Running head: A FAMILY NUTRITIONAL COLLABORATIVE

Community Health Project Paper Part II:

The Community Foodbank: A Family Nutritional Collaborative

Eskedar Asamnew, Danielle Beard, Katie Harris, Charlotte Harrison, Amanda Hawley, Kerri

Healy, Ashley Montoya, Angela Nelson, Shivanee Sathia, Chelsea Weaks

Old Dominion University

Community Health Project Paper Part II:

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The Community Foodbank: A Family Nutritional Collaborative

Nurses and healthcare providers play an essential role in providing education regarding

adequate nutrition and healthy lifestyle habits in adults and children. Although nutrition

education is often provided to individuals, familial nutritional education occurs infrequently,

which can lead to a knowledge deficit regarding the benefits of healthy eating and how to cook

with fresh fruits and vegetables. With this in mind, our community health group chose to create

food cards that were specifically designed for families, including adults and young children.

Each card consisted of nutritional information about a specific fruit or vegetable, its health

benefits, as well as a simple recipe. The goal of this project is to provide adults and children with

nutritional information that they can utilize at home to make healthier food choices and discover

new ways to incorporate common fruits and vegetables into their diets.

Planning

Identified Health Problem

The Sentara Norfolk General Hospital Community Health Needs Assessment (2016)

describes needs throughout the Virginia Beach, Norfolk, Chesapeake, Portsmouth, and Suffolk

communities by conducting surveys in these Sentara Hospital service areas. Of this population,

79% of the adults older than eighteen years of age are at risk for having less than five servings of

fruits and vegetables a day (Sentara Norfolk General Hospital, 2016). In addition, 24% of

children ages 10-14 and only 8% of children 14-19 met CDC’s recommended guidelines for fruit

and vegetable intake (Sentara Norfolk General Hospital, 2016). Those who were surveyed stated

that they believed some of the biggest health problems in their community were “healthy eating,

access to care, [and] prevention and early detection” (Sentara Norfolk General Hospital, 2016, p.

81). In the study, 27% of the total participants selected “Food Safety Net (e.g. food bank,
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community gardens, school lunches, etc.)” as a main community service that needed

improvement (Sentara Norfolk General Hospital, 2016, p. 83). This suggests that current

interventional programs such as the Foodbank alone is not enough to inherently address

nutritional deficits in the community. Food insecurity is defined as “a lack of consistent access to

enough food for an active, healthy life” (Feeding America, 2018, p. 2). In the state of Virginia,

10.6% of the population is food insecure, which is slightly less than the United States, which has

a food insecurity rate of 12.9% (Conduent Healthy Communities Institute, 2018a). According to

Conduent Healthy Communities Institute (2018a), 19% of the population in Norfolk, Virginia are

categorized as food insecure which is actually 10% higher than in its sister city Virginia Beach.

The Foodbank of Southeastern Virginia and the Eastern Shore are members of Feeding

America and are committed to eliminating hunger and food insecurity in the Hampton Roads

area by providing nutritious meals through numerous food outreach programs. The annual

statement from 2015-2016 reports that the Foodbank was able to provide over 15 million meals

to those who were hungry and food insecure (Foodbank, 2016). Through the BackPack Program,

the Foodbank filled 62,379 bags of food for 3,473 students, 1.4 million pounds of food was

delivered through Mobile Pantries, and the Kids Cafe fed 2,200 children (Foodbank, 2016).

Although there are programs in place to address this food insecurity, we saw that there was a

need for a resource to inform those receiving aid of proper nutrition. We realize that those who

are food insecure may not always select certain fruits or vegetables because they are unsure of

how to cook or eat them.

Priority Nursing Diagnosis

After assessing our selected aggregate and identifying a main health problem, we

determined the priority nursing diagnosis to be deficient knowledge. As we reviewed the

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objectives for Healthy People 2020, we chose a few that we wished to focus on. These include

the following: “NWS-14: Increase the contribution of fruits to the diets of the population aged 2

years and older [and] NWS-15: Increase the variety and contribution of total vegetables to the

diets of the population aged 2 years and older” (Healthy People 2020, 2018, para.5). Though

these goals set by Healthy People 2020 are objectives for the nation as a whole, the information

gathered through our assessment and research support that this is also a local issue. The Norfolk

