A Content Analysis of Nutrition Education Curricula Used With Low-Income Audiences

Abstract

In developing recommendations for core measures/items for the evaluation of the Youth Expanded Food and Nutrition Education Program (EFNEP), three nutrition education curricula, implemented by land grant universities, were content analyzed. Selection criteria included the following: Curriculum content must include all EFNEP core content areas and must be implemented in more than one state with school children in third through fifth grades. Content analysis strategies were employed to identify and describe common areas/themes and mediators of behaviors addressed across the selected curricula. Content analysis coding was based on a list of behavioral mediators, which have empirical associations with nutrition, physical activity, and food safety. The most evident approaches identified across the three curricula were to enhance motivation, teach cognitive knowledge, and practice behavioral skills. The presence of self-regulation and environmental theory–based strategies was limited in all three curricula. In addition, multiple themes for nutrition, physical activity, and food safety were commonly addressed across curricula with multiple educational strategies. Based on these findings, recommendations for developing content appropriate measures and items for an outcome evaluation tool for Youth EFNEP are provided.

Keywords

behavior change theory curriculum school health nutrition health education

Background

School-based nutrition education programs promote healthy lifestyles among children and contribute to the prevention of childhood obesity (Sharma, 2011; Veugelers & Fitzgerald, 2005; Zenzen & Kridli, 2009). The youth component of the Expanded Food and Nutrition Education Program (EFNEP) operates through the land grant universities and is one example of a federally funded program that provides nutrition education each year to more than U.S. 400,000 low-income children (U.S. Department of Agriculture, National Institute of Food and Agriculture, 2010); with the goal of enabling them to “acquire the knowledge, skills, attitudes, and changed behaviors necessary for nutritionally sound diets” (U.S. Department of Agriculture, National Institute of Food and Agriculture, 2010). To accomplish this goal, Youth EFNEP paraprofessionals provide a series of nutrition education lessons in the following core areas: diet quality, physical activity, food safety, food preparation, and food choices. State EFNEP coordinators can develop new or use existing education curricula to meet the specific needs of the diverse audiences in their state (Guthrie, Stommes, & Voichick, 2006). If a state EFNEP coordinator chooses to use an existing curriculum, it is typically one developed by other land grant universities.

During the summer of 2009, the authors conducted a preliminary review of the most widely used Youth EFNEP curricula and agreed that most of the curricula were developed based on the experiential learning model (ELM) and addressed a variety of behavioral mediators predominately from social cognitive theory (SCT; Bandura, 2004; Kolb, 1984). SCT suggests that effective nutrition education programs designed for children include essential components such as motivational–informational (why change and how to change) and opportunities to develop social and self-management, to promote environmental support, and to build self-efficacy to support behavior change and overcome difficulties (Bandura, 2004; Contento, 2008).

For Youth EFNEP evaluation, however, there is a need for standard and robust measures that are based on national goals as well as the curricula objectives, content, and learning experiences used by this program to address changes on mediators of behavior and/or behavior change (Contento, 2011; Townsend & Kaiser, 2007).

A theory-driven, standardized, valid, and reliable outcome evaluation measure is critical for Youth EFNEP at a national level across all the curricula for several reasons. First, given the problem of childhood obesity and food insecurity among low-income audiences, Youth EFNEP needs to measure and compare the effectiveness and quality of states’ approaches. Second, in 2011, EFNEP was appropriated $68.70 million (Cornerstone Team, 2011); therefore, a standard outcome evaluation tool will help for accountability and to determine if the resources are used efficiently. Lastly, an outcome evaluation tool in conjunction with process evaluation methods will provide useful information to improve the program delivery, staff trainings, and the overall program.

In an attempt to begin the process of developing core measures for the outcome evaluation of Youth EFNEP, this study focuses on the content analysis of several common nutrition education curricula used with EFNEP audiences in Grades 3 through 5. The aim of this study was to explore and understand the common topics and theory-based strategies addressed across youth EFNEP curricula in order to identify a theoretical model for developing appropriate outcome evaluation measures for the Youth EFNEP program. More specifically, this content analysis was designed to answer the following evaluation questions:

Evaluation Question 1: To what degree are the content areas of nutrition, physical activity, and food safety employed across the selected Youth EFNEP curricula?

Evaluation Question 2: What theory-based strategies (mediators of behavior) are most prevalent across these Youth EFNEP curricula?

