Expanded Food And Nutrition Education Program Participants Research Articles

Expanded Food and Nutrition Education Program Generates Economic Value Through Body Mass Index Improvement: A Cost-Benefit Analysis

Prior economic evaluations of the Expanded Food and Nutrition Education Program (EFNEP) perform cost-benefit analyses (CBA) reliant on self-reported behavioral data and unvalidated criteria for disease prevention. This study aims to conduct a CBA of Colorado and Washington EFNEP using an objective biomarker, Body Mass Index, to monetize program benefits. A longitudinal study of a convenience sample of EFNEP participants was conducted utilizing a single-group pretest-posttest design. Results indicate Colorado and Washington EFNEP generates $9.23 of benefits per $1.00 of costs and demonstrate the feasibility and value of using biomarkers in economic evaluations of nutrition education interventions delivered through Extension.

Association Between Educational Attainment and EFNEP Participants’ Food Practice Outcomes

ObjectiveExamine the association between educational attainment and improvement in food practice outcomes of the California Expanded Food and Nutrition Education Program (EFNEP) participants. DesignSecondary data analysis. ParticipantsA total of 19,089 participants, 92.3% female, 77.2% Hispanic, 19.7% with ≤ sixth-grade education, and 68.9% with incomes ≤ 100% of the federal poverty level. Main Outcome MeasuresImprovement in food resource management practices (FRMP), nutrition practices, and food safety practices (FSP). AnalysisWilcoxon signed rank tests examined pre-post outcomes. Mann-Whitney U tests compared whether participants in the lowest and highest educational attainment quartiles had similar levels of improvement. ResultsCalifornia EFNEP is associated with improved FRMP (z = −95.33), nutrition practices (z = −94.91), and FSP (z = −92.37); (P < 0.001). Lowest educational quartile was associated with more improvement in FRMP and FSP (P < 0.001). Conclusions and ImplicationsCalifornia EFNEP contributed to improved food practice outcomes for low and high educational attainment participants. Program content and instruction are effective across the education continuum.

P099 Collaboration Yields Evidence-Based and Stakeholder-Reviewed Online Nutrition Content for Patient Activated Learning System

<h3>Background</h3> The Patient Activated Learning System (PALS) is a free web-based patient application platform designed for low literacy audiences. Evidence-based information is presented in single-objective webpages, with content ranging from pharmacological treatment to behavioral approaches to disease prevention and management. Multidisciplinary collaboration that includes nutrition education program stakeholders may benefit PALS nutrition content development. <h3>Objective</h3> Pilot methods to develop and evaluate acceptability of PALS nutrition pages with a team of physicians, nutrition researchers, and Expanded Food and Nutrition Education Program (EFNEP) educators and participants. <h3>Study Design, Setting, Participants</h3> We conducted a feasibility and acceptability study with convenience samples of geographically dispersed EFNEP educators and participants in New York. We identified commonly asked cardiovascular disease (CVD) related nutrition questions using two online surveys of educators (n = 12, n = 45), then used a rapid systematic review of relevant scientific evidence and practice guidelines to generate PALS pages. We assessed page acceptability in focus groups with educators (n = 10) and interviews with participants (n = 12). <h3>Measurable Outcome/Analysis</h3> Educator-generated questions were grouped thematically, condensed, and rated based on perceived relevance. Researchers iteratively coded focus group and interview transcripts, independently summarized feedback, and met to discuss acceptability-related findings. <h3>Results</h3> Educators identified 33 common CVD-related nutrition questions; highest rated questions informed development of 4 PALS pages about coconut oil, saturated and unsaturated fat, and fiber. Educators reported the pages were clear, concise, and acceptable for educators and participants. The combination of text and figures addressed a range of learning needs, and educators appreciated the behaviorally focused content. Most EFNEP participants found the content relevant, easily digestible, and helpful. Incorporating practical information in colorful figures was particularly appealing. Participants demonstrated an understanding of the content. Most would return to PALS, citing clarity and trustworthiness of information provided. <h3>Conclusions</h3> The multidisciplinary team successfully engaged EFNEP stakeholders in the development and review of evidence-based nutrition online information, which helped generate relevant, clear, appealing, and trustworthy content. Lessons learned can inform development of PALS content and may apply to other eHealth platforms. <h3>Funding</h3> Cornell Center for Health Equity

