Background
Availability of FV
Conceptualisation, design and methods
Needs assessment (step 1)
The planning group
Target groups
Target group analysis
Setting
The Danish school system
Outside school hours
Youth schools, recreational junior-and youth clubs
Local sports associations and sports clubs
Project name and visual identity
Programme theory and outcomes
Matrices (step 2)
Behavioural performance objective: | Determinants: | |||
---|---|---|---|---|
Awareness | Knowledge | Attitude | Parental intake | |
Become aware of own FV intake in relation to national recommendations |
Change objective: Assess/evaluate own FV intake |
Change objective: Know the national FV recommendations Know the size of one portion of vegetables |
Change objective: Change perceptions of the importance and relevance of eating FV |
Change objective: Become aware of parents FV intake |
Theoretical methods: Feedback |
Theoretical methods: Information Skills training |
Theoretical methods: Reinforcement |
Theoretical methods: Social comparisons | |
Practical application: Register own FV intake as part of curricular activities (computer tailoring) |
Practical application: Class-based educational activities or schoolchild-parent assignment: How much does a portion weigh? Gain knowledge of Recommendations Weigh FV |
Practical application: Experience immediate positive outcomes of eating FV versus e.g. chocolate Class discussion about immediate benefits of eating FV |
Practical application: Register parents' FV intake as part of homework |
Environmental performance objective: | Determinants: | |||
---|---|---|---|---|
Availability | Accessibility | Taste preferences | Peers/social norms | |
Create a more supporting school environment for eating FV |
Change objective: Provide free FV daily |
Change objectives: Allocate time to intake of FV Provide kitchen tools |
Change objective: Challenge adolescents' taste preferences by exposing them to a variety of FV |
Change objective: Create a pleasant eating environment Change adolescents' perception of appropriate time, settings and situations for eating FV Create role models for eating FV among classmates |
Theoretical methods: Facilitation |
Theoretical methods: Information Facilitation |
Theoretical methods: Information Facilitation |
Theoretical methods: Habit formation Social comparisons Mobilising social networks Modelling | |
Practical application: Free FV programme |
Practical application: Teacher leaflet with ideas for a class- based FV break Provision of a class-kit to all school classes |
Practical application: Ensure variety in the FV delivery (give local FV providers an order list) |
Practical application: Provision of class kit Music Candle lights FV break FV host/duty (peer-led) |
Design of intervention programme (step 3 + 4)
School class Educational strategy |
Pupil work book/teacher manual to monthlyguided classroom activities to be integrated in different school subjects. Main activities: Computer tailoring, statistics on FV intake in school class, how much is a portion?, introduction to the five basic tastes, taste testing of FV, FV research & conference, analysis of commercial for unhealthy food, development of commercial for FV, barriers for eating FV in social situations, FV & the body, FV & the family. | 2 assignments per month (September-May). Certain assignments are compulsory | D: Awareness of own FV intake, knowledge of recommended intake levels, taste preferences, media influence, peer influence, social skills, short term outcome expectations, family influence. P: to modify predisposing factors which hinders or facilitates motivation for change (e.g. knowledge, awareness, attitude, perceptions); to improve children's FV preparation skills; to make children aware of what influences their FV preferences; to enable children to obtain FV in different situations and develop skills to ask for FV in a variety of settings; to make children aware of the importance of FV intake for health and well-being. | Behavioural experiments, skills training, role play, modelling, social comparisons, barrier identification, relapse prevention, consciousness raising, and information processing. |
School class and home Educational strategy |
