The Journal of School Nursing2023, Vol. 39(6) 444–455© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI:10.1177/10598405211036892journals.sagepub.com/home/jsn
The purpose of this quasi-experimental study was to evaluate the effects of two farm-to-school programs, specifically the Field-to-Fork Multi-visit Program (N = 264) and the Field-to-Fork After-school Club (N = 56), on nutritional outcomes of elementary school students (third to fifth grade) from urban, diverse, and lower-income communities. Data were collected via self-report surveys measuring: (a) knowledge of recommendations for daily fruit and vegetable intake; (b) fruit and vegetable consumption; (c) knowledge of cooking a healthy recipe using vegetables; and (d) desire for farm fresh foods at school. Statistical analyses included McNemar’s and Wilcoxon signed rank tests. The proportion of students knowing how to cook a vegetable rich recipe increased with both programs (Multi-visit Program p < .001; After-school Club p = .002). Vegetable consumption increased with the After-school Club (p = .002). Farm-to-school programming can increase knowledge of cooking vegetable rich recipes and vegetable intake among elementary school students from diverse, urban, and lower-income communities.
Keywordsfarm-to-school, nutrition, garden-based education, school-aged children
Maintaining a healthy dietary pattern, including the consumption of a variety of fruits and vegetables, is consistently associated with better health outcomes and reduced risk of chronic diseases throughout the lifespan, yet children in the United States (U.S.) eat substantially fewer fruits and vegetables than is recommended (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2020). On average, children and adolescents eat 0.54 cup-equivalents per 1,000 calories (CEPC) of vegetables per day falling far short of the target 1.16 CEPC of vegetables per day and 0.60 CEPC of fruit per day compared to the target of 0.93 CEPC of fruit per day (Office of Disease Prevention and Health Promotion [ODPHP], n.d.). These statistics are concerning because healthy dietary patterns during childhood, including adequate fruit and vegetable consumption, are vital to the prevention of obesity (Bray et al., 2018), and are ultimately associated with eating patterns later in life (Movassagh et al., 2017). Furthermore, the prevalence of childhood obesity in the United States has increased over the past few decades with 18.4% of school-aged children qualifying as obese in 2016 (Hales et al., 2017).
Childhood obesity disproportionately affects certain demographic groups within the U.S. population. For example, school-aged children of color, specifically Hispanic or Latino children and non-Hispanic Black children, experience disproportionately higher rates of obesity compared to all U.S. children (ODPHP, n.d.). Additionally, children of lower socioeconomic status have an increased likelihood of being overweight or obese compared to children from households of higher socioeconomic status (Williams et al., 2018). There is evidence that the coronavirus disease 2019 (COVID-19) pandemic worsened childhood obesity rates, especially among lower-income populations and children of color (Jenssen et al., 2021).
School nurses have the necessary knowledge, skillset, and holistic understanding of the social determinants of health to be leaders in the development of policies and strategies in their schools, districts, and communities to address the increasing rates of childhood obesity (National Association of School Nurses [NASN], 2016; 2018). As such, school nurses and other school health professionals play a critical role in advocating for, designing, implementing, and evaluating school-based programs to improve school-based nutrition services and school environments to support healthy dietary choices among children (NASN, 2017). This role aligns with the whole school, whole community, whole child (WSCC) approach that emphasizes the importance of collaboration among schools and communities for the development of policy that leads to healthy school aged children (NASN, 2017; ASCD & Centers for Disease Control and Prevention, 2014).
