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Volume 1: No. 3, July 2004
ORIGINAL RESEARCH
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| Figure 1. Act in Time poster developed by the National Institutes of Health to provide information on warning signs of heart attack and importance of calling 911 for emergency medical services. |
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Based on the original content of the Rapid Early Action for Coronary Treatment (REACT) research program developed by the National Institutes of Health (NIH), the Act in Time campaign provides information on the warning signs of heart attack and the importance of calling 911 for emergency medical services (http://www.nhlbi.nih.gov/ actintime/) (14). Our adaptation of Act in Time included several components designed specifically for a workplace intervention. First, all employees at the three sites received a one-time distribution of Act in Time brochures and wallet cards with their pay stubs (15). Second, Act in Time posters were placed on bulletin boards, in hallways, and in all bathrooms at each work site during the six-week test period (Figure 1). Third, also for six weeks, all employees received weekly e-mail messages and contest questions addressing the signs and symptoms of heart attack. Participants who answered the questions correctly were included in a weekly drawing for prizes (e.g., pedometers). Approximately one third of all employees participated in these weekly e-mail contests (participation ranged from 29% to 36%). The total estimated cost for intervention materials and staff time was $1037 (mean cost per employee = $1.98).
To evaluate this intervention, we conducted baseline and follow-up telephone surveys. The baseline survey took place over a two-week period in April 2003, and attempts were made to contact all 523 employees at each of the three sites. Respondents were asked a series of seven standardized questions about the signs and symptoms of heart attack from the Behavioral Risk Factor Surveillance System survey (Table 1) (16). The follow-up telephone survey was administered in July 2003 to the 401 employees responding to the initial baseline survey. The participants again were asked questions about the signs and symptoms of heart attack and the need to use 911. Respondents were also asked the following questions to assess their awareness of intervention activities:
Data analyses were completed using SPSS version 10.0 statistical analysis software (Chicago, Ill). Independent t-tests and Pearson chi-square tests were used to compare the characteristics of respondents to the baseline and follow-up surveys. Pearson chi-square tests were used to assess differences in the proportion of respondents correctly identifying each individual sign and symptom of heart attack and the proportion identifying five or more signs and symptoms of heart attack at baseline compared to follow-up. Pearson chi-square tests were also used to assess the differences in the proportion of respondents correctly answering the question regarding the need to use 911 at baseline compared to follow-up.
Of the 523 employees, 401 (77%) completed the baseline survey. Of these 401 respondents, 337 (84%) completed the follow-up survey. There were no statistically significant differences in age between baseline and follow-up: baseline respondent mean age was 46.4 years (SD 9.3); follow-up respondent mean age was 46.6 years (SD 8.9). Nor were there statistically significantly differences in sex between baseline and follow-up: 71% of baseline respondents were women, and 72% of follow-up respondents were women (data not shown). Similarly, there were no differences in the proportion of respondents from each of the three work sites at baseline or follow-up (site one, 58% responded at baseline, 57% at follow-up; site two, 38% at baseline, 40% at follow-up; site three, 4% at baseline, 4% at follow-up).
Awareness of selected signs and symptoms increased significantly among employees from baseline to follow-up: pain or discomfort in the jaw, neck, or back (awareness increased from 69% to 91%); and feeling weak, light-headed, or faint (awareness increased from 79% to 89%) (Table 2). Awareness of chest pain, pain or discomfort in the arms or shoulders, and shortness of breath was greater than 90% at baseline and did not increase significantly at follow-up. The proportion of respondents who correctly reported that "sudden trouble seeing in one or both eyes" was not a sign or symptom of heart attack did not change significantly from baseline to follow-up. At baseline, 69% of respondents reported five or more of the signs and symptoms of heart attack correctly, and this increased to 89% at follow-up. Additionally, awareness of the need to use 911 emergency telephone services increased significantly from 84% to 90% between baseline and follow-up.
At baseline, women were more likely than men to report that pain or discomfort in the jaw, neck, or back was symptomatic for AMI (72% of women, 61% of men, P = .02). This difference in response between men and women persisted at follow-up (94% of women, 84% of men, P = .006). There were no significant differences in awareness of other AMI signs and symptoms or the need to use 911 emergency telephone services by sex at baseline or follow-up (data not shown). Employees 45 years and older were more likely to recognize pain or discomfort in the jaw, neck, or back compared with younger employees at baseline (74% of older employees, 61% of younger employees, P = .008). Younger employees were more likely to report feeling weak, light-headed, or faint as an AMI symptom compared with older employees at baseline (87% of younger employees, 75% of older employees, P = .003). There were no other statistically significant differences for AMI signs and symptom awareness or the need to use 911 between younger and older employees at baseline (data not shown). At follow-up, younger employees had a higher level of awareness of the need to use 911 services compared with older employees (96% of younger employees, 87% of older employees, P = .006). There were no other statistically significant differences in the awareness of AMI signs and symptoms between younger and older employees at follow-up (data not shown).
