Volume 36 Number 6
|
December 1998 Volume 36 Number 6 |
|
|
Editor's PageDear Reader, With this issue of the Journal of Extension, it can be said that the "pioneer era" of the electronic journal has come to a close. Beginning with the February 1999 issue, the Journal will be completely Web-based. But, even more importantly, some of the key people in the transition from hard copy to electronic delivery are also ending their service to the Extension System as members of the Journal's board of directors. Judith Jones of Virginia Tech, has completed her duties as a member of the board and she, and her memory, will be missed greatly. Dr. Jones made the original motion to move the Journal to an electronically-produced publication. She and her colleagues at Virginia Tech than provided leadership in making the move. The Journal's server was located in Blacksburg, Mike Lambur became editor, and the technology support staff became important players. For the last few years, Patrick Robinson of Virginia Tech has provided leadership from the technology side. Robinson will no longer be involved after this issue. The folks at Ohio State will now maintain the server and be the technological support people. As editor, I owe a huge debt to both Judith Jones and Patrick Robinson. Dr. Jones has been tremendously supportive. Robinson has been a patient teacher about how to use the technology. I will miss them both. Now, it's Ohio State that will be providing leadership into this new phase of the electronic Journal of Extension. Tom Archer, of Shelby County, is the new president of the board of directors. Jim Lemon and his shop on the Columbus campus will be maintaining the server and giving technical support. All are great people with whom to work. And so, it's a tip of the hat to those who made the change possible and a salute to the new leadership who are poised to the take the Journal into the next century. In the meantime, I wish all our readers the best of all possible worlds in the 1999. Len Calvert, editor
Extension Journal, Inc.Extension Journal, Inc. is a quasi-official body of the National Association of State Universities and Land-Grant Colleges and the Extension Committee on Organization and Policy (ECOP). It is a nonprofit corporation organized for the purpose of publishing a journal for professional Extension staff, adult educators, and community developers. Board of Directors: Michael Lambur, President, Virginia, member-at-large Ex-officio: Leonard Calvert, Oregon, Editor Editorial Committee: Joyce Alves, University of Arizona
What is Extension's Itinerary for Information Superhighway Travel?Joseph L. Donaldson
There's something strange about this college gig I'm into now. First of all, I've been in college seven years. Learning has become a merry-go-round and I just can't seem to get my footing right to hop off. My current gig is information technology in the agricultural sciences. How should colleges of agriculture respond to all this technology stuff? It's an interesting question. But I just keep coming up with more intriguing questions. How can farmers benefit from information technology? What about rural communities? Do college students learn more when they use the Web? So the merry-go-round keeps going faster and faster. I've often thought about what I would be doing if I hadn't gone to college. Because about 15-20% of the graduates from my high school go to college, it's common for us college-bound seniors to have a back-up plan. I still remember mine - to work in one of the local apparel factories. At the time, I thought it could be the perfect job for a guy with a high school diploma. But I made this plan before NAFTA and the relocation of the apparel industry to our Central and Latin American neighbors. Just two years ago, Osh Kosh B'Gosh closed four factories in my tiny county alone, Clay County, Tennessee (7,000 residents). One in every three adults was unemployed. So times have been tough for those people - and would have been for me, too, had I not gotten on the college merry-go-round. Yet I can't help but wonder about my life if I had taken another direction. The best I can visualize, I'd be raising hogs and chickens and growing tobacco and vegetables on the family spread. Of course, life would be much simpler and much more difficult at the same time. There's an uncertainty to farming; being at the mercy of the weather is riskier than betting against Bill Gates' takeover of the world. So like all farmers I know, I'd be looking for information to reduce my uncertainty. I'd need to know about black shank, the AIDS-epidemic of a tobacco field...poultry nutrition...brucellosis and other bacterial swine diseases...vegetable marketing. I couldn't exactly depend on the radio for much help. You see, people who know about radio and radio marketing aren't too excited about opening a radio station in such a small county. After all, radio stations can't sell ads if there are hardly any businesses to buy 'em. And the station that's 45 miles away which carries a farm news report has weak reception in our area. Then there are the big Nashville country radio stations - I can tune them in perfectly. But, since they started describing country music as "hot," "new," and "progressive," they no longer carry farm reports. I could turn to other information sources. Other tobacco farmers, for one. But there are not many of them left since the government started an all-out assault on tobacco companies. The companies are buying cheap foreign tobacco to save enough money to pay legal bills. And of all the other information sources - farm magazines, newspapers, bulletins, salespersons - none would fascinate me like the World Wide Web. Everybody's carried away with it. Everybody's telling you to "visit" them on their Website. On a trip to town to pick up a thingamajig to fix the tractor, I might stop by the local library to take a spin on the information superhighway. Give it a try - see how I can prevent black shank from killing my profits this year like it did last. Being an industrious and observant farmer, I'd click on a search icon. Then I'd type T-O-B-A-C-C-O and be dazzled by the number of sites available on the subject. I'd have information from the National Kill-The-President's-Tobacco-Tax Coalition, The National Smokers Federation, and other sites far removed from the tobacco field and my problems. I would be vexed at all the flashing advertisements and useless trivia. (I know this for sure because I still remember what it felt like to explore the Web for the first time.) So, confused, frustrated, and with a resolve never to waste time on such a useless thing again, I'd head back to the farm. Of course, I'd still need to know about black shank, the AIDS- epidemic of a tobacco field...poultry nutrition...brucellosis and other bacterial swine diseases...vegetable marketing. And I'd probably call the county Extension agent for help. But then again, the county agent's probably at a meeting at the university, learning how to create a Web page. The points I'm making: (1) Let's not be so caught up in Web novelty that we forget that methods and media are to reach and teach. I'm reminded of how teachers once delivered lessons full of spontaneity and energy as they drew and outlined and illustrated on the chalkboard. But all of that was before teachers decided they should use their new overhead projector because, as we all know, it would make for more educated students. Except now practically all teachers who use the noisy, distracting overhead do so with the same prefabricated transparencies year-after-year. (2) Before we set our sites and dedicate our educational efforts to information superhighway travel, we've got to commit ourselves to taking people with us on that journey. Perhaps Extension futurists of the 1950s envisioned most of their educational programs delivered via television. And look what happened to the once-promising tube. Television has become a wasteland where the ills of society (dysfunctional families, brawls, adultery, not to mention the talk show fascination with topics like bisexual love triangles) are given a showplace. Of course, one can often find a thought-provoking piece on Public Broadcasting. But, Julia Child, Charlie Rose, and Jim Lehrer do not exactly share the information that has the potential to positively change lives like most Extension topics: parenting, technical skills in agriculture, decision-making, and other skills for daily living. But back to the Web. I see Extension specialists delivering timely information to agents through the Web. Newsletters that would once have taken two weeks to draft, copy, fold, and mail are now delivered instantaneously. I'm just not convinced that timely delivery alone will allow us to help those most in need. I think we need to be leaders in helping people access and use technology for their own benefit. Some experts have told me that the crux of this debate about technology and what society does with it (a debate which I think Extension ought to be having) will not be about access but rather literacy. These experts contend that "WebTV" technology will allow inexpensive World Wide Web access through any television set, and that the real social issue will be technology literacy, teaching people to understand and use "WebTV" for educational purposes. Regardless, I think Extension can play an important role. (3) For these and other reasons, we who are Extension educators must become Web leaders of adult education and information delivery. People have to see and use their Web browsers for timely, relevant, research-based information/education to believe they can. Yet, with all the "Web presence" now enjoyed by state Extension organizations around the country, we are not leaders at all. We are part of the blind majority using technology to widen the already deep chasm between the rich and the poor. We need to answer pressing questions:
The answers to these questions should provide Extension with the direction it needs to chart a course for information superhighway travel. Otherwise, we will leave too many people behind on that journey. Let's be pioneers - and leaders - in this information age. Realizing that, before we can be pioneers or leaders, we must be explorers. I contend that Extension is currently exploring the information superhighway without an itinerary, or at best, an ill-constructed one.
