Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Nutrition knowledge, attitudes and practices of public health nurses in Greater Vancouver Nichols, Susan Deborah Caroline 1974

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1974_A6_7 N52_9.pdf [ 6.8MB ]
Metadata
JSON: 831-1.0099928.json
JSON-LD: 831-1.0099928-ld.json
RDF/XML (Pretty): 831-1.0099928-rdf.xml
RDF/JSON: 831-1.0099928-rdf.json
Turtle: 831-1.0099928-turtle.txt
N-Triples: 831-1.0099928-rdf-ntriples.txt
Original Record: 831-1.0099928-source.json
Full Text
831-1.0099928-fulltext.txt
Citation
831-1.0099928.ris

Full Text

NUTRITION KNOWLEDGE, ATTITUDES, AND PRACTICES OF PUBLIC HEALTH NURSES IN GREATER VANCOUVER by SUSAN DEBORAH CAROLINE NICHOLS B.H.E.,, University of B r i t i s h Columbia, 1970 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n the D i v i s i o n of Human N u t r i t i o n School of Home Economics We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September, 1974 In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r an advanced degree at the U n i v e r s i t y o f B r i t i s h Co lumb ia , I ag ree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s tudy . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . It i s u n d e r s t o o d that c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i thou t my w r i t t e n p e r m i s s i o n . Department o f Home Economics, D i v i s i o n of Human N u t r i t i o n The U n i v e r s i t y o f B r i t i s h Co lumbia Vancouver 8, Canada August, 1974 ABSTRACT The findings of N u t r i t i o n Canada, a national n u t r i t i o n survey, have emphasized the importance of n u t r i t i o n education to the public. It i s a fact that the health professional most often disseminating n u t r i t i o n information to the public i s the public health nurse. Thus there was a need to i n v e s t i -gate the n u t r i t i o n a l knowledge of public health nurses, as well as t h e i r attitudes toward n u t r i t i o n , and the kind of n u t r i t i o n information they are offering to the public. This study involved t e s t i n g the dependent variables: n u t r i t i o n knowledge, attitudes and practices of public health nurses and comparing these with the independent variables: educational background, recency of a c q u i s i t i o n of nursing related degree, years of nursing experience, age, q u a l i f i c a -t i o n of the educators who taught n u t r i t i o n i n the t r a i n i n g curriculum, years of home economics studied i n high school, number of n u t r i t i o n related communications with a n u t r i t i o n -i s t , and other types of n u t r i t i o n experience or education. The nature of the re l a t i o n s h i p of knowledge, attitudes, and practices, and the in t e r r e l a t i o n s h i p s of knowledge and attitudes with practices were determined. Data were coll e c t e d by a mail questionnaire which yielded a response rate of 85.1%. Coding and computer analysis of data resulted i n percentage mean scores i for the t e s t s of n u t r i t i o n knowledge, attitudes, and practices of 75.79, 89.48, and 65.08 respectively. The areas of n u t r i t i o n knowledge i n which the public health nurses scored lowest were n u t r i t i o n and pregnancy-related to requirements and supplementation, knowledge about nutrient requirements, nutrient composition of foods, and weight reduction. Tests of n u t r i t i o n attitudes revealed that the nurses had poor attitudes toward the importance of meal planning. Public health nurses demonstrated poor practices i n counselling the public i n budgeting, vegetarian d i e t s , and dietary manipulation of f a t s . Nurses showed poor personal n u t r i t i o n practices i n meal management and i n adher-ing to the recommended cereal group intake of the B.C. Daily Food Guide. Regression analysis indicated that the factors related to n u t r i t i o n knowledge were educational background, recency of a c q u i s i t i o n of nursing related degree, and years of experience. Factors related to n u t r i t i o n attitudes were age, home economics t r a i n i n g i n high school, number of consultations with a n u t r i t i o n i s t , and attendance at n u t r i t i o n courses i n continuing education. N u t r i t i o n practices were related to opportunities for consultation with a n u t r i t i o n i s t and attendance at n u t r i t i o n conferences. P a r t i a l c o r r e l a t i o n analysis of the dependent variables revealed s i g n i f i c a n t and d i r e c t r e l a t i o n s h i p s between knowledge and a t t i t u d e s , practices and attitudes, and practices and knowledge. The i i weakest rela t i o n s h i p was between knowledge and attitudes. The strongest rel a t i o n s h i p was between knowledge and practices. Recommendations for a more e f f e c t i v e inservice n u t r i t i o n education program for public health nurses were made. TABLE OF CONTENTS Page ABSTRACT 1 LIST OF TABLES v i LIST OF FIGURES ix ACKNOWLEDGEMENTS x CHAPTER: I. INTRODUCTION 1 Background and Need Statement of the Problem Hypotheses D e f i n i t i o n of Terms Assumptions Organization of the Study I I . REVIEW OF THE LITERATURE 15 Mail Questionnaires Knowledge, Attitudes, and Practices Knowledge Attitudes Practices Relationships of Knowledge, Attitudes and Practices Knowledge Related to Practices Attitudes Related to Practices Interrelationships of Knowledge, Attitudes and Practices I I I . DESIGN OF THE STUDY . . . 35 Data C o l l e c t i o n Instruments Procedure Data Analysis i v CHAPTER: IV. FINDINGS AND INTERPRETATIONS Page 43 Results for Tests of N u t r i t i o n Knowledge, Attitudes, and Practices Results for the Demographic Data Instrument Lowest Mean Score Statements Factors Related to N u t r i t i o n Knowledge Factors Related to N u t r i t i o n Attitudes Factors Related to N u t r i t i o n Practices Correlations of N u t r i t i o n Knowledge, Attitudes, and Practices Results of Hypotheses Tested V. SUMMARY AND IMPLICATIONS 75 Summary Implications APPENDICES 83 A. Data C o l l e c t i o n : Instruments and Key. . . 83 B. Pretest Questionnaire 94 C. Cover and Follow-up Letters 96 D. Flowchart of Research Procedure 99 E. An Instructional Development Program Plan for Inservice N u t r i t i o n Education for Public Health Nurses . . . 101 LITERATURE CITED 132 v LIST OF TABLES Table Page 1. Scoring System for N u t r i t i o n Knowledge 3 7 Instrument 2. Scoring System for N u t r i t i o n Attitudes Instrument . . . . . . 37 3. Scoring System for N u t r i t i o n Practices Instrument . . . . . . . . . . . . . . . . . 39 4. Test Results f o r N u t r i t i o n Knowledge, Attitude s , and Practices . . . . . . . . . . 45 5 . Univariate Frequency Table of Nursing Education. 4 6 6. Univariate Frequency Table of Recency of Degree. . . . . . . . . . . . . . . . . . 47 7. Univariate Frequency Table of Years of Experience. . . . . . 48 8. Univariate Frequency Table of Age 49 9. Univariate Frequency Table of N u t r i t i o n Education 49 10. Univariate Frequency Table of Years of Home Economics . . . . . . . . • 50 11. Univariate Frequency Table of Number of Consultations. . . . • 51 12. Univariate Frequency Table of Other N u t r i t i o n Education or Experience. . . . . . 51 13. Statements Measuring N u t r i t i o n Knowledge on Which Respondents Achieved Lowest Mean Scores. 53 v i Table Page 14. Statements Measuring N u t r i t i o n Attitudes and Practices on Which Respondents Achieved Lowest Mean Scores. . . 54 15. Multiple Regression Results for A l l Independent Variables Studied and the Knowledge Test Score . . . . . . 56 16. Stepwise Regression Results f o r A l l Independent Variables Studied and the Knowledge Test Score ; 57 17. Stepwise Regression Results for Single Independent.Variables and the Knowledge Test Score Yielding Non-Significant Findings • • • • 57 18. Stepwise Regression Results for Single Independent Variables and the Knowledge Test Score Yielding S i g n i f i c a n t Findings . . . . . . . . . . . . 58 19. Multiple Regression Results f o r " A l l Independent Variables Studied and the Attitudes Test Score . . . . . . . . . . . 60 20. Stepwise Regression Results for A l l Independent Variables Studied and the Attitudes Test Score . . . . . . . . . • • . 61 21. Stepwise Regression Results for Single Independent Variables and the Attitudes Test Score Yielding Non-Significant Findings • • • 61 22. Stepwise Regression Results for Single Independent Variables and the Attitudes Test Score Yielding S i g n i f i c a n t Findings . . . . 62 23. Multiple Regression Results for A l l Independent Variables Studied and the Practice Test Score. . . . . . . 63 v i i Table Page 24. Stepwise Regression Results for A l l Independent Variables Studied and the Practice Test Score • 64 25. Stepwise Regression Results for A l l Independent Variables and the Practice Test Score Yielding Non-Significant Findings 65 26. Stepwise Regression Results for Single Independent Variables and the Practice Test Score Yielding S i g n i f i c a n t Findings 66 27. C o e f f i c i e n t s of the Regression Equation for the Dependent Variable Knowledge . . . . 67 28. C o e f f i c i e n t s of the Regression Equation for the Dependent Variable Attitude 67 29. C o e f f i c i e n t s of the Regression Equation for the Dependent Variable Practice. . . . . 68 30. Sample-" Product Moment Correlation of N u t r i t i o n Knowledge, Attitudes, and Practices. 69 31. P a r t i a l C orrelation Results for Knowledge, Attitudes, and Practices 69 v i i i LIST OF FIGURES Figure Page 1. Public Health Units i n Greater Vancouver . . . . . . . . . . . 13 2. Models Showing the Possible Inter-r e l a t i o n s h i p s Between N u t r i t i o n Knowledge, Attitudes, and Practice 34 3. Knowledge - Attitudes - Practice Model. . . . 7 0 i x ACKNOWLEDGEMENTS The author wishes to express her appreciation to her major advisor, Nancy Schwartz, for her advice, a s s i s t -ance and encouragement during the preparation and execution of t h i s study. Gratitude i s also extended to Rosamond Sarles, f r i e n d and committee member, f o r her genuine i n t e r e s t and counsel p r i o r to and during the graduate program. Acknowledgement i s expressed to committee member Dr. I. Desai for h i s cooperation and p r a c t i c a l suggestions. Public health nurses and t h e i r supervisors i n Greater Vancouver are g r a t e f u l l y acknowledged for t h e i r p a r t i c i p a t i o n and interest i n the study. Thanks are also extended to those colleagues who assisted by pretesting the questionnaires and offering h e l p f u l suggestions. Sincere gratitude i s expressed to Christopher Webber for h i s advice and invaluable assistance with computer programming and s t a t i s t i c a l analysis of the data. Truly h e a r t - f e l t appreciation i s extended to the author 1s husband, Ian, and to her children, L i s a and Stephanie, for t h e i r support, encouragement, understanding and help throughout the graduate program. x CHAPTER I INTRODUCTION Background and Need The importance of n u t r i t i o n education for Canadians has recently been emphasized with the release of the pre-liminary r e s u l t s of N u t r i t i o n Canada (1973). Some of the findings indicate that: a. more than f i f t y percent of Canadians are overweight. b. i r o n deficiency a f f e c t s a large proportion of Canadians, including pregnant women, 0-11 month old babies, women and men. c. protein deficiency i s seen i n Canadian women during pregnancy and i n a notable proportion of children under 5 years. d. there i s a shortage of calcium and vitamin D i n di e t s of many infants, children, and adolescents. N u t r i t i o n Canada marks the f i r s t time that evidence has c l e a r l y shown a need for sound n u t r i t i o n knowledge among the Canadian public. " . . . attention should be given to early detection of such problems and to the development of prevention programs for the future." (p. 115). Within each province, a number of municipalities and regional health units employ n u t r i t i o n i s t s who are . . . involved with t h e i r community. However, the 2 health professional most frequently involved i n the d i r e c t dissemination of n u t r i t i o n information to the public i s the public health nurse, (p. B-7) This i s true i n Vancouver where there are 140 public health nurses and only three n u t r i t i o n i s t s working for the Vancouver Health Department, and three n u t r i t i o n i s t s seconded to several c i t y agencies. Richmond, Burnaby, North Vancouver and West Vancouver employ no n u t r i t i o n i s t s at t h i s time. Furthermore, the public health nurses form the majority of a l l the health workers who are potential n u t r i t i o n educators i n the public health system. Mayer (1970) stated that: N u t r i t i o n i s t s and health educators are unanimous i n declaring that (the public) needs more n u t r i t i o n education. The unspoken assumption i s that the professionals know how to do i t (p. 80). Newton (1970) f e l t i t was time to t e s t t h i s assumption: If nurses say they include n u t r i t i o n a l care i n t h e i r practice, i t i s time to c l a r i f y how, when, and what kind (p. 10). This knowledge i s needed i n order to develop more e f f e c t i v e n u t r i t i o n inservice education programs for public health nurses. At the present time there i s no d e f i n i t i v e proof of the need for ongoing n u t r i t i o n inservice education programs that would update and supplement the educational background and practice of public health nurses (Prater 1970). E f f e c t i v e n u t r i t i o n programs cannot be planned without pr i o r information on the n u t r i t i o n knowledge, attitudes, and s k i l l s of the public health nurse. This information would be invaluable i n enabling the n u t r i t i o n i s t to use her time as a consultant to the public health nurses most e f f i c i e n t l y (Sarles 1974). 3 A search of the l i t e r a t u r e indicates very l i m i t e d data on the n u t r i t i o n knowledge, attitudes, and practices of nurses. In Canada there has been no research reported i n the professional l i t e r a t u r e on t h i s subject. In the United States one study which measured the n u t r i t i o n know-ledge of public health nurses was conducted by Harrison et a l . (1969). I t was found that there was a greater v a r i a b i l i t y i n the knowledge of the physiological and psycho-s o c i a l factors which relate to n u t r i t i o n and food intake than there was i n the knowledge of the more d i r e c t n u t r i t i o n f a c t s such as the a v a i l a b i l i t y of s p e c i f i c nutrients. Level of education and years of experience were variables that were p o s i t i v e l y related to n u t r i t i o n knowledge. This study did not r e l a t e knowledge to attitudes and pr a c t i c e s . Newton (1967) has studied C a l i f o r n i a hospital nurses and reported " i n d i f f e r -ent attitudes" regarding n u t r i t i o n . Although no s t a t i s t i c a l r e s u l t s were reported, nurses on a l l staff l e v e l s gave low p r i o r i t y to n u t r i t i o n and reported negative reactions to t h e i r educational experience i n n u t r i t i o n and/or di e t therapy. Schwartz (1973) i n a study of high school graduates, reported that attitudes are related to practices whereas there i s no re l a t i o n s h i p between knowledge and practices. Thus i t appears that there i s a need to investigate not only the n u t r i t i o n knowledge of public health nurses but also t h e i r attitudes and practices regarding n u t r i t i o n . A search of the l i t e r a t u r e , therefore, reveals that 4 the dissemination of n u t r i t i o n information to the public i s v i t a l and public health nurses are i n an excellent position to do t h i s . However, i t i s not clear what type of n u t r i t i o n knowledge the nurses have, and what informa-t i o n they are giving to the public. There i s a need to determine the n u t r i t i o n knowledge, attitudes, and practices of public health nurses i n an area such as Vancouver. With these findings i t would be possible to analyze the need for n u t r i t i o n inservice education programs for public health nurses and to plan such programs with good judgement. Because previous research has indicated that n u t r i t i o n educa-t i o n and experience of, as well as consultation to, the public health nurse a f f e c t s her n u t r i t i o n knowledge, i t would appear useful to investigate the n u t r i t i o n knowledge, attitudes, and practices i n r e l a t i o n to these extraneous var i a b l e s . It would also be informative to determine the rel a t i o n s h i p between n u t r i t i o n knowledge, attitudes, and practices. Statement of the Problem A survey was conducted among public health nurses i n Vancouver, Richmond, Burnaby, North Vancouver, and West Vancouver, to determine the extent of t h e i r n u t r i t i o n know-ledge, attitudes, and practices. Comparisons were made among the public health nurses based on: 1. educational background 2. recency of a c q u i s i t i o n of nursing-related degree 5 3. years of nursing experience 4. age 5. q u a l i f i c a t i o n of the educator who taught n u t r i t i o n i n the nursing t r a i n i n g curriculum 6. years of home economics—including foods and n u t r i t i o n — s t u d i e d i n high school 7. number of communications with a n u t r i t i o n i s t regarding n u t r i t i o n - r e l a t e d problems 8. other types of n u t r i t i o n experience or education The study was conducted with the cooperation and approval of the Medical Health O f f i c e r s and nursing supervisors i n Greater Vancouver as well as the C i t y of Vancouver Research and Evaluation Committee. Complete anonymity of the public health nurses was maintained. The following objectives were established for invest-igating the problem: 1. To determine whether s i g n i f i c a n t differences exist i n the n u t r i t i o n knowledge, att i t u d e s , and practices of public health nurses i n Greater Vancouver as related t o: a. educational background i . e . Bachelor of Nursing, Registered Nurse, Registered Nurse plus Public Health Diploma, Master of Nursing, additional f i e l d education. b. recency of a c q u i s i t i o n of nursing-related degree i . e . within 5 years, more than 5 years and less than 10 years ago, and more than 10 years ago. 6 c. years of nursing experience i.e l e s s than 1 year, more than 1 year and les s than 5 years, more than 5 and les s than 10 years, and more than 10 years. d. age i . e . under 25, between 25 and 40, and over 40. e. q u a l i f i c a t i o n of the educator who taught n u t r i t i o n i n the nursing t r a i n i n g curriculum i . e . n u t r i t i o n i s t or d i e t i t i a n , nursing i n s t r u c t o r , or other f . years of home economics—including foods and n u t r i -t i o n — s t u d i e d i n high school i . e . none, 1-2 years, 3-4 years g. number of nu t r i t i o n - r e l a t e d communications with a n u t r i t i o n i s t i n the l a s t four weeks ( i f the n u t r i t i o n consultant services have been available f o r over 6 months) i . e . none, 1-2, 3-4, 5 or more h. other types of n u t r i t i o n experience or education 1. e. attendance at expectant parent's c l a s s , cooking for own family or frien d s , cooking classes, n u t r i t i o n courses i n continuing education, n u t r i t i o n conferences 2. To determine among the public health nurses, the nature of the re l a t i o n s h i p of n u t r i t i o n knowledge, att i t u d e s , and practices, and the i n t e r r e l a t i o n s h i p of knowledge and attitudes with practices. 7 Hypotheses The following n u l l hypotheses were tested: 1. There w i l l be no s i g n i f i c a n t differences achieved i n t e s t s of n u t r i t i o n knowledge, attitudes, and practices of public health nurses based on educational background. 2. There w i l l be no s i g n i f i c a n t differences achieved i n t e s t s of n u t r i t i o n knowledge, att i t u d e s , and practices between public health nurses who acquired t h e i r most recent nursing-related degrees within the l a s t f i v e years and those who acquired t h e i r degrees more than f i v e years ago. There w i l l be no s i g n i f i c a n t d i f f e r -ences achieved i n t e s t s of n u t r i t i o n knowledge, a t t i -tudes, and practices between public health nurses who acquired t h e i r most recent nursing degrees more than ten years ago and those who acquired t h e i r degrees less than ten, but more than f i v e years ago. 3. There w i l l be no s i g n i f i c a n t differences achieved i n t e s t s of n u t r i t i o n knowledge, attitudes, and practices of public health nurses based on years of experience. 4. There w i l l be no s i g n i f i c a n t differences achieved i n tests of n u t r i t i o n knowledge, attitudes, and practices of public health nurses based on age. 5. There w i l l be no s i g n i f i c a n t differences achieved i n t e s t s of n u t r i t i o n knowledge, attitudes, and practices between public health nurses who received n u t r i t i o n education i n the nursing curriculum and those who did 8 not. Among the public health nurses who received n u t r i t i o n education i n the nursing curriculum, there w i l l be no s i g n i f i c a n t differences achieved i n t e s t s of n u t r i t i o n knowledge, attitudes, and practices between the public health nurses who received n u t r i -t i o n education from a q u a l i f i e d n u t r i t i o n i s t or d i e t i c i a n and those who did not. 6. There w i l l be no s i g n i f i c a n t differences achieved i n t e s t s of n u t r i t i o n knowledge, attitudes, and practices between the public health nurses who received home economics n u t r i t i o n education i n high school and those who did not. 7. There w i l l be no s i g n i f i c a n t differences achieved i n t e s t s of n u t r i t i o n knowledge, attitudes, and practices between public health nurses who have had the services of a n u t r i t i o n consultant for more than six months and those who have had the services for l e s s then six months. Among the public health nurses who have had the services of a n u t r i t i o n consultant f o r more than six months, there w i l l be no s i g n i f i c a n t differences achieved i n t e s t s of n u t r i t i o n knowledge, attitudes, and practices based on the number of n u t r i t i o n - r e l a t e d communications with the n u t r i t i o n i s t . 