The Idea book : sharing nutrition education experiences

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Food and
Nutrition
Service
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The Idea Book
Sharing Nutrition
Education Experiences
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Prepared by:
Nutrition and Technical Services Division for
Special Supplemental Food Program for Women, Infants, and Children
Food and Nutrition Service
United States Department of Agriculture
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The Special Supplemental Food Program for Women, Infants, and Children
is open to all eligible people regardless of race, color, sex, or national
origin.
Firm or product names used in this publication are solely for the purpose of provid­ing
specific information. Mention of these names does not constitute warranty of a
product by the U.S. Department of Agriculture or an endorsement of it by the
Department to the exclusion of other products.
September 1 981
Contents
1 Introduction
1 How to Use This Idea Book
3 Chapter 1 Content: What Should I Consider When Planning a
Nutrition Education Program?
4 Understanding the Health Needs of Your Community
4 Ideas for Nutrition Education Topics
6 Two Methods for Developing Additional Topics
9 Chapter 2 Formats: How Can I Best Structure Nutrition Education
Through Lesson Plans?
10 General Principles
10 Examples of Lesson Plans
17 Writing Behavioral Objectives
18 Conclusion
19 Chapter 3 Materials: What Should I Consider When Selecting
Nutrition Education Materials?
20 Locating Materials
21 Evaluating an'd Selecting Materials
29 Developing and Adapting Materials
33 Chapter 4 Methods: How Can I Get the Results I Want?
34 Identifying Motivations of WIC Participants
35 Nutrition Education as a Process
36 Using Media Effectively
37 Adapting Learning Situations to the Local Program
38 Individual versus Group Educational Approaches
38 Involving Children
39 Extending the Learning Environment beyond the WIC Setting
41 Chapter 5 Evaluation: How Can I Tell if Our Nutrition Education
Efforts Are Effective?
42 Considerations in Planning Your Evaluation
43 Categories of Evaluation
45 Types of Evaluation
45 The Outcome Evaluation
51 Conclusion
53 Chapter 6 Documentation: Why Should I and How Can I Document
the Delivery of Nutrition Education?
54 The Role of Documentation
54 The Kinds of Information to Record
55 The Retrieval System
56 Sharing Methods: Five Approaches Plus a Summary Report
The Idea Book
The Idea Book II
71 Chapter 7 Providers: How Can I Extend and Effectively Use
Personnel?
72 Staff Contributions from the Public and Private Sectors
72 Roles of Nutrition Education Providers
74 Relationships of Nutrition Education Providers
78 Training Nutrition Education Providers
83 Chapter 8 Obstacles: What Are Other Local Programs Doing to
Overcome Their Obstacles?
84 Managing Children while Counseling Adults
84 Motivating Clients to Participate
86 Managing Excess Caseloads
86 Conclusion
87 Chapter 9 Resources: Where Can I Obtain Current Nutrition
Education Materials?
88 Sources within the Government
89 Sources within the Private Sector
•
Introduction
Teaching the WIC participant to care for her nutritional well-being and that
of her family is an enormously difficult, yet fulfilling challenge. This book
is an attempt to help you respond to that challenge.
This book is a way to share ideas and approaches from around the country.
These approaches come from and are meant to be shared with you, the
local WIC nutritionists. This book is a way to achieve this exchange on a
national scale.
Several of the more formidable tasks that you encounter have been high­lighted
here. This book makes no attempt to address all issues pertinent to
the delivery of nutrition education, nor does it exhaustively cover any one
issue, nor is it a policy document on nutrition education. It is simply a way
of exchanging some approaches and ideas that can become the seeds of
future improvements. Indeed, as better materials and approaches are devel­oped,
we will try to keep you informed of changes and also keep everyone
current on latest theories and techniques. If you would like to contribute to
this exchange, send your ideas, techniques, and methods to your State
WIC nutritionist.
We chose examples and illustrations using simple criteria. The methods
showcased in this book were either some of the most creative, or they
represented a method or approach in common use throughout the country.
To the extent possible, we tried to remain sensitive to geographic distribu­tion.
How to Use This Idea Book
To use this book most efficiently, you should first understand how it is
written and organized. It is written to share information and exchange
ideas about certain pieces of the nutrition education puzzle. It is not in­tended
to be an instructional manual that takes the reader through a step­by-
step analysis of how to plan, deliver, and evaluate nutrition education.
This book focuses on various kinds of issues. Consequently it contains
sections of marked contrast. For instance, the chapter on evaluation is
highly philosophical, while the chapter on obstacles exclusively presents
what is currently being attempted in the field.
Some of the examples are adapted, while others are shared without any
modification. Should you want to change any of the illustrative examples
to meet your local needs, we would encourage you to adapt them in appro­priate
ways.
Finally, you should note that this book is meant for you, the local WIC
nutritionist. However, we also anticipate that this book will be of assis­tance
to you in training paraprofessionals.
The Idea Book 1
The Idea Book 2
The Idea Book Chapter 1
CONTENT:
What Should I Consider
Wh.en Planning a
Nutrition Education
Program?
4 Understanding the Health Needs of Your Community
4 Ideas for Nutrition Education Topics
4 For Pregnant Women
5 For Mothers of Infants and Children
5 For Children
6 General
6 Two Methods for Developing Additional Topics
6 Brainstorming and the Delbecq Method
The Idea Book 3
The Idea Book 4
When planning the nutrition education program for your WIC participants,
you must consider topics that are required in the Federal regulations, as
well as topics not required. You can locate the regulations for the nutrition
education component of the WIC Program in the Federal Register. Remem­ber
that all three types of nutrition education contacts mentioned in the
regulations must be designed to meet the different cultural and language
needs of the program participants. This chapter gives examples of some
topics that are being used in a number of States, and presents ideas on
how to develop and incorporate additional topics that complement those
described in the Federal regulations.
Understanding the Health Needs of Your Community
When you are attempting to tailor your nutrition education program to your
local needs, you need to gather two kinds of information: information on
the major nutritional problems of the local WIC participants, and informa­tion
from participants and other health and community professionals. You
can receive this information on relevant health status from a sample survey
of clinic or hospital charts or records. If your WIC Program is participating
in the nutritional surveillance study being conducted by the Center for
Disease Control (CDC) of the U.S. Department of Health and Human Ser­vices,
their statistics can also be helpful. Other sources of local informa­tion
can come from surveys conducted by other agencies in your commun­ity
such as the Expanded Food and Nutrition Education Program (EFNEP),
and from vital and health statistics of the county. You can obtain county
information from the official sources that are listed in your telephone direc­tory.
The policy for reviewing medical records varies from hospital to
hospital. To determine whether you can review medical records, contact
the legal section within the medical record department of your hospital.
This section will clarify what outside research, if any, they permit. They
may also be able to tell you about the official procedures required to gain
access to the records.
Ideas for Nutrition Education Topics
Most State plans include lists of topics for nutrition education. The follow­ing
is a partial list of these topics arranged by target group.
For Pregnant Women
WIC foods as sources of energy and nutrients during pregnancy.
Risk factors for poor pregnancy outcome.
Factors that limit or prevent adequate nutrition during pregnancy (pica).
Adequate weight gain during pregnancy.
Reasons for increased energy and nutrient needs during pregnancy.
Methods of reducing the risks of complications of pregnancy (anemia,
toxemia, prematurity, diabetes mellitus, hypertension).
Common gastrointestinal problems (nausea, vomiting, and constipation).
Reasons for completing hemoglobin and hematocrit tests during pregnancy.
Preparing for breastfeeding.
Advantages of breastfeeding.
Breastmilk (composition, benefits).
WIC foods as sources of energy and nutrients during lactation.
Appropriate diet when breastfeeding.
Care of nipples and breast massage.
Expression of breast milk.
Potential barriers to breastfeeding.
Hazardous substances that may pass into breastmilk.
Preparing infant formula.
For Mothers of Infants and Children
Risk factors associated with inadequate growth and development.
Breastfeeding.
Infant formula.
Plotting and interpreting an infant's or child's length and weight on a
growth chart.
Relationship of the developmental stages of infants to infant feeding
behaviors.
WIC foods as sources of energy and nutrients.
Key nutrients in foods and their function during early growth and
development.
Introduction of solid foods.
Nursing bottle syndrome.
Food jags and small appetites.
Snacking.
Learning problems affecting food intake and food practices.
Relationship between physical activity and weight control.
Eating problems during infancy and childhood leading to obesity.
Relationship of early feeding habits to the development of adult eating
habits.
Relationship between food and dental health.
Effect of TV commercials on eating and shopping behaviors.
Vitamin and mineral supplementation.
Learning through foods (includes building self-concept and developing
feeding skills).
Nutrition and infection-building your child's resistance.
Special dietary needs for developmental disabilities and handicapping
conditions.
Long-term nutrient/caloric needs of infants and preschoolers.
For Children
Nutrition in relation to:
• dental health
• growth and development
• obesity
• diet-related disease
• snacking
• physical activity
• food preparation
• food activities
The Idea Book 5
Brainstorming
The Idea Book 6
General
Comparative shopping for foods.
Meal planning.
Nutrition labeling.
Food additives.
Recipes for WIC foods.
Safe food handling and storage.
High nutrient density foods vs. low nutrient density foods.
Specific nutrient/caloric needs of individual participants.
Foods that are high-cost nutrient sources vs. lower-cost nutrient sources.
Two Methods for Developing Additional Topics
State and local programs use various methods to develop topics that com­plement
the minimum requirements outlined in the regulations. Below are
two methods that local programs use to develop additional topics and to
order them according to priority.
Brainstorming and the Delbecq Method
You can use both brainstorming and the Delbecq method to generate addi­tional,
often novel, topics. You can use these methods in ways that involve
the participants and other health and community professionals. For each
of these processes, make sure that all participants perceive the assign­ments
in the same way: While most of us have encountered brainstorming
in an informal or formal setting, the less widely known Delbecq technique
deserves a more detailed explanation.
Both methods can be effective in a variety of settings and for different pur­poses.
For instance, brainstorming can be used among health profes­sionals
to generate ideas on how to better document the nutrition educa­tion
contact or on how to deliver the message. It can just as easily be used
to produce additional ideas for topics.
Brainstorming, done correctly, very quickly produces a great number of
ideas. Start by gathering a willing group of people. A leader will explain the
problem and the ground rules of brainstorming. One or several people are
selected to record the ideas-either on paper or on a blackboard. The
leader gives the group the signal to start and joins the group. Without
hesitation or inhibition, members of the group speak their ideas as quickly
as each person thinks of them.
Effective brainstorming depends on the brainstorming DOVE. Adhere to
these essential elements:
D-Defer judgment.
Express all your ideas. Do not prejudge yourself.
The Delbecq
Method
0-Be offbeat.
Many creative ideas often sound silly at first. You may feel awkward shar­ing
these unusual ideas, but many times they blossom into something
important.
V-Find a vast number of ideas.
Quantity, not quality, is the goal of brainstorming.
E-Be expansive.
Expand on the ideas of others. Piggyback on their suggestions. Use them
as a springboard. This is only possible if you establish a dialogue among
all participants in the group.
The Delbecq method, sometimes called the nominal group process, is an
orderly way to gather ideas from a group. Like brainstorming, this process
can be used to generate new ideas for educational sessions for partici­pants.
And, it also provides a mechanism for selecting the most appro­priate
one or ones.
The Delbecq method helps to ensure that everyone participates equally.
Your group may be dominated by one or several members who are the
loudest, talk the fastest, or have the most authority. By following these
steps, you can ensure that all voices will be heard equally.
To start the process you'll need to gather a group of people and decide on
a leader. Each group member has 10 to 15 minutes to write down a certain
number of ideas. The leader then asks each member to state one item from
their list. The item is written on a blackboard or flipchart without comment
from the group.
Once all items are on the board, you have generated ideas but in a dif­ferent
manner than in brainstorming. Now the Delbecq method continues
beyond the point where brainstorming stops, and selects the best idea(s).
Allow 15 to 20 minutes to discuss each item in turn. Participants then
choose a set number of topics that are most important to them. They then
order these from the most to least important. Members then record the
rankings on a tally sheet. The leader tallies the votes and offers the results
to the group.
The Idea Book 7
The Idea Book 8
The Idea Book Chapter 2
FORMATS:
How, Can I Best Structure
Nutrition Education
Through Lesson Plans?
10 General Principles
10 Examples of Lesson Plans
17 Writing Behavioral Objectives
18 Conclusion
The Idea Book 9
Definition
of Terms
The Idea Book 10
General Principles
The lesson plan is a working document that helps you to organize, order,
and approach all the tasks involved in teaching. Its design should be sim­ple
to allow all those who use it to receive essential information at a
glance. A lesson plan should be modifiable, relevant to clients' needs and
environment, planned for marginal rather than radical changes, and planned
with time constraints in mind. The lesson plan should describe the goal. It
should also describe the educational activities, and how and how well they
are implemented. This rational sequence of steps characterizes a "means­ends"
model. A good lesson plan enhances orderly and careful thinking
and makes it easier for you to evaluate efforts.
To illustrate the current thinking in the construction of lesson plans, this
chapter presents several representative formats from various States and
discusses some of their features. As new terms surface in each lesson
plan they are defined. The lesson plan formats are ordered according to
their degrees of complexity. The simplest formats are presented first and
the most complex last.
Examples of Lesson Plans
Lesson Plan 1
Lesson plan 1 proceeds from a general identification of the problem to
concrete steps in meeting stated behavioral objectives. The categories of
content, method, and materials are consolidated into an entry called
"Learning Activities." The "Evaluation" entry describes informal feedback.
Although the terms used in lesson plans are familiar to most nutrition edu­cation
providers, they may mean different things to different people. To in­sure
that all the terms mean the same thing to everyone who reads them,
they are defined as follows:
Target
Identifies the participant to whom the lesson plan is directed. This may or
may not be the person actually receiving the instruction. The use of a
target helps the nutrition educator maintain focus and avoid digression.
Example: Target-child (the instruction receiver may actually be the parent
or caretaker.)
