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HEALTH EDUCATION RESEARCH
Theory & Practice
Vol.15 no.3 2000
Pages 317–326
The ‘Heart Attack Survival Kit’ project: an intervention
designed to increase seniors’ intentions to respond
appropriately to symptoms of acute myocardial
infarction
Hendrika Meischke, Mickey Eisenberg1, Sharon Schaeffer2 and
Daniel K. Henwood2
Abstract
The purpose of this study was to test the effectiveness of a ‘Heart Attack Survival Kit’, disseminated via two different delivery methods,
designed to increase seniors’ intentions to call
911 and take an aspirin in response to a cardiac
emergency. Twelve-hundred seniors were randomly assigned to (1) receiving a Kit via a
home visit by an Emergency Medical Technician
(EMT), (2) receiving a Kit via direct mail or (3) a
control group. All participants were telephoned
and asked how they would respond to a cardiac
emergency. Results showed that respondents in
the intervention group (EMT and direct mail
group combined) reported a greater frequency
of the recommended coping response to AMI
(39%) than respondents in the control group
(10%) (P ⬍ 0.000). Within intervention groups,
47% in the EMT group and 30% in the direct
mail group (P ⬍ 0.000) reported intentions to
take the appropriate response to AMI. The
results suggest that a Heart Attack Survival
Kit, especially when delivered door-to-door by
EMTs, can be an effective way of educating
seniors about cardiac emergencies.
Introduction
This year 1 500 000 Americans will have a new
or recurrent acute myocardial infarction (AMI) and
Department of Health Services and 1Department of
Medicine, University of Washington, Seattle, WA 981956123, and 2King County Emergency Medical Services
Division, Seattle, WA 98104-4039, USA
© Oxford University Press 2000
about one-third of them will die (American Heart
Association, 1996). The two most critical actions
a patient can take when faced with AMI symptoms
are: (1) seeking prompt medical care, preferably
by calling 911, so therapy can begin soon after
onset of AMI and (2) taking an aspirin at onset of
a heart attack. These recommendations have been
endorsed by the National Heart, Lung and Blood
Institute as well as the American Heart Association
(National Institute of Health, 1997; Hennekens
et al., 1998). However, many AMI patients do not
follow these life-saving actions. This paper reports
on the results of an intervention designed to
increase intentions among seniors 65 years and
older to respond promptly and appropriately to
symptoms of AMI.
Seeking prompt medical care for
symptoms of AMI
Thrombolytic therapy can alter the course of AMI,
reducing morbidity and mortality (Yusuf et al.,
1985; Marder and Sherry, 1988). However, its
efficacy decreases with increasing time between
symptom onset and treatment (Second International
Study of Infarct Survival Collaborative Group,
1988). Patient delay accounts for most of the delay
in receiving thrombolytic therapy (Dracup et al.,
1995). Quick use of emergency medical services
(EMS) for AMI symptoms can dramatically shorten
overall prehospital delay time (Grim et al., 1989;
Weaver et al., 1990). Unfortunately, over half of
all patients admitted to the hospital for possible
AMI do not call 911 (Ho, 1991).
Small- and large-scale interventions have been
conducted to reduce prehospital delay time for
symptoms of AMI and increase utilization of the
317
H. Meischke et al.
emergency medical services for AMI patients (Ho
et al., 1989; Herlitz et al., 1992; Blohm et al.,
1994, 1996; Eppler et al., 1994; Gaspoz et al.,
1996; Meischke et al., 1997). These interventions
have been only moderately successful. It appears
from these and other studies that it is inherently
difficult to persuade people to take a seemingly
‘drastic’ action (i.e. call 911) for a seemingly nonemergent situation (i.e. chest pain). Focus group
research with AMI patients showed that people
prefer to wait and see before taking actions which
could be embarrassing to them (Finnegan et al.,
submitted). It seems plausible that one way to
‘legitimize’ calling 911 for an often ambiguous
situation is to have the people who are most
immediately involved in people’s handling of emergencies, i.e. the local firefighters, persuade people
that calling 911 is the best action to take in response
to AMI symptoms.
Aspirin use and AMI
Experimental and clinical investigations have
shown that early administration of aspirin during
an AMI significantly reduces AMI mortality
(Fuster et al., 1993; Hennekens et al., 1994; Collins
et al., 1997). There are important reasons why
patients should be encouraged to take an aspirin
when they first experience symptoms of AMI.
