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3 P’s in a Pod Program:

Increasing Fruit and Vegetable Consumption Among Low Income Black/African American

Families living in Mattapan, MA

Emir Duhovic

Lynn Ibekwe

Ivory Sangah Kim

Thien H. Nguyen

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Introduction

Obesity has become a national public health problem in America. Today, health

professionals are calling obesity in the United States a “crisis” and the number one health threat

facing our nation (Peeters et al., 2003). The number of American adults and children who are

either overweight or obese has dramatically increased over the past 30 years. In 1980, 46% of

the adult population was classified as either overweight or obese. Today, 68%, or 190 million

adults, are categorized as overweight or obese. In addition, nearly one-third of American

children and adolescents are currently at an unhealthy weight (Levi et al., 2010). Various

programs have been implemented to combat the obesity epidemic in the U.S; very few have

demonstrated a reduction in overweight and obesity prevalence (Odgen & Caroll, 2010).

Obesity is a multifactorial condition; genetic, environmental, social, and behavioral

factors play a role in determining body weight. In most cases, overweight and obesity result

from an energy imbalance, in which the intake of calories is greater than its expenditure. An

adult is considered overweight if his or her body mass index (BMI) is 25-29.9 and obese if his or

her BMI is 30 or higher. Overweight among children ages 2 to 19 years is defined as a BMI at or

above the 85th percentile and lower than the 95th percentile for children of the same age and

sex. Obesity among children is defined as a BMI at or above the 95th percentile (CDC, 2012).

Being overweight or obese increases the risk of many chronic health problems, including

heart disease, stroke, type 2 diabetes, and cancer (NIH, 1998; Bradbard, Michaels, Flemings, &

Campbell, 1997). Obesity is associated with a 7-year life decrease for women and a 6-year life

decrease for men (Peeters et al., 2003). An estimated 110,000 Americans die each year as a

result of being overweight or obese (Levi et al., 2011). Children who are too heavy also have

higher rates of high blood pressure, high cholesterol, type 2 diabetes, asthma, and joint

problems than normal-weight children (Biro & Wein, 2010). They are also more likely to suffer

from depression, low self-esteem, and poor social functioning (Hassink, 2007).

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As the rate of obesity has increased, the related health care costs have also increased.

In 2008, medical costs associated with obesity were estimated at $147 billion, which exceeded

the costs spent on cigarette smoking and alcoholism combined (Finkelstein, Trogdon, Cohen &

Dietz, 2009). Compared to healthy-weight adults, obese adults spend 42% more on healthcare

(Bradbard et al., 1997). Decreased worker productivity, restricted activity, and increased work

absenteeism, have contributed indirectly to the high costs of obesity (Finkelstein et al., 2009;

Bradbard et al., 1997).

The purpose of the 3 P’s in a Pod intervention is to promote healthy eating behavior by

increasing the consumption of fruits and vegetables in low-income Black/African-American

families with children for the residents of Mattapan, Boston, Massachusetts. This will be

achieved by improving access to fruits and vegetables, understanding and decreasing meal

preparation time, cooking healthier meals, and understanding proper nutrition.

Unhealthy Eating in America

To promote health, a predominantly plant-based diet, rich in fruits and vegetables, is

recommended. Furthermore, total caloric intake should be controlled to achieve and maintain a

healthy body weight. Eating a diet abundant in fruits and vegetables throughout the lifespan

protects against a variety of chronic diseases, including heart disease, cancer, stroke, and

diabetes (WHO/FAO, 2003).

Reports have indicated that the majority of Americans do not eat a healthy diet. Very few

individuals meet the United States Department of Agriculture’s (USDA) recommended intake of

fruits and vegetables. The over-consumption of unhealthy fats and added sugars and under-

consumption of fruits and vegetables is common in the American population (Krebs-Smith,

Guenther, Subar, Kirkpatrick, & Dodd, 2010). Total daily energy intake for American adults has

increased by 570 calories over the past 30 years; increased portion size and frequency of eating

and drinking occasions have accounted for most of the rise in total caloric intake (Duffey &

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Popkin, 2011). The lack of nutrient-rich foods in the diet and over-consumption of excess

calories have contributed to the current obesity epidemic and other high rates of diet-related

chronic diseases (Smith et al., 2010).

Similar to adults, the diet patterns of American children are not as healthy as they should

be. Children today are eating more saturated fat, sodium, and sugar and less calcium and fiber

than what is recommended for good health. Close to 40% of the calories consumed by

American children are in the form of “empty calories” (Reedy & Krebs-Smith, 2010). These

empty calories come from food such as cookies and beverages such as soda and fruit drinks.

While intake of processed foods and sugar-sweetened beverages among children is high, their

consumption of fruits and vegetables is low. Only one in five American children ages 2 to 19 eat

the recommended 5 or more servings of fruit and vegetables per day. French fries constitute

nearly 25% of all the vegetables consumed by children and adolescents (Krebs-Smith, Cook,

Subar, Cleveland, Friday, & Kahle, 1996). The low consumption of fruits and vegetables are

even more pronounced in low socioeconomic and minority groups (Perry et al., 1998).

Socioeconomic Status (SES) and Obesity

Many studies have found a strong association between obesity and SES, with low SES

groups suffering from higher rates of obesity compared to their higher SES counterparts

(Molarius et al., 2000; Health of Boston, 2011; Drewnowski & Darmon, 2005; Morland et al.,

2006). This association exists partly due to poor eating habits common across all

socioeconomic groups, but are most prevalent among individuals from low SES backgrounds

(Drewnowski & Darmon, 2005; Drewnowski & Spector, 2004). Individuals who have limited

economic resources tend to live in neighborhoods that have fewer supermarkets and decreased

access to healthy foods compared to those who live in more affluent neighborhoods (Horowitz,

2004). Diets consumed by individuals with a low SES are more likely to consist of high intakes

of fat and sugar, but very low intakes of fruits and vegetables (Drewnowski & Specter, 2004).

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High Obesity Rates Among Low SES Families - Boston & Mattapan

Similar to the discrepancy of obesity rates in the U.S. as a whole, there is a disparity in

obesity rates between low SES and high SES neighborhoods in Boston. In 2007, the Boston

Collaborative for Food and Fitness (BCFF) conducted a food and fitness assessment of six

Boston neighborhoods of interest: Jamaica Plain, East Boston, Roxbury, North Dorchester,

South Dorchester, and Mattapan (Newby, 2010). Five of these six neighborhoods have the

highest rates of chronic diseases and obesity compared to the rates of all other Boston

neighborhoods and the overall rate in Boston. 37% of adults in Mattapan, 32% in North

Dorchester, 29% in Roxbury, 28% in South Dorchester, and 28% in East Boston are obese

compared to Boston’s overall percentage of 22%. Each of these neighborhoods have a median

household income between $25,000 and $45,000, with Mattapan (18%) among the highest

percentage of families with incomes below the poverty level compared to the Boston's overall

percentage of 17% (Health of Boston, 2011).

Mattapan has the highest rate of obesity compared to all other neighborhoods in Boston.

In Mattapan’s population of 18,317, 83% of residents identify as Black/African American and

10% identify as Latino. 32% of residents speak a language other than English at home; French

(19%) and Spanish (9%) are the two most common (Health of Boston, 2011). Family

households, which is defined as households that consist of a primary caregiver with at least one

child, make up 70% of all households in Mattapan (Health of Boston, 2011). Since the majority

of Mattapan residents identify themselves as non-Hispanic Black/African American, the 3 P’s in

a Pod program will be aimed at Black/African American families (Health of Boston, 2011).

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Determinants of Unhealthy Eating Behavior Among Low SES Populations (See Table 1)

Accessibility

The characteristics of a neighborhood play an important role in its food environment and

ultimately to the development of obesity among its residents. Food security, defined as food

access and the ability to acquire nutritionally adequate options, can influence unhealthy eating

behaviors among individuals (Gross et al., 2012). Individuals who live in food insecure

neighborhoods are less likely to have a healthy diet compared to their counterparts (Anderson,

2007). Often times, low SES neighborhoods have an abundance of fast food restaurants and

convenience stores, which lack healthy food choices (Larson et al. 2009). Nationally, zip codes

of low SES neighborhoods have 30% more convenience stores and 25% fewer chain

supermarkets than zip codes of moderate SES neighborhoods (Treuhaft & Karpyn, 2010).

Many studies have found that the presence of supermarkets or full-line grocery stores

(e.g. Stop ‘n Shop, Shaws) is associated with a lower prevalence of obesity, while the presence

of convenience stores is associated with a higher prevalence (Morland et al., 2006). Large

supermarkets in the community can offer food at a lower price and more healthier food options

when compared to smaller grocery stores and convenience stores. The lack of supermarkets in

urban areas like Mattapan can contribute to higher food prices and unhealthy food options.

