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ESEARCH ARTICLE

ncreasing Nutrition Literacy: Testing theffectiveness of Print, Web site, andame Modalities

ontinuing Education Questionnaire available at www.sne.org/ Meets Learning Need Codes for RDs and DTRs 4010, 5090,nd 6050.

ami J. Silk, PhD1; John Sherry, PhD1; Brian Winn, MA2; Nicole Keesecker, MA4;ildred A. Horodynski, PhD, RNC3; Aylin Sayir, MA5

BSTRACT

Objective: To examine the effectiveness of three modalities for delivery of nutrition education.

Design: Between-subjects, repeated-measures design.

Setting: Data were collected at community agencies or during home visits.

Participants: Low-income, European American and African American mothers (N � 155).

Intervention: Participants were exposed to nutrition education material in 1 of 3 modalities (acomputer game, The Fantastic Food Challenge; Web site; or pamphlet). Likeability, nutrition knowl-edge, intention to use, and demographic measures followed the intervention at T1 and T2.

Main Outcome Measures: 5-point Likert-type scales measured likeability (5 items), and 33multiple-choice questions measured knowledge.

Analysis: Data were analyzed using analysis of variance (ANOVA) and analysis of covariance(ANCOVA) procedures using SPSS version 15.0 (SPSS Inc., Chicago, IL) software, P � .05.

Results: Overall, the Web site was liked more than the other conditions with this audience ofwomen. Significant differences in attention, understanding, and intent to use the informationexisted across modalities. The Web site performed better than other modalities on knowledgeoutcomes, with no differences in knowledge retention from T1 toT2.

Conclusions and Implications: The Web site modality performed best with this audience ofwomen, indicating that interactive computer games may not confer greater benefits than traditionalmodes of information delivery for all audiences, particularly those with low computer skills.

Key Words: nutrition literacy, evaluation, entertainment-education, media uses and gratifications

(J Nutr Educ Behav. 2008;40:3-10)

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NTRODUCTION

he diets of Americans have changed considerably over theast several decades.1 Decision making around healthfulood selection has been complicated by the increase ofrocessed food products available at supermarkets, prolifer-

Department of Communication, Michigan State University, East Lansing, MichiganTelecommunication, Information Systems, and Media, Michigan State University,ast Lansing, MichiganDepartment of Nursing, Michigan State University, East Lansing, MichiganCenter for Health and Social Sciences, University of Chicago, IllinoisBarbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, Mich-gan

ddress for correspondence: Kami J. Silk, PhD, 566 Communication Arts andciences, East Lansing, MI 48824; Phone: (517) 355-0221; Fax: (517) 432-1192;-mail: silkk@msu.edu

t2008 SOCIETY FOR NUTRITION EDUCATIONoi: 10.1016/j.jneb.2007.08.012

tion of restaurants offering inexpensive meals, and theising number of meals that Americans eat outside of theome.2 Research suggests that for most people, taste andost-effectiveness are the 2 primary determinants of indi-idual food choices, with convenience and cost as the 2ariables that matter most for lower-income populations;utrition was deemed less important than the aforemen-ioned reasons.3 Healthful diet decisions are essential forombating the overweight and obesity problem in thenited States, and interventions to increase nutrition lit-

racy are often adopted to educate low-income individuals,ith print brochures and materials as the primary means forelivering health information.4 However, interactive medianterventions that are educational and entertaining mighte more attractive for communicating nutrition informa-ion and increasing retention.5 The current study evaluates

he effectiveness of 3 different modalities for delivery of

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4 Silk et al/EFFECTIVENESS OF PRINT, WEB SITE AND GAME MODALITIES

utrition education material, and results are interpretedithin the media uses and gratifications (MUG) paradigm,hich identifies different motivations for the use ofedia.6-8 The problem of low nutrition literacy is defined,

ideo games as an entertainment-education strategy arehen discussed, and finally the MUG theory is presented.

