Online WIC Nutrition Education to Promote Farmers' Market Fruit and Vegetable Purchases and Consumption

Study Overview
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Brief Summary
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This study is evaluating the WIC Fresh Start program, a theory-driven, web-based nutrition education lesson to promote farmers' market fruit and vegetable purchases and consumption among women enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC).

Detailed Description
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This study is evaluating the WIC Fresh Start program, a theory-driven, web-based nutrition education lesson to promote fruit and vegetable (FV) consumption among women enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). Designed to leverage vouchers provided to WIC participants for FV purchases through the Farmers' Market Nutrition Program (FMNP) and monthly cash value vouchers (CVVs) redeemable at farmers' markets, the lesson is conceptually grounded in formative research on knowledge, attitudes and skills influencing farmers' market FV purchases and consumption and theoretical understanding of approaches for modifying them. Lesson content delivery is primarily through short video segments and audio output to increase accessibility for low-literate learners. Informed by a community-based participatory research approach, WIC participants are engaged as full partners in the development of the lesson and the delivery of content (videos feature WIC participants). The setting is a large WIC agency serving three New Jersey counties. Separate samples of women were recruited to participate in 1) focus groups for guiding lesson content development (N = 56 participants) and pretesting the resulting content (N = 52 participants), 2) cognitive testing to assess the clarity and interpretability of items and response formats in measures of knowledge, attitudes and skills developed for the study (N = 15), 3) one-on-one sessions to assess reactions to initial versions of video segments developed for the lesson (N = 20), and 4) the outcome evaluation (N = 744). Stratified based on FMNP voucher receipt, participants are randomized to receive the lesson or existing online health education. Outcome measures (administered orally to reduce literacy demands of the response task) are completed at pretest (immediately before the lesson), posttest (two weeks after the lesson), and 3 and 6 months after posttesting. Short- and long-term lesson effects on FV intake, FMNP voucher redemption and the redemption of CVVs at farmers' markets will be evaluated. Evidence for mediation by knowledge, attitudes, and skills of lesson effects on FV intake and voucher redemption, dose-response relationships, and user satisfaction with the lesson also will be examined.

Official Title
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Online WIC Nutrition Education to Promote Farmers' Market Fruit and Vegetable Purchases and Consumption

Conditions
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Cardiovascular Diseases, Cancer, Type 2 Diabetes, Obesity

Intervention / Treatment
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* Behavioral: WIC Fresh Start Program
* Behavioral: Existing Online Health Education


