EFNEP RELATED RESEARCH, PROGRAM EVALUATION AND OUTREACH

• Sponsoring Institution: National Institute of Food and Agriculture
• Project Status: TERMINATED
• Funding Source: HATCH
• Reporting Frequency: Annual
• Accession No.: 1002156
• Project No.: WYO-508-14
• Multistate No.: NC-2169
• Project Start Date: Nov 30, 2013
• Project End Date: Sep 30, 2018

Project Director
Wardlaw, MA, .

Recipient Organization
UNIVERSITY OF WYOMING
1000 E UNIVERSITY AVE DEPARTMENT 3434
LARAMIE,WY 82071-2000

Performing Department
Family And Consumer Sciences

Non Technical Summary
STATEMENT OF THE PROBLEM: The Expanded Food and Nutrition Education Program (EFNEP) was established by Congress in 1968 to assist low-income families gain the "knowledge, skills, attitudes, and changed behaviors necessary for nutritionally sound diets" (USDA, 1983). The program also seeks to contribute to personal development and the improvement of the total family diet and well-being. In 1968, nutritional well-being meant ensuring adequate calories, vitamins, and minerals to support normal growth (Carpenter, 2003). But, today the most common nutritional concerns have dramatically changed to obesity and related chronic disease prevention. In fact, obesity has become the hallmark of low-income adults, particularly women (Drewnowski, 2009) with a concurrent rise in chronic diseases including Type II diabetes, hypertension, heart disease, and all cancers (Guh et al., 2009). These diseases are all higher among low income, racial and ethnic minorities (Braveman et al., 2010; Drewnowski, 2009). It has been hypothesized that the types of foods most affordable and most readily available on a limited income are energy dense with higher quantities of fats and added sugars. However, this theory cannot be substantiated because information about what low-income individuals and their families actually eat is limited due to current methods used to gather food intake information. Developing new dietary assessment methods that provide the information relevant to today's food intake and practices aids in determining the most effective nutrition education.In terms of personal development and well-being, improved diet and nutrition appear to have an impact beyond promoting good physical health. For the past 40 years, participants have reported improvements in self-esteem, moral direction, and sense of belonging in their communities from EFNEP participation (Arnold & Sobal, 2000; Auld et al., in press). Research is needed to substantiate these findings and determine how the program effects positive emotional and social changes as well as the economic benefits of such programming. Gaining an understanding of a possible wider influence of EFNEP participation will provide a more sophisticated evaluation of EFNEP's overall value.Dietary Assessment: EFNEP paraprofessionals conduct all assessments and lessons with EFNEP clientele. These EFNEP educators are high school graduates (or GED) and members of the community they support making them peers of the participants (Devine et al., 2006). They are trained in using hands-on, interactive teaching methods and they are supervised by university and county-based extension faculty at Land Grant Universities. To curb costs, EFNEP lessons have largely moved from one-on-one to group sessions (Dollahite and Scott-Pierce, 2003). Groups can range in size from 2 to over 30 individuals. At the first and last of these sessions, a dietary assessment is conducted with a group-administered 24-hour dietary recall using a multi-pass method. In addition, a Food Behavior Checklist containing at least 10 standard items that include nutrition-related questions is administered.The 24-hour dietary recall (24HDR) is generally considered to be the "gold standard" for dietary assessment (Van Staveren et al., 2012). However, this classification comes with a caveat - to be considered valid and reliable, the assessment must be conducted by a highly-trained professional, usually a Registered Dietitian (RD). The respondent is asked to describe all foods and beverages consumed in the previous 24-hour period or from midnight to midnight. A major limitation of the 24HDR is the respondent's ability to recall all items. The RD must be skilled in probing for forgotten foods and beverages and assisting with portion size estimation. In addition, the RD must understand how to conduct the interview without leading the respondent to state foods not eaten or to provide socially desirable responses as opposed to accurate reporting.In EFNEP, paraprofessionals are trained to conduct 24HDR with groups of participants using a multiple pass method. Conducting the recall in a series of steps, or passes, is thought to decrease memory lapses (Arab et al., 2011; Thompson & Subar, 2008). The steps of the multiple pass include: listing foods/beverages consumed, probing for commonly omitted items, stating time and place of food consumption, probing for portion size, and ending with a final review. Again, validity of the multiple pass method has only been determined with highly-trained interviewers and primarily in one-on-one situations. The single study that examined one-on-one versus group administrations of the method was marred by serious methodological flaws (Scott et al., 2007). However, this study forms the basis for the group administration of the 24HDR in EFNEP.Currently EFNEP's impact and effectiveness is determined by measured changes in dietary intake and selected food-related behaviors tracked for individual clientele. Over time, program reach and educational methods have changed and it has been many years since these indicators have been tested. Valid and reliable information about dietary intake is essential to determine the best direction for nutrition education and to determine if positive changes in dietary intake are made based on the education provided. This is important information for program funders, implementers and educators. Therefore, it is imperative to determine whether the current methods used to assess dietary intake are reliable and valid.Behavior Checklist: A Behavior Checklist (BC) is also used to evaluate the effectiveness of EFNEP by identifying changes made from the education provided. The BC is composed of 10 mandatory, or core, questions designed to evaluate food-related behaviors that are not captured by 24HDR. Each question is answered using a five point Likert scale. The conceptual domains include Food Resource Management, Nutrition Practices, and Food Handling and Safety. The 10 core items were established in 1993, after being tested for construct validity, reliability, sensitivity and difficulty. Later, an optional bank of questions, most of which have not been rigorously tested, were allowed to be chosen as supplemental items to the 10 core questions. Unpublished studies have suggested that some positive behavior changes clearly increase in frequency of occurrence from the beginning to the end of the program, while others do not; but there is insufficient empirical evidence to support this.Because changes to positive, healthy food behaviors should result in changed eating patterns and healthier diets, dietary assessment and behavior change should go hand-in-hand to help guide the direction of nutrition education and assess the effectiveness of EFNEP programming. Further testing of Behavior Checklist items is needed to determine if the core set is the best set of items and to determine its relationship to the dietary intake assessment. Both measures together may create a much clearer picture for programming and evaluation.This researcher's role with the project is to provide leadership for the overall project, as co-chair for the Dietary Assessment and Behavior workgroup and as a liaison to complimentary national committees. Also, this researcher will identify opportunities to assist with research by finding target audiences and obtaining IRB approvals as needed.

