- Email: [email protected]
Statewide Dissemination of a Nutrition Program: Show the Way to 5-a-Day
Statewide Dissemination of a Nutrition Program: Show the Way to 5-a-Day JEAN HARVEY-BERINO,' JEAN
F. E W I N G , * B R I A N F L Y N N , ~AND J U L I E ROYERW I C K '
'Department of Nutritional Sciences, University ofVermont, Burlington,Vermont 05405-0148; 2Vermont Department of Health; Burlington,Vermont 05405-0148; "Office of Health Promotion Research, University ofVermont, Burlington, Vermont 05405-0148
ABSTRACT Increasing nutrition education in elementary schools is a goal for all nutrition educators. However, adoption of nutrition programs and curricula by busy teachers is a challenge. The "Show the Way to 5-a-Day" nutrition guide was developed to help young children increase fruit and vegetable consumption by having teachers partner with grocery stores to get produce contributed to the classroom.The guide was based on the principles of Social CognitiveTheory and developed and pilot tested with input from elementary school teachers. The objectives of the current project were to evaluate the systematic, statewide dissemination of this program; determine the importance of teacher training from the state department of health; and determine the factors distinguishing teachers who responded to and/or adopted the program from those who did not. Approximately 50% of teachers accepted a free guide and an additional 50% of these "respondents" reported implementing it. Use of the program was positively influenced by teacher training and, aside from age, there were no significant differences between teachers who adopted the program and those who did not.
INTRODUCTION Although its role is complex, nutrition has emerged as one of the major modifiable risk factors for cancer.' Consumption of a diet high in fruits and vegetables is recognized as being associated with lower cancer risk.' Unfortunately, dietary intake of fruits and vegetables remains lower than the recommendation of five servings per day. In fact, less than 3% of adults surveyed reported eating this targeted amount. InVermont, daily consumption of an average of 1.9 servings of fruits and vegetables is lower than national estimates of 3.5 servings per day.3In addition,Vermonters have high rates of breast and colon cancer. Because of this, diet was selected as a major focus for intervention as part of a National Cancer Institutefunded Data-based Intervention Research Program awarded
This work was supported by NCI grant #5UOICA50109. Address for correspondence: Jean Harvey-Berlno, Ph.D., R.D., Department of Nutritional Sciences, University ofVermont, Burllngton,VT 05405-0148;Tel: (802) 6560668; Fax: (802) 656-0407; E-mall: [email protected]. 01998 SOCIETY FOR N U T R I T I O N EDUCATION
to the state health department. The primary strategy chosen was to encourage increased fruit and vegetable consumption through the 5 a Day for Better Health4 program. Elementary schools were chosen as the target for the intervention. However, prior to developing a statewide dissemination plan for the intervention, a number of pilot studies were conducted. In the first pilot, the principal, teachers, and students at one school developed a nutrition program with consultation from the health department.A local grocery store chain provided produce at wholesale cost to use in classrooms for 4 weeks.Teachers used the produce in the classroom in all subjects; parents were involved through homework, weekly newsletters, and parents' night activities. The whole school adopted the campaign with projects displayed throughout the school.Teachers returning a process evaluation questionnaire agreed that they would recommend the program. Seventyfive percent of parents who responded reported that their child's attitude toward eating fruits and vegetables had changed as a result of the project. The second pilot consisted of five intervention and two control schools.Teachers and staff in those schools were introduced to the program through a 1-hour slide presentation that illustrated teaching methods used in the first pilot. Teachers were given a list of classroom activities developed by the first school and encouraged to develop their own innovative ways to use the donated produce. Teachers integrated the storedonated produce into geography, writing, science, social studies, mathematics, music, art, and drama classes. All students were given a brief, self-administered, twoquestion survey in class before the program began and a posttest 6 weeks after the end of the program. In response to the question "How many times should a person eat fruits and vegetables?" there was a substantial increase in the proportion of children participating in the intervention who believed that they should eat five servings of produce daily; at baseline, 14% of the students answered "5" versus 81% at follow-up. In contrast, there was no change among students in the control schools; 11% answered "5" at both measurement times. In response to the question "How many times did you eat fruits and vegetables yesterday?" there was an increase in the mean number of fruits and vegetables that intervention students reported consuming.There was no change in reported
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Harvey-Berino et al./5-A-DAY NUTRITION PROGRAM
consumption in the control schools. Students who knew the 5 a Day rule tended to report consuming, on average, more fruits and vegetables than those who did not know the rule. This was true at both assessment times and in both control and intervention schools. Based on the success of these pilot studies, the department of health expanded the activity guide into a resource guide called "Show the Way to 5-a-Day." The development of the guide was done with consultation and input from teachers and students and was based on the principles of Social Cognitive T h e ~ r y Social .~ Cognitive Theory posits that an individual's behavior is determined by personal factors and environmental influences.Therefore,"Show the Way to 5-a-Day" was designed to emphasize many of the concepts of Social Cognitive Theory: a change in the school environment (to be focused on healthy eating), observational learning, skill building, enhancing self-efficacy (by using, cooking, eating fresh produce), positive reinforcement from teachers, and changing expectancies (the values children may place on eating five a day). The decision was made to attempt to disseminate this program to schools throughout the state.Therefore, the major objectives of the current project were to systematically promote use of the fully developed version of "Show the Way to 5-a-Day" in elementary schools throughout the state and to assess the effectiveness of these efforts.The specific objectives of the evaluation were to assess the dissemination method, to determine the importance of teacher training by the health department, and to determine factors distinguishing teachers who responded and/or adopted the program from nonrespondents and nonusers.
METHODS Two major adaptations of the "Show the Way to 5-a-Day" program were required to expand implementation from pilot schools to statewide use. The first feature of the pilot programs that was challenging to replicate on a statewide scale was provision of teacher training. Since training was relatively expensive as compared to other program components, the study design evaluated the contribution of externally supported teacher training to effective program implementation. The "Show the Way to 5-a-Day" program developed for the pilot studies was designed to be implemented by schools in collaboration with local grocers.These partnerships were facilitated by state health department staff. Creating and sustaining similar partnerships for schools across an entire state also presented a major challenge in designing the dissemination effort. A standard component of the "Show the Way to 5-a-Day" program materials was information on how teachers could solicit donated produce from grocery stores. Part of the statewide dissemination plan, however, was to have the health department facilitate the creation of the grocery store:school link for as many schools as possible. Thus, the research design provided that a representative group of schools would receive teacher training support from
a state health department consultant, while remaining schools would receive only the program materials. Some schools would receive facilitated linkages with grocers and some would have to develop their own links.
"Show the Way to 5-a-Day" program. The main goal of the "Show the Way to 5-a-Day" program was to increase consumption of fruits and vegetables among elementary school children. The primary educational method used to achieve this goal was providing modeling and opportunities to practice fruit and vegetable consumption in nontraditional settings such as mathematics and social studies classes. For example, one homework lesson was to have students do a "grocery store research" project where they went to a grocery store with an adult, purchased two pieces of produce they had chosen to write a poem or a report about, research the fruit-describe its skin, seeds, etc.-and then taste test it in two different forms: cooked or raw. Another popular lesson was to have students in mathematics class make a whole class graph and histogram of their preferred fruits and vegetables after they had tasted each different piece of produce in class. Other methods used were providing information about the importance of fruits and vegetables in a healthful diet and providing a supportive environment for diet changes at home and school. A central component of the program was the instructional materials provided to teachers.These included: an overview of the educational strategies used; a summary of the process needed to initiate the program within the classroom and the school and with parents and grocers; sample lesson plans and teaching concepts; teaching materials such as classroom handouts and games; a review of the nutritional basis of the 5-a-Day for Better Health campaign; an outline of possible cafeteria activities; and a list of other information sources.
