Increasing African-American Participation in Nutrition Education Programs for Low-Income Consumers

Introduction

In 1969, when Los Angeles County Cooperative Extension began to deliver nutrition education programs to low-income families in the Adult Expanded Food and Nutrition Education Program (EFNEP), the program used a home visitation model to deliver nutrition education through one-to-one visits. The participants were predominantly African American and Latino. Culturally competent nutrition educators visited homemakers with young children to provide nutrition and food safety information. The goal was to help these families to adopt a more nutritious diet that was affordable on a low income.

The program proved to be both popular and successful, graduating in excess of 10,000 participants per year in the early 1980's. Food recall data showed that participants changed their eating practices, significantly increasing their consumption of milk products, fruits, and vegetables. These changes increased their intake of Vitamins A, C, and calcium (Del Tredici, Omelich, Laughlin, & Joy 1988). While the number of low-income residents in Los Angeles County increased considerably, resources to the nutrition education programs did not keep pace with this growth. Consequently, the labor-intensive, one-to-one teaching method was discontinued, and group teaching was initiated. Groups were identified and organized by agencies that serve low-income families.

In the early 1990's, the Food Stamp Nutrition Education Program (FSNEP) was initiated in Los Angeles County, specifically targeting food stamp recipients with the same information that had been provided so successfully through EFNEP. While it might seem that the two programs targeted the same audience, it is important to recognize that FSNEP included families as well as individuals without children, while EFNEP targeted families with children. 

During the past 10 years, there has been a dramatic reduction in the number of African-American participants in both of Los Angeles County Cooperative Extension's low-income nutrition education programs. However, the demographics suggest that there is still a substantial population of low-income African-American families in the county who are in need of the information provided in the program. The study described here represents an attempt to understand the cause of this reduction of African-American participants in EFNEP and FSNEP, and to identify strategies that will help the programs increase their service to this audience.

Tracking the Reduction in Program Participation by African-Americans

At the time the EFNEP program was initiated (1969), African-Americans constituted up to 70% of the audience enrolled in the program. That proportion dropped steadily through the years, and during the last half of the 1990's, dropped precipitously, from 16% in 1994-95 to 6% in 1999-2000. In 2000-2001, the program enrolled fewer than 100 African-Americans, who represented only 7% of the total EFNEP enrollment. Figure 1 illustrates this fact.

Figure 1.
Participation in Los Angeles County Adult EFNEP by Ethnic Group, 1994-2001 (Source: Los Angeles County EFNEP Participation Records)

This reduction in African-American enrollment in the EFNEP program must be considered in the light of significant changes in the ethnic makeup of the low-income population of Los Angeles County, particularly among African-Americans and Hispanics, as shown in Table 1.

Table 1.
Changes in African-American and Hispanic Low Income Demographics in Los Angeles County, 1970-2000

	All Families	African- American Families	Hispanic Families*
1970 percent with incomes below poverty level	8.2%	20.4%	12.8%
1980 percent with incomes below poverty level	10.5%	20.9%	18.2%
% change, 1970-1980	+28%	+2%	+42%
1990 percent with incomes below poverty level	11.6%	19.2%	19.8%
% change, 1980-1990	+10.4%	-8.1%	+8.7%
2000 percent with incomes below poverty level	14.4%	13.1%	18.4%
% change, 1990-2000	+24.1%	-3.1%	-8%
* "Hispanic" Families is not a consistent term in the US Census, making for some uncertainty when reporting over several census periods. Source : U.S. Census of Population: California, Characteristics of the Population and Social and Economic Characteristics of the Population, 1970, 1980, 1990, 2000

As Table 1 illustrates, several demographic trends have likely affected participation of low-income families in Los Angeles County Cooperative Extension's nutrition education programs. First, the percentage of low-income families in the county has increased substantially, from 8.2% in 1970, to 14.4% in 2000. Most of that growth appears to have been among the Hispanic population. During the same time period poverty rates for ethnic groups other than African American and Hispanic did not change significantly. Rates of Hispanic families in poverty appear to have increased during the period, but because of the uncertainty caused by shifting racial designations in the US Census, it is unclear whether this observation is accurate.

However, African-American rates of poverty appear to have decreased substantially over the same period, thereby reducing the percentage of eligible African American families from 20.4%, or one in 5 African American families, to 13.1, or one in 7.5 African American families. Because the African American population has not grown substantially during the past 30 years, there has been a substantial reduction in the number of African-Americans in the pool of potential nutrition education program participants. Table 2, below, illustrates the growth in median incomes of the major racial groups in Los Angeles County during the period from 1980 to 2000.

