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Participants
A total of 471 college students enrolled in the study during the spring semester 2002. Participants were recruited using a stratified random sample of classes from upper and lower division general education classes. Final class selection was dependent on obtaining instructor permission to enter classes. A proportionate number of students from lower and upper division classes were selected. The study protocol and survey instrument were approved by the university’s institutional review board for the protection of human subjects.

Design

All participants were asked to complete a survey designed to assess the dietary and exercise habits and perceived barriers to following a healthy lifestyle of college students. The current survey was adapted from a University of North Florida’s survey of diet and exercise of freshman (Rodriguez, 1999). The survey had 38 questions and was divided into three sections. The first section (six questions) asked for anthropometric and demographic data. The second section (20 questions) asked participants about their current dietary habits and perceived barriers to eating a healthy diet. The third section (nine questions) asked participants about their current physical activity patterns, perceived body image and perceived barriers to an active life. The survey took approximately 15 minutes to complete.

Statistical Analyses

We used the SPSS package (LEAD Technologies, Inc.) for Windows, release 11.0, to analyze the data. Frequencies were used as descriptors of the student population. Chi-Square (χ2) statistics were used to examine differences in frequencies of responses to questions on dietary and exercise habits and perceived barriers to following a healthy lifestyle by gender.

Results

Approximately 60% of the participants were female and most were aged 18-21 years. There were very few graduate students represented in this sample. Thirty-one percent of the population had a body-mass-index (BMI) greater than 25 based on self-reported height and weight data, indicating a high percentage of overweight (BMI 25 – 29.9) and obese (BMI > 30) individuals in such a young population. Forty percent of men compared with 20% of women had a BMI greater than 25. One question on the survey asked participants if they had lost, gained or had no change in weight in the last few years. Of the 414 participants who responded to this question, 46% stated they had gained weight, 30% had no change in weight, and 24% had lost weight. Of those that had gained weight, the average + SD gain was 12 + 10 pounds (range: 2 – 100 pounds).

Discussion
As hypothesized, more clinical skills are needed to secure health education positions in the clinical setting. Most respondents felt a CHES certification was beneficial to their positions. When asked what heath educators could do to “sell” themselves to prospective employers, 60% (n=15) said demonstrating knowledge of health education, program planning, program implementation, evaluation and grant writing were the best skills to have to sell themselves. In addition, being able to communicate or explain what health educators can do for a company was answered by 24% (n=6) of the respondents. Twelve percent (n=3) said to research the company and find out how you can meet their needs. One respondent (4%) suggested taking examples of work done from internships and classes such as brochures, PowerPoint® presentations, display boards, and other works to show the prospective employer. When asked about other course work they would recommend in terms of academic preparation to be a health educator in a clinical setting, 24% (n=6) said clinical physiological testing skills were important to know. Twelve percent (n=3) said volunteer experience in a clinical setting was important, marketing and sales courses, communication classes and education courses would be helpful. Counseling or social work courses, medical terminology and nutrition courses were the answer given by 8% (n=2) of the respondents of courses helpful in preparation of a career as health educators.

What do these results mean for the profession of health education? If upon graduation, health education students want to work in the clinical setting, they must make good choices on how to choose their elective courses. The courses they choose should emphasize clinical skills, communication, education, marketing, counseling, medical terminology, and nutrition. They should also have volunteer experience in a clinical setting, and choose to complete an internship in a clinical setting. After graduation, when trying to gain employment in a clinical setting, they need to be able to demonstrate the knowledge they possess, the experiences they have gained and demonstrate what they can offer to prospective employers. Many employers do not know very much about health education graduates and need to be educated to the benefits of hiring a health educator to fill clinical positions.

This study was not without its limitations. The greatest limitation was the selection of the participants. The snowball sampling technique was used because resources were limited and a probability sample was too costly and time consuming to complete. Non-probability samples have limitations because results can only be generalized to those who participated. Bias may occur since those who are not included in the sample may differ in ways from those who are included in the sample (McKenzie et al., 2005).

Conclusions
In conclusion, additional studies on health educators working in the clinical setting need to be completed to gain a better understanding of the profession. Leaders of organizations who employ people in clinical settings need to have a better understanding of what health educators are doing and the potential they can bring to an organization. In order to change the mind-set of many who feel that only those with clinical training should do patient education creates a great obstacle, which needs to be overcome. Only with more information available and continued monitoring of credentialing to provide a set of standards for health educators, can attitudes be changed and gains be made in the area of health educators working in a clinical setting.

