August 1998 // Volume 36 // Number 4 // Feature Articles // 4FEA4
Increasing Fruit and Vegetable Consumption among Middle School Students: Implementing the 5-A-Day Program
Research shows that populations consuming diets rich in fruits, vegetables, and grain products have significantly lower rates of many types of cancer. University of Nevada Cooperative Extension developed, implemented, and evaluated an educational program based on Social Learning Theory to increase knowledge, improve attitudes, and promote consumption of fruits and vegetables among middle school students in two Nevada schools. Results showed that students' attitudes about the acceptability of eating fruits and vegetables improved significantly (p =.005) as did their perception of their ability to eat five fruit and vegetables per day (p<.0001). Students demonstrated a high level of knowledge of the health benefits of eating fruits and vegetables on the pre-test (mean score of 55 points out of 75 points) and showed no significant increase on the post-test.
Research literature clearly states that populations consuming diets rich in vegetables, fruits, and grain products have significantly lower rates of many types of cancer (Public Health Service, 1988.). Unfortunately, the 1989-1991 Continuing Survey of Food Intakes by Individuals showed that only 32% of Americans currently consume the minimum numbers of five servings of fruits and vegetables each day (Krebs-Smith, 1995). In addition, the 1991 5 A Day Baseline Survey found that only eight% think they should eat five or more fruits and vegetables each day for good health (Subar, Heimendinger, Krebs-Smith, Patterson, Kessler, & Pivonka, 1992).
Education is one way to increase the consumption of fruits and vegetables. Research shows that those who think they should eat more fruits and vegetables are more likely to do so (Subar et al., 1992). Those who develop the habit of eating more fruits and vegetables early in life are more likely to continue those habits into adulthood (Subar et al., 1992). The 5-A-Day for Better Health Program is a national effort to increase Americans' fruit and vegetable consumption to five servings daily - one of the objectives of Healthy People 2000 (U.S. Department of Health and Human Services (DHHS), 1991).
Program Development and Implementation
Through partnerships with county school districts, school food services, retail supermarkets, and produce companies, the University of Nevada Cooperative Extension developed, implemented, and evaluated a 5-A-Day program in two Nevada middle schools with diverse student bodies from low socio-economic backgrounds were chosen since research has shown this audience has a higher incidence of chronic disease (DHHS, 1991).
The goal of this 5-A-Day program, called "Take Five," was to increase knowledge, improve attitudes, and promote the consumption of fruits and vegetables. The program, based on Social Learning Theory, used a combination of educational methods to influence behavior change. The Social Learning Theory, also known as Social Cognitive Theory (Bandura, 1977, 1986) is unique in that it provides a framework for designing interventions for the individual as well as the environment. The underlying assumption of Social Learning Theory is that behavior is dynamic and depends on personal and environmental constructs that influence each other simultaneously (Perry, Baranowski, & Parcel, 1990). The "Take Five" program used this theory by incorporating environmental modifications, observational learning, and reinforcement to enhance self-efficacy and influence behavior.
The implementation of the "Take Five" program required a high degree of collaboration. While strong support for the program was provided by school principals, it was also essential that teachers, school secretaries and custodians support the effort because they influence school programs and policy.
One day a week for 16 weeks, teachers taught a "Take Five" lesson in their homeroom classes. Lesson concepts were then reinforced that day at lunchtime with fruit and vegetable samples and poster displays in the cafeteria. This also provided opportunities for students to observe other students and teachers consuming fruits and vegetables.
An incentive program in which students earned "points" for prizes encouraged participation. Each week when students sampled a new fruit or vegetable, they were given point stickers to place on a prize card. Filled prize cards were entered in the prize drawing. Most prizes were donated by fruit and vegetable companies and included such items as beach towels, baseball caps, watches, and T-shirts.
Parents received a monthly newsletter which contained nutrition information, serving ideas, recipes, and money-saving supermarket coupons for fruits and vegetables to encourage fruit and vegetable consumption at home.
The program was evaluated using a pyre-/post-design. Teachers administered the evaluation instrument to students prior to and upon completion of the program. The 43-item instrument assessed knowledge, behavior, and attitudes about eating fruits and vegetables. The instrument included closed-ended questions with ordered, five-point response sets (e.g., "strongly disagree" to "strongly agree"), three-point sets (i.e., "true", "false", "don't know"), open-ended questions, and a food frequency questionnaire (FFQ) adapted by National Cancer Institute staff from the questions of the FFQ of Block, Woods, Potosky, Clifford (1990). Demographic data was also collected.
