- Email: [email protected]
Perceptions of adolescents involved in promoting lower-fat foods in schools: Associations with level of involvement
RESEARCH Research and Professional Briefs
Perceptions of Adolescents Involved in Promoting Lower-Fat Foods in Schools: Associations with Level of Involvement SAMIA HAMDAN, MPH, RD; MARY STORY, PhD, RD; SIMONE A. FRENCH, PhD; JAYNE A. FULKERSON, PhD; HELEN NELSON, MEd
ABSTRACT This article describes perceptions of adolescents involved in peer-led school-based nutrition promotions encouraging lower-fat food purchases and assesses the differences by level of student involvement. Surveys were administered at schools. Data were collected from 397 high school students from 10 Minnesota schools randomized to the intervention condition of the Trying Alternative Cafeteria Options in Schools study. Students were categorized as highly involved (n⫽54) or less involved (n⫽343) based on their level of involvement in promotional activity implementation. 2 tests were conducted to measure the differences between highly-involved and less-involved students in perceptions and attitudes about lower-fat foods. Highly-involved students were significantly more likely than less-involved students to report more healthful eating behaviors and positive attitudes toward lower-fat foods. Student involvement in nutrition interventions should be integrated into programs aimed at increasing healthful food choices among adolescents. J Am Diet Assoc. 2005;105:247-251.
S
tudies have found that the diets of most adolescents do not follow the US Dietary Guidelines (1-3). A recent study found that only 52% of female adolescents and 45% of male adolescents met the recommenda-
S. Hamdan is a research associate at the School Nutrition Association, Alexandria, VA; at the time of the study, she was a graduate student in the Division of Epidemiology, University of Minnesota, Minneapolis. M. Story is a professor, S. French is a professor, and H. Nelson is a coordinator, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis. J. Fulkerson is an associate professor, School of Nursing, University of Minnesota, Minneapolis; at the time of the study, she was a research associate, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis. Address correspondence to: Mary Story, PhD, RD, Division of Epidemiology, University of Minnesota, 1300 S 2nd St, Suite 300, Minneapolis, MN 55454-1015. E-mail: [email protected] Copyright © 2005 by the American Dietetic Association. 0002-8223/05/10502-0007$30.00/0 doi: 10.1016/j.jada.2004.11.030
© 2005 by the American Dietetic Association
tion of 30% or less of total energy from dietary fat (3). With an abundance of high-fat and high-sugar foods available in schools, innovative and effective strategies are needed to promote healthful food choices among adolescents. Peer-led initiatives offer a promising approach for encouraging behavior change among adolescents. Peer-led promotions remove the passivity that adolescents may experience in traditional health education settings, and have been found to improve young people’s self-esteem, self-efficacy, knowledge, and attitudes (4,5). Peer-led approaches may be more effective than adult-led health education in changing adolescent health behavior (6,7). Peer participation can directly affect the social environment, can provide positive role models, and can help change social norms (4,5). In addition, there is some evidence showing that students who are peer leaders benefit more in terms of behavior change and skill development compared with their fellow students who were not peer leaders (4,8). Peer leadership efforts have been explored in several adolescent health interventions, such as those for the human immunodeficiency virus (9-11), tobacco (12,13), alcohol (14), substance use (15), bullying (16), and asthma (17). Few peer leadership efforts have been examined in relation to nutrition (18,19). The Trying Alternative Cafeteria Options in Schools study aimed to increase the number of lower-fat food items available on a la carte and vending lines and to increase sales of lower-fat foods in high schools during the 2000 to 2002 school years (20). Ten schools were randomized to the intervention condition, and 10 schools to the control condition. Student-led promotional activities were incorporated into the intervention schools. The current study describes the perceptions and attitudes of students directly involved in implementing the promotional activities. The specific objectives were to (a) describe the perceptions of students involved in peer-led nutrition promotions, and (b) determine whether perceptions differed by level of student involvement. Little descriptive information about peer leaders in nutrition-related promotions is available in the published literature. METHODS As part of the Trying Alternative Cafeteria Options in Schools intervention, student-led promotional activities were implemented to promote awareness and purchase of lower-fat foods among high school students by (a) involving students in implementing promotional activities, (b) increasing student awareness of lower-fat foods, and (c)
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Promotion
Description of promotion
