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Only a small percentage of college students are consuming the recommended number of servings for fruits, vegetables, and dairy (Hiza & Gerrior, 2002; Georgiou et al., 1997). In the present survey, 58% and 64% of the participants state they consume vegetables or whole or canned fruit less than once per day, respectively. This agrees with the 51% of participants who rate the “healthiness” of their eating habits as poor or fair. Dinger and Waigandt (1997) surveyed over 2,600 college students and found that 40% had not eaten any fruit in the previous 24 hours and 55% had not eaten green salad or cooked vegetables. According to a study by Debate et al. (2001), in a population of 630 college students, only 18% consume 5 servings per day of fruits and vegetables, 7% consume 6 or more grain products, and 53% consume 2 or more dairy products. An earlier study by Melby et al. (1986) reported that 69% of college students do no eat any fruit once a day and 48% eat vegetables less than once a day. These findings are cause for concern because there is ample data suggesting that fruit and vegetable consumption may be protective against most cancers and cardiovascular disease. The decreased risk of chronic disease associated with a plant-based diet may be due to substances in fruit and vegetables such as antioxidants, folate, fiber, potassium, flavonoids and numerous other phytochemicals (Hyson, 2002; Van Duyn & Pivonka, 2000).

The most common barrier cited to eating well is “lack of time.” Other common reasons are “lack of money” and “taste preferences.” Lopez-Azpiazu et al. (1999) examined perceived barriers of healthy eating among 1009 Spanish adults, over the age of 15 years, and found the common barriers were “irregular work hours,” “willpower,” and “unappealing food.” Lappalainen et al. (1997) reported that “irregular work hours,” “giving up foods I like,” and “willpower” are the most common barriers to trying to eat healthier in a large study with over 14,000 European adults, 15 years of age and older. The present survey noted some differences in barriers between men and women. More women state “lack to time,” while three times as many men state “don’t care.”

The steepest decline in physical activity occurs during adolescence and young adulthood (Allison et al., 1999; Grace, 1997; Leslie et al., 1999). Pinto and Marcus (1995) report that 46% of young adults on college campuses are inactive or active irregularly and only about 35% have a regular schedule of physical activity. This is similar to results of Dinger and Waugandt (1997) who found that 30% of college students did not engage in moderate physical activity the previous week and only 45% report participating in vigorous physical activity. Haberman and Luffey (1998) also state that only 39% of 302 college students exercise enough to meet the Healthy People 2000 goal for activity. In contrast, in this particular population of college students, 84% state they currently exercise. However, it should be noted that exercise (frequency or intensity) was not defined. Despite this high reported rate of activity, 42% state they exercise less since attending college. Leslie et al. (1999) found that about 70% of a population of over 2,700 college students report less activity at college. Men exercise more frequently and at a greater intensity level than women and men select strength-training and competitive sports more than women. Women select aerobics more than men. These gender differences also are reported by Leslie et al. (1999) and Pinto and Marcus (1995).

The main reason participants’ exercised in this survey was for “health.” Among other stated reasons, women exercise because of weight and stress reduction and men exercise for enjoyment and gains in muscle and strength. Similarly, Myers and Roth (1997) found that college women exercise for its psychological and body image benefits and Leslie et al. (1999) found that men are motivated to exercise for muscle.

Discussion
The purpose of this survey was to assess the diet and exercise habits and perceived barriers to following a healthy lifestyle of college students and to determine if differences exist by gender. The survey population is young; most students are 21 years of age or younger, and there are a fairly even distribution of students by class standing. Twenty-five percent of students have a body mass index (BMI) placing them in the overweight category and 6% are classified as obese. In close agreement with the current survey, Lowry et al. (2000) report that 35% of college students are overweight or obese based on the 1995 National College Health Risk Behavior Survey. In contrast, Haberman and Luffey (1998), in a population of 302 college students, report that 8% are overweight. Female students in this survey population have a similar incidence of overweight (20%) as that reported by Anding et al. (2001) in a small population of 60 female students (25%). While 40% of men in this survey have a BMI greater than 25, 19% of these men report that they strength-train and 41% report they do a combination of exercise. Many of these men may have a greater proportion of lean body mass. Self-reported height and weight data must be viewed with caution as Jacobson and DeBock (2001) recently reported that college men underestimate height and college women underestimate weight.

Many college students have poor nutritional habits (Georgiou et al., 1997). Most do not meet the minimum recommended intake of dietary fiber, fruits, and vegetables; and exceed recommended intakes of total fat and saturated fat, sugar, and sodium (Anding et al., 2001; Grace, 1997; Hiza & Gerrior, 2002; TLHS, 2000). Thirty-three percent of this survey population report they consume breakfast “never” or “seldom.” Hertsler and Frary (1989) studied food behavior among 212 college students where 43% report skipping breakfast more than half the time. Eighty percent also indicate that they snack one to three times per day while 4% note four or more times per day. In the present survey, 63% are inclined to snack one to two times per day, 26% three to four times per day and 5% four or more times per day. “Boredom” was the most frequently cited reason for snacking. The present survey also found gender differences in types of snack foods and additional reasons for snacking. Men state “partying” as a reason for snacking more frequently than women and women state “emotional” more frequently than men. While most students snack on chips, crackers, or nuts; men snack on fast foods more and on ice cream, cookies and candy less frequently than women. Twenty-six percent of women and 38% of men in the current study report drinking regular soda or other sugared beverages one or more times per day. While the authors defined a serving as equaling one cup, it is clear that most students purchase much larger sodas; the standard serving sold on campus is 20 ounces. Larger portion sizes leading to significantly increased caloric intake are implicated in the national obesity epidemic (Young & Nestle, 2002). Soda may be just one source of excess calories in the college students’ diet. A recent study (Lang, 2003) suggests that the “freshman 15,” the gain of 15 pounds of weight by freshman during the first year of college, may be a real phenomenon fostered by “all you can eat” dining facilities, evening snacks, consumption of junk food, and dieting. It is reported that nation wide binge-drinking among college students exceeds 40% (Grace, 1997). Men are heavier drinkers than women in the present survey where 15% state they usually drink 22 or more drinks per week. Wechsler et al. (Wechsler & Isaac, 1992; Wechsler et al., 2000) also confirm that male students drink more frequently than female students.

