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Evaluation of nutritional education using concept mapping
Patient Education and Counseling 52 (2004) 183–192
Evaluation of nutritional education using concept mapping Silvana Franc¸aa, Jean Franc¸ois d’Ivernoisa, Claire Marchanda, Catherine Haennib, Juan Ybarrac, Alain Golayb,* a
Health Education Laboratory, UPRES, EA 3412, WHO Cooperating center for Development of Human Resources in Healthcare, UFR-SMBH, Universite´ Paris Nord, Paris, France b Division of Therapeutic Education for Chronic Diseases, Department of Internal Medicine, University Hospital Geneva, 24, rue Micheli-du-Crest, 1211 Geneva 14, Switzerland c Departament d’Obstetricia i Ginecologia, Institut Universitari Dexeus, Barcelona, Spain Received 10 February 2002; received in revised form 15 December 2002; accepted 24 January 2003
Abstract The concept mapping method is presented in the current study as a new tool to assess the learning process taking part in the hallmark of a nutritional education program addressed to obese diabetic patients. Population: eight patients were interviewed prior to and after completion of 1-week in-hospital stay during which concept maps were designed. Concept maps quantitative and qualitative analysis disclose both (i) the importance of previous knowledge among patients prior to nutritional education and (ii) the maintenance of misconceptions after it. Nutritional education allows patients to acquire and structure their knowledge while providing them with a certain amount of medical vocabulary. An underlying correlation between concept maps design and the results of psychological tests identifying eating behaviour troubles (EBT), depression or anxiety has not been clearly identified. However, the nutritional education is more beneficial to those patients with a higher degree of self-assertiveness and with a lesser degree of anxiety, depression and eating disorder. # 2003 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Concept mapping; Nutritional education; Nutritional evaluation; Personality traits
1. Introduction Concept mapping is presented in the current paper as a new tool to evaluate nutritional knowledge. According to their inventors [1], a concept map is an individual’s graphic representation of cognitive organisation of a certain issue, based on a central concept. Concept mapping is originally designed as learning tool for schoolchildren and students. Later on concept mapping is conceived as a tool to evaluate patient education [2,3]. Hence, our study has been designed and conducted along the same line of thought. To the best of our knowledge this is the first report of the use of concept mapping in the nutritional education field. Patient education’s goal is to develop autonomy among individuals affected by chronic diseases [4]. This autonomy will enable patients to implement behavioural adaptations to their daily life in order to take charge of their disease all over their life-span. According to Krause and Mahan [5], *
Corresponding author. Tel.: þ41-22-372-97-04; fax: þ41-22-372-97-15. E-mail address: [email protected] (A. Golay).
nutritional education is a process allowing to change habits and eating behaviours in a permanent, voluntary and conscious way all along the life-span. The concept of eating behaviour as pointed out by Apfeldorfer [6], avoids reducing nutritional education to a simple diet issue. Eating behaviour appears as a reflection of the individual’s personality, with its strengths and weakness, his more or less rational beliefs and also including this family and personal history [7,8]. Evaluating nutritional education is indeed a difficult task which brings up an inadequacy between the patient’s nutritional information and the education which would enable him to modify his/her eating habits on a daily and long term basis [9]. A psycho-pedagogical approach to nutritional education has been proven to be a possibility to obtain significant behaviour modifications concerning diabetes care at 2 years [10] and 50% of success concerning weight loss at 5 years [11]. The works of Gardner and Ausubel [12,13] in the field of cognitive psychology underline the importance of previous knowledge in the learning process, i.e. what a patient learns during an educational program is influenced by the set of knowledge which he possesses prior to education [2].
0738-3991/$ – see front matter # 2003 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S0738-3991(03)00037-5
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In the same line of thought, it has been shown that concept mapping act as a link between previous and newly acquired knowledge [2]. Additionally, concept mapping reveal the complex set of cognitive changes which an triggered by education and their interference by emotional factors. The aim of our study is to evaluate nutritional education using concept mapping methodology. Along this qualitative study, we have attempted to disclose the link between concept maps content and psychological test results. The latter were set to dwell into EBT in obese patients and test whether EBTs could have a translation into concept mapping.
2. Materials and methods 2.1. Research area This study has been conducted at the Division of Therapeutic Education for Chronic Diseases, University Hospital Geneva. Eight (N ¼ 8) obese type 2 DM patients underwent two structured interviews in order to design concept maps before and after a nutritional education program. For each individual patient, the first concept map (Fig. 1) was built along the first interview on the first in-hospital day—prior to nutritional education. The second concept map (Fig. 2) was built on the last day of hospitalisation— post NE. During that period all patients underwent a fullfledged clinical, biochemical and psychological evaluation.
The main goals of this program are to (i) develop and improve patient’s knowledge regarding diabetes, obesity and nutrition, (ii) encourage patients to modify their eating habits and meanwhile improving the management of their chronic disease. Practical tests such as capillary glycemic controlled are one of the keen features of the program which include three practical sessions by day. Additionally nutritional exercises are proposed along each meal. Thirteen interactive courses are included in the week’s schedule. Theoretical courses alternate with nutritional educationoriented sessions all along with a cognitive-behavioural approach which specifically targets EBT [14,15]. The efficacy of this week of nutritional education has proven its benefits with a significant improvement of eating behaviours 2 years thereafter [10]. This program is run on a weekly basis at the Division of Therapeutical Education for Chronic Diseases. Table 1 depicts its objectives. 2.2. Subjects Our group included eight (N ¼ 8) Type 2 Diabetic patients (5 M, 3F) aged 62 3 years old. They were all overweight and their body mass index (BMI) averaged 31:1 1:3 kg/m2. Five out of eight were married and five out of eight were retired. None of them had ever participated in a nutritional educational program previously. An informed written consent was obtained from each patient after thorough and clear explanation of the aims, goals and characteristics of the
Table 1 Educational program for diabetic patients Time
Monday
07:30
Glycemias, insulin, technical learning Breakfast, practical exercises Welcome Initial statement
08:00 08:30 09:00 10:00
I choose my three snacks
11:30
Glycemias, insulin, technical learning Lunch, buffet, practical exercises
12:00 13:00
Tuesday
Healthcare team meeting I do also treat my diabetes while eating Eye examination
Thursday
Friday
Let us go for a walk . . .
Medical
Thinking about my physical activity
Visit
I use my capillary glycemia results to . . . Reading and understanding food labels
I treat my diabetes (nurse)
14:00
My worries regarding my diabetes
Objective’s session (team)
16:00
Initial statement
I recognize and react upon my hypoglycemias
17:15
Glycemias, insulin, technical learning Dinner
17:30
Wednesday
Long term–uncon-trolled diabetes complications (physician) I take care of my feet and assess my shoes
I can variate my feeding, as an expert Round table living with my diabetes What to do with my diabetes in case of infections
Discovering relaxation Private interviews
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Fig. 1. Concept map elaborated with one patient number 3 prior to nutritional education.
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Fig. 2. Concept map elaborated with the patient number 3, after nutritional education. Note: the number indicated the seven first concepts said by the patient in their emergence order.