In response to the increasing rates of childhood obesity and consistent with the WSCC approach, over 42,000 schools across the United States have implemented farm-to-school policies and programming (National Farm to School Network [NFSN], n.d.). Farm-to-school programs aim to educate children and their families about agriculture and nutrition, increase availability of locally grown fresh foods, and strengthen local communities and food systems. While farm-to-school programs vary in their specific components, the National Farm-to-School Network defines such programs as incorporating at least one of the following: (a) use of local foods in schools for lunches, snacks, or taste testing, (b) activities for students to learn about agriculture, food, and/or nutrition, and (c) school-based gardens for experiential student learning opportunities (NFSN, n.d.). Researchers have found that children who grow their own food are more likely to express a preference for and/or consume fruits and vegetables (Gatto et al., 2017; Kim & Park, 2020). There is also increasing empirical evidence supporting the use of hands-on garden-based nutrition education programs, such as school-based gardens, to increase preferences for and consumption of fruits and vegetables among youth (Savoie-Roskos et al., 2017). Despite the potential benefits of garden-based learning and increasing farm-to-school policies, socio-economic inequities remain in the presence of school-based gardens to support such educational opportunities. Specifically, the prevalence of school-based gardens is lower among schools serving communities with higher portions of low-income families (Turner et al., 2016).
There is also limited empirical evidence of the effects of farm-to-school programming designed for schools serving racially and ethnically diverse, urban, and lower-income communities (Greer et al., 2019). Two empirical studies of farm-to-school programs for racially and ethnically diverse and lower-income communities are the LA Sprouts (Davis et al., 2016) and TX Sprouts (Davis et al., 2021) programs. Both programs provided culturally appropriate educational lessons and hands-on activities related to gardening, nutrition, and cooking for predominantly lower-income and Hispanic and/or Latino elementary school students (Davis et al., 2016). The LA Sprouts program was a 12-week after-school program that increased student nutrition and gardening knowledge, but did not affect student self-efficacy or attitudes towards cooking or gardening among the sample (Davis et al., 2016). While the students in both the control and intervention group decreased their vegetable intake, the intervention group had a smaller decrease in their intake than the control group. The program also improved student body mass index and waist circumstance among the intervention group (Gatto et al., 2017). The TX Sprouts program offered 18 in-class student lessons delivered by hired educators plus nine monthly lessons for parents and families delivered outside of school hours. This program increased vegetable intake among the students (Davis et al., 2021).
Empirical studies testing farm-to-school programs designed to reach non-Hispanic Black youth in lower-income areas are even more limited. Evans et al. (2012) found that a multicomponent garden-based intervention increased fruit and vegetable consumption among an ethnically diverse (59% Hispanic; 16% African American) and predominantly lower-income (70% low-income) sample of middle school students in Texas. Knapp et al. (2019) explored the perceptions of school-based kitchen garden programs among low-income, African American children and parents from New Orleans, Louisiana. The school-based gardening programs were well received. Participants expressed an appreciation for the development of food-related life skills, for nutrition and health knowledge, and for the role the programs had on families, schools, and the community.
While most empirical evidence supports farm-to-school programs, such as educational school gardens, as having a small positive influence on vegetable intake, the evidence remains mixed (Khan & Bell, 2019; Savoie-Roskos et al., 2017). There is significant variation in the specific components included in farm-to-school programs, as well as the logistics of implementing the programs. For example, differences exist in the setting (in-class, school garden, community garden, or farm), timing (during the school day vs. afterschool), and dosage (frequency and duration of lessons, experiences, and visits) of the activities and programs (Savoie-Roskos et al., 2017). Prescott et al. (2020) analyzed data from the 2015 Farm-to-School Census questionnaire and concluded that the most common farm-to-school components included: promoting foods produced at school, serving locally produced foods in the cafeteria, taste testing of local foods, visiting farms or orchards, and changing the lunchroom environment (Prescott et al., 2020). Research supports the use of comprehensive, multicomponent programs to increase fruit and vegetable intake among youth (Muzaffar et al., 2018; van den Berg et al., 2020). Multicomponent programs also led to increases in factors theorized to predict and affect fruit and vegetable intake, such as increased self-efficacy for eating fruits and vegetables, increased knowledge of fruits and vegetables, and decreased preference for unhealthy foods among youth (Evans et al., 2012).
The variation in the implementation of farm-to-school programs, continued mixed findings, and limited research evaluating programs designed for diverse, urban, and lower-income communities, highlights the need for further testing of innovative, multicomponent farm-to-school education programs designed to reach populations at an increased risk for obesity. Therefore, the purpose of this program evaluation research was to evaluate the effects of two farm-to-school programs designed for elementary school students from diverse, urban, and lower-income communities on the following nutritional outcomes: (a) knowledge of recommendations for daily fruit and vegetable intake; (b) fruit and vegetable consumption; (c) knowledge of cooking a healthy recipe using vegetables; and (d) desire for farm fresh foods at school.
