The Effectiveness of a Public Nutrition Education and Wellness System Program

Introduction: Need for Program Evaluation

Public nutrition education programs, designed to improve public health and well being, began about 100 years ago. Through this process, we assist people in making decisions regarding their eating practices by applying knowledge from nutrition science about the relationship between diet and health. Increasing interest in rigorous evaluation of public programs has resulted in widely believable evaluations indicating that a number of targeted programs have been effective in meeting their goals. Evidence supports the theory that nutrition education programs that provide culturally sensitive educational activities and opportunities have proven to result in positive behavior change in the targeted audience (Blank, 1997).

But how can one be sure if educational programs are effective and worth the investment of money, energy, and time? Existing studies indicated that food programs should include a nutrition education component, and the effectiveness of nutrition education when coordinated with a food assistance program should be researched further (Sexauer, 1978). Multiple factors affecting eating practices must be assessed if effective educational approaches and nutrition messages are to be developed for all segments of the population (Anderson, 1994). Formal evaluation is a vital element in determining program success and preventing unwarranted expenditure of resources without adequate results.

Evaluating the United States Department of Agriculture's nutrition education effort remains difficult. A combination of factors--paucity of data, inadequate funding, and change in expected evaluation outcomes--has created a challenging environment for USDA to assess the overall effectiveness of its nutrition education activities. Activities that do have an evaluation component indicate varying degrees of effectiveness (The State of Nutrition Education in USDA, 1997).

Measuring performance of individuals who complete an educational program is a recognized method for evaluating the effectiveness of training programs (Wehrenberg, 1983). Government accountability rules and public scrutiny are leading to a closer evaluation of the effectiveness of educational programs. Regulatory agencies and educational entities must continue efforts to keep decision-makers and other stakeholders informed about how the educational needs of clientele are being met in order to merit support (Carpenter, 1997).

Purpose

The study described here evaluated the effectiveness of the Families First: Nutrition Education and Wellness System (FF NEWS) Program in Texas, a culturally sensitive nutrition education program organized by four 1890 institutions of the Southwest Region of the United States Department of Agriculture: Food and Nutrition Services (FNS). The study examined differences that existed between pre-and post-test as it related to participants' food preparation, food purchase, and health status.

To accomplish the purpose of this study, the following research questions were addressed.

• What changes in food-preparation practices occurred among program participants as related to (a) age, (b) ethnicity, (c) education, and (d) gender?

• What changes in the adoption of food-purchase practices occurred among program participants as related to (a) age, (b) ethnicity, (c) education, and (d) gender?

• What statistically significant differences existed in the health status of program participants as related to (a) age, (b) ethnicity, (c) education, and (d) gender?

The study sought to identify the following:

• The impact of nutrition education to limited resource clientele;

• If changes were warranted to improve the program outreach, content, and methodology; and

• If improved strategies, approaches, and technologies deemed crucial for ongoing program effectiveness were warranted.

Methods and Procedures

Population and Instrumentation

The study's population were participants in the Families First: Nutrition Education and Wellness System (FF NEWS) Program in Texas, which is a nutrition education intervention program designed to help families select and prepare meals consistent with their cultural traditions while improving their overall health. Useable surveys (n=62) were derived from the 66 Food Stamp recipients or low income African Americans, European Americans, and Hispanics from four of the nine counties enrolled in the FF NEWS Program between October 1998 and May 2000. Survey forms that were incomplete were not included in the study.

The four counties in this study were selected because of their density and proximity to urban areas. Additionally, these counties had large numbers of food stamp recipients and diverse populations when compared to other counties served. Pre- and post-test surveys were used with program participants to measure knowledge, skills and behavior changes as a result of program delivery.

The FF NEWS program consisted of 55 lessons organized into four instructional modules: (1) Balancing Food Preferences with Knowledge of Nutrition, (2) Health Status and Age-Related Nutritional Needs, (3) Enhancing Management Skills, and (4) Ensuring Food Quality and Safety. Each module ranged from six to 19 class sessions, which lasted 1 1/2 hours each. The program included a curriculum developed to integrate themes on basic nutrition, physical activity, resilience, self-reliance, self-esteem, and personal responsibility. The curriculum also featured specific goals and objectives that recognize and appreciate the role of family and culture in fostering lifestyle changes in nutritional practices. Participants volunteered to enroll in the classes.

Data were collected from program participants using a two-part written survey designed by an 1890 five-state consortium:

• Part I (a Family Profile) sought the following information:
  • Participants' personal characteristics (mainly demographics);
  • Persons living in the household;
  • Head of the household;
  • Health conditions of household members;
  • Services received from the Department of Human Services;
  • How participants were informed of the FF NEWS Program.
• Part II (a 33-item, three-point Likert scale survey) collected pre- and post-test data regarding nutrition practices such as meal planning and preparation, food consumption, recipe modification, sanitation practices, and food safety.

Likert scale values and levels of practices were (1) rarely, (2) sometimes, and (3) most of the time. Results of the survey identified changes in food-preparation practices, food-purchase practices, and health status of the targeted population.

Procedure and Data Analysis

The survey data generated were both descriptive and comparative. Descriptive statistics were used for reporting personal characteristics of the participants, knowledge gained, and effectiveness of the FF NEWS Program. The SAS 6.12 procedure (SAS Institute, 1999) was employed to calculate frequencies, percentages, central tendencies, and variability for all of the variables.

Results were reported using numerical and graphic techniques. Analysis of interpretation of the data followed principles prescribed in Educational Research: An Introduction by Borg and Gall (1989). An alpha level of P≤0.05 was used to determine statistical significance.

