Prenatal Education Intervention for Increasing Knowledge and Changing Attitude Toward Offspring Obesity Risk Factors

Abstract

This pre- and post-test quasi-experimental design study pilot tested an educational intervention designed to increase knowledge of and change attitudes toward prenatal factors that increase risk of childhood offspring obesity in 36 pregnant women. Educational intervention content included monitoring blood glucose, gestational weight gain in pregnancy, healthy lifestyle choices, and breastfeeding. Education intervention delivery method included: Verbal, written, and video. Participants’ knowledge improved after the intervention for most topics (p = .03–.000). Their attitude score also differed before and after intervention (p = .002). Video delivery mode was the most useful, attractive, and most helpful method. This study showed an education intervention could potentially increase pregnant women’s knowledge and attitudes toward offspring obesity risk factors.

Obesity has more than doubled in children and tripled in adolescents in the past 30 years (Ogden et al., 2014). Approximately 18.5% of children and adolescents in the United States are considered obese (Centers for Disease Control and Prevention [CDC], 2016). Alabama is rated second most obese state in the United States and ranks 14^th in childhood obesity with rates higher among low-income, rural, and minority populations (Dalenius et al., 2012). Reducing risks for childhood obesity is a priority for healthcare providers (Barlow, 2007; Association of Pediatric Nurse Practitioners, 2015). Indeed, the United States Department of Health and Human Services ([USDHHS], 2014) emphasizes reducing the proportion of children and adolescents who are obese and preventing inappropriate weight gain in youth as two of its Healthy-People-2020 goals related to nutrition.

Measures to prevent childhood obesity should ideally begin before a woman becomes pregnant, but certainly during pregnancy (Sabin & Kiess, 2015). Literature suggests that maternal and gestational diabetes (DM), maternal malnutrition, maternal poor lifestyle choices, increased gestational weight gain, and lack of breastfeeding adversely affect offspring obesity (American College of Obstetricians and Gynecologists [ACOG], 2013a; ACOG, 2013b; ACOG, 2020; Pate et al., 2013; Seipel & Shafer, 2013; Sharma et al., 2008; Weng et al., 2012). Women may be unaware about these prenatal factors influencing their infants’ risk of childhood obesity.

MATERNAL AND GESTATIONAL DIABETES MELLITUS

Pérez and Kac (2013) describe the offspring cycle: indicating women, who are obese during prepregnancy, are more likely to have infants that store excess body fat. Ouyang et al. (2016) reported that children whose mothers were obese and had gestational DM had a higher risk of becoming obese, as compared to children whose mothers were obese, but did not have gestational diabetes. Other studies that compared obesity rates among children born to women with and without pre-gestational/gestational diabetes found a higher prevalence of obesity among the offspring born to women with pre-gestational /gestational diabetes (Gillman et al., 2003; Kim et al., 2012; Mustila et al., 2013). Similarly, offspring exposed to hyperglycemia in utero is associated with childhood obesity. For example, children born to mothers with type 1 diabetes mellitus, have an increased risk of being overweight or obese (Kawasaki et al., 2018).

MATERNAL MALNUTRITION

Maternal malnutrition during pregnancy plays a role in determining the long-term health effects upon the infant (Dadi & Desyibelew, 2019; Wang et al., 2012). Mothers who are underweight before conceiving have an increased risk for offspring obesity (Yu et al., 2013). In addition, the Dutch Famine Birth Cohort Study, a retrospective study, found that young men who were exposed to maternal famine during the first two trimesters of pregnancy were more susceptible to obesity and other health problems (Ravelli, 1976). It is possible that infants who develop during a state of maternal undernutrition, may be preprogrammed in utero, resulting in an increased risk for childhood and adult obesity, and diabetes. These epigenetic changes ultimately impact the infant’s appetite and function of adipose tissue resulting in childhood obesity (Ross & Desai, 2013).

MATERNAL LIFESTYLE CHOICES

Poor maternal lifestyle choices, such as inadequate diet, lack of exercise, and smoking and alcohol consumption, affect the development of obesity in children. A randomized controlled trial that implemented an antenatal dietary and physical activity intervention found significant reductions in the risk of infants being born with high birth weight (Dodd et al., 2015). Lack of exercise and sedentary activities such as television and computer use can certainly add to the problem of maternal obesity (deJong et al., 2013; Remacle et al., 2004), which adversely increase the chance of offspring obesity (Dalenius et al., 2012). The ACOG recommends exercise should be encouraged pre-pregnancy, during pregnancy and postpartum. Women need to participate in a routine of moderate-intensity exercise for 30 minutes per day, most days of the week. (ACOG, 2020; Dhana et al., 2018). This can be a challenge for women of all ages, including pregnant women.