P011 Exploring How Community Research Partnerships May Affect Enrollment and Graduation Rates for the University of Georgia EFNEP

<h3>Background</h3> Federal nutrition education programs like EFNEP (the Expanded Food and Nutrition Education Program) use a peer educator model to teach low-income Americans about healthy eating behaviors. Collaborative partnerships are an essential means to the sustainability and reach of the EFNEP program. The University of Georgia (UGA) EFNEP has not previously measured the impact community research partnerships may have on enrollment and graduation rates for EFNEP programming. <h3>Objective</h3> To examine how the research process for recruiting, incentives offered, and continued contact with a community research partner affect UGA EFNEP enrollment and graduation rates. <h3>Study Design, Setting, Participants</h3> Morehouse School of Medicine (MSM) partnered with UGA Extension/EFNEP to examine how a community nutrition intervention may affect nutrition outcomes of expecting mothers and fathers (Project DINE). UGA EFNEP provided an eight-week virtual nutrition education to three counties (rural and metro-areas). Participants were African American, expecting a baby, and enrolled in Healthy Start. Participants who completed the program received up to $200 per person ($400 per couple) in financial incentives. <h3>Measurable Outcome/Analysis</h3> Enrollment, participation and graduation rates data were analyzed using the USDA NIFA Web-based Nutrition Education, Evaluation and Reporting System (WebNEERS). Study participants' data were analyzed and compared to data for EFNEP participants in similar communities who were not enrolled in any research project <h3>Results</h3> For FY21, preliminary data indicate that UGA EFNEP Project DINE participants (n = 64) had a graduation rate of 51.6%, whereas, UGA EFNEP participants from these communities (and who were not participating in Project DINE) (n = 159) had a graduation rate of 33.3% <h3>Conclusions</h3> Community research partnerships may positively affect UGA EFNEP graduation rates. More research is needed to explore specific relationships between graduation rates and factors such as research recruitment methods, financial incentives, and target populations. <h3>Funding</h3> EFNEP

P089 A Retrospective Pretest-Posttest Design as an Alternative Evaluation Method for EFNEP

<h3>Background</h3> The Expanded Food and Nutrition Education Program (EFNEP) evaluates its behavioral outcomes using prospective pretest-posttests, which can be prone to response shift bias. A retrospective survey design can be a potential solution. <h3>Objective</h3> To examine program participants' understanding and preferences regarding retrospective versions of the EFNEP Adult Questionnaire (AQ). <h3>Study Design, Setting, Participants</h3> One-on-one, semi-structured interviews were conducted with 23 EFNEP adult participants/graduates in four US states/territories in 2020-2021. Participants were shown retrospective pretests and posttests in the "side-by-side" and "separate page" formats, which included one question from each of the AQ domains of diet quality, physical activity, food resource management, food safety and food security. AQ questions were modified by adding "Before EFNEP" for the pretest and "Now" for the posttest timeframes. <h3>Measurable Outcome/Analysis</h3> Demographic characteristics (e.g., age, gender, education), and AQ format preferences were collected. Audio transcripts were analyzed using template analysis and NVivo 1.5. <h3>Results</h3> Most of the participants were female (87%) and high school graduates (70%); their mean age was 35 years. For the "Before EFNEP" questions, participants mentioned "any time before the past two months" or provided the particular month before EFNEP lessons took place. Regarding the "Now" questions, emerging themes were relevant to the past weeks or past month. Some participants indicated that additional descriptions such as "in the week before EFNEP" were helpful in pinpointing the intended timeframe. Most (18/23) of the participants could correctly differentiate the time periods between the "Before" and "Now" questions. Most participants preferred the "side-by-side" (vs "separate page") format. <h3>Conclusions</h3> A retrospective AQ, especially in a side-by-side format, may be an appropriate alternative to the prospective surveys to evaluate behavioral outcomes of adult EFNEP participants. Next steps include piloting the retrospective survey to examine its criterion validity and feasibility with a larger sample. <h3>Funding</h3> Agricultural Experiment Station, NC3169 Multistate Project

