Food stamp nutrition education study case study report

              Nutrition Assistance Program Report Series
The Office of Analysis, Nutrition and Evaluation
Food Stamp Program Report No. FS-OO-NE
FoodStamp Nutrition Education Study
Case Study Report
ISDA UnitedStates Foodand August 2000 Department of Nutrition y
Agriculture Service
2O0Z6H(eZ5 O
JSDA Unitedstates Food and August, 2000
Department of Nutrition Food Stamp Program
Agriculture Service Repoit No. FS-00-NE
Food Stamp Nutrition Education Study
Case Study Report
Authors:
Jean Anliker
Loren Bell
Chris Miller
Jennifer Matheson
Submitted by: Submitted to:
Health Systems Research, Inc.
1200 18* St. NW Suite 700 Office of Analysis, Nutrition, and Evaluation
Washington, DC 20036 3101 Park Center Drive, Room 503
Alexandria, VA 22302-1500
Project Director: Loren Bell Project Officer: Patricia McKinney
This study was conducted under Contract number 53-3198-7-015 with the Food and Nutrition Service.
This report is available on the Food and Nutrition Service web site: http://www.fhs.usda.gov/oane.
Suggested Citation:
U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and Evaluation,
Food Stamp Nutrition Education Study: Case Study Repoit, by Jean Anliker, Loren Bell, Chris Miller, and
Jennifer Matheson. Project Officer, Patricia McKinney. Alexandria, VA: 2000.
£
ACKNOWLEDGEMENTS
This report was prepared by Jean Anliker, Loren Bell, and Chris Miller of Health Systems
Research, Inc. (HSR) and Jennifer Matheson of the Research Triangle Institute under contract to
the Food and Nutrition Service (Contract No. FNS-53-3198-7-015). Other staff contributing to
this project includes Nadia Shahmehri of HSR.
We wish to acknowledge the support and assistance we receiv ed from Patricia McKinney who
served as our Project Officer for this study and provided valuable guidance and thoughtful
review.
Most importantly, special thanks go to all of the project directors responsible for implementing
the State nutrition education plans who contributed their time to complete survey forms and
participate in the telephone interviews that provided much of the information for this project.
Without their cooperation this report would have not been possible.
NON-DISCRIMINATION POLICY
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activities on the basis of race, color, national origin, gender, religion, age, disability, political
beliefs, sexual orientation, or marital or family status. (Not all prohibited bases apply to all
programs.) Persons with disabilities who require alternative means for communication of
program information (Braille, large print, audiotape, etc.) Should contact USDA's TARGET
Center at (202) 720-2600 (voice and TDD)."
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-
W, Whitten Building, 14,h and Independence Avenue, SW, Washington, DC 20050-9410 or call
(202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.
Food Stamp Nutrition Education Study
Summary of Findings
Background
Food Stamp Program (FSP) regulations give States the option to include nutrition education
activities as part of their administrative operations. The purpose of this study was to describe
how States have elected to provide nutrition education and information to food stamp recipients
and eligibles under this optional authority. Data were collected from a review of the 38 State
food stamp Nutrition Education Plans approved by the Food and Nutrition Service in FY 1997, a
mailed survey of all implementing agencies providing nutrition education for each State, a
follow-up survey of those responding to the mail survey, and in-person interviews in six local
sites.
The specific objectives of the study were to describe the organizational structure and
administrative components of agencies implementing food stamp nutrition education; key design
features of food stamp nutrition education activities, including setting goals and objectives;
identifying the target audience and developing nutrition education messages; approaches being
used by States to implement their nutrition education; and efforts to assess the effectiveness of
the nutrition education programs.
Findings
Organizational structure and administrative components:
• State Food Stamp Programs contract with many different implementing agencies to
deliver nutrition education. Of the 38 States with approved plans in 1997, 29 States had
only one implementing agency, seven States had two implementing agencies and two States
had three or more implementing agencies. Agencies included the Cooperative Extension
Service (CES), State public health agencies, nutrition education networks, State welfare
agencies, a State Department of Aging, and other university-affiliated programs not attached
to the CES.
• Twenty-two agencies (44%) used one Statewide approach targeting the same audiences,
using the same materials, and following similar delivery protocols. Nineteen agencies
used State-level administration but developed customized plans for different target
audiences/geographic areas whereas nine agencies used a system that allows for local
administration and implementation of nutrition education activities.
Key design features of nutrition education activities:
• The target audience selected by most agencies was families. These included families with
young children, single parents, pregnant women or parents of school-aged children. Other
vulnerable groups (such as persons with disabilities, the homeless, unemployed persons and
persons with chronic diseases) were also targeted. In addition 57 percent reported targeting
individuals whose primary language was one other than English.
///
• Nutrition messages were designed to meet behavioral objectives. Eighty percent of the
agencies reported focusing their nutrition messages on purchasing healthy food and eating a
healthful diet.
Implementation approaches:
• All implementing agencies delivered nutrition education in-person using structured
groups, structured one-on-one, unstructured individual or group sessions. Twenty-two
agencies also delivered nutrition education using mass media primarily through radio
(including public service announcements about their programs in order to recruit clients).
• The majority of agencies deliver nutrition in the target population's community. The
most popular site was community-based centers or buildings rather than government or
university facilities.
• Of the 36 agencies reporting educational level of staff delivering nutrition education 28
used peer educators who had a high school diploma or GED. Peer educators were lay
individuals who were members of the community in which they worked who had been
trained to teach basic nutrition education.
Efforts to assess effectiveness:
• Seventy-eight percent of the implementing agencies reported conducting both process
and outcome evaluations. However, the methods and units of measure differed so much
across States that meaningful comparisons could not be made.
Lessons Learned
The target audience. Recruiting the target audience to attend the sessions and convincing them
that nutrition education is important were common challenges. Additionally, developing
appropriate methods and materials for delivering nutrition education is difficult because the
target audience is so diverse.
Collaborators. Agency officials noted that their programs would not have been as successful
had they not developed relationships with community agencies—especially those that refer
clients to the program. The difficulty of working with the WIC program was noted by three
agency officials who cited conflicts in client scheduling and difficulty coordinating nutrition
messages.
Staff. Some of the most common issues noted were the difficulty in recruiting bi-lingual staff,
problems with retaining staff once hired because of low pay, and finding nutrition educators who
work well with low-income clients.
Accounting. The budget process is more complex than local agencies are used to. Local agencies
benefit if they have an accounting system that can accommodate different financial reporting
requirements of FNS, the State FSP agency and their own Agency or university.
June 2000 /•
Food Stamp Nutrition Education Study
Case Study Report Summary
Background
The purpose of this case study was to provide the Food and Nutrition Service with descriptive information about
bow local programs implement State policy to provide nutrition education to food stamp recipients and eligibles
under Food Stamp Program (FSP) regulations whereby States have the option to include nutrition education
activities as part of their administrative operations.
Initially six States were selected to represent food stamp nutrition education programs that had been in operation
for at least two years and included States that direct nutrition education activities from the State-level as well as
those who allow local flexibility in planning nutrition education programs. Criteria for selection also included
urban and rural areas, diverse target populations, and varying educational requirements of the nutrition
educators.
Findings
• All of the programs had strong relationships with their State's TANF and Food Stamp Program. In
most cases, the nutrition education activities counted towards meeting TANF or State FSP requirements for
clients to participate in education and training activities. The sites relied heavily on collaborative
relationships to recruit clients.
• Many classes and activities are geared toward helping clients improve their shopping skills and their
ability to manage resources. All of the programs used a basic curriculum developed by the Cooperative
Extension Service in their State. However, some are allowed to modify the curriculum to meet the
individual needs of a client or group of clients.
• There was a strong difference of opinion as to the importance of using professional versus
paraprofessional nutrition educators. Sites using paraprofessional indicated that peer educators can
relate better to the needs of clients and are more effective in recruiting. The weakness to this approach is the
high level of turnover among paraprofessional staff. Sites that require staff to have a minimum of a
bachelor's degree stated that the educators are better able to customize the messages to meet client needs
and are in a better position to provide accurate answers to technical questions.
• The primary mode of providing nutrition education at these sites was individual one-on-one and small
gioup sessions. Rural sites tended to conduct more one-on-one sessions than non-rural areas. Users of one-on-
one modes felt that they were the most effective means of creating behavioral change because they were
often conducted in the client's home using a strong hands-on approach which could be adapted to the
individual needs of the client. In contrast, sites using primarily small group sessions felt that peer support
provided by group members played an important role in changing behaviors. In addition the small groups
allowed the nutrition educator to reach significantly more clients than one-on-one.
• All of the sites cited strong collaborative relationships as a key to their success. The agencies relied on
community organizations serving the same target population as the primary method for referral and
recruitment of participants.
V
Table of Contents
Section I. Overview and Summary of Case Studies 1
Section II. Individual Case Study Results
Virginia Case Study Report 13
I. Introduction 13
II. Components of Food Stamp Nutrition Education 14
III. Evaluation of Nutrition Education Activities 26
IV. Factors Facilitating the Provision of Nutrition Education 27
V. Barriers to Providing Nutrition Education 28
VI. Lessons Learned 30
North Carolina Case Study Report 33
I. Introduction 33
II Components of Food Stamp Nutrition Education 34
HI. Evaluation of Nutrition Education Activities 41
IV. Factors Facilitating the Provision of Nutrition Education 42
V. Barriers to Providing Nutrition Education 42
VI. Lessons Learned 44
Oklahoma Case Study Report 45
I. Introduction 45
II. Components of the Food Stamp Nutrition Education Program 45
III. Evaluation of Nutrition Education Activities 56
IV. Factors Facilitating the Provision of Nutrition Education 56
V. Barriers to Providing Nutrition Education 57
VI. Lessons Learned 58
Iowa Case Study Report 62
I. Introduction 62
II. Components of Food Stamp Nutrition Education 63
III. Evaluation ofNutrition Education Activities 73
Food Stamp Nutrition Education Study - Case Study Report
VI
IV. Factors Facilitating the Provision of Nutrition Education 73
V. Barriers to Providing Nutrition Education 74
VI. Lessons Learned 75
Colorado Case Study Report 77
I. Introduction 77
II. Components of Food Stamp Nutrition Education 78
III. Evaluation ofNutrition Education Activities 89
IV. Factors Facilitating the Provision of Nutrition Education 90
V. Barriers to Providing Nutrition Education 92
VI. Lessons Learned 93
New Hampshire Case Study Report 95
I. Introduction 95
II. Components of Food Stamp Nutrition Education 96
III. Evaluation of Nutrition Education Activities 101
IV. Barriers to Providing Nutrition Education 101
V. Factors Facilitating the Provision of Nutrition Education 102
VI. Lessons Learned 103
Food Stamp Nutrition Education Study • Case Study Report
LiL
Section I
Overview and Summary of Case Studies
In 1997, the Food and Nutrition Service (FNS) commissioned a study of State-level efforts to
provide food stamp recipients and eligibles with nutrition education. The purpose of the study
was to provide FNS with descriptive information about how Food Stamp Nutrition Education has
been implemented in States utilizing the optional nutrition education provisions of the Food
Stamp Program. As a part of that study, six local case studies were conducted to examine how
local programs implement State policy. This report presents information obtained from the six
case studies.
This report is organized into an introductory section, followed by the six individual case study
reports. This introductory section presents an overview of the selection process for the case
study sites, a review ofcommon program elements found among the sites, and a summary of
findings. The data collection instruments used for the case studies are located in Appendix A.
