Task 8.3 - Final Report -Contract No. AG-3198-D-15-0122_clean2.docx

FDPIR Nutrition Paraprofessional Training Assessment for Indian Tribal Organizations Deliverable 8.3: Final Report | Contract #: AG-3198-D-15-0122

September 1, 2018

Submitted to:

Akua White, MS, RDN Nutritionist Food Distribution Division Nutrition Services and Access Branch 3101 Park Center Drive, Room 508 Alexandria, VA 22302-1500

Prepared by:

2M Research 1521 N. Cooper St. Suite 600 Arlington, TX 76011

Mathematica Policy Research P.O. Box 2393 Princeton, NJ 08543

Table of Contents

Deliverable 8.3: Final Report

AG-3198-D-15-0122 | 2M Research | i Executive Summary The Food Distribution Program on Indian Reservations (FDPIR) is a federal program that provides U.S. Department of Agriculture (USDA) foods to low-income households located on Indian reservations and to Native American families residing in designated areas near reservations and in the State of Oklahoma (U.S. Department of Agriculture [USDA] Food and Nutrition Service [FNS], 2017a). The program is administered by USDA Food and Nutrition Service (FNS) at the federal level and locally by Indian Tribal Organizations (ITOs) or State agencies (SAs). ITOs and SAs order from a list of available foods, which are purchased and shipped by USDA, and the food packages are distributed to participating households. Under FDPIR, approximately 276 tribes receive benefits through 102 ITOs and 3 SAs (USDA FNS, 2017b).

In order to provide ITOs that do not already have a dietitian or nutritionist on staff the ability to provide at least basic nutritional counseling, the Food Distribution Division (FDD) at USDA/FNS is considering developing and conducting a nutrition paraprofessional training program for SA and ITO staff. This study is a part of continuing efforts by FNS to ensure high-quality service delivery and is intended to assess ITO staff[footnoteRef:2] interest in USDA-funded nutrition education training that will provide ITO staff with the knowledge and skills needed to serve as nutrition paraprofessionals for their organizations. FNS contracted with 2M Research and Mathematica Policy Research (hereafter referred to as the “research team”) to conduct semi-structured telephone interviews with ITO Directors, ITO staff, and stakeholders to determine whether there is interest in a nutrition paraprofessional training for ITO staff. The following research questions were of primary interest: [2: ITO staff were the focus, as most FDPIR benefits are distributed by ITOs rather than SAs.]

1. Are ITOs interested in a nutrition paraprofessional training project?

2. Will ITOs allow staff to take the training at the expense of normal duties?

3. What are motivational factors for staff to participate in training?

4. Who should deliver the training to FDPIR staff?

5. Which nutrition training topics do ITOs and other staff/organizations think are valuable?

This report presents findings from semi-structured telephone interviews conducted between January 26, 2018 and March 20, 2018 with ITO Directors, ITO staff, and stakeholders. An iterative coding process and thematic analysis was conducted on data from the 44 interviews. Findings describe key issues related to this nutrition paraprofessional training including, but not limited to, the current state of FDPIR nutrition education, interest in nutrition paraprofessional training, thoughts and recommendations for training structure and design, and potential challenges to providing nutrition education to FDPIR participants. Key findings from the research questions are provided below and additional detail is provided in the report.

ITO Staff are Interested in a Nutrition Paraprofessional Training Those interviewed indicated that while some ITO staff have nutrition education backgrounds, there are significant gaps in training, and additional nutrition education of all ITO staff would be beneficial. Most respondents (including ITO staff) believed ITO staff would be interested and motivated to participate in a nutrition paraprofessional training if it were offered by USDA. Both ITO Directors and ITO staff described an interest in gaining more technical nutritional knowledge that would help them answer questions from FDPIR participants.

ITOs Will Allow Staff to Take a Nutrition Paraprofessional Training Respondents did not anticipate barriers related to obtaining permission from their ITOs to attend training as long as staff are available, and the program has capacity to cover work duties for those staff while they are at the training. The burden placed when staff attend trainings may be more significant for small ITOs with smaller staffs, since there would be fewer staff members available to maintain a high quality of service delivery if some of the staff were to attend a training. Respondents noted that arrangements have been made for staff to attend trainings and conferences in the past, so while it may be challenging to plan for appropriate coverage—especially in small ITOs or those with a small number of staff—it is possible.

ITO Staff are Motivated by Several Factors to Take a Nutrition Paraprofessional Training ITO staff reported that one of their key motivations for participating in a nutrition paraprofessional training is to ensure that their FDPIR participants receive high-quality and relevant nutrition education and support, whereby they can better serve their larger community. Respondents reported that other incentives such as social recognition, professional merits, academic credits, and certificates of completion may also help to motivate staff to participate in the nutrition paraprofessional training. Stakeholders and one ITO Director indicated that assurances of ongoing support services after the training session to help ITO staff if they encounter barriers in implementing the training may also motivate ITO staff engage in training opportunities.

