Duration: 10/01/2008 to 09/30/2013

Administrative Advisor(s):

NIFA Reps:

Non-Technical Summary

Statement of Issues and Justification

Stakeholder Need - The Expanded Food and Nutrition Education Program (EFNEP) was established by Congress in 1968, when the plight of low-income American families, including hunger and malnutrition, came to public attention. The goal of EFNEP is to assist low-income audiences in acquiring the knowledge, skills, attitudes, and changed behaviors necessary for nutritionally sound diets, and to contribute to their personal development and the improvement of the total family diet and nutritional well-being.

In 1969, the primary nutritional problems of EFNEPs participants were energy inadequacy and vitamin and mineral deficiencies which resulted in growth deficits (Carpenter, 2003). Current nutritional problems of limited-resource families include energy excess, resulting in overweight and obesity, and early development of chronic diseases (CDC, 1985-2006). Further, the science of nutrition has revealed new diet-disease relationships, national dietary guidelines continue to evolve, and new food choice behaviors emerge as more food is purchased and consumed away from home.

Given these significant societal changes, the methods EFNEP currently uses to evaluate dietary quality and program impact need to be reexamined. EFNEP and Extension leaders recognize the need to verify the validity of current approaches and/or develop new approaches for evaluating the EFNEP.

Importance and Consequences of the Work - Currently program impact is determined by changes in dietary intake and selected food related behaviors. Trained EFNEP paraprofessionals conduct 24-hour dietary recalls as part of pre/post assessments. Collecting dietary information using a 24-hour dietary recall is relatively quick, when compared to a food record, and is more appropriate than a food frequency questionnaire for populations with diverse diets and/or limited education (Pao & Cypel, 1996). The method is considered valid for estimating the food and nutrient intakes of large groups but is generally not sufficient for understanding an individuals intake. Disadvantages of the method include a reliance on memory, a tendency for people to provide socially acceptable responses and an underestimation of quantities consumed (Pao & Cypel, 1996).

The 24-hour dietary recall is best conducted by a well-trained professional. There are questions about this method being used by EFNEP paraprofessionals. The newer Multiple Pass Method, a five stage process for questioning about food (Conway et al., 2003), and conducting the recalls with groups complicate the process. Consistent, accurate and reliable impact data are critical to program accountability and ultimately to continuation of funding.

Participation in EFNEP, for both educators and participants, also leads to reported changes beyond improvements in diet and nutrition, including pursuing additional education, enhanced employment or health status, and greater community involvement. Arnold and Sobal (2000) examined food practices and nutrition knowledge after participants graduation from EFNEP and observed that EFNEP may have broader impacts beyond food and nutrition, influencing other domains of the lives of participants, and that those impacts may provide increased personal capabilities and confidence that enable people to improve both nutritional and non-nutritional practices.

A continuing strength of EFNEP is its delivery by paraprofessionals, hired not for their subject matter knowledge but for their life experiences and their ability to relate to participants. The effect of the paraprofessional relationship with the EFNEP participant and the familys Quality of Life (QOL) has been anecdotally noted as a benefit of the program, but has not been measured. Nor has the programs impact on the paraprofessionals Quality of Life been assessed, i.e., EFNEPs influence on their future education, employment and life satisfaction.

Technical Feasibility  Assessment of diet quality has long been part of EFNEP evaluation. Information is reported annually at the state and national levels and has been used to successfully maintain funding for the program. The dietary data collected from the 24 hour recall are entered into a software program and sent to a central data base. Reports are generated that provide information on an individuals general dietary status as well as EFNEP participants in total.

The Behavior Checklist for the EFNEP Nutrition Education Evaluation and Reporting System (NEERS 5) is composed of 10 mandatory questions designed to evaluate food related behaviors not captured by 24-hour recalls. Each question is answered using a five point Likert scale. The conceptual domains of the Behavior Checklist include Food Resource Management, Nutrition Practices, and Food Handling and Safety.

The original committee that developed the Behavior Checklist convened in 1990. The core 10 questions were finalized in 1993 after undergoing tests to establish construct validity, reliability, sensitivity and difficulty. In spite of this testing, some states expressed concerns about some questions. In 1994-97, a committee worked to review and revise the EFNEP Behavior Checklist. During this time, the Reporting System was modified to include an additional, optional bank of questions; states could select from this set of questions to add to the core based on their programs goals and objectives.

