill Pickles (1137
Mg.), Big Mac hamburger (1570 Mg.),i
etc.
1,0
"""
APPENDIX F
LESSON PLAN IV
( 10 minutes)
TOPIC:
HEART ATTACK RISK FACTORS
OBJECTIVE:
1) The student will have a simple individual assessment of his own
chance of suffering a heart attack.
2) Reinforce the need for a salt restricted diet.
EVALUATION
CRITERIA:
After the game of RISKO, selected students will be asked their scores
questioned whether they are or feel they should be minimizing salt
intake.
LEARNING OPPORTUNITIES
CONTENT
1.
Review need to reduce salt in diet
to lower risk for heart attack
1.
The instructor will review how
salt affects blood pressure and
the need to reduce salt intake.
The relationship, between high
blood pressure and heart attacks
will be reiterated.
2.
Heart attack risks assessment by
Risko
2.
The game of RISKO is introduced,
the rules gone over and the student "plays" the game to assess
his own risk for heart attack.
I
'-~-
---·-----
/
U1
0
LESSON PLAN IV {Continued)
CONTENT
a.
b.
LEARNING OPPORTUNITIES
Eight risks with assessed value
in six discrete levels.
Age, Heredity, Weight, Smoking,
Exercise, Diet, Blood Pressure,
and Sex
3.
The instructor will ask selected
students their score and ask how
they now feel about reducing salt
intake.
l11
f-'
52
R I S K 0
The purpose of this game is to give you an
estimate of your chances of suffering heart attack.
The game is played by making squares which--from
left to right--represent an increase in vour RISK FACTORS.
These are medical conditions and habits associated with
an increased danger of heart attack. Not all risk factors are measurable enough to be included in this game;
see back of sheet for other RISK FACTORS.
RULES
Study each RISK FACTOR AND its row. Find the box
applicable to you and circle the large number in it. For
example, if you are 37, circle the number in the box
labeled 31-40.
numbers.
risk.
SCORE
After checking out all the rows, add the circled
This total--your score--is an estimate of your
IF YOU SCORE:
6-11
Risk well below average
12-17
Risk below average
18-24
Risk generally average
25-31
Risk moderate
32-40
Risk at a dangerous level
41-62
Danger urgent. See your doctor now.
HEREDITY:
Count parents, grand-parents, brothers, and
sisters who have had heart attack and/or stroke.
TOBACCO SMOKING:
If you inhale deeply and smoke a cigarette way
down, add one to your classification. DO NOT subtract
because you think you do not inhale or smoke only a half
inch on a cigarette.
EXERCISE:
Lower your score one point if you exercise
regularly and frequently.
53
R I S K 0
(Continued)
CHOLESTEROL OR SATURATED FAT INTAKE LEVEL:
A cholesterol blood level is best. If you can't
get one from your doctor, then estimate honestly the
percentage of solid fats you eat. These are usually of
animal origin -- lard, cream, butter, and beef and lamb
fat.
If you eat much of this, your cholesterol level
probably will be high. The U.S. average, 40%, is too
high for good health.
BLOOD PRESSURE:
If you have no recent reading but have passed
an Insurance or Industrial examination chances are you
are 140 or less.
SEX:
This line takes into account the fact that men
have from 5 to 10 times more heart attacks than women of
child bearing age.
-----~----------~
Age
Heredity
Weight
10 to 20
21 to 30
1
2
No known
history of
heart disease
1 relative
with cardiovascular
disease
Over 60
1
2
More than
5 lbs
below
standard
weight
-5 to +5
lbs
standard
weight
i
\ Tobacco
Smoking
Nonsmoker
I
0
2 relatives
with cardiovascular disease
Over 60
3
6-20 lbs
over
weight
Cigar
and/or
pipe
J
3
10 cigarettes or
less a
day
1
51 to 60
1 relative
with cardiovascular
disease
Under 60
6
2 relatives
with cardiovascular disease
Under 60
3 relatives
with cardiovascular disease
Under 60
4
6
7
21-35 lbs
over
weight
36-50 lbs
over
weight
51-65 lbs
over
weight
3
20 cigarettes a
day
2
61 to 70
5
4
2
1
0
41 to 50
31 to 40
5
7
6
40 cigarettes a
day or
more
10
30 cigarettes a
day
4
U1
I
L-~. · · - - · - - - - - - - - - ·-·
.;:..
Exercises
Cholesterol
or Fat %
in Diet
Intensive
occupational
and recreational
exertion
J'.1oderate
occupational
and recreational
exertion
1
2
Cholesterol
below 100
mg.%
Diet contains no
animal or
solid
fats
Cholesterol
161-205
mg.%
Diet contains 10%
animal or
solid
fats
2
Cholesterol
206-230
mg.%
Diet contains 20%
animal or
solid
fats
120
upper
reading
140
upper
reading
1
Blood
Pressure
100
upper
reading
1
2
Sedentary
work and
intense
recreational
exertion
Sedentary
occupational
and moderate
recreational
exertion
3
Cholesterol
231-255
mg.%
Diet contains 30%
animal or
solid
fats
4
150
upper
reading
Complete
lack of
all
exercise
6
8
Cholesterol
256-280
mg.%
Diet contains 40%
animal or
solid
fats
5
Cholesterol
281-400
mg.%
Diet contains 50%
animal or
solid
fats
160
upper
reading
200 or over
upper
reading
5
3
3
Sedentary
work and
light recreational
exertion
4
7
6
8
I
--·--·--·-·-·---- ---------- ---···-
---------------
----------------------
..
U1
U1
Sex
Female
40-50
Female
under
40
Female
over 50
Stocky
Male
Hale
Bald
Stock
~1ale
1
2
3
5
6
7
U'1
0'1
APPENDIX G
LESSON PLAN V
( 10 minutes)
TOPIC:
REDUCING THE RISK OF CARDIOVASCULAR DISEASE
CONCEPT:
Cardiovascular diseases, the leading death cause, is largely a
preventable disease.
OBJECTIVES:
1) The student will be able to identify most of the leading causes of
cardiovascular disease.
2) Reinforce the need to reduce salt in the diet.
EVALUATION
CRITERIA:
Identifying the leading causes of cardiovascular disease as part of
written multiple choice questions.
LEARNING OPPORTUNITIES
CONTENT
1.
Review of circulatory system,
especially the heart
1.
The teacher will use film strip
and tape to review cardiovascular
system and risks that were identified in the first lesson.
2.
Identify leading risks and how to
minimize their effects in your
life
2.
The teacher will reinforce the need
to minimize salt in the diet and
query students whether they are
working toward that end.
--···-··-·---------
·-·-··------------··--- -
...
Ul
-...j
LESSON PLAN V (Continued)
CONTENT
3.
LEARNING OPPORTUNITIES
Review the relationship between
hypertension and salt intake
U1
00
59
..
-
- · · - - - - - - - - ----.
APPENDIX H
SEMANTIC DIFFERENTIAL QUESTIONNAIRE
Test Instructions
***** IMPORTANT.
PLEASE READ THE FOLLOWING *****
INSTRUCTIONS CAREFULLY.
The purpose of the next section of this
questionnaire is to determine the meanings of certain
concepts to various people by having them judge each concept against a series of descriptive scales.
In complet-
ing this section, please judge the concepts on the basis
of what they mean to
~·
Following each concept is a
set of 7-point scales on which you are to judge that concept.
Please mark on each of the scales wherever you
feel the concept should be rated.
Work rapidly; don't
take too long to make any one rating; and rate according
to your first impressions.
Examples.
1.
If you felt that the concept was very closely related
with one end of the scale, you might place you check
mark as follows:
DICTATOR
up ------ ------ ------ ______ : ______ ------ --~X___ down
· · - - - - - - -··
-----
60
2.
If you felt that the concept was quite closely related
to one side of the scale, you miqht check as follows:
OATMEAL COOKIES
.
3.
.
.
.
X :
-- : --- .-- .-- .-- .--
desirable
undesirable
If the concept seemed only slightly related to one
side as opposed to the other, you might check as
follows:
CLOUD
easy
4.
- - : - - :-X
-: - - : - - : - - : - -
difficult
If you considered the scale completely irrelevant or
both sides equally associated, you would check the
middle space on the scale:
TREE
idealistic
NOTE:
X :
-- : -- -- : ----
realistic
Nork rapidly; it is your first impressions that
arewanted.
DIETING
DIT
1
good
DIT
2
strong
DIT
3
tasty
DIT
4
valuable
DIT
5
kind
DIT
6
happy
DIT
7
healthy
DIT
B
needed
-
l"JEIGHT CONTROL
. .
-- : -- : -- -- -- : -- : -- bad
.
-- : -- : -- -- : -- : -- : -- weak
.
-- : -- : -- : -- : -- .-- : -- distasteful
.
. .
-- : -- -- : -- -- -- : -- worthless
.
.
-- -- : -- : -- -- : -- : -- cruel
.
.
-- : -- -- : -- : -- : -- -- sad
. . .
-- : -- : -- : -- -- -- -- sick
. .
.
- - : -- .-- -- : -- : -- -- unneeded
61
--
------~---
------------~~-
.. ---
SALT
SLT
1
tasty
SLT
2
happy
SLT
3
good
SLT
4
strong
SLT
5
healthy
SLT
6
valuable
SLT
7
fair
SLT
8
pleasant
SLT
9
nice
.
