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Comparison of the beliefs and practices of EFNEP clients with staff perceptions of clients
RESEARCH ARTICLE
Comparison of the Beliefs and Practices of EFNEP Clients with Staff Perceptions of Clients
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BARBARA BREMNER, CATHY C. CAMPBELL, AND JEFFERY SOBAL Division of Nutritional Sciences, Cornell University, Ithaca, New York 14853
ABSTRACT This study examined how accurately the paraprofessionals and professionals employed by the Expanded Food and Nutrition Education Program (EFNEP) in New York State perceived the beliefs and practices of their clients. Because paraprofessionals are indigenous workers, they are assumed to have more accurate perceptions of clients than professionals, potentially making them more effective communicators. A series of36 semistructured interviews with program clients and staff was employed to develop the quantitative measuring instruments used in personal interviews with a purposive sample of 51 clients and as a self-administered questionnaire with all EFNEP staff (43 professionals and 173 paraprofessionals). Results showed that both paraprofessionals and professionals held inaccurate perceptions of their clients in the areas of health, nutrition, resource management, learning, and knowing. EFNEP staff frequently underestimated the ability and self-esteem of clients and the extent to which clients adhered to and considered important the EFNEP objectives. Contrary to expectation, paraprofessionals did not have perceptions of clients that were any more accurate than were those of professionals. These findings suggest that attention to the recruiting, hiring, and training practices of the EFNEP may reduce the disparities between staff perceptions and client responses.
Service, Home Economics and Human Nutrition, U.S. Department of Agriculture. The objectives of the program are "to assist low-income families and youth acquire the knowledge, skills, attitudes, and changed behaviors necessary for nutritionally sound diets and .to contribute to their personal development and the improvement of total family diet and nutritional welfare." 3 As with many other human service programs that originated around that time, the EFNEP employs indigenous paraprofessionals to deliver their service. 4,s The term "indigenous" is used here to describe personnel with socioeconomic and cultural characteristics similar to the client population, including living in the same neighborhood. Paraprofessionals are any persons with a level of education less than that typically required by professionals. 6 Indigenous paraprofessionals are employed both to provide jobs and careers for the unemployed and because they are cheap and plentiful,7-9 From an organizational standpoint, indigenous paraprofessionals are thought to "close the gap" between human service agencies and their clients. The gap includes both cultural and social class differences as well as the distance between bureaucratic features of many agencies and the poor. IO In particular, with relevance to this study, indigenous paraprofessionals are thought to be more knowledgeable than professionals about the attitudes, values, and practices of community residents. II These characteristics of indigenous paraprofessionals are assumed to assure the kind of relationship that fosters mutual understanding, reciprocity, and the desired change in clientsY This study examined how accurately the paraprofessionals and professionals employed by the EFNEP in New York State perceive the beliefs and practices of their clients. It was hypothesized that paraprofessionals would have more accurate perceptions of clients than would the professionals, potentially making them more effective communicators. In addition, the study investigated whether there were subgroups of paraprofessionals who differed in the accuracy of their perceptions of clients. It was hypothesized that paraprofessionals with demographic characteristics similar to clients, or who had been employed for a shorter duration of time, may have more accurate perceptions of clients. A secondary objective was to understand the beliefs and
(fNE 26:123-130,1994)
INTRODUCTION The Expanded Food and Nutrition Education Program (EFNEP) is one of the programs targeted at low-income audiences that grew out of the United States' "war on poverty" in the 1960s.I.2 The EFNEP is part of Extension "Barbara Bremner is currently a nutritionist with the State WIC program in Austin, Texas, and Cathy Campbell is currently enrolled at the Vancouver School of Theology, British Columbia. This paper is drawn from a 1992 M.S. Thesis by Barbara Bremner in the Division of Nutritional Sciences at Cornell University. The research was supported by the Expanded Food and Nutrition Education Program of New York State and the Division of Nutritional Sciences, Cornell
University. An earlier version of the paper was presented at the 1992 annual meeting of the Society for Nutrition Education. Address for correspondence: Barbara Bremner, 1905 West 34th Street, Austin, TX 78703; Tel: (512) 371-0636. <01994 SOCIETY FOR NUTRITION EDUCATION
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practices of EFNEP participants. A method to determine whether paraprofessionals in the EFNEP are indigenous (as reflected here by accurate perceptions of the clients) may be useful in the future for investigating whether paraprofessionals who are indigenous are more effective than paraprofessionals who are not. METHODS This study included two phases, an instrument development stage and the final survey. Both phases explored beliefs and practices relating to three main constructs: (1) health and nutrition; (2) resources and their management; and (3) learning and knowing. These constructs were chosen a priori to reflect the activities of the EFNEP: the first two constructs focus on what the program teaches, while the third relates to the educational process of the EFNEP. In addition, a number of theoretical concepts relating to poverty, fatalism, and self-esteem guided the study and will be elaborated on in the discussion. The University Human Subject's Committee approved the study protocol, and all interviews were conducted with the written, informed consent of respondents. Instrument development. Ethnographic research methods were employed to develop two validated quantitative measuring instruments: an interview schedule for clients and a self-administered questionnaire for staff. The questionnaire was reviewed by a group of extension specialists and university faculty. Thirty-six interviews with a purposive sample of respondents were conducted by the first author in a three-cycle process. In the first cycle, six clients, six paraprofessionals, and two professionals were interviewed using a semistructured format and open-ended questions. These interviews were used to explore the constructs of interest. Emphasis was placed on letting respondents describe their world in the way they experienced it. After listening to tape recordings of all the interviews, verbatim transcriptions were made of responses that best expressed the interviewees' beliefs and practices relating to the constructs under investigation. In the second cycle, the interviews with six clients, six paraprofessionals, and one professional became more structured and used progressively more fixed-response formats. The wording of questions and response options was based on terms and phrases used by respondents in the first cycle. The evolving measurement instrument was therefore representative of the respondents' beliefs, practices, and language. In the third instrument development cycle, three clients, four paraprofessionals, and two professionals who were interviewed in the first cycle were re-interviewed using a structured format. Their responses in the two interviews were compared to assess the consistency in response between qualitative and quantitative approach and the meaningfulness of the overall instrument.
The final survey. Self-administered questionnaires for EFNEP staff and structured personal interviews with clients were used to collect data in the final survey. Two survey methods, self-administered questionnaires and personal interviews, were employed because of the different reading and writing abilities of respondents. The ethnographic interview process suggested that the clients' response rate to a self-administered questionnaire would be unacceptably low.
Staff respondents. All EFNEP staff in New York State participated in this study. Questionnaires were mailed through the State Cooperative Extension system to 43 professionals (39 agents, 2 program leaders, and 2 extension associates) and 173 paraprofessionals (nutrition teaching assistants). Of the 216 questionnaires sent out, 199 (92%) were completed and returned. Client respondents. A purposive sample of 51 clients was interviewed in six carefully selected sites, two in New York City and four upstate. Based on EFNEP records, clients at these sites were representative of all New York State clients in terms of their living area (urban/rural), race/ethnicity, age, income, and educational background. At each site, paraprofessionals scheduled interviews with their newest clients, to represent a range of demographic backgrounds. Newly enrolled clients were chosen so that the beliefs they expressed were their own and not those they had learned in the program. The first author interviewed all clients in upstate New York; a trained, bilingual interviewer conducted the New York City interviews. Upstate clients were usually interviewed in their homes, while in New York City, most interviews were conducted at the EFNEP meeting site. The instruments. The content of the self-administered questionnaire and interview protocol were identical except that (1) the instructions and stem for each question were modified to suit the format; (2) the self-administered questionnaire, in addition to asking EFNEP staff about their own beliefs and behaviors, also requested them to answer as they thought their clients would; (3) the self-administered questionnaire contained items requesting demographic information, whereas for interviewees this information was ascertained from EFNEP records; and (4) the personal interview questionnaire was translated into Spanish for clients who spoke Spanish. The exact wording and response formats of the subset of nine questions used in this paper are presented in Appendix 1. Coding and data analysis. Written responses to the interviews and questionnaires were coded using a numerical coding guide and edited as described below. The sevenpoint ranking of Question 1 was reduced to a three-point ranking by recoding approximately the top one quarter as
an "important" reason, the next one half as "quite important", and the remaining quarter as "not important". The first six items (or less if fewer were given) on each menu in Question 3 were coded according to the type of food. Food items were then classified into the Four Food Groups plus a non-nutrient dense group, using the EFNEP food classification system as a guide. The first six problems mentioned (or less if fewer were given) in Question 9 were also coded, using an exhaustive list of options. Responses were then sorted and combined into categories that addressed broader issues. The analysis plan used a series of comparisons of beliefs and practices. First, to determine how accurately EFNEP staff perceive the beliefs and practices of their clients, comparisons were made between the responses of (1) clients and paraprofessionals' perceptions of clients and (2) clients and professionals' perceptions of clients. Second, to assess whether there was a subgroup of paraprofessionals who differed in the accuracy of their client perceptions, four additional comparisons were made between the responses of paraprofessionals (1) who had a high school education or less and those with post-secondary education; (2) who were 36 years or less (one standard deviation above the mean client age) and those who were older than 36 years; (3) who had personal experience with public assistance or food stamps and those who did not; and (4) who were employed by the EFNEP for 1 year or less and those who had been employed for 19 or more years (these cutoff points were based on the distribution of employment duration data). Data were entered into a spreadsheet and then transferred to the SYSTA T computer package for statistical analysis. 13 To test for significant differences in belief and practice between the comparison groups listed above, two types of statistical tests were performed. Two sample t-tests were used for continuous variables such as age and income with two-tailed tests considered significant if p ::; .05. For categorical variables, Chi-squares with p ::; .05 were considered significant.
