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OutcomeandprocessevalofaNorwegian.pdf
Outcome and process evaluation of a Norwegian school-randomized fruit and vegetable intervention:
Fruits and Vegetables Make the Marks (FVMM)
E. Bere 1 *, M. B. Veierød
1,2 , M. Bjelland
1 and K.-I. Klepp
1
Abstract
This study reports the effect of the Fruits and Vegetables Make the Marks intervention, a school-based fruit and vegetable intervention consisting of a home economics classroom com- ponent and parental involvement and encour- aged participation in the Norwegian School Fruit Programme, all delivered during the school year of 2001–02. Nine randomly chosen schools received the intervention and 10 schools served as control schools. Participating pupils completed questionnaires at baseline (September 2001), at Follow-up 1 (May–June 2002) and at Follow-up 2 (May 2003). A total of 369 pupils (69%; mean age, 11.3 years at baseline) participated in all three surveys. No effect of the intervention was found for intake of fruit and vegetables eaten at school or all day, neither at Follow-up 1 nor at Follow-up 2. On analysing the effects on potential mediators, significant differences between intervention and control groups were found for Awareness of the five-a-day recommendations only. The intervention programme was rated as very good by the teachers, and the pupils reported that they enjoyed it. However, the intervention failed to change fruit and vegetable intake, pro- bably because it did not succeed in changing
the pupils’ preferences for or the accessibility of fruit and vegetables—the two strongest corre- lates of children’s fruit and vegetable intake.
Introduction
In Norway, the majority of children do not eat fruit
and vegetables in accordance with the national
recommendations of at least five portions of fruit
and vegetables a day [1, 2]. A number of school-
based interventions have demonstrated that increas-
ing children’s fruit and vegetable intake is possible
[3], even though effects, for the most part, have
been small and the long-term persistence of such
changes is largely unknown [4].
Extensive reviews of previous school-based fruit
and vegetable interventions provide useful recom-
mendations for successful programmes [3, 5–7].
Programmes should consist of multi-components
(such as including both school and home environ-
ments), include education directed at behavioural
change, be of adequate time and duration, include
messages specifically targeting fruit and vegetable
intake (as opposed to healthy eating in general) and
be based on an appropriate theoretical framework.
Social Cognitive Theory (SCT) provides a useful
and frequently applied framework for behaviour
change [8, 9]. SCT postulates that behaviour, in-
cluding dietary behaviour, is the result of environ-
mental factors (such as easily accessible fruit and
vegetables or observation of important others per-
forming the behaviour) and personal factors (such
as preferences and self-efficacy). SCT also postu-
lates that behaviours can affect the environment and
cognitions and that all three factors (behavioural,
1Department of Nutrition and 2Department of Biostatistics,
Institute of Basic Medical Sciences, University of Oslo,
Box 1046, Blindern, 0316 Oslo, Norway
*Correspondence to: E. Bere.
E-mail: [email protected]
HEALTH EDUCATION RESEARCH Vol.21 no.2 2006
Theory & Practice Pages 258–267
Advance Access publication 11 October 2005
� The Author 2005. Published by Oxford University Press. All rights reserved. For permissions, please email: [email protected]
doi:10.1093/her/cyh062
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personal and environmental) affect each other in
constant reciprocal relationships [8].
The present study was designed to investigate
whether a school-based educational programme
based on ‘state-of-the-art’ intervention strategies
and applying a theoretical framework based on
SCT would lead to a significant increase in the
overall fruit and vegetable consumption among
sixth grade children. The present paper reports
outcome and process evaluation of the Fruits and
Vegetables Make the Marks (FVMM) intervention.
Method
The study sample presented in this paper is part of
a larger cohort, the FVMM cohort. This cohort
consists of pupils who were in sixth and seventh
grade classes during the school year of 2001–02 in
38 schools in two Norwegian counties, Hedmark
and Telemark. Two parallel intervention studies,
one in each county, were conducted in sixth grade
classes during this school year. This paper evaluates
the intervention conducted in Telemark County.
The parallel intervention conducted in Hedmark
County is presented elsewhere [10].
Design and procedure
A total of 24 randomly chosen schools were invited
to take part in the FVMM project in Telemark
County, and 19 schools agreed to participate. These
schools were then randomly assigned to an in-
tervention group or a control group. The interven-
tion was delivered in the sixth grade classes from
October 2001 to April 2002. Three surveys were
conducted; baseline (September 2001), Follow-up 1
(May–June 2002) and Follow-up 2 (May 2003). At
each survey, questionnaires were completed by the
pupils in their classrooms in the presence of a
trained project worker who guided the pupils
through the dietary assessment component
(24-hour recall) of the survey. One school lesson
(45 min) was used to complete the questionnaire.