A. Overview of Case Study Site Selection
The goal of the case study reports is to provide descriptive information about how local programs
implement nutrition education activities for food stamp recipients and eligibles. In order to
select appropriate case study sites, information obtained from a review of State food stamp
nutrition education plans (NEPs) was used to identify those States with local programs that had
been operating for at least two years. The process for selecting the specific State and local
programs is described below:
Food Stamp Nutrition Education Study - Case Study Report Page 1
Selection of specific States was hased upon two factors. First, State
administrative structures were reviewed to identify States that both direct their
nutrition education activities from the State-level as well as those States who
allow local flexibility in planning nutrition education programs. Four of the
States selected were "State-directed" and two allowed local flexibility in
developing their nutrition education plans.
Second, no two States were to be located within the same FNS geographic region.
This allowed for examination of any regional differences in how the programs are
implemented.
A diverse group of local programs were selected based upon their geographic
location (rural and urban areas); the diversity of target populations, such as
whether they target the general food stamp population or whether they target sub-groups
of eligibles, such as teens, mothers of young children, or the elderly; and
the education requirements set for nutrition educators, particularly the use of
paraprofessional as compared to programs requiring staff with at least a Bachelors
degree. Individual States were asked to recommend local programs meeting these
criteria, such as a rural program serving primarily teens with paraprofessional
educators.
One of the issues addressed in deciding on the selection process was whether to include FNS-sponsored
nutrition education networks in the case study sites. After much deliberation, the
nutrition networks were excluded from consideration from the case studies. The main reasons
for excluding the nutrition education networks were that a separate evaluation of nutrition
education networks was already being conducted, and because the nutrition education networks
primarily use social marketing as their method of delivering nutrition education, there was little
in the way of local implementation activities being undertaken. As a result, all of the case study
sites selected were operated by the Cooperative Extension Service.
Table 1.1 below displays the selected States and the criteria with which they were matched.
Food Stamp Nutrition Education Study - Case Study Report Page 2
Table 1.1.
Case Study Site Selection, by Criteria Used
State Type of Program
Administration
Geographic
Location
Primary Target
Audience
Nutrition
Educators
Colorado Local Flexibility Urban Low-Income
Audiences in
General
Require
Bachelors's
Degree
Oklahoma State-Directed Rural Food Stamp
Recipients and
Eligibles
Paraprofessional
North Carolina State-Directed Rural Mothers of
Young Children
Paraprofessional
Iowa State-Directed Rural Mothers of
Young Children/
Some Elderly
Paraprofessional
Virginia Local Flexibility Suburban Food Stamp
Recipients
Paraprofessional
New Hampshire State Direcied Rural Pregnant Teens
and Young
Mothers
Require
Bachelors Degree
B. Overview of the Case Study Methodology
Individual site visits were conduced at each of the six selected local programs over a three
month period. The primary metnod of data collection was interviews with key program staff and
with representatives from collaborative agencies. In addition, data collectors observed nutrition
educators conducting at least one nutrition education class. During this observations, the data
collectors also conducted group interviews, when appropriate, with clients participating in the
nutrition education sessions.
Case study guides for each of these data collection efforts were developed and can be found in
Appendix A. Data from the entire data collection effort was aggregated and summarized into a
Food Stamp Nutrition Education Study - Case Study Report Page 3
single case study report. Each report is organized in the same manner, and is divided into six
sections. These sections include:
■ An introductory section describing the local agency;
■ A description of the program components of the local nutrition education efforts;
■ A discussion of efforts made by the local program to evaluate their nutrition
education activities;
■ A description of barriers faced by the local program in implementing and
maintaining their nutrition education activities;
■ A review of factors that have facilitated the provision of nutrition education to
low-income clients; and
■ A discussion of lessons learned from implementing their programs.
C. Common Program characteristics of the Case Study Sites
The sites selected for the case studies provide nutrition education on a broad variety of topics to
diverse populations. Each ofthe local programs visited is responsible for recruiting clients,
scheduling nutrition education classes, and completing enrollment and evaluation paperwork on
each of their clients. While the case stuoy sites were selected for their diversity, there were a
number of program characteristics common among the sites. These include:
■ All of the programs included in the case studies have strong relationships with
their State's TANF and Food Stamp Programs. In most cases, the nutrition
education activities delivered by the agencies counted towards meeting TANF
program requirements for clients to participate in education and training activities.
Many of the classes and activities conducted are geared towards helping clients
improve their shopping skills and their ability to manage resources.
■ All of the nutrition education sites rely heavily on collaborative relationships to
recruit clients. The agencies visited market their programs to community agencies
that serve low-income clients within each nutrition education agency's geographic
service area. These collaborative arrangements are the primary method used for
the recruitment and referral of clients in to the nutrition education program. All of
the agencies visited cited strong collaborative relationships as a key to their
success.
Food Stamp Nutrition Education Study - Case Study Report Page 4
All of the programs use a basic curriculum developed by the Cooperative
Extension Service in their State. While some of programs are allowed to modify
the curriculum to meet the individual needs of a client or group of clients, the
curriculum is always used as the basis for presenting nutrition education
messages.
All of the agencies visited use the Cooperative Extension Evaluation Reporting
System (ERS) as the basis for conducting reviews of their program outcomes.
D. Summary of Case Study Findings
This section provides a summary of the key findings from the case study visits. It is important to
remember that the sites selected for these case studies are not necessarily representative of the
diverse and numerous local programs around the country. The information provided in these
case studies is descriptive in nature, and should be used to help in understanding how local
programs might be implemented.
This findings section presents a summary of some of the more common issues identified across
the six case study sites. These summaries are divided into three categories: findings related to
program diversity, findings related to challenges faced by local program in implementing their
nutrition education plans, and findings related to positive lessons learned. Each of these three
areas is discussed below:
1. Summary of Findings Related to Program Diversity
When examining the major difference oetween the approaches used by the local programs, three
specific topics stood out. First, the required education level of nutrition educators was a major
issue for most local program staff, with strong feelings expressed about their agency's own
approach.. Second, the mode of providing nutrition education was examined, comparing
agencies using a group teaching approach with those focusing on individual, one-on-one
nutrition education sessions. Finally, issues related to local flexibility in diverting from the
State's prescribed approach when presenting nutrition education topics and issues were
examined. Each of these three areas is discussed below.
Food Stamp Nutrition Education Study - Case Study Report Page 5
a. Education Level of Nutrition Educators
There is a strong difference of opinion as to the importance of using professional versus
paraprofessional nutrition educators. Each of the sites was asked about the strengths and
weaknesses of their approach. The sites that use paraprofessional staff generally recruit
staff from the communities in which nutrition education is being provided. Officials
from these sites argued that using persons who come from the community being served
can relate better to the needs of the clients and are more effective in recruiting. In
addition, the paraprofessional staff often are viewed by the clients as "peer educators"
and feel that these nutrition educators will have a better understanding of the issues and
problems they face.
Agencies that use paraprofessionals cited one weakness in their approach; the high level
of turnover among paraprofessional staff. Agency officials in all of the case study sites
using paraprofessional noted that salary levels for paraprofessional staff are very low, and
once the nutrition educator gains some work experience, they often leave for a better
paying job. This means that agencies are constantly experiencing staff turnover, which
affects both the continuity of the program and increases new employee training costs for
the State agency.
Agencies that require their staff to have a minimum of a bachelors degree argued that
delivering nutrition education is a complex process, requiring the educator to customize
the messages to meet client needs and be in a position to answer technical questions In
this regard, professional nutrition educators are better prepared to adapt their lessons to
meet individual needs and provide accurate answers to technical questions.
An additional advantage of using staff with higher education levels is that programs tend
to experience less turnover, and thus are able to maintain program continuity. Both sites
that used professional staff indicated that they have been able to establish long-term
relationships with agencies and resources within their community, and thus have been
able to effectively recruit new clients.
Food Stamp Nutrition Education Study - Case Study Report Page 6
The only disadvantage noted for the use of professional educators was related to client
scepticism about the nature of the program. One program representative explained that
professional nutrition educators are often viewed with some scepticism by potential
clients, as they tend to feel the material that will be presented may not relate to their
individual circumstances or it may be "too academic." Overcoming this scepticism has
been a challenge for agencies using professional nutrition educators, and has been offset
somewhat by the long-term relationships established by the nutrition educators within
their communities.
b. Different Modes of Providing Nutrition Education
The two main modes of providing nutrition education used by the case study sites were
individual one-on-one and small group sessions. All of the programs visited use both
methods to a certain extent, but have chosen one as their primary method of delivering
nutrition education and the other as a less preferred method.
Programs located in rural areas tended to conduct more one-on-one sessions than those
located in more populated areas. The use of one-on-one was described by one program
representative as the most effective means of creating behavioral change. These sessions,
often conducted in the individual's home, use a strong hands-on approach and can be
adapted to the individual needs of the ciient. Often the nutrition education can be tied in
to the preparation of a family meal, and thus creating a sense of accomplishment at the
end of the session.
In contrast, programs that primarily use small group sessions noted that peer support
plays an important role in changing client behaviors. The fact that the group membeis
can use each other as sounding boards for ideas and issues seems to play an important
role in the success of the group education approach. In addition, the use of small groups
allows the nutrition educator to reach significantly more clients than a one-on-one
approach.
Food Stamp Nutrition Education Study - Case Study Report Page 7
c Local Flexibility in Implementing Nutrition Education Activities
Most of the local programs were allowed some degree of flexibility in presenting
nutrition education topics and designing activities. In those programs which allowed the
most flexibility, nutrition educators noted that while they always use the curriculum
provided by the State as the basis for their presentations, they tend to skip or shorten
lessons that do not seem appropriate for their clients.
Once example of the need for flexibility cited by a nutrition educator related to providing
nutrition education to pregnant teens. This educator noted that the basic curriculum was
directed at persons who were more self-sufficient than most pregnant teens, who often
live with their parents and do not do the shopping for the family. The nutrition educator
modified her approach to emphasize healthy eating rather than the curriculum- directed
activities supporting the development of shopping skills.
In two programs where less flexibility is allowed, nutrition educators noted that clients
can become bored with the lessons if they don't directly relate to their particular situation.
In these cases, the nutrition educators rely on clever and innovative methods to keep the
sessions interesting and maintain the client's attention. An additional issue noted was the
fact that clients tend to complain that there are too many lessons, requiring several trips to
come to the classes, or that the individual lessons are too long. The two programs that
noted this problem are working with State officials in an attempt to modify the
curriculum to either reduce the number of lessons or reduce the amount of material
covered during each lessons in order to shorten the time it takes to present the
information.
Food Stamp Nutrition Education Study - Case Study Report Page 8
2. Summary of Findings Related to Challenges Faced by Local Programs in
Implementing Nutrition Education Plans
Local staff were asked to describe the challenges they have faced in implementing their
programs. While each individual agency noted challenges that were somewhat unique to their
particular circumstances, there was some commonality in three areas. These areas include
recruitment of clients, limits on the use of Federal ana State funds, and unique issues facing rural
programs. Each of these three findings is discussed below.
a. Problems and Issues Related to Recruiting Clients
All of the local programs noted some problems with recruiting clients for their programs.
The most common problem was the perception on the part of a potential client that the
nutrition education sessions would be uninteresting. In order to overcome this problem,
several of the local programs would develop sample lesson plans, and then conduct a
sample class at a community agency providing some other type of social and/or health
service. This method allowed potential clients to see for themselves the type of
information provided and the methods used. Hands-on activities were usually used in
these demonstration classes to capture potential client interest. Potential clients were then
allowed to sign up for classes after the session.
