Using Low-Literacy Newsletters to Provide Nutrition Education for Limited-Resource Individuals

Progress toward improving the health status of Americans will not be made unless special emphasis is placed on educating the limited-resource population. The Nutrition Education Program (NEP) in Alabama created new opportunities to reach food stamp recipients and other limited-resource individuals. Although it is a challenge to reach the 200,000+ food stamp recipients, NEP uses a variety of methods to reach this audience. Paraprofessionals teach through class series and single presentations, conduct food demons t rat ions, a n d display exhibi ts . Statewide activities include a 1-800 nutrition hotline and NEP coalitions throughout the state. One method used to meet the massive educational challenges of NEP was a newsletter series entitled Food News. The primary goal of Food News was to communicate nutrition messages in an interactive, easy-to-understand way to the target audience. Since newsletters were distributed at food stamp centers, there was a ootential to reach a different audience than those who attend structured nutrition classes. A secondary goal was to develop a database of limited-resource individuals who would be willing to participate in further assessments. The content and style of Food News were based on guidelines for low-literacy print materials in nutrition for adults.'.' Seven developmental guidelines were used: (1) Each Food News emphasized a specific topic, and information was repeated throughout each newsletter to enhance learning. (2) How-to information was included; the front of the two-sided publication presented nutrition information, whili the back presented the same information as a learn-by-doing self-test activity. Readers could answer learn-by-doing questions on the back by using information on the front. Learn-by-doing activities were designed to be easy to complete, with an example of how to answer the activity. (3) The Food News had a combination of expert and peer input. Nutritionists developed sample copies with appropriate content, style, and format. In pretesting, limited-resource individuals gave opinions on clarity and acceptability. Newsletters were finalized based o n this input, which dealt mainly with recipes. For example, summer squash was used in a recipe instead of zucchini, which is not commonly consumed by the target audience. (4) A traditional southern recipe was used in each newsletter. Nutritionists modified the recipes for fat content and consumers taste tested the foods for acceptability. (5) Specific and concise terminology was used. Short sentences with one-syllable words and simple illustrations were provided. For example,"Fast food has a lot of fat" was accompanied by a list of fast foods and drawings of corresponding pats of fat in each food. (6) In addition, direct, positive statements were used rather than complex, negative sentences. An example was "Eating less fat helps your heart and weight," rather than "If you don't eat a lot of fat you won't be as likely to have a heart attack or gain weight." (7) Active voice (e.g., "Use the unit price") was used instead of passive verbs (e.g., "The unit price should be used"). The researchers wrote at a thirdgrade level or below according to the Fog I n d e ~ . ~ In designing Food News for low-literate adults, five specific format guidelines1 were used. First, all six issues of Food News were printed front to back with red ink on heavyweight card-stock paper to make them attractive and eyecatching. Second, illustrations were directly related to content and reflected common Southern foods.Third, a serif type using capital and lower case letters was used for better readability. Fourth, each layout was designed to have as much white space as possible to assist readability. Last, the 8% x 14-inch size publications were folded in half for easy storage in a cookbook. The newsletters were distributed cost effectively through food stamp centers in six urban areas. Approximately 70,000 newsletters, enough for one per urban food stamp household, were available with food stamps received over the counter. In contrast, two-thirds of recipients live in rural areas and receive food stamps by mail. These individuals did no t receive newsletters due to prohibitive postal costs and budget constraints. Readers' comprehension of the nutrition information on the mass-distributed newsletters was assessed. This was accomplished using a perforated business reply mail (BRM) card attached to the newsletters. After readers voluntarily indicated their responses to the learn-by-doing questions on this card, it was mailed to the researchers. These questions were a replication of the learn-by-doing activity contained in the newsletter. The responses were evaluated to determine readers' understanding of newsletter content. For this article, the results of the responses to a learn-by-doing activity from one Food News are provided in Table 1. T h e major ingredients of Hamburgervegetable Soup, the recipe for this particular Food News, were used in the learn-by-doing activity. For each of the ingredients, two unit prices were shown. In general, the unit prices varied according to national versus store brands and size of food packages. Readers were asked to circle which unit price was the better buy for each ingredient. Over 70% of respondents correctly identified the better food buy for all ingredients (seeTable 1); answers for each ingredient were statistically significant (p i .05, chi-square goodness-of-fit test). A second objective of Food News was to develov a database of food stamp recipients willing to participate in further assessments. Readers who returned the B R M card provided name, address, and telephone number. There was a box for the reader to check: "Check the box if you are willing to let us call you.We will ask questions about how you shop and eat." O f