Table 2.
Median Income Growth in Los Angeles County by Ethnic Group, 1980-2000

Race / Ethnicity	White	African- American	Asian, Pacific Islanders	Hispanic (any race)	American Indian
1980 Median Income	$23,217	$14,879	$23,676	$15,531	$17,890
1990 Median Income	$51,580	$29,774	$43,035	$26,791	$34,620
% Change 1980-1990	+122%	+100%	+82%	+73%	+93%
2000 Median Income	$48,602	$33,905	$47,631	$33,820	$36,201
% Change 1990-2000	-6.8%	+13.8%	+6.7%	+26.2%	+4.6%

As Table 2 illustrates, African-Americans, who had the lowest median incomes of any ethnic group in the county at the time of the 1980 census, have experienced significant income growth during the past 20 years. This table confirms the trend suggested in Table 1, which showed a reduction in poverty rates for African-Americans. This data provides support for our initial hypothesis that African Americans, over time, have become a smaller part of the potential audience for low-income nutrition education programs in Los Angeles County.

In addition, the low-income African-American population has dispersed geographically, and low-income census tracts in South Central and Central Los Angeles that were solidly African-American in 1970 have become predominantly Latino in 2000. Although the program has geographically broadened its service areas beyond the traditional African-American and Hispanic community boundaries of 1970, the increased dispersal of the low-income population has made it difficult to reach the county's eligible audience of African-Americans.

Why It Is Important to Reach More African-Americans

As our initial observations confirmed, there are fewer African-American families to be served by Cooperative Extension's low-income nutrition education programs, and the population that remains is no longer residentially concentrated in the communities where EFNEP and FSNEP once served them. Given the reduced poverty rates among African American families, the reduction in their participation in these programs appears on the surface to present no major problem. However, when one reviews the health statistics for African-Americans, quite a different story emerges.

African-Americans appear to be at higher risk for a number of serious health problems than other ethnic groups. Many of these health problems have direct linkages to nutrition and diet. Nationally, rates of diabetes, kidney failure, cardiovascular disease, childhood asthma, and infant mortality are all higher for African-Americans than for the population as a whole (CDC 2002b).

To illustrate this point we will consider the examples of diabetes and kidney failure. Latinos experience nearly twice the rate of Type II diabetes as whites, while African-Americans experience a 70% higher rate of the disease than whites. Recent health statistics indicate that African-Americans are more likely than other ethnic groups to experience serious complications of diabetes, including kidney failure, circulatory problems leading to amputation, and blindness (Carter, Pugh, & Monterossa, 1996; Mokdad, 2000). Kidney failure, also known as end-state renal disease, strikes one in twelve, or 8% of African-Americans, usually as a result of diabetes or high blood pressure (Kiberd, 2002). Control of both of these underlying conditions requires careful attention to diet.

Another major health problem facing many Americans is cardiovascular disease. The Centers for Disease Control report that cardiovascular disease at all stages is about 30% more prevalent among African-Americans than among whites (CDC, 2002a). Further, African-Americans are more likely to die of heart attack or stroke than either whites or Latinos. Managing cardiovascular disease and avoiding a catastrophic heart attack or stroke requires lifestyle changes, including dietary changes.

Finally, a recent study of childhood asthma suggests that low birth weight may be related to one-third of all childhood asthma cases. African-Americans are nearly three times more likely to be born with low birth weight than white babies (Joseph, 2000) and account for over 30% of childhood asthma sufferers, although they represent no more than 12% of the youth population. Low birth weight can be prevented in most cases by assuring that pregnant women adopt nutritious diets.

It appears that understanding and adhering to appropriate nutritional guidelines might reduce these adverse health outcomes that disproportionately impact African Americans. As a result, Cooperative Extension's EFNEP and FSNEP programs need to improve their outreach to the African-American community to increase the enrollment and retention of these families in nutrition education programs.

Methodology

In order to increase African-American participation in nutrition education classes, we believed it was important to understand the audience's perception of its needs in this area, as well as their ideas about the kind of program that would attract them. We decided to conduct focus groups with community members and interviews with community-based health and nutrition professionals. Focus groups are ideal for obtaining the ideas of potential participants in a relaxed, discussion format when interaction and exploration of ideas and points of view are needed (Kreuger, 2000).

We began by interviewing 10n community-based health and nutrition professionals in the fall of 2000, and winter and spring of 2001. We conducted most of the interviews prior to conducting the focus groups for two reasons: first, to help us understand the issues we should target in the focus groups, and second, to ask for the assistance of these professionals in identifying groups or agencies that might provide focus groups for this project. During spring 2001, we held seven focus groups in the greater Los Angeles area with 70 low-income African-Americans. At the conclusion of each focus group, participants were provided with a $20.00 gift certificate for a local supermarket.