Development of a National Dietary Behaviors Questionnaire for EFNEP Adult Participants

ObjectiveDevelop and establish the reliability and validity of dietary behavior evaluation questions for the Expanded Food and Nutrition Education Program (EFNEP). DesignA mixed-methods study using cognitive interviews, expert panels, test/retest reliability, and pretests/posttests. Setting14 states across the US. ParticipantsA convenience sample of low-income EFNEP or EFNEP-eligible participants for cognitive interviews (n = 111), reliability testing (n = 181), and sensitivity to change testing (n = 382). Main Outcomes MeasuresIndicators of face and content validity, temporal reliability, and sensitivity to change. AnalysisQuestions interpreted as intended in cognitive interviews, intraclass correlation coefficient and Spearman rank-order correlation for reliability testing; paired t tests or Wilcoxon signed-rank tests for sensitivity to change; and exploratory factor analyses to identify possible scales. ResultsCognitive interviews resulted in 3 rounds of question revisions; reliability value ranges were 0.48–0.77 for intraclass correlation coefficient and 0.43–0.77 for Spearman rank-order correlation. For sensitivity to change, 9 items had evidence of change (P < 0.05) between pretests and posttests, whereas 5 items had evidence for change after removing those with little room to change. Two scales were identified: diet quality and non-cheese dairy. Conclusions and ImplicationsThe EFNEP's new dietary behavior evaluation questions demonstrated face and content validity, moderate to strong reliability, and sensitivity to detect self-reported behavior changes among low-income, diverse populations (culturally, racially/ethnically, and level of education) across 14 states. Nutrition education programs targeting similar behaviors with English speaking clients could consider this dietary behavior questionnaire.

Perceived neighbourhood food environment and overweight and obesity among Supplemental Nutrition Assistance Program-Education (SNAP-Ed) participants in the Midwest US.

To evaluate the relationship between neighbourhood food environment perceptions and obesity among Supplemental Nutrition Assistance Program-Education (SNAP-Ed) or Expanded Food and Nutrition Education Program (EFNEP) participants. A cross-sectional study conducted during SNAP-Ed or EFNEP programme participation in six states in the Midwest US between May 2016 and November 2017. Community centres, food pantries and other SNAP-Ed or EFNEP recruitment locations. Convenience sample of 1743 low-income, adult nutrition education programme participants. Controlling for participant location and other demographic variables, those who perceived that a large selection of fruits and vegetables were available to them were 22 % less likely to be obese (adjusted odds ratio 0·78, 95 % CI 0·63, 0·97). In addition, participants who perceived the distance to the grocery store where they purchased most of their groceries to be greater than 5 miles were 1·36 times more likely to be overweight or obese than those who travelled shorter distances for their groceries. SNAP-Ed or EFNEP participants' weight status may be associated with their perceptions of their neighbourhood food environments. Programmes incorporating nutrition education and food access initiatives should attempt to better understand participant perceptions in order to address barriers in their efforts and to ensure that healthy food is accessible to low-income residents.

P166 Exploratory Test of ASA24 to Collect 24-Hour Recalls in the Expanded Food and Nutrition Education Program

