Evaluation of the Rethink Your Drink 9th-12th Grade Curriculum, 2017 Prepared for: California Department of Public Health Nutrition Education and Obesity Prevention Branch Prepared by: Nutrition Education and Obesity Prevention Research and Evaluation Unit, Nutrition Policy Institute, University of California, Division of Agriculture & Natural Resources Authors: Ron Strochlic, MS, Nutrition Policy Institute, University of California, Division of Agriculture & Natural Resources Kaela Plank, MPH, Nutrition Policy Institute, University of California, Division of Agriculture & Natural Resources Sridharshi Hewawitharana, MPH, Nutrition Policy Institute, University of California, Division of Agriculture & Natural Resources Marianne Hernandez, MS, Nutrition Education and Obesity Prevention Branch, California Department of Public Health Jackie Richardson, MIB, Nutrition Education and Obesity Prevention Branch, California Department of Public Health Kenneth Hecht, JD Unit Director, Nutrition Policy Institute

Pat Crawford, DrPH, RD Principal Investigator, Nutrition Policy Institute

July 2018

This material was funded by USDA's Supplemental Nutrition Assistance Program-SNAP This project was supported by funds received from the State of California, Department of Public Health.

i

ExecutiveSummaryRethinkYourDrink(RYD)isaCaliforniaDepartmentofPublicHealth(CDPH)NutritionEducationObesityPreventionBranch(NEOPB)Initiativedesignedtoprovidenutritioneducationanddevelopskills,suchaslabelreading,tohelppeoplemakehealthierbeveragechoicesincludingwater,fat-freeorlow-fat(1%)milk,and100%juiceinlimitedamounts.ARethinkYourDrinkhighschoolcurriculumtargetingstudentsingrades9-12wasdevelopedin2012.Thecurriculumpromotesfourkeybehaviors:• Drinkwaterinsteadofsugarydrinkssuchassodas,energydrinks,andjuicedrinks.• Choosefromavarietyofhealthydrinkoptionssuchaswater,1%milk,fat-freemilk,100%

fruitjuice,orunsweetenedteaorcoffeeoversugarydrinks.• UsetheNutritionFactslabeltochoosefoodsandbeverageswithlesstotalsugars.• UsetheIngredientListtochoosefoodsandbeverageswithlittleornoaddedsugars.Thecurriculumconsistsoffour50-60-minutelessonsthatbuildononeanotherandaredesignedtobetaughtoverthecourseofseveralweeks.Learningobjectivesaretoexpandstudentunderstandingoftheeffectsofexcessivesugarconsumptiononhealth;increaseawarenessofwhichbeveragesstudentsandtheirpeerschoosetodrinkandreasonsforchoosingthosebeverages;communicatetheimportanceofaccessingvalidhealthinformationandteachstudentshowtousethenutritionfactslabelstocomparesugarcontentofvariousbeverages;identifyandevaluatetheinternalandexternalinfluencesthataffectfoodandbeveragechoices;identifythestepsofthedecision-makingprocessanduseittomakehealthierbeveragechoices.AnevaluationoftheRYDcurriculumwasconductedbytheUniversityofCaliforniaNutritionPolicyInstitutein2017toaddressthefollowingquestions:• WhatimpactsdidtheRYDcurriculumhaveonhighschoolstudents’knowledge,attitudes

andbehaviorsregardingsugar-sweetenedandnon-sugarydrinks?• Whatwereteacherandstudentperceptionsofthecurriculum?• Whatrecommendationsdidteachersandstudentshaveforenhancingandimprovingthe

curriculum?

Evaluationmethodsincludeda2-grouppre-posttestadministeredtointerventionandcomparisongroupstudentsimmediatelypriortoandfollowingcurriculumimplementation;focusgroupdiscussionswithinterventiongroupstudents;anonlinesurveyofinterventiongroupteachers;andsemi-structuredinterviewswithinterventiongroupteachers.Thestudentsurveyassessedbehaviors,knowledge,self-efficacy,andattitudes,whilestudentfocusgroupsassessedperceptionsofthecurriculumandrecommendationsforimprovements.Theteachersurveyassessedcurriculumimplementation,whiletheteacherinterviewselicitedperceptionsofthecurriculumandrecommendationsforimprovements.

ii

Keyfindingsfromthestudentsurveyincludethefollowing:• Withrespecttoconsumptionpatterns,therewasnosignificantdifferenceinthenumber

ofsugarsweetenedbeveragesconsumed,suchassoda,sportsdrinksandflavoredmilk,betweeninterventionandcomparisongroupstudents.However,theinterventionwasassociatedwithaslightbutstatisticallysignificantdecreaseinconsumptionofdietsodaaswellaswithasmallincreaseinthenumberoftypesofhealthydrinksstudentschosewheneatingout(0.19;95%CI:0.05,0.34).

• StudentsexposedtotheRYDcurriculumreportedincreaseduseofnutrientlabelingofbeveragesascomparedtostudentsnotexposedtoit.Interventionstudentsreportedasmall,butstatisticallysignificantgreaterincreaseinthefrequencyofreadingtheNutritionFactsLabelwhenchoosingadrinkcomparedtocomparisongroupstudents(0.10;95%CI:0.03,0.17).

• TheRYDcurriculumhadlimitedeffectsonknowledgeassociatedwithself-efficacy.Interventionstudentsreportedasmallbutstatisticallysignificantgreaterincreaseintheirunderstandingofreasonsforchoosingcertainbeveragesascomparedtocomparisongroupstudents(0.19;95%CI:0.07,0.32).

• TheRYDcurriculumhadnosignificantimpactsonstudentattitudesregardingconsumptionofsugarandsugarydrinks.

• StudentsreceivingtheRYDcurriculumreportedchangesintheinfluenceoftwofactorsaffectingbeveragechoice.Theinterventionwasassociatedwithsmallbutsignificantdecreasesintheself-reportedamountofinfluenceofnumberofcaloriesinadrink(0.17;95%CI:0.11,0.23)aswellasbeverageadvertisements(0.18;95%CI:0.12,0.24)onbeveragechoice.

Keyfindingsfromtheteachersurveyandinterviewsandstudentfocusgroupsincludethefollowing:• Teachersfeltpositivelyaboutthecurriculum.Teachersagreedwiththefollowing

statementsregardingeachofthelessons:“Thetrainingadequatelypreparedmetoteachthislesson,”“Ifeltadequatelypreparedtoteachthislesson,”and“TheContentStandardshelpedidentifythelesson’sfitwithgrade-levelinstructionrequirements.”

• Teachersbelievedthatthelessonswerewell-alignedwithlearningobjectives.Nearlyallteachersfeltthelessonswere“very”or“somewhat”well-alignedwiththelearningobjectivespresentedforeachlesson.

• Teachersdidnotimplementallcomponentsofthecurriculum.Duetolackoftimeand/orreluctancetoburdenstudentswithadditionalhomework,teachersconsistentlyreportedthattheydidnotincorporatethelastcomponentsofthecurriculum.

