Association Between Educational Attainment and EFNEP Participants’ Food Practice Outcomes

ObjectiveExamine the association between educational attainment and improvement in food practice outcomes of the California Expanded Food and Nutrition Education Program (EFNEP) participants.DesignSecondary data analysis.ParticipantsA total of 19,089 participants, 92.3% female, 77.2% Hispanic, 19.7% with ≤ sixth-grade education, and 68.9% with incomes ≤ 100% of the federal poverty level.Main Outcome MeasuresImprovement in food resource management practices (FRMP), nutrition practices, and food safety practices (FSP).AnalysisWilcoxon signed rank tests examined pre-post outcomes. Mann-Whitney U tests compared whether participants in the lowest and highest educational attainment quartiles had similar levels of improvement.ResultsCalifornia EFNEP is associated with improved FRMP (z = ?95.33), nutrition practices (z = ?94.91), and FSP (z = ?92.37); (P < 0.001). Lowest educational quartile was associated with more improvement in FRMP and FSP (P < 0.001).Conclusions and ImplicationsCalifornia EFNEP contributed to improved food practice outcomes for low and high educational attainment participants. Program content and instruction are effective across the education continuum.     

Evaluation of a Policy,Systems, and Environmental-Focused Faith-Based Health Promotion Program

ObjectiveThis study assessed the impact and lessons learned from implementing policy, systems, and environmental (PSE) changes through Faithful Families Thriving Communities (Faithful Families), a faith-based health promotion program, in 3 southern states.MethodsFaithful Families classes and PSE changes were implemented through a coordinated effort between the Expanded Food and Nutrition Education Program (EFNEP) and Supplemental Nutrition Assistance Program–Education (SNAP-Ed). Changes were measured using a faith community assessment, site reports, and annual reporting.ResultsThirteen faith communities participated in the intervention. A total of 34 PSE changes were implemented across the 3 states, affecting 11 faith communities with 4,810 members across sites.Conclusions and ImplicationsPrograms such as Faithful Families can allow EFNEP and SNAP-Ed to coordinate to implement PSE changes in community settings. However, these types of coordinated programs to support faith communities require time for relationship building and trust, adequate training, and strong support for faith-based lay leaders as they carry out this work.     

Development of Reliable and Valid Questions to Assess Food Resource Management Behaviors in Adults With Limited Income

ObjectiveDevelop reliable, valid questions to assess changes in food resource management (FRM) behaviors in adults with limited incomes.DesignQuestionnaire development using a mixed-methods approach: content validity (subject matter and curricula), face validity, temporal reliability (test-retest), sensitivity to change, and exploratory factor analysis (EFA).SettingCommunity settings in 12 states.ParticipantsConvenience samples of English-speaking Expanded Food and Nutrition Education Program (EFNEP) or EFNEP-eligible adults: 105 (cognitive interviews), 181 (test-retest), 185 (sensitivity), and 389 (EFA) adults.Variables MeasuredBehaviors related to FRM skills: planning, shopping, and budgeting.AnalysisConsistency and agreement in cognitive interviews and temporal reliability; sensitivity at posttest (paired t tests, Wilcoxon signed-rank tests); internal consistency of scales identified in EFA (Cronbach α). P < 0.5.ResultsAll questions had acceptable temporal reliability ranges for the intraclass correlation coefficient (0.48–0.74) and Spearman rank-order correlation (0.48–0.73). All questions were sensitive to change at posttest (P < 0.001). Planning and saving scales, revealed by EFA, demonstrated internal consistency (> 0.80 Cronbach α).Conclusions and ImplicationsThe 9 FRM behavior questions have acceptable temporal reliability and content and face validity and can be used nationally by EFNEP to assess participants’ self-reported behavior changes. Other nutrition programs with similar audiences and content could use these questions to measure changes in FRM behaviors.     

