Duration: 10/01/2013 to 09/30/2018

Administrative Advisor(s):

NIFA Reps:

Non-Technical Summary

Statement of Issues and Justification

STATEMENT OF THE PROBLEM: The Expanded Food and Nutrition Education Program (EFNEP) was established by Congress in 1968 to assist low-income families gain the knowledge, skills, attitudes, and changed behaviors necessary for nutritionally sound diets (USDA, 1983). The program also seeks to contribute to personal development and the improvement of the total family diet and well-being. In 1968, nutritional well-being meant ensuring adequate calories, vitamins, and minerals to support normal growth (Carpenter, 2003). But, today the most common nutritional concerns have dramatically changed to obesity and related chronic disease prevention. In fact, obesity has become the hallmark of low-income adults, particularly women (Drewnowski, 2009) with a concurrent rise in chronic diseases including Type II diabetes, hypertension, heart disease, and all cancers (Guh et al., 2009). These diseases are all higher among low income, racial and ethnic minorities (Braveman et al., 2010; Drewnowski, 2009). It has been hypothesized that the types of foods most affordable and most readily available on a limited income are energy dense with higher quantities of fats and added sugars. However, this theory cannot be substantiated because information about what low-income individuals and their families actually eat is limited due to current methods used to gather food intake information. Developing new dietary assessment methods that provide the information relevant to todays food intake and practices is essential to determine the most effective nutrition education.

In terms of personal development and well-being, improved diet and nutrition appear to have an impact beyond promoting good physical health. For the past 40 years, participants have reported improvements in self-esteem, moral direction, and sense of belonging in their communities from EFNEP participation (Arnold & Sobal, 2000; Auld et al., in press). Research is needed to substantiate these findings and determine how the program effects positive emotional and social changes as well as the economic benefits of such programming. Gaining an understanding of a possible wider influence of EFNEP participation will provide a more sophisticated evaluation of the EFNEPs overall value.

Dietary Assessment: EFNEP paraprofessionals conduct all assessments and lessons with EFNEP clientele. These EFNEP educators are high school graduates (or GED) and members of the community they support making them peers of the participants (Devine et al., 2006). They are trained in using hands-on, interactive teaching methods and they are supervised by university and county-based extension faculty at Land Grant Universities. To curb costs, EFNEP lessons have largely moved from one-on-one to group sessions (Dollahite and Scott-Pierce, 2003). Groups can range in size from 2 to over 30 individuals. At the first and last of these sessions, a dietary assessment is conducted with a group-administered 24-hour dietary recall using a multi-pass method. In addition, a Food Behavior Checklist containing at least 10 standard items that include nutrition-related questions is administered.

The 24-hour dietary recall (24HDR) is generally considered to be the gold standard for dietary assessment (Van Staveren et al., 2012). However, this classification comes with a caveat  to be considered valid and reliable, the assessment must be conducted by a highly-trained professional, usually a Registered Dietitian (RD). The respondent is asked to describe all foods and beverages consumed in the previous 24-hour period or from midnight to midnight. A major limitation of the 24HDR is the respondents ability to recall all items. The RD must be skilled in probing for forgotten foods and beverages and assisting with portion size estimation. In addition, the RD must understand how to conduct the interview without leading the respondent to state foods not eaten or to provide socially desirable responses as opposed to accurate reporting.

In EFNEP, paraprofessionals are trained to conduct 24HDR with groups of participants using a multiple pass method. Conducting the recall in a series of steps, or passes, is thought to decrease memory lapses (Arab et al., 2011; Thompson & Subar, 2008). The steps of the multiple pass include: listing foods/beverages consumed, probing for commonly omitted items, stating time and place of food consumption, probing for portion size, and ending with a final review. Again, validity of the multiple pass method has only been determined with highly-trained interviewers and primarily in one-on-one situations. The single study that examined one-on-one versus group administrations of the method was marred by serious methodological flaws (Scott et al., 2007). However, this study forms the basis for the group administration of the 24HDR in EFNEP.

Currently EFNEPs impact and effectiveness is determined by measured changes in dietary intake and selected food-related behaviors tracked for individual clientele. There are questions about the validity of the dietary intake results obtained by EFNEP paraprofessionals with limited training using a multiple pass method in a group setting. Valid and reliable information about dietary intake is essential to determine the best direction for nutrition education and to determine if positive changes in dietary intake are made based on the education provided. This ultimately is the basis for continuing the programs funding. Therefore, it is imperative to determine whether the current methods used to assess dietary intake are reliable and valid.

