Australian tertiary students’ attitudes towards youth obesity in educational institutions

Abstract

Educational institutions have been identified as ideal locations to implement health promotion strategies that aim to prevent and treat youth obesity. However, the tertiary training of future health promoters currently lacks health and nutrition instruction. This study sought to investigate attitudes towards youth obesity and perceptions of the roles of schools and educators in strategies to treat and prevent youth obesity. Participants (n = 155) were tertiary students who enrolled in a general-level health and nutrition elective that housed an intervention to increase awareness of obesity. Baseline and post-intervention responses to the Perceptions of Youth Obesity and Health Education questionnaire were collected and compared spanning the 12 weeks. Agreement that health is linked to being of normal weight and that general educators should have a major role in school strategies did not waver over the course of the intervention. The belief that schools are ideal places for obesity prevention strategies was higher at baseline than post-intervention. It was desired that obesity awareness would increase but perceived importance of involvement of school staff in youth obesity strategies did not increase. Further research is required to investigate the influence of attitudes and perceptions held by future health promoters towards their roles in prevention and treatment strategies on professional practice.

Keywords

Obesity prevention health professionals health and physical educators interventions higher education

Background literature

The World Health Organization sums up the importance of chronic diseases such as overweight and obesity through the reporting of global rates of prevalence, identifying them as largely preventable public health issues. According to the World Health Organization, global statistics show that 1.4 billion people aged 20 years or more are classified as overweight, with 500 million of these individuals classified further as obese (World Health Organization, 2014). In the population aged five years or younger, 40 million individuals are classified as overweight, with excess adiposity appropriate for their height, weight, age and gender (World Health Organization, 2011). Mimicking these figures is the Australian prevalence of adult and youth overweight and obesity, where two thirds of the adult population and a quarter of the population aged between two and 17 years old have been classified as overweight or obese (Australian Institute of Health and Welfare, 2014).

With prevalence at epidemic status in countries such as Australia and the US (World Health Organization, 2000), extensive research has been conducted on the success of health promotion strategies aimed at preventing or treating overweight and obesity. Of specific interest to this study are strategies employed to prevent and treat youth obesity in schools. Educational institutions spanning primary and secondary education are often chosen as ideal settings to conduct interventions aimed at reducing the prevalence of youth obesity (Trost, 2006). Strategies employed in these settings have had mixed or limited success (Vander Schee and Gard, 2013) due to varying issues with resources, educators’ knowledge or attitudes and methodological shortcomings. Higher rates of success in youth obesity intervention strategies have involved targeting participants during their formative childhood years rather than once they have reached adulthood (Stern et al., 1995).

Just as important as the setting chosen to conduct public health strategies are the people who are responsible for executing the interventions. Influential to the success of public health promotion interventions are the health promoters’ preparedness to fulfil their roles, the adequacy and accuracy of knowledge they possess to conduct the intervention and the methodology they employ. School educators who conduct health-based interventions in schools such as those aimed at overweight and obesity are often perceived as agents of health promotion. However, their competence to fulfil this role and level of training required to do so is subject to external and intra-professional scrutiny along with their appropriateness for this role (Fahlman et al., 2011). Of all educators, those most likely to be attributed with the task of being health promoters in Australian schools and be personally accountable for enacting prevention strategies against youth obesity are health and physical educators (Webb and Quennerstedt, 2010).

For school-based strategies to prevent and treat youth obesity to have the best chance of being successful and effective, educators such as health and physical education (HPE) educators need to recognise their capacity as health promoters in schools and be invested in this role (Speller et al., 2010). The success of school-based strategies is also influenced by the personal views and attitudes of the educators who are responsible for administering the programmes or interventions. Educators who conduct school-based interventions are recommended to retain an attitude and behaviour that is positive towards all participants, especially those who fall outside of the normal weight range (Irwin et al., 2003). School-based health promotion strategies are also more likely to be successful if the interventions and strategies are approached with enthusiasm by the conveners and the educators recognise that there is an acute need for the strategies to be conducted (Walker, 2011).