Participating home economics teachers completed
two questionnaires assessing the implementation of
the curriculum and their evaluation of its different
activities. Ethical approval and research clearance
were obtained from The National Committees for
Research Ethics in Norway and the Norwegian
Social Science Data Services.
Study sample
A total of 538 sixth graders were invited to par-
ticipate. Twenty-one children refused to participate;
67 children did not attend class at the time of the
baseline survey, and they were not re-contacted.
Of the 450 pupils who participated at baseline, 78
pupils were not able, for various reasons, to
participate at Follow-up 1 or Follow-up 2 and three
pupils were excluded due to inconsistent responses.
Thus, 369 children (69%) completed all three
surveys and composed the study sample employed
in this paper, 169 boys and 200 girls, 190 inter-
vention and 179 control pupils. Average age was
11.3 years at baseline, 12.0 at Follow-up 1 and 13.0
at Follow-up 2.
Teachers at eight of the nine intervention schools
completed the home economics questionnaires.
Intervention programme
The intervention consisted of three components:
(i) Classroom component
The curriculum was based on our previous experi-
ence [11, 12], international research literature [3, 5–
7] and focus group interviews with sixth grade
pupils [13] and was designed to be consistent with
the objectives stated in the National Curriculum
[14]. The curriculum was delivered during sixth
grade home economics classes by the regular home
economics teacher following a 1-day training
workshop. The curriculum was delivered in seven
sessions over a 7-month period from October 2001
to April 2002. Each session lasted for a duration of
three school lessons (i.e. 3 3 45 min). The pupils
received an introduction to the health benefits of
eating fruit and vegetables and recommendations
regarding healthy levels of fruit and vegetable
intake. As home economics is typically taught in
a school-kitchen setting, every session included
preparation of dishes based on a variety of fruit and
vegetables (to increase pupils’ practical skills, sense
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of self-efficacy and taste preferences for fruit and
vegetables). In addition, each session started by
having the pupils prepare fruit and vegetables for
consumption during the sessions as snacks. A
number of small-group activities included taste
testing (preferences) and information concerning
fruit and vegetables about quality, usability, taste
and availability in their local areas. Pupils mon-
itored their own fruit and vegetable intake for 3
days, followed by self-assessment and goal set-
ting for future intake (awareness/perceived per-
sonal need for increased consumption). A ‘fruit
and vegetable event’ was conducted for either
parents or younger children within the schools.
During the events, various fruit and vegetable
dishes were served, and pupils informed their
parents or the younger children about the project.
The home economics teachers were encouraged
to include more fruit and vegetables throughout
the school year as part of the regular home eco-
nomics curriculum.
As part of the intervention, each school received
NOK 50 (;EUR 6) per pupil for the school year to
facilitate the increased use of fruit and vegetables.
(ii) Parental involvement
Six newsletters were distributed to the parents
during the intervention period. The aims of the
newsletters were to increase communication be-
tween parents and their children concerning fruit
and vegetables and to stimulate increased avail-
ability and accessibility of fruit and vegetables
at home. Each newsletter had a special theme
(1: berries, 2: vegetables, 3: fruits, 4: potatoes,
5: salads, 6: fruits, berries and vegetables), and
they all included health-related information, theme
recipes, concrete activities for parents and children
to do together (e.g. gathering wild berries or grow-
ing vegetables and herbs at home) and a competi-
tion for the children to win a fruit and vegetable
gift certificate.
The project was introduced to the parents at
parents’ meetings at school, where information
concerning fruit, vegetables and health was pro-
vided and questions from the parents were answered
by project staff members.
(iii) School Fruit Programme
A national fruit and vegetable subscription pro-
gramme [15] exists in Norway. All elementary
schools are offered to take part in this programme,
and it is up to the schools to decide whether to
participate or not. At participating schools, pupils
who subscribe receive a piece of fruit or a carrot
each school day, usually at lunch (in Norway, most
school children bring their own sandwiches for
lunch, as no school meals are typically offered).
The subscription cost for the parents was (and still
is) NOK 2.50 per school day (;EUR 0.30).
The programme is subsidized by the Norwegian
Government by NOK 1.00 per pupil per school
day. The fee is paid by the parents for a semester
at a time.
All schools in Norway, including intervention
and control schools in the present study, were of-
fered the subscription programme in the school year
of 2001–02. Project staff encouraged the interven-
tion schools, by a letter to the school principals,
to take part in this subscription programme as part
of the overall intervention. The subscription pro-
gramme started in October 2001 and lasted
throughout the school year (i.e. June 2002).
