EVALUATION OF A POLICY, SYSTEM, AND ENVIRONMENTAL SCHOOL-BASED FRUIT AND VEGETABLE INTERVENTION

Objectives: To determine the effect of a policy, systems, and environmental (PSE) intervention, Students Take Charge! (STC), among 4th and 5th grade students from low-income communities on 1) fruit and vegetable (FV) intake, and 2) PSE and FV knowledge, and self-efficacy (SE) to ask for FV at school and home. Methods: A quasi-experimental design was used involving six schools over two years. Schools were purposely selected; two schools each year either received STC or standard instruction. The study sample includes students (n=326 intervention; n=351 comparison) providing pre and post data (baseline and post-assessment at week 18). Supplemental Nutrition Assistance Program-Education (SNAP-Ed) educators provided the 8-lesson STC curriculum across 18 weeks; comparison students received standard instruction. STC is a school-based PSE intervention focusing on empowering students to make FV-based changes at school and at home. STC taught students about wellness policies, persuasive messages, and making requests; it cumulated with a vote to add a student submitted FV-based recipe to the school lunch menu. In addition, STC provided information about the importance of FV intake. Students completed the STC survey at both time points assessing FV intake, knowledge and SE. Analyses compared intervention and comparison students from baseline to post-assessment using analysis of covariance (ANCOVA) for objective 1 and multivariate analysis of variance (MANOVA) objective 2. Results: From baseline to post-assessment, there were significant differences (p<0.01) between intervention and comparison students; intervention students had higher fruit intake, increased PSE knowledge and SE in school. There were no between group differences in vegetable intake, FV knowledge, or in students SE to ask parents for FV in the home when comparing the intervention group to the control group. Conclusion: STC was associated with an increase in fruit intake, PSE knowledge and student SE to ask for FV in school. STC may require additional strategies, including home-based strategies, to increase vegetable intake, FV knowledge, and student SE to ask for FV at home.


INTRODUCTION
The prevalence of childhood obesity in the United States has increased from 16.8% in 2007-2008 to 18.5% in 2015-2016. [1][2][3] According to the 2015-2016 Center for Disease Control (CDC) data, 1 in 5 school age children and young adults between 6 and 19 years of age in the United States are obese. 4 Some factors associated with the prevalence of childhood obesity include overconsumption of food and beverages as well as inadequate physical activity. 4 Increasing fruit and vegetable (FV) intake in children has been associated with decreased childhood obesity and decreased chronic disease risk. 5 FV are important sources of vital micronutrients (vitamins and minerals) necessary for children's growth and development and many children are not meeting the current recommendations. 5,6 Research suggests that educating school children about the importance of nutrition improves health-related behaviors such as FV consumption as well as FV knowledge and self-efficacy (SE). 7 Policy, System, and Environmental (PSE) Interventions extend the reach of educational interventions. PSE interventions do this by use a multi-level approach to change behaviors at an individual level and community level. 9 For example, a traditional nutrition education workshop provides participants with nutrition related information about the importance of eating more FV. To further enhance the desired behavior change, PSE interventions could change options in the cafeteria to include more FV that the children enjoy. [9][10][11] Current research suggests school-based PSE interventions can decrease childhood obesity and be more sustainable than providing nutrition education alone. 12 Many PSE interventions focus on increasing FV consumption to decrease the risk of obesity. 8,10 However, only a few studies have focused on FV intake behavior among students attending low-income schools. [13][14][15] Low socioeconomic status is associated with increased childhood obesity risk. 16 Students attending low-income schools have low FV consumption due to decreased access to healthy foods and increased consumption of more readily available processed foods high in saturated fat, sodium, and added sugar. [17][18][19] knowledge and self-efficacy (SE) are also important variables that can be effected by socioeconomic status. 7 SE is defined as an individual feels empowered, confident, and able to execute the behavior necessary to complete a specific task. 20 Hall and colleagues found that students attending low-income schools had lower knowledge and SE scores than students attending higher-income schools. 7 Past studies have looked at student SE related to FV intake but only few studies have focused on asking SE. [21][22][23] Asking SE is defined as an individual feels empowered, confident, and able to ask others for the material necessary to execute a behavior change and has not be measured in past PSE interventions.
PSE interventions have been utilized in past studies to improve FV intake.
School-based PSE interventions that focused on changing the school cafeteria menu options or included a wellness committee to promote FV intake resulted in a greater increase in FV intake from baseline to post-assessment in the intervention group when compared to the comparison group. 17,24 However, few PSE interventions focus primarily on increasing FV intake in students in low-income schools. [24][25][26] Students Take Charge! (STC) is one of the few school-based PSE interventions to measure asking SE for FV at home and school. STC was based on a program developed by the pilot study, EMPOWER, a program that was specifically designed for low-income schools. Although EMPOWER resulted in no change in FV intake, researchers found a significant increase in knowledge as well as qualitative data suggest dietary and SE improvements. 27,28 Modified based on process data from the EMPOWER intervention, STC is an eight-week PSE program developed by the University of Rhode Island (URI) Supplemental Nutrition Assistance Program-Education (SNAP-Ed). STC focuses on empowering low-income 4 th and 5 th graders to increase FV consumption at school and home. Findings from preliminary qualitative studies with a subset of the STC sample suggest an increase in SE 29 , but no increase in FV consumed at school based on Digital Photography of school lunches. 30 Additional studies are needed to determine if PSE interventions are effective in improving FV intake and asking SE in students attending low-income schools. The primary aim of this study is to determine the effect of STC on FV intake among 4 th and 5 th grade students in low-income schools. The secondary aim is to determine the effect of STC on knowledge and selfefficacy related to FV.

