The Influence of the Youth Expanded Food and Nutrition Education Program on Nutrition Knowledge and Self-Reported Behaviors of Elementary School Children

Introduction

Statistics concerning the health status of children in the United States are startling. Results from the 1999-2000 National Health and Nutrition Examination Survey (NHANES) indicate that compared to 1980, the proportion of children and adolescents who are overweight has gone up three times to an estimated 15% (National Center for Health Statistics, 2000). Assessment of dietary intake of children indicates that an over-consumption of calories, saturated fats, sugar, and sodium coexists with under-consumption of calcium, iron, fiber, fruits, vegetables, and milk (Nicklas et al., 2004). According to USDA's Healthy Eating Index, 88% of children 7-9 years of age had diets that were poor or needed improvement (Carlson, Lino, Gerrior, & Basiotis, 2003).

Overweight during childhood and adolescence is associated with overweight during adulthood (Guo, Roche, Chumlea, Gardner, & Siervogel, 1994). In addition, Type 2 diabetes, hypertension, and high blood lipids occur more often in overweight youth (Dietz, 1998).

There is evidence that establishing healthy eating habits in childhood is critical as these patterns are carried over to adulthood (Keldar, Perry, Kleppo, & Lytle, 1994). It is easier to establish good habits at an early age than to make changes of poor ones as an adult (Ritchie et al., 2001). While poor nutrition is seen in all segments of the population, there is a link between poverty and poor nutrition (Adams, Grummer-Stran, & Chavez, 2003). Effective nutrition education has been suggested as a means to help children learn the basics of good nutrition to make healthy food choices (Center for Disease Control, 2002).

The federally funded Youth Expanded Food and Nutrition Education Program (EFNEP) is designed to provide nutrition education to disadvantaged urban youth. It is offered through schools as an enrichment of the curriculum, in after-school programs, through 4-H EFNEP clubs, day camps, residential camps, community centers, neighborhood groups, and home gardening workshops (CSREES, 2004). In Cuyahoga County, the program is implemented in four sessions, over a 2- to 4-week period during the school year as enrichment to the class curriculum or in after-school settings. In the summer months, youth-EFNEP is implemented at summer camps. Each year, youth-EFNEP in Cuyahoga County reaches over 3000 children.

Although there have been numerous studies in the recent years on the benefits and effectiveness of nutrition education programs, no thorough evaluations of Youth EFNEP have been conducted since the two studies of Youth EFNEP that were conducted soon after the program was started (Boone & White, 1970; Gross, 1971). Since the 1970's, the nutritional concerns among children have changed, the basic nutrition messages have evolved, and implementation of EFNEP has been changed in response.

Purpose

The purpose of the study described here was to assess the effectiveness of Youth EFNEP on the nutrition knowledge and self-reported behavior of 3rd and 4th grade children as implemented in Cleveland Municipal Schools in Cuyahoga County, Ohio.

Methods

Subjects

The sample for the study comprised of children attending 3rd and 4th grades in the Cleveland Municipal schools. Eighty-five percent of the students attending Cleveland Municipal schools qualify for free and reduced lunches. The sample for the intervention group (n = 438) was students enrolled in the EFNEP program. All students participating in the EFNEP program in the spring of 2000 were eligible for the study. All third and fourth grade students (n = 299) from two Cleveland Municipal schools with similar demographic characteristics to the experimental schools, but who were not participating in the EFNEP program, were used as the control group.

Curriculum

Nutrition Educators from Ohio State University Extension presented the four-session Youth EFNEP curriculum to children in classroom settings over a 2- to 4-week period. Lessons included the Food Guide Pyramid, Food Groups and Nutrients, Planning and Choosing Nutritious Meals and Snacks, Nutrition Labels, and Food Safety. The lessons were based on Purdue University Extension's curriculum Professor Popcorn, with some local modification.

Evaluation Method

A 15-question self-administered survey was developed based on a survey used by Michigan State University (Michigan State University Extension, 1998). The instrument was field tested with children for content, readability, understandability, clarity, and attractiveness of presentation. Based on the results of the field testing, the survey instrument was modified. Third and fourth grade teachers and nutrition experts reviewed the survey to ensure content validity of the instrument. Instrument reliability was tested by administering the survey twice to the same group of children. The test retest match was 70 - 74%. Cronbach's alpha for the instrument was .63.

The survey contained 10 multiple-choice, knowledge-based questions related to the food guide pyramid, food groups, food safety, making healthy choices, and five self-reported behavior questions for snack and breakfast consumption and food safety. The survey was administered to the experimental group before and after the intervention, while the control group was surveyed without the intervention. The control group teachers were asked not to discuss nutrition between the pre and post surveys.

Statistical Analysis

In order to ensure confidentiality of program participants, each child was assigned an identification number. All the selected children were asked to fill out pre- and post-test surveys. Only children who filled out both pre- and post-test surveys were included in the analysis. The data were analyzed using the SPSS software. Descriptive statistics were used to analyze the demographic characteristics of the control and experimental groups. Mean test scores were computed for knowledge and behavior related variables.

