In-depth review of selected EFNEP curricula updated for the 2005 dietary guidelines and MyPyramid

December 2006, Vol. 11, No. 2
ISSN 1540 5273

Kathryn Rogers, MS
Department of Food Science and Human Nutrition
Colorado State University
Fort Collins, Colorado 80523-1571

Ann Diker MS, RD
Department of Food Science and Human Nutrition
Colorado State University
Fort Collins, Colorado 80523-1571

Patricia Kendall, PhD, RD
Department of Food Science and Human Nutrition
Colorado State University
Fort Collins, Colorado 80523-1571

Susan Baker, EdD
Colorado State University
Department of Food Science and Human Nutrition
214E Gifford
Fort Collins, CO 80523-1571
970-491-5798
sbaker@cahs.colostate.edu

Abstract

The release of Dietary Guidelines for Americans 2005 and development of the MyPyramid food guidance system rendered nutrition education materials based on previous guidelines out-of-date. Thus, education materials for community nutrition programs such as the Expanded Food and Nutrition Education Program (EFNEP) needed to be revised or replaced, a process that also provided an opportunity to reassess curricula currently in use. The purpose of this project was to conduct an in-depth review of curricula from multiple states, either currently under revision or recently developed, for possible future use with adult EFNEP audiences. Seven curricula were selected for review. The peer-review process served as an effective method for identifying the appropriateness and accuracy of curricula for a specific target audience. Curricula are typically written by subject-matter experts, therefore, the content was found to be consistently accurate. However, many of the curricula reviewed could have been improved by deliberate efforts to incorporate additional adult learning principles.

Keywords: EFNEP, peer-review, nutrition education, community nutrition programs, curricula evaluation

Introduction

The release of Dietary Guidelines for Americans 2005 (HHS/USDA 2005) and development of the MyPyramid food guidance system (USDA-CNPP 2005) immediately rendered nutrition education materials (based on the previous guidelines) out-of-date. Thus, the educational materials used by the Cooperative Extension Service’s Expanded Food and Nutrition Education Program (EFNEP) needed to be revised or replaced.

Since the Dietary Guidelines for Americans were first published in 1980, the U.S. Department of Health and Human Services (HHS) and U.S. Department of Agriculture (USDA) jointly have revised and updated them approximately every five years, based on current research. The Dietary Guidelines for Americans are scientifically based food consumption recommendations for Americans, designed to promote health and decrease the risk of chronic diseases (Schneeman 2003). They also provide the groundwork for federal nutrition policies, allowing the government to have a firm and united stance on health and nutrition (McMurry 2003). Federal nutrition education programs, such as the Expanded Food and Nutrition Education Program (EFNEP) and Food Stamp Nutrition Education (FSNE), need to be based on the most current Dietary Guidelines for Americans. The latest version, Dietary Guidelines for Americans 2005, addresses individuals age two years and older, as well as specific populations such as the elderly, pregnant women, and nursing mothers (HHS/USDA 2005).

The MyPyramid food guidance system, released in April 2005 by the U.S. Department of Agriculture’s Center for Nutrition Policy and Promotion (USDA-CNPP), is designed to help Americans interpret the 2005 Dietary Guidelines and make healthful food choices (USDA-CNPP 2005). A main feature of the system is the new MyPyramid symbol, designed as a pictorial interpretation of the 2005 Dietary Guidelines to replace the Food Guide Pyramid. Because most nutrition education curricula and intervention programs have been based on the Dietary Guidelines for Americans and Food Guide Pyramid, the recent revisions to these tools have resulted in the need to revise nearly all nutrition education curricula and materials used in community nutrition education programs. Such a need also provides an opportunity to rethink curricula development. The purpose of this project was to conduct a systematic assessment of available EFNEP curricula and an in-depth review of selected curricula being revised or rewritten to incorporate MyPyramid and the 2005 Dietary Guidelines.

Methods

Preliminary work. A survey was sent to all state EFNEP coordinators in the U.S. to assess the following aspects of their current curriculum: teaching methods, lesson format, detail of lesson plans, hands-on activities, and EFNEP coordinators’ attitudes toward their current curricula. Curriculum attributes of specific interest for inclusion in the in-depth review project included the following: (1) materials developed for Hispanic audiences, (2) low-literacy visuals and handouts, (3) lessons designed to be taught in any order, and (4) teaching materials that were appropriate for groups of five to twelve people.