• Thecurriculummaybemoreeffectivewithyoungerstudents.Studentsfeltthathighschoolstudentshaveingrainedhabitsthatcanbehardtobreak,whileteachersnotedtheinformationwasredundantforsomestudents,whohadalreadybeenexposedtoit.

iii

ThelimitedimpactoftheRYDcurriculumonthekeyoutcomesofinterest,i.e.studentintakeofsugarydrinksandhealthyalternativessuggeststhatthatthiscurricularapproachalonemaybeinsufficienttoachievebehaviorchangeonitsown.ThatisconsistentwiththeSNAP-Edtheoryofchange,whichpositsthatacombinationofeducationalapproaches,policysystemsandenvironmentalchange(PSE),andsocialmarketingarerequiredtoachieveconsistentandenduringbehaviorchange.EvaluationfindingssuggestthatthecurriculumshouldberevisedinaccordancewiththestudentandteacherfeedbackandimplementedwithcomplementaryPSEandsocialmarketingapproaches.

1

Introduction

RethinkYourDrink(RYD)isaCaliforniaDepartmentofPublicHealth(CDPH)NutritionEducationObesityPreventionBranch(NEOPB)Initiativedesignedtoprovidenutritioneducationanddevelopskills,suchaslabelreading,tohelppeoplemakehealthierbeveragechoicesincludingwater,fat-freeorlow-fat(1%)milk,and100%juiceinlimitedamounts.Recenteffortstotaxsugarydrinkshaveraisedawarenessoftheirimpactonhealthandhavemadeeffortstopromotehealthybeveragechoicesparticularlytimely.NEOPB,whichisfundedbytheUnitedStatesDepartmentofAgricultureSupplementalNutritionAssistanceProgram-Education(SNAP-Ed),addressesrisingobesityratesthroughstatewide,regional,andlocalprogramsandpartnershipsthatpromotehealthyeating,physicalactivity,andfoodsecuritywithanemphasisoncommunitieswiththegreatesthealthdisparities.

In2009,theBayAreaNutritionandPhysicalActivityCollaborative(BANPAC)launchedthefirstmulti-countyRethinkYourDrinknutritioneducationcampaigntoencouragetheconsumptionofwaterinsteadofsugarydrinks.ThecampaignwasimplementedinsixBayAreacounties:Alameda,ContraCosta,Marin,SanFrancisco,SanMateoandSantaClara,andincludedconsumereducationaswellasrecommendationsforenvironmentalsupportsthatpartnerorganizationscouldimplementtofacilitateconsumerchoiceandincreaseaccesstohealthybeverages.ThecampaignwasbasedontheAlamedaCountyPublicHealthDepartment’ssuccessfulSodaFreeSummerCampaign,aseason-longpublichealtheventthatencouragedconsumerstodrinkwaterinsteadofsoda.

The2010DietaryGuidelinesforAmericans(DGA),urgedAmericanstoconsumefeweraddedsugars,specificallyfromsodasandothersugarydrinks.iIn2012,CDPHreleasedaresearchbriefbasedontheresultsofthreestatewidesurveysondietandphysicalactivitypracticesamongadults,teens,andchildren.iiThesurveyfindingsrevealedthatapproximatelyhalfofCaliforniachildren,teens,andadultsdrankatleastoneservingofasugarydrinkdaily.TheCDPHbriefalsohighlightedassociationsbetweensugarsweetenedbeverageintakeanddemographicandsocioeconomicfactors;consumptionofhealthyandlesshealthyfoods;healthbehaviors;psychosocialfactors;andthehome,work,andschoolenvironments.BasedonthesefindingsanddirectionfromtheDGA,CaliforniaSNAP-Ed,withCDPHsupport,begantoimplementhealthybeverageeducationstatewidethroughlocalandregionalefforts.Today,RethinkYourDrinkisprimarilyimplementedthroughSNAP-Ed-fundedlocalpartners.

ThisreportpresentstheresultsofanevaluationoftheRethinkYourDrinkeducationalprogramdesignedforandimplementedamong9ththrough12thgradestudents.Previousevaluationsofschool-basedcurriculapromotinghealthybeveragechoicesamongelementaryagestudentshaveshownmixedresults.Whereassomefoundself-reportedreductionsinsugarydrinkconsumptioniii,ivalongwithincreasedwaterconsumption,vothersfoundnochangesinself-reportedsugarydrinkorwaterconsumption.vi,viiNostudieswithcomparablecurriculatargetinghighschoolyouthwereidentified.

2

BackgroundoftheRethinkYourDrinkHighSchoolCurriculum

TheRethinkYourDrinkhighschoolcurriculumemergedfromadesiretoprovideskills-basedhealthybeverageinstructiontoadolescents,agroupwithhighratesofsugar-sweetenedbeverageconsumption.ThelessonsweredevelopedtocomplementexistingRethinkYourDrinkmaterials,aswellasotherhealthybeveragematerialsdevelopedbytheAlamedaCountyPublicHealthDepartment,BANPAC,theOrangeCountyNutritionandPhysicalActivityCollaborative,theNorthcoastNutritionandFitnessCollaborative,andtheGoldCountryHealthEatingActiveLivingCollaborative.Inpartnershipwithclassroomteachers,whosefeedbackwasincludedin2011,andeducationandpublichealthexperts,NEOPBdevelopedtheRethinkYourDrinkhighschoolcurriculumin2012.Thecurriculumwaspilot-testedattenin-andafter-schoolprogramsservingmiddleandhigh-school-agedyoutharoundthestate.ThepilottestwasevaluatedbyreviewersfromCDPH,theCaliforniaHealthyKidsResourceCenterandtheCaliforniaDepartmentofEducation.Twoschooldistrictcoordinatorsalsocontributedrecommendationsforimprovement.ThematerialswerereleasedforstatewideimplementationthroughSNAP-Edfundedprojectsin2012.Sincethen,thematerialshavebeenrevisedtoreflecttheupdated2015-2020DGAsandthecurriculumhasbeenshortenedtoensurethatthelessonscanbecompletedwithinaverageclasstimeof50-60minutes.

TheRYDhighschoollessonsincorporatenutritionandphysicalactivityrecommendationsfromtheUnitedStatesDepartmentofAgricultureandtheDepartmentofHealthandHumanServices’2015DietaryGuidelinesforAmericansandthe2008PhysicalActivityGuidelines,whichemphasizetheimportanceofbalancingcaloricintakewithphysicalactivity.Onesignificantrecommendationincludeslimitingcaloricintakefromsoda,energy,andsportsdrinks—eachamajorsourceofaddedsugarandcaloriesinthedietofmanyAmericans.

TheRYDcurriculumisalsobasedontheHealthEducationContentStandardsforCaliforniaPublicSchools,viiiwhichidentifyessentialhealthknowledgeandskillsthatstudentsshouldhaveateachgradelevel,andtheCaliforniaNutritionCompetenciesixforgrades9-12,whichidentifynutritionknowledgeandskillsstudentsneedtomakehealthfulfoodchoices.