.
-- .-- : -- : -- .-- : -- : -.
.
- - : -- : -- : -- -- : -- --- : -- .-- : -- ..-- .-- : -.
-- : -- : - - : -- : -- -- : -.
.
- - : -- : -- -- : - - -- : - .
- - : -- : - - : - - : -- -- : - .
-- : -- : -- : -- - - : -- : -.
.
-- : -- -- : - - : -- : - - -- - : - - : - - : -- : - - : -- : - 0
distasteful
sad
bad
weak
sick
worthless
unfair
unpleasant
awful
S~·iOKING
SMK
1
needed
SMK
2
f__ alr
.
s_~U<
3
brave
SMK
4
good
SMK
5
valuable
S1'.1IK
6
tasty
s~~K
7
happy
SMK
8
pleasant
SI-~K
9 interesting
SMK 10
healthy
.
-- : -- : -- : - - : -- : - - .- . .
- - : -- : - - - - -- : -- : - .
- - : -- : -- : - - : - - -- : -.
-- .-- : -- : -- -- : -- : --- : -- : - - : -- : -- : -- : -- - : - - : -- : - - : -- : -- : --- : -- : - - : - - : -- .-- : -.
-- : -- : -- : - - : -- : -- -.
.
-- : -- : - - : -- -- : -- -. . . . . .
- - .-- .-- -- .-- - - .--
unneeded
unfair
co\<rardly
bad
worthless
distasteful
sad
unpleasant
boring
sick
62
Controlling diet, like minimizing salt intake,
can reduce the tendency toward hypertension
and a shorter life.
CDT
1
CDT
2 interesting
CDT
3
healthy
CDT
4
fair
CDT
5
nice
CDT
6
brave
CDT
7
happy
CDT
8
pleasant
CDT
9
kind
CDT 10
valuable
CDT 11
tasty
CDT 12
strong
CDT 13
good
needed
~-
.
.
-- : -- .-- : -- : -- .-- : --- : -- : -- : -- : -- : -- : -.
. .
-- : -- : -- -- : -- -- --- : -- : -- .-- : - - : -- : -.
- - .- - : -- : -- : -- -- : --- : -- : -- : -- : -- : -- : --- : -- : -- : -- : -- : -- : -.
- - : -- -- : -- : -- : -- : -.
- - : -- : -- -- : -- : -- : --- : -- : -- : -- : -- : -- : -.
. .
- - : -- -- -- : -- -- : -.
.
-- : - - : -- -- : -- : -- --- : -- : -- : -- : -- : - - : --
--~·-~-~------
···------------
·-~
~--~-~~
unneeded
boring
sick
unfair
awful
cowardly
sad
unpleasant
cruel
worthless
distasteful•
weak
bad
~-·---~~~----------
63
APPENDIX I
HEALTH QUESTIONNAIRE
HIS
HIS
1.
2.
Which of the following are the three leading
causes of death in the United States?
Check ( ) the three leading causes. Circle
the ( ) of the highest cause.
1.
Accidents
2.
Old Age
3.
Influenze and pneumonia
4.
Cancer
5.
Homicide
6.
Diseases of the heart
7.
Tuberculosis
8.
Snake bite
Exercise that increases blood flow through the
heart and large muscles for a continuous period
promotes physical fitness. A physical activity
that best meets this requirement is:
A.
Jogging or bicycling
B.
Lifting weights
C.
Pushups
D.
Playing football
~
~~
-~
--
-~-----~
-----~-
64
HIS
HIS
HIS
3.
4.
5.
Hypertension means the same thing as:
A.
Headaches
B.
Obesity
c.
Abnormally elevated blood pressure
D.
Heart beat rhythm defect
E.
Heart failure
Hypertension can best be determined by:
A.
A health history
B.
Blood test
c.
X-ray
D.
Observing life style
E.
Blood pressure measurement
Hypertension symptoms are:
A.
Sleepiness
B.
Sharp pains in the arms
c.
Headaches and dizziness
D.
Nervousness, flushed face, and rapid
pulse
E.
Absence of symptoms
65
HIS
HIS
HIS
6.
7.
8.
Which items of the following list are important
in reducing blood pressure:
A.
Sugar
B.
Pepper
c.
Salt
D.
~\Teight
E.
Exercise
F.
Regular physical checkups
G.
Lots of rest
H.
Smoking
I.
Drinking
loss
Which of the following statements are true:
A.
Hypertension occurs only in people over
40.
B.
Hypertension is more prevalent in some
ethnic groups.
C.
Hypertension occurs at any age.
D.
Diet can influence hypertension.
The most important reason for reducing table
salt in the diet if a person has hypertension
is that:
A.
Salt causes people to drink more water.
B.
Excess salt ingestion contributes to
poor blood pressure control.
c.
Excess salt causes the arteries to
narrow.
D.
Excess salt may interfere with the
heartbeat.
------------
66
HIS
9.
Which of the following foods are high in salt?
) check those with high salt content.
sugar
peanut butter
mayonnaise
canned soups
MSG (monosodium glutamate)
ice cream
bouillon
hot dogs
canned fruits
syrup
baby foods
milk
bacon
chocolate milk
cold cuts
beer
potato chips
Pepsi, orange, coke
pickle
hamburgers
cookies
---·------------
67
HIS 10.
Which seasonings are high in salt content?
(
) check those high in salt.
catsup
onions
pepper
barbecue sauces
soy sauce
garlic
mushrooms
jelly
olives
cooking wine
meat sauces
curry
pineapple
green peppers
68
HIS 11.
Which of the following effects hypertension?
(
) check correct statements.
weight
tight fitting clothes
exercise
smoking
drinking alcohol
cleanliness
stress
high calorie foods
low calorie foods
heredity
69
APPENDIX J
RAN SCORES OF STUDENTS TESTS
The detail results of the pre and post tests of
the control and experimental groups are furnished.
Definitions of the variables and their numerical values are
as follows:
I.
Physical Measurements
A.
B.
Ethnic
~.-Jhite
3.
4.
Spanish
Other
Sex
1.
2.
II.
III.
Black
1.
2.
Male
Female
Health Questionnaire
A.
PHIS 1 - PHIS 11 are the pretest questions
listed in Appendix E. The "P" suffix refers
to the Pre test.
B.
HIS 1 - HIS 11 are the posttest questions
listed in Appendix E.
C.
The variable values are the number of right
answers for each question. For example HIS 11=
4 means 4 of the answers to question 11 were
correct.
Semantic Differential Questionnaire
A.
Each question in this section has a score from
1 to 7. Appendix D furnishes a detail definition of the scoring and meaning of the test.
B.
All pretest scores have a "P" as the initial
letter of the variable.
70
c.
Variables numeric value refer to the
descriptive variable as defined in Appendix D.
DIT 7 means the 7th variable on the diet
concept.
D.
Variable names are listed in Appendix D.
!
I
i
I
_J
PEYSICAI.
IKi?CRl~ATION
EXPr-:HI~fEN'I'!,L
-·-···-------- 0!3S ·-·-·ETC _____ SX ____ AG
1
2
3
4
·------ s ····
1
1
t
2
1
2
1
2
1·-··-- 2 --··-
16
15
1.6
16
16 ·---·
~
i '·
GRO-:JP
I
PWT
PSYS
PuiS
2l't
l'•J
116
133
121 -·
140
130
100
130
124
78
76
64
68
· - - 74 --·---
1
2
15
us· 110
1
1
2
15
117
100
g
2
1
15
135
130
q
2
1
16
174
120
10
2
1
15
134
102
· u - - z - - - c - - 1 5 -·--154- --uo - 12
2
1
15
108
112
13
2
1
18
135
122
14 ---·- 2 ----1 ---- 16
112 ... 1!0 -----·
6
wr
svs-ots
217
1'·6
111
130
126
124 --·
98
104
102 ___
ua--·
64
at,
7a
54
56-----·
66
u1
100
ao
70
1C9
100
58
66
124
138 ·- 82
72
166
132
60
58
128
140
56
1o - - 1 5 2 - - u a - - s a
84
114
108
66
68
128
138
66
70 ··- 112 ·--- 118 --··· 70
15
2
1
15
120
110
66"
108
114
56
16
2
1
15
136
144
78
130
138
76
- - - - - - - - - - - - - - - - 11 - - 2 - - r - - - 1 6 - - 2 23 ~ z o - - - 6 o·---2 o:; - - uz - - 7 o : - - - - - 11l
2
1
16
21)8
132
sa
196
136
6c
19
2
1
16
135
1ft0
58
128
130
Et,
20 ··--- 2 - - - 1 ---·-· 15 -- 15L. ·-· 126 -·-· -· 68 ·--- 150
120 --·- 7J
21
2
1
15
140
108
64
140
138
64
22
2
1
15
118
c;a
76
110
122
64
- - - - - - - - - - - - - - - - 23 ___ 2 ____ 1 ___ 16 --·137--···· cu;----64 - - - - 1 2 9 - - 1 1 0 - 10 _ __
24
25
---·--------- 26
27
23
2
1
lb
2
l
15
--.2 ···-·-·· 1. ··-··· 16 ·-·
2
2
1
1
15
16
148
120
64
lft9
128
70
144 -··· 126 ---· 82
--·
u,o .....
