short fat questionnaire: a self-administered measure of fat-intake behaviour

34. Wiesner D. Professionolization under domination: the nutural therapies in Australia [thesis]. Sydney: University o f New South Wales. 1983. mission. 1990.

35. Australian Bureau o f Statistics. Australia in pofile-tht 1986 censtrc:asummary of mjwfindings. Cat. no. 2502.0. Canberra: ABS, 1988.

36. ANOP Research Services. Community attitudes to Medicare. Canberra: Unpublished report to the Health Insurance Com-

37. Australian Bureau of Statistics. Sydney: a social atlas. Cat no. 2502.1. Canberra: ABS, 1991.

38. Furnham A, Smith C. Choosing alternative medicine: a comparison of the beliefs of patients visiting a general practitioner and a homoeopath. Soc Sci Med 1988; 26: 685-9.

Short fat questionnaire: a self-administered measure of fat-intake behaviour

Annette J. Dobson,' Rosan Blijlevens,* Hilary M. Alexander,' Nicola Croce,' Richard F. Heller,' Nick Higginbotham,' Gaynor Pike,' Ronald Plotnikoff,' Anne Russell' and Rhonda Walker' 'Centre fw Clinical Epidemiology and Biostatistics, University of Newcastle 'Department of Human Nutrition, Wageningen Agricultural University, Netherlands

Abstract A brief questionnaire has been developed to measure behaviour related to dietary fat intake. It is self-administered and self-coded. Mean completion time is about three minutes. Criterion validity was assessed by comparison with a well-established food frequency questionnaire using 124 adults from Newcastle and Sydney. The correlations with the questionnaire scores were: r = 0.55 for total fat as a percentage of total energy, r = 0.67 for saturated fat as a percentage of total energy, and r = 0.44 for polyunsaturated to saturated fat ratio. Reproducibility was assessed by re-use by 25 subjects after seven to nine months (r = 0.85). When used in a community survey of over 300 randomly chosen people in the Hunter Region, the mean scores for men and for women and among different age groups were significantly different. The questionnaire was strongly associated with other scales measuring attitudes, behaviour and knowledge related to low-fat diets. The questionnaire appears suitable for rapid self-assessment by subjects, and as it directs their attention to aspects of their diet which might need improvement, it could be used for health education. It might also be used for epidemiological studies to rank subjects broadly according to their fat-intake behaviour. (AustJ Public Health 1993; 17: 144-9)

ietary intake is difficult to measure validly and reliably.' For clinical use, dietary histories are D usually taken. These involve long interviews

between the dietitian and client to obtain a qualitative or semi-quantitative assessment of food consumption. For population research purposes however, quantitative measures which are reproducible and correlate well with calculated nutrient intake are needed.

Broadly speaking, there are two approaches to measurement of diet. One approach is to record the food consumed over a specified period, for example, by recall of all food and drink taken during the last 24 hours or by weighing and recording total intake over several days. The other approach is to obtain information about 'usual' intake using a detailed questionnaire covering both frequency and quantity of food

Correspondence to Professor AJ Dobson, Centre for Clinical Epi- demiology and Biostatistics, University of Newcastle, New South Wales, Australia, 2308. Fax (049) 68 4742.

con~umed.~ .~ Both approaches involve coding every food item and converting these to nutrient components by a computer program based on food composition tables. Thus both require considerable time and resources to administer and analyse.

For many purposes, for example large-scale epidemiological research or rapid self-assessment by subjects, shorter, simpler measurement methods have been de~eloped .~- '~ These are usually self- administered questionnaires. Most require coding and computer analysis of food There are some, however, which provide a simple scoring sys- tem directly from the questionnaire items."-'O These reduce or eliminate the need for coding and analysis. However, because they do not involve direct use of food tables, the food items have to be culturally specific. For example, a study of men working in Brit- ish industry in the late 1970s included questions about sausages, eggs and bacon,g while a questionnaire used in a Norwegian study included items about sour milk and cod-liver oil.Io

144 AUSTRALIAN JOURNAL OF PUBLIC HEALTH 1993 VOL. 17 NO. 2

SHORT FAT QUESTIONNAIRE

... Please circle only one number for 6 How many times a week do you eat 12 How often do you eat cream?