The focus group tapes were transcribed, and along with the interview notes, were reviewed in detail by the authors. We performed a content analysis to identify themes and patterns among the interviews and focus groups, as well as between the focus groups as a whole and the interviews as a whole. The notes from this process were used to develop the findings presented below. This method of analyzing focus group data is consistent with procedures in the literature (Krueger & Casey 2000; Morgan,1998; Hedrick, Bickman, & Rog 1993).

Findings

Interviews

The interviews with community-based nutrition and health professionals identified several avenues that could be used to increase the visibility of the EFNEP/FSNEP program in the African-American community. Those most frequently mentioned included ministers or churches, community-based organizations, and, for youth, radio and television. Community-oriented newspapers were mentioned, but several of the respondents felt that the low-income African-American audience may not really be "tuned in" to the newspapers. These informants indicated that the message that "sells" the program should be something meaningful to the participants, such as management or control of diabetes, the connection between nutrition and health, and maintaining a healthy lifestyle despite the stress of daily life.

The respondents stressed that EFNEP needed an "image transplant." To attract more African-American participants, the program should create brochures with African-American images. Several of the respondents felt that advertising the term "low income" was a turn-off for low-income audiences and that we need to emphasize other needs of the audience. These respondents felt we could target the audience by location without emphasizing the "low income" image. Over half of the respondents indicated that the "image" of the program needed updating, and one indicated that EFNEP as a name had no appeal or name recognition. One said that it reminded her more of an eye chart than a nutrition education program.

The respondents also addressed prevalent myths that might prove to be barriers to participation among some members of the target audience that need to be addressed and overcome by nutrition education. Two of the myths mentioned most frequently were that African-Americans accept being overweight as natural and that they have a fatalistic view of lifestyle-influenced diseases such as diabetes and hypertension.

These experts also suggested innovative approaches for working with the African-American community. They often mentioned that proper nutritional practices are antithetical to the pervasive practice in our culture of eating out. Portions are often too large, there is little control over fat or seasonings, and eating out is relatively expensive. One respondent suggested a format for program sessions that would stress comparisons between "eating out" and "eating in" in the areas of cost, nutritional value, portion size, and perhaps even convenience.

Several of the respondents also stressed the need to keep preparation ideas quick and simple because people don't want to spend a great deal of time cooking. Others said that the program might provide small incentives, such as key chains, videos of recipes and preparation techniques, or perhaps kitchen utensils with our logo. Several respondents also emphasized the importance of taste testing as an incentive to getting participants interested and willing to try new nutritional approaches to better nutrition.

Focus Groups

The focus groups reinforced much of what was suggested in the interviews and provided additional insights on how to encourage more participation by African-Americans. For example, several focus group participants indicated that personal invitations would be more persuasive than impersonal flyers or brochures. One participant said, "Everyone wants to feel important," while another said "The personal touch is best."

The focus group participants expressed concern and some understanding of the relationship of diet and nutrition to many of the diseases that affect African-Americans disproportionately, including diabetes and hypertension. However, many of their responses also included myths and misinformation on nutrition. The prevalence of these myths and incorrect information underscores the needs of this audience for a research-based nutrition education program.

The focus group participants expressed interest in a nutrition program that has a lively pace and opportunities for food demonstrations and "taste-testing." Several of them indicated interest in classes that required "assignments" or out-of-class preparation, so that they would become more engaged with the program. All of the focus groups acknowledged the many demands on their time, but most indicated that they were willing to participate in a program of 1 to 1 1/2 hours in length, and four to six sessions in duration, especially if the classes addressed topics of high interest. Overall, participants emphasized liveliness and pacing, rather than on strict adherence to time.

Focus group participants agreed with the experts interviewed on the need to be more descriptive of the program's content than the currently used "EFNEP" or "FSNEP." Some participants wanted the program to play down the fact that it was directed toward low-income families, asserting that the label "low-income is a turn-off" and that they would be unlikely to participate in "another program for poor people." As one participant indicated, "everybody needs to know how to save money and eat right."

Most participants indicated they would be more likely to attend a program that "spoke" to them with brochures and materials that depicted African-Americans. Their comments indicated that the materials should be colorful and upbeat, with more of an advertising focus than a strictly educational one. All of the focus groups agreed that it would be important to have nutrition educators who understand and are sensitive their cultural practices and would address holiday food preparation.

Focus group participants were not interested in an overtly religious approach, as a few of the interview respondents had suggested. In fact, only a few of them suggested church facilities for holding the programs, which was something of a surprise, given the influence of religious leaders cited by interview respondents. Most felt that religious beliefs (and the dietary practices that relate to some religions) are too diverse for any nutrition program to try to address. Most of their suggestions of potential locations were community-based service agencies or recreation centers, indicating a relatively high comfort level with receiving services within their communities.