Animal Health Component

0%

Research Effort Categories

Basic

0%

Applied

60%

Developmental

40%

Classification

Knowledge Area (KA)	Subject of Investigation (SOI)	Field of Science (FOS)	Percent
703	6099	1010	100%

Knowledge Area
703 - Nutrition Education and Behavior;

Subject Of Investigation
6099 - People and communities, general/other;

Field Of Science
1010 - Nutrition and metabolism;

Keywords

dietary and food behavior assessment

limited resources

nutrition education

paraprofessionals

Goals / Objectives
To test the validity and reliability of the EFNEP 24HDR methods. To identify and/or develop valid behavior checklist survey items that assess diet quality, nutrition-related behavior, and food resource management related behaviors due to EFNEP participation.

Project Methods
Objective 1 - 24 HDR: A survey of EFNEP coordinators, developed by a training protocol will be tested with multiple states and territories to assess the accuracy and feasibility of EFNEP paraprofessionals administering the 24HDR using the improved procedures against more expensive and/or time consuming "gold" standards for dietary assessment.An investigation of the ASA24 computerized dietary recall method with EFNEP clientele will be led by Nevada. An NIH proposal is being resubmitted to determine the accuracy of reported energy intake using the ASA24 in a sample of low-income, low-educated Hispanic women and the accuracy of the group administered written 24-hour recall. This comparison will utilize doubly-labeled water for validity. Objective 2 - Behavior Checklist: Investigators in 3-5 curricula are used by over 90% of states. Given the content and objectives of the primary curricula used in EFNEP, potential behavior checklist questions will be identified or developed and pilot tested for wording, understanding, and the best response category alternative. The items will be tested for face, content, and construct validity as well as reliability using cognitive interviews, expert panels, comparison of data to more rigorous measures, and test-retest procedures, respectively.

Progress 11/30/13 to 09/30/18

Outputs
Target Audience:Public policy decision makers; state and federal legislators; program sponsors; limited-resource participants; state EFNEP coordinators, supervising educators, and paraprofessionals; local, state, and federal stakeholders; researchers; and others who provide or influence decisions about nutrition education to low income audiences. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?Wyoming facilitated the presentation at the Society for Nutrition Education and Behavior Program (EFNEP): A Model for Improving Nutritional Health and Well-being of Low-Income Families Past - Present - Future. Presentation; Society for Nutrition Education and Behavior: Honor the Past, Embrace the Present, Define the Future. July 2017: Washington DC. https://drive.google.com/file/d/0B0sEMSS0-sYsQ0ZQN0lPQ3JFeWs/view How have the results been disseminated to communities of interest?The EFNEP Food and Physical Activity Questionnaire is available online and is being used nationally in EFNEP. What do you plan to do during the next reporting period to accomplish the goals? Nothing Reported

Impacts
What was accomplished under these goals? 1) Wyoming did not provide significant input toward research on the EFNEP 24HDR. 2) Wyoming assistedin the development of the EFNEP Food and Physical Activity Questionnaire (FPAQ) through planning meetings, reviewing print materials for research and training, coordinating project team meetings, and serving as co-chair for two years. In addition, Wyoming provided leadership for the writing and submission of the continuation of this project with a 5-year proposal for NC3169. Wyoming also coordinated efforts and documents to pursue support and resources for future efforts to assess cost benefit and cost effectiveness of EFNEP.