Behavior Checklist: A Behavior Checklist (BC) is also used to evaluate the effectiveness of EFNEP by identifying changes made from the education provided. The BC is composed of 10 mandatory, or core, questions designed to evaluate food-related behaviors that are not captured by 24HDR. Each question is answered using a five point Likert scale. The conceptual domains include Food Resource Management, Nutrition Practices, and Food Handling and Safety. The 10 core items were established in 1993, after being tested for construct validity, reliability, sensitivity and difficulty. Later, an optional bank of questions, most of which have not been rigorously tested, were allowed to be chosen as supplemental items to the 10 core questions. Unpublished studies have suggested that some positive behavior changes clearly increase in frequency of occurrence from the beginning to the end of the program, while others do not; but there is insufficient empirical evidence to support this.

Because changes to positive, healthy food behaviors should result in changed eating patterns and healthier diets, dietary assessment and behavior change should go hand-in-hand in determining the direction of nutrition education and in evaluation of the effectiveness of EFNEP programming. Further testing of Behavior Checklist items is needed to determine if the core set is the best set of items and to determine its relationship to the dietary intake assessment. Both measures together may create a much clearer picture for programming and evaluation.

Quality of Life: Maslows (1954) 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. EFNEP focuses on low-income clientele who often have difficulty meeting the basic physical needs for food and shelter. The program helps families manage their resources so that they can obtain healthy and safe food and, as a side benefit, food resource management helps them to meet housing needs. Meeting these lower-level needs allows the clientele to move toward psychological fulfillment. Thus, EFNEP has broader impact beyond food and health into increased quality of life.

Diener and Dieners (1995) work support the supposition that programs like EFNEP can have broader impacts. Their research determined 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 quality of life. Later work with homeless people found several common characteristics including dissatisfaction with their material quality of life, especially their housing, income, and health (Biswas-Diener & Diener, 2006). Similarly, individuals with very low incomes were highly dissatisfied with their personal quality of life including their morality, physical appearance, and intelligence with one exception. When homeless individuals experienced good social relationships not only was their perception of well-being higher but also the psychological costs of material deprivation were mitigated (Diener & Seligman, 2002). Because EFNEP is based on hiring educators from the same community who had experienced poverty themselves, a large part of the EFNEP experience relies on establishing good social relationships.

There is much anecdotal evidence, including testimony to Congress, that EFNEP participation results in increased quality of life. Arnold and Sobal (2000) found a 33% increase in community involvement at churches, food pantries and schools among program graduates and attributed this to encouragement from the nutrition paraprofessionals. They also found an increase in employment among graduates in one of two counties. Auld et al. (in press) likewise found that EFNEP graduates reported an increase in positive views about themselves, e.g., self-acceptance and self-esteem, as well as improved sense of hope and belonging. As to whether these are isolated findings or whether these are common perceptions from participation is unknown. Also, the extent to which these findings were based on the economy of the time, interaction with the nutrition paraprofessional, others in the program, or other influences is unknown. Determining whether EFNEP participation provides a broader benefit of improved quality of life is needed to have a greater knowledge of the programs impact. If EFNEP participation also results in a perception of improved quality of life, a more sophisticated program evaluation can be conducted to expand the understanding of EFNEPs benefits with respect to costs.

Cost-benefit: Cost-benefit analysis (CBA) is a classical economic tool often used to help determine who is impacted and by how much. This method fits under welfare economics (Johannesson, 1995a). The key point is that cost and health outcomes are measured in monetary units (Burney & Haughton, 2002; Lambur et al., 1999; Rajgopal et al., 2002; Schuster et al., 2003; Joy, Pradhan, & Goldman, 2006; Wessman, Betterley, & Jensen, 2001). However, for cost-effectiveness analysis (CEA), the method most often used for health care program evaluations (Johannesson, 1995a; Brown et al., 2007; Dollahite, Kenkel, & Thompson, 2008; Eklund et al., 2005; Sweat et al., 2000; Teng, Osgood, & Chen, 2001), there is an adjustment for quality of life. If participating in EFNEP results in an improved quality of life and a potential reduction of diet-related diseases, the resulting cost and benefit to society is not well understood. Measuring economic viability of such intervention programs is increasingly vital to justify expenditures to funders, including Congress. It is also important to maximize targeted outcomes for a level of program funding across regions and demographics.