Instruments
The pupil questionnaire included a 24-hour fruit
and vegetable recall, questions assessing potential
mediators of their fruit and vegetable intake and
intervention evaluation items. The home economics
teachers responded to two separate evaluation ques-
tionnaires (mid- and post-intervention) assess-
ing the implementation of the curriculum and their
evaluation of its different activities.
Fruit and vegetable intake
A written 24-hour fruit and vegetable recall was
used to assess pupils’ fruit and vegetable intake.
The 24-hour recall was read aloud to the pupils
by a project worker. Fruit and vegetable intake the
previous day was recorded for school days (i.e.
the survey was conducted on weekdays Tuesday
through Friday). The 24-hour recall separated the
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day into five time periods (before school, at school,
after school, at dinner and after dinner). The pupils
recalled the types of fruit and vegetables they ate at
the different time periods in household measures
(e.g. 1 apple, 12 grapes) or in portions (e.g. one por-
tion of mixed green salad). The household measures
were coded into portions per day, and one portion
was set at ;80 g [ranging from 65 g (one carrot)
to 105 g (one apple/one orange)]. The conversions
from household measures to portions were based
on household measures and food weights published
by The Norwegian National Association for Nutri-
tion and Health [16]. Juices and potatoes were not
included in the fruit and vegetable calculations.
Measures of the pupils’ fruit and vegetable intake at
school (abbreviated: FV at school) and their total
fruit and vegetable intake the previous day (abbre-
viated: FV all day) are used in this paper to assess
the intervention effect on fruit and vegetable intake.
In a prior test–re-test study, the 24-hour recall
provided consistent responses over a 14-day test–
re-test period [17]. In a validation study, same-age
pupils were capable of recalling the previous day’s
intake of vegetables, but overestimated their fruit
intake compared with the validation method (7 days
recording of pre-coded diaries) [17].
Potential mediators of fruit and vegetable intake
Potential psychosocial mediators of fruit and veg-
etable intake were assessed using the framework of
SCT and included the following scales: Home
Accessibility (five items, e.g. ‘Mother or father
sometimes cuts up fruit or vegetables for me as
a snack’), Modelling (four items, e.g. ‘My mother
eats lots of fruit and vegetables’), Intention to eat
five-a-day (one item, ‘I intend to eat at least five
portions of fruit and vegetables a day’), Preferences
(four items, e.g. ‘Fruit and vegetables make my
meals taste better’), Self-Efficacy to eat five-a-day
(three items, e.g. ‘For me, it would be easy to eat
more than five servings of fruit and vegetables
every day’) and Awareness of the five-a-day rec-
ommendation (one item, ‘How many servings of
fruit and vegetables should a person your age eat
every day?’). All items (except Awareness) were
statements measured on a five-point scale ranging
from ‘I fully disagree’ to ‘I fully agree’ and were
scored from �2 to 2. The awareness item had seven response alternatives ranging from ‘None’ = 0 to
‘More than five-a-day’ = 6. The scales have pre-
viously been described and have shown acceptable
test–re-test reliability (0.51 < Pearson’s correlation
coefficient > 0.74) and internal consistency re-
liability (0.41 < Cronbach’s a > 0.69) [18].
Process-evaluation variables
A number of process-evaluation items were in-
cluded in the Follow-up 1 survey (individual-level
variables) and in the home economics teacher
questionnaires (school-level variables).
Overall project assessment. Home economics teachers were asked to rate the project as poor, fair,
good or very good.
Home economics curriculum. Home economics teachers reported their implementation of the
seven sessions as not implemented (scored 0),
partly implemented (scored 0.5) or fully imple-
mented (scored 1). These seven scores were added,
giving a scale ranging from 0 to 7. Pupils’ en-
joyment of the curriculum was measured by four
questions (presented in Table III). These questions
were added, giving a scale ranging from �5 to 8 and categorized into tertiles: low (�5 to 2), medium (3 and 4) and high (5 to 8) levels of
enjoyment.
Newsletters. Home economics teachers reported on how many of the newsletters they handed out
(0 to 6). Family usage of the newsletters was me-
asured by three questions (presented in Table III).
These questions were added, giving a scale ranging
from �3 to 6, and then categorized into tertiles: low (�3 to 0), medium (1 and 2) and high (3 to 6) usage of the newsletters.
Parent meeting. Whether a parent meeting was held or not.
School Fruit Programme. Whether the school participated in the School Fruit Programme or not
was assessed by information from the Norwegian
Fruit and Vegetable Marketing Board. The pupils
were asked whether they subscribed to the pro-
gramme or not.
