Girl Scouting: An Effective Channel for Nutrition Education

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Girl Scouting: An Effective Channel for Nutrition Education

KAREN WEBER CULLEN,' L . KAY BAR THO LO MEW,^ AND GUY S . PARCEL^ 'University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030; 2Center for Health Promotion, Research,

and Development, School of Public Health, University of Texas-Houston, Houston, Texas 77225

ABSTRACT Community youth groups may provide an untapped channel for nutrition education. Children's fruit and vegetable (F&V) intake is one-half of the 5 A Day goal. This study evaluated the effect of a 4-week, theory-based F&V nutrition program for fourth to sixth-grade Junior Girl Scouts. Twenty-two troops were recruited, stratified by grade level, and randomized into intervention or control conditions. Interven- tion condition troop leaders received a manual and instruction on how to conduct the activities. F&V intake and measures assessing knowledge, skills, F&V preferences, self-efficacy, norms, and barriers were completed 1 week before and about 1 week after the intervention was completed. F&V intake was also assessed 3 months later. Pretest F&V intake for the 259 girls was 2.60 servings per day-3.0 for the intervention group. Signifi- cant increases in F&V intake (to 3.4 servings per day), knowledge, and F&V preferences were found for the intervention condition troops. F&V intake returned to pretest levels 3 months 1ater.This study indicates that social groups can provide a channel for nutrition education.Although increased F&V was not sustained, booster lessons and troop commitment to serving F&V could promote positive norms and social support for eating F&V, leading to increased F&V consumption.

INTRODUCTION

Chronic diseases, such as cardiovascular disease (CVD) and cancer, account for nearly two-thirds of all deaths in the United States.' Recent dietary guidelines recommend diets that are low in fat and saturated fat, high in fiber, and rich in vitamins A and C and other phytochemicals to reduce the risk factors for CVD'-3 and cancer.'^^.^ Fruits and vegetables (rich sources of beta-carotene, retinoids, other antioxidants [vitamins C and El) and phytochemicals thought to inhibit cancer initiation and are the only two food

This research was partially funded by the 1994 Hertzler Grant from the American Dietet~c Association. Address for correspondence: Karen Weber Cullen, Dr. P.H., R.D., L.D., Research Associate, Department of Behavioral Science-Box 243, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston,TX 77030;Tel: (713) 792- 0919; Fax (713) 794-4730. 01997 SOCIETY FOR NUTRITION EDUCATION

groups that have consistently been shown to decrease the risk of almost every group of cancers studied.' Eating at least five servings of fruits and vegetables (F&V) each day is a current recommendation for healthful diets.8

Neither children nor adults are meeting these recom- mendati0ns.A national survey of 4700 family members from 2000 households found an average daily F&V intake of three serving^.^ An average daily intake of 2.65 servings of F&V was found in a group of 196 fourth- and fifth-grade children.1° In a survey of 1797 second- and fifth-grade students in NewYork, 20% had not eaten any fruit, 58% had juice but no fruit, 15% ate no vegetables, and 40% ate no vegetables except potatoes and tomato sauce." Only 14% of 14- to 22- year-old persons completing a national survey reported eating five or more servings of F&V per day.12

Since many of our eating habits and patterns as adults are established in early childhood, children are an important target for interventions to change nutrition behavior.13-l6 Early youth nutrition education programs that focused on knowledge gain were not successful in achieving behavior change.17Js More recent school-based programs target the personal, parental, and other environmental factors that influence food choice^.'^-^^ Personal influences include individ- ual behaviors (skills and knowledge) and the perceived envi- ronment (norms); cognitive factors include personal values, degree of self-management, self-efficacy, and beliefs about ability and outcomes; and environmental factors include models (parents, friends, teachers,TV stars), networks (fami- lies and peer groups), social systems (schools and work- places), and community message structures (advertising).I9

Although these school programs have achieved modest suc- cess in promoting behavior change, researchers have proposed using other settings and networks, such as community and leisure-time settings, for health education p r~grams .~~ ,~~-*~These settings can provide additional support, motivation, and reinforcement for behavior change.The Girl Scout organization is an excellent example of a community network; approximately 3 d i o n girls and 600,000 volunteer adults are involved in this organization in the United States. Moreover, the promotion of health and fitness is a national Girl Scout o b j e c t i ~ e . ~ ~ Since Girl Scouts earn badges that require the completion of art, craft, and skill development activities, a badge promoting F&V intake was developed for 9- to 12-year-old Junior Girl Scouts.

