The nationwide training for nutrition educators aims to build skills for successfully planning, implementing, and evaluating policy, systems and environmental (PSE) change strategies that make healthy food and activity choices easier for low-income populations. The competency-based training provides professional development, continuing education credits, and certification in core competencies for nutrition and health professionals. The training is based on a national assessment of PSE training needs, conducted by RNECE-northeast, and the Developing a Curriculum (DACUM) study, conducted by the RNECE-PSE Change Center. RNECE-northeast staff are leading the development of the training program in collaboration with the PSE Change Center and the Nationwide Training Workgroup*.
Module A: Defining PSEs
Make sense of the terminology; Understand the importance of community context; Understand PSE resources; Provide example PSE resources; Support staff and community partners
Module B: Identifying Community Needs and Opportunities
Understand demographic data; Understand the community of interest; Assess current efforts; Understand community needs assessment methods
Module C: Building Multi-Level, Multi-Sector Partnerships
Identify multi-level and multi-sector partners; Communicate interests to potential partners; Coordinate collective resources
Module D: Creating PSE Action Plans
Select PSE approach; Identify evaluation methods; Prepare an action plan
Module E: Implementing PSE Action Plans
Review action plan; Train staff and partners; Monitor PSE implementation; Identify next steps
Module F: Evaluating PSE Strategies
Evaluate PSEs; Share PSE evaluation findings; Refine action plan(s); Plan for sustainability
Nationwide Training Workgroup
Alice Ammerman, DrPH, RNECE-South; Catalina Aragón, MS, CN, RNECE-West; Kathleen Cullinen, PhD, RD, NC-RNECE-North Central; Marsha Davis, PhD, RNECE-PSE Change Center; Janet Kurzynske, Ph.D., R.D., RNECE-National Coordination Center; Kathryn Yerxa, MS, RD, RNECE-Northeast
Contact us at FNECfirstname.lastname@example.org for more information.
The Systematic Review is in progress.
What is the evidence for the effectiveness of combining direct nutrition education (DNE) with PSE changes, compared to either of these strategies alone, on weight status and food and nutrition behaviors related to obesity prevention?
Review Inclusion Criteria using PICO
- Problem (Domain) – Obesity prevention
- Population – Non-clinical, community dwelling adults and children >2 y.o., in middle and high income countries
- Intervention – Must include both PSE and DNE using RCT or quasi-experimental design
- Comparison – Allows for comparison of combined PSE-DNE approach to either PSE or DNE alone
- Outcomes – Weight status and/or food and nutrition behaviors
Systematic Review Protocol
The protocol has been registered with International Prospective Intervention Comparison Outcomes (PROSPERO) and the search of twelve databases completed: 11,192 articles were identified.
Systematic Review Workgroup
Alisha Gaines, PhD; Joan Paddock Doyle, PhD, MPH, RD; Tisa Fontaine Hill, MS; Michelle Scott-Pierce, MBA; and Debbie Sellers, PhD, Cornell University; Cindy Fitch, PhD, West Virginia University; Barbara Lohse, PhD, Rochester Institute of Technology.
The goal of the center’s signature research program is to investigate whether direct nutrition education delivered in combination with policy, systems, and environmental (PSE) changes is more effective in improving healthy nutrition and physical activity behaviors than either strategy alone.
The program includes 5 research projects encompassing variation in race, ethnicity, cultural contexts, target audience, and methods of delivery. Two projects were implemented in SNAP-Ed and three projects were implemented in EFNEP. Three projects were conducted in urban settings, one project was conducted in a suburban setting, and one project was conducted in a rural setting at two sites within micropolitan areas. One project was a randomized controlled trail (RCT) and four projects used quasi-experimental designs.
1) Adopting Healthy Habits in Worksites: Increasing adoption and acceptability of policy, systems, and environmental changes within agencies serving low-income families
Dollahite J, Fontaine Hill T, Sellers D, Cornell University and Cornell Cooperative Extension
Objective: To assess the effects of adding direct education to PSE change efforts in three worksites (2 Head Start programs and 1 Community Action Planning Council). Specifically, the study is assessing the effects of adoption and implementation of PSEs; assessing the effects of providing direct education and PSE changes; and comparing the effect of PSE only to the effect of PSE and direct education.
Participants: Across all three worksites, there are 140 agency staff (46% low income) and 449 parents/clients (84% low income).
