Educational strategies

Change your teaching style. Make blogs, iPods, and video games part of your pedagogy. . . . A new generation of students has arrived-and sorry, but they might not want to hear your lecture for an hour.1

Do you know who Digital Natives are? Are you a Digital Immigrant? Probably so. Do you know what the Digital Divide is? The Internet has changed the focus and learning styles of a generation we call Millennials or Generation Y. Classroom education has changed as the needs, interests, and learning styles adjust to the Digital Natives.2 Recognizing differences in learning styles is usually the first step in designing effective educational programs, whether for students, professionals, the public, or patients. But how often have we considered generational learning styles as we develop our patient and family education?

Digital Natives is a term applied to students who have spent their lives learning with computers, listening to music on iPods, playing video games, and networking or socializing on cell phones or with instant messaging.2 Some refer to this generation as Millennials or Generation Y. Born after 1982, they have grown up with computers and their knowledge of digital equipment seems almost innate. Their education has included access to instant information via the Internet resulting in very different learning styles and interests. This difference in education will soon cause many of us to make adjustments in our teaching styles because Digital Natives are not limited to students. Hospitalized patients, transplant recipients, clinic patients, and our younger healthcare providers: physicians, nurses, pharmacists, and social workers can be Digitial Natives.

Those of us born before 1982 are considered Digital Immigrants because we have become fascinated by and adopted aspects of the new technology.2 Some of us have transitioned to the digital era for professional survival. Most of the literature about Generation Y learning styles is directed at students in classrooms.3-5 However, an understanding of these changes in learning styles needs to be applied to hospital and clinic settings for patient education to be effective. We may find that our current educational tools may limit how our younger patients access information to learn.

Generational Learning Styles

The several generations from the 20th Century have varied learning styles.6 Those born before 1944 are referred to as the Silent Generation. This group learns from books and respectful listening in a classroom setting. Baby boomers are those born between 1945 and 1960 and continue to learn through books, although television and movies have influenced their learning styles. Generation X refers to individuals born between 1961 and 1981. Their learning style began to include more demonstrations and interactive learning. Books were still part of learning with this group but styles were beginning to change. Now, Digital Natives, or Generation Y, challenge us to relook at our styles of teaching, for their styles of learning are quite different. If we continue to provide slide presentations and books to supplement and complement the presentations, we may be missing our target goals.

When educating patients, the public, or professional colleagues we should continue to evaluate learning styles but we should also be prepared to design and vary our educational programs with consideration to the generation. Setting up a video for patients to watch has never seemed an effective or personal way of providing education. And Millennials would be "like, totally bored." Give them an interactive video game on transplantation and you will find an enthusiastic response. Make the interactive video game available on the handheld computer and you may have a patient who understands the risks and benefits of transplantation, the role of immunosuppression, and the need to call you when a fever sets in.

The Digital Generation

It has been noted that children today take technology for granted. By the age of 7, most children have used a cell phone, mastered TV-on-demand and played computer games.3 By 13, they are surfing the Internet for educational purposes as well as not such educational endeavors. The library is becoming a meeting place rather than an educational resource. The fast paced learning style of Generation Y has caused some analysts to express concern over attention deficits in this population. However, those who have studied this group find them to be smart but impatient with an expectation of immediate results.1 Many come to a transplant center for their initial visit with a plethora of information they have downloaded from the Internet. This generation has mastered the art of multitasking through life with an arsenal of electronic devices.1 Our challenge is to provide them with accurate information in a format that will grab their attention.

Bridging the Digital Divide

The Digital Divide is a term that refers to disparities in access to information technology.4 Economics certainly are a consideration in access to tools for continuing patient education. Some socioeconomic groups do not have computers or digital tools. For this group, the written word, slides, and reinforcement of education with each clinic visit or phone call will continue to be the best method for providing education. The term Digital Divide also may be applied to the gap between learning styles of Digital Natives and Digital Immigrants as well as being applied to our adult transplant clinic waiting areas and the pédiatrie or adolescent transplant programs. The Digital Divide may be found in the way Digital Immigrants educate Digital Natives. The term is actually quite versatile.

