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In community-based peer education models, it is necessary to understand the relationship between learning, context and paraprofessional identity construction. Social relations are important in community education program implementation (Merriam, Caffarella, & Baumgartner, 2007); impacting power structure within communities and organizations (Cervero & Wilson, 1994, 2006; Forester, 1989). This study explored the conceptual and practical role of experience in a paraprofessional educator model and focused on the situated, contextual experiences of paraprofessionals in the communities they work and live as unique, challenging, and potentially positive for learning outcomes. Schön's narrative dialogue of reflection (1983) proved to be the essential missing piece in working with community educators toward successful development and autonomy. In-depth qualitative interviews with 19 paraprofessional community-based peer educators with a state level family nutrition program contributed to findings relevant to how social context, critical reflection, and identity development influence an understanding of experience and the ability to impact knowledge and behavior change in clients. Individual interviews and focus groups allowed narrative exploration of topics as they evolved throughout the study; giving voice to paraprofessional program assistants in a way not previously done. The findings of this study provide insight necessary for the assessment of new conceptualizations of practice for paraprofessional models in expanding community impact and highlight the need for assessment of contemporary program delivery in a way that fosters the continual development of lay educators through reflective practice. Recommendations are made for a reassessment of historically significant program models in order to embrace paraprofessionals as more broadly defined socially mediated and socially situated influential practitioners. / Ph. D.

The Expanded Food and Nutrition Education Program (EFNEP) is a federal program designed to improve the nutritional status of the population and provide employment for paraprofessional aides from the indigenous target population and an example of a change agency. Diffusion and change literature offer many models and possible personality characteristics that may be associated with effective change agents. The purpose of the study was to examine characteristics of paraprofessionals employed in the Adult phase of Virginia EFNEP and their relationship to paraprofessional effectiveness and how well they fit the diffusion model. Effectiveness for the paraprofessional was measured as homemaker success (change in nutrient intake and food behavior) and as paraprofessional performance (workload and home visit evaluation). Personality, training, and demographic characteristics of the 40 paraprofessionals were obtained through a mailed Paraprofessional Questionnaire and the Sixteen Personality Factor (16PF) Test. Demographics, food behavior and knowledge, and nutrient intake for a sample of three homemakers per paraprofessional (N=116) were obtained from EFNEP Family Records. Homophily, the measure of correspondence, was calculated by comparing each paraprofessional with their sample of three homemakers. Three personality factors (concrete thinking, impulsivity, and self-discipline) along with homophily were correlated with change in food behavior, none with change in nutrient intake, and two (concrete thinking and low tension) along with perfect match homophily were correlated with workload. There were no apparent difference in training. When all factors were analyzed by stepwise multiple regression, homophily along with three of the second-order personality factors were related to change in food behavior. One second order factor, low anxiety along with perfect match, was related to workload. Implications for practice include: (a) EFNEP paraprofessionals, in part, appear to be fitting the model of change agent effectiveness, in that homophily is influencing the homemakers and (b) low anxiety and low tension appear to be related to effectiveness and could be used in employee selection and future training. Recommendations for future study include: (a) further study into quantification of homophily and (b) investigation of relationship of characteristics to supervisor view of effectiveness. / Ph. D.

