Can first-year nursing students effectively plan and implement a health fair as a learning opportunity? Can microcomputers be used appropriately to influence client participation and to enhance the nurse-client interactions? These are questions discussed by the faculty of a required sophomore nursing course in a baccalaureate program which focuses on the concept of health - its assessment and promotion.
This curriculum defines a twofold health component that focuses both on client health and the students' own health awareness and health practices. Health is the overall focus of the sophomore year and a return to these concepts occurs in the senior year. The sophomore curriculum deals, in part, with health assessment, health promotion, and health education. Health concepts often encounter resistance by entering students who frequently hold preconceptions of "real nursing" as a critical care drama. Strategies to stimulate student interest and utilization of these health concepts have been explored. Numerous teaching methods have been employed toward this end such as lecture, audiovisuels, paper-pencil assessment tools, client interviews, clinical experiences, and most recently, universitywide health fairs. Some of the most innovative tools lie in microcomputer technology.
What follows is a selected review of literature on the health fair as a mode of health care delivery, its value as a learning opportunity, and the advantages of microcomputer use. Subsequent experience with two separate student-sponsored health fairs provides answers to the questions posed and suggests direction for future health fairs and additional learning opportunities.
Health Fairs Provide Service and Learning
Experts predict that the key to continued progress in health care "may no longer be the high cost, high technology" of curative care, but in changing definitions of health and interventions that occur at a stage prior to the onset of the disease, i.e., health promotion and illness prevention (Doerr & Hutchins, 1981, p. 299). However, individuals generally find it easier to depend on healers rather than attempting the more difficult task of living wisely to promote their own health (Dubos, 1961). The health fair has been identified as a means to introduce and stimulate the practice of healthful behaviors and to reinforce those healthful behaviors in individuals already practicing them (Germer & Price, 1981). Once the information is presented and the proper intervention explained to the client, the individual can determine if making a lifestyle change is of greater benefit than continuing in the same pattern. Several surveys have shown that health fair activities can be incentives toward behavioral change (Wear, Hawley, & James, 1980; Wilkinson & Tylden-Patterson, 1979). With a behavioral focus, the health fair can encourage lifestyle awareness and education. One way to achieve this is to organize the fair by concepts; for example, one station on smoking behavior instead of separate displays by several different organizations that provide related information (Blumenthal & Kahn, 1979). When health screening is combined with an educational presentation, success is increased by creating a teachable moment (Blumenthal & Kahn, 1979).
It has been hypothesized that health fairs might be reaching a unique population that normally would seek out health information - those individuals who are directed internally or possess an internal locus of control. However, results of one study indicate that health fair participants can include those with either internal or external locus of control (Germer & Price, 1981). Health fairs also might attract those who recognize or fear some potential health risk, who then can be directed appropriately.
An additional benefit of health fairs developed and staffed by nurses and nursing students is that of enlightening the public on the role of the nurse in health education (Desai, Hotchkiss, Fletcher, & McCann, 1977).
The health nur as a learning opportunity has been implemented with a variety of student populations: nursing students in a community health course, junior level nursing students and members of nursing student organizations; elementary education majors; health education, family life and pharmacy students; and medical students (Alcena, 1978; Culang, Josephson, Marcus, & Vezina, 1980; Farrar, 1981; Mason & Calvacca, 1982; Petty & Pratt, 1983; Watts & Stinson, 1981). These experiences were described as valuable in providing the opportunity to plan creatively, to develop increased confidence in teaching skills and in interacting with participants, to use skills of assessment, and to formulate educational strategies applicable to future client situations.
Advantages of Microcomputer Use
The computer is experiencing a rebirth in nursing education since the advent of more affordable microcomputers. Its potential in nursing education and health care is only beginning to be realized. The microcomputers offer several distinct features including affordability, portability, durability, color graphics, and audio. The microcomputer also offers the capability for interaction, knowledge assessment, immediate feedback to enhance motivation, record keeping, novelty, extensive and rapid computing power, reliability and validity of content, and accessibiUty (Chen, Houston, & Burson, 1983; Lyons, Krasnowski, Greenstein, Maloney, & Tatarezuk, 1982; Weinberg & Scott, 1983).