... each question ... Circle the number which applies to your diet ... How often do you eat fried food with a batter or breadcrumb coating? Six or more times a week (4), three to five

sausages, demon, salamis, meat pies, hamburgers or bacon? Six or mote times a week (4), three to five times a week (3), once or twice a week (2), less than once a week (l) , never (0)

How do you spread butter/margarine on your bread?

Six or more times a week (4), three to five times a week (3), once or twice a week (2), less than once a week (l), never (0).

13 H~~ often do you eat ice Six or more times a week (4), three to five times a week (3), once or twice a week (2). less than once a week (1). never (0).

7

times a week (3), once or twice a week (2), less than once a week (l), never (0) How often do you eat grab-# cream sauces or cheese sauces? Six or more times a week (4), three to five times a week (3), once or twice a week (2), less than once a week (l), never (0) How often do you add butter; margarine, oil or sour cream to vegetables. cooked rice or spaghetti? Six or more times a week (4), three to five times a week (3), once or twice a week (2), less than once a week (l), never (0) How often do you eat wgetables that are fried or roasted with fat or oil? Six or more times a week (4), three to five times a week (3), once or twice a week (2), less than once a week (l), never (0)

How is your meat usually cooked? Fried (4), stewed or goulash (3), grilled or roasted with added oil or fat (2), grilled or roasted without added oil or fat (l), eat meat occasionally or never (0)

Thickly (3), medium (2), thinly ( l ) , dont use butter or margarine (0) How many times a week do you eat chips or French fries? Six or more times a week (4), three to five times a week (3), once or twice a week (2), less than once a week (1). never (0)

How often do you eat pastries, cakes, sweet biscuits or croissants? Six or mole times a week (4), three to five times a week (3), once or twice a week (2), less than once a week (l), never (0).

10 How many times a week do you eat chocolate, chocolate biscuits or sweet snack bars? Six or more times a week (4), three to five times a week (3), once or twice a week (2), less than once a week ( l ) , never (0).

11 How many times a week do you eat potato crisps, corn chips or nuts? Six or more times a week (4), three to five times a week (3), once or twice a week (2), less than once a week (l), never (0).

8

9

. ,- . . I .. 14 How many times a w e k do you eat

cheddar; &am or other h a d cheese, cream cheese or cheese like camembert? Six or more times a week (4), three to five times a week (3), once or twice a week (2), less than once a week (l), never (0).

15 M a t type of milk do you drink or use in cooking or tea and coffee? Condensed (4), fullcream (3, fullcream and reduced fat (2), reduced fat ( l ) , skim or none (0).

16 How much of the skin on your chicken do you eat? Most or all of the skin (2), some of the skin (l), none of the skin/l am a vegetarian (0).

17 How much of the fat on your meat do you eat‘? Most or all of the fat (2), some of the fat (1). none of the fat/l am a vegetarian (0).

Thank you for your co-operation.

Figure 1: Short fat questionnaire (version Bl. When the questionnaire is self-administered, the response options are set out on separate lines.

We have developed a short questionnaire to assess behaviour in relation to dietary fat consumption in the Australian population in the 1990s. The main purpose of the ‘short fat questionnaire’ was to have a brief instrument which people could use to assess their own fat consumption. It should be easy to complete and be directly coded by the subjects them- selves. It should direct their attention to aspects of their diets which might need improvement. A second- ary purpose was to obtain a measure which could be used to rank subjects broadly according to their fat- intake behaviour. In this paper we report how the questionnaire was designed and tested and we pre- sent some results obtained when it was used in a community survey.

