Enhancing Effectiveness in Nutrition Education - Expanded Food

Enhancing Nutrition Education Effectiveness

Isobel Contento, PhD, CDN Teachers College Columbia University California UC-SNAP-Ed December, 2011

Exciting Time for Nutrition Education

Exciting Time for Nutrition Education

So why is it so challenging?

Contento 2000

Biologically Determined Behavioral Predispositions: •Taste/pleasure •Sweet, sour, salt, bitter •Hunger/satiety mechanisms •Sensory specific satiety

Preferences, dislikes: Sensory-affective factors

FOOD CHOICE AND DIET-RELATED BEHAVIORS

Newborns like sweet solutions

Newborns dislike bitter solutions

Contento 2000

Experience with Food: Associative conditioning Biologically Determined Behavioral Predispositions: •Taste/pleasure •Sweet, sour, salt, bitter •Hunger/satiety mechanisms •Sensory specific satiety

Physiological conditioning: •Familiarity: learned safety •Conditioned food preferences •Conditioned satiety

Social conditioning: •Social affective context •Parenting practices

Preferences, dislikes: Sensory-affective factors

FOOD CHOICE AND DIET-RELATED BEHAVIORS

Contento 2000

Person-Related Determinants Experience with Food: Associative conditioning

Intra-person factors

•Perceptions Physiological •Attitudes Biologically •Beliefs conditioning: determined •Motivations & •Familiarity: behavioral values learned safety predispositions: •Personal •Conditioned food •Taste/pleasure meanings preferences •Sweet, sour, salt, bitter •Knowledge & •Conditioned satiety •Hunger/satiety mechanisms skills •Sensory specific satiety Social conditioning: •Social norms •Cultural •Social affective norms context Inter-person •Parenting practices

factors

Family & social networks

Sensory-affective factors

Beliefs, attitudes, norms, knowledge, skills

FOOD CHOICE AND DIET-RELATED BEHAVIORS

Contento 2000

Social /Environmental Determinants: Person-Related Determinants Experience with Food: Associative conditioning

Physical/ built environment • Food availability • Built environment

Intra-person factors Social/cultural •Perceptions environment: Physiological •Attitudes Biologically •Social relations •Beliefs conditioning: determined •Cultural practices •Motivations & •Familiarity: behavioral •Social structures values learned safety predispositions: •Public policy •Personal •Conditioned food •Taste/pleasure meanings preferences •Sweet, sour, salt, bitter •Knowledge & Economic •Conditioned satiety •Hunger/satiety mechanisms skills environment •Sensory specific satiety •Social norms •Resources Social conditioning: •Cultural •Price norms •Social affective •Time context Inter-person Informational •Parenting practices factors environment Family & social •Advertising networks •Education •Media FOOD CHOICE AND DIET-RELATED Social environmental Sensory-affective Beliefs, norms BEHAVIORS influences factors attitudes, skills

Ecuador: $31.50

Mexico: $189

United States: $342

US. Challenges

Triple By-Pass Café

Environmental factors:

Physical/food environment

Intra-person •Food availability factors: (under & over) Experience with food: •Perceptions • Technology Associative conditioning •Attitudes Social •Beliefs environment: Physiological Biologically •Motivations & determined •Social influences conditioning: values behavioral •Cultural practices •Personal •Familiarity: predispositions: •Social structures, meanings learned safety •Taste/pleasure •Sweet, sour, salt, bitter •Hunger/satiety mechanisms •Sensory specific satiety •Brain mechanisms

•Conditioned food preferences •Conditioned satiety

Social conditioning:

•Knowledge & skills •Social norms •Cultural norms

organizations •Policy

Economic environment •Resources •Price •Time

•Models Inter-person •Rewards factors •Social affective Informational Family & social context Environment networks •Advertising •Education •Media

FOOD CHOICE AND DIET-RELATED BEHAVIORS

Contento 2000

Survey When you decide you want to make a change in your eating habits, but can’t seem to do it, what would you say is the principal reason? I don’t think the food will taste as good

27%

I guess it’s really not that important to me

22%

I don’t have the time

20%

I don’t know how

15%

Don’t know

16%

Public Opinion Survey: Nutrition and You I am already doing it

38%

I know I should, but….