Using information from this national survey, the curricula of 18 states were identified for potential inclusion in the in-depth curricula review. Each EFNEP coordinator in these 18 states was sent an electronic communication including a URL that the coordinator could use to access a web-based questionnaire designed to assess intent to revise/rewrite the current curriculum, nutrition education theories used in developing the curriculum, format of lesson plans, lesson length, size of group the curriculum was written for, visuals included, hands-on activities included, and inclusion of other topics (e.g., a lesson for mothers and infants). Permission to include their curricula in the in-depth review also was sought from the respondents. Those who agreed to the in-depth review process (and had indicated they were in the process of revising or rewriting their curricula and had curricula available for review) were asked to send three copies of their current, revised, or rewritten curriculum.

In-depth review panel. Seven EFNEP and/or FSNE coordinators representing different regions of the nation and three professionals at Colorado State University with expertise in nutrition education for limited-resource audiences were recruited to review the received curricula. Each curriculum was evaluated by one external and one internal (Colorado State University) reviewer.

Review tools. Two tools were used to review the curricula received. The first tool was developed by project investigators and was intended to assess the strengths and weaknesses of specific lessons within the curricula (Figure 1). A panel of five nutrition education experts evaluated this review tool to ensure content and face validity. The second tool was slightly adapted from the Iowa State University Extension’s Guide to Evaluating Written Nutrition Education Materials (Betterley and Dobson 2000) and designed to analyze the readability, content, and design of the EFNEP curricula materials received.

Review process. Each reviewer was sent a copy of one curriculum, both review tools, and a cover letter with review instructions. Reviewers were given five weeks to complete the process and return the results of their in-depth reviews. Once all curricula and review tools were returned, feedback from each internal reviewer was compared with the results of the external reviewer of the same curriculum.

Results and discussion

The sample. Of the 18 state EFNEP coordinators asked to complete the web-based questionnaire, 12 responded (66.7 percent response rate). Of these, seven curricula were selected for the in-depth review process based on intent to rewrite or revise, the timeline in which the rewriting/revising would be completed, curricula available for review, and responses to the web-based questionnaire revealing attributes included in the curriculum that were deemed desirable. Copies of the seven curricula were requested for the peer-review process.

Curriculum attributes. The results from the web-based questionnaire for the seven curricula included in the in-depth review are shown in Table 1. Most of the curricula reviewed were undergoing revision. Two were in the process of being completely re-written. Most curricula (six of seven) also were available in Spanish. The developers indicated use of a wide variety of educational theories in developing the curricula, with no theory predominating across the seven curricula reviewed. Lesson length varied from 30 to 60 minutes, with all developers indicating that lessons could be taught in any order. Lesson plan detail and types of visual aids used also varied widely across the seven curricula, as shown in Table 1.

Topics addressed in curricula. Of the twenty-three topics reviewers were instructed to look for in their review, most of the curricula addressed nearly all of the topics, but no one curriculum addressed all twenty-three topics (Table 2). Topics addressed by all curricula included the food groups, physical activity, label reading, food safety, food budgeting/shopping, meal planning, breast vs. bottle, fat intake, portion size, and variety. Two topics (salt intake and eating away from home) were addressed in fewer than half of the curricula reviewed.

Readability, content, and design attributes. The responses by the peer reviewers to Review Tool 2 for the curricula they reviewed are summarized in Table 3. All curricula received high marks for clarity of purpose, accuracy of information, appropriate paragraph structure, appropriate tone, inclusion of recipes, and readable type size and style. Reviewers questioned the usefulness of some of the information in two of the curricula and the appropriateness of some of the tables, charts, graphs, and illustrations for three of the curricula reviewed.

Curriculum design components. Subject matter content was typically deemed by reviewers as technically accurate and appropriate for the limited-resource target audience. This was expected, as educational materials developed for use by EFNEP or other community nutrition education programs almost always are developed by subject matter experts with advanced degrees in nutritional sciences.

