rural classification. 12 The Health Resources and Services Administration( HRSA) defines rural areas as non-metropolitan counties or metropolitan census tracts with Rural-Urban Commuting Area codes 4-10. Similarly, the Economic Research Service( ERS) uses Rural-Urban Continuum Codes to differentiate rural and urban areas, categorizing counties by urbanization and proximity to metro areas. Wayne County fits these rural definitions because it is non-metropolitan and exhibits characteristics of low population density. Therefore, Spring Valley High School, located in Wayne County, qualifies as a rural institution under these federal guidelines, aligning with the criteria used by the HRSA and ERS. 12
The study curriculum was developed by third-year medical students with input from healthcare professionals. The modules targeted four key health issues pertinent to rural WV: substance misuse, physical activity and obesity, mental health, and adult education. See Table 2 for the title, topics, and activities included in each module. Each module was approximately 45 minutes in length and designed to be interactive. No formal pilot testing of the modules or preand post-module surveys was conducted before implementation. However, content design and structure were closely modeled after the HNVP, which demonstrated success in a similar population.
Modules were delivered over four weeks by the same group of five medical students. Each module included a combination of lecture-based teaching, interactive activities, and discussions. Students participated in hands-on activities, and module surveys were conducted before and after each module to measure knowledge gain and attitude shifts.
Pre- and post-module surveys concerning knowledge gain and attitudes toward the topics were administered using RedCap to ensure anonymity. The module survey included five-point Likert scale questions assessing knowledge, attitudes, and comfort levels in discussing health topics with professionals. Each model was assessed using 3-4 Likert scale questions per module( e. g.,“ I understand the signs of addiction” for knowledge,“ I believe physical activity can impact long-term health” for attitudes, and“ I would feel comfortable discussing this topic with my doctor” for comfort). A full list of module survey questions is available upon request.
Data were collected anonymously to avoid bias and protect participant confidentiality. The primary independent variable was the module survey timing( pre- or post-module), categorized as“ Survey.” School characteristics or student demographics were not collected to maintain anonymity. The dependent variable,“ Score,” was generated from the pre- and post-module survey responses. Scores were numerical averages of module survey items, ranging from 1( least positive) to 5( most positive), reflecting students’ knowledge, attitudes, and comfort levels in discussing health issues.
The module survey items were designed to assess students’ knowledge, attitudes, and comfort in discussing health topics. However, due to intentional overlap in item content, where some questions addressed more than one of these domains, the data were analyzed using a single composite score per module. This composite score reflects the overall change in health literacy and comfort rather than independent domain-specific outcomes. The Kolmogorov-Smirnov test was employed to test the sample population for normal distribution. For normally distributed data, a two-tailed paired t-test was employed to compare the mean scores of the pre- and post-module surveys. The paired t-test was chosen because it is designed to evaluate the difference between two related samples, making it suitable for the pre-and post-intervention study design. Results were presented as means with 95 % confidence intervals, and statistical significance was set at p ≤ 0.05. This project was approved by the Marshall University Institutional Review Board( protocol # 2132594).
RESULTS
The pre-module survey of the first module was completed by 112 students, while 91 of those students completed the post-module survey. Comparison of the composite scores on a Likert scale from pre-module survey and post-module survey showed a significant increase in post-module survey scores( 4.22) compared to pre-module survey scores( 3.19)( Figure 1, * p < 0.0001; two-tailed paired t-test).
The pre-module survey of the second module was completed by 111 students, while 105 completed the post-module survey. Comparison of composite scores for this module showed a significant increase in post-module survey scores( 4.34) compared to pre-module survey scores( 3.50)( Figure 2, * p < 0.0001; twotailed paired t-test).
The pre-module survey of the third module was completed by 101 students, while 81 completed the post-module survey. A significant increase in post-module survey scores( 4.32) was observed compared to pre-module survey scores( 3.03)( Figure 3, * p < 0.0001; two-tailed paired t-test).
The pre-module survey of the fourth module was completed by 113 students, while 95 of them completed the post-module survey. A significant increase in post-module survey composite score( 4.42) was observed compared to the pre-module survey composite score( 3.23)( Figure 4, * p < 0.0001; two-tailed paired t-test).
The average retention rate, defined as the percentage of students who completed both the pre- and post-module surveys for each module, was 85.1 %, with the physical activity module having the highest retention rate of 94.6 % and the mental health module having the lowest at 80.2 %. Additionally, each pre- and post-module survey question had a significant increase in Likert score from the pre-module survey to the post-module survey across all four modules( p < 0.0001, two-tailed paired t-test). Question-by-question t-test analysis for each survey module for both pre- and post-module surveys is available upon request.
DISCUSSION
This study aimed to develop a sustainable education model centered on four key topics: substance misuse, physical activity, mental health, and adult education. The primary goal was to improve students’ health literacy, enhance students’ connections with healthcare providers, and promote their willingness to discuss healthcare concerns with a provider in the future. This study incorporated modified modules
18 • www. wvsma. org