Development of a Color-Coded Bilingual Food Label for Low-Literacy Latino Caretakers

Development of a Color-Coded Bilingual Food Label for Low-Literacy Latino Caretakers

LAUREN H A L D E M A N , ~ RAFAEL PEREZ-ESCAMILLA, ' A N N M. FERRIS, ' LINDA DRAKE, ' DAVID H I M M E L G R E E N , ~ HARBY B O N E L L O , ~ ANIR G O N Z A L E Z , ~ SOFIA SEGURA-MILL AN,^

IVETTE M E N D E Z , ~ ANGELA B E R M U D E Z , ~ A N D NANCY ROMERO-DAZA~ 'Department of Nutritional Sciences, University of Connecticut, Storrs, Connecticut 06269;

2Hispanic Health Council, Hartford, Connecticut 06106

ABSTRACT The purpose of this study was to develop a bilin- gual, user-friendly food label (UFFL) for low-literacy audiences. The UFFL developed was based on (a) a quantitative and quali- tative needs assessment of Food and Drug Administration (FDA) food label understanding and use, (b) the development of a UFFL, and (c) a qualitative evaluation of the UFFL. Subjects con- sisted of a convenience sample (N = 150) of low-income Latino caretakers living in Hartford with children under 6 years of age, who were recruited &om local community agencies.The primary outcomes measured in this study were food label use, knowledge, and understanding. Chi-square analyses were conducted to deter- mine relationships between subjects' socioeconomic status and demographic characteristics with food label use, knowledge, and understanding. Although 96% of respondents were familiar with the FDA food label, only 30% used it routinely when grocery shopping. FDA food label knowledge was positively associated (p I .05) with younger age, level of education, and being an Eng- lish speaker. A UFFL was developed that included color coding, bilingual text, and a shaded Food Guide Pyramid. Results indi- cated that participants found the UFFL easy to understand.The UFFL can be used as a nutrition education tool and the method- ology developed may help food policy makers to improve the nutrition education value of the FDA food label.

INTRODUCTION

Food labels are found on most food products sold in the United States.' Thus, food labels have the potential to become one of the most significant tools for providing nutrition edu- cation and information to the public.2 However, according to the 1997 American Dietetic Association Nutrition Trends Survey, only 27% ofAmericans pay close attention to the food

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . This study was funded by the Unlted States Department ofAgriculture Food Stamps Program and the Storrs Agricultural Experiment Station. Address for correspondence: Lauren Haldeman, MS., Deparanent of Nutritional Sciences (U-17), University of Connecticut, 3624 Horsebarn Road, Storrs, C T 06269;Tel: (860) 486-3010; Fax (860) 486-3674; E-mail: [email protected]. 02000 SOCIETY FOR NUTRITION EDUCATION

label.3A review of the consumer food label format preference s t u d i e ~ ~ , ~ ~ revealed that middle-class American consumers prefer more user-friendly food labels (UFFL) that contain more in f~ rmat ion ,~ bar graph^,^ numeric format^,^ and color coding."hese studies led to the development of the Food and Drug Administration (FDA) food label and may help us understand the low use as well as the barriers associated with consumers' ability to understand the FDA food label.

Both the type and presentation of information in the label have important effects on comprehension and preference of label f ~ r m a t . ~ . ~ Limited availability of reliable food label infor- mation,' low literacy skills, and a lack ofbasic nutrition knowl- edge8-lo are all barriers to consumer food label use. This may be attributed to the fact that adequate information about how to use the food label is not readily available" or written at an appropriate literacy level.' According to the National Adult Literacy Survey, over 40 million Americans age 16 and older have significant literacy needs, and of those with lowest liter- acy levels, 43% live in poverty and 17% receive Food stamp^.'^

The Latino population is of particular concern because it is experiencing the fastest annual growth rate in the United States13 and often lives under conditions of poverty. Puerto Ricans, the predominant group in this study, complete an average of only 8 years of schooling.13

Additionally, according to Contento et al. (1995),14 there are few nutrition education studies that address the Latino population.Thus, the specific aims of this study were to (a) assess the FDA food label understandings of low-income Latino women living in Hartford, Connecticut with children under 6 years of age; (b) develop a UFFL; and (c) evaluate its effectiveness using a qualitative approach. Hartford was an appropriate location to conduct this research as 89% of Latino caretakers receive food stamps or Aid to Families with Dependent Children (AFDC).I5

METHODS

The methodological strategy for this study (Fig. 1) followed three steps: (1) a needs assessment consisting of data from a

Journal o f Nutrition Education Volume 32 Number 3 May June 2000 153

* Dotted lines indicate studies being conducted at the same time as the food label survey ** 1 Public Health journalist 1 Ph.D. Nutrition (Nutrition education) 1 Ph.D. Nutrition

1 Ph.D. Public Policy 1 Ph.D. candidate (Nutrition) 2 Ph.D. Anthropology 3 Latino Nutrition educators

(N = 500)

Figure 1. Methodological strategy used for development of a user-friendly food label.