Evaluation Question 3: How are theory-based strategies incorporated in these Youth EFNEP curricula?

Method

Sample

A web-based survey was sent to state EFNEP coordinators (n = 75) at land grant universities in 50 states and 6 U.S. territories, with the purpose of identifying nutrition education curricula to be considered for content analysis. Thirty-three state coordinators responded to the survey (response rate 44%). In total, they reported 17 different curricula used with school-aged participants.

Four inclusion criteria were established for selecting curricula: (a) Curriculum had to be implemented in more than one state; (b) with school-aged children, in Grades 3 through 5; (c) had to include all Youth EFNEP core areas; and (d) had to be readily available. Only three met the inclusion criteria. Table 1 presents the curricula included in this analysis.

Table 1

General Characteristics of Curriculums Included in the Content Analysis

Name of Curriculum	Developer	Theoretical Framework	Grades	Format/ No. of Lessons	Evaluation Measures
JIFF	MSUE	ELM	Third to fifth	One general curriculum for all grades/8 lessons	Knowledge, attitudes, and behaviors
SMN	UME	ELM	Pre-K to eighth	Specific curriculum for each grade/number of lessons varies	Knowledge
EMPPP	PUE	ELM	First to sixth	Specific curriculum for each grade/5 lessons each	Knowledge and behaviors

NOTE: The content analysis included curricula only for 3rd, 4th and 5th grades. JIFF = Jump into the Food and Fitness; SMN = Show me Nutrition; EMPPP = Exploring MyPyramid with Professor Pop Corn; MSUE = Michigan State University Extension; UME = University of Missouri Extension; PUE = Purdue University Extension; ELM = Experiential Learning Model.

Measurement

Coding tools and corresponding coding guide were developed to answer the evaluation questions of this study. Also, an adapted version of the “General Curriculum Information Form” from the Health Education Curriculum Analysis Tool (HECAT) was incorporated into the data collection materials to help reviewers become familiar with the curriculum content, and to register general information from the curriculum (Centers for Disease Control and Prevention [CDC], 2007).

Specifically, the coding guide included variables that were based on SCT (Bandura, 2004), literature review (CDC, 2007; Doshi, Patrick, Sallis, & Calfas, 2003; Hansen, Dusenbury, Bishop, & Derzon, 2007) and on a preliminary reading of each curriculum’s lessons. The format of the coding guide was organized as follows:

First, the coding guide was divided into three core content areas: nutrition, physical activity, and food safety. Next, SCT was used to guide the coding of each core content area according to theory-based strategies related to behavior change. SCT is a widely accepted school-based nutrition education theoretical framework (Auld, Romaniello, Heimendinger, Hambidge, & Hambidge, 1998; Baranowski et al., 2000; Reynolds et al., 2000) and was used to facilitate the process of coding implicit–explicit mediating variables used across curricula for influencing behavior change. Each core content area was divided into five broad theory-based strategy categories that were labeled as information, materials, and/or activities incorporated in the curricula that focused on changing participants’ (a) motivation, (b) cognitive knowledge, (c) perceived environmental influences, (d) self-regulation skills, and (e) personal self-efficacy and behavioral skills (Hansen et al., 2007). Additionally, each category sorted by core content area, included a list of ideal indicators (theme codes) to facilitate the data collection process (Alshamrani, 2008). Instructional strategies codes (type of learning and application experiences) were also used to assess how theory-based strategies were incorporated across curricula. The first draft of the coding guide was reviewed for content validity by two experts in the areas of nutrition and physical activity, and pilot-tested by 10 trained nutrition undergraduate students. Results from the expert reviews and pilot test were used to modify the coding guide.

Research Team

Under the supervision of one health promotion and education expert, 10 trained nutrition students from the Department of Food, Nutrition, and Packaging Sciences at Clemson University, carried out the curricula review. Trainings involved learning about Youth EFNEP, behavioral theories, techniques for content analysis, and how the data collection materials work.