30%

Don’t bother me

32%

ADA: Attitudes, Beliefs, Behaviors. Nutrition and You. Trends. 2002

Why nutrition education is exciting and challenging What professionals recommend

What people want

More fruits and vegetables

Tasty foods

More whole and less-processed grains

Familiar

Variety

Easy (to buy, prepare & eat)

Less fat, sugar, sodium

Good value for money (cheap)

Balance food intake and physical activity

Healthy

What the food system supplies All the basic foods in abundance Fast foods high in fat, sugar and salt Sweetened beverages Large portions Low prices

Key elements of effectiveness

•

Focuses on specific behaviors, actions, practices

• Identifies and addresses influences /potential mediators of behavior change • Uses theory and research to design educational strategies directed at these potential mediators • Addresses the multiple levels of influences

Behavior-focused If Goal is to prevent overweight :

Behaviors =  Eat more fruits and vegetables  Eat fewer high-fat, high-sugar foods  Increase physical activity  Watch portion sizes

Behavior-focused If Goal is to contribute to food system sustainability:

Behaviors =  Eat more local fruits & vegetables  Eat fewer processed, packaged snacks  Cook more at home

Eat More/Eat Less Dietary Intakes as a % of Recommended Goals/Limits

US Dietary Guidelines 2010 Messages

• Balance your calories -- Enjoy your food but eat less -- Avoid oversized portions

• Foods to increase -- Make half your plate fruits & vegetables -- Switch to fat free or low-fat milk

• Foods to reduce -- Choose lower sodium foods -- Drink water instead of sugary drinks

Key elements of effectiveness

•

Focuses on specific behaviors, actions, practices

• Identifies and addresses influences /potential mediators of behavior change • Uses theory and research to design educational strategies directed at these potential mediators • Addresses the multiple levels of influences

Pre-1995: knowledge based programs:

Intervention

Moderators (SES, etc)

Knowledge

Behavior Source: Figures modified from Baranowski, 2007

Theory- based programs

Intervention Moderators

Psychosocial mediators

Behavioral outcomes 

Theory-based programs

Intervention

Determinants/ mediators

Behavioral outcomes

Health outcomes

Health outcomes from  behavior change programs Baranowski, SNE 2007

Key elements of effectiveness

• Focuses on specific behaviors, actions, practices • Identifies and addresses influences /potential mediators of behavior change

• Uses theory and research to design educational strategies directed at these potential mediators • Addresses the multiple levels of influences

Theory from social science Theory is: • A conceptual map, derived from evidence, to help us understand how various influences on food-related behavior are related to behavior/ taking action Biological Psychological Behavioral Environmental influences

Mediators/ Theory constructs

predict

Diet & PA behaviors

Nutrition education is about identifying and addressing relevant influences on, or mediators of, change

Theories and Models: Example KAB model Knowledge

Attitudes

Behaviors

Outcome Expectations Physical Social Self-evaluative

Self-efficacy

Goal Intention

Skills

Social Cognitive Theory (Bandura)

Self-regulation Processes (Goal setting)

BEHAVIOR

ENVIRONMENT Socio-structural factors Facilitators and impediments

Consequences

Theories and Models - Examples • Stage theories: behavior change is a process Motivational (Pre-Action) Phase thinking…

Action Phase doing!

Key elements of effectiveness

•

Focuses on specific behaviors, actions, practices

• Identifies and addresses influences /potential mediators of behavior change • Uses theory and research to design educational strategies directed at these potential mediators

• Addresses the multiple levels of influences

Multiple mediation model Parent education

Moderating variables

50%

Parent mediators 25%

Parent behaviors

Home environment 6.25%

12.5%

Child Psycho-socials

Child behaviors

Family based programs

3.13%

Baranowski, SNE 2007

Child health outcomes

Multiple mediation model Parent education

Other actions Parent mediators Parent behaviors

Home environment

Child Psycho-socials

Family based programs

Child behaviors

Child health outcomes

Theory-Based + Social-Ecological Approach

Intervention Policy/ Environment Psychosocial mediators Moderators

Biology & food experience Behavioral outcomes

Health outcomes

.