The Food Literacy Project, Inc., established in 2006, is Louisville, Kentucky-based 501c3 nonprofit organization with a mission of cultivating food justice through increasing access to healthy foods in underresourced areas, providing experiential education programs for youth focused on nutrition, agriculture, and the food system, and empowering youth to create change in their own lives, families, and communities (The Food Literacy Project, n.d., “Mission & Visionâ€). As part of the organization’s programming, the Food Literacy Project collaborates with local public schools to provide two farm-to-school programs for elementary school students: (a) the Field-to-Fork After-school Club and (b) the Field-to-Fork Multi-visit Program. Both programs offer experiential learning opportunities designed to improve food literacy, food access, and dietary behaviors of children from diverse, urban, and lower-income communities.
A quasi-experimental, pretest–posttest design was used to evaluate the effects of the Field-to-Fork Multi-visit Program and the Field-to-Fork After-School Club. The programs were multicomponent, experiential learning programs implemented in collaboration with the local public elementary schools. The Multi-visit Program provided six in-class lessons (30–45 min per lesson) plus two to three farm field trips (2–4 hr each) for elementary school students. The After-school Club was a voluntary program delivered after school hours. This program consisted of 8- to 10-weekly sessions for the elementary school students (up to 2.5 hr each) and included a 4- to 5-week Family Engagement Series tailored for caregivers and parents. The program designs were grounded in social cognitive theory (Bandura, 1998) and emphasized improving self-efficacy as well as personal (e.g., knowledge, attitudes), behavioral (e.g., practice and skills), and environmental (e.g., social expectations among peers and/or family, access to farm-fresh produce) determinants of farm-fresh produce preparation and consumption. Educational experiences were based in the Flow Learning™ principles of Cornell (2015) using strategies such as playfulness and meaningful content, enhancing receptivity through the senses, hands-on experiences with nature, and reflection sharing. Significant cultural, access, and language considerations were given to the specific needs of these populations throughout the development process.
Four public, Title I urban elementary schools located within a large Midwestern school district participated in the research study. All schools were in neighborhoods with high poverty rates (range: 18.4%–37.6%) and low rates of educational attainment with only 7.9%–12.6% of the communities obtaining a bachelor’s degree (U.S. Census Bureau, 2019). In addition, these neighborhoods experienced disproportionately high rates of chronic illnesses such as cancer as well as higher rates of all-cause mortality compared to the metro area as a whole (Center for Health Equity, 2017). The neighborhoods surrounded an urban farm in one of the most diverse areas in the city, in which 8.5% of the population was foreign-born, reflecting the area’s status as a prime resettlement area for immigrants and refugees (Center for Health Equity, 2014, 2017). Most of the students in the participating elementary schools qualified for free or reduced lunch (range: 72%–94%). The schools had diverse demographic characteristics including student bodies of 275–592 students, 27%–79% African American, 10%–43% White, 1%–25% Hispanic, and 4%–17% other ethnicities (Jefferson County Public Schools, 2018; 2019). Participants in the research study consisted of third to fifth grade students from the four schools during the 2017–2018 and 2018–2019 academic years. The After-school Club also incorporated caregivers of the participating students through the Family Engagement Series.
The Field-to-Fork Multi-visit Program and the Field-to-Fork After-school Club provided educational lessons and hands-on activities designed to increase knowledge and appreciation for the Field-to-Fork key concepts, such as nutrition and health, the food system, horticulture, and cooking and preparing healthy recipes made from fresh foods (culinary lessons). Both programs included regular taste testing of locally grown produce along with the culinary components.
All lessons were provided by the Food Literacy Project educators whose educational and professional backgrounds included public health and health education and a commitment to the promotion of diversity, equity, and inclusion. Families of participants in both programs were regularly informed of additional family engagement activities offered at the Food Literacy Project’s outdoor classrooms at their urban and residential farming locations. Details specific to each program are described below.
