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[Insert title here] Option 1 – Research Proposal Course: KIN 330 Term: Winter 2007 Jacqueline Leung [student ID here] Katy Lo [student ID here] Chris Tsoi [student ID here] Joanna Wu [student ID here] Abstract [insert here] Introduction The research project described in this proposal aims to investigate the effect of a theorybased intervention on the dietary habits of university students. This is an important area of study because students often fail to make healthy nutritional choices (Misra, 2000). Von Ah (2006) reports that a lack of basic nutritional knowledge and appreciation for the importance of healthy eating is compounded by the high levels of stress which students experience in university. This phenomenon is particularly injurious in freshman year, a time of transition where students may face financial pressures, challenges to their time management ability, and an academically imposing course load. Under such circumstances, it is almost inevitable that a student with little nutritional knowledge who fails to find healthy eating important will start to develop poor dietary habits. There is little disagreement in the literature that such habits lead to undesirable health outcomes. For instance, Huang et al. (2004) found that 25% of cancer-related deaths were attributable to poor dietary choices, such as a high-fat/low-fiber pattern. Whitney and Rolfes (2005) also comment that obesity is often a consequence of poor diet, and in turn can lead to cardiovascular conditions such as high blood pressure and high cholesterol. An intervention to improve students’ dietary habits during such a formative time in their lives, then, is well justified. In preparing and planning this research study, the literature on past dietary interventions was extensively reviewed. The purpose of the review was to consolidate existing knowledge of nutrition intervention effectiveness to inform the development of the intervention at the heart of this study. It was found that interventions tended to focus on one of three routes to behavior change: cognitive (increasing participants’ knowledge about nutrition), behavioral (direct modification of behavior), or affective (changing participants’ emotions and feelings towards healthy eating). Firstly, cognitive or “knowledge-based” approaches to nutrition intervention programs were found to be effective. Klohe-Lehman (2006) found that with weight-management programs, nutrition education was a strong predictor of effective weight control. Furthermore, favorable weight loss in obese and overweight low-income mothers was found to be related to the extent of their nutritional knowledge. In another study, a 4-month intervention that used newsletters and computer-based communication to increase fruit and vegetable consumption by college students aged 18 to 24 years was found to be highly successful, as the experimental group showed an increase in vegetable and fruit consumption which was significantly greater than that observed in the control group (Richards, Kattelmann, & Ren, 2006). Frenn (2003) found that classroom-style nutrition instruction was also effective. Students in a treatment group who received classroom and environment interventions showed improvements from baseline for their usual food choices (such as a greater tendency to choose lower fat foods), whereas students receiving the environment intervention only and those receiving nothing at all showed no changes in their usual food choices scores. Lastly, an expansive study on the effects of the 1990 Nutrition Labeling and Education Act, which allowed the FDA greater control over the accuracy of health claims on food labels, found that customers who were able to understand and use the label information showed healthier purchasing behaviors (Marietta, Welshimer, & Long Anderson, 1999). Secondly, there was much found in the literature to support an affective-based nutrition intervention. Specifically, McKinley (2006) found that the greatest barrier encountered in encouraging healthier dietary habits in young adults was in convincing them that a healthy diet was an attractive and attainable lifestyle. Other relevant factors were the subject’s emotional responses to the taste and appearance of food, time and effort required to prepare the food, choice and availability of food, and the perceived relationship between the food and their body image. Many affective-based interventions involve the principle of cognitive dissonance, which is an internal feeling of discomfort and unrest resulting from a discrepancy between two beliefs, or between a belief and a behavior. Leary, Tchividjian, and Kraxberger (1994) reported the success of interventions which induced students to develop positive feelings about healthy eating behaviors. When these feelings were juxtaposed with the subjects’ unhealthy behavior patterns, they often resolved the conflict by changing their behavior. Researchers have also found success in using a corollary of the cognitive dissonance concept: when the idea or attitude presented to a person is compatible with their existing beliefs, they are highly likely to adopt it. This was put into practice by Fulkerson, French, and Story (2004) who noted that adolescents seeking to lose weight had highly positive attitudes towards low-fat foods. The unsurprising result of a subsequent study was that dietary improvement interventions focusing on the increased consumption of low-fat foods were more successful than those highlighting other aspects of healthy eating behavior, such as eating more fruits and