TheRYDHighSchoolCurriculumpromotesfourkeybehaviorsamongstudents:• Drinkwaterinsteadofsugarydrinkssuchassodas,energydrinks,andjuicedrinks.• Choosefromavarietyofhealthydrinkoptionssuchaswater,1%milk,fat-freemilk,100%

fruitjuice,orunsweetenedteaorcoffeeoversugarydrinks.• UsetheNutritionFactslabeltochoosefoodsandbeverageswithlesstotalsugars.• UsetheIngredientListtochoosefoodsandbeverageswithlittleornoaddedsugars.DescriptionoftheRethinkYourDrinkcurriculum

Thecurriculumincludestwolessons,eachofwhichconsistsoftwoparts,foratotaloffour50-60-minutesessionsthataresequential,buildononeanother,andaredesignedtobetaughtoverthecourseofseveralweeks.Eachlessoncontainsanoverviewofitsobjectives,key

3

messages,materials,andadditionalreferences,andidentifiesCaliforniaHealthEducationContentStandards,andCaliforniaNutritionEducationCompetenciesaddressed.LessoncomponentsincludeaWarmUp,MainActivity,CoolDown,CheckforLearning,HomeConnection,andExtension/Links.Extensionideasandlinkstoothercoresubjectandcontentareasareincludedforgreaterapplicationoftheskillslearned.Thecurriculumincludesteacherresources,lessonoutline,andlessonhandouts.Theestimatedteacherpreparationtimeis20minutesforeachlesson.

Lesson1(“What’sinYourDrink?”)isdividedintoLesson1A“LearningtheFacts”andLesson1B“SugarSleuths.”Lesson2(“ThinkBeforeYouDrink!”)isdividedintoLesson2A“WhatInfluencesYourHealth?”andLesson2B“ChoosingDrinksforHealth.”

Lesson1A’slearningobjectivesaretoexpandunderstandingoftheeffectsofexcessivesugarconsumptiononoverallhealthandtoincreaseawarenessofwhatbeveragesstudentsandtheirpeerschoosetodrinkaswellasreasonsforchoosingspecificbeverages.Activitiesinclude“LearningtheFactsCardsMatch-up”and“LearningtheFactsBingo,”interactiveactivitiesinwhichstudentsmatchfactsanddefinitionsorquestionsandanswers.Lesson1Ahasanoptionalhomeworkactivityinwhichstudentsinterviewfamilymembersaboutbeveragesthattheydrinkandhowtheyfeelaboutthehealtheffectsoftheirchoices.

Lesson1B’slearningobjectivesaretocommunicatetheimportanceofaccessingvalidhealthinformationandtoteachstudentshowtousetheNutritionFactslabelstocomparesugarcontentofvariousbeverages.Activitiesinclude“HowMuchSugar,”inwhichstudentslearntocalculatetheamountofsugarindifferentbeveragesusingsugarcubes,andthe“NutritionFactsScavengerHunt,”inwhichstudentslearntoreadtheNutritionFactslabel.AnoptionalhomeworkactivityconsistsoffillinginablankNutritionFactslabelworksheetwithinformationabouttwodrinksconsumedathome.

Lesson2A’slearningobjectivesaretoidentifyandevaluatetheinternalandexternalinfluencesthataffectfoodandbeveragechoices.The“WhatAreMyInfluences?”activitypromotesstudentawarenessofthereasonsbehindbeveragechoices.Themandatoryhomeworkassignment,“AssessingMyDrinkOptions,”encouragesstudentstothinkaboutthefactorsinfluencingtheirpersonalbeveragechoices.

Lesson2B’slearningobjectivesaretoidentifythestepsofthedecision-makingprocessandhowtouseittomakehealthierbeveragechoices.Lessonactivitiesincludethe“Decision-MakingProcess,”inwhichstudentsdiscusstheresultsoftheLesson2A“AssessingMyDrinkOptions”homeworkassignmentinsmallgroups,andthe“ChooseaHealthyDrinkChallenge,”inwhichstudentscommittochoosinghealthierbeveragesbasedonanevaluationofvaluesandconsequences,andmakeaplantocarryouttheirdecision.Studentsreceivea“HealthyBeverageHighlights”handoutsummarizingallkeymessagesafterthislesson.

4

Theneedforapilottesttoexamineprogrameffectivenessandimplementationchallenges

AnevaluationofthisprogramwasconductedbyNPIin2017.ItwasguidedbythedesireoftheCDPHtobetterunderstandthebenefitsofthecurriculumandwaysinwhichimplementationcouldbeenhanced.Theevaluationaddressedthefollowingquestions:• WhatimpactsdidtheRYDcurriculumhaveonhighschoolstudents’knowledge,attitudes

andbehaviorsregardingsugar-sweetenedandnon-sugarydrinks?• Whatwereteacherandstudentperceptionsofthecurriculum?• Whatrecommendationsdidteachersandstudentshaveforenhancingandimprovingthe

curriculum?

Selectingsitesforthepilottest

AlistofhighschoolsinSacramentoandYoloCountiesmeetingtheSNAP-Edqualifyingthresholdofatleast50percentofstudentseligibleforfreeorreducedpricemealsandwithcomparabledemographiccharacteristics,wascompiled.CDPHstaffcontactedschooladministratorsatqualifyingschoolstoassessinterestinparticipatinginthiseffort.AdministratorsexpressinginterestdirectedCDPHstafftospecificteachers,whowerecontactedbyCDPHstaffandofferedastipendforparticipation.Seventeachersatfiveschoolsagreedtoparticipate.Thefinalsampleconsistedofthreeinterventionschools(twoinSacramentoCountyandoneinYoloCounty)andtwocomparisonschools(oneinSacramentoCountyandoneinYoloCounty),withfourandthreeteachersrespectively.Threeinterventiongroupteachersvolunteeredtoimplementthecurriculuminmorethanoneclass.Thefinalinterventiongroupconsistedofeightclasses,includingHealth(n=2classes),AVID(collegeprep,n=2classes),Economics(n=3classes),andPhysicalEducation(n=1class).Thecomparisongroupconsistedofthreeteacherswithoneclasseach:Health,PhysicalEducationandForensics.Allstudentsininterventionandcomparisonclassroomswereeligibletoparticipateintheevaluation.ParticipantdemographicsarepresentedinTable1.

Methodsusedtoexaminetheeffectivenessofthecurriculum

TheRYDcurriculum’simpactonstudentknowledge,attitudes,andbehaviorswasassessedviapre/post-testsurveyadministeredintheclassroom.An“optout”letterwassenthometostudents’parents/guardians,providinginformationabouttheresearchandrequestingthatparents/guardiansreturnasignedlettertotheschooliftheydidnotwanttheirchildtoparticipateinthispieceoftheevaluation.Studentswereinformedtheycoulddeclinetoparticipateinthesurveywithnonegativeconsequences.

Interventiongroupstudentscompletedtheself-administeredpre-testandpost-testsurveysduringclasstime,twoweekspriortoandthreeweeksfollowingimplementationofthe

5

curriculum.Comparisongroupstudentscompletedthesurveyswithinthesametimeframe.StudentswhooptedoutoftheRethinkYourDrinkevaluationcompletedanalternateactivityinordertoremainindistinguishablefromparticipants.Membersoftheresearchteamproctoredsurveyadministration,andansweredstudents’questions.

