Research Paper Markush

Assessing the Effect of Inquiry-based Education on Diet and Nutrition Health Literacy at

Gateway Regional High School Huntington, Massachusetts

December 30, 2010

Susan MarkushEd. M Candidate, Harvard Graduate School of Education

Teacher Education Program

Acknowledgements

This project would not have been possible without the help and advice of the following people:

The Participating Students at Gateway Regional High School

Jean Garriepy, Health Education Teacher at Gateway Regional High School

Patricia Shields, BS Candidate 2011, Fordham University, Statistics/Data Advisor

Eileen Hirsch, Head of Gateway School-Based Health Center

Kay Merseth, Director of Teacher Education Program, Harvard Graduate School of Education

Renee Aird, Mass Department of Public Health, Director of School Based Health Centers

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Abstract

Background: Current research indicates that adolescents are at an increased risk of becoming obese and overweight and of developing heart disease and diabetes. However, the low literacy skills of the nation’s children and a lack of standardized, comprehensive health curriculums in grades K – 12 prevents many adolescents from receiving proper education about healthy weight attainment. Thus far, little research on effective classroom health literacy education has been documented. Aim: The objective of this project was to assess current health literacy and understanding of diet and nutrition among adolescents attending a small, “high-need” high school, and then to assess the effect that a six-session, inquiry-based diet and nutrition course had on their skills. Student engagement and satisfaction was also evaluated to help with future curriculum development and teaching methods improvement.Methods: The diet and nutrition workshop was taught over six, one-hour sessions to 19 students at Gateway Regional High School in Huntington, Massachusetts. The students ranged in age from 14 years to 18 years. The students were given a pre-class survey and a post-class survey to assess the effectiveness of a diet and nutrition course on their current levels of knowledge. A teacher/course evaluation was administered during the last class to assess overall student satisfaction with the course and instructor irrespective of the survey results.Results: Most students’ post-class scores were significantly higher than their pre-class scores, demonstrating the effect of a focused, inquiry-based health education. In addition, all of the students enjoyed the course, most stated that they learned a meaningful (habit changing) amount about diet and nutrition, and all thought the course should be mandatory for all high school students.Conclusion: The implementation of a focused, inquiry-based workshop into a general high school health curriculum improved student’s health literacy and knowledge of diet and nutrition. Expanding this kind of research should be considered in an effort to gather actionable data and to create a standards-based, engaging and effective health education for adolescents.

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Introduction

Current research indicates that adolescents are at an increased risk of becoming obese and

overweight and of developing heart disease and diabetes. However, the low literacy skills of the

nation’s children and a lack of standardized, comprehensive health curriculums in grades K – 12

prevents many adolescents from receiving proper education about healthy weight attainment

(DHHS, 2010). Educating adolescents about nutrition and physical activity while they are

vulnerable to developing poor lifestyle habits is central to comprehensive preventive medicine.

To address the issue of poor health literacy, school curriculums that reduce skill deficits and

maximize technology use must be developed.

Today, 18% of children in America, ages 12 – 19, are overweight, and the number

continues to grow (NHANE 2004). This is three times the percentage of overweight children

recorded in the early 1970’s (Ogden et al 2006). This prevalence is largely attributable to

decreased physical activity and increased intake of low-nutrient, calorie-dense foods. Children

who are overweight by 24 months of age are five times more likely than normal weight children

to become overweight adolescents (Nader et al 2006) and are thus more likely to develop

obesity-related illnesses such as diabetes and cardiovascular disease as they approach adulthood.

In 2003, Surgeon General Carmona stated “Low health literacy contributes to our

nation’s epidemic of overweight and obesity.” The Healthy People 2010 project named obesity

as one of its top ten health priorities. Even so, the goal to reduce prevalence in adolescents has

not been met (CDC 2010). For this reason, the Department of Health and Human Services has

carried this priority over into the Healthy People 2020 project. To function in society, people need

a general set of literacy skills such as reading, writing, basic math, speech and comprehension.

However, on a continuum, health literacy is more advanced than general literacy and requires a more

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sophisticated skill (APHA 2010). It is also important to note that limited understanding of health

concepts and health information is not solely a problem of persons with low literacy skills.

Highly literate, well-educated individuals also report difficulty understanding information

provided to them by health care workers.

