Influence of Cultural Immersion on Willingness to Try Fruits and Vegetables Among Children in Guam: the Traditions Study
Condition: Food Preferences
Study type: Interventional

Summary: 
      The purpose of the Traditions study was to examine the influence of cultural immersion on
      willingness to try fruits and vegetables among children, 3-12 y, in Guam. The primary
      objective of this study was to examine willingness to try fruits and vegetables and fruit and
      vegetable intake among children attending three existing summer camp programs: a cultural
      immersion camp, a university day camp, and a recreational sports camp. The primary hypothesis
      was that children attending the cultural immersion camp would have higher willingness to try
      fruits and vegetables (WillTry score) and a higher intake of fruits and vegetables compared
      to children attending both, the university day camp and recreational sports camp, without
      cultural immersion.

      A pre-post, quasi-experimental design was used to evaluate 3 summer camps with different
      exposure levels of cultural immersion. High, moderate, and zero (cultural) exposure was
      provided by a cultural immersion camp (CIC), a university-based day camp (UDC), and a
      recreational sports camp (RSC), respectively. CIC delivered 4 culturally adapted nutrition
      lessons within the context of Chamorro cultural traditions as part of the cultural immersion
      camp activities. The UDC delivered the same lessons within a physiology framework. The RSC
      was without nutrition lessons and cultural immersion. Children 3-12 years old registered in
      any of the three summer camp programs were eligible to participate. Data collection was
      primarily administered at two assessment periods: before (± 2 weeks) and after (± 1 week)
      each summer camp program. Children's willingness to try fruits and vegetables, the primary
      outcome, was assessed with the interview-administered Adapted WillTry tool. The secondary
      outcome was fruit and vegetable intake as servings/day in the CIC to UDC only. Fruit and
      vegetable intake was assessed using the mobile food record (mFR), which is an app running on
      an iPod Touch based on the technology assisted dietary assessment (TADA) protocols. Outcomes
      examined Adapted WillTry post-scores for local novel and local common fruits and vegetables
      and fruit and vegetable servings/day using multivariate regression models adjusting for the
      relevant pre-score, sex, age, ethnicity, dose, BMI percentile, and parent's cultural
      affiliation. Therefore, additional measures like sociodemographic information, anthropometry
      (i.e. heights and weights), and parent's cultural affiliation were collected to account for
      potential confounders.
    

Detailed description: 
      A pre-post quasi-experimental design was used to observe outcomes (i.e., willingness to try
      FV and FV intake) between three existing summer camp programs in Guam: cultural immersion
      camp (CIC), university day camp (UDC), and recreational sports camp (RSC). This
      natural-setting, multi-arm parallel design was used as an alternative to a resource intensive
      infrastructure and the organizations were willing to incorporate activities to answer the
      research question.

      The CIC and UDC programs were nearly matched for daily activities (e.g., physical activity,
      cooking demonstrations/taste testing, crafts). The same four Traditions lessons (Figure 1)
      were incorporated into CIC and UDC and delivered by the same educators. These lessons
      featured local FV and promoted positive associations with eating FV. In CIC, the context of
      Chamorro cultural traditions, practices, and values was tied to FV. Chamorro is the language,
      culture, and ethnicity of Guam and the Marianas. In UDC, consuming healthy foods was
      introduced within a context of nutrition and human physiology. The four lessons were adapted
      with permission from a culturally-relevant Hawai'ian nutrition curriculum to make them
      relevant to Guam and the Chamorro culture. This curriculum complemented Hawai'i and Guam
      Department of Education K-12 Content and Performance Standards.

      The CIC activities perpetuated the Chamorro culture and language through song/chanting,
      dance, prayer, arts and crafts, cooking, outdoor activities, and gardening based on
      traditional and contemporary practices. Chamorro was spoken about 80% of the time, including
      the delivery of key messages in the Traditions lessons. All activities operated on indigenous
      values of respect, love, humility, reciprocity, and camaraderie. The UDC activities focused
      on promoting healthful present-day recreational activities and global foods. The activities
      were an extension of the Expanded Food and Nutrition Education Program mission. RSC was
      exclusively physical activity. Upon completion of the last assessments, educators provided
      one Traditions lesson for registrants at RSC.

      Data collection occurred at two assessment periods: before (± 2 weeks) and after (± 1 week)
      each program. The first assessment was completed at each camp setting. The second was also
      completed at camp or at a pre-arranged location, such as the children's home or a
      child-friendly public space (e.g., the mall). Children completed the interview-administered
      Adapted WillTry tool, which measures children's willingness to try FV and was previously
      validated for children 3-11 years old in Guam. FV intake was assessed using the mobile food
      record (mFR). The mFR is an app that has been shown to be a useful method for dietary
      assessment with adolescents. Only participants in CIC and UDC were asked to use the mFR due
      to a limited number of iPods.