Sixty-two point five percent (n=25) of health educators who were invited to participate in the study did so by either answering the questionnaire verbally over the telephone or completing a questionnaire and returning it by email. These 25 individuals worked for 12 different agencies. Of the agencies and organizations employing the participants in the study, most 75% (n=9) of these agencies were not-for-profit organizations. Of those who participated, 98% (n=23) were females and 44% (n=11) were CHES certified. Another 16% (n=4) reported to have taken the exam and were awaiting results at the time this survey was conducted.

When participants were asked about their job title, 15 different job titles were given. Sixty-eight percent of the respondents (n=17) reported the number of health educators on staff was between one and five. When the respondents were asked about their major job responsibilities, community education was the most reported response, followed by management, teaching nutrition/fitness, patient education, scheduling, program planning, coordination of planning, being a community liaison, and supervision.

A number of questions were asked about the services provided by the health educators and their agencies. Eighty-four percent (n=21) offered public education. Seventy-two percent (n=18) offered employee education, and 64% (n=16) offered patient education programs. There were 88% (n=22) who reported attending health fairs, with 72% (n=18) who attended less than 19 per year. When asked if they charged for health education programs, 64%, (n=16) did not charge. Yet, 68% (n=17) of the respondents reported they relied on grant dollars for program funding. Of those who relied on grant funding, 28% (n=7) of the respondents reported 90-100% of their budget was grant funded.

When asked with what agencies they worked most closely, 44% (n=11) worked with voluntary agencies, 36% (n=9) worked with schools, 36% (n=9) work with local health departments, 16% (n=4) work with county tobacco coalitions, 12% (n=3) with hospitals, state health departments, churches or religious organizations, and health centers, 8% (n=2) with state agencies, and less that 4% (n=1) worked with city government, centers for aging, YMCA, community agencies and federal agencies.

One hundred percent of the respondents reported offering activities outside the clinical setting (also known as outreach programs). In these outreach programs, 80% (n=20) used printed materials, 76% (n=19) offered educational programs, and 60% (n=15) offered free health screenings. Most respondents (80%, n=32) reported that their agency paid for materials instead of getting donations for materials or creating their educational materials in-house.

Several questions were asked about the Certified Health Education Specialist (CHES) credential. Most of the respondents, 72% (n=18) felt the CHES certification was helpful in their positions. There were 56% (n=14) who said the CHES certification was necessary to sell themselves to potential employers. Only 16% (n=4) of the respondents felt a CHES certification was not necessary in their positions.

Participants
The participants in this study were selected using a snowball sample. A snowball sample includes those identified by the researchers and others referred by initial participants (McKenzie, Neiger, & Smeltzer, 2005). In this study the researchers initially identified 20 potential participants. These individuals were called and invited to participate in the study. If they agreed, they were interviewed. At the conclusion of the interview, they were asked to give the name(s) of other health educator(s) working in Indiana in a clinical setting, thus, the snowballing of the sample. A total of 40 individuals were contacted using this process with 25 (62.5%) willing to participate.

Instrumentation
An original questionnaire was created to identify the roles and responsibilities of health educators from Indiana working in clinical settings. Perhaps the most challenging aspect of developing a useful instrument was deciding what information was needed to better understand health educators and their roles in the clinical setting. The researchers developed an initial pool of 20 questions for the instrument. A review of the questions by a university professor was used to establish face validity. Content validity was established using a jury of experts. The jury was composed of six health educators working in a clinical setting. After the jurors agreed to participate, they were emailed a letter explaining the purpose of the instrument, a draft of the instrument and instructions for completing three tasks. First, they were asked to read each question and to make suggestions for making any unclear questions better. Second, they were asked to offer suggestions or new questions they thought should be included in the instrument. And third, each was asked to rate the questions as either essential, useful but not essential, or not necessary. Upon receipt of the jurors’ work, unclear items were rewritten, and some questions were deleted and added. The final instrument contained 24 questions.

Data Collection
Data were collected via a telephone or email survey. When the subjects were contacted by telephone, they were asked if they would be willing to participate in a survey about health educators working in a clinical setting. If so, they were interviewed then or at another convenient time. If the subjects felt uncomfortable about being interviewed by telephone, or did not have time for a telephone interview, the questionnaire was emailed to them for completion. Of the 25 completed questionnaires, two (8%) were completed via telephone and 23 (92%) were completed via email.

