Each year, the Expanded Food and Nutrition Education Program (EFNEP) and Food Stamp Nutrition Education (FSNE) receive around 60 million dollars in federal funding. In order to document impacts, it is critical that these programs utilize valid and reliable instruments. By having validated instruments that measure behavior changes, it can be documented that these federally funded programs are achieving program objectives. To date, research on measurements of change is either lacking or under-reported. The goal of this study was to develop a valid and reliable assessment instrument to be utilized with a specific curriculum titled Healthy Futures, which is used within Virginia FSNE. To accomplish this, an expert panel was assembled to conceptualize and construct the instrument. The instrument was pilot-tested, evaluated, then finalized and tested. Results with 73 individuals representing 34 white, non-Hispanics and 36 non-Hispanic blacks, found that the physical activity and dietary quality domains of the instrument had achieved an acceptable test-retest reliability coefficient of .70, however the food safety domain achieved a 0.51. For validity, the instrument scored an overall Spearman Correlation Coefficient of 0.28 for physical activity, 0.34 for food safety, and 0.20 for dietary quality. All three domains were sensitive to change (p < 0.0001). The results indicate that this instrument could detect dietary and physical activity change among limited resource participants of FSNE with confidence. / Master of Science

Each year approximately 7,500 low-income Virginia families are enrolled in the Expanded Food and Nutrition Education Program (EFNEP), administered through the Virginia Cooperative Extension (VCE). Chronic disease and health conditions cost society an estimated $250 billion each year in medical charges and lost productivity. It has been assumed that the numerous diet and food-related changes made by EFNEP participants will lead to a reduction in the risk of chronic disease among homemakers, and perhaps, other family members. Thus, the improved diets and behaviors resulting from EFNEP participation may result in substantial future savings in healthcare costs among participants. This study explores the possibility of potential economic benefits for the Virginia EFNEP participants. In 1996, the Virginia Cooperative Extension was awarded a grant from the Cooperative State, Research, Education, and Extension Service, United States Department of Agriculture (CSREES, USDA) to conduct a cost-benefit study of EFNEP in Virginia. Though computation of the cost-benefit ratio for the Virginia adult EFNEP includes both direct and indirect benefits, this study addressed only the assessment of the direct tangible benefits based on the savings from economic costs of avoided diseases. Existing EFNEP data for the 1996 fiscal year was used to identify optimal nutritional behaviors that can delay or prevent the onset of certain chronic diseases and health conditions. The economic costs of diseases were identified from scientific literature and translated as potential benefits. The administration costs of EFNEP were also compiled. The total direct tangible benefit for the diseases and conditions identified was estimated to be $17,770,722. Along with the indirect tangible benefits ($321,462), the total tangible benefits for the Virginia EFNEP was calculated to be $18,092,184. The direct tangible costs associated with the Virginia EFNEP in 1996 was $1,922,204. The benefit-cost ratio for the Virginia EFNEP for the 1996 fiscal year for the subset of the population practicing the optimal nutritional behaviors is calculated at $9.41/$1.00 (a $9.41 return for every $1 invested in EFNEP in Virginia). Also, a benefit of $2.45 to $1.00 was calculated when only 25% of those participants practicing optimal nutritional behaviors were assumed retain these behaviors through life. For a program of the magnitude of EFNEP, these results are very gratifying. / Ph. D.

The feasibility and effectiveness of video instruction as an alternate means of delivering nutrition education to low-income homemakers were examined in this study. Demographic and mediating variables that may affect the success of video instruction were also investigated. Consenting EFNEP and SCNEP homemakers (N=105) were randomly assigned to receive either video lessons with follow-up telephone discussions and intermittent home visits (Video Group) or face-to-face home visits/small group sessions (Traditional Group). Assessments of locus of control and cooking reinforcement values (RVs) were conducted at baseline. Dietary and food-behavior changes were assessed using 24-hr recalls and a 14-item behavior checklist questionnaire, respectively. Questionnaires were used to assess the Program Assistants' (PAs) and participants' perceptions of video instruction. Analytic measures included multivariate analyses of variance, analyses of variance, <I>t</I>-tests, chi-squared tests, and frequency calculations. Experiment-wise significance was set at <I>p</I> < 0.05 with correction using the Bonferroni method. Seventy-three participants completed the study. For both groups, significant improvements were seen from pre to post intervention in vitamin C intakes, the number of servings consumed from the Fruit Group, and food behavior checklist scores. The Traditional Group also increased their intakes of vitamin A, vitamin B₆, calcium, and fiber. There was no difference in the change of dietary intakes and behavior checklist scores between the two groups. No effects were found for race, age, residence, locus of control, or cooking RV. Video instruction was well received by most participants and PAs and was substantially less expensive than traditional instruction. Due to the effectiveness and acceptability of video instruction, it should be considered when delivering nutrition education to low-income homemakers. / Master of Science