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study. The whole procedure was approved by the local ethics committee. Diabetes duration averaged 9:1 0:7 years. Most patients presented with DM-related complications such as background diabetic retinopathy (4/8), mild peripheral diabetic neuropathy—assessed by diminished tuning fork vibration perception—(3/8). Hypertension (defined as BP values > 140/90 mm Hg) was detected in six patients. None of them presented with either micro-albuminuria or proteinuria. Half of them (4/8) presented with criteria for the diagnosis of EBT according to the DSM IV. Moreover, their scores at the Eating Disorder Inventory confirmed the diagnosis of EBT in patients 1, 5, 6 and 7.
or ‘‘field of knowledge’’ and the true/false type of knowledge were also analysed prior to and after nutritional education. Ranking the links between first level concepts into categories allows the identification of cause and effect links [2]. They are formulated by words or expressions, such as ‘‘caused by’’, ‘‘bring up’’, ‘‘provokes’’, ‘‘due to’’, ‘‘that give’’, etc. Other conditional links, such as ‘‘when’’, ‘‘if’’, or ways of behaving links, such as: ‘‘one must start’’; ‘‘one has to’’; have been searched. Additionally, finality links, such as ‘‘to>;’’ to do>; ‘‘to obtain’’; have been identified. Finally, links of general expression, such as ‘‘it is one’’, ‘‘because’’, ‘‘meaning’’, ‘‘it is as if’’, have also been searched for.
2.3. Interviews and concept mapping
2.5. Psychological tests
According to Novak and Gowin’s method [1], formerly addressed to secondary school students, a concept map represents a sort of knowledge cartography of a given individual regarding a central concept. The central concept of our study is the word ‘‘fat’’, written in the centre of a white sheet of paper. The method is based on asking the patient to write around all the words that concepts ‘‘fat’’ freely evokes. Then the patient is encouraged to establish explicit links between words. In our study, concept maps were not drawn by patients themselves. This task was performed by the interviewer who put down the patient’s responses while, following an explanatory interview technique, invited the patient to set precise limits to his wording. Interviews were audio-taped. Patients used their own vocabulary to spontaneously express whatever they felt related to the concept of fat. The first concepts (or first levels concepts) to be evoked were put down as they appeared. Later on throughout the interview patients were asked to clarify the links between all concepts (concepts links). Each individual interview lasted 30 min approximately. The same methodology was used during the second interview without allowing patients to refresh the first interview’s concept map. This was set henceforth to allow the expression of new ideas while privileging spontaneity as a way to disclose their knowledge.
All patients underwent psychological testing in the hallmark of nutritional education. The presence of EBT was evaluated using a semi-structured interview according to the DSM IV criteria and the Eating Disorder Inventory 2 [16]. Depression was evaluated using HAD-D [17] and BECK 21 [18] tests. BECKs scores in the 9–18 range disclosed mild depression while the 19–29 range discloses a modest depression and scores above 29 point out a severe depression [19]. HAD-D scores in the 7–10 range point out a few depressive elements while scores above 11 are considered to represent many depressive elements [17]. Anxiety was evaluated using the HAD-A test. Scores between 7 and 10 translate a mild anxious state which turns into an important anxious state when the score is above 10 [17]. Self-affirmation was evaluated using the RATHUS methodology [20,21]. Scores between 30 and þ30 disclose mainly affirmed behaviours. Scores above þ30 point out an aggressive behaviour while those under 30 disclose an inhibited behaviour [19].
2.4. Concept mapping analysis The quantitative analysis takes into account the number of first concepts to be stated as well as the total number of concepts appearing prior to and after nutritional education. The number of new concepts stated during the second interview and the total number of repeated concepts along the two interviews were also recorded. Finally, the total number of concept links disclosed during both interviews were also recorded. The qualitative analysis is primarily focused on the nature of the first concepts as well as that of concepts giving rise to several links, termed super ordinate concepts, prior to and after nutritional education. The nature of concepts gathering
3. Results 3.1. Analysis of psychological tests Tables 2 and 3 depict psychological test’s scores. Anxiety, assessed by HAD-A test, averaged 6:4 1:3. Interestingly, three patients scored above 7 which indicates rather anxious profiles. Depression was evaluated simultaneously by both HAD-D and BECK 21 test. The inter-test degree of correlation was excellent (r ¼ 0:60; P < 0:02). Only one patient disclosed depression scores at both tests. Self-affirmation was evaluated using the Rathus test. Two patients (1 and 6) disclosed aggressive behaviour with scores of 37 and 51, respectively. Of note, one of them (1) had also high score depression at HAD-D and BECKs tests. The rest of them disclosed self-affirmed scores range between 6 and 25. EBT were evaluated using a semi-directed interview according to the DSM IV criteria. Patients 1, 3, 6 and 7
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Table 2 Patient’s psychological characteristics Patients number
HAD-A
HAD-D
BECK
Rathus
1 2 3 4 5 6 7 8 Mean S.E.M.
14 4 9 8 3 6 3 4 6.4 1.3
9 3 1 5 1 6 6 2 4.1 1.0
21 4 7 3 2 6 9 2 6.8 2.2
37 9 6 5 17 51 17 25 17.2 6.9
fulfilled the criteria for EBT and even disclosed values above the average in several sections of EDI 2 (depicted in Table 3). 3.2. Quantitative analysis of concept maps Tables 4 and 5 depict the concept maps data collected for quantitative analysis. Prior to nutritional education (test 1), patients already disclosed a remarkable amount of knowledge (20:4 1:6). After nutritional education (test 2) knowledge had increased up to 22:5 1:9. Interestingly, five patients increased the number of concepts expressed in concept maps, while two of them did not modify them and the remaining patient (8) decreased the number of concepts by three after nutritional education. The knowledge gain attained through nutritional education averaged two concepts. The quantitative increase of new concepts acquired through nutritional education is relevant: depending on patients, 12 1:6 (range 8–19) new concepts appeared at test 2; nevertheless, a certain number of concepts appearing on test 1 reappeared unchanged at test 2. Repeated concepts averaged 10:5 0:8 (range 8–15) depending on patient’s individual concept mapping and accounted for almost half of the concepts appearing at test 2.