120
114
12,
6'+
68
66-------
78
155
128
88
80
140
108
80
----------------·29·---2--l--16--l4L~--~24 ____ 7 J - - 1 4 3 - - l ) 4 - - 6 6 - - - - - 30
2
1
15
31
2
2
lS
32----z·----z··---15···33
1
2
lo
34
2
2.
15
152
135
148
1'•6
128
l30
135
132
72
134
120
64
148
114
12
145
108
68
us··--··1oz·---··74 ____ 1lb ---· !1B - - - 7 8 - - -
175
126
ll4
104
-----------------.:3s·--z---z--l6 ____140--iJO
66
us
110
60
64
105
102
68
as_ _ _l3s--uo·--·s4··-- - - - - -
36
2
2
15
1~5
126
80
135
102
64
_}?._ _ _~----- _?___ ...!~------~28____ !.~0. ____ :!_~------~.?2_____ 12!______ ~~------....:I
1-'
------------- -------- ·----------
PHYSICAL
INFORMATION
. -··---·
EXPERIMENTAL GROUP
--- ·- -------
oas--e-rc-- sx·---AG--PwT--Psvs·--·Pois--wr ·---svs
38
---------- 39
40
2
--------- 2
2
2
2 ·---·
2
ors
15
137
15 ------- 115- -16
140
121
72
130
118
80
106 ·-- ----- 72 -··---- 116 -----·130 ·---· 70
116
66
112
104
66
41
2
2
15
120
128
60
116
120
68
- - - - - 4 2 _____ 2 ___ 2 - - - 1 5 ___ 1 5 7 - 130--··· 78 -----154 ___ 136--80 _ _ _ __
1
16
130
122
80
132
116
74
1
16
124
12G
70
120
138
56
45···---- 3 ---·--· 1--- ... 15 --- 125 -----132 ---· 73 ...... 118- -·· 140 ---- 68
46
3
1
15
126
106
72
127
110
70
47
3
1
16
137
128
74
130
•
•
-----48
3
2
16--135--124
64 ___ 1 3 1 - - t 2 o - - 7 o · · - - - - 49
3
2
17
123
110
78
122
102
64
43
44
50
-----·51
52
53
----~54
55
3
3
3
2
15
3----2---18-3
2
15
3
2
16
4
1--15
4
1
15
115
120
66
110
ll4
64
115 ---118 ·-----· 68- -·---112 --· 110 ----56 -·
126
9o
68
112
104
sa
103
128
16
97
114
60
162
11"6
72
i54
128
6,..- - - - 142
148
90
136
132
80
-----------
.
-----------------------·---------------
-------...J
tv
lfE,1LTII
~LESTIONNAIRE__
...
EXPERIMENTAL GROUP
----·- ---------··-·--·-·-- ·-····------ .
CBS
PHI Sl
PHIS2
...... ---- 1 .. --·- 2 ------. 2
3
2
3
----4---35
6
7
2
1
. -- 2 ··- ---· -
---··-· .
PHlS3
PHIS4
PHI 55
PHIS6
PHIS7
0
1
0
l.
2
1 .. --
1
1
1
...
1
0
6
2
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PHISl
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37
3
38
3
39
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42
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45
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47
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49 _ _ _
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1
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1
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PHIS4
0
1
o
PHIS5
PHlS6
PHIS7
PHIS8
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0
2
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1
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6
6
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2
2
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2
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51
2
2
53
54
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2
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2
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4
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2
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3
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Q~'ESTIO!lNAIRE ..
-···---·-·-- ___
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EXPERIHENTAL GROUP
-------- ·---·-··----- - - - --··--·-·- --OBS
HISl
----······-----···----·----- -·---··-·------------------,----HIS3
HIS4
HISS
HIS6
HIS 7
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HIS9
H!Sll
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6
3
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1
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1
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1 ···--··- 1 -·--- ·-. 0
2
2
4
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3
2
2
3
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1
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l
1
0
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0
0
11
1
1
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8
8
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7
4
5
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2
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1
1
10
9
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1
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3
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6
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5
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3
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20
3
1
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3
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2
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29
30
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3
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1
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2
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4
6
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2
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5
5
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5
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. __________________________ ----· ______ HEALTH QUESTIONNAIRE
.
------------
EXPERIHENTAL GROUP
----· ... --------- ----OBS
37
HISl
3 ·-
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-- ----------·----·.
HISZ
HIS3
1
1
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1
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HI S7
1
0
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38
2
1
1
1
1
2
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39
2
1
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2
1
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1
1
42
3
1
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41
3
1
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1
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0
3
6
4
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4
5
3
1
9
5
5
2
5 . -
1
3
0
0
6
9
4
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4
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2
1
5
5
3
1
0
10
4
2
1
1
1
0
3
1
1
2
4
1
1
0
2
47
3
1
i
1
1
1
0
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1
3
6
2
44
2
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1
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45
46
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1
48
3
0
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1
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4
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6
5
2
1
5
4
3
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50
3
1
1
1
0
3
2
1
4
4
3
51
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1
1
1
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l
3
0
1
2
3
1
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3
8
2
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53
54
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3
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1
0
1
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1
2
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1
1
2
1
3
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4
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2
2
3
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0'1
SE!JJ.li!T!C DIFFERENTIAL
--- ----------- --
-----··-
-------
EXPER!HENTAL GROUP
·--------------·- --- -·OBS
PDHl
·-------- -----------
--· ·--·- --· ·-· -· ·--------·--
·-·---- ... .
POIT2
PDIT3
PDIT4
1
2
4
4
5
. . .... ..
l
3
4
3
l
7
4
- - - - - - - - - - - - - - . 4 ·-·--·- 4 -------4 - - - - · - 3 ·-·----- ·--·
5
4
PDIT5
5
4
PL>l T6
PDIT7
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4
4
4
3
3
4
1
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1
2
1
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·-
1
4
3 ·------ 5
5
1
l
4
1
4
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1
1
6
1
2
l
2
2
4
4
1
3
'•
3
2
4
__ 11 _ _ _ _ 21______ 1l
11
1 ---1
7
1
4
5
8
2
3
4
9 ___ 21
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11
12
13
... --
1
4
1------4-
l
4
1
1
1 --···-·-·· 2
14
15
1
2
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17
2
18
1
2
5
2
l
2
4
1
4
-·· - ... 1 --·--·-- ·- 1 - ·-----· 2 ·----·-
1
3
1
l
2
4
2
4
l
4
19·-·---- 4. - - - · .. 4 ---·-·- 4
20
2
4
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6
2
3
1
3
l
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3
2
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3
-- . -· -
4 -----·· 3 - - - - - -
1
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1
4
5
4
1 - - - 1 ----- 1 ·----
3"
1
4
35
4
1
l
2
2
2
2
2
3
i
1---4
1
2
4
1
1
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21
4
5
22--2
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23
3
2
24
3
3
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6
4
4
5
4----44-----4
6
3
4
3
5
1
3
1
4 ·-·--·· 2 - - - - 4 -··--·-··--· 4 - - - - -
26
1
27
1
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1
3
29
. 3
1
1
4
3
4
4
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35
_ _ _ _ _ _ _ _ _ _ _ _ _ __;;3_;;6_
2
1
l
2
1
2
4
4
2
3
2
4
l
2
~---·-
4
3---1
3
1
2
2 ----·-· 3
l
1
2
1
1
2
4-
l
2
4
1
1
2
2
4
5
3
30
5
5
5
4
4
31 - - - - L - - - · - 2 ·------ 4 -·------- 1·------- 6.
32
33
4
1
1
3
3
1
4
2
2
4
6
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4
2
2
4
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1
1
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5
4
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1
1
1
l
2
1
i·----
2
1 -----....]
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________ ------··--------- ____ SEMANTIC DIFFERENTIAL ________
_________
PDITl
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38
3
39
'40
41
42
----··43
44
45
46
47
4
48
49
50
51
52
53
54
--·ss
-----
-----------------
EXPERIHENTAL GROUP
.._____
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PDIT2
·-- -··
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POIT3
POI T4
3 --------- 3·--- ---------
3
1
r
1
1
3
1
4
4
2
2
3
4
2
I
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5
4
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1
4
6
5
3
5
4
4
6 _______ 5
3 _______ 7
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2
3
3
5
4
1
3
7
6
6
4
5
2
4
l
l
3
2
4
POITS
2 ... -· -- ··- . 4
3
3
PDIT6
PDIT7
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4
5
4
4'1
3
l
1
1
3
4
3
-------- 1 ·-- ------- 3' -- -----·
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5
5
5
4
4
2
4
3
6
3
4
3
6
6
7
--·----·- --------·· ----------4
1
3
4
5
2
4
3
4
3
3
6
6
l
1
6
5
4
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4
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3
4
3
4
1
1
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2
3
1
2
2
4
5
2
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2
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6
3
7
1
1
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3
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1
4
2
2
1
1"
2
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co
------------------
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SE!~,\NT!C
DIFFERENTIAL
EXPE.'~IH:=:r>TAL
·:----.
