Duration: 10/01/2023 to 09/30/2028

Administrative Advisor(s):

NIFA Reps:

Non-Technical Summary

Statement of Issues and Justification

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.  

 

Related, Current and Previous Work

Related Work:

A CRIS search was conducted to review active projects with the keyword “EFNEP,” without the keyword “NC3169,” with grant years between 2018 and 2022, resulting in 24 projects. Projects starting before 2018 which were extended were excluded, resulting in 21 projects reviewed. Of these, 1 project (1027902) is an AFRI grant written by members of NC3169 to fund the Cost-Benefit Analysis project. Another (1023420) is an AFRI grant awarded for the maintenance of the Web-based Low-Income Nutrition Education Evaluation and Reporting System (WebNEERS). Our multistate group plans to work closely with the WebNEERS developers to coordinate our evaluation-based research with the reporting system utilized by EFNEP educators. The remaining 19 projects were unrelated projects that used EFNEP educators to carry out project activities (n=8), created expanded or innovative EFNEP programming (n=5), used EFNEP evaluation tools (n=2), used a territory EFNEP office as a physical resource (n=1), recruited EFNEP participants (n=1), referred participants to EFNEP services (n=1), and mentioned EFNEP in their literature review (n=1). Notably, our multistate group’s work will result in more rigorously tested evaluation tools for other projects to utilize.

A NIMSS search revealed three other active, related projects:

• W2194: Children's Healthy Living Network (CHLN) in the U.S. Affiliated Pacific Region is a network of land grant institutions, mostly in the U.S. Pacific, that develop and disseminate child obesity programming at the policy, systems, and environmental levels. Notably, they leverage the resources developed by EFNEP in their states/territories. However, their project does not have the same national scope or implications that we propose for NC4169.


• W4003: Parental practices supporting positive eating behaviors during independent eating occasions among early adolescent children focuses on obesity prevention interventions among early adolescents and their parents. Many of the proposed strategies, including cooking demonstrations and online education, are educational strategies also utilized by EFNEP, although EFNEP’s primary target audience is families with young children.


• NC1193: Promotion of Health and Nutrition in Diverse Communities of Emerging Adults is a Healthy Campus Research Consortium that uses policy, systems, and environmental strategies on college/university campuses to improve the dietary behaviors of college-aged emerging adults. Emerging adults are a newly identified target audience for EFNEP, although due to federal eligibility guidelines, EFNEP educators typically do not recruit emerging adult participants from colleges or universities.

 

Current Work:

NC3169 researchers conducted a cost-benefit analysis pilot using participants from the WA and CO EFNEPs. Based on the participants’ BMI changes between enrollment and 1 year post-EFNEP, the cost-benefit model predicted almost $10 in future healthcare cost savings for every $1 invested in EFNEP programming (the data have been submitted for peer review).

An EFNEP-specific QoL tool has been developed to measure the quality-of-life changes undergone by participants and/or EFNEP peer educators due to being a part of EFNEP. This tool is undergoing face validity assessment via cognitive interviews with former EFNEP participants.

EFNEP peer educators are being interviewed by NC3169 researchers to determine how the 24HDR is being administered in practice (e.g., extent and frequency of 24HDR trainings, administration methods, and utilization of a multi-pass method).

A Spanish translation of the FPABQ has been developed and has undergone a content validity assessment via expert review by a panel of experts in the EFNEP domains (Diet Quality, Physical Activity, Food Resource Management, Food Safety, and Food Security) who speak Spanish as a native language. The translated FPABQ is ready for cognitive interviews with Spanish-speaking EFNEP-eligible participants.

 

Previous Work:

Another EFNEP workgroup, co-led by Dr. Geb Bastian (who is also part of NC3169), developed an EFNEP 6^th-12^th Grade Questionnaire. This questionnaire had undergone content validity, face validity, internal reliability, and preliminary criterion validity assessment as part of Dr. Bastian’s dissertation work.¹⁹

A literature search of the PubMed, ERIC, and Web of Science databases to identify EFNEP-related research published since 2018 that involved multiple states and was not affiliated with NC2169 or NC3169 resulted in 9 articles, of which two-thirds had current or former NC3169 members on the author list.