utrition Literacy

ccording to the Healthy Eating Index (HEI), most peoplen the United States do not maintain healthful diets.9

nhealthful diets, along with low levels of physical activitynd economic and social factors, are antecedents that con-ribute to obesity and overweight.10 Research reveals thatnly 44% of male adolescents and 27% of female adoles-ents meet the minimum average daily goal of at least 5ervings of vegetables and fruits.11 Individuals with lowerncomes and less education are also more likely to haveoorer diets than those individuals with more income andducation.9 Many interventions—including worksite inter-entions,12 school-based programs,13 and government-unded programs14—have been created, with varying de-rees of success, to address nutrition knowledge deficits.utrition interventions will continue to be created because

vidence suggests that nutrition literacy is 1 key reason forifferences in diet, with more healthful eating practicesmong individuals positively related to higher nutritioniteracy.15 Nutrition literacy can be defined similarly toealth literacy as the degree to which individuals canbtain, process, and understand the basic health (nutrition)nformation and services they need to make appropriateealth (nutrition) decisions,16 with the qualification thathe definition is nutrition specific. Nutrition literacy can beddressed via strategies that integrate a technology compo-ent that aims to improve the quality and dissemination ofutrition education. Mothers serve as an excellent group fornutrition education intervention, as they are typically therimary meal decision makers who prepare food in familyouseholds17 and serve as role models for health practices.18

ntertainment Education Via Video Games

n recent years, media campaigners realized that dissemina-ion of didactic health material often fails to engage targetudiences. To address this problem, a growing number ofesearchers are using “entertainment education” (edu-ainment) strategies.19,20 This strategy places the healthessage within entertaining and engaging media content

uch as soap operas, songs, plays, or computer games toncrease audience members’ understanding of a specificealth issue (eg, nutrition, AIDS, immunization, etc.).hile entertainment holds the audience’s attention, the

ealth message is communicated. This method has shownramatic increases in the number of audience members

ttending to health messages versus traditional types of b

edia presentations (eg, books, magazines, newspapers, ra-io, television, film).7

Because of the amount of media choice available, re-earchers in the United States must consider the compar-tive advantages of competing media.19 Media that take andu-tainment approach may provide advantages of reachinglarge audience, cost-effectiveness, audience interest, and

ensitivity to health literacy. Additionally, research consis-ently shows that media can perform well in knowledgeain.21 The sensitivity to health literacy is an especiallymportant issue because learning depends on the ability ofealth educators to effectively convey complex informationelated to healthful nutritional choices (eg, purchase, stor-ge, nutritional balance, threat of spoilage, etc.). Videoames, in particular, appear to be a potentially effectiveedium for entertainment education that communicatesutrition information because they can be: (1) highly ap-ealing, (2) capable of delivering a complex message, and3) inexpensive to disseminate.

ideo games. The interactive, goal-directed nature ofomputer and other video games is theorized to result in anutotelic (ie, intrinsically satisfying) flow state,22 wheresers experience intense focus, awareness, and concentra-ion on the game. In the context of a nutrition game,layers, particularly those who are comfortable with com-uters, have the opportunity to gain and retain nutritionnowledge.23 Video games are a very popular medium,specially for younger generations, who are often targetedor nutrition interventions. Research shows small genderifferences in the amount of game play, but some researchhows that males and females do not like the same type ofames.24 Casual games (eg, quiz/trivia), a favorite amongomen, provide the format design for the interactive game

ested in this study.

essage complexity. Unlike traditional media, videoames are not restricted by linearity.25 The dynamic naturef games allows users to explore the material in a variety ofays and to connect content in ways that are not always

ransparent in linear presentations. Additionally, gamesave the ability to simplify complex information intomaller units that are easier to integrate, a benefit to bothow- and high-literate users who report a preference forimple presentations of information.26 Computer games canenefit low-literate individuals greatly because they nor-ally do not involve dense written information for users to

rocess.

issemination issues. Delivery and dissemination ofutrition information can be a costly endeavor when oneonsiders the educational materials and personnel necessaryo present content. Computer games provide a cost-ffective means for dissemination, because they can often

e downloaded for free via the Internet or copied onto

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Journal of Nutrition Education and Behavior ● Volume 40, Number 1, January/February 2008 5

