Health teacher perceptions and teaching practices regarding disordered eating behaviors in high school students.
High school students (Health aspects)
|Publication:||Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Newsletter Subject: Health Copyright: COPYRIGHT 2006 American Journal of Health Studies ISSN: 1090-0500|
|Issue:||Date: Summer-Fall, 2006 Source Volume: 21 Source Issue: 3-4|
|Topic:||Event Code: 200 Management dynamics|
|Product:||Product Code: E197400 Students, Senior High|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
Abstract: This investigation assessed health teachers'
perceptions and teaching practices regarding disordered eating
behaviors. Surveys (n=600) were mailed to a random sample of high school
health teachers. The 32-item survey utilized several theoretical
constructs. Most respondents (88%) agreed that health teachers should
provide disordered eating behavior education, yet 25% currently do not.
The majority of respondents (84%) could confidently refer students to
receive help for disordered eating but only 36% indicated they had a
cooperative referral plan. Findings delineate the perceived importance
of disordered eating as a health problem in high schools and the role
health teachers can play in prevention.
Obesity and overweight among youth has gained significant attention due the increase in the number of young people who are classified in these categories. While most of the focus has been placed on lack of physical activity or consumption of high fat or high sugar foods, less emphasis has been placed on issues of disordered eating in the form of self starvation, binge eating and purging, or various other forms of unhealthy eating behaviors. Some of these behaviors may be the result of weight concerns or other underlying social or mental health issues. The National Eating Disorders Association (NEDA) estimates 10 million girls and women, and one million boys and men struggle with some type of eating disorder (NEDA, 2004). Homeier (2004) estimated that 1% of teens in the United States have an eating disorder. Although most professionals agree that school health educators should provide instruction in eating disorder prevention, there is some discrepancy about appropriate content and the most effective instructional methodologies.
Some researchers (Carter, Stewart, Dunn, & Fairburn, 1997) have argued that simply providing information about eating disorders has the potential to do more harm than good. Muir, Wertheim and Paxton (1999) found that instruction on "appropriate" Body Mass Index (BMI) sometimes contributed to negative affect concerning body image and resulted in adolescent girls being more prone to potentially unhealthy dietary behaviors. Other researchers have reported significant reductions in factors that contribute to the development of eating disorders using an intervention focused on improving self-esteem (O'dea & Abraham, 2000). There is also some concern about the tenuous relationship between increased levels of knowledge and positive modifications in health behavior. Increases in knowledge often translate into changes in behavior as a delayed effect, meaning changes might be observed well after the intervention (Grave, De Luca, & Campello, 2001).
Eating disorders are a multifaceted problem stemming from physical and psychological stress, cultural expectations, family interaction, fear of weight gains that normally accompany puberty, and a myriad of other contributing factors (LoBuono, 2001; Manley, Rickson, & Standeven, 2000). This health problem crosses all gender, cultural, age and socioeconomic strata. While adolescence is believed to be a critical time in the development of disordered eating behaviors, children as young as first grade report the desire to be thinner (Collins, 1991).
The age of students should be considered when teaching eating disorder prevention. Studies designed to determine the cause of young girls' concerns about weight found that the importance peers place on weight and eating was strongly related to the development of excessive weight concerns in both elementary and middle school students (Taylor et al., 1998; Muir, Wertheim & Paxton, 1999). Taylor et al. (1998) suggested that prevention programs should include both boys and girls because the pressure from peers was perceived to come from both sexes. These results suggest that effective school based eating disorder prevention programs should be implemented as early as the elementary grades and should include both males and females.
Teaching strategies and mode of delivery may also affect the success of an intervention program. Several reports have supported the idea that a didactic (information only) approach is not as effective as experiential learning (Grave, 2003; Kater, Rohwer, & Levine, 2000). Hands-on, experiential learning strategies at the upper elementary grades have been successful at improving knowledge, positive attitudes, healthy intentions related to body image and weight, and recognition of the hazards of weight loss strategies in upper elementary grade students (Kater, Rohwer, & Levine, 2000). Peer support group interventions using a life skills approach have also shown success in improving weight and appearance esteem, as well as eating attitudes and behaviors (McVey et. al, 2003). O'dea and Abraham (2000) chose to implement a program that used cooperative and interactive learning with a student-centered approach focused on developing self-esteem, not simply giving information on the dangers of eating disorders. This intervention program improved students body satisfaction, body image, attitudes toward eating and students overall self-perceptions with no negative side effects. Improvements in body image and eating attitudes were still present at the 12-month follow up.
