FOOD SAFETY AND SCHOOL GARDEN PROGRAM

................................................................................................................. ii ACKNOWLEDGMENTS .......................................................................................... iv PREFACE ..................................................................................................................... v TABLE OF CONTENTS ............................................................................................ vi LIST OF TABLES ..................................................................................................... vii LIST OF FIGURES .................................................................................................. viii MANUSCRIPT ............................................................................................................. 1 REVIEW OF LITERATURE ................................................................................... 30 APPENDIX A. SCHOOL LETTER ......................................................................... 63 APPENDIX B. FSSGP CURRICULUM ................................................................. 64 APPENDIX C. STUDENT ASSESSMENTS ......................................................... 71 APPENDIX D. PRE/POST TEST ID ROSTER ....................................................... 78 APPENDIX E. PARENT/GUARDIAN FOLLOW-UP ........................................... 80 APPENDIX F. FSSGP MATERIALS ...................................................................... 81


LIST OF TABLES
Foodborne illness affects public health and is an economic burden (Scharff 2012). An estimated 48 million people, or 1 in 6 Americans, are affected by foodborne illness annually and approximately 128,000 hospitalizations and 3,000 deaths occur each year (CDC 2013). It is estimated that foodborne illness costs the United States over $77 billion each year (Scharff 2012). Foodborne illness outbreaks, including those due to produce, have increased for the past four decades (Painter and others 2013;Sivapalasingam and others 2004;Tauxe and others 1997). Moreover, all reported foodborne outbreak data display clear trends of increases in foodborne illnesses due to produce (DeWaal and others 2006; FSMA and others Painter and others 2013).
Multiple factors are associated with the increase in produce-related foodborne illnesses including inadequate food safety knowledge resulting in unsafe food handling practices and increases in both home produce-gardens and fresh produce consumption (Kim and others McGill and others 2015;NGA 2014;Redmond and others 2003). A review of observational consumer food safety studies showed that consumers have relatively low levels food safety knowledge and when observed, exhibit risky food handling behaviors (Redmond and others 2003). While research has shown that home gardeners have inadequate food safety knowledge (Pivarnik and others 2006;Pivarnik and others 2008), 48% of home gardeners reported the reason they garden is to grow safer produce than they can buy from stores and/or farms ). The number of home produce gardens increased more than 20% . Therefore, increases in gardening and produce consumption could potentially contribute to the increase in produce-related foodborne illnesses.
Produce grown anywhere, commercial farms and home and school gardens, can be the source of pathogenic microorganisms, since similar food handling practices are needed to keep produce safe. Commercial farmers are involved in multiple food production practices, such as growing, harvesting, processing, and distributing. All steps in production have the potential for microbial contamination. For example, improper personal hygiene practices, unsafe water and manure treatment, and improper sanitation of equipment are all sources of microbial contamination (FDA/CFSAN 1998). Home gardeners and those involved with school gardens plant, harvest and handle post-harvest produce, and therefore are likely to have the same microbial contamination concerns (URI 2015).
Home gardener programs have been established and implemented. Home gardeners have the opportunity for education on proper food safety principles with regards to safe planting and composting, checking for a safe water supply, safe harvesting of garden produce, and preparing and storing fresh produce (URI 2015). It is important for students participating in school garden programs to be educated on the same basic food safety principles surrounding school garden.
Since school garden-related food safety education programs for elementary school students have not been well studied, the overall goal of this study was to create a food safety program using school garden-related activities for first to fifth grade students in Rhode Island (RI). Specific objectives were to: assess students' overall knowledge change of basic school garden-related food safety principles from pre-to post-intervention; evaluate the program via students' ratings of the activities; and assess reported student-to-parent/guardian interaction.

Program Design
The Food Safety School Garden Program (FSSGP) was developed in conjunction with Farm Fresh Rhode Island's (FFRI) Farm to School Project funded by the Food and Nutrition Service of the United States Department of Agriculture (USDA). The food safety information used in FSSGP was based primarily on the principles described in "Food Safety Tips in School Gardens" (NFSMI and others 2011). Additionally, Good Agricultural Practices regarding produce safety for commercial growers (FDA/CFSAN 1998;URI 2015) were used and adapted for the FSSGP.
The FSSGP consisted of two 40-60 minute interactive lessons that were divided into four categories: 1) bacteria, 2) hand washing, 3) produce washing, and 4) container washing. The categories, topics and interactive activities are outlined in Table 1. The topics included within the bacteria category were "good" versus "bad" bacteria and keeping pets and animals out of the garden. The interactive activity for bacteria was Pass the Apple (Mulligan 2014), which used stickers and two apples to visually show how bacteria can spread. The topics included in the hand washing category were the proper method, when, and why to wash hands. A simulated hand washing activity was created to practice the proper method to wash hands. The produce washing category, included the proper method for washing produce, throwing away rotten produce, and not eating directly from the garden. A large activity board with laminated pictures of fruits and vegetables was created to help the students understand the concept of washing all different types of fruits and vegetables. Finally, the washing containers category contained topics such as, proper method and when to wash harvesting containers.

Student Assessment
A 10 question, multiple-choice assessment was used to test school gardenrelated food safety knowledge of elementary school students pre-and postintervention ( Table 2). The format of the questions and/or answers were developed from previously tested food safety knowledge assessments (Pivarnik and others 1994;Pivarnik and others 2006). The questions were divided into the categories described above: three questions on bacteria, hand washing and produce washing, and one question on container washing. All questions had three or four answers and "I do not know" was a possible answer for every question. In an effort to reduce guessing, students were encouraged to circle "I do not know" if they did not know the answer.
Knowledge-based questions were graded as right or wrong. For statistical assessment purposes, "I do not know" was considered and coded as incorrect, as it reflected a lack of knowledge (Pivarnik and others 2006). Students that scored 80% or better were considered proficient in the subject matter (Pivarnik and others 2006).
In addition to the 10 knowledge-based questions, the post-test included two program evaluation questions and one question on intent to disseminate, or tell their parents/guardians, about information learned in the FSSGP (Table 3). Program evaluation questions asked students to circle the topic they felt was most important and to rate how much they liked each activity. Students had the option to circle a smiling face, neutral face, or frowning face if they liked the activity, thought it was okay or disliked it, respectively.
The pre-and post-tests were administered to all participating students and each question was read aloud to compensate for all reading and comprehension levels (Pivarnik and others 1994). Students were assigned ID numbers for the assessments and teachers kept the student ID rosters between lessons to maintain student anonymity. Only students who completed both pre-and post-tests were included in the statistical analyses. Two educational specialists reviewed the assessments for readability and clarity and revisions were made as suggested.

