NC2169: EFNEP Related Research, Program Evaluation and Outreach
(Multistate Research Project)
Status: Inactive/Terminating
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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 todays food intake and practices is essential to determine 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 the EFNEPs 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 respondents 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 EFNEPs impact and effectiveness is determined by measured changes in dietary intake and selected food-related behaviors tracked for individual clientele. There are questions about the validity of the dietary intake results obtained by EFNEP paraprofessionals with limited training using a multiple pass method in a group setting. 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 ultimately is the basis for continuing the programs funding. 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 in determining the direction of nutrition education and in evaluation of 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.
Quality of Life: Maslows (1954) widely accepted hierarchy of human needs states that basic physical needs (food, shelter, water) must be satisfied before a person can attain higher order psychological fulfillment. EFNEP focuses on low-income clientele who often have difficulty meeting the basic physical needs for food and shelter. The program helps families manage their resources so that they can obtain healthy and safe food and, as a side benefit, food resource management helps them to meet housing needs. Meeting these lower-level needs allows the clientele to move toward psychological fulfillment. Thus, EFNEP has broader impact beyond food and health into increased quality of life.
Diener and Dieners (1995) work support the supposition that programs like EFNEP can have broader impacts. Their research determined that people do not adapt to long periods of extreme poverty and those living in poverty typically experience lower levels of subjective well-being or low quality of life. Later work with homeless people found several common characteristics including dissatisfaction with their material quality of life, especially their housing, income, and health (Biswas-Diener & Diener, 2006). Similarly, individuals with very low incomes were highly dissatisfied with their personal quality of life including their morality, physical appearance, and intelligence with one exception. When homeless individuals experienced good social relationships not only was their perception of well-being higher but also the psychological costs of material deprivation were mitigated (Diener & Seligman, 2002). Because EFNEP is based on hiring educators from the same community who had experienced poverty themselves, a large part of the EFNEP experience relies on establishing good social relationships.
There is much anecdotal evidence, including testimony to Congress, that EFNEP participation results in increased quality of life. Arnold and Sobal (2000) found a 33% increase in community involvement at churches, food pantries and schools among program graduates and attributed this to encouragement from the nutrition paraprofessionals. They also found an increase in employment among graduates in one of two counties. Auld et al. (in press) likewise found that EFNEP graduates reported an increase in positive views about themselves, e.g., self-acceptance and self-esteem, as well as improved sense of hope and belonging. As to whether these are isolated findings or whether these are common perceptions from participation is unknown. Also, the extent to which these findings were based on the economy of the time, interaction with the nutrition paraprofessional, others in the program, or other influences is unknown. Determining whether EFNEP participation provides a broader benefit of improved quality of life is needed to have a greater knowledge of the programs impact. If EFNEP participation also results in a perception of improved quality of life, a more sophisticated program evaluation can be conducted to expand the understanding of EFNEPs benefits with respect to costs.
Cost-benefit: Cost-benefit analysis (CBA) is a classical economic tool often used to help determine who is impacted and by how much. This method fits under welfare economics (Johannesson, 1995a). The key point is that cost and health outcomes are measured in monetary units (Burney & Haughton, 2002; Lambur et al., 1999; Rajgopal et al., 2002; Schuster et al., 2003; Joy, Pradhan, & Goldman, 2006; Wessman, Betterley, & Jensen, 2001). However, for cost-effectiveness analysis (CEA), the method most often used for health care program evaluations (Johannesson, 1995a; Brown et al., 2007; Dollahite, Kenkel, & Thompson, 2008; Eklund et al., 2005; Sweat et al., 2000; Teng, Osgood, & Chen, 2001), there is an adjustment for quality of life. If participating in EFNEP results in an improved quality of life and a potential reduction of diet-related diseases, the resulting cost and benefit to society is not well understood. Measuring economic viability of such intervention programs is increasingly vital to justify expenditures to funders, including Congress. It is also important to maximize targeted outcomes for a level of program funding across regions and demographics.