The concept links (shown in Table 5) averaged 22:8 1:9/concept map at test 1. After nutritional education, they increased slightly to 24:5 1:9/concept map (p ¼ ns). Six out of eight patients increased their number of concept links at test 2, while in the remaining two this number decreased. 3.3. Qualitative analysis of concept maps The first concepts expressed by patients at test 1 were, by order of frequency: weight (five times), complications (four times), foodstuff (three times), body, oil and health (two times each). At the second test the first concepts change their nature: the word ‘‘overweight’’ appears (seven times), food (four times), cardio-vascular disease (three times), need and oleaginous (twice each). Two types of first-level concept links disclose an increase after nutritional education: the cause and effect links and the conditional links despite the fact that the total number of concept links had barely changed between both tests. Noteworthy, links of general expression were the rarest at both tests, respectively. ‘‘Ways of behaving’’ links remained quantitatively unchanged despite nutritional education. The nature of knowledge fields encountered at the first test are still present after nutritional education. In three patients, three new knowledge fields appear at the second test while simultaneously three new knowledge fields disappear in other three patients. The following knowledge fields remain unchanged after nutritional education: diet characteristics (detailed recording of daily eating habits) and main principles, non-diet characteristics and excessive fat consumption consequences. Those concept fields whose number increase after nutritional education are: physical activity, diabetes, fat’s role and alimentary sources of fat. Nutritional education allows patients to acquire a certain amount of medical vocabulary. These technical terms account for 7.2% of the total number of concepts at test 2. They underline the increased accuracy of the patient’s vocabulary (visible fat, hidden fat, animal fat, vegetal fat,
Table 3 Patient’s eating behaviour trouble’s characteristics Patients number
Drive for thinness
Bulimia
Body dissatisfaction
Ineffectiveness
Perfectinism
Interpersonal Interoceptive Maturity distrust awareness fears
Asceticism
Impulse regulation
Social insecurity
1 2 3 4 5 6 7 8
8 2 4 1 6 5 10 1
5 0 0 0 1 1 0 0
13 4 2 9 11 11 12 0
8 0 2 3 1 0 0 0
1 10 5 0 4 3 7 3
1 0 2 1 4 3 4 3
1 4 1 3 1 0 4 0
2 4 5 1 0 4 2 1
4 6 7 0 8 4 6 2
1 0 1 2 0 2 5 0
3 0 3 4 0 0 5 0
Mean S.E.M.
4.6 1.2
0.9 0.6
7.8 1.8
1.8 1.0
4.1 1.1
2.2 0.5
2.0 0.6
2.4 0.6
4.7 11
1.4 0.6
1.9 0.7
Range of normality (Gardner)
3.3–7.7
0.3–2.1
9.2–15.2
0.7–3.9
3.7–8.7
0.7–3.3
0.9–5.1
1.4–4.0
1.8–5.0
0.7–3.9
1.8–4.8
S. Franc¸a et al. / Patient Education and Counseling 52 (2004) 183–192 Table 4 Number of concepts prior to and after nutritional education After
Repeat
New
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degree of anxiety, depression and without EBTs disclosed a tendency towards a more effective learning.
Patients number
Before
Percentage of new concepts
1 2 3 4 5 6 7 8
18 18 21 27 27 18 15 19
18 22 29 30 27 19 19 16
8 9 10 12 15 12 10 8
10 13 19 18 12 7 9 8
55.5 59.1 65.5 60 44.4 36.8 47.3 50.0
Mean
20.4
22.5
10.5
12.0
52.3
S.E.M.
1.6
1.9
0.8
1.6
3.3
calories) or pertain to physio-pathological concepts (i.e. stroke, thrombosis, cardiac frequency, insulin transport, toxins, . . .). Two independent nutritionist experts were requested to examine patient’s concept maps. Their analysis reveals the presence of totally or partially wrong knowledge in addition to ‘‘lack of knowledge’’ areas at both tests. At test 1 and 2 totally wrong and 4 partially wrong concepts were identified in addition to five ‘‘lack of knowledge’’ areas. Moreover at test 2 it is surprising to recall four totally wrong and three partially wrong concepts in addition to two ‘‘lack of knowledge’’ areas; nevertheless, the wrong concepts were different at both tests. Although their total number of super ordinate concepts does not change after nutritional education, they tend to recall more frequently the notion of ‘‘excessive body weight’’ (two patients) and that of ‘‘cholesterol’’ (two patients) at test 1. At test 2 these notions are again found in the same number of subjects in addition to that of ‘‘equilibrated diet’’ (two patients) and ‘‘diabetes’’ (two patients). All psychological tests were subjected to statistical correlation with the number of concepts and links prior to and after nutritional education. Interestingly enough, there is a significant correlation between the degree of self-affirmation and the delta of concepts prior to and after nutritional education (r ¼ 0:69; P < 0:05). All other correlation’s were not significant; nevertheless, those patients with a lesser Table 5 Number of links prior to and after nutritional education Patients
Before
After
1 2 3 4 5 6 7 8 Mean S.E.M.
21 18 28 30 28 18 16 23 22.8 1.9
20 23 31 32 30 20 21 19 24.5 1.9
3.4. Examples of qualitative analysis Female patient aged 63 years old presenting with obesity (BMI 32.5 kg/m2) and whose Type 2 diabetes mellitus was diagnosed two years ago is admitted to the hospital in order to improve her treatment. The concept maps designed with this patient responses are depicted in Fig. 1 (prior to nutritional education) and Fig. 2 (after nutritional education). 3.4.1. The ‘‘bringing to the fore’’ of aestheticallyinfluenced knowledge Table 6 shows that the first concept evoked by this patients prior to nutritional education is that of an athletic body. She directly associates this word with the central concept, fat-by the following link of general expression: ‘fat is little by little store in the body’’. For her, this storage is directly associated with aesthetics (second level concept). On the contrary, the last term evoked by this patient, ‘‘diet’’, belongs to one of the super ordinate concepts. The latter is represented by four ‘‘ways of behaving’’ links, two links of general expression and one finality link.
Table 6 First concepts, links and types links at tests (1 and 2) from patient 3 Patient number 3
First concepts
Number of links by first concept
First test
1. Athletic body 2. Food 3. Obesity
2 3 6
4. Sport 5. Unhappy
2 2
6. Diseases
2
7. Diet
7
Total
7
Second test
1. Needed in small 2 quantities
Total
23
2. Obesity
5
3. Unhappy
3
4. 5. 6. 7.
