Health Promotion International Advance Access originally published online on June 20, 2007
Health Promotion International 2007 22(3):218-226; doi:10.1093/heapro/dam016
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Fresh Kids: the efficacy of a Health Promoting Schools approach to increasing consumption of fruit and water in Australia
Western Region Health Centre, 72-78 Paisley St, Footscray, Victoria 3011, Australia
* Corresponding author. E-mail: sharon.laurence{at}heartfoundation.com.au
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONTHE FRESH KIDS PROGRAMMEMETHODOLOGYRESULTSDISCUSSIONREFERENCES |
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The Fresh Kids programme utilized the Health Promoting Schools (HPSs) framework to design a whole-of-school, multifaceted intervention targeting specific behaviours to promote healthy eating and reduce the risk factors associated with childhood obesity. The aim of the programme was to evaluate the effectiveness of the HPS framework to increase fruit and water consumption among primary school-aged children over a 2-year period. The study design was an interrupted time series. Four primary schools in the inner west of Melbourne, Australia, participated in the programme intervention. Baseline data were collected using a lunch box audit to assess the frequency of children with fresh fruit, water and sweet drinks, either brought from home or selected from canteen lunch orders. The lunch box audit was repeated periodically for up to 2 years following programme implementation to assess the sustainability of dietary changes. Across all participating schools, significant increases between 25 and 50% were observed in the proportion of children bringing fresh fruit. Similarly, all schools recorded increases between 15 and 60% in the proportion of students bringing filled water bottles to school and reductions between 8 and 38% in the proportion of children bringing sweet drinks. These significant changes in dietary patterns were sustained for up to 2 years following programme implementation. Targeting key nutrition behaviours and using the HPS framework is an effective and simple approach which could be readily implemented in similar childhood settings. Effective strategies include facilitating organizational change within the school; integrating curriculum activities; formalizing school policy and establishing project partnerships with local community nutrition and dietetic services.
Key words: health promoting schools; childhood obesity; nutrition; dietitians
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONTHE FRESH KIDS PROGRAMMEMETHODOLOGYRESULTSDISCUSSIONREFERENCES |
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In Australia between 1985 and 1995, the prevalence of overweight in children almost doubled, whereas levels of obesity more than tripled (Waters and Baur, 2003
). The problem continues to worsen. Conservative estimates indicate that overweight and obesity affect 23% of Australian children and adolescents (Booth et al., 2001). At a regional level, more recent data indicate that 26% of boys and 24% of girls across years 2–10 are above healthy weight (Booth et al., 2006). One of the determinants of this alarming increase in obesity is poor dietary intake. Specific dietary habits have been shown to be predictive of weight gain, including poor intake of fruit and vegetables (Lin and Morrison, 2002; Conrey et al., 2004) and high intakes of sweetened drinks (Ludwig et al., 2001; Welsh et al., 2005; Gill et al., 2006). Both these dietary trends have been documented by population-level studies of Australian children. The most recent National Nutrition Survey (NNS) found that 40% of 5–8 year olds ate no fruit and 
30% ate no vegetables on the day of survey (Magarey et al., 2001), and compared with all other age groups, children (5–12) and adolescents (13–18) had significantly higher energy intake from sweetened drinks (31 and 37%, respectively) (Bell et al., 2005).
In public health efforts to curb this trend, primary schools have been identified as key settings for developing interventions to positively influence eating behaviour (Department of Health and Ageing, 2003). In the USA and UK, a number of randomized, controlled trials of school-based interventions to increase fruit and vegetable consumption have shown modest improvements, though sustainability of such changes is unclear, as interventions were < 6 months in duration and were evaluated within 12 months after the intervention (Perry et al., 1998; Baranowski et al., 2000; Warren et al., 2003). Other US studies targeting fourth and fifth graders, including the High-Five-Project (Reynolds et al., 2000) and the Eat Well and Keep Moving Program (Gortmaker et al., 1999), found improvements in fruit and vegetable consumption, although one study (James et al., 2004) found reductions in carbonated drinks as well as reduced numbers of overweight and obese children, 13–24 months after the intervention period.
