INTRODUCTION
In developed and developing countries, many projects have demonstrated that enhanced communication efforts can improve the health and well being of populations. More recently computer-mediated communications have emerged as a viable means of both gathering and disseminating nutrition information. Interactive computer-mediated communication incorporates stand-alone computer applications or software, multimedia applications, on-line services, and interactive television. These services are used to inform and influence the public for a wide variety of reasons. This paper will highlight the opportunities that new technologies provide for nutrition educators; describe computer-mediated services used for nutrition education; list issues important to nutrition educators; and explore opportunities for expanded uses of computer-mediated nutrition education programs in both developing and developed countries.
Computer-mediated communications can be grouped under two headings, Stand-alone Applications and Linkage Applications. Stand-alone Applications are computer programs that run without connection to telephone, television, satellite, or other electronic transmissions. These applications have received the greatest use in nutrition education to date. The use of Linkage-applications, through electronic mail (e-mail), Internet, and World Wide Web (WWW), in nutrition education is just emerging.
The area of emerging communication technologies is filled with new terminology. A glossary of terms is provided at the end of the paper.
I. STAND-ALONE APPLICATIONS
Stand-alone applications have been designed to provide information and training in nutrition education for the public, the paraprofessional, and the professional. Programs are available on floppy disks, CD-ROM disks, and laser disk with accompanying floppy disks. Programs are accessed by the user at a computer work station or at a kiosk. A comprehensive list of nutrition software is not currently available. The Food and Nutrition Information Center (FNIC) of the United States Department of Agriculture (USDA) maintains the largest listing, about 200 programs, of food and nutrition software. The list represents about half of the food and nutrition applications available in North America. Lists of programs are available by writing or emailing a request to the library.
The major types of programs designed for both professionals and consumers include nutrient analysis, food service and recipe management, menu planning, clinical nutrition, drug-nutrient interaction, health risk assessment and lifestyle prescription, food and nutrition education, and games. In addition to programs designed specifically for food and nutrition education, there are general production tools such as graphics packages, computer photo and clip art collections, and presentation software used by nutrition educators to enhance their work.
The programs described in this section are for illustrative purposes. Other programs are available, but those described are most familiar to this author and are predominantly from North America. Their inclusion does not imply endorsement.
A. NUTRIENT ANALYSIS 1. BASED ON FOOD INTAKE RECALLS/RECORDS.
During the 1980s and 1990s, software to analyze food intake proliferated. A list of foods and beverages, along with the serving sizes, for one or more days is keyed into the computer program. The program calculates the nutrient intake of individuals or groups of individuals and compares it to a nutrient standard. A personal nutrient profile is created, usually with a printout. Most applications require keyboard entry, but researchers interested in expanding the consumer reach of these programs have successfully demonstrated that consumers of a wide range of socioeconomic and educational levels can use a touch-screen computer system for diet analysis.
Several authors have described considerations for selecting a computerized dietary analysis system (Buzzard et al, 1991; Seaman,1992; Nieman et al, 1992; LaComb et al, 1992). The nutrient must be accurate, verified, and large enough to meet the intended task. Most programs use the USDA nutrient database as the standard. Some programs augment the USDA database with information from commercial sources and allow the addition of more foods or ingredients. Nutrient adequacy is usually defined by the U.S. Recommended Dietary Allowances. Some programs use other standards, including the Recommended Dietary Intake for Canadians, the U.S. Food and Drug Administration (FDA) labeling standards (Recommended Daily Intake or RDI and Daily Values or DV), Food Guide Pyramid servings, and other food grouping systems. A few software vendors customize programs with international standards and foods. Computerized databases for food consumption information are available from FAO as well as other international organizations. The International Network of Food Data Systems (INFOODS) has food composition databases organized for regions of the world.
Matching the education or research needs with the program is important, because prices vary from less than $5 to several $1,000 U.S. Hardware requirements also increase as the complexity of the programs increases. The cost is based on number of foods in the database, number of nutritive components analyzed, and program capabilities such as types of reports generated (e.g. lists, graphs, summaries, dietary advice), and availability of updates and technical support. Programs generally are distributed on multiple floppy disks.
