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Evaluation of the problem solving method in nutrition education Beggs, Louise Alice 1987

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EVALUATION OF THE PROBLEM SOLVING METHOD IN NUTRITION EDUCATION By LOUISE ALICE BEGGS B. S c . ( F . S c . ) / M c G i l l U n i v e r s i t y , 1984 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES ( S c h o o l o f F a m i l y and N u t r i t i o n a l S c i e n c e s ) We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA J u l y 1987 (c) L o u i s e A l i c e Beggs, 1987 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 DE-6(3/81) ABSTRACT The purpose of t h i s s t u d y was t o e v a l u a t e the problem s o l v i n g method a p p l i e d t o a s e l f - i n s t r u c t i o n a l m a t e r i a l i n n u t r i t i o n e d u c a t i o n . A c o m p a r a t i v e e v a l u a t i o n d e s i g n was employed to d e t e r m i n e the v a l u e of a problem s o l v i n g model r e f l e c t e d i n a c o m m e r c i a l l y d e v e l o p e d m a t e r i a l , r e f e r r e d t o as the ' C a lcium C a l c u l a t o r ' . Data were c o l l e c t e d u s i n g a q u a s i -e x p e r i m e n t a l randomized group p r e t e s t , p o s t t e s t r e s e a r c h d e s i g n . A p a n e l of judges then e v a l u a t e d the impact of the problem s o l v i n g method i n n u t r i t i o n e d u c a t i o n . Three r e s e a r c h q u e s t i o n s were g e n e r a t e d f o r the purpose of t h i s s t u d y . The f i r s t i n v o l v e d comparing impacts produced by the two forms of the 'Calcium C a l c u l a t o r ' . Measures of impact, s e l e c t e d based on l e a r n e r o b j e c t i v e s of the 'Calcium C a l c u l a t o r ' , were l e a r n e r s ' : a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s ; p e r c e p t i o n of problem s o l v i n g a b i l i t y and s e l f - r e p o r t e d d i e t a r y c a l c i u m i n t a k e . The second r e s e a r c h q u e s t i o n was posed t o i n v e s t i g a t e the n a t u r e of r e l a t i o n s h i p s between l e a r n e r s ' l e v e l s of s e l f - e s t e e m and measures of i n s t r u c t i o n a l impact. I n f l u e n c e s of s e l e c t e d biodemographic v a r i a b l e s on change i n the measures of impact were e x p l o r e d i n the t h i r d r e s e a r c h q u e s t i o n . E i g h t e e n groups of women (n=241) from community c e n t r e s were randomly a s s i g n e d t o one of t h r e e i n t e r v e n t i o n groups: Groups A and B were exposed t o a c t i v e problem s o l v i n g i i methods w h i l e group C viewed a f i l m , a p a s s i v e i n f o r m a t i o n -o r i e n t e d i n s t r u c t i o n a l t e c h n i q u e . The l a t t e r group was i n c l u d e d i n . t h e s t u d y s i n c e a c t i v e l e a r n i n g was h y p o t h e s i z e d t o r e s u l t i n g r e a t e r impact than p a s s i v e l e a r n i n g . P r e t e s t d a ta were c o l l e c t e d u s i n g a s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e and food i n t a k e form. P o s t t e s t d a t a were c o l l e c t e d an average of 4.7 weeks l a t e r u s i n g a m o d i f i c a t i o n of the p r e t e s t q u e s t i o n n a i r e which i n c l u d e d a s e l f - e s t e e m s c a l e , a l o n g w i t h the food i n t a k e form. F o r t y - f o u r p e r c e n t of women (n=l06) who completed p r e t e s t q u e s t i o n n a i r e s r e t u r n e d f o r the p o s t t e s t s e s s i o n . P a r t i c i p a n t s i n a l l t h r e e i n t e r v e n t i o n groups e x p e r i e n c e d i n c r e a s e s i n a t t i t u d e s c o r e s from p r e - t o p o s t t e s t , and thes e changes were s i g n i f i c a n t w i t h i n groups B and C. P e r c e p t i o n s of problem s o l v i n g a b i l i t y were m a i n t a i n e d w i t h i n i n t e r v e n t i o n groups B and C, y e t de c r e a s e d s i g n i f i c a n t l y w i t h i n i n t e r v e n t i o n group A. S i g n i f i c a n t i n c r e a s e s i n s e l f - r e p o r t e d d i e t a r y c a l c i u m i n t a k e s o c c u r r e d i n a l l t h r e e i n t e r v e n t i o n groups among non-pregnant women whose p r e t e s t d i e t a r y c a l c i u m i n t a k e s were below t h e i r Recommended N u t r i e n t I n t a k e . Impacts produced by form A and B of the 'Calcium C a l c u l a t o r ' were s i g n i f i c a n t l y d i f f e r e n t on o n l y one dependent v a r i a b l e : p e r c e p t i o n of problem s o l v i n g a b i l i t y (p<0.05). Changes i n the dependent v a r i a b l e s produced by problem s o l v i n g v e r s u s non-problem s o l v i n g i n t e r v e n t i o n s were not s i g n i f i c a n t l y d i f f e r e n t . Changes i n d i e t a r y c a l c i u m i n t a k e and a t t i t u d e toward d i e t a r y c a l c i u m and o s t e o p o r o s i s were not s i g n i f i c a n t l y c o r r e l a t e d w i t h s e l f - e s t e e m l e v e l s . However, p o s i t i v e s i g n i f i c a n t c o r r e l a t i o n s were i d e n t i f i e d between l e a r n e r s ' l e v e l s of s e l f - e s t e e m and change i n l e a r n e r s ' p e r c e p t i o n s of t h e i r problem s o l v i n g a b i l i t y ( p < 0 . 0 l ) . Measures of impact were i n f r e q u e n t l y i n f l u e n c e d by the biodemographic v a r i a b l e s . Of the a s s o c i a t i o n s t h a t were i d e n t i f i e d , most i n v o l v e d d i e t a r y c h a r a c t e r i s t i c s of p a r t i c i p a n t s . Yet change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y was a l s o a f f e c t e d by a c o m b i n a t i o n of t h r e e demographic v a r i a b l e s : age, employment s t a t u s and e d u c a t i o n . A p a n e l of u s e r s (n=9) of e d u c a t i o n a l m a t e r i a l s was asked t o make judgements on s e l e c t e d study r e s u l t s . A l t h o u g h judges d i d not d i s t i n g u i s h between impacts produced by the two problem s o l v i n g m a t e r i a l s , they acknowledged t h a t : (1) an i m p o r t a n t r e l a t i o n s h i p e x i s t s between s e l f -esteem and l e a r n e r s ' p e r c e p t i o n s of t h e i r problem s o l v i n g a b i l i t y and (2) the problem s o l v i n g method i s v a l u a b l e when d i r e c t e d t o s p e c i f i c k i n d s of l e a r n e r s . The q u a s i - e x p e r i m e n t a l r e s e a r c h d e s i g n used i n t h i s s t u d y appeared a p p r o p r i a t e f o r t h e e v a l u a t i o n of i n n o v a t i v e i n s t r u c t i o n a l methods. Two main advantages of the d e s i g n were i t s c o m p a r a t i v e n a t u r e and i t s use of a p a n e l of e x p e r t s t o judge the r e l a t i v e e f f e c t i v e n e s s of both forms of the 'Calcium C a l c u l a t o r ' as w e l l as the v a l u e of the problem s o l v i n g method and s e l f - e s t e e m i n m a t e r i a l d e s i g n . i v TABLE OF CONTENTS PAGE ABSTRACT i i LIST OF FIGURES x i i LIST OF TABLES x i i i ACKNOWLEDGEMENT x v i i CHAPTER I INTRODUCTION 1 Background to the Problem 1 The Impact of N u t r i t i o n E d u c a t i o n i n N o r t h America 1 The 'Calcium C a l c u l a t o r ' 5 Statement of the Problem 9 Research Q u e s t i o n s 10 Hypotheses 12 For Research Q u e s t i o n 1 12 For Research Q u e s t i o n 2 13 For Research Q u e s t i o n 3 14 D e f i n i t i o n of Terms 15 Assumptions 17 CHAPTER I I REVIEW OF THE LITERATURE 18 I n t r o d u c t i o n 18 The Impact of N u t r i t i o n E d u c a t i o n 18 L e a r n i n g T h e o r i e s i n E d u c a t i o n 20 I n s t r u c t i o n a l Methods i n N u t r i t i o n E d u c a t i o n 22 P a s s i v e I n s t r u c t i o n a l Methods 22 A c t i v e I n s t r u c t i o n a l Methods 23 S e l f - A s s e s s m e n t 25 S e l f - I n s t r u c t i o n 26 v TABLE OF CONTENTS (co n t ' d ) PAGE C h a r a c t e r i s t i c s of A d u l t L e a r n e r s 27 The Problem S o l v i n g I n s t r u c t i o n a l Method 29 Problem S o l v i n g Methods f o r P e r s o n a l Behaviour Change 30 Problem S o l v i n g Methods A p p l i e d t o N u t r i t i o n E d u c a t i o n 34 The M o t i v a t i o n G e n e r a t i n g Paradigm 37 S e l f - E s t e e m 38 E v a l u a t i o n P r a c t i c e s i n N u t r i t i o n E d u c a t i o n 42 E v a l u a t i o n D e s i g n s 43 Comparative E v a l u a t i o n i n E d u c a t i o n 44 Meas u r i n g I n s t r u c t i o n a l Impact 45 Q u e s t i o n n a i r e s 45 Q u e s t i o n n a i r e D esign 46 Q u e s t i o n n a i r e A d m i n i s t r a t i o n 49 Measurement of Change i n D i e t a r y B e h a v i o u r ... 50 A n a l y s i s of I n s t r u c t i o n a l Impact 51 R e s p o n s i b i l i t y f o r J u d g i n g the Val u e of a Program . 53 The R o l e of C a l c i u m i n O s t e o p o r o s i s 55 D i e t a r y C a l c i u m I n t a k e s of Women 57 The Role of C a l c i u m i n P r e v e n t i o n and Treatment of O s t e o p o r o s i s 59 Summary 60 CHAPTER I I I METHODS 62 Design 62 S p e c i f i c a t i o n of the V a r i a b l e s 64 v i TABLE OF CONTENTS (cont'd) PAGE Sample 65 Data C o l l e c t i o n I n s t r u m e n t s 68 The Q u e s t i o n n a i r e 69 The Food I n t a k e Form 79 The S e l f - E s t e e m S c a l e 81 Form B of the ' C a l c ium. C a l c u l a t o r ' 82 Data C o l l e c t i o n P r o c e d u r e s 84 P r e t e s t Data C o l l e c t i o n 84 I n t e r v e n t i o n 85 P o s t t e s t Data C o l l e c t i o n 88 P r e p a r a t i o n of the Data f o r A n a l y s i s 91 A n a l y s i s of the Data 92 The Biodemographic V a r i a b l e s 92 For Each Research Q u e s t i o n 96 Research Q u e s t i o n 1 97 Research Question.2 98 Research Q u e s t i o n 3 99 Judgement of the A n a l y z e d Data 100 P r e p a r a t i o n f o r the Judgement Phase 100 S e l e c t i o n of the Judgement Panel 102 The Judgement P r o c e s s 103 Judgement Q u e s t i o n s 104 L i m i t a t i o n s of the Study 106 CHAPTER IV RESULTS AND DISCUSSION 107 I n t r o d u c t i o n 107 The Study Sample 107 v i i TABLE OF CONTENTS (cont'd) PAGE S e l e c t e d Biodemographic C h a r a c t e r i s t i c s of P a r t i c i p a n t s 110 Comparison of P a r t i c i p a n t s by E x t e n t of P a r t i c i p a t i o n 120 R e l i a b i l i t y of the Measurement S c a l e s 123 The S e l f - E s t e e m S c a l e 123 The A t t i t u d e S c a l e 125 The P e r c e p t i o n S c a l e 127 D i f f e r e n c e s among I n t e r v e n t i o n Groups on P r e t e s t Dependent V a r i a b l e s 127 For Research Q u e s t i o n 1 131 Hypotheses 1.1 and 1.4: Impacts on D i e t a r y C a l c i u m I n t a k e 133 Hypotheses 1.2 and 1.5: Impacts on A t t i t u d e toward D i e t a r y C a l c i u m and O s t e o p o r o s i s . 142 Hypotheses 1.3 and 1.6: Impacts on P e r c e p t i o n of Problem S o l v i n g A b i l i t y ... 152 Impacts R e l a t i v e t o Adherence t o the Problem S o l v i n g S t e p s 163 For Research Q u e s t i o n 2 167 H y p o t h e s i s 2.1: R e l a t i o n s h i p s between S e l f - E s t e e m and Change i n A t t i t u d e 170 H y p o t h e s i s 2.2: R e l a t i o n s h i p s between S e l f - E s t e e m and Change i n P e r c e p t i o n of Problem S o l v i n g A b i l i t y 178 v i i i TABLE OF CONTENTS (cont'd) PAGE H y p o t h e s i s 2.3: R e l a t i o n s h i p s between S e l f - E s t e e m and Change i n D i e t a r y C a l c i u m I n t a k e 186 For Research Q u e s t i o n 3 189 E f f e c t s on Change i n A t t i t u d e toward D i e t a r y C a l c i u m and O s t e o p o r o s i s 190 E f f e c t s on Change i n D i e t a r y C a l c i u m I n t a k e . 192 E f f e c t s on Change i n P e r c e p t i o n of Problem S o l v i n g A b i l i t y 192 P a r t i c i p a n t s ' Responses t o the I n t e r v e n t i o n s 198 R e s u l t s of the Judgement Phase 200 I n d i v i d u a l Judgements 200 Group Judgements 206 Judges' Comments f o r F u t u r e Research 215 CHAPTER V SUMMARY, IMPLICATIONS AND RECOMMENDATIONS .. 217 Summary 217 Purpose 217 Procedure 218 A n a l y s i s 220 Ps y c h o m e t r i c P r o p e r t i e s of the I n s t r u m e n t s .. 221 R e s u l t s 222 For R e s e a r c h Q u e s t i o n 1 222 For R e s e a r c h Q u e s t i o n 2 223 For R e s e a r c h Q u e s t i o n 3 225 P a r t i c i p a n t s ' Responses t o the I n t e r v e n t i o n 226 i x TABLE OF CONTENTS (cont'd) PAGE R e s u l t s from the Judgement Phase 226 I m p l i c a t i o n s 228 I m p l i c a t i o n s r e l a t e d t o the 'Calcium C a l c u l a t o r ' 228 I m p l i c a t i o n s r e l a t e d t o N u t r i t i o n E d u c a t i o n . 229 I m p l i c a t i o n s r e l a t e d t o E v a l u a t i o n R e s e a r c h i n N u t r i t i o n E d u c a t i o n 231 Recommendations 232 C o n c l u s i o n 234 LITERATURE CITED 235 APPENDIX A : Form A and Form B of the 'Calcium C a l c u l a t o r ' and Common Concern Sheets 245 APPENDIX B : C e r t i f i c a t e of A p p r o v a l f o r Research : U n i v e r s i t y E t h i c s Committee A p p r o v a l 255 APPENDIX C : Cover L e t t e r and Q u e s t i o n n a i r e f o r P r e t e s t Data C o l l e c t i o n 257 APPENDIX D : Cover L e t t e r and Q u e s t i o n n a i r e f o r P o s t t e s t Data C o l l e c t i o n 264 APPENDIX E : V a l i d a t i o n Forms f o r Items from the P r e - and P o s t t e s t Q u e s t i o n n a i r e 278 APPENDIX F : V a l i d a t i o n Forms f o r Form B of the 'Calcium C a l c u l a t o r ' 292 APPENDIX G : The C u l t u r e - F r e e S e l f - E s t e e m I n v e n t o r y 298 x TABLE OF CONTENTS (cont'd) PAGE APPENDIX H : Forms used t o Compare R e s u l t s of a Twenty-four Hour R e c a l l t o the Food I n t a k e Form 300 APPENDIX I : S t a n d a r d i z e d Procedure f o r the P r e t e s t Workshops 305 APPENDIX J : Pearson C o r r e l a t i o n C o e f f i c i e n t s f o r "below RNI" Data (Research Q u e s t i o n 2) ... 309 APPENDIX K : Judgement M a t e r i a l s 319 x i LIST OF FIGURES PAGE 1. T h e o r e t i c a l model of the r e l a t i o n s h i p between s e l f - e s t e e m , b e h a v i o u r and a t t i t u d e toward the b e h a v i o u r 7 2. A problem s o l v i n g sequence f o r p e r s o n a l change 31 3. Problem s o l v i n g sequence i n the m o t i v a t i o n g e n e r a t i n g paradigm '36 4. An e v a l u a t i o n method a p p l i e d t o the 'Calcium C a l c u l a t o r ' 63 5. P e r c e n t a g e s of p a r t i c i p a n t s w i t h d i e t a r y c a l c i u m a t or above Recommended N u t r i e n t I n t a k e b e f o r e and a f t e r workshops, by i n t e r v e n t i o n group 136 x i i LIST OF TABLES PAGE 1. Sample s i z e s by i n t e r v e n t i o n group 67 2. Content v a l i d a t i o n of the q u e s t i o n n a i r e : d i s t r i b u t i o n of judges' r a t i n g s of item r e l e v a n c e t o the c o n t e n t c o n s t r u c t 74 3. Content v a l i d a t i o n of the q u e s t i o n n a i r e : p e r c e n t a g e of judges who s t a t e d t h a t items were r e p r e s e n t a t i v e of t h e i r s u b s c a l e 76 4. R e l a t i o n s h i p of the s t e p s i n form B t o the Havelock (1973) model 83 5. Data s o u r c e s f o r the dependent and independent v a r i a b l e s a t p r e t e s t 86 6. Data s o u r c e s f o r the dependent and independent v a r i a b l e s a t p o s t t e s t 90 7. P r e - a n a l y s i s h a n d l i n g of the d a t a 93 8. Community groups which p a r t i c i p a t e d i n C a l c i u m and Bone H e a l t h Workshops 108 9. D i s t r i b u t i o n of p r e t e s t p a r t i c i p a n t s (n=241) by biodemographic v a r i a b l e s , w i t h i n i n t e r v e n t i o n groups 111 10. D i s t r i b u t i o n of p o s t t e s t p a r t i c i p a n t s (n=l06) by biodemographic v a r i a b l e s , w i t h i n i n t e r v e n t i o n groups 116 11. D i s t r i b u t i o n of p a r t i c i p a n t s who a t t e n d e d both p r e - and p o s t t e s t (n=l06) by biodemographic v a r i a b l e s , w i t h i n i n t e r v e n t i o n groups 119 12. D i s t r i b u t i o n of p r e t e s t p a r t i c i p a n t s on s e l e c t e d biodemographic v a r i a b l e s , based on e x t e n t of p a r t i c i p a t i o n 121 13. I n t e r n a l c o n s i s t e n c y c o e f f i c i e n t s f o r the s e l f - e s t e e m s c a l e a t p i l o t t e s t i n g and i n the a c t u a l study 124 14. I n t e r n a l c o n s i s t e n c y c o e f f i c i e n t s f o r the a t t i t u d e s c a l e a t p r e - and p o s t t e s t 126 15. I n t e r n a l C o n s i s t e n c y C o e f f i c i e n t s f o r the P e r c e p t i o n S c a l e at P r e - and P o s t t e s t 128 x i i i LIST OF TABLES (cont'd) PAGE 16. Comparison of mean p r e t e s t v a l u e s f o r the dependent v a r i a b l e s , by i n t e r v e n t i o n group 129 17. Comparison of mean p r e t e s t v a l u e s f o r the dependent v a r i a b l e s , by e x t e n t of p a r t i c i p a t i o n ... 132 18. Comparison of p r e - and p o s t t e s t v a l u e s f o r mean d i e t a r y c a l c i u m i n t a k e w i t h i n i n t e r v e n t i o n groups 134 19. Comparison of change i n d i e t a r y c a l c i u m i n t a k e among i n t e r v e n t i o n groups A, B and C 137 20. Comparison of change i n d i e t a r y c a l c i u m i n t a k e between i n t e r v e n t i o n groups A and B 139 21. Comparison of p r e - and p o s t t e s t v a l u e s f o r ATTITUDE TOWARD DIETARY CALCIUM and OSTEOPOROSIS w i t h i n i n t e r v e n t i o n group A 143 22. Comparison of p r e - and p o s t t e s t v a l u e s f o r ATTITUDE TOWARD DIETARY CALCIUM and OSTEOPOROSIS w i t h i n i n t e r v e n t i o n group B 144 23. Comparison of p r e - and p o s t t e s t v a l u e s f o r ATTITUDE TOWARD DIETARY CALCIUM and OSTEOPOROSIS w i t h i n i n t e r v e n t i o n group C 145 24. Comparison of change i n ATTITUDE TOWARD DIETARY CALCIUM and OSTEOPOROSIS among i n t e r v e n t i o n groups A, B and C 149 25. Comparison of change i n ATTITUDE TOWARD DIETARY CALCIUM and OSTEOPOROSIS between i n t e r v e n t i o n groups A and B 150 26. Comparison of p r e - and p o s t t e s t v a l u e s f o r PERCEPTION OF PROBLEM SOLVING ABILITY w i t h i n i n t e r v e n t i o n group A 153 27. Comparison of p r e - and p o s t t e s t v a l u e s f o r PERCEPTION OF PROBLEM SOLVING ABILITY w i t h i n i n t e r v e n t i o n group B 154 28. Comparison of p r e - and p o s t t e s t v a l u e s f o r PERCEPTION OF PROBLEM SOLVING ABILITY w i t h i n i n t e r v e n t i o n group C 155 29. Comparison of change i n PERCEPTION OF PROBLEM SOLVING ABILITY among i n t e r v e n t i o n groups A, B and C 159 x i v LIST OF TABLES (cont'd) PAGE 30. Comparison of change i n PERCEPTION OF PROBLEM SOLVING ABILITY between i n t e r v e n t i o n groups A and B 160 31. D i s t r i b u t i o n of p a r t i c i p a n t s on adherence t o the problem s o l v i n g s t e p s , w i t h i n i n t e r v e n t i o n groups A and B 164 32. Comparison of p a r t i c i p a n t s on change i n the dependent v a r i a b l e s by degree of adherence t o the problem s o l v i n g s t e p s 166 33. Comparison of mean s e l f - e s t e e m s c o r e s , by i n t e r v e n t i o n group 168 34. Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and ATTITUDE TOWARD DIETARY CALCIUM AND OSTEOPOROSIS f o r p o o l e d data 171 35. Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and ATTITUDE TOWARD DIETARY CALCIUM AND OSTEOPOROSIS f o r p o o l e d group A da t a 173 36. Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and ATTITUDE TOWARD DIETARY CALCIUM AND OSTEOPOROSIS f o r p o o l e d group B da t a 174 37. Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and ATTITUDE TOWARD DIETARY CALCIUM AND OSTEOPOROSIS f o r p o o l e d group C dat a 175 38. Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and PERCEPTION OF PROBLEM SOLVING ABILITY f o r p o o l e d data 179 39. Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and PERCEPTION OF PROBLEM SOLVING ABILITY f o r p o o l e d group A da t a ... 181 40. Pearson C o r r e l a t i o n C o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and PERCEPTION OF PROBLEM SOLVING ABILITY f o r p o o l e d group B d a t a ... 182 41. Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and PERCEPTION OF PROBLEM SOLVING ABILITY f o r p o o l e d group C d a t a ... 183 xv LIST OF TABLES (cont'd) PAGE 42. Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and d i e t a r y c a l c i u m i n t a k e 187 43. D i s t r i b u t i o n of p a r t i c i p a n t s w i t h i n i n t e r v e n t i o n groups by e x t e n t of s a t i s f a c t i o n w i t h t h e i n t e r v e n t i o n 198 44. Frequency of comments on the i n t e r v e n t i o n , by i n t e r v e n t i o n group 199 45. D i s t r i b u t i o n of judges' responses t o d a t a sheet A . 201 46. D i s t r i b u t i o n of judges' responses to q u e s t i o n 1 f o r d a t a sheet B 204 47. D i s t r i b u t i o n of judges' responses to q u e s t i o n 2 f o r d a t a sheet B 206 48. D i s t r i b u t i o n of group judgement responses t o data sheet A 207 49. D i s t r i b u t i o n of group judgement responses t o q u e s t i o n 1 f o r data sheet B 209 50. D i s t r i b u t i o n of group judgement responses t o q u e s t i o n 2 f o r d a t a sheet B 211 51. D i s t r i b u t i o n of judges' responses to Statement 1 of the c o n c l u d i n g judgements, by group 213 52. D i s t r i b u t i o n of judges' responses t o Statement 2 of the c o n c l u d i n g judgements, by group 214 x v i ACKNOWLEDGEMENT I would l i k e t o e x p r e s s my most s i n c e r e g r a t i t u d e t o Dr. Nancy Schwartz, my main t h e s i s a d v i s o r , f o r p r o v i d i n g u n f a i l i n g e n thusiasm, c a r e and p r o f e s s i o n a l i s m throughout the p e r i o d of r e s e a r c h and i n the p r e p a r a t i o n of t h i s m a n u s c r i p t . A p p r e c i a t i o n i s a l s o extended t o Dr. Susan Ba r r f o r her a s s i s t a n c e as a committee member and i n her much-a p p r e c i a t e d r o l e as my second t h e s i s a d v i s o r . I would a l s o l i k e t o thank Dr. Don W i l s o n from the F a c u l t y of E d u c a t i o n f o r h i s e n t h u s i a s t i c s u p p o r t and concern f o r the v a l u e of t h i s r e s e a r c h . A l s o , a s p e c i a l thank you t o Dr. Dan Perlman f o r j o i n i n g the committee i n - p r o g r e s s and e x p r e s s i n g i n t e r e s t i n the p r o j e c t . S p e c i a l a p p r e c i a t i o n i s a l s o due t o V i r g i n i a Green f o r her e x p e r t and p a t i e n t a s s i s t a n c e w i t h the s t a t i s t i c a l a n a l y s i s of the p r o j e c t d a t a . A l s o , warm a p p r e c i a t i o n i s e x p r e s s e d t o both R o b e r t a Crosby and M a r c i a Pederson f o r t h e i r i n v a l u a b l e a s s i s t a n c e i n p r e p a r i n g t a b l e s and t y p i n g t h e m a n u s c r i p t . I would a l s o l i k e t o thank the B.C. D a i r y F o u n d a t i o n f o r f u n d i n g my r e s e a r c h . A l s o , a ve r y s p e c i a l thank you to the two n u t r i t i o n e d u c a t o r s from the B.C. D a i r y F o u n d a t i o n , Sydney Massey and J i l l B u r c h i l l , who performed the p r e t e s t workshops. Warmest thanks a r e extended t o G i l l A c k h u r s t , N u t r i t i o n C o o r d i n a t o r a t the B.C. D a i r y F o u n d a t i o n , f o r her c o n s t a n t enthusiasm and i n t e r e s t i n the r e s e a r c h . F i n a l l y , a most s i n c e r e and p e r s o n a l thank you t o Br u c e , my husband, f o r h i s l o v i n g s u p p o r t , guidance and u n d e r s t a n d i n g throughout t h i s c h a l l e n g i n g e x p e r i e n c e . x v i i CHAPTER I INTRODUCTION Background t o the Problem In a r a p i d l y c h a n g i n g t e c h n o l o g i c a l s o c i e t y i n which the number and v a r i e t y of food p r o d u c t s a r e c o n t i n u a l l y i n c r e a s i n g , consumers need s k i l l s t o make the b e s t p o s s i b l e food c h o i c e s . Canadians a r e s u b m i t t e d t o a b a r r a g e of f o o d -and n u t r i t i o n - r e l a t e d myths which need t o be supplemented and r e p l a c e d w i t h s c i e n t i f i c i n f o r m a t i o n communicated through n u t r i t i o n e d u c a t i o n (Gussow 1984). The p r o c e s s of n u t r i t i o n e d u c a t i o n i s d e f i n e d as the t e a c h i n g of v a l i d a t e d , c o r r e c t n u t r i t i o n knowledge i n ways t h a t promote the development and maintenance of p o s i t i v e a t t i t u d e s toward food, as w e l l as f a v o u r a b l e h a b i t s of food consumption (Johnson and Johnson 1985). N u t r i t i o n e d u c a t i o n i s t h e r e f o r e concerned w i t h the a c t u a l q u a l i t y of i n f o r m a t i o n b e i n g conveyed as w e l l as the methods by which the message i s r e l a y e d . The Impact of N u t r i t i o n E d u c a t i o n i n N o r t h America S i n c e the e a r l y 1900's c o n s i d e r a b l e r e s e a r c h i n both Canada and the U n i t e d S t a t e s has c e n t r e d on the impact of n u t r i t i o n e d u c a t i o n . I n i t i a l l y , e v a l u a t i o n r e s u l t s were based on o b j e c t i v e measures of knowledge g a i n s . S i n c e the 1970's, however, b e h a v i o u r change has become r e c o g n i z e d as 1 the p r i m a r y g o a l of n u t r i t i o n e d u c a t i o n (Johnson and Johnson 1985) and i s t h e r e f o r e i n c r e a s i n g l y acknowledged as a key c r i t e r i o n f o r the judgement of program impact. R e g a r d l e s s of the impact c r i t e r i a chosen, some r e s u l t s of n u t r i t i o n e d u c a t i o n e v a l u a t i o n s have been d i s c o u r a g i n g (Gussow 1984) or a t ve r y l e a s t , ambiguous ( A x e l s o n et a l . 1985). In t h e i r m e t a - a n a l y s i s of n u t r i t i o n e d u c a t i o n , Johnson and Johnson (1985) r e p o r t e d t h a t w h i l e some s t u d i e s have shown a p o s i t i v e r e l a t i o n s h i p between i n c r e a s e d n u t r i t i o n knowledge s c o r e s and improved d i e t a r y b e h a v i o u r (McDonald et a l . 1981; Smith and James 1980) the m a j o r i t y of s t u d i e s have not (Byrd-Bredbenner e t a l . 1984; Schwartz 1975; P i c c a r d i and P o r t e r 1976). Nor has a p o s i t i v e n u t r i t i o n -and f o o d - r e l a t e d a t t i t u d e been c o n s i s t e n t l y a s s o c i a t e d w i t h more f a v o u r a b l e d i e t a r y b e h a v i o u r s (Johnson and Johnson 1985). I t has been c o n c l u d e d by Johnson and Johnson (1985) t h a t n u t r i t i o n e d u c a t i o n : (1) has s i g n i f i c a n t l y i n c r e a s e d l e v e l s of n u t r i t i o n knowledge among l e a r n e r s ; (2) tends t o f o s t e r more p o s i t i v e a t t i t u d e s toward fo o d ; and (3) r e s u l t s i n some c o n s t r u c t i v e changes i n p a r t i c i p a n t s ' p a t t e r n s of food consumption. The above a u t h o r s have a l s o s t r e s s e d , however, t h a t p o t e n t i a l remains f o r g r e a t e r e d u c a t i o n a l impact on f o o d - r e l a t e d b e h a v i o u r s . I t has been f u r t h e r argued t h a t t o be most e f f e c t i v e , n u t r i t i o n e d u c a t o r s s h o u l d be concerned w i t h the methods of i n s t r u c t i o n t h e y employ. The k i n d s of i n s t r u c t i o n a l methods chosen by n u t r i t i o n e d u c a t o r s may have been a t l e a s t p a r t l y r e s p o n s i b l e f o r the d i s a p p o i n t i n g outcomes of some 2 n u t r i t i o n e d u c a t i o n programs. In f a c t , Hochbaum (1981) contended t h a t n u t r i t i o n e d u c a t i o n i s founded on s e v e r a l i n v a l i d a s s u m p t i o n s , the most d e t r i m e n t a l b e i n g t h a t the p r o v i s i o n of n u t r i t i o n i n f o r m a t i o n t o consumers w i l l be s u f f i c i e n t m o t i v a t i o n f o r b e h a v i o u r change. In 1973, Whitehead completed a comprehensive r e v i e w of e v a l u a t i o n s t u d i e s i n n u t r i t i o n e d u c a t i o n and noted the e x c e s s i v e emphasis b e i n g p l a c e d on i n f o r m a t i o n d i s s e m i n a t i o n and the r e s u l t i n g i n c o n s i s t e n t impacts of i n s t r u c t i o n . C o n s e q u e n t l y , she advocated t h a t s u c c e s s f u l i n s t r u c t i o n s h o u l d be d e s i g n e d t o e n able l e a r n e r s t o r e c o g n i z e t h e i r own n u t r i t i o n a l c o n c e r n s and a s s i s t them t h r o u g h a c t i v e p r o c e s s e s of problem s o l v i n g such t h a t they l e a r n t o r e s o l v e these c o n c e r n s . The s u g g e s t i o n t h a t n u t r i t i o n e d u c a t o r s i n c o r p o r a t e g r e a t e r a c t i v e s t u d e n t i n v o l v e m e n t i n the l e a r n i n g p r o c e s s i s not new, however, h a v i n g been recommended by B e r g e v i n i n 1957. More r e c e n t l y , Johnson and Johnson (1985) c o n c l u d e d t h a t a s h i f t i n the s e l e c t i o n of i n s t r u c t i o n a l methods by n u t r i t i o n e d u c a t o r s i s s t i l l v e r y n e c e s s a r y . The m a j o r i t y of n u t r i t i o n e d u c a t i o n programs e v a l u a t e d t o date have r e l i e d h e a v i l y on p a s s i v e l e a r n i n g methods i n which p a r t i c i p a n t s a r e not e x p e c t e d t o c o n t r i b u t e a c t i v e l y t o the e d u c a t i o n a l e x p e r i e n c e . As a r e s u l t , the dominant methods of i n s t r u c t i o n c o n t i n u e t o be l e c t u r e s and the p r o v i s i o n of w r i t t e n i n f o r m a t i o n . Few e d u c a t i o n a l a t t e m p t s which i n c l u d e d a c t i v e l e a r n i n g methods by n u t r i t i o n e d u c a t o r s have been documented. 3 Examples of some of these i n c l u d e food t a s t i n g d e m o n s t r a t i o n s ( A l f o r d and T i b b i t t 1971), s c h o o l l u n c h a c t i v i t i e s (Smith and James 1980), l a b e l r e a d i n g and e x p l o r a t i o n s of f a d d i e t s (Byrd-Bredbenner et a l . 1984). These e v a l u a t i o n s have been performed t o measure the impact of s p e c i f i c programs and as a r e s u l t , have not i n v o l v e d e v a l u a t i o n of the e d u c a t i o n a l d e s i g n upon which the s p e c i f i c i n s t r u c t i o n a l methods were based. Johnson and Johnson (1985) a l s o urged n u t r i t i o n e d u c a t o r s t o r e i n f o r c e the c o n c e p t u a l b a s i s of program d e s i g n . S p e c i f i c i n s t r u c t i o n a l methods need t o be e v a l u a t e d t o v a l i d a t e and e x p l a i n t h e i r e f f e c t i v e n e s s . A c t i v e l e a r n i n g methods s h o u l d be d e s i g n e d based upon the r e c o g n i t i o n of p s y c h o s o c i a l f a c t o r s which a f f e c t b e h a v i o u r change (Sims 1981A; W o o l c o t t e t a l . 1983; B i r c h 1981). Most e a r l i e r programs by n u t r i t i o n e d u c a t o r s f a i l e d t o acknowledge some of the e n v i r o n m e n t a l , s o c i a l and p s y c h o l o g i c a l i n f l u e n c e s on n u t r i t i o n - r e l a t e d b e h a v i o u r s (Johnson and Johnson 1985). As a r e s u l t , r e s e a r c h e r s have r e c e n t l y begun r e l a t i n g p e r s o n a l i t y c h a r a c t e r i s t i c s t o s p e c i f i c h e a l t h and n u t r i t i o n - r e l a t e d b e h a v i o u r s . L e a r n e r s ' l e v e l s of s e l f - e s t e e m , e s p e c i a l l y t h e i r f e e l i n g s of p e r s o n a l competence, may i n f l u e n c e the e x t e n t t o which they a r e w i l l i n g t o adopt new h e a l t h - r e l a t e d b e h a v i o u r s and a t t i t u d e s ( P l a t h and B e l z e r 1985). As w e l l , s p e c i f i c e d u c a t i o n a l methods may be more e f f e c t i v e f o r i n d i v i d u a l s depending upon t h e i r l e v e l of s e l f - e s t e e m . Not o n l y have v e r y few e v a l u a t i o n s f o c u s e d on the impact 4 of s p e c i f i c i n s t r u c t i o n a l methods, but 87 p e r c e n t of the e v a l u a t i o n s i n n u t r i t i o n e d u c a t i o n have been of s c h o o l - b a s e d programs d e s i g n e d f o r c h i l d r e n (Johnson and Johnson 1985). There i s , t h e r e f o r e , a need f o r e v a l u a t i o n of i n s t u c t i o n a l methods which i n c o r p o r a t e elements of a c t i v e l e a r n e r p a r t i c i p a t i o n . T h i s need i s e s p e c i a l l y r e a l i n the i n s t r u c t i o n of a d u l t l e a r n e r s . I t has a l s o been suggested t h a t a d u l t s may be e s p e c i a l l y r e s p o n s i v e t o a c t i v e l e a r n i n g methods which i n c l u d e l i f e - l i k e problem s o l v i n g sequences (Shannon and S m i c i k l a s - W r i g h t 1979). I f n u t r i t i o n e d u c a t o r s can v a l i d a t e i n s t r u c t i o n a l s t r a t e g i e s which r e c o g n i z e some of the many f a c t o r s which a f f e c t f o o d - r e l a t e d b e h a v i o u r s and d e s i g n a c t i v e l e a r n i n g methods based on these o b s e r v a t i o n s , more f a v o u r a b l e impacts on n u t r i t i o n a t t i t u d e s , knowledge and p r a c t i c e s might be r e a l i z e d . The ' Calcium C a l c u l a t o r ' The 'Calcium C a l c u l a t o r ' (Appendix A) was d e s i g n e d by the B.C. D a i r y F o u n d a t i o n (1985) t o a s s i s t s e n i o r a d o l e s c e n t s and a d u l t s i n i n c r e a s i n g t h e i r d i e t a r y c a l c i u m i n t a k e . I t i s an i n n o v a t i v e n u t r i t i o n e d u c a t i o n m a t e r i a l d e s i g n e d t o r e f l e c t the problem s o l v i n g method of i n s t r u c t i o n , as d e s c r i b e d i n a model f o r n u t r i t i o n e d u c a t i o n ( S h o r t r i d g e 1985). As such, i t i n v o l v e s the l e a r n e r i n s e l f - a s s e s s m e n t of h i s / h e r d i e t a r y c a l c i u m i n t a k e and then g u i d e s the l e a r n e r through a • s t e p - b y - s t e p sequence t o 5 i d e n t i f y ways t o i n c r e a s e h i s / h e r c a l c i u m i n t a k e , as n e c e s s a r y . The 'Calcium C a l c u l a t o r ' d i f f e r s from o t h e r documented n u t r i t i o n e d u c a t i o n m a t e r i a l s i n t h a t i t : (1) h i g h l i g h t s the importance of i n d i v i d u a l r e s p o n s i b i l i t y f o r a s s e s s i n g p e r s o n a l c a l c i u m i n t a k e s as w e l l as f o r making p l a n s f o r d i e t a r y change; (2) s u p p o r t s the development of s e l f - a s s e s s m e n t s k i l l s ; (3) r e f l e c t s the importance of l e a r n e r - g e n e r a t e d i n f o r m a t i o n , and (4) i s su p p o r t e d by the r a t i o n a l e of the M o t i v a t i o n G e n e r a t i n g Paradigm which suggests t h a t p a r t i c i p a n t s ' f e e l i n g s toward themselves may both enhance and be enhanced t h r o u g h the use of a problem s o l v i n g sequence. S h o r t r i d g e (1985) d e s c r i b e d a r a t i o n a l e f o r the proposed s u c c e s s of the problem s o l v i n g model used i n the 'Calcium C a l c u l a t o r ' , which he termed the M o t i v a t i o n G e n e r a t i n g Paradigm. He suggested t h a t the maintenance of p o s i t i v e f e e l i n g s toward s e l f i s i n t e g r a l t o b e h a v i o u r and t h a t the use of a problem s o l v i n g s t r a t e g y i s c o m p a t i b l e w i t h f a v o u r a b l e l e a r n e r s e l f - c o n c e p t s . An i n d i v i d u a l w i t h a p o s i t i v e f e e l i n g of s e l f - c o n f i d e n c e i s a l s o more l i k e l y t o attempt a problem s o l v i n g sequence. The manner i n which s e l f - c o n c e p t i s d e s c r i b e d by S h o r t r i d g e more c l o s e l y p a r a l l e l s the d e f i n i t i o n of s e l f -esteem found i n p s y c h o l o g y l i t e r a t u r e . T h e r e f o r e , r e l a t i n g the s e l f - e s t e e m l e v e l s of p a r t i c i p a n t s u s i n g the 'Calcium C a l c u l a t o r ' t o outcome measures c o u l d p r o v i d e s u p p o r t f o r the r a t i o n a l e b e h i n d the problem s o l v i n g model r e f l e c t e d i n the 'Calcium C a l c u l a t o r ' . 6 F i g u r e 1 d e s c r i b e s the proposed r e l a t i o n s h i p between s e l f - e s t e e m , b e h a v i o u r and a t t i t u d e toward the b e h a v i o u r . F e e l i n g s of s e l f - c o m p e t e n c e may m o t i v a t e a l e a r n e r t o use a problem s o l v i n g m a t e r i a l and make subsequent d i e t a r y changes. Having s u c c e s s f u l l y s o l v e d the problem might i n t u r n r e i n f o r c e the l e a r n e r ' s p o s i t i v e f e e l i n g s toward s e l f . I n d i v i d u a l s h a v i n g h i g h e r l e v e l s of s e l f - e s t e e m may a l s o e x p r e s s more p o s i t i v e a t t i t u d e s toward d i e t a r y p r a c t i c e s . s e l f - e s t e e m : f e e l i n g s of competency be h a v i o u r a t t i t u d e toward the behav i o u r Key: r e l a t i o n s h i p s u p p o r t e d by the l i t e r a t u r e r e l a t i o n s h i p h y p o t h e s i z e d f o r the purpose of t h i s study F i g . 1. T h e o r e t i c a l model of the r e l a t i o n s h i p between s e l f - e s t e e m , b e h a v i o u r and a t t i t u d e toward the b e h a v i o u r 7 The 'Calcium C a l c u l a t o r ' i s a l s o d e s i g n e d t o respond to a s p e c i f i c h e a l t h c o n c e r n of the Canadian p o p u l a t i o n . The g o a l of t h i s m a t e r i a l i s t o a s s i s t women t o i n c r e a s e t h e i r d i e t a r y c a l c i u m i n t a k e and the r e b y p o s s i b l y reduce t h e i r r i s k f o r o s t e o p o r o s i s . O s t e o p o r o s i s i s a c r i p p l i n g bone d i s e a s e i n which bone mass i s reduced, thus r e n d e r i n g the i n d i v i d u a l prone to f r a c t u r e s . P r e s e n t l y , one i n f o u r w h i t e women i n Nor t h America over the age of 60 s u f f e r s from t h i s d i s e a s e . The m o r t a l i t y r a t e secondary t o o s t e o p o r o t i c bone f r a c t u r e s i s 15 p e r c e n t ( J o s s e 1983). T h i s d i s e a s e , t h e r e f o r e , e n t a i l s g r e a t c o s t t o the i n d i v i d u a l as w e l l as t o the h e a l t h c a r e system. The N u t r i t i o n Canada survey (1973) r e v e a l e d t h a t Canadians a re not immune t o inadequate n u t r i t i o n a l i n t a k e s of key n u t r i e n t s . T h i s was found t o be s t r i k i n g l y t r u e f o r c a l c i u m . L ess-than-adequate d i e t a r y i n t a k e s of c a l c i u m (300-500 mg per day) c h a r a c t e r i z e d 22.3 p e r c e n t of women aged 20 t o 39, and 26.1 p e r c e n t of women aged 40 t o 64. With i n c r e a s i n g age, the adequacy of d i e t a r y c a l c i u m i n t a k e c o n t i n u e d t o d e c l i n e . Two more r e c e n t Canadian s t u d i e s have documented the d i e t a r y c a l c i u m i n t a k e s of p r e - and p o s t -menopausal women. A n a l y s i s of c a l c i u m consumption of 100 pre-menopausal women r e v e a l e d an average i n t a k e below the Canadian Recommended N u t r i e n t I n t a k e ( S c y t h e s et a l . 1982). 0'Conner e t a l . (1985) documented t h a t most post-menopausal women i n t h e i r sample had r e p o r t e d d i e t a r y c a l c i u m i n t a k e s which b a r e l y met the Canadian Recommended N u t r i e n t I n t a k e . 8 S e v e r a l r e s e a r c h e r s have argued t h a t meeting the p r e s e n t Canadian Recommended N u t r i e n t I n t a k e i s s t i l l not s u f f i c i e n t t o o f f s e t the r i s k of o s t e o p o r o s i s . Heaney et a l . (1978) have recommended d i e t a r y c a l c i u m i n t a k e s of 1000 mg t o 1500 mg d a i l y f o r p r e - and post-menopausal women, r e s p e c t i v e l y . The N a t i o n a l I n s t i t u t e of H e a l t h i n the U n i t e d S t a t e s has s u p p o r t e d these recommendations. The pr e s e n t Canadian Recommended N u t r i e n t I n t a k e recommends o n l y 700 mg f o r pre-menopausal women and 800 mg f o r p o s t -menopausal women. Inadequate d i e t a r y c a l c i u m i n t a k e has been a s s o c i a t e d w i t h an e l e v a t e d r i s k of o s t e o p o r o s i s (Heaney e t a l . 1978; Recker and Heaney 1985; J o s s e 1983). S a n d l e r e t a l . (1985) have suggested t h a t adequate l i f e - l o n g d i e t a r y i n t a k e of c a l c i u m r e s u l t s i n a l a r g e r a d u l t peak bone mass and reduced l i k e l i h o o d of an o s t e o p o r o t i c f r a c t u r e . I n c r e a s i n g the d i e t a r y i n t a k e of c a l c i u m by post-menopausal women may a l s o r e t a r d bone l o s s (Heaney e t a l . 1982). T h e r e f o r e , Canadian women whose c a l c i u m i n t a k e does not at l e a s t meet the p r e s e n t recommended i n t a k e l e v e l a r e a t r i s k f o r o s t e o p o r o s i s and a r e , c o n s e q u e n t l y , prime c a n d i d a t e s f o r n u t r i t i o n e d u c a t i o n . Statement of the Problem The purpose of t h i s study was t o e v a l u a t e the problem s o l v i n g method a p p l i e d t o n u t r i t i o n e d u c a t i o n . In or d e r t o do so, impacts produced by two forms of the 'Calcium 9 C a l c u l a t o r ' were compared (form A and form B ) . Form A i s the o r i g i n a l v e r s i o n of the 'Calcium C a l c u l a t o r ' d e s i g n e d from the problem s o l v i n g model by S h o r t r i d g e (1985) and form B a m o d i f i e d v e r s i o n which r e f l e c t s the problem s o l v i n g model by Havelock (1973). A comparison was a l s o made between problem s o l v i n g and non-problem s o l v i n g i n t e r v e n t i o n s w i t h the use of a c o n t r o l group exposed t o a f i l m . The pr i m a r y f o c u s of the study was the comparison between the two forms of the 'Calcium C a l c u l a t o r ' . Secondary t o t h a t was the comparison between p r o b l e m - s o l v i n g v e r s u s non-problem s o l v i n g i n t e r v e n t i o n s . Based upon the recommendation of Talmage et a l . (1979) t h a t n u t r i t i o n e d u c a t o r s make g r e a t e r use of e v a l u a t i o n r e s e a r c h methods, a q u a s i - e x p e r i m e n t a l random group, pre-and p o s t t e s t d e s i g n was used t o measure the impact of the t h r e e i n t e r v e n t i o n s among groups of women i n the Vancouver and Burnaby a r e a s . Measures of impact i n c l u d e d s e l f - r e p o r t e d d i e t a r y c a l c i u m i n t a k e ; a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s and p e r c e p t i o n of problem s o l v i n g a b i l i t y . P o s t t e s t g e n e r a l s e l f - e s t e e m s c o r e s were r e l a t e d t o measures of impact. Research Q u e s t i o n s 1. ( a ) . D i d forms A and B of the 'Calcium C a l c u l a t o r ' produce s i g n i f i c a n t l y d i f f e r e n t impacts on women's a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s ; p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t y and t h e i r d i e t a r y p r a c t i c e s , as 10 d e f i n e d i n t h i s study? ( b ) . D i d forms A and B of the 'Calcium C a l c u l a t o r ' produce s i g n i f i c a n t l y d i f f e r e n t impacts on women's a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s ; p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t y and t h e i r d i e t a r y p r a c t i c e s , when compared to the impacts produced by the c o n t r o l m a t e r i a l ? 2. I s t h e r e a s i g n i f i c a n t r e l a t i o n s h i p between women's s e l f - e s t e e m s c o r e s and t h e i r a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s ; p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t y and t h e i r d i e t a r y p r a c t i c e s ? 3. I s t h e r e a s i g n i f i c a n t d i f f e r e n c e i n women's a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s ; p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t y and t h e i r d i e t a r y p r a c t i c e s among groups d e f i n e d i n terms of the f o l l o w i n g v a r i a b l e s : (a) demographic v a r i a b l e s : ( i ) age ( i i ) s o c i o - e c o n o m i c s t a t u s ( i i i ) e d u c a t i o n (b) d i e t a r y v a r i a b l e s ( i ) a l l e r g y toward and/or i n t o l e r a n c e of m i l k or m i l k p r o d u c t s ( i i ) s e a s o n a l v a r i a t i o n i n m i l k and m i l k p r o d u c t i n t a k e ( i i i ) use of a c a l c i u m - c o n t a i n i n g supplement ( i v ) weight f o r h e i g h t (v) use of a s p e c i a l d i e t (c) m i s c e l l a n e o u s v a r i a b l e s ( i ) degree of adherence t o the t h r e e key s t e p s i n the problem s o l v i n g sequence ( i i ) p r e t e s t s e l f - r e p o r t e d awareness of o s t e o p o r o s i s 1 1 Hypotheses For Research Q u e s t i o n 1 From a review of the l i t e r a t u r e , i t was p o s t u l a t e d t h a t the more an e d u c a t i o n a l m a t e r i a l resembles a documented problem s o l v i n g model, the g r e a t e r w i l l be i t s impact. In a d d i t i o n , the more c l o s e l y a l e a r n e r f o l l o w s the s t e p s i n the problem s o l v i n g sequence, the more l i k e l y t h e i n d i v i d u a l i s t o be s u c c e s s f u l a t p r o d u c i n g a change. The f o l l o w i n g h y potheses were proposed: 1.1 Women exposed t o form B of the 'Calcium C a l c u l a t o r ' w i l l have s i g n i f i c a n t l y g r e a t e r change i n t h e i r d i e t a r y p r a c t i c e s than w i l l women exposed t o form A of the 'Calcium C a l c u l a t o r ' . 1.2 Women exposed t o form B of the 'Calcium C a l c u l a t o r ' w i l l have s i g n i f i c a n t l y g r e a t e r change i n t h e i r a t t i t u d e s c o r e s toward c a l c i u m and o s t e o p o r o s i s than w i l l women exposed t o form A of the 'Calcium C a l c u l a t o r ' . 1.3 Women exposed t o form B of the 'Calcium C a l c u l a t o r ' w i l l have s i g n i f i c a n t l y h i g h e r change i n p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t y than w i l l women exposed t o form A of the 'Calcium C a l c u l a t o r ' . 1.4 Women exposed t o form A or B of the 'Calcium C a l c u l a t o r ' w i l l have s i g n i f i c a n t l y g r e a t e r change i n t h e i r d i e t a r y p r a c t i c e s than w i l l women exposed t o the c o n t r o l 12 m a t e r i a l . 1.5 Women exposed t o form A or B of the 'Calcium C a l c u l a t o r ' w i l l have s i g n i f i c a n t l y g r e a t e r change i n t h e i r a t t i t u d e s c o r e s toward c a l c i u m and o s t e o p o r o s i s than w i l l women exposed t o the c o n t r o l m a t e r i a l . 