Several researchers provide guidelines and suggestions for school personnel who are in a position to teach curriculum including eating disorder prevention (Jones, Brener & McManus, 2004; Lytle et al., 2004; O'dea & Abraham, 2001). A solid knowledge base in nutrition, weight issues, and eating disorders is critical. Both incorrect knowledge and inappropriate perceptions toward weight issues and body image may be transferred from teacher to student. Therefore, it is imperative that pre-service teachers and in-service teachers receive training that improves knowledge, but also positively influences beliefs, attitudes and perceptions of eating disorder issues (O'dea & Abraham). Jones, Brener & McManus reported that only 32.1% of teachers in middle/junior and senior high participated in staff development programs enhancing knowledge of dietary behaviors. Teachers who received staff development in a specific area were more likely to teach four or more hours of that topic (Jones et al.). Lytle et al. suggested that teachers may not view nutritional issues as being as important as other health topics and that there is a need for more training in the area of nutrition education to improve teachers' confidence in implementing behaviorally based intervention curricula.
While there is clearly a need for more training, teachers also report a need for a school resource person for eating disorder prevention. Teachers must be aware of referral processes, should an eating disorder case need medical intervention (Smolak, Harris & Levine, 2001). Researchers suggest that schools, communities and teachers must all be included in an interdisciplinary team.
This type of ecological approach allows for not only direct instruction in nutrition, weight management, decision-making, self-esteem and other areas related to eating disorder prevention, it also facilitates the development of a social environment conducive to healthy dietary behavior. Such approaches should include teachers, counselors, nutrition services staff, administrators and variety of community resources. By implementing more of a coordinated and sequential effort in the schools to address this issue there is increased reinforcement through instruction, more opportunities to identify at risk students and direct them to appropriate treatment services, and opportunities to create a supportive environment at school and in the home. Use of the Coordinated School Health Program (CSHP) which includes health education, physical education, health services, nutrition services, health promotion for staff, counseling and psychological services, and family and community involvement may be a useful model in planning efforts to address disordered eating behaviors among youth.
Professionals in the field of eating disorders suggest that teachers and personnel in the middle and high school environment in particular are in a keyposition to affect this problem at the level of primary prevention (Massey-Stokes, 2000). However, it is unclear to what extent teachers are addressing the issue of eating disorders, or what perceptions and beliefs are held by teachers regarding eating disorder prevention. Piran (2004) reported that only three studies had been conducted on teacher's roles in the prevention of eating disorders at any level. The purpose of the study was to investigate school health educators' perceptions, beliefs, and practices regarding the teaching of eating disorder prevention.
A directory of public schools (N = 96,570) was obtained from the United States Department of Education. Only schools identified as traditional senior high schools (grades 9-12) were selected for possible inclusion in this study. The list was further reduced by eliminating schools that were at the upper and lower population extremes (+/- 2 standard deviations from the mean). The resulting population (n = 5,511) was used to select a random sample of senior high schools.
A power analysis was conducted to determine adequate sample size. With a potential population size of 5,511 and expecting that there will be limited variability in the responses of this population, an 80/20 split was used, with a sampling error of +/-5%, at the 95% confidence level. Based on this methodology estimates can be made with a sample size of 305 participants. To account for possible non-respondents and undeliverable addresses, 600 high schools were randomly selected. All surveys were mailed to the attention of the health educator.
The four-page questionnaire consisted of 32 items; 16 items assessed teaching practices or activities related to disordered eating (methods of delivery, current practices); 6 items assessed the role of the school or health educator in addressing the problem of disordered eating behaviors in youth (should schools health educators educate on this issue, presence of a cooperative referral plan for identification and treatment); 1 item assessed teachers perceptions of the perceived prevalence of disordered eating in the teacher's school; and 9 items assessed demographic variables (sex, age, level of education, whether the school had a Coordinated School Health Program). A thorough review of the literature in the area of disordered eating curriculum was conducted to construct all survey items. The survey was sent to 5 experts in the areas of school health, nutrition, counseling and survey research to establish content validity and minor changes in wording and formatting were made.