Another problem cited by four of the programs visited was the difficulty in reaching
clients who speak languages other than English. Only two of the programs visited had
staff that could conduct nutrition education lessons in Spanish, and none of the programs
could provide lessons in other languages used by their target audience. In order to
receive nutrition education services, clients must have some understanding of English to
be able to participate. As a first step in addressing the problem, two of the programs were
working on translating more materials to languages other than English and working on
developing meal planning and food preparation classes using foods that would be more
familiar to persons from diverse ethnic backgrounds.
Food Stamp Nutrition Education Study - Case Study Report Page 9
b. Issues Associated With Funding Restrictions
Four ofthe local programs noted that restrictions on the use of funds for support services
limit their effectiveness in recruiting and presenting nutrition education lessons. In
particular, restrictions on using program money for child care and transportation were
cited as problems. Nutrition educators in these four programs noted that it would be
much easier to both recruit and provide services to clients if they could use a portion of
their budget to provide support services.
In addition, two local programs noted that limits on the amount of funding they receive
have required them to solicit in-kind contributions from community agencies or local
merchants in order for them to conduct specific classes. For example, food preparation
demonstrations are effective means of teaching healthy eating, but often the local
program budget does not have sufficient funds for purchasing the foods needed for the
class. The two programs citing this issue have worked with local food banks and with
local grocery stores to obtain donated foods for their cooking demonstrations, but noted
that it was unreasonable to expect that the donations would always continue.
c Unique Challenges Facing Rural Programs
A number of challenges were noted by the programs serving rural geographic areas,
including difficulty recruiting clients, the lack of support resources for referrals, and
difficulties with scheduling classes for a limited number of individuals. However, most
common among the challenges noted was the amount oftime that it takes the nutrition
educator to travel to sites where they conduct their nutrition education classes. Two of
the nutrition educators working in rural programs noted that it was common for them to
travel for long distances, only to find that the clients that had been scheduled failed to
show up for the classes. One other educator noted that as much as 20 percent of her time
was taken up by traveling, which severely limits the amount of time she has for teaching,
recruiting, and completing administrative tasks.
Food Stamp Nutrition Education Study • Case Study Report Page 10
3- Summary of Findings Related to Positive Lessons Learned
Local programs were asked to identify the positive lessons learned from their implementation of
their nutrition education programs. While local programs cited a number of positive experiences
that were somewhat unique to their particular situation, there were four positive lessons that
seemed to be common to most or all of the local programs, including:
■ Strong partnerships with other agencies serving low-income clients are
critical to the success ofthe local nutrition education programs. All of the
local programs cited strong community partnerships as a key to their program's
success. These partnerships assist the local nutrition education program with
client recruitment, provide a source for client referrals, and often provide
resources that are normally unavailable to the nutrition education program.
Maintaining these relationships can require a significant effort on the part of the
local nutrition education program. One local program noted that when a
collaborative agency changes its executive director, or loses key staff,
relationships often have to be rebuilt with the new personnel in order to continue
to be effective.
■ The most successful methods ofpresenting nutrition education are the use of
hands-on and interactive activities. Nutrition educators from all of the local
programs were in agreement that the best methods for providing nutrition
education information to low-income audiences involve using methods that allow
the client to interact with the educator or other members of the group. In addition,
the use of food demonstrations, group meal planning and preparation, and group
shopping trips to teach nutrition principles make the program both interesting and
fun.
■ Adapting the nutrition education program to the needs ofdifferent groups of
clients is key to maintaining client participation. Nutrition educators at four of
the six local sites emphasized the need to adapt the curriculum to the needs of the
clients in order to hold their attention and provide them with an incentive to
continue attending classes. Understanding the diverse needs of low-income
clients, and making the nutrition education relevant to the life circumstances of
the clients was cited as key to conducting a successful program.
■ Strong support from the State sponsoring agency is critical to the success of
local programs. All of the nutrition educators cited the support they receive from
the State Cooperative Extension Service as extremely important in maintaining
their program. In addition to providing the funding for the local nutrition
education program, the State sponsoring agency provides the curriculum, nutrition
education materials, and appropriate training for local program staff. In addition,
Food Stamp Nutrition Education Study • Case Study Report Page 11
the State sponsoring agency assists the local programs with conducting needs
assessments and providing data for conducting local program evaluations.
Without this type of support, the local programs would not be able to continue to
provide high-quality services to their clients.
In this section, the selection process utilized for the case study sites was discussed, the common
elements of the local programs were described, and the summary of common findings was
presented. However, each case study report provides unique information about the local program
selected for examination. The next section presents individual reports from the six case study
sites, identifying the processes used to provide nutrition education, and the individual issues
faced by each local agency.
Food Stamp Nutrition Education Study - Case Study Report Page 12
Virginia Case Study Report
I. Introduction
The Virginia Food Stamp Nutrition Education Program operates a Statewide program called
Smart Choices for Nutrition Education Program (SCNEP). The first site visit for this study of
the program was conducted over a two-day period in September 1999 (plus a short visit two
days later to observe a nutrition education group session) in the Northern District, which is
spread across 29 rural and suburban counties. The Northern District area program coordinator
is located in Warrenton, VA. The State sponsoring agency is Virginia Cooperative Extension,
Virginia Polytechnic Institute and State University, based in Blacksburg, VA.
In-person interviews were conducted with four people: the Area Program Coordinator, two
nutrition educators, and a food bank representative. Two nutrition education sessions were also
observed, one with an individual teen mother at her home and another with a group of Spanish-speaking
senior citizens at a community center.
This local program is a component of the largest Food Stamp Nutrition Education Program in
the Commonwealth of Virginia. Area program coordinators get directives from the State
coordinator on issues such as what populations to reach, what core materials to use, and how
much money to spend. Outside of the basic State guidelines set out by their nutrition education
plan, the local SCNEP has quite a bit of flexibility to tailor the program to fit the demographics
of the population, regional issues, or other logistical variations. Some of these, such as the use
of bilingual materials, are discussed later in this report. The State-level administrators do not
overstep any local-level boundaries in their involvement and monitoring of local activities.
Food Stamp Nutrition Education Study - Case Study Report Page 13
The program in the Northern Virginia region employs 23 nutrition educators, one area program
coordinator, and one full-time and one half-time secretary. They currently have 21.5 FTEs
with three positions vacant, but they will wait to hire for these positions until there are five
openings, because they conduct the three-week initial training in a small group to provide
quality education.
II. Components of Food Stamp Nutrition Education
A. Target Audience and Eligibility
The SCNEP offers its services primarily to those who receive or are eligible to receive food
stamps. Their clients are 185 percent above poverty level or less, preferably at 125 percent of
the poverty level. In all counties, the target population is anyone who is in need, and clients
range from teen girls at high risk of pregnancy to the elderly. The State-level SCNEP
administrators initially were the ones who designated the target population. It became an
approved part of the annual Nutrition Education Plan (NEP), and each area program
coordinator follows guidance from the NEP. The State received a waiver to deliver service to
non-food stamp recipients who are food stamp eligible, in part because of the large number of
elderly who are eligible and in need of nutrition education. There are a large number of
eligible elderly clients in VA who do not receive food stamps because they fear lengthy and
complicated paperwork or they feel the amount of assistance they will receive is not worth the
trouble of applying. The Virginia SCNEP includes both an adult and a youth component that
are run separately. This case study focuses on the adult component.
Basically there is no single population that is targeted more than others in the State. Visits to
two locations of the local SCNEP found one exception, where there is a nutrition educator
whose first language is Spanish and who teaches classes in Spanish (although she teaches in
English when necessary). This same site also focuses their outreach to groups of retired adults
(with some additional focus on Spanish-speaking retirees). The other site visited serves the
Food Stamp Nutrition Education Study - Case Study Report Page 14
broad population that is set out in the NEP, and focuses on a broader range of food stamp
recipients and eligibles such as single parents, teen parents, and families with small children.
The nutrition educators have been using the nutrition education materials with the target
population for years. Educators do pre- and post-tests to measure the amount of change in
client eating behavior, thereby indicating the clients' ability to comprehend the curriculum.
Most of the materials are written at an 8th grade reading level, and there are materials in
Spanish for Hispanic clients. Some of the items that are in Spanish are brochures received
from agencies on topics of health, food safety, etc. and often the aforementioned Spanish-speaking
educator translates recipes and materials into Spanish for her clients. These materials
are used as supplements to the main curriculum, which is only written in English. One
nutrition educator spoke about the appropriateness of the materials for the cultural and social
needs of her audience of Spanish- speaking elderly and said,
"The information is simple and easy. We don't use big words and it's easy to
understand. Plus, they have me to explain things that are tough."
Other non-English speaking populations that have been reached in the Northern Virginia area
of the program include Vietnamese, Cambodian, Somalian, African, Russian, Czech, Chinese,
Greek, and Italian populations. All of these clients were able to understand enough English to
benefit from the nutrition education, though there are others who need service who do not
understand English. These potential participants are unable to be reached by this program
since there are no educators who speak all of those different languages.
B. Qualifications of Nutrition Educators
The nutrition educators in SCNEP are paraprofessionals and are called program assistants.
Their primary responsibility is to provide nutrition education to food stamp recipients and
people who are eligible for food stamps. Another important responsibility is to recruit
participants, develop relationships with local agencies and programs who provide contacts for
recruitment, and find agencies that will provide food for food demonstrations and food baskets
for needy families who are enrolled in the program. The nutrition educators also keep records
Food Stamp Nutrition Education Study - Case Study Report Page is
on each participant, including pre-test data, post-test data, information on each lesson taught,
and participants' progress and behavior change. An important part of their job is resource
management whereby they make sure there are community resources available to participants
and make participants aware of those resources.
The program prefers that nutrition educators have a high school diploma or GED, but that is
not a strict requirement. Some of their educators have some college course work, some have a
bachelor's degree, and some have graduate course work. The program does not required a
specific background in nutrition education, but provides each new employee with extensive
training on the approach used by Virginia Cooperative Extension This training is provided
because new employees may be misinformed about nutrition concepts, as their knowledge may
not be derived from research-based nutrition information. It is often easier to teach employees
the research-based information from scratch than try to change their previously held
assumptions. In addition, it is important that educators have a good work ethic and a heart for
working with people. It is important that they be "hands-on," non-judgmental, able to work
with ethnically diverse populations, and have some experience with volunteer work or have
taught a class before.
One additional responsibility of the nutrition educators is to recruit a few community
volunteers to help them with their work. These volunteers usually help with recruiting clients,
teaching lessons, giving food demonstrations, maintaining equipment and supplies, and
collecting data for family records. The number of volunteers each educator has depends on the
size of the county and how much need the educator has for help. The volunteers are required to
attend a 10-hour training session on food and nutrition taught by Cooperative Extension.
C. Training of Nutrition Educators
All nutrition educators are trained initially during a three-week intensive small-group session.
The main presenter is the area program coordinator who is assisted by veteran nutrition
educators. Extension agents, and other experts and professionals. They feel having the initial
Food Stamp Nutrition Education Study - Case S udy Report Page 16
training conducted in a group is more efficient and that group participation makes for a richer,
more collaborative training. The initial training of nutrition educators is mandatory. Only
those who are able to attend the full training are eligible for hire.
The initial training covers all of the basic nutrition information that is the core curriculum for
the program. The training is conducted using a standard presentation format complete with
demonstrations, overheads, and handouts. The training is very hands-on and interactive.
Educators learn to use the materials from the curricula and have all of the resources available to
them in their offices. Besides learning about the curricula, other topics they discuss include
how to complete paperwork, how to recruit clients, how to solicit community resources, job
benefits, food safety, health risk reduction, recognizing personality traits in people, and how to
work with limited income audiences.
In addition to the formal curricula, other materials that are used during training and for
nutrition education dissemination are received from other agencies, organizations, and
associations such as the American Heart Association, Head Start, WIC, and the Dairy Council.
