This methodology chapter is divided into six subdivisions:

• subjects,

• subject preparation,

• topic survey,

• patient questionnaire,

• nutrition test,

• education sessions, and

• experimental design.

The 15 family practice residents in training at the Union Hospital Family Practice Center in Terre Haute (Indiana, U.S.A.) participated in this study. The sample included five first-year, five second-year, and five third-year residents. All residents completed their medical education from an accredited medical school prior to their residency training. Subjects included seven males and eight females.

No formal preparation of the subjects occurred. The purpose of the nutrition program was explained to the residents and they were encouraged to attend the sessions. The lectures were part of normally scheduled noon educational sessions that all residents were expected to attend when possible.

Survey conducted to determine nutrition topics for lectures. Prior to the formal nutrition series, the residents and faculty members were surveyed to determine their preference for session topics. The survey listed 40 nutrition topics with the request to rate each topic as either essential, important, desirable, or not appropriate for inclusion in their education and training. (See Appendix A.) The 40 topics were obtained from a nationwide study of medical and dental schools that determined the most important nutrition topics for inclusion in a medical curriculum (Weinsier, Boker, Brooks, Kushner, Visek, Mark, Lopez-S, Anderson and Block, 1989). Eleven topics were chosen--those rated highest in the local survey.

The 11 topics chosen were diabetes, pregnancy and lactation, pediatrics, hyperlipidemia, enteral nutrition, parenteral nutrition, obesity, supplements and antioxidants, vegetarian diets, cancer and AIDS, and renal disease.

A patient questionnaire was developed to determine the residents’ nutrition-related behaviors and the patients’ perception of the amount, type and effectiveness of nutrition information presented during regular visits with their physicians. Pilot studies on the patient questionnaire were run to evaluate the patients’ ability to understand the questions, to determine the questionnaire effectiveness, and to determine the receptionists’ response to distributing the questionnaire.

Pilot study identified problems with survey and process--these were resolved. An initial four-day pilot study found problems with the distribution of the questionnaire, the wording of one of the questions, and identified patient concerns regarding the purpose of the questionnaire. Revisions to the questionnaire were made based on these problems and concerns. The purpose and importance of the questionnaire distribution were discussed with the receptionists. Additionally, the receptionists and two members of the research team were available during the survey periods to help the patients in filling out the questionnaire and to answer any questions that might arise.

Laminated signs were developed and placed in the patient checkout area. The signs explained the study’s purpose and encouraged the patients to complete the study questionnaire. A second four-day pilot study was run to test the new questionnaire. The pilot found the revised questionnaire effective in resolving the earlier problems.

Relevant nutrition-related behaviors for the study, were defined as:

• supplying nutrition handouts to patients,

• discussing nutrition with patients, and

• making nutrition recommendations to patients.

Survey was given to patients in checkout procedure. The study questionnaire (see Appendix B) consisted of eight questions and was administered to the patients by the receptionists during the patient checkout procedure. The questionnaire was distributed Monday through Friday for three consecutive weeks. This distribution occurred both immediately prior to the beginning of the nutrition education program, and immediately after its completion.

The patient survey was used to assess/measure any changes in the nutrition related behaviors of the residents before and after the nutrition education program. Two of the questions in the patient survey were designed to determine the nature of the patient’s visit and the duration of the current medical concern. The reason for the patient’s visit might influence the nature of the interaction between the patient and the physician. As to the reason for the visit, the patient could choose between "Prenatal Visit," "Well-child Visit," "Physical/Check-up,â or "Other" with an opportunity to describe "Other". When the patient left a question blank, data for the question was entered as no response rather then as a negative response.

Comprehensive 55 question nutrition test was administered to residents both pre- and post-education program. A comprehensive, 55-question nutrition test was developed (see Appendix C) and pre-tested with residents who were expected to complete their residency before the beginning of the actual study. The same test was administered to the residents in the study immediately prior to the beginning of the educational program. A post-test was administered to the residents immediately after the completion of the program. The test consisted of five questions from each of the eleven lecture topic areas. Medical Nutrition And Disease (Morrison and Hark, 1995), a textbook that was written for use in similar programs, was used as the basis for the tests. Multiple choice, clinically based questions were either chosen from the textbook, and/or developed to evaluate the residents’ nutrition knowledge and its application.

Training consisted of 11 nutrition education sessions conducted one or two times monthly, over a period of 9 months. Registered Dietitians with advanced degrees and/or specialized training in the specific topic areas were chosen to teach each topic. These dietitians were selected from the local area, and included Indiana State University nutrition professors, as well as hospital and community dietitians.

Residents were co-educators in team-teaching model for program lectures. Topic material was presented in two components using an active learning/team-teaching model. This model utilized the residents as co-educators for each of the topic areas. Residents were able to sign up in advance for topics of personal interest and were then assigned a topic from their chosen preferences. The first component was a didactic summary of the topic, presented by the dietitian. The second component, which was presented by the resident, was clinically based and presented a textbook clinical case study of a patient. Residents were also encouraged to incorporate recent actual case studies into this part of the lecture. The clinical component concluded with a question and answer session.

Bullet-point handouts were distributed to the residents for each topic at the end of each session. These handouts emphasized the key points covered in the lectures. The handouts acted as a reference source for the residents for use in their regular daily patient interactions. The key points from each lecture were also put on a computer file and distributed to each of the residents laptop computers through e-mail.

Effect of educational program on nutrition knowledge of residents. Residents were grouped by years in training. Pre- and post-test scores were determined on a 1-55 point scale for the 55 question comprehensive test. A paired t-test was used to analyze for differences in individual scores.

Effect of educational program on nutrition related behaviors with patients. To determine the effects of the educational program on the residents’ nutrition related behaviors, the total number of responses on the patient questionnaires were grouped by the occurrences in the categories of nutrition related handouts, nutrition related discussions, nutrition related recommendations, patient requests for information and the adequacy of the residents’ response to patient requests as perceived and determined by the patient. Chi-square statistics were used to test for significant differences before and after treatment. Scores were analyzed for each category and for category totals.

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