A Nutrition Paraprofessional Training Should be Delivered by a Native American or Someone Familiar with Native American Communities, Knowledgeable about FDPIR, and with Nutrition Expertise Stakeholders reported that having a Native American trainer or someone familiar with Native American communities would help to foster trust between the trainer and trainees, leading the trainees to be more receptive to the information being presented during the nutrition paraprofessional training. Because of the unique needs of FDPIR participants, it is important for the trainers to be knowledgeable about FDPIR and to provide information in a culturally competent manner that will resonate with those being trained and the population ultimately served by the program. Trainers should also have expertise in nutrition, with the ability to break down complex nutrition information into easily digestible messages for ITO staff.

Several Nutrition Topics Were Identified as Valuable to Include in a Nutrition Paraprofessional Training The top three most important topics identified by respondents to include in a nutrition paraprofessional training were (1) menu planning and meal preparation using FDPIR foods, (2) storing foods safely, and (3) nutritional quality of FDPIR foods. Other topics that were also offered for consideration included (1) eating more fruits and vegetables; (2) incorporating more whole grains; (3) reducing salt, fat, and sugar; (4) reading nutrition labels; (5) managing food portion sizes; and (6) gardening.

Considerations When Creating and Implementing a Nutrition Paraprofessional Training Although respondents indicated that the preferred length and format of a nutrition paraprofessional training is dependent on other factors such as whether it is held in person or virtually, the most frequent preferences included an in-person training held at multiple regional locations for 1–2 days, during business hours. Respondents also thought that the training should include 15–25 trainees and utilize hands-on activities, role-playing, food demonstrations, trivia games, and opportunities for group discussion. Tribal holidays and cultural gatherings, national and regional conferences, and events specific to the summer and winter seasons should also be considered when scheduling a training. For example, many respondents suggested not having the training during times when tribal holidays and cultural gatherings, and events specific to the summer and winter seasons take place. However, other respondents suggested that it may be convenient to have the training coincide with national and regional conferences. The in-person nutrition paraprofessional training should also be supplemented by online resources (e.g., webinars or other nutrition education resources), follow-up trainings held online, and additional technical assistance.

The findings from this study can be used by USDA and FDPIR program staff to inform decision making related to the development and implementation of future FDPIR nutrition trainings.

Introduction The Food Distribution Program on Indian Reservations[footnoteRef:3] (FDPIR) is a federal program that provides U.S. Department of Agriculture (USDA) foods to low-income Native American and non-Native American households that reside on a reservation, as well as those living in approved areas near a reservation or in the State of Oklahoma that contain at least one person who is a member of a federally recognized tribe (U.S. Department of Agriculture [USDA] Food and Nutrition Service [FNS], 2017a). The program is administered by USDA Food and Nutrition Service (FNS) at the federal level and locally by Indian Tribal Organizations (ITOs) or State agencies (SAs). ITOs and SAs order from a list of nearly 100 available foods or products (USDA FNS, 2017b), which are purchased and shipped by USDA, and the food packages are then distributed to participating households. FDPIR participants are certified for up to 12 months (elderly and disabled households up to 24 months) on both an income and non-income basis set by the Federal Government. Households may not participate in both FDPIR and the Supplemental Nutrition Assistance Program (SNAP) in the same month (USDA FNS, 2017b). Under FDPIR, approximately 276 tribes receive benefits through 102 ITOs and 3 SAs (USDA FNS, 2017b). In FY 2017, approximately 90,000 participants received benefits under FDPIR (USDA FNS, 2018). [3: FDPIR is authorized under Section 4(b) of the FOOD AND NUTRITION ACT OF 2008 [As Amended Through P.L. 113–79, Enacted February 07, 2014].]

FDPIR is particularly important, as Native Americans in rural areas experience greater food insecurity than any other group in the United States (Bauer et al., 2012; Kaufman, Dicken, & Williams, 2014). This population also experiences a higher age-adjusted prevalence of diabetes than any other ethnic group in the country (American Diabetes Association, n.d.). To address these needs, effective nutrition education programs that are well designed, culturally appropriate for diverse tribal cultures, and tailored to the specific needs of Native Americans are warranted (Jackson & Mead, 1990; Parker et al., 2011).