BENEFITS OF THIS PROJECT: The clientele of EFNEP consist of low-income families (income at or below 185% of the federal poverty threshold) self-reported as: 53% White, 26% African American, 4% American Indian or Alaska Native and 3% Asian or Pacific Islander and 39% reported their ethnicity as Hispanic (2011 NEERS 5 data). Thus, EFNEP participants are among the groups most likely to be obese with one or more obesity-related chronic diseases. EFNEP operates in 800 counties in all 50 states and six territories reaching 130,485 adults and 479,398 youth in 2012. The total number of lessons taught annually to these adults and youth is estimated at 3.9 million. For the 2012 Federal Fiscal Year, the total distribution of funds authorized under the Smith-Lever Act was $69,678671 (USDA, 2013) It is imperative that the value of this enormous effort be maximized both in terms of effectiveness of nutrition education and on wider benefits that have the potential to improve quality of life. Evaluating the impact of the program requires dietary and behavior change assessments that are as valid and reliable for this audience as possible. Determining the impact of program participation on broader, quality of life issues will strengthen the understanding of EFNEPs benefits.

The accurate assessment of EFNEP impacts is critical to program success. This project will provide updated valid, reliable methods for measuring dietary quality in the EFNEP population. In addition, we will determine which of these methods are most specific, accurate and sensitive to change, and least burdensome for EFNEP participants. Burden may pertain not only to time required for completing the instruments, but also to issues of format, clarity, complexity, cultural appropriateness, and literacy level. These methods will not only document program performance, but also provide valuable needs assessment data to inform future planning and implementation.

This project will also lead to a better understanding of the non-dietary impacts of EFNEP. Both qualitative and quantitative methods will be used to assess the Quality of Life (QoL) of participants and paraprofessionals, allowing EFNEP to quantify non-dietary impacts for the first time in the programs 40 plus year history. In addition, developing a standard CBA and CEA process will provide a framework for states to conduct meaningful assessments.

NEED FOR COOPERATIVE WORK: A multistate approach is essential for this project because of the scope of EFNEP. Each state/region has access to unique groups of limited-resource EFNEP participants that would not be available from any single state. Variables that differ across states include: obesity rates, employment opportunities, education, age, income, proportion of urban versus rural households, and mixes of racial/ethnic groups, to name a few. With multi-state involvement and input, a more complete access to and understanding of demographic, cultural and other impacts on our diverse participant groups will be possible.

Related, Current and Previous Work

RELATED: A CRIS search of EFNEP identified one project with an objective of developing culturally-competent EFNEP programming that will reduce food insecurity among recipients of Supplemental Nutrition Assistance Benefits (formerly food stamps). Other projects were specifically focused on childhood obesity. A search on dietary assessment showed 32 projects including NC 1169. The projects were using various established tools to assess dietary intake of different groups, evaluating nutrition education programs, or developing food frequency tools to measure specific nutrients. Four projects focused on the behavioral checklist questions using responses to the 10 core items to test program outcomes. One project was found examining factors that contribute to quality of life among rural low-income families. This is being conducted at the University of Kentucky. Current NC1169 investigator, Hazel Forsyth is from University of Kentucky and she will contact the researcher and determine if cooperative work with NC1169 could be beneficial.

CURRENT: Focus groups are being conducted in five states (CO, KY, NJ, OK, SC) to determine EFNEP clienteles perceptions of the 24HDR process. Focus group interviews with EFNEP participants tied to their QoL before and after graduating from EFNEP are being conducted in seven states (AZ, CO, KS, NE, OH, SC, VA). Transcripts are currently being analyzed from over 60 phone interviews with EFNEP coordinators, paraprofessional educators, and community partners about how EFNEP affects the QoL of participants and educators. These interviews were done in Guam and eight states (ID, IN, KY, ME, NH, NM, UT, WV). Preliminary results support that EFNEP has a large, positive impact on QoL  for both educators and participants. Three doctoral candidates are presently involved with this project; their approved prospecti relate to the 24HDR, Behavior Checklist and Quality of Life.

Michigan State University has a small pilot study estimating the CBA and CEA of EFNEP. This study will determine the relationship among nutrition education, nutrition and physical activity behavioral changes, and biological changes. The training and biometric measures will be used to estimate the health impact and calculate CBA and CEA. First, we will investigate all relevant alternatives to CBA and CEA related to nutrition education training and address the criticism of this methodology, and adjust the formula to capture all relevant direct and indirect costs and consequences of the training. These may include: current disease state, household demographics, socio-economic distribution, satisfaction with health, and quality of life. The second step is to predict the obesity cases averted utilizing body-mass index (BMI) by a certain age as shown in Brown et al. (2007). Based on these estimates, the Life table (Peeters et al., 2003) will be used to estimate the health care benefits. Lastly, a BMI progression model and scenarios analysis will be used to determine the sensitivity of the CBA/CEA results.

