From the Journal of Health Care for the Poor and Underserved
23.4, November 2012
Nicholas I. Sikic, MD, MPH
Nancy Erbstein, PhD
Kearnan Welch, MS
Ethan Grundberg, MS
Elizabeth Miller, MD, PhD
Abstract: Introduction. This study examined the acceptability and feasibility of Fresh Producers, a student-run fruit and vegetable distribution program at three urban high schools located in low-income neighborhoods, and its potential impact on the nutrition and professional development of participating students. Methods. Thirteen focus groups conducted with 72 students explored the program’s impact on their dietary habits and professional skill development, and discussed program challenges. Responses were coded for common themes by multiple investigators. Results. Participants reported increased fruit and vegetable consumption, and improved interpersonal, team-building, and organizational skills. Challenges included integration into the school schedule and environment and limited faculty support for business activities. Conclusion. This program is acceptable and feasible for secondary school students in a variety of school settings. Students reported positive changes in professional skills and nutrition. Training and support for students and faculty, including strategies to improve program integration into the school context, could increase participation.
Fruit and vegetable consumption among American children and adolescents remains far below recommended levels. Nutritional surveys have found that only about 10% of adolescents meet the daily recommendations for fruit and vegetable intake, and that the largest source of vegetables that children and adolescents consume are fried potatoes.1–3 These surveys also show that the least affluent children and adolescents eat the fewest fruits and vegetables and consume the most fast food and soda.2,4,5 Low-income youths often live in food deserts, areas without supermarkets or access to healthy foods such as fresh fruits and vegetables.6–8
Improving fruit and vegetable consumption among children and adolescents could have an important public health impact. Increased intake of fruits and vegetables has been associated with improved symptoms of respiratory illness in childhood,9–11 decreased markers of heart disease in adolescence,12 and lower rates of chronic diseases later in adult life.13–15 Although the relationship between obesity and produce consumption in children and adolescents has not been established, initial studies have shown that a higher intake of and preference for fruits and vegetables is associated with healthier weights in children.16–18
As the central institution in children’s lives, schools have become a natural proving ground for interventions aimed at increasing fresh produce intake.19,20 These interventions have increasingly focused on non-didactic, experiential strategies, such as garden projects and cooking classes.21,22 Many of these school-based interventions have been shown to improve student knowledge and attitudes about fruits and vegetables and increase their intake of fresh produce.23–28 Because most of these interventions have been implemented in elementary schools, few have involved secondary school students, raising questions about effective and sustainable strategies for improving fresh produce consumption among adolescents.
Fresh Producers. Fresh Producers is a non-profit school-based program that provides high school students with an entrepreneurial experience and empowers them to become the source of convenient, affordable fresh fruits and vegetables in their communities. Based in South Sacramento, a multi-ethnic urban area that was recently identified as a major food desert,29 the program has the dual objectives of increasing fruit and vegetable consumption in communities with low access to fresh produce, while providing participants with experience running their own business. Students function as co-owners would, managing various functions of distribution, product marketing, and point of purchase sales. They take weekly orders for fresh fruits and vegetables throughout the school year, and then receive seasonal, fresh produce through a wholesaler, which they repackage and arrange for customer pick-up. The opportunity to earn income for themselves or their school is an additional incentive to participate in the program. Since its inception in 2007, Fresh Producers has delivered over 125,000 servings of fresh produce in the greater Sacramento area.
The Fresh Producers program was first developed in 2007 at a charter high school, where it was part of a multidisciplinary curriculum designed to teach 11th and 12th grade students about nutrition and provide them with the skills to assess and improve the health of their community. The curriculum was taught across different subjects with the involvement of multiple classes and teachers. Fresh Producers facilitated student activities in the community, which included selling fresh fruit and vegetable boxes in the surrounding neighborhood.
