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New developments in nutrition education utilising computer technology

Kathryn M. Kolasa1

1 Professor and Section Head, Nutrition Education and Services, East Carolina University School of Medicine, Greenville, North Carolina 27858 USA.

Introduction
Stand-alone applications
Linkage applications and the global information highway
Issues in computer hardware, software and training for nutrition educators
Conclusion
Recommendations
References

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 communication technologies 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 nutrition education programmes utilising computer technology in both developing and developed countries. The last significant review of the use of computers in nutrition education was prepared in 1984 (Shannon, 1984).

Computer communications can be grouped under two headings, stand-alone applications and on-line applications. Stand-alone applications are computer programmes 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.

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. Programmes are available on floppy disks, CD-ROM disks, and laser disks with accompanying floppy disks.

Programmes are being used at computer work stations or at kiosks. A comprehensive list of nutrition software is not currently available. The Food and Nutrition Information Centre (FNIC) of the United States Department of Agriculture (USDA) maintains the largest listing, about 200 programmes, of food and nutrition software. The list represents about half of the food and nutrition applications available in North America. Lists of programmes are available by writing or e-mailing a request to the library.

The major types of programmes designed both for 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 programmes 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, that are used by nutrition educators to enhance the production, adaptation, and dissemination of nutrition education materials.

The programmes described in this section are for illustrative purposes. Other programmes are available, but those described are most familiar to this author and are predominantly from North America. Their inclusion does not imply endorsement.

Nutrient analysis

Based on food intake recalls/records

During the 1980s and 1990s, software to analyse food intake proliferated. A list of foods and beverages, along with the serving sizes, for one or more days is keyed into the computer programme. The programme 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 programmes have successfully demonstrated that consumers of a wide range of socio-economic and educational levels can use a touch-screen computer system for diet analysis.

Several authors have described considerations for selecting a computerised dietary analysis system (Buzzard, Price & Warren, 1991; Seaman, 1992; Nieman et al., 1992; LaComb, Taylor & Noble, 1992; Lee, Nieman & Rainwater, 1995). The nutrient database is the most important feature. The database must be accurate, verified, and large enough to meet the intended task. Most programmes use the USDA nutrient database as the standard. Some programmes 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 programmes use other standards, including the Recommended Dietary Intake for Canadians, the U.S. Food and Drug Administration (FDA) labelling standards (Recommended Daily Intake or RDI and Daily Values or DV), Food Guide Pyramid servings, and other food grouping systems. A few software vendors customise programmes with international standards and foods. Computerised databases for food consumption information are available from FAO as well as other international organisations and country food and nutrition institutes. The International Network of Food Data Systems (INFOODS) has food composition databases organised for regions of the world.

Matching the education or research needs with the programme is important, because prices vary from less than US $5 to several US $1,000. Hardware requirements also increase as the complexity of the programmes increases. The cost is based on the number of foods in the database, number of nutritive components analysed, and programme capabilities, such as types of reports generated (e.g. lists, graphs, summaries, dietary advice), and availability of updates and technical support. Generally, programmes are distributed on multiple floppy disks or CD-ROM disks.

Programmes that analyse nutrient intake were welcomed by researchers and hospital dieticians. They found computerised nutrient analysis significantly reduced both the time and effort of calculating intakes using calculators and food composition books. The programmes have now been used extensively for classroom assignments from elementary through to 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 co-operative extension service professionals, fitness trainers, food scientists and food service professionals. The programmes are used in doctors' clinics as part of medical assessments or nutrition counselling sessions.

Programmes have also been developed for the home computer market. The popularity of these diet analysis programmes 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). Multimedia programmes, such as "Pyramid Challenge" (Dennison, 1995) combining video, slides, graphics, voice, and text with the interaction of computers, are expected to expand the use of nutrient analysis in nutrition education programmes.

The effectiveness of these programmes 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 nutrient analysis to be used more frequently in education and counselling settings.

Nutrient analysis based on food frequency questionnaires (FFQs)

The FFQ is a short-cut method for collecting information about dietary intake. First, a computerised software made it possible to easily estimate reliable nutrient intakes. But the questionnaire remained difficult to self-administer because keyboard entry was required. Then, a 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 and the computer was programmed to calculate the nutrient intake. The expensive price 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 counselling. Hardware has become more affordable and others have demonstrated the cost effectiveness and feasibility of this method (Suitor & Gardner, 1992; Byron, 1995). More recently, the growing availability of multimedia hardware has made it possible to programme 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 programme uses storytelling, sound, video, and other aids to personalise the questionnaire and reduce the tedium and reading ability needed to complete the data input of traditional FFQs. "Nutrition DISCovery" is based on the Health Habits and History Questionnaire, Dietary Analysis System, National Cancer Institute (Block, 1989). Food items are organised 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 colour 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 non-readers to use the programme 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 programme is currently only in English, it is feasible to have additional languages made available to the user.

The effectiveness of this type of programme for collecting nutrient information and changing behaviour of users is under study (Sumner, Keller & Diamond, 1996). 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 programmes, when compared with pencil and paper or partially automated questionnaires, will result in more reliable data because serving sizes are represented better. The programme also allows collection of dietary data when the expert interviewer is unavailable or unaffordable.

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 programmes used for nutrient analysis 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 programme 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, and use graphics, music and animation. Several outlets were used to publicise the programme. The software was promoted (i) in newsletters sent to working mothers, (ii) during a satellite media tour of a popular junior high school television celebrity, (iii) to food, health and computer news editors, and (iv) by placing it in grocery stores in a kiosk at point-of-purchase, near the potato display, with recipe cards and information on how to obtain the software distributed in the kiosk; (v) on Internet where the programme is available for downloading; and (vi) in print advertisements.