Results showed that students' attitudes about the acceptability of eating fruits and vegetables improved significantly (p=.005), as did their perception of their ability to eat five fruits and vegetables per day (p<.0001). Post-test results also showed a greater number of students (42%) knew they should eat five fruits and vegetables each day compared to the pretest (12%). Students demonstrated a high level of knowledge of the health benefits of eating fruits and vegetables on the pretest (mean score of 55 points out of 75 points) and showed no significant increase on the post-test.
Though 46% of students stated they ate more fruits and vegetables as a result of the program, results of the FFQ were not useful since large numbers of students used the highest category to report consumption (five or more times per day). The validity of this tool for elementary-school children was questioned in a recent article by Baranowski, Smith, Baranowski, Wang, Doyle, Loin, Hear, Resnicow (1997). They reported that the large number of response categories with varying frequencies and time intervals may have been confusing for children of this age. With similar results of the FFQ with middle-school age children, the use of this tool with children seems limited.
While approximately 4,500 newsletters containing coupons were sent to the students' homes, only 82 of the coupons were redeemed at the designated supermarkets. Reasons for this poor return might include: target audience may not have been accustomed to using coupons; the coupons were not viewed as valuable; or the supermarkets may not have had accurate tracking of those coupons redeemed. Also, due to the fact that other supermarkets accept competitor's coupons, the "Take Five" coupons may have been redeemed elsewhere and could not be tracked.
School programs like the "Take Five" program require support from all levels. Not only do principals, teachers and food service personnel need to be highly supportive, but also ancillary employees such as school secretaries and custodians. Much to our surprise, custodians, not the food service director, often dictated which fruits and vegetables were acceptable for serving in the cafeteria. Due to the janitorial problems they could create, some fruits and vegetables, such as blueberries and grapes, were not allowed to be served regardless of how nutritious or well-liked the foods were by the students. Involving custodians in the early stages of program development may prove advantageous in implementation.
While students showed a high degree of enthusiasm toward the program and were quite willing to try the variety of fruits and vegetables, it was not possible to objectively measure behavior changes. What was evident was that students enjoyed the program and devoured fruit and vegetable samples each week and, in many instances, requested multiple servings until the abundant supplies were depleted. Teachers claimed that students seemed more well-behaved on "Take Five" program days in order to get to the cafeteria in time to participate in the fruit and vegetable samplings. For future programs, alternative methods to assess dietary intake should be included.
In summary, the "Take Five" program improved or enhanced students' attitudes towards the acceptability of eating fruits and vegetables and their perception as to whether they could eat five fruits and vegetables each day. Though incentives were offered to encourage participation, it became clear that they weren't needed.
Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall.
Bandura, A. (1986). Social Foundations of Thought and Action. Englewood Cliffs, NJ: Prentice-Hall.
Baranowski, T., Smith, M., Baranowski, J., Wang, D., Doyle, C., Loin, L., Hear, M., Resnicow, K. (1997). Low Validity of a seven-item fruit and vegetable food frequency questionnaire among third-grade students. Journal of the American Dietetic Association, 97, 66-68.
Block, G., Woods, M., Potosky, A., Clifford, C. (1990). Validation of a self-administered diet history questionnaire using multiple diet records. Journal of Clinical Epidemiology, 43, 1327-1335
Krebs-Smith, S. M., Cook, A., Subar, .A. F., Cleveland, L., Friday, J. (1995). US Adults' Fruit and Vegetable Intakes, 1989 to 1991: A Revised Baseline for the Healthy People 2000 Objective. American Journal of Public Health, 85, (12), 1623- 1629.
Perry, C.L., Baranowski, T., and Parcel, G.S. (1990). How individuals, environments, and health behavior interact: Social Learning Theory. In K. Glans, K. Lewis, B. River (Ens.), Health Behavior and Health Education: Theory Research and Practice (pp. 161-186). San Francisco: Jossey-Bass Publishers.
Public Health Service (1988). The Surgeon General's Report on Nutrition and Health (DHHS Publication No. PUS 88-50210). Washington, DC: U.S. Government Printing Office.
Subar, A. S., Heimendinger, J., Krebs-Smith, S. M., Patterson, B. H., Kessler, R., Pivonka, E. (July 1992). 5 A Day For Better Health: A Baseline Study Of Americans' Fruit And Vegetable Consumption. Rockville, MD: National Cancer Institute.
United States Department of Health and Human Services (1991). Healthy People 2000 (DHHS Publication No. PUS 91- 50212). Washington, DC: U.S. Government Printing Office.
Author Notes: Funding for this project was provided by the Nevada State Preventative Health Advisory Committee.