In order to compare the change in scores from pre to post, difference in scores (post - pre) were computed for control and experimental groups. Differences were then compared using t-test between experimental and control groups. The data were analyzed for the entire group and then for sub-groups by grade level and gender.

Results

Surveys from 438 matched pairs from the experimental group and 299 matched pairs from the control group were used in the analysis. The demographic characteristics of the participants in the control and experimental groups were similar (Table 1). Blacks were the largest racial group represented in the experimental and control groups. Males and females were equally split in both the groups.

The changes from pre- to post-test in knowledge and behavioral scores for the experimental and control group were compared for the entire sample and separately for 3rd and 4th graders and for boys and girls. The mean knowledge scores and the significance levels for comparison of differences (post-pre) in scores for control and experimental groups are presented in Table 2. The experimental group had a mean knowledge score of 5.8 at pre-test and a mean score of 7.3 at post-test. For the control group, the mean knowledge scores changed from 6.0 to 6.2. The difference between post-pre for the experimental and control groups was 1.5 and 0.2, respectively.

A t-test comparison of these differences was statistically significant. The change in scores was similar when the analysis was done separately for gender and grade levels. The knowledge scores were also analyzed for three specific areas, namely, Food Guide Pyramid (FGP) knowledge (five questions), Healthy Choices knowledge (three questions), and Food Safety knowledge (two questions), with significant changes consistently in favor of the experimental group. The largest differences were observed in the FGP knowledge category.

Table 3 shows the mean behavior scores and the significance levels for comparison of differences (post-pre) in scores between control and experimental groups. As can be seen from the table, the scores for most self-reported behaviors, both overall and specific, remained unchanged from pre- to post- intervention in both the experimental and control groups. The overall behavior score for the control group remained unchanged at 7.0 and for the experimental group changed marginally from 6.9 to 7.0. There was no statistically significant difference in mean changes between experimental and control groups. Similar results were obtained when the analysis were done at the sub-group level for boys and girls and for 3rd and 4th graders.

Discussion

The study described here assessed the impact of Youth EFNEP on the nutrition knowledge and self reported behavior of children in grades three and four, as implemented in Cleveland Municipal schools in Ohio. The study was unique because it used control and experimental groups for data analysis. In addition, because there have been few comprehensive evaluations of the Youth EFNEP program, the findings are a significant contribution to research literature.

The majority of the experimental and control participants were 4th graders, because that was the grade level at which most of the programming was focused. Both the control and experimental groups had an equal representation of the three primary ethnic groups--Black, White, and Hispanics. The demographic mix of the sample was similar to the demographics of the school district, with Black children being represented in largest numbers.

The intervention made a significant impact on the nutrition knowledge of program participants compared to the control group. The students improved their overall score after participating in EFNEP classes. The largest increase was seen in knowledge related to the Food Guide Pyramid. Students' knowledge increased significantly in the other two areas, healthy choices and food safety, but the change was smaller in magnitude. These results may be reflective of the amount of time devoted to teaching the Food Guide Pyramid compared to other concepts (healthy choices and food safety) and lower initial scores.

The results were positive in favor of the experimental group for gender and grade level and also for specific nutrition knowledge categories studied, suggesting that the intervention made a positive impact on all children irrespective of age and gender, and that all areas of nutrition knowledge evaluated were positively affected. The results of the study were consistent with other investigations that have found a positive impact of nutrition education on knowledge of program participants (Murphy, Youatt, Hoerer, Sawyer, & Andrews, 1994).

While Youth EFNEP had a strong impact on the nutrition knowledge of the program participants, no significant impact was made on their scores for overall change in nutrition behaviors. In a few instances where significant results were obtained, the change in behavior scores was too small to be of empirical value. The results of sub-group analysis by gender and grade level also showed no impact of the intervention. Research in school-based nutrition education has found that change in nutrition-related behaviors requires more intense, long-term interventions (Norton, Falciglia, & Wagner, 1997).

The students in Cuyahoga County participated in four sessions of nutrition education. Given the pressures of meeting other curricular requirements and statewide testing, as well as absence of minimal standards for nutrition education, the schools were unable to provide more than four class periods of contact time with the children in a given year. This amount of exposure to nutrition education, while adequate to bring about changes in knowledge, may not be adequate to influence children's behavior.

Measuring self-reported behavior change in children is a challenge, given the lack of validated instruments. It is possible that the instrument used in this study was not sensitive enough to capture small behavior changes.

Another possible reason for lack of change in nutrition-related behaviors could be that children have little control over their nutritional environments. In recent years, the role of home and school environments in influencing children's dietary behavior has been extensively studied (Cullen et al., 2004; French, Story, Fulkerson, & Gerlach, 2003). The lack of behavioral change with classroom-based nutrition education emphasizes the need to address the issues of school and home food environment so children can put learned knowledge into practice and improve their dietary behaviors.

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