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CUES TO HEALTHY DECISION-MAKING AMONG COLLEGE STUDENTS: RESULTS FROM A PILOT STUDY

Satya P. R ao, PhD , MCHES* Department o f Public Health Sciences

New Mexico State University

V alerie Lozano, MPH School o f Nursing

New Mexico State University

M urad Taani, B SN Department o f Public Health Sciences

New Mexico State University

Problem Almost 60% o f college students consume less than two serv ings o f fruits and vegetables a day while 40-50% either exercise irreg ularly or do not exercise. When surveyed in another study, half o f the students responded that they had not received any information about healthy eating and behaviors from their colleges while nearly 60% said they would be interested in receiving such information. Therefore col lege environments provide opportunities for implementing interven tions that encourage healthier lifestyles including on healthy nutrition and physical activity.

Purpose and Method The purpose o f the current pilot study was to implement and evaluate a campus-wide campaign o f cues to healthy decision-making to improve students’ knowledge and awareness about healthier lifestyle choices and to serve as reminders towards positive changes in health-related behaviors and actions.

Results Based on analysis, 86% (48) o f the participants indicated that they had learned something from reading the information on the table toppers and 75% (42) agreed that the information had made them more aware and reminded them o f healthier lifestyle choices.

Conclusions The need for such communication-based campaigns using cues to healthy decision-making show promise among college students.

Key Words: Cues, Obesity, Nutrition, Physical Activity, Diabetes

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Introduction

Nearly one-third o f American adults aged 20 years or older are overweight and 33.8% are obese, triggering obesity-related condi tions, such as heart disease, stroke, and Type II Diabetes (Ogden & Carroll, 2010). Research suggests that the above conditions may be largely linked to a person’s choices, behaviors, and lifestyle (Kees 2011; Nyaga 2000). Kees (2011) suggests that consumers make poor health decisions because of a low tendency to consider the potential costs o f their behaviors as noted particularly among college students. These health decisions by college students are further negatively impacted by stress and time constraints related to managing and balancing coursework, employment, relationships, and families, making eating healthy meals and being physical active problematic and low on the priority list (Kees, 2011).

Choices and decision-making

College years present a different set o f nutritional priorities including with eating habits. Many factors play a role in obesity among college students such as unhealthy dietary choices and physical inactivity. Most student diets disproportionately include fast foods that are high in calories, fat, and sodi um content (Cluskey & Grobe, 2009; Kelly, Mazzeo, & Bean, 2013). Existing evidence shows that negative changes can occur in several health behaviors during young adults’ progression from high school to college (Racette, Deusinger, Strube, Highstein, & Deusinger, 2005).

On an average day, college students con sume one serving o f fruit, 1.5 servings o f vegetables, half a serving o f low-fat dairy, and 1.4 servings o f whole grain daily (Kelly, Mazzeo, & Bean, 2013). These numbers are considerably lower in some men and non white students, are severely lower than the recommended dietary intake, and continue

to decrease during the course of students’ first year o f college (Kelly, Mazzeo, & Bean, 2013). According to the Healthy Campus 2010 Report, 5.4% college students reported eating zero servings o f fruits and vegetables a day and 58.3% consumed 1-2 servings o f fruits and vegetables daily (ACHA, 2011). In addition, nearly half o f the 104,826 participat ing U.S college students, when asked if they had ever received information on nutrition from their colleges, responded that they had not. In addition, nearly 60% said they would be interested in receiving such information (ACHA, 2011). Therefore college environ ments provide opportunities for implement ing interventions that encourage healthier lifestyles and enhancement o f self-efficacy and healthy decision-making.

Existing data indicates that college stu dents favor processed foods that cost less than healthy foods. These dietary decisions are linked to inadequate access to healthy foods, easy access to fast foods, the high cost of healthier alternatives, and limited peer support for healthier food choices (Cluskey & Grobe, 2009). The diminished health and increased weight gain o f college students are associated with inadequate nutritional habits, sedentary lifestyle and decreased physical activity, and a heightened stress level. In addition, weight gain among undergraduate college students is distinctively related to stress levels (Jackson, Berry, & Kennedy, 2009). Often, demanding schedules and difficulties balancing various priorities leave students little time to shop, prepare meals, and engage in physical activ ity. Therefore, physical activity is sacrificed and healthier foods are replaced by cheaper, less nutritious and more convenient fast food options (Meltzer, Fontaine, Colbert, Creadore, & Cuoco, 2007).

Grace (1997) found that students who live away from campus had increased health risks: such as a Body Mass Index (BMI) at the overweight and obesity levels, smoking,

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consumption of alcohol, and consumption of fewer and less variety of fruits, vegeta bles, and dairy products. Since smoking and alcohol consumption are generally not permitted in students’ residence halls, many students choose to live outside the campus accounting for their dietary choices and increased health risks of obesity and over weight (Brunt & Rhee, 2008).