Upon receipt of each completed questionnaire, each was coded and the data were transferred to a computer scan form. Data analysis included tabulation of frequencies and percentages.

This study examined the task of health educators working in a clinical setting to better understand their roles. The study was designed as a descriptive, cross-sectional survey using a convenience sample of health educators who worked in clinical settings in Indiana and who had a college degree in health education. Forty health educators were contacted and 62.5% of the subjects participated in the survey. Results indicated most jobs were similar in nature and the health education curriculum studied helped them in the roles they were serving. However, many educators felt there were other content areas of study that would have been helpful to prepare them for working in the clinical setting. A majority of the respondents reported that having Certified Health Education Specialist (CHES) certification was helpful and necessary in their positions.
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Introduction
The process to define the role of a health educator began in 1978. By 1981, the generic role was defined. Shortly thereafter came the writing of the Competency-Based Framework for the Professional Development of Certified Health Education Specialist (National Commission for Health Education Credentialing, Inc. [NCHEC], 1996). Recent challenges in public health since September 11, 2001, have highlighted the role of health educators and research has described its supply, geographic distribution, educational preparation and desired competencies (Finacchio, Love, & Sanchez, 2003).

Even though there appears to be a need for health educators, and we profess to prepare generic health educators, some have questioned whether it is possible to do so because of the peculiarities of each setting (McKenzie, 2004). Examples of such peculiarities include the culture in the business world (work site setting), and the language used in health care (clinical setting). Because of some of these peculiarities, it has been very difficult for health educators to secure health education positions in the clinical setting. Employers have been more inclined to hire individuals with clinical training than health educators for health education positions in the clinical setting. While the work of health educators in community health settings is well understood, very little information has been written on this subject of health educators working in the clinical setting. Therefore, the purpose of this study was to find out more about the work of health educators in the clinical setting. This information would not only be helpful to new health educators seeking employment in a clinical setting, but also to healthcare organizations that could benefit from employing health educators.

In targeting populations for intervention it is helpful to understand the existing socioeconomic status (SES), therefore, every effort was made to interview men of different socioeconomic and education levels, but as was shown in the demographics the socioeconomic status there was very little difference between blacks and whites in the sample. According to Robbins, et. al., 2000 & Liu, et. al., 2001, people in higher economic status may have an advantage in that they can afford better health insurance and access to health care, and may therefore experience a higher survival rate. In their study men with higher socioeconomic status reported more frequent prostate screening than men in lower SES. In our study, however, there was a lack of variation in screening behavior by race.

More Blacks than Whites indicated that the television was their most important source of information on prostate cancer, followed by regular newspapers and literature received at health centers. Television as a medium for educating men seems to be crucial and should be utilized more by people working with African Americans in the field. When comparing the two groups it appeared that more whites than blacks received information from health centers as well as from their personal physicians, but this was not significant.

This study is not without its limitations. In the present study, there was a sole dependence on self-report measures to gather data. Also, the cross-sectional design disallows any allusion to causality. More sophisticated designs are necessary to establish causality in previous studies. It should be noted also that the sample size was somewhat small especially for White males in the study. However, the intent was to study Blacks, but a cohort of White men was included in order to make comparisons and strengthen the study. Therefore, results may not be representative of all Blacks and Whites in the counties. Most men were surveyed at churches, organizations or at the workplace, and it is possible that those who completed the survey were already actively engaged in prostate cancer screening and education. While there are some important limitations with the study, some of the strengths of the study should be noted as well. This present study sheds important light on the topic characterized by a paucity of empirical analyses. Because of the importance of the subject, this study has implications for health promotion and education of men in general and particularly Black men who tend to have a larger burden of the disease.

Aggressive health promotion for early detection of prostate cancer is likely to increase participation in programs. If we are able to distinguish and enumerate some reasons for lack of early detection especially in black men, and explain attitudes that prevent them from seeking help early, health providers will be better able to translate this into more appropriate service and reduce the disparities that exist between the two groups. The findings may be quite different if we had a larger percent of men from a lower socioeconomic and educational background. We therefore recommend further study with a larger group of men, particularly Black men in lower socioeconomic status. Future studies could include more cultural factors and their impact on early prostate screening.

