The Impact of Interactive Multimedia on Nutrition and Physical Activity Knowledge of High School Students

Introduction

Adolescence is a time of rapid physical and psychological development. Healthy eating and physical activity patterns during adolescence promote optimal growth and development, prevent health problems such as obesity and overweight, and may prevent chronic diseases such as heart disease, stroke, and certain forms of cancer (The Surgeon General's call to action to prevent and decrease overweight and obesity, 2001). Overweight and obesity are increasing among adolescents in the United States. There are three times as many overweight teens today as there were two decades ago (Troiana & Flegal, 1998; Ogden, Flegal, Carroll, & Johnson, 2002; Strauss & Pollack, 2001).

The epidemic of childhood overweight is a complex problem with many contributing factors (Ritchie et al., 2003; Hill & Peters, 1998; Davison & Birch, 2001). Lack of adequate physical activity and poor eating patterns are two widely recognized contributors to the problem (Nutrition and Your Health: Dietary Guidelines for Americans, 5^th edition, 2000; Centers for Disease Control and Prevention, 1996).

On average, teens have diets that are too high in fat, saturated fat, and sodium as well as too low in fruits and vegetables, fiber, and calcium (Wilson, Enns, & Goldman, 2004; Munoz, Krebs-Smith, Ballard-Barbash, & Cleveland, 1997; Kirby, Baranowski, Reynolds, Taylor, & Binkley, 1995; Baranowski et al., 1997; Basch, Zybert, & Shea, 1994). Adolescents often consume snacks that are high in fat, sugar or sodium (Grunbaum et al., 2004; Ludwig, Peterson, & Gortmaker, 2001; Nestle, 2000). Almost 80% of high school students consumed less than the recommended five servings of fruits and vegetables a day, and over 80% consumed less than the recommended three servings of milk a day (Grunbaum et al., 2004).

Over 40% of teens are not vigorously active on a regular basis, with 12% reporting no recent physical activity (Grunbaum et al., 2004). Participation in all types of physical activity declines significantly during adolescence (Schlicker, Borra, & Regan, 1994; Telama & Yang, 1997). Enrollment in physical education classes is dropping, and many schools have decreased or even eliminated entirely the requirement for physical education at the high school level. Positive physical activity patterns in the teen years are important as they are likely to continue through adulthood (Telama & Yang, 1997).

Creative ways to encourage young people to develop positive lifelong eating and physical activity patterns are needed. The main venue for nutrition and physical activity education programs for adolescents is school-based interventions (Center for Disease Control and Prevention, 1996). The Coordinated School Health Model indicates that adequate physical activity and healthy eating for all students are critical for the well-being of young people (Marx, Wooley, & Northrop, 1998). Schools are an important venue in establishing and promoting lifelong healthy habits and offer ways to incorporate various learning strategies.

Successful strategies for encouraging students to adopt these habits involve self-assessment (Telama & Yang, 1997; Lytle & Achterberg, 1995); are behaviorally based (Lytle & Achterberg, 1995; Contento, Manning, & Shannon, 1995); allow for active participation; and include intensive instruction time (Lytle & Achterberg, 1995; Contento, Manning, & Shannon 1992). Computer-assisted instruction has been proposed as a successful way to incorporate these strategies. Interactive computer technology allows students to progress at their own pace, to utilize several instructional techniques, and to evaluate themselves and their understanding throughout the learning experience. Many programs have been designed for younger students, but there are few targeted at high school students that address nutrition and physical activity.

Purpose

The purpose of the project described here was to assess the effectiveness of an interactive multimedia product, SyberShop, to increase knowledge and influence behavior change in nutrition and physical activity in adolescents.

Methods

SyberShop Development

SyberShop was created by Extension Specialists and partners from the Division of Public Health and Department of Public Instruction to provide a much-needed resource for professionals working with high school students. Teachers receive SyberShop free of charge after attending a ½ day training conducted by Agents with NC Cooperative Extension Service. The training covers how to use the CD in the classroom, subject matter information on physical activity and healthy eating, and how using SyberShop can address required objectives in the standard course of study. In addition to the findings presented in this article, anecdotal responses from hundreds of health education instructors who have received training through Extension have been overwhelmingly positive as they continue to use SyberShop in the classroom. This project represents a unique partnership between Extension and the Department of Public Instruction.

