An Evaluation of the Fruit, Vegetable and Physical Activity Toolbox for Community Educators Presented by Field Research Corporation February 6, 2008

2 Background/Objectives This is a presentation of findings from the evaluation of The Fruit, Vegetable and Physical Activity Toolbox for Community Educators (Toolbox), a multi-component resource designed to assist community based organizations and direct health centers providing health education. The African American Campaign Division of The Network for a Healthy California recently tailored the Toolbox to focus on the health promotion needs of low-income, African American women. The Network contracted with Field Research Corporation (Field) to assist in an evaluation of the Toolbox. To evaluate the effectiveness of the Toolbox, Network staff selected six, one-hour lessons representative of the overall Toolbox: three nutrition lessons, two physical activity lessons, and one community empowerment lesson.

3 Background/Objectives (continued) The study was designed to test the effectiveness of the revised Toolbox when used with this target audience. Specifically, we were looking to see if women exposed to the Toolbox sessions over a six-week period changed their fruit and vegetable consumption, physical activity practice or the psychosocial determinants of the behaviors. Additionally, this study aimed to gather information about Toolbox recruitment and implementation procedures that may impact future strategies for implementing it statewide in California.

4 Methodology Study Design A quasi-experimental design was used for the evaluation; before and after surveys were completed by a sample of women (treatment group) who attended the six one-hour sessions, and a sample of women (control group) who did not receive the intervention. Data were collected using a longitudinal design; the same women completed the pre- and post-surveys, over a six-week period in October and November The pre-survey was administered immediately before the first class. The post-survey was administered directly following the final class. The study was conducted in four cities in California: Sacramento, Oakland, Los Angeles, and Fresno. All participants were given $100 grocery cards at the completion of the post-survey in appreciation for their time. Treatment women also received a $50 American Express Gift card after the third class.

5 Methodology Recruitment The target audience for this study was low income, African American women. At least 75% of the women recruited for participation were at or below 185% of the Federal Poverty Level. Participants were randomly recruited to either the control or treatment group and were not informed that the other was an option. A variety of recruitment methods were utilized including: telephone contact of lists of potentially eligible participants, flier distribution, announcements in programs expected to have a high concentration of eligible candidates, and highly targeted, in-person intercepts at appropriate locations. In total, there were 171 post-surveys completed for the control group, and 156 for the treatment group. The retention rate for women in the treatment section was 84% and 86% for the control group.

6 Methodology Study Participants Women qualified to participate if they were African American, and between the ages of 18 and 54. Women with diabetes, on strict medically prescribed diets, or enrolled in formal weight management programs were ineligible because of potential inability to change fruit and vegetable consumption levels. The same eligibility criteria for the treatment group applied to the control group. Demographic characteristics of women across the two samples were compared; there were no significant differences between the two. This strengthens the validity of study findings.

7 Methodology Analysis Our primary analysis was examining change over time in our main outcome measures within the treatment and control groups. Significance tests were conducted to test for statically significant differences between the pre- and post-survey results. All significance tests were were assessed at the 95% confidence level, a P-value less than or equal to 0.05 is considered statistically significant by this standard. P-values have been provided throughout the report text. The main outcome measures were those assessing knowledge, beliefs, and behaviors related to nutrition, physical activity, and community advocacy. This presentation focuses on the primary outcome measures. There were no trends observed in the data that the intervention had different effects across sub-groups.

8 Methodology Limitations Some sensitization among control group participants may have taken place. It is likely that completing the pre-survey and being enrolled in a nutrition and physical activity study caused women to think about their diet and physical activity level. This may result in a change in the control group’s responses over time, even though they did not receive the targeted intervention. The intervention for this study required women to participate in an hour- long intervention for six consecutive weeks. Therefore it is plausible that, despite efforts to randomize group assignments, women who completed the intervention were more motivated to participate, interested in the study topics, and/or likely to make the targeted behavior changes than women in the control group.