Evaluation of the effectiveness of this programme to increase sales and consumption of potatoes is in progress. Retailers participating in the kiosk trial reported potato sales increased by 5-20%. In the first six months, as estimated, 30 million Americans were exposed to the message and 17,000 copies of the software were distributed. Testimonials from consumers suggest that this software is engaging enough to use, takes the tedium out of menu planning, and encourages parent-child interaction about nutrition. Nutritionists suggest that this type of programme may help individuals follow dietary guidelines. The programme demonstrates a benefit of computer applications: providing information when and where the public wants it.

Clinical nutrition

There are a limited number of computer programmes for assessing the nutritional status of patients; charting medical records; teaching patients about diet and disease; growth monitoring (Anon, 1986) and for computer-assisted education and continuing education for health and medical professionals.

Assessment tools

Applications that use computer capabilities in calculations and data management are widely available. Software for desktop computers and programmes 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 for 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.

An example of a health information system software is "ProMis". It is a tool to manage large amounts of data like severity of malnutrition or diarrhoea. Save the Children used the system to rectify discrepancies in food rationing (Hendricks, 1995). There is a potential to build nutrition education systems into these data systems.

Nutrient-drug interaction

Nutrient-drug interaction software is an example of a specialised database 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.

Patient education

Programmes to provide dietary information and education to patients are available for individuals with diabetes, hypertension, heart disease, and complex medication regimens. These programmes teach patients about causes of the disease, symptoms, complications, dietary management and menu planning. The levels of personalisation and interactivity vary greatly.

Of particular interest is the "Touch Video for WIC", developed to meet the need to provide consistent nutrition education with limited professional nutrition staff. Six modules were designed for delivery on an interactive video disk kiosk. Information on breast-feeding, healthy eating habits, shopping, smoking cessation, an introduction to the WIC programme and an eligibility screening tool, have been successfully used with about 55% of the case-load for the state of Maine, USA. Multiple media are used in many modules, from full-motion video to straight text. Almost all clients reported positive feelings about using the programme to learn. A few felt it was "non-human" 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 favoured a combination of a live counsellor and computer. These programmes and additional modules are being converted to CD-ROM to expand distribution possibilities.

The value of the programmes has been demonstrated in the following ways: delivering consistent and concise nutrition and health counselling, even when a professional nutritionist is not available; engaging clients for a longer period of time because the programme is interactive; creating more time for critical one-to-one counselling; 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 information and education: it consistently provides standard answers to predictable questions. Other advantages are that it is non-judgmental, it affords privacy in learning and it assures equality of information to the user. Nutrition workers sometimes fear they will be replaced. Training of nutrition workers to use these technologies to enhance their work is needed.

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. Often these programmes, or portions of these programmes, can be adapted for consumer use. The nutrition programmes 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 programmes 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.

· Text-on-screen examples:

"Nutrition and the Practising Physician" (Schoenberger, Betz & Mascitti, 1994) is an example of a computer-assisted instruction programme that addresses both the prevention and management of diseases including obesity, hypertension, diabetes, and lipid disorders. The programme provides nutrition information and counselling 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, & Lasswell, 1995), is in production. "Nutrition and Disease Prevention", a computer-assisted training and continuing education programme, was designed for health care in developing countries (National Capitol Systems Inc, 1984).

· Multimedia examples:

Multimedia programmes for health professionals and students are promoted as ways to increase learning and retention in a shortened learning time, captivate students, and provide realism, role modelling and simulations. Many programmes requiring a computer and a laser disk were developed for nursing and medical education (O'Neill, 1990). Until recently, videodisk technology was required to show realistic video on a computer.

One of the few nutrition interactive videodisk programmes produced is "Cardiovascular Health: Focus on Nutrition, Fitness and Smoking Cessation" (Kolasa & Jobe, 1994). The technology is used for role modelling. Physicians are seen completing nutrition assessments and counselling their patients in ambulatory clinics. Users chart their own path through the programme. Self-assessment tools give users immediate feedback about their own diet and exercise pattern. The programme 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 programme was evaluated by medical students (Kolasa et al., 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 programme demonstrates the ability of computer multimedia programmes to: (i) effectively model nutrition assessment and counselling behaviours; (ii) ensure consistency and equality of learning opportunities; and (iii) expose learners to master teachers and subject matter experts. Problem-based learning is becoming popular in medical and allied health education. Images of Cancer Prevention, The Nutrition Cancer Link (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 favouring multimedia suggest that outcome-based testing will demonstrate multimedia courses to be superior. In the meantime, since the cost of developing these programmes is high, some educators wonder if the use will become widespread. Whether computer-based instruction in developed and/or developing countries will maximise learning for the dollars spent is being debated (Reeves, Harmon & Jones, 1993; Reeves, 1992).

· Applications to distance learning:

CAI is a distance learning approach. Programmes 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: (i) cases can be staged to challenge both the novice and the expert; and (ii) content can be indexed for easy access to any term, image, or sound. This approach may be very helpful in training field-workers in the developing world.

Several commercial vendors of journals distributed on interactive CD-ROM include cases to reinforce knowledge gained through reading. Continuing education credits are often available. Educators have noticed that CAI and other computer 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 wherever computer instructions occur. There is a shift in the 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.

Food and nutrition education instructional programmes and games

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 food and nutrition instructional programmes have been designed for school-age children.

One example is an interactive programme, "Ship to Shore" (Pennsylvania State University, 1993). The programme, delivered on floppy disk, uses nutrition as the vehicle to integrate mathematics, 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 programmes that has a completed evaluation (Matheson & 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 animation 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 focused on and interpreted correctly. Problem-solving assignments with an evaluation component were effective in helping students enjoy learning.

For children, delivered on CD-ROM

While the multimedia CD-ROM market in the United States is exploding with programmes for children, there are only a few nutrition education programmes. One of the most popular and widely distributed CD-ROM programmes is the "5-A-Day Adventures" (Dole Food Co., 1994). This interactive programme with music and video was designed to increase the consumption of fruits and vegetables and support the United States' "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 e-mail address to write to characters in the programme. 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 programmes to capture children's attention, increase their knowledge and change behaviour.