Reasons for health. The accuracy of paraprofessionals' and professionals' perceptions of client beliefs about reasons for health is presented in Figure 1. The seven reasons are arranged from those that are beyond human control ("fate" and "heredity") to those under greater personal control ("lifestyle" and "nutrition"). Tests of significance were based on the three-point rankings of each of the reasons for health. In all the reasons except "the environment", perceptions of staff differed significantly from what clients actually reported. Program staff said that clients would rank "fate" and "heredity" more highly than they actually did, while staff believed clients would rank "the immune system," "your attitude," "nutrition," and "lifestyles" less highly (all p < .05). Except for "heredity" and "the environment," slightly more paraprofessionals than professionals correctly predicted client responses. Younger paraprofessionals were more likely than older paraprofessionals to believe clients would rank "lifestyles" and "the immune system" as important contributors to health, but the difference was not significant (p > .07). Paraprofessionals who had personal experience with public assistance or food stamps thought clients would rank the effect of "heredity" on health more highly than those who had no personal experience (p < .05). Meaning of eating right. Both paraprofessionals and professionals had very inaccurate perceptions of what eating right means to clients, as shown in Figure 2, where options are arranged in ascending order by client choice. Sixty-one percent of the paraprofessionals and 42% of the professionals believed that clients would define eating right in monetary terms, compared to only 7% of clients who actually did. A third of the professionals also thought that, for clients, eating right means "no junk food." Clients, on the other hand,
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Ufoslyles :.-• • •
RESULTS
Demographics. Paraprofessionals share few demographic characteristics with the clients in this study. They were older (mean of 46 years vs. 28 years), better educated (59% had more than a high school education vs. 27% of the clients), and reported larger family incomes (mean of $1,7351 month vs $5911month; all p < .001). Fewer paraprofessionals than clients lived in inner city areas (26% vs. 61%; p < .001), and slightly fewer paraprofessionals were from minority groups (36% vs. 43%; NS). The paraprofessionals were similar in age to the professionals (mean of 46 years vs. 45 years) and lived in similar types of residential areas. The paraprofessionals had worked in the EFNEP for a mean of 9.6 years, compared with 9.8 years for the professionals.
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Journal of Nutrition Education Volume 26 Number 3
Nutrition
&:J
Professionals' perceptions of clients
• •
Paraprofessionals' perceptions of clients Clients' actual responces
Attitude
ImmuneSysIeIII Environment
W
ID
~
~
~
Percentage
~
m
~
~
~
(%)
Figure 1. Comparison of staff perceptions versus client responses about the important reasons for health .•• p < .01, ••• p < .001; Chi-square tests between paraprofessionals' perceptions of
clients and clients' actual responses and between professionals' perceptions of clients and clients' actual responses
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Bremner et al.lBELIEFS AND PRACTICES OF EFNEP CLIENTS
defined eating right as "a balanced diet," "the four food groups," and "plenty of variety." Younger paraprofessionals were less likely than were older paraprofessionals to believe that clients would define eating right as "having enough money" (p < .01). Describing a good meal. A food group breakdown of how clients described a good meal, as well as the way EFNEP staff thought they would, is presented in Table 1. In general, paraprofessionals believed that clients would include more of the four food groups, especially breads and cereals, in the meal than clients actually did. Forty-one percent of the paraprofessionals described a meal including all four food groups, compared with 29% of the clients and 15% of the professionals (NS) . Professionals underestimated how many clients would include a vegetable or fruit in their meal. An important finding is that about three times as many staff believed clients would include a non-nutrient dense food in their meal than was actually reported by the clients. In a frequency count of food items, chicken, milk, corn, potato, rice, and bread were included most often by clients, paraprofessionals, and professionals. However, clients went on to mention a wide range of meats and meat alternatives, vegetables, and fruits in their meals. Staff were more likely to believe that clients would include non-nutrient dense foods (including fries, soda, Kool-aid, and cake) and inexpensive foods (such as hot dogs and macaroni and cheese) in their meals. Perhaps it is for this reason that when asked whether they would call the clients' meal they described "good," 34% of paraprofessionals and 58% of professionals said " no." Financial control. Clients reported feeling significantly more in control of their finances (42%) than either paraprofessionals (2%) or the professionals (0%) believed they would (both p < .001). Some of this difference may be due to a more rigid definition of financial control by EFNEP staff
... ~ I'Tolessional.' perception. 01 clients
Low salt, lat" sugar
•••• Paraprofes.sioNls· perceptions of clients • Oiont,' actual responses
Me.t, potato" • veg. No;ml< IoocIs
Having enough money
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_ _ __
10
20
30
40
50
60
70
Percentage (%)
Figure 2.
Comparison of staff perceptions versus client re-
sponses about what eating right means. "'p < .001; Chi-square tests between all paraprofessionals' perceptions of clients and all clients' actual responses and between all professionals' perceptions of clients and all clients' actual responses
(they often emphasized formal budgeting techniques), whereas clients relied on, and felt comfortable with, more informal budgetary control mechanisms. Paraprofessionals did not perceive their clients' financial control any more accurately than did the professionals. However, paraprofessionals who had been employed with the EFNEP for a long time thought that clients felt a greater degree of financial control than did newly employed paraprofessionals (p < .05). Almost half (49%) of the clients reported that they always keep track of their money, although only 3% of the paraprofessionals and 2% of the professionals thought that clients always did (p < .001) . Most EFNEP staff believed clients sometimes or occasionally kept track of their money. Being smart and being a teacher_Program staff significantly underestimated the proportion of clients who
Table 1. Comparison of staff perceptions versus client responses about what constitutes a good meal. Perceptions of Client Responses Clients' Actual Responses (n
% (n)
m
49)
Paraprofessionals (n
= 154)
Professionals (n = 40)
% (n)
% (n)
37.5 (15)
Food groups included
Dairy
40.8 (20)
53.2 (82)
Meat and alternatives
98.0 (48)
98.7 (152)
92.5 (37)
100.0 (49)
94.8 (146)
90.0 (6)' 67.5 (27)
Vegetables and fruit Bread and cereal
53.1 (26)
83.8 (129)'"
All four food groups
28.6 (14)
40.9 (63)
15.0 (6)
Non-nutrient dense foods
14.3 (7)
41.6 (64)'"
42.5 (7)*'
'p < .05; "p < .01; "'p < .001; Chi-square tests between paraprofessionals' perceptions of clients and clients' actual responses and between profeSSionals' perceptions of clients and clients' actual responses.
thought they were smart. While 63% of clients assessed their "smartness" in the most positive way possible, only 15% of paraprofessionals and 17% of professionals believed clients would do so (both p < .001). Paraprofessionals and professionals were more likely to perceive clients as "sometimes" feeling smart. Paraprofessionals who had personal experience with public assistance or food stamps were less likely than those who did not to report that clients think of themselves as smart (p < .01). Program staff also significantly underestimated the proportion of clients who think of themselves as a teacher. About five times the number of clients reported feeling like a teacher (53%, usually with their children) than either paraprofessionals (9%) or professionals (10%) thought would do so (both p < .001). The younger paraprofessionals were more likely than older paraprofessionals to believe that clients think of themselves as a teacher (p < .05). The accuracy with which program staff perceived the form of "smartness" valued by clients is reported in Figure 3, which arranges options in ascending order by client choice. During the instrument development phase, each of these categories emerged as a discrete component of being "smart". Both paraprofessionals (p < .001) and professionals (p < .01) held significantly inaccurate perceptions of clients, especially in underestimating the importance of" common sense" to clients. In addition, paraprofessionals believed clients value "knowing the right way to do things" (often used in the context of wanting to fit in with society) more than was reported by clients. Professionals also overestimated the value clients place on being "street smart."