Media campaign
Students convey nutrition messages and increase awareness of lower-fat foods using school newspaper, Web site development, and school TV information spots. Self-assessment survey identifying foods that are typically chosen in cafeteria and vending machines. Ideas for lower-fat options are provided on survey and free sample of lower-fat snack is given away. Free samples of lower-fat foods distributed, along with taste test survey. Comparisons are made between regular and lower-fat items. Free samples of selected fruit or vegetables are offered for 2 days and then sold at a reduced price for the following 2 to 3 weeks. Students use video/TV/camera production to develop public service announcements to increase awareness of lower-fat items, fruits, and vegetables. Students create a poster promoting lower-fat foods. The posters are voted on by students and foodservice staff for prizes. Students receive raffle tickets for each lower-fat food item purchased and turn it into a drawing for a chance to win a prize. Students create T-shirts promoting lower-fat foods and healthy eating. Students, faculty, and/or foodservice staff vote for five favorite designs. Winning students receive gift certificates. Students develop, implement, and evaluate a multi-component marketing campaign. Activities are measured by sales data, student survey analysis, and process evaluation measures. Students create their own promotion tailored to their school needs. Students develop and implement a promotion adhering to the study parameters with TACOS staff approval. Students develop “Top Ten Reasons for Eating Lower-Fat Foods” and convey reasons to student body with use of posters, PA announcements, newspaper, and/or TV advertisements. Students conduct a survey on the student body assessing what factors influence their peers’ food choices and how students view lower-fat foods. The student group creates a summary report on the results and participates in an evaluation with TACOS staff. TACOS staff purchases newspaper ads in school newspapers to highlight study goals and events. Foodservice staff selects two to four lower-fat items to highlight for this promotion. Students receive coupons good for one of the highlighted foods. In some schools, students assist with coupon distribution.
Self-assessment survey Taste testing Fruit and vegetable Public service announcements Poster contest Raffle event T-shirt contest Promotional campaign Create your own promotion Challenge game Student survey Newspaper advertisements Coupon kick-off
Figure. Peer-led, school-based promotional activities implemented during years 1 and 2 of the Trying Alternative Cafeteria Options in Schools (TACOS) study.
increasing sales of lower-fat foods in the a la carte and vending lines. Promotional activities were developed and implemented by student groups with the support of Trying Alternative Cafeteria Options in Schools staff and school faculty advisors. Promotional activities are described in the Figure. Students in the 10 intervention schools who participated in the student promotions were classified into two groups. Highly-involved students (n⫽54) were defined as those who volunteered to participate as part of an extracurricular activity (eg, student council groups), internship, or independent class project, and had the responsibility of planning, implementing, and evaluating promotions as part of a small group activity. Less-involved students (n⫽343) were defined as those who participated because their teachers were implementing the activities as part of the classroom curriculum (eg, a health class). These students participated 5 hours or less by assisting with material development or promotion implementation as part of a class project. A survey was developed to assess students’ perceptions of eating behaviors, attitudes, and social norms related to lower-fat foods, and perceived benefits and experiences gained from being involved in the Trying Alternative Cafeteria Options in Schools promotional activities. Our study as-
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sessed students’ opinions specifically related to student involvement in the Trying Alternative Cafeteria Options in Schools promotional activities; therefore, a control group was not included. Analyses of the data were conducted using SAS (version 8, 2001, SAS Institute, Cary, NC). 2 analyses were conducted to compare responses between highly involved and less involved students. A conservative P value (P⬍.001) was used to adjust for multiple comparisons. RESULTS A high percentage of both highly involved and less involved students reported that the Trying Alternative Cafeteria Options in Schools program helped them to recognize which foods were lower in fat and that they had perceived more students eating lower-fat foods in the school cafeteria since the inception of the Trying Alternative Cafeteria Options in Schools program (Table). A high percentage of highly involved and less involved students also reported that the Trying Alternative Cafeteria Options in Schools study showed better results in increased awareness and purchases of lower-fat foods among adolescents because of student involvement; the majority in both groups reported that