Materials and methods ‘Facts on fat’ kit The questionnaire was developed from a series of questions which form part of the ‘Facts on fat’ kit developed by the Health Promotion Services Branch of the Health Department of Western Australia.” Each part of the kit includes a quiz to help people identify sources of fat in their diets. For example, the first question of Step 1 of the kit is ‘How often do you eat fried food with a batter or breadcrumb coating?’. The possible responses and scores are: almost daily (3), several times a week (2), about once a week (1) and less than once a week or never (0). There are 19 such questions. We chose to use these as the basis for our questionnaire because of their face validity and their origin as instruments to draw the attention of

people to aspects of their diets which might need change. Version A of the short fat questionnaire Based on results of pilot testing we made several changes to the ‘Facts on fat’ questions. The wording of some questions was changed to avoid the assump- tion that those answering always cooked their own food; for example, ‘How do you cook meat?’ was changed to ‘How is your meat usually cooked?’. Some questions about similar foods were combined. One question was added about ice cream. Questions about types of spread used on bread and types of cheese eaten were omitted. Consequently this version had 16 questions. Experience suggested that more response categories were needed, particularly to distinguish occasional users from nonusers of a food item. Thus the response categories were redefined and scored from 0 to 4, except for the question on how thickly butter or margarine was spread, for which scores from 0 to 3 were retained. A total score was obtained simply by adding the scores from the individual questions. Version B of the short fat questionnaire In the ‘Facts on fat’ kit there are separate questions about trimming fat off meat and skin off chicken. In Version A of the questionnaire these were combined but some people told us that they trimmed fat but not skin and this response option was not offered. There- fore the question combining both (referred to as the ‘skin and fat’ item) was deleted and two new questions were added, one about fat on meat and the

AUSTRALIAN JOURNAL OF PUBLIC HEALTH 1993 VOL. 17 NO. 2 145

D O B S O N ET AL

other about skin on chicken; each has scores from 0 to 2. This 17-item version, with total score in the possible range 0 to 63, is given in Figure 1.

CSIRO fd-Ji-equmuy questionnaire To assess the validity of the short fat questionnaire, total scores were compared with results obtained from a 1 79-item food-frequency questionnaire developed by the Commonwealth Scientific and Industrial Research Organization (CSIRO). This has been widely used in Australian studies of dietary intake.12J3 Subjects report how many times a food is eaten, per day, week or month. When the serve size is different from the standard size given, the subject is required to describe the serve size. Supplementary questions relate to methods of food preparation. Quantities eaten per day of each of 19 nutrients are computed using t h e computer program FREQUAN.I2 Total fat and saturated fat as percentages of total energy intake (percentage total fat and percentage saturated fat) and polyunsaturated to saturated fat ratio (P:S ratio) are then calculated. Testing the questionnaires Versions A and B of the short fat questionnaire were tested on 124 people (53 men and 71 women). They were: volunteers from the staff and students of the Centre for Clinical Epidemiology and Biostatistics at the University of Newcastle (n = 15); cleaners and voluntary workers at the Royal Newcastle Hospital and community members in Newcastle (n = 44); and community members from western Sydney who par- ticipated in a dietary study conducted by the Depart- ment of Community Medicine at the University of Sydney (n = 65). All were aged over 18 years and they ranged from students to retired people. There was also a wide range of socioeconomic status.

Initially the Newcastle subjects completed version A and the CSIRO questionnaire. After seven to nine months the 25 whom we were able to contact again completed version B, together with the ‘skin and fat’ item from Version A. Their scores were used to assess the intrasubject reproducibility of Version A. Twenty-three of this group recorded their times to complete version B and the additional item. The 39 who could not be contacted were mainly students and hospital volunteers.

The 65 subjects from Sydney completed the CSIRO questionnaire and Version B. Their results, together with those of the 25 Newcastle subjects who had completed the CSIRO questionnaire and Ver- sion B (that is, data for a total of 90 subjects), were used to assess the validity of the short fat questionnaire.

