Viviendo Mejor Educational Program

“VIVIENDO MEJOR”: APRENDER, PRACTICAR Y COMPARTIR IDEAS PARA

‘VIVIR MEJOR’.

“LIVING BETTER”: LEARNING, PRACTICING AND SHARING WAYS

TO‘LIVE BETTER’.

AN EDUCATIONAL PROGRAM FOR HISPANIC IMMIGRANTS IN GREENWOOD, SC

NUTRITN 572: Nutrition Education Project Implementation & Evaluation

Prepared by Lynsey BockOnline MPH in Nutrition Student, University of Massachusetts Amherst

Greenwood County, SC

Source: http://geology.com/county-map/south-carolina-county-map.gif

Research: Assessing the Target Audience

Results of Community Needs Assessment of Hispanic Immigrants in Greenwood, SC, October 2011

Greenwood County, SC obesity rate of 33% (County Health Rankings, 2011) higher than average rates of poverty and unemployment (Your Food Environment Atlas, 2010) lower than average income levels and persons meeting guidelines for recommended physical

activity (USDA Agricultural Research Center, 2009). Hispanic immigrants in Greenwood

greater obesity risk due to other factors that contribute to poor health and disproportionately affect Hispanics (Lopez-Quintero et al., 2009): low socioeconomic status, lack of education, inability to readily access healthcare and public resources, etc.

no public transportation to healthful grocery stores (Your Food Environment Atlas, 2010) little to no knowledge about local community gardens (Healthy Greenwood Neighborhoods,

2011) inconvenience of Farmers’ Markets or produce stands (Your Food Environment Atlas, 2010) few consistent and dependable primary care options (due to immigrant status) lack of access to some entitlement programs (due to immigrant status) negative effects of acculturation

Contributors to Obesity

“Despite the obvious necessity for intervention, there are no programs in Greenwood County to address the issue of obesity among the Hispanic immigrant population. Programming is needed to educate, counsel and support those who are obese or at risk of being obese.”

-Statement of the Nutritional Problem, Community Needs Assessment of

Hispanic Immigrants in Greenwood, SC,

October 2011

Barriers to preventing or

reversing obesity among Hispanic

immigrants in Greenwood

Overall Program Goal

This educational program will equip participants with the knowledge to identify local health and community resources, to associate diet and lifestyle to weight and overall health, and also to recognize the affects of acculturation within their population — both positive and negative — in efforts to reduce the prevalence of obesity among Hispanic immigrants in Greenwood, South Carolina.

Outcome Objectives:

1. The Hispanic immigrants participating in this educational program will increase their knowledge of local resources that provide fresh produce (e.g. community gardens, farmers’ markets and stands, food pantries), as well as knowledge of recreational opportunities and available primary care clinics in Greenwood by identifying at least two of each when prompted at the completion of the course.

2. The Hispanic immigrants participating in this educational program will demonstrate increased health literacy and nutritional knowledge by scoring higher on a post-assessment at the completion of the course than they did on their pre-assessment when the course began.

3. The Hispanic immigrants participating in this educational program will communicate both positive and negative acculturation practices that are prevalent in their community through facilitated group discussion and individually identify five key behaviors associated with acculturation that they could focus on after completion of the course.

Process Objectives:

1. The community nutritionist will conduct two 2 hour sessions per week for a total of four weeks and 16 hours to cover the core curriculum of the program.

2. The community nutritionist will provide within each session an intentional 20 minute time-frame for “Q&A” from the clients for specific questions, and should note any supplemental resources or information that she can bring to upcoming sessions to meet individual needs.

3. The community nutritionist will conduct both pre- and post- assessments with the program participants to determine baseline knowledge and newly acquired-knowledge through participation, as indicated in the curriculum timeline.

Logistics of Viviendo Mejor

La Puerta de Esperanza (LPE):

A Perfect Fit “The Door of Hope” non-profit organization established in the community (since 2003) relationship with many families already facilitates classes

M/W 9:30-11:30 (throughout the school year) (Lynsey) familiar with students as English teacher

Looking forward –a new direction

Logistics of Viviendo Mejor (cont.)

Students/Target Audience Hispanic immigrants residing in Greenwood Monday and Wednesday mornings from 9:30 a.m.

until 11:30 a.m primarily young non-working Hispanic women with

small children in the home ~10-12 students no criteria for eligibility

tailored for Spanish-speakers other members of the community welcome

Logistics of Viviendo Mejor (cont.)