Food Label Survey (N = 150) (NW = 12) A-SSESSMENT*

household-to-household food and nutrition knowledge, atti- tudes, and behaviors (KAB) community survey ( N = 500)16; a food label survey ( N = 150); and three focus group sessions ( N = 12 participants)17; (2) UFFL development; and (3) a qualitative evaluation consisting of a focus group ( N = 8 par- ticipants) and peer review.The KABI6 survey and the three focus group sessions took place in parallel to the food label survey, all of which comprised the needs assessment phase of this study. Therefore, results from the KAB16 survey and the three focus group sessions17 will be used only in support of the findings from the food label survey.

KAB survey. The KABl6 survey was a household-to- household community survey of nutrition knowledge, atti- tudes, and behaviors conducted in five predominantly Latino neighborhoods in Hartford. Neighborhoods were selected if, according to census data, at least half of the residents were Latino. Households that included at least one child 12 years or younger were selected. Interviewers began interviewing on a randomly selected street in the center of each neigh- borhood and then moved to other streets until the sample size (N = 500) was reached. Respondents were interviewed in their households by one of three trained bilingual, bicul- tural interviewers; the interview took approximately 2 hours to complete.

I

I I I I

I

Recruitment and interview process. Upon receipt of the human subjects' consent, interviewers recruited a conve- nience sample (N = 150) of low-income Latino caretakers living in Hartford with children under 6 years of age from existing programs in a local health agency ( N = 80), com-

I

I I

I I

munity programs (Special Supplemental Nutrition Program for Women, Infants and Children; Expanded Food and Nutri- tion Education Program), and area hospitals ( N = 33), and through word of mouth (N = 21), area elementary schools ( N = 12), and flyers (N = 4).Afier obtaining their verbal con- sent, participants were given an appointment to come to the local health agency for the interview. All three interviewers were bilingual/bicultural. Due to the possibility of language barriers, the survey was available in both Spanish and Eng- lish and was administered individually by one of three bilin- gual, bicultural interviewers or the study coordinator. The interview lasted approximately 15 minutes and upon com- pletion each participant received a $5.00 incentive and a packet of nutrition education materials consisting of the Food Guide Pyramid, information about child nutrition

I I I I I I L-- - - -- - -

User-Friendly Food +--------I PRODUCT DEVELOPMENT

topics, healthy recipes, and suggestions on how to access food in Hartford.

For training, all interviewers were required to read the sur- vey to familiarize themselves with the content, meet with the

Peer Review**

study coordinator to go over interviewing techniques, answer any questions related to the survey content, and conduct practice interviews with a community member before begin- ning the study.

QUALITATIVE

Food label survey. The central part of the needs assess- ment was the food label survey, which was conducted from January to June 1997.The development of this survey took place from October to December 1996 with input from five expert community nutritionists. It was pretested with employees of a local health agency, which is a community- based research and service organization located in the heart

(N = 8) - EVALUATION

154 Haldeman et al./FOOD LABEL FOR LOW-LITERACY LATINO CARETAKERS

of Hartford's Latino community.15 Input from the local health agency employees was especially important because many of them come from the Latino community in Hart- ford. Content validity was assessed by circulating the survey among nutrition professionals and community members within the target population. Survey revisions were made according to the feedback that was received. The survey included low-income Latino women living in Hartford with children under 6 years of age and was developed to assess pre- liminary information on FDA food label knowledge, atti- tudes, and behaviors.

The food label survey was divided into the following sec- tions: (1) socioeconomic status and demographic informa- tion, (2) FDA food label knowledge and use, (3) shopping habits, and (4) Food Guide Pyramid knowledge.The first sec- tion of the food label survey consisted of questions relating to the socioeconomic and demographic characteristics of the target population. Data about family characteristics, ethnic- ity, and level of education, as well as economic status, were collected. Economic status was based on whether the subject received or was eligible for Food Stamps at the time of the interview.The second section of the survey asked questions relating to the importance of food labels to the subjects, whether they ever learned about the FDA food label, where they get their information, and if they use the FDA food label when deciding which foods to buy.