Community suroey Version B of the short fat questionnaire, together with the ‘skin and fat’ item from Version A, was used as part of a community survey of knowledge, attitudes and behaviour related to cardiovascular disease. Data were obtained from 328 subjects randomly selected from the electoral rolls for the Cessnock district and an area to the west of Lake Macquarie in the lower Hunter region of New South Wales. These areas have low socioeconomic status

and high rates of heart disease. The survey included demographic questions, three attitudinal scales, a behavioural scale related to following a low-fat diet and questions to measure knowledge of heart disease. The attitudinal scales were:

‘Self-efficacy’ - to measure perceived ability to follow a low-fat diet. This consisted of seven items such as ‘How confident are you that you will be able to stick to low-fat foods when family members or friends have brought high-fat foods into your house?’. ‘Response efficacy’ - to measure perceived effects of following a low-fat diet. This consisted of six items such as ‘My general health will improve if I eat less fatty and fried foods’. ‘Intentions’ - to describe reported intentions to follow a low-fat diet. This consisted of four items such as ‘Do you plan to follow a low fat diet?’.

The items for all three scales had response options with five-point Likert scales. The scores for each scale were obtained by adding the scores for all items.

The behavioural scale measured stage of dietary behaviour. It consisted of six increments ranging from ‘I haven’t given much thought to changing my eating habits to eat less fatty and fried foods’ (Stage 1) to ‘As part of my regular diet I generally avoid fatty and fried foods’ (Stage 6).

The knowledge scale consisted of twenty items, nine of which concerned dietary factors related to heart disease. These nine items were used in the analyses.

Statistical analysis To test the intrasubject reproducibility the product- moment correlation coefficient (and 95 percent confidence interval) was calculated.

To test the criterion validity of the short fat questionnaire, the total scores were correlated with percentage total fat, percentage saturated fat and P:S ratio as measured by the CSIRO food frequency questionnaire.

Data obtained in the community survey were ana- lysed to compare mean scores among demographic groups using analysis of variance. To investigate relationships between fat scores and each of the attitudinal, behavioural and knowledge scales separ- ately, partial correlation coefficients (holding effects of gender and age constant) were calculated.

Results The short fat questionnaire scores were approximately normally distributed; for the community survey (n = 328) the mean was 23.49 with a standard deviation of 7.57 and range 3 to 50. The intrasubject reproducibility for Version A was high with a correlation coefficient of r = 0.85 (95 percent confidence interval (CI) 0.69 to 0.93).

The criterion validity of the questionnaire score is demonstrated in Tables 1 and 2 by comparing it with results from the CSIRO questionnaire. The correlations were: for percentage total fat, r = 0.55 (CI 0.39 to 0.68), for percentage saturated fat, r = 0.67 (CI 0.54 to 0.77) and for P:S ratio, r=-0.44 (CI -0.60 to -0.26). When quartiles of the distribution of


SHORT FAT QUESTIONNAIRE

Table 1 : Performance of the short fat questionnaire ~~~

No. of Summary subiects statistic 95% CIO

lntrosubject reproducibility of Version A-correlationb between scores 7 to 9 months aport 25 0.85 0.69 to 0.93

CorrelotionO of scores from Version B with results from CSIRO questionnoire

Percentage totol fot Percentoge soturoted fat Polyunsoturoted/soturoted ratio

Time to complete Version B ond the ’skin ond fat’ item from Version A (minutes)

90 90 90

0.55 0.39 to 0.68 0.67 0.54 to 0.77 -0.44 -0.60 to -0.26

23 3.3 (range 1 to 61

Notes: lo1 CI =confidence intervol. lbl Product-moment correlotion coefficients

short fat questionnaire scores were compared with quartiles of the distributions of the fat measures, 38 per cent and 43 per cent of subjects were in the same quartiles for percentage total fat and percentage saturated fat respectively arid another 46 per cent and 44 per cent respectively differed by one quartile (Table 2). Mean values of percentage total fat and percentage saturated fat increased in successive quartiles of scores and mean scores increased in successive quartiles of fat measures (Table 2).

Results obtained in the community survey are shown in Tables 3 and 4. Questionnaire scores were significantly lower for women than men and they decreased significantly with age. Although there were differences in mean scores among occupation groups these were no longer apparent when adjusted for age differences. The three attitude scales and the scales for behaviour and knowledge in relation to low fat diets were all significantly correlated with the questionnaire scores (Table 4).