Existing EFNEP data confirm the existence of self-reported behavior changes. For example, behavior checklist data show clearly that some behaviors change dramatically in their frequency of occurrence (eating breakfast, reading labels, comparing prices) while others change much less (running out of food, letting foods sit out).

Many years of accumulated dietary intake and behavioral checklist data are accessible to the multistate research team which consists of experts in EFNEP programming and/or research as well as research colleagues with expertise in evaluation, dietary assessment, biological assessments, qualitative research methodology, and data mining.

Multi-State Effort - A multistate approach is essential for this project because it brings together the varied expertise needed to comprehensively address complex issues. In addition, each state 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 proportion of urban versus rural participants and mixes of racial/ethnic groups. With multi-state involvement and input, we will have a more complete understanding of cultural and other impacts on our diverse participant groups.

Likely Impact from Successful Project - 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 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 program 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 of participants and paraprofessionals, allowing EFNEP to quantify these non-dietary impacts for the first time in the programs nearly 40 year history.

Related, Current and Previous Work

Current Work - EFNEP is supported through 3(d) Smith-Lever funding, as legislated by Congress, administered by CSREES-USDA, and implemented by the Cooperative Extension System through Land-Grant Universities. In 2006, EFNEP reached 150,270 adults and 409,389 youth directly and more than half a million family members indirectly. The program operated in 800 counties in all 50 states and six territories. EFNEP participants were 30% white, 39% Hispanic, 26% African American, 2% American Indian or Alaska Native and 3% Asian or Pacific Islander. Eighty-four percent of EFNEP families are at or below 100% of poverty (NEERS 5 data).

Low income families have been the most vulnerable to both under-nutrition and over-consumption (Drewnowski and Darmon, 2005). The last four decades have also seen changes in ethnic diversity among low income families; yet many cultural differences in food consumption patterns and behaviors have not been quantified.

Participation in EFNEP should result in: 1) improved diets and nutritional welfare for the total family; 2) increased knowledge of the essentials of human nutrition; 3) increased ability to select and buy food that satisfies nutritional needs; 4) improved practices in food production, preparation, storage, safety and sanitation; and 5) increased ability to manage food budgets and related resources such as food stamps (USDA, 1983).

EFNEP educators are paraprofessionals who follow a research-based learning model which allows them to effectively reach and educate program participants. EFNEP educators are: 1) members of the community they support and, therefore, peers of their participants; 2) trained and supervised by university and county based extension faculty; 3), skilled in hands-on, interactive teaching methods; 4) able to influence behavior and change/impact the lives of those they teach; and 5) dedicated to reaching diverse, low income populations. Research of adult learning has demonstrated the value of this personal, applied approach, especially when working with low-income families (Devine, et al., 2006).

The Dietary Guidelines for Americans (DG) and MyPyramid, specifically emphasize consumption of low fat, nutrient-dense foods, limited sugars and alcohol, and increased physical activity. In contrast, food consumption research shows low-income families often consume low cost, high fat, high calorie foods that provide more calories for less money. (Drewnowski and Darmon, 2005). Furthermore, these documents, designed for the general public, are less accessible to low-income families who often cannot access the internet. Thus, EFNEP plays a critical role in bringing nutrition information to families most in need, in a practical, hands-on, applied way.

Participants food consumption and behaviors are assessed through the 24-hour dietary recalls and food behavior checklist. This information is entered into NEERS 5 that calculates information on total calories; total fat, saturated fat, protein, and carbohydrate; dietary fiber (grams); vitamins A, C and B12; iron and calcium; and food group consumption patterns. The participants data are compared to specific indicators of current food guidance systems and recommended behaviors, and a summary report is generated. This information is used to determine programming needs of the individual participant and to identify the broader needs of participant groups.

