Effect of a nufrifion educafion program, "Learning by feaching", on aciolescents' knowle(jge and beliefs
Ulla Holund Royal Dental College, Aarhus, Denmark
•Holund U: Effeet of a nutrition education program, "Learning by teaching", on adolescents' knowledge and beliefs. Comtnunity Dent Oral Epidemiol 1990; 18: 61-5. Abstract - The purpose of this study was to evaluate the impact of a health education program on a group of adolescents' cognition (knowledge of sugar and caries (SUCA), knowledge of sugar and nutrition (SUNU), and beliefs about susceptibility (SUSC) and self-efficacy (SELF)). The strategy used was to make 14-yi-old students learn about nutrition and dental health through teaehing lO-yr-old students this topic. A pretest-posttest non-equivalent control group design was used. The experimental group consisted of four 8th grade classes from two schools and the reference group of four 8th grade classes frotn two comparable schools. The data was collected prior to, immediately after, and, for the experimental group, 2 months after the program implementation. Analysis of covariance with pretest measures as covariates showed no effect of the program on SUCA, SUSC, and SELF, while a significant interaction effect of study group and gender was found on SUNU, Neither social class of mother nor caries activity had a significant interaetion effect on knowledge and beliefs during the course. Future health education research should focus upon the effect of different educational approaches addressing beliefs more salient to adolescents.
The ultimate goal of any health education program is to influence health by changing behavior. Numerous theories have been put forward to explain whieh processes an individual goes through in order to adopt a new behavioral pattern. The PRECEDE framework is a guide to action rather than a causal explanation of health behavior, but it points out the common themes from the many models attempting to explain human behavior namely the influence on behavior from personal faetors (i.e. knowledge, beliefs, attitudes, and values) and from the environment in which one lives (1). The present paper will concentrate on the impact of a health education program on knowledge and beliefs. Knowledge can be described as factual information, whereas belief pertains to the degree to which one subjectively accepts an association between some object or behavior (e.g. sugar consumption) and a consequence (e.g. dental caries). According to the Health Belief Model readiness to take action for health steins among other things from the perception of susceptibility to the disease and its
potential severity (3), Thus, according to this model, one of the cognitive structures to be infiuenced by a nutrition education program should be the beliefs concerning susceptibility to diet-related diseases. Another widely used theory. Social Learning Theory, adds the construct "self-efficacy" to the cognitive elements (4), This construct refers to the beliefs about one's capability to perform specific behaviors in specific situations. Thus, one may feel susceptible to caries and believe that sugar redtietion is effective in preventing dental disease, and actually possess the skills to cut down on sugar but still lack the confidence to be able to do so. According to the Theory of Cognitive Dissonance (5) a nutrition education program might be successful if it could infiuence at least some of these cognitive elements, because the drive toward consistency will help create changes in other elements (e.g. attitudes and behavior). The purpose of the study was to evaluate the effect of a nutrition education progam on knowledge and beliefs about susceptibility and self-efficacy.
Key words: adolescents; beliefs: caries; diet; knowledge; nutrition education; self-efficacy Royal Dental College, Vennelyst Boulevard 9, 8000 Aarhus C, Denmark Accepted for publication 26 September 1989
Program description
"Learning by teaching" is a nutrition education program designed to teach 14yr-old students about nutrition and health. The overall goal of the nutrition education was to establish positive eating patterns for the prevention of dental and general disease (Fig. 1). This paper describes the program and presents the results of the program's effect on the cognitive structures: knowledge and beliefs about susceptibility and self-efficacy. "Learning by teaching" was based on the assumption that group discussions and role playing affect the cognitive structures of an individual (2), Thus, the educational strategy was to make 14-yrold students learn about dental and general health and nutrition by teaching 10yr-old students this topic. Prior to the teaching situation the 14yr-olds worked in groups with different topics. The classroom teacher was responsible for the implementation of the program, whieh took place in the courses of Danish and social subjects covering 25-30 lessons. The target group was the
62
HOLUND