8. There w i l l be no s i g n i f i c a n t differences achieved i n t e s t s of n u t r i t i o n knowledge, attitudes, and practices of public health nurses based on other types of n u t r i t i o n 9 education or experience: such as, attendance at expectant parent's class, cooking for own family or friends, cooking classes, n u t r i t i o n courses i n continuing education, n u t r i t i o n conferences. 9. There w i l l be no positive r e l a t i o n s h i p among the scores for n u t r i t i o n knowledge, attitudes, and practices achieved by the public health nurses. . D e f i n i t i o n of Terms The following terms were defined for the purpose of t h i s -study: Public Health Nurse Gives nursing care to persons i n establishments such as government and voluntary health agencies, or homes and c l i n i c s , and i n s t r u c t s people i n d i v i d u a l l y or i n groups i n health education and disease prevention. V i s i t s homes to give nursing care, and advises families on care of patients and maintenance of h e a l f u l environ-ment. Gives help to patients a f f l i c t e d with mental and physical disorders. A s s i s t s persons with s o c i a l , emotional, or other problems to secure aid through commun-i t y resources. Teaches maternal and c h i l d care and other subjects related to i n d i v i d u a l and community welfare. A s s i s t s i n preparation of special studies and i n research programs. Cooperates with families and community agencies and medical persons to arrange for care of sick or injured persons and to carry out immunization programs. May function as a member of an agency e.g. Red Cross or . . . V.O.N. (Canadian C l a s s i f i c a t i o n and Dictionary of Occupa-tions 1971) For the purpose of the study, the public health nurses i n the population sample included only those nurses working i n the f i e l d . Administrative nursing supervisors were not included unless they had a function i n community f i e l d work. 10 Health Department or Unit A community health centre that consists of a group of health professionals including public health nurses, serving a population's health needs within a specified boundary. Greater Vancouver Includes Burnaby Corporation, D i s t r i c t of North Vancouver, Municipality of West Vancouver, Municipality of Richmond, and the C i t y of Vancouver. Vancouver The C i t y of Vancouver has a t o t a l population of 430,210. It i s divided into 5 health units: fiorth, West, Burrard, South, and East ( F i g . l ) . Richmond The Municipality of Richmond has a population of 62,120. It covers the area designated i n Figure 1. There i s a central health department. North Vancouver The D i s t r i c t of North Vancouver and the C i t y of North Vancouver have a population of 89,710. There i s one health unit, the North Shore Unit ( Fig. l ) . West Vancouver The Municipality of West Vancouver has a population of 11 36,440. There i s a h e a l t h u n i t c a l l e d the North Shore Sub-Office ( F i g . 1 ) . Burnaby Burnaby C o r p o r a t i o n has a p o p u l a t i o n of 125,645, and one h e a l t h u n i t . I t covers the area designated i n Figure 1. N u t r i t i o n Knowledge Knowledge of b a s i c p r i n c i p l e s and concepts of n u t r i -t i o n ; t o be measured and nu m e r i c a l l y scored by a d m i n i s t r a -t i o n of a p r e v i o u s l y v a l i d a t e d t e s t (Schwartz 1973). An a t t i t u d e i s a "learned, emotionally toned p r e d i s p o s i t i o n t o r e a c t i n a p a r t i c u l a r way toward something" (Redman 1968 p. 67). N u t r i t i o n a l Prar.tir.fts P r a c t i c e s include the techniques and i n f o r m a t i o n p e r t a i n i n g t o n u t r i t i o n that are used by the p u b l i c h e a l t h nurses i n c o u n s e l l i n g t h e i r c l i e n t s as w e l l as the food s e l e c - ' t i o n of the p u b l i c h e a l t h nurses themselves. N u t r i t i o n i s t This i s a supervisory p r o f e s s i o n a l work i n the f i e l d of n u t r i t i o n as r e l a t e d t o the o v e r a l l p u b l i c h e a l t h and s o c i a l w e l f a r e programs. An incumbent of t h i s c l a s s p l a n s , organizes and supervises a l l aspects of an e d u c a t i o n a l and a d v i s o r y program designed t o promote and maintain adequate standards and p r a c t i c e s of n u t r i t i o n i n the M e t r o p o l i t a n Health area, and has r e s p o n s i b i l i t y f o r i n t e g r a t i n g t h i s phase of p u b l i c h e a l t h and welfare w i t h the o v e r a l l programs ( C i t y of Vancouver, 1965). 12 A v a i l a b i l i t y of a N u t r i t i o n Consultant In the C i t y of Vancouver three n u t r i t i o n i s t s are available for consultation to the public health nurses. Two n u t r i t i o n i s t s work out of four units. One n u t r i t i o n -i s t works at the central o f f i c e i n the Health Department and i s responsible for the f i f t h health u n i t . No n u t r i t i o n consultants work for the health departments i n North Vancouver, West Vancouver, Burnaby, or Richmond. Assumptions The following assumptions have been made for the purpose of t h i s study: 1. The revisi o n s made to the data c o l l e c t i o n instruments for the purpose of t h i s study did not a l t e r t h e i r v a l i d i t y . 2. The public health nurses were able to respond to a mail questionnaire. 3. The public health nurses completed the questionnaire honestly and without the help of books or other resources. 4. The public health nurses were involved i n at least some kinds of n u t r i t i o n counselling i n th e i r work. 5 . The public health nurses were involved i n meal planning and food preparation i n t h e i r private l i v e s . 6. The public health nurses each had an established dietary behavior and thus exhibited consistent and steady food habits. 456 W. Broadway 306 Abbott St. 2112 W. 42nd Ave. 1530 W. 8th Ave. 6405 Knight Rd . 2610 Victoria Dr. Q Burnaby Health Unit, Municipal Hall Q North Shore Health Un i t_ 253 E. 14th St. CJ North Shore Sub-office Municipal Hall O Richmond Health Unit, Municipal Hall Vancouver 876 1313 Vancouver 684 4191 Vancouver 261 6366 Vancouver 736 9844 Vancouver 321 6151 Vancouver 872 2511 Burnaby 299 7211 North Van. 983 5231 West Van. 922 9135 Richmond 278 5511 GO 14 Organization of the Study This study begins with a review of the pertinent l i t e r a t u r e i n chapter I I . This i s followed by a chapter explaining the design of the study; the data c o l l e c t i o n instruments, procedures and analyses. Chapter IV i s a presentation of the r e s u l t s of the survey, including s t a t i s t i c a l analyses. The f i n a l chapter, chapter V, i s a summary of the study, along with implications drawn from the r e s u l t s . 15 CHAPTER II REVIEW OF THE LITERATURE Studies that seek data on variables such as knowledge, attitudes, or practices, generally take the form of survey research. Several methods, interview or questionnaire, can be employed i n order to c o l l e c t the required data. Many studies have been car r i e d out on the r e l a t i o n s h i p between a single dependent variable; either n u t r i t i o n knowledge, n u t r i -t i o n attitudes, or n u t r i t i o n practices, and independent variables such as age, education, and n u t r i t i o n education. Studies have produced c o n f l i c t i n g r e s u l t s on the r e l a t i o n -ships between n u t r i t i o n knowledge and practice, and n u t r i t i o n attitudes and practices. Various models have been developed to depict i n t e r r e l a t i o n s h i p s between n u t r i t i o n knowledge, attitudes, and practices. Although i t i s a recognized fact that the nursing profession has a r e s p o n s i b i l i t y for public n u t r i t i o n , there i s very l i t t l e research on the assessment of the n u t r i t i o n knowledge, attitudes, and practices of the profession. Mail Questionnaire Harris (i960) stated that when the questionnaire method i s employed i n survey research, 16 . . . measures are related one to another, u n t i l a structure behind miscellaneous b i t s of a t t i t u d e , information, and behavior becomes apparent (p. 1447). A mail questionnaire i s a data c o l l e c t i o n instrument that i s completed by an informant rather than by the researcher, and col l e c t e d through the mail with no d i r e c t contact between the researcher and the informant. Clarke (1970) stated that the primary j u s t i f i c a t i o n for the use of the mail questionnaire i s that there be a need for information that cannot be reasonably obtained i n any other way. The most important part of survey research i s the questionnaire i t s e l f . R e l i a -b i l i t y and v a l i d i t y of the.data depend on the q u a l i t y of the questionnaire. The questions or statements must encompass a l l the necessary information; be clear, unambiguous and e a s i l y answered; and be e a s i l y computed and analyzed. The techniques of question asking, questionnaire construc-t i o n . . . and content analyses, and the equipment for data processing - though s t i l l open to refinement and improvement - are s u f f i c i e n t l y well developed to guarantee a valuable picture of any area of content proposed for study (Harris 1960 p. 1459). There are both advantages and disadvantages i n the use of the mail questionnaire i n survey research. A prime advant-age i s that the mail questionnaire i s a r e l a t i v e l y inexpensive way to c o l l e c t survey data. Jackson (1961) estimated that an interview i s 60 times more expensive than the questionnaire method. It i s often easier to reach busy people by mail than to interview them personally; an important advantage i n survey research. The mail questionnaire eliminates the problem of interviewer and respondent bias. This bias arises i n the 17 interview s i t u a t i o n i f the interviewer influences responses through explanations or vocal expressions, or i f the respondent biases h i s answers simply because the interview-er i s present. When a person i s alone and answering a questionnaire, he may give freer information and more candid answers than i f the investigator were present. Thus the questionnaire method may produce more v a l i d data than the interview method (Frazer and Lazarsfeld 1945). The question-naire i s designed to obtain single, d i r e c t answers i n order to simplify the analyses of r e s u l t s . Thus i t i s a disadvan-tage that the mail questionnaire does not allow for extensive responses to s p e c i f i c questions. Another l i m i t a t i o n i s that the respondent may not answer honestly. Rummel (1964) suggested that an assurance of c o n f i d e n t i a l i t y and good intent w i l l encourage the respondent to give genuine answers. A respondent of a mail questionnaire has the opportunity to consult with books or other people. This i s es p e c i a l l y true i f a test of knowledge i s involved. A f i n a l l i m i t a t i o n to the mail questionnaire i s that the researcher has no control over who responds and who does not. This problem of non-response can be a s i g n i f i c a n t disadvantage (Jackson 1961, Norman 1948). There are two types of nonresponse: p a r t i a l or item nonresponse, and complete nonresponse. With item nonresponse, the questionnaire i s returned with one or more questions unanswered. Complete nonresponse s i g n i f i e s that the question-naire i s returned blank or not returned at a l l . Ferber (1966) 18 stated that the e f f e c t s of item nonresponse can be substan-t i a l and overlooking such e f f e c t s may produce biased r e s u l t s , Donald (i960) f e l t that those least l i k e l y to answer a question are those least l i k e l y to answer favour-ably. In a consumer survey he found that item nonresponse was highest for women, housewives or r e t i r e d people, and people with low l e v e l s of education. The frequency of large numbers of omissions increased with age. He found that the questions l e f t out were ones requiring some.thought and e f f o r t i n answering. Complete nonresponse may also bias r e s u l t s . Eckland (1965) stated that i t i s most l i k e l y that those who do not reply are those who would give the unfavourable answers. If t h i s i s true, and the responders do not represent the entire population studied, then the problem of nonresponse bias a r i s e s . If a survey has complete nonresponse and item non-response, then the bias i s compounded. Nonresponse bias decreases as the response rate i n -creases. Harris (i960) stated that although a 60$ response rate i s good, i t i s not high enough to eliminate the e f f e c t s of b i a s . An 80$ response rate i s necessary before the e f f e c t s of bias can be negated. At t h i s rate of response, the s t a t i s t i c a l r e s u l t s are the same as i f 100% of the survey population responded. Pace (1939) determined some factors that influence whether or not a person responds to a mail questionnaire. A greater i n t e r e s t i n the subject under study w i l l lead to a 19 greater chance that the person w i l l respond, A person who i s prompt and conscientious i s more l i k e l y to respond than one who i s not. If a potential respondent has time a v a i l -able f o r extra a c t i v i t i e s , then he i s more l i k e l y to f i l l i n and return the questionnaire than a would-be respondent with no free time. If a person i s embarrassed about answering the questions, or i f he fears that h i s answers may a f f e c t h i s status i n some way, then the chances of him responding are decreased. Loyalty to the sponsoring i n s t i -t u t i o n i s a factor that increases response rate i n a study population. Reuss (1943) found that respondents are more highly educated and more i n t e l l i g e n t than nonrespondents. There i s controversy over whether or not the sex of the respondent i s a factor influencing response (Gannon 1971, Bennett and H i l l 1964). Gannon (1971) found that respondents generally f i t into the 20-49 year age bracket and the non-respondents are either younger or older. Franzen and Lazarfeld (1945) concluded that i f the population i s homo-geneous, then the problem of nonresponse bias w i l l not a r i s e . However, Clausen and Ford (1947) pointed out that no matter how homogeneous a group i s with respect to occupation or education, i f the subject i s of interest to some and not to others, then nonresponse bias could very e a s i l y be a factor that must be considered. Larson and Catton (1959) suggested that late returners are s i milar to nonreturners. Therefore i t i s possible to check i f there i s a nonresponse bias by comparing the early 20 and late returns. Differences i n scores should be i n the same d i r e c t i o n as the scores would be i f comparisons could be made of the returners and nonreturners, although the extent of bias w i l l not be indicated. If such comparisons do show possible bias, then Mayer and Pratt (1966) suggested that the scores of nonreturners can be estimated by analysing the trends between early and late responders and extrapolat-ing these trends to the nonresponders. As previously mentioned, nonresponse bias can be minimized by increasing the percent of returns to at least 80%. Many methods can be employed to increase returns. The i n i t i a l appeal i n the cover l e t t e r i s important. It should not be emotional but should appeal to the respondent's a l t r u i s t i c sense (Clauser and Ford, 1947, Dillman 1972-73). An assurance of c o n f i d e n t i a l i t y has been shown to increase response, as may the offer of a reward. It i s advantageous to have a sponsor who i s related to the population endorse the project and urge a l l questionnaire receivers to respond. The use of a deadline has been shown to stimulate immediate heavy response ( F e r r i s s 1951). It i s h e l p f u l to personalize the cover l e t t e r as much as possible, either by using s p e c i f i c names i n the s a l u t a t i o n or signing each l e t t e r personally (Dillman 1972-73, Longworth 1953). The format of the questionnaire i t s e l f i s important. Dillman (1972-73) f e l t that size and length intimidate people and suggested printing the questionnaires so that they appear smaller. However, Donald (i960) reported high response rates with questionnaires 21 up to 20 pages i n length. Printed questionnaires are also more l i k e l y to be returned than mimeographed material which tends to be thrown away. Enclosing a self-addressed and stamped return envelope has been shown to increase returns ( F e r r i s s 1951). The questionnaire should be sent at an appropriate time. Holidays are times of poor response. Norman (1948) stated that the highest returns are obtained when questionnaires are received at the beginning of the week. One of the most important methods used to increase returns i s the use of the follow-up technique (Dillman 1972-73, Levine and Gordon 1958, Long-worth 1953, Norman 1948). Letters, postcards, phone c a l l s are a l l used, but the most important factor is persistance. Eckland (1965) increased h i s returns from 67% to 94% merely by persistent follow-up. Knowledge. Attitudes, and Practices Knowledge The l e v e l of n u t r i t i o n knowledge of homemakers was assessed by Young et a l . (1956) i n 2 upstate New York c i t i e s . The method used was personal interviews between a trained interviewer and the homemaker. The l a t t e r was defined as the person responsible for planning the food i n the home. A pre-tested, open-end type questionnaire was used. The assess-ment of n u t r i t i o n knowledge was based on the number of food groups for which the homemaker could give a n u t r i t i o n a l l y 22 correct reason for including i n meals. It was found that 20-30% of the homemakers studied answered 1-2 groups c o r r e c t l y and thus had 'some* knowledge of n u t r i t i o n . No correct answers were given by 30-50% of the sample who therefore were c l a s s i f i e d as having 'no1 n u t r i t i o n know-ledge. When the dependent variable, knowledge, was related to the independent variable, age, i t was demonstrated that n u t r i t i o n knowledge decreased as the age of the homemaker increased. Young also found a d i r e c t r e l a t i o n s h i p between the educational attainment and the l e v e l of n u t r i t i o n know-ledge. In f a c t , "formal educational attainment seemed the most important, single factor related to knowledge of n u t r i t i o n " (p. 222). The homemakers who reported having studied n u t r i t i o n i n school had more n u t r i t i o n knowledge than those who d i d not. These r e s u l t s on the r e l a t i o n s h i p of n u t r i t i o n education and educational attainment related to n u t r i t i o n knowledge were supported by Morse et a l . (1967). These researchers tested mothers using the Kilander Information Test that covered a wide range of p r a c t i c a l information on n u t r i t i o n and d i e t . The t e s t s were administered during home v i s i t s to the mothers. Results showed that higher l e v e l s of education were related to better n u t r i t i o n knowledge. A course i n n u t r i t i o n was d i r e c t l y b e n e f i c i a l to the score without being related to the l e v e l of higher education. Wang's (1971) assessment of the n u t r i t i o n knowledge of 4-H Youths, 13-15 years old, and middle aged Homemakers 23 i n Maryland related n u t r i t i o n education to knowledge. A questionnaire regarding f a c t s and f a l l a c i e s or miscon-ceptions of food indicated that the women i n the home-maker clubs were better able to d i f f e r e n t i a t e accurately between fact and f a l l a c y than were low income women or 4-H Youths. Schwartz (1973), however, i n her research of the r e l a t i o n s h i p of n u t r i t i o n education to subsequent n u t r i t i o n knowledge, attitudes, and practices of high school graduates, found that there was no s i g n i f i c a n t difference between the graduates who had taken home econom-i c s i n school and those who had not. The method used i n t h i s study was administration of mail questionnaires to Ohio high school graduates 4 years after graduation. Data on the n u t r i t i o n knowledge of public health nurses i n Michigan health agencies were co l l e c t e d by Harrison et a l . (1969) by means of a questionnaire. Results showed a greater v a r i a b i l i t y i n the knowledge of physiological and psychosocial factors related to n u t r i t i o n than i n the knowledge (of the more di r e c t n u t r i t i o n f a c t s such as nutrients i n foods and tools used i n planning and evaluating d i e t s . It was found that the l e v e l of education, years of experience and type of agency were the variables that showed 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 to n u t r i t i o n knowledge. Nurses with t h e i r Bachelor of Nursing degrees had s i g n i f i c a n t l y more n u t r i t i o n knowledge than did the Registered Nurses i n a l l categories except 'nutrients i n foods'. As the years of experience increased, so did the 24 l e v e l of n u t r i t i o n knowledge as determined from the t o t a l score. If the agency where the nurse worked employed a n u t r i t i o n consultant, then the n u t r i t i o n knowledge increased as the years of experience increased. If no consultant was available, then n u t r i t i o n knowledge was related to educational l e v e l . The n u t r i t i o n knowledge of second year medical students i n New England was examined by P h i l l i p s (1971) by means of objective t e s t items of multiple choice type regarding normal n u t r i t i o n and diet therapy. The r e s u l t s showed that the majority of the students were not aware of important basic concepts and information related to n u t r i t i o n . Attitudes N u t r i t i o n a l b e l i e f s among a low income urban popula-t i o n were surveyed by Comely et a l . (1963) by means of 2-hour personal interviews. The sample included white and black fa m i l i e s and over 50% of the people studied had l e s s than 8 years of formal education. N u t r i t i o n a l b e l i e f s were measured by agreement or disagreement to s p e c i f i c food f a l l a c i e s , such as f i s h being brain food and red meat causing high blood pressure. It was found that as the age of the head of the family increased, there was a decrease i n the percent of those who were informed about food b e l i e f s . As the educational l e v e l of the subjects increased, the acceptance of f a l l a c i e s was lower. O v e r a l l , i t appeared that 25 the n u t r i t i o n a l knowledge of the population was low and there was generally an i n s u f f