The First Fifty Years of the 4-H Program
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Intervention | ||||||
| Pre-test(n=79) | 3.3 | 0.0a | 41.4 | 1.1 | 3.3 | 0.0 |
| Post-test(n=77) | 3.6 | 0.0*** | 65.1 | 1.4*** | 3.3 | 0.1 |
| Follow-up | ||||||
| <2 yr (n=18) | 3.5 | 0.1*** | 59.1 | 2.9*** | 3.2 | 0.1 |
| 2-3 yr (n=46) | 3.6 | 0.0*** | 60.4 | 1.8*** | 3.3 | 0.1 |
| 3+ yr (n=37) | 3.6 | 0.1*** | 63.5 | 2.1*** | 3.3 | 0.1 |
| a: Least square mean SEM. ***p<.001 | ||||||
Dietary Intake
Participants' dietary intake is described in Table 2. Total kilocalorie intake increased significantly from the intervention to the follow-up of three or more years (p<.001). Percent of total kilocalories as fat was significantly lower than the intervention (mean SEM : 351) in the follow-up up to two years (301), in the follow-up two to three years (311), and the follow- up three or more years (271). Percent of kilocalories from saturated fat, polyunsaturated fat, and monounsaturated fat all decreased significantly from the intervention to the follow-up of three or more years only. Dietary cholesterol (mg) decreased significantly from the intervention (27611) to the three follow- up groups (19821, 21113 and 17518, respectively). Fiber increased significantly from the intervention in the follow-up of up to two years (p<.01) and the follow-up of two to three years (p<.001). Fiber intake was not significantly different from baseline in the follow-up of three or more years since program completion.
Table 2
Dietary intake at the start of the Healthy Heart Program, compared to the follow-up groups.
Follow-up groups
Baseline(n=63) <2 yr(n=28) 2-3 yr(n=60) 3+ yr(n=36)
| Total kcal | 1702 | 62a | 1624 | 120 | 1682 | 74 | 1979 | 104* |
| %kcal fat | 35 | 1 | 30 | 1** | 31 | 1** | 27 | 1*** |
| %sat fat | 12 | 0.5 | 11 | 1 | 11 | 0.5 | 10 | 1* |
| %polyunsat fat | 7 | 0.5 | 6 | 1 | 6 | 0.5 | 5 | 0.5** |
| %mononunsat fat | 14 | 0.5 | 13 | 1 | 13 | 0.5 | 9 | 1*** |
| Cholesterol (mg) | 276 | 11 | 198 | 21** | 211 | 13*** | 175 | 18*** |
| Sodium (mg) | 2553 | 88 | 2337 | 169 | 2357 | 104 | 2175 | 146* |
| Fiber (g) | 20 | 4 | 48 | 9** | 47 | 5*** | 23 | 7 |
| a: Least square mean SEM. *p<.05, **p<.01, ***p<.001 | ||||||||
Physiological Measurements
As illustrated in Table 3, blood cholesterol (mmol/L) decreased significantly (p<.05) from baseline (6.000.10) to the follow-up of three or more years (5.500.15), but did not change from baseline to the follow-up of up to two years (6.050.10) or the follow-up of two to three years (5.800.10). HDL cholesterol did not differ significantly between baseline and follow-up. Blood triglycerides also did not change from baseline to follow- up. LDL cholesterol (mmol/L) decreased significantly (p<.001) from baseline (4.250.15) to the follow-up of two to three years (3.550.10) and the follow-up of three or more years (3.150.15), although there was no change from baseline to the follow-up of up to two years (4.05 0.15). Risk ratio was calculated from serum total cholesterol divided by HDL cholesterol, both in mg/dL. Risk ratio is reported this way for more accuracy since changing to mmol/L required rounding the values for serum total cholesterol and HDL. Risk ratio decreased significantly (p<.001) from baseline (5.230.21) to the follow-up of two to three years (220.16) and the follow-up of three or more years (3.840.24), but not to the follow-up of up to two years (5.070.26).
Systolic blood pressure also decreased significantly from baseline to the follow-up of two to three years (p<.001) and to the follow-up group of three or more years (p<.01). Diastolic blood pressure decrease significantly from baseline to the follow -up of up to two years (p<.05) and the follow-up of two to three years (p<.01), but not to the follow-up of three or more years. Body weight did not differ significantly between the intervention and the follow-up of up to two years, but did decrease significantly (p<.01) from the intervention to the follow-ups of two years or more.
Table 3
Physiological measurements at the start of Healthy Heart Program, compared to follow-up groups
Follow-up groups
Baseline(n=63) <2 yr(n=29) 2-3 yr(n=59) 3+yr(n=37)
| Cholesterol (mmol/L) |
6.00 | 0.10ab | 6.05 | 0.10 | 5.80 | 0.10 | 5.50 | 0.15* |
| HDL (mmol/L) |
1.40 | 0.05b | 1.30 | 0.05 | 1.40 | 0.05 | 1.35 | 0.05 |
| Triglycerides (mmol/L) |
1.45 | 0.05c | 1.55 | 0.10 | 1.55 | 0.10 | 1.50 | 0.10 |
| LDL (mmol/L) |
4.25 | 0.15b | 4.05 | 0.15 | 3.55 | 0.10*** | 3.15 | 0.15*** |
| Risk ratio (Chol/HDL) |
5.32 | 0.21 | 5.07 | 0.26 | 4.22 | 0.16*** | 3.84 | 0.24*** |
| Systolic BP (mmHg) |
138 | 2 | 132 | 3 | 126 | 2*** | 130 | 2*** |
| Diastolic BP (mmHg) |
78 | 1 | 74 | 1* | 74 | 1** | 78 | 1 |
| Body weight (kg) |
75 | 1 | 74 | 1 | 73 | 1** | 72 | 1** |
| a: Least square mean SEM. | ||||||||
| b: (Total cholesterol, HDL, LDL) mmol/L 0.02586 = mg/dL). | ||||||||
| c: (Triglycerides) mmol/L 0.01129 = mg/dL. | ||||||||
Discussion
The long-term effectiveness of the Healthy Heart Program was determined using changes in participant knowledge, attitude, and standard locus of control. Assessments included intervention pre- and post-tests and follow-up tests. Changes in participant behavior were noted using dietary and physiological measures. The Healthy Heart Program had a positive effect on participant behavior, similar to that found in the Stanford Five-City Project (Young, et al., 1996).