1 1 1 2
7
Heaviness Unaesthetic Sweating Food
15
Nature of first links 2 3 2 2 2 2 1 1 1 1 4 1 2
Generality Generality Generality Causative Behaviour Generality Generality Behaviour Generality Causative Behaviour Finality Generality
4 Types of link 1 Generality 1 2 3 2 1 1 1 1 1 1
Finality Generality Causative Generality Causative Generality Causative Conditionality Generality Behaviour
5 Types of link
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3.4.2. Bringing up knowledge in regard to eating behaviour–attitudes towards diet For this particular patient, one must follow a diet to eliminate fat, to control obesity and also to eliminate one’s poor body image. For this same patient follow a diet means simply to eat with a balanced diet (second level concept) while watching out for food quantity (second level concept). In order to do so, she recalls the composition of a meal (concrete concepts at the second level) considering the quality and quantity of foods. She also develops the idea of, every now and then, making excursions out of ‘‘diet’’ to ‘‘hold out’’. In this same line of thought, she provides examples of fat-rich foods to be forbidden when dieting. Finally, the patient declares to follow a diet to be in a ‘‘better health’’. For her, the latter means to feel good and obtain good chemical results. 3.4.3. Bringing up emotionally and psychologically influenced knowledge prior to nutritional education The concept ‘‘obesity’’ belongs to a pre-test super ordinate concept (six links). It is indeed worthwhile describing the performance which the patient has attached to it. Hence, she defines obesity, through the image of somebody ‘‘full of fat’’. For her, fat is the source of this disease. The latter shortens life expectancy (second level concept). For this patient, having an overweight induces a poor body image. Moreover, she maintains that the sport and the diet allow yourself to control obesity. 3.4.4. The birth of a new concept after nutritional education The direct association between the fat and body concepts arising at test 1 disappears at test 2. Moreover, a new concept is born meanwhile ‘‘the need of small quantities’’. This concept is associated by a link of general expression to the concept ‘‘fat’’ and by a finality link to the concept ‘‘wellbeing’’. For this patient, people must only harbour a small quantity of fat in their bodies to feel good. It is likely that the nutritional education sessions attended during her in-hospital stay may have induced a modification of the first concept at test 2. 3.4.5. New knowledge linked to a psycho-affective logbook Table 6 allows the reader to verify that the term obesity reappears at test 2 while keeping its super ordinate status concept. On the contrary, the patient defines obesity by different ways at test 2: ‘‘too much weight, shame of your body, difficulty to move or to play sports’’ and even ‘‘obesity is un-aesthetic’’. Altogether the latter suggests that obesity, through its superimposed body image, constitutes a major preoccupation in her daily life. This patient’s specific talk discloses a suffering, unwell state. For this patient, eating too much is at the origin of obesity, a disease which may cause a poor body image and a heaviness. At this particular point, the patient is not associating obesity with poor body image through a link of general expression but a cause and effect
link. This look discloses once again the worries of the individual concerning his or her body image. Finally, the association between obesity and heaviness is an example of a new association which appears as a new main concept at test 2 concept maps. 3.4.6. Repeated concepts Table 6 discloses that four out of the seven first concepts evoked by patient 3 at test 2 were already present at the first test: ‘‘food, obesity, poor body image and body’’.
4. Discussion and conclusions The aim of our study is to analyse the benefits and limitations of concept mapping employed as a tool to assess patient’s knowledge in the hallmark of nutritional education. The paper is centred on qualitative changes regarding patient’s knowledge ranking and organisation. This qualitative study is not designed to assess changes in eating behaviour occurring after nutritional education. Therefore and taken into account the original design of the protocol we are well aware of the limitations regarding extrapolation and generalisation of results. Moreover, the population sample is indeed reduced and the time lag between both tests is short. This discussion will not, intendedly, either reach the pedagogic characteristics of the nutritional education program nor take into account the eventual relationships between concept maps, clinical data and further eating behaviours. Concept maps disclose the extent of patient’s prior nutritional knowledge which explains why the real average gain in knowledge is limited to two concepts and the links after nutritional education. Therefore, our eight patients had somewhere acquired, by themselves or through interaction with healthcare professionals, an important baggage of knowledge. The latter is frequently observed in the nutritional hallmark. Additionally, concept mapping have the power to disclose qualitative changes intervening after nutritional education. The first concepts formulated by patients change their nature after nutritional education becoming more accurate and specific. Super ordinate concepts, those which set-up the largest knowledge baggage, do not increase numerically between the two tests. Interestingly, they disclose and education related change in orientation since new concepts (i.e. equilibrated food and diabetes) appear among four patients. Otherwise knowledge fields disclose stability since half of those disclosed at test 1 are again found at the second test. The latter underlines the importance of prior knowledge as a relatively stable structure upon which education may attach new knowledge [13,22]. Knowledge field—whose number increases between both tests—seem to translate education’s effect; they bring up diabetes, fat and physical activity’s respective roles in weight gain. The latter three issues are particularly developed throughout the nutritional education program followed by patients at our service.
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Changes concerning the nature of concept links are also identified: both the number of cause ands effect links and conditional links increase at test 2. The rise in the first category links conveys the improved physio-pathology mastery by patients. It seems that nutritional education renders patients more capable to explain the causes and effects between the different phenomenon. Additionally, a greater number of conditional links appear in the cognitive arena secondary to the development of an algorithm-type of reasoning. Concept mapping also disclose the purchase of medical vocabulary by patients, which after the nutritional education program, is close to that of the healthcare team. This finding is in accordance with previous studies [3]. Obviously, the goals of therapeutic education extend themselves way beyond this aspect; nevertheless, a sound and skilful management of medical vocabulary facilitates communication with the healthcare team, and creates a favourable condition to establish a therapeutic alliance. Our study, probably due to patient’s shortage, is unable to certify whether concept maps are correlated with psychological tests. Hence, among the 11 items belonging to the EBTs test, only two (interpersonal distrust and asceticism) seem to be represented by specific concepts appearing in the concept maps of five patients. Therefore, it seems premature to maintain that concept mapping methodology is capable of strengthening EBTs research by psychological tests. Only self-affirmation discloses a significant correlation with concept’s quantitative changes prior to and after nutritional education (P < 0:05). Nutritional education is more beneficial to those patients with a higher degree of selfaffirmation. In addition, depressive and/or anxious states do not seem to induce modifications in the learning process but the results did not reach significancy. Again, patient’s shortage makes it impossible to draw any valid conclusion from this preliminary data. Franca et al. [23] conducted a simple-blinded study with obese ‘‘under-evaluators’’ and ‘‘normo-evaluators’’ profiles. Both categories were indistinguishable by means of concept mapping; nevertheless concept maps allowed spotting certain concepts and types of reasoning which, later on, seemed to be particularly adapted to patient’s personality profiles. According to the latter it seems legitimate to say that concept mapping discloses the ability to underline some concepts and knowledge fields which appear to be linked to personality traits. Further research will be necessary to dwell systematically on the eventual relationship between psychological tests and concept maps in the EBTs scenario. 4.1. Conclusions Concept mapping methodology seems to provide basic information concerning patient’s prior knowledge and its set-up as well as the effects of education on patient’s
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cognitive system transformation. Unfortunately, this method has its setbacks, it is time-consuming, requires the intervention of a fully-trained professional who masters the interview’s technique and is capable of analysing concept maps. These are the main restrains which make it unfeasible to apply this methodology to all patients undergoing educational programs on a systematic basis. On the contrary, it seems necessary to develop this methodology in order to be used as a diagnostic tool for cognitive difficulties disclosure in some patients. 4.2. Practice implication Concept mapping provides us with means to perform an accurate and sound analysis of patient’s prior knowledge and its set-up as well as the effects of education on their cognitive system transformation. Regarding patients with EBTs, concept mapping seems incapable of neither disclosing the specific trouble nor confirm the psychological test results. On the contrary, concept mapping seems to gather information regarding certain personality traits revealed by psychological tests. Therefore, concept mapping can be conceived as a diagnostic method for learning difficulties as well as a complementary tool to investigate certain EBTs. Finally, nutritional education is more beneficial to those patients with a higher degree of self-affirmation.
