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8-9SCTresearcharticle.pdf

G E N E R A L A R T I C L E

The Role of Social Cognitive Theory in Farm-to-School-Related Activities: Implications for Child Nutrition* LINDA BERLIN, PhDa,b KIMBERLY NORRIS, PhDc JANE KOLODINSKY, PhDd,e ABBIE NELSON, MSf

ABSTRACT BACKGROUND: Farm-to-school (FTS) programs are gaining attention for many reasons, one of which is the recognition that they could help stem the increase in childhood overweight and obesity. Most FTS programs that have been evaluated have increased students’ selection or intake of fruits and vegetables following the incorporation of FTS components. However, the wide range of activities that are typically part of FTS programs make it difficult to pinpoint which components have the greatest potential to improve students’ health behaviors. Within the field of nutrition education, theory-based interventions that target the key underlying factors influencing health behavior offer the most promise.

METHODS: We review existing research on dietary health impacts and implications of 3 key FTS-related activities and explore the component activities of FTS in terms of their potential to address the key constructs of social cognitive theory (SCT) — which is a current best practice in the field of nutrition — suggesting that FTS programs incorporating a diverse set of activities appear to be most promising.

RESULTS: We find that components of FTS programs incorporate many of the key theoretical constructs in SCT, and show that FTS programs have great potential to facilitate movement toward desired dietary changes. However, it is unlikely that a set of activities in any one current FTS program addresses multiple constructs of the theory in a systematic manner.

CONCLUSION: More intentional inclusion of diverse activities would likely be beneficial. Future research can test these assertions.

Keywords: nutrition and diet; school food services; health educators; school health instruction.

Citation: Berlin L, Norris K, Kolodinsky J, Nelson A. The role of social cognitive theory in farm-to-school-related activities: implications for child nutrition. J Sch Health. 2013; 83: 589-595.

Received on April 3, 2012 Accepted on August 12, 2012

The farm-to-school (FTS) movement gained tractionduring the 1990s, and then flourished over the next decade, resulting in an estimated 2,000 programs in nearly 9,000 schools across the country by 2008.1 Lacking a precise definition, FTS programs are characterized as linking farmers and K-12 schools with the primary purposes of contributing to nutritious meals and education for youth and better incomes for farmers who market locally. Additional goals include enhancing youth’s appreciation and awareness

aExtension Assistant Professor, ([email protected]), Department of Nutrition and Food Sciences, University of Vermont, 109 Carrigan Drive, Burlington, VT 05405-0086. bDirector, ([email protected]), Center for Sustainable Agriculture, University of Vermont, 109 Carrigan Drive, Burlington, VT 05405-0086. cAssociate Agent, ([email protected]), Food Supplement Nutrition Education, University of Maryland, 10632 Little Patuxent Parkway, Suite 435, Columbia, MD 21044. dProfessor and Chair, ([email protected]), Community Development and Applied Economics, University of Vermont, 109 Carrigan Drive, Burlington, VT 05405. eDirector, ([email protected]), Center for Rural Studies, University of Vermont, Morrill Hall Rm. 202, Burlington, VT 05405. f Director, ([email protected]), Vermont Food Education Every Day, NOFA-Vermont, PO Box 697, 14 Pleasant Street, Richmond, VT 05477.

Address correspondence to: Linda Berlin, Extension Assistant Professor, ([email protected]), Department of Nutrition and Food Sciences, University of Vermont, 109 Carrigan Drive, Burlington, VT 05405-0086.

*Indicates CHES continuing education hours are available. Also available at http://www.ashaweb.org/continuing_education.html

of agriculture, food, and nutrition, strengthening local economies, and furthering youth’s sense of connectedness to the community.2,3

As a result of FTS programs’ diverse purposes and grassroots nature, the types of activities they encom- pass vary considerably from program to program. This variety may be due to a view that FTS efforts appear to be best designed from the ground up. Despite this diversity, most FTS programs serve locally produced foods in the school cafeteria,4,5 often highlighting fresh or processed fruits and vegetables (eg, kale,

squash, tomato sauce), dairy and meat products, eggs, beans, and other value-added items (eg, pesto, granola, cider). In addition to locally sourced food served in the cafeteria, components of FTS activities common to many programs include taste tests, lessons on healthful food choices, farm visits, school gardens, recycling activities, and composting systems.