Ballet dancers are a unique population of athletes in that, unlike other sports, their success strictly depends on both physical capabilities and aesthetic factors. While the physical demands of the performing sport are strenuous, ballet dancers are often required to exhibit a thin physique, frequently resulting in weights 10-12% below the ideal. These low weights are commonly achieved by low energy intakes which increase dancers' susceptibility to the development of various health conditions. Research investigating the health of dancers, however, is limited and hampered by methodological limitations. To address these issues, we tested the hypothesis that dancers would report a low habitual energy intake and, therefore, be subject to conditions comprising the Female Athlete Triad, including low energy availability, suboptimal bone density and menstrual irregularities. In addition, we hypothesized that elite female dancers would have lower than expected resting metabolic rate (RMR) based upon their fat-free mass, and thus greater energetic efficiency as a result of chronic energy deficiency. As hypothesized, dancers reported a significantly lower energy intake and exhibited a lower RMR as compared to lean, pair-matched controls. Because treatment of these metabolic abnormalities is challenging, prevention of adverse health outcomes among adolescent pre-professional dancers is key in promoting overall health and optimal performance. Through our subsequent 'formative work', we determined that the current availability of nutrition education offered to both professional and pre-professional dancers is minimal and of questionable quality. Thus, we developed, implemented, and evaluated a DVD-based educational program, entitled "Nutrition for Optimal Performance", aimed at improving health knowledge and behaviors of pre-professional adolescent ballet dancers. Our findings indicate that participants increased their knowledge of basic nutrition principles and self-efficacy for adopting healthier dietary habits, as compared to pre-program and control group scores, and that knowledge gains were sustained at a six-week follow-up assessment. Collectively, these studies provide the field of dance medicine with novel findings related to the characteristics and health conditions of professional ballet dancers, and the effectiveness of a low-resource, disseminable nutrition education program which promotes the health and optimal performance of pre-professional adolescent ballet dancers. / Ph. D.

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.

Dietary improvement was assessed using 24-hour food recall in a sample of 180 homemakers who had completed six to 18 months of instruction in the Virginia Expanded Food and Nutrition Education Program (EFNEP) to determine whether they retained dietary improvement six to 36 months after leaving the program. These homemakers provided additional information on Perceived Educational Gains and Program Benefits received from participating in EFNEP. Family factors were explored which were believed to be related to dietary change - Family Composition, Family Resource Assistance, Household Roles and Responsibilities, Family Support, and Family Diet Control. Diet Scores increased significantly (p<.01) from program Entry to Exit; greatest increases were in average daily servings from milk and fruit-vegetable groups. Slight but significant (p<.01) regression occurred in average Diet Score and servings of milk from Exit to Follow-up. Homemakers with higher Diet Scores at program Entry had higher scores at program Exit and Follow-up, and higher Program Benefit Scores. Length of time in program was not significantly associated with Dietary Improvement or Retention. High average Educational Gain and Program Benefit Scores at Follow-up were evidence that EFNEP was successful from the perspective of homemakers served. Family Composition was not associated with Dietary Improvement. Family Support emerged as the only family measure related to diet; higher Family Support Scores were associated not only with greater Perceived Educational Gains and Program Benefits, but also with higher Diet Scores at program completion and follow-up. Results of the study confirmed the Virginia EFNEP to be effective in improving diets of homemakers and sustaining these changes, and suggested a key role for family support in influencing dietary outcome and program success from the view of participants. / Ph. D.