Results and Discussion

Demographics

The following describes the survey respondents' predominant demographic characteristics:

• Gender: 90% female
• Age Range: 15 years old to 94 years old (45% between 31 years old and 46 years old)
• Ethnicity:
  • African Americans--55%
  • European Americans--21%
  • *Hispanics--20%
• Educational Attainment Level:
  • GED--27%
  • High school diploma--27%
  • Less than GED or diploma--32%

* Statistical analysis of information on those designated as Hispanic showed that no matching tasks existed or they did not complete all items needed to analyze across demographics; thus, information was not reported on this group because reliability was not considered sufficient.

Differences in Food-Preparation Practices

Table 1 summarizes the cumulative pre-test and post-test mean scores regarding food-preparation practices. The mean difference score of 5.4 yielded a t value of 2.59, P≤0.05, indicating that participants had increased their knowledge of food-preparation practices.

Regarding participants' food-preparation practices, statistically significant differences existed between pre- and post-test mean scores as related to participants' age, ethnicity, and education attained. Compared to younger individuals, older individuals were more apt to adopt food-preparation changes. Findings suggested that mean scores of participants with vocational certification revealed a statistically significant difference from participants who completed a bachelor's degree. However, no statistically significant difference was found regarding participants' food-preparation practices in terms of their gender.

Differences in Food-Purchase Practices

In analyzing changes in food-purchase practices that occurred as a result of participation in the program, researchers observed the following:

• Participants adopted enhanced food-purchase-practice skills following training;

• Age and gender did not affect adoption of food-purchase practices;

• Participants who had a vocational certificate adopted food-purchase practices most of the time.

Table 2 shows differences in scores related to food-purchase practices.

Differences in Health Status

The following was noted regarding differences in participants' health status as measured by level of physical involvement and status of chronic illness:

• The mean score rating of participants' health status improved from pre-test to post-test, but the difference was not statistically significant (P=0.19);

• Level of education played a critical role in knowledge gain and health status in that participants with higher levels of education revealed evidence of receiving a greater impact from the program;

• Analysis indicated some degree of success in improving participants' health status as measured by level of physical involvement and status of chronic illness.

Most Effective Program Recruitment Strategies

• Word of mouth was the most prevalent method in recruiting individuals to participate in the program (22 participants learned about the program through a friend);

• As suggested by Blank (1997), the culturally sensitive curriculum was considered a positive factor in participant recruitment.

Conclusions and Implications

Positive Effects on Dietary Habits

• The culturally sensitive curriculum allowed program staff to be effective in program delivery, thus achieving a primary goal of improved dietary habits (Blank, 1997);

• The hands-on, practical approach allowed the program participants to gain the practical skills necessary to make positive behavior changes in dietary habits (CSREES, 2000);

• The program's effectiveness can be determined best by the participants' retention of knowledge and adopted practices (Extension Review, 1987);

• The program is an effective nutrition education program enhancing participants' knowledge gain in food-preparation and food-purchase practices.

Recommendations

• Evidence showed that the program's impact on participants was affected by their level of education. Knowing the types of courses that the participants had taken would be useful to offer a more meaningful explanation to the observed trends. If the courses taken related to food handling/processing or closely allied medical fields (e.g., vocational nursing), that would easily have explained why those participants with a vocational/technical background had much higher adoption ratings than the rest of the respondents.

• Regulatory agencies and educational entities must continue efforts to keep decision-makers and other stakeholders informed about how the educational needs of clientele are being met in order to merit support (Carpenter, 1997). Nutrition education programs that provide culturally sensitive educational activities and opportunities, like the FF NEWS Program, have proven to result in positive behavior change in the targeted audience (Blank, 1997). Because the FF NEWS Program proved to be valuable and had a positive impact on participants, the United States Department of Agriculture and the Texas Department of Human Services should continue to fund and expand these types of nutrition education programs.

• This program should be used as a mechanism for enhancing food-preparation and food-purchase practices for selected audiences. As suggested by Willis (1998), improved nutrition and health have been proven to reduce absenteeism, health care costs, and infant mortality and increase longevity, employability, worker production, and quality of life.

References

Anderson, J.E. (1994, September). What should be next for nutrition education? American Institute of Nutrition. 124 (9s), 1828s-1832s.

Blank, R.M. (1997). It takes a nation. Princeton, NJ: Princeton University Press.

Borg, W.R., & Gall, M.D. (1989). Educational research: An introduction. (5th ed.). New York, NY: Longman Publisher USA.

Carpenter, Zerle L. (1997, September). FY 98 brings challenges, opportunities. Inside Extension, 7 (1), pg. 1.

Cooperative State Research, Education, and Extension Service. (2000). Expanded food and nutrition education program. Washington, DC.

EFNEP-Nutrition education in action. (1987, November). Extension Review, 10, 4-6. Washington, DC: United States Department of Agriculture.

SAS Institute, Inc. (1999). Statistical Analysis System Program 6.12. Cary, NC.

Sexauer, B. (1978, September). Food programs and nutritional intake: What evidence. Agriculture Food Policy--United States Department of Agriculture. 13 (2), 39-43.

The State of Nutrition Education in USDA. (1997) Family Economics and Nutrition Review. 10 (2), 38-41.

Wehrenberg, S.B. (1983). Training: Evaluation of training. Personnel Journal. 62, 698-702.

Willis, L.W. (1998). Annual report: Making an impact in Texas. Prairie View, TX: Prairie View A&M University, Cooperative Extension Program.