Laura Ruiz

Teacher Survey for Nutrition Knowledge and Attitudes: Testing for Validity and Reliability

Abstract

Objective The purpose of this study is to create and validate a survey intended to collect nutrition knowledge & attitudes of U.S. teachers. Methods The survey was developed to gather information covering six themes of nutrition knowledge and attitudes of U.S. teachers. Testing of the survey involved two waves and cognitive testing of three respondents in the first wave of testing. Wave one of testing involved a convenience sample of teachers and non-teachers and wave two of testing involved teachers of a school district in Texas. A reliability test was performed using Cronbach’s Alpha. Validity testing was done using a Wilcoxon rank-sum test.

ResultsWave one of testing involved 24 respondents. Wave two of testing involved 70 responses from teachers and 78 non-teaching school staff. A Cronbach’s Alpha score of α=0.41 indicates low reliability of nutrition knowledge questions. However, validity was found in the nutrition knowledge question with teachers scoring higher after nutrition education through employer or worksite wellness (P=0.011 and P=0.005 respectively).

ConclusionsThis study indicates valid survey with low reliability. Additional editing and testing is needed to determine reliability of nutrition knowledge questions.

Laura Ruiz

Introduction

Obesity rates in the United States have been steadily climbing over the past 15 years. This includes obesity seen in youth. Children ages 2-19 years saw an obesity rate at 17% in 2014.1 This is especially concerning because children who are obese are much more likely to remain obese into adulthood.2,3 With the adult obesity rate being 36.5% in 2014, prevention strategies are needed more than ever.1 While it is important to emphasize a healthy lifestyle at home, it is also crucial to teach obesity prevention activities in school. Many studies can be found on looking at family and environmental factors in relation to childhood obesity; however, few studies4-6 look at teacher health in comparison. Children spend many hours in the classroom and teachers have a substantial effect on a child’s life. Improving teacher health can have greater effects in the classroom environment when trying to prevent childhood obesity.4

It is important for educators to have a strong base in nutrition and health in order to teach effective obesity prevention strategies. Teachers who do not have proper nutrition education cannot be expected to effectively teach nutrition in the classroom. The lack of nutrition education may also carry over to a teacher’s nutrition habits, of which can be observed by students. Many teachers may not have recent or any formal training in nutrition. The purpose of this study is to create and validate a survey intended to collect nutrition knowledge and attitudes of U.S. teachers. This survey will be used in further studies with the intention to prevent childhood obesity.

Methods

Survey questions were developed from six themes based on the desired nutrition knowledge from teachers. From those themes, twenty-one sub-themes were developed to further categorize questions. The themes and sub-themes are illustrated in Figure 1. Survey themes and sub-themes were developed after looking at previous literature to determine gaps in the collection of teacher health and nutrition knowledge. Past surveys were discovered of teachers’ nutrition knowledge on the Food Pyramid and MyPlate.7-8, 12 From these surveys, gaps were found among the themes Teaching Efficacy, Attitudes & Practices, Role Modeling, and Perceived Health of Students. Many questions used in this survey were taken from surveys previously tested for validity and reliability.7-13 On the final survey, 17 original questions were developed to ensure all themes were represented. Sub-themes that contain only original questions are Previous Nutrition Education, Barriers to Nutrition Education, Perceived Health of Current Diet, Desire to Change Diet, Foods Eaten in Front of Students, and Perception of Students’ Nutrition Knowledge.

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The initial survey contained 148 questions that covered each of the sub-themes in the survey design. Each survey question was then analyzed and discusses to determine its appropriateness for the survey, if the question is repeated at all among the other questions, and for comprehension. The survey was then edited to 48 questions; 13 questions regarding Nutrition Knowledge, 8 questions regarding Teaching Efficacy, 9 questions regarding Attitudes & Practices, 5 questions regarding Perceived Health of Students, 3 questions regarding Role Modeling, and 10 questions regarding Demographics.

Figure 1. Six themes of survey questions with Sub-Themes listed below.

