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RESEARCH AND PROFESSIONAL BRIEFS

dentification of factors affectingurchasing and preparation of fruit andegetables by stage of change for low-ncome African American mothers usinghe think-aloud method

ELEN HENRY, MS, RD; MARLA REICKS, PhD, RD; CHERY SMITH, PhD, MPH, RD;

ATHY REIMER; JANINE ATWELL, MS; RUTH THOMAS, PhD

BSTRACT

he objective of this study was to identify factors affecting the purchase and prep-ration of fruits and vegetables according to stage of change for low-income Africanmerican women with young children. The think-aloud method was used to collecterbalization data in grocery stores as women shopped (N�70) and in their homesuring meal preparation (N�68). Audiotaped verbalizations were transcribed ver-atim before encoding. Content analysis procedures were used to identify commonhemes by stage of change. Factors affecting decision making that varied by stagef change were preferences and specific needs (eg, for meals, for family members).references regarding variety, quantity, color, and liking were more often ex-ressed by women in later stages. Women in the later stages also often used meal-lanning skills to include fruits and vegetables in meals. Interventions could be tai-

ored according to selected factors regarding purchase and preparation of fruitsnd vegetables by stage of change to contribute to greater changes in intake. J Am

he protective role of fruits and vege-tables against chronic disease is sup-ported by epidemiologic and clinical

vidence (1-4). Chronic diseases such asancer and heart disease are more prev-lent among minorities compared withhites (5), although intake of fruits andegetables are lower than recommended

H. Henry is a graduate student, M. R

ociate professor, and K. Reimer is a g

cience and Nutrition, University of M

arent educator for the Early Childho

or the Anoka-Hennepin Independent

ime the work was completed she was

ork, Family and Community Educat

N, and R. Thomas is a professor, Dep

ity Education, University of Minneso

Address correspondence to: Marla R

nce and Nutrition, University of Min

5108. E-mail: mreicks@umn.edu

Copyright © 2003 by the American D

0002-8223/03/10312-0008$30.00/0

doi: 10.1016/j.jada.2003.09.039

or low-income and African Americanroups (6,7).The Transtheoretical model is a frame-

ork that has been used to addresseadiness to modify lifestyle behaviors,ncluding diet (8). The stages of changes a central construct defining a series ofteps through which behavior changes

ks is a professor, C. Smith is an as-

uate student, Department of Food

nesota, St. Paul, MN; J. Atwell is a

Family Education (ECFE) Program

ool District (ISD) District 11, at the

raduate student in the Department of

, University of Minnesota, St. Paul,

tment of Work, Family and Commu-

St. Paul, MN.

ks, PhD, RD, Department of Food Sci-

ota, 1334 Eckles Ave, St Paul, MN

tetic Association.

q

Journal of THE A

re made progressing from not thinkingbout changing to making and maintain-ng the change for more than 6 months.revious studies used traditional meth-ds to identify factors affecting fruit andegetable consumption in African Amer-can populations that relied on retro-pective responses (9-11) and wereased on the stages of change (12-13).his study uses the think-aloud method

o capture verbalizations of thoughtsade concurrent with task performance

14). The think-aloud method has previ-usly been used in studies involving cog-itive interviewing related to vocationalducation and dietary intake (15-19).articipants are instructed to fully ver-alize all thoughts concurrent with taskerformance. It is thought that thisethod can produce a more accurate rep-

esentation of the salient factors that are inocal attention when decisions are made.

The ability to study decision-making inhe context in which decisions are made14) represents a novel way to explainifferences in intake between women inarlier versus later stages of change. Theurpose of this study was to explore thealient factors that influenced fruit andegetable selection and incorporationnto meals using the think-aloud methodith a group of low-income African Amer-

can women according to stages of changeor increasing fruit and vegetable intake.