It could be that our waiting rooms in hospitals and clinics may become media labs in the very near future to meet educational needs of the digitally savvy. The September 2006 issue of Progress in Transplantation will focus on transitioning adolescents to the adult transplant team. In surveying several authors and colleagues about how their educational approaches are changing with the digital generation appearing in transplant settings, one coordinator noted their adult waiting rooms needed updating to support the needs of this group. It seems our pediatric colleagues have already assessed the learning needs of Generation Y and have placed computerized programs and tools in their waiting areas. As the adolescents transition into the adult transplant programs, they are bored when finding no computers or digital education in the waiting areas. Other colleagues reported using more variations in their educational programs. Print materials are transformed into CD-ROM while educational information is now Web-based for easy access and reinforcement.

The limiting factors for most hospitals seem to be cost and time involved in developing or transforming waiting rooms and educational materials. Transplant coordinators are committed to patient education of transplant candidates, recipients, and their families. With most of us being Digital Immigrants we must ensure that we are competent in developing educational resources for our Digital Natives and digitally savvy patient population. Working with your IT department may prove to be an effective approach to increasing the availability of Web-based information that can be downloaded to digital tools. The ability to develop patient education programs is a gift that most transplant coordinators possess innately. Although we are labeled as mere Digital Immigrants, I know we can master the digital world; it is just not innate for us.

Malaysia Higher Education

FROM Africa to the Middle East and China, the foreign student population in Malaysia is steadily growing from day to day. With three more years to 2010 - the end of the five-year Ninth Malaysia Plan - Malaysia has surpassed the half-way mark of seeing itself as a global education hub inhabited by 100,000 students from overseas.

More than 55,000 foreign students from over 100 countries are currently pursuing their pre-tertiary and tertiary studies at various educational institutions in Malaysia.

To date, Malaysia boasts over 17 public educational institutions, an International Islamic University, 21 private universities, five foreign university branch campuses, over 500 private colleges, as well as 32 international schools and 14 expatriate schools for local as well as international academic needs.

Reputable universities from the United Kingdom and Australia have set up branch campuses in Malaysia, while their counterparts from the United States, Canada, France and Germany are offering external, twinning as well as franchised degree programmes in collaboration with local institutions. Their selling point is none other than to provide an affordable alternative for local (or overseas) students to acquire prestigious university qualifications with lower living expenses.

According to StudyMalaysia.com, the cost of living is in the RM800 to RM1,000 per month range or RM9,600 to RM12,000 per year for a student. This, however, depends on the student's lifestyle as well as the cost of living that varies from one location to another (the cost of living in the city is about 10% higher).

For international students, it is estimated that completing a three-year degree programme would require about RM60,000 to RM90,000 to cover their tuition fees and living expenses. Apart from the affordable living cost and tuition fee, international students can also study one degree programme in a Malaysian university and earn two degree qualifications upon graduation - one from the Malaysian university and the other from a reputable foreign university.

DIRECT COST

Starting way back in the early 1980s, Malaysia has been acknowledged as one of the regional pioneers in the development and promotion of transnational Bachelor's Degree programmes, collaborating with reputable universities from countries like the United Kingdom, the United States, France, New Zealand, Germany and Australia.

A hallmark of "Study in Malaysia", the "2+1" undergraduate twinning degree programme has helped many local and international students save substantial costs in their pursuit of internationally recognised Bachelor's Degree programmes.

According to StudyMalaysia, enrolling in a "3+1" twinning degree engineering programme in Malaysia can save a student a staggering A$60,000 (RM117,940) in tuition fees and living costs compared to doing the entire four-year degree course in Australia.

An extension of a twinning programme, a "3+0" Bachelor's Degree programme from leading foreign universities also entails big cost savings. For example, the tuition fee for a three-year UK Engineering Degree in Malaysia is about US$13,100 (RM45,313) compared to US$16,500 (RM57,060) per year in the UK.