For many years, studies have known that smoking is a risk factor for low birth weight infants and small for gestational age infants (SGA = <10% weight for their age) (Lumley et al., 2008; Samper et al., 2011). Current epidemiological data suggested a causal relationship between women who smoke during pregnancy and an increased risk for offspring to become obese (Behl et al., 2013). Additional studies have identified maternal smoking during pregnancy as a risk factor for high BMI in early childhood (Ino et al., 2011; Beyerlein et al., 2011). Similarly, the National Nurses’ Health Study and Growing Up Today Study (GUTS) recruited over 115,000 women and over 24,000 of their offspring and found that being a non-smoker was associated with a 31 percent decrease in offspring obesity ( Brigham and Women’s Hospital and Harvard Medical School, 2009). It is postulated that nicotine in cigarettes, via the mechanism of vasoconstriction, reduces the blood supply to the fetus and causes malnutrition in utero (Behl et al., 2013).

Studies show that long term effects of prenatal alcohol exposure can increase the risk for obesity in offspring (Dobson, 2016, Chapter 17). Amos-Kroohs and colleagues (2016) suggested children with fetal alcohol syndrome disorder (FASD) had increased adiposity which may be related to behavioral and dietary practices, which, in turn, may increase chance of becoming obese. A sample of 74 children with FASD (31.1%) were never full/satisfied and (27.7%) snacked constantly (Amos-Kroohs et al., 2016).

GESTATIONAL WEIGHT GAIN

The CDC reports that only about one-third (32%) of women gain the recommended amount of weight during pregnancy and most women (48–60%) gained too much weight during pregnancy (CDC, 2018). Fraser et al. (2010) found that women who gained more weight than recommended during pregnancy were more likely to have children with a higher BMI and higher fat mass than children of mothers who gained less than the recommended weight during pregnancy. In the Healthy Start study, researchers found the greater the weight gain of the mom during pregnancy is directly related to offspring adiposity at birth (Starling et al., 2015). In fact, women gaining excess weight during the first trimester showed not only offspring with more adipose tissue but also increased cardiovascular risks (Cnattingius et al., 2012). These associations indicate an intrauterine influence on childhood obesity (Starling et al., 2015). This increased weight gain during pregnancy has a significant impact on childhood obesity. Obese mothers had an 18.3% increased rate of large for gestational age (LGA) offspring compared to mothers with appropriate birth weight for gestational age (Cnattingius et al., 2012), and infants born LGA were more likely to be overweight (odds ratio [OR] = 1.23) later in life (Kuhle et al., 2010). Additionally, infants demonstrated an increased risk for childhood obesity for children born to mothers who were obese before and/or during their pregnancies as compared to children born to non-obese mothers (Bamman et al.,2014; Pikrola, 2010).

BREASTFEEDING

Many studies have been conducted to establish a relationship between breastfeeding and protective factors for childhood obesity. Six systematic reviews and meta-analyses concluded infants who were breastfeed have a 12–24% less chance of developing obesity than infants who were formula fed (Woo & Martin, 2015). Other studies focus on the duration of breastfeeding as a protective factor for childhood obesity. One study demonstrated that for mothers who breastfed ≥6 months, their infants had a decreased risk of childhood obesity at age 2 years (Bider-Canfield et al., 2016). Similarly, mothers who practiced exclusive breastfeeding longer than 6 months was associated with a lower risk of overweight in their children and adolescent (Tambalis et al., 2018; Ip et al., 2009; Portela et al., 2015).

Prevention of childhood obesity should begin prior to conception and continue throughout the pregnancy. Indeed, as a woman prepares to get pregnant and when she is pregnant, she may be more receptive to information offered about these topics. Therefore, providing education during prenatal clinical visits is critically important to increase the likelihood of delivering a healthy baby.