The most fundamental question that needs to be answered is, What is/are the best method(s) for measuring the dietary intakes and related behaviors of EFNEP participants? Measures must be reliable, valid, and sensitive to change as a result of intervention. The methods must work well in a group setting and for individuals. They must not be too burdensome for respondents and be able to measure foods from diverse cultural groups. The methods must provide information on nutrient and food intake  information that is useful for selecting the most critical nutrition education areas for the participants. A number of methods exist for collecting dietary intake data. Fewer are available that include behavioral aspects of food choice. Dietary quality is determined by both the food eaten and the context within which it is eaten.

Previous Work, Measurement of Dietary Quality in EFNEP - In 1990, the EFNEP Evaluation and Reporting System Development Committee was formed and charged with standardizing and aggregating dietary assessment data in EFNEP. The committee investigated both dietary and behavior assessment. The committee identified the 24-hour recall as the most appropriate method of collecting basic dietary data because: 1) it had been validated in the literature; 2) it was equally reliable regardless of racial or ethnic group; and 3) the burden on participants was acceptable. The committee developed a standardized method for collecting dietary recall data, gathered data to include commonly-consumed cultural foods in the nutrient database, developed a method of coding all foods in the database, and designed the output reports.

The Food Behavior Checklist - The original 10 questions were finalized for use with EFNEP in 1993, after undergoing tests of construct validity, reliability, sensitivity and difficulty. In 1994-97, a committee worked to review and revise the EFNEP Behavior Checklist. During this time, the EFNEP reporting system was modified to include an additional bank of questions, allowing states to select optional questions based on their individual program goals and objectives (in addition to the required 10 questions).

As the number of EFNEP studies increased over the years, the demand for documented validity and reliability of EFNEP evaluation tools also increased. In 2000  2001 Health Systems Research joined Research Triangle Institute in a project to further examine the Behavior Checklist data. Since data could not be validated using direct observations, indicators already within EFNEPs database were used to examine the consistency of responses (internal reliability and validity).

Over 5000 subjects (non-pregnant women aged 19 to 50) provided baseline data for both the behavior checklist and the dietary recalls; 40.6% were White, 52.6% Black. 4.9% Hispanic, 1.3% Asian, and 0.5% Native American. The mean percentage of poverty was 44.6%. All completed 10-item checklists were tested for reliability using Cronbachs alpha. The overall results were 0.71 for the raw alpha and 0.72 for the standardized alpha, an acceptable level of reliability.

Need to examine EFNEP Evaluation - The previous work described above accomplished three things: 1) set a precedent for steps that can be taken in the revision, development, and/or testing of diet quality and behavioral indicators for EFNEP; 2) showed that multi-state datasets can be aggregated and meaningful internal analyses can be conducted to help document validity, reliability, specificity, and sensitivity; and 3) showed that the current Behavior Checklist questions are specific and sensitive to change (acknowledging that some are more so than others).

Although the EFNEP Behavior Checklist has been a valuable tool in the past, it is time to reassess all of EFNEPs evaluation tools. New research, the changing food supply, and emerging social and cultural factors may cause a new set of indicators to yield more meaningful results. Thorough and continued testing of evaluation tools is essential for ensuring program viability. Several approaches can be used to assess and improve evaluation techniques.

Qualitative methods, including cognitive interviews, are effective for assessing the clarity and understandability of questions, the ease and appropriateness of use for diverse population groups (including diversity of foods consumed, target behaviors, and languages and literacy levels), and the burden on participants (including time and complexity) and the paraprofessionals (including need for props or visuals).

There are several accepted quantitative methods for measuring food intake. All have advantages and disadvantages (Pao and Cypel, 1996). The 24-hour dietary recall method currently used in EFNEP is known to be valid and reliable when conducted by a highly trained professional in a one-on-one situation. Whether it remains valid and reliable when used in a group setting is not clear. To determine the most reliable and valid methods for measuring dietary quality in an EFNEP setting will first require a thorough examination of the current method, the 24-hour recall, and other accepted methods for measuring food intake. For example, only one study could be found that examines the validity of 24-hour recalls administered with groups (Farris et al., 1985). That study examined recalls in children aged 10-18, not adults, and preceded the development of the multiple-pass dietary recall method (Conway et al., 2003).