Discussion Our aim was to develop a simple measure or score which correlates with fat consumption in individuals. We did not aim to measure the actual amounts of fat consumed nor the amounts of fat as percentages of

total energy. The objective was to help subjects identify aspects of their diets which could be improved by reducing fat consumption. We wanted the instrument to be suitable for self-administration, take only a short time to complete, and not require coding or computer analysis from food tables. Ideally, it had to be sufficiently accurate and reliable to classify individuals or groups into ordinal categories, according to behaviour related to fat consumption.

The face validity of the questionnaire derives from its origin as a health education tool. Its criterion validity was assessed by comparison of short fat questionnaire scores with the CSIRO food frequency questionnaire. The correlations between short fat questionnaire scores and percentage total fat (r = 0.55) and percentage saturated fat (r = 0.67) are of similar magnitude to those reported in other studies (see Table 5). All such comparisons among instruments based on recalled frequency of food consumption may, of course, be biased because of correlated errors between responses to the instruments being compared.

The reproducibility of scores obtained about seven to nine months apart (correlation 0.85 for Version A) in our study was higher than obtained by others (see Table 6). The subjects in our study, as in the others, may have changed their diets between measurement

Table 2: Comparison by quartilesO of short fat questionnaire scores (Version B) and total fat as a percentage of total energy (percentage total fat) and saturated fat as a percentage of total energy (percentage saturated fat)

measured by the CSIRO food-frequency questionnaire

Short fat questionnaire scores Mean

I1 7 18-22 23-27 228 score

Percentage total fat < 30.0 30.0 to < 34.5 34.5 to < 37.5 237.5 Mean percentage

total fot

Percentage saturated fat < 11.0 11.0 to < 13.2 13.2 to < 15.5 21 5.5 Mean percentage

soturoted fat

1 1 9 1 1

29.1

14 5 3 0

9.9

8 7 5 6

33.2

8 9 5 4

12.4

3 4 7 6

35.3

0 7 6 7

14.6

1 3 9 9

38.0

1 3 8

10

15.4

17.2 20.7 26.3 27.1

15.6 21.9 25.1 29.1

Note: lo1 It wos not feasible to divide the distributions into quartiles exactly.

AUSTRALIAN JOURNAL OF PUBLIC HEALTH 1993 VOL. 17 NO. 2 I47

DOBSON E l Al

Table 3: Short fat questionnaire scores obtained in the community survey for demographic groups

No. of Mean Standard subiects scores error P O

Gender Men 160 25.21 0.63 <O.OOl Women 168 21.87 0.58

Age groups (years) 18 to 35 100 26.64 0.75 <O.OOl 36 to 55 134 23.33 0.60 56 and over 94 20.39 0.87

Note: la) P-value from one-factor analyses of variance.

times. Therefore very high correlations would not be expected, particularly if the subjects knew their first scores and received other feedback from the initial measurements (in our study they received the CSIRO questionnaire results, but no intervention). Higher correlations are often reported for foods eaten habitually rather than those eaten less regularly. In the case of fat, this is usually attributed to the fact that foods with high fat content are among the food items commonly used.I6 The high reproducibility we found for questionnaire scores may, however, mean that it will be insensitive to changes in dietary behaviour. This possibility requires further investigation before the instrument could be used in evaluation of intervention programs.

For the health educational objective of our instrument, inclusion of items high in saturated fat was important. Thus it was pleasing that the correlation between scores and percentage saturated fat was, in fact, higher than for percentage total fat and that a large and statistically significant negative correlation was obtained with the P:S ratio.

