Validation of a Teen Paraprofessional Peer-Teaching Model In Teen Parenting Nutrition Education
Validation of a Teen Paraprofessional Peer-Teaching Model In Teen Parenting Nutrition Education
Siew Sun Wong
Assistant Professor and Extension Nutrition Specialist
Utah State University
Sylvia Keller, MS, RD
Public Health Nutritionist
West Valley City, UT
Keywords: Teen pregnancy, teen parenting, peer teaching, paraprofessional, nutrition education
Peer teaching through a teen-paraprofessional model has not been tested in pregnancy nutrition education. This 4-week pilot study was designed to evaluate the effectiveness of this model. Two teen mothers were trained as peer nutrition educators (PNEs). Participants (n=77) consisted of 14-18 year-old, non-pregnant, non-nursing, single females. There were 23 case participants (cases) taught by PNEs and 54 participants (controls) taught by adult educators. PNEs taught 6 lessons each to 10-13 case participants over a 4-week period as an afterschool program. The study assessed knowledge, diet, physical activity, and behavior. Three months after the study ended, a post-study assessment was conducted among cases. Case participants improved in nutrition knowledge, diet, physical activity, and behaviors. Eighty-three percent of case participants liked or very much liked being taught by a peer. This pilot study found that teen mothers aged 18-19 are capable of teaching their peers accurate nutrition information and of effectively motivating them to achieve healthy lifestyles.
Each year, teenage pregnancy affects 750 thousand 15-19 year-old teens in the U.S. (Kost, Henshaw, and Carlin 2010). The national average cost per year for prenatal care and delivery per 17-year-old or younger pregnant teen is $4,080 (Kost, Henshaw, and Carlin 2010). In Utah 31 percent of residents are under age 18 (Davidson 2008; U.S. Census Bureau 2008). Teen births accounted for 6.6 percent of all reported births in Utah in 2006 (CDC 2010), with a birthrate of 34 per one thousand 15-19 year-old females (CDC 2010). The highest teen pregnancy rate and birthrate occurred in the Hispanic population at 132 per 1,000 and 99 per 1,000, respectively (Kost, Henshaw, and Carlin 2010). Although Utah ranked 33rd in teen birthrates in the U.S. (Kost, Henshaw, and Carlin 2010), it has the lowest teen abortion rates in the country (6/1,000), along with South Dakota (Kost, Henshaw, and Carlin 2010). Seventy-one (71) percent of teen pregnancies in Utah result in live births (Guttmacher Institute 2010). As high as 20 percent of teens in Utah reported having repeated teen pregnancies (Williams and Delavan 2004). Almost one in ten (9.2 percent) teenage mothers in Utah gave birth to a low birth weight baby (Nagle et al. 2008). In addition to prenatal care, this situation also requires greater need for social support among this high-risk population, including nutrition education programs.
Classically, the two major delivery modes for nutrition education programs among pregnant teens are the professional and paraprofessional models. The key difference between the two models is the educator’s level of professional training in nutrition. Compared to the professionals, the paraprofessionals are peer educators who do not have formal education in nutrition. Rather, some of them are volunteers, many of whom are indigenous to the target population and trained to teach basic nutrition to their communities. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) uses the professional model where registered dietitians teach the nutrition lessons. The Expanded Food and Nutrition Education Program (EFNEP) and Supplemental Nutrition Assistance Program Education use the paraprofessional model where adult paraprofessionals teach the nutrition lessons. For decades, these programs continue to improve pregnant teens’ nutrition knowledge, diet, physical activity, and/or behaviors (National Institutes of Food and Agriculture 2009). However, there is a lack of evidence that teen paraprofessionals are capable of accurately and effectively teaching their peers pregnancy nutrition information. Therefore, this pilot study implemented the proven effective paraprofessional model in a younger population and measured the effectiveness of the teen paraprofessional peer-teaching model in improving nutrition knowledge, resource management skills, behavior, and self-esteem. The ultimate target population is pregnant teens, however, before conducting the intervention among high-risk pregnant teens, it is critical to pilot-test the peer-teaching model. We chose to do this among non-pregnant teens to avoid any appearance of risk to mother and baby in the pilot and because the model had not yet been proven.