In an effort to improve health literacy-that is, “the degree to which individuals have the

capacity to obtain, process and understand basic health information and services needed to make

appropriate health decisions”, (CDC 2010)- the DHHS National Action Plan to Improve Health

Literacy has identified seven major goals to reach by 2020. Goal Three states “Incorporate

accurate, standards-based, and developmentally appropriate health and science information and

curricula in child care and education through the university level”. The creation of a standards-

based, collaborative health education curriculum with accurate health information will increase

overall literacy skills and promote a healthier and a more successful quality of life. This goal

provides an excellent platform for collaboration between health, language, science and math

classes in secondary school settings.

Research shows that when there is support and reinforcement outside of a basic diet and

nutrition education, there is a 51% greater tendency for comprehension and thus sustainable,

positive change in dietary habits (Steptoe et al 2004). Certainly, diet and nutrition could be

reinforced in biology by relating biological systems; food production could be reinforced in

ecology classes; label reading and calorie computation could be reinforced in math classes, and

so on. It has been proven that repetition is key to learning and that learning improves knowledge

and self-efficacy. It has been suggested by health psychologists that self-efficacy and

knowledge

have mediating effects on dietary habits (Reynolds et al 2002). Thus far, little

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research on effective classroom health literacy education, especially collaborative teaching, has

been documented. Howard K. Koh, M.D., M.P.H. Assistant Secretary for Health, states that in

going forward, “actions need to be evaluated. Groups should document the short and long term

effects of efforts to improve health literacy whenever possible”.

Though there has been an official issuance of National Health Education Standards,

significant barriers to health literacy attainment continue to exist in our nation’s public schools.

These barriers include conflicting information, inadequately designed curricula, poorly trained

teachers, and a lack of resources (DPHHS 2010). According to the 2004 Institute Of Medicine

(IOM) report on health literacy, the lack of consistent health curricula across grades K-12 will

likely negatively affect adult health literacy in the future. As stated earlier, there is a high

likelihood that obese adolescents will go on to become obese adults who will then navigate the

health system because of obesity-related illness. Therefore, many, including the IOM, propose

incorporating health related tasks into classroom lesson plans in order to directly impact the

future population (Gray et al 2004).

Although states like Massachusetts are suggesting implementation of a system-wide

nutrition education program implemented in grades pre-K through 12 (as outlined in the

Massachusetts Curriculum Framework), most districts are struggling to incorporate an effective

program. Often, a major shortfall in the public school curricula that cover nutrition and health is

the failure to address where food originates and how it is produced. Moreover, the USDA

dietary guidelines that are provided can be hard to understand, are usually under debate, and can

be confusing even to a highly literate person.

People’s health literacy shapes their health behaviors, and in due course, health and

wellbeing. In the US, for example, about half or 90 million of adults are thought to be deficient

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in the literacy skills needed to effectively use the US health care system. According to the

National Assessment of Educational Progress (NAEC 2009), 27% of twelfth-grade students

score below the basic level in reading. This means that they do not have the knowledge or skills

to understand or evaluate written material, provide relevant details, or comprehend and integrate

the written documents they read.

Often, patient information in primary care doctors’ offices intended for

adolescents contains language more difficult than the reading level for the average American

adult, approximately a ninth grade level (NCES 2002). Patients with low literacy are less likely

to understand the adverse health consequences of obesity, the need to lose weight, and how to

balance caloric intake and energy expenditure to maintain healthy weight. These individuals

may also have more difficulty asking for help regarding weight loss. Not surprisingly, these

insufficiently literate, vulnerable populations have the highest rates of obesity. Despite the

emerging body of knowledge about the effects and consequences of obesity and low literacy,

very few studies have explored the relationship between literacy and weight loss knowledge

(Kennen et al, 2005).

In the article ‘Tipping the Scales: The Effect of Literacy on Obese Patients’ Knowledge

and Readiness to Lose Weight” (Kennen et al, 2005), outline the results of their study of obese

patients in Louisiana. By administering a REALM test, they learned that only one in three

patients read at, or above, a ninth grade level. “A substantial minority of patients could not read

the following words on the REALM: obesity, diabetes, nutrition, calories, exercise, meals and

fats” (Kennen 2005). This research suggests that the majority of patients in public health clinics

may not be able to read, understand, and act on currently available weight loss information, and

that adolescents may not be learning this information in school.

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Adolescents generally start making decisions about their own health around the age of

fifteen (Taylor et al 1984). Therefore, teaching basic health literacy skills in relation to nutrition

such as reading nutrition labels, calculating body mass index, and estimating caloric needs would

be an investment in inclusive education and comprehensive health care. Strategies for

educational administrators, managers and policymakers to promote health literacy include

incorporating the national health education standards in school curriculum reform initiatives, and

ensuring that all students can pass National Assessments of Educational Progress assessments.