i c i e n t amount of information on adequate d i e t s . These r e s u l t s were contradicted by Wilson (1968) who related women's food b e l i e f s to ecological f a c t o r s . The sample studied consisted of 73% homemakers and 28% employed women. A questionnaire was administered to determine concepts related to food facts and f a l l a c i e s . Wilson found that as the educational l e v e l of the women increased, there was a concomitant increase i n the acceptance of fa l s e food b e l i e f s . F a l l a c i e s included the idea that honey and vinegar aid weight reduction and onions a r e good for respiratory i l l s . Education i n nu t r i t i o n , however, did help to eliminate food f a l l a c i e s : those with backgrounds i n home economics and n u t r i t i o n did not accept food f a l l a c i e s accepted by t h e i r peers with higher educations i n academic d i s c i p l i n e s other than home economics. The r e s u l t s of Schwarts (1973) contradicted these findings but were i n agreement with the r e s u l t s of the study done by Comely. Backgrounds i n home economics did not s i g n i f i c a n t l y improve attitudes toward foods i n her study. Attitudes were related to r e s p o n s i b i l i t y for food and meal preparation. Newton et a l . (1967) reported on a project that determined the a c t i v i t i e s of hospital nurses i n r e l a t i o n to th e i r patient's n u t r i t i o n needs. This was a 2 year study that was composed of interviews and observations made by a 26 research n u t r i t i o n i s t . Although no s t a t i s t i c a l r e s u l t s were presented, i t was concluded that the nurses on a l l staff l e v e l s reported negative attitudes toward t h e i r educative experiences i n n u t r i t i o n or die t therapy. The nurses gave low p r i o r i t y to n u t r i t i o n i n patient care. Practices The l i t e r a t u r e reveals c o n f l i c t i n g r e s u l t s as to which independent variables a f f e c t n u t r i t i o n p r a ctices. Kunkel and H a l l (1958) analyzed the e f f e c t of a one-semester, co-educational foods course on food habits of 47 adolescent boys and 38 adolescent g i r l s . Three day food records, habit check l i s t s , and objective t e s t s were administered at the beginning and end of the semester. Kunkel found that the g i r l s showed a s i g n i f i c a n t improvement i n intake of a l l food groups except c i t r u s f r u i t s by the end of the semester. The boys improved s i g n i f i c a n t l y i n a l l groups except vegetables. Ov e r a l l , 44% of the students taking the foods course improved t h e i r ratings while only 11% of a control group not taking a foods course improved t h e i r r a t i n g s . Young et a l . (1956) studied the actual feeding practices of t h e i r homemaker popu-l a t i o n . Q u a l i t a t i v e information on feeding practices, such as the food served to the family i n the previous 24 hours, and quantitative information, such as the amounts of c e r t a i n key foods used the previous week were obtained. It was found that higher educational attainment led to the family being 27 served more balanced diets and thus practices were related to educational l e v e l . Mason and Rivers (1970) determined factors that influenced the plasma ascorbic acid l e v e l s i n pregnant women i n a New York outpatient c l i n i c . The women consumed se l f - s e l e c t e d diets and took no vitamin supplements for vitamin C. Blood samples were drawn and i t was found that the subjects who had received dietary i n s t r u c t i o n had higher plasma ascorbic acid l e v e l s than those who did not. Again, n u t r i t i o n education was related to n u t r i t i o n practices. Schwartz (1973) contradicted these findings. She found that graduates of home economics did not exhibit better n u t r i t i o n practices than non-home economics graduates. Relationships of Knowledge. A t t i t u d e s f and Practices In a review of the s o c i o l o g i c a l l i t e r a t u r e Kiesler et a l . (1969) stated that " i t i s commonly assumed that attitudes and behaviors are c l o s e l y related i n a natural setting" (p. 23). Poolton (1972), i n a paper on n u t r i t i o n education, stated that: . . . with expanded i n t e r e s t , r e s u l t i n g from deeper understanding of n u t r i t i o n , there w i l l be a change i n f e e l i n g s , attitudes, or values, and a correspond-ing change i n behavior (p. 113). This p o s i t i v e r e l a t i o n s h i p between knowledge,; attitudes, and practices i s known as a consistency r e l a t i o n -ship. However, Wicker (1969), analyzed the s o c i o l o g i c a l research on attitudes to jobs related to'job absences, a t t i -tudes and behavior toward minority groups, and attitudes and 28 behavior toward cheating on examinations. He concluded from the overall r e s u l t s that i t i s more l i k e l y that attitudes w i l l be unrelated or only s l i g h t l y related to overt behaviors than that attitudes w i l l be c l o s e l y related to practices. This i s known as an inconsistency prediction. Swanson (1972) explained the inconsistency r e l a t i o n s h i p by the fact that attitudes may be more resistent to change than behavior. That i s , behaviors may change before attitudes, and the i n d i v i d u a l learns to l i v e with the inconsistency. Wicker (1971) postulat-ed additional factors, personal and s i t u a t i o n a l , that influence attitude-behavior r e l a t i o n s h i p s . These factors need to be taken into account when predicting overt behaviors. The personal factors include other attitudes that the i n d i v i d u a l has; competing motives; verbal, i n t e l l e c t u a l and s o c i a l a b i l i t i e s which may hinder the a b i l i t y of the person to translate his attitude into e f f e c t i v e work; and a c t i v i t y l e v e l which may or may not be conducive to consistent behavior. S i t u a t i o n a l factors, which may be more important than personal factors, include s o c i a l norms and role requirements leading to behavior inconsistent from attitudes; i n t e r f e r i n g behaviors that do not allow the expected behavior to function; and expected conse-quences of various behaviors which may influence the overt behavior. A f i n a l s i t u a t i o n a l factor i s one c a l l e d the 1 s p e c i f i c i t y of attitude objects'. That i s , consistency follows i f both the attitude and the behavior are s p e c i f i c . Inconsistency develops i f either attitude or behavior i s not s p e c i f i c . Harris (i960) concluded: . . . overt behavior can be looked upon as a compromise -the term "interaction" i s more appropriate - r e f l e c t i n g the net e f f e c t of the entire structure of goal - seeking drives and c a p a b i l i t i e s of the i n d i v i d u a l and the array of goals, obstacles, and detours, comprising the s i t u a -t i o n a l setting (p. 109). 29 The r e s u l t i s that there may be no obvious r e l a t i o n s h i p between the dependent variables knowledge, attitudes, and practices. Knowledge Related to Practice Young et a l . (1956) expanded th e i r work on the n u t r i t i o n knowledge of homemakers and related the n u t r i t i o n knowledge to subsequent feeding practices and the adequacy of the food that was served to the family. It was found that there was a d i r e c t r e l a t i o n s h i p between the l e v e l of n u t r i t i o n knowledge and feeding practices and food adequacy. As the number of homemakers with n u t r i t i o n knowledge increas-ed, the adequacy of the food prepared improved proportion-at e l y . Morse (1967) expanded the study of the n u t r i t i o n knowledge of mothers and related the knowledge to the n u t r i -t i o n a l status of t h e i r c h i l d r e n . The n u t r i t i o n a l status was presumed to be an i n d i c a t i o n of the mothers* practices of n u t r i t i o n i n feeding t h e i r o f f s p r i n g . In the mid-morning, each c h i l d had blood samples taken on which biochemical analyses were carried out. Linear correlations were run between blood determinations and the n u t r i t i o n knowledge scores of the mothers. I t was found that for the boys and g i r l s the plasma ascorbic acid was the only chemical determination showing a positive c o r r e l a t i o n with the scores. This was expected as a morning glass of j u i c e with vitamin C a f f e c t s the plasma ascorbic acid l e v e l i n a short time and 30 n u t r i t i o n education stresses the importance of vitamin C. The male childre n showed s i g n i f i c a n t c o r r e l a t i o n s between the mothers' knowledge of n u t r i t i o n and plasma carotene l e v e l s . This demonstrated that the mothers knew that the provitamin was present to a large extent i n plants and animals. Plasma cholesterol also showed s i g n i f i c a n t c o r relations i n the boys. Emmons and Hayes (1973) conduct-ed a study i n New York to determine the n u t r i t i o n knowledge of children and t h e i r mothers and the r e l a t i o n s h i p of t h i s knowledge to the c h i l d r e n s 1 d i e t s . Both the mothers and the children were asked what types of food were necessary for good health and why. Twenty-four hour food r e c a l l s were obtained. The data showed that the feeding practices of the mothers were better than t h e i r knowledge of n u t r i t i o n which was small. Thus the feeding practices were not based on an understanding of n u t r i t i o n and no r e l a t i o n s h i p was found between n u t r i t i o n knowledge and p r a c t i c e . Attitudes Related to Practice Newton and Newton (1950) studied the r e l a t i o n s h i p of mothers' attitudes toward breast feeding and the success of l a c t a t i o n . They studied 91 maternity ward patients who did not refuse to breast feed. Their attitudes were deter-mined by interviews within 24 hours of d e l i v e r y . The new mothers were asked how they f e l t about breast feeding. The responses provided for were: "positive", "doubtful", 31 " i n d i f f e r e n t or indecisive", and "negative". On the 4th day a f t e r b i r t h , the babies were weighed before and afte r being sent to the breast. The mothers with negative attitudes gave 35 grams of milk to t h e i r babies compared with 59 grams given by the mothers with p o s i t i v e a t t i t u d e s . These differences were s t a t i s t i c a l l y s i g n i f i c a n t . Success, as measured by no needed supplement, was seen i n 74% of the mothers with positive attitudes, while only 26% of the mothers with negative attitudes were successful at breast feeding. Thus the attitudes were d i r e c t l y related to practices. Sims and Morris (1974) examined the n u t r i t i o n a l status of preschool children by means of hemoglobin, hema-t o c r i t , t o t a l serum proteins and serum albumin analyses; height, weight and anthropometric measures; and three one day dietary records. Home interviews was the method used to c o l l e c t family environment data which included agreement or disagreement with a " n u t r i t i o n i s important" a t t i t u d e . Although simple correlations between the biochemical measures and family c h a r a c t e r i s t i c s were inconclusive, the "n u t r i t i o n i s important" attitude did relate to ce r t a i n patterns of the children's nutrient intakes. Mothers who agreed with t h i s attitude had children who had higher intakes of calcium and ascorbic a c i d . Mothers with a poor attitude to n u t r i t i o n had children with higher intakes of c a l o r i e s , carbohydrate, iron and thiamin; nutrients found i n enriched bread and cereal products. Children of mothers with positive n u t r i t i o n attitudes showed a positive c o r r e l a t i o n between 32 c a l o r i e s and the scaled height-weight-for-age values. Thus i t was concluded that these children were l e s s l i k e l y to be overweight or underweight. Also a posi t i v e associa-t i o n was found between protein and iron intakes of children of mothers with the " n u t r i t i o n i s important" attitude as well as an association between protein and i r o n intakes and hemoglobin. Thus attitudes were found to be related to practices. Interrelationships of Knowledge, Attitudes, and Practices Eppright et a l . (1970) studied a number of variables i n r e l a t i o n to food energy and nutrient intake of children, and made associations between the scores of the mothers 1 scores on n u t r i t i o n knowledge and attitude t e s t s , and the n u t r i t i o n a l q u a l i t y of the children's d i e t s . Trained i n t e r -viewers administered tests of n u t r i t i o n knowledge and attitude toward meal planning, food preparation, n u t r i t i o n , and permissiveness i n feeding children. Three-day diet records were obtained. It was found that knowledge was highly and p o s i t i v e l y correlated with attitude toward n u t r i -t i o n . Knowledge also was p o s i t i v e l y correlated with meal planning and to a lesser extent to food preparation. Permissiveness was s i g n i f i c a n t l y and negatively correlated with attitudes to n u t r i t i o n , n u t r i t i o n knowledge, and attitudes toward meal planning. It was found, i n r e l a t i n g 33 knowledge scores to n u t r i t i v e value of diets without supplements, that the n u t r i t i o n scores were s i g n i f i c a n t l y related to ascorbic acid, n i a c i n , phosphorus, protein, r i b o f l a v i n , calcium and c a l o r i c value of food consumed. Of the attitudes tested, permissiveness was most s i g n i f i -cantly related to the n u t r i t i v e value of the food eaten: permissiveness adversely and s i g n i f i c a n t l y affected a l l dietary components but f a t . Attitude to n u t r i t i o n had l i t t l e r e l a t i o n to the n u t r i t i o n content of the d i e t . The statement, "children do not grow c o r r e c t l y i f eating an improper d i e t " , found agreement with 82% of the mothers but t h i s had no co r r e l a t i o n with the nutrient content of the d i e t . When the diets were supplemented with vitamins, there was a c o r r e l a t i o n . between n u t r i t i o n attitudes and nutrient intake, indicating that the mothers with favourable attitudes to n u t r i t i o n were more l i k e l y to give supplements to t h e i r c h i l d r e n . Thus, n u t r i t i o n knowledge, and attitudes to meal planning, food preparation, and permissiveness were int e r r e l a t e d factors influencing the quality of the c h i l d -ren's d i e t s . Attitudes to n u t r i t i o n wererwithout influence on the n u t r i t i o n a l q u a l i t y of the d i e t . The model explain-ing t h i s i n t e r r e l a t i o n s h i p appears i n Figure 2. Schwartz (1973) investigated the r e l a t i o n s h i p between previous enrollment i n home economics courses and present knowledge, attitudes, and practices of Ohio high school graduates. Comparisons were made between graduates with 2 to 3 years of home economics and./those not enrolled 34 i n any such course. S i g n i f i c a n t c o r r e l a t i o n c o e f f i c i e n t s were found for n u t r i t i o n knowledge and attitudes, and for n u t r i t i o n attitudes and practices. The c o r r e l a t i o n between n u t r i t i o n knowledge and practice was very low and non-signi-ships of n u t r i t i o n knowledge, attitudes and practices are possible as conceived by Schwartz (1973). Knowledge and attitudes may independently influence practices, with no re l a t i o n s h i p between themselves. Or, knowledge may influence practices both d i r e c t l y and i n d i r e c t l y , and at the same time attitudes may mediate knowledge and practices ( F i g . 2). f i c a n t ( Fig. 2). Several other models of the i n t e r r e l a t i o n -N u t r i t i o n knowledge and attitudes to meal planning, food preparation and permissiveness are i n t e r r e l a t e d factors influencing dietary practice (Eppright). N u t r i t i o n knowledge and attitudes and n u t r i t i o n attitudes and practices are p o s i t i v e l y correlated. There i s no c o r r e l a t i o n between n u t r i t i o n knowledge and practice (Schwartz). N u t r i t i o n knowledge and attitudes independently influence practice. N u t r i t i o n knowledge influence practices both d i r e c t l y and i n d i r e c t -l y , and at the same time attitudes mediate knowledge and practices. F i g . 2. Models showing the possible i n t e r r e l a t i o n s h i p s between n u t r i t i o n knowledge, attitudes and practic e . 35 CHAPTER III DESIGN OF THE STUDY This study was designed to investigate the n u t r i t i o n knowledge, attitudes, and practices of public health nurses i n Greater Vancouver. Also investigated were the e f f e c t of s p e c i f i c independent variables upon n u t r i t i o n knowledge, attitudes, and practices, and the relationships among the dependent variables. The study was conducted i n cooperation with the Medical Health O f f i c e r s and nursing supervisors i n Greater Vancouver and the C i t y of Vancouver Research and Evaluation Committee. Data C o l l e c t i o n The data were collected by means of self-administered mail questionnaires. The questionnaires were designed to measure, separately, n u t r i t i o n knowledge, n u t r i t i o n attitudes, and n u t r i t i o n practices, as well as to c o l l e c t demographic information on the independent variables. Instruments Data c o l l e c t i o n instruments (Appendix A) were adapted for measurement of four c r i t e r i o n variables: 36 1. N u t r i t i o n Knowledge N u t r i t i o n knowledge was measured by a t e s t consist-ing of 40 statements based on Newton's (i960) suggestions of the n u t r i t i o n knowledge that nurses should possess, i . e . "common tools used i n the planning and evaluation of d i e t s ; c u l t u r a l , economic, psychological and physiological factors which influence food intake; and nutrients i n foods." This test was developed and validated i n previous research by Harrison and co-workers (1969). The instrument, as revised for t h i s study, provided for two responses to each statement. The f i r s t response indicated whether the respondent believed the statement to be either true or f a l s e . The second response indicated one of four possible degrees of c e r t a i n t y for the answer. This method of information r e t r i e v a l was validated i n previous research by Schwartz (1973). Each of the state-ments was scored between 0 and 7 (see table 1), with a possible n u t r i t i o n knowledge score between 0 and 280 for the entire t e s t . 2. Attitudes Toward Food and N u t r i t i o n Attitudes of the subjects with respect to t h e i r perception of the importance of n u t r i t i o n were measured by the test developed by Schwartz (1973), similar to the knowledge test previously described, and adapted for t h i s research project. The test consisted of 14 statements r e f l e c t i n g attitude toward n u t r i t i o n and eating habits of the general public and toward n u t r i t i o n counselling at work. Attitudes 37 TABLE 1 Scoring System for N u t r i t i o n Knowledge Instruments Scale Response Degree of Certainty Very Confident 1 Moderately Moderately Confident Doubtful 2 3 Very Doubtful 4 TRUE True 7 6 5 4 False 0 1 2 3 FALSE False 7 6 5 .4 True 0 1 2 3 TABLE 2 Scoring Svstem for N u t r i t i o n Attitudes Instrument Scale Response Degree of Certainty Very Confident 1 Moderately Moderately Confident Doubtful 2 3 Very Doubtful 4 AGREE Agree 7 6 5 4 Disagree 0 1 2 3 DISAGREE Disagree 7 6 5 4 Agree 0 1 2 3 38 toward personal n u t r i t i o n a l practices, meal planning and preparation were also investigated to ascertain whether or not what the nurse teaches c a r r i e s conviction. As with the knowledge t e s t , the attitudes test provided for two responses to each statement, agree or disagree, and degree of c e r t a i n t y . Each statement was scored between 0 and 7 (see table 2), with a possible attitudes score between 0 and 98. 3. N u t r i t i o n a l Practices This part of the questionnaire consisted of a t o t a l of 20 statements concerning the practice of imparting n u t r i t i o n information to the public as well as the personal dietary practices of the public health nurses. The responses indicated the frequency of s p e c i f i c practices and took the form, "always," "frequently," "sometimes," and "never." The statements regarding the practice of imparting n u t r i t i o n information to the public also provided for the response "not involved i n counselling t h i s group." Each statement was scored between 0 and 3 (see table 3), with a possible practice score between 0 and 60. If a statement was answered by "not involved i n counselling t h i s group," that statement was not counted i n the scoring and the grading was adjusted. 