In the Australian school curriculum, students receive the most health and nutrition education under the reformed syllabus of HPE (Lynch, 2014). The subject is mandatory for all students until the 10th grade and is taught by HPE educators (Australian Curriculum Assessment and Reporting Authority, 2014). The syllabus outcomes for this subject include building awareness of the ways that nutrition and food can be used to improve health and well-being and to provide students with an understanding of the range of influences on food choice from a sociocultural view (Australian Curriculum Assessment and Reporting Authority, 2012). The level and accuracy of nutrition knowledge held by practicing HPE educators is influential on their ability to fulfil pedagogical requirements for the HPE syllabus (Tinning, 2004). Whilst the HPE syllabus is taught by HPE educators, other educators are also responsible for providing health and nutrition education in schools, including general educators (Pérez-Rodrigo and Aranceta, 2001). If educators are under-equipped with nutrition knowledge, students under their instruction risk receiving incorrect nutrition information and may go on to develop unhealthy eating behaviours. This includes students who are overweight or obese who may have a higher investment in achieving weight loss under the incorrect nutrition advice from their educators, going on to practice unhealthy eating and dieting behaviours (Carter et al., 1997) in order to achieve goals of unsuitable weight loss (Moy et al., 2013).

Pre-service professionals perceive the goals of health education, instruction in HPE classes and outcomes of youth obesity strategies differently according to the degree in which they are enrolled.

General pre-service educators were asked to rank the importance of five curricular outcomes of health and nutrition classes in schools and rated fitness and physical activity as the outcomes of highest importance (Kulinna et al., 2010). These took precedence over self-actualisation, motor and social skill development. This showed that the general educators were aware that fitness and physical activity would be emphasised and be necessary to combat youth obesity (Kulinna et al., 2010). In a similar study, general pre-service educators and pre-service HPE educators ranked curricular outcomes differently, with pre-service HPE educators adding nutrition education to the list of curricular outcomes, assigning it third place in importance (Kinnunen and Lewis, 2013).

The tertiary education that educators receive is fundamental to their future efficacy and roles in schools. If pre-service educators do not receive an adequate tertiary tuition in nutrition, they risk basing their lessons on outdated nutrition knowledge once employed (Yager, 2010). As a group, pre-service educators have been shown to possess inadequate levels of nutrition knowledge to be health educators prior to employment in schools (Rossiter et al., 2007), putting them at risk of transferring inappropriate nutrition education to all students, including those who are overweight and obese. Pre-service HPE educators have been shown to be receptive to promoting health in schools (Savage, 1995) yet demonstrate a lack of comprehension on the complex aetiology of obesity. Instead of acknowledging the role of genetics and heredity in causing youth obesity, pre-service HPE educators are likely to attribute obesity to poor eating behaviours (Greenleaf and Weiller, 2005). When provided with a list of causes ranging from hormonal imbalances to cultural factors, practicing HPE educators rank factors within the control of an obese individual much higher than those external to control such as biomedical or sociocultural influences. These perceptions put professional practice at risk of being biased and inaccurate for overweight or obese youth (Greenleaf and Weiller, 2005).

Further putting future educators at risk of being ineffective health educators is the amount and type of health education offered to pre-service educators in Australian higher education institutions, which differs according to type of education degree that students are enrolled in. Pre-service HPE educators are provided with more options to enrol in subjects involving health education, nutrition and human development than general educators, despite the potential for general educators to still have roles involving health and nutrition education in schools outside of the HPE subject (Yager, 2010). For practicing educators to be effective health educators, the training that they receive during their tertiary studies and clarification of their role in health promotion is vital (Yager, 2010). The higher education that these pre-service educators receive is also a potential influence on the ways that future educators will treat overweight students in their care and be involved in health education (Martínez-López et al., 2010).

Perceptions of the roles of schools and educators in health-promoting strategies are diverse, with public opinion placing high expectation on educators. Within the profession, this opinion is not shared by all educators (Rutz, 1993). School-based activities to promote physical activity and prevent obesity are often perceived by the public to be the principle responsibility of educators, yet the educators themselves fail to agree with this perception (Yager and O’Dea, 2005) and do not feel competent to fulfil this role in health promotion and obesity prevention (Davidson, 2007).

