Gay, transgender education lacking.(JOURNAL WATCH: Highlights from the June, July issue of the American Journal of Public Health)(Brief article) - The Nation's Health

Aside from HIV/AIDS, health issues affecting the lesbian, gay, bisexual and transgender population are not likely to show up in research and lesson plans offered at schools of public health across the nation, according to a June study in APHA's American Journal of Public Health.

While 41 percent of the 102 schools that responded to mailed questionnaires, reported having at least one faculty member who was conducting research on an issue related to lesbian, gay, bisexual or transgender health, the majority of the research was on HIV/AIDS. In addition, fewer than 9 percent of the departments had offered a course covering lesbian, gay, bisexual or transgender health topics in the previous two years, other than courses on HIV/AIDS. The majority of schools include sexual orientation in their non-discrimination policy, but fewer than 50 percent offered domestic partner health insurance benefits to same-sex partners of faculty, staff and students.

0-Year Roadmap for Reaching Public Health Education Goals: Healthy People 2020 Education for Health Initiative Featured in the American Journal of Preventive Medicine. - Education Business Weekly

Launched on December 2, 2010, Healthy People 2020 is an ambitious, science-based, 10-year agenda for improving the health of all Americans. A key component, Education for Health, is an educational roadmap to achieve the Healthy People 2020 goals. Formulated by the Healthy People Curriculum Task Force, this set of new and revised educational objectives provides a vehicle for promoting the discussion and progress that will be needed to achieve an integrated, seamless approach to education for health for the American public as well as for health professionals. The February 2011 issue of the American Journal of Preventive Medicine features a series of articles that examine public-health educational needs and goals for the U.S.

'The Task Force envisions a decade-long process to define and implement specific learning outcomes that can be integrated across the educational continuum,' commented Richard K. Riegelman, MD, PhD, George Washington University School of Public Health and Health Services, and David R. Garr, MD, Medical University of South Carolina, co- chairs of the Task Force. 'Interprofessional prevention education, in which health professionals learn and practice together, is seen by the Task Force as a key method for implementation. Understanding the roles played by a range of clinical health professionals is also essential for achieving optimal communication and understanding. Healthy People 2020 and discussions and pilot programs that connect public health, clinical health professions, and educators from the pre-K years through graduate school will be increasingly critical in the future. Stimulating these discussions and encouraging pilot efforts will continue to be central to the missi!

on of the Healthy People Curriculum Task Force.'

Keywords: Curriculum, Education, Public Health.

April 2, 2008. AAHPERD Journal Writers' Workshop.(Conferences & Workshops)(American Alliance for Health, Physical Education, Recreation and Dance)(Brief article) - JOPERD--The Journal of Physical Education, Recreation & Dance

April 2, 2008. AAHPERD Journal Writers' Workshop, Tampa, FL. Scheduled from 9:00 to 11:00 a.m. at the AAHPERD National Convention and Exposition, this free workshop will provide insights on writing for peer-reviewed journals and getting manuscripts published. Following an introductory overview, attendees will have the opportunity to meet with editors and reviewers in roundtable sessions to learn about the participating journals and get valuable advice on how to improve their skills and submit acceptable manuscripts. Registration is required. To register, go to the special events section of the AAHPERD convention page at www.aahperd.org.

Hospital Executive Mary Eleanor Noone; Active in Health Care Education, Journals - The Washington Post

Mary Eleanor Noone, 62, a Bethesda resident and registered nursewho was a senior vice president at Providence Hospital, died Jan. 13at Sibley Memorial Hospital. She had cancer.

Ms. Noone, who came to the Washington area in 1964, was aPennsylvania native.

She was a nursing graduate of the University of Maryland andreceived a master's degree in nursing administration from CatholicUniversity.

She began her career in 1964 as a nursing-educator at theWashington Hospital Center, where she worked until joining Providencein 1986 as its vice president for nursing. She was promoted to seniorvice president in 1998.

Ms. Noone had served on the editorial board of Nursing ConnectionsJournal and had served on the board of both the Washington BioethicsNetwork and the American Health Association.

She was a member of the American Organization of Nurse Executives,the Amerian Geriatric Society and Sigma Theta Tau, the nationalnursing honor society. Since 1980, she had been active in educationprograms for Japanese health care personnel. She also had lectured onhealth care ethics.

Ms. Noone, who was a member of Holy Trinity Catholic Church inGeorgetown, was a member of the Archdiocese of Washington Health CareNetwork and the John Carroll Society.

She was a fellow of the Johnson & Johnson-Wharton School ofMangagement for nurses at the University of Pennsylvania.

Study calls infomercials on health products suspect - The Herald News - Joliet (IL)

It is no secret that television infomercials are heavy on bogus, money-back guarantees and light on truth and accuracy.A new study from Brigham Young University says that health- related infomercials are particularly suspect.'Results from this study suggest that most health-related infomercials have crossed the line and operate in the domain of deception,' writes Susan Hill, a BYU assistant professor of medicine and lead author of the report.

Even more shocking, Hills explains in her study, is that 'a large number of the FTC (the Federal Trade Commission) consumer- fraud cases involve health and fitness products, and infomercial trade associations report that the No. 1 selling category of infomercial products are health and fitness items.'

In other words, as bad as these TV spots are, they are not going away, the study concludes. FTC officials also told Hill their truth-in-advertising enforcement programs are not stringent enough to squash these bogus claims.

Hill's findings, based on analysis by Gordon Lindsay, Steve Thomsen and Astrid Olsen, all with BYU's Department of Health Science, are reported in the latest issue of the American Journal of Health Education.

The Washington-based nonprofit American Association for Health Education, which publishes the journal, says it is too early for infomercial retailers to respond to the analysis.

In the study, four trained observers watched 31 half-hour, health-related infomercials. The spots were aired on six major networks. They included pitches for exercise equipment, drug and herbal supplements, food-preparation gear and personal hygiene products. Among the 'implied benefits' outlined in the spots: increased memory, cancer-fighting properties, increased muscle bulk and improved sexual performance.