1.6 Women exposed t o form A or B of the 'Calcium C a l c u l a t o r ' w i l l have s i g n i f i c a n t l y h i g h e r change i n p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t y than w i l l women exposed t o the c o n t r o l m a t e r i a l . For Research Q u e s t i o n 2 I t has been r e p o r t e d t h a t i n d i v i d u a l s w i t h h i g h e r l e v e l s of s e l f - e s t e e m tend t o f o l l o w more h e a l t h f u l p r a c t i c e s and a r e more l i k e l y t o be w i l l i n g t o adopt h e a l t h y b e h a v i o u r s ( P l a t h and B e l z e r 1985). The f o l l o w i n g hypotheses were proposed: 2.1 Women h a v i n g h i g h e r l e v e l s of s e l f - e s t e e m w i l l have g r e a t e r change i n t h e i r a t t i t u d e s c o r e s on c a l c i u m and o s t e o p o r o s i s . 2.2 Women h a v i n g h i g h e r l e v e l s of s e l f - e s t e e m w i l l have g r e a t e r change i n t h e i r p e r c e p t i o n of problem s o l v i n g a b i l i t y . 2.3 Women h a v i n g h i g h e r l e v e l s of s e l f - e s t e e m w i l l have g r e a t e r change i n t h e i r d i e t a r y p r a c t i c e s . 1 3 For R e s e a r c h Q u e s t i o n 3 The f o l l o w i n g n u l l h ypotheses were t e s t e d f o r the t h i r d r e s e a r c h q u e s t i o n : A. Demographic V a r i a b l e s 3.1 There w i l l be no s i g n i f i c a n t d i f f e r e n c e i n t h e mean change s c o r e s f o r the dependent v a r i a b l e s between p r e - and post-menopausal women, where age 49 i s s e t as the c r i t e r i o n t o c l a s s i f y women i n t o e i t h e r group ( M a t k o v i c e t a l . 1979). 3.2 There w i l l be no s i g n i f i c a n t d i f f e r e n c e i n mean change s c o r e s f o r the dependent v a r i a b l e s between women of h i g h e r s o c i o - e c o n o m i c s t a t u s and those of lower s o c i o - e c o n o m i c s t a t u s . 3.3 There w i l l be no s i g n i f i c a n t d i f f e r e n c e i n mean change s c o r e s f o r the dependent v a r i a b l e s between women who a r e more h i g h l y educated from those who are l e s s e d ucated. B. D i e t a r y V a r i a b l e s 3.4 There w i l l be no s i g n i f i c a n t d i f f e r e n c e i n mean change s c o r e s f o r the dependent v a r i a b l e s between women who a r e a l l e r g i c t o , or i n t o l e r a n t o f , m i l k or m i l k p r o d u c t s and those who a r e n o t . 3.5 There w i l l be no s i g n i f i c a n t d i f f e r e n c e i n mean change s c o r e s f o r the dependent v a r i a b l e s between women who a r e a t more or l e s s f a v o u r a b l e w e i g h t s f o r t h e i r h e i g h t s . 3.6 There w i l l be no s i g n i f i c a n t d i f f e r e n c e i n mean change 1 4 s c o r e s f o r the dependent v a r i a b l e s between women who a r e on a s p e c i a l d i e t , (weight r e d u c t i o n , d i a b e t i c , sodium or s a l t r e s t r i c t i o n , low f a t or c h o l e s t e r o l , v e g e t a r i a n , o t h e r ) , and those who are n o t . 3.7 There w i l l be no s i g n i f i c a n t d i f f e r e n c e i n mean change s c o r e s f o r the dependent v a r i a b l e s between women who a r e t a k i n g a c a l c i u m - c o n t a i n i n g supplement and those who a r e not . 3.8 There w i l l be no s i g n i f i c a n t d i f f e r e n c e i n mean change s c o r e s f o r the dependent v a r i a b l e s between women who r e p o r t s e a s o n a l v a r i a t i o n s i n t h e i r i n t a k e of m i l k and m i l k p r o d u c t s and those who do n o t . C. M i s c e l l a n e o u s V a r i a b l e s 3.9 There w i l l be no s i g n i f i c a n t d i f f e r e n c e i n mean change s c o r e s f o r the dependent v a r i a b l e s between women who f e e l h i g h l y aware of o s t e o p o r o s i s and those who do n o t . 4.0 There w i l l be no s i g n i f i c a n t d i f f e r e n c e i n mean change s c o r e s f o r the dependent v a r i a b l e s between women who completed the f i r s t two s t e p s i n the problem s o l v i n g sequence and those who d i d n o t . D e f i n i t i o n of Terms a d u l t women Women a t or above the age of 19. 1 5 p a r t i c i p a n t s a t t i t u d e toward d i e t a r y c a l c i u m & o s t e o p o r o s i s p e r c e p t i o n of problem-s o l v i n g a b i l i t y d i e t a r y c a l c ium i n t a k e Women i n the Vancouver and Burnaby area s who bel o n g t o community c e n t r e s which meet the c r i t e r i a f o r i n c l u s i o n i n t h i s s t u d y , (page 17). The e x t e n t t o which p a r t i c i p a n t s agree w i t h s t a t e m e n t s c o n c e r n i n g d i e t as a s o u r c e of c a l c i u m , r i s k of o s t e o p o r o s i s , and the r e l a t i o n s h i p between d i e t a r y c a l c i u m i n t a k e and r i s k f o r o s t e o p o r o s i s . The e x t e n t t o which p a r t i c i p a n t s agree w i t h s tatements c o n c e r n i n g t h e i r a b i l i t y t o i d e n t i f y a problem, p l a n t o meet a g o a l and t o a c h i e v e the g o a l . P a r t i c i p a n t ' s u s u a l d i e t a r y c a l c i u m i n t a k e based on s e l f - r e p o r t e d r e c a l l of c a l c i u m - r i c h foods. problem s o l v i n g model form A form B The p r o c e s s of s y s t e m a t i c s o l u t i o n of a p a r t i c i p a n t ' s c o n c e r n s r e g a r d i n g d i e t a r y c a l c i u m i n t a k e , based on the p r o c e s s d e s c r i b e d by S h o r t r i d g e (1985). T h i s model i s an o p e r a t i o n a l i z e d d e s c r i p t i o n of a problem s o l v i n g method of i n s t r u c t i o n . The o r i g i n a l v e r s i o n of the ' C a l c i u m C a l c u l a t o r ' d e v e l o p e d by the B.C. D a i r y F o u n d a t i o n (1985), based on the problem s o l v i n g model of S h o r t r i d g e (1985). The m o d i f i e d v e r s i o n of form A developed f o r the purpose of t h i s s t u d y , based.on the model of Havelock (1973). i n s t r u c t i o n a l methods f a c i l i t a t o r The t e c h n i q u e s used by e d u c a t o r s t o convey i n f o r m a t i o n . These are d i f f e r e n t i a t e d by the degree of l e a r n e r i n v o l v e m e n t i n the p r o c e s s of i n s t r u c t i o n , b e i n g e i t h e r a c t i v e or p a s s i v e . An example of an a c t i v e i n s t r u c t i o n a l method i s problem s o l v i n g . A n o n - d i r e c t i v e i n d i v i d u a l who w i l l guide p a r t i c i p a n t s , i n a workshop, t h r o u g h the p r o c e s s i n v o l v e d i n u s i n g the 'Calcium C a l c u l a t o r ' (form A or B) and w i l l p r o v i d e r e s o u r c e s t o p a r t i c i p a n t s upon t h e i r r e q u e s t s e l f - The c o m p l e t i o n of a s p e c i f i c t a s k by the assessment l e a r n e r : she w i l l d e c i d e whether or not d i e t a r y c a l c i u m changes a r e n e c e s s a r y based on the comparison of her r e c a l l e d c a l c i u m 16 i n t a k e t o the Canadian Recommended N u t r i e n t I n t a k e (1983). T h i s d e c i s i o n w i l l be independent of i n p u t from the f a c i l i t a t o r . degree of adherence t o the problem s o l v i n g sequence s e l f - e s t e e m occupat i o n The p a r t i c i p a n t ' s s e l f - r e p o r t e d use of the s t e p s i n the problem s o l v i n g sequence. F e e l i n g s of a p a r t i c i p a n t toward h e r s e l f , as measured by s c o r e s o b t a i n e d from the C u l t u r e -Free S e l f - E s t e e m I n v e n t o r y ( B a t t l e 1976). P a r t i c i p a n t ' s r e p o r t e d o c c u p a t i o n used t o produce a socio-economic s t a t u s i n d e x based on B l i s h e n ' s method f o r women ( B l i s h e n and C a r r o l l 1978). c r i t e r i a f o r s e l e c t i o n of groups i n t h i s study The group must be a b l e t o meet on a t l e a s t two o c c a s i o n s . The group s h o u l d c o n s i s t m o s t l y of women. The group s h o u l d be l o c a t e d i n the Vancouver or Burnaby area s and be a c c e s s i b l e t o the r e s e a r c h e r s . At l e a s t 10 women sho u l d form the group. Assumpt i o n s Assumptions u n d e r l y i n g t h i s study were: 1. F a c t o r s o t h e r than the i n t e r v e n t i o n d i d not c o n t r i b u t e t o changes measured i n the dependent v a r i a b l e s from p r e - t o p o s t t e s t . 2. P o s t t e s t q u e s t i o n n a i r e s r e t u r n e d t o the r e s e a r c h e r by m a i l were completed by the a c t u a l study p a r t i c i p a n t . 1 7 CHAPTER I I REVIEW OF THE LITERATURE I n t r o d u c t i o n T h i s c h a p t e r p r o v i d e s a review of l i t e r a t u r e on n u t r i t i o n e d u c a t i o n , the use of problem s o l v i n g methods and e v a l u a t i o n methodology as a background f o r the r e s e a r c h . I t i s i n t e n d e d t o s u p p o r t the need f o r e v a l u a t i o n r e s e a r c h i n n u t r i t i o n e d u c a t i o n on the impact of i n s t r u c t i o n a l methods such as problem s o l v i n g f o r a d u l t l e a r n e r s . S i n c e a problem s o l v i n g method c o u l d be used t o a s s i s t women i n i n c r e a s i n g t h e i r d i e t a r y c a l c i u m i n t a k e s , a b r i e f r e v i e w on the r e l a t i o n s h i p between d i e t a r y c a l c i u m i n t a k e s and o s t e o p o r o s i s w i l l a l s o be p r o v i d e d . The Impact of N u t r i t i o n E d u c a t i o n N u t r i t i o n e d u c a t i o n i s d e f i n e d as the p r o c e s s of t e a c h i n g v a l i d a t e d , c o r r e c t n u t r i t i o n knowledge i n ways t h a t promote the development and maintenance of p o s i t i v e a t t i t u d e s toward f o o d , as w e l l as f a v o u r a b l e h a b i t s of f o o d consumption (Johnson and Johnson 1985). The t e a c h i n g of n u t r i t i o n - r e l a t e d i n f o r m a t i o n t o the Canadian p u b l i c has become a n e c e s s i t y t o a s s i s t i n d i v i d u a l s i n making h e a l t h y food c h o i c e s i n an i n c r e a s i n g l y commercial environment (Gussow 1984). E d u c a t o r s and government o f f i c i a l s a r e now j o i n i n g n u t r i t i o n e d u c a t o r s i n a c k n o w l e d g i n g the e s s e n t i a l 18 l i n k s between good h e a l t h , p o s i t i v e h e a l t h p r a c t i c e s and n u t r i t i o n knowledge. In f a c t , i n a l o n g range h e a l t h promotion p l a n approved by the Canadian C a b i n e t i n 1981, n u t r i t i o n was i d e n t i f i e d as one of s i x n a t i o n a l h e a l t h p r i o r i t i e s . The government's d i r e c t i v e s t a t e d t h a t n u t r i t i o n e d u c a t i o n e f f o r t s s h o u l d be s p e c i f i c a l l y t a r g e t e d t o s i x p o p u l a t i o n groups, one of which was women ( N i e l s e n 1983). D e s p i t e growing r e c o g n i t i o n of the importance of n u t r i t i o n e d u c a t i o n , A x e l s o n et a l . (1985) p o i n t e d out t h a t the r e s u l t s of m e t a-analyses of documented e d u c a t i o n a l programs have been c o n t r a d i c t o r y . No r e l a t i o n s h i p has been c o n s i s t e n t l y d e s c r i b e d between i n c r e a s i n g n u t r i t i o n knowledge and i m p r o v i n g n u t r i t i o n b e h a v i o u r (Schwartz 1975; Sims 1981A; G i l l e s p i e 1981), nor has an e f f e c t on b e h a v i o u r been noted s i m p l y by i n f l u e n c i n g a t t i t u d e s . A l t h o u g h Johnson and Johnson (1985) have a t t r i b u t e d p o s i t i v e e f f e c t s on b e h a v i o u r change t o n u t r i t i o n e d u c a t i o n , G i l l e s p i e (1981) contended t h a t i n g e n e r a l , i n s t r u c t i o n a l programs have f a l l e n s h o r t of the e x p e c t a t i o n s of n u t r i t i o n e d u c a t o r s . Recommendations from e v a l u a t i o n s of n u t r i t i o n e d u c a t i o n programs have i n c l u d e d the s u g g e s t i o n t h a t n u t r i t i o n e d u c a t o r s e x p l o r e new methods of i n s t r u c t i o n . The m a j o r i t y of e d u c a t i o n a l programs have used methods based on the d i s s e m i n a t i o n of knowledge where the premise i s taken t h a t p r o v i d i n g i n f o r m a t i o n w i l l promote b e h a v i o u r change (Johnson and Johnson 1985). More s p e c i f i c a l l y , i t has been recommended t h a t 19 n u t r i t i o n e d u c a t o r s d e p a r t from the use of p a s s i v e l e a r n i n g methods such as l e c t u r e s , t o adopt a c t i v e l e a r n i n g methods i n which s t u d e n t s a r e i n v o l v e d i n p e r s o n a l problem s o l v i n g sequences t o respond t o t h e i r n u t r i t i o n a l c o n cerns (Whitehead 1973; Johnson and Johnson 1985). S u c c e s s f u l methods of f o s t e r i n g a c t i v e s t u d e n t l e a r n i n g i n c l u d e s e l f -i n s t r u c t i o n where l e a r n e r s p r o g r e s s a t t h e i r own pace (Shannon and S m i c i k l a s - W r i g h t 1979) and s e l f - a s s e s s m e n t by s t u d e n t s of t h e i r own n u t r i t i o n a l needs (Johnson and Johnson 1985). Problem s o l v i n g methods may i n v o l v e both of thes e t e c h n i q u e s . Johnson and Johnson (1985) have f u r t h e r proposed t h a t s i n c e n u t r i t i o n e d u c a t i o n programs have produced some p o s i t i v e e f f e c t s on b e h a v i o u r , a t t i t u d e s and knowledge, i t i s no l o n g e r n e c e s s a r y t o e s t a b l i s h t h a t n u t r i t i o n e d u c a t i o n can c r e a t e i m p o r t a n t impacts. R a t h e r , they have suggested a need f o r t h e o r y - d r i v e n r e s e a r c h t o more f u l l y u n d e r s t a n d both f o o d - r e l a t e d b e h a v i o u r s and the i n s t r u c t i o n a l methods which might best a f f e c t them. T h i s p o i n t i s advocated by G i l l e s p i e (1981) who s t a t e d t h a t i n orde r t o advance the p r a c t i c e of n u t r i t i o n e d u c a t i o n , r e s e a r c h must d e s c r i b e t h e i n c o r p o r a t i o n and e v a l u a t i o n of t h e o r e t i c a l models of beh a v i o u r and i n s t r u c t i o n i n program d e s i g n . L e a r n i n g T h e o r i e s i n E d u c a t i o n T h e o r i e s of human be h a v i o u r developed by p s y c h o l o g i s t s have p r o v i d e d one of the f o u n d a t i o n s f o r e d u c a t i o n a l t h e o r i e s and methods. N u t r i t i o n e d u c a t o r s i n t u r n , have 20 been h i g h l y i n f l u e n c e d by the f i e l d of e d u c a t i o n i n t h e i r program d e s i g n and methods of i n s t r u c t i o n . The argument f o r g r e a t e r use of a c t i v e e d u c a t i o n a l methods i s echoed i n the f i e l d of e d u c a t i o n as w e l l . Two f i r m l y e s t a b l i s h e d l e a r n i n g t h e o r i e s c o n t r a s t s h a r p l y w i t h a s l i g h t l y more r e c e n t t h e o r y proposed by C a r l Rogers. C o g n i t i v i s m and B e h a v i o u r a l i s m , though d i s s i m i l a r i n t h e i r e x p l a n a t i o n s of human b e h a v i o u r , both t e n d t o encourage the use of p a s s i v e l e a r n i n g methods (Boyd 1973). C o g n i t i v i s m i s the b e l i e f t h a t l e a r n i n g i s based on mental p r o c e s s i n g , w h i l e B e h a v i o u r a l i s m s u g g e s t s t h a t b e h a v i o u r change r e s u l t s from a response t o e n v i r o n m e n t a l s t i m u l i . The e d u c a t i o n a l i m p l i c a t i o n s d e r i v e d from t h e s e t h e o r i e s a r e s i m i l a r as b o t h d e f i n e the r o l e of the i n s t r u c t o r as a l e a d e r w i t h a h i g h degree of c o n t r o l over the l e a r n i n g e x p e r i e n c e . C o n s e q u e n t l y , l e a r n e r r e s p o n s i b i l i t y and involvement i n the e d u c a t i o n a l p r o c e s s a r e not e s s e n t i a l . An i n s t r u c t i o n a l method based on t h e B e h a v i o u r a l i s t t h e o r y i s t h a t of b e h a v i o u r m o d i f i c a t i o n . The C o g n i t i v i s t o r i e n t a t i o n has produced such methods as the l e c t u r e and r o l e - m o d e l i n g . A c o n t r a s t i n g t h e o r y of l e a r n i n g proposed by C a r l Rogers (1951) i s t h a t of Humanism. I n t e g r a l t o t h i s t h e o r y i s the b e l i e f t h a t l e a r n i n g b e h a v i o u r i s g e n e r a t e d by c h a r a c t e r i s t i c s w i t h i n the i n d i v i d u a l . The Humanist approach i n c o r p o r a t e s Maslow's s e l f - a c t u a l i z a t i o n t h e o r y , d e s c r i b i n g b e h a v i o u r as a c t i o n d e s i g n e d t o f u l f i l l an i n n e r 21 r e a l i z a t i o n . As a r e s u l t , the i n s t r u c t i o n a l i m p l i c a t i o n s of t h i s t h e o r y d i f f e r from the p r e c e e d i n g two. Rogers argued t h a t t e a c h i n g s h o u l d be l e a r n e r - c e n t e r e d , where s t u d e n t s are encouraged t o assume r e s p o n s i b i l i t y f o r the l e a r n i n g p r o c e s s w h i l e b e i n g a c t i v e l e a r n i n g p a r t i c i p a n t s . A key g o a l of Humanist methods i s the development of l e a r n e r s e l f -assessment s k i l l s . The v a l u e of t h i s approach i s becoming i n c r e a s i n g l y r e c o g n i z e d w i t h i n the f i e l d of e d u c a t i o n (Boyd 1973) . I n s t r u c t i o n a l Methods i n N u t r i t i o n E d u c a t i o n Johnson and Johnson (1985) have c l a s s i f i e d n u t r i t i o n e d u c a t i o n programs by the k i n d s of i n s t r u c t i o n a l methods employed, whether they be a c t i v e or p a s s i v e . I n s t r u c t i o n a l methods used by n u t r i t i o n e d u c a t o r s are t e c h n i q u e s d e s i g n e d t o convey n u t r i t i o n - r e l a t e d i n f o r m a t i o n (Schwartz 1985). P a s s i v e t e a c h i n g methods i n c l u d e n u t r i t i o n l e c t u r e s and the p r o v i s i o n of d o c u m e n t a t i o n . A c t i v e l e a r n i n g methods, on the o t h e r hand, u s u a l l y i n v o l v e the p a r t i c i p a t i o n of the l e a r n e r i n s k i l l - r e l a t e d a c t i v i t i e s such as menu p l a n n i n g or g r o c e r y s h o p p i n g . P a s s i v e I n s t r u c t i o n a l Methods Many n u t r i t i o n e d u c a t i o n programs have u t i l i z e d p a s s i v e i n s t r u c t i o n a l methods, e s p e c i a l l y i n programs d e s i g n e d f o r a d u l t l e a r n e r s . Rosander and Sims (1981) d e s c r i b e d an a f f e c t i v e - b a s e d n u t r i t i o n e d u c a t i o n program f o r women i n the c h i l d - b e a r i n g y e a r s where p a r t i c i p a n t s were i n s t r u c t e d i n 22 group s e s s i o n s . N u t r i t i o n knowledge g a i n s were e v i d e n c e d y e t no such s u c c e s s was noted w i t h a t t i t u d e or b e h a v i o u r change. K a p l o w i t z and Olson (1983) d e s i g n e d a b r e a s t f e e d i n g e d u c a t i o n program f o r low income women i n which f i v e pamphlets were m a i l e d t o the s u b j e c t s ' homes. R e s u l t s demonstrated an i n c r e a s e i n knowledge but d i d not y i e l d more p o s i t i v e a t t i t u d e s toward, nor i n c r e a s e the use or d u r a t i o n o f , b r e a s t f e e d i n g . In summary, s e v e r a l programs i n n u t r i t i o n e d u c a t i o n f o r a d u l t s have r e l i e d on p a s s i v e l e a r n i n g methods and have e v i d e n c e d i n c o n s i s t e n t , i f not d i s a p p o i n t i n g , measures of s u c c e s s when be h a v i o u r change i s c o n s i d e r e d . A c t i v e I n s t r u c t i o n a l Methods Few programs i n the n u t r i t i o n e d u c a t i o n l i t e r a t u r e have employed o n l y a c t i v e l e a r n i n g methods. Those programs which have done so have been d e s i g n e d l a r g e l y f o r c h i l d r e n . For i n s t a n c e , A l f o r d and T i b b i t (1971) used food t a s t i n g d e m o n s t r a t i o n s w i t h s t u d e n t s , w h i l e Smith and James (1980) employed s c h o o l l u n c h a c t i v i t i e s among grade s c h o o l c h i l d r e n t o promote d i e t a r y b e h a v i o u r change. The l a t t e r r e p o r t e d i n c r e a s e s i n knowledge and improved d i e t a r y b e h a v i o u r . Byrd-Bredbenner e t a l . (1984) e v a l u a t e d n u t r i t i o n i n s t r u c t i o n based on c u r r i c u l u m g u i d e s which i n c l u d e d a c t i v e methods f o r j u n i o r and h i g h s c h o o l s t u d e n t s . Though r e s u l t s i n d i c a t e d improved knowledge s c o r e s , l i t t l e change i n a t t i t u d e was noted i n grades seven and e i g h t and l i t t l e improvement i n food f r e q u e n c y s c o r e s was r e p o r t e d . 23 A l i t e r a t u r e s e a r c h f a i l e d t o produce e v i d e n c e of a d u l t n u t r i t i o n e d u c a t i o n programs based s o l e l y on a c t i v e methods of i n s t r u c t i o n . The v a s t m a j o r i t y of programs i n the n u t r i t i o n e d u c a t i o n l i t e r a t u r e have i n c o r p o r a t e d c o m b i n a t i o n s of a c t i v e and p a s s i v e l e a r n i n g methods. For i n s t a n c e , Looker et a l . (1982) d e s c r i b e d n u t r i t i o n e d u c a t i o n modules f o r h o s p i t a l employees which i n c l u d e d both the v i e w i n g of a v i d e o t a p e , l e a d e r - d i r e c t e d d i s c u s s i o n s , and a c t i v i t i e s such as food d e m o n s t r a t i o n s and r o l e p l a y i n g . Only knowledge change was measured, w i t h p o s i t i v e g a i n s r e s u l t i n g from the i n t e r v e n t i o n . E v a l u a t i o n s of e d u c a t i o n a l programs u s i n g q u a s i -e x p e r i m e n t a l random group d e s i g n s have tended t o r e v e a l i n c r e a s e s i n n u t r i t i o n - r e l a t e d knowledge s c o r e s ( S c h a f e r 1986; Brush et a l . 1986; R i e s and Schoon 1986) w i t h o u t c o n c u r r e n t p o s i t i v e e f f e c t s on a t t i t u d e . The l a t t e r has been a t t r i b u t e d t o a p o s s i b l e c e i l i n g e f f e c t w i t h a t t i t u d e ( R i e s and Schoon 1986; Brush et a l . 1986). R e s e a r c h e r s have observed h i g h p o s i t i v e a t t i t u d e s a t p r e t e s t which were e s s e n t i a l l y m a i n t a i n e d a t p o s t t e s t . Daelhousen and G u t h r i e (1982) r e p o r t e d s i m i l a r f i n d i n g s u s i n g a randomized s u b j e c t d e s i g n . Among programs f o r a d u l t s which have employed b o t h a c t i v e and p a s s i v e l e a r n i n g methods, the means of a c h i e v i n g a c t i v e l e a r n e r p a r t i c i p a t i o n have d i f f e r e d . Two methods which are recommended as p o t e n t i a l l y s u c c e s s f u l are s e l f -assessment and s e l f - i n s t r u c t i o n . 24 S e l f - A s s e s s m e n t S e l f - a s s e s s m e n t , i n v o l v i n g i d e n t i f i c a t i o n by the l e a r n e r of d i f f e r e n c e s between the i n d i v i d u a l ' s p e r c e i v e d b e h a v i o u r and s t a n d a r d s of d e s i r a b l e b e h a v i o u r , i s r e p o r t e d by s o c i a l p s y c h o l o g i s t s t o be an i m p o r t a n t m o t i v a t o r t o b e h a v i o u r change (Rokeach 1979; Bandura and Cervone 1983). L e a r n e r s who d i a g n o s e a need t o change t h e i r b e h a v i o u r themselves a r e more l i k e l y t o be committed t o t h a t change (Havelock 1969). In few documented n u t r i t i o n e d u c a t i o n programs have l e a r n e r s been r e s p o n s i b l e f o r a s s e s s i n g t h e i r own n u t r i t i o n a l performance. P o d e l l et a l . (1978) d e s c r i b e d a program on c a r d i o v a s c u l a r n u t r i t i o n w i t h i n a b i o l o g y c o u r s e f o r h i g h s c h o o l s t u d e n t s i n which l e a r n e r s where encouraged t o e v a l u a t e t h e i r d i e t a r y i n t a k e of s a t u r a t e d f a t and c h o l e s t e r o l . P e t o s a (1986) has recommended t h a t c h i l d r e n be encouraged t o d e v e l o p self-management s k i l l s t h r o ugh h e a l t h -r e l a t e d s e l f - a s s e s s m e n t a c t i v i t i e s . W i t h r e s p e c t t o a d u l t l e a r n e r s , Cramwinckel et a l . (1984) r e c e n t l y r e p o r t e d the use of a games board t o a s s i s t a d u l t s i n comparing t h e i r d i e t a r y i n t a k e t o the German d i e t a r y s t a n d a r d . More r e c e n t l y , H a l e and D a v i s (1986) p u b l i s h e d a s e l f - a s s e s s m e n t form f o r use by a d u l t s t o e v a l u a t e t h e i r own c a f f e i n e i n t a k e . Sims (1981 A) and Contento et a l . (1986) have both recommended t h a t i n s t r u c t i o n a c h i e v e s i t s maximum p o s s i b l e e f f e c t i v e n e s s when combined w i t h s o c i a l r e i n f o r c e m e n t of change. As a r e s u l t , s t u d e n t s may p e r f o r i n s e l f - a s s e s s m e n t s 25 of t h e i r d i e t a r y i n t a k e and then be encouraged t o share t h e i r f i n d i n g s i n a group s e t t i n g . P l a n n i n g d i e t a r y changes f o r the group, based upon group needs assessment, was r e p o r t e d as s u c c e s s f u l i n promoting i n d i v i d u a l b e h a v i o u r change. In r e v i e w i n g the l i t e r a t u r e , i t became c l e a r t h a t s e l f - a s s e s s m e n t may be d e f i n e d i n two d i f f e r e n t ways. W i t h i n the f i e l d of e d u c a t i o n , s e l f - a s s e s s m e n t i s a t t i m e s equated w i t h the e v a l u a t i o n by l e a r n e r s of t h e i r own s k i l l s , a b i l i t i e s or performances. In c o n t r a s t , though, the same term may denote the v a l u e an i n d i v i d u a l p l a c e s on c e r t a i n i s s u e s . For the purpose of t h i s r e s e a r c h , s e l f - a s s e s s m e n t i s d e f i n e d i n the former manner, where a l e a r n e r compares h i s / h e r f o o d r e l a t e d b e h a v i o u r t o a d i e t a r y s t a n d a r d i n o r d e r t o d e c i d e whether or h i s / h e r d i e t a r y performance i s a c c e p t a b l e . S e l f - I n s t r u c t i o n S e l f - i n s t r u c t i o n i s a n o t h e r method by which l e a r n e r s may be a c t i v e l y i n v o l v e d i n the l e a r n i n g p r o c e s s . D e s p i t e the l a c k of documented use of s e l f - a s s e s s m e n t i n n u t r i t i o n e d u c a t i o n , t h e r e does appear t o be a g r a d u a l t r e n d toward the development of more s e l f - i n s t r u c t i o n a l u n i t s f o r a d u l t l e a r n e r s . Daelhousen and G u t h r i e (1982) d e s c r i b e d a s e l f -i n s t r u c t i o n a l u n i t f o r pregnant women which i n c l u d e d a v i d e o c a s s e t t e tape and pamphlets l o c a t e d i n p h y s i c i a n s ' o f f i c e s . 26 The a u t h o r s measured i n c r e a s e d n u t r i t i o n - r e l a t e d knowledge f o l l o w i n g use of the u n i t , y e t no changes i n f o o d - r e l a t e d a t t i t u d e or b e h a v i o u r were noted. A s e l f - i n s t r u c t i o n a l v i d e o c a s s e t t e tape was d e s i g n e d on t h e t o p i c of a n u t r i t i o u s b r e a k f a s t as p a r t of the Coronary Primary P r e v e n t i o n T r i a l i n the U n i t e d S t a t e s (Pace e t a l . 1983). D i e t a r y b e h a v i o u r change was observed one week a f t e r use of the u n i t y e t no s i m u l t a n e o u s change i n a t t i t u d e s or knowledge o c c u r r e d . S i m i l a r i n s t r u c t i o n a l m a t e r i a l s have been d e s c r i b e d f o r the r e i n f o r c e m e n t of r e n a l d i e t i n s t r u c t i o n by F a l c i g l i a e t a l . (1984). They a l s o r e p o r t e d an i n c r e a s e i n n u t r i t i o n - r e l a t e d knowledge w i t h no s i g n i f i c a n t improvement i n a p p l i c a t i o n of t h i s i n f o r m a t i o n or i n l e a r n e r compliance w i t h the r e n a l d i e t . V a r y i n g degrees of s u c c e s s have been produced by the use of s e l f - i n s t r u c t i o n a l methods. I t has been proposed t h a t p r o v i d i n g s o c i a l r e i n f o r c e m e n t w i t h s e l f - i n s t r u c t i o n a l methods may f u r t h e r enhance t h e i r impact. Both s e l f -assessment and s e l f - i n s t r u c t i o n a l methods, however, appear t o o f f e r p o t e n t i a l i n the d e s i g n of n u t r i t i o n e d u c a t i o n programs f o r a d u l t s g i v e n the unique c h a r a c t e r i s t i c s of thes e l e a r n e r s . C h a r a c t e r i s t i c s of A d u l t L e a r n e r s I t i s e s s e n t i a l t h a t e d u c a t i o n a l programs d e s i g n e d f o r women r e s p e c t the unique c h a r a c t e r i s t i c s of the s e l e a r n e r s . 27 U n l i k e s c h o o l - a g e l e a r n e r s , a d u l t s expect t o o b t a i n immediate use of the knowledge and s k i l l s they a c q u i r e and c o n s e q u e n t l y a r e more r e s p o n s i v e to l i f e - l i k e problem s o l v i n g approaches. Shannon and S m i c i k l a s - W r i g h t (1979) have suggested t h a t i n many i n s t a n c e s a d u l t l e a r n e r s a r e more r e s p o n s i v e t o a c t i v e r a t h e r than p a s s i v e methods of i n s t r u c t i o n . I t i s not s u r p r i s i n g , f o r example, t h a t Potoczney and G i e s e b r e c h t (1985) r e p o r t e d v e r y p o s i t i v e feedback from a d u l t p a r t i c i p a n t s t o a Food C a s i n o games e x h i b i t p i l o t -t e s t e d i n Ottawa as p a r t of N a t i o n a l N u t r i t i o n Month i n Canada. S i m i l a r f a v o u r a b l e r e s u l t s were produced by a German study i n which a d u l t s a s s e s s e d t h e i r own d a i l y food c h o i c e s . N e i t h e r the games e x h i b i t nor the games board were i n t e n d e d t o be s e l f - i n s t r u c t i o n a l , though both i n v o l v e d l e a r n e r s i n a c t i v e p a r t i c i p a t i o n . S i n c e 70 p e r c e n t of l e a r n i n g by a d u l t s o c c u r s o u t s i d e of the f o r m a l e d u c a t i o n system, t h e r e i s a need f o r s e l f -i n s t r u c t i o n a l m a t e r i a l s f o r t h e s e i n d i v i d u a l s ( K o l a s a e t a l . 1979). These methods p r o v i d e the b e n e f i t s of f l e x i b i l i t y of time and p l a c e of use, more s u i t a b l e t o the needs of t h e a d u l t l e a r n e r . In summary, t h e r e e x i s t s a need f o r e v a l u a t i o n s of the impact of a c t i v e i n s t r u c t i o n a l methods which encourage l e a r n e r p a r t i c i p a t i o n t h r o u g h s e l f - a s s e s s m e n t and s e l f -i n s t r u c t i o n . T h i s need i s e s p e c i a l l y e v i d e n t f o r the a d u l t l e a r n e r . Problem s o l v i n g i s an e d u c a t i o n a l method which may be s e l f - i n s t r u c t i o n a l and i n c o r p o r a t e s e l f - a s s e s s m e n t 28 a c t i v i t i e s . The Problem S o l v i n g I n s t r u c t i o n a l Method Problem s o l v i n g can be d e f i n e d as a p r o c e s s by which a l e a r n e r s a t i s f i e s h i s / h e r needs (K a v e l o c k 1969). The use of a problem s o l v i n g sequence o r i g i n a t e d i n the s c i e n t i f i c method where a l o g i c a l p r o c e s s i s f o l l o w e d t o d e s c r i b e and t e s t an h y p o t h e s i s i n o r d e r t o draw a c o n c l u s i o n . The problem e x p l o r e d u s i n g the s c i e n t i f i c method i s one e x t e r n a l t o the i n d i v i d u a l , such as why a p l a n t r e q u i r e s l i g h t f o r growth. The t e a c h i n g of s c i e n c e c o n t i n u e s t o r e f l e c t the use of problem s o l v i n g methods. The B r i t i s h Columbia C u r r i c u l u m Guide f o r Grade 10 s c i e n c e encourages a c t i v e s t u d e n t i n q u i r y and h y p o t h e s i s t e s t i n g . Home economics t e a c h e r s have proposed g r e a t e r use of problem s o l v i n g sequences t o encourage the development of r e a s o n i n g s k i l l s i n s t u d e n t s ( S p i t z e 1986). Helm (1983) s t a t e d t h a t the development of t h i n k i n g s k i l l s i n home economics i n v o l v e s the p r o d u c t i o n of t r a n s f e r a b l e r a t i o n a l t h i n k i n g p a t t e r n s which a re not l i k e l y t o be f o s t e r e d w i t h the use of p a s s i v e i n s t r u c t i o n a l t e c h n i q u e s such as me m o r i z a t i o n and the s i m p l e p r o v i s i o n of i n f o r m a t i o n . The method of s o l v i n g a problem u s i n g a l o g i c a l sequence has been adapted f o r use i n o t h e r c o n t e x t s as w e l l . Kurfman (1977) has d e s c r i b e d d e c i s i o n making as a p r o c e s s of i n t e r e l a t e d s t e p s which can be f o l l o w e d t o make d e c i s i o n s 29 f o r a c t i o n . U n l i k e a problem s o l v i n g model, however, d e c i s i o n making i n c o r p o r a t e s the r e c o g n i t i o n t h a t an i n d i v i d u a l ' s v a l u e s and f e e l i n g s a f f e c t the d e c i s i o n making p r o c e s s . A problem s o l v i n g p r o c e s s , t h e r e f o r e , i n which c h o i c e s a r e o f f e r e d and i n d i v i d u a l s u b j e c t i v i t y may e n t e r c o u l d be termed a d e c i s i o n making approach. A l t h o u g h problem s o l v i n g methods a r e r e c e i v i n g more widespr e a d use i n g e n e r a l , r a r e l y has the purpose of i t s use been t o s o l v e a need p e r s o n a l t o the i n d i v i d u a l . Problem S o l v i n g Methods f o r P e r s o n a l B e h a v i o u r Change Havelock (1969) proposed t h a t i n a d d i t i o n t o u s i n g problem s o l v i n g t o e x p l o r e s o c i a l , s c i e n t i f i c and b u s i n e s s i s s u e s , t h i s method c o u l d a l s o be a p p l i e d t o a s s e s s and s o l v e problems i n t e r n a l t o the i n d i v i d u a l and t h e r e f o r e be s u p p o r t i v e of p e r s o n a l b e h a v i o u r change. In 1973, Havelock p u b l i s h e d a model of the p r o c e s s by which human b e i n g s l o g i c a l l y s o l v e p e r s o n a l l y r e l e v a n t problems. F i g u r e 2 d e s c r i b e s the c y c l e i n which an i n i t i a l d i s t u r b a n c e t r i g g e r s an i n d i v i d u a l t o f e e l the need t o a c t . Once t h i s need i s p e r c e i v e d as a problem, the i n d i v i d u a l s e a r c h e s f o r , and a p p l i e s s o l u t i o n s t o the problem. I f the p erson i s then s a t i s f i e d t h a t the problem i s s o l v e d , the p r o c e s s i s c omplete. I f the i n d i v i d u a l i s not s a t i s f i e d w i t h the s o l u t i o n , the p r o c e s s i s r e p e a t e d . The s u c c e s s f u l use of the Havelock (1973) model n e c e s s i t a t e s the r e c o g n i t i o n of f i v e f a c t o r s : 1. The need of the user d i c t a t e s what i n f o r m a t i o n s h o u l d be 30 I I I . D i a g n o s i s of the need as a problem I I . F e e l i n g of a need t o a c t 7 IV. Search f o r s o l u t i o n s I. I n i t i a l d i s t u r b a n c e 7. V. A p p l i c a t i o n s of p o s s i b l e s o l u t i o n s t o the problem "change agent" \ \ \ s VI. S a t i s f a c t i o n t h a t the problem i s s o l v e d F i g . 2. A problem s o l v i n g sequence f o r p e r s o n a l change (Havelock 1973) 31 s u p p l i e d . C o n s e q u e n t l y , t h i s i n s t r u c t i o n a l method i s not c o n t e n t - f o c u s e d , but r a t h e r l e a r n e r - f o c u s e d . 2. The user must dia g n o s e the need as a problem, thus i n v o l v i n g the l e a r n e r i n s e l f - a s s e s s m e n t of a need t o a c t i n o r d e r t o s o l v e the problem. 3. The e x t e r n a l r e s o u r c e person s h o u l d be n o n - d i r e c t i v e . Thus, the r o l e of the e d u c a t o r i s to a s s i s t , r a t h e r than d i r e c t , the l e a r n e r . 4. Resources i n t e r n a l t o the i n d i v i d u a l s h o u l d be f u l l y u t i l i z e d ( s k i l l s and knowledge, f o r example). 5. S e l f - i n i t i a t e d change w i l l have the s t r o n g e s t user commitment and b e s t chance f o r l o n g term s u c c e s s . U n l i k e B e h a v i o u r a l i s t - o r i e n t e d methods, problem s o l v i n g i m p l i e s t h a t the l e a r n e r i s a r a t i o n a l b e i n g c a p a b l e of l o g i c a l l y p r o c e s s i n g i n f o r m a t i o n . In a d d i t i o n , t h i s method r e f l e c t s Humanist elements s i n c e b oth s e l f - a s s e s s m e n t s k i l l s and l e a r n e r r e s p o n s i b i l i t y f o r d e c i s i o n - m a k i n g are key components. The user (or l e a r n e r ) compares h i s / h e r b e h a v i o u r t o a s t a n d a r d t o judge whether or not b e h a v i o u r change i s n e c e s s a r y . Once the d e c i s i o n t o a c t i s made by the l e a r n e r , he/she i s encouraged t o assume r e s p o n s i b i l i t y f o r the r e s u l t i n g l i f e s t y l e changes. Problem s o l v i n g methods a p p l i e d t o p e r s o n a l b e h a v i o u r change a r e a l s o s u p p o r t i v e of s e l f - i n s t r u c t i o n . By t h i s method, the focus i s on s k i l l s development, such t h a t the i n s t r u c t i o n a l m a t e r i a l s h o u l d be l o g i c a l l y sequenced, easy t o f o l l o w and r e q u i r e a minimum of e x t e r n a l a s s i s t a n c e . 32 L e a r n e r s may, however, r e q u e s t f u r t h e r i n f o r m a t i o n so t h a t support f o r the l e a r n e r s h o u l d be a v a i l a b l e . The g e n e r a l i n t e n t i o n of t h i s method i s , however, the development of independent l e a r n e r s . The p r i m a r y g o a l of problem s o l v i n g i s t o produce b e h a v i o u r change t h r o u g h s k i l l s development. I t i s f e l t t h a t i n so d o i n g , problem s o l v i n g may a l s o f a v o u r a b l y impact upon a l e a r n e r ' s a t t i t u d e toward the s p e c i f i c b e h a v i o u r . The method i s not p r i n c i p a l l y one of i n f o r m a t i o n d i s s e m i n a t i o n . C onsequently measures of impact f o r problem s o l v i n g methods, such as the one d e s c r i b e d by Havelock (1973), would i n c l u d e changes i n l e a r n e r b e h a v i o u r and a t t i t u de. W i t h i n the f i e l d of home economics, t e a c h e r s have been recommended t o employ methods of i n s t r u c t i o n l i k e problem s o l v i n g , where l e a r n e r s a re i n v o l v e d i n r e f l e c t i v e t h i n k i n g . T h i s t r a n s i t i o n r e p r e s e n t s a d e p a r t u r e from the concept of i n s t r u c t i o n as a p a s s i v e , d e d u c t i v e p r o c e s s towards the r o l e of i n s t r u c t i o n t o f o s t e r a c t i v e l e a r n e r s e l f - a s s e s s m e n t of i s s u e s (American Home Economics A s s o c i a t i o n 1979). The e v a l u a t i o n of a problem s o l v i n g model would, t h e r e f o r e , r e p r e s e n t a s t e p i n the d i r e c t i o n toward which home econo m i s t s have been urged t o s t r i v e . T h i s recommendation i s echoed i n the f i e l d of n u t r i t i o n e d u c a t i o n . 33 Problem S o l v i n g Methods A p p l i e d t o N u t r i t i o n E d u c a t i o n In Whitehead's (1973) review of over 100 p u b l i s h e d e v a l u a t i o n s of n u t r i t i o n e d u c a t i o n programs, she s u g g ested t h a t n u t r i t i o n e d u c a t i o n might be a f a c t o r i n i m p r o v i n g the d i e t a r y p r a c t i c e s of l e a r n e r s i f they a r e i n v o l v e d i n s i t u a t i o n s of a c t i v e and p e r s o n a l problem s o l v i n g . However, a review of the l i t e r a t u r e on n u t r i t i o n e d u c a t i o n f o r a d u l t s f a i l e d t o r e v e a l e v a l u a t i o n s on the impact of problem s o l v i n g methods i n which s e l f - a s s e s s m e n t was employed t o produce p e r s o n a l b e h a v i o u r change. R e c e n t l y S h o r t r i d g e (1985), i n c o n j u n c t i o n w i t h the D a i r y C o u n c i l of C a l i f o r n i a , d e s i g n e d a problem s o l v i n g model which can be used i n a d u l t n u t r i t i o n e d u c a t i o n . F i g u r e 3 r e p r e s e n t s the problem s o l v i n g model of S h o r t r i d g e (1985). The l e a r n e r i n i t i a l l y i d e n t i f i e s h i s / h e r need t o a c t by comparing h i s / h e r f o o d p r a c t i c e s w i t h d i e t a r y s t a n d a r d s , t h e r e b y i n v o l v i n g the l e a r n e r i n s e l f - a s s e s s m e n t . The l e a r n e r then s e t s g o a l s f o r change by e x p l o r i n g p o s s i b l e s o l u t i o n s t o the problem t o s e l e c t the best a l t e r n a t i v e . A d i e t a r y p l a n i s then made t o f o r m a l i z e these changes. The t h i r d s t e p i n v o l v e s l e a r n e r management of the s o l u t i o n by m e n t a l l y r e v i e w i n g p r a c t i c a l i m p l i c a t i o n s i n v o l v e d i n the i n t e n d e d change. The r o l e of the n u t r i t i o n e d u c a t o r u s i n g t h i s model i s c o n s u l t a t i v e r a t h e r than d i r e c t i v e . The n u t r i t i o n e d u c a t o r i s termed the h e l p e r or f a c i l i t a t o r , e q u i v a l e n t to the change agent i n the Havelock (1973) model. As such, the 34 f a c i l i t a t o r may a s s i s t l e a r n e r s i n f o l l o w i n g the p r o c e s s or may p r o v i d e them w i t h r e s o u r c e s a t the l e a r n e r ' s r e q u e s t . The r o l e of the n u t r i t i o n e d u c a t o r i n t h i s model, as w e l l as i n t h a t by Havelock (1973), i s c o n s i s t e n t w i t h t h a t d e s c r i b e d i n C a r l Rogers' Humanist t h e o r y . Problem s o l v i n g methods have been i n c o r p o r a t e d i n a n u t r i t i o n e d u c a t i o n program e v a l u a t e d among f i f t h g r a d e r s i n the U n i t e d S t a t e s . The program, e n t i t l e d the ' S e c r e t s of Success' ( D a i r y C o u n c i l of C a l i f o r n i a 1978), i n c l u d e d s e l f -assessment a c t i v i t i e s , d i e t p l a n n i n g and r o l e p l a y i n g . The program was i n i t i a l l y t e s t e d i n 23 f i f t h grade c l a s s r o o m s i n Oregon. Niedermeyer et a l . (1982) r e p o r t e d i n c r e a s e d n u t r i t i o n knowledge s c o r e s from 53 pe r c e n t on p r e t e s t t o 81 p e r c e n t on p o s t t e s t . P o s i t i v e b e h a v i o u r change, e v a l u a t e d by f o u r food group i n t a k e adequacy, was obser v e d i m m e d i a t e l y f o l l o w i n g the program as w e l l as t h r e e months a f t e r w a r d s . The same program was t e s t e d by the B.C. D a i r y F o u n d a t i o n w i t h 124 f i f t h g r a d e r s i n the Vancouver a r e a . U n p u b l i s h e d data suggest an i n c r e a s e i n consumption of a l l fo u r food groups i m m e d i a t e l y a f t e r the program. P r e - and p o s t t e s t i n g of n u t r i t i o n knowledge r e v e a l e d a 109 p e r c e n t i n c r e a s e from 99 st u d e n t r e s p o n s e s . The s p e c i f i c problem s o l v i n g model d e s c r i b e d by S h o r t r i d g e (1985) has y e t t o be e v a l u a t e d i n an e d u c a t i o n a l m a t e r i a l i n t e n d e d f o r a d u l t s . Given the e d u c a t i o n a l support f o r t h i s s t r a t e g y , t o g e t h e r w i t h the f a v o u r a b l e r e s u l t s of the ' S e c r e t s of Success' program, such an e v a l u a t i o n c o u l d p r o v i d e v a l u a b l e r e s u l t s f o r n u t r i t i o n e d u c a t o r s i n v o l v e d i n 35 Problem i d e n t i f i c a t i o n i d e n t i f i c a t i o n of u s u a l food h a b i t s comparison of u s u a l h a b i t s t o a s t a n d a r d "Helper' / / 11. Goal s e t t i n g . s e t t i n g g o a l s u s i n g a d i e t a r y p l a n ( s a t i s f a c t i o n w i t h s o l u t i o n ) \ I I I . G o a l achievement . mental r e h e a r s a l of the p l a n F i g . 3. Problem s o l v i n g sequence i n the m o t i v a t i o n g e n e r a t i n g paradigm ( S h o r t r i d g e 1985) 36 d e s i g n i n g m a t e r i a l s f o r a d u l t l e a r n e r s . Y e t , to be most u s e f u l , r e s e a r c h i n n u t r i t i o n e d u c a t i o n needs not o n l y t o v a l i d a t e i n s t r u c t i o n a l methods but a l s o a s s e s s r a t i o n a l e s f o r the outcomes of s p e c i f i c i n t e r v e n t i o n s . S h o r t r i d g e (1985) has d e s c r i b e d the M o t i v a t i o n G e n e r a t i n g Paradigm t o e x p l a i n the proposed s u c c e s s of the problem s o l v i n g model he d e v e l o p e d . The M o t i v a t i o n G e n e r a t i n g Paradigm In the M o t i v a t i o n G e n e r a t i n g Paradigm, the r a t i o n a l e b e h i n d the problem s o l v i n g model d e s c r i b e d by S h o r t r i d g e (1985), m o t i v a t i o n f o r b e h a v i o u r i s r e c o g n i z e d t o be i n t r i n s i c t o the i n d i v i d u a l . M o t i v a t i o n f o r b e h a v i o u r change i s suggested t o be dependent on the maintenance and enhancement of a l e a r n e r ' s image of h i m / h e r s e l f . The M o t i v a t i o n G e n e r a t i n g Paradigm i n c o r p o r a t e s c o n c e p t s from Rokeachs' b e h a v i o u r a l t h e o r y . T h i s t h e o r y suggests t h a t d i s s o n a n c e between an i n d i v i d u a l ' s p e r c e i v e d b e h a v i o u r and a v a l u e d s t a n d a r d of b e h a v i o u r s h o u l d m o t i v a t e the i n d i v i d u a l t o b r i d g e the gap, s i n c e i n d i v i d u a l s a r e more w i l l i n g t o adapt t h e i r b e h a v i o u r than t o change t h e i r f i r m l y e s t a b l i s h e d image of t h e m s e l v e s . As a r e s u l t , s e l f - a s s e s s m e n t by l e a r n e r s of t h e i r n u t r i t i o n a l needs s h o u l d p r o v i d e them w i t h m o t i v a t i o n t o a c t i f the i n d i v i d u a l p e r c e i v e s e i t h e r a t h r e a t t o the maintenance of h i s / h e r s e l f - c o n c e p t or the p o t e n t i a l t o e m b e l l i s h i t . S h o r t r i d g e (1985) has a l s o suggested t h a t a problem s o l v i n g method which i s l e a r n e r - f o c u s e d , easy t o use 37 and p e r s o n a l l y r e l e v a n t s h o u l d be f a v o u r a b l e t o an i n d i v i d u a l ' s f e e l i n g s of competence and a b i l i t y . The m a t e r i a l may a l s o a p p e a l more t o those l e a r n e r s who f e e l c o n f i d e n t i n t h e i r own a b i l i t y t o a s s e s s and s o l v e p e r s o n a l l y r e l e v a n t problems. S h o r t r i d g e (1985) proposed t h a t the use of a problem s o l v i n g model may t h e r e f o r e be r e l a t e d t o l e a r n e r s ' s e l f -c o n c e p t s . The manner i n which S h o r t r i d g e d e f i n e s s e l f -c o n c e p t , as f e e l i n g s of an i n d i v i d u a l toward s e l f , i s s i m i l a r t o the term s e l f - e s t e e m as d e f i n e d i n the p s y c h o l o g y l i t e r a t u r e . In o r d e r , t h e r e f o r e , t o e x p l o r e the a c c u r a c y of the r a t i o n a l e f o r t h i s t e a c h i n g method, i t would be b e n e f i c i a l t o r e l a t e s e l f - e s t e e m s c o r e s of p a r t i c i p a n t s t o measures of i n s t r u c t i o n a l impact. S e l f - E s t e e m The term s e l f - e s t e e m has a t t i m e s been used i n t e r c h a n g e a b l y w i t h t h a t of s e l f - c o n c e p t . The two c a n , however, be d i s t i n q u i s h e d i n t h a t "... s e l f - c o n c e p t r e f e r s t o a p e r s o n s ' p e r c e p t i o n s of h i s / h e r c h a r a c t e r , a b i l i t i e s , and r e l a t i o n s h i p s w i t h o t h e r s and the environment; s e l f -esteem on the o t h e r hand, r e f e r s t o the emotions a s s o c i a t e d w i t h t h i s c o g n i t i v e s e l f - a s s e s s m e n t " ( P l a t h and B e l z e r 1985, p . 