Programs that analyze nutrient intake were welcomed by researchers and hospital dietitians. They found computerized nutrient analysis significantly reduced both the time and effort of calculating intakes using calculators and food composition books. The programs have now been used extensively for classroom assignments from elementary through medical school students, and have been offered as a nutrition education service in shopping malls and health fairs, in science exhibits, and by public health and Cooperative Extension Service professionals, fitness trainers, food scientists and food service professionals. The programs are used in physician offices as part of a medical assessment or nutrition counseling session.
Programs also have been developed for the home computer market. The popularity of these diet analysis programs continues to grow as consumers become aware of the relationships between food intake and health and want to tailor their own dietary intake (e.g. to be lower/higher in calories or fat).
The effectiveness of these programs for computing nutrient intake for research and education purposes, identifying nutrient excesses and deficiencies, and teaching food composition to varied audiences is well documented. The speed of calculation has allowed nutrientanalysis to be used more frequently in education and counseling settings.
2. NUTRIENT ANALYSIS BASED ON FOOD FREQUENCY QUESTIONNAIRES(FFQ). The FFQ is a short-cut method for collecting information about dietary intake. First, computerized software made it possible to easily estimate reliable nutrient intakes. But the questionnaire remained difficult to self-administer because keyboard entry was required. Then, software was developed to ease data collection. In the mid 1980s Jacobson (1984) demonstrated that clients in public health clinics would use a computer touch screen to report their food intake. The FFQ was presented on a computer screen; the computer was programmed to calculate the nutrient intake. The expense of the hardware prohibited the wide-scale adoption of this method, even though staff who interviewed clients about food intake were freed to spend more time on counseling. Hardware has become more affordable and others have demonstrated the cost effectiveness and feasibility of this method (Suitor and Gardner,1992; Byron, 1995). More recently, the growing availability of multimedia hardware made it possible to program a FFQ to be user friendly for a wider audience, including those with low literacy skills.
"Nutrition DISCovery", delivered on CD-ROM, (Interactive Design and Development, 1995) is one example. This program uses story telling, sound, video, and other aids to personalize the questionnaire and reduce the tedium and reading ability needed to complete the data input of tranditional FFQs. "Nutrition DISCovery" is based on the Health Habits and History Questionnaire, Dietary Analysis System, National Cancer Institute (Block, 1989). Food items are organized within categories similar to the aisles of a supermarket. Introductory screens to each food category include both an audio prompt and a short video clip to remind the user of a variety of foods and eating occasions. Rather than selecting from a list of foods, the user identifies the foods eaten from 100 color food items shown on the screen. The user is asked the quantity and frequency of only those foods selected. Answers are entered using a mouse. Audio and visual cues allow nonreaders to use the program successfully. The user can look at the results on screen or receive a printout. For example, a screen of the USDA Food Guide Pyramid shows the user the number of servings reported and the number recommended for his or her age group. Educational statements are
generated for users with high fat or high sodium intake and for those who exceed their healthy weight by 15+%. The storage capacity of the CD-ROM allowed the developer to include a nutrition education section with games, quizzes on knowledge, and immediate feedback. An important advance in nutrition discovery is that in addition to estimating the nutrients in an individual's long-term, usual, self-selected diet, it reports to the user the number of servings from the USDA Pyramid. While this program is currently only in English it is feasible to have additional languages made available to the user.
The effectiveness of this type of program for collecting nutrient information and changing behavior of users is under study. The multimedia application is expected to engage the user effectively and result in a higher percentage of completed questionnaires from people of all reading levels. It is expected that multimedia programs when compared with pencil and paper or partially automated questionnaires will result in more reliable data because serving sizes are represented better. The program also allows collection of dietary data when the expert interviewer is unavailable or unaffordable.
3. OTHER NUTRIENT DATABASE APPLICATIONS (e.g. FOOD SERVICE AND RECIPE MANAGEMENT, MENU PLANNING). Computer software for hospital, school food service, and other food service or institutional applications are outside the scope of this paper. Basic software programs used for nutrient analyses are used for these functions. Additional functions generate nutrient analysis, costing and quantity conversions of recipes, food production reports, inventory listing, and purchasing.