Quality of Life & Well Being - Understanding the possible wider influence of EFNEP is a worthwhile endeavor that will provide a more sophisticated assessment of the programs true value. Maslow (1954) postulated his widely accepted hierarchy of human needs maintaining that basic physical needs (food, shelter, water) must be satisfied before a person can attain higher order psychological fulfillment, herein referred to as Quality of Life (QOL). The perspective is particularly relevant to EFNEP clientele given their low income status which often makes it difficult to meet housing and food needs. Maslow and others maintain that unless these two deficiency needs are met, a person cannot move toward fulfilling other higher level needs.

Diener and Diener (1995) 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. Biswas-Diener and Diener (2006) found several common characteristics among homeless people in diverse settings including dissatisfaction with their material quality of life, especially their housing, income, and health. Similarly, they are highly dissatisfied with their personal quality of life including their morality, physical appearance, and intelligence. However, good social relationships not only increased subjective well-being but also mitigated, to some extent, the psychological costs of material deprivation (Diener and Seligman, 2002). This has strong implications for EFNEP participants who, though not generally homeless, are often impoverished.

There are several measures of QOL including the United Nations Human Development Index (HDI) (Alzate, 2006) and the University of Torontos Quality of Life Profile (CHP, 1991) which identifies the degree to which a person enjoys the important possibilities of his or her life. Alzate (2006) used HDI to measure QOL in Georgia welfare recipients and concluded that the HDI may be a powerful and versatile tool to study single mothers in welfare states.

The Quality of Life Profile, developed by the Center for Health Promotion (CHP, 1991), has three domains: being, belonging and becoming. Within this framework, EFNEP directly addresses the first sub-domain of physical being which includes; physical health, personal hygiene, nutrition, exercise, grooming and clothing, and general physical appearance. Other domains and sub-domains are indirectly affected by EFNEP, including psychological being (self-acceptance, satisfaction with self, thinking and acting independently), social belonging (relationship with social and cultural groups with which one identifies), community belonging (access to education, employment, social services) and personal growth (learning about new things, solving problems) (CHP, 1991).

2a. CRIS Search - A CRIS search was conducted in July, 2007 using the terms EFNEP or Expanded Food and Nutrition Education Program, and all the nutrition-related, Knowledge Area CRIS codes: 701 (Nutrient composition of food), 702 (Requirements and function of nutrients and other food components), 703 (Nutrition education and behavior), and 704 (Nutrition and hunger in the population). Sixteen active projects were found (see subset of references); none address the purpose of the present project proposal  to strengthen the quality of evaluation for EFNEP and assess the impact of EFNEP on quality of life. Twelve of the sixteen projects have obesity prevention as a primary goal (3-5, 7-12, 14-16) while 10 address highly specific populations (1-4,7-10,12, 13). A second wider CRIS search included the term low income and excluded the EFNEP terms; 85 projects were found, none similar to the proposed project.

Objectives

1. Complete a thorough review of the literature to identify all existing valid and reliable methods appropriate for measuring dietary quality among EFNEP participants, and develop qualitative and quantitative criteria to use in the evaluation and selection of the best dietary quality assessment(s) for EFNEP, considering sensitivity to change and burden on the participants.
   
2. Through qualitative, quantitative, and biomarker research, test the most promising of these measures for use with EFNEP audiences, evaluate them using the criteria in Objective 1, and select the best measure(s).
   
