CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
AN INDIVIDUALIZED PROGRAM FOR
TUBERCULOSIS EDUCATION
A project submitted in partial satisfaction of the
requir~ments for the degree of
Master of Public Health in
Community Health Education
'nv
~J
Enid Bayer
August 1981
The project of Enid Bayer is approved:
Dl~.
Seymour Eiseman
D~~Robinson
Dr. G. B. Krishnamurty,
Chairperson
California State University, Northridge
ii
ACKNOWLEDGEMENTS
I am dE:eply grateful to my committee members Dr.
~·Jaleed
A1kateeb,
James Robinson, Dr. Michael Kline and Dr. G. B. Krishnamurty for
their guidance and assistance in enabling me to see this project
thr'OU g h.
I am espeti!ll1y thankful and appreciative of my committee chairman,) Dr·. G. B. Krishnamurty, for his generous offering of time, t:xper-
t1se and encouragement because, \'iithout hirn the realization
projE,ct
~<tould
o~
this
not have occun·ed.
A note of sincere appreciation to Dr. James Robinson for his ex-
pert advice and last minute attention to my needs.
Special thanks to my husband, Arnie, for his helpful suggestions,
natience, and support when I needed them the most.
I appreciate the cooperation of the
s·~aff
at the Inglelttood Health
Genter for their subject matter and technical editing and for putting
aside precious time for consultation.
I also appreciate Deborah
Collins and Nancy Johnson fer their typing and assistance in the preparation of this project.
!lty gratitude to Carol
~~ol-ris,
Pub1 ic >leal th Nurse at the Paramount
Un1fied School district, for without her invaluable help I cou1d not
have implemented the program.
Fina1'1y,
rt
note of thanks to the students who par·ticipated in the
te.stin9, for ·U--i::ir cooperation and attentiveness.
iii
TABLE OF CONTENTS
Page
APPROVJ\.L PAGE
ACKNOVJLEDGnlENTS • . • • • • • • • • • • • . • • • • • • • • • • • .. • .. • • • • • • • • • .. • • • • •
iii
LIST OF TABLES .•••••••.•.•.., ••.•••••••.• , • • • • • • • • . • . • • . . • . • • • •
vi
t.. rs·r OF FIGURES
6o<'.lt'
......
6
......
1!
..............
"$
..
l'>
....
.,.
...................
.,
••••
vi·i
viii
ABSTR,4CT
CHAPTERS
I.
II.
I I I.
INTRODUCTION , ................................ , •.•••••.
.
Statement of the Problem ..... ................. ..
4
Purpose of Project
...........
4
Limitations of Project .... .....•. ....•..........
4
Definitions of Terms .........................•..
5
REVIEVJ OF LITER.t\TURE • . . .. • • • • • • • • • • • • • • • • • • • • • • • • • • • •
6
Programmed Instruction . . . . . .. . .. . . . . . .. . .. . . . . ..
6
Tuberculosis-Characteristics of the Disease.....
23
Tubercu1os·is Education Programs . . . . . . . . . . . . . . . . .
25
METHODS
e
" ......
'1.
e
~
r "' ,. •
Q
~..................
go
••
.,
~
••
o • • • • • "- . . . . . . . . . . . . . . . . ,
•
•
J..
30
Development of the Instructional Program ....... .
30
Population Selection and Cr'iteda ............... .
34
Testing and Evaluation ...........•..............
IV.
INSTRUCTIONAL PROGRAM ••• ".............................
36
V.
RESULTS AND DISCUSSION •••. ••• ••••••.••••••••••• ••••••
58
VI.
SUMMARY AND RECOMMENDATIONS ·······-··················
69
Summary .........•..............•........•.......
69
iv
TABLE OF CONTENTS (continued)
Page
Recomme:ndat ions • • • • . • . • • • • • • • • • • • • • • • • • • • • • • • •
71
BIBLIOGRAPHY
72
APPEND I X • , ••.••••••••••••••••••.•••••••••..••.••••••••••• , • • • •
77
A.
PRELIMINARY PRETEST AND POSTTEST ..... ..........
v
78
LIST OF TABLES
TABLE
Page
1.
Pretest Scores of Preliminary Group Testing ........... 59
2.
Posttest Scores of Preliminary Group Testing .....•.... 59
3.
Achievement of Behavioral Objectives for' Preliminal"Y
Group Testing, for Posttest ........................ 62
4.
Pretest and Posttest Scores of
5.
Achievement of Behavioral Objectives for Final Group 67
Testing with Revised Pretest and Posttest, ........ .
vi
Final Group Testing ... 64
LIST OF FIGURES
FIGURE
Page
for Individual Try-Out .................... 32
1.
f~ethodo1ogy
2.
Deve'lopment of Progl~am
?
Comparison of Pretest and Posttest Scores of
~he Three Classes for Preliminary Group Testing .... 60
4.
Relationship of Scores from Final Group Testing
~·.
and Testing
Proc(-?dure • ,...••... 33
with Revised Pretest and Posttest ..........•...... 66
vii
ABSTRACT
AN INDIVIDUALIZED PROGRAM FOR
TUBERCULOSIS EDUCATION
by
Enid Bayer
Master of Public Health in Community Health Education
lhe purpose of this project was to develop and test a programmed
instructional booklet to be utilized as an individualized program for
tuberculosis education .
The program was developed and written according to vital tuberculosis information which is needed to make an informed health decision.
Information ranges from:
1) how one may contract the disease;
2) how it affects the various bodily systems; and 3) chemoprophylactic
therapy to stop the disease from spreading.
The progr1m was administered to high school students, sequentially
one person at a time, and the program was revised until itwas successfully completed by two individuals in succession.
viii
Three high school
classes, with 21-23 pupils each, from the Paramount Unified School
District participated in the preliminary group testing of the program.
A fourth Paramount high school class participated in the final group
testing.
The
Student.~
s
11
t" test, ca 1cu·l a ted for unpa h·ed samp·i es ~ found
the differ·ence between the pretest and posttest scores statistical'ly
significant for both the preliminary and fin&l group testing.
The
results of the final group testing indicated a more effective testing
instrument and reinforcement of information dealt with in the program.
The program may be adapted to several health or medical education
settings and used in conjunction with other teaching methods.
It may
be translated for usage among populations of different cultural backgrounds and languages.
ix
Chapter I
INTRODUCTION
Tuberculosis (TB) contt·ol in Los .A.nge1 es County has become increasingly difficult due to the influx of immigrants from Mexico and
elsewhere.
In addition to great numbers, the variety of ethnic groups,
language barriers and socio-economic differences have created a lack
of sufficient outreach programs.
These outreach programs may consist
of screening and education for diagnostic purposes and for imparting
knowledge of the disease.
Besides the problems of ensuring contact
and compliance of the visible population, there are barriers
·ing the invisible
infl~enc-
population 3 those v1ho have been in Los f.\ngeles County
less than one year.
In 1979, out of 27,669 reported cases in the United States, California had the most reported cases of tuberculosis of any state
(3,642), mostly in the age range of 30
y~ars
and older.
the disease is not diagnosed and is in an advanced
bil ity is greater.
(6:9)
sto~li::,
Uhen
comrnunica-
SJ,'!Tiptoms of tuberculosis tend to be 'less obvious
in o~der persons than young adults.
unrecognized spreaders of infection
(38)
a~d
Older persons r~main the
may never seek a physician's
care.
The 1979-80 Los Angeles County Grand Jury found Los Angeles to
have the tt1orst TB problem in the lhited States.
Insufficient screen-
ing of immigrants from Southeast Asia and Mexico was the main factor
contributing to the spread of infection.
The screening of
2
undocumented workers tends to be inadequate because they desire
ity and fear identification.
anon~ri­
They live incrowded conditions, are
usually nutritionally deficient, and are susceptible to tuberculosis
infection.
These problems have a serious impact on the rest of
(27)
the population because of the nature of the disease.
An illegal alien
may have active pulmonary TB and not seek cares thereby spreading lB
bacteria to a great number of people.
)r
(27)
The incidence of tuberculosis in the U.S. is 13 cases per 100,000
population; however, this incidence is much higher in Indochina (1,000
per 100,000 population),
r~exico
and Central and South America.
incidence figure for Los Angeles has reached 19 per 100,000.
The
(28)
The infection rate is clearly rising and the undocumented worker is
one who must
be
reached.
Tuberculosis education hopes to accomplish a greater awareness of
the disease properties, and subsequent change in attitudes and health
behavior within the population least likely to follow through with an
appropriate medical regimen.
This researcher has chosen the individ-
ualized instructional programming technique as a candidate method for
tuberculosis education.
Individualized instructional programming has been used in a variety of health education settings.
Literature Review.
Examples will be discussed in
The individualized teaching method does notre-
quire the assistance of a teacher.
It is self-pacing and each student
moves at his o·m rate, obtaining immediate feedback to his own responses.
Thre~
classes of Paramount High School students were chosen
to test this p:"ogrammed approach to teaching.
One crHerion for
3
seiection of Los Angeles County high school students for the testing
of the
pt~ogram
was the gr·eat percentage of infection found among
school age children, which was considerably greater than school age
children in other metropolitan areas.
{28)
The Paramount Unified
School District is located within the Southeast Health Services District of Los- Ange'les County.
The target population for the testing
was composed of four classes of students at the Patamount High Schoo·!.
Paramount cons·ists of a significant
~1exican
and Latin P.medcan 1ower-
income population, which is highly mobile and lives in substandard and
crowded conditions.
Much of the Latin community has had inadequate
health care in the past, and because of fear of identification, and
various cultural beliefs, do not seek medical aid.
Despite some
screening and diagnosis of TB in this area, medical regimens are often
not followed.
The administration of screening programs in 1970 and
1979 documented an increase in the incidence of TB in the refJion.
This researcher has recognized the almost
insurmount~ble
(8)
problem
of implementing effective TB education in L.A. County Health Clinics.
Therefore, a long-term goal of this instructional booklet would be the
distribution of its information to the families of the high school
students.
Q,,Jing to the undocumented worker population and other
people who are inaccessible to county health services, an individualized, mobile educational program is a potential solution to the TB
control problem.
The schools are an excellent source of an
impressio~
able and informed population that may distribute health information
and, hopefully, affect health behaviors among family members.
4
Statement of the Problem
Due to the influx of immigrants from Mexico and abroad, TB control has become incr·easing1y difficult.
A too·! for more
~~ffective
and
efficient TB education is needed.
Put~pose
of
Projec~
The purpose of this project was to develop a programmed instructional booklet to be utilized as an individualized pr0gram for tuberculosis education.
Limitations of
1.
Projec~
The fact that the program was implemented in a high schoo 1
class and not in a clinical setting limits its genera1izability to
such settings.
2.
There may be a 1ack of rnotivat ion to read and compl <;te the
booklet if the students felt their health was not threatened by tuberculosis.
3.
The desirable health behavior of seeking preventative health
care is a long range goal and was not investigated in this project.
4.
The instructional program was written at the reading ability
level of the high school student.
5.
County.
This was a sample from a problem population in Los Angeles
Applicability
and
acceptance of such a program to other popu-
lations ha.s yet to be determined.
6.
Language barriers, dealing with lack of grasp of the English
language have not been adjusted in this program.
There are future
possibilities of Spanish, Vietnamese and other translations for other
5
populations, including the family members of those being tested.
Definitions of Terms
Branching
Sequens:~:
a teaching pt'Ogram vJhich a 11 ows the 1earner
to choose an answer and routes him to information according to
the choice
\vhich
he
has
made.
(5:ix)
an answer which the learner thinks in his own
~9vert_~espondinq:
mind, ie1 \'Jhich cannot be seer..
Criterion Behavior:
(5:ix)
the behavior which the programmer expects of
the student after completing the program.
Initial Behavior:
presumed
(5:ix)
pre-knowledge which is a prerequisite
for the program.