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Statistical analysis
Of the study sample, some pupils (16 at baseline, 25
at Follow-up 1 and 18 at Follow-up 2) did not
attend school the day before the survey day. They
were therefore excluded from the respective FV at
school analyses, but they were included in all other
analyses presented in this paper.
The effects of the intervention on fruit and
vegetable intake and on the potential mediators
were analysed on follow-up values by mixed-model
regression (the Linear Mixed Models procedure,
SPSS 12.0). In addition to condition, the models
included baseline score, pupil’s gender and school
(random, nested within condition). The models
were tested for interaction effects between condi-
tion and gender, and because no interaction effects
were seen, boys and girls were combined in all
analyses. The residuals were examined and model
assumptions were met.
The effect of the different levels of the catego-
rized process-evaluation variables on FV all day
were analysed on follow-up values by mixed-model
regression (the Linear Mixed Models procedure,
SPSS 12.0), using a sub-sample consisting of inter-
vention schools only. In addition to the respective
process-evaluation variables, the models included
FV all day baseline score and pupil’s gender.
For assessing potential differences between
pupils participating in all three surveys, and those
not participating in all surveys (attrition analyses),
the two-sample t-test was used for baseline com- parisons as regards fruit and vegetable intake and
the psychosocial variables.
SPSS version 12.0 was used for all analyses. All
P-values are two sided.
Results
Main effects of the intervention
No effect of the intervention was seen for intake of
fruit and vegetables eaten at school or all day,
neither at Follow-up 1 nor at Follow-up 2 (Table I).
As regards the psychosocial scales, significant dif-
ferences between intervention and control groups
were only found for Awareness (Table II).
Process evaluation
Seven of the home economics teachers rated the
project as very good, while one teacher rated the
project as good.
The implementation of the curriculum ranged
from 2.5 to 7. Only one school implemented all
sessions as planned, but six of the eight schools
answering the questionnaires had values of 5.5 or
above. No relation between the amount of the cur-
riculum implemented and the effect of the interven-
tion were seen for FV all day neither at Follow-up 1
nor at Follow-up 2 (data not shown). The mean
score of the pupils’ Curriculum enjoyment scale
Table I. Effect of the FVMM intervention on fruit and vegetable intake at school and all day
Variable Group Baseline a
Follow-up 1 b
Follow-up 2 b
Crude
mean
Adjusted
mean
CI Crude
mean
Adjusted
mean
CI Crude
mean
Adjusted
mean
CI
FV at school
(portions
per day)
Intervention 0.41 0.44 (0.25, 0.63) 0.40 0.37 (0.22, 0.52) 0.23 0.22 (0.06, 0.38)
Control 0.34 0.33 (0.15, 0.51) 0.30 0.31 (0.17, 0.44) 0.34 0.35 (0.20, 0.51)
P-value 0.40 0.53 0.23
FV all day
(portions
per day)
Intervention 2.80 2.82 (2.22, 3.43) 2.25 2.20 (1.80, 2.60) 1.98 1.94 (1.58, 2.30)
Control 2.61 2.56 (1.97, 3.15) 2.10 2.12 (1.73, 2.51) 2.14 2.14 (1.79, 2.50)
P-value 0.51 0.76 0.41
Intervention group n = 190; control group n = 179. a Linear Mixed Model adjusted for gender and school as a random factor nested within condition.
b Linear Mixed Model adjusted for
baseline scores, gender and school as a random factor nested within condition.
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was 3.3 (Table III). The pupils who indicated high
enjoyment of the curriculum showed significant
effect of the intervention, both at Follow-up 1 and
at Follow-up 2, compared with the pupils who
liked the curriculum the least (Table IV).
All six newsletters were reported handed out to
the pupils except for one letter in one school. The
mean score of the newsletter usage scale was 1.5
(Table III). The pupils with high usage of the
newsletters showed significant effect of the inter-
vention, both at Follow-up 1 and at Follow-up 2,
compared with the pupils with low usage of the
newsletters (Table IV).
Parent meetings were held at five of the nine
intervention schools. The pupils at intervention
schools who arranged parent meetings did not
show any greater effect of the intervention com-
pared with pupils at intervention schools not
arranging the parent meeting neither at Follow-up
1 nor at Follow-up 2 (data not shown).
Of the nine intervention schools, four partici-
pated in the School Fruit Programme at both
Follow-up 1 and at Follow-up 2, and of the 10
control schools three participated at Follow-up 1
and five at Follow-up 2. A total of 42 intervention
pupils and 26 control pupils subscribed at Follow-
up 1, and 28 and 46 at Follow-up 2, respectively.