The biggest problems of limited-income people. The range and depth of problems faced by limited-income people mentioned by the respondents was vast. Those problems mentioned by more than one fifth of clients, paraprofessionals, or professionals are presented in Figure 4, where options are arranged in ascending order by client choice. The problem cited most often by all respondents was that limited-income people do not have enough money. Program staff focused on a range of material resources - including money, housing, and health care - as well as on the personal deficiencies of limited-income people. By contrast, clients stressed the absolute lack of money and food, and the implications ofliving with constant economic constraints.
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Journal of Nutrition Education Volume 26 Number 3 •• El 8ei"8 peopIeSl1\lrt
Professionals' perceptions of clients
•••• Paraprofcssional,' perceptions of clients
•
Clients' actual respon .....
Having wisdom
Being street smart
to do thlf185 Knowing therighl way Having common !eRIe
iiiliililii!ZZZl
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!!I!!!!!!!!!!I!!!!!!!!!I!!!!!!!!!!I!!!!!!!!!!!!!!!!~.....J
20
10
30
Percentage (%)
40
60
Figure 3. Comparison of staff perceptions versus client responses about the form of "smartness" valued .•• p < .01, ••• p < .001; Chi-square tests between all paraprofessionals' perceptions of clients and all clients' actual responses and between all professionals' perceptions of clients and all clients' actual responses.
which suggests that poor people are different from middleclass Americans in how they think, feel, and act.14 This cultural deficiency model, popular in the 1960s and '70s, has largely been replaced by the "underclass" concept,15 which also proposes that a segment of the poor are economically deprived and manifest a distinctive set of values, attitudes, beliefs, norms, and behaviors. 16 ,17 The consequence of the "culture of poverty" view of the poor, and to a lesser extent the "underclass" concept, is that the principle causes of their plight are assumed to be the internal deficiencies of their way of life. The proposed solution under this perspective is to be found through education, social work, and psychiatry, rather than doing
Crime/.Icohol/a_ low oeU eoteem
o
Professionals' ~ns
• •
Paraprofesionals' perceptions Clienls' perceptions
re"".. lIy deficlenl Don'l plan/budget
Transport Hulth and helllII coou
Limiled education/;>!> oIdl.. roor or costly houling
Prejudice/inequity I!!!~~~ Can'l gel.head/hope....
DISCUSSION
Not trough food
HIving logo wilhout Noterough""""'Y
1;;iiiiiiiii;~
____
L.o
The results show that in almost every respect EFNEP staff held inaccurate perceptions of their clients. Differences between what clients reported and staff perceived illustrate four interrelated, underlying themes: education, fatalism, self-esteem, and indigenousness.
Figure 4. Comparison of staff versus client perceptions about the perceived problems of limited-income people. Up to six prob-
The need for education. One view of the poor in the United States is built on the idea of a "culture of poverty,"
lems mentioned by each respondent were analyzed and problems mentioned by more than one fifth of clients, paraprofessionals, or professionals are reflected in the figure.
o
10
20
30
40
Percentage (%)
50
60
128
Bremner et al.lBELIEFS AND PRACTICES OF EFNEP CLIENTS
away with poverty using economic or economically related interventions.!8.!9 Many of the problems that EFNEP staff perceived limited-income people to be facing emphasize the deficiencies of the poor. Far more often than the clients themselves, staff spoke oflimited-income people as "lacking" education, job skills, life skills, parenting skills, and budgeting skills. In addition, staff wrote about limited-income people in pejorative ways: the poor are lazy; unmotivated; they do not plan ahead or budget their money. In the ways they described the beliefs and practices of their clients, program staff also demonstrated that they do not think clients do the right things or know the right way to do things . Few paraprofessionals or professionals thought that clients would describe eating right as "a balanced diet," or that clients would serve what the staff considered a "good meal." Staff also underestimated how important clients thought nutrition is to health and did not think that clients are in control of their money or keep track of it very often. These findings show that EFNEP staff use the "culture of poverty" perspective of the poor, and consider clients to be in need of education. Clients, on the other hand, frequently demonstrated that they know nutritionally appropriate behaviors. They know what eating right means and are able to describe a "good meal." As suggested by their own description oflimited-income peoples' biggest problems, clients may be prevented from doing what they see as the right thing because they simply don't have enough money. Clients may also choose to act differently or eat low-nutrient dense food because of other desires, preferences, or pressures, not because they don't know any better. The difference in the perceived need for education between staff and clients is perhaps inevitable. The EFNEP is an education program, requiring that staff highlight ways in which client knowledge, attitudes, and practices can be improved. However, these findings suggest that the program may benefit from focusing less on providing information and more on identifYing the barriers to and incentives for behavior change. The former tends to emphasize client deficiencies, whereas the latter acknowledges the unfavorable living circumstances of clients and the ability of clients to make positive changes in their lives.
Fatalism versus personal control. The "culture of poverty" and "hard-to-reach" concept suggest that poor people hold fatalistic views and lack a sense of personal control in their lives. 20 ,2! In addition, the health literature frequently suggests that people with low socioeconomic status are less likely to take personal control of their health care. 22-25 EFNEP staff perceived clients to be very fatalistic about reasons for health, in line with the concept of a low health locus of control. However, clients expressed less fatalistic attitudes about health than they were perceived to do by program staff. Clients also ranked many of the "lifestyle"
factors as being more important than staff thought they would, showing that they are more conscious of their own health than staff perceive. In addition, clients expressed a greater degree of financial control than staff believed they would.