Goal
A broad statement based on an identified need that states the subject of
the lesson plan.
Example: To decrease the prevalence of anemia.
The following construction describes a basic design for writing a goal.
To I action verb I condition, attitude, or behavior to be changed.
Example: To I increase I calcium intake.
Example: To I heighten I awareness of the benefits of preparing food by
steaming it.
If the target group is not already independently identified on the lesson
plan, or if the target is not the person actually receiving instruction, the
goal statement should identify who will be receiving the instruction.
Example: Target: 5- to 12-month-old infant.
Goal: To increase the correct selection by a parent or caregiver of iron­fortified
cereal at the grocery store.
Example: N6 target group is identified.
Goal: To increase awareness of newly certified participants of the Family
Service Center and EFNEP in our town.
Objectives
Specific aims that include built-in, nonbehavioral criteria that can be
measured. The following construction demonstrates a basic design for
writing objectives.
To I action verb I desired result or outcome I target group I time frame
or completion date.
Example: To I increase I breastfeeding by 50 percent I in WIC mothers I
by 1982 as compared with WIC mothers in 1979.
Lesson Plan 1
(Adapted from Missouri WIC)
Target: P~ ~ .
Goal: J<r~ "tA<. ~(~ ~
Objective: o/ 1.98~ so~mtc71.L w:Jc .~~ ~
~~~~vYL..! t/78 .
Behavioral Objectives Learning Activities
(content, method,
materials)
Evaluation
The Idea Book 11
The Idea Book 12
Behavioral Objectives
The aims of instruction that require observable performance or behavior as
the test for determining that learning has occurred. The following construc­tion
demonstrates a basic design for writing behavioral objectives.
Person to be instructed I action verb that describes specific and easily
recognizable behavior I direct object of the verb expressed in a specific
quantity I time frame.
Example: To I list I three foods in the dairy group I after the second visit.
Example: Participant will I identify I four dietary practices that may harm
fetal development I after seeing the movie (name) on recommended and
nonrecommended dietary practices during pregnancy.
In each case, the results should be specific, tangible, recognizable, and
easy to count. In each case, the performance or behavior required at the
end of instruction should be limited by a specific time deadline. Imposing
these ground rules will give you continual and definite feedback about just
how much each participant is learning. Constant feedback will tell you
whether to provide more review or to try another approach. Behavioral
objectives play a crucial role in the teaching process because they
enhance dynamic interchange between the learner and the teacher and
because they help both parties focus on the weak spots.
Learning Activity '
The means by which behavioral objectives are achieved.
Content
The actual substance of learning material to master.
Methods
The process or strategy for selecting resources most appropriate for the
specific needs of participants and the sequence or order for their presenta­tion.
Materials
The actual resources used for teaching participants.
Evaluation
The process of appraising learning performance or outcome in relation to
the stated behavioral objectives, or goals.
Definition
of Terms
Lesson Plan 2
(Adapted from the Food and Nutrition Service Southwest Regional Office)
Target: "Pan...uNl 0'""1..... ~
Goal: ;1c-~ Uu 0-NJWI.tJ~ ?b OM.d.. ~c"t.t\.k ~o._Q_
\AAR_ ot ~ ~ <b ~~ ~~
Behavioral Objectives: :1-o- ~ ~ ~ ~ \.Qu_ ~
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.:k-~~~{~ ~~~~0...~ ~
~ ~~ ~6-t-v. of. crrmhlo~
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Time: 2.0- "?.O ~
Staff Member: ~ ~ ~ ( Q Y\~)
Content
1. Introduction
c~~­~~~
Lesson Plan 2
Methods Materials
1. P"-llA.. our ~. 1.~
2.~~.-tr~
~. u
2.~
This lesson plan adds two additional headings: "Time" and "Staff
member."
Time
The time category notes the length of time a staff member interacts with
recipients. This represents a conscious effort to document and thereby
justify the specific contribution of every staff member in terms of a
measureable quantity-minutes. Time notation contributes information for
cost/benefit analyses.
The Idea Book 13
Lesson Plan 3
Staff Member
Under "Staff Member," you will find a description of the nutrition educa­tion
provider. This entry serves to increase accountability in education ef­forts.
Staff member notation contributes information for cost/benefit
analyses.
Lesson Plan 3
The expanded format of this lesson plan reflects greater emphasis on the
importance of evaluation. The result of an evaluation can convey informa­tion
about a program to the general public.
(Adapted from Oregon WIC)
Goal: ~ ~ ~ <-O"VUJ: ~
~~~~~
Target: S V:s- 1 ci ~ crt~ ~~
Staff Member:~~~~~
Evaluation (Nutritionist's
Behavioral Objective Materials Suggested Time Observations)
for Completion Identify weak and strong
areas. Date comments.
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L\JtlQ~ \..we- - ~~~ CJ"Y\.. ·~ OJV\.4 ~lk =~~~
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\:u~~ '7/ I "~/'8Cl ( l-ti 5)
The Idea Book 14
Definition
of Terms
Lesson Plan 4
Lesson Plan 4
This lesson plan presents a problem statement, adds a heading for docu­mentation
and consolidates the "Staff Member" heading with "Materials"
under a new heading called " Resources."
Problem
The concrete and documented identification of a need that justifies conse­quent
remedial action. The following construction describes a basic design
for writing a problem.
Gerund form of an action verb I reference to a specific survey, test,
report I exact identification and number of the target population I
numerical description of the problem.
Example: Auditing I the Red Cross mobile unit hematological values I we
find that 60 percent of participating pregnant females I demonstrated
serum folic acid values below 5 ng/ml (normal= 6.1 ng/ml).
Example: Scoring I the answers of the State WIC nutrition knowledge
test I we find that 40 out of the 50 newest participants scored below 65
percent.
Documentation
Techniques used to organize and store, in a specific location such as the
certification folder, all the services and contacts that the participant
receives.
(Adapted from North Carolina WIC)
Knowledge or Attitudinal
Needs
Behavioral
Objectives
Activities/
Method
Resources
Target:~
Evaluation Documentation
The Idea Book 15
Lesson Plan 5
Lesson Plan 5
The expanded format of lesson plan 5 emphasizes the importance of
documentation. Specific notation of time, methods, and human resources
allows you to use this format in two ways. You can use it to guide the se­quence
of instruction or as a document. For both uses, you should store
this sheet and future continuation sheets where they can easily be found.
(Adapted from West Virginia WIC)
Behavioral Learning Materials Staff Min. Type of Type of Evaluation
Objectives Activities Member's Contact Counseling
Initials Identify weak
and strong
areas. .>....- ~ ~
C1S en ::J
'c0: a: a. '0 Date/Comment ()
0 ::J ·:;
en ~ 0 (Nutritionist's () O'l '0 C1S Q) .....
~ c: CD C/) I - Observations)
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The Idea Book 16
Writing Behavioral Objectives
Recently, nutrition educators have focused on writing successful behav­ioral
objectives and incorporating action verbs that demonstrate that learn­ing
has occurred. Certainly, correct construction of behavioral objectives is
essential to any lesson plan.
All action verbs are not created equal. You should try to avoid exclusive
reliance on verbs such as: listing, identifying, comparing, contrasting,
labeling, saying, reciting, quoting, distinguishing, and telling. These verbs
require the least amount of intellectual skill. Continual tasks in this area
can bore the learner.
A second reason to avoid exclusive use of these verbs is the current think­ing
of education researchers that such tiny islands of isolated information
contribute very little to changing dietary attitudes and behavior. Unless
nutrition learning can be integrated into a larger network of comprehension
that, in turn, relates to the recipients' own frame of reference, effecting
changes in attitude is extremely difficult. To absorb small bits of knowl­edge
the participant must achieve some objectives that require higher in­tellectual
skill. Behavioral objectives incorporating tasks in application give
the learner this opportunity. For example, once he or she knows that
calcium is important for fetal development and that its most absorbable
form occurs in dairy products, he or she should practice applying that
knowledge in adapting a menu or constructing a grocery list.
The verbs associated with the application of this higher intellectual skill
are: adapt, arrange, assess, build, compute, construct, create, formulate,
project, recommend, and use. Mastering objectives on this level can reward
the participant with a sense of self-satisfaction because bits of acquired
knowledge have actually been successfully applied to a greater and more
realistic problem. '
Contemporary psychologists assert that the greatest rewards of education
occur on this higher level of learning, the level of problem solving. Suc­cessful
problem solving gives the learner a sense of pride, self-confidence,
power, and independence. These psychological states of mind strongly
affect motivation to continue learning to change attitudes and ultimately,
to modify behavior. For these reasons, consider not only the basic con­struction
of behavioral objectives, but the depth of learning they require as
well. Examples of action verbs to use in behavioral objectives of this
highest level of learning are: deduce, defend, evaluate, explain, generalize,
interpret, judge, and recommend.
Example: Your best friend, who is also pregnant, tells you that she doesn't
like milk. Recommend three substitute food items to her and defend your
recommendation of each.
To solve this problem, the recipient must understand the contributions that
milk makes to a developing fetus, and she must know other food sources
of these same nutrients.
The Idea Book 17
The Idea Book 18
Example: Your best friend, who is also pregnant, complains to you that she
finds it very hard to get her housework done and wishes that she had more
energy. Suggest a nutritional cause of her fatigue and recommend two
items for her to eat.
To solve this problem, the recipient must be able to identify a major
symptom of iron deficiency anemia and know food sources containing
relatively high amounts of iron.
Conclusion
These five lesson plans have been arranged in order of increasing com­plexity
of planning and information retrieval. Over time, lesson plans have
grown more complex due to: 1) increasing sophistication in applying
education theory to nutrition, and 2) a growing recognition of the impor­tance
of accountability. Since educators have become more accountable
for their actions, they are finding more and more that they must include
evaluation and documentation in their lesson plans.
You should not sacrifice clarity of presentation to these increases in com­plexity.
Consider only those innovations that might be tailored to your own
particular needs and that promise to maximize the effectiveness of each of
your lesson plans.
The Idea Book Chapter 3
MATERIALS:
What Should I Consider
Whe'n Selecting Nutrition
Education Materials?
20 Locating Materials
20 Local, State, and Federal Government
20 Professional Associations
21 Special Interest Organizations
21 Educational Institutions and Libraries
21 National Voluntary Health Organizations
21 Public Interest Groups
21 Nonprofit and Trade Organizations
21 Commercial Companies
21 Evaluating and Selecting Materials
22 Written Materials
28 Audiovisuals
29 Developing and Adapting Materials
29 General Guidelines
31 Making Materials Responsive to Special Groups
The Idea Book 19
The Idea Book 20
Nutrition education materials may be used in your program to introduce
nutrition concepts or to reinforce information presented by other methods.
To select those instructional aids that are best suited to your WIC audi­ences
with their specific educational goals, you should adopt a systematic
approach. This chapter illustrates ways you can do this.
In some cases, there may be a lack of appropriate materials for certain
groups of WIC participants such as migrant farm workers or various ethnic
groups. Consequently, you may need to adapt existing pamphlets, flip
charts, posters, and other materials.
Locating Materials
Suggestions for where you might locate nutrition education materials are
listed below. For the address and description of sources identified by an
asterisk (*), refer to Chapter 9.
local, State, and Federal Government
Programs that provide nutrition education to participants:
1. U.S. Department of Agriculture, Food and Nutrition Service
*Special Supplemental Food Program for Women, Infants,
and Children (WIC)
Child Care Food Program
School Lunch Program
Nutrition Education and Training Program
Food Stamp Program
Commodity Supplemental Food Program
Food Distribution Program for Indians
*Food and Nutrition Information Center (FNIC)
2. U.S. Department of Health and Human Services
Maternal and Infant Care Projects
Maternal and Child Health Projects
Head Start Program
3. Other State and local government health and social services
Professional Associations
The American Dietetic Association
The American Medical Association
The American Dental Association
The American Public Health Association
The American Home Economics Association
Special Interest Organizations
*Society for Nutrition Education
La Leche League-local office
Educational Institutions and Libraries
Colleges and universities
National Voluntary Health Organizations
(and State and local affiliates)
American Heart Association
American Diabetes Association
March of Dimes
Public Interest Groups
The Children's Foundation
Center for Science in the Public Interest
Nonprofit and Trade Organizations
(Such as The Nutrition Foundation*, Florida Citrus Commission, Cereal
Institute, National Dairy Council, United Fresh Fruit and Vegetable Asso­ciation,
National Livestock and Meat Board, Egg Board, the Nutrition Today
Society)
Commercial Comp~nies
(Such as food companies, film companies, and supermarket chains)
Evaluating and Selecting Materials
After you locate materials, the next step is for you to evaluate them for
their suitability to your p·rogram. Questions that you should ask yourself
and other professionals when reviewing and evaluating instructional aids
are: What is the purpose of the materials? Are they consistent with our
local and State nutrition education plans and WIC Program regulations?
Who is the intended audience? Is there excessive promotion of a commer­cial
product or other bias? What is the cost of the material? Are alternative
materials available? Is the nutrition information presented scientifically
valid? Establish a panel of professionals qualified to make this judgment
on scientific reliability or rely on a review in reputable journals such as the
Journal of the American Dietetic Association and the Journal of Nutrition
Education.
The Idea Book 21
The Idea Book 22
Written Materials
Written materials are frequently used in educational programs as instruc­tional
aids. They are popular among educators because they can reach
large audiences with information at a relatively low cost. Their use may
meet with only limited success, however, unless the printed material has
characteristics well suited to its audience and purpose. A systematic and
standardized approach to assess printed materials can help you select
nutrition handouts that will be effective with different groups of WIG par­ticipants.
The following chart identifies how characteristics of printed
materials influence the learning process.
Relationship between the Characteristics of Printed
Materials and Factors Involved in the Learning Process
Source: Excerpt of a chart from Anderson, M.L.F., Olson, C.M. and Rhodes, K. ,
" Development and Pilot Testing of a Tool for Evaluating Printed Materials,"
Journal of Nutrition Education 12:51 , 1980.