The attitude scores from the Healthy Heart Program increased from the intervention pre-test, to the intervention post-test, and the follow-up tests. In a survey of 606 cardiac patients in New England, Southern California and the Midwest, the attitude of the majority of the patients was one of belief that diet is very important in the treatment and prevention of heart disease, yet the average knowledge score on a nutrition quiz was less than 50%, a score that would be expected from just chance guessing (Plous, Chesne, & McDowell, 1995). The average intervention pre- test knowledge score for the Healthy Heart Program participants was also less than 50%, but after the Healthy Heart Program, mean intervention post-test and follow-up knowledge scores were above 59%. Participants retained the knowledge they had gained after the Healthy Heart Program.
Unfortunately, as with the Stanford study, the Healthy Heart Program did not show any significant treatment effect to increase self-efficacy, or locus of control, similar concepts relating to a person's belief about his/her ability to control or change his/her life (Young, Haskell, Taylor, & Fortmann, 1996). On the other hand, the participants' locus of control scores did not decrease either. The mean age of the Healthy Heart Program participants was considerably lower than a larger study of older persons whose locus of control decreased as they aged (Goldsteen, Counte, & Goldsteen, 1995).
The mean locus of control score for the participants in the Healthy Heart Program was already quite high at the start of the intervention so that significant increases over the course of the intervention and follow-up assessments may not be realistic. The fact that the participants enrolled in the Healthy Heart Program suggests that they felt they had some control over their health outcomes.
Many of the dietary changes in the Healthy Heart Program participants were positively directed toward lower heart disease risk. Many reports and studies point to the importance of dietary intervention in reducing the risks of CHD (Baer, 1993; Expert Panel, 1993; Fortmann, Taylor, Flora, & Winkleby, 1993; Gambera, Schneeman, & Davis, 1995; Geil, Anderson, & Gustafson, 1995; Oyster & Thompson, 1996; Posner, Cupples, Gagnon, & Wilson, 1993; Posner, et al., 1995; USDHHS, 1990).
As noted in the results, the participants experienced many healthy changes in line with recommendations by the Dietary Guidelines for Americans, the NCEP, and Healthy People 2000 (Expert Panel, 1993; Kennedy, Meyers, & Layden, 1996; USDHHS, 1990). Some explanation for the high mean values for fiber intake in the follow-ups of up to three years may spring from the "oat bran craze" taking place in the late 80s and early 90s. Many of the participants reported eating oatmeal and oat bran in their food record in these follow-up groups. It may be possible that the "oat bran craze" had started to fade by the follow-up of three or more years since program completion when the fiber intakes returned closer to baseline again.
At the start of the intervention and in all of the follow-up groups, serum total cholesterol fell in the borderline-high range of 5.2 to 6.2 mmol/L as identified by the NCEP (Expert Panel, 1993) and was significantly lower than the intervention in the follow-up of three or more years. Although the Healthy Heart participants HDL cholesterol did not change significantly from baseline to the follow-ups, HDL cholesterol values were above 0.9 mmol/L, the level at or above which the NCEP does not consider a risk factor for CHD (Expert Panel, 1993). In fact, HDL cholesterol levels were closer to 1.6 mmol/L, which is considered to be a negative risk factor for CHD by the NCEP (Expert Panel, 1993).
The Pawtucket Heart Health Program, a community-based educational program in Rhode Island, did not result in any significant changes in blood pressure over an eight-to-nine year period (Carleton et al, 1995). The Healthy Heart Program evaluation did result in significant changes in blood pressure over the course of the follow-up assessments. There was a significant decline in systolic blood pressure from the intervention to the follow-ups of two or more years and a significant decline in diastolic blood pressure from the intervention to the follow-ups of up to three years. Mean blood pressure never exceeded 140/90 mm Hg for the intervention or the follow-ups, the level at or above which the NCEP identifies as hypertension (Expert Panel, 1993).
Data from the Framingham Heart Study and the National Health and Nutrition Examination Survey II suggested that a 2 mm Hg reduction in diastolic blood pressure could result in a 6% decrease in risk for CHD (Cook, Cohen, Herbert, Taylor, & Hennekens, 1995). In the follow-ups of up to three years, there was about a 4 mm Hg drop in diastolic blood pressure from the intervention. The Healthy Heart Program participants lost weight and decreased their sodium intake over the course of the follow- up assessments. These favorable lifestyle changes may have contributed to the decreases in blood pressure in the follow-up groups (Cutler, 1995; Herbert, et al., 1995).
Despite such favorable results from this evaluation of the Healthy Heart Program, it would be too optimistic not to point out one obvious and important limitation of the study. There was no control group. Using each subject as his/her own control was one possibility, but this would have less statistical power than group data. Previous studies of the Health Heart Program could possibly serve as comparisons for the present evaluation, but these studies were earlier and would not reflect the secular trends which took place during the present study (Anderson & Gunn, 1981; Lopez & Anderson, 1991). Results of the Minnesota Heart Health study and others suggest that secular trends may have had an impact on the Healthy Heart Program participants (Fortmann et al., 1993; Giles, et al., 1993; Luepker et al, 1994; Murray, 1995; Posner et al., 1995).
Application
Findings from this evaluation provide evidence that small, community-based group nutrition education programs may reduce CHD risks through positive changes in participants' attitudes, knowledge and behaviors and that those changes may be maintained over time. The apparent long-term effectiveness of this program clearly supports the pivotal role of Extension agents in teaching in the community and in working with health professionals, such as dietitians, to delivery quality education that can truly make a difference.
References
American Dietetic Association. (1992). Chicago: American Dietetic Association Clinical Nutrition Manual.
American Heart Association. (1994). Dallas, TX: Heart and stroke facts: 1994 Statistical Supplement.
American Heart Association of Colorado. (1996). Denver: Cholesterol Ratio and Risk Factors and Coronary Heart Disease.
Anderson, J. & Gunn, S. (1981). The Healthy Heart program: A delivery model for rural areas. Rural Health, 7, 12-17.
Baer, J. T. (1993). Improved plasma cholesterol levels in men after a nutrition education program at the worksite. Journal of the American Dietetic Association, 93, 658-663.
Brownson, R. C., Smith, C. A., Pratt, M., Mack, N. E., Jackson-Thomas, J., Dean, C. G., Dabney, S., & Wilkerson, J. C. (1996). Preventing cardiovascular disease through community- based risk reduction: The bootheel heart health project. American Journal of Public Health, 86, 206-213.
Carleton, R. A., Lasater, T. M., Assaf, A. R., Feldman, H. A., & McKinlay, S., (Pawtucket Heart Health Program Writing Group) (1995). The Pawtucket Heart Health Program: Community changes in cardiovascular risk factors and projected disease risk. American Journal of Public Health, 85, 777-785.
Cook, N. R., Cohen, J., Herbert, P. R., Taylor, J. O., & Hennekens, C. H. (1995). Implications of small reductions in diastolic blood pressure for primary prevention. Archives of Internal Medicine, 155, 701-709.
Croft, J. B., Temple, S. P., Lankenau, B., Heath, G. W., Macera, C. A., Eaker, E. D., & Wheeler, F. C. (1994). Community intervention and trends in dietary fat consumption among Black and White adults. Journal of the American Dietetic Association, 94, 1284-1290.