One example of a consumer version of menu-planning multimedia software, delivered on floppy disk, is "Ready, Set, Dinner," (U.S. National Potato Board, 1994). This software was developed for use in a communication program designed to increase the consumption of fresh potatoes. Multimedia menu-planning software allows the user to easily search a library of 40 recipes, create menus and shopping lists, find nutrition information, use graphics, music and animation. Several outlets were used to publicize the program. The software was promoted a) in newsletters sent to working moms, b)during a satellite media tour of a popular junior high school television celebrity, c) to food and health and computer news editors, and d) by placing it in grocery stores in a kiosk at point-of-purchase, near the potato display. The kiosk distributes recipe cards and information on how to obtain the software; e) on Internet where the program is available for downloading; and f) in print advertisements.
Evaluation of the effectiveness of this program to increase sales and consumption of potatoes is in progress. Retailers participating in the kiosk trial reported potato sales increased 5-20%. In the first six months as estimated 30 million Americans were exposed to the message and 17,000 copies of the software have been distributed. Testimonials from consumers suggest this software in engaging enough to use and takes the tedium out of menu planning and encourages parent-child interaction about nutrition. Nutritionists suggest that this type of program may help individuals follow dietary guidelines. The program demonstrates a benefit of computer applications: providing information when and where the public wants it.
B. CLINICAL NUTRITION. There are a limited number of computer programs for assessing nutritional status of patients; charting medical records; teaching patients about diet and disease; and for computer-assisted education and continuing education for health and medical professionals.
1. ASSESSMENT TOOLS. Applications that use computer capabilities in calculations and data management are widely available. Software for desk-top computers and programs for hand-held computers are useful for many formulas used in nutrition assessment, including basal metabolic energy needs, Body Mass Index (BMI), desirable body weight, nitrogen and diabetic food exchanges. Adjustments can be made based on a variety of parameters. These tools are useful in hospital and community research and service settings. They allow the use of more precise calculations rather than "rule of thumb" calculations with fewer errors in making decisions about nutrition care. These tools can be less cumbersome than manuals.
2. NUTRIENT-DRUG INTERACTION. Nutrient-drug interaction software is an example of a specialized data base for clinical nutrition. It allows the user to quickly assess any nutrients that may be compromised with a medication regimen. These aids make it more likely that interactions will be considered when prescribing medicines.
3. PATIENT EDUCATION. Programs to provide dietary information and education to patients are available for individuals with diabetes, hypertension, heart disease, and complex medication regimens. These programs teach about causes of the disease, symptoms, complications, dietary management and menu lanning. The levels of personalization and interactivity vary greatly.
Of particular interest is the "TouchVideo for WIC" developed to meet the need to provide consistent nutrition education, with limited professional nutrition staff. Six modules were designed for delivery on interactive video disk kiosk. Information on breastfeeding, healthy eating habits, shopping, smoking cessation, an introduction to the WIC program and an eligibility screening tool have been successfully used with about 55% of Maine's caseload. Multiple media are used in many modules from full-motion video to straight text. Almost all clients reported positive feelings about using the program to learn. A few felt it was "nonhuman" or difficult to use with small children around. No one reported being intimidated by the computer. Knowledge gains and positive attitudinal shifts have been reported (Byron, 1995). Most clients favored a combination of live counselor and computer. These programs and additional modules are being converted to CD-ROM to expand distribution possibilities.
The value has been demonstrated in the following ways: delivering consistent and concise nutrition and health counseling even when a professional nutritionist is not available; engaging clients for a longer period of time because the program is interactive; creating more time for critical one-to-one counseling; and crossing cultural and language barriers. Some users preferred the computer interview to an interview with a health care professional. This application also demonstrates an important advantage of computer-mediated information and education: it consistently provides standard answers to predictable questions. It is nonjudgmental and affords privacy in learning. It assures equality of information to the user.
