Implementation of an Educational Program to Improve Knowledge and Attitudes of Healthier Eating Practices and Benefits of Physical Activity among Residents of Smith Island,Maryland

Abstract

Obesity rates in the United States have drastically increased over the past 20 years. According to the Center for Disease Control and Prevention, the obesity rate for adults has nearly doubled since 1990, reaching as high as 32.2% among adult men and 35.5% among adult women. One rural community, Smith Island, Maryland, has special challenges in obtaining a healthy lifestyle due to their insolated environment. Although there have been small measures to reduce obesity on Smith Island, the need for further education is essential. The purpose of this program evaluation was to determine if a culturally sensitive educational program increases the knowledge of healthy eating practices and benefits of physical activity among residents of Smith Island. A convenience sample of 25 residents living on Smith Island was used. Residents were recruited to participate in an educational program that focused on healthier eating and benefits of physical activity. Overall, participants scored higher on the posttest compared to the pretest (t=−6.28, p<0.001). Additionally, the participants felt more confident in making changes in food choices (t=−4.64, p<0.001) and making nutritious meals for their families (t=−4.54, p<0.001). There was an increase in knowledge of healthy eating practices and benefits of physical activity in a rural community through the use of culturally sensitive educational tools. This demonstrates the need for culturally appropriate educational tools that focus on improving healthier eating habits and benefits of physical activity as a plausible strategy to reduce risk for obesity.

Introduction

The prevalence of obesity rates has increased drastically over the last 20 years in the United States with the average adult body mass index (BMI) reaching as high as 28.¹ According to the Center for Disease Control and Prevention, the obesity rate for adults has nearly doubled since 1990, reaching 32.2% among adult men and 35.3% among adult women.² Given this, obesity continues to be a public health concern in the United States and throughout the world.

Interestingly, obesity was once considered to be prevalent in only urban and suburban settings; however, it has now become a concern in rural areas as well.³ Research has demonstrated that rural communities are at higher risk for obesity due to the environment in which they live above and beyond the individual characteristics of the population living in that environment.^1,4 These environments, commonly referred to as obesogenic environments, are areas that promote overweight and obesity on a population level by offering community attributes such as physical inactivity and unhealthy food choices.^5,6

Contribution of Demographics

Interestingly, one of the factors related to the increase in obesity in rural areas may include four specific demographic features. First, older individuals tend to have higher obesity rates, and the population in rural America is older than in the rest of the country.⁴ Generally speaking, as people age, they tend to engage in less physical activity, reducing the number of calories needed. However, in many populations, there is a reduction in physical activity without a reduction in caloric intake, which increases the population's risk of being overweight and/or obese.⁷ This is especially common in rural areas, where the age of the population is increasing.⁸ Second, research has demonstrated that people with lower levels of education consume more calories compared to educated individuals, and again, people in rural populations tend to fall into this category.¹ More specifically, individuals with lower levels of education typically have less exposure or ability to comprehend dietary, nutritional, and health information. The prevalence of obesity among adults at all levels of education is increasing, but is more dramatic in people with lower levels of education. For example, the prevalence of obesity increased from 15.3% to 23.4% in college graduates, but increased from 31.7% to 42.1% in those with less than a high school diploma.⁹ Further research has demonstrated that a solid knowledge base necessary to provide good nutrition and importance of physical activity are limited in rural areas. Most are not educated about the importance of proper nutrition, correct portion size, and daily fat intake, which can lead to poor food choices.

Third, research posited that low-income individuals are significantly more likely to be overweight or obese than those individuals with higher incomes levels.¹⁰ Healthy, lean foods like fruits, vegetables, and fish are much more expensive than foods high in fat and calories, such as prepared foods, starches, and “junk food.” Thus lower-income populations are more likely to purchase processed foods, high-calorie foods, or “junk foods” due to the cost limitation of fresh and “healthy” foods. Lastly, one of the contributing factors to the nutritional challenges faced by those living in rural areas is the remote location and limited growing season, which impacts the availability of fresh food and healthy choices. In conclusion, it is important to understand that isolated rural communities have unique demographic characteristics that may promote the prevalence of overweight and obesity in their communities.