Parent/Guardian Letter and Follow-up
Participating teachers sent home a letter to all parents/guardians regarding the FSSGP at the start of the first lesson. At the completion of the program, students were given a follow-up questionnaire as well as a Garden to The Institutional Review Board at the University of Rhode Island approved the protocol, assessments, and educational materials.

Program Implementation
The elementary school students who participated in the FSSGP were recruited through the existing FFRI Farm to School programs. The two lessons were conducted at least one week apart between September and December 2014. The first lesson began with the pre-test followed by instruction on the first three categories (Table 1), the second lesson included a review of the first lesson material and the fourth category, and the remainder of the lesson consisted of two review activities that incorporated all information presented to the students. All students participated in the "What's Wrong with this Picture?" activity (Pivarnik and others 1994) and the lesson concluded with Food Safety Bingo (grades 1-3) or Food Safety Jeopardy (grades 4-5).
At the end of the second lesson, students completed the post-test. Students were given an educational handout that summarized sources of bacteria from the garden and how to prevent the spread of bacteria, a "Wash Fruits and Vegetables Before Eating" pencil, and small bar of soap that used in the simulated hand washing activity.

Statistical Analysis
The statistical software, SPSS (Version 21.0, 2012, Armonk, NY), was used for all statistical analyses. Means with standard deviations and descriptive statistics (frequencies and percentages) were reported for the knowledge-based pre-and posttests and program evaluation responses. Paired t-tests were used to determine mean score differences at 95% confidence interval for overall score and within grades.
Differences between grades on pre-and post-tests were analyzed using analysis of variance with a Scheffe Post Hoc test. Analysis of covariance was used to determine if post-test knowledge score differences remained significant between grades when controlling for the differences in pre-test scores. Finally, Pearson's chi-square test was used to assess knowledge-by-category on pre-and post-tests.

RESULTS
A total of 203 students from four RI elementary schools participated in the first lesson and completed the pre-test of the FSSGP. Two schools were located in Providence, one in Pawtucket, and one in Newport. Approximately 94% (183/194) of students completed the program during regular school hours (n=183): 34% in first grade, 27% second grade, 9% third grade, 20% fourth grade, and 10% fifth grade (Table 4). The remaining 6% (11/194) were of first and second grade students in an after school program.

Knowledge Responses
Students had a mean knowledge score of 55.6±18.8% on the pre-test and 80.6±18.6% on the post-test, which was a 25 percentage point increase in knowledge (p < .001) ( Table 5). Significant knowledge increases also occurred from pre-to posttest within all grades (p < .001). Second grade students (n=56) had the highest increase (31.7%) and first graders (n=67) had the least (18.2%). Most students answered between 4 and 6 questions correctly (range: 1-10) on the pre-test; whereas the majority of students answered 9 or 10 questions correctly (range: 2-10) on the post-test ( Figure   1) after intervention. and fifth grade students, respectively. Grades 2-5 did not significantly differ from each other. Analysis of covariance determined that statistical significance was independent of the initial knowledge score variations.
Pre-and post-test knowledge scores for each category are illustrated in Figure   2. Correct baseline knowledge for container washing was the highest and produce washing the lowest, 77.6% and 12.9%, respectively. The container washing category consisted of one question, whereas the other three categories consisted of three questions. Overall, knowledge within each category improved significantly (p < .05) following the intervention.

Program Evaluation
The majority of the students rated each activity as okay or better in the posttest evaluation (Table 6). More than half of the students indicated that they liked the activities "very much". Results from the post-test indicated 84% (n=161) of the students indicated that they would tell their parents/guardians about what they learned in the FSSGP.

Parent/Guardian Follow-Up
A total of 59 parent/guardian follow-up questionnaires were returned to the teachers. Of those 59 returned, 76% (n=45) of the parents/guardians indicated their child spoke with him/her about the FSSGP. Two returned questionnaires that indicated, "yes", their child spoke to them about what they learned were not included in the analysis as the indicated topic(s) were unrelated to those taught in the FSSGP.
Written responses were compiled and categorized into five categories: bacteria, hand washing, produce washing, animals, and other ( Figure 4). Any topic mentioned that did not fall into one of the first four categories but was related to food safety in or gardening, were included in the "other" category. The "other" topics were grouped into one category due to the low frequency and high variability of each topic.
Examples of topics in the "other" category included any response about general food safety, gardening, planting, and containers. Of the 45 parents/guardians who indicated that their child spoke to them about the program, the majority wrote one or more school garden-related food safety topics.

