Development and Evaluation of Activity-Oriented Nutrition Classes for Pregnant and Parenting Teens

Adolescence is a period of profound physical, social, and psychological development. Coupling pregnancy and parenthood with this stage of growth can put both the mother and child at health and behavioral risk (Flanagan, McGath, Meyer, & Coll, 1995). Due to the biological changes occurring during adolescence and pregnancy, nutritional requirements increase. Unfortunately, when needs are highest, many teens are dieting, skipping meals, snacking, consuming fast foods, and performing other poor dietary habits (Gutierrez & King, 1993). Research has shown that some of the nutrients most needed during this period, for example, energy, calcium and iron, are also the ones most lacking in the teens' diets (Sargent, Schulken, Kemper, & Hussey, 1994). Providing school or community-based nutrition education for pregnant and parenting teens may be one way to help improve the dietary intake of the teen and her child.

According to Story & Resnick (1986), interventions that focus on the environment, behavior, and personality of the teen will have a better chance of making a positive impact. Thus, to be effective, nutrition interventions for teens should consider the environment (school, home) of the teen, teach teens skills and behaviors through active participation, foster the development of an internal locus of control and help build the confidence necessary to make dietary changes. With these components in mind, we sought to locate and/or adapt a nutrition education curriculum for pregnant and parenting teens for use in a joint project between the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Colorado State University Cooperative Extension (CE).

The purpose of this study was to develop and pilot test a four week nutrition workshop series designed for pregnant and parenting teens as part of the Teen Parents for Healthy Children project. The objectives were to help teen participants: (a) increase their knowledge of good nutrition practices for pregnant and postpartum women, infants, and children, (b) increase their ability to plan nutritionally balanced meals/snacks, interpret food labels, and select, buy and/or prepare appropriate foods to meet their own and their families' needs, and (c) improve their dietary behavior and intake. Evaluation of the effectiveness of the program was measured by pre and post knowledge questionnaires, behavior/skill checklists, and 24-hour food recalls.

Based on WIC's 3-month check pick-up cycle, we chose to limit our curriculum to four classes. It was envisioned that teens would attend a nutrition education class as part of their WIC check pick-up appointment every three months for a year. We selected four lessons from the University of New Hampshire Cooperative Extension's Great Beginnings Curriculum (Burke, Long, & Luppold, 1994) to modify and adapt for the project. Using a combination of social and cognitive learning theories, we modified the lecture-oriented classes into interactive nutrition activity-oriented classes using the constructs of behavioral capability, expectations, and expectancies. The four nutrition activities were evaluated for suitability by WIC nutritionists and educators in five metro counties.

Pre- and post-knowledge questionnaires, skill/behavior checklists, and 24-hour food recalls were used to assess the effectiveness of the workshop series. A separate questionnaire was used to gather demographic information. The 20-point knowledge questionnaire was adapted from the knowledge test provided with the Great Beginnings curriculum. Cronbach's alpha reliability analysis yielded an alpha coefficient of 0.78, which is considered quite acceptable. The 8-item skill/behavior checklist and 24-hour recall instruments were adapted directly from those used nationally by the Expanded Food and Nutrition Education Program (EFNEP). Questions on the skill/behavior checklist were classified as nutrition practices (five questions) or food resource management practices (three questions).

The initial design of the project called for recruiting teens through the WIC program. It was projected that approximately 60 pregnant and parenting Colorado WIC teens would be reached during the pilot evaluation. However, recruiting the teens, finding classroom space, and working with WIC's 3-month out appointment system proved most difficult and we moved our pilot evaluation to the public schools. In the end, we held classes at one WIC clinic in Arvada and three public high schools (Denver, Aurora, and Fort Collins). For comparative purposes, a group of pregnant and parenting teens at one of the high schools took all of the tests, but did not participate in the workshop series.

To fit the time and curriculum constraints of participating schools, the workshop series consisted of four one-hour classes which extended over a period of four weeks. At each class, participants received handouts which complemented the information presented. The same instructor facilitated all the classes and administered the evaluation instruments ensuring consistency in format and content.

Statistical analysis of data from the evaluation instruments was performed by Colorado State University Statistical Services using the Statistical Package of the Social Sciences (SPSS), release 5.0, March 1993. The level of significance was set at p < 0.05. frequencies were calculated for the demographic information. paired 2-tailed t-tests were used to compare mean scores on pre and post knowledge tests. one-way analysis of variance was used to determine any significant differences between the treatment and control groups. chi-square multiple range tests were used to analyze changes in skill/behavior by location.

From August through October 1995, 60 teens from the four locations took part in the workshop series. The control group consisted of 10 teens who did not participate in the classes, but took pre and post questionnaires. Because of frequent illness and absenteeism among these high risk pregnant and parenting teens, paired pre/post data was available for only 39 treatment and 10 control participants.

Very few demographic differences were seen among the treatment and control groups. Overall, participants ranged in age from 13 to 20 years old; mean age was 16.3 (+/-1.5). Educational level ranged from 7th to 12th grade; mean grade level was 9.7 (+/ -1.3). Most of the participants were either White (54%) or Hispanic/Mexican American (26%). More than half (61%) of the participants were pregnant and the rest had delivered their babies. Most (71%) of the children were under 1 year of age. The majority (78%) of teens who had delivered were not nursing. Two- thirds of the teens were on the WIC program.

Almost all (98%) of the teens lived with other people. More teens (40%) lived with their mothers only than either their fathers only (4%) or both parents (29%). In the majority of homes (64%), one of the teen's parents did most of the food purchasing; 15% of the teens reported purchasing food in combination with a parent. Likewise, 47% of the participants reported a parent doing all the cooking, while 28% shared cooking responsibilities.