The FDPIR program works to offer nutrition education that ensures recipients receive help with their dietary needs (Shanklin, Usher, & Wildfire, 1992). To meet this priority, training is currently offered on how to successfully administer FDPIR for ITO and SA staff. Additionally, since 2008, FNS has provided Food Distribution Program Nutrition Education (FDPNE) grants to ITOs and SAs so they can provide nutrition education to participants. This training for how to successfully administer FDPIR and the FDPNE grants is designed to enhance nutrition knowledge and foster positive lifestyle changes (USDA FNS, 2017c). SNAP, authorized by the Food and Nutrition Act of 2008, Public Law 110-246, allows FNS to award funds to FDPIR to conduct nutrition education activities for FDPIR and FDPIR-eligible participants. Although training is offered on the administration of FDPIR and grants are available to provide nutrition education for FDPIR participants, currently there is no nutrition training program provided by USDA that would provide education and training to ITO and SA staff.

ITO staff may be FDPIR participants’ only source for receiving nutrition guidance. Moreover, there are many FDPIR local sites without access to a Registered Dietitian or organizations that can provide information or help with nutrition education. Therefore, FNS’s Food Distribution Division (FDD) is considering developing and delivering a nutrition paraprofessional training to SA and ITO staff to provide ITOs that do not already have a dietitian or nutritionist on staff the ability to provide at least basic nutrition education and information. This study is a part of FNS’s continued efforts to ensure high-quality service delivery and is intended to assess ITO staff[footnoteRef:4] interest in USDA-funded nutrition education training that will provide ITO staff with the knowledge and skills needed to serve as nutrition paraprofessionals for their organizations. FNS specified the following questions of interest: [4: ITO staff were the focus, as most of the FDPIR benefits are distributed by ITOs rather than SAs. ]

· Are ITOs interested in a nutrition paraprofessional training project?

· Will ITOs allow staff to take the training at the expense of normal duties?

· What are motivational factors for staff to participate in training?

· Who should deliver the training to FDPIR staff?

· Which nutrition training topics do ITOs and other staff/organizations think are valuable?

This study sought to improve FNS’s understanding of the needs and desire for nutrition paraprofessional training for ITOs and SAs participating in FDPIR and to better understand the best way to deliver this type of training. The overall findings from this study provide insight into whether ITO staff who are responsible for administering FDPIR would be interested in participating in a USDA-funded nutrition paraprofessional training, and the best way to provide this kind of training so that it meets the greatest needs of ITOs and FDPIR participants.

This report presents the study findings by describing the current state of FDPIR nutrition education, future plans for ITO staff nutrition education, interest in nutrition paraprofessional training, willingness of ITO staff to take on roles as educators for FDPIR participants, how a nutrition paraprofessional training should be developed and delivered (including barriers and willingness to participate in evaluation), and current and perceived future challenges to providing nutrition education to FDPIR participants. This report also details ITO staff needs and offers recommendations regarding content and delivery format that may be used to inform the development of a nutrition paraprofessional training.

Methods The purpose of this study was to inform USDA about how best to develop a future nutrition paraprofessional training program. To accomplish this task, 2M Research and Mathematica Policy Research (hereafter referred to as the “research team”) conducted a qualitative formative evaluation, which is often implemented prior to an intervention in order to gain an understanding of the target population, the most effective program design and structure, and ways to tailor the program for specific cultures and regions (Gittelsohn et al., 1999; Higgins et al., 1996; Gittelsohn et al., 2006). By collecting and utilizing qualitative data, formative research studies can delve deeper into why participants responded a certain way to gain a better understanding of their perspective and allow for the exploration of any special considerations or circumstances prior to creating a program or intervention. Formative research studies are particularly useful prior to implementing large, national programs, as the findings can help program developers avoid any foreseeable pitfalls.

For this project, the research team employed semi-structured interviews. Semi-structured interviews rely on a written list of topics and corresponding questions that allows for interviewers and respondents to divert and explore new, relevant ideas that arise during the interview. Semi-structured telephone interviews were conducted by the research team in conformance with the Technical Approach approved by FNS and the Office of Management and Budget (OMB) Information Collection Request (ICR) package clearance approved by OMB on November 17, 2017.

The research team collected telephone interview data from three respondent types: (1) ITO Directors, (2) ITO staff, and (3) stakeholders. With the permission of each respondent, each of the interviews (N = 44)[footnoteRef:5] were audiorecorded, then transcribed. The transcriptions were deidentified to ensure that the confidentiality of each respondent was maintained. The transcripts were then imported into NVivo 11 qualitative data analysis software for coding. [5: There are fewer transcripts than the number of participants because one interview included four individuals (one ITO Director and three ITO staff). Additionally, audio recording failed for one interview, and interview notes were substituted in place of a transcript.]

Below, additional information about the identification and recruitment process for each of the respondent types (i.e., ITO Directors, ITO staff, and stakeholders) is provided. Data were collected between January 26, 2018 and March 20, 2018. Table 1 depicts an overview of the final number of respondents, by respondent type.