Determinants of nutrition label use among college students.(Research Articles)(Report) - American Journal of Health Education

Abstract

The purpose of this research was to assess the frequency of nutrition label use among college students and its relationship to nutrition and label knowledge, attitudes, and beliefs regarding diet-disease relationships, and to determine factors predictive of frequent or infrequent label use. This study utilized a cross-sectional design. Volunteer participants included a convenience sample of 1,294 students from a large university in Texas. A 57-item surrey instrument was used to assess nutrition label knowledge, attitudes, behaviors, and beliefs about diet-disease relationships. Open-ended items were included to capture reasons for frequent/infrequent label use. Statistical analyses included frequency distributions, Pearson's correlations, independent sample t-tests, and binary logistic regression. Label users had greater knowledge, more favorable attitudes, and more accurate perceptions of diet-disease relationships than nonusers. Females exhibited greater knowledge, more favorable attitudes, and more frequent label use than males. Health reasons, looking for specific information, weight control, and knowledge predicted frequent label use. Desire for certain foods, time constraints, and 'don't care' attitudes predicted infrequent use. These predictors of frequent/infrequent use suggest important points of intervention for increasing label use among selected groups of college students.

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Beginning in 1994, the U.S. Food and Drug Administration (FDA) began to require standardized labeling of most packaged foods, under the Nutrition Labeling and Education Act (NLEA) of 1990. (1-3) This policy was designed to provide a consistent and reliable source of nutrition information and promote healthy food choices. (1,4) It was believed that providing such information to consumers would facilitate adoption of healthier nutrition practices. (1,5) Such a concept has been supported empirically (1,6,7) and suggests that availability of nutrition labeling could lead to a decrease in the incidences of certain nutrition-related conditions. (1)

In Healthy People 2010, proper use of nutrition labels is one of the topics considered essential in nutrition education, (8) and given the theoretical link between nutrition label use and improved health, several researchers have focused attention on factors related to label-reading behavior. A 1995 study found that both gender and educational level of respondents influence label-reading behavior. (9) An additional study reported that label use among a sample of college students differed by gender. (10) For males, beliefs in the trustworthiness of nutrition label information and diet-disease relationship (between fiber and cancer) differed between label users and non-users. (10)

Another study examining knowledge, attitudes, and self-reported behaviors of college students regarding the NLEA showed prior nutrition education increased nutrition knowledge, and knowledge was positively associated with attitudes and label-reading behaviors. (11) Although knowledge and attitudes associated with reading labels did not differ by gender, female college students were significantly more likely to use nutrition labels than males. (11) However, no study exists that provides a comprehensive examination of college students' attitudes, knowledge, beliefs on diet-disease relationship, and label-reading behavior.

In light of this, the past four years of American Journal of Health Education (AJHE) issues (Volume 33, Issue 3; Volume 37, Issue 2) were examined for all nutrition-related articles. A total of nine research articles (12-20) and seven teaching ideas (21-27) were identified. None of the research articles focused specifically on label use, in spite of a recommendation by the Committee on Use of Dietary Reference Intakes in Nutrition Labeling that additional research focus on consumer use of nutrition labeling. (3) Instead, AJHE topics included disordered eating, (14,15,19) intuitive eating, (16,17) and other nutrition subjects such as emotional eating, (12) interventions, (13,18) and dietary patterns. (20) For the most part, articles focused on very specific areas of nutrition research rather than on general label-reading behaviors. This is of particular interest due to the foci of several teaching articles. Of the seven teaching ideas, four were related to facilitating proper nutrition label use (21,24-26) (three of which focused on specific nutrients (24-26)). This discrepancy between the focus of current research articles and the teaching articles may be indicative of a need for researchers to better address topics that practitioners face on regular basis, such as nutrition label use.

The purpose of this research was to assess the frequency of nutrition label usage among college students and determine if label users differed from non-users in terms of their knowledge of nutrition labels and basic nutrition information, attitudes toward nutrition labels, and beliefs about diet-disease relationships (specifically, fat and heart disease, fiber and cancer, and calcium and osteoporosis). In addition, factors associated with label use versus non-use were also examined.

Four research questions guided this study: (1) What percentage of college students use nutrition labels when purchasing foods? (2) Do label users differ from non-users in terms of nutrition label knowledge, attitudes toward nutrition labels, and beliefs about diet-disease relationships? (3) Is there a gender difference in knowledge, attitudes, beliefs about diet-disease relationships, and label reading behavior? (4) What factors predict the use of nutrition labels?

METHODS

Design

Following approval from the Institutional Review Board for the Protection of Human Subjects, 16 instructors teaching a total of 88 physical education activity program classes consented to allotting class time for data collection from students. A research representative visited each class to discuss the project, answer questions, and distribute and collect informed consent forms and surveys. Surveys contained questions about demographic characteristics, nutrition label use, knowledge, attitudes, and beliefs regarding diet-disease relationships. Survey completion took approximately eight minutes, and students were not compensated for participation. The informed consent forms and surveys were separated immediately upon receipt in order to preserve anonymity.

Sample

Using a cross-sectional research design, a convenience sample of 1,294 students at a large university in Texas comprised the sample for this study. Students aged 18 years and over were recruited from 88 physical education activity program courses for voluntary participation. These classes are part of general course requirements for all university students and hence provided the best representation of a university-wide student undergraduate population; they are not specific to health, physical education, or kinesiology majors. Of an estimated 2,756 eligible participants (estimated due to the fact that participating instructors did not provide actual attendance counts for the days of survey distribution), 1,294 students completed surveys, yielding a response rate of approximately 47%. It is possible that response rate was low due to the students' option of leaving class early or completing the survey.

Measures

The 57-item survey instrument was modified from an instrument used in previous research. (7,8) The 39-item instrument used by Marietta and colleagues that examined nutrition label knowledge, attitudes, and behaviors of college students (Cronbach's alpha = 0.80) was used as the foundation for the current study. (11)

The original instrument (11) was modified through the addition of three knowledge questions (regarding trans fatty acids, ordered ingredient listings, and requirements for health related claims), three behavioral questions (regarding use of labels at point of purchase, dependence on health claim statements in product selection, and use of labels to regulate daily nutrient intake), and three diet-disease relationship questions (addressing links between dietary fat and heart disease, dietary fiber and cancer, and calcium and osteoporosis). In addition, items were added to assess students' use of dietary supplements (two items) and demographic characteristics specific to the population.