Journal of Nutrition Education Volume 29 Number 2 March April 1997 87

Social Cognitive Theory (SCT) was used to guide the selection of the behavioral determinants and intervention methods." Specifically, the intervention constitutes badge activities that attempt to increase the knowledge, skills, and self-efficacy of the Girl Scout to identify current F&V intake, set goals for intake, identify barriers to eating F&V, and mon- itor intake.28 Troop support encourages F&V eating. behaviors and promotes the acceptability of eating F&V. This report presents the results of an evaluation to determine the effectiveness of the Eat 5 badge to increase F&V intake in 9- to 12-year-old Junior Girl Scouts. It was hypothesized that F&V intake would be related to self-efficacy, barriers, norms, behavioral capability (knowledge and skills), and fruit and vegetable preferences, and that girls in troops completing the Eat 5 badge would report greater intakes of F&V, greater levels of self-efficacy, knowledge, and F&V preference, and reduced negative influences from norms and barriers than girls in troops not completing the badge.

METHODS

Subjects. Twenty-two Junior Girl Scout troops with approximately 300 girls were recruited from a local Girl Scout Council.There were eight fourth-grade troops, seven fifth-grade troops, two sixth-grade troops, and five mixed troops with fourth-, fifth-, and sixth-grade girls. All troops met weekly for 1 to 1; hours, with the exception of one sixth-grade troop, which met biweekly. This study was approved by the Committee for the Protection of Human Subjects at the University ofTexas Health Science Center at Houston and the Girl Scout Council. Both parental and Girl Scout consent was obtained.

Study design. A randomized pretest-post-test control group design was used. The participating troops were randomized by grade level into intervention or control condition to ensure an even distribution of girls by grade in the intervention and control conditions. A nested hierarchical design, evaluating the effects of both the study condition and troop membership on F&V intake, was used to answer the primary study questions.29

Intervention. Table 1 presents the performance objectives and required activities for the intervention that were to be completed over four troop meetings. In Session 1, the girls learned how to complete 3-day food records and chose a buddy to call during the week and encourage to complete the food record.The remaining activities, completed during the subsequent three meetings and estimated to last about 1 hour, were designed to increase F&V exposure and preparation skills and knowledge and skills in self-evaluation, self- monitoring, goal setting, and problem solving, and to estab- lish troop norms for serving and eating F&V. F&V were prepared and tasted at each meeting. Parent information sheets were sent home to enlist parental support for supply-

Table 1. Eat 5 badge performance objectives and required activities.

Performance Objectives

The Girl Scout will be able to:

1. Evaluate personal food record for fruit and vegetable intake.

2. Identify barriers to eating fruits and vegetables.

3. Plan menus that include five servings of fruits and vegetables

each day.

4. Select fruits and vegetables to eat in many settings (home,

school meals, grocery stores, restaurants).

5. Prepare fruits and vegetables for personal and family

consumption.

Required Activities

1. Complete a 3-day food record.

2. Complete the two weekly food monitoring sheets.

3. Evaluate home, school lunch (or school snack bar menu),

and a restaurant menu for fruits and vegetables.

4. Try one new fruit or vegetable each week for 2 weeks.

5. Create an advertising program for eating five fruits and

vegetables (in your patrol).

6. Plan menus for your family for one weekend (both Saturday

and Sunday). Include five servings of fruits and vegetables

for each day. Prepare a fruit or vegetable dish or both for two

of those meals for your family.

7. Prepare a suggested list of fruit and vegetable snacks that

would be appropriate for Girl Scout parties and campouts.

8. Plan the meals for a Girl Scout campout for a weekend (2

days) with five servings of fruits and vegetables for each day.

ing fruits and vegetables for tasting and to encourage F&V consumption at home. Girl Scouts completing the badge activities received an Eat 5 badge designed for this study.

Leader training. The intervention condition troop leaders received the leader manual by mail about 2 weeks before Session 1. Immediately prior to Session 1, each leader met with the investigator to review the lessons and receive the handouts and badges.The principal investigator taught Ses- sion 1. All intervention condition leaders were asked to complete an Implementation Log after each session, identi- fying the activities completed, girls' responses, and leader comments.