( 22:97)
Linear Sequence:
an instructional program \'lhich takes the learn-
through small steps which do not allow him to deviate.
Overt ResQondif.l9_:
giving a response which can be seen and meas-
ured, ie, by writing, drawing, speaking, etc.
Programmer:
(5:x)
(5:xi)
the person who reconstructs the content information
into a self-instructionalized form.
Remedial
Sequence~
a teaching program found in a Branching type
sequence that gives reasons for a response being incorrect. (39:8)
Chapter II
REVIEW OF LITERATURE
Introduction
The following chapter traces the origin of programmed learning
and the men who influenced its development.
The structure of program-
med material and different schools of thought are reviewed and analyzed.
l\n
app1 ication of the programming process follows
~>lith
refer-
ence to the military, industrial and medical fields.
The TB disease process is examined from the onset of the disease
to TB control, treatment and its impact upon the U.S. population.
A
variety of programs and theories to encourage preventive health behavior
~vill
be discussed.
_Proqrammed Instruction
Programmed instruction is a process by which material of a program is structured so that a 1earner may make a series of-respcnses to
a series of problems by performing a physical task, or speaking theresponse to himself or aloud.
The learner proceeds in short steps at
his own pace, receiving immediate confirmation of the correctness of
his answers.
The format is structured so that he may be redirected to
another teaching item which will cladfy any misunderstanding.
(5:17)
The prognmmed learning process is an attempt to implement findings of psychology in a classroom or other teaching situation.
Job
train·ing programs in the form of computerized learning systems have
utilized programmed learning extensively.
6
Educational programmers, as
7
opposed to industrial
programmers~
have been accused of stressing the
theoretical, rather than practical aspects of programming, therefore
causing diverse opinions in the structure of programmed material.
An
attempt to coordinate the efforts of various vwrkers in the programmed
learning field caused the establishment of the National Center for
Programmed Learning in 1966 at the University of Bit·mingham.
A confer-
ence, sponsored by the f\.s.:;ociation for Programmed Learning, is held
yearly to gather people from different backgt·ounds to coordinate efforts and disseminate knowledge.
Its hi story and devel o_prnent.
(5:1)
Proponents of programmed self-
instruction maintain that this is not a new method of teaching; the
basic procedure is found as far back as the Socratic dialogue.
What
is new is the development of a science and technology based on a method employed by the great teachers of the past.
Therefore, some aspects
of the art of teaching may become a part of the science of learning
through programmed self-instruction.
(14)
The first actual programs were developed in the United States and
vJere known as
11
programmed instr·uction".
The English termed it
11
pro-
grammed leat·ning" which might be more accurate because it is a learneroriented system presented in an auto-instructional manner.
existence of programmed
1 earning
(5:2)
owes much to the study of behavior
psychologists such as Freud and original theories of Greek philosophers.
Edward L. Thorndike (1874-1949) has contributed greatly to the
development of programmed learning with his "Law of Effect", which
The
by
8
states that 1earning vJhich is accompanied by satisfaction on the part
of the student is mote likely to be retained.
more likely to be repeated, as
frustration and displeasure.
1eat~ner: s behavior.
of reward
10
11
o~posed
Successful actions are
to learning accompanied by
The reward of success "re·l nforces" the
Psychologists use the term rei nfor~ceru instead
11
and term anything that has the effect of strengthening a
successful response a "re·lnforcer
11
•
(5:2)
The programmed instruction movement gained impetus when Sydney L.
Pressey introduced the hardware {the teaching machine
device) to programmed learning.
ot~
presentation
Pressey developed a series of objec-
tive tests for students at a teachers' college.
Through a specially
prepared program, the students wou1d immediately discover if chosen
answers were correct, obtain immediate feedback, and proceed on their
own.
Programmed learning ensures that the student only proceeds to
new material once he has
maste1~ed
the previous exercise.
(40)
In investigations which have taken into account modes of education in relation to functioning outcomes, the importance of frequent
experience with the tools and activities utilized to teach subject
matter has been emphasized.
Recent efforts at increased educational
effectiveness have stressed social factors such as:
motivation and
continued stimulation from other pupils, teachers. parents and community.
Recent works on automated instruction deemphasize socialization
possibilities.
Pressey argues that teaching machines could be shared
fun and might further desirable socialization of school work.
{40)
Green (15:122) claims that the teaching machine is not simply
another audio-visual aid, and represents the first practical
9
application of laboratory techniques to education.
grammed instruct·ion, as
~v"ith
The task of pro-
all instruct·ion, involves the cond'ition-
ing of a behavioral repertory and bringing that class of behaviors
under the control of particular features of the environment.
The basic paradigm of programmed instruction involves the interaction of two persons:
"ieal~ning
the programmer and the student, therefore, the
process as it is contro11 (~d
by progl~ammed
instr·uction differs
in no essential way from the learning process as it is controlled in
the classroom.
The essential characteristic that distinguishes a
teaching situation from ordinat"Y social interaction between two ·individua1s is the intent on the part of one member to modify the behavior
of the other.
This is a highly individualistic process and the teach-
er must make use of response differentiation to establish some specific behavioral repertory in the other individual so that a learning
process may occur.
Programmed instruction differs from the simple
differentiation process in that it is unidirectional in nature.
The
program must be constructed in order to anticipate the many possible
questions that may occur, and at that point the programmer can no
longer assist.
(15:115)
Contributions of behavior· psychologists and other educatip_t!alists.
Dr. B. F. Skinner, primarily a behavioral psychologist,
agrees with Green that as a rule it is desirable to move slowly,
at least in the early stages, and for this r2ason small steps in
the program are more desirable,
but Skinner feels that the optimal
step size is an experimental question.
So, the paradigm for a
10
particul~r
learning situation in automated instruction corresponds more
closely to differentiation than it does to experiments in the learning
process under fixed experimental design.
(15:115)
Education a1 i sts have borrowed termi no 1ogy and some techwi ques
from the Russian physiologist Pavlov involving stimulus mediation and
solicited
re~ponse
from the learner.
Skinner's operant conditioning
uses reinforcement following a successful action which is a link in a
chain of behavioral pattern development.
Positive reinforcement is
usually preferred over negative reinforcement in a teaching situation,
but it has a 1so been found that negat-ive rei nfor·cement ma.y be more
effective than no reinforcement at all.
(5)
A program consists of a
series of stimuli designed to exert increasing control over a gradually
developing behavior·a 1 repertory.
Reinforcement derived from matching
behavior to the stimulus requirements leads to the differentiation
procedure.
(15:126)
Functionalists have concentrated on the constructive aspects of
human learning, or Cognitive Theories of Construction.
(24:29)
These
functionalists include Hebb, Paiget, and psychologists of the Gestalt
school of thinking.
These sources confirm the assumption that con-
structive activity is an essential component of human thought.
They
also support Thorndike and Skinner concerning the teacher and his efforts to make the learning situation demand constructional responses
from the learner.
Hebb's views explain how learning becomes general-
ized and concepts come into being.
Hebb's theory implies that a learn-
er tends to construct on the basis of his previous learnings, that he
is less dependent upon the immediate perceptual elements and that
11
learning proceeds by conceiving similarities, reorderings, and
recn~­
binations (or a pupil's growing power to recognize his experience).
The Gestalt school believes that the learning of any
curre~t
material
is the joint product of memory traces and the nature of the pr·obl em
before him.
Paiget, extending the constructive theory, believes that the
child does not merely discover significant relations in his learning,
he makes them.
This i nteil ectua 1 construction has Hs origins in
sensorimotor activity and later coordination which becomes written in
thought.
All these thoughts bring the teacher or programmer to the
same conclusion, that he must make the learning as constructive as
pass i bl e.
The structure of DYJ)J]!_ammed learning
an~b1
ems with .its
methods.
Programmed learning has become more of a process than a
product.
In the 1960s, programmed instruction consisted of a book
(or pages presented on a teaching machine) where the learner proceeded
in short steps at his own pace, receiving immediate knov1ledge of the
correctness of his answers.
Today it is an instructional system using
programmed books, teaching machines, audio-visual devices, and instructors trained in formulating objectives and diagnosing teaching
results.
(5:16)
The principles on
~'lhich
founded consist basically of:
programmed iearning was originally
behavioral anclysis (in order to form
objectives), continuous active responding, immediate confirmation,
self-pacing, small steps (depending upon type of material) and
12
validation (testing the program on sample groups and editing material
on the basis of feedback).
presumed pre-knowledge is
standar~d
•rnitial behavior• is established where
specified~
The programmer specifies the
of learner performance by \'Jhich the success or failure of the
program is g3uged, and this is called the ;criterion behavior•.
The programmer shou-id specify and communicate those educational
intents he has selected, a task that could be accomplished through
correctly stated objectives.
Mager (32) states that an objective is
an intent communicated by a statement describing a proposed change in
a learner, a statement of
~'/hat
the learner is to be like when he has
successfully completed a learning experience.
To be useful, objec-
tives must measure performance in terms of goals.
Another advantage
of clearly defined objectives is that the student is provided the
means to evaluate his own progress at any place along the route of instNction.
As the program proceeds, it places greater demands on the learner and forces him to think and discriminate, rather than learn by
rote.
Frame writing becomes an important aspect of the programs,
where automatic responding may lead to little retention of information.
Frames are small units which make up the program.
Each frame
is based on knowledge already possessed by the student, and each frame
adds a very small increment to this knowledge, moving the student
steadily toward the terminal behavior or knowledge of the subject.
frame ordinari:J introduces only one concept at a time, along with an
identifying cho.racteristic or partial definitions of it.
In subse-
quent frames the concept is built up and the student acquires all of
A
13
the responses that are a necessary part of understanding the concept.
(11:14)
Continuous active responding is solicited and called operant con-·
ditioning
by
behavioral psychologists.
Learning in these terms is de-
fined as a change in behavior which is observable and measurable and
is brought about by shaping or conditioning the learner's behav·ior.
A
series of prompts (or stimuli) are presented and a series of responses
are elicited with immediate confirmation of the correct answer, or reinforcement.
(5:26)
G. 0. M. Leith of the National Center for Programmed Learning,
has done research on overt responding vs covert responding.
Overt or
active responses, which provide the learner with feedback, can be superior to covert responses in many cases by he.lping him to retain
material better.
Covert responses, which are passive responses not
demanding feedback, can be super·ior in special cases where a student
has good academic ability and is bored with tedious responding.
( 5: 27)
Deterline (12) states that we cannot be sure that covertresponses
will always occur, and in order to hold the student•s attention and
prevent competing responses (e.g. day dreaming), overt responses are
generally called for.
One technique is to ask for overt responses
periodically, maintaining attention and sustaining occurrence of covert responses.
There are two basic schools of thought concerning types of programming.
Both techniques use active student response, immediate
feedback and
s~lf-pacing,
but the main difference is in the sequencing
14
ofthe material.
The Skinner-·type or linear
pr~ogramming
is
11
extrinsic-
ally programmed'', where the sequence is mo~e rigidly established by
the program writer than by the student.
Crowder
1
S
''intrinsic program-
rrri ng 11 or branching a 11 ows a student to take a route that is determined
by
his own response.
The branching type provides correct answers plus
remedial sequences which give reasons
fot~
a response be·ing incorrect.
(39:8}
Leith explains that the branching sequence seems better able to
provide evaluation of progress and generalization of learning.
How-
ever, if revisions and application tests are distributed at intervals
in a linear program, as done by Holland and Skinner, evaluation would
seem to be quite easy in the linear sequence.
Branching is essential-
ly a didactic device rather .than a psychological theory.
A branching
sequence assumes that learners make mistakes and then utilize the errors to correct mistakes.
The fundamenta 1 differences bet\.-Jeen 1i near
and branching programs are contained in:
1
J..
the differences in attitudes to and use of errors
....?
the difference in emphasis upon how much is taught before
the pupil is questioned
3.
the form of the pupil's responses
(24:28)
Crowder (9:28-30) visualizes intrinsic programming as a truly
automated process, since presentation of material is directly controlled by the activity of the student.