"Dr. Health'nstein's Body Fun" (Cancer Research Foundation of America, 1994) is a child's multimedia CD-ROM programme that is an adventure game and fantasy programme to encourage healthy choices and promote a lifetime of fitness and health. This application demonstrates how play can be used to teach nutrition. Some people refer to these programmes as "edutainment". They argue that today's youth need programmes like these to engage them in learning. They do have the capability of giving personal feedback. No formal evaluation is planned.

For adults, delivered by interactive videodisk

The use of multimedia is not reserved for children alone. "StampSmart" is a multimedia programme currently being tested in an inner city Food Stamp office (Campbell, 1995). It requires a videodisk 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-fibre 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 changes in participants' eating habits are expected in autumn 1995.

"HealthTalk" is an example of a multimedia programme designed for low literacy populations (Strecher et al, 1993). The programme 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 personalised educational and behaviour change programme, tailored to the specific dietary and lifestyle factors of the user. The programme 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 programme also provides printed feedback for the user to take home. Results of an 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 users 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.

Other kiosk applications

Several programmes described above either have been or could be delivered using a kiosk. Interactive kiosks that dispense information, coupons and recipes are increasing in popularity in the U.S. The kiosks can be free standing or set directly on the store shelf.

Several programmes have reported that multimedia interventions are successful in changing nutrition knowledge and the attitudes of the users. The University of Texas Medical Branch in Galveston used touch-screen kiosks with bilingual programmes about pregnancy, infant nutrition, infant and childhood safety and immunisation in community-based clinics. The federal and many state co-operative extension services (CES) have used kiosks to deliver information in public places. For example, the Virginia CES 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 programmes 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 desire 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 a day, can adapt to the user's culture, including language, and are polite and on time.

Unfortunately, funding for continued or expanded use of successful multimedia programmes is difficult to obtain.

Production tools

Computer software for word processing and data storage are commonly used by nutrition educators developing and operating nutrition education programmes. However, the capability of the computer to enhance nutrition education publications is not always used. This could have an immediate impact on nutrition education.

Computer tailored messages

Word processing and desktop publishing software enable nutrition educators without computer programming expertise to develop printed materials personalised for their audiences. The computer simplifies the design and creation of multiple tailored versions of printed materials instead of using a single standardised version. More sophisticated processes can be used to individualise elements of the content as well as the structure of printed materials. A few nutrition-related programmes 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 behaviour change programmes, based on algorithms, tailored to the specific needs of the user. The programme eliminates extraneous material and presents only the information most relevant to the user. This application demonstrates that modem computer technology can allow busy health professionals to recapture the benefits of personalised attention that have been lost by the use of generic pamphlets and newsletters.

Tailoring graphics/or nutrition education

Nutrition educators preparing printed materials for use in developing countries often encounter difficulty in preparing art work. The Manoff Group used computer graphic software to build better nutrition education posters and counselling cards (Tisa, 1991). While the debate continues about the quality of nutrition education materials needed for effective communication programmes, 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 programme. Photographs were considered but few families were willing to pose. Some photographs were obtained and scanned into computer files. An artist, using a graphics software, produced an image bank which was used for pre-testing posters and counselling cards. The pre-testing 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 programmes may allow economies in material production budgets, 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 programmes.

Improvement in word processing and desktop 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, telephone number, or other information. The files were prepared to be printed on standard printers. Nutrition education programme developers could use this approach for materials that could be tailored if desired, and to print at the delivery site. This would allow local workers to adapt materials to their audience, and make savings in printing and distribution.

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 colour, or labels a picture. Users can access professional art illustrations at low cost. These programmes 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 utilised with the objective of enhancing nutrition education materials designed to reach high-risk populations with limited reading ability within two different Food and Nutrition Programmes. Foods were photographed, scanned/digitised, and modified using a photo-graphic software. These digitised and modified pictures were incorporated into the Creditable and Non-creditable Food Guide for the Colorado Child and Adult Care Food Programme, originally in a text format. Although a ceiling effect was seen in the statistical analysis regarding improvement of behaviour - of child care providers and in 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 digitise labels of allowable foods with multiple brand choices within a food category, e.g. ready-to-eat cereals, and incorporate those in the guide in place of the current text list.

Reading level evaluation

Nutrition educators use software programmes to evaluate reading grades.

Electronic publishing improves access to information, and increasingly, individuals and organisations in the developing world are finding ways to use technologies in spite of the difficulties (Gibbons, 1995).

Presentation software

Presentation software allow 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 programmes to enhance their lectures. The perceived benefits include improved visualisation 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 are also using presentation software to enhance their presentations.

Other stand-alone applications

The CD-ROM disk 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 disks with health information. Most CD-ROM databases are updated regularly. These databases are appropriate for professionals and consumers who need detailed information in a few specialised 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 on-line services grows (described later in this paper). Others believe there is great potential for the use of CD-ROM libraries of nutrition information, especially in developing countries and other areas where the costs and reliability of telecommunication remain prohibitive.

Linkage applications and the global information highway

If you give a nutrition educator or a consumer a computer that can communicate with other computers through phone lines, satellite transmissions or network wires, you have given that individual an entrance ticket to Cyberspace or the Global Information Highway. In this section of the paper I will focus on the dissemination and retrieval of food and nutrition information by electronic means such as e-mail, Internet, world wide web (WWW) and other computer networks, electronic databases, electronic bulletin board systems, faxes, and interactive non commercial television. While much of the information presented is of interest to the professional community, access to these technologies is available to consumers. This decentralisation of access to information has great implications for nutrition educators as well as governments and international agencies who support nutrition education programmes. Therefore, discussion of these technologies is appropriate in a paper describing nutrition education for the public.

While some people discount these technologies as a passing fad, the importance of these technologies in the information age, in both developed and developing countries, is acknowledged by nutrition educators interested in learning how best to use these systems.