Measures. Girl Scouts completed a 1-day Food Recogni- tion Form (FRF) and a Determinants of Food Behavior Questionnaire (DFBQ) assessing personal and environmental determinants hypothesized to influence F&V consumption immediately before Session 1 was taught and about 1 week after the badge activities were completed. The Girl Scouts completed the intervention in four troop meetings. Three months later, the girls who were present at the troop meeting completed a third FRF and the control condition troops received the intervention materials.Al1 data were collected by the first author (KWC). No record was maintained

88 Cullen et al./GIRL SCOUTING

of the activities each girl completed. Data from all girls who were present at each data collection were analyzed.

FGV intake. Change in daily consumption of servings of F&V after completing the Eat 5 program was the major dependent variable evaluated in this study. The daily intake of fruit, vegetables, and 100% fruit juice was measured with the FRF, a one-page modified food frequency questionnaire that listed foods within 12 food groups.There were 10 fruits, 13 vegetables, and 2 fruit juices listed, with space to write in other F&V items. The girls checked off the foods that they consumed in the previous 24 hours, and the items identified in the F&V categories were summed for a measure of F&V consumption. The FRF was previously validated in a pilot

In this pilot study, 75 Junior Girl Scouts were taught how to complete a 3-day food record at one Girl Scout meeting.Two weeks later, the food records were collected and the girls completed a 1-day FRF used in a previous study3' Thirty-one girls (41%) returned 3-day food records. Servings of F&V from the food records were obtained by using the portion sizes identified in the Food Guide Pyramid.32 Serv- ings of F&V from the FRF were obtained by summing the number of F&V items checked. No difference was found in mean F&V intake between the two methods (p = .98). Mean F&V intake from the FRF was 2.08 f 1.87 servings per day; mean F&V intake from food records was 2.10 + 1.50 servings per day.This FRF appears to be an acceptable measure of group mean F&V intake in this population.

Personal and environmental determinants. Knowledge of F&V needs, F&V preparation skills, self-efficacy, F&V preferences, norms, and barriers were assessed with the DFBQ. These scales were previously validated in a pilot study.31 Five items measured skills in food preparation, menu planning, and grocery shopping (e.g.,"How many times in a week do you help prepare your lunch?") with a 4-point Likert scale (never to every day). Seven items measured self-efficacy for preparing, selecting, and eating F&V (e.g., "How sure are you that you can eat the vegetables your Mom fixes for supper?") using a 4-point Likert scale ("I'm sure I can't," "I think I can," " 1 I m sure I can," "I'm very sure I can"). Eight items measured barriers to eating F&V (e.g., "There are not a lot of F&V at my house") using a 5-point scale (strongly disagree to strongly agree). The perceived influence of parents, friends, and teachers on eating F&V was measured with a 4-point scale (never to always), and the attention paid to that influence was measured using a 3-point scale (none, some, a lot). The responses were multiplied to obtain a measure of sub- jective norms for teachers, parents, and friends and summed to create the norms scale.There were three knowledge questions specific to F&V (e.g., "At least how many servings of F&V should you eat each day?"). F&V preferences were measured for 10 fruits and 10 vegetable^.^^ The girls were asked how much they liked the fruit or vegetable (a lot, a little, or not). Ethnicity, family composition, and grade in school were also recorded.

Data analysis. Frequency distributions of ethnicity and family composition were reported by condition (intervention and control). Scale scores were calculated for knowledge, barriers, self-efficacy, norms, skills, and F&V preferences.Analy- sis of variance (ANOVA) was used to compare troops in the intervention and control conditions. Spearman rank corre- lation analysis was used to evaluate the association between the hypothesized determinants and F&V intake of the girls. A nested hierarchical ANOVA, using troop as the unit of analysis, was used to assess change in F&V intake, skills, knowledge, self-efficacy, norms, barriers, and F&V preferences. SPSS (SPSS 6.1 for Windows, 1994, SPSS Inc., Chicago, IL) and SAS (release 6.0,1994, SAS Institute, Cary, NC) were used for the analyses.

RESULTS

Demographics and attrition. The girls participating in this study were 75% Caucasian, 11% Hispanic, 3% African- American, and 11% other ethnic groups. Ninety-one percent of the girls lived with both parents.There were no significant differences between intervention and control conditions for ethnicity (p > .43), family composition (p > .94), or grade level (p > .08).

All of the troops participated in the post-test and 3-month follow-up. However, 48 girls (18.5%) were not present at the post-test and an additional 48 girls (23%) were missing at the 3-month follow-up.There were no significant differences in demographics or pretest F&V intake between those missing and the girls who completed all of the measures. Due to time and budget limitations, those missing at the data collection times were not contacted to complete the measures.