Training o f teachers and staff. The second major component of this program was the training of teachers and other school personnel by a health department consultant. The main training objective was to facilitate collaboration among teachers, administrators, and staff in planning and implementing the program.The external training support included a 1-hour visit to the school by the health department consultant to catalyze initiation of program planning.This visit included a presentation to the teachers and key staff on the program background, rationale, and objectives, a description of classroom activities and linkages, and examples of implementation ideas from pilot study schools.The consultant provided additional support and advice through follow-up telephone calls and made a follow-up visit during the program implementation for reinforcement. Links with grocers. Fruits and vegetables were obtained for classroom activities in some schools through cooperative
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Journal of Nutrition Education Volume 30 Number 1
agreements with grocery chains and stores. Agreements to provide free produce three times a week for 4 weeks were obtained from the three major chains serving the state of Vermont before schools began to implement the program.This feature of the program was available to a limited number of schools in the state having access to stores owned by the major chains that agreed to participate.
Dissemination plan. The primary objective of the dissemination effort was to facilitate implementation of the "Show the Way to 5-a-Day" program inVermont elementary schools during spring. The principles of the Diffusion of Innovations theory6 were used in designing the dissemination plan, the survey, and the evaluation and interpretation of results.The Diffusion of Innovations theory originated as a way to help explain the process by which an innovation (in this case "Show the Way to 5-a-Day") is communicated and adopted so that it would have predictive validity from one innovation to the next.'The main target population for the dissemination effort was third-grade teachers in public schools throughout the state of Vermont.Although the program was designed for use with third and fourth graders, the dissemination effort was targeted to a single grade to provide a more focused picture of responses to the initial offer. The current state educational directory was used to identify 135 eligible public schools that had pupils in the third grade. A list was created that generated mailing labels addressed to "Third Grade Teacher" at each school. A 1-page flyer was sent to all schools in November; these flyers described the program, showed sample contents of the "Show the Way to 5-a-Day" guide, and included a form offering a free copy. If a teacher requested a copy, the number of thirdand fourth-grade teachers in those schools was obtained from the school secretary and copies of the guide were sent to these teachers by January. This approach was taken to facilitate engagement of the entire school in program implementation. After 47 (35%) participating schools were identified through responses to the initial mailing, eight of these were systematically selected to receive training support for teachers and other key personnel from the state health department consultant. These schools were chosen to include a mix of larger (more urban and greater than 500 students) and smaller (rural with less than 500 students) schools in a variety of types of communities. Seven of the eight schools accepted the training support offer. Linkage arrangements with grocery chains were limited to a total of 29 schools in the state.The number of schools that could be linked was limited by the number of schools each participating grocery store was willing to sponsor and the fact that some schools did not have a grocery store in close geographic proximity. Teachers who had been sent "Show theway to 5-a-Day" guides were notified by letter from the state health department of these cooperative agreements. T h e letter also offered to assist schools in obtaining this help from individual stores. Because the linkage and training arrangements were not random, an attempt was made to characterize the differences
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between schools that received help and those that did not. There was no significant difference between schools that got training or were linked with a grocery store and those that were not with regard to years teaching, hours spent teaching nutrition, school size, number of students per class, number of classes team taught, or multigrades.There was, however, a significantly higher proportion of teachers with post-master's degree credits (64% vs. 19%, p < .01) who received training.
Evaluation design. The overall dissemination effort was assessed through analyses of responses to offers of the "Show the Way to 5-a-Day" program and through reports of program implementation from individual teachers. Reports of program participation were not obtained from parents, foodservice staff, grocers, or students because of evaluation resource limitations. The impact of two variations in the type of external support for program implementation offered to schools was assessed. The 47 schools that accepted the initial "Show the Way to 5-a-Day" guide offer included seven schools that also were offered and accepted training support and 39 schools that were not offered training support.These 47 schools were also offered assistance in being formally linked by the state health department with a grocery store; of this group, 17 were linked and 30 were not 1inked.The seven schools that were to receive training support from the department of health were also among the 17 that got grocery store links. In other words, seven schools got both training support and grocery store links. Research questions. Four main research questions were addressed by this study. 1.
2.
3.
4.
How successful was the initial offer of the "Show the Way to 5-a-Day" program to third-grade teachers? Related questions concerned the personal and professional characteristics of those w h o did and did not accept the offer. What were the differences in the level of implementation of the "Show the Way to 5-a-Day" program between teachers who actively requested the guide versus those who received it because a colleague accepted the offer? What was the impact of external training on level of implementation of the guide? Average levels of use among third- and fourth-grade teachers were compared for schools that received and did not receive training from the state health department consultant. What was the impact of external facilitation of grocery store linkage on level of program implementation within schools? Average levels of use among third- and fourthgrade teachers were compared for schools that received and did not receive grocery store linkage from the state health department staff.
Study samples. Three groups of teachers were identified as sources of the data required to address these questions.
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Harvey-Berino et
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Nonrespondents. The first study sample consisted of a systematic selection of third-grade teachers from schools in which no teacher responded to the initial mailing offering the "Show the Way to 5-a-Day" guide.The selection procedure was designed to provide a sample of teachers representative of the total group of nonrespondents.The sample was selected using a list of public schools with a third grade but without a teacher responding to the initial offer; this list was arranged alphabetically by name of school district. Schools were chosen (in alphabetical order) from this list until a total of 77 schools were identified. School secretaries were then contacted to obtain the name of the third-grade teacher or teachers in each school most likely to have received the flyer. Through this procedure, 87 third-grade teachers from 77 schools were identified out of a total of 88 eligible schools that did not respond to the initial offer. Respondents. T h e second study sample consisted of all third-grade teachers who responded to the initial offer by requesting a copy of the resource guide.These 47 interested teachers were referred to as the respondents. Recipients. The third study sample consisted of third- and fourth-grade teachers who had received a copy of the resource guide only because a colleague in their school had requested a copy. These teachers could generally be assumed to have been unaware of the initial mailing.This group of additional potential program implementers was called the recipients. Measurement. Data were collected from these three groups of teachers through mail surveys. T h e evaluation methodology, dissemination plan, and surveys were developed by health educators knowledgeable in Diffusion of Innovations theory6 in the University Office of Health Promotion Research.The surveys were pretested on a group of nutrition, health education, and public health professionals and modified for clarity. Because resources were limited and the survey did not measure any psychosocial constructs, formal reliability testing and validity testing were not done. Personalized letters and questionnaires were sent to each teacher.Those who did not return a completed questionnaire after 1 month were sent a second letter reminding them about this request.Those who did not return a completed questionnaire within 1 month after the second letter were contacted by telephone.Teachers were asked not to write their name or the name of their school on the questionnaire to ensure confidentiality of responses; survey forms were identified by unique codes, however, to identify those who had returned completed questionnaires. The personalized letters mailed to nonrespondent teachers in February provided background information on the dissemination study and a gift certificate incentive for participation.This mailing also included a copy of the flyer used to solicit teacher requests for the "Show the Way to 5-a-Day" guide to remind teachers about the initial offer.This survey included questions about recall of the flyer, reasons for nonresponse to the offer, suggestions concerning future elemen-
tary school health education dissemination efforts, and descriptive information about the teacher's nutrition education practices and professional and personal characteristics. These questions were presented on two sides of a single sheet; a stamped return envelope was included. A more detailed questionnaire was sent to the third-grade respondent teachers and to the third- and fourth-grade recipient teachers.These questionnaires were sent in late April, after the recommended program implementation period. Procedures were similar to those described above, except that a copy of the "Show the Way to 5-a-Day" guide cover was included with the mailing.The questionnaire for these teachers included questions tailored to each teacher's level of use of the "Show the Way to 5-a-Day" guide. The briefest set of questions applied only to teachers who said that they had not received a copy of the guide or that they had received it and not looked at it.They were asked if they had observed use of the guide by other teachers or by the foodservice staff in their schools; they were also asked to provide the same descriptive information requested from the nonrespondent teachers.Those who looked d use through the "Show theway to 5-a-Day9'guide but d ~ not it were also asked about their impressions. Teachers reporting that they used the "Show the Way to 5-a-Day" guide were asked a detailed set of questions about program implementation in addition to questions about use by others in the school.These questions asked about collaboration for program implementation within the school and creation of linkages with parents and grocers, assessments of the usefulness of specific components of the guide, assessments of the quality of the guide, and comments or suggestions. These data collection procedures were approved by the Committee on Human Research of the University ofVermont. Data analysis plan. Analyses related to the first research question compared the characteristics of nonrespondents and respondents using chi-square methods and analysis of variance for continuous variables. For the second research question, differences in levels of use of the program were assessed for respondents and recipients similarly using chisquare analyses and analysis of variance. For analyses focused on assessment of the effects of normal versus training support for implementing the program, responses from normal support respondents and recipients were combined and compared with responses from training support respondents and recipients using chi-square methods and analysis of variance.A similar approach was taken to assess the effects of externally facilitated linkage with grocery stores. Alpha level was set at .05.