The capacity for individuaüzing instruction, providing immediate feedback, allowing student self-pacing and timing, requiring active student/client participation, providing personalized information, and allowing the student/ client to experiment without embarrassment are important qualities for nursing applications. Research has demonstrated the effectiveness, individualization, time-savings, and receptivity of students to computer-assisted instruction (CAI) (Bitzer & Boudroux, 1980; Cosky, 1980; Edwards, Norton, Taylor, Weiss, & Dusseldorp, 1975; Jenkins & Dankert, 1981; Joiner, Miller, & Silverstein, 1981; Kulik, Kulik, & Cohen, 1980; Magidson, 1978; Smith, 1973; Sustik & Brown, 1979). The application of CAI in the patient education area also has demonstrated merit in numerous studies (Chen et al., 1983; EIUs & Raines, 1981; ElUs, Raines, & Hakanson, 1982; Lyons et al., 1982). The advantages demonstrated with student applications of CAI hold true for use with patients studied in a variety of settings. Ellis, et al. (1982) further demonstrated that patients actually preferred the computer to human instruction on embarrassing subjects, that patients recaUed more from computer interactions than from comparable spoken/written instruction, and that computerized health behavior evaluations motivated change in selected behaviors.
The novelty of the microcomputer increases the numbers of participants at health fairs and using microcomputers often provides individuals with a first exposure to computers. Ellis and Raines (1981) found that health fair participants waited in lines up to 30 minutes for a chance to use microcomputers running four programs related to good health habits - coronary risk, exercise/weight, life expectancy, and Ufestyle. Those participants receiving some assistance using the microcomputers rated the experience significantly more helpful than those unassisted users.
Quality interactive computer programs are becoming available for health assessment and client education. These are intended as supplemental tools and not as a replacement for personal interactions.
Two five-hour health fairs open to interested staff, faculty, and students were piloted in March and May 1983 at two university locations. Both of these locations, the student health center and a student activities center, offered space and some financial assistance. Nursing students compiled materials and equipment from a variety of community agencies as weU as devising their own resources.
The health fair included 10 stations for assessment and education. These were: vision; blood pressure and cardiac risks; hearing; substance abuse; nutrition; safety; rest/ sleep/exercise; stress management; first aid; and sexuality. Nursing students planned and staffed the stations with input from faculty using principles of teaching, learning, and health promotion from course content. Students used posters, models, quizzes, handouts, microcomputers, demonstrations, and screening procedures. Microcomputers were utilized at three stations: stress management, substance abuse (smoking), and nutrition.
At the stress management station, clients completed a questionnaire on current support systems and recent life changes. Nursing students entered the client data into the microcomputer. The software, "Stress Test" (Ohio Department of Mental Health, 1980), was designed for the Radio Shack TRS-80 microcomputer and was provided by a local mental health center. Hardware was loaned by Radio Shack. The computer quickly produced a printout of the client's stress and support level scores along with the individual's potential for illness during the next year if the current lifestyle were maintained. The nursing student was responsible for interpreting the results to the client and providing educational follow-up, such as demonstration of relaxation techniques.
The substance abuse station included education on effects of smoking and strategies for quitting. "Why smoke? Quit!" (Skillman & Burson, 1983) was the software used. This program presented 18 statements about smoking to the user who rated the applicability of these statements to self on a Likert-type scale. The program analyzed the results and identified the main reasons why the individual smoked, e.g., for stimulation or for tension relief. Individualized tips to quit based on this analysis concluded the program. Approximately 10 minutes were needed to complete the program. "Why smoke? Quit!" is designed for the Apple Microcomputer. Both software and hardware were provided by a university department. Students compiled materials to demonstrate the effects of smoking, oriented clients to interact with the computer, and provided educational fi»llow-up on smoking cessation such as behavior modification techniques and referral to community resources.