2 ) . Both f a c t o r s may i n f l u e n c e b e h a v i o u r . The h y p o t h e s i s t h a t s p e c i f i c c h a r a c t e r i s t i c s of a l e a r n e r may be b e n e f i c i a l t o s u c c e s s f u l outcomes w i t h problem s o l v i n g methods i s not new. Bruner (1966) c i t e d mental f i x e d n e s s as c o n t r a r y t o e f f e c t i v e problem s o l v i n g . 38 Houtz and Speedie (1978) s t u d i e d 91 f i f t h g r a d e r s t o i d e n t i f y p e r s o n a l i t y c h a r a c t e r i s t i c s f a v o u r a b l e t o problem s o l v i n g . They found f l u e n c y w i t h i d e a s , l o g i c and t o t a l mental f l e x i b i l i t y t o be p r e d i c t o r s of p o s i t i v e performance. These f i n d i n g s are c o n s i s t e n t w i t h the s u g g e s t i o n t h a t Humanist t e a c h i n g methods which emphasize l e a r n e r s e l f -assessment and s e l f - i n s t r u c t i o n , a r e most a p p r o p r i a t e f o r i n d i v i d u a l s h a v i n g complex and f l e x i b l e minds (Boyd 1973). A l i t e r a t u r e s e a r c h f o r s t u d i e s r e l a t i n g s e l f - e s t e e m l e v e l s t o problem s o l v i n g outcomes was not s u c c e s s f u l , s u g g e s t i n g t h a t s e l f - e s t e e m l e v e l s of p a r t i c i p a n t s have not y e t been r e l a t e d t o i n s t r u c t i o n a l impacts produced by problem s o l v i n g methods. H e a l t h e d u c a t i o n l i t e r a t u r e i n g e n e r a l i s , however, s u p p o r t i v e of the h y p o t h e s i s t h a t p o s i t i v e l e v e l s of s e l f -c oncept or s e l f - e s t e e m of p a r t i c i p a n t s a r e r e l a t e d t o more f a v o u r a b l e h e a l t h - r e l a t e d p r a c t i c e s , independent of any e d u c a t i o n a l i n t e r v e n t i o n . P r o c haska et a l . (1982) found h i g h e r l e v e l s of s e l f - c o n c e p t among i n d i v i d u a l s who had q u i t smoking. The f r e q u e n c y of b r e a s t s e l f - e x a m i n a t i o n ( H a l l e l 1981) and of m e d i c a t i o n c o m p l i a n c e ( L i t t e t a l . 1982) have both been p o s i t i v e l y c o r r e l a t e d w i t h h i g h e r s e l f - c o n c e p t s c o r e s . A l t h o u g h Neale et a l . (1969) have not found s e l f -c oncept t o be a p r e d i c t o r of more p o s i t i v e h e a l t h - r e l a t e d b e h a v i o u r s , a g e n e r a l t r e n d a c r o s s s t u d i e s i n h e a l t h e d u c a t i o n s u g g e s t s t h a t such a r e l a t i o n s h i p may indeed e x i s t . R esearch on the r e l a t i o n s h i p of s e l f - e s t e e m t o d i e t a r y 39 p r a c t i c e s has been c o m p l i c a t e d by the f a c t t h a t v a r i o u s demographic c h a r a c t e r i s t i c s have been i d e n t i f i e d as r e l a t e d t o s e l f - e s t e e m . Not o n l y do males tend t o have h i g h e r g l o b a l l e v e l s of s e l f - e s t e e m than females ( S a n d e l i n 1981), but h i g h e r s c o r e s on t h i s c h a r a c t e r i s t i c have a l s o been a s s o c i a t e d w i t h h i g h e r s o c i o - e c o n o m i c s t a t u s (Stanwyck 1983) and h i g h e r academic achievement ( S a n d e l i n 1981). S e v e r a l of t h e s e demographic f a c t o r s are known t o be r e l a t e d t o food p r a c t i c e s as w e l l . A few r e s e a r c h e r s i n n u t r i t i o n e d u c a t i o n have, however, begun to e x p l o r e the r e l a t i o n s h i p of s e l f - c o n c e p t to f o o d -r e l a t e d b e h a v i o u r s . S c h a f e r and Y e t l e y (1975) d e s c r i b e d food faddism as a b e h a v i o u r performed t o m a i n t a i n and r e a f f i r m the s e l f - c o n c e p t i n c e r t a i n i n d i v i d u a l s . In 1979, S c h a f e r r e l a t e d s e l f - e s t e e m l e v e l s of young m a r r i e d women t o the q u a l i t y of t h e i r d i e t s . U s i n g the Gough and H e i l b r a m s ' A d j e c t i v e C h e c k l i s t , he found the more p o s i t i v e the s e l f -esteem r a t i n g , the fewer empty c a l o r i e s were consumed. Research on the r e l a t i o n s h i p between impacts of n u t r i t i o n e d u c a t i o n programs and l e v e l s of s e l f - e s t e e m c o u l d not be found i n the n u t r i t i o n e d u c a t i o n l i t e r a t u r e . Thus, i t appears t h a t s e l f - e s t e e m may be r e l a t e d t o d i e t a r y b e h a v i o u r , y e t f u r t h e r work i s n e c e s s a r y t o c l a r i f y the r o l e of i n s t r u c t i o n a l methods r e l a t i v e t o s e l f - e s t e e m , and u l t i m a t e l y t o b e h a v i o u r change. D e s p i t e the p o t e n t i a l v a l u e of r e s e a r c h on s e l f - e s t e e m , one of the major d i f f i c u l t i e s of such p r o j e c t s l i e s i n the s e l e c t i o n of an a p p r o p r i a t e measurement s c a l e . In W y l i e ' s 40 (1974) comprehensive review of s e l f - c o n c e p t and s e l f - e s t e e m s c a l e s , she emphasized the d i f f i c u l t y i n s e l e c t i n g one which has c o n f i r m e d v a l i d i t y and r e l i a b i l i t y . In r e v i e w i n g s c a l e s which are a p p r o p r i a t e f o r a d u l t s , f o u r were s p e c i f i c a l l y e x p l o r e d f o r the purpose of t h i s r e s e a r c h : The Tennessee S e l f - C o n c e p t S c a l e ( F i t t s 1964); the Texas S o c i a l B e h a v i o u r I n v e n t o r y ( H e l m r e i c h and Stapp 1974); Rosenberg's S e l f - E s t e e m S c a l e (Rosenberg 1979); and the C u l t u r e - F r e e S e l f - E s t e e m I n v e n t o r y ( B a t t l e 1976). The l a t t e r was s e l e c t e d f o r t h i s s t u d y because i t : (1) i s s u f f i c i e n t l y s i m p l e and r a p i d t o a p p l y , u n l i k e the more l e n g t h y and complex Tennessee S e l f - C o n c e p t S c a l e ( F i t t s 1964); (2) asks q u e s t i o n s r e g a r d i n g f e e l i n g s of competency and c o n f i d e n c e r a t h e r than b e i n g d e s i g n e d t o measure f e e l i n g s of e f f e c t i v e n e s s i n s o c i a l i n t e r a c t i o n s , as i s the case w i t h the Texas S o c i a l B e h a v i o u r I n v e n t o r y ( H e l m r e i c h and Stapp 1974); and (3) e n a b l e s the r e s e a r c h e r t o d e r i v e t h r e e s e l f - e s t e e m s u b - s c a l e s ( g e n e r a l , s o c i a l , and p e r s o n a l ) , whereas the Rosenberg (1979) S e l f - E s t e e m S c a l e p r o v i d e s o n l y one g e n e r a l s c o r e f o r s e l f - e s t e e m . The manual on the C u l t u r e - F r e e S e l f - E s t e e m I n v e n t o r y ( B a t t l e 1976) r e p o r t e d i n t e r n a l c o n s i s t e n c y c o e f f i c i e n t s r e s u l t i n g from s c a l e a d m i n i s t r a t i o n t o 127 s t u d e n t s e n r o l l e d i n an i n t r o d u c t o r y e d u c a t i o n a l p s y c h o l o g y c o u r s e a t the U n i v e r s i t y of A l b e r t a . The r e l i a b i l i t y c o e f f i c i e n t s were: 0.78 f o r g e n e r a l s e l f - e s t e e m , 0.57 f o r s o c i a l s e l f - e s t e e m , and 0.72 f o r p e r s o n a l s e l f - e s t e e m . Ludwig et a l . ( l 9 8 l ) , however, a d m i n i s t e r e d the s c a l e t o 56 female n u r s e s i n 41 C i n c i n n a t i and found lower c o e f f i c i e n t s of r e l i a b i l i t y f o r a l l t h r e e s u b s c a l e s , most n o t i c e a b l y w i t h s o c i a l s e l f -esteem: 0.20. P r e t e s t i n g f o r s c a l e r e l i a b i l i t y was t h e r e f o r e recommended p r i o r t o i t s use i n r e s e a r c h work. D e s p i t e measurement d i f f i c u l t i e s and i n s t r u m e n t l i m i t a t i o n s , i t i s s u r p r i s i n g how few s t u d i e s i n n u t r i t i o n e d u c a t i o n have e v a l u a t e d the r e l a t i o n s h i p between s e l f -esteem and e d u c a t i o n a l impact s i n c e s e l f - e s t e e m i s r e c o g n i z e d by s o c i a l p s y c h o l o g i s t s to be an i m p o r t a n t d e t e r m i n a n t of b e h a v i o u r . E v a l u a t i o n P r a c t i c e s i n N u t r i t i o n E d u c a t i o n E v a l u a t i o n i s d e f i n e d as a p r o c e s s of d e t e r m i n i n g program worth based upon whether program o b j e c t i v e s have been a c h i e v e d (Berk 1981, p . 4 ) . In a d d i t i o n , e v a l u a t i o n s can be d e s c r i b e d a c c o r d i n g t o the k i n d s of i n f o r m a t i o n and d e c i s i o n s they a r e i n t e n d e d t o produce. A summative e v a l u a t i o n i s performed t o d e c i d e whether t o c o n t i n u e , fund, or implement a program. F o r m a t i v e e v a l u a t i o n s , on the o t h e r hand, are i n t e n d e d t o a s s i s t program d e v e l o p e r s by p r o v i d i n g feedback on the s t r e n g t h s and weaknesses of the p a r t i c u l a r program or m a t e r i a l . E v a l u a t i o n r e s e a r c h combines the purpose of e v a l u a t i o n w i t h the use of a p p r o p r i a t e s c i e n t i f i c methodology (Talmage et a l . 1979). The emergence of t h i s r e l a t i v e l y new f i e l d can be a t t r i b u t e d t o a s h i f t i n the types of e v a l u a t i o n d e s i g n s employed by r e s e a r c h e r s . 42 E v a l u a t i o n D e s i g n s The m a j o r i t y of e v a l u a t i o n s i n n u t r i t i o n e d u c a t i o n have employed a n o n - e x p e r i m e n t a l Input/Output d e s i g n as d e s c r i b e d by Talmage (1980), i n which a t r e a t m e n t group i s p r e - and p o s t t e s t e d w i t h o u t comparison t o a c o n t r o l group. P o d e l l et a l . (1978) e v a l u a t e d the impact of a c a r d i o v a s c u l a r n u t r i t i o n program i n a grade 10 b i o l o g y c o u r s e i n New J e r s e y u s i n g p r e - and p o s t t e s t i n g of one e x p e r i m e n t a l group. Looker et a l . (1982) e v a l u a t e d changes i n n u t r i t i o n knowledge u s i n g a p r e t e s t , p o s t t e s t d e s i g n f o r two n u t r i t i o n modules d e s i g n e d f o r h o s p i t a l s t a f f members. A major c r i t i c i s m of the n o n - e x p e r i m e n t a l method i s the d i f f i c u l t y i n a t t r i b u t i n g s o l e c r e d i t f o r outcomes t o the i n s t r u c t i o n a l i n t e r v e n t i o n s i n c e r e s u l t s a r e e x p r e s s e d o n l y r e l a t i v e t o the groups' i n i t i a l c h a r a c t e r i s t i c s . Y e t , t h i s method i s o f t e n the o n l y p o s s i b i l i t y where r a n d o m i z a t i o n of s u b j e c t s t o t r e a t m e n t and c o n t r o l groups i s not r e a l i s t i c . In o r d e r t o overcome some of the d i f f i c u l t i e s i n h e r e n t i n the n o n - e x p e r i m e n t a l I nput/Output d e s i g n , n u t r i t i o n e d u c a t o r s have begun t o use e x p e r i m e n t a l or q u a s i -e x p e r i m e n t a l d e s i g n s t o e v a l u a t e programs or m a t e r i a l s among tre a t m e n t and c o n t r o l groups. E v a l u a t i o n r e s e a r c h methods a r e t h e r e f o r e becoming i n c r e a s i n g l y w i d e s p r e a d i n n u t r i t i o n e d u c a t i o n . For i n s t a n c e , P i c a r d i and P o r t e r (1976) e v a l u a t e d a Food and N u t r i t i o n m i n i - c o u r s e f o r Grade 10 and 12 s t u d e n t s i n Boston u s i n g random a l l o c a t i o n of c l a s s e s t o e i t h e r 43 c o n t r o l or e x p e r i m e n t a l groups. S c h a f e r (1986) r e c e n t l y used a q u a s i - e x p e r i m e n t a l study d e s i g n t o compare the change i n n u t r i t i o n - r e l a t e d knowledge and p r a c t i c e s of an e x p e r i m e n t a l group exposed t o an i n n o v a t i v e n u t r i t i o n e d u c a t i o n program r e l a t i v e t o t h a t of a preformed comparison group which was e n r o l l e d i n a n o n - n u t r i t i o n r e l a t e d e x t e n s i o n c o u r s e . The above d e s i g n was o n l y employed as p a r t of S c h a f e r ' s (1986) p i l o t s t u d y . Q u a s i - e x p e r i m e n t a l d e s i g n s may be more p r a c t i c a l f o r many r e s e a r c h e r s than e x p e r i m e n t a l d e s i g n s s i n c e s u b j e c t s need not be randomly a l l o c a t e d to t r e a t m e n t s . R a t h e r , p r e -e s t a b l i s h e d groups a r e randomly s e l e c t e d t o r e c e i v e , or not t o r e c e i v e , t r e a t m e n t . W i t h t h i s method, co m p a r a t i v e e v a l u a t i o n s a re p o s s i b l e . Comparative E v a l u a t i o n i n E d u c a t i o n A wave of c u r r i c u l u m development o c c u r r e d i n the U n i t e d S t a t e s i n the 1960's and 1970's due both t o new government l e g i s l a t i o n and i n c r e a s e d f u n d i n g . Many e v a l u a t i o n s were s p e c i f i c a l l y performed t o compare academic achievements of s t u d e n t s taught by t r a d i t i o n a l v e r s u s i n n o v a t i v e methods. Walker and S h a f f a r z n i c k (1974) reviewed 23 s t u d i e s i n which t r a d i t i o n a l and i n n o v a t i v e l e a r n i n g methods were compared. A n a l y s i s of the r e s u l t s i n d i c a t e d t h a t i n n o v a t i v e programs were a s s o c i a t e d w i t h h i g h e r p o s t t e s t achievement s c o r e s when the c o n t e n t of t e s t s used resembled the c o n t e n t m a t e r i a l of the i n n o v a t i v e program. The same t r e n d was seen 44 f o r t e s t s c o n t a i n i n g t r a d i t i o n a l c o n t e n t a p p l i e d t o t r a d i t i o n a l methods. A t e s t b i a s i s t h e r e f o r e a p o t e n t i a l problem i n a c o m p a r a t i v e e v a l u a t i o n d e s i g n . To overcome t h i s d i f f i c u l t y , t r e a t m e n t s a d m i n i s t e r e d t o the comparison groups s h o u l d be as s i m i l a r as p o s s i b l e . I f an i n s t r u c t i o n a l method i s b e i n g e v a l u a t e d , two groups r e c e i v i n g m a t e r i a l s which r e f l e c t the i n s t r u c t i o n a l method t o v a r y i n g degrees c o u l d be compared. The i n s t r u m e n t used t o measure the i n t e r v e n t i o n impact would not be b i a s e d toward e i t h e r group s i n c e both r e c e i v e d m a t e r i a l s of s i m i l a r c o n t e n t and s t y l e . A c o m p a r a t i v e e v a l u a t i o n may a l s o be s u b j e c t t o the Hawthorne e f f e c t i f d i f f e r e n t m a t e r i a l s a r e p r o v i d e d t o t r e a t m e n t and c o n t r o l groups (Wolf 1984). Groups may s i m p l y respond more f a v o u r a b l y t o a pamphlet than t o an a u d i o -v i s u a l m a t e r i a l f o r i n s t a n c e , so t h a t comparing impacts between the two groups i s d i f f i c u l t . To reduce the l i k e l i h o o d of a Hawthorne e f f e c t , groups s h o u l d be exposed t o m a t e r i a l s of s i m i l a r appearance. Measuring I n s t r u c t i o n a l Impact Q u e s t i o n n a i r e s One of the most f r e q u e n t l y used i n s t r u m e n t s t o a s s e s s program impact i s the q u e s t i o n n a i r e . The s e l f - a d m i n i s t e r e d w r i t t e n q u e s t i o n n a i r e o f f e r s s e v e r a l unique a d v a n t a g e s : (1) i t makes p o s s i b l e the i n d i r e c t measurement of a t t i t u d e s and p e r c e p t i o n s , which cannot be measured d i r e c t l y ; (2) i f 45 p r o p e r l y d e v e l o p e d and a d m i n i s t e r e d , i t p r o v i d e s a c c u r a t e i n f o r m a t i o n ; (3) i t i s easy and i n e x p e n s i v e t o a d m i n i s t e r ; (4) i t reduces the l i k e l i h o o d of an i n t e r v i e w e r e f f e c t and (5) i t p e r m i t s s i m u l t a n e o u s group data c o l l e c t i o n (Hunt 1979). The s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e , which c o n s i s t s of a s e r i e s of s e l e c t e d q u e s t i o n s , may a l s o p r e s e n t c e r t a i n d i s a d v a n t a g e s : (1) i t i s dependent upon the v a l i d i t y of p a r t i c i p a n t s e l f - r e p o r t ; (2) i t n e c e s s i t a t e s l e a r n e r r e a d i n g and w r i t i n g s k i l l s and (3) i t s h o u l d be r e a s o n a b l y s h o r t t o min i m i z e respondent burden (Hunt 1979). D e s p i t e the p o t e n t i a l d i f f i c u l t i e s w i t h t h i s method, i t s many advantages make i t a method of c h o i c e i n the e v a l u a t i o n of program impact. Q u e s t i o n n a i r e Design Sims (1981B) has d e s c r i b e d f o u r s t e p s i n the d e s i g n of q u e s t i o n n a i r e s . These a r e : (1) e x p r e s s i o n and d e s c r i p t i o n of the domain t o be measured; (2) f o r m u l a t i o n of the s p e c i f i c items t o be used t o measure the c o n s t r u c t , w i t h r a n d o m i z a t i o n of e q u a l numbers of n e g a t i v e l y and p o s i t i v e l y worded s t a t e m e n t s ; (3) v a l i d a t i o n and r e l i a b i l i t y t e s t i n g of the m a t e r i a l and (4) s e l e c t i o n of an a p p r o p r i a t e response s c a l e . A t t i t u d e or p e r c e p t i o n c o n s t r u c t s must be d e f i n e d p r i o r t o i n s t r u m e n t development. C o n s t r u c t s s h o u l d be s e l e c t e d as measures of impact based upon the s p e c i f i c o b j e c t i v e s of an e d u c a t i o n a l program. 46 A l a r g e number of items a r e then g e n e r a t e d by the r e s e a r c h e r . I t i s recommended t h a t from an i n i t i a l l y e x t e n s i v e l i s t of i t e m s , those best s u i t e d t o the i n s t r u m e n t be chosen f o l l o w i n g assessment of the i n s t r u m e n t ' s v a l i d i t y and r e l i a b i l i t y . V a l i d i t y has been d e f i n e d as the e x t e n t t o which a t o o l measures what i t i s i n t e n d e d t o measure (Talmage and Rasher 1981). Two important components of v a l i d i t y a r e c o n t e n t and f a c e v a l i d i t y . Content v a l i d i t y i s an e x p r e s s i o n of the r e p r e s e n t a t i v e n e s s and a p p r o p r i a t e n e s s of items t o the c o n s t r u c t they are i n t e n d e d t o measure. Assessment of c o n t e n t v a l i d i t y i s a c h i e v e d by o b j e c t i v e c o n t e n t a r e a s p e c i a l i s t s who judge the r e l a t i o n s h i p of items t o c o n t e n t c o n s t r u c t s . Items r e c e i v i n g a low r a t i n g f o r a p p r o p r i a t e n e s s or r e p r e s e n t a t i v e n e s s are dropped from the q u e s t i o n n a i r e . Face v a l i d i t y r e p r e s e n t s an assessment of the appearance of f e a s i b i l i t y of the i n s t r u m e n t t o p o t e n t i a l u s e r s i n terms of i t s w o r d i n g , format, items and d i r e c t i o n s (Talmage and Rasher 1981). A d r a f t q u e s t i o n n a i r e i s a d m i n i s t e r e d t o p r o f e s s i o n a l s who s e r v e the t a r g e t l e a r n e r , or t o a c t u a l p o t e n t i a l u s e r s , f o r t h e i r feedback. Subsequent changes are made t o the q u e s t i o n n a i r e . R e l i a b i l i t y i s d e f i n e d as the tendency of an i n s t r u m e n t t o y i e l d s i m i l a r s c o r e s upon r e p e a t e d a d m i n i s t r a t i o n s (Basch and G o l d 1985). I n t e r n a l c o n s i s t e n c y r e f l e c t s the degree t o which each i t e m , or c l u s t e r of i t e m s , r e l a t e s t o the t o t a l 47 q u e s t i o n n a i r e s c o r e . A common method of d e t e r m i n i n g i n t e r n a l c o n s i s t e n c y i s Cronbach's a l p h a (Talmage and Rasher 1981). A f t e r a d m i n i s t r a t i o n of the i n s t r u m e n t , t h i s s t a t i s t i c i s c a l c u l a t e d t o r e p r e s e n t how h i g h l y the q u e s t i o n n a i r e would c o r r e l a t e w i t h a p a r a l l e l q u e s t i o n n a i r e . A c c e p t a b l e q u e s t i o n n a i r e r e l i a b i l i t y i s a c r i t e r i o n f o r i n s t r u m e n t v a l i d i t y . N u n a l l y (1967) and Hunt (1979) have proposed g u i d e l i n e s on a c c e p t a b l e l e v e l s f o r c o e f f i c i e n t s of r e l i a b i l i t y . A modest r e l i a b i l i t y of 0.5 t o 0.6 may be s u i t a b l e f o r survey work and c o r r e l a t i o n a l a n a l y s i s ( N u n a l l y 1967). Hunt (1979) recomended a l e v e l of a t l e a s t 0.5 u n l e s s the i n s t r u m e n t i s t o be used f o r p r e d i c t i v e p u r p o s e s , where an a l p h a of at l e a s t 0.9 i s n e c e s s a r y . S i n c e a h i g h e r a l p h a i s not n e c e s s a r y f o r most a p p l i c a t i o n s , and s i n c e t r y i n g t o i n c r e a s e the c o e f f i c i e n t a l s o i n v o l v e s i n c r e a s i n g q u e s t i o n n a i r e l e n g t h , a l e v e l of 0.70 would be s a t i s f a c t o r y f o r a q u e s t i o n n a i r e measuring e d u c a t i o n a l impact. A f t e r the q u e s t i o n n a i r e has been deemed v a l i d and r e l i a b l e , Sims (1981B) recommended t h a t a response s c a l e be chosen. The most f r e q u e n t l y employed response format f o r a t t i t u d e and p e r c e p t i o n measurement i s the agreement s c a l e (Henerson et a l . 1978). Respondents r e p o r t on the i n t e n s i t y t o which they agree w i t h a s t a t e m e n t , g e n e r a t i n g a range of s c o r e s . A f i v e - p o i n t L i k e r t s c a l e d e s c r i b e s a continuum of response from s t r o n g l y agree (5 p o i n t s ) t o s t r o n g l y d i s a g r e e (1 p o i n t ) . T h i s format p r o v i d e s the advantage of q u a n t i f i c a t i o n of a t t i t u d e s and p e r c e p t i o n s (Sims 1981B; Henerson et a l . 1978). 48 A r a t i n g s c a l e may be s u b j e c t t o p a r t i c u l a r e r r o r s which w i l l a f f e c t the v a l i d i t y and r e l i a b i l i t y of the i n s t r u m e n t . Four p o t e n t i a l e r r o r s a r e : (1) a h a l o e f f e c t , the tendency of respondents t o have a c o n s i s t e n t o v e r - a l l response t o q u e s t i o n s ; (2) l e n i e n c y and s e v e r i t y e r r o r , where i n d i v i d u a l s tend t o respond p o s i t i v e l y or n e g a t i v e l y t o a l l q u e s t i o n s ; (3) e r r o r of c e n t r a l tendency, i n which respondents chose a non-commital r e p l y c o n s i s t e n t l y and (4) p r o x i m i t y e r r o r , i n which the sequencing of items i n the q u e s t i o n n a i r e i n f l u e n c e s p a r t i c i p a n t r e s p o n s e . D e s p i t e these s o u r c e s of p o s s i b l e e r r o r , the r a t i n g s c a l e i s u s e f u l f o r q u a n t i f i c a t i o n of i n d i r e c t e d u c a t i o n a l impacts and c o n s e q u e n t l y , f o r data a n a l y s i s . Q u e s t i o n n a i r e A d m i n i s t r a t i o n In o r d e r t o maximize the p o t e n t i a l of q u e s t i o n n a i r e based d a t a c o l l e c t i o n , the a d m i n i s t r a t i o n of t o o l s s h o u l d be s t a n d a r d i z e d (Talmage and Rasher 1981). The l e n g t h of time p r o v i d e d t o complete the q u e s t i o n n a i r e ; the i n s t r u c t o r p r e s e n t ; the sequence of l e a r n i n g e v e n t s and the q u e s t i o n n a i r e a d m i n i s t e r e d s h o u l d be c o n s i s t e n t from one a p p l i c a t i o n t o the n e x t . The time d e l a y between p r e - and p o s t t e s t use of the q u e s t i o n n a i r e s h o u l d a l s o be u n i f o r m f o r a l l i n t e r v e n t i o n s . A d e l a y time of 4 t o 6 weeks has been recommended as l o n g enough f o r l e a r n e r s t o have f o r g o t t e n the q u e s t i o n s , yet s t i l l be i n f l u e n c e d by program impact ( C a r r u t h e t a l . 1977). 49 Measurement of Change i n D i e t a r y B e h a v i o u r One of the i n s t r u m e n t s most f r e q u e n t l y used t o measure group mean i n t a k e s of n u t r i e n t s i s the t w e n t y - f o u r hour r e c a l l , or m o d i f i c a t i o n s of i t . T h i s method o f f e r s the advantages of s h o r t n e s s of l e n g t h and ease of a d m i n i s t r a t i o n . Research has been r e p o r t e d on b o t h i t s v a l i d i t y and r e l i a b i l i t y . G e r s o v i t z e t a l . (1978) e x p l o r e d the v a l i d i t y of a t w e n t y - f o u r hour r e c a l l and a seven day food r e c o r d f o r the measurement of mean d i e t a r y c a l c i u m i n t a k e s . When a c t u a l d i e t a r y c a l c i u m i n t a k e s of n o n - i n s t i t u t i o n a l i z e d e l d e r l y men and women were compared t o tho s e e s t i m a t e d by a t w e n t y - f o u r hour r e c a l l , the l a t t e r was found t o exceed, though not s i g n i f i c a n t l y , the former. I t was found t h a t the r e c a l l tended t o over e s t i m a t e a c t u a l consumption, where the seven day food r e c o r d r e s u l t e d i n u n d e r e s t i m a t e d i n t a k e s . D i f f e r e n c e s between the two methods f o r group means were n o t , however, s i g n i f i c a n t l y d i f f e r e n t . K a r v e t t i and Knuts (1985) found s i m i l a r r e s u l t s w i t h a t w e n t y - f o u r hour r e c a l l i n e s t i m a t i n g m i l k and m i l k p r o d u c t i n t a k e . From r e s e a r c h on the v a l i d i t y of t w e n t y - f o u r hour r e c a l l s , i t appears t h a t : (1) i t may be prone t o ov e r -r e p o r t i n g of low i n t a k e s and u n d e r - r e p o r t i n g of h i g h i n t a k e s such t h a t i n the e v a l u a t i o n of e d u c a t i o n a l programs the p o s s i b i l i t y e x i s t s t h a t an a c t u a l d i f f e r e n c e i n i n t a k e s between groups may not be d e t e c t e d ; and (2) i t y i e l d s comparable i n f o r m a t i o n on group mean i n t a k e s t o a seven day 50 h i s t o r y w h i l e r e q u i r i n g a s h o r t e r p e r i o d of r e c a l l and l e s s p a r t i c i p a n t e f f o r t ( G e r s o v i t z e t a l . 1978). R e l i a b i l i t y of the t w e n t y - f o u r hour r e c a l l i s dependent upon: (1) b i o l o g i c a l v a r i a b i l i t y , s i n c e i n d i v i d u a l s eat d i f f e r e n t l y on d i f f e r e n t days and (2) measurement e r r o r (Rush and K r i s t a l 1982). V a r i a b i l i t y may be i n f l u e n c e d by food a v a i l a b i l i t y , income, age, sex, day of the week and so on. Beaton et a l . (1983) i d e n t i f i e d some of the s o u r c e s of v a r i a b i l i t y i n c a l c i u m i n t a k e among women. When c a l c i u m i n t a k e was ex p r e s s e d r e l a t i v e t o energy i n t a k e , two i n f l u e n c e s were s i g n i f i c a n t : (1) the i n t e r v i e w e r and (2) the day of the week, w i t h the lowest d i e t a r y c a l c i u m i n t a k e r e p o r t e d on Sundays and the h i g h e s t on Tuesdays and Wednesdays. The t o t a l e x p e c t ed v a r i a b i l i t y i n d i e t a r y c a l c i u m i n t a k e s of women u s i n g a t w e n t y - f o u r hour r e c a l l i s h i g h . Beaton e t a l . (1983) r e p o r t e d t o t a l v a r i a b i l i t y on a twenty-f o u r hour r e c a l l of women's c a l c i u m i n t a k e s t o be 57.7%. I n t e r - i n d i v i d u a l v a r i a b i l i t y was 32.7% and i n t r a - i n d i v i d u a l v a r i a t i o n was even g r e a t e r , a t 47.5%. Such l a r g e v a r i a b i l i t y may reduce the p o s s i b i l i t y of d e t e c t i n g s i g n i f i c a n t l y d i f f e r e n t mean i n t a k e s between groups of women. A n a l y s i s of I n s t r u c t i o n a l Impact A consensus does not e x i s t i n the p s y c h o m e t r i c l i t e r a t u r e on which method of s t a t i s t i c a l a n a l y s i s i s bes t 51 f o r the measurement of e d u c a t i o n a l impact. L i n n and S l i n d e (1977) have c r i t i c i z e d the use of g a i n s c o r e s ( i . e . change from pre t o p o s t t e s t ) f o r the f o l l o w i n g r e a s o n s : ( l ) u s u a l l y change s c o r e s c o r r e l a t e n e g a t i v e l y w i t h p r e t e s t s c o r e s , such t h a t the h i g h e r the i n i t i a l v a l u e f o r a v a r i a b l e , the l e s s change w i l l l i k e l y o c c u r ; (2) change s c o r e s may be a s s o c i a t e d w i t h low r e l i a b i l i t y when c o r r e l a t i o n s from p r e -to p o s t t e s t a r e h i g h , and thes e c o r r e l a t i o n s a r e o f t e n 0.7 or g r e a t e r and (3) change s c o r e s a r e m e a n i n g l e s s u n l e s s the same measurement t o o l i s a d m i n i s t e r e d a t b o t h p r e - and p o s t t e s t . Those who oppose the use of g a i n s c o r e s i n e v a l u a t i o n s of e d u c a t i o n a l impact have o f f e r e d a l t e r n a t i v e methods t o a s s e s s change (Cronbach and Furby 1970). Two of thes e a r e : (1) r e s i d u a l g a i n s c o r e s , where a g a i n i s r e s i d u a l i z e d by e x p r e s s i n g the p o s t t e s t s c o r e as a d e v i a t i o n from the r e g r e s s i o n l i n e of p o s t t e s t on p r e t e s t v a l u e s . T h i s method i s not a p p r o p r i a t e i f a h i g h c o r r e l a t i o n e x i s t s between p r e -and p o s t t e s t v a l u e s . A l s o , i t may not be p o s s i b l e t o use t h i s method i f p r e - t o p o s t t e s t c o r r e l a t i o n s w i t h i n i n t e r v e n t i o n groups a r e too d i s s i m i l a r t o be compared. (2) a n a l y s i s of c o v a r i a n c e , i n which p r e t e s t v a l u e s of the v a r i a b l e s are used as c o v a r i a t e s t o c o n t r o l f o r d i f f e r e n t mean p r e t e s t v a l u e s among groups. D e s p i t e the f a c t t h a t t h i s i s a f a i r l y s e n s i t i v e method f o r group mean comp a r i s o n s , i t p r e s e n t s an i m p o r t a n t l i m i t a t i o n : i t i s e s p e c i a l l y prone t o p r e t e s t measurement e r r o r . I f s t a t i s t i c a l t e s t i n g f o r d i f f e r e n c e s among the i n t e r v e n t i o n 52 groups does not r e v e a l any s i g n i f i c a n t d i f f e r e n c e s on the p r e t e s t dependent v a r i a b l e s , a n a l y s i s of c o v a r i a n c e may not be n e c e s s a r y . Huck and McLean (1975) have i n s t e a d recommended the use of one-way a n a l y s i s of v a r i a n c e w i t h g a i n s c o r e s . The assumptions u n d e r l y i n g t h i s method, as w i t h c o v a r i a n c e , a r e : (1) r a n d o m i z a t i o n ; (2) l i n e a r i t y of data and (3) homogeneity of r e g r e s s i o n s l o p e s . W i t h one-way a n a l y s i s of v a r i a n c e one makes the a d d i t i o n a l assumption t h a t the g a i n s c o r e need not be a d j u s t e d f o r any p r e t e s t i n f l u e n c e . I f i n t e r v e n t i o n groups have s t a t i s t i c a l l y comparable mean p r e t e s t v a l u e s , t h i s assumption c o u l d be made. One-way a n a l y s i s of v a r i a n c e i s , t h e r e f o r e , an a c c e p t a b l e method of a n a l y s i s f o r the assessment of e d u c a t i o n a l impact. In summary, i t i s p o s s i b l e t o use a s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e a l o n g w i t h a t w e n t y - f o u r hour r e c a l l t o compare g a i n s c o r e s of i n s t r u c t i o n a l i m p a c t s , a n a l y z e d u s i n g one-way a n a l y s i s of v a r i a n c e . Doing so would r e p r e s e n t the f u l l d e s c r i p t i o n of program impact. However, S c r i v e n (1967) has argued t h a t an e v a l u a t i o n i s o n l y complete once the program or m a t e r i a l has been both f u l l y d e s c r i b e d and f u l l y judged. R e s p o n s i b i l i t y f o r J u d g i n g the Value of a Program S c r i v e n (1967) argued t h a t e v a l u a t i o n s a r e not complete u n t i l judgement has been re n d e r e d on the r e s u l t s by the e v a l u a t o r . He based t h i s argument upon the premise t h a t the 53 e v a l u a t o r , b e i n g i m p a r t i a l t o the e v a l u a t i o n outcome, i s b e t t e r s u i t e d t o make e x p e r t judgements on a program than a r e the c o n t e n t - e x p e r t s i n v o l v e d i n the program i t s e l f . Stake (1967), however, proposed t h a t judgement s h o u l d be performed by a l l those who have a p o l i t i c a l l y - v e s t e d i n t e r e s t i n the e v a l u a t i o n r e s u l t s , s i n c e e v a l u a t i o n s a r e based upon the c l a r i f i c a t i o n of i s s u e s . A c c o r d i n g t o Stake (1967), the e v a l u a t o r i s s u b j e c t i v e l y i n v o l v e d i n the judgement p r o c e s s . More r e c e n t l y , S t u f f l e b e a m (1971) has argued t h a t the e v a l u a t o r remain o b j e c t i v e r e l a t i v e t o e v a l u a t i o n r e s u l t s . C o n s e q u e n t l y , the e v a l u a t o r ' s r o l e c o n s i s t s of c o l l e c t i n g d a t a upon which d e c i s i o n s r e g a r d i n g a program w i l l be made. These r e s u l t s a re p r o v i d e d t o a l l d e c i s i o n - m a k e r s who then make judgements about program worth. In k e e p i n g w i t h the argument of S t u f f l e b e a m t h a t the judgement p r o c e s s be shared w i t h o t h e r s , the B.C. Department of E d u c a t i o n (1975) c u r r e n t l y recommends t h a t judgement on e d u c a t i o n a l programs be made by a u d i e n c e s who share a conc e r n f o r the study r e s u l t s . I t would t h e r e f o r e be u s e f u l t o form a p a n e l of judges t o det e r m i n e program worth based on e v a l u a t i o n r e s u l t s . P a r t i e s who s h o u l d b oth c o n t r i b u t e t o the judgement on program worth and be p r o v i d e d w i t h summary r e s u l t s i n c l u d e : (1) p o l i c y makers; (2) program s p o n s o r s ; (3) e v a l u a t i o n s p o n s o r s ; (4) t a r g e t p a r t i c i p a n t s ; (5) program c o m p e t i t o r s and (6) c o n t e x t u a l i n t e r e s t p a r t i e s ( R o s s i e t a l . 1979). 54 In o r d e r f o r f u r t h e r r e f i n e m e n t s of i n s t r u c t i o n a l methods i n n u t r i t i o n e d u c a t i o n t o o c c u r , e v a l u a t i o n s are s p e c i f i c a l l y needed of a c t i v e l e a r n i n g approaches, such as problem s o l v i n g . The more e f f e c t i v e the i n s t r u c t i o n a l methods used by n u t r i t i o n e d u c a t o r s , the b e t t e r the e d u c a t i o n a l needs of the p u b l i c w i l l be met. A contemporary h e a l t h problem of r e a l concern t o Canadian women i s t h a t of o s t e o p o r o s i s and d i e t a r y c a l c i u m . N u t r i t i o n e d u c a t i o n i s w a r r a n t e d t o respond to t h i s c o n c e r n . The Role of C a l c i u m i n O s t e o p o r o s i s The term o s t e o p o r o s i s r e f e r s to "a group of d i s e a s e s of d i v e r s e e t i o l o g y c h a r a c t e r i z e d by a r e d u c t i o n i n the mass of bone t o a l e v e l a t which the s k e l e t o n can no l o n g e r m a i n t a i n i t s i n t e g r i t y " ( J o s s e 1983, p.2113). Of the many p o s s i b l e causes of p r i m a r y o s t e o p o r o s i s , e x p e r t s have i d e n t i f i e d two major ones: d e f i c i e n c y of e s t r o g e n and d e f i c i e n c y of d i e t a r y c a l c i u m ( N a t i o n a l I n s t i t u t e of H e a l t h Consensus Conference 1984, p.799). O s t e o p o r o s i s i s the most common m e t a b o l i c bone d i s e a s e a f f e c t i n g the e l d e r l y ( J o s s e 1983). The i n c i d e n c e of o s t e o p o r o s i s i n c r e a s e s w i t h age and i s f o u r t i m e s more p r e v a l e n t among women than men. I t has been e s t i m a t e d t h a t 25 p e r c e n t of w h i t e women over the age of 60 s u f f e r from o s t e o p o r o s i s i n N o r t h A m e r i c a . In a d d i t i o n , a t l e a s t t e n p e r c e n t of women over the age of 50 s u f f e r from bone l o s s s e v e r e enough t o cause h i p , v e r t e b r a l or l o n g bone f r a c t u r e s . C o m p l i c a t i o n s of o s t e o p o r o t i c f r a c t u r e s a r e 55 a s s o c i a t e d w i t h a m o r t a l i t y r a t e of f i f t e e n p e r c e n t ( J o s s e 1983). A g r e a t d e a l of r e s e a r c h has r e c e n t l y f o c u s e d on the r e l a t i o n s h i p between d i e t a r y c a l c i u m i n t a k e s and the i n c i d e n c e of o s t e o p o r o s i s i n women. M a t k o v i c et a l . (1979) e x p l o r e d the bone s t a t u s and f r a c t u r e r a t e s of two Y u g o s l a v i a n r e g i o n s w i t h d i f f e r e n t average d i e t a r y c a l c i u m i n t a k e s . Women from the lower c a l c i u m i n t a k e a r e a consumed 445 mg/day c a l c i u m , w h i l e those from the h i g h e r i n t a k e group consumed 940 mg/day c a l c i u m . The r a t e of fem o r a l f r a c t u r e was s i g n i f i c a n t l y h i g h e r i n the former group, e s p e c i a l l y f o r women between the ages of 45 t o 49, and f o r those over 60. The r a t e of forearm f r a c t u r e was n o t , however, s i g n i f i c a n t l y d i f f e r e n t between the two p o p u l a t i o n s . R e s u l t s of t h i s study suggested t h a t the e x p r e s s i o n of o s t e o p o r o s i s may be r e l a t e d t o d i e t a r y c a l c i u m i n t a k e . S i m i l a r f i n d i n g s have r e c e n t l y been documented by S a n d l e r et a l . (1985). They r e l a t e d post-menopausal bone d e n s i t y of women t o t h e i r s e l f - r e p o r t e d m i l k consumption throughout c h i l d h o o d and a d o l e s c e n c e . Two hundred and t w e n t y - f i v e w h i t e , post-menopausal women not r e c e i v i n g e s t r o g e n t h e r a p y were r e c r u i t e d and t h e i r bone d e n s i t i e s r e p e a t e d l y a s s e s s e d by CT scan of the dominant r a d i u s . C u r r e n t c a l c i u m i n t a k e s were e s t i m a t e d from t h r e e - d a y food r e c o r d s , and p r i o r i n t a k e by r e t r o s p e c t i v e s e l f - r e p o r t . R e s u l t s suggested a n e a r l y l i n e a r r e l a t i o n s h i p between f r e q u e n c y of m i l k and m i l k p r o d u c t consumption and bone 56 d e n s i t y throughout the l i f e s t a g e s . The r e s e a r c h e r s proposed t h a t adequate l i f e l o n g m i l k and m i l k p r o d u c t consumption p r o v i d e s a h i g h degree of p r o t e c t i o n a g a i n s t a g e - r e l a t e d bone l o s s . The s u b j e c t s were n o t , however, f o l l o w e d p r o s p e c t i v e l y f o r bone f r a c t u r e i n c i d e n c e . Though some r e s e a r c h e r s have c o n c l u d e d t h a t d i e t a r y c a l c i u m may p l a y o n l y a minor r o l e i n the i n c i d e n c e and trea t m e n t of o s t e o p o r o s i s ( M a r t i n and Houston 1987; R i i s et a l . 1987), d i e t a r y c a l c i u m s u p p l e m e n t a t i o n from m i l k has been shown t o improve m e t a b o l i c c a l c i u m b a l a n c e s . In a study by Recker and Heaney (1985), an e x p e r i m e n t a l group of 22 post-menopausal women r e c e i v e d 1471 mg of c a l c i u m per day from m i l k . U s i n g m e t a b o l i c b a l a n c e and k i n e t i c s t u d i e s , i t was d i s c o v e r e d t h a t c a l c i u m b a l a n c e s improved s i g n i f i c a n t l y i n the tre a t m e n t group, s u g g e s t i n g a p o s s i b l e r e d u c t i o n i n t h e i r r i s k of o s t e o p o r o s i s . D i e t a r y C a l c i u m I n t a k e s of Women D i e t a r y c a l c i u m i n t a k e s of women a r e g e n e r a l l y i n f e r i o r t o the recommended i n t a k e s proposed by government h e a l t h departments. The HANES I (1971-1974) and HANES I I (1976-1980) s u r v e y s i n the U n i t e d S t a t e s r e v e a l e d t h a t between the ages of 18 and 30, when peak bone mass i s be i n g d e p o s i t e d , more than t w o - t h i r d s of American women i n g e s t e d l e s s than the U.S. Recommended D i e t a r y A l l o w a n c e f o r c a l c i u m on any g i v e n day. A f t e r age 35, the p r o p o r t i o n of women f o r whom t h i s was t r u e i n c r e a s e d t o 75 p e r c e n t (Heaney e t a l . 1982). 57 R e s u l t s of the N u t r i t i o n Canada Survey (1973) echoed the s e f i n d i n g s . The average d a i l y c a l c i u m i n t a k e by Canadian women was between 300 t o 500 mg/day f o r 22.4 p e r c e n t of thos e aged 20 t o 39, i n c r e a s i n g t o 26.1 p e r c e n t f o r those aged 40 t o 64. T h i s l e v e l of c a l c i u m i n t a k e i s w e l l below the Canadian Recommended N u t r i e n t I n t a k e of 700 t o 800 mg c a l c i u m per day f o r women i n t h i s age group. More r e c e n t l y , two Canadian s t u d i e s have a s s e s s e d the d i e t a r y c a l c i u m i n t a k e s of women. Scy t h e s e t a l . (1982) a n a l y z e d the d i e t a r y i n t a k e s of 100 pre-menopausal women from a u n i v e r s i t y community on s e l f - s e l e c t e d d i e t s . The average c a l c u l a t e d c a l c i u m i n t a k e s from one-day food r e c o r d s was 890 ± 342 mg/day compared t o 694 ± 293 mg/day by a n a l y z e d i n t a k e . The two v a l u e s were c o n s i d e r a b l y d i f f e r e n t due t o i n a c c u r a t e e s t i m a t e s of p o r t i o n s i z e s and the use of weight e d fo o d sample averages i n food c o m p o s i t i o n t a b l e s . However, the second v a l u e f a i l e d t o meet the Canadian Recommended N u t r i e n t I n t a k e f o r c a l c i u m . O'Conner e t a l . (1985) r e c e n t l y p u b l i s h e d a s i m i l a r s tudy on the c a l c i u m i n t a k e s of 96 post-menopausal women l i v i n g i n a u n i v e r s i t y community. S e l f - r e p o r t e d c a l c i u m i n t a k e was 797 + 288 mg/day compared to 769 ± 4 1 2 mg/day by c h e m i c a l a n a l y s i s . E l e v e n p e r c e n t of the women had c a l c u l a t e d c a l c i u m i n t a k e s of l e s s than t w o - t h i r d s of the Canadian Recommended N u t r i e n t I n t a k e (1983). I t appears t h a t some pe r i m e n o p a u s a l women i n Canada s t i l l have inadequate d i e t a r y c a l c i u m i n t a k e s . T h i s may 58 c o n t r i b u t e t o an i n c r e a s e d r i s k f o r o s t e o p o r o s i s . Some r e s e a r c h e r s a r e p r o p o s i n g t h a t t o more f u l l y reduce women's r i s k f o r t h i s d i s e a s e , d i e t a r y c a l c i u m i n t a k e s i n excess of the p r e s e n t Canadian Recommended N u t r i e n t I n t a k e g u i d e l i n e s a r e n e c e s s a r y (Heaney et a l . 1978). The Role of C a l c i u m i n P r e v e n t i o n and Treatment of O s t e o p o r o s i s The p o t e n t i a l f o r r e d u c i n g the r i s k of o s t e o p o r o s i s appears g r e a t e s t f o r young women. Combined w i t h o t h e r r i s k -r e d u c i n g b e h a v i o u r s , i m p r o v i n g d i e t a r y c a l c i u m i n t a k e s i n women p r i o r t o the menopause may c o n t r i b u t e t o the p r e v e n t i o n of t h i s bone d i s e a s e . F o l l o w i n g the menopause, d i e t a r y c a l c i u m appears t o o f f e r some p o t e n t i a l t o p r e v e n t o s t e o p o r o s i s as w e l l . Heaney e t a l . (1978) proposed t h a t the n e g a t i v e c a l c i u m b a l a n c e s e v i d e n c e d i n post-menopausal women may be o f f s e t by markedly i n c r e a s e d d i e t a r y c a l c i u m i n t a k e s , t h e r e b y p o s s i b l y r e d u c i n g t h e i r r i s k of o s t e o p o r o t i c f r a c t u r e s . As a r e s u l t , the N a t i o n a l I n s t i t u t e of H e a l t h i n the U n i t e d S t a t e s has recommended d a i l y i n t a k e s of 1000 mg c a l c i u m f o r p r e -menopausal women and 1500 mg f o r post-menopausal women. For those women who have a l r e a d y e x p e r i e n c e d an o s t e o p o r o t i c f r a c t u r e , A l banese e t a l . (1985) have suggested t h a t improved d i e t a r y c a l c i u m i n t a k e s may reduce the r i s k of subsequent f r a c t u r e s . Women may be d i f f e r e n t i a t e d by t h e i r menopausal s t a t u s and bone h e a l t h , and t h e r e f o r e by the r o l e t h a t d i e t a r y 59 c a l c i u m may p l a y i n t h e i r r i s k f o r o s t e o p o r o s i s . In the case of n o n - o s t e o p o r o t i c women, p o t e n t i a l e x i s t s f o r the p r e v e n t i o n of t h i s d i s e a s e , whereas among o s t e o p o r o t i c women d i e t a r y c a l c i u m s u p p l e m e n t a t i o n i s one p o s s i b l e t h e r a p e u t i c m o d a l i t y . M a t k o v i c et a l . (197 9) suggested t h a t women can be d i s t i n g u i s h e d by age as pre-menopausal, under age 49, and post-menopausal a t age 49 or ov e r . The p o t e n t i a l f o r d i e t a r y c a l c i u m t o a f f e c t the p r e v e n t i o n and treatment of o s t e o p o r o s i s may d i f f e r among t h e s e v a r i o u s groups of women. I t a p p e a r s , t h e r e f o r e , t h a t o s t e o p o r o s i s i s an impo r t a n t h e a l t h problem of g r e a t c o s t b o t h t o the i n d i v i d u a l and the h e a l t h c a r e system. Support e x i s t s f o r the recommendation t h a t consuming a t l e a s t the p r e s e n t Canadian Recommended N u t r i e n t I n t a k e of c a l c i u m may o f f s e t the r i s k of o s t e o p o r o s i s f o r women. D e s p i t e t h e s e f i n d i n g s , i t i s s t i l l e v i d e n t t h a t f o r the most p a r t , many Canadian women are not consuming enough c a l c i u m t o meet t h e i r recommended i n t a k e . A need e x i s t s f o r e f f e c t i v e n u t r i t i o n e d u c a t i o n f o r women which would enable them t o a s s e s s t h e i r own d i e t a r y c a l c i u m i n t a k e s and encourage them to modify t h e i r d i e t a r y p r a c t i c e s a c c o r d i n g l y . The 'Calcium C a l c u l a t o r ' i s an e d u c a t i o n a l m a t e r i a l i n t e n d e d t o respond t o t h i s need ( d e s c r i b e d i n Chapter I ) . Summary In r e v i e w i n g the l i t e r a t u r e , i t became c l e a r t h a t a need e x i s t s f o r e v a l u a t i o n s of a c t i v e l e a r n i n g methods i n n u t r i t i o n e d u c a t i o n . T h i s i s e s p e c i a l l y t r u e f o r a d u l t s . A 60 problem s o l v i n g i n s t r u c t i o n a l method has been d e s c r i b e d i n a model f o r s p e c i f i c a p p l i c a t i o n t o n u t r i t i o n e d u c a t i o n . The 'Calcium C a l c u l a t o r ' has been d e s i g n e d t o r e f l e c t t h i s model. T h e r e f o r e , an e v a l u a t i o n of the problem s o l v i n g method e x e m p l i f i e d by the 'Calcium C a l c u l a t o r ' would p r o v i d e v a l u a b l e i n f o r m a t i o n t o n u t r i t i o n e d u c a t o r s r e s p o n s i b l e f o r the development of f u t u r e programs and m a t e r i a l s . A q u a s i - e x p e r i m e n t a l c o m p a r a t i v e e v a l u a t i o n d e s i g n was employed t o p e r f o r m t h i s e v a l u a t i o n . Chapter I I I p r o v i d e s f u r t h e r d e t a i l s on the e v a l u a t i o n d e s i g n and methodology. 