Beruflich Dokumente
Kultur Dokumente
2 1996
Theory & Practice Pages 187-204
of perceived vulnerability to a disorder and the control over that action. The Theory of Planned
belief that a particular health measure will be Behaviour maintains that a health behaviour will
sufficient to overcome this vulnerability. This be adopted if an individual believes that the advant-
enables understanding of why people practice ages of success outweigh the disadvantages of
health behaviours and prediction of some of the failure, if they believe they are expected to perform
circumstances under which their health behaviour the behaviour by people with whom they wish to
will change. However, undertaking many health comply, and if they have enough control over
behaviours also requires a sense of personal control, internal and external factors influencing the attain-
i.e. a belief that it is actually possible to perform ment of the behavioural goal (Taylor, 1986). Thus,
the health behaviour. Bandura (1977, 1986) feelings of perceived control and self-efficacy
reasoned that an important determinant of the appear to be important in demonstrating attitude-
practice of health behaviours is a sense of self- behaviour consistency, even when there is a clear
efficacy which is the belief that an individual can behavioural intention to act on an attitude.
control their practice of a particular behaviour. The uptake and maintenance of health-related
Self-efficacy affects a range of health behaviours behaviour will also be determined by an indi-
including weight control (Strecher et aL, 1986) vidual's readiness to change, as proposed by
and quitting smoking (Prochaska and DiClemente, Prochaska and DiClemente (1983). The stages of
1984). In reviewing the role of self-efficacy in change model, which relates to the transtheoretical
achieving health behaviour change, Strecher et aL model of behaviour change (Prochaska and
(1986) found strong relationships between self-
188
Nutritional knowledge and behaviour in adolescents
189
D.Gracey et al.
In the self-efficacy section students ranked items of which was correct A total nutrition knowledge
according to their confidence that they could do score was obtained by adding the responses, scoring
them (sure they could = 1, sure they could not = one for each correct answer and zero otherwise.
6). Only 18 of the 61 items from those used by
Sallis et al. (1988) were chosen to keep the Lifestyle factors
questionnaire to a manageable length. This subset In the school time available, it was impossible to
had previously been validated by the Department use diet records or detailed food frequency ques-
of Medicine, Royal Perth Hospital. These items tions to gauge nutrient intake. A 30-item food
were of the form: 'How sure are you that you variety score adapted for Western Australian chil-
could ....' followed by statements such as 'stick dren (Milligan, 1994) was used as a measure of
to healthy foods when eating with friends' or eating diversity. In assessing food variety, indi-
'substitute reduced fat milk for whole milk'. viduals were asked to tick which of 30 food items
Control over food intake was assessed with a they had eaten in the past week. Responses do not
five-point Likert scale which ranged from almost measure frequency of consumption but the number
always (1) to never (5) (Williams et al, 1993). of different foods eaten during the week. The food
Items were: (1) Do you have any say in what variety score addresses the first dietary guideline
foods are bought at home? (2) Do you have any for Australians to 'enjoy a wide variety of nutritious
say in how food is prepared or cooked at home? foods' (NHMRC, 1993). A high food variety score
(3) Do you choose what goes onto your plate? (4) indicates compliance with this NHMRC guideline
and has been shown in other populations to correl-
190
Nutritional knowledge and behaviour in adolescents
Internal consistency was assessed using Cronbach's Table I shows means and confidence intervals
OL As internal reliability for the self-efficacy scale for the age, weight, height and body mass index
was acceptable (Cronbach's a = 0.8763), a total (BMI) for the respondents. Girls at the high SES
score was calculated by summing the responses to school were significantly shorter and lighter than
all self-efficacy questions. Responses were recoded those at the other school; however, there was no
as 'most important' = 6 and 'least important' = significant difference for BMI. The mean BMI for
1, so that higher values indicated greater levels of boys and girls at all schools corresponded to
self-efficacy. Similarly a total score was calculated reported normal values for this age group
for locus of control (Cronbach's a = 0.7683). (Hammer, 1991).
