The Expanded Food and Nutrition Education Program (EFNEP) has been Extension’s cornerstone nutrition education program for over 50 years, impacting the lives of over 34 million low-income families.¹ Evaluation and research have been essential EFNEP components since its inception, including studies on behavioral assessment, cost-effectiveness, and the dose-response relationship of EFNEP lessons.^2,3 EFNEP research and evaluation questions have changed over time to accommodate a diversifying target population and advances in both technology and nutrition education theories and practice. Notably, over the past 15 years, this multistate group, in its past three iterations, has been a key partner in conducting multistate research and evaluation studies on EFNEP’s behalf.

For this next 5-year cycle, the following projects are proposed:

Cost-Benefit Analysis:

Chronic diseases represent a complex, growing health problem in the US, with six in ten Americans having a chronic disease.⁴ Chronic diseases place a significant economic burden on the nation, accounting for $3.24 trillion of the nation’s healthcare expenditures and $4.95 billion in lost wages annually.^5,6 EFNEP directly addresses chronic disease risk reduction by providing education to improve diet quality and physical activity among low-income families.

With limited public funding available, an effective means to estimate, evaluate, and communicate the economic value generated by EFNEP through chronic disease risk reduction is critical for program stakeholders. Cost-benefit analysis serves as a quantitative, rigorous means to estimate the economic value generated by a nutrition education program. In a survey conducted at the 2021 National EFNEP Coordinators Conference via Zoom poll, 80% of EFNEP program coordinators indicated they were “very interested” in utilizing a cost-benefit analysis tool to assess the economic value created by their program. The development and application of an objective cost-benefit analysis methodology will result in accurate estimates of the economic value generated by EFNEP through chronic disease risk reduction and will inform stakeholders and policymakers of potential programmatic improvements.

This work is feasible when undertaken as a multistate effort, which allows for representation of the national scope of EFNEP and for the formation of an experienced, interdisciplinary team of EFNEP program coordinators, nutritionists, economists, and statisticians. A pilot BMI-based cost-benefit analysis of the Colorado and Washington adult EFNEPs, undertaken by research team members, and prior nutrition education cost-benefit analyses further support the technical feasibility of this research.^7,8

Quality of Life:

Maslow’s widely-accepted hierarchy of human needs states that basic physical needs (food, shelter, water) must be satisfied before a person can attain higher order psychological fulfillment.⁹ EFNEP focuses on low-income audiences who often have difficulty meeting the basic physical needs for food and shelter. The program helps families manage resources through menu planning, food purchasing, and food storage. As an added benefit, practicing food resource management skills can help in other household management areas. Meeting these needs allows EFNEP participants to move toward psychological fulfillment and improved quality of life (QoL).

Previous research has shown that people do not adapt to long periods of extreme poverty, and those living in poverty typically experience lower levels of subjective well-being, or low QoL.¹⁰ Individuals with very low incomes were highly dissatisfied with their personal QoL; however, when homeless individuals experienced good social relationships, not only was their perception of well-being higher but the psychological costs of material deprivation were mitigated.¹¹ Because EFNEP hires paraprofessional educators who are from the target population communities and have experienced poverty themselves, a large part of the EFNEP experience relies on establishing good social relationships. In recent years, EFNEP delivery has looked very different as programs shifted to remote delivery and in-person contact was minimized, primarily due to the COVID-19 pandemic. Social interaction is a key facilitator of adult learning and the way this is incorporated into online platforms can vary.¹² To our knowledge, the impact of this change in delivery on EFNEP participants’ or educators’ perceived social support and the interplay of delivery and support on QoL has not been studied.

EFNEP programs report annual impacts, including anecdotal evidence of participants’ improvements in self-esteem, moral direction, and sense of community belonging as a result of EFNEP participation.¹³ Earlier work from this multistate research group found that EFNEP graduates and educators reported an increase in positive views about themselves, e.g., self-acceptance and self-esteem, as well as an improved sense of hope and belonging.^14,15 Determining whether EFNEP participation provides a broader benefit of improved QoL is needed for greater knowledge of the program’s impact. Currently available QoL tools either assess QoL in the context of chronic diseases/disabilities or in terms of overarching constructs (religion, marriage, etc.) that are not applicable to EFNEP. Based on pilot studies noted above, NC3169 developed an EFNEP-specific QoL tool and began validating this questionnaire to provide a means to quantify EFNEP benefits beyond the knowledge and skills taught in EFNEP lessons. If EFNEP participation results in a perception of improved QoL, program evaluation could expand the understanding of EFNEP’s benefits, e.g., improved QoL may predict sustained healthy behavior changes and, ultimately, improved health status. 

24-Hour Recall:

The 24-hour dietary recall (24HDR) is generally considered to be the gold standard for dietary assessment.¹⁶ In EFNEP, paraprofessionals are trained to conduct 24HDR with groups of participants. However, this participant-recorded group-administered procedure for collecting 24HDR has never been validated.¹⁷ Recent research has questioned the quality of the data obtained due to inconsistency in the protocols used to collect the 24HDR and variation in the training given to personnel.¹⁸ Valid and reliable information about dietary intake is essential to determine program efficacy. Therefore, it is imperative to continue researching methodologies to improve dietary data collection.