First, the sooner the aspirin is given, the more
quickly the drug will have treatment benefits.
Second, aspirin as a treatment for evolving AMI
is still under-administered by health care providers
even though ineligibility criteria are few (Eisenberg
and Topol, 1996; Hennekens et al., 1998). For these
reasons, patients’ self-administration of aspirin for
symptoms of AMI may greatly benefit the patient
when the aspirin ingestion is part of a ‘prompt’
coping response, including calling 911.
In this project the objective was to test an
intervention designed to increase seniors’ intentions to (1) call 911 and (2) take an aspirin in
response to AMI symptoms.
Theoretical foundation of intervention
The conceptual foundation for the intervention was
based on Leventhal’s self-regulatory model of
318
health and illness (Leventhal et al., 1984). According to this model a person assesses a symptom
episode based on general knowledge as well as
personal experience with illness episodes. The
actual heart emergency is the initiating factor in
the cascade of events in the model. Regardless of
the timing or nature of this recognition, the person
will do two things: react emotionally to the recognition and develop an internal understanding or
mental representation of what the symptoms that
s/he is experiencing mean to her. Results from
focus group discussions with AMI patients revealed
that fear and denial were frequently experienced
during the cardiac emergency (Finnegan et al.,
submitted). This mental representation will then
influence any future actions, such as taking aspirin,
calling 911, asking someone for advice, denying
the importance of the problem and/or avoiding
thinking about one’s personal risk for a heart
attack. Research shows that patients who believed
that their symptoms were cardiac in origin sought
medical care faster and used the EMS system
more often than those who did not believe their
symptoms were cardiac in origin (Johnson and
King, 1995; Meischke et al., 1995).
Shortening the cognitive and behavioral processes suggested by the self-regulatory model, and
changing the kind of coping strategies heart attack
patients apply during a heart emergency, could
mean the difference between life and death. Educating older adults about the importance of being
‘prepared’ for this emergency (and giving them
the tools to be prepared) will likely aid people in
accurately assessing the representation of the health
threat and reducing lengthy and unproductive coping strategies and appraisals. This ‘preparedness’
will be accomplished by the home delivery of a
‘Heart Attack Survival Kit’, which includes:
(1) Eye-catching design and adhesive strips for
‘permanent’ placement in the home.
(2) List of the warning signs of AMI.
(3) Strong recommendation to call 911.
(4) Strong recommendation to take an aspirin for
chest pain.
(5) One 325 mg uncoated adult aspirin.
The ‘Heart Attack Survival Kit’ project
(6) Basic steps of CPR.
(7) Space for medications/allergies and important
phone numbers.
A home visit by an emergency medical technician was believed to provide the best opportunity
for educating seniors about the importance of
calling 911 and taking an aspirin in response to
AMI symptoms.
Development of the Heart Attack Survival
Kit
The Heart Attack Survival Kit was developed over
a 1-year period with the help of a commercial
marketing company. Several iterations of the Kit
were tested with groups of seniors age 65 and
older until the Kit was designed in a way that
appeared useful and attractive to the target audience. Furthermore, the results of the focus groups
suggested that seniors preferred direct mail, doctor’s offices or pharmacies for dissemination of
the Kit. Although it was clear from the discussions
with the focus group participants that firefighters
were perceived as highly credible sources of health
information, many seniors had reservations about
a personal visit of any kind. Most believed they
would not be home and if they were home they
probably would not answer the door if they believed
a stranger was calling. This prompted us to test
two delivery methods: a home visit by an EMT
and direct mail.
Hypotheses
We hypothesized that, compared to seniors who
did not receive the Kit, those who did receive the
Kit would more frequently report intentions to
engage in the two recommended coping strategies
in response to AMI symptoms: calling 911 and
ingesting an aspirin. Second, we hypothesized that
seniors randomized to the EMT-delivery group
would be more likely to report intentions to engage
in the recommended coping strategies than seniors
randomized to the direct mail group. We also
hypothesized that seniors who reported that they
had actually received the Kit from a local firefighter
would be (1) more likely to report intentions to
engage in the recommended coping strategies and
(2) more likely to have placed the kit in a visible
place in their home than seniors who reported they
had received the Kit via direct mail. Additionally,
we investigated the relationship between intervention status (e.g. EMT-delivery, direct mail or control
group) and the recommended coping strategies
while accounting for demographic variables such
as age, gender and education.