According to the 2009 Community Food Security Coalition report, there are no full-service

grocery stores within Mattapan’s boundaries (Figure 15).

Along with the high cost of healthy foods in low SES neighborhoods, long commutes and

lack of transportation to supermarkets are major barriers to residents. The Boston Collaborative

Food and Fitness Assessment found that a majority of individuals living in Boston

neighborhoods do not consume the recommended level of fruits and vegetables at home

(Newby, 2010). They found that residents in Mattapan were less likely to shop at their preferred

supermarkets compared to other Boston residents, due to accessibility issues such as long

commute time and high cost of healthy foods (Newby, 2010). This poses a challenge for urban

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residents who lack reliable personal vehicle and to people who rely heavily on public

transportation.

All of these factors limit many residents to shop at corner stores or convenience stores

for their groceries. Thus, access in terms of distance and costs are barriers within the Mattapan

community and may play an important role in the low consumption of fruits and vegetables.

Food Preparation Behavior

Another factor relating to dietary quality is the food and meal preparation behavior within

the household. The USDA conducted 28 focus groups with food stamp participants across six

major cities to better understand the food choices made by low SES families (Bradbard et al.,

1997). Focus group participants were aware of the poor nutritional quality of their current eating

habits and the need to serve more low-fat, high fiber foods. However, these families were

uncertain how they would translate their understanding to specific food choices. Many

participants expressed difficulty in understanding nutritional food labels and translating the

information to prepare healthier meals (Bradbard et al., 1997).

In a qualitative study conducted by Luca, Barg, Karasx, Palmer, & Long (2011), urban,

low-income African Americans understood that foods from African American cooking traditions

were unhealthy, such as frying and flavoring foods with animal fats and salt. However, the

participants in the study had little knowledge in preparing healthy meals. Many believed that in

order for foods to be healthy, they had to be “bland” with “not too much seasoning.” Younger

individuals of the group seemed to have the least food preparation skills as they relied on

convenience foods and did less cooking in the kitchen. To increase consumption of healthy

foods, participants believed that they needed greater knowledge and skills of healthier

preparation methods. In addition, they believed that their consumption of fruits and vegetables

would increase if they were exposed to them in more “flavorful” ways (Luca et al., 2011).

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Time Constraints

Bradbard et al. (1997) discussed that an important consideration for food and meal

preparation is the time it takes to prepare a meal. Families who receive food stamps often do

not have regular meals together at home, especially in households with one or more adults who

work long hours (Bradbard et al., 1997; Devine et al., 2009). In such households, family

members are expected to prepare food for themselves for breakfast and lunch (Bradbard et al.,

1997). In order to reduce time and effort in preparing meals, parents decrease their

expectations of food and eating quality (Devine et al., 2009). Parents often end up relying on

easy-to-prepare convenience foods for dinner which are usually high in calories, sodium, trans

fat, and cholesterol, which all have negative effects on health (Bradbard et al., 1997; Devine et

al., 2009).

Blake et al (2011) conducted a telephone survey of a random sample of 25 mothers and

25 fathers of different races (Black, White, and Hispanics) in New York city. Each participant

had low to moderate income (<$60,000), worked 20 or more hours a week, and had one or

more children age 16 or younger at home. Each participant’s diet quality was assessed using

the Healthy Eating Index 2005 (HEI). The investigators found that parents who typically worked

nonstandard hours (does not hold a 9am-5pm job), worked overtime, and had partners who also

worked irregular hours had the highest frequency of missing family meals. In addition, these

parents had low HEI scores for whole fruits, total fruits, dark green and orange vegetables,

whole grains, and milk consumption. On the other hand, parents who worked regular hours

reported the highest frequency of home-cooked family meals and the lowest frequency of

having meals away from home. Furthermore, these parents had substantially higher HEI scores

for dark green and orange vegetables, total grains, whole grains, and milk consumption. Non-

Hispanic Black parents who worked nonstandard hours or worked overtime were the most likely

to report having few home-cooked meals and a higher number of meals consumed away from

home.

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In Mattapan, 41% of the residents work full time. 68% of the residents report regularly

eating meals away from home (Newby, 2010). It is predicted that parents who work long hours

would be more likely to prepare nutritious meals at home, if preparation time was reduced.

Food Purchasing Behavior

Food purchasing behavior is directly affected by a number of factors such as a person’s

knowledge of nutrition, financial constraints, availability of food options, cultural beliefs, and

one’s attitudes about food and health in general (Beto, Sheth, & Rewers, 1997). In addition to

increasing access and decreasing food preparation time, food purchasing behavior may help

explain the food choices that low SES families make (French, Wall & Mitchell, 2010; Ricciuto,

Tarasuk & Yatchew, 2006). Although there has been compelling evidence that identify physical

accessibility to grocery stores and financial constraints as the primary barriers in food choices

(Giskes et al., 2007; Horowitz, 2004; Newby, 2010; Sobal et al., 2006), researchers have

identified cultural factors to be a potential modifier of the families’ food purchasing behavior

(Sobal et al., 2006; Falk et al., 1996).

Cultural and ethnic traditions were shown to have a large impact in food purchasing and

preparation behaviors, especially among low-income Black/African American mothers (Devine,

Sobal, Bisogni & Connors, 1999; Sanjur, 1982). Primary caregivers of low SES families

discussed that their families enjoy traditional foods and tend to resist new recipes or changes to

their meals (Bradbard et al., 1997).

In BCFF’s report, 80% of Mattapan residents reported that taste had a great impact on

food purchasing behavior (Newby, 2010). On the other hand, only 53% of Mattapan residents

reported price to have a great impact on their buying behavior. In order to effectively change

their food purchasing behavior, it is critical to emphasize how cultural-specific meals can be

prepared in healthier ways while maintaining its flavors.

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Methods, Applications and Strategies (Table 2) :

Table 2 demonstrates the methods, applications and strategies for the determinants of

unhealthy eating behaviors among low SES Black/African American families in Mattapan. The

proposed methods and strategies are based on a combination of social theories and

approaches to better serve the target population: Health Belief Model, Framing Theory, Social

Cognitive Theory, and Community-Based Delivery.

Applying Theory to Intervention

Health Belief Model emphasizes the importance of education as an effective tool to

change behavior. The proposed intervention will provide an educational component of nutrition

knowledge and cooking skills. The Framing Theory will also be utilized in order to reframe their

negative/barrier-oriented perceptions and attitudes about healthy eating to positive/opportunity-

oriented perceptions and attitudes by promoting self-efficacy through the the use of

communication of educational materials and motivational interviewing during home visits. The

Social Cognitive Theory’s concept of modeling will be introduced in the intervention by providing

cooking demonstrations. Through these demonstrations, families will learn how to cook quick

and healthy meals by observing and being asked to partake in the demonstrations. This will give

participants the practical skills needed to translate prior nutrition knowledge and newly gained

knowledge into healthy meals.

Lastly, a community-based delivery will be employed in an effort to strengthen

community buy-in, engagement, and empowerment. This approach is useful when working with

communities with limited economic resources and decision-making power due to constraints in

their social environment (Israel, Schulz, Parker, & Becker, 1998). Sampling from these multiple

theories results in a multi-factorial approach aimed at changing behavior for the intended

population.

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Proposed Intervention (Table 4):

A multifactorial intervention will be implemented to increase fruit and vegetable

consumption among low-income Black/African American families living in Mattapan, called 3 P’s

in a Pod. This intervention will involve a community-based delivery consisting of group cooking

demonstrations and collaboration with local mobile produce vendors. Additionally, monthly

home visits will be conducted to provide individualized attention. The multifactorial approach will

help to promote healthy eating behaviors, and ultimately, decrease the prevalence of obesity-

related illnesses in the population. This plan also includes a proposed budget for the

implementation of the intervention (Figure 16).

Community-based Delivery with Mattapan Community Health Center:

The 3 P’s in a Pod intervention will be executed by a study team at the Mattapan

Community Health Center (MCHC). MCHC’s mission is to improve the quality of life for all

residents of Mattapan and surrounding communities by providing comprehensive, accessible,

affordable, and culturally appropriate community health care services, including primary and

preventative health services. In the past, the health center has launched initiatives that have

addressed some of the major health issues in the community, such as the high diabetes rate in

Mattapan (Kelley, 2010).