RESULTS Survey responses. Questionnaires were mailed to 171 third- and fourth-grade teachers from 47 different schools who received a copy of the "Show the Way to 5-a-Day" guide (respondents and recipients). A total of 89 completed ques-
Journal of Nutrition Education Volume 30 Number 1
January
tionnaires were returned for a teacher response rate of 52%. These 89 responses represented 33 different schools for a school response rate of 70%. Among the 47 respondents receiving a questionnaire, 27 were returned for a teacher and school response rate of 57%. Eighty-seven questionnaires were mailed to third-grade teachers not responding to the brochure advertising a copy of the nutrition guide (nonrespondents). These 87 teachers represented 77 different schools. Fifty-two completed questionnaires were returned (59% teacher response), representing 52 different schools (68% school response). Characteristics o f respondents and nonrespondents. Survey responses from among the 35% of targeted teachers responding to the program offer and the 65% not responding to this offer were used to assess characteristics of respondents (n = 27) and nonrespondents (n = 52).The only significant difference f o u n d b e t w e e n respondents and nonrespondents was age of teacher, with respondents being significantly older than nonrespondents (44 k 8.3 vs. 40 ? 8.5, p I .05,Table 1).Chi-square analysis revealed no significant differences between the number of respondents and nonrespondents who participated in team teaching or multigrade classrooms or their educational 1evel.A separate analysis was done for the nonrespondent teachers who reported having seen the brochure but did not request a free copy of the guide (23%, n = 12).This group of teachers (the "true" nonrespondents) did not differ significantly from the other nonrespondent (n = 40) or respondent teachers with regard to the variables discussed above. Thus, all nonrespondent teachers were grouped together for further analysis. Nonrespondent survey. Among the nonrespondents, 23% (n = 12) of teachers said that they had seen the brochure
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offering a free copy of the nutrition guide; 13.4% were not sure that they had ever seen the brochure. O f those saying that they had seen the brochure, the following responses were given as to why they did not respond to the offer: already have an existing program (25%), did not seem appropriate for use at our school (38%), or did not get to it (25%). For the three teachers saying that they already had an existing program, only one was using a program that emphasized 5 a Day, the "Changing the Course" curriculum from the American Cancer Society. O f those responding to the question eliciting suggestions for improving the method of distributing information to teachers, the following were the most frequent suggestions given: mail offer to teachers at school or home by name (i.e., not to the "attention of the third-grade teacher") (25%), mail offer to all third-grade teachers in the school (40%), send curriculum directly (20%), send offer in June for following year (lo%),or send to the attention of the school nurse (5%). Levels o f implementation among respondents and recipients. Forty-two percent of those returning the respondent survey reported using the nutrition guide.An additional 8% reported looking through the guide and were therefore able to provide feedback on its contents, layout, etc.Table 2 reports the overall impressions and assessment of the guide by these individuals. Generally, teachers rated the guide as being"good,""very good," or "excellent." However, they felt that using the guide was time consuming, it did not readily fit into existing curriculum, and a year of planning was necessary before adoption of the guide was realistic. An additional 25% of teachers felt that obtaining fruits and vegetables was too difficult o r expensive. Table 3 shows the differences in level of implementation of the guide by whether the teacher was a respondent or a recipient. There were no significant differences between those teachers that
Table 1. Teacher and school characteristics mean and (SD). Respondents
Nonrespondents
(N = 27)
(N = 52)
Table 2. Respondent and recipient impressions and overall assessment of guide (%) (N = 89). Impressions of guidea
Age Gender (malelfemale)
45 (8.3)' 7%193%
40 (8.5)* 2%/98%
Hours teach nutrition
8.6 (5.9)
13.4 (11.8)
Too complicated
Number students in school
231 (164)
255 (184)
Too difficult or expensive to obtain fruits and vegetables
Number students in class
20.0 (4.8)
19.5 (4.3)
Does not fit in current curriculum
Bachelor's
1%
2%
Should not be done by classroom teacher
Master's degree
2%
2%
Bachelor's +
68%
64%
Master's +
Takes too much time
Duplicates similar program I am using
Teacher education
Need to plan using this program a year ahead Assessment of quality of guide
27%
32%
Poor
Number teachers team teacha
2.0 (.47)
1.6 (.51)
Acceptable
Number of years teaching
15.0 (7.4)
13.7 (7.4)
Good Very good
*p 5.05.
Excellent
"Mean (standard derivation).
Outstanding
.Reflects the number of teachers who team teach a course when a course is team taught.
aSubjects were asked to check any statement with which they agreed.
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Harvey-Berino et al./5-A-DAY NUTRITION PROGRAM
Table 3.
Implementation of the guide (%). Training
No Training
Grocery
No Grocery
Respondents
Recipients
Support
Support
Store Link
Store Link
(n = 27)
(n = 62)
(n = 14)"
(n = 75)
(n = 13)a
(n = 76)
Used guide Discussion of guide with others Principal Other teachers Foodservice staff School nurse Parents Local grocer Use of guide by other teachersd Classroom teachers Art and music teachers Physical activity teachers Foodservice staff Whole school =ncorresponds to the number of teachers responding, not the number of schools that received training support or a grocery store link. bSignificantly different from training support at p < .05. "Significantly different from grocery store link at p < .05. dPercentage,by type, of "other teachers" using the guide.
requested the nutrition guide on their own (respondents) and those who received it unsolicited (recipients) with regard to whom they contacted regarding use of the guide, whether they used contributed produce or bought their own, or the type of teacher most likely in their school to use the guide. Impact o f training support. Chi-square analysis was done to determine the differences between teachers in schools that received training versus no training support (Table 3).The teachers in schools that received training support were significantly more likely to use the guide and have other teachers, including art, music, and physical education teachers, use the guide. Training support teachers were also significantly more likely to use contributed produce. Analysis of variance was used to test for differences between the perceived quality of the guide for training support versus normal support.There were no significant differences in the perceived quality of the guide. Impact of grocery store linkage. Chi-square analysis was similarly done to determine the differences between schools that had been linked with grocery stores and had produce donated for classroom use and those schools that had not been linked with a grocery store (see Table 3). Schools that were linked to a grocery store (and also had teacher training) were significantly more likely to use the guide and to have other teachers (specifically art, music, and physical education teachers) use the guide. Analysis of variance again
revealed no difference in overall rating of the guide for schools that were not linked to a grocery store.