vegetables. Thirdly, some dietary interventions are based on the direct manipulation of behavior, rather than indirectly through increasing knowledge (cognitive) or altering emotions (affective). These interventions are usually derived from behavioral change theories such as B.F. Skinner’s operant conditioning (1938), where it is believed that the results of a person's behavior will increase or decrease the likelihood of that behavior occurring again in the future. Horne, Lowe, Bowdery, and Egerton (1998), for example, describe a particularly successful intervention where children who received rewards for eating fruits and vegetables demonstrated a marked and longlasting increase in consumption of these healthy foods. The intervention created for this study utilizes the strengths of the studies described in the literature review, and then attempts to improve on them in a crucial area. The strengths of the studies are in their faithful application of theoretical and experimental findings to the created interventions. Our intervention will do the same: it is based on elements and constructs from Social Cognitive Theory and the Health Beliefs Model. This act of using multiple theories as the basis for our intervention, though, is where it departs from most interventions attempted in the past: where interventions have historically relied on the manipulation of a single pathway (cognitive, affective, or behavioral), our intervention will address all three elements at once. This is possible because the aforementioned constructs and theories collectively encompass each of the affective, behavioral, and cognitive pathways to change. Towards this end, findings by Zanna and Rempel (1988) are encouraging as they show how addressing all of the pathways at once result in a synergistic effect that is powerful in changing a person’s overall attitude – and thus his/her habits – towards a practice such as healthy eating. Given this data, we expect that our intervention will be successful in creating or reinforcing a healthy eating lifestyle for the student participants. The main outcome variable of interest will be their actual dietary choices (the behavior pathway), but their nutritional knowledge (cognitive pathway) and attitudes towards healthy eating (affective pathway) will be measured as well. We expect that subjects receiving the intervention will show improvements in these areas which will be (statistically) significantly greater than anything seen in the control group. Furthermore, because of the comprehensive nature of the intervention in addressing all three pathways, changes in one are expected to be highly correlated with changes in the others. Methods Research Paradigm We will be using an online survey tool to investigate the effect of a video-based intervention on the healthiness of subjects’ dietary choices, as well as the extent of their nutritional knowledge and their attitudes towards healthy eating. Variables of Interest The independent variable is the healthy eating intervention. It will be administered to the experimental group and withheld from the control group. The dependent variables are students’ dietary choices, nutritional knowledge, and attitudes towards healthy eating. The healthy eating intervention is a series of short television programs which will include dramas, informational presentations, and instructional sessions. These three types of programming collectively incorporate principles and constructs from Bandura’s Social Cognitive Theory and the Health Beliefs Model (most recently modified by Becker and Janz) in providing programming designed to affect subjects along the affective, behavioral, and cognitive pathways. The affective component of the television programs is delivered mostly through fear appeals. Fear appeals are deliveries of information designed to make the subject worried or afraid as a result of imagining some sort of bad outcome. They are then highly motivated to change their behavior to avoid the undesired consequence. In this intervention, fear appeals are made chiefly in two ways: firstly, informational presentations are given which explain the health burden created by poor dietary habits as well as the economic, psychosocial, and other practical consequences of ill health. This strategy is also related to the Health Beliefs Model, which states that if a person believes that failing to perform a healthy behavior will lead to severe negative consequences, he/she will tend to change their behavior in an attempt to avoid this. Secondly, actors in the dramas who make poor dietary choices will be shown suffering negative consequences as a result. This part of the intervention was inspired by the vicarious experience construct of Social Cognitive Theory, which states that people can take on beliefs and adopt attitudes about the outcomes of certain behaviors if they observe other people experiencing them – they need not experience anything themselves. The behavioral component of the television programming is delivered through another facet of the Social Cognitive Theory: modeling. This construct states that when people observe others performing behaviors which result in positive outcomes, they will be motivated to imitate the behavior of the model and furthermore can use the model’s example to understand how the behavior is performed (this is vicarious learning). We will take advantage of this tendency with our intervention: actors in the dramas will be shown making positive choices and reaping the resultant rewards. Social Cognitive Theory also states that imitation of behavior is more likely to