PREVIOUS: A comprehensive review of the literature manuscript (in revision for resubmission) examining the research basis for dietary assessment methods used with low-income adults was prepared through a collaboration of six states (CA, KY, NV, OK, WA, WY). A searchable EFNEP research database was developed to assist practitioners, students, and researchers (Scholl, Paster & Jankowski, 2011). The database received the 2011 NIFA (National Institute of Food and Agriculture) Partnership Award for Effective and Efficient Use of Resource and the 2013 AgNIC (Agricultural Network Information Cooperative) Partnership Award. It identifies and categorizes all known research studies conducted about EFNEP since 1969 and currently houses 550 studies about EFNEP clientele, curricula, and staff. As part of NC1169_TEMP, project investigator Jan Scholl will update this database to aid in further development of research in this area.

A survey of EFNEP coordinators perceptions of the current 24HDR method was conducted with 35 states and territories responding. Data analysis suggests that the method is considered cumbersome and time-consuming. Coordinators stated concerns that the findings from the 24HDR have limited validity (manuscript in revision for resubmission). A pilot study with EFNEP clientele comparing an electronic, self-administered 24HDR (ASA 24) with the current group 24HDR method at intake was conducted in seven states (AZ, CO, KY, OK, UT, WA, WY). No difference in number of foods reported or nutrient intakes were found. Although the majority of the participants were able to successfully complete the electronic 24HDR regardless of literacy level, some Hispanic clients who speak English as a second language reported challenges with the computer method that was only available in English.

The electronic, self-administered 24HDR demonstrated that EFNEP participants were able to effectively use the ASA24 (manuscript in revision for resubmission). Following the pilot study, an NIH proposal was submitted to determine the accuracy of reported energy intake using the ASA24 in a sample of low-income, low-educated Hispanic women and the accuracy of the group-administered written 24HDR. The study will compare the estimated energy intake between the computer and written tools and then validate energy intake using doubly-labeled water. Based on NIH feedback, the proposal is under revision for resubmission September 2013.

In preparation for the QoL focus groups, specific recruitment and training protocols were developed and incorporated into a DVD filmed at Colorado State University and edited (and funded) at Kansas State University. The seven states (AZ, CO, KS, NE, OH, SC, VA) involved participated in a training Webinar and are currently recruiting and/or conducting the focus groups that will be completed in the summer of 2013.

Work on NC 1169 from 2008 to date has focused on the following: (1) Identifying time efficient, user-friendly, valid and reliable methods for measuring dietary intake and food-related behaviors among EFNEP clientele. Surveys or interviews of EFNEP Coordinators, paraprofessionals, and clientele have been conducted in 20 states and one territory (CO, KY, NJ, OK, SC, AZ, KS, NE, OH, VA, ID, IN, ME, NH, NM, UT, WV, WY, NV, WA, and Guam). An electronic 24HDR has been tested for feasibility of use among EFNEP clientele. Next steps include further validation of the electronic 24HDR to quantify accuracy of reporting. Also, a comparison of findings from group dietary recalls conducted by EFNEP paraprofessionals with those from Registered Dietitians will determine if more comprehensive and standardized training can result in valid and reliable 24HDR results from EFNEP paraprofessionals. (2) Reviewing nutrition domain behavioral checklist items to identify those that have been systematically tested and those that need further testing. Next steps are to determine existing or new nutrition domain behavioral checklist items that best predict positive behavior changes from program participation. (3)Assessing and characterizing multiple methods to measure QoL. Major themes of QoL impacts have been documented from EFNEP coordinators, paraprofessionals, participants and community partners. Next steps are to determine the extent of positive changes in perception of QoL among EFNEP participants and to determine effective methods to measure change in QoL due to EFNEP participation. Also, the relationship of EFNEP indicators and economic benefits will be examined.

Objectives

1. To test the validity and reliability of the EFNEP 24HDR methods.
   
2. To identify and/or develop valid behavior checklist survey items that assess diet quality, nutrition-related behavior, and food resource management related behaviors due to EFNEP participation.
   