A Randomized Controlled Trial of a Community-Based Nutrition Education Program for Low-Income Parents

ObjectiveAssess effectiveness of the Expanded Food and Nutrition Education Program on nutrition behaviors post-education and longitudinally.DesignSwitching replications randomized experimental design. Participants randomly assigned to immediate education (IE) or delayed education (DE). Participants in IE received intervention the first 8 weeks, and those in DE the second 8 weeks, with no intervention during alternate periods. Data were collected in 3 repeated measures.ParticipantsParents (n = 168 randomized; n = 134 completed) of children in 2 Head Start and 6 low-income schools.InterventionEight weekly workshops, based on Eating Right is Basic-Enhanced adapted to incorporate dialogue approach with experiential learning.Main Outcome MeasuresTen-item self-reported behavior checklist on nutrition, food resource management, food safety, and food security; responses on a 5-point scale reporting frequency of behavior.AnalysisChi-square, analysis of variance, and multiple regression.ResultsGroups were demographically similar. Both groups reported improved behaviors pre- to post-education (P < .05). There was no significant difference between groups at Time 1 (T1) or DE control period (T1 vs T2). Changed IE behavior was retained T2 to T3. A multiple regression model of overall change, controlling for T1 score and educator, showed significant improvement (n = 134, β = 5.72, P < .001).Conclusions and ImplicationsPositive outcomes were supported by this experimental study in a usual program context, with reported behavior changes retained at least 2 months.     

Long-term Student Outcomes of the Integrated Nutrition and Physical Activity Program

ObjectiveTo examine the long-term effects of the Integrated Nutrition and Physical Activity Program (INPAP), a school-based nutrition education program.DesignQuasi-experimental design comparing intervention and comparison cohorts at 3–6 years after delivery of the INPAP intervention on nutrition- and physical activity–related outcomes.SettingThis study was conducted in 1 school district in a low-income rural county of ～15,000 residents in south-central Colorado.ParticipantsIn second grade, intervention and comparison cohorts included 173 (fall 2000) and 190 (fall 1999) students, respectively. Approximately 60% of these students completed assessments in eighth grade.InterventionsINPAP is an experiential school-based nutrition education program, grounded in social cognitive theory and Piaget's cognitive development theory and adapted for use in a rural setting.OutcomesNutrition and physical activity knowledge, self-efficacy, attitudes and behaviors, body mass index.AnalysisWilcoxon signed rank test, chi-square test for proportions, and t test for means.ResultsLong-term effects were observed in nutrition-related knowledge and attitudes but not self-efficacy or behavior change. The effects that did occur were attenuated over time.Conclusion and ImplicationsThis study found that INPAP implemented in elementary school had limited lasting effects by the end of middle school, a time when students have increased autonomy to make food choices.     

COVID-19 Benefits and Dietary Behaviors Among Mothers From Low-Income,Food-Insecure Households

ObjectiveTo examine the dietary behaviors of mothers from very low food security (VLFS) households following the availability of coronavirus disease 2019 (COVID-19) unemployment and Supplemental Nutrition Assistance Program benefits.MethodsDiet and food security status were obtained from 2,584 California mothers during Federal Fiscal Year 2020. Fruits, vegetables, and 100% fruit juice (FV100%FJ), sugar-sweetened beverages, and water intake, and Healthy Eating Index-2015 scores, were compared across 4 groups (before vs after COVID-19 benefits by VLFS vs non-VLFS households) with race/ethnicity and age as covariates.ResultsBefore COVID-19 benefits, VLFS was associated with fewer cups of FV100%FJ (P = 0.010), more fluid ounces of sugar-sweetened beverages (P = 0.004), and poorer diet quality (P = 0.003). After COVID-19 benefits, mothers from VLFS vs non-VLFS households reported similar dietary outcomes. VLFS mothers reported 0.96 (95% confidence interval, 0.53–1.38) more cups of FV100%FJ after COVID-19 benefits.Conclusions and ImplicationsCoronavirus disease 2019 benefits may have reduced dietary inequities among low-income families. Associations between increased Supplemental Nutrition Assistance Program and unemployment benefits and decreased costs associated with the negative health outcomes linked to food insecurity and poor diets would be of value.     