Using four laminated models of FDA food labels con- taining varying nutrient information, interviewers asked respondents seven questions that were used to assess the sub- ject's level of FDA food label knowledge. Respondents were shown one model FDA food label and asked "How many servings are in this product?,""What is the percent daily value for fat in one serving of this product?,""How many servings of this product would you need to eat to meet your daily requirement for vitamin A?," "Is this a high-sodium food? Why?," and "Is this a high-fat food? Why?" Interviewers then showed the respondents three different model FDA food labels and asked "Which of these products has the lowest per- cent daily value for fat in one serving?" and "Which of these foods would you choose in order to get all of the calcium your body needs for the day?"

To determine the relevance of nutrition education focus- ing on the FDA food label among this target population, questions relating to shopping habits were asked. Specifically, subjects were asked if the foods they buy were mostly canned/packaged or fresh. In addition, subjects were asked what changes to the FDA food label were necessary to increase their use of the FDA food label.

The last section of the survey focused on questions about the Food Guide Pyramid. Subjects were asked whether they had ever seen the Food Guide Pyramid, as well as questions relating to serving sizes and the recommended number of daily food group servings.

Focus groups. During the needs assessment phase, three focus group sessions took place.17These focus group sessions

included assessing general nutrition topics with an emphasis on the FDA food label and aiding in the development of a more understandable and meaningful food label.

The focus group participants were recruited from the existing local health agency programs. In addition, two of the bilingual/bicultural interviewers for the food label survey recruited focus group participants from a group of women who participated in a previous nutrition needs assessment. Inclusion criteria used for the food label survey were also used to recruit participants for all three focus groups. The same participants for focus group 1 (N = 7) were asked back to participate in the second focus group (N = 6) so that there could be more continuity in the process. New individuals (N = 5) were recruited for the third focus group because after numerous unsuccessful attempts to contact the same indi- viduals from the first two focus groups, it was necessary to recruit new participants. Because focus group 2 was a con- tinuation of focus group 1 and included the same individu- als, it should be clarified that focus group 1 actually took place in two sessions.Therefore, focus groups 1 to 3 will be referred to as focus group sessions (N = 12) rather than three separate focus groups.

A bilingual/bicultural moderator, the study coordinator, and a bilingual/bicultural local health agency employee attended and reached a consensus of key findlngs at the end of each focus group. Before each session, a list of questions was developed to guide the discussion. Each session lasted approximately 90 minutes, was tape recorded, and the bilingual/bicultural local health agency employee present took written notes.

Product development. All of the data collected from the food label survey and the focus group sessions served as a guideline for developing the UFFL. The food label and KABI6 surveys provided quantitative data regarding what information this population needed on the FDA food label, how they felt it should be organized, and whether they understood how to read/use the FDA food label. The three focus group sessions17 served as a means for gaining a more in-depth understanding of the barriers for effective FDA food label use. Participants were asked to state what they would do to change the FDA food label to make it more useful to them. Each focus group session built on the previous one.All of the recommendations given by the participants were used to make changes to the FDA food label.

The literacy level of the text of the UFFL was evaluated using the Microsoft Word@ Flesch-Kincaid readability scores. The Flesch-Kincaid readability score indicated that the user- friendly food label was written at a second-grade level and the Flesch reading ease score was between 90 and 100. The percent daily value ranges used for the color-coded scale to classify a specific nutrient's contribution to the diet were low (0%-5%),18 medium (6%-9%), high (10%-19%) , I 9 and very high (>20%).19

Last, with the guidance of a graphic artist, the UFFL was designed using the computer programs PageMaker0 and Illustrator@.

Journal of Nutrition Education Volume 32 Number 3 May June 2000 155

Qualitative evaluation of UFFL. A new group of indi- viduals (N = 8) participated in a fourth focus group (dura- tion = 90 minutes). The final draft of the UFFL was intro- duced in this group and participants were asked to compare the FDA food label and the UFFL and to make suggestions. Final revisions were made according to these recommenda- tions.The purpose of this group was to determine if, for this group, the UFFL was easy to understand.This was done to test what would happen if a new food label were actually used in the marketplace. Recruitment and procedures were similar to those used for the previous three focus group sessions.17

Once the UFFL was developed, it was circulated among professionals in the fields of nutrition, public health, and anthropology. Feedback received from the focus group and the peer reviewers was then used to further revise the UFFL.