Spearman correlation coefficients were used to
examine relationships between psychological vari- Stages of change
ables, nutrition knowledge and eating patterns, and A significantly greater (P < 0.05) percentage of
these relationships were explored further using boys at the low SES school (70%) considered that
linear regression. A level of P < 0.05 was consid- they made healthy food choices compared to the
ered significant high SES school (57%) and the private school
(55.1 %). Significantly more girls (79.7%) than boys
Results (59.5%) tried to choose healthy foods (P < 0.05).
Among students in the maintenance phase (eat-
Subjects ing a healthy diet for more than 6 months) there
Variable Low SES school Private school High SES school Total
Age (yean)
boys 15.7 (153-15.9) 15.8 (15.6-16.0) 15.8(15.6-15.9) 15.8(15.7-15.9)
girls 15.6(153-15.8) 15.8 (15.6-16.0) 15.9(15.8-16.0) 15.8(15.7-15.9)
Weight (kg)
boys 64.2 (61.0-67.0) 69.8 (62.5-77.1) 64.5 (62.6-663) 65.6 (63.5-67.7)
girts 56.9(52.7-61.0) 56.0 (54.0-58.0) 52.5 (50.7-54.3)" 54.6 (53.2-56.0)"
Height (cm)
boys 175.8 (172.6-179.0) 176.3(173.5-179.2) 174.1 (172.2-176.1) 175.0(173.6-176.4)
girls 165.2(162.7-167.8) 169.2(167.0-171.3) 164.0(1623-165.4)" 165.8(164.6-166.9)
BMI (kg/m2)
boys 20.7(19.8-213) 22.6(20.1-25.1) 21.2(20.7-21.8) 213 (20.8-22.2)
girls 20.8(19.6-22.1) 19.7(19.0-20.4) 193 (18.9-20.2) 19.9 (19.4-20.4)*
'P < 0.05 in one-way ANOVA for differences 1between schools. Low SES. n = 85: private, n = 104; high SES, n = 202.
191
D.Gracey et al.
the low SES (26.7%) and high SES (26.4%) schools Overall, health beliefs considered to be true by the
(/> < 0.05). Significantly more girls (30.3%) than largest proportion of students related to improving
boys (15.7%) were classified in the action phase health (81%), feeling energetic (63%), feeling
(P < 0.05). good (62%), lowering cholesterol (61%), testing
Amongst those who said they did not try to eat willpower (57%), weight control (53%) and
a healthy diet, 63% were pre-contemplators who improving appearance (44%). Significantly more
did not intend ever to eat a healthy diet. A girls than boys believed that the benefits of a
significantly higher proportion of boys who were healthy diet related to improving health, feeling
precontemplators came from the high SES school good about oneself, weight control, improving
(54.7%) compared with 18.9% from the low SES appearance, feeling energetic, testing their
school and 26.4% from the private school willpower and saving money.
(P < 0.05). Similarly, for girls precontemplators Table II shows the percentage of boys and girls
comprised 56.5% from the high SES school, 17.4% ranking health values in the highest two categories.
from the low SES school and 26.1% from the The health values considered important by the
private school (P < 0.05). Boys made up a greatest proportion of students overall were
significantly greater proportion (P < 0.05) of the improving health (82%), increasing energy (81%),
pre-contemplators (69.7%) than girls (30.3%). feeling good about oneself (80%), weight control
(61%), improving appearance (58%), saving money
Health beliefs and values (58%) and lowering cholesterol (51%). The propor-
Table II. Percentage of responses ranked in the highest two categories for health beliefs and values
Items for beliefs and values relating to the effects of Responses in the highest two categories (%)
a healthy diet
Beliefs Values
192
Nutritional knowledge and behaviour in adolescents
The response for health beliefs and health values differences in healthy food choices in relation to
did not differ significantly between schools. school. Boys who considered their food choices as
healthy had significantly greater self-efficacy
Barriers to change
scores than other boys. Similarly girls who reported
Table HI shows the items used and the percentage trying to eat a healthy diet had a higher self-
of boys and girls ranking barriers to change in the efficacy score than those reporting unhealthy diets.