Table 1 | Interview Count by Respondent Type

Respondent Selection To ensure that a cross-section of opinions on the nutrition paraprofessional training and the needs of ITOs were captured, the research team worked with FNS to identify respondents representing three primary respondent types: (1) ITO Directors, (2) ITO staff, and (3) stakeholders. The selection of the respondents differed slightly between each of the respondent types. These are briefly detailed in the next few sections.

ITO Director Selection To gather information from diverse ITOs, the research team used size (i.e., average monthly number of FDPIR participants in fiscal year [FY] 2015) as the primary criterion for selecting ITOs for the study. Data from 2015, the most recent data available at the time of initial selection, were used to sort ITOs into large, medium, and small groups. The large ITOs had an average monthly FDPIR participation of 3,939 recipients; the medium ITOs had an average monthly FDPIR participation of 743 recipients; and the small ITOs had an average monthly FDPIR participation of 194 recipients. The research team also considered other characteristics, such as geographic diversity, FNS region, and other unique factors (e.g., particularly large areas of coverage, extreme rurality).

A total of eight small, nine medium, and six large ITOs were selected as part of the initial sample, with an additional three medium ITOs and one small ITO selected as alternates, if individuals from an ITO were unable or unwilling to participate. The 23 ITOs selected represented 6 FNS Regional Offices (ROs): The Southwest Region, Mountain Plains Region, Western Region, Midwest Region, Southeast Region, and Northeast Region. The proposed list of ITOs was sent to FNS for approval and was finalized after consulting with the FNS ROs. The ITO Directors from each of the final ITOs were recruited for participation in an interview.

ITO Staff Selection ITO staff who participated in the study were referred to the research team by ITO Directors who completed the interview (n = 18). After the ITO Directors were interviewed, they were asked to identify one of their staff members who would be willing to complete a telephone interview with the research team; ITO Directors were asked to select a staff member that had expressed interest in nutrition education or had knowledge of what FDPIR participants and/or other Food Distribution Program (FDP) staff might want or need in terms of nutrition education training. Each ITO Director was asked to provide the research team with the contact information of their identified ITO staff member.

Stakeholder Selection In addition to ITO Directors and staff, stakeholders with expertise in ITOs, nutrition, and working with Native American populations were also included in the study, as they could provide unique perspectives on the format and delivery of a nutrition paraprofessional training. FNS provided the research team with the names, affiliations, and contact information of 16 stakeholders who had agreed to participate in interviews about a potential nutrition paraprofessional training program for ITO staff. These stakeholders included the following:

· Indian Health Services (IHS) clinic and/or hospital staff

· ITO Nutritionists

· Staff from Native American Land Grant Colleges

· FNS RO Nutritionists

· Staff from government agencies that provide services to Native Americans

· Staff from First Nations Development Institute Recruitment In general, similar recruitment procedures were employed across all respondent types, each of which are briefly described below.

ITO Director Recruitment FNS recruited selected ITO Directors for participation by sending an email to the corresponding ROs, alerting them that at least one ITO in their region had been selected for participation in the study. The email included the following:

· A list of all selected ITO Directors’ contact information in their region

· A preformatted letter that the RO could send to the selected ITO Directors Once the ROs confirmed that letters were sent to the ITO Directors, FNS informed the research team that they could begin recruitment. The research team then sent an email to each selected and alternate ITO Director requesting their participation. The research team made up to three additional points of contact (two emails and one telephone call) with selected ITO Directors for recruitment. After an interview was scheduled, someone from the research team sent the respondent a calendar invitation with conference call-in information and the date and time of the interview. The research team also sent a confirmation email approximately 2 business days prior to the telephone interview as a reminder. A total of 18 ITO Director interviews were completed by the research team.

ITO Staff Recruitment After the research team obtained contact information for an ITO staff member from the ITO Director, the research team sent an invitation email and up to three additional points of contact (two emails and one telephone call) to each identified ITO staff member requesting their participation. Once an interview was scheduled, the research team sent a calendar invitation with conference call-in information and the date and time of the interview to the respondent. A confirmation email was also sent approximately 2 business days prior to the telephone interview. The research team completed 14 ITO staff interviews.[footnoteRef:6] [6: Two additional ITO staff responded to our initial request for an interview; however, despite several attempts, the research team was unable to subsequently reach them.]

Stakeholder Recruitment The research team sent an email to each stakeholder to introduce the study and confirm their availability to participate in a telephone interview; stakeholders were contacted up to two additional times for recruitment if the research team did not hear back from them after the initial email. After scheduling an interview, the research team sent the respondent a calendar invitation with conference call-in information and the date and time of the interview. Finally, the research team sent the respondent a confirmation email approximately 2 business days prior to the telephone interview. The research team completed 15 stakeholder interviews.