DISCUSSION
The goal of this study was to create a school garden-related food safety education program for elementary schools with school gardens. The hypothesis was that students' knowledge of school garden-related food safety would increase from pre-to post-intervention. Knowledge increased overall and across all grades. This finding shows that first to fifth grade students participating in the FSSGP would significantly increase their school garden-related food safety knowledge upon completion of the program.
First grade students scored significantly lower than the other four grades on both the pre-and post-test. The lower scores could be due to a lack of previous gardening experience, the complexity of the program information, lower reading levels , and/or differences in school approaches. The established school garden programs, through which the FSSGP was conducted, start in first grade.
Therefore, previous gardening experience could have had an impact on baseline knowledge scores, however, that does not explain the smaller increase from pre-to post-intervention of the first grade students compared to those in the other four grades.
Many of the first grade students were unable to read and despite reading both assessments aloud, misunderstanding and/or misinterpretation of questions could have occurred. Lower first grade knowledge scores could be due to differences in school approaches and/or geographical area however, that cannot be confirmed, as we did not have first and second graders at the same school. The FSSGP may not be as suitable for first graders as compared to second through fifth, although, first graders still had a significant increase in knowledge from pre-to post-intervention.
Overall, the students became proficient (>80%) in the school-garden related food safety material after the education intervention. For example, prior to the intervention, more than half of students indicated that it was acceptable to eat directly out of the garden without washing. Following the intervention, 80% of the students answered the question correctly indicating that eating directly from the garden without washing is unacceptable and unsafe. The consequence of eating directly from the garden without washing is an increased risk for foodborne illness. Since children have a heightened susceptibility to foodborne illness, food safety education prior to engaging in school garden activities is necessary.
The 10-question assessment resulted in an unequal distribution of categories.
Statistically, knowledge significantly increased across all four categories however, the four categories were not equally distributed. The containers category was only representative of one question and the other three categories consisted of three questions each. While knowledge of containers appeared to be much higher than the other three categories, it was only one question and results may have been different had more questions been asked. However, based on previous food safety knowledge assessments for elementary-aged students, the short duration, and specificity of our program, a relatively short 10-question assessment was regarded as optimal (Eves and others 2006;Pivarnik and others 1994).
It has been well established that students enjoy learning and retain information better if practically or experientially applied (Eves and others 2006;Faccio and others 2013;Vygotsky 1967). In previous studies, students who participated in experientialbased food safety programs rated the activities highly (Faccio and others 2013;Losasso and others 2014;Pivarnik and others 1994). This study produced similar results: the majority of the students rated all activities as satisfactory (okay) or better while simultaneously and significantly increasing their knowledge. Faccio and others (2013) found the students in the experiential group in their study learned and retained significantly more complex and detailed food safety information compared to the students in the didactic, theoretical approach group. Similarly, students participating in nutrition education and school garden activities retained more nutrition knowledge post-intervention than those exposed only to nutrition education and those in the Food safety education programs for students are primary prevention for foodborne illnesses (Losasso and others 2014) and are often conducted in school settings. Few food safety education programs have been conducted with students in after school programs. The one after-school class of students that participated in the FSSGP was used as a pilot test to determine whether or not the currciculum would be suitable in that type of learning environment. Though several students appeared distracted and restless throughout parts of the instruction, there were no significant knowledge differences between the first and second graders in the after-school program compared with students in the in-school classes (data not shown).
Additionally, given that the majority of the classes were in-school, there was limited time and access to hand-washing sinks and therefore, the simulated hand-washing activity was the most feasible.
Upon completion of the program, 161 students indicated they would tell their parents/guardians about the FSSGP and what they learned. Thirty percent (59/194) of all parent/guardian follow-up questionnaires were returned. Based on the number and variety of topics written by parents/guardians, the children were able to reiterate and explain a variety of the produce-related food safety topics upon returning home.
Parents/guardians described multiple topics, for example, "wash your hands for 20 seconds; keep animals out of the garden; and wash your fruits and veggies before eating them." The approach and effect of children's intent to disseminate information to their families has been elucidated by the Theory of Planned Behavior .
This behavioral theory describes that intention is the strongest predictor of actual behavior. Thus, children who intended to tell their parents/guardians what they learned might be more likely to engage in proper food safety behaviors and teach what they learned to their family. Parent/guardian responses on the follow-up reflected a strong indication that students understood the information and taught their family what they learned. Additionally, students who spoke to the parents may be retaining more of the information (Losasso and others 2014).
Parents/guardians are often targeted for food safety education programs, as they are typically the primary food preparer in the home (Meysenburg and others 2014;Stenger and others 2014). However, findings from this study support existing research that children are able to gain knowledge of correct food safety principles, start to develop proper food safety behaviors, and continue to build the fundamental foundation of food safety knowledge and behaviors (Eves and others 2006;Faccio and others 2013). The results of this current study showed that educating children on school garden-related food safety principles also allows the family to be a secondary target audience that will receive proper food safety information.

CONCLUSION
The FSSGP was successful at educating elementary school students on school garden-related food safety principles as evidenced by: the significant increases in knowledge overall, by grade and by category, and the student dissemination of information to their families. Furthermore, this curriculum was appropriate for multiple grade levels (grades 1-5). The interactive activities, rated as satisfactory or better by the majority of students, may have helped to reinforce the information taught in the program.
For future research, the FSSGP could be tested in after-school programs on a larger scale and in summer camps that incorporate gardening activities. Perhaps incorporating additional hands-on garden activities into the program may further proper food safety behavior development. The FSSGP was conducted in a primarily urban population and could be tested in first to fifth grade classes in other rural or suburban regions of the United States.   Total --194 10 a in-school classes (n=183); b after-school classes (n=11). Table 5 -Knowledge scores of students in all grades that participated in the food safety and school garden program a,b indicate significant differences between pre-test and post-test at p < .001; 1,2 indicate significant differences between grades for the pre-test or post-test at p < .05.

Absolute change (%)
All Grades (n=194  Additionally, observational studies confirm that individuals are more likely to selfreport proper food safety practices than to perform them when observed ( Possible reasons for the increase in fruit and vegetable consumption are globalization of the food supply (Tauxe and others 1997), expansion of national and statewide campaigns and nutrition assistance programs that promote fruit and vegetable intake in order to reduce rates of obesity and other chronic health conditions (Altman 2008;FNS 2012), and the increase in home gardens (NGA 2014).
The popularity of school gardens has also increased nationally in the US.
Currently, 44% of schools participate in Farm to School programs, some with school gardens and 13% plan to implement a Farm to School program in the near future Pivarnik and others 1994; Richards and others 2008). Therefore, it is hypothesized that food safety education programs can be adapted for and used in school garden programs.