      Other Measures: Parents completed a questionnaire that included information about the child's
      age, sex, language spoken, religion, and birthplace. Parent's cultural affiliation was
      determined using their responses reported on a cultural affiliation questionnaire, which
      assesses one of four modes of acculturation: traditional, integrated, assimilated, or
      marginalized. The same scoring system was used as described by Kaholokula and others.
      Anthropometric assessments were completed at a time designated as least disruptive to camp
      activities. Height and weight were measured using a portable Seca scale and stadiometer
      (PE-AIM 101) using centimeters and kilograms, respectively. These measurements were converted
      to body mass index (BMI) as [kg/(height, m)2]. Dose was assessed by recording attendance at
      camp and at each Traditions lesson.

      For participation, all children were given a gift card, in $5 or $10 denominations, one
      before and one after camp assessments. Remuneration varied due to the different types and
      lengths of involvement for participants depending on camp program.

      Sample size was determined using estimates for the Adapted WillTry local novel and local
      common FV scores from data representing children similar to children recruited for this
      study. The main outcomes, model 1 and model 2 were powered at 0.8 for a minimum detectable
      difference (MDD) of 0.43 for the local novel score and 0.41 for the local common score which
      corresponded to proposed sample sizes of n=60 for CIC, n=30 for UDC, and n=30 for RSC. For
      Model 3, based on the UDC and RSC sample sizes MDD was 0.49 and 0.47 for local novel and
      local common, respectively. For the secondary outcome, post-FV intake, the MDDs were 0.877,
      0.3132, and 0.6265 per day dependent on the baseline FV consumption being 2, 1 or 1.5 which
      yielded sample sizes for CIC (n=60) and UDC (n=30).

      Data were entered using a Microsoft Access (Microsoft Corp) tool specifically designed for
      this study. Double-data entry procedures were used and PROC COMPARE in SAS 9.3 (SAS
      Institute, Inc.) was performed until both data entries achieved 100% matching. A trained
      analyst examined images, identified all whole FV (e.g., FV mixed dishes, fruits, vegetables),
      and amounts consumed. FV (100%) juices were excluded. FV intake was calculated by dividing
      the total FV by the total number of days eating occasions were captured using the mFR.

      Categorical variables were examined using frequencies and for quantitative variables means
      and standard deviations were used. Differences between camps in Adapted WillTry FV
      post-scores (i.e. local novel, local common, and imported) were examined using univariate
      ANOVA adjusted for pre-scores. To examine the previously observed incremental trend of the
      Adapted WillTry FV scores, where each score was statistically significantly different from
      one another, the paired t-tests for each pre- and post-assessment score in all camps were
      performed. Analytical analyses were conducted using IBM SPSS Statistics version 21 (IBM
      Corporation, Armonk, NY).

      Potential confounders were included in models using indicator variables for age (i.e., 3-6y,
      7-8y, 9-12y), ethnicity (i.e., Chamorro, Chamorro Mixed, Other), and sex. Categories of
      parent's cultural affiliation were analyzed as traditional and integrated. In these models,
      children whose parents were categorized as marginalized (n=2) or assimilated (n=1) were
      eliminated due to small numbers. Lesson and camp attendance dose for CIC and UDC were
      calculated using the sum of days participants attended lessons and camp days divided by the
      total possible lesson and camp days, respectively. A dichotomous variable was created for
      high and low dose using the 50th percentile cut-point for lessons and camp dose. BMI was
      modeled as a continuous variable.

      To examine the primary hypothesis, indicator variables were created for each camp for
      relevant comparisons in Models 1, 2, and 3. Multiple linear regression models for the three
      Adapted WillTry post-scores (dependent variables) were fit separately to examine whether and
      how much the Adapted WillTry scores differed by camp program accounting for potential
      confounders (i.e., pre-scores, participant's age, sex, ethnicity, BMI, parent's cultural
      affiliation, and lesson and camp days dose). The final model included Adapted WillTry
      pre-scores, sex, age, and ethnicity. For whole FV intake, multiple linear regression models
      were used to examine differences in post-FV intake/day (dependent variable) between UDC and
      CIC. The final model included pre-FV intake/day, age, ethnicity, and parent's cultural
      affiliation (independent variables).
    

Intervention name(s): Cultural immersion
Intervention type(s): Behavioral
Intervention description(s): The primary intervention was the cultural immersion within CIC. Unique to the Traditions study were culturally-adapted nutrition lessons incorporated into CIC and UDC. CIC had a high cultural dose as the Traditions lessons were implemented within the cultural immersion context of the camp. The UDC had moderate cultural dose from the Traditions lessons only. RSC was without cultural immersion and Traditions lessons or had zero cultural dose.
Other intervention name(s): Culturally adapted nutrition lessons
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Keywords: fruits and vegetables; cultural immersion