An additional concern to students’ di etary behaviors is their lack of or limited engagement in physical activity. Studies with undergraduate, graduate, and medical students suggest that between 40-50% of the student participants either exercised ir regularly or did not exercise at all (Nelson, Story, Larson, Neumark-Sztainer, & Lytle, 2008; Racette, Deusinger, Strube, Highstein, & Deusinger, 2005).

Cues to Healthy Decision-making

Due to the negative health implications of college students’ unhealthy eating habits and sedentary lifestyle, it is vital to investigate the dynamics that predict and adequately ad dress them. The Health Belief Model (HBM) explicates and predicts health behaviors and suggests that changes in behaviors are esti mated by perceived susceptibility, severity, benefits, and barriers, cues to action, and self-efficacy. Park (2011) examined HBM constructs and found cues to action to be a significant predictor of behavioral intention of weight reduction. A cue to action is a mo tive to readiness and refers to influences of social environment, such as family, friends and mass media. Cues to action are important in serving as specific motivators necessary to prompt appropriate health behaviors and can be internal or external.

Consequently, the framing and communi cations of cues to healthy decision-making has the potential to improve students’ knowl edge and awareness of healthy lifestyles. Additionally, when such cues are framed

and communicated in creative, simple, goal-oriented, and straightforward ways that include the ‘problem(s)’ and highlight the positive and/or the negative aspects of specific behaviors and tasks involved they have the potential to influence students to adopt more healthy lifestyles (McCormick & McElroy, 2009). The purpose of the current pilot study was to implement and evaluate a campus-wide communications campaign of cues to healthy decision-making to im prove students’ knowledge and awareness about healthier lifestyle choices and serve as reminders towards positive changes in health-related behaviors and actions. Few studies have evaluated interventions that have used cues to actions to improve college students’ unhealthy eating and sedentary lifestyles. Therefore, the findings from the current pilot study have the potential to add to the existing scant literature.

Methods

The “Good Choices Make Damn Good Looking Aggies” campaign was implement ed at a college campus in Southwest United States in November 2010 before the holiday season and final exams.

Study design

The study and its post-test only protocol were approved by the university Institution al Review Board (IRB). Two sets of table toppers were developed with various health and lifestyle facts to serve as cues to healthy decision-making. Figure 1 shows the content included in the two table toppers developed for the campaign. The content was printed on colorful paper, folded into a tent, and rein forced with tape to be able to stand vertically on tables. Framing of cues in the form of “did you know” statements expressing the costs of not adopting a healthy behavior versus the benefits of adopting healthy habits were in cluded in each of the table toppers. In addition

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the title of the campaign was prominently displayed along with the incentives included in a random drawing for participants who completed the evaluation survey and provided their first names and e-mail addresses sepa rately. Instructions to complete the evaluation survey were also included.

Protocol

Before the start of the campaign an an nouncement was sent out through the campus website encouraging participation. Each of the two table toppers were displaced for one whole week starting on a Monday morning by placing them on tables at three eating establishments on campus that were housed in the same building. The table toppers were checked every day to make sure that they were in place for the diners to notice and read. Any discarded or displaced table toppers were re placed. Evaluation surveys were placed next to sealed survey drop boxes strategically and conveniently located close to the cash regis ters and were emptied out daily. The survey was limited to enrolled students and excluded staff, faculty, and other university personnel and employees.

Table Toppers

The first table topper included the fol lowing nutritional cues 1.) Frozen food is as good for you as fresh food 2.) There are 10 packets of sugar in one can of soda, and 3.) Drinking 8 glasses of water a day may help you lose about 8 pounds in one year. They also included the following healthy lifestyle cues: 1) Adults need between 7.5-9 hours of sleep per night to function at their best 2.) Exercise can improve appearance, and 3.) Twenty five minutes of exercise is all it takes to improve mood and ward off depression. The second table topper included a different set of nutritional cues as follows: 1.) Whole fruit has more fiber and fewer calories than juice 2.) The acid found in strawberries

fights tartar from teeth 3.) College students don’t get enough calcium, and 4.) If you’re thirsty you are already dehydrated. Healthy lifestyle cues included in this table topper consisted of the following statements: 1.) High levels of stress decrease your immune system function making it easier for you to get sick 2.) Our skin starts to age when we are bom, 3.) Breakfast eaters are champions of good health, and 4.) Walking 6-9 miles a week helps improve memory.