Background Interest exists to standardize and improve data collection and coding in Expanded Food and Nutrition Education Program (EFNEP) classes by switching from a paper-and-pencil 24-hour recall to the Automated Self-Administered 24-hour Recall (ASA24); however, it is important to address the feasibility of putting this into practice. Objective To do an initial pilot test to compare the use of ASA24 with paper-and-pencil recalls with EFNEP participants. Study Design, Settings, Participants Ten EFNEP paraprofessional educators were recruited from three states and trained to use ASA24. Participants were randomized at the class level to complete either ASA24 or a paper-and-pencil recall at program entry and the alternate method at exit. Participants (n = 37 entry, n = 30 exit) and paraprofessionals completed questionnaires about usability, confidence, preference, and perceived accuracy at entry and exit. Seven paraprofessionals participated in online focus groups or qualitative interviews. Measurable Outcome/Analysis Questions about usability, confidence, and perceived accuracy were scored on a Likert scale from strongly disagree (1) to strongly agree (5); scores were analyzed using descriptive statistics. Qualitative interviews and focus groups were transcribed, and two researchers coded and developed themes using inductive content analysis. Results Average scores for usability, confidence, and perceived accuracy were very similar for ASA24 and the paper-and-pencil recall. When asked which method they preferred, both the participants and paraprofessionals were evenly split. In the qualitative interviews, almost all of the paraprofessionals felt that ASA24 would result in more accurate recalls. The major barriers mentioned were lack of computer literacy of some participants and problems with internet connectivity. Conclusion ASA24 may be comparable to the paper-and-pencil recall in usability, confidence, perceived accuracy, and preference for both EFNEP participants and paraprofessionals. Qualitative analysis indicates that ASA24 may work better with participants who are computer literate, and may yield more accurate results. Funding USDA.

P183 Predictors of Diet Quality in the Adult Expanded Food and Nutrition Education Program in Nevada

Background Healthy dietary patterns are associated with decreased risk of chronic disease. Dietary patterns are best captured in the form of diet quality scores incorporating positive and negative aspects of the diet. The Healthy Eating Index-2015 (HEI-2015) is a diet quality measure based on the Dietary Guidelines for Americans 2015. The Expanded Food and Nutrition Education Program (EFNEP) is a federal program that reaches limited resource audiences in the U.S. EFNEP evaluation includes a 24-hour diet recall before and after a nutrition education program, which is converted into a HEI-2015 diet quality score. Objective To determine changes in HEI-2015 score before and after a nine-week nutrition education program, Eating Smart and Being Active, and to determine predictors of improvement. Study Design, Settings, Participants This was a one group pre-test post-test study and included EFNEP participants in Nevada in FY18. Measurable Outcome/Analysis The 24-hour recall data was used to create a HEI-2105 diet quality score. Other data included sex, ethnicity, education, age, household income, and number of sessions attended. Results The sample (n = 212) was 98% female, 86% Hispanic, with an average age of 36.5 years. A paired t-test found that HEI-2015 scores improved from pre to post-test from 58.0 to 64.7 (P = .001). Multiple regression analysis indicated three predictors explained 36% of the variance (R2 = 0.36, F(3,208) = 38.68, P Conclusion The nine-week intervention produced improvement in diet quality in Nevada EFNEP participants. Those with the greatest improvement had the lowest diet quality at pre-test, were female, and attended the greatest number of sessions. Reaching those with the poorest diet quality and implementing effective retention strategies are key to the maximum utilization of limited nutrition education resources. Funding None.

Positive Change in HEI-2005 Dietary Scores of Low-Income Adults After Participation in the Expanded Food and Nutrition Education Program (EFNEP) (P16-049-19)