Two computerized health appraisals were planned for the nutrition station. "Nutrition Profile" and "Skinfold Body Composition" (Hall, 1981 a & b) were loaned by a cooperating university department. "Nutrition Profile" is a 44-item questionnaire designed to evaluate eating habits and provide recommendations for improvement. The questionnaire is designed to be completed in 5 to 8 minutes, data entered in 1 to 2 minutes, and the report printed in 30 seconds. The report provides the individual with a graphic summary of the number of servings consumed from each food group compared to the recommended amounts; a summary of the major nutritional factors comparing consumption to recommendations; and a list of personalized recommendations for improving nutrition. "Skinfold Body Composition" is designed to assess body composition using three skinfold measurements, frame size, age, height, and weight. The report calculates and interprets body composition. Both programs were written for the Radio Shack TRS-80 and the IBM-personal computer. Hardware was loaned by Radio Shack. Students were assigned to research related topics, identify resources, practice using the software and collecting related data, and design appropriate interpretive and educational materials. The health appraisals were to stimulate awareness, provide a substantial data base expethently, and serve as a basis for follow-up education or referral.
The number of participants at the March health fair was 200 during a five-hour period. Two hundred fifty attended the May health fair in a similar time period. The majority of participants at each fair were under 25 years of age. A sample of written subjective evaluations of the fairs were obtained from 50% who attended in March and 33% of those participating in May. Respondents rated the usefulness of each station they attended, reported any previously unknown health problems, and identified major health concerns. Based on these written evaluations, estimated attendance at individual stations ranged from 23% to 65% of all participants. Attendance at stations incorporating microcomputer programs is summarized in Table 1.
Stress and its management is a common concern of the college student, so it is not possible to credit high participation to microcomputer use alone. This was a popular station resulting in participants waiting to have their data entered on the microcomputer. Based on the initial success of the microcomputer at this station in March, additional software was explored for use at the May fair.
The increase in attendance at the station on substance abuse (smoking) from one fair to the next can be attributed to a number of factors. This station was allotted more space and visibility at the second fair and incorporated additional large visual aids, as weil as the microcomputer. Twentynine (12%) of the participants completed the software, "Why smoke? Quit!" in the five-hour period of the health fair resulting in very little vacant time. One disadvantage of this program was that it did not print out hard copy and users needed to make their own notes. Nursing students had devised a supplemental handout to accompany the program. The use of color graphics in the program helped to create and maintain interest.
A slight decrease in attendance at the nutrition station might reflect the sampling and reporting. The nutrition profile generated substantial interest but technical problems limited the availability of this program to only one and a half hours. Nevertheless, 53 (21%) of the participants completed the nutrition profile. Some of these clients completed the questionnaire while the computer was unavailable and had the analysis sent to them. Unlike the other two programs on stress and smoking, this software has the capacity to compile and analyze group data. Group statistics generated by the computer included total numbers; age; physical activity level; eating habits (e.g., breakfast, snacking); salt usage; water intake; alcohol use; daily servings from each food group; refined and empty calorie foods; and caloric intake by nutrient source.
ATTENDANCE BY PERCENT OF TOTAL HEALTH FAIR PARTICIPANTS
A sampling of the analysis generated includes findings that 70% only occasionaUy or seldom eat breakfast; 53% are deficient in fruit intake; 42% are deficient in consumption of milk products; 51% exceed the RDA of calories; and 72% consume more than 300 mg/day of cholesterol. Educational needs also were surveyed by this program. Participants indicated an interest in attending the following nutritional programs if offered in their community: low cholesterol meals (N = 9); budget meal planning (N = 17); vegetarian cookery (N = 9); nutrition for health seminar (N = 15); and weight control class (N = 18).
The skinfold body composition program was not used because of inadequate hardware. Instead of using a microcomputer, manual calculations were made for 131 individuals. A microcomputer would have facilitated the speed and accuracy of calculations; reduced waiting time allowing more participants to be evaluated; provided a more informative summary and analysis handout to each participant; and generated group statistics.