Characteristics Learning Factors
-
~ c:-
c:- <ZI -~ 0 () .~ cG:-o ~ c:- c::- c::- ·:::' <ZI
-
~ c:- 1' -~ ~ -~ c:- :£? <:" -~ ............. 0 ...... . 0 Go :p -Q ~
(;~ ...... ~& ! ~
Readability
Avoidance of technical language
Use of noncircular definitions
Hyphens not used
Positive writing style
Use of an active voice
Suitable reading level
Stereotyping
-
- Positive role models of women
Appropriate minority representati
Different lifestyles presented in a
on
Format
----------
Paper quality
Size and style of print
Length of paragraphs
Placement and readability of tables
Use of illustrations
General format
Content ---------
Accurate content
Organization of content
Summaries and reviews
positive way
and graphs
Material reflective of needs and i nterests of
readers
Use of real life situations
-
Subject matter presented in a fa ir , objective manner
~:::: ·S :::: 0
"<~ "<($
r-
. .· - --
• t--- -- . . • -• -
• . --
- --
• --
-.
.. -.-
--
-
. - .- - . -
f- c:-
<rr .fE () "< ~ ct ct
--
- . -- . .• .
• f---
•
• . .
-
- . .. -- .. .
.. -- . • --f---
-t-
1-. - ---
Note from the preceding chart that a printed material is
More Readable,
if it: • uses an active
voice
• uses a positive
writing style
(Do vs. Don't)
Motivating,
• has positive
role models for
participants
and
• is sensitive to the
needs and interests
of readers
• presents different
lifestyles in a
positive way
• uses real-life situa­tions
Easily Understood,
• has illustrations
and/or graphs
• avoids technical
language
• is at a suitable
reading level
• is well organized
You can use the preceding criteria to help you develop your own method to
objectively select printed materials for your program. Or you might want to
use or adapt existing evaluation instruments that are based on this or
similar criteria. For instance, Cornell University developed an evaluation in­strument
using this crLteria to assess nutrition education materials
targeted for pregnant teenagers. A portion of this instrument follows. This
example illustrates how you can assess the readability of an item by using
rating factors pertaining to readability such as the use of active voice,
positive writing style, and appropriate reading level. Cornell's instrument
also includes a summary sheet on which to transfer ratings, so that the
relative strengths and weaknesses of a nutrition handout can be quickly
determined. Part I of this summary sheet pertains to readability of.
materials.
Cornell's instrument additionally includes an index that educators can use
to make fairly accurate and quick determinations of the reading (grade)
level of a material for an audience (assuming you know the approximate
reading level of the audience). It is a particularly useful tool since
educators frequently underestimate the difficulty of printed materials.
Developers of Cornell's evaluation instrument assessed an adequate
reading level of a nutrition handout for a pregnant teenager to be at the
sixth or seventh grade level, with superior ratings for materials at lower
grade levels and poor ratings for those at higher grade levels. These opera­tional
definitions for the ratings of poor, adequate, and superior make the
evaluation instrument more objective.
The Idea Book 23
The Idea Book 24
Part I EXCERPT FROM AN EVALUATION TOOL FOR WRITTEN MATERIALS
(Developed at Cornell University, Division of Nutritional Sciences, 1979)
NAME OF MATERIAL
SOURCE ORGANIZAT~I~O~N~--------------------------~P7A~GE~S~------------
AUTHOR~-------------------------------------COST. ____________ _
DIRECTIONS: Evaluate the material using the guidelines below, placing a check mark
next to the description that most appropriately applies in each category.
NOTE: The nonapplicable category should be used when the other ratings can not be
fairly applied. For example, a two-page flyer should not be penalized for not
having a summary.
READABILITY: Choose two pages from the main body of the text, and rate for each
readability factor on the basis of these two pages, unless otherwise
instructed.
la. Avoidance of overtechnical language
_____ Superior: an average of two or fewer technical terms are used per page
______ Adequate: an average of three technical terms are used per page
Poor: an average of four or more technical terms are used per page
- Nonapplicable
lb. Technical words, if used, are explained
______ Superior : definitions provided for two or more of the technical terms
found in the material
______ Adequate: definition is provided for one of the technical words found in
the material
Poor: no definitions provided for technical words found in the material
Nonapplicable
lc. Hyphens
_____ Superior: no hyphens used in materials
_____ Adequate: average of two or fewer hyphens per page
_____ Poor: average of three or more hyphens per page
_____ Nonapplicable
ld. Writing Style
_____ Superior: material is light, giving reader a sense of active involvement
with the material; written in a positive style; an average of one
or no instances of negative wording (e.g., "don 1 t eat ... ") per page
______ Adequate: material is easy to read, but does not personally involve the
reader; average of two instances of negative wording per page
_____ Poor: academic style or other style that would turn teens away is used;
average of three or more instances of negative wording per page
_____ Nonapplicable
le. Active Voice
_____ Superior: an active voice (e.g., "you need ... you eat") rather than a
passive voice (e.g., "can be influenced ... has been shown " ) is
used at least 75 percent of the time
_____ Adequate: an active voice is used from 50 to 74 percent of the time
Poor: an active voice is used less than 50 percent of the time
_Nonapplicable
lf. Suitability of Reading Level (see Fry graph, which follows)
Superior: reading level of material is fifth grade or lower
Adequate: reading level is sixth or seventh grade
Poor: reading level is eighth grade or higher
_____ Nonapplicable
lg . Reading Level is. _____________________ ___
RATING SUMMARY SHEET
DIRECTIONS: Darken boxes appropriate for rating each topic
(P=poor; A=adequate; S=superior) leaving blanks for non­applicable
categories. Afte
to this form, it may be used
and weaknesses of materials.
la. Avoidance of overtechni
r the ratings have been transferred RATINGS
to quickly assess relative strengths p A s
cal language
b. Noncircular definitions of technical words
c . Hyphens not used
d . Writing style
e. Active voice
f . Suitability of reading level
la.
b.
c.
d.
e.
f.
Reading Level Index (The Fry Graph)*
How to Use the Fry Graph to Determine the Reading Level of a Material
NOTE: You may need to modify the recommended number of words and
sentences to use this index to accommodate printed materials of short
length.
1. Select three 100-word passages from near the beginning, middle, and
end of the material. Skip all proper nouns.
2. Count the total number of sentences in each 100-word passage (esti­mating
to the nearest tenth of a sentence). Average these three numbers
(add together and divide by three).
3. Count the total number of syllables in each hundred-word sample. There
is a syllable for each vowel sound; for example: cat (1), blackbird (2),
continental (4). It is convenient to count every syllable over one in each
word and add 100. Average the total number of syllables for the three
samples.
4. Plot on the graph the average number of sentences per 100 words and
the average number of syllables per 100 words. Most plot points fall
near the heavy curved line. Perpendicular lines mark off approximate
grade level areas.
Example
100-word sample
100-word sample
100-word sample
AVERAGE
Sentences per 1 00 Words
9.1
8.5
7.0
3)24.6
8.2
Syllables per 1 00 Words
122
140
129
3)391
130
5. Plotting these averages on the graph, we find they fall in the fifth grade
area: hence, the material is about fifth grade difficulty level. If great
variability is encountered either in sentence length or in the syllable
count for the three selections, then randomly select several more
passages and average them in before plotting.
*Edward Fry, "Readability Formula That Saves Time," Journal of Reading, Vol II,
No.7, (April 1968), pp. 513-516; 575-578.
The Idea Book 25
The Idea Book 26
THE FRY GRAPH
Average number of syllables per 100 words
Short words Long words
/08 I 12 116 120 12'1 !28 1"32 136 /l.f() /'f'f N8 !52 15'6 160 10£1. !b8 172
rn ~ JSO E u 2o. o ~--+--+---+--+-+-t---11-+--+-...,.__,""""~--::;,~,r+-+-+-+-+--+--+--+-+-+-+--+-+-+-+-+-+--+-+-l--l
~ ~ I b. 71-+-+-++-+-t-lf-_,-±ooooo!'"'91-+-+-t-+-t-t-+-++-+-l--t-+-t-+-t---t-+-++-H
0 c 14.31-+--+-!--+-~.-..,+. _,~,~-+-~~__,""""i--::;,i,~-+-+-l-+--+--+--+-+-l-+--+-+-+-l-+-+--+-+-~
~ ~ f 2 Sl--t----1'~'-h~otif"'-"!--H,t+-...,.-+,.....~'""T-+--t-11-+---i -+-1--+--+---+--+-+-1-+-+--+-+-l-+-+---t--1
I / . I 1--+~2:::+--t--+~-+,;.,.."'~-+-t-t,--::J----t--+-+-- f--t-t---i--+-+-+--+ -t---t-+--+--t-t-+-+-t
{ 0.01-+--+"=t-+"""'~.,.._.l._.--+-t~----::;lo'""l-+"--:1. -~-+-+-+-t--t---+---+-+-1--+-+--+-+-t--+--+--t -..._
..._ 0
Q) .r:.
o.(j)
(/)
Q)
(.)
c
-Q) c
Q)
(/) -0
~2~---+~~~~t-t~a~~~...,.-t~~~~~t-t-+-t-+-t---i-+-+-+-1-+~-+-+-+-t-t
831-+~-t~3~...,.4~~~~~4~~~~~~+-t-t-+-t-+-t---i-+-+-t-+--t--+-t-1-~+-t
151-+~~~+,~9-+,.....~~R-~+~~+-f-+.~~-~-~-+--+--t-+-1--+--+-+-~--+--t-~
7. ( f--+-t--+'"'t-:-:7:+-~..,..T--.t.~. ...9 -t-+--t~~-+--+-+-t-+-t-+-+-+-+-t--+-t--+-+--r-+--i
fa.71-+-+-t-.~f-:5::t~~"",..,.._-i'l,.r-t-t~~+-t--t-+-t,-=-+-t--t-+-l-+--t-+-~-+-t-~
~3+-+-t--~~~~+---i--+~~~~t-+-t--+-1-~~+-h,~t-+-+--t--1--t-+--t-r+--t
G8t-+-+--t-1-~+---ir+-t--~~·,~-t-11--t-+~~t-1-/~+---i-+-+-t-+--+--~~H
55~~+-t-r-t-~~-t-~-P·~~~/~+-~~~h/~~~-+-t-~
5.3 ~ j"''lllllllll: ~ i/ I
<o
50 ~ ~~ 111111111111.. ~ / ' r ~ * ~-:~~:::::::::~~:::::-r.""~-/0-+-~f-=7:+-_-l+/_ _,_+-t----='!1/,.... ~... ..- .+ ..._-+-+-+-+l/-lr-+-J~--"f--1'-+-+-H
c ,,3 1'0
~ ~ .... IJ I
c Q) ..,. ~ ~ s / r r'llllllllll..., 1
Q) c 4.2 ~-4r- , 9 ,., J 1
Ol ~ f/..O I ~ G.c / 10 I I ~--· ~ Ol 3. 8 . \ ...q .-.,,_- .--'---'-...li--.-=-~L-t-,..-t-,ft-----c-::--1-t--'--'-.L-L--j
~ g 3. 7 1 .........-. LEvE +-~)4--+1'--''~ 1+-.:...1.-=;2'-C-1"--'+o:;-='--:.:;:L:..::Er-G-E-T-t
<( ....J 3.0 I I 1 ll' I I I
NOTE: The " Readability Graph" is not copyrighted. Anyone may reproduce it in any
quantity, but the author and the editors would be pleased if the source was cited.
The Cornell instrument illustrates one method that can be used to sys­tematically
evaluate print materials. Other evaluation methods may be
more subjective as illustrated by the following instrument developed by the
WIC Program in California.
The Cornell and California approaches are but two of a large number of
equally valid methods for assessing printed materials for your program.
Title:
Prepared :
Available from:
Type of Material:
Single page
Pamphlets _pgs.
Poster
Intended use:
Teaching aid
SelfA.i ns true t ion
PRINTED i'IATERIALS EVALUATION
(From California WIC)
Available in:
English
Spanish
Educational level:
Copy Attached: Yes D No 0
Date Produced:
Cost;
Target Group:
Prenatals
Breast feeding
Parents of Children
Parents of Infants
Children: Specify age
Staff
Purpose: D Arouse Interest D Develop AttitudeE> 0 G1ve Information D Stir to Action
Central Theme:
Concepts Presented:
Content: D well organized 0 accurate
0 ethnic/role stereotyping
D relevant D positive approach
D lack of commercialism
Readability: (length of sentences and paragraphs, style, tone, etc.)
Organization/Format: (layout, shape, size, color, illustrations)
Additional Comments:
General Evaluation: 0 Superior &
Essential D Excellent &
Desirable
0 Could Use 0 Reject
Ev•l~tor:·-------------------------------------------------- Dste:. ___________ _
The Idea Book 27
The Idea Book 28
Audiovisuals
When selecting audiovisual materials, you will need to consider both visual
and audio appeal in addition to content and appropriateness for the target
group. You can use the following form from Wisconsin NET to evaluate the
suitability of an audiovisual such as a film, filmstrip, or slide/tape presenta­tion
for specific groups of WIC participants.
AUDIOVISUAL MATERIALS EVALUATION FORM
(Adapted from Wisconsin NET)
TITLE of MATERIAL----------------------------
SUBJECT EMPHASIS ___________________________ _
IDENTIFICATION of TARGET AUDIENCE
1. Which of the following audiences is the material appropriate for?
Prenatal ( )
Breastfeeding ( )
Parents of infants ( )
Parents of children ( )
Children: Specify age ( )
Staff -- ( )
Other ( )
Please rate each statement on a scale from 1 to 5.
2. Concepts presented in a logical manner.
3. Concepts agree with accepted scientific
principles of sound nutrition.
4. Material addresses relevant issues.
5. Subject matter of a permabent nature.
6. Material is free of commercial product
promotion.
7. Material addresses both views of
controversial issues.