3. To determine which quality of life constructs are affected by EFNEP for both participants and paraprofessionals
   

Methods

Reliability, validity and sensitivity of dietary intake assessment are reduced by limited training, under-reporting bias; social desirability of responses, and other factors. These limitations decrease the ability to: 1) identify food intake; 2) identify behaviors that can be modified for better health; 3) identify alternative behaviors that can be promoted in the place of unhealthy behaviors; 4) develop effective nutrition programming that encourages participants to adopt the healthier behaviors; and 5) measure effectiveness in promoting change. Before describing specific methods, we will define the various population groups that will be referred to in this study. EFNEP professionals will be defined as university and county Extension faculty/staff who supervise and/or oversee EFNEP from a state and local level. EFNEP paraprofessionals or educators are the local staff who directly deliver the program to the participants. Key informants are former graduates of the program. Program partners that might include county commissioners or extension board members; local community leaders; state and local WIC, Headstart, Food Stamp and Commodity program supervisors; public health department leaders; job training program leaders, or leaders in community action and social service organizations such as the Salvation Army, Goodwill etc. To describe the populations that are going to reached in this research project the following demographic information will be collected: Age, relationship to EFNEP (participant, educator, supervisor, partner, etc.), education level, race/ethnicity, rural/urban location, gender, state/county, and years associated with program. Objective 1 (Identification of potential evaluation tools) - To address objective 1, the following steps will be taken: 1) A thorough review of the literature will be conducted to identify all existing valid and reliable methods appropriate for measuring dietary quality among EFNEP participants in relation to the national EFNEP Objectives. In this literature review, we will consider the following: a. Previous studies of EFNEP. b. A range of dietary assessment indicators. Using existing EFNEP data, we will examine constructs associated with the 24-hour recalls and behavior checklist questions. For example, do the assessments measure foods, nutrients, behavioral variables, and/or other variables? c. Have the methods or indicators been assessed for reliability and validity? d. Are the instruments sensitive and specific? How well does each instrument identify nutritional problems? 2) Develop criteria to use in the evaluation and selection of the best dietary quality assessment(s) for EFNEP. a. Selection of qualitative and quantitative criteria will be made based on the review of literature and input from EFNEPs participants, paraprofessionals, and supervisors. b. Using the national EFNEP objectives, the domains to be evaluated will be prioritized for judging the specific behaviors that are most important to assess. 3) The identified qualitative and quantitative criteria will be applied to the most appropriate assessment tools (from the review of literature) resulting in a list of potentially applicable tools for assessing current dietary and other food related behaviors. Objective 2 (Testing of potential evaluation tools) - To address objective 2, the following steps will be taken. 1) Analyze existing national data that includes 24-hour recalls and behavior checklist indicators. 2) Conduct field testing with audiences similar to EFNEPs. The specific tests will depend in part on the kinds of tests already reported in the literature to identify the best tools to use by EFNEP. 3) Address the following questions: a) What is the most meaningful, appropriate method of dietary assessment? b) Does the validity, reliability and sensitivity of dietary intake methods change when conducted with groups and with individuals? c) What type of paraprofessional training in data collection methods increases validity and reliability? d) What dietary assessment measures are most appropriate in real world settings? e) Which methods require reasonable participant burden? Qualitative data are valuable for identifying limitations of assessment tools and exploring ways to minimize those limitations. Improvements can be made not only in the tools themselves, but in the development of protocols that guide the paraprofessionals in collecting the data. Qualitative studies will include cognitive testing of questions and instruments, in-depth interviews of individuals, and focus groups (Ruud et al, 1993; Betts et al, 1993). We will use these methods to study the: 1) Clarity and understandability of questions, and the use of words and/or photographs; 2) Need for and nature of effective props to help respondents; 3) Ease of use for diverse population groups; 4) Burden on participants; 5) Burden on the paraprofessionals; 6) Understanding and skills of the paraprofessionals regarding the collection of data; and 7) Training methods to prepare paraprofessionals to collect more complete and accurate data. We will also apply quantitative methods to assess the suitability of dietary assessments for EFNEP. Examples of quantitative tests for dietary assessment will include: 1) comparison of results to existing data bases to determine if the data is reasonable; 2) comparison to