Volunteer Staff Lynsey Bock: Lead Teacher Edith Pineda: Teacher and Translator Rachel Beita: Teacher and Translator Carol Gray (Director of La Puerta de Esperanza): Transportation/Childcare Nancy McQuown: ChildcareMaterials and Resources handouts: adapted online resources; several specifically developed, translated

or modified to be educational appropriate. volunteer translator and guest speakers/facilitators

Zumba instructor, yoga instructor, family medicine doctor paper (for handouts)- accounted for in budget costs incurred for building usage or transportation provided- accounted for in

budget healthy snacks and additional food costs for demonstrations-ONLY NEW COST

Intervention Model

Proposed Intervention Model Target Group is “Individuals” (Boyle & Holben 105)

seeking to influence family units through whole-family nutrition better nutrition for themselves and spouses also for children in the home and children on the way (discussion of prenatal

nutrition)

Level II “Level of Intervention” (Boyle & Holben 105)

proposing to “change lifestyles” through the small-group educational programming

Behavior Change Models

Relevant Behavior Change ModelsThe Health Belief Model (Boyle & Holben 513-514)

students’ perceived susceptibility or severity of the risk –i.e. obesity education on disease risk, relationship to diet, consequences of the

disease, impact on lifestyles. students’ perceived benefits and barriers

role models and data to support behavior change, “how-to” education for cooking, making substitutions in recipes, alternatives that are cost-effective and available for low-budget families.

social network of support (students share many of the same barriers and are working to find practical ways to overcome them)

self-efficacy training and demonstrations for healthier alternatives in dietary and lifestyle

choices small class size = personal coaching and counseling for individual needs

and concerns.

Behavior Change Models (cont.)

Relevant Behavior Change ModelsTranstheoretical Model (Stages of Change) (Boyle &

Holben 509)

curriculum lends itself to clients on various levels: basic education (Precontemplation or Contemplation

stages) application of the knowledge (such as recipes,

community resource lists or facilitated discussions) (Preparation, Action or Maintenance stages)

Pre-assessment and dietary questionnaires provide the facilitators with insight as to where clients are on this spectrum of stages.

Proposed Timeline for Viviendo Mejor: Recruiting Students

Two Weeks Prior to First Class: sign at La Puerta de Esperanza brochures on “Viviendo Mejor”

practitioners at La Clinica Gratis refer patients announcement at La Luz (Spanish language

service) at local Nazarene Church announcement on La Puerta de Esperanza’s

website and Facebook page. contact previous English students

introduce new curriculum encourage them to invite friends/neighbors

Inside of distributed brochure

Proposed Timeline for Viviendo Mejor: Schedule of Classes

Class One: The Food Pyramid/Plate: Guidelines for General Nutrition

1. Nutrition Pre-assessment and Dietary Questionnaire2. Go over MyPyramid and “Choose My Plate”3. Samples of serving sizes 4. Activity: “Choose my Plate” coloring sheet and food

cut-outs Design a “balanced” meal, placing foods in the correct grouping.

5. Healthy Snack Lesson: Tortilla roll-ups with banana and peanut butter

6. Take Home: Provide additional plates/food cut-outs to take home for children.

Nutrition Pre-assessment &

Dietary Questionnaire

My Pyramid

Source: http://www.choosemyplate.gov/foodgroups/downloads/sp-MiniPoster.pdf

Choose My Plate

Source: http://www.choosemyplate.gov/espanol/mini_poster_spanish_final.pdf

Choose My Plate Activity

Source: http://www.choosemyplate.gov/espanol/spmyplate_coloringsheet.pdf

Class Two: Labels/Food Health Claims: What do they mean? What do I look for?

1. Exploring Food Labels handout2. “Food Label Reference Guide” handout.3. Cardstock Nutrition Facts/Datos Nutricionales

Students conveniently take with them to the grocery store for quick translation reference

Color Guide: Values they want low or should use caution with are colored red; values they want high are colored green.

4. Activity: Sort through nutrition labels1. 1. Pick the “healthiest” based on the label. Defend your decision to the class. 2. 2. Pick one you believe is not healthy and explain this to the class as well.

5. Food Claims handout6. Discussion on misleading food labeling claims

1. Students should write down the claim in English so they can recognize it. 2. Show compiled samples (e.g. Chip bag that claims ‘a full serving of

vegetables’.)