PROCESS
(1 • very low, 5 • very high)
1121314151
1 I 2 I 3 I 4 I 5
1 I 2 I 3 I 4 I 5
1121314 I 5
1 I I 3 I 4 I 5
1 I I 3 I 4 I 5 I
Please rate each statement on a scale from 1 to 5. (1: very low, 5 • very high)
8. Concepts appropriate for target population.
9. Length of presentation appropriate for
target population.
10. Manner of presentation appropriate for
target population.
1 I I 3 I 4 I 5 I
1 I I 3 I 4 I 5
I 3 I 4 I 5 I
11. Material motivates the student to learn.
12. Aesthetic visual appeal of material.
13. Aesthetic auditory appeal of material.
GUIDELINES for USAGE
1 I 2 I 3 I 4 I s I
1121314151
1 I 2 I 3 I 4 I s I
14. What degree of nutrition knowledge is needed by the instructor of thia
material?
__ No background
Supplementary teacher instr~ction
--If needed, is a clear and specific teacher guide provided?
__ Formal nutrition training
15. Are there activities or resources you suggest using in cooperation
with thi s material? Yes__ No __
Comments :
16. Have you previously used this material or are you aware of any
situations in which thig material was used? Yes__ No __
If yes, please comment on effectiveness.
17. Material is applicable to which of the following teaching methods?
-Presentation of factual materials Yes No
-Applied: requiring students to use the knowledge in various
situations Yes No
-Problem solving :---requiring student to analyze and synthesize
knowledge and use their judgmental skills Yes No
-Individual Instruction__ Group SettinL_-
18. Would you recommend this resource for the WIC Program? __ _
Why?
ADDITIONAL COMMENTS
Reviewer's Signature
Date Reviewed
Developing and Adapting Materials
General Guidelines
Some WIC programs may need to adapt existing nutrition education
materials or develop new ones for groups of WIC participants who have
special needs or different lifestyles. The following are general guidelines
for developing materials.
• Make sure that materials are relevant to audience concerns, needs, inter­ests,
attitudes, knowledge, language skills, media preferences, and
cultural and lifestyle characteristics.
Examples: 1. Use ideas from magazines and television that are popular
with the audience. Possibilities are nutrition quizzes and illustrated materi­als
with "soap opera" story lines. For instance, WIC participants and staff
could assemble a "photo-novel," which is a story told by photographs and
captions. 2. See that people who are illustrated in materials are represen­tative
of the audience. Also consider using role models in materials.
The Idea Book 29
The Idea Book 30
• Pretest materials with the audience. Check for comprehension, cultural
sensitivity, stereotyping, clarity, and persuasiveness.
• Recognize that the motivational aspects of materials are critical. Prepare
materials that will entertain and involve participants and encourage their
use of problem-solving skills.
Examples: 1. Use puppets to convey nutrition messages to children;
2. Have mothers take active roles in plotting the growth progress of their
babies by entering notes on a form as the physician, nurse, or nutritionist
makes observations and measurements; 3. Have adults plan a day's menu
incorporating "Dietary Guidelines for Americans," U.S. Department of
Agriculture, Department of Health and Human Services, Home and Garden
Bulletin, No. 232, February 1980.
• Emphasize the best and most current nutritional concepts. Include the
principles of the "Dietary Guidelines for Americans" in addition to ad­dressing
the nutritional risk factors of participants.
• Vary the size of print.
• Use illustrations.
• Use single concept messages whenever possible.
These guidelines are illustrated in the following example.
COMPLETE PROTEIN WITHOUT MEAT
.. AN~ PROTEJN IS CQW'!..EJE: u03~ ~
OEGGS~s
~PLANT Pla1IEIN IS INCOMPLETE:
II> TO MAJl.E. PLANT PROTEIN ((WPLETE SERVE ltXBHER
oil GRAINS+ LEGUMES
0 NUTS OR SEEDS +LEGUMES
R ~y PLANT ProTEIN+ PNY ANIMAL PROTEIN
EXAMDlE5 OF NON-MEAT DISHES WITH CDMP1.fiT PROTEIN
>PEANUT P..~l'l 5-'t<OWICI< 0.1 """""'-"' GR~IN 9m:M>
Making Materials Responsive to Special Groups
Additional challenges are presented in producing materials for participants
.Pf a different ethnic background who speak a different language. Examples
are Spanish-speaking populations, Southeast Asians, Haitians, migrants,
and American Indians.
In developing materials for these groups, you should attempt to:
• Understand participants' lifestyles and food habits.
• Identify and reinforce positive aspects of these lifestyles.
• Recognize your own cultural biases. For instance, grouping foods into
the traditional and familiar food groups may be both inappropriate and
ineffective as a way of teaching diet planning to people for whom a meal
is rice, eaten with a side dish of vegetables and a little fish.
With regard to translation:
• Carefully select translators and people to verify translation to promote
accuracy. Whenever possible, use people who are bilingual and familiar
with technical health terms.
• Recognize that totally accurate translations may be difficult because
concepts of food and health can be specific to the culture.
• Consider producing materials both in a native language and in English to
help participants learn English at the same time they learn about nutrition.
The two short nutrition education pieces that follow on this and the next
page illustrate many of these principles.
The Idea Book 32
CAN HURT YOUR
UNBORN BABY
If you are ..... .
trying to get pregnant
or
think you are pregnant
.... Don't Drink
Help your Baby get
a Good Start in Life!
Studies show that pregnant
women who drink may have
babies who are smaller than
normal
You can help your baby by
knowing the dangers of drinking
during pregnancy. Let your
families know, too. It is impor­tant
to help pregnant women
not drink.
NEED HELP?
It is not easy to stop drinking.
If you need help, call or visit:
and have difficulty learning
It is also believed that drink­ing
too much alcohol in­creases
the chances of
having babies with birth
defects.
ALL THESE PROBLEMS ARE
PERMANENT AND CANNOT
BE CHANGED.
WHY?
When the
drinks.
goes
blood to the
blood. This
the baby as
grows and
ops, because
alcohol is
poison
The amount of alcohol that is
dangerous to the fetus is un­known.
Even two drinks may
harm the baby during the stage
of development.
THE BEST ADVICE IS DON'T
DRINK AT ALL WHILE
PREGNANT!
Have a healthy pregnancy
- eat proper food
-exercise
- get proper prenatal care
- eliminate anything which may
be harmful to your baby such
as alcohol, cigarettes, and
drugs.
Alcohol also enters a mother's
milk so don't drink while breast
feeding.
The Idea Book Chapter 4
METHODS:
How Can I Get the
Results I Want?
34 Identifying Motivations of WIC Participants
35 Nutrition Education as a Process
36 Using Media Effectively
37 Adapting Learning Situations to the Local Program
38 Individual versus Group Educational Approaches
38 Involving Children
39 Extending the Learning Environment beyond the WIC Setting
The Idea Book 33
The Idea Book 34
Creating and guiding learning activities toward nutrition education goals is
challenging. Your goal may be to help WIC participants make informed
choices about the foods that they eat so they maintain desirable eating
behaviors and modify undesirable ones. Factors that affect an individual's
food choices include physiological and psychological makeup, and social,
cultural, and environmental influences. Consequently, modifying eating
behavior often requires that you reach a goal slowly, in small sequential
steps. Behavior modification is justified only if, in your professional judg­ment,
the specific benefits of changing an eating behavior outweigh the"'
possible adverse consequences of maintaining that behavior. For example,
you should consider the effect the change might have on family or other
social relationships. Recognizing the many connections that food has in
the lives of people is important not only in identifying nutrition education
goals, but also in identifying the best means to attain these goals. In a nut­shell,
you should select nutrition education methods for their ap­propriateness,
efficiency, and effectiveness. As an example, identifying
motivations of WIC participants can help you select the most appropriate
methods for working toward educational goals.
Identifying Motivations of WIC Participants
Each day WIC participants are exposed to food messages from a variety of
sources. Sources of information include mass communication channels
such as radio, television, and newspaper, and informal communication
channels such as conversations with family and friends. The WIC partici­pant
selectively listens to certain messages. The food messages that are
most likely to get through to the participants are those that reinforce
things that the participant already believes. Those messages that are most
important to individuals and are contained within their present value
systems will have the greatest impact. There are many motivating factors
that affect how receptive a participant will be to any message. Being sen­sitive
to these motivations enables the effective communicator to tailor
messages to the participant.
The following motivations of WIC participants were identified and became
a foundation upon which to base the accompanying education strategies.
Participation Motivation
• Self-esteem
• Improved appearance
• Acceptance by peers
and community
Nutrition Education Strategy
Have recipe contest with prizes for
winning participants (See Sandra
Copple-Chapter 8)
Emphasize appearance benefits of
losing weight (See newsletter in this
chapter)
Make nutrition education a social
activity (See Marcelle Guth­Chapter
8)
Nutrition Education as a Process
You can view nutrition education as an ongoing process, regardless of
whether your goals are to maintain or to modify participants' behaviors. In
the latter case, an understanding of the steps people may go through in
adopting new ideas can help you select appropriate methods to encourage
the adoption of new ideas.
The stages identified below and the mother's expression of these stages
illustrate the process involved in a decision to breastfeed.
Stage in Adopting a New Idea
1. Awareness
2. Interest and information seeking
3. Evaluation
(or Mental Application)
4. Trial
5. Further information seeking
6. Adoption -
Mother's Expression of Stage
"I see a lot of mothers breastfeed­ing
their babies these days."
"I didn't nurse my first baby. Is
there any reason why I should
breastfeed this one?
"Can anyone do it?" "Will my
breasts sag when I quit nursing?"
"Will I have to stop nursing when I
go back to work?"
"How will my husband react if I
nurse the baby in public?"
"I think I'll try it."
"What if my nipples get sore?"
"How long should I try to breast­feed?"
"I really enjoyed breastfeeding my
baby."
"It's a lot easier than making
formula. I'd encourage others to
try it."
Adopting new ideas will occur at different rates among WIC participants
depending on an individual's learning rate and style. For some, the process
may not go beyond the initial awareness stage. For others, ideas may be
tried out before seeking information about or making an evaluation of the
situation.
You may want to select nutrition education methods corresponding to the
adoption stage reached by the WIC participant. For example, mass media
techniques often are most effective in drawing attention to an idea and
creating interest and desire for more information. On the other hand, infor­mal
channels of communication such as family and friends may have the
most impact in the final stages of adopting a new idea, since this involves
The Idea Book 35
The Idea Book 36
accepting and incorporating the idea into a lifestyle. When obstacles occur
in the educational process, you should consider the possible causes.
Here are two questions you might ask to help you focus on the nature of
the obstacle:
• Is the message being attended to? If not, why not?
• Is the participant at a point in which he or she may desire more specific
information on a subject?
With answers to these questions, you can revise nutrition education
methods accordingly.
Using Media Effectively
When selecting a means to communicate messages, you should consider
the message to be delivered and the audience(s) to be reached. Successful
advertising techniques can help you effectively communicate via the mass
media.
For instance, you can apply the following tips when conveying a message
through a pamphlet, poster, or by radio.
Use:
• Positive messages
• Single concept messages
• Slogans
• Repetition
• Variety of methods to communicate the same message
Participants are likely to be more receptive to positive communication,
such as "Breast Milk is the Best Milk for Babies," than to receiving
negative messages, such as "Bottlefeeding is Harmful to Your Baby." Also,
selecting only one topic or single concept to convey in a pamphlet, poster,
or radio message will help insure that participants absorb the message.
For instance, "Eat Whole Grains" could be the focus of a brochure or
poster. Using catchy phrases or slogans are also ways to interest par­ticipants
and aid in their retention of information. Here are some examples:
Nutrition, your best physician.
Your food, chance or choice?
A moment on the lips, forever on the hips.
Drinking like a fish is all right,
if you drink what a fish drinks.
Live healthy, well-thy, and wise.
Be safe at the plate.
Overeating is like a credit card-splurge now, pay later.
What you eat today is what you wear tomorrow.
What you eat in private, shows in public.
You are what you eat.
Repeating the nutrition education message can also aid retention. Nutri­tion
education messages can be reinforced through a variety of methods
including structured educational sessions in the WIC clinic, posters
displayed in waiting rooms, newsletters for participants to take home, and
informal contacts between the nutrition educator and participant.
Some media sources are useful when working with both large and small
groups. Films, filmstrips, and flip charts are examples. The impact of these
materials depends not only on their content and message but also on how
they are used in an educational session. In particular, combining these
channels of communication with informal and interpersonal channels can
be very effective. For example, after a media presentation, you can en­courage
WIC participants to discuss the topics presented. Discussion
might also be encouraged during the media presentation itself. Pauses
between slides can provide participants an opportunity to ask questions.
Printed materials such as pamphlets can be used to initiate group discus­sion
and enhance their meaning to the participant.
The participant's family, friends, and community ties are informal com­munication
channels that you can use in the educational process. A hus­band
or other family member could accompany a WIC mother to educa­tional
sessions at the local agency or become involved in the discussion of
nutritional issues at home.
Adapting Learning Situations to the Local Program
WIC Program resources and the realities of WIC Program operations are
major considerations in selecting nutrition education approaches. Nutrition
educators are becoming very creative in finding ways of making the most
of limited resources, such as space, for the delivery of nutrition education.
Example: The Waiting Room .
Many programs teach nutrition while participants wait to be certified or to
pick up food instruments. These nutrition messages reinforce nutrition con­cepts
that have been presented in educational sessions and on occasion
introduce new concepts. Films, slide shows, display boards, posters, and
self-instructional aids have all been used to teach nutrition. Methods that
entertain and involve participants are particularly effective. Participants
can work a crossword puzzle that tests their nutrition knowledge, as they
sit in the waiting room. This could provide useful information to the partici­pant
and at the same time tell the WIC staff something about the client's
level of nutrition knowledge. You could also use nutrition games to
educate and entertain children in the waiting room.
Integrating nutrition education into the overall WIC Program offers addi­tional
challenges for WIC staff. The times at which participants are
scheduled for nutrition education contacts must be both workable for WIC
staff as well as convenient for participants. To accomplish this, many WIC
programs arrange to have nutrition education contacts coincide with clinic
visits and with certification and pickup of food instruments. Another ap­proach
used to accommodate the WIC participant is scheduling evening or
weekend sessions and special classes for working mothers.