This study's modified instrument contained 6 sections measuring knowledge, attitudes, behaviors, beliefs about diet-disease relationships, supplement use, and basic demographic information. The knowledge section contained 11 multiple-choice questions that tested the students' knowledge of basic nutrition concepts important for utilizing nutrition labels. This section also involved questions with pictures of nutrition labels that required each student to demonstrate his or her ability to read the labels correctly.

The attitude scale was comprised of five questions that assessed perceptions of usefulness, truthfulness, and accuracy of nutrition labels on a Likert scale ranging from 1 (Strongly Disagree) to 5 (Strongly Agree). Due to recent attention focused on the addition of trans fatty acid content to nutritional labels, (28) the attitude scale was modified from the original instrument in order to include an question regarding perceptions of the usefulness of information regarding trans fatty acids. Reliability measures were calculated for attitudes toward nutrition labels revealing a Cronbach's alpha of 0.54. Sufficient validity for the attitude scale was not supported by the factor analysis, and correlations between attitude scale items were low.

The four-item behavior scale assessed use of nutrition labels in selecting foods for purchase and/or consumption (scored on a five-point Likert scale from 1=Strongly Disagree to 5=Strongly Agree). An example is, 'When eating foods, I use the information on the 'Nutrition Facts' label to help me fit that food into my daily diet.' Behavior scale scores yielded a Cronbach's alpha of 0.71. A principle components confirmatory factor analysis with Varimax rotation supported validity for the behavior scale; all scale items loaded on a single factor and accounted for approximately 58% of the variance.

The diet-disease relationship scale consisted of three items taken from a 2000 study of student perceptions of relationships between diet and certain diseases. (10) Three items from the study were added to the Marietta and colleagues instrument (11) in order to measure the degree to which students believed a relationship existed between dietary fat and heart disease, dietary fiber and cancer, and calcium and osteoporosis, on a scale from 0 (no relationship) to 7 (strong relationship). The diet-disease relationship data yielded a Cronbach's alpha of 0.63. Principle components confirmatory factor analyses with Varimax rotation indicated all items loaded on a single factor and accounted for approximately 58% of the variance, providing support for validity of the diet-disease scale. Validity and reliability measures for the individual scales were not provided in the Marietta and colleagues study; (11) therefore, comparisons to previous use of the instrument could not be made.

Analysis

Basic descriptive statistics such as frequencies, means, and standard deviations were obtained for demographic variables and knowledge, attitudes, beliefs, and label-reading behavior. Bivariate analyses included Student's independent sample t-tests to compare label use and gender groups and Pearson's correlations for association between the constructs.

Responses to an open-ended question ('Provide the reason why you do or do not look at nutritional facts labels on foods.') explored the reasons for use of nutritional labels and were analyzed for recurring themes and coded into nine subcategories: health reasons, looking for specific information, don't care attitude, felt no need to read labels, weight control, already familiar with the labels on products purchased regularly, time (felt it took too long), buy the foods they want, and failure to understand or trust label content. Coding was conducted by two researchers, and any discrepancies regarding categorization were settled by consensus during the coding process.

A binary logistic regression was used to identify significant predictors of label use. The dependent variable was frequent/infrequent label use (as opposed to use/nonuse) in order to take advantage of a more even distribution of the variable. Respondents were classified as 'frequent' label users (42.4%) if they indicated use of nutrition labels 'always' or 'often.' Those who reported use of labels 'sometimes' or 'never' were classified as 'infrequent' users (57.6%). Predictor variables included knowledge, attitudes, beliefs about diet-disease relationships, and reasons for label use. Data analyses were performed using the Statistical Package for Social Science (SPSS) software.

RESULTS

Sample Characteristics

Demographic analyses revealed 52% of the sample was female and 94% of the sample indicated 'American' as their nationality (Table 1). Generalizability of results from the sample to the university's undergraduate population is increased due to the relative similarities of the sample characteristics for gender and national origin to that of the university population; 'nontraditional' students and graduate students were underrepresented.

Utilization of Nutrition Labels

A total of 85.4% of participants claimed to look at nutritional facts labels when purchasing foods 'sometimes' (n = 553, 43.0%),'often' (n = 350, 27.2%), or 'always' (n = 195, 15.2%). The remaining 14.6% (n = 187) reported they 'never' utilize the nutrition labels in purchasing decisions. Nine participants did not provide a response to this question. (Missing data was less than 1%.)

Knowledge, Attitudes, Beliefs, and Behavior

Pearson product-moment correlations revealed that all correlations between knowledge, behavior, attitudes, and beliefs about diet-disease relationships were positive and statistically significant at the 0.01 alpha level; however, these appear to be weak associations (Table 2). The strongest relationship was found between attitudes and behavior (r = 0.353).

Label Users vs. Nonusers

T-tests were conducted to determine if label users differed from nonusers regarding knowledge, attitudes, and beliefs about diet-disease relationships (see Table 3). In terms of knowledge, label users exhibited significantly higher mean scores (M = 4.6013, SD = 1.600) than did nonusers (M = 3.8079, SD = 1.681), indicating label users had higher nutrition and label use knowledge. Label users also exhibited more favorable attitudes towards nutrition label use (21.4417, SD = 2.898) than nonusers (M = 19.4516, SD = 3.070). Finally, the analyses indicated label users scored significantly higher (M = 16.2567, SD = 3.085) on questions related to diet-disease relationship than did nonusers (M = 15.2556, SD = 3.657), reflecting more accurate perceptions of the relationships between diet and heart disease, cancer, and osteoporosis. The largest effect size was found for attitudes toward nutrition labels (Table 3).