Cutler, J. A. (1995). Progress in life-style intervention for prevention and treatment of high blood pressure. Annals of Epidemiology, 5, 165-167.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (1993). Summary of the second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). Journal of the American Medical Association, 269, 3015-3023.
Farquhar, J. W., Fortmann, S. P., & Maccoby N. (1990). Effects of community-wide education on cardiovascular disease risk factors: The Stanford Five-City Project. Journal of the American Medical Association, 246, 359-365.
Fortmann, S. P., Taylor, C. B., Flora, J. A., & Winkleby, M. A. (1993). Effects of community health education on plasma cholesterol levels and diet: The Stanford Five-City Project. American Journal of Epidemiology, 137, 1039-1055.
Gambera, P. J., Schneeman, B. O., & Davis, P. A. (1995). Use of the Food Guide Pyramid and US Dietary Guidelines to improve dietary intake and reduce cardiovascular risk in active- duty Air Force members. Journal of the American Dietetic Association, 95, 1268-1273.
Geil, P. B., Anderson, J. W., & Gustafson, N.J. (1995). Women and men with hypercholesterolemia respond similarly to an American Heart Association step 1 diet. Journal of the American Dietetic Association, 95, 436-441.
Giles, W. H., Anda, R. F., Jones, D. H., Serdula, M. K., Merritt, R. K., & DeStefano, F. (1993). Recent trends in the identification and treatment of high blood cholesterol by physicians. Journal of the American Medical Association, 269, 1133-1138.
Goldsteen, R. L., Counte, M. A., & Goldsteen, K. (1995). Health status, the health events of significant others, and health locus of control. Journal of Aging Studies, 9, 83-99.
Herbert, P.R., Bolt, R.J., Borhani, N.O., Cook, N.R., Cohen, J.D., Cutler, J.A., Hollis, J.F., Kuller, L.H., Lasser, N.L., Oberman, A., Miller, S.T., Morris, C., Whelton, R.K., & Hennekens, C.H. (1995). Design of a multicenter trial to evaluate long-term life-style intervention in adults with high- normal blood pressure levels: Trials of Hypertension Prevention (Phase II). Annals of Epidemiology, 5, 130-139.
Hunink, M. G. M., Goldman, L., Tosteson, A.N.A., Mittleman, M. A., Goldman, P. A., Williams, L. W., Tsevat, J., & Weinstein, M. C. (1997). The recent decline in mortality from coronary heart disease, 1980-1990. Journal of the American Medical Association, 277, 535-542.
Kennedy, E., Meyers, L., & Layden, W. (1996). The 1995 Dietary Guidelines for Americans: An overview. Journal of the American Dietetic Association, 96, 234-237.
Lopez, L. M., & Anderson, J. E. L. (1991). Worksite nutrition program can alter dietary attitudes about heart disease. Occupational Health and Safety, 60, 60-63.
Luepker, R. V., Murray, D. M., Jacobs, D.R., Mittelmark, M. B., Bracht, N., Carlaw, R., Crow, R., Elmer, P., Finnegan, J., Folsom, A. R., Grimm, R., Hannan, P. J., Jeffrey, R., Lando, H., McGovern, P., Mullis, R., Perry, C. L., Pechacek, T., Pirie, P., Sprafka, J. M., Weisbrod, R., & Blackburn H. (1994). Community education for cardiovascular disease prevention: Risk factor changes in the Minnesota Heart Health Program. American Journal of Public Health, 84, 1383-1393.
Murray, D. M. (1995). Design and analysis of community trials: Lessons from the Minnesota Heart Health Program. American Journal of Epidemiology, 569-575.
Nutrifit Computer Program (1980, rev. 1994). Fort Collins: Colorado State University Cooperative Extension.
Oyster, G. & Thompson, D. (1996). Estimated effects of reducing dietary saturated fat intake on the incidence and costs of coronary heart disease in the United States. Journal of the American Dietetic Association, 96, 127-131.
Plous, S., Chesne, R. B., & McDowell, A. V. (1995). Nutrition knowledge and attitudes of cardiac patients. Journal of the American Dietetic Association, 95, 442-446.
Posner, B. M., Cupples, L. A,. Gagnon, D., Wilson, P. W. F., Chetwynd, K., & Felix, D. (1993). Healthy People 2000 - The rationale and potential efficacy of preventive nutrition in heart disease: The Framingham Offspring-Spouse Study. Archives of Internal Medicine, 153, 1549-1556.
Posner, B. M., Franz, M. M., Quatromoni, P. A., Gagnon, D. R., Sytkowski, P. A., D'Agostino, R. B., & Cupples, L. A. (1995). Secular trends in diet and risk factors for cardiovascular disease: The Framingham Study. Journal of the American Dietetic Association, 95, 171-179.
SAS Institute, Inc. (1989-92). Cary, NC: SAS 6.09 TS039.
Shea, S., Basch, C. E, Wechsler, H., & Lantigua, R. (1996). The Washington Heights-Inwood Healthy Heart Program: A 6-year report from a disadvantaged urban setting. American Journal of Public Health, 86, 166-171.
Stern, M. P., Farquhar, J. W., Maccoby, N., & Russell, S. H. (1976). Results of a two-year health education campaign on dietary behavior: The Stanford Three-Community Study. Circulation, 54, 826-832.
U.S Department of Health and Human Services (USDHHS). (1990). Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC, DHHS Publication (PHS) 91-50213.
U.S Department of Health and Human Services (USDHHS). (1996). Health United States 1995. Hyattsville, MD, DHHS Publication (PHS) 96-1232.
U.S Department of Health and Human Services (USDHHS). (1990). Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC, DHHS Publication (PHS) 91-50213.
Young, D. R., Haskell, W. L., Taylor, C. B., Fortmann, S. P. (1996). Effect of community health education on physical activity knowledge, attitudes, and behavior. American Journal of Epidemiology, 144, 264-274.
Scott Leavengood
Wood Products Extension Agent
Oregon State University Extension Service
Klamath Falls, Oregon
Internet address: scott.leavengood@orst.edu
Bob Love
Wood Products Extension Assistant
Oregon State University Extension Service
Corvallis, Oregon
Introduction and Background
Oregon State University's (OSU) wood products Extension program expanded in mid-1994 as part of an Oregon legislative package to deliver educational programs specific to the state's value-added wood products industry. In the preceding 18 years, OSU's wood products Extension program consisted of one campus- based specialist primarily serving large sawmills. Between July 1994 and April 1995, five new faculty were added. Two of the new faculty are campus-based specialists; the others are county agents with "area" (multi-county) assignments.
This discussion is presented from the perspective of two of the new agents to assist other Extension professionals develop and expand program areas. Also, in presenting successful approaches, the paper serves to remind readers of the time-tested methods of successful Extension programs.
First Steps and Findings
The first steps included: Identifying the audience to be served, determining their educational needs, and building awareness of the new program. Numerous industry directories were used for audience identification. Agents made personal visits to owners and managers of approximately 200 companies to introduce themselves, the new program, and to determine educational needs. A formal educational needs assessment of the Oregon wood products industry (Hansen & Smith, 1997) was conducted during the first year in order to obtain information to guide program development. The needs assessment was conducted via questionnaires mailed to 1,286 companies, every identified wood product manufacturer in the state.