In the studies reviewed, successful interventions have been underpinned by the behaviour change theory, with an emphasis on curriculum activities that incorporate experiential learning, role modelling, knowledge and skill acquisition and motivational strategies to change attitudes and behaviour (Contento, 1995; Auld et al., 1999; Warren et al., 2003). The majority of studies are also multicomponent to the degree that they involve food service promotion activities as well as parental engagement (Baranowski et al., 2000; Reynolds et al., 2000). However, there have been a limited number of studies using strategies aimed specifically at creating a supportive school environment over the longer term.
In designing multifaceted nutrition programmes within the school setting, the Health Promoting Schools (HPSs) framework provides a useful model (Colquhoun et al., 1997; Australia Health Promoting Schools Association, 2001). The framework shifts the emphasis from an exclusive focus on classroom education towards a more comprehensive approach in which health promotion is incorporated consistently across three key domains: partnerships and services (school–home–community interaction); school organization, ethos and environment and school curriculum, teaching and learning (Australia Health Promoting Schools Association, 2001). However, there is little published on the effectiveness of specific healthy eating interventions using HPS processes in Australia. Recently, a breakfast promotion intervention based on the HPS framework was found efficacious in improving the quality of breakfast consumption by upper primary schoolchildren (Radcliffe et al., 2005). The framework requires further application and evaluation with respect to healthy eating.
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THE FRESH KIDS PROGRAMME |
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TOPSUMMARYINTRODUCTIONTHE FRESH KIDS PROGRAMMEMETHODOLOGYRESULTSDISCUSSIONREFERENCES |
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The Fresh Kids programme utilized the HPS framework to create supportive school environments to promote healthy eating and reduce the risk factors associated with childhood obesity. First trialled in two pilot primary schools in Melbourne's inner west, the programme continued to expand over a 4-year period through leadership by the Western Region Health Centre, in partnership with schools, local government, the WestNet disability agency and linkages with fruit and vegetable wholesalers (www.vichealth.vic.gov.au). Programme objectives and intervention strategies are detailed in Table 1.
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This paper describes the impact evaluation of the effectiveness of the Fresh Kids programme in influencing dietary consumption of fruit and water and sweet drinks over a 2-year period. An important element of this evaluation was to test the HPS framework with respect to the efficacy of the intervention.
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METHODOLOGY |
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TOPSUMMARYINTRODUCTIONTHE FRESH KIDS PROGRAMMEMETHODOLOGYRESULTSDISCUSSIONREFERENCES |
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Subjects
The first four primary schools (Schools A, B, C, D) to implement the Fresh Kids programme between 2001 and 2004 have been included in this evaluation. Since 2005, the programme has expanded to include 35 primary schools across Melbourne's western suburbs.
The most systematic evaluation was undertaken in the two original primary schools (Schools A and B) which implemented the programme in early 2002 and participated in the evaluation until 2004. A further two schools (Schools C and D) joined the programme in late 2003 and participated in the evaluation for 9 months only. For all participating schools, baseline data were first collected prior to the implementation of the Fresh Kids programme. Impact evaluation was undertaken through periodic data collection for up to 2 years to assess the sustainability of observed dietary patterns.
The four schools are located within an urban multicultural municipality in which a high proportion of the residents experience socio-economic disadvantage (Maribyrnong Municipal Public Health Plan, 2003–2006). In Schools A, B and D, 60–90% of the students are from culturally and linguistically diverse families, with the majority from Vietnam (Table 2).