occur if the model is either of high status or perceived to be similar to the subjects. This important fact is carefully considered in the intervention: the actors will be fellow students or professors whom the students look up to as authoritative and wise. Lastly, the television programs will contain components aimed at affecting the cognitive pathway to behavior change. This is fairly straightforward: it will involve the visual and verbal transfer of information. The theoretical basis for this strategy is found in the Health Belief Model, which says that the benefits which a person perceives will result from a behavior and the perceived barriers to performing that behavior will affect the way in which the person in question actually behaves. Education and traditional knowledge transfer can be instrumental in these areas because a barrier to performing behavior is frequently a lack of knowledge of how it can be done – for example, how to cook a healthy meal or how to read nutritional labels. The perceived benefits for eating healthily can also be communicated through traditional knowledge transfer: the television programs will include information about how eating healthily can improve academic performance, increase alertness, save money, and so on. The first dependent variable, dietary choices, will be operationally defined as the subject's adherence to the healthy eating guidelines given in Nutrition Recommendations...A Call for Action, a summary report from the Canada's Department of National Health and Welfare which subsequently provided the basis for Canada's Guidelines for Healthy Eating. The report was the result of research into areas such as what the optimum percentage of caloric intake should be from fat, or what the required amount of Vitamin C should be in order to avoid deficiency. The recommendations given are based on these findings. Because these recommendations are evidence-based and essentially serve as national standards, they are suitable as operational definitions for the variable of dietary choice. This measure will be quantified by counting the number of guidelines which the subject shows adherence to. The second dependent variable is nutritional knowledge, which is important because it allows one's desire to eat healthily to be actualized. Parmenter and Wardle (1999) argue that a functional knowledge of nutrition can be divided into four main areas: basic knowledge of dietary recommendations, awareness of the nutrients provided by certain foods, ability to identify the overall healthiest food amongst an array of choices, and knowledge of the health implications of eating or failing to eat certain foods (Parmenter & Wardle, 1999). Thus, nutritional knowledge will be operationally defined as the score one receives on a test designed to evaluate knowledge in each of these areas. Content and face validity for the test are expected to be high because the cognitive component of the intervention intends to explicitly address these areas as well. The third dependent variable is attitude towards healthy eating. This variable encompasses the subjects' intentions and emotions towards many different aspects of healthy eating. The ones targeted for research, however, are those which have been shown to be related to health. A review of the literature reveals many different aspects of healthy eating attitudes which have been shown to be of significant consequence to overall health and actual dietary choices. These include the importance of staying current with nutritional science by reading books and magazines, opinion of the benefit of foods labeled "low fat" or "diet" (Ralph, Seamen, & Woods, 1996), the meaning and importance of healthy eating (Akamatsu, Maeda, Hagihara, & Shirakawa, 2005), willingness to pay more for healthier foods, and trusted sources of information on healthy eating (Lappalainena, Kearney, & Gibney, 1998). Thus the attitude towards healthy eating will be defined as the score which the subject receives on a test whose question items sample these categories. Participants In designing this study, the ethical implications of the participant recruitment technique, the intervention itself, and the data-gathering process were fully considered. For this study, in accordance with the rules laid out for research studies involving human participants, all guidelines laid out in the Tri-Council Policy Statement will be followed. The study will also be reviewed by the Office of Research Ethics and the Human Research Ethics Committee. Only after the study has passed ethical review will students be approached to participate by filling out the questionnaire described in the “Materials” section. Full confidentiality and anonymity will be assured during the questionnaires, and access to study results will be available to participants who are interested. Unfortunately, due to the design of the study, complete anonymity cannot be assured: although the questionnaire will be completed online and thus keep subjects unaware of the identities of other subjects, the researchers will have access to personal information. This is because the study requires the same participants to complete and return a total of three subsequent questionnaires, and so their student number and email address must be known to facilitate future contact and to match the three surveys together for each subject. Due to the non-invasive nature of our data-gathering methods, no conceivable harm is being done to the participants. The intervention is also very non-invasive: both the control group and the treatment group are not put at any elevated risk by