A Service Learning Program in Providing Nutrition Education to Children

Content Organization and Preparation

The service-learning program, titled “Kids Eat Healthy,” is conducted in the second semester of the first year of the pharmacy curriculum as part of the required 2-credit Pharmacist Provided Care course. The project was well-planned with a simple curriculum that would allow students to serve, educate, and care for members of the community in a relatively low-risk setting. The nutrition information in the course is basic but important for the students to learn and allows them an avenue to provide care at a point in the curriculum when drug knowledge is minimal.

One faculty member from the school of pharmacy coordinated the service-learning project in collaboration with a registered dietitian with the Sarasota County Schools Food and Nutrition Services. The registered dietitian organized the logistics for the project, identified the 3 schools and specific classes that would receive the presentations, and created an assignment schedule. The 3 schools were chosen based on the relatively high number of students at those schools who received free or reduced priced lunches compared to that number at other schools in the district. This was done to target lower socioeconomic students who are believed to be at higher risk of becoming overweight or obese.

Development, implementation, delivery, and assessment of this project required approximately 80 hours of the faculty and dietitian's time in addition to the time invested by the dietitian in instruction.

Pharmacy Student Training

The registered dietitian developed and presented weekly nutrition lectures to students at the pharmacy school. After each of the 4 presentations, she gave the lesson plans for presenting the material to elementary school children to the pharmacy students. The first lecture delivered to the pharmacy students reviewed the purpose of the service-learning experience, the basics of the food pyramid, and serving sizes appropriate for each food group. The second lecture focused on balance and portion sizes, and the breakdown of nutrition labels. The third lecture covered healthy snacking, diabetes basics, and examples of healthy snacks and portion sizes; pharmacy students also completed a fast-food worksheet in which they had to calculate the total calories and fat contained in their favorite fast-food meal. The final lecture introduced the “go, slow, and whoa foods”¹⁷ guidelines for grocery shopping, and facts about organic foods. In addition to the lesson content, pharmacy students were trained in how to best interact with young children in a classroom setting. Through a coordinated effort with the instructor of the Effective Communications course in which the pharmacy students also were enrolled, students received a 2-hour lecture on the developmental levels of children, different teaching methodologies, and best practices for communicating with children.

The nutrition lessons taught by the registered dietitian and the communication lectures used the first 4 stages of Bloom's Taxonomy: knowledge, comprehension, application, and analysis.¹⁸ The comprehension stage was addressed through assignments and examinations designed to ensure that retention of knowledge was achieved by the pharmacy students. The application stage was accomplished by the students teaching the nutrition lesson plans in the elementary schools, where the students were able to apply the knowledge that was taught in the classroom. The analysis stage was accomplished through students’ pre- and post-experience reflections, which were incorporated into the required course assignments. The reflections asked the students questions such as, “How as a future pharmacist do you envision yourself promoting healthy behaviors in your patients?” and “Do you think you had an impact on the elementary school students, and what impact did the elementary school students have on you?”

Implementation in Elementary Schools

On the days of the student presentations in the schools, one or more faculty members and the registered dietitian served as liaisons between the pharmacy students and the assigned school. Two to 3 pharmacy students were assigned to each of the selected kindergarten through third grade classes. Using visual aids, educational videos, games, homework sheets, and a food tasting experience (Table 2), the students presented the nutrition lessons in 30-minute sessions, once a week for 4 weeks. The students returned to the same class each week to allow them to build a rapport with the children.

Pharmacy Student Survey

At the beginning of the service-learning experience, a pre-experience survey instrument was administered to the pharmacy students to measure their perceived attitudes, skills, and knowledge. The same survey instrument was administered at the end of the experience to measure the program outcomes. Part one was a 7-question instrument designed by the pharmacy faculty members and used a 5-point Likert scale ranging from strongly agree to strongly disagree. Statements such as “I am comfortable talking with children between the ages of 5 and 8,” and “I believe that I will have/had a significant impact on elementary students through the ‘Kids Eat Healthy’ program” were asked. Part two was a 14-question instrument, which used a 3-point Likert scale ranging from “quite a lot” to “not at all.” Students were asked to rate their perceived improvement on statements relating to knowledge, skills, and attitudes.