14-yr-olds, who by actively taking a position in favor of healthy food in the presence of younger pupils were expected to change their own knowledge and beliefs in accordance with the information presented. The program was introduced by the author who acted as a consultant during the course, A videotape on dietary habits in Denmark and the factors influencing these was shown. The students were told that they were going to influence the diet of 4th graders in order to make them more healthy when they reached the 8 th grade than they themselves now were. They were made the experts and accordingly they were obliged to disseminate correct information. A box with relevant literature, group tasks, and a computer program was given to each class. In order to have a concrete starting point each of the students were to do a dietary interview with a pupil from the 4th grade. After that the children were divided into four groups working with four different topics. Finally, the groups were to demonstrate their results and conclusions to the 4th grade. All the tasks were to be solved in the local community in which the school was situated. The first group was called the Computer group. The participants of this group should analyze the dietary habits of the 4th graders with respect to distribution of energy on fat, protein, and carbohydrate. They should illustrate and evaluate the dietary habits of the most and the least healthy pupil according to the pyramid plan and they should demonstrate statistics of between meals and candy consumption. Program materials and procedures Implementation of program
The next group was the Culture group. The tasks of this group were to study how national and local factors influence the dietary habits. The objectives of these tasks were to make the students understand the limitations of the "free choice". They visited supermarkets to look at food supply, and the arrangement of foods among other things. They took photos and interviews, which was used later for poster production. The third group was called Food and Fashion group. The participants of this group worked with body image and commercials. Among other things they visited a work-out studio, where they interviewed the owner and some users on their view on staying healthy, whether this implied physical exercise alone or healthy eating as well. They analyzed commercials for their contradictory messages associating youth, smartness, and healthiness with soft drink and sweet food consumption. The last group was the Health group. The task of this group was to compare the caries prevalence of 4th and 8th grade students and to suggest to the 4th graders how they could secure better dental health for themselves when they grew older. One of the tasks was to plan the arrangement of a place at the school selling the foods neeessary to be strong, healthy, and good looking. The children also planned a strategy for marketing their products so as to make their peers accept the alternative and healthy foods. Finally, the 8th graders were to present the results and conclusions of their work on posters, which they would present to the 4th graders in a way the younger pupils were able to understand.
Each class received a box containing a teacher's manual, a student hand-out package, relevant literature, and a computer program for diet analysis. The teacher's manual contained a plan for the whole program, background information, and group worksheets. The student hand-out package included fact sheets and group worksheets. Material and method Study group and design
The study was conducted in the municipality of Aarhus in the Fall of 1985, and repeated in the Spring of 1986. A preand posttest design was used which involved an experimental group that participated in the program for 3 weeks, and a reference group that was offered participation in the program after the second data collection (Table 1), The sample consisted of 127 adolescents 14 yr old from four schools. The schools were allocated to two groups that were comparable with respect to type of residence, family income, and socioeconomic status. The groups were randomly assigned to either experiment or reference group. Thus, four 8th grade classes from two schools (« = 64) were given the program in December 1985, and four 8th grade classes from two other schools (« = 63) served as reference classes, and were given the program in March 1986, Table 1 shows the design and time schedule. Due to attrition (four individuals moved away and nine were ill at the second examination) the final sample consisted of 114 students (59 in the experimental and 55 in the reference group).
"LEARNING BY TEACHING"
PERSONAL FACTORS
ENVtRONMENT Social influences
Proximate outcomes
Curriculum material
changed knowledge and beliefs
changed attitudes and values
changed dietary behaviour
Improved nutritional status Distant outcomes Improved dental and general health
Fig. 1. Conceptual model of "Learning by teaching".
(family, pcera, mass media) School variahles (atmosphere and food availability)
Data collection, development ot measuring instruments, and operationalization of variables
Social and psychological variables were collected prior to, immediately after and, for the experimental group, 2 months after the program implementation. Cognitive variables (knowledge and beliefs regarding nutrition and health) were tapped as part of a 20-page survey (taking 30-45 min to complete). The questionnaire was administered so that the pupils were ensured anonymity. The class teacher was not allowed to be present to avoid influencing the children's answers.