Linear programming is auto-
matic, but not automated, since what the student does does not affect
the course of the process.
The basic difference between linear and
intrinsic programming is that each is concerned with a different part
15
of the educational process.
The
linear programmer elicits the response
because he believes the making of the response is an essential part of
the learning process.
In a branching program, the programmer elicits
the response in order to see if the student has learned, and this information determines whether the next po·int is to be presented, or
whether additional material on the previous point is required.
An in-
trinsic program is an automated process where the presentation of
material to the student is determined directly by the student himself,
and it may be that no two students take the same course through the
material.
The linear program is an automatic process. in that it op-
erates untended, but it is not an automated process because it is not
self-correcting.
Mathetics is another method of programmed instruction, originally
conceived by Gilbert.
(39:10)
Mathetics, dedved fr·om the Gl""eek \'lOrd
'to learn 1 , is characterized by:
3) precise use of mediators;
illustrations;
2) large step size;
4) distinctive format;
6) great amount of covert responding;
immediate confirmation;
quences.
1) lack of bulk;
and
5) lavish use of
7) absence of
8) lack of normal-order performance se-
(39:10)
Cybernetics, developed by Gordon Pask (5:13),
tak<:~s
pr·ogramming
into a field of computerized adaptive teaching machines which control
the path taken by the learner according to his performance.
The more
rapidly the learner progresses, the more rapidly will he taken through
an increasingly sophisticated program.
In order to evaluate program effectiveness, the empirical tryout
and revision of instructional materials must occur.
Revision is
16
merely the application of development techniques at a different point
.
t.
1n ,.. 1me.
Applied in a sufficient number of tryout cycles, student
failure can be eliminated.
What is difficult to do is to bring about
the elimination of these failures in a minimal number of tryout cycles
and with a minimal amount of change consistent with program efficiency.
(16:187)
Gropper (16:187) claims that there is no generalizable technology
for rev·ising instructional materials, and that current practice h:3s
overemphasized student errGr rates, with insufficient emphasis being
given to types of errors which the students have committed.
Errors
made both during instruction and on criterion tests have been used as
the chief guides to program revision. The interrelationships between
program error rate and test error rate have been highly ambiguous.
Deterline (12) also believes that evaluation of program and pupil
performance depends not ordy on hm'l well
01~
how poorly program mechan-
ics work, but if performance objectives can be met.
Programmed in-
struction is concerned with highly individualized interactions between
the student and the instruction itself.
Any index of group perform-
ance on a program should be of as little importance to the
it is to the programmer.
teache~
as
The programmer needs to know how well the
program achieves its objectives and identify all of the program deficiencies as indicated by student errors and difficulties.
A frequently used measure of program e-Ffectiveness is the "gain
score"
~tJhic
ance.
This comparison is necessary in order ·to determine how much of
h is the di ffet'ence between pretest and post test perform-
a change in behavior the program actually produces.
The absolute
17
amount of gain is not as important by itself as it is in relation to
terminal leve·l of performance as ·indicated by the posttest scores.
(12)
Magdarz (31:12) claims that there is a problem with pretesting
and it primarily stems from the way course objectives are developed.
Often these objectives are only of the terminal type and the cnab·l ing
objectives that lead up to the terminal objectives are ignored.
terms of a hierarchical structure, such as Bloom
1
the objectives
S1
specify the higher level behaviors such as "applicat·ionn or
but fail to specify the lov1er level behaviors.
solution to this pretesting problem:
terminal test itern 11 •
(31:12)
In
~1agdarz
11
analysis",
recommends a
"establishing a context for the
This method is especially appiiccb'le to
branching type programmed instruction.
The course is designed with a
summary presentation for each terminal objective.
Those students w'ith
a significant amount of the termina-l behavior deal with a summary presentation, briefly touching on all topics within the terminal objectives
hierarchy.
Lengthy repetition, practice, and feedback normally
found in the regular instructional treatment of a ·lesson is not provided.
This method could make current branching type programmed in~tudent.
struction more efficient and less frustrating to the
Skinner defines verbal behavior as
11
behavior which depEnds for
its reinforcement upon the actions of other persons. 11
(
15:115)
The
behavior that the teacher seeks to mod"ify is verbal behavior, therefore, the learning process, as it is controlled by programmed instruction, differs in no essential \vay from the learning
controlled in the classroom.
pt~ocess
as it is
A student using programmed instruction
18
will be able to proceed at his own
can.
advancing as rapidly as he
level~
Under these conditions the conventional grading system will have
to he overhauled since a grade wi 11 be useful only in showing how far
a student has gone.
(14)
In experiments designed to compare the effectiveness of programmed instruction and classroom teaching, it is essential that the content covered be identical.
Because classroom teaching cannot be scrut-
inized like programmed material, it cannot be established that the same
material was covered to the same degree.
There are also different
opinions as to the choice of dependent variables against which the instructional methods will be evaluated.
Hartley (20:54) suggested that
posttests should be given shortly after instruction and at a later
date to provide a measure of retention.
Evans (20:54) believed that
student attitudes should be routinely used
programmed learning.
~s
criteria in studies of
By using different programs to teach different
ages and abilities, the particular strengths for each approach \'Jill be
established.
A complementary relationship, rather than a competitive
relationship might be established.
The development of programs for use in public schools reflects a
dilemma found in educational institutionsc.
Courses in mathematics,
foreign languages, and subjects where the objectives consist of intellectual and skill acquisition, have received more attention by programmers than social sciences and language arts.
This is probably
true because of the philosophy related subject areas and controversy
over behavioral objectives which must be wr1tten in regard to acceptable behavior.
There is considerable difference of opinion as to
what can be programmed now and.whai we may
gram.
e~entually-be
able to pro-
As mentioned previously9 part of the difficulty in programming
all subject matter is related to a philosophical dilemma rather than a
programming difficulty.
(36)
Leedham (23:87) states that the first essential for a program aimed at any population is that it must be comprehensible to that population.
The language should be geared to the reading ability of the
group, the size of step must be appropriate to their intelligence
range, and any pre-knowledge assumed in the program must be possessed
by
all who make use of it.
It seems essential that pragrams should be
written by teachers specializing in the intended subject area.
In the
past it was thought that successful programs could only be written by
psychologists, accompanied by a subject-matter expert.
The behavior-
ist .theory, from which programmed learning supposed'ly sprang. justified
this approach, but there has been no accepted theory of programming
and Leedham feels there is no necessity for programs to be written by
psychologists.
(23:87)
Meierhenry (36) believes that the methodology with which the content is presented in the program requires the joint efforts of both
theorists and practitioners.
In addition, 1earners should be observed
in order to give the programmer assistance in both content and presentation decisions, but where the program covers new
material~
much in-
sight must come from the content specialist.
One often-voiced objection of auto-instruction is that it might
dehumanize education.
Oeterline (11:9) claims this is not valid be-
cause one of the attractive features of auto-instruction is its
20
potential ability to provide mass _instruction in a highly personalized
manner.
The student, in a way, interacts with the person who prepared
the conceptual material that the machine or program contains.
Auto-
instruction can do much to overcome the difficulties that accompany
mass education and the need for educating more students with fewer
teachers,
Lindvall and Belvin {25) believe that programmed instruction has
failed to make its potential impact upon the schools because administrators in the schools have tended to adopt programmed materials instead of the pri nc i pl es of programmed instruction.
Programmed in-
struction must be applied more inclusively to the development of the
entire school curriculum, its materials, media, and personnel .
.B_p£] ication of prograptrned instruction to a variety of
sett1I~·
The greatest number of studies in the development and use of programmed instruction have been completed in industry and in the military.
(13)
According to Downing, (13)
public schools because
whole courses
inste~d
~reducers
the progress is slowly moving toward
have made the mistake in programming
of small sections of courses.
The by-product of
programming is better conventional teaching where more emphasis is
given to stated objectives, to pupil involvement, and the teacher assuming more
res~onsibility
for the students• giving correct responses.
Programmed instruction is a particularly promising educational
innovation that can help both medical students and practicing physicians meet new objectives in medical education.
Rather than only the
acquisition of knowledge, objectives can be formulated to acquire selection, organization and evaluation of new knowledge.
Programmed
21
instruction is also a means of making material available for continuing self-education.
At Dartmouth Medical
~chool,
Drs. Green, Weiss
and Nice researched the applicability o.f programmed instruction in a
medical school.
The investigators concluded that programmed instruc-
tion is an effective technique for teaching laboratory courses, such
as parasitology.
Students achieved a s i gnificanUy high test perform-
ance in this course compared to other students following conventional
instruction.
Less study effort was required
by
the more productive
students to reach the same high levels of performance, while the less
productive students required less study time and achieved higher
scores.
Better utilization of a student's study time was made and he
obtained the background knowledge and freedom to profit from bedside
and laboratory discussions with instructors.
(45)
Individualized instructional programming has been used successfully in a variety of health education settings.
A self-instructional
programmed course \'las developed to train occupational health nurses to
provide employee mental health care.
(42)
The
tt~ainir.g
of occupation-
al health nurses to recognize and deal constructively with the emotional problems of employees seemed to be a potentially important step tovm.rd the reduction of mental health problems.
According to the pre/
post test scores, the trainees learned the units taught, but the overall achievern,ent of course goa.ls remained to be tested.
Course goals
included h0\1/ the nurses dealt with problems in the mental health
arena~
and how effectively they used the interviewing and counseling skills.
Another program was developed by Janet Christine Orr on the subject of birth control methods and alternatives to teenagers.
(39)
22
The self-instructional program was well received by high school
students as an exciting way of learning and a tasteful way of handling
such a del·icate subject.
Pertinent information was retained and the
students enjoyed the opportunity of participating in the development
of the program.
It was the conclusion of this author that this partic-
ular education a1 approach may be
inst~umentaJ_in_affectirLg __heJ}clth_
deci sian-making.
A well received instructional program was implemented in 1977
during a blood pressure screening program for members of a blue collar
union.
The nature of the individualized format allowed for conveniEnce
of implementation.
The members reacted favorably to the program and
the improved preventi've health behavior was parti a11 y attr·i buted to the
program•s effectiveness.
(35)
Programmed instruction was successfully used as a teaching tool in
another documented study involving discharged hospital patients placed
on 1ong-term anticoagulant therapy.
( 7)
This instruct ion pr·oved to be
a reliable source of information and involved the learner in active
participation.
The general application of this teaching tool allowed
for age, education,
ences.
occupation~
intelligence and reading skill
diffet~­
Also, those who participated in the programmed instruction
learned significantly more than those who received a handout sheet
(passive instruction).
Even family members expressed interest in the
program after becoming aware of its existence.
Subjective ratings
by
the experimental subjects indicated much interest in this teaching
tool.
They also commented on the efficiency and effectiveness of its
method and content.
The authors recommended that more programmed
23
instruction be developed for patients to learn about specific illnesses
and compliancy with medical regimens.
In addition, they felt that
programmed instruction allows for· more economic utiiization of the
health professional's tinw.
(7)
Lumsdaine and Glaser (29:563)
believ~d
to utilize these means of instruction
that a conscious attempt
forc~s
the educator to become
explicit both about his instruct·ional goals and about the means by
which he expects to attain them.
The explicit identification of var-
iables and functional relationships which influence the modification
of behavior through instruction will continue to be at the heart of
effective attempts to improve education.
All of the current work in programmed instruction as well as most
educational research in the United States is represented
istic approach.
a behavior-
Progress has been made in instructional technology be-
cause of such an approacb.
Tuberculosis -
by
(36)
Charactet:!_s~;_i£.i.
of the Disease
Tuberculosis is an infectious disease caused by the tubercle
bacillus Ittcobacteri urn
!~jJercu]_os is,
closely related organisms.
the human var·i ety of a group of
It usually involves the lungs, but the dis-
ease process can be generalized throughout the body.