Coding Procedure

Three curricula that met all inclusion criteria were content analyzed through an iterative process. The units of data collection were all written messages, information and activities included in the lesson plans, except the lesson titles, objectives, and background information for the teachers. Because some curriculums were extensive or had a separated book per grade, at least three students were assigned per curriculum. Each reviewer first read each lesson to get familiarize with the curriculum. Second, one “HECAT General Curriculum Information Form” was completed per curriculum. Third, by using the coding guide each reviewer independently content analyzed an assigned section of the curriculum and inserted the results on the coding forms. The research team met biweekly to discuss and agree about the process and classification of the codes (Cassata & Cox, 2009). A doctoral student coordinated all the processes, reviewed the accuracy of the codes and updated the coding guide as codes were added, modified, and/or deleted during the analysis process (Neuendorf, 2002).

Analysis

All materials associated with one curriculum were analyzed as an individual unit, even if they were separated by grade. Descriptive and comparative analyses were performed for all the variables of interest in several ways.

First, to examine the degree to which each content area was employed across curricula, a mean percentage was calculated for the three core content areas. For example, the prevalence of nutrition content across curricula was calculated based on all the ideal indicators that comprised nutrition themes (codes) found in each curriculum.

Second, to examine the prevalence of theory based strategies across curricula, theory based strategies were grouped into the three core content areas, and a mean percentage was computed for each theory-based strategy with the following formula: [(Sum of occurrence of all separate theory-based strategies/total occurrence of all theory-based strategies) × 100] (Doshi et al., 2003; Paek, Bae, Hove, &Yu, 2011).

Third, to examine how these theory-based strategies were incorporated across curricula, the specific nutrition, physical activity and food safety themes commonly addressed by all curricula were identified by each theory-based strategy. Additionally, these common themes across curricula were rated according to the type of instructional strategy used to address the themes. Ratings were from 1 = only information is provided to 3 = information and more than one opportunity or activity to apply and practice learned knowledge and/or skills are provided (CDC, 2007).

Results

The content analysis results yielded information regarding the common theory-based strategies employed across all the curricula for the content core areas of nutrition, physical activity, and food safety. Nutrition, physical activity, and food safety themes addressed by each theory-based strategy were also identified and also their level of application or learning strategy.

Evaluation Question 1: To what degree are the content areas of nutrition, physical activity, and food safety employed across the selected Youth EFNEP curricula?

Nutrition, physical activity, and food safety were the three core content areas that emerged from a preliminary qualitative review of the curricula. The largest core content area addressed in all curricula was nutrition (70%), followed by physical activity (17%), and food safety (13%).

Evaluation Question 2: What theory-based strategies are most prevalent across the selected Youth EFNEP curricula?

Figure 1 displays the mean presence of theory-based strategies employed across all curricula and sorted by core content area. Findings suggest that the most common approach for promoting behavioral change across curricula and within core content areas was to enhance motivation, teach cognitive knowledge, and practice behavioral skills. The mean presence of self-regulation and environmental theory-based strategies was limited across curricula, therefore within core content areas too.

Figure 1

Mean Prevalence of Theory-Based Strategies Across All Curricula Sorted by Core Content Areas

Evaluation Question 3: How were these theory-based strategies incorporated across the selected Youth EFNEP curricula?

Table 2 displays how the selected Youth EFNEP curricula addressed each theory-based strategy. Specifically, this table reports on the nutrition, physical activity, and food safety themes that were derived from each theory-based strategy, which were addressed across all selected curricula. Additionally, this table presents the extent to which these common themes were implemented by each curriculum. Results show that several themes were commonly addressed across curricula, and that most of the curricula tended to address these themes with information and at least one “hands-on” opportunity to practice the learned knowledge and skills. The following section includes qualitative information to complement the results from Table 2.