ThestudentsurveysincludedquestionsadaptedfromtheNEOPB“WhatDoYouDrink?”survey(unpublished)aswellasnewly-developedquestions.Bothpre-testandpost-testsurveysassessedstudentbehaviors,knowledge,self-efficacy,andattitudes:• Behaviors:frequencyofconsumptionofsugar-andnon-sugarsweetenedbeverages

(times/day);preferredtypeofmilk;mostfrequentlyconsumedbeveragesathome,schoolandwhenout;frequencyofreadingtheNutritionFactsLabelandIngredientsListwhenchoosingadrink(4-pointscale:Always,Usually,Sometimes,Never);

• Knowledge:abilitytorankbeveragesbasedonsugarcontent,identifybeverageswithaddedsugar,identifytheamountofsugarinabeverage,identifyhealthimpactsofsugarconsumptionandidentifybeverageswithaddedsugarbasedonareviewoftheNutritionFactsLabelandIngredientsList;andunderstandingofthedifferencebetweennaturally-occurringandaddedsugars(4-pointscale:Verywell,Somewhatwell,Notverywell,Notatallwell);

• Self-efficacy:confidenceinabilitytoidentifyahealthybeverageandfindvalidhealthinformationaboutdifferentbeverages(4-pointscale:Veryconfident,Somewhatconfident,Notveryconfident,Notatallconfident);self-perceptionofextenttowhichtheyunderstandtheirreasonsforchoosingcertainbeverages(4-pointscale:Verywell,Somewhatwell,Notverywell,Notatallwell);

• Attitudes:agreementwithstatementsthat“Consumingtoomuchsugarcanimpactmyhealth”and“Iwouldliketodrinkfewersweeteneddrinks”(5-pointscale:Stronglyagree,agree,don’tagreeordisagree,Disagree,Stronglydisagree);andextenttowhichinternalandexternalfactorsinfluencebeveragechoices(4-pointscale:Alot,Alittle,Notmuch,Notatall).

Allstudentswhocompletedboththepre-andpost-testsurveywereincludedintheanalysis.Intheanalysis,ordinalcategoricaloutcomesweretreatedascontinuousoutcomesandanalysisofcovariancewasconductedontheirchangescores,controllingforpre-testscores.Forbinaryoutcomes,generalizedestimatingequationsmodelswerefitusingprocgenmod.Allanalyseswereadjustedforgrade,gender,andrace/ethnicity,andaccountedforclusteringbyteacher.AllanalyseswereconductedusingSAS9.4.

Methodsusedtocollectteacherandstudentfeedback

TeacherandstudentinputregardingtheRYDcurriculumwaselicitedviaasurveyofandinterviewswithinterventiongroupteachersandfocusgroupswithinterventiongroupstudents.Teacherswereaskedtocompleteanonlinesurveytoprovidefeedbackonthecurriculumand

6

lessonimplementationafterteachingeachlesson.Toencouragetimelyresponse,linkstothesurveysweresenttoteachersonceaweekonthedaytheywerescheduledtoteacheachlesson.Thesurveyelicitedteacherperceptionsregardingpreparednesstoteachthelesson;organization;clarityofinstructions;timeallocation;lessonflow;appropriatenessoflearninglevel;studentengagement;appropriatenessfordiverseculturesandindividuals;modifications;andfeedbackonindividuallessoncomponents.

Inaddition,semi-structuredkey-informantinterviewswereconductedwitheachoftheinterventionteacherswithinfourweeksofcompletingthecurriculum.Theinterviewselicitedteacherperceptionsofthecurriculum,includinghowwellthecurriculummetitsoverallobjectiveofincreasingstudentknowledgeandpromotinghealthybeveragechoices,alongwithrecommendationsforimprovingthecurriculum.

Twofocusgroupswereconductedwith9thgradeinterventiongroupstudentsattwoschoolswithinthefour-weekperiodfollowingcurriculumcompletion.Participationinthefocusgroupswasonan“opt-in”basis,requiringsignedparentalconsentandstudentassent.Lettersweresenthometoparents/guardiansexplainingthepurposeofthefocusgroupsandrequestingsignedconsentforstudentstoparticipate.Studentswereinformedthattheycoulddeclineparticipationinthefocusgroupswithnonegativeconsequences.

Twenty-oneparentsprovidedconsentandthirteenstudentsagreedtoparticipateinfocusgroups(nineatoneschool,fouratanother),whichlasted23and40minutes,respectively.

Thefocusgroupstookplaceduringschoolhoursinprivateclassroomsateachschoolsite.Eachfocusgroupwasconductedbytwomembersoftheresearchteam,withonefacilitatingandtheothertakingnotesandaskingoccasionalfollowupquestions.Inaddition,aschoolstaffmemberwaspresentateachfocusgroup,inaccordancewithschoolregulations.Toreducepotentialbias,theschoolstaffmemberwasnotintimatelyfamiliarwiththestudents,satatadistancefromthefocusgroup,andworkedonunrelatedmaterial.Afocusgroupscriptwasusedtoreduceinterviewerbiasduringdiscussions.

Thefocusgroupselicitedstudents’perceptionsoftheRYDcurriculum,including:whichcomponentstheyfeltweremosteffectiveinachievingthecurriculum’sobjectives;whichactivitiestheywouldkeepiftheyweretodesignasimilarcurriculumforhighschoolstudents;howtheywouldmodifythecurriculumtomakeitmoreengaging;andthecurriculum’simpactsonstudentknowledge,attitudesandbehaviorsregardingSSBs.Participantsexandrace/ethnicitywererecordedbasedonobservation.

Thekeyinformantinterviewsandfocusgroupswereaudiorecordedtosupplementdetailednotes.Interviewandfocusgroupresultswereanalyzedusingcontentanalysis.Inadditionto

7

generalfindings,theanalysisidentifiedconcordantanddiscordantemergentthemesbetweenstudentandteacherexperiencesandperspectivesregardingRYD.

Schoolprotocolwasfollowedforon-sitevisitationduringallresearchactivities.Allresearchteammembersunderwentafingerprintscan(LiveScan);acredentialedK-12teacherwaspresentintheroomatalltimes;andschoolsign-in/sign-outprocedureswerefollowed.

Descriptionofthesampleofstudentsselected

Theinterventiongroupconsistedof2489th-12thgradestudentsineightclassroomsatthreepublichighschoolsinSacramentoandYoloCounties,CA.Thecomparisongroupconsistedof1029th-12thgradestudentsinthreeclassroomsattwopublichighschoolinSacramentoandYoloCounties,CA.Theparent/guardianofoneinterventiongroupstudentreturnedasignedletteroptingtheirstudentoutofthesurvey.Twootherstudentsdeclinedtoparticipateinthesurvey.

Threehundredforty-ninestudentscompletedapre-testsurvey(ncomparison=101,nintervention=248)and333studentscompletedapost-testsurvey(ncomparison=102,nintervention=231).Studentswhodidnotcompletebothsurveysweredroppedfromanalyses,yieldingafinalsampleof222interventionand92comparisonstudents.Therewerenosignificantdifferencesbetweeninterventionandcomparisongroupstudentswithrespecttokeydemographiccharacteristics(Table1).

8

Table1.Demographicsofstudentsininterventionandcomparisongroup,RethinkYourDrinkEvaluation,YoloandSacramentoCounties,CA,2016-17(ncomparison=92,nintervention=222) ComparisonGroup InterventionGroup p-value2

n %(SE)1 n %(SE)1GenderMale 47 51.09(7.10) 114 51.35(4.85)

0.174Female 38 41.30(4.52) 104 46.85(5.24)Other 5 5.43(2.21) 3 1.35(1.06)Missing 2 2.17(2.03) 1 0.45(0.43)Grade9th 50 54.35(27.79) 84 37.84(26.21)

0.85610th 6 6.52(6.10) 23 10.36(9.97)11th 15 16.30(13.61) 31 13.96(13.43)12th 15 16.30(13.61) 84 37.84(29.56)Missing 6 6.52(3.18) 0 0.00(0.00)Race/EthnicityMultiple 11 11.96(4.83) 47 21.17(1.73)

0.866

Asian 13 14.13(6.13) 26 11.71(7.00)Black/AfricanAmerican 5 5.43(5.08) 7 3.15(1.72)Latino 47 51.09(8.26) 108 48.65(13.24)White 14 15.22(3.06) 31 13.96(3.98)Missing 2 2.17(1.07) 3 1.35(0.60)

1Percentsadjustedforclusteringbyteacher.2Differencesincategoricalvariablesbetweencomparisonandinterventiongroupsbychi-squaretest.Boldfaceindicatesstatisticalsignificanceatp<0.05.