ObjectivesEFNEP helps low-income audiences acquire the knowledge and skills necessary to plan, procure, and prepare nutritionally sound diets. The study objective was to determine EFNEP participants’ change in HEI-2005 scores in 2013–2014. MethodsThis study was a secondary analysis of the 24 hour recall (24HR) data collected from EFNEP participants from October 2012 - September 2014. EFNEP staff entered entry/exit 24HR data into a web-based data evaluation program using the Food and Nutrient Database for Dietary Studies (version 3.0). Initial data set (n = 135,021) was cleaned (n = 122,961) and categorical variables established for demographic predictor variables of interest (n = 97,522). Statistical analysis was performed using the car and lsmeans packages. In addition, linear models including age group, education, gender, race/ethnicity and entry HEI-2005 score were used. To account for testing multiple components, a Bonferonni adjusted ANOVA F-test was calculated. ResultsThe mean (sd) HEI scores were 51.1 (13.7) at entry and 56.5 (13.7) at exit, with a change of 5.4 (16.7) after completion of the program (P < 0.05); nine of 12 component scores increased. The change in HEI-2005 scores was significantly greater as age increased, with increasing education, and in women. Thirty-two % of the HEI score increase was due to increased fruit intake, 17% from increased vegetable intake, 17% from increased intake of “milk” and 20% due to decreased intakes of solid fats, alcohol and added sugar (increase in this component score reflects a decreased intake). Three component scores slightly decreased over the program - total grains, oils, and sodium (decrease in sodium score reflects an increased sodium intake). ConclusionsThe results reported here are the first known national documentation of change in HEI dietary quality due to EFNEP participation. Results indicate that EFNEP participation improves diet quality based on change in HEI-2005. This improvement was evident in nine of 12 HEI-2005 components and across all demographic characteristics. Results suggest EFNEP improves diets of this vulnerable population, potentially reducing chronic disease risk. Funding SourcesAgriculture Experiment Station NC2169: EFNEP Related Research, Program Evaluation and Outreach. Supporting Tables, Images and/or Graphs▪▪▪▪

Taste Is Everything: The Role of Sensory Evaluation in Nutrition Education for Low-Income Populations (OR13-04-19)

ObjectivesTo measure acceptance of recipes taught and demonstrated through the University of Georgia Supplemental Nutrition Assistance Program Education (SNAP-Ed) and Expanded Food and Nutrition Education Program (EFNEP) nutrition education curricula through sensory evaluation. MethodsSensory evaluation was conducted on seven newly developed recipes through the SNAP-Ed Food Talk: Farmer’s Market curriculum and sixteen existing recipes through the EFNEP Food Talk curriculum. To evaluate acceptance of the recipes, SNAP-Ed and EFNEP program participants were provided with a nine-point hedonic scale with 1 being ‘dislike extremely’ and 9 being ‘like extremely.’ Program participants were asked to rate for overall liking (OL) of the recipe and liking of additional sensory attributes, including appearance, flavor, texture, saltiness, and sweetness. Recipes were prepared following standardized instructions for consistency of preparation and portion size. ResultsA total of 1438 SNAP-Ed and EFNEP participants (78% female, 66% African American) evaluated 7 newly developed recipes (n = 563) and 16 existing recipes (n = 872). The Curly Noodle Supreme (OL = 6.11, flavor = 5.58, texture = 6.56) and Cheesy Broccoli Soup (OL = 6.63, flavor = 6.51, texture – 6.64) had the lowest ratings from the 16 existing recipes. The Chicken Chili with White Beans (OL = 7.34, flavor = 7.11, texture = 7.31) and Vegetarian Tacos (OL = 7.28, flavor = 7.04, texture = 7.15) had the highest ratings from the 7 newly developed recipes. With standard range of acceptability for a recipe being 7.0 and higher in sensory evaluation, these ratings provide justification for the addition of newly developed recipes and modification or replacement of existing recipes into the SNAP-Ed and EFNEP nutrition education curricula. ConclusionsThe study findings suggest that sensory evaluation has the potential to contribute to the development, testing, and modification of recipes that are more responsive to the unique sensory preferences of low-income populations for nutrition education programs. Funding SourcesUSDA SNAP-Ed, USDA EFNEP.

Self-regulation Capacity Of Low-income Mothers In Community-based Nutrition Program