more rigorous dietary assessment techniques such as 3-day food records; and 3) use of selected biomarkers. Biomarkers would not be used with general EFNEP participants but could be used to test the validity of dietary assessment methods. For example, specific biomarkers can be used to indicate consumption of specific food groups. Biomarkers may include: hemoglobin or hematocrit levels to assess consumption of iron rich foods, serum folate to reflect foods rich in this nutrient, serum carotenoid and Vitamin C levels for fruits and vegetables, and serum Vitamin D for fortified foods such as milk and some milk products. Examples of quantitative tests for other food related behaviors include statistical test of reliability (test-retest and internal consistency), paired t tests, and measures of sensitivity to change. The sensitivity of different measurements can be tested at different levels: as data from individual participants or groups (data summarized by county, state, or ethnic groups). Different data analysis techniques can be compared to find the most appropriate analysis approach and for the purpose of comparing sensitivity and burden. Data mining, a rapidly developing area of computer science research that can be readily adapted to study EFNEP data to discover patterns and information from data that can be used to develop more specific measurement methods, programming or interventions. Once the most sensitive and least burdensome measurement of dietary quality has been identified, feature reduction, a common technique in data mining, can be used to filter out some of the less related questions from the survey or questionnaire, further reduce the time and complexity burden on the participants. Another common technique, association rule mining, can be used to identify changes in behaviors that correlate with the change in diet quality measurement (Liang et al.; Lu et al.). Objective 3 (Identification of Quality of Life constructs affected by EFNEP) - The impact of EFNEP on the Quality of Life of both paraprofessionals and participants will be examined using qualitative and quantitative methods: free listings, qualitative interviews, focus groups, and the University of Torontos Quality of Life Profile. Table 1 shows the proposed study populations, sample sizes, and year in which one or more of the methods will be used to gather data. The combination and sequence of these methods, as well as the specific populations studied, will provide greater insights and depth of understanding regarding the quality of life. Triangulation will enhance the validity and reliability of the proposed research, enhance the quality of the findings, and assist in the interpretation of findings (Seale, 1999) and help control potential bias from any single method (Golafshani, 2003). This research will explore the cultural domains within the concepts of QOL among EFNEP participants, paraprofessional staff, professionals and community stake-holders. A domain is a culturally defined category, i.e., how a group of people, Hispanic, EFNEP participants for example, share a common set of perceptions, beliefs and values. The semantic terms that comprise a domain and the relationship between items within a domain vary from group to group. Table 1. Synopsis of the Objective 3, Quality of Life, research plan Study Population Sample Size Method Year EFNEP Professionals 15-20 Phone Interviews 1-2 Key Informants  Exemplary Participants 15-20 Phone Interviews 2 Community Partners 15-20 Phone Interviews 2 Paraprofessionals 20-30 Free Listing 1 4-6 # Teleconference focus groups 2-3 50-100 Quality of Life Profile 1-4 EFNEP Participants 20-30 Free Listing 1 9-15 groups * Face to face focus groups 2-3 100 - 150 Quality of Life Profile 1-4 # Participants within the focus groups with paraprofessionals will be from different states, i.e., they will not know each other * 3-5 in-person focus groups with each of three ethnic groups (white, Hispanic, African American) 1) Free-listing - This technique will permit primary audiences (paraprofessionals and participants) to help define issues affecting their quality of life prior to conducting interviews and focus groups, ensuring that the topics discussed will reflect concerns of the primary audiences. Free-listing is a semi-structured method used to identify common domain descriptors. In this case, respondents will first be asked to Name all the things that improve their quality-of-life. The number of respondents needed depends on the domain(s) of interest; the more agreement about a domain, the fewer respondents are needed. Twenty to 30 respondents should be enough to get a good representation (Weller & Romney, 1988). When conducting qualitative research, data collection and analysis are simultaneous processes. Therefore, after having run five to six respondents through the free-listing exercise, we will create lists of all items, sorted by average rank. Rank order will change with the addition of each new respondent. When the ranks remain relatively stable, no new respondents will be added. Free-listing provides an excellent way to explore the common understanding of a domain. Brewer (2002) recommends that additional techniques, such as nonspecific prompting, be used along with free listing. Another method is reading back the participants free list to help participants review their responses and add items if necessary. (Brewer et al., 2002) A third supplementary technique is to use semantic cues. The