Contribution of the Environment, Lifestyle, and Culture

Traditionally, rural areas have experienced a lower incidence of overweight and obesity due to the increased physical demands that are characteristic of an agrarian lifestyle.^6,11 However, this is no longer the case, and as a result, rural residents are experiencing an increased prevalence of obesity and overweight compared to their urban counterparts.¹ Public health research has indicated that modification of the underlying environment influences may be necessary to affect population-level changes in health behaviors. In other words, there is an important association between the physical neighborhood environment and obesity, the majority of which is related to physical activity behavior.⁴

An example would be a neighborhood environment that is more “activity friendly” may result in higher levels of physical activity and reduced prevalence of obesity on a population level.^12,13 Americans who live in Appalachia are the least likely to be physically active in their leisure time compared to their counterparts in urban areas. Similarly, more than 29% of all adults living in rural areas reported getting no physical activity other than at their regular job.¹⁴ Thus those living in an urban area with sidewalks, walking trails, paved roads, and parks are more likely to engage in physical activities compared to communities without these amenities.

The contribution of lifestyle and cultural attributes to overweight and obesity are well documented in the literature. It is believed that one's culture and beliefs about obesity are related to one's control over obesity.¹⁴ The authors proposed that the more controllable people believe their obesity to be, the more they will take responsibility for their weight. Thus in an insulated community where individuals feel that they do not have the resources to control their obesity, being overweight or obese may become part of their normal lifestyle and culture.¹⁵

The People of Smith Island, Maryland

Smith Island is located in Somerset County, Maryland. Situated in the middle of the Chesapeake Bay, it is Maryland's only inhabited offshore island. It is accessible only by private boat or ferry. Smith Island is one of the poorest of Maryland's Eastern Shore counties.¹⁶ The majority of residents are watermen, and their families are considered to be low-income earners, with the median family household income being $35,553 (Smith Island) and $34,003 (Somerset County) compared to the median household income of $67,989 for the state of Maryland.^16,17 Additionally, Somerset County has a 23% poverty level, whereas the state of Maryland has an 8.3% poverty level.^16,18

The Smith Island residents are divided between three separate communities: Ewell, Rhodes Point, and Tylerton. Tylerton is separated from the other two communities by water. The other two communities are connected to each other by a 1 mile gravel road. All three communities are partially independent from each other, having their own church and cemetery, but sharing two post offices and a general store.

The total population of Smith Island includes 364 people (178 males and 186 females). The median age is 50.5 years, with the majority of population being Caucasian. Education level is described as 35% achieving less than a 9th grade education, 20% completing some high school, and 29.7% completing high school. Eight percent of the population has some college education but no degree.¹⁶

Most islanders are relatively inactive with little physical activity or exercise.¹⁹ They spend their leisure time watching television while snacking on high-calorie and/or high-fat foods.²⁰ Compounding this, there are no formal sport activities or extracurricular sporting events. The community does not have a gym or park to provide a place to exercise, walk, or jog. Further, the isolation of the island creates a barrier for access to formal exercise programs or facilities that encourage exercise. Studies have shown that people who live in neighborhoods with a high degree of walk ability walk more, have a lower mean body mass, and lower rates of overweight compared to those that live in less walkable neighborhoods such as Smith Island.²¹ Electric golf carts are used primarily for transportation due to the limited infrastructure and gravel roads. A few vehicles exist on Ewell and Rhodes Point; however, Tylerton does not allow vehicles except for their lone ambulance and fire truck.

Fresh vegetables and fruit are a limited staple in many homes, as there is only one convenience store on the island. In order to obtain fresh fruit and vegetables, the residents have to travel by boat to the mainland and obtain them from the grocery store. This limits the variety of this food group into their diet and may be a barrier for a well-balanced diet. Most residents rely on convenience of boxed and canned foods, which often are low in nutritional value and higher in fat. Additionally, cost is a concern in their food choices. Given their low income level, many residents of Smith Island are not able to afford a healthy diet.²²

Social networks, which are generally regarded as a positive aspect, may reinforce the unhealthy eating and sedentary behaviors of this community. Blankenua hypothesized that there is a relationship between obesity and social networks.²³ It predicts that if a person becomes obese, there is likelihood that a friend of theirs will also become obese. Thus, given the close-knit nature of this community, being overweight and/or obese may have simply become a “way of life.”