4. Demographic Information Demographic information, necessary for data analysis and i n t e r p r e t a t i o n , was obtained i n a section e n t i t l e d 39 "Information About You." This section was composed of 9 questions seeking information about nursing education, nursing experience, age, n u t r i t i o n education, a v a i l a b i l i t y of n u t r i t i o n consultation, and n u t r i t i o n experience. TABLE 3 Scoring System for N u t r i t i o n a l Practices Instrument Scale Key Response Score ALWAYS Always 1 Frequently 2 Sometimes 3 Never 4 Not involved 5 3 2 1 0 Question Invalidated NEVER Never 4 Sometimes 3 Frequently 2 Always 1 Not involved 5 3 2 1 0 Question Invalidated 40 Procedure The data c o l l e c t i o n instrument was pretested by-health care professionals i n an Adult Education course, and by graduate students i n Human N u t r i t i o n . A pretest questionnaire (Appendix B) was designed and used to c o l l e c t information on the c l a r i t y , precision, and context of the questionnaire for the purpose of improving the data c o l l e c -t i o n instrument. A t o t a l of 189 questionnaire packages were assembled Each package contained a copy of the f i n a l questionnaire, a cover l e t t e r , and an addressed, stamped, return envelope. The cover l e t t e r explained the purpose and authorization of the study, requested the cooperation of the subjects, and gave instructions for completing the forms and returning them by a s p e c i f i c date (Appendix C). Packages were d e l i v e r -ed by the researcher to the nursing supervisor of each health unit or department i n Greater Vancouver. The supervisors d i s t r i b u t e d the questionnaires to the public health nurses and thus there was no d i r e c t contact between the public health nurses and the researcher. The public health nurses were not required to sign t h e i r names and thus anonymity was maintained. After the i n i t i a l deadline, follow-up l e t t e r s were delivered by the researcher to the nursing supervisors who d i s t r i b u t e d the l e t t e r s to the public health nurses. The follow-up l e t t e r reminded the public health nurses of the survey, thanked them for t h e i r help i f they had r e p l i e d , and requested a reply by 41 Schedule Stage 1 - Planning and Preparation 1. Questionnaire development 2. Write and print cover l e t t e r and follow-up l e t t e r to public health nurses 3. Approval by Research and Evalu-ation Committee, nursing super-v i s o r s , and Medical Health O f f i c e r s 4. Pretest questionnaires and print questionnaires 5. Develop and print coding sheets 6. Prepare for computer program analysis January '74 February '74 February '74 February -March '74 March '74 March '74 Stage 2 - Data C o l l e c t i o n 1. Assemble questionnaire packages 2. Deliver questionnaires to the nursing supervisors for further d i s t r i b u t i o n to public health nurses 3. Deliver follow-up l e t t e r s to the supervisors for further d i s t r i b u -t i o n to the public health nurses 4. Phone follow-up requests to the supervisors March '74 March '74 A p r i l '74 May *74 Stage 3 - Data Analysis and Interpretation 1. Code questionnaire responses, check coding 2. Key punching of coded questionnaires 3. Data analyses by computer 4. Results and f i n a l report April-May »74 May '74 June '74 June-July '74 42 by another deadline i f they had not already done so (Appendix C). A second follow-up was carried out after the second deadline. This follow-up consisted of a phone c a l l to each nursing supervisor requesting that she remind the public health nurse of the survey. When a return of 85.1% was achieved, i t was f e l t that s u f f i c i e n t questionnaires had been obtained and no further follow-up was attempted. Public health nurses were then sent a key to the correct responses for the questionnaire. Appendix D contains a flowchart of the procedure for t h i s study. Data Analysis Data c o l l e c t e d were coded, key punched on cards, and treated s t a t i s t i c a l l y for t e s t i n g the hypotheses. a. Multiple and stepwise regressions were carr i e d out on the three dependent variables, knowledge, attitudes, and practices to determine whether the independent variables were factors which related to the dependent var i a b l e s . b. P a r t i a l c o r r e l a t i o n analysis was performed to determine the r e l a t i o n s h i p of n u t r i t i o n knowledge to attitudes and practices and the i n t e r r e l a t i o n s h i p of knowledge and attitudes with practices. 43 CHAPTER IV FINDINGS AND INTERPRETATIONS In t h i s survey of n u t r i t i o n knowledge, attitudes, and practices, questionnaires were di s t r i b u t e d to 189 public health nurses i n Greater Vancouver. The f i r s t objective was to determine whether s i g n i f i c a n t differences exist i n the n u t r i t i o n knowledge, attitudes, and practices of public health nurses as related to the independent variables: educational background, recency of ac q u i s i t i o n of nursing-related degree, years of, nursing experience, age, q u a l i f i c a t i o n of the educator who taught n u t r i t i o n i n the nursing t r a i n i n g curriculum, years of home econimics studied i n high school, number of nu t r i t i o n - r e l a t e d communications with a n u t r i t i o n i s t i n the l a s t four weeks, and other types of n u t r i t i o n experience or education. The second objective was to determine among the public health nurses, the nature of the r e l a t i o n s h i p of n u t r i t i a n knowledge, attitudes and practices, and the i n t e r r e l a t i o n s h i p of knowledge and attitudes with practices. The t e s t of n u t r i t i o n knowledge consisted of 40 statements, each answered by true or false and by the degree of certainty for the answer. Each statement was scored between 0 and 7. This score was converted into percentage so that a l l t e s t s , knowledge, attitudes, and practices, could 44 be analyzed from a common base. The mean score for the knowledge test was obtained by adding the percentage t o t a l s and div i d i n g by 161. The t o t a l mean score for each statement was obtained by dividing the sum of the statement scores for a l l the questionnaires by 161. Questionnaires which had more than 5 statements unanswered on any one tes t were excluded from the analysis of that t e s t . Questionnaires with l e s s than 5 statements unanswer-ed were included i n the anal y s i s . The incomplete statements were given a score analogous to the t o t a l mean score for that statement. The test for attitudes or opinions of n u t r i t i o n was designed to evaluate the public health nurses* perception of the importance of n u t r i t i o n . A t o t a l of 14 statements were answered by indicating "agree or disagree" and by the degree of certainty for the answer. The scoring and marking systems were similar to those used for the knowledge t e s t . The 20 statements that concerned the practices of the public health nurses i n imparting n u t r i t i o n information to the public as well as t h e i r personal dietary practices were answered by indicating the frequency of s p e c i f i c practices, that i s , 'always, 1 'frequently,' 'sometimes,' and 'never.' The possible scores were between 0 and 3. The scoring and marking systems were similar to those used for the knowledge and attitudes t e s t s . A t o t a l return of 161 questionnaires, 85.1%, was achieved. This return was high enough to eliminate any problems of non-response bias. 4 5 Results for Tests of N u t r i t i o n Knowledge. Attitudes and Practices Table 4 shows the test r e s u l t s obtained with the public health nurses for the te s t s of n u t r i t i o n knowledge, attitudes, and practices. The mean score for the opinions test was 89.48%. The knowledge test had a mean score of 75.79%. The lowest mean score was produced by the practice test r e s u l t s at 65.08%. TABLE 4 Test Results for N u t r i t i o n Knowledge  Attitudes and Practices Test Total Mean Score % Standard Deviation Attitudes 89.48 + 8.22 Knowledge 75.79 + 6.91 Practices 65.08 + 10.58 Results for the Demographic Data Instrument Univariate frequency tables were designed i n order to indicate how the public health nursing population was 46 dist r i b u t e d i n terms of the variables tested i n the d i f f e r -ent categories. Table 5 shows that 51% of the public health nurses had a Bachelor of Nursing degree. The other large category was that encompassing 37% of the population who were registered nurses with diplomas i n public health. TABLE 5 Univariate Frequency Table of Nursing  Education Variable Frequency Total Percentage BSN 1 82 50.93 RN +. PH 59 36.65 MSN 2 1.24 RN + PH + Other 10 6.21 RN + PH + BSN 5 3.11 Other 1 .62 BSN + Other 21 1.21 Total 161 The majority of public health nurses studied, 44% received t h e i r l a s t nursing-related degree more than 10 years ago (see table 6). The next largest group comprised 1 BSN indicates a Bachelor of Nursing degree. RN indicates a Registered Nurse. PH denotes a Public Health Diploma and MSN i s a Master of Nursing degree. The abbreviations w i l l be used i n future tables. 4 7 the nurses who received t h e i r degree less than 5 years ago; 32%. TABLE 6 Univariate Table of Recency of Degree Variable Frequency Total Percentage Less than 5 years ago 52 32.30 More than 5 and Less than 10 years ago 38 23.60 More than 10 years ago 71 44.10 Total 161 Table 7 depicts the years of experience category. A large majority, 57%, of the public health nurses had more than 10 years of nursing experience. There was only 24% of the nursing population with 1 to 5 years of experience. 4 8 TABLE 7 Univariate Frequency Table of Years of Experience Variable Frequency Total Percentage Less than 1 year 4 2.48 More than 1 and less than 5 years 39 24.22 More than 5 and le s s than 10 years 25 15.53 More than 10 years 92 57.14 No response 1 .62 Total 161 The public health nurses studied were evenly grouped i n r e l a t i o n to two of the age variables>(see table 8). Nurses over 40 years of age made up 45% of the popula-t i o n . The category over 25 and under 40 years of age was also f i l l e d by 45% of the population. There was 8% of the sample under 25 years of age. Thus, there were s l i g h t l y more public health nurses under 40 years of age than over 40. Table 9 shows the d i s t r i b u t i o n of public health nurses with respect to the type of n u t r i t i o n education they received during t h e i r nursing t r a i n i n g . N u t r i t i o n i s t s or d i e t i t i a n s were responsible for giving 47% of the public health nurses t h e i r n u t r i t i o n education. Nursing instru c t o r s 4 9 gave the next largest group, 35%, t h e i r n u t r i t i o n t r a i n i n g . TABLE 8 Univariate Frequency Table of Age Variable Frequency Total Percentage Under 25 13 8.07 Over 25 and under 40 73 45.34 Over 40 74 45.96 No response 1 .62 Total 161 TABLE 9 Univariate Frequency Table of N u t r i t i o n Education Variable Frequency Total Percentage No n u t r i t i o n education 1 .62 N u t r i t i o n i s t or d i e t i t i a n 76 47.20 Nursing Instructor 56 34.78 Other 5 3.11 Don't know who gave education 3 1.86 Nursing Instructor and d i e t i t i a n 17 10.56 Can't be sure i f had n u t r i t i a n education 31 1.86 Total 161 50 The univariate frequency table of years of home economics studied i n high school (see table 10), shows that 47% of the population had 1 to 2 years of home economics classes i n high school. Thirty percent had no high school home economics and 22% had 3 to 4 years of such education. The majority of public health nurses surveyed had the opportunity to consult with a n u t r i t i o n i s t (see table 11). The r e s u l t s showed that only 22% had no opportunity for consultation. (It appears that the nurses misunderstood the term ' a v a i l a b i l i t y of a n u t r i t i o n i s t ' because ac t u a l l y 48% of the public health nurses had no opportunity for consultation.) Twenty-seven percent made no use of the available service, 28% did so once or twice a month, and 17% did so 3 or 4 times a month. Very few, 5%, consulted with a n u t r i t i o n i s t more than 5 times i n a month. TABLE 10 Univariate Frequency Table of Years of Home Economics Variable Frequency Total Percentage 0 48 29.81 1-2 76 47.20 3-4 36 22.36 No response 1 .62 Total 161 51 TABLE 11 Univariate Freauencv Table of Number of Consultations Variable Frequency Total Percentage No opportunity 36 22.36 0 43 26.71 1-2 46 28.57 3-4 28 17.39 +5 8 4.97 Total 161 Table 12 indicates that 69% of the public health nurses had some type of n u t r i t i o n education or experience other than that received during t h e i r nursing t r a i n i n g . TABLE 12 Univariate Frequency Table of Other  N u t r i t i o n Education or Experience Variable Frequency Total Percentage None 49 30.43 Some 111 68.94 No response 1 .62 Total 161 52 Lowest Mean Score Statements Table 13 i s a c o l l e c t i o n of the statements on which the public health nurses received the lowest mean scores i n the t e s t of n u t r i t i o n knowledge. The lowest mean scores indicated that the public health nurses had r e l a t i v e l y l i t t l e knowledge i n the f i e l d of n u t r i t i o n and pregnancy related to requirements and supplementation. Knowledge of nutrient requirements was found to be low as was the knowledge of nutrient composition of c e r t a i n foods such as milk and apples. The areas of weight reduction, c a l o r i c value of foods and g e r i a t r i c n u t r i t i o n were also ones i n which the public health nurses knowledge was low. Table 14 i s a c o l l e c t i o n of the statements on which the public health nurses received the lowest mean scores i n the t e s t s of n u t r i t i o n attitudes and pra c t i c e . The lowest mean scores f o r the te s t s of n u t r i t i o n attitudes indicated that the prublic health nurses had poor attitudes toward the importance of meal planning. The lowest mean scores for tests of n u t r i t i o n practice demonstrated poor practices i n counselling the public on budgeting, vegetarian d i e t s , and dietary manipulation of f a t s . The public health nurses were shown to have poor personal n u t r i t i o n practices i n home management and i n adhering to the recommended cereal group intake of the B.C. Daily Food Guide. TABLE 13 Statements Measuring N u t r i t i o n Knowledge on Which Respondents Achieved Lowest Mean Scores Question Total Number Statement Possible Score Mean Score 7 The rate of iron absorption i s normally regulated by the body's need for iron* 7.0 3.6 9 A woman normally needs to increase her nutrient intake as soon as she learns she i s pregnant. 7.0 2.5 10 The recommended protein requirement for a pregnant woman i s 35 g. 7.0 4.5 13 Calcium needs of older people are less than those of younger adults, 7.0 4.3 15 The protein need of a healthy 158 pound man engaged i n strenuous physical labour i s the same as that of another healthy 158 pound man engaged 7.0 3.1 i n a sedentary occupation. 24 Taking calcium p i l l s i s a good substitute for an inadequate milk supply, 7.0 4.8 27 Apples are an excellent source of Vitamin C <• 7.0 4.9 33 Taking f o l i c acid preparations may obscure the symptoms of pernicious anemia, 7.0 4.1 35 Most people on a reducing diet should r e s t r i c t t h e i r sodium intake, 7.0 4.6 36 Ounce for ounce, f a t s give more than twice as many c a l o r i e s as carbohydrates or proteins.. 7.0 4.9 37 Soybeans are d e f i c i e n t i n the amino acid methioninec. 7.0 3.7 40 The iro n requirement f o r a pregnant woman i s 18 mg. 7.0 2.6 TABLE 14 Statements Measuring N u t r i t i o n Attitudes and Practices on Which Respondents Achieved Lowest Mean Scores Total Test Question Statement Possible Mean Number Score Score Attitudes 11 Planning the foods for a meal just before starting to cook 7.0 4.8 i s a r e a l timesaver, Practice 5 I give out low cost food ideas to low income peopleo 3.0 1.5 Practice 9 I remind the public that dried beans and peas served with whole wheat bread may be used 3.0 1.1 as a meat alternative. Practice 10 I encourage the use of poly-unsaturated o i l s over butter or 3.0 1.2 l a r d . Practice 15 I keep a record of the amount of money I spend on food t 3.0 1.3 Practice 19 I include at least three servings of whole grain or enriched cereal products i n my 3.0 1.4 d a i l y diet -> 5 5 Factors Related to N u t r i t i o n Knowledge Table 15 depicts the r e s u l t s of multiple regres-sion for a l l the independent variables studied related to the knowledge te s t score. Only one of the variables was found to be s i g n i f i c a n t l y related to the test score. Those public health nurses who had graduated less than 5 years ago achieved s i g n i f i c a n t l y lower scores for knowledge than nurses who had graduated 5 to 10 years ago. As was seen i n the univariate frequency table for recency of degree, 32% of the public health nurses received t h e i r degrees less than 5 years ago. Table 16 shows stepwise regression r e s u l t s for a l l the independent variables and these r e s u l t s indicate that those nurses who graduated less than 5 years ago achieved s i g n i f i c a n t l y lower scores than those who graduated more than 5 years ago. Stepwise regression r e s u l t s for single independent variables and the knowledge test score (see table 17), indicated that non-significant variables were age, n u t r i t i o n t r a i n i n g , years of home economics, number of consultations with a n u t r i t i o n i s t , and other n u t r i t i o n education or experience. Table 18 shows the single independent variables which were found to be s i g n i f i c a n t l y related to knowledge following stepwise regressions. The public health nurses who were registered nurses and had public health diplomas and Bachelor of Nursing degrees scored s i g n i f i c a n t l y higher on tests of knowledge than those nurses who did not have 56 TABLE 15 Multiple Regression Results f o r M l Independent  Variables Studied and the Knowledge Test  Score R^ = 0.1694. Fprob = 0.6902 Variable C o e f f i c i e n t Fprob Constant Education: (Base BSN) Years since degree (Base 5 - 1 0 ) Years Experience (Base 5 - 1 0 ) Age (Base 25-4C N u t r i t i o n t r a i n i n g (Base none) 7 3 . 6 5 2 9 RN+PH 0 . 5 7 2 8 MSN 3 . 3 0 4 4 RN+PH+Other - 2 . 3 6 1 1 RN+PH+BSN 5 . 1 0 4 3 Other - 1 1 . 8 5 8 7 BSN+Other - 1 . 9 0 6 7 i < 5 - 4 . 6 9 9 5 > i o - 1 . 3 2 7 9 <1 5 . 5 8 0 8 >1 & < 5 4 . 1 8 4 3 >10 3 . 2 3 4 9 i ^ 2 5 1 .0339 >) > 4 0 - 0 . 4 2 5 7 by n u t r i t i o n i s t or d i e t i t i o n - 0 . 2 4 6 8 Years (Base by nursing instructor by other means doesn't know by whom can't be sure i f had training' of home economics: 0 1 -2 ) 3 -4 Consultation with a n u t r i t i o n i s t : (Base 3 - 4 ) - no opportunity Other n u t r i t i o n education or experience: (Base none) 0" 1 - 2 +5 Prenatal classes Cooking for family Cooking classes N u t r i t i o n courses N u t r i t i o n conferences Other - 0 . 1 3 2 1 - 1 . 6 2 3 9 0 . 7 3 3 2 - 5 . 5 6 3 8 0 . 5 9 5 7 1 . 6 0 4 0 - 0 . 8 5 7 4 - 0 . 1 6 3 1 - 0 . 6 6 7 7 - 0 . 5 6 0 3 0 . 4 4 2 3 2 . 0 8 5 5 3 . 7 0 8 0 1 .6474 •0 .2093 - 0 . 2 6 0 2 0 .7026 0 . 5 8 1 5 0 .3900 0 .1587 0 . 1 2 6 5 0 . 7 2 7 7 0 . 0 2 5 2 * 0 .4636 0 .2721 0 .0742 0 .0985 0 .7304 0 .7914 0 . 8 7 1 0 0 . 9 0 4 0 0 . 7 0 7 9 0 .8526 0 .2595 0 .6905 0 .3230 0 .6696 0 . 8 9 4 0 0 . 7 1 7 2 0 .8378 0 . 7 9 2 4 0 . 1 3 4 5 0 . 1 8 1 8 0 .4293 0 .8521 0 .8363 S i g n i f i c a n t at 5% l e v e l TABLE 16 Stepwise Regression Results for A l l Independent  Variables Studied and the Knowledge Test Score R2 = 0.0733. Forob = 0.0089* Variable C o e f f i c i e n t Fprob Constant 75.4893 Less than 5 years since degree -2.8239 0.0145* S i g n i f i c a n t at 5% l e v e l TABLE 17 Stepwise Regression Results for Single Independent  Variables and the Knowledge Test Score Yielding  Non-Significant (n.s.) Finding's Independent Variable Significance of Poten-t i a l Independent Vari-ables  Age Nu t r i t i o n t r a i n i n g Years of home economics Number of consultations with n u t r i t i o n i s t Other n u t r i t i o n education or experience n. s. n. s. n.s. n. s. n.s. ,58 t h i s combination of degrees. Nurses who received t h e i r degrees less than 5 years ago scored s i g n i f i c a n t l y lower on the te s t s than nurses who received t h e i r degrees more than 5 years ago. Nurses who had more than 10 years of nursing experience scored s i g n i f i c a n t l y higher than nurses with l e s s than 10 years of experience. Thus nursing experience was very s i g n i f i c a n t l y related to n u t r i t i o n knowledge. Harrison (1969) found that as the years of experience increased, so did the l e v e l of n u t r i t i o n know-ledge of the public health nurses. Harrison further found that education was related to knowledge, however she found that i t was the public health nurses with the Bachelor of Nursing degrees who scored s i g n i f i c a n t l y higher. TABLE 18 Stepwise Regression Results for Single Independent  Variables and the Knowledge Test Score Yielding  S i g n i f i c a n t Findings Independent Variable R< Fprob Variable C o e f f i c i e n t Fprob Constant 74.9130 Education 0.0397 0.0439* RN+PH+BSN 6.1663 0.0489* Recency of Constant 76.7785 degree 0.0357 0.0173* Less than 5 years since degree -2.7734 0.0173* Years of Constant 74.5921 nursing experience 0.0260 0.0417* More than 10 years experience 2.2475 0.0417* S i g n i f i c a n t at b% l e v e l Factors Related to N u t r i t i o n Attitudes 59 Multiple regression r e s u l t s for a l l the independent variables studied i n r e l a t i o n to n u t r i t i o n opinions can be reviewed i n table 19. A l l the variables except years of home economics i n high school and consultation with a n u t r i t i o n i s t were found to have no s i g n i f i c a n t r e l a t i o n s h i p to the attitudes of the nurses. Those who had no home economics classes i n high school scored s i g n i f i c a n t l y lower on the opinions test than those who had 1 to 2 years of home economics. Nurses who never consulted with a n u t r i t i o n i s t but had the opportunity to do so scored s i g n i f i c a n t l y lower i n the test than those who had consulted 3 to 4 times with the n u t r i t i o n i s t . Stepwise regression r e s u l t s for a l l the independent variables studied (see table 20), 'were compared with a base of nurses who were over 25 years of age, had taken some home economics classes i n high school, and not taken n u t r i t i o n courses as continuing education. The r e s u l t s indicated that nurses under 25 years of age and with no home economics background i n high school scored s i g n i f i c a n t l y lower than nurses i n the base category. Those nurses who had taken n u t r i t i o n courses as continuing education scored s i g n i f i c a n t l y higher on the attitudes test than nurses i n the base category. The r e s u l t s of the stepwise regressions for the single independent variables (see tables 21 and 22), indicated that nurses under 25 years of age scored s i g n i f i c a n t -l y higher than those over 25 years of age. Nurses with no home economics background scored s i g n i f i c a n t l y higher than those with such a background. Nurses who had taken continuing education n u t r i t i o n courses scored s i g n i f i c a n t l y higher than those who had not. 60 TABLE 19 Multiple Regression Results for A l l Independent  Variables Studied i n the Attitudes Test Score  R^ = 0.2498, Fprob = 0.0928 " Variable C o e f f i c i e n t Fprob Constant Education: RN+PN (Base BSN) MSN RN+PH+Other RN+PH+BSN Other BSN+Other Years since <5 degree >10 (Base 5-10) Years ^ 1 experience >1 & ^5 (Base 5-10) >10 Age *25 (Base 25-40) >40 Nu t r i t i o n by n u t r i t i o n i s t or tr a i n i n g : d i e t i t i o n (Base none) by nursing instructor by other means doesn't know by whom can't be sure i f had tra i n i n g Years of home economics: 0 (Base 1-2) 3-4 Consultation with a n u t r i t i o n i s t : (Base 3-4) - no opportunity 0 1-2 +5 Other n u t r i t i o n education or experience (Base none) Prenatal classes Cooking for family Cooking classes N u t r i t i o n courses N u t r i t i o n conferences Other 94.2881 2.0610 2.8881 -0.0669 -2.9556 -6.6265 5.8555 -1.8041 0.1765 1.3687 2.7045 -1.3114 4.1626 1.2504 -1.4687 -2.5367 -1.4459 -9.4960 •3.6218 