The American Dietetic Association (2009) position statement recommends that all overweight and obese women of childbearing age should receive counseling on the roles of diet and physical activity prior to pregnancy and during pregnancy to improve pregnancy results. The ACOG Practice Guidelines suggest that providers should discuss the following topics during prenatal visits: healthy lifestyle, including eating healthy and adequate exercise, and proper weight gain based on the mother’s height and pre-pregnant weight (ACOG, 2013a). However, there is evidence that healthcare providers are not consistently following these recommendations (Herring et al., 2010). Barriers that prevent these providers from delivering counseling in these areas include lack of time, inadequate resources, problems during pregnancy that take precedence over obesity education, and difficulty discussing sensitive issues such as maternal weight with the patient (Stoland et al., 2010). Therefore, identifying an effective educational delivery mode that overcomes these barriers are needed to ensure that important information regarding prevention of childhood obesity is presented to expectant mothers and those planning to become pregnant.

Healthcare educational materials are available in many forms including verbal information from a healthcare provider, printed materials, video, and other programmed sessions for waiting room televisions, and digital educational tools (Soltani et al., 2015; Windham et al., 2014). Video education positively affected health beliefs regarding influenza vaccination during pregnancy in a randomized controlled trial (Goodman et al., 2015). Another study utilized video education to provide education to women regarding urinary incontinence and noted significant increases in knowledge levels after viewing the video (Seshan & Muliira, 2015). However, there is limited data discussing the use of video during an office visit as a tool to educate pregnant women about risk factors for childhood obesity. Therefore, this pilot intervention incorporated video education as a strategy in addition to verbal instruction and a written brochure to deliver educational content to pregnant women about risk factors for childhood obesity. The purpose of this study was to pilot test the prenatal educational intervention designed to increase knowledge of and change attitudes toward prenatal factors that increase risk of childhood offspring obesity.

METHODS

This pilot study was part of a bigger study designed to develop, implement, and evaluate an evidence-based prenatal educational program on prevention of childhood obesity delivered to expectant mothers within the healthcare setting. This study reported the results of the evaluation of the pilot intervention using a pre- and post-test quasi experimental design.

Sample and Setting

This study was approved by the Internal Review Board at the authors’ current institution. A convenience sample of pregnant women from one prenatal clinic in a Southeastern state was recruited for the study. Flyers about the study were posted at the clinic’s check-out window. Eligible women in the prenatal clinic were verbally informed of the study as they completed their office visit. Interested women were directed to the clinic’s conference room. The study was explained and informed consent was obtained.

Instruments

The questionnaire was developed based on focus group interviews with providers and literature reviews. First, a focus group with local obstetricians was used to help identify their perceptions of prenatal factors that may lead to offspring obesity that may be specific to the area. A convenience sample of four males and one female OBGYN physicians comprised the focus group. The providers see approximately 35,000 visits annually and an average of 1,200 babies delivered per year from the local community and surrounding counties. Guided discussion, moderated by a research team member, utilized the following questions: (a) What are some prenatal factors that may affect offspring obesity? (b) If you know a patient has a prenatal risk factor for offspring obesity, how do you intervene? (c) What information would you include in an educational session for pregnant women regarding preventing obesity in their children? (d) Based on your perception, what is the most effective way to provide offspring obesity education to your prenatal patients? Based on themes from the focus group and information from the additional literature review, a survey for pregnant women was developed.

The survey consisted of six demographic questions, 9 knowledge items, 16 attitudes questions, and 3 questions regarding which type of educational delivery mode they preferred. For the knowledge items, participants were asked to indicate if the factor would increase, have no influence, or decrease the risk of childhood obesity. Items also provided a “Do not know” option. The reliability coefficients for the knowledge scale were .69 and .36 for pre- and post-survey, indicating the items needed to be analyzed individually. The attitude items were utilized a 5-point Likert-type scale with 5 = Strongly Agree, 4 = Agree, 3 = Neutral, 2 = Disagree, and 1 = Strongly Disagree. Higher scores indicated a more positive attitude. The internal consistency reliability Cronbach’s alpha for the pre-test was .90, and for the post-test was .88, indicating the attitude scores for pre- and post-attitude scales were reliable. Finally, their preference in educational delivery mode were also using 5-point scale, rating from 5 = most preferable to 1 = least preferable. The higher scores also indicated a higher preference toward a specific delivery mode. Participants were administered the survey pre- and post-intervention.