Self-esteem and empowerment. Related to the issue of personal control are the concepts of self-esteem and empowerment, which are of particular interest because of the recent interest in the role of nutrition education as an instrument of empowerment. 26 ,27 Staffin this survey clearly perceived their clients as powerless and lacking in self-esteem. Almost a third of the staff specifically mentioned low self-esteem as being a problem for limited-income people, whereas few of the clients reported this as a concern. A strong indication that clients think of themselves in a more positive way than staff is their assessment of their own abilities. The majority of clients think of themselves as a smart person and as a teacher. Both of these self-assessments are positive indications of esteem and personal power. Staff were far less likely to perceive clients in these ways and more likely to view them in a demeaning manner. Indigenousness of paraprofessionals. Indigenous paraprofessionals were hypothesized to be more knowledgeable about the beliefs and practices of clients than were professionals. Previous studies have found this to be the case, such as the one by Grosser!! in New York City during the early years of paraprofessional employment. However, in the present study, the paraprofessionals did not have any more accurate perceptions of client beliefs and practices than did the professionals. On almost every construct tested, the paraprofessionals' perceptions of clients were very close to those of the professionals, and paraprofessional and professional perceptions of clients differed significantly from what clients actually reported. This suggests that either paraprofessionals were never aware of the beliefs and practices of their clients (perhaps that they were never indigenous), or that the attitudes and opinions of the professionals (and the program in general) predominate. A longitudinal study of perceptions of a cohort of paraprofessionals over time would be required to test these options. Some paraprofessionals were better at predicting client responses than were others. They included paraprofessionals whose age was more similar to that of clients (younger), and those who did not have personal experience with public assistance or food stamps. The reasons for this are unclear. A study that included a larger sample of paraprofessionals and clients would be required to investigate this question . Limitations. Several limitations of this study are relevant for interpreting the findings. First, all of the information is based on self-reports. The vested interests of clients and staff may have resulted in a response bias that made clients look better in their own eyes and more needy from the perspec-
May. June 1994
Journal of Nutrition Education Volume 26 Number 3
tive ofEFNEP workers. Second, staff were asked to generalize about their clients, or describe their "typical client," which may have fostered stereotyping. Third, the design is cross-sectional and did not permit longitudinal analysis or the detection of a cohort effect, which may be important in comparisons based on the employment duration of paraprofessionals. Similarly, staff may have been describing more than just their present clients when responding to questions, while only new clients were included in the sample. Fourth, the study assumes that data collected by personal interviews and self-administered questionnaires are comparable. This seems to be a reasonable assumption given that the interviews with clients were structured and followed the same question guide as in the staff questionnaires. Fifth, the study was conducted in only one state so that the specific results may not be generalizable nationally. The authors believe that these limitations fail to account for all of the differences observed and that the findings reveal a consistent gap between EFNEP clients and the paraprofessionals and professionals who work with them. CONCLUSIONS The overall conclusion of this study is that the majority of paraprofessionals and professionals employed by the EFNEP in New York State have inaccurate perceptions of their clients. Despite being valued for their indigenous qualities, the paraprofessionals in this study were demographically more similar to their professional colleagues than to the clients, and their perceptions of their clients were no more accurate. In addition, the direction ofEFNEP staff misperception was consistent in underestimating client beliefs and practices. While limitations in the methods and design may account for some of these misperceptions, the patterns in the findings suggest that the EFNEP can benefit from identifying ways to reduce the disparities between staff perceptions and clients. The response the EFNEP takes would depend partially on whether the negative staff attitudes about clients are present before staff begin with the program. It would also be important to know in what ways negative perceptions of clients are reinforced or challenged in the program. Neither of these questions can be answered by the present study and both need further investigation. However, the following policy changes could be used: The program could continue to emphasize recruiting unemployed or underemployed people, such as clients themselves. Hiring could include questioning applicants to ensure that potential employees have a perceptive and empathetic insight into the lives of the poor. Staff education could emphasize the clients' perspective, including their assets. This may involve discussions of the structural and environmental factors that contribute to poverty and the lifestyle of the poor14 •28 as well as the resourcefulness of limited-income people. 29 Roundtable discussions with cli-
129
ents may also help orient staff to the clients' perspective. The educational focus of the program could be shifted from information transfer (which emphasizes client deficiencies) to reducing barriers and providing incentives to behavior change (which fosters the ability of clients to make positive changes in their lives, despite unfavorable life circumstances) . It would be important to know whether the inaccurate staff perceptions have any effect on paraprofessionals' interactions with clients or on the programs' overall effectiveness. Many studies have documented that the EFNEP is effective in producing and maintaining significant improvements in the eating habits of its clients3Q-33 as well as in contributing to their personal development. 27 •34 The results of this study do not negate these findings, but do suggest ways that the EFNEP may be modified to meet clients' needs more effectively. Further research is necessary to determine whether paraprofessionals who are indigenous are more effective than paraprofessionals who are not. It is clear from this study that any investigation about indigenous workers must first assess the degree to which assumed indigenous characteristics are in fact present. REFERENCES 1. Synectics Corporation. The Expanded Food and Nutrition Education Program: historical and statistical profile. Washington, DC: U.S. Department of Agriculture, Science & Education Administration, Program Aid No. 1230, 1979: 1-4. 2. Chipman H, Kendall PA. 20 Years ofEFNEP: changes and challenges. J Nutr Educ 1989; 21:265-9. 3. U.S. Department of Agriculture, Extension Service. Expanded food and nutrition education program policies, 1983. 4. Gartner A. Paraprofessionals and their performance, a survey of education, health and social service programs. New York: Praeger, 1971. 5. Brager G. The indigenous worker: a new approach to the social work technician. Soc Work 1965; 10(2):33-40. 6. Rothman
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Planning and organizing for social change. New York:
Columbia University Press, 1974: 175. 7. Pearl A, Riessman F. New careers for the poor. New York: The Free Press, 1965. 8. Riessman F. Paraprofessionals: twenty years later. Soc Policy 1984; Winter: 39. 9. Pickett AL. The paraprofessional movement: an update. Soc Policy 1984; Winter: 40-3. 10. Reiff R, Riessman F. The indigenous paraprofessional: a strategy of change in community action and community mental health programs. Community Men Health Mon 1965; 1 :3-32. 11. Grosser C. Local residents as mediators between middle class professional workers and lower class clients. Soc Serv Rev 1966; 40:56-63. 12. Giblin PT. Effective utilization and evaluation of indigenous health care workers. Public Health Rep 1989; 104:361-8. 13. Systat, Inc. SYSTAT: Evanston, IL: Systat Inc., 1989. 14. Katz TJ. The undeserving poor. New York: Pantheon Books, 1989: 7.
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15. Morris M. From the culture of poverty to the underclass: an analysis
26. Kent G. Nutrition education as an instrument of empowerment. J Nutr Educ 1988; 20:193-5.
ofa shift in public language. Am Sociologist 1989; 20:123-33. 16. See KO . Comments from the special issue editor: approaching poverty
27 . Rody N . Empowerment as an organizational policy in nutrition intervention programs: a case study from the Pacific Islands. J Nutr
in the United States. Soc Prob 1991; 38:427-32.
Educ 1988; 20:133-41.
17. Richetts E, Sawhill!. Defining and measuring the underclass. J Policy
28. Zinn MB. Family, race and poverty in the eighties. Signs 1989;
Anal Man 1988; 7:316-25.
14:856-74.
18. Lewis O . La Vida: a Puerto Rican family in the culture of povertySanjuan and New York. New York: Random House, 1966.
29. Fitchen JM. Poverty in rural America: a case study. Boulder, CO: Wesrview Press, 1981.
19. Valentine CA. Culture and poverty: critique and counter-proposals.
30. Amstutz MK, Dixon DL. Dietary changes resulting from the Expanded
Chicago: The University of Chicago Press, 1968: 75.
Food and Nutrition Education Program. J Nutr Educ 1986; 18:55-60.
20. Lewis O. The culture of poverty. Sci Am 1966; 215:19-25. 21. Fremouth VS, Mettger W . Is there a hard-to-reach audience? Public
31. Tredici AM Del, Joy AB , Omelich CL, Laughlin SG. Evaluation study of the California Expanded Food and Nutrition Education Program:
Health Rep 1990; 105:232-8.
24-hour food recall. J Am Diet Assoc 1988; 88: 185-90.
22. Wallston B, Wallston K, DeVellis R. Development of the multidimensional health locus of control (MHLC) scales. Health Educ Mon
32. Torisky DM, Hertzler AA,JohnsonJM, et al. Viginia EFNEP homemakers' dietary improvement and relation to selected family factors. J
1978; 6:160-70.
Nutr Educ 1989; 21:249-58.
23. Cockerham WC , Lueschen G, Kunz G, SpaethJL. Social stratification and self-management of health. J Health Soc Behav 1986; 27:1-14.
33. ArmstrongJE, Butkus S, Movius M, Crowley D. The effect of changes in recruitment and instruction on characteristics of EFNEP enrolees
24. Calnan M. Maintaining health and preventing illness: a comparison of
and graduates. J Nutr Educ 1992; 24:87-90.
the perceptions of women from different social classes. Health Pro mot
34. Randall MJ, Brink MS, Joy AB. EFNEP: an investment in America's
1986; 1:167-77.
future. J Nutr Educ 1989; 21:276-9.
25. Dean K. Self-care components oflifestyles: the importance of gender, attitudes and the social situation. Soc Sci Med 1989; 29:137-52.
Appendix 1. WORDING OF QUESTIONS IN CLIENT INTERVIEWS AND STAFF SURVEYS." 1. Why do you(r clients)bthink that some people are more healthy than others? Please rank the seven ways listed below. Heredity "You get it from your parents"
Fate "It's meant to be that way"
Your attitude "Thinking positively"
Nutrition "What you eat"
Lifestyles "The way you live and take care of yourself"
The immune system 'Your resistance to germs"
The environment "Where you live"
2. Which way listed below best describes what 'eating right' means to you(r clients)? No junk food
Meat, potato, and a vegetable
A balanced diet
Low salt, low fat, and low sugar
Having enough money to buy what I need
Plenty of variety
The four food groups
3. If you(r clients) were serving your(their) family a good meal, but not an especially fancy one, what would be on the plate? 4.