The delivery of health and well-being education in subjects such as HPE is influenced by extrinsic and intrinsic factors to each educator, including their personal beliefs, levels of knowledge, training and personal nutrition-related behaviours and levels of body esteem (Haines et al., 2007). Sociocultural influences that pre-service educators are susceptible to include pressure to practice restrictive dietary habits such as dieting and maintaining a thin physique in order to feel engaged and enthused about being health educators (Schulken et al., 1997; Striegel-Moore et al., 1986). A consensus exists amongst practicing educators and those about to enter the profession that higher academic success will be achieved and classes will run more smoothly if the educators are slim and are seen to be model behaviours advocated by traditional approaches to well-being that advocate a focus on eating behaviours and food choices for weight loss (Hartline-Grafton et al., 2009; Wolford et al., 1988). Pedagogical methods, decisions regarding activities and expected outcomes are all affected by the personal values and belief systems that an educator holds, hence affecting the style and nature of education and the ability to be appropriate health promoters in schools (Malinowska, 2010).

The key aims of this research were to explore the perceptions of pre-service professionals towards the following concepts: the factors contributing to youth obesity, the roles of schools as institutions in which to address youth obesity, the roles of all general and HPE educators in treating youth obesity and general level of obesity knowledge and awareness. These factors have been assessed amongst practicing fitness professionals and elementary HPE educators, but have not been examined amongst pre-service professionals including educators and allied health professionals whose employment will require nutrition knowledge and obesity counselling skills. Further, the influence of degree choice is investigated to determine if tertiary students enrolled in education-related degrees are more likely to have higher obesity awareness and stronger perceptions than tertiary students enrolled in non-education-related degrees.

Research methodology

The datasets presented in this paper are part of a larger mixed-methods study investigating attitudes, perceptions and knowledge of pre-service professionals. Participants were sourced from a health and well-being elective open as a general health and nutrition elective to undergraduate students from a major university in Australia. Enrolments in the elective included students enrolled in education-related degrees (22%) and non-education-related degrees (78%). Education-related degrees included health and physical education and secondary and primary education. Non-education-related degrees included business, commerce, medicine and arts. Of all 155 participants, 67% were female (n = 104) and 33% were male (n = 51), and the average age was 21 years. Ethical approval to complete the study was granted by the University’s Human Ethics Committee. Overall retention rate was 66% factoring in students who withdrew from the elective after the first week.

The intervention for this study was embedded within a health and well-being elective which was offered to undergraduate students as an entry-level subject. The intervention and elective spanned 12 weeks and consisted of weekly sessions of lectures and tutorials. Lectures were conducted in a traditional style lasting two hours and tutorials were activity-based and lasted for one hour. The bulk of pedagogical content designed to modify knowledge of obesity was embedded into lecture content and tutorial activities were designed to stimulate critical thought and discussion of the weekly topics taught in lectures. Attendance requirements for the elective set at 90% to prevent failing based on presence ensured that students missed no more than two lectures or tutorials across the 12-week period.

Learning outcomes for the health and well-being elective included increasing general nutrition knowledge, skills in food purchasing and preparation, the links between diet and disease and awareness of health promotion campaigns designed to combat global rates of incidence of conditions such as overweight and obesity in the adult and youth population. Outcomes for the intervention included amelioration of negative weight-based attitudes held towards overweight and obese individuals and to increase awareness of the aetiology of obesity and the roles of schools and educators in youth obesity treatment and prevention strategies.

The theoretical frameworks that underpinned the nutrition education and pedagogy employed in this study were those of Health at Every Size (Reel and Stuart, 2012) and Fitness not Fatness (Langland, 2012), which advocate for a more holistic approach to health. In this way, the focus was shifted away from more biomedical and traditional approaches to overweight and obesity that advocate weight loss as the treatment for excess adiposity and towards the idea that each individual is unique and if all aspects of holistic health are addressed that it is possible to be healthy and fall outside of the healthy weight range (Robison, 2005).