METHODS
This study used a quasi-experimental design over two years to evaluate the impact of STC on FV intake, knowledge, and SE ( Figure 1). Intervention students received the STC intervention and comparison students received standard instruction without the STC program. STC was an 8-week school-based PSE intervention delivered biweekly that focuses on empowering students to make changes around what they eat at school with an emphasis on FV intake. The primary hypothesis is that FV intake will increase more from baseline to post-assessment in the intervention group than in the comparison group. The secondary hypothesis is that knowledge and selfefficacy related to FV will increase more from baseline to post-assessment in the intervention group than in the comparison group.

Design
STC intervention utilized a 2x2 quasi-experimental design that has two intervention groups and two comparison groups per year (four comparison and four intervention groups in total) with data collected at baseline and post-assessment (refer to Appendix B).

Research Participants
Two low-income racially and ethnically diverse school districts in Rhode Island participated in the study. Within those districts, elementary schools were selected based on principal consent and key informant recommendations in the community. Two schools were asked to participate in the Fall and were randomly selected to be in the intervention or comparison group. The districts were on average 64.5% Hispanic, 16% African American, 11% White, 3% Asian, 3.5% Multiracial, 1.5% Native American. 31 In these districts, about 88% of students are eligible for free or reduced price lunch. 32 According to the community eligibility provision, all students in the two districts receive free lunch because more than 70% of the population is considered low-income. 33 All students at participating schools with completed pre and post data were included in this study. Parents of participants were informed about the program and students could verbally decline to participate. The study was part of URI Institutional Review Board's exempt status. This secondary data analysis was approved by the University of Rhode Island Institutional Review Board.
As seen in Figure 2, the potential sample size was calculated as n=883 because of the students enrolled in the classes. The analytic sample size for the two years of STC that completed pre and post data for variables was n=722. Year 1 included two intervention schools (n=208) and two comparison schools (n=180). Year 2 included two intervention schools (n=167) and two comparison schools (n=223). The analytical sample did not include students who failed to complete the survey (refer to Figure 1 for specific sample size values). The analytical sample provides 80% statistical power (p<.05) to detect a small univariate effect size for the primary outcome (FV) and a small to medium effect size in a multivariate analysis for secondary outcomes (knowledge and SE). 34

Data collection
Identification (ID) numbers were provided to each student in the intervention and comparison groups. The ID number was used for data entry and analysis. The survey used was the STC Survey (Appendix D). The survey includes questions regarding gender, language spoken at home, ethnicity, race, knowledge of FV and PSE, FV intake, and FV self-efficacy questions. The baseline surveys were administered by URI SNAP-Ed Nutrition Educators a week before the first lesson (week 0) and the post-assessment surveys were administered a week after the last lesson (week 18). The intervention was 4 months since the lessons were provided every 2 weeks. Pre and post comparison data were collected within a two-week period of the intervention group data.

Intervention
The intervention school received a biweekly, 8-week nutrition education intervention with each lesson lasting 30 minutes. The comparison schools received standard instruction. Each lesson was taught by a SNAP-Ed Registered Dietitian (RD) and included a SNAP-Ed created FV nutrition education topic (refer to Appendix C) and PSE component. Family newsletter were sent home to parents including information regarding the lessons taught in class. The PSE components included: learning about the responsibilities of a wellness committee and how a committee can promote nutrition policy changes, interviewing family members about healthy foods, taste-testing recipes submitted by students, and designing marketing material for healthy foods. The program culminates in a recipe-tasting day in the school cafeteria, featuring a fruit-or vegetable-based recipe from one of the participating students. If the school student body likes the recipe, the goal was to add the recipe to the school and district-wide menu, thereby, changing the food environment and systems at school giving the participating students a voice in choosing the food that is available to them. Therefore, the over-arching goal of this intervention is to empower students to make changes around what they eat at school and home (with the main focus on FV intake).

Instruments
The instrument used in this study was the STC Survey (Appendix D). Students taking the survey were provided with instructions and received assistance by a SNAP-Ed Nutrition Educator (Appendix E). FV intake items on the survey were adapted from a validated survey 35 and the asking SE scale was adapted from a validated and reliable instrument that has been tested among 9 to 11-year old low-income students 21 and recently validated 36  The third item investigated if students understood persuasive messaging by providing them with four quotes and asking them to pick the quote they trust. For this knowledge section, the students/participants response is considered either correct (which was coded as 1) or incorrect (which was coded as 0) and scores were summed thus the response range is 0 (all incorrect) to 3 (all correct).
Asking SE related to FV at home and at school was explored utilizing student responses to asking SE related questions (Appendix H). There were six questions that asked students about how much they agree with statements relating to their ability to ask an adult at school (two items) or home (four items) for fruits and vegetables they like. Response categories included I disagree very much (score = 1), 1 disagree a little (score = 2), I am not sure (score = 3), I agree a little (score = 4) and I agree very much (score = 5). The responses were averaged per subscale (school and home) with a range of 1 (low self-efficacy) to 5 (high self-efficacy).