DISCUSSION The overall goal of this study was to determine the effectiveness of disseminating a nutrition guide. Additionally, because it is clear that awareness and knowledge of curriculum innovations do not necessarily lead to adoption or implementati or^,^^^ a secondary goal was to assess the impact of support from the department of health on implementation of the "Show the Way to 5-a-Day" program.The dissemination plan involved giving third-grade teachers an opportunity to request a free guide after receiving a brochure inviting them to do so.The initial success of offering the nutrition guide in this manner was moderate: 47 (35%) teachers from the original 135 schools targeted to receive the guide accepted the offer. This is a lower response rate than the average diffusion pattern would predict where generally 50% of teachers elect e difference to receive externally developed c u r r i ~ u l a . ~ T honly between those who accepted the offer (respondents) and those who did not (nonrespondents) was age, with respondents being older. It is difficult to explain the age difference as it was not associated with a difference in number of years spent teaching or level of teacher education. Any school characteristics investigated similarly had no influence on who initially accepted the offer of a free nutrition guide. Nonrespondent teachers who reported seeing the offer said that they did not
Journal of Nutrition Education Volume 30 Number 1
request a guide because they were already using a similar program or "Show the Way to 5-a-Day" did not seem appropriate for their school. Thus, these teachers did not perceive "Show the Way to 5-a-Day" as being better than what they were currently using or a "good fit" in their classroom or school. Previous evidence suggests that these are two common barriers to Diffusion of Innovations." Nonrespondent teachers did, however, have some valuable input regarding the method of distribution of the offer. Generally speaking, they felt that mailing the offer directly to each of them (either the brochure or the guide itself) would have been the most efficient and effective procedure. It is reasonable to assume then that other forms of dissemination that allowed for personal contact with a teacher would be effective.This could be reasonably accomplished through exhibits at teacher conferences, personal e-mail messages, and a direct mailing. Further research will need to evaluate the effectiveness and cost effectiveness of various strategies. "Show the Way to 5-a-Day" was intended to be a whole school effort. For this reason, the guide was mailed to every third- and fourth-grade teacher in a school that requested a copy.While general impressions of the guide were favorable, teachers reported some predictable barriers to the diffusion or adoption of the program,'a9 such as the time and planning it might take, the fact that it did not fit with current curricula or duplicated a curriculum in use, and the perception that the fruits and vegetables the program requires would be too expensive or difficult to obtain. Similar work on the diffusion ofAIDS curricula found that "perceived instrumentality" or the ease of use of the curricula played a major role in its adoption,1° thus suggesting that barriers reported to adoption of "Show the Way to 5-a-Day" are significant, albeit perhaps predictable, and need to be evaluated. In terms of how the dissemination technique influenced use of the guide, we were interested in whether there was any difference in level of implementation of the guide based on whether a teacher requested it himself/herself (respondent) or simply received it because another teacher in their school requested it (recipient). In other words, is there any benefit to simply mailing the guide without first soliciting interest as the nonrespondent teachers have suggested? O n e can conclude from the results of the analysis of respondents versus recipients that there may in fact be some benefit to doing a direct mailing of materials instead of first polling interest via a separate mailing. The same percentage (50%) of respondents and recipients reported implementing the guide at the same levels, suggesting again that an initial mailing may not be necessary. Because questionnaire response rate was approximately 50% and 50% of those teachers reported using the guide, the overall "Show the Way to 5-a-Day" implementation rate was approximately 25%. This rate exceeds diffusion predictions that estimate that 25% of teachers will actively take notice of new curriculum content while only 5% to 10% finally use h e research question of the curriculum in some ~ a y . ~ T third this investigation was to assess the impact of training support (external training) on the use of the guide. Again, we were
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interested in whether the staff and financial commitment devoted to teacher training was going to make a significant impact on the overall use and level of use of the guide. Goals of this training were not traditional, however. Instead of providing technical support (e.g., an update on nutrition principles as they relate to fruit and vegetable consumption), this "training" was intended to motivate the teachers to be creative and work together in a whole school effort focused on a theme: fruit and vegetable consumption.The results of the analysis of those that received training versus no training strengthen the argument for some level of teacher contact after the guide has been mailed. Training support served to increase the percentage of teachers who said that they used the guide.This in itself accomplished an important goal and is in agreement with other studies suggesting that the more help given to "users" of an innovation by the "resource sysThis would tem," the more likely it is to be implemented.7~11 suggest that exhibiting a curriculum at a teacher's conference would not result in the same level of implementation that an exhibit followed by teacher training would. Contact with the trainer additionally increased the number of schools that linked up with a grocery store to get produce contributed. Finally, the training support teachers were more likely to report use of the guide by other teachers, which was clearly a goal of the training. Research that can evaluate different methods of teacher training or types of follow-up contact with teachers will be valuable. The impact of the grocery store link had a similarly positive outcome. The effort of linking teachers with a community grocery store increased the level of use of the guide. In light of the fact that many teachers felt that the produce might be too expensive or difficult to procure, this technique clearly eliminated at least one barrier to implementation of "Show the Way to 5-a-Day." Moreover, teachers in these schools were more likely to discuss the guide with other teachers, and there was a trend toward increasing discussions with foodservice staff (p = .OB). Although this trend was not statistically significant, it is important to note. Recent efforts by the federal government to improve the quality and acceptability of school lunch (via theTeam Nutrition program) will only be successful with cooperation from the whole school environment. Teacher training (training support) alone did not produce a similar effect. It should be noted, however, that interpretation of the influence of the grocery store link should be made with some caution. There were too few teacher responses from schools with a grocery store link and no training support to assess whether linking with a grocery store alone was as effective as training support. In summary, the strengths of this project lie in the original research and development put into the construction of "Show the Way to 5-a-Day." It is novel for a public agency to use marketing techniques and health behavior theory to disseminate a nutrition education program. The guide was theory driven, pilot tested, and produced only after extensive input from teachers and students was solicited. Unfortunately, the dissemination evaluation of the guide was hampered by
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Harvey-Berino et al./5-A-DAY N U T R I T I O N P R O G R A M
a low teacher response rate to the questionnaires and the inability, in the time frame used, to assess the continuation or maintenance of use of the guide. It is possible, for example, that a number of teachers implemented the guide in the following school year. Better coordination with the department of education and a longer time frame to do follow-up would have improved the information obtained in this project. However, results of this study suggest that statewide dissemination of the "Show the Way to 5-a-Day" program was significantly enhanced by linking teachers with grocery stores and offering a minimal training or personal introduction to the guide. Finally, mailing the guide directly to teachers (by name) can be recommended as a cost-effective strategy for initial dissemination.
3. Subar AS, Heimendinger J, Krebs-Smith SM, Patterson BH, Kassler R , Pinvenka E. 5 A Day for better health: a baseline study ofAmerica's fiuit and vegetable consumption. Rockville, MD: National Cancer Institute, 1992. 4. Havas S, Heimendinger J, Reynolds K, et al. 5 A Day for better health: a new research initiative. J Am Diet Assoc 1994;94(1):32-6. 5. Bandura A. Social foundations of thought and action. Englewood Cliffs, NJ: Prentice-Hall, 1986. 6. Rogers EM. Diffusion of innovations. NewYork:The Free Press, 1983. 7. Orlandi MA, Landers C, Weston R , Haley N. Diffusion of health promotion innovations. In: Glanz K, Lewis FM, Rimer BK, eds., Health behavior and health education; theory, research and practice. San Francisco: Jossey-Bass, 1990:288-313. 8. Paulussen ThGW, Kok G, Schaalma HP. Antecedents to adoption of classroom-based AIDS education in secondary schools. Health Educ Res 1994;9:485-96. 9. Zaltman G, Duncan R. Strategies for planned behavior. New York:
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Wiley, 1977. 10. Paulussen ThGW, Kok G, Schaalma HP, Parcel GS. Diffusion ofAIDS
1. Gritz ER, Bastani R . Cancer prevention-behavior changesthe short and long of it. Prev Med 1993;22:676-88. 2. Steinmetz K.Vegetable, fruit and colon cancer in the Iowa women's health study.Am J Epidemiol 1994;139:1-15.
curricula among Dutch secondary school teachers. Health Educ Q 1995;22:227-43. 11. Oldenburg MA, Owen N. Preventive care in general practice in Australia. Pat Educ Couns 1995;25:305-10.