One educator said the training helped her become comfortable with using the materials and
conducting a lesson in from of a group of her peers. She said,
"1 was very afraid to stand infront of people, so they had me do it (infront of
the other trainees). The other program assistants gave me self-confidence. I
didn't know the materials before... I could not have done it without the
training."
After the initial training, the area program coordinator brings all of the new educators together
again twice during their first month in the field to be sure they are applying the cone ;pts
properly, to answer any questions, and to refresh them on any issues they did not absorb during
the initial training. The three-week training includes a lot of material that can easily be
forgotten if it is not used quickly or often, so the coordinator makes sure to touch base with all
of the new educators to ensure all questions are resolved.
Food Stamp Nutrition Education Study - Case Study Report Page 17
Nutrition educators receive in-service trainings every other month in the district office. Either
the area program coordinator, an Extension agent, or an expert in the field does the
presentation. All of the nutrition educators meet at a central location for the training. A
different topic is presented each time, either presenting new material or giving more in-depth
information on topics covered in the curricula. Some of the topics include breast-feeding, food
and money management, stress management, vitamins, aging, chronic disease, alternative
medicine exercise, and food safety. Other training opportunities afforded the nutrition
educators include computer classes through Extension and other continuing education courses
through local agencies.
SCNEP works with and has provided training to staff from their local Food Bank. The Food
Bank is highly collaborative and provides in-kind donations such as incentives for recruitment
and prizes for SCNEP graduates. They also provide some monetary donations, grant money,
food donations, and volunteer time. The training provided to the food bank employees
includes 16 hours of nutrition education instruction. The Food Bank often has staff members
who prepare meals but who have little knowledge of nutrition. The training covers topics such
as food labels, food preparation, and the Food Guide Pyramid. The local SCNEP conducts this
training once a year, or more often if there is a large number of new staff hired by the Food
Bank during the year.
D. Modes of Delivery
Nutrition education is delivered predominantly on a one-to-one basis or as a structured group.
Some group classes are taught in settings such as private homes, elderly communities or
Federally funded housing projects. Other locations where n-trition education is provided
include Extension offices, the Department of Social Services, senior citizen feeding sites, WIC
sites, homeless and domestic abuse shelters, county bilingual sites, military installations, and
churches. The area program coordinator said,
"We 've even gotten to the prisons. We 've developed so many relationships that
we've not had barriers [to reaching the target population]."
Food Stamp Nutrition Education Study - Case Study Report Page 18
Whether the nutrition educator does formal one-on-one education or a structured group lesson
depends on the clients and the location. In rural communities, for instance, where there are few
clients spread across wide areas of the county, one-on-one sessions are more practical since
people cannot travel hundreds of miles to meet in a "central" location. In urban and suburban
settings, group sessions are easier to organize because of the availability of public
transportation. The State coordinator would prefer for all of the nutrition education to be
provided one-on-one because of the individualized attention the clients get in that set up.
However, in some areas it is easy to have small groups, and teaching groups increases the
number of people who receive education. One nutrition educator said that she thinks clients
prefer one-on-one sessions because they are more focused and individualized, and allow for
more confidentiality.
No nutrition education is delivered through mass media broadcast. In the past, they have used
advertisements on the radio and on public television to promote the program, but not to deliver
education. Another form of mass media advertisement was a news story that a local television
station did of the program two years ago.
E. Content of Nutrition Education
The curricula used by the SCNEP are "Healthy Futures," "Smart Choices," and a curriculum
developed by Michigan State University. Each curriculum includes all of the dietary
guidelines including: eat a variety of food; maintain a healthy weight; choose a diet low in fat,
saturated fat and cholesterol; choose a diet with plenty of vegetables, fruits and grain products;
use sugars only in moderation; use salt and sodium only in moderation; and, if you drink
alcoholic beverages, do so in moderation. The curricula also involve the Food Guide Pyramid
throughout the course of the education. Each nutrition educator tailors the sequence of lessons
based on the individual needs of the client or group of clients. The two nutrition educators
with whom we spoke ranked their five most emphasized topics of nutrition education
differently. For the Spanish-speaking educator, she emphasized cholesterol and high blood
pressure first, then diabetes, then fiber, then fruit and vegetable consumption, then increased
Food Stamp Nutrition Education Study • Case Study Report Page 19
calcium. The other educator emphasized the Food Guide Pyramid first, then food safety,
reduced salt, reduced fat, and finally increased calcium. Other topics included in the
curriculum include:
■ A healthful diet (in general);
■ Eating five fruits/vegetables a day (5-A-Day program);
■ Food buying;
■ Food storage;
■ Food preparation/cooking skills;
■ Food budgeting;
■ Food safety and sanitation;
■ Health risk reduction and chronic disease;
■ Increased calcium intake for women;
■ Menu planning, pantry inventory, and meal management;
■ Obesity and weight management;
■ Physical activity and fitness;
■ Increased fiber intake; and
■ Reading food labels.
F. Process of Delivering Nutrition Education
Nutrition education is provided by the nutrition educators in a series of no less than six lessons.
Most of the lessons last between one and one and a half hours. It often takes up to one year for
a participant to complete the required courses for graduation, though the nutrition educators
work hard to ensure that participants are not enrolled longer than a year. They believe one year
is the maximum and optimal amount of time a participant should be in the program, and that is
Food Stamp Nutrition Education Study - Case Study Report Page an
plenty of time to complete the full course. As the participants begin to finish the prescribed
course of lessons, the nutrition educator completes a family record to monitor the change in
knowledge and behavior to determine if they have learned enough to successfully graduate. At
the time of graduation, each participant gets a certificate of completion. The educators noted
that many people feel very good about getting a certificate at the end because it gives them a
sense of accomplishment.
The nutrition educators are expected to increase the numbers of recruited and graduated clients
each year for the first three years After the third year their requirements do not increase. The
first year, educators in urban area arc expected to recruit 90 participants and graduate as many
as they can (though there arc no standards set). The second year they are expected to recruit
120 clients and graduate half of them, or 60 people. The third and subsequent years they are to
recruit 150 clients and graduate half of them, or 75 people. In order to reach these goals, it is
most effective to teach lessons in small group sessions instead of one-on-one, though
occasionally it is necessary to teach individuals who cannot make it to groups.
One nutrition educator in Northern Virginia discussed how she reduces attrition throughout the
year. She said that she develops relationships wi h her clients to encourage them to become
invested in the education. The more they feel they have a relationship with the educator, the
more likely they will keep their appointments for each lesson, take seriously the task of
changing behavior and knowledge, and continue through to completion. Anotner way to help
ensure optimal participation is to keep in touch on a constant basis, weekly if possible. This
lets each participant know that they are important enough to remember and that the educator is
counting on them to stay connected and involved. A final way to keep participants involved is
by tailoring the lessons and the way the entire course is taught to the needs of the individual. If
the clients feel their individual needs are of primary concern, they are more likely to invest
more fully, stay in the program to graduation, and get more out of their learning. Some of the
clients end up taking the course again in a group setting (without being enrolled a second time)
because they enjoy the class and working with the nutrition educator.
Food Stamp Nutrition Education Study - Case Study Report Page 21
The curriculum for "Eating Right is Basic" includes a small, tabletop flip-chart with all of the
lessons included. The nutrition educators are trained on how to use the flip-chart and often use
it in conjunction with other displays, hands-on activities, and materials. They also use games,
videos, and other materials including the "Healthy Futures" curriculum, the "Smart Choices in
the Grocery Store" curriculum, and a series of books from the University of Wisconsin
(keeping food safe, making the most of your food dollar, etc.). Though each nutrition educator
uses the same curriculum, teaching methods and styles vary from person to person. Educators
are given flexibility to teach in the way that feels most comfortable to them and in a way that is
received most positively by the clients. They do not use their curricula in a formalized, rigid
way, therefore. The education they provide is flexible and based on the needs of the
participants). They determine how to teach and in what format (one-on-one or group) based
on these needs. They know from experience what works best, and when they need to slightly
alter how to provide the education, they use their flexibility to cater to the changing needs of
the participants. One of the benefits of having bright, energetic nutrition educators is that they
are fully capable of modifying the education they provide based on their clients' needs.
G. Needs Assessment/Formative Research
The needs assessment for SCNEP was conducted years ago before this local program was
established. Therefore, the current area program coordinator was not involved in the needs
assessment activities. No formal, on-going needs assessment is conducted because they feel
they are reaching the people who are in need and because time is of the essence. Since
education is needed for those who are receiving or eligible for food stamps, that is the
population they focus on.
The area program coordinator said she is pleased with the number of clients enrolled in the
local SCNEP. More clients could be reached in Northern Virginia if there was more money to
hire additional nutrition educators, but for now they are at full capacity in terms of the numbers
they are able to reach.
Food Stamp Nutrition Education Study - Case Study Report Page 22
H. Coordination and Collaboration
One of the most important aspects of this local program's success is the collaborative
relationships that have been established and maintained. Every nutrition educator works with a
number of different programs to help with recruitment, service delivery, and other aspects of
programming. Some of the agencies that the nutrition educators in the Northern Virginia area
collaborate with include:
SHARE (Self Help And Resource Exchange, a non-profit food and
community network);
Legal Aid;
Department of Social Services;
Food stores;
Schools;
Churches;
Parks and Recreation Department;
County fairs;
Department of Mental Health;
Area Agency on Aging;
Geriatric clinics;
Emergency food services; and
Community centers.
Some of these collaborations help the educators with recruitment of participants. Other
agencies allow the educators access for advertisement purposes to find people who are eligible
for food stamps. Some agencies provide services or products to help the educators with their
program, such as food from the Food Bank for cooking demonstrations. The nutrition
Food Stamp Nutrition Education Study - Case Study Report Page 23
educators report that these collaborations are effective in part because there is good
communication, good follow-through, and a focus on a common cause to help people who are
on food stamps. The only collaboration that was not as effective in one county was with the
local WIC Program. Extension staff believe the problems result from a mis-understanding
regarding potential duplication between WIC and the agency in providing nutrition education
to food stamp recipients.
In talking with a member of the local Food Bank, it was learned that there are both significant
benefits and a few challenges in working with the local SCNEP. The initial challenge was
simply learning about each other's programs and functions. Soon, however, the food banks
were collaborating with Cooperative Extension to deliver nutrition education to food stamp
recipients and eligibles. The Food Bank partners with SCNEP to bring hands-on cooking skills
and other life-skills classes to people in the low-income communities they serve. Each session
includes eight classes where participants are taught nutrition, cooking skills, and life skills that
are taught by other professionals. All recipes and brochures are based on researched nutritional
information. A nutritionist oversees all classes. All foods used are easy to prepare, low cost,
easily accessible, nrtritious, and prepared in a healthy manner. Fresh produce is used at each
class and most of the ingredients are from the Food Bank. At the end ofevery class, each
participant receives a bag containing all the ingredients used in the recipe so he/she can prepare
the same recipe at home. This allows the participants to practice their skills and to share their
new knowledge and skills with their families.
This is just one example of a successful community collaboration. It has been effective
because of the good working relationship that has developed over time, getting stronger as time
goes on. With experience and time working together, there are fewer surprises, better relations,
and improved understanding between coordinators. Over time the Food Bank even came to
better understand the match rules, helping the collaboration run even more smoothly. Both
sides are interested in educating the low-income populations, but the program always needs
good management. The management breeds coordination, creates support and understanding,
and a need to remember that the bottom line is education. Caring local SCNEP coordinators
Food Stamp Nutrition Education Study - Case Study Report Page 24
make the collaboration work. Also, coordinating with SCNEP gives the Food Bank educators
a larger population of people that they can directly reach. Cooperative Extension also has a
larger set ofresources (money and materials) and better training materials than many other
agencies with whom the Food Bank coordinates.