Data Analysis and Statistics
All completed baseline and post-assessments from the four intervention and four comparison schools were included in the data analysis. Normality was assessed for continuous data, and the data was normally distributed. 34,37 Baseline data including demographic categorical data (e.g. grade, school, etc.), were analyzed using chi-square and continuous data (e.g. age) was analyzed using independent t-tests. School demographic information provided by the Rhode Island Department of Education (RIDE) were used for race because about 75% of students choose "other" as their race on the survey suggesting that race data from the survey may not be reliable (Appendix I). 31 FV intake was significantly different at baseline between the two groups.
Analysis of co-variance (ANCOVA) was used to control for this baseline difference as a covariate. Adjusted post mean+/-SE provided by ANCOVA was used to determine if there was a significant difference between group for FV intake.
To assess changes in knowledge, and SE from baseline to post-assessment in the intervention and comparison group, MANOVA was used to determine the overall effect and ANOVA was utilized to determine significant differences between groups and dependent variables independently. All analyses utilized SPSS and p<.05 determined statistical significance.

RESULTS
Baseline demographics are provided in Table 1. The intervention group (n=356) students was significantly younger and more likely to be in 4 th grade than comparison group (n=364) students (p<0.01). There were no other demographic differences between the intervention and comparison group. Overall, 49% were female, 67% reported speaking Spanish at home, 75% of the students' moms cook and 91% of the student's moms or dads do the shopping (see Table 1). Table 2 demonstrates that all schools included in the study had students with similar racial/ethnic backgrounds. As seen in the table demonstrating school-level data provides by RIDE, most students are Hispanic (62 to 67%) and were eligible for subsidized lunch (81 to 95%). The RIDE data were used because 75% of the children chose "other" on the survey (Appendix I). When comparing student reported demographics including speaking Spanish at home (67%) with percentage of Hispanics (62 to 67%) from the RIDE data, these percentages were very similar.
The primary hypothesis was that fruit intake and vegetable intake will increase more from baseline to post-assessment in the intervention group than in the comparison group. FV intake was significantly different at baseline, so ANCOVA was used to control for baseline intake as a covariate. As seen in Table 3 There was a statistically significant decrease within group for vegetable intake in the intervention (p=0.001) and the comparison (p=0.03) groups.
The secondary hypothesis was that knowledge and self-efficacy of FV will increase more from baseline to post-assessment in the intervention group than in the comparison group. Using MANOVA, there was an overall effect of group on change in FV knowledge, PSE knowledge, SE school, and SE home [F(4,595df)=10.5, p<0.001; Wilk's Λ = 0.93]. As seen in Table 4

DISCUSSION
The purpose of this study was to determine the effect of STC on FV intake and related variables in 4 th and 5 th grade students attending low-income schools.
Intervention students participating in STC study increased fruit intake, PSE knowledge, and SE at school more than comparison students. However, the intervention was not affect in increasing vegetable intake, FV knowledge, or SE at home. This study is one of the few PSE studies, delivered by SNAP-Ed, to specifically target low-income youth (an average of 88% eligible for free or reduced price lunch 31 ) with a high proportion of Hispanic students (67%) (refer to Table 2).
The results showed a higher fruit intake in the intervention group when compared to the comparison group, but no difference in vegetable intake. Other research has found that fruit intake is easier to change than vegetable intake in PSE interventions. 24,30,38,39 However, some PSE interventions in both high and low-income schools were successful in increasing both fruit intake and vegetable intake separately. 13,17,24 Another PSE intervention by Leines et al. focused on increasing FV intake in students from low-income schools and found an increase in fruit intake and vegetable intake separately. 13 The PSE component included training teachers and food service workers on strategies for increasing FV intake in children. 13 King and Ling also saw an increase in fruit intake and vegetable intake in kindergarten to third grade children, which may be attributed by training parents and the community to promote healthy behavior change. 15 Incorporating a heightened emphasis on the importance of vegetables by teachers and food service workers in the cafeteria may be necessary to improve students' eating behavior. Some strategies that could improve these results for the future include not only increasing vegetable availability at school but also including a stronger home or parent component, so that parents are encouraged to buy more vegetables for children to consume at home.
There was a statistically significant increase in PSE knowledge in the intervention group when compared to the comparison group from baseline to postassessment. There are no current studies measuring students PSE knowledge in a survey except those previously done in the pilot study. 28 Both this current study and EMPOWER indicate that there was an increase knowledge of what components are included in a PSE intervention. 28 When analyzing FV knowledge, there was no between group difference in the intervention and comparison group from baseline to post-assessment. A STC pilot study by Lepe et al. found a greater increase in FV knowledge from baseline to post-assessment in the intervention group when compared to the comparison group 28 , which may emphasize the need for further development of this instrument. 27,29 Knowledge and SE are associated with each other because understanding the importance of FV intake, may help increase students SE for asking for FV at school and home. 40 This study assessed students' SE for asking adults to provide FV with two scales, SE in school and SE at home. Intervention students increased SE in school more than comparison students but there was no difference in SE at home. Many studies have looked at students SE related to FV intake [21][22][23] but not many studies that measured FV asking SE 24 . In a preliminary STC study, Hafner et al. conducted focus groups among STC intervention students (n=32). 29 Students indicated higher SE after the intervention both at home and at school. 29 Students had a high home asking SE at baseline before the intervention (averaged around 4 on a 5-point scale), which could be another reason why SE did not significantly increase. Focus groups may be a better strategy when measuring students' SE at home due to the ceiling effect. 41 Future interventions should include a parent PSE intervention to understand more about the home environment and if including them in the intervention may improve students asking SE for FV at home.