D-ROMs for users. The Pew Internet & American Liferoject reports that approximately 55% of households thatarn less than $30 000 a year use the Internet,27 and 70%f American households with incomes of less than $25 000ave commercial game consoles (eg, PlayStation, XBox).28

n other words, many low-income individuals have accessn the home and the majority have game consoles, provid-ng easy access opportunities for an interactive nutritioname to saturate American households across different lev-ls of socioeconomic status.

edia Uses and Gratifications

espite the apparent advantages of video games forntertainment-education interventions, at least 1 mediaheory would suggest that they might not be appropriate forhis purpose. The MUG paradigm, one of the oldest andost robust traditions in media effects,6-8 focuses on how

ndividuals select and use media for their own needs; it alsossumes that individuals will seek out different media toatisfy their information, educational, entertainment, andther need states and motivations. Uses and gratificationsesearch delineates a set of use motivations common toarious media. For example, text-based media (eg, books,ewspapers, pamphlets) typically serve an informational

unction, whereas the main purpose for Internet use is toonduct research on topics of interest.29 Video games, onhe other hand, are most frequently used for the challengef beating the game or for competition among friends ratherhan for learning or information acquisition.30 Individualsearn over time which media do the best job of satisfyingheir perceived needs. In other words, although the grati-cations sought by individuals are important, actual grati-cations obtained from the media explain more variance inredicting behavior.31 Over a lifetime, individuals learnnd attend to whichever media best solves perceivedroblems.

In the context of increasing nutrition literacy, individ-als would likely have acquired preferences for how theyould like nutrition information communicated to them.s the number of media increases and access to these media

ecome easier (eg, via computers), health educators need toonsider what medium makes the most sense for the targetudience.32 Although consideration of an appropriate me-ium might seem a standard consideration given muchhought, programs often begin with a message and a me-ium, without consideration of the appropriateness of thatedium.22 Interactive media for entertainment education

urposes are increasingly being used to deliver health in-ormation,33 but the question remains regarding whetherames would be a preferred and effective medium for low-ncome mothers.

When one considers the challenges of cost, training,articipant engagement, message complexity, and dissemi-ation of educational materials that are associated with

utrition education programs,34 interactive technology in h

he form of computer games might provide a temptingvenue for the delivery of health information. Scant re-earch has begun to test different modalities for healthnformation delivery, identifying which strategies are mostffective.35 For example, Marks et al compared a Web-ased physical activity intervention with a print workbookondition among adolescent females. Results indicated thathe print workbook was more effective in increasing inten-ion and physical activity behavior. A Web-based activitymong adolescent females, however, is not the same as annteractive computer game for low-income participants thatntegrates strategy decisions, uses points as a means toeasure success, and features engaging activities in an

ntertaining way. Thus, it remains unclear how well annteractive game modality will perform as compared toraditional media in increasing nutrition literacy. The pur-ose of this study is to use the MUG paradigm to test these of video games for educational purposes, particularly forow-income women. Three modalities are tested, hypothe-izing that: (1) participants will report greater liking of thenteractive game; (2) participants will have higher nutri-ion literacy scores with media used for information pur-oses (pamphlet, Web site) than from media for whichearning is not a primary use (game); and (3) participants inhe media used for information purposes (pamphlet, Webite) will retain more nutrition knowledge from Time 1 toime 2 than from media for which learning is not a primaryse (video game).

ETHODSarticipants

articipants (N � 155) were recruited by 2 regional man-gers of the state Family Nutrition Program (FNP) whoork with dozens of community agencies and programs to

mprove the nutritional health status of community mem-ers. Participants were from 4 counties across Michigan,ngham (n � 50), Saginaw (n � 44), Bay (n � 49), andsabella (n � 12). The number of participants recruited inach county was based on the size of the FNP office, size ofutrition education programs provided, and ability to reacharticipants during the study period. Participants were fe-ale, between the ages of 18 and 50 years (mean � 33; SD8.28), had one or more children (84%) or were pregnant,

nd had a yearly income less than or equal to 185% of theederal poverty index, making them eligible for state andederally funded programs (eg, WIC and food stamp pro-rams). The racial composition of the sample was Europeanmerican (68%), African American (25%), Latino (5%),sian (1%), and other (1%). The majority (87%) of the

ample had less than a college education, with 44% of theample having only a high school diploma or GED equiv-lent. The majority had a computer in the home (65%),nd most (75%) reported having Internet access in the