When tissues are
infected, allergy is established and white blood cells surround the
bacilli.
Other cells surround the bacilli and form the characteristic
tuti'~;~le that gives tuberculosis its name.
Secondary factors related to tuberculosis infection are socioeconomic in nature;
infection due to overcrowded conditions and poor-
ly ventilated rooms are very imrortant factors.
Others include
24
unhealthy living habits, faulty nutdtion, iack of adequate sleep,
emotional stress, etc.
by inhalation
Infection with the tubercle bacillus occurs
of the organisms in
d~·op1et
form; expelled by coughing
or sneezing of the person with the disease.
Pulmonary tuberculosis,
the most common form of the disease, is rare in infancy and in the
puberty age period, but may develop soon after that.
In untreated
pulmonary TB there are repeated lapses and battles between the bcdy's
natura: resistance to the disease and the bacillus.
the disease occurs quickly, and recovery is slow.
with the gradual loss of functioning tissue.
Progression of
Scarring occurs
Formation of a cavity in
the 1ung is a dangerous occurrence for the victi•:1, his family and the
community.
Enormous amounts of virulent bacilli are released from the
cavity every day and may continue to be discharged for many year·s.
(1)
The onset of pulmonary tuberculosis is usually insidious.
The
symptoms are so vague that chances are four to one that the ct·isease
vJi"ll be ividespread
befol~e.
d·fagnosis.
The nature of pulrno!}"qX:.Y"tubercu-
-------
losis often progresses from its first stages of no demonstrable lesion
to a moderately advanced stage within a period of weeks.
ranging from a
11
Symptoms
Cold that hangs onu, fatigue, coughing, night S\·teats
and febdle episodes i'Jould eventually indicate the disease.
Before
the introduction of effective chemotherapy, relapses were generally
the rule.
In pre-chemotherapy times, 70 per:::ent of the patients were
dead within 10 years, 5 percent were still cf ronically ill, and only
25 percent had arrested the disease. 1\Today o?er 95 percent of patients
recover fully v1ith chemotherapy.
(1)
On the basis of tuberculin skin testing up to 1976, 16,000 of
the approximate
214,000~000
people of the United States were infected
with tubercle bacilli, mostly in the 45 years or older age bracket.
(1)
Prevalence of the tuberculin reactors were estimated to be about
0.2 percent among children of six years and 0.7 percent among youths.
(38)
Numbers of these infected individuals may break down with the
disease during their lifet1me.
These are people who were not adequate-
ly treated in the past with drugs, and make up the high-risk group.
The tuberculin skin test is the primary method for discovering infection.
People
~<~ho
have ha.d close, prolonged contact with the infected
individual are examined for infection.
Preventive drug treatment may
be given to contacts to ward off the development of the disease.
The control of tuberculosis will always be a problem because it is
difficult to find and treat all cases completely.
People who do not
feel in wi11 not readily accept treatment and take pills for the
fully prescribed course of time.
Interruptions of treatment and short-
ages of personnel for prolonged fo 11 ovv-ups 1ead to ineffective tteat-
men t an d re 1apses.
(38 ,,1
Tuberculosis Jducation Programs
The Division of Community Operations at the Massachusetts Depart-
ment of Public Health has analyzed the cost effectiveness of routine
comraunHy screening for tuberculosis of Massachusetts school children.
(33)
t'hey found that tuber·cul in screening in apparently healthy popu-
lations in
~assachusetts
tuberculosis cases.
yields little or
r0
active, unknown pulmonary
It was found that $33,550 was the cost of prevent-
ing a single case of active pulmonary
tuber~ulosis
in a healthy
26
adolescent population with 1.0 percent of tuberculin-positivereactors.
These cost calculations do not include school health nursing, health
education, program
administration~
or community follow-up care.
Some
physicians consider the dangers of prophylaxis treatment, or antituberculosis medication in otherwise healthy citizens, too high a price to
pay in an age when eat·ly active pulmonar·y disease is treatable and
curab1e.)f.:rmmigration and mor-e successful case findings are responsible
!c
for the ·increased notif·ications of active disease in urban
a~·eas.
The'·
Division of Community Operations recommended that concentr·ated screen·-
ing and
be
follo~-1-up
observations in high-risk communities are likely to
more rewarding than scr·eening of large numbers of children through_j
out a state.
(33)
In one instance, at a community teaching hospital in Columbias
South Carolina, the unique features of the tuberculin test led to inadequate identification of tuberculin reactors.
(3)
Test results were
not recorded for 23 percent of the instances in one audit.
In another
audit, test results were recorded in 56 percent of 34 instances, but
had been recorded properly in only 3 instances.
It was suggested that
the test 1aeked national guidel·ines for its actua1
and
perfol~mance
that the tests were likely to be not only misinterpreted but also uninterpreted.
In 1979, a symposium on the control and eradication of tuberculasis, composed of participants who were recognized nationally as experts
in tuberculosis, was asked to examine the fw!damental concepts and
basic issues in the control and eradication of tuberculosis.
(21)
Strategies for identification and evaluation included providing
2.7
training to medical and health professionals in meth6ds to identify,
locate 9 examine, and treat tuberculosis contacts.
The conference mem-
bers recommended the use of treatment programs that improve the chances
of pat·lent compliance, such as short-course chemotherapy and intennittent or supervised therapy.
Patient
educ~tion
using verbal, audio-
visual and printed inforTnation ·in the pat·ient's dom·inant language has
always been employed, but the need for· continual educat-ional efforts
during each encounter with the patient
w~s
emphasized.
Community workers may be the answer to a series of cultural problems in larger metropolitan areas, for planners and administrators of
medical programs.
These community workers may be effective in aiding
the administration of health education programs such as selfinstructional booklets.
Barriers to effective health care are due to
population mixtures. with their multiple races and ethic groups, social
and economic levels, religious and cultural backgrounds, immigrants and
fore·ign languages.
It v;as found that interpreters and other hea.lth
workers should be both bilingual and bicultural because understanding
the language did not necessarily guaranteee an understanding of the
cultural, racial, or ethnic practices and beliefs.
Well-motivated bi-
lingual and bicultural individuals with a limited education, less than
two years of college, did a far better job in. interpreting and communicating between patients and staff.
This is taking into considera
that the basic issue is patient compliance.
on
(10)
This researcher's programmed instructivn is partially based on
the Health Belief Model, {HBM).
(2)
Social ·psychologists who devel-
oped the basic philosophy of the HBM include:
Drs. Godfrey M.
2.8
Hochbaum, S. Stephan Keg,2·1 ~,s, Howard Leventhal and Irwin
~L.
Rosenstock.
The HBM accounts for personal health decision-making and a means of
explaining preventive health behavior.
process in which an
·indiv~dual
Health
decision-maki~g
is a
moves through a variety of physical and
psycholcgtcal circumstances where interaction with individuals an1
events occur.
The nature of these interactions may increase or
decrease the pr·obab"ll 'ity that a particular subsequent response w·r11 be
made.
(17:336)
The health decision-making process involves the de-
gree to which an individual believes that he is susceptible to a disease.
Perceived susceptibility and seriousness have a strong cogni-
tive component and depend greatly on the acquir'ed knovtl edge of the in·dividual.
The motivation behind the development of this instructional
program is based on the need for some cognitive knowledge to be acquired before informed heaith decis·i011-making can be attempted.
(17)
One of the best documented retrospective studies uti1izing this
theory was performed by Hochbaum.
( 18)
He stud·i ed more than 1, 000
adults in three cities in an attempt to identify factors underlying
the decision to obtain a chest x-ray for the detection of tubercu1osis.
Two
basic beliefs {involving perceived susceptibility
and
severity)
seemed to determine whether a respondent obtained a chest x-ray:
1)
whether he felt tuberculosis was a real possibility in his case; and
2) the extent to which he accepted the fact that one may have tubercu-
losis in the absence of all clinical symptoms.
Four out of five re-
spondents who displayed both be1iefs took tte pred·icted action, wh·ile
four of five persons who accepted neither
the predicted action.
of the
beliefs had not taken
Since an aim in pub'l'ic health is to increase
r
29
the number of people who take preventive action in the absence of symptoms, an objective of this instructional program is to impart enough
knowledge about susceptibility and severity of the disease to
~ake
possible this informed decisiorr.
Summar.J_
The development of programmed 1earning has had a construct·ive impact upon the teaching and learning process.
A more efficient and pro-
ductive method of teaching has evolved with active participation, as
opposed to passive, on the part of the learner.
Personnel in a variety
of teaching settings, including health education arenas, have adopted
this behavioristic approach to teaching and have adapted programmed instructional theories and methods to their particular needs.
This researcher discovered an expanding need in L.A. County for a
more efficient and effective TB education program among certain populations.
These people who either resist TB education efforts or are
unavailable for follow-up therapy must be reached in some vvay.
program is an attempt to impart enough
vent·ive action.
Th·is
knowledge to motivate to pre-
Chapter I II
METHODS
Deve 1op~~nt of the I ns~n..<s_t.i on~l__E_!'og__!'am
The instructional program was developed in a Los Angeles County
Health Clinic setting.
Specialists in the field ranging from physi-
cians, pub.lic health nurses~ heaHh educators and community health
vJorkers \'Jere observed and interviewed to discover the most vital
ihformation about tuberculosis needed by the target population.
At
that time, the target group was composed of patients being tested and
treated for tuberculosis.
Pertinent information was taken from educa-
tional materials in the clinic and other health education sources such
as medical journals and source books dealing with tuberculosis and lung
disease.
A linear type program was developed in accordance with principles
on which programmed learnirq was originally founded by B. F. Skinner
(15:115).
The for·mat was also developed in accordance with the
instructions and techniques of the Pro_grammed l.earni ng
Krishnamurty and Machiraju.
(22)
Ma~ua1
by
The program was based on an assump-
tion about the initial behavior of the target group, Paramount High
School Students.
These students were assumed to know very little
about tuberculosis, only that they had beer. tested for tuberculosis
and the disease has occurred among people in the community.
30
31
Behavioral objectives were formulated so that the learner would
be able to:
l.
identify the conditions under which a person may contract
tuberculosis bacteria
2.
differentiate betv,,een dormant and active tuber·cul osi s
3.
identify, from given alternatives, what might happen vJhen
dor·mant tuber'cul osi s becomes active and harms the body
4.
differentiate between TRUE and FALSE statements
tests for detecting tuberculosis
5.
identify the most important treatment for controlling
tuberculosis and reasons for taking this treatment for the
fully prescribed course of time
l~egarding
The program was then administered individually to a physician,
six public heaHh nurses, two communHy workers and a health educator'
who provided technical and subject matter editing for revision
purposes.
These initial implementations took place at Inglewood
Health Services, a branch of the Los Angeles County HeaHh Department.
Developmental testing of the program fol1owed with individual
administration to students possessing similar characteristics of the
target population.
The program was revised until it was successfully
completed by two individuals in succession.
Try-out is diagrammed in Figure 1.
(30)
Methodology for Individual
32
Figure 1
t~ethodo 1 ogy
for Individual Try-Out
Start hete
1
Try the draft on one
learner at a time
""~ Revise the part(s)
that does not
communicate
I
1
Revise frames
that c!o not
I
communicate
i
Does each frame
NO ------communicate
with the
·learner?
Does the total
program communicate
_Y_Es_ _~) with two
learne1~s
consecutively?
YES
l
Proceed for group
validation
33
The revised program was then personally introduced and administered by the author for preiiminary group testing to three high school
classes at Paramount Unified School District allowing three fiftyminute time periods for the pretest, program, posttest and discussion.
Revisions on the pretest and posttest, tri improve upon the validity of
the tests, were made and
d
final group testing was implemented in a
fourth high school class in the district, during a fifty-minute time
period.