61 CHAPTER I I I METHODS Desi g n For the purpose of t h i s e v a l u a t i o n , a q u a s i -e x p e r i m e n t a l randomized group p r e t e s t , p o s t t e s t r e s e a r c h d e s i g n was used (Van Dalen 1973). Groups of women from 18 community c e n t r e s were randomly a s s i g n e d t o one of t h r e e i n t e r v e n t i o n groups. In the c o n t e x t of a C a l c i u m and Bone H e a l t h Workshop, i n t e r v e n t i o n groups A and B were exposed t o problem s o l v i n g m a t e r i a l s w h i l e the c o n t r o l group, i n t e r v e n t i o n group C, viewed a f i l m . Data were c o l l e c t e d both a t p r e t e s t and 4 t o 9 weeks l a t e r (average 4.7 weeks) at p o s t t e s t . T h i s r e s e a r c h d e s i g n made p o s s i b l e a comparison between impacts produced by the two problem s o l v i n g m a t e r i a l s , forms A and B of the 'Calcium C a l c u l a t o r ' . By t h i s method,, i t was a l s o p o s s i b l e t o compare p r o b l e m - s o l v i n g v e r s u s non-problem s o l v i n g i n t e r v e n t i o n i m p a c t s . The c o m p a r a t i v e q u a s i - e x p e r i m e n t a l e v a l u a t i o n d e s i g n o f f e r e d two main advantages over both n o n - e x p e r i m e n t a l i n p u t / o u t p u t and p u r e l y e x p e r i m e n t a l r e s e a r c h d e s i g n s : (1) i t reduced the l i k e l i h o o d of both a Hawthorne e f f e c t and a t e s t b i a s and (2) i t made p o s s i b l e the use of n o n - e q u i v a l e n t preformed groups of p a r t i c i p a n t s (as d e s c r i b e d i n Chapter I I ) . F i g u r e 4 d e s c r i b e s the e v a l u a t i o n p r o c e s s f o l l o w e d i n 62 T e s t i n g the de v e l o p e d m a t e r i a l s : V a l i d i t y of the q u e s t i o n n a i r e and form B of the 'Calcium C a l c u l a t o r ' ; R e l i a b i l i t y of the s e l f - e s t e e m s c a l e and c o m p a r a b i l i t y of the food i n t a k e form t o a t w e n t y - f o u r hour r e c a l l P r e t e s t d a t a c o l l e c t i o n a t a C a l c i u m and Bone H e a l t h Workshop u s i n g a s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e and food i n t a k e form I n t e r v e n t i o n c o n s i s t i n g of e x p o s i n g p a r t i c i p a n t s t o problem s o l v i n g m a t e r i a l s (groups A and B) or t o a c o n t r o l f i l m (group C) P o s t t e s t d a t a c o l l e c t i o n on average 4.7 weeks a f t e r the workshop i n a group meeting u s i n g a m o d i f i e d form of the p r e t e s t q u e s t i o n n a i r e , the same food i n t a k e form and a s e l f -esteem s c a l e A n a l y s i s of the da t a by s t a t i s t i c a l means t o t e s t the study h y p o t h e s e s , i n v o l v i n g comparisons among d a t a from: I n t e r v e n t i o n Group A I n t e r v e n t i o n Group B I n t e r v e n t i o n Group C Judgement by a p a n e l of e x p e r t s on: (1) the r e l a t i v e impacts of the two forms of the 'Calcium C a l c u l a t o r ' and (2) the v a l u e of problem s o l v i n g i n s t r u c t i o n a l methods and s e l f - e s t e e m i n m a t e r i a l d e s i g n F i g u r e 4 : An e v a l u a t i o n method a p p l i e d t o the 'Calcium C a l c u l a t o r ' ( m o d i f i e d from S t u f f l e b e a m et a l . 1971) 63 t h i s s t u d y . The d e s i g n , m o d i f i e d from the model d e s c r i b e d by S t u f f l e b e a m et a l . (1971) i n c l u d e d the f o l l o w i n g s t e p s : (1) t e s t i n g f o r v a l i d i t y and r e l i a b i l i t y of the r e s e a r c h t o o l s ; (2) p r e t e s t d ata c o l l e c t i o n ; (3) i n t e r v e n t i o n ; (4) p o s t t e s t d a t a c o l l e c t i o n ; (5) a n a l y s i s of the d ata t o t e s t the study hypotheses and (6) judgement on d a t a r e l a t e d t o two of the t h r e e r e s e a r c h q u e s t i o n s . S p e c i f i c a t i o n of the V a r i a b l e s The dependent v a r i a b l e s measured t o compare the r e l a t i v e impacts of the t h r e e i n t e r v e n t i o n s were: (1) p a r t i c i p a n t s ' a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s ; (2) p a r t i c i p a n t s ' p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t i e s and (3) p a r t i c i p a n t s ' s e l f - r e p o r t e d d i e t a r y c a l c i u m i n t a k e . The independent v a r i a b l e s i n c l u d e d : (1) the type of i n t e r v e n t i o n ; (2) p r e t e s t s e l f - r e p o r t e d awareness of o s t e o p o r o s i s ; (3) age; (4) employment s t a t u s ; (5) s o c i o - e c o n o m i c s t a t u s ; (6) p r e t e s t s e l f - r e p o r t e d a l l e r g y or i n t o l e r a n c e t o m i l k or m i l k p r o d u c t s ; (7) J e t t e c l a s s i f i c a t i o n of s e l f - r e p o r t e d weight f o r h e i g h t ; (8) p r e -and p o s t t e s t s e l f - r e p o r t e d use of a c a l c i u m c o n t a i n i n g supplement; (9) p r e - and p o s t t e s t s e l f - r e p o r t e d pregnancy s t a t u s ; (10) p r e t e s t s e l f - r e p o r t e d h i g h e s t l e v e l of e d u c a t i o n ; (11) p r e t e s t s e l f - r e p o r t e d use of a s p e c i a l d i e t ; (12) p o s t t e s t s e l f - r e p o r t e d s e a s o n a l v a r i a t i o n i n m i l k or m i l k p r o d u c t i n t a k e ; (13) p o s t t e s t s e l f - r e p o r t e d adherence t o the problem s o l v i n g s t e p s and (14) p o s t t e s t s e l f - e s t e e m s c o r e . 64 Sample Groups of women from 18 community c e n t r e s i n Vancouver and Burnaby took p a r t i n t h i s s t u d y . P a r t i c i p a n t s were r e c r u i t e d by the f o l l o w i n g p r o c e s s : (1) community c e n t r e c o o r d i n a t o r s were t e l e p h o n e d and i f i n t e r e s t e d i n t a k i n g p a r t , were m a i l e d a l e t t e r of i n t r o d u c t i o n t o the study r e q u e s t i n g them t o respond i n w r i t i n g ; (2) upon r e c e i p t of a l e t t e r from the community c e n t r e , the c o o r d i n a t o r was te l e p h o n e d t o s e t a date and time f o r both the p r e - and p o s t t e s t s e s s i o n s i f the group met c r i t e r i a f o r i n c l u s i o n i n the study (as d e s c r i b e d i n Chapter I ) ; (3) a p r o m o t i o n a l l e t t e r was then m a i l e d t o each c e n t r e f o r p u b l i c i z i n g the workshops and p o s t t e s t s e s s i o n ; (4) the c o o r d i n a t o r was te l e p h o n e d one week p r i o r t o the workshop t o c o n f i r m adequate p a r t i c i p a t i o n ; (5) a f t e r the p r e t e s t s e s s i o n a reminder of t h e p o s t t e s t was m a i l e d t o each c o o r d i n a t o r ; (6) a f t e r the p o s t t e s t , a l e t t e r of thanks was sent t o each c o o r d i n a t o r a l o n g w i t h an i n v i t a t i o n t o r e c e i v e an a b s t r a c t of the stu d y r e s u l t s . By the above p r o c e d u r e , 38 community c e n t r e s i n the Vancouver a r e a and 10 from Burnaby were c o n t a c t e d . Of t h e s e , a t o t a l of 20 agreed t o p a r t i c i p a t e . Two groups c a n c e l l e d t h e i r workshops, however, due t o i n s u f f i c i e n t p r e - r e g i s t r a t i o n . The i n i t i a l c r i t e r i a f o r group s i z e was reduced from 10 t o 5 i n or d e r t o maximize the t o t a l number of p o s s i b l e i n t e r v e n t i o n groups. T a b l e 1 l i s t s the number of women r e c r u i t e d a t p r e t e s t 65 by i n t e r v e n t i o n group. R e c r u i t m e n t r e s u l t e d i n 241 women c o m p l e t i n g the p r e t e s t q u e s t i o n n a i r e : 76 i n i n t e r v e n t i o n group A; 106 i n i n t e r v e n t i o n group B and 59 i n i n t e r v e n t i o n group C. One hundred and s i x women r e t u r n e d f o r the p o s t t e s t s e s s i o n : 32 i n group A; 48 i n group B and 26 i n group C. Unequal numbers of women comprised each of the t h r e e i n t e r v e n t i o n groups a t p r e t e s t f o r two r e a s o n s . F i r s t , the community c e n t r e groups were randomly a s s i g n e d t o i n t e r v e n t i o n groups b e f o r e the number of p r e t e s t workshop p a r t i c i p a n t s c o u l d be known. Second, the number of p r e t e s t q u e s t i o n n a i r e s were counted f o r which women were both non-pregnant and h a v i n g a d i e t a r y c a l c i u m i n t a k e below t h e i r Recommended N u t r i e n t I n t a k e ("below RNI" q u e s t i o n n a i r e s ) . Community c e n t r e groups were a s s i g n e d , on an on-going b a s i s , i n o r d e r t o m a i n t a i n e q u a l numbers of "below RNI" q u e s t i o n n a i r e s per i n t e r v e n t i o n group. T h i s r e s u l t e d i n n e a r l y e q u a l numbers of "below RNI" q u e s t i o n n a i r e s i n each: 12 i n group A; 11 i n group B and 10 i n group C. Sample s i z e s were appr o x i m a t e d per i n t e r v e n t i o n group p r i o r t o data c o l l e c t i o n u s i n g p u b l i s h e d d a t a on d i e t a r y c a l c i u m i n t a k e s of women e s t i m a t e d w i t h t w e n t y - f o u r hour r e c a l l s . Two f a c t o r s were r e c o g n i z e d i n the s t a t i s t i c a l c a l c u l a t i o n s of sample s i z e : (1) v a r i a b i l i t y , where an average f i g u r e of 300 mg was chosen t o r e p r e s e n t the a n t i c i p a t e d s t a n d a r d d e v i a t i o n i n u s u a l i n t a k e and (2) the change i n i n t a k e t h a t would be s i g n i f i c a n t , which was set a t 66 Table 1: Sample s i z e s by i n t e r v e n t i o n group PRETEST No. of women who completed the p r e t e s t q u e s t i o n n a i r e No. of pregnant women a t p r e t e s t No. of women w i t h p r e t e s t d i e t a r y c a l c i u m i n t a k e s below the RNI POSTTEST No. of women who completed the p o s t t e s t q u e s t i o n n a i r e No. of women pregnant a t p o s t t e s t No. of women who were not pregnant a t both p r e - and p o s t t e s t and whose p r e t e s t c a l c i u m i n t a k e was below the RNI I n t e r v e n t i o n Group A B C 76 106 59 4 4 0 43 43 28 32 48 26 3 1 0 12 11 10 : Recommended N u t r i e n t I n t a k e (1983) 67 100 mg between p r e - and p o s t t e s t . W ith these v a l u e s i t was p o s s i b l e t o generate a l i s t of sample s i z e s f o r d i f f e r e n t magnitudes of c o r r e l a t i o n c o e f f i c i e n t s e x p e c ted between p r e -and p o s t t e s t a d m i n i s t r a t i o n of the food i n t a k e form. I t was ex p e c t e d , based upon the r e s e a r c h of Bowering e t a l . (1977), t h a t p r e - t o p o s t t e s t c o r r e l a t i o n s would exceed 0.8. For a p r e - t o p o s t t e s t c o r r e l a t i o n of 0.8 t o 0.9, the sample s i z e per i n t e r v e n t i o n group would need t o be 25 t o 50. Each of the t h r e e groups a t p r e t e s t c o n s i s t e d of a t l e a s t 59 women. Due t o a t t r i t i o n the p o s t t e s t sample s i z e s per i n t e r v e n t i o n group, were below 59. The a c t u a l p r e - t o p o s t t e s t c o r r e l a t i o n on the food i n t a k e form was a l s o l e s s than t h a t a n t i c i p a t e d : r=0.49. The s m a l l e r the c o r r e l a t i o n , the l a r g e r the sample s i z e n e c e s s a r y t o d e t e c t s t a t i s t i c a l d i f f e r e n c e . A l l d a t a c o l l e c t e d were anonymous and coded by i d e n t i f i c a t i o n number and t e l e p h o n e number f o r m a tching the p r e - and p o s t t e s t q u e s t i o n n a i r e s . A p p r o v a l f o r the stu d y was g r a n t e d by the U n i v e r s i t y of B r i t i s h Columbia B e h a v i o u r a l S c i e n c e s S c r e e n i n g Committee f o r Res e a r c h and Other S t u d i e s I n v o l v i n g Human S u b j e c t s (Appendix B ) . Data C o l l e c t i o n I n s t r u m e n t s P r e t e s t data were c o l l e c t e d u s i n g a s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e (Appendix C) and food i n t a k e form (Appendix C ) . P o s t t e s t data were c o l l e c t e d u s i n g a m o d i f i e d form of the p r e t e s t q u e s t i o n n a i r e (Appendix D) which i n c l u d e d a s e l f - e s t e e m s c a l e (Appendix G), a l o n g w i t h the food i n t a k e 68 form. Two i n s t r u m e n t s were d e s i g n e d s p e c i f i c a l l y f o r t h i s s t u d y : (1) the q u e s t i o n n a i r e t o measure both p a r t i c i p a n t s ' a t t i t u d e s and p e r c e p t i o n s , and (2) form B of the 'Calcium C a l c u l a t o r ' ( A p p e n d i x A ) . Two measurement i n s t r u m e n t s were adapted f o r use i n t h i s s t u d y : (1) the s e l f - e s t e e m s c a l e and (2) the food i n t a k e form of the o r i g i n a l (form A) 'Calcium C a l c u l a t o r ' ( A p p e n d i x A ) . The Q u e s t i o n n a i r e A q u e s t i o n n a i r e t o measure p r e - and p o s t t e s t a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s , and p e r c e p t i o n of problem s o l v i n g a b i l i t y was d e v e l o p e d f o r the purpose of t h i s s t u d y . The f o l l o w i n g s t e p s were t a k e n t o produce the i n s t r u m e n t : (1) p r e p a r a t i o n of a d r a f t q u e s t i o n n a i r e ; (2) c o n t e n t v a l i d a t i o n by a p a n e l of e x p e r t s ; (3) f a c e v a l i d a t i o n by g r a d u a t e s t u d e n t s i n F a m i l y and N u t r i t i o n a l S c i e n c e s and (4) subsequent r e f i n e m e n t s . In o r d e r t o produce a d r a f t of the q u e s t i o n n a i r e , Sims' (1981B) g u i d e l i n e s f o r the development of a t t i t u d e measurement i n s t r u m e n t s were f o l l o w e d . To measure both the a t t i t u d e and p e r c e p t i o n c o n s t r u c t s , s u b s c a l e s f o r each were w r i t t e n i n accordance w i t h the l e a r n e r o b j e c t i v e s of the 'Calcium C a l c u l a t o r ' . These a r e : (1) the l e a r n e r w i l l i d e n t i f y a need t o improve her d i e t a r y c a l c i u m i n t a k e and make d i e t a r y changes i f n e c e s s a r y ; (2) the l e a r n e r w i l l d e v e l o p c o n f i d e n c e i n her a b i l i t y t o a s s e s s her own n u t r i t i o n a l b e h a v i o u r and (3) the l e a r n e r w i l l d e v e l o p 69 c o n f i d e n c e i n her a b i l i t y t o a c h i e v e the i d e n t i f i e d d i e t a r y c h a n g e ( s ) . S i n c e p a r t i c i p a n t s were i n t e n d e d t o i n c r e a s e t h e i r d i e t a r y c a l c i u m i n t a k e i f n e c e s s a r y , the f i r s t a t t i t u d e s u b s c a l e w r i t t e n was p a r t i c i p a n t a t t i t u d e toward d i e t as a source of c a l c i u m . An example of an item from t h i s s u b s c a l e was, "I t h i n k I can get a l l the c a l c i u m I need from my d i e t . " Seven items were g e n e r a t e d t o form t h i s f i r s t s u b s c a l e . The second s u b s c a l e f o r the a t t i t u d e c o n s t r u c t was p a r t i c i p a n t a t t i t u d e toward d i e t a r y c a l c i u m r e q u i r e m e n t s s i n c e the p r o c e s s used i n the 'Calcium C a l c u l a t o r ' i n c l u d e d s e l f - a s s e s s m e n t of i n t a k e r e l a t i v e t o t h e Recommended N u t r i e n t I n t a k e . An example of an item from t h i s s u b s c a l e was, "I need more d i e t a r y c a l c i u m than men." Three items were produced f o r t h i s s u b s c a l e . P a r t i c i p a n t s ' a t t i t u d e s toward t h e i r own p e r s o n a l r i s k f o r o s t e o p o r o s i s c o n s t i t u t e d the t h i r d a t t i t u d e s u b s c a l e . I t was assumed t h a t exposure t o the i n t e r v e n t i o n would produce an i n c r e a s e d awareness of p e r s o n a l r i s k f o r o s t e o p o r o s i s . One of the f i v e items from t h i s s u b s c a l e was, "I f e e l t h a t I am a t r i s k f o r o s t e o p o r o s i s . " The f o u r t h s u b s c a l e was d i r e c t e d toward p a r t i c i p a n t a t t i t u d e r e g a r d i n g the r e l a t i o n s h i p between d i e t a r y c a l c i u m and the r i s k of o s t e o p o r o s i s . A g a i n , i t was f e l t t h a t i n d i v i d u a l s exposed to the i n t e r v e n t i o n s would become more aware of a r e l a t i o n s h i p between d i e t and r i s k f o r o s t e o p o r o s i s . An example of one of the f o u r items 70 r e p r e s e n t i n g t h i s s u b s c a l e was, "I f e e l t h a t g e t t i n g enough c a l c i u m i n my d i e t may h e l p me reduce my r i s k f o r o s t e o p o r o s i s . " The second c o n s t r u c t t o be measured by the q u e s t i o n n a i r e was t h a t of p a r t i c i p a n t s ' p e r c e p t i o n s of t h e i r problem s o l v i n g a b i l i t i e s . The o b j e c t i v e s of the 'Calcium C a l c u l a t o r ' suggest t h a t t h r o u g h i t s use p a r t i c i p a n t s s h o u l d have enhanced f e e l i n g s of competence and a b i l i t y . Four s u b s c a l e s were t h e r e f o r e w r i t t e n to measure the p e r c e p t i o n c o n s t r u c t . The f i r s t s u b s c a l e produced was t h a t of p a r t i c i p a n t s ' p e r c e p t i o n s of t h e i r w i l l i n g n e s s t o change food h a b i t s . T h i s s u b s c a l e was w r i t t e n upon the b a s i s t h a t enhancing l e a r n e r ' s w i l l i n g n e s s to change food h a b i t s might encourage them to make d i e t a r y c a l c i u m changes. The s t a t e m e n t , "At my age i t would be i m p o s s i b l e t o change my d i e t " r e p r e s e n t s one of the t h r e e items w r i t t e n f o r t h i s s u b s c a l e . A second s u b s c a l e was t h a t of p a r t i c i p a n t s ' p e r c e p t i o n s of t h e i r a b i l i t y to p e r f o r m s e l f - a s s e s s m e n t s of t h e i r n u t r i t i o n a l b e h a v i o u r . An example of one s u b s c a l e i t e m was, "I f e e l c o n f i d e n t d e c i d i n g what i s good or bad f o r my h e a l t h . " F i v e items were w r i t t e n to r e p r e s e n t t h i s s u b s c a l e . P a r t i c i p a n t s ' p e r c e p t i o n s of t h e i r a b i l i t y t o p l a n t o meet a g o a l formed the t h i r d s u b s c a l e . In both 'Calcium C a l c u l a t o r s ' l e a r n e r s c o mpleted a d a i l y meal p l a n t o i n c o r p o r a t e the d i e t a r y changes they wished t o make. An 71 example of one of the s i x items w r i t t e n f o r t h i s s u b s c a l e was, " I f I am g o i n g t o change something i n my d i e t , I l i k e t o make a p l a n which I can f o l l o w . " The f o u r t h s u b s c a l e f o r the p e r c e p t i o n c o n s t r u c t was i n t e n d e d t o measure p a r t i c i p a n t s ' p e r c e p t i o n s of t h e i r a b i l i t y t o a c h i e v e g o a l s they s e t f o r t h e m s e l v e s . The use of e i t h e r form of the 'Calcium C a l c u l a t o r ' was h y p o t h e s i z e d t o impact f a v o u r a b l y on l e a r n e r s ' f e e l i n g s of o v e r a l l competence i n a c h i e v i n g p e r s o n a l g o a l s . The s t a t e m e n t , "I am u s u a l l y s u c c e s s f u l once I d e c i d e t o do something" r e p r e s e n t s one of the seven items w r i t t e n f o r t h i s s u b s c a l e . A L i k e r t s c a l e (Henerson e t a l . 1978; C a r r u t h and Anderson 1977) was chosen t o measure the i n t e n s i t y of an a t t i t u d e or p e r c e p t i o n by the e x t e n t to which a p a r t i c i p a n t a g r e e d w i t h a s t a t e m e n t . P a r t i c i p a n t s responded by c i r c l i n g one o f : s t r o n g l y a g r e e , a g r e e , u n d e c i d e d , d i s a g r e e and s t r o n g l y d i s a g r e e . An odd-numbered s c a l e was s e l e c t e d s i n c e an e v e n l y numbered response s c a l e might f o r c e respondents t o take e i t h e r a p o s i t i v e or n e g a t i v e s t a n c e . The response produced by an even numbered s c a l e may t h e r e f o r e be a r t i f i c i a l . P o s i t i v e l y worded s t a t e m e n t s , judged by the i n v e s t i g a t o r t o r e f l e c t a p o s i t i v e a t t i t u d e or p e r c e p t i o n , were s c o r e d from 5 f o r s t r o n g l y a g r e e , t o 1 f o r s t r o n g l y d i s a g r e e . N e g a t i v e l y worded st a t e m e n t s were r e v e r s e s c o r e d , w i t h 5 p o i n t s g i v e n t o a response of s t r o n g l y d i s a g r e e t o 1 p o i n t f o r s t r o n g l y a g r e e . A p a n e l of f o u r c o n t e n t e x p e r t s , a l l n u t r i t i o n 72 e d u c a t o r s from the B.C. D a i r y F o u n d a t i o n , s e r v e d as c o n t e n t v a l i d a t o r s . Each judge was asked t o i n d e p e n d e n t l y review the d r a f t q u e s t i o n n a i r e and complete the v a l i d a t i o n p r o c e s s (Appendix E) a t the B.C. D a i r y F o u n d a t i o n . Two q u e s t i o n s were asked f o r each of the 40 items i n the d r a f t q u e s t i o n n a i r e , based upon the work of S u l l i v a n (1980): (1) To what e x t e n t i s the item r e l e v a n t t o the domain b e i n g measured? and (2) I s the item r e p r e s e n t a t i v e of the s u b s c a l e i n which i t has been p l a c e d ? The f i r s t q u e s t i o n was answered by a n i n e p o i n t s c a l e ( 9 , e x t r e m e l y r e l e v a n t t o 1, e x t r e m e l y i r r e l e v a n t ) . The second q u e s t i o n r e s u l t e d i n a Yes or No res p o n s e . In a d d i t i o n , judges were asked i f each s u b s c a l e appeared r e l e v a n t (Yes/No.) t o i t s c o n s t r u c t . T able 2 d e s c r i b e s the d i s t r i b u t i o n and mean of judges' responses t o the f i r s t q u e s t i o n . Items were removed i f they r e c e i v e d a mean r a t i n g of l e s s than 6.00 ( S u l l i v a n 1980). Items were a l s o removed i f they were p e r c e i v e d as a p p r o p r i a t e t o t h e i r s u b s c a l e by l e s s than 75% of the judges ( T a b l e 3 ) . In a d d i t i o n , t o m i n i m i z e respondent burden: (1) o n l y t h r e e s u b s c a l e s per c o n s t r u c t were chosen and (2) o n l y t h r e e items were i n c l u d e d per s u b s c a l e . Those items h a v i n g the h i g h e s t r a t i n g were chosen i f more than t h r e e items remained per s u b s c a l e . Each c o n s t r u c t was a l l o t e d t h r e e s u b s c a l e s of e q u a l numbers of i t e m s . T h i s was done s i n c e the c o n s t r u c t s were judged t o be of e q u a l i m p o r t a n c e , as were the s u b s c a l e s f o r each c o n s t r u c t . Some items were a l s o reworded based on feedback from the judges. 73 T a b l e 2 : Content v a l i d a t i o n of the q u e s t i o n n a i r e : d i s t r i b u t i o n of judges' r a t i n g s of item r e l e v a n c e t o the c o n t e n t c o n s t r u c t I tern Numbers D i s t r i b u t i o n of R a t i n g s Mean R a t i n g ATTITUDE D i e t as a source of c a l c ium 1 2 3 4 5 6 .7 1 1 2 3 1 1 2 2 1 1 1 1 1 2 1 2 8.25 8.00 8.25 6.50 7.00 8.25 6.00 D i e t a r y c a l c ium r e q u i rements 8 9 10 2 2 2 1 2 5.75 5.50 7.50 P e r s o n a l r i s k f o r o s t e o p o r o s i s 1 1 1 2 1 3 1 4 15 1 2 2 1 1 1 2 1 1 2 6.00 7.50 6.75 6.25 7.25 R e l a t i o n s h i p between d i e t a r y c a l c i u m and o s t e o p o r o s i s 16 1 7 18 19 2 3 1 2 8.50 8.00 6.75 8.00 74 T a b l e 2 : Content v a l i d a t i o n of the q u e s t i o n n a i r e : d i s t r i b u t i o n of judges' r a t i n g s of item r e l e v a n c e t o the c o n t e n t c o n s t r u c t ( c o n t i n u e d ) I tern Numbers D i s t r i b u t i o n of R a t i n g s Mean R a t i n g PERCEPTION W i l l i n g n e s s t o change food h a b i t s 1 2 3 2 3 3 7.00 8.25 8.25 A b i l i t y t o i d e n t i f y a g o a l 4 5 6 7 8 1 1 2 1 2 2 1 6.00 8.00 6.00 6.00 7.00 A b i l i t y t o p l a n t o meet a g o a l 9 10 1 1 1 2 1 3 1 4 3 2 2 4 2 1 7 , 7, 7 75 67 25 8.00 5.50 6.75 A b i l i t y a c h i e v e g o a l t o 1 5 1 6 17 18 19 20 21 1 2 3 1 3 3 1 2 5.75 8.00 8.25 5.75 7.33 8.25 8.25 75 T a b l e 3 : Content v a l i d a t i o n of the q u e s t i o n n a i r e : p e r c e n t a g e of judges who s t a t e d t h a t items were r e p r e s e n t a t i v e of t h e i r s u b s c a l e P e r c e n t a g e V o t i n g Yes Item Number ATTITUDE D i e t as a source of c a l c i u m 1 100 2 100 3 100 4 75 5 75 6 100 7 75 D i e t a r y c a l c i u m r e q u i r e m e n t s 8 100 9 75 10 100 P e r s o n a l r i s k f o r o s t e o p o r o s i s 1 1 75 12 75 13 100 14 100 15 100 R e l a t i o n s h i p between d i e t a r y c a l c i u m and o s t e o p o r o s i s 16 100 17 75 18 75 19 100 PERCEPTION Wi11ingness to change food h a b i t s 1 100 2 100 3 100 76 Table 3 : Content v a l i d a t i o n of the q u e s t i o n n a i r e : p e r c e n t a g e of judges who s t a t e d t h a t items were r e p r e s e n t a t i v e of t h e i r s u b s c a l e ( c o n t i n u e d ) Item Number Per c e n t a g e V o t i n g Yes A b i l i t y t o i d e n t i f y a g o a l 4 5 6 7 8 50 50 100 75 1 00 A b i l i t y p l a n t o a g o a l t o meet 9 10 1 1 1 2 1 3 1 4 1 00 75 50 100 75 1 00 A b i l i t y a c h i e v e t o a g o a l 1 5 1 6 1 7 18 19 20 21 50 1 00 1 00 50 50 100 1 00 77 Judges were a l s o asked how a p p r o p r i a t e each of the f o u r s u b s c a l e s were t o t h e i r r e s p e c t i v e c o n s t r u c t s . A l l of the s u b s c a l e s were deemed a p p r o p r i a t e by a l l f o u r judges. C o n s e q u e n t l y , the number of s u b s c a l e s per c o n s t r u c t was reduced t o t h r e e based upon how w e l l t h e i r r e s p e c t i v e items met the p r e - e s t a b l i s h e d c r i t e r i a . I t was r e c o g n i z e d t h a t r e d u c i n g the t o t a l number of q u e s t i o n n a i r e items may a l s o reduce the r e l i a b i l i t y of the s c a l e . However, the q u e s t i o n n a i r e had t o be s h o r t enough to be completed w i t h i n 15 m i n u t e s , p r i o r t o the C a l c i u m and Bone H e a l t h Workshop. A second d r a f t q u e s t i o n n a i r e was then produced c o n s i s t i n g of t h r e e s u b s c a l e s per c o n s t r u c t and t h r e e items per s u b s c a l e . The r e m a i n i n g a t t i t u d e s u b s c a l e s were: (1) d i e t as a s o u r c e of c a l c i u m ; (2) r e l a t i o n s h i p between d i e t a r y c a l c i u m and o s t e o p o r o s i s and (3) p e r s o n a l r i s k f o r o s t e o p o r o s i s . The r e m a i n i n g p e r c e p t i o n s u b s c a l e s were: (1) a b i l i t y t o i d e n t i f y a g o a l ; (2) a b i l i t y t o p l a n t o meet a g o a l and (3) a b i l i t y t o a c h i e v e a g o a l . Remaining items were th e n : (1) reworded i f n e c e s s a r y t o produce n e a r l y e q u a l numbers of p o s i t i v e l y and n e g a t i v e l y worded s t a t e m e n t s , and (2) randomized w i t h i n each c o n s t r u c t , a c c o r d i n g t o the recommendations of Henerson et a l . (1978). Q u e s t i o n s on p r e - and p o s t t e s t biodemographic d a t a were a l s o added t o the q u e s t i o n n a i r e a t t h i s t i m e . Face v a l i d a t i o n f o r r e a d a b i l i t y , wording and l a y o u t was 78 then performed by f i v e g raduate s t u d e n t s i n F a m i l y and N u t r i t i o n a l S c i e n c e s . They were asked t o comment on changes they would l i k e t o see made t o the q u e s t i o n n a i r e . Some wording changes were made, w i t h the e v e n t u a l p r o d u c t i o n of both a p r e - and p o s t t e s t a t t i t u d e and p e r c e p t i o n q u e s t i o n n a i r e (Appendix C and D, r e s p e c t i v e l y ) . R e l i a b i l i t y of the q u e s t i o n n a i r e was not p r e t e s t e d . Doing so would have made p o s s i b l e f u r t h e r improvements i n the i n s t r u m e n t (Basch and G o l d 1985). However, a l i m i t e d number of community c e n t r e s were a v a i l a b l e t o the r e s e a r c h e r . T h e r e f o r e , i t was not p o s s i b l e t o a c c e s s groups of women from community c e n t r e s f o r such t e s t i n g p r i o r t o the a c t u a l s t u d y . The Food I n t a k e Form The o r i g i n a l 'Calcium C a l c u l a t o r ' (form A) i n c l u d e d a r e c a l l c h e c k l i s t of c a l c i u m - c o n t a i n i n g foods eaten on the p r e v i o u s day. The c h e c k l i s t c o n t a i n e d 26 items which p r o v i d e from 50 t o 400 mg of c a l c i u m per s e r v i n g . N u t r i t i o n e d u c a t o r s from the B.C. D a i r y F o u n d a t i o n d e s i g n e d t h i s c h e c k l i s t based upon food c o m p o s i t i o n t a b l e s . In o r d e r t o a v o i d a s k i n g p a r t i c i p a n t s t o complete unnecessary forms, i t was f e l t t h a t t h i s s h o r t form would be s u i t a b l e t o measure d i e t a r y c a l c i u m i n t a k e at both p r e - and p o s t t e s t . However, b e f o r e r e a c h i n g a f i n a l d e c i s i o n i t was ne c e s s a r y t o compare the food i n t a k e form t o r e s u l t s from a t w e n t y - f o u r hour r e c a l l on d i e t a r y c a l c i u m i n t a k e . The food 79 i n t a k e form resembled a t w e n t y - f o u r hour r e c a l l i n t h a t i t r e q u e s t s the p r e v i o u s day's consumption of c a l c i u m - r i c h f o o d s . I t d i f f e r e d from a t w e n t y - f o u r hour r e c a l l i n t h a t o n l y c a l c i u m - r i c h foods were l i s t e d i n a c h e c k l i s t format. E l e v e n women employed by the U n i v e r s i t y of B r i t i s h Columbia completed f i r s t a t w e n t y - f o u r hour r e c a l l form (Appendix H) and on a subsequent day, the food i n t a k e form. I t was assumed t h a t d i e t a r y c a l c i u m i n t a k e s on both t e s t a d m i n i s t r a t i o n days would be c o n s i s t e n t f o r the same i n d i v i d u a l s . A l s o , the i n s t r u m e n t s were used i n the above o r d e r t o reduce the re s p o n d e n t ' s knowledge t h a t d i e t a r y c a l c i u m i n t a k e was b e i n g measured. Twenty-four hour r e c a l l s were coded and c a l c i u m i n t a k e s e s t i m a t e d u s i n g the A g r i c u l t u r e Handbook, number 456 (1975). The mean d i e t a r y c a l c i u m i n t a k e u s i n g the t w e n t y - f o u r hour r e c a l l was 881 + 528 mg compared t o 743 + 779 mg by the food i n t a k e form. A l t h o u g h the v a r i a b i l i t y produced by the food i n t a k e form was c o n s i d e r a b l y g r e a t e r than the 24-hour r e c a l l , the two were p o s i t i v e l y and s i g n i f i c a n t l y c o r r e l a t e d (r=0.85, p < 0 . 0 0 l ) . A p a i r e d t - t e s t r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e between t h e means of the two i n s t r u m e n t s (p=0.84). From these r e s u l t s , and f o r the conv e n i e n c e of stu d y p a r t i c i p a n t s , i t was d e c i d e d t o use the food i n t a k e form t o measure p r e - and p o s t t e s t s e l f - r e p o r t e d d i e t a r y c a l c i u m i n t a k e . E f f o r t s were made t o m i n i m i z e two s o u r c e s of p o t e n t i a l v a r i a b i l i t y i n r e c a l l e d d i e t a r y c a l c i u m i n t a k e s of women r e p o r t e d i n the l i t e r a t u r e . The e f f e c t of day of the week 80 was m i n i m i z e d i n t h i s s tudy by s c h e d u l i n g p o s t t e s t s e s s i o n s f o u r t o n i n e weeks a f t e r p r e t e s t on the same day of the week. Women who were p r e - and p o s t t e s t e d on a Monday may, however, have r e p o r t e d an u n u s u a l l y low i n t a k e . An i n t e r v i e w e r e f f e c t was u n l i k e l y s i n c e the food i n t a k e forms were s e l f - a d m i n i s t e r e d . The S e l f - E s t e e m S c a l e The p u b l i s h e d s e l f - e s t e e m s c a l e chosen f o r t h i s study was the C u l t u r e - f r e e S e l f - E s t e e m I n v e n t o r y , form AD (Appendix G). The s c a l e c o n s i s t e d of 40 i t e m s : 8 l i e d e t e c t o r i t e m s ; 8 items on s o c i a l s e l f - e s t e e m ; 8 on p e r s o n a l s e l f - e s t e e m and 16 on g e n e r a l s e l f - e s t e e m . The author of the s c a l e d e s c r i b e d i t as a g e n e r a l measure of an i n d i v i d u a l ' s f e e l i n g toward s e l f . The s e l f - e s t e e m s c a l e was p r e t e s t e d p r i o r t o d a t a c o l l e c t i o n t o determine i t s r e l i a b i l i t y . The C u l t u r e - F r e e S e l f - E s t e e m I n v e n t o r y was a d m i n i s t e r e d to 46 female s t u d e n t s t a k i n g an i n t r o d u c t o r y p s y c h o l o g y c o u r s e and f o u r female graduate s t u d e n t s i n F a m i l y and N u t r i t i o n a l S c i e n c e s . F o r t y - s e v e n s e l f - e s t e e m s c a l e s were f u l l y c o m p leted. The r e l i a b i l i t y c o e f f i c i e n t s c a l c u l a t e d were a l l g r e a t e r than 0.70. The s c a l e was s h o r t e n e d f o r the a c t u a l study by removing the 8 l i e d e t e c t o r i t e m s . These had v e r y l i t t l e v a r i a b i l i t y and s i n c e they d i d not a c t u a l l y form p a r t of the s c a l e , were s i m p l y removed w i t h o u t concern f o r e f f e c t s on 81 s c a l e r e l i a b i l i t y . S c ores f o r the t o t a l s c a l e were c a l c u l a t e d by t o t a l l i n g the p o i n t s on a l l 32 items where a h i g h s e l f - e s t e e m response was a c c o r d e d one p o i n t and a low response, z e r o . S u b s c a l e s c o r e s were d e r i v e d i n a s i m i l a r f a s h i o n . Form B of the 'Calcium C a l c u l a t o r ' The m o d i f i e d form of the 'Calcium C a l c u l a t o r ' was d e s i g n e d based upon the Havelock (1973) problem s o l v i n g model. T a b l e 4 r e l a t e s the Havelock model t o the s t e p s i n form B of the 'Calcium C a l c u l a t o r ' . Both c o n t e n t and f a c e v a l i d a t i o n of form B of the 'Calcium C a l c u l a t o r ' were performed. Three c o n t e n t e x p e r t s , P r o f e s s o r s from the F a c u l t y of E d u c a t i o n , i n d e p e n d e n t l y judged whether or not (Yes/No) form B was r e f l e c t i v e of both the s t e p s i n the Havelock model and the p r i n c i p l e s a s s o c i a t e d , w i t h the use of problem s o l v i n g (see Chapter I I ) . A l l t h r e e judges agreed t h a t form B met both of t h e s e c r i t e r i a . Judges were a l s o asked whether the m a t e r i a l s h o u l d be worded i n f i r s t or t h i r d p e r s o n . Judges d i s a g r e e d on t h i s p o i n t (Appendix F ) . However, s i n c e one f e l t v e ry s t r o n g l y a g a i n s t the use of f i r s t p e r s o n , i t was d e c i d e d t o word c o n t e n t i n the t h i r d p e r s o n . Face v a l i d a t i o n of the m a t e r i a l ' s l a y o u t and wording was performed by a c l a s s of 34 second year F a m i l y and N u t r i t i o n a l S c i e n c e u n d e r g r a d u a t e s , most of whom were female. Changes were made i n the p h r a s i n g of s t a t e m e n t s and i n m a t e r i a l l a y o u t as a r e s u l t . In a d d i t i o n , more d e t a i l e d 82 i n s t r u c t i o n s were added t o the m a t e r i a l ' s problem s o l v i n g s t e p s . F o l l o w i n g both of t h e s e p r o c e d u r e s , a f i n a l t w o - c o l o u r f o u r - p a n e l pamphlet was p r i n t e d (Appendix A ) . T a b l e 4 : R e l a t i o n s h i p of the s t e p s i n form B t o the Havelock (1973) model Steps i n Form B C o r r e s p o n d i n g Steps i n H a v e l o c k ' s (1973) model Step 1: I n i t i a l d i s t u r b a n c e E s t a b l i s h e s a d i s t u r b a n c e S tep 2: F e e l i n g a need t o a c t Assessment of d i e t a r y c a l c i u m i n t a k e S tep 3: Making a d e c i s i o n t o a c t Making a d i e t a r y p l a n S tep 4: E x p l o r i n g b a r r i e r s t o implementing change Step 5: M e n t a l r e h e a r s a l of the p l a n G e n e r a l s a t i s f a c t i o n t h a t the problem i s s o l v e d D i a g n o s i s of the need as a problem S e a r c h i n g f o r and a p p l y i n g s o l u t i o n s S e a r c h i n g f o r and a p p l y i n g s o l u t i o n s A p p l i c a t i o n of s o l u t i o n s S a t i s f a c t i o n t h a t the problem i s s o l v e d 83 Data C o l l e c t i o n P r o c e d u r e s P r e t e s t Data C o l l e c t i o n Two i n s t r u m e n t s were used t o c o l l e c t d a t a a t p r e t e s t : (1) the a t t i t u d e and p e r c e p t i o n q u e s t i o n n a i r e and (2) the food i n t a k e form. The q u e s t i o n n a i r e c o n s i s t e d of t h r e e p a r t s : (1) N u t r i t i o n A t t i t u d e s ( i t e m s 1 t o 9 ) ; (2) P e r c e p t i o n s about Y o u r s e l f ( i t e m s 1 t o 9 ) ; and (3) I n f o r m a t i o n about You - g e n e r a l q u e s t i o n s ( i t e m s 1 t o 4) and more p e r s o n a l q u e s t i o n s (1 t o 7 ) . The q u e s t i o n n a i r e was completed by p a r t i c i p a n t s p r i o r to the C a l c i u m and Bone H e a l t h Workshop. A f t e r the q u e s t i o n n a i r e s were c o l l e c t e d , the workshop began. D u r i n g the workshop, p a r t i c i p a n t s i n i n t e r v e n t i o n groups A and B used the food i n t a k e form as p a r t of the 'Calcium C a l c u l a t o r ' . P a r t i c i p a n t s were asked t o copy t h e i r r esponses onto a photocopy of the form f o r d a t a c o l l e c t i o n p u r p o s e s . The food i n t a k e form was a d m i n i s t e r e d t o i n t e r v e n t i o n Group C p a r t i c i p a n t s i m m e d i a t e l y a f t e r they completed the q u e s t i o n n a i r e and j u s t p r i o r t o v i e w i n g the f i l m . As a r e s u l t of u s i n g the food i n t a k e form f o r d a t a c o l l e c t i o n i n a l l t h r e e i n t e r v e n t i o n groups, i t s h o u l d be noted t h a t i n t e r v e n t i o n group C was exposed t o one p a r t of the problem s o l v i n g m a t e r i a l s . T h i s may have l e s s e n e d the c o n t r a s t between the problem s o l v i n g and non-problem s o l v i n g 84 i n t e r v e n t i o n i m p a c t s . However, the major focus and d i s c u s s i o n i n the c o n t r o l group c e n t r e d around the f i l m on o s t e o p o r o s i s . Table 5 l i s t s the s o u r c e s from which the dependent and independent v a r i a b l e s were c o l l e c t e d at p r e t e s t . I n t e r v e n t i on The f i r s t p a r t of these a c t i v e l e a r n i n g workshops f o c u s e d on s k i l l s development, w h i l e the l a t t e r p a r t d e a l t w i t h c o n t e n t and l e a r n e r - g e n e r a t e d i n f o r m a t i o n . At the b e g i n n i n g of the one-hour workshop, i n t e r v e n t i o n groups A and B completed the p r e t e s t q u e s t i o n n a i r e , and were then a s s i s t e d i n f o l l o w i n g the problem s o l v i n g p r o c e s s f o r t h e i r p a r t i c u l a r k i n d of 'Calcium C a l c u l a t o r ' . I n d i v i d u a l s were encouraged t o ask q u e s t i o n s about how t o complete s t e p s i n the p r o c e s s . P a r t i c i p a n t s c o u l d a l s o r e q u e s t more i n f o r m a t i o n on s p e c i f i c problems they were h a v i n g i n making d i e t a r y c a l c i u m changes. A p r e p a r e d s e t of q u e s t i o n -response s h e e t s of common co n c e r n s was g i v e n t o these i n d i v i d u a l s . I n f o r m a t i o n was o n l y p r o v i d e d upon s p e c i f i c p a r t i c i p a n t r e q u e s t . A f t e r c o m p l e t i n g the problem s o l v i n g p r o c e s s a g e n e r a l q u e s t i o n and answer p e r i o d f o l l o w e d . At t h i s t i m e , p a r t i c i p a n t s c o u l d ask any q u e s t i o n s they had about c a l c i u m and bone h e a l t h . D u r i n g i t s one hour workshop, i n t e r v e n t i o n group C the c o n t r o l group, f i r s t c ompleted both the q u e s t i o n n a i r e and the f o o d i n t a k e form. A f t e r w a r d s , p a r t i c i p a n t s viewed the 85 f i l m " S t a l k i n g the S i l e n t T h i e f " . The f i l m p r o v i d e d a d e s c r i p t i o n of o s t e o p o r o s i s and i t s p r e v e n t i o n and t r e a t m e n t , i n c l u d i n g i n f o r m a t i o n on the r o l e of d i e t a r y c a l c i u m . A q u e s t i o n and answer p e r i o d f o l l o w e d , i d e n t i c a l t o t h a t f o r the o t h e r two i n t e r v e n t i o n groups. Workshops were h e l d at each of the i n d i v i d u a l community c e n t r e s . An i n t r o d u c t i o n t o the workshop and q u e s t i o n n a i r e a d m i n i s t r a t i o n was done by the i n v e s t i g a t o r . In the problem s o l v i n g i n t e r v e n t i o n , a n u t r i t i o n e d u c a t o r from the B.C. D a i r y F o u n d a t i o n p r o v i d e d p r o c e s s i n f o r m a t i o n . For both p r o b l e m - s o l v i n g and non-problem s o l v i n g i n t e r v e n t i o n s , the n u t r i t i o n e d u c a t o r l e d the q u e s t i o n and answer p e r i o d . I t was f e l t t h a t l e s s p o s s i b i l i t y e x i s t e d f o r b i a s i n the p r e s e n t a t i o n of the two forms of the 'Calcium C a l c u l a t o r ' i f the i n v e s t i g a t o r d i d not a c t i v e l y t a k e p a r t i n the p r o c e s s . I t was r e c o g n i z e d t h a t preformed groups a s s i g n e d t o the i n t e r v e n t i o n s were n o n - e q u i v a l e n t because p a r t i c i p a n t s themselves c o u l d not be randomly a s s i g n e d t o the i n t e r v e n t i o n s . However, e f f o r t s were made t o c o n t r o l v a r i a b i l i t y among the groups by s t a n d a r d i z i n g the p r e t e s t and p o s t t e s t s e s s i o n s . T h i s was a c c o m p l i s h e d by: (1) f o l l o w i n g a u n i f o r m p r o c e s s a t each s e s s i o n (Appendix I ) ; (2) t i m i n g a l l workshops t o l a s t a p p r o x i m a t e l y one hour and (3) p r o v i d i n g , i n 15 of 18 workshops, the same n u t r i t i o n e d u c a t o r a t p r e t e s t . P o s t t e s t Data C o l l e c t i o n Two i n s t r u m e n t s were used t o c o l l e c t d a t a from 88 p a r t i c i p a n t s a t p o s t t e s t : (1) a m o d i f i e d v e r s i o n of the p r e t e s t a t t i t u d e and p e r c e p t i o n q u e s t i o n n a i r e and (2) the food i n t a k e form. The same items measuring p a r t i c i p a n t a t t i t u d e s and p e r c e p t i o n s a t p r e t e s t were i n c l u d e d i n P a r t I and P a r t I I of the p o s t t e s t q u e s t i o n n a i r e . The t h i r d p a r t of the q u e s t i o n n a i r e c o n s i s t e d of a s e l f - e s t e e m s c a l e (32 i t e m s ) , f o l l o w e d by: I n f o r m a t i o n About You, g e n e r a l q u e s t i o n s ( i t e m s 1 t o 5) and more p e r s o n a l q u e s t i o n s ( i t e m s 1 and 2) and the food i n t a k e form. The p o s t t e s t q u e s t i o n n a i r e was a d m i n i s t e r e d by the i n v e s t i g a t o r at a h a l f hour meeting which a g a i n took p l a c e a t the community c e n t r e . A f t e r p a r t i c i p a n t s had completed the q u e s t i o n n a i r e , a q u e s t i o n and answer p e r i o d f o l l o w e d . The l a t t e r was performed by the i n v e s t i g a t o r , who a l s o p r o v i d e d r e f r e s h m e n t s f o r the p a r t i c i p a n t s . P a r t i c i p a n t s a t p r e t e s t who knew they would not be a b l e t o r e t u r n f o r p o s t t e s t , were g i v e n the o p t i o n of b e i n g m a i l e d a p o s t t e s t q u e s t i o n n a i r e the day a f t e r the p o s t t e s t s e s s i o n . Twelve of 106 p o s t t e s t q u e s t i o n n a i r e s were r e t u r n e d by t h i s method. I t was assumed t h a t these q u e s t i o n n a i r e s d i d not d i f f e r from o t h e r s c o l l e c t e d a t the a c t u a l p o s t t e s t s e s s i o n . No d i s t i n c t i o n s were t h e r e f o r e made between the c o l l e c t e d or m a i l e d p o s t t e s t q u e s t i o n n a i r e s i n the da t a a n a l y s i s . T a b l e 6 l i s t s the sources from which the dependent and independent independent v a r i a b l e s were c o l l e c t e d a t p o s t t e s t . I t s h o u l d be noted t h a t the p o s t t e s t q u e s t i o n n a i r e 89 Table 6 : Data sources f o r the dependent and independent v a r i a b l e s a t p o s t t e s t Dependent V a r i a b l e s Data Source P a r t i c i p a n t s ' a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s as d e s c r i b e d i n T able 5 P a r t i c i p a n t s ' p e r c e p t i o n of • as d e s c r i b e d i n T able 5 t h e i r problem s o l v i n g a b i l i t i e s 3. P a r t i c i p a n t s e l f - r e p o r t e d d i e t a r y c a l c i u m i n t a k e Independent V a r i a b l e s 1 . s e l f - e s t e e m score P e r c e i v e d need t o i n c r e a s e p r e t e s t d i e t a r y c a l c i u m i n t a k e S e l f - r e p o r t e d adherence to s t e p s i n the p r o b l e m - s o l v i n g sequence 4. P a r t i c i p a n t s a t i s f a c t i o n 5. S e a s o n a l v a r i a t i o n i n m i l k and m i l k p r o d u c t i n t a k e 6. Use of a c a l c i u m -c o n t a i n i n g supplement 7. Pregnancy s t a t u s q u e s t i o n n a i r e , p a r t V ( f o o d i n t a k e form) raw s c o r e from q u e s t i o n n a i r e , p a r t I I I s u b s c a l e s c o r e s : g e n e r a l - items 1, 3, 5, 7 , 9 , 11, 15, 16, 19, 20, 21, 23, 24, 26, 30 and 31 p e r s o n a l - items 10, 13, 14, 18, 22, 27, 29, and 32 s o c i a l - items 2, 4, 6, 8, 12, 17, 25, and 28 I n t e r v e n t i o n groups A and B o n l y : q u e s t i o n n a i r e , p a r t IV, i t e m 5 ( g e n e r a l ) I n t e r v e n t i o n groups A and B o n l y : q u e s t i o n n a i r e , p a r t IV ( g e n e r a l ) items 3 ( a , b, c) I n t e r v e n t i o n groups