researcher goes through each of the items on the list and asks the participant to think about which items are similar to or like other items and if any other items might be missing from this group. (Brewer, 2002; Brewer et al., 2002) 2) Qualitative Phone Interviews - In-depth or unstructured interviewing is a primary means of data collection in qualitative research. We will interview EFNEP professionals and paraprofessionals, community partners and former EFNEP participants who experienced significant quality of life improvements after participation in EFNEP. Conducting these interviews over the phone will provide several advantages. Several interviewers in one or two states can be thoroughly trained to conduct consistent interviews, thereby controlling for any potential interviewer effect. Phone interviews mitigate the challenges of scheduling face-to-face interviews. These interviews will be audio-taped to ensure accurate data for analysis. 3) Focus Groups - Focus groups are an effective technique to collect data regarding perceptions, opinions and insights on pre-identified topics that other techniques (surveys, interviews) would not uncover (Krueger, 1994; Kitzinger, 1995). Identification of group norms and values is more successful using group interviews and additional insights on the thinking of a particular target audience is often better revealed through focus group discussions than one-on-one interviews (Morgan, 1997; Morrison-Beedy et al., 2001). The development of focus group discussion guides will occur during the analysis and data collection from the free listing and key informant interviewing. We will have representation from the three main ethnic groups of EFNEP participants and paraprofessionals, projecting 3 to 5 focus groups each for Hispanics, non-Hispanic Whites, and African Americans participants and 4-6 total for paraprofessionals. Several members of this proposals writing team have extensive experience conducting research using focus groups, including the teleconference focus group proposed to be used with paraprofessionals. Focus groups via teleconference can be a time and cost efficient method of reaching people separated by significant geographical distances. Caution should be used to ensure participant comfort level with both the others involved in the focus group, confidentiality of information shared, as well as the process being used. In order to reach a nationally represented sample of paraprofessionals, face to face focus groups are not practical. Standard procedures will be followed for all focus groups (Krueger, 1994). 4) Quality of Life Profile - The Quality of Life Profile questionnaire from the University of Toronto will also be used to assess EFNEP paraprofessionals and participants. Samples of both groups will complete the QOL tool twice. Newly hired paraprofessionals in multiple states will complete the questionnaire prior to their initial training and one year later to assess baseline and potential changes in their quality of life that might be attributed to EFNEP. Similarly, a sample of EFNEP participants in various states and from various racial and ethnic groups will complete the questionnaire prior to their first class and six months or one year later to assess baseline, potential changes and sensitivity of the measure, particularly to see if specific domains or sub-domains of the Quality of Life Profile are especially sensitive to EFNEP induced changes. The Quality of Life Profile is applicable to all persons, with or without developmental disabilities and was developed through analysis of literature and qualitative data collected through focus groups and interviews. It was subsequently tested with adults with and without physical and developmental disabilities, adolescents, and older adults. The model is multidimensional and assumes that the quality of life is holistic in nature and includes components on physical, psychological, and spiritual dimensions. (CHP, 1991). The profile includes three domains (Being, Belonging, and Becoming) each with three sub-domains that are assessed by three items. Individuals quality of life is dependent on the relative importance assigned to and the degree of satisfaction with each item. Subjects are also asked to rate the nine sub-domains on their perceived control and opportunities within that domain. All ratings are based on a five point Likert scale. Reliability, as determined through Cronbachs alpha coefficients (measure of internal consistency), was above 0.70 for all sub-domains relative to Importance except Spiritual Being (0.68) and Community Belonging (0.62). Relative to Satisfaction, all measures exceeded 0.70 while the nine Control and Opportunities had internal consistencies of 0.87 and 0.92, respectively. Project Limitations - While we acknowledge that a control or comparison group would be beneficial for more fully testing the evaluation approaches being examined in this study, particularly the Quality of Life, project leaders deemed it prudent at this time not to have a control group. Given the time and resources necessary to incorporate a control group and that objectives 1 and 2 are testing the validity of different approaches to collect dietary quality data and objective 3 is, in essence, a pilot relative to exploring QOL, it seems reasonable to consider a control group after the best assessment tools have been determined and if Quality of Life is established as a valuable and sensitive approach.