Procedure
In the spring of 1998, 1200 addresses and names
of individuals age 65 years and older in the Kent,
Washington area were obtained from a commercial
mailing list. These 1200 individuals were randomly
assigned to one of three groups: EMT door-todoor-delivery group, direct mail group and control
group (no Kit). In the EMT door-to-door-delivery
group, seniors received a passive consent letter in
the mail informing them that a Kent firefighter
would be stopping by in the near future to give
out a valuable Heart Attack Survival Kit. All
firefighters are trained as EMTs in King County,
Washington. Twelve percent of participants in the
EMT-delivery group mailed in a postcard indicating
they did NOT want a visit by a firefighter, leaving
352 people available for a door-to-door contact.
Firefighters filled out tracking forms indicating the
type of contact made, the duration of the visit and
the outcome of the visit. Firefighters had a script
to guide their interactions but they were allowed
to answer questions regarding the Kit’s contents.
They were instructed to hang the Kit (which was
placed in a plastic doorhanger bag) on the doorknob
if nobody opened the door at the specific household.
In the direct mail intervention seniors received the
Heart Attack Survival Kit and a letter explaining
the purpose of the Kit through the mail. The control
group did not receive any intervention. This study
was reviewed and approved by the Internal Review
Board (IRB) of the University of Washington.
Three firefighters from the Kent fire department
completed 350 household contacts during day time
hours (9 a.m. to 5 p.m.) over a 2-week period.
From the tracking forms it appeared that (210)
60% of the 350 households that were approached
by a firefighter had resulted in a contact with an
319
H. Meischke et al.
Fig. 1. Flow chart of study participants. *All 400 participants in each group were contacted by telephone regardless of intervention
delivery status.
eligible study participant (i.e. person on mailing
list or spouse). In 38% of cases firefighters put the
Kit on the doorknob and in 2% of cases the
address on the list was wrong or no eligible study
participant was living at that address. All 1200
individuals were contacted by phone between 1
and 6 weeks after having the intervention, by one
of five interviewers who were blinded to study
interventions and hypotheses. (See Figure 1 for
flow chart of study participants.)
Survey instrument
The telephone survey included questions regarding
intentions to cope in response to symptoms of
AMI, exposure and evaluation of the Heart Attack
Survival Kit.
To assess intentions to respond in a prompt and
appropriate manner, interviewees were asked two
320
open-ended questions: ‘If you experienced symptoms of a heart attack, what would be the first
thing you would do?’ and ‘What would be the
second thing you would do?’. Answers were coded
as (1) calling 911, (2) taking aspirin and (3) other.
To make sure that we would obtain information
from all participants on intentions to use the
recommended coping strategies, interviewees were
also asked to rate (‘1’ very likely, ‘2’ somewhat
likely, ‘3’ somewhat unlikely’ and ‘4’ not at all
likely) the following statements: ‘How likely is it
that you would call 911 if you were experiencing
symptoms of a heart attack?’ and ‘How likely is
it that you would take an aspirin if you were
experiencing symptoms of a heart attack?’.
To assess exposure to the Heart Attack Survival
Kit, respondents were asked: ‘Do you remember
receiving a red flyer in the shape of a doorhanger
The ‘Heart Attack Survival Kit’ project
in the past month telling you how to respond to
symptoms of a heart attack?’. Regardless of the
response respondents were asked: ‘This flyer/doorhanger had the name Heart Attack Survival Kit
written on the front. Do you remember receiving
such a Kit?’. If respondents answered affirmatively
they were asked: ‘How did you receive this Kit?’.
To assess attention to and evaluation of the
Heart Attack Survival Kit, we asked respondents
who reported that they had received the Kit the
following questions: (1) ‘Do you have the Heart
Attack Survival Kit in your home?’. If no, ‘What
did you do with it?’. If yes, ‘If you needed it right
now would you be able to find the Heart Attack
Survival Kit?’. Subsequently respondents were
asked where they had placed the Kit and what
they remembered about the content of the Kit.
They were also asked if they liked the Kit and if
they thought the Kit was useful or upsetting. The
last part of the survey included questions about
demographic characteristics such as age, gender,
income and educational level.