A and B: q u e s t i o n n a i r e , p a r t IV ( g e n e r a l ) item 4 I n t e r v e n t i o n group C: q u e s t i o n n a i r e , p a r t IV ( g e n e r a l ) i t e m 3 q u e s t i o n n a i r e , p a r t IV i t e m 1 ( g e n e r a l ) q u e s t i o n n a i r e , p a r t IV ( g e n e r a l ) item 2 q u e s t i o n n a i r e , p a r t IV ( p e r s o n a l ) i t e m 1 90 g i v e n the problem s o l v i n g groups d i f f e r e d on q u e s t i o n s r e l a t e d t o the independent v a r i a b l e s number 2, 3 and 4 i n Table 6 from t h a t g i v e n t o the non-problem s o l v i n g groups. P r e p a r a t i o n of the Data f o r A n a l y s i s A l l p r e t e s t q u e s t i o n n a i r e s i n which p a r t i c i p a n t s had i n c l u d e d a t e l e p h o n e number were g i v e n an i d e n t i f i c a t i o n number. A f t e r each workshop, q u e s t i o n n a i r e s were coded f o r d a t a e n t r y on computer f i l e s . P r e t e s t d a t a were e n t e r e d i n t o computer f i l e s by i n t e r v e n t i o n group. P o s t t e s t q u e s t i o n n a i r e s were matched t o p r e t e s t q u e s t i o n n a i r e s by t e l e p h o n e number. The p o s t t e s t q u e s t i o n n a i r e was then g i v e n i t s i d e n t i f i c a t i o n code from the p r e t e s t q u e s t i o n n a i r e . A l l data on each matched q u e s t i o n n a i r e were then coded and e n t e r e d i n t o p o s t t e s t d a t a f i l e s , a g a i n by i n t e r v e n t i o n group. I t s h o u l d be noted t h a t of the 18 community groups which p a r t i c i p a t e d i n t h i s s t u d y , 15 were a c t u a l l y community c e n t r e s , one was a h e a l t h u n i t and two were c h u r c h - r e l a t e d groups. However, s i n c e the m a j o r i t y were community c e n t r e s and no i m p o r t a n t d i f f e r e n c e s c o u l d be i d e n t i f i e d among thes e groups, a l l 18 were termed "community c e n t r e " groups and no d i s t i n c t i o n s were made i n the d a t a a n a l y s i s . A f t e r a l l p r e - and p o s t t e s t d a t a had been c o l l e c t e d , a program was run t o merge the p r e - and p o s t t e s t d a t a by i d e n t i f i c a t i o n number, c l a s s i f i e d by i n t e r v e n t i o n group. Data i n t h i s merged f i l e had been s c o r e d w i t h computer 91 a s s i s t a n c e and were ready f o r the a c t u a l d a t a a n a l y s i s . T a b l e 7 d e s c r i b e s p r e - a n a l y s i s h a n d l i n g f o r a l l v a r i a b l e s measured. One p o i n t s h o u l d be made about the p r e -a n a l y s i s d a t a h a n d l i n g : A l a r g e number of women i n the study were unemployed y e t d i d not appear t o be of low s o c i o -economic s t a t u s . C o n s e q u e n t l y the B l i s h e n and C a r r o l l (1978) index f i g u r e s d i d not seem t o be r e a l i s t i c measures of s ocio-economic s t a t u s f o r the purpose of t h i s s t u d y . I n s t e a d , employment s t a t u s was chosen f o r use i n the a c t u a l d a t a a n a l y s i s i n p l a c e of socio-economic s t a t u s . A n a l y s i s of the Data A s s i s t a n c e w i t h the s t a t i s t i c a l a n a l y s i s of data was sought from the S t a t i s t i c s C e n t r e i n the F a c u l t y of A r t s . T h i s s e c t i o n o u t l i n e s the p r o c e d u r e s used i n the a n a l y s i s of da t a r e l a t e d t o the biodemographic v a r i a b l e s and t o the t h r e e r e s e a r c h q u e s t i o n s . For a l l a n a l y s e s , subprograms from the S t a t i s t i c a l Package f o r the S o c i a l S c i e n c e s , v e r s i o n X (Nie 1983) were employed. A l l r e s u l t s from the a n a l y s e s were e x p r e s s e d a t the 0.05 l e v e l of s i g n i f i c a n c e , u n l e s s o t h e r w i s e i n d i c a t e d . The Biodemographic V a r i a b l e s U n i v a r i a t e frequency d i s t r i b u t i o n s were computed f o r the demographic v a r i a b l e s by i n t e r v e n t i o n group u s i n g the sub-program FREQUENCIES. These were performed t o r e c l a s s i f y v a r i a b l e s as n e c e s s a r y so t h a t non-empty c e l l s c o u l d be used f o r a n a l y s i s . As a r e s u l t of the frequ e n c y d i s t r i b u t i o n 92 T a b l e 7 : P r e - a n a l y s i s h a n d l i n g of the da t a Dependent V a r i a b l e s 1. P a r t i c i p a n t s ' a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s 2. P a r t i c i p a n t s ' p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t i e s 3. P a r t i c i p a n t s e l f - r e p o r t e d d i e t a r y c a l c i u m i n t a k e Independent V a r i a b l e s 1 . age 2. soci o - e c o n o m i c s t a t u s 3. e d u c a t i o n Data H a n d l i n g Each i t e m had a max-imum p o s s i b l e s c o r e of 5 p o i n t s . P o i n t s f o r a l l items were t o t a l l e d f o r raw o v e r - a l l s c o r e s and by s u b s c a l e f o r sub-s c a l e s c o r e s (as above) The number of m i l l i g r a m s of c a l c i u m consumed per day as e s t i m a t e d from the food i n t a k e form Number rounded t o the c l o s e s t year from the b i r t h d a t e r e p o r t e d A two d i g i t index was a s s i g n e d each p a r t i c i p a n t based upon, the method of B l i s h e n and C a r r o l l (1978). The h i g h e r the i n d e x , the h i g h e r i s i t s a s s o c i a t e d socio-economic s t a t u s . Women who were unemployed were a s s s i g n e d an index of z e r o . P a r t i c i p a n t s i n d i c a t e d which of the f o l l o w i n g was t h e i r h i g h e s t l e v e l of s c h o o l i n g : (1) l e s s than grade seven (2) some h i g h s c h o o l , d i d not graduate (3) h i g h s c h o o l graduate (4) v o c a t i o n a l or t e c h n i c a l (5) some c o l l e g e or u n i v e r s i t y (6) c o l l e g e or u n i v e r s i t y g raduate (7) p o s t g r a d u a t e degree 93 T a b l e 7 : P r e - a n a l y s i s h a n d l i n g of the da t a ( c o n t i n u e d ) Independent V a r i a b l e s 4. a l l e r g y or i n t o l e r a n c e t o t o m i l k or m i l k p r o d u c t s 5. weight f o r h e i g h t A s c o r e of 1 t o 7 was used t o i d e n t i f y l e v e l s of s c h o o l i n g A yes/no response was p r o v i d e d a l o n g w i t h an open-ended q u e s t i o n on the type of a l l e r g y or i n t o l e r a n c e The J e t t e (1984) c l a s s i f i c a t i o n of weights f o r h e i g h t f o r Canadian women was used t o group women i n t o one of f i v e c a t e g o r i e s : (1) underweight (2) s l i m (3) s a t i s f a c t o r y (4) heavy (5) e x c e s s i v e A s c o r e of 1 t o 5 d e s c r i b e d a p a r t i c i p a n t on t h i s v a r i a b l e 6. use of a c a l c i u m -c o n t a i n i n g supplement 7. use of a s p e c i a l d i e t A yes/no response was p r o v i d e d A yes/no response was p r o v i d e d a l o n g w i t h a s e l e c t i o n of t y p e s : (1) weight r e d u c t i o n (2) d i a b e t i c (3) sodium or s a l t r e s t r i c t i o n (4) low f a t / c h o l e s t e r o l (5) v e g e t a r i a n (6) o t h e r (open-ended) When a d i a b e t i c d i e t was i n d i c a t e d w i t h another d i e t , the v a r i a b l e was coded as d i a b e t i c 8. degree of adherence t o the problem s o l v i n g s t e p s P a r t i c i p a n t s were asked i f they completed each of the 3 s t e p s i n the problem s o l v i n g sequence. Adherence was d e f i n e d f o r a n a l y s i s as the c o m p l e t i o n of s t e p numbers 1 and 2 of the S h o r t r i d g e model 94 T a b l e 7 : P r e - a n a l y s i s h a n d l i n g of the d a t a ( c o n t i n u e d ) Independent V a r i a b l e s 9. p a r t i c i p a n t awareness of o s t e o p o r o s i s 10. s e a s o n a l v a r i a t i o n i n m i l k or m i l k p r o d u c t i n t a k e 11. pregnancy s t a t u s 12. s e l f - e s t e e m score 13. p a r t i c i p a n t s a t i s f a c t i o n w i t h the i n t e r v e n t i o n P a r t i c i p a n t s responded t o how aware they f e l t they were on a f o u r - p o i n t s c a l e : one p o i n t f o r unaware to f o u r p o i n t s f o r v e r y aware A yes/no response was p r o v i d e d A yes/no response was p r o v i d e d P a r t i c i p a n t s responded yes/no t o 32 q u e s t i o n s . A response r e p r e s e n t i n g h i g h s e l f - e s t e e m s c o r e d one p o i n t , and a low s e l f - e s t e e m response z e r o . A yes/no response format was p r o v i d e d a l o n g w i t h an open-ended q u e s t i o n f o r r e a s o n s . 95 g e n e r a t e d , a few v a r i a b l e s were re-grouped: (1) age: Two c a t e g o r i e s were produced from a c o n t i n u o u s v a r i a b l e : (a) l e s s than or eq u a l t o age 49 or (b) over 49; (2) e d u c a t i o n : Two c a t e g o r i e s were formed from the p r e v i o u s seven l e v e l s : (a) l e s s than or e q u a l t o h i g h s c h o o l or (b) p o s t s e c o n d a r y ; (3) weight f o r h e i g h t : The f i v e J e t t e c l a s s i f i c a t i o n s were reduced t o t h r e e : (a) underweight, (b) s a t i s f a c t o r y , or (c) overweight and (4) awareness of o s t e o p o r o s i s : Four l e v e l s of response were compressed i n t o two: (a) h i g h or (b) low. In o r d e r t o t e s t f o r s i g n i f i c a n t d i f f e r e n c e s among the t h r e e i n t e r v e n t i o n groups, C h i - s q u a r e a n a l y s i s was performed u s i n g the subprogram CROSSTABS. By t h i s method, frequency d i s t r i b u t i o n s as w e l l as means and s t a n d a r d d e v i a t i o n s were produced f o r each biodemographic v a r i a b l e w i t h i n i n t e r v e n t i o n groups A, B and C. S i m i l a r a n a l y s e s were performed t o compare the d i s t r i b u t i o n of women by biodemographic v a r i a b l e s who took p a r t i n both s e s s i o n s v e r s u s t h o s e who p a r t i c i p a t e d o n l y i n the p r e t e s t . For Each Research Q u e s t i o n Impacts were measured as change s c o r e s c a l c u l a t e d by s u b t r a c t i n g p r e t e s t s c o r e s from p o s t t e s t s c o r e s . No s p e c i a l measures were taken f o r m i s s i n g d a t a as o n l y complete c a s e s f o r v a r i a b l e s were used i n the a n a l y s i s . A l l p r e - and p o s t t e s t comparisons were based upon matched d a t a . A n a l y s e s were done on t h r e e d i f f e r e n t g r o u p i n g s of the d a t a : (1) a l l p o o l e d d a t a by i n t e r v e n t i o n group ; (2) o n l y 96 d a t a of non-pregnant women whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was below the Canadian Recommended N u t r i e n t I n t a k e ("below RNI" data) and (3) o n l y data of non-pregnant women whose p r e t e s t d i e t a r y c a l c i u m i n t a k e s were at or below the N a t i o n a l I n s t i t u t e of H e a l t h ' s Consensus Conference recommended i n t a k e l e v e l of 1000 mg/day f o r pre-menopausal women ("at or below NIH" d a t a ) . Research Q u e s t i o n 1 (a) D i d forms A and B of the 'Calcium C a l c u l a t o r ' produce s i g n i f i c a n t l y d i f f e r e n t i mpacts on women's: a t t i t u d e toward d i e t a r y c a l c i u m and o s t e o p o r o s i s ; p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t y and d i e t a r y c a l c i u m i n t a k e ? (b) D i d forms A and B of the 'Calcium C a l c u l a t o r ' produce s i g n i f i c a n t l y d i f f e r e n t impacts on women's a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s ; p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t y and d i e t a r y c a l c i u m i n t a k e , when compared t o the impacts produced by the c o n t r o l i n t e r v e n t i o n ? The main data a n a l y s i s procedure chosen f o r t h i s q u e s t i o n was one-way a n a l y s i s of v a r i a n c e . To v e r i f y the a p p r o p r i a t e n e s s of the d a t a on the dependent v a r i a b l e s f o r a n a l y s i s of v a r i a n c e , two s t e p s were t a k e n : (1) h i s t o g r a m s w i t h superimposed normal d i s t r i b u t i o n s were g e n e r a t e d u s i n g the subprogram FREQUENCIES and (2) B a r t l e t t - B o x t e s t s of homogeneity of 97 v a r i a n c e were performed u s i n g the ONEWAY subprogram. V a r i a b l e s f o r which the v a r i a n c e s were s i g n i f i c a n t l y d i f f e r e n t among the t h r e e groups were s u b m i t t e d t o non p a r a m e t r i c t e s t s : K r u s k a l - W a l l i s and Median, f o r k-independent samples. For the m a j o r i t y of d a t a , t w o - t a i l e d one-way a n a l y s i s of v a r i a n c e was performed u s i n g the ONEWAY subprogram w i t h "a p r i o r i " c o n t r a s t s . The "a p r i o r i " c o n t r a s t s were: (1) form A v e r s u s form B, where the l a t t e r was p r e d i c t e d t o have the g r e a t e r impact and (2) form A and form B v e r s u s the c o n t r o l m a t e r i a l , where the former were p r e d i c t e d t o have the g r e a t e r impact. To e x p l o r e w i t h i n - i n t e r v e n t i o n group changes from p r e -to p o s t t e s t on the dependent v a r i a b l e s , t w o - t a i l e d p a i r e d t -t e s t s were done u s i n g the subprogram T-TESTS. Research Q u e s t i o n 2 I s t h e r e a s i g n i f i c a n t r e l a t i o n s h i p between women's s e l f - e s t e e m s c o r e s and t h e i r : a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s ; p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t y and d i e t a r y c a l c i u m i n t a k e ? C o r r e l a t i o n a n a l y s i s was performed t o dete r m i n e the d i r e c t i o n and s i g n i f i c a n c e of r e l a t i o n s h i p s between s e l f -esteem s c o r e s and the dependent v a r i a b l e s . T h i s a n a l y s i s was a c h i e v e d u s i n g the subprogram PEARSON CORR. A n a l y s i s 98 produced Pearson product-moment c o r r e l a t i o n s and t w o - t a i l e d t e s t s of s i g n i f i c a n c e f o r a l l p o s s i b l e r e l a t i o n s h i p s . R esearch Q u e s t i o n 3 I s t h e r e a s i g n i f i c a n t d i f f e r e n c e i n women's: a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s ; p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t y and d i e t a r y c a l c i u m i n t a k e among groups d e f i n e d a c c o r d i n g t o the f o l l o w i n g v a r i a b l e s : (1) demographic v a r i a b l e (a) age (b) employment s t a t u s (c) e d u c a t i o n (2) d i e t a r y v a r i a b l e s : (a) a l l e r g y t o m i l k or m i l k p r o d u c t s (b) s e a s o n a l v a r i a t i o n i n m i l k p r o d u c t i n t a k e (c) use of c a l c i u m - c o n t a i n i n g supplement (d) weight f o r h e i g h t (e) use of a s p e c i a l d i e t (3) m i s c e l l a n e o u s v a r i a b l e s : (a) adherence t o the t h r e e s t e p s of the problem s o l v i n g model (b) awareness of o s t e o p o r o s i s ? A n a l y s i s of v a r i a n c e was used t o e x p l o r e the e f f e c t s of the independent v a r i a b l e s on change i n the dependent v a r i a b l e s u s i n g the subprogram ANOVA. S c h e f f e range t e s t s were a p p l i e d t o s i g n i f i c a n t i n t e r a c t i o n s t o i d e n t i f y s i g n i f i c a n t l y d i f f e r e n t g roups. V a l u e s were e n t e r e d f o r a n a l y s i s i n the forms produced by the p r e v i o u s l y mentioned subprogram CROSSTABS. S c a t t e r p l o t s were a l s o d e r i v e d t o r e l a t e the independent v a r i a b l e s t o the dependent v a r i a b l e s 99 u s i n g the REGRESSION subprogram. A n a l y s i s was done on p o o l e d data and "below RNI" d a t a . A n a l y s e s not s p e c i f i c a l l y r e l a t e d t o e i t h e r of the t h r e e r e s e a r c h q u e s t i o n s were a l s o performed. These i n c l u d e d : (1) one-way a n a l y s i s of v a r i a n c e on the p r e t e s t dependent v a r i a b l e s by i n t e r v e n t i o n group t o v e r i f y the e q u a l i t y of t h e i r means; (2) T - t e s t s on the e q u a l i t y of means of the dependent v a r i a b l e s between women who p a r t i c i p a t e d i n o n l y the p r e t e s t and those who took p a r t i n b o th p r e - and p o s t t e s t ; (3) one-way a n a l y s i s of v a r i a n c e on the dependent v a r i a b l e s by degree of p a r t i c i p a n t adherence t o the problem s o l v i n g s t e p s ; (4) one-way a n a l y s i s of v a r i a n c e on s e l f - e s t e e m s c o r e s by i n t e r v e n t i o n group t o v e r i f y e q u a l i t y among group means and (5) r e l i a b i l i t y a n a l y s i s to d e r i v e Cronbach's a l p h a f o r the a t t i t u d e and p e r c e p t i o n s c a l e s a t both p r e - and p o s t t e s t , as w e l l as the s e l f - e s t e e m s c a l e a t p o s t t e s t . Judgement of the A n a l y z e d Data P r e p a r a t i o n f o r the Judgement Phase P r i o r t o the a c t u a l judgement p r o c e s s , m a t e r i a l s were p r e p a r e d t o p r o v i d e p a n e l i s t s w i t h : (1) i n f o r m a t i o n r e q u i r e d t o make judgements and (2) judgement q u e s t i o n s and response forms. The p r o c e s s of p r e p a r i n g these m a t e r i a l s c o n s i s t e d o f : (1) making a d r a f t d e s c r i p t i o n of the background t o the s t u d y , r e s u l t s and judgement q u e s t i o n s and then r e v i s i n g i t t o i n c o r p o r a t e feedback from the t h e s i s a d v i s o r and two 100 committee members; (2) a s s e s s i n g f a c e v a l i d i t y w i t h t h r e e graduate s t u d e n t s and one s e s s i o n a l l e c t u r e r i n Human N u t r i t i o n who were asked t o comment on w o r d i n g , l a y o u t , and the amount of time needed to respond t o each of the judgement q u e s t i o n s and then (3) p r e p a r i n g a r e v i s e d s e t of m a t e r i a l s . The f i n a l judgement m a t e r i a l s (Appendix K) c o n s i s t e d o f : (1) a background and need f o r the s t u d y ; (2) d a t a sheet A f o r r e s e a r c h q u e s t i o n 2 and d a t a sheet B f o r r e s e a r c h q u e s t i o n 1; (3) group response forms f o r both r e s e a r c h q u e s t i o n s and (4) i n d i v i d u a l c o n c l u d i n g judgement forms. For r e s e a r c h q u e s t i o n 1, p o o l e d p r e - and p o s t t e s t data f o r i n t e r v e n t i o n groups A and B were p r e s e n t e d f o r a t t i t u d e and p e r c e p t i o n d a t a . S t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e s between i n t e r v e n t i o n groups A and B w i t h "below RNI" d a t a were d i s p l a y e d s e p a r a t e l y from the mean p r e - and p o s t t e s t s c o r e s . For r e s e a r c h q u e s t i o n 2, c o r r e l a t i o n v a l u e s and sample s i z e s were p r o v i d e d f o r r e l a t i o n s h i p s between the t h r e e s e l f - e s t e e m s u b s c a l e s and changes i n the dependent v a r i a b l e s f o r p o o l e d d a t a . A g a i n , s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p s were l i s t e d s e p a r a t e l y . I t was d e c i d e d t o p r e s e n t n u m e r i c a l r e s u l t s s e p a r a t e from the r e s u l t s of s t a t i s t i c a l t e s t i n g of them. T h i s was i n t e n d e d to p e r m i t judges t o choose e i t h e r form of i n f o r m a t i o n as a b a s i s f o r judgements. 101 S e l e c t i o n of the Judgement P a n e l Judgement on both the v a l u e of the problem s o l v i n g method of i n s t r u c t i o n and the r o l e of s e l f - e s t e e m i n the d e s i g n of e d u c a t i o n a l m a t e r i a l s was sought from a p a n e l of s e l e c t e d j u d g e s . Nine women were chosen t o r e p r e s e n t f o u r groups h a v i n g p r o f e s s i o n a l and p u b l i c i n t e r e s t i n the e v a l u a t i o n r e s u l t s . These f o u r groups were: (1) p r o d u c e r s of n u t r i t i o n e d u c a t i o n m a t e r i a l s : one n u t r i t i o n e d u c a t o r from the B.C. D a i r y F o u n d a t i o n and a home economist w i t h the Beef I n f o r m a t i o n C e n t r e ; (2) p r o f e s s i o n a l u s e r s of n u t r i t i o n e d u c a t i o n m a t e r i a l s : a p u b l i c h e a l t h n u t r i t i o n i s t from the Vancouver H e a l t h Department, a p u b l i c h e a l t h n u t r i t i o n i s t c u r r e n t l y c o m p l e t i n g a d o c t o r a t e i n a d u l t e d u c a t i o n and a n u t r i t i o n c o n s u l t a n t w i t h the p r o v i n c i a l M i n i s t r y of H e a l t h ; (3) p e r s o n a l u s e r s of n u t r i t i o n e d u c a t i o n m a t e r i a l s : a master's s t u d e n t i n c o u n s e l l i n g p s y c h o l o g y and a community c e n t r e c o o r d i n a t o r who had been a p a r t i c i p a n t i n the stu d y ; and (4) f u t u r e p r o f e s s i o n a l u s e r s of n u t r i t i o n e d u c a t i o n m a t e r i a l s : r e p r e s e n t e d by two f o u r t h - y e a r d i e t e t i c s s t u d e n t s . Judges met as a group f o r t h r e e and one h a l f hours i n the F a m i l y and N u t r i t i o n a l S c i e n c e s b u i l d i n g a t the U n i v e r s i t y of B r i t i s h Columbia. 1 02 The Judgement P r o c e s s The judgement p r o c e s s c o n s i s t e d of e x p o s i n g judges t o s e l e c t e d study r e s u l t s and a s k i n g them t o respond t o s p e c i f i c q u e s t i o n s or s t a t e m e n t s . These were g e n e r a t e d from the s t u d y ' s f i r s t two r e s e a r c h q u e s t i o n s . The sequence i n c l u d e d : (1) an i n t r o d u c t i o n by the i n v e s t i g a t o r (15 m i n u t e s ) ; (2) judges read the background i n f o r m a t i o n on the study (15 m i n u t e s ) ; (3) when f i n i s h e d , each judge i n d e p e n d e n t l y asked t o r e c e i v e d a t a sheet A and completed the a s s o c i a t e d judgement q u e s t i o n (50 m i n u t e s ) ; (4) a c o f f e e break f o l l o w e d (15 m i n u t e s ) ; (5) a l l judges were then g i v e n d a t a sheet B and completed the a s s o c i a t e d judgement q u e s t i o n s (35 m i n u t e s ) ; (6) judges w i t h i n each of the f o u r d i f f e r e n t groups d i s c u s s e d the judgement q u e s t i o n s and wrote group responses t o them (25 m i n u t e s ) ; (7) v e r b a l summaries by each group were made t o t h e i n v e s t i g a t o r (15 m i n u t e s ) ; (8) i n d i v i d u a l judges then responded t o the c o n c l u d i n g judgement st a t e m e n t s (5 m i n u t e s ) ; (9) v e r b a l summary responses were then g i v e n by each judge f o l l o w e d by an open d i s c u s s i o n (20 m i n u t e s ) . A few p o i n t s s h o u l d be made about the judgement p r o c e s s used f o r t h i s s t u d y . F i r s t , judges were not exposed t o the m a t e r i a l s p r i o r t o meeting t o a v o i d t h e i r d i s c u s s i n g the 103 i n f o r m a t i o n w i t h non-judges. A l s o , d a t a r e l a t i n g t o s e l f -esteem were p r e s e n t e d f i r s t , f o l l o w e d by those comparing impacts produced by form A and B of the 'Calcium C a l c u l a t o r ' as i t was f e l t t h a t the g e n e r a l q u e s t i o n s h o u l d precede the more s p e c i f i c q u e s t i o n of d i f f e r e n c e s between the two forms of the 'Calcium C a l c u l a t o r ' . In a d d i t i o n the purpose of group d i s c u s s i o n s was not t o a c h i e v e consensus by f o r c i n g judges t o r e a c h a u n i f o r m r e s p o n s e . R a t h e r , emphasis was p l a c e d on e x p l o r i n g reasons f o r d i f f e r e n t v a l u e s t a n c e s t a k e n . A l s o , responses t o the c o n c l u d i n g judgement statements were i n t e n d e d t o be q u a n t i f i a b l e , t h e r e f o r e a L i k e r t - t y p e response s c a l e ( 1 , s t r o n g l y d i s a g r e e t o 5, s t r o n g l y agree) was used. Q u a n t i t a t i v e d a t a c o l l e c t e d from the judgement p r o c e s s was summarized by freq u e n c y of response among the j u d g e s . Q u a l i t a t i v e responses were e x p l o r e d f o r t r e n d s i n v a l u e s t a n c e s , and f o r recommendations and i m p l i c a t i o n s f o r f u t u r e r e s e a r c h . Judgement Q u e s t i o n s The judgement q u e s t i o n f o r r e s e a r c h q u e s t i o n number 2 (data sheet A) was "Which r e l a t i o n s h i p s between s e l f - e s t e e m and p a r t i c i p a n t s ' b e l i e f s and a c t i o n s do you c o n s i d e r m e a n i n g f u l i n the d e s i g n of e d u c a t i o n a l m a t e r i a l s ? L i s t t he r e l a t i o n s h i p s . " For r e s e a r c h q u e s t i o n 1 ( d a t a sheet B ) , the judgement q u e s t i o n s were: (1) "What d i f f e r e n c e s between the two forms 1 04 of the 'Calcium C a l c u l a t o r ' do you f e e l are m e a n i n g f u l i n the d e s i g n of e d u c a t i o n a l m a t e r i a l s ? L i s t the d i f f e r e n c e s " ; (2) "From the d i f f e r e n c e s you have i d e n t i f i e d above, which form of the 'Calcium C a l c u l a t o r ' do you judge more e f f e c t i v e ? P l e a s e check one: A, B, or n e i t h e r and g i v e r e a s o n s . " As c o n c l u d i n g judgements, judges r e c o r d e d the e x t e n t to which they agreed w i t h two s t a t e m e n t s : (1) " P a r t i c i p a n t s ' s e l f - e s t e e m s h o u l d be a c o n s i d e r a t i o n i n the d e s i g n of n u t r i t i o n e d u c a t i o n m a t e r i a l s " and (2) " N u t r i t i o n e d u c a t i o n m a t e r i a l s s h o u l d i n c o r p o r a t e problem s o l v i n g methods of i n s t r u c t i o n t o a s s i s t p a r t i c i p a n t s i n making d i e t a r y changes." Reasons f o r responses were a l s o r e q u e s t e d . 1 05 L i m i t a t i o n s of the Study Some l i m i t a t i o n s were r e c o g n i z e d as i n t e g r a l t o the study d e s i g n employed. These were: (1) the p o s s i b i l i t y of a l o c a l h i s t o r y e f f e c t between p r e - and p o s t t e s t i n g ; (2) the p o s s i b i l i t y of a s e l e c t i o n - m a t u r a t i o n e f f e c t i n p a r t i c i p a n t s , independent of the i n t e r v e n t i o n ; (3) non-random p a r t i c i p a n t assignment t o i n t e r v e n t i o n groups; (4) the use of i n d i r e c t s e l f - r e p o r t e d measures of impact, i n c l u d i n g a t w e n t y - f o u r hour r e c a l l type i n s t r u m e n t ; (5) the p o s s i b i l i t y of v o l u n t e e r s e l f - s e l e c t i o n b i a s ; (6) the p o s s i b i l i t y of both a t e s t b i a s and Hawthorne e f f e c t i n f l u e n c i n g comparisons between p r o b l e m - s o l v i n g and non-problem s o l v i n g i n t e r v e n t i o n impacts and (6) the p o s s i b i l i t y of b i a s between c o l l e c t e d and m a i l e d p o s t t e s t q u e s t i o n n a i r e s . Other l i m i t a t i o n s s p e c i f i c t o the r e s e a r c h q u e s t i o n s a d d r e s s e d i n c l u d e d : (1) o n l y two models of the problem s o l v i n g method of i n s t r u c t i o n were e v a l u a t e d ; (2) measures of impact, upon which the worth of the method was a s s e s s e d , were o n l y t h r e e : a t t i t u d e s , p e r c e p t i o n s and d i e t a r y c a l c i u m i n t a k e and (3) the method was o n l y e v a l u a t e d among a d u l t women. R e s u l t s from the data a n a l y s e s and judgement phase w i l l be p r e s e n t e d i n Chapter IV. 106 CHAPTER IV RESULTS AND DISCUSSION I n t r o d u c t i o n T h i s c h a p t e r p r e s e n t s the r e s u l t s of the a n a l y s i s of dat a c o l l e c t e d a t p r e - and p o s t t e s t . As w e l l , r e s u l t s from the judgement p a n e l a re p r e s e n t e d on the v a l u e of the problem s o l v i n g method and s e l f - e s t e e m i n the d e s i g n of m a t e r i a l s i n n u t r i t i o n e d u c a t i o n . The d i s t r i b u t i o n of biodemographic v a r i a b l e s w i t h i n i n t e r v e n t i o n groups w i l l be p r e s e n t e d f i r s t f o l l o w e d by r e l i a b i l i t y c h a r a c t e r i s t i c s of the measurement i n s t r u m e n t s . R e s u l t s of h y p o t h e s i s t e s t i n g f o r each of the t h r e e r e s e a r c h q u e s t i o n s w i l l then be d e s c r i b e d . T h i s c h a p t e r w i l l c o n c l u d e w i t h r e s u l t s from the judgement phase. The Study Sample Groups of women from the Vancouver and Burnaby a r e a s were r e c r u i t e d t o ta k e p a r t i n t h i s r e s e a r c h . E i g h t e e n community groups were a s s i g n e d t o one of t h r e e i n t e r v e n t i o n s : A, the o r i g i n a l 'Calcium C a l c u l a t o r ' (n=7 g r o u p s ) ; B, the m o d i f i e d 'Calcium C a l c u l a t o r ' (n=7 g r o u p s ) ; or C, the c o n t r o l f i l m (n=4 g r o u p s ) . T a b l e 8 l i s t s the community c e n t r e groups which took p a r t i n the s t u d y , a l o n g w i t h the i n t e r v e n t i o n group t o which they were a s s i g n e d . A t o t a l of 241 women completed 107 T a b l e 8: Community groups which p a r t i c i p a t e d i n C a l c i u m and Bone He a l t h Workshops Community I n t e r v e n t i o n No. of P a r t i c i p a n t s No of Time of Group pre post 1 below R N I 1 1 weeks to Follow-up Assignment (I) (S) Seekers Church Group Form B 12 10 4 5 X K i t s i l a n o Form B 5 5 0 5 X Marpole Oakrldge Form A 15 6 4 4 X Mt. P l e a s a n t Form A 5 1 0 4 X S. H e a l t h U n i t C o n t r o l 10 2 1 9 X Arbutus Club C o n t r o l 23 11 6 4 X K i l l a r n e y C o n t r o l 5 4 1 4 X W i l l i n g d o n Form B 2 23 12 2 5 X F a l s e Creek Form B 3 16 10 1 4 X Renfrew Form A 7 1 1 4 X Jewish Form A 8 5 1 4 X Champlain Form B 11 0 0 4 X K e r r i s d a l e Form B 28 4 1 4 X West End Form B 11 7 2 4 X R i l e y Park Form A 14 6 1 4 X Cameron Form A 14 8 3 4 X Edmonds C o n t r o l 21 9 3 8 X E a s t b u r n Form A 13 5 2 4 X 1 Number of p a r t i c i p a n t s who were not pregnant at e i t h e r pre- o r p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was below the Recommended N u t r i e n t I n t a k e . ( I ) : I n i t i a l Assignment ( S ) : Subsequent Assignment 2; by I n s t r u c t o r #2 , - A l l n o n - i n d i c a t e d groups were by the main I n s t r u c t o r by I n v e s t i g a t o r #3 n — i r #3-1 108 the p r e t e s t q u e s t i o n n a i r e : 76 i n group A; 106 i n group B and 59 i n group C. Of t h e s e , 106 women r e t u r n e d f o r p o s t t e s t : 32 i n group A; 48 i n group B and 26 i n group C. F o r t y - f o u r p e r c e n t of p r e t e s t p a r t i c i p a n t s completed the p o s t t e s t q u e s t i o n n a i r e . T h i s f i g u r e i n c l u d e s 12 p a r t i c i p a n t s who c o u l d not a t t e n d the p o s t t e s t s e s s i o n and r e t u r n e d t h e i r q u e s t i o n n a i r e s by m a i l . D i s t i n c t i o n s were not made between these q u e s t i o n n a i r e s and those c o l l e c t e d a t p o s t t e s t . They were t h e r e f o r e a n a l y z e d a l o n g w i t h the l a t t e r . I t had been hoped t h a t a l a r g e r p e r c e n t a g e of women would have r e t u r n e d f o r the p o s t t e s t . The r e t e n t i o n r a t e was, however, comparable t o t h a t of s i m i l a r s t u d i e s u s i n g a p r e t e s t , p o s t t e s t d e s i g n . R e i s and Schoon (1986) r e p o r t e d a r e t e n t i o n r a t e of o n l y 8% f o r t h e i r t r e a t m e n t group and 10% f o r the c o n t r o l group i n an eight-week c a f e t e r i a - b a s e d n u t r i t i o n program. Brush e t a l . (1986) documented an 80% c o m p l e t i o n r a t e o.f p o s t t e s t q u e s t i o n n a i r e s f i v e weeks a f t e r p r e t e s t . In the l a t t e r s t u d y , p o s t t e s t q u e s t i o n n a i r e s were m a i l e d t o p a r t i c i p a n t s absent from the l a s t n u t r i t i o n c l a s s and a monetary i n c e n t i v e p r o v i d e d . The p o s t t e s t s e s s i o n s took p l a c e between f o u r and n i n e weeks a f t e r p r e t e s t . T h i r t e e n of 18 p o s t t e s t meetings took p l a c e f o u r weeks a f t e r p r e t e s t , w i t h an average f o l l o w - u p time f o r a l l groups of 4.7 weeks. Four t o s i x weeks have been recommended as an i d e a l d e l a y time between p r e - and p o s t t e s t i n g ( C a r r u t h et a l . 1977). T a b l e 8 a l s o i n d i c a t e s by whom the p r e t e s t workshops 109 were g i v e n . The same n u t r i t i o n e d u c a t o r from the B.C. D a i r y F o u n d a t i o n performed 15 of the 18 workshops. Two workshops c o u l d not f i t i n t o her s c h e d u l e and were l e d by another n u t r i t i o n e d u c a t o r . One workshop had t o be completed by the i n v e s t i g a t o r s i n c e n e i t h e r n u t r i t i o n e d u c a t o r was a b l e t o a t t e n d the s e s s i o n . The proce d u r e f o l l o w e d a t each workshop was s t a n d a r d i z e d and r e s u l t s from a l l workshops p o o l e d i n the da t a a n a l y s i s . A l l p r e t e s t q u e s t i o n n a i r e s were coded and matched by te l e p h o n e number. Only p o s t t e s t q u e s t i o n n a i r e s which c o u l d be matched w i t h a p r e t e s t q u e s t i o n n a i r e were used t o t e s t the t h r e e study h y p otheses. S e l e c t e d Biodemographic C h a r a c t e r i s t i c s of P a r t i c i p a n t s T a b l e 9 d e s c r i b e s the d i s t r i b u t i o n of t e n p r e t e s t biodemographic v a r i a b l e s w i t h i n the t h r e e i n t e r v e n t i o n groups. Three v a r i a b l e s were demographic: age, employment s t a t u s and h i g h e s t l e v e l of e d u c a t i o n . Seven were r e l a t e d t o d i e t a r y p r a c t i c e s : a l l e r g y or i n t o l e r a n c e t o m i l k or m i l k p r o d u c t s ; use of a c a l c i u m - c o n t a i n i n g supplement; weight f o r h e i g h t ; use of a s p e c i a l d i e t ; pregnancy s t a t u s ; s e l f - r e p o r t e d awareness of o s t e o p o r o s i s and adequacy of d i e t a r y c a l c i u m i n t a k e r e l a t i v e t o the Recommended N u t r i e n t I n t a k e l e v e l . Women were c l a s s i f i e d as a t or below age 49, or over 110 T a b l e 9: D i s t r i b u t i o n of p r e t e s t p a r t i c i p a n t s (n=241) by biodemo-graph i c v a r i a b l e s , w i t h i n i n t e r v e n t i o n groups Biodemographic v a r i a b l e s Form A 1 I n t e r v e n t i o n Group n Form B J C o n t r o l 1 Age 49 o r l e s s over 49 Employed Yes No E d u c a t i o n h i g h s c h o o l or l e s s p ost-secondary A l l e r g y or i n t o l e r a n c e to m i l k or mi l k products Yes No Use of a c a l c i u m -c o n t a i n i n g supplement Yes No Weight f o r h e i g h t underweight s a t i s f a c t o r y overweight Use of a s p e c i a l d i e t Yes No Pregnant Yes No Awareness of o s t e o p o r o s i s low high Adequacy of c a l c i u m i n t a k e Yes No 39 (52) 36 ( 4 8 ) * (m=l)2 27 (37) 46 (63) (m=3) 32 (43) 42 (57) (m=2) 7 (10) 63 (90) (m=6) 36 (52) 33 ( 4 8 ) * (m=7) 20 (27) 28 (38) 26 (35) (m=2) 20 (28) 52 (72) (m=4) 4 (6) 69 (94) (m=3) 18 (25) 55 (75) (m=3) 33 (52) 31 ( 4 8 ) * (m=12) 44 (43) 58 ( 5 7 ) * (m=0) 22 (23) 72 (77) (m=12) 38 (39) 60 (61) (m=8) 7 (8) 81 (92) (m=18) 31 (35) 58 ( 6 5 ) * (m=17) 29 (30) 31 (31) 38 (39) (m=8) 27 (27) 73 (73) (m=6) 4 (4) 91 (96) (m=ll) 32 (33) 66 (67) (m=8) 63 (72) 24 ( 2 8 ) * (m=19) 16 (29) 39 ( 7 1 ) * (m=3) 13 (25) 39 (75) (m=7) 30 (56) 24 (44) (m=5) 7 (13) 46 (87) (m=6) 28 (53) 25 ( 4 7 ) * (m=6) 10 (18) 24 (43) 22 (39) (m=3) 20 (36) 35 (64) (m=4) 0 (0) 53 (100) (m=6) 15 (26) 43 (74) (m=l) 31 (53) 27 ( 4 7 ) * (m=l) 1 percentages i n parentheses ^ m i s s i n g v a l u e s * s i g n i f i c a n t d i f f e r e n c e s among groups at the p<0.05 l e v e l by C h i - s q u a r e a n a l y s i s 111 age 49. Except f o r i n t e r v e n t i o n group A, the m a j o r i t y of women i n each group were over age 49. The perc e n t a g e of women over age 49, c o n s i d e r e d t h e r e f o r e t o be postmenopausal, were: 48% i n group A; 57% i n group B and 71% i n group C. The mean ages, + s t a n d a r d d e v i a t i o n s , per i n t e r v e n t i o n group were: 49+15 i n group A; 56+20 i n group B; and 57+13 i n group C. The mean age f o r a l l t h r e e groups was 54, w i t h an age range of 22 t o 89. I n t e r v e n t i o n group C c o n s i s t e d of a s i g n i f i c a n t l y g r e a t e r p r o p o r t i o n of women over age 49. Schwalbe e t a l . (1986) r e p o r t e d a n e g a t i v e , though n o n - s i g n i f i c a n t , c o r r e l a t i o n between working women's l e v e l s of s e l f - e s t e e m and age ( r = - 0 . l 0 ) . C o n s e q u e n t l y , i n t e r v e n t i o n group C might have been e x p e c t e d t o have a lower mean l e v e l of s e l f - e s t e e m . Age has a l s o been n e g a t i v e l y c o r r e l a t e d w i t h n u t r i t i o n - r e l a t e d b e h a v i o u r s ( F o r s t e r - C o u l l 1985). T h e r e f o r e , i n t e r v e n t i o n group C may have been l e s s l i k e l y t o r e p o r t p o s i t i v e d i e t a r y b e h a v i o u r s . No r e l a t i o n s h i p , however, has y e t been d e s c r i b e d between age and problem s o l v i n g a b i l i t y . The m a j o r i t y of women i n a l l t h r e e i n t e r v e n t i o n groups were unemployed: 63% i n group A; 77% i n group B, and 75% i n group C. The p r o p o r t i o n of unemployed women was not s i g n i f i c a n t l y d i f f e r e n t among i n t e r v e n t i o n groups. Except f o r group C, the m a j o r i t y of women i n groups A and B had a t l e a s t p o s t - s e c o n d a r y e d u c a t i o n . F o r t y - f o u r p e r c e n t of women i n group C had p o s t - s e c o n d a r y e d u c a t i o n compared t o 57% i n group A and 61% i n group B. Very few women i n any of the i n t e r v e n t i o n groups 1 12 r e p o r t e d h a v i n g an a l l e r g y or i n t o l e r a n c e t o m i l k or m i l k p r o d u c t s . Those r e p o r t i n g an a l l e r g y or i n t o l e r a n c e accounted f o r 10% of women i n group A; 8% i n group B and 13% i n group C. Groups were not s i g n i f i c a n t l y d i f f e r e n t on t h i s v a r i a b l e . The above p e r c e n t a g e s a re h i g h e r than the 4% p r e v a l e n c e r e p o r t e d among women i n Vancouver by F o r s t e r -C o u l l (1985). The m a j o r i t y of women i n groups A and C r e p o r t e d u s i n g a c a l c i u m - c o n t a i n i n g supplement: 52% i n group A; 53% i n group C compared t o 35% i n group B. S i g n i f i c a n t l y fewer women i n group B r e p o r t e d u s i n g a c a l c i u m - c o n t a i n i n g supplement. T h i s p a t t e r n i s r e f l e c t e d by the d i e t a r y adequacy of c a l c i u m i n t a k e w i t h i n i n t e r v e n t i o n groups. Only 28% of women i n i n t e r v e n t i o n group B had a p r e t e s t d i e t a r y c a l c i u m i n t a k e below t h e i r Recommended N u t r i e n t I n t a k e l e v e l . In groups A and C , almost h a l f of the women had p r e t e s t d i e t a r y c a l c i u m i n t a k e s below the Recommended N u t r i e n t I n t a k e l e v e l : 48% i n group A and 47% i n group C. Regarding the use of c a l c i u m - c o n t a i n i n g supplements, groups A and C r e p o r t e d l e v e l s of use comparable t o those r e p o r t e d f o r g e n e r a l supplement use i n B r i t i s h C olumbia: 62% (Canadian F a c t s 1983). B a r r (1986) r e p o r t e d t h a t o n l y 8% of omnivorous female marathoners and 22% of omnivorous f i t n e s s c l a s s p a r t i c i p a n t s i n B r i t i s h Columbia used c a l c i u m -c o n t a i n i n g supplements. The pe r c e n t a g e use was h i g h e r f o r those who were s e m i - v e g e t a r i a n : 33% and 22% f o r marathoners and f i t n e s s c l a s s p a r t i c i p a n t s , r e s p e c t i v e l y . The h i g h 113 l e v e l s of r e p o r t e d use among p a r t i c i p a n t s i n t h i s study may r e f l e c t g r e a t e r awareness of t h e i r r i s k f o r o s t e o p o r o s i s or g r e a t e r awareness of the inadequacy of t h e i r d i e t a r y c a l c i u m i n t a k e s r e l a t i v e t o t h e i r needs. I t i s a l s o p o s s i b l e t h a t p a r t i c i p a n t s d i d not d i s t i n g u i s h between a m u l t i - v i t a m i n and a c a l c i u m - c o n t a i n i n g supplement. S i g n i f i c a n t l y fewer women i n group B had p r e t e s t d i e t a r y c a l c i u m i n t a k e s below the Recommended N u t r i e n t I n t a k e l e v e l . I t would appear t h a t a t the o u t s e t , i n t e r v e n t i o n groups A and C had g r e a t e r p o t e n t i a l f o r i n c r e a s e s i n the number of women whose d i e t a r y c a l c i u m i n t a k e c o u l d be improved. The p r o p o r t i o n of women i n group B w i t h p r e t e s t d i e t a r y c a l c i u m i n t a k e s below the Recommended N u t r i e n t I n t a k e i s comparable t o the 30% r e p o r t e d f o r B r i t i s h Columbia i n the N u t r i t i o n Canada (1973) s u r v e y . Groups A and C had s i g n i f i c a n t l y h i g h e r p r o p o r t i o n s of women w i t h inadequate p r e t e s t d i e t a r y c a l c i u m i n t a k e s . C o n s e q u e n t l y , i t was c o n s i s t e n t t h a t t h e s e two groups r e p o r t e d s i g n i f i c a n t l y g r e a t e r use of c a l c i u m - c o n t a i n i n g supplements. L e s s than h a l f of the women i n the t h r e e i n t e r v e n t i o n groups r e p o r t e d u s i n g a s p e c i a l d i e t . T h i r t y - s i x p e r c e n t of the women i n group C s a i d they d i d , compared t o 28% i n group A and 27% i n group B. Groups were not s i g n i f i c a n t l y d i f f e r e n t on t h i s v a r i a b l e . A p p r o x i m a t e l y t w o - t h i r d s of the women i n each i n t e r v e n t i o n group had s e l f - r e p o r t e d w e i g h t s a p p r o p r i a t e t o t h e i r h e i g h t s . T h i s i s c o n s i s t e n t w i t h the v e r y low 1 1 4 f r e q u e n c y of use made of s p e c i a l d i e t s , i n c l u d i n g w e i g h t -r e d u c i n g d i e t s . Only 35% of women i n group A had e x c e s s i v e w e i g h t s f o r h e i g h t ; 39% i n both groups B and C. Les s than 10% of women i n each i n t e r v e n t i o n group were pregnant a t p r e t e s t : 6% i n group A, 4% i n group B, and none i n group C, where 71% of women were post-menopausal. The m a j o r i t y of women i n each i n t e r v e n t i o n group c o n s i d e r e d themselves "aware" or "very aware" of o s t e o p o r o s i s a t p r e t e s t : 75% i n group A; 67% i n group B; and 74% i n group C. Groups were not s i g n i f i c a n t l y d i f f e r e n t on t h i s v a r i a b l e . C h i - s q u a r e a n a l y s i s of the s e l e c t e d biodemographic v a r i a b l e s among the t h r e e i n t e r v e n t i o n groups r e v e a l e d few d i s t r i b u t i o n s which were s i g n i f i c a n t l y d i f f e r e n t from those expected.. Three v a r i a b l e s were s i g n i f i c a n t l y d i f f e r e n t among the t h r e e groups: age; adequacy of p r e t e s t d i e t a r y c a l c i u m i n t a k e and use of a c a l c i u m - c o n t a i n i n g supplement. T a b l e 10 l i s t s s e l e c t e d biodemographic v a r i a b l e s c o l l e c t e d a t p o s t t e s t , w i t h i n each of the t h r e e i n t e r v e n t i o n groups. The f o u r v a r i a b l e s were: use of a c a l c i u m -c o n t a i n i n g supplement; p a r t i c i p a n t ' s p e r c e i v e d need t o i n c r e a s e her p r e t e s t d i e t a r y c a l c i u m i n t a k e ; s e a s o n a l v a r i a t i o n i n m i l k or m i l k p r o d u c t i n t a k e and pregnancy s t a t u s . Ten p e r c e n t or fewer of the women i n each group were pregnant a t p o s t t e s t : 10% i n group A; 2% i n group B, and none i n group C. The p e r c e n t a g e s f o r groups A and B changed 115 T a b l e 10: D i s t r i b u t i o n of p o s t t e s t p a r t i c i p a n t s (n=106) by biodemographic v a r i a b l e s , w i t h i n i n t e r v e n t i o n groups I n t e r v e n t i o n Biodemographic V a r i a b l e s Form A^ - Form B^ Controls-Use of a c a l c i u m - c o n t a i n i n g supplement Yes 16 (50) 17 (37) 12 (46) No 15+1 (47+3) 2 29 (63) 14 (54) (m=0) 3 (m=2) (m=0) Adequacy of c a l c i u m i n t a k e Yes 19 (68) 37 (82) 20 (80) No 9 (32) 8 (18) 5 (20) (m=4) (m=3) (m=l) P e r c e i v e d need to i n c r e a s e c a l c i u m i n t a k e ( s e l f r e p o r t ) Yes 15 (58) 12 (27) N/A 4 No 11 ( 4 2 ) * 32 ( 7 3 ) * N/A (m=6) (m=4) Seasonal v a r i a t i o n i n m i l k and m i l k product i n t a k e Yes 6 (19) 11 (23) 1 (4) No 26 (81) 37 (77) 25 (96) (m=0) (m=0) (m=0) Pregnant Yes 3 (10) 1 (2) 0 (0) No 28 (90) 47 (98) 26 (100) U = l ) (m=0) (m=0) * p e r c e n t a g e s i n parentheses 2 T h i s c a t e g o r y i n c l u d e s i n d i v i d u a l s who r e p o r t e d they d i d not use a c a l c i u m -c o n t a i n i n g supplement and those who were not sure t h e i r supplement c o n t a i n e d c a l c i u m . 