Overall, no large differences in the proportions
of individual subscribers were found between the
intervention group and the control group at Follow-
up 1 (22% versus 15% subscribers) or Follow-up
2 (15% versus 26% subscribers).
Attrition
No statistically significant differences were found
between pupils participating in all three surveys
(n = 369) and pupils not participating in all surveys (n = 81) as regards baseline values of fruit and vegetable intake and psychosocial variables (0.20 <
P > 0.65).
Table II. Effect of the FVMM intervention on potential psychosocial mediators
Variable (items, range) Group Baseline a
Follow-up 1 b
Follow-up 2 b
Crude
mean
Adjusted
mean
CI Crude
mean
Adjusted
mean
CI Crude
mean
Adjusted
mean
CI
Accessibility at home
(five items, �10/10) Intervention 4.0 4.0 (3.2, 4.8) 4.6 4.5 (4.1, 5.0) 4.9 4.9 (4.2, 5.5)
Control 3.7 3.6 (2.9, 4.4) 4.5 4.5 (4.1, 5.0) 5.1 5.0 (4.4, 5.7)
P-value 0.49 0.99 0.67 Modelling (four
items, �8/8) Intervention 1.9 2.0 (1.3, 2.7) 2.2 2.2 (1.5, 2.9) 1.7 1.7 (1.2, 2.3)
Control 1.9 1.9 (1.2, 2.5) 2.2 2.1 (1.5, 2.8) 1.6 1.6 (1.2, 2.1)
P-value 0.79 0.96 0.84 Intention to eat
five-a-day
(one item, �2/2)
Intervention 0.1 0.2 (�0.1, 0.4) 0.5 0.5 (0.3, 0.6) 0.3 0.3 (0.1, 0.5) Control 0.3 0.2 (0.0, 0.5) 0.4 0.3 (0.1, 0.5) 0.5 0.4 (0.3, 0.6)
P-value 0.64 0.24 0.28
Preferences (four
items, �8/8) Intervention 2.5 2.5 (1.8, 3.1) 2.3 2.4 (1.9, 2.9) 2.1 2.1 (1.4, 2.9)
Control 2.8 2.7 (2.1, 3.4) 2.9 2.8 (2.3, 3.3) 2.7 2.6 (1.9, 3.4)
P-value 0.56 0.31 0.36
Self-Efficacy to eat
five-a-day
(three items, �6/6)
Intervention 0.1 0.1 (�0.3, 0.5) 0.5 0.5 (0.1, 0.9) 0.5 0.5 (0.1, 1.0) Control 0.2 0.2 (�0.3, 0.6) 0.7 0.6 (0.2, 1.0) 0.9 0.8 (0.4, 1.3) P-value 0.88 0.60 0.31
Awareness of
five-a-day
(one item, 0/6)
Intervention 3.4 3.4 (3.1, 3.8) 4.0 4.1 (3.8, 4.4) 3.8 3.9 (3.7, 4.1)
Control 3.6 3.6 (3.3, 3.9) 3.4 3.4 (3.2, 3.7) 3.5 3.5 (3.3, 3.7)
P-value 0.57 0.003 0.01
Intervention group n = 190; control group n = 179. a Linear Mixed Model adjusted for gender and school as a random factor nested within condition.
b Linear Mixed Model adjusted for
baseline scores, gender and school as a random factor nested within condition.
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Discussion
The results presented in this paper show that
a school-based randomized intervention, designed
on what we perceived as state-of-the-art interven-
tion strategies, did not have any effect in increasing
school children’s intake of fruit and vegetables.
The intervention consisted of several compo-
nents including education directed at behavioural
change, it was rather extensive (lasted throughout
a whole school year), and it included messages
specifically targeting fruit and vegetable intake—
as several extensive reviews have concluded that
school-based fruit and vegetable interventions
should be in order to be successful [3, 5–7]. An
important point, however, is that most fruit and
vegetable interventions reviewed have not been es-
pecially successful. The five-a-day multi-component
Table III. Descriptives of Curriculum enjoyment and Newsletter usage process-evaluation items and scales within the
intervention group
Range/response alternatives Mean SE
Curriculum enjoyment
1. How did you like the home economics
fruit and vegetable teaching
Very good (2), good (1), less good (�1), bad (�2), did not have such teaching (0)
0.72 0.09
2. Did you like the fruit and vegetable
dishes you made at school?
Most of them (2), some (1), no (�1), we did not made such dishes (0)
1.24 0.06
3. Have you increased your skills in making fruit
and vegetable dishes during this school year?