Data analyses. Descriptive statistics and bivariate analy- ses were conducted using FDA food label use and knowledge as outcome variables and language, age, education, ethnicity, and Food Stamp eligibility as independent variables. Analy- sis was done using the Statistical Program for the Social Sci- ences for Windows (SPSS).20 A two-tailed p value I .05 was used as criterion for statistical significance.

A content analysisz1 of qualitative data was used to ana- lyze the data from the fourth focus gr0up.A bilingual/bicul- tural community nutritionist transcribed and translated the recordings from focus group 4. Once transcribed, the study coordinator assessed the information for recurrent patterns and common themes or concepts brought up by different individuals on more than one occasion.

RESULTS

KAB survey. The majority of respondents were women (89.0%) approximately 33 years of age who were the moth- ers of at least one child less than 12 years of age living in the household. O f all respondents, 90.0% reported being Latino, 96.0% of whom identified themselves as Puerto Rican. Level of formal education among Latinos was low, with only 32% graduating from high school. Income level among Latinos was also low, with 74.0% receiving Food Stamps.With regard to food labels, 94.0% of Latinos indicated that they were familiar with them, but only 18% reported always using food labels when grocery shopping.

Food label survey.

Socioeconomic status and demographics. Respondents for this survey were female caretakers living in Hartford with, on average, one to two children 5 years of age or 1ess.M of these women were Latino, with the majority being Puerto Rican (89.3%) .These women were, on average, 28.0 ? 8.7 years and 56.0% spoke only Spanish in the home.Approximately one-

third (34.0%) of the respondents reported having received their high school diploma or General Educational Develop- ment (G.E.D.) high school equivalency certificate and 52.7% had not completed high school. Only 13.3% attended schooling beyond high school.Thus, this was a low educa- tion level and low-income population with 84.0% of the respondents receiving Food Stamps or eligible to receive Food Stamps at the time of the study.

FDA food label knowledge. When respondents were pre- sented with the FDA food label, 89.2% reported that they understood the label information. However, they were unable to correctly answer specific questions about the information found on the FDA food label. For instance, the majority of respondents could not determine how many servings were in one container (63.8%), the percent daily value for fat in one serving (53.7%), or how many servings of the product they would need to eat to meet their daily requirement for vitamin A (89.3%). When asked to determine whether a product was high in fat or sodium, a higher percentage of respondents answered correctly. However, further probing revealed that the respondents were answering correctly based on incorrect reasoning. The product food label used for this line of questioning indicated a food product containing 3 grams of fat and 300 milligrams of sodium per serving. Although some respondents correctly identified the product as high in sodium (66.4%) and low in fat (58.1%), the most frequent reason given for answering this way was that 300 is larger than 3.

FDA food label use. Ninety-six percent of the respondents reported that they had seen the FDA food label and a majority of them (97.9%) had seen it in the grocery store or on food cans and packages. However, of those who had seen it, only 32.7% had ever been taught how to use the FDA food label. Survey results revealed that little to no nutrition education on the FDA food label was coming from media sources (newspapers, television, magazines) or other easily accessible means.The fact that only a small per- centage of respondents reported ever having learned about the FDA food label may help to explain the small percent- age (29.5%) of respondents who reported looking at the FDA food label all of the time when they are grocery shop- ping. Respondents are being exposed to the FDA food label regularly as 71.3% of respondents reported buying their groceries most often in cans or packages that contain the FDA food label. The low level of FDA food label use among this group is not due to a lack of interest, as over 90% reported a strong interest in learning more about nutrition and the food label. Respondents' top three rec- ommendations for increasing their FDA food label use included making the FDA food label bilingual (65.0%), pro- viding more education on how to read the label (58.0%), and making the FDA food label easier to read (47.0%).

156 Haldeman et al . /FOOD LABEL F O R LOW-LITERACY LATINO CARETAKERS

Results from the KAB survey16 were highly consistent with these findings.

Food Guide Pyramid. Of those surveyed, 94.7% of the respondents reported having seen the Food Guide Pyramid. However, less than half of the respondents were able to cor- rectly identify the recommended daily number of servings for fruit (44.7%), vegetables (42.0%), dairy (48.0%), meats (47.3%), and grains (12.7%). Additionally, only 26.7% of respondents knew the number of fluid ounces in a cup and only 24.0% knew how many slices of bread were considered a serving.

