Online MS in Nutrition Education Professorial Lecturer Dr. Elizabeth Cotter presented on October 9, 2015 about her research on community-based, obesity prevention in affordable housing communities. She spoke about the Vive Sana program, a community gardening and nutrition education program taking place in Arlington, VA and targeting low-income, food insecure households. Formative research, program planning, culturally tailored intervention strategies, and next steps in the reduction of health disparities was discussed.
The following is a partial transcript of the archived presentation, which can be viewed here.
American University Admissions: We are thrilled to have Dr. Elizabeth Cotter, Professorial Lecturer in the Department of Health Studies with us today. After a brief introduction, Dr. Cotter will truly demonstrate Nutrition Education in Action by sharing her research on community-based, obesity prevention in affordable housing communities. She will speak about the Vive Sana program, a community gardening and nutrition education program taking place in Arlington, VA and targeting low-income, food insecure households. Later in the session, Dr. Cotter and I will provide some additional information about the Master of Science in Nutrition Education program here at American University. This will include an overview of the program and the curriculum, a bit about the online platform used for our courses, and types of careers our students are interested in.
At the end of our presentation we will have time for questions and answers and I will also quickly run through what is required to apply and our admissions process.
Introduction to Dr. Elizabeth Cotter
American University Admissions: Dr. Cotter is a professorial lecturer in the Department of Health Studies at American University. She is a licensed psychologist with clinical and research interests broadly related to the prevention of eating and weight-related concerns.
She is particularly interested in the evaluation of culturally-tailored health promotion interventions, especially in underserved communities. She is also interested in cultural factors that may be protective against body image concerns in women. Prior to coming to American, Dr. Cotter was a postdoctoral fellow at Virginia Commonwealth University, participating in research examining the effectiveness of culturally-sensitive pediatric obesity prevention programming.
Dr. Cotter earned her PhD in Counseling Psychology from the University of Wisconsin – Milwaukee and received her BA in Psychology from Michigan State University.
Lastly, Dr. Cotter was the course developer for three courses in the Nutrition Education program: Health Communications, Changing Health Behaviors, and Multicultural Health, which we’ll go into more detail about later.
Vive Sana: A Community Based Nutrition Education Intervention
Dr. Elizabeth Cotter: Hi everyone, thank you so much for having me. My name is Elizabeth Cotter and I am a faculty member in the Nutrition Education MS program. Today I am going to be sharing with you some research I’ve been working on over the past several years focused on reducing low income families’ risk for obesity and health disparities, particularly those living in affordable housing communities. I’ll plan to speak for about 20 minutes or so, and then I’m looking forward to hearing your questions and feedback. Just to give you an idea of what I’ll be discussing today, I’ll start by describing some of the formative research we conducted in our partner community, Columbia Grove, an affordable housing community located in Arlington, VA, and then I’ll discuss the obesity prevention pilot program we developed and ran. Further, I’ll talk about what I believe the next steps in community-based programs should include and future plans for this line of research. And finally, throughout the talk I’d like to weave in components of the Nutrition Education curriculum that I believe are relevant to this type of programming.
Community Based Participatory Research Framework
Before we get into the program itself, I thought it might be helpful to talk about the framework that has guided my research. We do focus heavily on models and theory In the MS in Nutrition Education program, because we believe they guide health educators in terms of which variables to focus on to best influence behavior change. The framework that guided this particular program was the Community Based Participatory Approach, which is focused on conducting research WITH communities, as opposed to in communities. In other words, researchers must recognize the community’s assets and strengths, their expertise, and their role as an equal partner in the programming.
Scope of the Problem
Given the time limits, I won’t talk too much about existing research on obesity in the Hispanic/Latino population. Let me just say that the research suggests that clear health disparities exist in this country, and low income populations and Latino Americans are at heightened risk for obesity and its associated comorbidities, which is one of the reasons why we chose to partner with Columbia Grove.
Focus Group Findings: Community Strengths
To better understand our partner’s needs and barriers, we started with focus groups and I’ll present our findings here. We conducted focus groups with 21 community members. These were audio recorded, transcribed, and then we analyzed the dominant themes, and identified three major themes: Community Strengths, Community Barriers to Health, and Requested Resources. The quotes on this slide represent the community strengths, which fell under three categories: the responsiveness of community leadership and staff, the close location of grocery stores (these individuals don’t live in a food desert), and existing programs in the community that promoted health. Again, in line with the CBPR model I mentioned earlier, we want to capitalize on existing strengths. On a side note though, you’ll focus a lot on focus groups and other forms of formative research throughout the Nutrition Ed program. For example, one focus of the Nutrition Education Methods course is to perform a needs assessment for a specific audience to identify their needs as well as potential barriers to nutrition-related behavior change. You will then use that data to develop a nutrition-related lesson plan.