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[19] Bouvard M, Cottraux J. Protocoles et e´ chelles d’e´valuation en psychiatrie et en psychologie (protocols and evaluation scales in psychiatry and psychology). Paris: Masson; 1996. [20] Rathus SA. A thirty item schedule for assessing assertive behaviour. Behav Ther 1973;4:298–406. [21] Bouvard M, Cottraux J, Mollard E, Messy PH, Defayolle M. Validation et analyse factorielle de l’e´ chelle d’affirmation de soi de Rathus (validation and analyse of the factorial self-esteem scale by Rathus). Psychiatr Med 1986;18:759–63. [22] Giordan A. Les conceptions de l’apprenant. Un tremplin pour l’apprentissage, Sciences Humaines (conceptions of the learner. A way for the learning process). Hors Se´ rie 1996;12:48–51. [23] Franca S, Marchand C, Crapletm C, Basdevant A, Ivernois (d’) JF. Application of ‘‘Concept mapping’’ in obese subjects: a pilot study in normo and under reporters. Diabetes Metab 2002;3(29):72–8.
Evaluation of nutritional education using concept mapping Silvana Franc¸aa, Jean Franc¸ois d’Ivernoisa, Claire Marchanda, Catherine Haennib, Juan Ybarrac, Alain Golayb,* a
Health Education Laboratory, UPRES, EA 3412, WHO Cooperating center for Development of Human Resources in Healthcare, UFR-SMBH, Universite´ Paris Nord, Paris, France b Division of Therapeutic Education for Chronic Diseases, Department of Internal Medicine, University Hospital Geneva, 24, rue Micheli-du-Crest, 1211 Geneva 14, Switzerland c Departament d’Obstetricia i Ginecologia, Institut Universitari Dexeus, Barcelona, Spain Received 10 February 2002; received in revised form 15 December 2002; accepted 24 January 2003
Abstract The concept mapping method is presented in the current study as a new tool to assess the learning process taking part in the hallmark of a nutritional education program addressed to obese diabetic patients. Population: eight patients were interviewed prior to and after completion of 1-week in-hospital stay during which concept maps were designed. Concept maps quantitative and qualitative analysis disclose both (i) the importance of previous knowledge among patients prior to nutritional education and (ii) the maintenance of misconceptions after it. Nutritional education allows patients to acquire and structure their knowledge while providing them with a certain amount of medical vocabulary. An underlying correlation between concept maps design and the results of psychological tests identifying eating behaviour troubles (EBT), depression or anxiety has not been clearly identified. However, the nutritional education is more beneficial to those patients with a higher degree of self-assertiveness and with a lesser degree of anxiety, depression and eating disorder. # 2003 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Concept mapping; Nutritional education; Nutritional evaluation; Personality traits
1. Introduction Concept mapping is presented in the current paper as a new tool to evaluate nutritional knowledge. According to their inventors [1], a concept map is an individual’s graphic representation of cognitive organisation of a certain issue, based on a central concept. Concept mapping is originally designed as learning tool for schoolchildren and students. Later on concept mapping is conceived as a tool to evaluate patient education [2,3]. Hence, our study has been designed and conducted along the same line of thought. To the best of our knowledge this is the first report of the use of concept mapping in the nutritional education field. Patient education’s goal is to develop autonomy among individuals affected by chronic diseases [4]. This autonomy will enable patients to implement behavioural adaptations to their daily life in order to take charge of their disease all over their life-span. According to Krause and Mahan [5], *
Corresponding author. Tel.: þ41-22-372-97-04; fax: þ41-22-372-97-15. E-mail address: [email protected] (A. Golay).
nutritional education is a process allowing to change habits and eating behaviours in a permanent, voluntary and conscious way all along the life-span. The concept of eating behaviour as pointed out by Apfeldorfer [6], avoids reducing nutritional education to a simple diet issue. Eating behaviour appears as a reflection of the individual’s personality, with its strengths and weakness, his more or less rational beliefs and also including this family and personal history [7,8]. Evaluating nutritional education is indeed a difficult task which brings up an inadequacy between the patient’s nutritional information and the education which would enable him to modify his/her eating habits on a daily and long term basis [9]. A psycho-pedagogical approach to nutritional education has been proven to be a possibility to obtain significant behaviour modifications concerning diabetes care at 2 years [10] and 50% of success concerning weight loss at 5 years [11]. The works of Gardner and Ausubel [12,13] in the field of cognitive psychology underline the importance of previous knowledge in the learning process, i.e. what a patient learns during an educational program is influenced by the set of knowledge which he possesses prior to education [2].
0738-3991/$ – see front matter # 2003 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S0738-3991(03)00037-5
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In the same line of thought, it has been shown that concept mapping act as a link between previous and newly acquired knowledge [2]. Additionally, concept mapping reveal the complex set of cognitive changes which an triggered by education and their interference by emotional factors. The aim of our study is to evaluate nutritional education using concept mapping methodology. Along this qualitative study, we have attempted to disclose the link between concept maps content and psychological test results. The latter were set to dwell into EBT in obese patients and test whether EBTs could have a translation into concept mapping.
2. Materials and methods 2.1. Research area This study has been conducted at the Division of Therapeutic Education for Chronic Diseases, University Hospital Geneva. Eight (N ¼ 8) obese type 2 DM patients underwent two structured interviews in order to design concept maps before and after a nutritional education program. For each individual patient, the first concept map (Fig. 1) was built along the first interview on the first in-hospital day—prior to nutritional education. The second concept map (Fig. 2) was built on the last day of hospitalisation— post NE. During that period all patients underwent a fullfledged clinical, biochemical and psychological evaluation.
The main goals of this program are to (i) develop and improve patient’s knowledge regarding diabetes, obesity and nutrition, (ii) encourage patients to modify their eating habits and meanwhile improving the management of their chronic disease. Practical tests such as capillary glycemic controlled are one of the keen features of the program which include three practical sessions by day. Additionally nutritional exercises are proposed along each meal. Thirteen interactive courses are included in the week’s schedule. Theoretical courses alternate with nutritional educationoriented sessions all along with a cognitive-behavioural approach which specifically targets EBT [14,15]. The efficacy of this week of nutritional education has proven its benefits with a significant improvement of eating behaviours 2 years thereafter [10]. This program is run on a weekly basis at the Division of Therapeutical Education for Chronic Diseases. Table 1 depicts its objectives. 2.2. Subjects Our group included eight (N ¼ 8) Type 2 Diabetic patients (5 M, 3F) aged 62 3 years old. They were all overweight and their body mass index (BMI) averaged 31:1 1:3 kg/m2. Five out of eight were married and five out of eight were retired. None of them had ever participated in a nutritional educational program previously. An informed written consent was obtained from each patient after thorough and clear explanation of the aims, goals and characteristics of the
Table 1 Educational program for diabetic patients Time
Monday
07:30
Glycemias, insulin, technical learning Breakfast, practical exercises Welcome Initial statement
08:00 08:30 09:00 10:00
I choose my three snacks
11:30
Glycemias, insulin, technical learning Lunch, buffet, practical exercises
12:00 13:00
Tuesday
Healthcare team meeting I do also treat my diabetes while eating Eye examination
Thursday
Friday
Let us go for a walk . . .
Medical
Thinking about my physical activity
Visit
I use my capillary glycemia results to . . . Reading and understanding food labels
I treat my diabetes (nurse)
14:00
My worries regarding my diabetes
Objective’s session (team)
16:00
Initial statement
I recognize and react upon my hypoglycemias
17:15
Glycemias, insulin, technical learning Dinner
17:30
Wednesday
Long term–uncon-trolled diabetes complications (physician) I take care of my feet and assess my shoes
I can variate my feeding, as an expert Round table living with my diabetes What to do with my diabetes in case of infections
Discovering relaxation Private interviews
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Fig. 1. Concept map elaborated with one patient number 3 prior to nutritional education.