Table 2

Analysis of the Application of Theory-Based Strategies Across All Curricula

	Learning/Application Scoring
Theory-Based Strategy/Common Themes	JIFF	SMN	PP
Motivational strategies
Nutrition themes
Importance/benefits of eating whole grains	1	1	3
Importance/benefits of eating vegetables	1	3	3
Importance/benefits of eating fruits	1	3	3
Importance/benefits of eating dairy products	1	3	3
Importance/benefits of eating meat and beans	1	3	3
Importance/benefits of eating a variety of foods	1	3	3
Importance/benefits of eating breakfast	2	2	3
Tasting a variety of foods	3	3	3
Physical activity themes
Importance/benefits of being physically active everyday	1	3	1
Food safety themes
Importance/benefits of hand washing	2	2	1
Importance/benefits of keeping everything clean	1	2	2
Importance/benefits of storing food properly	1	2	1
Importance/benefits of cooking food properly	1	2	1
Importance/benefits of separating food properly	1	2	1
Importance/benefits of washing fruits and vegetables	1	2	1
Cognitive knowledge strategies
Nutrition themes
Variety of foods from each food group	3	3	3
Recommended daily servings from each food group	2	3	2
Size of servings from each food group	1	2	3
Examples of healthy snack choices	2	3	2
Examples of nutritious breakfast foods	2	3	2
Concept of whole grain	1	1	2
Physical activity themes
Recommended amount of physical activity	3	3	1
Levels of physical activity according to MyPyramid	1	3	1
Ways to increase daily physical activity	2	2	2
Identify physically active and physically inactive behaviors	1	2	2
Food safety themes
When hands should be washed	2	2	1
Methods to keep food safe (e.g., “fight BAC rules”)	1	2	3
Foods that would be safe to eat a room temperature	1	1	1
Foods that need to be kept cold	1	2	1
Behavioral skill–building strategies
Nutrition themes
Reading food labels to make healthy eating choices (low fat, low sugar, low sodium)	3	3	3
Plan and prepare healthy meals and snacks	3	3	3
Physical activity themes
Practice a variety of physical activities and/or physically active games	3	3	3
Food safety themes
Practice how to wash hands	2	2	2
Practice how to clean fruits and vegetables	2	2	2
Practice safe food storage practices	2	2	2
Self-regulation strategies
Nutrition themes
Set a goal to improve food choices	3	2	2
Monitor progress in attaining healthy food choices	2	3	2
Physical activity themes
Set a goal to increase daily physical activity	3	2	2
Monitor progress in attaining a physical activity goal	2	3	2
Environmental strategies
Parents involvement to encourage healthy food choices	1	1	1

NOTE: Scores: 1 = only information; 2 = information and one opportunity or activity to apply and practice learned knowledge and/or skills; 3 = information and more than one opportunity or activity to apply and practice learned knowledge and/or skills. JIFF = Jump Into the Food and Fitness; SMN = Show Me Nutrition; PP = Professor Pop Corn.

Application of Motivational Educational Strategies

All the selected curricula addressed personal motivational strategies through focusing on the benefits of each food group of MyPyramid, eating a variety of foods, eating breakfast, daily physical activity, hand washing, keeping everything clean, washing fruits and vegetables, and storing/separating foods properly. Other positive outcomes were mentioned, such as the benefits of nutrients and of limiting the amount of fat and added sugar; however, they were not present across all curricula. Oral explanations, visuals, reinforcing questions, handouts, and some hands-on activities such as match games (i.e., food groups and benefits) and team discussions were the most common educational activities used to learn and apply these motivational strategies. Another finding was that in most lessons of all the selected curricula, tasting activities were incorporated.

Application of Cognitive Educational Strategies

Many of the educational experiences, especially for the nutrition core area, were designed to increase cognitive knowledge necessary to support behavior change. The knowledge-related themes commonly included in all curricula were as follows: concepts from MyPyramid such as knowing a variety of foods from each food group; food group serving sizes and number of servings recommended per day; examples of healthy snacks choices and of nutritious foods for breakfast; daily recommendation of physical activity; MyActivity Pyramid levels; ways to be active every day (i.e., rope jumping, playing a sport or active games); when hands should be washed; methods to keep food safe (i.e., “Fight BAC rules”); foods that would be safe to eat at room temperature and foods that need to be kept cold. These themes were addressed through oral explanation and discussions (i.e., cases scenarios to identify improper food safety practices). Handouts, games, food models, and questions were also used as instructional strategies to reinforce the concepts learned.

Application of Behavioral Skill–Building Educational Strategies

All the analyzed curricula provide both passive and hands on experiences (i.e., clear instructions, demonstrations, guided practice, games, worksheets, visuals) for the students to learn and practice how to apply essential behavioral skills. For example, all the curricula included several activities to teach food labels and to compare food products. Also, a common behavioral approach across curricula was to instruct students on how to plan and prepare a healthy snack, based on MyPyramid food groups. For physical activity, all curricula included both individual and group-cooperative opportunities for students to participate in several types of physical activities or games such as jumping, stretching, running in place, dancing, and muscle movements. Relative to food safety, all curricula provide opportunities of food preparation to show how to wash hands, to clean fruits and vegetables, and applying safe food storage practices.

