Health Promotion International, Vol. 14, No. 3, 241-250,
September 1999
© Oxford University Press 1999
Effects of a community-based nutrition education program on the dietary behavior of Chinese-American college students
The NYC Department of Health, 933 39th Street, Brooklyn, NY 11219 and 1 Chinese-American Association of New York City, 65—69 Lispenard St, 2nd Fl., New York, NY 10013, USA
Address for correspondence: Wei Yue Sun Research and Development Unit Family Health Services The NYC Department of Health 933 39th Street Brooklyn, NY 11219 USA
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONS AND RECOMMENDATIONSREFERENCES |
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This study applied the PRECEDE model to investigate dietary predisposing, enabling, reinforcing factors and dietary behavior among Chinese-American college students with a community-based nutrition education program (Group 1), and those without the program (Group 2). A total of 218 students participated in the study. A PRECEDE instrument, including nutritional knowledge, perception of diet and health, dietary instruction, media influence, social support, and dietary behavior, was employed to collect pre- and post-test data. Students in Group 1 improved perception of diet and health, dietary instruction, social support, and dietary behavior significantly after joining the program. Although not significant, students in Group 1 improved nutritional knowledge and media influence after completing the program. These results suggest PRECEDE components are important in changing dietary behavior.
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONS AND RECOMMENDATIONSREFERENCES |
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Coronary heart disease (CHD) is the leading cause of death in the USA causing some 570 000 premature deaths each year (Brown et al., 1989
). Approximately half of Americans over 65 have CHD. However, modifiable risk factors, e.g. elevated levels of plasma total and LDL cholesterol, and low levels of plasma HDL cholesterol, are probably more important than age alone in the etiology of CHD (Brown et al., 1989). For populations in which the mean plasma cholesterol concentration is relatively high, e.g. those in the USA, prospective observational studies indicate a strong, direct association between plasma cholesterol concentration and CHD (Wenxun et al., 1990; Yudkin, 1992). Diets high in energy density, total fat, saturated fatty acids and cholesterol, and low in the ratio of polyunsaturated to saturated fatty acids are associated with increased plasma total cholesterol and LDL cholesterol, and an increase in susceptibility to CHD. On the other hand, diets low in total fat, saturated fat and cholesterol are thought to be protective against CHD (Wenxun et al., 1990; Yudkin, 1992).
International comparisons have shown that the prevalence of CHD varies greatly from one country to another. Crude death rates from CHD for 1987 were reported as 36.9 per 100 000 and 15.6 per 100 000 for the urban and rural population in China, respectively, which were approximately one-tenth of the rates for the USA (Li et al., 1992). Surveys show that the diet of Chinese populations in the Beijing and Guangzhou areas of China have high carbohydrate content, mainly from starch, and a relatively low fat content, which makes up 18—31% of the total caloric intake from fat. The proportion of saturated fat is low, only 5—8% of total caloric intake. On the other hand, the diet of Americans contains a considerably higher percentage (40%) of energy from fat, with 13% of the caloric intake from saturated fat (Li et al., 1992). The mean daily intake of cholesterol is less than 300 mg among native Chinese, while a distinctly higher intake of up to 500 mg or more is found in Americans (Li et al., 1992; Chen, 1992).
Native Chinese have a lower incidence of CHD than Americans do. However, the incidence of and mortality from CHD increases as Chinese migrate to the USA (Pinnelas et al., 1992). Data from a CHD risk factor and cholesterol screening in an ethnic community in New York City suggests that the influence of environment on mean total plasma cholesterol is important. Chinese living in New York City's Chinatown have higher levels of total and LDL cholesterol than would be expected from studies of Chinese living in China. The differences of CHD incidence and plasma cholesterol levels may be attributed to the change of dietary behavior after migration to the USA (Pinnelas et al., 1992). Results from researches conducted by Sun (1994), Sun and Chen (1994), and Sun and Wu (1997) indicated that Chinese-American adolescents consumed more total fat, saturated fat and cholesterol, and less complex carbohydrate and fiber when compared with native Chinese adolescents in China.
Though some studies have investigated the effects of dietary behavior on CHD among Chinese-Americans, few have analyzed dietary behavior itself and factors affecting it. Also, a family community-based program which applied the PRECEDE model to nutritional education was successful in influencing dietary behavior of Mexican-American adolescents (Boreham et al., 1993), but few such studies have been applied to Chinese-Americans. The present study applied the PRECEDE model to analyze the effects of a community-based nutrition education program on the dietary behavior among Chinese-American college students. The results may help to identify factors affecting dietary behavior and illustrate the important role of a community-based education program in preventing unhealthy dietary behavior and risk factors of CHD among Chinese-Americans.