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rocedures

his study was approved by the university Institutionaleview Board. The research employed a between-subjects,

epeated-measures design, with exposure to one interven-ion condition with a post-intervention questionnaire atime 1 and a second questionnaire administered less thanweeks later to measure nutrition knowledge at Time 2.

articipants came to a Michigan State University (MSU)xtension office or community agency or participated inheir own home with an extension agent. After consent wasbtained, participants were randomly assigned to 1 of 3edia modality conditions: (1) interactive game (Fantasticood Challenge), (2) Web site, or (3) print. Laptop com-uters, with necessary software preloaded, were used for thenteractive game and Web site conditions. An 8-page,ull-color brochure was created for the print condition.

Participants spent 20-30 minutes reviewing the nutri-ion content in the assigned experimental condition. Par-icipants were also asked to use their time wisely and spendn equal amount of time on each portion of the material tonsure exposure to all the different areas of nutrition infor-ation. While engaging with the information, study ad-inistrators were nearby to answer participant questions,onitor the time, and assist with technology if needed, but

therwise they did not interact with the participants orbserve them closely. The game, Web site, or pamphlet wasade unavailable to the participant before the survey be-

an. The Time 1 survey included an assessment of likeabil-ty; intention to use nutrition information; knowledgetems; and demographic indicators. The survey took be-ween 15 and 25 minutes to complete. On completion ofhe initial survey, participants scheduled a date and time toomplete the follow-up survey. Additionally, they weresked to fill out their name and address on a postcard whichas sent as a reminder 3 days before the scheduled follow-p. If obtaining an address was not possible, participantsere asked for their phone number, and a reminder call wasiven. Approximately 10-12 days later (T2), participantsompleted the post-intervention knowledge survey, whichontained the same knowledge items as the T1 survey. Theesponse rate for the T2 survey was 100%. On completionf the survey, participants were thanked and received anonorarium in the form of a grocery store gift card.

ntervention Materials

he content of the intervention was the same across eachf the 3 conditions, with the modality being the onlyariable manipulated. Each modality contained informa-ion about: the USDA MyPyramid food guidance system;ood groups (bread; fats, oils, and sweets; dairy, meat, veg-table, and fruit); serving sizes; safety and storage (cup-oard, freezer, and refrigerator); meal ideas (recipes); andricing (overall and per serving). Each condition was in-roduced to the participant by a trained study administrator,

owever no nutrition information other than that provided t

y the game, Web site, or pamphlet was given to thearticipant that day.

omputer game. The Fantastic Food Challenge (FFC),eveloped through a partnership between MSU Extensionnd the MSU Communication Technology Laboratory andunded partially by the USDA, is a set of games designed tootivate low-income adults to learn about nutrition, food

afety, food preparation, and comparative pricing. Throughhe use of digital game play, key concepts from the basicood-nutrition curricula are cast in a fun, engaging experi-nce. As participants played the games, they were exposedo food and nutrition information designed to help themake more informed food choices in the real world. For

xample, participants were asked to direct food objects thatrop from the top to the bottom of the screen to theppropriate storage place, and they were asked to calculatehat product is most cost-effective based on the size of the

ood product, number of servings, and cost of the product.

eb site. The Web site was designed by researchers inhe MSU Communication Technology Laboratory. It con-ained the same content as the FFC, but the informationas presented in a Web site format, with pull-down infor-ation provided under text headings. The Web site fea-

ured the same content categories, nutrition information,nd overall graphic design as the game. It was, however, lessnteractive than the game, and it also included an optionor healthful recipes.

amphlet. The pamphlet was also designed by projectesearchers. The pamphlet was the least interactive of the 3ntervention conditions, as it simply provided the sameritten content as the FFC and the Web site, but in a

ri-fold, paper format. The pamphlet featured the sameontent categories, nutrition information, and overallraphic design as the other 2 conditions.