highest two categories of importance. The barrier Locus of control scores showed similar patterns
to change considered important by the largest to those for self-efficacy, with significantly higher
proportion of students, combining responses from values in girls (Table IV). For those reporting their
boys and girls, was healthy food not being available diet as healthy, locus of control score was higher
at home (45.1%). Other barriers related to healthy than in other students. There were no significant
foods being unavailable in school canteens differences in locus of control scores according
(41.4%), ignorance of calorie content (40.3%), to school.
sugar and fat content (42.2%) and fibre content
(41.1%) of food, lack of control over buying of
food (40.2%), and problems in sticking to a healthy Control over food intake
diet (39.6%), particularly in girls. Girls were signi- Table V shows the proportion of boys and girls
ficantly more likely than boys to report a number who considered they 'almost always' or 'quite
of barriers including family support, ignorance often* had control over their food intake. Signific-
of fibre content, insufficient planning time and antly more girls than boys had some say over how
TaWe IIL Percentage of responses in the highest two categories for items relating to perceived barriers to eating a healthy diet
Boys Girls
Foods that fit into a healthier diet are not available at home 45.4 44.9
I find it difficult to make healthy food choices at the school canteen 40J 42.0
I do not know which foods are best to reduce sugar and fat 38.3 45.2
I have no control over the foods available at home 37.4 42.9
1 do not know how many calories are in different foods 35.6 42.3
I do not know which foods are high in fibre 35.3 46.2*
I have trouble knowing how much I should eat 32.6 37.6
I have trouble sticking to a healthy diet 32.4 44.7*
I find it difficult to choose healthy foods for school lunches 31.6 35.7
I have trouble choosing healthy foods when I am out with family or friends 29.8 36.1
My family does not support my efforts to eat a healthier diet 29.4 35.9"
I don't see any benefit! from my efforts to eat a healthier diet 26.6 32.1
It is difficult to find time to plan healthy meals 26.3 36.91
It is difficult for me or my family to shop for the foods I need 24.5 30.5
I use food as a treat orrewardfor myself 20.2 26.0
I find that a healthy diet is too expensive 17.6 24.9
193
D.Gracey et aL
Table IV. Self-efficacy scores and locus of control scores (mean and 95% Cl) related to gender and to healthy or unhealthy food
choices
Self-efficacy
boys 76.4b 66.5 72.41
(73.2-79.6) (62.5-70.4) (69.9-74.9)
girts 80.2" 70.8 78.3
(77.7-82.8) (65.7-76.4) (76.0-80.6)
Locus of control
boys 16.6b 14.9 15.9°
(16.2-16.9) (14.2-15.5) (153-16.3)
17.2b 15 J 16.8
girls
(16.9-17.5) (14.2-16 3) (163-17.1)
V < 0.05 for gender difference; bP < 0.05 for difference between patterns of food choice (Mann-Whitney test).
Table V. Percentage of boys and girls ranking responses to questions related to eating patterns as 'almost always' or quite
often'
Boys Girls
Table VL Percentage of boys and girls correctly answering nutrition knowledge questions
Boys Girls
194
Nutritional knowledge and behaviour in adolescents
school. Only 43.4% of girls at the low SES school 3.0) for the high SES school (Kruskal-Wallis
regularly ate breakfast, compared to 72.3% at the 14.97, P = 0.0000). For fruit the mean score was
private school and 73% at the high SES school 3.0 ( O 2.6-3.2) for the low SES school, 3.4 ( a
(X2 19.16, P = 0.0140). The respective proportions 3.1-3.7) for the private school and 3.3 (CI 3.1-
for boys were 72.5, 74 and 72.7%. There were no 3.5) for the high SES school (Kruskal-Wallis
significant differences by school for boys. 6.05, P = 0.0421). The low SES school scored
significantly lower in consumption of nuts (Krus-
Nutrition knowledge
kal-Wallis 6.49, P = 0.0389) with a mean score
Eight items pertaining to nutrition knowledge were of 0.4 (CI 0.3-0.6) compared with the private
included in the questionnaire (Table VI). The mean school (0.7, Q 0.6-0.9) and high SES school (0.6,
score of correct responses was significantly greater CI 0.5-0.7). Separate analysis by gender for cereal
(Mann-Whitney 2.54, P = 0.011) for girls (5.3, and fruit showed no significant differences for
Q 5.0-5.5), than for boys (4.8, CI 4.5-5.0). Table boys but for girls there were significant differences
VI shows the items and the percentage of boys for both food groups due mainly to very low
and girls who answered each item correctly. At consumption amongst the girls at the low SES
least 60% of students answered items correctly school (Kruskal-Wallis for cereal 5.98, P = 0.0288,
except for the three questions relating to fat content for fruit 8.90, P = 0.0117). The mean score for
of foods. cereals for girls was 3.0 (CI 2.8-3.2) at the low
A number of misconceptions were evident For SES school, 3.4 (CI 3.2-3.6) at the private school
example, 22% of students believed that white bread
195
D.Gracey et al.