Community Health Improvement Plan outlines key health issues within the multiple districts of

Norfolk, highlighting the need for nutritional education for the general public as many

individuals simply do not know how to cook healthy foods (Toxcel, 2017). Multiple members of

our group attended the Foodbank’s Mobile Pantry to volunteer and handed out food to those in

need. We observed many reported cases in which individuals from the community would refuse

to take certain food products, especially fresh produce, because they did not know how to

prepare it, store it, or otherwise utilize the food product. Other identified barriers that contribute

to this knowledge deficit are lack of access to informative materials and educational programs or

the underutilization of available community resources (Toxcel, 2017). Whether this is due to the

lack of education, access to health care, or awareness of nutrition supporting programs, it is

obvious that the population as a whole has a deficit in knowledge.

Objectives and Measurable Outcomes

We established several measurable outcomes, based on the Healthy People 2020

objectives and our nursing diagnosis, in order to evaluate how our educational intervention

would affect the deficit of knowledge in the community. The goals of Healthy People 2020

created based on the nutrition and weight status of the community are in general to increase the

variety and consumption of both fruits and vegetables (Healthy People 2020, 2018). This can be
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further broken into clearer, more focused outcomes to address the multiple components that

would contribute to the increase in the consumption of produce. First, we hope that our

intervention would stimulate an increase in knowledge of the benefits of consuming fruits and

vegetables. Second, we would also like to see an increase in the knowledge of how to properly

store and prepare fruits and vegetables. Third, clients that receive the nutritional education

should verbalize their satisfaction or concerns with the information and amenities provided. This

supports our overarching goal to increase the number of individuals that utilize available

resources in the community due to greater awareness and a better understanding of their purposes

or support. Lastly, an increase of those who consume and receive fruits and vegetables from the

Foodbank would also be noted. In order to measure these objectives, a survey could be created to

assess knowledge, attitudes, and fruit and vegetable intake among the Norfolk community before

and after the implementation of our intervention.

Intervention

Implementation

Our intervention would be considered a primary intervention, as it aims to prevent

disease or injury before it occurs. It serves to teach the population about what eating healthy

entails and how to achieve it. We started developing an intervention based off of three food card

prototypes that were made by nursing students in another community health group. These food

cards all provided information on broccoli, but the presentation of the information varied in

format, font, and recipes. The food cards were designed to educate the reader on the nutritional

facts of broccoli including why they should eat it, how it should be stored and prepared, and

what time of the year it should be bought. Each card also included a recipe in order to make the

incorporation of that food item simpler within a meal. A survey conducted by Produce for Better
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Health Foundation (PBH) (2017) identified these pieces of information as motivators for

including fruits and vegetables into their diet.

Using a food card evaluation survey that had already been approved through the ODU

Institutional Review Board (IRB), we would determine which food card prototype was preferred.

The evaluation survey included questions about whether the cards were easy to read, if the

instructions were easy to follow, if the information would help the reader use the food, if they

liked the design of the card, and whether they would use the card at home. All these questions

were asked for each of the three food cards on a numeric scale of 1 to 5. There was also a space

on the evaluation survey for participants to include feedback regarding any parts of the cards that

we had not specifically addressed.

Each member of our group printed out the three prototype food cards and numerous

evaluation surveys and collected data within the community. Collectively, we compiled the

results from a total of 78 completed surveys. All the responses were organized into an excel

spreadsheet to evaluate which card had the most favorable ratings in each category. By averaging

all of the numeric scores for each card, we found that “prototype 1” was preferred in every

category. As this prototype was favored by our population, the food cards we developed were

modeled after that prototype’s design

Our intervention was supported by the Population Health Learning Hubs Grant which is

supported by the American Association of Colleges of Nursing and the Centers for Disease

Control. The funding from that grant included the production of six food cards for distribution to

the Foodbank. As we originally intended to address nutrition education in children, we decided

to create 10 food cards, three of which would be designed for the pediatric population. We

altered the formatting slightly for the kids cards to include pictorial anchors and instructions with
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simplified vocabulary. Five fruits and five vegetables were chosen based upon our observations

that recipients would choose not to take certain items because they were not sure how to prepare,

store, or cook with them. Based on those experiences, we chose items that would be available

from the Foodbank. As a group, we each picked one of the fruits or vegetables and compiled

helpful nutritional information and a recipe about each food product. In the survey conducted by

PBH (2017), 41% of the sample strongly agreed that a hurdle to consumption of fruit and

vegetables was unfamiliarity with the foods and how to prepare them. The goal of these food

cards is to make these unfamiliar foods less intimidating and to encourage families to incorporate

new fruits and vegetables into their food preparation for their family.