Methods
Of the 1200 follow-up phone calls, 705 were
completed interviews, 180 refusals, 125 no contact
during study period, 89 ineligible (i.e. deceased,
moved away, nobody over 65 years of age), 63
non-working number, 24 disabled (deaf, very ill,
language difficulty) and 14 other (on vacation,
etc.). The respondent refusal rate was 20% based
on a formula by Lavraskas (Lavraskas, 1987).
Results
A total of 705 participants were interviewed, 268
from the EMT-delivery group, 214 from the direct
mail group and 223 from the control group. Eighty
percent (217) of people in the EMT-delivery group
remembered the red doorhanger/flyer and 55%
(118) of people in the direct mail intervention. Of
the 217 seniors in the EMT-delivery group who
reported receiving the Kit, 36% (79) had received
the Heart Attack Survival Kit as a doorhanger on
their doorknob.
The demographic characteristics of the total
sample was as follows: (51%) male, mean age of
73, with a standard deviation of 6.4. Education:
8% reported less than high school degree, 33% a
high school degree, 30% some college and 29% a
college degree or higher. Income: 19% reported
income levels below $20 000, 34% reported income
of $20 000–40 000, 15% reported income levels
of $40 000–60 000, 7% reported income levels
greater than $60 000 and 25% either did not know
or refused to answer this question. In 84% of the
interviews the person on the mailing list was
reached. In 16% of the completed interviews the
spouse of the person on the list was interviewed.
There were no statistically significant differences
in any of the demographic characteristics between
the three study groups (i.e. EMT-delivery, direct
mail or control).
Intentions to respond to symptoms of
AMI
Since the main recommendation of the Heart Attack
Survival Kit was to motivate seniors to (1) call
911 and (2) take an aspirin for heart attack symptoms, we investigated differences between groups
for intentions to call 911 and taking aspirin (combined) as a coping strategy for AMI. To answer
our first hypothesis we combined participants randomized to the EMT-delivery group with those
randomized to the direct mail group (i.e. intervention group) and compared their responses to participants in the control group. Table I shows that
respondents in the intervention group reported a
greater frequency of the recommended coping
response to AMI than respondents in the control
group. It appears that this result was mostly caused
by differences in intentions to ingest aspirin, as
part of the coping response rather than calling 911.
The two groups were equal in their intentions to
call 911 as a first as well as second action in
response to AMI. However, intentions to take an
aspirin as a first or second action in response to
AMI symptoms was significantly greater in the
intervention than the control group. Responses to
the forced-choice continuous likelihood questions
resulted in similar outcomes.
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H. Meischke et al.
Table I. Main results for intervention status and intended coping response for symptoms of AMI
Calling 911 and taking aspirin as response to AMI symptomsa
Call 911 as first response to AMI symptomsa
Call 911 as second action in response to AMI symptomsa
Take aspirin as first response to AMI symptomsa
Take aspirin as second action in response to AMI symptomsa
Likelihood of calling 911b
Likelihood of taking aspirinb
aχ2
Intervention (N ⫽ 482) (%)
Control (N ⫽ 223) (%) P value
39
75
18
13
28
1.2
1.8
10
72
15
3
9
1.2
2.6
0.00
0.28
0.26
0.00
0.00
0.87
0.00
analyses.
bt-tests.
Table II. Comparison of intervention groups: EMT-delivery versus direct mail
Calling 911 and taking aspirin as response
to AMI symptomsa
Calling 911 and taking aspirin as response
to AMI symptomsa
Do you like the Kit?
Do you have the Kit in your home?
If you needed the Kit right now could you find it?
How useful is the Kit? (‘very useful’)
aThis
bThis
Seniors randomized to EMTdelivery groupa (N ⫽ 266) (%)
Seniors randomized to
direct mail group
(N ⫽ 212) (%)
P value
46.6
29.7
0.000
Seniors who remember receiving
the Kit from a firefighter
(N ⫽ 137) (%)b
Seniors who remember
receiving the Kit via
mail (N ⫽ 116) (%)
P value
56.9
98.5
97.1
93.8
75.4
42.2
89.6
91.5
90.4
73.7
0.014
0.002
0.088
0.561
0.437
group includes seniors who received the Kit via doorknob.
group does not include seniors who received the Kit via doorknob.
