Comparison of a 5-a-Day social marketing intervention and school-based curriculum.

Abstract: The purpose of this study was to compare a social marketing campaign to a 5-a-Day curriculum-only intervention, and to no intervention on increasing fruit and vegetable consumption. Researchers developed the intervention based on formative research needs assessment with the target audience. Outcome measures included fruit and vegetable consumption, self-efficacy, asking behaviors, and attitudes toward presentation of fruit and vegetables. Thirteen significant changes from pretest to posttest were noted in the social marketing intervention, and nine significant changes in the curriculum-only intervention. Implications for practice include using multicomponent interventions and incorporating both a cognitive approach and school-based environmental changes.

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The current level of fruit and vegetable consumption in the United States is below recommended levels for both adults and children. Adult consumption levels are estimated between 3.5 and 5.2 servings per day (Johnston, Taylor, & Hampl, 2000; Thompson et al., 1999). Only 20% of children, aged 2-18, and 23.9% of adolescents, grades 9-12, eat five or more servings of fruits and vegetables per day (CDC, 2000; Krebs-Smith et al., 1995).

One promising approach to increasing fruit and vegetable consumption among adults, adolescents, and children is social marketing, defined as "the application of commercial marketing technologies to the analysis, planning, execution, and evaluation of programs designed to influence the voluntary behavior of target audiences in order to improve their personal welfare and that of their society" (Andreasen, 1995, p.7). Social marketing strategies have been used in varying degrees for nearly 30 years in international and domestic settings, their primary intent being to improve health conditions and quality of life in general (Neiger et al., 2001; Schellenberg et al., 2001), however, there is relatively little research documenting whether this consumer-focused, consumer-driven approach is effective among adolescent populations.

The primary objective of this study was to examine the effect of a social marketing campaign on fruit and vegetable consumption among middle-school adolescents compared to a 5-a-Day curriculum intervention and to no intervention. Further, the effect of the interventions on school faculty, and parents of students was examined. The paper outlines for practitioners how social marketing can be applied in a public health setting, and it may serve as a model for other practitioners in implementing social marketing activities.

DESIGN AND IMPLEMENTATION

Design. This study used a quasiexperimental design with repeated measures. The independent variable was type of intervention: social marketing (SM), 5-a-Day curriculum-only (CO), or no-intervention (NI).

The development of the SM intervention was based on results of formative research. Formative research is defined as identifying the wants and needs of the target audience, as well as factors that influence its behavior including benefits, barriers, and readiness to change (Bryant, 1998). Formative research included 100 one-on-one interviews with students and six focus groups with students, parents, faculty, and staff. All interventions resulting from formative research were pretested with the priority population, and revisions were made accordingly.

The research team used the qualitative software Nonnumerical Unstructured Data Indexing Searching and Theorizing (NUD*IST [4.0.sup.a]) to organize the formative research data to write a summary of the findings. These summary reports guided the development of the interventions. A self-scoring checklist was developed to ensure that the research team developed interventions in response to consumer preferences as identified in the formative research. The checklist included 14 statements regarding factors such as the degree to which the research team had read the data report, referred to data in their comments, and made comments in context of the needs and wants of the target audience.

The 8-week SM intervention consisted of school-wide events, communications, and food service modifications in the cafeteria. School-wide events included a kick-off assembly where students were introduced to 5-a-Day, serving sizes, and intervention components; a 4-week contest where students recorded the number of servings of fruit and vegetables they ate; weekly snack breaks during reading period; and an ending cafeteria celebration. Communications included 5-a-Day related fruit and vegetable posters in classrooms, a banner in the cafeteria, messages on an electronic scrolling marquee, announcements over the public address system, and a display in the front hall. Food service modifications included increasing the type and variety of fruits and vegetables served in the cafeteria (e.g., vegetable pizza, grapes, kiwi, etc.), changing how they were displayed (e.g., individual serving containers, serving dip with vegetables, and not offering over-ripe bananas, etc.), and providing disposable food trays that enabled students to carry multiple food items.