The rapid expansion of FTS has been part of a broader food system relocalization movement in the United States. Other facets of this movement, which may or may not happen in communities with FTS programs, have included the revival of farmers’ mar- kets, development of direct marketing relationships between farmers and restaurant operators, forma- tion of CSAs or ‘‘community supported agriculture,’’ and numerous other connections among producers, processors, distributors, and consumers of food.2 Pro- ponents of the food relocalization movement often cite improved food quality and safety, small-scale food production, biodiversity, resource protection, commu- nity well-being, democratic participation, and regional palates.6 Despite their long list of attributes, the con- cepts of ‘‘local’’ and ‘‘regional,’’ as they apply to food systems, are no more precisely defined than is the term ‘‘farm-to-school.’’

FTS programs are gaining attention for their potential to help stem the increasingly prevalent trend of childhood overweight and obesity. A comparison of National Health and Nutrition Examination Survey (NHANES) data over more than 30 years (1976-1980 and 2009-2010) shows that the prevalence of obesity has increased for children aged 6-11 years, from 6.5% to 18.0%; and for those aged 12-19 years from 5.0% to 18.4%.7,8 Increased consumption of fruits and veg- etables has been recognized as a successful strategy for reducing overweight and obesity,9 and is of particular interest here because greater access to produce is often a core component of FTS efforts.10 In fact, the Centers for Disease Control and Prevention (CDC) has identified FTS programs as an effective approach to improving student health through healthier school meals as well as nutrition and eco-literacy involving hands-on and out-of-doors experiences.11

Many FTS programs that have been evaluated have increased students’ selection or intake of fruits and veg- etables following the incorporation of FTS components such as including locally grown produce into school meal selections, creating school gardens, and provid- ing classroom-based nutrition education.10 Of 5 studies that also examined FTS participants’ dietary behavior outside of school, 4 found increases in the selection or intake of fruits and vegetables by the children. Another study of primary data from 7 school-based nutrition intervention studies — not necessarily incorporating components of FTS programs — showed a net increase of 0.45 servings of fruits and vegetables per student.12

While there are few specific FTS program evaluations, many of the individual activities that are sometimes part of FTS programs such as school gardens have been researched outside of the FTS context. These identify public health implications, including impacts on nutrition knowledge, food preference, and dietary behaviors. The following sections review existing research on the dietary health impacts and implications of three key FTS-related activities. Then, we explore the component activities of FTS in terms of their potential to address the key constructs of social cognitive theory (SCT) — a health behavior change theory on which nutrition interventions are commonly based — suggesting that FTS programs incorporating a diverse set of activities appear to be most promising in this regard.13

LITERATURE REVIEW

Research and evaluations that examined the impacts of food-related activities in the school setting are included in this review if they are typical of the types of activities that are conducted within a FTS context. Because FTS does not have a precise definition, not all activities reviewed here were necessarily linked in the school setting to a defined FTS program. Much of the research cited here was identified through a 2009 review by Joshi et al,1

and augmented with additional research published after that report. The 3 broad areas of focus include classroom-based nutrition education activities, school gardens, and food interventions such as school lunch menu changes and taste tests.

Component One: Nutrition Education Interventions for Children

One of the most explicit goals of FTS is to improve childhood nutrition. Programs may attempt to increase knowledge and awareness, change attitudes, improve skills, or alter behaviors, to positively impact health measures. Despite great interest in this goal, research specifically designed to identify how FTS nutrition education components influence child nutrition has been limited. Furthermore, it is challenging to compare results across the few studies that have been done, due to the diverse array of approaches that fall under the broad definition of FTS.10

Studies show benefits of combining experiential nutrition education with that based in the class- room. Classroom-based nutrition education programs yielded increases in fruit and vegetable consumption among students, from 0.20 to 0.99 servings.14,15 A study of classroom-based nutrition education and hands-on gardening activities for fourth grade students showed that compared with a control group, both these activities ‘‘significantly improved the nutrition

knowledge of the students,’’ as long as 6 months after the intervention. Furthermore, while both activities increased students’ preferences for certain vegetables, the garden-based nutrition education did so for a greater number of vegetables.16