In order to reduce overweight and/or obesity in a rural community, a dual strategy of a healthful diet and increased physical activity is required.²⁴ However, rural communities are sufficiently different from urban and suburban communities and require special considerations for assessing and enhancing the relationship between the physical environment and active living.¹³

In such a small, isolated rural community as Smith Island, these residents demand support and encouragement, and maintain a sense of fun, enthusiasm, and no pressure.^25,26 Programs should be based on fostering community spirit and should enable everyone to pull together for a common goal, creating a sense of achievement for the entire community.²⁷ It is essential to develop preventive health strategies that would affect the community and society as a whole by developing a healthy lifestyle, combining balanced nutrition with low energy intake and increased physical activity.²⁸

Despite the documented benefits of weight management, people with low incomes and low levels of education who live in rural areas are less likely to engage in these benefits compared to individuals with higher socioeconomic status and higher levels of education.⁸ Given this, Smith Island, Maryland, may be considered an obesogenic environment. Thus the purpose of this program was to determine if a cultural sensitive educational program increases the knowledge of healthy eating practices and benefits of physical activity among residents of Smith Island.

Program Description

The program given was based on a modified version of the Dietary Guidelines for Adult Americans in order to meet the specific needs of this culturally unique population.²⁹ These modifications were sensitive to this population and the activities were designed to provide practical examples. These educational interventions could relate how diet and exercise might offer benefits in establishing improved eating habits with modifying cultural favorite items.³⁰ Table 1 illustrates instructional strategies designed to incorporate cultural considerations for this population.

Table 1.

Educational Program Cultural Considerations

Current program	Culture considerations	Adjustment for cultural consideration
Basic food group	Describe foods consumed from each food group by the participants	Identify foods normally eaten and incorporate cultural food choices from each food group
Clarify available foods from each food group	Limitation to fresh fruits and vegetables	Serve frozen fruit/veg instead of canned or fresh
Categorize health benefits of each food group	Discuss how foods currently are eaten and what risks are increased with those foods	Explain and give examples of each food group and what health benefits provided to reduce health risks
Review recommended serving size	Consider what is usual “serving size”	Show the difference of “normal” serving size and how “usual” serving size may be different
Review items on food labels	Discuss what foods are “normally” eaten	Describe how certain foods can be healthier by reading the food labels (low sodium)
Review how to choose food from reading labels	Many foods do not have labels because made from scratch	Review ingredients of recipes and how to make healthier (decrease sugar or fat)

Methods

Procedures

Following approval by the University of Maryland Institutional Review Board (IRB), subjects were recruited from Smith Island, Maryland, to participate in the program. Flyers were placed in prominent areas such as the post office, island stores, and the church bulletin. Inclusion criteria for program participation require participants be residents of Smith Island, Maryland, and aged 20 or older. The educational program was held in the Smith Island Community Center, which is a neutral and geographically convenient site for participants. Upon arrival at the site, potential participants were provided with a full verbal explanation of the purpose and intent of the program, as well as a copy of the informed consent by the researcher. Participants were asked to review the informed consent and were given ample opportunity to ask questions about the study. Following informed consent, each participant was assigned a program number and was asked to complete the pretest.

Following the completion of the pretest, the formal education program on healthy eating habits and benefits of physical activity began. Table 2 provides an example of the content taught during the program. The class was conducted by a nurse practitioner and given on a day most suitable to the participants. The program given was based on a modified version of the Dietary Guidelines for Adult Americans in order to meet the specific needs of this culturally unique population.¹⁰ These activities were designed to provide practical examples of how changes could have benefits in establishing more healthy eating habits with modifying cultural favorite items.³⁰

Table 2.