Additionally, creating and requiring annual coursework in health literacy and health education

for all students in secondary schools would promote an improvement in health literacy (DPHHS

2010).

Furthermore, educators can utilize technology and the internet to enhance lesson plans

and improve health literacy. As a result of the federal “e-rate” program in the US, an initiative

to connect schools to the Internet- 98% of public high schools offered students access to the

internet in the fall of 2000 compared to 35% in 1994- and, on average, the ratio of students to

instructional computers was five to one (NCES 2001). A cross sectional school-based study

found that adolescents value the internet as a source of health-related information, including diet,

fitness, and exercise. The view of the internet as a “trustworthy” and “relevant” source of

information was independent of the student’s sex, ethnicity, or parent’s education (Borzekowski

et al, 2001). In another study, many adolescents expressed through focus groups that the

internet was their main source of information (Gray et al 2004).

Technology is not the complete answer, however. The internet and other media

marketplace information sources shape people’s health perceptions, choices and behaviors and

can have negative impacts on people’s health literacy (WHCA 2009). Many students reported

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literacy difficulties using the internet for health information, including spelling medical terms

incorrectly (such as diabetes and cardiovascular)), judging the relevance of information obtained,

and knowing which sites to trust (Gray et al 2005). Identifying these deficits can lead to

curriculum interventions and adaptations.

Obesity contributes to the development of many diseases and leads to the need to

access the healthcare system. In the settings where people have poor health literacy, this can be

especially challenging for the average population. Investing in the health education of

adolescents to 1) decrease the disease burden of obesity and 2) increase the health literacy skills

of the population will benefit the adolescents and the health care system in general. Innovative

curricula and the use of technology can engage the adolescent population and make tasks such as

reading food labels and considering caloric expenditure relevant and fun.

The hypothesis of this paper’s research is that an inquiry-based course (that included

biological references, technology, group work, group discussion, health article reading, writing,

puzzles and games, math and numeracy skills, and information that was relevant to adolescent

life) incorporated into a regular health education class would engage students and significantly

increase their knowledge of core diet and nutrition literacy concepts.

Methods

Subjects

A class of 19 students taking a Health Education Course at Gateway Regional High

School in Huntington, Massachusetts participated in this study. The workshop curriculum was

pre-approved by the Health Educator who helped administer the pre and post surveys, and who

remained present for all but one of the six classes. This class was ideal for this study because it

was highly inclusive and closely represented the demographics of the high school: there were 9

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males and 8 females; 4 Freshman, 4 Sophomores, 5 Juniors, and 4 seniors; 4 students had lived

there all their life, 9 students had moved there within the last 5 – 10 years, 5 students had moved

there within the last 5 years and 1 student was new this school year; 2 of the students had part-

time jobs in the fast food industry; 8 students ate school lunch daily, 8 students ate school lunch

2 -3 times a week, and 11 students ate school lunch 1 or less times a week; 1 student was on a

504 plan, and 3 students had IEP’s. None of the students were in the National Honor Society, but

9 students had taken advanced or AP classes. 17 students stated that they had taken Health

Education courses in the past. The remaining 2 students stated that they did not know. There

were no students of color. There were no ELL students.

Gateway Regional High School is considered a rural, high need (28.2% of students

qualified for free or reduced meals) school that services children from seven different towns.

There are 347 students enrolled in grades 9 – 12. Of these 177 are male and 170 are female.

Much like urban schools, budgets are strained, enrollment is down and poverty (28.2%) among

students is high. Unlike urban high schools, 96.3% of the students are considered white with

English as their primary language. 100% of the classrooms have computers and wireless internet

access. 36% of the students are planning on attending 4-year college after graduation and 39%

are planning on attending a 2-year college after graduation. For 2009, 78.8% of the 99 seniors

graduated. Of those, 54.3% were low income. For the MCAS tests of spring 2010, 91% of

students scored at proficient or above on the English Language as compared to 68% statewide.

29% scored at advanced/above proficient on English language. 73% of the students scored at

proficient or above on Math as compared to 59% statewide.

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Procedure

The Health Educator administered a multiple-choice pre-class survey one week before

the classes began. The teacher was instructed to verbally explain the directions written on the

survey and to emphasize the importance of honesty in answering the questions. Once there were

no further questions from the students, the survey was filled out. It began with 15 demographic

questions. The remainder of the survey was divided into five sections, or composites, for a total

of 30 questions. All questions were ordinally ranked using the Likert scale, multiple choice,

True/False and fill in the blank. The first composite was designed to assess healthy diet habits

and consisted of 8 questions. The second composite was designed to assess nutrition literacy and

comprehension and consisted of 6 questions. The third composite was designed to test medical

terminology and consisted of 6 questions. The fourth composite was designed to assess common

misconceptions and consisted of 5 questions. The fifth composite was designed to assess

numeracy skills and consisted of 4 questions (see attachment). All 19 students were present to fill

out the pre-class survey.