Nutrition education
63
Table I. Design an(J time schedule
Group Experimental (« = 59) Reference (n = 55)
Interviews and selfadministered questionnaire
Nutrition education (3 weeks)
X X
X
Nov.85
Dec.85
Before filhng in the questionnaire the pupils were informed about the procedure and encouraged to give answers that were as honest as possible. This instrument was developed based on theoretical constructs suggested by the PRECEDE framework (1), the Health Belief Model (3), and Soeial Learning Theory (4). The items were generated and analyzed for comprehensibility in a pilot study comprising 23 14-yr-olds from a school that did not participate in the main study. Subsequently, the questionnaire was revised and four outcome measure indices were developed. Internal consistency analysis in terms of the alpha coefficient (6) was performed on the pretest data for each of the outcome measures. Coefficient alpha indicates the average intercorrelation between the test items and any set of items drawn from the same domain (i,e, items measuring the same variable). Coefficient alpha increases as the intercorrelations between the test items rise. Factual knowledge of the sugar - caries relationship was measured by an additive index based on six items, and knowledge of general nutrition and sugar was measured by an index consisting of two items. Each item was recoded into a diehotomous variable (correct versus incorrect), all of which were summed to yield a possible score range of 0-6 and 0-2, respectively (Cronbach's alpha = 0,42 and 0,60, respectively). The second type of cognitive variables measured was beliefs about susceptibility to diet-related diseases, A belief-score was computed for each respondent by summing the perceived susceptibility for overweight, coronary heart disease, and dental caries (three 4-point items). The potential score range was 3-12 (Cronbach's alpha = 0,57), Self-efficacy was measured on a 5point probability scale by adding responses to two statements concerning 1) the student's ability to cut down on sugar if
Interviews and selfadministered questionnaire
Nutrition education (3 weeks)
Interviews and selfadministered questionnaire
X X
X
X (X)
Jan./Feb.86
March 86
April 86
necessary and 2) the probability that he/ she would actually do so within 2 months. The potential score range was 2-10 (Cronbach's alpha 0,79), The pre- and posttests were identical as regards content, only the wording of some of the items was changed in order to prevent carry-over effect. Data on social and individual characteristics were obtained as part of a semistructured dietary interview. The validity of this questionnaire has been described elsewhere (7), Social characteristies were represented by mother's occupation (social status high ("1") and low ("0"), Individual characteristics were gender (boy = "0", girl = " l " and "caries-activity" (low = "0", high = "I"), Prevalence of approximal carious lesions was used as an indicator of caries activity, and measured using routinely taken bitewing radiographs. The radiographs were examined by the author using MATTSON'S (8) magnifying viewer for radiographs. The observations were recorded according to GRONDAHL'S (9) classification sys-
tem for approximal carious lesions. Subsequently this variable was dichotomized considering those with one or more carious lesions penetrating more than halfway through the enamel to be "caries active" and the rest "caries inactive". Data attalysis - The outcome variables were analyzed controlling for gender, social class and "caries activity", comparing the intervention group and the reference group. Analysis of covariance (ANCOVA) was used to assess differences between the two groups. The pretest scores served as covariates to control for potential baseline differences between the groups (10), All main effects were assessed as well as the study group by gender, study group by social class, and study group by caries prevalence twoway interaction terms. Subsequently, the long term effect on cognition at 2 tnonths postintervention was addressed.
Results Progam ettects
The progam had no effect on knowledge of sugar and caries, while gender and study group had a significant interaction effect on knowledge of sugar and nutrition (Table 2). The girls in the experiment group scored lower on the posttest than did the girls of the reference group, while the boys in the experiment group demonstrated higher sugar and nutrition knowledge compared to the reference group boys. Neither social class of mother, nor "caries activity" had a significant influence on knowledge acquisition during the course. Perceiving oneself susceptible to diet-related diseases was not significantly altered by the educational program nor was there any effect of the program on the perception of self-efficacy. This lack of effect was also present across gender, social class, and caries activity. Long-term effect
The experimental group did not improve their knowledge during the course, but the level of knowledge on sugar and caries was maintained at the 2-month follow-up as well as the knowledge of sugar and nutrition. The beliefs concerning susceptibility to diet-related diseases were maintained and self-efficacy in coping with sugar consumption was slightly improved at the 2-inonth follow-up examination (Fig. 2). Discussion
A major assumption of health belief research is that beliefs can be changed in desired directions once the desirable levels of beliefs have been identified. However, most investigations have not looked at the mechanisms for changing health beliefs. The present study examined the effect of a health education program on knowledge and beliefs. The
64
HOLUND
Table 2. Main and interaction effects of study group and gender on knowledge of sugar and caries (SUCA), knowledge of sugar and nutrition (SUNU), beliefs concerning susceptibility (SUSC), and self-efficacy (SELF). (Analysis of covarianoe with pretest measures used as covariates) Posttest means adjusted for pretest values SUCA (0-5)
SUNU (0-2)
SUSC (3-12)
SELF (2-10)
Boys Girls
2.42 2.51
0.84 0.38
6.20 7,15
7.57 7.02
Boys Girls
2.35 1.78
0.45 0.54
6.29 6.59
7.59 6.97
Group
Gender
Exp. Ref.
P-values Study group Gender Study group by gender
0.162 0.364
0.182 0.115
0.554 0.048*
0.991 0.068
0.188
0.023*
0.308
0.916
corroborated by KELLY et al. (11).