4. COMPUTER-ASSISTED INSTRUCTION FOR HEALTH PROFESSIONALS. Although this paper focuses on the use of technology for consumer nutrition education applications are available for the nutrition education of students, paraprofessionals, and professionals. Many times these programs, or portions of these programs can be adapted for consumer use. The nutrition programs available generally include content such as the relationship of diet to a disease, components of nutritional assessment, diet history methods, and patient case studies. These programs vary from computer-text-on-screen to computer-based multimedia applications. Users have found text-on-screen applications valuable for the immediate feedback provided by drills and quizzes.
a. TEXT-ON-SCREEN EXAMPLES. "Nutrition and the Practicing Physician" (Schoenberger et al, 1994) is an example of a computer assisted instruction program that addresses both the prevention and management of disease including obesity, hypertension, diabetes, and lipid disorders. The program provides nutrition information and counseling strategies known to foster a positive physician/patient relationship. Each module takes about 45 minutes to complete. The user's knowledge is tested and compared to professional standards. Case studies are presented and the users answer multiple choice questions about case management. This type of computer-assisted instruction (CAI) takes advantage of learning theories involving reinforcement of learning experiences, the advantages of self-paced learning, and repetition of difficult material. The Health Sciences Consortium has created an authoring template to assist subject matter experts in writing computer-based cases. A series, including nutrition and diabetes (Kolasa, Lasswell, and Lasswell, 1995) is in production. A program "nutrition and disease prevention: acomputer assited training and continuing education program was desgined for health care in developing countries (National Capitol Systems, Inc, 1984).
b. MULTIMEDIA EXAMPLES. Multimedia programs for health professionals and students are promoted as ways to increase learning and retention in a shortened learning time, captivate students, provide realism, role modeling and simulations. Many programs requiring a computer and a laser disk were developed for nursing and medical education (O'Neill, 1990). Until recently, videodisc technology was required to show realistic video on a computer.
One of the few nutrition interactive videodisc programs produced is "Cardiovascular Health: Focus on Nutrition, Fitness and Smoking Cessation" (Kolasa and Jobe, 1994). The technology is used for role modeling. Physicians are seen completing nutrition assessments and counseling their patients in ambulatory clinics. Users chart their own path through the program. Self assessment tools give users immediate feedback about their own diet and exercise pattern. The program tests users' ability with simulated cases. As a final test, users complete a clinical challenge by reading a patient's chart, providing nutrition assessment and prescribing a management plan. The computer tracks the users' paths and performance. Instructors can check the users' performance. The program was evaluated by medical students (Kolasa and coworkers, 1995). Users acceptance of multimedia education depended on their learning style and interest in nutrition. Users liked actually seeing physicians in the patient care setting. This program demonstrates the ability of computer mediated multimedia programs to: a) effectively model nutrition assessment and counseling behaviors; b) ensure consistency and equality of learning opportunities; and c) expose learners to master teachers and subject matter experts. Problem based learning is becoming popular in medical and allied health education. "The Nutrition Cancer Link: A Case Approach to Cancer Risk Reducation" (Kolasa, Jobe, Miller, 1995) demonstrates using the computer to replace, in part, the group's tutor. This is useful if subject matter experts are scarce.A medical nutrition curriculum to be used by first year medical students as part of their basic science course is being developed at the University of North Carolina, Chapel Hill.
Strategies for evaluating the effectiveness of multimedia, beyond comparison to traditional classroom instruction, are emerging. Initially students taking multimedia and those taking traditional lecture courses test similarly. Educators favoring multimedia suggest that outcome based testing will demonstrate multimedia courses to be superior. In the meantime, since the costs of developing these programs is high, some educators wonder if the use will become widespread. Whether computer-based instruction in developed and/or developing countries will maximize learning for the dollars spent is being debated (Reeves et al, 1993; Reeves, 1992). c. APPLICATIONS TO DISTANCE LEARNING. Computer assisted-instruction (CAI) is a distance learning approach. Programs that provide performance feedback and coaching have demonstrated improved learning in distance education and training situations. Computer based case studies teach the learner nutrition assessment practices, perform assessment tasks, and interpret results. Simulated experiences allow users to practice. Users can uncover new information as they progress through case studies or realistic simulations. Specific and important findings can be highlighted. Although CAI cannot replace many clinical or nutrition education experiences, it can help build and maintain cognitive and analytic skills in an interactive format. Some other advantages are: a) cases can be staged to challenge both the novice and the expert; and b) content can be indexed for easy access to any term, image, or sound.