The evaluation study protocol including a waiver of documentation of informed consent was approved by the University of Louisville Institutional Review Board. Consent procedures and documents were created in collaboration with the participating public school district. Parents and guardians of children in the Field-to-Fork Multi-visit Program received study information with an option to not participate in the evaluation portion of the program. Parents and guardians of children in the Field-to-Fork After-school Club received study information during an in-person information session with an option to not participate in the evaluation portion of the program.
Field-to-Fork Multi-visit Program. The Multi-visit Program provided six in-class lessons (30–45 min per lesson) plus two to three field trips to the local urban farm (2–4 hr each) spread throughout the academic year. Farm field trip experiential learning settings included the sensory garden, barn, farm fields, and picnic areas. Field-to-Fork key concepts were reinforced through interactive and engaging hands-on educational activities linked to the core content subject areas (e.g., science and language arts). The lessons incorporated the use of school gardens when available and applicable, although this was a minor component of the program. School administrators, staff, and teachers and Food Literacy Project educators coordinated extension assignments such as creative writing and creating poetry, short stories, reflective narratives, and art for each lesson to further integrate lessons with core content. Recipes from the culinary lessons and information on farmers markets and other resources for finding local produce were sent home to parents and caregivers. See Table 1 for a sample program overview including key concepts and activities for each session.
Field-to-Fork After-school Club. The After-school Club consisted of 8- to 10-weekly sessions (up to 2.5 hr each) conducted outside of normal school hours at the partner schools. Some club sessions took place at the urban farm within walking distance of one of the partner schools. In addition to covering the Field-to-Fork key concepts taught in both programs, the After-school Club lessons and activities were designed to increase social support and develop leadership, teamwork, and communication skills to help students become drivers of change for healthy lifestyles within their families and schools. For example, each week, students took home a healthy recipe along with samples of fresh seasonal produce allowing them to prepare the vegetable rich meal at home with their families. In addition, the program supported the launch and/or maintenance of school gardens and helped to cultivate an invested cohort of students and teachers who provided sustainable leadership in maintaining and enhancing the gardens.
Parents and caregivers of the students were encouraged to attend the complementary 4- to 5-week Family Engagement Series as part of the 8- to 10-week program. During these Family Engagement sessions, additional tailored education and activities were provided that emphasized nutrition, healthy foods, gardening, farming, and cooking for the caregivers. Parents and caregivers were also provided fresh locally grown produce grown on the farms and other pantry items donated by a local natural food market and wellness center to create the new recipes together as a family at home. Also, to increase outreach and flexibility for the families, a single parent or caregiver did not have to commit to the entire series. This meant that more than one parent or caregiver could attend the program with a single child. See Table 2 for a sample program overview including key concepts, recipes, and activities for each club session.
Data were collected via paper and pencil surveys administered to students during the 2017–2018 and 2018–2019 academic years. Student participants of both programs received the same questionnaires. Knowledge of the recommendations for fruit and vegetable intake from the 5-2-1-0 recommendation (Rogers & Motyka, 2009) was measured using single-item questions: (1) “How many total servings of fruit and vegetables should you eat each day?†with answer options “0 servings,†“1–2 servings,†“3–4 servings,†or “5 or more servings†(correct answer). Fruit intake was measured using the question, “Yesterday, did you eat ANY fruit? Do not count fruit juice.†with answer options of “No, I did not eat any fruit yesterday,†“Yes, I ate one fruit yesterday,†“Yes, I ate two fruits yesterday,†and “Yes, I ate three or more fruits yesterday.†Similarly, vegetable intake was measured by the question, “Yesterday, did you eat ANY vegetables? Vegetables are salads; boiled, baked, and mashed potatoes; and all cooked and uncooked vegetables. Do not count French fries or chips.†Response options mirrored that of the fruit intake question. Knowledge of how to cook a healthy recipe using vegetables and desire to have farm fresh vegetables available at school were measured by the following questions with “Yes/No†response options: “Do you know how to cook a healthy recipe using vegetables?†and “Would you like to have fresh foods from a vegetable farm available at your school?†Parent and caregiver demographic data were collected via paper and pencil surveys for descriptive purposes during the Family Engagement Series.