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Lunchbox audits
In Australia, primary school students typically consume lunch in the classroom, either as a packaged lunch brought from home or pre-ordered and delivered from the school canteen. As such, the key quantitative method to detect change in school dietary patterns in the Fresh Kids programme was the lunchbox audit. This methodology has been used to monitor nutritional intake in clinical situations and shown to be reliable (Kelly, 1999
; Hamilton, 2002). A simple audit template with written instructions was designed by the programme coordinator and used across all schools across subsequent years to ensure consistency. Classroom teachers performed the survey through observational recording of lunchbox contents, which included food and drink choices brought from home as well as those selected from canteen lunch orders. Teachers sensitively integrated the audits within curriculum programmes, usually at the beginning of the school day or before recess, prior to any food/drink being consumed. The audit involved recording the frequency of children observed with the following food and drink items in class, using the following criteria (Box 1): Box 1: Criteria for recording frequency of children observed with food and drink items
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In all schools, baseline surveys were undertaken on a designated day before the Fresh Kids programme had commenced. Subsequent surveys were then undertaken on a periodic basis after the implementation of the school ‘fruit and water’ policy. There was no consistency in the timing of surveys conducted, which was dependent on the school organizational capacity. The overall follow-up response for the lunchbox surveys was 81% of the total school population. In all but one instance (School A baseline audit), researchers attempted to survey all eligible students in a school. For School A baseline audit, it was only possible to get a convenient sample of one grade at each year level in the school.
Permission to record lunchbox choices as part of the Fresh Kids programme was obtained by both the Department of Education, Employment and Training and the Catholic Education Office (reference SOS 001928) in August 2001. Parental permission was also obtained. The exact date for the survey was not disclosed to parents or students in order to minimize possible social desirability bias.
Nature of the Fresh Kids intervention built upon HPS framework
Utilizing the HPS framework, the Fresh Kids programme focused upon organizational change mechanisms. Table 1 details the objectives and intervention strategies undertaken within participating schools under the three HPS domains. The change process was facilitated by external programme coordination and the nomination at each school of a lead teacher to plan and implement activities. Key interventions included the scheduling of class-time ‘fruit breaks’ during which children consumed only fresh fruit and or vegetables brought from home, and the encouragement of drinking water only during class time (prohibiting sweet drinks). Such daily practices were formalized by the development of school ‘fruit and water’ policies that were developed in consultation with school staff and formalized by school management and school council. The concept of school-based ‘fruit and water’ policies was first successfully developed in primary schools in Western Australia (Hawkings, 2000).
Organizational change was enhanced by nutrition education activities initiated by teaching staff, often in association with the seasonal ‘Fresh Fruit Weeks’. A range of existing nutrition education ideas and resources were provided for teachers; however, specific nutrition education resources were not developed. Seasonal ‘Fresh Fruit Weeks’ created educational opportunities and exposed children to the taste and variety of fresh seasonal fruits.
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RESULTS |
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TOPSUMMARYINTRODUCTIONTHE FRESH KIDS PROGRAMMEMETHODOLOGYRESULTSDISCUSSIONREFERENCES |
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Across all participating schools, increases between 25 and 50% (mean 41%) were observed in the proportion of children bringing fresh fruit for up to 2 years after the initial implementation of the Fresh Kids programme (Table 3). Similarly, all schools recorded increases between 15 and 60% in the proportion of children bringing filled water bottles to school for up to 2 years (Table 4).
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The increases in the proportion of children drinking water were inversely related to the reductions observed in the proportion of children with sweetened drinks, including cordials, soft drinks and fruit juices. Significant reductions between 8 and 38% were observed among all schools in the proportions of children bringing sweet drinks or ordering them through canteen lunch orders (Table 5). However, for all schools, the data collection for sweet drinks was less consistent and as such the sustainability of the trend for sweet drink reduction is less clear. Reducing demand for soft drink in School B was verified by the school canteen manager, who claimed demand for soft drinks had reduced from 144 to 24 cans per fortnight after the implementation of the Fresh Kids programme (personal communication, Laurence 2004).