BENEFITS OF THIS PROJECT: The clientele of EFNEP consist of low-income families (income at or below 185% of the federal poverty threshold) self-reported as: 53% White, 26% African American, 4% American Indian or Alaska Native and 3% Asian or Pacific Islander and 39% reported their ethnicity as Hispanic (2011 NEERS 5 data). Thus, EFNEP participants are among the groups most likely to be obese with one or more obesity-related chronic diseases. EFNEP operates in 800 counties in all 50 states and six territories reaching 130,485 adults and 479,398 youth in 2012. The total number of lessons taught annually to these adults and youth is estimated at 3.9 million. For the 2012 Federal Fiscal Year, the total distribution of funds authorized under the Smith-Lever Act was $69,678671 (USDA, 2013) It is imperative that the value of this enormous effort be maximized both in terms of effectiveness of nutrition education and on wider benefits that have the potential to improve quality of life. Evaluating the impact of the program requires dietary and behavior change assessments that are as valid and reliable for this audience as possible. Determining the impact of program participation on broader, quality of life issues will strengthen the understanding of EFNEPs benefits.
The accurate assessment of EFNEP impacts is critical to program success. This project will provide updated valid, reliable methods for measuring dietary quality in the EFNEP population. In addition, we will determine which of these methods are most specific, accurate and sensitive to change, and least burdensome for EFNEP participants. Burden may pertain not only to time required for completing the instruments, but also to issues of format, clarity, complexity, cultural appropriateness, and literacy level. These methods will not only document program performance, but also provide valuable needs assessment data to inform future planning and implementation.
This project will also lead to a better understanding of the non-dietary impacts of EFNEP. Both qualitative and quantitative methods will be used to assess the Quality of Life (QoL) of participants and paraprofessionals, allowing EFNEP to quantify non-dietary impacts for the first time in the programs 40 plus year history. In addition, developing a standard CBA and CEA process will provide a framework for states to conduct meaningful assessments.
NEED FOR COOPERATIVE WORK: A multistate approach is essential for this project because of the scope of EFNEP. Each state/region has access to unique groups of limited-resource EFNEP participants that would not be available from any single state. Variables that differ across states include: obesity rates, employment opportunities, education, age, income, proportion of urban versus rural households, and mixes of racial/ethnic groups, to name a few. With multi-state involvement and input, a more complete access to and understanding of demographic, cultural and other impacts on our diverse participant groups will be possible.
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 the EFNEPs 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 respondents 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 EFNEPs impact and effectiveness is determined by measured changes in dietary intake and selected food-related behaviors tracked for individual clientele. There are questions about the validity of the dietary intake results obtained by EFNEP paraprofessionals with limited training using a multiple pass method in a group setting. 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 ultimately is the basis for continuing the programs funding. 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 in determining the direction of nutrition education and in evaluation of 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.
Quality of Life: Maslows (1954) widely accepted hierarchy of human needs states that basic physical needs (food, shelter, water) must be satisfied before a person can attain higher order psychological fulfillment. EFNEP focuses on low-income clientele who often have difficulty meeting the basic physical needs for food and shelter. The program helps families manage their resources so that they can obtain healthy and safe food and, as a side benefit, food resource management helps them to meet housing needs. Meeting these lower-level needs allows the clientele to move toward psychological fulfillment. Thus, EFNEP has broader impact beyond food and health into increased quality of life.
Diener and Dieners (1995) work support the supposition that programs like EFNEP can have broader impacts. Their research determined that people do not adapt to long periods of extreme poverty and those living in poverty typically experience lower levels of subjective well-being or low quality of life. Later work with homeless people found several common characteristics including dissatisfaction with their material quality of life, especially their housing, income, and health (Biswas-Diener & Diener, 2006). Similarly, individuals with very low incomes were highly dissatisfied with their personal quality of life including their morality, physical appearance, and intelligence with one exception. When homeless individuals experienced good social relationships not only was their perception of well-being higher but also the psychological costs of material deprivation were mitigated (Diener & Seligman, 2002). Because EFNEP is based on hiring educators from the same community who had experienced poverty themselves, a large part of the EFNEP experience relies on establishing good social relationships.