Component Two: School Gardens A review of 11 studies showed that garden-

based nutrition interventions have varying impacts on youth’s produce consumption. Of the featured studies, conducted between 1990 and 2007, 5 were school- based, involving children ages 5-15. Of the 4 studies that looked at actual changes in fruit and vegetable intake, 3 found evidence of increased intake. Of the 6 studies that considered fruit and vegetable preferences, 2 showed increased preferences. Of the 3 studies that examined willingness to taste fruits and vegetables, 2 reported increased willingness to taste.17

More recent research has provided clearer evidence that garden-based education improves youth’s appre- ciation of fresh produce. Garden education programs have been shown to improve attitudes toward fruits and vegetables for second to fifth graders.18 In addi- tion, a 12-week pilot intervention for fourth to sixth graders through a summer YMCA program showed increases in the variety of fruits and vegetables ‘‘ever eaten,’’ as well as improvements in vegetable prefer- ences and requests for fruits and vegetables at home.19

A 28-week study of second graders in a school setting showed that youths involved in gardening in addi- tion to classroom-based nutrition education were more likely to choose and consume vegetables in the cafe- teria, as compared with a control group and another group who only received classroom-based nutrition education. The group that participated in gardening activities also showed improved nutrition knowledge and taste ratings compared with the control group.20

Although these studies’ results are promising, their limitations — including small sample sizes, lack of long-term follow-up, convenience samples, and frequent absence of control groups — prevent firm overall conclusions about school gardens’ impacts on youth’s consumption of and preferences for fresh fruits and vegetables.

Component Three: School Lunch Option, Taste Tests, and Farm Connections

School-based interventions to improve nutrition often incorporate some combination of taste tests in the classroom or cafeteria, more healthful food choices available in the cafeteria, and connections between children and local farmers. Given prominent goals to improve children’s suboptimal intake of fruits and vegetables, such as those put forth in the most recent Child Nutrition Reauthorization Act, much

of the recent research on the impact of school food interventions focuses on produce consumption.

Seven studies featured in a review of FTS program evaluations showed that participation in FTS programs increased cafeteria offerings of fruits and vegetables. Subsequently, participating students chose more fruits and vegetables than they did before their participation in the programs.1 One study in this review reported that on days when the salad bar was available, approx- imately 85% of students selected fruits and vegetables, compared to 35% choosing fruits and vegetables when only hot lunch was available. Between 80% and 90% of the salad bar produce that students selected was unprocessed, compared to only 10% to 20% of the hot lunch fruits and vegetables they chose.21 Similar studies in Compton, California, showed that students choosing foods from FTS salad bar lunches selected between 90% and 140% of United States Department of Agriculture (USDA)-recommended daily servings of fruits and vegetables, while students choosing hot lunch selected just 40% to 60% of the recommended servings. For comparison, both groups took close to the recommended amounts of proteins and grains; this suggests that gains in fruit and vegetable consumption may be a unique contribution of school lunch salad bars.22

Across the nation, salad bar lunches consistently offer nearly twice the servings of fruits and vegetables that hot lunches provide.21 In Oregon, FTS salad bar programs raised the average servings of fruits and vegetables taken by students from 1.24 to 2.26.23 In Los Angeles schools, students self-reported eating an average 4.09 daily servings of fruits and vegetables when participating in salad bar lunch programs, com- pared to 2.97 daily servings prior to the introduction of the salad bar. Students selecting the salad bar also reported consuming fewer total daily calories, cholesterol and fats.24 Pennsylvania parents reported that their children opted for healthier foods at home when participating in FTS interventions, specifically noting that they ate fewer foods high in fats and salt.25

FTS programs can be a boon to school lunch programs’ revenue, as studies show that they typically increase school meal participation rates between 4% and 16%.26-28 This is an important part of school food services’ budgets, because they must cover part of their operating costs through sales of full-price meals. They are also reimbursed by the USDA per meal served for purchases of commodity foods, as well as for serving free and reduced-price meals to eligible students.29 One California school meal cost analysis showed that participation rate increases of as little as 8% can offset additional costs of labor related to an FTS salad bar program.27

Little research was identified describing how taste tests within FTS programs affect actual student dietary behavior. Practitioners use taste tests to introduce

students to nutritious food choices, to educate students about what makes food healthy, and to allow food service providers to assess the feasibility of serving new foods.30 The link between taste tests and actual food choice and intake has yet to be made.