Strengths and Limitations
Some strengths of this study include that it is one of the few school-based PSE interventions in primarily low-income schools. Another strength is that the PSE intervention was specifically designed for the schools included in the study by SNAP-Ed. The RD educator and data collection was consistent throughout the 2-year study.
Some limitations of this study are that it lacked randomization and there were differences between groups at baseline ( Table 2). While this study is not generalizable to other populations, it was conducted in low-income schools that contained a high percentage of Hispanic children, who are at a higher risk for poorer dietary behaviors. 42 Another limitation of this study is that the STC Survey is not validated but components of the survey were taken from previous validated surveys. 21,36 Furthermore, FV intake was self-reported by students, which can lead to estimation errors. 43 This can also be a strength because it allows more data to be collected.
Another limitation is that this study did not include a qualitative component, which could help determining if students FV knowledge and/or home SE has changed overtime.

Implications for Research and Practice
STC is one of the few school-based PSE interventions focusing on evaluating student FV intake in low-income schools. 13,17 These results indicate that STC was effective in increasing fruit intake, PSE knowledge, and SE at school. These results suggest that more strategies are needed when trying to promote vegetable intake but results are similar to other school-based PSE interventions. 30,39 More strategies including providing and introducing more vegetables by taste testing vegetables in the classroom and training teachers and food services workers to promote behavior change have been seen to increase vegetable intake in prior PSE intervention. 13,15 Additional strategies include adding a PSE component for parents to increase understanding of why FV are important and why their children should be consuming more FV may increase behavior change. Qualitative studies are needed to further evaluate asking SE at home and school. These results may also emphasize the need for a validated survey to assess FV knowledge. This study adds to the literature focused on increasing FV intake in students attending low-income schools. 13,14,17 It can also aid in the future development of the PSE programs to promote more positive FV behavior changes in students attending low-income schools.

Year
Academic Semester

Comparison Intervention
Year 1 Fall School A (4 th ) School B (4 th ) Spring School D (5 th ) School C (5 th )

Year 2
Fall School E (5 th ) School A (4 th ) Spring School F (5 th ) School D (4 th ) a= There were 2 students who did not answer this question on the survey. b= There were 14 students who did not answer this question on the survey. c= Some students did not respond to this question, this is why n=691. d= Some students did not respond to this question, this is why n=692. e= Some students did not answer this question, so this is why n=694. * = p<0.05 ** = p<0.01 *** = p<0.001 SD = standard deviation  += FV intake was significantly different at baseline, so analysis of covariance (ANCOVA) was used instead to assess if adjusted post mean+/-SD was higher or lower when comparing the intervention and comparison group. a= Some students did not answer this question on the survey, therefore n=677. * = p<0.05 ** = p<0.01 *** = p<0.001 SD = standard deviation

A. LITERATURE REVIEW I. Introduction
Childhood obesity continues to be a concern, especially among low-income racially and ethnically diverse children. 1 One factor associated with childhood obesity is decreased fruit and vegetable (FV) intake. 2  Charge! (STC) program is a PSE intervention that focuses on increasing FV intake, knowledge, and self-efficacy (SE) in students attending low-income, urban schools.
The goal of this review is to discuss the prevalence of childhood obesity, the impact of socioeconomic status (SES) on multiple variables including FV intake, introduce the social cognitive theory and self-efficacy 12 , then provide an in-depth overview of FV PSE interventions, and lastly discuss prior research on STC. Only results for children in the following studies will be reviewed due to the focus is on interventions for elementary age children.  19,20 A strategy to address childhood obesity is increased FV intake and availability in the environment. As discussed previously, there is a correlation between increased FV intake and decreased chronic disease risk, such as obesity. 21 FV are important sources of vital micronutrients (vitamins and minerals) necessary for child growth and development and can help promote healthy weight. Promoting higher intake of FV can be difficult depending on environmental factors such as socioeconomic status, which will be discussed next.

III. Impact of SES on Nutrition-related Outcomes in Children
SES has an effect on overall FV intake, knowledge and SE. SES refers to the level of education, income, and occupation an individual holds. 22 An individual's SES offers insight to the available resources they may or may not have available to them. 22 Those with low-SES or students attending low-income schools receive food assistance provided through the National School Lunch Program. The National School Lunch Program in Rhode Island provides students with low-cost or free nutritious lunches to over 72,000 children every day. 23 The Community Eligibility Provision (CEP) of the school lunch program allows schools that have a large proportion of low-income families to provide students with free meals during school without individual income verification. If a school has greater than or equal to 70% free or reduced lunch eligibility, then all students receive free or reduced lunch. 219,203 One-third to one-half of meals are consumed at school, thus foods that are provided to students during school hours should include healthy options such as FV. 25 A recent meta-analysis found that studies that including increasing fruits and vegetables at mealtimes during school by implementing policies, increased consumption of fruits by 0.27 servings/day, vegetables were only slightly impacted, and FV together increased by 0.28 servings. 25 The FV options that schools provide can play a key role in what foods students consume. 26 Other components such as FV knowledge and SE are effected by socioeconomic status. 27 Title I schools have greater than or equal to 40% of children that are low-income and receive free or reduced lunch. 28 Non-Title I schools have less than 40% of students receiving free or reduced lunch. 28 The next sections will focus on how low SES can affects FV intake, knowledge, and student's SE for asking for FV at school and home.