ImpactoftheRYDcurriculumonstudentknowledge,attitudesandbehavior

StudentsurveyfindingsregardingimpactsoftheRYDcurriculumonstudentknowledge,attitudesandbehaviorarepresentedbelow.Withrespecttoconsumptionpatterns,therewasnotasignificantdifferenceinthenumberofsugarsweetenedbeveragesconsumed,suchassoda,sportsdrinksandflavoredmilk,betweeninterventionandcomparisongroupstudents.However,theinterventionwasassociatedwithaslightbutstatisticallysignificantdecreaseinconsumptionofdietsodaaswellaswithasmallincreaseinthenumberoftypesofhealthydrinksstudentschosewheneatingout(0.19;95%CI:0.05,0.34)(Table2).

9

Table2:ImpactofRethinkYourDrinkcurriculumondietarybehaviorsregardingsugar-andnon-sugarydrinks,RethinkYourDrinkEvaluation,SacramentoandYoloCounties,2017.

InterventionGroup ComparisonGroup

Adjusted1Mean

DifferenceinChangeBetween

Interventionand

Comparison

p-value

n

Adjusted1MeanChange

(post-pre)

n

Adjusted1MeanChange

(post-pre)

(95%ConfidenceInterval)

Dietarybehaviorsinthelast24hoursConsumptionofregularsoda(containers/glasses/bottles/cans) 208 -0.10 82 0.06 -0.16

(-0.42,0.10) 0.23

Consumptionofdietsoda(containers/glasses/bottles/cans) 205 0.03 81 0.12 -0.10

(-0.18,-0.02) 0.02

Consumptionof100%juices210 0.00 82 -0.05

0.060.50

(containers/glasses/bottles/cans) (-0.11,0.22)Consumptionoffruitdrinksandfruitnectars 205 0.11 80 0.18

-0.070.52

(containers/glasses/bottles/cans) (-0.28,0.14)Consumptionofsportsdrinks

210 -0.32 83 -0.320.01

0.95(containers/glasses/bottles/cans) (-0.25,0.26)Consumptionofenergydrinks

213 -0.08 83 -0.080.01

0.93(containers/glasses/bottles/cans) (-0.09,0.10)Consumptionofflavoredmilkandmilktypedrinks 212 0.20 84 0.16

0.040.61

(containers/glasses/bottles/cans) (-0.11,0.19)Consumptionofregularplainwhitemilkormilksubstitutes 210 -0.16 84 -0.17

0.010.90

(containers/glasses/bottles/cans) (-0.20,0.22)Consumptionofreducedfatplainwhitemilk 210 -0.19 83 -0.11

-0.080.44

(containers/glasses/bottles/cans) (-0.29,0.12)Consumptionofsweetenedcoffeeandteadrinks 213 -0.10 84 -0.14

0.040.11

(containers/glasses/bottles/cans) (-0.01,0.08)Consumptionofunsweetenedcoffeeandteadrinks 209 0.11 84 0.14

-0.030.59

(containers/glasses/bottles/cans) (-0.15,0.09)

10

InterventionGroup ComparisonGroup

Adjusted1Mean

DifferenceinChangeBetween

Interventionand

Comparison

p-value

n

Adjusted1MeanChange

(post-pre)

n

Adjusted1MeanChange

(post-pre)

(95%ConfidenceInterval)

Consumptionofflavoredwaters210 -0.31 83 -0.19

-0.110.29

(containers/glasses/bottles/cans) (-0.32,0.10)Consumptionofplainwater(taporbottled) 215 0.04 84 0.15

-0.110.24

(containers/glasses/bottles/cans) (-0.30,0.08)Frequencyofdrinkingfromthewaterfountain(numberoftimes) 217 0.24 83 0.20

0.040.76

(-0.22,0.30)

Dietarybehaviors:General

Numberoftypesofunhealthydrinks2chosenatschoolcafeteria(outof5) 130 0.18 60 0.12

0.060.25

(-0.04,0.17)Numberoftypesofhealthydrinks3chosenatschoolcafeteria(outof5) 129 0.17 60 0.20

-0.030.76

(-0.25,0.18)Numberoftypesofunhealthydrinks2chosenwheneatingout(outof5) 219 0.05 84 0.05

0.001.00

(-0.21,0.20)Numberoftypesofhealthydrinks3chosenwheneatingout(outof5) 219 -0.25 84 -0.44

0.190.01

(0.05,0.34)Numberoftypesofunhealthydrinks2chosenwhenbringinglunchtoschool(outof5)

164 -0.11 70 -0.05-0.06

0.56(-0.27,0.14)

Numberoftypesofhealthydrinks3chosenwhenbringinglunchtoschool(outof5)

164 -0.12 70 0.01-0.13

0.17(-0.31,0.05)

Numberoftypesofunhealthydrinks2chosenat/broughttoschool(outof5)

212 0.13 81 0.120.01

0.89(-0.17,0.19)

Numberoftypesofhealthydrinks3chosenat/broughttoschool(outof5)

206 0.23 78 0.28-0.06

0.42(-0.19,0.08)

1Adjustedforbaseline,grade,gender,andrace/ethnicity.2Unhealthydrinksincluderegularsoda;dietsoda;fruitdrinks(not100%juice,notdiet);sweetenedcoffeeorteadrinks(notdiet);flavoredmilkormilkdrinks(hotchocolate,yogurtdrinks,smoothies).3Healthydrinksinclude100%fruitjuice;unsweetenedcoffeeorteadrinks;plainwhitemilkormilksubstitutes(soy,almond,ricemilk,etc.);bottledwater(plainorsparkling);tapwater.

11

StudentsexposedtotheRYDcurriculumreportedincreaseduseofnutrientlabelingofbeveragesascomparedtostudentsnotexposedtoit.Interventionstudentsreportedasmall,butstatisticallysignificantgreaterincreaseinthefrequencyofreadingtheNutritionFactsLabelwhenchoosingadrinkcomparedtocomparisongroupstudents(0.10;95%CI:0.03,0.17)(Table3).

Table3:ImpactofRethinkYourDrinkcurriculumonnutritionknowledgebehaviors,RethinkYourDrinkEvaluation,SacramentoandYoloCounties,2017.