Several commercial vendors of journals distributed on interactive CD-ROM include cases to reinforce knowledge gained through reading. Continuing education credits often are available.
Educators have remarked that CAI and other computer-mediated instruction require a new way of looking at higher and continuing education. Instructors must adopt a new role, transforming themselves from lecturer to guide.
In a real sense this transformation happens everywhere computer mediated instructions occur. There is a shift of control of information. The instructor is no longer the gatekeeper of information. Some professionals fear loss of control of information. Others welcome the opportunities to enhance the educational process.
C. FOOD AND NUTRITION EDUCATION INSTRUCTIONAL PROGRAMS AND GAMES.
1. FOR CHILDREN, DELIVERED ON FLOPPY DISK. Children tend to be early adopters of recreational and educational uses of computers. It is not surprising, then, that most of food and nutrition instructional programs have been designed for school-age children.
One example is an interactive program, "Ship to Shore" (Pennsylvania State University, 1993). The program, delivered on floppy disk, uses nutrition as the vehicle to integrate math, science, language arts, and social studies for late elementary school age children. Students take the part of apprentices to Christopher Columbus and face a series of decisions about their food supply while sailing from Europe to the New World. It is one of the few programs that has a completed evaluation (Matheson and Achterberg, undated) which showed that integrating nutrition into other subject areas is an effective method to teach nutrition content. They also noted that the format of the lesson, in addition to the organization of the content, was important to promote learning. Stories and character identification effectively aroused students' feelings and engaged them in lessons. Sounds and animations incorporated into these stories helped students use their imagination. But, attention must be given to realism and accuracy of graphics to assure that the embedded nutrition concepts are attended and interpreted correctly. Problem solving assignments ith an evaluation component were effective in helping students enjoy learning.
2. FOR CHILDREN, DELIVERED ON CD-ROM. While the multimedia CD-ROM market in the United States is exploding with programs for children, there are only a few nutrition education programs. One of the most popular and widely distributed CD-ROM programs is the "5-A-Day Adventures" (Dole Food Co., 1994). The interactive program with music and video was designed to increase the consumption of fruits and vegetables and support the United State's "5 A Day for Better Health" campaign. It includes activities about nutrients in fruits and vegetables, serving sizes, label reading, simple recipes and making salads. One feature, quick-time-movies, is used to show movies of foods growing and being processed. Students who have never seen a banana tree, for example, can watch the banana form and grow, and then be picked and packaged for shipment. Activities for teachers and parents are on the disk. Children are given an email address to write to characters in the program. There is a Dole 5-A-Day World Wide Web site. A comprehensive evaluation is being conducted with results expected in 1996. Preliminary findings suggest that this application demonstrates the ability of multimedia programs to capture children's attention, increase their knowledge and change behavior.
"Dr. Health'nstein's Body Fun" (Cancer Research Foundation of America, 1994) is a child's multimedia CD-ROM program that is an adventure game and fantasy program to encourage healthy choices and promote a lifetime of fitness and health. This application demonstrates how gaming can be used to teach nutrition. Some people refer to these programs as "edutainment". They argue that today's youth need programs like these to engage them in learning. They do have the capability of giving personal feedback. No formal evaluation is planned.
3. FOR ADULTS, DELIVERED BY INTERACTIVE VIDEODISC. The use of multimedia is not reserved for children alone. "StampSmart" is a multimedia program currently being tested in an inner city Food Stamp office (Campbell, 1995). It requires a videodisc player and keypad. "StampSmart" is an effort to teach low fat, low cholesterol and high vegetable diets to women who receive food stamps. A soap opera video is the "hook" to get the women to use the computer. The nutrition lessons and questions are like the commercial breaks between the story segments about a woman on trial for murdering her husband. It turns out the husband died of natural causes, a heart attack. Lessons are on low-fat, high fiber eating. It takes participants about 30 minutes to view the video and answer questions on the computer screen. Results of the evaluation study to determine participants' eating habit changes are expected in fall, 1995.