Most studies of dietary measurement have not examined the ability of the methods to distinguish between populations known or believed to differ in their diets.lg When the short fat questionnaire was used in a community survey we found differences between mean scores for men and women and among age groups which were statistically significant. The higher fat scores for men than women were not consistent with the findings of the National Dietary Sur- vey of Adults which reported slightly higher intake of total fat as a percentage of total energy among women.'O This discrepancy is probably due to the relatively strong emphasis on meat and meat products in the short fat questionnaire (four out of 17 items). The National Dietary Survey showed that men obtained a relatively higher proportion of total fat from meat and meat products than women. There- fore they would be expected to score relatively more highly on the short fat questionnaire. Lower scores among older people are consistent with other recent findings. 13,P0

The strongly significant associations between the scores and the scales of attitudes, behaviour and knowledge about low-fat diets are encouraging. This may not, however, be unexpected since items in the questionnaire and some items in the other scales are related in content. The knowledge scale was less cor-

Table 4: Partial correlation coefficients (adiusted for age and gender) for short fat questionnaire scores and measurements on the attitude, behaviour and

knowledge scales obtained in the community survey

Scale

~~

Partial correlation 95% confidence coefficients intervals

Self-efficacy -0.42 -0.50 to -0.34 Response efficacy -0.33 -0.42 to -0.22 Intentions -0.55 -0.62 to -0.47 Stage of dietary behaviour -0.46 -0.54 to -0.37 Knowledge -0.16 -0.26 to -0.05

related with questionnaire scores than were the other scales, and intentions and stages of dietary behaviour had the highest correlations. According to Fishbein and Ajzen, intention usually predicts behaviour." In a review of the literature over the past 15 years, there is consistent empirical evidence of strong correlations between intentions and behaviour.22 So it is reassuring that intentions and stage of behaviour are about equally strongly associated with self-reported actual behaviour, the questionnaire score, in this study.

In summary, the simple questionnaire described, here has reasonably good validity and reproducibility for assessing fat-intake behaviour. Because it is self- administered, easy to use and short, it is practical for use in community surveys. It can be used to rank subjects broadly according to their fat-intake behaviour. At this stage its sensitivity to change in behaviour, and hence its use for evaluation of programs, has not been determined; neither has its value for aetiological studies.

Acknowledgments We would like to thank Dr Karen Webb and other members of the Department of Community Medicine of the University of Sydney at Westmead Hospital for their assistance testing the questionnaire.

References 1 .

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Willett W. Nutritional epidemiology. New York: Oxford Uni- versity Press, 1990. Baghurst KI, Baghurst PA. The measurement of usual dietary intake in individuals and groups. Trans Menzies Foundation. 1981; 3: 139-60. Horwarth CC. Food frequency questionnaire: a review. A w t J Nutr Diet 1990; 47: 71-6. Willett WC, Sampson L, Stampfer MJ, Rosner B, et al. Reproducibility and validity o f a semiquantitative food frequency questionnaire. Am J Epidemiol 1985; 122: 51-65. Jain MG, Harrison L, Howe GR, Miller AB. Evaluation o f a self-administered dietary questionnaire for use in a cohort study. Am J Clin Nutr 1982; 36: 931-5. Pietinen P, Hartman AM, Haapa E, Rasanen L, et al. Reproducibility and validity o f dietary assessment instruments. I . A self-administered food use questionnaire with a portion size picture booklet. Am J Epzdemiol 1988; 128 :

Pietinen P, Hartman AM, Haapa E, Rasanen L, et d. Reproducibility and validity o f dietary assessment instruments. 11. A qualitative food frequency questionnaire. Am J Epidemiol 1988; 128: 666-75.

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Kinlay S, Heller RF, Halliday JA. A simple score and questionnaire to measure group changes in dietary fat intake. Preu Med 1991; 20: 378-88. Heller RF, Tunstall-Pedoe HD, Rose C. A simple method of assessing the effect of dietary advice to reduce plasma choles- terol. Prev Med 1981; 10: 364-70. Jacobsen BK, Bonaa KH. The reproducibility of dietary data from a self-administered questionnaire. The Tromso study. IntJ Epidemiol 1990; 19: 349-53. Miller M, Swanson M, Coli T, et al. ‘Facts on Fat’: a community education campaign. Proceedings of the 6th National Conference of the Dietitians Association of Australia, Perth,