The PRECEDE model was developed by Green and Kreuter (1986). It has been widely tested in various settings and accepted as an effective planning framework for health education and promotion. The PRECEDE model is considered to be a more comprehensive model for the study of health behavior when compared to other behavior models (Mullen et al., 1987). Numerous studies and applications of the PRECEDE model on health promotion planning, intervention and evaluation, e.g. AIDS education (Alteneder et al., 1992), smoking cessation (Lichtenstein and Hollis, 1992), hypertension prevention (Meagher and Mann, 1990), cancer prevention (Michielutte et al., 1989), exercise (Paradis et al., 1995), and sexual education (Rubinson and Baillie, 1981) have been conducted. These studies showed that the components of the PRECEDE model (predisposing, enabling and reinforcing factors) are important to change unhealthy behaviors, e.g. smoking, lack of exercise and lack of cancer screening. In addition, the PRECEDE model has been proved to be an effective framework to assess knowledge, attitude toward sexuality and unproductive sexual behavior, as well as knowledge, attitude toward hypertension and risky behavior of hypertension, e.g. high salt and high fat diet. Few studies have been conducted and minimal information is available regarding the application of the PRECEDE framework on dietary behavior, especially in the Chinese population. The PRECEDE model postulates three components of influence on behavior: predisposing, enabling and reinforcing factors.
- Predisposing factors are those antecedents to behavior that provide the rationale or motivation for the behavior, e.g. nutritional knowledge and perceptions of diet and health.
- Enabling factors are those antecedents to behavior that allow a motivation to be realized, e.g. dietary instruction.
- Reinforcing factors are those subsequent to a behavior that provide a continuing reward or incentive for the behavior and contribute to its persistence or repetition, e.g. media influence and social support.
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METHODS |
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Subjects
This study was approved by the Institute Review Board, Education Board of New York City. An informed consent form was signed by each student respondent. Subjects consisted of two groups. The first and second groups consisted of 112 (Group 1) and 106 (Group 2) Chinese-American college students, respectively. Eight colleges in New York City participated in the study. They were selected because they were located in the areas of five Chinese communities in New York City. Most Chinese families in New York City resided in these Chinese communities and their children went to the colleges closed to these Chinese communities. Students in these colleges represented the majority of Chinese college students in New York City. A list of students' identification numbers was provided by the Chinese-American Student Associations of these colleges. Subjects were selected randomly from this list and then divided randomly into two groups defined as experimental (Group 1) and control (Group 2) groups. One hundred and ninety-seven students in Group 1 and 162 students in Group 2 were originally selected with a target of enough subjects to represent the population. After selection, 141 students in Group 1 and 132 students in Group 2 completed the pretest. One hundred and twelve students in Group 1 and 106 students in Group 2 participated and completed the post-test. Demographic data of the subjects are listed in Table 1
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Instrument
The survey used in this study consisted of four parts designed to assess: predisposing factors, including nutritional knowledge and perceptions of diet and health; enabling factors, including dietary instruction; reinforcing factors, including media influence and social support; and dietary behavior. The first three parts were developed by Caggiula and Watson (1992), and modified for the present study. According to Caggiula and Watson, face validity was checked and established by a group of health professors. Internal consistency was assessed by calculating the consistency coefficients, and they ranged from 0.76 to 0.96 (Caggiula and Watson, 1992
).
The fourth part of the survey addressing dietary behavior was developed by Cornor et al. (1992). The validity and reliability of the survey were tested by Cornor et al. Face validity was reviewed by a group of health professors. Validity was also assessed by testing the correlations of the summary scores from the 24-h dietary recall and scores from this survey. The correlation coefficients for cholesterol-saturated fat were 0.65, and for carbohydrate the score was 0.62. The reliability of the survey was assessed by the test—retest procedure. The correlation coefficients were 0.95 for cholesterol-saturated fat and 0.88 for carbohydrate score (Cornor et al., 1992).
The entire survey was translated in Chinese. Both English and Chinese versions of the survey were distributed to students. The Chinese version was reviewed by three Chinese health professors to assure the accuracy and relevancy of the translation. The reliability of the Chinese version was tested again by the test—retest procedure with 30 students from these eight colleges. The correlation coefficients were 0.79, 0.72, 0.80, 0.76 and 0.82 for nutritional knowledge, perception of diet and health, dietary instruction, media influence, and social support, respectively.