Gender Differences

Gender differences in knowledge, attitudes, beliefs about diet-disease relationships, and label use behavior were also examined using t-tests (see Table 4). Significant differences were noted (p<0.01) between males and females for all four variables. Although females scored significantly higher than males in nutritional knowledge, attitudes toward nutrition labels, beliefs about diet-disease relationship, and nutrition label usage, none of the effect sizes were large (refer to Table 4). (Cohen's recommendations for interpreting effect sizes classify effect sizes of 0.16-0.42 as small to medium. (29))

Determinants of Label Use

Results of the binary logistic regression revealed seven significant predictors of frequent or infrequent nutrition label use (see Table 5). Four variables predicted frequent label use: health reasons [OR = 4.079, 95% CI (2.272, 7.324)], looking for specific nutrient information [OR = 3.552, 95% CI (2.014, 6.267)], weight control [OR = 2.940, 95% CI (1.476, 8.032)], and knowledge [OR = 1.199, 95% CI (1.061, 1.354)], and three variables predicted infrequent use: buy the foods one wanted regardless of nutrition content [OR = 0.354, 95% CI (0.167, 0.768)], time constraints [OR = 0.237, 95% CI (0.103, 0.542)], and didn't care [OR = 0.182, 95% CI (0.091, 0.363)].

DISCUSSION

The purpose of this study was to examine college students' label usage and determine if users and non-users differed in terms of knowledge of nutrition labels, attitudes toward labels, and beliefs about diet-disease relationships. Results indicated that all the variables were significantly associated with each other. Significant differences were also noted with significantly higher knowledge, more favorable attitudes toward reading labels, and more accurate perceptions of diet-disease association among label users than nonusers. The finding of greater use of nutrition labels by females is consistent with other research results. (7,30,31)

Although statistically significant differences were found, it is important to understand that statistical significance is not necessarily equivalent to practical significance. An examination of mean differences in scores indicates that the statistical significance captured in this study may be primarily a function of large sample size (as illustrated by several low effect sizes). Therefore, additional analyses were conducted to elicit further information that could lead to more relevant and practical applications.

Results of a logistic regression revealed significant predictors of both frequent and infrequent label use. Predictors for frequent label use included health reasons (control diabetes, balance diet, be 'healthier,' etc.), looking for specific nutrition information (such as calories, fat grams, carbohydrates), weight control, and knowledge. Respondents' desire to purchase foods they wanted regardless of nutrition content, time constraints, and simply a 'don't care' attitude were predictors of infrequent label use.

The reasons for label use that significantly predicted frequent or infrequent use provide the most relevant information for both researchers and practitioners. The four factors that predicted label use could provide focal points for nutrition education programs that encourage nutrition label use among college students. For example, given the large odds ratio for health reasons, it might be useful for practitioners to incorporate messages related to health benefits of using nutrition labels to make wise dietary choices. In addition, the apparent importance of looking for specific information on labels would indicate that health/nutrition educators should tailor messages to audiences that include the specific pieces of information that are important consideration for their needs; for example, patients with heart disease might want to pay particular attention to fat content and cholesterol. Pointing out specific values of interest might enable consumers to utilize labels more effectively without feeling overwhelmed by abundance of information provided. This may help avoid confusion over labels that even nutrition professionals deem as problematic. (32) A 2005 review of the literature supports this and provides further evidence that label users are motivated to read nutrition labels when searching for specific nutrient content such as sugar, calories, and fat. (33)

Another significant predictor of frequent label use was knowledge, although it had a relatively small odds ratio as compared to the other three predictors. This could indicate that while nutritional knowledge may be essential for label use behavior, it is not a sufficient reason for label use. Therefore, nutrition education programs that simply target an increase in knowledge of nutritional labels among a college population may not result in increased label use.

The fourth predictor of frequent label use was weight control. A review of the data revealed that many participants use nutrition labels to select foods that allowed for effective weight maintenance or loss. National data from the Behavioral Risk Factor Surveillance System reveal a increase in obesity among young adults (aged 18-34 years) from 7.4% in 1990 to 16.5% in 2002. (34) Further, the 1995 College Health Risk Behavior Survey found one in five college students was overweight, and 30.8% of students had reported dieting within the 30 days prior to the survey. (35) Hence, use of nutrition labels for weight maintenance and weight loss is reasonable, and is supported by prior research. (1)

While this seems logical to most health/ nutrition educators, a twist on this concept emerged in the data. Several respondents indicated that it was unnecessary for them to lose weight; therefore, they did not look at nutrition labels. For example, one participant stated, 'I am thin and in shape, so I don't worry about this [nutritional] information.' This finding may be indicative of an attitude among some college students that healthy dietary practices correspond solely to weight. It may be important for practitioners working with this age group to emphasize other important reasons for good nutrition practices.

Of the three significant predictors of infrequent label use, the one that may have the most practical implications is related to time constraints. The students in this sample seemed to feel that reading nutrition labels was time consuming, and benefits gained from familiarization with nutrition content did not outweigh this loss of time. Due to this, practitioners might want to stress that with proper understanding of reading nutrition labels, the process does not have to be time-consuming or labor-intensive.

Implications for Practitioners

The previous discussion section identified multiple findings of relevance to practitioners. In order to facilitate a smooth transition between research and practice, the following provides a summary of implications addressing key focal areas for practitioners working to increase use of nutrition labels. First, explain that there are health benefits in using nutrition labels for proper food selection. Second, teach students/clients which specific components of the nutrition label are important for making food selections to meet their individual needs. Third, remain aware that nutrition knowledge, in and of itself, may not be sufficient to prompt use in food selection. Fourth, while many individuals may choose to use nutrition labels to assist in weight loss or maintenance, it is important to continue to emphasize the need for proper nutrition (and thus, the use of nutrition labels) in maintaining health dietary practices, regardless of current weight status (i.e., being 'thin and in shape' does not eliminate the need for healthy eating). Finally, stress that with a basic understanding of nutrition labels, using them is neither time-consuming nor labor-intensive.

Limitations

This study has several limitations. A self-selection bias and non-random sample may have influenced the results; however, the sampling of students in required physical education activity classes provided enhanced representation. The sample characteristics were similar to the demographics of the university population and hence support generalizibility of findings for the sampled university. The findings, however, cannot be applied to all college students. Future studies should use random samples from several universities in order to increase generalizability.

Reliability and validity of the attitude scale was relatively low (Cronbach's alpha = 0.54). While the instrument for this research was based on one utilized in research previously published in a major peer-reviewed journal, (11) the attitude scale data collected from its use in this study were not found to be reliable. Although the most relevant results for practitioners were not based on this scale, it is recommended that all results based on the attitude scale be interpreted with caution.