The first wave of testing the survey involved a convenience sample of teachers and non-teachers recruited over social media. Respondents were able to click a link which took them to the survey in Google Forms format. All respondents’ survey submissions were anonymous and there was no way to connect information provided in the survey to any respondent. From those responses, three respondents agreed to participate in cognitive testing. Cognitive testing is done to ensure quality and clarity of questions by allowing a certain number of respondents to discuss questions in an open-type interview.14,15 The cognitive testing interviews were organized into six subjects: Think Aloud/General, Comprehension, Retrieval, Confidence, Difficulty, and Answer Appropriateness. The Think Aloud/General, Comprehension, and Retrieval subjects were asked as open ended questions. The Confidence and Difficulty questions were answered on a Likert-type scale and the Answer Appropriateness questions were answered as yes or no with the possibility of additional discussion. Figure 2 shows the cognitive testing subjects along with the questions asked. Survey questions 1-12 went through all six subjects of cognitive testing. Survey questions 13-48 went through the

Nutrition Knowledge

Dietary & School Health Guidelines

MyPlate

Knowledge of Access to Nutrtiion

Information

Teaching Efficacy

Previous Nutrition Education

History of Teaching Nutrition in the

Classroom

Barriers to Nutrition Education

Perceived Importance of

Nutrition Education

Attitudes & Practices

Types and Frequency of Foods Eaten

Perceived Health of Current Diet

Desire to Change Diet

Perceived Health of Students

Perception of Students' Nutrition

Knowledge

Perception of Parents' Nutrition

Knowledge

Perception of Students' Health

Status

Students' Nutritional Needs

at Home

Role Modeling

Perceived Health Status

Foods Eaten in Front of Students

Foods Provided to Students

Demographics

Age, Race, Ethnicity, Gender

Subject & Grade Level Taught/

Number of Years Teaching

Highest Level of Education Obtained

Health Information

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Think Aloud/General, Comprehension, and Answer Appropriateness subjects of cognitive testing. A total of two cognitive tests were done. The first had two respondents of the survey, and the second only had one respondent.

Figure 2. Cognitive testing subjects with subject questions below.

Each cognitive testing interviewee’s answer were put into one of numerical categories based on their response. For the Think Aloud/General question, responses were categorized as: (1) positive response, (2) neutral response, or (3) negative response. Key words were observed that assisted with judgement in categorization of answers such as “good question, bad question, I don’t like this question, etc.” There were three categories of which the interviewee’s responses to the Comprehension question were placed in: (1) no confusion, (2) minor confusion, (3) major confusion. Interviewee’s answers to the Retrieval question answers were also placed into three categories: (1) easy retrieval, (2) moderate retrieval, (3) difficult retrieval. The Confidence and Difficulty questions were answered by the respondents on a scale rating from one to five. The interviewee’s answers in the last category, Answer Appropriateness, were placed into three categories: (1) yes, (2) somewhat, and (3) no.

Wave two of testing consisted of a sample of teachers from an independent school district in Texas. Consent was given from the superintendent of the school district. The link to the survey was sent by email to the superintendent who then sent the link to all teachers in the school district. The school district consists of five elementary schools (grades Pre-Kindergarten-4th), one intermediate school (grades 5th-6th), one junior high (grades 7th-8th), and one high school (grades 9th-12th). Teachers were given a week and five days to complete the survey and all submissions were anonymous. Figure 3 shows the version of the survey used for wave two testing. Results from the cognitive test and wave two survey were transferred into Microsoft Excel16 so the data could be viewed for errors. The data was then analyzed using SAS17. Tests for internal consistency of nutrition knowledge questions were done using Cronbach’s Alpha with the level of

Think Aloud/General

Do you have any comments or concerns with this question?

Comprehension

Is there anything about this question that is confusing?

Retrieval

How did you come up with your answer?What was your thinking process?

Confidence

On a scale of 1 to 5, with 1 being not confident and 5 being very confident, how confident are you in your answer to this question?

