The Stanford Nutrition Action Program: A Dietary Fat Intervention for Low-Literacy Adults
Howard-Pitney B, Winkleby MA, Albright CL, Bruce B, Fortmann SP "The Stanford Nutrition Action Program: a dietary fat intervention for low-literacy adults." Am J Public Health 1997; 87: 12: 1971-6:
Abstract overview:
This study examines the effectiveness of The Stanford Nutrition Action program (SNAP) curriculum in lowering the dietary fat intake among low-income adults who have low literacy skills.
As the American population becomes more and more diverse it can be hard to identify subgroups that may be at high risk for cardiovascular disease. One group at risk are adults with limited literacy abilities, and it is estimated that as many as 90 million or 48 percent of Americans fall into this category. Traditionally, low literacy rates have been positively correlated with lower education levels, income levels and occupational status, all of which are predictors of cardiovascular disease risk factors.
This study compares the effectiveness of the SNAP classroom-based nutrition curriculum with another curriculum that was designed for low-income people, but that was not necessarily tailored to low-literacy adults. The SNAP materials use methods especially developed for adults with low literacy skills and consider principles of social learning theory and adult learning into the curriculum.
More than 350 participants attended 24 classes that were randomized in the study. Eighty percent of the participants were women, and follow-up participation was strong: Seventy-nine percent of participants completed the baseline and first follow-up measurement. That number only fell by ten percent (to 69%) for participants who completed all three follow-up measurements.
The SNAP intervention consisted of a 6-week classroom-based curriculum that targeted low-fat eating guidelines and featured a goal-setting component. Very few written materials were used in the classroom, with much emphasis on an interactive learning environment. A 12-week maintenance period followed that included contact with participants by telephone or mail. These contacts were made by SNAP teachers and research assistants and were designed to provide support and encouragement to participants.
By contrast, the General Nutrition Intervention consisted mostly of lectures, a review of class handouts and recipes and the preparation of a recipe for the class to sample.
At three different times in the study data were collected from the participants in the form of a questionnaire developed for lower reading levels. Questionnaires were collected when the participants first started the program (baseline), one week after finishing the classroom portion of the intervention (first follow-up), and one week after the maintenance portion of the intervention (second follow-up). Approximately 5 months lapsed between the baseline and second follow-up data collection.
This study finds that the SNAP classes demonstrated greater improvement in nutrition knowledge, attitudes, and self-efficacy than those participants who only took part in the General Nutrition curriculum. SNAP participants also showed greater reductions in the amount of total fat and saturated fat that they consumed in their diets. Eight weeks after baseline data were assessed, the SNAP group showed a four percent reduction in the calories from total fat that they consumed. By contrast, the General Nutrition Intervention participants showed a one percent reduction in total fat consumed when assessed at the same time.
Perhaps the most promising news is that all the positive intervention effects in the SNAP group were maintained for three months after the intervention was completed.
Secondary findings of the study:
There were no significant differences in body mass index or blood cholesterol between the SNAP participants and the General Nutrition Intervention participants. Because this study only followed participants for three months, it is not surprising that these two physiological measures showed no change. SNAP curriculum emphasized eating less fat, but did not significantly address eating fewer calories or exercising.
Implications and recommendations from the study:
This study demonstrates the need for appropriate health education materials for the millions of adults in the United States with low literacy skills. Community-based programs and health professionals who serve these populations might do well to incorporate culturally sensitive materials aimed at low-literacy learning into their programs. Additionally, the goal-setting aspect of each SNAP classroom lesson was very important to achieving behavioral change. And the follow-up support through phone calls and mail may explain how participants maintained the high level of change that they made during the classroom phase of the study.
Proposed news articles and related information:
- Where else might low-literacy educational materials help address health concerns of this at-risk population?
- Harvard School of Public Health; Health Literacy Studies and Health Literacy Studies in the News
- Harvard School of Public Health How to Create and Assess Print Materials; by Rima E. Rudd –
- The Journal of Medical Internet Research; Internet Usage by Low-Literacy Adults Seeking Health Information
- National Institute for Literacy; Literacy Promotion in Healthcare Settings