F. E W I N G , * B R I A N F L Y N N , ~AND J U L I E ROYERW I C K '
'Department of Nutritional Sciences, University ofVermont, Burlington,Vermont 05405-0148; 2Vermont Department of Health; Burlington,Vermont 05405-0148; "Office of Health Promotion Research, University ofVermont, Burlington, Vermont 05405-0148
ABSTRACT Increasing nutrition education in elementary schools is a goal for all nutrition educators. However, adoption of nutrition programs and curricula by busy teachers is a challenge. The "Show the Way to 5-a-Day" nutrition guide was developed to help young children increase fruit and vegetable consumption by having teachers partner with grocery stores to get produce contributed to the classroom.The guide was based on the principles of Social CognitiveTheory and developed and pilot tested with input from elementary school teachers. The objectives of the current project were to evaluate the systematic, statewide dissemination of this program; determine the importance of teacher training from the state department of health; and determine the factors distinguishing teachers who responded to and/or adopted the program from those who did not. Approximately 50% of teachers accepted a free guide and an additional 50% of these "respondents" reported implementing it. Use of the program was positively influenced by teacher training and, aside from age, there were no significant differences between teachers who adopted the program and those who did not.
INTRODUCTION Although its role is complex, nutrition has emerged as one of the major modifiable risk factors for cancer.' Consumption of a diet high in fruits and vegetables is recognized as being associated with lower cancer risk.' Unfortunately, dietary intake of fruits and vegetables remains lower than the recommendation of five servings per day. In fact, less than 3% of adults surveyed reported eating this targeted amount. InVermont, daily consumption of an average of 1.9 servings of fruits and vegetables is lower than national estimates of 3.5 servings per day.3In addition,Vermonters have high rates of breast and colon cancer. Because of this, diet was selected as a major focus for intervention as part of a National Cancer Institutefunded Data-based Intervention Research Program awarded
This work was supported by NCI grant #5UOICA50109. Address for correspondence: Jean Harvey-Berlno, Ph.D., R.D., Department of Nutritional Sciences, University ofVermont, Burllngton,VT 05405-0148;Tel: (802) 6560668; Fax: (802) 656-0407; E-mall: [email protected]. 01998 SOCIETY FOR N U T R I T I O N EDUCATION
to the state health department. The primary strategy chosen was to encourage increased fruit and vegetable consumption through the 5 a Day for Better Health4 program. Elementary schools were chosen as the target for the intervention. However, prior to developing a statewide dissemination plan for the intervention, a number of pilot studies were conducted. In the first pilot, the principal, teachers, and students at one school developed a nutrition program with consultation from the health department.A local grocery store chain provided produce at wholesale cost to use in classrooms for 4 weeks.Teachers used the produce in the classroom in all subjects; parents were involved through homework, weekly newsletters, and parents' night activities. The whole school adopted the campaign with projects displayed throughout the school.Teachers returning a process evaluation questionnaire agreed that they would recommend the program. Seventyfive percent of parents who responded reported that their child's attitude toward eating fruits and vegetables had changed as a result of the project. The second pilot consisted of five intervention and two control schools.Teachers and staff in those schools were introduced to the program through a 1-hour slide presentation that illustrated teaching methods used in the first pilot. Teachers were given a list of classroom activities developed by the first school and encouraged to develop their own innovative ways to use the donated produce. Teachers integrated the storedonated produce into geography, writing, science, social studies, mathematics, music, art, and drama classes. All students were given a brief, self-administered, twoquestion survey in class before the program began and a posttest 6 weeks after the end of the program. In response to the question "How many times should a person eat fruits and vegetables?" there was a substantial increase in the proportion of children participating in the intervention who believed that they should eat five servings of produce daily; at baseline, 14% of the students answered "5" versus 81% at follow-up. In contrast, there was no change among students in the control schools; 11% answered "5" at both measurement times. In response to the question "How many times did you eat fruits and vegetables yesterday?" there was an increase in the mean number of fruits and vegetables that intervention students reported consuming.There was no change in reported
30
Harvey-Berino et al./5-A-DAY NUTRITION PROGRAM
consumption in the control schools. Students who knew the 5 a Day rule tended to report consuming, on average, more fruits and vegetables than those who did not know the rule. This was true at both assessment times and in both control and intervention schools. Based on the success of these pilot studies, the department of health expanded the activity guide into a resource guide called "Show the Way to 5-a-Day." The development of the guide was done with consultation and input from teachers and students and was based on the principles of Social Cognitive T h e ~ r y Social .~ Cognitive Theory posits that an individual's behavior is determined by personal factors and environmental influences.Therefore,"Show the Way to 5-a-Day" was designed to emphasize many of the concepts of Social Cognitive Theory: a change in the school environment (to be focused on healthy eating), observational learning, skill building, enhancing self-efficacy (by using, cooking, eating fresh produce), positive reinforcement from teachers, and changing expectancies (the values children may place on eating five a day). The decision was made to attempt to disseminate this program to schools throughout the state.Therefore, the major objectives of the current project were to systematically promote use of the fully developed version of "Show the Way to 5-a-Day" in elementary schools throughout the state and to assess the effectiveness of these efforts.The specific objectives of the evaluation were to assess the dissemination method, to determine the importance of teacher training by the health department, and to determine factors distinguishing teachers who responded and/or adopted the program from nonrespondents and nonusers.
METHODS Two major adaptations of the "Show the Way to 5-a-Day" program were required to expand implementation from pilot schools to statewide use. The first feature of the pilot programs that was challenging to replicate on a statewide scale was provision of teacher training. Since training was relatively expensive as compared to other program components, the study design evaluated the contribution of externally supported teacher training to effective program implementation. The "Show the Way to 5-a-Day" program developed for the pilot studies was designed to be implemented by schools in collaboration with local grocers.These partnerships were facilitated by state health department staff. Creating and sustaining similar partnerships for schools across an entire state also presented a major challenge in designing the dissemination effort. A standard component of the "Show the Way to 5-a-Day" program materials was information on how teachers could solicit donated produce from grocery stores. Part of the statewide dissemination plan, however, was to have the health department facilitate the creation of the grocery store:school link for as many schools as possible. Thus, the research design provided that a representative group of schools would receive teacher training support from
a state health department consultant, while remaining schools would receive only the program materials. Some schools would receive facilitated linkages with grocers and some would have to develop their own links.
"Show the Way to 5-a-Day" program. The main goal of the "Show the Way to 5-a-Day" program was to increase consumption of fruits and vegetables among elementary school children. The primary educational method used to achieve this goal was providing modeling and opportunities to practice fruit and vegetable consumption in nontraditional settings such as mathematics and social studies classes. For example, one homework lesson was to have students do a "grocery store research" project where they went to a grocery store with an adult, purchased two pieces of produce they had chosen to write a poem or a report about, research the fruit-describe its skin, seeds, etc.-and then taste test it in two different forms: cooked or raw. Another popular lesson was to have students in mathematics class make a whole class graph and histogram of their preferred fruits and vegetables after they had tasted each different piece of produce in class. Other methods used were providing information about the importance of fruits and vegetables in a healthful diet and providing a supportive environment for diet changes at home and school. A central component of the program was the instructional materials provided to teachers.These included: an overview of the educational strategies used; a summary of the process needed to initiate the program within the classroom and the school and with parents and grocers; sample lesson plans and teaching concepts; teaching materials such as classroom handouts and games; a review of the nutritional basis of the 5-a-Day for Better Health campaign; an outline of possible cafeteria activities; and a list of other information sources.