7. Healthy Snack: Baby carrots, toasted pitas and hummus8. Take Home: Children’s worksheet for more practice

Exploring Food Labels

Handout

Source: http://www.kelloggsnutrition.com/files/KELL365_MN6-8span_1017.pdf (Page 14)

Food Label Reference

Guide Handout

Source: http://www.nourishinteractive.com/free_printables/hco/spanish-kids-how-to-read-food-labels-easy-chart-children-learning-food-labeling-nutrition.pdf

Nutrition Facts/Datos

Nutricionales

Food Labels Activity

Food Claims Handout

Source: http://www.nourishinteractive.com/free_printables/Spanish_family_nutrition/Nutrient_Claims_Reference_Chart.pdf

Misleading Labeling Claims

(This is a teacher resource, not a student

handout.)

Adapted from http://www.cncahealth.com/health-info/ge

neral/fooled-by-food-labels.htm

Take Home Handout: Practice Reading Labels

Source: http://www.nourishinteractive.com/free_printables/food-labels/spanish-comparing-food-labeling-nutrition-facts-

fill-in-blanks-food-label-worksheets.pdf

Class Three: The Whole Family: Infant and Child Nutrition Benefits of breastfeeding handout Preschool Nutrition handout Activity: Create a “kid-friendly” healthy snacks

at several snack stations. Homework: Students complete dietary recall

survey (to be used the following week)

“Working with moms, it is important to teach them (with examples) how to cook different kinds of food for their kids. It is difficult for them to change their own traditions but if you tell them is important for their kids’ health, this may motivate them.”

-Edith Pineda, La Puerta de Esperanza translator

Benefits of Breastfeeding

Handout

Adapted fromhttp://www.kingcounty.gov/healthservices/healt

h/personal/breastfeeding/advantages.aspx

Preschool Nutrition Handout

Source: http://www.choosemyplate.gov/foodgroups/downloads/Pointers4Preschoolers-SPAN.pdf

Station One:

Animal Cracker

Matching Game

Children find a match, name the animal, then eat

them.

Station Two:

Applesauce Painting

Provide applesauce colored with food coloring; sanitized

small paint brushes, and a large tray or

plate; children create a scene and then eat

the applesauce.

Station Three:

Trail Mix Mania

Provide a variety of different fun

ingredients for children to create their own special mix of trail mix –

but limit the M&M’s!)

Station Four:

Create-a-Face

Use a tortilla as the face and have a variety of healthy foods for children to design a face –e.g. raisins, small marshmallows,

peanuts, grapes, pretzel sticks, etc.

Class Four: Holistic health: Exercise and Lifestyle Choices Discuss “Healthy Weight” with provided BMI chart. Discuss affordable exercise suggestions for busy

families Discuss calorie counts for certain activities/chores

Compare to calorie counts for exercise to calories in soda, candy, etc.

Guest: Coordinator of Zumba classes at local community center visits

Activity: Representative from Wellness Works of Greenwood conducts a light yoga class with the mothers; shows them simple techniques to practice at home.

Healthy Snack: Popsicles made from yogurt & frozen fruit

Class Five: Meal Planning: Practical & Affordable Ways to Eat Healthy

Handout on substitutions to common dietary choices/ingredients (Using previous week’s dietary recall as a reference also.)

Activity- Cooking Demonstration: Rice Bowl brown rice boiled, seasoned pinto beans pico de gallo toppings: lime juice, cilantro, lettuce, avocado, fat free

sour cream, part-skim queso fresco Followed a reduced fat recipe; no oil in rice or beans)

Take home: Sample recipes with substituted ingredients (e.g. black bean burgers, lasagna made with spinach and ground turkey, etc.)

Suggestions for Substitutions

Class Six:(RESCHEDULED FOR SPRING)Home Gardening and “Homesteading”

Handouts and discussion on gardening techniques around the home: growing your own herbs (to replace salt or butter in flavoring) container gardening (and self-watering containers), square-foot gardening for small spaces and getting started in

South Carolina (specific planting dates). benefits of growing your own produce.

Activity: Travel to Seaboard Jardin Maravilloso a local community garden in conjunction with La Puerta discuss opportunities for involvement; participants receive free

produce practically year-round hands-on training for planting, pruning and watering.

