Review of nutrition education research in the Journal of Nutrition Education and Behavior, 1998 to 2007

Addressing the Gap of Nutrition in Medical Education: Experiences and Expectations of Medical Students and Residents in France and the United States

Distinct pedagogical approaches within medical curricula in France and in the U.S. reflect a growing recognition of the importance of nutrition to address major public health challenges. However, recent generations of medical students have expressed mixed opinions regarding nutrition education. What pedagogical approach may improve nutrition education? Despite different medical systems, students from both France and the U.S. share similar concerns and expectations, that nutrition knowledge must be embedded in the curriculum and must be engaging. Hands-on, system-based, epistemological, and multidisciplinary approaches need better articulation to forge a robust medical curriculum. In the rapidly changing contexts of medicine and public awareness, social science research may facilitate recommendations for improved nutrition education.

Mi Vida Saludable: Content Validity and Reliability of The Preferences and Self-Efficacy of Diet and Physical Activity Behaviors Questionnaire for Latina Women (PSEDPALW) for Cancer Survivors

The purpose of this study is to conduct validity and reliability testing of a new instrument, the Preferences and Self-Efficacy of Diet and Physical Activity Behaviors Questionnaire for Latina Women (PSEDPALW), which is for women who identify as Latina and are breast cancer survivors. PSEDPALW measures preferences and self-efficacy for four behaviors: physical activity (PA), fruit and vegetable (FV) intake, dietary fat (DF) intake, and added sugar (AS) intake (eight scales in total). Validity testing was conducted through an expert panel review and a cognitive interviewing focus group (n = 4). Reliability was tested via internal consistency reliability (n = 118) and test-retest reliability (n = 30). Validity testing was used to refine PSEDPALW. Reliability testing was conducted on three versions with 104, 47, and 41 items. PA scales had acceptable Cronbach's α (>0.70) but low ICC (NS). FV and DF scales had acceptable Cronbach's α (>0.70), with preferences for the shorter (47- and 41-item) versions (Cronbach's α < 0.70), and all scales had moderate ICC (p < 0.05, except the FV scale on the 104-item version (p = 0.07)). The AS preferences scale had Cronbach's α < 0.70, with self-efficacy > 0.70 for all versions and ICC moderate for all versions (p ≤ 0.01). PSEDPALW may be useful to assess diet and physical activity preferences and self-efficacy in theory-based diet and physical activity interventions in women who identify as Latina and are breast cancer survivors.

Position of the Society for Nutrition Education and Behavior: Nutrition Educator Competencies for Promoting Healthy Individuals, Communities, and Food Systems: Rationale and Application

It is the position of the Society for Nutrition Education and Behavior that to improve the health of individuals, communities, and food systems, it is essential that nutrition educators meet each of 6 content competencies (basic food and nutrition knowledge, nutrition across the life cycle, food science, physical activity, food and nutrition policy, and agricultural production and food systems) and 4 process competencies (behavior and education theory; nutrition education program design, implementation and evaluation; written, oral, and social media communication; and nutrition education research methods). These competencies reflect the breadth of the nutrition education field and are grounded in peer-reviewed research. The rationale and evidence base for these competencies are presented. They are designed for educational institutions to plan curricula and programs; public, private, and nonprofit organizations for training; individuals for professional development; and policymakers and advocates to inform strong, comprehensive nutrition education policy.

Effectiveness of a Nutrition Education Program in Improving Mothers’ Knowledge and Feeding Practices of Infants and Young Children in Sudan

Objective: To assess the effect of a designed nutrition education program (NEP) on maternal Knowledge and practices  Methods: A control two groups quasi-experimental pre- and post-experimental were adopted. Data were collected through personal interviews of two groups using a validated questionnaire. The nutrition education program was conducted in three phases. Phase one was the pre-evaluation; phase two was the program's implementation, and phase three entailed post-evaluation of the program. Results: The results supported the efficient role of the NEP intervention in raising mothers ' Knowledge and practices towards nutritional care of children under two years in Sennar Locality. No statistically significant differences were found between the two groups with the controlled variable, mother age, mother education, mother occupation, husband occupation, No of children less than five years, family size, and infant age. This indicates that the two groups were homogenous. No significant difference between the two groups in mothers' Knowledge and practices before applying the NEP. The results showed the effectiveness of the NEP in developing experimental group mother's Knowledge and practices, comparing post-test with pre-test in favor of post-test to be statistically significant. NEP has a  greater effect in developing mother's awareness post-test measuring and developing mother's Knowledge and practices comparing post-test with pre-test. Conclusions and Implications: It can be concluded that nutrition education intervention demonstrated its effectiveness in maternal Knowledge and practices. The study provided valuable baseline information to develop appropriate training courses and nutrition education programs to raise maternal Knowledge and practices towards infants and young children's nutrition.  