Table. Student perceptions by level of involvement in TACOSa student promotions, N⫽397
Perceptions Eating behaviors I eat more lower-fat foods because of being involved in TACOS TACOS did not change the way I choose foods I pay more attention to what I eat because of the TACOS program TACOS did not influence me to eat more fruits and vegetables Attitudes Participation in TACOS has not improved my attitude toward lower-fat foods Participation in TACOS has improved my attitude toward fruits and vegetables Social norms My friends thought it was cool to be part of TACOS It is cool to eat lower-fat foods at school I have not noticed more students eating lower-fat foods since the TACOS program started TACOS did not have an impact on the number of students eating lower-fat foods in the school cafeteria Student involvement I believe the TACOS study benefited from having students involved in promotion activities I believe student involvement in TACOS promotion activities resulted in more students trying lower-fat foods at my school Student involvement in TACOS promotions is not important in changing the way teens eat Experiences gained from TACOS I did not learn new skills from working with the TACOS program Because of TACOS, I was able to taste lower-fat foods, fruits, and vegetables that I would not have tried otherwise TACOS has helped me to recognize what foods are lower in fat
Total (Nⴝ397) % agree
Highly-involved studentsb (nⴝ54) % agree
Less-involved studentsc (nⴝ343) % agree
2 value
P valued
32.1
67.9
26.5
36.2
⬍.0001
60.7
20.8
67
41
⬍.0001
40.2
69.2
35.8
21
⬍.0001
49
5.7
55.7
46
⬍.0001
48.7
1.9
56
53.8
⬍.0001
54.8
88.5
49.7
27.4
⬍.0001
37.1 62.3
65.4 84.9
32.7 58.7
20.6 13.4
⬍.0001 ⬍.0001
64.3
26.4
70.2
38.3
⬍.0001
55.6
9.4
62.9
53.1
⬍.0001
70.6
19.3
⬍.0001
98.1
54.1
36.3
⬍.0001
28.3
0
32.8
24.7
⬍.0001
41.3
3.7
47.3
36.5
⬍.0001
60.9
92.6
55.9
26.4
⬍.0001
64.8
88.7
61.1
15.3
⬍.0001
74.6
60
100
a
TACOS⫽Trying Alternative Cafeteria Options in Schools. Highly-involved⫽students who participated in planning, implementing, and evaluating promotional activities as part of an extracurricular activity, internship, or independent class project. c Less-involved⫽students who participated by assisting with material development or with implementation of TACOS promotions as part of the required class curriculum, and who spent less than 5 hours on TACOS promotions over the 2-year duration of the study. d P values compare highly involved and less involved students. b
student involvement was important in changing the way adolescents eat and resulted in more students trying lower-fat foods. Significant group differences were found between the highly involved and the less involved students across all of the content domains of eating behaviors, attitudes, social norms, student involvement, and experi-
ences gained from the Trying Alternative Cafeteria Options in Schools study. Highly-involved students were significantly more likely than less involved students to perceive that the Trying Alternative Cafeteria Options in Schools study changed the way they chose foods, afforded them the opportunity to try lower-fat foods and fruits and vegetables that they would other-
February 2005 ● Journal of the AMERICAN DIETETIC ASSOCIATION
249
wise not have tried, influenced them to eat more fruits and vegetables, improved their attitudes towards lower-fat foods, and had an impact on the number of students eating lower-fat foods in the school cafeteria. Less-involved students were significantly more likely than highly involved students to be in the 10th grade (89% of less involved compared with 32% of highly involved students were in the 10th grade, respectively; P⬍.001). Race and sex were not significantly associated with level of involvement; 91% of highly-involved and 83% of less-involved students were white, and 65% of highly-involved and 59% of less-involved students were female. DISCUSSION Overall, results showed that students believe that student involvement benefits nutrition-based promotional efforts, and that these efforts are effective in changing student food choices. These findings are consistent with those of the Randomized Intervention of Pupil Peer-Led sex education study, in which peer educators expressed positive opinions of school-based peer-led education (21). These data indicate that youth may prefer to deliver health education themselves and to receive it from their peers. Students who were highly involved in promotional activities through extracurricular activities or an independent class project were more likely than less-involved students to perceive that the Trying Alternative Cafeteria Options in Schools program had positive effects on their choosing and eating healthful foods. Nearly all of the highly-involved students and over half of those less involved reported that student involvement in the Trying Alternative Cafeteria Options in Schools study resulted in more students trying lower-fat foods. These findings are consistent with the Teens Eating for Energy and Nutrition at School study, which found that peer leaders who had the highest level of exposure to the intervention showed the greatest improvements in consumption of fruits and vegetables (22).
