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Cancer Care Ontario's *Take 5: 5-10 a day...your way* Vegetable and Fruit Behaviour Change Intervention

I Introduction
II The Take 5 Program
III Piloting Take 5
IV Evaluating Take 5
V Learning From Take 5
VI Next Steps
VII References

--by Lise Smedmor, MEd, RD, Communication Consultant to the Nutrition Resource Centre's *Take 5: 5-10 a day, your way* Transition Project

Based on the report, "Evaluation of a Vegetable and Fruit Behavioural Intervention: *Take 5: 5-10 a day...your way* Results from Twelve Pilot Sites in Ontario" prepared by Myrna Wright and Melody Roberts, Cancer Care Ontario, and Harry Cummings and Associates

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I Introduction

Scientific evidence points to increased vegetable and fruit consumption as an important factor in the prevention of a number of chronic diseases including cancer (World Cancer Research Fund, American Institute for Cancer Research, 1997; Steinmetz and Potter, 1996), cardiovascular disease (Ness and Powles, 1997; Joshipura et al., 2001; Gillman et al., 1995), and diabetes (Ford and Mokdad, 2001). In line with the Cancer Care Ontario (CCO) mandate of providing leadership across all areas of the cancer system, an effective, population-based approach to increase the number of people consuming 5 to 10 servings of vegetables and fruit was needed.

*Take 5* is a community-based, multi-component, vegetable and fruit behaviour change program. Its goal is to promote consumption of 5 to 10 servings of vegetables and fruit every day by informing, educating, and supporting behaviour change related to vegetable and fruit acquisition, preparation, storage, and eating among women aged 25 to 45 with children 14 years of age or under.

The project was led by CCO under the direction of Melody Roberts, Manager, Prevention Unit, and Myrna Wright, Senior Health Education Consultant.

This article will discuss the program and its pilot phase, and evaluation.

II The Take 5 Program

*Take 5* is based on social learning theory and includes behaviour change principles designed to increase vegetable and fruit consumption, such as self-monitoring and goal setting, reinforcement and reward of positive behaviours with small incentives, and social support and knowledge exchange opportunities.

The program was designed by a behavioural psychologist, based on formative research, and vetted by an advisory committee. The curriculum was developed by a registered dietitian and reviewed for clear language and design before being pilot tested.

The program consists of six interactive training modules and is delivered over the course of six consecutive weeks by a trained facilitator. It focuses on
* increasing self-efficacy (e.g., choosing vegetables and fruit when highly anxious or emotionally upset)
* reducing barriers to vegetable and fruit consumption through group learning exercises and experience sharing (e.g., women participate in personal goal setting and self monitoring to question how they think about vegetables and fruit)
* fostering adequate social support to facilitate these changes in the reality of women's everyday lives (e.g., informal discussion and taste testing of new recipes)

Each module provides background information, activity materials and handouts, Vegetables and Fruit A to Z, and recipes. The training sessions consist of warm-up activities, discussion, hands-on activities, and a snack break.

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III Pilot Testing Take 5

A pilot test, funded by CCO, was conducted in 2002-2003 in order to determine the effectiveness of *Take 5* and to inform the formal adoption of the program for a potential provincial roll out in 2004.

Five CHCs and seven public health units were chosen to represent a cross section of the Ontario population, reflecting north/south, urban/rural, Aboriginal, Francophone, and multicultural communities. Sites had to demonstrate established community partnerships/coalitions and other complementary interventions that would provide environmental support to *Take 5*. Program facilitators, ranging from registered dietitians to community nutrition workers, attended a training day.

Each test site was responsible for recruitment: CCO provided the sites with recruiting materials, a number of sites established informal contact with other sites to share strategies and ideas, and many sites considered word of mouth to be an important factor in generating awareness, especially in smaller communities.

The twelve sites recruited a total of 163 women; the final analysis focuses on the 91participants that met the age criteria and completed the pre-intervention survey, the end of program questionnaire, and the three-month post program questionnaire.

The participants in the pilot sites worked well together and several groups have formed support networks and are still meeting after completion of the program.

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IV Evaluating Take 5

The study used a multiple methods approach. Standardized evaluation tools (including pre-intervention, end of program, and three-month post-behavioural evaluation surveys; standardized comment sheets for each session; and weekly journals with questions regarding each module for facilitators) were developed for program facilitators, agency administrators, and program participants and were designed to collect information that would facilitate the use of the RE-AIM analytical framework (Glasgow et al., 1999; please see OHPE 367.2 for more information).

The objectives of the evaluation were
* To determine the extent to which the program causes change in the consumption of vegetables and fruit among program participants
* To determine the extent to which the program causes changes in behaviour, skills, and knowledge associated with the increase the consumption of vegetables and fruit
* To assure or improve the quality of the program design, materials, and delivery
* To determine the practicality of the intervention being used at the local and provincial levels
* To examine the organizational opportunities and barriers for implementing and evaluating the program at the local and provincial levels
* To determine the appropriate resources, training, and technical assistance needed for adoption, implementation, and maintenance of the program at the local and provincial levels

The full evaluation report, including detailed information about RE-AIM, will be available on the CCO website.