This pilot study, entitled Care for Two program (CARE42), was reviewed and approved by Utah State University Institutional Review Board. All participants completed the youth assent and had written parental consent. Between November 2008 and June 2009, the study occurred in Salt Lake County where the teen pregnancy rate was the highest in Utah. Phase 1 focused on the Peer Nutrition Educator (PNE) training and evaluation. Phase 2 focused on measuring the impact of this model.
Phase 1. Two WIC graduates, proficient in conversational English, were trained over 2 weeks to teach 6 of 12 lessons from the field-tested Teen Parents curriculum (Elliott et al. 2007). These lessons included “Have a Healthy Baby: Weight Gain during Pregnancy,” “Special Nutrient Needs,” “Take Care of Your Baby’s Health,” “Fast Food and Healthy Snacks,” “Get the Most for Your Money and “What Should I Eat?” Since WIC already teaches a thorough lesson about food safety, this study did not teach a food safety lesson but integrated food safety practices into food demonstrations.
Before training, each PNE candidate received a curriculum binder and a CD containing videos of the six lessons and an adapted Collaborative Institutional Training Initiative module about research privacy and confidentiality. These seven videos were developed by the principal investigator and research assistant (RA). Each independent study lesson ranged from 7-18 minutes.
In week 1, the research assistant (RA), a registered dietitian, trained the PNE candidates to teach all six lessons and showed them ways to improve their teaching skills. All training was done in English. During the same week, PNE candidates took Exam 1 where each candidate taught an assigned series of lessons to one another in the RA’s presence. The RA evaluated the content accuracy presented by each PNE, and PNE candidates also provided immediate feedback, following each lesson. Both PNEs passed Exam 1.
In week 2, each PNE candidate taught the same lessons again to the same training group. The RA evaluated the content accuracy and candidates’ teaching skills. Both PNEs passed Exam 2 and were qualified to teach peer participants.
In week 3, PNEs started teaching the 4-week course. In week 4, the PNEs met with the principal investigator and RA for the first follow-up group meeting. The principal investigator followed up with the PNEs about their teaching experience. At the same meeting, the RA showed the PNEs how to perform a food demonstration.
During weeks 7 and 8, PNEs finished with teaching all 6 lessons. The RA interviewed the PNEs on their perceived accuracy and effectiveness of a PNE compared to that of an older nutrition educator and on their greatest personal growth as a result of the study. PNEs provided feedback to improve future studies. Each PNE received a one-time honorarium of $200 and an employment opportunity with EFNEP.
Phase 2. Recruitment of 14-18 year-old, non-pregnant, non-nursing, single females, living in Salt Lake County, occurred between weeks 1 and 3. Personal contacts at schools and churches and posting flyers were major recruitment approaches.
Between weeks 3 and 7, PNEs taught 23 participants at two sites. Participants were assigned to two groups based on residential location in proximity to Site 1 or Site 2. To ensure teaching competency, the RA was present at each lesson to supervise, monitor, and evaluate. Each group met face-to-face six times, up to three times per week, for four consecutive weeks. The length of each lesson was about 30 minutes. PNEs used PowerPoint and visual aids to teach. Every lesson began with a review of the previous lesson. Next, the lecture integrated an oral presentation with interactive activities, including games, worksheets, and a group discussion. Each lesson ended with a review of the lesson. The PNEs provided additional teaching sessions to participants who had missed previous lessons. The seventh face-to-face contact at week 8 was a graduation ceremony. PNEs taught a food demonstration, and the RA collected all exit data from the participants. Each participant received a gift bag for completing the pilot study. Three months after the end of the study, the RA collected post-study dietary and physical activity assessments from these participants.
To lower attrition, the RA consulted with school teachers who worked closely with these participants to identify motivators and barriers for them to complete the study. As a result, the RA provided rides for Site 1 participants throughout the study and school credit for Site 2 participants. Lesson-related healthy snacks and door prizes were also provided to both groups.