However, the food bank representative also noted that not every part of the collaboration with
SCNEP has worked as well for the Food Bank. The representative noted that working with
SCNEP creates the appearance of too many bosses for the Food Bank educators. The Food
Bank educators have to respond to their supervisors at Cooperative Extension, the Food Bank
supervisors, and to area program coordinators. This creates a number ofdemands on the
educators and takes away time from teaching. Also, the Food Bank representative believes that
Cooperative Extension asks for too much paperwork, which takes away from time educating
the target audience. In addition, because food per se is not the specific focus of the SCNEP in
the way it is for the Food Bank, it can be more challenging to work with SCNEP as opposed to
other groups who focus mainly on food distribution. Finally, because of the large number of
people that the educators are required by Cooperative Extension to reach, the Food Bank
representative worries about a reduction in the quality of education in the interest of gaining
more participants.
I. Nutrition Education Plan
SCNEP is run based on a Statewide Nutrition Education Plan (NEP) and each local program
follows guidance from the Statewide NEP. No districts have their own plans independent of
the State plan. The area program coordinators have input to the State's NEP each year but they
do not participate in the actual writing, which is done by the State coordinators at Virginia
Tech. In general, the NEP in Virginia has remained relatively constant over the years. One
change in the NEP was in the specified target audience. In the past, the State coordinator was
more hopeful about being able to get all ofthe numbers of participants by only recruiting food
stamp recipients. When educators began experiencing difficulties getting enough participants,
they identified a large portion of people who need nutrition education who were eligible but not
Food Stamp Nutrition Education Study - Case Study Report Page 25
receiving food stamps. Once this was determined a few years ago, the NEP was rewritten to
include a waiver to provide education to both food stamp recipients and eligibles.
The grant money from the NEP is divided out by district based on the number of nutrition
educators in that region. They are also given a flat sum of $2,500 per year in this district for
incidentals and training.
The program in the Northern Virginia district implemented their program activities as they
were prescribed in the NEP. The State coordinator purposely wrote their NEP to be broad and
flexible so that they have leeway to change subtle aspects as needed. The area program
coordinator said,
"We learn as we go. Flexibility is built in. I let the program assistants do it to
the level they want to do it. 1 give them suggestions but then let them go tap into
resources. We recognize it's aprocess and we give it time. Though we haven't
made many changes to the program."
III. Evaluation of Nutrition Education Activities
The State coordinator ofthe SCNEP evaluates the numbers reached using the ERS system,
with individual participants as a unit of measure. Clients are tracked at the State level and
program assistants are kept informed of behavior changes through a computer-generated
program (ERS). Their annual reports are generated for the period May through April.
The State coordinator conducts evaluations of the entire program, though it is the nutrition
educators who evaluate the progress of their clients over the course of all sessions. The area
program coordinator works with the educators n 'be beginning and as needed to ensure they
understand how to use the ERS diagnostic report tor client evaluative purposes. They use the
ERS system lesson logs, and family records to evaluate the progress ofthe clients. The
coordinator also does small performance reviews of each nutrition educator each year.
Food Stamp Nutrition Education Study - Case Study Report Page 26
In terms of how well the program operated this year based on their planned versus actual
activities, the educators with whom we spoke reported having exceeded the numbers of
participants they were required to graduate this past year. They attribute that, in part, to being
"seasoned" educators who have established rapport with agencies and who have good
reputations in the community. Knowing a lot about a community helps, as well as developing
strong ties with the local Extension agent. They often get referrals from past and current
participants. One educator also added some outreach techniques this year, which helped her
gain greater numbers of participants. One new strategy was using flyers. Another was making
more recruitment phone calls to agencies and potential participants. Finally, having a volunteer
who works with each educator is an excellent way to increase recruitment since two people
working toward gaining higher numbers is always better than one. The educators both said
they need to continually think up new and better ways to recruit participants and promote the
program to keep the numbers up. They added that they have enough money to run their
classes, travel as needed, and buy new supplies, which helps them effectively run their
education sessions.
IV. Factors Facilitating the Provision of Nutrition Education
Overall, having exceptional nutrition educators, the ERS charts collection system, and a variety
of resources and teaching materials are what facilitate the successful execution of the local
program. Other facilitators are discussed below in more detail.
One facilitating aspect of the SCNEP is having the State program structured such that there are
five area program coordinators who administer the local programs. This allows the
coordinators to provide continuity of administration across a wider area than if there were
double or triple that number of coordinators. The area coordinators all report to the State
coordinator but are responsible for monitoring the ongoing operation and management of
SCNEP in their region.
The one area program coordinator with whom we spoke reported that one facilitator for her
Food Stamp Nutrition Education Study - Case Study Report Page 27
program was having a supportive and effective State coordinator. She said it helps to have her
leadership, and her care for low-income populations comes through in her commitment to the
success of the program across the state. The State coordinator always makes time for the area
program coordinator and is well-informed about how the program is running and what issues
are in need of attention.
One aspect of the program that facilitates implementation has to do with the cooperative
Extension home economists in the communities. The home economists take new nutrition
educators to local agencies to introduce them to agency representatives. Networking with
agency representatives is an important way home economists help educators develop
relationships in the community. These relationships are often important in helping with
recruitment, securing in-kind donations, and networking.
Another part of the program that facilitates its success is the continuity that the nutrition
educators provide to the education process. The program reports a very low attrition rate for
educators, even though they make comparatively small salaries. Their commitment to the work
and their enjoyment of their job encourages them to stay, which helps the program's overall
success. As mentioned before, each nutrition educator also has the help of a volunteer in their
community who helps with outreach, fixing food bags, helping with food demonstrations,
cleaning up after lessons, etc. This is another one ofthe facilitators to effective implementation
of the program.
One nutrition educator said she felt that the opportunities afforded all staff for continuing
education was a major facilitator. She noted that the classes that the area program coordinator
developed or facilitated were very helpful to her in her job. In addition to the classes, other
resources, such as the area program coordinator, other Extension agents, and other experts who
teach the courses were helpful as well. They teach important skills, give new and improved
knowledge, and suggest better ways to teach the nutrition education in a hands-on, interactive
way.
Food Stamp Nutrition Education Study - Case Study Report Page 28
V. Barriers to Providing Nutrition Education
There were a number of barriers that had to be overcome this year in order for the SCNEP to
run effectively. For instance, the amount of funds that the area program coordinator was able
to collect this past year was less than she needed to reach all of those participants she wanted.
Many of the funds she is able to collect were not eligible for federal reimbursement, which is
frustrating in times when they are struggling to raise enough money for the year.
Another major barrier is the salary for the nutrition educators. The economy is so good in the
Northern VA area that most people could easily find better paying jobs. Virginia's nutrition
educators get paid better than those in other states, though it is not enough to keep people
satisfied with the salary. Besides the fear of losing trained and effective educators, the
coordinator finds that applications for the open positions are few and far between because of
low pay in the Northern Virginia economy. This sometimes makes it difficult to find enough
applicants.
As mentioned earlier, one barrier to getting the required number of participants each year is
when food stamp recipients and eligibles are widely spread out across a long distance. In these
counties, participants must have transportation so that they can travel to meet in a centralized
location for the nutrition education each month. Since this is often not a viable option,
nutrition educators often end up doing one-on-one education, making it very difficult for them
to get the number of participants they are required to have. Along the same lines, it is
sometimes difficult for the nutrition educators in the spread out counties to travel as much as
they need to on the travel allowance they are given. Especially when clients who are being
given one-on-one education are not home at the scheduled time, the mileage cost can be an
issue.
Another barrier involves key agencies that are too busy to effectively collaborate with the
program. The type of help SCNEP usually counts on is having agencies help provide potential
clients to the educators. Because the agencies are too busy or because SCNEP is a low priority
Food Stamp Nutrition Education Study - Case Study Report Page 29
for them, some of them provide only minimal assistance. One agency helped by generating a
list of people an educator could contact, but did no work to help contact or encourage client
participation.
Another barrier that was faced were problems trying to collaborate with local WIC programs.
Because WIC does not generally provide information regarding shopping skills and resource
management, the nutrition educator providing food stamp nutrition education wanted to recruit
WIC clients to provide this additional information. However, when the nutrition educator went
to the WIC representative to discuss working collaboratively to try to get more clients recruited
into the program, she was turned away. The person told her that because the educator was a
paraprofessional without a degree or certificate, they would not promote the program nor help
with recruiting clients. The sense ofthe food stamp nutrition educator is that WIC wants
nutrition education to be taught to their clients only by degreed educators.
Food demonstrations are an important part of successful nutrition education. The educators
often find it difficult to secure locations where there are cooking facilities where
demonstrations and hands-on cooking can be conducted. A similar barrier involves not having
TVs and VCRs to show videos associated with some nutrition lessons. Though there are a few
VCRs available to educators, they have to be checked out and are sometimes not available as
easily as if each educator had her own equipment.
One environmental factor that is a burden to full and effective implementation of the program
is public transportation. Even in the cities where there are buses, clients (especially elderly
clients) do not know how or do not want to learn to use buses or the subway to get to education
sessions. In addition, a lot of clients are single parents caring for young children at home,
making it difficult to get them to attend classes unless childcare is offered. Finally, some
educators go to very poor areas with sub-standard housing in order to teach nutrition, making
their jobs more difficult, though they note that this does not stop them from teaching these
clients.
Food Stamp Nutrition Education Study - Case Study Report Page 30
VI. Lessons Learned
The following are some lessons that the area program coordinator and the nutrition educators
have learned through their tenure in this local program.
■ Presenting a positive image is key. The more people that hear about the
program, the more it will grow. Presenting the program to administrators of
other agencies helps to promote it, as well as lets the public know the program
exrts. Other ways of advertising include setting up displays at agencies, having
the nutrition educators go to health and wellness fairs, and making connections
at churches and grassroots organizations that can help recruit clients.
■ Teaching nutrition education using pure lecture format without the use of
demonstrations and visuals is highly ineffective. The best lessons are those that
are interactive, hands-on, and full of visuals. Participants love food
demonstrations as well as cooking with the educator. Demonstrating how to
cook a meal, having fun with it, then giving participants a food basket with all
the needed ingredients and the recipe is a great way to get them to try to cook a
dish at home for their family. Participants also respond we U to "shock" visuals
such as the examples of what clogged arteries look like.
■ For truly successful implementation, the program needs as many agencies to be
involve .1 as possible in order to help network and advertise the program.
■ You need nutrition educators who have a heart for people. You also need to
train educators on a regular basis to ensure they are up to date on all of the
information they need to address.
■ One thing the area program coordinator hopes to do differently in the future is
spend more time fostering a strong and trusting relationship between herself and
the new educators. She said she would like to spend more time with each new
educator because they often begin relatively shy and somewhat intimidated.
She wants to help them feel more comfortable immediately.
■ Running the SCNEP is more about management and supervision than about
having experience or a background in nutrition. The area program coordinator
spends a lot of time building a relationship with local Extension agents since
they conduct a good portion of the training provided on an on-going basis. She
takes a great deal of time to foster those relationships with Extension agents,
both in the office and in the community.
■ The educators believe that it is very important to develop a personal yet
professional relationship with the participants. Some participants simply need
Food Stamp Nutrition Education Study - Case Study Report Page 31
to feel they are accepted, befriended, and loved. They need to feel respected. It
is also good to try to give the participants something during the course of the
education, whether it be friendship, a listening ear, food samples, a certificate of
graduation, or some other gift or incentive.