The development team for SyberShop consisted of two nutrition experts, a physical activity expert, a health education expert, and multimedia and computer professionals. The CD can be used on either a PC or Mac platform and can be used individually or in the classroom as a supplemental teaching tool. SyberShop is composed of five modules that allow students to learn about different aspects of physical activity and healthy eating. The modules contained on SyberShop are Virtual Food Court, Virtual Cafeteria, Building Blocks, Body Dimensions, Be Active (Table 1).

SyberShop also contains a teacher's guide in portable document format (pdf). The guide contains background information on all SyberShop modules, technical assistance in using the CD, individual and group activities for each module, a test bank, and the correlation of SyberShop to the grade 9-12 Standard Course of Study for math, science, and healthful living (North Carolina Standard Course of Study, 2004).

Participants

Participants in the project were students enrolled in a freshman level health education course at a North Carolina high school. There were five classes total participating in the project (n=109). Two classes used SyberShop as the teaching method for nutrition and physical activity (experimental group) (n=44), one class used traditional lecture as the teaching method for nutrition and physical activity (lecture group) (n=21), and two classes received no nutrition or physical activity education (control group) (n=44). The same instructor taught the SyberShop experimental groups and the lecture group. Most (95%) of the students were in the ninth grade, with the remainder being in the tenth grade. Groups were evenly distributed with respect to male and female.

Questionnaire

The written script for all the information presented in SyberShop was used to develop a knowledge and intent to change behavior questionnaire. The questionnaire was designed to test the effectiveness of the program in the classroom. A review of the literature and suggestions from professionals working with adolescents guided the development of the questionnaire. Multiple-choice was used for the knowledge component and a Likert scale for the behavior change component. A bank of 71 knowledge questions and 40 intent to change behavior questions were developed. Nutrition professionals reviewed the bank of questions to determine clarity and eliminate overly difficult or trivial questions. The knowledge component of the questionnaire was reduced to 41 items and was sent to nutrition and physical activity education professionals for content review.

The revised questionnaire was pilot tested using a sample of the priority population to determine the overall reliability of the instrument. Forty-two (n=42) high school students were administered the pre-test while attending a required health education class. The students had already completed the nutrition and physical activity curriculum requirements prior to taking the test. Between the time of the pre-test and the post-test, no additional nutrition or physical activity information was given to the students. Two weeks following the administration of the pre-test, the students were given the same test that served as the post-test.

Based on the test item difficulty score and results from the content review, four questions were removed and three questions were revised to yield a final questionnaire of 37 multiple-choice questions (28 nutrition and 9 physical activity). The questionnaire also included eight Likert scale intent to change behavior questions and four questions on the enjoyment and possible future use of SyberShop.

Intervention

The control group was administered the pre-test followed by 2 weeks of health education that was not related to nutrition or physical activity. They were then administered the post-test. The lecture group was administered the pre-test then received approximately five class periods of traditional nutrition and physical activity instruction (i.e., lecture), after which they received the post-test. Each class period was 90 minutes long, with approximately 80 to 85 minutes of actual teaching time. The health education instructor presented the usual nutrition and physical activity lectures.

The experimental group used SyberShop in lieu of the usual nutrition lectures given by the health education instructor. Students were given the pre-test prior to using SyberShop. The students used SyberShop in a computer lab setting, with each student assigned his or her own computer. The students used SyberShop for five class periods of 90 minutes each. The exposure time to the program was 450 minutes or seven and one half hours total, minus a few minutes each day to open and close the program.

The students used SyberShop to complete assignments given by the health education instructor. The assignments were chosen from the SyberShop Teacher's Guide located on SyberShop. The health education instructor and a member of the research team observed students using the program. The students were able to successfully move through all the components of the CD and complete all assignments over the 5-day period. After using SyberShop, the experimental group was administered the post-test.

Results

The data were analyzed using SPSS for Windows v.10 (SPSS, 2000). Three students were excluded from the knowledge component of the data analysis as they did not complete both the pre- and post-test. An analysis of variance test was computed on the pre-test scores for all three groups. The results yielded no significant differences for the overall scores or for the separate nutrition and physical activity scores for the pre-test (Table 2).

The knowledge scores were analyzed using a one-way analysis of variance for overall scores, nutrition scores, and physical activity scores. A harmonic mean sample size was used to adjust for unequal sample sizes.