There were 10 items for nutritional knowledge, and five items each for perception of diet and health, dietary instruction, media influence, and social support. In each item, scores were ranked according to scales from 1 (most negative response) to 4 (most positive response).
The major groups of foods and fluids addressed in the fourth part of the survey were: (i) meat, fish and poultry; (ii) dairy products and egg; (iii) fats and oils; (iv) sweets and snacks; (v) grains, beans, fruits and vegetables; (vi) beverages; (vii) salt; and (viii) restaurant foods. There were 38 items in this part. Examples of the predisposing, enabling and reinforcing factors; and dietary behavior are presented in Table 2.
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Procedures
With assistance from the health educators in the study colleges, the survey was administrated to all subjects in Group 1 and Group 2 in pretest. Students selected for the study were informed orally by the health educators, and an invitation to be interviewed at the student health center was sent to each of the participants. Phone calls were made to students 1 day prior to the meeting to increase the participation rate. Students were invited to attend the meeting in the health center. Consequently, 148 students in Group 1, and 137 students in Group 2 attended the meeting. The survey was administered by school health educators with the assistance of an instructional protocol. Informed consent forms were signed by students in the meeting. The purpose and procedure of the study were explained to students by health educators. A standard protocol regarding the entire survey was read to the students by health educators. Subjects were asked to collect the pretest survey and complete it independently in the health center. Food models, e.g. 3 oz chicken, pork, beef, a cup of rice, noodles, a cup of different kinds of vegetables, fruits, a slice of pizza, a serving of hamburger, hot dog, sandwich, salad, french fries and others were shown to the students to assist students in answering the dietary behavior questions accurately, because the same amount of food may be answered by students differently. Sample foods were listed in the survey to assist students to complete the dietary behavior questions accurately. These sample foods included the kinds of food, amount of food and seasonings on the food. Any questions about completing the questionnaire were resolved by the health educators at the meeting. One hundred and forty-one students in Group 1 and 132 students in Group 2 returned the completed pretest survey. Surveys were withdrawn from seven students in Group 1 and five students in Group 2 because many questions were not answered.
A community-based nutrition education program sponsored by the Chinatown Community Board was offered to the students in Group 1. This program consisted of the following. (i) Workshops with different topics, e.g. self-monitoring, goal setting, recognition of high fat food, effects of healthy and unhealthy food on health such as cardiovascular health and cancer, and food label reading. Chinatown community leaders, neighborhood group leaders, family members, students and college health educators were invited to attend the workshops. Chinese registered dieticians were invited to give lectures. Videotapes and group discussions were also used. (ii) Activities, e.g. recipe modification, predicting and planning problems, case presentation, watching local TV healthy food selection program, resisting peer pressure, eating out and choosing healthy food to eat, party and food choosing, and a grocery store tour. Again, Chinatown leaders, neighborhood group leaders, parents, college health educators and students were invited to attend. A description of the intervention program is presented in Table 3. During this period, students in Group 2 were asked to continue their routine college and family activities, which were periodically verified by phone calls by health educators. Results of the study also indicated that scores in all variables remained unchanged as shown in the post-test, indicating food control elements were in place during the intervention period.
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The intervention program included 13 sections with 2 weeks for each section. The educational strategies were designed based on the PRECEDE model. Nutritional knowledge (predisposing factor) was emphasized in sections 1—3 (self monitoring, goal setting reflecting goals of Healthy People 2000, and recognition of high fat, saturated fat, cholesterol, carbohydrate and fiber food). Perception of diet and health (predisposing factor) was emphasized in section 4 (effects of healthy and unhealthy foods on health, e.g. cardiovascular health and cancer, including case presentations for positive and negative outcomes of health and unhealthy diet). Dietary instruction (enabling factor) was emphasized in sections 4—5 (label reading, recipe modification, food cooking and storage). Media influence (reinforcing factor) was emphasized in sections 9—11 (watching TV program in local TV station regard healthy diet ‘Five a Day’, and party and food choosing, eating out and choosing healthy food to eat, and grocery store tour and food selection). Social support (reinforcing factor) was emphasized in sections 6—8 and 12—13 (predicting and planning for problems, resisting peer pressure, identifying support, planned and unplanned breaks in routine, and pressure from friends).