It is important to remember that all participants' needs are different. Each
person has a different level of knowledge, a different set of life circumstances
surrounding food and nutrition, and a different way of learning. The educators
said they have to be flexible and aware of their participants' needs at all times.
One educator recommended that all area program coordinators shadow their
educators at least once a year to see how difficult their jobs are. She noted that
the coordinators could benefit from seeing how difficult recruitment is, how
frustrating it is to deal with cancellations, and see how some of the performance
expectations and goals set for all educators are too high for those in more rural
communities. She noted that some of the guidelines are unreasonable for those
operating in a spread-out, rural county. She also suggested that policymakers
increase salaries for educators. She said low salary affects morale and retention
of educators.
As a parting comment, the area program coordinator said, "We're making '
difference in lives and creating empowerment!"
Food Stamp Nutrition Education Study - Cas« Study Report Page 32
North Carolina Case Study Report
I. Introduction
North Carolina has 17 programs as a part of its program to provide nutrition education to low-income
individuals and families. One of the many programs is called Out For Lunch (OFL).
The OFL program was selected from North Carolina's 17 programs for this case study because
it existed in FY 1997 when the study began. OFL's main mission is to provide food and
nutrition education and food resource management for limited resource families in 41 North
Carolina counties. The primary audience is young women who are food stamp eligible and
their preschool children, though the program is open to all food stamp recipients and eligibles.
The OFL program for school-age children is currently present in 13 counties. The State
sponsoring agency is North Carolina State University Cooperative Extension and the specific
OFL program visited was a joint county program between Craven and Pamlico Counties in the
eastern part of North Carolina.
Each participating OFL county has a contract with Cooperative Extension that is developed
between the State OFL director and the county The team of agencies that work together in the
OFL effort are North Carolina State University, the North Carolina Department of Social
Services, and the participating county. For the county to participate, the county contract has
the following terms:
■ T*"i county must provide access to a food laboratory (or similar setting
conducive to hands-on experience for 12 adults) for the parents, a separate room
for children under 3 and a separate room for those 3-5 years old (conducive to
minimal food preparation, finger painting, etc.). These rooms should be in the
same building.
Food Stamp Nutrition Education Study - Case Study Report Page 33
The project budget will provide resources for food demonstration items, food
preparation equipment and the program assistants. Resources for participant
transportation are not included. The county is expected to provide a nrans of
transportation for par . ipants. Availability of transportation is a requirement
for receiving OFL funding.
The project contains an optional school-age curriculum for 6-11 year-olds for
the summer months. The OFL program does not provide funding for the
school-age component. If implemented, the county would need to provide adult
staff and or volunteers and resources to conduct activities.
OFL funding cannot be used for copies of handouts for participants, office
equipment office furniture, food laboratory appliances, preschool furniture, or
supplemental supplies (toys, cribs, mats, etc.)
The county is expected to provide paraprofessionals hired to conduct the
program with access to office space and equipment.
The OFL program has a standard curriculum, but the local program assistants have the
flexibility to tailor their programs to fit the demographics of their participants, regional issues,
or other logistical variations. The State-level administrators play an integral role in supporting
the local level programs by providing time and aid to the local level coordinators and program
assistants. Also, Cooperative Extension provides regional supervising agents to provide direct
support to the local programs and to serve as trainers for the program assistants. The OFL
program in North Carolina employs approximately 80 program assistants (two per county;
although some program assistants cover more than one county), eleven supervising agents, and
two coordinators at the State level. This report concentrates on the Craven/Pamlico County
program where two program assistants serve both counties.
II. Components of Food Stamp Nutrition Education
A. Target Audience and Eligibility
The initial planning for the program began in 1995 with a preschool program for children of
parents who were a part of the North Carolina Work First Program. Through cooperation
Food Stamp Nutrition Education Study - Case Study Report Page 34
between the Food Sfamp Program, the Expanded Food and Nutrition Education Program
(EFNEP), and the development of county relationships with organizations like food banks and
Family Resource Centers, the program was able to expand to adults.
The OFL program offers its services to those who receive or are eligible to receive food
stamps. Participants are 185 percent above poverty level or less. In order to tailor the classes
to meet the specific needs of Hispanics, the elderly and other groups, OFL participant handouts
have been modified. Modifications include translation of materials for Spanish-speaking
participants by volunteers and by two program assistants who are Hispanic. A resource review
is also underway to contribute to the modification of OFL to meet the needs of senior adults.
Also, on occasion, program participants are blind, hearing impaired, disabled, or
developmentally delayed, and it is up to the individual program assistants to decide how best to
work with these individuals and tailor their programs to fit the needs of these individuals.
The primary audience in Craven/Pamlico County is women who are food stamp eligible and
their preschool children. In recent years, some men have chosen to participate in the program
and their numbers are steadily increasing. The program serves a total caseload of 550 adults
and preschoolers.
When speaking with program participants in the Craven/Pamlico program, it was obvious that
they are very interested in the program. Most feel that they are learning a great deal and they
are thankful that their children are able to participate. Also, c'derly participants enjoy being
able to attend because they still want to learn and it makes them feel that people are concerned
about their well-being and they feel more of a part of the community.
B. Qualifications of Nutrition Educators
The nutrition educators in the OFL program are paraprofessionals and are called program
assistants. Their primary responsibility is to provide nutrition education to food stamp
recipients and people who are eligible for food stamps. Another important responsibility is to
Food Stamp Nutrition Education Study - Case Study Report Page 35
recruit participants and develop relationships with local agencies and programs who provide
contacts for recruitment. The program assistants also keep records on each participant,
including registration information, feedback and success stories, and evaluation forms filled
out at the end of each session.
The OFL program hires paraprofessionals who have high school diplomas or GEDs. Some of
the educators have some college coursework, some have a bachelor's degree, and some have
graduate coursework, but they prefer that the educators have little to no prior experience in
nutrition because they prefer to teach all of the nutrition information from the start. They also
find that some people with college backgrounds create too ngid a classroom environment, to
which participants do not respond well. Also, individuals with college backgrounds do not
tend to understand the population as well as those who are indigenous. It is important that the
program assistants build a non-threatening environment and help create dignity and pride in the
participants.
C. Training of Nutrition Educators
All program assistants undergo a total of four weeks of training. For three weeks, the program
assistants go to "boot camp" for training on basic food and nutrition, development ofteaching
skills, and recruiting skills/methods. The fourth week is devoted to the OFL program itself and
how it operates. The training program for the program assistants is conducted by the regional
supervising agent along with guest presenters. The goal ofthe supervising agents is not only to
increase knowledge, but to create a fun atmosphere so that the new program assistants feel
excited about the job they are starting as well as make them feel that there are people who will
support them in their effort to teach nutrition.
To enhance communication and training after the initial "boot camp" among all involved in the
OFL program, quarterly regional meetings are conducted. The meeting sites are strategically
positioned in five areas of the State, requiring county staff to travel no further than one hour to
attend the meetings. The primary purpose of the meetings is to provide ongoing training for
Food Stamp Nutrition Education Study - Case Study Report Page 36
the program assistants and other county staff who deliver the OFL program. The quarterly
meetings allow all Extension personnel involved in managing and implementing the program
to receive program updates, share ideas for continuous program improvement, and brainstorm
solutions to common roadblocks in the program. Feedback from participants in the meetings
has been favorable. Meeting participants indicate their pleasure in being involved in the
"continued evolution" of the program. Ideas generated from staff at regional meetings are
integrated into the program (where appropriate) as a means of implementing continuous quality
improvement. The ability to have input to help create and to improve OFL is very important to
the program assistants because it also allows them to feel like the State directors are accessible.
In addition to the quarterly district group meetings, the supervising agents conduct periodic in-service
trainings, and 2000 will mark the second Statewide program assistant conference.
D. Modes of Delivery
Nutrition education is delivered in a structured group setting. The adults are in one group, and
the children are in another group in a separate room. The parents are more than welcome to go
and look in on their children as they feel it is necessary. In situations where a participant is of
an extremely low-literacy level, the low-literacy participant will be partnered within the group
or one-on-one help may occur. The classes in Craven/Pamlico are taught in various
community locations including churches, community centers, County Extension offices,
schools, homes, and volunteer fire department buildings. Programs are not held in government
offices because ofthe audience's negative associations with government buildings.
Typically, the classes are Tuesday, Wednesday or Thursday because those are the days when
participant attendance tends to be better, but there are occasional classes on the weekends. Due
to the hands-on nature of the classes (emphasis on food preparation), there is a maximum of 12
participants for the adult class. There may be more in the preschool class. The program
assistants try to create an interactive environmen* to create interest in the lesson.
Food Stamp Nutrition Education Study - Case Study Report Page 37
E. Content of Nutrition Education
For the adult class, the first three classes center on fruits and vegetables and the last session
focuses on dairy foods with other topics mixed into the discussions. Each week the program
assistants discuss various topics ranging from food safety to shopping. The classes for the
preschool children mirror the adult program.
The curricula use dietary guidelines including: eat a variety of foods; choose a diet low in fat,
saturated fat, and cholesterol; choose a diet with plenty of vegetables, fruits and grain products;
use sugars only in moderation; and use salt and sodium only in moderation. The curriculum
also involves the food guide pyramid as a major concept throughout the course. Each nutrition
educator tailors the sequence of lessons based on the individual needs of the client or group of
clients. The two nutrition educators with whom we spoke ranked their most emphasized topics
of nutrition education differently. For the adult educator, she emphasized healthy eating, food
budgeting, food safety, germs, and cooking skills. The preschool educator emphasized germs,
fruits, vegetables, and healthy snacking.
F. Process of Delivering Nutrition Education
OFL follows an established curriculum of four sessions (one session per week) for four to five
hours at a time. At the completion ofthe four classes there is a graduation ceremony which
includes a certificate ofcompletion. The program assistants in Craven/Pamlico and their
supervising agent emphasized how important earning the certificate is to the participants.
Often, this program is only the opportunity they have had to earn something in their life and
the certificate generates a significant amount of pride.
The nutrition educators in the Craven/Pamlico program also noted how important it is to relate
to the participants. Program assistants have to be willing to share information and be open to
share ofthemselves to get participants to buy in to the program. One key to getting program
assistants to relate to the participants is having North Carolina make an effort to hire program
Food Stamp Nutrition Education Study - Case Study Report Page 38
assistants who are indigenous to the food stamp population. In this way, the program assistants
have a better knowledge of the population they are teaching; likewise, they may already have
built relationships with current and potential participants. Currently, 70 percent of the program
assistants in North Carolina are indigenous to the population, and many have been on food
stamps at one time or another.
The first hour of the class contains the topic of the day. The program assistants, through
discussion, teach the participants about healthy eating, new foods, and how the foods will be
used in meal preparation and planning. The remainder of the session includes hands-on
learning activities involving the topic ofthe day as well as the preparation of a full meal for
lunch. While the food is cooking, the program assistants go back to a discussion format on
nutrition topics. After the meal is over, the participants receive a bag of food and cooking
supplies to fix the same meal at home for their families. The preschool class is conducted in
much the same manner except adapted to preschooler skills. The primary difference is that
physical activity is also included in the preschool class.
The most important aspect of the OFL program is its hands-on nature. During participant
interviews, it was stated that the active learning as well as the positive energy and open nature
of the program assistants made the participants want to learn more. Many wish that classes
were every day and the mothers who have children participating in the program, noted how the
children became more interested in their food and wanted to help more with food preparation at
home. A telling remark by one participant was, "Once you see it (food) and use it (food
preparation), you want to do it (food preparation)."