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONTHE FRESH KIDS PROGRAMMEMETHODOLOGYRESULTSDISCUSSIONREFERENCES |
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The Fresh Kids programme demonstrated significant increases in fruit and water and a reduction in sweet drinks observed across primary school-aged children, sustained for up to 2 years after programme implementation. Targeting key nutrition behaviours and using the HPS framework to design whole-of-school, multifaceted interventions was an effective and simple approach which could be readily adapted and implemented for other childhood settings.
The success of the Fresh Kids programme in producing sustainable increases (25–50%) in children having fresh fruit for consumption over time was significant considering high levels of socio-economic disadvantage, coupled with multicultural diversity of the school communities. Before programme implementation, baseline data identified an average of only 29% of children, across four participating schools, bringing fresh fruit for consumption during school hours. This appears low in comparison with the NNS data, which observed that 60% of children reported consuming fruit across the whole day (Margarey et al., 2001). Furthermore, recent survey data from schoolchildren in Geelong found that 68% children had fruit in their lunchboxes (Sanigorski et al., 2005). The determinants of poor consumption in this study are not clear; however, a lower consumption of fruit and vegetables across socio-economically disadvantaged populations has been reported in the literature (Mishra, 2002).
For sweetened drinks, including fruit juice, soft drinks and cordials, baseline data for the Fresh Kids programme showed that on average, 40% of children prior to programme implementation had sweet drinks during the school day, either brought from home or from school canteen lunch orders. Increasing sweet drink consumption is reflected in national dietary survey data which show that between 1985 and 1995, the mean intake of sweetened drinks has increased by > 200 g per day for boys and 150 g for girls (Cook et al., 2001). The initial popularity of sweet drinks over water in this sample group as well as nationally is likely to stem from the appeal of the ‘sweet’ taste, in addition to the influence of marketing, and the increasing accessibility and affordability of these products. This is supported by local research indicating that new arrivals to Melbourne from migrant or refugee backgrounds frequently report an increase in consumption of sweetened beverages on settling in Australia (Burns et al., 2000).
This study adds to the limited research literature that describes and supports the use of the HPS framework. The framework provided the conceptual thinking in the design of multifaceted strategies around two specific dietary behaviours. It encouraged a whole-of-school approach, which required a commitment by all school staff that was sustained through the formulation of policy. This is in contrast to school-based trials which typically target discrete year levels and design-specific, time-limited curriculum activities and often use externally recruited nutrition educators rather than regular school teachers (Reynolds et al., 2000; Warren et al., 2003; James et al., 2004). The whole-of-school approach adopted in this programme allowed a longer term view, with a focus on building programme sustainability and organizational change.
The Fresh Kids programme narrowly targeted two dietary behavioural change strategies, specifically promoting the consumption of fresh fruit and water. Discouragement of sweet drinks was not directly targeted, and the efficacy of water in displacing sweet drinks was a significant finding of this study. In a review of strategies for the prevention of childhood overweight, it has been recommended that single behaviours be targeted in a comprehensive and multifaceted manner, with evidence suggesting children and their families are less likely to incorporate numerous lifestyle changes all at once, and that more targeted and simple to adopt messages may be more effective (Ritchie et al., 2001). Our findings support the need for narrowly targeting specific dietary behaviours that are reinforced using multicomponent strategies.
Facilitating organizational change within schools was the key strategy for influencing eating behaviour change in the Fresh Kids programme. Many studies based solely on a ‘dissemination of information and teaching of skills model have not been effective in bringing about behaviour change’ (Contento, 1995). Through creating organizational changes to encourage children to eat fruit and drink water daily within class, the emphasis was upon ‘incidental’ and ‘experiential’ learning that reinforced formal nutrition education delivered periodically. This was enhanced by role modelling of eating behaviour by teachers (Auld et al., 1999) and the use of incentives such as ‘house points’ by some teachers to encourage students to include fresh fruit and vegetables in their lunchboxes. The emergence of ‘peer’ support for healthy eating behaviour was another influential factor (Contento, 1995). The organization of the ‘fruit break’ supported all students to eat fruit in class and as such it became more socially acceptable as ‘everyone else was eating it’. Teachers describe that healthy eating soon became part of the ‘school culture’ and in time, it was the ‘students that remind the teacher it is time for fruit break’. The establishment of whole-of-school ‘fruit and water’ policies were critical in formalizing and sustaining these practices over the longer term.