1.7488 -3.8010 -5.1027 -2.1159 -1.1817 0.6246 1.0046 -4.8565 3.7739 -0.6383 -0.3556 0.2251 0.6715 0.9307 0.4856 0.4657 0.3584 0.4571 0.8906 0.7999 0.3173 0.5683 0.2301 0.5200 0.5379 0.2697 0.7634 0.0842 -3.7011 0.5198 0.0314 0.3455 0.0902 0.0238* 0.3188 0.7424 0.7542 0.5379 0.1059 0.1065 0.6866 0.8127 S i g n i f i c a n t at b% l e v e l 61 TABLE 20 Stepwise Regression Results for a l l Independent  Variables Studied and the Attitudes Test Score  R2 = 0.1580. Fprob = 0.0001* Variable C o e f f i c i e n t Fprob Constant Less than 25 years 0 years of home economics N u t r i t i o n courses 90.7727 -5.8396 -3.9259 5.9273 0.0111* 0.0046* 0.0035* * S i g n i f i c a n t at b% l e v e l TABLE 21 Stepwise Regression Results for Single Independent  Variables and the Attitudes Test Score Yi e l d i n g  Non-Significant (n.s.) Finding's Independent Variable Significance of Potential Independent Variables Education n.s. Recency of degree n.s. Years of nursing experience n.s. N u t r i t i o n t r a i n i n g n.s. Number of consultations with a n u t r i t i o n i s t n.s. 62 TABLE 22 Variables and the Attitudes Test Score Yielding S i g n i f i c a n t Findings Independent Variable R 2 Fprob Variable C o e f f i c i e n t Fprob Age 0.0264 0.0383* Constant 89.7464 Less than 25 years old -4.9548 0.0383* Years of home 0.0450 0.0072* Constant 90.5055 economic s 0 years -3.8563 0.0072* Other n u t r i t i o n education 0.0522 0.0039* Constant 88.6597 or experience N u t r i t i o n courses 6.0214 0.0039* • t t S i g n i f i c a n t at 5% l e v e l Factors Related to N u t r i t i o n Practice Multiple regression r e s u l t s for a l l the independent variables studied (see table 23), showed that none of the independent variables accounted s i g n i f i c a n t l y for the differences i n score r e s u l t s for the n u t r i t i o n practice t e s t . The r e s u l t s of stepwise regression for a l l of the 30 independ-ent variables and the practice t e s t score are shown i n table 24. The base for comparing the r e s u l t s i s one of public TABLE 23 63 Multiple Regression Results fox All,Independent Variables Studied and the Practices Test. S_cjQ.rj5 R^= Q .1886 , Fprob = Q.4880 Variable C o e f f i c i e n t Fprob Constant Education: (Base BSN) RN+PH MSN RN+PH+Other RN+PH+BSN Other BSN+Other Years since degree (Base 5-10) Years Experience (Base 5-10) Age (Base 25-40) <5 >10 <1 7 1 & 4 5 > 1 0 < 25 >40 Nu t r i t i o n t r a i n i n g : by n u t r i t i o n i s t or d i e t i t i a n (Base none)by nursing instructor by other means doesn't know by whom can't be sure i f had tr a i n i n g Years of home economics: 0 (Base 1-2) 3-4 Consultation with a n u t r i t i o n i s t : (Base 3-4) Other n u t r i t i o n education or ? xperience: Base none) no opportunity 0 1-2 +5 Prenatal classes Cooking for family Cooking classes N u t r i t i o n courses N u t r i t i o n conferences Other 61.1184 1.7814 -1.7333 -4.8935 5.6899 -3.6428 -2.8336 -3.4418 -1.4888 -0.7904 3.9001 3.4641 2.2561 1.1257 2.8920 -0.4272 7.5171 1.0129 7.4427 -2.9152 0.7729 -4.6890 -3.6055 0.0757 1.7046 -0.9105 2.8236 3.1682 -0.8377 3.1322 -0.4480 0.4315 0.8250 0.2093 0.2976 0.7503 0.7293 0.2851 0.5809 0.8817 0.2790 0.2435 0.6272 0.6638 0.3482 0.8580 0.2464 0.8594 0.3161 0.1823 0.7445 0.1064 0.2167 0.9273 0.7192 0.7329 0.1773 0.4308 0.7762 0.1279 0.8198 6 4 health nurses who had an opportunity to consult with a n u t r i t i o n i s t and public health nurses who had attended n u t r i t i o n conferences. The r e s u l t s showed that public health nurses who had no opportunity to consult with a n u t r i t i o n i s t scored s i g n i f i c a n t l y lower on the practice t e s t than those public health nurses i n the base category. Public health nurses who had attended n u t r i t i o n conferences scored s i g n i f i c a n t l y higher than nurses i n the base category. TABLE 24 Stepwise Regression Results for A l l Independent  Variables Studied and the Practices Test Score  = 0.0846. Fprob = 0.0084* Variable C o e f f i c i e n t Fprob Constant 64.0062 No opportunity to consult with a n u t r i t i o n i s t -3.8606 0.0465* Attendance at n u t r i t i o n conferences 4.0884 0.0193* S i g n i f i c a n t at b% l e v e l Stepwise regression r e s u l t s for the i n d i v i d u a l independent variables and the dependent variable practice scores (see 65 table 25), showed that a l l the potential independent variables were non-significant for education, recency of degree, years of experience, age, n u t r i t i o n t r a i n i n g , years of home economics i n high school, and number of consultations with a n u t r i t i o n i s t , TABLE 25 Stepwise Rearession Results for Independent Variables and the Practices Test Score Yi e l d i n a Non-Sianificant (n.s .) Findinas Independent Variable Significance of Potential Independent Variable Education n.s. Recency of degree n.s. Years of experience n.s. Age n.s. N u t r i t i o n t r a i n i n g n. s. Years of home economics n. s. Number of consultations with a n u t r i t i o n i s t n. s. The s i g n i f i c a n t variable that was indicated by stepwise regression was other n u t r i t i o n education or experience (see table 26). The public health nurses who had attended n u t r i t i o n conferences scored s i g n i f i c a n t l y higher on tests of n u t r i t i o n practice than those public health nurses who had not attended conferences. 66 TABLE 26 Stepwise Regression Results for Single Independent Variables and the Practice Test Score Yielding  S i g n i f i c a n t Finding? Independent Variable R2 Fprob Variable C o e f f i c i e n t Fprob Other n u t r i - Constant 63.4901 t i o n 0.0471 0.0228* education or Nut r i t i o n experience conferences 3.7896 0.0313* * S i g n i f i c a n t at 5% l e v e l Correlations of N u t r i t i o n Knowledge, Attitudes, and Practices C o e f f i c i e n t s of the regression equation for the dependent variable knowledge (see table 27) demonstrate that n u t r i t i o n attitudes and practice were s i g n i f i c a n t l y and d i r e c t l y related to knowledge. However, the r e l a t i o n s h i p between practices and knowledge was the strongest of the two. ' The c o e f f i c i e n t s of the regression equation for the dependent variable attitudes (see table 28) indicate that knowledge and practices were s i g n i f i c a n t l y and d i r e c t l y related to attitudes, although the r e l a t i o n s h i p between practices and attitudes was the stronger of the two. The c o e f f i c i e n t s of the regression equation for the dependent variable practice (see table 29) show that attitudes and knowledge were s i g n i f i c a n t l y and d i r e c t l y related to TABLE 27 C o e f f i c i e n t s of the Regression Equation  For the Dependent Variable Knowledge  R^ = 0.1214, Fprob = 0.0001* Variable C o e f f i c i e n t Fprob Constant 52.5178 Attitudes 0.1330 0.0458* Practice 0.1746 0.0011* S i g n i f i c a n t at 5% l e v e l TABLE 28 C o e f f i c i e n t s of the Regression Equation  For the Dependent Variable Attitudes  R2 = 0.1095, Fprob = 0.0002* Variable- C o e f f i c i e n t Fprob Constant 62.7086 Knowledge 0.1908 0.0458* Practice 0.1892 0.0031* S i g n i f i c a n t at 5% l e v e l 68 TABLE 29 C o e f f i c i e n t s of the Regression Equation  For the Dependent Variable Practice  R^ = 0.1495. Fprob = 0.0000 Variable C o e f f i c i e n t Fprob Constant 8.2726 Attitude 0.2993 0.0031* Knowledge 0.3962 0.0011* S i g n i f i c a n t at 5$ l e v e l practice, although the r e l a t i o n s h i p between knowledge and practices was the strongest of the two. These l a t t e r two relationships were the strongest of a l l the knowledge, attitudes, and practices r e l a t i o n s h i p s . Table 30 shows the r e s u l t s of the sample moment cor r e l a t i o n on n u t r i t i o n knowledge, attitudes, and practi c e . Table 31 i l l u s t r a t e s the r e s u l t s of p a r t i a l c o r r e l a t i o n f o r knowledge, attitudes, and practices. The r e s u l t s of both these tables emphasize the d i r e c t relationships between knowledge and attitudes, practices and attitudes, and practices and knowledge. Again the r e s u l t s show that the weakest rel a t i o n s h i p was between knowledge and attitudes. The strong-est r e l a t i o n s h i p was between knowledge and practices. Thus a model for the relationships between the n u t r i t i o n knowledge, attitudes, and practices of public health 69 TABLE 30 Sample Product Mpment Correlation of  N u t r i t i o n Knowledge. Attitudes. and Practices Variable Attitudes Knowledge Practice Attitudes Knowledge Practice 1.0000 0.2368 0.2938 1.0000 0.3138 1.0000 TABLE 31 P a r t i a l Correlation Results for Knowledge. Attitudes, and  Practices Variable Attitudes Knowledge Practice Attitude Knowledge Practice 1.0000 0.1593 0.2380 1.0000 0.2630 1.0000 70 nurses was designed. Figure 3 i l l u s t r a t e s the model: F i g . 3. Knowledge, attitudes, practice model weakest r e l a t i o n s h i p — — . strongest r e l a t i o n s h i p 4 weakest d i r e c t i o n — strongest d i r e c t i o n Results of Hypotheses Tested In terms of the hypotheses, the r e s u l t s of the study may be stated: 1. There were s i g n i f i c a n t differences achieved i n t e s t s of n u t r i t i o n knowledge between public health nurses who were registered nurses and had public health diplomas and Bachelor of Nursing degrees and public, health nurses who had any other type of educational background. There were no s i g n i f i c a n t differences achieved i n t e s t s of n u t r i t i o n attitudes and practices of public health nurses based on educational background. 2. There were s i g n i f i c a n t differences achieved i n tests of n u t r i t i o n knowledge between public health nurses who acquired t h e i r most recent nursing-related degrees within 7 1 the l a s t f i v e years and those who acquired t h e i r degrees more than f i v e years ago. There were no s i g n i f i c a n t differences achieved i n t e s t s of n u t r i t i o n attitudes and practices between public health nurses who acquired t h e i r most recent nursing-related degrees within the l a s t f i v e years and those who acquired t h e i r degrees more than f i v e years ago. There were no s i g n i f i -cant differences achieved i n tests of n u t r i t i o n knowledge, attitudes, and practices between public health nurses who acquired t h e i r most recent nursing degrees more than ten years ago and those who acquired t h e i r degrees less than ten but more than f i v e years ago. 3. There were s i g n i f i c a n t differences achieved i n te s t s of n u t r i t i o n knowledge between public health nurses who had more than ten years of nursing experience and those who had less than ten years of nursing experience. There were no s i g n i f i c a n t differences achieved i n te s t s of n u t r i t i o n attitudes and practices of public health nurses based on years of experience. 4. There were no s i g n i f i c a n t differences achieved i n tests of n u t r i t i o n knowledge and practices of public health nurses based on age. There were s i g n i f i c a n t differences achieved i n t e s t s of n u t r i t i o n attitudes between public health nurses who were less than twenty-five years old and those who were more than twenty-five years o l d . 5 . There were no s i g n i f i c a n t differences achieved i n te s t s of n u t r i t i o n knowledge, attitudes, and practices between 72 public health nurses who received n u t r i t i o n education i n the nursing curriculum and those who did not. Among the public health nurses who received n u t r i t i o n education i n the nursing curriculum, there were no si g n i f i c a n t differences achieved i n t e s t s of n u t r i t i o n knowledge, attitudes, and practices between public health nurses who received n u t r i t i o n education from a q u a l i f i e d n u t r i t i o n i s t or d i e t i t i a n and those who did not. 6. There were no s i g n i f i c a n t differences achieved i n te s t s of n u t r i t i o n knowledge and practices between public health nurses who received home economics n u t r i t i o n education i n high school and those who did not. There were s i g n i f i c a n t differences achieved i n te s t s of n u t r i t i o n attitudes between public health nurses who had received no home economics tr a i n i n g i n high school and those who had received one to four years of home economics t r a i n i n g . 7. There were no s i g n i f i c a n t differences achieved i n te s t s of n u t r i t i o n knowledge and attitudes between public health nurses who have had the services of a n u t r i t i o n consultant for more than six months and those who have had the services for l e s s than six months. There were s i g n i f i c a n t differences achieved i n te s t s of n u t r i t i o n practices between public health nurses whohave had the services of a n u t r i t i o n consultant for more than six months and those who have had the services for l e s s than 73-six months. Among the public health nurses who have had the services of a n u t r i t i o n consultant for more than six months, there were no s i g n i f i c a n t d i f f e r -ences achieved i n tests of n u t r i t i o n knowledge and practices based on the number of nu t r i t i o n - r e l a t e d communications with the n u t r i t i o n i s t . Among the public health nurses who had the services of a n u t r i -t i o n consultant for more than six months, there were s i g n i f i c a n t differences achieved i n t e s t s of n u t r i t i o n attitudes based on the number of nu t r i t i o n - r e l a t e d communications with the n u t r i t i o n i s t . There were no s i g n i f i c a n t differences achieved i n te s t s of n u t r i t i o n knowledge of public health nurses based on other types of n u t r i t i o n education or experience. There were no s i g n i f i c a n t differences achieved i n tests of n u t r i t i o n attitudes of public health nurses based on attendance at expectant parent 1s classes, cooking for own family, attendance at cooking classes, and attend-ance at n u t r i t i o n conferences. There were s i g n i f i c a n t differences achieved i n t e s t s of n u t r i t i o n attitudes of public health nurses based on attendance at n u t r i t i o n courses. There were no s i g n i f i c a n t differences achieved i n t ests of n u t r i t i o n practices of public health nurses based on attendance at expectant parents* classes, cooking for own family, attendance at cooking classes and attendance at n u t r i t i o n courses. There were s i g n i -f i c a n t differences achieved i n te s t s of n u t r i t i o n 7 4 practices of public health nurses based on attendance at n u t r i t i o n conferences. 9. There were positive relationships among the scores for n u t r i t i o n knowledge, attitudes, and practices achieved by the public health nurses. The weakest positive r e l a t i o n s h i p was between knowledge and a t t i -tudes. The strongest r e l a t i o n s h i p was between know-ledge and practices. 75 CHAPTER V SUMMARY AND IMPLICATIONS This chapter i s a b r i e f review of the study; i t s design, o b j e c t i v e s , procedure, and major f i n d i n g s . The chapter concludes w i t h recommendations and i m p l i c a t i o n s drawn from the r e s u l t s . Summary The study was designed t o i n v e s t i g a t e the n u t r i t i o n knowledge, a t t i t u d e s , and p r a c t i c e s of p u b l i c h e a l t h nurses i n Greater Vancouver. The o b j e c t i v e s were: 1. To determine whether s i g n i f i c a n t d i f f e r e n c e s e x i s t i n the n u t r i t i o n knowledge, a t t i t u d e s , and p r a c t i c e s of p u b l i c h e a l t h nurses as r e l a t e d t o a. e d u c a t i o n a l background i . e . Bachelor of Nursing, Registered Nurse, Registered Nurse plus P u b l i c H ealth Diploma, Master of Nursing, a d d i t i o n a l f i e l d education. b. recency of a c q u i s i t i o n of n u r s i n g - r e l a t e d degree i . e . w i t h i n 5 years, more than 5 years and l e s s than 10 years ago, and more than 10 years ago. c. years of nursing experience i . e . l e s s than 1 year, more than 1 year and l e s s than 5 years, more than 5 and l e s s than 10 years, and 76 more than 10 years. d. age i . e . under 25, between 25 and 40, and over 40. e. q u a l i f i c a t i o n of the educator who taught n u t r i -t i o n i n the nursing c u r r i c u l u m i . e . n u t r i t i o n i s t or d i e t i t i o n , nursing i n s t r u c t o r , or other. f . years of home economics - i n c l u d i n g foods and n u t r i t i o n - studied i n high school i . e . none, 1-2 years, and 3-4 years. g. number of n u t r i t i o n - r e l a t e d communications w i t h a n u t r i t i o n i s t i n the l a s t four weeks ( i f the n u t r i t i a n c o n sultant s e r v i c e s have been a v a i l a b l e f o r over 6 months) i . e . none, 1-2, 3-4, and 5 or more. h. other types of n u t r i t i o n experience or education i . e . attendance at expectant parent's c l a s s , cooking c l a s s e s , n u t r i t i o n courses i n c o n t i n u i n g educa-t i o n , and n u t r i t i o n conferences. 2. To determine among the p u b l i c h e a l t h nurses, the nature of the r e l a t i o n s h i p of n u t r i t i o n knowledge, a t t i t u d e s , and p r a c t i c e s , and the i n t e r r e l a t i o n s h i p of knowledge and a t t i t u d e s w i t h p r a c t i c e s . The data were c o l l e c t e d by means of 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 s which measured, s e p a r a t e l y , n u t r i t i o n knowledge, a t t i t u d e s , and p r a c t i c e s . As w e l l , the q u e s t i o n n a i r e s c o l l e c t -7 7 ed demographic information on the independent va r i a b l e s . The t e s t of n u t r i t i o n knowledge consisted of 40 statements based on the n u t r i t i o n knowledge that nurses should possess. The t e s t of n u t r i t i o n attitudes consisted of 14 statements r e f l e c t i n g attitude toward n u t r i t i o n and eating habits of the general public and toward n u t r i t i o n counselling at work. Attitudes toward personal n u t r i t i o n a l practices were also investigated to ascertain whether or not what the nurse teaches c a r r i e s conviction. The test of n u t r i t i o n practices consisted of 20 statements concerning the practice of imparting n u t r i t i o n information to the public as well as the personal dietary practices of the public health nurses. The demographic section c o l l e c t e d information on nursing education, nursing experience, age, n u t r i t i o n education, a v a i l a b i l i t y of n u t r i t i o n consulta-t i o n , and n u t r i t i o n experience or education a f t e r graduation. A t o t a l of 189 questionnaires were d i s t r i b u t e d to the public health nurses by the nursing supervisors. The question-naires were returned to the researcher through the mail. Follow-up consisted of a l e t t e r and a phone c a l l to each nursing supervisor and yielded a f i n a l response rate of 85.1%. The data were coded, key punched on cards, and treated s t a t i s t i c a l -l y for testing the hypotheses. Multiple and stepwise regres-sions were ca r r i e d out to determine which independent variables were related to the dependent varia b l e s . P a r t i a l c o r r e l a t i o n analysis was done to determine the r e l a t i o n s h i p of n u t r i t i o n knowledge to attitudes and practices, and the i n t e r r e l a t i o n s h i p of knowledge and attitudes with practices. Analyses were 78 tested at the 5% l e v e l of: s i g n i f i c a n c e . The major findings were: 1. The majority of public health nurses studied had Bachelor of Nursing degrees, received t h e i r degrees more than 10 years ago, had more than 10 years of nursing experience, were between 25 and 40 years of age, had received t h e i r n u t r i t i o n education i n the t r a i n i n g curriculum from either a n u t r i t i o n i s t or a d i e t i t i a n , had 1 to 2 years of home economics classes i n high school, consulted with a n u t r i -t i o n i s t 1 to 2 times a month, and had been involved i n some type of n u t r i t i o n education or experience after graduation. 2. The mean score test r e s u l t s for tests of n u t r i t i o n know-ledge, at t i t u d e s , and practices, were 75.79%, 89.48%, and 65.08% respectively. 3. The lowest mean scores indicated that the area i n which the public health nurses had the least knowledge was n u t r i t i o n and pregnancy related to requirements and supplementation. Knowledge was also i n s u f f i c i e n t i n the areas of nutrient requirements, nutrient composition of foods, g e r i a t r i c n u t r i t i o n , c a l o r i c value of foods, and weight co n t r o l . 4. The poorest n u t r i t i o n attitude that the public health nurses had was related to the importance of meal planning. 5. N u t r i t i o n practices c a r r i e d out least frequently by the public health nurses included counselling the public on budgeting, vegetarian d i e t s and dietary manipulation of f a t s . Poorest personal practices were i n home management 7 9 and i n adhering to the recommended cereal group intake of the B.C. Daily Food Guide. 6. Public health nurses scored s i g n i f i c a n t l y higher on the tes t s of n u t r i t i o n knowledge i f th e i r educational back-ground was a combination of Registered Nurse and Public Health Diploma plus a Bachelor of Nursing degree. Nurses scored s i g n i f i c a n t l y lower on te s t s of n u t r i t i o n know-ledge i f they had graduated l e s s than 5 years ago. Nurses scored s i g n i f i c a n t l y higher on te s t s of n u t r i t i o n know-ledge i f they had more than 10 years of nursing experience. 7. Neither age, n u t r i t i o n education i n the t r a i n i n g c u r r i c u -lum, home economics classes i n high school, consultations with a n u t r i t i o n i s t , or continuing education i n n u t r i t i o n had any s i g n i f i c a n t e f f e c t s on n u t r i t i o n knowledge. 8. Public health nurses who were under 25 years of age and had received home economics t r a i n i n g i n high school scored s i g n i f i c a n t l y lower on the te s t s of n u t r i t i o n a t t i t u d e s . 9. Public health nurses who did not consult with a n u t r i t i o n -i s t when they had the opportunity to do so scored s i g n i f i -cantly lower on n u t r i t i o n attitudes t e s t s . 10. Public health nurses who had taken some n u t r i t i o n courses as continuing education scored s i g n i f i c a n t l y higher on the n u t r i t i o n attitudes t e s t s . 