*P
Ulla Holund Royal Dental College, Aarhus, Denmark
•Holund U: Effeet of a nutrition education program, "Learning by teaching", on adolescents' knowledge and beliefs. Comtnunity Dent Oral Epidemiol 1990; 18: 61-5. Abstract - The purpose of this study was to evaluate the impact of a health education program on a group of adolescents' cognition (knowledge of sugar and caries (SUCA), knowledge of sugar and nutrition (SUNU), and beliefs about susceptibility (SUSC) and self-efficacy (SELF)). The strategy used was to make 14-yi-old students learn about nutrition and dental health through teaehing lO-yr-old students this topic. A pretest-posttest non-equivalent control group design was used. The experimental group consisted of four 8th grade classes from two schools and the reference group of four 8th grade classes frotn two comparable schools. The data was collected prior to, immediately after, and, for the experimental group, 2 months after the program implementation. Analysis of covariance with pretest measures as covariates showed no effect of the program on SUCA, SUSC, and SELF, while a significant interaction effect of study group and gender was found on SUNU, Neither social class of mother nor caries activity had a significant interaetion effect on knowledge and beliefs during the course. Future health education research should focus upon the effect of different educational approaches addressing beliefs more salient to adolescents.
The ultimate goal of any health education program is to influence health by changing behavior. Numerous theories have been put forward to explain whieh processes an individual goes through in order to adopt a new behavioral pattern. The PRECEDE framework is a guide to action rather than a causal explanation of health behavior, but it points out the common themes from the many models attempting to explain human behavior namely the influence on behavior from personal faetors (i.e. knowledge, beliefs, attitudes, and values) and from the environment in which one lives (1). The present paper will concentrate on the impact of a health education program on knowledge and beliefs. Knowledge can be described as factual information, whereas belief pertains to the degree to which one subjectively accepts an association between some object or behavior (e.g. sugar consumption) and a consequence (e.g. dental caries). According to the Health Belief Model readiness to take action for health steins among other things from the perception of susceptibility to the disease and its
potential severity (3), Thus, according to this model, one of the cognitive structures to be infiuenced by a nutrition education program should be the beliefs concerning susceptibility to diet-related diseases. Another widely used theory. Social Learning Theory, adds the construct "self-efficacy" to the cognitive elements (4), This construct refers to the beliefs about one's capability to perform specific behaviors in specific situations. Thus, one may feel susceptible to caries and believe that sugar redtietion is effective in preventing dental disease, and actually possess the skills to cut down on sugar but still lack the confidence to be able to do so. According to the Theory of Cognitive Dissonance (5) a nutrition education program might be successful if it could infiuence at least some of these cognitive elements, because the drive toward consistency will help create changes in other elements (e.g. attitudes and behavior). The purpose of the study was to evaluate the effect of a nutrition education progam on knowledge and beliefs about susceptibility and self-efficacy.
Key words: adolescents; beliefs: caries; diet; knowledge; nutrition education; self-efficacy Royal Dental College, Vennelyst Boulevard 9, 8000 Aarhus C, Denmark Accepted for publication 26 September 1989
Program description
"Learning by teaching" is a nutrition education program designed to teach 14yr-old students about nutrition and health. The overall goal of the nutrition education was to establish positive eating patterns for the prevention of dental and general disease (Fig. 1). This paper describes the program and presents the results of the program's effect on the cognitive structures: knowledge and beliefs about susceptibility and self-efficacy. "Learning by teaching" was based on the assumption that group discussions and role playing affect the cognitive structures of an individual (2), Thus, the educational strategy was to make 14-yrold students learn about dental and general health and nutrition by teaching 10yr-old students this topic. Prior to the teaching situation the 14yr-olds worked in groups with different topics. The classroom teacher was responsible for the implementation of the program, whieh took place in the courses of Danish and social subjects covering 25-30 lessons. The target group was the
62
HOLUND