The post-test survey was administered to the same students using the same procedure as in the pretest. Twenty-nine subjects in Group 1 and 26 subjects in Group 2 dropped out after 7 months because they had moved. Completed surveys were collected by the college health educators and sent to the researchers.
Data analysis
Scores were calculated for each student in predisposing factor (nutritional knowledge, and perceptions of diet and health), enabling factor (dietary instruction), and reinforcing factor (media influence and social support), as well as dietary behavior. Scores ranged from 10 to 40 in nutritional knowledge (higher score indicated better knowledge), from 5 to 20 for each of perception of diet and health (higher score indicated more positive perception), dietary instruction (higher score indicated better dietary instruction), media influence (higher score indicated more positive media influence) and social support (higher score indicated better social support). For dietary behavior, scores ranged from 0 to 250 with higher score indicating better dietary behavior.
A multivariate analysis of variance (MANOVA) was used to compare differences among the two groups' scores in all variables in the pretest. A multivariate analysis of covariance (MANCOVA) was used to compare differences among two groups' scores of all the variables in the post-test by controlling pretest scores as a covariable. Multiple regression analysis was used to test the predictive effects of variables including predisposing factor (nutritional knowledge, and perceptions of diet and health), enabling factor (dietary instruction) and reinforcing factor (media influence and social support) in the baseline (pretest) scores on dietary behavior in post-test in the control group (Group 2).
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RESULTS |
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The results showed that no significant differences existed in nutritional knowledge, perception of diet and health, dietary instruction, media influence, social support, and dietary behavior between these two groups at pre-test (F = 0.67, p = 0.52 for knowledge; F = 1.12, p = 0.38 for perception; F = 1.72, p = 0.32 for instruction; F = 0.88, p = 0.49 for media influence; F = 1.04, p = 0.41 for social support; and F = 2.11, p = 0.21 for dietary behavior, Table 4
).
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Results from MANCOVA indicated that Group 1 exhibited a significantly improved perception of diet and health, dietary instruction, social support, and dietary behavior after joining the community-based program (F = 6.17, p < 0.02 for perception; F = 7.05, p < 0.016 for dietary instruction; F = 25.62, p < 0.001 for social support; and F = 21.98, p < 0.001 for dietary behavior). There were no significant differences in scores on nutritional knowledge and media influence between Group 1 and Group 2 (F = 1.67, p = 0.28 for knowledge; and F = 1.72, p = 0.22 for media influence, Table 5
).
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The multiple regression analysis indicated that predisposing factor [nutritional knowledge (p = 0.049), and perceptions of diet and health (p = 0.036)], enabling factor [dietary instruction (p = 0.022)], and reinforcing factor [media influence (p = 0.047) and social support (p = 0.012)] were significant factors predicting dietary behavior (Table 6
).
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONS AND RECOMMENDATIONSREFERENCES |
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Students in Group 1 improved their perception of diet and health, dietary instruction, social support, and dietary behavior significantly after joining the program. These results suggest that PRECEDE components are important in changing dietary behavior, and the findings were similar to those reported by Boreham et al. (1993) who found significantly improved nutrition knowledge, perception of diet and health, social support and dietary behavior among Mexican-American adolescents after they joined a family community-based nutrition education program designed based on the PRECEDE framework. In the present study, the majority (86%) of Chinese students were recent immigrants who had immigrated to the USA within 10 years. The socio-economic environments, values, beliefs, culture influence and lifestyle including dietary behavior of these students were somewhat between those of traditional Chinese and mainstream Americans. Although they may have adopted some American lifestyles, including dietary behavior, they still adhere to traditional Chinese culture and customs (Sun and Wu, 1997
). Chinese students prefer to cook by themselves or with family, eat with the family, eat more fruits, vegetables and starch products, and eat less meat, dairy products, oil and other fatty foods (Sun, 1994). After completing the community- and family-based nutritional education program, their traditional Chinese beliefs, values, customs and lifestyle including dietary behavior were reinforced and overrode the mainstream American culture and lifestyle. Improved dietary behavior of students in Group 1 is the result of improvement of their perceptions of diet and health, dietary instruction, and social support which were major components of the PRECEDE model. These results suggest that the PRECEDE model does influence dietary behavior among Chinese-American students. The combination of predisposing, enabling and reinforcing factors is important in improving dietary behavior among these students. There was no significant improvement in nutritional knowledge after joining the program. Again, most students in this study were recent immigrants. Their nutritional knowledge was relatively weak when compared with American students due to difference of educational system including health education classes in school between China and the USA. There were fewer health education or health-related classes in the curricula in school in China, and students in China receive 2 h per week of biology classes which cover very limited nutrition knowledge, compared to more hours per week of health education and health-related classes for students in the USA. The lack of health education classes may be a factor affecting nutritional knowledge in Chinese students. In a short period of time, it is difficult to improve their nutritional knowledge to a significant level. In addition, there was no significant improvement in media influence after joining the program. These recent immigrant students were unlikely to be exposed to TV, radio and magazine healthy food educational programs significantly because of their cultural, environmental and language barriers.