Training o f teachers and staff. The second major component of this program was the training of teachers and other school personnel by a health department consultant. The main training objective was to facilitate collaboration among teachers, administrators, and staff in planning and implementing the program.The external training support included a 1-hour visit to the school by the health department consultant to catalyze initiation of program planning.This visit included a presentation to the teachers and key staff on the program background, rationale, and objectives, a description of classroom activities and linkages, and examples of implementation ideas from pilot study schools.The consultant provided additional support and advice through follow-up telephone calls and made a follow-up visit during the program implementation for reinforcement. Links with grocers. Fruits and vegetables were obtained for classroom activities in some schools through cooperative
January
Journal of Nutrition Education Volume 30 Number 1
agreements with grocery chains and stores. Agreements to provide free produce three times a week for 4 weeks were obtained from the three major chains serving the state of Vermont before schools began to implement the program.This feature of the program was available to a limited number of schools in the state having access to stores owned by the major chains that agreed to participate.
Dissemination plan. The primary objective of the dissemination effort was to facilitate implementation of the "Show the Way to 5-a-Day" program inVermont elementary schools during spring. The principles of the Diffusion of Innovations theory6 were used in designing the dissemination plan, the survey, and the evaluation and interpretation of results.The Diffusion of Innovations theory originated as a way to help explain the process by which an innovation (in this case "Show the Way to 5-a-Day") is communicated and adopted so that it would have predictive validity from one innovation to the next.'The main target population for the dissemination effort was third-grade teachers in public schools throughout the state of Vermont.Although the program was designed for use with third and fourth graders, the dissemination effort was targeted to a single grade to provide a more focused picture of responses to the initial offer. The current state educational directory was used to identify 135 eligible public schools that had pupils in the third grade. A list was created that generated mailing labels addressed to "Third Grade Teacher" at each school. A 1-page flyer was sent to all schools in November; these flyers described the program, showed sample contents of the "Show the Way to 5-a-Day" guide, and included a form offering a free copy. If a teacher requested a copy, the number of thirdand fourth-grade teachers in those schools was obtained from the school secretary and copies of the guide were sent to these teachers by January. This approach was taken to facilitate engagement of the entire school in program implementation. After 47 (35%) participating schools were identified through responses to the initial mailing, eight of these were systematically selected to receive training support for teachers and other key personnel from the state health department consultant. These schools were chosen to include a mix of larger (more urban and greater than 500 students) and smaller (rural with less than 500 students) schools in a variety of types of communities. Seven of the eight schools accepted the training support offer. Linkage arrangements with grocery chains were limited to a total of 29 schools in the state.The number of schools that could be linked was limited by the number of schools each participating grocery store was willing to sponsor and the fact that some schools did not have a grocery store in close geographic proximity. Teachers who had been sent "Show theway to 5-a-Day" guides were notified by letter from the state health department of these cooperative agreements. T h e letter also offered to assist schools in obtaining this help from individual stores. Because the linkage and training arrangements were not random, an attempt was made to characterize the differences
February 1998
31
between schools that received help and those that did not. There was no significant difference between schools that got training or were linked with a grocery store and those that were not with regard to years teaching, hours spent teaching nutrition, school size, number of students per class, number of classes team taught, or multigrades.There was, however, a significantly higher proportion of teachers with post-master's degree credits (64% vs. 19%, p < .01) who received training.
Evaluation design. The overall dissemination effort was assessed through analyses of responses to offers of the "Show the Way to 5-a-Day" program and through reports of program implementation from individual teachers. Reports of program participation were not obtained from parents, foodservice staff, grocers, or students because of evaluation resource limitations. The impact of two variations in the type of external support for program implementation offered to schools was assessed. The 47 schools that accepted the initial "Show the Way to 5-a-Day" guide offer included seven schools that also were offered and accepted training support and 39 schools that were not offered training support.These 47 schools were also offered assistance in being formally linked by the state health department with a grocery store; of this group, 17 were linked and 30 were not 1inked.The seven schools that were to receive training support from the department of health were also among the 17 that got grocery store links. In other words, seven schools got both training support and grocery store links. Research questions. Four main research questions were addressed by this study. 1.
2.
3.
4.
How successful was the initial offer of the "Show the Way to 5-a-Day" program to third-grade teachers? Related questions concerned the personal and professional characteristics of those w h o did and did not accept the offer. What were the differences in the level of implementation of the "Show the Way to 5-a-Day" program between teachers who actively requested the guide versus those who received it because a colleague accepted the offer? What was the impact of external training on level of implementation of the guide? Average levels of use among third- and fourth-grade teachers were compared for schools that received and did not receive training from the state health department consultant. What was the impact of external facilitation of grocery store linkage on level of program implementation within schools? Average levels of use among third- and fourthgrade teachers were compared for schools that received and did not receive grocery store linkage from the state health department staff.
Study samples. Three groups of teachers were identified as sources of the data required to address these questions.
32
Harvey-Berino et
al./5-A-DAY NUTRITION PROGRAM
Nonrespondents. The first study sample consisted of a systematic selection of third-grade teachers from schools in which no teacher responded to the initial mailing offering the "Show the Way to 5-a-Day" guide.The selection procedure was designed to provide a sample of teachers representative of the total group of nonrespondents.The sample was selected using a list of public schools with a third grade but without a teacher responding to the initial offer; this list was arranged alphabetically by name of school district. Schools were chosen (in alphabetical order) from this list until a total of 77 schools were identified. School secretaries were then contacted to obtain the name of the third-grade teacher or teachers in each school most likely to have received the flyer. Through this procedure, 87 third-grade teachers from 77 schools were identified out of a total of 88 eligible schools that did not respond to the initial offer. Respondents. T h e second study sample consisted of all third-grade teachers who responded to the initial offer by requesting a copy of the resource guide.These 47 interested teachers were referred to as the respondents. Recipients. The third study sample consisted of third- and fourth-grade teachers who had received a copy of the resource guide only because a colleague in their school had requested a copy. These teachers could generally be assumed to have been unaware of the initial mailing.This group of additional potential program implementers was called the recipients. Measurement. Data were collected from these three groups of teachers through mail surveys. T h e evaluation methodology, dissemination plan, and surveys were developed by health educators knowledgeable in Diffusion of Innovations theory6 in the University Office of Health Promotion Research.The surveys were pretested on a group of nutrition, health education, and public health professionals and modified for clarity. Because resources were limited and the survey did not measure any psychosocial constructs, formal reliability testing and validity testing were not done. Personalized letters and questionnaires were sent to each teacher.Those who did not return a completed questionnaire after 1 month were sent a second letter reminding them about this request.Those who did not return a completed questionnaire within 1 month after the second letter were contacted by telephone.Teachers were asked not to write their name or the name of their school on the questionnaire to ensure confidentiality of responses; survey forms were identified by unique codes, however, to identify those who had returned completed questionnaires. The personalized letters mailed to nonrespondent teachers in February provided background information on the dissemination study and a gift certificate incentive for participation.This mailing also included a copy of the flyer used to solicit teacher requests for the "Show the Way to 5-a-Day" guide to remind teachers about the initial offer.This survey included questions about recall of the flyer, reasons for nonresponse to the offer, suggestions concerning future elemen-
tary school health education dissemination efforts, and descriptive information about the teacher's nutrition education practices and professional and personal characteristics. These questions were presented on two sides of a single sheet; a stamped return envelope was included. A more detailed questionnaire was sent to the third-grade respondent teachers and to the third- and fourth-grade recipient teachers.These questionnaires were sent in late April, after the recommended program implementation period. Procedures were similar to those described above, except that a copy of the "Show the Way to 5-a-Day" guide cover was included with the mailing.The questionnaire for these teachers included questions tailored to each teacher's level of use of the "Show the Way to 5-a-Day" guide. The briefest set of questions applied only to teachers who said that they had not received a copy of the guide or that they had received it and not looked at it.They were asked if they had observed use of the guide by other teachers or by the foodservice staff in their schools; they were also asked to provide the same descriptive information requested from the nonrespondent teachers.Those who looked d use through the "Show theway to 5-a-Day9'guide but d ~ not it were also asked about their impressions. Teachers reporting that they used the "Show the Way to 5-a-Day" guide were asked a detailed set of questions about program implementation in addition to questions about use by others in the school.These questions asked about collaboration for program implementation within the school and creation of linkages with parents and grocers, assessments of the usefulness of specific components of the guide, assessments of the quality of the guide, and comments or suggestions. These data collection procedures were approved by the Committee on Human Research of the University ofVermont. Data analysis plan. Analyses related to the first research question compared the characteristics of nonrespondents and respondents using chi-square methods and analysis of variance for continuous variables. For the second research question, differences in levels of use of the program were assessed for respondents and recipients similarly using chisquare analyses and analysis of variance. For analyses focused on assessment of the effects of normal versus training support for implementing the program, responses from normal support respondents and recipients were combined and compared with responses from training support respondents and recipients using chi-square methods and analysis of variance.A similar approach was taken to assess the effects of externally facilitated linkage with grocery stores. Alpha level was set at .05.