The response formats utilized for the majority of the questionnaire were a 5 point Likert-type scale (strongly disagree to strongly agree) or other closed format items (yes/no/unsure, check all that apply). Several theoretical models were utilized in the development of the questionnaire. Use of Stages of Change identified if health teachers had not seriously thought about teaching a unit on disordered eating (pre-contemplation), if they have informally considered teaching a unit on disordered eating but have no plans to begin such a program (contemplation), if they plan on teaching a unit on disordered eating behaviors by the next school year (preparation), if they have been teaching a unit on disorders eating behaviors for one school year or less (action), or if they have previously taught a unit on disordered eating behaviors in the classroom but no longer do so (termination). The second behavioral model utilized was the Health Belief Model. Behavior change is more likely to occur when perceived benefits outweigh perceived barriers to change. In this case, teachers were asked to identify some of the positive benefits of teaching students about disordered eating and some of the barriers for incorporating this material into the classroom.
The third behavioral construct utilized was self efficacy. Self efficacy is the confidence a person feels about performing a certain behavior or activity, this also includes confidence in overcoming barriers to perform that behavior (Glanz, Rimer and Lewis, 2002). This study assessed health teacher's self-efficacy in teaching students five topics related to the prevention of disordered eating and six outcome expectations related to the prevention of disordered eating behaviors.
Stability/reliability was established utilizing test/retest. A pilot test of the instrument was completed with a convenience sample of 30 health teachers. Individuals participating in the pilot test were asked to complete the survey twice, with a one week interval. An analysis of results from the first and second surveys yielded a correlation coefficient of .64 on Likert-type scale items and 74% agreement on multiple response questions.
Multiple techniques were utilized to increase the response rate of the study (Summers and Price, 1997). Questionnaires were sent through the mail using a three-wave mailing, a hand-signed cover letter, a self-addressed, stamped return envelope with first-class postage stamps, and a one dollar incentive. The survey was printed in a booklet-style format on green paper. Prior to sending out the survey, approval was granted from the University Human Subjects Committee.
Survey data were entered into the computer using SPSS 12.0. Descriptive statistics (frequencies, range of scores, means, and standard deviations) were utilized to describe respondents in terms of their demographic and background characteristics, as well as current teaching practices. To assess variations in teaching practices among demographic variables of sex, race/ethnicity, geographic location, and level of education, a series of chi-square analyses, ANOVAs, and multivariate analysis were performed. Level of significance was set a priori at 0.05. During post-hoc analysis a Bonferroni test was utilized.
DEMOGRAPHIC AND BACKGROUND CHARACTERISTICS
A total of 600 surveys were mailed to senior high health teachers. Six surveys were undeliverable and 332 were returned for an overall response rate of 56%. The sample was predominantly female (58%), white (94%), and had a master's degree (41%; Table 1). Years of teaching was fairly evenly distributed, however, over one third, (38%) had 20 or more years of teaching experience. Teachers overwhelmingly identified health education as their area of formal training (86%), while 52% also identified physical education. Only 10% identified nutrition as their area of formal training. Ninety-six percent of teachers were currently teaching in their area of certification. Participating schools were relatively evenly distributed geographically with 42% identified as rural, 38% suburban, and 20% urban. Only 22% of teachers specifically acknowledged the use of the Coordinated School Health Program.
A series of statistical tests were conducted to examine any interactions between the independent variables: sex, age, race, education, school location, years of teaching experience, primary teaching assignment, and participation in a Coordinated School Health Program. No significant interactions were found.
Pearson correlation found significant relationships between years of teaching and those receiving formal training concerning eating disorders. Level of education was positively associated with perceived self efficacy in teaching about disordered eating behaviors. Level of education was found to be significantly associated with the perceived benefit that teaching about disordered eating may help identify students with eating disorders. Education was also was significantly related to the use of guest speakers while school location was significantly related to use of the internet as a teaching tool. Race was found to have a significant relationship on the use of the internet and outcome expectations that teaching about disordered eating would decrease the chances of developing an eating disorder. Race was also found to significantly correlate with the perceived outcome that by instructing students on psychological factors that their chances of developing an eating disorder would be decreased.