The intervention team will be comprised of a principal investigator (PI), a study

coordinator (SC), two research assistants (RAs), a community health worker (CHW), and a

nutritionist. The Principal Investigator will lead the study and make all the major decisions

related to the study. The PI will also be responsible for obtaining funding and completing all

steps required to launch the intervention. The Study Coordinator will assist the PI in developing

the necessary materials, hiring support staff, creating appropriate training materials for RAs and

the CHW, relaying relevant program guidelines to the nutritionist and volunteer chefs, managing

the budget for the study, and any other tasks delegated from the PI. The research assistants will

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work with the study coordinator and will be responsible for promotion and advertising,

recruitment of recipient families, data collection, and any other tasks delegated from the study

coordinator. The nutritionist will work alongside the volunteer chefs to modify recipes to cater to

recipient population’s cultural tastes, maximize nutrient content and provide nutrition facts for

the recipes being demonstrated. The community health worker’s role will be to conduct monthly

home visits for the families that are enrolled in the study.

Collaborative partnerships will be intertwined within each component of the intervention.

For example, a partnership with Mattahunt Community Center, which is equipped with a full

service kitchen and open space for community events, provides a favorable setting for the

delivery of the nutrition education and cooking demonstration component of the intervention.

The intervention team within MCHC will also collaborate with existing mobile produce vendors to

address the issue of food access and purchasing in the Mattapan community. The study

research team will reach out to community centers, churches, and community leaders to

encourage participation of families in the 3 P’s in a Pod intervention. The goal of this strategy is

to strengthen community buy-in, engagement, and empowerment in turn encouraging family

participation.

Eligibility and Recruitment:

Recruitment will be executed through advertisements of the intervention program

throughout the community of Mattapan using flyers, word of mouth from community leaders and

members, and social networking. Eligible participants in the intervention are low-income

Mattapan families with children who identify themselves as Black and/or African American.

Potential participants will complete a questionnaire over the phone to see if they meet the study

eligibility criteria (Figure 1). For the purpose of this intervention, low-income families are based

on the size of a family defined by the Office of Postsecondary Education (Figure 2).

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The study will recruit 20 families to participate in the intervention. It is expected that the

families attend the cooking demonstrations and allow community health workers to conduct

home visits. Participants will complete a self-administered pre-test questionnaire to assess their

current dietary habits and barriers to fruit and vegetable consumption (Figure 3). Parent/s or

caregiver/s will complete the pre-test questionnaire at the site of the first cooking demonstration

session before it begins. The same questionnaire will also be administered at the final home

visit to assess changes in their dietary habits and barriers to fruits and vegetables consumption.

A separate questionnaire will be administered at the 3-month and 6-month mark to assess

participants’ satisfaction with activities being delivered. This will be part of the process

evaluation to assess program’s objectives and success throughout the program.

To motivate eligible families to participate in the intervention and to decrease dropout

rates that previous cooking demonstration interventions have experienced (Cooking Matters,

2011), a coupon of $5 will be distributed each family who attend each demonstration session

that can be used to purchase produce from the mobile vendors at the site. Home visits will also

be incorporated in order to provide personalized nutrition education and address the unique

needs of each family in order to have high adherence, compliance and retention rates.

Cooking Demonstration & Nutrition Education:

Understanding the demographic of Mattapan, culturally sensitive cooking

demonstrations can change negative attitudes that many minority families have towards healthy

foods. In the span of 6 months, 12 one-hour cooking demonstration sessions will be led by

collaborating with chefs from local restaurants in the Boston area or other volunteer chefs.

Black/African American chefs are preferred due to cultural and community similarities. By

working with chefs from the community, this intervention will not only provide culturally sensitive

nutrition knowledge for families but will also empower the volunteer chefs to become leaders of

healthy eating behaviors within the community.

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The cooking demonstrations will achieve the objective by introducing how to prepare

inexpensive, tasty and healthy meals, enhancing nutrition knowledge, decreasing cooking

preparation time, and changing food purchasing behavior. Both the nutritionist and volunteer

chefs will collaborate on the recipes being presented in order to highlight the ethnic and cultural

background of the participating families such as using familiar herbs, spices and/or methods of

cooking. The collaboration will also make sure that the recipes are low in calories and high in

essential vitamins, minerals, fiber, and other nutrients in fruits and vegetables. The recipes must

be approved by the research team before being demonstrated for the participants.

Each volunteer chef will demonstrate the modified recipe, emphasizing the affordability,

tastiness and short preparation time of each meal. Families will be encouraged to partake in the

preparation and cooking process such as chopping, stirring, and mixing, to enhance their

experience and understanding. The meals will incorporate the seasonal produce options that

the Bell Tower Foods or Mattapan Mobile Farmstand offers. With one of the mobile produce

vendors present at the site after each cooking session, the volunteer chefs and research team

will encourage the families to purchase produce items used during the session to replicate

presented meals at home. Families will also be able to redeem the coupon voucher at the

mobile produce vendors to purchase fruits and vegetables at affordable prices on the day of the

demonstration.

A recipe pamphlet containing the demonstrated recipe with its nutrition facts will be

distributed to each family per demonstration (Figure 4). These pamphlets will also include a

nutritional “fun fact” about the main healthy ingredient being used. This will help to introduce

new and practical nutrition knowledge. The recipes provided will factor in time constraints,

helping families to decrease their meal preparation time. It will also provide the estimated cost of

preparing each meal to change the perception that healthy eating is costly. In addition, providing

a small sample of the presented dish for participating families to taste will encourage them to

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understand that healthy foods can be tasty, and consequently, to purchase more fruits and

vegetables.

Along with the pamphlet, families will also receive easy-to-read educational material that

reviews basic nutrition concepts. Topics that are covered in the material will include the

following: food groups, macronutrients, micronutrients, how to read food labels, tips to choose

the healthiest options in the supermarket, and nutrition myths (Figure 5). The educational

material will be reviewed one-on-one with parents during the home visits.

Collaboration with Bell Tower Foods & Mattapan Mobile Farmstand:

Mobile food vendors are a fairly new concept and are usually located in disadvantaged

or underserved neighborhoods to improve access and address the problem of “food deserts.”

For example, People’s Grocery Mobile Market in Oakland, California (founded in 2001) turned

an old postal truck into a grocery store with shelves, bulk bins, and refrigeration to serve low-

income neighborhoods in west Oakland. The mobile market accepted government food stamps

as a form of payment. In 2004, membership doubled to over 200 members in the Oakland area

serving about 3,500 customers per year (Suutari, 2006). Sales have doubled since its inception,

with 60% of respondents saying they had tried new types of healthy food. Additionally, 55% of

participants reported that they regularly ate more fruits and vegetables, and customers reported

they were eating healthier and trying more kinds of food (Suutari, 2006). The mobile market has

expanded across the United States with two currently serving the Boston area- Bell Tower

Foods and Mattapan Mobile Farmstand.

The collaboration with Bell Tower Foods Truck and Mattapan Mobile Farmstand will

provide participants with access to fresh produce. After each cooking demonstration session,

one of the mobile produce vendors will be present at the site for program participants to

purchase affordable fruits and vegetables. The participating families will be able to use their

SNAP benefits, other food assistance program benefits, and coupon vouchers (obtained at the

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cooking demonstrations) to pay. Convenient access to fresh and affordable produce will help to

change the food purchasing behavior of the participating families, as it encourages families to

eat more fruits and vegetable and to apply knowledge obtained at cooking demonstrations when

purchasing food items for their family.

Personalized Nutrition Education Through Home Visits:

Home visits will be another component of the intervention for the families enrolled in the

program. Previous studies have shown that home visiting programs can improve the health and

wellbeing of families. They have been promoted as a way to prevent a range of health problems

in children from vulnerable and disadvantaged families (Wen, Baur, Rissel, & Wardel, 2007).

In recent years, home visits have expanded to include obesity prevention efforts. Home-

based interventions through home visits have been shown to be beneficial in addressing some

of the risk factors linked to obesity, such as poor diet and sedentary lifestyle (Wen, Domenico,

Elliott, Bindon, & Rissell, 2009). Participants in interventions that have incorporated home visits

have expressed positive attitudes toward the home visits; the participants described home visits

as “enjoyable and something that they looked forward to”. Having the same health coach for

each home visit was welcomed by parents, helping to foster “mutual rapport, trust, and

confidence” (Wen et al., 2009, p. 579). Parents reported that they felt more comfortable asking

questions and felt that they and their children were being cared for. There was a 95% retention

rate for mothers participating in a home visit intervention that addressed risk factors for

childhood obesity (Wen et al., 2009). By integrating home visits as a part of the program, it will

decrease the dropout rate of the cooking demonstration classes. In addition to making a positive

impact on eating and physical activity behaviors among families, home-based interventions

have also been effective in reducing mean BMI for young children. Home visits have beneficial

effects as they provide one-on-one attention and can be tailor to the unique needs of each

family (Wen, Baur, Simpson, Rissel, Wardle, & Flood, 2012).