GROUP
-------------------------- -------.--------- ------ ---------·- ------· ------ass
DITl
DIT2
01T3
01T4
O!T5
DIT6
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on a
- - - - - - ---·------ 1 -------3 ·- -------·--1 ------ · 2 ··----------·2. ---···-- 2---------------2 ·- ·----- 2-----22
4
5
4
3
3
2
3
l
7
7
3
2
1
4---·s·-----3 - - - - 3 - - - - 1 - - - - 7 - - - - 3
5
1
1
1
3
3
8
1
2
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1
9
1
3
4
1
10 ___ 1 - - - - l - - - - - . z · - - - - 1
2
3
3
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1
2
1
2
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7
4
2
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1
4
l
1
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61
1
11
1
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11
1
1
5
2
l
1
1
l
12
l
l
4
1
1
4
3
2
13 -·--- 1 ------ 1 ----- ]. ------ 1 - - - - 2 ------·-- 1----- 1 - - - - 1
14
15
1
3
1
4
3
3
2
2
..
4
3
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17
3
1
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3
4
3
18
1
2
2
1
1
1
19 ----·2 ------2-----3----------2 - - - 3 ---------2---
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2
1
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5
6
2
4
23
24
25 ---
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2
6
4
4
4
2 ----- 4 ----- 4
2
5
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26
2
2
2
2
1
1
1
27 ___- 31
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41
42 _ _ _ _ 3l _ _ _43
51
31
l -----3
3
5
4
3
3
29
5
30
6
31 . ----- 1
32
1
33
1
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4----4
4
5
- - - - l -------4-4
4
2
3
1
2
4
2
5
2
2
2
1
4
7
2
4
3
1
20
21
- - - - - - - - - - - - 2 2 ___ :::;
3
5
2
4
2
2
4
2
2
4
2------
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2
1
2
1
2
2
2
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1
2
7
5
1 -----1
1
1
6
6
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3
2
3
2
i
5
4
1 -----1-1
1
1
2
1
1·------
2
3
2
2
____ 2: ________2
1
1
35
2
2
3
3
---------------~~
1
2
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2
......,
1.0
-----·---·-·------- --···---------
________________ . SEHANTIC DIFFERENTIAL
EXPERIHE!ITAL GROUP
OBS
--------··
DITl
OIT2
----·· --- 37. ------- 4
38
39
1
4
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---· ... ---· 4 - -·-
1
4
4--
OIT3
OIT5
OiT4
5 ----·-.
2 ·--··- -·
2
6
4
4"
1
4
4
4
1-
44
45
2
3
2
3
2
3
4
5
2
3
1
5
4
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47
48
5
3
4
4
50
5
2
4
5
51
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1
3
4
3
4
2
3
4
OIT7
·----· 4 - - - - · 3
l
41
4
5
1
1
7
42
2
3
4
2
4
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DIT6
53
54
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4
1
1
2
3
1
2
1
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1
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4
2
4
l
l
4
1------
7
1
1
2
3
2
2
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2
4
3
4
4
2
4
4
4
5
1
2
3
5
3
5
3
6
2
5
7
l
6
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3
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49 ----- 1 _ _ _ .. 4 ------·· ·4··-------- -----2 ·------· 3- --· ---- 1 - - - - - l
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l
1
3
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1
3
l
1
l
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0
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SDW<TIC DIF'F'"O::REt!TIAL
EXPERIHEN':::'Al, GROlJP
PSLTl
CBS
PSLT Z
PSLT3
PSLT4
PSLT5
-------- .. -·- ----- --------·
PSLT6
PSLTS
PSLT7
PSLT9
5
- --· 4
5
4
5
4 -- --·-- --
4 -------5-----5
3
3
4
4
4
4
7
4
1
4
7
5
4
5
4
4
4
4
6
5
4
5
5
4
3
4
4
4
6
7
3
-- __ .. 3 - ·-··
4
4
3
3
4
4
4
3
5
4
5 --------· '• ·-------- 5
5
4-------
8
9
3
4
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4
4
4
5
5
4
3
3
4
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2
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3
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4
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11
1
3
12
4
3
13 ----- 1 --- ·--- -- 2
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2
3
4
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2
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4
3
1
7
7
2
6
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2·
3
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4
2
2
1
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1
7
1 -------
14
2
3
3
4
2
3
4
2
4
15
3
4
4
3
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4
4
3
1
5
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4
4
4
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17
3
4
4
3
2
4
4
4
4
18
4
4
5
4
6
4
4
4
4
20
3
3
4
3
4
3
4
4
4
3
3
4
3
3
3
3
3
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19 - - - 4 - - - - - - ·5------5------ 3-------5-------4 · - - -
21
2
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2
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23
2
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4
6
24
2
2
2
2
2
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27
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29
- - - - - - - . . : · 330
1 ____
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2
4
3
4
3
2
1
2
3 -----· 4------ 2 -----·-- 4----------
3
6
6
6
2
3
3
3
3
4
b
42
4
6
4
42 _____ 34 __________ 6
5 _______ 63 _______
7
3
5
2
4
5
75 - - - - - -45 - - - - 4
5
4
4 - - - 34 - - - - - 4
3
2
3
4
4
3
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3
2
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3
7
3
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42
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3
32
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3
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4
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3
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36
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4
4
4
3
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3
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00
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EXPERIMENTAL GROUP
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PSlT3
PSLT4
PSL T5
PSLT6
PSLT7
4
4
5
6
5
7
7
4
6
4
1
3
4
1
1
4
3
4
40 ________ 7 ______ 4----------7-·
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4
4
OBS
PSL Tl
-- ---· ·-- .... 37
PSLT2
3 ···-· ..
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38
3
5
39
3
41
7
2
7
4
3
7
3
7
3
7
4
5
4
2
6
6
4
4
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4
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6
4
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5
4
42
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45
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6
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47
5
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1
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4
5
5
48
4
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5
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3 --·-----
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4
50
3
51
3
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1
53
3
54
4
- - - - - - 5 5 - - - - - - '4 ....
2
4
5
4
6
4
4
3
2
4
3
4
4
3
3
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PSLT8
PSLT9
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7
3 ·------
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1
1
4
4
4
4
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4
6
3
4
6
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3
4
5
3
5
4
6
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4
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4
5
4
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4
3
4
2
3
5
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4
3
3
5
2
l.
2
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4---4
4
6
5
4
4
3
4
4
4
4------ ·--- 4 ---·-·-4 ---· - - - 4 - - - - - - - 4 - - - - -
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N
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SF.l'.ANTIC D!FFEHB!TIAL
-------------- .. ·····
....
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EXPERIHENTAL GROU?
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---·--~--
OBS
SLTl
SLTZ
SLT3
SLT4
SLTo
SLT5
SLT7
SLTS
SLT9
1
5
4
5
3
5
5
3 .. ·-·--- 3----- 3
2
6
b
6
6
5
1
5
4
3
4
4
7
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4
4
71 · - - · · 1 -----15 -----14
51_ _ _61_ _ __
5
4
5
4
5
5
1
4
5
4
6
2
2
4
2
5
4
3
3
4
4
2
2
5
4
7
4
5
8
5
4
7
4
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7
6
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4
6
4
4
7
3
4
3
5
6
6.
6
6
5
4
7
7
2 ---··1 - - 5
4
4
5
5
5
4
3
1
4
4
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11
6
12
7
13. --···· 1 ---14
4
15
3
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17
2
4
7
2
5
4
3---5
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7
5
6
4
1
7
1
1
1 ·---··- 2 ·--· . 1 -- -----· 2 ... - --
5
6
b.
4
4
3
18
3
4
5
19 ·--·· 4 - - - - · 6 ·-----·-- 6
1
2
3
2
4
23
2
3
24
3
26
7
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4
5
4
6----6
20
21
5
2
3
5
5
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2
30
4
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3
33
1
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35
36
3
1
4
4 --· ·--- 5 -----·- 6 - - - - - -
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6
7
1----
5
6
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4
4
4
4
4
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4
3
5
3
4
3.
5-----1-----6
4
3
s
4
4
2
b
4
4
2
4
3
4
4
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2
3
3
2
7
2
1
7
7
3
2
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1
1
4
7
2
6
2
2
7
2
4
1
4
25··-·---· 2 -- ·---·- 3 ···- ----- 3 · · ·------- 3
21
2
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2
2
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3
4
3
4----
7 ·· ----4------ 4 - - - - 4 · - - - 4
3
3
4
3
4
4
5
3
5
4
3 - - - - - 4 - - - · 5 - - s· ------- 6
4
4
3
5
4
4
3
4
3
2
3
3
z
5._ _ _....::4::------
2
2-------1 - - - - 1 - - - -
4
2
4
3
7
1
4
6
5
4
4
4
3
3
4
4
l
3
3----
4
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4
2
3
2 _ _ __
00
w
·-------
SEMANTIC DIFFERENTIAL
- ·····---------·-· ·-·---------
EXPERIHEr-."TAL GROUP
-----·· -------·
OBS
SLTl
---····------
SLT2
SLT3
- - - 37 ______ 4 ________ 4__________ 7···---- -· ..