The program became focused solely on the student-run sales of fruit and vegetable boxes, without the multidisciplinary curriculum, when it expanded to two new schools in 2009: a continuation school for students at risk of not graduating from high school, where it was run as a stand-alone extracurricular activity, and a traditional four-year high school, where it became a project for students in the school’s business academy. At both schools, the program involved 11th and 12th grade students. A percentage of the proceeds from fruit and vegetable sales were returned to the two schools. At the traditional high school, this revenue funded academic and extracurricular activities, and at the continuation high school participating students received the proceeds in the form of gift cards.
This study was designed as an initial evaluation of the acceptability, feasibility, and potential impact of Fresh Producers among students in the three high schools described above, focusing on three specific areas of inquiry: 1) impact of the program on the nutrition and dietary choices of participants; 2) the professional skills development reflected on by participants; and 3) challenges with program implementation and feedback for improvement.
Participants. Thirteen focus groups were conducted with a total of 72 students at the three participating high schools: eight focus groups with 54 students at the charter school, three focus groups with 10 students at the traditional high school, and two focus groups with eight students at the continuation school. All three high schools are located in low-income neighborhoods in South Sacramento, with student bodies that are predominantly African American and Latino. More than 50% of students at each school are eligible based on family income for free or reduced price meals from the National School Lunch Program. All focus group participants were in either 11th or 12th grade. The focus groups were conducted in the spring of 2009 at the charter school and the spring of 2010 at the traditional and continuation schools.
Students returned signed parental consent forms, and completed a youth assent form. The written consent forms were reviewed aloud in detail, confidentiality was discussed, and questions were answered about how the information would be used. The study design was reviewed and approved by the University of California at Davis Institutional Review Board.
Data collection. Focus groups were semi-structured, pursuing questions in three areas: (1) the program’s impact on participants’ dietary choices, including any changes in fruit and vegetable consumption; (2) participants’ development of organizational, communication, and team-building skills; and (3) participants’ suggestions for improving program implementation. Each focus group included between two to 12 students and lasted 30 to 60 minutes. They were conducted by research team members, and took place on the campuses of the three participating schools. A research team member took notes during the focus groups at the charter school; at the traditional and continuation high schools focus groups were documented via notes and audio-recordings.
Data analysis. The authors developed a list of provisional themes and sub-themes related to the focus group questions. Audio-recordings from the traditional and continuation high schools were transcribed, and each transcript was then reviewed and coded for these themes by three members of the evaluation team. Notes taken at the charter school were also reviewed and coded by three members of the evaluation team. Using the method of thematic analysis described by Ryan and Bernard,30,31 initially the three coders created an a priori list of codes related to key themes of interest such as community engagement, business skills, fresh produce consumption, and challenges with program implementation. Additional codes were added as these emerged in the review of each transcript, discussed among the team, and the range of responses confirmed through an iterative process of multiple reviews of the transcripts. Differences in coding were discussed until consensus was achieved.
Participant responses largely focused on the three areas of interest (dietary impact, professional development, and program challenges) but one additional major theme arose from the discussions: the financial incentive to take part in Fresh Producers. This theme emerged only at the continuation high school, where students were paid with gift cards for their work with the program, and was a key feature of the program reported
by all of the focus group participants at that school.
Promotion of a healthy diet. At both the charter school and traditional high school, the majority of students in the focus groups reported an increase in fruit and vegetable intake because of their involvement with Fresh Producers. They also reported developing knowledge about healthy foods and nutrition. Students specifically mentioned consuming more fruits and vegetables and less soda and junk food, as well as increasing their levels of exercise.
- My diet has improved. I know more about calories and vitamins now.
- I saw different types of produce. I didn’t realize that there is more than one type of cucumber.
- I eat fewer sweets now, and more produce.
At the continuation high school, however, only one of the eight students in the focus
groups reported eating more fruits and vegetables after participating in Fresh Producers.
The other students reported that their dietary and exercise habits had not changed.
- I don’t like fruit.
- I already eat fruits and vegetables.
Professional skill development. The majority of students at all three high schools felt that they had gained valuable work experience from Fresh Producers. Being part of a team and working in a sales environment were identified as important factors, and students reported improved interpersonal, time management, and team building skills. Students at each school felt that the experience they had gained would be valuable for
them in future jobs.