Descriptive statistics including frequencies and percentages were calculated for sample characteristics and major variables. Students who concurrently participated in both programs (n = 15) were exclude from the analysis. Chi-square and Fisher’s exact tests were used to test for differences in proportions of baseline measures between those who completed the program and those who did not. Preprogram and postprogram proportions were compared using McNemar’s Test for dichotomous outcome variables (e.g., knowledge of recommendations, knowledge of cooking healthy recipes using vegetables, and desire for farm fresh produce available at school). Wilcoxon signed rank test was used to compare preprogram and postprogram scores for ordinal outcome variables (e.g., fruit and vegetable consumption). Statistical analysis was conducted using SPSS Statistical Software version 26. Statistical significance was set at p <.05.
The Multi-visit Program sample included 264 students, ages 7–10 years, a slight majority of whom were female (53%) and Black or African American (56%) (Table 3). The baseline survey was completed by 316 students; 264 of those students also completed the post survey (16.5% attrition). There were no significant differences in baseline measures of major outcome variables by completion group.
At the end of the program, the proportion of students who reported knowing how to cook a healthy recipe using vegetables (n = 173 [68.7%]) was significantly higher than at baseline (n = 135 [53.6%]; p < .001). There was no significant effect of the program on student knowledge of fruit and vegetable recommendations; student fruit and vegetable consumption; or student desire for farm fresh foods available at school.
The sample from the After-school Club included 56 students, ages 7–11 years; 66% of the students were female, 38% identified as Black or African American, and 13% identified as Hispanic or Latino (Table 3). The baseline survey was completed by 92 students; 56 of those students also completed the post survey (39.1% attrition). There were no significant differences in baseline measures of major outcome variables by completion group.
Among the sample of caregivers (N = 88; age range = 16–71 years) in the Family Engagement Series, 46.5% identified as white, 39.5% Black or African American, and 9.3% Hispanic or Latino. Furthermore, a total of seven different languages were spoken among the caregivers, with almost one-fifth (19.5%) of the caregivers reporting speaking Spanish (n = 9, 10.3%) or other languages (n = 8, 9.2%; Arabic, Vietnamese, Albanian, Karem, Zomi). Parent and caregiver demographic characteristics are displayed in Table 4. Parents and caregivers attended at least one session but did not have to commit to the entire Family Engagement Series. Consequently, more than one parent or caregiver per child could attend throughout the program, resulting in a higher number of parents and caregivers sampled than children in the program.
Student vegetable consumption increased from preprogram to postprogram (Z = −3.148, p = .002); the greatest increase occurred in the proportion of students who ate three or more servings of vegetables (n = 4 [7.1%] vs. n = 18 [32.1%]). The proportion of students who reported eating no servings of vegetables per day decreased from 30.4% (n = 17) preprogram to 16.1% (n = 9) postprogram. The percentage of students who reported knowing how to cook a healthy recipe using vegetables also increased from preprogram to postprogram (n = 27 [50.9%] vs. n = 43 [81.1%], p = .002). However, the program had no effect on fruit consumption, desire for farm fresh foods at school, or student knowledge of recommendations for daily fruit and vegetable intake (see Table 5 for details).
Given the school nurse’s role as a leader in the development of school and community policies and programs that support the health and wellbeing of all children (NASN, 2017), it is important for nurses to understand the evidence supporting farm-to-school programs. Previous research findings have indicated that school nurses are eager to gain more knowledge and experience with these programs (Muckian et al., 2017). Furthermore, advocates for increasing the adoption of fresh fruits and vegetables in schools recommend empowering school nurses to lead in forging partnerships with farm-to-school programs (Schultz & Thorlton, 2019). In this manuscript, we provided a detailed overview of two farm-to-school programs along with empirical evidence regarding their effects on: (a) student knowledge of recommendations for daily fruit and vegetable intake; (b) student fruit and vegetable consumption; (c) student knowledge of cooking a healthy recipe using vegetables; and (d) student desire for farm fresh foods available at school. Both programs provided multicomponent, experiential learning to students from four urban elementary schools serving lower-income and racially and ethnically diverse communities. In total, the programs reached 320 unique elementary school students from the ages of 7–11 years during the 2017–2018 and 2018–2019 academic years. The After-school Club also included parents and caregivers who were similarly diverse in race and ethnicity.