Intervention

In addition to practice guidelines by ACOG and the American Academy of Pediatrics, existing literature regarding maternal factors affecting childhood obesity was used to guide the development of the education contents. The scripts of the verbal, written, and video educational materials were reviewed by a panel of experts in the School of Nursing as well as an obstetrician/gynecologist to ensure the face and content validity of the educational information being delivered. The educational content of the intervention included controlling diabetes by monitoring blood glucose if recommended by doctor, proper nutrition, appropriate lifestyle choices such as a healthy diet and exercise, appropriate gestational weight gain during pregnancy, and choosing to breastfeed.

After the participants completed the pre-intervention survey, they were randomly assigned using the Latin Square method to the order in which method they would receive the educational content. Each participant received all three delivery modes during the session. The verbal information was presented by nursing faculty. Each participant was given a brochure for review during the session that provided summary points of the selected educational topics. The video: https://vimeo.com/125198220 was shown using a laptop in the conference room. After completing the three modes of education, participants were asked to complete the post-intervention survey of knowledge and attitudes toward risk factors, and an evaluation of the three different educational modes.

Statistical Analysis

Participants’ responses to the knowledge items were examined using McNemar tests to examine knowledge changed before and after the educational intervention. Paired samples t-test was used to compare participants’ attitude change before and after the intervention. Finally, participants’ preference for the educational material delivery modes were analyzed using Wilcoxon Signed Ranks Tests to examine the preference change before and after the intervention.

RESULTS

Demographics

Thirty-six pregnant women between the ages of 17 and 40 (M = 28.39, SD = 5.21) participated in the study. Among these participants, 80.6% of them were Caucasian (n = 29), 16.7% were African American (n = 6), and 2.8% was Asian (n = 1). Twelve of them had some graduate degree (33.3%), 17 of them had some college credit or college degree (47.22%), and 7 of them had some high school or high school diploma (19.44%). Half of them were pregnant with their first baby (n = 18, 50%), nine of them were at their second pregnancy (25%), eight of them were having a third baby (22.2%), and one was at her fourth pregnancy (2.8%). The weeks of pregnancy ranged from 9 to 39 weeks (M = 27.19, SD = 9.57).

Knowledge

Items of the knowledge scale were analyzed separately. Results indicated that participants’ knowledge toward prenatal risk factors were improved after the educational intervention in prenatal diet choices, physical activities, maternal smoking, alcohol use, and excess gestational weight gain (p = .001, p < .001, p = .03, p = .02, p = .03, respectively, Table 1).

Table 1. Data Analysis Results for Knowledge of Prenatal Risk Factors (n = 36).

Risk factors	Testing time	Correct	Incorrect	p
Maternal diabetes	Pre	34 (94.44%)	2 (5.56%)	1.00
	Post	34 (94.44%)	2 (5.56%)
Gestational diabetes	Pre	30 (83.33%)	6 (16.67%)	.13
	post	35 (97.22%)	1 (2.78%)
Maternal malnutrition	Pre	24 (66.67%)	12 (33.33%)	.39
	post	28 (77.78%)	8 (22.22%)
Prenatal diet choices	Pre	17 (47.22%)	19 (52.78%)	.001**
	post	30 (83.33%)	6 (16.67%)
Physical activity	Pre	16 (44.44%)	20 (55.56%)	<.001***
	post	31 (86.11%)	5 (13.89%)
Maternal smoking	Pre	18 (50.00%)	18 (50.00%)	.03*
	post	24 (66.67%)	12 (33.33%)
Maternal alcohol use	Pre	18 (50.00%)	18 (50.00%)	.02*
	post	25 (69.44%)	11 (30.56%)
Excess gestational weight gain	Pre	29 (80.56%)	7 (19.44%)	.03*
	post	35 (97.22%)	1 (2.78%)
Breast feeding	Pre	19 (52.78%)	17 (47.22%)	.39
	post	23 (63.89%)	13 (36.11%)

^*p < .05, % = percent

^**p < .01

^***p < .001

Attitude

Participants’ mean score of their pre- and post-attitude scale was significantly more positive after the educational intervention with moderate effect size (t₍₃₅₎ = 3.39, p = .002, Cohen’s d effect size d = 0.57; pre-survey: M = 4.51, SD = 0.45; post-survey: M = 4.69, SD = 0.35).

Preference of Educational Delivery Modes

Before intervention, about 50% of participants indicated they preferred verbal and brochure materials, but only 25% of participants preferred video delivery mode. However, more participants (63.9%) found the video to be the most preferred delivery mode following the intervention. When comparing the degree of preference change, their preferences toward the video delivery mode was statistically significant higher after the intervention (p = .001, Table 2).