Assessment of a Nutrition Education Program designed to Enhance Mothers’ Attitudes on Infants and Young Children feeding in Sudan

Objective: To assess the effect of a designed nutrition education program (NEP) on maternal attitudes.  Methods: A control two groups quasi-experimental pre- and post-experimental were adopted. Data were collected through personal interviews of two groups using a validated questionnaire. The nutrition education program was conducted in three phases. Phase one was the pre-evaluation, phase two was the program’s implementation, and phase three entailed post evaluation of the program. Results: The results supported the efficient role of the NEP intervention in raising mothers’ attitudes towards nutritional care of under two years in Sennar Locality, Sudan. There was no significant difference between the two groups with respect to the controlled variables; mother age, mother education, mother occupation, husband occupation, number of children less than 5 years, family size, and child’s age, which indicates that the two groups were homogenous, i.e., no significant difference between mothers’ attitude of the two groups before applying the NEP. The results showed the effectiveness of the NEP in developing experimental group mother’s attitudes, comparing post-test with pre-test in favor of post-test to be statistically significant. NEP has a huge impact in developing the mother’s awareness post-test, measuring and developing the mother’s attitudes compared to post-test with pre-test. Conclusions and Implications: The nutrition education intervention demonstrated its effectiveness in maternal attitude. The study provided valuable baseline information to develop appropriate training courses and nutrition education programs to raise maternal awareness and attitudes towards infants and young children’s nutrition.                                                                                                                                          

Serious Games for Nutritional Education: Online Survey on Preferences, Motives, and Behaviors Among Young Adults at University

Background

Data on nutritional information and digital gameplay are limited among young adults in Germany.

Objective

This survey aimed to gather data on nutritional information sources and digital games for nutritional education (preferences, motives, and behaviors) among young adults at both Munich universities in Germany.

Methods

An online survey was developed by an multidisciplinary research group using EvaSys, an in-house survey software. The questionnaire (47 items) covered questions about baseline characteristics (eg, housing situation and weight), nutrition (eg, nutritional information sources), and digital (nutritional) gameplay (eg, preferences, motives, and behaviors). A feedback field was also provided. This publication is based on a selection of 20 questions (7 baseline characteristics, 2 nutrition, 11 gameplay). Young adults, primarily Munich university students aged from 18 to 24 years, were invited to participate by digital and nondigital communication channels between 2016 and 2017. Statistical analyses were performed using Excel 2013 (Microsoft Corp) and R version 3.1.3 (R Foundation for Statistical Computing).

Results

In total, 468 young adults (342/468, 73.1% women; 379/468, 81.0% university students) participated. Most of the participants (269/468, 57.5%) were aged 18 to 24 years with a BMI in the normal weight range (346/447, 77.4%). Mean body weight was 65.5 [SD 14.0] kg. Most participants reported getting nutritional information from the internet (372/467, 79.7%) and printed media (298/467, 63.8%), less than 1.0% (2/467, 0.4%) named digital games. Apps (100/461, 21.7%) and university/workplace (146/461, 31.7%) were the most desired sources for additional information about nutrition, while 10.0% (46/461, 10.0%) of participants stated wanting digital games. Almost two-thirds (293/468, 62.6%) of participants played digital games, while one-fifth (97/456, 21.3%) played digital games daily using smartphones or tablets. Finally, most respondents (343/468, 73.3%), mainly women, expressed interest in obtaining nutritional information during digital gameplay. However, significant gender differences were shown for nutritional acquisition behaviors and digital gameplay preferences, motives, and behaviors.

Conclusions

Our survey population reported playing digital games (especially men) and wanting nutritional information during digital gameplay (especially women). Furthermore, university or workplace are named as preferred settings for nutritional information. Therefore, a digital game app might have the potential to be a tool for nutritional education among young adults within the university or workplace environment.