InterventionGroup ComparisonGroup

Adjusted1Mean

DifferenceinChangeBetween

Interventionand

Comparison

p-value

n

Adjusted1MeanChange

(post-pre)

n

Adjusted1MeanChange

(post-pre)

(95%ConfidenceInterval)

FrequencyreadtheNutritionFactsLabel(4pointLikertscale2) 217 0.11 82 0.01

0.100.01

(0.03,0.17)FrequencyreadtheIngredientsList(4pointLikertscale2) 216 0.22 84 0.16

0.060.16

(-0.03,0.15)

AbilitytoreadNutritionFactsLabel 175 0.09 64 0.070.02

0.85(-0.20,0.25)

1Adjustedforbaseline,grade,gender,andrace/ethnicity.2All4pointscaleshavevaluesfromnever(1)-always(4).

12

TheRYDcurriculumhadlimitedeffectsonknowledgeassociatedwithself-efficacy.Interventionstudentsreportedasmallbutstatisticallysignificantgreaterincreaseintheirunderstandingofreasonsforchoosingcertainbeveragesascomparedtocomparisongroupstudents(0.19;95%CI:0.07,0.32)(Table4).

Table4:ImpactofRethinkYourDrinkcurriculumonnutritionknowledgeandself-efficacy,RethinkYourDrinkEvaluation,SacramentoandYoloCounties,2017.

InterventionGroup ComparisonGroup

Adjusted1Mean

DifferenceinChangeBetween

Interventionand

Comparison

p-value

n

Adjusted1MeanChange

(post-pre)

n

Adjusted1MeanChange

(post-pre)

(95%ConfidenceInterval)

Confidenceinabilitytoidentifyhealthybeverages 215 0.14 80 0.17

-0.030.62

(4-pointLikertscale2) (-0.16,0.10)Understandingofreasonsforchoosingcertainbeverages 215 0.29 82 0.10

0.19<0.01

(4-pointLikertscale3) (0.07,0.32)Confidenceinabilitytofindvalidhealthinformationaboutbeverages 214 0.27 81 0.38

-0.110.26

(4-pointLikertscale2) (-0.29,0.08)Understandingofdifferencebetweennaturalandaddedsugars 215 0.36 82 0.26

0.100.13

(4-pointLikertscale3) (-0.03,0.23)Numberofdrinkscorrectlyidentifiedascontainingsugar(outof4) 219 0.25 84 0.22

0.030.81

(-0.23,0.30)Numberofdrinkscorrectlyidentifiedascontainingaddedsugar(outof13) 219 -0.02 84 0.02

-0.040.78

(-0.35,0.26)Numberofingredientscorrectlyidentifiedasbeingtypesofaddedsugar(outof5)

219 0.38 84 0.070.31

0.10(-0.06,0.68)

Numberofhealthconditionscorrectlyidentifiedasresultofconsumingalotofsugar(outof5)

219 0.17 84 0.21-0.05

0.70(-0.28,0.19)

1Adjustedforbaseline,grade,gender,andrace/ethnicity.2Valuesfromnotatallconfident(1)–veryconfident(4).3Valuesfromnotatallwell(1)–verywell(4).

13

TheRYDcurriculumhadnosignificantimpactsonstudentattitudesregardingconsumptionofsugarandsugarydrinks(Table5).

Table5:ImpactofRethinkYourDrinkcurriculumonattitudesregardingconsumptionofsugarandsugarydrinks,RethinkYourDrinkEvaluation,SacramentoandYoloCounties,2017.

InterventionGroup ComparisonGroup

Adjusted1Mean

DifferenceinChangeBetween

Interventionand

Comparison

p-value

n

Adjusted1MeanChange

(post-pre)

n

Adjusted1MeanChange

(post-pre)

(95%ConfidenceInterval)

Agreementwithstatement:Iwouldliketodrinkfewersweeteneddrinks 198 0.06 74 -0.04

0.100.32

(5-pointLikertscale2) (-0.10,0.30)Agreementwithstatement:Consumingtoomuchsugarcanaffectmyhealth 215 0.04 80 0.03

0.010.91

(5-pointLikertscale2) (-0.13,0.15)1Adjustedforbaseline,grade,gender,andrace/ethnicity.2Valuesfromstronglydisagree(1)–stronglydisagree(5).

StudentsreceivingtheRYDcurriculumreportedchangesintheinfluenceoftwofactorsaffectingbeveragechoice.Theinterventionwasassociatedwithsmallbutsignificantdecreasesintheself-reportedamountofinfluenceofnumberofcaloriesinadrink(0.17;95%CI:0.11,0.23)aswellasbeverageadvertisements(0.18;95%CI:0.12,0.24)onbeveragechoice(Table6).

14

Table6:ImpactofRethinkYourDrinkcurriculumonfactorsinfluencingbeveragechoice,RethinkYourDrinkEvaluation,SacramentoandYoloCounties,2017.

InterventionGroup ComparisonGroup

Adjusted1Mean

DifferenceinChangeBetween

Interventionand

Comparison

p-value

n

Adjusted1MeanChange

(post-pre)

n

Adjusted1MeanChange

(post-pre)

(95%ConfidenceInterval)

Taste211 0.02 81 -0.01

0.030.39

(4-pointLikertscale2) (-0.04,0.10)Cost

209 0.20 81 0.170.03

0.67(4-pointLikertscale2) (-0.12,0.18)Whatfriendsdrink

210 0.20 79 0.190.02

0.80(4-pointLikertscale2) (-0.11,0.15)Whatfamilydrinks

211 0.13 80 0.070.07

0.38(4-pointLikertscale2) (-0.08,0.21)Amountofsugarinthedrink

208 0.19 80 0.090.10

0.10(4-pointLikertscale2) (-0.02,0.23)Numberofcaloriesinthedrink

210 0.01 80 -0.160.17

<0.01(4-pointLikertscale2) (0.11,0.23)Whetherthedrinkishealthy

210 0.11 81 0.010.09

0.34(4-pointLikertscale2) (-0.10,0.28)Adsforthedrink

210 0.15 80 -0.030.18

<0.01(4-pointLikertscale2) (0.12,0.24)Whetherthedrinkgivesenergy

209 0.51 80 0.400.11

0.14(4-pointLikertscale2) (-0.04,0.26)Whetherthedrinkhasvitamins,minerals,orprotein 210 0.11 80 -0.01

0.120.21

(4-pointLikertscale2) (-0.07,0.31)Whetherthedrinkhelpsconcentrate

207 0.25 80 0.38-0.13

0.17(4-pointLikertscale2) (-0.31,0.06)Whetherthedrinkhelpsstayhydrated

211 0.22 79 0.24-0.02

0.82(4-pointLikertscale2) (-0.21,0.17)

1Adjustedforbaseline,grade,gender,andrace/ethnicity.2Valuesfromalot(1)–notatall(4).