Social /Environmental Determinants: Person-Related Determinants Experience with Food: Associative conditioning

Physical/ built environment • Food availability • Built environment

Intra-person factors Social/ cultural •Perceptions environment: Physiological •Attitudes Biologically •Social relations •Beliefs conditioning: determined •Cultural practices •Motivations & •Familiarity: behavioral •Social structures values learned safety predispositions: •Public policy •Personal •Conditioned food •Taste/pleasure meanings preferences •Sweet, sour, salt, bitter •Knowledge & Economic •Conditioned satiety •Hunger/satiety mechanisms skills environment •Sensory specific satiety •Social norms •Resources Social conditioning: •Cultural •Price norms •Social affective •Time context Inter-person Informational •Parenting practices factors environment Family & social •Advertising networks •Media

Nutrition Education

FOOD CHOICE AND DIET-RELATED BEHAVIORS

Social-Ecological Approach • A supportive social and physical environment is required for intentions or decisions to be translated into action and for them to be maintained long term. • Levels – individual, interpersonal, institutional/organizational, community, and policy and systems • Addressing multiple levels can allow for a program to have sufficient duration and intensity.

Definition of nutrition education • Nutrition education is any combination of educational strategies, accompanied by environmental supports, designed to facilitate voluntary adoption of food choices and other food and nutrition-related behaviors conducive to health and well-being (of individuals, community, planet) • Nutrition education is delivered through multiple venues and involves activities at the individual, community, and policy levels.

Policy actions Regulatory actions Legislation

Social and Cultural Norms and Values Societal & cultural norms & practices

Belief systems Heritage Religion Lifestyle Body image

Sectors of Influence Food & beverage industry Health care system

Health care systems Media

Government Public health Food assistance programs

Environmental Settings

Homes Workplaces Schools

Community Grocery stores design Restaurants Public Recreational policy facilities

Availability Access Barriers Opportunities

Individual factors

Social structures Social support Social networks Collective empowerment

InterINterIn Food preferences & enjoyment Beliefs, attitudes, values, Knowledge & skills, Gene-environment interactions Self-efficacy/ agency Demographic factors

Psychosocial factors: Outcome expectations Motivations Self-efficacy Behavioral capabilities

Social and Cultural Norms and Values Policy actions Systems Regulatory actions

Societal & cultural norms & practices

Belief systems Heritage Religion Lifestyle Body image

Sectors of Influence Food & beverage industry Health care system

Health care systems Media

Government Public health Food assistance programs

Environmental Settings

Homes Workplaces Schools

Community Grocery stores design Restaurants Public Recreational policy facilities

Availability Access Barriers Opportunities

Individual factors

Social structures Social support Social networks Collective empowerment

InterINterIn Food preferences & enjoyment Beliefs, attitudes, values, Knowledge & skills, Gene-environment interactions Self-efficacy/ agency Demographic factors

Psychosocial factors: Outcome expectations Motivations Self-efficacy Behavioral capabilities

Social and Cultural Norms and Values Policy actions Systems Regulatory actions

Societal & cultural norms & practices

Belief systems Heritage Religion Lifestyle Body image

Sectors of Influence Food & beverage industry Health care system

Health care systems Media

Government Public health Food assistance programs

Environmental Settings

Homes Workplaces Schools

Community Grocery stores design Restaurants Public Recreational policy facilities

Availability Access Barriers Opportunities

Individual factors

Social structures Social support Social networks Collective empowerment

InterINterIn Food preferences & enjoyment Beliefs, attitudes, values, Knowledge & skills, Gene-environment interactions Self-efficacy/ agency Demographic factors

Psychosocial factors: Outcome expectations Motivations Self-efficacy Behavioral capabilities