FV intake
This section will discuss FV intake and how SES can impact children's overall intake. According to the United States Department of Agriculture (USDA) in 2007 to 2010, 60% of children ages 1-18 years did not meet the recommended intake for fruit and 93% did not meet the recommended intake for vegetables per day. 29 The Center for Disease Control (CDC) recommends that FV are available or offered to children during school 30 , which can increase the likelihood that children will consume adequate FV. 31 In low-income families, consumption of FV is low due to decreased access to healthy foods and increased consumption of more easily available processed foods high in saturated or solid fat, sodium, and added sugar. 32,33,34 Low-income populations' decrease in FV intake has been shown to increase their risk of coronary heart disease, stroke, obesity and type 2 diabetes. 35 In general, most children are not meeting the current recommendations for FV and these habits can continue into adulthood. 36,37 School, home, and community-based interventions have been used in the past to promote FV intake in children to improve diet quality. The next section will discuss FV knowledge and how knowledge is affected by SES.

FV Nutrition Knowledge
This section will discuss how FV knowledge overall is affected by SES. SES has been seen to have a significant effect on dietary behaviors and diet quality. 38 In Nebraska-Lincoln, Title 1 and non-Title 1 schools participated in a nutrition education intervention called Fuel Up that was created to change 5 th grade students overall knowledge of specific nutrition topics. One Title 1 school (n=58) and three non-Title 1 schools (n=135) participated in the post-survey only design study. 34 34 The Fresh Fruit and Vegetable Program introduced students to fruits and vegetables. 26 The Fuel Up to Play 60 program is a school-based nutrition and physical activity program that encourages students to lead healthy lives. 39 Both the Fresh Fruit and Vegetable Program and the Fuel Up to Play 60 program are funded by the USDA. 26,39 The postsurvey provided to the students at each school was the validated Healthy Habits survey that evaluated the students overall nutrition knowledge including the following topics, the five food groups, nutrition benefits, recommended daily intake, healthy snacks, and breakfast benefits. 27 The results indicated that the non-Title 1 group scored better than the Title 1 group for knowledge variables, including significantly higher average scores for knowledge when identifying food in the vegetable (p=0.026) and lean protein groups (p=0.008), whole grain versus refined grains (p=0.01), and recommended daily intakes of fruit and vegetables (p=0.004). 34 The overall knowledge of health-related behaviors was also significantly higher in the non-Title I than in the Title I group. 34 These results suggest that there is an increased need for nutrition related school-based interventions in Title I schools because of their lower knowledge. 34

The Social Cognitive Theory
This section will focus on the social cognitive theory and how reciprocal determinism and SE constructs (including individuals confidence asking for FV) were used in prior FV intervention to promote positive behavior change. Interventions that are informed by behavioral theories are more likely to be effective at shaping health behaviors, including diet. 40 One theory that is commonly used in the design of schoolbased nutrition interventions is the social cognitive theory. The main goal of the social cognitive theory is to promote change and maintain positive behavior. The six constructs of the social cognitive theory are reciprocal determinism, behavioral capability, observational learning, reinforcement, expectation, and SE. 40 This theory focuses on how important it is to not only educate and increase knowledge to promote healthy lifestyle changes but to also increase SE. The social cognitive theory has been associated with increased lifestyle behavior changes. 41 The constructs of the social cognitive theory that were utilized in the STC intervention (which will be discussed later on in this review) are reciprocal determinism and SE. Reciprocal determinism refers to a person's interaction with the environment and how this effects their behavior. 40 SE is referred to as the "beliefs in one's capabilities to organize and execute the courses of action required to produce given levels of attainments." 40 The next study will explain how the social cognitive theory and it's constructs was utilized to promote behavior change.
One intervention utilizing the social cognitive theory constructs, reciprocal determinism and SE, was a single-group pretest, posttest design for an after-school program including urban Native American youth. 41 There were 65 children ages 5 to 10 years and 39 adolescents ages 11 to 18 years in the study (total n=104). 41 The intervention lasted 7 months and focused on improving nutrition self-efficacy by student taste testing two food options to see if the students could determine the healthier option confidently, discussing ways to achieve balance with exercise and healthy eating, and children working with the adolescents in the study to promote modeling. 41 The environmental was also changed in the cafeteria by only providing option slow in fat and increasing the availability of FV for dinner that was provided to the students in the after school program. 41 Education was also provided to teach students how to make healthy choices in their environment using situations in their everyday life. 41 The lessons were 30 to 60 minutes monthly and were provided to both the children and adolescents. 41 In this study, personal and environment factors of the social cognitive theory were addressed in the hopes of increasing students SE for choosing and having healthier options. 41 This differs from asking SE because students are not asking adults for healthier options but are picking the options themselves in this study. SE was measured using a self-efficacy questionnaire with a response scale of 1 to 3, 3 being the highest SE and scores were averaged. 41 The mean+/-SD for SE at baseline to post-assessment was 2.06+/-0.50 to 2.34+/-0.41 in the children (p=0.002). 41 Overall this intervention resulted in a significant improved self-efficacy related to choosing and having healthier options in children. 41 This study demonstrates how reciprocal determinism of the social cognitive theory was utilized to promotive increased SE. 41 The social cognitive theory can be used to promote FV intake, knowledge, and SE in school-based PSE intervention (this will be defined in a later section). The environment plays an important role in the development of obesity and poor dietary quality and Fetter and colleagues found changes in the environment promote healthy behavior changes. 42 Changes in the school food environment and the home food environment have a potential impact on the children's eating behavior. 42 The next section will define and discuss school-based PSE interventions and how they were used to improve dietary behaviors in children.