Effectiveness of an Adult Food Literacy Program

Nutrition education programs aim to improve food literacy domains covering the planning and management, selection, preparation and cooking and eating of healthy food. Reviews indicate programs are effective but acknowledge challenges with evaluation of community focused delivery. Food Sensations^® for Adults (FSA) is a free four-week nutrition and cooking program targeted at low-to-middle income Western Australians who would like to improve their food literacy. The aim of this research was assess how effective FSA is in changing food literacy and selected dietary behaviours. Statistical analysis identified a significant increase in postprogram scores for domains of planning and management, selection and preparation using factor scores (n = 1092). The proportion of the score increase in the postprogram scores compared to the preprogram scores was 10–25%. There was also a significant increase in self-reported fruit and vegetable serve intake, equating to an average increase of ¼ serve/day of fruit and ½ serve/day of vegetables. Of those classified as low food literacy, 61–74% improved postprogram scores in the three domains. FSA is effective in improving food literacy and dietary behaviours and the results add to the evidence base as to how effective these programs can be and for whom they should be targeted for future success.

Reduced Morbidity Motivated Adoption of Infant and Young Child Feeding Practices after Nutrition Education Intervention in Rural Malawi

This study assessed caregivers' knowledge and practices and factors that influence the adoption of improved infant and young child feeding (IYCF) practices after nutrition education in Kasungu and Mzimba districts among 198 caregivers. Mixed-methods convergent-parallel design, including knowledge tests, focus group discussions, and in-depth interviews in the intervention areas, was used to collect quantitative and qualitative data. Data were analyzed using count regression and content analysis, which showed that knowledge increased among caregivers after nutrition education. The knowledge about diet diversification for young children as well as about hygienic practices when preparing food and during feeding improved in addition. Enhanced health among children motivated caregivers to apply improved IYCF practices. The study was based on the caregivers' reports. Long-term effects of exposure to nutrition education are unknown. However, the nutrition education that focused on the child's health benefits motivated mothers to adopt improved IYCF practices.

A Multicomponent, School-Based Intervention, the Shaping Healthy Choices Program, Improves Nutrition-Related Outcomes

OBJECTIVE

To evaluate the effectiveness of the Shaping Healthy Choices Program (SHCP).

DESIGN

A clustered, randomized, controlled intervention lasting 1 school year.

SETTING

Schools in northern and central California.

PARTICIPANTS

Fourth-graders (aged 9-10 years) at 2 control schools (n = 179) and 2 intervention schools (n = 230).

INTERVENTION

Garden-enhanced education, family, and community partnerships; increased regionally procured produce in the lunchroom; and school-site wellness committees.

MAIN OUTCOME MEASURES

Changes in body mass index (BMI) percentiles/Z-scores; nutrition knowledge, science process skills, and vegetable identification and preferences; and reported fruit and vegetable intake.

ANALYSIS

Student t test, chi-square, ANOVA of change, and multilevel regression mixed model to evaluate change in outcomes with school as a random effect to account for cluster design effects. Statistical significance was set at P < .05.

RESULTS

There was a greater improvement in BMI percentile (-6.08; P < 0.01), BMI Z-score (-0.28; P < .001), and waist-to-height ratio (-0.02; P < .001) in the intervention compared with the control schools.

CONCLUSIONS AND IMPLICATIONS

The SHCP resulted in improvements in nutrition knowledge, vegetable identification, and a significant decrease in BMI percentiles. This supports the concept that the SHCP can be used to improve the health of upper elementary school students.

Development and validation of an Arabic questionnaire to assess psychosocial determinants of eating behavior among adolescents: a cross-sectional study

BACKGROUND

There is a scarcity of studies that evaluate the psychosocial determinants of eating behavior among adolescents in the Eastern Mediterranean region. The availability of such data is limited by the lack of valid culturally appropriate tools. The current study aims to develop and validate an Arabic questionnaire that measures psychosocial determinants of eating behavior among adolescents.

METHODS

A cross-sectional study was carried out to validate a five-scale questionnaire developed to measure nutrition-related knowledge, attitude, practices, and self-efficacy and social norms. Content validity was assessed by Lawshe's method, factor analysis was used to assess construct validity, and Cronbach's α was used to test internal consistency. Temporal stability was assessed by test-retest reliability. A random sample of public and private school students participated in the validation study.