Baghurst KI, Record SJ. A computerised dietary analysis sys- tem for use with diet diaries o r food frequency questionnaires. Community Health Stud 1984; 8: 11-8. Baghurst KI, Record SJ, Baghurst PA, Syrette JA, et al. Sociodemographic determinants in Australia of the intake of food and nutrients implicated in cancer aetiology. Med J Auct 1990; 153: 444-52. Tjfinneland AT, Overvad K, Haraldsdottir J. Bang S, et al. Validation of a semiquantitative food frequency questionnaire developed in Denmark. Int J Epidemiol 1991; 20:

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INFORMATION A N D HEALTH CARE

diet in an elderly population. J Epidemiol Community Health 1990; 44: 162-9. Colditz GA, Willett WC, Stampfer MJ, Sarnpson L, et al. The influence of age, relative weight, smoking and alcohol intake on the reproducibility of a dietary questionnaire. I n t J Epidenriol 1987; 16: 392-8. Van Beresteyn ECH, vant’Hof MA, van der Heiden- Winkeldermaat HJ, ten Have-Witjes A, et al. Evaluation of the usefulness of the cross-check dietary history method in longitudinal studies. J Chronic Dis 1987; 40: 105 1-8. Margetts BM, Cade JE, Osmond C. Comparison o fa food frequency questionnaire with a diet record. IntJ Epidemioll989;

Lee-Han H, McGuire V, Boyd NF. A review of the methods used by studies of dietary measurement. J Clin Epidemiol 1989; 42: 269-79. Department of Community Services and Health. Natiunul dietaty survq, of adults. No. 2, Nutrient Intakes. Australian Gov- ernment Publishing Service, 1983. Fishbein M, Ajzen I. Attitudes toward objects as predictors of single and multiple behavioural criteria. Psycho1 Rm 1974; 81: 59-74. Ajzen I. Attitude, structure and behaviour. In: Pratkanis A, Breckler S, Greenwald A, editors. Attifude, stmture and func- tion. Hillsdale, New Jersey: Lawrence Erlbaum Associates. 1989: 241-74.

8: 868-73.

Evaluating preventive

the importance of information sources for health care in rural Australia

John S. Humphreys, Frances Rolley and Herb C. Weinand Department of Geography a d Planning, University of New England, Armidale

Abstract: Health promotion and prevention are critical elements of public health programs designed to improve health status and extend life chances. The pattern of mortality and morbidity in rural Australia suggests a particularly important role for health promotion and preventive measures in country areas. However, the importance of preventive health measures and how people access health-related information is not well understood. This study examines which sources of health-related information are most valued by rural residents and whether the importance attributed to different sources varies according to age, sex and geographic location. The results demonstrate the overwhelming importance of the general practitioner and pharmacist in provision of preventive health information for all rural people. There is a need to ensure that the work carried out by all those involved with health promotion is closely integrated with that of rural general practitioners. (AustJ Public Health 1993; 17: 149-57)

n recent years, health promotion and the provision of preventive health services and health- I related information have been emphasised in

addition to curative health care initiatives. The pattern of mortality and morbidity in rural areas of Aus- tralia differs significantly from that of metropolitan regions.’V2 Most notable are the above-average incidences of suicide, accidents and injuries and prevalences of skin, respiratory and musculoskeletal disease^.^ The profile of ill-health in rural areas suggests a particularly important role for health promotion and preventive measures as means of improv-

Correspondence to Dr John S Humphreys, Department of Geography and Planning, University of New England, Armidale, NSW 2351. Fax (067) 71 1787.

ing health status and reducing the demand for curative health services.

Rural areas throughout Australia are disadvan- taged with respect to both the availability of, and access to, many health care service^.^ The problems which characterise rural residents’ access to curative services may be just as important in affecting their ability to acquire information on measures relating to preventive care. To date; however, the role of preventive health measures and how people access health-related information is not well understood.

Given remoteness from major urban centres where information sources and health care services are con- centrated, how do rural inhabitants gain information on ways to improve their health and to prevent ill- health? This study reports the results of research con-

AUSTRALIAN JOURNAL OF PUBLIC HEALTH 1993 VOL. 1 7 NO. 2 149

short fat questionnaire: a self-administered measure of fat-intake behaviour

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