receiving or not receiving the intervention. The control group will not experience the removal of materials beneficial to healthy eating habits; the natural layout and environment in the University of Waterloo Cafeteria will be maintained. On the other hand, the treatment group will not receive any sort of damaging materials which could affect healthy eating; instead an environment will be created in which students have the opportunity to become more aware of nutritional concepts and develop healthy eating habits. This study uses deception as part of its data-gathering methods – no participant will be informed that the healthy eating television programming is part of a study. Instead, the information sheet will merely state that its purpose is to look at the eating habits of university students. The rationale for this is our desire to avoid social psychological phenomena such as “control group behavior”, whereby a control group behaves differently because they are aware that they are being deprived of a treatment being received by the experimental group, thus invalidating the experiment. Also, we would like to avoid the tendency of participants responding to the questionnaire in a way that would please the experimenter. There will be an informational document provided upon the final questionnaire which will describe the study in full, including a confession to the deception and an explanation of why it was necessary. Unfortunately, the anticipated breadth of the study will preclude the experimenters from personally delivering this information and answering follow-up questions immediately, but the document will list contact information for the experimenters and encourage the subjects to write if they have any additional questions. Lastly, it will give instructions for accessing the study results when available. The sample group for this study will be composed entirely of first year students at the University of Waterloo who live in either Village 1 or Ron Eydt Village. Since the Department of Housing and Residences does not allot residence assignments to first year students on the basis of age, ethnicity, or program of study, each group will be randomized with respect to these variables and are therefore assumed to be representative of the overall population (first year university students). As well, the initial questionnaires will be administered to all people in the chosen residences. The chances of getting these returned from all the same ethnicities and programs will be low. To also ensure validity in this, several questions in the questionnaire such as: What is your ethnicity, how old are you, what program are you, what year are you in, will help when analyzing the data what other extraneous variables could have come into play to effect the random selectivity. All participants in this study will be volunteers, and it is acknowledged that those who volunteer are frequently well-educated, intelligent, and of higher social class. However, the reality of Canadian society today is that these traits are generally true of all university students. Thus it is doubtful that the characteristics of the participants will represent a significant departure from the characteristics of the population whom we wish to extrapolate their results to. As well, due to the confidentiality of this study, people will be unable to tell if their classmates have participate in it, and so there will not be any social pressure affecting the decision to complete the questionnaire . Materials The test will consist of 3 parts - one for each of the dependent variables. Other researchers have already developed and validated tests for evaluating each of the areas, so their work will be adopted and extended for the purposes of this research project. Firstly, subjects will be asked to complete a web-based food intake assessment developed and validated (face and content validity) by McCargar, Hanning, Jessup, and Lambraki (2003). The survey is designed to gather data about dietary habits which can be directly used in a nutrition analysis program such as ESHA Research's Food Processor SQL. This program will be used to analyze variables such as caloric distribution, total calories consumed, and sodium content and can thus provide an indication of the extent to which the diet complies with the Nutrition Recommendations for Canadians (Health Canada, 2004), which has been used as the operational definition for dietary habits, as discussed in the previous section. Since the survey by McCargar et al. (2004) relies partially on a 24-hour recall of food eaten, a single administration of it does not allow for unrepresentative data - for example, a subject whose 24-hour recall reveals excessively high alcohol intake only because he was attending a birthday party. As well, it is recognized that self-report measures suffer from unreliability due to participants' forgetfulness. To rectify these concerns, the Iowa State University Foods method will be applied to the results. It is a statistical method which accounts for the limitations and inaccuracies of single 24-hour recalls better than multiple administrations of the test can (Dodd, Guenther, Freedman, Subar, Kipnis, & Midthune, et. al, 2006). Secondly, subjects will be asked to complete an academic-type quiz to assess their level of nutritional knowledge. Question items will be taken from the questionnaire developed by Parmenter and Wardle (1999), and will be unique from pre-test to post-test so that testing effects are unable to limit internal validity. The questionnaire has been extensively tested for content validity and ability