Focus Group Findings: Barriers to Health
Unfortunately, statements related to barriers were most frequent. Common stated barriers included lack of access to fresh, healthy foods; a lack of knowledge about living healthfully; lack of motivation; lack of exercise opportunities; lack of insurance or access to medical care; and cultural norms around cooking and preferred foods that were not particularly healthy, as one woman stated, “But not all Latinos like to eat healthy... Because we have learned to cook well. And when we say that something should have vegetables and stuff …we want to cook the pupusas.” This definitely clued us in that any recommendations we made had to be culturally relevant and using traditional foods.
Focus Group Findings: Requested Resources
Finally, these quotes are representative of the third theme, requested resources. Some of the most commonly requested resources included nutrition education sessions, a community garden, opportunities for exercise, and medical care. I think the first quote really highlights participants’ excitement about the community garden, as one member said, “Well I think for a community garden, you can actually see the results, you can eat your produce…Everyone would want to do that. It would be healthier than what you could get at the food bank or places where a lot of low income people get their food.”
Columbia Grove Pilot Program
We used this formative research to inform a pilot program that I completed with my research assistants throughout the spring and summer of 2014. I am going to focus on the intervention itself, to give you an idea of some feasible, culturally sensitive, experiential strategies that can improve health literacy and reduce risk for obesity in community settings. 30 households in total participated, 17 in the actual intervention and 13 as a comparison group who did not receive the intervention, but still completed assessment surveys for a small cash incentive. Our program itself was 8 weeks long, and focused on the development of a community garden and interactive, culturally relevant nutrition education programming. As a side note, in your research methods course, you’ll learn a lot about research design, and the relevant benefits of having a comparison group or a control group, and in fact, you’ll get the chance to pitch your own research proposal as well.
A primary aspect of the program was the community garden. Based on resident feedback, we felt this was an appropriate way to increase access to fresh healthy foods, and also to provide education to enrolled children about where food comes from. In addition, a garden was culturally relevant to the families. Many of them spoke about having a garden in their country of origin or while growing up. On the right I’ve listed past research providing evidence of the many benefits of gardening, including improved diet, more opportunities for physical activity while caring for the garden, stress reduction, and enhanced relationships between community members.
In addition to the garden, another experiential strategy we used was cooking classes. Cooking classes are great activities for skill building, and research supports their efficacy in community settings. There are also many sample curriculums available, such as Cooking Matters, which many of you may be familiar with. We held two cooking classes focused on recipes that incorporated produce from the garden. We also focused on recipes that were reported as favorites by the participants, with healthy tweaks made as needed. Research indicates that community cooking classes can enhance confidence in preparing healthy meals, knowledge regarding nutrition and food preparation, and the nutrition content of one’s diet. Research does suggest that longer term interventions with multiple classes are preferable, but unfortunately given the brief nature of the pilot and lack of resources this wasn’t feasible for us.
Low Cost Strategies
As you’ll learn in the Health Communication and the Multicultural Health courses, it’s critical to tailor health information to the unique needs and barriers, and cultural values, of your target audience. We incorporated a number of strategies that were specific to individuals in low income housing, who are on a budget and more likely to rely on the food bank, as well as food assistance. Some of the adaptations we made included using food that was distributed from the food bank in our recipes, incorporating canned and frozen produce options which are cheaper and store longer, teaching participants how to freeze meals so they last longer, and using low cost protein options, like meat free recipes including beans, eggs, or dairy.
Food Label Literacy and Grocery Shopping
Another important concept in the Health Communication course is health literacy. This is a person’s ability to understand and comprehend health related information. As you may know, most Americans cannot understand and interpret the information on a food label. This is particularly true for our participants, who were native Spanish speakers. Indeed, many of our participants mentioned that they struggled making choices at the store because they didn’t know which options were healthiest and they couldn’t interpret food labels. We actually combined information on food label literacy with a grocery store tour. We developed a highly interactive tour in which we focused on the outer ring of the store. In each section (e.g. produce, dairy) we purchased a product for participants to try. Throughout, we challenged participants to select items off the shelves and interpret the information (e.g. how many servings in the entire package? How big is one serving? How much sodium? Can you find an item with a more desirable amount?). A sample curriculum that you may be interested in is Nutrition Detectives, which is free and created by David Katz. In the Health Communication course, you will practice creating materials that are understandable by a wide audience, but creating an infographic on a nutrition-related topic and is written at a maximum of an 8th grade reading level.