"HealthTalk" is an example of a multimedia program designed for low literacy populations (Strecher et al, 1993). The program is based on a frequently viewed television talk show. Hosts, experts and lay persons interact to provide nutrition information. "HealthTalk" is housed in a kiosk and equipped with a television remote control. It collects dietary information, processes it to create a computer personalized educational and behavior change program tailored to specific dietary and lifestyle factors of the user. The program uses algorithms encouraging goal setting for selected dietary problems and subsequently provides performance based feedback. The user can interact with four sessions that build on information collected from previously viewed sessions. The program also provides printed feedback for the user to take home. Results of extensive evaluation to describe motivation to change, perceived threat, stage of change, self efficacy, social support and quality of life related to dietary change is expected in 1996. Data describing the degree to which patients were engaged in the intervention, their level of satisfaction with this form of intervention and the participation cost in terms of lost work time, transportation and child care, are being examined.
4. OTHER KIOSK APPLICATIONS. Several programs described above either have been or could be delivered using a kiosk. Interactive kiosks that dispense information, coupons, recipes are increasing in popularity in the U.S. The kiosks can be free standing or set directly on the store shelf.
Several programs have reported that multimedia interventions are successful in changing nutrition knowledge and attitudes of the users. The University of Texas Medical Branch in Galveston used touch screen kiosks with bilingual programs about pregnancy, infant nutrition, infant and childhood safety and immunization in community based clinics. The federal and many state Cooperative Extension Services have used kiosks to deliver information in public places. For example, the Virginia Cooperative Extension Service placed kiosks in shopping malls and libraries and reached people not usually served by the CES (Gleason, 1991). The University of New Mexico delivered food safety and quality programs to Native American audiences. These applications demonstrate that people, with limited or no computer skills,willingly obtain information from a computer where and when they desired it. They found traditional Native Americans as well as younger adults were pleased to interact with the systems and "Walk In Beauty With Food Safety". Kiosks are successful delivery systems when requests for information are predictable. They have a consistently good attitude, are accurate 24 hours per day, can adapt to the ser's culture, including language, and are polite and on time.
Unfortunately, funding for continued or expanded use of successful multimedia programs is difficult to obtain.
D. PRODUCTION TOOLS.
Computer software for wordprocessing and data storage are commonly used by nutrition educators developing and operating nutrition education programs. However, the capability of the computer to enhance nutrition education publications is not always used.
1. COMPUTER TAILORED MESSAGES. Word processing and desk-top publishing software enable nutrition educators without computer programming expertise to develop print materials personalized for their audiences. The computer simplifies the design and creation of multiple tailored versions of printed materials instead of using a single standardized version. More sophisticated processes can be used to individualize elements of the content as well as the structure of printed materials. A few nutrition related programs allow the user to input demographic and other personal data and receive a risk profile tailored message. For example, "Partners in Prevention--Nutrition" (Campbell et al, 1994) uses information to create behavior change programs, based on algorithms, tailored to the specific needs of the user. The program eliminates extraneous material and presents only the information most relevant to the user. This application demonstrates that modern computer technology can allow busy health professionals to recapture the benefits of personalized attention that has been lost by the use of generic pamphlets and newsletters. 2. TAILORING GRAPHICS FOR NUTRITION EDUCATION. Nutrition educators preparing printed materials for use in Third World countries often encounter difficulty in preparing art work. The Manoff Group used computers graphic software to build better nutrition education posters and counseling cards (Tisa, 1991). While the debate continues about the quality of nutrition education materials needed for effective communication programs, social marketing researchers have documented that the effectiveness of high quality, tailored nutrition education materials outweigh the benefits of local ownership of nutrition education materials. In Swaziland (SNNC, 1992) an experienced artist was not available to develop the graphics needed for a weaning program. Photographs were considered but few families were willing to pose. Some photographs were obtained and scanned into computer files. An artist, using graphics software, produced an image bank which was used for pretesting posters and counseling cards. The pretesting research identified several needed changes that usually would have required reshooting photographs or redrawing pictures. The changes were easily made using the computer graphics software and the final flip chart and cards were printed locally. Images like these can be modified and used for other projects. This application demonstrates that image data banks for nutrition education programs may create economies in materials production budgets often sought without sacrificing the ability to tailor materials to an audience. These materials, however, must be produced following the same standards of nutrition education materials development used in other successful programs.