Application of Self-Regulation Educational Strategies

Self-regulation approaches were addressed across curricula for the core areas of nutrition and physical activity. To encourage students to improve behaviors during the program and in the future, all curricula include activities for setting healthy goals and monitoring progress toward the goals. For instance, for physical activity, in almost every lesson of the curricula sampled, there was a portion devoted to reminding the students to record their daily exercise/physical activity.

Application of Environmental Educational Strategies

The curricula analyzed did not include much information or opportunities regarding personal, family, and/or peer norms that influence behavioral change related to nutrition, physical activity and food safety. However, to promote a supportive environment, all curricula included newsletters, which are sent to parents after each lesson. These newsletters included information and healthy recipes to improve children’s food choices and encourage parents and children to cook together. For example, if the lesson was about whole grains, then the newsletter includes tips for parents about learning how to incorporate more whole grains in family meals.

Discussion

Findings from this study suggest that content analysis could be used to identify and select appropriate theory-driven curricula content for the program logic model outcomes. Also, the results of this study can be used as a foundation to develop, identify, and/or select evaluation tools for Youth EFNEP that “matched” the program scope and content. Knowing the content elements and how behavior change is commonly addressed across the selected curricula (theory into practice) may help EFNEP administrators and researchers to prioritize which core measures and questions could be potentially included in an outcome evaluation tool for Youth EFNEP. Furthermore, it may protect against type III error whereby there is a mismatch between what was delivered in the program and the intended change measured through the evaluation (Kalafat, Illback, & Sanders, 2007).

This content analysis of three youth nutrition education curricula demonstrates that the primary focus of the reviewed curricula was nutrition followed by physical activity and food safety. These findings are consistent with review articles of school-based nutrition interventions, where most of the interventions analyzed targeted both nutrition and physical activity behaviors (Roseman, Riddell, & Haynes, 2011; Sharma, 2011; Zenzen & Kridli, 2009). Focusing on these two behaviors is particularly important for Youth EFNEP participants, who are at greater risk of childhood obesity and food insecurity (Nord, Coleman-Jensen, Andrews, & Carlson, 2010; Troiano & Flegal, 1998; Lutfiyya, Garcia, Dankwa, Young, & Lipsky, 2008). However, since the reviewed curricula devote more time to nutrition, it would be important to complement these curricula with other materials that place a stronger emphasis on physical activity and food safety.

In this study, the coding system used for the curricula content analysis provided a systematic framework to identify which themes were commonly addressed across curricula. Examples of themes commonly addressed within the nutrition core content area were aspects related to label reading, choosing/preparing healthy snacks, eating breakfast, and the basics of MyPyramid such as variety, food groups, recommended daily servings, and serving sizes. For physical activity, the curricula commonly addressed a variety of ways to increase physical activity; and for food safety, the emphasis was on aspects related to hand washing and food safety practices such as cleaning, cooking, storing, and avoiding cross-contamination.

Although the purpose of this study was not to assess the quality or effectiveness of the reviewed curricula in terms of how to change mediating variables and/or behavioral change, the present study demonstrates that by assessing the type (presence or not presence), frequency (mean prevalence), and intensity (type of educational experiences used to both learn and apply) of theory-based strategies used, researchers were able to have insight not only about the curricula content and specific themes but also about which implicit/explicit mediating variables related to child nutrition, physical activity, and food safety behavioral change were commonly targeted across curricula. In fact, the major findings of the content analysis of theory-based strategies used revealed that the included curricula really focus on increasing knowledge, motivation, and skills. It is interesting that the curricula did not include much opportunity for family involvement and/or for self-regulation and or for addressing how participants would handle environmental barriers/challenges. Many studies suggest that strong inclusions of parental support and an analysis of barriers, planning, and evaluation of goals are extremely important to change behavior by increasing participants’ self-efficacy (Anderson, Winnett, Wojcik, Winnett, & Bowden, 2001; Beckman, Hawley, & Bishop, 2006; Wright, Wilson, Griffin, & Evans, 2010).

Finally, to link core content areas, themes, and theory-based strategies, all curricula included educational activities mainly guided by the experiential learning model—learn by doing approach (Kolb, 1984). For example, a combination of oral explanations, guided practice, games, demonstrations, skill building, food preparation, and tasting activities were commonly included across curricula to actively involve students rather than only using didactic instructional strategies.