It was soon recognized that enormous diversity (products produced, processes used, company size, level of technology, raw materials), results in equally diverse educational needs. Discussions during personal visits revealed several issues common to a broad cross-section of the industry. These issues included: (a)the need for reliable sources of raw material; (b) trained entry-level employees, and (c) industry's desire to educate the general public about the wood products industry.
The educational needs assessment of the Oregon wood products industry revealed several distinctly different needs. The top ten educational needs, in order of priority, were:
Trials - Initial Challenges
Serving the wood products industry via Extension agents is truly a "new product." As with all new products, several challenges were encountered. Though the list is long, please remember that challenges may also be viewed as opportunities not yet taken.
Industry diversity - To attract busy people to an educational program, the focus must be on solving a specific problem or building specific skills. For a diverse industry, this is a challenge. Very broad subject area programs have not been well attended. At the same time, focusing on a specific industry segment (furniture makers for example) in a specific region of the state, often leaves few companies to target for educational programs.
New clientele - Personal visits to manufacturers revealed that most industry personnel are unfamiliar with the Extension Service. Therefore, it is difficult for them to determine how to use Extension's services.
Numerous new assistance organizations - This challenge can be described as "alphabet soup" or "acronym overload." In just a few short years, numerous organizations have begun offering assistance to the wood products industry. In Oregon alone, the list includes:
Though all the organizations offer different specific services, industry personnel often seem frustrated and confused by the apparent lack of coordination among organizations and the deluge of needs assessment surveys. Many industry personnel feel the time to analyze the situation has come and gone; it is time for action.
New program, old expectations - Organizationally, Oregon State's wood products Extension program is a subset of the Forestry Extension program. Herein lies another challenge; a new program faced with old expectations. Extension foresters serve the educational needs of the state's small woodland owners and resource professionals. OSU's Extension Forestry program has been in existence for over 30 years and clientele are aware of and value the service provided by forestry specialists and agents. Unfortunately, small woodland owners and resource professionals often do not understand or care about the distinction between a "wood products agent" and a "forestry agent." Thus clientele have educational expectations and feel alienated if those expectations are not met. The objectives of a woodland owner and that of a wood products manufacturer are quite different. It is difficult finding mutual areas of professional concern between resource management and manufacturing assistance programs within Forestry Extension.
Disconnects in Research/ Extension faculty - This is a universal challenge for all Extension program areas. The objective is for field agents to bring research needs of their communities to the research faculty on campus. The research faculty conduct the research, and the Extension faculty disseminate the results back to the people who can put the information to work. However, research funding is often the missing link. Research is expensive and therefore what often appear to be simple projects cannot be researched due to prohibitively high expenses for most small- and medium-sized manufacturers.
Distance to the clientele - Oregon is a large state (tenth largest in the U.S., over 62 million acres) with rural populations needing help with economic development. Many clientele are located in sparsely populated areas where the economy is less developed than urban areas. When success of an outreach program is often gauged in terms of number of firms reached, serviced, or adapting technology, the temptation is to work in the more densely populated areas where the time-distance factors are more surmountable.
Trials - Tactics That Were Not Wildly Successful
It has been said that the seeds of success are sown in failure. The following experiences are presented as lessons learned so that others can better adapt programs to fill their needs. Remember, solutions were adapted as discussed in the "Triumphs- Successful Tactics" section, from other seemingly unrelated disciplines. The intent is to help build on successful programs and ideas already implemented. Because "failure" is a natural part of the learning process, it is difficult to separate what does not work without discussion of what does work. Please refer to "Triumphs- Successful Tactics" for more detailed discussion of solutions.
"Conversation without demonstration"- This approach can be summarized as introducing agents and program without describing what can be done to help a firm. It is important to realize that everyone is tuned to WIFM, "what's in it for me?," especially busy small-business managers. Because of the clientele's unfamiliarity with manufacturing Extension programs, it is important to have an attention-gathering introduction illustrating accomplishments and describing what can be done for the firm. With this fast-paced clientele, it is important to break the preoccupation barrier and initiate a dialogue to begin to understand the needs of each individual firm. Only then can needs be identified and solutions found. The experience with conversations without demonstrations is that they end ambiguously with comments like "the next time you stop by bring a load of lumber." People naturally want answers to pressing problems or dilemmas.
Lack of contacts - Once a dialog is started, the next bridge to cross is gaining understanding of the client's unique concerns. Lack of effective contacts to address those concerns quickly becomes the next obstacle. Each firm has unique concerns. It is impossible for any one person to have expert knowledge of each niche product firm. Once each firm's unique needs are determined, the needs can be linked to resources. It takes time to develop this type of knowledge and a "tool kit" of resources. However, it becomes easier as experience is gained. In some cases, the answers may never be found. Yet, in most of the cases "the more you know, the easier it is to know more" and effective linkages can be made.
General subject area workshops - Very broad subject area workshops such as "Wood Tech 101" attracted few attendees. Discussions with clientele revealed that most small- to medium- sized manufacturers are too busy to attend a workshop regardless of when it is held. To draw them away from the mill, the workshop must address a critical challenge they are experiencing. For the lesser-populated regions of the state, travel distance is also a significant barrier to workshop attendance. Also, for small- to medium-sized firms, shorter workshops tend to be more attractive than longer workshops because of the opportunity costs associated with the time away from production. The smaller the firm, the higher the proportional short-term opportunity costs to attend workshops.
Triumphs - Successful Tactics
While this lengthy list of challenges and approaches that have not worked is daunting, several tactics having positive impacts have been found after four years of experience. Admittedly, many of these tactics are simply a return to the roots of Extension, methods that have made Extension successful for decades.
Personal coaching - Busy people are most receptive to "just-in- time" learning because of the uniqueness, limited resources, and comprehensive nature of the manager's work. It can be beneficial for people in a firm to "get out of the box" by accessing an outside person for questions, finding a connection, or getting a different perspective. Because of the diversity of firms, it is often difficult to know specific answers. By using a coaching style, it is often possible to find answers by helping do the homework once the assignment is clear.
Please note that the analogy here is one of a coach rather than a teacher to help find the answers. Industry, particularly the wood products industry, is composed of very individualistic, entrepreneurial people. As a general rule they want to learn, yet like many, do not like to be taught. Creating a learning culture in an organization seems to work best using the indirect approach. Creating a learning culture may be fostered via existing publications, programs, or institutions.
Another tactic is to link firms with other firms to help solve the problem. The Extension agent serves to facilitate communication between a number of people. This technique yields a higher probability of identifying the problem and finding a solution than does direct assistance. Similar to a team approach, a member of one linking firm is more likely to see the root issue and perhaps someone else may know how to make improvements or fix the problem.
Database marketing - By constructing an accurate and current database of information, it is possible to review conversations and meeting notes. Database information helps with follow-up and helps agents refer people to appropriate sources. Databases can help screen information specific to one type of company. For example there is little use announcing a workshop on "Painting and Finishing" to a facility that does not produce a finished product. Using flexible database marketing means sending the announcement only to firms making a finished product.