Social and Cultural Norms and Values Policy actions Systems Regulatory actions

Societal & cultural norms & practices

Belief systems Heritage Religion Lifestyle Body image

Sectors of Influence Food & beverage industry Health care systems Media

Government Public health Food assistance programs

Environmental Settings

Homes Workplaces Schools

Community Grocery stores design Restaurants Public Recreational policy facilities

Availability Access Barriers Opportunities

Individual factors

Social structures Social support Social networks Collective empowerment

InterINterIn Food preferences & enjoyment Beliefs, attitudes, values, Knowledge & skills, Gene-environment interactions Self-efficacy/ agency Demographic factors

Psychosocial factors: Outcome expectations Motivations Self-efficacy Behavioral capabilities

Social and Cultural Norms and Values Policy actions Systems Regulatory actions

Societal & cultural norms & practices

Belief systems Heritage Religion Lifestyle Body image

Sectors of Influence Food & beverage industry Health care systems Media

Government Public health Food assistance programs

Environmental Settings

Homes Workplaces Schools

Community Grocery stores design Restaurants Public Recreational policy facilities

Availability Access Barriers Opportunities

Individual factors

Social structures Social support Social networks Collective empowerment

InterINterIn Food preferences & enjoyment Beliefs, attitudes, values, Knowledge & skills, Gene-environment interactions Self-efficacy/ agency Demographic factors

Psychosocial factors: Outcome expectations Motivations Self-efficacy Behavioral capabilities

A Logic Model for Planning Nutrition Education

Inputs

Outputs

Outcomes

What we invest

What we do

With what results

Stepwise Procedure for Planning Theory‐Based Nutrition Education

Issues / concerns

1 or a few related major issue(s)

Behaviors

Clearly defined behaviors  for audience

Determinants / mediators

Mediators specific for behaviors for given audience 

Step 3

Theory

Theory model based on evidence  for behavior for given audience

Step 4

Objectives

Clearly stated objectives for  mediators

Activities/ Procedures

Specific activities/ procedures   for mediators

Evaluation

Evaluation for  mediators & outcomes

Step 1

Inputs

Step 1

Step 2

Outputs

Step 5

Outcomes

Step 6

Step 1: Select behavior or action

Select behavior or community action that will be the focus of the program based on analysis of issues or concerns

Using theory to design an inquirybased science curriculum for middle school students for obesity prevention

Foods & food components to decrease • Eat less frequently at fast food places -aim for no more than 3 times a week. • Eat fewer packaged snacks--aim for no more than 150 calories a day. • Drink fewer sweetened beverages--aim for no more than 8 ounces a day.

Food and drinks to increase • Eat more fruit and vegetables--aim for at least 4.5 cups a day. • Drink more water--aim for 8 cups a day. • Walk more (include stairs!)--aim for at least 10,000 steps per day.

Stepwise Procedure for Planning Theory-Based Nutrition Education

Step 1

Inputs

Step 1

Step 2

Outputs

1 or a few related major issue(s)

Behaviors

Clearly defined behaviors for audience

Determinants / mediators

Mediators specific for behaviors for given audience Theory model based on evidence for behavior for given audience

Step 3

Theory

Step 4

Objectives

Clearly stated objectives for mediators

Activities/ Procedures

Specific activities/ procedures for mediators

Step 5

Outcomes

Issues / concerns

Step 6

Evaluation

Evaluation for mediators & outcomes

Step 2: Identify potential mediators

• Awareness of health consequences e.g. diabetes • Increase personal benefits: convenience, taste, feeling full, cost • Reduce barriers to healthy eating • Increase autonomy/ competence in healthful personal choices

Focus groups: Perceptions of motivations, benefits, barriers, and information channels • Benefits for health already known

• Barriers: difficult to add to diet; inconvenient - cost (families) - taste & familiarity (children)

Stepwise Procedure for Planning Theory-Based Nutrition Education

Issues / concerns

1 or a few related major issue(s)