Overall, results showed that students believe that student involvement benefits nutrition-based promotional efforts, and that these efforts are effective in changing student food choices. Both groups were also highly likely to perceive that student involvement in promotional activities was beneficial to the effectiveness of the Trying Alternative Cafeteria Options in Schools study, and was important in changing the way that adolescents eat. Perhaps adolescents believe that peer influence is more likely to change fellow students’ eating behaviors than is adult-led nutritional education. Peer-led promotions can improve the self-efficacy and self-esteem of adolescents, as well as define their ability to make an impact on others (23). Students benefit the most when they are provided with opportunities to be creative and responsible in developing activities (24,25).
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Autonomy and decision-making power may be factors influencing student experiences. Autonomy allows adolescents to feel competent and empowered by acknowledging skills and abilities (4), and could therefore encourage skill development and foster interest in healthful eating. Highly-involved students were more likely to report gaining new skills compared with less-involved students. The opportunity to develop leadership and career-enhancing skills is considered to be one of the many personal benefits of peer-assisted programs (10). Our findings indicate that participation in the Trying Alternative Cafeteria Options in Schools promotions improved the self-efficacy of students in identifying lower-fat foods. Social cognitive theory considers self-efficacy to be the central aspect in promoting behavior change (26). Future interventions should develop measurable outcomes to assess the relationship between change in self-efficacy and change in behavior in peer-led programs. A strength of this study is that it provided insight about the attitudes of students involved in a peer-led school-based nutrition intervention, an area in which little published data are available. A limitation of this study was that baseline data were not collected to provide objective information about differences in perceptions before and after involvement in the Trying Alternative Cafeteria Options in Schools program. CONCLUSIONS ●
●
●
Students with a high level of involvement in nutritionbased promotional activities report positive attitudes toward healthful eating. Future interventions should actively involve adolescents in the planning and implementation phases of nutrition-based promotional programs. Involving students in promotional activities should be explored as a strategy to promote healthful eating in secondary school settings.
References 1. Troiano RP, Briefel RR, Carroll MD, Bialostosky K. Energy and fat intakes of children and adolescents in the United States: Data from the National Health and Nutrition Examination Surveys. Am J Clin Nutr 2000;72(suppl):S134-S153. 2. Munoz KA, Krebs-Smith SM, Ballard-Barbash R, Cleveland LE. Food intakes of US children and adolescents compared with recommendations. Pediatrics. 1997;100:323-329. 3. Neumark-Sztainer D, Story M, Hannan P, Croll J. Overweight status and eating patterns among adolescents: Where do youths stand in comparison with the Healthy People 2010 objectives? Am J Public Health. 2002;92:844-851. 4. Turner G. Peer support and young people’s health. J Adolesc. 1999;22:567-572. 5. Cowie H. Peers helping peers: Interventions, initiatives and insights. J Adolesc. 1999;22:433-436. 6. Mellanby AR, Rees JB, Tripp JH. Peer-led and adultled school health education: A critical review of available comparative research. Health Educ Res. 2000; 15:533-545.
7. Mellanby AR, Newcombe RG, Rees J, Tripp JH. A comparative study of peer-led and adult-led school sex education. Health Educ Res. 2001;16:481-492. 8. Komro KA, Perry CL, Murray DM, Veblen-Mortensen S. Peer-planned social activities for preventing alcohol use among young adolescents. J Sch Health. 1996; 66:328-334. 9. O’Hara P, Messick BJ, Fichtner RR, Parris D. A peerled AIDS prevention program for students in an alternative school. J Sch Health. 1996;66:176-182. 10. Ebreo A, Feist-Price S, Siewe Y, Zimmerman RS. Effects of peer education on the peer educators in a school-based HIV prevention program: Where should peer education research go from here? Health Educ Behav. 2002;29:411-423. 11. Strange V, Forrest S, Oakley A, The RIPPLE Study Team. Peer-led sex education—Characteristics of peer educators and their perceptions of the impact on them of participation in a peer-education program. Health Educ Res. 2002;17:327-337. 12. Bloor M, Frankland J, Langdon NP, Robinson M, Allerston S, Catherine A, Cooper L, Gibbs L, Hamilton-Kirkwood L, Jones E, Smith W, Spragg B. A controlled evaluation of an intensive, peer-led, schools-based, anti-smoking programme. Health Educ J. 1999;58:17-25. 13. Koumi I, Tsiantis J. Smoking trends in adolescence: Report on a Greek school-based, peer-led intervention aimed at prevention. Health Promot Int. 2001; 16:65-72. 14. Komro KA, Perry CL, Veblen-Mortensen S, Williams CL. Peer participation in Project Northland: A community-wide alcohol use prevention project. J Sch Health. 1994;64:318-322. 15. Black DR, Tobler NS, Sciacca JP. Peer helping/involvement: An efficacious way to meet the challenge of reducing alcohol, tobacco and other drug use among youth. J Sch Health. 1998;68:87-93. 16. Naylor P, Cowie H. The effectiveness of peer support systems in challenging school bullying: The perspec-
17. 18.