There is much anecdotal evidence, including testimony to Congress, that EFNEP participation results in increased quality of life. Arnold and Sobal (2000) found a 33% increase in community involvement at churches, food pantries and schools among program graduates and attributed this to encouragement from the nutrition paraprofessionals. They also found an increase in employment among graduates in one of two counties. Auld et al. (in press) likewise found that EFNEP graduates reported an increase in positive views about themselves, e.g., self-acceptance and self-esteem, as well as improved sense of hope and belonging. As to whether these are isolated findings or whether these are common perceptions from participation is unknown. Also, the extent to which these findings were based on the economy of the time, interaction with the nutrition paraprofessional, others in the program, or other influences is unknown. Determining whether EFNEP participation provides a broader benefit of improved quality of life is needed to have a greater knowledge of the programs impact. If EFNEP participation also results in a perception of improved quality of life, a more sophisticated program evaluation can be conducted to expand the understanding of EFNEPs benefits with respect to costs.
Cost-benefit: Cost-benefit analysis (CBA) is a classical economic tool often used to help determine who is impacted and by how much. This method fits under welfare economics (Johannesson, 1995a). The key point is that cost and health outcomes are measured in monetary units (Burney & Haughton, 2002; Lambur et al., 1999; Rajgopal et al., 2002; Schuster et al., 2003; Joy, Pradhan, & Goldman, 2006; Wessman, Betterley, & Jensen, 2001). However, for cost-effectiveness analysis (CEA), the method most often used for health care program evaluations (Johannesson, 1995a; Brown et al., 2007; Dollahite, Kenkel, & Thompson, 2008; Eklund et al., 2005; Sweat et al., 2000; Teng, Osgood, & Chen, 2001), there is an adjustment for quality of life. If participating in EFNEP results in an improved quality of life and a potential reduction of diet-related diseases, the resulting cost and benefit to society is not well understood. Measuring economic viability of such intervention programs is increasingly vital to justify expenditures to funders, including Congress. It is also important to maximize targeted outcomes for a level of program funding across regions and demographics.
BENEFITS OF THIS PROJECT: The clientele of EFNEP consist of low-income families (income at or below 185% of the federal poverty threshold) self-reported as: 53% White, 26% African American, 4% American Indian or Alaska Native and 3% Asian or Pacific Islander and 39% reported their ethnicity as Hispanic (2011 NEERS 5 data). Thus, EFNEP participants are among the groups most likely to be obese with one or more obesity-related chronic diseases. EFNEP operates in 800 counties in all 50 states and six territories reaching 130,485 adults and 479,398 youth in 2012. The total number of lessons taught annually to these adults and youth is estimated at 3.9 million. For the 2012 Federal Fiscal Year, the total distribution of funds authorized under the Smith-Lever Act was $69,678671 (USDA, 2013) It is imperative that the value of this enormous effort be maximized both in terms of effectiveness of nutrition education and on wider benefits that have the potential to improve quality of life. Evaluating the impact of the program requires dietary and behavior change assessments that are as valid and reliable for this audience as possible. Determining the impact of program participation on broader, quality of life issues will strengthen the understanding of EFNEPs benefits.
The accurate assessment of EFNEP impacts is critical to program success. This project will provide updated valid, reliable methods for measuring dietary quality in the EFNEP population. In addition, we will determine which of these methods are most specific, accurate and sensitive to change, and least burdensome for EFNEP participants. Burden may pertain not only to time required for completing the instruments, but also to issues of format, clarity, complexity, cultural appropriateness, and literacy level. These methods will not only document program performance, but also provide valuable needs assessment data to inform future planning and implementation.
This project will also lead to a better understanding of the non-dietary impacts of EFNEP. Both qualitative and quantitative methods will be used to assess the Quality of Life (QoL) of participants and paraprofessionals, allowing EFNEP to quantify non-dietary impacts for the first time in the programs 40 plus year history. In addition, developing a standard CBA and CEA process will provide a framework for states to conduct meaningful assessments.
NEED FOR COOPERATIVE WORK: A multistate approach is essential for this project because of the scope of EFNEP. Each state/region has access to unique groups of limited-resource EFNEP participants that would not be available from any single state. Variables that differ across states include: obesity rates, employment opportunities, education, age, income, proportion of urban versus rural households, and mixes of racial/ethnic groups, to name a few. With multi-state involvement and input, a more complete access to and understanding of demographic, cultural and other impacts on our diverse participant groups will be possible.