Example of Program Content

Lesson title	Objective	Lecture content	Activity	Outside activity
Food guide pyramid	1. Describe food guide pyramid 2. Clarify different food groups 3. Give examples from each food group 4. Explain health benefits of each food group	1. Definitions/examples for each food group 2. Discussion of daily recommendations for each food group	Interactive: identify food items and accurately categorize them by food group	Daily nutrition log
Serving size	1. Identify the recommended serving sizes 2. Identify serving sizes/servings per container of common foods 3. Demonstrate portion size with serving size	1. Define serving size 2. Discuss difference between portion and serving size	1. Have participants pour out typical amount they consume 2. Measure what they have poured out and compare to actual serving size	Daily nutritional log
Food labels	1. Explain how to read food labels. 2. Identify serving sizes, servings per containers, calories, fat, carbohydrates, protein, vitamins, and minerals	1. Discuss importance of reading food labels and how they can help make choices	Participants bring in five food products with half healthy alternatives and half less healthy and compare the differences	Daily nutrition log and bring in food labels
Carbs and sugar	1. Identify the components of carbohydrates listed on food label—dietary fiber and sugar 2. Describe health risks of consuming a high-calorie, high-sugar diet	1. Discuss carbohydrate content in common foods	Participants pour a 2-liter bottle of soda into a glass of how much they usually drink and calculate the amount of sugar in each poured serving.	Daily nutritional log
Hunger and satiety gap	1. Explain the difference between hunger and satiety 2. Identify ways to curb hunger and prevent overeating at meals	1. Discuss ways to control second helpings especially over the holidays	Participants practice eating slowly without distractions	Daily nutritional logs

After the conclusion of the program, the participants were asked to complete the posttest. The posttest contained the same 20-question test administered prior to implementation of the program, with the exclusion of the demographic questions. Participants had 30 minutes to complete the posttest, after which the formal educational session was concluded and the participants were dismissed. The participants were not directly paid for their participation, but there were light refreshments (e.g., bottled water, vegetables, and fruit) available during the program.

Validation of the program and test instrument

A test blueprint was used in order to validate the overall content validity of the program. The questions from the pretest/posttest were assigned according to content and objectives of the program. The test blueprint objectives are located in the left-hand column, and topics from the program selected are located across the top row. Table 3 illustrates the test blueprint to validate content of the program. The blueprint helps ensure that the developer obtains the desired coverage of topics and level of objectives. The content areas listed in the test blueprint are frequently drawn directly from the results of a test analysis. These content areas comprise the knowledge, skills, and abilities that have been determined to be the essential elements of competency for the project. In addition to the listing of content areas, the test blueprint specifies the number or proportion of items that are planned to be included on each test form for each content area. These proportions reflect the relative importance of each content area to competency.

Table 3.

Educational Program on Healthier Eating Practices and Physical Activity Test Blueprint

Content	Attitude	Food groups	Serving size	Labels	Physical activity	Health risks	Total
Learning objectives
Recognize the most nutritious foods and effective physical activity for weight management	1 Q# 1	1,1,1,1,1,1, Q# 4,5,6,7,8,9		1Q# 16	1Q# 15	1Q# 13	10
Describe a healthy diet of fruit, vegetables, whole grains, dairy, protein, and fats			1,1,1Q# 10, 11, 12		1Q# 17		4
Create a nutritious meal plan for themselves and their families		1,1Q# 3, 20					2
Identify the amount of physical activity to promote a healthy weight	1Q# 2				1Q# 14		2
Create an exercise program to meet the adult guidelines					1,1Q# 18, 19		2
							T=20

Q#, see corresponding question in Table 4.

Most test blueprints also indicate the levels of cognitive processing that the examinees will be expected to use in responding to specific items such as knowledge and application.³¹ It is critical that the test blueprint and test items include a substantial proportion of items targeted above the knowledge-level of cognition. A typical test blueprint is presented in a two-way matrix with the content areas listed in the table rows and the cognitive processes in the table columns. The total number of items specified for each column indicates the proportional plan for each cognitive level on the overall test, just as the total number of items for each row indicates the proportional emphasis of each content area.³¹ The test blueprint was used to guide the educational pretest and posttest. Use of a test blueprint helps ensure that the goals and plans for the test are met.

The Flesh-Kincaid Grade Level Readability Formula, which is built into the Microsoft Word software, was used to calculate the reading level of both the pretest/posttest questions and the educational program material. The grade level for the pretest and posttest questions was 4.5, and the grade level for the educational program material was 3.5. It was important to this program that the participants were able to understand and read the information provided because they were required to read the booklet that was given to them.