E-mail or electronic mail

The E-mail is a basic communication tool. Nutrition educators from different parts of the world are using e-mail to exchange ideas, projects, and data easily, quickly and relatively inexpensively. The power of e-mail is that it brings people together regardless of distance. It allows the attachment of files. The recipient can put a file into a word processor, edit and revise the document and use it or return it to the sender.

There are a variety of ways to communicate with individuals and with large numbers of users through e-mail. These include electronic fora and discussion groups. These groups exist on the Internet as well as on commercial on-line services. Some fora or lists are fully automated, others are maintained and administered by individuals. Some have limited access and others are open to everyone in the world. Some are two-way fora that allow members to discuss a topic. Others are one-way services that send newspapers, reports, and other publications to subscribers.

There are fora and discussion groups interested in international health issues. Only a few examples are cited here. See the reference section of this paper for additional health-related listings.

Food and nutrition examples

While there is a number of fora that may include food and nutrition education issues, there are a limited number of exclusive food and nutrition lists or fora. Food and nutrition education professionals are currently seeking and providing information using both the commercial on-line services and the Internet. More nutrition educators need to participate. There are also lists that allow anyone to ask for and receive information. Some of the topics include discussion and support of weight loss, recipe, and foodlore exchange, vegetarianism, food composition, food safety, and nutritional epidemiology. Some, but not all professionals, believe that an important drawback to this freedom to give and receive information is that there is no agency or unit responsible for the accuracy of the information. These fora and discussion groups are open to users from around the world. Some believe that quality control systems need to be put in place. Others stress that we need to teach professionals and consumers alike how to assess the validity and applicability of the information, since we have never been able to control nutrition misinformation.

Examples for meeting international community need

There is a growing number of resources of interest to the international community. Examples related to nutrition education are noted here.

· World Bank PHNLink:

World Bank PHNLink is an electronic network system that links population, health, and nutrition specialists around the world through communication, interaction, and information sharing. In mid-1995 it had an estimated 1,000 subscribers. It operates two services through Internet. PHNFlash is a weekly electronic newsletter and archiving service containing information about population, health, and nutrition programmes and projects.

Information can be posted. Electronic newsletters like "Mothers and Children", a bulletin published three times a year in English, French and Spanish by the Clearinghouse on Infant and Maternal Nutrition and the American Public Health Association, are delivered more quickly and inexpensively to a greater number of readers. Additionally, the "Mothers and Children" newsletter has articles on technology such as "using video presentations for community development" and "using electronic mail".

· OMNI:

The Opportunities for Micronutrient Intervention (OMNI) was developed and funded by the Office of Nutrition of the United States Agency for International Development (USAID). Its mission is to control and prevent micronutrient deficiencies in developing countries. As part of its information dissemination effort, it uses electronic networking. For example, OMNI post reports on the micronutrient interventions. OMNI has supported work to improve the availability and access to micronutrient databases. A background paper including recommendations was prepared in 1995.

· VITA:

VITA supports a free, public, on-line discussion forum, Devel-L. It provides opportunity to exchange ideas related to technology transfer in international development.

· Clearinghouse on Infant Feeding and Maternal Nutrition:

The Clearinghouse has actively supported the assessment of information needs as well as the dissemination of resources. The Clearinghouse has collaborated with field-based organisations to strengthen their capacity to produce and disseminate information (Gibbons, 1984).

Regional networking tools

Many countries do not yet have direct access to the Internet and/or have inadequate telephone lines. Systems for networking are being developed to prevent the developing world from becoming more isolated from information sources. The emergence of cellular telephones may change the landscape of telephone communications where telephone systems have not worked. Many communications experts believe that within ten years communication linkages will not be a real problem.

Fidonet

Kenya has not had direct access to the Internet. However, the African Regional Centre for computing is able to communicate and network internationally through the Internet directly, using a low-cost dial-up technology based on Fidonet. Fidonet offers three main services: electronic mail, conference mail, and file transfers. Communication can occur several times a day (Ochuaodho, 1994).

HealthNet

SatelLife/HealthNet is a telecommunications system that links health-care workers around the world and provides them with access to appropriate sources of information. In 1995 it operated in 16 African and five Asian countries. The system, initiated by SatelLife, is a combination of low-earth-orbit satellites, ground stations and telephone-based electronic mail networks. It has been designed to function reliably and inexpensively even in areas where there are poor or non-existent telecommunications infrastructures. This and other computer networks offer exciting possibilities for ending the isolation of people in remote areas with poor access to information. While there are no projects in the area of nutrition as yet, there are plans to distribute material from various health studies conducted by the Academy of Educational Development. HealthNet offers e-mail, electronic conferencing, and long-distance education.

Worldwide networking tools

Other networking tools, also known as utilities, allow users to explore and locate valuable resources anywhere in the world. Some of the better known tools include Almanac, Gopher, and the WWW. Almanac and Gopher allow only text. Almanac is an information server, where requests are submitted and processed through the e-mail. Gopher is a tool that provides a menu structure for navigating and locating resources world-wide. WWW is used by millions of people. Users with direct access to Internet, as well as those who use a commercial vendor to access it, can receive graphics, pictures, sound, and video. The statistics keep changing but one prediction is that there will be more than 11 million users of WWW by 1998. In February 1995 an estimated 27,000 sites existed with more than five million documents. The number of sites is doubling every 53 days and the number of documents is doubling every six months. At present it is recognised as a fairly inexpensive way for organisations to offer information about themselves to anyone who seeks it, or stumbles on it while "surfing" the Web. The Web displays information in the form of pages which can contain colour photographs, recorded voices or musical selections as well as text. The text can include highlighted words that are called Hyperlinks and refer the user to other pages. Two popular web browsers, "Netscape" and "Mosaic" can take you to a WWW Home Page at the click of a mouse. That Home Page may simply provide a directory of the information stored at that site. It may also allow the user to interact and complete activities like subscribing to a newsletter. Universities and governments were the first to operate Web Sites, as the computers in which Web information resides are known. But businesses and individuals are now doing so. For example, a student put the USDA Food Guide Pyramid on a Home Page. A Nutrition Home Page from Mexico can be reached at the address: http://www.spin.com.mx/nutrimex/nutrimex.html. There are many Home Pages for health organisations and food industries.