The instrument itself may have additional limitations. Although constructed based on surveys used in previous research, it is important to consider the practical significance of some of the items. For example, is it really important to know what percent of daily values a food must contain to be labeled 'High in Calcium,' or is it more important to know one should choose foods high in calcium and that the claim printed on the box is legitimate?

Recommendations

These limitations lead to several recommendations for future research. Studies that focus on skills (such as actually reading nutrition labels) and knowledge should include questions with practical significance to enhance relevance of results. Use of random samples and ethnic and age variations will provide important information for practitioners.

Ultimately, researchers work to increase knowledge that can be translated into practice, which ideally will lead to better quality of life. In order to reach this goal, researchers should pay attention to the practicality of their work. Doing so should facilitate a more clear translation of research into practice, thus helping to bridge the gap that often exists between them.

Future studies should also add qualitative components for an in-depth understanding of certain constructs such as reasons for nutrition label use. The use of open-ended items in this study provided depth to the findings that might have been overlooked had responses been restricted to previously identified categories. These responses allowed researchers to extract factors that were both predictive of the behavior of interest and that serve as logical points of intervention for practitioners.

ACKNOWLEDGMENTS

The authors would like to thank graduate and undergraduate student members of the Alpha Pi chapter of Eta Sigma Gamma for their assistance in the data collection process. Special thanks are also extended to the PEAP lecturers and Dr. Danny Ballard for their support of this project.

REFERENCES

(1.) Neuhouser ML, Kristal AR, Patterson RE. Use of food labels is associated with lower fat intake. J Am Diet Assoc. 1999;99:45-53.

(2.) Levy AS, Fein SB. Consumers' ability to perform tasks using nutrition labels. J Nutr Educ. 1998;30:210-217.

(3.) Committee on Use of Dietary Reference Intakes in Nutrition Labeling. Dietary reference intakes: Guiding principles for nutrition labeling and fortification. Washington, D.C.: National Academies Press; 2003.

(4.) Glanz K, Hewitt AM, Rudd I. Consumer behavior and nutrition education: An integrative review. J Nutr Educ. 1992;24:267-277.

(5.) Subcommittee on Interpretation and Uses of Dietary Reference Intakes, Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Institute of Medicine. Dietary reference intakes: Applications in dietary planning. Washington, D.C.: National Academies Press; 2003.

(6.) Kreuter MW, Brennan LK, Scharff DP, Lukwago SN. Do nutrition label readers eat healthier diets? Behavioral correlates of adults' use of food labels. Am J Prev Med. 1997; 13:277-283.

(7.) Byrd-Bredbenner C, Kiefer L. The ability of elderly women to perform nutrition facts label tasks and judge nutrient content claims. J Nutr Elderly. 2000;20(2):29-45.

(8.) U.S. Department of Health and Human Services. Healthy People 2010: Understanding and improving health. Washington, D.C.: U.S. Government Printing Office; November 2000.

(9.) Guthrie AF, Fox JJ, Cleveland LE, Welsh S. Who uses nutrition labeling, and what effects does label use have on diet quality? J Nutr Educ. 1995;27:163-172.

(10.) Smith SC, Taylor JG, Stephen AM. Use of food labels and beliefs about diet-disease relationships among university students. Public Health Nutr. 2000;3:175-182.

(11.) Marietta AB, Welshimer KJ, Anderson SL. Knowledge, attitudes, and behaviors of college students regarding the 1990 Nutrition Labeling Education Act food labels. J Am Diet Assoc. 1999;99:445-449.

(12.) Hawks SR, Goudy MB, Gast JA. Emotional eating and spiritual well-being: A possible connection? Am J Health Educ. 2003;34:30-33.

(13.) McMahan S, Hampl J, Chikamoto Y. A 'fat' tax: Knowledge and attitudes of snack food taxing among college students. Am J Health Educ. 2003;34:329-334.

(14.) Bungum TJ, Lofton S. The association of body mass index, perceived body mass index, and predictors of eating disorders among a sample of college students. Am J Health Educ. 2003;34:337-342.

(15.) Thatcher W, Rhea D. Influences on body image and disordered eating among secondary school students. Am J Health Educ. 2003;34:343-350.

(16.) Hawks S, Merrill RM, Madanat HN. The intuitive eating scale: Development and preliminary validation. Am J Health Educ. 2004;35:90-99.

(17.) Hawks S, Madanat H, Hawks J, Harris A. The relationship between intuitive eating and health indicators among college women. Am J Health Educ. 2005;36:331-336.

(18.) Vecchiarelli S, Prelip M, Slusser W, Weightman H, Neumann C. Using participatory action research to develop a school-based environmental intervention to support healthy eating and physical activity. Am J Health Educ. 2005;36:35-42.

(19.) Burckes-Miller M, Burak LJ. Sports participation and disordered eating behaviors and beliefs of middle school girls. Am J Health Educ. 2002;33:338-343.

(20.) Snelling AM, Schaeffer M, Lehrhoff S. Dieting and nutrition patterns of college females: Implications for college health educators. Am J Health Educ. 2002;33:357-361.

(21.) Hyman B. What's for lunch: Ideas for nutrition education. Am J Health Educ. 2002;33:373-375.

(22.) Black AK. The dietary guidelines for Americans 2000: A Web-based learner application. Am J Health Educ. 2003;34:105-108.

(23.) Herring JL. A rainbow day of eating. Am J Health Educ. 2003;34:243-245.

(24.) Fuller H, Damico A. Fat, friend, and foe: Exploring the physiological and social aspects of body fat. Am J Health Educ. 2005;36:117-119.

(25.) Albert N. How much sodium is in your diet? Am J Health Educ. 2005;36:120-123.

(26.) Yates J, Corrigan M. Fiber is your friend. Am J Health Educ. 2005;36:185-186.

(27.) Aleong C. Changing behavior through nutrition education and nine bracelets. Am J Health Educ. 2006;37:117-121.

(28.) Trans fat to be added to nutrition facts label. Food Insight. 2003:5.

(29.) Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Lawrence Earlbaum Associates; 1988.

(30.) Satia JA, Galanko JA, Neuhouser ML. Food nutrition label use is associated with demographic, behavioral, and psychosocial factors and dietary intake among African Americans in North Carolina. J Am Diet Assoc. 2005;105:392-402.