Foodborne Illness
Foodborne illness affects health and is an economic burden in the US (Scharff 2012). An estimated 48 million people are affected by foodborne illness annually (CDC 2013). Approximately 128,000 hospitalizations and 3,000 deaths occur each year (CDC 2013) and foodborne illness costs the US over $77 billion (Scharff 2012).
Because most foodborne illnesses can be prevented and/or greatly reduced with adoption of proper food safety practices, government money spent on managing foodborne illness could be used to address other public health challenges (Losasso and others 2014; Soon and others 2012). Foodborne illness is a concern for all persons and especially high-risk populations such as children, pregnant women, and the immuno-

 Technology Advancements in Surveillance Detection
Surveillance of foodborne illness outbreaks has increased due to technological advancements in the detection of microbial pathogens (CDC 2011a). Practitioners and laboratory staff in hospitals are now required to conduct more testing and report detection of foodborne pathogens to the National Notifiable Diseases Surveillance System (CDC 2011a). Table 1 lists the surveillance systems/networks currently in place. Each surveillance system is used to detect different pathogens and sites of contamination and most of the surveillance systems rely on data from state and local health agencies. Because the surveillance systems now detect sources and sites of contamination more efficiently and effectively, governing agencies can better predict and monitor outbreak sources to enforce better food safety practices in areas prone to contamination (CDC 2011a).  USDA 2014). Despite the technological advancements in the surveillance for foodborne illness outbreaks, the statistics provided by these surveillance systems represent only a small subset of the foodborne illnesses that actually occur in the community due to underreporting and under-diagnosing (CDC 2011a).  (2006) conducted a random survey with 762 New England home gardeners and reported that participants scored the lowest on the food safety topics pertaining to: hand hygiene, the association of produce with pathogenic bacteria, safety of organic produce, washing produce, use of manure and compost, water supply safety, and home canning. Verrill and others (2012) found that consumers are less likely to wash the outside skin of fruits and vegetables if they peel and cut the products since they are unaware that potential pathogens could contaminate the edible portion through cutting.

Food Safety Knowledge and Food Handling Practices
A recent example of pathogens on the outer surface spreading to the inner surface was in 2011, 147 illnesses and 33 deaths were caused from Listeria monocytogenes on cantaloupes (CDC 2012). Produce can be susceptible to pathogen contamination and must be properly washed prior to consumption, as standard practice.
Li-Cohen and others (2002) found that consumers had poor hand hygiene.
Almost 50% of consumers surveyed reported not washing their hands prior to handling fresh produce. Many foodborne illness outbreaks are the result of contamination via pathogens of fecal origin, which is likely to occur when consumers neglect to wash their hands prior to handling "ready to eat" foods (PFSE 2010). Fresh produce falls under "ready to eat" foods if consumed raw. Consumer understanding of the reasons why hand washing is important and implications of not, is essential in the prevention of foodborne illnesses.
Because unsafe food handling is the major cause of foodborne illness outbreaks (Anderson and others 2004), the Partnership for Food Safety Education (PFSE) (2010) created the "Fight Bac!" initiative to educate the general public on safe food handling practices and foodborne illnesses through a website that contains printable fact sheets, multimedia, and promotes food safety campaigns. "Fight Bac!" outlines the four most important areas of food safety: clean, separate, cook, and chill.
All safe food-handling practices fall under these four major areas. "Clean" refers to ensuring hands and surfaces are clean during the preparation process. "Separate" refers to avoiding cross-contamination of ready-to-eat foods and raw, to-be-cooked foods. "Cook" refers to ensuring all foods are either cooked or reheated, as required, to specific internal temperatures to destroy pathogens. Finally, "Chill" refers to ensuring that leftover foods are refrigerated promptly for proper cooling, as pathogens can grow exponentially between the temperatures of 40°F and 140°F. Following these safe foodhandling practices can reduce the risk of pathogen contamination and/or growth.
Additionally, according to Anderson and others (2004), self-reported food safety knowledge and behaviors do not reflect actual, observed food safety behaviors.
A study by Li-Cohen and others (2002) reported that 97% of survey respondents reported always cleaning surfaces during food preparation; whereas, Anderson and others (2004) showed that only 33% of participants were observed thoroughly cleaning food preparation surfaces. Consumers inflate their own proper food safety behaviors and are often worse when actual behavior is observed.
Specifically for produce-related food handling, the same unsafe practices can occur in home and school gardens as on large-scale farms, as the basic food safety principles are the same. However, home and school gardeners do not have the same opportunities to receive food safety education and training as large-scale farmers (Pivarnik and others 2008). For example, the GAP program is in place to educate and train farmers to integrate food safety practices from harvest to distribution, and reduce risk of pathogen contamination. However, the same targeted outreach regarding produce planting, harvesting, and post-harvest handling practices is not available for home and school gardeners. Therefore, home and school gardeners may also have unsafe food handling practices due to a lack of food safety knowledge (Pivarnik and others 2008).
Although many individuals are involved in food production, such as growers, producers, manufacturers, distributors, and preparers, the consumer is the last person involved and is still critical for preventing foodborne illnesses (Redmond and others 2003). Therefore, consumer education of risks associated with foodborne illnesses and preventive measures to protect themselves and others are important in order to reduce the number of foodborne illness outbreaks.

Fruit and Vegetable Consumption
Fruit and vegetable consumption per capita has increased (Casagrande and others 2007; Kim and others 2014; McGill and others 2015) although other sources report that fruit and vegetable consumption has declined (CDC 2011b). Kim and others (2014) report that fruit consumption increased 13% from 2003 to 2010 among children. Tauxe (2009) found with the increase in fruit and vegetable consumption, there was an increase in produce-related foodborne illness outbreaks. Globalization of the food supply, combating health conditions, prevalence of federal and statewide nutrition assistance programs, and an increasing number of home produce gardens are possible contributors to the increase in produce consumption and thus, potentially to the increase in produce-related foodborne illness outbreaks.