Clinical research conducted in the United Kingdom demonstrates that exposure to a vegetable through 8 daily taste tests increased children’s preferences for that vegetable more effectively than reward methods, when compared with control groups.31 Taste tests held in a school setting in Burlington, Vermont, facilitated the integration of new, healthy food items into the school lunch menus, including pesto pasta and pesto pizza, chicken caesar salads, minestrone soup, and granola-yogurt parfaits.32

School food service professionals interviewed in a set of case studies observed that students are more willing to eat fresh fruits and vegetables if they have interacted with the farmer who grew them, through activities such as field trips to the farm or visits by the farmer to the school.33 These qualitative observations warrant further research into the effects that educational interactions with farmers have on students’ consumption of fresh fruits and vegetables.

Overall, research has shown these are positive gains from the implementation of FTS programs. However, given the variety of interventions across FTS programs and the grassroots efforts by communities to imple- ment them, FTS programs consist of interventions in search of a theory that provides a conceptual frame- work upon which to build testable hypotheses. Given that FTS programs require resources to implement, having impact research to show the efficacy is an important next step toward policy changes that may help stem the rising tide of childhood obesity.

Farm-to-School and Behavior Change Theory Theory-based interventions that target key factors

influencing health behavior are a current best practice in the field of nutrition education. The social ecological model is one relevant theory that describes 5 levels on which health-related behaviors and conditions are influenced: intrapersonal, interpersonal, institutional, community, and public policy.34,35 There are multiple theories that address how change might happen at each of these levels of influence, some of which are particularly suited for certain types of interventions.

Social cognitive theory, although primarily focused on the interpersonal sphere of influence, also encompasses factors linked to the intrapersonal, institutional, and community levels. This theory is frequently the framework around which youth-related food and nutrition interventions are designed because of its: (1) emphasis on approaches that are important to youth, such as positive reinforcement and (2) applicability to public health issues, as evidenced by its

recent applications in these fields.36-38 It is, therefore, a good fit for considering the factors associated with FTS impacting students’ food-related decision-making and behaviors.

SCT addresses the relationship among 3 factors that have to do with how people acquire and maintain health-related behaviors: the environment, personal characteristics, and personal experience. These 3 factors operate in a reciprocal manner with each influencing the others, and are translated into a number of specific constructs which can help shape the components of an intervention. For example, an intervention built on SCT might incorporate a changed environment (institutional and community level), positive reinforcements for new behaviors (intrapersonal level), and opportunities to build or enhance behavioral capability (intrapersonal level), self-control (intrapersonal level), and self-efficacy, such as through modeling (interpersonal level).13,39

To understand how the key constructs of SCT relate to FTS activities, the following list provides a basic outline of the constructs 39 and indicates how they might apply to dietary behavior change that incorporates more local, healthful foods:

• Behavioral capability: youth having the knowledge and skills that are necessary to choose and consume a diet that incorporates local, healthful foods.

• Expectations: youth having beliefs about the likely outcomes of consuming a healthful diet that includes local foods.

• Expectancies: youth valuing the results of eating a diet consisting of healthful, local foods.

• Locus of control: youth’s perception of who reinforces continued consumption of local, healthful foods.

• Reciprocal determinism: interaction between a youth and his or her environment that results in consumption of more healthful, local foods.

• Reinforcement: a youth’s response related to the con- sumption of local, healthful foods that increase the chance of the behavior being repeated; reinforce- ment can be provided internally (by oneself) or externally (by another);

• Self-control or self-regulation: youth gaining control by monitoring and adjusting personal behaviors (consumption of local, healthful foods).

• Self-efficacy: youths’ confidence in their ability to consume local, healthful foods.

• Emotional coping response: how youth deal with the sources of anxiety that surround their consumption of local, healthful foods.

DISCUSSION

Vermont Food Education Every Day (VT FEED) provides a concrete example of how SCT can be incor- porated into FTS programs. Many FTS programs in

Vermont have been initiated or supported by VT FEED, which encourages and provides technical assistance to schools through its ‘‘3 Cs’’ model: classroom, cafeteria, and community. Schools with the most comprehen- sive programs — those that incorporate all 3 Cs in their efforts to improve their food environments — would likely touch upon the intrapersonal, interpersonal, and community spheres of influence addressed in the social ecological model and SCT. Although VT FEED did not intentionally design its interventions around health behavior-change theory, and no peer-reviewed research yet considers FTS programs in this light, the rest of this paper explores how components of FTS programs in Vermont do (or do not) address key con- structs of SCT, and discusses these programs’ likelihood of influencing long-term health behavior change.