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The home visits will be adapted and modified from an intervention done by Taveras et al.

(2012). In Taveras et al.’s study (2012), the researchers developed a home-based program for

low SES minority parents in Boston. Health educators visited each family and used motivational

interviewing to encourage healthy household routines, such as eating healthy meals regularly as

a family. The intervention was specifically tailored to the needs of each family; researchers

conducted a baseline assessment of the home environment and the social supports, barriers,

and facilitators to behavior change (Taveras et al., 2012).

While the cooking demonstration sessions in 3 P’s in a Pod provide general tips on

healthy cooking, the home visits will provide personalized nutrition education for each family.

There are three purposes of home visits in this intervention. First, they help each family to make

and achieve monthly dietary goals. Second, they serve to increase parents’ knowledge about

nutrition and healthy eating. This increased knowledge will help families make healthier food

choices. Finally, home visits will help increase parents’ self-efficacy of purchasing and

preparing healthy foods through motivational interview.

In the span of the 6-month 3 P’s in a Pod program, six one-hour home visits will be

conducted by a community health worker (Figure 6). At the first home visit, the community

health worker will review the pre-test questionnaire with the parent/s to better understand the

strengths and weaknesses of the family’s current diet. The CHW will emphasize the strengths

and positive assets that each family has and reframe their unique barriers as an opportunity to

make the necessary dietary changes. At this visit, the CHW and family will work together to

develop healthy dietary goals and behavioral changes that can be achieved throughout the

course of the intervention. The specific goal for increasing fruit and vegetable consumption will

be realistic, measurable, and attainable for each family. The family will be instructed to keep a

monthly log that tracks the number of fruits and vegetables consumed each day (Figure 6).

After the first home visit, the remaining monthly home visits will serve as a check-in to

review progress and monitor possible setbacks to the family’s healthy eating behavior. Dietary

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and behavior change goals that were made the previous month will be reviewed. The CHW will

discuss the family’s eating habits since the previous home visit. He or she will ask how fruits

and vegetables have been incorporated into the family’s diet. The CHW will try to address and

help the family overcome any barriers that prevented them from meeting their diet goals. For

example, the CHW will give advice on how barriers, such as time or financial constraints, can be

surpassed. They will use motivational interviewing to enhance the family’s motivation to

overcome any setback and help to support the positive diet changes already made (Taveras et

al., 2012).

At these home visits, the parent/s and the CHW will also discuss the nutrition information

learned from the educational material provided at the cooking demonstrations. An activity, such

as reading the nutrition label on the packaged food in the kitchen, will help parents to

understand how to make healthier choices. Suggestions to plan, purchase and prepare healthier

foods will be made.

Adoption, Implementation, & Sustainability of Program (Table 3):

Adoption of Program:

Every year, Mattapan Community Health Center (CHC) assesses the health status of

Mattapan and its neighborhoods by looking at the annual health report produced by the Boston

Public Health Commission. This report provides a review of selected health conditions, risk

behaviors, and social determinants of health. In recent reports, obesity was found to be the

biggest problem for the community of Mattapan (Newby, 2010). Mattapan CHC will choose a

program to address with the obesity problem in their community.

Previous interventions have demonstrated the efficacy of cooking demonstrations when

combined with nutrition education to increase the intake of healthier food options. Other

interventions have provided mobile product vendors to solely address access as a determinant

for increasing the intake of produce. However, no intervention has combined all the components

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together to address all barriers to increase the intake of fruits and vegetables. Therefore,

Mattapan CHC will adopt a program that combines both nutrition education and the availability

and accessibility of mobile produce vendors with cooking demonstrations, the 3 P’s in a Pod

Program. To effectively address the obesity problem in Mattapan, Mattapan CHC must

understand the advantages of the proposed program and how it will meet the needs of

Mattapan’s dominant demographic groups compared to other available programs. Mattapan

CHC must also see the value and importance of the program and expect it to meet the needs of

the Mattapan community by improving health outcomes of residents. This will help accomplish

Mattapan CHC’s goal to decrease the prevalence of obesity in Mattapan in order to improve the

overall health outcomes of its residents.

In order to execute the program, Mattapan CHC will first develop a research team

responsible for implementing the program. They will select a principal investigator (PI), study

coordinator (SC), two research assistants (RAs), a nutritionist, and a community health worker

(CHW) who possess the necessary skills to successfully implement the 3 P’s in a Pod program.

Mattapan CHC will also partner with Mattahunt Community Center (CC) to utilize the local

center as the venue of the cooking demonstrations. Understanding the importance of the

cooking demonstration, Mattahunt CC will agree that the goals of the cooking demonstrations

are valuable to the community and will make their community space available for program use.

As a result of Mattahunt CC’s importance to many Mattapan residents and its ties to the

community, it is expected that this partnership will encourage the community to participate in the

program.

An additional partnership with Bell Tower mobile produce vendor and Mattapan Mobile

Farmstand will help to increase the availability of affordable produce in Mattapan. Recognizing

the food desert situation in Mattapan, the mobile produce vendors will expect that their presence

in Mattapan and collaboration with MCHC will increase residents’ access to produce. Hence, the

20

mobile produce vendors will react favorably to the objectives of the program due to its alignment

with their mission.

As a final step needed for Mattapan CHC to successfully adopt the program, the

research team will recruit local chefs willing to volunteer their time to be cooking leaders for the

cooking demonstrations. To ensure that the volunteer chefs will be effective, they will

understand and respond favorably to the importance of the cooking demonstrations. It is also

important that they feel confident in their ability to conduct the cooking demonstrations and

effectively communicate the importance of healthy food preparation to participating families.

Implementation of Program:

After the program is successfully adopted, the PI and SC at Mattapan CHC will create an

implementation plan that will outline the details of the program. In order for the implementation

to be effective, both the PI and SC will understand and express confidence in their ability to

organize and execute the program before teaching others. The PI and SC will orient the

implementation plan with the rest of the research team and the volunteer chefs. To ensure

fidelity and complete understanding of the program, the research team and the volunteer chefs

will describe the implementation plan and its objectives to the PI and SC to demonstrate the

knowledge gained. To implement successfully, it is also important that the research team and

volunteer chefs react favorably towards the program and its outcome. The SC will provide

guidelines of pertinent nutritional knowledge that the nutritionist needs to pass on to the

volunteer chefs and the community health worker. The SC will discuss the barriers that the

community has and provide demographic information about Mattapan residents and other

necessary information to the nutritionist in order for the nutritionist to have a better

understanding of the target population. This will help the nutritionist to work with the chef and

the other members of the research team to create the appropriate recipes for the cooking

demonstrations.

21

After the nutritionist understands the demographics of Mattapan and the barriers its

residents may face, the volunteer chefs and the research team will be oriented in nutrition

education by the nutritionist. They will learn the key components of a healthy diet and

understand nutrition facts regarding the recipes in the recipe pamphlets. Furthermore, they will

learn the skills needed to educate participants and convey nutrition information in an easy way

for participants to understand.

For the cooking demonstrations, volunteer chefs will be responsible for teaching each

session. By working with the nutritionist, the chefs will develop many easy, low cost, tasty,

healthy recipes that will be appropriate for the Mattapan community. They will also be able to

substitute unhealthy ingredients in the recipes with healthier ingredients. For example, low fat or

no fat milk will be used instead of whole milk in recipes. When cooking healthier versions of their

recipes, the volunteer chefs will understand the need to use inexpensive ingredients that are

available to purchase either in Mattapan or at the mobile vendors.

In order for the volunteer chefs to cook the healthy meals at the cooking classes, the

mobile vendors, such as Bell Tower Foods, will provide the fresh and affordable produce for the

program. These vendors will expect that over the span of 6 months, participants will attend the

one-hour cooking demonstration sessions and purchase their produce. Mobile produce vendors

will have positive attitudes toward the program and understand that their service is improving

food access in the community.

Another important component of 3 P’s in a Pod is the home visits conducted by the

community health worker. The community health worker will be able to and express confidence

in conducting motivational interviews to increase participants’ self-efficacy and encourage

dietary behavior changes.

Throughout the implementation of the program, the research team will ensure that each

component is completed and executed properly and as intended. Every member of the research

22

team will express confidence in their ability to carry out their component of the program

successfully and as intended and expect the program to run smoothly and according to the plan.

Sustainability of Program:

After the 6-month program is completed, Mattapan CHC will draft a proposal for Robert

Woods Johnson Foundation (RWJF) for a grant to sustain the program. The proposal will

describe the objectives of the program and how it aligns with the objectives of RWJF. Taking

into account RWJF’s previous efforts to minimize health disparities in the US, the proposal will

describe the importance of the 3 P’s in a Pod program and its impact on the health of residents

in Mattapan.