How in control of your(their) finances do you(r clients) feel? Totally in control
Somewhat in control
Not at all in control
5. How often do you(r clients) keep track of where your(their) money goes? Always
6.
Usually No
Knowing the right way to do things
Having intelligence
Being "street smart"
Having common sense
Having wisdom
Do you(r clients) think of yourself(themselves) as a teacher? Yes
9.
Sometimes
There are many different ways a person can be "smart". Which way is most important for you? Being "people smart"
8.
Occasionally
Do you think you(r clients think they) are smart? Yes
7.
Sometimes
No
Sometimes
From your experience, what are the biggest problems that limited-income people face?
aThis is not the original order of questions. bWords in parenthesis were separate questions in the self-administered questionnaire.
Never
Comparison of the Beliefs and Practices of EFNEP Clients with Staff Perceptions of Clients
*
*
BARBARA BREMNER, CATHY C. CAMPBELL, AND JEFFERY SOBAL Division of Nutritional Sciences, Cornell University, Ithaca, New York 14853
ABSTRACT This study examined how accurately the paraprofessionals and professionals employed by the Expanded Food and Nutrition Education Program (EFNEP) in New York State perceived the beliefs and practices of their clients. Because paraprofessionals are indigenous workers, they are assumed to have more accurate perceptions of clients than professionals, potentially making them more effective communicators. A series of36 semistructured interviews with program clients and staff was employed to develop the quantitative measuring instruments used in personal interviews with a purposive sample of 51 clients and as a self-administered questionnaire with all EFNEP staff (43 professionals and 173 paraprofessionals). Results showed that both paraprofessionals and professionals held inaccurate perceptions of their clients in the areas of health, nutrition, resource management, learning, and knowing. EFNEP staff frequently underestimated the ability and self-esteem of clients and the extent to which clients adhered to and considered important the EFNEP objectives. Contrary to expectation, paraprofessionals did not have perceptions of clients that were any more accurate than were those of professionals. These findings suggest that attention to the recruiting, hiring, and training practices of the EFNEP may reduce the disparities between staff perceptions and client responses.
Service, Home Economics and Human Nutrition, U.S. Department of Agriculture. The objectives of the program are "to assist low-income families and youth acquire the knowledge, skills, attitudes, and changed behaviors necessary for nutritionally sound diets and .to contribute to their personal development and the improvement of total family diet and nutritional welfare." 3 As with many other human service programs that originated around that time, the EFNEP employs indigenous paraprofessionals to deliver their service. 4,s The term "indigenous" is used here to describe personnel with socioeconomic and cultural characteristics similar to the client population, including living in the same neighborhood. Paraprofessionals are any persons with a level of education less than that typically required by professionals. 6 Indigenous paraprofessionals are employed both to provide jobs and careers for the unemployed and because they are cheap and plentiful,7-9 From an organizational standpoint, indigenous paraprofessionals are thought to "close the gap" between human service agencies and their clients. The gap includes both cultural and social class differences as well as the distance between bureaucratic features of many agencies and the poor. IO In particular, with relevance to this study, indigenous paraprofessionals are thought to be more knowledgeable than professionals about the attitudes, values, and practices of community residents. II These characteristics of indigenous paraprofessionals are assumed to assure the kind of relationship that fosters mutual understanding, reciprocity, and the desired change in clientsY This study examined how accurately the paraprofessionals and professionals employed by the EFNEP in New York State perceive the beliefs and practices of their clients. It was hypothesized that paraprofessionals would have more accurate perceptions of clients than would the professionals, potentially making them more effective communicators. In addition, the study investigated whether there were subgroups of paraprofessionals who differed in the accuracy of their perceptions of clients. It was hypothesized that paraprofessionals with demographic characteristics similar to clients, or who had been employed for a shorter duration of time, may have more accurate perceptions of clients. A secondary objective was to understand the beliefs and
(fNE 26:123-130,1994)
INTRODUCTION The Expanded Food and Nutrition Education Program (EFNEP) is one of the programs targeted at low-income audiences that grew out of the United States' "war on poverty" in the 1960s.I.2 The EFNEP is part of Extension "Barbara Bremner is currently a nutritionist with the State WIC program in Austin, Texas, and Cathy Campbell is currently enrolled at the Vancouver School of Theology, British Columbia. This paper is drawn from a 1992 M.S. Thesis by Barbara Bremner in the Division of Nutritional Sciences at Cornell University. The research was supported by the Expanded Food and Nutrition Education Program of New York State and the Division of Nutritional Sciences, Cornell
University. An earlier version of the paper was presented at the 1992 annual meeting of the Society for Nutrition Education. Address for correspondence: Barbara Bremner, 1905 West 34th Street, Austin, TX 78703; Tel: (512) 371-0636. <01994 SOCIETY FOR NUTRITION EDUCATION
123
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Bremner et aJ.lBELIEFS AND PRACTICES OF EFNEP CLIENTS
practices of EFNEP participants. A method to determine whether paraprofessionals in the EFNEP are indigenous (as reflected here by accurate perceptions of the clients) may be useful in the future for investigating whether paraprofessionals who are indigenous are more effective than paraprofessionals who are not. METHODS This study included two phases, an instrument development stage and the final survey. Both phases explored beliefs and practices relating to three main constructs: (1) health and nutrition; (2) resources and their management; and (3) learning and knowing. These constructs were chosen a priori to reflect the activities of the EFNEP: the first two constructs focus on what the program teaches, while the third relates to the educational process of the EFNEP. In addition, a number of theoretical concepts relating to poverty, fatalism, and self-esteem guided the study and will be elaborated on in the discussion. The University Human Subject's Committee approved the study protocol, and all interviews were conducted with the written, informed consent of respondents. Instrument development. Ethnographic research methods were employed to develop two validated quantitative measuring instruments: an interview schedule for clients and a self-administered questionnaire for staff. The questionnaire was reviewed by a group of extension specialists and university faculty. Thirty-six interviews with a purposive sample of respondents were conducted by the first author in a three-cycle process. In the first cycle, six clients, six paraprofessionals, and two professionals were interviewed using a semistructured format and open-ended questions. These interviews were used to explore the constructs of interest. Emphasis was placed on letting respondents describe their world in the way they experienced it. After listening to tape recordings of all the interviews, verbatim transcriptions were made of responses that best expressed the interviewees' beliefs and practices relating to the constructs under investigation. In the second cycle, the interviews with six clients, six paraprofessionals, and one professional became more structured and used progressively more fixed-response formats. The wording of questions and response options was based on terms and phrases used by respondents in the first cycle. The evolving measurement instrument was therefore representative of the respondents' beliefs, practices, and language. In the third instrument development cycle, three clients, four paraprofessionals, and two professionals who were interviewed in the first cycle were re-interviewed using a structured format. Their responses in the two interviews were compared to assess the consistency in response between qualitative and quantitative approach and the meaningfulness of the overall instrument.
The final survey. Self-administered questionnaires for EFNEP staff and structured personal interviews with clients were used to collect data in the final survey. Two survey methods, self-administered questionnaires and personal interviews, were employed because of the different reading and writing abilities of respondents. The ethnographic interview process suggested that the clients' response rate to a self-administered questionnaire would be unacceptably low.