Personal and environmental determinants. No significant differences were found on the pretest for any scale between conditions (Table 2). F&V intake was significantly correlated with self-efficacy (r = .26, p < .012), barriers (r = .26,p = .OOO),vegetable preference (r = .23,p = .000),hit preference (r = .16, p < .013), and norms (r = .14, p < .024). Internal consistency coefficients for the scales, with the exception of the skills scale, were within acceptable limits for behavioral research and are presented in Table 2. The skills scale assessed level of skills for several areas associated with food preparation: preparing breakfast, lunch, and other meals; menu planning; and grocery shopping.

The intervention significantly increased the knowledge (p < .0002), fruit preference (p < .0459), and vegetable preference (p < .0496) of the girls in the intervention conhtion troops compared with girls in the control condition troops. However, no change was found for self-efficacy, barriers, norms, or skills.

F&V intake. Only 20% of this sample consumed five or more servings of F&V per day; 17% reported consuming no F&V on the survey day.Table 3 presents F&V intake for the

Journal of Nutrition EducationVolume 29 Number 2 March April 1997 89

Table 2. Pretest ranges, means, standard deviations, and Cronbach's alpha of the DFBQ scales for the total sample of Girl Scouts by condition.

Mean (SD)

Number of Overall

Scale Items Alpha Range (n = 210)

Intervention Control

(n = 101) (n = 109)

Barriers 8 .74 4-23 19.50 (3.40) 19.97 (3.10) 19.13 (3.60)

Fruit 10 .72 0-2 1.41 (0.39) 1.39 (0.37) 1.45 (0.37)

preference

Knowledgea 3 .63 0-3 0.38 (0.76) 0.40 (0.65) 0.37 (0.85)

Norms 4 .69 0.3-26 14.02 (5.37) 13.65 (5.36) 14.36 (5.46)

Self-eff icacy 7 .70 0.4-17 7.35 (2.28) 7.26 (2.27) 7.42 (2.29)

Skills 5 .51 0.4-12 5.93 (1.47) 6.1 1 (1.47) 5.75 (1.45)

Vegetable 10 .74 0-2 0.83 (0.44) 0.83 (0.45) 0.83 (0.43)

preference

aKR2, used to calculate internal consistency for this scale.

Girl Scouts by condition at each measurement.There were significant differences in F&V intake between conditions at pretest. A nested ANOVA model with troop as the unit of analysis and pretest F&V intake and grade as covariates was used to assess the impact of the Eat 5 program on F&V intake. The change in F&V intake for girls in the intervention condition troops was significantly greater at post-test than the control condition troops (p < ,0019) but returned to pretest levels at the 3-month follow-up (p > .13).

Leader implementation of the Eat 5 program. Mean completion of implementation of the Eat 5 program (the "dose") was 87% among the nine intervention condition leaders who returned the leader 1ogs.This was calculated from the leader logs by summing the activities completed and dividing by the total number of intervention activities. The F&V tasting and creating an advertising program for F&V were the most popular activities.The activity most often not completed was reviewing the homework assignments. All of the

leaders expressed the opinion that the idea of the Eat 5 badge was a good one but identified a need for more time to complete the activities and a reduction of papenvork/homework.

Girl Scout evaluation of the Eat 5 program. One hun- dred girls (99%) completed post-test evaluation forms.Tasting fruit and some vegetables was indicated as the most liked activ-

ity in the Eat 5 program. Creating the advertising campaign was also a favorite activity.About one-half of the girls suggested reducing the papenvork/homework in the program.

DISCUSSION

The pretest mean F&V intake of 2.6 servings per day reported in these fourth-, fifth-, and sixth-grade girls was consistent with the poor F&V intake of children reported in other re~earch.'~.~' In this study, pretest F&V intake was significantly correlated with several personal and environmental determinants. Girls who reported higher levels of self-efficacy, higher F&V preferences, more positive norms, or fewer barriers reported greater intakes of fruits and vegetables.

At post-test, the girls in the intervention condition troops who completed the Eat 5 badge reported a significantly greater intake of F&V compared with girls in the control condition troops, after adjusting for grade level and pretest

F&V intake. However, the increased F&V intake of girls in the intervention condition troops was not sustained 3 months later. There was no change in self-efficacy, barriers, skills, or norms after the intervention.