There are several limitations on this study. First, results could not be generalized because there was no random selection of curricula, new curricula could have been added since the research began, and the curricula sample was small (n = 3). However, selection criteria were established to identify curricula that are used by more than one state and that included all the EFNEP core content areas. Second, although SCT was used to guide the coding and efforts were made to establish the content validity of the content analysis coding guide, it is not clear to what extent the coding was accurate enough to capture the entire scope addressed in the curricula, Some of the main barriers included the wide variety of contents and approaches included in the reviewed curricula and the difficulties of conceptualizing and operationalizing the categories and codes used. Third, this study focuses on evaluating common elements of the reviewed curricula necessary to establish a foundation for questionnaire development; it did not evaluate other characteristics of the curricula such as age-appropriateness, cultural appropriateness, adherence to dietary recommendations, and other factors that may affect the quality and effectiveness. Future research could complement this type of study, with other curriculum evaluation tools and with a comprehensive outcome and process evaluation of the implementation of the program.

Conclusion

In spite of the limitations, this study has practical implications especially for questionnaire development. Results suggest that this type of content analysis could be used as a systematic approach to review, select, and/or improve nutrition education materials. This study expands the current knowledge related to theory adherence of nutrition education curricula used with EFNEP youth participants. This is imperative, as preventing childhood obesity has become a public health priority. Findings from this content analysis could be used as a theoretical model to develop, identify, and/or select evaluation tools/questions with content appropriateness. Moreover, results showing the emphasis on individual level (intrapersonal) mediating variables with an incomplete level of attention to interpersonal and environmental constructs, suggest that, in the same way, evaluation measures should focus on knowledge, motivation, self-efficacy, intention, and potentially initiating behavior change, not on sustained behavior change, which requires attention to be placed on interpersonal and environmental factors as well.

Footnotes

Authors’ Note

This research was a collaborative effort between researchers at Clemson University and Colorado State University. The authors want to thank all the EFNEP State Coordinators and/or staff who responded to the web-based survey that informed the research team about curricula used at their states with third, fourth, and fifth graders. In addition, special thanks to the nutrition undergraduate students from the Creative Inquiry FDSC 450 Section 03 from the Department of Food, Nutrition, and Packaging Sciences at Clemson University, who were part of the data collection team: Ginger Thomas, Trisha Hall, Victoria Hayden, Amelia Gannon, Melissa Ikerd, Hannah Clarck, Kathryn Lybran, Carli Onksen and Laura Johnson. This was a curricula content analysis and human subjects were not used, therefore human subjects approval was not sought. This study was supported by the Clemson University Creative Inquiry Initiative, and by the MICIT/CONICIT Government of Costa Rica.

References

Alshamrani

S. M.

(2008). Context, accuracy, and level of inclusion of nature of science concepts in current high school physics textbooks. (Doctoral dissertation, University of Arkansas). Retrieved from http://search.proquest.com/docview/304690016/fulltextPDF?accountid=6167

Anderson

E. S.

Winett

R. A.

Wojcik

J. R.

Winett

S. G.

Bowden

(2001). A computerized social cognitive intervention for nutrition behavior: Direct and mediated effects on fat, fiber, fruits, and vegetables, self-efficacy, and outcome expectations among food shoppers. Annals of Behavioral Medicine, 23, 88-100.

Auld

G. W.

Romaniello

Heimendinger

Hambidge

(1998). Outcomes from a school-based nutrition education program using resource teachers and cross disciplinary models. Journal of Nutrition Education, 30, 268-280.

Bandura

(2004). Health promotion by social cognitive means. Health Education & Behavior, 31, 143-164.

Baranowski

Davis

Resnicow

Baranowski

Doyle

Lin

L. S.

. . . Wang

D. T.

(2000). Gimme 5 fruit, juice, and vegetables for fun and health: outcome evaluation. Health Education & Behavior, 27, 96-111.

Beckman

Hawley

Bishop

(2006). Application of theory-based health behavior change techniques to the prevention of obesity in children. Journal of Pediatric Nursing, 21, 266-275.

Cassata

L. C.

Cox

T. M.

(2009). Evaluation tool for clinical nursing textbooks: Bridging content analysis with evidence. Journal of Nursing Education, 48, 301-309.