• Two of the studies were related to the 24HDR. Gills et al used the 24HDRs from the 2012-2014 national EFNEP datasets to demonstrate that participants’ Healthy Eating Index scores increased between pre- and post-assessment.²⁵ Spruance et al evaluated a training to teach EFNEP peer educators how to use ASA-24 for 24HDR collection; only half of educators felt prepared to use ASA-24 after the training.²⁶


• Two studies evaluated supplemental content for the Eating Smart Being Active^27,28 Moreover, Aragon et al investigated the fidelity peer educators had to the supplemental lesson material,²⁹ and Chlipalski et al found that EFNEP peer educators would be receptive to online trainings for such content.³⁰

The remaining studies investigated policy, systems, and environmental approaches to EFNEP/SNAP-Ed education (n=2), and food environments among SNAP-Ed and EFNEP participants (n=1). While these are important areas of inquiry, they fall less within the proposed scope of NC4169, and perhaps may be best suited for integration with some of the aforementioned multistate efforts.

Objectives

1. Analyze the economic value generated by adult EFNEP through chronic disease and condition risk reduction.
   
2. Investigate the impact of EFNEP education on participants’ and educators’ quality of life.
   Comments: a. Determine if participants’ changes in quality of life are attributable to EFNEP using a validated EFNEP-tailored questionnaire. b. Determine if program delivery and perceived social support are related to EFNEP participants’ and paraprofessionals’ changes in quality of life.
3. Improve the standardization and methodological rigor of EFNEP evaluation.
   Comments: a. Develop standardized training and administration protocols for EFNEP educators for the paper-and-pencil and ASA24 group administered 24HDR. b. Further establish the validity and reliability of the EFNEP 6th-12th Grade Questionnaire, beyond the initial work that has been completed by a prior EFNEP workgroup. c. Develop a standardized Spanish translation of the FPABQ and conduct necessary validity and reliability testing.
4. Examine the content and implementation characteristics, and effectiveness of EFNEP curricula that target adults’ nutrition- and physical activity-related behaviors.
   Comments: a. Examine the facilitators and barriers among EFNEP educators for successful implementation of physical activity content in EFNEP lessons. b. Develop sets of best practices for effective teaching modalities that correspond with successful implementation, participant engagement and/or behavior change.

Methods

Objective 1: Analyze the economic value generated by adult EFNEP through chronic disease and condition risk reduction.

Two analytical approaches will be employed. The first approach will use chronic disease biomarker data to estimate the economic benefits created by adult EFNEP. A paired location untreated control group quasi-experimental design will be used to collect data on four chronic disease biomarkers: height, weight, blood pressure, and HbA1c. Biomarker data will be collected during three time periods (pre, 6 months post, and 1 year post) for 500 adults in four states (CO, FL, MD, WA). Following collection, data will be pooled to create a dataset representative of the national adult EFNEP. Multivariate regression analysis using the dataset will identify the impact of EFNEP on chronic disease biomarkers. A biomarker cost-benefit analysis methodology will then be developed and applied to objectively assess the economic value generated by adult EFNEP through chronic disease risk reduction.

The second analytical approach will use standard EFNEP program data to estimate the economic benefits generated by adult EFNEP. Food and physical activity behavioral data will be obtained from WebNEERS for all state EFNEP programs. First, a framework will be developed to link self-reported food and physical activity and dietary intake data to chronic disease risk. The resulting framework will then be incorporated into a cost-benefit analysis to provide a second, alternative assessment of the economic benefits generated by the program.

 

Objective 2: Investigate the impact of EFNEP education on participants’ and educators’ quality of life.

2a. Determine if participants’ changes in quality of life are attributable to EFNEP using a validated EFNEP-tailored questionnaire.

Investigators will conduct a national, longitudinal study of 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. Free-living, English-speaking, nonpregnant EFNEP participants will be recruited. The EFNEP Quality of Life (E-QoL) survey will be administered electronically at three time points: 1) baseline (after class one, before class two), 2) post (after the last class), and 3) six months after the post assessment. Data will be analyzed with repeated measure analysis of variance.

 

2b. Determine if program delivery and perceived social support are related to EFNEP participants’ and paraprofessionals’ changes in quality of life.