Class Seven: Health Risks & Alternatives Discuss specific dietary “problem areas”: The reality of sugar-

sweetened beverages, fried foods, etc. by providing nutritional information. Discussion on the reality of fast food; healthier options when

eating out Activity: Students examine printed fast-food nutrition

information: to identify nutritional information for commonly purchased items to identify healthier menu options based on nutrition facts

Discuss the concept of “acculturation”; brainstorm with facilitated discussion how diets have changed since emigrating to the U.S. and suggest affordable alternatives for reversing negative effects.

Discuss local resources to combat barriers; provide poster developed by Healthy Greenwood Neighborhoods for contact information.

Source: http://www.healthygreenwoodneighborhoods.org/wp-content/uploads/2009/05/Greenwood-County-Family-Resource-Information.jpg

Class Eight: Chronic Disease: Warning Signs and Interventions

RESCHEDULED FOR JANUARY Chronic Disease and Obesity handout (Review BMI).

Discuss: What are these diseases? Guest Speakers: Family medicine doctor from La

Clinica Gratis speaks to patients about obesity, chronic disease and implications for health and lifestyle. Diabetes counselor from La Clinica also attends to discuss diabetes. Extended Q & A session.

Post-assessment and evaluation. Healthy Snack: Homemade veggie pizza with whole-

wheat crust; salad with a variety of dressings

Student Evaluations & Feedback

What are three behaviors you would like to change in your or your family’s diet and lifestyle? Eat more vegetables To not use as much fat in cooking/To eat less fat To eat less sugar To exercise more To learn to make more salads To learn not to “stress eat”/Eat less junk food

Do you think you will be successful in making these changes? Why or why not? “It will be difficult for me” “I think I can little by little” “Yes, I only need to be more persistent and mature.” (In response to reducing fat in cooking) “Yes! It’s healthier and more

economical!” “I hope to be successful [with exercise and eating more salads], but right

now my excuse is that it’s cold!”

Student Evaluations & Feedback (cont.) Which change do you think will be the easiest to make?

Learning to cook healthfully “Reducing breads and sodas in my diet” Eating more vegetables Cutting out junk food

Which change do you think will be the most difficult? Eating more vegetables Reducing tortillas in my diet Cooking without fat Exercising Cutting out junk food

Student Evaluations & Feedback (cont.) What class was the most interesting and helpful personally?

Nutrition Facts/Labels “When we learned to make healthy snacks and desserts”

What class was the most difficult for you to understand? Nutrition Facts

Would you recommend these nutrition classes to a friend or family member? Why or why not? “Yes, I believe that most of my friends do not have a good nutrition education.” “Yes, so we can better feed our children.”

Do you have other suggestions? More nutritional recipes to try at home “Teach us to prepare more salads, snacks and meals!”

Evaluation: LPE Staff

Successes: Class content: hands on, use of visual aids and examples, great variety of

topics, educationally appropriate Trying new foods (some they had never heard of before or had any

experience with), providing an opportunity they may not take at home (because of time and money)

Relevant topics: addressing health issues (including obesity) present among the students; providing nutrition as a tool for controlling their health

Equipping: recipes, handouts to use while shopping Personal: providing personal suggestions as a result of student questions Specifics: Information about sodas, sugar and oil were particularly relevant Feedback from students: It has been fun for them. They are surprised by

some things that they like. They are also surprised at how unhealthy some of the foods they eat are! 

Attendance!

Evaluation: LPE Staff (cont.)

“They now are equipped to make a choice about what they eat and how they exercise.”

–Rachel Beita

“Many are becoming interested in weight control, and health issues so that makes them interested [in the class content].”

–Carol Gray

“Learning how to read the nutrition labels was important for them. Some of them carry their label you gave them in their bags when they go to the grocery store.”

–Edith Pineda

Evaluation: LPE Staff (cont.)