Parent-focused interventions occurred at the SM school only, and included communications and one event. Communications included four 5-a-Day newsletters that were mailed home, and a display at the parent-teacher conference. The display contained food samples, 5-a-Day information, recipes, and a 5-a-Day cookbook. Parents who did not attend the conference received the cookbook in the mail. The parent event was a series of four 1-hour cooking classes held at the school once a week for 4 weeks.

The faculty at the SM school participated in the contest to eat more fruit and vegetables. They were also exposed to all the 5-a-Day communications at the school.

At the CO school, students enrolled in seventh-grade health classes during two trimesters (A or B) received a series of four 5-a-Day lessons taught by the health teacher. The four-lesson limit was a directive from the school district. The content of the lessons included serving sizes, positive effects of eating five fruits and vegetables, goal setting, barriers, strategies to overcome barriers, strategies to include more fruit and vegetables in the diet, personal assessment of intake, and comparing intake to recommended levels. There were no interventions for the faculty or parents at this school.

Recruitment and Sampling. Three middle schools (7th-8th grade) within a large, metropolitan, inner-city school district were selected for participation. A convenience sample was used to allow researchers greater flexibility in selecting schools composed of ethnically diverse and low-income students and families (criteria required by the Centers for Disease Control and Prevention, which funded the study). Therefore, the participating schools were matched initially, by ethnic composition and socioeconomic status (i.e., percent of students eligible for free and reduced lunch), and assignment to treatment condition was made prior to pretesting.

A random sample, stratified by grade and gender, of students from both the SM school (N = 177) and NI school (N = 165) were selected to complete a pre-post survey; the CO school sample included all students who were enrolled in health classes during either trimester A or B, and were present on the day the pretest was administered. The sample size was selected based on a power calculation for a sign test (alpha .05, 2-tailed, .80 power) (SamplePower 1.0, 1997). The sample was nearly equal for gender and the mean age was 13.01 years. Retention rates ranged from 87% to 93%.

A convenience sample of parents from each school was selected to participate in a pre-post telephone survey (SM: N = 110; CO: N = 103; NI: N = 101). The schools would not provide a list of telephone numbers of parents; therefore the research firm who conducted the survey purchased a sample from a vendor (a standard procedure in survey research).

All faculty at each school were asked to complete a pre-post paper-and-pencil survey on a voluntary basis (SM: N = 22; CO: N = 16; NI: N = 21). The response rate was 50% to 57%. The school district prohibited the collection of demographic and socioeconomic data for any of the study participants, including faculty and parents.

Instruments. Student fruit and vegetable consumption was measured with items from the Youth/ Adolescent Food Frequency Questionnaire (Rockett, Wolf, & Colditz, 1995). Self-efficacy was measured by a four-item scale (Beech, Rice, Myers, Johnson, & Nicklas, 1999), Cronbach a = .93 (C. Johnson, personal communication, January, 2000). The research team's addition of one item to the self-efficacy scale (i.e., self-efficacy for eating fruit and vegetables at school), resulted in a five-item scale, a = .60. Asking behaviors (e.g., asking to have fruit or vegetables for snacks, writing fruit, fruit juice, or vegetables on the shopping list) were measured by a ten-item scale, a=.84 (Perry et al., 1998). Two items, including frequency of asking a parent to buy fruit or vegetables at the grocery store, were added by the researchers after the questionnaire was pilot tested. Internal consistency for the new scale was a = .87.

The research team developed a scale to assess presentation of fruit and vegetables offered in the cafeteria. This represented student perceptions of whether or not fruit and vegetables were fresh and clean, a factor identified as a barrier to consumption by students during the formative research, and also cited in the literature (Neumark-Sztainer, Story, Perry, & Casey, 1999), a = .90. Knowledge of the recommended number of servings for fruit and vegetables was measured by one question (Perry et al., 1998). The research team created two questions to determine frequency of choosing fruit or vegetables at lunch.