196
Nutritional knowledge and behaviour in adolescents
Fig. 1. Frequency of smokers (a) and drinkers (b) and mean cigarette (c) and alcohol (d) consumption for smokers and drinkers
by school for girls (SI) and boys ( • ) . *P < 0.005 for difference between schools.
1992). The alcohol intake in 10 boys (18% of male the high SES school. For weekend television view-
drinkers) and one girl exceeded the safe drinking ing the mean number of hours per day was 4.5
guidelines. No information was available to distin- (CI 3.7-5.4) for girls and 5.0 (CI 3.9-6.0) for boys
guish a pattern of regular drinking from binge at the low SES school, 3.1 (CI 2.6-3.7) for girls
drinking at weekends. and 4.9 (CI 4.0-5.9) for boys at the private school,
and 4.4 (CI 3.8-4.9) for girls and 6.3 (CI 5.0-7.6)
for boys at the high SES school. Girls watched a
Television viewing mean of 2.6 h/day (CI 2.3-2.9) during the week
Both boys (Kruskal-Wallis 13.07, P = 0.0014) and 4.1 h/day (CI 3.7-4.4) at weekends. The
and girls (Kruskal-Wallis 25.5, P = 0.0000) at the respective means for boys were 3.3 h/day (CI
private school watched significantly fewer hours 2.8-3.9) and 5.6 h/day (CI 4.9-6.4). Differences
of television during the week and girls at the private between boys and girls were significant for both
school also watched significantly less television at weekday and weekend viewing (Mann-Whitney
weekends (Kruskal-Wallis 10.81, P = 0.0045). 2.62, P = 0.0081; 3.65, P = 0.0001).
The mean number of hours of television per day Television watching during the week correlated
during the school week was 3.4 (CI 2.6-4.2) for negatively with nutrition knowledge scores (r =
girls and 3.7 (CI 2.9-4.5) for boys at the low SES -0.1170, P = 0.028). There were no significant
school, 1.5 ( O 1.1-2.0) for girls and 2.2 (CI 1.7- correlations between television watching and BMI,
2.6) for boys at the private school, and 2.7 (CI nor between TV watching and fat score or food
2.3-3.1) for girls and 3.8 (CI 2.9, 4.7) for boys at variety score.
197
D.Gracey et al.
TbMe VIL Regression models with measures of eating habits as dependent variables
198
Nutritional knowledge and behaviour in adolescents
consistent with reports showing self-efficacy to be reflect their more realistic views of meal prepara-
a key factor in the eating behaviour of middle tion. Greater understanding of the benefits of a
aged women (Shannon et aL, 1990). We found healthy diet and skills in preparing quick, easy,
that boys had significantly lower self-efficacy nutritional meals may overcome the perceived
scores than girls, in line with the report of Sallis barrier of planning time. In regression models,
et aL (1988). Conversely, Kingery (1990) found control over foods bought at home was a significant
no differences in self-efficacy associated with gen- independent predictor of healthy eating patterns
der in his study of college students. Self-efficacy and more girls than boys were able to influence
did not differ according to SES in our study, again what they ate, particularly relating to food prepara-
consistent with the findings of Sallis et aL (1988). tion at home, choosing food served and choosing
Using the same locus of control questions as school lunch. Encouraging boys to take part in
Falconer et aL (1993), we obtained similar findings. these processes may improve their food choices
However, self-efficacy was a better predictor of and improved availability of healthy foods both at
eating habits than locus of control as previously home and at school is needed.