The Idea Book 37
The Idea Book 38
Individual versus Group Educational Approaches
Successful WIC programs use both approaches to teach nutrition par­ticipants.
Each approach has its distinct merits. Compare the advantages
of each.
INDIVIDUAL vs.
• Education tailored to individual
needs and resources.
• High degree of interaction
between participant and nutrition
educator.
• Close monitoring of nutrition
education progress possible.
Involving Children
GROUP
• Efficient: reaches more
participants.
• Can bring together people with
common needs and interests (for
instance, mothers with preschool­age
children, or breastfeeding
mothers).
• Learning occurs through
exchange of ideas among peers.
• Support for new behaviors
provided by group.
You can also direct nutrition education efforts toward preschool-age
children enrolled in WIC. At ages 2, 3, and 4 years, children become
increasingly aware of food and begin to adopt attitudes toward food that
become lifelong eating habits. The WIC Program provides an excellent
opportunity to complement and supplement childrens' home-based food
experiences. Food experiences in the WIC setting can provide young
children with a variety of sensory experiences that will enrich their overall
development and encourage positive eating behaviors. Parents can benefit
from observing children involved in various activities in the WIC setting
and comparing the developmental stages of other children to their own.
Concepts that range from where food comes from to how foods are
prepared and what foods are healthy can be presented to children in the
WIC setting. Exploration and experimentation are two approaches to food
education that work well with preschool children. This is an excellent
opportunity to use volunteers and paraprofessionals to help children ex­plore
and experiment with food.
Some nutrition education activities for preschool-age children are described
below.
• Read books or tell stories about food.
• Let children examine different foods.
• Use a "black box" with different nonperishable foods inside to shake so
that children may guess what is inside.
• Allow children to smell different spices in jars.
• Have children mimic an adult behavior using make-believe foods, such
as kneading bread dough or shaping meat patties made from clay or play
dough.
• Set up a grocery corner made from a large packing crate and stock it
with such items as empty cans and boxes. Let children pretend they are
shopping for food.
A group at a WIC clinic may be of different ages and abilities. This can be
a decided advantage. A mature child will be able to assist a young child in
a learning activity.
Learning activities designed for children can also be designed to reach
parents. For example, puppet shows with a nutrition theme might appeal to
both parents and children.
Extending the Learning Environment beyond the WIC Setting
You can reinforce nutrition education messages received in the WIC set­ting
by extending the educational process to other settings. Nutrition
education for WIC clients can take place in food stamp offices, Head Start
centers, supermarkets, and even laundromats. The possibilities are almost
limitless.
Some supermarket ideas include tear-off recipe cards placed near WIC
foods on supermarket shelves with the recipe on the front and nutrition
information on the back, and slide and tape presentations on WIC food
preparation at a market that is frequented by WIC clients.
In a home delivery system, recipes, nutrition newsletters, and information
sheets can be delivered with the food.
In the Dodgeville, Wisconsin WIC project, the staff uses parent meetings
and newsletters of the local Head Start Program to reinforce nutrition
messages. They also plan nutritious snacks for Head Start meetings.
Other WIC projects including those that provide home delivery of WIC
foods have begun newsletters for participants. An example of a newsletter
from the California WIC Program follows.
The Idea Book 39
The Idea Book 40
TIBURICO VASQUEZ HEALTH CENTER APRIL 1980
Dear Participant:
Once again, it is springtime!! Time to get ready to enjoy the warm weather.
But, if you are like most of us, you will find your summer clothes are a little
tight from those extra pounds that the inactivity and holiday eating of
winter brings.
Both shedding winter pounds or losing large amounts of excess weight are
difficult to do without a firm commitment. THERE IS NO EASY WAY. Fad
diets are dangerous to your health and rapid weight loss is usually re­gained
quickly. You may need to change your FOOD HABITS PERMA­NENTLY
to prevent obesity from being a way of life for you.
DO YOU REALLY WANT TO LOSE WEIGHT AND KEEP IT OFF?
Your Motivation Must Be High
Think About These Facts
Twenty-five pounds of excess weight over
the age of forty decreases your chance for
a long life by 25%.
Overweight women often have more diffi­culty
during pregnancy and labor.
Overweight women are often discriminated
against when they look for a job.
Obesity leads to crippling and often fatal
diseases like high blood pressure, heart
disease and diabetes.
YOU CAN DO IT!
(Adapted from California)
The Idea Book Chapter 5
EVALUATION:
How Can I Tell if Our
Nutrition Education
Efforts Are Effective?
42 Considerations in Planning your Evaluation
43 Categories of Evaluation
45 Types of Evaluation
45 The Outcome Evaluation
45 Knowledge
48 Attitudes/Beliefs
48 Behavior
50 Improvement in Nutritional Status
51 Conclusion
The Idea Book 41
The Idea Book 42
Evaluation is the process of measuring the effectiveness and appropriate­ness
of an activity or intervention. You may determine the success of any
intervention in many ways ranging from very informal verbal feedback to
numerical data that can be analyzed with statistical methods. Evaluation
provides a rational approach to program monitoring and development.
A key element to recognize is that, no matter how informal, an evaluation
requires documentation. Unless recorded, the utility of the entire evalua­tion
is suspect and often of little value. Your challenge is to recognize and
record the results of your nutrition education efforts.
It is methodologically difficult to substantiate the connection between
nutrition education and the improved health of WIG participants. Other WIG
program benefits such as health care and the food package are more tangi­ble
influences on health status. These more direct influences make it more
difficult to measure the relative impact of nutrition education on the health
of participants. Furthermore, the failure to measure the effects of nutrition
education discourages any attempt to systematically improve the nutrition
education program.
Without documented support of nutrition education, this component of the
WIG Program is vulnerable in times of escalating program costs and
dwindling resources.
Recognizing all these factors, some nutrition educators have begun to
develop new methods of evaluation. They have begun to look to the quanti­tative
methodologies of the social and behavioral scientists. Creatively
coupling these methods of the social scientist with the traditional tools of
the biological and physical scientist can create the bridge necessary to
link educational activity with the improvements in nutritional status.
Furthermore, when we 'focus on the health benefits of nutrition education,
we should not forget to assess other effects such as improvements in
family food purchasing practices.
This chapter discusses several approaches to evaluation as well as some
specific techniques that may help you assess the progress of your nutrition
education efforts.
Considerations in Planning your Evaluation
How useful an evaluation will be depends upon how well it is designed.
Often an evaluation will be conducted that bears little or no relation to the
original purpose of the program. Other evaluations have been designed
with little regard for cost, personnel, or time requirements. The best evalua­tors
always keep in mind the audience for whom the evaluation is being
performed, the purpose of the evaluation, and how the results will be
presented and used. An outline of key considerations to keep in mind while
designing and carrying out your evaluation follows.
Evaluation Planning Sheet-WIC Programs
(Adapted from the Food and Nutrition Service Southeastern Regional Office)
DECISION
SITUATION:
PURPOSE:
AUDIENCE:
ISSUES:
What category of evaluation will be conducted?
What will the evaluation achieve?
Who is the evaluation for?
What do you want to find out? What decisions are to
be made?
EVIDENCE: What information will be needed?
DATA GATHERING: How will information be collected?
ANALYSIS:
REPORTING:
RESOURCES:
a. Instrument, task force, interview, committees, com­puter
programs? What questions will be asked to
get information?
b. From whom? Source of information-sampling.
c. Time schedule: When?
d. Information to be collected by whom?
What does the data mean?
a. Instructions for editing, coding, and tabulating.
b. Relationships, correlations, and comparisons to be
made.
c. Statistical analysis to be used.
d. Analysis and interpretation to be done by whom?
When?
e. Conclusion and recommendation to be developed
by whom?
How can the evaluation findings be reported?
a. Means of presenting the findings.
b. Format of the report.
c. Date for reporting the findings.
a. Personnel requirements: staff time.
b. Budget: money.
Categories of Evaluation
There are two broad categories of evaluation, formative and summative.
They serve two very different purposes.
In general, you use the formative evaluation to improve your program or ac­tivity.
A formative evaluation can convey qualitative information and may
not require extensive planning. A summative evaluation is highly technical,
quantitative, and must be carefully organized.
The Idea Book 43
The Idea Book 44
Purpose-
Timing-
Methods-
Scope-
Formative
1. to modify and improve a
program or activity
2. ongoing and may involve
immediate and continual
feedback
3. may be anecdotal or
informal
4. can be focused and
narrow, and can address
individual and isolated
aspects of the program
Summative
1. to gauge the impact
and appropriateness of
a program or activity
2. at the conclusion of a
specific effort or project
3. generally analytical,
statistical, and research­like
4. usually comprehensive
Your whole approach to an evaluation depends on whether you intend to
conduct a formative or a summative evaluation. The planning investment,
the data gathering, the information analysis, the overall resource commit­ment,
and most activities related to the evaluation are more time-intensive
and costly in a summative evaluation. For efficiency, you should first
decide which type of evaluation best suits your purpose.
A "Litmus Test" for Distinguishing
between Formative and Summative Evaluation
Procedures:
1. Test both questions
against your evaluation.
2. Note which one "fits"
best.
3. Read results off standard
reference chart.
Recommendations:
Standard Reference Chart
If Then
How It is a
did we SUMMATIVE
do? Evaluation.
"fits" best
How It is a
are we FORMATIVE
doing? Evaluation.
"fits" best
If the purpose of your evaluation is to tell you how well the program is run­ning,
then good formative evaluation provides the information that you
need to adjust or fine tune a program until it operates smoothly. Only then
can you undertake a meaningful summative evaluation or performance test.
Do not automatically discontinue a program or activity if the formative
evaluation indicates the need for modification. Decide whether the problem
lies with the activity itself or with the mechanics of how the program is
run. For instance, the women may have appeared uninterested in your
lesson on "maintaining optimal iron status," but their apparent lack of in-
terest may have been due to the presence of their toddlers. When the
distraction is removed, you may find that it wasn't the topic itself, nor the
way the message was delivered that was the chief cause of the earlier
failure to communicate. However, do not hesitate to discontinue a program
or activity if negative results are obtained from a well-designed summative
evaluation. Continuing to operate an ineffective nutrition education pro­gram
is unconscionable.
Types of Evaluation
There are three basic types of evaluation. Each of these can be either for­mative
or summative.
Type of Evaluation
Strategy Evaluation
Process Evaluation
Outcome Evaluation
Describes
The degree to which the intervention responds
to the identified problems of the target group.
How well the activity was conducted.
The extent to which the anticipated outcome
was achieved.
Of all these, the outcome evaluation deserves the most attention. Results
of outcome evaluations best justify the intervention, program, or activity by
confirming its beneficial impact. Outcome evaluations present a picture of
the impact of the program on the participants.
The Outcome Evaluation
The most prevalent method for describing the sequence of outcomes that
Tesults from a nutrition education activity is found in the KABINS model.
This model assumes that changes in knowledge (K) lead to changes in at­titudes
(A) that result in altered behaviors (B) and ultimately, result in
improved nutritional status (INS). Knowledge does not necessarily lead to
action. Recently, evaluators have begun to measure behavior intentions as
well as reported behaviors in order to more fully measure the effects of the
nutrition education activities.
Knowledge
Questions concerning knowledge about nutrition are generally easy to
develop from the curriculum or lesson plan. For instance, if you are
presenting a lesson on iron-rich foods to children enrolled in WIG, you
might ask, "What foods are rich in iron?" The ease in forming knowledge
questions may be deceptive, especially for young children. With children,
the way that the questions are presented is critical.
Questions should be written or spoken very clearly so that they are cor­rectly
understood by most children. The instructor should be sensitive to
the knowledge level of young children when testing the way that they
relate to food and groups. For example, young children may respond nega-
The Idea Book 45
The Idea Book 46
tively to questions about "cereals" or even "cornflakes" even though they
eat them regularly at home. They may refer to their cereal only by a brand
name. In this case, their unfamiliarity with the words "cereal" or "corn­flakes"
will result in an answer that does not describe their real knowledge
or attitude. Such errors in test questions are extremely difficult to detect
without pilot testing the questions beforehand. Whether for children or
adults, you should present new questions to a sample group and revise
them before using them in a final questionnaire.
A good method to use in testing changes in nutrition knowledge of chil­dren
is to have an adult instructor or leader, who is trained for this task,
read validated questions to the children and have them respond to "pic­ture"
scales. The following example illustrates this technique and the level
of questioning that is suitable for children ages 3 to 5. In the picture scale,
notice that the evaluation can be graded in an easily measurable way. This
type of numerical data lends itself to objective analysis.
Instructions for the Test Giver
Example of a Method to Test the Nutritional Knowledge of Children
(Adapted from NTS Research Corporation, Durham, North Carolina)
Point to the star and the number one on your instruction sheet. Then, run your finger horizontally
across the first row to point out the four pictures. Then say: " I am going to read the question for
these pictures. Put a circle around the picture you choose." Read the first question.
1. (star) A well balanced diet is important because:
A. It helps me make B. It helps me grow C. It helps me sing
friends. and develop. better.
*1
D. It helps me act
grown up.
When the children have marked the first item, check to see that they have circled one of the pic­tures
in the first row. Continue read ing the items to the children. Maintain a steady pace. If one or
more of the children indicate that they do not understand a given item, reread that item, using ex­actly
the same reading. However, avoid repetition of every item. Continue reading:
2. (butterfly) A person needs more food for energy when:
A. She watches B. She is fat. C. She gets more D. She studies a lot.
television. exercise.
Answer Sheet for the Child
More sophisticated tools can be used with adults. With adults, you should
try to test not only for recall of information, but also, for its application in a
problem-solving situation. In particular, note the evaluation for Perfor­mance
Objective No. 2 that follows. Notice also that the activity is docu­mented
and the objective is stated in measurable terms.
(Adapted from California WIC)
OUTCOME OBJECTIVE A.