Parent and faculty fruit and vegetable consumption, self-efficacy, and knowledge of 5-a-Day were measured using questions developed by the National Cancer Institute (NCI). Fruit and vegetable consumption was measured with a 7-item food frequency questionnaire. Psychometrics on these scales are not currently available; however, they have been used in NCI 5-a-Day research studies (Hunt et al., 1998; Thompson et al., 1999). Five questions measured parent attitudes and behavior related to fruit and vegetable consumption (Perry et al., 1998).

Data collection. A pretest survey was completed by students at the SM and NI schools, and faculty and parents at each of the three study schools two weeks prior to the beginning of the interventions. Posttests for each study group were completed one month after the interventions concluded. Students in the CO school completed the pretest prior to the curriculum being taught, and completed a posttest one month after instruction concluded. The data were collected using participant self-report.

Statistical analysis. Nonparametric tests were selected because the data represented the ordinal level of measurement. Specific tests included Kruskal-Wallis one-way analysis of variance, Wilcoxon signed rank, Mann-Whitney U, Mann-Whitney, McNemar, Fisher's exact, and Spearman's rank-order. The Holms stepdown procedure (Pett, 1997) for post hoc comparisons was used to adjust for inflated type I error when comparing results between study groups. The median was reported as the measure of central tendency. All study results presented in this paper report the change in the median score from pre- to posttest. Because the Wilcoxon signed rank test and Mann Whitney test use sum of ranks and mean ranks to calculate the test statistic, there can be a significant change from pre- to posttest while there is no change in the median value.

At the CO school, the health teacher modified her presentation of the curriculum from trimester A to B. Although the content remained the same, how she presented the concepts varied as her comfort level with the material increased. Therefore, because both trimesters did not receive the exact same curricula intervention, the data from each trimester were analyzed separately.

PROGRAM OUTCOMES

Student Differences Between Study Groups. There was one significant difference from pre- to posttest among students between the study groups: for students choosing fruit at lunch ([c.sup.2.sub.k-w] = 12.562, p = .006). Post hoc analysis indicated that from pre- to posttest the SM group reported choosing fruit at lunch more often (Md = 3.0) than CO group trimester B (Md = 2.0) (z = -3.229, p = .001). Additionally, the CO group trimester A chose fruit more often (Md = 3.0) than trimester B (Md = 2.0) (z = -2.898, p = .004), and the NI group chose fruit more often (Md = 2.0) than the CO group trimester B (Md = 2.0) (z = -2.914, p = .004).

Student Behavioral Differences Within Study Groups. Within group analysis revealed that change in fruit and vegetable consumption was only seen in the CO group trimester A. Specifically, significant differences were found with respect to consumption of fruit (Table 1).

Student Psychosocial Differences Within Study Groups. Students in the CO group trimester A significantly increased their median score for asking behavior related to fruit and vegetables overall from pretest (Md = 3.1) to posttest (Md = 3.2) (p = .035), and for fruit-only, from pretest (Md = 3.4) to posttest (Md = 3.6) (p = .037). Students at the NI school significantly increased their median score in two areas of asking behaviors: total score for fruit and vegetables from pretest (Md = 2.65) to posttest (Md = 2.80) (p = .02), and total score for vegetables only from pretest (Md = 2.2) to posttest (Md = 2.4) (p = .035).

The SM intervention was effective at increasing the percentage of students who knew the recommended number of servings of fruit and vegetables a person should eat each day from 22.2% at pretest to 44.1% at posttest (p = .000). Additionally, the CO intervention was effective at significantly increasing knowledge of the number of recommended servings of fruit and vegetables in trimester A from 35% at pretest to 61.7% at posttest (p = .001), but not in trimester B (pretest = 41.9%, posttest = 52.4%) (p = .099).

In the CO group, the self-efficacy total score was significantly lower from pretest (Md = 2.8) to posttest (Md = 2.4) for trimester A (p = .04) and for trimester B from pretest (Md = 2.8) to posttest (Md = 2.4) (p = .009).