(31.) Huang TTK, Kaur H, McCarter KS, Nazir N, Choi WS, Ahluwalia JS. Reading nutrition labels and fat consumption in adolescents. J Adolesc Health. 2004;35:399-401.

(32.) Mitka M. Food fight over product label claims: Critics say proposed changes will confuse consumers. J Am Med Assoc. 2003;290:871-875.

(33.) Cowburn G, Stockley L. Consumer understanding and use of nutrition labeling: A systematic review. Public Health Nutr. 2005;8:21-28.

(34.) Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System: Trends data nationwide grouped by age. Available at: http://apps.nccd.cdc.gov/brfss/ Trends/agechart.asp? qkey=10010&state=US. Accessed November 10, 2005.

(35.) Centers for Disease Control and Prevention (CDC). Youth risk behavior surveillance: National College Health Risk Behavior Survey--United States, 1995. MMWR. November 14 1997;46(SS-6):1-54.

Magic, morals and health.(Health Education--Our Heritage)(Reprint) - American Journal of Health Education

This paper is reformatted and reprinted as part of the 40th Anniversary of the American Journal of Health Education (originally School Health Review) Health Education--Our Heritage. The original article appeared in Volume 1, School Health Review (November 1969, pp. 5-9). At the time, Warren R. Johnson was professor of health education and physical education at the University of Maryland, College Park, MD. A commentary on the 2010 relevance to health education of Dr. Johnson's paper immediately follows this reprinted version.

My original plan for this article was to discuss a matter over which Plato fought with the rhetoricians, namely: Is (health) education concerned primarily with influencing people to think and act, or is it concerned with teaching them how to think and act? However, it seemed to me desirable to deal first with what is, perhaps, a still more fundamental matter. Therefore, this discussion is concerned with pointing out (1) that the ancient magic-morals-health complex is still very much with us and (2) that if modern health education is to become a respected academic discipline and significant contributor to human health and survival, it must actively disavow the reality of this complex and commit itself objectively to is available data.

Magic has to do with the supernatural and the unnatural. It is indifferent to natural law and science and is aloof from scientific inquiry. Its existence depends upon unquestioning faith. Granted such faith, it is extraordinarily potent. If it does not move mountains, it convinces the faithful that it can. It can damage health (1,2) and perhaps, restore it (e.g., Lourdes and Oral Roberts). It has, historically and cross-culturally, been closely tied in with and supportive of morals and religion. ('Even in ... religions like Judaism and Protestantism, the conservatism of the religious mentality has preserved the magical-sacramental attitude toward reality.' (3,4) Deviant behavior tends to contain within itself the threat of magical retribution, if not to oneself, to one's loved ones ('What did I do to deserve this?').

Morals have to do with right and wrong, with good and bad, as defined by a particular society. The word derives from 'customs.' By definition, morals as well as customs may differ tremendously from society to society, right being wrong or more or less right or wrong, depending on where one happens to grow up. (5,6) Morals sometimes have the support and backing of laws, as in the case of our sex morals, but nearly always they are protected by magical forces via the superego and conscience.

Health may be defined narrowly as freedom from symptoms, or more broadly even than WHO's famous definition, as for example 'high level wellness' in all respects. (7) In modern times, health has been striving for a scientific base, as has also, sluggishly, education associated with it. Still, to a remarkable extent, and in many ways, health persists in being an issue of morals and thereby subject to magical influence. (8)

It is doubtless unfortunate, but not surprising, that this should be so. For we are at the flowing end point of a very long tradition in which the tie-in of magic, morals and health has simply been taken for granted, like the male-female double standard, befouling the environment, having wars, taking pride in irrationality, etc. Of course, we do not tend to take very literally the magical physical or mental punishments of, for example, Prometheus or Orestes. But the ills of Job and Lot's temptors and the magical curing of ailments by Jesus and the saints have been and still are taken quite literally. All of this contributes to the formation of a societal magic-mindedness concerning health.

The subject of sex provides a dramatic example of the viability of magic-morals in our perception of health. To take one of many possible examples, masturbation has an especially interesting history. (9-11) In our tradition, this story began with the Onan mythology (Leviticus) in which, for whatever reason, God smote Onan dead for spilling his seed upon the ground. Masturbation has since been a violation of morals and severely punished, if not physically by someone, by black magic via the superego. In due course, medicine of the past century joined forces with the religion-morals tradition to make masturbation the magical cause of all manner of diseases and mishaps ranging from pimples, sexual malfunctions, anxiety, mental retardation and madness, to death and damnation. It also threatened the body social, for as physician-anthropologist Mantegazza wrote:

   Masturbation is a true physical and moral   disease, which tends to leave a mark of   abjectness and decadence with a people   or with a race. It debases the man.... The   sexual embrace very rarely slays with its   excesses; whereas masturbation is often   suicide.... Until every man has ... a   woman, the nauseous stench of solitary   vice will continue to contaminate every   vein of our body social ...

This nonsense was published in 1885, but a paperback edition of its source, The Sexual Relations of Mankind, which appeared in the 1960s, is cited by some today as modern anthropological evidence of the ills created (magically) by masturbation. Moreover, the psychiatric literature of not many years ago was full of descriptions of disturbance supposedly caused by it--which is one of the reasons why physicians still send worried people off to psychiatrists for treatment of their masturbation 'problems.' A 1969 college health text advises that fighting off the 'undesirable' behavior results (magically) in 'maturity in thought and action.'

Some progress is being made in removing black magic from the masturbation-health picture. Theologians are beginning to let the spook yield up the ghost, as it were. (11,12) Medical educators have begun to help lay the old bugaboo to rest. (13,14) Moreover, perhaps we are beginning to realize that our anti-smut, anti-pornography efforts are based in considerable part on belief in black magic. Anthony Comstock, the originator of our present postal obscenity laws and a contemporary of Mantegazza, believed that if young men are sexually aroused by viewing nudity or reading about sex, they will be driven to find sexual release, most likely masturbation, and will thereby bring down upon themselves and society all of the ills described above. Thus, a major and most troublesome social health law is based on a lingering belief in Puritan morals backed by black magic.