Factors associated with FDA food label knowledge. Bivari- ate analyses revealed no significant associations between respondent's language, age, ethnicity, level of education, or Food Stamp eligibility and whether the respondents looked at the FDA food label when they were grocery shopping. By contrast, significant relationships were found between respondents' level of education, language, and age and their ability to correctly answer specific questions about the FDA food label (Table 1).

Product development. The development of the UFFL was the result of findings from the food label and KAB16 sur- veys, the first three focus group sessions,17 and two qualita- tive evaluations (Table 2).The UFFL (Fig. 2) was designed as a nutrition education tool for low-literacy audiences. Its pur- pose is to provide this target audience with the necessary information in an easy-to-understand format needed to

Table 1. Factors associated with food label knowledge.

make healthy food selections. Based on the constant and con- sistent request from focus group participants, the back of the UFFL (Fig. 3) included a set of instructions on how to read the 1abel.The instructions would be used as an education tool and would not be on the product.

Qualitative evaluation. The final focus group (N = 8) began with a brief, general discussion of the FDA food label (a copy ofwhich was given to each participant). Participants were able to identify specific information on the FDA food label. However, there was a general agreement that many people do not use or understand the FDA food label. Over- all, there was a positive response to the UFFL. Participants reported that it was easy to use and understand.

Peer review. One structural change made after receiving feedback from peer reviewers was with the color-coded scale.To avoid the "stoplight effect," it was recommended to change the red to purple to avoid having FDA food label users think that a red box in front of a nutrient meant that it was always "bad" for them (i.e., the "very high" connotation is very different if a product is high in fadcalories versus cal- cium or folic acid).

DISCUSSION

It was evident from the food label survey and focus group session findings that this community required more educa- tion to effectively use the FDA food label to make healthier

Servings Needed

Servings per unit % DV Fat in One Serving Product with Lowest % for Daily Calcium

(N = 149)* (N = 149)' DV for Fat (N = 146)' Requirement (N = 146)'

% (p Value) % (p Value) % (p Value) % (p Value)

Language

Spanish only

English or EnglishlSpanish

Age 15-1 9 years

20-35 years

2 36 years

School (completed)

c Eighth grade

Some high school

High school1G.E.D

Some college

'Missing data due to (1) skipped clause in survey, (2) one participant unable to read.

** Chi-square analyses + significant at p value < .05.

DV = daily value.

Journal of Nutrition Education Volume 32 Number 3 May June 2000 157

Table 2. Justification for changes made to FDA food label.

User-Friendly Food Label Justification

Section I Bilingual information FLS, NAFG

Addition of color-coding scale KAB, FLS, NAFG

Deletion of serving size weight FLS

Use of "servings per unit" NAFG

Inclusion of the "% calories from fat" NAFG

Section II

Section Ill

Changed to "% Daily Need" NAFG

Included color coding to indicate whether a food is low, medium, FLS, NAFG

high or very high in specific nutrient

Removed nutrient weights FLS

No color coding for sugars and dietary fiber FLS, NAFG

Vitamins and minerals are included as two clearly identified groups NAFG

Each vitamin and mineral is color coded NAFG

Removed information on percent daily values for 2000- and 2500- NAFG

calorie-a-day diet and calories per gram

Included Food Guide Pyramid indicating the number of food group FLS, NAFG

servings needed everyday for a 2000-calorie-a-day diet

Included the number of food group servings in one serving of the FLS, NAFG

product both in text and shading

Provided footnotes to explain that % daily need and servings needed FLS, NAFG

everyday are based on a 2000-calorie-a-day diet and to explain the

Food Guide Pyramid shading

Section IV Instructions on how to use FLS, NAFG, FFG

KAB = knowledge, attitudes, and behaviors survey; FLS = detailed food label survey; NAFG I-IV = needs assessment focus group sessions;

FFG = fourth focus group.

food selections. The food label survey did reveal that those with a lower level of education were less likely to correctly use the FDA food label. This finding is supported by previ- ous s t ~ d i e s . ~ . * , ~ ~ AS with the food label survey, Levy et al. (1992)4 also found that age was significantly associated with label comprehension. For this group, information about the FDA food label needs to be readily accessible for them to take the time to look at it and then to use it. However, to under- stand the need to first look at the FDA food label and what exactly they need to be looking for, it is imperative that nutrition information and education be made readily avail- able. Interestingly, respondents perceived that they under- stood the information in the FDA food label; however, when asked specific questions about it, they were unable to answer correctly.Therefore, the nutrition information on the UFFL needed to be written at an appropriate literacy level and in a format that was easily understandable-thus, the Span- ish/English version. The enthusiastic request for and accep- tance of the color coding by the respondents in this study indicates that this format is culturally appropriate for this group. It is also likely that the UFFL may be attractive to other ethnic groups as well. Although the vast majority of those interviewed were familiar with the FDA food label and

the Food Guide Pyramid, most were not using them effec- tively to make food selections. According to both the food label survey and the focus groups, the number one reason for this is a lack of understanding of the information.With regard to the FDA food label, this can be attributed to a lack of appropriate education and information. Guthrie et al. (1995)1° support these findings and report that lack of nutri- tion knowledge may be a significant barrier to more wide- spread effective use of nutrition labeling.