Difficulty

On a scale of 1 to 5, with 1 being very difficult and 5 being very easy, how difficult or easy did you find this question?

Answer Appropriateness

Do you feel the answer choices or answer format to this question was appropriate?

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internal consistency set at α=0.70. Tests for validity of nutrition knowledge questions were done with a Wilcoxon rank-sum test with significance set at P<0.05.

Results

Wave one of testing yielded 23 respondents. The respondents consisted of 65% females, 26% males, 9% did not answer, 78% are of White/Caucasian race, 22% are Hispanic or Latino, 13% are 18-24 years, 52% are 25-34 years,13% are 35-44 years, 4% are 45-54 years, and 18% are 55-64 years. There were 4 respondents who identified as having teaching experience, with 2 identifying currently teaching 5 th grade. The average score of respondents on the nutrition knowledge section of the survey was 72% with the range of scores being 42% to 92%. The average score of respondents claiming they have not had any nutrition training was 81% while those who have claimed to have some type of nutrition training had an average score 69%.

Interviewees of the cognitive testing consisted of two males and one female. Interviewees’ professions are a curriculum developer of a school district, an utility company employee with previous teaching experience, and a university student studying to be a teacher. The Think Aloud/General subject averages are 1.67-2.33. Survey questions 48, 43, and 22 had the highest scores indicating a more negative response. The Comprehension subject averages are 1-1.67. Survey questions 2 and 43 had the highest scores indicating more confusion. The Retrieval subject averages are 1.00-2.67. Survey questions 3 and 7 had the highest scores indicating more difficulty in answer retrieval. The Confidence subject averages are 2.00-5.00. Survey question 7 had the lowest score indicating less confidence in answer choice. The Difficulty subject averages are 2.00-5.00. Survey question again had the lowest score indicating a more difficult question to answer. The Answer Appropriateness subject averages are 1.00-1.33. Questions 4, 5, 9, 31, 34, 38, 44, and 47 had the highest scores indicating less appropriateness of answer choices or answer format. After the wave one of testing and the cognitive testing interview, seven questions or the answer choices or formats of those questions were changed.

Wave two of testing yielded a total of 148 respondents. Of these responses, 2 were blank and were deleted from the dataset. Another response provided inappropriate responses such as a height of 7 feet, an impossible choice for gender, and chose every box for race/ethnicity. Due to these responses, the record was deleted from the dataset. For the weight category, one respondent wrote “na” and another respondent wrote “idk.” These results were not indicative of a weight in pounds and the variable in that record was deleted to be blank. One respondent answered “yes” for the gender category and that variable in the record was deleted to be blank. For the dataset

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specific of teachers, records were not included if they included two or more survey answers as “Not Applicable/I am not a teacher”.

Teachers made up 70 responses and non-teaching staff made up 78 responses. The school district consists of 309 teachers, providing a teacher response rate of 22.7%. Of the teachers who responded, 80% are female, 13% are male, and 7% did not answer the gender question. The average score of teachers on the nutrition knowledge section of the survey was 70% with the range of scores being 17% to 100%. The average score of respondents claiming they have not had any nutrition training was 71% while those who have claimed to have some type of nutrition training had an average score 69%. Table 1 displays the distribution of certain variables by averages score on the nutrition knowledge questions and by average BMI.

Table 1. Distribution of Teachers by Average Nutrition Knowledge Score and Average BMIVariable Average Score of

Nutrition Knowledge Questions Mean (SD)

Average BMIMean (SD)

Years Teaching Less than 5 years 0.68 (0.11) 26.82 (3.88)5-9 years 0.66 (0.09) 28.74 (8.82)10-14 0.66 (0.18) 27.28 (6.29)15-19 0.65 (0.12) 28.34 (7.06)20 or more 0.77 (0.14) 28.51 (5.00)

Participation in Wellness programs

No, I have not participated

0.70 (0.11) 26.78 (7.70)

Yes, I participated once

0.63 (0.22) 30.47 (8.38)