reported (Kaplan, 1984). Students' self-perception of ignorance about
The health-belief model suggests an association nutrient content of foods was supported by
between dietary behaviour and an individual's responses to nutrition knowledge questions, par-
perception of risk (Thomas, 1994) and has been ticularly concerning fat content Serious miscon-
used to measure beliefs and values influencing ceptions indicated difficulties in translating nutrient
199
D.Gracey et aL
in primary school children in Perth by comparing tion was lower than at the high SES school. The
results with diet records in the same subjects NHMRC dietary guidelines (1993) recommend
(Milligan, 1994). In other populations, Ries and water as the preferred drink for children. In our
Dachler (1986) have shown it to be of value in study, girls at the private school conformed to this
dietary assessment The food variety score provides guideline drinking the most water and little soft
some information about foods actually eaten and drink. The high consumption of soft drinks by
targets the first of the national nutritional guidelines other students suggests this is an area which could
for Australians, i.e. to enjoy a wide variety of be targeted for intervention. Greater intake of nuts,
nutritious foods. Kinlay et al (1991) have validated less salt use, less consumption of soft drinks and
their fat score against food frequency methods and greater consumption of water in private school
recommend this technique as useful in population- students suggest that their dietary patterns are more
based studies. consistent with national dietary guidelines.
The fat score in the present study was higher in There is an increasing trend toward adolescent
boys than girls and in students who considered dieting (Gortmaker et al, 1987), raising concerns
their food choices unhealthy. Drinkers and smokers about developmental delay and increased incidence
also had higher scores for fat intake which is of eating disorders. Although the student popula-
consistent with the reported association between a tion studied here conformed to previously reported
high fat, low fibre diet, smoking (Fulton et aL, normal values for BMI (Hammer et al, 1991),
1988) and drinking (Herbeth et aL, 1988). Less over half of the girls and 20% of boys considered
200
Nutritional knowledge and behaviour in adolescents
per day for females and not more than four drinks improved dietary practices with involvement of the
per day for males (NHMRC, 1992). The pattern family in nutrition education programs compared to
of binge drinking common in young adults entirely school-based programs (Vandongen et al,
(Wechsler and Isaac, 1992) places them at further 1995). However, these programs, designed for
risk in the short term in relation to traffic accidents, primary school children, are not immediately
violence and other social problems. In the longer applicable to older students. One possible approach
term, cardiovascular risk is increased when associ- is the use of mailed material directed at educating
ated with higher blood pressure (Wannamethee parents which Crockett et al (1989) have shown
and Shaper, 1991) and lower HDL cholesterol to be effective in improving knowledge about
(Gruchow et al, 1982). If health-related behaviour nutrition, modifying diet-related behaviours, invol-
is to be improved in this age group, smoking and ving children in nutritional activities at home and
at-risk drinking must be targeted. influencing foods available at home. Healthy foods
Television watching has also been linked with should also be available at school canteens and
an unhealthy diet, high cholesterol levels (Hei several schools are attempting to address this need
et al, 1990) and obesity (Dietz and Gortmaker, through parent-teacher groups. There is a need for
1985). This may be influenced by unhealthy nutri- more widely accessible information applicable to
tion messages in commercials (Lank et al., 1992), allowing healthy food choices in school canteens.
eating snack foods and decreased physical activity For example, in Western Australia, the recently
(Robinson et al, 1993). In our study, television formed West Australian Canteen Association is
watching was a significant independent predictor providing resources and support to facilitate
201
D.Gracey et al.
to developing media campaigns publicising nutri- ContentoJ.R. and Murphy.B.M. (1990) Psychosocial factors
differentiating people who reported making desirable changes
tional messages appropriate to this age group. in their diets from those who did not. Journal of Nutrition
The present study has shown trends in nutrition- Education, 22, 6-14.
related behaviour as well as smoking, drinking and CrocketLSJ., Mullisjt., Perry.C.L. and LuepkerJtV. (1989)
television watching among senior high school Parent education in youth-directed nutrition interventions.
Preventive Medicine. 18, 475-491.
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to devise appropriate health promotion programs, at the television set? Obesity and viewing in children and
educators need to understand these patterns of adolescents. Pediatrics, 73, 307-312.
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