In the SM group, there was a non-significant increase in the median score for overall fruit and vegetable presentation in the cafeteria from pretest (Md = 3.0) to posttest (Md = 3.25) (p = .067). In the CO group trimester B, and the NI group there was a significant increase in the median score for overall fruit and vegetable presentation in the cafeteria from pretest (Md = 3.0; Md = 3.0) to posttest (Md = 3.25; Md = 3.0) (p = .005; p = .004).

Parent Behavioral Differences Within Study Groups. Within the SM group there was a significant difference from pre- to posttest in the median score for the number of servings of fruit and vegetables consumed by parents, as measured by responses to the food frequency questionnaire (Table 2). Additionally, within the SM group, there was a significant difference in the median score for the number of servings of fruit consumed by parents on a daily basis from pretest (Md = 1.0) to posttest (Md = 2.0) (p = .013). In the CO group, there was a significant difference in the servings of vegetables consumed each day from pretest (Md = 1.0) to posttest (Md = 1.0) (p = .039). Additionally, parents in the SM group perceived they consumed more fruit and vegetables from pre- (Md = 3.0) to posttest (Md = 4.0) (p =.002) (e.g., thinking about all of the fruits and vegetables you eat, including juices, salads, and potatoes, on average how many servings of fruits and vegetables do you eat each day?).

Parent Psychosocial Differences Within Study Groups. Among parents in the SM group, there was a significant difference from pretest (Md = 5.0) to posttest (Md = 5.0) for self-efficacy for eating three servings of fruit and vegetables a day (p = .025), but not for five servings (Md = 3.0, 4.0) (p = .051). Results indicate that at posttest, parents felt very sure in their ability to eat the recommended servings of fruit and vegetables daily.

Parents in the SM group reported significant differences in two attitudes from pre- to posttest: increased agreement with the statement that fruit and vegetables are too hard to prepare (Md 1.0, 1.0) (p = .001) and decreased agreement with the statement that they prefer to eat foods other than fruit and vegetables (Md = 3.0, 2.0) (p = .015). Data from parents in the NI group also indicate an increased agreement in the belief that fruit and vegetables are too hard to prepare (Md = 1.0, 1.0) (p = .001) and in the importance of their child eating fruit and vegetables daily (Md = 10.0, 10.0) (p = .004).

Among parents in the SM group, results indicate three significant differences between pre- and posttest for parent behavior related to serving fruit and vegetables. These included serving fruit with dinner (Md = 2.0, 3.0) (p = .008), serving vegetables with dinner (Md = 4.0, 4.0) (p = .009), and serving fruit, fruit juice, or vegetables as a snack (Md = 3.0, 4.0) (p = .012). Among parents in the NI group serving fruit with dinner (Md = 3.0, 3.0) (p = .010) and fruit, fruit juice, or vegetables as a snack (Md = 3.0, 4.0) (p = .004) were also significant.

A significant difference was found among parents concerning knowledge of how many servings of fruit and vegetables a person should eat each day in the SM group (pretest = 45.8%, posttest = 68.6%) (p = .002) and the CO group (pretest = 61.2%, posttest = 76.6%) (p = .036).

Faculty Behavioral Differences Between Study Groups. There were significant differences in median changes between study groups with regard to self-efficacy for eating five servings of fruit and vegetables ([c.sup.2.sub.k-w = 5.976, p = .050). Post hoc analysis indicated that at posttest faculty in the SM group reported higher self-efficacy (Md = 5.0) than the faculty in the NI group (Md = 4.0) (p = .013).

Faculty Behavioral and Psychosocial Differences Within Study Groups. Within the study groups, there was no significant increase in median score for the actual number of servings of fruit and vegetables consumed, as measured by the food frequency questionnaire, or for self-efficacy for eating recommended servings of fruit and vegetables.