- It’s taught me social skills, like how to really get out there and speak and know how to come up to a person and present yourself.
- You get a good mindset from doing this. You need to know what you’re doing . . . you need to know how to talk to [customers].
- I have a better understanding of the business world now.
Several students also noted that the experience changed their attitudes and behaviors toward school, describing how these shifted over time.
- Fresh Producers made me more involved with school. It started off as a lot of work,
but then it became fun. It will be good for my application and for a business major.
- I can’t act like I used to [in school], I had to grow and evolve.
However, this was not a broadly shared outcome.
Financial incentive. The financial incentive of working with Fresh Producers was not mentioned as a key motivator by students at the charter high school, where no proceeds were returned to the site, or the traditional high school, where the money from fruit and vegetable sales were spent on classroom activities. At the continuation high school, where students were paid for their work with gift cards, earning an income was a major motivation for all of the students in the focus groups.
- I wanted to make some quick money.
- [Fresh Producers] made me want to wake up and get $10.
- They said go to Fresh Producers, come here at 8 o’clock ’cause you’re getting some money.
Acceptability, feasibility, and implementation challenges. Overall, students were positive about program implementation. They found the program itself to be appropriate for a school setting and logistically viable. Students at all three schools reported that the system for taking orders and providing deliveries ran smoothly, with no significant breakdowns. Deliveries were on time and contained the correct number of orders, and customer feedback was generally positive about the content and delivery of the fresh produce parcels. The majority of students felt that the program was a good “real-world” supplement to their classroom learning, and that the faculty and staff involved with Fresh Producers emphasized the educational experience as well as the business components.
However, students also identified program challenges. At the charter high school, students reported that some of the participating teachers seemed unfamiliar with the goals of Fresh Producers and with the integrated curriculum that was intended to build associated academic skills and knowledge. The students felt that this led to a lack of faculty support for program activities at the school.
At the traditional high school, where Fresh Producers was a project for students involved in the school’s business academy, students struggled to find potential customers. They also felt that the produce could have been marketed in a more student-friendly manner.
- It was hard to get people to buy. Students aren’t interested.
- It was hard to establish connections, [students] weren’t listening.
- We should sell individual fruits so you can grab and go.
- There should be smaller bags of produce.
At the continuation high school, the main challenge identified by students was the lack of an organized system for their financial reimbursement. It was difficult for them to determine exactly how much money they had earned and what they were owed, and they said that they did not receive gift cards at regular intervals. Every student in the focus groups identified this as the major challenge with the program.
- The pay wasn’t right, though. Everybody was unhappy with the pay.
- [My teacher] tried to say it was a job that was going to help us get money but all we get is $10 every, what, two or three weeks?
- You want the money to be fair.
Despite the problems with their payments, all of the students at the continuation school emphasized that they would still be willing to work with the program in the future, with the hope that a smoother payment process could be devised.
The Fresh Producers program was found to be both acceptable and feasible to students at three different high schools, with self-reported improvement in participants’ nutrition and professional skills. The program was designed to engage high school students both as a community health activity and as an entrepreneurial experience. Focus group discussions highlight that this dual interface did affect at least some participants’ dietary habits and professional development. However, student attitudes about the program, and what they felt they learned from the experience, varied greatly at the different program sites.
The varied experiences and opinions of students at each school highlight the program’s flexibility and its ability to engage students on different levels. The program can succeed as either a classroom or extracurricular activity, and in both a traditional high school as well as in schools with alternative curricula. In these diverse settings, the program was found to encourage the professional development of students, promote healthier
eating, and encourage students to think explicitly about the health of their community.
Fresh Producers had a positive effect on the nutrition of students at the charter high school, where it was part of a multidisciplinary health and nutrition curriculum, a result that has been seen with similar curricula that have included school gardens.22–27 At the traditional high school, where the program was a classroom activity for business academy students who received no associated health education, students also reported increased consumption of fruits and vegetables and decreasing junk food and soda intake. At the continuation high school, however, there was little or no change reported in the diet of students after their experience with Fresh Producers.
