EFNEP's impact on the quality of life of its participants and educators

Implementation Science Strategies Promote Fidelity in the Food, Feeding, and Your Family Study

OBJECTIVE

Use of implementation science strategies to promote fidelity in the Food, Feeding, and Your Family study.

DESIGN

Cluster randomized controlled trial with 3 conditions: control, in-class, or online, delivered in English or Spanish. Observations of 20% of classes.

SETTING

Expanded Food and Nutrition Education Program (EFNEP) in 2 states.

PARTICIPANTS

EFNEP peer educators (n = 11).

INTERVENTION

Parental feeding content incorporated into EFNEP lessons (in-class) or through text with links to videos/activities (online). Extensive educator training, scripted curriculum, frequent feedback.

ANALYSIS

Assessment of fidelity compliance. Qualitative analysis of verbatim educator interviews and classroom observer comments.

RESULTS

During 128 class observations (40-45 per condition), peer educators followed scripted lesson plan 78% to 89% of the time. There was no evidence of cross-contamination of parental feeding content in control and only minor sharing in online conditions. Variations with fidelity were primarily tied to the EFNEP curriculum, not the parent feeding content. Educators (n = 7) expressed favorable opinions about the Food, Feeding, and Your Family study, thought it provided valuable information, and appreciated support from EFNEP leadership.

CONCLUSIONS AND IMPLICATIONS

Incorporating implementation science strategies can help ensure successful adherence to research protocols. With proper training and support, EFNEP peer educators can deliver an evidence-based curriculum as part of a complex research study.

Feasibility of Colocating a Nutrition Education Program into a Medical Clinic Setting to Facilitate Pediatric Obesity Prevention

Purpose:

Within a medical clinic environment, pediatric obesity prevention education for families faces challenges. Existing long-term government-funded nutrition education programs have the expertise and staff to deliver. The purpose is to determine feasibility of colocating the Expanded Food and Nutrition Education Program (EFNEP) into a medical clinic setting to support pediatric obesity prevention.

Methods:

Physicians from a large university teaching and research hospital (n = 73) and 4 small Medicaid-serving community clinics (n = 18) in the same geographic area in northern California were recruited and trained in the patient-referral protocol for a primary prevention intervention provided by EFNEP. The 8-week intervention deployed in the medical clinics, included general nutrition, physical activity and parenting topics anchored with guided goal setting and motivational modeling. Referral, enrollment, and attendance data were collected for 2 years. Parent and physician feasibility surveys, parent interviews and parent risk assessment tools were administered. Paired-sample t-test analysis was conducted.

Results:

Twenty intervention series with parents of patients (n = 106) were conducted at 5 clinics. Physicians (n = 92) generated 686 referrals. Every 6 referrals generated 1 enrolled parent. Physicians (91%, n = 34) reported the intervention as useful to families. Parents (n = 82) reported improved child behaviors for sleep, screen time, physical activity, and food and beverage offerings (P < .0001) and at family mealtime (P < .001). Focus group interviews (n = 26) with 65 participants indicated that parents (97%) reacted positively to participating in the intervention with about a third indicating the classes were relevant to their needs.

Conclusion:

The intervention is a feasible strategy for the 5 medical clinics. Physicians referred and parents enrolled in the intervention with both physicians and parents indicating positive benefits. Feasibility is contingent upon physician awareness of the intervention and motivation to refer patients and additional EFNEP and clinic staff time to enroll and keep parents engaged.

Use of Survival Analysis to Predict Attrition Among Women Participating in Longitudinal Community-Based Nutrition Research

OBJECTIVE

To identify participant characteristics and study methodology that influenced the completion of a 15-month community-based longitudinal study evaluating the impact of the Supplemental Nutrition Assistance Program Education and Expanded Food and Nutrition Education Program.

DESIGN

Observational longitudinal 15-month study across 12 data collection timepoints. Sociodemographic characteristics were collected with a paper-based survey at baseline.