 Globalization
The increase in importing and exporting goods/services has resulted in the globalization of the food supply (FDA 2015). Globalization of the food supply increased 27% from 1990 to 2005 and is continuing to increase (FDA 2015). The global food supply of diverse commodities may be a contributing factor to the increase in fresh produce consumption (Tauxe and others 1997). Prior to importing fruits and vegetables from other countries, fruits and vegetables were only available in certain areas of the country during specific times of the year. From 1970 to 2007, fresh produce availability increased 28%, partly due to globalization (Tauxe 2009). With the increase in globalization in the past three decades, contamination of the food supply can have a worldwide impact. Companies in the US now import from countries all over the world and need to ensure purchases are made from safe food supplies to decrease the risk of foodborne illness (Scharff 2012).

 Health Conditions
Obesity, cardiovascular disease (CVD), and type 2 diabetes are three globally prominent public health challenges (Bazzano 2005  One of MyPlate's recommendations is to make "half of your plate fruits and vegetables" (USDA/CNPP 2011a).

The American Heart Association (AHA) as well as the American Diabetes
Association (ADA) have specific diet recommendations to reduce the risk of CVD and type 2 diabetes, respectively (ADA 2015; AHA 2015). The AHA recommends consuming a variety of fruits and vegetables to control weight, cholesterol, and blood pressure. The ADA's recommendation is to fill your plate with a variety of non-starchy vegetables and smaller portions of starchy foods and meats. In an effort to prevent health conditions such as obesity, CVD, and type 2 diabetes, national campaigns and associations recommend to consume a healthy diet, higher in a variety of fruits and vegetables.

 Health Promotion Programs o Supplemental Nutrition Programs
Participants receiving benefits from the Women Infants and Children (WIC) assistance program and/or the Supplemental Nutrition Assistance Program (SNAP), can participate in nutrition education sessions as part of their monthly benefits (Altman 2008). These two programs share a similar goal: to improve the likelihood that participants receiving benefits will purchase healthier food options, such as fruits and vegetables in place of low-nutrient, high calorie options (Altman 2008).

o National School Lunch Program
The standards for the National School Lunch Program (NSLP) have recently changed to ensure that fruits and vegetables are offered in schools daily (FNS 2012).
In addition to enforcing the new changes of the NSLP, the goal of schools that have school gardens is to serve the produce grown as snacks and/or as part of meals.
Incorporating fresh produce grown in school gardens into daily snacks and meals is an efficient way to expose students to new kinds of fruits and vegetables, increase fruit and vegetable intake, and reduce cost. While there are many benefits to school gardens, food safety issues are likely to occur without implementation of a food safety plan including proper food safety knowledge about planting, harvesting and postharvest handling.

School Gardens and Education
Currently, school gardens are used as an educational tool and/or food source to enhance academic instruction for scientific principles taught in classrooms such as general science, environmental studies, and nutrition (Graham and others 2005).
School gardens allow students access to fresh, nutritious produce, enhance academic performance, and are effective in increasing nutritional knowledge and healthy eating behaviors (NGA 2014). Nationally, 44% of the schools participate in Farm to School programs, which may include school gardens and an additional 13% have committed to implementing a Farm to School Program in the near future (USDA 2014). Farm to School programs provide schools with the opportunity to partner with local farms and support the local food movement, serve students fresh produce, and start a school garden that can provide students with educational opportunities in addition to fresh produce (USDA 2014).
The USDA and National Food Service Management Institute (NFSMI and others 2011) created a document entitled "Food Safety Tips in School Gardens" that describes proper food safety principles for those involved in school gardens. The food safety issues that need to be considered when starting a school garden include: site selection and water, fertilizer, compost, and manure use. For those involved in the garden, personal hygiene and hand washing, clean harvesting equipment, and washing produce prior to consumption are critical food safety principles.  (2002) conducted a nine-lesson, garden-based nutrition education curriculum with fourth-grade students from three schools. School 1 was the control (CO) school (n=61 students), school 2 received nutrition education only (NE) (n=71 students), and school 3 received nutrition education and hands-on gardening activities (NEG) (n=81 students). Overall, nutrition knowledge scores significantly increased in both NE and NEG compared to CO from pre-to post-test and knowledge was retained at a 6-month follow-up. Vegetable preferences were highest in the NEG group following the intervention but also improved significantly in NE students. (2009)  increased. This study also found that attitude was the highest predictor of intentions related to gardening behaviors at pre-and post-intervention for both boys and girls.