Program Evaluation

The formal educational program focused on healthy eating habits and benefits of physical activity. The average age of the participants was 61.4 (SD=13.65) years of age. Sixty-five percent of the sample was female (n=17), with 35% being male 3% (n=8). All of the participants were Caucasian (100%), and the average number of years of education was 10.8 years (SD=1.8).

The average score on the pretest was 11 out of 17, and the average score on the posttest was 14 out of 17. The remaining three questions asked the participants how confident they were in making changes in choices, making changes in activity, and making meals for their families. Participants scored higher (number of questions answered correctly on the test) on the posttest compared to the pretest (t=−6.28, p<0.001), indicating increased knowledge of healthy eating habits and the benefit of physical activity.

In analyzing individual questions, there were significant differences in pre- and posttest mean scores. Participants had higher mean scores posttest on the following test items: eating in moderation (t=−5.09, p<0.001); balance of daily calorie sources (t=−3.77, p<0.01); fat content (t=−2.82, p<0.01); canola oil (t=−2.29, p<0.05); dairy products (t=−2.58, p<0.05); vegetable groups (t=−1.44, p>0.05); lean meat (t=−2.87, p<0.01); starches (t=−3.46, p<0.05); exercise (t=−2.13, p<0.05); improved health (t=−2.44, p<0.01); and use of canned peaches in lieu of fresh fruit (t=−3.98, p<0.001), demonstrating increased knowledge with this content. Additionally, the participants felt more confident in making changes in their food choices (t=−4.64, p<0.001) and making a nutritious meal for their families (t=−4.54, p<0.001) after the intervention. There was not a significant increase in knowledge from questions addressing the food pyramid (t=−1.35, p>0.05) and questions regarding physical activity (t=−1.55, p>0.05) following the intervention. Table 4 represents the list of questions given to the participants.

Table 4.

Pretest/Posttest

Question 1–3	Not at all	Somewhat	Definitely
1. How confident are you in making changes in your food choices?	__________	__________	__________
2. How confident are you making changes in your activity level?	__________	__________	__________
3. How confident are you making a nutritious meal for your family from the food pyramid	__________	__________	__________

Question 4–20	True	False
4. The food pyramid suggests that we eat a varied diet.	__________	__________
5. The principle of eating in moderation means that you should eat a moderate number of different foods.	__________	__________
6. For the average person, the ideal balance of daily calorie sources are 30% or less of calories from fat and 55–60% from carbohydrates.	__________	__________
7. Most of the fats you eat should be polyunsaturated and monounsaturated fats.	__________	__________
8. Canola oil is an unhealthy saturated fat.	__________	__________
9. Foods containing a high proportion of saturated fat include dairy products.	__________	__________
10. Two slices of bread are a correct serving size from the bread, cereal, rice, and pasta groups.	__________	__________
11. A correct serving size from the vegetable group would be half a cup of broccoli.	__________	__________
12. 4–5 ounces of cooked lean meat, poultry, or fish equals one serving from meat, poultry, fish, dry beans, eggs, and nut group.	__________	__________
13. Too much sodium in food choices has been linked to high blood pressure.	__________	__________
14. Eating unhealthily and a lack of physical activity increases your risk for being overweight or obese.	__________	__________
15. According to the dietary guideline, it is recommended that adults be physically active two times per week.	__________	__________
16. The serving size on the Food Guide Pyramid and on the food label is the same.	__________	__________
17. Yams, potatoes, and corn are considered vegetables but they are high in starch and should not be used in your dietary plan.	__________	__________
18. Walking or gardening is an example of physical activity.	__________	__________
19. Increasing physical activity at any age can improved health benefits.	__________	__________
20. Canned peaches packed in juice are an alternative healthy choice from the fruit group for a dessert choice in a menu for snack.	__________	__________

Discussion

This program illustrates the effectiveness of an educational intervention in increasing knowledge of nutrition and benefits of healthier eating habits among a specific population. On completion of this program, participants' knowledge had increased, as demonstrated by a significant statistical difference between pretest and posttest scores. The most significant difference related to food and how healthy alternatives can impact good nutrition and improvement of health. More importantly, this program provided much needed insight into how culture and attitudes influences a population's decision making for food choices. As demonstrated, food has been the foundation and an integral part of the Smith Island culture. With this strong foundation of eating in a particular way, participants were therefore required to approach healthy eating and physical activity as a new way of thinking within their family.