(refet' to Figure 2)
Figure 2
Development of the Program
and
Testing Procedure
l
Objectives Formulated
draft
Cr it i
quf by
1
Experts
(Revisions)
Indiv·idual Try-outs on 12 L.A. County H.S. Students until 3
consecutive successes
l
1
(Revisions)
Preliminary Group Testing in 3 Classes
(Pre and Posttest Revisions)
Final Group Testing in 1 Cl1ss
I
F·ina1 'nstrument
/"---
'
34
Each time the individualized program was
adminis~ered
these
instructions were given:
1.
This book"let is a form of Programmed Instruction, a method
of learning material by moving at your own pace and correcting your own answers.
2.
You will be learning about tuberculosis and what it can do
to your body.
3.
You must remember to follow directions as closely as possible
and to concentrate. Don't hesitate to ask me questions.
4.
You are not being tested, we are testing the program.
Population Selection and Criteria
The target population was composed of four lOth grade classes in
the Paramount Unif·ied School District, located in the Southeast Health
Services Region of Los Angeles County.
One criterion for the selec-
tion of this group was an increase in the incidence of tuberculosis
in that region.
Mantoux tests adrn·inistered to 3,649 students in the
Southeast Health Services Region, in 1970, indicated a 2.0% positive
reaction to the tests.
In 1979, another testing of 6)S23 students
resulted in a 4.2% positive reaction, or a 2.2% increase in incidence.
(8)
Considerations in selection of the lOth grade classes were
interest and desire of the class instructors to
cooperate~
Other criteria for subject selection were that the students must
be able to read, write and understand English; th2 majority viere to
belong to the lower-middle income bracket; and they must have been of
mixed cultural backgrounds including Black, Spanish, oriental and
white origins.
Test_1.D.!l__~d [_valuation
The students were tested by
administe~ing
contained in the booklet. -The students • scores
the pretest and posttest
~'iere
treated statisti-
ca11y by using the student•s test to compare the pretest and posttest
results.
The tests evaluated behavioral objectives indicated in the
Development of the Instructional Program.
It was necessary to expand
the form of the behavioral objectives into the test format to make
possible a more comprehensive evaluation of program effectiveness.
A
subjective evaluation was accomplished by informal conversations by
this researcher with the students and instructors during and after the
administration of the program.
The subjective evaluation pertained to
program effect·iveness, including content, methods and ·long-range goal
attainment.
llSurnmary 11 and
A discussion of these results can be found in the
11
Recommendations 11 sections.
Chapter IV
INSTRUCTIONAL PROGRAM
AN INDIVIDUALIZED PROGRAM
FOR TUBERCULOSIS EDUCATION
37
Pretest and Posttest
This test will find out how much you knov'l about TB.
Choice - X correct answer for each question:
1.
t~ultiple
A person can get TB most likely by
a.
being in the same room with someone who has dor·mant TB
b.--being in a health clinic to be tested fat· TB
c.- breath·ing in air containing TB germs
2.
A person with active TB can spread the germs by
a.
sneezing, coughing or speaking
b.--touching utensils someone else might touch
c ·==sneezing, coughing or eating
3.
A person may not get TB if he
a.
washed his hands before eating
b. =---has good body resistance
c. ___goes to see his doctor regularly
4.
When a person with low resistance breathes in TB germs, the
germs may attack his body
a.
when he is workinq with someone who has active TB
b.--when his great, great grandmother had TB
c._
5.
if he forgets to take aspir·in on a regular basis
TB germ takes
bJo forms in the body
coated and uncoated
b.--round and tubercle
c.----dormant and active
The
a.
6.
One chat'acteristic of a "sleeping" TB germ "is that
a.
if the victim sneezes, coughs or speaks the TB germ can be
---given to someone else
b.
it is in many parts of the body
c.~it started to do damage and shovJ obvious symptoms
7.
One characteristic of a 11 Waking" TB germ is that
a.
if victim sneezes, coughs or speaks the TB germ can be given
---to someone else
b.
cannot give germ to someone else
did damage but healed itself leaving scars
c:--·
S.
TB germs attack living tissue and the most common parts of the
body wher•:: TB gei11ls at~e found are
a.
the: lungs
b.---lymph glands and 1ungs
c. __ lym~h glands, kidneys, lungs and spine
33
9.
TB spt'eads in the body
break out of the
~enter the victim
c.
~nter the victim
a.
b: .
lO.
when ush~eping;' TB germs
walls that have controlled them
by someone sneezing
by someone coughing
vJhHe blood cells attack TB germs
a.
wall them in, and now they are active
b.-.--wall them in, and novJ they are dormant
c.-.--wall them in and form holes or cuvities
11 ~
When TB germs wake up and become active they
a.
leave cavities and holes where living tissue has been
---"eaten up"
b.
form more scars and spread to other parts of the body
c. __
do not spread, but do damage where they originated
12.
Does a person with TB have obvious symptoms?
a.__yes
b.
no
c.---sometimes
l~
Early symptoms of a TB victim include
a.
spitting up blood, chest pains
b.---unexplained weight loss, tiredness
c.-- chronic cough
14.
The TB germs become uncontrolled when
a.
there aren't enough red blood cells to control them
b.------there aren't enough v1hite blood cells to control them
c.
scars are formed in the bodily organ it's affect·ing
15.
TB is a secret disease because
a.
the TB germ can be active for a long time and the victim
----may not know he has the germ
b.
the disease should be kept a secret from your friends
c.__
only a TB skin test can identify the presence of the TB
germ
16.
The following tests are used to detect TB germs in the body:
a.
tuberculin skin test, blood pressure tests
b.--tuberculin skin test, X-rays, sputum tests
c._
X-rays, endurance tests, tuberculin skin tests
17.
A positive tuberculin skin test means
a._;,L_the TB germ is active in the body
b.
the TB germ is dormant in the body
c.--a fr-· se reaction, active TB is present, or dormant TB is
pre~:e:'1t
39
18.
A chest X-ray indicates scars or cavities in the lungs; this means
a.
TB germ may be presenf-·and is either~ dormant or active
b.---~he TB germ is awake and you can wait awhile before seeking
-----treatment
c. _ _the TB germ is asleep and you can wait whi1e before seeking
treatment
19.
A person who has symptoms of TB must take medication
a.
until a friend says that he look~ healthy enough
b.----until he feels healthy
c .=-__for the fully prescribed course of tirne
20.
One of the many reasons why medication must be taken is
a.
to prevent others fr·om catching it
b.
it might help so it 1 s worth trying
c . - - i t makes you feel well right away, then further medication
is not necessary
40
TUBERCULOSIS:
THE SECRET DISEASE
A SELF-INSTRUCTIONAL PROGRAM ON HOW
YOU CAN CONTROL TUBERCULOSIS (TB)
THIS PROGRAM WILL HELP YOU UNDERSTAND
HOW YOU MAY GET TB AND WHAT YOU CAN DO
TO PREVENT THE DISEASE FROM SPREADING
AS YOU READ THIS PROGRAM. FOLLOW ALL
DIRECTIONS AND ANSWER THE QUESTIONS
CAREFULLY
WHEN YOU HAVE ANSWERED THE QUESTIONS, YOU
MAY CHECK YOUR ANSWERS WITH THOSE FOUND AT
THE BOTTOM OF THE PAGE
CORRECT YOUR MISTAKES, IF ANY, BY FILLING
IN THE CORRECT ANSWERS (EXCEPT FOR THE
PRE-TEST AND POST-TEST)
Cover the answers at the bottom of the page
A.
A person can get tuberculosis (TB) by breathing in air containing
TB germs.
These germs can usually be found in the lungs.
A person with
active TB sprays -----+)
the germs by sneezing,
cou qb..:L!:!_g_ or ~a ki fl9.
TB germs
someone else
leave lungs_,.; breathes in the
and enter
.· germs
air
Fi11 in the blanks:
A person can get TB when another person with ac1_iv~- TB
1.)
sprays the germs by
or· _ _ __
Now check your answers with those at the bottom of the page,
then continue reading.
B.
Sometimes a person breathes in
a~tive
TB germs but doesn't get TB.
This may be because his body resistance (or ability to fight off
disease) is good.
bodily system.
Sti 11, other times, the germs may attack his
This happens when resistance is low .
. Read why a person's resistance is low and TB germs attack:
doesn't get enough sleep
~
had TB before
TB
eats poorly-..__
GERMS
has an ill ness
ATTACK
/
is working with
someone with
active TB
is an alcoholic ~~·--·~"'·~is very old and
or takes drugs~
resistance is low
is a child and resistance
is 1ow
---------------· -------------------------------------------------------
answers:
1.)
sneezing, coughing or speaking
42
Cover the answers at the bottom of the page
A person with
..a..ui.Y.e
TB sprays germs into the air and infects
another person.
Put a ( x ) next to the correct answers:
~lhen
a person with 1ov~ resistance breathes in TB germs, the
gel'ms may attack his body:
l)
when he eats poor-ly.
2)
when he doesn't 9et enough sleep.
-----when his great, great grandmother had TB.
4) ------when he is an alcoholic.
3)
5)
when he has an illness.
6)
when he goes to see his doctor regularly.
7} ________when he fol~gets to wash his hands before eating.
S) ______when he had TB before.
9)
- - -when he is
a child or older person with low resistance.
10 ) ____when he is wot·ki ng with someone who has active TB.
Now check your answers with those at the bottom of the page.
You may review Part B.
answers:
1) X
2) X 3)
4)
X
5)
X
6)
7)
8) X
9) X
10) X
43
C.
The TUBERCULOSIS genn takes
t\<10
forms in the body.
One is the
dormant
active (waking up) form.
- - (sleeping) form, and the other is -----
Read information in the boxes:
--,
( ~~AKI NG --~fl. GERM
in many parts of body
pa r'ts of body
entered and causes very
mild iliness
woke-up from sleep and
started attacking body
did some damage but
healed itself leaving
scars
started to do ddmage
and show symptoms
germs stay alive, fali
asleep and stop doing
damage
victim sneezes. coughs
or speaks and gives TB
germ to someone else
cannot give germ to
someone else
1----·-
44
Carefuliy read the infor·rnation ·in the boxes.
the correct answers:
Fill in the blanks with
(Complete entire page before checking your
answers)
The
t~tJo
forms the TB germs take in the body:
-----
........
--·------------"'~·-
1)
____
--~
--- ·--,
....{. )
(
in many parts of body
in many parts of body
entered and causes very
woke-up from sleep and
started attacking body
mn d n 1ness
did some damage but
healed itself leaving
scars
and
stay alive, fall
asleep and stop doing
damage
victim sneezes, coughs
or speaks and gives TB
germ to someone else
g~rms
started to do damage
show symptoms
cannot give germ to
someone else
answers:
1) dormant (sleeping) germ
2) active (waking up) germ
D.
Draw a line from the FORM OF TB GERM to WHAT HAPPENS IN THE BODY:
If you have problems you may refer to the boxes on the previous
page.
FOR~1
WHAT HAPPENS IN THE BODY
0 F TB GERM
dormant (sleeping)
in many parts of body
show many symptoms
person can spray germs
and give someone TB
active (waking up)
woke up from sleep and
started attacking body
did some damage but
healed itself leaving
scars
entered and caused
mild illness
germs alive, but dormant
answers:
dorman~~
_ : : i-show
n many
..........
-__
many
....... ..
active
····-==:.-
person can ...... .
from, ... .
~~·did some damage ..
~entered and, .... .
_erms alive ..... .
·-
--viOke up
46
E.
When the TB germ first attacks the body it kills some living
tissue,
Usually there are so few symptoms (similar to a cold),
the person does not know that he has TB.
Sometimes, this first
infection is sedous, especially in infants and young adults.
TB germs can strike
ony~vhere
favorite place to attack.
White blood cells attack the TB
germs. wall them in and form
is now dormant.
in the body, but the lungs ar·e a
_?~ar~_in
the lungs.
The TB germ
47
F.