Diet is strongly associated with many risk factors for chronic disease. Educational programs such as the Expanded Food and Nutrition Education Program (EFNEP) are designed to improve dietary behaviors among low-income populations. Although EFNEP has seen improvements, they do not yet meet recommendations. Self-regulation is the process of guiding thoughts, feelings, and behaviors to stay in line with perceived goals. Previous studies have been successful in eliciting behavior change when improving self-regulation in conjunction with dietary education. PURPOSE: The purpose of this study was to examine self-regulation in EFNEP participants and its relationship to participants change in dietary behavior. METHODS: All participants were currently enrolled in EFNEP and were asked to complete an additional self-regulation survey. This survey included five questions on a Likert scale from 1-5, with 5 indicating high self-regulation. These were averaged to assess overall self-regulation capacity pre- and post-program. Fruit and vegetable intake were measured using EFNEPs current diet-recall survey. RESULTS: On average, the participants had low levels of self-regulation both pre- and post-intervention (2.74 ± 0.71 and 2.59 ± 0.78, respectively). Regarding vegetable intake, there was no statistically significant change from pre- to post-program (1.51 ± 1.36 and 1.42 ± 1.32 cups, respectively). However, there was a statistically significant different regarding fruit intake, increasing from 0.86 ± 0.94 to 1.39 ± 1.39 cups per day. Neither fruit nor vegetables increased to MyPlate recommendations. CONCLUSIONS: Participants self-regulation capacity was on average low, and did not increased from pre- to post-program. Results also indicate that fruit and vegetable intake did not reach MyPlate recommendations. From these results, we can conclude that self-regulation training may be a necessary supplement to the program to see improvements in the participants dietary behavior.

Communicating and Assessing Physical Activity: Outcomes From Cognitive Interviews With Low-Income Adults

ObjectiveThis investigation sought to identify the physical activity (PA) terms and concepts that are best understood by low-income adults. DesignThis was a cross-sectional study using semistructured cognitive interviews that employed retrospective verbal probing techniques. SettingInterviews were conducted in Expanded Food and Nutrition Education Program (EFNEP) sites in New Jersey, Tennessee, and Washington. ParticipantsA convenience sample of 57 adults participating in or eligible for participation in EFNEP. Phenomenon of InterestParticipants’ interpretations and conceptualizations of PA concepts and terms. AnalysisTemplate and constant comparative analysis. ResultsParticipants interpreted many PA terms and concepts in unintended ways. Exercise was the term that came closest to conveying moderate to vigorous PA. Terms used to describe muscle-strengthening activities were mostly understood. Intentional engagement in extra activities was difficult for participants to conceptualize despite multiple tested wordings; making small changes to be active came closest to conveying this concept. Participants’ comprehension of the PA terms differed by their PA and literacy levels. Conclusions and ImplicationsNutrition educators should be mindful of the terminologies they used in communicating messages and assessing PA behaviors to EFNEP participants or similar populations.

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

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

Environmental Barriers to Healthful Dietary and Physical Activity Behaviors in the EFNEP Participant Population

Direct education programs, including the Expanded Food and Nutrition Education Program (EFNEP), target personal barriers to enable behavior change. However, an opportunity exists to pursue a holistic policy, systems, and environment approach by targeting some environmental barriers (limited availability, high cost, safety, lack of transportation, and challenges caused by poor weather). The Western Regional Nutrition Education and Obesity Prevention Center of Excellence initiated a study to gather perspectives of EFNEP paraprofessional educators on how environmental barriers affect EFNEP participants and environmental changes which could be made to encourage more healthful participant behaviors. Ten telephone focus groups were held with fifty EFNEP educators from ten states during April and May of 2016. Focus groups were audio-recorded, transcribed, and independently coded by two reviewers to identify recurring themes. Educators provided valuable anecdotal evidence regarding environmental barriers and generated potential solutions for specific barriers based on examples from their communities. For example, potential solutions to the availability barrier include creating mobile farmers’ markets, partnering with volunteer groups to provide free food delivery from food banks or retailers to areas with limited access, working with alternative retailers to offer produce in urban areas, providing seeds to encourage home gardening, or facilitating development of or participation in community gardens. Results will guide additional research and inform development of environmental support activities for direct education programs reaching low-income participants. Activities will aim to empower participants to change environmental barriers in their micro-environments.

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

ObjectiveTo 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. DesignSurvey of EFNEP participants from 2011 to 2012. SettingExpanded Food and Nutrition Education Program sites serving limited-resource families in 1 rural and 1 urban/suburban county in Washington State. ParticipantsExpanded Food and Nutrition Education Program participants (urban/suburban: n = 647; rural: n = 569). Main Outcome MeasureExpanded Food and Nutrition Education Program completion/graduation. AnalysisMultivariate 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. ResultsAssociations 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 ImplicationsThis 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.