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Fig. 2. Concept map elaborated with the patient number 3, after nutritional education. Note: the number indicated the seven first concepts said by the patient in their emergence order.
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study. The whole procedure was approved by the local ethics committee. Diabetes duration averaged 9:1 0:7 years. Most patients presented with DM-related complications such as background diabetic retinopathy (4/8), mild peripheral diabetic neuropathy—assessed by diminished tuning fork vibration perception—(3/8). Hypertension (defined as BP values > 140/90 mm Hg) was detected in six patients. None of them presented with either micro-albuminuria or proteinuria. Half of them (4/8) presented with criteria for the diagnosis of EBT according to the DSM IV. Moreover, their scores at the Eating Disorder Inventory confirmed the diagnosis of EBT in patients 1, 5, 6 and 7.
or ‘‘field of knowledge’’ and the true/false type of knowledge were also analysed prior to and after nutritional education. Ranking the links between first level concepts into categories allows the identification of cause and effect links [2]. They are formulated by words or expressions, such as ‘‘caused by’’, ‘‘bring up’’, ‘‘provokes’’, ‘‘due to’’, ‘‘that give’’, etc. Other conditional links, such as ‘‘when’’, ‘‘if’’, or ways of behaving links, such as: ‘‘one must start’’; ‘‘one has to’’; have been searched. Additionally, finality links, such as ‘‘to>;’’ to do>; ‘‘to obtain’’; have been identified. Finally, links of general expression, such as ‘‘it is one’’, ‘‘because’’, ‘‘meaning’’, ‘‘it is as if’’, have also been searched for.
2.3. Interviews and concept mapping
2.5. Psychological tests
According to Novak and Gowin’s method [1], formerly addressed to secondary school students, a concept map represents a sort of knowledge cartography of a given individual regarding a central concept. The central concept of our study is the word ‘‘fat’’, written in the centre of a white sheet of paper. The method is based on asking the patient to write around all the words that concepts ‘‘fat’’ freely evokes. Then the patient is encouraged to establish explicit links between words. In our study, concept maps were not drawn by patients themselves. This task was performed by the interviewer who put down the patient’s responses while, following an explanatory interview technique, invited the patient to set precise limits to his wording. Interviews were audio-taped. Patients used their own vocabulary to spontaneously express whatever they felt related to the concept of fat. The first concepts (or first levels concepts) to be evoked were put down as they appeared. Later on throughout the interview patients were asked to clarify the links between all concepts (concepts links). Each individual interview lasted 30 min approximately. The same methodology was used during the second interview without allowing patients to refresh the first interview’s concept map. This was set henceforth to allow the expression of new ideas while privileging spontaneity as a way to disclose their knowledge.
All patients underwent psychological testing in the hallmark of nutritional education. The presence of EBT was evaluated using a semi-structured interview according to the DSM IV criteria and the Eating Disorder Inventory 2 [16]. Depression was evaluated using HAD-D [17] and BECK 21 [18] tests. BECKs scores in the 9–18 range disclosed mild depression while the 19–29 range discloses a modest depression and scores above 29 point out a severe depression [19]. HAD-D scores in the 7–10 range point out a few depressive elements while scores above 11 are considered to represent many depressive elements [17]. Anxiety was evaluated using the HAD-A test. Scores between 7 and 10 translate a mild anxious state which turns into an important anxious state when the score is above 10 [17]. Self-affirmation was evaluated using the RATHUS methodology [20,21]. Scores between 30 and þ30 disclose mainly affirmed behaviours. Scores above þ30 point out an aggressive behaviour while those under 30 disclose an inhibited behaviour [19].
2.4. Concept mapping analysis The quantitative analysis takes into account the number of first concepts to be stated as well as the total number of concepts appearing prior to and after nutritional education. The number of new concepts stated during the second interview and the total number of repeated concepts along the two interviews were also recorded. Finally, the total number of concept links disclosed during both interviews were also recorded. The qualitative analysis is primarily focused on the nature of the first concepts as well as that of concepts giving rise to several links, termed super ordinate concepts, prior to and after nutritional education. The nature of concepts gathering
3. Results 3.1. Analysis of psychological tests Tables 2 and 3 depict psychological test’s scores. Anxiety, assessed by HAD-A test, averaged 6:4 1:3. Interestingly, three patients scored above 7 which indicates rather anxious profiles. Depression was evaluated simultaneously by both HAD-D and BECK 21 test. The inter-test degree of correlation was excellent (r ¼ 0:60; P < 0:02). Only one patient disclosed depression scores at both tests. Self-affirmation was evaluated using the Rathus test. Two patients (1 and 6) disclosed aggressive behaviour with scores of 37 and 51, respectively. Of note, one of them (1) had also high score depression at HAD-D and BECKs tests. The rest of them disclosed self-affirmed scores range between 6 and 25. EBT were evaluated using a semi-directed interview according to the DSM IV criteria. Patients 1, 3, 6 and 7
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Table 2 Patient’s psychological characteristics Patients number
HAD-A
HAD-D
BECK
Rathus
1 2 3 4 5 6 7 8 Mean S.E.M.
14 4 9 8 3 6 3 4 6.4 1.3
9 3 1 5 1 6 6 2 4.1 1.0
21 4 7 3 2 6 9 2 6.8 2.2
37 9 6 5 17 51 17 25 17.2 6.9
fulfilled the criteria for EBT and even disclosed values above the average in several sections of EDI 2 (depicted in Table 3). 3.2. Quantitative analysis of concept maps Tables 4 and 5 depict the concept maps data collected for quantitative analysis. Prior to nutritional education (test 1), patients already disclosed a remarkable amount of knowledge (20:4 1:6). After nutritional education (test 2) knowledge had increased up to 22:5 1:9. Interestingly, five patients increased the number of concepts expressed in concept maps, while two of them did not modify them and the remaining patient (8) decreased the number of concepts by three after nutritional education. The knowledge gain attained through nutritional education averaged two concepts. The quantitative increase of new concepts acquired through nutritional education is relevant: depending on patients, 12 1:6 (range 8–19) new concepts appeared at test 2; nevertheless, a certain number of concepts appearing on test 1 reappeared unchanged at test 2. Repeated concepts averaged 10:5 0:8 (range 8–15) depending on patient’s individual concept mapping and accounted for almost half of the concepts appearing at test 2.