Within 6 months of participation in the nutrition education program, 60 percent of the prenatal
women will demonstrate knowledge of the nutritional needs during pregnancy and lactation based
on the revised guidelines established in Nutrition During Pregnancy and Lactation (NDPL).
PERFORMANCE OBJECTIVES
1. Pregnant/lactating women
will identify the food
groups.
2. Pregnant/lactating women
will identify at least two
foods within each of the
food groups based on the
revised NDPL guidelines.
3. Pregnant/lactating women
will identify the amount of
food needed from each
group per day based on
the revised NDPL guide­lines.
4. OPTIONAL: Pregnant/
lactating women will be
able to evaluate their food
intake for one day by
stating if they have eaten
the number of foods from
the food groups based on
the revised NDPL guide­lines.
LEARNING ACTIVITIES
Describe topics, methods,
and teaching materials
Individual counseling by nutritionist or
aide each trimester comparing recall to
six food groups. Handout " Food for a
Healthy Mom & Baby" given to each
entering pregnant/lactating woman.
Prenatal Class. " Diet During Preg­nancy"
stresses using the food groups
as a guide. Uses " Inside My Mom,"
food models. Each prenatal group
discussion.
Information included as part of indi­vidual
counseling by nutritionist and in
prenatal class, as noted above.
EVALUATION
Diet improved at
trimester checks.
Post-test: Using food
models, one participant
makes appropriate daily
menu. Other partici­pants
fill out sample
24-hour recall in the
appropriate food cate­gories.
OPTIONAL: Pregnant/
lactating women will
identify any and all
suboptimal areas of in­take
of the food groups
and record their intent
to remedy the areas.
DOCUMENTATION
Eligibility card or
chart.
File kept by nutri­tionist.
The Idea Book 47
The Idea Book 48
Attitudes/Beliefs
Knowledge about nutrition is closely related to beliefs about nutrition. As
with knowledge, questions about attitude and attitude change can be
developed from the curriculum with little difficulty. The "Smiley Face" por­tion
of the evaluation form that follows illustrates one method for testing a
child's food attitudes. Notice how the measurement of attitudes toward
certain foods is accompanied by a measure of the child's reported eating
behaviors.
Evaluation of a Child's Food Attitude and Eating Behavior
(Adapted from Arizona NET)
SNACK PREFERENCE
DIRECTIONS: 1. Fill in the code number given by teacher Code ____ _
2. Check the box that tells how you feel about food listed.
3. Check the box that tells how often you eat it for a snack.
PREFERENCE FREQUENCY
FOOD
Li.© .o t Li©me D@..i ke Nev.6?j •st ed Daily Onac e Onac e HEavredrl y
v " Week Month
DONUTS
CUPCAKES/CAKES
fill in your favorite
'
TWINKlES
COOKIES
fill in your favorite
CRACKERS
fill in your favorite
GRANOLA/GRANOLA BARS
POPSICLES
CANDY BAR
fill in your favorite ---
OTHER CANDY
GUM: regular
sugarless
MARSHMALLOWS
POTATO CHIPS
CORN CHIPS
PRETZELS --
CHEETOS - r-
POPCORN -- 1---
NUTS/CORN NUTS -- --- - -
OTHER (List)
--- - --r--
ICE CREAM/ICE CREAM BAAS
MILK SHAKES
-- --~
Behavior
Although measures of knowledge and attitude are important components
of outcome evaluations, they are not enough to describe the final outcome.
Knowledge and attitude testing should be complemented by measuring
changes in other outcomes such as behavior, behavior intentions, and im­provements
in nutritional status. The plan on page 47 includes examples of
evaluations of both behavior (see Performance Objective No. 1) and
behavior intentions (see OPTIONAL Objective No. 4).
Traditionally, the nutritionist has measured the eating or feeding behaviors
reported by the target audience or participant to gauge the impact of nutri­tion
education on behavior. The 24-hour recall or a similar instrument such
as the 7-day food frequency questionnaire are some of the most commonly
used instruments for measuring eating behaviors.
Considerable research has shown that measuring an intention to behave in
a certain way is a powerful predictor of the way one actually acts. An
evaluation of reported behaviors can be strengthened by measurements of
behavior intentions that confirm the reported behaviors. Compare the
following "twin pairs" of questions designed to test the behaviors of WIC
participants.
Questions to Test
In
Children
Adults
Reported Behavior and
What did they eat for
breakfast today?
What snacks did they have
yesterday?
Did they ask their parents to
prepare or buy a special food
yesterday?
What did they serve for
breakfast today?
Have they exercised today?
Behavior Intentions
What do children intend to
eat tomorrow for breakfast?
What snacks do they think
they will have tomorrow?
Did they intend to ask their
parents for a special food
tomorrow?
What do they intend to serve
for breakfast tomorrow, and
why did they choose these
foods?
Do they intend to exercise
tomorrow?
Although what a person says they intend to eat does not always accurately
predict what they really do eat, the degree of error is generally no greater
than the discrepancy between what a person tells you that they ate and
what they actually consumed. Whether you choose to test for the intended
behavior or the reported behavior, it is often influenced by many factors.
As nutritionists we are more familiar with-and therefore, have greater con­fidence
in-measures of reported behaviors. Although understandable,
past reliance on reported behaviors should not automatically preclude us­ing
tests of behavior intentions to assess changes in behavior.
The Idea Book 49
The Idea Book 50
A second factor to consider is whether you have an opportunity to review
reported behaviors. Many programs report difficulty in scheduling the two
required contacts within a certification period. To measure reported behav­iors
requires a followup questionnaire, food frequency, or dietary recall at a
later date. Intended behavior can be immediately measured at the close of
that nutrition education contact. Not only is this more efficient, it also
removes the possibility that other factors may have intervened between the
nutrition education session and the measurement of behavioral changes.
These intervening factors may have caused the reported behavioral change
that is measured.
Third, you should consider the person that you are counseling. A person
must possess a certain level of intellectual and forecasting skills before
you can accurately measure behavior intentions. On the other hand,
honesty is needed for valid measurement of reported eating behaviors. For
instance, while some adults may "conceal" items they ate, a child will
usually "confess" that he or she had a twinkie and a jelly doughnut
washed down with a soft drink for breakfast. On the other hand, an adult is
generally better equipped to predict what he or she will eat tomorrow or
the next day. Consequently, measurements of reported behaviors might be
more appropriate for children, while testing behavior intentions might be
more effective with adults.
Improvement in Nutritional Status
The WIC Program requires that certain aspects of nutritional status be
measured, such as weight gain and iron status. Even with sophisticated
computer analysis of such data, it may be impossible to define the role of
nutrition education in effecting the observed change in nutritional status.
There are many factors in addition to nutrition education that influence
these changes. The best approach that is available to us today is to forge a
strong sequential link between the nutrition education and the observed
improvements in nutritional status. If we start with the improvements
shown in the outcomes that usually occur first-such as the knowledge,
attitude, and behavior changes-and follow through to changes in health
status that are recorded much later, then we have constructed a logical se­quence
that supports an argument that nutrition education played a part in
causing the observed improvements in nutritional status.
In constructing your outcome evaluation, remember that the parts of a
puzzle by themselves are not as meaningful as they are when assembled in
a single picture. Try, therefore, to include as many elements of this scheme
as possible in each evaluation tool and plan.
Conclusion
Past evaluations have not demonstrated that improvements in physio­logical
or biochemical indicators of health specifically result from nutrition
education efforts. There are several reasons for this:
1. Improvements in nutritional status generally occur over a long period of
time. It may take several months to change dietary habits and several
more months after that before physiological and biochemical indicators
actually reflect them.
2. When health indicators are affected, it is difficult to decide whether the
change occurred because of nutrition education or because of another
influence such as: supplemental food, genetic makeup, birth order,
general educational level, or income level.
Because it is so difficult to credit nutrition education for specific improve­ments
in well-being, it is important to study the intermediate changes that
result from nutrition education efforts such as changes in knowledge, atti­tudes,
and behaviors. Changes in these areas demonstrate the immediate
effects of nutrition education. In the long run, when definite physiological
improvements are measured, you will be able to take greater credit for your
nutrition education efforts by demonstrating solid links that led to the
desired physiological change.
The Idea Book 51
The Idea Book 52
The Idea Book Chapter 6
DOCUMENTATION:
Why Should I and How Can
I Document the Delivery of
Nutrition Education?
54 The Role of Documentation
54 The Kinds of Information to Record
55 The Retrieval System
56 Sharing Methods: Five Approaches Plus a Summary Report
56 Approach 1: Lesson Plans
57 Approach 2: Nutrition Care Plans
61 Approach 3: Progress Notes
63 Approach 4: Flowsheets
63 Approach 5: The Certification Form
68 A Summary Report: Local Agency Monthly Activities Report
The Idea Book 53
The Idea Book 54
In recent years there has been a growing emphasis on documentation of
services and outcomes within the health arena. This emphasis reflects the
increasing pressures within administrative agencies for program account­ability.
This chapter responds to this challenge for increased accountability
by discussing the various purposes for documentation, the kinds of infor­mation
that should be included, the places where such information may be
recorded and stored, and several ways that local programs accomplish this
task. The examples from local programs, which vary in format and scope
as well as purpose, illustrate different approaches to documentation. Ex­amples
are found at the end of this chapter.
The Role of Documentation
"Why should I document?"
Careful documentation of services is an integral component of any well­managed
program. Documentation not only is required by the Federal regu­lations,
it also has other functions. Orderly documentation can strengthen
the viability of your program by enhancing accountability and becoming a
resource for reports, audits, quality assurance measures, and program
evaluation. Systematic documentation organizes participant information for
all members of the health team involved with the participant. This pro­motes
continuity of care by reducing redundancy and minimizing over­sights
and omissions. In this way, it encourages the referral of participants
to other services. Systematic documentation also gives staff members and
other community agency professionals the opportunity to identify candi­dates
for other appropriate programs.
The Kinds of Information to Record
"What must and what should I document?"
Often there are many questions that you would like answered about each
nutrition education contact but staff, time, and space on the recording
instrument limit your choices. The following list presents examples of the
kinds of information that other programs either require or recommend.
Those prefaced with an asterisk(*) are usually required, while the other
examples are suggestions for very useful, supplemental information.
* Content of the counseling session.
* The type (basic, secondary, or high risk) of nutrition education received
by each participant (7 CFR §246.9 (e)(1)).
* The inability or refusal of a participant to attend or participate in nutri­tion
education (§246.9 (e)(1)).
* The name of the provider and date of contact.
* The name of the participant. Where contact is with both the parent and
the guardian of an infant or child, both names should be recorded.
* Written assessment by the nutritionist, nurse, or physician of the partici-pant's
needs and problems.
• The method of counseling received (group, individual, audiovisual, etc.).
• The position of the provider (EFNEP aide, nutritionists, clerk, etc.).
• The specific behavioral objectives for the participant.
• Materials used with or given to the participant.
• Participant's response to counseling.
• Progress of the participant and future plans.
• Evaluation of the participant's success in achieving the behavioral objec­tive(
s), particularly at the close of each certification period.
The Retrieval System
"Where do I record and store the information?"
When you are deciding where to record and store information, keep in mind
not only your constraints but your reasons for documentation. How you
answer the question of why documentation is important to your program
will generally depend on your reasons for needing the documentation.
Once these reasons are clear, you can more easily select the appropriate
place to record and store the information. For instance, if you are inter­ested
in conducting a long-term prospective analysis of the effects of your
nutrition education activities, then you may seriously consider recording
and storing your selected information on computer tapes. If your highest
priority is to promote coordination of services within a total health team,
then the use of progress notes within the participant's medical or clinic
records would inform all health team members of the participant's needs,
progress, and suggested plans. A conventional computerized system might
do little to facilitate the transmittal of participant information among the
various members of the health team. On the other hand, retrieving statisti·
cal data from medical records or clinic charts is a formidable task if under­taken
without the aid of a computer.
There are trade-offs involved with other systems. For example, a tracking
system' using punch cards such as the one that follows will enable you to
analyze the progress and results of your program in a relatively simple way
without a computer. Recording and storing all information in your certifica­tion
file will allow you to keep a highly centralized file of the participants'
records.
The Idea Book 55
The Idea Book 56
Tracking Card System for Documentation
(from Montana WIC)
Using item by item coding, the provider records the selected information by
punching out completely the hole along the periphery of the card. With a
special needle, the provider can then stack and track selected subgroups
within the program. Note that this system also records other relevant bits
of information both on the side shown and the reverse side (not shown
here) .
.• • ~ • •
Cl) . ~~ .. ~ u.
• ~i\3
ii'
• N . - • • . ~
• • • • • • • • • • • • • • • • • • • • • • 1 2 3 4 5 I I 2 3 1 2 3 4 5 1 2 3 4 5 1 2 3 4
FOOD VOUCHERS MAR. STATUS EDUCATION RACE AGE
Name ______________ Birthdale Age __
Address ___________ City Phonet ____ _
Date of Initial Certification------LMP EOC _____ _
PregravktWeight ____ Height ____ Month Prenatal Care(Medical)began ___ _
Smoking:_· ___ pack(s) per day Alcohol Consumption: __ oz. per day Of week (e i re~ one)
MedicaiHistory: --------- Obstetrical History:--------
lnfant BW Length Gestational Age
ANEMIA ABWG WT. GN
2 3 .. 5 • 1 2 3 5 • • • • • • • • • • • • • • • • • • • •
Sharing Metho~s: Five Approaches Plus a Summary Report
" In what ways can I keep these records?"
There are a variety of ways for you to gather the desired information.
Neither the five categories presented in this section, nor the examples
within each category, are intended to be exhaustive. They merely represent
how some other programs have approached this question. Designing the
method that best satisfies your program will involve consideration of many
factors ranging from your available " hardware" to any applicable rules and
guidelines promulgated by your State agency and by the Food and Nutri­tion
Service regional office. The following five categories illustrate several
popular designs that can be tailored for your program. Each of these five
approaches is followed by an illustration of that method.