3 M i s s i n g v a l u e s 4 N/A - not a p p l i c a b l e * s i g n i f i c a n t d i f f e r e n c e s among groups at the p<0.05 l e v e l by C h i - s q u a r e a n a l y s i s 116 n o n - s i g n i f i c a n t l y from p r e - t o p o s t t e s t . The m a j o r i t y of women r e p o r t e d t h a t t hey d i d not v a r y t h e i r d i e t a r y i n t a k e of m i l k or m i l k p r o d u c t s a t d i f f e r e n t t i m e s of the y e a r . The percentage of women who r e p o r t e d v a r i a t i o n i n use were: 19% i n group A; 23% i n group B and 4% i n group C. S i n c e the m a j o r i t y of women a t p o s t t e s t r e p o r t e d r e l a t i v e l y s t a b l e m i l k and m i l k p r o d u c t p r a c t i c e s , i t was u n l i k e l y t h a t s e a s o n a l v a r i a t i o n might a c c o u n t f o r changes i n i n t a k e from p r e - t o p o s t t e s t . The p r o p o r t i o n of women u s i n g a supplement w i t h i n each i n t e r v e n t i o n group changed n o n - s i g n i f i c a n t l y from p r e t e s t t o p o s t t e s t . Fewer women i n groups A and C used a supplement a t p o s t t e s t : 52% v e r s u s 50%; and 53% v e r s u s 46%, r e s p e c t i v e l y . S l i g h t l y more women i n group B r e p o r t e d u s i n g a supplement a t p o s t t e s t : 35% v e r s u s 37%. The change i n supplement use r e s u l t e d from a change i n the c o m p o s i t i o n of each i n t e r v e n t i o n group from p r e - t o p o s t t e s t . The p r o p o r t i o n of women u s i n g supplements remained s t a b l e among women who a t t e n d e d both p r e - and p o s t t e s t . Because of w i t h i n - g r o u p changes i n r e p o r t e d use of c a l c i u m - c o n t a i n i n g supplements, i n t e r v e n t i o n groups were no l o n g e r s i g n i f i c a n t l y d i f f e r e n t on t h i s v a r i a b l e a t p o s t t e s t . S i g n i f i c a n t l y fewer women i n group B r e p o r t e d a s e l f -p e r c e i v e d need t o i n c r e a s e t h e i r p r e t e s t d i e t a r y c a l c i u m i n t a k e : 27% v e r s u s 58% i n group A. Only the two i n t e r v e n t i o n groups which performed a s e l f - a s s e s s m e n t of t h e i r d i e t a r y c a l c i u m i n t a k e , groups A and B, were asked t h i s q u e s t i o n . The responses of both groups were c o n s i s t e n t 1 17 w i t h the p r o p o r t i o n of women whose p r e t e s t d i e t a r y c a l c i u m i n t a k e s were below the Recommended N u t r i e n t I n t a k e l e v e l s : 48% i n group A and 28% i n group B. Si n c e a l l t h r e e study hypotheses were t e s t e d u s i n g d a t a from p a r t i c i p a n t s who a t t e n d e d both p r e - and p o s t t e s t , C h i - s q u a r e a n a l y s e s on the p r e t e s t biodemographic v a r i a b l e s were performed w i t h these p a r t i c i p a n t s (Table 11). D i s t r i b u t i o n s of women w i t h i n groups on the biodemographic v a r i a b l e s were s i m i l a r t o tho s e p r e s e n t e d f o r a l l p a r t i c i p a n t s . The o n l y v a r i a b l e upon which groups d i f f e r e d s i g n i f i c a n t l y was adequacy of p r e t e s t d i e t a r y c a l c i u m i n t a k e . S i g n i f i c a n t l y fewer women i n group B had inadequate s e l f - r e p o r t e d d i e t a r y c a l c i u m i n t a k e s at p r e t e s t : 23% i n group B v e r s u s 55% i n group A and 42% i n group C. Of note i s the f a c t t h a t among these p a r t i c i p a n t s , i n t e r v e n t i o n group C no l o n g e r c o n s i s t e d of a s i g n i f i c a n t l y g r e a t e r p r o p o r t i o n of post-menopausal women. In summary, p a r t i c i p a n t s v a r i e d l i t t l e among the t h r e e i n t e r v e n t i o n groups and shared many c h a r a c t e r i s t i c s . Most of the women who took p a r t i n t h i s study tended t o : be postmenopausal; consume adequate amounts of d i e t a r y c a l c i u m a t p r e t e s t ; be unemployed; have r e c e i v e d p o s t - s e c o n d a r y e d u c a t i o n and c o n s i d e r t h e m s e l v e s aware of o s t e o p o r o s i s . In a d d i t i o n , many of the stu d y p a r t i c i p a n t s took p a r t i n f i t n e s s a c t i v i t i e s a t t h e i r r e s p e c t i v e community c e n t r e s . A few p o i n t s s h o u l d be d i s c u s s e d r e l a t i v e t o the study sample. The f a c t t h a t most women who p a r t i c i p a t e d were 118 T a b l e 11: D i s t r i b u t i o n of p a r t i c i p a n t s who attended both pre- and p o s t t e s t (n=106) by biodemographic v a r i a b l e s w i t h i n i n t e r v e n t i o n groups Biodemographic V a r i a b l e s Form A 1 I n t e r v e n t i o n Form B 1 C o n t r o l J Age 49 or l e s s over 49 Employed Yes No E d u c a t i o n h i g h s c h o o l or l e s s post secondary A l l e r g y or i n t o l e r a n c e to m i l k or m i l k products Yes No Use of a c a l c i u m -c o n t a i n i n g supplement Yes No Weight f o r h e i g h t underweight s a t i s f a c t o r y overweight Use of a s p e c i a l d i e t Yes No Pregnant Yes No Awareness of o s t e o p o r o s i s low h i g h Adequacy of c a l c i u m i n t a k e Yes No 18 (56) 14 (44) (m=0) 2 13 (42) 18 (58) (m=l) 9 (28) 23 (72) (m=0) 3 (10) 27 (90) (m=2) 14 (47) 16 (53) (m=2) 10 (31) 13 (41) 9 (28) (m=0) 9 (28) 23 (72) (m=0) 2 (7) 29 (93) (m=l) 4 (13) 27 (87) (m=l) 13 (45) 16 ( 5 5 ) * (m=3) 23 (48) 25 (52) (m=0) 14 (30) 32 (70) (m=2) 16 (33) 32 (67) (m=0) 4 (10) 37 (90) (m=7) 17 (39) 27 (61) (m=4) 12 (25) 18 (37) 18 (38) (m=0) 11 (23) 36 (77) (m=l) 2 (4) 45 (96) (m=l) 10 (21) 37 (79) (m=l) 34 (77) 10 ( 2 3 ) * (m=4) 8 (33) 16 (67) (m=2) 6 (25) 18 (75) (m=2) 10 (42) 14 (58) (m=2) 2 (8) 23 (92) (m=l) 12 (46) 14 (54) (m=0) 5 (19) 11 (42) 10 (39) (m=0) 7 (27) 19 (73) (m=0) 0 (0) 25 (100) (m=l) 9 (35) 17 (65) (m=0) 15 (58) 11 ( 4 2 ) * (m=0) * p e r c e n t a g e s i n parentheses 2 m i s s i n g v a l u e s 3 s i g n i f i c a n t d i f f e r e n c e s among groups at p<0.01 l e v e l by C h i - s q u a r e a n a l y s i s 119 postmenopausal may be due t o the f a c t t h a t : (1) thes e o l d e r women were more a v a i l a b l e t o come t o the workshops, s i n c e most workshops were h e l d d u r i n g the day, or (2) they may be more i n t e r e s t e d i n t a k i n g a c t i o n t o reduce t h e i r r i s k f o r o s t e o p o r o s i s than younger women. O s t e o p o r o s i s may appear more imminent t o o l d e r women d e s p i t e the f a c t t h a t the p r e v e n t i o n p o t e n t i a l f o r d i e t a r y c a l c i u m appears g r e a t e s t p r i o r t o the menopause (Heaney e t a l . 1978). A l s o , the m a j o r i t y of women had l i m i t e d p o t e n t i a l f o r improvements i n t h e i r d i e t a r y c a l c i u m i n t a k e r e l a t i v e t o the Recommended N u t r i e n t I n t a k e . However, p o t e n t i a l f o r changes above the r e l a t i v e l y low p r e s e n t recommended l e v e l was p o s s i b l e w i t h i n a l l t h r e e groups. In g e n e r a l , p a r t i c i p a n t s i n the study appeared t o be d i s p l a y i n g r i s k - r e d u c i n g b e h a v i o u r c o n s i s t e n t w i t h a m o t i v a t e d , aware consumer. C o n s e q u e n t l y , women i n t h i s s tudy were not n e c e s s a r i l y t y p i c a l of the g e n e r a l p o p u l a t i o n of Canadian women. Comparison of P a r t i c i p a n t s by E x t e n t of P a r t i c i p a t i o n T a b l e 12 p r o v i d e s a comparison of p a r t i c i p a n t s who a t t e n t e d b oth the p r e - and p o s t t e s t s e s s i o n s w i t h those who a t t e n d e d o n l y the p r e t e s t , on p r e t e s t biodemographic v a r i a b l e s . More women who r e t u r n e d f o r p o s t t e s t were younger; employed; b e t t e r e ducated; made s l i g h t l y l e s s use of c a l c i u m - c o n t a i n i n g supplements; made l e s s use of a s p e c i a l d i e t ; were more aware of o s t e o p o r o s i s , and consumed 1 20 T a b l e 12: D i s t r i b u t i o n of p r e t e s t p a r t i c i p a n t s on s e l e c t e d biodemographic v a r i a b l e s , based on extent of p a r t i c i p a t i o n S e l e c t e d biodemographic v a r i a b l e s P a r t i c i p a t i o n  P r e - and P r e t e s t o n l y P o s t t e s t Age 49 or l e s s 50 ( 3 9 ) 1 49 (47) over 49 78 (61) 55 (53) (m=7) 2 (m=2) Employed Yes 29 (25) 33 (33) No 89 (75) 68 (67) (m=17) (m=5) i d u c a t i o n h i g h s c h o o l or l e s s 65 ( 5 3 ) * 35 (34) post secondary 57 (47) 69 (66) (m=13) (m=2) A l l e r g y or i n t o l e r a n c e to m i l k or m i l k p r o d u c t s Yes 12 (10) 9 (9) No 103 (90) 87 (91) (m=20) (m=10) Use of a c a l c i u m -c o n t a i n i n g supplement Yes 52 (47) 43 (43) No 59 (53) 57 (57) (m=24) (m=6) Weight f o r h e i g h t underweight 32 (26) 27 (25) s a t i s f a c t o r y 41 (34) 42 (40) overweight 49 (40) 37 (35) (m=13) (m=0) Use of a s p e c i a l d i e t Yes 40 (33) 27 (26) No 82 (67) 78 (74) (m=13) (m=l) Pregnant Yes 4 (3) 4 (4) No 114 (97) 99 (96) (m=17) (m=3) Awareness of o s t e o p o r o s i s low 42 (34) 23 (22) h i g h 83 (66) 87 (78) (m=10) (m=2) Adequacy of c a l c i u m i n t a k e Yes 65 (59) 62 (63) No 45 (41) 37 (37) (m=25) (m=7) 1 percentages i n parentheses 2 m i s s i n g v a l u e s * s i g n i f i c a n t d i f f e r e n c e s among groups at p<005 level, by Chi-square a n a l y s i s 121 adequate p r e t e s t d i e t a r y c a l c i u m i n t a k e s . The m a j o r i t y of th e s e d i f f e r e n c e s were not s i g n i f i c a n t , however. C h i - s q u a r e a n a l y s i s r e v e a l e d t h a t t h e s e two types of p a r t i c i p a n t s d i f f e r e d s i g n i f i c a n t l y on o n l y one v a r i a b l e : h i g h e s t l e v e l of e d u c a t i o n . More women who p a r t i c i p a t e d i n both s e s s i o n s had r e c e i v e d p o s t - s e c o n d a r y e d u c a t i o n . Perhaps both problem s o l v i n g and non-problem s o l v i n g workshops appealed t o more educated women. I t i s p o s s i b l e t h a t the l e v e l of language used by the f a c i l i t a t o r or i n the m a t e r i a l s t h e m s e l v e s , was more a p p e a l i n g t o those w i t h a h i g h e r e d u c a t i o n . The problem s o l v i n g m a t e r i a l s , by t h e i r v e r y d e s i g n , n e c e s s i t a t e c e r t a i n r e a d i n g , w r i t i n g and ma t h e m a t i c a l a b i l i t i e s which may have d i s c o u r a g e d l e a r n e r s weaker i n those s k i l l s . The r a t e of a t t r i t i o n , however, was comparable among a l l t h r e e i n t e r v e n t i o n g roups: 58% i n group A; 55% i n group B; and 56% i n group C. I t i s t h e r e f o r e , u n l i k e l y t h a t the n a t u r e of problem s o l v i n g v e r s u s non-problem s o l v i n g m a t e r i a l s a f f e c t e d r e t e n t i o n . I t i s p o s s i b l e t h a t women w i t h h i g h e r l e v e l s of e d u c a t i o n were more m o t i v a t e d t o pursue h e a l t h - r e l a t e d b e h a v i o u r s . The p o s s i b i l i t y a l s o remains, however, t h a t the d a t a c o l l e c t i o n i n s t r u m e n t s , which i n v o l v e d r e a d i n g and w r i t i n g s k i l l s , may have d e t e r r e d l e s s educated p a r t i c i p a n t s from r e t u r n i n g t o complete the p o s t t e s t q u e s t i o n n a i r e . 1 22 R e l i a b i l i t y of the Measurement S c a l e s I n t e r n a l c o n s i s t e n c y of the measurement s c a l e s was c a l c u l a t e d u s i n g Cronbach's a l p h a . The a c c e p t a b l e l e v e l of a l p h a chosen f o r t h i s study was 0.70, based upon the recommentations of N u n a l l y (1967). The S e l f - E s t e e m S c a l e Table 13 l i s t s the c o e f f i c i e n t s of r e l i a b i l i t y f o r the o v e r - a l l s e l f - e s t e e m s c a l e , as w e l l as i t s s u b s c a l e s , a t both p i l o t t e s t and i n the a c t u a l s t u d y . At p i l o t t e s t i n g , a l l t h r e e s u b s c a l e s and the o v e r - a l l s e l f - e s t e e m s c a l e had r e l i a b i l i t y c o e f f i c i e n t s of a t l e a s t 0.70. In the a c t u a l s t u d y , a l l c o e f f i c i e n t v a l u e s d e c r e a s e d . In a d d i t i o n one s u b s c a l e , "SOCIAL" had an u n a c c e p t a b l e r e l i a b i l i t y c o e f f i c i e n t of 0.43. The drop i n v a l u e of the r e l i a b i l i t y c o e f f i c i e n t s from p i l o t t o a c t u a l a d m i n i s t r a t i o n may be due t o two main so u r c e s of v a r i a t i o n : (1) s u b j e c t response v a r i a t i o n s i n c e d i f f e r e n t groups of women used the s c a l e f o r the p i l o t v e r s u s a c t u a l a p p l i c a t i o n and (2) v a r i a t i o n s i n t e s t a d m i n i s t r a t i o n , s i n c e at the p i l o t t e s t , the s c a l e was a d m i n i s t e r e d a l o n e , whereas i n the st u d y , women completed the s c a l e as p a r t of the p o s t t e s t q u e s t i o n n a i r e . C a u t i o n s h o u l d be a p p l i e d i n i n t e r p r e t i n g r e s u l t s a s s o c i a t e d w i t h the s o c i a l s e l f - e s t e e m s u b s c a l e due t o i t s low r e l i a b i l i t y . Concern over t h i s s u b s c a l e has a l s o been e x p r e s s e d by Ludwig et a l . (1981). In a d m i n i s t e r i n g the 123 T a b l e 13: I n t e r n a l c o n s i s t e n c y c o e f f i c i e n t s f o r the s e l f - e s t e e m s c a l e at p i l o t t e s t i n g and i n the a c t u a l study S c a l e Cronbach's c o e f f i c i e n t of r e l i a b i l i t y p i l o t sample study sample (n=47) (n=46) GENERAL (16 items) 0.84 0.77 PERSONAL (8 items) 0.76 0.74 SOCIAL (8 items) 0.80 0.43 O v e r - a l l (32 items) 0.90 0.82 124 s e l f - e s t e e m s c a l e t o 56 female nurses i n C i n c i n n a t i , the c o e f f i c i e n t of r e l i a b i l i t y f o r the s o c i a l s u b s c a l e was o n l y 0.20, d e s p i t e a c c e p t a b l e a l p h a s f o r the o v e r - a l l s c a l e and i t s two o t h e r s u b s c a l e s . The A t t i t u d e S c a l e Table 14 l i s t s the c o e f f i c i e n t s of r e l i a b i l i t y f o r the o v e r - a l l a t t i t u d e s c a l e and i t s t h r e e s u b s c a l e s a t p r e - and p o s t t e s t . C o e f f i c i e n t v a l u e s i n c r e a s e d s l i g h t l y from p r e - t o p o s t t e s t . Only f o r the a t t i t u d e s u b s c a l e "DIET" d i d the v a l u e of a l p h a d e c r e a s e . The g e n e r a l i n c r e a s e i n r e l i a b i l i t y c o e f f i c i e n t s a t p o s t t e s t i s c o n s i s t e n t w i t h r e p o r t s of o t h e r s . Brush e t a l . (1986) r e p o r t e d p r e t e s t r e l i a b i l i t y f o r an a t t i t u d e s c a l e of 0.70, which i n c r e a s e d to 0.80 a t p o s t t e s t . A second exposure t o t h e q u e s t i o n s and response s c a l e o f t e n e n a b l e s p a r t i c i p a n t s t o respond s l i g h t l y more c o n s i s t e n t l y as a group (Henerson et a l . 1978). At p r e t e s t , two s c a l e s f e l l s h o r t of an a c c e p t a b l e l e v e l of i n t e r n a l c o n s i s t e n c y : the o v e r - a l l a t t i t u d e s c a l e (<X=0.66) and i t s s u b s c a l e "RELATIONSHIP" ( o< =0.33). The r e l i a b i l i t y c o e f f i c i e n t of the o v e r - a l l a t t i t u d e s c a l e was v e r y c l o s e t o 0.70 a t p r e t e s t and a c t u a l l y i n c r e a s e d t o 0.70 at p o s t t e s t . The s u b s c a l e "RELATIONSHIP" however appeared u n r e l i a b l e a t both p r e - and p o s t t e s t (<*=0.40). T h e r e f o r e , c a u t i o n need be a p p l i e d i n i n t e r p r e t i n g r e s u l t s r e l a t e d t o 1 25 T a b l e 14: I n t e r n a l c o n s i s t e n c y c o e f f i c i e n t s f o r the a t t i t u d e s c a l e at p r e - and p o s t t e s t S c a l e Cronbach's c o e f f i c i e n t of r e l i a b i l i t y p r e t e s t sample p o s t e s t sample (n=200) (n=98) DIET AS A SOURCE OF CALCIUM (3 items) 0.80 0.79 PERSONAL RISK FOR OSTEOPOROSIS (3 items) 0.70 0.73 RELATIONSHIP BETWEEN DIETARY CALCIUM AND THE RISK OF OSTEOPOROSIS (3 items) 0.33 0.40 O v e r - a l 1 (9 items) 0.66 0.70 126 t h i s s u b s c a l e . A l l o t h e r p o s t t e s t c o e f f i c i e n t s of r e l i a b i l i t y met, or exceeded, 0.70. The P e r c e p t i o n S c a l e T a b l e 15 l i s t s the c o e f f i c i e n t s of r e l i a b i l i t y f o r the t o t a l p e r c e p t i o n s c a l e and i t s s u b s c a l e s a t p r e - and p o s t t e s t . C o e f f i c i e n t s f o r the o v e r - a l l p e r c e p t i o n s c a l e and i t s s u b s c a l e s i n c r e a s e d a t p o s t t e s t , c o n s i s t e n t w i t h r e s u l t s from the a t t i t u d e s c a l e . At p r e t e s t , two p e r c e p t i o n s u b s c a l e s had r e l i a b i l i t y c o e f f i c i e n t s below 0.70: "GOAL PLANNING" ( <X =0.44) and "GOAL ACHIEVEMENT" (oc=0.55). At p o s t t e s t , the l a t t e r s u b s c a l e ' s r e l i a b i l i t y i n c r e a s e d t o 0.64, whereas the former s u b s c a l e ' s r e l i a b i l i t y remained v e r y low, a t 0.46. C a u t i o n i s t h e r e f o r e w a r r a n t e d i n e x p l o r i n g r e s u l t s r e l a t e d t o e i t h e r of these s u b s c a l e s , e s p e c i a l l y s u b s c a l e "GOAL PLANNING". The c o e f f i c i e n t of r e l i a b i l i t y f o r the o v e r - a l l p e r c e p t i o n s c a l e though, appeared more than s a t i s f a c t o r y at both p r e t e s t («* =0.79) and p o s t t e s t ( <x =0.82). D i f f e r e n c e s Among I n t e r v e n t i o n Groups on P r e t e s t  Dependent V a r i a b l e s T a b l e 16 l i s t s the mean ± s t a n d a r d d e v i a t i o n s f o r the p o o l e d p r e t e s t v a l u e s of t h e dependent v a r i a b l e s by i n t e r v e n t i o n group. The dependent v a r i a b l e s were: d i e t a r y c a l c i u m i n t a k e ; a t t i t u d e toward d i e t a r y c a l c i u m and o s t e o p o r o s i s and p e r c e p t i o n of problem s o l v i n g a b i l i t y . 127 T a b l e 15: I n t e r n a l c o n s i s t e n c y c o e f f i c i e n t s f o r the p e r c e p t i o n s c a l e at p r e - and p o s t t e s t S c a l e Cronbach's c o e f f i c i e n t of r e l i a b i l i t y p r e t e s t sample p o s t t e s t sample (n=205) (n=99) GOAL IDENTIFICATION (3 items) 0. .70 0. .79 GOAL PLANNING (3 items) 0. ,44 0. ,46 GOAL ACHIEVEMENT (3 items) 0. .55 0. .64 O v e r - a l 1 (9 items) 0. ,79 0. .82 128 Table 16: Comparison of mean p r e t e s t v a l u e s f o r the dependent v a r i a b l e s , by i n t e r v e n t i o n group Dependent V a r i a b l e s I n t e r v e n t i o n Form A Form B C o n t r o l D i e t a r y c a l c i u m i n t a k e (mg/d) 939 ± 843 1 (n=64) 2 1109 ± 610 (n=87) 856 ± 572 (n=59) A t t i t u d e toward d i e t a r y c a l c i u m and o s t e o p o r o s i s (maximum s c o r e = 45) 30 ± 5 (n=69) 31 + 5 (n=82) 29 + 5 (n=49) S u b s c a l e s : DIET AS A SOURCE OF CALCIUM (maximum s c o r e = 15) 9 ± 3 (n=72) 9 + 3 (n=87) 9 + 3 (n=53) PERSONAL RISK FOR OSTEOPOROSIS (maximum score = 15) 8 ± 3 (n=72) 9 ± 2 (n=85) 8 + 3 (n=52) RELATIONSHIP BETWEEN DIETARY CALCIUM AND THE RISK OF OSTEOPOROSIS (maximum score = 15) 13 ± 2 (n=71) 12 + 2 (n=94) 1 3 + 2 (n=54) P e r c e p t i o n of problem s o l v i n g a b i l i t y (maximum s c o r e = 4 5 ) 36 ± 5 (n=70) 35 ± 4 (n=84) 35 + 6 (n=51) S u b s c a l e s : PROBLEM IDENTIFICATION (maximum s c o r e = 15) 12 ± 6 (n=75) 12 + 2 (n=90) 12 ± 3 (n=55) GOAL PLANNING (maximum score = 15) 12 ± 2 (n=71) 11 ± 1 (n=89) 12 + 2 (n=53) GOAL ACHIEVEMENT (maximum s c o r e = 15) 12 ± 2 (n=73) 11 ± 2 (n=89) 12 + 2 (n=52) *• mean +• standard d e v i a t i o n 2 sample s i z e s i n parentheses a, a: I d e n t i c a l l e t t e r s denote s i g n i f i c a n t d i f f e r e n c e s among groups at t h e 0.05 l e v e l 129 Group B r e p o r t e d a h i g h e r mean d i e t a r y c a l c i u m i n t a k e (1109 + 6 1 0 mg/d) compared to group A (939 + 843 mg/d) and group C (856 ± 572 mg/d), though d i f f e r e n c e s among groups were not s i g n i f i c a n t by one-way a n a l y s i s of v a r i a n c e . D e s p i t e group C's o l d e r mean age, women i n t h i s group d i d not d i s p l a y s i g n i f i c a n t d i f f e r e n c e s i n p r e t e s t d i e t a r y b e h a v i o u r . The s e l f - r e p o r t e d d i e t a r y c a l c i u m i n t a k e s a r e a l l i n excess of the mean r e p o r t e d i n t a k e s of Canadian women i n the N u t r i t i o n Canada (1973) s u r v e y . They more c l o s e l y resemble i n t a k e s r e p o r t e d f o r a more educated group: 881+292 mg/d f o r female h i g h s c h o o l t e a c h e r s ( S k i n n e r and Woodburn 1986); or 1049±525 mg/d f o r a group of women h a v i n g 3 t o 4 y e a r s of po s t - s e c o n d a r y e d u c a t i o n ( L u t z 1986). I t i s a l s o p o s s i b l e t h a t d i e t a r y c a l c i u m i n t a k e s of women have i n c r e a s e d i n the decade between 1973 and 1983. Of a maximum p o s s i b l e s c o r e of 45, group A had a mean o v e r - a l l a t t i t u d e s c o r e of 30 ± 5; group B, 31 + 5 and group C, 29 + 5. The a t t i t u d e s u b s c a l e "RELATIONSHIP" had h i g h e r mean v a l u e s w i t h i n each i n t e r v e n t i o n group than d i d e i t h e r of the two o t h e r s u b s c a l e s . Groups were not s i g n i f i c a n t l y d i f f e r e n t , however, on these v a r i a b l e s . On the o v e r - a l l p e r c e p t i o n s c o r e , of a maximum p o s s i b l e of 45, group A had a n o n - s i g n i f i c a n t l y h i g h e r s c o r e of 36 + 5 v e r s u s 35 ± 4 i n group B and 35 ± 6 i n group C. A l l t h r e e s u b s c a l e s had h i g h mean v a l u e s , among a l l t h r e e i n t e r v e n t i o n groups. 130 One-way a n a l y s i s of v a r i a n c e among the t h r e e groups on the dependent v a r i a b l e s r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e s . I t c o u l d t h e r e f o r e be assumed t h a t the t h r e e groups were comparable on mean v a l u e s of the p r e t e s t dependent v a r i a b l e s . T a ble 17 p r o v i d e s a comparison of the mean p r e t e s t v a l u e s , ± s t a n d a r d d e v i a t i o n s , f o r the dependent v a r i a b l e s between women who took p a r t i n both the p r e - and p o s t t e s t s e s s i o n s and those who a t t e n d e d o n l y the p r e t e s t . One-way a n a l y s i s of v a r i a n c e between the two t y p e s of p a r t i c i p a n t s r e v e a l e d a s i g n i f i c a n t d i f f e r e n c e among groups on p r e t e s t p e r c e p t i o n of problem s o l v i n g a b i l i t y . P a r t i c i p a n t s who r e t u r n e d f o r p o s t t e s t had s i g n i f i c a n t l y h i g h e r p r e t e s t s c o r e s on p e r c e p t i o n of problem s o l v i n g a b i l i t y . I n t e r v e n t i o n , r e g a r d l e s s of t y p e , may have a p p e a l e d t o those w i t h h i g h e r l e v e l s of p e r c e p t i o n of problem s o l v i n g a b i l i t y . In g e n e r a l though, a b i a s on the dependent v a r i a b l e s , due t o a t t r i t i o n , seemed u n l i k e l y . For a l l t h r e e r e s e a r c h q u e s t i o n s , and t h e i r accompanying h y p o t h e s e s , r e s u l t s from d a t a a n a l y s i s a re r e p o r t e d a t the 0.05 l e v e l of s i g n i f i c a n c e u n l e s s o t h e r w i s e s p e c i f i e d . R e search q u e s t i o n s were answered by t e s t i n g t h e i r r e s p e c t i v e hypotheses ( l i s t e d i n Chapter I ) . For Research Q u e s t i o n 1 D i d forms A and B of the 'Calcium C a l c u l a t o r ' produce s i g n i f i c a n t l y d i f f e r e n t impacts on women's 131 Table 17: Comparison of mean p r e t e s t v a l u e s f o r the dependent v a r i a b l e s , by extent of p a r t i c i p a t i o n Dependent V a r i a b l e s P a r t i c i p a t i o n D i e t a r y C a l c i u m Intake (mg/d) A t t i t u d e toward d i e t a r y c a l c i u m and o s t e o p o r o s i s (maximum s c o r e = 45) P r e t e s t o n l y 992 ± 770 1 ( n = l l l ) 2 30 ± 5 (n=104) Pre-and P o s t t e s t 979 ± 546 (n=99) 31 ± 5 (n=96) Su b s c a l e s : DIET AS A SOURCE OF CALCIUM (maximum s c o r e = 15) PERSONAL RISK FOR OSTEOPOROSIS (maximum score = 1 5 ) RELATIONSHIP BETWEEN DIETARY CALCIUM AND THE RISK OF OSTEOPOROSIS (maximum score = 15) P e r c e p t i o n of problem s o l v i n g a b i l i t y (maximum s c o r e = 4 5 ) 9 ± 3 (n=112) 9 ± 3 (n=110) 12 ± 2 (n=115) 35 ± 5 a (n=108) 9 ± 3 (n=100) 9 ± 2 (n=99) 13 ± 2 (n=104) 36 ± 4 a (n=97) S u b s c a l e s : PROBLEM IDENTIFICATION (maximum s c o r e = 15) GOAL PLANNING (maximum score = 15) GOAL ACHIEVEMENT (maximum s c o r e = 15) 12 ± 2 (n=117) 11 ± 2 (n=117) 11 ± 2 (n=114) 12 ± 2 (n=103) 12 ± 1 (n=100) 12 ± 2 (n=100) 1 mean ± standard d e v i a t i o n 2 sample s i z e s i n parentheses a,a: I d e n t i c a l l e t t e r s denote s i g n i f i c a n t d i f f e r e n c e s among groups at the 0.05 l e v e l . 132 a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s ; p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t y and d i e t a r y p r a c t i c e s ? D i d forms A and B of the 'Calcium C a l c u l a t o r ' produce s i g n i f i c a n t l y d i f f e r e n t impacts on women's a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s ; p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t y and t h e i r d i e t a r y p r a c t i c e s , when compared t o impacts produced by the c o n t r o l m a t e r i a l ? H y p o t h e s i s 1.1 and 1.4: Impacts on D i e t a r y C a l c i u m I n t a k e Table 18 l i s t s p r e - and p o s t t e s t d i e t a r y c a l c i u m i n t a k e s , ± s t a n d a r d d e v i a t i o n s , by i n t e r v e n t i o n group. For p o o l e d matched d a t a , the p r e t e s t mean ± s t a n d a r d d e v i a t i o n s i n mg/d per i n t e r v e n t i o n group were: A, 741 ± 456; B, 1214 ± 581; and C, 913 + 483. Groups A and C had i n c r e a s e d mean p o s t t e s t i n t a k e s , though the i n c r e a s e was o n l y s i g n i f i c a n t i n group C. I n t e r v e n t i o n group B e x p e r i e n c e d a n o n - s i g n i f i c a n t d e c r ease i n mean p o s t t e s t d i e t a r y c a l c i u m i n t a k e from p r e - t o p o s t t e s t . For "below RNI" d a t a , s i g n i f i c a n t i n c r e a s e s from p r e -t o p o s t t e s t o c c u r r e d w i t h i n a l l t h r e e i n t e r v e n t i o n groups: group A ( t = -2.76, df = 8 ) ; group B ( t = -3.47, df = 8, p < 0.01); and group C ( t = -3.71, df = 10, p < 0.01). The i n c r e a s e i n "below RNI" i n t a k e i n group A r e s u l t e d i n a mean i n t a k e g r e a t e r than the Recommended N u t r i e n t I n t a k e f o r pre-menopausal women: 414 ± 240 t o 750 ± 395 1 33 T a b l e 18: Comparison of p r e - and p o s t t e s t v a l u e s f o r mean d i e t a r y c a l c i u m i n t a k e w i t h i n i n t e r v e n t i o n groups C a l c i u m p r e t e s t i n t a k e * p o s t t e s t t Degrees o f Freedom P I n t e r v e n t i o n Group A A l l pooled data 741 ± 456 (n=26) 908 ± 433 (n=26) -1. 85 25 NS 2 Matched 'below RNI 1 d a t a 3 414 ± 240 ( n = l l ) 750 ± 395 ( n = l l ) -2. 76 10 p<0.05 Matched 'at or below NIH' d a t a 4 563 ± 303 (n=16) 773 ± 356 (n=16) -2. 06 15 NS I n t e r v e n t i o n Group B A l l pooled d a t a 1214 ± 581 (n=41) 1170 ± 436 (n=41) 0. 51 40 NS Matched 'below RNI' da t a 551 ± 153 (n=9) 899 ± 292 (n=9) -3. 47 8 p<0.01 Matched 'at or below NIH' dat a 676 ± 219 (n=14) 969 ± 369 (n=14) -2. 96 13 p<_0.01 I n t e r v e n t i o n Group C A l l pooled data 913 ± 483 (n=25) 1167 ± 490 (n=25) -2. 78 24 p<0.01 Matched 'below RNI' d a t a 509 ± 231 ( n = l l ) 884 ± 418 ( n = l l ) -3. 71 10 p<0.01 Matched 'at or below NIH' dat a 596 ± 269 (n=14) 971 ± 465 (n=14) -3. 99 13 p<0.01 mean - standard d e v i a t i o n NS: not s i g n i f i c a n t . P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l -cium i n t a k e was below the Recommended N u t r i e n t I n t a k e P a r t i c i p a n t s not pregnant at pre- o r p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was at or below 1000 mg/d 134 mg/day. Changes i n d i e t a r y c a l c i u m i n t a k e w i t h i n groups B and C r e s u l t e d i n mean p o s t t e s t i n t a k e s i n e x c e s s of the Recommended N u t r i e n t I n t a k e f o r post-menopausal women: group B, 551 + 153 to 899 + 292; group C, 509 + 231 t o 884 + 418. I n c r e a s e s i n d i e t a r y c a l c i u m i n t a k e a l s o o c c u r r e d w i t h i n a l l t h r e e groups when o n l y "at or below NIH" d a t a were e x p l o r e d . The i n c r e a s e s were o n l y s i g n i f i c a n t however, w i t h i n groups A and C. T h e r e f o r e , w i t h i n the t h r e e i n t e r v e n t i o n groups, f o r p a r t i c i p a n t s f o r whom t h e r e was p o t e n t i a l t o i n c r e a s e t h e i r d i e t a r y i n t a k e t o a d i e t a r y s t a n d a r d , s i g n i f i c a n t improvements i n i n t a k e were n o t e d . F i g u r e 5 r e p r e s e n t s the percentage of p a r t i c i p a n t s who a t t e n d e d both p r e - and p o s t t e s t , by i n t e r v e n t i o n group, who had adequate d i e t a r y c a l c i u m i n t a k e s b e f o r e and a f t e r the workshops. A l l t h r e e groups e x p e r i e n c e d an i n c r e a s e i n the p r o p o r t i o n of women consuming adequate i n t a k e s : A, 45% t o 68%; B, 77% t o 82%; and C, 58% t o 80%. The g r e a t e s t i n c r e a s e i n p r o p o r t i o n o c c u r r e d w i t h i n groups A and C. However, groups were not s i g n i f i c a n t l y d i f f e r e n t . T a b l e 19 p r e s e n t s r e s u l t s of comparisons among the t h r e e i n t e r v e n t i o n groups on mean change i n d i e t a r y c a l c i u m i n t a k e from p r e - t o p o s t t e s t . One-way a n a l y s i s of v a r i a n c e was perfomed on the mean change v a l u e s . No s i g n i f i c a n t d i f f e r e n c e s were noted f o r p o o l e d d a t a ; "below RNI" d a t a o r f o r "at or below NIH" d a t a . B a r t l e t t - B o x t e s t s f o r 135 100 — 90 -80 -70 c%; 60 -50 -40 30 -20 -10 -45% n=28 (m=4) 68% n=28 (ra=4) 77% n=45 (m=3) Legend: I 1 » b e f o r e workshop = a f t e r workshop m = m i s s i n g cases 82% n=45 (m=3) 58% n=25 (m=l) 80% n=25 U=l ) I n t e r v e n t i o n GrouDS F i g u r e 5: Percentages of p a r t i c i p a n t s w i t h d i e t a r y c a l c i u m at or above Recommended N u t r i e n t Intake b e f o r e and a f t e r workshops, by i n t e r v e n t i o n group. 136 T a b l e 19: Comparison of change 1 i n d i e t a r y c a l c i u m i n t a k e among i n t e r v e n t i o n groups A, B and C Comparison For pooled d a t a 3.04 NS 2 F o r 'below RNI' d a t a 3 0.04 NS For 'at or below NIH' d a t a 4 0.71 NS Degrees of freedom =2 1 change = p o s t t e s t - p r e t e s t v a l u e 2 not s i g n i f i c a n t at 0.05 l e v e l 3 P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was below the Recommended N u t r i e n t Intake 4 P a r t i c i p a n t s not pregnant at pre- or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was at or below 1000 mg/d 137 homogeneity of v a r i a n c e i n d i c a t e d no s i g n i f i c a n t d i f f e r e n c e s among group v a r i a n c e s . T a ble 20 p r o v i d e s r e s u l t s of "a p r i o r i " c o n t r a s t t e s t s between mean change s c o r e s of group A v e r s u s group B. No s i g n i f i c a n t d i f f e r e n c e s were observed f o r p o o l e d d a t a ; "below RNI" da t a or f o r "at or below NIH" d a t a . A l s o , no s i g n i f i c a n t d i f f e r e n c e s r e s u l t e d from "a p r i o r i " c o n t r a s t t e s t i n g of problem s o l v i n g v e r s u s non-problem s o l v i n g impacts (not shown). In summary, a l l t h r e e i n t e r v e n t i o n s r e s u l t e d i n i n c r e a s e d d i e t a r y c a l c i u m i n t a k e s f o r women whose p r e t e s t i n t a k e s were below the Recommended N u t r i e n t I n t a k e l e v e l . The changes w i t h i n i n t e r v e n t i o n groups A and B from p r e - to p o s t t e s t were n o t , however, s i g n i f i c a n t l y d i f f e r e n t . D e s p i t e the s i g n i f i c a n t i n c r e a s e i n s e l f - r e p o r t e d d i e t a r y c a l c i u m i n t a k e among women i n i n t e r v e n t i o n group C, "a p r i o r i " c o n t r a s t t e s t i n g r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e between impacts produced by peaton et a l . (1983) have r e p o r t e d t h a t i n t r a - i n d i v i d u a l v a r i a b i l i t y i n womens' d i e t a r y c a l c i u m i n t a k e i s g r e a t e r than i n t e r - i n d i v i d u a l v a r i a b i l i t y . T h i s may a l s o , t h e r e f o r e , have c o n t r i b u t e d t o the t o t a l v a r i a b i l i t y and subsequent n o n - s i g n i f i c a n t d i f f e r e n c e i n impact noted among the t h r e e i n t e r v e n t i o n groups. I t has a l s o been suggested t h a t though group d i e t a r y c a l c i u m i n t a k e i s measured more r e l i a b l y than a re o t h e r n u t r i e n t s u s s i n g a t w e n t y - f o u r hour r e c a l l tends t o be h i g h . 1 38 T a b l e 20: Comparison of change* i n d i e t a r y c a l c i u m i n t a k e between i n t e r v e n t i o n groups A and B Degrees of Comparison t Freedom p Form A v s . Form B f o r a l l pooled d a t a 1.67 89 NS 2 Form A v s . Form B f o r 'below RNI 1 d a t a 3 -0.08 28 NS Form A v s . Form B f o r 'at or below -0.61 41 NS NIH 1 d a t a 4 change = p o s t t e s t - p r e t e s t not s i g n i f i c a n t . P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was below the Recommended N u t r i e n t I n t a k e P a r t i c i p a n t s not pregnant at pre- or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was at or below 1000 mg/d 139 For "below RNI" d a t a , p r e t e s t and p o s t t e s t v a r i a b i l i t y as a percentage of the mean was: 58% and 53% f o r group A; 28% and 32% f o r group B; and 45% and 47% f o r group C. P r e t e s t and p o s t t e s t v a r i a b i l i t y w i t h i n groups A and C c l o s e l y resemble the 58% r e p o r t e d by Beaton et a l . (1983). V a r i a b i l i t y w i t h i n group B was c o n s i d e r a b l y l e s s than i n the two o t h e r i n t e r v e n t i o n g roups, a l t h o u g h t e s t s f o r homogeneity of v a r i a n c e s r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e s among a l l t h r e e groups. The h i g h t o t a l v a r i a b i l i t y may have reduced the l i k e l i h o o d of d e t e c t i n g s i g n i f i c a n t l y d i f f e r e n t impacts among the t h r e e i n t e r v e n t i o n groups. In a d d i t i o n , change s c o r e s were c a l c u l a t e d as the sum of the d i f f e r e n c e s i n each woman's i n t a k e from p r e t e s t t o p o s t t e s t . C o n s e q u e n t l y , change s c o r e s a r e e s p e c i a l l y s u b j e c t t o i n t r a - i n d i v i d u a l v a r i a b i l i t y i n i n t a k e . Beaton et a l . (1983) have r e p o r t e d t h a t i n t r a - i n d i v i d u a l v a r i a b i l i t y i n womens' d i e t a r y c a l c i u m i n t a k e i s g r e a t e r than i n t e r - i n d i v i d u a l v a r i a b i l i t y . T h i s may a l s o , t h e r e f o r e , have c o n t r i b u t e d t o the t o t a l v a r i a b i l i t y and subsequent n o n - s i g n i f i c a n t d i f f e r e n c e i n impact noted among the t h r e e i n t e r v e n t i o n groups. I t has a l s o been suggested t h a t though group d i e t a r y c a l c i u m i n t a k e i s measured more r e l i a b l y than a re o t h e r n u t r i e n t s u s i n g a t w e n t y - f o u r hour r e c a l l , two t o f i v e a d m i n i s t r a t i o n s of the i n s t r u m e n t may be n e c e s s a r y t o a c h i e v e maximum p o s s i b l e r e l i a b i l i t y (Rush and K r i s t a l 1982). T h e r e f o r e , r e p e a t e d p r e - and p o s t t e s t a d m i n i s t r a t i o n 1 40 of the t w e n t y - f o u r hour r e c a l l i n s t r u m e n t may have y i e l d e d more p r e c i s e e s t i m a t e s of i n t a k e . R e g a r d l e s s of the i n d i s t i n g u i s h a b l e d i f f e r e n c e s among i n t e r v e n t i o n t y p e s , i n t e r v e n t i o n i n g e n e r a l appeared t o have a f a v o u r a b l e e f f e c t on d i e t a r y c a l c i u m i n t a k e w i t h i n groups. The w i t h i n - g r o u p i n c r e a s e s i n d i e t a r y c a l c i u m i n t a k e s f o r "below RNI" d a t a a r e c o n s i s t e n t w i t h the s i g n i f i c a n t l y improved d i e t a r y b e h a v i o u r o b s e r v e d among a d u l t s exposed to an a f f e c t i v e - b a s e d workshop program on g e n e r a l n u t r i t i o n (Brush et a l . 1986). Both e x p e r i m e n t a l and c o n t r o l groups e x p e r i e n c e d i n c r e a s e d d i e t a r y s c o r e s a t p o s t t e s t f i v e weeks l a t e r , u s i n g a q u a l i t a t i v e l y - s c o r e d t w e n t y - f o u r hour r e c a l l . The m a j o r i t y of n u t r i t i o n e d u c a t i o n i n t e r v e n t i o n s , however, have r e s u l t e d i n n o n - s i g n i f i c a n t improvements i n d i e t a r y b e h a v i o u r a t p o s t t e s t . For i n s t a n c e , pregnant women exposed t o a s e l f - i n s t r u c t i o n a l program i n a d o c t o r ' s o f f i c e e x p e r i e n c e d n o n - s i g n i f i c a n t i n c r e a s e s i n p o s t t e s t d i e t a r y b e h a v i o u r s c o r e s (Daelhousen and G u t h r i e 1982). S c h a f e r (1986) a l s o r e c e n t l y r e p o r t e d n o n - s i g n i f i c a n t improvements i n d i e t a r y b e h a v i o u r of h e a l t h p r o f e s s i o n a l s who took p a r t i n a s e l f - i n s t r u c t i o n a l home stu d y c o u r s e on g e n e r a l n u t r i t i o n . Improvements i n d i e t a r y b e h a v i o u r were o n l y s i g n i f i c a n t i n the e x p e r i m e n t a l group at p i l o t t e s t . T h e r e f o r e , the s i g n i f i c a n t i n c r e a s e s noted among women i n t h i s s tudy who had p r e t e s t d i e t a r y c a l c i u m i n t a k e s below t h e i r Recommended N u t r i e n t I n t a k e most c l o s e l y resemble the r e s u l t s of Brush et a l . (1986). Both study i n t e r v e n t i o n s were s i m i l a r i n t h a t they: (1) a c t i v e l y i n v o l v e d a d u l t 141 l e a r n e r s i n a workshop s e t t i n g and (2) used a n u t r i t i o n e d u c a t o r as f a c i l i t a t o r . However, the workshop employed by Brush et a l . (1986) f o c u s e d p r i m a r i l y on a t t i t u d e , r a t h e r than s k i l l s development. The n o n - s i g n i f i c a n t l y d i f f e r e n t among-group impacts on d i e t a r y c a l c i u m i n t a k e o b s e r v e d i n t h i s s t u d y a r e comparable t o r e s u l t s r e p o r t e d by Daelhousen and G u t h r i e (1982). These r e s e a r c h e r s d e s c r i b e d n o n - s i g n i f i c a n t d i f f e r e n c e s between d i e t a r y b e h a v i o u r s of t h e i r e x p e r i m e n t a l and c o n t r o l groups at p o s t t e s t . The study by B r u s h et a l . (1986) d i d , however, r e v e a l s i g n i f i c a n t l y d i f f e r e n t i n c r e a s e s between the t r e a t m e n t and c o n t r o l groups seven weeks a f t e r p o s t t e s t . The d i f f e r e n c e s , though, had not been s i g n i f i c a n t by p o s t t e s t . The s i g n i f i c a n t among-group d i f f e r e n c e s i n impact r e p o r t e d by Brush et a l . (1986) suggest t h a t perhaps d i f f e r e n c e s may o n l y become s i g n i f i c a n t s e v e r a l weeks a f t e r p o s t t e s t . In t h i s s t u d y , the p o s s i b i l i t y e x i s t s t h e r e f o r e t h a t the n o n - s i g n i f i c a n t among-group d i f f e r e n c e s were due t o : (1) an i n s u f f i c i e n t l y l o n g p e r i o d of o b s e r v a t i o n , or (2) t o p r o p e r t i e s of the d i e t a r y measurement t o o l i t s e l f . Hypotheses 1.2 and 1.5: Impacts on A t t i t u d e Toward D i e t a r y C a l c i u m and O s t e o p o r o s i s  T a b l e s 21, 22 and 23 l i s t p r e - and p o s t t e s t v a l u e s , + s t a n d a r d d e v i a t i o n s , f o r the o v e r - a l l a t t i t u d e s c a l e and i t s s u b s c a l e s by i n t e r v e n t i o n group. 1 42 Table 21: Comparison of pre and p o s t t e s t v a l u e s f o r ATTITUDE TOWARD DIETARY CALCIUM and OSTEOPOROSIS w i t h i n i n t e r v e n t i o n group A ATTITUDE (9 items) p r e t e s t p o s t t e s t t Degrees of p freedom A l l pooled data 31 ± 6 1 (n=27) 32 ± 6 (n-27) -1.75 26 NS 2 A l l 'below RNI' d a t a 3 28 ± 5 (n=10) 29 ± 7 (n=10) -0.98 9 NS A l l 'at or b e l o w 4 NIH' dat a 29 ± 5 (n=15) 31 ± 7 (n-15) -1.72 14 NS S u b s c a l e s : DIET AS A SOURCE OF CALCIUM A l l pooled data 9 ± 3 (n=30) 10 ± 3 (n=30) -1.48 29 NS A l l 'below RNI' d a t a 7 ± 3 ( n = l l ) 8 ± 3 ( n = l l ) -0.98 10 NS A l l 'at or below NIH' dat a 8 ± 3 (n=16) 9 t 3 (n=16) -1.26 15 NS PERSONAL RISK FOR OSTEOPOROSIS A l l pooled data 9 ± 3 (n=29) 9 ± 3 (n=29) 0.92 28 NS A l l 'below RNI' d a t a 7 ± 3 ( n = l l ) 8 + 3 ( n = l l ) 1.69 10 NS A l l 'at or below NIH' dat a 8 ± 2 (n-17) 9 ± 3 (n-17) -2.87 16 p<0.01 RELATIONSHIP BETWEEN DIETARY CALCIUM AND THE RISK OF OSTEOPOROSIS: A l l pooled d a t a 13 ± 2 (n-31) 14 ± 2 (n=31) -1.93 30 NS A l l 'below RNI' d a t a 13 ± 2 (n=12) 13 + 2 (n=12) -0.30 11 NS A l l 'at or below NIH' dat a 13 ± 2 (n=18) 13 ± 2 (n=18) -1.23 17 NS * mean ± standard d e v i a t i o n 2 not s i g n i f i c a n t . 3 P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was below the Recommended N u t r i e n t Intake 4 P a r t i c i p a n t s not pregnant at p r e - o r p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was at or below 1000 mg/d 143 Table 22: Comparison of p r e - and p o s t t e s t v a l u e s f o r ATTITUDE TOWARD DIETARY CALCIUM and OSTEOPOROSIS w i t h i n i n t e r v e n t i o n group B ATTITUDE (9 items) p r e t e s t p o s t t e s t t Degrees of p freedom A l l pooled data 31 ± 5 (n=44) 33 + 5 (n=44) -2 .60 43 p<0.01 A l l 'below RNI' d a t a 2 3 0 + 4 (n=9) 32 ± 5 (n=9) -0 .91 8 NS 3 A l l 'at or below 4 NIH' data 30 ± 5 (n=14) 33 ± 5 (n=14) -1 .72 13 NS S u b s c a l e s : DIET AS A SOURCE OF CALCIUM A l l pooled data 9 ± 2 (n=45) 10 + 3 (n=45) -2 .93 44 p<0.01 A l l 'below RNI' data 9 ± 2 (n=9) 9 ± 3 (n=9) -0 .32 8 NS A l l 'at or below NIH' data 9 ± 2 (n=15) 10 + 3 (n=15) -1 .35 14 NS PERSONAL RISK FOR OSTEOPOROSIS A l l pooled data 9 + 2 (n=44) 9 + 3 (n=44) -0 .58 43 NS A l l 'below RNI' dat a 9 ± 2 (n=9) 9 ± 3 (n=9) -0 .36 8 NS A l l 'at or below NIH' dat a 9 ± 1 (n=14) 9 + 3 (n=14) -0 .87 13 NS RELATIONSHIP BETWEEN DIETARY CALCIUM AND THE RISK OF OSTEOPOROSIS: A l l pooled d a t a 13 ± 2 (n=46) 13 ± 2 . (n=46) -1 .45 45 NS A l l 'below RNI' d a t a 12 ± 2 (n=10) ' 13 ± 2 (n=10) -1 .15 9 NS A l l 'at or below NIH 1 d a t a 13 ± 2 (n=16) 13 ± 2 (n=16) -1 .16 15 NS 1 mean ± standard d e v i a t i o n 2 P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was below the Recommended N u t r i e n t Intake 3 not s i g n i f i c a n t . 