PERCEPTIONS OF THE IMPORTANCE OF EDUCATING ON DISORDERED EATING
Over three-fourths (76%) of respondents indicated that they perceived the topic of disordered eating to be as important as any other health education topic. While there seemed to be an important emphasis on teaching on this topic, less than half of teachers (45%) agreed that disordered eating was a significant problem in their school. Only a small number (<1%) perceived educating on disordered eating to be the most important health topic while the same percentage (<1%) indicated that this topic was not as important as other health topics.
PERCEIVED LEVEL OF PREPARATION FOR TEACHING DISORDERED EATING PREVENTION
Teachers were asked if they had ever received any formal training in the prevention of eating disorders. Only 55% reported being trained to deal with eating disorders in their pre-service teacher education program. With so few teachers being educated on this topic it was not surprising that a plurality of respondents (86%) believed that there was a need for more in-service training. There is also a lack of referral plans or services for students identified with possible disordered eating behaviors. Just over one-third (36%) of teachers stated that their school had a cooperative plan in place to deal with disordered eating issues in students.
Teachers were also asked to rate their capability of teaching the five topics related to the prevention of disordered eating. Teachers had high efficacy expectations (77% or more strongly agreed/agreed) for all five of the topics: types of disordered eating behaviors (93%), recognition of disordered eating behaviors (86%), differences between good and bad nutrition (98%), psychological factors that may accompany disordered eating (77%), and where to go for help for a disordered eating behavior (84%; Table 2).
Teachers reported feeling high efficacy expectations to teach information regarding disordered eating. However, regarding outcome expectations, only 48% agreed that teaching information about disordered eating behaviors would decrease students' chances of developing an eating disorder. Most teachers (62%) agreed that teaching proper eating habits could reduce the occurrence of disordered eating behaviors (Table 2).
A series of statistical tests were conducted on perceived self-efficacy for teaching on the various topics related to disordered eating education. Race was found to have a significant effect on teachers feeling qualified to teach on this topic.
STAGE OF CHANGE FOR TEACHING DISORDERED EATING EDUCATION
The vast majority of teachers (75%) indicated that they had provided instruction on the topic of disordered eating within the last year and were currently in the action phase (Table 4). Few teachers (6%) reported that they had not considered teaching a unit about disordered eating within the next year. For those teaching on this topic, 63 percent reported using simple instruction only. Teachers also reported using video and film to teach (75%), with 32% using expert guest speakers to supplement instruction (Table 3).
BARRIERS AND BENEFITS TO TEACHING DISORDERED EATING EDUCATION
Perceived outcome was assessed regarding teaching about disordered eating. A majority (92%) of teachers agreed that increased awareness of eating disorders was a benefit to teaching the subject (Table 4). Fifty-one percent believed that an important benefit of teaching about eating disorders was an enhanced ability to identify students with this problem. Only 1% of respondents perceived no benefit to teaching this topic.
Barriers to teaching material on disordered eating were also examined. Forty percent of teachers believed there were no barriers to teaching about disordered eating. The main perceived barrier (39%) to teaching material on this topic was not enough time to adequately educate students (Table 4). Only 10% of teachers believed that students would not be receptive to the information.
Eating disorders remain a significant threat to the health and well being of thousands of young men and women. Although the number of those affected may seem small compared to other health issues disordered eating behaviors may contribute to other serious health issues such as depression and even suicide. Between 5-20% of individuals struggling with anorexia nervosa will die. The probability of death increases within that range depending on the length of the condition (Zerbe, 1995). Schools are a logical place to implement proactive educational measures to lower the incidence and prevalence of these problems. A majority of teachers surveyed reported offering instruction on disordered eating behaviors. Most teachers also perceived that instruction concerning disordered eating behaviors was as important as any of the other topics covered in health education classes. However, despite the documented prevalence of eating disorders, less than half of teachers surveyed perceived eating disorders to be a significant problem at their school. Teachers felt that disordered eating education programs were beneficial in enhancing student awareness of their own potentially harmful nutritional behaviors; it seems that teachers themselves are less aware of signs and symptoms manifested by students exhibiting disordered eating patterns.