A survey will be developed to capture EFNEP participants’ perceptions of EFNEP programming in relation to social support, engagement, experiential learning, and other educational resources or interventions outside of EFNEP (e.g., utilizing the MyPlate app, and exposure to policy, systems, or environmental changes). A second survey will be developed to be completed by EFNEP instructors. This survey will capture quantitative data on class delivery, including instructors’ number of years of service, the number of lessons, and the number of teaching hours, as well as qualitative data on the instructor’s perceptions of class engagement. The E-QoL survey will be administered before and after a series of EFNEP classes. The surveys on participant perceptions and class delivery will be administered upon class completion. Data will be assessed for relationships between program delivery and change in QoL.

 

Objective 3: Improve the standardization and methodological rigor of EFNEP evaluation.

3a. Develop standardized training and administration protocols for EFNEP educators for the paper-and-pencil and ASA24 group administered 24HDR.

Based on work completed in NC2169 and NC3169, the investigators will continue to evaluate and recommend the best 24HDR data collection forms, training practices and 24HDR training protocols for EFNEP paraprofessionals. A critical examination of current practices and the objectives of the 24HDR will be conducted using data gathered from EFNEP coordinators and educators in NC3169.

Investigators will evaluate food-related behavior change by EFNEP participants using the standardized food recall forms and protocols in a geographically diverse representative sample with a comparison group.

 

3b. Further establish the validity and reliability of the EFNEP 6th-12th Grade Questionnaire, beyond the initial work that has been completed by a prior EFNEP workgroup.

To further establish the validity and reliability of the EFNEP 6th-12th Grade Questionnaire (6-12GQ), three tests will be conducted during this 5-year cycle: confirmatory factor analysis, test-retest reliability, and criterion validity. Each test will utilize a convenience sample of middle and high school students who are “income eligible” for EFNEP (i.e., attend a school where ≥50% of students qualify for free or reduced-price school meals). The samples will include students from multiple states that reflect the regional and racial/ethnic diversity of the national EFNEP audience.

Confirmatory factor analysis will be used to confirm the EFNEP 6-12GQ’s previously identified factor structure, which was determined via exploratory factor analysis. Model fit will be assessed using multiple tests, including chi-square, comparative fit index, and root mean square error of approximation. Test-retest reliability will be used to assess the EFNEP 6-12GQ’s stability using two administrations from the same sample of students, conducted 7-10 days apart with no interventions in between. Spearman rank correlations and t-tests will be conducted to measure the test-retest reliability.

Criterion validity will be used to measure the Dietary Quality and Physical Activity questions against objective measures, i.e., diet recalls and accelerometry, respectively. Three multiple-pass diet recalls will be collected from the participants by trained nutritionists/dietitians. Accelerometry data will be collected using triaxial accelerometers worn for ≥10 hours per day for 7 consecutive days. The EFNEP 6-12GQ will be administered to the participants after they are done with the diet recalls/accelerometry. After computing the collected data to units that can be compared to the EFNEP 6-12GQ questions (e.g., servings of fruit, number of days engaged in exercise), Spearman rank correlations will be conducted to assess the validity of the objective measures and the survey questions.

 

3c. Develop a standardized Spanish translation of the FPABQ and conduct necessary validity and reliability testing.

Investigators in CA, NJ, and TX will lead the testing of the Spanish version of the FPAQ. The translated questions will be tested for face validity, confirmatory factor analysis, sensitivity, internal consistency, and test-retest reliability. Face validity will be established through cognitive interviews with Spanish-speaking adults. Reliability tests will be conducted with representative samples of EFNEP-eligible Spanish-speaking adults following standard psychometric procedures. Reliability and validity testing will build on the previous work of NC2169 and NC3169, during which experts³¹ and target respondents were involved to achieve clarity, adequacy, and conceptual equivalence of the Spanish version to the original English version.³² To the extent possible, we will follow the original protocols for reliability and validity testing of the FPABQ.²⁰ Relevant alternate protocols for cross-cultural adaptation of survey tools will be considered as appropriate.³³

 

Objective 4: Examine the content and implementation characteristics, and effectiveness of EFNEP curricula that target adults’ nutrition- and physical activity-related behaviors.

4a. Examine the facilitators and barriers among EFNEP educators for successful implementation of physical activity content in EFNEP lessons.