3. To determine if EFNEP participation influences Quality of Life (QoL) and if improved QoL is associated with sustained positive behavior changes.
   
4. To investigate EFNEP outcomes that indicate cost benefit and cost effectiveness of the program to participants and communities.
   

Methods

Objective 1 - 24 HDR: A survey of EFNEP coordinators, developed by a Colorado graduate student, will identify existing procedures for collecting and training for 24 HDR using quantitative and qualitative methods. Also, comparisons will be done of the data from 24 HDR collected by trained EFNEP paraprofessionals and Registered Dietitians in one-on-one, small and large group settings in Colorado. Investigators will recruit up to six additional states to provide the group size variation. Investigators will evaluate and select the best 24HDR training practices, and develop standardized 24HDR training protocols for EFNEP paraprofessionals. Training protocols will be tested with multiple states and territories to assess the accuracy and feasibility of EFNEP paraprofessionals administering the 24HDR using the improved procedures against more expensive and/or time consuming gold standards for dietary assessment. An investigation of the ASA24 computerized dietary recall method with EFNEP clientele will be led by Nevada. An NIH proposal is being resubmitted to determine the accuracy of reported energy intake using the ASA24 in a sample of low-income, low-educated Hispanic women and the accuracy of the group administered written 24-hour recall. This comparison will utilize doubly-labeled water for validity. Objective 2 - Behavior Checklist: Investigators in Colorado and Washington will take the lead to identify nutrition and food resource managementrelated behavioral objectives and content in the EFNEP curricula used by the majority of states; 3-5 curricula are used by over 90% of states. Given the content and objectives of the primary curricula used in EFNEP, potential behavior checklist questions will be identified or developed and pilot tested for wording, understanding, and the best response category alternative. The items will be tested for face, content, and construct validity as well as reliability using cognitive interviews, expert panels, comparison of data to more rigorous measures, and test-retest procedures, respectively. Objective 3 - Quality of Life: Previous work of NC1169 investigators and anecdotal evidence confirmed that EFNEP positively affects QoL. The following steps are being taken to develop and test a quantitative QoL assessment tool that can be used by EFNEP as a stand-alone outcome assessment or in conjunction with other measures including cost benefit analyses. Data from the pilot study (Auld et al., in press), interviews and focus groups will be integrated in developing a quantitative QoL questionnaire tailored to EFNEP. Initial validation of that tool will include similar steps to those described above for the Behavior Checklist items: use of cognitive interviews to establish face validity, use of QoL experts (one is Mike Steger, Colorado State University and NC1169_TEMP investigator) to establish content validity, comparison of data with other QoL or related measures to establish construct validity, and test-retest to establish reliability. Investigators will conduct a national, longitudinal study with a comparison group of non-EFNEP participants, to confirm the impact of EFNEP on QoL in both the short and longer term to see if changes are maintained at six months. Objective 4 - Cost Benefit Analysis: An economic study of the effectiveness of EFNEP will be led by Michigan State University. In addition to demographic and economic data currently collected, partnering organizations will facilitate the collection of key health status data of those participants which could include: BMI, blood pressure, current disease state, and hemoglobin A1c. This data will be used to develop, test and calibrate theoretical economic models that associate EFNEP training, demographic, economic, QoL, and health status indicators. Based on the outcome of the pilot project work, a national protocol will be developed to conduct an economic analysis of EFNEP. States and territories will be recruited that can gather the required data based on the models developed.

Measurement of Progress and Results

Outputs

• Valid and reliable 24HDR conducted by EFNEP paraprofessionals
• Valid and reliable behavior checklist items that provide the best indication of nutrition and food resource management changes
• Valid and reliable QoL survey instrument
• Model for measuring CBA/CEA for EFNEP participants, families and communities
• Standardized training protocols for all assessment tools including DVDs written manuals, and online resources
• 6) Reports, articles, and presentations reflecting the work of project investigators and partners

Outcomes or Projected Impacts

• Successful completion of the proposed multistate project NCTEMP_1169, will have four important impacts: 1) investigators on the project will develop new skills to study and assess programmatic impacts in dietary behaviors, quality of life and economic benefit. 2) The entire EFNEP system will have an enhanced understanding of and confidence in EFNEP program impacts. 3) EFNEP coordinators and paraprofessionals will have access to protocols and training for implementing valid and reliable tools to assess program impacts. 4) At the federal level, National Program Leaders and Congress will have greater knowledge of the importance of EFNEP for the long-term health and wellness of individuals, families, communities, and the nation as a whole.
• Congressional stakeholders will have increased confidence in EFNEPs outcomes and therefore support continuation of EFNEP funding into the future.
• In the long term, the work of this project will have greater potential impact with nutrition education beyond EFNEP, including SNAP-Ed as well as the many nutrition education projects using EFNEPs evaluation tool. Although the outputs, or assessment tools, are designed for low-income nutrition education, there may be future application to nutrition education for other income levels.