Database marketing also enables linking of "sushi bars and bait shops." In manufacturing, one firm's by-product or excess capacity can be another's treasure. Picture vertically integrating a combination bait shop and sushi bar. It would be environmentally friendly, trendy, organic, and nothing would be wasted. Face it, making raw fish appealing to pocketbook and palate is an art form. The problem is we are not in the best position to understand customer needs. The entrepreneur has the best knowledge of risks, appeal to a niche market, how to make, package, and sell the product. However, by understanding the manufacturing process and maintaining an accurate and flexible database, surplus raw material or plant capacity can often be identified and agents can help facilitate these underutilized inputs to firms who can create value for the customer.
Specialty workshops - To be effective, workshop topics need to be specific and relevant for the clientele. Not only can they reach existing clients but they can be useful in identifying previously undetected firms. Examples of workshops that have received significant interest are pricing, new product development, finishing, Internet marketing, and discussions of alternative sources of raw material supply ("new" or under-utilized species). The common thread is that all tend to be modular in nature and can be presented in a relatively short time, certainly no longer than one day. It is known that conducting the workshops during the summer months is not favorable. However, the best time to do workshops (evenings, weekends, weekdays, Friday afternoon), is still not apparent.
Specialized programs - This is easiest to explain with an example. The Western Juniper (Juniperus occidentalis) Commercialization Project has increased exposure of OSU's new program and serves the needs of a broad range of clientele. Western juniper commercialization efforts serve the wood products industry by developing products and markets for an under-utilized species, and in the process, the agriculture industry benefits by the offset in range improvement costs (most Eastern Oregon ranchers consider western juniper to be a noxious weed). An agent assists by serving on the project's steering committee, by constructing and maintaining an accurate clientele database, and by distilling research and disseminating technical information. There are now over 800 individuals on the Western Juniper Newsletter mailing list compared to 150 individuals and organizations four years ago.
Pleasant persistence - This approach is analogous to drip irrigation. Like drip irrigation we are working with limited resources ("water") and can't simply saturate the market ("the field") in our outreach efforts. Services need to be presented to the clientele so that they can go back to the source of those outreach efforts once that pressing "just-in-time" piece of knowledge, information, or linkage is identified. Like starting a new business with a new product, our program is similar in that we need to sustain our efforts for the adequate response time to determine what works and does not, build credibility and relationships, and have the tenacity to allow time for an adequate response to be determined.
Distance learning - Relatively simple techniques such as publishing and distributing a very simple electronic newsletter or "e-zine" have been well received. Composed of short articles, alerting readers of resources and trends builds infrastructure as the industry evolves "on-line." Sent by e-mail, it does not require use of a Web browser and is a way to keep program efforts in the clientele's consciousness. It has opened up an avenue leading to questions, referrals, new clients, and forming discussion groups. It is low-cost and a way to leverage resources in reaching out to clientele, about half of which now have access to the Internet. New subscribers are added every day. Any subscriber who does not want the e-zine can be quickly removed, thereby keeping the "noise level" in check.
"Service, service, and more service" - Building a successful outreach program takes time and requires building the confidence and trust of industry personnel. Every effort has been made to go overboard to assist manufacturers when they ask for assistance. This may sound obvious; however like everyone else, agents get busy, and it is easy to hurriedly answer a request for assistance or refer clientele to someone else. However, making service a priority has resulted in continued contacts from clientele.
Partnerships - In the "Trials - Challenges" section, the problem of the initial lack of coordination among organizations serving the wood products industry was described. Over time, partnerships have been formed that have paid off in numerous ways. Some examples of the benefits include referrals for assistance, sponsorship of educational programs, assistance with advertising and delivery of educational programs, as well as increased confidence from industry as it sees the service organizations working together.
Summary and Conclusions
Expanding an outreach program requires patience as well as innovative and coordinated efforts. In the past four years in Oregon, several challenges have been faced resulting from the diversity of the industry, lack of familiarity with university outreach programs, and initial lack of coordination among service organizations. Several tactics have proved successful, including personal coaching, building partnerships, and providing a high level of service. These are tried and true Extension methods, revised to suit a new audience. Other methods, such as database marketing and distance learning are relative newcomers to Extension and are proving quite successful.
References
Hansen, E.N., & Smith, R. (1997). Assessing educational needs of the forest products industry in Oregon and Virginia, Forest Products Journal, 47(4),36-42
Marisa B. Warrix
Extension Agent, Family and Consumer Sciences
Internet address: warrix.1@osu.edu
Margarita Bocanegra
Educator, Expanded Food & Nutrition Education Program
Internet address: bocanegra.1@osu.edu
Ohio State University Extension
Cuyahoga County
Cleveland Heights, Ohio
Extension has served Hispanic clients in a variety of ways over the past 50 years. Subject matter areas include foods and nutrition (predominantly through the Expanded Food and Nutrition Education Program), youth development, and general agriculture and home economics (Brandsburg, 1991). Some states have developed curricula, translated materials, and hosted Spanish radio programs or created videotapes to better serve this clientele. The number of Hispanic staff varies from state to state, as does the extent of programming.
By the year 2000, Hispanics will outnumber African-Americans and become the "majority minority." This rapidly growing population has a high percentage of very young children and a relatively large number of women of childbearing age (Delgado 1980). Hispanic women have higher birth rates than African- American and Caucasian women.
While women's increased participation in the labor force has been well documented, Hispanic women have shown the most rapid gains since the 1980s (Cattan, 1988). Continuous increase in the number of Hispanic females in the work force will have a tremendous impact on child care services. More recently, the urgency to move women off the welfare role will impact child care services and create employment opportunities for Hispanic women as family child care providers.
Since 1989, over 500 Hispanic family day care providers have participated in training sponsored by Ohio State University Extension in Cleveland. The following article outlines critical factors for success in developing day care training workshops for Hispanics. These factors include understanding the importance of Hispanic culture, values, and attitudes; becoming familiar with personalism and familism; using day care as an employment strategy; increasing Hispanic involvement in Extension programming; and developing culturally relevant nutrition lessons. This article focuses on one Extension county's effort to develop educational programming that targets Hispanic women.
Background
In the late 1980s, Ohio Legislative Rep. Jane Campbell identified a critical need for formalized family day care provider training. She called upon Extension's Family and Consumer Sciences agents to take a leadership role in training. Ohio family day care providers have maintained their U.S. Department of Agriculture (USDA) food approval by mandatory participation in a nutrition class once a year. Sponsors recommended that providers seek additional training in first aid, business administration, record keeping, child abuse, communicable diseases, and child development. Extension agents were well trained to teach all of these subjects, or partner with others.
In Cuyahoga County, 57% of families currently send their children to family day care facilities (personal communication, March 15, 1997). Approximately 200 of the 2,000 women who provide care are Hispanic and the number is growing. For Hispanic providers in Cleveland culturally appropriate training conducted in Spanish had not been available in local communities. In the absence of such programs, Extension became involved.
One cultural factor that affects successful programming with Hispanic populations is the involvement of a committed bilingual staff member or volunteer who can provide ongoing communication and serve as a liaison to the Hispanic community. The county has an Expanded Food Nutrition Education Program (EFNEP) nutrition educator on staff with 24 years of experience in the Hispanic community. This nutrition educator is also employed part time with Ohio's largest USDA Family Day Care Food sponsor. Through EFNEP contacts, the nutrition educator has recruited many Hispanic women to become family day care providers.