Table 1 provides a description of the types of activities that are often incorporated into FTS programs. It then describes whether each activity takes place in the classroom, cafeteria, or community, and which, if any, of the constructs of SCT are addressed when the activity is carried out.

As noted previously, the activities incorporated into each FTS program are not consistent across programs, making it impossible to draw a conclusion about the extent to which the constructs of SCT are addressed through FTS. However, some generalizations can be made from the content of Table 1.

First, the activities that are commonly part of FTS do touch upon many of the theoretical constructs in SCT, and often an activity has the potential to address a number of constructs. Second, and most importantly, FTS programs are likely to modify the students’ food environment while simultaneously providing opportunities for them to learn through observation of others (modeling) during activities such as taste tests, eating in the cafeteria, gardening, and cooking.30 Together these approaches have great potential to facilitate movement toward desired dietary change. However, more research is needed to test these assertions.

Another question to guide further research is whether there are any approaches covered in SCT that could be integrated more consistently into FTS programs. Specific questions to ask toward this end include: Is parental involvement in FTS programs adequate to reinforce key messages at home, and thereby help establish a stronger sense of control (‘‘locus of control’’) in students? How can empirical evidence be used to assess the value of local foods in nutrition education to justify use of the classroom setting to develop expectations and expectancies? and Are students provided with positive reinforcement when they make nutritionally beneficial choices in the cafeteria? Further research that explores the links between FTS and behavior change theory will enable a closer examination of some of these questions. Ta

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FTS programs that incorporate a number of diverse activities are apt to lead to positive dietary behavior change, in part because of their capacity to address multiple constructs of SCT. However, because most FTS programs are locally driven and differ from place to place,5 they do not necessarily combine multiple activities using SCT or any theory as guidance. For this reason it is unlikely that many programs address multiple constructs in a systematic manner. Research focusing on the ability of individual FTS-program components to bring about dietary changes through these constructs, as well as research on the synergistic effects of combining components toward this end, will help to shape the intentional inclusion of diverse activities in future FTS models and possibly contribute to the creation of a universal FTS best practices framework to guide local efforts.

A clear need remains for further research on the nutrition and health impacts of students’ participation in FTS. Incorporation of SCT described here provides an opportunity to build a more robust body of knowledge supporting FTS programs’ improvement of students’ diets.

IMPLICATIONS FOR SCHOOL HEALTH

The complex and diverse goals of FTS programs makes it too easy to use a scattershot approach when identifying interventions that might contribute to important outcomes. Furthermore, the FTS focus on ‘‘local’’ food and community may translate into a value being placed on grassroots efforts throughout the educational components of the program rather than an incorporation of best practices identified through research or adopted from other locales. How then do practitioners reconcile these seemingly opposite values of ‘‘grassroots’’ vs ‘‘best practices?’’

Perhaps the first step is to recognize that these values are not necessarily mutually exclusive. School communities can coalesce around the broad concept of FTS, consider ways they might capitalize on local resources, and still take advantage of the documented experiences of other programs. School leaders must recognize that cafeteria-based changes may not be enough to result in positive nutrition-related behavior changes. Forming school committees that undertake FTS planning which broadly considers the cafeteria, classroom and community as venues for education and change would likely help to create strong, comprehensive programs. Teachers, school health practitioners, parents, and others should be members of these committees. Researchers should continue to look for best practices that are theoretically grounded, practical, and affordable, and educators should help publicize the results of this research. As the FTS concept spreads through communities across the nation, and these communities use scarce resources to

achieve their aspirations, it is incumbent on members of each community to carefully consider the best, reasoned approach.

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2. Bagdonis JM, Hinrichs CC, Schafft KA. The emergence and framing of farm-to-school initiatives. Agric Human Values. 2009;26(1-2):1-13.

3. Farm to School. 2009. Available at: http://www.farmtoschool. org. Accessed September 22, 2009.

4. Kloppenburg JJ, Hassanein N. From old school to reform school? Agric Human Values. 2006;23(4):417-421.

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