Data collection and data analysis tools. The major outputs for this study include demography, teaching evaluations (for PNE only), pre-post assessments of knowledge (3-item AA format), diet and physical activity (24-hour recall conducted in-person or through phone contact), behavioral checklist (15-item, adapted from a validated EFNEP questionnaire, focusing on resource management skills, nutrition practices, food safety practices, and physical activity)(Anliker, Willis, and Montgomery 1998), and an Exit Survey (13-item). The 24-hour dietary recall was collected using the CSFII Multiple-Pass Method. The 24-hour physical activity recall was collected together where the type of activity and duration were asked. MyPyramid Tracker (USDA Center for Nutrition Policy and Promotion 2009), Food Processor (Version 10.6, 2010, ESHA Research, Salem, OR) and the National EFNEP Evaluation and Reporting System (NEERS, Version 5) were used to enter and analyze dietary and physical activity data. Diet analyses included estimation of total calories, carbohydrates, protein, fat, fiber, sodium, calcium, iron, folate, and vitamin C. Physical activity credited minutes and estimated calorie expenditure were calculated using MyPyramid Tracker. IBM SPSS statistical software for Windows (Version 18, 2010, SPSS Inc. Chicago, IL) was used for statistical data analyses.
PNE. Two married teen mothers were recruited to be PNEs. One was an 18-year-old non-Hispanic White, and the other was a 19-year-old African American. At baseline, both PNEs scored high in teaching evaluation, focusing on content accuracy and teaching effectiveness (e.g., baseline scores averaged 89.5 out of 100). Throughout the study, PNE1 taught a total of 24 sessions and PNE 2 taught 22 sessions. These sessions included the training sessions, the regularly scheduled classes, and 4-6 make-up lessons provided to absentees within the same week of the missed lesson. Although the PNE’s pre-post teaching evaluation scores did not increase significantly over 22-24 teaching sessions, a positive trend was observed. The pre-post exit survey showed both PNEs met program objectives and significantly improved their self-esteem (data not shown).
Control Participants. Fifty-four 14-18 year-old, non-pregnant, non-nursing, single female EFNEP graduates were included as the control participants. They were 58 percent non-Hispanic White, 35 percent Hispanic, 5 percent African American, and 2 percent Asian, Pacific Islander, or Native Hawaiian. Seventeen (17) percent were 15 year-olds, 27 percent were 16 year-olds, 38 percent were 17 year-olds, and 18 percent were 18 year-olds. Mean participant age was 16.6 years old. On average, they received 10 group lessons in three months taught by an experienced adult paraprofessional, using a different curriculum but still focusing on basic nutrition, fitness, resource management skills, and food safety. The control group participated between Oct 2008 and September 2009.
Case Participants. Twenty-eight 14-18 year-old, non-pregnant, non-nursing, single female high school students were recruited as case participants. Five Hispanic participants withdrew because of scheduling conflicts. All remaining 23 participants completed the study. The final sample consisted of 52 percent Hispanic, 35 percent non-Hispanic White, 13 percent Pacific and Asian participants. Thirteen (13) percent were 14 year-olds, 22 percent were 15 year-olds, 22 percent were 16 year-olds, 39 percent were 17 year-olds, and 4 percent were 18 year-olds. Mean age was 16 years old. Participants in Site 1 were mainly non-Hispanic White but included Hispanics, Pacific Islanders, and Asians. Participants in Site 2 were Hispanic only. There was no significant difference in age between the two sites.
PNE 1 taught 13 case participants at Site 1, and PNE 2 taught 10 case participants at Site 2. Case participant’s pre-post knowledge test scores were statistically significant among all samples (p<0.001), between and within sites (p<0.001), with Site 1 having a significantly higher score than that of Site 2 (p<0.01).
Table 1. Pre-post case participants’ exit survey scores.
[Table 1. Pre-post case participants’ exit survey scores]
|Question: “How would you rate your confidence level now compared to your confidence level before you started receiving CARE42 Program nutrition lessons?”|
|Case Group (n=23)|
|1.6 ± 0.8||4.1 ± 0.7|
|2.4 ± 0.9||4.4 ± 0.6|
|1.7 ± 0.8||4.1 ± 0.7|
|1.8 ± 0.9||4.1 ± 0.9|
|3.9 ± 1.1||4.8 ± 0.5|
|3.2 ± 1.2||4.6 ± 0.7|
|2.8 ± 1.5||4.7 ± 0.6|
|2.1 ± 0.8||4.2 ± 0.7|
|2.1 ± 1.0||4.4 ± 0.7|
|2.5 ± 1.3||4.3 ± 0.8|
|2.6 ± 0.9||4.4 ± 0.7|
|3.2 ± 1.2||4.7 ± 0.6|
|Total Exit Survey Scores||29.9 ± 5.3||52.7 ± 4.0|
a 1=very low, 2=low, 3=medium, 4=high, 5=very high; p<0.001 for all samples and all race/ethnic subgroups.