Heim and others
However, girls were less likely to follow-through with the intended behavior change compared to the boys. The authors' speculated that either the girls may not have developed the appropriate skills for behavior change and/or differences in cognition between girls and boys were not considered during the program. Finally, Parmer and others (2009) conducted a 28-week garden-based nutrition education curriculum with 115 second grade students. The students were assigned into three groups: NE, NEG, and CO. The students were tested for baseline produce-related knowledge, preference, and consumption and again at the end of the 28 weeks. Results of the post-test indicated that the students in the NEG and NE groups had significant improvements nutrition knowledge and taste ratings than those in the CO.
In conclusion, school gardens have a positive impact on nutrition knowledge and consumption of fresh fruit and vegetables. However, school garden-related food safety has not been addressed in any previous school garden research. Since students actively participate in school garden-related activities, it is important they learn pertinent school garden-related food safety principles. If students remain unaware of food safety risks in the garden, they put themselves and their peers at risk for foodborne illness. Haapala and others (2004) conducted a survey to assess reported food safety perceptions, food handling behaviors, and food safety knowledge of 178 seventh and eighth grade students. The Protection Motivation Theory was used to assess students' food safety perceptions. While students had a good understanding of the severity of foodborne illness and 20% indicated having been ill due to foodborne illness, their perceived susceptibility to foodborne illness was relatively low. There appeared to be a disconnect between knowledge and risk among these students. Despite knowing the risks of improper food safety, students perceived their own risk to be low. The food handling section of the survey consisted of 15 questions classified into five key categories. Students had the option to skip questions if they had not engaged in any of the behaviors specified. Of the five categories, students reported washing their hands and chilling foods promptly after consumption most often. Students scored 7.2 ± 1.6 out of 10 general food safety knowledge questions. In conclusion, Haapala and others (2004) believed that these findings justify the need for education programs on proper food handling behaviors for students in order to reduce the risk of foodborne illnesses, as they will eventually become more involved in food preparations. Eves and others (2006) surveyed 2259, 4-14 year olds in the United Kingdom (UK) regarding reported food hygiene knowledge and attitudes, food handling behaviors, and barriers to practicing proper food handling behaviors. Students were divided into three groups based on grade levels in the UK: Key Stage I (~4-7 years olds), Key Stage 2 (~7-11 year olds), and Key Stage 3 (~11-14 year olds). All students had very good knowledge of when, how, and why to wash hands (over 90% of students answered most hand washing questions correctly). Approximately 64% of the 4-7 year olds, 52% of the 7-11 year olds, and 31% of the 11-14 year olds reported "always" washing hands before eating. In general, food safety knowledge increased with age; however, many of the reported behaviors, such as hand washing, decreased with age. These findings were similar to those found in the study by Haapala and others (2004). Finally, unpleasant and inconvenient hand washing facilities at the schools were noted as barriers to more frequent hand washing, and some students reported avoiding the facilities completely. Eves and others (2010) reported results of the 732, 5-7 year old subset data that was collected by Eves and others (2006). The same knowledge, attitudes, behavioral, and barrier results were reported in addition to in-depth analysis of qualitative interview data that were previously only briefly reported. Students had relatively good knowledge of the importance of washing produce; over 90% of the students identified that fruits and vegetables needed to be washed prior to consumption. Furthermore, 96% of students answered the hand washing before eating question correctly but only 64% reported "always" washing hands before eating. The interviews revealed that the students who understood the reasons for proper food handling were more likely to engage in the proper food safety behaviors. Additionally, Students were able to verbalize the concept of microorganisms and how they relate to the humans, food and illness. The authors conclude that children as young as 5 years old have good knowledge of food safety but may need reinforcement from educators, health promotion professionals and parents in order to practice proper food handling behaviors more often.

Food Safety Education with Children
Ovca and others (2014) found similar results to the previously described studies (Eves and others 2006;Eves and others 2010;Haapala and others 2004).
Perceived risk of foodborne illness was assessed by 6 statements with which students had to either "agree" or "not agree" and students reported personal experiences with food preparation and foodborne illness. General food safety knowledge was assessed by 18 true-false questions and self-reported behaviors were assessed using a 5-point Likert scale. Out of the 1272, 10-12 year old students surveyed in Slovenia, the majority had high perceived severity and low perceived vulnerability of foodborne illness. Knowledge scores related to hand washing and food preparation were also much higher than the corresponding reported behaviors. The results of this study suggested that food safety education programs should be implemented in elementary and middle schools for children to establish a foundation of proper food safety practices.
A food safety education program was pilot tested by Burney and others (2007).
Food Safety in the Classroom curriculum was developed in an effort to combine food safety principles with other core middle school curriculum subjects such as math, science, social studies, and language arts. Food safety extension personnel taught the 7 th grade teachers the food safety curriculum and the teachers then taught their students in 5-7 lessons. Preliminary results showed increases in knowledge for both teachers and students as well as increases in hand and contact surface washing behaviors. Richards and others (2008) used the Food Safety in the Classroom curriculum previously pilot tested by Burney and others (2007) with 233 seventh grade students.
This study evaluated the impact of the curriculum on the student's food safety knowledge and reported behaviors. The assessments were given at pre-intervention, post-intervention, and six weeks post-intervention (follow-up). Students scored 51±4.9% on the pre-test, 72±5.4% on the post-test, and 69±6.3% on the follow-up test.
Students had a knowledge retention rate of 86%, which was a significant increase in overall knowledge from pre-to 6 weeks post-intervention (p < .001). As for selfreported behaviors, students scored 73.4±5.1% on the pre-test, 80.5±5.5% on the posttest, and 81.9±4.9% on the follow-up test. Similar to the findings of the knowledge surveys previously discussed, self-reported food handling behaviors do not coincide with food safety knowledge scores (Eves and others 2006;Eves and others 2010;Haapala and others 2004;Ovca and others 2014). The curriculum tested in this study population successfully increased students' food safety knowledge and self-reported food handling behaviors. However, self-reported behaviors can be inflated and may not be indicative of true behaviors when observed (Anderson and others 2004). Faccio and others (2013) conducted an experimental food safety education program with 249 fifth grade students at 12 schools. The goal of this study was to increase students' understanding of microorganisms, to explain how bacteria relates to humans, food and illness, and to improve students' overall food safety knowledge. The students were assigned to either an experiential group or a theoretical group. Students in the experiential group participated in actual microbiological experiments, whereas students in the theoretical group received the same conceptual information although it was through a didactic approach. Students were evaluated by drawings (249 preintervention and 243 post-intervention) and 141 interviews (71 pre-intervention and 70 post-intervention). Students were asked to draw a picture based on the title "The Microorganism and I" and the definition of a microorganism. Approximately 5 students per class were then chosen for an interview, during which the students were asked series of questions about how to interpret their drawings. Student's drawings in the experiential group were more detailed, accurate, displaying causal linkages between actions of microorganisms and subsequent consequences on humans. The results of this study showed that a practical, hands-on approach was more effective at educating children on microorganisms and food safety than a didactic approach. Due to the complexity of the study design and the inclusion of both quantitative and qualitative variables, this methodology would be difficult to replicate. This study involved a team of researchers, educators, and statistical experts from different disciplines.
Losasso and others (2014) used the same data collected by Faccio and others (2013) with the addition of a parental component. This study analyzed the changes in food safety knowledge and proper food handling behaviors of the 249 fifth grade students through pre-and post-tests. Students were either in the experiential group or the theoretical group. Parents' perceptions of the student's behaviors were measured and compared to the students' self-reported behaviors at pre-and post-intervention.
The results showed that overall, student's knowledge increased from preto postintervention. However, student's knowledge stayed the same in the fruit and vegetable handling category, hand hygiene, and insight into the flu virus. The students demonstrated a high baseline knowledge of fruit and vegetable handling and hand hygiene whereas, knowledge regarding the flu virus remained the same following the intervention, likely due to the difficulty of the information presented. Self-reported food handling behaviors of the students significantly increased from pre-to postintervention and more so in the experiential group compared to the theoretical group.
There was a "fair" agreement pre-intervention between the parent's perception of the student's behaviors and it increased to a "slight" agreement post-intervention.
Based on previous knowledge surveys and intervention studies (Burney and others 2007;Eves and others 2006;Eves and others 2010;Haapala and others 2004;Losasso and others 2014;Ovca and others 2014;Richards and others 2008), there are varying results of students' food safety knowledge scores and reported behaviors. Students in the US have poor knowledge but report good food handling behaviors (Burney and others 2007;Richards and others 2008), whereas in the UK, students have good knowledge but report poor food handling behaviors (Eves and others 2006;Eves and others 2010). Most studies used surveys with a relatively low number of questions and studies with a younger population (5-7 year olds) used either pictures or drawings to appropriately and more effectively assess knowledge and behaviors. Furthermore, there is a disconnect between food safety knowledge and reported food handling behaviors. However, it is evident that students as young as 5 years old can and should be educated to recognize and understand unsafe food-related situations to protect themselves from foodborne illness.