14-yr-olds, who by actively taking a position in favor of healthy food in the presence of younger pupils were expected to change their own knowledge and beliefs in accordance with the information presented. The program was introduced by the author who acted as a consultant during the course, A videotape on dietary habits in Denmark and the factors influencing these was shown. The students were told that they were going to influence the diet of 4th graders in order to make them more healthy when they reached the 8 th grade than they themselves now were. They were made the experts and accordingly they were obliged to disseminate correct information. A box with relevant literature, group tasks, and a computer program was given to each class. In order to have a concrete starting point each of the students were to do a dietary interview with a pupil from the 4th grade. After that the children were divided into four groups working with four different topics. Finally, the groups were to demonstrate their results and conclusions to the 4th grade. All the tasks were to be solved in the local community in which the school was situated. The first group was called the Computer group. The participants of this group should analyze the dietary habits of the 4th graders with respect to distribution of energy on fat, protein, and carbohydrate. They should illustrate and evaluate the dietary habits of the most and the least healthy pupil according to the pyramid plan and they should demonstrate statistics of between meals and candy consumption. Program materials and procedures Implementation of program
The next group was the Culture group. The tasks of this group were to study how national and local factors influence the dietary habits. The objectives of these tasks were to make the students understand the limitations of the "free choice". They visited supermarkets to look at food supply, and the arrangement of foods among other things. They took photos and interviews, which was used later for poster production. The third group was called Food and Fashion group. The participants of this group worked with body image and commercials. Among other things they visited a work-out studio, where they interviewed the owner and some users on their view on staying healthy, whether this implied physical exercise alone or healthy eating as well. They analyzed commercials for their contradictory messages associating youth, smartness, and healthiness with soft drink and sweet food consumption. The last group was the Health group. The task of this group was to compare the caries prevalence of 4th and 8th grade students and to suggest to the 4th graders how they could secure better dental health for themselves when they grew older. One of the tasks was to plan the arrangement of a place at the school selling the foods neeessary to be strong, healthy, and good looking. The children also planned a strategy for marketing their products so as to make their peers accept the alternative and healthy foods. Finally, the 8th graders were to present the results and conclusions of their work on posters, which they would present to the 4th graders in a way the younger pupils were able to understand.
Each class received a box containing a teacher's manual, a student hand-out package, relevant literature, and a computer program for diet analysis. The teacher's manual contained a plan for the whole program, background information, and group worksheets. The student hand-out package included fact sheets and group worksheets. Material and method Study group and design
The study was conducted in the municipality of Aarhus in the Fall of 1985, and repeated in the Spring of 1986. A preand posttest design was used which involved an experimental group that participated in the program for 3 weeks, and a reference group that was offered participation in the program after the second data collection (Table 1), The sample consisted of 127 adolescents 14 yr old from four schools. The schools were allocated to two groups that were comparable with respect to type of residence, family income, and socioeconomic status. The groups were randomly assigned to either experiment or reference group. Thus, four 8th grade classes from two schools (« = 64) were given the program in December 1985, and four 8th grade classes from two other schools (« = 63) served as reference classes, and were given the program in March 1986, Table 1 shows the design and time schedule. Due to attrition (four individuals moved away and nine were ill at the second examination) the final sample consisted of 114 students (59 in the experimental and 55 in the reference group).
"LEARNING BY TEACHING"
PERSONAL FACTORS
ENVtRONMENT Social influences
Proximate outcomes
Curriculum material
changed knowledge and beliefs
changed attitudes and values
changed dietary behaviour
Improved nutritional status Distant outcomes Improved dental and general health
Fig. 1. Conceptual model of "Learning by teaching".
(family, pcera, mass media) School variahles (atmosphere and food availability)
Data collection, development ot measuring instruments, and operationalization of variables
Social and psychological variables were collected prior to, immediately after and, for the experimental group, 2 months after the program implementation. Cognitive variables (knowledge and beliefs regarding nutrition and health) were tapped as part of a 20-page survey (taking 30-45 min to complete). The questionnaire was administered so that the pupils were ensured anonymity. The class teacher was not allowed to be present to avoid influencing the children's answers.