Participants were surveyed in the first week (n = 155) of enrolment in the health and well-being elective and at the conclusion in the 12th week (n = 98) using the Perceptions of Youth Obesity and Physical Education Questionnaire (Price et al., 1990). This instrument was chosen as it was developed to assess perceptions of the role of physical education in dealing with and managing youth overweight and obesity, was found to have internal reliability of α = 0.65, which was sufficient given the variety of topics covered by the questionnaire, and had a test–retest reliability of r = 0.79 (Price et al., 1990; Savage, 1995). The questionnaire had 52 statements requiring a response indicating degree of agreement or disagreement on a seven-point Likert scale. Sub-questions of the instrument measured perceptions about obesity including agreement with factors that contribute to childhood obesity (12 items), perceptions of the problem of youth obesity and roles of schools and physical education in dealing with obesity (30 items).

Data were gathered online using a survey-hosting website, coded and then entered into SPSS version 21.0 (IBM, 2012). Analysis was conducted in accordance with two other published papers which grouped answers according to strong agreement, neutrality or strong disagreement (Hare et al., 2000; Price et al., 1990). Participants were analysed as a whole group at baseline (week one) and post-intervention (week 12).

Results

Participants who completed the questionnaire at baseline were matched via date of birth and weight to results gathered post-intervention. Datasets were compared using a series of McNemar–Bowker tests for symmetry to assess if attitudes or obesity awareness changed over the period of the intervention. Attitudes and perceptions were compared between baseline and post-intervention, including the importance of involvement of various school staff in youth obesity prevention strategies, the roles of schools in youth obesity prevention strategies and general obesity awareness. Significance was set at p < .05 as suggested for use in datasets of this size and type (Pallant, 2013).

Perceptions regarding factors that contribute to youth obesity

There were no significant differences in perceptions of factors that contribute to youth obesity between baseline and results from week 12. Over the course of the intervention, three factors had a low average ranking as having a role in youth obesity. These were peer pressure with 10.4% agreement, low socioeconomic status at 5.9% and a lack of self-control at 5.9%. The top three factors which garnered the highest average response rate as having a major role in youth obesity rates were poor eating behaviours (79.1%), excessive calorie consumption (75.2%) and sedentary lifestyle (70.8%).

Rating of the appropriate level of involvement of school personnel in treating youth obesity

Table 1 displays the results of each rating for school personnel in involvement in treating youth obesity as either having a major role, minor role or no role at all. When comparing baseline and post-intervention results, there was a significant change in perceptions surrounding the importance of HPE educators in treating youth obesity [p < .05 (7.94, 3)]. No significant change was found for ratings of involvement of school nurses, counsellors or general educators.

Table 1.

Change in perceived importance of educators, ancillary staff and medical support staff in treatment of youth obesity in schools, between baseline and post-intervention (n = 98).

	No role	Minor role	Major role	p-value	Cramer’s V (effect size)
	n (% change)	n (% change)	n (% change)	p-value	Cramer’s V (effect size)
Roles of educators
Health and physical educators	5 (+67%)	27 (+93%)	66 (–19%)	.047*	.103
School nurse	11 (–27%)	38 (–12%)	49 (+23%)	.439	.616
School counsellor	16 (+60%)	42 (+24%)	40 (–26%)	.215	.230
General educator	18 (+50%)	42 (+27%)	38 (–28%)	.060	.453

*p < .05.

At baseline, the majority of the cohort rated HPE educators as the most appropriate school personnel to be involved in youth obesity treatment programmes, with 82.7% agreement with them having a major role. This compared to only 14.3% rating them as having a minor role only in treatment programmes and 3.1% agreeing that HPE educators should have no role in obesity treatment programmes. While the proportion of participants who believed that HPE educators should have no role in youth obesity treatment programmes stayed approximately the same at the conclusion of the intervention, there were shifts in proportions who ranked involvement as major or minor. The proportion of participants who ranked HPE educators as the most ideal school personnel to have a major role in school based treatment strategies decreased over the 12 weeks, falling from 82.7% agreement at baseline to 67.3% agreement post-intervention. The proportion of participants who ranked ideal involvement of HPE educators in obesity treatment in schools rose from 14.3% at baseline to 27.6% post-intervention.