A lot (2), some (1), no (�1), don’t know (0) 0.69 0.07
4. Has the home economy teaching made you
more positive towards fruit and vegetables?
Much (2), some (1), no (�1), don’t know (0) 0.59 0.08
Scale �5/8 3.25 0.24 Newsletter usage
1. Have you read the newsletters All (2), some (1), none (�1), have not got any newsletters (�1)
0.82 0.08
2. Have you posted the newsletters on the wall
at home
All (2), some (1), none (�1), have not got any newsletters (�1)
0.68 0.09
3. Have you tried any of the recipes at home? All (2), some (1), none (�1), have not got any newsletters (�1)
�0.10 0.08
Scale �3/6 1.39 0.20
Table IV. Effect of Curriculum enjoyment and Newsletter usage on FV all day within the intervention group
Variable Group Baseline a
Follow-up 1 b
Follow-up 2 b
Crude
mean
Adjusted
mean
CI Crude
mean
Adjusted
mean
CI Crude
mean
Adjusted
mean
CI
Curriculum
enjoyment
Low (n = 64) 2.5 2.5 (1.9, 3.2) 1.7 1.8 (1.3, 2.2) 1.5 1.5 (1.1, 2.0)
Medium (n = 47) 2.8 2.8 (2.0, 3.5) 2.2 2.3 (1.7, 2.8) 1.7 1.7 (1.2, 2.2)
High (n = 73) 3.0 3.0 (2.4, 3.6) 2.8 2.7 (2.3, 3.1) 2.5 2.5 (2.1, 2.9) P 0.64 0.01 0.004
Newsletters usage Low (n = 57) 2.3 2.3 (1.6, 3.0) 1.4 1.5 (1.1, 2.0) 1.3 1.3 (0.9, 1.8)
Medium (n = 57) 2.4 2.4 (1.7, 3.1) 1.9 2.0 (1.5, 2.5) 1.5 1.5 (1.0, 1.9) High (n = 58) 3.4 3.4 (2.8, 4.0) 3.2 3.0 (2.6, 3.4) 2.8 2.8 (2.4, 3.2)
P 0.03 <0.001 <0.001
a Linear Mixed Model adjusted for gender.
b Linear Mixed Model adjusted for baseline scores and gender.
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programmes in the United States reported interven-
tion effects in the order of 10–15% [4, 19, 20], an
exception being the High 5 project, which achieved
an effect of 66% on fruit and vegetable intake after
the first year of intervention (follow-up difference
divided by baseline intake) and 39% after the
second year [21]. However, in two separate medi-
ation analyses, the mediators explained each <10%
of the observed increase in fruit and vegetable
intake [22, 23]. Therefore, it is unknown what
caused most of the change in intake and which of
the ‘multi-components’ really did work. The pos-
itive effects of the High 5 intervention was, how-
ever, not confirmed by an observational study
conducted in the school cafeteria [21].
The focus on cognitive and practical barriers to
eating behaviour change has been suggested as
a possible explanation for the limited impact of fruit
and vegetable campaigns [24]. An alternative is an
environmental approach; creating changes in the
children’s food environment as compared with cog-
nitive changes. Few environmental interventions
have, however, been conducted. A recent review
reported only three stand-alone environmental in-
terventions promoting fruit and vegetables in school
settings [25]. All other environmental interventions
reported in this review were parts of larger multi-
component interventions, which did not separately
evaluate the environmental component (i.e. the
High 5 project described above). More recently,
we have shown that, with the same research instru-
ments as used in the present study, increasing the
accessibility of fruit and vegetables at school (fruit
at no parental cost) is effective in increasing school
children’s intake of fruit and vegetables [10, 26].
A major problem with the present intervention is
that it did not increase reported Preferences or
Accessibility at home. Interventions work by me-
diating variables [27], and as the Preferences and
Accessibility at home scales have showed to be the
strongest correlates of fruit and vegetable intake
among Norwegian sixth and seventh graders
(Pearson’s correlation coefficients were 0.45 and
0.44, respectively) [28], they possess the greatest
mediation potential. A positive change in these two
factors would theoretically result in an increased
intake. Previous research suggests that children’s
dislike of foods can be transformed into liking of
foods with repeated tasting or ‘exposure’ to those
foods [23, 29]. Therefore, the taste testing and the
repeated eating of fruit and vegetables were in-
cluded in the curriculum to increase the children’s
preferences. The newsletters were made to stimu-
late the parents to increase availability and acces-
sibility of fruit and vegetables at home. In spite
of the fact that the pupils liked the curriculum and
that several families read the newsletters, it did not
create any changes in the children’s preferences or
perception of the accessibility at home.