Boost computer tailoring. Separate tests for fruit and vegetable intake. Tailored feedback. | September (in class), December (at home) and May (in class) | D: Awareness; taste preferences, situational norms. P: to increase children's awareness of recommended intake and own intake; to change children's perceptions of appropriate time, settings and occasions for eating FV; to change taste preferences; to collect process data on use of FV programme. | Self-monitoring of behaviour and feedback, reinforcement, consciousness raising, and taste acquisition theory. |
School class Educational strategy |
Script for FV project week/pupil workbook. Day 1: Set FV goals or make day meal plan with FV, day 2: examine access to FV at home and in local area, day 3: Visit supermarket and make a dish with V, day 4: Boost journalist for a day (interview peers about eating habits), and day 5: Self-evaluation of meeting FV goals/meal plan and school event with parents in the evening. | One week e.g. in October/November. Two days of the programme are compulsory for schools | D: Self-efficacy, situational norms, perceived FV availability, shopping skills, FV preparation skills, parental- and peer influence. P: to modify predisposing factors which hinders or facilitates motivation for change (e.g. knowledge, awareness, attitude, perceptions); to improve children's skills. | Specific goal setting, review of behavioural goals, planning, social comparisons, skills training, information seeking of FV access. |
School Educational Strategy (training of staff) |
One-day-workshop for year 7 teachers: 1. Information on rationale for Boost and intervention components. 2. How to integrate FV in schools (FV breaks and hands-on teaching). 3. Cooking activities with cook. 4. Teacher feedback on 1st draft of Boost educational material. | Before intervention start (April 2010) | D: Knowledge, attitude, skills for preparing FV snacks. P: to establish motivation and create a receptive environment; to ensure the programme is feasible and acceptable to the teachers and do not increase their workload; to provide inspiration for FV breaks; to facilitate teacher network. Formative research: teacher feedback on preliminary drafts of educational material. | Skills training, prompt identification as role model and social support. Social comparisons. Reinforcement. |
School class Educational strategy |
3 competitions for pupils from intervention schools based on curricular activities (Prize: money for school class): 1) Best FV commercial or FV research poster, 2) best map of access to FV in local area, 3) nomination of 3 favourite FVs and 3 least favourite FVs. Boost posters for school and classrooms of year 7 pupils. | Distributed in January 2011 (Spring term). Deadlines: Feb/March and April/May2011 | D: Attitude. P: to enthuse children to stay motivated; to create sustained project support. Midterm reminder of curricular component. | Reinforcement, cues/reminders. |
School/home Educational and environmental strategy |
Parent-school meeting: information on Boost/launch of the intervention. | Visit by Boost project group in August/September 2010 | D: Parental support, parental knowledge, parental attitude. P: to inform parents about the intervention; to establish motivation and create a receptive environment; to make parents understand the value/benefits of the intervention; to create parental support towards intervention goals; to create awareness about recommended intake levels for 13- year-olds and actual intake levels among Danish teenagers. To prompt parents to support their children in eating more FV. | Prompt social support, and consciousness raising. |
School/home Educational and environmental strategy |
Parent event as part of project week
| One day during project week e.g. in October or November | D: Social norms, social support. P: to create parental support. | Prompt social support |
Home Educational and environmental strategy |
Guided pupil-parent activities as part of pupil workbook: examine access to FV at home, examine parents' and siblings' FV taste preferences and monitor parents' intake of FV during one week. | 2 assignments during September-June | D: Home availability, family taste preferences, family FV intake, awareness. P: to make children aware of what influences their FV preferences, to prompt children to find FV at home; to make parents aware of own behaviour. | Prompt social support, consciousness raising, environmental change. |