38
7
39
--40
41
3
3
5
4
3
7
7
7
42
4
3
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44
1
7
ft:
5
48
3
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1
50
6
51
2
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53
6
54
4
45
--46
47
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6
4·
4
5
6
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7
4
5
SLT4
6
5
3
7
SLT6
SLT5
·---· -····· ..
5
5
4
7
-
..
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-
6
6
3
SLT7
-----·-··
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T
7
7
7
7
6
2
6
5
-·-··--------- 7 --·------ 2 -----3
1
7
7
7
7
6
4
5
4
-3
5
5
5
6
6
7
7
4
4
4
5
__ 7 ______
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1
1
1
5
2
6
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4
6
5
7
3
7
"6
4
7
6
6
6
6
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4
1
6
5
6
6---
SLTS
3
2
4
4
3
7
1
4
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5
4
SlTCJ
·-----:c.----2
3
7
1
4
3
1
3
7
1
--··-
4
2
2
6
7+
6
5
5
5
3
4
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5
4
7
3
3
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3
6
6
1
4
4
6
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5
6
4
2
2
5
1.
6
6
----------------·00
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-----·- ---
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I'
SE}:ANTIC DIFFERENTIAL
- --- -----
EXPERIHF.:NTAL GROUP
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OBS
---------1 ·-
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-· ·····--
PSMK2
.
4
6
4
..
PSMK3
---· -
-- ·-
.
PSMK4
PSMK5
-- .. -
... - .
2
4
3
4
7
r.
4
5
4
3
1
7
-,-------7··---7 ----.
5
7
4
6
7
7
7
8
9 ____ 77
"10
1
---------1-- 1---- 1
7
.. - ----
1
-,
-
--------
7
7
7
7
7
7------7
1
1
1
7
4
4
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4
.
PSMK7
PSMK8
PSHK9
----------------- -----
PSt~K6
- ..
.
5
5
6
4
1
7
7---·-··--7 - - - - - 7
6
1
7
7
1
7
1
1
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1
1
7
4
7
1
7
7
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4
5
7
5
7
7
4
4
3.
7
7
1
1
1
4
1
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1
1
1
7
7----7
7
7
4
7
6
5
7
1
12.
7
7
7
7
----------------- -------- -- -; --------·· 5 ·--------- -1·------.- 6
1
13
1
1
7
14
1
1
7
1
1
7
6
5
1
5
15
6
6
4
1
6
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7
16
1
7
1
1
1
1
7
7
17
5
5
6
4
4
s
5
4
Ul
7
7
7
----------- 7 - - - - 7 ---------- 7 ------- 6 ------ 7 -------- 1
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19
6
6
5
6
5
6
5
5
7
20
4
1
7
4
4
7
7
6
4
4
6
21
5
5
3
5
5
6
1---1
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- 7
1
7
22
7
7
7
23
6
4
4
6
6
4
3
3
3
7
24 ___ 77 _____ 77---------7-------7---------7
1
7
7
1
7
1
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11
7
---·-
zo
27
28
29
30
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32
4
7
4
---- ·-··-------·-····
5
4
7
1
7
5
5
1
7
7
7
5
4
7
5
______ 77 _ _ _ _ 7-------7-----7
1
1
4
4
6
4
34
5
7
7
35
5
5
36
7
7
33
7
5
1
4
4-
5
7
1
4
7
4
7
7
3
7
-,
1
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1
5
7
7
1
4
1
1
5
3
4
7
7
7
4
7
4
5
5
5
7------,-----7 -----14
7
1
5
6
.'
3
3
7
7
3
7
7
4
2
7
3
7
7
7
----------
PS~KlO
4
7
------ 1
7
1
7
7
----- 77 - - - - 7
7
7
1
------
1
1
7
6
1
7
1
------ 7
1
7
7
3
7
7
7
1
4
6
1
4
1
7
2
1
6
3
6
7
----
7
3
6
co
lJ1
SEl'J~!~TIC 1IFFZREN~IAL
EXPERD1E:NTAL GTIOUP
-----
----;·- -·· ------- ..
PSMKl.
PSMK2
PSI-lK3
··-··----
OBS
37
38
39
--40-
.
7
7
7
7
7
Itt
42 --- .. ---. 3
43
7
1
44
1
4-5
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47
48
49
50
51
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53
6
7
4
7
7
7
54
55 - - - 7 · ·
PSMK5
7
4
"7
7
1
4
7
7
7
- - - - - 7 ----------7 - - - - . 7 ----------·
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7
4
4
7
4
2
5
7
4
6
7-----7
7
4
6
1
1
"7
4
5
7
7
--------··
7
4
4
3
3
4
5
6
-7
7
1
6
4
7
_54_ _ _ _ _6
7 _____1
7
. ....
5
------ 77 ----- 47 ------2
PSMK't
----------------
------
-------
PSMK6
7
1
1
7
1
1
1 -------· 7
PSMK7
PSMKS
1
7
1
4
1
7
---------- . 7 - - - - - 1-
PSHK9
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7
1
7
PSP'KlO
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7
1
7
7
7
7
4
s
3 ···-· ....
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1
t
6
4
1
1
5
7
4
7
1
1
1
6
7
7
6
6
6
7
6
7
5
6
1
4
5
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7
4
5
1
5
3
3
5
4
3
3
5
4
3
5
4
3
4
7
7
1
7
7
7
5
6
7
4
7
7
4 ------- ___ 6
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4
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7
7
4
7
7
3
L
7
1
7
4
1
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SEHANTIC DIIT'"i:RENTIAL
I
..--
EXPERIH£NTAI. GROUP
·----·-----------··
CBS
SMKl
r·
SMK2
··
···-·--··-----·-··-··-----· ..
···-·---·-·
SMK3
SMK4
SMK5
S~IK6
-------------------------
SMK7
SMKS
SMK9
SHKlO
4 ----
4
6
5
6 · ··---
1 ----·---1-----1
2
7
7
1
6
l
6
4
1
7
3
7
4
4
7
7
7
7
7
7
4
7
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7
5
7
7
7
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6
4
4
5
4
4
4
7
4
18
7
7
7
7
1
7
7
7
1
19 ---6·---···-- 1 ------· 6---··-·7 ·---·--· 6 ··---- 6----- 7 - - - · 7 · - - - 6
7
7
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4
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7
5
7
7
7
6
5
6
5
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8
7
7
7
9
1
7
1
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11
7
7
7
12
7
7
1
- - - - - - - - · 13 - - - 7 . -----·1 ------ 6 ------·
14
1
7
7
1
6
5
15
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4
20
21
6
5
6
4
5
4
23
7
4
24
7
26
27
7
7
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6
1
7
1
1
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1
7
1
7
1 -·-----· 1
1
1
7
1
7
7
7
5
1
3
5
7
7
7
7
1
1
4
5
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7
1
5
7
- ..
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1
7
1
7
7
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7
7
7
7
7
7
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7
1
7. .
6
5
7"
7
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7--~--7--
T
7
6
r
6
6
4
5
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7
5
6
2
3
7
7
7
7
6
1
6
7
7
1
7
7------7
7
7
7
7 · · - - - - -4-7
1
1
1
7
? _ _ _ ____;._
7
7
7
7
1
7 -----7
7
5
7
7
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1
6
6
1
7
6
1
1
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1
1
7
7
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7
5
1
7
6
5
4
- - - - - 2 5 - - , - - - - - 7 - - - - - - 7 - - - 7 · - - - - · 7 ------ 7 · - - - - 7 · - - 7·-----7
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7
1
1----4
1
1
5
7-------
7
7
7-------
29
7
30
7
31--7
32
1
33
7
7
7
5
4
7 ·---7
7
4
4
3
7
1
1
1
6
5
5
6
1----·1·------·T·----1
7
7
4
~7
7
1
7
7
6
1----1---7
4
3
7
7
5
7
35
36
5
7
4
7
7
7
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-------
7
7
4
7
7
7
7
1
5
6
1
4
6----.;,------7
5
7
6
----------
00
--....1
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. I
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PHI S1
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PHIS3
PHIS4
PHIS5
PHIS6
PHIS7
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PHI S8
PHI S9
PHISlO
PHI Sll
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2
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6
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29
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30
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0
2
3
1
5
5
1
1
32
1
3
2
2
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1
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6
33
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0
5
5
1
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2
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l
3
0
1
6
2
5
35
1
l
1
2
1
3
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2
1
5
1
6
36
2
1
1
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3
3 -·-·---- -· 1
l
z
3
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1
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1
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-------
I
---------
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CONTROL GROUP
------·····------······-·
085
------ ------·------
PHI S1
PH1S2
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31
3
3
38
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2
40 -------3·----·
t.l
2
42 ... 2 ........ ··-·
43
2
44
3
45 _ _ _ _ 22 _______
46
1
L
1
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PHIS3
L
1
l
PHIS4
PH!S5
L
c
1
0
PHIS6
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PH! SS
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2
2
1
2
2
1
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5
2
l
2
2
1
2
0
2
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2
2
l
2
3
1
4
2
0
2 ----1------o
PHIS9
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PHIS10
----
.