Table II shows the results of the second and
third hypotheses. Within intervention groups,
participants in the EMT-delivery group reported
significantly greater intentions to use the recommended coping response to AMI symptoms than
participants in the direct mail group. When the
sample was limited to the participants who reported
they had actually received the Kit, the results were
similar; those participants who reported receiving
the Kit from a firefighter were significantly more
likely to report intentions to use the recommended
coping strategy than those participants who
reported receiving the Kit via direct mail. Addition-
322
ally, seniors who had received the Kit from a
firefighter were significantly more likely to say
they liked the Kit and slightly more likely to report
they had the Kit in their home than seniors who
reported they had received the Kit via direct mail.
There were no differences in participants’ ability
to locate the Kit during the interview or in their
perceived usefulness of the Kit. Since our objective
was to compare direct mail and EMT home delivery, and since the sample of people who reported
receiving the Kit via doorknob was much smaller
(N ⫽ 79) than the other two groups, we excluded
this group from this analysis.
The ‘Heart Attack Survival Kit’ project
To assess the impact of demographic variables
on intentions to take the appropriate response to
AMI, we conducted a logistic regression analysis
including age, gender, education and intervention
status (i.e. EMT-delivery group, direct mail and
control group) on appropriate response to AMI
(i.e. take aspirin and call 911 as the first two action
responses to AMI symptoms). The analysis showed
that there were two variables significantly related
to the outcome variable: gender and intervention
status. Compared to women, men were less likely
to intent to respond appropriately to AMI symptoms than women (odds ratio of 0.67, P ⬍ 0.03).
Compared to the control group, respondents in the
EMT-delivery group and direct mail group were
significantly more likely to report intentions to call
911 and take aspirin as a response to AMI symptoms (odds ratios of 6.9 and 3.3, respectively, P ⬍
0.000). Age and education were not significant in
the model.
Evaluation of Kit
Most people who recalled receiving the Kit could
locate the Kit in their home. Although no systematic tally was performed of the open-ended
responses as to the location of the Kit, the responses
seemed to indicate that the Kits were placed by
the phone, on the refrigerator, kitchen cupboard or
other place. Respondents remembered the main
messages of the Kit. Respondents correctly identified the following messages as being part of the
Kit: symptoms of AMI (71%), recommendation to
call 911 for symptoms of AMI (78%), recommendation to take aspirin for AMI (80%), CPR
instructions (54%) and packet of aspirin (88%).
Ninety-one percent reported they liked the Kit and
71% reported the Kit was ‘very’ useful. Almost
nobody thought the Kit was very upsetting (0.3%).
Discussion
The objective of the current study was to investigate
the effectiveness of a Heart Attack Survival Kit,
designed to increase intentions to respond appropriately to symptoms of acute myocardial
infarction. We tested two delivery methods: door-
to-door delivery by local firefighters and direct
mail.
Consistent with our hypotheses, seniors in the
intervention groups (EMT-delivery or direct mail)
were more likely to report intentions to use prompt
and appropriate coping responses to AMI symptoms than seniors in the control group. Most of
the difference appeared to stem from differences in
intentions to ingest an aspirin for AMI symptoms,
rather than differences in intentions to call 911.
Intentions to call 911 for heart attack symptoms
were high across the groups (around 75%) so a
ceiling effect may have contributed to lack of
differences among the groups. There were significant differences between intervention and control
conditions in people’s intentions to take an aspirin
for AMI symptoms. In a related study we found
that few people know about the benefits of aspirin
for AMI treatment (King County, EMS, unpublished data, 1997). Thus, this new information may
have affected people’s intended coping responses.
Seniors in the EMT-delivery group differed
significantly from seniors in the direct mail group
in their ability to recall receiving the Heart Attack
Survival Kit. Some of the recall difference between
the two groups may have been due to the fact that
persons in the direct mail group were, on average,
reached by phone several days later (mean of 3.4
weeks) than persons in the EMT-delivery group
(mean of 2.4 weeks). However, the analyses which
are limited to only those people who report actually
having received the Kit show that seniors who
received the Kit from a local firefighter were
more likely to report intentions to comply with
recommended coping strategies, liked the Kit better
and were slightly more likely to report they had
the Kit in their home than seniors who reported
they had received the Kit via direct mail. This
suggests that the interpersonal encounter with a
firefighter has benefits above and beyond the
information that was presented in the Kit itself. To
assess the impact of the firefighter visits over time
we called back the 138 seniors who reported they
had received the kit via a firefighter, a full year
after the intervention (i.e. the Spring of 1999). Of
the 114 seniors who completed this follow-up
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H. Meischke et al.
survey, 75% recalled the firefighter visit and 76%
were able to locate the Kit in their home upon
request. Compared to other types of public education interventions in this and related areas
(Meischke et al., 1995, 1999) the Heart Attack
Survival Kit intervention seems to have a persuasive and lasting impact.