DISCUSSION

Results suggest that the impact of the intervention, either social marketing or classroom curriculum, on fruit and vegetable consumption was limited. The marginal effect on overall consumption may be explained by any of several factors that affect eating patterns, including individual, environmental, and behavioral influences (Perry, Lytle & Kelder, 1994, as cited in Story & Neumark-Sztainer, 1996). The curriculum-only intervention addressed individual factors (e.g., self-efficacy, knowledge) and behavioral factors (e.g., skills) but did not address the environmental aspect (e.g., access, availability). In contrast, the social marketing intervention addressed environmental factors, but was limited in addressing individual factors, and did not include behavioral factors. Studies showing an increase in fruit and vegetable consumption among high-school-aged adolescents (Nicklas, Johnson, Myers, Farris, & Cunningham, 1998) and elementary-school-age children (Perry et al., 1998), have involved multiple components.

Changes in student asking behaviors were seen in both the CO group trimester A and NI group. The changes seen in the CO group could be due to the fact that the curriculum emphasized goal setting, barriers to eating fruit and vegetables, and strategies to overcome barriers and include more fruit and vegetables in the diet. These results are similar to those reported by Baranowski et al. (2000) who found that, after a classroom-based curriculum for fourth- and fifth-grade students, asking behaviors were significantly different.

While students in both the SM group and CO groups demonstrated change from pre- to post-intervention, more changes overall were seen within the CO group, particularly trimester A. One possible reason for these findings is that the CO intervention was focused with a captive audience, while the SM intervention was school-wide with broad environmental changes and communications. One key factor is that both approaches resulted in increased knowledge of the appropriate number of servings of fruit and vegetables a person should eat. The changes seen within trimester A as compared to trimester B may be attributable to the fact that the teacher's presentation style and application of material varied from trimester A to B.

There were a number of significant changes among parents in the SM group. Parents reported a significant increase in consumption of fruit and vegetables, fruit-only, perception of how many servings of fruit and vegetables they ate, self-efficacy for eating three servings of fruit and vegetables, and knowledge of the recommended number of servings of fruit and vegetables a person should eat each day. In the SM group, specific intervention components and communications were designed exclusively for parents. These interventions were developed in response to factors identified by parents during the formative research that were both facilitators and barriers to fruit and vegetable consumption. The increase in awareness could be explained by the fact that the parents were potentially exposed at least six times to the 5-a-Day message. Parents in the CO group also increased awareness about the recommended servings of fruit and vegetables daily. One explanation for the change in awareness among parents in the CO group could be that the parents in this group had a child in the health classes, and perhaps the message was transferred to the parents.

Availability of fruit and vegetables at home has been reported as a factor in fruit and vegetable consumption (Corwin, Sargent, Rheaume, & Saunders, 1999; Hearn et al., 1998). In the present study, parents reported serving fruit for dinner four to six times per week and serving vegetables for dinner and fruit, fruit juice, or vegetables as snacks every day. From pre- to posttest, the SM group parents reported significant differences in serving fruit at dinner, vegetables at dinner, and fruit, fruit juice, or vegetables as a snack. This is in contrast to the literature by Perry et al. (1998) that reported no change in parent behavior. The NI group also reported increase of frequency of serving fruit at dinner, and fruit and vegetables as a snack. One possible explanation for this could be that barriers were reduced as availability and variety of fruit and vegetables increased with the season. It has been reported that adults eat more fruit and vegetables in the summer, or when in season (Uetrecht, Greenberg, Dwyer, Sutherland & Tobin, 1999).

There was no increase in fruit and vegetable consumption for faculty in any of the three study groups. These results are both similar to and in contrast to the two 5-a-Day studies that reported the impact of a school-based intervention on faculty. Story et al. (2000) found that faculty who had taught a nutrition curriculum in their classroom reported that their consumption of fruit and vegetables was higher than usual. Resnicow et al. (1998) reported that a combination of a classroom curriculum and an employee wellness program had no impact on either student or teacher outcomes.