4 P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was at or below 1000 mg/d 144 Table 23: Comparison of p r e - and p o s t t e s t v a l u e s for ATTITUDE TOWARD DIETARY CALCIUM and OSTEOPOROSIS w i t h i n i n t e r v e n t i o n group C ATTITUDE (9 items) p r e t e s t p o s t t e s t t Degrees of p freedom A l l pooled data 30 ± 3 1 (n=21) 32 ± 4 (n=21) -2 .62 20 p<0.05 A l l 'below RNI 1 d a t a 2 31 ± 2 (n=8) 33 ± 5 (n=8) -1. .67 7 NS 3 A l l 'at or below NIH' d a t a 3 31 ± 5 ( n = l l ) 38 ± 4 ( n = l l ) -2. .66 10 p<0.05 S u b s c a l e s : DIET AS A SOURCE OF CALCIUM A l l pooled data 9 ± 2 (n=24) 10 ± 2 (n=24) -2, .20 23 p<0.05 A l l 'below RNI' dat a 9 ± 1 (n=10) 10 ± 3 (n=10) -1. .72 9 NS A l l 'at or below NIH 1 data 9 ± 2 (n=13) 10 i 2 (n=13) -2, .25 12 p^0.05 PERSONAL RISK FOR OSTEOPOROSIS A l l pooled data 8 ± 2 (n=23) 9 ± 2 (n=23) -1. .32 22 NS A l l 'below RNI' data 9 ± 3 (n=9) 10 ± 2 (n=9) -0, .74 8 NS A l l 'at or below NIH' data 9 ± 3 (n=12) 10 ± 2 (n=12) -1. .43 11 NS RELATIONSHIP BETWEEN DIETARY CALCIUM AND THE RISK OF OSTEOPOROSIS: A l l pooled d a t a 13 ± 2 (n-25) 13 ± 2 . (n=25) -0, .72 24 NS A l l 'below RNI' d a t a 14 ± 1 ( n = l l ) 13 t 2 ( n = l l ) 0. .19 10 NS A l l 'at or below NIH' d a t a 14 ± 1 (n=14) 14 ± 2 (n=14) -0.19 13 NS mean ± standard d e v i a t i o n P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was below the Recommended N u t r i e n t I n t a k e not s i g n i f i c a n t . P a r t i c i p a n t s not pregnant at pre- o r p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was at or below 1000 mg/d 145 For p o o l e d d a t a w i t h i n group A, the mean p r e t e s t and p o s t t e s t o v e r - a l l a t t i t u d e s c o r e s were: 3 1 + 6 and 3 2 + 6 of a t o t a l of 45 p o s s i b l e p o i n t s . S l i g h t i n c r e a s e s from p r e - t o p o s t t e s t were a l s o seen f o r s u b s c a l e s "DIET" and "RELATIONSHIP". No change was observed i n the s u b s c a l e "RISK" f o r p o o l e d d a t a . None of the i n c r e a s e s f o r p o o l e d d a t a were s i g n i f i c a n t . For "below RNI" d a t a , i n c r e a s e s from p r e - t o p o s t t e s t o c c u r r e d i n the o v e r - a l l a t t i t u d e s c a l e on two of i t s s u b s c a l e s "DIET" and "RISK". A g a i n , none of the d i f f e r e n c e s were s i g n i f i c a n t . One s i g n i f i c a n t i n c r e a s e was noted f o r "at or below NIH" d a t a : on the s u b s c a l e "RISK" where the p r e t e s t s c o r e , 8 + 2 , i n c r e a s e d t o 9 + 3 (t = -2.87, df = 16, p < 0.01). T h e r e f o r e , w i t h i n group A, a t t i t u d e s c o r e s g e n e r a l l y i n c r e a s e d , though not s i g n i f i c a n t l y , from p r e - t o p o s t t e s t . For p o o l e d data w i t h i n group B (Table 21), the mean p r e t e s t and p o s t t e s t v a l u e s f o r o v e r - a l l a t t i t u d e s c o r e s were: 31 ± 5 and 33 ± 5, which r e p r e s e n t e d a s i g n i f i c a n t i n c r e a s e ( t = -2.60, df = 43, p <_ 0.01). The o n l y s u b s c a l e which e v i d e n c e d an i n c r e a s e was "DIET" and the i n c r e a s e was s i g n i f i c a n t ( t = -2.93, df = 44, p < 0.01). For "below RNI" d a t a , n o n - s i g n i f i c a n t i n c r e a s e s o c c u r r e d on the o v e r - a l l a t t i t u d e s c o r e as w e l l as on the s u b s c a l e "RELATIONSHIP". Sc o r e s on the o t h e r two s u b s c a l e s were m a i n t a i n e d from p r e - to p o s t t e s t . Two a t t i t u d e measures i n c r e a s e d , though non-s i g n i f i c a n t l y , w i t h the "at or below NIH" da t a w i t h i n group 1 46 B: the o v e r - a l l a t t i t u d e s c a l e and i t s s u b s c a l e "DIET". T h e r e f o r e , the o v e r a l l a t t i t u d e s c o r e f o r p o o l e d d a t a i n c r e a s e d s i g n i f i c a n t l y w i t h i n group B, from p r e - t o p o s t t e s t . Other n o n - s i g n i f i c a n t i n c r e a s e s w i t h i n group B a l s o o c c u r r e d . Table 23 l i s t s the p r e - and p o s t t e s t mean v a l u e s f o r the o v e r - a l l a t t i t u d e s c o r e and i t s s u b s c a l e s i n i n t e r v e n t i o n group C. For p o o l e d d a t a , the mean p r e - and p o s t t e s t v a l u e s f o r o v e r - a l l a t t i t u d e s c o r e s were: 30 + 3 and 32 + 4, a s i g n i f i c a n t i n c r e a s e ( t = -2.62, df = 2 0 ) . I n c r e a s e s o c c u r r e d on two of the t h r e e s u b s c a l e s : "DIET" and "RISK" where the former was s i g n i f i c a n t ( t = -2.20, df = 23) . For "below RNI" d a t a , n o n - s i g n i f i c a n t i n c r e a s e s o c c u r r e d on the o v e r - a l l s c a l e as w e l l as on two of i t s s u b s c a l e s : "DIET" and "RISK". A de c r e a s e from p r e - t o p o s t t e s t , though not s i g n i f i c a n t , was noted on s u b s c a l e "RELATIONSHIP". Two s i g n i f i c a n t i n c r e a s e s o c c u r r e d w i t h "at or below NIH" d a t a , s i m i l a r t o p o o l e d d a t a : o v e r - a l l a t t i t u d e s c a l e ( t = -2.66, df = 10) and s u b s c a l e "DIET" ( t = -2.25, df = 12). A n o n - s i g n i f i c a n t i n c r e a s e was a l s o noted on s u b s c a l e "RISK". In summary, w i t h i n a l l t h r e e i n t e r v e n t i o n groups i n c r e a s e s o c c u r r e d i n the a t t i t u d e measures. However, i n c r e a s e s w i t h p o o l e d d a t a were o n l y s i g n i f i c a n t i n groups B and C. More s i g n i f i c a n t changes were noted f o r p o o l e d 147 r a t h e r than "below RNI" or "at or below NIH" d a t a . T h i s may be due t o the s m a l l e r sample s i z e s a s s o c i a t e d w i t h the l a t t e r two d a t a groups. T a b l e 24 p r o v i d e s a comparison of the mean group change s c o r e s i n the a t t i t u d e measures among a l l t h r e e i n t e r v e n t i o n g r oups. One-way a n a l y s i s of v a r i a n c e r e v e a l e d non-s i g n i f i c a n t l y d i f f e r e n t impacts on a t t i t u d e . A B a r t l e t t - B o x t e s t f o r homogeneity of v a r i a n c e i n d i c a t e d s i g n i f i c a n t d i f f e r e n c e s i n v a r i a n c e among the t h r e e groups on change i n the a t t i t u d e s u b s c a l e "RISK" f o r "below RNI" (F=0.08, df=2) and "at or below NIH" da t a (F = 0.15, df = 2, p < 0.001) and change i n s u b s c a l e "RELATIONSHIP" f o r p o o l e d d a t a (F = 0.31, df = 2, p < 0.01). Non-parametric t e s t s , Median and K r u s k a l - W a l l i s , were used t o compare change i n t h i s v a r i a b l e among the t h r e e i n t e r v e n t i o n groups. No s i g n i f i c a n t d i f f e r e n c e s were d e t e c t e d (not shown). Table 25 p r o v i d e s r e s u l t s on "a p r i o r i " c o n t r a s t t e s t i n g between i n t e r v e n t i o n groups A and B. No s i g n i f i c a n t d i f f e r e n c e s were o b s e r v e d f o r p o o l e d "below RNI" or f o r "at or below NIH" d a t a . "A p r i o r i " c o n t r a s t s of problem s o l v i n g v e r s u s non-problem s o l v i n g impacts a l s o r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e s (not shown). In summary, a l l t h r e e i n t e r v e n t i o n s appeared t o produce a f a v o u r a b l e impact on a t t i t u d e measures w i t h i n groups. The e f f e c t s however, on o v e r - a l l a t t i t u d e were o n l y s i g n i f i c a n t w i t h i n groups B and C. Change i n s c o r e s from p r e - t o p o s t t e s t were not s i g n i f i c a n t l y d i f f e r e n t between i n t e r v e n t i o n groups A and B, nor between problem s o l v i n g and 148 T a b l e 24: Comparison of change 1 i n ATTITUDE TOWARD DIETARY CALCIUM and OSTEOPOROSIS among i n t e r v e n t i o n groups A, B and C F P ATTITUDE (9 items) For pooled d a t a For 'below RNI' d a t a 3 F o r 'at or below NIH' d a t a 4 S u b s c a l e s : DIET AS A SOURCE OF CALCIUM (3 items) For pooled d a t a F o r 'below RNI' dat a F o r 'at or below NIH' d a t a PERSONAL RISK FOR OSTEOPOROSIS (3 items) For pooled d a t a F o r 'below RNI' d a t a F o r 'at or below NIH' dat a RELATIONSHIP BETWEEN DIETARY CALCIUM AND THE RISK OF OSTEOPOROSIS (3 items) For pooled d a t a F o r 'below RNI' d a t a F o r 'at or below NIH' dat a degrees of freedom = 2 * change = p o s t t e s t - p r e t e s t 2 not s i g n i f i c a n t at 0.05 l e v e l 3 P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was below the Recommended N u t r i e n t I n t a k e 4 P a r t i c i p a n t s not pregnant at p r e - o r p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was at or below 1000 mg/d 0.15 0.02 0.01 NS^ NS NS 0.07 0.22 0.07 NS NS NS 0.30 0.08 0.15 NS NS NS 0.31 0.68 0.38 NS NS NS 149 T a b l e 25: Comparison of change 1 i n ATTITUDE TOWARD DIETARY CALCIUM and OSTEOPOROSIS between i n t e r v e n t i o n groups A and B Degrees of Comparison t freedom p ATTITUDE (9 items) Form A vs. Form B f o r a l l pooled d a t a -0. .21 89 NS Form A v s . Form B f o r 'below RNI' d a t a 3 - o ! .17 24 NS Form A vs. Form B f o r 'at or below NIH' d a t a 4 -0, .32 37 NS S u b s c a l e s : DIET AS A SOURCE OF CALCIUM (3 items) Form A vs. Form B f o r pooled d a t a -0. .33 96 NS Form A v s . Form B f o r 'below RNI' d a t a 0. ,50 27 NS Form A vs. Form B f o r 'at or below NIH 1 d a t a 0. .07 41 NS PERSONAL RISK FOR OSTEOPOROSIS (3 Ltems) Form A v s . Form B f o r pooled d a t a -0. ,26 93 NS Form A v s . Form B f o r 'below RNI 1 d a t a -0. .33 26 NS Form A v s . Form B f o r 'at or below NIH ' d a t a 0. ,44 40 NS RELATIONSHIP BETWEEN DIETARY CALCIUM AND THE RISK OF OSTEOPOROSIS ( 3 items) Form A v s . Form B f o r pooled d a t a 0. .19 99 NS Form A vs. Form B f o r 'below RNI' d a t a -0. .85 30 NS Form A v s . Form B f o r 'at or below NIH ' d a t a -0. ,11 45 NS change = p o s t t e s t - p r e t e s t not s i g n i f i c a n t . P a r t i c i p a n t s not pregnant at pre- or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was below the Recommended N u t r i e n t Intake P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was at or below 1000 mg/d 150 non-problem s o l v i n g i n t e r v e n t i o n s . T h e r e f o r e , h y p o t h e s i s 1.2 and 1.5 were not s u p p o r t e d . A few p o i n t s w i l l be d i s c u s s e d . R e g a r d i n g the s p e c i f i c s u b s c a l e s , s u b s c a l e "DIET" tended t o i n c r e a s e w i t h i n a l l t h r e e i n t e r v e n t i o n groups f o r a l l t y p e s of d a t a . I t would appear t h a t i n t e r v e n t i o n encouraged more f a v o u r a b l e a t t i t u d e s toward d i e t as a source of c a l c i u m , r e g a r d l e s s of whether problem s o l v i n g was used. In a d d i t i o n , i n t e r v e n t i o n groups A and C e x p e r i e n c e d more p o s i t i v e s c o r e s on s u b s c a l e "RISK" f o r a l l t y p e s of d a t a . T h i s may i n d i c a t e t h a t i n t e r v e n t i o n , r e g a r d l e s s of t y p e , had some f a v o u r a b l e impact on p a r t i c i p a n t s ' a t t i t u d e s toward t h e i r p e r s o n a l r i s k f o r o s t e o p o r o s i s , i n t h a t they became more aware of t h e i r r i s k f o l l o w i n g i n t e r v e n t i o n . A l l t h r e e i n t e r v e n t i o n groups i n t h i s s tudy e x p e r i e n c e d i n c r e a s e d o v e r - a l l a t t i t u d e s c o r e s , f o r p o o l e d d a t a . The n o n - s i g n i f i c a n t i n c r e a s e o b s e r v e d w i t h i n group A i s s i m i l a r t o r e s u l t s r e p o r t e d by Daelhousen and G u t h r i e (1982). They d e s c r i b e d a s m a l l , n o n - s i g n i f i c a n t i n c r e a s e i n mean a t t i t u d e s c o r e s w i t h i n t h e i r e x p e r i m e n t a l group a t p o s t t e s t . The s i g n i f i c a n t i n c r e a s e s w i t h i n groups B and C c o n t r a s t w i t h the t r e n d of m a i n t a i n e d , or o n l y s l i g h t l y improved, a t t i t u d e s c o r e s from p r e - t o p o s t t e s t r e p o r t e d i n the n u t r i t i o n e d u c a t i o n l i t e r a t u r e . Recent work by b o t h R e i s and Schoon (1986) and Brush et a l . (1986) r e v e a l e d the maintenance of p o s i t i v e n u t r i t i o n -r e l a t e d a t t i t u d e s among a d u l t s i n e x p e r i m e n t a l groups from p r e - t o p o s t t e s t . Brush e t a l . (1986) suggested t h a t a 151 c e i l i n g e f f e c t may occur w i t h a t t i t u d e s s i n c e a d u l t s may have o v e r - a l l p o s i t i v e a t t i t u d e s toward n u t r i t i o n which are not l i k e l y t o be f u r t h e r enhanced. However, i n t h i s study women d i d e x p e r i e n c e improvements d e s p i t e t h e i r h i g h p r e t e s t a t t i t u d e s c o r e s . P a r t i c i p a n t s had p r e t e s t s c o r e s over 60% of the maximum p o s s i b l e s c o r e : 69% i n group A; 69% i n group B and 67% i n group C. T h e r e f o r e , even a t the s e p r e t e s t l e v e l s , some p o t e n t i a l f o r improvement remained. I t i s p o s s i b l e however, t h a t had p a r t i c i p a n t s e n t e r e d the study w i t h lower mean a t t i t u d e s c o r e s , the magnitude of change from p r e - t o p o s t t e s t may have been g r e a t e r . Perhaps t h i s would have i n c r e a s e d the l i k e l i h o o d of d e t e c t i n g s i g n i f i c a n t l y d i f f e r e n t amounts of change among i n t e r v e n t i o n groups. The p o s s i b i l i t y a l s o remains t h a t among-group d i f f e r e n c e s may have been s i g n i f i c a n t i f : (1) a l o n g e r p e r i o d of o b s e r v a t i o n were employed, s i n c e a t t i t u d e s a r e d i s t a l measures of program outcomes ( S t . P i e r r e 1982) and (2) the measurement i n s t r u m e n t had been more s e n s i t i v e t o s m a l l e r changes i n a t t i t u d e . Hypotheses 1.3 and 1.6: Impacts on P e r c e p t i o n of Problem S o l v i n g A b i l i t y  T a b l e s 26, 27 and 28 l i s t p r e - and p o s t t e s t v a l u e s , +. s t a n d a r d d e v i a t i o n s , f o r the o v e r - a l l p e r c e p t i o n s c a l e and i t s s u b s c a l e s , by i n t e r v e n t i o n group. For p o o l e d d a t a w i t h i n group A, the mean p r e t e s t and p o s t t e s t o v e r - a l l p e r c e p t i o n s c o r e s were: 37 +. 4 and 35 ± 5. 152 T a b l e 26: Comparison of p r e - and p o s t t e s t v a l u e s f o r PERCEPTION OF PROBLEM SOLVING ABILITY w i t h i n i n t e r v e n t i o n group A PERCEPTION (9 items) p r e t e s t p o s t t e s t t Degrees of p freedom A l l pooled data 37 ± 4 1 (n=29) 35 ± 5 (n=29) 2.19 28 p<0.05 A l l 'below RNI' d a t a 2 36 ± 4 ( n = l l ) 34 ± 7 ( n = l l ) 1.49 10 NS 3 A l l 'at or below NIH' d a t a 4 37 ± 4 (n=16) 34 ± 6 (n=16) 2.01 15 NS S u b s c a l e s : PROBLEM IDENTIFICATION (3 items) A l l pooled data 13 ± 1 (n=31) 12 ± 2 (n=31) 1.66 30 NS A l l 'below RNI' d a t a 12 ± 1 (n-12) 1 1 + 3 (n=12) 1.40 11 NS A l l 'at or below NIH' data 12 ± 2 (n=17) 12 + 3 (n=17) 1.61 16 NS GOAL PLANNING (3 Ltems) A l l pooled data 12 + 1 (n=30) 11 + 2 (n=30) 3.07 29 p<0.01 A l l 'below RNI' dat a 12 ± 1 ( n = l l ) 11 ± 2 ( n = l l ) 2.02 10 NS A l l 'at or below NIH'' dat a 12 ± 1 (n=17) 11 + 2 (n=17) 2.91 16 p<0.01 GOAL ACHIEVEMENT (3 Ltems) A l l pooled data 12 ± 2 (n-31) 11 + 2 (n=31) 1.01 30 NS A l l 'below RNI' dat a 12 ± 2 ( n = l l ) 1 1 + 2 ( n = l l ) 0.86 10 NS A l l 'at or below NIH' dat a 12 + 2 (n-17) 11 ± 2 (n=17) 1.07 16 NS * mean +• standard d e v i a t i o n 2 P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was below the Recommended N u t r i e n t Intake 3 not s i g n i f i c a n t . 4 P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was at or below 1000 mg/d 153 T a b l e 27: Comparison of p r e - and p o s t t e s t v a l u e s f o r PERCEPTION OF PROBLEM SOLVING ABILITY w i t h i n i n t e r v e n t i o n group B PERCEPTION (9 items) p r e t e s t p o s t t e s t t Degrees of Freedom P A l l pooled data 36 ± 4 1 (n=42) 36 ± 3 (n=42) -0.55 41 NS 2 A l l 'below RNI' d a t a 3 36 ± 4 (n=9) 37 ± 4 (n=9) -1.39 8 NS A l l 'at or below 35 ± 4 37 ± 3 -1.85 15 NS NIH' d a t a 4 (n=16) (n=16) S u b s c a l e s : PROBLEM IDENTIFICATION (3 items) A l l pooled data 13 ± 2 (n=45) 12 ± 1 (n=45) 0.26 44 NS A l l 'below RNI' d a t a 13 ± 1 (n=10) 13 ± 1 (n=10) -0.23 9 NS A l l 'at or below NIH' data • 13 ± 1 (n=17) 13 ± 1 (n-17) -0.53 16 NS GOAL PLANNING (3 items) A l l pooled d a t a 12 ± 1 (n=30) 12 ± 2 (n=30) 0.37 45 NS A l l 'below RNI' dat a 11 + 1 (n=9) 12 ± 2 (n=9) -0.63 8 NS A l l 'at or below NIH 1 d a t a 11 ± 1 (n=17) 12 ± 2 (n=17) -1.07 15 NS GOAL ACHIEVEMENT (3 items) A l l pooled data 12 ± 2 (n=44) 12 ± 1 (n=44) -1.41 43 NS A l l 'below RNI' d a t a 11 ± 2 ( n = l l ) 12 ± 1 ( n = l l ) -1.51 8 NS A l l 'at or below NIH' data 11 ± 2 (n=16) 12 ± 1 (n-16) -2.00 15 NS ?• mean ± standard d e v i a t i o n 2 not s i g n i f i c a n t . 3 P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was below the Recommended N u t r i e n t I n t a k e 4 P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was at or below 1000 mg/d 154 Table 28: Comparison of p r e - and p o s t t e s t v a l u e s f o r PERCEPTION OF PROBLEM SOLVING ABILITY w i t h i n i n t e r v e n t i o n group C PERCEPTION (9 items) p r e - t e s t p o s t - t e s t t Degrees of Freedom P A l l pooled data 35 ± 5 1 (n=21) 36 ± 5 (n=21) -0 .70 20 NS 2 A l l 'below RNI' d a t a 3 36 ± 5 (n=8) 36 ± 4 (n=8) -0 .64 7 NS A l l 'at or below NIH' d a t a 4 35 ± 4 ( n = l l ) 35 ± 5 ( n = l l ) -0 . 14 10 NS S u b s c a l e s : PROBLEM IDENTIFICATION (3 items) A l l pooled data 12 ± 2 (n=23) 12 ± 3 (ii=23) 0 .32 22 NS A l l 'below RNI' data 13 ± 1 (n-10) 12 ± 1 (n=10) 0 .32 9 NS A l l 'at or below NIH' data 12 ± 2 (n=13) 12 ± 2 (n=13) 0 .23 12 NS GOAL PLANNING (3 items) A l l pooled data 12 ± 2 (n=24) 12 ± 1 (n=24) -0, . 72 23 NS A l l 'below RNI' d a t a 12 ± 1 (n=10) 12 ± 1 (n=10) -0 .63 9 NS A l l 'at or below NIH' data 12 ± 1 (n=13) 12 ± 1 (n=13) 0, .33 12 NS GOAL ACHIEVEMENT (3 items) A l l pooled d a t a 11 i 2 (n=23) 12 i 2 (n=23) - i ; .71 22 NS A l l 'below RNI' d a t a 1 1 + 2 (n=9) 12 ± 2 (n=9) -1. .46 8 NS A l l 'at or below NIH' data 11 ± 2 (n=12) 12 ± 2 (n=12) -0. .92 11 NS mean ± standard d e v i a t i o n not s i g n i f i c a n t . P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was below the Recommended N u t r i e n t I n t a k e P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was at or below 1000 mg/d 155 The d e c r e a s e from p r e - t o p o s t t e s t was s i g n i f i c a n t ( t = 2.19, df = 28, p < 0.05). Decreases were a l s o observed on a l l t h r e e s u b s c a l e s . The dec r e a s e was s i g n i f i c a n t f o r s u b s c a l e "PLAN" ( t = 3.07, df = 29, p < 0.01). The tendency of s c o r e s t o dec r e a s e from p r e - t o p o s t t e s t w i t h i n group A was a l s o e v i d e n t w i t h "below RNI" d a t a . None of these d e c r e a s e s , however, were s i g n i f i c a n t . D ecreases from p r e - t o p o s t t e s t o c c u r r e d w i t h "at or below NIH" da t a f o r a l l measures except s u b s c a l e "IDENTIFY". The d e c r e a s e was s i g n i f i c a n t f o r s u b s c a l e "PLAN" ( t = 2.91, df = 16, p < 0.01). T h e r e f o r e w i t h i n group A, i n t e r v e n t i o n appeared t o c r e a t e a n e g a t i v e impact on p a r t i c i p a n t s ' p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t i e s . I t s h o u l d be noted t h a t i n t e r v e n t i o n group A: tended t o be younger than the o t h e r two groups; c o n s i s t e d of more women who were employed; was composed of more pregnant women a t both p r e - and p o s t t e s t ; and had the h i g h e s t s e l f - r e p o r t e d awareness of o s t e o p o r o s i s . D i f f e r e n c e s were not d e t e c t e d s t a t i s t i c a l l y , however. For p o o l e d d a t a w i t h i n group B (T a b l e 2 7 ) , the mean p r e t e s t and p o s t t e s t o v e r - a l l p e r c e p t i o n s c o r e s were: 36 + 4 and 36 + 3. E s s e n t i a l l y , no change was noted i n the o v e r - a l l s c o r e . The same was t r u e f o r i t s s u b s c a l e s "PLAN" and "ACHIEVE". A d e c r e a s e , though n o n - s i g n i f i c a n t , o c c u r r e d i n s u b s c a l e "IDENTIFY". For "below RNI" d a t a , s m a l l i n c r e a s e s i n the o v e r - a l l p e r c e p t i o n s c o r e and i t s s u b s c a l e s "PLAN" and "ACHIEVE" were 1 56 n o t e d . The mean sco r e on s u b s c a l e "IDENTIFY" d i d not change from p r e - t o p o s t t e s t . None of the changes i n "below RNI" data were s i g n i f i c a n t . The same was t r u e f o r "at or below NIH" d a t a . Non-s i g n i f i c a n t i n c r e a s e s o c c u r r e d on the o v e r - a l l s c o r e and i t s s u b s c a l e s "PLAN" and "ACHIEVE". No change was observed i n s u b s c a l e "IDENTIFY". T h e r e f o r e w i t h i n group B the m a j o r i t y of impacts on p e r c e p t i o n of problem s o l v i n g a b i l i t y i n v o l v e d no change, or were p o s i t i v e , though n o n - s i g n i f i c a n t . These changes were more i n keeping w i t h the i n t e n d e d outcomes of the i n s t r u c t i o n a l i n t e r v e n t i o n . T a b l e 28 l i s t s the p r e - and p o s t t e s t mean v a l u e s f o r p e r c e p t i o n of problem s o l v i n g a b i l i t y w i t h i n i n t e r v e n t i o n group C. For p o o l e d data w i t h i n group C, the mean p r e - and p o s t t e s t o v e r - a l l p e r c e p t i o n s c o r e s were: 3 5 + 5 and 36 + 5, a n o n - s i g n i f i c a n t i n c r e a s e . S u b s c a l e "ACHIEVE" i n c r e a s e d n o n - s i g n i f i c a n t l y . Only one of the t h r e e s u b s c a l e s changed from p r e - to p o s t t e s t f o r "below RNI d a t a " : s u b s c a l e "IDENTIFY" d e c r e a s e d , n o n - s i g n i f i c a n t l y , from 13 + 1 t o 12 + 1 . Only one p e r c e p t i o n measure changed, and i n c r e a s e d , from p r e - t o p o s t t e s t w i t h "at or below NIH" d a t a : s u b s c a l e "ACHIEVE". The i n c r e a s e was not s i g n i f i c a n t . T h e r e f o r e , groups B and C were s i m i l a r i n t h a t both e x p e r i e n c e d no change or s m a l l , n o n - s i g n i f i c a n t , i n c r e a s e s on the p e r c e p t i o n measures. The n e g a t i v e impact o b s e r v e d i n group A was not r e f l e c t e d i n e i t h e r of the s e two groups. 157 S i n c e groups B and C were exposed to a problem s o l v i n g and a non-problem s o l v i n g i n t e r v e n t i o n , r e s p e c t i v e l y , and e x p e r i e n c e d s i m i l a r p a t t e r n s of e f f e c t , the u n f a v o u r a b l e impact noted i n group A does not appear t o be due t o the type of i n t e r v e n t i o n i t r e c e i v e d . R a t h e r , i t i s more l i k e l y t h a t s p e c i f i c c h a r a c t e r i s t i c s of group A i n f l u e n c e d i t s resp o n s e . T a b l e 29 p r o v i d e s a comparison of the mean change s c o r e s on p e r c e p t i o n of problem s o l v i n g a b i l i t y among the t h r e e i n t e r v e n t i o n groups. One-way a n a l y s i s of v a r i a n c e was performed on the d a t a . For p o o l e d d a t a , d i f f e r e n c e s among groups were s i g n i f i c a n t on s u b s c a l e "PLAN" (F = 3.65, df 2) . No s i g n i f i c a n t d i f f e r e n c e s were r e v e a l e d w i t h "below RNI" d a t a . However, d i f f e r e n c e s among the i n t e r v e n t i o n groups were s i g n i f i c a n t w i t h "at or below NIH" d a t a on the o v e r - a l l s c o r e (F = 3.69, df = 2) and s u b s c a l e "PLAN" (F = 4.24, df = 2 ) . B a r t l e t t - B o x t e s t s of homogeneity of v a r i a n c e s i n d i c a t e d s i g n i f i c a n t l y d i f f e r e n t v a r i a n c e s f o r one v a r i a b l e : change i n s u b s c a l e "IDENTIFY" f o r "below RNI" (F=1.25, df=2, p<0.01) and "at or below NIH" data (F = 1.18, df=2 ) . Non-parametric t e s t s , Median and K r u s k a l - W a l l i s , r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e s among the t h r e e groups on change i n v a l u e of t h i s v a r i a b l e . T a b l e 30 p r o v i d e s r e s u l t s on "a p r i o r i " c o n t r a s t t e s t i n g of the mean change s c o r e s between i n t e r v e n t i o n groups A and B. For p o o l e d d a t a , the two were s i g n i f i c a n t l y 158 T a b l e 29: Comparison of change 1 i n PERCEPTION OF PROBLEM SOLVING ABILITY among i n t e r v e n t i o n groups A, B and C PERCEPTION (9 items) For pooled d a t a 2.71 NS 2 F o r 'below RNI' d a t a 3 2.23 NS For 'at or below NIH' d a t a 4 3.69 p<0.05 S u b s c a l e s : PROBLEM IDENTIFICATION (3 items) For pooled d a t a 0.85 NS F o r 'below RNI' dat a 1.25 NS For 'at or below NIH' dat a 1.80 NS GOAL PLANNING (3 items) For pooled d a t a 3.65 p<0.05 For 'below RNI' d a t a 2.32 NS For 'at or below NIH' dat a 4.24 p<0.05 GOAL ACHIEVEMENT (3 Ltems) For pooled d a t a 2.42 NS For 'below RNI' d a t a 1.86 NS F o r 'at or below NIH' d a t a 2.24 NS degrees o f freedom = 2 1 change = p o s t t e s t - p r e t e s t 2 not s i g n i f i c a n t at 0.05 l e v e l 3 P a r t i c i p a n t s not pregnant at pre- o r p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was below the Recommended N u t r i e n t Intake 4 P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was at or below 1000 mg/d 159 T a b l e 30: Comparison of change 1 i n PERCEPTION OF PROBLEM SOLVING ABILITY between i n t e r v e n t i o n groups A and B Comparison Degrees of freedom PERCEPTION (9 items) Form A vs. Form B f o r a l l pooled d a t a Form A v s . Form B f o r 'below RNI 1 d a t a 2 Form A vs. Form B f o r 'at or below NIH' d a t a 4 -2.07 -1.94 -2.68 89 25 40 p<0.05 NS 3 p<0.05 Su b s c a l e s : PROBLEM IDENTIFICATION (3 items) Form A v s . Form B f o r pooled data -1 .23 96 NS Form A vs. Form B f o r 'below RNI' d a t a -1 .45 29 NS Form A v s . Form B f o r 'at or below NIH' d a t a -1 .82 44 NS GOAL PLANNING (3 items) Form A vs. Form B f o r pooled d a t a -2 .08 97 p<0.05 Form A v s . Form B f o r 'below RNI' d a t a -1 .90 27 NS Form A vs. Form B f o r 'at or below NIH' da t a -2 .86 43 p<0.01 GOAL ACHIEVEMENT ( 3 items) Form A v s . Form B f o r pooled data -1 .70 95 NS Form A vs. Form B f o r 'below RNI' da t a -1 .58 26 NS Form A v s . Form B f o r 'at or below NIH' da t a -2 .01 42 p<0.05 change = p o s t t e s t - p r e t e s t P a r t i c i p a n t s not pregnant at pre- o r p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was below the Recommended N u t r i e n t I n t a k e not s i g n i f i c a n t . P a r t i c i p a n t s not pregnant at p r e - or p o s t t e s t and whose p r e t e s t d i e t a r y c a l c i u m i n t a k e was at or below 1000 mg/d 160 d i f f e r e n t on o v e r - a l l p e r c e p t i o n s c o r e (t = -2.07, df = 89) and s u b s c a l e "PLAN" ( t = -2.08, df = 97). For "below RNI" d a t a , none of the impacts produced by i n t e r v e n t i o n A and B were s i g n i f i c a n t l y d i f f e r e n t . For "at or below NIH" d a t a , s i g n i f i c a n t l y d i f f e r e n t impacts were observ e d i n the o v e r - a l l p e r c e p t i o n s c o r e ( t = -2.68, df = 4 0 ) , and s u b s c a l e s "PLAN" ( t = -2.86, df = 43, p < 0.01) and "ACHIEVE" ( t = -2.01, df = 4 2 ) . "A p r i o r i " c o n t r a s t s between problem s o l v i n g and non-problem s o l v i n g i n t e r v e n t i o n s were not s i g n i f i c a n t f o r a l l t y p e s of d a t a . However, the comparison on s u b s c a l e "PLAN" approached s i g n i f i c a n c e (p = 0.056) f o r p o o l e d d a t a . In summary, some p o s i t i v e impacts on p e r c e p t i o n of problem s o l v i n g a b i l i t y were noted i n groups B and C. S i g n i f i c a n t l y d i f f e r e n t impacts were produced by i n t e r v e n t i o n A v e r s u s B. Impacts produced by problem s o l v i n g v e r s u s non-problem s o l v i n g i n t e r v e n t i o n s were not s i g n i f i c a n t l y d i f f e r e n t . C o n s e q u e n t l y , h y p o t h e s i s 1.3 was s u p p o r t e d whereas h y p o t h e s i s 1.6 was not s u p p o r t e d . Two p o i n t s w i l l be d i s c u s s e d . F i r s t , s i g n i f i c a n t d i f f e r e n c e s i n impact between i n t e r v e n t i o n groups A and B may not be as c o n v i n c i n g as they appear. S u b s c a l e "PLAN" was a s s o c i a t e d , a t both p r e - and p o s t t e s t , w i t h a c o e f f i c i e n t of r e l i a b i l i t y of o n l y 0.44 and 0.46, r e s p e c t i v e l y . T h e r e f o r e , change measured by t h i s s u b s c a l e may not be r e l i a b l e . In a d d i t i o n , d i f f e r e n c e s observed between impact on the 161 o v e r - a l l p e r c e p t i o n s c o r e i n i n t e r v e n t i o n group A v e r s u s B were not as exp e c t e d . I t was a n t i c i p a t e d t h a t p e r c e p t i o n of problem s o l v i n g a b i l i t y would be enhanced i n b o t h groups, w i t h the l a r g e r e f f e c t b e i n g produced by i n t e r v e n t i o n B. The s i z e of the mean change between the two groups i s due, i n s t e a d , t o a s i g n i f i c a n t d e c r e a s e i n o v e r - a l l p e r c e p t i o n s c o r e w i t h i n group A. E f f o r t s were not made t o c o n t r o l s t a t i s t i c a l l y f o r the d i f f e r e n c e s i n biodemographic c h a r a c t e r i s t i c s which d i s t i n g u i s h e d group A from group B. Give n the s i m i l a r i t y i n responses i n groups B and C, i t would appear t h a t the e f f e c t seen i n group A i s due t o c h a r a c t e r i s t i c s of t h a t group r a t h e r than t o the s p e c i f i c n a t u r e of the i n t e r v e n t i o n t o which i t was exposed. I t i s d i f f i c u l t t o r e l a t e the p r e s e n t study r e s u l t s on p e r c e p t i o n of problem s o l v i n g t o the n u t r i t i o n e d u c a t i o n l i t e r a t u r e s i m p l y because a p u b l i s h e d study on s i m i l a r i n s t r u c t i o n a l impacts c o u l d not be found. P o s s i b l y , impacts on p e r c e p t i o n of problem s o l v i n g a b i l i t y may be s i m i l a r t o those r e p o r t e d on a t t i t u d e i n the l i t e r a t u r e . S p e c i f i c a l l y , the c e i l i n g e f f e c t d e s c r i b e d by Brush e t a l . (1986) r e g a r d i n g change i n a t t i t u d e s may be comparable t o r e s u l t s o b s e r v e d on p e r c e p t i o n of problem s o l v i n g a b i l i t y i n t h i s s t u d y . W i t h the e x c e p t i o n of i n t e r v e n t i o n group A, p e r c e p t i o n s c o r e s e i t h e r remained c o n s t a n t or i n c r e a s e d non-s i g n i f i c a n t l y w i t h i n i n t e r v e n t i o n groups. P a r t i c i p a n t s i n a l l t h r e e groups a t p r e t e s t had o v e r - a l l p e r c e p t i o n s c o r e s above 75% of the maximum p o s s i b l e s c o r e : 82% i n group A, 1 62 and 89% i n group B and 78% i n group C. Perhaps women f e l t g e n e r a l l y competent a t s o l v i n g problems and were u n l i k e l y t o change t h a t p e r c e p t i o n of t h e m s e l v e s . I t i s a l s o p o s s i b l e t h a t women i n group A had l e s s f i x e d p e r c e p t i o n s of t h e i r problem s o l v i n g a b i l i t y than d i d women i n the o t h e r two i n t e r v e n t i o n groups. In a d d i t i o n , i t i s a l s o p o s s i b l e t h a t the measurement i n s t r u m e n t was not s u f f i c i e n t l y s e n s i t i v e t o d e t e c t s m a l l changes i n p e r c e p t i o n of problem s o l v i n g a b i l i t i e s . P e r c e p t i o n of problem s o l v i n g a b i l i t y may be r e l a t e d t o the concept of s e l f - e f f i c a c y d e s c r i b e d by Lawrance and McLeroy (1986). Though p e r c e p t i o n s c o r e s were not e x p l o r e d i n r e l a t i o n t o b e h a v i o u r change i n t h i s s t u d y , Lawrance and McLeroy (1986) have suggested t h a t p e r c e p t i o n s of s e l f -e f f i c a c y toward a s p e c i f i c behaviour, may p r e d i c t the a c t u a l performance of t h a t b e h a v i o u r . P e r c e p t i o n of problem s o l v i n g a b i l i t y measured i n t h i s study was not s p e c i f i c a l l y r e l a t e d t o change i n d i e t a r y c a l c i u m i n t a k e s . F u r t h e r r e s e a r c h i s n e c e s s a r y t o e s t a b l i s h whether p e r c e p t i o n of s p e c i f i c b e h a v i o u r s may indeed p r e d i c t the a c t u a l b e h a v i o u r . Impacts R e l a t i v e t o Adherence t o the Problem S o l v i n g Steps I t was proposed t h a t the more c o m p l e t e l y women i n i n t e r v e n t i o n groups A and B f o l l o w e d the problem s o l v i n g s t e p s , t he g r e a t e r t he i n s t r u c t i o n a l impact might be. Ta b l e 31 d e s c r i b e s the d i s t r i b u t i o n of p a r t i c i p a n t s by adherence t o the t h r e e problem s o l v i n g s t e p s w i t h i n 163 T a b l e 31: D i s t r i b u t i o n of p a r t i c i p a n t s on adherence* to problem s o l v i n g steps w i t h i n i n t e r v e n t i o n groups A and B I n t e r v e n t i o n Groups Adherence: Yes No Completion of Step 1 Yes No Completion of Step 2: Yes No C o m p l e t i o n of Step 3: Yes No 18 ( 7 5 ) 2 6 (25) (m=8)2 28 (100) 0 (0) (m=4) 18 (75) 6 (25) (m=8) 15 (75) 5 (25) (m=12) 21 (49) 22 (51) (m=5) 44 (98) 1 (2) (m=3) 22 (51) 21 (49) (m=5) 28 (76) 9 (24) (m=ll) 1 adherence = c o m p l e t i o n of s t e p 1 and s t e p 2 of the problem s o l v i n g m a t e r i a l s 2 percentages i n p a r e n t h e s e s 3 m = m i s s i n g v a l u e s 164 i n t e r v e n t i o n groups A and B. Adherence was d e f i n e d as s e l f -r e p o r t e d c o m p l e t i o n of the f i r s t two problem s o l v i n g s t e p s : s e l f - a s s e s s m e n t of d i e t a r y c a l c i u m i n t a k e and p r e p a r a t i o n of a d i e t a r y p l a n t o i n c r e a s e d i e t a r y c a l c i u m i n t a k e . The t h i r d s t e p was mental r e h e a r s a l of the p l a n . A l l of the women a t p o s t t e s t i n group A and 98% of those i n group B r e p o r t e d p e r f o r m i n g a s e l f - a s s e s s m e n t of t h e i r d i e t a r y c a l c i u m i n t a k e s . N o n - s i g n i f i c a n t l y fewer women i n group B (51%) completed s t e p 2 than i n group A ( 7 5 % ) . A p p r o x i m a t e l y the same p r o p o r t i o n of women i n group A (75%) and group B (76%) completed the t h i r d s t e p . C o m p l e t i o n of both s t e p 1 and s t e p 2 was r e p o r t e d by 75% of women i n group A compared t o o n l y 49% i n group B. Groups A and B were not s i g n i f i c a n t l y d i f f e r e n t on thes e v a r i a b l e s by Ch i - s q u a r e a n a l y s i s . I t s h o u l d be noted, however, t h a t fewer women i n i n t e r v e n t i o n group B needed t o make a d i e t a r y p l a n , s t e p 2, than d i d women i n group A. T w o - t a i l e d t - t e s t s were performed on change s c o r e s of the dependent v a r i a b l e s by adherence t o the problem s o l v i n g s t e p s . T a b l e 32 r e v e a l s no s i g n i f i c a n t d i f f e r e n c e between women who d i d adhere t o the s t e p s and those who d i d n o t , f o r po o l e d data from i n t e r v e n t i o n groups A and B. For "below RNI" d a t a , impact on one p e r c e p t i o n s u b s c a l e "IDENTIFY", was s i g n i f i c a n t l y d i f f e r e n t ( t = -2.52, df = 15). For t h i s group of women, t h e r e f o r e , adherence may have a f f e c t e d t h e i r p e r c e i v e d a b i l i t y t o i d e n t i f y a problem. S i m i l a r t e s t s were a p p l i e d t o compare impacts produced 165 Table 32: Comparison of p a r t i c i p a n t s on change in the dependent var i a b l e s by degree of adherence* to the probelm s o l v i n g steps t Degrees of P freedom CALCIUM INTAKE For a l l data -1 , .18 57 NS For 'below RNI1 d a t a 3 1. .00 14 NS For 'at or below NIH' d a t a 4 -0. .19 23 NS CTITUDE TOWARD DIETARY CALCIUM AND OSTEOPOROSIS For a l l data 0. .91 58 NS For 'below RNI' data 0, .97 13 NS For 'at or below NIH' data 1. .26 22 NS Subscales: DIET AS A SOURCE OF CALCIUM For a l l data 1. .42 61 NS For 'below RNI' data L. .21 14 NS For 'at or below NIH' data 1. .87 23 NS PERSONAL RISK FOR OSTEOPOROSIS For a l l data 0.69 60 NS For 'below RNI' daca 1.04 14 NS For 'at or below NIH' data 0.89 24 NS RELATIONSHIP BETWEEN DIETARY CALCIUM AND OSTEOPOROSIS For a l l daca -0 .80 62 NS For 'below RNI1 data -0 .77 15 NS For 'at or below NIH' daca -0 .85 25 NS PERCEPTION OF PROBLEM SOLVING ABILITY For a l l data 0 .71 58 NS For 'below RNI' data 0 .53 14 NS For 'at or below NIH' data 0 .96 24 NS Subscales: PROBLEM IDENTIFICATION For a l l data -0 .37 62 NS For 'below RNI' data -2 .52 15 p<0.01 For 'at or below NIH' data -I .10 25 NS GOAL PLANNING For a l l data 1 .19 62 NS For 'below RNI' data -0 .07 14 NS For 'at or below NIH' data 0 .64 25 NS GOAL ACHIEVEMENT For a l l daca 0 .01 61 NS For 'below RNI' data 1 .94 14 NS For 'at or below NIH' data 1 .04 25 NS * adherence = se l f - r e p o r t e d completion of both step- 1 and seep 2. ^ not s i g n i f i c a n t . 3 P a r t i c i p a n t s who were not pregnant at pre- or posttest and whose pret e s t calcium intake was below the Recommended Nutrient Intake. P a r t i c i p a n t s who were not pregnant at e i t h e r pre- or posttest and whose pretest calcium intake was at or below 1000 mg/d. 166 between women who used a l l t h r e e problem s o l v i n g s t e p s t o those who d i d not (not shown). A s i g n i f i c a n t d i f f e r e n c e i n impact was noted once a g a i n on the p e r c e p t i o n s u b s c a l e "IDENTIFY" f o r "below RNI" d a t a . However, the l i k e l i h o o d of a s i g n i f i c a n t d i f f e r e n c e a r i s i n g by chance w i t h these numerous t - t e s t s i s h i g h . C o n s e q u e n t l y , the s i g n i f i c a n t r e l a t i o n s h i p observed may have been the r e s u l t of chance. No s i g n i f i c a n t d i f f e r e n c e s were obser v e d w i t h "at or below NIH" d a t a . A few comments s h o u l d be made r e g a r d i n g these r e s u l t s . One, adherence d i d not seem t o i n f l u e n c e i n t e r v e n t i o n impact. P a r t i c i p a n t s may have f o r g o t t e n c o m p l e t i n g the s t e p s and t h e r e f o r e s a i d they d i d n o t . I t i s a l s o p o s s i b l e t h a t a n o t h e r problem s o l v i n g s t e p , not m o n i t o r e d i n t h i s s t u d y , had t o be completed f o r f u l l i n t e r v e n t i o n impact t o be n o t e d . For Research Q u e s t i o n 2 I s t h e r e a s i g n i f i c a n t r e l a t i o n s h i p between women's s e l f - e s t e e m s c o r e s and t h e i r : a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s ; p e r c e p t i o n of t h e i r p roblem s o l v i n g a b i l i t i e s and d i e t a r y p r a c t i c e s ? T h i s q u e s t i o n was answered by t e s t i n g i t s a s s o c i a t e d h y p o theses. T a b l e 33 l i s t s the o v e r - a l l s e l f - e s t e e m s c o r e s , and s u b s c a l e s c o r e s , + s t a n d a r d d e v i a t i o n , by i n t e r v e n t i o n group. A l l t h r e e i n t e r v e n t i o n groups o b t a i n e d a mean of a t l e a s t 75% of the maximum p o s s i b l e s c o r e of 32 on the o v e r -167 T a b l e 33: Comparison of mean s e l f - e s t e e m s c o r e s , by i n t e r v e n t i o n group. Subsca l e I n t e r v e n t i o n Group Form A Form B C o n t r o l G e n e r a l s e l f - e s t e e m 1 3 + 3 1 2 + 2 1 3 + 3 (maximum score=16) (n=30) (n=39) (n=19) S o c i a l s e l f - e s t e e m 7 ± 1 7 ± 1 7 ± 1 (maximum score=8) (n=30) (n=41) (n=19) P e r s o n a l s e l f - e s t e e m 5 + 2 6 ± 2 5 ± 2 (maximum score=8) (n=28) (n=45) (n=20) O v e r - a l 1 25 ± 6 26 + 3 26 ± 5 (maximum score=32) (n=26) (n=36) (n=14) 168 a l l s e l f - e s t e e m s c o r e : 25 ± 6 f o r group A; 26 ± 3 f o r group B; and 26 ± 3 f o r group C. D e s p i t e i n t e r v e n t i o n group C's s i g n i f i c a n t l y g r e a t e r p r o p o r t i o n of post-menopausal women, t h i s group had l e v e l s of s e l f - e s t e e m comparable t o those of women i n the o t h e r two i n t e r v e n t i o n groups. B a t t l e (1976) suggested t h a t 50% of women would be ex p e c t e d t o a c h i e v e between 23 and 24 on the o v e r - a l l s c o r e . T h e r e f o r e , women i n a l l t h r e e i n t e r v e n t i o n groups s c o r e d s l i g h t l y above-average on the o v e r - a l l s e l f - e s t e e m s c o r e . S u b s c a l e s c o r e s f o r a l l t h r e e i n t e r v e n t i o n groups were a l s o a t l e a s t 75% of the maximum p o s s i b l e s u b s c a l e s c o r e . A l l t h r e e i n t e r v e n t i o n groups s c o r e d above 11 on the g e n e r a l s e l f - e s t e e m s c o r e , which r e p r e s e n t s the e x p e c t e d s c o r e f o r 50% of women ( B a t t l e 1976): group A, 13 + 3; group B, 12 + 2; and group C, 13 + 3. F i f t y p e r c e n t of women would be e x p e c t e d t o s c o r e between 6 and 7 on the s u b s c a l e "SOCIAL". The mean s c o r e f o r a l l t h r e e i n t e r v e n t i o n groups was 7 ± 1. On the s u b s c a l e "PERSONAL", 50% of women would be ex p e c t e d t o have a s c o r e of f o u r . A l l t h r e e i n t e r v e n t i o n means were i n exce s s of t h i s v a l u e : group A, 5 + 2 ; group B, 6 + 2 ; and group C, 5 + 2 . I t t h e r e f o r e appears t h a t women i n a l l t h r e e i n t e r v e n t i o n groups had above-average s e l f - e s t e e m s c o r e s . One-way a n a l y s i s of v a r i a n c e on mean s c o r e s among the i n t e r v e n t i o n groups r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e s . T h e r e f o r e , a l l t h r e e groups appeared comparable i n t h e i r 169 l e v e l s of s e l f - e s t e e m . H y p o t h e s i s 2.1: R e l a t i o n s h i p s Between S e l f - E s t e e m and Change i n A t t i t u d e  T a b l e 34 l i s t s Pearson product-moment c o r r e l a t i o n c o e f f i c i e n t s f o r r e l a t i o n s h i p s , w i t h p o o l e d d a t a , between s e l f - e s t e e m s c o r e s and p r e - , p o s t - and change v a l u e s f o r the o v e r - a l l a t t i t u d e s c o r e and i t s s u b s c a l e s . One s i g n i f i c a n t r e l a t i o n s h i p o c c u r r e d between s e l f -esteem and the p r e t e s t v a r i a b l e s f o r p o o l e d d a t a , between s e l f - e s t e e m s u b s c a l e "PERSONAL" and a t t i t u d e s u b s c a l e "RISK" (r=0.33, p < 0.01). Three r e l a t i o n s h i p s were p o s i t i v e and s i g n i f i c a n t w i t h the p o s t t e s t v a r i a b l e s : (1) between s e l f - e s t e e m s u b s c a l e "PERSONAL" and a t t i t u d e s u b s c a l e "RISK" (r=0.29, p < 0.01), and (2) between s e l f - e s t e e m o v e r - a l l s c a l e and a t t i t u d e s u b s c a l e "RISK" (r=0.25); and (3) between s e l f - e s t e e m s u b s c a l e "SOCIAL" and a t t i t u d e s u b s c a l e "RISK" ( r = 0.23). No s i g n i f i c a n t r e l a t i o n s h i p s were observed between s e l f - e s t e e m s c o r e s and change i n a t t i t u d e s c o r e s , f o r p o o l e d d a t a . T h e r e f o r e , a c r o s s d a t a from a l l t h r e e groups, the h i g h e r women's p e r s o n a l and s o c i a l s e l f - e s t e e m i n g e n e r a l , the more they f e l t a t r i s k of o s t e o p o r o s i s a t both p r e - and p o s t t e s t . T a b l e s 35, 36 and 37 p r e s e n t Pearson product-moment c o r r e l a t i o n c o e f f i c i e n t s f o r r e l a t i o n s h i p s between s e l f -170 Table 34: Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and ATTITUDE TOWARD DIETARY CALCIUM AND OSTEOPOROSIS f o r pooled data S e l f - E s t e e m S c a l e s S u b s c a l e s O v e r - a l 1 General P e r s o n a l S o c i a l P r e t e s t 0.21 1 ATTITUDE 0.13 0.16 0.06 ( f u l l scale=9 items) (n=75) (n=85) (n=88) (n=85) S u b s c a l e s : DIET AS A SOURCE OF 0.06 0.10 0.10 -0.02 CALCIUM (3 items) (n=76) (n=87) (n=90) (n=88) PERSONAL RISK FOR 0.20 0. 14 0.33 2 0.05 OSTEOPOROSIS (3 items) (n=75) (n=86) (n=88) (n=86) RELATIONSHIP BETWEEN DIETARY CALCIUM AND <0.01 0.12 0.01 0.03 OSTEOPOROSIS (3 items) (n=76) (n=88) (n=92) (n=90) P o s t t e s t ATTITUDE 0.10 0.11 0.12 0.10 ( f u l l scale=9 items) (n=73) (n=84) (n=86) (n=86) S u b s c a l e s : DIET AS A SOURCE OF 0.02 0.07 0.06 -0.002 CALCIUM (3 items) (n=75) (n=87) (n=90) (n=88) PERSONAL RISK FOR 0.25 1 0.17 0.29 2 0.23 1 OSTEOPOROSIS (3 items) (n=74) (n=85) (n=88) (n=88) RELATIONSHIP BETWEEN DIETARY CALCIUM AND -0.03 0.02 -0.08 0.05 OSTEOPOROSIS (3 items) (n=76) (n=87) (n=91) (n=89) Change from p r e - to p o s t t e s t ATTITUDE <0.01 <0.01 0.09 0.07 ( f u l l scale=9 items) (n=72) (n=81) (n=84) (n=82) S u b s c a l e s : DIET AS A SOURCE OF -0.03 -0.02 -0.02 0.02 CALCIUM (3 items) (n=75) (n=86) (n=89) (n=87) PERSONAL RISK FOR 0.03 0.02 -0.12 0.06 OSTEOPOROSIS (3 items) (n=73) (n=83) (n=85) (n=84) RELATIONSHIP BETWEEN DIETARY CALCIUM AND -0.03 -0.10 -0.08 -0.02 OSTEOPOROSIS (3 items) (n=76) (n=87) (n=90) (n=89) t w o - t a i l e d t e s t 1 p<0.05 2 p<0.01 3 p<0.001 171 esteem and a t t i t u d e s c o r e s f o r p o o l e d d a t a w i t h i n i n t e r v e n t i o n groups A, B and C r e s p e c t i v e l y . W i t h i n group A, no s i g n i f i c a n t r e l a t i o n s h i p s were noted f o r any of the d a t a . W i t h i n group B, f o r p o o l e d p r e t e s t d a t a , two s i g n i f i c a n t r e l a t i o n s h i p s o c c u r r e d : (1) between s e l f - e s t e e m s u b s c a l e "PERSONAL" and a t t i t u d e s u b s c a l e "RISK" ( r = 0.50, p < 0.001) and (2) between s e l f - e s t e e m s u b s c a l e "PERSONAL" and a t t i t u d e o v e r - a l l (r=0.32). For p o s t t e s t d a t a , s e v e r a l s i g n i f i c a n t r e l a t i o n s h i p s were observed w i t h i n group B: (1) between s e l f - e s t e e m s u b s c a l e "SOCIAL" and the o v e r - a l l a t t i t u d e s c o r e (r=0.36) as w e l l as i t s s u b s c a l e s "DIET" ( r = 0.31), and "RISK" (r = 0.44, p < 0.001); (2) between the o v e r - a l l s e l f - e s t e e m s c o r e and a t t i t u d e s u b s c a l e "RISK" (r = 0.36) and (3) between s e l f - e s t e e m s u b s c a l e "GENERAL" and a t t i t u d e s u b s c a l e "RELATIONSHIP" (r = -0.33) and (4) between s e l f - e s t e e m s u b s c a l e "PERSONAL" and a t t i t u d e s u b s c a l e "RISK" ( r = 0.39, p <. 0.01). Of note i s the f a c t t h a t one of the s i g n i f i c a n t r e l a t i o n s h i p s was n e g a t i v e , not c o n s i s t e n t w i t h the t r e n d of p o s i t i v e r e l a t i o n s h i p s seen p r e v i o u s l y w i t h p o o l e d data from a l l t h r e e groups. No s i g n i f i c a n t r e l a t i o n s h i p s e x i s t e d between s e l f -esteem and change s c o r e s . W i t h i n group C (Table 3 7 ) , f o r p o o l e d p r e t e s t d a t a , two p o s i t i v e s i g n i f i c a n t r e l a t i o n s h i p s were n o t e d , between s e l f -esteem s u b s c a l e "SOCIAL" and: (1) o v e r - a l l a t t i t u d e s c o r e ( r 1 72 T a b l e 35: Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and ATTITUDE TOWARD DIETARY CALCIUM AND OSTEOPOROSIS f o r pooled group A d a t a S e l f - E s t e e m S c a l e s P r e t e s t ATTITUDE ( f u l l scale=9 items) S u b s c a l e s : DIET AS A SOURCE OF CALCIUM (3 items) O v e r - a l 1 0.13 (n=25) 0.07 (n=26) General 0.22 (n=28) 0.07 (n=29) S u b s c a l e s P e r s o n a l 0.12 (n=27) 0. 16 (n=28) S o c i a l -0.11 (n=28) -0.18 (n=29) PERSONAL RISK FOR 0.15 0.24 0.14 OSTEOPOROSIS .(3 items) (n=25) (n=29) (n=27) -0.11 (n=29) RELATIONSHIP BETWEEN DIETARY CALCIUM AND 0.14 0.25 0.028 OSTEOPOROSIS (3 items) (n=26) (n=30) (n=28) P o s t t e s t ATTITUDE 0.15 0.23 0.17 ( f u l l scale=9 items) (n=24) (n=27) (n=25) S u b s c a l e s : DIET AS A SOURCE OF 0.05 0.12 0.10 CALCIUM (3 items) (n=25) (n=29) (n=27) 0.07 (n=30) - 0 1 1 (n=28) -0.21 (n=29) PERSONAL RISK FOR 0.26 0.29 0.31 OSTEOPOROSIS (3 items) (n=25) (n=28) (n=26) -0.003 (n=29) RELATIONSHIP BETWEEN DIETARY CALCIUM AND 0.20 0.28 0.11 OSTEOPOROSIS (3 items) (n=26) (n=29) (n=27) Change from p r e - to p o s t t e s t ATTITUDE 0.13 0.10 0.13 ( f u l l scale=9 items) (n=23) (n=25) (n=24) S u b s c a l e s : DIET AS A SOURCE OF <0.001 0.05 -0.05 CALCIUM (3 items) (n=25) (n=28) (n=27) PERSONAL RISK FOR 0.09 0.04 0.04 OSTEOPOROSIS (3 items) (n=24) (n=27) (n=25) 0.14 (n=30) 0.03 (n=26) -0.08 (n=28) 0.19 (n=28) RELATIONSHIP BETWEEN DIETARY CALCIUM AND 0.07 0.03 0.09 OSTEOPOROSIS (3 items) (n=26) (n=29) (n=27) 0.06 (n=30) t w o - t a i l e d t e s t 1 p<0.05 2 p<0.01 3 p<0.001 173 TabLe 36: Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and ATTITUDE TOWARD DIETARY CALCIUM AND OSTEOPOROSIS f o r pooled group B d a t a P r e t e s t ATTITUDE ( f u l l scale=9 items) S u b s c a l e s : DIET AS A SOURCE OF CALCIUM (3 items) O v e r - a l 1 0.15 (n=36) 0.09 (n=36) S e l f - E s t e e m S c a l e s S u b s c a l e s General 0.04 (n=39) 0 11 (n=39) P e r s o n a l 0.32 1 (n=42) 0.13 (n=43) S o c i a l 0. 18 (n=39) 0.16 (n=40) PERSONAL RISK FOR 0.25 -0.08 0.50 J OSTEOPOROSIS (3 items) (n=36) (n=39) (n=42) 0.09 (n=39) RELATIONSHIP BETWEEN DIETARY CALCIUM AND OSTEOPOROSIS (3 items) P o s t t e s t ATTITUDE ( f u l l scale=9 items) S u b s c a l e s : DIET AS A SOURCE OF CALCIUM (3 items) PERSONAL RISK FOR OSTEOPOROSIS (3 items) RELATIONSHIP BETWEEN DIETARY CALCIUM AND OSTEOPOROSIS (3 items) Change from p r e - to p o s t t e s t ATTITUDE ( f u l l scale=9 items) S u b s c a l e s : DIET AS A SOURCE OF CALCIUM (3 items) PERSONAL RISK FOR OSTEOPOROSIS (3 items) -0.09 (n=36) 0.12 (n=36) 0.03 (n=36) 0.36 1 (n=36) -0.27 (n=36) -0.04 (n=36) -0.06 (n=36) 0.14 (n=36) 0.06 (n=39) -0.01 (n=39) 0.07 (n=39) 0.14 (n=39) -0.33 1 (n=39) -0.06 (n=39) -0.03 (n=39) 0.23 (n=39) 0.03 (n=44) 0.21 (n=43) 0. 12 (n=44) 0.39 2 (n=44) -0.14 (n=44) -0. 14 (n=42) 0.02 (n=43) -0.12 (n=42) -0.04 (n=41) 0.36 1 (n=40) 0.31 1 (n=40) 0.44 2 (n=41) 0.01 (n=40) 0.21 (n=39) 0.23 (n=40) 0.23 (n=39) RELATIONSHIP BETWEEN DIETARY CALCIUM AND -0.15 -0.29 -0.15 OSTEOPOROSIS (3 items) (n=36) (n=39) (n=43) -0.06 (n=40) t w o - t a i l e d t e s t 1 p<0.05 2 p<0.01 3 p<0.001 174 Table 37: Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and ATTITUDE TOWARD DIETARY CALCIUM AND OSTEOPOROSIS f o r pooled group C d a t a S e l f - E s t e e m S c a l e s S u b s c a l e s P r e t e s t ATTITUDE ( f u l l scale=9 items) S u b s c a l e s : DIET AS A SOURCE OF CALCIUM (3 items) PERSONAL RISK FOR OSTEOPOROSIS (3 Ltems) RELATIONSHIP BETWEEN DIETARY CALCIUM AND OSTEOPOROSIS (3 Ltems) P o s t t e s t ATTITUDE ( f u l l scale=9 Ltems) S u b s c a l e s : DIET AS A SOURCE OF CALCIUM (3 items) PERSONAL RISK FOR OSTEOPOROSIS (3 Ltems) RELATIONSHIP BETWEEN DIETARY CALCIUM AND OSTEOPOROSIS (3 items) Change from p r e - to p o s t t e s t ATTITUDE ( f u l l scale=9 items) S u b s c a l e s : DIET AS A SOURCE OF CALCIUM (3 items) PERSONAL RISK FOR OSTEOPOROSIS (3 items) O v e r - a l 1 0.11 (n=14) -0.10 (n=14) 0.31 (n=14) -0. 