SyberShop was effective in increasing knowledge in students. The post-test scores between the SyberShop and the control group were significantly different, as seen in Table 2. The SyberShop group scored 28% higher on the post-test compared to the control group (p < 0.001) and 19% higher than the lecture group (p<0.05) for the overall scores. There was also a difference in post-test scores when examining the separate areas of nutrition and physical activity, although it did not reach statistical significance.

The questionnaire included eight Likert scale intent to change behavior questions to examine if the increases in knowledge would influence future behaviors with respect to physical activity and nutrition. The scores for the intent to change behavior questions were averaged for each group. The scale ranged from 5 = "strongly intend to adopt the behavior in question within the next month" to 1 = "strongly do not plan to adopt this behavior within the next month." The scores for each group are listed in Table 3 for the pre-test and post-test. Scores ranged from a high of 4.13 to a low of 2.48 for the positively worded questions. There was one question that was worded in a negative manner. The experimental group had four areas in which students planned to adopt a new behavior, whereas the lecture group had five areas in which students intended to adopt the healthy behaviors. There were no significant differences in intent to change behavior from pre-test to post-test in any of the groups for any of the behaviors.

The students were asked four questions regarding the usefulness, ease of use, level of fun, and whether they would recommend the program to their friends. No post-tests were excluded from analysis regardless of whether the student completed the pre-test. Students would have opinions of SyberShop regardless of the amount of time spent on the program. Thus, all student's opinions were included in the analysis. Forty-seven (47) students gave their opinions on the computer program, 72% indicated that the program was fun to use, 68% of the students said they would recommend this program to a friend, and 52% said they would use SyberShop in the future.

During the observation of the experimental group, the students were interested in the activities and had to be monitored from advancing to other modules in SyberShop not being covered that day. The excitement lasted throughout the five class periods because each day involved a new module, new activities, and new information.

Discussion

Identifying innovative and effective means to educate young people about healthy eating and physical activity is critical. A review of 30 education curricula found that approximately half of the programs used fantasy, curiosity, and challenge to convey the content material (Matheson & Spangler, 2001). They propose that students are motivated to continue learning if they are intrinsically motivated because the program is fun. Challenging activities stimulate curiosity, attention, and learning because they engross the student. Programs that include sensory curiosity seem to be critical for engaging the student in a fun, learning environment.

The research reported here examined the use of multimedia technology to improve knowledge and intent to change behavior. The most obvious finding of the research was that knowledge of nutrition and physical activity increased significantly with the use of the multimedia program compared with traditional lecture. This finding points to the importance of incorporating new and innovative strategies in the classroom to engage students in learning about these important health issues.

Findings of the research did not indicate a change in intent to adopt a new health behavior in the experimental, lecture, or control group. These findings are consistent with findings from other researchers that suggest that 10-15 hours of intervention are needed to increase knowledge, but up to 50 hours may be needed to see change in behavior (Contento, Manning, & Shannon, 1992). This commitment of time may not be possible with more emphasis being placed on subjects that are included in end-of-grade testing. Other methods such as integration of nutrition and physical activity into subjects other than health or the commitment of more class time to these subjects may be needed to see positive behavior change.

Interactive multimedia programs such as SyberShop address some of the specific challenges presented to instructors who teach high school health education. These challenges include a lack of time and lack of current knowledge about nutrition and physical activity.

The first challenge for health education instructors is lack of time. Findings of the research indicate that the use of multimedia, interactive materials is a good way to engage students and see positive changes with respect to knowledge. Interactive multimedia offer instructors an option to traditional lecture in enhancing and reinforcing learning in their students. In North Carolina, nutrition and physical activity education are typically presented during the health education class for freshman over a 1- to 2-week period. Once this class is completed, the student is not required to take any more health education classes. This limited amount of health education is an issue across the nation.

The limited instructional time that is allocated to nutrition and physical activity needs to be as productive as possible. The research examined the results of using SyberShop for five 90-minute sessions. This is the traditional amount of time allotted for nutrition and physical activity education for freshmen students in health education. As seen in the results, even this short time frame was sufficient to see a knowledge improvement when compared to traditional lecture.

A second challenge is that many health education instructors lack formal nutrition and physical activity training. Without formal training, instructors may not be comfortable teaching about nutrition and physical activity. SyberShop and other interactive educational programs can serve as a valuable tool to assist instructors in educating students about nutrition and physical activity.

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