G. Needs Assessment and Formative Research
The local programs in North Carolina are not directly involved in the needs assessment
process. All needs assessment activities and formative research are conducted at the State
level.
Food Stamp Nutrition Education Study • Case Study Report Page 39
H. Coordination and Collaboration
An important aspect to any program's success is collaboration with other organizations.
Collaboration with North Carolina's Work First Program has been very helpful for recruiting
participants for OFL. Work First in Craven/Pamlico County became involved with OFL after
the Work First Assistant Director observed an OFL presentation and was "thoroughly
impressed." OFL was integrated into the Work First Job Readiness Class. Work First felt
OFL would be a perfect match to improve learning skills as well as work skills for those
interested in entering the food service industry, and the Job Readiness Class participants
needed nutrition and parenting skills. The Craven/Pamlico County Work First representatives
say, "Keep the program!" They have observed so much improvement in job and life skills in
their Job Readiness Class participants. The number one complaint about the OFL program is
that it should have more money to provide more transportation. There are also other
collaborations with community organizations and businesses to get items for the OFL
participants and space for classes.
One relationship that continually needs to be worked on is the relationship with the Department
of Social Services (DSS). Over time the relationship with OFL and the State DSS has
improved through constant meetings and relationship building. The relationship with DSS is
important because the program money flows through DSS as well as contract approval, and
buy-in to the program's benefits is necessary from DSS officials. The greatest difficulty comes
with DSS officials at the local level, where it is harder to get buy-in to the program. There is a
great amount of turnover at the local level so educating the officials is a continual process, and
many DSS local directors do not feel that education should be a part of DSS's job.
I. Nutrition Education Plan
The OFL program is a part of a Statewide nutrition education plan (NEP) and each local
program follows the guidance from the Statewide NEP. The counties do not have their own
plans independent of the State plan. The local program coordinators and staff have input to the
Food Stamp Nutrition Education Study - Case Study Report Page 40
State's NEP each year but they do not participate in the actual writing, which is done by the
State administrators at North Carolina State University. To write the new proposal, there is an
OFL Project Team who collect information from the various county programs. A Planning
Retreat is conducted to evaluate the progress of the program and develop ideas for program
growth and enhancement for the upcoming proposal period.
Following is the summary of activities from October I, 1998, to September 31, 1999:
5,607 families were enrolled in the OFL program;
9,896 preschoolers participated in the program;
518 school-age children participated in the program, which was delivered in
after school programs;
514 volunteers supported the program;
21,576 contacts were made to recruit, inform, and enroll eligible participants;
and
Six additional county programs were successfully linked to the State's Work
First Program as optional components.
III. Evaluation of Nutrition Education Activities
State administrators ofthe OFL program evaluate the numbers reached using registration
information, feedback and success stories from the participants; comments from the evaluation
forms filled out at the end of each OFL session, and feedback from all of the program
assistants and supervising agents gathered at meetings and through the email network.
Evaluation of the entire program is done on a continual basis at the State level as well as the
local level.
The monthly narratives supplied by the program assistants report program outcomes that may
not be captured in quantitative data. Narratives from program assistants indicate that several
participants continue to develop improved self-image and self-confidence as a result of
Food Stamp Nutrition Education Study - Case Study Report Page 41
learning and implementing new food behaviors. Program assistants also indicate that the
particip ints request that additional sessions be taught to enhance their new knowledge and to
provide 'hem with additional skills in food selection, preparation, and safety.
Program assistants working with preschoolers continue to report an improved awareness of
different foods, especially fruits and vegetables, among participants. Where many children are
reluctant to try new foods at the beginning of the program, program assistants report an
increased curiosity and willingness to taste as the children become an active part of the
program. Program assistants also write that children often ask their parents for foods similar to
those they tasted as part of the OFL program, thus reinforcing the parents' active tole in
shaping children's food habits.
IV. Factors Facilitating the Provision of Nutrition Education
The number one facilitator for a successful program is having enthusiastic and caring program
assistants. Without good program as: .tants, the participants will not come to the programs,
there will be no word of mouth to generate new participants, and the participants will not learn
anything from the classes. As one participant said,
"The program assistants make you want to come back "
Other facilitators are:
■ Developing relationships with program collaborators through communication
and coordination.
■ Creating relationships between State program administrators, supervising
agents, and program assistants to develop ownership ofthe OFL program
through communication.
■ Having a set curriculum to breed continuity to the program, although the built in
flexibility of the curriculum now allows program assistants to reach their target
audience.
■ Hiring program assistants who are indigenous to the population that is being
served.
Food Stamp Nutrition Education Study - Case Study Report Page 42
Having strong State coordinator leadership.
Establishing good working relationships with other organizations working with
low-income populations (e.g., WIC, EFNEP).
V. Barriers to Providing Nutrition Education
The greatest barrier to the program reported by the local staff involves finding funds that are
eligible for Federal reimbursement. From an administration standpoint, it is difficult to
document funding sources because the State uses two different documenting systems (the
University system and FNS' system). Also, staff believe that regulations regarding which
funds are eligible for Federal reimbursement are too prohibitive, especially when using space
as in-kind match. Staff believe that if the regulations were changed so that fair market value of
the space could be credited towards Federal reimbursement, then the program would have
funds to expand.
Other program and participant barriers are:
■ FNS guidelines for the program continually change, so rules cannot be counted
on to remain consistent and the rule changes tend to be more restrictive than
helpful to program development (e.g., rules for allowable expenses have
become more rigid).
■ Writing a proposal each year makes it difficult for long term planning. A
minimum ofa two-year proposal plan would be better.
■ There is usually a delay with the contract approval and funds having to go
through DSS. It would be better to have the funds go straight from FNS to the
State sponsoring agency.
■ Because the program is dependent on finding local funds that are eligible for
USDA reimbursement, it is sometimes difficult for counties to supply the
appropriate funds to sustain/improve the program.
■ The population is hard to reach. Many times the population is "too proud" to
come to Cooperative Extension for help.
■ Getting listings of potential participants from DSS is difficult.
Food Stamp Nutrition Education Study - Case Study Report Page 43
Transportation, though provided, is too limited to reach all those eligible for
participation. The program could expand to more counties, and if counties did
not have to arrange for transportation then funds could be used to provide
transportation.
Many wish funds could be used for child care for those participants with
children too young to attend OFL.
There continue to be problems with program acceptance in the community.
VI. Lessons Learned
The following are some lessons that the State and local coordinators have learned through their
tenure as administrators of the OFL:
■ The most successful strategies to reach the audience are word of mouth,
speaking with community leaders, speaking with former participants, speaking
with agencies who work with similar populations (e.g., WIC, Work First, Head
Start), and speaking with DSS.
■ Direct mail is the most unsuccessful way to reach this population.
■ In developing the program, make sure to listen to and be responsive to the needs
of the program assistants. Create a standard/Statewide program that has
flexibility built into it. The standard program also makes it easier to show
outcomes.
■ If the program were to be started over, the State coordinator said that she would
have more help at the State level (full-time evaluator and more administrative
staff). Currently, almost all of the money goes to the county programs.
■ The most important advice for other local directors was to be accessible to the
program assistants and do not micro-manage them. Also, the program assistants
need good initial training, so try to develop a good evaluation program. From
the State director point of view, it was important to not micro-manage and also
to start small (e.g., pilot program) and then expand slowly.
■ The administrators would like to see parenting and financial planning courses to
be allowed as a part of FSNEP programs.
Food Stamp Nutrition Education Study - Case Study Report Page 44
Oklahoma Case Study Report
I. Introduction
The Oklahoma FSP nutrition education program is known as the ONE (Oklahoma Nutrition
Education) program, and is run through the Cooperative Extension program at Oklahoma State
University. Two sites were selected for visits, both in rural areas. One was in Altus County
and the other in Beckham County. Interviews were conducted with four people including the
ONE Program Coordinator, two Nutrition Educators, a representative from the cou. y
Temporary Assistance to Needy Families (TANF) Program. Two nutrition education cl sses
were also observed, one with a group of three woman at a client's home and the other at a
TANF teaching site. The following sections highlight the major elements of the sessions
observed.
II. Components of Food Stamp Nutrition Education
A. Target Audience and Eligibility
The overall target audience for the ONE program is low-income audien.es. with food stamp
recipients and eligibles as a priority. Most of the participants are over the age of 18, but they
do serve a small population of teen parents. A number of persons being served consist of
persons who work for social and health service providers, but still qualify as low-income.
These individuals are composed of home health care workers, nurses, and day care providers.
Food Stamp Nutrition Education Study - Case Study Report Page 45
The program has tracked the number of people se.ved this past year by counting both families
and individuals. The total number of families served was 526 and the total number of
individuals 1,306. Ofall participating families, 58% or 305 families had members who were
food stamp recipients while the remaining families had member who were eligible for food
stamp benefits, but not currently receiving them.
The program ensures that the nutrition education is appropriate for the population by tailoring
classes to the needs of the individual or small group. The nutrition educators monitor progress
of each client using the ERS data collection system and, through consistent client feedback,
modify the education accordingly. The cultural appropriateness of materials is monitored in a
similar fashion, by assessing how well the materials work with the population and by hiring
educators who represent the demographic characteristics of the target population (e.g, placing
African-American educators in communities that are predominantly African-American). The
nutrition education materials are general enough to be used statewide, so the cultural
appropriateness of the materials has to be monitored site-by-site or person-by-person. By using
nutrition educators from the community to teach the classes, the cultural appropriateness of the
materials can be consistently monitored.
The nutrition educator is responsible for tailoring the education to the specific needs of the
client For example, while there are some Spanish-speaking clients in the OK communities
visited, the availability of nutrition education materials in Spanish is limited. Where materials
are not available in Spanish (e.g., recipes) they are translated or interpreted by Spanish-speaking
educators. The ONE program administrators make a conscious effort to hire Spanish-speaking
educators in communities where it is likely a large portion of clients are Spanish-speaking.
In another case, an educator works with a client who is blind, though none of the
materials are developed for the blind. It is her interactions with him and her ability to tailor the
materials and the lessons to him that make the program a success for this client.
Some of the other special populations nutrition educators work with include teenagers in high
school classes. TANF recipients, people with mental and physical disabilities, people in drug
Food Stamp Nutrition Education Study Case Study Report Page 46
treatment programs, and clients from a local hospital's psychiatry ward who are preparing to be
reintegrated into the community.
B. Qualifications of Nutrition Educators
The skills and education requirements for employing the nutrition educators consist of having a
high school diploma or GED, having a good attitude, having a lot of initiative, and being a self-starter.
It is important for the educators to not only teach, but to motivate the participants to
achieve healthier lives through healthier eating. The educators are required to recruit their own
clients through contacting other community agencies for help and using their own
resourcefulness to find new clients in their county. Educators are also required to maintain
working relationships with other community agencies, not only for recruitment purposes, but to
more effectively network within the community at large. In addition, the nutrition educators
must fill out their own paperwork associated with each client. There is initial paperwork,
ongoing monthly paperwork, and graduation paperwork to be done for each client.
Direcung the activities of the nutrition educators is the program Coordinator. The
Coordinator's position is a three-quarter-time position, and has the support of a half-time
secretary. There are eight full time (40 hours per week) nutrition educators in this region. The
Coordinator, secretary, and two of the local nutrition educators share office space at the
Extension office in Altus. All other nutrition educators in the state have an office in the county
Extension office along with other Extension staff. Currently thi:re is one nutrition educator
position vacant due to a recent resignation.
The first job of the new educator is to learn the basic information of the curriculum, to meet
key representatives in the community, and begin networking to recruit clients. After their
initial training, the Coordinator visits the educator periodically for a few months to help the
educator become acclimated to the program and to answer any questions they might have. The
Coordinator believes it helps to revisit some of the training material early on so that the
information is reinforced.