The Eat 5 program was effective in increasing knowledge of F&V, fruit preferences, and vegetable preferences among girls in the intervention troops. A key component of the Eat

Table 3. Mean daily servings of fruits and vegetables at the three measurements for the total sample by condition.

Pretest Post-test 3-month Follow-up

Sample n Mean (SD) n Mean (SD) n Mean (SD)

Total 259 2.20 (2.13) 21 0 2.70 (1.93) 162 2.60 (1.73) Intervention 126 3.02 (2.21)'t 101 3.39 (1.93)' 80 2.89 (1.60) Control 133 2.20 (1.96)t 109 2.06 (1.71) 82 2.32 (1.81)

'Significant difference, p < .01, pretest to post-test values; +significant difference, p < .01, at pretest.

90 Cullen et al./GIRL SCOUTING

5 program was the preparation and tasting of F&V at three of the troop meetings, and both leaders and Girl Scouts reported that this was a favorite activity in the intervention. Research has identified taste and exposure to foods as important determinants of food p r e f e r e n ~ e . ' ~ , ~ ~ - ~ ' Increased nutrition knowledge10~19.21~38~39 and F&V preference^'^." have been reported as outcomes in previous studies.

Other studies using theory-based nutrition education emphasizing behavioral changes have reported positive changes in food behavi~r.'~,'~,~~,~~-~~The methods and strategies used in these interventions also included self-assessment, self-monitoring, goal setting, behavioral capability, and mod- eling. Most of these programs lasted a minimum of 10 ses- sions and three have reported continued positive results at follow-up measurement^.^^^^^^^^

The finding that self-efficacy, barriers, skills, and norms did not change after the intervention could explain the lack of sustained F&V intake 3 months later. From a theoretical perspective, the most powerful enhancer of self-efficacy is the actual performance of the behavior with feedback and rein- f~rcement .~ ' In this intervention, the girls had some opportunity at troop meetings to practice food-related slulls by preparing and eating F&V. Perhaps more extensive structured opportunities to practice at home with parents, where most food preparation actually takes place, should have been pro- vided.This type of activity would be expected to also influence the girls' perception of parental norms as well as to affect barriers related to parent behavior. Establishing F&V as usual foods for Girl Scout events and as choices in other social settings (e.g., school lunch and restaurants) would help to reset norms. The Eat 5 badge activities were completed in four meetings, with pre- and post-tests occurring only 5 to 6 weeks apart. In previous research, diet self-efficacy was increased after 2-year school-based cardiovascular health promotion programs for third and fourth graders that included both a classroom curriculum and cafeteria changes."~~~ The leader and Girl Scout evaluations indicated difficulty in completing the current activities within the four-meeting period with too much homework-like material. In response to these evaluations, the intervention was revised to focus on the eight activities distributed over a longer period of time rather than the four-session program evaluated in this study. This would allow the girls to practice and receive reinforcement for F&V preparation and eating behaviors, to perceive new norms for eating F&V within their troop as these foods were regularly served for snacks and possibly at home, and to receive support for identieing and reducing barriers to eating F&V.

Limitations o f this study. All data were collected from self-report instruments and were subject to human error and bias.The FRF measured F&V intake for only 1 day and may not be a true measure of F&V intake.There is a large amount of variation associated with such a limited measure and can only be used as a measure of group nutrient/food intake.45 A further limitation is that the ethnicity and family composition of the girls were not representative of the general pop-

ulation. However, there is no reason to believe that the theoretical determinants of eating behavior would be different for other groups of girls. Similar results would be expected with other population groups if the intervention activities are tailored specifically for these groups.

CONCLUSIONS

This study shows that knowledge about F&V, F&V preferences, and F&V intake in 9- to 12-year-old girls can be improved over the short term by a relatively brief intervention delivered through the unique channel of community youth groups.There may be several reasons for these findings. The social context of Girl Scouting was a good setting for an intervention with theory-based behavioral activities that targeted increasing personal control of and self-efficacy for selecting, preparing, and eating F&V. Support and social reinforcement for eating F&V were obtained from troop leaders, fellow Girl Scouts, and parents.The results were good and could be made even stronger by increased performance to enhance self-efficacy, by more activities to ensure gener- alization of skills to the home setting, and by establishing F&V as usual foods in all food settings.