Sample ITO Directors As illustrated in Table 2 below, the largest groups of ITO Directors were from medium ITOs and located in the Southwest FNS region. ITO Directors’ years of experience in working with either their ITO and/or directly with the FDP ranged from just more than 1 year to more than 35 years of experience. While ITO Directors did not report having a formal background in nutrition (e.g., obtained a degree in nutrition, or had formal education in nutrition), many stated that they have operational knowledge of their ITO (i.e., what is going to work and what is not going to work when providing nutrition education) and its needs (e.g., health-related nutrition needs).

ITO Staff Since ITO Directors were asked to identify ITO staff who had expressed interest in nutrition education or had knowledge of what FDPIR participants and/or other ITO staff may want or need in terms of nutrition education training, it was common for ITO staff to report nutrition-related roles. Some of the ITO staff interviewed had dedicated nutrition roles which included self-reported titles such nutritionists, nutrition educators, and nutrition technicians. Some ITO staff had roles that served or advised as a part of a regional food package committee. Other roles of ITO staff who were interviewed included certifiers (i.e., staff responsible for determining FDPIR participant eligibility), cashiers, clerks, administrative assistants, and warehouse workers.

Table 2 below provides a summary of the ITO Directors and ITO staff who participated in interviews, as well as their FNS region and ITO size.

Table 2 | Study Sample ITO Directors and ITO Staff, by ITO Size and FNS Region

ITO Director (n = 18) ITO Staff (n = 14)*

ITO Size

FNS Region

*Note: One telephone interview included three ITO staff members and one ITO Director.

Stakeholders Most stakeholders had formal nutrition education backgrounds. Most were registered dietitians, and the remaining stakeholders had backgrounds in public policy, nutrition, and epidemiology. Most stakeholders also reported that they had experience working with ITOs, and a little more than half of the stakeholders interviewed reported that they interact with FDPIR. Additionally, a few stakeholders reported that they were Native Americans. About half of stakeholders reported that they have experience leading and designing nutrition education trainings for FDPIR staff or ITO staff. Most of the remaining stakeholders reported experience providing nutrition education in some capacity, such as through trainings for the public or in developing nutrition education materials for ITOs to use.

Analytic Approach The research questions developed by FNS served as the guiding framework for data analysis. The research team, in conjunction with FNS, used the research questions to develop the study’s semi-structured interview guides (see Appendices A–C for the interview guides) and an outline of the major topics and areas of interest to FNS. The primary areas of interest included (1) the current state of nutrition education, (2) ITO interest in future training programs, (3) preferred training implementation format, and (4) challenges to implementing nutrition education trainings. Table 3 maps the five overarching research questions (listed previously on page 5) to the FNS areas of interest. The section of the report where each research question is answered is also included in Table 3.

Table 3 | Alignment of FNS Areas of Interest and Research Questions with Corresponding Report Section

The research team used an iterative coding process to code the qualitiative data for analysis. As a first step, the research team used the topics identified by FNS, as well as the respective interview guide topics and research questions, to group the data by hierarchically-ordered codes. Using NVivo qualitative analysis software, one or more codes were assigned to relevant excerpts of the transcripts.

Once the data were grouped by the higher-level codes (i.e., the first level in the hierarchically ordered codes) in NVivo, the research team began a thematic analysis of the coded data to identify and define more specific topics and themes. For example, across all respondent types, the research team coded interview data related to a specific code (e.g., “motivation to participate in nutrition professional training”). The research team then exported and reviewed specific code data to identify more specific themes and subtopics, such as “recognition of achievement.” The respondent type (i.e., ITO Director, ITO staff, stakeholder) was considered in analysis to identify consensus and differences between ITO respondent and stakeholder perspectives.

Each member of the research team thematically coded and analyzed specific sections of the data to allow research team members to gain the most familiarity with the nuanced, qualitative data, and to become the “data expert” for their section. The research team convened frequently to discuss and resolve any arising challenges during the coding process to ensure reliability and accuracy of analyses.

Findings The findings presented in the next several sections of the report are organized around the themes that were identified across multiple respondents, with respondent type indicated where the opinions expressed differed across respondent types.[footnoteRef:7] Deidentified quotes are provided, where appropriate, to demonstrate the meaning of the findings. If needed, quotes were modified with bracketed text to improve readability. It should also be noted that the research team worked with FNS to prioritize the interview questions; in some cases, not all questions on each interview guide were asked of all respondents. Reasons for not asking all interview questions include time constraints and the prioritization of certain questions, which were identified with FNS as having high importance for thorough discussion. Thus, some topic areas may have limited information for certain respondent types. [7: When “ITO respondents” is used, this refers to both ITO Director and ITO staff respondents.]