RESULTS Survey responses. Questionnaires were mailed to 171 third- and fourth-grade teachers from 47 different schools who received a copy of the "Show the Way to 5-a-Day" guide (respondents and recipients). A total of 89 completed ques-
Journal of Nutrition Education Volume 30 Number 1
January
tionnaires were returned for a teacher response rate of 52%. These 89 responses represented 33 different schools for a school response rate of 70%. Among the 47 respondents receiving a questionnaire, 27 were returned for a teacher and school response rate of 57%. Eighty-seven questionnaires were mailed to third-grade teachers not responding to the brochure advertising a copy of the nutrition guide (nonrespondents). These 87 teachers represented 77 different schools. Fifty-two completed questionnaires were returned (59% teacher response), representing 52 different schools (68% school response). Characteristics o f respondents and nonrespondents. Survey responses from among the 35% of targeted teachers responding to the program offer and the 65% not responding to this offer were used to assess characteristics of respondents (n = 27) and nonrespondents (n = 52).The only significant difference f o u n d b e t w e e n respondents and nonrespondents was age of teacher, with respondents being significantly older than nonrespondents (44 k 8.3 vs. 40 ? 8.5, p I .05,Table 1).Chi-square analysis revealed no significant differences between the number of respondents and nonrespondents who participated in team teaching or multigrade classrooms or their educational 1evel.A separate analysis was done for the nonrespondent teachers who reported having seen the brochure but did not request a free copy of the guide (23%, n = 12).This group of teachers (the "true" nonrespondents) did not differ significantly from the other nonrespondent (n = 40) or respondent teachers with regard to the variables discussed above. Thus, all nonrespondent teachers were grouped together for further analysis. Nonrespondent survey. Among the nonrespondents, 23% (n = 12) of teachers said that they had seen the brochure
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33
offering a free copy of the nutrition guide; 13.4% were not sure that they had ever seen the brochure. O f those saying that they had seen the brochure, the following responses were given as to why they did not respond to the offer: already have an existing program (25%), did not seem appropriate for use at our school (38%), or did not get to it (25%). For the three teachers saying that they already had an existing program, only one was using a program that emphasized 5 a Day, the "Changing the Course" curriculum from the American Cancer Society. O f those responding to the question eliciting suggestions for improving the method of distributing information to teachers, the following were the most frequent suggestions given: mail offer to teachers at school or home by name (i.e., not to the "attention of the third-grade teacher") (25%), mail offer to all third-grade teachers in the school (40%), send curriculum directly (20%), send offer in June for following year (lo%),or send to the attention of the school nurse (5%). Levels o f implementation among respondents and recipients. Forty-two percent of those returning the respondent survey reported using the nutrition guide.An additional 8% reported looking through the guide and were therefore able to provide feedback on its contents, layout, etc.Table 2 reports the overall impressions and assessment of the guide by these individuals. Generally, teachers rated the guide as being"good,""very good," or "excellent." However, they felt that using the guide was time consuming, it did not readily fit into existing curriculum, and a year of planning was necessary before adoption of the guide was realistic. An additional 25% of teachers felt that obtaining fruits and vegetables was too difficult o r expensive. Table 3 shows the differences in level of implementation of the guide by whether the teacher was a respondent or a recipient. There were no significant differences between those teachers that
Table 1. Teacher and school characteristics mean and (SD). Respondents
Nonrespondents
(N = 27)
(N = 52)
Table 2. Respondent and recipient impressions and overall assessment of guide (%) (N = 89). Impressions of guidea
Age Gender (malelfemale)
45 (8.3)' 7%193%
40 (8.5)* 2%/98%
Hours teach nutrition
8.6 (5.9)
13.4 (11.8)
Too complicated
Number students in school
231 (164)
255 (184)
Too difficult or expensive to obtain fruits and vegetables
Number students in class
20.0 (4.8)
19.5 (4.3)
Does not fit in current curriculum
Bachelor's
1%
2%
Should not be done by classroom teacher
Master's degree
2%
2%
Bachelor's +
68%
64%
Master's +
Takes too much time
Duplicates similar program I am using
Teacher education
Need to plan using this program a year ahead Assessment of quality of guide
27%
32%
Poor
Number teachers team teacha
2.0 (.47)
1.6 (.51)
Acceptable
Number of years teaching
15.0 (7.4)
13.7 (7.4)
Good Very good
*p 5.05.
Excellent
"Mean (standard derivation).
Outstanding
.Reflects the number of teachers who team teach a course when a course is team taught.
aSubjects were asked to check any statement with which they agreed.
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Harvey-Berino et al./5-A-DAY NUTRITION PROGRAM
Table 3.
Implementation of the guide (%). Training
No Training
Grocery
No Grocery
Respondents
Recipients
Support
Support
Store Link
Store Link
(n = 27)
(n = 62)
(n = 14)"
(n = 75)
(n = 13)a
(n = 76)
Used guide Discussion of guide with others Principal Other teachers Foodservice staff School nurse Parents Local grocer Use of guide by other teachersd Classroom teachers Art and music teachers Physical activity teachers Foodservice staff Whole school =ncorresponds to the number of teachers responding, not the number of schools that received training support or a grocery store link. bSignificantly different from training support at p < .05. "Significantly different from grocery store link at p < .05. dPercentage,by type, of "other teachers" using the guide.
requested the nutrition guide on their own (respondents) and those who received it unsolicited (recipients) with regard to whom they contacted regarding use of the guide, whether they used contributed produce or bought their own, or the type of teacher most likely in their school to use the guide. Impact o f training support. Chi-square analysis was done to determine the differences between teachers in schools that received training versus no training support (Table 3).The teachers in schools that received training support were significantly more likely to use the guide and have other teachers, including art, music, and physical education teachers, use the guide. Training support teachers were also significantly more likely to use contributed produce. Analysis of variance was used to test for differences between the perceived quality of the guide for training support versus normal support.There were no significant differences in the perceived quality of the guide. Impact of grocery store linkage. Chi-square analysis was similarly done to determine the differences between schools that had been linked with grocery stores and had produce donated for classroom use and those schools that had not been linked with a grocery store (see Table 3). Schools that were linked to a grocery store (and also had teacher training) were significantly more likely to use the guide and to have other teachers (specifically art, music, and physical education teachers) use the guide. Analysis of variance again
revealed no difference in overall rating of the guide for schools that were not linked to a grocery store.