Behaviors

Clearly defined behaviors for audience

Step 2

Determinants / mediators

Mediators specific for behaviors for given audience

Step 3

Theory

Theory model based on evidence for behavior for given audience

Step 4

Objectives

Clearly stated objectives for mediators

Activities/ Procedures

Specific activities/ procedures for mediators

Step 1

Inputs

Outputs

Step 1

Step 5

Outcomes

Step 6

Evaluation

Evaluation for mediators & outcomes

Step 3: Select theory or create model

Select theory based on research evidence for behavior and population

Theory from social science Theory is: • A conceptual map, derived from evidence, to help us understand how various influences on food-related behavior are related to behavior/ taking action Biological Psychological Behavioral Environmental influences

Mediators/ Theory constructs

predict

Diet & PA behaviors

Theories and Models: Example KAB model Knowledge

Attitudes

Behaviors

Social Cognitive Theory Outcome Expectations Physical Social Self-evaluative

Self-regulation Processes (goal setting)

Goal Intention

Self-efficacy

BEHAVIOR Food & nutrition Skills

Perceived Barriers

Motivation Based on Bandura 2000

Autonomous motivation

ENVIRONMENT

Action

Consequences

Theory & components Theory: • Health Belief model, focusing on overcoming barriers Components: • Mass media campaign • Classroom lessons • Grocery stores • Community outreach

Stepwise Procedure for Planning Theory-Based Nutrition Education

Issues / concerns

1 or a few related major issue(s)

Behaviors

Clearly defined behaviors for audience

Determinants / mediators

Determinants/ mediators specific for behaviors for given audience

Step 3

Theory

Theory model based on evidence for behavior for given audience

Step 4

Objectives

Clearly stated objectives for mediators

Activities/ Procedures

Specific activities/procedures for mediators

Step 1

Inputs

Step 1

Step 2

Outputs

Step 5

Outcomes

Step 6

Plan evaluation

Plan evaluation for mediators & outcomes

Step 4 & 5: Translate behavioral theory into educational activities

Translate behavioral theory into educational objectives and activities

Planning Nutrition Education

Motivational pre-action phase:

Action and maintenance phase:

Why-to take action

How-to take action

Environmental/ policy support component

Conceptual Framework for Theory-Based Nutrition Education: A Logic Model Inputs/ Resources

Outputs: Theory-Based Intervention

Strategies directed at mediators of food choice and diet-related action

People Time Materials Money Space Partners Needs assessment process:

Motivational phase mediators - Risks, concerns - Benefits, barriers - Attitudes - Food preferences - Self-efficacy

Action phase mediators - Action plans - Knowledge - Food skills - Selfregulation skills - Personal agency

- Social norms

Environmental Supports - Interpersonal: social support - Institutional/ community actions - Policies, systems, food environment

Outcomes

Intervention Activities

Food system impacts

Conduct classes; Facilitate groups; Develop products, resources; Work with families; Work with institutions & community partners; Work with media;

Food behaviors/ practices Fruits & vegetables Calcium rich foods Resource management. etc

Improved health Decreased disease risk Decreased food insecurity

Societal impacts

Work with policy makers

Contento, 2002

Conceptual Framework Linking Behavioral Theory And Nutrition Education Inputs/ Resources

Outputs: Theory-Based Intervention

Strategies directed at mediators of food choice and diet-related action

People Time Materials Money Space Partners Needs assessment process:

Motivational mediators - Risks, concerns - Benefits, barriers - Attitudes - Food preferences - Self-efficacy - Social norms

Action phase mediators - Action plans - Knowledge - Food skills - Selfregulation skills - Personal agency

Environmental Supports - Interpersonal; social support - Institutional/ community actions

Outcomes

Intervention Activities

Food system impacts

Conduct classes; Facilitate groups; Develop products, resources; Work with families; Work with community partners; Work with media; Work with policy makers

Food behaviors/ practices Fruits & vegetables Calcium rich foods Resource management. etc

Improved health Decreased disease risk Decreased food insecurity

Societal impacts

- Policies, systems , food environment

Contento, 2000

Selecting Educational Strategies for Potential Personal Mediators Of Motivation

Linking mediators, strategies, activities Mediator/dete rminant of behavior change /theory construct

Educational activities/ learning (Participant will be able to:) experiences Educational objectives

USDA Messages for 8-10 Year-Old Children • Eat smart to play hard. Drink milk at meals. • Fuel up with milk at meals. And soar through your day like a rocket ship. • Snack like a super hero. Power up with fruit and yogurt. • Eat smart to play hard. Eat fruits and veggies at meals and snacks. • Fuel up with fruits and veggies. And soar through your day like a rocket ship.