Table 1 shows pre-post exit survey results and was only administered to the case participants. Case participants had significant pre-post differences in meeting program objectives and an increase in self-esteem. Positive behavioral changes in all 15 behaviors were significant within each site and between both pilot study sites (p<0.001).
Table 2. Behavioral change among cases and controls.
[Table 2. Case-control behavioral change comparisons]
|2.4 ± 0.9||3.0 ± 0.7***||2.5 ± 1.3||3.7 ± 1.1***|
|3.3 ± 1.3||3.5 ± 1.1||2.9 ± 1.5||4.0 ± 1.1***|
|4.2 ± 1.0||4.0 ± 1.0||2.5 ± 1.4||1.7 ± 1.0***|
|2.9 ± 1.4||3.3 ± 1.2||2.8 ± 1.4||3.7 ± 1.0***|
|4.0 ± 1.0||4.3 ± 0.9||4.0 ± 1.1||4.5 ± 1.0*|
|3.2 ± 1.1||3.3 ± 1.2||2.9 ± 1.4||4.3 ± 1.1***|
|3.3 ± 0.9||4.2 ± 0.8***||3.1 ± 1.4||4.0 ± 1.0**|
|2.8 ± 1.4||3.0 ± 1.1||2.2 ± 1.3||2.9 ± 1.1**|
|2.4 ± 1.0||3.5 ± 1.1***||2.0 ± 1.3||3.4 ± 1.3***|
***p<0.001, **p<0.01, *p£0.05.
a Mean score, maximum score of 5 from ratings: 1=Never, 2=seldom, 3=sometimes, 4=most of the time, 5=almost always. Coding for questions 5 and 6 were reversed in this table.
Table 2 shows changes in 9 behaviors compared among cases and controls. There were more significant improvements among the control group than the case group (9 out of 9 vs. 3 out of 9), indicating a higher impact in behavioral changes among controls.
Table 3. Other behavioral change among cases.
[Table 3. Other behavioral change among cases]
|3.4 ± 0.8||3.4 ± 0.7|
|3.0 ± 1.1||3.7 ± 0.9**|
|4.0 ± 1.0||4.4 ± 0.8*|
|3.9 ± 1.2||4.2 ± 0.9|
|2.9 ± 1.1||3.9 ± 0.9***|
|3.7 ± 1.1||4.4 ± 0.8*|
***p<0.001, **p<0.01, *p<0.05.
a, Mean score, maximum score of 5 from ratings: 1=never, 2=seldom, 3=sometimes, 4=most of the time, 5=almost always. Coding for question 2 was reversed in this table.
Table 3 shows additional questions collected among cases only about other behavioral changes. Case participants reported skipping meals less frequently, washing hands before eating, participating in planned exercise, and taking opportunities to be physically active more frequently.
Table 4. Mean physical activity levels, caloric and nutrient intakes.
[Table 4. Mean physical activity levels, caloric and nutrient intakes]
|Dietary and Physical Activity Indicators||First
|Second 24hdr||Pre-Post Difference
|Case Participants (n=23)|
|Physical activity credited minutes||95 ± 74||238 ± 132||0.00|
|Energy expenditure from physical activity (kcal)||1,283 ± 587||1,880 ± 762||0.00|
|Total Calories (kcal)||1,625 ± 658||1,681 ± 593||0.75|
|Carbohydrate (g)||217 ± 87||229 ± 88||0.62|
|Protein (g)||62 ± 29||59 ± 19||0.75|
|Fat (g)||60 ± 29||62 ± 30||0.79|
|Fiber (g)||13 ± 6||15 ± 11||0.41|
|Sodium (mg)||2,519 ± 1,222||2,882 ± 1,477||0.33|
|Calcium (mg)||902 ± 655||833 ± 443||0.68|
|Iron (mg)||12 ± 5||14 ± 4||0.03|
|Vitamin C (mg)||93 ± 82||94 ± 96||0.96|
|Folate (mg)||262 ± 119||323 ± 164||0.14|
|Control Participants (n=54)|
|Physical activity (min/day)||30 or less||30-60||0.00|
|Total Calories (kcal)||1,582 ± 635||1,918 ± 690||0.00|
|Carbohydrate (g)||209 ± 89||244 ± 89||0.01|
|Protein (g)||59 ± 29||81 ± 30||0.00|
|Fat (g)||59 ± 30||72 ± 34||0.02|
|Fiber (g)||11 ± 5||18 ± 8||0.00|
|Sodium (mg)||2,565 ± 1,305||3,556 ± 1,302||0.00|
|Calcium (mg)||723 ± 540||1,190 ± 510||0.00|
|Iron (mg)||13 ± 9||16 ± 6||0.03|
|Vitamin C (mg)||44 ± 51||75 ± 55||0.00|
a 24hdr, 24-hour dietary recall. 24-hr dietary and physical activity recalls were collected from the cases at week 8 (end of study for cases) and three months after the end of the study, and controls at week 1 and up to 6 months later.