 Disseminate Information
Targeting children through education programs increases the likelihood of reaching a larger audience, as children are more likely to disseminate information to their families (Heim and others 2011). Additionally, when children share new information with their families and friends, they are better able to retain the information (Losasso and others 2014).
In a garden-based nutrition education program for children, parents were involved to assess nutrition knowledge, fruit and vegetable consumption, and the extent of dissemination of information from child to parent (Heim and others 2011).
Heim and others (2011) included parents in their pre-and post-assessments and sent home weekly newsletters and recipes. The child's preand post-assessments included questions regarding fruit and vegetable availability in the home and how often they asked for fruits and vegetables. To coincide, one of the questions on the parent's assessment was if and how often their child asked for fruits and vegetables at home to assess the child's asking behavior and intake of fruits and vegetables. At the end of the intervention, parents reported that their child was asking for fruits and vegetables more often.
Parents were involved in the food safety study conducted by Losasso and others (2014) to assess their perceptions of their child's food handling and hygiene behaviors. On the pre-test, parent's perceptions of their child's behavior were low-tomoderately correlated with their child's reported behaviors. On the post-test however, it was evident that awareness of behaviors and child-to-parent interaction increased based on the correlation between the parent's perceptions of the child's behaviors and the child's reported behaviors.

 High Risk
Children are at a higher risk for foodborne illness (Trusts 2014). The increased risk is partly due to children's low body weight, less acidic stomach, underdeveloped immune system, and increased vulnerability to infection (Faustman and others 2000;FDA 2013;Trusts 2014). Children are also considered more vulnerable to infection due to their dependence on others to prepare their meals (Buzby 2001;Trusts 2014).
Moreover, children may not have been previously targeted for food safety education programs, as they are not as active in the preparation of their own food.

Conclusion
Even though most foodborne illnesses are preventable, foodborne illness remains a health and financial burden in the US (Scharff 2012). Furthermore, producerelated foodborne illnesses have been on the rise since the 1970's, potentially due to the increase in government response to foodborne illness through advancements in foodborne illness surveillance detection systems/networks (CDC 2011a) and stricter enforcement of guidelines for producers, manufacturers, and other food-handlers (Sivapalasingam and others 2004). The rise of produce-related foodborne illness could also be due to the increase in fresh produce consumption (Kim and others 2014; McGill and others 2015), poor food safety knowledge and unsafe food handling practices (Redmond and others 2003), and/or the increase in home and school gardens (NGA 2014;USDA 2014). However, definitive conclusions cannot be made.
With the increase in school gardens, it is imperative that students learn food safety principles surrounding school garden activities. Food safety education has not yet been implemented into school garden programs and therefore, the goal of this study was to integrate school garden-related food safety principles into school garden programs in Rhode Island elementary schools. The primary objective was to assess students' knowledge change from preto post-intervention. The secondary objectives were to 1) assess students' knowledge change by grade and by each of the four categories, 2) evaluate the program via students' ratings of the activities; and 3) assess reported student to parent/guardian interaction.