Nutrition education
63
Table I. Design an(J time schedule
Group Experimental (« = 59) Reference (n = 55)
Interviews and selfadministered questionnaire
Nutrition education (3 weeks)
X X
X
Nov.85
Dec.85
Before filhng in the questionnaire the pupils were informed about the procedure and encouraged to give answers that were as honest as possible. This instrument was developed based on theoretical constructs suggested by the PRECEDE framework (1), the Health Belief Model (3), and Soeial Learning Theory (4). The items were generated and analyzed for comprehensibility in a pilot study comprising 23 14-yr-olds from a school that did not participate in the main study. Subsequently, the questionnaire was revised and four outcome measure indices were developed. Internal consistency analysis in terms of the alpha coefficient (6) was performed on the pretest data for each of the outcome measures. Coefficient alpha indicates the average intercorrelation between the test items and any set of items drawn from the same domain (i,e, items measuring the same variable). Coefficient alpha increases as the intercorrelations between the test items rise. Factual knowledge of the sugar - caries relationship was measured by an additive index based on six items, and knowledge of general nutrition and sugar was measured by an index consisting of two items. Each item was recoded into a diehotomous variable (correct versus incorrect), all of which were summed to yield a possible score range of 0-6 and 0-2, respectively (Cronbach's alpha = 0,42 and 0,60, respectively). The second type of cognitive variables measured was beliefs about susceptibility to diet-related diseases, A belief-score was computed for each respondent by summing the perceived susceptibility for overweight, coronary heart disease, and dental caries (three 4-point items). The potential score range was 3-12 (Cronbach's alpha = 0,57), Self-efficacy was measured on a 5point probability scale by adding responses to two statements concerning 1) the student's ability to cut down on sugar if
Interviews and selfadministered questionnaire
Nutrition education (3 weeks)
Interviews and selfadministered questionnaire
X X
X
X (X)
Jan./Feb.86
March 86
April 86
necessary and 2) the probability that he/ she would actually do so within 2 months. The potential score range was 2-10 (Cronbach's alpha 0,79), The pre- and posttests were identical as regards content, only the wording of some of the items was changed in order to prevent carry-over effect. Data on social and individual characteristics were obtained as part of a semistructured dietary interview. The validity of this questionnaire has been described elsewhere (7), Social characteristies were represented by mother's occupation (social status high ("1") and low ("0"), Individual characteristics were gender (boy = "0", girl = " l " and "caries-activity" (low = "0", high = "I"), Prevalence of approximal carious lesions was used as an indicator of caries activity, and measured using routinely taken bitewing radiographs. The radiographs were examined by the author using MATTSON'S (8) magnifying viewer for radiographs. The observations were recorded according to GRONDAHL'S (9) classification sys-
tem for approximal carious lesions. Subsequently this variable was dichotomized considering those with one or more carious lesions penetrating more than halfway through the enamel to be "caries active" and the rest "caries inactive". Data attalysis - The outcome variables were analyzed controlling for gender, social class and "caries activity", comparing the intervention group and the reference group. Analysis of covariance (ANCOVA) was used to assess differences between the two groups. The pretest scores served as covariates to control for potential baseline differences between the groups (10), All main effects were assessed as well as the study group by gender, study group by social class, and study group by caries prevalence twoway interaction terms. Subsequently, the long term effect on cognition at 2 tnonths postintervention was addressed.
Results Progam ettects
The progam had no effect on knowledge of sugar and caries, while gender and study group had a significant interaction effect on knowledge of sugar and nutrition (Table 2). The girls in the experiment group scored lower on the posttest than did the girls of the reference group, while the boys in the experiment group demonstrated higher sugar and nutrition knowledge compared to the reference group boys. Neither social class of mother, nor "caries activity" had a significant influence on knowledge acquisition during the course. Perceiving oneself susceptible to diet-related diseases was not significantly altered by the educational program nor was there any effect of the program on the perception of self-efficacy. This lack of effect was also present across gender, social class, and caries activity. Long-term effect
The experimental group did not improve their knowledge during the course, but the level of knowledge on sugar and caries was maintained at the 2-month follow-up as well as the knowledge of sugar and nutrition. The beliefs concerning susceptibility to diet-related diseases were maintained and self-efficacy in coping with sugar consumption was slightly improved at the 2-inonth follow-up examination (Fig. 2). Discussion
A major assumption of health belief research is that beliefs can be changed in desired directions once the desirable levels of beliefs have been identified. However, most investigations have not looked at the mechanisms for changing health beliefs. The present study examined the effect of a health education program on knowledge and beliefs. The
64
HOLUND
Table 2. Main and interaction effects of study group and gender on knowledge of sugar and caries (SUCA), knowledge of sugar and nutrition (SUNU), beliefs concerning susceptibility (SUSC), and self-efficacy (SELF). (Analysis of covarianoe with pretest measures used as covariates) Posttest means adjusted for pretest values SUCA (0-5)
SUNU (0-2)
SUSC (3-12)
SELF (2-10)
Boys Girls
2.42 2.51
0.84 0.38
6.20 7,15
7.57 7.02
Boys Girls
2.35 1.78
0.45 0.54
6.29 6.59
7.59 6.97
Group
Gender
Exp. Ref.
P-values Study group Gender Study group by gender
0.162 0.364
0.182 0.115
0.554 0.048*
0.991 0.068
0.188
0.023*
0.308
0.916
corroborated by KELLY et al. (11).
*P