Because many of the participants were concerned about the connection between nutrition and health, a number of suggestions were made about inviting their family and friends to attend nutrition classes with them. Some indicated this would give them a "support group" for maintaining healthy dietary practices after the classes were concluded. Some participants also expressed a desire for classes to be held in the evening or on weekends, and for providing childcare or supervision during the classes.

Conclusions

The focus groups and interviews were a good source of information on changes Cooperative Extension should consider if our nutrition education programs are to reach the substantial number of African Americans in Los Angeles County who are in need of them. In reviewing the findings, it appears that many of the suggestions and ideas that can potentially benefit EFNEP and FSNEP in reaching more of its potential African-American audience would be of assistance in reaching any underserved racial or ethnic group. And most of them can be implemented with modest effort and cost. Among the most easily implemented are the following.

1. Develop materials that reflect images of the audience we are attempting to reach, including the dietary concerns of that audience.

2. Make connections between dietary practices and health concerns very concrete, addressing options for reducing sodium and/or moderating sugars in the recipes we provide and demonstrate.

3. Identify the programs by something other than their acronyms, which do not resonate with nutrition education to the intended audience.

4. Select locations for the programs that reflect the fact that the African-American population has dispersed from its traditional base in South Central Los Angeles.

5. De-emphasize the "low-income" designation of the audience for whom the program is intended. We can ensure that we continue to reach a low-income audience by other methods, such as by selecting the location in which we recruit and by doing eligibility screening.

6. Consider revising the attendance guidelines to encourage participants to attend classes in "teams," so that they can support each other in adopting healthier food practices.

7. Emphasize food demonstrations in the nutrition education classes.

8. Add an out-of class component to the classes, which encourages participants to get additional information by visiting a supermarket, reading a nutritional label, or conducting an informal survey of friends and family.

9. Create new methods of publicizing the programs and inviting participation by personalizing the invitation in some way.

Other ideas appear to require administrative changes in the way our nutrition education programs are delivered.

1. Consider holding the classes in the evening or on weekends. Programs are usually held Monday-Friday, but the mobility of our low-income audience, coupled with the fact that many of them are now working or attending school, may require that we shift class schedules to accommodate their needs.

2. Consider having childcare or supervision during the classes. Neither EFNEP nor FSNEP regulations currently allow for utilizing resources to provide childcare. It is possible that an ancillary funding source could be sought to cover these expenses.

3. Consider advertising the program in ethnic media outlets, such as radio stations and newspapers. Costs for such advertising would also need to be underwritten by a new source of funding, unless they are accepted as Public Service Announcements.

Our research on African American participation in the EFNEP and FSNEP programs and our analysis of data from the interviews and focus groups clearly indicate that we must change the programs to reach more low-income African American families in Los Angeles County. We believe that marketing, outreach, and recruitment need a completely new focus and that program delivery, content, and teaching quality also need changes. It is important to note that most of the recommended changes could be implemented within a program's existing resources and within a reasonable time frame of 1 to 3 years.

References

Carter, J. S., Pugh, J. A., & Monterossa, A. (1996). Non insulin-dependent diabetes mellitus in minorities in the United States. Annals of Internal Medicine, 125, 221-232.

CDC Office of Communication (2002). Racial and ethnic disparities in health status. Available at:http://www.cdc.gov/od/oc/media/pressrel/fs020514b.htm/

CDC Office of Communication. (2002). Infant mortality and low birth weight among black and white infants. United States, 1980-2000. Morbidity and Mortality Weekly Report, July 12, 2002. Available at: http://www.cdc.gov/od/oc/media/mmwrnews/no20712.htm/

Del Tredici, A. M., Omelich, C. L., Laughlin, S. G., & Joy, A. B. (!988). Evaluation study of the California Expanded Food and Nutrition Education Program: 24-hour food recall data. Journal of the American Dietetic Association, 88:2, 185-191.

Hedrick, T. E., Bickman, L. & Rog, D. J. (1993). Applied research design: a practical guide. Thousand Oaks, CA: Sage.

Joseph, C. L., Ownby, D. R., Peterson, E. L., & Johnson, C. C. (2000) Racial differences in physiologic parameters related to asthma among middle-class children. Chest 117:5,1336-1341.

Kiberd, B. A., & Clase, C. M. (2002). Cumulative risk for developing end-stage renal disease in the US population. Journals of the American Society of Nephrology, 13, 1635-1640.

Kreuger, R. A., & Casey, M. A. (2000) Focus groups: a practical guide for applied research. (3^rd ed.). Thousand Oaks, CA: Sage.

Mokdad, A. H., Ford, E. S., & Bowman, B. A. (2000). Diabetes trends in the U.S.: 1990-1998. Diabetes Care, 23:9, 1278-1273.

Morgan, D. L. (1998). Planning focus groups. Thousand Oaks, CA: Sage.