APPENDICES APPENDIX A. SCHOOL LETTER
To whom it may concern, -School Name -has graciously allowed Farm Fresh RI to conduct school garden programs in our school. The students at our school have benefited from learning about local foods, farming, and nutrition through school garden activities during the regular school day and/or in after-school programs. I understand that Valerie Calberry, a graduate student at the University of Rhode Island, will be developing and delivering a food safety school garden program to multiple classes in our after school program as a compliment to the Farm Fresh RI programs. As food safety is an equally important part in maintaining the health of our students, we welcome the food safety school garden program to the students that are already participating in the Farm Fresh RI Farm to School program. Activity-Pass the Apple. This activity shows how easily bacteria can spread without knowing it  Give two stickers to each student, one will be for them to keep and the other they will place on one of the apples that are being passed around. Pass around the two apples and make sure everyone in the class places their stickers on one and touches the other.
? Did the apple change at all as it was passed around the room?  There were stickers placed on the apple  The stickers show how bacteria can spread from child to child, from child to apple, and apple to child ? Has anyone ever heard of bacteria?  Bacteria cannot be seen all the time because they are micro-organisms meaning they are very small living cells that can only be seen under a microscope ? Has anyone ever used a microscope? (Show picture of bacteria under a microscope and petri dishes poster)  Even if a food, looks, smells and tastes good to eat, that does not mean there aren't any bacteria on it!  Bacteria are everywhere! ? Do you know that there are "good" and "bad" types of bacteria?
 Good bacteria are in some of our favorite foods like yogurt, cheese and pickles o Show yogurt, cheese, pickles props  Bad bacteria are not suppose to be in our food and can make us sick There are a couple reasons bacteria grow in our food…  First, they can grow in our food through moisture and warmth. For example, if we leave our food out in the sunlight for a couple hours  Second, they can be put on our food if it is touched with a dirty object. Like our hands or containers if they are not cleaned the right way We have learned about how bacteria can spread and how to properly wash our hands and fruits and vegetables. We also remember that pets and animals should stay out of the garden! ? How should we properly clean our containers we use for harvesting (picking) our fruits and vegetables from the garden?  With soap and water before and after placing the fruits and vegetables in them  Show clean and dirty containersask which container would be best ? What is the proper way to store our fruits and vegetables after we have cut them up so bacteria can't get at them?  Make sure the container has a lid that fits airtight so no bacteria can get in (show air-tight container)  Place in the refrigerator so the bacteria don't grow as fastremember, bacteria need warmth to grow! Activity-What's Wrong with this Picture?  Two pictures will be shown containing improper food safety methods in the garden and in the kitchen. Ask the students to identify what is going wrong in the picture and why they think it's wrong.  Garden: Animal/pet in the garden, dirty containers (2), eating directly from the garden/not washing fruit/vegetable before eating, eating without washing hands  Kitchen: Washing vegetables in a sink full of soap, eating without washing hands, eating without washing fruit/vegetable, holding pet while handling food, dirty container Activity-Bingo (grades 1-3)  Distribute one bingo card and several bingo chips to each student.  Read clues aloud until someone calls bingo.  Play 2-3 games depending on time.
 Each group will compete against one another in a Jeopardy game that is based on the information they have learned.  Determine which group will go first and ask them to pick a category, once the question is read anyone in the class can answer.  Call on whoever raises their hand first, if they get it wrong, call on someone from a different group. Whichever group answers the question correctly gets the points and then gets to pick the next category.
Wrap up: Ask the students if they have any questions with anything they have learned Teachers will distribute and collect the post-tests according to student ID roster  Read all questions aloud to the students and allow time for them to answer questions Farm Fresh Rhode Island (FFRI) has been teaching your child about school gardening, local farms and farming, and introducing them to new fruits and vegetables. As a compliment to the ongoing FFRI program, FFRI has invited me, Valerie Calberry, a graduate student from the University of Rhode Island to develop and present a Food Safety School Garden Program, which will include 2 activity-based lessons on food safety for school/home gardening.
Farm Fresh RI's mission is to grow a local food system that values the environment, health and quality of life of Rhode Island's farmers and eaters. Their goals include building a healthier community and increasing access to fresher, tastier food. Food safety related to freshly grown produce (fruits and vegetables) is another very important aspect to learn and practice. Teaching food safety to your child through activities centered around the school garden allows for a great way for them to learn about keeping produce safe to eat.
This Food Safety School Garden Program will take place during or after school. The topics that will be covered are hand hygiene and the ways to ensure safe planting, harvesting, and handling of fresh produce. As with the FFRI programs, we will be asking your child some questions before and after the program to see if he or she understands food safety information and enjoys the lesson and activities. We are hoping to expand this opportunity to other schools with gardens. These questions will not be used as a grade for your child.
At the end of the Food Safety School Garden Program, your child will receive a handout of the food safety and gardening topics and also a very short and simple 4question questionnaire for you to fill out, which will be voluntary and anonymous. When you receive the handout and questionnaire, please fill out your answers and send it back to school with your child within one week if you would like to provide answers.
Thank you in advance for your time and effort. Please contact your child's school teacher if you have any questions.
Sincerely, Valerie Calberry APPENDIX E. PARENT/GUARDIAN FOLLOW-UP Dear Parents/Guardians, As you may remember, we sent home a letter with your child describing the Food Safety School Garden program conducted by Valerie Calberry, a graduate student from the University of Rhode Island. If you would like to and have the time, please fill out the short questionnaire below about the Food Safety School Garden Program in which your child participated. This evaluation will help make the program better. Please return the questionnaire to your child's teacher within one week. Responses are not required but encouraged. Thank you in advance for your time and effort.
Please circle the answers to the questions listed below. 1a. Did your child tell you anything they learned in the Food Safety School Garden

Food Safety Bingo Clues
Seeds -Things that you plant in the soil that grow into plants Banana -Yellow fruit that you need to wash before peeling and eating it Potato -Vegetable you need to scrub the dirt and bacteria off Cantaloupe (melon) -Fruit you need to scrub the skin before cutting it up Strawberry -Red fruit that you need to wash with cool, running water Dirty radishes -Red vegetable that has dirt on it Spinach -Green leafy vegetable that you will pick and wash right before you eat it Orange -This is a fruit that you need to wash and then either peel or cut into slices before you eat it

Bruised Peach -Fruit that you would not eat because it is bruised and cracked
Cracked Tomato -Red vegetable that you would not eat because it is cracked and damaged Peppers & tomato -These vegetables are being washed with cool, running water Watering can -This is used to water the vegetables at the root Clean container -This is the proper container to harvest fruits and veggies Dirty container -You must first wash this before you can use it to harvest fruits and veggies Hand washing -You do this with warm soapy water for 20 seconds Bar soap -The bar form of the thing that you must use to wash your hands properly. It becomes bubbly when you scrub your hands with it Petri Dish -This is the growth of bacteria from unwashed fingers Rake -This is a gardening tool used to scrape and soften the soil Spade (pointy hand shovel) -This is used to dig small holes in the soil to plant seeds Shovel -This is used to dig big holes in the ground to plant things like trees Soil -This is the stuff that you plant fruit and vegetable seeds into

Raccoon -Wild animal you need to keep out of your garden
Dog -Pet that may want to follow you into the garden but should be kept out of it Fence -This is used to keep pets and animals out of the garden