The majority (72%) felt that their doctors cared about them enough and did not withhold important information from them, but 21% said they were uncertain as to whether their doctors would withhold information. Fifty-three percent did not believe that prostate cancer was a common part of aging, but 34% were uncertain.

Overall, 53% of respondents and 55% of Blacks expressed uncertain feelings as to whether or not they were likely to develop prostate cancer. The majority (82%) believed that prostate cancer can be cured if detected early and 83% believed that screening is effective in finding the cancer early. Most (48%) were uncertain as to whether a person with prostate cancer will die within a few years and 43% did not believe they will die within a few years. Although 72% believed that men can have prostate cancer without having a family history of the disease, 25% were uncertain.

Generally, most respondents (60%) said that they wanted to do what their immediate family thought was important for detecting prostate cancer early. More Blacks (82%) than Whites (55%) said that they would do what their family member thought was important. Half (50%) said that they would get tested for prostate cancer if their wife or girlfriend told them to get a test.

Discussion
This exploratory analysis done with the use of descriptive statistics yielded some valuable results. It was found that most of the men in the sample did not find it difficult to obtain screening for prostate cancer. However, far too many did not avail themselves of this vital screening. That finding shows that while they have the sense that the screening is important, knowledge alone did not offer sufficient motivation to take decisive action to engage in health-seeking behaviors. Also, it was found that among those who had regular checkups, about half of the men did not discuss prostate cancer with their doctors. These findings are interesting in that they point to the fact that there are indeed barriers that short-circuit the motivation necessary for acting consistent with knowledge about this important health concern, prostate cancer. These findings are consistent with those of Fearing, et. al., 2000, and Etzioni, et. al., 2002).

Another interesting finding of the study was the lack of knowledge of the men about the presence of prostate cancer in their family history. This finding points to the need of men in this context to be sensitized to risk factors for prostate cancer and how to manage these risk factors. Doctors played a crucial role in the diagnosis of this problem. Therefore, patients should be invited to discuss the issue on their regular checkups and care should be taken to educate men about this problem

Participants were asked how difficult it was for them to obtain a screening test for prostate cancer. The majority (76%) reported that it was not difficult, 15% thought that it was difficult and 9% reported that they did not know whether or not it was difficult to obtain a screening test for prostate cancer. A little more than half of the sample (54%) reported that they had a prostate test within the last year, at the time the survey was conducted, but 46% did not have a test within that year. As to whether screening for prostate cancer was part of their regular medical check-up, 58% reported yes and 42% indicated that this was not a part of their regular check-up. More Whites (62%) than Blacks (57%) said that prostate screening was part of their regular medical check-ups. As to whether their doctor discussed prostate cancer or the need for screening with them, 50% said yes while the other 50% said no.

The television ranked highest as their source of information about prostate cancer, followed by their doctor and brochures at health centers. Participants were asked about their knowledge about screening tests for prostate cancer. Of the sample, 67% indicated that they knew what screening tests are done for detecting prostate cancer. There were 33% that did not know. Participants were asked about their family history of prostate cancer. Twenty-five percent did not know about their family history, and 22% said that they had a relative with prostate cancer. Of the relatives who had prostate cancer, 38% were fathers, 17% brothers, 19% cousins, and the rest were other relatives.

Of those who indicated that they had a relative with prostate cancer approximately 30% of them said that they had a prostate test within the last year. Only 13% of respondents said that they had experienced having prostate cancer themselves or were told that they had an enlarged prostate. When comparing Blacks and Whites on this question, more Blacks (15%) than Whites (10%) were told that they had cancer of an enlarged prostate. They were asked if they had a personal family doctor and 81% said yes, however, there were some differences when comparing Blacks and Whites. More Whites (92%) than Blacks (77%) reported having a personal family physician they can see on a regular basis.

When responding to attitudes and beliefs about prostate cancer screening, 84% either agreed or strongly agreed that if they had prostate cancer it would be serious enough to want to do something about it. Over 65% felt that the blood test for prostate cancer, PSA can detect the cancer early, 33% were not sure what tests were actually carried out and 42% believed that screening would be uncomfortable. Those who felt that the screening would be uncomfortable were also less likely to get screened.