As a step toward improved standardization of 24HDR procedures, a crosswalk review of the data collection instruments, and data collection protocols currently utilized will be investigated. A common data collection instrument and protocol will be recommended for implementation of the pen-and-paper 24HDR and the online Automated Self-Administered 24-Hour (ASA24) data collection procedure, which is being piloted by a select number of EFNEPs. Lastly, efforts will begin to validate the 24HDR instruments and data collection protocols.

Youth Evaluation:

Pre-post questionnaires have been utilized with middle and high school-aged EFNEP participants to assess EFNEP’s behavioral impacts with these populations. Historically, these questionnaires have been developed by national committees of EFNEP stakeholders with expertise in youth and adolescent programming. However, time and resource constraints had prevented rigorous validity and reliability testing of these questionnaires.

From 2018-2022, a separate workgroup developed and tested a revised questionnaire for EFNEP participants in grades 6-12.¹⁹ The questionnaire’s development and testing followed a 5-step process utilized by a prior iteration of this multistate group (NC2169) to develop and test the Food and Physical Activity Behavior Questionnaire (FPABQ).²⁰ Despite promising results from that workgroup’s initial work, more testing is needed to further establish the validity and reliability of the EFNEP 6th-12th Grade Questionnaire, namely: test-retest reliability, confirmatory factor analysis, and criterion validity assessments using “gold standards” of dietary and physical activity assessment, e.g., diet recalls and accelerometry.

A multistate effort will allow for the recruitment of a diverse sample of low-income, middle and high school students from various geographic regions, improving the generalizability of our results. Moreover, this multistate group’s specific expertise with developing rigorously tested behavioral questionnaires for low-income populations (i.e., the FPABQ) will be helpful as we continue to further develop and test this tool. The final output for this project will be the most rigorously tested questionnaire developed for EFNEP middle and high schoolers, with sufficiently established validity and reliability. This will allow EFNEP implementers to assess the impacts of their adolescent educational efforts.

Spanish Adult Questionnaire Translation:

The FPABQ, which comprises 25 of the 30 items on the EFNEP Adult Questionnaire, has only been tested with English-speaking EFNEP-eligible populations. This is of concern because 40% of EFNEP graduates identified themselves as Hispanic (2016), many of whom are immigrants from Spanish-speaking countries. This proportion is in line with current trends in the national Hispanic population growth, which grew by 23% in the past decade, outpacing the nation’s overall population growth of 7%. According to the 2020 Census Survey, 29.5% and 41.4% of household income for Hispanics (any race) fall below 150% and 200% of the federal poverty level (FPL), respectively, giving some indication of Hispanic individuals who qualify for EFNEP (which requires an income <185% of the FPL). In contrast, only 14.1% and 20.9% of non-Hispanic Whites fall below 150% and 200% of the FPL, respectively. More than 20 states and 1 territory offer EFNEP classes in Spanish, which need to be evaluated with language-appropriate tools. Also, 39% of those who speak Spanish at home have limited ability to speak English, further emphasizing the importance of offering EFNEP programming and evaluation in Spanish. Reliability and validity testing of a standardized Spanish translation of the FPABQ is necessary to ensure the tool is equally effective with Spanish-speaking populations.

Curricula Content Analysis:

EFNEP provides practical, interactive, evidence- and research-based nutrition education that aims to improve nutritional health and well-being among families with limited financial resources. To achieve this overarching goal and related behavioral changes, educational program content must address the core focus areas of EFNEP (i.e., diet quality, physical activity, food resource management, food safety, and food security). 

The effectiveness of interventions for behavior change depends on a variety of characteristics such as research-based content, theoretical basis, inclusion of different learning styles and kinesthetic activities.²¹ The duration and dosage of intervention, along with fidelity during implementation, are also critical components.²²

In the previous decade, a few studies examined the content of the EFNEP curricula. Hernández-Garbanzo et al. analyzed the coverage of nutrition and physical activity topics in the youth curricula.²³ In 2013, Murray et al. focused on the nutrition content of EFNEP lessons for adults and its alignment with the 2010 Dietary Guidelines for Americans (DGA).²⁴ They reported that even when various curricula covered the same topics, there were differences in frequency, depth of instruction, and methods used to reinforce learning. 

Although these earlier reports have been very useful, up-to-date analyses of EFNEP curricula are necessary for multiple reasons. First, there have been substantial changes in the lesson content, evaluation instruments, and national physical activity and nutrition guidelines (e.g., DGA), which are necessary for EFNEP to follow. Second, physical activity has been included in the EFNEP lessons, but the degree of coverage, teaching methods, other implementation characteristics, and related behavioral outcomes have not been examined. Facilitators and barriers to the provision of adequate physical activity content is another substantial gap in our current knowledge that needs to be addressed to help improve the effectiveness of programming.

Another critical issue that necessitates an updated and comprehensive examination of the EFNEP curricula is the technological developments in recent years that resulted in drastic changes in the availability of nutrition and health-related information as well as changes in teaching and learning tools for EFNEP providers and participants. Furthermore, the COVID-19 pandemic and its impact on staffing and public health guidelines caused EFNEP providers to modify their programming. Many programs have been implementing online sessions to varying degrees, and such transitions are expected to continue. The extent of use and effectiveness of these newer approaches (e.g., engaging participants to achieve the desired behavioral outcomes) are currently not known and must be examined.