Perceptions regarding the roles of schools in treating youth obesity

Each individual statement of this scale required participants to rank their agreement or disagreement on the seven point Likert scale. Answers were grouped into three resulting categories, scored as strong disagreement, strong agreement or neutrality. Table 2 shows that two statements showed significant changes in opinions between baseline and week 12.

Table 2.

Number of participants who rated the roles of schools and displayed obesity awareness post-intervention (n = 98) and the percent change in proportion from baseline.

	Neutral	Strong disagreement	Strong agreement	p-value	Cramer’s V (effect size)
	n (% change)	n (% change)	n (% change)	p-value	Cramer’s V (effect size)
Roles of schools
Weight control programmes specifically for treating obese youth should be available in all schools	60 (–37%)	2 (0%)	36 (+61%)	.002^**	.114
Parents would not be supportive of schools becoming a place for the treatment of youth obesity	63 (–22%)	19 (+74%)	16 (0%)	.034^*	.266
Statements about youth obesity
With proper guidance, most obese youth are able to lose significant amounts of weight	53 (–23%)	2 (0%)	43 (+28%)	.034^*	.137

*p < .01.

**p < .05.

Note: strong agreement was categorised from answers 6 or 7 on the Likert scale combined and strong disagreement from answers 1 or 2 when 1 = strong disagreement and 7 = strong agreement.

The first statement which showed a significant swing in opinions was that ‘weight control programmes specifically for treating obese youth should be available in all schools’ [p < .01 (14.67, 3)]. While the proportion of participants who strongly disagreed with this statement remained at 2.0% across 12 weeks, the proportion of participants who exhibited neutrality or strong agreement with this statement changed. At baseline, 38.8% of participants were neutral towards this statement and this rose to 61.2% at the conclusion of the intervention. Conversely, at baseline 59.2% of the cohort strongly agreed with the statement and this fell to 36.7% agreement post-intervention.

The second statement which showed a significant change in opinions over the 12-week period was that ‘parents would not be supportive of schools becoming a place for the treatment of youth obesity’ [p < .05 (8.65, 3)]. The proportion of participants who strongly agreed with this statement was stable across the 12-week period, remaining at 16.3% strong agreement. The proportion of participants who were neutral towards this concept decreased by 22% between baseline and post-intervention. There was an increase in the proportion who strongly disagreed with this statement, rising 74% between baseline and post-intervention.

Perceptions of the roles of HPE educators in treating youth obesity

No significant changes in opinions were observed between baseline and post-intervention for any of the statements regarding the roles of HPE educators in treating youth obesity. The majority of the cohort strongly agreed with the statement that ‘physical education classes with a focus on teaching life-long fitness should be provided to school youth’, with an average of 80.2% strong agreement measured at the two time points. More than half of the cohort strongly agreed that ‘PE teachers should be role models by setting an example and maintaining a normal weight’ with an average of 63.2% agreement with this statement between baseline and week 12. Strong disagreement was observed on the statement that ‘there is not enough time in physical education classes to help youth improve their physical fitness’ which averaged 39.7% strong disagreement across the two time points.

General knowledge, perceptions and awareness of youth obesity

One statement designed to measure general knowledge and awareness of youth obesity was found to be significant for the cohort with a change in awareness observed between baseline and week 12 [p < .05 (8.67, 3)], as shown in Table 2. The proportion of the cohort who strongly disagreed with the statement that ‘with proper guidance most obese youth are able to lose significant amounts of weight’ remained stable between the two time points at 2.0%. The proportion of participants who retained neutrality towards this statement decreased 23% between baseline and post-intervention. Conversely, there was a 28% increase in the proportion of the cohort who strongly agreed with the statement measured between baseline and post-intervention.