Semi-structured interviews will be conducted with a national sample of EFNEP educators (n=25-30) to examine their perceived barriers and facilitators in providing PA content as well as successful implementation strategies that they use to engage adult participants and promote physical activity. After initial testing with a subset of educators, the interview tool will be revised and adapted based on research team and peer educator feedback. The virtual interviews will be audio-recorded and transcribed, and analysis of the qualitative data will be completed using an inductive and deductive content analysis³⁴ to help shape themes until saturation is reached. 

 

4b. Develop sets of best practices for effective teaching modalities that correspond with successful implementation, participant engagement and/or behavior change.

Instruments will be developed to evaluate the content and implementation characteristics of the curricula used in adult EFNEP lessons. This process will be informed by previously published content analysis methods,^21,23,24,35 and will be adapted according to the current dietary and physical activity guidelines and recent EFNEP implementation changes (e.g., online teaching).

The FY 2023 national data for adult EFNEP participants, including the curriculum characteristics (e.g., description, dosage, modality) and behavioral outcomes, will be obtained from the national program office. Based on this dataset, the most widely used curricula will be selected for further analyses. Additional content details will be collected from the authors of the selected curricula.

To examine the implementation characteristics and potential deviations from the original content of the selected curricula, a sample of EFNEP supervisors, coordinators, and peer educators will be surveyed. A comprehensive database will be established by combining the national dataset with the additional information collected from the authors and the EFNEP managers/educators.

Content analyses will include: a) curriculum and implementation characteristics (e.g., modality, dosage, deviations from the original content, supplementary components, engagement and reinforcement methods); b) content coverage in comparison to the national physical activity and dietary guidelines and correspondence with the national evaluation tools; and c) associations between the implementation/content characteristics and behavioral outcomes.

To gain further insights about adult EFNEP participants’ engagement in the learning process and potential influences on their behavioral outcomes, we will make a concerted effort to include relevant questions from the Quality of Life (QoL) surveys (see Objective 2b). We will aim to gather pilot data from the participants on the types of information sources (within or outside EFNEP) or PSE (policy, systems, environment) level factors that they have been exposed to and might have influenced their behavioral patterns.

All sample selections for Objective 4b will be done with attention to regional and program size/funding tier representation. The analyses will utilize a mixed methods approach by incorporating qualitative data analyses (e.g., for semi-structured interviews and open-ended questions) as well as descriptive statistics (e.g., for content and implementation characteristics) and regression models (e.g., for testing potential relationships between the behavioral outcomes and curriculum characteristics). 

Measurement of Progress and Results

Outputs

• 1. Valid and reliable instruments that capture EFNEP’s myriad impacts on a diverse range of target audiences (E-QoL, 6-12GQ, Spanish FPABQ).
• 2. Standardized protocols for administering pen-and-paper and ASA-24 24HDRs to EFNEP participants.
• 3. Graduate students trained in conducting program evaluation research for federally funded nutrition education programs.
• 4. Scientific articles, presentations at scientific and professional conferences, and Extension publications on EFNEP-related research.

Outcomes or Projected Impacts

• 1. Increased accuracy and reliability of EFNEP program impacts, leading to better reporting and communicating to key partners and stakeholders.
• 2. Increased program effectiveness and consistency across LGU implementers as EFNEP peer educators are trained using standardized, evidence-based approaches.
• 3. Better communication with key stakeholders, e.g., legislators, about EFNEP’s impact on healthcare costs and participants’ and peer educators’ quality of life.
• 4. Improved rigor of nutrition education and behavior science as NC4169’s methods and outputs are adapted by other researchers and programs.

Milestones

(1):• Develop study protocols • Obtain IRB approvals • Recruit partner states • Recruit graduate students • Seek extramural funding • Conduct Spanish FPABQ cognitive interviews with EFNEP participants • Begin biomarker CBA study • Develop the framework for the behavioral CBA • Obtain FY 2023 adult data from NIFA for curricula analysis

(2):• Continue biomarker and behavioral CBA studies • Conduct psychometric testing for E-QoL, 6-12GQ, and Spanish FPABQ • Recruit control group for 24HDR study • Collect data from the most popular EFNEP curricula from their authors • Conduct implementation methods interviews, surveys, and process evaluations for curricula study