Strategies to enhance motivation

Increase awareness of risks or concerns: Self-assessment Self-assessments, trigger films, pictures, charts, striking national or local statistics, personal stories, pictures of portion sizes

Sugar intake Mediator of Behavior Change

Objective Perceived risk: People who assess how self- assessment much added sugar they get compared to a each day in their sweetened standard drinks compared to recommendation will have increased desire to reduce their intake

12-ounce regular soft drinks

20 - ounce regular soft drinks

Outcome Expectations: Perceived Risk

Fat intake Mediator of Behavior Change

Perceived risk

Objective People who assess how much fat (saturated) they eat each day compared to recommendation will have increased desire to eat less fat

Session 8

Fat clogging tube activity Mediator of Behavior Change

Perceived risk

Objective People who watch the fat clogged tube activity will --- recognize themselves as susceptible to heart disease. -- appreciate the need to evaluate their lifestyle to reduce disease risk.

Strategies to enhance motivation Increase perception of benefits Why should I take action?

Modifying traditional recipes Mediator of Behavior Change

Perceived benefits

Objective Parents who taste traditional foods prepared in more healthful ways will appreciate their taste

Beliefs about taste

Pedometers Mediator of Behavior Change

Perceived benefits

Objective Youth who assess their daily step counts and compare to the 10,000 steps per day recommendation will have increased desire to take more steps.

Fruit and Veggies Mediator of Behavior Change

Perceived benefits

Objective Children who cook vegetables and eat what they cooked will like the taste of vegetables.

Physical Activity Mediator of Behavior Change

Perceived benefits

Objective People who see posters will increase their physical activity.

Benefits

Strategies to enhance motivation Reduce perception of barriers/ Increase self-efficacy

“Pick a better snack” posters Mediator of Behavior Change

Barriers/selfefficacy (decreased perception of barriers)

Objective People who examine these posters/ bill boards will have increased confidence in their ability to incorporate fruits and vegetables throughout the day.

http://www.idph.state.ia.us/pickabettersnack/

Reducing barriers /enhancing self-efficacy

Pick a better snackTM

Pick a better snack

Chapter 4

Conceptual Framework Linking Behavioral Theory And Nutrition Education Inputs/ Resources

Outputs: Theory-Based Intervention

Strategies directed at mediators of food choice and diet-related action

People Time

Motivational mediators

Materials

- Risks, concerns

Money

- Benefits, barriers

Space

- Attitudes

Partners

- Food preferences

Needs assessment process:

- Self-efficacy - Social norms

Intervention Activities

Action mediators

Conduct classes;

- Action plans

Facilitate groups;

- Knowledge - Food skills

Develop products, resources;

- Selfregulation skills

Work with families;

- Personal agency

Work with community partners;

Environmental Supports - Interpersonal: social support - Institutional/ community actions

Outcomes

Work with media; Work with policy makers

Food system impacts

Food behaviors/ practices Fruits & vegetables Calcium rich foods Resource management. etc

Improved health Decreased disease risk Decreased food insecurity

Societal impacts

- Policies, systems, food environment

Contento, 2000

Strategies to facilitate action

Action plans: Setting goals for behavior or collective action

Goal-setting/ action plans are powerful because they bridge the intention-to-action gap

Cooking and Eating for Health Project Mediator of Behavior Change

Action plans: self-regulation skills

Objective Women who set specific and measurable action plans and monitor their progress will make changes to eat a macrobiotic-style wholefoods diet