The Expanded Food and Nutrition Education Program (EFNEP) and its youth component, 4-H EFNEP, were established nationwide by the Cooperative Extension Service in 1969. 4-H EFNEP provides nutrition education to low-income youth, aged 5 to 19 years; however, there has been no standard instrument to evaluate behavior change among participants in Virginia or nationwide. A 24-item Youth Food Behavior Checklist (YFBC) was developed based on 13 topics and food-related behaviors taught in 4-H EFNEP. Data were collected on 47 youth enrolled in 4-H EFNEP in the summer of 1998. The YFBC was tested for test-retest reliability and ability of each item and the total instrument to detect change from pre- to post-intervention. The YFBC demonstrated good test-retest reliability with a Pearson Correlation of 0.81. Overall, the YFBC demonstrated sensitivity to detect change in nutrition behaviors, by showing positive change for some items and negative change for other items in all but nine of the participants. The YFBC also appeared to successfully measure behaviors taught in 4-H EFNEP lessons, as questions regarding only two topics did not demonstrate change from pre- to post-intervention. Since not all checklist items showed significant positive change from pre- to post-intervention, the YFBC should be tested again with a larger sample and in situations where the intervention and the administration of the instrument are better controlled. This would increase the power of the study and the credibility of the YFBC as an assessment instrument for wider use in 4-H EFNEP. / Master of Science

Childhood obesity has increased significantly in the past decade. The same factors putting adults at risk for obesity apply to children as well. For children, the family environment may be one of the largest factors. Obesity affects both adults and children of low socioeconomic status. It also affects families living in the Appalachian region of the United States more frequently than other regions. The purpose of this study was to examine the relationships between obesity related behaviors and nutrition education among Appalachian participants in the Expanded Food and Nutrition Education Program (EFNEP). For this study eleven educators from the Appalachian region who work with the EFNEP/SNAP-Education program were interviewed by telephone. Their responses to questions were coded according to a pre-prepared answer guide. From answers provided by staff there are some areas that the EFNEP program could focus on more. Some of these areas include educating participants on budgeting and family finance, cooking skill, parenting skills and physical activity. Answers provided by participants in this study suggest that educators feel fairly successful with making changes related to healthy eating but less successful with making changes in participant’s physical activity.

Food insecurity and diet quality are concerns in low-income populations, contributing to high rates of obesity. Food management skills may enable low-income populations to obtain a healthy food supply rather than relying on less expensive and less nutritious foods to fill their diets. The purpose of this study was to assess the relationship between food management practices and diet quality in SNAP-ED/EFNEP participants. This study examines the association between food management behaviors and dietary outcomes (Healthy Eating Index totals, total calories, carbohydrates, protein, fat, and fiber, and servings of fruits, vegetables, milk, and meats/beans) as measured by the Behavior Checklist and diet information collected by Extension Program assistants for 1,585 participants in Kentucky counties (n=57) during 2010-2011. The results of the cross-sectional analysis suggest that food management practices can help low-income SNAP-ED and EFNEP participants obtain more food for their families. However, diet quality was only improved for the variable ‘healthy foods,’ (participants who responded that they thought about healthy foods when deciding what to feed their families). It was concluded that an integrated approach of food management practices and nutrition education is needed to improve diet quality for low-income populations.

Since the federal budget for EFNEP is over $66 million, it is crucial to know the effectiveness of program attributes that may bolster its effectiveness. The aim of this study was to determine how effectiveness of Youth EFNEP programs in Virginia is affected by participant, instructional and curriculum attributes for youth enrolled in Healthy Weight for Healthy Kids (HWHK). An ordered probit model was employed to study how these attributes affect dependent variables: Whole Grain, Fruits, Colored Vegetables, MyPlate, and Breathe Hard behavioral scores. The model assessed the probability of a participant having an improved score or improved behavior. Participant Attributes Results: In general, the chosen variables for participant characteristics consistently reduced the probability of participants having an improved behavior score. Instructional Attributes Results: African Americans Program Assistants were consistently associated with negative marginal effects on positive behavioral scores with the exception of the positive Breathe Hard behavioral score. Other PA attributes were not consistently associated with any behavioral models but were heterogeneous in terms of their marginal effects on the positive behavioral scores. Curriculum Attributes results: The curriculum attributes had more positive marginal effects than negative marginal effects across all the five behavioral scores. Attributes that were consistently associated with having a positive marginal effect on behavioral scores were program duration, smart foods lesson, and lesson duration. Other HWHK lessons were not consistent in increasing or reducing the probability of an improved behavior. / Master of Science