Next, I’d like to quickly share with you the results of the program. The results of participant satisfaction questionnaires were very promising. 100% of participants strongly agreed that 1) participating in the program helped them to eat healthier, 2) they felt more confident preparing healthy food, and 3) they could incorporate what they learned into their daily life. However, when we went to analyze differences on outcomes like body index, or dietary content we did not find any significant differences between groups. Obviously this is pretty frustrating, but I think there are some reasons why this might be: One was the measurement of BMI as the primary outcome, weight is not likely to change in a brief, 8 week program, and perhaps attitudes like self-efficacy, or measures of knowledge, might have had a greater likelihood of change had we measured them. Another was attendance, families were a bit more involved in the garden then the classes, and on average only about half the participants attended any given class. This may have been because they were uncomfortable sharing in a group setting, or it might have been the time of the classes. Another explanation might be response bias, meaning participants may not have wanted to tell us if they had soda for lunch or 4 pieces of pizza for dinner. We had a great relationship with community members and they knew we were passionate about health, so they may not have wanted to let us down.
We also didn’t measure some other important variables that were perhaps linked to garden participation. Past research has linked community gardens to enhanced community connectedness and trust, and I think this was true for our program as well. A quote from the building manager really emphasizes this as she said: “The residents truly enjoyed the garden this year and I think it was a great success. I believe that [gardening] is a great way for our residents to not only relax, but it has given them an outlet and opened the lines of communication between neighbors.
So, the next step for this program involves running an enhanced version of the original program, through a grant I recently from the Aetna Foundation. We are going to recruit around 40 families to participate, and increase the number of garden beds so that every enrolled household has their own personal plot. We will also plant seasonally appropriate vegetables throughout the year. The nutrition education component will increase from 4 to 8 sessions, and we will include more information on parental stress and empowerment, as we know parental stress is linked to childhood obesity, including in Latino families. We will also add a text messaging component as a low cost, feasible way to reach those with our messages even if they can’t attend all the in-person programming. Finally, we will enhance the measures we use to include concepts related to self-efficacy, community connectedness, and stress and well-being. Of course, I would like to acknowledge and thank the colleagues, students, and APAH staff who worked with me to complete this project. I obviously couldn’t have done it without their help.
Online MS in Nutrition Education
Dr. Elizabeth Cotter: Our coursework is really divided into two areas of study. About half of our courses are more science-based, meaning we will dive deeply into the science of nutrition, including understanding the biological basis of nutrient needs, how nutrition relates to chronic disease, why certain vitamins and minerals are required in the body, and how nutrition needs might vary across the lifecycle or between individuals depending on their health status and lifestyle. In contrast, the applied coursework is really focused on how to best share and disseminate all the nutrition science information that you’ve learned in order to encourage behavior change. These courses will focus on things like developing nutrition education intervention strategies and materials, program planning, tailoring interventions to diverse target audiences, and developing motivational interviewing skills. We hope that both of these facets of the curriculum will give you a well-rounded education in the field of nutrition education, and feeling confident to plan and provide nutrition education in a wide range of settings.
Course Spotlight: Changing Health Behavior
Next, I’d like to quickly give some detail about one of the courses in the program, Changing Health Behavior. The learning objectives of this course include: 1) being able to identify health concerns relevant to nutrition and eating behaviors, and then recommend evidenced-based actions for treatment; 2) the ability to construct a comprehensive plan for a behavior change program; 3) the ability to recognize the relationship between stress and health and recommend stress reduction strategies that might also influence eating and weight behaviors, and 4) demonstrating the ability to track and monitor your own behavior, and develop a personal plan for sustainable change. One of the most fun activities we do in this class is a health coaching video. Students record a video of themselves providing health coaching to a volunteer. This might be a friend, family member, or classmate. Students begin to use the motivational interviewing techniques we learn in this class (things like reflections, open-ended questions), and then we all watch each others’ videos and provide feedback and suggestions. The goal is for this course is for you to fully understand the relationship between mental health and physical health, and how stress might influence eating and weight, how to develop effective behavior change plants, and also to feel comfortable using helping skills to communicate nutrition information to others.
Admissions Adviser: Nutrition Educators are in demand. Whether addressing chronic illness, the obesity epidemic or the needs of an aging population, highly credentialed nutrition educators are needed in a wide variety of areas. Graduates of the Nutrition Education program will be qualified to work in a variety of settings, including: Public Health Departments, Nonprofit Organizations, School Systems, USDA/Government, Gyms/ Health Clubs, Food Companies, Corporations and Community Organizations.
Thank you again for joining us today! If you are interested in learning more about the online MS in Nutrition Education, please reach out to one of our admissions representatives at 855-725-7614.
To learn more about American University’s online Master of Science in Nutrition Education, request more information or call us toll free at 855-725-7614.