Supporting Research

Liu, Stephenson, Houlihan, & Gustafson (2017) were interested in determining which

marketing strategies might positively influence the health choices of residents in counties with

high obesity rates. They launched a social marketing campaign in 17 grocery stores in five rural

counties in Kentucky and collected 240 participant surveys (Liu et al., 2017). Interventions

included relocating high-calorie options to side aisles, promoting health options through food

samples and recipe cards, and offering promotional discounts on fruits and vegetables (Liu et al.,

2017). By analyzing and evaluating the participant surveys, the researchers determined that the

recipe cards directly influenced the participants’ frequency of fruit and vegetable consumption

(Liu et al., 2017). While all interventions implemented in this study show promise and can

contribute to influencing positive health choices, the recipe cards were well received and proven

effective.

While Liu et al. (2017) examined ways to intervene in grocery stores, another study

conducted by Nour, Rouf, & Allman-Farinelli (2018) assessed the use of a much different
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platform, social media and mobile-gaming. Utilizing the COM-B framework model, researchers

developed a prototype smartphone application to monitor vegetable intake alongside attainable

daily and weekly consumption goals (Nour et al., 2018). Researchers also tested the effectiveness

of sending a series of push notifications that provided motivational messages describing the

health benefits of consuming vegetables and tips on implementing vegetable substitutes in

everyday recipes (Nour et al., 2018). In addition to utilizing the smartphone application, 32

young adults also participated in five focus groups in the greater Sydney area of Australia to

further determine knowledge, preferences and behaviors (Nour et al., 2018). Among this

aggregate, nutritional knowledge was identified as a target area for future intervention, as only 2

out of 32 participants correctly identified a serving amount of vegetables (Nour et al, 2018).

Upon further evaluation, researchers determined that 50% of the participants believed receiving

recipes would help them consume more vegetables (Nour et al, 2018). Tips on how to integrate

vegetables into everyday foods and the use of videos demonstrating how to prepare the

vegetables were also well-received (Nour et al., 2018). While a smartphone application would

not be a suitable platform for some targeted populations, the delivery of nutritional education and

the use of recipes were still highlighted as ways to improve vegetable consumption.

A randomized controlled trial performed by Gans et al. (2018) in 15 subsidized housing

sites examined the impact of a year-long multilevel intervention on fruit and vegetable intake.

Nutritional education interventions were paired with the implementation of discount, mobile fruit

and vegetable markets in the targeted areas (Gans et al, 2018). Part of the nutritional education

intervention included sending participants educational materials to include 48 recipe cards (Gans

et al., 2018). Researchers determined that 27% of the experimental group participants used all of
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or most of all the recipe cards received, while 47% reported using some of the recipes (Gans et

al., 2018). Moreover, higher increases in fruit and vegetable intake were seen in those who tried

most or all recipes provided as opposed to those who used few or none of the recipes provided

(Gans et al., 2018). This study not only highlights the efficacy of providing nutritional education

to improve fruit and vegetable intake, but also addresses the financial burden and accessibility

issues that can come with purchasing these items.

In a review article by Glanz and Yaroch (2004), the authors examined supermarket-based

and community environmental, policy, and pricing strategies for increasing intake of fruits and

vegetables. They performed an extensive search of published journal articles, reports, and

inquiries to leaders in the field to identify strategies, examples, and research on how to increase

fruit and vegetable intake in grocery stores and communities (Glanz & Yarloch, 2004). They also

gathered input from participants in the CDC/ACS-sponsored Fruit and Vegetable, Environment

Policy and Pricing Workshop held in September of 2002 (Glanz & Yarloch, 2004). They

identified four key types of grocery-store-based interventions which included point-of-purchase