The benefits of electronic information found on WWW are: around the clock accessibility, low cost, and immediate availability. Often the data available are more up-to-date than printed materials. The cost to the user is usually the telephone call or Internet connection. A browser allows users to easily go to WWW sites without using complicated computer commands.

Another example of a WWW site of value to nutrition educators is the site maintained by The International Food Information Council (IFIC, 1995). The site provides colourful graphics and text, educational materials, scientific research, recent survey data, and tips for health professionals and educators. There is a special section for journalists reporting on food, nutrition and health topics, as well as sound bits from noted experts. It can be reached by using its WWW address http://ificinfo.health.org or Gopher address of gopher://ificinfo.health.org.

Food and nutrition on-line services

The Food and Nutrition Information Centre (FNIC) of the USDA, National Agricultural Library, Beltsville MD ([email protected]) has been a leader in cataloguing sources of food and nutrition information available electronically. Electronic databases are computerised collections of information, usually covering a specific subject, that are arranged to facilitate efficient retrieval and use.

Computer on-line services offer fast, low-cost access to much of the world's accumulated nutrition and medical wisdom. On-line can deliver up-to-the-minute information. It is much like having access to a library without leaving the office, complete with a personal librarian to conduct a search. It is possible to instantly retrieve information like abstracts, read material on screen, and download material as hard copy. Subscriptions to on-line databases are good for people who want current and general information. Some on-line services have Personal Clipping Services, that alert the user automatically to new items of interest.

The services available are constantly changing. Some of the better known include the International Food and Nutrition Database (IFAN), a full text database containing a wide range of food and nutrition documents for health professionals and consumers (ceasing operation autumn, 1995). The Agricola database from the National Agricultural Library and Medline produced by the National Library of Medicine are on-line and useful in locating journal citations on specific topics such as food and nutrition and medical topics. Some other databases include WHO Micronutrient Deficiency Information System (MDIS), and PAHO/WHO Nutrition database system. Others exist, that are limited to data on a specific nutrient or condition.

There are also electronic journals and newsletters available through commercial on-line services. Some are electronic versions of publications also distributed in print such as the magazine "Cooking Light". Others are designed and transmitted only electronically to permit greater reach and frequency of updates.

Electronic bulletin board systems

These computerised systems usually focus on a specific subject area and a target audience. The users can access publications, bibliographies, software, calendars, bulletins, and other resources. Some of the better known ones include the Agricultural Library Forum (ALF) of the USDA, and the Nutrient Data Bank Bulletin Board from the Agricultural Research Service, which offers computer files on the nutrient composition of food. The U.S. Food and Drug Administration maintains a board with food labelling, food safety and food regulation information. The Technology Transfer Automated Retrieval System (TEKTRAN) contains information about the latest studies in agriculture, food, and nutrition. Research results and interpretative summaries are provided. For example, The Food Guide Pyramid database is a collection of nutrition education materials that feature the Food Guide Pyramid. Listings include the source, ordering information, language, audience and keywords and it is found on ALF and the FNIC Gopher. There are several other bulletin boards with information of interest to the international health community.

Other electronic services

Fax on demand

This is also referred to as information in an instant. Many groups are allowing access to information such as news releases and journal advertisers, by fax on demand. An individual using a touch-tone phone can call a known fax service, listen to the menu and request information that will then be faxed. A subscription service like AG Daily News, lists daily information available by fax. This system allows fast and low-cost distribution of information to those who seek it.

Computer conferencing

Computer conferencing is available at different levels of interaction from one-way video with various types of communication support, to the most sophisticated systems of two-way audio and with two-way video.

· University courses:

Several universities like Kansas State University (KSU), USA, are offering their traditional classes through computer conferencing. At KSU several food science courses are transmitted to the student's home or office. The student needs a personal computer with a modem. A communication software is provided, and access comes through a toll-free long distance connection. Training in computer communications is included at the beginning of the course. Benefits include university credits or Continuing Education Units (CEUs), ability to identify new resources and contacts, interaction with others in the same field, improvement of knowledge, and professional development.

Montana State University offered a food safety telecomputing course to teachers nationwide. Teachers dialed into the university via modem and hooked into a computer conferencing system. Participants could take the course on their own time schedule. The students communicated with each other through e-mail and bulletin boards about their experiences implementing food safety activities in their classroom (Stein, 1994).

· Personal conferencing:

Video conferencing is also available, that allows a person to use the computer at his/her desk, and on demand meet with one or several colleagues for real time interactions including video. This technology is being used for participation in remote teaching or distance learning by widely dispersed faculties or experts. This system also allows attendance at regional meetings, sharing visual images with distant colleagues, work group meetings with participants at multiple world-wide sites, consultation with experts and attendance at committee meetings.

Interactive television (ITV)

The commercial communication industry focuses its attention on the ability of consumers to use ITV for home shopping. But there is growing use of ITV for educational (often called distance learning) and health services (Telemedicine). ITV, which requires either satellite transmission or sophisticated phone lines, provides several levels of interaction. Some systems allow one-way video. Some one-way video systems are enhanced by the use of telephone lines, faxes or the e-mail. Other systems allow one-way video but two-way audio.

· Telemedicine:

Telemedicine is broadly defined as the use of telecommunication technologies to deliver medical information and services. It generally means, however, the use of remote electronic clinical consultation. It is typically two-way video and two-way audio, which enables diagnosis, treatment and other health-care activities. Some of the opportunities that Telemedicine provides include extending the expertise of health-care professionals to rural clinics, nursing homes and ultimately individual homes; allowing specialty consultations to a patient in his/her home community; creating an environment for collegial relationships to develop among people in different locations; and transmitting and receiving continued education. Clinical telemedicine programmes are underway in 40 of the 50 states in the USA.