In written evaluation, participants overwhelmingly rated each station as useful or very useful. Twenty-six percent of the participants rated the total fair as very useful, while 67% identified it as useful. Five percent of those attending the March fair reported that a previously unknown health problem was detected at the health fair, while 13% reported this at the May fair. Referrals to appropriate university and/or community services were initiated.
Nutrition, exercise, vision, hearing, blood pressure, and stress were identified as major health concerns by participants on written evaluations. A total of 45 individuals (22%) identified 85 concerns at the March fair, while 39 individuals (15%) identified 64 concerns at the May fair (Table 2).
Health fairs, in the future, should be planned to incorporate and enhance content on these more common concerns. Software related to areas which did not previously use the microcomputer can be explored.
FREQUENCY OF MOST COMMON CONCERNS
Can sophomore nursing students effectively plan and implement a health fair as a learning opportunity? Yes, students were able to operationalize health content into concrete assessment tools and educational materials. Positive participant response is one indication of successful implementation. Participants rated the fairs as useful or very useful in relation to their health needs. Participants at the first fair in the student health center included health professionals on the staff at the center. These professionals gave very positive comments concerning the professionalism of the students and the effectiveness of their efforts. Staff at both locations invited future health fairs at their sites.
It was found that not all stations were attended by each participant, which corresponds to findings by Wilkinson and Tylden-Patter8on (1979), however, overall general attendance neared the capacity of space, equipment, materials, and quality interaction opportunities. Blood pressure and visual acuity screening had high attendance percentages at 64% and 63% respectively. This validates Blumenthal and Kahn's (1979) findings on the popularity of screening components, although this is rarely the major goal of health fairs. Continuing to include screening at future health fairs can encourage attendance by the community. The fact that previously unknown health problems were reported by participants at each health fair, indicates another aspect of successful implementation. Common major health concerns identified by participants on their written evaluations coincided with stations that were included in both fairs.
The nursing students themselves were able to identify benefits such as recognizing that they had pertinent knowledge to share with clients; applying teaching-learning principles; providing a valued service to the university community; critically analyzing types of strategies and making concrete suggestions for future student groups; and an increasing awareness of the availability of community resources. Students were enthusiastic in client encounters and took the initiative to form impromptu small group discussions in some areas. They rated this as a very enjoyable experience in spite of the work entailed.
Can microcomputers be used appropriately to influence cUent participation and enhance the nurse-client interactions? Appropriate integration of the microcomputer was demonstrated in part by the students' development of tools for eUciting accurate client data and follow-up educational materials and activities. Nursing students were familiar with the software and able to assist participants in its use. Both analytical and interactive programs were used in the setting creating variety. The computers attracted a large portion of the health fair participants and sufficient interest from participants to tolerate long, uncomfortable waits. Computer use was greeted enthusiastically by both students and health fair participants.
Overall, insufficient hardware hindered participation at stress and nutrition stations. Participants waited in long lines to be evaluated. To facilitate traffic flow, one person entered all data from each participant's questionnaire, eliminating the client-computer interaction desired. Because of congestion, all participants did not receive consistently the individual assistance planned in completing and interpreting the profiles.
Judging by client and student receptivity, more software packages could be integrated into the health fair as they become available, leaching and referral would receive even more emphasis in the future, if the computer could be used to generate faster and more thorough client assessments to provide the student with a substantial baseline for interpretation and counseling. The computer also can produce group statistics to support future health fair planning and follow-up.
Other future adaptations could include: different locations for the health fair with varied target populations; a larger area to facilitate traffic flow; increased participant evaluation; an expanded budget to increase advertising and available materials; and the potential for an interdisciplinary health fair.
The health fair will be continued as a learning opportunity on the sophomore level. The novelty and capabilities of the microcomputers, coupled with the enthusiasm and knowledge level of the nursing students, enhanced the health fair as a service and as a learning opportunity.
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ATTENDANCE BY PERCENT OF TOTAL HEALTH FAIR PARTICIPANTS
FREQUENCY OF MOST COMMON CONCERNS