a Improvement in word processing and desk top publishing software enables nutrition educators with limited computer skills to prepare professional looking newsletters, nutrition education booklets and materials. As part of its Physician Initiative, the American Dietetic Association prepared and distributed floppy disks with patient education handouts in files. These files could be easily changed to add the physician's name, address, phone, or other information. The files were prepared to be printed onstandard printers. Nutrition education program developers could use this approach to design materials that would be tailored, if desired, and printed at the delivery site.
47 3. CLIP ART AND PHOTO COLLECTIONS. Inexpensive photo collections and clip art software packages are also widely available. These packages are graphic images in computer readable form and are usually intended for reuse and modification by the user who selects, resizes, adds color or labels a picture. Users can access professional art illustrations at low cost. These programs can produce the graphics for print or slide or computer presentations.
An example is the work done by Gould and Anderson (1995). Basic computer graphics have been utilized with the objective of enhancing nutrition education materials designed to reach high risk populations with limited reading ability within two different Food and Nutrition Programs. Foods were photographed, scanned/digitized, and modified using photo-graphic software. These digitized and modified pictures were incorporated into the Creditable and Non-creditable Food Guide for the Colorado Child and Adult Care Food Program, originally in a text format. Although a ceiling effect was seen with the statistical analysis regarding improvement of behavior--child care providers menu reporting--the guide was well received as noted with a simple attitudinal questionnaire.
A project in progress includes the incorporation of graphic clip art into the Colorado WIC Allowable Food Guide. Based on results from preliminary evaluation of samples of nutrition professionals, WIC staff, and WIC clients, the guide is well received. They recommend the inclusion of more detailed graphics. Scanning technology is being used to digitize labels of allowable foods with multiple brand choices within a food category, eg. ready-to-eat cereals, and incorporate those in the guide in place of the current text list.
4. READING LEVEL EVALUATION. Nutrition educators use software programs to evaluate reading grade.
Electronic publishing improves assess to information, and increasingly, individuals and organizations in the developing world are finding ways to use technologies in spite of the difficulties (Gibbons, 1995).
5. PRESENTATION SOFTWARE. Presentation software allows nutrition educators with multimedia computers to enhance their presentations by incorporating visuals, sound, animation, texts, and video. Nutrition instructors at many colleges and universities are beginning to use presentation programs to enhance their lectures. The perceived benefits include improved visualization and animation and progressive disclosure of information. For example, an instructor can use an animated chemical or physiological reaction providing the learners with a vivid picture of the reaction. It provides the instructor with an improved ability to present abstract or complex material resulting in increased comprehension and interest. Students report that the animations are more helpful than static slides. Beerman (1995) noted that the academic performance of the average student was improved and most students agreed that multimedia facilitated their learning. Speakers at professional meetings also are using presentation software to enhance their presentations.
OTHER STAND-ALONE APPLICATIONS. The CD-ROM disc can be viewed as a storage system. Databases and literature are delivered on CD-ROM. CD-ROM databases offer instant access to full articles with simplified search and retrieval processes. Nutrition materials are found on discs with health information. Most CD-ROM databases are updated retgularly. These databases are appropriate for professionals and consumers who need detailed information in a few specialized areas.
Some think the use of CD-ROMs as information and storage retrieval systems in the developed world will be short lived as the access to online services grows (described later in this paper). Others believe there is great potential for the use of CD-ROMS libraries of nutrition information, especially in developing countries and other areas where the costs and reliability of telecommunication remain prohibitive.
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