prevention of serious outcomes. The general public was informed that a great many people have the disease without knowing it, that it can easily be detected. and effectively treated, and that longterm persistence in therapy can prevent a stroke, heart failure, and kidney failure. Voluntary health organizations, health professional organizations, labor, industry, consumer groups, and federal agencies have worked together effectively in ways that provide useful models for other health problems. Since hypertension is especially prevalent in the black community, a special effort in minority communities has been mounted in recent years. In view of the heavy burden of illness altogether in these communities, the lessons learned from the hypertension program may well be useful in other contexts. Recent surveys give encouraging indications with respect to effectiveness of this program. For example, a 1977 study of more than 100,000 residents of Chicago showed that 9 out of 10 people with elevated blood pressure were aware of it and about 60 percent of hypertensives were being effectively treated. 20 The Stanford Heart Disease Prevention Program, a multifaceted research effort, has shown that decreasing risk factors associated with cardiovascular disease is possible through health education. 21 The main risk factors addressed in this two-year community education field study were cigarette smoking, high plasmacholesterol concentrations, and high blood pressure. The experiment involved two experimental Northern California communities (and one control community), and used either mass media alone or mass media plus face-to-face counseling of high risk individuals. Key aspects were: • the mass media materials were devised to teach specific behavioral skills, e.g., preparation of a palatable low-fat diet-as well as offering health-relevant information and affecting motivation to change behavior in health-promoting • both the mass media approaches and the face-to-face instruction used wellestablished behavioral science principles to achieve changes in behavior; ⚫ the design of the campaign was based upon analysis of the knowledge deficits and the media-consumption patterns of the intended audience. Among high-risk participants receiving the combination of annual survey, mass media exposure, and intensive instruction, there was a 30 per cent reduction of overall cardiovascular disease risk—almost all of which was achieved in the first year of the program, and sustained through the second year. High-risk individuals who received only the annual survey and mass media education reduced their risk by about 10 per cent the first year and 25 per cent after two years. In contrast, high-risk participants in the control community exposed to the survey alone did not appreciably change their risk of heart disease. Indeed, the risk to all participants in the control community increased about seven per cent during the study period. A much larger effort to establish the effectiveness of cardiovascular risk-factor reduction in decreasing the incidence of heart attack and stroke has been going on for six years, involving 180,000 persons, virtually the entire population of North Karelia, Finland. 22 At the outset, this county has proportionately more heart disease deaths than any other part of Finland, with most of the regional difference related to a higher incidence of the common cardiovascular risk factors-cigarette smoking, elevated blood pressure, and elevated plasma cholesterol. The state-financed prevention program was planned in cooperation with the World Health Organization. Major components of the program were: 1) health education through a variety of community resources, including local newspapers and radio; 2) hypertension screening with intensive group health education directed at high-risk individuals; and 3) early diagnosis, treatment, and rehabilitation, involving many existing health and social services of the county. In the first four and one-half years of the program, the percentage of middle-aged men (25-59 years) who smoke was reduced through a combination of education and legal measures (forbidding smoking in public buildings and on public transport). During the same period, dietary fat was reduced, the program having gained the cooperation of the local dairy and food industry in fat reduction efforts. Nearly every adult in the county receives regular blood pressure measurement, and the percentage of men and women on antihypertensive medication has increased. A reduction in blood pressure has occurred among the 17,000 registered hypertensive individuals. The result of these combined efforts |