MORAL NOTIONS OF NORMALITY

The multidimensional concept of normalcy is of special interest. Our magic-mindedness makes us incredibly vulnerable to threats posed by such words as 'normal.' Am I? Is my child? Is this behavior? Actually, of course, normality may be defined in several ways, including statistically, culturally, medically and morally. Most definitions acquire overtones of morals, deviating from whatever norm is likely to be construed in good-bad terms, which is to say, in terms of morals. Notions of a normality based on morals give rise to many curious interpretations of what is healthy and what isn't. Thus, many medical specialists do not seem to notice when they step out of their area of expertise and into the role of authoritative moralist on matters of normalcy, as for example, in connection with homosexuality, nudity, child rearing and other mysteries. Similarly, health educators, as well as psychiatrists, often find themselves calling the play with regard to what people should do to be normal, and decorum winds up looking like a health issue. Following are some examples of how the word normal makes people toe the mark by its magic.

Normalcy has some quite rigid, though unrealistic, requirements to make concerning such things as when a child should begin eating solid foods, be toilet trained, crawl, walk, talk, be ready for formal schooling, not be selfish, etc. Various forms of persecution, often times beyond belief, are utilized to drive the child toward the magically blessed norm. The young must not be interested in sex, self-stimulated or otherwise, although playing doctor may verge upon normalcy. Presently, gender role becomes a matter of normalcy, and one may quickly wonder darkly about the little boy who prefers to play with girls or has 'female mannerisms' (which, in point of fact, usually reduces to matters of faulty body mechanics). A real boy (normal) should be aggressive, sports and mechanically minded, mesomorphic, a good eater, outgoing. A normal girl may be a bit of a tomboy, but her main job is to learn how to be a graceful composite of Zsa Zsa Gabor and the Virgin Mary.

Disease and ailments, though by definition abnormal, are still not free of a status in morals. Most people will admit to having such diseases as measles; but cancer, epilepsy, psychiatric disorders and VD are tainted, as it were. Tuberculosis used to be. About the only good thing that can be said for heart disease is that is has tended to be socially acceptable. Mental retardation is slowly becoming so, but the stigma is still very much there.

Incidentally, food and sex afford an interesting contrast with regard to looking at normality from opposite ends. The sacrosanct status of eating--eating heartily, having three squares a day, feasting, using sweet-fatty foods as rewards for good behavior, glorifying meat, etc.--has given rise to the widespread disease of over nutrition. (15) On the other hand, the traditional denigration of sex has made it the principal target of morals and has given rise to a host of problems. It is perhaps amusing that the unmentionables are unspeakable; but the epidemic diseases of impotency and frigidity are not amusing. (14) Nor are the human relations problems which arise from the ineffability of personal sexual matters. (10,17)

It is clear that language plays a major, though generally unnoticed, role in the dynamics of the magic-morals-health complex. Indeed, language is perhaps the major means whereby that complex is perpetuated, and it seems deserving of some detailed consideration. (18) Immediate as opposed to chronic effects of language are easily demonstrated. Thus, word association-polygraph studies are based on physiological responsiveness to 'loaded' words. A person happily eating candy or a sandwich begins to retch upon learning that the candy is a grasshopper and the sandwich is made of rattlesnake meat. The food is the same; only the words are changed.

SOCIALLY DAMAGING EFFECTS OF LANGUAGE

The preconditioning effects of language are greater than commonly realized. Emotional trauma tends to become associated with happenings only when people talk or otherwise communicate about them in catastrophic terms. Thus, events ranging from sexual molestation, religious doubt, divorce and the death of a loved one to economic depressions, floods and bombings tend to acquire psychiatric overtones only if the language of catastrophe is associated with them. (19,20) Masturbation and childhood sex play--homosexual or heterosexual--have no known ill effects as such, but innumerable people have been made to feel guilt-ridden and self-despising for much of a lifetime because of what was said and otherwise communicated to them by adults who 'caught' them and invoked the magic of morals. Guilt and self-hate are, of course, major contributors to psychological illness.

Certain words are taboo in most languages (21) but in some, like our own, their use is also generally assumed to pose a threat to public moral health by means of a kind of voodoo. The young are punished when they demonstrate themselves wicked undesirables by using 'dirty' words, which everyone knows should be avoided by circumlocution. The first University of California student uprising was not met with force until someone put an impolite word on a placard. This word, being a clear-cut affront to morals and thereby, magically, to social health, led to the unleashing of the armed and eager police. Parents rarely feel as righteous in their savagery as when responding to such words.

In upholding the conviction, jail sentence, and fine of Ralph Ginzburg, the U. S. Supreme Court was concerned mainly, perhaps, with the socially damaging effects of words. For example, the Court found it damning that he had had his magazine, Eros, mailed from Intercourse and Blue Balls, Pennsylvania, so as to have the benefit of their somewhat droll postmarks. He thereby betrayed the 'lear of the sensualist' (neither word defined) which, magically, for reasons of morals, posed a threat to the moral health of the people.

A few additional examples may suggest the magnitude of the role of language in the magic of morals and health. Syphilis, which was associated darkly with sex moralistically long before it was microbiologically, is a dirty word. Thus, we are still able to tolerate the disease but not the word and words associated with it. So it flourishes. Cleanliness is next to godliness, and nothing is so dirty as dirty words. The word fluoridation has become a matter of black magic for some groups, white magic for others. The angry extremes seem unable to deal with the subject, only emotionally with the word. John Lear of the Saturday Review is something of a villain to many public health authorities for attempting to maintain an open dialogue concerning this shotgun prophylactic. 'Smoking' was a magic-morals issue long before there was evidence on the subject. The ferocious attacks on 'marijuana' users are not based on data of commensurate strength; it would seem that the roots of these attacks are not to be found in health science but in the dirtiness of the word, as well as the inquisition and subsequent witch hunts. The health-by-magic mentality is appalled by reports of pot smoking or wenching by 'our boys' in Vietnam; but is seems curiously indifferent to the weekly fatality listings of 'our boys.' Morals must be served at all costs. After all, Rome sickened and died, magically, for reasons of morals; and so, it is claimed, will we.