Challenges & Suggestions: A lot of new information and new concepts; took more time to explain than

anticipated Translating also adds to time Lack of a kitchen- a kitchen would offer a lot of opportunity for healthy cooking

demonstrations and hands-on learning Issue of motivation- some view changes as too much of a sacrifice, “set in their

ways” Social/familial barriers still exist: husbands, etc. are used to “normal” ways of

cooking, eating, so there’s more “risk” involved in making changes different levels of education; some already were very familiar with concepts;

others did not know the words in their own language, which created difficulties. Educational barriers to assessment/evaluation Consistency of students (Attendance Incentive?)  provide more “take home” resources- recipes, etc. provide more “rare” vegetables that they aren’t familiar with and new dishes for

them to try

Planning for the Future

Completing Class Six: Home Gardening & Homesteading

Completing Class Eight: Chronic Disease: Warning Signs & Interventions

Completing Final Evaluations & Post-Assessments Developing further curriculum (e.g. cooking, fitness

classes) Possible field trip: Grocery Shopping

Conclusions

Necessity of Post-Assessment & Final Evaluation

Conclusions: If these classes were offered again to a similar group of students, modifications would include: More class sessions or reduced content Narrower outcome objectives Modified form of assessment & evaluation

References

Boyle, M., and Holben, D. (2010). Community Nutrition in Action, An Entrepreneurial Approach. (5th ed.). Belmont, California: Wadsworth, Cengage Learning.

Choose my Plate.gov. Consejos para ayudar a los niños de edad preescolar. Retrieved on November 8, 2011 from http://www.choosemyplate.gov/foodgroups/downloads/Pointers4Preschoolers-SPAN.pdf

Choose my Plate.gov. Mi Plato. Retrieved on November 8, 2011 from http://www.choosemyplate.gov/espanol/spmyplate_coloringsheet.pdf.

Choose my Plate.gov. Que hay en su plato? Retrieved on November 8, 2011 from http://www.choosemyplate.gov/espanol/mini_poster_spanish_final.pdf.

County Health Rankings. 2011 Greenwood South Carolina. Retrieved on September 28, 2010 from http://www.countyhealthrankings.org/south-carolina/greenwood.

CNCA Health. Fooled by Food Labels: 9 Deceptive Claims to Watch Out For. Retrieved on October 16, 2011 from http://www.cncahealth.com/health-info/general/fooled-by-food-labels.htm.

Geology.com. South Carolina County Map. Retrieved on November 30, 2011 from http://geology.com/county-map/south-carolina-county-map.gif.

References (cont.)

Healthy Greenwood Neighborhoods. Community Produce Garden Grants. Retrieved on October 8, 2011 from http://www.healthygreenwoodneighborhoods.org/?page_id=130.

Healthy Greenwood Neighborhoods. Neighborhood Wellness. Retrieved on October 8, 2011 from http://www.healthygreenwoodneighborhoods.org/?page_id=40

Kelloggs Nutrition. L.A.U.N.C.H. Grades 6-8. Retrieved on November 8, 2011 from http://www.kelloggsnutrition.com/files/KELL365_MN6-8span_1017.pdf.

Lopez-Quintero C., Berry E., Neumark Y. (2009). Limited English Proficiency is a barrier to receipt of advice about physical activity and diet among Hispanics with chronic diseases in the United States. American Dietetic Association, 109: 1769-1774.

My Pyramid.gov. MiPiramide. Retrieved on November 8, 2011 from http://www.choosemyplate.gov/foodgroups/downloads/sp-MiniPoster.pdf.  

Nourish Interactive. Carta de Referencia de Reclamaciones Nutritivas. Retrieved on November 8, 2011 from http://www.nourishinteractive.com/free_printables/Spanish_family_nutrition/Nutrient_Claims_Reference_Chart.pdf.

References (cont.)

Nourish Interactive. Free Printables. Retrieved on November 8, 2011 from

http://www.nourishinteractive.com/free_printables/food-labels/spanish-comparing-food-labeling-nutrition-facts-fill-in-blanks-food-label-worksheets.pdf.

Nourish Interactive. Guía de Referencia Para La Etiqueta Alimenticia. Retrieved on November 8, 2011 from http://www.nourishinteractive.com/free_printables/hco/spanish-kids-how-to-read-food-labels-easy-chart-children-learning-food-labeling-nutrition.pdf.

Public Health: Seattle and King County. How breastfeeding is best for you and your baby. Retrieved on October 5, 2011 from http://www.kingcounty.gov/healthservices/health/personal/breastfeeding/advantages.aspx.

USDA Agricultural Research Service. South Carolina Nutrient Intakes. Retrieved on September 28, 2011 from http://www.ars.usda.gov/Services/docs.htm?docid=15727. 

Your Food Environment Atlas. Greenwood Food Environment Data. Retrieved on September 28, 2011 from http://maps.ers.usda.gov/FoodAtlas/foodenv5.aspx.