Although not significant (F = 1.67, p = 0.28 for nutritional knowledge; F = 1.72, p = 0.22 for media influence), students in Group 1 improved their nutritional knowledge and media influence to a certain extent after completing the program (Table 5
). In addition, results from the multiple regression analysis indicated that nutritional knowledge and media influence were significant factors predicting dietary behavior. These results suggest that components of the PRECEDE model including nutritional knowledge (predisposing factor) and media influence (reinforcing factor) are also important to improve students' dietary behavior. To improve students' nutritional knowledge and positive media influence significantly, a community-based nutritional educational program may need a longer period of time and more activities focusing on these areas.
The findings of this study further support the results from Paradis et al. (1995). They applied the PRECEDE model to develop a heart health promotion program focusing on dietary behavior for low income, low education young adults in Montreal, Canada. Ten dietary interventions have been developed and tested in this community. The interventions included healthy recipes contests, menu labeling and health food discount programs in restaurants, nutrition education campaign, healthy eating, educational material, print and electronic media campaigns, heart health fairs, and community events. The results of the study indicated that subjects improved their dietary behavior significantly after completing the program.
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CONCLUSIONS AND RECOMMENDATIONS |
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Due to the limitation of geographic locations, small number of subjects and complexity of dietary behavior measurement, results of this preliminary investigation need to be interpreted cautiously. Also, because the study focused on Chinese-American students, it is not appropriate to apply the study findings to other ethnic groups. However, this preliminary study was unique because it evaluated the effects of a community-based nutritional education program on dietary behavior in Chinese-American students which is an important factor that contributes to CVD. More studies with subjects from other areas of the USA are needed to investigate the present issue. Measurement of blood cholesterol levels among students may be included in future studies to support the hypothesis that differences of CVD incidence are caused by differences of dietary behavior among Chinese-American students. This is needed because blood cholesterol levels influenced by dietary behavior are important risk indicators of CVD. Multiple measurements of dietary behavior, e.g. food frequency, 24 h recall, 24 h record, as well as food intake questionnaire, which was used in this study, should be applied to investigate dietary behavior among college students.
This study examined the effects of a community- and family-based intervention program on the dietary behavior of Chinese-American students. Results indicated that those in the program showed significantly improved dietary predisposing, enabling and reinforcing factors; and dietary behavior.
Nutrition education programs have until now generally been aimed at adults, in whom the atherosclerotic process is already advanced and their dietary behavior is already formed. The adoption of healthy dietary behavior must, however, be encouraged from an early age. This is not only because unhealthy dietary behavior at an early age is a potential risk factor of adulthood CHD, but also because such behavior can last for a long time (Boreham et al., 1993).
Nutrition education programs should focus on all components of the PRECEDE framework including: predisposing factors, e.g. nutritional knowledge, attitude and perceptions of diet and health; enabling, e.g. dietary instruction; and reinforcing factors, including media influence as well as social and family support. More attention should be paid to culture, environment, customs and socio-economic factors, because these are key factors affecting dietary behavior among Chinese-American adolescents.
More information about health food selection, preparation and cooking, storage, and food label reading should be offered to students. Dissemination of this information could be done via TV, radio, newspapers, newsletters, brochures, videotapes and computer software. Fast food advertising should be controlled, especially in the Chinatown area, to reduce the negative media influence. Education of the owners and managers of restaurants and food services is important for achieving this goal.
A comprehensive college nutrition education and promotion program should be offered to Chinese-American students. This program should include college health educators, community leaders, family members and students. Because many Chinese-American students live in Chinatown, and they retain the culture of respecting community leaders, the latter could play an important role in influencing their dietary behavior. Though some Chinese-American adolescents have already adapted an American lifestyle, Chinese culture, e.g. family values still affect their behavior. So, education of parents and family members can also influence students' dietary behavior.
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