A significant problem for health education programs, including nutrition education, is that successful programs often are not maintained, institutionalized, or diffused to other settings. The implications regarding program implementation and diffusion of the current study are significant. If adopted and implemented nationally, the program has the opportunity to reach millions of girls through this one network and to become a model for the development of programs for other youth groups.This is particularly encouraging from a program institutionalization perspective because many organizations such as Girl Scouts have stable structures with the ability to deliver activities to members with very little ongoing pro- grammatic support. Because of the difficulty associated with changing dietary behavior, new channels for nutrition education warrant identification, and the study reported here is a good example of a new and important channel.

ACKNOWLEDGMENTS

This paper is taken from the doctoral dissertation completed by the first author (KWC) at the University ofTexas-Hous- ton, School of Public Health. Many thanks to the staff at the SouthTexas Girl Scout Council and to the leaders and members of the 22 Girl Scout troops who participated in this study.

REFERENCES

1. U.S. Department of Health and Human Services, Public Health Ser-

vice. Healthy People 2000: national health promotion and disease pre-

vention objectives-full report. DHHS publication no. (PHs) 91-

50212.Washlngton, DC: U.S. Government Printing Office, 1991.

Journal of Nutrition EducationVolume 29 Number 2 March April 1997 91

2. U.S. Department of Agriculture. Dietary Guidelines for Americans.

Washington, DC: USDA, 1995.

3. American Heart Association.The American Heart Association Diet - an eating plan for healthy Americans. Dallas, 1985.

4. American Cancer Society. Nutrition, common sense, and cancer. New

York: American Cancer Society, 1985.

5. Greenberg ER, Baron JA,TostesonTD, et al.A clinical trial of antioxidant

vitamins to prevent colorectal adenoma. N Engl J Med 1994;331:141-7.

6. The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group.

The effect of vitamin E and beta carotene on the incidence of lung can-

cer and other cancers in male smokers. N Engl J Med 1994;330:1029-35.

7. Willett W,Trichopoulos D. Nutrition and cancer: a summary of the evi-

dence. Cancer Causes and Control 1996;7:178-80.

8. Havas S, Heimenchnger J, Reynolds K, et al. 5 a day for better health:

a new research initiative. J Am Diet Assoc 1994;94:32-6.

9. Lofgren PA. Eating in America today: a dletary pattern and intake

report. Food Nutr News 1994;66(2):9-11.

10. Domel SB, Baranowski T, Davis H, et al. Development and evaluation

of a school intervention to increase fruit and vegetable consumption

among 4th and 5th grade students. J Nutr Educ 1993;25:345-9.

11. Wolfe WS, Campbell CC. Food pattern, diet quality, and related charac-

teristics of school cluldren in NewYork. JArn Diet Assoc 1993;93:1280-4.

12. Center for Disease Control. Health risk behaviors among adolescents who

do and do not attend school - United States, 1992. MMWR 1994;43:

129-32.

13. Birch LL. Children's food preferences: developmental patterns and envi-

ronmental influences. Ann Child Dev 1987;4:171-208.

14. Rozin PThe acquisition of food habits and preference. In: Matarazzo JD,

Weiss SM, Herd JA, Miller NE, eds. Behavioral health: a handbook ofhealth

enhancement and disease prevention. NewYork:JohnWiley & Sons, 1984.

15. Wynder EL. Primary prevention of cancer.The case for comprehensive

school health education. Cancer 1991;67(Suppl6): 1820-3.

16. Roberts MC, Maddux JE, Wright L. Developmental perspectives in

behavioral health. In: Matarazzo JD,Weiss SM, Herd JA, Miller NE, eds.

Behavioral health: a handbook of health enhancement and disease pre-

vention. NewYork: John Wiley & Sons, 1984:590-607.

17. Contento IR.The effectiveness of nutrition education and implications

for nutrition education policy, programs, and research: a review of

research. J Nutr Educ 1995;27:279-418.

18. Hochbaum GM. Strategies and their rationale for changing people's

eating habits. J Nutr Educ 1981;13 (Suppl):S59-65.

19. Perry CL, Mullis R M , Maile MC. Modifying the eating behavior of

children. J Sch Health 1985;55:399-402.

20. Perry CL, Murray DM. Enhancing the transition years: the challenge

of adolescent health promotion. J Sch Health 1982;52:307-11.

21. Parcel GS, Simons-Morton B, O'Hara NM, et al. School promotion of

healthful dlet and physical activity: impact on learning outcomes and

self-reported behavior. Health Educ Q 1989;16:181-99.