9 Major Study Findings There is strong evidence of effects that the Toolbox session were effective. Across the majority of measures, in all study topics, there were significant changes over time observed among treatment women and no corresponding change among control women.

10 Major Study Findings Knowledge There was evidence of the intervention’s effectiveness on increasing participants’ nutrition and physical activity-related knowledge. On the majority of knowledge-related measures, there was a significant increase over time in the percent of treatment women that correctly answered the question. On the community advocacy knowledge measure, there was no evidence of effects. Only 43% of women were able to correctly identify six steps for community advocacy on the post-test, and there was no significant difference over time in the percent of women who were able to do so.

11 Major Study Findings Beliefs Data indicate that the Toolbox sessions were effective in increasing participants’ beliefs about the importance of healthy eating and physical activity. There were significant increases in the percent of women that strongly agreed with provided statements on all four measures on this topic. After attending the Toolbox sessions, women reported stronger self- efficacy beliefs on all measures related to nutrition and community advocacy. Significant increases over time were observed among the treatment women but not among control women. Results from physical activity-related self-efficacy measures were mixed; there was evidence of effects on three of the five measures in this section.

12 Major Study Findings Behaviors There is strong evidence that the intervention was effective in changing participants targeted health behaviors. There were significant increases in the percent of treatment women eating the recommended number of cups of fruit and vegetables, and getting the recommended amount of physical activity between the pre- and post-surveys. No significant changes were observed over time among the control women.

13 Nutrition Knowledge Recommended amount of fruits and vegetables adults should eat each day for good health

14 Nutrition Knowledge The number of cups equivalent to a handful of fruits and vegetables

15 Nutrition Knowledge Three factors that determine the amount of fruits and vegetables recommended for a person to consume daily

16 Nutrition Knowledge Best ways to help reduce risk of chronic disease

17 Physical Activity Knowledge Recommended amount of moderate-intensity physical activity adults should get daily

18 Physical Activity Knowledge Level of intensity of physical activity that makes you breathe hard and sweat

19 Community Advocacy Knowledge The best steps for advocating for more fruits, vegetables, and physical activity in a community, percent correct

20 Importance of Eating Healthy Percent agreeing that their family’s health will benefit if they serve more fruits and vegetables

21 Importance of Eating Healthy Percent agreeing that they may develop health problems if they do not eat enough fruits and vegetables

22 Importance of Physical Activity Percent agreeing that their family’s health will benefit if they are more physically active

23 Importance of Physical Activity Percent agreeing that they may develop health problems if they are not physically active

24 Self-Efficacy Beliefs About Nutrition Percent confident that they can prepare a healthy recipe that includes at least a ½ cup of fruits or vegetables per serving

25 Self-Efficacy Beliefs About Nutrition Percent confident that they can remember the importance of eating fruits and vegetables when eating away from home

26 Self-Efficacy Beliefs About Nutrition Percent confident that they can buy more fruits next time they shop

27 Self-Efficacy Beliefs About Nutrition Percent confident that they can buy more vegetables next time they shop

28 Self-Efficacy Beliefs About Nutrition Percent confident that they can plan meals or snacks with more fruits

29 Self-Efficacy Beliefs About Nutrition Percent confident that they can plan meals or snacks with more vegetables

30 Self-Efficacy Beliefs About Nutrition Percent confident that they can add more fruits or vegetables as snacks at work

31 Self-Efficacy Beliefs About Nutrition Percent confident that they can find out about how many cups of fruits and vegetables they need every day for good health

32 Self-Efficacy Beliefs About Nutrition Percent confident that they can use the Fruit and Vegetable Scoreboard to help set a goal to meet their recommended amount of fruits and vegetables

33 Self-Efficacy Beliefs About Physical Activity Percent confident that they can use the Physical Activity Scoreboard to create a weekly physical activity routine

34 Self-Efficacy Beliefs About Physical Activity Percent confident that they can apply the principles of exercise safety to their physical activity routine