Students were asked how often they ate meals. Breakfast is the most commonly missed meal. Responses (% of participants) are as follows; Breakfast: never (8), seldom (25), sometimes (21), usually (24), always (23); Lunch: never (1), seldom (2), sometimes (16), usually (44), always (37); Dinner: never (0), seldom (1), sometimes (4), usually (30), always (65). There are no differences between male and female participants.

Students were asked about frequency of snacking and consumption of soda and alcohol. Most students (63%) are inclined to snack one to two times per day. While “boredom” is the most frequently cited reason for snacking, men state “partying” as a reason for snacking more frequently than women and women state “emotional” more frequently than men. Most students snack on chips, crackers, or nuts; but men snack on fast foods more and on ice cream, cookies and candy less frequently than women. Men consume larger quantities of both soda and alcoholic beverages than women. Fifty-eight percent of participants state they eat vegetables less than once per day and 64% eat whole or canned fruit less than once per day.

When asked to rate the “healthiness” of their eating habits, 51% of participants state “poor” or “fair.” When asked to state the reasons for poor eating habits, 40% state “lack of time,” 22% state “lack of money,” 15% state “taste preferences” and 24% state other reasons. Some of the other reasons stated include “no motivation” (n = 21), “convenience” (n = 20), and “dine at student cafeteria” (n = 17). Forty-two percent of women state “lack of time” compared with 36% of men, whereas 3% of women state “don’t care” compared with 11% of men (χ2, p < 0.05). Exercise Habits, Body Image and Perceived Barriers to Exercise
Eighty-four percent of participants state they currently exercise and the same percentage state they exercised prior to attending college, however, 42% state they exercise less since attending college. Men exercise more frequently and at a greater intensity level than women, see Table 4. In regard to type of exercise, women do more aerobics and less strength-training and partake in fewer competitive sports than men. Men appear to be more confident with their body image. The most commonly cited reason why the participants exercised is “health” (n = 251). There are other stated differences between men and women, see Table 5. Women exercise for reasons of weight and stress reduction and men exercise for enjoyment and gains in muscle and strength. The most commonly cited barriers to exercise are “lack of time” (n = 171), “lack of motivation” (n = 103) and “lack of willpower” (n = 45). There are no differences in barriers to exercise by gender.

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).

The authors assessed the diet and exercise habits and perceived barriers to following a healthy lifestyle of 471 college students. Sixty percent of the participants were female and 31% had BMIs > 25. Breakfast was the most commonly missed meal and 63% of students snacked one to two times per day. Fifty-eight percent of participants ate vegetables and 64% ate whole or canned fruit less than once per day. Men consumed more soda and alcohol and used higher fat dairy, ate more meat, and ate fewer vegetables and fruits than women. Over half of the subjects rated their diet as poor or fair with “lack of time” listed as the number one barrier to eating well. Men exercised more frequently and at greater intensity than women and were more confident with their body image. The most common barrier to exercise was “lack of time.” The results of this study have implications for the design of general and specific diet and physical activity interventions among college students.

Introduction

Introduction
Diet related diseases including cardiovascular disease, cancer, and stroke are consistently among the top three leading causes of death (American Cancer Society, 2000). A new report, issued by the Institute of Medicine (IOM) of the National Academy of Sciences, suggests that to save the most lives from chronic disease, policy makers, health care providers and researchers should focus their efforts on helping people to stop smoking; maintain a healthy weight and diet; exercise regularly; and drink alcohol at low to moderate levels (American Cancer Society, 2003). Most college students may not achieve the nutrition and exercise guidelines designed to reduce the risk of chronic disease, typically consuming diets high in fat, sodium, and sugar and low in fruits and vegetables (Anding et al., 2001; Dinger & Waigandt, 1997; Grace, 1997; Hiza & Gerrior, 2002; TLHS, 2000). These poor eating habits may result from frequent snacking, excess dieting, and consumption of calorie dense but nutrient poor snacks and meals, such as those provided by fast food restaurants (Georgiou et al., 1997).

In addition, despite the recognized benefit of exercise, surveys of college students’ health habits indicate that only 35% have a regular schedule of physical activity and that a slightly higher proportion of men (40%) than women (32%) regularly exercise (Pinto et al., 1998). However, college students are at a time and place in their lives where their behavior is conducive to change. In fact, the students’ social role of learner is largely defined by a readiness to change (NIH, 1998). Therefore, college campuses serve as crucial settings to overcome perceived barriers to healthy diet and exercise habits, and implement effective interventions (Wallace et al., 2000). Ideally, if college students make positive changes in exercise and dietary habits, these changes could persist into adult years. The purpose of this survey was to assess the diet and exercise habits and perceived barriers to following a healthy lifestyle of college students and to determine if differences exist by gender. The results may have implications for the design of effective general and gender specific interventions for college students.

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.