Current State of Nutrition Education at ITOs Current State of Nutrition Education at ITOs Key Findings: Due to FDPIR participant requests, ITO staff are currently providing nutrition education through a variety of strategies and modes:

· Engaging in informal conversations during food package delivery

· Hiring consultants to conduct cooking demonstrations

· Partnering with local and national agencies to obtain nutrition education resources and materials Although some ITOs employ formally trained nutrition educators (e.g., nutritionists), many ITOs do not have access to resources or staff needed to carry out direct FDPIR participant education.

This section details findings related to the current state of nutrition education offered to FDPIR participants and offered to ITO staff. Each subsection includes findings about the nutrition education currently offered to FDPIR participants, background of ITO staff providing nutrition education to participants, current training opportunities available to ITO staff, and persistent gaps or needs that should be considered to effectively deliver nutrition education to FDPIR participants.

Nutrition Education Currently Offered to FDPIR Participants To establish a baseline for the types of nutrition education currently offered to FDPIR participants, respondents were asked to discuss what is currently available. Most respondents noted that nutrition education provided to FDPIR participants occurred as informal conversations with ITO staff during FDPIR food package pickup or drop-off. During these informal conversations, FDPIR participants sometimes asked the ITO staff nutrition-related questions. More formal nutrition education offered at ITOs included cooking demonstrations and the distribution of printed nutrition-related materials (e.g., pamphlets or brochures).

Some ITO staff shared that they conducted cooking demonstrations to promote use of FDPIR food package items in healthy recipes. Most ITO respondents conducted, or in some cases brought in an outside instructor to conduct, cooking demonstrations for FDPIR participants. These demonstrations were held at FDPIR food package pickup locations, community centers, and demonstration kitchens multiple times each month. ITO respondents indicated that often, the purpose of the cooking demonstrations was to highlight food package items which might be less popular among FDPIR participants, with the goal of increasing participant use of these foods. Less frequently, these cooking demonstrations were used to show how fresh fruits and vegetables could be substituted for more commonly used canned items. ITO respondents noted that the benefits of cooking demonstrations include FDPIR participants tasting samples of new or unfamiliar foods and learning recipes and how foods are prepared. Several ITO respondents reported holding food demonstrations specifically for children and elderly populations, and some ITO respondents discussed specific classes for men and mothers.

We have an extension agent that comes in from [University Name]. She'll come in and she'll prepare a recipe with some of our harder to move [FDPIR food package] items. She'll do the food demo and provide the recipe and we'll encourage people to try it and get them to talking about ways that they can use the same products different ways so that they can change the nutrition in the recipe to fit their family. — ITO Director Partnering with outside agencies and organizations appears to be a fairly common strategy for obtaining nutrition education resources. Several ITOs partnered with community organizations, such as extension offices, universities, and tribal agencies, and a few ITOs partnered with national organizations, such as IHS, to provide nutrition education. These partners were involved in cooking demonstrations to provide additional expertise and add a variety of options to the demonstrations. Through partnerships, ITO staff arranged classes and informal interactions between FDPIR participants and registered dietitians to discuss health-related nutrition topics (e.g., regulation of glucose levels for diabetic individuals).

Other nutrition education activities included providing printed nutrition-related materials such as recipes using FDPIR foods, MyPlate resources, and booklets and pamphlets on nutrition topics. ITO respondents obtained technical assistance (TA) resources from sources such as Cooking Matters, USDA-sponsored programs, and the Academy of Nutrition and Dietetics (formerly the American Dietetics Association). ITO staff could easily mail order or download these nutrition-related materials so that the information could be provided to FDPIR participants. Other printed materials focused on topics such as food safety; healthy recipes; decreasing salt, fat, and sugar; and eating more fresh fruits and vegetables.

Current ITO Nutrition Education Providers Respondents reported that ITO staff were the primary providers of ongoing nutrition education to FDPIR participants. Respondents from smaller ITOs tended to report a variety of non-dedicated nutrition ITO staff as those who delivered nutrition education. It was rare in the smaller ITOs to have a dedicated staff person who was only responsible for nutrition education services. In contrast, respondents indicated that larger ITOs were more likely to report having a dedicated nutrition person(s) to support nutrition education activities. Providers of FDPIR Participant Nutrition Education Key Findings: The type of ITO staff varied by ITO size; larger ITOs reported access to a dedicated FDPIR nutrition staff member, while smaller ITOs had fewer resources and staff split time across multiple programs. Most ITO staff who are currently providing nutrition education to FDPIR participants do not have formal training or background in nutrition education.