(POP) information on healthy food options; reduced prices and coupons for fruits and

vegetables; increased availability, variety, and convenience; and promotion and advertising of

fruits and vegetables (Glanz & Yarloch, 2004). These four interventions modestly increased the

purchase and consumption of fruits and vegetables (Glanz & Yarloch 2004). Additionally, they

suggested that church-based programs, child care center policies, and multi-sectoral community

approaches show promise in influencing eating behaviors (Glanz & Yarloch 2004). Importantly,

all of the grocery store interventions are feasible and are not difficult to implement.
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In 2017, Tobey et al. published their findings on how the Food Hero social marketing

campaign recipe project affected eating behaviors (Tobey et al., 2017). Created by the Oregon

State University Extension Service, the Food Hero social marketing campaign was designed to

increase fruit and vegetable (FV) consumption of Oregon residents eligible for Supplemental

Nutrition Assistance Program (SNAP) (Tobey et al., 2017). The FV-focused recipe project

strategically formulates and shares recipes to help families and food service sites successfully

access and prepare healthy recipes (Tobey et al., 2017). Recipes are delivered to the target

population through a Web site, social media, media buys in grocery stores, and online (Tobey et

al., 2017). The impact of the Food Hero recipe project was measured using tasting assessments in

schools where more than 50% of children qualified for free and reduced meals, parent recipe

surveys completed by parents/caregivers of those children, and web measurement tools (Tobey et

al., 2017). The researchers examined outcomes over the course of four years, from 2012-2015

(Tobey et al., 2017). The results of the study demonstrated that 79% of parents and caregivers

reported that their children talked about what they had learned in school about healthy eating,

and 69% reported that their children asked for specific recipes (Tobey et al., 2017). It also

showed that 72% of parents and caregivers also reported making at least one Food Hero recipe

(Tobey et al., 2017). In addition, 53% made changes in the foods their family ate and 14%

bought foods that were different from their usual routine (Tobey et al., 2017). Impressively, over

four years, recipe page views on the campaign website increased by 1,728% (>290,735), recipe

comments from online users also increased by 125% (>625), and website–based Pinterest pins

also increased 7,922% (>235,000) (Tobey et al., 2017). This study demonstrated that the Food
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Hero social marketing and recipe program has positively impacted fruit and vegetable

consumption among low-income children and families.

Barriers

We ran into some barriers while working to implement nursing interventions for the

Kids’ Cafe in Diggstown. Originally, our plan was to attend the Diggstown campus throughout

the fall semester to implement the interventions developed and instituted by ODU Nursing Class

of 2018. Unfortunately, several barriers including miscommunications, unclear expectations, and

an unyielding timeline prohibited us from meeting with the administration or the students in the

community at Diggstown. Since we were unable to implement our nursing interventions at

Diggstown, we worked to develop a new intervention that could be implemented through the

Foodbank, which had been our main community partner during the summer semester. The

Foodbank had determined a need for informative index cards describing different fruits and

vegetables, their nutritional value, as well as a simple recipe so that patrons could easily prepare

the foods they had received. Because our initial intent was to develop and implement

interventions for children at Diggstown, we decided to make half of our fruit and vegetable cards

to be age-appropriate for younger chefs-in-the-making. We included the same nutritional

information on the front of the card but then used picture anchors with accompanied simplified

instructions to make the information more accessible to younger users. We did find the

formatting of each individual card to be more difficult than anticipated, as the adult cards are

bulleted lists but the children’s cards include pictorial anchors that accompany the instructions.

Organized laterally across the back of each card, these pictorial anchors are kid-friendly and will

hopefully encourage parents to cook with their children.

Evaluation
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Plan for Evaluation

As stated in our interventions, the IRB approved survey was distributed to a variety of

individuals in the local community to evaluate three food card prototypes that were developed by

a fellow community health group. We were able to collect and analyze this data and were

therefore successful in completing this part of the intervention. The next step was to create ten

food cards catered toward the adult population. Our group chose various fruits and vegetables

similar to the fresh produce available at the Food Bank. We chose rutabagas, sweet potatoes,

zucchini, and mangoes because we found that they were often left over at mobile food pantries or

at the Foodbank. We also included strawberries, pineapples, blueberries, apples, and red bell

peppers as they are more popular produce items. However, after a more thorough assessment of

the community’s needs, we chose to make three of the ten food cards applicable to children. The

three kids’ cards consisted of information about zucchini, red bell peppers, and mangoes. To

ensure that these cards were appropriate for children, we included simple recipe instructions with

fewer ingredients as well as step-by-step pictures that followed the recipe’s guidelines.