The use of convenience samples reduces the ability to generalize findings to all ethnically diverse and low-income populations, as well as middle-school students. However, non-probability samples are generally acceptable when the study of relationships among variables is more important, as in this study, than describing a population in general (Cozby, 1997). Both intervention groups completed a posttest one month after the conclusion of the intervention. The curriculum-only intervention was shorter, as a result of the four-lesson limit mandated by the school district. But this duration is supported by Contento et al. (1995) who reported a median value of three hours for school-based nutrition education. Because of the difference in lengths of intervention, the elapsed time between the pretest and posttest was shorter for the CO groups compared to the SM group and NI groups. Finally, all measures were self-report and subject to bias. Although this does not represent a phenomenon unseen in most field research that relies on voluntary participation, it does represent a limitation. This bias is reduced when valid and reliable scales are used as in this study.

CONCLUSION

While changes in overall fruit and vegetable consumption among students was limited to choosing more fruit at lunch, 13 significant changes were noted in the SM intervention and 9 significant changes were detected in the CO intervention among students, parents, and teachers. In general, a multicomponent intervention that is based on social marketing principles, and that combines cognitive approaches with environmental changes may potentially be most effective in changing fruit and vegetable consumption among adolescents, though not tested in this intervention. Even a well-designed social marketing intervention that focuses almost exclusively on environmental changes to support healthy behaviors may not accomplish the same degree of change without this cognitive element (i.e., specifically addressing servings and serving sizes, how to consume adequate servings, and how to reduce barriers).

Two primary implications for health education have been identified. The first is the need for multicomponent interventions. An impact on behavior and knowledge was seen in both schools where an intervention occurred. The results could perhaps be more significant if a classroom curriculum and environmental and policy changes are included in the same intervention. This multicomponent approach is supported by research that indicates that several factors influence dietary behavior, including personal and environmental elements (Ciliska, Miles & O'Brien, 2000; Domel et al., 1996; Resnicow et al., 1997). The results of the present study suggest that, to affect fruit and vegetable consumption among middle-school adolescents, a combination of classroom education and environmental changes may be needed.

With the increasing demands placed on schools for improved test scores, particularly in math and reading, other curricula, including nutrition education, compete for time (Story & Neumark-Sztainer, 1996). However, school is the primary setting for students to receive nutrition education, and students report schools and teachers as the best source for nutrition information (Borra, Schwartz, Spain, & Natchipolsky, 1995). Decreasing barriers, including the need to increase the availability and accessibility of fruit and vegetables, may not by themselves increase consumption. Understanding that five servings each day are needed and why eating fruit and vegetables is also important. Therefore, it is suggested that school-based efforts to address nutrition and dietary behaviors include working within the existing school infrastructure to make environmental and policy changes, provide ongoing communications to support classroom education, allow opportunities for students to practice skills and behaviors, and encourage healthy lifestyles.

The second recommendation is inclusion of secondary priority audiences in nutritional interventions focused on children and adolescents. This study suggests that a school-based intervention influenced a secondary priority audience of parents. Over time, the influence of appropriate secondary priority audiences on primary priority audiences is vital to sustained behavior change (CDC, 1999). Specifically, research has noted the influence of parents, including availability and accessibility of foods in the home, on child and adolescent eating behaviors (Gracey, Stanley, Burke, Corti, & Beilin, 1996; Resnicow et al., 1998).

This study suggests that even though social marketing may be an effective strategy to design appropriate environmental changes related to fruit and vegetable consumption among adolescents, it may be inadequate to sustain significant behavior change independent of cognitive or traditional curricular components. Social marketing principles may also be valuable in raising awareness of 5-a-Day and the consumption of fruit and vegetables among parents and teachers. Health educators should not overlook this type of effect on secondary priority audiences. Combining social marketing-based environmental and communication strategies with curricular approaches that are influenced by social marketing or selected on other merits represents an effective strategy for 5-a-Day improvements among adolescents, their parents, and their teachers.