When funding is secured from RWJF, the Mattapan CHC coordinator will incorporate the

3 P’s in a Pod program to the Mattapan CHC as a part of the center’s obesity prevention effort.

In order to successfully incorporate the program to the Mattapan CHC, the CHC coordinator will

recognize the importance of integrating the program into center events/projects and feel

confident in being able to execute the program without the research team. The CHC coordinator

will also describe how to integrate the program into the center’s events/projects.

To sustain and maintain the program as part of the curriculum at Mattapan CHC, the

appointed program associate’s job description will entail overseeing and executing the 3 P’s in a

Pod program to clarify the program champion. The Mattapan CHC will outline the basic

knowledge and skills needed of the program associate. In addition, the Mattapan CHC will

expect that the program associate is qualified and will lead the program successfully.

3 P’s in a Pod will continue to collaborate with the chefs and mobile vendors that have

volunteered in the past by building rapport and a relationship with the chefs and mobile vendors.

Additionally, all recipes and pamphlets used in the program will be kept for future use. The

community health worker will help to train lay health workers from the community to conduct

effective home visits. The lay workers will learn with the skills and techniques that are necessary

23

to effectively execute motivational interviewing and feel confident in their ability to successfully

conduct a home visit. Figure 14 explains the transition of leaders and interaction of all

stakeholders from adoption to implementation to sustainability of the program.

Evaluation:

Process evaluation will be used to determine the elements and processes that are

presented both within and around program adoption and implementation to ensure fidelity of the

program. First, to ensure that the program was implemented as intended, a checklist will be

conducted at the demonstration and at home visits (Figure 6; Figure 9).

Additionally, sales of produce from the mobile produce vendors will collected after each

night of sales to make sure that the produce trucks are being utilized as intended.

In order to ensure that the program reached the intended target population, only families that fit

the inclusion criteria (i.e. race, residence, income) are eligible to enroll in the program attend the

cooking demonstrations, and receive discounted coupons to purchase produce from the mobile

truck at the time of the demonstration. A program schedule will be created and reminders (via

email, telephone) will be sent to the mobile produce vendors and volunteer chefs (Figure 10).

Given the study design and procedure, the following areas will be examined to ensure

program quality and success through process and outcome evaluation.

Process Evaluation:

A schedule will be made in order for volunteer chefs and mobile produce vendors to

make sure they adhere and comply with the set dates of the demonstrations (Figure 10).

To ensure that people in the program received the services that they are supposed to

receive, there will be a cooking demonstration sign-in sheet at every demonstration; keeping

track of the number of attendees at each cooking class will help to assess the dose-response

relationship (Figure 11). There will also be a checklist for each demonstration to make sure

24

everyone follows protocol and everything is in place. Additionally, a member of the research

team will collect the coupons, used by participants, from the mobile produce vendors to observe

the effectiveness of reinforcement vouchers in purchasing healthy produce. Furthermore, CHW

will track the number of visits each family receives during the 6-month period. The CHW will

have an itemized list of topics to discuss with the families at each home visits to ensure that all

families are receiving the same message (Figure 7; Figure 9).

Lastly, to evaluate participants’ satisfaction with the program’s services, a post survey

will be given to the participants. The satisfaction survey, modified from the Body and Soul

intervention and the Cooking Matters intervention, will be given to participants at the 3-month

and 6-month mark (National Cancer Institute, 2004; Cooking Matters, 2011) (Figure 12). This

will ensure that the program is being delivered as intended. Additionally, volunteer chefs and

mobile vendors will be asked to complete a satisfaction survey to assess their attitude with the

program (Figure 13).

The average cost of each person will be documented by keeping track of the number of

cooking lessons attended and the number of home visits for each family. The SC will oversee

the budget to ensure the program is within the budget.

Outcome Evaluation:

The outcome evaluation will assess the impact of the program, addressing several

impact questions regarding outcomes of interest (Figure 17). The 3 P’s in a Pod program’s

overarching goal is to reduce the risk of obesity and diet-related illnesses among Black/African

American families living in Mattapan, MA. The logic behind this program is that improving food

planning behavior, reducing meal preparation time, and modifying food purchasing behavior

towards healthier food options (by directly influencing participants’ knowledge, attitudes,

expectations, and self-efficacy) helps to achieve the program’s overarching goal. To assess

these changes, a survey will be administered to participants at baseline and at the end of the

25

program (Figure 3). It will assess the changes that relate to intermediate, long-term, and health

and quality of life outcomes of interest.

The program also aims to facilitate participants’ behavior change by collaborating with

mobile produce vendors to increase the availability of fruits and vegetables for participants.

Having a produce vendor present at the site is intended to address the barriers that families

experience in accessing healthy food options in Mattapan. To assess the effectiveness of the

environmental component, a modified satisfaction survey will be administered to participants at

the 3-month and 6-month mark; this survey will assess families satisfaction with program

services, including access to mobile produce vendors (Figure 12).

These assessment tools, in combination, will test the program’s overall impact on the

family’s targeted behavior (Figure 3). Changes in all of the individual level and environmental

level determinants are intermediate outcomes that will lead to long-term outcome changes, such

as increased fruit and vegetable consumption and increased availability of fruit and vegetables

in Mattapan residents. By targeting and achieving changes in the proposed outcomes, it is

hypothesized that participants will have a reduced risk of obesity and diet-related illnesses over

time.

26

Appendix

27

Figure 1:

Eligibility Questionnaire

What is your household income level? (Please check one option below)

_______ less than $20,000

_______$20,000 - $24,999

_______$25,000 – $29,999

_______$30,000 – $34,999

_______$35,000 - $39,999

_______$40,000 - $44,999

_______$44,000 - $49,999

_______$50,000 - $54,999

_______$55,000 - $59,999

_______$60,000 or above

Including yourself, how many people are in your household? ______________________

What is your gender?

Male_______ Female_______

What do you identify yourself as?

_______White

_______African-American/Black

_______Asian

_______Other

If other, please specify: _________________________________________________

Are you a resident of Mattapan?

­Yes_______ No_______

28

Figure 2:

Definition of Low-Income According to Family Size

Size of Family

Unit

48 Contiguous States, D.C., and Outlying Jurisdictions

1 $16,755

2 $22,695

3 $28,635

4 $34,575

5 $40,515

6 $46,455

7 $52,395

8 $58,335

29

Figure 3:

Pretest and Posttest Questionnaire

Nutrition and Eating Habits Questionnaire

Who prepares meals in your home?

How many minutes, on average, does it take you to prepare 1 meal at home?

How many meals do you eat away from home on weekdays?

Breakfast?_____________ Lunches?____________________ Dinner?__________________

How many meals does your child(ren) eat away from home on weekdays?

Breakfast?_____________ Lunches?_____________________Dinner?__________________

How many meals do you eat away from home on weekends?

Breakfast?_____________ Lunches?____________________ Dinner?__________________

How many meals does your child(ren) eat away from home on weekends?

Breakfast?_____________ Lunches?____________________ Dinner?__________________

30

List restaurants where your family often eats:

Think about your eating habits in the past 6 months about how often do you eat each of the

following groups. Remember breakfast, lunch, dinner, snacks and eating out. Check one box for

each food.

Fruits and

vegetables

Less than

1x WEEK

Once a

WEEK

2-3 times a

WEEK

4-6 times a

WEEK

Once a DAY 2+ a DAY

Fruit juice

(e.g.

orange,

apple,grape,

fresh, frozen

or canned

and NOT

sodas or

other drinks)

Fruit (fresh,

frozen

canned

without

syrup)

Potatoes,

any kind,

including

baked,

mashed or

fried.

Vegetable

juice (tomato

juice, V-8,

carrot)

Green salad

Vegetables

(including

string beans,

peas, corn,

broccoli)

31

*Adapted from NutritionQuest, 2009. http://www.nutritionquest.com/wellness/free-assessment-tools-for-

individuals/fruit-vegetable-fiber-screener/

How often do you eat at home?

_______ Never

_______ Less than one time/week

_______ Once a week

_______ 2-4 times/week

_______ 5-6 times/week

_______ Daily

How often does your child(ren) eat at home?

_______ Never

_______ Less than one time/week

_______ Once a week

_______ 2-4 times/week

_______ 5-6 times/week

_______ Daily

What kinds of fat do you use for frying and sautéing at home?

_______Butter

_______Margarine

_______Olive Oil

_______Cooking Spray (e.g.PAM)

_______Shortening or lard

How many hours do you work per week?

How many hours does your spouse work per week? (If applicable)

Where does your family do most of the grocery shopping (name the supermarket, grocery store,

convenience store, farmer’s market, etc.)?

How long does it take you to commute to the grocery store where you most frequent at?