In chapter 1, a comprehensive meta-analysis is conducted to synthesize the effectiveness, cost, and cost-effectiveness of lifestyle diabetes prevention interventions and compare effects by intervention delivery agent and channel. Sixty-nine studies meet inclusion criteria. The results show that participants receiving intervention with nutrition education experienced a reduction of 2.07 kg (95% CI: 1.52 to 2.62; p<0.001; 95% CI: 88.61% to 92.87%) in weight at 12 months with effect sizes over time ranging from small (0.17, 95% CI: 0.04 to 0.30; p=0.012; 95% CI: 80.42% to 91.14%) to medium (0.65, 95% CI: 0.49 to 0.82; p<0.001; 95% CI: 98.52% to 98.94). In sum, lifestyle interventions are effective in reducing body weight and glucose-related outcomes. Dietitian-delivered interventions achieve greater weight reduction compared to those delivered by other personnel. In chapter 2, this study attempts to examine the effects of household relative deprivation on children's health outcomes. A modified household production model is developed with energy intake, energy expenditure and a composite good as main inputs in the health production. A two-stage Stackelberg game facilitates the need to model the parent-child interaction which follows similar structure as You and Davis (2011). We use three measurements of relative deprivation based on per capita household income and four reference groups based on combinations of geographic and demographic characteristics. The results show that relative deprivation is negatively associated with child health. In chapter 3, we define "process benefits" as the direct effect on utility from engaging in an activity and examine how "process benefits" associated with food activities, both uptake and duration, are related to factors such as socio-economic status and demographics. A household production model is utilized to demonstrate the vital role of process benefits in home food production and the implications it will have for nutrition based policies targeting resources. The results display that the process benefits are associated with some demographic characteristics. This implies that shortfalls in food activities are not simply a matter of technology or resource shortfalls, but also reflect disutility associated from these activities which in turn will attenuate the impact of policies design to merely address resource shortfalls. / Ph. D. / Evaluation of programs is a vital part in health economics for it is important in understanding the effect and limitation of a program from an economic perspective. Three applications are included in this dissertation. The first application is to synthesize the overall effectiveness of diabetes prevention program including nutrition education; the second application is to evaluate if there is a negative association between relative deprivation and children’s health outcomes; the third one is to explain the small effect of nutrition policy, such as SNAP. Type 2 diabetes (T2D) has increased significantly worldwide, leading to substantial increases in total economic costs in the US. A proliferation of studies have attempted to translate lifestyle interventions into clinical and community practice in an attempt to halt this growing public health epidemic. Therefore, there is a need to investigate the effectiveness of interventions including nutrition education for diabetes prevention. The results show that diabetes prevention program with nutrition education is effective in reducing body weight and glucose-related outcomes. China has reached the fastest rate of growth in economy since the implementation of reform and become the world’s second largest economy. However, improvement in health fails to accompany the massive growth in material living standards for the Chinese population. This observation prompts us to investigate the relative deprivation hypothesis. The results show that children who are more relatively deprived have poor health outcomes. Food assistance programs, e.g., Supplemental Nutrition Assistance Program (SNAP), have been developed to improve people’s health. However, the nutrition level recommended by those programs are still not met for the targeted population. The results show that respondents who enjoy cooking spend more time on activities related to food production, such as food preparation, presentation and clean up. And the small effect of nutrition policies is due to the disutility from the process of food production.

In 1981, President Ronald Reagan issued Executive Order 12291 which requires Federal agencies to perform benefits assessments of proposed major regulations and prohibits them from taking regulatory action unless potential benefits exceed potential costs to society. A review of welfare economics literature and applications of the CBA model to health, education, and nutrition is presented. CBA for use in the Cooperative Extension Service Expanded Food and Nutrition Education Program (EFNEP) is then systematically examined using the following criteria: 1) theoretical considerations - can the economic criterion appropriately be applied to EFNEP?; and 2) application of the CBA model - can it be made operational? Following the critique of application of CBA to EFNEP, conclusions are drawn as to the appropriate use of CBA or alternative techniques in evaluating EFNEP and similar programs. / Doctor of Philosophy

With obesity in adolescents becoming a major health problem in the United States, there has been an expansion in the use of nutritional education programs as intervention. Effective nutrition education can decrease the incidence of obesity and other diet-related chronic diseases, type-2 diabetes, cardiovascular disease, and hypertension. This dissertation in practice proposes to design a nutrition education program, integrating farm and culinary activities into a nutrition education curriculum. The program is designed as a stand-alone program, but for this practice, implementation integrates the nutrition education program into the Film @ 6 after-school program – a STEM-focused program designed to assist sixth graders in their first year of middle school – at Southeast Middle School in Salisbury, Rowan County, North Carolina (NC). This experiential nutrition education program will provide instruction and activities in order to increase nutritional knowledge, improve culinary techniques, and increase consumption of fruits, vegetables, and minimally processed foods of sixth grade students as a means to address the overweight and obesity risks of middle school children. Children and adolescents are considered the priority population for intervention strategies because 70% of obese adolescents become obese adults and it is difficult to reduce excessive weight once established (Dehghan, Akhtar-Danesh, & Merchant, 2005).