11. Public health nurses scored s i g n i f i c a n t l y lower on t e s t s of n u t r i t i o n practices i f they had no opportunities to consult with a n u t r i t i o n i s t . 12. Public health nurses scored s i g n i f i c a n t l y higher on t e s t s 80 of n u t r i t i o n practices i f they had attended n u t r i t i o n conferences after graduation from t h e i r nursing t r a i n i n g . 13. N u t r i t i o n practices were not s i g n i f i c a n t l y related to educational background, recency of a c q u i s i t i o n of nursing related degree, years of experience, age, n u t r i t i o n education i n the t r a i n i n g curriculum, or home economics classes i n high school. 14. There were s i g n i f i c a n t and d i r e c t r e l a t i o n s h i p s between n u t r i t i o n knowledge and attitudes, knowledge and practices, and attitudes and practices. The strongest r e l a t i o n s h i p was between knowledge and practices. Implications 1. The r e s u l t s of t h i s study indicate that public health nurses need to improve t h e i r knowledge of n u t r i t i o n and pregnancy, nutrient requirements, nutrient composition of foods, g e r i a t r i c n u t r i t i o n , c a l o r i c value of foods and weight c o n t r o l . 2. The findings reveal that the public health nurses need to improve t h e i r practices i n counselling the public i n budgeting, vegetarian d i e t s , and dietary manipulation of f a t s . 3. The r e s u l t s indicate that n u t r i t i o n knowledge and pract-ices are s i g n i f i c a n t l y , d i r e c t l y , and very strongly r e l a t e d . Thus a sound knowledge of n u t r i t i o n i s important 81 i f good n u t r i t i o n practices are to be i n s t i t u t e d by the public health nurses. Although the r e s u l t s also show that practices are s i g n i f i c a n t l y and d i r e c t l y related to attitudes toward n u t r i t i o n , attitudes do not relate strongly to knowledge but to practices which d e f i n i t e l y originate from n u t r i t i o n knowledge. Thus i t seems most imperative that sound n u t r i t i o n knowledge be i n s t i l l e d i n the public health nurses. 4. It appears that neither n u t r i t i o n education i n the t r a i n i n g curriculum nor continuing education i n n u t r i t i o n improve the n u t r i t i o n knowledge of the public health nurses. Because knowledge d i r e c t l y and strongly influences p r a c t i c -es, i t would seem important that n u t r i t i o n knowledge be e f f e c t i v e l y presented to the public health nurses through these two r e l i a b l e sources of n u t r i t i o n information. There i s a need to investigate, modify, and improve the present n u t r i t i o n education given to nurses both i n the t r a i n i n g i n s t i t u t i o n s and i n inservice education. An i n s t r u c t i o n a l development program has been designed as a suggestion for developing more e f f e c t i v e inservice n u t r i t i o n education. It may be reviewed i n Appendix E. This i n s t r u c t i o n a l program has been designed using the r e s u l t s of t h i s study. 5 . . Because public health nurses demonstrate s i g n i f i c a n t l y poorer n u t r i t i o n practices i f they have no opportunities to consult with a n u t r i t i o n i s t , i t appears extremely important that there be enough n u t r i t i o n i s t s to serve 82 adequately as consultants to the nurses i n a continuous, ongoing manner. In conclusion, the r e s u l t s of N u t r i t i o n Canada (1973) indicated that there i s a need for more n u t r i t i o n education to be offered to the public. Public health nurses are i n the best p o s i t i o n to do t h i s . Thus i t i s imperative that the public health nurses have adequate n u t r i t i o n knowledge, and that they implement sound n u t r i t i o n practices. N u t r i t i o n education both i n the t r a i n i n g curriculum and i n inservice education needs to be investigated and improved. N u t r i t i o n i s t s are necessary and e f f e c t i v e consultants to the public health nurses. APPENDIX A DATA COLLECTION INSTRUMENTS AND KEY 8 4 No. Card • ' ' NUTRITION OPINIONS Some statements concerning nu t r i t i o n and eating habits are made below. We are interested in your judgement of each statement, in terms of how i t r e f l e c t s your personal opinion or feelings. I f the statement describes how you f e e l , c i r c l e 'A' for agree; i f the statement does not describe how you f e e l , c i r c l e 'D' for disagree. After you have made your decision, indicate how-certain you are about the decision: C i r c l e 1. i f you are very confident about your decisicuv (A or D) 2. i f you are moderately confident about your decision 3. i f you are moderately doubtful about your decision 4. i f you are very doubtful about your decision Please be sure to respond twice to each statement. Sample: Nutrition i s important to good health. This opinion i s agreement, with moderate confi-dence, tnat nutrition i s important to good health. D 1 0 3 1. Foods have so many vitamins added now that people do not have to worry about the foods they select. 2. As long as people are not sick, they must be eating right. 3. Even i f I take vitamins, I f e e l I should be concerned about my diet. 4. I am concerned about getting the people I counsel to eat foods that are of high n u t r i t i o n a l value. 5. Children should be allowed to eat whatever they want. 6. Time devoted to planning a shopping l i s t i s time well invested. 7. Cooking i s an important creative art. 8. I fin d food preparation i s rewarding because my family and friends l i k e my cooking. 9. Cooking requires too much of my time. Agree or Degree of Disagree Certainty A D A D A D A D A D A D A D A D A D 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 ' 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Disregard this Column -1-85 10. What I eat doesn't r e a l l y influence what I teach people about nu t r i t i o n . 11. Planning the foods for a meal just before starting to cook i s a re a l time saver. 12. I fin d n u t r i t i o n interesting. 13. I look forward to mealtime. 14. Achieving a thin appearance i s more important to me than getting an adequate diet . Agree or Degree of Disagree Certainty A D A D A D A D A D 3 4 3 .4 1 2 3 4 PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED NUTRITION KNOWLEDGE .' Disregard t h i s Column Some statements concerning n u t r i t i o n are made below. Indicate whether you think each statement i s true or f a l s e . C i r c l e 'T' for true and 1F' for fa l s e . After you have reached t h i s decision, indicate how certain you are about your answer. C i r c l e 1. i f you are very confident about your decision (Tor F) 2. i f you are moderately confident about your decision 3. i f you are moderately doubtful about your decision 4. i f you are very doubtful about your decision Please be sure to respond twice to each statement. 2. Green leafy and yellow vegetables are important in the diet primarily because they are a good source of Vitamin A. Large doses of multivitamin p i l l s may be harmful. 3. An obese person can be malnourished. An obese pregnant woman should be placed on a reducing d i e t . Vitamin A may be poorly absorbed on a low fat d i e t . Iron i s the only nutrient for which the average woman has a greater recommended need than" the average man. True or False T F T F T F T F Degree of Certainty 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Disregard t h i s Column -2-86 True or Degree of False certainty Disregard t h i s Column The rate of iron absorption i s normally regulated by the body's need for iron. T F 1 2 3 4 45 46 10. 11. In some food patterns, raw cabbage can be an important source of ascorbic acid. A woman normally needs to increase her nutrient intake as soon as she learns she i s pregnant. The recommended protein requirement for a pregnant woman i s 35 gms. It i s often d i f f i c u l t for senior c i t i z e n s to reduce their c a l o r i c intake but keep other nutrients at adequate l e v e l s . T F T F T F T F 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 47 48 49 50 51 52 53 |54 12. Over an extended period of time, high fat diets enable many people to lose weight rapidly. 13. Calcium needs of older people are less than those of younger adults. T F T F 1 2 3 4 1 2 3 4 55 56 57 58 14. A whole baked potato has more Vitamin C than instant mashed potatoes. 15. The protein need of a healthyl58 pound man engaged i n strenuous physical labour i s the same as that of another healthy 158 pound man engaged in a sedentary occupation. 16. Potatoes and bread should be eliminated from the diet of someone trying to lose weight. 17. The nutrients included in the Canadian Dietary Standards are the only ones that must be included i n the diet. T F T F T F T F 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 59 60 61 62 63 64 65 66 18. Pantothenic acid w i l l prevent the gray-ing of hair. ' 19. Adding soda to vegetables during prepar-• ation tends -to destroy the Vitamin C content of the food. T :F T F 1 2 3 4 1 2 3 4 67 68 69 70 20. It' i s essential for a l l people to take Vitamin E supplements in addition to the daily diet. -T F 1 2 3 4 71 | 72 21. A weight loss of 5 pounds a week i s a reasonable goal for weight reduction. T F 1 2 3 4 73 74 -3-87 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. .32. .33. 34. 35. The outcome of pregnancy i s governed in part by the state of nu t r i t i o n before pregnancy. It i s extremely d i f f i c u l t for a person to get enough of the B vitamins from our Canadian diet . Taking calcium p i l l s i s a good substitute for an inadequate milk intake. True or False T F Healthy adults should take food supple-ments or vitamin p i l l s to ensure having a l l the nutrients needed for good nu t r i t i o n . A good n u t r i t i o n a l practice i s to eat a wide variety of foods from day to day. Apples are an excellent source of Vitamin . C. . . . . . . L.. Healthy, active, young children require some concentrated sweets each day for energy needs. Use of the Daily Food Guide in planning the family meals insures provision of an adequate diet. •-8 oz. of an orange drink has the same t o t a l  n u t r i t i v e value as 8 oz. of pure orange juice. It i s impossible for an ovo-lacto vegetarian (eating eggs and milk but no meat) to obtain an adequate diet . The appetite of an infant.generally increases between 12 and 18 months of age. Taking f o l i c acid preparations may obscure the symptoms of pernicious anemia. Children need multiple vitamin p i l l s to ensure good health. . . . Most people on a reducing d i e t should r e s t r i c t their sodium intake. T F T F T F T F T F. T F. T F F T F' T F T F T > T F Degree of Certainty 1 2 3 4 3 4 1 2 3 4 ! Disregard 1 t h i s Column 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3.4 1. 2 3. 4 1 2 3 4 No. Card 5 6 19 20 21 22 23 24 25 26 -4-88 True or Degree of False Certainty Disregard this Column -36- Ounce for ounce, fats give more than twice as many calories as carbohydrates or proteins. T F 1 2 3 4 27 28 37. Soybeans are deficien t i n the amino acid methionine. T F 1 2 3 4 29 30 38. Green peppers, strawberries, and canta-loupes are good sources of Vitamin C. T F 1 2 3 4 31 32 39. The protein value i n a glass of recon-stituted skim milk powder i s not as great as the protein value in a glass of fresh whole milk. T F 1 2 3 4 33 34 40. The iron requirement for a pregnant woman i s 18 mgs. T F 1 2 3 4 35 36 PLEASE CHECK TO BE. SURE ALL STATEMENTS HAVE BEEN ANSWERED INFORMATION ABOUT YOU Please check (v') or f i l l i n the blanks where appropriate. Disregard this Column What unit or health department are you working in? West Vancouver North Vancouver Burnaby Richmond Burrard North South East West •City of Vancouver 37 What i s your nursing-related educational background? Please check a l l that apply: BSN • , RN plus Public Health MSN Additional nursing education (please specify) 38 89 Disregard t h i s Column When did you receive your l a s t nursing-related degree or diploma? less than 5 years ago more than 5 years ago and less than 10 years ago more than 10 years ago 39 How many years of nursing experience have you had? less than 1 ' more than 1 and less than 5 more than 5 and less than 10 more than 10 40 What i s your age? under 25 over 25 and under 40 over 40 41 During your nursing education, did you receive any nutr i t i o n education? no 42 _y.eJL can't be sure If the answer was yes, Who taught the nu t r i t i o n course? q u a l i f i e d n u t r i t i o n i s t or d i e t i t i a n nursing instructor  other- please specify -don't know How many years of home economics (that included foods and nutrition) did you have i n high school? 0 years 1-2 years 43 3-4 years Have you had the opportunity to get advice from a nutrition consultant who has worked in your unit or department for more than 6 months? 44 yes If the answer was yes, -What i s the number of communications (written, telephone, discussion, group talk etc.) that you.have had with a n u t r i t i o n i s t i n the l a s t 4 weeks? 0 1-2 3^4 5+ -6-90 Disregard this Column 9. Is there any other education or experience i n nu t r i t i o n that you have had? no yes If the answer was yes, please specify what that education or experience was-attendance at expectant parent's class cooking for. own family or friends cooking classes nut r i t i o n courses in continuing education nut r i t i o n conferences other, please specify below-45 PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED NUTRITION PRACTICES Some statements concerning the kind of n u t r i t i o n counselling you do are made below. Please indicate whether you carry out the s p e c i f i c practice- 'Always'.'Frequently', 'Sometimes', or 'Never', by c i r c l i n g the appropriate number 1-4. If you are not involved in counselling that particular group of people, c i r c l e number 5. Sample. ^ encourage pregnant women to take iron supplements. Always Frequently Sometimes Never Not involved i n counselling t h i s group 1 (2) 3 4 5 This answer would indicate that you frequently encourage iron supplements for pregnant women. Disregard Always Frequently Some- Never Not t h i s .,. " , ' -times- • Coun- C o l u m n s e l l i n g I discuss the p o s s i b i l i t y of breast feeding with the pregnant women I counsel. I encourage increased a c t i v i t y for the over-weight people that I see at work. this group 4 5 46 47 91 Always I assess the food and nut r i t i o n habits of the people I counsel by one or more of the following techniques: home assessment, 24 hour r e c a l l , food record or diet history. I recommend multivitamin supplements for healthy, well-fed 2-3 year olds. I give out low cost food ideas to low income people. I check the l i v i n g arrangements of g e r i a t r i c people for the ease of meal preparation. Fre-quently Some-times Never Not Counsel1-.ing t h i s group j Disregard ' this Column 48 49 50 51 10. I analyze the diets of preg-nant women for the amounts of milk or milk products consumed. I ask mothers from what sources their children obtain Vitamin C. I remind the public that dried beans and peas served with whole wheat bread may be used as a meat alternative. I encourage the use of polyunsaturated o i l s over butter or lard. !52 53 54 55 Some statements concerning your personal n u t r i t i o n a l practices are made below. Please indicate whether you carry out the s p e c i f i c practice 'Always', 'Fre-quently', 'Sometimes', or 'Never', by c i r c l i n g the appropriate number 1-4. Always Fre- Some- Never -Disregard quently times '.this ' * ! Column 11. I try to eat a food ... > containing Vitamin C 1 2 3 4 .56; every day. ; -8-92 Always Fre- Some-quently times Never {Disregard this I Column 12. I take a multivitamin sup-plement regardless of what I am eating. 13. . I plan my meals following the recommendations of the Daily Food Guide. 14. I cook broccoli i n a l o t of water u n t i l i t i s very very tender to eat. 57 58 59 15. I keep a record of the amount of money I spend on food. 1 16. I include 12 ounces of. milk or the equivalent in 1 my daily d i e t . 17. I take Vitamin C tablets when I f e e l a cold coming on. 1 18. T ?.ll°vT leftover, cooy^d. and stuffed chicken or 1 turkey to cool down to room temperature before putting i t into the refri g e r a t o r or freezer. 19. I include at least three servings of whole grain or 1 enriched cereal products i n my daily d i e t . 60 61 62 63 64 20. I include an iron-rich food i n my weekly diet . 65 PLEASE CHECK TO BE SURE ALL STATEMENTS HAVE BEEN ANSWERED Thank you for taking the time to complete t h i s questionnaire. -9-93 KEY TO ANSWERS FOR QUESTIONNAIRE Section Statement Opinions No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Answer D D A A D A A A D D D A A D Knowledge No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Answer T T T F T T T T F F T F F T No. 15 16 17 18 19 20 21 22: 23 24 25 26 27 28 Answer T F F F T F F T F F F T F F No. 29 30 31 32 33 34 35 36 37 38 39 40 Answer T F F F T F F T T T F F Practice No. 1 2 3 4 5 6 7 8 8 10 11 12 13 14 Answer 1 1 1 4 1 1 1 1 1 1 1 4 1 4 No. 15 16 17 18 19 20 Answer 1 1 4 4 1 1 APPENDIX B PRETEST QUESTIONNAIRE 95 (please make coEeseato after the questions) PRETEST COVER LETTER 1. Za tha purpose of tha queotiennaire explained well? Yes No 2o Are the insjtructione adequate? Yea Ho 3» Doss the l e t t e r malte you want to f i l l i n the questionnaire!? Yes No G5SSSRAL LAYOUT I* Do you feel ths crdar of tha sections io-e. Opinions-Knowledge-Information-Praaticasj J.3 appropriate? ; Yes No AHSjffiRIMG SCHB.aS I. Are ths instructions for answarir.g claar? Yae No 20 Is the answering oshess easy to follow? Yes . Wo 3„ Is there adequate space, for answers? Yes No 1„ Are any statements: Section and # comment ambiguous __ ; not complete too long too easy or too d i f f i c u l t 2o Do any question.? use specialised languaga that would not be appropriate for public health nurses? Yes No Which one(o) 3o Bo you think ths etataniants are adequate to obtain information on Knowledge, Attitudes B and Practices of public health nurses? Yss No OVERALL OraSTIOaNAXRS 1, IG the questionnaire too long? Yea 2„ Is the.questionnaire too time consuming? No Y 9 8 No APPENDIX C COVER AND FOLLOW-UP LETTERS 9 7 THE UNIVERSITY OF BRITISH COLUMBIA V A N C O U V E R 8, C A N A D A DIVISION O F H U M A N N U T R I T I O N S C H O O L O F H O M E E C O N O M I C S A p r i l , Dear P u b l i c H e a l t h Nurse: P u b l i c h e a l t h nurses have an important r o l e to p l a y i n n u t r i t i o n e d u c a t i o n . The need f o r such e d u c a t i o n t o Canadians has r e c e n t l y been emphasized with the r e l e a s e o f the p r e l i m i n a r y r e s u l t s o f N u t r i t i o n Canada. Some of the f i n d i n g s i n d i c a t e t h a t more than f i f t y p e r c e n t of a l l Canadians are overweight, i r o n d e f i c i e n c y a f f e c t s a l a r g e p r o p o r t i o n of the p o p u l a t i o n , and t h e r e i s a shortage o f c a l c i u m and v i t a m i n D i n the d i e t s o f many i n f a n t s , c h i l d r e n , and a d o l e s c e n t s . T h i s i s the f i r s t time i t has been shown t h a t the Canadian p o p u l a t i o n needs sound n u t r i t i o n a l knowledge. PHNs are i n an e x c e l l e n t p o s i t i o n to g i v e t h i s knowledge. I t i s hoped t o d e v e l o p a more e f f e c t i v e n u t r i t i o n i n s e r v i c e education program f o r p u b l i c h e a l t h nurses. To b e s t p l a n such a program, i t i s necessary t o f i r s t a s s e s s the l e v e l of n u t r i t i o n knowledge, a t t i t u d e s , and p r a c t i c e s of PHNs. Thus we are r e q u e s t i n g your c o o p e r a t i o n i n o b t a i n i n g t h i s i n f o r m a t i o n . Your judgment, as r e f l e c t e d i n your answers to the q u e s t i o n s , i s c o n s i d e r e d v e r y important i n the assessment d i s c u s s e d above. We hope you w i l l take the time to answer these q u e s t i o n s . The medical h e a l t h o f f i c e r i n your area has g i v e n a p p r o v a l f o r your p a r t i c i p a t i o n i n t h i s study. The r e s u l t s w i l l be r e t u r n e d i n a r e p o r t to your agency and may be used by the nurses and n u t r i t i o n i s t s i n promoting more u s e f u l n u t r i t i o n i n s e r v i c e e d u cation programs. 1. P l e a s e read the d i r e c t i o n s c a r e f u l l y and be sure t o answer a l l s e c t i o n s of the q u e s t i o n n a i r e . 2. I t i s not n e c e s s a r y to s i g n your name, thus anonymity i s assured. 3. I t i s extremely important t h a t you answer these q u e s t i o n s as f u l l y and a c c u r a t e l y as you can, without any h e l p , and a t a time when you can devote your f u l l a t t e n t i o n t o the q u e s t i o n n a i r e . 