Social Media as a Supplement to Face-to-Face Education: The Perspectives of Expanded Food and Nutrition Education Program Paraprofessionals and Graduates

Using social media is an inexpensive, innovative approach to supplementing direct education provided by the Expanded Food and Nutrition Education Program (EFNEP). Focus group research was conducted with EFNEP paraprofessionals (n = 33) and participants (n = 39) to inform the development of a social media presence for the program. Although recommendations by EFNEP's social media committee focus on providing online articles, focus group results suggest that content should be presented as colorful pictures and videos, portraying recipes and nutrition tips. Also, the study highlights the importance of using engaging, colorful visuals when using social media as a form of indirect education.

Physical Activity Behavior Change of EFNEP Adult Participants: Item Generation, Validity, and Reliability Testing

To develop and validate self-report physical activity (PA) items designed for assessing physical activity behavioral change among low-income women who participate in the Expanded Food and Nutrition Education Program (EFNEP). The Community Nutrition Education logic model, adapted with constructs of Theory of Reasoned Action, and Theory of Planned Behavior provided the theoretical framework to develop the PA items. The study design for questionnaire development and testing included 6 phases: curricula content analysis; conceptualization and item generation; expert reviews; revisions; cognitive interviews and rigorous psychometric testing. The study was conducted in 6 South Carolina rural counties and with EFNEP eligible mothers. Seventeen items were developed on PA psychosocial mediating variables including attitudes, subjective norm, perceived behavioral control and intention; and 12 items were developed in 4 PA dimensions: home, yard, walk, and work. Content validity was assessed through curricula content analysis, expert reviews (n=8) and cognitive interviews (n=14). 302 mothers from low-income communities in South Carolina completed the PA questionnaire. Factor validity was assessed through Exploratory Factor Analysis (EFA). Reliability (n=50) was assessed using Cronbach for internal consistency and Spearman correlation for test-retest reliability. Predictive validity was assessed (n-50) using accelerometer data. Factor analysis revealed three interpretable factors for the set of PA psychosocial items, with adequate factor loading, acceptable internal consistency and test-retest reliability. No significant association was found for predictive validity analysis. Although further research is needed, this study provided an important methodological foundation for the evaluation and measurement of PA behavior among low-income EFNEP participants.

The Quality of Diets Reported by Expanded Food and Nutrition Education Program (EFNEP) Participants in the Mountain Region

The 24-hr recalls of dietary intake collected from EFNEP participants have not been widely used. We compared the quality of diets reported by participants when entering the program with those reported when exiting. This study was a secondary analysis of data collected from 3,365 female participants in the 8 states of the mountain region from October 2010 through September 2011. The education program was delivered and the pre- and post-intervention recalls were collected by trained paraprofessionals in participants' homes or community settings. Because the 2005 Dietary Guidelines were in effect when the curriculum was developed, the Healthy Eating Index (HEI)-2005 was selected as the diet quality indicator. We calculated mean HEI-2005 scores and, using the USDA/CNPP Food Prices Database, the mean cost of reported diets. Significant differences were determined using Wilcoxon signed-rank tests. At entry the mean total HEI-2005 score was 49.1 (out of a possible 100); and at exit, 55.2. Nine of the 12 component scores improved significantly while Sodium worsened. The mean cost of the diets reported at entry was $4.35; at exit it was 12% higher, $4.76. Because of the self-reported data, lack of biomarkers, and no control group, it is difficult to conclude that diet quality improved; however, it is likely that diet quality improved in the short-term and was accompanied by an increase in food cost. The HEI can be used in the evaluation of other programs as well.

Improving the Quality of Data From EFNEP Participants With Low Literacy Skills: A Participant-driven Model

Low literacy skills and poor evaluation tool readability combined with the stresses of the classroom environment create a high cognitive load for Expanded Food and Nutrition Education Program (EFNEP) participants, resulting in lower quality data. The authors advocate for 9 strategies for improving the participant cognitive load for the evaluation process using the EFNEP Family Record as an example.