A potential explanation for this discrepancy may be the relative lack of pre-service or in-service education received by many school health educators. Slightly more than half of the sample in this project reported having received any specific training about eating disorders in their pre-service programs. Perhaps in response to this deficiency, a great majority of the teachers expressed a desire for more in-service training in the area. Ongoing in-service programs, providing teachers with skills to identify students at risk for eating disorders, as well the skills to deliver effective educational programs on the topic would be beneficial.
Further compounding the problem is a general lack of systematic referral mechanisms for students who manifest symptoms of eating disorders. Less than half of teachers surveyed said that their school had a cooperative plan to deal with eating disorder related issues. Counselors, physical educators, and other school professionals should be part of an ecological approach to identification, education and facilitation of treatment of students with disordered eating patterns. Utilization of the tenets of the Coordinated School Health Program could assist with amelioration of shortcomings in existing referral plans. Compliance could be enhanced through a network of in-service and other support mechanisms.
Most teachers involved in this study reported that they provided their students with instruction on the topic of eating disorders. As self-efficacy for teaching this topic increased, the likelihood of a teacher including eating disorders in their health instruction also increased. However, it should be noted that while teachers felt high levels of self-efficacy when providing information based instruction, they also perceived that this form of instruction alone was not particularly effective as a mechanism to assist students in avoiding the development of eating disorders. It is well documented in health behavior change literature that information dissemination alone is rarely sufficient to motivate behavior change. Skill based training on implementation of empirically supported intervention techniques could enhance teacher self efficacy.
Finally, lack of time was cited as a barrier to instruction by many teachers. Once again, appropriate in-service training may assist teachers with the process of integrating eating disorder instruction into other health topics (i.e. decision-making, self esteem, self concept), alleviating to some extent time pressures in an already full curriculum.
A common underlying theme in the results of this study is the lack of a structured, comprehensive process for educating high school students about disordered eating behaviors. A mechanism for remediating this problem may be the more widespread use of the Coordinated School Health Program. A very small number of teachers surveyed (22%) acknowledged use of CSHP at their school. The model would allow teachers and school administrators to deliver direct instruction on health education topics and also offer integrated and/or correlated instruction through such avenues as the physical education program. The school counselor could be a valuable asset in structuring effective referral mechanism for those students dealing with social and/or psychological issues related to their eating behaviors. The nutrition services component offers the opportunity to reinforce instruction through the offering of healthy meal choices. Health services could assist with behavioral screenings designed to identify students with potential eating disorders. Finally, the parental and community involvement component of the model could be effectively utilized to enhance awareness and provide interpersonal support to students. The Coordinated School Health Program, by design, allows educators to take an ecological approach to such complex issues as disordered eating behaviors, as well as a mechanism for remediation through the educational process.
SUGGESTIONS FOR FUTURE STUDY
Future research in this area should focus on identification of effective in-service techniques to enhance teachers' self-efficacy in delivering eating disorders education. Also, examination of existing curricular approaches to identify the most effective approaches to eating disorders education (i.e., skill based vs. knowledge based approaches) could assist in development of effective curricula that is consistent with time constraints faced by teachers in the field. Finally, examination of the reasons for relatively low levels of utilization of the Coordinated School Health program and the subsequent development of strategies to increase use of these programs could also be of benefit.
Because of the self-report nature of this mailed survey, some data may have been over or under reported. This may be due to a perceived pressure to respond to questions in a socially desirable way. If so, this would threaten the internal validity of the study. The monothematic nature of the questionnaire may have caused biased responses in that some respondents may have thought about and answered differently if they had not been forced to think about the issue in a concentrated form. If so, this too would threaten to the internal validity. Lastly, this survey was a closed-format instrument, which did not attempt to elicit additional information from the respondents other than what was addressed in each item. To the extent that an important item may not have been included this could have been a threat to the internal validity of the findings.