We were successful in creating the food cards in time to meet the deadline for production.

The final cards are in the process of being professionally printed and we anticipate that they will

be distributed at the Foodbank by the end of December 2018. We hope these cards will

eventually be provided at mobile pantries, the Foodbank marketplace, Kids’ Cafe locations, and

other events. As referenced in the objectives section of this paper, our expected outcomes

included increased educational knowledge, an increase in the utilization of community resources,

such as the Foodbank, as well as an increased understanding of how adequate nutrition impacts

overall health. However, because the food cards have not been printed nor distributed, we cannot

evaluate if the expected outcomes of this intervention were met at this time.
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Alternative Interventions

The following suggestions are alternative interventions and were not implemented

throughout our semester. One alternative intervention would target the younger population by

playing food group games. This intervention would help increase the children’s knowledge on

the five different food groups: fruits, vegetable, dairy, grains, and lean meats/poultry. A

matching game could be utilized in which the child would be asked to match a food with its

correct name, food group, storage and a listed benefit of the food group. The games would be

played three times with the same group of children and the results would be recorded based on

their performances on each round. After the third game, we would reassess their performance

with the goal of finding an increased knowledge on the different food groups. An additional

alternative intervention would be to present fruits and vegetables on an aesthetically appealing

plate or bowl. According to the Canadian Journal of Public Health (2013), children prefer foods

that are presented in colorful and decorative wraps because they rely more on aesthetics. This

data encourages parents to make their fruits and vegetables visually appealing to their children.

This intervention would involve encouraging the parents to track the number of slices or pieces

of fruits their child consumes and the percentage of vegetables consumed. Lastly, we believe it is

important to provide parent teaching surrounding the nutritional information of certain meals, as

nutritional education of parents could be a barrier to education of the child aggregate. Therefore,

an alternative intervention could include conducting an in-person lesson or providing printed

notes with instruction for parents who cannot participate in the in-person teaching session. We

would hope by improving the education of parents this would affect the knowledge and food

habits of their children. We recommend these alternative interventions as we feel that they would

complement our primary intervention of the food cards.

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Recommendations

During the semester, we were able to successfully create the ten food cards and provide

them for printing. To move this project forward, the food cards must be provided to the

Foodbank along with recommendations for their use. We suggest the cards be linked to the

distribution of the items they describe. For example, at a mobile pantry when providing bags of

frozen blueberries, the Foodbank could also include a food card with that fruit and recipe for its

use. This would be a more effective way of making sure the information is supplied to families

than simply having the cards available when someone asks for them. This would be especially

important for fresh fruits or vegetables since they must be used before they expire. This project

has many opportunities for continuation by subsequent groups of students. One such

continuation may be to develop alternate cards that have different recipes for different seasons

and multiple recipes for one fruit or vegetable. For example, replacing one recipe for popsicles

that is popular in the summer with an option for a warm meal in the winter.

Additional recommendations for evaluation would include a further investigation into the

efficacy of the kid’s food cards. While our aggregate was intended to focus on children with food

insecurity, we ultimately approached the nutrition education and encouraged healthier choices by

educating both adults and children. The available literature focuses primarily on food or recipe

card usage, but does not address the optimal format to communicate or provide this information.

As such, we recommend evaluating the format further, especially the newly developed kids

cards. Alternative options to tailor the food cards to children include creating placemats with the

food information, holding cooking classes for the children to create the recipes on the food cards,

and evaluating the phrasing of the food cards to ensure the content is at an appropriate reading

level. These would be beneficial to better revise and refine the existing food cards.
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Finally, providing these cards as a piece of a larger nutritional education program would

be a reasonable approach to better integrate their usage and create an increased rate of usage.

These cards can be utilized differently and would need to be evaluated in each of these settings

to determine their applicability and worth the cost of their production.

Implications

The use of food cards in our community was intended to create an improved knowledge

base and a wider array of food options for the people in our community who face food insecurity.

These cards will be used to directly educate the public, and while we do not have any discrete

evaluations at this point, the provision of access to this information is intended to enable our

aggregate to make informed decisions. Ideally, that would include an increase in their

consumption of fruits and vegetables; however, if we only provided additional access, this is a

successful move toward empowering their decisions. The goal is for these cards to broaden the

aggregate’s ability to utilize all of the food that is available to them and to do so in a way that is

satisfactory to their families.