The Multi-visit Program and the After-school Club had significant positive effects on the number of students who reported knowing how to cook a healthy recipe using vegetables. Both programs had several features that likely contributed to their success in improving this outcome including evidence and theory-based lessons, school garden-based learning experiences, and culinary experiences with taste testing. Substantial portions of content were devoted to teaching the students how to prepare healthy, vegetable rich recipes followed by taste testing of these recipes. Culinary components are common among farm-to-school programs and often involve cooking classes or demonstrations, in-class nutritional education, meal preparation activities, and taste testing sessions (Muzaffar et al., 2018). While it is difficult to parse out the effects of incorporating such a focus on learning how to cook vegetable rich recipes, previous research that evaluated the impact of farm-to-school programming with culinary components had promising results. Such programming incorporating culinary components has been associated with increased vegetable preferences, willingness to try new foods, vegetable consumption, and gardening and nutrition knowledge (Kim & Park, 2020), along with improved self-efficacy for cooking among youth (Jarpe-Ratner et al., 2016; Kim & Park, 2020). Furthermore, evidence supports psychosocial factors related to cooking such as attitude, motivation, and self-efficacy as predictors of increased vegetable intake among low-income elementary school students (Landry et al., 2019). This evidence suggests that improving factors such as knowledge and self-efficacy related to cooking with vegetables may be a contributing factor for improving the dietary patterns of children.
Students who participated in the After-school Club significantly increased their intake of vegetables per day after participating in the program. The largest changes were seen in a decrease in the number of students who reported eating zero vegetables per day and an increase in the number of students who reported eating three or more vegetables per day, as previously discussed. There was no significant increase in fruit servings per day, which was not surprising, as there was more emphasis on vegetables than fruits throughout the program. Similar results regarding fruits have been found in larger studies of farm-to-school programs, such as by Jones et al. (2015) who studied the effects of farm-to-school programs on consumption of fruits and vegetables across 18 schools (12 farm-to-school programs; six matched control schools) in South Carolina and found that while the students in the schools with farm-to-school programs consumed more vegetables, they also ate slightly fewer fruits (Jones et al., 2015).
The After-school Club consisted of 8–10 weekly sessions located at the schools with some participants attending sessions at a local urban farm within walking distance of one of the partner schools. While this may appear to be a significant time commitment, the duration of this program was shorter than other well-known programs, such as the 12-week after school LA Sprouts program (Davis et al., 2016). The program was a voluntary program offered outside of normal school hours which likely drew upon individuals and families who were interested in the Field-to-Fork topics such as food, nutrition, and horticulture.
The After-school Club had direct parental/caregiver involvement through the Family Engagement Series which included tailored education, discussions, and culinary experiences with taste testing of recipes. The involvement of parents and caregivers was a strength of this program as there is substantial evidence supporting parental involvement in health education programs for children (Knapp et al., 2019; Spears-Lanoix et al., 2015). Similarly, parental support for and parental role modeling of health behaviors are related to child health behaviors (Bassul et al., 2020; Hartson et al., 2018). In fact, the family and home environment have been found to account for 50% of the variance in child fruit and vegetable consumption (Gross et al., 2010). Given the racial and language diversity of the children’s caregivers in this study, the implications of their involvement in programming are important. Research findings from a recent school-based gardening intervention for low-income, diverse, urban school children underscored the cultural and community significance that immigrant families can bring when collaborating in gardening opportunities (Greer et al., 2019). Including families and caregivers in the After-school Club may have served as an important reinforcing factor in vegetable consumption behavior among children, further supporting that family and community engagement in farm-to-school programming can be instrumental in supporting a culture of health (Robert Wood Johnson Foundation, 2018).