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25. 26.
tives of teachers and pupils. J Adolesc. 1999;22:467479. Gibson PG, Shah S, Mamoon HA. Peer-led asthma education for adolescents: Impact evaluation. J Adolesc Health. 1998;22:66-72. Story M, Lytle LA, Birnbaum AS, Perry CL. Peer-led school-based nutrition education for young adolescents: Feasibility and process evaluation of the TEENS study. J Sch Health. 2002;72:126-132. Perry CL, Klepp KI, Halper A, Dudovitz B, Golden D, Griffin G, Smyth M. Promoting healthy eating and physical activity patterns among adolescents: A pilot study of “Slice of Life.” Health Educ Res: Theory Pract. 1987;2:93-103. French S, Story M, Fulkerson J, Gerlach A. Food environment in secondary schools: A la carte, vending machines, and food policies and practices. Am J Public Health. 2003;93:1161-1167. Strange V, Forrest S, Oakley A, The RIPPLE Study Team. What influences peer-led sex education in the classroom? A view from the peer educators. Health Educ Res. 2002;17:339-349. Birnbaum AS, Lytle LA, Story M, Perry CL, Murray DM. Are differences in exposure to a multicomponent school-based intervention associated with varying dietary outcomes in adolescents? Health Educ Behav. 2002;29:427-443. Crockett LJ, Petersen AC. Adolescent Development: Health Risks and Opportunities for Health Promotion. Promoting the Health of Adolescents: New Direction for the 21st Century. New York, NY: Oxford University Press; 1993. Pearlman DN, Camberg L, Wallace LJ, Symons P, Finison L. Tapping youth as agents for change: Evaluation of a peer leadership HIV/AIDS intervention. J Adolesc Health. 2002;31:31-39. Baldwin J. Using peer education approaches in HIV/ AIDS programs for youth: A review of the literature. Peer Facilitator Q. 1995;12:34-37. Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, NJ: Prentice-Hall; 1986.
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Perceptions of Adolescents Involved in Promoting Lower-Fat Foods in Schools: Associations with Level of Involvement SAMIA HAMDAN, MPH, RD; MARY STORY, PhD, RD; SIMONE A. FRENCH, PhD; JAYNE A. FULKERSON, PhD; HELEN NELSON, MEd
ABSTRACT This article describes perceptions of adolescents involved in peer-led school-based nutrition promotions encouraging lower-fat food purchases and assesses the differences by level of student involvement. Surveys were administered at schools. Data were collected from 397 high school students from 10 Minnesota schools randomized to the intervention condition of the Trying Alternative Cafeteria Options in Schools study. Students were categorized as highly involved (n⫽54) or less involved (n⫽343) based on their level of involvement in promotional activity implementation. 2 tests were conducted to measure the differences between highly-involved and less-involved students in perceptions and attitudes about lower-fat foods. Highly-involved students were significantly more likely than less-involved students to report more healthful eating behaviors and positive attitudes toward lower-fat foods. Student involvement in nutrition interventions should be integrated into programs aimed at increasing healthful food choices among adolescents. J Am Diet Assoc. 2005;105:247-251.