· Opportunities for distance learning:

The potential for ITV in distance learning is great. There are several examples of the use of interactive TV for distance learning in public health and nutrition. Several public health nutrition programmes have used satellite television to extend the reach of high demand courses or workshops. Toll-free numbers are available to allow students live interaction with the instructor. These programmes allow field-workers to obtain important education without being away from their jobs for long periods of time. Local workshops often supplement the broadcasts (Haughton, 1995).

Several food and nutrition agencies have used interactive TV for training conferences. For example, the North Carolina and Georgia Co-operative Extension Services developed a food safety conference for child-care workers. The programme was transmitted to audiences across the two states. The audience had the opportunity to complete learning activities with others at their site as well as the chance to call in questions to a panel of experts. Learners were able to communicate with the instructors via telephone. Videotapes of the presentation which included the instructor's presentation as well as pre-recorded videos that demonstrated the issues, activity kits, and slides of bacteria, were made and distributed for later reuse. Evaluation is in progress (Lackey, 1995). Instructors at several universities teach nutrition workshops or courses using two-way audio and two-way video systems (similar to the Telemedicine described earlier) that allow students to interact as if they were sitting in a classroom (Balch, 1995).

Several types of systems have been described above. The use of computer conferencing and ITV can expand the reach of education. Learners can access information regardless of place and time. There are always trade-offs. As the level of interactivity among instructors and learners increases, the learner loses control over time and place for learning. The use of these technologies for distance learning are being evaluated. Some of the issues under study include ease of use and learning the system, aesthetic appeal, clarity of feedback, error handling and controls for parallel and serial group communications, and costs.

In addition to televised conferencing, instant two-way audio communication via satellite has been successful in nutrition education in the South Pacific (Renda & Riordan, 1983).

Issues in computer hardware, software and training for nutrition educators

Several issues are beyond the scope of this paper, including: (i) specific hardware and software requirements needed for nutrition education programming; (ii) specific computer skills needed by the nutrition educator; and (iii) selection of an appropriate computer consultant. There are organisations and agencies dedicated to the development of educational multimedia and distance education. They should be consulted for answers to those questions. For example, OMNI (1995) described hardware and software requirements for users of micronutrient databases as well as capacity and skill for application and use. The Board on Science and Technology for International Development (BOSTID) also has relevant fact sheets for the novice computer user. Johnson (1992) describes keys to sustainable microcomputer-based information systems in developing countries.

Professional groups are beginning to identify what the term "computer literacy" means for its profession. For example, the Society for Teachers of Family Medicine's Working Group on Computer Applications in Medicine recently proposed computer skills that should be acquired by all medical students before they complete their training. The tentative list includes working knowledge of e-mail, word processing, spread sheets, computerised medical records, and data management programmes such as SPSS or SAS. A similar set of skills needs to be developed for nutrition educators.

Most individuals develop computer skills by reading manuals; viewing videotapes; trial and error at the computer; conferring with a colleague or a computer tutor; learning from men-children; or attending workshops and classes sponsored by employers, community colleges and commercial companies. There has been little specific computer skills training for nutrition educators.

Some organisations, such as the Association for Progressive Communications, the Clearinghouse on Infants and Maternal Nutrition, SatelLife, BOSTID and the Society for Teachers of Family Medicine, have developed fact sheets and articles as introductions to understanding terminology and these tools. These materials are appropriate for nutrition educators to use in their personal computer skill development. The Clearinghouse on Infant Feeding and Maternal Nutrition has held workshops for capacity building and strategic development of communications.

The Society for Nutrition Education (SNE) has included programming to increase awareness about technology in nutrition education for several years. SNE has sponsored a session at its annual meeting where software authors interacted one-to-one with meeting participants to discuss the software they authored, the resources needed to develop the programmes, the acceptability to the intended audiences, evaluation data, and the trials and tribulations of developing computer-based applications. Several on-line applications have also been demonstrated at the SNE meeting. In 1995 SNE offered its first all day hands-on multimedia development workshop. All of these activities have been well received by participants. More hands-on training activities need to be supported at the meetings nutrition educators attend. Organisations have been reluctant to schedule these type of sessions because of logistics and expense.

Nutrition educators planning to create computer programmes have either needed to identify an instructional designer and computer programmer to work with them or personally develop those skills. There are how-to books on creating all types of software programmes and Home Pages. Most programmes described in this paper were developed by teams with the nutrition educator as the content specialist. Kolasa (1994) has described the roles and responsibilities of the multimedia team developing nutrition education materials. She assumes that nutrition educators do not have the time, interest or skills to develop these programmes. The talents and roles of other professionals, including the instructional designer and computer programmer, in the development of software programmes must be respected. The nutrition educator's time is best spent in determining the food and nutrition message and then ensuring its accuracy when delivered.

Conclusion

Computer technologies, both stand-alone and on-line applications, provide many opportunities for nutrition education. However, to date there have been only a limited number of programmes developed and evaluated. Nutrition educators have had minor participation in online applications. Examples demonstrating some of those opportunities have been described. There is a variety of issues facing nutrition educators who choose to use technology to enhance their efforts.

Access

The issues of access by the professional for stand-alone applications is often overstated. In developed and developing countries it is common for projects and programmes of all sizes to have a computer. The capabilities of most computers, even if purchased for other activities, are often not fully utilised. Computers can be used for more than word processing and data storage. However, nutrition educators need training and time to practice. They need time to experiment adding nutrition education to assessment programmes. For the public, access is becoming less of an issue. Interactive television, kiosks in medical centres, physicians offices, libraries, grocery stores, and work sites, have been used successfully in nutrition education efforts. Most stand-alone applications can be loaded on computers housed in kiosks and placed in public places.