The intervention was equally effective in increasing overall awareness of signs and symptoms of heart attack among men (14 percentage point increase, P = .02) and women (23 percentage point increase, P < .001) as well as younger (22 percentage point increase, P < .001) and older (20 percentage point increase, P < .001) employees from baseline to follow-up (Figure 2). Awareness of the need to use 911 emergency telephone services increased significantly in women (9 percentage point increase, P = .005) and younger employees (11 percentage point increase, P = .004), but did not change significantly in men (1 percentage point decrease, P = .97) or older employees (3 percentage point increase, P = .34) from baseline to follow-up (Figure 3).
Figure 2.
Awareness among Montana state health department employees of five or more heart attack signs and symptoms at baseline and follow-up, by sex and by
age, 2003.
(A text description of this chart is also
available.)
Figure 3.
Awareness among Montana state health department employees of need to use 911 emergency telephone services if someone is
having a heart attack or stroke at baseline and follow-up, by sex and by age, 2003.
(A text description of this chart is also
available.)
Results of survey questions designed to assess participant awareness of intervention activities are presented in Table 3.
This low-cost workplace intervention was effective in increasing employee awareness of the signs and symptoms of a heart attack and the need to use 911 emergency telephone services. The intervention was equally effective in increasing awareness in both older and younger employees and had a slightly greater impact on women than men. Interestingly, the effect on increasing awareness of the need to use 911 services was found only in women and younger employees and not in men or older employees.
We were unable to identify other similar workplace intervention studies for comparison. At baseline, state health department employees were slightly more aware of signs and symptoms of heart attack and the need to use 911 compared to Montana adults overall. In a 2001 survey of Montana adults, only 60% were aware that pain or discomfort in the jaw, neck, or back were signs and symptoms of a heart attack, and 74% were aware that feeling weak, light-headed, or faint were signs and symptoms of a heart attack (17). More than 90% of adult Montanans in 2001 were aware of the signs and symptoms of chest pain, pain or discomfort in the arms or shoulders, and shortness of breath, and 82% knew to call 911 if someone is having a heart attack or stroke.
Large community intervention studies using mass media campaigns have had mixed effects on heart attack signs and symptoms awareness, use of emergency medical services, and reduction in patient delay in receiving services for persons experiencing AMI (14,18-24). A recent review of the literature provides a number of strategies for improving future community-based efforts to reduce patient delay times. These strategies include targeting high-risk groups; addressing emotional (e.g., denial) and social (e.g., inclusion of family members in education programs) issues; emphasizing cognitive aspects such as the physiologic consequences of delay; educating individuals on how to evaluate their symptoms; and developing messages specific to men and women (25). Integrating workplace awareness campaigns within larger community-based efforts may be an effective approach for reaching family and friends of persons at high risk for AMI. State health departments are attractive workplaces to pilot such interventions.
This study, however, has a number of limitations. First, all MT DPHHS employees in the three sites were exposed to the intervention, and a comparison group not receiving the intervention was not used. Other factors may have increased employee awareness outside of the intervention, although we believe that this is unlikely. Second, we used telephone surveys of employees to evaluate this intervention, and respondents were asked "aided" questions to indicate which of the possible symptoms described by the interviewer were symptoms of a heart attack. Previous studies using unaided, open-ended questions have found lower levels of heart attack awareness (26). Aided questions may overestimate awareness of signs and symptoms, and unaided questions may underestimate awareness. Third, the baseline telephone survey itself may have increased respondent awareness of the signs and symptoms. Fourth, the follow-up telephone survey took place during the summer months (July and August) and resulted in a smaller sample size (n = 337). The lack of response was due mostly to contact with answering machines, no answers, or no eligible respondent at telephone number (15%). Finally, we were not able to quantify the relative contributions of each of the intervention activities to increases in awareness.
Our findings show that this low-cost intervention can be easily replicated in other workplaces. The State of Montana will promote this type of intervention at work sites through the newly convened Governor's Council on Worklife Wellness. Increased awareness of the signs and symptoms of heart attack and the need to use 911 are important for individuals at high risk of AMI as well as family members and friends who are often the first people to have contact with persons potentially experiencing AMI.
This project was supported through a cooperative agreement (U50/CCU821287-02) with the Centers for Disease Control and Prevention (CDC) Cardiovascular Health Branch. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. We would like to thank and acknowledge Linda Priest and the staff members of Northwest Resource Consultants for their expertise and work on the telephone surveys. We also thank Jason Swant and Linda Schofield from the Montana Cardiovascular Health Program for their assistance with this project.
Corresponding Author: Todd S. Harwell, MPH, Montana Department of Public Health and Human Services, Cogswell Building, C-317, PO Box 202951, Helena, MT 59620-2951. Telephone: 406-444-1437. E-mail: tharwell@state.mt.us.
Author Affiliations: Crystelle C. Fogle, RD, MS, MBA, Carrie S. Oser, MPH, Lynda L. Blades, MPH, Steven D. Helgerson, MD, MPH, Dorothy Gohdes, MD, Michael R. Spence, MD, MPH, Drew E. Dawson, Montana Department of Public Health and Human Services, Helena, Mont.
*URLs for nonfederal organizations are provided solely as a service to our users. URLs do not constitute an endorsement of any organization by CDC or the federal government, and none should be inferred. CDC is not responsible for the content of Web pages found at these URLs.
Table 1.
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aCenters for Disease Control and Prevention (16).
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The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
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