Limitations

Due to time constraints and the various barriers previously discussed, we were unable to

complete the original intervention we planned to implement at Kids Cafe this fall. Therefore, we

were not able to utilize both semesters to fully expand and implement our modified educational

intervention. A major limitation of our food card project is that the semester is over and we are

therefore unable to evaluate the outcomes. Since the cards are in the process of being printed and

distributed at the Foodbank, we cannot yet determine the effectiveness of the cards. Further

limitations include challenges often faced by new research studies, such as small sample size,
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potential inaccurate responses due to misinterpretation of survey questions, “design problems,

and weakness in collection procedure” (Fain, 2015, p. 275).

Conclusion

It is our hope that educational intervention through food cards will positively influence

the food choices of our aggregate population. We believe that these food cards for both kids and

adults will not only increase the aggregate’s nutritional knowledge on certain fruits and

vegetables, but also allow for utilization of the produce that is available to them. We have laid a

foundation for future nursing students to continue our intervention by evaluating the efficacy of

the food cards. Future nursing students can expand upon these cards and facilitate the

distribution of the food cards. As nurses, one of our main priorities is to care for the patient

holistically in order to promote overall health. The promotion of proper nutrition is necessary in

improving the individual’s food choices and supporting his or her overall health. Hopefully,

these interventions implemented on the individual and familial level will lead to a healthier

overall community.
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References

Conduent Healthy Communities Institute. (2018a). Food insecurity rate for Norfolk,

Virginia. Retrieved from

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Conduent Healthy Communities Institute. (2018b). Food insecurity rate for Virginia Beach,

Virginia. Retrieved from

http://www.ghrconnects.org/index.php?module=indicators&controller=index&action=vie

w&indicatorId=2107&localeId=3002&periodId=271

Elliott, C. D., Hoed, R. C., & Conlon, M. J. (2013). Food branding and young children's taste

preferences: A reassessment. Journal of Canadian Public Health, 104(5): e364-e368.

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Feeding America. (2018). What is food insecurity? Retrieved from

https://hungerandhealth.feedingamerica.org/understand-food-insecurity/

Foodbank of Southeastern Virginia and the Eastern Shore. (2016). Leading the effort to eliminate
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hunger in our community. Retrieved from https://foodbankonline.org/wp-

content/uploads/2018/01/dcve.pdf

Gans, K. M., Risica, P. M., Keita, A. D., Dionne, L., Mello, J. , Stowers, K. C., Papandonatos,

G., … & Gorham, G. (2018). Multilevel approaches to increase fruit and vegetable intake

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Glanz, K., & Yarloch, A. L. (2004). Strategies for increasing fruit and vegetable intake in

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Medicine,39(2), 75-80. doi:10.1016/j.ypmed.2004.01.004

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Liu, E., Stephenson, T. Houlihan, J., & Gustafson, A. (2017). Marketing strategies to encourage

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Nour, M. M., Rouf, A. S., & Allman-Farinelli, M. (2018). Exploring young adult perspectives on

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vegetable intake. Appetite, 120(1), 547-556. doi: 10.1016/j.appet.2017.10.016

Produce for Better Health Foundation. (2017). 2017 fruits and vegetables survey: Preliminary

findings on consumer consumption, detractors and drivers, and message implications.

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[PowerPoint slides]. Retrieved from

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Manore, M. M. (2017). Can healthy recipes change eating behaviors? The food hero

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Retrieved from https://www.norfolk.gov/DocumentCenter/View/31480.

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Honor Statement
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“I pledge to support the Honor System of Old Dominion University. I will refrain from any form

of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a

member of the academic community it is responsibility to turn in all suspected violators of the

Honor Code. I will report to a hearing if summoned.”

Names: Eskedar Asamnew, Danielle Beard, Katie Harris, Charlotte Harrison, Amanda Hawley,
Kerri Healy, Ashley Montoya, Angela Nelson, Shivanee Sathia, & Chelsea Weaks

Signatures: Eskedar Asamnew, Danielle Beard, Katie Harris, Charlotte Harrison, Amanda Hawley, Kerri
Healy, Ashley Montoya, Angela Nelson, Shivanee Sathia, & Chelsea Weaks

Date: December 14, 2018