The intervention did, however, increase the
pupil’s Awareness of the five-a-day recommenda-
tion. Reynolds and colleagues [23] found that
Awareness (similar scale, but they called it knowl-
edge) was a significant mediator in the High 5
Alabama study (fourth graders), but that it only
explained 9.8% of the increase in fruit and vegeta-
ble intake. In the same study, they found that the
five-a-day Power Plus intervention in Minnesota
did have an effect on both intake and Awareness,
but that the effect in intake not was due to the
increase in Awareness [23]. In the baseline survey
of the FVMM project, Awareness was significantly
correlated with intake (Pearson’s r = 0.25) [28]. Data from the control groups of the FVMM project
showed that seventh graders aware of the recom-
mendation ate on average 2.1 portions per day
compared with 1.6 portions per day for those not
aware (E. Bere, unpublished data). The difference
among aware and not aware parents was greater
than for the pupils (2.7 versus 1.9 portions per day,
respectively, for parents aware and parents not
aware) (unpublished data). The reason why the
observed increase in Awareness in the present
study did not affect any increase in intake could
be that the effect of the intervention was too small
or that the differences in intake between those
aware and those not aware are not large enough.
Due to greater differences between aware and
not aware parents, increasing awareness of the
five-a-day recommendation could be a more
important strategy to increase fruit and vegetable
intake for adults than for children.
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In the present study, the intervention schools
were encouraged to take part in the national School
Fruit Programme. Neither at Follow-up 1 nor at
Follow-up 2 was the subscription rate much higher
in the intervention group than in the control group.
The formal letter to the intervention schools’
principals encouraging them to take part in the
programme clearly did not result in increased
participation in the subscription programme, nor
did the FVMM intervention.
Only one school reported to have implemented all
sessions as planned, and a few schools reported
rather low degrees of implementation. However,
no relations were observed between the degree of
implementation and fruit and vegetable intake. The
intervention was rated as very good by most of the
teachers, and the pupils reported that they enjoyed
it. The usage of the newsletters could, however,
have been better. The pupils who enjoyed the
curriculum the most and the pupils with the highest
usage of the newsletters had a significantly higher
intake of fruit and vegetables compared with those
in the lowest groups at both follow-up surveys. This
indicates that the intervention had an effect for
those who liked it the most and for those who
used the newsletters. These pupils, however, had
a higher fruit and vegetable intake at baseline,
and the intervention seemed to increase the already
existing differences in fruit and vegetable intake.
The strength of the present study is that it is
a school-randomized study [30] including a rather
large number of schools. Sixty-nine percentage of
the eligible pupils participated in all three surveys.
No differences were found between the study
sample (who participated in all three surveys)
and those only participating at baseline, and we do
not believe that this attrition caused any substantial
bias in the results presented.
Conclusion
This paper shows that the FVMM intervention,
based on state-of-the-art intervention strategies re-
commended by several review articles, did not have
any effect in increasing school children’s intake of
fruit and vegetables. The reason probably being that
the intervention did not succeed in changing the
pupils’ preferences for, or the accessibility of, fruit
and vegetables—the two strongest correlates of
children’s fruit and vegetable intake.
Acknowledgements
The authors thank participating pupils and teachers.
This study was funded by the Norwegian Research
Council. The newsletters were developed in col-
laboration with the Norwegian Cancer Society
which also funded this part of the intervention.
References
1. National Nutrition Council. Anbefalinger for økt inntak av frukt og grønnsaker [in Norwegian]. Oslo: National Nutrition Council, 1996.
2. Øverby NC, Andersen LF. Ungkost-2000: Nationwide Dietary Survey Among 4th and 8th Graders in Norway [in Norwegian]. Oslo: Directorate for Health and Social Affairs, Department for Nutrition, 2002.
3. Ciliska D, Miles E, OBrien MA et al. Effectiveness of community-based interventions to increase fruit and vege- table consumption. J Nutr Educ 2000; 32: 341–52.
4. Baranowski T, Davis M, Resnicow K et al. Gimme 5 fruit, juice, and vegetables for fun and health: outcome evaluation. Health Educ Behav 2000; 27: 96–111.
5. Contento I. The effectiveness of nutrition education and implications for nutrition education policy, programs, and research: a review of research. J Nutr Educ 1995; 27: 297–418.
6. Hursti UKK, Sjoden PO. Changing food habits in children and adolescents. Experiences from intervention studies. Scand J Nutr 1997; 41: 102–10.
7. Hoelscher DA, Evans A, Parcel GS, Kelder SH. Designing effective nutrition interventions for adolescents. J Am Diet Assoc 2002; 102: S52–63.