Participant involvement. A recommendation of reviewers for many of the curricula was the need to increase the amount of participant involvement. Reviewers consistently identified limited or no active involvement of participants in the learning experience as a weakness of the curricula they reviewed.

Detailed and thorough lesson plans. EFNEP employs paraprofessional nutrition educators to deliver structured curricula to limited-resource adults (Brink 2000). Reviewers consistently indicated the need for detailed and thorough lesson plans as a necessity to ensure consistency of educational delivery from one paraprofessional to another. While detailed, thorough lesson plans are an advantage to any curriculum, this level of lesson plan was deemed an essential element of curricula that would be delivered by paraprofessionals. A specific component that was missing from many of the curricula reviewed was an outline of the time required for each aspect/segment of the lesson plan. Having a guide/suggestion of how much time each segment of the lesson plan should take is very valuable to educators, especially paraprofessionals. Another common reviewer response was that the lessons plans contained a great deal of content — too much content for a typical 60-minute lesson. Often, lesson plans were not broken down into concrete segments with active participant involvement designed into the lesson plan. Rather, they seemed to be a compilation of numerous facts — information (technically accurate) with little or no thought about how it would be delivered.

Literacy level of target audience. The literacy level of the target audience is an important consideration in the design of curricula (Safeer and Keenan 2005). The literacy level of the target audience should be considered when developing all components of a curriculum. Typically, reviewers were concerned with the reading level of educational materials that would be seen by the participants — including visuals, handouts, and the amount of white space in each. Similarly, curriculum developers should be concerned with the reading level of all curriculum materials. For example, if the reading level is assessed only on the participant materials, the lesson plans may include terminology that is unfamiliar to the target audience. Educators likely will use the terminology included in the lesson plan without thinking about its familiarity to the audience.

Recipes and food activities. The inclusion of recipes and food activities was viewed as a strength of all of the curricula reviewed. The more the participants are actively engaged in the food preparation activity, the greater the chance they will repeat the practice after the educational experience (Klinedinst 2005). Demonstrating the preparation of a recipe is better than having a prepared food product for learners to taste, and having participants actively involved in the food preparation activity is better than viewing a demonstration conducted by an expert.

Background information. Inclusion of background information for the paraprofessional was seen as a strong plus in some of the curricula reviewed. Background information should be viewed essentially as a mini subject-matter reference book specific to the lesson. By being mindful of the audience’s reading level and of technical jargon, curriculum developers can provide paraprofessional educators with a reference tool to help answer questions relative to the topic but beyond the scope of the lesson plan. This background information may be used as a reference to answer questions, as a self-guided independent study for paraprofessionals, or as training materials/resources when training new paraprofessionals.

Visuals are an important component of any educational materials developed for limited-resource audiences. This target audience prefers and responds more favorably to pictures/photographs than to clipart or cartoons (Weiner et al. 2004). Realism is preferred to abstract images. Care should be taken to include ethnic diversity in the illustrations. The seven curricula reviewed varied widely in use of visuals. In some instances, visuals were not available for review. Some of the curricula had clipart or cartoon visuals, while others included actual photographs. The use of ethnic diversity was limited in some, but not all, of the curricula visuals.

Cost of curriculum materials is another important consideration for curriculum developers. For programs with numerous educators (such as EFNEP), program leaders are concerned with the cost of curriculum materials and supplies. Will program leaders have to purchase curriculum materials for each educator, or is there an option to purchase a master copy and reproduce it? Similarly, what will be the availability and affordability of curriculum materials other than the written lesson plans, handouts, etc.? Are there easy-to-understand directions as well as identified cost of lesson activity props, kits, etc.? The availability and affordability of these items is a concern for program leaders interested in purchasing curriculum materials. The cost of curriculum materials could not be assessed at the time of the review due to incomplete revisions of the curricula.

Strengths and limitations

This review of EFNEP curricula revised for the 2005 Dietary Guidelines and MyPyramid was far from exhaustive. According to the results of the survey of the 18 EFNEP coordinators, multiple states planned revisions to be completed after the curricula review. However, the need to get current and accurate EFNEP materials to paraprofessional educators as quickly as possible after the release of the 2005 Dietary Guidelines and MyPyramid necessitated reviewing curricula before revisions were complete.