Milestones

(1):tober, 2013 through September, 2014. Project investigators will build on the momentum and accomplishments from the 2008-2013 multistate project (NC1169). Efforts to include the following: Identify existing procedures for collecting and training for 24 HDR using quantitative and qualitative methods. Identify behavioral objectives for EFNEP participants. Complete validation of the QoL instrument. Prepare recruitment and research protocols for testing nation-wide of the QoL instrument with participants and paraprofessionals. Explore relationships of EFNEP indicators to health status of EFNEP participants. Submit manuscript(s) to peer-reviewed journals. Submit grant proposal(s).

(2):tober, 2014 through September, 2015. Efforts to include the following: Analyze 24HDR data collected from trained EFNEP paraprofessionals and RDs. Conduct research on ASA24 computerized dietary recall method. Develop and conduct validity testing on nutrition and food resource management domains of the behavior checklist question set. Conduct QoL instrument testing along with assessments of behavior. Develop, test and calibrate theoretical economic models for assessing economic and health indicators. Continue manuscript and grant proposal development.

(3):tober, 2015 through September, 2016. Efforts to include the following: Evaluate and select 24HDR training procedures and design and test protocols. Continue research on ASA24 computerized dietary recall. Analysis, revise and continue research on nutrition and food resource management domains of the behavior checklist question set. Continue QoL instrument testing and behavioral assessment. Begin analysis of QoL and health outcome data. Assess, develop, and implement economic methods to evaluate EFNEP participant health outcomes. Continue manuscript and grant proposal development.

(4):tober, 2016 through September, 2017. Efforts to include the following: Test 24HDR training protocols for accuracy and feasibility. Analyze and share results from ASA24 computerized dietary recall data. Process QoL and health outcome data. Identify and collect economic, demographic, and health outcome data that inform an economic analysis of the effectiveness of EFNEP. Examine potential relationships between QoL and economic indicators. Continue manuscript and grant proposal development.

(5):tober, 2017 through September, 2018. Efforts to include the following: Disseminate results of 24HDR, ASA24, nutrition and food resource management behavior checklist question sets, and QoL assessments and recommend national standards for collection of EFNEP impacts. Develop protocol for conducting economic analysis of EFNEP. Develop materials for training coordinators and paraprofessional educators in new data collection procedures. Continue report and manuscript development. Assess potential for and prepare proposals for future multi-state research projects.

Projected Participation

View Appendix E: Participation

Outreach Plan

Results of this project will be disseminated to intended users in a variety of ways. Manuscripts and reports will be submitted. Proposals for presentations and workshops at regional and national meetings will be submitted to share findings with professionals within EFNEP and other related programs such as SNAP-Ed. Potential meetings include the Society for Nutrition Education and Behavior, International Society for Behavioral Nutrition and Physical Activity, Experimental Biology, and the annual meeting of EFNEP Coordinators. Project personnel will also offer to serve in an advisory capacity to national EFNEP leaders who could utilize project outputs in the development of reports for Congressional leaders who annually vote on the continuation and/or potential increases in EFNEP funding. Clientele will be reached through the revisions made to materials/approaches based on project outputs.

Organization/Governance

The investigators; comprised of researchers and EFNEP Coordinators from participating land-grant universities, Regional Administrative Advisor, and USDA NIFA Representative; will be organized and governed as specified in the North Central Regional Association (NCRA) guidelines (2005) (http://nrca.info).

Given the complexity of this project, the group is divided into two objective work groups, Dietary Assessment and Behavior (DAB) and Quality of Life (QoL). Each group will elect a chair, or co-chairs, and a secretary at the annual meeting. The entire group will elect a chair and co-chair. These elected positions will comprise the Executive Committee (EC). Efforts will be made to ensure that the EC will include representatives with research and EFNEP experience.

The EC will schedule conference calls (monthly for work groups and biannually for whole group); ensure project progress; complete annual reports to AES; and coordinate writing assignments (reports, manuscripts, recommendations, and papers or presentations at professional meetings).

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