SETTING

Five counties across central and southern Illinois.

PARTICIPANTS

Women, aged 18 to 65 years (n = 297), recruited at sites likely to serve families eligible for the Supplemental Nutrition Assistance Program Education and Expanded Food and Nutrition Education Program (housing departments, child care centers, etc).

MAIN OUTCOME MEASURES

Predictors of participant attrition during the study duration.

ANALYSIS

Cox proportional hazard models.

RESULTS

Ninety-seven participants were retained across the full study. In unadjusted models, greater income and education levels were significantly related to lower attrition; however, this relationship did not persist in a multivariate model. When adjusted for other characteristics, larger household size was the only measured variable significantly related to greater odds of attrition (odds ratio = 1.09; 95% confidence interval = 1.02, 1.17).

CONCLUSIONS AND IMPLICATIONS

Several characteristics predicting attrition in other settings were not significant in this study. Future attrition analyses that evaluate social support, transportation capacity, and type of phone in longitudinal nutrition education studies are warranted.

Evaluation and Lessons Learned From the Development and Implementation of an Online Prenatal Nutrition Training for EFNEP Paraprofessionals

OBJECTIVE

Design, implement, and evaluate the effectiveness of a video-based online training addressing prenatal nutrition for paraprofessional peer educators.

METHODS

Quasi-experimental pre-posttest study with 2 groups of paraprofessionals working for the Expanded Food and Nutrition Education Program in 17 states and US territories: intervention (n = 67) and delayed intervention comparison group (n = 64). An online training was systematically developed using Smith and Ragan's instructional design model, the Cognitive Theory of Multimedia Learning, principles of adult learning, and selected constructs of the Social Cognitive Theory. Changes in knowledge, identification of inappropriate teaching practices, and self-efficacy, were assessed. Within- and between-group comparisons were done using ANCOVA.

RESULTS

The intervention group scored significantly higher (P < .05) in all evaluations compared with preassessments and the comparison group. After delayed intervention, the comparison group scored significantly higher (P < .05) than in preassessments. Paraprofessionals reacted positively to future online trainings and were interested in them.

CONCLUSIONS AND IMPLICATIONS

A video-based online training is an effective method to complement in-person trainings to prepare paraprofessionals to teach nutrition lessons.

The Expanded Food and Nutrition Education Program's Impact on Graduates' Quality of Life

OBJECTIVE

To determine how the Expanded Food and Nutrition Education Program (EFNEP) affects the quality of life (QoL) of its low-income adult participants.

METHODS

A cross-sectional exploratory study using focus groups (n = 15) in 8 states with EFNEP participants (n = 111) 2-4 months after graduation. Focus groups were conducted with non-Hispanic white (4 groups), black (4), English-speaking Hispanic (4), and Spanish-speaking Hispanic (3) respondents. A priori template analysis based on constructs from the University of Toronto's Quality of Life Profile for Adults and constant comparative procedures were used to generate results.

RESULTS

Participants reported following healthier dietary and physical activity behaviors and having increased motivation to improve themselves and greater satisfaction with life. All groups noted being a more positive influence on their families and a having willingness to learn and try new things.

CONCLUSIONS AND IMPLICATIONS

The EFNEP enhances the QoL of its participants, which suggests that the program's benefits go beyond participants' documented nutrition and health-related behavior changes. In the future, EFNEP might examine whether improved QoL is also a predictor of sustained behavior change and a means for differentiating program impacts owing to variations in dose (number of contacts) or delivery methods (face-to-face vs online).

EFNEP's Impact on Exemplary Educators' Quality of Life

OBJECTIVE

To determine how the Expanded Food and Nutrition Education Program (EFNEP) affects the quality of life (QoL) of its exemplary paraprofessional educators.

METHODS

Qualitative telephone interviews with EFNEP supervisors (15), educators (28), and agency partners (15). Template analysis based on the University of Toronto's QoL constructs.