Last, the results of the final focus group indicated a strong connection between the UFFL and participants' ability to correctly retrieve information from the label. With the UFFL, participants were able to correctly identi6 whether a food was high, medium, or low in a particular nutrient as well as how many servings of each food group they should con- sume everyday.The findings from the final focus group sup- port the need for designing a more UFFL. Ideally, a more UFFL would not only enable those consumers involved in this study to make well-informed food selections, it would also increase their overall use of the FDA food label.

There are some limitations to this study. First, for the pur- poses of this study, a convenience sample was used. However, the high consistency of findings between the KAB survey,16

158 Haldeman et al./FOOD LABEL F O R LOW-LITERACY LATINO CARETAKERS

Nutrition FactWDatos de Nutricidn I Sewing Size = 1 cup Very HlghlMuy Alto Porci6n = I taza HigWAlto Sewings per unit = 2 M s d l u ~ l a n o , Porciones por unidad = 2 Lowmab 1

Amount Per 1 CuplCantidad Por 1 Taza Calorlmd 150 Calories from Fat/Calorlas de Grasa: 70 C8lori8s %Calories from Fat/% Calorlas de Grasa: 47% I % Daily Need/% Requerimiento Diario*

FaWOrasa 12%

Saturated FatIGrasa Saturada 28% I

Dietary Fiberffibra Dietaria 0961

SugarslAzlicar 11 g

PmtmlnlPmtmh8 89

Vitamin J Vimin CMtamina C 4% -

Vitarninrs Vitamin A N i i n a A 6% , Vitamin DNiimina D U% I

Minonld Calcium/Calcio 30%

'Servings needed everyday1 "Servings in one cup of this product1 'Porciones requeMas diariamente "Porciones en una taza de este

pmducto:

Figure 2. Front view of the user-friendly food label.

Journal of Nutrition Education Volume 32 Number 3 May June 2000

rpdtb(md Faanp*nwamm, m apdtbbcd ihnyoupl(1S- I mmamwawdtbbcdihnyoupl( me( ismem=sm) . ~ b u w I b o d o U b s l d h c # m f W ~ acwamd-catwawIrrIrr

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8.rrhg.prmm.2 m-(*r,ap#prrq

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-Amount Po# 1 CuCIC.ntldad Por 1 T a u bwd* IMbrMmbxmtbHh . . . . . . . . - .

- % Dally Mood/% Roquorinlonto DIario"

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Figure 3. Back view of the user-friendly food label.

160 Haldeman et al./FOOD LABEL F O R LOW-LITERACY LATINO CARETAKERS

the food label survey, and the three focus groups" strongly supports the external validity of these findings. In addition, the study was limited to Latino women caretakers and did not address the needs of children or men.

Another study limitation is that this study did not include an assessment of the knowledge gained or understood between the FDA food label and the UFFL in this group, and only a small number of focus groups were conducted for this evaluation.The positive response to the UFFL may have been due to the fact that the UFFL was bilingual. A comparison of use and understanding between the FDA food label and the UFFL among this group and a more in-depth evaluation of the effectiveness of the UFFL are areas for future research.

IMPLICATIONS FOR RESEARCH AND PRACTICE

As the development of the FDA food label took in excess of 6 years, the UFFL designed as a product of this study should not be seen as a replacement for the FDA food label. Rather, the methodology used to develop the UFFL may be used to aid the U.S. Department ofAgriculture and the FDA in the development of an improved food label.

Additionally, nutrition educators can use the UFFL to aid consumers on how to read the FDA food label and under- stand concepts needed to better use it.The methodology used in this study can serve as a model for developing other cul- turally appropriate nutrition education materials.This is par- ticularly urgent as both the food label survey and the focus group results revealed a strong need for more culturally appropriate general nutrition education interventions, as well as the strong interest this community has in learning more about nutrition.

ACKNOWLEDGMENT

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