In some of our smaller ITOs where they have limited staff, it could be the [ITO] Director that's actually out there doing cooking demonstrations providing nutrition education at distribution. Sometimes in some of our ITOs, it's the [ITO] certifiers that will provide nutrition education interaction while they're working with the participants to pick out their food items for the month. Some of our larger ITOs, they have [ITO] staff who are nutrition educators, and those staff are specifically employed to do nutrition education with FDPIR participants, and those cross a wide range of background as well, too. Quite frankly, some of the [ITO] staff just have an interest in nutrition. The minority actually, in my experience, have formal nutrition education professionally. — Stakeholder Of the respondents who stated that ITO staff were the ones who delivered nutrition education to FDPIR participants, several indicated that all ITO staff, regardless of formal role or position, contributed to FDPIR participant nutrition education. Nutrition education providers included ITO Directors, certification clerks, and other ITO staff. A few of these respondents stated that there were one or two staff members responsible for providing nutrition education and, in some instances, the ITO staff member(s) worked in conjunction with a nutritionist or dietitian from a local health organization or university. Of the ITOs with a dedicated nutrition person on staff, nutrition staff roles included nutrition educators, registered dietitians, and/or nutritionists.

Although some ITO staff, especially those in larger ITOs, have more formal training in nutrition (e.g., obtained a degree in nutrition, or had formal education on nutrition), most respondents indicated that the majority of ITO staff providing nutrition services do not have any formal training or a background in nutrition. However, many respondents noted that ITO staff who provide nutrition education to FDPIR participants have a strong interest in nutrition, and one reported that a staff member became a certified nutrition educator while working for FDPIR. Several other respondents noted that some ITO staff have participated in nutrition education training while working for FDPIR.

The [nutrition educator] that’s been here [number] years now, she, I want to say, just [has a] high school diploma, but she’s had so much training over the years on nutrition education. She’s still [participating in] a lot of training. — ITO Director In addition, several respondents mentioned that some of the ITO staff who provided nutrition education had training in a field that was applicable to providing nutrition education to FDPIR participants. For example, one respondent went to culinary school and worked for years in the restaurant industry, so he/she could easily contribute to the cooking demonstrations. Another respondent reported being certified in health conditions and exercise, so their ITO has plans to incorporate physical activity into their nutrition education program.

ITO Staff Knowledge Given the variability in staff training and background, it was not surprising to find that staff knowledge about nutrition varied as well. ITO respondents reported greatest knowledge of the following topics: eating more fresh fruits and vegetables, MyPlate recommendations, physical activity/exercise, and Native American traditional foods. Less often did ITO respondents indicate that they had knowledge of the following topics: menu planning, heart health, portion size, and nutrient value of foods. Stakeholders generally agreed that ITO staff are most knowledgeable about these topics and believed ITO staff have additional “operational knowledge” about their communities. One stakeholder described operational knowledge:

I think a lot of [ITO staff] have obviously much better operational knowledge of their particular community, what's going to work, what's not going to work. I think pragmatically they know what they have to do to maintain program integrity, and kind of get the food out into their communities, but also, I think [ITO staff] have good intentions of wanting to increase nutrition education where best they can. — Stakeholder While there were some areas where ITO staff had knowledge, respondents noted distinct gaps in nutrition knowledge, which limited the ability of ITO staff to thoroughly address FDPIR participants’ questions relating to dietary and health concerns and nutrient values. The most commonly noted gaps were regarding diabetic-friendly diets, and how to best utilize FDPIR food package items to help maintain healthy blood sugar levels. Relatedly, some ITO respondents discussed lack of knowledge about heart-healthy diets, and a few respondents mentioned renal-friendly diets for participants undergoing renal dialysis.

Recommendations

· The administration of the FDPIR program involves a wide variety of ITO staff (e.g., directors, certification clerks, food distribution staff) who may benefit from additional nutrition training.

· Given the varied exposure to nutrition education, varied access to materials, and high levels of interest across ITO staff, a nutrition paraprofessional training may provide needed resources and improve the quality and consistency of educational services.