The concept links (shown in Table 5) averaged 22:8 1:9/concept map at test 1. After nutritional education, they increased slightly to 24:5 1:9/concept map (p ¼ ns). Six out of eight patients increased their number of concept links at test 2, while in the remaining two this number decreased. 3.3. Qualitative analysis of concept maps The first concepts expressed by patients at test 1 were, by order of frequency: weight (five times), complications (four times), foodstuff (three times), body, oil and health (two times each). At the second test the first concepts change their nature: the word ‘‘overweight’’ appears (seven times), food (four times), cardio-vascular disease (three times), need and oleaginous (twice each). Two types of first-level concept links disclose an increase after nutritional education: the cause and effect links and the conditional links despite the fact that the total number of concept links had barely changed between both tests. Noteworthy, links of general expression were the rarest at both tests, respectively. ‘‘Ways of behaving’’ links remained quantitatively unchanged despite nutritional education. The nature of knowledge fields encountered at the first test are still present after nutritional education. In three patients, three new knowledge fields appear at the second test while simultaneously three new knowledge fields disappear in other three patients. The following knowledge fields remain unchanged after nutritional education: diet characteristics (detailed recording of daily eating habits) and main principles, non-diet characteristics and excessive fat consumption consequences. Those concept fields whose number increase after nutritional education are: physical activity, diabetes, fat’s role and alimentary sources of fat. Nutritional education allows patients to acquire a certain amount of medical vocabulary. These technical terms account for 7.2% of the total number of concepts at test 2. They underline the increased accuracy of the patient’s vocabulary (visible fat, hidden fat, animal fat, vegetal fat,
Table 3 Patient’s eating behaviour trouble’s characteristics Patients number
Drive for thinness
Bulimia
Body dissatisfaction
Ineffectiveness
Perfectinism
Interpersonal Interoceptive Maturity distrust awareness fears
Asceticism
Impulse regulation
Social insecurity
1 2 3 4 5 6 7 8
8 2 4 1 6 5 10 1
5 0 0 0 1 1 0 0
13 4 2 9 11 11 12 0
8 0 2 3 1 0 0 0
1 10 5 0 4 3 7 3
1 0 2 1 4 3 4 3
1 4 1 3 1 0 4 0
2 4 5 1 0 4 2 1
4 6 7 0 8 4 6 2
1 0 1 2 0 2 5 0
3 0 3 4 0 0 5 0
Mean S.E.M.
4.6 1.2
0.9 0.6
7.8 1.8
1.8 1.0
4.1 1.1
2.2 0.5
2.0 0.6
2.4 0.6
4.7 11
1.4 0.6
1.9 0.7
Range of normality (Gardner)
3.3–7.7
0.3–2.1
9.2–15.2
0.7–3.9
3.7–8.7
0.7–3.3
0.9–5.1
1.4–4.0
1.8–5.0
0.7–3.9
1.8–4.8
S. Franc¸a et al. / Patient Education and Counseling 52 (2004) 183–192 Table 4 Number of concepts prior to and after nutritional education After
Repeat
New
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degree of anxiety, depression and without EBTs disclosed a tendency towards a more effective learning.
Patients number
Before
Percentage of new concepts
1 2 3 4 5 6 7 8
18 18 21 27 27 18 15 19
18 22 29 30 27 19 19 16
8 9 10 12 15 12 10 8
10 13 19 18 12 7 9 8
55.5 59.1 65.5 60 44.4 36.8 47.3 50.0
Mean
20.4
22.5
10.5
12.0
52.3
S.E.M.
1.6
1.9
0.8
1.6
3.3
calories) or pertain to physio-pathological concepts (i.e. stroke, thrombosis, cardiac frequency, insulin transport, toxins, . . .). Two independent nutritionist experts were requested to examine patient’s concept maps. Their analysis reveals the presence of totally or partially wrong knowledge in addition to ‘‘lack of knowledge’’ areas at both tests. At test 1 and 2 totally wrong and 4 partially wrong concepts were identified in addition to five ‘‘lack of knowledge’’ areas. Moreover at test 2 it is surprising to recall four totally wrong and three partially wrong concepts in addition to two ‘‘lack of knowledge’’ areas; nevertheless, the wrong concepts were different at both tests. Although their total number of super ordinate concepts does not change after nutritional education, they tend to recall more frequently the notion of ‘‘excessive body weight’’ (two patients) and that of ‘‘cholesterol’’ (two patients) at test 1. At test 2 these notions are again found in the same number of subjects in addition to that of ‘‘equilibrated diet’’ (two patients) and ‘‘diabetes’’ (two patients). All psychological tests were subjected to statistical correlation with the number of concepts and links prior to and after nutritional education. Interestingly enough, there is a significant correlation between the degree of self-affirmation and the delta of concepts prior to and after nutritional education (r ¼ 0:69; P < 0:05). All other correlation’s were not significant; nevertheless, those patients with a lesser Table 5 Number of links prior to and after nutritional education Patients
Before
After
1 2 3 4 5 6 7 8 Mean S.E.M.
21 18 28 30 28 18 16 23 22.8 1.9
20 23 31 32 30 20 21 19 24.5 1.9
3.4. Examples of qualitative analysis Female patient aged 63 years old presenting with obesity (BMI 32.5 kg/m2) and whose Type 2 diabetes mellitus was diagnosed two years ago is admitted to the hospital in order to improve her treatment. The concept maps designed with this patient responses are depicted in Fig. 1 (prior to nutritional education) and Fig. 2 (after nutritional education). 3.4.1. The ‘‘bringing to the fore’’ of aestheticallyinfluenced knowledge Table 6 shows that the first concept evoked by this patients prior to nutritional education is that of an athletic body. She directly associates this word with the central concept, fat-by the following link of general expression: ‘fat is little by little store in the body’’. For her, this storage is directly associated with aesthetics (second level concept). On the contrary, the last term evoked by this patient, ‘‘diet’’, belongs to one of the super ordinate concepts. The latter is represented by four ‘‘ways of behaving’’ links, two links of general expression and one finality link.
Table 6 First concepts, links and types links at tests (1 and 2) from patient 3 Patient number 3
First concepts
Number of links by first concept
First test
1. Athletic body 2. Food 3. Obesity
2 3 6
4. Sport 5. Unhappy
2 2
6. Diseases
2
7. Diet
7
Total
7
Second test
1. Needed in small 2 quantities
Total
23
2. Obesity
5
3. Unhappy
3
4. 5. 6. 7.