b NA, not available from EFNEP.
Table 4 shows pre-post physical activity and dietary differences among cases and controls. While the case group did not change their dietary practices they did significantly increase their mean amount of time in physical activity from 95±75 minutes to 238±132 minutes (p<0.001). This was also significant for all race/ethnicity subgroups: Asians and Pacific Islanders (p<0.01), Hispanics (p<0.01), and non-Hispanic Whites (p<0.01). The case group had a significant increase in energy expenditure from physical activity from 1,283±587kcal to 1,880±762kcal (p<0.001). This increase was also significant for Hispanics (p<0.01) and non-Hispanic Whites (p<0.05). Among the control group, the mode for physical activity duration shifted from 30 minutes or less to 30-60 minutes per day (p<0.001). The most common physical activities were running/jogging, walking, jump roping, dancing to the radio, and the sports basketball, volleyball, biking, and swimming.
For diet, mean protein intake showed no significant change overall for the case participant group however, within the group, it significantly decreased among the non-Hispanic White case group by 12g (p<0.05) and increased among the Hispanic case group by 5g (p<0.01). Mean iron intake increased among all case participants from 12 mg/d to 14 mg/d (p<0.05). Among the control group, a subset of five participants, all non-Hispanic Whites, completed EFNEP within a month. The rest completed the program between 2 and 6 months, which is typical to EFNEP. This subset (n=5) showed significant increase in calories (from 1,970±722 to 2,531±1, 190kcal/d, p<0.05) and protein (from 77±43 to 113±38g/d, p<0.01). As enrollment in EFNEP passed beyond a month, all other nutrient intake increments became significantly increased. Within the control group, while the Hispanics (n=18) increased in caloric, carbohydrate, protein, fat, fiber, sodium, calcium, iron and vitamin C intakes (p<0.01), the non-Hispanic Whites (n=31) increased in protein, fiber, sodium, calcium and vitamin C intakes (p<0.01).
Figure 1. Case groups’ Likert scale on how much they liked to be taught by a peer educator rather than an older educator in teen parenting nutrition education.
[Figure 1. Cases’ rating on being taught by a peer educator]
Overall, this teen paraprofessional peer-teaching model was very well received. Figure 1 shows that 19 of 23 (83 percent) case participants “liked very much” and “liked” to be taught by a peer educator rather than an older educator in teen parenting nutrition education. Their written comments reported that they learned more or learned well with a peer educator, felt very comfortable talking to a peer educator, and felt it was fun to learn about nutrition this way. Two participants had a neutral response. Two other participants rated “disliked” or “disliked very much”; they felt older educators could have answered more questions. There was no significant site effect or participant’s age effect in this rating. Site 1 participants who rated themselves higher in the exit survey of overall improvement tend to like being taught by a PNE. Site 2 participants who scored higher on pre-post knowledge tests tend to like being taught by an older nutrition educator rather than by a peer educator.
This study positively impacted case participants in self-esteem, nutrition knowledge, nutrition practices, food safety, resource management, iron intake, and physical activity. Higher exit mean scores on the behavioral checklist and physical activity level indicate the effectiveness of a peer-teaching paraprofessional model. It also indicates that PNEs are capable of teaching effectively, and that this study met its stated goal to increase participants’ confidence in their increase in nutrition knowledge, resource management skills, positive behavioral change, and self-esteem. Comparative impacts were also achieved by other peer-teaching-peer programs (Redman 1987; Greenhalgh 1995; Coob 1997; Houghton and Roche 2001; Story et al. 2002; Gibson 2007; Becker et al. 2008; Horwitz et al. 2009; Zhang 2010).