RESULTS

All the five scales demonstrated excellent content validity (content validity ratio, CVR ≥0.778). Factor analysis revealed several dimensions for each scale. Cronbach's α for the identified dimensions or subscales ranged between 0.495 and 0.809 indicating acceptable internal consistency. Cronbach's α for the total scales ranged between 0.759 and 0.836. Test-retest analysis revealed good temporal stability (intraclass correlation, ICC >0.7).

CONCLUSIONS

A psychometrically valid tool to measure psychosocial determinants of eating behavior was developed. This tool can serve as a potential instrument for pretest and impact evaluation of ongoing nutrition education interventions and curricula. Based on results obtained from this tool, efficacious modifications can be instilled for nutrition policies and interventions.

Using a Systematic Approach and Theoretical Framework to Design a Curriculum for the Shaping Healthy Choices Program

OBJECTIVE

To examine the use of a systematic approach and theoretical framework to develop an inquiry-based, garden-enhanced nutrition curriculum for the Shaping Healthy Choices Program.

METHODS

Curriculum development occurred in 3 steps: identification of learning objectives, determination of evidence of learning, and activity development. Curriculum activities were further refined through pilot-testing, which was conducted in 2 phases. Formative data collected during pilot-testing resulted in improvements to activities.

RESULTS

Using a systematic, iterative process resulted in a curriculum called Discovering Healthy Choices, which has a strong foundation in Social Cognitive Theory and constructivist learning theory. Furthermore, the Backward Design method provided the design team with a systematic approach to ensure activities addressed targeted learning objectives and overall Shaping Healthy Choices Program goals.

CONCLUSIONS AND IMPLICATIONS

The process by which a nutrition curriculum is developed may have a direct effect on student outcomes. Processes by which nutrition curricula are designed and learning objectives are selected, and how theory and pedagogy are applied should be further investigated so that effective approaches to developing garden-enhanced nutrition interventions can be determined and replicated.

Development and Validation of the Guide for Effective Nutrition Interventions and Education (GENIE): A Tool for Assessing the Quality of Proposed Nutrition Education Programs

OBJECTIVE

To develop and validate the Guide for Effective Nutrition Interventions and Education (GENIE), a checklist of research-based quality indicators for nutrition education programs.

DESIGN

A prospective test of criterion validity and inter-rater reliability of a new tool comparing expert assessments and trained reviewer GENIE scores of the same nutrition education proposals.

PARTICIPANTS

Ten nutrition education experts; 13 volunteer reviewers.

VARIABLES MEASURED

GENIE's face, content, and criterion validity and inter-rater reliability compared using expert assessments and reviewer objective and subjective scores.

ANALYSIS

Reviewer scores compared using Spearman correlation. Inter-rater reliability tested using intra-class correlation (ICC), Cronbach alpha, and ANOVA. Criterion validity tested using independent t test and point bi-serial correlation to compare reviewer with expert scores.

RESULTS

Correlation found between total objective and total subjective scores. Agreement found between reviewers across proposals and categories considering subjective scores (F = 7.21, P < .001; ICC = 0.76 [confidence interval, 0.53-0.92]) and objective scores (F = 7.88, P < .001; ICC = 0.82 [confidence interval, 0.63-0.94]). Relationship was not significant (r = .564, P = .06) between expert and reviewer proposal scoring groups (high, medium, and low).

CONCLUSIONS AND IMPLICATIONS

Results support the validity and reliability of GENIE as a tool for nutrition education practitioners, researchers, and program funding agencies to accurately assess the quality of a variety of nutrition program plans.

Evaluation outcomes of a long-running adult nutrition education programme

Objective

For more than 20 years, the FOODcents adult nutrition education programme has been delivered to Western Australians. The aim of the programme is to provide disadvantaged individuals with the knowledge, skills and motivation to buy healthy foods on a limited budget. The present study evaluated whether the FOODcents curriculum and the way it is delivered are effective in improving participants’ nutrition-related knowledge and behaviours.

Design

Evaluation data were collected via in-session pre–post questionnaires and a post-course online questionnaire.

Setting

Western Australia.

Subjects

Data were collected from participants attending just over one-half (54 %) of the FOODcents courses conducted over the two-year evaluation period. In total, 927 course participants provided usable data.

Results

After exposure to the course, respondents demonstrated an improved ability to: (i) categorize foods according to the frequency with which they should be consumed and the proportion of the food budget that should be allocated to them; (ii) correctly interpret nutrition labels on food products; and (iii) appreciate the link between diet/obesity and a range of diseases. Improvements in the latter were especially pronounced among participants of low socio-economic status. In terms of behaviour change, significant improvements in fruit and vegetable consumption were reported, along with reductions in the consumption of fast food. Participants of low socio-economic status reported the greatest changes.