(Under the "3+0" arrangement, Bachelor's Degree programmes from foreign leading universities are conducted in their entirety by private higher educational institutions in Malaysia.)

Closely related to the "3+0" programme is the offering of courses by foreign universities in Malaysia. Since 1998, five international universities, including Australia's Monash University and UK's University of Nottingham, have set up their branch campuses in Malaysia, offering exactly the same degrees as their main campus abroad.

In terms of cost comparison, the tuition fee of a three-year UK Engineering Degree is priced at about US$7,600 (RM26,277) per year in the Malaysian branch campus as opposed to US$22,300 (RM77,100) per year in the UK main campus.

Nutrition Education In Preschools In Malaysia

1. INTRODUCTION

Health has been the ultimate agenda to be acquired by most regions in the world for the coming millennium as emphasised in the "Alma Ata Declaration" that health should be accessible to all by year 2000. This declaration has strongly influenced the Malaysian government in her aims to promote health education and healthy lifestyle among the people. In line with this agenda, Malaysian Ministry of Health with the co-operation of both the private sector and public organization has conducted series of healthy lifestyle campaigns. In a survey reported in local newspaper (Berita Harian, 12 Oct.2000), in 1995, 21% of the Malaysian population are found to be overweight and 6.2% are obese. Overall, the urban population tends to be more overweight (17.5%) compared to the rural population (15.5 %) of Malaysia. In 1996 another survey was conducted, and out of the 80,000 people surveyed, it was found that 16.6% were overweight, and up to 4.4% reached the level of obeity, while 25.2% were reported to be under weight. Though the percentage in overweight and obesity cases have shown a decrease, the fact remains that health messages or campaigns has not yet reached the Malaysian population effectively, especially, the younger generation.

Food is actually very closely related to our social and cultural lives. It forms an integral part of our family, religions and cultural celebrations. Many aspects of food are culturally determined: such as what parents think is appropriate to be eaten; how we eat (with fingers, spoon and forks, or chopsticks); with whom we eat, and when we eat throughout the whole day. Children, in particular, rely on their parents' and caregivers' attitude and behaviour in terms of providing the appropriate healthy choices of food, environment and living conditions. Teaching children to make healthy choices in the food they select is certainly a worthwhile goal and one that will affect their lives through adulthood.

Children are building their bodies that are to last them a life-time, therefore they must know that the food they eat has a direct relationship to the quality of their health. They must be informed that consuming processed foods or foods high in sugar, salt and fat are physically detrimental. An intervention program in preschools is necessary to instill in children a positive attitude towards food.

This paper, based on a research currently undertaken at the University of Science Malaysia (USM) funded by the Ministry of Science, Technology and Environment Malaysia, aims to promote healthy lifestyle among Malaysian children. This research is part of a bigger study conducted nationwide, in colaboration with the School of Medicine, USM. The study focuses on nutrition education in preschool children as we believe that children have much to learn about food and nutrition. Reaching children at this age is important because it is easier to encourage healthy habits during initial behaviour development than to alter existing behaviour (Vance, 1973). Moreover, nutrition education is essential for preschool children because the quality of their nutrition has a direct impact on their growth and development as well as their nutritional status throughout life. This paper will describe how the nutrition education in preschool in Malaysia is being implemented and how the children perceived the importance of foods and good eating habits.

2. RESEARCH PROBLEM

A survey conducted by the Malaysian Ministry of Health in 1991 showed that most of Malaysian preschool children suffered from iron deficiency and malnutrition (Khairuddin, 1991), especially those in the rural areas. Due to the poor nutritional state, combined with frequent episodes of infections and intestinal parasitism, resulted in high rates of absenteesm in rural schools (Kandiah, 1991). However, the state of health has increased rapidly lately due to the great development in the health sector and in the economic achievement, increasing the quality of life, both in the urban and rural areas in Malaysia.