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Amy Thompson, PhD, is an Assistant Professor in the Department of Adult Counseling, Health, and Vocational Education at Kent State University. Carla Smith, PhD, is an Assistant Professor in the School of Health and Human Performance at Eastern Michigan University. Barry Hunt, EdD, is a Professor in the Department of Food Science, Nutrition, and Health Promotion at Mississippi State University. Cathy Sharp, MS, is an Adjuct Faculty at Mississippi College. Please send all correspondence to Amy Thompson PhD, CHES, Assistant Professor, Department of Adult Counseling, Health, and Vocational Education, Kent State University, P.O. Box 5190, Kent, OH 44242; PHONE: (330) 672-0676; FAX: (330) 672-3063; EMAIL: firstname.lastname@example.org.
Table 1. Demographics and Background Characteristics of Responding Teachers Demographic n % Race/Ethnicity Caucasian 312 94 African American 11 3 Asian/Pacific 4 1 Hispanic 1 <1 Other 1 <1 Sex Male 136 41 Female 195 59 Level of Education Associate Degree 5 2 Bachelor's 129 39 Master's 135 41 Beyond Master's Degree 56 17 Other 7 2 Location of School Urban 67 20 Suburb 127 38 Rural 138 42 Formal Area of Training * Counseling 7 2 Health Education 284 86 Nutrition 33 10 Physical Education 171 52 Psychology 2 <1 Other 59 18 Coordinated School Health Program Yes 72 22 No 130 39 Unsure 126 38 Years of Teaching 1-5 4 14 5-10 54 16 10-15 44 13 15-20 58 17 20+ 125 37 Certified in Primary Teaching Area Yes 320 96 No 9 3 n = 327-331 * Respondents could select more than one answer Table 2. Perceived Self-Efficacy in Teaching Information on Disordered Eating Strongly Strongly Agree/ Disagree/ Item Agree Disagree n (%) n (%) Efficacy Expectations I feel qualified to teach my students.... the different types of eating disorders 308(93) 15(6) behaviors. how to recognize eating disorders. 286(86) 19(6) the differences between good and bad 326(98) 3(1) nutrition. about psychological factors that may 255(77) 34(10) accompany disordered eating. where to go for help. 278(84) 23(7) Outcome Expectations By instructing my students about ... the different types of disordered-eating 177(48) 31(9) behaviors, their chances of developing a disorder will decrease. recognizing potential disordered eating 214(58) 18 (5) behaviors, their chances of developing a disorder will decrease. proper eating habits, their chances of 228(62) 22(7) developing a disorder will decrease. the differences between good and bad 212(57) 27(8) nutrition, their chances of developing a disorder will decrease. the psychological factors that may 199(52) 16(5) accompany disordered eating, their chances of developing a disorder will decrease. places to receive help for a disordered- 169(45) 44(13) eating behavior, their chances of developing a disorder will decrease. n = 332 Table 3. Teachers Stage of Change Regarding Teaching Information on Disordered Eating Item n % I have not seriously thought about teaching 20 6 a unit on disordered eating in my classroom by the next year. (Pre-contemplation) I have informally considered teaching a unit on 20 6 disordered eating behaviors in my classroom. (Contemplation) I am planning to teach a unit on disordered eating 14 4 behaviors in my classroom by the next year. (Preparation) I have been teaching a unit on disordered eating 249 75 behaviors in my classroom for one year or more. (Maintenance) I have previously taught a unit on disordered 21 6 eating behaviors in my classroom, but I no longer teach eating disorders to my students. (Relapse) n = 332 Table 4. Perceived Benefits and Barriers to Teaching Disordered Eating Item n % Benefits There are no benefits 3 1 Decreases health complications associated 148 45 with disordered eating Increases awareness of disordered-eating behaviors 306 92 Decreases disordered eating behaviors 159 48 Identification of students with disordered-eating 170 51 behaviors Barriers 135 41 There are no barriers There is not enough time to educate students 130 39 on eating disorders There are not enough financial resources available 80 24 My school would not approve of me educating students 3 1 on disordered eating patterns Parents would not approve 3 1 Students would not be receptive to the information. 34 10 n = 332
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