Conclusions

The results indicate that the FOODcents nutrition education programme improves participants’ nutrition-related knowledge and behaviours.

Maternal knowledge after nutrition behavior change communication is conditional on both health workers' knowledge and knowledge-sharing efficacy in rural Haiti

In the context of a food assistance program in rural Haiti, we developed measures of the effectiveness of community health worker (CHW)-delivered behavior change communication (BCC). We administered knowledge tests to 954 mothers and 38 CHWs to define 4 measures: CHW knowledge, maternal knowledge, knowledge-sharing efficacy (proportion of CHW knowledge shared), and shared correct knowledge between the CHWs and the mothers with whom they interacted. On the basis of the tests, CHWs had high knowledge (93% correct), mothers scored 72% on maternal knowledge, the proportion of CHW knowledge shared was 75%, and shared correct knowledge between CHWs and mothers was 70%. Factors affecting maternal knowledge included CHW characteristics (unmarried: β = -0.070, P < 0.05), long duration (19-45 mo) of program participation (β = 0.034, P < 0.05), and having multiple sources of health and nutrition information (β = 0.072, P < 0.01). Shared correct knowledge and CHW knowledge-sharing efficacy were positively associated with CHW (age, education) and program participation characteristics. We parsed the relative contributions of CHW characteristics to total and proportion of shared CHW knowledge. We observed a positive association between CHW education and shared correct knowledge between the CHWs and mothers (β = 0.328, P < 0.01), not because of more knowledge (β = -0.012, P > 0.05) but rather because of greater knowledge-sharing efficacy (β = 0.340, P < 0.01). These measures provide a means of examining features of program delivery and interpreting impact evaluation results. They show that BCC outcomes are conditional on both frontline workers' knowledge and knowledge-sharing efficacy. Whereas most programs focus on content training to improve CHWs' knowledge, it is also important to strengthen process training and support to foster knowledge-sharing efficacy.

Perceptions of healthful eating and influences on the food choices of Appalachian youth

OBJECTIVE

Patterns of overweight and obesity have an unequal geographic distribution, and there are elevated rates in Appalachia. Perceptions of Appalachian youth toward healthful eating and influences on food choice were examined as part of formative research to address these disparities.

METHODS

Eleven focus groups, averaging 6 youth (n = 68) and moderated by experienced local residents, were conducted with participants aged 8-17. Session transcripts were coded for thematic analysis, using measures to enhance rigor and transferability.

RESULTS

Participants discussed numerous internal and external factors affecting dietary choices. They expressed confidence in their own nutritional knowledge, and they stressed the importance of taste preferences, cost, convenience, social influences, and advertising on diet.

CONCLUSIONS AND IMPLICATIONS

Appalachian youth awareness of the multiple influences on diet may create opportunities for multifaceted, ecologically based interventions. In particular, participants stressed the importance of social influences on diet and on successful nutrition programming.

Validation of a general nutrition knowledge questionnaire in a Turkish student sample

OBJECTIVE

To validate the general nutrition knowledge questionnaire developed by Parmenter and Wardle (1999) in a Turkish student sample.

DESIGN

The original questionnaire of Parmenter and Wardle (1999) was modified and translated into Turkish. The modified questionnaire was administered to second year undergraduate students. Some students completed the questionnaire twice for the measurement of test-retest reliability. Statistical analysis was performed on the responses to measure the internal reliability, test-retest reliability and construct validity.

SETTING

Students completed the questionnaire under supervision. The questionnaire was completed at the end of lectures. Retest was carried out two weeks after first administration of the test.

SUBJECTS

A total of 195 undergraduate students studying either nutrition and dietetics (n 90) or engineering (n 105) participated in the study. Of these, 125 students completed the questionnaire on two occasions.

RESULTS

Overall internal reliability (Cronbach's α = 0·89) and test-retest reliability (0·86) were high. Significant differences between the scores of the two groups of students indicated that the questionnaire had satisfactory construct validity.

CONCLUSIONS

The modified version of the general nutrition knowledge questionnaire can be used as a tool to examine the nutrition knowledge of adults in Turkey. In the next stage of the study, some adjustments need to be made to the items that led to low reliability values so that these items will be more applicable to the eating habits and patterns of Turkish people.