Staff respondents. All EFNEP staff in New York State participated in this study. Questionnaires were mailed through the State Cooperative Extension system to 43 professionals (39 agents, 2 program leaders, and 2 extension associates) and 173 paraprofessionals (nutrition teaching assistants). Of the 216 questionnaires sent out, 199 (92%) were completed and returned. Client respondents. A purposive sample of 51 clients was interviewed in six carefully selected sites, two in New York City and four upstate. Based on EFNEP records, clients at these sites were representative of all New York State clients in terms of their living area (urban/rural), race/ethnicity, age, income, and educational background. At each site, paraprofessionals scheduled interviews with their newest clients, to represent a range of demographic backgrounds. Newly enrolled clients were chosen so that the beliefs they expressed were their own and not those they had learned in the program. The first author interviewed all clients in upstate New York; a trained, bilingual interviewer conducted the New York City interviews. Upstate clients were usually interviewed in their homes, while in New York City, most interviews were conducted at the EFNEP meeting site. The instruments. The content of the self-administered questionnaire and interview protocol were identical except that (1) the instructions and stem for each question were modified to suit the format; (2) the self-administered questionnaire, in addition to asking EFNEP staff about their own beliefs and behaviors, also requested them to answer as they thought their clients would; (3) the self-administered questionnaire contained items requesting demographic information, whereas for interviewees this information was ascertained from EFNEP records; and (4) the personal interview questionnaire was translated into Spanish for clients who spoke Spanish. The exact wording and response formats of the subset of nine questions used in this paper are presented in Appendix 1. Coding and data analysis. Written responses to the interviews and questionnaires were coded using a numerical coding guide and edited as described below. The sevenpoint ranking of Question 1 was reduced to a three-point ranking by recoding approximately the top one quarter as
an "important" reason, the next one half as "quite important", and the remaining quarter as "not important". The first six items (or less if fewer were given) on each menu in Question 3 were coded according to the type of food. Food items were then classified into the Four Food Groups plus a non-nutrient dense group, using the EFNEP food classification system as a guide. The first six problems mentioned (or less if fewer were given) in Question 9 were also coded, using an exhaustive list of options. Responses were then sorted and combined into categories that addressed broader issues. The analysis plan used a series of comparisons of beliefs and practices. First, to determine how accurately EFNEP staff perceive the beliefs and practices of their clients, comparisons were made between the responses of (1) clients and paraprofessionals' perceptions of clients and (2) clients and professionals' perceptions of clients. Second, to assess whether there was a subgroup of paraprofessionals who differed in the accuracy of their client perceptions, four additional comparisons were made between the responses of paraprofessionals (1) who had a high school education or less and those with post-secondary education; (2) who were 36 years or less (one standard deviation above the mean client age) and those who were older than 36 years; (3) who had personal experience with public assistance or food stamps and those who did not; and (4) who were employed by the EFNEP for 1 year or less and those who had been employed for 19 or more years (these cutoff points were based on the distribution of employment duration data). Data were entered into a spreadsheet and then transferred to the SYSTA T computer package for statistical analysis. 13 To test for significant differences in belief and practice between the comparison groups listed above, two types of statistical tests were performed. Two sample t-tests were used for continuous variables such as age and income with two-tailed tests considered significant if p ::; .05. For categorical variables, Chi-squares with p ::; .05 were considered significant.
Reasons for health. The accuracy of paraprofessionals' and professionals' perceptions of client beliefs about reasons for health is presented in Figure 1. The seven reasons are arranged from those that are beyond human control ("fate" and "heredity") to those under greater personal control ("lifestyle" and "nutrition"). Tests of significance were based on the three-point rankings of each of the reasons for health. In all the reasons except "the environment", perceptions of staff differed significantly from what clients actually reported. Program staff said that clients would rank "fate" and "heredity" more highly than they actually did, while staff believed clients would rank "the immune system," "your attitude," "nutrition," and "lifestyles" less highly (all p < .05). Except for "heredity" and "the environment," slightly more paraprofessionals than professionals correctly predicted client responses. Younger paraprofessionals were more likely than older paraprofessionals to believe clients would rank "lifestyles" and "the immune system" as important contributors to health, but the difference was not significant (p > .07). Paraprofessionals who had personal experience with public assistance or food stamps thought clients would rank the effect of "heredity" on health more highly than those who had no personal experience (p < .05). Meaning of eating right. Both paraprofessionals and professionals had very inaccurate perceptions of what eating right means to clients, as shown in Figure 2, where options are arranged in ascending order by client choice. Sixty-one percent of the paraprofessionals and 42% of the professionals believed that clients would define eating right in monetary terms, compared to only 7% of clients who actually did. A third of the professionals also thought that, for clients, eating right means "no junk food." Clients, on the other hand,
JIII-.-
Ufoslyles :.-• • •
RESULTS
Demographics. Paraprofessionals share few demographic characteristics with the clients in this study. They were older (mean of 46 years vs. 28 years), better educated (59% had more than a high school education vs. 27% of the clients), and reported larger family incomes (mean of $1,7351 month vs $5911month; all p < .001). Fewer paraprofessionals than clients lived in inner city areas (26% vs. 61%; p < .001), and slightly fewer paraprofessionals were from minority groups (36% vs. 43%; NS). The paraprofessionals were similar in age to the professionals (mean of 46 years vs. 45 years) and lived in similar types of residential areas. The paraprofessionals had worked in the EFNEP for a mean of 9.6 years, compared with 9.8 years for the professionals.
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May • June 1994
Journal of Nutrition Education Volume 26 Number 3
Nutrition
&:J
Professionals' perceptions of clients
• •
Paraprofessionals' perceptions of clients Clients' actual responces
Attitude
ImmuneSysIeIII Environment
W
ID
~
~
~
Percentage
~
m
~
~
~
(%)
Figure 1. Comparison of staff perceptions versus client responses about the important reasons for health .•• p < .01, ••• p < .001; Chi-square tests between paraprofessionals' perceptions of
clients and clients' actual responses and between professionals' perceptions of clients and clients' actual responses
126
Bremner et al.lBELIEFS AND PRACTICES OF EFNEP CLIENTS
defined eating right as "a balanced diet," "the four food groups," and "plenty of variety." Younger paraprofessionals were less likely than were older paraprofessionals to believe that clients would define eating right as "having enough money" (p < .01). Describing a good meal. A food group breakdown of how clients described a good meal, as well as the way EFNEP staff thought they would, is presented in Table 1. In general, paraprofessionals believed that clients would include more of the four food groups, especially breads and cereals, in the meal than clients actually did. Forty-one percent of the paraprofessionals described a meal including all four food groups, compared with 29% of the clients and 15% of the professionals (NS) . Professionals underestimated how many clients would include a vegetable or fruit in their meal. An important finding is that about three times as many staff believed clients would include a non-nutrient dense food in their meal than was actually reported by the clients. In a frequency count of food items, chicken, milk, corn, potato, rice, and bread were included most often by clients, paraprofessionals, and professionals. However, clients went on to mention a wide range of meats and meat alternatives, vegetables, and fruits in their meals. Staff were more likely to believe that clients would include non-nutrient dense foods (including fries, soda, Kool-aid, and cake) and inexpensive foods (such as hot dogs and macaroni and cheese) in their meals. Perhaps it is for this reason that when asked whether they would call the clients' meal they described "good," 34% of paraprofessionals and 58% of professionals said " no." Financial control. Clients reported feeling significantly more in control of their finances (42%) than either paraprofessionals (2%) or the professionals (0%) believed they would (both p < .001). Some of this difference may be due to a more rigid definition of financial control by EFNEP staff
... ~ I'Tolessional.' perception. 01 clients
Low salt, lat" sugar
•••• Paraprofes.sioNls· perceptions of clients • Oiont,' actual responses
Me.t, potato" • veg. No;ml< IoocIs
Having enough money
iiiiiiii~iii~iii~"'___-
Plenty 01 variety • The lour lood groupo •
__
_ _ __
10
20
30
40
50
60
70
Percentage (%)
Figure 2.