Design: Worksites are implementing PSE changes to promote eating more fruits/vegetables, drinking water instead of sugar-sweetened beverages, and increasing physical activity. Some agency staff and clients are also participating in direct education (Healthy Children, Healthy Parents Making a Difference!). Data collection includes participants reported behavior and BMI in Year One (T1+T2) and Year Two (T3+T4) as well as environmental scans and policy adoption for PSEs.
2) Nutrition Ed, Access and Texting (NEAT): Combining the Hartford Mobile Market with e-Marketing
Damio G, Pérez-Escamilla R, Segura-Pérez S, Hispanic Health Council, Hartford CT and Yale School of Public Health, New Haven CT
Objective: To assess the effects of combining nutrition education with produce vouchers and a text messaging campaign promoting fresh produce purchases at the Hartford Mobile Market (HMM) on access, purchase and intake of fruits and vegetables.
Participants: Parents with children age five years or younger.
Design: All participants received a MyPlate SNAP-Ed direct education lesson and were randomly assigned to the intervention group (n=100) or control group (n=93). The intervention group received daily text messages for thirty days promoting the use of the HMM, as well as $20 in HMM coupons as incentives. The control group received daily text messages about free public events in the city. Surveys were conducted at baseline and six weeks after enrollment. Participants were mostly female (97%), Hispanics (79%), and SNAP beneficiaries (81%). There were no between-group differences at baseline.
Results: The participants in the intervention group spent more on fruit weekly ($42 vs $30, p=.027), were more likely to purchase fruits and vegetables at the mobile market (46% vs. 23%, p=.002), and consumed 0.33 more daily servings of fruit compared to the participants of the control group. The intervention group participants redeemed 67% of coupons received. HMM users were very satisfied with price and quality of the produce and customer service.
Conclusion: NEAT is a culturally sensitive social marketing intervention that led to improved access to and purchase of produce and consumption of fruits in an urban low-income community.
3) Transforming Lifestyles: Integrating Direct Nutrition Education with Physical Activity Using the Health Care System Expansion Model
Mehta M, Sankavaram K, Benoit-Moctezuma D, Song H-J, Ashburn L, University of Maryland Extension, College Park MD
Objective: To test the effectiveness of engaging primary health care providers in assessing children’s physical activity levels and providing information and referrals to physical activity resources and EFNEP.
Participants: The study engaged medical providers at seven clinic sites: intervention n=12; control n=8. Latino parent-child dyads (children 5-18; BMI = overweight/obese) were recruited: intervention n=23, control n=26.
Design: Quasi-experimental with a convenience sample of participants assigned at the clinic level. All clinic sites screened children for overweight/obesity and referred at-risk families to EFNEP nutrition education, Eating Smart Being Active and Cooking Matters for Kids (Health Care System Model). In the intervention clinics, two physical activity screening questions were added to the clinical protocol and electronic record. In addition to BMI, providers screened at-risk children for physical activity (PA), provided age-appropriate PA tip sheets and a free/low-cost community resource list for PA (Health Care System Expansion Model). Data were collected at the beginning and end of the six-week interventions.
Results: Providers in the experimental clinic sites found the screener easy to use (<3 min), helpful in communication, and recommended routine use. Compared to control sites, providers more frequently discussed BMI & PA with parents. Overall, providers mentioned that of community programs, only EFNEP provided lifestyle intervention. Parents in the experimental sites found the screener provided an opportunity to ask questions and receive guidance. Compared to control sites, parents in the experimental group increased PA, though not significantly (p=0.11). There were also improvements in the Healthy Eating Index (HEI) reflecting the impact of EFNEP (control group p=.06, intervention group p=.02). Children: When comparing the intervention group to the control group, there was an increase in physical activity in older children and a decrease in screen time in younger children, however the study was underpowered to see significant differences. Altogether, the two groups of children experienced improvements in dietary intake reflecting the impact of EFNEP: increased vegetables (p<0.001), fruits (p<0.04), low fat foods (p=0.05) and healthy snacks (p<0.006). Several measures also indicated that children significantly decreased intake of sugar-sweetened beverages.
Conclusion: Overall, this study suggests that incorporating screening questions about physical activity as part of routine vital signs in healthcare settings provides a promising strategy for encouraging physicians to engage children and their parents in discussions regarding weight and sustainable physical activity. Time for additional participant enrollment would have improved statistical power and the potential for finding significant changes in PA.