valuation Instrument

he evaluation instrument, developed by the researcheam, was designed to assess likeability, knowledge out-omes, demographic variables, and other self-reported vari-bles like computer ability, nutrition knowledge, and accesso technology. The likeability measure was adapted fromrevious research,36-38 whereas knowledge questions wereased on the EFNEP Evaluation and Reporting Systemeveloped by USDA for EFNEP at the federal level.12

ikeability. Likeability was measured using 9 items on a-point Likert-type scale. These 9 items were examinedcross 3 dimensions, including: 4 items to measure attention� � .84; eg, “The game/Web site/pamphlet kept my at-

ention,” and “I thought the game/Web site/pamphlet was

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Journal of Nutrition Education and Behavior ● Volume 40, Number 1, January/February 2008 7

nteresting.”), 3 items for understanding (� � .88; eg, “Thenformation in the game/Web site/pamphlet was useful”nd “The game/Web site/pamphlet was easy to under-tand”), and behavioral intention to use the information inhe future (� � .76; eg, “I intend to use the informationresented in the game/Web site/pamphlet” and “If possible,would return to the information presented in the game/eb site/pamphlet”).

nowledge. Thirty-three multiple-choice questionsere asked to evaluate knowledge gain. Each question hadchoices for the answer. The knowledge measures tested

everal content areas including: the USDA MyPyramid (4tems; eg, “How many food groups does the food guideyramid include?”); food groups (4 items; eg, “A carton ofggs belongs in which food group?”); servings (5 items; eg,How many servings of fruit should a person eat eachay?”); serving sizes (5 items; eg, “What is one serving sizef vegetables?”); food safety and storage (10 items; eg,Where would you store an open jar of salsa with the lidightly closed?”); and pricing (5 items; eg, “Five (5) servingsf hamburger cost $2.00. Seven [7] servings of chicken cost3.50. Which food item costs less per serving?”).

emographics and self-report. Twelve demo-raphic questions asked participants about their gender,ace/ethnicity, age, number of children, highest level ofducation, yearly income, computer ability (eg, “I feel mybility to use a computer is: Very Strong/Very Weak”;-point semantic differential scale), nutrition knowledgeeg, “I would rate my knowledge of nutrition informations: Not at all Knowledgeable/Very Knowledgeable”; 5-pointemantic differential scale), computer ownership, and In-ernet access.

ESULTS

he analyses of hypotheses 1 and 2 were based on aetween-subjects, 1-way analysis of variance (ANOVA).or hypothesis 1, the results revealed a significant effect (F2, 153] � 3.73, P � .05), explained in post hoc Bonferroni

eans tests by the Web site (4.29, SD � .45) being likedore than the pamphlet (mean � 3.99, SD � .66) and the

able 1. Mean Ratings for Liking, Attention, Understanding, and Intention

Pamphlet (n � 57)(mean [SD])

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iking 3.99a (0.66)ttention 3.80a (0.73)nderstanding 4.27a,b (0.70)

ntention 3.89a (0.74)

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*P � .05

ame condition (mean � 4.06, SD � .66). Subsequently,ikeability was divided into 3 subgroups for post hoc anal-sis: attention, understanding, and intent to use the infor-ation in the future. In all 3 cases, there were significant

ifferences between means, with the Web site modalityating highest in attention paid to modality, understandingf content, and intent to return to the modality for addi-ional information. Both the Web site and video gameodalities were rated significantly higher on attention; the

ideo game was rated significantly lower than the Web siten ease of understanding; and the Web site was significantlyigher than the pamphlet on intention to use in the futureTable 1).

Hypothesis 2 predicted participants will have higherutrition literacy scores with media that is used for infor-ation purposes (eg, print and Web site) than from media

or which learning is not a primary use (eg, game). Eachutritional knowledge question was scored either correct1) or incorrect (0), and then the number of correct an-wers was summed. One-way ANOVA of the total numberf correct answers by modality resulted in a significant mainffect for modality in overall knowledge (F [2, 154] � 4.03;� .05), and the effect was accounted for by respondents

n the Web site group (mean � 25.59, SD � 3.56) learningignificantly more than those in the game group (mean �3.17, SD � 4.95), according to post hoc Bonferroni anal-sis. Subsequent 1-way ANOVA of the knowledge sub-roups resulted in a significant difference in knowledgebout MyPyramid (F [2, 154] � 4.26, P � .01) and the sizef food servings (F [2, 154] � 4.76, P � .01). In both cases,laying the game (MyPyramid mean � 2.32, SD � 1.02;ood Serving Size mean � 2.55, SD � 1.40) resulted inignificantly less knowledge than using the Web siteMyPyramid mean � 2.90, SD � 0.92) or the pamphletfood serving size mean � 3.35, SD � 1.42). This hypoth-sis was supported (Table 2).

