Introduction

Most students want to but do not eat at least five servings of fruits and vegetables per day.  Increasing fruit and vegetable intake with social marketing messages was the problem addressed by the research aided by the Dr. Joel Grinolds Pacific Coast College Health Association Grant.  The theoretical framework of the program focuses on the stages of change of the students and student decisions to eat healthful food choices shaped by recommendations from national and government organizations.

Social marketing uses successful techniques of commercial marketers.[1]  Rather than top-down conveyance of information, social marketing addresses the needs and desires of the target audience and build programs from there.  The focus is on consumers with research and evaluation, and uses the same four commercial marketing Ps of product, price, place and promotion.

It has been suggested that individuals develop good health habits in stages[2] and that interventions should match a person’s readiness to change or adopt a new, healthful behavior.[3]  The stages of change approach, originally described by Prochaska and DiClemente,[4] has been successfully applied to a number of unhealthy practices, including smoking, consuming high fat diets, and delinquent behavior.

Health assessments at Cal Poly Pomona indicate that most students do not eat enough, but do want to eat more, fruits and vegetables per day.  Health Risk Appraisal results over a nine year period show that less than half, most recently 91%, do not eat at least five servings of fruits and vegetables per day.  This is more than the 73% of adults in the US[5] who do not eat the recommended minimum.

Further surveys asking students what they wanted to do to improve their health in the next six months indicate that better nutrition was desired.  Specifically, within the next six months, most students, 65%, were at a stage of readiness, contemplative stage, to eat more fruit and vegetables per day.  They indicated that they were serious or very serious about eating more fruits and vegetables.  This behavior ranked fifth of 34 behaviors.  Handwritten responses for self-determined needs or concerns found that 25% wanted to improve nutrition as a second choice after wanting to increase physical activity (52% wrote something related to physical activity).  As their second choice for a behavior to improve, the most frequent was to improve nutrition with 31% writing something related to nutrition.

The American Cancer Society and Produce for Better Health Foundation[6] “Eat ‘5-a-Day’ for Better Health” slogan was selected as the message to use in a tailored behavior change social marketing campaign.  “5-a-Day” is one of the seven “structural measures” recommended by Healthway[7] for its funded programs for which several of the measurable objectives were derived.

The goal of the program was to promote increases of fruit and vegetable intake by Cal Poly Pomona students with a budget of $2,500 (see Appendix I).  The objective was to increase fruit and vegetable intake.  The measurable objectives, based partially on Healthway's Graduated Project Evaluation for funding under Australian $10,000 (US $6,500), were:

Promotional Measures

Output measures.  Bulk materials such as promotional leaflets and advertising (Figures 1 through 6).

Sales Measures

Dollar amount of salad bar sales in campus dining facilities.

Target Measures

Survey of those targeted.  Based on dollar value of the project.  (see Figure 7)

Educational Measures – Impact  Measures[8]

Total number of participants exposed to educational activities, frequency of exposure and average duration of exposure.

Cognitive / Attitudinal Measures (Effectiveness Measures)

These are derived from the surveys noted in Target Measures (Figure 7).  They include:

1.      unprompted recognition of health messages,

2.      prompted recognition from a prompt list,

3.      comprehension (the knowledge question: understand the message),

4.      acceptance (the attitude question: agreement with the health message),

5.      intention (intend to act on the health message),

6.      action (outcome measure, take some form of action based on the message). 

Methods

The theoretical framework of the program focuses on the stages of change of the students and student decisions to eat healthful food choices shaped by recommendations from national and government organizations. Since the social marketing and stages of change concepts can be related to healthy food choices, the project consisted of bulk materials presented to students.  A postcard was sent to nearly 8,000 students and table tents were placed on tables in two primary campus eating areas.  Approximately 5,800 cards were sent to 20 to 29 year olds, the target group with a slightly higher interest in eating more fruits and vegetables.  The cards were also sent to 20 to 29 year olds not living in the Cal Poly Pomona 91768 zip code.  Nearly 2,200 students living the 91768 zip code live in university housing and received the card without postage in their apartment or residence hall mailbox.  This occurred during the month of March 1998.  Additionally, a limited number of awards (5-a-Day lunch totes) were given to those using a frequent buyer card and purchasing 9 servings of fruits and vegetables.  One year after promotional materials were sent, during a two-week period of March 1999, the survey of participants was completed.