For Cyberspace access, the concerns at first appear to be more serious, especially where telephone lines are unreliable. Some professionals in developing countries are finding ways to access the e-mail. Many agencies are concerned with preventing the creation of a greater information gap between developing and developed countries. Alternatives to traditional phone systems are being developed. In places where fax transmissions are possible, the simple addition of a modem and computer with a communication software may make communications faster and less expensive than taxing. Perhaps the biggest barrier to access is the attitude of nutrition educators themselves. Nutrition educators need to be informed and participate, as appropriate, in these information technology access issues. Nutrition educators should not wait until they are given access but work toward obtaining access to Internet or other networks. Nutrition educators need to participate in health-related discussion groups and other networks to create a presence for nutrition. Where e-mail is available but under utilised, nutrition educators may need orientation programmes to become more comfortable with communicating by computers. Then they should use the e-mail to exchange programme ideas and successes. Nutrition educators need to incorporate the new technologies to process and exchange information. Additionally they should not wait until access is achieved, but rather be developing plans, programmes, and databases to be ready for implementation when access barriers are eliminated. Nutrition educators need to collaborate with those who have access.

Effectiveness

The use of technology will not guarantee a more successful nutrition education or communication programme. The design and selection of appropriate technology for the purpose of the programme are critical. In some cases, programmes can reduce the human time needed to collect and analyse data, thereby increasing the time for counselling or teaching, or reaching more people. Technology can be used to enhance the efforts of nutrition educators but all forms of communication can be effective. While computers provide a powerful medium, other means of communication may be more appropriate to a given situation. It is important to determine the way the intended audience learns, and then to design programmes and campaigns that use a combination of media. Some elements of computer programmes that are important to evaluate with the intended audience in mind include: instructional design; branching capability (too much or too little); screen design; learner control and user interface; navigational issues; realism related to the programme's goals; level of decision making; feedback; record keeping; and balance of video, audio, animation, text and graphics. There is a growing body of literature describing the elements of software design important to successful computer nutrition education efforts.

Elements such as storytelling and interactivity are critical to engaging the user. Strategies for evaluating effectiveness are needed.

For the public

Technology can be used to enhance the efforts of nutrition educators. Computer technology, especially multimedia for nutrition education, requires that programme planners have a vision for educating in a different manner. These applications hold great promise but are new and only limited evidence has been accumulated to demonstrate that computer programmes may be more effective than current communication techniques in nutrition education. Computer programmes have been effective in: providing the public with access to information when health professionals are unavailable; engaging a user visually, sometimes for longer periods of time, to enhance learning; creating tailored messages that enhance behaviour change and compliance; giving straight information without bias; allowing conversations between health-care professionals and patients without regard to distance or time; providing medical decision support and expert advice; tailoring information to age, sex, language, literacy level, ethnic background, socio-economic status, geographic location, lifestyle, and/or medical history; and helping consumers to ask better questions and be more involved in their nutrition treatment plans. These programmes will only be successful, however, if they are designed to reach out to people and entice them to participate in their health care.

For production of quality nutrition education materials

Resources for the development and production of quality nutrition education materials are always scarce. Computer programmes can provide real economies in materials production, printing and distribution.

For the nutrition professional

For the nutrition professional, computer technologies hold promise for maximising education. The participants of the 1994 Bellagio Conference and the International Conference on Nutrition (1992) noted that responsive training and research efforts were needed to improve the efforts to reduce global malnutrition. The Bellagio conference report included a guiding principle that suggested training programmes should use a variety of methods including technologies appropriate to the training context. Computer technologies can meet some of the training principles outlined. They can be field-based, reiterative, and designed to build and maintain confidence. Computer technologies can be used in distance learning and require little absence from the job site. E-mail and electronic networks can be used for continuing education and discussion among trainees.

Consultation

There are many computer consultants available. Selecting the consultant who knows what hardware and software best suits the nutrition education programme is critical. Johnson (1992) described seven important keys to sustainable development of microcomputer-based information systems in developing countries. These can be helpful in selecting a consultant. Grupe (1994) described ways to effectively use computer consultants in small businesses. Many of the points are relevant for nutrition educators. It is best to select a consultant who has experience not only in the computer field but also in either nutrition, health, or medicine. The consultant needs to be able to train the staff in the use of the hardware and software. The trainer needs to do more than demonstrate the programme. The trainer needs to supervise the trainee "driving the programme". Training should be available to both women and men.

Purchasing software from an established company that produces easy-to-use software may mean there is no need for a trainer. However, time specifically for the nutrition educator to set up and practice the use of the software is imperative.

For nutrition educators developing software, selecting a programmer who knows the appropriate code (i.e., C Language or Authorware) and Platform (i.e., IBM or MAC) is critical. An instructional designer is needed to ensure the programme is educationally sound and programmable. A project manager is needed to ensure all the components are identified, acquired and compiled according to the time and budget schedules.

Recommendations

All nutrition educators must become familiar with computer technologies in order to determine those which might enhance their efforts in nutrition education for the public. All nutrition educators should receive training in computer skills and be given opportunities to practise those skills. They should obtain access to the Internet or other electronic networks to enable them to exchange food and nutrition information. They should participate. Nutrition educators who use computer software should provide feedback and evaluation data to the programme developers regarding its effectiveness in their setting. Some nutrition educators must actively test nutrition education delivered via new technologies.

For nutrition educators to be able to determine which computer technologies might enhance their efforts, governments and international agencies supporting nutrition education efforts must create opportunities:

(i) For capacity building. Nutrition educators need funded opportunities to obtain the computer skills needed to use stand-alone and on-line applications. They need time and access to equipment to practise those skills.

A number of institutions and agencies are committed to supporting professionals in adopting and using communication technologies. New programmes may not be needed. However, it appears that nutrition educators are not involved in these organisations nor do they have access to the materials. The FAO nutrition programme could collect and distribute handouts on building computer skills. The programme could also sponsor participation of nutrition educators in courses and workshops offered by commercial as well as educational institutions or organisations. They could provide opportunities at the regional level, similar to the SNE sessions where nutrition educators become more familiar with both stand-alone and on-line linkage applications.