DISCUSSION The overall goal of this study was to determine the effectiveness of disseminating a nutrition guide. Additionally, because it is clear that awareness and knowledge of curriculum innovations do not necessarily lead to adoption or implementati or^,^^^ a secondary goal was to assess the impact of support from the department of health on implementation of the "Show the Way to 5-a-Day" program.The dissemination plan involved giving third-grade teachers an opportunity to request a free guide after receiving a brochure inviting them to do so.The initial success of offering the nutrition guide in this manner was moderate: 47 (35%) teachers from the original 135 schools targeted to receive the guide accepted the offer. This is a lower response rate than the average diffusion pattern would predict where generally 50% of teachers elect e difference to receive externally developed c u r r i ~ u l a . ~ T honly between those who accepted the offer (respondents) and those who did not (nonrespondents) was age, with respondents being older. It is difficult to explain the age difference as it was not associated with a difference in number of years spent teaching or level of teacher education. Any school characteristics investigated similarly had no influence on who initially accepted the offer of a free nutrition guide. Nonrespondent teachers who reported seeing the offer said that they did not
Journal of Nutrition Education Volume 30 Number 1
request a guide because they were already using a similar program or "Show the Way to 5-a-Day" did not seem appropriate for their school. Thus, these teachers did not perceive "Show the Way to 5-a-Day" as being better than what they were currently using or a "good fit" in their classroom or school. Previous evidence suggests that these are two common barriers to Diffusion of Innovations." Nonrespondent teachers did, however, have some valuable input regarding the method of distribution of the offer. Generally speaking, they felt that mailing the offer directly to each of them (either the brochure or the guide itself) would have been the most efficient and effective procedure. It is reasonable to assume then that other forms of dissemination that allowed for personal contact with a teacher would be effective.This could be reasonably accomplished through exhibits at teacher conferences, personal e-mail messages, and a direct mailing. Further research will need to evaluate the effectiveness and cost effectiveness of various strategies. "Show the Way to 5-a-Day" was intended to be a whole school effort. For this reason, the guide was mailed to every third- and fourth-grade teacher in a school that requested a copy.While general impressions of the guide were favorable, teachers reported some predictable barriers to the diffusion or adoption of the program,'a9 such as the time and planning it might take, the fact that it did not fit with current curricula or duplicated a curriculum in use, and the perception that the fruits and vegetables the program requires would be too expensive or difficult to obtain. Similar work on the diffusion ofAIDS curricula found that "perceived instrumentality" or the ease of use of the curricula played a major role in its adoption,1° thus suggesting that barriers reported to adoption of "Show the Way to 5-a-Day" are significant, albeit perhaps predictable, and need to be evaluated. In terms of how the dissemination technique influenced use of the guide, we were interested in whether there was any difference in level of implementation of the guide based on whether a teacher requested it himself/herself (respondent) or simply received it because another teacher in their school requested it (recipient). In other words, is there any benefit to simply mailing the guide without first soliciting interest as the nonrespondent teachers have suggested? O n e can conclude from the results of the analysis of respondents versus recipients that there may in fact be some benefit to doing a direct mailing of materials instead of first polling interest via a separate mailing. The same percentage (50%) of respondents and recipients reported implementing the guide at the same levels, suggesting again that an initial mailing may not be necessary. Because questionnaire response rate was approximately 50% and 50% of those teachers reported using the guide, the overall "Show the Way to 5-a-Day" implementation rate was approximately 25%. This rate exceeds diffusion predictions that estimate that 25% of teachers will actively take notice of new curriculum content while only 5% to 10% finally use h e research question of the curriculum in some ~ a y . ~ T third this investigation was to assess the impact of training support (external training) on the use of the guide. Again, we were
January
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interested in whether the staff and financial commitment devoted to teacher training was going to make a significant impact on the overall use and level of use of the guide. Goals of this training were not traditional, however. Instead of providing technical support (e.g., an update on nutrition principles as they relate to fruit and vegetable consumption), this "training" was intended to motivate the teachers to be creative and work together in a whole school effort focused on a theme: fruit and vegetable consumption.The results of the analysis of those that received training versus no training strengthen the argument for some level of teacher contact after the guide has been mailed. Training support served to increase the percentage of teachers who said that they used the guide.This in itself accomplished an important goal and is in agreement with other studies suggesting that the more help given to "users" of an innovation by the "resource sysThis would tem," the more likely it is to be implemented.7~11 suggest that exhibiting a curriculum at a teacher's conference would not result in the same level of implementation that an exhibit followed by teacher training would. Contact with the trainer additionally increased the number of schools that linked up with a grocery store to get produce contributed. Finally, the training support teachers were more likely to report use of the guide by other teachers, which was clearly a goal of the training. Research that can evaluate different methods of teacher training or types of follow-up contact with teachers will be valuable. The impact of the grocery store link had a similarly positive outcome. The effort of linking teachers with a community grocery store increased the level of use of the guide. In light of the fact that many teachers felt that the produce might be too expensive or difficult to procure, this technique clearly eliminated at least one barrier to implementation of "Show the Way to 5-a-Day." Moreover, teachers in these schools were more likely to discuss the guide with other teachers, and there was a trend toward increasing discussions with foodservice staff (p = .OB). Although this trend was not statistically significant, it is important to note. Recent efforts by the federal government to improve the quality and acceptability of school lunch (via theTeam Nutrition program) will only be successful with cooperation from the whole school environment. Teacher training (training support) alone did not produce a similar effect. It should be noted, however, that interpretation of the influence of the grocery store link should be made with some caution. There were too few teacher responses from schools with a grocery store link and no training support to assess whether linking with a grocery store alone was as effective as training support. In summary, the strengths of this project lie in the original research and development put into the construction of "Show the Way to 5-a-Day." It is novel for a public agency to use marketing techniques and health behavior theory to disseminate a nutrition education program. The guide was theory driven, pilot tested, and produced only after extensive input from teachers and students was solicited. Unfortunately, the dissemination evaluation of the guide was hampered by
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Harvey-Berino et al./5-A-DAY N U T R I T I O N P R O G R A M
a low teacher response rate to the questionnaires and the inability, in the time frame used, to assess the continuation or maintenance of use of the guide. It is possible, for example, that a number of teachers implemented the guide in the following school year. Better coordination with the department of education and a longer time frame to do follow-up would have improved the information obtained in this project. However, results of this study suggest that statewide dissemination of the "Show the Way to 5-a-Day" program was significantly enhanced by linking teachers with grocery stores and offering a minimal training or personal introduction to the guide. Finally, mailing the guide directly to teachers (by name) can be recommended as a cost-effective strategy for initial dissemination.
3. Subar AS, Heimendinger J, Krebs-Smith SM, Patterson BH, Kassler R , Pinvenka E. 5 A Day for better health: a baseline study ofAmerica's fiuit and vegetable consumption. Rockville, MD: National Cancer Institute, 1992. 4. Havas S, Heimendinger J, Reynolds K, et al. 5 A Day for better health: a new research initiative. J Am Diet Assoc 1994;94(1):32-6. 5. Bandura A. Social foundations of thought and action. Englewood Cliffs, NJ: Prentice-Hall, 1986. 6. Rogers EM. Diffusion of innovations. NewYork:The Free Press, 1983. 7. Orlandi MA, Landers C, Weston R , Haley N. Diffusion of health promotion innovations. In: Glanz K, Lewis FM, Rimer BK, eds., Health behavior and health education; theory, research and practice. San Francisco: Jossey-Bass, 1990:288-313. 8. Paulussen ThGW, Kok G, Schaalma HP. Antecedents to adoption of classroom-based AIDS education in secondary schools. Health Educ Res 1994;9:485-96. 9. Zaltman G, Duncan R. Strategies for planned behavior. New York:
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