Table 1. Change in Student Daily Consumption of Fruit and Vegetables.

                      Social Marketing   Curriculum-Only
                      Intervention         Trimester A

Fruit and Vegetables
N                        149                53
Increased rank (%)        51 (34.2)         26 (49.1)
Ties (%)                  44 (29.5)         13 (24.5)
Decreased rank(%)         54 (36.2)         14 (26.4)
Median (pre / post)       3.0 / 3.0         5.0 / 5.0
p                           .986              .055

Fruit Only
N                        163                57
Increased rank(%)         65 (40.0)         30 (52.6)
Ties (%)                  40 (24.5)         13 (22.8)
Decreased rank(%)         58 (35.6)         14 (24.6)
Median (pre / post)       2.0 / 2.0         2.0 / 2.0
p                           .082              .008 *

Vegetables Only
N                        153                56
Increased rank (%)        39 (25.5)         19 (33.9)
Ties (%)                  61 (39.9)         18 (32.1)
Decreased rank (%)        53 (34.6)         19 (33.9)
Median (pre / post)       1.0 / 1.0         2.0 / 2.0
p                          .112              .461

                      Curriculum-Only
                       Trimester B      No-Intervention

Fruit and Vegetables
N                        91               136
Increased rank (%)       34 (37.4)         55 (40.4)
Ties (%)                 31 (34.1)         26 (19.1)
Decreased rank(%)        26 (28.6)         55 (40.4)
Median (pre / post)      5.0 / 5.0         4.0 / 4.0
p                          .531              .345

Fruit Only
N                        97               149
Increased rank(%)        37 (38.1)         61 (40.9)
Ties (%)                 28 (28.9)         33 (22.1)
Decreased rank(%)        32 (33.0)         55 (36.9)
Median (pre / post)      2.0 / 2.0         2.0 / 1.0
p                          .496              .094

Vegetables Only
N                        97               147
Increased rank (%)       26 (26.8)         48 (32.7)
Ties (%)                 53 (54.6)         46 (31.3)
Decreased rank (%)       18 (18.6)         53 (36.1)
Median (pre / post)      2.0 / 2.0         2.0 / 1.0
p                          .195              .951

* significant at p <. 05
Note. The scale ranged from 0 to 10 servings per day.

Table 2. Parent Consumption of Fruit and Vegetables as Measured by the
Food Frequency Questionnaire

Group               N    Median   Mann-Whitney     z
Social Marketing
         Pretest   110     2.0       -2.144      .032
        Posttest    88     3.0

 Curriculum-Only
         Pretest   102     3.0       -1.684      .092
        Posttest    76     2.0

 No-Intervention
         Pretest    99     2.0       -.190       .849
        Posttest    92     2.0

Note. Scale: 1 = 1 serving per day, 2 = 2 servings per day, 3 = 3
servings per day, 4 = 4 servings per day 5 = 5 servings per day, 6 = 6
or more servings per day.

Acknowledgment. This publication was supported by Grant/Cooperative Agreement H75/CCH817490-01 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC.

HEALTH EDUCATION RESPONSIBILITY AND COMPETENCY ADDRESSED

Responsibility IV: Evaluating Effectiveness of Health Education Programs

Competency D: Infer implications from findings for future program planning.

Subcompetency 3: Apply findings to refine and maintain programs.

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Rosemary Thackeray, Ph.D., M.P.H., and Brad L. Neiger, Ph.D., CHES are in the Department of Health Science at Brigham Young University. Heather Leonard and Joan Ware, M.S.P.H. are with the Utah Department of Health in Salt Lake City, Utah 84116. Gregory J. Stoddard, M.P.H. is with The University of Utah Hospital. Address correspondence to Rosemary Thackeray, Ph.D., M.P.H., Department of Health Sciences, Brigham Young University, 229B Richards Building, Provo, Utah 84602; PHONE: [phone]; FAX: [phone]; E-MAIL: [e-mail].