4. Answering the q u e s t i o n n a i r e w i l l take approximately 15-20 minutes. We r e c o g n i z e the amount o f time and e f f o r t i t w i l l take f o r you to f i l l out t h i s q u e s t i o n n a i r e and we a p p r e c i a t e your c o o p e r a t i o n . Please m a i l the completed form immediately, i f p o s s i b l e , or by A p r i l 11, 1974. A stamped, addressed envelope i s e n c l o s e d f o r your convenience. Thank you f o r your i n t e r e s t and v a l u a b l e a s s i s t a n c e . S i n c e r e l y , Nanc/ E. Schwartz 0 A s s i s t a n t P r o f e s s o r Human N u t r i t i o n , UBC Susan D.C. N i c h o l s Graduate Student . Hunan N u t r i t i o n , UBC THE UNIVERSITY OF BRITISH COLUMBIA V A N C O U V E R 8 , C A N A D A DIVISION O F H U M A N N U T R I T I O N S C H O O L O F H O M E E C O N O M I C S A p r i l 19, 1974 Dear Public Health Nurse: A few weeks ago you were asked to participate i n a survey of nutrition knowledge, attitudes, and practices. You received a questionnaire and we requested that i t be returned by A p r i l 11, 1974. If you have f i l l e d i n and returned the questionnaire, we thank you for your cooperation and valuable assistance. If you have not yet returned the questionnaire, we would appreciate i t i f you could do so before A p r i l 3 0 , 1 9 7 4 . If you have misplaced the questionnaire, please ask your nursing supervisor to obtain another one for you. Thank you again for your help. Sincerely, Nancy uE. Schwartz Assistant Professor Human Nutrition, UBC Susan D.C. Nichols Graduate Student Human Nutrition, UBC APPENDIX D FLOWCHART OF RESEARCH PROCEDURE 1 0 0 Stage 1 Planning and  Preparation Stage 2  Data C o l l e c t i o n Purpose and D e s i g n K — Approval of proposal] by Nursing Research and Evaluation Committee questionnaires cover l e t t e r demographic info, coding sheets follow-up computer program \ Assemble questionnaires pretest and print questionnaires 4. Deliver packages to (health departments or units Deliver follow-up l e t t e r s Phone follow-up Stage 3 Data Analysis and s i / Interpretation Code questionnaires and Demographic informa-l t i o n Data Analysis) [ Resultsl ^ [Check coding Flowchart of Research Procedure APPENDIX E AN INSTRUCTIONAL DEVELOPMENT PROGRAM PLAN FOR INSERVICE NUTRITION EDUCATION FOR PUBLIC HEALTH NURSES OUTLINE FOREWORD PREPARATION PHASE Target population Job description Program prerequisites Assessment of inservice n u t r i t i o n education needs Program objectives C r i t e r i o n examination Summary DEVELOPMENTAL PHASE Introduction and general discussion Program unit plans Prenatal n u t r i t i o n General n u t r i t i o n G e r i a t r i c n u t r i t i o n Weight control Vegetarian diets Low income groups N u t r i t i o n information resources Public n u t r i t i o n education techniques Summary IMPROVEMENT Introduction Five steps of evaluation Analysis of evaluation Summary BIBLIOGRAPHY 103 PREPARATION PHASE Target Population: PHNs i n Greater Vancouver The target population i n t h i s plan i s the public health nurses i n Greater Vancouver, i . e . , North Vancouver, West Vancouver, Burnaby, Richmond and Vancouver. This group includes only the nurses working i n the f i e l d , involved i n community counselling. Nursing supervisors and administrat-ors w i l l not be included. Job Description: Gives n u t r i t i o n counselling i n a l l phases of the l i f e cycle while being aware of the c u l t u r a l , economic and physiological factors that influence food intake This description encompasses only the description of the " n u t r i t i o n job" of the public health nurses. It i s a fact that public health nurses do counsel the public i n n u t r i t i o n . N u t r i t i o n Canada stated: Within each province, a number of municipalities and regional health units employ n u t r i t i o n i s t s who are . . . involved with t h e i r community. However, the health professional most frequently involved i n the d i r e c t dissemination of n u t r i t i o n information to the public i s the public health nurse. (B-7) In Vancouver, t h i s i s also the case. There are 140 public health nurses and only three n u t r i t i o n i s t s working for the c i t y health department. Richmond, Burnaby, North and West Vancouver employ over 60 PHNs and no n u t r i t i o n i s t s at a l l . 104 Thus the public health nurses are i n the best s t r a t e g i c a l position to counsel the public i n n u t r i t i o n . Newton stated that the n u t r i t i o n knowledge that PHNs should have and apply i n th e i r counselling encompasses: "common tools used i n the planning and evaluation of d i e t s ; c u l t u r a l , economic arid physiological factors that influence food intake; nutrients i n foods; and r e l i a b l e resources of n u t r i t i o n information." (p. 317). This i s probably the most accurate description available on what the PHN should be aware of i n order to counsel the public i n n u t r i t i o n . Task Analysis The PHN should be able to give n u t r i t i o n counselling i n a l l phases of the l i f e cycle. She should be aware of the current n u t r i t i o n information available i n prenatal, infant, childhood, adolescent, adult, and g e r i a t r i c n u t r i t i o n and she should be able to counsel e f f e c t i v e l y i n these areas. She should be able to give s c i e n t i f i c a l l y approved informa-t i o n i n these areas. She should be able to give s c i e n t i f i c a l -l y approved information i n the areas of general n u t r i t i o n , weight control, vegetarianism and food fads. She should be able to deal with low income groups i n order to improve t h e i r n u t r i t i o n a l status. She should be aware of the basic p r i n c i p l e s used i n the n u t r i t i o n education of the public and she should be aware of and use approved n u t r i t i o n resource materials. 105 Course Prerequisites PHNs i n need of increased knowledge of n u t r i t i o n concepts, more positive attitudes toward food and n u t r i t i o n , and improved behavior or n u t r i t i o n a l practices should be exposed to i n -service n u t r i t i o n education. The r e s u l t s of N u t r i t i o n Canada showed that more than f i f t y percent of a l l Canadians are overweight, that iron deficiency a f f e c t s a large proportion of Canadians including young babies, men, and pregnant women, that protein deficiency occurs i n some pregnant women and i n a notable number of children under 5 years age, and that the die t s of many infants children, and adolescents are de f i c i e n t i n calcium and vitamin D. Obviously the public needs more n u t r i t i o n education. It has already been pointed out that the PHN i s i n the best position to give t h i s type of education to the public. Thus, any PHN who i s i n need of inservice n u t r i t i o n education should have i t available to her. Assessment of Inservice N u t r i t i o n Education Needs Method: Questionnaire In order to develop e f f e c t i v e inservice education i n n u t r i t i o n for a l l PHNs i n need of i t , i t i s f i r s t very important to determine what the-PHN knows and f e e l s about n u t r i t i o n and what type of n u t r i t i o n information she i s giving 106 to the public. That i s , i t i s necessary to determine her n u t r i t i o n a l knowledge, attitudes, and practices. With t h i s information, i t i s possible to compare what she does know, f e e l , and practice i n n u t r i t i o n , with what she should know, f e e l and practi c e . This comparison demonstrates whether or not there i s a need to develop a better inservice n u t r i t i o n education program than there i s at present. Also with the r e s u l t s of what the PHNs1 knowledge, attitudes, and practices are, i t i s possible to determine the rel a t i o n s h i p between these dependent variables, for example, the r e l a t i o n -ship of knowledge and attitudes to practices. The p r a c t i c a l significance of these findings w i l l be discussed i n the section on program objectives. The assessment of inservice n u t r i t i o n education needs of the public health nurses has been done by means of a self-administered questionnaire. Program Objectives The r e s u l t s of the questionnaire survey on n u t r i t i o n knowledge, attitudes, and practices of the public health nurses show that the public health nurses need to increase t h e i r knowledge i n the areas of n u t r i t i o n and pregnancy related to requirements and supplementation, nutrient require-ments of various l i f e cycle categories, nutrient composition of foods, c a l o r i c value of foods, g e r i a t r i c n u t r i t i o n , and weight c o n t r o l . The practices that need to be improved include counselling the public on budgeting, vegetarian diets and dietary manipulation of f a t s . The public health nurses need 107 to improve t h e i r own home management practices as well as t h e i r intake of the recommended servings from the cereal group of the B.C. Daily Food Guide. The r e s u l t s of p a r t i a l correlations analysis carried out on the findings of n u t r i t i o n knowledge, attitudes, and practices indicate that the strongest r e l a t i o n s h i p between the dependent variables i s between knowledge and practice with the most s i g n i f i c a n t e f f e c t being the effect of n u t r i t i o n knowledge on practices. Thus the i n s t r u c t i o n a l plan concentrates on giving out the necessary n u t r i t i o n knowledge, knowing t h i s w i l l r e s u l t i n improved n u t r i t i o n a l practices. The i n s t r u c t i o n a l and behavioral objectives for the inservice n u t r i t i o n education program for public health nurses reads: To offer to the PHN, knowledge i n the areas of prenatal n u t r i t i o n , general n u t r i t i o n (including nutrient requirements, composition of foods, and types of f a t s i n various foods), vegetarian d i e t s , n u t r i t i o n and budgeting i n low income groups, g e r i a t r i c s and weight control, so that the public health nurses w i l l be able to counsel pregnant mothers, the general public, vegetarians, low income groups, g e r i a t r i c people and weight control target groups, using acceptable s c i e n t i f i c information on n u t r i t i o n . C r i t e r i o n Examination The evaluative test i s developed from the program objectives. For the purpose of t h i s inservice education program, the parts of the questionnaire that have demon-strated d e f i c i e n c i e s i n knowledge and practices are the parts included i n the evaluative test questionnaire. If 108 t h i s inservice education plan i s actually put into practice, i t i s also suggested that a wider variety of questions concerning the d e f i c i e n t areas be developed for the evaluat-ive questionnaire. This w i l l avoid the p o s s i b i l i t y of the nurses remembering the correct answers to the assessment questionnaire statements but not having acquired further information i n the area. (The correct answers to the assess-ment questionnaire were dis t r i b u t e d to the nurses after the assessment phase was completed.) As a preliminary guide to the preparation of the c r i t e r i o n questionnaire, i t i s suggested that the statements used include: 1. The rate of iro n absorption i s normally regulated by the body's need for i r o n . 2. A woman normally needs to increase her nutrient intake as soon as she learns she i s pregnant. 3. The recommended protein requirement for a pregnant woman i s 35 g. 4. Calcium needs of older people are less than those of younger adults. 5. The protein need of a healthy 158 pound man engaged i n strenuous physical labour i s the same as that of another healthy 158 pound man engaged i n a sedentary occupation. 6. Taking calcium p i l l s i s a good substitute for an inadequate milk supply. 7. Apples are an excellent source of Vitamin C. 8. Taking f o l i c acid preparations may obscure the symptoms of pernicious anemia. 109 9. Most people on a reducing diet should r e s t r i c t t h e i r sodium intake. 10. Ounce f o r ounce, f a t s give more than twice as many cal o r i e s as carbohydrates or proteins. 11. Soybeans are de f i c i e n t i n the amino acid methionine. 12. The ir o n requirement for a pregnant woman i s 18 mgs. 13. I give out low cost food ideas to low income people. 14. I remind the public that dried beans and peas served with whole wheat bread may be used as a meat al t e r n a t i v e . 15. I encourage the use of polyunsaturated o i l s over butter or l a r d . 16. I keep a record of the amount of money I spend on food. 17. I include .at least three servings of whole grain or enriched cereal products i n my d a i l y d i e t . These are the statements that achieved the lowest mean score on the assessment questionnaire. The use of an evaluative t e s t questionnaire w i l l make v a l i d comparisons between pre and post t e s t s possible. This w i l l be elaborated on i n the section on the program improvement phase. 1 1 0 Summary of Preparation Phase TARGET POPULATION public health nurses i n Greater Vancouver Nl/ PROGRAM PREREQUISITES PHNs showing a need for inservice educa-t i o n i n n u t r i t i o n should have i t a v a i l -able to them JOB DESCRIPTION n u t r i t i o n counselling i n a l l phases of the l i f e c y c l e . awareness of the c u l t u r a l , economic, and physiologi-c a l factors that influence food intake. TASK ANALYSIS eff e c t i v e counselling i n prenatal, general,.and g e r i a t r i c n u t r i t i o n , e f f e c t i v e counselling i n the areas of weight control] vegetarianism, n u t r i t i o n i n low income groups, appropriate use of educa-t i o n techniques and n u t r i -t i o n resources ASSESSMENT OF INSERVICE EDUCATION NEEDS questionnaire method, to determine the r e l a t i o n of actual to ideal situa-t i o n . to determine the relation-ships between KAPs.  COURSE OBJECTIVES - to bridge the gap between the actual and the ideal s i t u a t i o n of KAPs. 4 / CRITERION EXAMINATION - evaluative test developed! from program objectives. - questionnaire composed of d e f i c i e n t areas from assessment questionnaire. I l l DEVELOPMENTAL PHASE Introduction and General Discussion The developmental phase of t h i s project involves f i v e steps. F i r s t , the in d i v i d u a l units of the program must be planned. This involves i d e n t i f y i n g the s p e c i f i c job tasks that need to be taught. These job tasks have been outlined i n the presentation of objectives. The second step i n t h i s phase involves the selection of methods to be used i n de l i v e r i n g the program to the PHNs. Techniques are important as t h e i r appropriateness determines the effectiveness of the program to a large extent. Instruc-t i o n a l procedures are not normally determined t h i s early on in the development phase. In the case of t h i s inservice education program, however, i t i s imperative that the program be incorporated as "painlessly" as possible into the nurses 1 routines: i . e . , n u t r i t i o n counselling i s only part of a public health nurse's t o t a l job task. There are many other phases of health care that she i s involved i n . Thus i t i s not f e a s i b l e to expect that an inservice n u t r i t i o n education program for the PHN take up a l l the nurse's time freed for continuing education. It i s f e l t that inservice n u t r i t i o n education should be incorporated into the existing d a i l y routine and not require more demands on the nurse's already booked schedule. The program should reach the nurse where she i s — a t the health unit, i n the school, at the well baby c l i n i c . Thus i t i s imperative that techniques that are 1 1 2 available to do t h i s be i d e n t i f i e d early on and the most useful ones selected for use i n the program (see summary of development phase for a l i s t of techniques selected for the program u n i t s ) . The program content and i n s t r u c t i o n a l plans are set up so that the job tasks discussed above can be taught. The fourth step i s the sequencing of the units . Sequencing i n i t s e l f i s not important as each task i s independent of the others. This i s fortunate because i t i s planned to present the various i n s t r u c t i o n a l units i n d i v i d -u a l l y to the health units or departments. Thus, for example, while one department i s receiving i n s t r u c t i o n on vegetarian-ism, another may be having i n s t r u c t i o n on prenatal n u t r i t i o n . So although each i n s t r u c t i o n a l unit does not have to f i t into a sequencing pattern, the t o t a l delivery of the units to a l l health departments must be planned so that each health unit w i l l always have some form of n u t r i t i o n education i n progress. In t h i s way the inservice education can be disseminated evenly to a l l health departments This inservice education w i l l be a continuous process. The section i n t h i s paper on the Improvement Phase of instruc-t i o n a l development w i l l describe how t h i s program w i l l be kept relevant and thus how i t w i l l be possible to continue the program i n d e f i n i t e l y . The following pages are proposed i n s t r u c t i o n a l units; job tasks, techniques, and program content. These units are not meant to be complete lesson plans. They are meant only as suggestions of what may be done i f t h i s service program i s implemented. 113 The f i n a l step i n the developmental phase i s the program tryout. It i s proposed that the entire program be t r i e d out on one health department. Any p r a c t i c a l problems of program presentation w i l l be settled at t h i s stage. JOB TASK TECHNIQUE PRENATAL slid e and tape on NUTRITION prenatal n u t r i t i o n COUNSELLING -approximately 10 mins. i n length (so no one w i l l miss i t due to lack of time) -self-operating show -nurse pushes 'on' switch and tape and slid e s operate simultaneously -to be placed i n a quiet area of the health unit (prefer-ably one which i s often passed by the PHNs so that the show w i l l not be missed) -show should run for 2 weeks i n each health unit so that i l l n e s s , busy days, days of f , etc. w i l l not be reasons for avoiding t h i s educational unit. UNIT GENERAL PLANS PROGRAM CONTENT  Focus of KAP: Knowledge TAPE Introduction: importance of prenatal n u t r i t i o n to outcome of pregnancy (2 mins.) Food Selection: extension of Daily Food Guide, -stress increase i n Vitamin D, r i b o f l a v i n , calcium -food sources. (3 mins.) Pattern of Weight Gain: -20-25 l b s . -danger signal: sudden increase after 20th week. (2 mins.) Obesity and Pregnancy: -period to avoid weight reduction. (1 min.) Pregnancy and the Adolescent: -extra stress due to her own growth needs added to foetal needs, ( l min.) Suggestions re Breast Feeding  Advice. (1 min.) Nut r i t i o n Prenatal Counselling: -check every woman's intake -suggestions for improvement -follow-up. ( l min.) REFERENCES SLIDE picture of well Maternal nourished and N l i t r i -malnourished . t i o n and neonate Course of Pregnancy 4 pictures of food groups and da i l y amounts for pregnancy graph of wt. gain Shank p. 6 obese pregnant woman with an X through the words 'weight reduction' slide of the extra needs of the preg-nant teen pictured i n terms of food. M slide of PHN talking to pregnant woman & suggestions written to one side. EDUCATIVE TECHNIQUE PROGRAM CONTENT REFERENCE B u l l e t i n Board Displays - to be displayed i n prominent area of health unit where a l l w i l l see - displayed for 2 weeks before rotated to another unit KAP_focus: Knowledge  Note: t h i s i s very nonspecific outline as the actual content greatly depends on the r e s u l t s of the assessment. However, examples are given: 1. Vitamin E Holmes, A.C. - facts about vitamin E Permanent Question Box - and B u l l e t i n Board with written questions and answers to be main-tained by u n i v e r s i t y n u t r i t i o n students on bimonthly basis found i t useful i n curing heart disease^ i n f e r t i l i t y , etc. ^ Dietary Standards what are they? how to use them tear sheets of standards enough for a l l health professional i n unit JOB TASK COUNSELLING IN GERIATRIC NUTRITION TECHNIQUE Sli d e and tape on g e r i a t r i c n u t r i t i o n Approximately 10 minutes i n length Self-operating Same st i p u l a t i o n s as with educative unit on prenatal n u t r i t i o n PROGRAM CONTENT REFERENCE KAP focus: Knowledge and Practice . TAPE Introduction: importance of n u t r i t i o n i n elderly popu-l a t i o n min.) Dietary Pattern -nutrients needs same -c a l o r i c needs decrease -ideal intake (4 min.) Problems of reaching elderly -hearing - sight -reaction time ways to overcome these problems when teaching senior c i t i z e n s . (2 mins.). Methods to Improve Nutrition- a l Status of Elde r l y -organize into groups for mealtime company -provide n u t r i t i o n and consumer information i n informal and relaxed setting, accompany with n u t r i t i o n a l refreshments and l i g h t recreation, e.g. painting. (3 mins.) SLIDE Picture of active senior c i t i z e n vs. inactive one 4 slides of food groups with lower c a l o r i c suggestions Huiatt, A p. 683 3 slides depicting these handicaps 2 sl i d e s depicting• these happenings Martin, J p. 439 as JOB TASK EDUCATIVE TECHNIQUE COUNSELLING Demonstration: IN OBESITY to PHNs involved i n weight control group counselling the demonstration w i l l be carried out by a n u t r i t i o n -i s t during a weight control group meeting so t h i s w i l l not take extra time from the PHNs schedule Private Discussion: Between PHN and n u t r i t i o n -i s t following group meeting PROGRAM CONTENT REFERENCE KAP focus: Practice Knowledge This demonstration i s of a food game that has been found effective i n teach-ing to weight control groups a. cafeteria setting b. play foods c. participants pick out diet from foods d. score points e. ensuing discussion points up factors i n well balanced d i e t , choosing low c a l . food substitutes, etc. Private discussion with PHN following meeting w i l l give chance for n u t r i t i o n i s t to stress basic weight loss ideals: - weight loss rate - importance of exercise - i n d i v i d u a l i z i n g food intake - retaining food habits - non-recommended diets and the i r dangers Kornblueh, M p. 47 JOB TASK EDUCATIVE TECHNIQUE PROGRAM CONTENT REFERENCE COUNSELLING Vegetarian Lunch KAP focus: Knowledge and VEGETARIANS for PHNs i n each unit Practice Lecture Noon Meal: ( l serving) during lunch Discussion Soy patties with tomato sauce—2 Baked potato — 1 Margarine — 1 pat" Cooked frozen peas —6. cup Dressing — t b s p . Wheat r o l l Margarine — 1 pat Sli c e d peaches — ^ cup Soymilk — 8 oz. Lecture - what i s a vegetarian diet? - s t r i c t - ovolacto - what kinds of foods to include: dry beans, dry peas, l e n t i l e s , nuts, whole grains, d i f f e r e n t / o n . \ f r u i t s and vegetables, milk and \zu mins.; m i l k p r o d u c t s a n d e g g s # Register, - what nutrients may be deficient? V.D. Vitamin B 12, calcium, Vitamin D, P» 253 r i b o f l a v i n , iodine - animal vs. plant proteins Discussion Ways to counsel vegetarians— a. explain n u t r i t i o n a l needs b. show how well or poorly I A C , . \ choices are meeting needs l 4 U m i n s " ' c. show how to improve diet d. leave c l i e n t to own decision making CO JOB TASK COUNSELLING LOW INCOME GROUPS EDUCATIVE TECHNIQUE 1. P a r t i c i p a t i o n i n a low cost meal/high cost meal buffet 2. Discussion - t o t a l time: 1^ hours - buffet to rotate to each u n i t . PROGRAM CONTENT REFERENCE KAP focus: Knowledge, Attitudes, and Practices 1. A buffet style lunch with high cost dishes and low cost substitutes. Cost per:, serving and main nutrients per serving to be placed on a card by each dish. a. beef (steak) chop suey/ l i v e r chop suey b. wild rice/brown r i c e c. fresh grape and pineapple f r u i t plate/banana and orange f r u i t plate d. macaroons/oatmeal cookies e. cartoned skim milk/ reconstituted skim milk 2. Discussion during lunch headed by a n u t r i t i o n i s t : a. low cost food plan ,: d i s t r i b u t e tearsheets b. low cost substitutes Heinzelman, W.B c. p r i n c i p l e s to use when p. 12-13 communicating with low income people: B r i l l , N. - setting: relaxed p. 631 - genuine f r i e n d l i n e s s - l i s t e n i n g with interest Brannan, B.J. - watching for responsive- p. 214 ness - showing respect for judge- Beavers, I. ment P« 35. - consulting him as coworker, etc. JOB TASK AWARENESS OF NUTRITION INFORMATION RESOURCES EDUCATIVE TECHNIQUE 1, information sheets e t c. mailed to the PHNs once a month (Total Time: 10 mins.) PROGRAM CONTENT REFERENCES KAP focus: Knowledge 1. Directory of Community Nut r i t i o n Services 2. B u l l e t i n on Reliable N u t r i t i o n References 3. Information sheet on N u t r i t i o n Aides—Food for your Needs 4. Sheet on D i a l - A - D i e t i t i a n 5. Copy of J . Mayer's L i s t of Not Recommended Books on "Nutrition" 6. Paper on the ways i n which the community n u t r i t i o n i s t can help the PHN and her c l i e n t s KAP focus: Knowledge, Attitudes and Practices 1. B u l l e t i n Board Display: Erhard, D, various food systems within p. 21 the counterculture 2. Taped description of: Natural Food Movement—Yoga, Rhrets, Mucusles Diet, Krishnas, Vegans Cosmic Nutrit i o n Movement—Zen, o Macrobiotics, Messiah's Crusade Health Food Movement—P.C. Bragg, H. Shelton, C. Fredericks, c . u Adelle Davis. Sipple, H.L, 3. Ways to Coordinate E f f o r t s to combat Quackery and Faddism. p. 823. JOB TASK EDUCATIVE TECHNIQUE PROGRAM CONTENT REFERENCE AWARENESS AND USE OF EDUCATIVE TECHNIQUES IN PUBLIC NUTRITION EDUCATION F l i p chart and tape recording - each PHN to be given a f l i p chart - the tape w i l l be c i r c u -lated to a l l PHNs i n order that they be given a clear explana-t i o n of the chart - t h i s method allows the PHN to learn the informa-t i o n i n her own time - tape to run for 20 minutes KAP focus: Knowledge, Practice. 