Learning to set action plans

Courtesy of Rosenthal Center for Complementary and Alternative Medicine, Columbia University

Choice, Control & Change (C3) Mediator of Behavior Change

Goal-setting: self-regulation skills

Objective Students will be able to select a goal to work on, monitor progress, and demonstrate competence in eating and walking

By collecting and analyzing personal food and activity data…

• Selfassessment compared to a standard

Goal Setting

Create a contract, pledge or action plan

Create a contract, pledge or action plan

Create a contract, pledge or action plan

Strategies to facilitate action

Learning food and nutrition skills

Eating Your Colors Mediator of Behavior Change

Food and nutrition skills (how-to knowledge)

Objective Students who complete the session will be able to identify F&V of different colors and state how much they should eat each day.

Food and nutrition knowledge and skills

Eating Your Colors Mediator of Behavior Change

Food and nutrition skills (skills building)

Objective Students who complete the session will be able to prepare a fruit salad with fruits of different colors.

Food preparation skills

Families learning cooking skills

Learning to cook healthy at a WIC program

Courtesy of FoodChange

Sequencing strategies Sequenced events of instruction

Description

Excite: Gain attention Attention getter: self-assessment, health benefit or threat Explain: Present stimulus or new material

Tailor messages to audience’s prior knowledge & values, make the message personally meaningful. “What’s in it for me?” (why-to take action) Demonstrate effectiveness of taking action Make the desired action easy to do

Expand: Provide guidance and practice

Provide how-to information; use credible social models. Provide authentic practice and feedback

Exit: Apply and close

Provide opportunities for participants to determine how they will use what they learn. Action plans, goal contracts, group commitments

Conceptual Framework Linking Behavioral Theory And Nutrition Education Inputs/ Resources

Outputs: Theory-Based Intervention

Strategies directed at mediators of food choice and diet-related action

People Time Materials Money Space Partners Needs assessment process:

Motivational phase mediators - Risks, concerns - Benefits, barriers - Attitudes - Food preferences - Self-efficacy

Action phase mediators - Action plans - Knowledge - Food skills - Selfregulation skills - Personal agency

- Social norms

Environmental Supports - Interpersonal: social support - Institutional/ community actions - Policies, systems, food environment

Outcomes

Intervention Activities

Food system impacts

Conduct classes; Facilitate groups; Develop products, resources; Work with families; Work with institutions & community partners; Work with media;

Food behaviors/ practices Fruits & vegetables Calcium rich foods Resource management. etc

Improved health Decreased disease risk Decreased food insecurity

Societal impacts

Work with policy makers

Contento, 2000

School lunches: from this….

School lunches: to this….

School food service can provide an opportunity for children to taste and enjoy new vegetables

Courtesy of Cookshop, Food Bank for New York City

Environmental supports for action Environmental intervention: grocery stores • Shelf labeling

• Coupons for F&V • Recipes

Grocery stores

Courtesy of Pick a better snackTM

Pick a better snackTM

Conceptual Framework for Theory-Based Nutrition Education: A Logic Model Inputs/ Resources

Outputs: Theory-Based Intervention

Strategies directed at mediators of food choice and diet-related action

People Time Materials Money Space Partners Needs assessment process:

Motivational phase mediators - Risks, concerns - Benefits, barriers - Attitudes - Food preferences - Self-efficacy

Action phase mediators - Action plans - Knowledge - Food skills - Selfregulation skills - Personal agency

- Social norms

Environmental Supports - Interpersonal: social support - Institutional/ community actions - Policies, systems, food environment

Outcomes

Intervention Activities

Food system impacts

Conduct classes; Facilitate groups; Develop products, resources; Work with families; Work with institutions & community partners; Work with media;

Food behaviors/ practices Fruits & vegetables Calcium rich foods Resource management. etc

Improved health Decreased disease risk Decreased food insecurity

Societal impacts

Work with policy makers

Contento, 2002

Planning Nutrition Education: Program Components Inputs/ Resources

Outputs: Theory-Based Intervention Designing the intervention

Design products

Classroom Component Nutrition educators Space Materials Money Partners: teachers, principal,s chool food service, wellness policy council Issue/ needs analysis process