Home Educational and environmental strategy |
Parental newsletters: FV snacks, FV throughout the day, FV & sport, barriers for serving FV, acquired taste & taste prejudices, tips to continuance of FV school programmes after funding exceeds, preservation and storage of FV, saving time and money when shopping FV, recipes on quick simplemeals with FV. | 6 issues: October, November, January, Marts, April, May | D: Parental facilitation, parental knowledge, attitude, modelling, situational norms, accessibility, perceived parental barriers (perceived affordability, satiety value, preparation methods, time), modelling. P: to make parents aware of own behaviour and act as role models by eating FV with children; to prompt parents to increase availability/accessibility to FV at home; to prompt parents to make FV easy accessible (ready-to-eat) for their children; to prompt parents to provide their children with FV to bring to school. | Prompt identification as role model, social support, barrier identification, and environmental change. |
Local community/school Educational strategy |
Guided pupil visits in grocery stores in school neighbourhood (pupil workbook). | One day during project week e.g. in October or November | D: Knowledge, media influence, perceived FVavailability, shopping skills. P: to make children aware of how grocery stores try to influence what people purchase, to modify predisposing factors which hinder or facilitate motivation for change (e.g. knowledge, awareness, attitude, perceptions) as well as skills for shopping FV. | Prompt barrier identification, skills training |
Local community/school Educational strategy |
Create a map on where to find FV in school neighbourhood (pupil workbook). | One day during project week e.g. in October or November | D: Perceived FV availability, skills. P: to modify predisposing factors which hinder or facilitate motivation for change (perceptions); to make children identify different places where they can get FV. | Prompt barrier identification |
Local community: sports clubs Educational and environmental strategy |
Facts sheets to coaches and managers of sport clubs: 1) How to increase children's access to FV during sport (e.g. during practices, competitions, all- day events), 2) to teach children the importance of healthy food when being physical active and 3) to be aware of the coach's status as a role model for eating behaviours. | January (to be implemented in the spring term) | D: Availability, social support, modelling, attitude. P: to increase children's access to FV in leisure time, to encourage sports coaches to be role models. | Provide information about behaviour- health link. Facilitation. Prompt identification as role model, social support, and environmental change |
Local community: youth clubs Educational and environmental strategy |
Facts sheets to managers of youth clubs: 1) Tips to increase children's access to FV in leisure time (e.g. offering FV snacks, providing recipes with FV), and 2) to teach children the importance of healthy food. | January (to be implemented in the spring term) | D: Availability, social support, knowledge, attitude. P: to increase children's access to FV in leisure time. | Provide information about behaviour- health link. Facilitation. Prompt social support and environmental change |
Local community/home/leisure time: Educational and environmental strategy |
Newsletter to parents: tips on healthy, nutritious snacks and beverages for sporty teenagers. Information about recommendations. | January 2011 | D: Home facilitated leisure time availability, parental support, parental knowledge, situational norms, and accessibility. P: to prompt parents to provide their children with FV to bring to leisure time activities; to make FV a natural part of leisure time activities. | Provide information about behaviour- health link. Prompt social support and environmental change. Facilitation. Mobilising social networks. |
Local community: Educational and environmental strategy |
Boost poster for local providers of FV and participating sports- and youth clubs. | Distributed in January 2011 (Spring term) | D: Attitude, norms, awareness. P: to create project support; to promote social responsibility image of involved partners. Midterm reminder. | Cues/reminders |