1. P r i n c i p l e s of Learning  and Teaching (comic s t r i p i n chart voices dubbed i n tape) - ask right questions - l i s t e n to answers - involve learner i n learning process - work from learner's knowledge - teach what i s useful - appraise to see i f i n practice - suggestions for tech-niques most useful at each step i n guiding change - elements of discovery, i n t e r e s t , meaning - how to plan learning experience 2. N u t r i t i o n Education (three pages of notes on chart, commentators' voice explains the notes) a. basic n u t r i t i o n to teach public b. how to use food guide c. techniques PHNs can use to modify patients' food habits Butterworth, T.H. p. 15 Craig, D.G. P. 22 Poolton, M.A. p.110 Wagner, F.E. p. 34 H i l l , M.M. p. 20 S a i l o r , N.M. p. 756 ro i—• 1 2 2 Summary of the Developmental Phase UNIT OUTLINE (job tasks) PHNs must be able to give counselling i n : 1. prenatal n u t r i t i o n 2 . general n u t r i t i o n 3 . g e r i a t r i c n u t r i t i o n 4 . weight control 5 . vegetarian d i e t s 6 . n u t r i t i o n i n low income groups PHNs must be aware of 1. n u t r i t i o n information resources 2 . public n u t r i t i o n education techniques  TECHNIQUE SELECTION 1. slide and tape for prenatal n u t r i t i o n 2 . s l i d e and tape for g e r i a t r i c n u t r i t i o n 3 . demonstration on technique to be used i n weight control group 4. p a r t i c i p a t i o n i n and discussion of vegetarian lunch 5 . displays on aspects of general n u t r i t i o n 6 . p a r t i c i p a t i o n i n and discussion of a low cost meal 7. b u l l e t i n board displays on community and l i t e r a r y n u t r i t i o n resources 8. f l i p chart and recording of public education techniques  SEQUENCING  to be determined when f i n a l i z e d program content prepared [PROGRAM CONTENT proposed content i d e n t i f i e d INSTRUCTIONAL PLANS I PROGRAM TRYOUT'I 123 IMPROVEMENT PHASE  Introduction The improvement phase of t h i s inservice education program involves evaluating various aspects of the program and, with the r e s u l t s of the evaluation, r e v i s i n g and changing the i n s t r u c t i o n a l content and/or the program objectives. The re s u l t should be a program of continuing relevance to the required job performance, pa r t i c i p a n t s ' needs, n u t r i t i o n research, and education techniques. G i f f t has described evaluation as: . . . a systematic and conscious appraisal to improve a program or to measure i t s ultimate r e s u l t s . Any educational e f f o r t should include periodic appraisal of i t s q u a l i t y , s u i t a b i l i t y , effectiveness, and e f f i c i e n c y , with'the complexity of the appraisal process adjusted to the need and the p r a c t i c a l l i m i t a -t i o n s , (p. S - 5 ) Evaluative procedures f i t onto a continuum, progressing from the simple method of observation, through the more complex method of structured examination, to the most refined method, evaluative research. Observation involves the task of making value judgements on a program's worth. The major drawback to t h i s method i s that i t i s extremely d i f f i c u l t to minimize personal b i a s — o f t e n one sees what one wants to see. Structured examination generally i s a study, done i n a system-a t i c way, of the process of the program but i s not a method that gathers information about the outcome of i n s t r u c t i o n . That i s , there i s no e f f o r t made to compare change i n behaviour 124 with the program objectives. The most v a l i d and s o p h i s t i -cated method of evaluation i s evaluative research i n which the e f f e c t s of a program are measured by a defined process. There are several reasons why evaluation i s import-ant. An extremely p r a c t i c a l reason i s that the r e s u l t s of an evaluation enable the fund administrators and the people responsible for allowing a program to continue, to under-stand the usefulness of a prggram. Another reason for evaluation i s that i t allows for the avoidance of drawing unsustained conclusions as to the effectiveness of a program. It allows for i n t e l l i g e n t decision-making about necessary program changes. Thus a program can be kept up to date and continued success i s ensured. It should be stressed that evaluator bias must be avoided with any evaluative procedure. Often an evaluator wants to show only positive r e s u l t s and d i r e c t s the evalua-t i o n toward these ends. Obviously, every e f f o r t should be made to make sure the evaluator has an objective, non-biased attitude and an equally non-biased procedure for the evalua-t i v e process. Five Steps for Evaluation For t h i s inservice education program, there are f i v e necessary evaluative steps. The f i r s t three steps involve checking to see how well the i n s t r u c t i o n meets the objectives. The f i r s t of these steps involves comparing the performance of the program r e c i p i e n t s with the objectives. For example, i f one of the objectives i s to present, to the nurse, prenatal 125 n u t r i t i o n knowledge so that she can e f f e c t i v e l y counsel pregnant women i n n u t r i t i o n , then i t i s important to determine whether or not the PHNs involved i n the program do actually show improved maternal n u t r i t i o n counselling i n r e l a t i o n to that which went on prior to the i n s t i t u t i o n of the inservice education program. This step involves evaluative -research. As already discussed, the i n i t i a l preprogram r e s u l t s of the questionnaire serve as the method of determining what the objectives for the course should be. For the f i r s t step i n the evaluative process, the parts of the questionnaire that relate to the objectives combine to make an evaluative questionnaire and the data collected from t h i s questionnaire can be compared with the r e s u l t s of these parts obtained i n the assessment period. Thus there w i l l be a comparison of performance with objectives. If the comparison i s favourable, then i t can be concluded that the c r i t e r i a of performance objectives has been met and no changes are necessary i n this regard. However, i f the comparison i s poor, t h i s i s a good ind i c a t i o n that program format, methods and/or techniques need to be changed. The second step to ascertain whether or not the in s t r u c t i o n i s adequate to meet the objectives involves comparing the current n u t r i t i o n education techniques with those used i n the program i n i t s o r i g i n a l state. Systematic structured examination of present techniques and program techniques w i l l give the evaluative data. Even i f the f i r s t 126 step of evaluation shows performance meeting objectives, i t i s s t i l l possible to incorporate new techniques into the educative content so that the program w i l l improve and produce even better r e s u l t s . The t h i r d step i n the check on adequacy of instruc-t i o n involves a comparison of the current n u t r i t i o n research and thinking with those presented i n the program. The science of n u t r i t i o n i s constantly changing and improving theory and discovering new f a c t s . Thus the content of any n u t r i t i o n education program must be continually updated to include the new findings. The method used i n t h i s evaluative procedure again i s structured examination of current l i t e r -ature and program content. The l a s t two steps i n t h i s evaluative process are a check to see how the objectives continue to meet the job requirements. The fourth step, then, i s a comparison of the knowledge, attitudes and practices (evaluative research) of new personnel with the r e s u l t s of the knowledge, attitudes, and practices test of the nursing staff employed at the beginning of the program. It i s possible that after a year the majority of personnel (due to staff turnover) w i l l have completely d i f f e r e n t needs i n order to meet the n u t r i t i o n counselling performance required of public health nurses. If t h i s i s found to be the case, the objectives of the inservice program w i l l need to be revised so that the knowledge, attitudes and practices of the nurses w i l l be improved to 127 meet the exis t i n g job requirements. It i s hoped that the preprogram questionnaire be given to each new PHN on a r r i v a l so that a f i l e of t h i s information be up to date and analyzed every six months. The f i f t h step of the evaluative process i s a struc-tured examination of the n u t r i t i o n counselling that i s required of public health nurses. It i s possible that the number of n u t r i t i o n i s t s employed by the health departments w i l l increase. This would serve to free the PHNs from at least some n u t r i t i o n counselling and thus change the n u t r i -t i o n job requirements for PHNs. A change i n job requirements could mean a necessary change i n program objectives, depend-ing on whether any objectives relate to changes i n job requirements. Analysis of Evaluation The f i n a l step i n the improvement phase i s the analysis of the evaluation r e s u l t s and the r e v i s i o n and t r y -out of the program content to encompass any necessary changes that w i l l improve the i n s t r u c t i o n , and/or bring the program up to date. Because of the nature of the n u t r i t i o n inservice education, and because of the continual need for the evalua-t i v e process, t h i s improvement phase continues as long as the program i s i n operation and i s a continuous process. As soon as there i s an in d i c a t i o n for the need for evaluation i n any area, i t i s done. However, without any i n d i c a t i o n apparent the entire process should be carried through at least every six months. 128 Summary CHECK ON ADEQUACY OF INSTRUCTION TO MEET OBJECTIVES Comparison of performance with obiectives : Comparison of current n u t r i t i o n education techniques with those used i n program being evaluated Comparison of current n u t r i t i o n research and thinking with program content CHECK TO SEE HOW THE OBJECTIVES CONTINUE TO MEET THE JOB REQUIREMENTS |Comparison of new nursing] personnel's KAP with the re s u l t s of the existing program r e c i p i e n t s KAP [Job a n a l y s i s — h a s i t changed1^ REVISION AND TRYOUT 129 BIBLI03RAPHY Ase, K., "Nutrition education of public health nursing." Amer. J . Publ Health. 56: 938, 1966. Beavers, I., "Hard to reach - fact or f i c t i o n . " Ext. Service  Rev. 35:36, 1964. Brannon, B.J.,"Training for work with low income groups." Ext, Service Rev.. 35:214, 1964. B r i l l , N., "Communicating with low income f a m i l i e s . " J . Home  Econ. 58:631, 1966. Butterworth, T.H., "Learning-Principles, Practices, and Peanuts." J . Amer. Dietet. Assoc. 49:15, 1966. Chamberlain, V.M., "Oops! We'd better go shopping." What's New i n Home Econ. 33(8):83, 1969. Consumer and Marketing Service, USDA. Food-Buying Tips for Low Income People." Agr. Marketing 10(10):3, 1965. Craig, D.G.,"Guiding the change process i n people." J . Amer. Dietet. Assoc. 58:22, 1971. Davis, R.J., "The relation/between n u t r i t i o n knowledge:and the dietary intake of selected women: a basis for adult education program development." Ed. D. Disserta-t i o n , I l l i n o i s University, Urbana-Champaign, I l l i n o i s . 1971. Echols, I.J. "Comparative Group Approaches." J . Amer.  Dietet. Assoc. 59:460, 1971. Erhard, D., "Nutrition education for the 'Now' generation." J. Nutr. Educ. 2:135, 1971. . "The new vegetarians." N u t r i t i o n Today. 9:20, 1974. Fleck, H., "How Questions Stimulate Learning." P r a c t i c a l /  Forcast. 11(5) : 9 , 1965. G i f f t , H.H., M.B. Washbon and G.G. Harrison. N u t r i t i o n . Behavior, and Change. 130 Harris, B.M. et a l . Inservice education: A guide to better practice. Englewood C l i f f s : N.J. Prentice H a l l , Inc. 1969. Hayter, J . "Guidelines for selecting learning experiences." Nurs. Outlook. 15(12):63, 1967. Health and Welfare Canada. Selected N u t r i t i o n Teaching Aids for Public Health Nurses. Information Canada: Ottawa, 1973. Heinzelman, W.B., and F.D. Hoecker. "A change i n attitudes -produced by s k i l l f u l face-to-face communication." Ext. Services Rev. 37(6):12, 1966. H i l l , M.M., and L. Page. "The food guide - a t o o l for teaching n u t r i t i o n . " Nutr. Comm. News. May-June, 1963. Holmes, A.C., Vi s u a l Aides i n N u t r i t i o n Education: A Guide  to Their Preparation and Use. FAO Book. 1968 and 1971. Huiatt, A. and B.L. Hockin. "Nutrition programs for senior c i t i z e n s . " J . Home Econ. 63:683, 1971. Jones, E.P., "Program evaluation as an operational t o o l . " J . of Nutr. Educ. 2(1):19, 1970. Kintzer, R.C., "Approaches to teaching adults." J . Amer.  Dietet. Assoc. 50:475, 1967. Kornblueh, M. "The c a f e t e r i a l food game." Nurs. Outlook. 15(2):47, 1967. Leverton, R.M. "What i s n u t r i t i o n education?" J . Amer.  Dietet. Assoc. 64:17, 1974. Maternal N u t r i t i o n and the Course of Pregnancy. National Acadamy of Sciences, Wash. D.C. 1970. M i l l e r , D.C, Handbook of Research Design and S o c i a l Measure- ment. New York: David McKay Co. Inc., 1970. Newton, M.E., M.E. Beal and A.L. Strauss. " N u t r i t i o n a l Aspects of Nursing Care." Nurs. Res. 16:46, 1967. Norman, R.D., "A review of some problems related to the mail questionnaire technique." Educ. and Psych. Measure- ment. 8:235, 1948. Martin, J . "Changes i n Adults which Aff e c t Teaching." J . Amer. Dietet. Assoc. 43:439, 1963. . . 131 Poolton, M.A., "Predicting application of n u t r i t i o n education." J. Nutr. Educ. 4:110, 1972. Register, V.D., and L.M. Sonnenberg. "The Vegetarian Diet." J . Amer. Dietet. Assoc. 62:253, 1973. Robinson, M.F. "Consumer Use of Foods." N u t r i t i o n Program  News. Sept.-Oct., 1973. S a i l o r , N.M., "Nutrition knowledge applied to everyday l i v i n g . " Nurs. Outlook. 9:756, 1961. Selected N u t r i t i o n Teaching Aids for Public Health Nurses. Health and Welfare Canada. Information Canada: Ottawa, 1973. Shank, R.E. "A Chink i n our Armour." N u t r i t i o n Today. 5:2, 1970. Sipple, H.L., "Combating N u t r i t i o n Misinformation through Coordinated Programs." Amer. J . Publ, Health. 54:823, 1964. Spitze, H.T., "Innovative techniques for teaching n u t r i t i o n . " J t Nutr, Educ. 2:156, 1971 Stucky, V.T., "Tape recording, booklet teach d i e t s . " Hosp. 42(24):78, 1968. Wagner, F.E., "Some p r i n c i p l e s of adult education." J . Amer. Dietet. Assoc. 44r34, 1964. Wilson, C.S. and S. Knox. "Methods and Kinds of N u t r i t i o n Education (1961-1972): A selected annotated b i b l i o -graphy. J. of Nutr. Educ. 5(l) Supp. 2:77, 1973. LITERATURE CITED 133 Bennett, C.M., and R.E. H i l l , J r . 1964. "A comparison of selected personality c h a r a c t e r i s t i c s of responders and non-responders to a mailed questionnaire study." J . Educ. Res. 58:178. Canadian C l a s s i f i c a t i o n and Dictionary of Occupations. 1971. 1:126 (Occupational Code 3131-118). C i t y of Vancouver. Job Description of N u t r i t i o n i s t . Class No. 279 and 281, 1965. ' Clarke, D.H., and H.H. Clarke, 1970. Research Progress i n Physical Education. Recreation, and Health. Englewood C l i f f s : Prentice H a l l . Clausen, J.A. and R.N. Ford. 1947. "Controlling bias i n mail questionnaires." J . Amer. S t a t l . Assoc. 42:499. Comely, P.B., S.K. Bigman and D.D. Watts. 1963. " N u t r i t i o n a l b e l i e f s among a low income urban population." J . Amer. Dietet. Assoc. 42:131. Dillman, D.A. 1972-73. "Increasing mail questionnaire response i n large samples of the general public." Publ. Opin. Quart. 36:254. Donald, M.H. 1960. "Implication of mail questionnaire data." Publ. Opin. Quart. 24:99. Eckland, B.K. 1965. "Effects of prodding to increase mail-back returns." J . Applied Psych. 49:165. Emmons, L. and M. Hayes. 1973. "Nutrition knowledge of mothers and children." J . Nutr. Educ. 5:134. Encyclopedia of Educational Research. 1960 ed. S.v. "Attitudes," "Survey research methods." by C.W. Harris. Eppright, E.S., H.M. Fox, B.A. Fryer, G.H. Lamkin and V.M. V i v i a n . 1970. "The north central regional study of d i e t s of preschool children. Part 2. N u t r i t i o n knowledge and attitudes of mothers." J . Home Econ. 62:327. Ferber, R. 1966. "Item nonresponse i n a consumer survey." Publ. Opin. Q u a r t . 30:399. F e r r i s s , A.L. 1951. "A note on stimulating response to questionnaires." Amer. Socl. Rev. 16:247. Franzen, R., and P.F. Lazarsfeld. 1945. "The mail question-naire as a research problem." J . of Psych. 20:293. 134 Gannon, M.J., J.C. Nothern, and S.J. C a r r o l l . 1971. "Characteristics of nonresponse amongi.workers." J . Applied Psych. 55:586. Harrison, G.G., A.M. Sanchez and CM. Young. 1969. "Public health nurses' knowledge of n u t r i t i o n . " J . Amer. Dietet. Assoc. 55:133. Jackson, R.M. and J.W.M. Rothney. 1961. "A comparative study of the mailed questionnaire and the* interview i n follow-up studies." Personnel and Guidance J . 39: 569. Ki e s l e r , C.A., B.E. C o l l i n s and N. M i l l e r . 1969. Attitude  Change. New York: John Wiley and Sons. Kunkel, N. and H. H a l l . 1958. "Influence of n u t r i t i o n teaching on adolescent's eating habits." J . Amer. Dietet. Assoc. 34:1220. Larson, R.F. and W.R. Catton, J r . 1959. "Can the mail-back bias contribut to a study's v a l i d i t y ? " Amer. Soc. Rev. 24:243. Levine, S., and G. Gordon. 1958. "Maximizing returns on mail questionnaires." Publ. Opin. Quart. 22:568. Longworth, D.S. 1953. "Use of a mail questionnaire." Amer. Socl. Rev. 18:310. Mason, M. and J . Rivers. 1970. "Factors influencing plasma ascorbic acid l e v e l s In pregnant women." J . Amer. Dietet. Assoc. 56:313. Mayer, J . 1970. "Commentary." J . Nutr. Educ. 2:80. Mayer, C.S., and R.W. Pratt, J r . 1966. "A note on non-response i n a mail survey." Publ. Opin. Quart. 30:637. Morse, E.H. M.M. Clayton and L. de.G. Cosgrove, 1967. "Mothers' n u t r i t i o n knowledge." J f Home Econ. 59:667. Newton, M.E., 1960. "What every nurse needs to know about n u t r i t i o n . " Nurs. Outlook. 8:316. , 1970. "Nutrition content i n "/the nursing c u r r i c u l a : potential for deletion." J . Nutr. Educ. 1:9. ... , M.E. Beal and A.L. Strauss. 1967. N u t r i t i o n a l aspects of nursing care." Nurs. Res. 16:46. Newton,. N. and M. Newton, 1950. "Relationship of a b i l i t y to breast feed and' maternal attitudes toward breast feeding." P e d i a t r i c s . 5:869. 135 Norman, R.D. 1948. "A review of some problems related to the mail questionnaire technique." Educ. and Psych. Measurement. 8:235. Nu t r i t i o n Canada. National Survey. 1973. A report by Nu t r i t i o n Canada to the Department of National Health and Welfare. Pace, C.R. 1939. "Factors influencing questionnaire returns from former university students." J . Applied Psych. 23:388. P h i l l i p s , M>G. 1971. "The n u t r i t i o n knowledge of medical students." J . Med. Educ. 46:86. Poolton, M.A. 1972. "Predicting application of n u t r i t i o n education." J . Nutr. Educ. 4:110. Prater, B.M. 1970. "Nutrition content i n the nursing c u r r i c u l a : reaction paper." J . Nutr. Educ. 1:11. Redman, B.M. 1968. The process of patient teaching i n  nursing. St. Louis: The C.V. Mosby Co. Reuss, C.F. 1943. "Differences between persons responding and not responding to a mailed questionnaire." Amer. Soc. Rev. 8:433. Rummel, J.F. 1964. ''An introduction to research procedures i n education. New York: Harper and Row, Publishers. Sarles, R.W. Senior N u t r i t i o n i s t for the C i t y of Vancouver Health Department. 1974. Personal communication. Schwartz, N.E. 1973. "The re l a t i o n s h i p of n u t r i t i o n educa-to subsequent n u t r i t i o n knowledge, att i t u d e s , and practices of Ohio High School graduates." Ph.D. Dissertation, Ohio State University. Sims, L.S., and P.M. Morris. 1974. "N u t r i t i o n a l status of preschoolers." J . Amer. Dietet. Assoc. 64:492. Swanson, J.C. 1972. "Second thoughts on knowledge and attitude e f f e c t s upon behavior." J . Sch. Health 42:363. Young, CM., K. Berresford and B.G. Walner. 1956. "What the homemaker knows about n u t r i t i o n . I I I . Relation of knowledge to practice." J . Amer. Dietet. Assoc. 32:321. , B.G. Waldner and K. Berresford. 1956. "What the homemaker knows about n u t r i t i o n . I I . Level of n u t r i t i o n a l knowledge." J . Amer. Dietet. Assoc. 32:218. 136 Wang, V.L. 1971. "Food information of homemakers and 4-H youths." J . Amer. Dietet. Assoc. 58:215. Wicker, A.W. 1971. "An examination of the 'other variables' explanation of attitude-behavior inconsistency." J. Personality and Soc. Psych. 19:18. Wilson, M.M. and M.W. Lamb, 1968. "Food b e l i e f s as related to e c o l o g i c a l factors i n women." J . Home Econ. 60:115. 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0099928/manifest

Comment

Related Items