8. Bandura A. Social Foundations for Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall, 1986.
9. Baranowski T, Perry CL, Parcel GS. How individuals, environments, and health behavior interacts: social cognitive theory. In: Glanz K, Lewis FM, Rimer BK (eds). Health Behavior and Health Education: Theory Research, and Practice. San Francisco: Jossey-Bass Publishers, 1997, 153–78.
10. Bere E, Veierød MB, Bjelland M, Klepp KI. Free school fruit–sustained effect 1 year later. Health Educ Res 2005; doi:10.1093/her/cyh063.
11. Klepp K-I, Wilhelmsen BU. Nutrition education in junior- high-schools—incorporating behavior-change strategies
E. Bere et al.
266
D ow
nloaded from https://academ
ic.oup.com /her/article-abstract/21/2/258/672191 by guest on 14 July 2020
into home economics courses. Health Educ Res 1993; 8: 547–54.
12. Klepp K-I, Øygard L, Tell GS, Vellar OD. Twelve year follow-up of a school-based health education programme. Eur J Public Health 1994; 4: 195–200.
13. Lund-Iversen K. 6th Graders Opinions About Fruit and Vegetables [in Norwegian]. Oslo: Institute for Nutrition Research, 2000.
14. The Norwegian Ministry of Education. The Curriculum for the 10-year Compulsory School [in Norwegian]. Oslo: Norwegian Board of Education, 1996.
15. The Norwegian Fruit and Vegetable Marketing Board/ Directorate for Health and Social Affairs, Department for Nutrition. Fruit and Vegetable Subscription in Norway. Available at: http://www.skolefrukt.no. Accessed: August 29, 2005.
16. Blaker B, Aarsland M. Mål og vekt [in Norwegian]. Oslo: The Norwegian National Association for Nutrition and Health, 1989.
17. Andersen LF, Bere E, Kolbjørnsen N, Klepp K-I. Validity and reproducibility of self-reported intake of fruit and vegetable among 6th graders. Eur J Clin Nutr 2004; 28: 771–7.
18. Bere E, Klepp K-I. Reliability and construct validity of parental and self-reported determinants of fruit and vegeta- ble intake among 6th graders. Public Health Nutr 2004; 7: 353–6.
19. Nicklas TA, Johnson CC, Myers L, Farris RP, Cunningham A. Outcomes of a high school program to increase fruit and vegetable consumption: Gimme 5—a fresh nutrition concept for students. J Sch Health 1998; 68: 248–53.
20. Perry CL, Bishop DB, Taylor G et al. Changing fruit and vegetable consumption among children: the 5-a-day power plus program in St Paul, Minnesota. Am J Public Health 1998; 88: 603–9.
21. Reynolds KD, Franklin FA, Binkley D et al. Increasing the fruit and vegetable consumption of fourth-graders: results from the High 5 project. Prev Med 2000; 30: 309–19.
22. Reynolds KD, Yaroch AL, Franklin FA, Maloy J. Testing mediating variables in a school-based nutrition intervention program. Health Psychol 2002; 21: 51–60.
23. Reynolds KD, Bishop DB, Chou C-P, Xie B, Nebeling L, Perry CL. Contrasting mediating variables in two 5-a- day nutrition intervention programs. Prev Med 2004; 39: 882–93.
24. Wardle J, Cooke LJ, Gibson EL, Sapochnik M, Sheiham A, Lawson M. Increasing children’s acceptance of vegetables; a randomized trial of parent-led exposure. Appetite 2003; 40: 155–62.
25. French SA, Staples G. Environmental interventions to promote vegetable and fruit consumption among youth in school settings. Prev Med 2003; 37: 393–610.
26. Bere E, Veierød MB, Klepp K-I. The Norwegian School Fruit Programme: evaluating paid vs. no-cost subscription. Prev Med 2005; 41: 462–70.
27. Baranowski T, Lin LS, Wetter DW, Resnicow K, Hearn MD. Theory as mediating variables: why aren’t community interventions working as desired? Ann Epidemiol 1997; 7: S89–95.
28. Bere E, Klepp K-I. Correlates of fruit and vegetable intake among Norwegian school children: parental and self-reports. Public Health Nutr 2004; 7: 991–8.
29. Birch LL, Fisher JO. Development of eating behaviors among children and adolescents. Pediatrics 1998; 101: 539–49.
30. Murray DM. Design and analysis of group-randomized trials. New York: Oxford University Press, 1998.
Received on January 30, 2004; accepted on September 19, 2005
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ic.oup.com /her/article-abstract/21/2/258/672191 by guest on 14 July 2020