Comparison of staff perceptions versus client re-
sponses about what eating right means. "'p < .001; Chi-square tests between all paraprofessionals' perceptions of clients and all clients' actual responses and between all professionals' perceptions of clients and all clients' actual responses
(they often emphasized formal budgeting techniques), whereas clients relied on, and felt comfortable with, more informal budgetary control mechanisms. Paraprofessionals did not perceive their clients' financial control any more accurately than did the professionals. However, paraprofessionals who had been employed with the EFNEP for a long time thought that clients felt a greater degree of financial control than did newly employed paraprofessionals (p < .05). Almost half (49%) of the clients reported that they always keep track of their money, although only 3% of the paraprofessionals and 2% of the professionals thought that clients always did (p < .001) . Most EFNEP staff believed clients sometimes or occasionally kept track of their money. Being smart and being a teacher_Program staff significantly underestimated the proportion of clients who
Table 1. Comparison of staff perceptions versus client responses about what constitutes a good meal. Perceptions of Client Responses Clients' Actual Responses (n
% (n)
m
49)
Paraprofessionals (n
= 154)
Professionals (n = 40)
% (n)
% (n)
37.5 (15)
Food groups included
Dairy
40.8 (20)
53.2 (82)
Meat and alternatives
98.0 (48)
98.7 (152)
92.5 (37)
100.0 (49)
94.8 (146)
90.0 (6)' 67.5 (27)
Vegetables and fruit Bread and cereal
53.1 (26)
83.8 (129)'"
All four food groups
28.6 (14)
40.9 (63)
15.0 (6)
Non-nutrient dense foods
14.3 (7)
41.6 (64)'"
42.5 (7)*'
'p < .05; "p < .01; "'p < .001; Chi-square tests between paraprofessionals' perceptions of clients and clients' actual responses and between profeSSionals' perceptions of clients and clients' actual responses.
thought they were smart. While 63% of clients assessed their "smartness" in the most positive way possible, only 15% of paraprofessionals and 17% of professionals believed clients would do so (both p < .001). Paraprofessionals and professionals were more likely to perceive clients as "sometimes" feeling smart. Paraprofessionals who had personal experience with public assistance or food stamps were less likely than those who did not to report that clients think of themselves as smart (p < .01). Program staff also significantly underestimated the proportion of clients who think of themselves as a teacher. About five times the number of clients reported feeling like a teacher (53%, usually with their children) than either paraprofessionals (9%) or professionals (10%) thought would do so (both p < .001). The younger paraprofessionals were more likely than older paraprofessionals to believe that clients think of themselves as a teacher (p < .05). The accuracy with which program staff perceived the form of "smartness" valued by clients is reported in Figure 3, which arranges options in ascending order by client choice. During the instrument development phase, each of these categories emerged as a discrete component of being "smart". Both paraprofessionals (p < .001) and professionals (p < .01) held significantly inaccurate perceptions of clients, especially in underestimating the importance of" common sense" to clients. In addition, paraprofessionals believed clients value "knowing the right way to do things" (often used in the context of wanting to fit in with society) more than was reported by clients. Professionals also overestimated the value clients place on being "street smart."
The biggest problems of limited-income people. The range and depth of problems faced by limited-income people mentioned by the respondents was vast. Those problems mentioned by more than one fifth of clients, paraprofessionals, or professionals are presented in Figure 4, where options are arranged in ascending order by client choice. The problem cited most often by all respondents was that limited-income people do not have enough money. Program staff focused on a range of material resources - including money, housing, and health care - as well as on the personal deficiencies of limited-income people. By contrast, clients stressed the absolute lack of money and food, and the implications ofliving with constant economic constraints.
127
May • June 1994
Journal of Nutrition Education Volume 26 Number 3 •• El 8ei"8 peopIeSl1\lrt
Professionals' perceptions of clients
•••• Paraprofcssional,' perceptions of clients
•
Clients' actual respon .....
Having wisdom
Being street smart
to do thlf185 Knowing therighl way Having common !eRIe
iiiliililii!ZZZl
I====~ii~~::
!!I!!!!!!!!!!I!!!!!!!!!I!!!!!!!!!!I!!!!!!!!!!!!!!!!~.....J
20
10
30
Percentage (%)
40
60
Figure 3. Comparison of staff perceptions versus client responses about the form of "smartness" valued .•• p < .01, ••• p < .001; Chi-square tests between all paraprofessionals' perceptions of clients and all clients' actual responses and between all professionals' perceptions of clients and all clients' actual responses.
which suggests that poor people are different from middleclass Americans in how they think, feel, and act.14 This cultural deficiency model, popular in the 1960s and '70s, has largely been replaced by the "underclass" concept,15 which also proposes that a segment of the poor are economically deprived and manifest a distinctive set of values, attitudes, beliefs, norms, and behaviors. 16 ,17 The consequence of the "culture of poverty" view of the poor, and to a lesser extent the "underclass" concept, is that the principle causes of their plight are assumed to be the internal deficiencies of their way of life. The proposed solution under this perspective is to be found through education, social work, and psychiatry, rather than doing
Crime/.Icohol/a_ low oeU eoteem
o
Professionals' ~ns
• •
Paraprofesionals' perceptions Clienls' perceptions
re"".. lIy deficlenl Don'l plan/budget
Transport Hulth and helllII coou
Limiled education/;>!> oIdl.. roor or costly houling
Prejudice/inequity I!!!~~~ Can'l gel.head/hope....
DISCUSSION
Not trough food
HIving logo wilhout Noterough""""'Y
1;;iiiiiiiii;~
____
L.o
The results show that in almost every respect EFNEP staff held inaccurate perceptions of their clients. Differences between what clients reported and staff perceived illustrate four interrelated, underlying themes: education, fatalism, self-esteem, and indigenousness.
Figure 4. Comparison of staff versus client perceptions about the perceived problems of limited-income people. Up to six prob-
The need for education. One view of the poor in the United States is built on the idea of a "culture of poverty,"
lems mentioned by each respondent were analyzed and problems mentioned by more than one fifth of clients, paraprofessionals, or professionals are reflected in the figure.
o
10
20
30
40
Percentage (%)
50
60
128
Bremner et al.lBELIEFS AND PRACTICES OF EFNEP CLIENTS
away with poverty using economic or economically related interventions.!8.!9 Many of the problems that EFNEP staff perceived limited-income people to be facing emphasize the deficiencies of the poor. Far more often than the clients themselves, staff spoke oflimited-income people as "lacking" education, job skills, life skills, parenting skills, and budgeting skills. In addition, staff wrote about limited-income people in pejorative ways: the poor are lazy; unmotivated; they do not plan ahead or budget their money. In the ways they described the beliefs and practices of their clients, program staff also demonstrated that they do not think clients do the right things or know the right way to do things . Few paraprofessionals or professionals thought that clients would describe eating right as "a balanced diet," or that clients would serve what the staff considered a "good meal." Staff also underestimated how important clients thought nutrition is to health and did not think that clients are in control of their money or keep track of it very often. These findings show that EFNEP staff use the "culture of poverty" perspective of the poor, and consider clients to be in need of education. Clients, on the other hand, frequently demonstrated that they know nutritionally appropriate behaviors. They know what eating right means and are able to describe a "good meal." As suggested by their own description oflimited-income peoples' biggest problems, clients may be prevented from doing what they see as the right thing because they simply don't have enough money. Clients may also choose to act differently or eat low-nutrient dense food because of other desires, preferences, or pressures, not because they don't know any better. The difference in the perceived need for education between staff and clients is perhaps inevitable. The EFNEP is an education program, requiring that staff highlight ways in which client knowledge, attitudes, and practices can be improved. However, these findings suggest that the program may benefit from focusing less on providing information and more on identifYing the barriers to and incentives for behavior change. The former tends to emphasize client deficiencies, whereas the latter acknowledges the unfavorable living circumstances of clients and the ability of clients to make positive changes in their lives.
Fatalism versus personal control. The "culture of poverty" and "hard-to-reach" concept suggest that poor people hold fatalistic views and lack a sense of personal control in their lives. 20 ,2! In addition, the health literature frequently suggests that people with low socioeconomic status are less likely to take personal control of their health care. 22-25 EFNEP staff perceived clients to be very fatalistic about reasons for health, in line with the concept of a low health locus of control. However, clients expressed less fatalistic attitudes about health than they were perceived to do by program staff. Clients also ranked many of the "lifestyle"
factors as being more important than staff thought they would, showing that they are more conscious of their own health than staff perceive. In addition, clients expressed a greater degree of financial control than staff believed they would.