Effective leadership and dedicated resourcing at the local level were likely to be the final key factor in the success of the Fresh Kids programme. Schools are recognized as the platform for a host of social, environmental and health initiatives aiming to engage, educate and influence the next generation. In addition to an already ‘over crowded curriculum’, it is often unrealistic to expect schools will prioritize nutrition initiatives over many other worthy programmes, all of which are likely to be beyond schools' core business (Auld et al., 1999). The appointment of a community dietitian to initiate, coordinate and guide the programme assisted to prioritize the nutrition agenda, while increase the capacity of schools and specifically the teaching staff to be engaged. This role for the dietitian is well recognized (ADA, 2003). Project leadership was the first step in creating local partnerships that expanded to include the local council and a disability support agency which coordinated a delivery service using local fruit and vegetable wholesalers. The long-term planning approach fostered through the HPS model was the cornerstone for formalizing partnerships which moved beyond loose networks to true collaborations.
The Fresh Kids programme was funded primarily as a health promotion intervention, rather than a research project and as such there were a number of limitations in research methodology. Regular data collection using the lunchbox audit methodology was an important component of the original programme evaluation plan; however, in the absence of dedicated research funding, participation in data collection depended upon school staff willingness and time. There was limited capacity, therefore, to monitor the reliability of the lunchbox audits or to ensure consistency in the timing and, therefore, the ‘season’ in which the lunchbox audits were undertaken over successive years. The methodology was further limited in that it was indicative of ‘what’ children had in their lunchbox or what they purchased from the canteen, rather than what they actually consumed. As such, the results provide an indication of food selection patterns, rather than actual consumption which would need further determination of food wastage or even swapping by the children and was beyond the scope of this programme. Another limitation of this project was the lack of a control group. However, although controlled trials offer the most rigorous scientific evidence in public health interventions, this is often difficult to achieve in community interventions because of cross-contamination of information between test and control populations. This project was essentially an interrupted time series which offers second-level evidence of effectiveness. However, the size of the behavioural changes in this study exceeded any sectoral changes in fruit or water consumption in primary schoolchildren in Australia that could be predicted from current consumption (Margarey et al., 2001; Bell et al., 2005). The changes were also observed consistently across the four study schools and in two of the schools for up to 2 years. These factors add weight to the veracity of our findings in the absence of control schools.
Targeting key nutrition behaviours and using the HPS framework to develop a whole-of-school approach have been shown to be an effective and simple approach which could be readily implemented in similar childhood settings. Effective strategies include facilitating organizational change within the school, integrating curriculum activities, developing school policy and establishing project partnerships with local community nutrition and dietetic services.
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ACKNOWLEDGEMENTS |
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The authors wish to thank Christie Walton, Donald Gibb, Lindy Marlow, Barbara Gillies, Ayhan Akin, Denise O'Shea, Suzy Honisett and Lynley Dumble for their active support and commitment to the Fresh Kids programme. We also wish to acknowledge student dietitians from Deakin and Monash universities who assisted with data collection and analysis, as well as Mary Stewart for developing the printed water bottle concept. The authors also thank Natalie Chahine, Andrea Potter and Jaime Timmerman, who continue to support the expansion and development of the Fresh Kids programme across schools in the inner west of Melbourne. This project was originally funded by the National Child Nutrition Programme, Commonwealth Department of Health and Ageing and continues to be supported by the Telstra Foundation.
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