Yes, I participated several times

0.69 (0.13) 27.77 (5.28)

Yes, I participate often 0.79 (0.11) 28.45 (3.73)Number of Times Fruit was Consumed in Last Week

0 Times 0.72 (0.05) 29.60 (10.05)1-3 Times 0.69 (0.12) 29.10 (6.87)4-6 Times 0.75 (0.18) 27.22 (5.02)7-9 Times 0.65 (0.14) 28.35 (5.30)10 or More Times 0.69 (0.12) 21.36 (0.56)

Gender Male 0.67 (0.23) 26.58 (4.19)Female 0.72 (0.12) 28.13 (6.46)

Age 18-24 Years 0.46 (0.41) 24.65 (0.63)25-34 Years 0.67 (0.11) 26.19 (3.56)35-44 Years 0.65 (0.11) 28.47 (8.54)45-54 Years 0.74 (0.12) 28.32 (5.34)55-64 Years 0.74 (0.16) 29.30 (7.04)

Race/Ethnicity White/Caucasian 0.71 (0.12) 27.32 (5.70)Hispanic/Latino 0.69 (0.09) 28.22 (5.41)Multi-Race/Ethnicity 0.57 (0.27) 31.69 (11.13)

Cronbach’s Alpha was used to test for internal consistency of the questions testing nutrition knowledge. It was determined the nutrition knowledge questions did not reach

Laura Ruiz

the level for internal consistency (Cronbach α=0.41). With the removal of 4 questions in the nutrition knowledge section, a higher level for internal consistency was reached, but was still not determined to be consistent (Cronbach α=0.56).

A Shapiro-Wilk test was run to test for the normality of Nutrition Knowledge score data. A score of p=0.0002 was found, indicating the distribution is not normal. From this finding, it was decided the Wilcoxon rank-sum test is appropriate for this data. The Wilcoxon rank-sum test provided p-values for the average nutritional knowledge score of teachers compared to types of nutrition education they have received. Statistically significant differences in nutrition knowledge scores were found for teachers who had previous nutrition education with worksite wellness (p=0.005) and with their employer (p=0.011). Teachers who received any nutrition education (p=0.980), nutrition education with a college or university (p=0.747), nutrition education with a community organization (p=0.422), or any other nutrition education (0.985) did not have statistically significance in difference of scores. Table 2 displays these results.

Table 2. Average Nutrition Knowledge Score of Teachers with Different Types of Nutrition Education TrainingVariable Mean (SD) 95% CI PAny Nutrition Education 0.71 (0.12) 0.67 0.74 0.980College or University Coursework 0.70 (0.14) 0.64 0.76 0.747Worksite Wellness 0.76 (0.14) 0.70 0.81 0.005*Employer 0.78 (0.16) 0.70 0.87 0.011*Community Organization 0.73 (0.13) 0.64 0.83 0.422Other Nutrition Education 0.69 (0.10) 0.46 0.93 0.985

CI, Confidence Interval; * denotes statistically significant result when p<0.05.

Discussion

This study is intended to present the validity and reliability of a survey developed to test and collect information about teacher health and nutrition knowledge. The questions in this survey were derived from a variety of other surveys along with original questions intended to measure gaps in existing literature. This survey is intended to be used in a variety of projects in the future.

The reliability of nutrition knowledge questions in this survey is questionable due to the Cronbach’s score of 0.41. However, a recent study has shown that Cronbach’s Alpha may be unreliable and there are other tests that may be preferred.18 A different test of reliability should be done along with additional changes to the survey. Validity of the nutritional knowledge portion was found to be good with nutritional knowledge scores found significant in teachers who have had previous nutrition education with worksite wellness and with their employer. Teachers did not have significantly higher nutrition knowledge scores with previous nutrition education in college or university coursework,

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community organization, or other. This may be due to the quality and amount of time that has passed since they have taken those nutrition education courses. This hold especially true since 70% of the teachers in this survey have 10 or more years of teaching experience.