Centers for Disease Control and Prevention. (2007). Health education curriculum analysis tool (HECAT). Atlanta, GA: Author.

Contento

I. R.

(2008). Nutrition education: Linking research, theory, and practice. Asia Pacific Journal of Clinical Nutrition, 17, 176-179.

10.

Contento

I. R.

(2011). Nutrition education: Linking research, theory, and practice (2nd ed.). Sudbury, MA: Jones & Bartlett Learning.

11.

Cornerstone Team. (2011). Cornerstone report from Washington: House Appropriations Committee Approves Ag Bill. Retrieved from http://www.land-grant.org/reports/2011/02-11.html

12.

Doshi

Patrick

Sallis

J. F.

Calfas

(2003). Evaluation of physical activity web sites for use of behavior change theories. Annals of Behavioral Medicine, 25, 105-111.

13.

Guthrie

J. F.

Stommes

Voichick

(2006). Evaluating food stamp nutrition education: Issues and opportunities. Journal of Nutrition Education and Behavior, 38, 6-11.

14.

Hansen

W. B.

Dusenbury

Bishop

Derzon

J. H.

(2007). Substance abuse prevention program content: Systematizing the classification of what programs target for change. Health Education Research, 22, 351-360.

15.

Kalafat

Illback

R. J.

Sanders

(2007). The relationship between implementation fidelity and educational outcomes in a school-based family support program: Development of a model for evaluating multidimensional full-service programs. Evaluation and Program Planning, 30, 136-148.

16.

Kolb

D. A.

(1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice Hall.

17.

Lutfiyya

M. N.

Garcia

Dankwa

C. M.

Young

Lipsky

M. S.

(2008). Overweight and obese prevalence rates in African American and Hispanic children: An analysis of data from the 2003-2004 national survey of children’s health. Journal of the American Board of Family Medicine, 21, 191-199.

18.

Neuendorf

K. A.

(2002). The content analysis guidebook. Thousand Oaks, CA: Sage

19.

Nord

Coleman-Jensen

Andrews

Carlson

(2010). Household food security in the United States, 2009 (Economic Research Report No. ERR-108). Retrieved from http://blogs.desmoinesregister.com/dmr/wp-content/uploads/2010/11/ERR108.pdf

20.

Paek

H. J.

Bae

B. J.

Hove

(2011). Theories into practice: A content analysis of anti-smoking websites. Internet Research, 21, 5-25.

21.

Reynolds

K. D.

Franklin

F. A.

Leviton

L. C.

Maloy

Harrington

K. F.

Yaroch

A. L.

. . . Jester

(2000). Methods, results, and lessons learned from process evaluation of the High 5 school-based nutrition intervention. Health Education & Behavior, 27, 177-186.

22.

Roseman

M. G.

Riddell

M. C.

Haynes

J. N.

(2011). A content analysis of kindergarten 12th grade school-based nutrition interventions: Taking advantage of past learning. Journal of Nutrition Education and Behavior, 43, 2-18.

23.

Sharma

(2011). Dietary education in school-based childhood obesity prevention programs. Advances in Nutrition, 2, 207S-216S.

24.

Townsend

M. S.

Kaiser

L. L.

(2007). Brief psychosocial fruit and vegetable tool is sensitive for the U.S. Department of Agriculture’s nutrition education programs. Journal of the American Dietetic Association, 107, 2120-2124.

25.

Troiano

R. P.

Flegal

K. M.

(1998). Overweight children and adolescents: Description, epidemiology, and demographics. Pediatrics, 101(3 Pt. 2), 497-504.

26.

U.S. Department of Agriculture, National Institute of Food and Agriculture. (2010). Expanded Food and Nutrition Education Program resources. Retrieved from www.nifa.usda.gov/nea/food/efnep/resources.html

27.

Veugelers

P. J.

Fitzgerald

A. L.

(2005). Effectiveness of school programs in preventing childhood obesity: A multilevel comparison. American Journal of Public Health, 95, 432-435.

28.

Wright

M. S.

Wilson

D. K.

Griffin

Evans

(2010). A qualitative study of parental modeling and social support for physical activity in underserved adolescents. Health Education Research, 25, 224-232.

29.

Zenzen

Kridli

(2009). Integrative review of school-based childhood obesity prevention programs. Journal of Pediatric Health Care, 23, 242-258.