Do you receive any food assistance program (SNAP, WIC, etc.)?

Yes____________ No_______________

If so, what kind?

Do you think that fruits are too expensive to purchase?

Yes_____________No _______________

Do you think that vegetables are too expensive to purchase?

Yes_____________No_________________

32

Please indicate your level of agreement with each of the following statements circle the

appropriate number):

I am confident in cooking with healthy ingredients.

1 2 3 4 5

Strongly

Disagree

Disagree Neutral Agree Strongly

Agree

Based on my current purchasing behavior, I feel I can prepare healthy meals for my family.

1 2 3 4 5

Strongly

Disagree

Disagree Neutral Agree Strongly

Agree

I am comfortable in using the nutrition knowledge to prepare my meals.

1 2 3 4 5

Strongly

Disagree

Disagree Neutral Agree Strongly

Agree

I feel confident in substituting unhealthy ingredients with healthier options when preparing a meal

for my family.

1 2 3 4 5

Strongly

Disagree

Disagree Neutral Agree Strongly

Agree

I feel confident in my ability to prepare quick and nutrition meals

1 2 3 4 5

Strongly

Disagree

Disagree Neutral Agree Strongly

Agree

I believe that healthy foods are tasty.

1 2 3 4 5

Strongly

Disagree

Disagree neutral Agree Strongly

Agree

33

How many servings of fruit and vegetables a day do you think experts are advising people to eat?

(One serving could be, for example, an apple or a handful of chopped carrots)

A glass of unsweetened fruit juice counts as a serving of one fruit (a medium-sized apple, a small

banana).

_______ Agree

_______ Disagree

_______ Not sure

Are you aware of any major health problems or diseases that are related to a low intake of fruit

and vegetables?

_______ Yes

_______ No

_______ Not sure

If yes, what diseases or health problems do you think are related to a low intake of fruit and

vegetables?

____________________________________________________________________________________

____________________________________________________________________________________

___________________________________________________________________________________

34

Figure 4:

Sample Recipe Pamphlet

Spicy Jimaca and Mandarin Orange Salad

Fun Fact: Jicama is a good source of Vitamin C and very low in calories.

Total Time: 25 minutes

Prep Time: 15 minutes

Cost Per Serving: $1.50

All fruits and vegetables can be purchased after the demonstration outside at the mobile produce vendor.

Ingredients:

● 1 Jicama Peeled and Cut

into 1/4 by 1 inch

● Juice of One Orange

● Juice of One Lime

● Juice of 1/2 Grapefruit

● 1/4 Teaspoon Salt

● 1/4 Cup Olive Oil

● 1 Red Apple, Corned and

Julienned

● 1 (15 ounce) Can

Mandarin Oranges,

drained

● 2 Tablespoons Cilantro

Finely Chopped

● 1/2 Teaspoon Chili Powder

● 6 Leaves of Romaine

Lettuce

Procedure:

1 In a large glass bowl,

combine the jicama with

the orange lime and

grapefruit juices and salt.

2 Toss to mix and let sit,

covered at room

temperature for 1 hour.

3 About 15 minutes before

serving add the olive oil,

apple, mandarin oranges

and cilantro to the bowl

and toss thoroughly.

4 Season with the chili

powder taste for seasoning

and toss again. scoop

salad evenly into lettuce

leaves and serve

Nutritional Info:

Calories-190, Fat-9g,

Protein-2g, Fiber-6g, Calcium-

30mg, Iron-1mg

Prepping Advice:

Cut fruits and vegetables ahead for

easy access the next day. This

goes the same for meat – marinate

a day ahead to cut down on

preparation time the next day.

Marinating meat ahead of time

gives the meat more flavors and

makes it more tender.

Source:

Let's Cook/Vamos a Cocinar

(Klarin, Katie and Knizewki,

Ritamaria).

35

Figure 5:

Educational Material

*Will be given after the cooking demonstrations and reviewed at the home visits

Example 1:

Reading the nutrition label can be confusing. Here are some simple pointers for the next time you pick up

a packaged food item at the supermarket. Remember: the more practice you get reading the labels, the

better you will become in using them as a tool to improve your child's health!

● Always look at the serving size. Nutrition information provided on a label is based on only one

serving. The nutrition label below shows that there are 2 servings per container. If you or you

child ate the whole container you would have consumed a total of 520 calories (260 x 2).

● Eat less fat, especially saturated fat. Avoid trans fat. Limit total cholesterol. The product below is

high in saturated fat because a single serving provides 25% of the daily value for saturated fat.

Look for foods that have less than 20% of the daily value for saturated fat per serving.

● Reduce the amount of sodium eaten during the day; most of our sodium comes from processed

foods, so be on the lookout for high sodium levels.

● Eat foods high in complex carbohydrates and dietary fiber. You will need to look at the ingredient

label to see if the product is whole grain. Look for words such as "100 % whole grain," "whole

wheat," or "brown rice."

● Decrease the amount of sugar in your child's diet. Read the ingredient label to identify added

sugars. A couple of names for added sugar include high fructose corn syrup, cane juice, fruit juice

concentrate, and honey.

36

Figure 5:

Educational Material Example 2

*given after the cooking demonstrations and reviewed at the home visits

http://www.choosemyplate.gov/healthy-eating-tips/ten-tips.html

37

Figure 6:

Specific Goals for Home Visits

1st month home visit:

● CHW meets all the families in the program

● CHW review’s pre-test questionnaire with the parent/s in detail

○ Discussion with parent(s) regarding the strengths and weakness of their diet

○ Assets and barriers to making dietary changes

● CHW and parent(s) make healthy diet goals

● CHW provides monthly log for parents to track intake of fruits and vegetables

2nd-6th Home Visit:

● Discussion about past month dietary habits

● Review of past month fruit and vegetable log

● Have any diet changes been made?

○ If family did not achieve monthly goal, what were some barriers that family

experienced?

○ How can barriers be overcome for the next month?

● Detailed review of nutrition educational material

● CHW and parent(s) make diet goals for the next month.

○ What needs to be changed?

○ Is goal realistic and attainable for the next month?

○ What steps can family make to sure that their goal is achieved?

38

Figure 6:

Sample Family Monthly Log of Goals and Accomplishments

Smith Family:

Visit Date Accomplishment Task/Discussion Goals for next visit CHW comments

February 16 - Review pre-test questionnaire

- Discuss diet goals

- Discuss assets and barriers

- Log fruit and vegetable

intake for the month.

- Meeting went great.

- No concern.

- Next meeting will be on

March 23 at 6pm.

March 20 - Diet goal 1 met. - Review last month’s fruit and

vegetable intake log

- Review barrier #1

- Discuss purchasing

healthy foods on a

budget

April 20 - Diet goal 2 met - Discuss barrier #2

- Review fruit and vegetable logs

- Discuss preparing

healthy meals

39

Figure 7:

Sample Overall Home Visit Goals for Family

In the space provided, write the number of servings of fruit and vegetables you ate during each day. Specify which fruits and

vegetables you ate

My personal goals: I will eat ____servings of fruit and ____servings of vegetables every day during the month.

40

Figure 8:

Checklist of ‘3 P’s in a Pod’ cooking demonstration

Checklist for ‘3 P’s in a Pod’ Lesson

Date/time: ____________________ Session # _______________

Sign-in attendance sheet for parents and their children

Mobile vendors on site?

Nutritionist on site?

Volunteer chef on site?

Name of volunteer chef: ____________________________________

Ingredients (fruits, vegetables, oil, spices, etc)

Utensils (knives, pots, pans, plates, cutting board, spoons, forks, etc)

Recipes pamphlets ready to be distributed

Recipe being prepared: ______________________________________

Venue is clean and prepared

First aid available

Signatures:

Nutritionist Mobile produce vendor Volunteer chef

41

Figure 9:

Checklist for 3 P’s in a Pod Home Visits

Checklist for ‘3 P’s in a Pod’ Home Visits

Date/time: ____________________ Home Visit # _______________

Research staff set up a monthly home visit appointments for each family

Research staff contact the family 24-hours in advance to confirm home visit appointment

Community health worker meets with each family once a month

CHW reviews pre-test questions with the parent(s) during first visit

CHW discusses the following with parents

o Strengths and weakness of current diet

o Barriers to healthy eating and how to overcome these barriers

o Nutrition educational material provided at cooking lesson

Motivational interviewing used by CHW with parents during visit

CHW reviews progress and setbacks to healthy eating behavior during each subsequent

visit.

Questions to ask during the visit:

1 On a typical day during the past month, how many fruits and vegetables did your family members

eat?