Discussion

The average age of the cohort surveyed in this study was lower than that of participants in other studies who have utilised the Perceptions of Youth Obesity and Physical Education questionnaire, attributed to the time at which they were surveyed. Whilst participants in this study completed the questionnaire during tertiary studies, the results from other studies have focused on practicing physical educators (Greenleaf and Weiller, 2005; Price et al., 1990) and practicing health and fitness professionals (Hare et al., 2000) whose average ages ranged from 37 to 42 years of age and represented opinions and knowledge influenced by the period of employment in their position.

Similar to other studies, the belief that sedentary lifestyles are a key factor that contribute to youth obesity was strong in this research, seen in an average agreement rate of 75% strong agreement spanning the intervention. Despite the magnitude, it was still lower than that reported amongst practicing physical educators who demonstrated 97% (Greenleaf and Weiller, 2005) and 82% (Price et al., 1990) strong agreement with this statement. It is possible that the diversity of disciplines surveyed in this research helped to account for the lower agreeance with this statement with students enrolled in non-health-related degrees more likely to underestimate the importance of lifestyle factors in obesity management in the youth population than those enrolled in health-related degrees. Agreement with the importance of lifestyle factors in obesity management has been reported as high as 89% (Hare et al., 2000), which is higher than that observed in this study. This is not unexpected as the professionals surveyed had, on average, 10 years of industry experience compared to the cohort of this study who were still completing undergraduate study.

Perceptions regarding the importance of HPE educators as having a role in treating youth obesity rather than other schools staff including counsellors and general educators were not as strong as those seen in similar studies. This positively reflected upon the content and delivery of the intervention which aimed to build appreciation for a multidisciplinary approach to treating youth obesity in schools. In this study, the proportion of participants who thought HPE educators should have a minor role increased over the period of the intervention as the proportion of participants who thought they should have a major role dropped. This was a desired change, recognising the importance of a multidisciplinary approach to youth obesity treatment in schools rather than resting the obligation on the sole shoulders of one type of educator. At the conclusion of the intervention, the majority of the cohort (67%) agreed that HPE educators should have a major role in these strategies; however, this is smaller than that found in other studies of practicing HPE educators who rated 84% and 95% agreement with this statement, respectively (Greenleaf and Weiller, 2005; Price et al., 1990). It is possible that the varied enrolment of tertiary students in the health and wellbeing elective contributed to this lower level of agreement. Although students may have had a high level of interest in nutrition and health, not all would have been influenced by career choice on their perceptions of the roles and responsibilities of educators in school based youth obesity treatment strategies.

On the statement that ‘weight control programmes should be available in all schools specifically for obese youth’, post-intervention levels of agreement seen in this study’s cohort were vastly different to those observed amongst studies conducted on practicing educators. At post-intervention, the majority of participants agreed (37%) with the statement rather than disagreed with it (2%), but this level of agreement was much lower than the reported 95% seen in practicing physical educators across all levels of schooling (Greenleaf and Weiller, 2005) or 91% agreement amongst elementary school practicing physical educators (Price et al., 1990). One of the main aims of the intervention was to increase awareness of the aetiology and treatment of youth obesity, and the desired answer for this statement was for the majority of participants to strongly disagree with the statement, recognising that singling out obese youth for a treatment programme would have the potential to stigmatise them and place unnecessary emphasis on their weight status. Although this desired degree of disagreement was not observed in the responses, it is promising that the level of agreement observed is lower than that of published levels amongst practicing educators. The fact that the majority of responses post-intervention were neutral towards this statement is interpreted in a positive way, preferred over strong agreement which would reflect a failure of the intervention to achieve its aim of increasing awareness.