School component
One-day workshop for teachers
School availability of FV
A pleasant and enjoyable eating environment
Boost classroom curricular activities
Development of written teaching material
Computer tailored feedback
Development of Computer tailoring
Home component
Parent school meetings
Parental newsletters
School event
Teenager-parent assignments
Local community component
Availability in local area
Availability of FV in sports-and youth clubs
Considerations of at risk groups
Control group
Adoption, implementation and sustainability (step 5)
Adoption
Recruitment of schools
Recruitment of FV providers and fundraising
Adoption among teachers and parents
Recruitment of sports-and youth clubs
Planning for implementation and sustainability
Planning for adoption and dose received among teenagers
Evaluation design (step 6)
Trial registration
Power calculations
Study design, sampling, selection criteria, recruitment, and randomisation
Effect-evaluation
Questionnaires
Concepts | Operationalization/definition | Pupil Parent Principal | Teacher (PE)* | Observations/photos | Local provider (PE)* | Manager youth club* | Manager sports club* | Coach sports club* | FG* (PE) | CT* (PE) | ||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Distal outcome**:
| ||||||||||||
Adolescents' FV intake (amount) | 24-hour recall questionnaire (converted to grams per day) | X | ||||||||||
Adolescents' usual FV intake | FFQ | X | ||||||||||
Proximal outcomes**:
| ||||||||||||
ENVIRONMENTAL DETERMINANTS | ||||||||||||
Actual and perceived availability: | Covered dimensions: quantity, variety, quality, appearance, accessibility, convenience, parental facilitation, visibility, time for eating FV, access to unhealthy food | |||||||||||
at school
| (see dimensions above) | X | X | X | X | X | X | X | X | |||
at home
| (see dimensions above) | X | X | |||||||||
in the leisure time
| (see dimensions above) | X | X | X | X | X | ||||||
in the (school-) neighbourhood
| (see dimensions above) | X | X | X | X | |||||||
SOCIAL DETERMINANTS | ||||||||||||
Social norms: situational norms | Number of meals, situations, occasions and settings perceived as appropriate for eating FV | X | X | |||||||||
Parental influence
| ||||||||||||
Dietary knowledge | Knowledge of national FV recommendations | X | ||||||||||
Attitude | Perceived importance of child eating FV | X | ||||||||||
Actual and perceived FV intake | FFQ/24-hour recall questionnaire similar to distal outcome | X | X | |||||||||
Usual intake of unhealthy food | Intake of soft drinks, sweets and salty snacks (FFQ) | X | ||||||||||
Modelling | If parents are eating FV together with children | X | X | |||||||||
Perceived barriers | Access, time, money, convenience, preparation skills | X | ||||||||||
Peer influence
| ||||||||||||
FV intake | If best friends are eating FV | X | ||||||||||
Social norms: peer norms | If it is 'cool' to eat FV in school class. If the majority of peers are eating FV in school and in the leisure time | X | X | |||||||||
Teacher influence
| ||||||||||||
Modelling | How often teachers eat delivered FV together with pupils | X | X | |||||||||
Attitude | Perceived importance of promoting healthy eating in school | X | X | |||||||||
Sport coach influence
| ||||||||||||
Modelling | If sports coaches are eating FV during practice | X | ||||||||||
Attitude | Perceived importance of children eating FV during practice | X | ||||||||||
Proximal outcomes**:
| ||||||||||||
PERSONAL DETERMINANTS | ||||||||||||
Taste preferences | Liking of FV and number of different FV liked | X | X | |||||||||
Dietary knowledge | Knowledge of national FV recommendations | X | ||||||||||
Awareness | Awareness of whether they meet national recommendations | X | X | |||||||||
Short term outcome expectations | Perceived immediate effects of eating FV: e.g. more energy, feel better, FV not filling enough, FV allergy | X | ||||||||||
Potential positive side effects:
| X | |||||||||||
More energy | Loss of energy during the school day | X | X | X | ||||||||
School concentration | Unable to concentrate during class lessons | X | X | X | ||||||||
Wellbeing | Children's level of life satisfaction, if they most of the time are feeling well and full of energy | X | X | |||||||||