to evaluate its four main areas of focus: basic knowledge of dietary recommendations, awareness of the nutrients provided by certain foods, ability to identify the overall healthiest food amongst an array of choices, and knowledge of the health implications of eating or failing to eat certain foods (Parmenter & Wardle, 1999). Subjects will be explicitly requested to not consult any resources while performing the test, so that their score is an accurate indicator of what their own level of knowledge is. To this end, they will be told that the test scores will not be used for any form of evaluation, but simply rather as research data. [Not sure if the following section should be in the "Variables" section, but we'll put it here for now] Thirdly, the test will evaluate the subjects' attitudes towards the most relevant issues surrounding healthy eating. A review of the literature reveals many different aspects of healthy eating attitudes which have been shown to be of significant consequence to overall health and actual dietary choices. These include the importance of staying current with nutritional science by reading books and magazines, opinion of the benefit of foods labeled "low fat" or "diet" (Ralph, Seamen, & Woods, 1996), the meaning and importance of healthy eating (Akamatsu, Maeda, Hagihara, & Shirakawa, 2005), willingness to pay more for healthier foods, and trusted sources of information on healthy eating (Lappalainena, Kearney, & Gibney, 1998). A list of sample questions for evaluating these items is provided in the appendix of this report. It is recognized that subject characteristics such as socioeconomic, demographic, and lifestyle factors affect each of the dependent variables (Deshmukh-Taskar, Nicklas, Yang, & Berenson, 2007). Although the experimental design will significantly limit the extent to which these factors can confound the results, the survey will also include basic questions to assess these categories so that any variability explained by them can be ascertained. The issues which these queries will specifically address include physical activity level, ethnicity, and gender, which have been found by Deshmukh et al. to make significant differences. Procedure This is a longitudinal study that takes place over a span of 3 years. The procedure is adapted from a between subject, randomized multi-group pretest and posttest control group design. It will follow two groups of students throughout the entire study: the distribution of the students into groups will occur through the random allocation procedure employed by the Department of Housing and Residences. Questionnaires will be deployed before and after the intervention to test treatment effects and to maintain internal validity. As well, a final third questionnaire will be given after three years to assess the long term effects of the intervention. At the beginning of the study, the first questionnaire will be administered, along with an information sheet describing the purpose of the study and its longitudinal nature. Implementation of the first questionnaire will prior to the beginning of the year during the residence application process, after their acceptance to the university has been confirmed. This first data set will hold initial information for each of the participants and provide a benchmark to compare later results against. The same questionnaire will be given to both sets of students, but only one cafeteria will contain the intervention (Ron Eydt Village) - the other (Village 1) will continue as normal. This arrangement was chosen because of the spatial relationship between the cafeterias: since Village 1 is located between Ron Eydt Village and the main campus, students from Ron Eydt passing through Village 1 would be exposed to, and affected by, the environment of their cafeteria. Conversely, Village 1 students would rarely have reason to venture to Ron Eydt Village (exceptions to this behavior will be grounds for exclusion, as explained in the “Hypothesized Results” section). Given this, it is logical to place the control group in Village 1. Instead of administering the questionnaire by paper, it will be given online, in a similar format to many of the other questionnaires needed to be filled out prior to first year. This decision was made because it will expedite the data collaboration process and be more convenient for the students: the questionnaire can be finished whenever they have time, and does not require them to hand it in or mail it anywhere. External studies provide assurance that an internet survey will produce results similar to those with more traditional approaches. The questionnaire will be available on UW-ACE at the beginning of July before entering University, and end at the end of September. Like any other questionnaire, a paragraph will be provided to instruct those who choose to participate what our study is about (briefly) as well as a short informed consent section to ensure confidentiality. Though this questionnaire will be identical to the questionnaires being handed out after the intervention, an extra question added to this first questionnaire would be which stream the student falls under. As stated on the housing website of University Waterloo (http://www.housing.uwaterloo.ca/residences/allocation_details.html), students who live in Village 1 or Ron Eydt Village are those who fall into an 8 –stream style of study. This does not exclude any topic of study, but it does limit those who are able to fill out the survey. Thus, we have included this question in the first questionnaire which asks which stream they fall under. This