Publications

Progress 10/01/16 to 09/30/17

Outputs
Target Audience:Public policy decision makers; state and federal legislators; programsponsors; limited-resource participants; state EFNEP coordinators, supervising educators, and paraprofessionals; local,state, and federal stakeholders; researchers; and others who provide or influence decisions about nutrition education to low incomeaudiences. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?Presentation at the Society for Nutrition Education and Behavior Program (EFNEP): A Model for Improving Nutritional Health and Well-being of Low-Income Families Past - Present - Future. Presentation; Society for Nutrition Education and Behavior: Honor the Past, Embrace the Present, Define the Future. July 2017: Washington DC. https://drive.google.com/file/d/0B0sEMSS0-sYsQ0ZQN0lPQ3JFeWs/view Presentation at EFNEP Coordinators Meeting, March 2017: Arlington, VA. Baker, S., Barale, K., Palmer-Keenan, D., Franck, K., Auld, G. Food and Physical Activity Behaviors Questionnaire. https://www2.ag.purdue.edu/programs/hhs/efnep/Conferences/015_ThursdayMorning_EvidenceBase_QuestionaireEFNEP_Presentation2017.pdf How have the results been disseminated to communities of interest?Food and Physical Activity Behaviors Questionnaire is available online. What do you plan to do during the next reporting period to accomplish the goals?Complete sensitivity testing of the EFNEP Food and Physical Activity Questionnaire.

Impacts
What was accomplished under these goals? EFNEP nutrition education assessment will improve due to accurate and reliable measures of diet and physical activity related behavior change. This will result from the use of the research-tested Food and Physical Activity Questionnaire (FPAQ), protocols and training developed by NC2169 and implemented nationally October, 2017 in EFNEP to replace the previous behavior checklist.

Publications

Progress 10/01/15 to 09/30/16

Outputs
Target Audience:The audiences for this project include public policy decision makers; state and federal legislators; program sponsors; limited-resource participants; state EFNEP coordinators, supervising educators, and paraprofessionals; local, state, and federal stakeholders; researchers; and others who provide or influence decisions about nutrition education to low-income audiences. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided? Nothing Reported How have the results been disseminated to communities of interest?The following presentations and/or posters have been shared. Baker, S., Barale, K., Franck, K., Kahn, T., Walsh, J. A New Behavior Checklist - What It Means for You. Expanded Food and Nutrition Education Program (EFNEP) Coordinators' Meeting. Washington, D.C., March 2015 Brewster, P.J., Guenther, P.M., Jordan, K.C., Hurdle, J.F. Development and validation of a novel household grocery food purchase quality score. FASEB Journal 29:131.3 (abstract). Presented at Experimental Biology, Boston, March 2015 Brite-Lane A, Phelps J, Fuller S, Crook Tand Hakkak R. Evaluating Effectiveness of the Arkansas Expanded Food and Nutrition Education Program on Changing Food Resource Management and Nutrition Practice Outcomes. FASEB J April 2015 29:911.7 Murray, E., Baker, S., Auld, G. (July 2015). Nutrition Education Content in Curricula Used to Teach EFNEP Adults and a Comparison to the U.S. Dietary Guidelines. 2015 Annual Meeting of the Society of Nutrition Education and Behavior. Pittsburgh, PA. Conference Proceedings Volume 47, Issue 4, Abstract S61. Townsend, M, Schneider, C, Donohue, S, Barale, K, Wilson, M, Smiley, J. Sharing Resources to Improve the Quality of the EFNEP Group 24H Diet Recalls. Expanded Food and Nutrition Education Program (EFNEP) Coordinators' Meeting. Washington, D.C. March 2015. Schneider, C, Neelon, M, Algert, S, Johns, M, Lamp, C, Towsend, M. What Does a Quality EFNEP Recall Look Like? Expanded Food and Nutrition Education Program (EFNEP) Coordinators' Meeting. Washington, D.C. March 2015. Scholl, J. Presentation on the EFNEP Database at American Evaluation Association in Denver, Colorado. October, 2014. Spencer, R, Thomsen M, Nayga R, Fuller S. Effect of the Commercial Food Environment on Expanded Food and Nutrition Education Program (EFNEP) Participant's Diet Quality. Food Distribution Research Society Annual Conference, Philadelphia, PA October 9-12, 2015. Dawahare, M (Grad Student), Durr, C (Grad Student), Walters, J, Forsythe, H. EFNEP Participants Perceptions of the 24 hour recall University of Kentucky School of Human Environmental Sciences All-School Conference and Symposium. 2015. Walsh J, Hinkle A. Exploring Quality of Life of EFNEP Participants. Presented at the Extension Professional Association of Florida Annual Meeting, Naples, FL, August 2015. Yerxa, K, Bonnett, R, Camire, ME. An Evaluation of the Long-term Knowledge and Behavior Change for Participants in UMaine Extension's Expanded Food and Nutrition Education Program. Expanded Food and Nutrition Education Program (EFNEP) Coordinators' Meeting. Washington, D.C. March 2015. What do you plan to do during the next reporting period to accomplish the goals?Complete validity testing for food security, food resource management and physical activity behavior checklist items. Develop and test formating options for the behavior checklist. Pilot test ASA24. Continue research of 24HDR methodology. Begin development and testing of Spanish translations including cognitive, test/retest.. Begin testing retrospective pre/post administration of behavior checklist. Identify funding sources for cost benefit analysis research.