S
tudies have found that the diets of most adolescents do not follow the US Dietary Guidelines (1-3). A recent study found that only 52% of female adolescents and 45% of male adolescents met the recommenda-
S. Hamdan is a research associate at the School Nutrition Association, Alexandria, VA; at the time of the study, she was a graduate student in the Division of Epidemiology, University of Minnesota, Minneapolis. M. Story is a professor, S. French is a professor, and H. Nelson is a coordinator, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis. J. Fulkerson is an associate professor, School of Nursing, University of Minnesota, Minneapolis; at the time of the study, she was a research associate, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis. Address correspondence to: Mary Story, PhD, RD, Division of Epidemiology, University of Minnesota, 1300 S 2nd St, Suite 300, Minneapolis, MN 55454-1015. E-mail: [email protected] Copyright © 2005 by the American Dietetic Association. 0002-8223/05/10502-0007$30.00/0 doi: 10.1016/j.jada.2004.11.030
© 2005 by the American Dietetic Association
tion of 30% or less of total energy from dietary fat (3). With an abundance of high-fat and high-sugar foods available in schools, innovative and effective strategies are needed to promote healthful food choices among adolescents. Peer-led initiatives offer a promising approach for encouraging behavior change among adolescents. Peer-led promotions remove the passivity that adolescents may experience in traditional health education settings, and have been found to improve young people’s self-esteem, self-efficacy, knowledge, and attitudes (4,5). Peer-led approaches may be more effective than adult-led health education in changing adolescent health behavior (6,7). Peer participation can directly affect the social environment, can provide positive role models, and can help change social norms (4,5). In addition, there is some evidence showing that students who are peer leaders benefit more in terms of behavior change and skill development compared with their fellow students who were not peer leaders (4,8). Peer leadership efforts have been explored in several adolescent health interventions, such as those for the human immunodeficiency virus (9-11), tobacco (12,13), alcohol (14), substance use (15), bullying (16), and asthma (17). Few peer leadership efforts have been examined in relation to nutrition (18,19). The Trying Alternative Cafeteria Options in Schools study aimed to increase the number of lower-fat food items available on a la carte and vending lines and to increase sales of lower-fat foods in high schools during the 2000 to 2002 school years (20). Ten schools were randomized to the intervention condition, and 10 schools to the control condition. Student-led promotional activities were incorporated into the intervention schools. The current study describes the perceptions and attitudes of students directly involved in implementing the promotional activities. The specific objectives were to (a) describe the perceptions of students involved in peer-led nutrition promotions, and (b) determine whether perceptions differed by level of student involvement. Little descriptive information about peer leaders in nutrition-related promotions is available in the published literature. METHODS As part of the Trying Alternative Cafeteria Options in Schools intervention, student-led promotional activities were implemented to promote awareness and purchase of lower-fat foods among high school students by (a) involving students in implementing promotional activities, (b) increasing student awareness of lower-fat foods, and (c)
Journal of the AMERICAN DIETETIC ASSOCIATION
247
Promotion
Description of promotion
Media campaign
Students convey nutrition messages and increase awareness of lower-fat foods using school newspaper, Web site development, and school TV information spots. Self-assessment survey identifying foods that are typically chosen in cafeteria and vending machines. Ideas for lower-fat options are provided on survey and free sample of lower-fat snack is given away. Free samples of lower-fat foods distributed, along with taste test survey. Comparisons are made between regular and lower-fat items. Free samples of selected fruit or vegetables are offered for 2 days and then sold at a reduced price for the following 2 to 3 weeks. Students use video/TV/camera production to develop public service announcements to increase awareness of lower-fat items, fruits, and vegetables. Students create a poster promoting lower-fat foods. The posters are voted on by students and foodservice staff for prizes. Students receive raffle tickets for each lower-fat food item purchased and turn it into a drawing for a chance to win a prize. Students create T-shirts promoting lower-fat foods and healthy eating. Students, faculty, and/or foodservice staff vote for five favorite designs. Winning students receive gift certificates. Students develop, implement, and evaluate a multi-component marketing campaign. Activities are measured by sales data, student survey analysis, and process evaluation measures. Students create their own promotion tailored to their school needs. Students develop and implement a promotion adhering to the study parameters with TACOS staff approval. Students develop “Top Ten Reasons for Eating Lower-Fat Foods” and convey reasons to student body with use of posters, PA announcements, newspaper, and/or TV advertisements. Students conduct a survey on the student body assessing what factors influence their peers’ food choices and how students view lower-fat foods. The student group creates a summary report on the results and participates in an evaluation with TACOS staff. TACOS staff purchases newspaper ads in school newspapers to highlight study goals and events. Foodservice staff selects two to four lower-fat items to highlight for this promotion. Students receive coupons good for one of the highlighted foods. In some schools, students assist with coupon distribution.