The changing eating habits due to introduction of fast foods and the affluent lifestyle has given wide variety of selection of foods to children. A lot more choices are available and this causes children to be picky when it comes to food. Moreover, nowadays it is more difficult to remain aware of nutritional values of food because of prepackaging, vending machines and fast-food restaurants. More often than not, "formulated", fabricated, fake food are displacing wholesome foods in the diet, especially children's foods and snacks. Parents also wrongfully teach their children by using rewards to encourage their children to eat. Remarks such as "eat your rice and after that you can have your ice-cream" encourages children to want to eat more sweet and sugary foods. This indicates the lack of awareness and knowledge among children (and adults) regarding what is good food for healthy growth.

The latest Trent among families in Malaysia is to have meals outside because working mothers do not have time to prepare home-cooked food. This "eating out" lifestyle further agravate the problems of unhealthy eating and unbalance diets. We find now, more and more children are eating foods bought from stalls along roadsides or from fast food restaurants. Hence, there is a real great need to educate children (as well as parents) on the importamce of good nutrition for healthy growth and for prevention of illness.

3. RESEARCH OBJECTIVES

The main purpose of this study is to design a program, which helps children develop important concepts, attitudes and behaviour toward food. Nutrition education should take place through the child's actual experiences and be focused on attitudes and feelings as well as development of concepts. Children should be educated to be able to make wise choices about food on their own from the variety of foods available around them and to practice orderly meals and good eating habits.

4. METHODOLOGY

4.1 The Conceptual Framework

Healthy lifestyle means positive health, and is defined as an above average status regarding the physiological, mental and social abilities as a human (WHO, 1990). According to WHO, "health is the status of full mental, physical and social well being and not merely an absence of illness and/or infirmaity". Therefore it is necessary to apply substantial effort to assure the full realization of the potential in all children, in order to develop them further through all available means. Healthy lifestyle in this study is defined as having correct knowledge, attitude and practices about food and eating habits.

The theoretical basis for behaviour modification and attitude changing in this study comes from "Orem Advanced Nursing Theories". This theory encompasses three sub theories, which explains people's attitudes of making healthy choices for themselves. This is followed by the demand of taking the right action in making choices and eventually the forces, which would drive them to take actions for practicing healthy choices throughout life. In the case of young children, they do not personally perform all action requirements within their therapeutic self-care demand, because parents and teachers are expected to provide the necessary structure and supervision so that the child's therapeutic self-care demand is met. Children need to be fostered in order to develop their self-care agency through the design of health education program that enables them to distinguish between healthy and unhealthy choices.

Orem has theorized that self-care agency development is dependent upon three underlying components (Orem, 1995): foundational capabilities and dispositions (as "pre-action" capacities that influence the perception of health), and judgement about the need to take action. This development process according to the cognitive development theory is the learning process, which apprently goes through several stages: i.e., perception, attention, exercise or work, memory and learning. Taking this point into consideration, the intervention program designed in this study is made into an instructional mode with the integration of cognitive strategies in order to promote long term healthy behaviors and to guide lifestyle choices.

2. Research Design

The study used a pretest/posttest quazi-experimental design in which six preschools were involved. All of the 6 preschools were from the urban area in Penang and they participated voluntarily in this project.

3. Sample

Altogether 200 children age 5 to 6 year are involved and all of them are from averange income groups (SES) families. One hundred of them were in the experimental group and the other one hundred made up the control group.

4.4 The Intervention Program: The Nutrition Education

The following conceptual framework is used for the development of intervention program on nutrition education in this study. Part of the concepts was adopted from the USDA Dietary Guidelines for Americans (1995).

1. Nutrition is a process by which food and other substances eaten to make the child grow, be healthy and to get energy to work and play.
2. Many kinds and combination of food can lead to a well-balanced diet
3. No food by itself has all the nutrients needed for full growth and health.
4. Eat plenty of grains products, vegetables and fruits.
5. Choose diet low in fat
6. Choose diet moderate in sugar and salt
7. Drink a lot of water and milk
8. The effects of unhealthy eating patterns include under nutrition, iron deficiency anemia and overweight and obesity.