13 (n=14) -0.13 (n=13) -0.13 (n=14) 0.01 (n=13) -0.13 (n=14) 0.26 (n=13) -0.10 (n=14) -0.32 (n=13) General 0.31 (n=18) 0.16 (n=19) 0.35 (n=18) 0.03 (n=19) -0.01 (n=18) -0.06 (n=19) 0.01 (n=18) 0.06 (n=19) -0.33 (n=17) -0.19 (n=19) -0.36 (n=17) P e r s o n a l 0.10 (n=19) -0.13 (n=19) 0.27 (n=19) -0.04 (n=20) -0.20 (n=18) -0.16 (n=19) 0.01 (n=18) -0.18 (n=20) -0.31 (n=18) -0.08 (n=19) -0.34 (n=18) S o c i a l 0.56 1 (n=18) 0.19 (n=19) 0.66 2 (n=18) 0.09 (n=19) 0.29 (n=18) 0.02 (n=19) 0.43 (n=18) -0.03 (n=19) -0.25 (n=17) -0.16 (n=19) -0.22 (n=17) RELATIONSHIP BETWEEN DIETARY CALCIUM AND 0.02 0.03 1 -0.15 OSTEOPOROSIS (3 items) (n=14) (n=19) (n=20) -0.12 (n=19) t w o - t a i l e d t e s t 1 p<0.05 2 p<0.01 3 p<0.001 175 =0.56) and (2) a t t i t u d e s u b s c a l e "RISK" (r = 0.66, p< 0.01). No s i g n i f i c a n t r e l a t i o n s h i p s o c c u r r e d between s e l f -esteem and p o s t t e s t d a t a . One p o s i t i v e s i g n i f i c a n t r e l a t i o n s h i p o c c u r r e d w i t h the change d a t a : between s e l f - e s t e e m s u b s c a l e "GENERAL" and a t t i t u d e s u b s c a l e "RELATIONSHIP" ( r = 0.03). No s i g n i f i c a n t r e l a t i o n s h i p s were noted w i t h data p o o l e d from a l l t h r e e i n t e r v e n t i o n groups, as w e l l as w i t h i n groups, f o r "below RNI" d a t a (Appendix J ) . T h i s i s l i k e l y due t o reduced sample s i z e s a s s o c i a t e d w i t h "below RNI" d a t a . In summary, some s i g n i f i c a n t r e l a t i o n s h i p s between a t t i t u d e , e s p e c i a l l y s u b s c a l e "RISK", and s e l f - e s t e e m s u b s c a l e s o c c u r r e d and the s e tended, o v e r - a l l , t o be p o s i t i v e . No s i g n i f i c a n t r e l a t i o n s h i p s were noted between the o v e r - a l l s e l f - e s t e e m s c o r e and change i n the o v e r - a l l a t t i t u d e s c o r e . C o n s e q u e n t l y , h y p o t h e s i s 2.1 was not s u p p o r t e d . In c h a p t e r 1 (page 7 ) , a model was p r o v i d e d of the a n t i c i p a t e d r e l a t i o n s h i p between s e l f - e s t e e m and change i n a t t i t u d e toward d i e t a r y c a l c i u m and o s t e o p o r o s i s . The l a c k of c o n s i s t e n t r e l a t i o n s h i p s , e s p e c i a l l y between the two o v e r - a l l s c a l e s , s u g g e s t s a weaker r e l a t i o n s h i p between s e l f - e s t e e m and a t t i t u d e than had been proposed. The r e l a t i o n s h i p was i n i t i a l l y d e s c r i b e d based upon c o n s i s t e n t a s s o c i a t i o n s found i n h e a l t h e d u c a t i o n l i t e r a t u r e between s e l f - e s t e e m l e v e l s and h e a l t h - r e l a t e d b e h a v i o u r . 176 A t t i t u d e s were assumed t o be e x p r e s s i o n s of b e h a v i o u r , such t h a t the more f a v o u r a b l e the b e h a v i o u r , the more f a v o u r a b l e might be the a t t i t u d e . I t was proposed, t h e r e f o r e , t h a t the h i g h e r the l e v e l of s e l f - e s t e e m , the g r e a t e r would be the p o t e n t i a l f o r p o s i t i v e change due t o i n t e r v e n t i o n . However, a s t r o n g r e l a t i o n s h i p between s e l f - e s t e e m and change i n a t t i t u d e toward d i e t a r y c a l c i u m and o s t e o p o r o s i s was not i d e n t i f i e d i n t h i s s t u d y . T h e r e f o r e , the r e l a t i o n s h i p between s e l f - e s t e e m and a t t i t u d e may be independent of i n t e r v e n t i o n such t h a t l e v e l s of s e l f - e s t e e m may not p r e d i c t the amount of change i n a t t i t u d e an i n d i v i d u a l i s l i k e l y t o make as a r e s u l t of i n t e r v e n t i o n . 1 77 H y p o t h e s i s 2.2: R e l a t i o n s h i p s Between S e l f - E s t e e m and Change i n P e r c e p t i o n of Problem S o l v i n g A b i l i t y In g e n e r a l , s c o r e s on p e r c e p t i o n of problem s o l v i n g a b i l i t y c o r r e l a t e d p o s i t i v e l y and s i g n i f i c a n t l y w i t h s e l f -esteem s c o r e s . T a b l e 38 l i s t s the Pearson product-moment c o r r e l a t i o n s f o r p o o l e d data f o r r e l a t i o n s h i p s between p e r c e p t i o n s c o r e s and s e l f - e s t e e m . For a l l p r e t e s t d a t a , s e v e r a l p o s i t i v e s i g n i f i c a n t c o r r e l a t i o n s were no t e d : (1) between the o v e r - a l l s e l f -esteem s c o r e and o v e r - a l l p e r c e p t i o n s c o r e ( r = 0.28) and p e r c e p t i o n s u b s c a l e "PLAN" (r = 0.29, p < 0.01); (2) between s e l f - e s t e e m s u b s c a l e "GENERAL" and o v e r - a l l p e r c e p t i o n s c o r e ( r = 0.27, p <. 0.01) and p e r c e p t i o n s u b s c a l e "PLAN" ( r 0.28, p < 0.01) and (3) between s e l f - e s t e e m s u b s c a l e "PERSONAL" and o v e r - a l l p e r c e p t i o n s c o r e ( r = 0.26). For p o o l e d p o s t t e s t d a t a , p o s i t i v e s i g n i f i c a n t r e l a t i o n s h i p s o c c u r r e d between a l l p o s s i b l e r e l a t i o n s h i p s of s e l f - e s t e e m t o p e r c e p t i o n , except one: self-est.eem s u b s c a l e "SOCIAL" and p e r c e p t i o n s u b s c a l e "IDENTIFY". H a l f of the p o s s i b l e r e l a t i o n s h i p s between s e l f - e s t e e m and change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y were p o s i t i v e and s i g n i f i c a n t l y c o r r e l a t e d . Among these was the r e l a t i o n s h i p between o v e r - a l l s e l f - e s t e e m and change i n the o v e r - a l l p e r c e p t i o n s c o r e ( r = 0.30, p .< 0.01). In summary, f o r p o o l e d d a t a , p o s i t i v e s i g n i f i c a n t r e l a t i o n s h i p s e x i s t e d between the o v e r - a l l s c o r e f o r s e l f -esteem and change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y , as w e l l as between t h e i r r e s p e c t i v e s u b s c a l e s . T h e r e f o r e , 178 T a b l e 38: Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and PERCEPTION OF PROBLEM SOLVING ABILITY f o r pooled d a t a . S e l f - E s t e e m S c a l e s S u b s c a l e s O v e r - a l l G e n e ral P e r s o n a l S o c i a l P r e t e s t PERCEPTION ( f u l l scale=9 items) S u b s c a l e s : PROBLEM IDENTIFICATION (3 items) GOAL PLANNING (3 items) GOAL ACHIEVEMENT (3 items) P o s t e s t PERCEPTION ( f u l l scale=9 items) S u b s c a l e s : PROBLEM IDENTIFICATION (3 items) GOAL PLANNING (3 items) GOAL ACHIEVEMENT (3 items) Change from p r e - to p o s t t e s t PERCEPTION ( f u l l scale=9 items) S u b s c a l e s : PROBLEM IDENTIFICATION (3 items) GOAL PLANNING (3 items) GOAL ACHIEVEMENT (3 items) 0.28 1 (n=73) 0.27 2 (n=85) 0.26 1 (n=87) 0.07 (n=85) 0.14 (n=7 5) 0.10 (n=87) 0.17 (n=90) 0.01 (n=89) 0.29 2 (n=75) 0.28 2 (n=87) 0.19 (n=90) 0. 15 (n=88) 0.25 (n=74) 0.29 (n=86) 0.23 (n=88) -0.04 (n=87) 0.52 3 (n=73) 0.50 3 (n=84) 0.41 3 (n=89) 0.26 1 (n=87) 0.32 2 (n=73) 0.26 1 (n=85) 0.32 2 (n=90) 0.16 (n=87) 0.53 3 (n=76) 0.51 3 (n=88) 0.36 3 (n=93) 0.30 2 (n=90) 0.51 3 (n=76) 0.54 3 (n=87) 0.34 3 (n=92) 0.23 1 (n=90) 0.30 2 (n=70) 0.30 2 (n=81) 0. 16 (n=83) 0.28 2 (n=82) 0.26 1 (n=72) 0.22 1 (n=84) 0.18 (n=87) 0.18 (n=86) 0.31 2 (n=75) 0.32 2 (n=87) 0.19 (n=90) 0.20 (n=88) 0.20 (n=74) 0.20 (n=85) 0.08 (n=87) 0.26 2 (n=87) t w o - t a i l e d t e s t 1 p<0.05 2 p<0.01 3 p<0.001 179 the h i g h e r women's l e v e l s of s e l f - e s t e e m , the h i g h e r were t h e i r p e r c e p t i o n s of problem s o l v i n g a b i l i t i e s a t both p r e -and p o s t t e s t , and the g r e a t e r the change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y . W i t h i n the t h r e e i n t e r v e n t i o n groups ( T a b l e s 39, 40 and 41) s i g n i f i c a n t r e l a t i o n s h i p s were a l s o a p p a r e n t . The p a t t e r n of r e l a t i o n s h i p s e v i d e n c e d w i t h p o o l e d data was r e f l e c t e d w i t h i n group A. W i t h p r e t e s t d a t a , two of the p r e v i o u s l y - i d e n t i f i e d r e l a t i o n s h i p s were no l o n g e r s i g n i f i c a n t : (1) between the o v e r - a l l s e l f - e s t e e m s c o r e and the o v e r - a l l p e r c e p t i o n s c o r e and (2) between s e l f - e s t e e m s u b s c a l e "GENERAL" and the o v e r - a l l p e r c e p t i o n s c o r e . A p o s i t i v e s i g n i f i c a n t r e l a t i o n s h i p was i d e n t i f i e d between s e l f - e s t e e m s u b s c a l e "PERSONAL" and p e r c e p t i o n s u b s c a l e "PLAN" ( r = 0.38) . With r e s p e c t t o p o s t t e s t group A d a t a , the p a t t e r n of r e l a t i o n s h i p s was i d e n t i c a l t o t h a t f o r p o o l e d d a t a . Changes i n p e r c e p t i o n were p o s i t i v e l y and s i g n i f i c a n t l y c o r r e l a t e d w i t h s e l f - e s t e e m s c o r e s f o r a l l but one r e l a t i o n s h i p : s e l f - e s t e e m s u b s c a l e "PERSONAL" and p e r c e p t i o n s u b s c a l e "ACHIEVE". I n t e r v e n t i o n group A e x p e r i e n c e d a s i g n i f i c a n t d e c r e a s e i n p e r c e p t i o n of problem s o l v i n g a b i l i t y , making more l i k e l y the d e t e c t i o n of a r e l a t i o n s h i p between s e l f - e s t e e m and change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y . D e s p i t e the s i g n i f i c a n t , p o s i t i v e r e l a t i o n s h i p between s e l f - e s t e e m and change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y observed w i t h i n group A, the mean o v e r - a l l 180 T a b l e 39: Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and PERCEPTION OF PROBLEM SOLVING ABILITY f o r pooled group A d a t a P r e t e s t PERCEPTION ( f u l l scale=9 items) S u b s c a l e s : PROBLEM IDENTIFICATION (3 items) GOAL PLANNING (3 items) GOAL ACHIEVEMENT (3 items) P o s t t e s t PERCEPTION ( f u l l scale=9 items) S u b s c a l e s : PROBLEM IDENTIFICATION (3 items) GOAL PLANNING (3 items) GOAL ACHIEVEMENT (3 items) Change from p r e - to p o s t t e s t PERCEPTION ( f u l l scale=9 items) S u b s c a l e s : PROBLEM IDENTIFICATION (3 items) GOAL PLANNING (3 items) GOAL ACHIEVEMENT (3 items) S e l f - E s t e e m S c a l e s General P e r s o n a l S o c i a l O v e r - a l 1 0.34 (n=25) 0:20 (n=26) 0.45 1 (n=25) 0.26 (n=25) 0.73 3 (n=25) 0.54 2 (n=25) 0.73 3 (n=26) 0.75 3 (n=26) 0.29 (n=29) 0. 15 (n=30) 0.42 1 (n=29) 0.21 (n=29) 0. 71 3 (n=29) 0.47 2 (n=29) 0.73 3 (n=30) 0.75 3 (n=30) Su b s c a l e s — 0.37 (n=27) 0.27 (n=28) 0.38 1 (n=27) 0.27 (n=27) 0.66 3 (n=27) 0.61 3 (n=27) 0.60 3 (n=28) 0.61 3 (n=28) 0.08 (n=28) -0.03 (n=30) 0.31 (n=28) -0.05 (n=29) 0.43 1 (n=29) 0.22 (n=29) 0.48 2 (n=30) 0.50 2 (n=30) 0.71 3 (n=24) 0.58 2 (n=25) 0.53 2 (n=25) 0. 51 2 (n=25) 0.74 3 (n=28) 0.50 2 (n=29) 0.60 3 (n=29) 0.51 2 (n=29) 0.48 2 (n=26) 0.57 2 (n=27) 0.38 1 (n=27) 0.28 (n=27) 0.65 3 (n=27) 0.37 1 (n=29) 0.39 1 (n=28) 0.56 2 (n=29) t w o - t a i l e d t e s t 1 p<0.05 2 p<0.01 p<0.001 181 T a b l e 40: Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and PERCEPTION OF PROBLEM SOLVING ABILITY f o r pooled group B d a t a S e l f - E s t e e m S c a l e s S u b s c a l e s P r e t e s t PERCEPTION ( f u l l scale=9 items) S u b s c a l e s : PROBLEM IDENTIFICATION (3 items) O v e r - a l 1 0.27 (n=34) 0.21 (n=35) General 0.26 (n=37) 0. 18 (n=38) P e r s o n a l 0.12 (n=42) 0.10 (n=43) S o c i a l 0. 16 (n=39) 0.09 (n=40) GOAL PLANNING (3 items) 0.30 (n=36) 0.26 (n=39) 0.18 (n=44) 0.21 (n=41) GOAL ACHIEVEMENT (3 items) 0.13 (n=35) 0.22 (n=38) 0.02 (n=43) 0.01 (n=40) P o s t t e s t PERCEPTION ( f u l l scale=9 items) S u b s c a l e s : PROBLEM IDENTIFICATION (3 items) 0.27 (n=35) 0.16 (n=35) 0.12 (n=37) -0.08 (n=38) 0.29 (n=43) 0.21 (n=44) 0.28 (n=40) 0.19 (n=40) GOAL PLANNING (3 items) 0.30 (n=36) 0.22 (n=39) 0.22 (n=45) 0.36 1 (n=41) GOAL ACHIEVEMENT (3 items) 0.15 (n=36) 0.15 (n=38) 0.19 (n=44) 0.09 (n=41) Change from p r e - to p o s t t e s t PERCEPTION -0.02 -0.16 0.14 ( f u l l scale=9 items) (n=33) (n=35) (n=40) S u b s c a l e s : PROBLEM IDENTIFICATION -0.09 -0.26 0.06 (3 items) (n=34) (n=37) (n=42) 0.09 (n=38) 0.03 (n=39). GOAL PLANNING (3 items) 0.07 (n=36) 0.02 (n=39) 0.07 (n=44) 0. 19 (n=41) GOAL ACHIEVEMENT (3 items) -0.03 (n=35) -0.11 (n=37) 0.13 (n=42) 0.07 (n=40) t w o - t a i l e d t e s t 1 p<0.05 2 p<0.01 3 p<0.001 182 T a b l e 41: Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and PERCEPTION OF PROBLEM SOLVING ABILITY f o r pooled group C d a t a P r e t e s t PERCEPTION ( f u l l scale=9 items) S u b s c a l e s : PROBLEM IDENTIFICATION (3 items) GOAL PLANNING (3 items) GOAL ACHIEVEMENT (3 items) P o s t t e s t PERCEPTION ( f u l l scale=9 items) S u b s c a l e s : PROBLEM IDENTIFICATION (3 items) GOAL PLANNING (3 items) GOAL ACHIEVEMENT (3 items) Change from p r e - to p o s t t e s t PERCEPTION ( f u l l scale=9 items) S u b s c a l e s : PROBLEM IDENTIFICATION (3 items) GOAL PLANNING (3 items) GOAL ACHIEVEMENT (3 items) S e i f - E s t e e m S c a l e s General P e r s o n a l S o c i a l O v e r - a l 1 0.24 (n=14) 0.02 (n=14) 0.08 (n=14) 0.45 (n=14) 0.30 (n=19) 0.01 (n=19) 0.16 (n=19) 0.51 1 (n=19) Su b s c a l e s 0.35 (n=18) 0.14 (n=19) -0.003 (n=19) 0.53 1 (n=18) -0.10 (n=18) 0.05 (n=19) -0.31 (n=19) -0.09 (n=18) 0.25 0.44 0.20 -0.28 (n=13) (n=18) (n=19) (n=18) 0.03 0.20 0.05 0.03 (n=13) (n=18) (n=19) (n=18) 0.35 0.42 0.25 -0.52 1 (n=14) (n=19) (n=20) (n=19) 0.33 0.54 1 0.19 -0.26 (n=14) (n=19) (n=20) (n=19) -0.02 0.19 -0.16 -0.18 (n=13) ,(n=18) (n=17) (n=17) -0.03 0.31 -0.34 0.00 (n=13) (n=18) (n=18) (n=18) 0.28 0.24 0.25 -0.19 (n=14) (n=19) (n=19) (n=19) -0.28 -0.09 -0.24 -0.12 (n=14) (n=19) (n=18) (n=18) t w o - t a i l e d t e s t 1 p<0.05 2 p<0.01 3 p<0.001 183 p e r c e p t i o n s c o r e d e c r e a s e d w i t h i n t h i s group. The s i g n i f i c a n t d e c r ease i n mean change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y may have r e s u l t e d from extreme d e c r e a s e s i n some i n d i v i d u a l v a l u e s . As a r e s u l t , f o r the m a j o r i t y of women w i t h i n i n t e r v e n t i o n group A, the r e l a t i o n s h i p between s e l f - e s t e e m and p e r c e p t i o n of problem s o l v i n g a b i l i t y was s t i l l t r u e . W i t h i n group B, no s i g n i f i c a n t r e l a t i o n s h i p s were i d e n t i f i e d between s e l f - e s t e e m and p r e t e s t , p o s t t e s t or change d a t a . A r e l a t i o n s h i p between s e l f - e s t e e m and change was not l i k e l y s i n c e group B e x p e r i e n c e d no change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y . Only two p o s i t i v e s i g n i f i c a n t r e l a t i o n s h i p s o c c u r r e d w i t h group C p r e t e s t d a t a : (1) between s e l f - e s t e e m s u b s c a l e "GENERAL" and p e r c e p t i o n s u b s c a l e "ACHIEVE" ( r = 0.51) and (3) between s e l f - e s t e e m s u b s c a l e "PERSONAL" and p e r c e p t i o n s u b s c a l e "ACHIEVE" ( r = 0.53). Two s i g n i f i c a n t r e l a t i o n s h i p s e x i s t e d w i t h p o s t t e s t d a t a , one p o s i t i v e , between s e l f - e s t e e m s u b s c a l e "GENERAL" and p e r c e p t i o n s u b s c a l e s "ACHIEVE" (r = 0.54); and one n e g a t i v e , between s e l f - e s t e e m s u b s c a l e "SOCIAL" and p e r c e p t i o n s u b s c a l e "PLAN" ( r = -0.52). No s i g n i f i c a n t r e l a t i o n s h i p s were noted between s e l f -esteem s c o r e s and change s c o r e s on p e r c e p t i o n of problem s o l v i n g a b i l i t y w i t h i n group C. Group C d i d not e x p e r i e n c e a s i g n i f i c a n t change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y from p r e - t o p o s t t e s t . For p o o l e d "below RNI" d a t a , the t r e n d of p o s i t i v e 184 s i g n i f i c a n t r e l a t i o n s h i p s p e r s i s t e d d e s p i t e reduced sample s i z e s (Appendix J ) . As was the case w i t h p o o l e d w i t h i n group d a t a , "below RNI" da t a f o r group A most c o n s i s t e n t l y r e f l e c t e d t he p a t t e r n seen w i t h p o o l e d d a t a from a l l t h r e e groups. In summary, a t r e n d i n r e l a t i o n s h i p s f o r p o o l e d d a t a suggested t h a t the h i g h e r a woman's l e v e l of s e l f - e s t e e m , the h i g h e r would be her p r e - and p o s t t e s t s c o r e on p e r c e p t i o n of her problem s o l v i n g a b i l i t y . A l s o , the h i g h e r her l e v e l of s e l f - e s t e e m , the g r e a t e r would be the change i n p e r c e p t i o n of her problem s o l v i n g a b i l i t y . T h i s p a t t e r n was most e v i d e n t w i t h i n group A. H y p o t h e s i s 2.2 was t h e r e f o r e s u p p o r t e d . These r e s u l t s a r e s i m i l a r t o c o r r e l a t i o n a l a n a l y s i s r e p o r t e d by B a t t l e (1976) i n which he i d e n t i f i e d a s i g n i f i c a n t p o s i t i v e r e l a t i o n s h i p between s e l f - e s t e e m s c o r e s and elementary s t u d e n t s ' p e r c e p t i o n s of t h e i r g e n e r a l academic a b i l i t i e s ( r = 0.70, p < 0.01). U n f o r t u n a t e l y , B a t t l e has not r e p o r t e d s i m i l a r work w i t h a d u l t s , u s i n g the a d u l t v e r s i o n of h i s s e l f - e s t e e m s c a l e . R e s u l t s from t h i s s t u d y a r e a l s o c o n s i s t e n t w i t h the r e s e a r c h by Schwalbe et a l . (1986). These workers found p o s i t i v e s i g n i f i c a n t r e l a t i o n s h i p s between working women's l e v e l s of s e l f - e s t e e m and t h e i r p e r c e i v e d competence i n the workplace ( r = 0.18, p < 0.01). The a u t h o r s proposed t h a t a h i g h f e e l i n g of p e r s o n a l competence may have a f a v o u r a b l e e f f e c t on womens' s e l f - e s t e e m , though a c a u s a l r e l a t i o n s h i p 185 has y e t t o be d e f i n e d . From the r e s u l t s of t h i s s t u d y , as w e l l as the work by B a t t l e (1976) and Schwalbe e t a l . (1986), i t c o u l d be argued t h a t p e r c e p t i o n of problem s o l v i n g a b i l i t y i s a c o r r e l a t e of g e n e r a l s e l f - e s t e e m . As a r e s u l t , a h i g h e r p e r c e p t i o n of p e r c e p t i o n of problem s o l v i n g a b i l i t y would c o n t r i b u t e t o a h i g h e r l e v e l of s e l f - e s t e e m . T h i s s u g g e s t i o n i s a l s o s u p p o r t e d by Moon (1976) who d e s c r i b e d a model i n which an i n d i v i d u a l ' s p e r c e p t i o n of h i s / h e r performance impacts d i r e c t l y on s e l f - c o n c e p t , of which s e l f - e s t e e m i s a component. I t i s , t h e r e f o r e , not s u r p r i s i n g t h a t a p o s t i v e s i g n i f i c a n t r e l a t i o n s h i p e x i s t e d between g l o b a l p e r c e p t i o n of problem s o l v i n g a b i l i t y and g l o b a l s e l f - e s t e e m , as measured i n t h i s s t u d y . H y p o t h e s i s 2.3: R e l a t i o n s h i p s Between S e l f - E s t e e m and Change i n D i e t a r y C a l c i u m I n t a k e  Table 42 l i s t s the Pearson product-moment c o r r e l a t i o n s between d i e t a r y c a l c i u m i n t a k e and s e l f - e s t e e m s c o r e s f o r po o l e d d a t a . For p o o l e d d a t a from a l l t h r e e groups, one p o s i t i v e s i g n i f i c a n t r e l a t i o n s h i p e x i s t e d , between . s e l f - e s t e e m s u b s c a l e "PERSONAL" and p o s t t e s t d i e t a r y c a l c i u m i n t a k e ( r = 0.22) . W i t h i n group A, one p o s i t i v e s i g n i f i c a n t c o r r e l a t i o n was observed between s e l f - e s t e e m s u b s c a l e "GENERAL" and p o s t t e s t i n t a k e (r = 0.42). One p o s i t i v e s i g n i f i c a n t r e l a t i o n s h i p o c c u r e d i n group 186 T a b l e 42: Pearson c o r r e l a t i o n c o e f f i c i e n t s between s e l f - e s t e e m s c a l e s and d i e t a r y c a l c i u m i n t a k e S e l f - E s t e e m S c a l e s — S u b s c a l e s — F o r a l l pooled d a t a O v e r - a l 1 General P e r s o n a l S o c i a l P r e t e s t 0.04 (n=72) 0.07 (n=82) 0.07 (n=86) -0.15 (n=86) P o s t t e s t 0. 18 (n=71) 0.13 (n=83) 0.22 1 (n=86) 0.04 (n=84) Change from p r e -to p o s t t e s t 0.08 (n=67) -0.01 (n=77) 0.13 (n=79) 0.21 (n=80) For pooled Group A d a t a P r e t e s t 0.10 (n=24) 0. 16 (n=27) 0. 13 (n=25) -0.15 (n=28) P o s t t e s t 0.38 (n=23) 0.42 1 (n=27) 0.36 (n=25) 0. 10 (n=27) Change from p r e -to p o s t t e s t 0.23 (n=21) 0.17 (n=24) 0.20 (n=22) 0.27 (n=25) F o r pooled Group B d a t a P r e t e s t -0.07 (n=34) 0.05 (n=36) -0.004 (n=41) -0.07 (n=39) P o s t t e s t 0.18 (n=35) -0.06 (n=38) 0.28 (n=42) 0.28 (n=39) Change from p r e -to p o s t t e s t 0.22 (n=33) -0.09 (n=35) 0.27 (n=38) 0.36 1 (n=37) For pooled Group C d a t a P r e t e s t 0.06 (n=14) -0.08 (n=19) 0.05 (n=20) -0.28 (n=19) P o s t t e s t -0.30 (n=13) -0.16 (n=18) -0.05 (n=19) -0.72 3 (n=18) Change from p r e -to p o s t t e s t -0.46 (n=13) -0.10 (n=18) -0.11 (n=19) -0.37 (n=18) t w o - t a i l e d t e s t 1 p£0.05 2 p<0.01 3 p<_0.001 187 B d a t a , between s e l f - e s t e e m s u b s c a l e "SOCIAL" and change i n i n t a k e ( r = 0.36). W i t h i n group C, one r e l a t i o n s h i p was s i g n i f i c a n t , a l t h o u g h n e g a t i v e , between s e l f - e s t e e m s u b s c a l e "SOCIAL" and p o s t t e s t i n t a k e ( r = -0.72, p < 0.001). The m a j o r i t y of c o r r e l a t i o n c o e f f i c i e n t s f o r r e l a t i o n s h i p s w i t h group C d a t a were n e g a t i v e . Only one r e l a t i o n s h i p was n e g a t i v e i n group A and f i v e , of a p o s s i b l e 12, i n group B. For p o o l e d "below RNI" d a t a (Appendix J ) , a few p o s i t i v e s i g n i f i c a n t r e l a t i o n s h i p s e x i s t e d , s i m i l a r t o those o b s e r v e d w i t h a l l p o o l e d d a t a and w i t h i n group d a t a . In summary, no s i g n i f i c a n t r e l a t i o n s h i p s were noted f o r p o o l e d d a t a between the o v e r - a l l s e l f - e s t e e m s c o r e and change i n d i e t a r y c a l c i u m i n t a k e . Trends i n r e l a t i o n s h i p s were not c o n s i s t e n t w i t h i n the t h r e e i n t e r v e n t i o n groups. S e l f - e s t e e m s c o r e s w i t h i n group B, and t o a l e s s e r e x t e n t , group C tended t o be s i g n i f i c a n t l y r e l a t e d t o p o s t t e s t d i e t a r y c a l c i u m i n t a k e s . Yet some of the r e l a t i o n s h i p s between s e l f - e s t e e m and change i n c a l c i u m i n t a k e were p o s i t i v e w i t h i n group B and n e g a t i v e w i t h i n group C. The group h a v i n g the p a t t e r n of r e l a t i o n s h i p s most c o n s i s t e n t w i t h t h a t of p o o l e d data was group A. G i v e n the l a c k of r e l a t i o n s h i p s between the o v e r - a l l s e l f - e s t e e m s c o r e and change i n d i e t a r y c a l c i u m i n t a k e , as w e l l as the v a r i a b l e w i t h i n - g r o u p p a t t e r n of r e l a t i o n s h i p s , H y p o t h e s i s 2.3 was not s u p p o r t e d . In c h a p t e r I (page 7 ) , i t was p o s t u l a t e d t h a t a s t r o n g 188 r e l a t i o n s h i p might e x i s t between s e l f - e s t e e m and change i n d i e t a r y b e h a v i o u r g i v e n s upport i n the l i t e r a t u r e f o r g r e a t e r use of h e a l t h - r e l a t e d b e h a v i o u r among i n d i v i d u a l s w i t h h i g h e r l e v e l s of s e l f - e s t e e m ( H a l l e l 1982; L i t t e t a l . 1982; P l a t h and B e l z e r 1985). The proposed r e l a t i o n s h i p was not s u p p o r t e d by r e s u l t s of t h i s s t u d y . Neale et a l . (1969), however, d i d not f i n d a p o s i t i v e s i g n i f i c a n t c o r r e l a t i o n between l e v e l s of s e l f - e s t e e m and h e a l t h - r e l a t e d b e h a v i o u r s . None of the above s t u d i e s , though, r e l a t e d l e v e l s of s e l f - e s t e e m t o program impact on d i e t a r y b e h a v i o u r . No such s t u d i e s c o u l d be found i n the n u t r i t i o n e d u c a t i o n l i t e r a t u r e . For Research Q u e s t i o n 3 I s t h e r e a s i g n i f i c a n t d i f f e r e n c e i n women's: a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s ; p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t y and t h e i r d i e t a r y p r a c t i c e s among groups d e f i n e d i n terms of the f o l l o w i n g v a r i a b l e s : (a) demographic v a r i a b l e s : ( i ) age ( i i ) employment s t a t u s ( i i i ) e d u c a t i o n (b) d i e t a r y v a r i a b l e s ( i ) a l l e r g y or i n t o l e r a n c e t o m i l k or m i l k p r o d u c t s ( i i ) s e a s o n a l v a r i a t i o n i n use of m i l k or m i l k p r o d u c t s ( i i i ) use of a c a l c i u m - c o n t a i n i n g supplement ( i v ) weight f o r h e i g h t (v) use of a s p e c i a l d i e t 189 (c) m i s c e l l a n e o u s v a r i a b l e s ( i ) adherence t o the problem s o l v i n g s t e p s ( i i ) awareness of o s t e o p o r o s i s ? N u l l h y p o t h e s i s 3.1 t o 4.0 were t e s t e d t o answer the above q u e s t i o n . A n a l y s i s of v a r i a n c e , f o l l o w e d by a S c h e f f e range t e s t , was used t o t e s t the e f f e c t s of the l i s t e d independent v a r i a b l e s on mean change s c o r e s i n the dependent v a r i a b l e s . E f f e c t s on Change i n A t t i t u d e Toward D i e t a r y C a l c i u m and O s t e o p o r o s i s . Two c o m b i n a t i o n s of independent v a r i a b l e s produced s i g n i f i c a n t e f f e c t s on change i n a t t i t u d e toward d i e t a r y c a l c i u m and o s t e o p o r o s i s : (1) a l l e r g y , by use of a supplement a t p r e t e s t , by use of a s p e c i a l d i e t (F = 6.17, df = 1, p < 0.01); and (2) a l l e r g y , by use of a supplement a t p o s t t e s t , by use of a s p e c i a l d i e t (F = 5.86, df = 1). A S c h e f f e t e s t c o u l d not be performed f o r e i t h e r due t o i n s u f f i c i e n t c e l l s i z e s . From the a n a l y s i s of v a r i a n c e i t appeared t h a t women who were on a s p e c i a l d i e t y e t d i d not have an a l l e r g y or i n t o l e r a n c e t o m i l k or m i l k p r o d u c t s and d i d not use a supplement, had a change i n a t t i t u d e s c o r e below the grand mean. The o p p o s i t e was t r u e of women who were on a s p e c i a l d i e t y e t d i d have an a l l e r g y or i n t o l e r a n c e and used a supplement. P a t t e r n s were, t h e r e f o r e , d i f f e r e n t among women on a s p e c i a l d i e t when grouped by use of a supplement and use of a s p e c i a l d i e t . The g r e a t e s t change above the grand 190 mean o c c u r r e d among women who had an a l l e r g y or i n t o l e r a n c e t o m i l k or m i l k p r o d u c t s and d i d not use a supplement. The l a t t e r o b s e r v a t i o n , however, may not be r e l i a b l e s i n c e t he c e l l s i z e f o r t h i s c a t e g o r y was v e r y s m a l l . Women who d i d not r e p o r t u s i n g a s p e c i a l d i e t e x p e r i e n c e d changes above the grand mean i f they d i d not have an a l l e r g y or i n t o l e r a n c e and used a supplement, as w e l l as i f they n e i t h e r had an a l l e r g y nor used a supplement. The g r e a t e s t change above t h e grand mean o c c u r r e d among women from the l a t t e r c a t e g o r y , though c e l l s i z e s were s m a l l once a g a i n . Use of a s p e c i a l d i e t i t s e l f had a s i g n i f i c a n t main e f f e c t upon change i n a t t i t u d e (F = 5.64, df =1). Women who were not on a s p e c i a l d i e t had a g r e a t e r mean change than d i d those who were on a s p e c i a l d i e t . P a t t e r n s d e s c r i b e d above were a l s o i d e n t i f i e d w i t h the s i g n i f i c a n t i n t e r a c t i o n of a l l e r g y or i n t o l e r a n c e t o m i l k or m i l k p r o d u c t s by use of a supplement a t p o s t t e s t by use of a s p e c i a l d i e t . T h e r e f o r e , d i e t a r y c h a r a c t e r i s t i c s had some s i g n i f i c a n t e f f e c t s on change i n a t t i t u d e toward d i e t a r y c a l c i u m and o s t e o p o r o s i s . P a t t e r n s of change were d i f f e r e n t among women on a s p e c i a l d i e t . I t i s p o s s i b l e t h a t women on a s p e c i a l d i e t d i f f e r i n a t t i t u d e toward d i e t a r y c a l c i u m and o s t e o p o r o s i s from those who a r e not on a s p e c i a l d i e t . The l a t t e r e x p e r i e n c e d g r e a t e r impacts on a t t i t u d e toward d i e t a r y c a l c i u m and o s t e o p o r o s i s . I t s h o u l d a l s o be noted 191 t h a t no more than 10 p e r c e n t of study p a r t i c i p a n t s r e p o r t e d an a l l e r g y or i n t o l e r a n c e t o m i l k or m i l k p r o d u c t s , and o n l y o n e - t h i r d of p a r t i c i p a n t s r e p o r t e d u s i n g a s p e c i a l d i e t . E f f e c t s on Change i n D i e t a r y C a l c i u m I n t a k e Only one main e f f e c t on change i n d i e t a r y c a l c i u m i n t a k e was s i g n i f i c a n t : a l l e r g y or i n t o l e r a n c e t o m i l k or m i l k p r o d u c t s (F = 5.35, df = 1 ) . As would be e x p e c t e d , women who were not a l l e r g i c or i n t o l e r a n t t o m i l k or m i l k p r o d u c t s e x p e r i e n c e d change i n d i e t a r y c a l c i u m i n t a k e g r e a t e r than the grand mean (123 mg g r e a t e r than the grand mean), whereas women who were a l l e r g i c or i n t o l e r a n t t o m i l k or m i l k p r o d u c t s e x p e r i e n c e d changes below the grand mean (328 mg below the grand mean). Perhaps i n t e r v e n t i o n r e s u l t e d i n a d e c r e a s e i n d i e t a r y c a l c i u m i n t a k e among these w i t h an a l l e r g y , c o n t r a r y t o the i n t e n d e d outcome of the i n t e r v e n t i o n s . C o n s i s t e n t w i t h these s t u d y r e s u l t s , F o r s t e r - C o u l l (1985) found t h a t women's consumption of m i l k and m i l k p r o d u c t s appeared t o be de t e r m i n e d by the presence of a l l e r g i e s r a t h e r than by l e v e l of e d u c a t i o n or age. However, F o r s t e r - C o u l l (1985) d i d not e x p l o r e change i n i n t a k e f o l l o w i n g an e d u c a t i o n a l i n t e r v e n t i o n . E f f e c t s on Change i n P e r c e p t i o n of Problem S o l v i n g A b i l i t y U n l i k e change i n both d i e t a r y c a l c i u m i n t a k e and a t t i t u d e toward d i e t a r y c a l c i u m and o s t e o p o r o s i s , change i n 192 p e r c e p t i o n of problem s o l v i n g a b i l i t y was s i g n i f i c a n t l y i n f l u e n c e d by a c o m b i n a t i o n of demographic v a r i a b l e s . The e f f e c t produced by the f o l l o w i n g v a r i a b l e s was s i g n i f i c a n t : age, by e d u c a t i o n , by employment s t a t u s (F = 6.61, df = 1, p < 0.01). Among women who were employed, change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y was g r e a t e r than the grand mean, r e g a r d l e s s of age or l e v e l of e d u c a t i o n . Women who were post-menopausal and had r e c e i v e d p o s t - s e c o n d a r y e d u c a t i o n had changes above the grand mean, as d i d p r e -menopausal women who were l e s s w e l l e ducated. However, among women who were not employed, change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y was below the grand mean f o r pre-menopausal women who had r e c e i v e d h i g h s c h o o l e d u c a t i o n or l e s s , as w e l l as f o r post-menopausal women who were more h i g h l y educated. T h e r e f o r e , the p a t t e r n of change was d i f f e r e n t among women who were employed v e r s u s those who were n o t , a l t h o u g h employment s t a t u s i t s e l f d i d not produce a s i g n i f i c a n t main e f f e c t . A g a i n , c e l l s i z e s were s m a l l , such t h a t c a u t i o n i s wa r r a n t e d i n i n t e r p r e t i n g these r e s u l t s . A l t h o u g h n e i t h e r age nor e d u c a t i o n produced s i g n i f i c a n t main e f f e c t s on change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y , the mean change s c o r e s were: (1) h i g h e r among p o s t -menopausal women and (2) h i g h e r among those h a v i n g a h i g h s c h o o l e d u c a t i o n or l e s s . F u r t h e r r e s e a r c h i s n e c e s s a r y t o c l a r i f y the e f f e c t s of age, e d u c a t i o n and employment s t a t u s on an e d u c a t i o n a l impact measure, such as p e r c e p t i o n of problem s o l v i n g a b i l i t y . 193 The two-way i n t e r a c t i o n of use of a s p e c i a l d i e t by weight f o r h e i g h t was s i g n i f i c a n t on change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y (F=3.51, df=2). Women who were a t or below an a c c e p t a b l e weight f o r h e i g h t , and who f o l l o w e d a s p e c i a l d i e t e x p e r i e n c e d change i n p e r c e p t i o n above the grand mean. The o p p o s i t e was t r u e f o r women on a s p e c i a l d i e t who had e x c e s s i v e weights f o r t h e i r h e i g h t s . T h i s p a t t e r n was r e v e r s e d among women who were not on a s p e c i a l d i e t . Women a t or below a c c e p t a b l e weight f o r h e i g h t had changes i n p e r c e p t i o n below the grand mean, w h i l e women w i t h e x c e s s i v e body w e i g h t s e x p e r i e n c e d changes above the grand mean. Weight f o r h e i g h t had a s i g n i f i c a n t main e f f e c t on change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y (F=3.71, df=2). Women e x p e r i e n c e d i n c r e a s e d change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y r e l a t i v e t o the grand mean a t g r e a t e r weight f o r h e i g h t c l a s s i f i c a t i o n s . A S c h e f f e t e s t r e v e a l e d t h a t women who r e p o r t e d w e i g h t s below t h a t a c c e p t a b l e f o r t h e i r h e i g h t had s i g n i f i c a n t l y l e s s change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y than d i d women whose we i g h t s were i n excess of t h e i r a c c e p t a b l e weight f o r h e i g h t . P o s s i b l y women who were o v e r w e i g h t began the i n t e r v e n t i o n w i t h a l e s s p o s i t i v e p e r c e p t i o n of t h e i r own a b i l i t i e s and g a i n e d c o n f i d e n c e by c o m p l e t i o n of the workshops. P e r c e p t i o n of problem s o l v i n g a b i l i t y was a g e n e r a l measure i n t h i s s t u d y , not s p e c i f i c a l l y r e l a t e d t o 1 94 change i n d i e t a r y c a l c i u m i n t a k e . As a r e s u l t , women w i t h lower l e v e l s of s e l f - c o n f i d e n c e may a l s o have had lower s c o r e s on p e r c e p t i o n of problem s o l v i n g a b i l i t y . A lower l e v e l of s e l f - c o n f i d e n c e has been obse r v e d among i n d i v i d u a l s who a r e above t h e i r d e s i r a b l e weight ( P l a t h and B e l z e r 1985). These women may, t h e r e f o r e , have had g r e a t e r p o t e n t i a l f o r an i n c r e a s e i n p e r c e p t i o n of t h e i r problem s o l v i n g a b i l i t i e s as a r e s u l t of i n t e r v e n t i o n . In summary, a n a l y s i s of v a r i a n c e r e v e a l e d d i e t a r y c h a r a c t e r i s t i c s of p a r t i c i p a n t s as the most f r e q u e n t e f f e c t on change i n the dependent v a r i a b l e s . Only on p e r c e p t i o n of problem s o l v i n g a b i l i t y d i d demographic c h a r a c t e r i s t i c s have a s i g n i f i c a n t e f f e c t . Two f a c t o r s may have i n f l u e n c e d t h e s e r e s u l t s . F i r s t , c e l l s i z e s were s m a l l such t h a t i n t e r p r e t a t i o n of r e s u l t s i s d i f f i c u l t and S c h e f f e t e s t s o f t e n c o u l d not be a p p l i e d t o the d a t a . Sample s i z e s were s m a l l due t o l o s s e s of i n c o m p l e t e c a s e s f o r the m u l t i p l e comparison a n a l y s i s . As a r e s u l t , c o r r e l a t i o n a l a n a l y s e s were a l s o performed t o e x p l o r e r e l a t i o n s h i p s between the independent v a r i a b l e s and p r e t e s t and change v a l u e s of the dependent v a r i a b l e s . On the p r e t e s t dependent v a r i a b l e s , p o s i t i v e s i g n i f i c a n t r e l a t i o n s h i p s were seen between l e v e l of s e l f -r e p o r t e d awareness of o s t e o p o r o s i s and: a t t i t u d e ( r = 0.17); p e r c e p t i o n ( r = 0.22, p < 0.01) and d i e t a r y c a l c i u m i n t a k e ( r = 0.15). T h e r e f o r e , the h i g h e r women's s e l f - r e p o r t e d awareness of o s t e o p o r o s i s , the more p o s i t i v e were t h e i r p r e t e s t a t t i t u d e s toward d i e t a r y c a l c i u m and o s t e o p o r o s i s , 1 95 p e r c e p t i o n s of problem s o l v i n g a b i l i t y and d i e t a r y c a l c i u m i n t a k e s . P r e t e s t a t t i t u d e l e v e l s a l s o c o r r e l a t e d p o s i t i v e l y w i t h use of a s p e c i a l d i e t ( r = 0.16) and l e v e l of e d u c a t i o n (r = 0.27, p < 0.001). Both age ( r = -0.28, p < 0.001) and weight f o r h e i g h t (r = -0.20, p < 0.01) c o r r e l a t e d n e g a t i v e l y w i t h p r e t e s t a t t i t u d e s c o r e s . Age (r = -0.26, p < 0.001) c o r r e l a t e d n e g a t i v e l y w i t h p r e t e s t p e r c e p t i o n s c o r e s as w e l l . E d u c a t i o n was p o s i t i v e l y and s i g n i f i c a n t l y c o r r e l a t e d w i t h p r e t e s t l e v e l of p e r c e p t i o n of problem s o l v i n g a b i l i t y ( r = 0.30, p < 0.001). One s i g n i f i c a n t r e l a t i o n s h i p was noted f o r change s c o r e s on the dependent v a r i a b l e s , between change i n p e r c e p t i o n and weight f o r h e i g h t ( r = 0.25). G r e a t e r change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y o c c u r r e d among women w i t h h i g h e r weight f o r h e i g h t c l a s s i f i c a t i o n s . T h e r e f o r e , women w i t h w e i g h t s f o r h e i g h t below the a c c e p t a b l e l e v e l e x p e r i e n c e d l e s s change i n p e r c e p t i o n than d i d women who were c l a s s i f i e d as h a v i n g e x c e s s i v e w e i g h t s f o r h e i g h t s . T h e r e f o r e , from the c o r r e l a t i o n a l a n a l y s e s i t appears t h a t women who f e l t aware of o s t e o p o r o s i s and were younger tended t o have the most f a v o u r a b l e a t t i t u d e s toward c a l c i u m and o s t e o p o r o s i s , p e r c e p t i o n of problem s o l v i n g a b i l i t y and d i e t a r y c a l c i u m i n t a k e s a t p r e t e s t . Women a l s o tended t o have h i g h e r p r e t e s t s c o r e s on the f i r s t and second of th e s e v a r i a b l e s i f they were more h i g h l y educated. Yet change i n 196 the dependent v a r i a b l e s was o n l y r e l a t e d t o two d i e t a r y c h a r a c t e r i s t i c s . However, the s m a l l changes noted i n the dependent v a r i a b l e s makes the i d e n t i f i c a t i o n of s i g n i f i c a n t c o r r e l a t i o n s l e s s l i k e l y . In summary, from the a n a l y s i s of v a r i a n c e on change i n the dependent v a r i a b l e s , impacts on a l l t h r e e were i n f l u e n c e d by d i e t a r y c h a r a c t e r i s t i c s of the l e a r n e r s . However, change i n p e r c e p t i o n of problem s o l v i n g a b i l i t y was a l s o r e l a t e d t o l e a r n e r ' s l e v e l of e d u c a t i o n , employment s t a t u s and age. The magnitude of p o s s i b l e change i n the dependent v a r i a b l e s depends on t h e i r p r e t e s t v a l u e s p r i o r t o i n t e r v e n t i o n . In t h i s s t u d y , the h i g h e r a p a r t i c i p a n t ' s l e v e l of e d u c a t i o n and s e l f - r e p o r t e d awareness of o s t e o p o r o s i s , the h i g h e r the p r e t e s t v a l u e s of two of the dependent v a r i a b l e s . T h e r e f o r e , t o have the maximum p o s s i b l e p o t e n t i a l f o r i n c r e a s e from p r e - t o p o s t t e s t , independent of i n t e r v e n t i o n t y p e , p a r t i c i p a n t s would have t o r e p o r t low awareness of o s t e o p o r o s i s , have a c h i e v e d a lower l e v e l of e d u c a t i o n and be younger. However, a t t r i t i o n from p r e - t o p o s t t e s t was h i g h e s t among women w i t h lower l e v e l s of e d u c a t i o n . C o n s e q u e n t l y , d i r e c t i n g an i n t e r v e n t i o n t o l e a r n e r s w i t h these c h a r a c t e r i s t i c s might be s u b j e c t t o a l a r g e r r a t e of p a r t i c i p a n t a t t r i t i o n . 197 P a r t i c i p a n t s ' Responses to the I n t e r v e n t i o n s T a b l e 43 l i s t s the d i s t r i b u t i o n of p a r t i c i p a n t s w i t h i n i n t e r v e n t i o n groups by degree of s a t i s f a c t i o n w i t h t h e i r r e s p e c t i v e i n t e r v e n t i o n s . The q u e s t i o n a d d r e s s e d t o i n t e r v e n t i o n groups A and B was: "Do you f e e l the ' C alcium C a l c u l a t o r ' i s an e f f e c t i v e e d u c a t i o n a l m a t e r i a l f o r you?" and t o i n t e r v e n t i o n group C: "Was the C a l c i u m and Bone H e a l t h Workshop an e f f e c t i v e e d u c a t i o n a l approach f o r you?" The m a j o r i t y of women e x p r e s s e d s a t i s f a c t i o n w i t h i n a l l t h r e e groups: 89% i n group A; 95% i n group B and 89% i n group C. I n t e r v e n t i o n groups were not s i g n i f i c a n t l y d i f f e r e n t on t h i s v a r i a b l e . T a b l e 43: D i s t r i b u t i o n of p a r t i c i p a n t s w i t h i n i n t e r v e n t i o n groups by e x t e n t of s a t i s f a c t i o n w i t h the i n t e r v e n t i o n Response t o I n t e r v e n t i o n Group S a t i s f a c t i o n Q u e s t i o n A B C Yes 25 ( 8 9 ) 1 39 (95) 23 (89) No 3 ( 1 1 1 2 ( 5 ) 3 ( 1 1 ) (m=4)^ (m=7) (m=0) 1 : p e r c e n t a g e s i n p a r e n t h e s e s : m = number of m i s s i n g v a l u e s P a r t i c i p a n t s were a l s o asked t o comment on t h e i r r e p l y t o the above q u e s t i o n s . T a b l e 44 l i s t s the f r e q u e n c y w i t h which comments were l i s t e d . O v e r - a l l , comments were 198 p o s i t i v e , d e s c r i b i n g the problem s o l v i n g m a t e r i a l s as i n f o r m a t i v e and a w a r e n e s s - r a i s i n g . I t i s i n t e r e s t i n g t h a t a few women (n=3) s t a t e d t h a t the 'Calcium C a l c u l a t o r ' was c o n f i d e n c e - r a i s i n g s i n c e the r a t i o n a l e f o r the S h o r t r i d g e model proposes t h a t the use of problem s o l v i n g may enhance f e e l i n g s of p e r s o n a l competence and c o n f i d e n c e . T a b l e 44: Frequency of comments on the i n t e r v e n t i o n , by i n t e r v e n t i o n group Nature of the Comments: I n t e r v e n t i o n Group T o t a l A B C The I n t e r v e n t i o n was: In f o r m a t i v e 1 0 1 1 0 21 . Awareness-R a i s i n g 3 6 0 9 Easy t o Use 2 3 0 5 Conf i d e n c e -R a i s i n g 1 2 0 3 Two u n f a v o u r a b l e comments were made: the 'Calcium C a l c u l a t o r ' was not new t o one p a r t i c i p a n t , so she found i t of l i m i t e d use and another p a r t i c i p a n t was a l l e r g i c t o m i l k and m i l k p r o d u c t s and t h e r e f o r e s a i d she found the m a t e r i a l t o be of l i m i t e d h e l p t o h e r . Both comments were from members of i n t e r v e n t i o n group A. In summary, p a r t i c i p a n t s were g e n e r a l l y s a t i s f i e d t h a t the i n t e r v e n t i o n they were exposed t o was e f f e c t i v e f o r them, r e g a r d l e s s of t y p e . 199 R e s u l t s of the Judgement Phase T h i s p a r t of c h a p t e r IV l i s t s and d i s c u s s e s responses of i n d i v i d u a l s who made judgements on the v a l u e of the problem s o l v i n g method and the importance of s e l f - e s t e e m i n the d e s i g n of n u t r i t i o n e d u c a t i o n m a t e r i a l s . R e s u l t s from i n d i v i d u a l judgements w i l l be p r e s e n t e d f i r s t , f o l l o w e d by r e s u l t s of group judgements. I n d i v i d u a l Judgements Judges i n i t i a l l y answered i n d i v i d u a l l y the s i n g l e judgement q u e s t i o n f o r d a t a sheet A on s e l f - e s t e e m . The q u e s t i o n was: "Which r e l a t i o n s h i p s between s e l f - e s t e e m and p a r t i c i p a n t s ' b e l i e f s and a c t i o n s do you c o n s i d e r m e a n i n g f u l i n the d e s i g n of e d u c a t i o n a l m a t e r i a l s ? L i s t the r e l a t i o n s h i p s . " T a b l e 45 d e s c r i b e s the d i s t r i b u t i o n of i n d i v i d u a l judge's responses t o t h i s q u e s t i o n . T h e i r responses were c l a s s i f i e d by group. Four r e l a t i o n s h i p s were mentioned by at l e a s t one judge: (1) s e l f - e s t e e m and p e r c e p t i o n of problem s o l v i n g a b i l i t y ; (2) a t t i t u d e , o v e r - a l l , and s e l f -esteem; (3) change i n d i e t a r y c a l c i u m i n t a k e and s o c i a l s e l f - e s t e e m and (4) a t t i t u d e s u b s c a l e "RISK" and p e r s o n a l s e l f - e s t e e m . None of the f o u r r e l a t i o n s h i p s l i s t e d i n Table 48 was named by a l l n i n e j u d g e s . The one most f r e q u e n t l y mentioned was the r e l a t i o n s h i p between s e l f - e s t e e m and p e r c e p t i o n of problem s o l v i n g a b i l i t y (67% of j u d g e s ) . 200 T a b l e 45: D i s t r i b u t i o n of judges' responses t o dat a sheet A L i s t e d Responses by Group T o t a l R e l a t i o n s h i p s No. of D i e t i t i a n s F u t u r e Home Users Judges D i e t i t i a n s Economists (n=3) (n=2) (n=2) (n=2) (n=9) S e l f - e s t e e m and 2 2 2 6 2 p e r c e p t i o n of (67) p r o b l e m - s o l v i n g a b i l i t y A t t i t u d e o v e r - a l l 1 1 1 3 and s e l f - e s t e e m (33) Change i n c a l - 2 1 1 4 cium i n t a k e and (44) s o c i a l s e l f - e s t e e m A t t i t u d e s u b s c a l e 1 1 2 RISK and p e r s o n a l (22) s e l f - e s t e e m Judges were asked t o l i s t r e l a t i o n s h i p s between s e l f - e s t e e m and p a r t i c i p a n t s ' b e l i e f s and a c t i o n s which they f e l t were m e a n i n g f u l i n m a t e r i a l d e s i g n p e r c e n t a g e s i n p a r e n t h e s e s of judges who l i s t e d t h i s r e l a t i o n s h i p N e i t h e r of the two judges b e l o n g i n g t o the user group l i s t e d t h i s r e l a t i o n s h i p . There was, t h e r e f o r e , no agreement among the f o u r groups on s p e c i f i c r e l a t i o n s h i p s v a l u e d as m e a n i n g f u l . In g e n e r a l , judges c o n s i d e r e d s e l f - e s t e e m an imp o r t a n t f a c t o r i n the d e s i g n of e d u c a t i o n a l m a t e r i a l s . One judge commented t h a t " e d u c a t i o n m a t e r i a l s must make people f e e l t h a t they can be s u c c e s s f u l . " I m p l i e d i n t h i s comment i s the s u g g e s t i o n t h a t m a t e r i a l s s h o u l d r e i n f o r c e l e a r n e r ' s 201 s e l f - e s t e e m , or a t l e a s t not have an u n f a v o u r a b l e e f f e c t on l e a r n e r ' s f e e l i n g s toward t h e m s e l v e s . More s p e c i f i c a l l y , judges found the r e l a t i o n s h i p between s o c i a l s e l f - e s t e e m and d i e t a r y c a l c i u m i n t a k e of p o t e n t i a l use i n n u t r i t i o n e d u c a t i o n . One judge commented: "I would l i k e t o d e s i g n m a t e r i a l s t h a t promote a p o s i t i v e r e l a t i o n s h i p between s o c i a l s e l f - e s t e e m and a c t u a l e a t i n g b e h a v i o u r . " Another s t a t e d t h a t the r e l a t i o n s h i p might be