PHI Sll
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3
1
5
7
4
0
1
0
4
6
5
1 -·- ........ 1 ---- --. 1 ------· 0
6-5 ----4
1
1
1
0
4
2
5
1 .. -1
1
0
5 ·-· -------·---· 4
5
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1
0
0
5
6
6
1
1
1
1
8
4
4
1
1
1
1
3
6
1
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7
4
5
47
0
0
0
1
2
2
3
1
3
0
3
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1
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2 . -· .. - .. l
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49
3
1
1
1
l
1
1
0
6
3
1
0
50
1
0
0
2
2
0
1
l
3
2
3
1
1
0
4
51
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2
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5
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52
3
0
0
1
2
0
1
0
0
0
53
3
1
2
1
1
3
2
5
54
1
0
0
0
1
2
1
0
0
2
1
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2
0
0
0
4
56
3
1
1
4
1
1
1
57
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OBS
Hl S1
HlS2
HlS3
HIS4
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HIS6
HlS7
HISS
HI 59
HISlO
HlSll
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2
1
1
1
0
2
2
5
1
5
5
3
2
l
1
1
0
5
2
1
5
5
5
0
3
0
3
1
1
9
2
1
2
5
3
4 - - 2 - - - - - 1------1 --------1------- o ··----- 3 --------·· 2-------- f · - - - - s - - - 4
4
5
l
3
1
l
2
1
1
1
2
0
2
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3.
0 . -.
6
0
l
4
l
4
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2
l
1
0
0
2
0
8
2
4
0
8
l
1
2
l
0
1
1
7
l
1
2
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1
l
1
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1
8
2
5
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1
1
0
3
3
3
ll
2
1
1
1
0
1
2
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8
6
4
12
3
1
1
0
2
2
1
1
9
3
5
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L
3
13
1
5
1
2
3
14
3
1
0
1
1
5
0
9
6
2
5
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15
3
1
1!." _____ 1 _ _ _ _ 1
2
9
0
6
s
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f
0
2
4
3
0
6
2
1
0
0
2
1
17
1
0
6
3
5
18
1
1
3
1 ---- 0
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19
0
0
1
3
1
0
4
1
20
2
1
3
1
1
1
1
4
1
0
2
1
1
4
21 _ _33 _ _ _1
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5
5
1
24
3
l
1
1
2
1
1
10
6
6
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0
26
3
1
2
c
7
1
l
1
5
5
27
1
3
l
l
0
3
1
5
4
J
28 ___ 2
i
ci
2
1
1
3
2
i"
l
4
3
7
J.
29
0
1
4
l
1
2
6
2
1
9
30
0
0
1
3
1 ------3--4
5
1 ··- ···-·- 11 ---····--- 1
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3l
0
1
1
5
6
32
0
2
1
6
3
1
1
1
2
6
33
3
1
l
0
2
4
b
1
1
1
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34
35
36
2
3
2
i
l
l.
1
1
1
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0
3
1
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l
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5
2
2
3
2
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6
5
0
1
C)
5
3
6
i
5
6
1..0
-..J
HEALTH
QL"ESTIONN~IRE
. ------
CONTROL GROUP
--------- -------------------------. --- -----------------OBS
37
38
39
40
41
42
HISl
HIS2
-3 ----------1 -- --
HIS3
l
l
. HI 54
l
l
l
HI 55
·-·-·---
l
HIS6
2
0
.
---------------------
HIS7
2
l
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HIS9
HISlO
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l
l
2
l
3----- 0
HISll
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3
6
3
1
~
3
5
6
5
3-----l--·--c----1·------ o · - - - 3
6--3
5
2
1
1
1
0
2
2
l
6
4
0
2
l
0 ......
6
2
2
4
6
. -- .
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3
1
1
0
l
2
0
2
8
5
6
44
3
1
1
1
1
2
3
9
l
5
5
45
3
1
1
2
0
4
0
6
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46
3
1
1
l
1
8
4
4
47
1
0
1
1
0
3
0
4
.3
3
3
48
.3
l
1 ---·--·· 0 ----- 0 ------- 2 -------- 1 ---· ·------- 0
6
5
3
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·
a
·
49
0
0
0
1
1
5
1
5
3
50
2
1
0
0
0
1
1
2
1
2
1
l
1
51
3
0
l
2
1
4
0
1
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1----o
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0
52
3
l
1
1
0
53
2
1
1
2
2
l
4
2
2
l
54
3
1
1
0
0
2
1 -- ---- 00 _______11 _____ 23
0--------- 32
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0
56
1
1
0
1
0
l
2
l
2
2
3
57
l
l
l
0
8
4
3
2
2
1
3
3
1
l
0
1
----
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1.0
00
SE~lANTIC
-----·---····
-
DJFFERE:-:TIAI,
CONTROL GROUP
----- ----- ... ·--OBS
·PDITl
PD1T2
PDIT3
Pf'IT4
PDiT5
-·------------------PDIT6
POl T7
PDIT8
1.0
1.0
·---------· ·--·--·-
SEH.ANTIC
DIFFERENTI/~L
. ··--·-·-------·-·-·--·-·-----·-------·---
CONTROL GROUP
-----~---------------------·-
PDIT 1
OBS
- ---- .
-
--
37
38
----
3
5
39
2
40 -----··141
l
42 --.- -- ... -· 4
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2
44
3
45
1
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PDIT2
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4
3
-· ···-·· --
2
4
2
4
3
2- - - - - 2
-----
POIT4
PDITS
- ..
PDIT7
POITS
--------- -------------3
3
3
4
5
3
4
3
4
4
3
4
5
3
3
3
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.
7
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6
5
3
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.
6
1
1 .. ----------- 3
1
1
3
l
46
4
l
47
4
3
2
4
48 ·---------· 1 ···---------- 2 ----------- 2 -------- 1 . -------------49
1
l
4
1
50
6
7
2
2
4
2
2
51
l
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1
3
52
1
53
3
3
3
2
54 ----- 4 ------------ 4 ···------·· 4 - . ------------ 3 ---- ------- - - - 55
...
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2
3
2
0
0
56
0
1
4
4
57
1
2
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2
1
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PDIT3
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....
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l
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4
4
1
'•4
t
5
3
2
4
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5
5
4
2
2
3
.
-
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3
3
l
l
2
2
l --· ----- --- l -----1
2
3
3
2
2
1
2
1
2
4 --·----- 1 ----------- 1
1
1
1
3
1
2
2
1
2
1
1
1
1
2
3
4 -- ··-------···. 3 ---------- 3 ---------- 2
3
3
2
2
0
0
0
4
4
3
---
0
3
1--'
0
0
£EMANTIC DIFFERENTIAL ·--- _ _ _ - - - - - - - - - - - CONTROL GROUP
OBS
DlTl
0 1T2
DIT3
DIT4
01T5
DITo
DI T7
DIT8
2 ------·- 2 ·-·--- z·
1
1
1
1
1
1
4 --. ·-- 1 -- --·--- 1 - - - - · 4------ . L - .. - .. 1 - - - · 4
1·---l-----5
3
3
6
3
3
3
3
3
1
2
3
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6
2
1
1
2
1
1
2
5
2
7
4
4
6
4 --
4
3
a
2
s
z
2
1
l
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3
2
2
1
2
--
2
4
6
- .. 2
2
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4
4--------
2
1
3
3
1
2
3
2
1
1o ----4---- s----3 ----A
3
6
2
2
1
4
7
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6
1
9
u
3
12
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2
2
6
1
4
4
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l
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1
4
1
1 .. -- --· 4 . ··--·-. 4
2
1
1
. ··--·· 2 -·--·---· 3
14
1
1
3
15
1
2
4
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4
17
5
6
6
18
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1
7
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20
2
21
2
22·--3
23
1
24
2
1
2
1
2
3
3
3
4"
2
4
5
6
1
1
l
3 ·----· 3 ---- . -· 3 ----3
5
3
6
3
3
3
2
4
4
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4----4-2
5
1
3
4
2
4
3
4
4
25 . -··· 3 ·- ·-- ··-- 5 ------- 6 - ---·- 2 ·---··-- 5 ···-·· .. 5
26
2
5
b
2
4
t.
27
1
30
2
32
2
33
1
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29
3
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35
36
3
2
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6
5
l
2
2
3
4
4
4
4
3
6------
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1
2
i
1
2
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5
5
1
1
3 ----- 3
6
1
2
3
5
z
3------
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b
3
2
2
2
1
1
1
3
2
1
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4
4
1
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4
1
1
3
4
3
5
3
4
2
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3
4
2
4
4
l
3
5
l
T
3
t
1
2
4
6
4
2
4
5
1
1
3
2
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s
4
2
·-------
1-'
0
1-'
________
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DH'F'l!:RENTIAL ____________ . ______ - - - - - -
CONTROL GROUP
---------------------OBS
DITl
-------- 3 7
3
38
1
39
3
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41
42
------. 4 3--------
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DIT2
DIT3
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DIT5
OIT6
01 T7
OIT8
3
4
3
4
4
2
2
4
4
5
5
1
3
4
5
4
5
1
4
3
4
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2-
1
1
4
2
2
2
l
31 -------------24 -------·-· 66 ---·-·· -·--· 21 ---------- 22 ·- -· - -·· ... 32 ·-·------· 21
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1
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44
45
4
4
4
3
4
4
3
3
1
4
4
7
3
l
4
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4
1
1
1
2
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47
2
3
4
3
3
4
3
4
46--1
3
48
3
1
2
1
4
2
1
l
49 -- ----· 2--------2 ----. ---· 3 ------- --- 1 . - - - . 3 -- ---- -- 2 - - - - 3 -------- 1 ..