Subject Selection
The priority population for this study was Black and White men age 40 and older residing in San Bernardino and Riverside Counties in California. A population-based convenience sample was selected from community clubs, churches, worksites, and bus stops. Men fitting the age criteria who volunteered to complete the questionnaire were included in the study, and the questionnaire was self-administered. Altogether, a sample of 214 men was obtained.
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Instrumentation
A structured questionnaire was developed and pre-tested among Black and White men (n=25) within the priority population. After review and final changes, this questionnaire was used as the instrument for data collection for the present study. The questionnaire included 25 questions with several items to ascertain the respondents’ attitude towards prostate cancer screening and early detection, beliefs about prostate cancer, access to screening, prostate cancer information, and family history of prostate cancer. In addition, there were demographic questions such as age, education, income, marital status and occupation. Questions dealing with attitudes and beliefs about prostate cancer were measured using a five-point Likert Scale (strongly agree to strongly disagree). Participants were asked to respond to statements designed to measure attitudes and beliefs. This psychosocial scale for the measurement of attitudes and beliefs has been used for decades in various populations.

Procedure
Prior to conducting the survey, letters were sent to several churches and men’s organizations in the area explaining the purpose of the survey and asking them to encourage men within the age group to participate. Some churches and organizations responded positively and invited us to conduct the survey on a day and time designated by them. No follow-up was done on churches that did not respond. Men within the age criteria who volunteered to be in the study completed a questionnaire and returned it to the person collecting the data. Some church leaders and organizations asked that the questionnaires be left with them to be distributed to members. Completed questionnaires were returned in a sealed envelope. For anonymity, participants were asked not to write their names on the questionnaire. Both Black and White men were recruited to be part of the study.

Data Analysis
Data was entered and analyzed using the Statistical Packages for the Social Sciences (SPSS/PC) version 10. The data set was investigated for missing values and outliers, and irregular value recording. Descriptive information was calculated for all variables. Correlations were done on all major variables of interest for the present study.

Results
There were 214 who participated in the study and completed the survey. Of these, 75% were Black and 25% were White. Most (53%) were within the 40-50 years age group, 26% in the 51-60 age group, and 21% indicated that they were over 60 years old. Seventy-four percent were married, most had a college degree with a yearly income greater than $21,000. Approximately 39% reported earning $50,000 or more per year.

Black men have been shown to have a higher risk of prostate cancer when compared to men from other ethnic groups, and they also die at a younger age. Although many Black men are aware of the benefits of screening, they are less aware of limitations. Some researchers felt that decisions were made to participate in screening without fully understanding the necessity for screening. More information is needed to help them make informed decisions about prostate cancer screening for early detection (Taylor, et. al., 2001; Taylor, et. al., 2002). A study among African American men living in Philadelphia to ascertain how receptive they were to regular screening for prostate cancer, showed that African American males in that setting were willing to participate in annual prostate screening modalities. The study further indicated a need for education and advice about prostate cancer screening and prevention for Black men (Myers, et. al., 1996). This and other studies also indicate certain obstacles to screening and a need for education and advice about prostate cancer and participation in activities for early detection. Some obstacles to early detection included: being able to make and keep an appointment, and attitudes of other family members toward prostate screening. It is important to know that when the cancer is detected early, there can be a reduction in early mortality and an improvement in the quality of life as well. When the cancer the detected late, as in the case for many Black men, there is an increase in mortality and a faster rate of recurrence (Boyd, et. al., 2001; Kirby,1996; Banerjee, et. al, 2002).

A study of attitudes of Blacks toward prostate cancer screening trials was conducted in Los Angeles, California. Results indicated that African American males at the middle socio-economic level were more willing to participate in clinical trials when compared to those of lower socio-economic levels. The study also examined possible barriers to participation in screening and found that fear of medical experimentation and distrust for the “medical establishment” were main barriers for African Americans (Robinson, et. al., 1996). Differences in socio-economic status and survival after prostate for Black and White men are also supported by other studies (Robbins, et.al., 2000). Furthermore, younger Black men in a lower income bracket and with less education appear to have more prostate problems when compared to White men and the outcomes for treatment are not as promising for Black men who also experience poorer survival and increased mortality (Lubeck, et. al., 2001; Piffath, et. al., 2001; Walker, et. al., 1995).

The literature shows the importance to prostate cancer to men, especially to Black men. It further showed the importance of early detection in circumventing mortality rates as a result of prostate cancer. While many studies have focused on Black men and prostate cancer, many of them failed to investigate the factors that inhibit early detection. The present study seeks to fill this gap in the literature so as to affect better health seeking behaviors among Black and White men and to produce better outcomes with respect to prevention or early detection and treatment of prostate cancer.