(3):• Continue data collection and begin analyses • Begin criterion validity analysis for 6-12GQ • Disseminate standardized training resources for 24HDR

(4):• Continue data analyses • Provide recommendations for 6-12GQ and Spanish FPAQ to National EFNEP leaders at NIFA • Begin working on manuscripts and presentations

(5):• Complete analyses • Disseminate results via manuscripts, presentations, and Extension publications

Projected Participation

View Appendix E: Participation

Outreach Plan

Our outreach plan is as follows:

• Peer-reviewed manuscripts in scientific/professional journals, e.g., The Journal of Nutrition Education and Behavior, Journal of Extension, and The Journal of the Academy of Nutrition and Dietetics.


• Peer-reviewed posters and presentations at scientific/professional conferences, e.g., the Society for Nutrition Education and Behavior, National EFNEP Coordinator’s Conference, Association of SNAP Nutrition Education Administrators, and the Food and Nutrition Conference and Expo.


• Extension publications, e.g., eXtension trainings and bulletins.


• Reports to NIFA containing science-based recommendations for program policies and procedures.


• Communication with key stakeholders, e.g., Extension administrators and legislators, about our work.


• Clientele will be reached through peer educators implementing our group’s outputs, e.g., the new questionnaires.

 

Organization/Governance

Due to the complexity of our group and its aims, we are organized and governed in the following way:

• The overall group has 2-3 co-chairs, whose main responsibilities include scheduling two annual full-group meetings (an in-person meeting in October and a virtual meeting in April), compiling reports, and maintaining high level organization and project planning.


• The group has 3 subgroups: CBA, QoL, and Dietary Assessment and Behavior (DAB, which covers the projects in Objectives 3 and 4). Each subgroup has a chair and a secretary. The chair’s responsibility is to schedule and facilitate monthly subgroup meetings and compile accomplishments and impacts for the co-chairs as needed for reports. The secretaries take notes at each subgroup meeting, and work together to take notes at the full group meetings.


• All co-chairs, subgroup chairs, and subgroup secretaries are elected at each October full group meeting.


• 1-2 members each year volunteer as Annual Meeting Hosts. Their responsibility is to assist the co-chairs in planning the October full group meeting, which is hosted in or near their home state.

Besides these discrepancies, our group follows the governance guidelines outlined in the NCRA Guidelines for Multistate Research Activities.

Literature Cited

1. National Institute of Food and Agriculture. 2020 Impacts: Expanded Food and Nutrition Education Program (EFNEP). Accessed February 10, 2022. https://nifa.usda.gov/sites/default/files/2020%20EFNEP%20National%20Data%20Reports.pdf


2. Wang VL, Ephross PH, Green LW. The point of diminishing returns in nutrition education through home visits by aides: an evaluation of EFNEP. Health Educ Monogr. Spring 1975;3(1):70-88. doi:10.1177/109019817500300111


3. Wang VL, Ephross PH. ENEP evaluated. Journal of Nutrition Education. 1971;2(4):148-152. doi:10.1016/s0022-3182(71)80115-2


4. Centers for Disease Control and Prevention. About Chronic Diseases. Accessed October 7, 2022. https://www.cdc.gov/chronicdisease/about/index.htm


5. Buttorff C, Ruder T, Bauman M. Multiple Chronic Conditions in the United States. RAND Corporation; 2017.


6. Vuong TD, Wei F, Beverly CJ. Absenteeism due to Functional Limitations Caused by Seven Common Chronic Diseases in US Workers. J Occup Environ Med. Jul 2015;57(7):779-84. doi:10.1097/JOM.0000000000000452


7. Dollahite J, Kenkel D, Thompson CS. An economic evaluation of the expanded food and nutrition education program. J Nutr Educ Behav. May-Jun 2008;40(3):134-43. doi:10.1016/j.jneb.2007.08.011


8. Rajgopal R, Cox RH, Lambur M, Lewis EC. Cost-Benefit Analysis Indicates the Positive Economic Benefits of the Expanded Food and Nutrition Education Program Related to Chronic Disease Prevention. Journal of Nutrition Education and Behavior. 2002;34(1):26-37. doi:10.1016/s1499-4046(06)60225-x


9. Maslow A. Motivation and Personality. New York: Harper & Row; 1954.


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