Curriculum

The diet and nutrition curriculum used for these classes covered all key areas of Standard

3 of the Massachusetts Comprehensive Health Curriculum Frameworks. Each lesson plan was

created in an attempt to support all students’ learning, including special education students, by

using a variety of teaching tools including PowerPoint visuals, lectures, written materials, group

work to help with any comprehension barriers, independent reading, independent writing, public

speaking, self-reflection, numeracy activities and games that incorporated movement. Student

assessment was ongoing and was based on class participation, completed handouts, proof of

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active reading with a written response, inquiry-based questions and answers, and evidence of

knowledge displayed while peer teaching. Critical thinking and questioning was encouraged,

focusing less on the answer and more on the thought process. Discussions incorporated many

analogies and real-life examples in an effort to keep the material relevant to the students’ lives

(see copy of curriculum and lesson plans).

The second survey was taken one week after the course was completed. This instrument

was identical in format to the first survey. Substituting similar vocabulary or text modified a few

of the questions in order to encourage scores that reflected comprehension skills rather than

memorization skills. Both the pre- and post-class surveys were not designed to be additive

scales, but rather surveys of several areas of health literacy and beliefs, so the reliability of the

surveys was not computed. Sixteen students completed this survey. Three students were absent

the day of the survey. None of the participants dropped out.

During the last (sixth) class, a course evaluation was given to the students to fill out. It

consisted of 19 questions and was designed to assess their satisfaction with the instructor and

curriculum. (see attachment) The evaluation data and survey data were compared to determine

whether subjective learning was dependent or independent of objective learning (formal

assessment). The evaluation also gave invaluable feedback to the instructor that will be used to

improve teaching methods and curriculum content. Seventeen of the students participated.

In order to consolidate the data to a few descriptive dimensions, all the responses in each

of the five categories were entered individually into a SPSS statistics analysis program.

Responses were given a numerical value with the most desirable answers receiving the highest

value. General demographic information and course evaluation responses were obtained by

summing the responses, then using the SPSS to note strong correlations with any of the five

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categories. Because of the small size of the subject group, no responses were eliminated.

Results

The hypothesis of this research was confirmed. The participation in an inquiry-based

workshop increased students’ health literacy and knowledge about diet and nutrition. Scores on

the post-workshop survey were significantly higher than the pre-workshop survey, both overall

and within each category. This is especially significant because only 10 out of the 19 students

attended all six classes. The results could have been affected either positively or negatively,

however, if all 19 students had been present to take the post-workshop survey.

Descriptive Statistics

N Minimum Maximum Sum Mean Std. Deviation Variance

HealthyDHabits 19 20.00 40.00 562.00 29.5789 5.11334 26.146

NutrtnCompr 19 6.00 24.00 329.00 17.3158 4.48519 20.117

MedTerm 19 6.00 18.00 278.00 14.6316 3.16597 10.023

TestMiscon 19 5.00 14.00 223.00 11.7368 2.32957 5.427

LblReadNumSkil 16 4.00 8.00 108.00 6.7500 1.61245 2.600

Valid N (listwise) 16

Pre-Class Survey Results (Above)

Descriptive Statistics

N Minimum Maximum Sum Mean Std. Deviation Variance

HealthyDHabits 15 24.00 40.00 491.00 32.7333 4.21675 17.781

NutrtnCompr 16 14.00 24.00 344.00 21.5000 3.16228 10.000

MedTerm 16 10.00 17.00 231.00 14.4375 2.18994 4.796

TestMiscon 15 9.00 14.00 185.00 12.3333 1.44749 2.095

LblReadNumSkil 14 5.00 8.00 98.00 7.0000 1.10940 1.231

Valid N (listwise) 13

Post-Class Survey Results (Above)

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Pre-Class Survey Post-Class Survey

As indicated above, the mean scores are much higher for the composite variable testing

sections in the post class survey. The variance is lower by almost ten points in some testing

sections such as Healthy Diet Habits and Nutrition Comprehension. Overall, the variance is

lower for all cases in the post-class survey and the mean scores are higher for each category. The

standard deviation is much lower (up to 2 units of standard deviation lower) for all sections

signifying less variance in the students’ answers to the questions. This shows a higher number of

correct answers, less variability in responses, and overall higher comprehension in Healthy Diet

Habits, Nutrition Comprehension, Medical Terminology, Testing Misconceptions and Label

Reading and Numeracy Skills.