Evaluation Survey

The evaluation survey consisted of four questions, two dichotomous and two qualita tive open ended questions, taking about 5-10 minutes to complete. The following ques tions were included in the survey: 1.) Did you learn anything from reading the information on the table topper tents? 2.) Did the infor mation make you more aware of healthier lifestyle choices for yourself? 3.) How else was the information useful to you? 4.) What else about the campaign caught your atten tion? At the end of two weeks there were a total of 56 participants who completed the evaluation survey and dropped them in the boxes provided.

Incentives

Incentives in the form of gift certificates donated by local business were included in a drawing that was conducted in February 2011 and the winners notified via the e-mail they provided. The gift certificates included two fifteen dollar vouchers to health conscious restaurants, two forty dollar vouchers for body massages, and two vouchers for a body and fitness assessment. In addition, six t-shirts with the campaign logo served as additional incentives. Participants’ names were ran domly drawn from those who participated in the survey and provided their first name and email address.

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Results

A total o f 56 student participants completed the evaluation survey. Based on descriptive analysis 86% (48) o f the participants indicated that they had learned something from reading the information on the table toppers and 75% (42) agreed that the information had made them more aware and reminded them o f healthier lifestyle decisions. In addition, when asked if the information was useful to them, 45% (25) o f the participants indicated that the informa tion was either new and/or useful to them. Fifty-six percent o f them (n=14) highlighted the utility o f ‘healthy nutrition’ information, 24% specified the information and tips about exercise, and the remaining 20% mentioned lifestyle-related information such as about sleep and alcohol use. The remaining thirty one participants (55%) provided specifics about the cues they received that highlighted their cur rent choices, or reminded, and/or empowered them to make healthier choices as compiled in table 1. These cues fell into three categories: adding to existing participants’ knowledge; reminding participants o f what they already knew and could use in their lives; and empow ering them to make changes and take action towards a healthier lifestyle.

The last survey question inquired how the campaign caught participants’ attention. Thirty two percent (18) stated that the slogan was the most ‘noticeable attention grabber;’ 25% (14) m entioned the design and layout o f the table toppers was attractive; 13% (7) stated that the nutrition and life-style cues caught their atten tion; while only 5% (3) noticed the incentives such as massages included in the drawing.

Discussion Findings

The cues used in the cam paign highlighted the costs o f not adopting healthier behaviors versus the benefits o f adopting such behav iors. They were designed not to undermine w hat students already knew and were doing

b ut to provide them w ith sim ple and practical strategies that could be incorporated into their current everyday living.

The cues used in the campaign were not about judgm ent or preaching but to remind students o f what they already knew, add to their current knowledge, and empower them to incorporate their awareness into a healthier lifestyle. According to the Healthy Campus 2010 (ACFLA, 2011), 46% o f college students responded that that they never received informa tion about nutrition and healthy lifestyles from their institution o f higher learning - which is why it is critical to implement such campus-based interventions not only on nutrition and physical activity, but on other healthy lifestyle topics benefitting students. Ongoing and recurring campus interventions that incorporate cues to healthy decision-making on a variety o f topics can fill the information gap and when timed carefully can remind and empower students o f healthy decision-making. They also have the potential to augment existing cognitive and in- formation-based efforts through their emotional appeal, contextual and cultural relevance.

Study limitations

The current pilot cam paign had limitations including a small sample size. Since there was no estimate o f the total num ber o f student din ers during the two weeks o f the cam paign it was difficult to estim ate how representative the study participants were in com parison to other student diners. A nother lim itation was our reliance on participants’ responses in the evaluation survey. Further, the completion o f the surveys w as n ot m onitored and no research assistant w as available to answer questions that participants m ay have had o f the survey. Results reported here need to be replicated with larger sample sizes, in other college settings, and through the use o f reli able evaluation tools that docum ent the short and long-term benefits o f cues to healthy de cision-m aking am ong this population.

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Conclusion

Existing evidence highlights the rise o f contributing unhealthy choices and behaviors leading to obesity and obesity related condi tions among college students. The current pa per highlighted a campaign based on cues to healthy decision-making to improve college students’ knowledge and awareness and em power them to make healthier lifestyle choic es. Evaluation results reported here suggest that health communication campaigns based on cues to healthy decision-making show promise and need to be further investigated. Few studies have reported findings evaluating interventions that have used cues to actions specifically targeting college students and unhealthy eating and sedentary lifestyles. Therefore, the findings from the current pilot study have the potential to add to the existing scant literature.

References American College Health Assessment [ACHA] (2011).

National college health assessment II: Reference group data report. Healthy Campus 2010, 1-61.

Brunt, A. R., & Rhee, Y. S. (2008). Obesity and lifestyle in U.S. college students related to living arrange ments. Appetite,51(3), 615-621.