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V Learning From Take 5

A. Behaviour Change
* Total vegetable and fruit consumption increased three-fold from expected results from the literature as a direct result of participation in *Take 5*.
* Total vegetable and fruit consumption increased to 5.8 times per day three months after the program.
* Behaviour change was maintained three months post program.
* Greater increases in overall vegetable and fruit consumption were observed in participants with lower than average consumption pre-program.
* Participants showed increased confidence in maintaining behaviour in a variety of situations as a direct result of participation in the program.
* Participants experienced increased self-efficacy for both vegetable and fruit consumption.
* 91% of participants identified that *Take 5* contributed towards their increased consumption of vegetables and fruit and 96% of them shared program information with friends and family.
* 76% of the participants that were initially recruited for the program went on to complete the program.

B. Unintended Effects
* A number of agency administrators felt that *Take 5* extended the reach of the organization by bringing in first-time clients, connecting with different cultural groups, and increasing community awareness of their other programs.
* For the winter cohort, the pilot was ready at a time of the year (the beginning of January) when women were more conscious of or committed to making changes to their diet and were looking for this type of program.
* Agency administrators indicated that the program produced a very positive response from participants and facilitators noted that many left with a positive view of the agency.
* The program exposed staff to a comprehensive evaluation process that was "great for staff growth" and an excellent learning experience for the Community Food Advisors, students, and volunteers. One administrator viewed the program as a good public relations exercise by demonstrating the organization's interest in evaluation research.
* The program resulted in networking, establishing, and/or reinforcing links between the host agency and other community service providers as part of the recruitment and delivery process (including prompting a local grocery store to stock more exotic fruits and vegetables based on requests from participants and their friends and the establishment of two new locations of good food boxes and a class on how to prepare veggies). Several sites expressed interest in developing a post-program support group or self-help process.
* At the organizational level, one of the negative outcomes was that existing programs had to be rescheduled to accommodate the pilot due to space and human resource constraints.

C. Consistency in Program Delivery
* The facilitators' journals provided information on fidelity to various elements of the intervention's protocol. While all indicated that they followed the program as outlined, further reading indicated that some items/activities were omitted or the time spent on them minimized.
* It was only in the area of behaviour change that the program was not implemented with the same level of robustness, specifically as it related to setting goals, self-monitoring, and identifying barriers and supports in goal setting and positive reinforcement. The importance and need for specific training on behaviour change for personnel delivering *Take 5* is underscored.
* Feedback indicated that positive reinforcement challenged strongly held beliefs against rewarding people for eating healthy food and many facilitators did not encourage this practice. While intrinsic rewards are established with *Take 5*, they are initiated through extrinsic rewards. Therefore the Leader's manual is being improved with additional information.

D. Opportunities/Challenges for Subsequent Program Delivery
* In most of the sites, *Take 5* was viewed as a good fit with the agency mandate and in many cases complemented other food-related programs. Where the program was promoted among other agency staff it was well received.
* The program resulted in networking and establishing/reinforcing links between health centres/units and other community service providers as part of the recruitment and delivery process. Agency administrators and facilitators identified a number of opportunities for partnering with other local organizations (most often CHCs and public health units) in delivering *Take 5*.
* Organizations with volunteers could include them in recruiting, session preparation, transportation, and childcare. However, agency administrators stressed that the volunteer activities and roles need to be delineated so that the partnership is meaningful and fits with the program and agency mandate.
* Most site administrators indicated that the agency provided human resources as the largest of their in-kind contributions. However, facilitators also felt that time commitment would be reduced with subsequent offerings as facilitators become more familiar with the program and resources and less time would be spent on evaluation.
* Many of the test sites indicated that *Take 5* created a demand for subsequent offerings. Many of the participants indicated they would recommend the program to family and friends. One site is considering partnering with an Early Years program if it runs the program again. There was also interest in offering the program at worksites. Another site reported on men who contacted the organization to enroll but were turned away because of the participant criteria. Opportunities were also seen for tailoring the program to specific cultural groups.
* The program was clearly popular with the participants with completion rates equal to or better than other programs. Several sites did not have similar programs to make comparisons with but were impressed with the rates considering the six-week commitment.

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VI Next Steps

The Nutrition Resource Centre (NRC) is exploring future training, technical assistance, and support needs for *Take 5* (with the support of the Ontario Stroke Strategy) and assessing the potential for provincial uptake of *Take 5* by nutrition professionals in public health, CHCs, heart health coalitions, and other community agencies. This next phase of the project will be completed by the end of June.

For further information about the *Take 5* evaluation, contact Myrna Wright at

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