Measurement of Progress and Results

Outputs

• A critical literature review of dietary assessment methods tailored to limited resources audiences and a set of criteria with which to identify the most appropriate methods for use by EFNEP.
• Selection of the most viable methods of those identified in Output 1 relative to sensitivity and validity in the context of EFNEP data collection procedures.
• Identification of quality of life indices that are most influenced by the EFENP for paraprofessionals and participants.
• A searchable, bibliographic data base of all past research related to EFNEP.

Outcomes or Projected Impacts

• A new, modified set of evaluation tools/techniques for EFNEP will yield assessment data for this Federal Program that has increased credibility.
• In addition to dietary quality and food related behavior data, program leaders will be able to report non-nutrition outcomes such as increased quality of life indicators.
• The use of more sensitive evaluation tools should lead to the development of more effective nutrition education materials and teaching methodologies.
• A better understanding of the influence of education on behavioral change among low-income populations.
• Clearer programmatic/research linkages, connecting science and practice.
• Outcome/Impact 6. Stronger assessment measures that can better inform national data collection and, thus, decision making. Outcome/Impact 7. Because elements of this work will be conducted with low-income populations beyond EFNEP, research findings may have potential for broader applications to nutrition education with low-income audiences. In the long term, improvements in EFNEP could potentially lead to a better informed society relative to nutrition, food safety and food resource management contributing to a healthier society, requiring less intervention from the health care system. This better-informed society might be more food secure thus, improving their health status and reducing their needs for emergency food assistance. An improved health status will result in less demand for emergency medical resources, improved school outcomes as children are more food secure and experience less absenteeism due to illness.

Milestones

(1): Identify potential dietary evaluation methods and the criteria to judge their appropriateness for EFNEPs use. b) Collection of initial Quality of Life data among EFNEP paraprofessionals and participants. c) Completion of some of the free listing and qualitative interviews with targeted groups.

(2):a) Completion of the searchable, bibliographic data base. b) Completion of interviews and focus groups related to the Quality of Life objective. c) Assessment of the dietary and other food related behavior instruments. d) Submission of a review paper on dietary evaluation methods and criteria for judging in a limited-resource audience.

(4):a) Completion of data collection and analyses of instrument testing. b) Completion of Quality of Life data collection and analyses. c) Submission of manuscripts related to QOL and dietary and food related behavior assessments. d) Presentations at national and state EFNEP and professional society meetings.

Projected Participation

View Appendix E: Participation

Outreach Plan

The results of this project will be made available to intended users in a variety of ways. Manuscripts will be submitted to referred journals for publication. Proposals for presentations and workshops at national meetings will be submitted to share findings with professionals within EFNEP and other related programs such as Food Stamps. Potential meetings to target include the Society for Nutrition Education, Experimental Biology, and the annual meeting of EFNEP Coordinators. Project personnel will also offer to serve in an advisory capacity to national EFNEP leaders who could utilize project outputs in the development of reports for Congressional leaders who annually vote on the continuation and/or potential increases in EFNEP funding. Program clientele will be reached through the revisions made to program materials/approaches based on project outputs.

Organization/Governance

The committee, comprising the researchers and educators from participating stations, the Regional Administrative Advisor, and the USDA CSREES Representative will be organized and governed as specified in the North Central Regional Association (NCRA) guidelines (NCRA, 2005).

Given the complexity of this project, the Technical Committee, during the annual meeting, will elect a five member executive committee (EC) who will serve a staggered two year term. The EC will consist of two co-chairs, two vice-chairs (will assume roles of co-chairs in second year), and a secretary. The vice-chairs will serve as coordinators of objective work groups. Efforts will be made to ensure that the EC will include representatives with research and EFNEP experience.

The ECs functions will include: scheduling conference calls (monthly for EC and bimonthly for whole group); ensuring members and/or committees are making progress; completing annual reports to AES; and coordinating writing assignments (reports, manuscripts, recommendations, and papers or presentations at professional meetings).

Literature Cited

(16) CRIS references

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2. Dinstel, R., Cascio, J., Koukel, S. Food preparation and marketing 2006. CRIS Proj No: ALKN-06-07
3. Fleming, S., Ikeda, J. Randomized, controlled community intervention to reduce the risk of type 2 diabetes in overweight African American children. CRIS Proj No: CA-B*-NTS-7249-CG
4. Fleming, S., Ikeda, J. Evaluating a YMCA-based community intervention to reduce the risk of type 2 diabetes in overweight African American children. CRIS Proj No: CA-B*-NTS-7379-CG
5. Fleming, S., Crawford, P., Ikeda, J. An integrated approach to prevention of obesity in high risk families. CRIS Proj No: CA-B*-NTS-7625-RR
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16. Drewnowski, A., Townsend, M., Keim, N. Poverty and obesity: energy density and cost of diets. CRIS Proj No WNR-2003-05285

Proposal References

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Attachments

Land Grant Participating States/Institutions

AR, AZ, CA, CO, DC, DE, GA, IN, KS, KY, MA, ME, MI, NV, OH, OK, PA, WA, WY

Non Land Grant Participating States/Institutions