Six characteristics of nutrition education videos that support learning and motivation to learn

OBJECTIVE

To identify characteristics in nutrition education video vignettes that support learning and motivation to learn about feeding children.

METHODS

Nine focus group interviews were conducted with child care providers in child care settings from 4 states in the western United States: California, Idaho, Oregon, and Washington. At each focus group interview, 3-8 participants (n = 37) viewed video vignettes and participated in a facilitated focus group discussion that was audiorecorded, transcribed, and analyzed.

RESULTS

Primary characteristics of video vignettes child care providers perceived as supporting learning and motivation to learn about feeding young children were identified: (1) use real scenarios; (2) provide short segments; (3) present simple, single messages; (4) convey a skill-in-action; (5) develop the videos so participants can relate to the settings; and (6) support participants' ability to conceptualize the information.

CONCLUSIONS AND IMPLICATIONS

These 6 characteristics can be used by nutrition educators in selecting and developing videos in nutrition education.

Does a population-based multi-factorial lifestyle intervention increase social inequality in dietary habits? The Inter99 study

OBJECTIVE

To investigate whether the effect of an individualised multi-factorial lifestyle intervention on dietary habits differs across socioeconomic groups.

METHODS

The study was an individualised multi-factorial lifestyle intervention study with a control group, Inter99 (1999-2006), Copenhagen, Denmark. Participants in the intervention group (n=6 091) received lifestyle intervention during a five-year period. The control group (n=3 324) was followed by questionnaires. Multilevel regression analyses were used, including interaction term between intervention effect and socioeconomic position (SEP) and analysed separately for men and women. SEP was measured as length of education and employment status and dietary habits were measured by a validated food frequency questionnaire.

RESULTS

Men with a short education improved their dietary habits more (net-change [95% confidence interval]) (0.25 points [-0.01;0.52]) than men with longer education (0.02 points [-0.09;0.14]), (interaction: p=0.02). Furthermore, unemployed women improved their dietary intake more (0.33 points [0.05;0.61]) than employed women (0.01 points [-0.10;0.11]), (interaction: p=0.03). Similar results were found for fruit intake, whereas no significant interactions were found for fish, fat and vegetable intake.

CONCLUSIONS

Individualised dietary interventions do not increase and may even decrease or hinder further widening of the social inequalities in health due to unhealthy dietary habits among socially disadvantaged individuals.

Bone health nutrition issues in aging

Bone health is an important issue in aging. Calcium and vitamin D currently have the most focus in published research on nutrition and bone health in aging, although evidence from published research is not conclusive. A systematic review was conducted to determine the impact of dietary and supplemental interventions focused on calcium and vitamin D over the past 10 years. Using key words to search, and search limits (aging population, English), 62 papers were found related to diet, nutrition, and bone; and 157 were found related to calcium and bone. Our review found a positive effect on bone health for supplements; food-based interventions; and educational strategies. Although there may be a publishing bias related to non-significant findings not being published, our results suggest the effectiveness of food based and educational interventions with less economic impact to the individual, as well as less risk of physiological side effects occurring.

Participant-centered education: building a new WIC nutrition education model

OBJECTIVE

To assess the readiness of the Western Region Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) states to implement participant-centered nutrition education (PCE) and to develop a PCE model for WIC service delivery.

DESIGN

Formative research including on-line survey, qualitative in-depth interviews, focus groups, and observational assessments.

SETTING

WIC clinics within the Western Region WIC states.

PARTICIPANTS

State and local staff and WIC clients within 8 states, 2 tribal organizations, and 2 territories.

PHENOMENON OF INTEREST

Readiness indicators of states to implement and expand PCE elements to include in PCE model development.

ANALYSIS

On-line surveys were collected and analyzed. On-site assessment forms, interviews, and focus group findings were collected, coded, and summarized by themes.

RESULTS

Key themes from state and local findings guided the model development for PCE implementation in the Western Region WIC states. The PCE model must be flexible and systems oriented, contain strong training and mentoring components, and integrate cultural sensitivity to best reach program participants.

CONCLUSIONS AND IMPLICATIONS

The PCE model has the potential to improve WIC nutrition services and enable participants to make positive health-related behavior changes that will influence long-term health issues. Further outcome studies are needed to determine the success of PCE implementation in the Western Region WIC states.