Write True or False:
(use Tor F) if you cannot answer #l,
reread Part E.
1)
When TB germs first attack the body they kill some
living tissue.
2)
Because there are so fmv symptorns,.duting the dormant
form of TB, the person doesn•t know he has the disease.
3) _ _ _ The \'lhite blood ce 11 s attack the germs, wall them in,
and now they are active.
---·-~
4)
The white blood cells attack the germs, v.;a 11 them in'
and now they are dor·mant.
The dormant TB germs become active for many reasons.
already discussed these reasons.
We have
Review them if necessary
(refer to Part B).
---------------··-----------------------------------~-------------------
answers:
1) True
2) True
3) False
4) True
48
THE MOST COMMON PARTS
OF THE BODY WHERE MOST
DORMANT TB GERMS ARE
I FOUND
LYMPH GLANDS-----t
-~~--------LUNGS
)
*
FAVORITE
PLACE OF
ATTACK
~;_~,....:....,.,..,.-+-+·SPINE
I
Fill in the blanks:
\
(use the diagram for clues)
The most common parts of the body in which TB germs ii.re found
are:
1)
- - 2 )--~----·- 3) · - -
4) ----------
Put a (*) next to the body part that is a favorite place of attack.
Now check your answers.
ansvJers:
any. order:
1) lymph glands 2) kidney 3) lungs 4) spine
* 1ungs
49
/
LUNGS (
·
.
~
'
_/
)~.:..( ;
'J
~(
"')
~
{
I
TB germs multiply and b•·eak
't~-----'f.)ut of wall.
k'O~ \
~
TB germs leave ca~ities or
holes where they nave been.
There are not e~<?~~h white
blood ce11s to i 1r1 nt them.
~
~
"\~
\
Jl
.
TB germs spread to other
___.-1Jarts of LUNG and other
::...----places in the body.
As TB germs spread they
leave cavities or holes
where they have b~en ;·thereby "eating up" living
tissue and leaving holes.
There are not enough
white blood cells to fight
them.
TB GERMS ARE NOW ACTIVE
AND UNCONTROLLED
50
H.
Tube rc ulosis is a secret disease bee a use the TB genn can be
uncontrolled and ---active for a long time and a victim may not
know that he has the TB germ.
Here are --EARLY and
-~~JER_
symptoms
that might indicate that TB is present in the body and ACJIVE:
Symptoms of Victim
Ea_dl Svmptoms
Later Sy!!!_P.torns
unexplained loss of weight
night sv.Jeats
all the early symptoms plus:
tiredness
spitting up blood
chest pains
chronic cough
TB germ in sputum
nervous irritability
fever
chills
positive tests for TB
I.
Put a ( x ) next to the answers that tell what may happen when
___1) TB germs spread into lungs and sometimes other parts of the
body
----·_2) the victim may not know about it because he has few mild
early symptoms
_ _3) cavities are 1eft where TB germs were present, thereby "eating
up" living tissue
___4) the person can not Jive anyone the disease by coughing, speak-
ing or sneezing
___5) ther'e are not enousJh wh"ite blood cells to fight the TB germs
____6) if uncontrolled, the TB germs might develop into later
symptoms: spitting up blood, chest pains and chronic cough
answers:
1) X
2) X
3) X
4)
5)
X
6)
X
J.
There ar·e many tests used to discover TB in a victim.
are necessary because sometimes there are no
~.I~~·
Tests
The victim
might have a mild symptom (like a cold), and not know he has
active TB, and then give the disease to family and friends.
To find out how tests are used to discover TB, read the following
very carefully and let the arrows lead you in the right direction:
- TB infection ~-usp;~ because of:
d symptoms
• exposed to oerson with active infection
Lexij::ed to ~1any people, ~~ing children
Skin
skin
positive
result
r-:-----1
w -. I
No
·Chest X-ray to see
r-----~1 Fa1~~ 1 scars or if scars or c-:Jvities~~~?.r·s_'\JT8 0erm
~.~ Jo.!:l ~-. ...,co~.~a...~~ov....
L,.ll.+.1.1
...
• P...S..o~..--r.__ _.....:.,i~n_l~u::!n.:..:Sl~..,.........J
"7! do man t , take
treatment to
p:·E: vent from
becoming active
cavities (holes)
TB germ is active
Sputum test-to ma-ke
certain it is a TB
not TB
germ
ger'm and not another
TB germ
_______ ___j____, _________
VICTIM MUST GET
SPECIAL TREATMENT
FOR TB
I
~1
an;~;germ
i71
present, ttlerefore, treat1~e.]
for· another
di :,ease
~··-----
K.
Read the following and circle TRUE OR FALSE:
1) True
False
A negative tuberculin skin test means that the
person does not have TB
2) True
False
A negative tuberculin skin test means that the
person never vlill get TB, therefore he should
never have iinother test.
3) True
False
A positive tuberculin skin test means that the
person must have an X-ray to see if he has
dormant or active TB.
4) True
False
If the X-ray indicates dormant TB, he should
take treatment to prevent--theTB germ from
becoming active.
5) True
False
If the X-ray indicates active TB. he can go back
to his family and friends ---without any treatment.
6) True
False
If the person has dormant TB, he may go back to
his family and friends without treatment.
7) True
False · If the person with dorma~t TB does not have
treatment, his TB may become act_j_ve_.
answers:
1) True
2) False
3) True
4) True
5) False
6) False 7) True
L.
As you know:
DORMANT OR ACTIVE TB ·
\ . I .
med1cation for the
fully prescribed course
of time must be taken:
~the disease.
1.
to
2.
to prevent others from catching it.
3.
to keep dormant TB from becoming active TB.
4.
because TB is secretive. A person might feel
heal thy, but still have the TB germ acti.'{~ in
his body.
5.
taking medication for the fully prescribed
course of time is the ~1ost impor_!:ant treain:ent
for controlling TB~
contt~ol
Circle the correct answer:
These are all treatments for TB, the most important treatment for
controlling TB is:
get rest
eat well
medication for the fully
prescribed course of
time
get r·egulal"
checkups
Why must a person take medication for the fully prescr-ibed course of
time? (Fill in the #3 blank.)
1.
2.
to keep dormant TB from becoming active TB
even though the person might feel healthy, the
might
3.
be
TB germ
active.
---------------------------·-·-----·-·-------·
ans~tJers:
medication for the fully prescribed course of time
3) any of numbers l, 2, or 5 at the top of the page
54
Pretest and Posttest
This test will find out how much you know about TB.
Choice- X correct answer for each question:
Multiple
1.
A person can get TB most likely by
a.
being in the same room with someone who has dormant TB
b.=:- being in a health clinic to be tested for TB
c. ___breathing in air containing TB germs
2.
A person with active TB can spread the germs by
a. ___sneezing, coughing or speaking
b.
touching utensils someone else might touch
c._
sneezing, coughing or eating
3"
A person may not get TB if he
a.
washes his hands before eating
b.--has good body resistance
c.==::goes to see his doctor regularly
4.
When a person with low resistance breathes in TB germs. the
germs may attack his body
a .__when he ·j s working with someone who has active TB
b.
when his great, great grandmother had TB
c.--if he forgets to take as pi ri n on a regular basis
5.
The TB germ takes two forms in the body
a.
coated and uncoated
b.---round and tubercle
c.--dormant and active
6.
One character-istic of a "sleeping" TB germ is that
a.
if the victim sneezes, coughs or speaks the TB germ can
----be given to someone else
b.
it is in many parts of the body
c.
it started to do damage and show obvious symptoms
7.
One characteristic of a "waking" TB germ is that
a.
if victim sneezes, coughs or speaks the TB germ can be
----given to someone else
b.
cannot give germ to someone else
c._ did damage but healed itself leaving scars
8.
TB germs attack living tissue and the most common parts of
the body where TB germs are found are
a.
the lungs
b.--, ymph glands and 1 ungs
c. ____lymph glands, kidneys, lungs and spine
55
9.
10.
TB spreads in the body
a.
break out of the
b.
enter the victim
c.
enter the victim
~Jhi
when 11 sleeping 11 TB germs
walls that have controlled them
by someone sneezing
by someone coughing
te blood cel·l s attack TB germs
a.
wall them ·j n' and now they are active
b. --\vall them ; n' and now they are dormant
,.. ---wall the:n in and form holes or cavities
.....
11.
When TB germs wake up and become active they
a. ___leave cavities and holes where living tissue has ber::n
"eaten up''
b.
form more scars and spread to other parts of the body
c .=:::cto not spread, but do damage \vhere they Ot'i qinated
12.
Does a person with TB have obvious symptoms?
a . __yes
b.
no
c. ··--sometimes
13.
Early symptoms of a TB victim include
spitting up blood, chest pains
b.---unexplained weight loss, tiredness
c.~chronic cough
a.
14.
The TB get'ms become uncontro 11 ed when
a.
there aren't enough red blood cells to control them
b.---there aren't enough white blood cel'ls to control them
c.
scars are formed in the bodily organ it's affecting
15.
TB is a secret disease because
the TB germ can be active for a 1ong time and the victim
--may not know he has the germ
b.
the disease should be kept a secret from your friends
c.
only a TB skin test can identify the presence of the TB
germ
a.
16.
The following tests are used to detect TB germs in the body
a.
tuberculin skin test, blood pressure tests
b.--tuberculin skin test, X-rays, sputum tests
c. __
X-rays, endurance tests, tuberculin skin tests
17.
A positive tuberculin skin test means
a.
the TB germ is active in the body
b.--the TB germ is dormant in the body
c.---a false reaction, active TB is present, or dormant TB is
---·present
56
·18.
A chest X--ray ind-icates sc~s_ or cavitie?_ in the lungs; this means
a.
TB germ may be present and is either dormant or active
b.-- the TB germ is awake and you can wait awhile before seeking
treatment
c. _ _the TB germ is asleep and you can wait awhile before seeking
treatment
19.
A person who has symptoms of TB must take medication
a.
ur:ti1 a f}~iend says that he looks healthy enough
b.---until he feels healthy
c.=::::tor the fully prescribed course ·of time
20.
One of the many reasons why medication must be taken is
a.
to prevent others from catching it
b.---it might he-lp so it's worth trying
c.
it makes you feei \-Jell right away, then further medication
is not necessary
PLEASE TURN THE PAGE
57
Please check your answers and
circle the incorrect ones (if any)
1.
2.
c
a
3 .. b
4.
5.
6.
a
c
7.
b
a
8.
9.
c
a
10'
b
11.
12.
13.
14.
a
c
b
b
15 ·16.
a
17.
c
18.
19.
a
c
20.
a
b
Chapter If
RESULTS AND DISCUSSION
One purpose of this project was to develop and test a programmed
instruction booklet.
Individual try-out was administered sequentially
to one person at a time, and the program was revised until it was
successfully completed by two individuals in succession.
Individuals
selected for the try-out were chosen from Los Angeles County Health
Clinics and high schools.
Numerous revisions were made, including
changes in pretest and posttest format and specific instructions
v>Jithin the progr·am.
popu~ration
Group test·ing v.;as administered to the target
in two stages:
a preliminary group testing and a final
group testing with a revised
pret~st
and posttest.
The preliminary group testing done in three high school classes
produced the foil owing pretest and posttest scores.
Table 2)
(Table 1 and
The Student's t test calculated for paired and unpaired
sa.mp l es found s i gni fi cant differences between the pretest and posttest
scores, (p
<
.0005).
Figure 3 il'lustrates the significant
differences in both pretest and posttest results in the three groups.
58
~I'
J:J
Pretest Scores of Preliminary Group Testing
·--------------------------------· · - - - Group (n)
Mean
Range
Standard Deviation
--------------------------------
I
( 21)
7.8
4-10
1 • 37
II
(20)
7.6
6-9
.97
I II
(23)
7.7
4-10
1.27
Tota·l (64)
----
-------------~------------
Table 2
Posttest Scores of Preliminary Group Testiny
-------------------------------------Mean
Range
Standard Deviation
( 21 )
9.2
7-10
.90
II
(20)
8.9
7-1 c
. 99
pr
)• .J.