We speculate that the reason for these correlations is that those who liked or very much liked to be taught by a PNE see the PNEs as creditable sources of information and are more apt to apply their teachings. Redman also found among his PNEs that the more creditable the source, the more likely it is that attitudes will change among students (Redman 1987). Also, we speculate that those who tend to be more intellectual like to be taught by an older educator because they like to have their questions answered more thoroughly. Furthermore, this pilot study only had two PNEs and a component of this might be due to differences in the teaching styles and skills, confidence in nutrition knowledge, and the ability to answer more technical questions.
The success of this afterschool teen parenting nutrition program was due to strong motivations among the PNEs and RA. The PNEs were very cooperative and willing to provide make-up lessons for absentees. Post-program evaluation data collected three months after the nutrition program ended was challenging. The RA was persistent in reconnecting with all case participants, especially Hispanics, to collect data within the research timeline. In addition to multiple phone calls, the RA also visited some case participants in their homes as advised by the participants’ parents. A strong support system for the PNEs was also critical. The RA was present in all teaching sessions. Before each lesson, the RA met with the PNE 15-30 minutes earlier to discuss potential questions about the lesson. The RA also debriefed with each PNE about her teaching immediately after the end of each lesson. Group meetings among the principal investigator, RA, and PNEs further provided opportunities to share program success and troubleshoot challenges.
Both PNEs evaluated the pilot study. Things to keep in the program for future studies include use of a motivated and capable trainer for the PNEs, recruitment of WIC graduates as PNEs because they already have some nutrition background, PNE training sessions, use of PowerPoint for training and teaching, free rides for participants to attend program lessons, and continuation of the CARE42 Program. Things to change in the program for future studies include: increased duration of PNE training, more training on teaching skills, greater PNE confidence and professional dress for teaching their peers, increased incentive to cover PNE’s gas mileage reimbursement, recruitment of participants from mainstream high schools rather than alternative high schools, increase in class time from 30 to 45 minutes to allow more time for discussion, expansion of lesson topics to include neural tube defects and drugs during pregnancy because most case participants were very interested in these topics, use of nametags in class, avoidance of change in scheduled training time and location, and provision of drinks with snacks to attract more participants.
This pilot study has several strengths: 1) the study responded to an existing need for teen parenting nutrition education due to high teenage pregnancy rates in Utah, 2) use of a field-tested teen-parenting curriculum, 3) post-program impact evaluation among participants, 4) partnership with WIC, EFNEP, and a school, which enabled resource sharing among well-established federal nutrition programs, and 5) validation of this model among non-pregnant teens before targeting pregnant teens to reduce risk of misinterpretation of information delivered to the high-risk audience. Although prevention was not an outcome measure for this pilot study, nutrition training became very beneficial for two participants who reported being pregnant after completing the study.
The study also has its limitations. 1) Due to limited resources, the control group did not receive similar lessons nor the same number of lessons (8-10 versus the 6 that the case group received) as did the case group although the lessons still focused on basic nutrition, fitness, resource management, and food safety, and the control group is a subsample from the EFNEP graduate pool where they had already completed all program requirements. Since case participants received nutrition lessons from adult educators at school, the study assumed that case participants would be able to compare between two different modes of delivery, i.e., adult versus peer. 2) The study could only afford to collect two dietary and physical activity recalls. Case-control comparison was limited to a behavioral checklist, diet, and physical activity. 3) Because of the small sample size, findings needed to be generalized. The study purposively included more Hispanics to best reflect the teenage pregnancy rate in the state, which is 132 per one thousand 15-19 year-old Hispanic females (Kost, Henshaw, and Carlin 2010). 4) Some participants lacked interest in an afterschool program. Inconsistent attendance increased the PNEs’ and the RA’s burden to provide additional make-up sessions. 5) There was limited incentive to the PNEs and participants due to budget and resource constraints. Most importantly, there is the factor that the participants were not pregnant and may not truly represent the intended audience and also may not have had a ‘felt’ need for the information.
In conclusion, the teen paraprofessional peer-teaching model among teens can be effective in improving the PNEs’ and participants’ quality of life directly. This model has great potential in expanding and sustaining the outreach to teen parents, motivating them to achieve healthy lifestyles.
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