35 Self-Efficacy Beliefs About Physical Activity Percent confident that they can use walking as a form of physical activity at work

36 Self-Efficacy Beliefs About Physical Activity Percent confident that they can use walking as a form of physical activity at home

37 Self-Efficacy Beliefs About Physical Activity Percent confident that they can find out how many minutes of physical activity they need for good health

38 Self-Efficacy Beliefs About Advocacy Percent confident that they can identify things in their neighborhood that make it difficult to find and eat fruits and vegetables

39 Self-Efficacy Beliefs About Advocacy Percent confident that they can identify at least one way to overcome those things that make it difficult to find and eat more fruits and vegetables

40 Self-Efficacy Beliefs About Advocacy Percent confident that they can talk with people about the things in their community that make it difficult to find and eat more fruits and vegetables

41 Self-Efficacy Beliefs About Advocacy Percent confident that they can identify things in their community that make it difficult for them to be more physically active

42 Self-Efficacy Beliefs About Advocacy Percent confident that they can identify at least one way to overcome those things that make it difficult to be more physically active

43 Self-Efficacy Beliefs About Advocacy Percent confident that they can talk with people about the things in their community that make it difficult to be more physically active

44 Individual Change in Nutrition-Related Behaviors Reported change in the amount of fruit purchased over the past 6 weeks

45 Individual Change in Nutrition-Related Behaviors Reported change in the amount of vegetables purchased over the past 6 weeks

46 Individual Change in Nutrition-Related Behaviors Reported change in the amount of meals or snacks prepared with fruit over the past 6 weeks

47 Individual Change in Nutrition-Related Behaviors Reported change in the amount of meals or snacks prepared with vegetables over the past 6 weeks

48 Individual Change in Nutrition-Related Behaviors Reported change in the number of times fruits or vegetables were ordered as part of a meal or snack while dining out over the past 6 weeks

49 Individual Change in Nutrition-Related Behaviors Reported change in the number of times fruits or vegetables were eaten as a meal or snack at work over the past 6 weeks

50 Individual Change in Nutrition-Related Behaviors Percent of respondents in stages of contemplation regarding eating more fruits

51 Individual Change in Nutrition-Related Behaviors Percent of respondents in stages of contemplation regarding eating more vegetables

52 Individual Change in Physical Activity-Related Behaviors Percent of respondents who were physically active for 5 or more days in the past week

53 Individual Change in Physical Activity-Related Behaviors Percent of respondents who report being physically active for 5 or more days in a usual week

54 Individual Change in Physical Activity-Related Behaviors Percent of respondents in phases of contemplation in regard to being more physically active

55 Conclusions Overwhelmingly, data collected illustrate that the revised Toolbox was effective when used with its target audience, low-income, African American women –There was a significant increase in the percent of women who correctly answered most knowledge questions regarding physical activity and nutrition after participating in the intervention. –Data indicate that the treatment women were more likely to believe that eating fruits and vegetables and being physically active are important for their own health and the health of their families on the post-survey than they were before attending the Toolbox lessons. –Participants in the Toolbox were more likely to display self-efficacy beliefs across all nutrition related and to community advocacy related measures.

56 Conclusions (continued) –There were large increases in the percent of women physically active for at least five days a week after participation in the Toolbox sessions. –There were significant changes over time in the purchasing behaviors, meal and snack preparation, and in the actual consumption of fruits and vegetables by women who attended the Toolbox sessions.

57 Conclusions (continued) There were a few areas in which the intervention seemed to be less effective: –Women were unable to correctly identify the six best steps one should use for advocating for fruits, vegetables and physical activity in their neighborhood. –While there were significant increases in the nutrition knowledge among treatment women, less than half of the women, treatment and control, correctly answered questions about consumption recommendations and serving size on the post-survey. –On a number of the measures of self-efficacy related to physical activity, similar effects were observed among treatment and control women.