Low-income and minority youth are disproportionately affected by low food access, low dietary quality, and high levels of obesity. The Expanded Food and Nutrition Education Program (EFNEP) is designed specifically to assist limited resource youth and adult audiences to acquire the knowledge, skills, attitudes, and changed behavior necessary for nutritionally sound diets, and to contribute to their personal development and improvement of the overall family diet and nutritional well-being by using a peer-education model (USDA, 2012). To date, little published research exists on dietary patterns and food access among youth who participated in EFNEP. The specific research goals of this study were to: 1) explore baseline dietary and physical activity self-efficacy and behaviors of youth EFNEP participants and compare to national trends, 2) examine differences in self-efficacy and behaviors based on socio-demographic factors and food availability, and 3) determine the association between food availability and dietary behavior. This study consisted of conducting surveys with 1,864 low-income youth, ages 7 to 14 years old, across Virginia prior to participation in an obesity-prevention program. The survey consisted of a 55-item written pre, post-test instrument that had been previously tested for validity and reliability. Most participants reported availability across all food groups, with the exception of meat and beans (41.4%) and dessert (48.3%). Significantly less than half of participants reported not meeting dietary behavior thresholds for the following food groups: grains (27.0%); whole grain (19.7%); low-fat milk (31.5%); vegetables (18.2%); colored vegetables (15.3%); and baked foods (31.7%). Availability of meats and beans and fruits were higher among Latinos than non-Latinos. Younger participants reported a higher consumption of sugar-sweetened beverages and screen time; however, the children had participated in physical activity. Participants who reported a higher availability of fruits and vegetables at home also participated in physical activities at least once a day. This study provided insight into the availability of food, as well as food consumption among low-income audiences across Virginia, based on youth EFNEP reporting. The results highlighted the importance of strategic interventions to improve the availability of nutritious foods and obesity prevention strategies to enhance self-efficacy and intake of nutritious foods among low-income youth. / Ph. D.

Master of Public Health / Department of Human Nutrition / Mary L. Higgins / Nutrition education programs strive to help low-income people make optimal food choices while living on a limited budget. This study addressed perceived understanding, acceptance, and usability of Food and Nutrition Bytes, a set of 12 eight- to eleven-minute online Expanded Food and Nutrition Education Program (EFNEP) lessons. Clients in EFNEP during 2005-2006 were surveyed on internet usage and interest in online nutrition lessons. Lessons were developed and assessed for reading levels using two formulas. Clients and professionals in six Kansas counties completed a Likert scale survey and gave comments after they viewed one online lesson. Fifty-five percent of 75 EFNEP clients who had internet access indicated they were interested in taking nutrition lessons online. The new lessons averaged a 6.64 grade reading level. Two lessons had content that was rated too general to be useful. For the remaining lessons, both groups ranked their perceived understanding, helpfulness of graphics and audio, and usefulness of information at the first or second most-desirable rating. They rated length and amount of information as “Just Right.” The only difference found between the groups was when clients rated one lesson as having a little too much information and professionals rated it as having not quite enough (Mann-Whitney U = 35.0, p = 0.039). Within-sample associations were measured for two lessons. Clients older than 30 years of age found the Grains lesson’s pictures and graphics to be more helpful than did younger clients (Kendall tau-b = 0.593, p = 0.002). White clients evaluated the Cooking lesson as being easier to understand than did non-white clients (Kendall tau-b = -0.477, p = 0.020). The most frequent comments pertained to the importance of portion sizes and appropriate pictures and graphics. Overall, Food and Nutrition Bytes lessons were easy to read, and perceived by both clients and professionals to be easy to understand, helpful and useful, and also optimal in length and amount of information. Despite low numbers of EFNEP clients who had internet access, over half were interested in taking lessons online. Limitations of this study include small samples, convenience samples, subjects’ time constraints, and interviewer bias.

Food insecure individuals do not always have access to adequate food for a healthy lifestyle and are at high risk of detrimental health outcomes. Researchers hypothesize that food insecurity leads to changes in dietary practices, including greater overall food purchase in times of adequate resources and purchase of low-cost, unhealthful foods when resources are constrained. Most measures of food insecurity do not measure changes in dietary practices and dietary quality. Research findings suggest education that provides alternative strategies to manage resources and improve dietary practices can improve food insecurity. We assessed the relationship between 1) food security and ability to afford foods and 2) the impact of Expanded Food and Nutrition Education Program (EFNEP) in a low-income, multi-cultural population in Massachusetts. We used a pre/post-education survey design, including the USDA six-item Food Security Module (FSM), food-affordability questions and EFNEP behavior checklist. EFNEP participants experienced high rates of food insecurity with over 40% of participants classified as food insecure (N=80). Pre-EFNEP, individuals in households with low food security were less likely to report being able to afford healthy foods (51.5%) and fruits and vegetables (57.6%) throughout the month compared to those in households with high (80.9%) and marginal (78.7%) food security (P=0.007, P=0.051). Individuals in households with marginal, low and very low food security were less likely to report being able to afford the same kinds of food throughout the month compared to individuals in high food secure households (56.4% vs. 84%) (P=0.022). Individuals in food insecure households reported running out of food before the end of the month more often than their food secure peers (P=0.013). Post-EFNEP, a greater proportion of participants fell into the high and marginal categories of food security (60.0% to 71.7%, P=0.065). Our results indicate that food insecure households have a harder time affording healthy foods throughout the month, leading to poor diet quality that possibly contributes to poor health outcomes. The food affordability questions may capture changes in dietary practices in food insecure populations throughout the month. EFNEP can provide skills and knowledge to at risk populations to improve abilities and combat food insecurity.