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Symmetric Measures

Value

Asymp. Std.

Errora Approx. Tb Approx. Sig.

Interval by Interval Pearson's R .648 .126 3.065 .009c

Ordinal by Ordinal Spearman Correlation .675 .132 3.297 .006c

N of Valid Cases 15

a. Not assuming the null hypothesis.

b. Using the asymptotic standard error assuming the null hypothesis.

c. Based on normal approximation.

In the post-class survey, the students were asked “Did you, or will you, change your dietary

habits because of what you learned in this course?” Of the 16 students that answered, 3 chose ‘a

lot’ ; 9 chose ‘a little’; and 4 chose ‘not at all’. The students that indicated that they would

change their habits ‘a little’ or ‘a lot’, also had higher testing scores in the Healthy Diet Habits

composite. The table below supports a very strong correlation between a positive response to

changing eating habits and the healthy diet habits testing section of the survey. This may suggest

a positive correlation between Heath and diet comprehension and increased desire to apply and

change current behavior.

Course evaluation and the post-class survey question results showed high student

satisfaction with the course and instructor. ‘Class discussions’ was chosen as the ‘most valuable’

activity by most students (10/17). Other students preferred the videos (3/17), group work (2/17)

and unknown (1/17). The students’ least favorite activities were the PowerPoint lectures (7/16),

group work (6/16), class discussions (1/16), videos (1/16), and unknown (1/16). When asked

‘How useful were the lessons in teaching you about Diet and Nutrition?’ most students (14/17)

responded with a 4 (meaning mostly) or 5 (meaning very much). The remaining three students

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chose 3 (meaning some). All of the students indicated that this course should be mandatory for

all high school students. On a scale of 1 – 5 (1=not effective, 3=average, 5 = very effective),

most students (8/16) gave the instructor a ‘5’, and a ‘4’ (7/16). One student rated the instructor as

a ‘3’.

Discussion

This inquiry-based diet and nutrition course was introduced into an ongoing health

education class at a public high school in the hopes of gathering valuable educational and health

literacy data while providing students with usable knowledge that will help them to be health-

literate consumers and healthier people. The data collected suggests that the course was engaging

and improved the knowledge and health literacy skills of the students. The course also provided

the instructor with important teaching experience and invaluable feedback regarding curriculum

development and teaching methods.

Although the number of students in the class was small, it contained a balanced

proportion of ages, genders and learning abilities. The fact that each student that participated in

the post-class survey improved on his or her pre-class survey scores is encouraging. This

strongly suggests that an inclusive curriculum, which relies on an inquiry-based approach, would

be an effective method for increasing the health literacy of adolescents. Because the curriculum

incorporated biology, ecology, history, reading, writing and math into its subject matter, it could

easily be inserted into other required high school classes. This kind of cross-collaboration among

teachers would reinforce a useable and long-lasting educational experience for the students while

increasing their overall literacy, math and science skills, and ability to make good health choices.

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Even though this class did have a variety of ages and learning styles, all the students were

white and English speaking. Therefore, these results could not be applied to urban centers. Also,

due to the small class size and absenteeism, the research is in no way comprehensive. Future

studies, using a larger and more ethnically diverse subject group, need to take place in order to

substantiate what has been suggested here.

Another shortfall that may have affected the learning of the students, was the instructor’s lack of

experience teaching. Although the students enjoyed the teaching method and curriculum, an

experienced teacher may have been able to teach the course more effectively. Only three of the

classes managed to cover all the material on the agenda. This was due, in part, to great class

discussions, but also the instructor’s lack of experience in creating curriculum, guiding

discussions and pacing activities. One student remarked that the course was too short for the

amount of information given.

Nonetheless, the discussions were invaluable as a learning tool. The students asked many

medical questions related to diet and nutrition, which opened up some incredibly thoughtful and

engaging class discussions. Indeed, most students stated that ‘class discussion’ was the most

valuable activity. This kind of inquiry-based learning would not have taken place if the

instructor had not had a strong medical background. Currently, there is no standard training

requirement for Health Educators in public secondary schools. Highly trained teachers hired

specifically to teach health education should be placed in every school, and the course should be

mandatory.

In conclusion, expanding this kind of research should be considered in an effort to gather

actionable data and to create a standards-based, engaging and effective health education for

adolescents.

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