Participation in the survey was a required component of the course, and credit was given for completion. The surveys were administered online via SurveyMonkey.com (SurveyMonkey, PaloAlto, CA), which allowed students’ responses to remain anonymous. The research protocol was submitted to LECOM's Institutional Review Board and approved under exempt status.

The Mann-Whitney rank sum test was used to evaluate the difference between the pre- and post-experience survey scores. Data were entered into SigmaStat 3.0 (Aspire Software International, Ashburn, VA) for statistical analysis. A p of less than 0.05 was considered significant.

Ninety-six pharmacy students completed the pre- and post-experience survey instruments. The results are presented in Tables 3 and 4. On part I of the post-experience survey, greater than 90% of students agreed or strongly agreed that they had achieved the specific objectives for the activity. Among the general professional skills assessed, students rated “feeling a sense of community responsibility” and “taking responsibility as a healthcare provider” the highest. Students’ scores on items related to skills sets and community service were significantly higher on the post-experience survey, while scores on items related to students’ belief systems did not change significantly. On part II of the survey, students’ scores on items relating to talking with sick people or those of different cultures, interacting with difficult people, and showing empathy were significant between pre- and post-experiences; however, students perceived their participation in the activity as only “somewhat” related to these skills. The item on which students’ perceived they had improved the most from pre- to post-experience was time management. Students felt that their attitudes regarding “taking responsibility as a health care provider” and “feeling a sense of community responsibility” improved quite a lot (79% and 83% respectively on the post-experience survey. Two-thirds of the class thought their ability in “communicating verbally” was improved “quite a lot” by the service-learning program.

In response to the post-experience reflection questions, 1 pharmacy student stated that, “this experience has been very helpful and valuable in allowing me to work on communicating effectively with young children and speaking on a level of their understanding. It was also very helpful to have the nutritionist come in to teach and prepare us for our lessons, since teaching is a new experience for most of us.”

In regards to the impact the students felt that they had through this program, one student reported “the children definitely had a significant impact on me. Children can learn and grasp ideas so proficiently it truly amazed me. It was great to see them following along when we were doing the quizzes we gave them. I feel like we also had a notable impact on them as well. Every time we would come back after first working with them, the children were excited to see us. We would talk about things that we covered in past classes and they were able to reiterate every detail we had talked about.”

Tests of Elementary School Children

Prior to beginning the first lesson in each of the selected elementary school classes, the pharmacy students administered a pre-experience test to the children. At the end of the fourth lesson, a post-experience test was administered to the children. The test asked the children to match specific foods to the correct food groups as defined by the United States Department of Agriculture's (USDA's) MyPyramid. For example, one question asked them to identify which of the following would be included in the vegetable group: broccoli, carrots, grapes, pasta, spinach, and Swiss cheese. (The test is available at the MyPyramid.gov Web site, as part of a lesson plan targeted for children in first and second grade.)

An identification number created by the school system's registered dietitian was assigned to each elementary school student to protect the children's’ identity from the researchers. The Wilcoxon signed-rank test was used to evaluate the difference between the pre- and post-test scores for the elementary school children. Eighty-six students’ tests were excluded from analysis because the elementary student did not complete both the pre- and posttest.

Four hundred sixty-eight elementary school students completed the pre- and posttests. More kindergarten classes were represented in the study population because all three of the schools chosen had kindergarten classes participate, but the other grades were not represented at every school. The results are presented in Table 5. Knowledge of food group matching improved among students in all grade levels, with kindergarten students improving by 3.2 points, first grade improving by 2.8 points, second grade improving by 3.4 points, and third grade improving by 2.0 points. The baseline average score in order from kindergarten to third grade was 60%, 63%, 71%, and 81%. The percentage of students in each grade level whose test scores improved by 10% or more is as follows: kindergarten, 61%; first grade, 55%; second grade, 58%; and third grade, 40%. When the results were analyzed according to the food groups, the third grade group did not make significant improvement with the items for the vegetable group, and they also showed a decline in performance in the milk group. Overall, the third grade group had the least improvement compared to the other groups; however, they also had the smallest sample size.