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Pregnant or postpartum WIC participant Female caregiver of infant/child WIC participant Exclusion Criteria: Restrictions on food intake Classified by WIC as high risk/requiring an individualized nutrition care plan
Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: WIC Fresh Start Program<br>Participants in this arm receive the Fresh Start program. | Behavioral: WIC Fresh Start Program<br>* The intervention is an online lesson to promote farmers' market FV purchases and consumption. The lesson comprises three modules, each consisting of 1) behavior change content presented through a video segment featuring WIC participants, and 2) an interactive activity to build targeted knowledge, attitudes, and skills.<br>|
| Active Comparator: Existing Online Health Education<br>Participants in this arm receive existing online WIC health education. | Behavioral: Existing Online Health Education<br>* Any of seven existing online WIC health education lessons (lessons are available on breastfeeding, being active, fruits and vegetables, calcium, cholesterol, oral health and iron). The lessons consist of an introductory segment presented with online text and graphics. After reading this material, viewers have the option to complete one of four lesson activities. The activities provide opportunities for viewers to read further on the topic and are designed to reinforce key points of the lesson.<br>|
| Experimental: WIC Fresh Start Program (FMNP)<br>Participants in this arm receive the Fresh Start program and WIC Farmers' Market Nutrition Program (FMNP) vouchers redeemable at farmers' markets. | Behavioral: WIC Fresh Start Program<br>* The intervention is an online lesson to promote farmers' market FV purchases and consumption. The lesson comprises three modules, each consisting of 1) behavior change content presented through a video segment featuring WIC participants, and 2) an interactive activity to build targeted knowledge, attitudes, and skills.<br>|
| Active Comparator: Existing Online Health Education (FMNP)<br>Participants in this arm receive existing online WIC health education and WIC Farmers' Market Nutrition Program (FMNP) vouchers redeemable at farmers' markets. | Behavioral: Existing Online Health Education<br>* Any of seven existing online WIC health education lessons (lessons are available on breastfeeding, being active, fruits and vegetables, calcium, cholesterol, oral health and iron). The lessons consist of an introductory segment presented with online text and graphics. After reading this material, viewers have the option to complete one of four lesson activities. The activities provide opportunities for viewers to read further on the topic and are designed to reinforce key points of the lesson.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Participants Who Redeemed FMNP Vouchers | The state WIC agency is providing data on FMNP voucher redemption. | 6 months (2015 farmers' market season [June to November 2015]) | 
| Frequency of Fruit and Vegetable Intake | Times per day fruits and vegetable are consumed as assessed by a validated food frequency questionnaire. | Pretest, posttest (2 weeks after pretest), and 3- and 6-month follow-up | 
| Quantity of Fruit and Vegetable Intake | Cups per day consumed of fruits and vegetables as assessed by a validated fruit and vegetable screener. | Pretest, posttest, and 3- and 6-month follow-up | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Participants Who Redeemed Cash Value Vouchers at Farmers' Markets | The state WIC agency is providing data on cash value voucher redemption. | 6 months (2015 farmers' market season [June to November 2015]) | 
| Response to Survey Items Assessing Knowledge of the WIC Farmers' Market Nutrition Program Using a True/False Format. | Index of Knowledge of the FMNP Score range: 0-6 Higher scores indicates greater knowledge | Pretest, posttest, and 3- and 6-month follow-up | 
| Response to an Item Assessing Knowledge of WIC-authorized Farmers' Markets Using a Yes/no Format. | Knowledge of a farmers' market with farmers approved by WIC to accept WIC farmers' Market Nutrition Program and Cash Value vouchers Scores: No (0) and yes (1). Higher scores (yes responses) indicate that the respondent knows of a farmers' market with farmers approved by WIC to accept WIC farmers' Market Nutrition Program and Cash Value vouchers. Odds ratios and 95% confidence intervals indicate the likelihood of the outcome (knowledge of such markets) among those in the WIC Fresh Start (FMNP) arm relative to the comparator arm. | Pretest, posttest, and 3- and 6-month follow-up | 
| Response to Survey Items Assessing Attitudes Towards Farmers' Market Fruits and Vegetables Using 7-point Likert Rating Scales. | Attitudes towards Farmers' Market Fruits and Vegetables Score range: 6-42 Higher scores indicate more favorable attitudes | Pretest, posttest, and 3- and 6-month follow-up | 
| Response to Survey Items Assessing Awareness of Locally Grown, Seasonal Fruits and Vegetables Using a Yes/no Format. | Familiarity with Locally Grown Seasonal Items Score range: 0-3 Higher scores indicate greater familiarity | Pretest, posttest, and 3- and 6-month follow-up | 
| Response to Survey Items Assessing Fruit and Vegetable Food Safety Skills Using 7-point Likert Rating Scales. | Fruit and Vegetable Food Safety Skills Score range: 19-85 Higher scores indicate greater skills | Pretest, posttest, and 3- and 6-month follow-up | 
| Response to Survey Items Assessing Farmers' Market Asking Skills Using a Yes/no Format. | Farmers' Market Asking Skills Score range: 0-3 Higher scores indicate greater skills | Pretest, posttest, and 3- and 6-month follow-up | 
| Response to Survey Items Assessing Positive Outcome Expectations for Consuming Locally Grown Fruits and Vegetables Using a Yes/no Format. | Positive Outcome Expectations for Consuming Locally Grown Fruit and Vegetables Score range:0-3 Higher scores indicate more favorable ratings | Pretest, posttest, and 3- and 6-month follow-up | 
| Response to an Item Assessing Whether the Participant Ever Purchased Fruits and Vegetables at a Farmers' Market Using a Yes/no Format. | Lifetime Farmers' Market Fruit and Vegetable Purchases Scores: No (0), Yes (1). Higher scores (yes responses) indicate indicate that the respondent has ever purchased fruits and vegetables at a farmers' market. Odds ratios and 95% confidence intervals indicate the likelihood of the outcome (having ever purchased fruits and vegetables at a farmers' market) among those in the WIC Fresh Start (FMNP) arm relative to the comparator arm. | Pretest, posttest, and 3- and 6-month follow-up | 
| Response to Survey Items Assessing Farmers' Market Fruit and Vegetable Preparation Skills Using 7-point Likert Rating Scales. | Farmers' Market Fruit and Vegetable Preparation Skills Score range:12-84 Higher scores indicate greater skills | 2 weeks | 
| Response to an Item Assessing Whether the Participant Purchased Fruits and Vegetables at a Farmers' Market in the Past Two Weeks Using a Yes/no Format. | Recent Farmers' Market Fruit and Vegetable Purchases Scores: No (0), Yes (1). Higher scores (yes responses) indicate that the respondent purchased fruits and vegetables at a farmers' market in the past two weeks. Odds ratios and 95% confidence intervals indicate the likelihood of the outcome (having purchased fruits and vegetables at a farmers' market in the past two weeks) among those in the WIC Fresh Start (FMNP) arm relative to the comparator arm. | Pretest, posttest, and 3- and 6-month follow-up | 
| Response to an Item Assessing Behavioral Intentions to Purchase Fruits and Vegetables at a Farmers' Market in the Next Two Weeks Using a Yes/no Format. | Intentions to Purchase Fruits and Vegetables at a Farmers' Market Scores: no (0), Yes (1). Higher scores (yes responses) indicate that the respondent intends to purchase fruits and vegetables at a farmers' market in the next two weeks. Odds ratios and 95% confidence intervals indicate the likelihood of the outcome (intending to purchase fruits and vegetables at a farmers' market in the next two weeks) among those in the WIC Fresh Start (FMNP) arm relative to the comparator arm. | Pretest, posttest, and 3- and 6-month follow-up | 
| Response to Survey Items Assessing Knowledge of Locally Grown Seasonal Fruits and Vegetables Found at Farmers' Markets in July Using a Yes/no Format. | Knowledge of Locally Grown Seasonal Fruits and Vegetables found at Farmers' Markets in July Score range:0-9 Higher scores indicate greater knowledge | Pretest, posttest, and 3- and 6-month follow-up | 
| Response to Survey Items Assessing Food-specific Knowledge Using a True/False Format | Food-specific Knowledge Score range: 2-13 Higher scores indicate greater knowledge | Pretest, posttest, and 3- and 6-month follow-up | 
| Response to Survey Items Assessing Knowledge of Area Farmers' Markets | Farmers' Market-specific Knowledge Score range:0-2 Higher scores indicate greater knowledge | Pretest, posttest, and 3- and 6-month follow-up | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Fruit, vegetables, income, WIC program, farmers' market