15

SynthesisoffeedbackfromteachersandstudentsregardingimplementationoftheRYDcurriculum

Theteachersurveyandinterviewsandstudentfocusgroupselicitedperceptionsofthecurriculumandrecommendationsforimprovements,includingthesekeyfindings:

Teachersfeltpositivelyaboutthecurriculum.Theteachersagreedwiththefollowingstatementsregardingeachofthelessons:“Thetrainingadequatelypreparedmetoteachthislesson,”“Ifeltadequatelypreparedtoteachthislesson,”and“TheContentStandardshelpedidentifythelesson’sfitwithgrade-levelinstructionrequirements.”Teachersbelievedthatthelessonswerewell-alignedwithlearningobjectives.Nearlyallteachersfeltthelessonswere“very”or“somewhat”well-alignedwiththelearningobjectivespresentedforeachlesson.Allteachersreportedthatthenutritioneducationcompetencieshelpedthemunderstandthelesson’sfitwithhealtheducationcontentstandards.Teachersdidnotimplementallcomponentsofthecurriculum.Duetolackoftimeand/orreluctancetoburdenstudentswithadditionalhomework,teachersconsistentlyreportedthattheydidnotincorporatethelastcomponentsofthecurriculum,includingthe“CoolDown,”“CheckforLearning”and“Extension/Links.”Futureversionsofthecurriculummaywishtoconsideromittingthosecomponents,particularlyconsideringthateventeachersreceivingastipendinthispilotstudydidnotimplementthem.Teachersandstudentsbelievethatthecurriculumwouldbemosteffectivewithyoungerstudents.SomestudentsfeltthattheRYDcurriculummightbemoresuitableformiddleorelementarystudents,notingthathighschoolstudentshaveingrainedhabitsthatmaybehardtobreak.Astudentexplainedthat,“wealreadyhave...habitsand...can'treallybreakthem.”SomestudentsalsoreportedlearningthesameinformationfoundintheRTYDcurriculuminmiddleschool.Astudentcommentedthat,“thelearningwaskindofrepetitivebecause...in[middleschool]HealthSciencethey...alreadyteachyouthis...soIstillrememberit.”Thatwascorroboratedbyateacher,whofeltthecurriculum“wouldbebetterforamiddleschoollevel,”notingthat“alotofstudentssaidtheyalreadylearnedthisinhealth[class].”Werethecurriculumobjectivesachieved?Studentsreportedbeneficialchangesinknowledge,includingawarenessofnutritionfactslabels.Focusgroupparticipantsreportedincreasedawarenessoftheimpactofsugarydrinks.Forexample,onesaidtheRYDcurriculumhelps“peoplerealizehowmuchsugar...affectsyourbody.”Studentscitedincreasedabilitytoreadnutritionfactslabelsandcalculatetheamountofsugarinbeverageswithonesaying,forexample,“Icanread…thenutritionlabeleasierandcalculatehowmuchsugarisin[abeverage].”

16

Increasedstudentknowledgewasnotalwaysassociatedwithbehaviorchange.Onefocusgroupparticipantsaid:“I'lllookatthenutritionlabel,butIjustlikefiguringouthowmuchsugarisinitforfun;I'llstilldrinkit.”(AsimilarphenomenonwasreportedbyJensenatal.,xwhofoundincreasedreadingofnutritionfactslabelswithnochangeintheuseoflabelingtochoosefooditems.)Behaviorchangeoccurred,butonalimitedscale.Asmallnumberoffocusgroupparticipantsreportedbehaviorchanges,includingdrinkinglowerfatmilkathome,drinkingmorewaterandchoosingsmallerportionsofsugarydrinks.Asmallnumberoffocusgroupstudentsalsoreportedaskingtheirparentstostopdrinkingsodaandtopreparehealthybeveragesfromtherecipecardsprovidedaspartofthecurriculum.TeacherinterviewsandstudentfocusgroupsprovidedspecificfeedbackoneachofthefourRethinkYourDrinklessonsLesson1A:“LearningtheFactsCards”and“LearningtheFactsBingo”Moststudentsandteacherspraisedthesocialcomponentandinteractivenatureofthislesson,butmanystudentswerealreadyfamiliarwiththeinformationitprovidedandfeltthe“LearningtheFacts”cards’contentcouldbeimprovedbyprovidingadditionalfactsaboutSSBs.Further,somestudentswereconcernedthattheinformationprovidedinLearningtheFactsBingosimplyrestatedfactsalreadypresentedbytheLearningtheFactsCards.While3ofthe4teachersinterviewedpraisedthefactthatstudentsgotoutoftheirseatsandmovedaroundfortheseactivities,oneteacherhadreservationsaboutmovementaroundacrowdedclassroom.Lesson1B:“HowMuchSugar”WhenassessingLesson1B,studentsandteachersfocusedonincreasesinknowledgeaboutthesugarcontentofvariousbeverages.TheyagreedthatthetactileandvisualaspectsofthislessonsuccessfullyreinforcedtheRYDmessage.StudentsfeltthisactivitywasimpactfulbecauseitallowedthemtovisuallyseeandfeeltheamountsofsugaractuallycontainedinSSBs.Forexample,onesaid:“Ilikeditwhenliketheyshowedtheactualsugarscubes.Thatactuallyhelpedmeseelikehowmuchsugarisactuallyinit.”Teachersalsoappreciatedthatstudentscould“touchandfeelsugarcubes.[The]kidswerelike‘Wow.’[It]hithomewiththem.”Lesson2A:“WhatAreMyInfluences”Thisactivity,designedtoidentifyandevaluateinfluencesthataffectfoodandbeveragechoices,waswell-receivedbybothstudentsandteachers.Asastudentexplained,“Ilikedthat[activity]...becauseitmadeusrealize...whatinfluencesus.”Teachersfeltstudentsfoundtheactivityengagingbecauseitallowedthemtodiscusstheirpersonallives.Ateacherexplainedthat“formanystudents,thisactivityisthefirsttimethattheywereaskedtoconnecthowthey

17

areinfluencedtohowtheseinfluencesaffecttheirchoices.Theyenjoyedtalkingabouttheirlifeandreasonswhytheychoosecertaindrinks.”Anothernotedthatstudents“reallygotintoitandtalkedaboutfamilyandhowtheymakecertainchoices…andunderstandandfeelthepressureswhenaroundotherfriends.”Lesson2B:“DecisionMakingProcess”(withconsiderationofLesson2A’s“AssessingMyDrinkOptions”homeworkassignment)and“ChooseaHealthyDrinkChallenge”Thegoalofthislessonwastoidentifyandevaluatevariedinfluencesonfoodandbeveragechoices.Studentandteacherresponsestoboth“DecisionMakingProcessandthe“ChooseaHealthyDrinkchallenge”weremixed.“Decision-MakingProcess,”inwhichstudentsconsideredresponsestothe“AssessingmyDrinkOptions”homeworkassignment,wasnotverywellreceivedbysomestudents.Theyfoundthedecision-makingprocessoverlycomplexwithrespecttowhattheyfeltwasarelativelystraightforwardchoicebetweenhealthyandunhealthybeverages.Teacherscorroboratedstudentdislikeofthisactivity,notingthatitfeltredundantwithotherlessons.Asoneteachernoted,“As11thand12graders(16-18[yearsold]),theywerepoliteaboutmyinstructions,butseemedabitbored.”Thiswasechoedbyanotherteacher,whofeltthat“itwaskindofaboringlesson.Lotsofmetalkingatthemandthenaworksheettheydidbythemselves.Thestudentswerenotasintoitastheotherlessons.”However,a9thgradeteachersaidthatstudentsfoundthisactivitychallenging,andrecommendedthathavingtwoorthreeconcretecompleteexamplesusingthestepsintheDecisionMakingModelwouldbeveryhelpful.”Anotherteacherrecommended“bringout[the]beveragelabelsagain.Bringoutimagesofvariousbeveragesandsay,‘Sowhichoneareyougoingtochoosenow?’.”Teachersalsofelttheinstructionsneedtoprovidemoreexplanationofterminology.Studentsandteachersalsoexpressedmixedopinionsaboutthe“ChooseaHealthyDrinkChallenge”activity.Studentssuggestedthattheactivityshouldincludesettingsbeyondtheschoolenvironment.Asoneexplained:“Weonlyhavelikethreedrinksatschool:chocolatemilk,milk,andwater,so…itwasabithardtoanswerthequestion,‘Which[drink]would[you]choose?’whenthere’s[notmuchtochoosefrom].”StudentsandteachersfeltthatLesson2Bcouldpotentiallybeeliminatedfromfutureversionsofthecurriculum.Asateacherexplained,“Iwouldn’tteach[Lesson2B]again….Itwasboringandfeltredundantforalotoftheinformationinthislesson.Ithinkbynowtheyhavelearnedwhataregoodandwhatarepoorbeveragechoices.”Teachersandstudentsprovidedseveralconcreterecommendationsforimprovingthecurriculum.Theseincluded:• Reducingthecurriculumtothreelessons(1A,1Band2A).