Food Stamp Nutrition Education Study - Case Study Report Page 47
C. Training Nutrition Educators
When a new nutrition educator is hired, they are required to attend a training course for three
weeks duration following a specific training agenda. The Coordinator organizes the initial
training as necessary depending on when a new educator comes on board. In addition, the
initial training includes having the new employee shadow existing educators, meet agency
representatives, and prepare a lesson to present to a group.
Besides the three-week initial training, ongoing training is planned by the Coordinator, and
provided monthly. The educators and the Coordinator agreed that the ongoing training is
crucial to the successful implementation of the ONE program. Sometimes it is the Coordina'or
who runs the training, other times it is an Extension Specialist or other expert who is brought in
to conduct the sessions. One of the educators mentioned that there was a lot of training, which
she liked and found very helpful.
The ONE program provides training to other staff besides their own educators. For example,
training is provided to day care providers who work primarily in low-income communities.
These day care providers are themselves food stamp recipients or eligibles. A similar situation
occurs with some home health aids who are eligible to receive nutrition education but who
achieve a dual benefit in that they also prepare food and shop for tne clients they serve.
D. Modes of Delivery
The setting of nutrition education is left up to the discretion of the individual educator and is
designed to accommodate the needs of the population. Most nutrition education is delivered in
people's homes on a one-on-one or small group basis (this works well if there are multiple
people in a neighborhood who ar • enrolled). Both the Coordinator and an Educate said,
" We conduct the education primarily in homes. We encourage participants to
sit at their kitchen tables for lessons because we can use thefood they have in
their kitchen to do demonstrations. It s not as good in the family room because
the kitchen is where all ofthefood items are "
Food Stamp Nutrition Education Study - Case Study Report Rage 48
In some cases, education is taught in group rooms located in other service agencies. For
example the learning resource center (LRC) for TANF recipients is a site used where many
food stamp recipients and eligibles attend classes to promote self-sufficiency. In addition,
some nutrition education is conducted at schools in classrooms. Libraries and extension offices
have also been used.
While most of the nutrition education in the ONE program is delivered as formal one-to-one
education, small group education is also used. One ofthe benefits to small group lessons is
that they are able to present information to more people at the same time. In addition, the
interaction among participants is often helpful, with participants sharing experiences and
benefitting from hearing answers to other people's questions. One Educator said,
"Hike tofindpeople in groups. Some individuals are not as open, some are
really defensive. Some have been treated badly in the past, so they are more
comfortable in a group. That way there s not so much ofafocus on them. They
feel better having people like them in the group. Sometimes they are
embarrassedfor you to come into their homes. "
Regardless of the mode of education, each lesson begins with a set of prescribed objectives,
then the actual teaching session, followed by a review of what was learned during that session.
Sometimes the education is conducted in a more informal mode, especially if there are special
circumstances that require more flexibility such as a personal crisis that the client needs to
discuss. While none of the modes of r itrition education have been formally tested by the local
programs, the experience of the local educators has prepared them tc evaluate in a non-systematic
way whether the education, materials, and modes are working effectively.
E. Content of Nutrition Education
The ONE program is designed to provide practical information to its clients and uses a core
curriculum provided throughout the State called Eating Right is Basic. The curriculum consists
of sixteen basic lessons called "The Basics", which cover topics from how to shop for food,
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how to identify healthy food, food safety and preparation, and issues related to the nutrition of
children.
The general focus of the ONE program is to teach better nutrition and management of food
dollars. All components ofthe Dietary Guidelinesfor Americans are used in the nutrition
education curriculum for the ONE program. In addition, the Food Guide Pyramid is used as a
central component of the education. Both of the nutrition educators who were interviewed
confirmed that the dietary guidelines and Food Guide Pyramid are central to their teaching.
Although the core curriculum is the basis for education, any topics the educator thinks would
benefit a client can be presented to the Coordinator for approval. The Coordinator must first
approve the new topic and its associated materials. This will sometimes occur if there is a
special dietary or health need of one of the participants. For example, an additional topic might
be a discussion of specific food allergies. The materials for special topics can often be
accessed through a list of externally developed materials that is maintained at the Coordinator's
office for the benefit of the educators. In other cases there are specialists who work for
Extension who can give advice on other topics or where to get materials that are not available
to the ONE program.
Each nutrition educator focuses on or emphasizes some topics over others. The two educators
who were interviewed had slightly different ideas about their top five topics. One said meal
planning, then budgeting (stretching food dollar), then food labels, eating light is right, and
then the food guide pyramid were her list of priorities. The other educator indicated that food
budgeting, grocery shopping, food safety, reading labels, and meal planning were the most
important topics for the population she taught. One educator also reported that she has
experienced many illnesses in her life and she said she likes to teach from her own experience.
She says that while she tries not to get too personal with her clients, she does try to add a
personal component to her teaching so that they perceive her as warm, approachable, and not
intimidating.
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F. Process of Delivering Nutrition Education
Recruiting participants and assessing a client's eligibility are the first steps in the process of
reaching the target audiences. Once eligibility is established, the educator schedules the first
meeting. In most cases, the same weekly meeting time and r'ay is agreed upon so that both the
educator and client get into a routine. Participants are enrolled in the program for
approximately nine months, but no more than 12 months. The goal is to provide the client with
a minimum of three sessions a month.
The selection and order of topics presented is determined by the educator. One educator noted
that for some clients, they have to be "lured" in with a very interesting topic in the first session
or two in order to keep them coming back, so she will choose a topic that she knows is of
particular interest to that person. After successful completion of the entire course of lessons,
the individual "graduates" and is given a certificate of completion for finishing the course.
To aid in planning for each class, the educators hav a list of resource materials, maintained by
the secretary of the local ONE program. The list of materials is divided into curriculum
materials, games, and visuals. Some of the materials include the basic curriculum, recipe
books, a food dictionary, an exchange list for food planning, fact sheets, keys to successful
money management, practical food safety display, food safety bingo, a germ war game, a
"Take Aim Nutrition" game, food models and cutouts, thermometers, calcium teaching kit.
Food Guide Pyramid display, and "Play It Safe" posters. The secretary also maintains a printed
list of all of the ONE program videos and audiotapes that are available for use by the educators.
At any time, the educators can check out materials from the Extension office.
Educators are trained to use most of the resource materials, but they are encouraged to use
creativity and their best judgment in exactly how they conduct their lessons. For example,
though the Eating Right Is Basic curriculum includes a small table-top flip-chart which is
attractive, informative, and a very good resource, one Educator said she uses her flip-chart as a
reference during her presentation instead of reading it verbatim as the sole visual of the lesson.
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She prefers to incorporate more activities and more interactive displays and visuals instead of
depending on the flip chart to be the only visual and piece of information. She often uses
games, simulates a shopping trip, conducts food demonstrations using food she knows her
clients use regularly, and shows videos as other forms ofvisuals to stimulate learning during
her lessons.
Upon completion of the program, the goal is to have the clients consuming healthier foods
promoted by the Dietary Guidelines and the Food Guide Pyramid. They should be eating an
adequate amount of nutrient-dense food every day, improving food budgeting, improving meal
planning, being better purchasers of food, using available resources better, and using the
USDA food safety guidelines.
G. Needs Assessment/Formative Research
The needs assessment process for this local ONE program is not a formal one, as all of the
formal needs assessment was done at the state level before the program began. Informally, the
local program stays connected aad in-touch with the needs of the community and target
audience through its links with community agencies and by its ongoing work with the target
population. Every county in the state has different needs, so it is important for the Program
Coordinator to get feedback from the nutrition educators to ensure the materials are appropriate
for the population and that their needs are being met. The Coordinator told us that,
"Wejumped in and began working with the large!population right away
without doing our own. separate needs assessment From experience we know
what s working and what s not working with the clients
One important component of the ONE program is an annual retreat that is organized by the
Coordinator for all of the nutrition educators and the secretary They spend an entire day away
from the office in an informal, unstructured environment discussing the year's progress,
upcoming goals, and what changes need to be made for the upcoming year They have
brainstorming sessions, sharing sessions, planning sessions, and team building opportunities
The Coordinator believes this retreat is a great way to learn about the needs of the target
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pr-Hilation all over her region, come up with strategies for strengthening the program, and
building teamwork and morale among her staff. The retreat is viewed as a unique and creative
way for the local program to address accomplishments and difficulties, develop future
strategies to overcome obstacles, and develop a sense of camaraderie and respect among staff
H. Coordination and Collaboration
As noted above, collaboration between the ONE program and community agencies is critical to
the success of the program. Some of the major collaborators ofthe ONE program include the
Department of Human Services, The Health Department, Elder Care, mental health agencies,
substance abuse treatment programs, day cares, schools, and grocery stores. An example of a
collaboration that has worked well is that with a local grocery store. One of the nutrition
educators told us that the original idea came about because some ofthe educators felt it was not
appropriate for them to tell their clients what to eat without providing them with some of the
food they would be asked to try. The educator began by going to the manager oftwo local
grocery stores to ask if they could have the not-so-fresh fruits and vegetables that were no
longer abie to be sold but still edible. One of the managers agreed to pack up the produce that
was no longer sellable and have it available for the educators to pick up each week. The
educators and their volunteers have found this to be a wonderful addition to the program and a
way to put their teaching into action, as well as providing a needed service to their neediest
clients. This way, the educator and the grocery store are collaboratively helping those who are
hungry in the community.
In speaking to one of the ONE program's collaborators, a job developer for the Department of
Human Services' (DHS) Temporary Aid for Needy Families (TANF) program, it was learned
how effectively two agencies can work together. Initially, the relationship began when the
ONE program Coordinator went to the TANF office to ask to meet with the county director in
order to make them aware of the ONE program and to request that a TANF recipient apply for
the job of nutrition educator in that county. The Coordinator saw the Department of Human
Services as a very important partner in this c ,unty (as in all others), so she made a special
Food Stamp Nutrition Education Study Case Study Report Page S3
effort to foster the initial relationship and to collaborate with the TANF program. The
Coordinator discussed the ONE program with the TANF Director, highlighted how the two
programs do not overlap nor threaten each other, and emphasized the benefits the ONE
program could offer to TANF recipients. It was agreed that the two agencies would
collaborate, and their relationship has been steadily improving and strengthening ever since.
Some of the tasks the two agencies collaborate on include the hiring ofeducators in that
county, providing referrals to clients, maintaining ongoing communication and information
sharing, distributing program brochures, discussing the educational needs of the target
population, and attending each other's meetings. The TANF representative helps the nutrition
educator in acquiring new and needed resources when necessary, helps foster the existing
relationships between Extension and DHS, and provides invaluable networking opportunities.
The clients she helps the educator recruit are TANF recipients who are required by law to
attend classes while they are receiving aid. The ONE program is incorporated into the
curriculum for all TANF recipients in that county, so the nutrition educator has somewhat ofa
captive audience and does not have to go door-to-door recruiting this particular population.
The TANF representative noted that she feels her collaboration with the ONE program is very
effective. She mentioned that many TANF recipients remark about how much they got from
the lessons learned through the ONE program. Both agencies have one common goal and that
is to help TANF recipients or those who are receiving Food Stamps to reach self-sufficiency
and live healthier, better lives.
Some other reasons this collaboration works so well is that the TANF representative has
always felt nutrition was important to all people, she says that both agencies are very
cooperative by nature and the staff have wonderful attitudes, and having a common goal is
invaluable. In addition, the TANF representative and the ONE nutrition educator share an
office in the county DHS office, thereby fostering their working relationship and making it
easier to communicate