( 23)
8.9
6·-1 0
1.13
Group ( n)
-------------------------------------
I
Total (64)
--------·----
·-'------'-------~--------
The scores ranged from 4-10 in the pretest and 7-10 in the posttest.
This researcher questions the test 1 s effectiveness ccncerning
whether the students knew most of the information before beginning the
program.
The mean scores on the pretest and the approximate twd point
improvement on the posttest indicated a test that was either too easy
and guessing brought positive results, or a test that did not
60
Figure 3
Comparison of Pretest and Posttest
Scores of the Three Classes
for Preliminary Group Testing
'10
9
I
*
-
8
7
Q
u
E
s
6
T
I
I
I
0
N
5
s
4
3
2
** (n
==
**(n
21 )
GROUPS
*p
=
<
0.0005
III
II
I
**n = number of students tested
= 20)
**(n
==
23)
61
suffic-iently test what the program taught.
it is a combination of the two.
This researcher· feels
Students did mention that they were
able to guess at a fev1 answers but took an educated guess.
After
finishing the posttest there was a slight improvement irt their scores,
but the students expressed a more confident attitude as far as choosing
the correct answers.
Also, this researcher evaluated the questions
posed by the students, during and after the testing, which indicated
learning that was not tested in the posttest.
These questions per-
tained to symptGms of the disease and the number of tests available to
detect TB in the body's systems.
the students
absorb~d
This is similar to
It was noted by this researcher that
more information than was statistically assessed.
Magdarz•~
stated problem with posttesting; that
these objectives are only of the terminal type and the enabling objectives that lead up to the terminal objectives are ignor·ed.
(31 :12)
The evaluation of behavioral objectives, acquired from the program, indicated that most students achieved a majority of these
behavioral objectives.
(Table 3)
The students showed a sincere interest in the content and techniques of the program.
~rl
When this researcher approached the students
th the program, their attitudes were of cooperation and a ttent·i veness.
This researcher explained why the program was written and what their
part \'iou1 d be.
Even though they rea 1i zed that it wouldn't "count" on
their school records, they were still attentive.
An attempt was made
to motivate them into completing the program by perking their interests
and inquiring about their knowledge of the disease.
Their knowledge
didn 1 t seem to go beyond knowing that tuberculosis existed, periodic
62
Table 3
Achievement of Behavioral Objectives
for Preliminary Group Testing for Posttest
-Beha vi ora 1
Objectives
---·--·-
, __
2
-
3
4
5
..
Corresponding
Questions
Group
I ( 21 )
Group
II (20)
Group
III (23)
-~----
1
95%
95%
96%
2
100%
100%
96%
3
1007~
100%
100~~
-[ 4
67%
50%
63%
r-5
1oo~;
1 OO?b
-100%
6
100%
95%
87%
7
62%
65%
70%
95%
85%
87%
100%
100%
96%
100%
100%
100%
r:
{a
63
testing was done, and one could get quite ill.
They had no idea how
one contracted the disease and how it affected the bodi"ly systems.
The majority of the students finished the testing within 30-35
minutes.
Those who took more than 35 minutes appeared to be taking
more time to be accurate, or b~cause of daydreaming, finding the
questions ditf-icult, or arrived late and needed mor·e time to finish.
This information was accumulated by the researcher 1 S subjective
observations and interviews.
Questions during and after the implemen-
tation centered around sections G and H, which dealt with how TB germs
multiply.
The students seemed to be especially interested in how the
d·!sease neats up"
·1
iving tissue and what symptoms occu1·.
The students
appeared absorbed in the subject matter and very few questions were
asked during the implementation.
Several students commented that they found the format clever and
enjoyed working through the program.
The algorithm in section J was
noted as a creative way of teaching ·information.
One student showed
an interest in adapting it to other subject matter.
The majority of
the students felt that the subject matter was easy to grasp and that
they learned why medication should be taken for the fully prescribed
course of time.
This author considers this a very important concept,
since making a positive health decision depends upon understanding
that medication must be taken even though clinically-overt symptoms
may disappear.
There was some confusion as to what a positive tuberculin skin
test indicates.
Question #4 on the posttest was missed widely because
the program wasn 1 t successful in explaining how a false positive
G4
reaction can occur.
An additional frame after the algorithm (section
J) would probably have been beneficial.
The instructor, Mr. Maras was pleased with the students' attentiveness during the testing and at the outcome of the posttests.
He
was surprised that the program· was finish0d in the allotted amount of
time and that the students were able to handle the content.
A final group
testin~J
was implemented in another high school
health class at Paramount with a revised pretest and posttest.
A
revision and retesting wer·e deemed necessary because of the inability
of the original pretest and posttest to assess the achievement of
the behavioral objectives of the program.
The Student 1 s t test was
calculated for unpaired samples and found the difference between the
pretest and posttest scores statistically significant, (p
>
0.0005).
The means, ranges, and standard d•..:viations are presented in Table 4.
Table 4
Pretest and Posttest Scores of
Final Group Testing
Group IV
------Mean
Range
Standard
De vi a ti on
(22)
10.54
4-15
2. 75
Pas ttest (22)
16.09
7-20
3.23
Students (n)
Pretest
65
Figure 4 better illustrates the spatial relationship of pretest
and posttest scores.
Ia~h
line represents a student, starting with
the lowest pretest score and then indicating the posttest results.
More than one line radiating from a dot indicates more than one student
receiving that particular
scar~,
i.e. two students received 8 on the
pretest, but-one scored 14, and one 15 on the posttest.
The ranges
(4-15) and 7-20) in the scores are more representative of effective
testing of the information contained in the program"
the Paired Students• twas also significant (p
<
The p value for
.0005).
An increase
in the number of questions allowed for better testing of the information acquired from the program.
Further evaluation of the behavioral objectives acquired from the
program indicated that most of the students achieved a
the behavioral objectives.
t~1ajority
of
(Table 5)
In this final testing the students took a sincere interest in the
content and techniques of the program.
They were told by the instruc-
tor, Mr. Reaser, that it was extra-credit work, and they continued to
be attentive and work diligently for the entire fifty minute period.
Most students completed the program within a 30 to 35 minute time
period.
Mr. Reaser commented on how their powers of
were so intense.
~oncentration
He was also surprised that the students were so
attentive and that the posttest results were such an improvement over
the pretest results.
The students displayed a special interest in
part J, which dealt with the algoirthm and tests used to discover TB.
They dealt much better with questions pertaining to positive skin
test results and what scars or cavities indicate on a X-ray, than the
66
FIGURE 4
RELATIONSHIP OF SCORES FROM FINAL
GROUP TESTING WITH REVISED PRE/POST TEST
20
19
18
17
16
s,...
\..
0
R
E
s
15
14
13
12
11
10
9
8
7
6
54
3l
2
1
0
PRE
POST
* Each 1i ne
represents a student
** Represents
students
b10
67
Table 5
Achi everncnt of Beha v·i ora 1 Objectives for
Final Group Testing with Revised Pretest and Posttest
Behavioral Objectives
Corresponding
Questions.
r:
----l:
2
3
4
5
Group IV (22)
73%
100%
82%
100%
5
91%
6
64·%
7
86%
8
77%
9
86%
10
77%
11
73%
12
73~~
13
73%
14
91%
15
77%
16
68%
17
59%
18
68%
e
20
95% .
95%
1
,
63
preliminary group testing (see Table 5. questions 16. 17, and 18).
This score improvement may have been due to a more valid posttest.
The mode of medication was discussed and the
not always necessary when TB is detected.
~ct
that confinement is
The students worked
diligently to mark pretest and posttest scores and were pleased to
discover a significant improvement in their scores.
It is encouraging to think that the information learned or
reinforced from the program might be passed on to the families of the
students, the population which health education rarely reaches.
There
is a chance that these students might eagerly distribute information
about tuberculosis and the possibilities of some change in health
behavior due to informed decision making.
Chapter VI
SUMMARY AND RECOMMENDATIONS
~ummary
The purpose of this project was to develop and test a programmed
instructional booklet to be utilized as an individualized program
approach to tuberculosis education.
The program was developed in a
Los Angeles Health Clinic utilizing pertinent information needed by
the target population.
Tuberculosis control in Los Angeles County
has become increasingly difficult to achieve due to the influx of
immigrants from t'lexico and abroad.
A tuberculosis education program
appears to be of critical need in this area.
Specialists in the field, including physicians, public health
nurses, health education and community health workers were observed
and
intervie~tJed
target group.
to discover the most vital information needed by the
The program was then administered individually to
subject-matter specialists, or the tuberculosis control staff at the
clinic, for technical and subject-matter editing.
The booklet was written, in the linear style, in accordance with
principles on which programmed learning was originally founded.
Individual try-out of the program was administered to high school
students, and the program was revised unti 1 it was success fully
completed by two individuals in succession.
Three high school
classes from the Paramount Unified School District participated in the
preliminary group testing of the program in three, fifty minute time
70
periods.
A fourth class participated in a final group testing in an
additional fifty minute time period.
Ctiterion for selection of this
target population included the increased incidence of tuberculosis
found in that region, the lower-middle income bracket of mixed cultural
backgrounds, and ability to read, write and understand English.
In the preliminary group testing, the Student's t test calculated
for both paired and unpaired samples found the differences between the
pretest and posttest scores to be statistically significant.
There
was an approximate two-point improvement on the posttest scores; this
degree of improvement questioned the ability of the test to assess
what the program taught.
Evaluation of the behavioral objectives
indicated that most of the students were able to achieve the majority
of the behavioral objectives.
The students were attentive and showed
a sincere interest in the program.
A final group testing, with a revised pretest and posttest,
showed an increased degree of improvement in pretest and posttest
means, 10.5, 16.1, respectively.
This indicated a more effective
t.es ti ng instrument and reinforcement of information dealt with in
the program.
The Student's t test for both paired and unpaired
samples found the difference between the pretest and post. test scores
to be statistically significant.
The majority of the behavioral
objectives were to be achieved by more students.
The researcher
interviewed the students and it was revealed that they found the
program clever in its approach and the content absorbing and easy-tograsp.
The stjdents took a sincere interest in tuberculosis and its
manifestations.
-71
___
__
Recommendation:;
..._
,
This program can also be adapted to other health education
settings, such as clinics, hospitals, factories, community centers, or
any place where people might gather to be tested or treated.
A more
sophisticated version including medical terminology and treatment
alternatives might be utilized in nursing programs at Junior Colleges
or continuing nurse education classes.
The program can be translated
to adapt to populations of various cultural backgrounds and langudges.
It is also recommended that this program be used in conjunction
with other teaching approaches:
class discussions, one-on-one
discussions, audio-visual presentations, or as an introduction to a
tuberculosis unit in a classroom.
According to Downing (13), the
by-product of programming is better conventional teaching.
More
emphasis is given to stated objectives and to pupil involvement, where
better learning and informative decision making is the outcome.
72
BIBLIOGRAPHY
I•
American Lung l\s soc i a ti on. Intro_~_ycti on
6th edition, pp. 34-t.'lS, c. 1975.
2.
Becker, Jv1arsha1l, H., (ed.), The Health BeliE•f Model and Personal
He a Hh Behavior·, ~ea l_~i~S:~.t i or!.J12n.9..9.!'a~~.' Society fo t'
Pub"iic Health E.ducation, Vol. 2, No. 4, 1974.
3.
Bryan, Charles s. M.D., Unread Tuberculin Tests, lf.\MI\, Vol. 244,
No. ·10. pg. "1'126, Sept. 5, 1980.
4.
Benenson, AbramS. (ed.). Control of Communicable Diseases in Man.
c. 1970 by .APHA, Inc.-:-·nfth-prinfing:-1973, 316 pages.