Nine modules were developed and used in this study:

Module 1: Eat a wide variety of foods

Module 2: Eat plenty of fruits and vegetables

Module 3: Importance of grain products

Module 4: Drink a lot of water

Module 5: Food Guide Pyramid for a balanced diet

Module 6: Preparing and cooking our food

Module 7: Choose Healthy Snacks

Module 8: Milk for healthy and strong bones

Module 9: What is good eating habits?

These modules aims to

• To provide knowledge and understanding on the importance of eating variety of foods.
• To create positive attitude towards food
• To instill good eating habits and regular mealtime.
• To create awereness in the children to drink a lot of water, instead of sugary and carbonated drinks.
• To provide understanding on the importance of a balance-diet, and eating the amount according to the food guide pyramid
• To raise awereness among the children on the needs to drink milk for healthy development of bones, teeth and hair.
• To provide understanding on the importance of eating a lot of fruits and vegetables
• To instill awareness on the bad effects of junk-food

The intervention was administered over seven month's period. During this time teachers were regularly trained to teach these modules as lessons to be taught on a schedule, as well as to integrate throughout the day and made a part of many activities. The integrated activities include listening to stories, singing, hands-on activities, game and play activities. In line with the modules, teachers were also asked to provide nutritious snacks, controling the amount of sugar in drinks, and reducing the amount of salt used in food cooked at the centers. They were also encouraged to include a lot of vegetables (fibers) in the children's afternoon meals, and teaching them good manners during eating time. Teachers were to stress the importance of cleanliness in staying healthy and teaching them to brush their teeth after eating. Children in the experimental groups were always reminded of the problems related to nutrition including tooth decay, obesity, weak and tired, unable to play and hypersensitivity to foods through the activities conducted.

6. Test Instruments (KAP Questionnaires)

Three sets of tests were developed to measure knowledge (K), attitude (A) and practices (P) of children on their dietry habits, namely (i) The Children's Questionnaire, (ii) The Teacher's Inventory, and (iii) The Parents Inventory. The Children's Questionnaire was conducted using an interview method. A 15 minutes interview was conducted with each child over several consecutive days. The data from Parents' and Teachers' Inventories would be used to substantiate the children's questionnaire.

1. INITIAL RESULTS AND DISCUSSION

Pretest results show that the level of understanding of children about the concept of 'food' is indeed very superficial and simplistic. Children perceived eating as a way to ward off "hunger", "not get hungry", "not get stomach ache", "to be healthy", "not to be sick", or "not to die" . Only a very small percentage of children understood that eating is for "growth" and "to give energy for play" (Table 1, 2, and 3 in Appendix A). From this analysis, we can interprete that children still do not possess a clear grasp of the concept of 'eating'. To them, eating is only a spontaneous reaction to hunger.

Table 4, and 5 show that majority of children (91%) indicated that they do like eating vegetables, however unclear of the reason why. Table 6 and 7 shows various answers given by children when asked why they need to eat a variety of foods. Regarding their favorite drink, 53% of the children says they like to drink Milo or milk (Table 8) but again they are not sure of why they have to drink a lot of water.

These are some of the data from the pretest which show that the children do not yet comprehend the concept of nutrition. It is expected that after the intervention program, the children will develop a better understanding of the concept, acquire a positive attitude towards eating and able to incorporate this habit into their lifestyle.

It is hoped that through the modules children would learn to eat a variety of foods, increasing their awereness of reasons for selecting certain foods, and helping them develop positive attitude about food. Children's fear of a certain food, example green vegetable, can be reduced by simply increasing exposure to the food. Early experiences of preparing, tasting and eating nutritious foods can have an impact on their long-term eating preferences and habit. To help children learn to appreciate food, we involved them in cooking experience as part of the intervention program. They were taught to prepare simple sandwiches: cut tomatoes and cucumber, spread butter on the bread and put a layer of tuna or sardine, or prepare fruit salad: cut fruits, squeeze salad dressing onto the salad and mixing the salad.