Another strength of the After-school Club and Family Engagement Series was the inclusion of fresh, local produce for the children and their caregivers to take home with them to practice creating the new recipes at home. This increased access to fresh produce in the household without increasing financial strain on the family and it provided additional opportunities to practice cooking healthy, vegetable rich recipes. Furthermore, it created an opportunity for the family to practice cooking healthy recipes together, theoretically creating a home environment that encourages the consumption of fruits and vegetables (Ong et al., 2016).
The Multi-visit Program, which consisted of six in-class lessons and two to three farm field trips spread throughout the academic year, did not increase fruit or vegetable intake among the students. However, there was a general trend with the portions of students eating two servings and three or more servings of vegetables appearing to increase at the end of the intervention. In contrast to the After-school Club, the Multi-visit Program delivered a much less intense and less frequent intervention over a longer time. Eight to nine learning experiences throughout the academic year may not have been frequent enough messaging to affect long-term behavioral outcomes, despite the comprehensive nature of the program including education, hands-on activities, cooking activities with taste testing, and farm-field trips. Extension assignments were provided for teachers to incorporate and reinforce key concepts within the core curriculum, however, use of these assignments was not measured.
Despite most evidence supporting a small but positive influence of farm-to-school programs on dietary patterns (Savoie-Roskos et al., 2017), it is also sometimes the case that farm-to-school programs do not have significant overall effects on dietary patterns or only show a benefit for a subgroup of students (Bontrager et al., 2014). There are several evidence-based strategies that could improve the potential effects of the Multi-visit Program on fruit and vegetable consumption of students. One commonly used farm-to-school strategy that should be considered in future programming is the incorporation of local produce into cafeteria prepared meals and snacks, as well as environmental changes within the cafeteria that support healthier food choices. These strategies increase access to locally grown fresh produce on a regular basis while also providing more frequent and consistent health promotion messaging. For example, weekly snacks at school created using locally grown fresh produce has been shown to increase preferences for fruits and vegetables among children over a 4-month period (Triador et al., 2015).
Another evidence-based strategy that could be incorporated into future implementations of the Multi-visit Program is direct parental engagement or enhanced indirect parental involvement. There is evidence that indirect parental involvement such as having children share their school-garden experiences with their parents at home and including a weekly newsletter with tips, recipes, and home activities can affect parental value of fruit and vegetable consumption as well as increase fruit and vegetable availability at home (Heim et al., 2011). Although the Multi-visit Program included some messaging home to parents, it was much less frequent and less comprehensive. Further investigation is needed to determine if incorporating these strategies into the Multi-visit Program could increase the effectiveness of this program on nutritional outcomes.
There was no significant increase in knowledge of the recommendations for daily fruit and vegetable intake. While the information was a part of the programs’ overall core content, memorizing the recommendations was not the major focus of the experiential programs. Thus, it was not surprising that this detailed knowledge was not retained over the long study periods, particularly with such a young sample.
There was also no significant difference in the proportion of students who desired farm fresh vegetables available at school before and after the intervention; however, the proportions of students who reported wanting farm fresh vegetables at school at baseline was 88% and 96%, for the Multi-visit Program and the After-school Club, respectively. With such high proportions of students already desiring to have farm fresh vegetables available at school, statistically significant improvement would have been challenging to achieve. The baseline results alone highlight the natural interest of students in having farm fresh foods available at their schools.
The data were collected using simple, single-item questions making them extremely user-friendly; however, higher quality measures such as food frequency questionnaires, food diaries, or observable food intake should be considered for future studies. Suggestions for future studies include measuring self-efficacy of cooking healthy recipes, which is an important psychosocial predictor of behavior, and measuring body mass index or waist circumference to determine if improvements in vegetable and fruit intake translate into obesity prevention and treatment.
The sample sizes were small, particularly for the After-school Club, and attrition rates were 16.5% for the Multi-visit Program and 39.1% for the After-school Club. This was not surprising, given the length of the programs and the chronic absenteeism for the elementary schools participating in the programs (range: 18%–23%) (Jefferson County Public Schools, 2020). The high chronic absenteeism at the included elementary schools reflects the inherent difficulty in reaching some youth, especially for long-term interventions. Further investigation is needed to determine the effects and sustainability of these programs with larger samples.