Hypothesis 3 tested whether respondents retainednowledge of nutrition across a 2-week time span. A 1-wayepeated ANOVA for knowledge differences by modality at1 and T2 showed no significant effects for overall knowl-dge by time (F [1, 153] � 0.08, P � nonsignificant) or byodality (F [2, 152] � 2.60, P � nonsignificant). These

esults remained even after analysis of covariance

s Modalities

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b (0.45) 4.06a (0.66) 3.73*b (0.52) 4.12b (0.64) 5.87*a (0.48) 4.04b (0.78) 4.79*b (0.55) 4.02a,b (0.79) 3.20*

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ANCOVA) was conducted to control for age, liking of theedium, and self-perception of nutritional knowledge.

ISCUSSION

elivery of nutrition information via effective channels isn important issue as Americans continue to battle excesseight and cost-effectiveness of programs is under scrutinyy policy makers. According to uses and gratifications re-earch, health interventions and education endeavorshould use media that meet audience preferences for ob-aining nutrition information to maximize effectiveness.raditionally, print media have been used by health com-unicators for nutrition education purposes. Web sitesave also emerged as key sources of health information overhe past 5 to 10 years. Interactive games, however, are aovel strategy gaining in popularity, despite the unknownffectiveness of them as a learning tool. It is not surprisinghat there is an interest and growth in interactive games, asntertainment-education projects have shown some effectscross many health issues. What is surprising, though, is theack of forethought given to the appropriateness of inter-ctive games as an effective channel for health information.t may seem intuitive that games that educate are superioro less interactive technologies owing to the power ofntertainment-education strategies, but they may be morer less effective depending on the audience and context inhich they are delivered.

hrough the Lens of Uses and Gratifications

he results of this study support many of the assertions ofhe uses and gratifications paradigm. First, participants ap-eared to discriminate between modalities in terms of at-ention, understanding, and intention to use the mediumor future information. This audience of women reportedaying more attention to new media technologies of theeb site and game than the traditional print medium,

uggesting that novel presentations of information may beelpful in attracting interest. However, when it came to

able 2. Mean Number of Correct Responses to Nutrition Learning Measu

Pamphlet (n � 57)(mean [SD])

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earning 24.75b (4.76)yPyramid 2.71a,b (1.06)

ood groups 3.18 (0.83)ood servings 3.35a (1.42)erving size 3.19 (1.05)ood safety 8.98 (1.16)ood cost 3.34 (1.21)

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nderstanding the messages, the Web site proved signifi- t

antly better than the game. This result is to be expected,s research suggests that Web sites are most often used fornformation, whereas games represent intellectual chal-enges. In the end, the Web site attracted more attentionnd was believed to be better for understanding informationith this audience of women, leading participants to rate its the medium that they would most likely return to fordditional information.

Consistent with the uses and gratifications perspective,t is likely that the motivations of participants playing thenteractive game were likely on understanding the game,avigating it, and scoring points rather than focusing on

earning nutrition information. In other words, the gameas perceived as a game for this audience of women and

erved that function rather than an information function.his assertion is borne out by the fact that Web site users

earned the most, whereas game players learned the least.he types of information that best illustrate the learningifferential are the most complex and difficult areas:yPyramid and food serving sizes (in which the pamphletas significantly better than the game). Media such as Web

ites and traditional print allow users to spend as much times needed learning information. The ease of learning, plusast experience with these media, likely resulted in betterearning outcomes. Interestingly, there was no improve-ent in nutrition literacy from Time 1 to Time 2 byodality, even when controlling for a number of possible

ovariates. However, there was only one opportunity toearn information, and the participants may have neededdditional time with the media to show increases in learn-ng. Thus, practitioners should build multiple exposuresnto interventions. Importantly, there was no significantoss of information from any of the 3 modalities, so thenformation seems to have stayed with participants overime.