50
51
54
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1
2
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4
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2
4
3
4
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56
51
2
1
3
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53
1
3
2
2
6
3
4
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4
3
2
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6
2
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2
3
1
1
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2
f
3
4
3
4
3
4
3
______ 3 ______ 3 __________ 3 _____ 43 ____
4
1
4
4
2
4
------------- ------- ----------
2
1
-
1
3
t-------
3
2
3
0
2
----------- -· ----··- ----1-'
0
N
---------------·-··-·--
SEl'..ANTIC DIFFERENTIAL
··--
CO~TROL
-- ----·-----------
-·--- ~ -·-- ---- -·-·
---·····.
OBS
------- ---·-- --
. -·-
---------------- ..•. -----. --···
SLTl
SLT2
SLT3
SLT4
SlTS
1
1
1
1
1
4
l
7
2
4 -----·4. ----
1
1
5
4
l
7
5
·------- 5-·-----
5
6
5
4
5
5
1
2
3
4 ----
2.
5
6
1
7
---
SLT6
SLT7
1
.. -- 1 .. ---- -- 4
1
6
3
.3---4
SLTS
SLT9
1 ---- 1- - - 3
4
3
2
4
4-----
4
5
4
4
7
5
5
5
4
---- .. 6
4
8
7
2
7
4
5
6
9 ____ 23 _____ 35 _ _ _ 64 _____ 66 - - - - -72 - - - 66·
10
4
5
4
5
3
4
4
23
5
44.
3 ---2
11
6
4
3
3
4
4
6
2
-------- 4 -----· 4 -------· . 3---- --- .3
5
3
7
4
6
4
4
5
3
-4
7
3
5
4
4
1
2
1
6 -----
4
4
14
15
2
3
7
4
7
4
2
4
3---4
.3
5
17
6
4
6
7
4
7
12
- - - - - - - - - - - - - - - - - - - 13
16 ___ 4
18
19
4
7
1
6
1
4.
4 -------- 5 ------- 4 - - - - 2
3
------ 4------.5 ---·- 4 - - - -
4----
7
1
1
1
1
7
7
7
7
-··· 4 -------4 ----·-·4·------- 4------4 ----· 4 -----·--4 ------·4 - - - - - 4 - - - 3
5
4
6
-4·----i;
20
4
21
3
---------------22--3
------------
-- -----· ..... -·-----------·
GROUP
4
4
4
6
3
5
6
5---·4-
4
4
4
5
3
3
6
6
3----
23
24
25
3
2
2
2
3
4
3
2
1.
3
4
5
4
t.
'•
4
'•
4
3 ---------4 - - - - 4 -·------·· 4 --------- 6 --·------ 3 ---------4 ·----·· 3 - - - · 4
26
27
3
4
29
30
3
5
--------------28 ___ 7
31 ---- 4
32
1
33___41
______....;________ 34
35
3
-------~
4
4
5
4
3
5
5
4
-4
4
4----- 0
3
1
44
1
.4
4
4
4
4
4
'}
4
4
4
7---6
4
5
4
5
- - - - 6 - - - - - · 4------4
6
44
47
4
_ _ _ _ _ _ _ _ _ _ _ _ _ _?_6_ __ ~ ______4_____ ~--~--
5
4
4
4
4
4
4
6
5
7
3
3
4
4 ------ 6 - - - 4 · - - - 3
4
1
4
24
44
4
2
---~------~-
4
4
3
3
3
4
4----3
4
4 --2
44 : - - - 4
4
1-'
0
w
----·-·----·········--------- --·-----··--·- _____SEHANTIC DIFFERENTIAL.
CON'IROL GROUP
----··-----·-.
OBS
-------------
37
·-
SLTl
.
--------
l
3
.
-------·
----------·
SLT2
1
38
4
39
3
3
4 0 . ---- .3 -------4-
41
--------·-··
-
SLT3
SLT4
-
---·- ..
SLTS
-------
SLT6
----- ----------
7
7
1
--- .......... - 1 ---···....
2
3
7
4
4
3
4
4
46
3- - - - 3 · ·
4
4
47
3
4
3
4
48
4
4
5
2
-------·
--------- ---------·· ·------- ---------4
4
4
4
6
'•9
7
6
6
50
2
2
51
Q.
2
2
5
3
4-----4
52
4
4
4
.3
53
4
2
5
3
54
4
5
4
3
5 ____
- 2 ______ 2
·
·3-·55
3
3
56
4
6
3
4
3
4
3
3
4
5
51
-------- 42
43
44
45
--------------
--------
1
5
5
3
5
6
4 _____ 6
.4
3
3
7
7
7
7 ----------- 4
7 --- ---- ------------- 7
5
7
4
7
4
7
4
4
l
------------~--
,.-
4
4
SLT7
·····------
5
SLTS
-. ----------
l
SLT9
------
l
4
3
4
5
3
4
3
4
4
4
5
7
7
6
1 -------- ·---· 1
2
2
4
4
5
4
4
4
.
·-··.
---
.
5.
4
4
4
"4
..4
4
3
-------
4
4
5
3 ------- 4 ----- 3
5
4
4
4
5
3
2
4
2
4
4
4
4
3
4
4
4
.3 - -----·--·3
·---------3 ·-----
2
3
4
4
4
2
4
----
4.
,.
4
3
2
4
4
4
4
4
s·-------
3
4
4
1-'
0
~
.!':'EXANTIC DIF.•..-:..REtiTIAL
i
CONTROL GROUP
t
f'·
··----·----·---CBS
PSLT2
PSLTl
PSLT3
PSLT4
PSLT5
PSLT6
PSLT7
PSLT8
PSLT9
I
- ----·--
--·-------
3
2
1
3-----·-
5
4
3
4--------
4
7
2
3 ····---·----·
3
4
7
5
3
4
4 ··-----·4·--··-----
5
5
6
7
4
3
3-----4-
5
6
4
6
4
5
3
5
5
4
6
1
7
7
7
7
6
6
4
6
8
6
4
5
3
2
9
3
3
6
6
10 ______ 2 _____ 6 - - - - 4 - - - - 5 - - - - 35
4
6
5
4
33
5
2
3
4
2
3---
7
11
12
13
3
- ---
1
1
1
- -
- ------·
4
4
4
4 --· . -··
3
7
2
4
4
3
5
5
4
4
5
-3
5
6
5
4
4
5
18
3
7
5
4
7
1
4
4
6
4
5
3
i,.
~;·
7
. 5
3-
7
3
3
3
2
4--
---- 4 ----- - - 5 . · - - - - 3
l
4
2
4
2
4
5
2
5
3
- --- - 2 . --- -- - 4 -------·--- . 4 -- . ----- 4 ·------ 6 -
14
15
-----------·-16
17
-. --
3
3
3
---J
1
2
3
4---·---
5
4
6
3
4
4
3
5 -6
4
4
6
.4.
6
4--
5
5
4
5
5
4
4
4
7
5
4
3
5
3
4
4
3
7
3
3
7
3
3--
·-------- 19 ···------ 5 ---·---- 5 --·-·- 5 -----·-·--·--. 5 ·-----·---. 5 ------. 0 · - - - - 0 - - - - - 3 -----· 3
20
7
4
21
3
4
- - - - - - - - - - - 2 2 _ _ _ 3_ _ _ _3
5
-.r,:-
23
1
2
5
24
5
4
4
1
4
6
3
2
1
4
3
5
4
4
4
26
3
27
2
- - - - - - - - - - - 2 8 ___ 7
-4
4
4
4
3
5
4
4
4
4
4
3
4
3
3
"4
4
4
3
4
5
3
4
4
4
5
5
1
2
6
6
7
4
7
4
4
4
5
4
4
.4
- - - - - - 25·-·---z·· ---·---·- 4 --··--- 3
29
30
3
5
------ 4 - - - - 5 ··-----· 3 ··----- 3 ------ 3 ---·---- 3
31---- 3 · - - - - - 6 - - - - - . 6 · - - - · · 1 · · - - - - 1 · - - - 1 · - - - 6 - - - - - · 6-32
1
3
1
4
5
4
4
2
33
4
3
6
4
4
3
2
4
-----------·-3·4
4
4
35
2
4
_5 _ _ _ _ _ 4
4
4
4
5
~~----2---~-----~----'!-----~
3
4
2
4--
4
4
4
4_
3
4
4
4
5
____ }
1-'
0
U1
..... SE~.ANTIC DIFFERENTIAL ---. -------------
CONTROL GROUP
.
OBS
-· ·-------. --
PSLTl
PSLT2
-------- ... ------- .... ----·-·· ·-··
PSLT3
PSLT4
PSLT5
PSl T6
.... ·-
37
1
1
l
2
38
2
4
4
5
39
2
3
3
3
40-----2 --·······--·· 4 ·-·----3------4··-------·.
41
42
4
1
--·----·----·----. 43. ·--·1
44
2
45 _____ 42
"46
4
1
3
4
4
--5
47
1
43
3
···--------49
4
50
1
51
52
'33
1
3
2
----------
6
5
3
4
3
4
3
"3 --
·z·
4
1
4
3 --- - .. ---- ..