Asking Self-Efficacy for FV
In this section, SE and asking SE will be defined and past research will be discussed. SE is defined as allowing an individual to feel empowered, confident, and able to execute the behaviors necessary to complete a specific task. 40 Asking SE is defined as individual feels empowered, confidence, and able to ask others for the material necessary to execute a behavior change. For example, self-efficacy in asking for FV would be high in students would if they feel comfortable to ask their parents to buy FV they like at home. Students need to increase their asking SE to feel confident to ask their parents for FV. This construct is also related to social cognitive theory, which will be discussed in a later section. Increasing student's asking SE for FV can improve dietary behavior. 43 Guiding children to have high SE or feel a sense of empowerment to make healthy choices is an important component to include in PSE interventions, especially in low-income populations. 34 44,45 Power Play! Campaign's School Idea and Resource Kits study was a randomized control study that included 10 grade-specific FV lessons and assessed self-efficacy and knowledge. 44 The study focused on encouraging students to consume more fruits and vegetables by including the following PSE components: allowing the students to create their own persuasive messages, advertise the importance of FV, and role-play scenarios where the students can practice asking for FV at home. 44 There were 1,154 4 th and 5 th graders from 31 low-income schools and a 58% of students were Hispanic. 44 The self-efficacy survey included 8 questions on asking/shopping and 3 items related to eating, which were some of the questions created by Baranowski et al. 46 The intervention resulted in a significantly higher self-efficacy score in the intervention group than in the control group for asking/shopping (p=0.04). 44 This study is one of the few that have proven interventions focused on students in lowincome schools can be effective in increasing FV self-efficacy. 44 The limitation of this study was that it did not evaluate overall FV intake and if this behavior changed overtime. 44 Wright et al. The Fuel Up study discussed previously was one of the few programs that assessed SE with Title 1 children. 34 On the Healthy Habits Survey the students answered 10 items/statements regarding their confidence concerning the following topics: healthy meal identification, healthy meal choices, food group choices, meal planning, healthy choices in the presence of social pressure, healthy snack choices, and breakfast consumption. 34 These items were scored from 1 to 3, ranging from low being 1 to high being 3. 34 The program resulted in non-Title 1 students scored slightly higher for most variables related to SE when compared to the Title 1 students. 34 These results indicate the need for interventions that can empower student in Title 1 or lowincome schools to ask for healthy FV options. 34 behavior change programs because PSE intervention promote school-wide changes instead of just focusing on the individual students. 4 The goal of PSE interventions is to increase positive behavior by providing a school with the means to make these changes and then sustain these changes over time. 4,48,49 School-based PSE interventions provide students with the appropriate material to make sustainable behavior changes 35 and the following section will focus on the effectiveness and methods used in prior PSE interventions.

PSE Interventions not focused on income level
One of the larger PSE interventions is the Active for Life program, which was a cluster randomized control trial and is primary school-based intervention in England which focused on decreasing sedentary behavior and improving diet. 50 This study did not focusing on a specific income level. 50 Students in 4 th grade were recruited, randomized and measured at baseline before receiving the intervention during 5 th grade. 51 The sample consisted of 8 to 11 years old students; total n=2211, intervention n=1064, comparison n=1157. 50 The students received an outcome assessment survey 1 year post intervention during 6 th grade. 50 Active for Life is considered a PSE intervention because it focuses on the systems component of PSE by providing teachers with the means to educate in order to promoting behavior change in all the student envolved. 50 Training, lesson plans, resources and material for 16 lessons, and 10 parent-child homework assignments were provided. 50 The comparison schools were given none of the material. 50 The 5 th graders were also part of the immediate follow-up after the intervention in 5 th grade and received a one-year follow up during 6 th grade. 50 FV intake was measured using child-reported consumption and the validated 'Day in the Life Questionnaire.' 50 To measure screen time, a previously validated screen viewing questionnaire was used. 50 The results demonstrated no differences at the immediate follow-up between the intervention and comparison school when looking at the primary outcome of FV intake (p=0.42 at the end of intervention). 50 The intervention was successful in decreasing screen time on weekends (p=0.01) and decreasing the consumption of snacks (p=0.01) and highenergy drinks (p=0.002). 50 The intervention reported below focused on changing the cafeteria environment. defining it as a PSE intervention. 7 The PSE components include increasing opportunities during school lunch for the students to consume a variety of FV, providing students with role models eating FV, and instituting social support for children to promote FV consumption at lunchtime. 7 One day training lessons for food service staff was also provided. 7 The results of this study were that the intervention group consumed 0.14 servings more of fruits and vegetables than the control group.
Fruit intake in the intervention group was 0.79 servings of fruit and in the comparison group it was 0.63 servings of fruit consumed when the researcher was observing the students in the lunchroom. For fruit intake, there was a 0.16 difference, with the intervention group consuming more fruit than the comparison group. For vegetable intake alone, 0.27 servings were consumed in the intervention group and 0.29 servings were consumed in the comparison group. The comparison group consumed more vegetables than the intervention group by 0.02 servings. SE itself was not measured but was a component the researchers tried to increase by using this PSE approach. 7 The Cafeteria Power Plus Project did not focus on a low-income population, but did result in higher fruit intake after the intervention. 7 The next intervention was effective in improving healthy behavior changes.

Shape Up Somerville (SUS) was a quasi-experimental 2-year community-based
multi-component PSE intervention with the main goal of decreasing obesity prevalence and increasing positive behavior change such as increased FV intake. 20 The children in the intervention community were 6 to 8 years of age and were in the 10 Somerville public elementary schools (n=454). 20 This is a PSE intervention because the before-school environment was changed by increasing the fresh fruit, low-fat milk and whole grains in the free breakfast program and healthy eating was modeled by adults. At school, the environment was changed by changing school lunch by including more FVs each month, having taste tests of these FVs, educational posters and tabletop tents around the cafeteria, new kitchen preparation and serving equipment and training for food service staff, etc. The students in the intervention group also received a 30-minute nutrition and physical activity lesson on top of the PSE work.
The after-school environment was also changed by adding a 28-lesson curriculum including crafts, cooking demonstrations and physical activity games. This study saw no significant difference in FV intake based on parental reported intake of children; however, there was a significant decrease in BMI z scores comparing the intervention to the control communities. 20 This study highlights the importance of looking at many other factors and conducting future studies to measure behavioral change. 20 The next FV PSE intervention focused on lower-income youth.