These educational opportunities and increased awareness would elevate the level of computing knowledge among nutrition educators.

(ii) For nutrition educators to practise skills by having local governments supply computer hardware and software. Agencies could sponsor competitions for acquisition of hardware and software. Awards could be given for demonstration, implementation and expansion projects.

(iii) For nutrition educators to develop and evaluate new or adapt interactive approaches to nutrition education for new audiences. Little is known about the types of media and messages that appeal to different audiences.

Governments and international agencies must provide financial support for demonstration and evaluation of technology and innovative practices that allow recipients of nutrition education and promotion to receive messages tailored to their specific interests and needs. Projects for both consumers and professionals are needed.

FAO and other agencies should explore the opportunities that computer software provide for development, adaptation, and dissemination of print and graphic nutrition education materials.

(iv) For nutrition educators to use successful programmes. Government and international agencies must provide the financial support for widespread implementation of programmes that change users' behaviours.

(v) For directors, managers, and nutrition educators to discuss the impact of decentralisation of information.

Professionals at all levels and consumers will have access to both credible and inaccurate nutrition and self-help information. Governments should ensure that field-workers are not prevented from obtaining access to computer-mediated technology (stand-alone and, especially, linkage applications) because of a fear of loss of control of information or loss of power by their supervisors.

International and government agencies should provide the leadership for redefining the role of the nutrition educator during this time, characterised by the decentralisation of information. Agencies should provide workshops and other training opportunities for nutrition educators to develop skills to help consumers appropriately access and use available nutrition information.

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Shannon, B. (ed). 1984. Computers in nutrition education. J Nutr Educ, 16(2): 37-117.

Strecher, V., Bulger, D., Ammerman, A., Lutz, S, Kirkley, B, Keiserling, T & Bulger, J. 1993. HEALTHTALK, a computer-based interactive nutrition education programme. Presented at the American Public Health Association Annual Meeting.

Suitor, C.W. & Gardner, J.D. 1992. Development of an interactive, self administered computerized food frequency questionnaire for use with low income women. J Nutr Educ, 24(2): 82-86.

Simmer, N.E., Keller, B. & Diamond, L. 1996. Nutrition DISCovery personalized CD-ROM diet assessment programme. J Nutr Educ.

Swaziland National Nutrition Council (SNNC), Manoff Group. 1992. The Weaning Project. Improving young child feeding practices in Swaziland: project overview. Washington DC: Manoff Group, Inc. 38pp.

Sweeney, M.A. & Lester, J. Undated. Feeding Your Baby, University of Texas Medical Branch, Galveston.

Tisa, B. 1991. Picture perfect: generating graphics electronically. Development Communication Report, 73: 10-11.

Updegrove, N. 1990. Database searching: Information retrieval for nutrition professionals. J Nutr Educ, 22: 241-247.

U.S. National Potato Board. 1994. Ready, Set, Dinner. 7555 E. Hampden Ave, #412, Denver, Colorado 80231.

Other resources

The Alpha Media Catalog. 1-800-832-1000, PO Box 1719, Maryland Heights MO 63043-1719 (medical/nursing education video, computer education).

CAI Directory, Stewart Publishing Inc, 6471 Merritt Ct, Alexandria VA 22312; more than 500 computer assisted instruction programmes, including patient education

CD Rom Directory. Stewart Publishing Inc, 6471 Merritt Ct, Alexandria VA 22312; more than 350 titles for health sciences

Clearinghouse on Infant Feeding and Maternal Nutrition, Am. Public Health Assoc., 1015 15th St., N.W., Washington, DC 20005. (202) 789-5600, FAX: (202) 789-5661.

Database of Food and Nutrition Software and Multimedia Programmes. Nutrition Education Programmes. National Agricultural Library, Beltsville MD Jan 24, 1995

Health Sciences Consortium Computer Based Education Catalog. HSC 201 Silver Cedar Ct, Chapel Hill NC 27514-1517 fax 919-942-3689, 919-942-8731; 125 computer assisted and interactive video programmes

Kleeberg, P. 1995. Electronic mail: what is it? STFM Messenger.

Kleeberg, P. 1995. Electronic discussion groups: what are they? STFM Messenger: 4

Klein, D & Clements, C. 1990. Information via satellite: SatelLife projects for sharing medical information worldwide. Microcomputers for Information Management, 7(4): 293-301.

Lindsey, G., Novak, K., Ozgedez, S. & Balson, D. 1994. The CGNET Story: a case study of international computer networking. IDRC PO Box 8500, Ottawa Ontario, K1G3H9 ISBN 0-88936-678-0

National Research Council Office of Computer and Information Technology. Technology Fact Sheets. (1994-1995). Glossary and Frequently Used Computer Terms; Computer Hardware Components; Peripherals for Computers; Computer based communications; Internet Primer; Navigating the Internet; Fidonet; CD-ROM; Desktop Publishing; Operating Systems; Microprocessors; Local Area Networks; Monitors; Modems; Netiquette. 2101 Constitution Avenue, Washington DC 20418.

Shared Decision making Programmes. Foundation for Informed Medical Decision Making, PO Box 5457 Hanover NH 03755-5457, telephone 603- 650-1180, fax 603-650-1125.

Stein, M. 1995. The Science of Food Safety. A Telecommunication course as a model for reaching teachers with food safety information. Presented at Society for Nutrition Education.

Videodisc Directory. Stewart Publishing Inc, 6471 Merritt Ct, Alexandria VA 22312 703-354-8155 fax 703-354-2177; more than 500 proprietary and commercial videodisk projects for health sciences.

WC Brown Publishers. 2460 Kerper Blvd, Post Office Box 539 Dubuque IA 52001 800-351-7671.


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