Table 2. Participants’ Preference of Educational Delivery Modes (n = 36).

Delivery modes	Testing time	Most preferable	Preferable	Somewhat preferable	A little preferable	Least preferable	p
Verbal	Pre	20 (55.6%)	10 (27.8%)	5 (13.9%)	1 (2.8%)	0 (0.0%)	.96
	Post	18 (50.0%)	13 (36.1%)	5 (13.9%)	0 (0.0%)	0 (0.0%)
Brochure	Pre	17 (47.2%)	14 (38.9%)	5 (13.9%)	0 (0.0%)	0 (0.0%)	.19
	Post	14 (38.9%)	13 (36.1%)	8 (22.2%)	1 (2.8%)	0 (0.0%)
Video	Pre	9 (25.0%)	15 (41.7%)	10 (27.8%)	2 (5.6%)	0 (0.0%)	.001**
	Post	23 (63.9%)	10 (27.8%)	3 (8.3%)	0 (0.0%)	0 (0.0%)

^**p <.01, % = percent.

DISCUSSION

This study found that an educational intervention has the potential to improve pregnant women’s knowledge regarding how changes in maternal lifestyle and gestational weight control reduce the risk of offspring obesity and to change their attitude. However, the effects of this intervention for improving knowledge on how maternal/gestational diabetes, malnutrition and breastfeeding affecting child’s obesity are less promising. It is not surprising there were no significant differences from pre- to post-intervention for either of these risk factors because there were ceiling effects. For example, maternal diabetes and gestational diabetes were identified as risk factors for childhood obesity by most participants in this study at pretest (94.44% vs. 83.33%). That is, participants were already knowledgeable about the relationship between diabetes and offspring obesity. Therefore, it is unlikely to increase after the intervention.

The knowledge of how exercise can control maternal weight for the purpose of reducing the likelihood of offspring obesity differed significantly before and after intervention. In addition, most women in this study strongly agreed (after the intervention) they would control their weight by exercising if they knew gaining too much weight during pregnancy would increase their baby’s likelihood of developing childhood obesity. As recommended by ACOG (2015), women should be encouraged to exercise during pregnancy if they did not have any pregnancy complications. The current guidelines include 150 minutes per week of moderate-intensity aerobic activity such as brisk walking. Even though pregnant women have many bodily changes during pregnancy, exercise is beneficial to most women and carries minimal risks. Women should be encouraged to be physically active and exercise during pregnancy.

This study also found that there was increased knowledge regarding the effect of smoking on offspring obesity after intervention. In the past, smoking has been discouraged during pregnancy to help reduce the number of low birth weight infants. However, pregnant women may not be aware that smoking during pregnancy has also been linked to development of offspring obesity. This study showed an educational program can potentially increase knowledge of smoking as a risk factor for childhood obesity. Health care providers should teach women that any smoking during pregnancy may increase the likelihood of their child becoming obese.

Similarly, this study found the intervention may have the potential for improving knowledge on how alcohol consumption may affect offspring’s obesity. Traditionally, education provided to pregnant women regarding alcohol consumption in prenatal stage is to prevent Fetal Alcohol Syndrome. Informing pregnant women about alcohol’s effect on childhood obesity will give women an additional incentive to stop alcohol consumption before and during pregnancy. Counseling regarding smoking cessation and alcohol consumption should begin prior to pregnancy to promote the best outcomes in their offspring.

In this study, identification of excess maternal weight gain during pregnancy as a risk factor for childhood obesity significantly increased from pre-intervention to post-intervention. Interestingly, approximately 81% of women provided the correct answer to this question at pretest, and almost 97% of them answered correctly for the posttest. This indicates that women are familiar with how their weight can adversely affect their children, but our educational program reinforced their knowledge. The current ACOG recommendations include assessing and counseling women about appropriate weight gain during pregnancy (Rasmussen & Yaktine, 2009; ACOG, 2013a). During office visits, healthcare providers can discuss appropriate weight gain with pregnant women. Providers can identify community-based resources that are available for women and should consider referral to a nutritionist if needed. Stoland et al. (2010) reported that obese pregnant patients who received advice from healthcare providers about diet and exercise were more likely to report, at subsequent visits, they were working on improving these areas.