4) Sustaining a Successful Youth-Leader Program as part of a Multi-Level, Multi-Component Food Environment/Behavioral Intervention
Gittelsohn J, Trude A, Lachenmayr L, Johns Hopkins Bloomberg School of Public Health, Baltimore MD and University of Maryland Extension, Columbia MD
Objective: To test a model to train teen leaders to deliver nutrition education to younger youth and act as spokespersons in social media as part of a larger B’more Healthy Communities for Kids (BHCK) trial that includes environmental changes in food stores, carryouts, wholesalers and recreation centers to improve healthy food access.
Participants: Youth leaders ages 15-18; caregiver/child (ages 10-14) dyads. Intervention: leaders n=13; dyads: n=133. Controls: leaders n=11; dyads: n=103. The setting was low-income areas near Baltimore City recreation centers, populated predominately by African-Americans.
Design: BHCK employed a group-randomized controlled trial design and recruited caregiver-child dyads in 14 neighborhoods (intervention (n=7), control (n=7). The youth leader component used a quasi-experimental design. They were recruited and assigned to intervention and comparison groups based on availability. A train-the-trainer approach was employed, using content on building nutrition knowledge, food preparation skills, skill-based teaching methods, presentation skills, teamwork, and leadership. Youth leader teams were formed to act as spokespersons in BHCK social media, and deliver the SNAP-Ed and BHCK nutrition education in recreation centers, community corner stores and carryouts.
Results: Youth leaders showed more improvement in nutrition outcome expectations (i.e. expected health outcome from eating and drinking specific foods and beverages) compared to controls (p=.02). Youth-leaders who were more engaged with the intervention had significantly higher mean change of outcome expectancy compared to youth who did not participate in the youth leader program. For the younger youth receiving the nutrition education, energy and fat intake decreased more in the intervention than control group, but the study was underpowered to see significant differences.
Conclusion: Having older youth acting as role models in the context of a PSE approach improved youth-leader psychosocial factors and leadership skills for those most involved. The approach shows promise for positively influencing dietary behaviors of children receiving the program. The BHCK nutrition curriculum is being disseminated through SNAP-Ed to other community organizations.
5) Empowering Urban Schoolchildren to Increase Fruit and Vegetable Consumption though EFNEP-enhanced PSE Interventions
Sebelia L, Greene G, Mulligan K, University of Rhode Island, Providence, RI
Objective: To test the effectiveness of an intervention to engage 5th grade students in activities to change their school food environment.
Participants: 5th grade students in the urban Pawtucket School District which has an average of 74% free/reduced price lunch participation. Intervention: 2 schools, n=142 students; Control: 2 schools, n=178 students.
Design: Quasi-experimental in which students were assigned to groups at the school level. In both schools, students received the standard SNAP-Ed Fresh Fruit and Vegetable Curriculum. Intervention school students also received a new 10-week PSE curriculum, Students Take Charge!, in which students engaged with the school wellness committee and food service staff to change menus.
Results: Post intervention, the treatment group had a higher PSE knowledge score than the control group when adjusted for baseline score (p<.001). Intervention students were more likely to have an opinion about fruit/vegetable choices, and to recognize their school’s encouragement of eating fruits/vegetables, compared to controls. There were no significant changes in fruit/vegetable intake from pre to post in either treatment or control groups.
Conclusion: The new PSE curriculum represents a first step in efforts to engage students and school food service in PSE efforts and could result in more healthy changes introduced by students and implemented by food service and school administrations.
- Karene Booker
Department of Development Sociology
- Jamie Dollahite
Division of Nutritional Sciences
- Joan Doyle Paddock
Interim Director and Program Coordinator of Food and Nutrition Education in Communities (FNEC)
Division of Nutritional Sciences
- Donna Brown
Program Leader, Family & Consumer Science
Delaware State University Cooperative Extension
- Grace Damio
Director of Research & Service Initiatives
Hispanic Health Council
- Ann Ferris
Professor Emerita, Founding Director, Executive Committee member
Center for Public Health and Health Policy
University of Connecticut
- Cindy Fitch
WVU Extension Associate Dean of Programming & Research
Professor of Human Nutrition and Foods
West Virginia University
- Tisa Hill
Division of Nutritional Sciences
- Barbara Lohse
Wegmans School of Health and Nutrition
Rochester Institute of Technology
- Jeff Niederdeppe
Department of Communication
- Debbie Sellers
Director of Research & Evaluation, RCCP
Bronfenbrenner Center for Translational Research
- Christina Stark
Division of Nutritional Sciences
- Kate Yerxa
Associate Extension Professor. EFNEP Coordinator
University of Maine Cooperative Extension