Self-assessment survey Taste testing Fruit and vegetable Public service announcements Poster contest Raffle event T-shirt contest Promotional campaign Create your own promotion Challenge game Student survey Newspaper advertisements Coupon kick-off
Figure. Peer-led, school-based promotional activities implemented during years 1 and 2 of the Trying Alternative Cafeteria Options in Schools (TACOS) study.
increasing sales of lower-fat foods in the a la carte and vending lines. Promotional activities were developed and implemented by student groups with the support of Trying Alternative Cafeteria Options in Schools staff and school faculty advisors. Promotional activities are described in the Figure. Students in the 10 intervention schools who participated in the student promotions were classified into two groups. Highly-involved students (n⫽54) were defined as those who volunteered to participate as part of an extracurricular activity (eg, student council groups), internship, or independent class project, and had the responsibility of planning, implementing, and evaluating promotions as part of a small group activity. Less-involved students (n⫽343) were defined as those who participated because their teachers were implementing the activities as part of the classroom curriculum (eg, a health class). These students participated 5 hours or less by assisting with material development or promotion implementation as part of a class project. A survey was developed to assess students’ perceptions of eating behaviors, attitudes, and social norms related to lower-fat foods, and perceived benefits and experiences gained from being involved in the Trying Alternative Cafeteria Options in Schools promotional activities. Our study as-
248
February 2005 Volume 105 Number 2
sessed students’ opinions specifically related to student involvement in the Trying Alternative Cafeteria Options in Schools promotional activities; therefore, a control group was not included. Analyses of the data were conducted using SAS (version 8, 2001, SAS Institute, Cary, NC). 2 analyses were conducted to compare responses between highly involved and less involved students. A conservative P value (P⬍.001) was used to adjust for multiple comparisons. RESULTS A high percentage of both highly involved and less involved students reported that the Trying Alternative Cafeteria Options in Schools program helped them to recognize which foods were lower in fat and that they had perceived more students eating lower-fat foods in the school cafeteria since the inception of the Trying Alternative Cafeteria Options in Schools program (Table). A high percentage of highly involved and less involved students also reported that the Trying Alternative Cafeteria Options in Schools study showed better results in increased awareness and purchases of lower-fat foods among adolescents because of student involvement; the majority in both groups reported that
Table. Student perceptions by level of involvement in TACOSa student promotions, N⫽397
Perceptions Eating behaviors I eat more lower-fat foods because of being involved in TACOS TACOS did not change the way I choose foods I pay more attention to what I eat because of the TACOS program TACOS did not influence me to eat more fruits and vegetables Attitudes Participation in TACOS has not improved my attitude toward lower-fat foods Participation in TACOS has improved my attitude toward fruits and vegetables Social norms My friends thought it was cool to be part of TACOS It is cool to eat lower-fat foods at school I have not noticed more students eating lower-fat foods since the TACOS program started TACOS did not have an impact on the number of students eating lower-fat foods in the school cafeteria Student involvement I believe the TACOS study benefited from having students involved in promotion activities I believe student involvement in TACOS promotion activities resulted in more students trying lower-fat foods at my school Student involvement in TACOS promotions is not important in changing the way teens eat Experiences gained from TACOS I did not learn new skills from working with the TACOS program Because of TACOS, I was able to taste lower-fat foods, fruits, and vegetables that I would not have tried otherwise TACOS has helped me to recognize what foods are lower in fat
Total (Nⴝ397) % agree
Highly-involved studentsb (nⴝ54) % agree
Less-involved studentsc (nⴝ343) % agree
2 value
P valued
32.1
67.9
26.5
36.2
⬍.0001
60.7
20.8
67
41
⬍.0001
40.2
69.2
35.8
21
⬍.0001
49
5.7
55.7
46
⬍.0001
48.7
1.9
56
53.8
⬍.0001
54.8
88.5
49.7
27.4
⬍.0001
37.1 62.3
65.4 84.9
32.7 58.7
20.6 13.4
⬍.0001 ⬍.0001
64.3
26.4
70.2
38.3
⬍.0001
55.6
9.4
62.9
53.1
⬍.0001
70.6
19.3
⬍.0001
98.1
54.1
36.3
⬍.0001
28.3
0
32.8
24.7
⬍.0001
41.3
3.7
47.3
36.5
⬍.0001
60.9
92.6
55.9
26.4
⬍.0001
64.8
88.7
61.1
15.3
⬍.0001
74.6
60
100
a
TACOS⫽Trying Alternative Cafeteria Options in Schools. Highly-involved⫽students who participated in planning, implementing, and evaluating promotional activities as part of an extracurricular activity, internship, or independent class project. c Less-involved⫽students who participated by assisting with material development or with implementation of TACOS promotions as part of the required class curriculum, and who spent less than 5 hours on TACOS promotions over the 2-year duration of the study. d P values compare highly involved and less involved students. b