In 1989, legislation passed requiring the USDA Food and Nutrition Service to test innovative approaches to removing or reducing barriers to participation in the Child Care and Adult Food Care Program (CACFP) regarding family and group day care operating in low-income neighborhoods (Kuchak, 1993). Barriers identified were culture, language, education, the cost of recruiting and retaining low-income providers, and obtaining certification or alternate approval.
The USDA selected the Ohio Hunger Task Force sponsor as a demonstration site to help overcome these barriers in two Cleveland neighborhoods. The East Side neighborhood goal was to develop a higher retention rate of existing providers. The near West Side of Cleveland largely consisted of Hispanics with a low participation rate in organized day care. The West Side project made identifying and recruiting new Hispanic providers its goal. A mentor program was developed to support providers, help them to adjust, and enable them to achieve retention. This demonstration project set the stage for the development of an organized and motivated group of women with whom Extension would work.
The Hispanic/Latino Culture
Another important factor in working with Hispanics is understanding and identifying the subgroup to be served. Hispanics represent a mix of historical and cultural backgrounds. Groups vary in socioeconomic status, culture, and language. The three largest groups are Mexican-American, Puerto Rican, and Cuban (Delgado, 1980). In Cleveland, the dominant Hispanic group is of Puerto Rican heritage. Puerto Ricans began arriving in Cleveland after World War II as farms and factories recruited them for jobs. It is important to realize that Puerto Rico is a commonwealth, which makes Puerto Ricans United States citizens.
Hispanic families often have value systems that are different from each other and from those of Anglo families (Arce & Torres-Matrullo, 1978; Castro, 1977). Adherence to traditional values and beliefs varies in degree. Even a modern Hispanic family differs considerably from today's average family. The traditional role of manhood and womanhood in Hispanic culture also plays a role in the success of training programs.
The Hispanic family is often patriarchal, with male heads of the house fulfilling a strong authoritarian role. Male dominance, known as "machismo," is a socially constructed, learned, and reinforced set of behaviors comprising the content of male gender roles in Latino society (De la Cancela, 1986). Many Hispanic males prefer that their wives stay home with the children. Becoming a family day care provider allows these women the opportunity to bring in some income for the family without compromising the male's role as the breadwinner, thus possibly helping to maintain the home's cultural harmony.
The importance of culture in child development is widely recognized in the human services field. The Hispanic family is the most important vehicle for the transmission of values and beliefs. Many child care programs have encountered difficulty in recruiting Hispanic children because of language differences and cultural factors (Delgado & Scott, 1979). Research emphasizes that successful childcare for Hispanic children should focus on private homes rather than institutions. Within the traditional Hispanic culture, the function of child care has remained in the family. Parents view Hispanic family day care providers as extended family members. Parents also feel more comfortable and can exercise more control (Delgado, 1980).
Personalism and familism are key values present in the Hispanic culture. Personalism refers to the faith in person-to- person contact. In other words, there is no substitute for "face- to-face" interaction. Educators need to "personalize" their programming to reach out to the community. Familism refers to the central position that a family holds in the life of the individual. All decisions by the individual are made with regard to the well-being of the family. As a result, sometimes parents tend to be overprotective of their children, thereby limiting their children's ability to "expand their horizons" (Marsiglia, 1990). Personalism and familism also play a very important role in family day care. Parents need the assurance that the day care provider understands the value of the person-to-person interaction with their children and that the parents themselves should be considered the central influence in the child's life.
Nutrition Component
Effective educational design must be appropriate. Nutrition education serves as an example. Each sub-group consumes similar foods with different names. For example, dried beans and rice are staples among most Hispanics. Puerto Ricans refer to legumes or beans as habichuelas, while Mexicans call them frijoles. Correct food terminology and pronunciations help educators to avoid mistakes when referring to cultural foods. Spanish Food Guide Pyramids are available containing both English/Hispanic foods translated into Spanish.
The following steps are involved in the culture's adaptation: First, have a knowledgeable staff member identify some specific cultural foods. Second, have the staff member accompany you to a Hispanic grocery store to help you to become familiar with the foods. Third, acknowledge these foods as part of the provider's diet during the lesson, and then teach the provider where the foods fit into the Food Guide Pyramid. For example, root vegetables, called viandas (i.e., yucca, yauta, ame, or malanga), are staples in a Puerto Rican diet.
The 5-a-Day program is an important nutrition lesson that can introduce providers to a wider variety of more nutrient-dense vegetables like dark leafy greens and broccoli. Children who participate in the day care program will benefit from the addition of new foods that will broaden their nutritional base. In addition, knowledge of produce alternatives will allow providers more options for grocery shopping and price comparison in relation to nutritional value and taste.
Cultural Barriers
Cultural barriers identifies included:
Ways to Increase Hispanic Involvement in Day Care Programming
Other Considerations in Conducting Programs for Hispanic Communities
Summary
Culturally sensitive, quality day care training is needed by the growing Hispanic population. Extension agents must understand the cultural factors that affect a population in order to develop effective training programs that will empower women and provide them with the skills to function in the day care business. Extension agents need to view culture as an enabler rather than a resistant force. Extension agents' failure to understand Hispanic culture, values, and attitudes will ultimately result in under- used program services. Extension's training efforts with Hispanic day care providers in Cleveland have proven to be successful. Providers view Extension as a user-friendly agency that meets their social and cultural needs.
References
Arce, A. A., & Torres-Matrullo, C. (1978). Acculturation: A prime factor in mental health of Hispanics. Roche Reports: Frontiers of Psychiatry, 12 (1), 5-6.
Brandsberg, G. T. (1991). How Extension is serving Spanish- speaking clients in the United States. Paper presented at the National Extension Technology Conference, Hershey, PA.
Castro, F. G. (1977). Levels of acculturation and related considerations in psychotherapy with Spanish speaking surnamed clients. Los Angeles: University of California Press.
Cattan, P. (1988). "The growing presence of Hispanics in the U.S. work force." Monthly LaborReview 8: 9-14.
Caudle, P. (1993). "Providing culturally sensitive health care to Hispanic clients." Nurse Practitioner 10 (12):43-51.
De la Cancela. (1986). A critical analysis of Puerto Rican machismo: Implications for clinical practice. Psychotherapy, 23 (2),291-296.
Delgado, M. (1980). Providing childcare services for Hispanic families. Young Children 9:26-31.
Delgado, M. & Scott, T. F. (1979). Strategic intervention: A mental health program for the Hispanic community. Journal of Community Psychology, 7,187-91.
Kuchak, J. (1993). Low-income family day care home demonstration. U. S. Department of Agriculture (Final Report). Alexandria, Va.
Marsiglia, F.F. (1990). The ethnic warriors: Ethnic identity and school achievement as perceived by a selected group of mainland Puerto Rican students. Unpublished doctoral dissertation, Case Western Reserve University, Cleveland.