Current Nutrition Training Opportunities Prior to proposing a new nutrition paraprofessional training, it was important to determine ITO staff awareness and utilization of nutrition education resources and trainings. Respondents mentioned conferences and resources, such as websites and printed nutrition-related materials, as current training opportunities for ITO staff. These resources and trainings were most often cited as being sponsored or provided by USDA/FNS, tribes, First Nations Fund, and local universities/organizations. Currently Available Training Sponsors and Hosts Key Finding: USDA/FNS was most often cited as a current training sponsor by respondents. Training sponsors most frequently mentioned included the following:

· USDA/FNS (trainings and resources)

· Tribal-sponsored trainings (trainings and resources)

· First Nations (resources)

· Local universities/organizations (trainings and resources)

Although there were several similarities among responses from ITO respondents and stakeholder respondents regarding current trainings available to ITO staff, there were also some notable differences. Many ITO respondents said they were aware of nutrition education resources such as pamphlets, fact sheets, websites, cookbooks/recipes, but did not know of any formal nutrition education trainings available for ITO staff. ITO respondents most frequently reported conferences, and the previously mentioned resources, as sources where they obtained nutrition information. Respondents also mentioned a nutrition education symposium and nutrition education grants, but with much less frequency. Many ITO respondents said they were not aware of any available nutrition trainings outside of these resources and conferences. One ITO respondent stated:

There's lots of nutrition conferences [that update us]. I go to one in [State Name] every year, but other than that, there's no one that really just sits down and just teaches nutrition here. — ITO Staff Whereas ITO respondents did not mention specific knowledge of TA, some stakeholder respondents also noted that TA during FDPIR calls (e.g., presentations on a traditional food being added to food packages); Train-the-Trainer opportunities (e.g., during FDP meetings); and training collaboration opportunities with local programs, universities, and organizations (e.g., gardening organizations, health services organizations) were also available to ITO staff. One stakeholder stated that there are plenty of nutrition education information and training resources available for ITO staff but said that there seems to be a lack of knowledge about what is out there and where to find it.

Well, so there's a wealth of materials available through Cooperative Extension in the land-grant universities; in my experience they're not being tapped. And so, I think that's what you find a lot . . . there's work being done out there, it's just not connecting the dots. There are partnerships that could easily happen . . . There are gardening organizations, there's so many programs it's not really a lack of programs out there, it's just a lack of understanding about who's doing what. — Stakeholder Current Training Topics Available Current trainings and resources reportedly cover topics such as cooking demonstrations, recipe modifications (to make recipes healthier), general nutrient values of the foods in the FDPIR food packages, and basic nutrition information. Other topics mentioned included trainings on assessing the needs of the FDPIR participant and how to provide nutrition information and nutrition education to FDPIR participants and promote FDPIR food package items. Training Topics Currently Available Key Finding: Respondents cited topics from both nutrition education materials and trainings. Most frequently mentioned topics included the following:

· Cooking demonstrations

· Healthy recipe modifications

· Nutrient values of FDPIR foods

· Basic nutrition information

· Assessing FDPIR participant needs

· How to provide nutrition education to FDPIR participants

· How to promote FDPIR food package items

Some respondents reflected on the usefulness of trainings and noted that cooking demonstrations, recipe modifications, and training on the nutrient value of FDPIR food packages were most useful for ITO staff. Although some respondents believed that basic nutrition information (e.g., nutrition terminology, which foods are considered a protein, which foods are considered a grain) was useful, one respondent explained that after someone attends a training on basic nutrition, other similar trainings were not useful.

The only [trainings] that I know of are just the 45 minutes to hour-long trainings [you] get at the nutrition [meetings], and they're basically the same thing over and over again. It's like a nutrition bingo, or it is like a little MyPlate nutrition. It's the same thing every year. Once you've been [to one], you've kind of been [to all]. — ITO Director Recommendations

· Awareness of available nutrition education training and materials resources varied across ITO staff, so circulating available nutrition education trainings, materials, and resources may be an inexpensive and effective way to augment a nutrition paraprofessional training.

· Tailoring common nutrition education trainings to specific participants (e.g., tribal); contexts (e.g., rural, low access to resources); and health conditions (e.g., heart-healthy) may improve the uptake and utility of these resources.

Meeting FDPIR Participants’ Nutrition Education Needs Respondents reported mixed opinions on whether current nutrition education is meeting the needs of FDPIR participants, but overall agreed that nutrition education efforts could be enhanced through additional training (such as what would be provided through a nutrition paraprofessional training) to increase nutritional knowledge among ITO staff. Some ITO Directors reported that their program was meeting FDPIR participants’ needs, though they mentioned minor gaps that needed to be filled. The remaining ITO Directors either reported their program was not meeting FDPIR participants’ needs, or that it was meeting the basic needs but with major limitations or gaps in program service delivery. The ability to meet FDPIR participants’ needs seemed independent of whether the program had a dietitian or nutritionist on staff. It was noted that many of the dietitians or nutritionists on staff have limited interaction time with FDPIR participants; they primarily conducted cooking demonstrations or were “shared” with other programs and not dedicated full-time to the food distribution program. One ITO, for example, had access to dietitians and food demonstration specialists through a SNAP grant, but this still may not be sufficient:

When the [FDPIR] clients come in, unless it's an actual class or there's a [cooking class] going on, they're not having the interaction with the food demonstration specialist.