2 How were fruits and vegetables incorporated in the meals that you prepared?

3 Where did you shop for your produce this month?

4 What kind of food did you buy?

5 Were you able to afford enough produce this month?

6 How long did your meals take to prepare?

7 What is your family’s favorite dish? How was this prepared this month?

8 Have you read the nutrition material that you received from the cooking class? Let’s review some

of the key facts.

Signature:

Nutritionist Mobile produce vendor Volunteer chef

42

Figure 10:

3 P’s in a Pod Demonstration, Truck , & Home Visit Calendar

43

Figure 11: 3P’s in a Pod Cooking Demonstration Attendance Sheet

February 2013 March 2013 April 2013 May 2013 June 2013 July 2013

ID Family 1 (Feb 9)

2 (Feb 23)

3 (Mar 2)

4 (Mar 16)

5 (Apr 13)

6 (Apr 27)

7 (May 11)

8 (May 25)

9 (Jun 8)

10 (Jun 22)

11 (Jul 6)

12 (Jul 20)

1 Johnson family (2 adults, 1 child) X X

2 Smith family (2 adults, 2 children) X X

3 Patterson family (2 adults, 1 child) X X

4 Wilson family (2 adults, 4 children) X X

5 Holmes family (2 adults, 3 children) X X

6 Bosworth family (2 adults, 2 children) X X

7 Bradley family (2 adults, 3 children) X X

8 Anderson family (2 adults, 2 children) X X

9 Thompson family (2 adults, 5 children) X X

10 Walker family (2 adults, 4 children X

11 Farley family (2 adults, 2 children) X X

12 Hawks family (2 adults, 2 children) X X

13 Bryant family (2 adults, 1 child) X X

14 Joseph family (2 adults, 4 children) X X

15 Kennedy family (2 adults, 3 children) X X

16 Welker family (2 adults, 3 children) X X

17 Ross family (2 adults, 2 children) X X

18 Fredrick family (2 adults, 5 children) X X

19 McDonald family (2 adults, 2 children) X X

20 Hightower family (2 adults, 2 children) X X

44

Figure 12:

3 P’s in a Pod Participant Satisfaction Survey

Please take a few moments to answer the following questions. Your responses are completely

confidential and voluntary.

1. What is your overall rating of the 3 P’s in a Pod Program? Circle your response.

Excellent Good Fair Poor

Additional Comments?

____________________________________________________________________________________

2. What did you like best about the 3 P’s in a Pod Program?

____________________________________________________________________________________

3. What did you like least about the 3 P’s in a Pod Program?

____________________________________________________________________________________

4. What is your overall rating of the cooking demonstration sessions? Circle your response.

Excellent Good Fair Poor

Additional Comments?

____________________________________________________________________________________

5. What did you like best about the cooking demonstration sessions?

____________________________________________________________________________________

6. What did you like least about the cooking demonstration sessions?

____________________________________________________________________________________

7. What is your overall rating of the home visits? Circle your response.

Excellent Good Fair Poor

Additional Comments?

____________________________________________________________________________________

45

8. What did you like best about the home visits?

9. What did you like least about the home visits?

____________________________________________________________________________________

10. What is your overall rating of the presence of mobile food vendors after each cooking

demonstration? Circle your response.

Excellent Good Fair Poor

Additional Comments?

______________________________________________________________________________

11. What did you like best about the presence of mobile food vendors after each cooking

demonstration?

____________________________________________________________________________________

12. What did you like least about the presence of mobile food vendors after each cooking

demonstration?

____________________________________________________________________________________

13. Please give the cooking leaders an overall rating. Circle your response.

Excellent Good Fair Poor

Additional Comments?

____________________________________________________________________________________

14. Please give the nutritionist an overall rating. Circle your response.

Excellent Good Fair Poor

Additional Comments?

____________________________________________________________________________________

15. Please give the community health worker an overall rating. Circle your response.

Excellent Good Fair Poor

Additional Comments?

____________________________________________________________________________________

46

16. Please give the mobile food vendors an overall rating? Circle your response.

Excellent Good Fair Poor

Additional Comments?

____________________________________________________________________________________

17. Do you have any additional comments/suggestions/criticisms about the 3 P’s in a Pod

program?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

47

Figure 13:

3 P’s in a Pod Partner Satisfaction Survey

Please take a few moments to answer the following questions. Your responses are completely

confidential and voluntary.

1. What is your role in the 3 P’s in a Pod Program? Circle your response.

Bell Tower Foods Vendor Mattapan Mobile Farm Stand Vendor Cooking Leader

2. What is your overall rating of the 3 P’s in a Pod Program? Circle your response.

Excellent Good Fair Poor

Additional Comments?

____________________________________________________________________________________

3. How would you rate your satisfaction with your contribution to the 3 P’s in a Pod Program?

Circle your response.

Excellent Good Fair Poor

Additional Comments?

____________________________________________________________________________________

4. What do you like best about your contribution to the 3 P’s in a Pod Program?

____________________________________________________________________________________

5. What do you like least about your contribution to the 3 P’s in a Pod Program?

6. Is there anything you would change about your contribution?

____________________________________________________________________________________

7. Do you have any additional comments/suggestions/criticisms about the 3 P’s in a Pod program

and/or your contribution?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

48

Figure 14:

Organogram of Adoption/Implementation and Sustainability

49

Figure 15:

Map of Mattapan’s Retail Food Establishments

50

Figure 16:

3 P’s in a Pod Budget

51

Figure 17: Outcomes Evaluation Measures INTERMEDIATE OUTCOMES (Measure: Pre-Post Survey and Modified 3-month and 6-month Mark Survey)

Understanding nutrition facts o Knowledge

Is there an increase in the understanding of nutrition facts? Improved food planning behavior

o Knowledge Have participants demonstrated improved food planning behavior?

o Attitudes Have participants’ attitudes towards preparing healthy meals improved?

o Self-Efficacy Do participants feel competent in their ability to substitute unhealthy

ingredients with healthy ingredients in the meals they prepare for themselves? Their families?

Reduction in meal preparation time o Attitudes and Self-Efficacy

Do participants feel they have the appropriate knowledge needed to reduce meal preparation time?

o Knowledge and Outcome Expectations Have participants meal preparation time improved?

Modification of food purchasing behavior towards healthier foods o Knowledge

Can participants translate nutrition facts into practical food preparation behavior?

o Attitudes Increased belief that fruits and vegetables are affordable? Increased belief that healthy food options can be tasty?

o Self-efficacy Do participants feel confident in their ability to translate nutrition facts into

practical food preparation behavior? o Outcome Expectations

Is there a change in participants purchasing behavior? o Barriers

Do participants believe the mobile food vendors helped overcome barriers to purchasing fruits and vegetables?

Do participants believe the distribution of coupons for use at mobile food vendors helped overcome barriers to purchasing fruits and vegetables?

Do participants believe that using their SNAP benefits and other government assistance at mobile produce vendors helped overcome barriers to purchasing fruits and vegetables?

LONG-TERM OUTCOMES (Measure: Pre-Post Survey Questions)

Increase in fruit and vegetable consumption o Have participants increased their consumption of fruits and vegetables?

Increase in fruit and vegetable availability in Mattapan

52

o Do participants perceive the availability of fruits and vegetables has increased, as a result of the program?

HEALTH AND QUALITY OF LIFE (Measure: Pre-Post Survey Questions & Conclusions Based on Intermediate and Long-term Outcomes)

Reduce risk of obesity and diet-related illnesses o Based on measures from intermediate outcomes and long-term outcomes, have

participants reduced their risk of obesity? Diet-related illnesses?

53

Table 1: Performance Objectives & Determinants

Behavior: Low fruit and vegetable consumption among low-income families in Mattapan, MA.

Performance Objectives

Knowledge Attitudes Self-Efficacy Outcome Expectation Barriers

Individual level

Families will prepare healthier meals

Families will describe how to prepare foods in healthy ways

Express positive attitudes toward healthy meals

Confidence in the ability to prepare foods in a healthier way

Families will plan and prepare meals ahead of time to decrease time in the kitchen.

Families will know how to prepare quick and nutritious meals

Express positive attitudes towards cooking and eating meals at home

Families will have confidence to plan and prepare quick and nutritious meals at home

Families will expect that planning and preparing ahead will help with time constraints at home.

Families will purchase healthy food options

Know how to read nutritional labels and translate it practical food preparation behaviors

Believe that the fruits and veggies are affordable

Believe that healthy food options can be tasty.

Confidence to translate the knowledge gained (reading nutritional label) to actual food preparation behavior

Families will expect to be able to prepare healthier meals.

Families belief that if they overcome food access barriers, they will be more likely to purchase healthy food options

Environmental Level

Mobile produce vendors will provide low-cost produce.

Produce vendors will know when to be present at the site.