While few resources have been found regarding teacher’s health and nutrition, a similar study was done in California to show validity and reliability of a survey.8 However, this survey is meant to collect information on nutritional knowledge of adults, not specifically teachers. This study has a Cronbach’s Alpha for internal consistency as α=0.91. Several questions from that survey were used for the survey developed described in this study.

The primary limitation of this study is the sample population that took this survey. The teachers are a part of one school district in Texas, of which may not be representative of the U.S. population. There is also a possible selection bias because those who took the survey may be more likely interested in the subject of nutrition. Another limitation is a possible recall bias. All information collected is assumed true by the survey takers, and that leaves the option for error or untruthfulness from the survey taker. Lastly, the tool used to disseminate the surveys by email leaves the leeway of one person taking the survey multiple times. This could lead to repeated entries or different data from the same person.

Conclusion

Validity was confirmed in the survey but continued testing and changes to the survey are needed to confirm reliability. This survey is intended to be used across the U.S. and should be able to represent a diverse teacher population. With proper changes, this survey tool has the potential to collect a wide array of information that can be used to improve the health of teacher’s and their students.

Laura Ruiz

Figure 3. Survey used in Wave Two Testing.1. Which of these isn’t usually a whole grain?8

a. Popcornb. Oatmealc. Flour tortillasd. Brown ricee. Not sure

2. Which of these should you look for on a label to tell if a loaf of bread is whole wheat?8

a. 100% wheatb. Stone-ground wheatc. Cracked wheatd. Whole wheat is first in the ingredient liste. Not sure

3. Do you agree with the following statement? There is more protein in a glass of whole milk than in a glass of skimmed milk.9

a. Agreeb. Disagreec. Not sure

4. Choose the TWO proteins with the least amount of fat.13

a. Ground Beefb. White Fishc. Bacond. Black Beanse. Bologna

5. Why should you eat lean meat and poultry?8

a. They have more vitaminsb. To keep saturated fat lowc. To save moneyd. They have more fibere. Not sure

6. How are oils like olive and canola oil different from solid fats like butter and shortening?8

a. Oils are usually lower in saturated fatb. Oils raise LDL (bad) cholesterolc. Oils are usually higher in saturated fatd. Oils are always hydrogenatede. Not sure

7. Which of the following foods is highest in saturated fat?

a. Peanutsb. Skim milkc. Olive oild. Red meatse. Avocados

8. Which food has more total fat in a serving size of 4 ounces?8

a. Fried Chickenb. Salmon Filletc. They both have the samed. Not sure

9. What is the daily amount of vegetables an adult should eat?8

a. 1 to 2 cups each dayb. 2 to 3 cups each dayc. 5 to 6 cups each dayd. 6 to 7 cups each daye. Not sure

10. Do health experts recommend that people should be eating more, the same amount, or less of vegetables?9

a. Moreb. Samec. Lessd. Not Sure

11. Do health experts recommend that people should be eating more, the same amount, or less of sugary foods?9

a. Moreb. Samec. Lessd. Not Sure

12. Do health experts recommend that people should

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be eating more, the same amount, or less of salty foods?9

a. Moreb. Samec. Lessd. Not Sure

13. How much information has your school provided you with on nutrition education in the past year?10

a. More than I wantb. As much as I wantc. Less than I wantd. None

14. Have you ever received training on nutrition education in the following settings?

a. College or University Courseworkb. Employed School or School Districtc. Worksite Wellnessd. Community Organizatione. Common Threads’ Healthy Teacher

Trainingf. Other_______________________g. I have never received training on nutrition

education.