Impacts
What was accomplished under these goals? (1) A survey of EFNEP coordinators, developed by a Colorado graduate student, identified existing procedures for collecting and training for 24 HDR using quantitative and qualitative methods. Reserach comparing data collection methods has started with24 HDR collected by trained EFNEP paraprofessionals and Registered Dietitians in one-on-one, small and large group settings. (2) Behavior checklist survey items that assess diet quality, nutrition-related behavior, and food resource management related behaviors due to EFNEP participation have been identified and tested. These have been submitted to the national EFNEP program for implementation.

Publications

Progress 10/01/14 to 09/30/15

Outputs
Target Audience:The audiences for this project this yearinclude public policy decision makers; state and federal legislators; program sponsors; limited-resource participants; state EFNEP coordinators, supervising educators, and paraprofessionals; local, state, and federal stakeholders; researchers; and others who provide or influence decisions about nutrition education to low-income audiences. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided? Nothing Reported How have the results been disseminated to communities of interest? Nothing Reported What do you plan to do during the next reporting period to accomplish the goals? Revised timeline for checklist revision: December 2015 Complete cognitive interviews January - February 2016 Reliability testing February 2016 Questions to National Office March - August -2016 Validity testing

Impacts
What was accomplished under these goals? Objective 1. Completed comparison of EFNEP paraprofessional-conducted 24 hr dietary recall with RD-conducted 24 hr dietary recall with individuals Outputs: Findings in two states were comparable Began comparison of RD conducted 24 hr group recalls with RD conducted individual recalls Planned comparisons of paraprofessional group 24 hr recalls with RD group 24 hr recalls. Objective 2. Dietary quality & nutrition-­related behavior Completed cognitive interviews of EFNEP participants to determine their understanding of concepts. Tested, revised twice and retested. Outputs: Fourteen items identified for the nutrition domain of the EFNEP Food Behavior Checklist that will demonstrate changes from the program leading to improved dietary behaviors. Outputs: Identified 12 items for the EFNEP Food Behavior Checklist that will demonstrate changes from the program leading to improved resource management.

Publications

Progress 11/30/13 to 09/30/14

Outputs
Target Audience: Theaudiences for this project include public policy decision makers; state and federal legislators; program sponsors; limited-resource participants; state EFNEP coordinators, supervising educators, and paraprofessionals; local, state, and federal stakeholders; researchers; and others who provide or influence decisions about nutrition education to low-income audiences. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided? Nothing Reported How have the results been disseminated to communities of interest? Nothing Reported What do you plan to do during the next reporting period to accomplish the goals? Continue progress on behavior checklist items with face, content, and construct validity as well as reliability using cognitive interviews, expert panels, comparison of data to more rigorous measures, and test-retest procedures, respectively.

Impacts
What was accomplished under these goals? The 24-hour recall focus groups are in progress to see if it is measuring dietary intakes of EFNEP participants. Nine focus groups are complete. An article has been submitted on the ASA 24 pilot test. A grant has been submitted for additional testing of the ASA 24. The Dietary Assessment and Behavior workgroup continues to make progress on domains within the behavior checklist. For the nutrition-related content, a curricula content analysis is complete and is currently being reviewed by the expert panel. For physical activity, these two steps are also complete. Questions have been identified and are in review stage. For food resource management, cognitive testing of potential questions is underway.

Publications