1 1 1 2
7
Heaviness Unaesthetic Sweating Food
15
Nature of first links 2 3 2 2 2 2 1 1 1 1 4 1 2
Generality Generality Generality Causative Behaviour Generality Generality Behaviour Generality Causative Behaviour Finality Generality
4 Types of link 1 Generality 1 2 3 2 1 1 1 1 1 1
Finality Generality Causative Generality Causative Generality Causative Conditionality Generality Behaviour
5 Types of link
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3.4.2. Bringing up knowledge in regard to eating behaviour–attitudes towards diet For this particular patient, one must follow a diet to eliminate fat, to control obesity and also to eliminate one’s poor body image. For this same patient follow a diet means simply to eat with a balanced diet (second level concept) while watching out for food quantity (second level concept). In order to do so, she recalls the composition of a meal (concrete concepts at the second level) considering the quality and quantity of foods. She also develops the idea of, every now and then, making excursions out of ‘‘diet’’ to ‘‘hold out’’. In this same line of thought, she provides examples of fat-rich foods to be forbidden when dieting. Finally, the patient declares to follow a diet to be in a ‘‘better health’’. For her, the latter means to feel good and obtain good chemical results. 3.4.3. Bringing up emotionally and psychologically influenced knowledge prior to nutritional education The concept ‘‘obesity’’ belongs to a pre-test super ordinate concept (six links). It is indeed worthwhile describing the performance which the patient has attached to it. Hence, she defines obesity, through the image of somebody ‘‘full of fat’’. For her, fat is the source of this disease. The latter shortens life expectancy (second level concept). For this patient, having an overweight induces a poor body image. Moreover, she maintains that the sport and the diet allow yourself to control obesity. 3.4.4. The birth of a new concept after nutritional education The direct association between the fat and body concepts arising at test 1 disappears at test 2. Moreover, a new concept is born meanwhile ‘‘the need of small quantities’’. This concept is associated by a link of general expression to the concept ‘‘fat’’ and by a finality link to the concept ‘‘wellbeing’’. For this patient, people must only harbour a small quantity of fat in their bodies to feel good. It is likely that the nutritional education sessions attended during her in-hospital stay may have induced a modification of the first concept at test 2. 3.4.5. New knowledge linked to a psycho-affective logbook Table 6 allows the reader to verify that the term obesity reappears at test 2 while keeping its super ordinate status concept. On the contrary, the patient defines obesity by different ways at test 2: ‘‘too much weight, shame of your body, difficulty to move or to play sports’’ and even ‘‘obesity is un-aesthetic’’. Altogether the latter suggests that obesity, through its superimposed body image, constitutes a major preoccupation in her daily life. This patient’s specific talk discloses a suffering, unwell state. For this patient, eating too much is at the origin of obesity, a disease which may cause a poor body image and a heaviness. At this particular point, the patient is not associating obesity with poor body image through a link of general expression but a cause and effect
link. This look discloses once again the worries of the individual concerning his or her body image. Finally, the association between obesity and heaviness is an example of a new association which appears as a new main concept at test 2 concept maps. 3.4.6. Repeated concepts Table 6 discloses that four out of the seven first concepts evoked by patient 3 at test 2 were already present at the first test: ‘‘food, obesity, poor body image and body’’.
4. Discussion and conclusions The aim of our study is to analyse the benefits and limitations of concept mapping employed as a tool to assess patient’s knowledge in the hallmark of nutritional education. The paper is centred on qualitative changes regarding patient’s knowledge ranking and organisation. This qualitative study is not designed to assess changes in eating behaviour occurring after nutritional education. Therefore and taken into account the original design of the protocol we are well aware of the limitations regarding extrapolation and generalisation of results. Moreover, the population sample is indeed reduced and the time lag between both tests is short. This discussion will not, intendedly, either reach the pedagogic characteristics of the nutritional education program nor take into account the eventual relationships between concept maps, clinical data and further eating behaviours. Concept maps disclose the extent of patient’s prior nutritional knowledge which explains why the real average gain in knowledge is limited to two concepts and the links after nutritional education. Therefore, our eight patients had somewhere acquired, by themselves or through interaction with healthcare professionals, an important baggage of knowledge. The latter is frequently observed in the nutritional hallmark. Additionally, concept mapping have the power to disclose qualitative changes intervening after nutritional education. The first concepts formulated by patients change their nature after nutritional education becoming more accurate and specific. Super ordinate concepts, those which set-up the largest knowledge baggage, do not increase numerically between the two tests. Interestingly, they disclose and education related change in orientation since new concepts (i.e. equilibrated food and diabetes) appear among four patients. Otherwise knowledge fields disclose stability since half of those disclosed at test 1 are again found at the second test. The latter underlines the importance of prior knowledge as a relatively stable structure upon which education may attach new knowledge [13,22]. Knowledge field—whose number increases between both tests—seem to translate education’s effect; they bring up diabetes, fat and physical activity’s respective roles in weight gain. The latter three issues are particularly developed throughout the nutritional education program followed by patients at our service.
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Changes concerning the nature of concept links are also identified: both the number of cause ands effect links and conditional links increase at test 2. The rise in the first category links conveys the improved physio-pathology mastery by patients. It seems that nutritional education renders patients more capable to explain the causes and effects between the different phenomenon. Additionally, a greater number of conditional links appear in the cognitive arena secondary to the development of an algorithm-type of reasoning. Concept mapping also disclose the purchase of medical vocabulary by patients, which after the nutritional education program, is close to that of the healthcare team. This finding is in accordance with previous studies [3]. Obviously, the goals of therapeutic education extend themselves way beyond this aspect; nevertheless, a sound and skilful management of medical vocabulary facilitates communication with the healthcare team, and creates a favourable condition to establish a therapeutic alliance. Our study, probably due to patient’s shortage, is unable to certify whether concept maps are correlated with psychological tests. Hence, among the 11 items belonging to the EBTs test, only two (interpersonal distrust and asceticism) seem to be represented by specific concepts appearing in the concept maps of five patients. Therefore, it seems premature to maintain that concept mapping methodology is capable of strengthening EBTs research by psychological tests. Only self-affirmation discloses a significant correlation with concept’s quantitative changes prior to and after nutritional education (P < 0:05). Nutritional education is more beneficial to those patients with a higher degree of selfaffirmation. In addition, depressive and/or anxious states do not seem to induce modifications in the learning process but the results did not reach significancy. Again, patient’s shortage makes it impossible to draw any valid conclusion from this preliminary data. Franca et al. [23] conducted a simple-blinded study with obese ‘‘under-evaluators’’ and ‘‘normo-evaluators’’ profiles. Both categories were indistinguishable by means of concept mapping; nevertheless concept maps allowed spotting certain concepts and types of reasoning which, later on, seemed to be particularly adapted to patient’s personality profiles. According to the latter it seems legitimate to say that concept mapping discloses the ability to underline some concepts and knowledge fields which appear to be linked to personality traits. Further research will be necessary to dwell systematically on the eventual relationship between psychological tests and concept maps in the EBTs scenario. 4.1. Conclusions Concept mapping methodology seems to provide basic information concerning patient’s prior knowledge and its set-up as well as the effects of education on patient’s
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cognitive system transformation. Unfortunately, this method has its setbacks, it is time-consuming, requires the intervention of a fully-trained professional who masters the interview’s technique and is capable of analysing concept maps. These are the main restrains which make it unfeasible to apply this methodology to all patients undergoing educational programs on a systematic basis. On the contrary, it seems necessary to develop this methodology in order to be used as a diagnostic tool for cognitive difficulties disclosure in some patients. 4.2. Practice implication Concept mapping provides us with means to perform an accurate and sound analysis of patient’s prior knowledge and its set-up as well as the effects of education on their cognitive system transformation. Regarding patients with EBTs, concept mapping seems incapable of neither disclosing the specific trouble nor confirm the psychological test results. On the contrary, concept mapping seems to gather information regarding certain personality traits revealed by psychological tests. Therefore, concept mapping can be conceived as a diagnostic method for learning difficulties as well as a complementary tool to investigate certain EBTs. Finally, nutritional education is more beneficial to those patients with a higher degree of self-affirmation.
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