22. Edmundsen E, Parcel GS, Feldman HA, et al.The effects of the Child

and Adolescent Trial for Cardiovascular Health upon psychosocial

determinants of diet and physical activity behavior. Prev Med

1996;25:442-54.

23. Johnson DW, Johnson RT.The process of nutrition education: a model

for effectiveness. J Nutr Educ 1985;17(Suppl):Sl-44.

24. Mullen PD, Evans D, Forster J, et al. Settings as an important dimen-

sion in health education/promotion policy, programs, and research.

Health Educ Q 1995;22:329-46.

25. Dubas JS, Snider BA. The role of community-based youth groups in

enhancing learning and achievement through nonformal education. In:

Lerner RM, Ed. Early adolescence: perspectives on research, policy, and

intervention. Hillsdale, NJ: Erlbaum Associates, 1993:159-74.

26. Orullain BL. President's message. National Girl Scout Leader 1995;

Summer:4.

27. Bandura A. Social foundations of thought and action. Englewood

Cliffs, NJ: Prentice Hall, 1986.

28. Cullen KW, Bartholomew LK, Parcel GS, Kok G. Intervention mapping:

use of theory in the development of a nutrition program to increase fruit

and vegetable intake in 9-12-year-old girls. Manuscript in review, 1996.

29. Neter J,Wasserman W, Kutner MH.Applied linear statistical models, 3rd

Ed. Boston: Irwin Publishers, 1990.

30. Cullen KW. Development, pilot testing, and evaluation of a nutrition

education program designed to increase fruit and vegetable consump-

tion in girls, ages 9-12. Unpublished chssertation, University ofTexas-

Houston School of Public Health, 1995.

31. Simons-Morton BG, Baranowski T, Parcel GS, et al. Children's fre-

quency of consumption of foods high in fat and sodium. Am J Prev

Med 1990;6:218-27.

32. Human Nutrition Information Service. The Food Guide Pyramid.

Home and Garden Bulletin Number 252. Hyattsville, MD: U.S. Depart-

ment ofAgriculture, 1992.

33. Domel SB, Baranowski T, David H, Leonard SB, Riley P, Baranowski J.

Measuring fruit and vegetable preference among 4th and 5th grade stu-

dents. Prev Med 1993;22:866-79.

34. Birch LL.The role of experience in children's food acceptance patterns.

J Am Diet Assoc 1987;87(Suppl):S36-40.

35. Michela JL, Contento IR. Spontaneous classification of foods by ele-

mentary school-aged children. Health Educ Q 1984;11:57-76.

36. BaranowskiT, Domel S, Gould R , et al. Increasing h i t and vegetable con-

sumption among 4th and 5th grade students: results horn focus groups

using reciprocal determinism. J Nutr Educ 1993;25:114-20.

37. Contento IR, Michela JL, Goldberg CJ. Food choice among adolescents:

population segmentation by motivations. J Nutr Educ 1988;20:289-98.

38. Graves K, Shannon B, Sims L,Johnson L. Nutrition knowledge and atti-

tudes of elementary school students after receiving nutrition education.

J Am Diet Assoc 1982;81:422-7.

39. Shannon B, Chen AN.A three-year school-based nutrition education

study. J Nutr Educ 1988;20:114-24.

40. Coates TJ, Jeffery RW, Sllnkard LA. Heart healthy eating and exercise:

introducing and maintaining changes in health behaviors. Am J Public

Health 1981;71:15-23.

41. Walter HJ. Primary prevention of chronic disease among children: the

school-based "Know Your Body" intervention trials. Health Educ Q

1989;16:201-14.

42. Whlte AA, Slunner JD. Can goal setting as a component of nutrition edu-

cation effect behavior change among adolescents? J Nutr Educ 1988;20:

327-35.

43. Howison D, Neidermyer FS, Shortridge R . Field testing a fifth-grade

nutrition education program designed to change food-selection behav-

ior. J Nutr Educ 1988;20:82-6.

44. Perry C, Luepker RV, Murray DM, et al. Parent involvement with chil-

dren's health promotion: The Minnesota Home Team. Am J Public

Health 1988;78:1156-60.

45. Randall E. Measuring food use in school-aged children. J Sch Health

1991;61:201-3.

Documents

Girl Scouting: An Effective Channel for Nutrition Education