Although this study found there was an increase in the number of participants who identified breastfeeding as a method to decrease risk of childhood obesity, the increase was not significant. This question had the lowest percentage of correct answer at posttest as compared to other knowledge items. Only about a half the participants indicated breastfeeding would decrease their child’s risk of developing obesity at pretest, but our educational program only increased knowledge for another 11% for a total of 64%. This indicates that education content in this area may need to be strengthened.

Participants identified the video as the most preferred delivery mode for education on the post-intervention survey. Video delivery mode has been effective in previous studies (Goodman et al., 2015; Seshan & Muliira, 2015). Healthcare providers in primary care settings are often pressed for time and unable to devote the needed time for education. Presenting education through short videos regarding self-care during pregnancy to reduce risk of childhood obesity can be an effective teaching method. In addition, women often spend time waiting to be seen by healthcare providers and providing video education during this waiting time is a good use of their time as well. Providing education through videos followed by time for questions and reinforcement by healthcare providers can be an alternative approach.

LIMITATIONS

This study recruited a convenience sample of pregnant women in Alabama and the results may not be generalizable to women in other states. Most of these women were white and had some college education and many had one or more college degrees. Therefore, this pilot study sample is not representative of women from other educational backgrounds and ethnicities. All data were by self-report, so the responses may have been biased. Lastly, this pilot is a quasi-experimental design study. To identify the efficacy of the intervention and best delivery mode, a randomized controlled trial should be implemented. In addition, measuring knowledge and attitudes immediately after the intervention does not allow us to understand the long-term impact of the intervention.

IMPLICATIONS FOR PRACTICE

OBGYN professionals agree that gestational diabetes, excess gestational weight gain, lack of awareness of appropriate gestational weight gain, and high birth weight of an infant as risk factors of childhood obesity. The positive associations between prenatal risk factors and childhood obesity suggest that education for reducing childhood obesity must begin in the prenatal period. In addition, the prenatal period is a critical time for healthcare providers to intervene in the cycle of childhood obesity because pregnancy tends to be a teachable moment for many women. This is mainly because their care of and love toward their unborn child can provide the motivation to act upon these strategies. Women in the prenatal stage are more ready to learn new knowledge, willing to change their attitude, and likely to practice what they learned to have a positive influence on their unborn children. This is clearly evidenced in this pilot study as it showed a positive effect of the educational intervention for improving knowledge of and changing attitudes toward risk factors that affect childhood obesity.

Video delivery mode may be the best way for childbirth educators to educate pregnant women regarding risk factors for offspring obesity. Counseling pregnant women about prenatal obesity can be a difficult or sensitive topic and sometimes may seem offensive to the women. Video delivery mode may be a better option providing a nonjudgmental learning environment. Perhaps different videos for different populations may be more effective. A novel idea is to provide prenatal education to women attending centering pregnancy groups. Women choosing this type of prenatal care are more actively engaged in their own health information. Physicians and midwives would have more time to lead discussions with the group about preventing offspring obesity. Additional experts such as dieticians, public health educators, and physical therapists would be able to ensure women are provided with ideas about healthy eating, tips for smoking cessation, and appropriate exercise during pregnancy. Additional research is needed to assess the efficacy of this education intervention and best delivery mode to increase pregnant women’s knowledge and change their attitude toward maternal risk factors for offspring obesity improving obesity outcomes of future generationsa.

Biographies

ANN LAMBERT is an Associate Clinical Professor at Auburn University School of Nursing and a Certified Pediatric Nurse Practitioner. See teaches primarily in the undergraduate pediatrics and leadership courses and maintains clinical practice in primary care pediatrics. Her interests include offspring obesity, breastfeeding, and SIDS prevention.

CHIH-HSUAN Wang is an Associate Professor in the Department of Educational Foundations, Leadership and Technology in the College of Education at Auburn University. She primarily teaches research methods and data analysis course for graduate students. Her research interests include understanding students' motivation and learning outcomes in e-Learning environments and K-12 STEM areas, factors that influence international students‘ motivation and learning, and topics related to nursing and health education.

PAO-FENG TSAI is full Professor and Associate Dean for Research for the School of Nursing at Auburn University. She has made presentations at national and international conventions and published more than 50 articles. She is a grant reviewer for for NIH, Sigma Theta Tau International Honor Society of Nursing, American Nurses Foundation, Southern Nursing Research Society and others. Dr. Tsai is a fellow of the American Academy of Nursing.

DISCLOSURE

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

FUNDING

Auburn University Intramural Grant Program (IGP). (2014). Lambert awarded $8000.00 in support of the research project.