This difference in nutritional impact may be a result of several factors. Student involvement may have been self-selected based on the program design at each school, with financially motivated students choosing to work with the program at the continuation school where income was available, and more health-conscious students opting to participate at the other schools. The only site that supplied a nutrition curriculum to accompany Fresh Producers was the charter school. Teachers at the other two schools were free to emphasize the parts of the program that they felt were important. Despite the lack of structured health education, however, students at the traditional high school reported improved dietary habits, suggesting that a didactic component may not be necessary to improve nutrition.
Professional training was also an important part of the program, as the majority of students at all three schools reported gaining real-world job skills, including interpersonal and organizational skills and an improved ability to work as part of a team. Improvement in these types of job skills, as well as increased self-confidence and improved attitudes about school and future employment, have been seen in youth taking part in other entrepreneurial programs.32–34
The challenges reported at each site differed, reflecting differences in how the programs were organized at each school. At the charter school, faculty involvement in an ambitious integrated curriculum was variable and inconsistent. At the traditional high school, marketing fresh produce to other students was difficult to organize. At the continuation high school, the financial part of the program was the great motivator but also the greatest challenge, as students said they were not compensated adequately or in an organized manner.
Clearly, improved coordination of the program could overcome some of these challenges, possibly by providing more professional development and resources for participating teachers, and on-site support to teachers and students, perhaps in the form of a youth coordinator. Partnerships with local organizations such as 4-H clubs or community health agencies could provide additional expertise and resources. Strengthening program support could help students have a greater impact on their school and community, including working with school cafeterias and community partners to create youth-friendly campaigns that promote fruit and vegetable consumption.
Limitations of this study include the qualitative nature of the data collection. While the thematic analysis of the focus group discussions revealed a self-reported increase in fruit and vegetable consumption at two of the high schools involved, further research is needed to confirm this trend. Further study would involve pre- and post-participation surveys including 24-hour food recalls, and the measurement of the body mass index of participants to assess any impact the intervention has on obesity. Comparison with a control group would strengthen the findings.
Another limitation was the significant differences in the implementation of the program at each site. Complementary health education, incentives to participate, and levels of teacher involvement differed greatly between the schools, making it difficult to compare the impact of the program across the three sites. In addition, while this article assesses program acceptability and feasibility from the vantage point of participating students, further analysis should also attend to teacher and administrator experiences and examine the program’s impact on the general student body. Despite these limitations, the focus groups demonstrated that high school students in a variety of settings believed that the Fresh Producers program was acceptable and feasible in a low-income urban area with limited access to fresh fruits and vegetables. Our findings also suggest that operating a business selling fruits and vegetables can have an impact similar to other hands-on nutrition education, such as working in a school garden. Just as school gardens teach students how to grow and sustain plants, the students working with Fresh Producers learned how a business runs and how fruits and vegetables fit into their school environment. They saw how other foods competed with their own product, and learned how to market fresh produce to customers, especially their peers.
Motivating youth to think about their food system may also lead to innovative solutions for schools and communities in areas with low access to fresh produce. With an understanding of what appeals to their fellow students, family members, and local community, young entrepreneurs are a valuable resource for developing new strategies to increase fruit and vegetable consumption.
Nicholas Sikic is affiliated with the Pediatric Healthy Lifestyle Center, Department of Pediatrics, Santa Clara Valley Medical Center; Nancy Erbstein with the Department of Human and Community Development at the University of California, Davis (UC-D); Kearnan Welch with the Department of Pediatrics and the UC-D School of Medicine; and Ethan Grundberg with the Agricultural Sustainability Institute at UC-D. Elizabeth Miller is affiliated with the University of Pittsburgh School of Medicine and is Chief of Adolescent Medicine, Associate Professor in Pediatrics, Division of Adolescent Medicine at Children’s Hospital of Pittsburgh. Please address correspondence to Dr. Sikic at the Pediatric Healthy Lifestyle Center; Department of Pediatrics; Santa Clara Valley Medical Center, 751 South Bascom Ave; San Jose, CA 95128; (916) 801-0843; email@example.com.
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