MPLICATIONS FOR RESEARCHND PRACTICE

lthough the implications of this research indicate that

Modality

(n � 51)n [SD])

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b (3.56) 23.17a (4.95) 4.03*a (0.92) 2.32b (1.02) 4.26*3 (0.84) 3.21 (0.98) 0.46,b (1.28) 2.55b (1.40) 4.76*3 (0.97) 3.02 (1.07) 1.112 (0.91) 8.57 (1.86) 1.650 (1.26) 3.49 (1.28) 1.30

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Journal of Nutrition Education and Behavior ● Volume 40, Number 1, January/February 2008 9

ation endeavors, it can perhaps be argued that Web sitesre a smart strategy in certain contexts and groups. Forxample, when extending the reach of a program is essen-ial, a technology solution might be appropriate. Programsike the Expanded Food and Nutrition Education ProgramEFNEP) provide training for low-income families on howhey can make healthful, safe, and economical food choices.owever, only a small percentage of families in need ofutrition education are exposed; in Michigan, only 5% ofligible low-income families with young children receivehe training. Traditional education has demonstrated effec-iveness in improving diets and helping families stretchheir food dollars,2 but the number of people that instruc-ors can reach is limited by shrinking state budgets. Exam-ning the viability of technology as a strategy to increasehe reach of programs seems sensible because of the cost-ffectiveness of disseminating nutrition or other informa-ion via the Web or a CD-ROM.39 Web technology mayncrease access to health information, especially since theajority of homes, including those of low-income families,ave Internet access and/or computer devices in them.

It is also important to note that games like the Fantasticood Challenge may hold better potential for certain groupseg, youth audiences), but formative research needs to beonducted to make that determination. Rather than simplyeveloping a game for a generalized audience, it is criticalhat formative research identify audience preferences, be-iefs, knowledge, self-efficacy and level of computer literacy,nd other relevant information before a game is developed.athering this information is fundamental to the success of

ny health education program, health communication cam-aign, or gaming technology for health information pur-oses. Would the outcome have been different if the gamead been used by teens or children? Current gaming demo-raphics suggest that the solution may not be that easy.ccording to the Entertainment Software Association, the

verage age of video gamers—the early 30s—is the same asn this sample, and women in this age group are the mostikely demographic to play so-called “casual games” like theantastic Food Challenge.40 Although the authors failed toather direct data on the amount of casual game play thathe women in this sample do, national statistics suggest thathis sample should be familiar with these games. Futurenterventions that integrate media need to consider howeople use media in addition to what media they use. Theomen in the current study probably play casual games, but

hey do not use them for information and learning purposes;owever, they do use Web sites for information purposes.urther, future studies need to examine how game technol-gy might be used to complement traditional learning strat-gies rather than as a replacement for them.

imitations and Future Research

his study provides insight on the effectiveness of each of

he modalities in nutrition knowledge, but it has some

imitations. First, participant exposure to the nutrition in-ormation was standardized to balance exposure to thenformation across the 3 conditions. In reality, participantsould determine the amount of time they choose to spendavigating the information. Thus, it is possible that re-eated exposure to the different conditions might have ledo different knowledge outcomes for each of the modalities.

any of the participants were recruited through state-unded programs and were introduced to the study by theirutrition educator. Although this situation would not af-

ect the participants’ nutrition literacy score, social desir-bility could have influenced participant ratings of likeabil-ty. Another limitation is that many of the statisticallyignificant differences between the conditions were rathermall, which may lead some to question their practicalignificance. However, it is important to note that theffects were found in a relatively small sample, an indicatorf more robust findings in a larger sample. Even though theesearch did not find that interactive computer campaignsere effective with the present sample of women, it is quiteossible that they would be effective with other audiences.uture research should aim to test different types of audi-nces, increase study sample size, and mirror nutrition ed-cation conditions to increase external validity of thetudy. Future research should also be more longitudinal toeasure long-term retention and application of the infor-ation learned from different modalities.

UPPLEMENTARY DATAupplementary data associated with this article can be found,

n the online version, at doi:10.1016/j.jneb.2007.08.012.

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