Creating Healthful Home Food Environments: Results of a Study with Participants in the Expanded Food and Nutrition Education Program

ObjectiveTo evaluate a modified curriculum for the 6-session Texas Expanded Food and Nutrition Education Program (EFNEP) promoting healthful home food environments and parenting skills related to obesity prevention.DesignTwo-group randomized control trial; intervention versus usual EFNEP curriculum.SettingTexas EFNEP classes.Participants1,104 EFNEP clients in 100 classes.InterventionSix short videos, with goal setting, problem solving, guided discussion, and handouts, incorporated into existing EFNEP classes.Main Outcome MeasuresBody mass index (BMI), diet, psychosocial variables with baseline measurements, immediately post, and 4 months later.AnalysisMixed-model repeated measures analysis of variance.Results100 classes were randomized (54 intervention/46 comparison), with 1,006 participants at baseline (582 intervention, 424 comparison, 97% women, 89% Hispanic). Significant improvements over time were found for both groups' consumption of most food items and nutrients, and nearly all psychosocial variables, regardless of study group. Only the intervention group had a significant BMI decrease at post. Fidelity to the intervention class session structure was high, and comments from intervention staff and clients were positive.Conclusion and ImplicationsExisting EFNEP programs in local communities could have a significant impact on family dietary behaviors for populations at risk of obesity. Replication with similar populations is warranted.     

Development and Testing of a Nutrition,Food Safety,and Physical Activity Checklist for EFNEP and FSNE Adult Programs

ObjectiveTo develop and assess reliability and validity of the Nutrition, Food Safety, and Physical Activity Checklist to measure nutrition, food safety, and physical activity practices among adult Expanded Food and Nutrition Education Program (EFNEP) and Food Stamp Nutrition Education program (FSNE) participants.MethodsTest-retest reliability (Cronbach α), internal consistency (Pearson Correlation), criterion-related validity (Spearman Correlation Coefficients), and sensitivity-to-change, were calculated for dietary quality, food safety, and physical activity, based on data collected from 73 EFNEP and FSNE participants.ResultsNutrition and physical activity domains achieved reliability coefficients of 0.70. The instrument scored Spearman correlation coefficients of 0.20 for nutrition, 0.34 for food safety, and 0.28 for physical activity.Conclusions and ImplicationsThe instrument consistently measured dietary and physical activity practices, but not food safety. All domains obtained low correlation coefficients, although consistent with other studies' validity results.     

Development of a National Dietary Behaviors Questionnaire for EFNEP Adult Participants

ObjectiveDevelop and establish the reliability and validity of dietary behavior evaluation questions for the Expanded Food and Nutrition Education Program (EFNEP).DesignA mixed-methods study using cognitive interviews, expert panels, test/retest reliability, and pretests/posttests.Setting14 states across the US.ParticipantsA convenience sample of low-income EFNEP or EFNEP-eligible participants for cognitive interviews (n = 111), reliability testing (n = 181), and sensitivity to change testing (n = 382).Main Outcomes MeasuresIndicators of face and content validity, temporal reliability, and sensitivity to change.AnalysisQuestions interpreted as intended in cognitive interviews, intraclass correlation coefficient and Spearman rank-order correlation for reliability testing; paired t tests or Wilcoxon signed-rank tests for sensitivity to change; and exploratory factor analyses to identify possible scales.ResultsCognitive interviews resulted in 3 rounds of question revisions; reliability value ranges were 0.48–0.77 for intraclass correlation coefficient and 0.43–0.77 for Spearman rank-order correlation. For sensitivity to change, 9 items had evidence of change (P < 0.05) between pretests and posttests, whereas 5 items had evidence for change after removing those with little room to change. Two scales were identified: diet quality and non-cheese dairy.Conclusions and ImplicationsThe EFNEP's new dietary behavior evaluation questions demonstrated face and content validity, moderate to strong reliability, and sensitivity to detect self-reported behavior changes among low-income, diverse populations (culturally, racially/ethnically, and level of education) across 14 states. Nutrition education programs targeting similar behaviors with English speaking clients could consider this dietary behavior questionnaire.     

Evaluation of a USDA nutrition education program for low-income youth

OBJECTIVE: Examine effectiveness of a state's Youth Expanded Food and Nutrition Education Program (EFNEP) and assess the validity of the federal impact indicator method for reporting program outcomes. DESIGN: A randomized, controlled field trial of 229 groups with 5,111 youth, 9-12 years old, in community settings. INTERVENTION: 6- to 8- hour, 7-lesson education experience with food preparation and tasting, an education experience typical of EFNEP in California. OUTCOME MEASURES: US Department of Agriculture (USDA) impact indicators: nutrition knowledge, eating a variety of foods, food selection, and food preparation and safety practices. ANALYSIS: Analysis of covariance model controlling for pretest, gender, age, and ethnicity, with group nested in condition. RESULTS: Organizing responses by impact indicators, treatment participants made significant gains on the posttest compared to controls for 3 of 4 indicators (P < .008 to P < .0001). Gains were made by 34 to 68% of youth participants for 4 indicators. The impact indicator method for federal reporting compared favorably with results from a randomized controlled trial with groups nested in conditions. CONCLUSION AND IMPLICATIONS: This is the first report in the literature of (1) a large evaluation study of Youth EFNEP and (2) an estimate of the validity of the USDA impact indicator method for reporting program outcomes.     