RESULTS

The EFNEP had a positive impact on 6 of 9 a priori categories: physical being, psychological being, social belonging, community belonging, practical becoming, and growth becoming.

CONCLUSIONS AND IMPLICATIONS

The EFNEP enhances the QoL of its exemplary educators, which suggests that the program's benefits go beyond those documented in participants.

Participant and Household Characteristics Associated With Graduation From the Expanded Food and Nutrition Education Program

OBJECTIVE

To examine empirically participant and household characteristics associated with Expanded Food and Nutrition Education Program (EFNEP) graduation and to determine whether they differ across 2 counties.

DESIGN

Survey of EFNEP participants from 2011 to 2012.

SETTING

Expanded Food and Nutrition Education Program sites serving limited-resource families in 1 rural and 1 urban/suburban county in Washington State.

PARTICIPANTS

Expanded Food and Nutrition Education Program participants (urban/suburban: n = 647; rural: n = 569).

MAIN OUTCOME MEASURE

Expanded Food and Nutrition Education Program completion/graduation.

ANALYSIS

Multivariate logistic regression was used to examine associations of participant (ethnicity, race, age, education, pregnancy status, and nutrition knowledge/behavior at baseline) and household (number of people in the house, place of residence, and public assistance services) characteristics with EFNEP graduation.

RESULTS

Associations were moderated by county. For the urban/suburban county, participants living with more people (after controlling for the total number of adults) were more likely to graduate. For the rural county, participants living with fewer total adults (after controlling for the total number in the house) and those with better food safety practices at baseline were more likely to graduate.

CONCLUSIONS AND IMPLICATIONS

This study aids in understanding which participants are more or less likely to complete EFNEP successfully, and therefore can inform strategies aimed at increasing graduation rates.

Improved Overall Quality of Diets Reported by Expanded Food and Nutrition Education Program Participants in the Mountain Region

OBJECTIVE

To evaluate the Expanded Food and Nutrition Education Program, a large US Department of Agriculture nutrition education program for low-income people, by comparing the overall quality and cost of diets when entering and exiting the program.

METHODS

Secondary analysis of data collected in 2011 from female participants in the Mountain region. Dietary recalls were collected by paraprofessionals. Outcome measures were the differences between Healthy Eating Index-2005 scores and costs of diets at entry and exit. Significance was determined using the Wilcoxon signed-rank test.

RESULTS

At entry the mean total Healthy Eating Index-2005 score was 49.1 (out of a possible 100) and at exit, 55.2 (P < .001) (n = 3,338). Eight of 12 component scores also improved significantly whereas the sodium score worsened. The estimated median cost of diets was 13% higher at exit compared with entry.

CONCLUSIONS

Participants' overall diet quality improved and was accompanied by an increase in food cost.

Family nutrition program assistants' perception of farmers' markets, alternative agricultural practices, and diet quality

OBJECTIVE

To explore Family Nutrition Program assistants' perception of farmers' markets and alternative agricultural practices for themselves and their clients.

METHODS

Cross-section design, survey of Virginia Expanded Food and Nutrition Education Program (NEP) and Supplemental Nutrition Assistance Program-Education Family Nutrition Program assistants (n = 52) working with limited-resource populations.

RESULTS

Twenty-one percent to 55% of FNP assistants valued alternative agricultural practices, and only 5% to 8% of FNP assistants perceived that their clients did so. Benefits to shopping at farmers' markets included supporting local economies, and food price, quality, and safety. Barriers included lack of transportation, location/convenience, hours, and food prices. Assistants rated the benefits to shopping at farmers' markets similarly for themselves and their clients, but rated many of the barriers to shopping at farmers' markets as significantly lower (P < .05) for themselves than for their clients.

CONCLUSIONS AND IMPLICATIONS

Future assistant trainings should address the connection between agriculture and health, and how to overcome barriers to shopping at farmers' markets for their clients.