15. During this school year, did you teach any of the following nutrition and dietary behavior topics to your students? (Mark all that apply)7

a. Benefits of healthy eatingb. Benefits of drinking plenty of waterc. Benefits of eating breakfast every dayd. Using food labelse. Eating more fruits, vegetables, and whole

grain productsf. Choosing foods, snacks, and beverages

that are low in added sugarsg. Other_______________________h. None of the above

16. How strongly do you agree with the following

statement? I find it easy to incorporate nutrition lessons into my curriculum.

a. Strongly agreeb. Agreec. Undecidedd. Disagreee. Strongly disagree

17. How strongly do you agree with the following statement? I feel that my school or school district is supportive of nutrition education in the classroom.

a. Strongly agreeb. Agreec. Undecidedd. Disagreee. Strongly disagree

18. How strongly do you agree with the following statement? I have easy access to teaching materials or lessons on nutrition education for my classroom

a. Strongly agreeb. Agreec. Undecidedd. Disagreee. Strongly disagree

19. How important do you believe it is to teach students about nutrition as part of the school curriculum?12

a. Very Importantb. Importantc. Moderately Importantd. Slightly Importante. Not Important

20. How important is the subject of nutrition compared to other subjects you teach (such as math, English, science, etc.)?12

a. More Importantb. Same Importancec. Not as Important

21. How confident are you that you can change your students’ nutritional knowledge?12

a. Very Confidentb. Confidentc. Moderately Confidentd. Slightly Confident

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e. Not Confident

22. Are you on a special diet?9

a. Yes, a low carb dietb. Yes, a low fat dietc. Yes, a low calorie dietd. Yes, another

diet_______________________e. I am not on a special diet

23. On average, how long each weekday do you have to eat lunch?

a. I don’t eat lunchb. Less than 15 minutesc. 15-29 minutesd. 30-44 minutese. 45-59 minutesf. 60 or more minutes

24. During the past week, how many times did you eat fruit? Include fresh, canned, or frozen fruit.10

a. 0 Timesb. 1-3 Timesc. 4-6 Timesd. 7-9 Timese. 10 or More Times

25. During the past week, how many times did you have vegetables to eat other than potatoes? Include fresh, canned, or frozen fruit.10

a. 0 Timesb. 1-3 Timesc. 4-6 Timesd. 7-9 Timese. 10 or more Times

26. In general, how healthy is your overall diet? Would you say:

a. Excellentb. Very goodc. Goodd. Faire. Poor

27. Does your school or school district provide wellness programs or wellness incentives for teachers? (Can include online resources, stress

management classes, physical activity opportunities, etc.)

a. Yesb. Noc. Don’t Know

28. If yes, have you participated in a wellness program provided?

a. Yes, I participated onceb. Yes, I participated several timesc. Yes, I participate oftend. No, I have not participated

29. In the past, year have you attempted to:a. Gain Weightb. Lose Weightc. Keep the same Weightd. I don’t weigh myself

30. When you hear or read a new recommendation about nutrition, are you more likely to:10

a. Change food habits according to new recommendation

b. Wait to get more informationc. Ignore the new recommendation

31. In general, would you say your health is:10

a. Excellentb. Very goodc. Goodd. Faire. Poor

32. During the past 12 months, how many times did you go to a doctor, nurse or other health care provider to get care for yourself?10

a. Noneb. 1 timec. 2 timesd. 3 timese. 4 timesf. 5-9 timesg. 10 or more times

33. In the past week, what type of foods or drinks have you consumed in front of your students?

a. Vegetablesb. Fruits

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c. Sugary foods (candy, cookies, etc.)d. Salty foods (chips, crackers, etc.)e. Soda or sports drinksf. Coffee or teag. Waterh. I have not consumed food or drinks in

front of my students

34. Do you believe your students’ nutrition knowledge is:

a. Excellentb. Very Goodc. Goodd. Faire. Poor

35. Which of these bodies below do you think a 4th grade boy should look like?11

a. 1b. 2c. 3d. 4e. 5f. 6g. 7

36. Which of these bodies do you think a 4th grade girl should look like?11

a. 1b. 2c. 3d. 4e. 5f. 6

g. 7

37. On average, do you believe your students weigh:a. Too muchb. The right amountc. Too little (or not enough)

38. In your neighborhood, do you have easy access to: (mark all that apply)11

a. Walking or bike paths (sidewalks, crosswalks, etc.)