student involvement was important in changing the way adolescents eat and resulted in more students trying lower-fat foods. Significant group differences were found between the highly involved and the less involved students across all of the content domains of eating behaviors, attitudes, social norms, student involvement, and experi-
ences gained from the Trying Alternative Cafeteria Options in Schools study. Highly-involved students were significantly more likely than less involved students to perceive that the Trying Alternative Cafeteria Options in Schools study changed the way they chose foods, afforded them the opportunity to try lower-fat foods and fruits and vegetables that they would other-
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wise not have tried, influenced them to eat more fruits and vegetables, improved their attitudes towards lower-fat foods, and had an impact on the number of students eating lower-fat foods in the school cafeteria. Less-involved students were significantly more likely than highly involved students to be in the 10th grade (89% of less involved compared with 32% of highly involved students were in the 10th grade, respectively; P⬍.001). Race and sex were not significantly associated with level of involvement; 91% of highly-involved and 83% of less-involved students were white, and 65% of highly-involved and 59% of less-involved students were female. DISCUSSION Overall, results showed that students believe that student involvement benefits nutrition-based promotional efforts, and that these efforts are effective in changing student food choices. These findings are consistent with those of the Randomized Intervention of Pupil Peer-Led sex education study, in which peer educators expressed positive opinions of school-based peer-led education (21). These data indicate that youth may prefer to deliver health education themselves and to receive it from their peers. Students who were highly involved in promotional activities through extracurricular activities or an independent class project were more likely than less-involved students to perceive that the Trying Alternative Cafeteria Options in Schools program had positive effects on their choosing and eating healthful foods. Nearly all of the highly-involved students and over half of those less involved reported that student involvement in the Trying Alternative Cafeteria Options in Schools study resulted in more students trying lower-fat foods. These findings are consistent with the Teens Eating for Energy and Nutrition at School study, which found that peer leaders who had the highest level of exposure to the intervention showed the greatest improvements in consumption of fruits and vegetables (22).
Overall, results showed that students believe that student involvement benefits nutrition-based promotional efforts, and that these efforts are effective in changing student food choices. Both groups were also highly likely to perceive that student involvement in promotional activities was beneficial to the effectiveness of the Trying Alternative Cafeteria Options in Schools study, and was important in changing the way that adolescents eat. Perhaps adolescents believe that peer influence is more likely to change fellow students’ eating behaviors than is adult-led nutritional education. Peer-led promotions can improve the self-efficacy and self-esteem of adolescents, as well as define their ability to make an impact on others (23). Students benefit the most when they are provided with opportunities to be creative and responsible in developing activities (24,25).
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Autonomy and decision-making power may be factors influencing student experiences. Autonomy allows adolescents to feel competent and empowered by acknowledging skills and abilities (4), and could therefore encourage skill development and foster interest in healthful eating. Highly-involved students were more likely to report gaining new skills compared with less-involved students. The opportunity to develop leadership and career-enhancing skills is considered to be one of the many personal benefits of peer-assisted programs (10). Our findings indicate that participation in the Trying Alternative Cafeteria Options in Schools promotions improved the self-efficacy of students in identifying lower-fat foods. Social cognitive theory considers self-efficacy to be the central aspect in promoting behavior change (26). Future interventions should develop measurable outcomes to assess the relationship between change in self-efficacy and change in behavior in peer-led programs. A strength of this study is that it provided insight about the attitudes of students involved in a peer-led school-based nutrition intervention, an area in which little published data are available. A limitation of this study was that baseline data were not collected to provide objective information about differences in perceptions before and after involvement in the Trying Alternative Cafeteria Options in Schools program. CONCLUSIONS ●
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Students with a high level of involvement in nutritionbased promotional activities report positive attitudes toward healthful eating. Future interventions should actively involve adolescents in the planning and implementation phases of nutrition-based promotional programs. Involving students in promotional activities should be explored as a strategy to promote healthful eating in secondary school settings.
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