2. CONCLUSION

Good nutrition is essential to proper growth during childhood. To grow up healthy, with vitality and energy, children need adequate nutrition. Their early experiences of eating nutritious food can have an impact on their long term eating preferences and habits (Cosgrove, 1991). This study seeks to prove that we can instill in children healthy eating habits through good nutrition education, that would hopefully be continued through their lives. Many other similar studies have been conducted, in particular, in the USA (Smith, 1976; Karsch, 1977, Essa, Read and Haney-Clark, 1988; Birch et al., 1994) all show that they successfully promoted food and nutrition education to the preschool children. We hope to be able to produce a blueprint of Nutrition Education Curriculum for the preschoolers in Malaysia as a result of this study.

English Language Education at Malaysia

English language education in Malaysia is again in the focus of attention. It is a good thing that there is great concern for Malaysians to be proficient in the English language. Even as the government is considering whether mathematics and science should continue to be taught in English, the Minister of Education was reported in the local media of considering making “English Literature” a single paper at the primary school level. This news would have now sent alarm bells to another group of primary school teachers. There is already much concern about how the mathematics and science teachers are coping with their teaching in English! And now another surprise for primary school teachers.

I strongly advocate the teaching of literature. I am glad that we have a literature component in the language paper at both the primary and secondary school levels. Teachers seem to be getting comfortable with the idea of teaching literary texts in the language classroom. However, we have not seen of any findings from research conducted by the Ministry of Education on the implementation of the literature programmes at both the primary and secondary school levels. There have been some piecemeal researches done by university academics and graduate students which seem to suggest that teachers generally feel less threatened to teach literature now. They seem to have become comfortable teaching the prescribed texts and preparing students based on the present examination format. I dread to think how they will react when the next cycle of texts is announced and should there be any changes in the examination format.

I am sceptical about the call to make literature a single subject in the primary school curriculum, as reported by a local news agency. There are so many complaints about our students being overburdened at school. Do they need yet another subject? I don’t think so. The crux of our concern is the students’ proficiency in the English language. To help our students improve in their language ability, I think we need to look at the English language teacher and English language teaching.

What we could think of is on how to make English language teaching more effective. There is a need to look at English language teaching in both primary and secondary school levels and go to the cause of the problem. Introducing new programmes or subjects may not be the way forward.

I would like to highlight some of my concerns regarding the teaching of English in Malaysia. Although it will be wrong to blame teachers as the cause of the poor standards of English, I believe they have to take the bulk of this blame. First, we need to consider the English language proficiency of the English language teachers themselves. There is no denying that we have many teachers who are competent and proficient in the English language. However, there are many other English language teachers who need to improve their standard of English. There are teachers who have neither the competence nor the confidence to teach English.

Over the years to meet the need for English language teachers, we have had to lower our requirements and standards and accept people into the profession who are not equipped to teach the language. We need to work with these teachers. If we want our English language programmes to succeed, we need teacher who can speak, read and write well in English.

There are many English language teachers who are not trained to be English teachers but due to various circumstances have found themselves teaching English, many reluctantly and others for the lack of other options. These teachers lack pedagogical skills and often have low language proficiency too. They too need to be dealt with.

The effectiveness and the ability of numerous English language teachers who have been produced through “conversion” programmes have to be researched into. How effective are one-year programmes that attempt to produce English language teachers? There are already so many challenges with teachers that we produce in our four-year programmes, one can only imagine what these quick-fix teachers will face. The candidates chosen for these one-year programmes opt to teaching often not for the love of the language or teaching but as a last recourse to find a job. We need more teachers who see the profession as a vocation not a convenience.

Introducing literature in English as a subject in the primary school, I believe will only cause more problems than help to raise the standard of English among our students. Let us improve the existing literature component in the language programme. Let us even give more time to reading appropriate literary materials in the language classroom. But more importantly, let’s have teachers who are truly competent and proficient in the English language.