b. Availability of safe parks, playgrounds, community centers

c. Supermarkets or grocery stores that offer healthy food

39. How many consecutive years have you been teaching?

a. Less than 5 yearsb. 5-9 yearsc. 10-14 yearsd. 15-19 yearse. 20 or more years

40. What grade level are you currently teaching?a. Pre-Kb. Kindergartenc. 1st Graded. 2nd Gradee. 3rd Gradef. 4th Gradeg. 5th Gradeh. 6th Gradei. 7th Gradej. 8th Grade

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41. What subject are you currently teaching?a. Pre-Kb. Kindergartenc. General Elementary Educationd. Mathe. Englishf. Social Studiesg. Scienceh. Physical Educationi. Artj. Foreign Languagek. Other_____________________

42. What is the highest grade or level of school you have finished?8

a. Less than 8th gradeb. 8th through 11th gradec. High school diploma or GEDd. Vocational or technical traininge. Some collegef. Associate’s degreeg. Bachelor’s degreeh. Postgraduate

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43. At the end of the month after paying for mortgage, rent, bills, groceries, necessities, etc., how much money are you able to put aside? Your best estimate is fine.

a. Nothingb. $99 or lessc. $100 to $249d. $250 to $499e. $500 to $999f. $1,000 or More

44. What is your gender?_________________________________

45. How would you describe yourself? (Mark all that apply)

a. Native American or Alaska Nativeb. Asian or Asian Americanc. Black/African Americand. Hispanic or Latinoe. Native Hawaiian or other Pacific Islander

f. White/Caucasiang. Other _____________________

46. How old are you?a. 18-24 yearsb. 25-34 yearsc. 35-44 yearsd. 45-54 yearse. 55-64 yearsf. 65-74 yearsg. More than 75 years

47. About how tall are you without shoes?______ Feet ______ Inches

48. About how much do you weigh?______ Pounds

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8. Jones A, Zidenberg-Cherr S, Wooten Swanson P, et al. Reliability and validity of nutrition knowledge questionnaire for adults. Journal Of Nutrition Education And Behavior [serial online]. January 1, 2015;47(1):69-74. Available from: Scopus®, Ipswich, MA. Accessed September 7, 2016.

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10. D. Cantor, J. Covell, T. Davis, I. Park, L. Rizzo.  Health Information National Trends Survey 2005 (HINTS 2005): Final Report.  National Cancer Institute, Bethesda, MD (2005).

11. Ranjit N, Wilkinson AV, Lytle LM, Evans AE, Saxton D, Hoelscher DM. Socioeconomic inequalities in children’s diet: the role of the home food environment. The International Journal of Behavioral Nutrition and Physical Activity. 2015;12(Suppl 1):S4. doi:10.1186/1479-5868-12-S1-S4.

12. Hall E, Chai W, Albrecht J. A Qualitative Phenomenological Exploration of Teachers' Experience With Nutrition Education. American Journal Of Health Education [serial online]. May 2016;47(3):136-148. Available from: CINAHL Complete, Ipswich, MA. Accessed September 21, 2016.

13. Common Threads Small Bites Student Pre-Survey. Common Threads.14. Appendix 4: Cognitive Testing Interview Guide. Center for Disease Control and Prevention Website.

1-8. Accessed November 9, 2016. 15. Debbie C. Pretesting Survey Instruments: An Overview of Cognitive Methods. Quality of Life

Research [serial online]. 2003:229. Available from: JSTOR Journals, Ipswich, MA. Accessed November 9, 2016.

16. Excel. Microsoft; 2016.17. SAS. SAS Institute Inc. Verson 9.4. 2012.18. Trizano-Hermosilla I, Alvarado J. Best Alternatives to Cronbach's Alpha Reliability in Realistic

Conditions: Congeneric and Asymmetrical Measurements. Frontiers In Psychology [serial online]. May 26, 2016;:1-8. Available from: Academic Search Ultimate, Ipswich, MA. Accessed December 7, 2016.