Results

Promotional Measures

Output measures.  Six thousand post cards were sent to students 22 through 29 years of age and not living in the Cal Poly Pomona zip code of 91768.  Post cards were place in mailboxes of the 2,200 students living in residence halls and university apartments.  Receipt of post cards was during quarter the break at the beginning of March 1998.  600 table tents were placed in Los Olivos Commons dining facility for residence halls and the Campus Center and University Union dining facilities.

Target Measures

Survey of those targeted.  Thirty-eight students were surveyed.

Sales Measures

Dollar amount of salad bar sales in campus dining facilities.

January 1998	$14,911
February 1998	$13,162
March 1998 (Finals week and quarter break were in this month.)	$10,400
April 1998	$18,528
May 1998	$15,111

 

Educational Measures – Impact  Measures[9]

Total number of participants exposed to educational activities: 8,000 for post cards, number of 600 for table tents, 43 faculty, staff and students completed 10 visits to the salad bar with the frequent buyer card.

Cognitive / Attitudinal Measures - Effectiveness Measures

These are derived from the surveys noted in Target Measures (Figure 7).  They include:

1.      unprompted recognition of health messages: 33%

2.      prompted recognition from a prompt list: 62% for post card (all of these were in the target group of 20 to 29 year olds sent post cards), 35% for table tent

3.      comprehension (the knowledge question: understand the message): 97%

4.      acceptance (the attitude question: agreement with the health message): 77%

5.      intention (intend to act on the health message): 67%

6.      action (outcome measure, take some form of action based on the message).  46%

Limitations

Some limitations should be considered when interpreting the results of this program.  The data are generalizable to Cal Poly Pomona students.  The results are based on self-reported data.  Longitudinal study of this program would be the best way to assess vegetable and fruit intake.

Discussion

A year after the program many students could recall the 5-a-Day program.  All students surveyed who should have received the post card did recall seeing the card.  The 5-a-Day message seems to be very understandable.  However, acceptance of the message was hindered because some students do not know the size of a serving.  They tended to think five servings were each large (e.g. thinking a serving was one and half cups of vegetables).  Collaboration with Cal Poly Pomona’s Foundation Foods Services was critical to implementation of the program.  Food Services offered discounts and helped place table tents and posters.  Food Services appears to have had an increase in sales due to the 5-a-Day program.  Two months to compare in which students were attending regular classes for the entire months were February and April.  Salad bar sales in April were 41% higher in April after the 5-a-Day program.

Conclusions

Tailored behavior change messages appear to improve health behaviors of students.  The findings of this program suggest that it is likely that students will eat more fruits and vegetables if provided with 5-a-Day messages.

• One of the more effective methods marketing (P, Place of the four Ps) may be direct mail with post cards.
• The 5-a-Day message seems to be understandable and influential in creating the intention and causing greater intake of fruits and vegetables.
• Future programs should last longer and provide more frequent messages to cause more students to take “action” to eat more fruits and vegetables per day.  Additionally, this should be done in an effort to have a significant impact on the proportion of students eating at least five servings per day.  That is, to increase (similar to Healthy People 2010 National Objective criteria) to 15% to 20% the proportion of students eating the minimum recommended servings from the current 9%.
• Future studies should determine the duration of programs and frequency of messages necessary to achieve the objective listed above on a commuter campus.

Acknowledgements

Debbie Jackley coordinated the marketing and acquisition of materials.  Teresa Quijano assisted in program development and implementation.  Peer Health Educators assisted in developing the survey and surveying students.  Susan Bisaillon was the principal grant writer.

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