5.
Callender·, Patrician. Programm~-!_Lear.!!..ill.q_:__Its _Qeve_}opm~nt Jn9_
Structure, London: Longman, 1969, 120 pages.
6.
Center for Disease Control ~nnual Summary 1979: reported morbidity and mortality in the United States, t•lor·bidity and
Mot~tality vJeekly___R_~rt_ 19BO~
28 {54).------.---
7
'
.
t.2_~yng___Di.~~~·~'
Clark, Constance Mary B.S.N., M.S. and Bayley, E1izabeth ~Jc.lk
B.S.N., M.S., Evaluation of the Use of Programmed Instructio~
for Patients t~aintained on \·Jar·farin Therapy, f\meric:~n
.Journal of Public Health. 62:8, pp. 1135·~1139:-·Augtist 1972.
8.
County of Los Angeles. Department of Hea·i th Services. Commun-ity
Health Serv·i ces. ~a ntoux J§_s tLfo r l\qe Grt?_U,Q_0-1~__j~a r·s
los Angeles County b~egions and Di~~?79_End ·1210.
Regional vJorksheet, H--1175. Los Angeles, November 1973.
9.
Crowder, Norman A.• Programmed Instruction compared with
Automated Instruction. Trends in Proqrammed Instruction,·
Ofiesh, Gabriel D., Ed.---o.-, and-Meierltenry;-1fesley G.···Ph.D. editors; (papers from the first annual convention of
the Na tiona 1 Society fo1~ P1·ogrammed Instruction, Department
of /\ud·iovisual Instruct·ion, National Education 1\ssociation
and National Society for Programmed Instruction, c. 1964.)
10.
Curry, Francis J.,M.D.,
11.
Deterline, William A. An Introduction to Programmed
p,~en·~ice Han, Inc~962.-·--
F.C.C~P., Encounters in Training Clinic
Suppcrt Staff, Chest, Vol. 68, No. 3, September 1975,
supplemental. ----
I~~_!.!:.::.!.~tion.
73
12.
• Practical Problems in Program Production, The Sixty·-·-sixth Year Book of the National Society for the Study of
Education, Part II., ed-.-Philc-:-Tange (Chi.cago: The
University of Chicago Press, 1967).
13.
Downing, Carlton B., Programmed Instruction in Perspective,
Trends in Pr·ogrammed Instruction, ed. Gabriel D. Ofiesh Ed.D.
and Wesley G. Meierhenry Ph.D. (papers. from the fi-rst ~nnual
convention of the National Society for Programmed Instruction
Department of Audiovisual Instruction, National Education
As~;ociation and National Society for Progt~ammed Instruction,
c. 1964.)
14.
Fusco, Gene C., Programmed Self-Instruction: Possibilities ar.d
Limitation, Programmed Learning, ed. W.I. Smith and J.W.
~1oor·e, Van Nostrand, '1962. ·
15.
G·reen, Edward J. The Learning Process and Programmed
Holt, Rinehart and Winston, 1963, 228 pages.
16.
Gropper, George L. Diagnosis and Revision in the Development of
Instructional Materials. Educational Technology Publ icatfons
i 975.
InstJ~uction.
.
17.
Hochbaum, Godfrey M., Health Behavior.
1970.
'fI P0
, Public Participation in Medical Screening Programs:
--ASo-ciopsychologica1 Study, Public Health Service
Publication, no. 572. (Washington: U.S. Government
Printing Office, 1958.)
o
Wadsworth Publishing Co.,
19.
Horabi n, Ivan, Algorithms: Improving Human Performance, ..8.
Re~~.Q.rch Quarterly, t~arch 1972, pp. 28-47.
20.
Hughes, David C., arid Reid, Neil A., Programmed Learning and
Conventional Teaching, Educational Research, vol. 18, no. 1
November 1975, pp. 54-61.
2L
Kearns, Thomas J. and Russo, Pearl K., The Control and
Eradication of Tuberculosis, The New England Journal of
Medicine, Oct. 2, 1980, pp. 812-814.
Krishnamurty, G. B., and Machiraju, N. R., Instructional Systems
Design - an application of the programming process.
Department of Health Sciences, California State University,
Nortnddge. (mimeographed) c. U.S.A. 1975
23.
Leedhamj J. and Unwin D. Programmed Learning in the Schools.
Longmans, '1965.
---
74 •
24.
Leith, G. 0., Peel, E. A. and Curr. W. A. A Handbook of
.P..r.a.g.r.amrne..d._l_aa_min.g. . Uni ve r s i t y o f Bi rm i ngham , 1966 •
25.
Lindvall, C. M. and Bolvin, John 0., Programmed Instruction in
the Schools: An Application of Programming Principles in
1
Ind·iv·idua11y Prescribed Instruction, 1 The Six_!l:sixtb_
Ye~r Boo~__Q.f._!_be Na :!:i o_na 1 Society for the Stu~_f Educa ti O!l.•
Part II., ed. Phil C. Lange (Chicago: The University of
Chicago Press, 1967}.
26.
Los A~e}~s Herald Exa~iner~. (interview with Shirley Fannin,
Communicable Disease Control Chief for Los Angeles County),
\~ednesday,
Apr"il 12, 1978, p.
A~l7.
2l.
Lo~ 1'\ng~_l?S
28.
Los
29.
Lumsdaine, A. A. and Glaser, Robert, ed. Teaching Machines and
Programmed Le~rni~- A Source Book, (\tjashington, D.C.:
Department of Audio-Visual Instruction, National Education
Association, 1960).
30.
Machiraju, Nagabhushan Rao, Jlpplicatio_Q_of_lndivJdual Try-out
to Health Questionnaire Revision. Masters Thesis, San
Fernando Valley State College, June 1971, pp. 1-43.
31.
Magdarz, E. F., Pre-testing and Branching, NSPI Journal, vol. X,
no. 3, Apri"l 1971, pp. 12-13.
32.
Mager, R. Preparing Objectives for Programmed Instruction.
San Francisco: Fearon Publishers, 1961.
33.
Massachusetts Department of Public Health, Future of a Childcentered Tuberculosis Testing Pr·ogram. ~5!~....l!!.9_}_9.nd _you rnal
of ~edicine_, August 1972; 287(8), pp. 409-410.
34.
Maylock, Robert L., and McGregor, Rob Roy, Diagnosis, Prevention
and Early Therapy of Tuberculosis, D1sease a Month, t~ay 1976.
35.
McCianahan, Marilyn Ricae, A Blood Pressure Screenin_g Program
in a Blue Collar Union, Graduate Project, California State
Un1vt~l~sify, Northridge, June, 1977.
36.
Meierhenry, Wesley C., A Point of Transition, Trends in Prograrrme?
Instruction, ed. Gabriel D. Ofiesh, Ed.D. and Wesley G.
Meier·henry-Ph.D. (papers from the first annua1 convention
Ti.!!_les, Tuberculosis Problem in Los f,ngel es Is vJorst
of Cities in U.S. Report Says (information from report of
health services committee of 1979-80 Los Angeles County Grand
Jury), Wednesday, Sept. 3, 1980. Part 2, p. 8.
Angel~s
Times, Immigrant Tide Brings Public Health Concern,
Monday, July 23, 1979. Part 1, p. 1;
--75
of the National Society for Progra~med Instruction,
Department of Audiovisua·l Instruction, National Education
Association and Nati ona 1 Soc i et)' for Programmed Instruction,
c. 1964.
37.
Mush1in, Irving M. A.• and Collins, John Gary M.B.A., The
Tuberculosis Patient in the Central Harlem District of New
York City, American Journal ofPublic Health, Sept. 1975,
vol. 65, no-.9-,-pp. 959-966.
-·-----·--·
38.
Myers, Arthur J., Taper·ing Off of Tuberculosis Among the Elderly
American Journal of Public Health, Nov. 1976, val. 66, no.
11, pp-:licn :11otr:---------
39.
Orr, Christine Janet, Alternat-ives for Teenagers Relative to
Pr_egnancy, A Programnie-dlnstruction Ma-n-uaf, Graduate
Project, Cal'ifornia State University, Northr-idge, June 1976.
40.
Pressey, Sidney L., Some Perspectives and Major Problems
Rega1·ding "Teacl·dng Machines," Teaching Machines and
?rogrammed Learning - A Source Book, A.A. Lumsdaine and
Robert Glaser, ed., (Washington, D.C.: Department of
Audiovisual Instruction, National Education Association,
1960) pp. 497-505.
41.
Rosenberg, Stanley G., Patient Education Leads to Better Care
for Heart Patients, HSMA. {Health Services and Mental
Health Administr-ation)Health RepoFts, vo1. 86, no. 9,
September 1971, pp. 793-802.
42.
Shettel, Harris H. and Hughes, Ruth S., Design and Development of
a Self-Instructional Programmed Course to Train Occupational
Health Nurses to Provide In-Plant Employee Mental Health
Care, Instructional Technology in Medical Education, Jerome
Lysaught, ed. ( Proceed1 ngs of the Fifth Rocheste-r-Conference
on Self-Instruction in Medical Education.) April 1-3, 1971,
pp. 181-202.
43.
U.S. Department of Health, Education and Welfare, Public HeaHh
Service, Infectious Disease Research Tuberculosis, Medical
Newsletter, National-Institute of Health, prepared -by the
5ffice of Allergy and Infectious Diseases, Bethesda,
Maryland 20014. May 1975.
44.
Vital Health Statistics Data from the National Vital
Statistics System. Washington: Gc)vernment Printing Office.
76
45.
I
'
~hite,
M.S. Major General, USAF, Programmed Instruction in
Medica) Education, Trends in~rammed Instruction, ed.
Gabriel D. Ofies~ Ed.O. and Wesley G. Meierhenry Ph.D.
(papers from the first annual convention of the National
Society for Progr-ammed Instruction, Department of Audiovisual
Instruction. National Education Associatian and National
Society for Programmed Instruction), c. 1964.
APPENDIX
77
78
!\PPENDIX A
PRELIMINARY PRETEST AND POSTTEST
79
Pre-test and Post-·test
This test will find out how much you know about TB.
choice - X correct answer for each question:
l.
A person can get TB by
a.
talking on the telephone to someone with TB
b.
breathing in air containing TB germs
c . _ _being vJi th a friend vJhose unc 1e has TB
2.
A person with active TB can spread the germs by
·=-
a.
b
c. _
Multiple
sneezing, coughing or speaking
writing a 1 etter and sending it to someone
_co.l1ing someone on the telephone
3.
A person may not get TB if he
a.
takes two aspirin and goes to bed
b.---jogs around the block
c.~ has good body resistance (or ability to fight off disease)
4.
A positive tuberculin test means
a.
·the TB germ is active in the body
b.---the TB germ is dormant in the bodv
c.--a false reaction, active TB is pr·esent. or dormant TB
---is present
5.
TB germs attack 1 iving tissue and their favorite place of attack
is the
a.
kidney
b.--, ungs
c.--brain
6.
TB spreads iri the body when sleeping (or dormant) T8
a.
breaks out of the walls that have controlled them
b.
enters the victim by someone sneezing
c.
enters the victim by someone coughing
7.
Does a person with TB have obvious symptoms?
a.
ves
b.--no
c.--sometimes
8.
The following tests are used to detect TB germs in the body
a.
tuberculin skin test, blood pressure tests
b.--tuberculin skin test, X-rays, sputum tests
c.
X-rays, endurance tests, tubercul·in skin tests
80
9.
10.
A chest X-ray
means
a.
TB germ
b.=._you can
c .__you had
indicates
~E_Y'~-
or
cavi_~
in the lungs; this
may be present and is either dormant or active
v1ait av'lhile before seeking treatment
c. hi cken pox when you were five years old
A person who has symptoms of TB must take medication
a.
until a friend says that he looks healthy enough
b. ---unti 1 he fee 1s heal thy
c.---for the fu'lly prescr-ibed course of time