Low-income School-based PSE Interventions
As discussed previously, low-income youth are at higher risk for low FV intake. 35 One of the few PSE interventions focused on improving FV intake in students attending low-income schools include, Go Wild With Fruits and Veggies! (GWWFV) a PSE intervention. 6 GWWFV is a one group pre to post design with 7 FV lessons. 6 The students were 8 to 10 years of age and 4,128 students participated in the study. 6 This is a PSE intervention because there were also additional activities for the teachers, food service, and families to reinforce the system and environment changes being made in order to facilitate behavior change. 6  This survey was used to determine the effectiveness of GWWFV to increase FV intake. 6 The intervention group from baseline consumed 0.93+/-0.88 cups of fruit and after intervention consumed 1.57+/-0.89 cups of fruit. 6 The intervention group from baseline consumed 0.92+/-0.85 cups of vegetables and after intervention consumed 1.32+/-0.94 cups of vegetables. 6 This intervention demonstrated how students attending low-income schools can benefit from PSE related work, but a comparison group was not present.
Another PSE intervention focused on a low-income school was a 3-year, nutrition and physical activity study. 8 This study uses a quasi-experimental that included an intervention group only and evaluated the longitudinal effects of a 3-year, school-based PSE intervention. 8 The intervention was provided to four rural elementary schools in the southern United States (n=999). On average, 65% of the youth were eligible for free or reduced priced lunch and students age averaged 7.30+/-1.36 and 237 of students were in kindergarten, 232 students were in 1 st grade, 264 students were in 2 nd grade, 264 students were in 3 rd grade. The PSE components of this intervention includes, promotion for staff and family and community involvement, school wellness polices, and professional development. The goal for each school was to achieve 'bronze,' which is considered higher status of the HealthierUS School Challenge. The HealthierUS School Challenge: Smart Lunchrooms is the challenge to create a healthier school environment and increase physical activity. 52 The validated School Physical Activity and Nutrition questionnaire was used to measure fruit and vegetable consumption and physical activity. 53 The questionnaire was provided at baseline and then 12 follow-up assessments were conducted over 3 years. From baseline to follow-up, there was a significant increasing trend of percentages of children that met the overall recommendation for nutrition over time (from about 12% to 23%; p<0.001). The students FV intake average intake was about 2.58 servings at baseline and increasing by about 0.50 servings each month. 8 There was also a significant increase in physical activity after the intervention and during follow-up (p<0.001). 8 Overall, this PSE intervention was successful but did not include a comparison group. 8 Healthy options for nutrition environments in schools (Healthy ONES) is one of the few PSE intervention focused on primarily low-income schools. 9 This is a two- year, randomized group trial. 9 At baseline, three elementary and one middle school were randomly assigned to the intervention and another three elementary and one middle school were randomly assigned to the comparison group. 9 In this low-income district, there were a total of 4,033 students and of these students, 42% were Hispanic/Latino, 26% were African American, 21% were non-Hispanic white, and The studies provided in this section indicate that most but not all PSE interventions are effective in increasing FV or healthy dietary behaviors. [6][7][8][9]20,50 It also indicated a need for more PSE interventions focused on low-income populations and focused on components like increasing FV intake and students asking SE. In the studies above, for low-income youth, cafeteria PSE interventions were associated with increased FV intake. The next section will explain the importance of evaluating these types of intervention with specifically low-income youth.

V. Pilots and Preliminary Studies for STC
There is an increased need for evaluation of PSE interventions such as the STC program. STC is one of the few FV PSE interventions focused on 4 th and 5 th grade low-income youth. [7][8][9]50 Compared to past PSE interventions, it is the only study that include taste testing a recipe picked by the students and offering this recipe in the cafeteria for the whole school to sample. 54,55 It is also one of the few interventions that evaluate asking SE of FV at home and school. 54,55 The following section highlights other studies related to the STC PSE intervention.