The majority of the participants in this study agreed that schools are ideal places to prevent weight problems in children, with an average agreement rating of 64% across the 12-week period, changing very little between baseline and post-intervention. Although this level of agreement was high, it was still lower than that of similar research amongst practicing HPE educators whose agreement with this statement was reported as 84% (Greenleaf and Weiller, 2005). It is possible that practicing educators may have higher levels of investment in agreeing with this concept as they have awareness of the links between health, nutrition and the curriculum they must teach in order to promote health and well-being in schools. Pre-service professionals including general educators and HPE educators may have lower levels of knowledge of the curricular requirements that link health and nutrition. The pre-service professionals may also have a lower belief in singling out educational institutions as being the most important influence on youth obesity.

It must be noted that key differences existed between the cohort in this study and that of previous research. The sample size (n = 98) was smaller than that of studies published on elementary physical education teachers (n = 400) (Price et al., 1990) and practicing fitness professionals (n = 325) (Hare et al., 2000), and was not conducted amongst practicing professionals solely in the fitness industry or in health and nutrition education. All data collected from the survey were subject to the potential for self-reporting bias and selection bias – effects seen in previous research where participants who completed the survey had swayed opinions prior to answering the survey or pre-formed ideas due to the nature of their employment (Hare et al., 2000). Comparison between the proportions of participants who agreed and disagreed with each statement to Greenleaf and Weiller’s (2005) cohort may also present a potential issue due to differences in categorisation of agreement and disagreement. In this study, only two responses from the extreme options of the Likert scale were grouped for agreement or disagreement; however, Greenleaf and Weiller (2005) grouped the last three Likert responses, potentially widening the proportion of individuals in each category.

When Price et al. (1990) created the Perceptions of Youth Obesity and Physical Education Questionnaire, they noted in results gathered that there was a discord between the perceptions that schools are not doing enough to prevent youth obesity and that HPE educators should have a large role in youth obesity prevention strategies in schools. This phenomenon was also detected in this research, representing the issue of the potential strain between expectations placed on educators to be agents of health promotion strategies and the perceived personal investment in this role. Although discord was detected, this does not reflect the attitudes of practicing educators nor tertiary students at the conclusion of their studies. Instead, they represent the attitudes of tertiary students at the start of their education and not all of the cohort were destined for roles in education or health. Another potential drawback of the questionnaire was detected by other researchers (Hare et al., 2000) who noted that it was monothematic in nature, potentially leading to response bias and preventing the exploration of the extent of perceptions due to the closed-ended formatting of questions rather than open-ended.

Strengths of the study include the 63% response rate which was higher than the 42% response rate of a similar cohort of practicing HPE educators (Greenleaf and Weiller, 2005) and this may have been due to the incorporation of the instrument into allocated class time used for participants to complete the online survey instead of relying on responses being mailed back. Also, the apparent success of the intervention at increasing awareness of the roles of schools as ideal locations for health promotion strategies and the changes in perceptions regarding the roles of educators reflect positively on the design of the intervention and ability to modify perceptions.

More research is required to determine the influence of perceptions held at the tertiary level on the importance of schools in participating in strategies to combat youth overweight and obesity and influences on these attitudes into practice. On a national scale, it is hoped that the tertiary education provided to future professionals involved in roles of health promotion and health education widens to include more mandatory and open electives on nutrition and health education. It is already known that personal beliefs and dietary habits have a large influence on the way that educators conduct health and well-being education (Peters and Jones, 2010) and that the tertiary study that they undertake shapes their practice (Paakkari et al., 2010).

Recommendations arising from this study include the need for a control group to be integrated into the research methodology, helping it to transition from a quasi-experimental study to an experimental one. The use of a control group would also help determine the effect of the intervention on attitudes and knowledge, helping to control for the impact of external health and well-being education that participants may have been exposed to. Future surveys conducted in the higher education setting would also benefit from distinguishing which degree students were enrolled in or what major that they were undertaking, with differences in investment in health and nutrition expected for students enrolled in health-related degrees. Although the study design is rigorous as it measures students at baseline and post-intervention, it would yield practical information to measure of the retention of knowledge and attitudes through a follow-up survey conducted at least once after the conclusion of the post-intervention results. This would allow the long-term impact of the intervention to be assessed, with ramifications for the professional practice of professionals involved in health promotion and health education.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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