Behavioral goals: • Increase fruits & vegetables • Decrease sweet drinks • Decrease packaged snacks • Increase physical activity

Mediators addressed: -Risk perception -Benefits, -Preferences -Self-efficacy -Knowledge & skills -Self-regulation skills -Personal agency

Teacher lesson plans for XX sessions Student activities & worksheets

Family Component Behavioral goals: • Make fruits & vegetables more available to children • Decrease purchase of sweet drinks & packaged snacks • Engage in physical activity with children

Strategies directed at mediators -Risk perception -Benefits, -Preferences -Self-efficacy -Knowledge & skills -Action plans

Environmental Supports - School meals, school wide food policies - Social support, information environment

Family lesson plans for YY workshops; ZZ newsletters

Staff manual, policies, speakers, posters, newsletters

Student Outcomes

Short term:

Medium term:

Motivational mediators

Behaviors

-Risks, -Beliefs -Attitudes -Food preferences -Self-efficacy Action mediators -Knowledge -Food skills -Goal setting skills

• Increased fruits & vegetables • Decreased sweet drinks • Decreased packaged snacks • Increased physical activity

Long term: • Continued healthful practices • Improved health • Contributes to energy balance • Contributes to healthy body weight

Comprehensive approach  Individual-level activities Why to take action; How-to take action

 Environment /policy activities Both are needed

Stepwise Procedure for Planning Theory-Based Nutrition Education

Issues / concerns

1 or a few related major issue(s)

Behaviors

Clearly defined behaviors for audience

Step 2

Determinants / mediators

Mediators specific for behaviors for given audience

Step 3

Theory

Theory model based on evidence for behavior for given audience

Step 4

Objectives

Clearly stated objectives for mediators

Step 5

Activities/ Procedures

Specific activities/ procedures for mediators

Step 6

Evaluation

Plan evaluation for mediators & outcomes

Step 1

Inputs

Outputs

Outcomes

Step 1

Step 6: Planning the Evaluation

• Evaluating impact on health outcomes;

behaviors; determinants/ mediators

Why evaluate? • Determine if it achieved stated goals & objectives • Judge whether it contributed to larger goals such as improved well-being • Determine whether educational strategies & activities were appropriate • Determine whether program was implemented as planned • Provide feedback to intended audience

Logic Framework for Evaluating Theory-Based Nutrition Education Inputs/ Resources

Outputs: Theory-Based Intervention Strategies directed at mediators of food choice and diet-related action

People Time Materials Money Space Partners Needs assessment process

Motivational mediators • Risks, concerns • Perceived benefits, • Perceived barriers • Self-efficacy

Action mediators • Action plans • Knowledge • Food skills • Selfregulation skills • Personal agency

Environmental Supports • Institutional/ community actions • Food environment • Policies, systems

Short-term

Outcomes Medium-term

Long-term

Motivators Intervention Activities Conduct classes; Facilitate groups; Develop products, resources; Work with families;

• Risks, concerns • Benefits, barriers • Food preferences • Self-efficacy

Action mediators

Work with community partners;

• Knowledge • Food skills • Goal setting skills

Work with media;

Environment al

Work with policy makers

supports • Social structures • Environment • Policies

Food system impacts

Food behaviors/ practices Fruits & vegetables Calcium rich foods Resource management. etc

Biochemical risk status: •Bone markers, •Serum cholesterol

Improved health; Decreased disease risk Decreased food insecurity

Societal impacts

Linking outcomes, indicators and measures

Outcomes

Health/ Other Behaviors Psycho-social determinants/m ediators

Indicators of achievement of outcomes

Measures/ instruments for indicators

Linking outcomes, indicators and measures Health outcomes Heart disease risk Obesity

Indicators of achievement of outcomes

Measures/ instruments for indicators

Serum cholesterol Finger prick or via blood draw and lab analysis Reduced Heights & prevalence of weights BMI