Self-esteem and empowerment. Related to the issue of personal control are the concepts of self-esteem and empowerment, which are of particular interest because of the recent interest in the role of nutrition education as an instrument of empowerment. 26 ,27 Staffin this survey clearly perceived their clients as powerless and lacking in self-esteem. Almost a third of the staff specifically mentioned low self-esteem as being a problem for limited-income people, whereas few of the clients reported this as a concern. A strong indication that clients think of themselves in a more positive way than staff is their assessment of their own abilities. The majority of clients think of themselves as a smart person and as a teacher. Both of these self-assessments are positive indications of esteem and personal power. Staff were far less likely to perceive clients in these ways and more likely to view them in a demeaning manner. Indigenousness of paraprofessionals. Indigenous paraprofessionals were hypothesized to be more knowledgeable about the beliefs and practices of clients than were professionals. Previous studies have found this to be the case, such as the one by Grosser!! in New York City during the early years of paraprofessional employment. However, in the present study, the paraprofessionals did not have any more accurate perceptions of client beliefs and practices than did the professionals. On almost every construct tested, the paraprofessionals' perceptions of clients were very close to those of the professionals, and paraprofessional and professional perceptions of clients differed significantly from what clients actually reported. This suggests that either paraprofessionals were never aware of the beliefs and practices of their clients (perhaps that they were never indigenous), or that the attitudes and opinions of the professionals (and the program in general) predominate. A longitudinal study of perceptions of a cohort of paraprofessionals over time would be required to test these options. Some paraprofessionals were better at predicting client responses than were others. They included paraprofessionals whose age was more similar to that of clients (younger), and those who did not have personal experience with public assistance or food stamps. The reasons for this are unclear. A study that included a larger sample of paraprofessionals and clients would be required to investigate this question . Limitations. Several limitations of this study are relevant for interpreting the findings. First, all of the information is based on self-reports. The vested interests of clients and staff may have resulted in a response bias that made clients look better in their own eyes and more needy from the perspec-
May. June 1994
Journal of Nutrition Education Volume 26 Number 3
tive ofEFNEP workers. Second, staff were asked to generalize about their clients, or describe their "typical client," which may have fostered stereotyping. Third, the design is cross-sectional and did not permit longitudinal analysis or the detection of a cohort effect, which may be important in comparisons based on the employment duration of paraprofessionals. Similarly, staff may have been describing more than just their present clients when responding to questions, while only new clients were included in the sample. Fourth, the study assumes that data collected by personal interviews and self-administered questionnaires are comparable. This seems to be a reasonable assumption given that the interviews with clients were structured and followed the same question guide as in the staff questionnaires. Fifth, the study was conducted in only one state so that the specific results may not be generalizable nationally. The authors believe that these limitations fail to account for all of the differences observed and that the findings reveal a consistent gap between EFNEP clients and the paraprofessionals and professionals who work with them. CONCLUSIONS The overall conclusion of this study is that the majority of paraprofessionals and professionals employed by the EFNEP in New York State have inaccurate perceptions of their clients. Despite being valued for their indigenous qualities, the paraprofessionals in this study were demographically more similar to their professional colleagues than to the clients, and their perceptions of their clients were no more accurate. In addition, the direction ofEFNEP staff misperception was consistent in underestimating client beliefs and practices. While limitations in the methods and design may account for some of these misperceptions, the patterns in the findings suggest that the EFNEP can benefit from identifying ways to reduce the disparities between staff perceptions and clients. The response the EFNEP takes would depend partially on whether the negative staff attitudes about clients are present before staff begin with the program. It would also be important to know in what ways negative perceptions of clients are reinforced or challenged in the program. Neither of these questions can be answered by the present study and both need further investigation. However, the following policy changes could be used: The program could continue to emphasize recruiting unemployed or underemployed people, such as clients themselves. Hiring could include questioning applicants to ensure that potential employees have a perceptive and empathetic insight into the lives of the poor. Staff education could emphasize the clients' perspective, including their assets. This may involve discussions of the structural and environmental factors that contribute to poverty and the lifestyle of the poor14 •28 as well as the resourcefulness of limited-income people. 29 Roundtable discussions with cli-
129
ents may also help orient staff to the clients' perspective. The educational focus of the program could be shifted from information transfer (which emphasizes client deficiencies) to reducing barriers and providing incentives to behavior change (which fosters the ability of clients to make positive changes in their lives, despite unfavorable life circumstances) . It would be important to know whether the inaccurate staff perceptions have any effect on paraprofessionals' interactions with clients or on the programs' overall effectiveness. Many studies have documented that the EFNEP is effective in producing and maintaining significant improvements in the eating habits of its clients3Q-33 as well as in contributing to their personal development. 27 •34 The results of this study do not negate these findings, but do suggest ways that the EFNEP may be modified to meet clients' needs more effectively. Further research is necessary to determine whether paraprofessionals who are indigenous are more effective than paraprofessionals who are not. It is clear from this study that any investigation about indigenous workers must first assess the degree to which assumed indigenous characteristics are in fact present. REFERENCES 1. Synectics Corporation. The Expanded Food and Nutrition Education Program: historical and statistical profile. Washington, DC: U.S. Department of Agriculture, Science & Education Administration, Program Aid No. 1230, 1979: 1-4. 2. Chipman H, Kendall PA. 20 Years ofEFNEP: changes and challenges. J Nutr Educ 1989; 21:265-9. 3. U.S. Department of Agriculture, Extension Service. Expanded food and nutrition education program policies, 1983. 4. Gartner A. Paraprofessionals and their performance, a survey of education, health and social service programs. New York: Praeger, 1971. 5. Brager G. The indigenous worker: a new approach to the social work technician. Soc Work 1965; 10(2):33-40. 6. Rothman
J.
Planning and organizing for social change. New York:
Columbia University Press, 1974: 175. 7. Pearl A, Riessman F. New careers for the poor. New York: The Free Press, 1965. 8. Riessman F. Paraprofessionals: twenty years later. Soc Policy 1984; Winter: 39. 9. Pickett AL. The paraprofessional movement: an update. Soc Policy 1984; Winter: 40-3. 10. Reiff R, Riessman F. The indigenous paraprofessional: a strategy of change in community action and community mental health programs. Community Men Health Mon 1965; 1 :3-32. 11. Grosser C. Local residents as mediators between middle class professional workers and lower class clients. Soc Serv Rev 1966; 40:56-63. 12. Giblin PT. Effective utilization and evaluation of indigenous health care workers. Public Health Rep 1989; 104:361-8. 13. Systat, Inc. SYSTAT: Evanston, IL: Systat Inc., 1989. 14. Katz TJ. The undeserving poor. New York: Pantheon Books, 1989: 7.
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18. Lewis O . La Vida: a Puerto Rican family in the culture of povertySanjuan and New York. New York: Random House, 1966.
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19. Valentine CA. Culture and poverty: critique and counter-proposals.
30. Amstutz MK, Dixon DL. Dietary changes resulting from the Expanded
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20. Lewis O. The culture of poverty. Sci Am 1966; 215:19-25. 21. Fremouth VS, Mettger W . Is there a hard-to-reach audience? Public
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Appendix 1. WORDING OF QUESTIONS IN CLIENT INTERVIEWS AND STAFF SURVEYS." 1. Why do you(r clients)bthink that some people are more healthy than others? Please rank the seven ways listed below. Heredity "You get it from your parents"
Fate "It's meant to be that way"
Your attitude "Thinking positively"
Nutrition "What you eat"
Lifestyles "The way you live and take care of yourself"
The immune system 'Your resistance to germs"
The environment "Where you live"
2. Which way listed below best describes what 'eating right' means to you(r clients)? No junk food
Meat, potato, and a vegetable
A balanced diet
Low salt, low fat, and low sugar
Having enough money to buy what I need
Plenty of variety
The four food groups
3. If you(r clients) were serving your(their) family a good meal, but not an especially fancy one, what would be on the plate? 4.
How in control of your(their) finances do you(r clients) feel? Totally in control
Somewhat in control
Not at all in control
5. How often do you(r clients) keep track of where your(their) money goes? Always
6.
Usually No
Knowing the right way to do things
Having intelligence
Being "street smart"
Having common sense
Having wisdom
Do you(r clients) think of yourself(themselves) as a teacher? Yes
9.
Sometimes
There are many different ways a person can be "smart". Which way is most important for you? Being "people smart"
8.
Occasionally
Do you think you(r clients think they) are smart? Yes
7.
Sometimes
No
Sometimes
From your experience, what are the biggest problems that limited-income people face?
aThis is not the original order of questions. bWords in parenthesis were separate questions in the self-administered questionnaire.
Never