-------4
4
1
2
2
2
4
4
4
4
4
4
3
-4
2
54
4
4
·------ 4------- -----55
5
3
56
2
0
0
57
4
4
4
3
2
3
3
3
s·-
2
··-·--·-··
--- .
5
4
4
4
5
2
3
4 ···------··3 · - - - - 4 -
5
1
'~
····---
5
PSLTB
---------
4
6
6
6
7
.'
PSLT7
4
····------4
6
2
4
3
5
---------3 ··-------
0
o·
4
4
5
2
2
6
4
7
3
--4-
3
4
4
..
3
3
4
3
.
- ------- 1
1
3
----
1
1
3
4
3
s--
4
4
4
4
4
4
3
------ ----4
7
4
.
4
2
4
4
2
1
4
4
------
2
3
3
3
3
4
4"
4
J
-- ------·-
3
3
"2
PSLT9
4
2
3
3
4
4
-------··
"3 --------- 3
3
0
0
0
4
4
4
-----·
5
3
4--
3
- - - - 43
0
~
.......
0
0'1
------------···
--
. --- ..
···- ...
-
.
SF~""u\NTIC
-- ..... -
DIFFERENTIAL
-
.
-
'
-----------------
l
CONTROL GROUP
-- ------ .. ------------ -------------------CBS
SMK1
SMKl
- --·
SMK3
SMK~
1
7
7
7
2
7
4
4
7
3
7
4
·-4----7----···-7 ·--·--7-----·-5
6
7
8
9
-10
6
.
---- 1
7
7
4
7
4
1
5
-- --- 1
4
6
. ·····
-------
------
SMK5
SMK6
SMK7
7
7
1
1
7
7
4
2
b
7
5
_7 ________ 7·----·-·-7··--·
'7~
6
1
1
7
6
7 ....
7
7
6
6
-
7
7
·- .
7
4
4
3
6
---4---- 3'
----5----6.
5
4
-,
11
7
7
7
7
7
12 ------- 7
---------· 77 .. - --- 17 --· ----- . 77 ---- ·-·· 77 ----- 17 -----1
13
14
7
1
6
7
7
7
15
7
4
5
5
5
.. 5
·-·
16--7
'7
'1
1
7
1
17
7
7
7
4
5
6
7
18
7
7
7
7
1
-------------------------·-----7
19 ·--· 1 ----·-----·-- 7 · - - · --. 7
1
7
7
4
20
4
7
7
7
7
4
4
7
7
7
21
22---7
·-4
5'7
1
4
23
4
5
3
1
2
3
24
7
4
1
4
4 ------ 7 ------··
----------7·-·----- 1 - - - · 7 - - - - 7
25 ---- 1
b
6
4
4
5
26
6
4
1
7 ____4
1
7
7____ 7
27
6
28 - - 1
29
30
7
7
7
7
7
7
7 --------------·.
6'
·---7
6
31
32
7
4
7
33
1
4
4
7
34
7
35
7
4
4
36
7
1
7
--.,
------------------
1
7
7
7
7
SMK8
______ 7 _____
----··
1
7
7
6
1
7
7
1
SMK9
7
4
7 _ _ _ _ 4_
5
_7
6
SHK10
1
7
7
1
6
7
. ---· 1 . ·------ 7 -------. 7 - - - - - -
6
7
6
1
4
5
7
4
1
-2
7
2
7
1
- - - · 71 ---·-
7
7
1
7
7
7
7
4
7
----· 77
7
7
4
7
6
1
1
1
-----7---··
1
7
4
7
6
4
7
7
5
7
4
1
2
5
4
1
4
7
7
7
5
7
7
6
7
4
-----· 6 ----
5
7
6
i
7
7
7
7
7 - - - 6 · - - - -4
...r:
7
7
7
7
7
7
4
7
7---1
1
7
1
4
4
4
7
1
7
7
7
6
6
3
s
7
7
·----··· 7
7
7
7
7
1
·-
6
6
7
4
4
7
7
7
7
6
4
7
4
7
4
7---7
4
7
1
7
7
7
5
1
7
1
6
7
1-'
0
-....]
SEK.\N-r!C DIITERENTIAL
CONTROL GROUP
oos
SMKL
----------- 37 -- - 7
38
7
39
7
SNK3
SMKZ
- ---- 7
4
4
-----------,.o··---7---- 6 ---41
42
----------- 43
7
7
--- 1-- -
7
1
4
-------
7
7
5
1
7
1
7
44
7
4
4
45
7
4
4
46
7
47
7
_7_ _ _ - 1
1
6
SI·IK4
- --
!:MK5
SMK6
SM!<S
SMK9
------7------7
7
7
4
3
7----., - - - 1-1
7
7
7
7
1
7
7
7
7
-- 7 -- ---- 7 --- ---- 7 - - - - -
7 ---7
6
4
1
7
7
7
7
7
7
7
4
4
5
4
6
6
7
5
7
7
7
7
7
7
7
4
SHKlO
7
7
7
7
6
6
1----1 ---1
7
7
7
7
-1 -----
-1
1
7
7
5
SMK7
7
7
7
7----
1
7
7---
7----
48
7
4
4
1
7
7
4
?
4
7
- - - - - - 49 - - - 7----- 7 - - - - 7 -------- 7 ---- -- 7----- 7------ 1------ 1 - - - - - 1 - - - 7 - - -
50
7
7
4
3
1
7
2
51
6
5
7
5
6
5. .
6
52
7
3
T
-,----7----6
4
53
7
7
7
7
7
7
1
54 ________ 71 _______ 77 _____ 6-----7-----------,-7
1
7 -· _______ 67________ 1
-----55
7 _____
56
57
7
7
-----
1--
1
4
4
7
7
1
7
7
.
6
7
4
7
3
4
4
2
5
7
7
7
6;----
7
1
1 _______ 77 ____ _
6-----7
1
1
1
7
4
7
7
7
-------------- ------
I
1-'
0
00
SE:1At!'I'I::: DIFFERENTIAL
CON'rROT. GROUP
CBS
PSMKl
·--- ··-··· l . -- .... 7
- .. -
PSMK2
PSMK3
PSMK4
PSMK5
PSMK6
PSMK7
PSMKS
PSHK9
PSI'KlO
7
7
7
7
7
7 .. ----·- 7 - - - - · · It--
l"
2
7
7
7
7
7
5
4
4
1
6
'3
4
4
4
7
7
7
4
6
5
1
5
4
3
6
7
7
7 ·-·--·-·· 7 ·-. ·-- ... 4
4
6
4
3
7
7
6
7
7
4
7
7 -
5
7
5
5
5
7----
8
9
3
1
3
7
4
7
6
1
5
6
6
7
- 4-----7·--·-· -7-------7---------7 __________ 7' _ _ _ 7 ·-----...,
B
7
7
4
5
1
4------s
11
7
7
12
7
7
'13 ----- 7 ···---·-- 4 --· ·--14
15
1
7
20
7
7
···- ..
5-----7
7
4
4
7
7
----·· 4.-----74
6
4-
5
5
7
3
-------22
7'
7
6
4
5
7
7
4
4
4
5
4
7
--4-----r
-4
4
23
1
0
2
24
6
4
4
- - - - 25·----7-------7--------·7··
26
27
-------;zg
7
7
7
6
4
7
·4
5--
1
7
7
7
7
7
6
7
7
7
7
7
4
7
4
1
4··-----·----·· 1. ·-····-- .. 7 --·--·-·-·-· 6 -·- -----.. 6 - - - - - 6 ·-·----- 4 - - - 7 - - -
7
7
7
. -6
6
6
--------16--.--7
·7
·1·1
17
7
6
7
7
1
6
6
7
18
1 -----7
7 ____________ 17 ______ 7 ______
19 ____ 7 _ _ _ _ 7 __________ 47 _____ 7 ------·7
21
6
5
1
29
7
7
7
30
7
7
4
·31 _ _ _ 7 _____ 6 -------4
7
6
4
4
7
7
7
7
4
2
3
6
4
6
· 1----------1 ·--------7 ------·-·
6
7
6
7
7
7
7
7
1
7
7
7
·6- -------
6
7
s··-----7 ·
4
4
7
7
6
'7
3
5
4
6
4------6 ------
5
4
7
7
7
--6
7
7
4
6
1
7---6
7
7 _____ 17 _____
4
4
4
4
4
4·
6
7
6
4
l
1
7
7
1
1
-7----7-
4
6
7--3
6
--.- 7---
1
1
7----
1
l
6 -----
32
33
7
7
4
7
4
4
4
4
7
7
5
7
7
4
7
7
4
4
4
5
7
7
4
4
4
4
7
7
_4_ _ __
35
36
7
7
7
7
4
7
5
7
4
7
7
7
4
7
4
7
4
7
6
7
--~----34
7'
f-1
0
~-
r..__________ --
..
----·.
SEHA!~':'IC
. . ··- .
D!FFERENTIAL
··-------··------
CON'fROL GROUP
·---------------. -·---·-------- ... ----CBS
PSMKl
---------- .. 3 7- . ·-
PSMK2
PSMKJ
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