Limitations
Since this was a small field study it was not
possible to obtain outcome data (i.e. actual 911
calls or aspirin use). To obtain such data would
require a tremendous number of house visits and
medical record surveillance in many hospitals.
Thus, the reliance on self-reported intentions as a
proxy for actual behavior during a heart emergency.
Only a randomized community trial will be able
to assess the impact of the Heart Attack Survival
Kit and its delivery methods on actual behavior
change. Since the labor intensity of the project
might prohibit a large-scale program we interviewed the firefighters involved in the project about
the potential benefits of such a project to them.
Reports from the three participating firefighters
were unanimously positive. The firefighters felt
elated to meet and educate seniors in their community in a ‘non-crisis’ situation. In many cases firefighters were successful in actually taping the Kit
in the seniors’ home in a visible place. Although
door-to-door delivery of health information by
firefighters may be labor intensive we believe this
public education strategy is feasible and fits with
the mission of EMS. Fire departments have been
facing the dilemma of decreasing fire calls in the
past decades, due to automatic sprinklers, improved
fire-safe building design and construction, smoke
detectors, tougher building and fire codes, better
enforcement of those codes, and public fireeducation programs (Page, 1990; Gresham, 1994).
However, most fire departments have adopted additional roles/services including fire prevention and
education programs, and also with emergency
responses (Page, 1990). In 1995, the National
Highway Traffic Safety Administration (NHTSA),
in partnership with the Health Resources and
Services Administration (HRSA), Maternal and
324
Child Health Bureau (MCHB) commissioned the
development of the EMS Agenda for the Future,
in order to determine the most important directions
for future EMS development (Delbridge et al.,
1998). Of the 14 EMS attributes, identified as
requiring continued development, two areas seem
particularly relevant to the current project: (1) the
continued and expanded role of EMS in public
education, and (2) the role of EMS in prevention
activities. We believe that the Heart Attack Survival
Kit project is a public education activity that fits
this agenda. Innovative techniques must be tried
since the traditional public health interventions for
heart disease have been largely ineffective.
The consent procedures between the two intervention groups differed. Twelve percent of the
study participants in the EMT-delivery group
returned a post card indicating they did not want
to receive a visit by a firefighter. We did not have
such a procedure for participants in the direct mail
intervention. Although this may have introduced a
selection bias in our EMT-delivery group, we
believe this bias is minimal for two reasons. First,
20% of the returned post cards included reasons
for non-participation which did not reflect unwillingness to be visited, such as: too young, deceased,
wrong address or to the fact that participants knew
they would not be home (on vacation) in the next
couple of weeks. Second, although we did not
include the people who returned a post card in the
intervention, these people were included in our
follow-up telephone survey. If anything the inclusion of these participants may have diluted the
intervention effect in the EMT-delivery group since
they were excluded from the intervention. For
future study consent procedures for differing intervention strategies need to as similar as possible to
increase scientific rigor.
The results of this study show that the Heart
Attack Survival Kit was perceived as useful by the
target audience and did affect seniors’ intentions to
act in a prompt and appropriate response. It also
shows that exposure to the Kit and intentions to
act in the recommended ways were greatest in
the EMT-delivered intervention group. The effects
The ‘Heart Attack Survival Kit’ project
were particularly strong for the message on aspirin
ingestion during a heart emergency.
The firefighters participating in this research
project were extremely supportive and enthusiastic
about the project. Other fire districts may not be
as supportive. Thus, a larger scale study including
multiple fire districts will teach us a great deal
about the effectiveness of firefighters as public
health educators in different systems.
Acknowledgements
We are grateful for the unequivocal support we
received from Chief Angelo, Chief of Kent fire
district in implementing this field study in a timely
manner. We are also thankful for the enthusiastic
help we received from the three firefighters (Brian
Kingery, Brian Felczak and Mike Richardson) who
participated in this project. We thank the Medic One
Foundation for the financial support for this project.
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Received on October 2, 1998; accepted on May 20, 1999