Swarna Viegas
Former Extension Program Specialist
Internet address: gviegas@pop.kc-primary.net
Connie Betterley
State EFNEP Coordinator
Internet address: x1cbette@exnet.iastate.edu
Families Extension
Iowa State University
Ames, Iowa
There is considerable evidence (American Dietetics Association, 1994, Paneth 1995; Shiono & Behrman, 1995; Story, 1990; Story & Alton, 1995; Trouba, Okereke, & Splett, 1991; U.S. Department of Agriculture, 1994) that effective nutrition education interventions lead to satisfactory maternal weight gain during pregnancy and ultimately to reduced low birth weight and reduced infant mortality rates. These findings provided the basis for the implementation of the Stork's Nest project in Iowa, an educational intervention to teach women early in their pregnancies about proper nutrition; adequate weight gain; dangers of smoking, alcohol and illicit drug use; and importance of exercise.
Program Description
Through Extension Service/Womens, Infants, Children (WIC) plan of work dollars made available through Iowa's Expanded Food and Nutrition Education Program, Iowa State University Extension took leadership in developing Stork's Nest programs in three counties. Polk, Johnson, and Des Moines counties were selected because of high percentages of low birth weight (6.2%, 5.4%, and 5.2% respectively) (Iowa Kids Count, 1994). All were above the Healthy People 2000 goal of 5% low birth weight infants. The target population was pregnant women with one or more of the following risk factors: low income (below 125% of poverty), current or recent consumption of illicit drugs, current or recent consumption of alcohol, current smoker, less than 18 or greater than 35 years of age at the time of conception, pregnancy weight gain below recommended standards for normal/underweight women, pre-pregnancy weight below 90% standard, history of low birth weight baby or prematurity, parity greater than four, history of fetal or neonatal death, and less than 18 months between pregnancies.
The program was publicized through posters and brochures distributed to doctors' offices, hospitals, and social service agencies; articles in the press; and newsletters to service organizations. Presentations were scheduled with different social and health organizations to share information about the program with potential collaborators.
Personnel from diverse organizations participated in the Stork's Nest program by teaching, providing referrals, volunteering, and advising. Professionals from Extension and other agencies provided weekly educational classes at the Stork's Nest sites. Classes were offered in English and Spanish on nutrition, parenting, family planning, importance of seeking medical help, breast feeding, fetal development and child birth, safety, and prenatal and postnatal exercising, development of infants and toddlers, emotional health, and money management. The topics were covered in rotation over four or five weeks so participants entering the program at any time could receive information in all subjects. A local coordinator and a supervisor administered the program at each site. While the local coordinator was responsible for day-to-day management of the Stork's Nest, the supervisor was responsible for providing leadership that would determine program development.
Participants were recruited at WIC clinics, churches, and schools and assigned a case manager. Case managers referred clients to the local Stork's Nest coordinator, who followed up referrals with a telephone call or a letter of information about the project and enrolled interested participants. Case managers then worked with participants to set healthy behavior goals and to encourage healthy behaviors, such as attending WIC programs, keeping doctor appointments, stopping smoking, making healthy food choices, continuing or completing education, and using existing helping agencies to meet individual and family needs. Case managers kept a record of observed healthy behaviors in each participant's record book, awarding points for healthy behaviors recorded, based on predetermined guidelines. Participants could redeem their points at the Stork's Nest store for necessary supplies for the mother and baby.
Evaluation Design
Program effectiveness was evaluated using the pre-test-post- test evaluation design. Case managers collected demographic data from all participants at entry. One survey assessed practices relating to nutrition, food safety, and food resource management. A separate survey assessed knowledge regarding prenatal and infant diet. The exit survey included open-ended questions designed to elicit data on the perceived impact of the program. Exit data were collected when the baby was a year old or when the client informed the local Stork's Nest coordinator or case manager that she wished to exit the program.
Findings
The Stork's Nest coordinators reported facing challenges collecting data from the multiple instruments at two points in time because of practical difficulties involved. The estimated time for administering the instruments at entry for each client was one hour and sometimes more, depending upon the clients' literacy level. The clients were not always available and agreeable to commit their time for the post-test. So, although a total of 133 clients between January 1994 and August 1996 responded to evaluation instruments at program entry, exit information was not available for all 133. The results of the evaluation of knowledge of prenatal and infant nutrition and nutrition, food safety, and food resource management practices were based on the pre-test and post-test data provided by only a small number of participants from the Polk County site.
The qualitative data concerning perceived program impact was based on responses of clients from all three sites. Table 1 summarizes the participation of clients in each city and the numbers who provided evaluation data.
Table 1
Status of the clients in the program
| Clients | Polk County |
Johnson County |
Des Moines County |
Total |
| Referred | 637 | 91 | 86 | 814 |
| Enrolled | 637 | 91 | 86 | 814 |
| Exited | 362 | 14 | 54 | 430 |
| Continuing | 275 | 77 | 32 | 384 |
| Provided data | 53 | 63 | 17 | 133 |
Of the 133 participants providing entry data, 56% were Caucasian, 22% were African American, and 9% were Hispanic. Seventy-one (53%) of the respondents were twenty years of age or younger, nearly 50 (38%) were between 21-30 years of age, and 12 (9%) were over 30 years of age. Ninety-eight percent of the respondents from the Polk County Stork's Nest were 20 or younger, while the majority of clients in the other Stork's Nests were between 20 to 30.
Survey findings from pre-test to post-tests indicate that the percent of participants answering correctly increased for 14 out of the 20 items on the survey of knowledge about prenatal and infant diets. The mean post-test scores (mean = 15.03) was significantly higher than the mean pre-test scores (mean = 14.26) for the 37 clients who provided complete post-test data (t = - 2.59; p < .01), indicating a significant increase in knowledge of prenatal and infant nutrition.
Forty-two clients provided complete pre-test and post-test data on the 24-hour food recall. The data were analyzed using the EFNEP Evaluation Reporting System to compare the reported food intake to the minimum recommended number of 6-3-2-2-2 servings and to measure nutrient adequacy.
Eighty-six percent demonstrated a positive change in the in- take of one or more nutrients at exit. The mean number of servings of breads/cereals, fruits, meats, and dairy products increased. The dietary intake of grams of protein and dietary fiber of project participants was found to be higher at program exit when compared to program entry. The mean nutrient adequacy ratios from entry to exit were as follows: for protein .86 to .92; for iron .61 to .67; for calcium .58 to .59; for vitamin C .75 to .78; for B6 from .69 to .71. Although the mean number of servings of breads/cereals, fruits, meats, and dairy products increased in the positive direction, the participants did not meet the minimum requirements of a 6-3-2-2-2 diet.
A survey of practices related to nutrition, food safety, and food resource management was completed at both entry and exit by 20 participants. Findings showed that 12 (60%) clients more often thought about healthy food choices when deciding what to feed their family, 14 (70%) more often or always followed the recommended practice of not thawing food at room temperature, 9 (45%) more often compared prices before shopping.
To assess impact from a qualitative perspective, participants were asked two open-ended questions. In response to the first question "What impact did the educational component of the Stork's Nest have on you?" participants reported learning the importance of medical check-ups and immunizations, acquiring good parenting skills, changing their eating habits, comparing food labels, choosing more healthy foods, and following guidelines for preparing children's meals. Several participants reported that they stopped smoking.
The second question asked was "What impact did the program have on your baby?" Participants reported that the program helped them to make better personal decisions that