Approach 1: Lesson Plans
With only minor changes such as including the participant's name and
date, you can modify the lesson plans presented in Chapter 2 to describe
the educational session of the participant and to contain all the kinds of
information that you judge to be valuable. Using lesson plans adapted to
the individual to document nutrition education will provide you with very
specific information concerning the content of the educational contact.
Approach 2: Nutrition Care Plans
You must develop and use an individual care plan for all high-risk contacts,
and for all basic and secondary contacts when requested by the partici­pant.
This approach is generally the most comprehensive and often in­cludes
other methodologies. For instance, the nutrition care plan from
Montana that follows uses lesson plans and progress notes. The succeed­ing
care plan from Mississippi also includes on the first page a progress
note but uses the "SOAP" technique (see page 61). On all forms a sum­mary
statement is often essential if you hope to convey information to
other professionals. Notice how both of these care plans have a summary
section. This evaluation of the diet history and nutritional status will be an
invaluable aid to other professionals.
Nutrition Care Plan
(Adapted from Montana WIC)
Purpose: To propose a "plan of action" for the participant's nutritional risk
factor(s).
Instructions:
a. At the first WIC visit, the nutritionist checks the participant's nutrition
risk factors identified during the nutrition assessment. The nutrition risk
factors are then listed in order of priority on the care plan that follows.
b. The "plan of action" is completed within 30 days of the first visit. The
monthly education plan is based on each participant's nutritional needs.
As each nutrition education lesson plan is completed, the nutritionist or
nutrition aide dates and initials the appropriate columns. Referrals to
other health, welfare, and community agencies are recorded. If a mother
and several children are on the WIC Program, a family care plan is
recommended. The "plan of action" would include all the nutrition
needs of the family. These needs would then be ranked and their educa­tion
documented as in an individualized care plan.
c. Follow-through is recorded in "progress notes" to document additional
education provided and other pertinent data.
d. If group education is provided, it is documented either on the care plan
or progress notes.
e. At each 6-month reevaluation, the "Evaluation" section is completed
and progress is noted. The evaluation should relate to the problems
identified at the first visit and answer the question: "Were the problems
resolved?"
f. If participation in the program continues, update the care plan and make
changes as needed.
The Idea Book 57
The Idea Book 58
Care Plan
WOMAN INFANT
__ Pregnant ____L_ Age ~ ('f'NT .
__ Postpartum breast-feeding
__ Postpartum nonbreast-feeding
PROBLEMS
W&C I &C
__ underweight __ stunted
~overweight (95%) __ growth failure
__ anemia __ LBW
Date Completed ___ _
Date Revised
CHILD
__ Age ____ _
w
__ teenage pregnancy
__ past history of
___L__ inadequate diet ~feeding problem __ abnormal wt. gain
rrwr"J ..... ~ ~~Vv..~
tntr ,;..:t_ . C .h..awl.u, 'k-~ nM.IJL ( ~ 0 O'Z-J
__ chronic disease
__:L__ need for educa­tion
in
~~
Nutrition Education
__ other
~m\.~
PLAN OF ACTION
__ other
Date Initials
Completed
ID<t _____ _
NUTRITION CARE PLAN
(Adapted from Mississippi WIC) Date _______ _
Name------------------------ W ___ l ___ c __ _
Date of Birth _______ Race ___ EDC (W) _______ BW (I)-------
INITIAL CONSULTATION
HT. ____ WT. ---- HCT./HGB. ____ HC (I)----
Subjective Data
Objective Data (Summarize Diet History - Note other medical Data as indicated)
Assessment
Plan
NUTRITION EDUCATION OBJECTIVES
DATE OF EACH VISIT: I I I
REQUIRED OBJECTIVES:
L EXPLANATION OF WIC-SUPPLEMEJ\'TAL
2. PATIENT'S RISK CONDITION/NEED FOR WIC FOODS
3. REQUIREMENTS OF AND NEED FOR ADEQUATE DIET
4. NL'TRJTIONAL VALUE OF WIC FOODS/IN DIET
5. PROPER USE OF WIC FOODS ·
OTHER:
NOTE: Use above chart for stating objectives and noting achievement of each objective during initial and
subsequent consultations. Counsel concerning required objectives ( 1-5) in SEQUENCE.
e indicates positive behavioral change
+ indicates clear understanding
o indicates fair understanding·needs further reinforcement
- indicates poor understanding-Jack of comprehension
RECOMMENDATIONS. ACTIVITIES. FOLLOWjUP
U: Date __________ _
HT. ____ WT. ____ HCT./HGB. _____ HC (I)-----
Subjective Data:
Objective Data: (Summarize Diet History - Note medical data as indicated)
Assessment:
Plan : (Note objective achievement on front of care plan.)
RECOMMENDATIONS, ACTIVITIES, FOLLOWUP:
ill. Date __________ _
HT. ____ WT. ____ HCT./HGB. _____ HC (I)-----
Subjective Data:
Objective Data: (Summarize Diet History - Note medical data as indicated)
Assessment:
Plan: (Note objective achievement on front of care plan.)
RECOMMENDATIONS, ACTIVITIES, FOLLOWUP:
•
The Idea Book 59
•
The Idea Book 60
IV. Date __________ _
HT. ____ WT. ____ HCf./HGB. ____ HC (I)-----
Subjective Data:
Objective Data: (Summarize Diet History - Note medical datz as indicated)
Assessment:
Plzn: (Note objective achievement on front of can! plan.)
RECOMMENDATIO~S. ACTIVITIES. FOLLO\\UP:
(for subsequent consultations. •ttach lirCOnd l'iutritior. Care Pl.tn I
DIET HISTORY
24-HOUR DIETARY RECALL DATE: DATE:
Morning
Between
Midday
Between
Evening
Bedtime
•FOOD FREQUENCY
Milk· Fonnula
Whole
Skim, Lowfat
let Cream, Che-ese
Meat- Loan
Processed, Fatty
Substitutes
Bread & Breads
Cereal
Cereals
Baked Goods
Fruit & Vitamin C
Vegetables
Vitamin A
Other
Suear Benrages, Candy
Other
SUMMARY:
(Note nutrient deficiencies,
educational needs, undesirable
habits, etc.)
Determine:
If patient is on special diet, takes
supplements, medication for
chronic disease, PICA, alcohol,
drug abuse, etc.
•Specify by day, week or mo.
Approach 3: Progress Notes
Progress notes using techniques such as the "SOAP" (Subjective-Objec­tive-
Assessment-Plans) method can provide another member of your team
with a clear picture of a participant's previous session(s), status, and prog­ress.
Each part of a SOAP note has a specific function.
Procedures for Writing Nutrition Progress Notes
in WIC Charts or Medical Records Via the 5 0 A P Method
NUTRITION NOTE:
S: SUBJECTIVE DATA
0: OBJECTIVE DATA
A: ASSESSMENT
P: PLAN
Date
This includes (1) the dietary intake and food
habits as recorded on the 24-hour recall and/or
food frequency, (2) food habits,
(3) any statements made by the participant or
guardian that reflect nutritional status of the
participant, (4) any expressions of concern or
well-being concerning the participant.
For WIC this would include (1) height or recum­bent
length, (2) weight, (3) head circumference
(for infants), (4) hematocrit and/or hemoglobin.
In general, objective data includes all actual
clinical findings of lab tests, heights, weights,
skinfold measurements, etc., that have a direct
bearing on the nutritional management of the
individual's nutritional status.
Your professional appraisal of the participant's
nutritional status, based on the subjective and
objective data; your assessment of the partici­pant's
interest level.
This section includes (1) a summary of the
recommendations you made, (2) the changes the
participant is willing to make, (3) what was
discussed during the counseling session, (4) a
list of any materials given out, and your plan for
followup. Examples might include:
• See in 2 months re: vitamin C foods; or
• See in 6 months for certification; or
• See in next check pickup time to discuss
addition of exercise and foods rich in calcium.
The Idea Book 61
The Idea Book 62
Progress notes have been used most often as either a part of a more com­prehensive
care plan, or as a component of the participant's medical or
clinic records. Following is an illustration of SOAP progress notes from
Ohio.
SOAP Method of Documentation
Examples for Use
(Adapted from Ohio WIC)
Example 1 (6-week-old infant coming into the clinic for the first time)
S Both mother and infant are obviously overweight ... mother responds
automatically to his crying by giving him a bottle. Typical day's intake:
1% 13 oz. cans concentrated iron fortified formula (1 0-4 oz. bottles)
% jar strained cereal with fruit
% jar strained vegetables and meat
or record "see diet intake"
0 bw-7# (50%) bl-20" (50%)
today's wt.-13# (95%) length-22" (50%)
wt/ht 95%
or record "see certification form"
A overweight due to excessive food intake, early introduction of solid
foods.
P discussed increased probability that overweight infant may become
overweight adult and associated risks and reasons for delaying intro­duction
of solid foods. Suggested that crying is not always a sign of
hunger-that he may just want to be changed or held. Mother agreed
to:
1. Decrease formula from 40 to 32 oz. per day.
2. Replace % jar strained cereal with 2 T. infant cereal 3 times/
day.
3. Replace % jar strained vegetable and meat with % jar strained
vegetable.
4. Offer water more frequently instead of formula.
5. Not add anything until next visit scheduled for 6 weeks from
now.
Example 2 (Pregnant 15 yr. old coming to the clinic for the first time)
S Accompanied by mother-both seem very apprehensive. Both are pale
and appear to be underweight. Lives with parents and five younger
brothers and sisters. Will continue in school until pregnancy appears
obvious (it isn't yet). Plans to keep the baby.
Typical day's intake:
WIC breakfast
candybar during morning
lunch-sandwich (peanut butter, hamburger, hot dog, grilled cheese)
small bag potato chips
12 oz. can soda pop
dinner-meat or meat substitute (2 oz.)
Vz c. potatoes (boiled, roasted, fried)
1 slice bread with butter
1 cup milk
or record "see diet intake"
0 height-5' weight LMP-90#
wt.-20 wks. gestation-95#
hct.-31%
or record "see certification form"
A Low prepregnancy wt., inadequate wt. gain (due to desire to hide
pregnancy).
P Explained importance of adequate weight gain to healthy outcome of
pregnancy. Agree to (1) eat breakfast (cereal with milk, toast, juice),
(2) replace soda pop with milk, (3) eat a piece of fruit at lunch and a
vegetable at dinner. Discussed vitamins A and C in fruits and vegeta­bles.
Gave "How WIC Helps." To return in 2 weeks.
Approach 4: Flowsheets
Itemized checklists are quick ways to record information about a nutrition
education session. These range in complexity and in the amount of infor­mation
they gather from the very simple observations illustrated in the
form from Rhode Island that follows, to the comprehensive design from
North Dakota.
Approach 5: The Certification Form
The certification form itself is sometimes used. When the form is used to
record only the legal minimum, all of the other potential purposes are
foresaken.
The Idea Book 63
The Idea Book 64
Basic Contact at Initial Certification
(Example of Flowsheet from Rhode Island WIC)
0 Explanation of the WIC program as a supplemental food program
rather than a total food program.
(-"WIC means food & health care."-a Flyer)
0 Explanation of the food package.
(-"WIC allowed foods."-a Flyer)
0 Explanation that WIC foods are specifically for the WIC participant.
0 Explanation of the nutritional value of the WIC foods.
0 Explanation of the importance of good health care for participants of
all categories.
0 Explanation of individual's risk factor(s) based on data obtained from
nutritional/medical assessment.
0 Nutritional counseling based on data gathered from nutritional
assessment to insure an adequate diet.
(24-hour recall & food frequency)
0 Explanation of proper use of checks and 10 card.
0 Explanation of approved vendors in area where WIC checks may be
used.
0 Explanation of need for secondary contact.
0 Explanation of reason for high risk contact.
0 Appointment given for high risk contact---=--------=,.----
Date Time
The above statements have been explained to me in detail and I feel I have
understood all the information given to me.
Signed:
(Patient)
Witness: ------......,-=:-.,..,.-,;:-:--:....,.,.---,-..,.,....------­(
R. N./Nutritionist)
Nutrition Education Plan
Pregnant, Breastfeeding, Postpartum Women
(Example of Flow Sheet for North Dakota WIC)
Participant: _____________________________________________ P.riority
Date certified: #I. ___ _ II II _____ _ II III. _____ _
General information:
Referrals:
CODE RISK
__ Physician
_____ Prenatal classes
__ Family planning
Food stamps
--Laleche
AFDC
___ Other
I
101-2-3 Anemia +-- 104-5 Age: 19 or under/35 or oVer
1106 Less than 18 months between pregnancies
107 4 or more pregnancies
lUt -% under standard weight
109 20% over standardWeight · ~ - -~----- -- ··
110 Poor weight gain last pregnancy
1111 Under lOq gain by 20th week
L2 Insufficient gain after LOth week
113 Abnormal weight gain
114 Pre- eclampsia/eclampsia
115 HX. of miscarriages/abortions
llb HX. of neonatal deaths
117 HX. of premature or low birthweight infants
TI! HX. of failure to thrive infants
'TI9 Multiple fetuses IHO Disease condition: --f--
121 Breastfeeding mother of infant at risk
12 Emotional stress:
123 Alcohol/drug abuse
124 Smoking
125 Frequent colds and infections
1401 Low protein intake
1402 Low iron intake
403 Low calcium intake
404 Low vitamin C intake
1405 Low vitamin A intake
406 Low calorie intake
407 Low fruit & vegetable intake
408 Low bread & cereal intake
409 Pica - 4i() Unusual food habits
411 Alcohol more than 2 oz. day
412 High cone. CHO intake
1601 Postpartum: Medically at risk
~-- Postpartum: Inadequate diet
f-xtrTSkarreg.ression · ·
__________ Refused \o or unable to participate in nutrition education .
Reason:
II
-
IV
III
--
I. Basic contact: An explanation of one or more of the following topics mus t be given
during each certification period.
A. Nutritional risk conditions and ways to achieve an adequate diet (nutritional needs,
sources, and serving sizes).