Usual intake of unhealthy food | Intake of soft drinks, sweets and salty snacks (FFQ) | X | ||||||||||
School: environmental changes | Nutrition policies, FV programme, food availability | X | X | |||||||||
Unintended adverse outcome:
| X | |||||||||||
Bullying | How often they have been bullied at school in the past couple of months | X | ||||||||||
Weight- and eating related teasing | If class mates are teasing each other because of weight, lunch bags or eating habits | X | ||||||||||
School class thriving | If pupils in their class enjoy being together | X | ||||||||||
Free FV replace FV eaten at other times of the day** | Eating less FV at home (24-hour recall questionnaire). Fewer children bringing FV to school from home | X | X | X | ||||||||
Moderators:
| ||||||||||||
Socioeconomic position | Parent occupational social class | X | X | |||||||||
Socioeconomic position | Parental education | X | ||||||||||
Gender | Boys and girls | X | ||||||||||
Implementation degree | Dose delivered/received, fidelity: adherence to protocol | X | X | X | X | X | X | X | X | X | X | X |
Measures
Proximal outcomes of the intervention: Changes in determinants
Planned statistical effect analyses
Baseline data collection
Response rates and characteristics of pupils at baseline
Intervention sample (N = 1,121) | Control sample (N = 1,035) | ||||
---|---|---|---|---|---|
Sociodemographics | Percentage (N) of pupils reporting the given characteristic | N Missing | Percentage (N) of pupils reporting the given characteristic | N Missing | P-value from chi-square test or t-test |
Boys | 51.8% (581) | 0 | 51.9% (537) | 0 | p = 0.980 |
Mother is unemployed* | 12.0% (134) | 6 | 10.5% (108) | 1 | p = 0.169 |
Father is unemployed* | 6.8% (73) | 6 | 5.3% (53) | 1 | p = 0.237 |
Mothers' SEP* | 26.7% (295) | 6 | 27.9% (286) | 2 | p = 0.198 |
High (I + II) | 26.7% (295) | 29.9% (307) | |||
Medium (III + IV) | 23.9% (264) | 21.8% (223) | |||
Low (V + 7) | 22.7% (251) | 20.4% (209) | |||
Other (6 + 8) | |||||
Fathers' SEP* | 20.1% (218) | 6 | 18.9% (189) | 2 | p = 0.319 |
High (I + II) | 37.8% (411) | 41.4% (415) | |||
Medium (III + IV) | 18.9% (205) | 16.7% (167) | |||
Low (V + 7) | 23.2% (252) | 23.0% (230) | |||
Other (6 + 8) | |||||
Pupil was born in Denmark | 95.1% (1060) | 6 | 95.0% (983) | 0 | p = 0.988 |
Mother was born in Denmark |
83.4% (930)
| 6 |
86.1% (891)
| 0 |
p = 0.035
|
Father was born in Denmark |
84.1% (938)
| 6 |
88.3% (914)
| 0 |
p = 0.006
|
Speaking Danish at home | 95.7% (1068) | 6 | 96.2% (996) | 0 | p = 0.597 |
Primary outcomes
| |||||
Mean FJ intake (SD)** | 232.3 g/day (197.3) | 3 | 226.3 g/day (195.8) | 0 | p = 0.512 |
Mean V intake (SD)** | 129.5 g/day (158.0) | 3 | 142.1 g/day (165.5) | 0 | p = 0.094 |
Mean FJV intake (SD)** | 361.8 g/day (262.4) | 3 | 368.4 g/day (262.7) | 0 | p = 0.588 |
Meeting WHO guidelines of eating ≥ 400 g of FJV daily (24-hour recall)** | 40.7% (395) | 3 | 43.5% (395) | 0 | p = 0.818 |
Meeting national guidelines of eating ≥ 600 g of FJV daily (24-hour recall)** | 21.1% (205) | 3 | 22.1% (201) | 0 | p = 0.670 |
Eating F daily (FFQ) | 48.2% (538) | 5 | 48.5% (502) | 0 | p = 0.891 |
Eating raw V daily (FFQ) | 20.3% (227) | 5 | 21.5% (223) | 0 | p = 0.492 |
Eating cooked V daily (FFQ) | 6.3% (70) | 5 | 5.7% (59) | 0 | p = 0.577 |
Intervention sample (N = 1,121) | Control sample (N = 1,035) | ||||
---|---|---|---|---|---|
Percentage (N) of pupils reporting the given characteristic | N Missing | Percentage (N) of pupils reporting the given characteristic | N Missing | P-value from chi-square test | |
School availability of FV
| |||||
Having daily access to F in schools | 50% (558) | 6 | 46.6% (480) | 4 | p = 0.106 |
Having daily access to V in schools | 26.9% (300) | 6 | 27.4% (282) | 4 | p = 0.816 |
Home availability of FV
| |||||
Having daily access to F at home | 46.8% (522) | 6 | 43.4% (448) | 2 | p = 0.109 |
Having daily access to V at home | 53.8% (600) | 6 | 55.8% (576) | 2 | p = 0.365 |
Availability of FV at leisure time activities
| |||||
Always having access to F in at least one sports- or youth club* | 25.6% (232) | 8 | 30.0% (245) | 9 | p = 0.047 |
Always having access to V in at least one sports- or youth club* | 13.0% (118) | 8 | 12.0% (98) | 9 | p = 0.503 |