The parents and caregivers involved in the program were not required to commit to attending the entire series. Given the significant number of after-school hours required by the program, it was anticipated that requiring a commitment from a single parent or caregiver for the entire series would put undue time, access, language, or transportation strain on parents and caregivers, especially if they were caregiving for other members of the family or community. Having this flexibility potentially increased the number of unique parents and caregivers reached by the program, but it also limited our ability to collect reliable data and determine changes in parental and caregiver outcomes over time as well as analyze pre- and post-parent–child dyad data. Therefore, parental and caregiver data were limited to descriptive demographic information. Given the diversity of languages spoken by parents and caregivers, a language barrier could have interfered with participation in the programming. Lastly, following this evaluation, the program was delivered virtually due to the COVID-19 pandemic. Further evaluation is needed to determine the effects of virtual delivery on accessibility, engagement, sustainability, and outcomes, particularly for the After-school Club and Family Engagement Series.
Healthy eating, including adequate consumption of fruits and vegetables, is an important lifestyle factor for the prevention and management of childhood obesity. Farm-to-school programs have demonstrated promise in improving mediators of fruit and vegetable intake (Berezowitz et al., 2015), as well as increasing the consumption of fruits and vegetables among children (Savoie-Roskos et al., 2017). Findings from this study of two multicomponent, experiential learning farm-to-school programs for third to fifth grade students from four elementary schools located in diverse, urban, and lower-income communities showed that both the Field-to-Fork Multi-visit Program and the Field-to-Fork After-school Club produced an increase in knowledge of cooking healthy, vegetable rich recipes among the students, while the After-school Club that included a substantial Family Engagement Series increased vegetable intake among the students as well.
School nurses are health leaders in the schools and communities they serve. As such, they are in the unique position to create school environments and community collaborations that support healthy nutrition among students and a culture of health in the community (NASN, 2015; 2018). Understanding the evidence supporting farm-to-school programs will help school nurses engage in this mission to advocate for, design, and implement culturally sensitive programs, policies, and partnerships to improve the health and well-being of their students.
The evaluation study protocol was approved by the University of Louisville Institutional Review Board.
This study was conducted as part of a 2-year, USDA NIFA grant to The Food Literacy Project, Inc. with Drs. Aishia A. Brown and Kristi M. King serving as subcontract principal investigators.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Angelique Perez was the executive director for the Food Literacy Project; however, A. Perez was not involved in the data analysis or interpretation of the data.
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Food Literacy Project, Inc.—subcontracted from USDA NIFA grant.
Kimberly R. Hartson https://orcid.org/0000-0002-7186-9892
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Kimberly R. Hartson, PhD, RN is an Assistant Professor at the University of Louisville School of Nursing.
Kristi M. King, PhD, CHES is an Associate Professor at the University of Louisville Department of Health and Sport Sciences.
Carol O’Neal, PhD is an Associate Professor at the University of Louisville Department of Health and Sport Sciences.
Aishia A. Brown, PhD is an Assistant Professor at the University of Louisville School of Public Health and Information Sciences.
Toluwanimi Olajuyigbe, BSN, RN is a doctoral student at the University of Louisville School of Nursing.
Shakeyrah Elmore, MS, CHES is a doctoral student at the University of Louisville School of Public Health and Information Sciences.
Angelique Perez, MPH was the Associate Executive Director at the Food Literacy Project, Louisville, KY, USA.
1 School of Nursing, University of Louisville, Louisville, KY, USA
2 Department of Health and Sports Sciences, Student Activity Center—East (SAC-E) 105G, Louisville, KY, USA
3 Department of Health Promotion and Behavioral Sciences, School of Public Health and Information Sciences, University of Louisville, Louisville, KY, USA
4 The Food Literacy Project, Louisville, KY, USA
Corresponding Author:Kimberly R. Hartson, School of Nursing, K Building, University of Louisville, 555 South Floyd Street, Louisville, KY 40202, USA.Email: kimberly.rapp@louisville.edu