will help experimenters leave out those in 4 stream who may not experience the full 8months of intervention and therefore potentially skewing the results. After the first questionnaire has been administered, the intervention will begin. As stated earlier, those at Village 1 will carry on with regular cafeteria food, whereas Ron Eydt Village cafeteria will implement our intervention. This entails showing the television programming (described in the “Variables” section) in the Ron Eydt Village Cafeteria during meal times on multiple screens placed around the cafeteria and dining area. These locations will include the area where food is purchased – it is expected that students waiting in line with nothing else to do will watch the screens with high attentiveness. Also, in the main dining area, the majority of the tables and chairs in the cafeteria will be oriented towards a screen in an effort to promote increased interest and viewership. Lastly, because of the varying times that students eat, the program will commence at 7am when the cafeteria opens and will repeat throughout the day until 7pm when the cafeteria closes. After their first year is complete the intervention will end, and a second questionnaire will be administered prior to leaving residence. Once again, the questionnaire will be posted on UW ACE at the beginning of exams in April, and will end at the end of August. This time frame will accommodate students who choose to answer immediately after or during exams, as well as those who may fail to see the questionnaire until they register their courses for the next term. However, this second survey will be sent out to fewer people: only those who completed the first survey will have access to it. As stated earlier, these people will be identified through the use of their student ID and email address. Although the question items will remain the same (with an important exception, see “Materials”), an extra question will be included in this survey to assess the cafeteria in which the subject ate the most. This question will help experimenters to be aware of whether students in the experimental group were in fact exposed to the treatment, and whether control group participants did not experience the treatment to any significant degree. Lastly, as with the first questionnaire, a brief paragraph will be included to remind students of the study they are involved in, and that one last questionnaire would be given in three years’ time. After the second questionnaire closes, analysis of the short term intervention effects will be possible. The final step in this study will be to administer one last follow-up questionnaire to test the long term effects of our intervention. Once again, the list of participants is becomes narrower, because this list is based on the number of people who filled out the prior questionnaires. Questionnaires will go on UW-ACE in August of their third year; one year after the second survey is closed. It will stay online until December of the same year. This time period allows for all regular and co-op streams to see it on their UW-ACE. Like the first two questionnaires, a summary paragraph will be included with this questionnaire. Since deception is used, this paragraph will include debriefing information, including why deception was used, and how to access study results if they are interested. After the closing questionnaires in December the final statistical analysis will be run for the study to see the long term effects of an intervention like this. Hypothesized Results [insert here] References Zanna, M.P., & Rempel, J.K. (1988). Attitudes: A new look at an old concept. In D. Bar-Tal & A. Kruglanski (Eds.), The Social Psychology of Knowledge (pp. 315-334). New York: Cambridge University Press. http://www.emeraldinsight.com/Insight/viewContentItem.do?contentType=Article&hdAction=ln khtml&contentId=870423 Skinner, B.F. (1938). The Behavior of Organisms. Englewood Cliffs, NJ: Appleton-CenturyCrofts.Appendix Notes Make sure that I do the “definitions” in the Intro… So I’ll write up the literature review as if the interventions only focused on one of three things, and then say how ours is better because it combines multiple elements Does Katy link her ideas to the models she discusses? I may want to include Jacqueline’s stuff about what has been done at UW for nutrition – but would that just make our own intervention seem cheaper by comparison? Should probably also mention how the dependent variables will be measured Especially the first and third… Since I am making up the third one myself, should I talk about reliability/validity? Do I want to make sample questions for DV #3? Get Jacqueline/Katy to find references for the description of the intervention [Should also talk about how I plan to ensure that the test is reliable...] Test/retest? Parallel form? Split-half? We'll do split-half...meaning that the questions will be designed such that some of them have very high correlations with each other because they are asking about the same thing -- so if we don't see that correlation, we are in trouble... "The desire to cast one's attitudes in a better light is recognized, and will be addressed by..." the Marlowe-Crowne Social Desirability Scale, which provides an indication of the extent to which an individual has a need for approval and would thus alter his responses on questions such those presented in Section 3. How about validity for this part? Questions for Desmarais How detailed do we have to describe the other studies in the literature review? Is it OK to just organize the “Methods” section using headings?