Empowering Urban School Children to Increase Fruit and Vegetable
Consumption Through EFNEP-Enhance PSE Intervention (EMPOWER), the pilot program for STC, was a PSE intervention that focused on low-income, 5 th graders in Rhode Island. 56 The objective of the intervention was to empower urban school children to increase FV consumption. It utilized a tool that is not validated called the FV Checklist. This checklist was developed by SNAP-Ed to analyze overall child intake of FV from the day before. Using a quasi-experimental design with an intervention group (n=142) and comparison group (n=170), there was no significant difference in FV consumption between or within groups from pre to post-intervention.
However, there was a higher in PSE knowledge when comparing post adjusted values in the intervention group at 4.92+/-0.14 when compared to the comparison group at 3.76+/-0.13 (p=0.001). FV knowledge also was higher in the intervention group at 4.52+/-0.15 when compared to the comparison at 4.10+/-0.14 (p<0.05).
Lepe et al conducted a process evaluation of the EMPOWER pilot study. A rubric was created to evaluate the program delivery. Focus groups with students and semi-structured interviews with staff were conducted to evaluate outcome and process evaluation. 57 In the focus groups, students indicated that they made dietary changes after being part of the intervention although there were no changes in FV consumption (measured using survey in EMPOWER study). 57 SE was not measured in this study.
A preliminary study of STC looked at SE in a subset of students. Hafner used a 2x2 quasi-experimental mixed-method design that assessed SE using a survey created by SNAP-Ed and qualitative data (cognitive interviews and focus groups). 54 Portions of the survey were adapted from a validated survey. 44 This study only used data from the Fall 2017 group of students (n=142; intervention n=85, comparison n=57). This study assessed if student SE increased in the intervention group more than the comparison group. In addition, focus groups were conducted pre and post students at the intervention schools to ask students questions regarding their favorite FV's and who is responsible for the food at home or school. 54 55 A limitation to this study is the small sample size and the FV provided at lunchtime were not the same at baseline and follow up. This study highlighted the importance of environment and how the availability of FV in the lunchroom can effect overall FV intake and variety. 55 The pilot and preliminary studies suggest the need for further evaluation of the STC PSE intervention and its effectiveness to increasing FV intake, knowledge, and SE to improve children healthy eating behaviors and decrease the prevalence of childhood obesity. [54][55][56][57]

VI. Conclusion
Based on the research discussed above, the prevalence of childhood obesity has increased over time and low income youth are the most at risk due in part to poor dietary habits (including low intake of FV). 19,35 As explained in the social cognitive theory section of this review, reciprocal determinism and self-efficacy constructs need to be addressed to promote positive behavior change; these constructs has been utilized in the past and resulted in positive behavior changes. 40,41 This review also defined PSE intervention and how they work by changing policy, systems and the environment to promote positive behavior change. 4 This review also discussed seven past PSE intervention, three that did not focus on low-income youth 7,20,50 and three that had some low-income youth. 6,8,9 Depending on the method used, some school-based PSE interventions have been successful in increased positive behavior change like FV intake in children. [6][7][8][9] The methods used in successful studies included providing teachers with training, changing some options in the cafeteria, and changing other aspects of the school environment to promote healthy behavior change. 7,20,50 Of the PSE interventions that did not focus on low-income youth, only one intervention was successful in increasing FV behavior change; this intervention focused on changing the cafeteria environment to include more FV. 7 From this review, studies that were successful utilized many strategies including changing the environment so that more FV were available to children and educating adults and staff about the importance of FV.
PSE interventions that did include low-income youth focused on increasing FV knowledge, and changed some aspects of the cafeteria environment. 6,8,9 Two out of the three PSE interventions were successful in increasing nutrition knowledge. 6,8,9 As far as this writer knows, there has been few PSE interventions focused on increasing FV intake in low-income youth and few PSE interventions have focused on increasing students asking SE for FV at school and home.
have been conducted on the STC pilot or intervention, utilized outside data to determine if the program is successful. 54,55 Both preliminary STC studies found different results for fruit and vegetable intake. The secondary data analysis of STC reported in this thesis will help evaluate if the intervention is associated with increasing student FV intake, knowledge, and SE and provide more important data regarding the effectiveness of PSE intervention in low-income schools. • Report on most popular F&V class wanted to see in cafeteria • Why variety of F&V is important • Have students brainstorm ideas to overcome barriers to eating F&V • Read letter drafted for providence wellness committee/Sodexo, add line about barriers and have students initial signature sheet • Introduce environmental scan-have students do during lunch time next week (set up a schedule for them, give environmental scans to teachers to complete week of ______) • Handouts to take home: Eat variety of color, Family Newsletter #2

Lesson 3 March: Amounts of F&V/Recipe Reading (25-30 min)
• Amount of F&V to consume • Learn how to read a recipe • Math activity using information from recipe • Handouts to take home: F&V 2+2, Family Newsletter #3

Lesson 4 March: Go, Slow and Whoa (GSW) /Role-playing interviewing adult about favorite fruit or vegetable recipe (25-30 min)
• Hand in environmental scan completed week of _______ • Give permission slip for families to attend next PPSD wellness committee meeting • What are GSW foods • Role play interviewing an adult about a recipe • Review recipe criteria (we want these recipes to be GO recipes, so not too much sugar, salt, fat added to it AND need to have fruit or veggie as main ingredient in the side dish (provide examples of side dish recipes) • Handout to take home: 5 food groups (G,S,W) , Script for Recipe interview, Family Newsletter #4 • Give date that recipes must be submitted by. SNAP-Ed will filter through recipes and choose ones that meet the criteria (narrowing down to two recipes)

E. PRE/POST SURVEY SCRIPT
1 SAY → Hello everybody, my name is ______________, and I am from URI SNAP-Ed.
Over the next few months SNAP-Ed will be visiting your health class to conduct nutrition education workshops.
SAY → Before we start, we need you to complete a survey. We are going to complete the survey together. When you get a survey please leave it face down so that you are looking at PART 5.

DO NOT TURN THE SURVEY OVER UNTIL EVERYONE HAS ONE.
(once everyone has a survey have them flip it over, follow the prompts next to each survey question) 11. "At the store or farmer's market before they head out to shop or if you are with them while they shop" 12/13. "A few days in advance, not the day they are making dinner because they may not be able to go to the store that day to the buy the vegetable or fruit." 14./15. "For example on a table, countertop or in the refrigerator where you can reach them." 16./17. "This adult could be your teacher, a food service worker, health/PE teacher, or the Principal." 3. SAY → Thank you for completing the survey. Please put your pencils down when you are done and we will collect your surveys.