A major strength of this project was the involvement of individuals closely associated with EFNEP or FSNE. The input from the panel of experts relative to the web-based questionnaire and assessment tools was useful in the development of these documents, helping to ensure that the content was accurate, complete, and objective. Involvement of EFNEP and FSNE coordinators in the review aided in obtaining feedback from experts directly involved in programs targeting limited-resource audiences. Review of multiple EFNEP curricula from different regions of the country assisted in gauging the wide variety of EFNEP curricula available.

Because most states had not fully completed the revisions and rewritings of their EFNEP curricula by the time the project was executed, a weakness of the project is that reviewers often were able to review only the “old” curriculum and portions of a revised curriculum. In addition, reviewing curricula before the revision/rewriting process was finished resulted in the exclusion of many potentially appropriate curricula, again affecting the results of this study.

Conclusions

Given the above limitations, the following conclusions may be drawn:

1. The use of web-based questionnaires distributed through a professional listserv is an efficient and cost-effective method of gaining information quickly.
2. The peer-review process is an effective method of identifying the appropriateness and accuracy of curricula for a specific target audience, and nutrition professionals working with EFNEP and FSNE are willing to contribute their time to the peer-review of educational materials.
3. Curricula used by EFNEP typically are written by nutrition professionals; therefore, the subject-matter content is consistently accurate;
4. Curricula used by EFNEP often include limited participant involvement and could be improved by deliberate efforts to incorporate additional adult education learning principles;
5. Curriculum developers are cautioned to always keep the target audience (reading level, use of visuals, social norms, etc.) in mind when developing curriculum activities, handouts, visuals, and lesson plans.

The processes outlined in this project, along with the questionnaire and assessment tools developed, could be applied to a greater venture: reviewing a larger number of curricula, reviewing other nutrition education materials, and/or reviewing curricula of other programs with similar or differing target audiences.

Revised curricula updates

In August 2006, developers of the reviewed curricula where asked to provide updates on the state of their revision process. The following information summarizes the updates relative to each reviewed curriculum as of August 2006.

Florida. The developers of the Florida curriculum are in the last stages of reviewing the materials. Recipes included in the curriculum await editing. Flip charts will be created for each lesson in fall 2006. Educators are currently using the revised curriculum and have provided positive initial feedback. Developers predict that all revisions and materials will be completed by January 2007.

Iowa. The curriculum developers in Iowa decided not to continue with revisions to their previous curriculum — the curriculum included in our review. Instead they have joined a group of developers creating a new curriculum that will be used in multiple states. This curriculum is in the final stages of edits and corrections. Reviewers from multiple states have used an in-depth review tool to assess the lesson plans, visuals, and recipes included in this curriculum. Paraprofessionals from multiple states have been trained and are piloting the curriculum in their communities. Developers will make final edits to the curriculum based on feedback from the professional reviewers and results of the pilot testing by paraprofessionals. They expect the curriculum to be finalized and implemented by January 2007.

Massachusetts. The developers of this curriculum are continuing to make revisions as needed. The manual for the educators is finished; however, the booklets to be used by participants in class are still undergoing revision to reflect the 2005 Dietary Guidelines. Curriculum developers edit the booklets and print them as needed for specific lessons throughout the year. The curriculum has been in use for the last two to three years and revisions/updates are incorporated whenever possible.

Michigan. Developers plan on having the flip charts that accompany this curriculum finished by October 2006. The final version of the curriculum is predicted to be completed by December 2006. Implementation of the revised curriculum should occur between October 2006 and January 2007.

North Carolina. The revisions to the new curriculum developed for use in North Carolina are complete. The English version has been printed and distributed. The curriculum is in the process of being translated into Spanish and should be ready for use by November 2006.

Wisconsin. The educators in Wisconsin use booklets for each lesson (one booklet per topic). One of the booklets has been updated/revised to reflect the 2005 Dietary Guidelines and MyPyramid. Curriculum developers have decided against updating the other booklets and are currently evaluating other curricula as a possible replacement.