Cluskey, M., & Grobe, D. (2009). College weight gain and behavior transitions: Male and female differenc es. Journal o f The American Dietetic Association, 109,325-329.

Grace, T. W. (1997). Health problems o f college stu dents. Journal o f American College Health, 45(6), 243-251.

Jackson, R.A., Berry, T.R., & Kennedy, M.D. (2009). The relationship between lifestyle and campus eating be haviours in male and female university students. Col lege Student Journal, 43(3), 860-871.

Kees, J. (2011). Advertising framing effects and con sideration of future consequences. The Journal o f Consumer Affairs, 45(1), 7-32.

Kelly, N.R., Mazzeo, S.E., & Bean, M.K. (2013). Sys temic review o f dietary interventions with college students: Directions for firture research and practice. Journal o f Nutrition Education and Behavior, 45, 304-313.

McCormick, M., & McElroy, T. (2009). Healthy choices in context: How contextual cues can influence the persuasiveness of framed health messages. Judge ment and Decision Making, 4(3), 248-255.

Meltzer, K., Fonatine, E., Colbert, D., Creadore, J., & Cuoco, L. (2007). Communication campaign: College health and effects o f fast food. Comm 143, Persuasion and Influence Class. Retrieved April 5, 2013, from jsaw.lib.lehigh.edu/include/getdoc. php?id=1807&articl

Nayga, R.M. (2000). Nutritional knowledge, gender, and food label use. The Journal o f Consumer Affairs, 34, 97-113.

Nelson, M.C., Story, M., Larson, N.I., Neumark-Sz- tainer, D., & Lytle, L.A. (2008). Emerging adult hood and college aged youth: An overlooked age and weight-related behavior age. Obesity, 16(10), 2205-2211.

Ogden, C.L., & Carroll, M.D. (2010). Prevalence of overweight, obesity, and extreme obesity among adults. United States, Trends 1960-1962 Through 2007-2008. Centers fo r Disease Control and Preven tion. Division of Health and Nutrition Examination Surveys, 1-6.

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Table 1: Cues to Healthy Decision-Making (N=31)

Statements and comments by study participants in response to evaluation survey question #3: How else was the information useful to you?

Cues that added to existing participants’ knowledge

1. “I do not like fruits and vegetables but I realize I need them.”

2. ‘Frozen fruits and vegetables are just as good. Great!”

3. “It showed me that I need knowledge to make better choices.”

4. “The nutrition facts — I needed to know them and be reminded.”

5. “The toppers focused on things that I did not want to work on.”

6. “Gave me facts that I did not know such as the ‘thirst’ fact that I could use. The campaign was very useful.”

7. “Made me aware o f eating breakfast. I skip it all the time.”

8. “Healthy nutrition can be easy but has to be a priority.”

9. “Learning things about health I did not know but need to.”

10. “I became aware o f the unexpected benefits o f exercise.”

11. “I got cool facts about nutrition I can now use.”

12. “I learned all about sugar in cola. I do not want to drink it anymore.”

13. “It showed me what kinds o f things I was putting in my body.”

14. “Wow! 25 minutes o f exercise prevents depression and improves my mood.”

Cues that reminded participants of what they already knew and could use in their lives

15. “It was reminder to me about what I was putting in my body.”

16. “Reminded me o f how to become a healthier person.”

17. “Reminded me to relax and take some time for myself.”

18. “Reminded me o f the packets o f sugar in soda.”

19. “It showed to be healthier and not drink so much.”

20. “It made me realize how ‘really unhealthy’ I was.”

21. “It was about my awareness and what I can do for myself.”

22. “It was a good reminder o f how ‘lax’ I have been. I will not be drinking as much soda”

23. “It made me realize that I was not getting enough sleep.”

Cues that empowered participants to make changes towards a healthier lifestyle

24. “Helps me make better health choices.”

25. “Helped me make more nutritious and healthy choices for the future.”

26. “The campaign gave me tips for making better choices.”

27. “It helped me lead towards a healthier life and better choices.”

28. “I realized that I could make tad bit healthier choices.”

29. “It reminded me about better choices and lifestyle I can choose.”

30. “It convinced me that I could make the right choice for me.”

31. “Helps me become more involved about my health.”

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Park, D.Y. (2011). Utilizing the HBM to predicting fe male middle school students behaviors intention o f weight reduction/status. Nutrition Research & Prac tice, 5(4), 337-348.

Racettc, S.B., Deusingcr, S.S., Strube, M.J., Highstein, G.R., & Deusinger, R.H. (2005). Weight changes, exercise, and dietary pattemssuring freshman and sophomore years in college. Journal o f American College Health, 53(6), 245-251.

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