Developing a measure of behavior change in a program to help low-income parents prevent unhealthful weight gain in children

ObjectiveTo develop and test a brief measure of changes in eating, active play, and parenting practices after an intervention to help parents shape children’s choices and home environments.DesignSequential phases of development and testing: expert panel review, cognitive testing interviews, field testing, test-retest study, and assessment of convergence with detailed previously validated instruments.Setting and ParticipantsExpanded Food and Nutrition Education Program (EFNEP), New York State. Low-income parents of 3- to 11-year-old children; Cooperative Extension nutrition and parenting educators.Main Outcome MeasuresQuestionnaire reliability, validity, respondent comprehension, and feasibility of use in program contexts.AnalysisQualitative analysis of item comprehension. Correlational analysis of test-retest reliability and convergent validity.ResultsA behavior checklist was developed to assess change in parent-reported family eating, physical activity, and parenting practices addressed by an intervention. The checklist was feasible for use in EFNEP and questions were understood as intended. Test-retest reliability was good (r = 0.83) and scores correlated significantly (range, 0.25 to –0.60; P < .05) with detailed measures of dietary habits, parental modeling, physical activity, and home environment.Conclusions and ImplicationsDevelopment and testing in a program context produced a tool community nutritionists can use to evaluate educational interventions aimed at helping parents promote healthful eating and activity.     

Plate Waste in School Lunch: Barriers,Motivators, and Perspectives of SNAP-Eligible Early Adolescents in the US

ObjectiveTo determine barriers, motivators, and perspectives regarding plate waste reduction of early adolescents.DesignTrained interviewers conducted audio-recorded individual interviews with adolescents.SettingElementary schools implementing the National School Lunch Program in Hawai‘i, Montana, and Virginia.ParticipantsEarly adolescents (n = 47, aged 9–13 years) from families receiving or eligible to receive Supplemental Nutrition Assistance Program benefits were recruited to participate.Phenomenon of InterestFactors influencing plate waste among adolescents and potential plate waste reduction strategies.AnalysisCoders analyzed content and thematic data to identify code categories and themes.ResultsMain barriers to reducing school lunch plate waste were unsupportive school policy, undesirable food quality, satiation, and social influences. Key motivators to reducing school lunch plate waste were supportive school policy, including allowing students to share food with peers and save food to eat later; and social influences. Participants found it acceptable to throw away disliked food and unacceptable to throw away wanted food; they perceived that their peers did not care whether food was thrown away; and they thought their parents disliked wasting food.Conclusion and ImplicationsResults suggest that several factors might allow for minimization of school lunch plate waste in the National School Lunch Program, including improvements in food quality, food policy, and social influences. Under these important themes, strategies to employ may include improving food preparation and taste, allocating more time for students to finish lunch, allowing students to self-select food lunch items, and permitting them to share and save their leftover food.     

Development and Evaluation of the Infant Feeding Education Questionnaire for the Expanded Food and Nutrition Education Program

ObjectiveDevelop and evaluate the Infant Feeding Education Questionnaire (IFEQ) to measure the impact of the Expanded Food and Nutrition Education Program (EFNEP) infant-feeding education on knowledge, attitudes, and behavioral intent.MethodsEvaluation included content validity testing through expert reviews and cognitive interviews with low-income mothers (n = 37); construct validity using the known-groups technique (n = 679); convergent validity testing using the Infant Feeding Practices Study II questionnaire (n = 66); and test-retest reliability (n = 66).ResultsThe IFEQ had strong construct validity for knowledge and attitudes; IFEQ scores were significantly higher for the high-knowledge/attitude group (29.6 ± 3.08) than the low-knowledge/attitude group (14.5 ± 5.81; P < .001). The IFEQ failed to show convergent validity. The percent agreement between baseline and retest questions was moderate to high, indicating reliability over time.Conclusions and ImplicationsThis study represents the first steps in the development of the IFEQ. There's a need to perform further testing to establish convergent validity and pilot-test the questions following EFNEP infant-feeding education.     