Additionally, the project demonstrated the participants' confidence levels in making changes in food choices, along with incorporating these changes for their family, had significantly increased. It is important for the participants to feel they have the ability and confidence to make these changes from the knowledge they have gained during this educational program. With this new-found confidence and information, they can then develop their own plan and incorporate their cultural values along with their family needs.

The program also revealed that the questions on physical activity were not significant. This may have been related to a lack of demonstration and amount of time spent on that particular component within the program. Since many of the participants were older, they may have responded to more interaction than the primarily lecture-type format. The class about nutrition used many visual aids. Many examples and demonstrations were used to help facilitate learning. There were less demonstrations and visual support for the physical activity session. In future programs, more demonstrations and interaction will be included, which may increase the significance in the area of physical activity. Age may also be a factor affecting physical activity and how participants perceive the benefits of increased activity.

This strategic effort does promote awareness to reduce risks of overweight and obesity and promote change in this population. The program educated the residents of Smith Island on healthier eating practices and increased physical activity. The program did not concentrate on physical activity as much as the nutritional component. They were given the skills needed to facilitate behavior change by understanding the risks resulting from their actions. Through the pretest/posttest method, it measured if the program accomplished its goals and was effective by eliciting increased knowledge.

Future Recommendations

Evidence shows that prevention is potentially more efficient than treatment alone in reducing obesity and should be addressed with priority by the public health experts, academics, clinicians, and politicians.²⁷ It is important to have positive changes in healthier eating choices and physical activity, which could contribute to preventing the problem of overweight and obesity. By providing an educational program, this increases knowledge on healthy eating and benefits of exercise and why it could reduce obesity rates. Many of the participants may not have the skills or knowledge to make healthy choices. The program evaluation found if the participants were given tools and information on how to identify what is in each food group, the importance of reading labels, how to recognize a proper serving size, the benefits associated with increased physical activity, and risk associated with being overweight or obese, they could be taught what impact this has on their overall health and well-being. They are given strategies on how to make better choices and identify why certain choices impact their future health risks.

The strategy of an educational program is to create an environment conducive to obesity prevention by fostering healthier dietary habits, decreasing sedentary behaviors, and increasing physical activity among everyone to combat the obesity rate and detection of obesity risks. If a vulnerable population is given the opportunity, it impacts the community, the county, the state, and ultimately the country as a whole. This provides future opportunities for research and encourages following dietary and exercising recommendations to reduce obesity rates in these types of rural environments.

Limitations

The limitations to this program include the small group size and the specialized population. However, it is still possible to translate the information gained from this group and the results with several of the educational recommendations from the review of literature to develop a program that meets the needs of similar populations. On a larger level, the issue that seems to have the most impact on health risks associated with obesity, lack of knowledge, and opportunity is availability and access. The inability to be given the opportunity to receive this educational information needs to be addressed on a local, county, and state level. If all of the stakeholders involved created a plan to include rural areas and provide an opportunity, this would reduce barriers and would impact successfully the overall health and well-being of this vulnerable population. This would be the first step to facilitate change.

Conclusion

Assessing the needs of the population and creating a positive environment for knowledge and understanding of the effects of obesity will increase the probability of behavior change. By creating a better understanding of an improved diet and exercise plan, this could improve the future foundation and reduce obesity. Thus providing a program that explains the complexity and risks of obesity is essential.

An appropriate program in this circumstance is to individualize the educational program to provide a plan for a certain population; an educational program such as nutrition and physical activity based upon the assessed needs and cultural uniqueness of the population. It is equally important to discuss how to reduce those risks by creating positive changes in each individual's behavior from the new knowledge gained from the program. The program results suggest that the increased knowledge from this program will help participants identify healthier choices and promote healthier lifestyles. If the participants develop healthier lifestyles, this may reduce health risks associated with overweight and obesity.

Footnotes

Acknowledgments

The authors would like to thank the residents of Smith Island, Maryland, who were willing to participate in this study. Without them, this publication would not have been possible. We would also like to thank Carol O'Neil, PhD, RN, CNE, and Bridgitte Gourley, DNP, CRNP, for their support and mentorship during this project.

Disclosure Statement

No competing financial interests exist.

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