Results from the pre/post-knowledge questionnaires indicated a significant improvement in participants' nutrition knowledge score. Total mean pre-test scores were 59% and post-test scores were 87%, representing a significant 28% (p < 0.001) increase in knowledge score. in comparison, no change was seen in the pre- and post-knowledge scores of the control group (68% and 70%, respectively).

Among the treatment groups, 87% reported making a positive skill/behavior change in at least one of the eight nutrition or food resource management practices evaluated; 54% made a positive change in two or more, 39% in three or more, 16% in four or more, and 8% in 5 or more of the 8 skills/behaviors measured. More teens reported making changes in food resource management practices, such as planning meals ahead and using a shopping list, than in nutrition practices such as using the Food Guide Pyramid and selecting low fat foods at fast food restaurants. The mean number of positive skill/behavior changes made by location ranged from 1.4 for the control group to 2.5 for the Arvada treatment group. Differences in mean changes made were significant (p < 0.05) only between these two groups.

Comparison of pre/post 24-hour food recalls showed no change from pre to post workshop for either the treatment or control groups, thus indicating no positive nor negative effect on dietary behavior. The lack in dietary behavior change could be due to a variety of factors. An obvious factor was the short length of the workshop series. Given our initial constraints, the program was limited to four sessions. Although to expect dietary change in four sessions may be unrealistic, the results achieved with this program were no different than those reported by Alley, McCloud-Harrison, Peishe & Rafter (1995) for a nine-month long nutrition education program with pregnant teens. This would indicate that factors besides length may be important.

One important barrier to dietary change seen in this study and reported by Schneck, Sideras, Fox, & Dupuis (1990) was lack of control on the part of the teens regarding food purchasing and cooking practices in the home. Most teens in this study lived at home and were not responsible for food purchasing or cooking. Thus, it may have been difficult for them to make dietary changes.

Another factor interfering with dietary change may relate to teens' views on food and nutrition. Story and Resnick (1986), in their survey of 900 high school students, found that most teens thought they were too busy, and it was too inconvenient for them, to make dietary changes. Further, they felt no urgency to make dietary changes; for example, there was plenty of time later in life to worry about diet. Similar attitudes were expressed informally by the participants in this study. In terms of Prochaska's Stages of Change theory (Prochaska, Velicer, DiClements, Guadagnoli, & Rossi, 1990), these teens may have been in the precontemplation stage regarding dietary improvement. They would need to progress both through this stage and the contemplation stage to the action stage before any dietary change could be expected. This may take more than just time to accomplish.

As a result of this pilot evaluation we saw significant improvement in nutrition knowledge scores among teen participants in a four-session nutrition education program compared to no change in the control group. We also saw some positive movement in self-reported skills/behaviors among participants. Despite this, no changes were seen in dietary intake as recorded on 24- hour food recalls completed pre and post intervention.

Does this mean that short term nutrition education programs with this target audience are warranted? If the goal is improvement in nutrition knowledge, yes. If it is behavioral change, perhaps not. Gaining new knowledge is certainly an important step in the process of changing behavior, but does not guarantee such change. Readiness, willingness, self-efficacy and the ability to change are also crucial. Because these take much time and nurturance to develop, they may not be within the scope of many Cooperative Extension or WIC nutrition education programs targeted to this audience.

Based on the difficulty we experienced recruiting teens for non-mandated classes through WIC clinics, we recommend that when possible nutrition education programs for pregnant and parenting teens be incorporated as part of already established school curriculums for such teens. Because, as evidenced in this study, teens often don't have control over their home environment, involving the teen's family (especially the mother and/or grandmother) and significant friends or partners in the program is encouraged.

Cooperative Extension and WIC educators can provide a valuable service to such programs by serving on curriculum development committees and providing in-service trainings for teachers. In some cases it may be most efficacious for Extension or WIC educators to provide the nutrition education component of the curriculum or to provide an auxiliary after-school nutrition education program. By working together, classroom teachers in cooperation with Extension and WIC educators can ensure that the teens receive not only important nutrition information, but the incentives and support necessary to make positive changes in their diets.

Alley, H., McCloud-Harrison, J., Peisher, A.V., & Rafter, J.A. (1995). Expectations may be too high for changing diets of pregnant teens. Journal of Extension, 33(1).

Burke, J. Long, V. & Luppold, D. (1994). Great Beginnings: A nutrition curriculum for pregnant and parenting teens. Durham, NH: University of New Hampshire Cooperative Extension.

Flanagan, P.J., McGrath, M.M., Meyer, E.C., & Coll, C.G. (1995). Adolescent development and transitions to motherhood. Pediatrics, 96(2), 273-277.

Gutierrez, Y. & King, J.C. (1993). Nutrition during teenage pregnancy. Pediatric Annals, 22(2), 99-108.

Prochaska, J.O., Velicer, W.F., DiClemente, C.C., Guadagnoli, E., & Rossi, J.S. (1990). Patterns of change: Dynamic typology applied to smoking cessation. Behavioral Research 26, 83-107.

Sargent, M.E., Schulken, E.D., Kemper, K.A., & Hussey, J.A. (1994). Black and white adolescent females pre-pregnancy status. Adolescence, 29, 845-858.

Schneck, M.E., Sideras, K.S., Fox, R.A., Dupuis, L. (1990). Low-income pregnant adolescents and their infants: Dietary findings and health outcomes. Journal of the American Dietetic Association, 90, 555-558.

Story, M. & Resnick, M.D. (1986). Adolescents' views on food and nutrition. Journal of Nutrition Education, 18(4), 188- 192.

Acknowledgments: This project was jointly funded by Colorado State University Cooperative Extension and Cooperative State Research Education and Extension Service through CREES-USDA Project 93-ENEP-0-0600.