18

• Improvingflowbydesigningthecurriculumasasingleunittobetaughtoverseveralconsecutivedaysratherthanseveralweeks,allowingteacherstocontinueteachingincompleteactivitiesthefollowingday.

• Targetingyoungerstudentstopreventtheadoptionofunhealthyhabitsthatmaybecomeingrainedbyhighschool.

• IncludingPowerPointtypeslides(whichseveralteachershaddevelopedontheirown)tomakethecurriculummoreengagingforstudentsandeasierforteacherstoimpart.

• Providinghealthydrinksforstudentstosample,greateruseoftechnologyandonlineactivities,moregames,andmoreopportunitiesforsocialinteraction.

Studystrengthsandlimitations

Studystrengthsincludeapre-postdesignwithbothaninterventionandacomparisongroupandtheuseofmixedqualitativeandquantitativemethodstoelicitteacherandstudentfeedbacktoinformmodificationsoftheRYDcurriculum.TeachersandstudentsprovidedarangeofrecommendationsformodifyingtheRYDcurriculuminareasincludinglessonorganization,appropriatenessoflearninglevel,timeallocationandstudentengagement.Thisstudyalsohadseverallimitations.Interventionandcomparisongroupteachersreceivedastipendforparticipationintheresearch,whichmayhaveinfluencedcurriculumimplementationandmayhavealsoledtosocialdesirabilitybias,resultinginmorepositivesurveyresponsesthanmighthaveotherwisebeenthecase.Theprovisionofstipendsandthein-persontrainingoftheteachersmaylimitthegeneralizabilityofthefindings,giventhatisitnotlikelythatthesecomponentswouldbefeasibleshouldthecurriculumbeimplementedonalargerscale.Thelimitednumberofteacherswhowerewillingtoparticipatealsolimitedthegeneralizabilityoftheirexperiencewiththecurriculum.Limitationsofthefocusgroupsincludepossibleself-selectionbias.

ImplicationsforFutureEffortsThelimitedimpactoftheRYDcurriculumonthekeyoutcomesofinterest,i.e.studentintakeofsugarydrinksandhealthyalternativessuggeststhatthatthiscurricularapproachaloneisinsufficienttoachievebehaviorchange.ThisisconsistentwiththeSNAP-Edtheoryofchange,whichpositsthatacombinationofeducationalapproaches,policysystemsandenvironmentalchange,andsocialmarketingarerequiredtoachieveconsistentandenduringbehaviorchange.Furthermore,studentsandteachersalikenotedthatsomeofthecurriculumwasredundantwithlessonsreceivedinearliergradesandthatingeneralthismaterialismorelikelytohaveimpactwithyoungerstudents,whosehabitsmaybelessengrained.Severalsuggestionsweremadeforimprovingthelessons,eliminatinglesswell-receivedcomponents,andrestructuringandshorteningthecurriculumtoincreasefeasibilityandreceptivityonthepartofstudentsandteachers.Thesefindingssuggestthatthecurriculumshouldbe:1)revisedinaccordancewith

19

thesuggestedfeedbackdescribedinthereport;2)implementedwithcomplementaryPSEandsocialmarketingapproaches;and3)thatafterthesemodificationsaremadethecomprehensiveinterventionshouldbeevaluatedexactlyasitisintendedforlargescaledissemination,i.e.withoutcomponentssuchasstipendsandin-persontrainingwhicharenotfeasibleforwidespreadprogramimplementation.Furthermore,PSEapproachescouldbeevenmoreimpactfuliftheyweretoincludethebroadercommunitywherestudentslive.Thisistrueparticularlyinareaswhereschoolshavealreadyimplementedstrongsugarsweetenedbeverageschoolpolicieslimitingstudentacquisitionoftheseproducts.

20

REFERENCESCITED

iU.S.DepartmentofAgricultureandU.S.DepartmentofHealthandHumanServices.DietaryGuidelinesforAmericans,2010.7thEdition,Washington,DC:U.S.GovernmentPrintingOffice,December2010.iiKeihnerAJ,LinaresAM,RiderCD,SugermanS,MitchellPR,Hudes,M.Education,DietandEnvironmentalFactorsInfluenceSugar-SweetenedBeverageConsumptionAmongCaliforniaChildren,Teens,andAdults.Sacramento,CA:CaliforniaDepartmentofPublicHealth;2012.iiiBall,S.,Cohen,A.,&Meyer,M.(2012).Jumpintoaction.JournalofExtension[On-line],50(3),Article3FEA4.Availableat:http://www.joe.org/joe/2012june/a4.php.RetrievedJanuary16,2018.ivRider,C,Johnson-Arthur,C,Linares,A.(2015).RethinkYourDrink:YouthInterventionSuccessesandaCalltoAction.Posterpresentedatthe2015ChildhoodObesityConference,SanDiego,CA.NutritionPolicyInstitute,UniversityofCalifornia,DivisionofAgricultureandNaturalResources,Oakland,CA.vRider,C,Johnson-Arthur,C,Linares,A.(2015).RethinkYourDrink:YouthInterventionSuccessesandaCalltoAction.Posterpresentedatthe2015ChildhoodObesityConference,SanDiego,CA.NutritionPolicyInstitute,UniversityofCalifornia,DivisionofAgricultureandNaturalResources,Oakland,CA.viJensen,B.,Kattelman,K.,Ren,C.,&Wey,H.(2009).TheefficacyofKidQuest:anutritionandphysicalactivitycurriculumfor5thand6thgradeyouth.JournalofExtension[On-line],47(3),Article3FEA4.Availableat:https://www.joe.org/joe/2009june/a4.php.RetrievedJanuary16,2018.viiWikes,N.(2007).Theinfluenceofclassroomeducationonbeverageselectioninchildren.InMastersAbstractsInternational(Vol.46,No.04).RetrievedJanuary16,2018.viiihttps://www.cde.ca.gov/be/st/ss/documents/healthstandmar08.pdf.RetrievedJanuary23,2018.ixhttps://www.cde.ca.gov/ls/nu/he/documents/nergch1.pdf.RetrievedJanuary23,2018.xJensen,B.,Kattelman,K.,Ren,C.,&Wey,H.(2009).TheefficacyofKidQuest:anutritionandphysicalactivitycurriculumfor5thand6thgradeyouth.JournalofExtension[On-line],47(3),Article3FEA4.Availableat:https://www.joe.org/joe/2009june/a4.php.RetrievedJanuary16,2018.