Produce vendors will express favorable attitude towards providing low-cost produce to Mattapan

Produce vendors expect that families will purchase produce from them.

Expect their presence will increase access

Produce vendors will provide access.

54

Table 2: Methods & Applications/Strategies of Determinants

Determinants Methods Applications/Strategies

Individual Attitudes:

Families will express positive attitudes toward healthy

meals

Families will express positive attitudes towards cooking

and eating meals at home.

Families will believe that the fruits and veggies are

affordable

Modeling

Education

Framing

Culture-specific cooking lessons

Teach nutritional value of their current traditional meals.

Teaching healthier alternatives or substituting ingredients. Modifying

preferred meals to healthier ingredients

Environmental Attitudes:

Produce vendors will express favorable attitude towards

providing low-cost produce to Mattapan

Education

Describing the need for increased availability of fruits and vegetables

to mobile produce vendors.

Individual Knowledge:

Families will describe how to prepare foods in healthy ways

Families will be able to articulate locations where they can

purchase inexpensive, healthy food options locally.

Families will be able to understand that meal preparation

doesn’t have to be time consuming - know quick and

nutritious meals.

Families will know how to read nutritional labels and

translate it practical food preparation behaviors

Education

Modeling

Providing knowledge of quick meals through cooking demonstrations

and lessons.

Provide recipe booklet with nutritional facts.

Food access map are posted around the community and given during

lessons.

Weekly circular of produce specials/sales.

CHW will provide tailored nutrition education during home visits.

Environmental Knowledge: ● Produce vendors will know when to be present at the

site

Technical

Assistance

Creating a schedule for when the produce vendors need to be present.

Reminders to produce vendors (emails, telephone calls)

Individual Self-Efficacy: ● Families will express confidence in the ability to

prepare foods in a healthier way

● Families will believe that they have the ability to

overcome barriers to accessing low-cost, healthy

foods.

● Families will express confidence in translating the

knowledge gained (reading nutritional label) to actual

food preparation behavior

Modeling

Education

Motivational

interviewing

Cooking demonstrations

Recipe booklet with nutritional facts.

Motivational interviewing.

55

Individual Outcome Expectation: ● Families will expect to be able to prepare healthier

meals.

● Families will expect that planning and preparing ahead

will help with time constraints at home.

Education

Framing

Provide immediate low-cost access to ingredients and food options

discussed in cooking sessions via mobile vendors.

Cooking demonstrations

Home visits - motivational interviews

Environmental Outcome Expectations:

● Produce vendors expect that families will purchase

produce from them.

● Produce vendors will expect their presence will

increase availability

Technical

Assistance

Creating a schedule for when the produce vendors need to be present.

Reminders to produce vendors (emails, telephone calls)

Individual Barriers: ● Families believe that if they can overcome food access

barriers, they will be more likely to purchase healthier

food options.

Providing

access

Reinforcement

of availability

Providing coupons at every demonstration.

Ability to purchase with SNAP and other food assistance program

benefits.

Environmental Barriers: ● Produce vendors will provide low-cost produce.

Providing

access

Food truck will be present after cooking demonstration so families can

purchase produce introduced in the demonstration.

56

Table 3: Adoption, Implementation, & Sustainability Matrix

Performance Objectives Knowledge Skills & Self-Efficacy Outcome Expectations Attitudes

ADOPTION

PO 1: Mattapan CHC will evaluate the need for a program in Mattapan

Summarize needs

Prioritize needs

MCHC finds need in

Mattapan

PO 2: Mattapan CHC will find and adopt program that meets the needs of Mattapan

Mattapan CHC will

describe how this

program compares to

other available

programs

Mattapan CHC will

describe how it meets

the needs of the

dominant demographic

groups of Mattapan

Mattapan CHC expects

that the program will

meet the needs of

Mattapan community

and improve health

outcomes of Mattapan

residents

Mattapan CHC will

express favorably

towards the value and

importance of the

program.

PO 3: Mattapan CHC will identify research team.

Mattapan CHC will list

characteristics of a

good research team.

PO 4: Mattapan CHC will partner with Mattahunt CC as the cooking venue.

Mattapan CHC will

explain the importance

of cooking

demonstration to

Mattahunt CC.

Mattapan CHC expects

participation from the

community in the

program.

PO 5: Mobile produce vendors will partner with Mattapan CHC to increase availability.

Mobile produce

vendors will

understand the

Mobile produce

vendors expect

increased availability to

Mobile produce

vendors express

favorably towards

57

importance of food

availability in low-SES

neighborhoods.

affordable produce in

the low-income

community of

Mattapan.

objectives of the

program.

PO 6: Volunteer local chefs are identified by Mattapan CHC to conduct cooking demonstrations.

Volunteer chefs will

understand the

importance of cooking

demonstrations to the

community.

Volunteer chefs will

express confidence in

conducting cooking

classes to a large

group of people.

Volunteer chefs will

react favorably towards

the importance of the

cooking

demonstrations

Performance Objectives Knowledge Skills & self-efficacy Outcome expectation Attitudes

IMPLEMENTATAION

PO 1: Principal Investigator and Study Coordinator at MCHC will create implementation plan

PI and SC will describe

the components of the

implementation plan.

PI and SC express

confidence in being

able to organize and

develop a plan with

research team.

PO 2: The research team and volunteer chefs will be oriented in the implementation plan by the PI and SC.

The research team and

volunteer chefs will

describe the

implementation plan

and its objectives.

The research team and

volunteer chefs will

have the confidence to

implement the program

successfully.

The research team and

volunteer chefs will

react favorably towards

the program and its

outcome.

PO 3: SC will provide guidelines of pertinent nutrition knowledge that the nutritionist needs to pass on to the chef and CHWs.

PI/SC will provide

demographic

information about

target population to

nutritionist.

PI/SC describe the

barriers specific to

Mattapan in terms of

58

their nutrition needs.

PO 4: Volunteer chefs, community health workers, and research team will be oriented in nutrition education from the nutritionist.

Volunteer chefs,

community health

workers and research

team will know the

components of a

healthy diet.

They will understand

nutrition facts regarding

recipes that will be

provided.

Volunteer chefs,

community health

workers and research

team will have the

skills needed to

educate participants

and convey the

message in layman

term.

Volunteer chefs,

community health

workers and research

team will express

enthusiasm to learn

from the nutritionist.

PO 5: Volunteer chefs will teach the cooking classes.

Volunteer chefs will

understand the

parameters of

Mattapan community

(financial constraints,

demographics, food

preference,

availability, etc)

Volunteer chefs will

have the skills need to

cook the recipe.

Volunteer chefs will

express confidence in

their ability to develop

easy, low cost, tasty,

healthy recipes that will

be appropriate for the

Mattapan community

PO 6: Mobile Vendors will provide produce at cooking demonstrations.

Mobile vendors will

expect participation

from the community.

Mobile vendors will react favorably towards the importance of access in healthy eating.

PO 7: CHW will conduct home visits.

CHW will describe how

to conduct motivational

interviewing with

participants.

CHW will express confidence in being able to execute motivational coaching.

59

PO 8: Research Team will make sure each component of the intervention is completed properly and as intended.

Research team has

confidence to be able

to carry out

implementation plan.

Research team expects

program to run

smoothly according to

plan.

Performance Objectives Knowledge Skills & self-efficacy Outcome expectation Attitudes

SUSTAINABILITY

PO 1: Mattapan CHC will draft the proposal for Robert Woods Johnson Foundation (RWJF) grant.

Mattapan CHC will

describe objectives of

the program and how

they align with the

objectives of RWJF.

Mattapan CHC will

describe the

importance of the

program and need for

Mattapan residents.

Mattapan CHC will

expect that the RWJF

will support by funding

the program

PO 2: Mattapan CHC will implement the “3 P’s in a Pod” program as part of the community’s events.

CHC coordinator will

recognize the

importance of

integrating the

curriculum into center

events/projects.

CHC coordinator will

describe how to

integrate curriculum

into training - which will

contribute to its

continued use.

CHC coordinator will

feel confident in being

able to execute the

curriculum without the

research team.

CHC coordinator

expects positive

curriculum outcome.

CHC coordinator will

react favorably towards

the results of the

curriculum.

PO 3: Mattapan CHC will adopt curriculum as part of program

Mattapan CHC will

outline basic

Mattapan CHC expects

that the program

60

associate’s job description.

knowledge and skills

needed of the program

associate.

associate is qualified

and will lead the

curriculum

successfully.

PO 4: CHW will train the lay workers to conduct effective home visits.

CHW will describe

skills and techniques

necessary to conduct

motivational

interviewing to the lay

workers

CHW will express

confidence in their

ability to train the lay

workers effectively.

61

Table 4:

Logic Model of Intervention

62

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