Retention of nutrition knowledge and practices among adult EFNEP participants

This preliminary study examined long-term effects on food and nutrition behaviors and other benefits of the adult Expanded Food and Nutrition Program (EFNEP) on participants who completed the program. Data collection instruments included the Family Record form and at follow-up, an open-ended questionnaire to determine additional benefits. The impact of EFNEP on nutrition knowledge and practices and retention of information after graduation was examined among 50 participants in New York City who were assessed at program entry, graduation, and a 1-year follow-up. For 10 of 12 food behaviors, the participants improved significantly between entry and graduation. At follow-up the gains made during the program were maintained; significant improvement occurred for two behaviors. Data from a 24-hour recall revealed a significant decrease between entry and graduation in the amount and percentage of calories from fat. Between graduation and follow-up, mean protein, calcium, and vitamin A intakes declined but were within acceptable ranges or exceeded NRC RDAs. Significant increases in nutrition knowledge existed for all four items examined; additional increases in nutrition knowledge occurred between graduation and follow-up. The participants also attributed personal and social improvement to EFNEP participation at follow-up including help in their jobs, community participation, and improved family and personal health.     

State Implementation of SNAP Waivers and Flexibilities During the COVID-19 Pandemic: Perspectives From State Agency Leaders

ObjectiveTo describe state agencies’ implementation of the Supplemental Nutrition Assistance Program (SNAP) during the first year of the coronavirus disease of 2019 (COVID-19) pandemic, barriers and facilitators to SNAP implementation, and recommendations to improve SNAP implementation.DesignQualitative methodology guided by Bullock's determinants of policy implementation framework using 7 semistructured, virtual focus groups in April 2021.SettingTwenty-six states representing all 7 US Department of Agriculture Food and Nutrition Service regions.ParticipantsFour focus groups with state-level SNAP administrators and 3 focus groups with state-level SNAP supportive services (Supplemental Nutrition Assistance Program-Education, Employment & Training, and Outreach) supervisors (n = 62).Phenomenon of InterestSupplemental Nutrition Assistance Program implementation during the COVID-19 pandemic.AnalysisThematic analysis using a phronetic iterative approach.ResultsSix primary themes emerged: the policy response, technology needs, collaboration, participant communication, funding realities, and equity. Implementation challenges included the design of waivers in the early pandemic response, inadequate federal guidance and funding, outdated technology, and prepandemic regulations limiting state authority. Modernized technology systems, availability of virtual programming, partnerships, and enhanced benefits facilitated SNAP implementation.Conclusions and ImplicationsSupplemental Nutrition Assistance Program administrators adapted their programs to deliver services virtually during the COVID-19 pandemic. These experiences highlighted the importance of certain policy determinants, such as modernized technology and streamlined application processes, to improve outcomes for SNAP participants and staff.     

Communicating and Assessing Physical Activity: Outcomes From Cognitive Interviews With Low-Income Adults

Objective

This investigation sought to identify the physical activity (PA) terms and concepts that are best understood by low-income adults.

Does tailoring make a difference? A systematic review of the long-term effectiveness of tailored nutrition education for adults

Tailoring individualizes information to the receiver and provides a potential strategy for improving dietary intakes. The present systematic review summarizes evidence for the long-term ( ≥ 6 months) effectiveness of tailored nutrition education for adults and includes priority population groups. Key electronic databases and relevant bibliographies were searched for trials measuring the following outcomes: nutrition-related health behaviors (e.g., dietary intake and food purchases) and anthropometric measures. Data synthesis was comprised of meta-analysis (for 15 trials including all population groups) and narrative review (for five trials of priority population groups). Overall, the quality of the studies was moderate to good. Tailored nutrition education was found to be a promising strategy for improving the diets of adults (including those in priority population groups) over the long term. However, future studies should ensure adequate reporting of research design and methods and reduce the chances of false-positive findings by using more objective measures of diet, clearly identifying the primary study outcome, and concentrating on outcomes most relevant to nutrition-related disease.