Wyoming. The major revisions to the Wyoming curriculum are finished; however, developers continually update and improve the materials as needed. The curriculum is currently in use.

Acknowledgements

This study was supported by and conducted at Colorado State University in Fort Collins, Colorado, in the Department of Food Science and Human Nutrition. We thank all the professionals involved in the process, including those who responded to the questionnaire and allowed their curricula to be included in the review, as well as those who served as reviewers: Mary P. Wilson, MS, RD, Extension Nutrition Specialist, University of Nevada Cooperative Extension, University of Nevada, Reno; Joan Doyle Paddock, MPH, RD, EFNEP Coordinator, Cornell University; Amy Rettammel, MS, RD, Outreach Specialist, University of Wisconsin Cooperative Extension, Family Living Programs, Wisconsin Nutrition Education Program and University of Wisconsin Department of Nutritional Sciences; Linda S. Gossett, MPA, Extension Educator – EFNEP, University of Idaho; Gail M. Hanula, EdS, RD, LD, Department of Foods and Nutrition, Cooperative Extension, University of Georgia; Barbara Sutherland, PhD, EFNEP Director, University of California, Davis; Katherine Cason, PhD, RD, Clemson University; Sarah Morales, MS, RD, Food Stamp Nutrition Education Coordinator, Colorado State University.

References

Betterley, Connie, and Brenda Dobson. 2000. Guide to Evaluating Written Nutrition Education Materials. SP 119. Ames, Iowa: Iowa State University Extension,http://www.extension.iastate.edu/Publications/SP119.pdf.

Brink, Muriel. 2000. Expanded Food and Nutrition Education Program: A Precedent-Setting Program. Cortland: Easy Writer Publications.

HHS/USDA (U.S. Department of Health and Human Services and U.S. Department of Agriculture). 2005. Dietary Guidelines for Americans 2005. 6th ed., Washington, D.C.: U.S. Government Printing Office, http://www.healthierus.gov/dietaryguidelines.

Klinedinst, N.J. 2005. Effects of a nutrition education program for urban, low-income, older adults: a collaborative program among nurses and nursing students. Journal of Community Health 22(2): 93-104.

McMurry, Kathryn. 2003. Setting dietary guidelines: the U.S. process. Journal of the American Dietetic Association 103: S10-S16.

Safeer, Richard, and Jann Keenan. 2005. Health literacy: the gap between physicians and patients. American Family Physician 72(3): 463-468.

Schneeman, Barbara. 2003. Evolution of dietary guidelines. Journal of the American Dietetic Association 103: S5-S9.

USDA-CNPP (U.S. Department of Agriculture Center for Nutrition Policy and Promotion). 2005. MyPyramid Food Guidance System, http://www.mypyramid.gov.

Weiner, Janet, and Abigail Aguirre, Karima Ravenell, Kim Korath, Lindsay McDevit, John Murphy, David Asch, and Judy Snea. 2004. Designing an illustrated patient satisfaction instrument for low-literacy populations. American Journal of Managed Care. 11(Pt2): 853-860.

Figure 1. Review tool one

Part I: EFNEP curriculum review feedback

(A)  Specific lessons: These topics may be included in the curriculum as individual lessons. If the topic is not included in the curriculum, circle No to part (a) and move to the next lesson.

Table 1. Curriculum attributes as reported by curriculum developers

Y – Yes; included in curriculum
N – No; not included in curriculum
NR – No response
ALT – Adult Learning Theory
ELT – Experiential Learning Theory
SLT – Social Learning Theory
SoC – Stages of Change
SCLT – Social-Cognitive Learning Theory

Table 2. Topics addressed in each reviewed curriculum

T – Topic addressed in curriculum
% Yes – Percent of the seven curricula including the topic

Table 3. Review tool two: Curriculum readability, content, and design attributes as identified by peer reviewers

O – Both reviewers agreed that the curriculum had the attribute
X – Both reviewers agreed that the curriculum did not have the attribute
? – The two reviewers differed in their opinion regarding the attribute
N/A – Not applicable
% Yes – percent of states in which both reviewers agreed that the curriculum had the attribute

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