1. Anemia
2. Teenage pregnancy
3. Underweight
4. Overweight
5. Other high risk:
6. Low protein intak~e~----------------------------------
7 . Low iron in take
8. Low calcium intake
9. Low vitamin C intake
------------- 10. Low vitamin A intake
------------- 11 . Low calorie intake
------------- 12. Low fruit and vegetable intake
------------- 13. Low bread and cereal intake
------:----- 14 . Pica
------------- 15. Unusual eating habits
------------- 16 . Alcohol (more than 2 oz./day): Effect on fetal development.
-·-
--
The Idea Book 65
The Idea Book 66
B. --------------- Encouragement to breastfeed (Must be discussed with all pregnant women)
c. _____________ Explanation of program as a supplemental food program
D. --------------- Importance of prenatal health care
Nutritional value of supplemental foods:
l. Milk/ cheese
2. Eggs
3. Iron-fortified cereal
4. Vitamin C-rich juice
II. Secondary contact: All clients will receive a secondary contact consisting of an
explanation of one or more of the following topics during each certification
period.
A. Nutrition during pregnancy.
l. Foods for pregnancy
--------------- 2. Components of weight gain
------------- 3. Fetal growth and development
------------- 4. Vitamin and mineral supplements
------------- 5. Anemia and iron needs
------------- 6. Sodium needs
------------- 7. Nausea/vomiting
--------------- 8. Constipation
------------- 9. Heartburn
B. Nutritional needs of postpartum/breastfeeding women.
------------- 1. Nutrient needs during interconceptual period
--------------- 2. Nutrient needs while breastfeeding
------------- 3. Weight reduction
C. Benefits of a varied diet.
D. Preparation for breastfeeding.
-------------"' 1. Breastmilk composition/colostrum
------------- 2. Importance of breastfeeding (less allergies/more immunity)
--------------- 3. Maternal/ infant bonding
--------------- 4. Support of mate
5. Breast and nipple care
--------------- 6. Breast pumps/nursing bras
--------------- 7. Clothing/nursing in public
------------- 8. Inform hospital staff of your wishes: want infant within first
3 hours, no formula or glucose water, etc.
9. Feeding positions
---------------10. Frequency of feeding
-------------:11. What to expect the first week (milk production, leaking)
-------------:12. Importance of rest
_____________ .13. Prevention and treatment of engorgement
-------------:14. Additional water not needed
---------------'15. Going back to work
-------------:16. Supplemental feedings
_____________ .17. Problems:
E. Iron-fortified formula and bottle feeding.
------------- 1. Nutrients in formula-food for first year of life
------------- 2. Formula preparation
------------- 3. Techniques of bottlefeeding (bottles, nipples, holding newborn)
------------- 4 . Maternal/infant bonding
------------- 5. Amount and frequency of feeding
F. Feeding guidelines--delay introduction of solids.
--------------- 1. Reduce risk of allergies
2. Weight gain
--------------- 3. Physical development for solids
--------------- 4. Nuk nipples and pacifiers
G. Nutrients/topics of special need or interest
1. Folic acid ------------- 6. carbohydrates
2. B vitamins ------------- 7. Fats
3. Vitamin D ------------- 8. Cholesterol
4. Copper
5. Zinc
III. High-risk contact: All priority I pregnant women will receive an individual nutrition
care plan. Those high-risk women 8 months pregnant or less at initial visit will receive
a diet prescription calculated according to the Montreal diet dispensary method. Other
women will receive an individual care plan if they request one.
Care plan given: ______________________ __ Instruction by: __________________________ _
Comments/client's response:
Followup:
Good diet adherance I I Fair diet adherance I I Poor diet adherance I I
* S = Available in English & Spanish
NUTRITION EDUCATION MATERIALS (vfOR DATE WHEN USED)
General
What Is WIC? (Ross)
The WIC Program & Good Nutrition
(General Mills)
Nutrients and foods
Basic Food Groups (Dairy Council)
---Key Nutrients and The Basic Food
--- Groups {MCH)
S __ Iron: The Hard to Get Nutrient (MCH)
Key Nutrients: Iron (MCH)
---Iron Information (NE 07)
---Foods High in Iron (NE 118)
------Iron the Blood Builder (General Mills)
---Iron Recipes (NE /114)
-S--Calcium (NE 1120)
--Key Nutrients: Calcium (MCH)
---Calcium (General Mills)
---Calcium Recipes (NE 1113)
---Cheese Recipes (Dairy Council)
---Milk Recipes (Dairy Council)
S Vitamin A (MCH)
Key Nutrients: Vitamin A (MCH)
---Vitamin A (General Mills)
---Vitamin A Recipes (NE #11)
S Vi tam in C (MCH)
Key Nutr:i!ents: Vitamin C (MCH)
---Vitamin C (General Mills)
Vitamin C Recipes (MCH)
___ Key Nutrients: B Vitamins
___ Key Nutrients: Protein
___ Key Nutrients: Carbohydrates
Key Nutrients: Fats
---Breads and Cereals (MCH)
---WIC Ways with Cereal (NE #6)
Fruits and Vegetables (MCH)
___ Vegetarian Nutrition (Dairy Council)
Eggs (NE l/19)
---What's on a Label (NE #18)
---Fun Recipes with WIC Foods (NE 1121)
--- Films/filmstrips
___ Great Expectations
___ Healthy Mother/Healthy Baby
Inside My Mom
The Beginning of Life
Maternal Nutrition
---Alcohol: Crises for the Newborn
Unfinished Child
Prenatal Care
Breastfeeding Your Baby
First Foods
---Babies Need Iron
Homemade Baby Foods
Pregnancy/Postpartum
Help Your Baby to a Health Star t {MCH)
Diet Checklist for Women (MCH #12)
___ Nutrition and Pregnancy Weight Gain
Q's & A's (NE #4)
Weight Gain Grid
---Food for-the-Mother-to-Be (NE #1)
---Eating for Two (March of Dimes)
---Foods for the Teenager during Pr egnancy
---Inside Your Body/Inside Your Head (MOD)
---The Junk Food Blues (MOD)
Days of Change (MOD)
Food for Thought & Eating (MOD)
---Smoking and the Two of You (Lung Assoc . )
---Before You Drink, Think .• • (MOD)
---Data (Drugs, Alcohol, Tobacco Abuse
--- during Pregnancy) (MOD)
Be Good to Your Baby before It Is Born
-- (MOD)
Nutrition and the Pill (MCH)
--- Breastfeeding
Nature's Way to Feed Your Baby (NE #5)
---So You've Decided to Breastfeed Your
--- Baby (NE #25)
S Mothers & Fathers, Mave You Thought
-- about Breastfeeding? (MCH)
Nipple Care (Lsleche #103)
---Nursing Your Baby, Pryor
---Complete .sook of Breastfeeding (Seeger
--- and Olds)
Breast Is Best: A Couunon Sense Approach
---The Womanly Art of Breastfeeding (L .L.L.)
--- Infant Feeding
The First Twelve Months (MCH)
---Milk: Your Baby's First Food (NE 024)
---Newborn Booklet for Parents (MCH)
-----Formula Information (NE) #3)
---Primer on Infant Nutrition (MEAD-
--- Johnson)
Nutrition and the Critical First Year
--- of Life (Mead-Johnson)
___ Feeding Your Growing Baby (Ross)
Flip charts
___ Nutrition during Pregnancy (Cornell)
___ Components of Weight during Pregnancy
(Montana)
___ First Foods
___ Feeding Your Baby
The Idea Book 87
The Idea Book 68
A Summary Report: Local Agency Monthly Activities Report
To provide yourself with a periodic overview of your nutrition education
program, you can develop a review tool such as the summary instrument
developed by North Dakota. This type of monthly review provides the coor­dinator
of nutrition education and the administrator with an overview of the
range and concentration of activities, together with an estimate of cost
and a summary of referrals for the month.
Clinic Site. ________ _ Report Prepared By ______ _
LOCAL AGENCY ACTIVITIES REPORT
Month Of 19_
(From North Dakota WIC)
NUTRITION EDUCATION ACTIVITIES:
Title
Pregnant women receiving individual diet plans and/or counseling
Postpartum women receiving nutrition education consults
Parents/Guardians receiving nutrition education:
Consults on i nfant nutrition
Consults on child nutrition
TOTAL OF BASIC, SECONDARY AND HIGH-RISK CONTACTS
Group Activities Date
Topic: _____________ _
Topic: _____________ _
Newsletter (Note content and attach copy):
Bulletin Board (Note content and attach drawing):
Home Visits (Reason for and topic covered):
In-Service or Continuing Education (Activities attended):
Other Nutrition Education Activities :
Attendance
Comments (i.e., local needs for in-service topics, new brochures, films, etc., feelings
about success of various activities, evaluation of this month's activities, etc .):
NUTRITION EDUCATION COST:
No. To
( hrs x $ /hr 2 $
( hrs X $:----",hr a $----
( hrs X $ /hr • $
(--hrs x S /hr • $----(
(--hrs x $ /hr • S
( hrs X $ /hr a $----(
Staff Time
Fringe
Fringe 2 ( ___ _
(Time spent in individual or group nutrition education activities,
developing educational materials, time spent evaluating nutrition education
activitites, time spent writing local nutrition education plan, time at In­service
meetings)
Food Cost for Demonstration or Display
Equipment Costs (Describe: ____________________ _
Slides, Tapes, Food Models, etc. (Describe: ____________ _
Printing Cost (For What: ____________________ _
Postage (Not to include cost of mailing vouchers, notices, etc.)
Brochures Purchased (Name: ____________________ _
In-service Training Costs (Include Travel to State or Regional Meeting)
Miscellaneous (Itemize=----------------------
TOTAL NUTRITION EDUCATION COST
REFERRALS (A Family Counts as 1 Referral)
EPSDT
Food Stamps
AFDC (Aid to Families With Dependent Children)
Immunization Clinics
Prenatal Classes
Prenatal Care
Family Planning
Indian Health Services
Migrant Council
Migrant Health Services
Human Development Center
Private Physician
Alcohol and Drug Abuse Counseling
OPathreenrst s A_no_nym_ou_s ____________
TOTAL REFERRED
No. From
Outreach Activities:
Publicity (Attach Sample of Newspaper Articles):
Grocer Monitoring and Training Activities:
The Idea Book 69
The Idea Book 70
•
The Idea Book Chapter 7
PROVIDERS:
How· Can I Extend and
Effectively Use Personnel?
72 Staff Contributions from the Public and Private Sectors
72 Roles of Nutrition Education Providers
72 Professionals versus Paraprofessionals
73 WIC Participants
74 Integrating Community Programs with WIC
74 Relationships of Nutrition Education Providers
74 Organizing a Team Approach to Nutrition Education
76 Communication Links Among Providers and Participants
78 Training Nutrition Education Providers
78 Competency-based Training Guides
The Idea Book 71
The Idea Book 72
You can expand limited staff resources and enhance nutrition education
through: 1) staff contributions from the public and private sectors; 2) the in­creased
use of paraprofessionals and WIC participants as nutrition educa­tion
providers; and 3) coordination of nutrition education provided through
the WIC Program with other community resources. You can also build a
more effective program by training nutrition educators to meet recognized
sta.ndards of performance.
Staff Contributions from the Public and Private Sectors
You can extend limited staff resources by using volunteers and additional
funding sources. Volunteers that can be used in the delivery of nutrition
education include:
• church groups (in the Parris, Kentucky WIC Program, volunteers help
with holiday parties featuring WIC foods);
• students (the Dodgeville, Wisconsin WIC Program is using early
childhood development students to help with food activities with
children);
• community professionals (in the Menominee WIC project in Wisconsin,
two tribal health clinic nutritionists help the WIC staff deliver nutrition
education on major clinic days).
Funding for staff positions can come from a variety of sources. In two
Native American WIC projects in Wisconsin, the paraprofessional Indian
staff are funded by an Indian Health Service (U.S. Department of Health
and Human Services) grant to provide nutrition education. In the Wac­camaw
District of South Carolina, the Department of Education is paying
the salary of a full-time instructor to work with WIC participants. Staff posi­tions
have been created through the private sector as well. For instance, in
Wisconsin, two nutrition positions are funded by the National March of
Dimes.
Roles of Nutrition Education Providers
Professionals Versus Paraprofessionals
Professionals who provide nutrition education include nutritionists and
other health professionals such as nurses, health educators, and physi­cians.
Nutritionists have a primary responsibility in the overall planning,
implementation, and evaluation of nutrition education in the WIC Program.
Other health professionals, such as nurses, serve as important adjuncts to
WIC nutrition education efforts because of their health background and
their frequent contact with WIC participants in the clinic and at home. Mak­ing
nutritional assessments, reinforcing nutrition education, monitoring
progress, and making appropriate referrals are some of the functions
nurses may perform.
Paraprofessionals have also been very effective and efficient in teaching
nutrition education. Given proper training and supervision, paraprofes­sionals
such as nutrition aides and WIC clerks can perform a number of
the traditional functions of nutritionists. They may:
• prepare nutrition education materials such as posters, displays, and WIC
recipe books;
• schedule nutrition education contacts;
• provide basic and secondary nutrition education contacts;
• monitor progress of participants;
• document nutrition education contacts;
• make appropriate referrals.
Using paraprofessionals lets the nutritionist devote more time to other im­portant
areas of program planning, evaluation, and staff training. Other ad­vantages
to using paraprofessionals are:
• more services can be offered to participants;
• the cost of providing services can be reduced;
• paraprofessionals may share similar cultural and socioeconomic back­grounds
with participants and be able to exert the peer influence needed
to maintain or modify food habits, as appropriate.
You may want to consider these two limitations to using paraprofessionals:
• paraprofessionals need to be well-trained and carefully supervised;
• a high turnover rate among paraprofessionals is common due to their
low salaries. This makes it difficult to train and keep experienced
paraprofessionals.
WIC Participants
You can also use WIC participants effectively as a resource. Current
education theory identifies the value of variety in the delivery of an
educational me