Albert Ellis has made a large point of the implications of the word 'should' as a factor in mental health and rational living. (19) This word probably has important though, perhaps, subtle implications for other aspects of health as well. Frequently, 'should' implies the existence of a divinely inspired rule book of morals, the violation of which means punishment by magic. Such admonitions as you should (or should not) bathe every day, eat a large breakfast, clean up your plate, exercise daily, stop drinking or smoking, be popular, be involved in lots of activities, marry, have children, become a skilled sex partner before marriage, strive for simultaneous orgasm, sun bathe, etc., etc.--all such raise the question, 'Who says so?' And, 'What is supposed to happen to me if I don't?' 'You should ...' is quite different from citing the available evidence and drawing conclusions from it.

PLATFORMS FOR THE WOULD-BE MORALISTS

It has been my experience that the health educator most commonly gets involved in the magic-morals-health complex at this particular point--at the point where he acquires the notion that he knows how people should live and behave if they would be 'healthy'--healthy, of course, as defined by the particular health educator. I am not referring here just to the scouting manual type exhortation about such things as drinking, smoking, masturbating and helping old ladies across the street. Rather, I am trying to identify an entire philosophy of health education which is based upon morals-by-magic, rather than upon objective evaluation of available data. I am protesting the popular brand of health education which serves as a platform for the would-be moralist who pretends to have, or is in quest of, a scientific base for his magic-mindedness as he sets about telling people what they should do. Health is not witchcraft for converting the infidel. Still, how depressing it is that so many teaching health seem to know more about morals than ecology.

A recent event may illustrate my meaning. A college-level health educator stated that he was adjusting a graduate course on health science to make it a study of persuasion techniques so as to study ways of 'getting people to live the way they should--at least the way we think they should.' I am not concerned here with the colossal arrogance of the statement which implied the ability of a slowly emerging discipline not yet surfeit with intellectual giants to presume to tell people how they should live. (! am not disrespectful of the possible uses of persuasion techniques in health education.) The point is that this was not a statement about health at all. It was a statement about morals in the directive, Puritan tradition. Hell fire is no longer available to us. We must therefore resort, reluctantly, to subtle means of coercion. But we do know what is good for people and what they should do and be, even though as Dubos has emphasized repeatedly, we really don't know much about human health at all. (15)

Whenever one comments at all critically in the subject of morals, he risks being accused of being in favor of immorality, against values and ethics. Anthony Comstock rammed our postal obscenity laws through Congress on the threat that Congressmen were either for his brand of morals or they were immoral. The Far Right is currently playing this same game with regard to school sex education, and the invocation of magic-morals makes serious dialogue on the subject virtually impossible. In contrast, the scientist arguing against amoral science feels a certain obligation to define his terms in a way that encourages discussion. (22)

My impression is that a crucial but apparently little recognized issue in modern health education has to do with the question of whether we are data or magic-morals oriented. This question may be important for at least two reasons. First, health educators have to decide whether they do, indeed, possess an academic discipline in the same sense that other scientifically based subjects do. The study of magic-morals can be an academic discipline, but the practicing of it cannot. Second, when health educators do not try to act like professional moralists in their teaching, they are in a better position to help mankind deal with some of its major problems-problems of which if not soon confronted frontally and rationally will likely lead to the destruction of the race, perhaps even of life on earth. Our new knowledge of the moon and planets provides accurate and picturesque insights into what lies ahead for planet earth unless we soon see the need for desperate action relative to our collective health.

It seems to me that health education can have a future as a major academic discipline. However, it will not become one until, like chemistry emerging from alchemy or astronomy emerging from astrology, it emerges from the limbo state in which it is, to an amazing degree, still magic-morals looking furtively and futilely for its justification in science.

REFERENCES

(1.) Cannon WB. Voodoo death. Psychosomc Med. 1956;19:182.

(2.) Gellhorn E, Loofbourrow GN. Emotion and Emotional Disorders. New York: Harper, 1963.

(3.) Tillich P. The religious symbol. Daedalus. 1958;87:3-21.

(4.) LaBarre W. Religions, Rorschachs and tranquilizers. Am J Orthopsychiatry. 1959;39:688.

(5.) Ford CS, Beach FA. Patterns of Sexual Behavior. New York: Harper, 1951.

(6.) Kluckhohn C. Mirror for Man. New York: McGraw-Hill, 1954.

(7.) Dunn, HL High Level Wellness. R. W. Beatty Co., 1961.

(8.) Tillich P. The Relation of Religion and Health: A Symposium. New York: Association Press, 1958.

(9.) Dearborn LW. Autoeroticism. In Ellis A, Abarbanel, A. eds. Encyclopedia of Sexual Behavior (2nd ed). New York: Hawthorne, 1967.

(10.) Johnson WR. Human Sexual Behavior and Sex Education. Philadelphia: Lea & Febiger, 1968.

(11.) Johnson WR. Masturbation and the sexual revolution. In Semmens E. ed. Adolescent Sexual and Social Development: A Counselor's Guide. New York: Macmillan, 1969.

(12.) McInnes AG. Roundtable on moral aspects of sex counseling by physicians. Med Aspect Hum Sex. 1967;1:61.

(13.) Lief HI. Sex education of medical students and doctors. In Vincent, CE, ed. Human Sexuality in Medical Education and Practice. Springfield, IL: Charles C. Thomas, 1968.

(14.) Masters WH, Johnson VE. Human Sexual Response. Boston: Little Brown, 1966.

(15.) Dubos R. Man Adapting. New Haven, CT: Yale University Press, 1965.

(16.) Johnson WR. Masturbation. In Vincent CE, ed. Human Sexuality in Medical Education and Practice. Springfield, IL: Charles C. Thomas, 1968.

(17.) Kirkendall, L. Sex Education as Human Relations. New York: Inor, 1950.

(18.) Johnson WR, Belzer E. Language and health. J School Health. 1962;32:134.

(19.) Ellis A, Harper R. A Guide to Rational Living. Englewood Cliffs, NJ: Prentice-Hall, 1961.

(20.) Ellis A. Reason and Emotion in Psychotherapy. New York: Lyle Stuart, 1963.

(21.) Hayakawa SI. Language in Thought and Action. New York: Harcourt, Brace & World, 1939.