ETHODSow-income African American women

iving in the Minneapolis–St. Paul, MNrea were recruited via social service or-anizations and advertisements. Womenere included in the study if they identi-ed themselves as African American, hadchild under the age of 12 in their home

or whom they were the major person re-ponsible for acquiring and preparingood, lived in the United States for 15ears, were 18 to 45 years of age, andndicated that they were eligible for oner more of the following types of publicssistance: Special Supplemental Nutri-ion Program for Women, Infants, andhildren (WIC), food stamps, welfare,

ree or reduced-priced school meals forhildren, or food shelves. The study waspproved by the University Institutionaleview Board: Human Subjects Protec-

ion Committee. Participants were givenift certificates for groceries.About 10 to 18 women were recruited

nto each of the five stages of change forncreasing fruit and vegetable intake.articipants completed a food frequency

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MERICAN DIETETIC ASSOCIATION / 1643

(20) to estimate fruit and vegetable in-take. Based on estimated intake, womencompleted a staging algorithm to assesstheir readiness to increase fruit and veg-etable intake (21). Women were in-structed to say everything they werethinking as they selected groceries dur-ing a routine shopping trip and prepareda meal in their homes. Verbalizationswere recorded using a mini-cassette taperecorder in a small purse with a lapel mi-crophone. The investigator walked withthe woman as she shopped in the store orsat close by as she prepared the meal athome. Standardized nonleading promptswere used as needed to encourage con-tinued verbalization. A few brief ques-tions were asked before and after thethink-aloud session about typical shop-ping, meal preparation, and eating hab-its, and reflective questions about the ex-perience. Participants were asked toshop for and prepare their food in theirnormal manner.

Data were collected from 67 women infive large-scale discount grocery storespreferred by women as their usual storesand from 65 women in their homes. Twoparticipants could not be reached toschedule the home meal portion of thestudy. A pilot test had previously beenconducted with 12 participants to testand refine the procedures. Data fromthree women in the pilot test were usedin the final data analysis so that therewere 10 to 18 women per stage (N�70for purchasing and N�68 for meal prep-aration).

Audiotapes were transcribed verba-tim. Text related to fruits and vegetableswas encoded according to categoriesthat emerged from the data based on fac-tors considered in decision-making. Cod-ing was done independently by twoinvestigators, and differences were rec-onciled before entry into a database soft-ware program (File Maker Pro5; 1997–1999, Filemaker Inc., Santa Clara, CA).Coded units of text (8,907 total) weresorted by stage of change and coding cat-egories. Data were analyzed for recur-ring themes using content analysis pro-cedures (14,22). Common themes andrepresentative quotes were identified.Analysis of variance was used to detectdifferences in demographic characteris-tics by stage of change (P�.05) (Statis-tical Analysis System; version 6.12, SASInstitute Inc., 2001, Cary, NC).

RESULTS AND DISCUSSIONThe average age of participants was 32years (Table 1). The majority were single

mothers with two to three children, andwere high school graduates or had somepostsecondary training. All indicatedthat they received public assistancethrough WIC, welfare, food stamps, freeor reduced-price school meals for theirchildren, or food shelves. There were nodifferences by stage for any demographicvariables. Intake of fruit and vegetableswas higher as each stage advanced, fromabout three servings per day in the earli-est stage to about nine in the last stage(P�.0001).

Major factors influencing decisionmaking associated with fruit and vegeta-ble purchasing and preparation werepreferences, cost, and specific needs andwants for different fruits and vegetables.Other important factors included avail-ability, seasonality, appearance, conve-nience, nutrition/health, advice fromothers, and spoilage concerns.

Many participants verbalized theirpreferences regarding family likes anddislikes (eg, child) or preferred charac-teristics of fruits and vegetables (eg,fresh vs frozen). Those in the later stages(preparation, action, maintenance) gavegreater consideration to the quantity de-sired for meal planning and type of fruitsand vegetables (eg, Macintosh vs Brae-burn apples). Women in later stages con-sidered using a variety of fruits and veg-etables to avoid repetition. They alsospoke more often of using specific vege-tables to add color to make meals moreappealing and using color as an indicatorof quality compared with women in ear-lier stages. Women in later stages oftencommented that they liked specific fruits

and vegetables because they werehealthy foods. In a previous cross-sec-tional study with young adults, Ma andcolleagues (23) found that food prefer-ences were more important factors influ-encing the decision to consume morefruits and vegetables for those in the con-templation and preparation stages com-pared with the precontemplation stage.From these studies, it is apparent thatindividuals in more advanced stages maypay more attention to food preferences.

Participants expressed specific needsand wants for different fruits and vegeta-bles in regard to purchasing, meal plan-ning, and preparation. This involvedneeds for certain meals or snacks, use inrecipes or dishes, and use for themselvesor family members. Women in laterstages made greater use of lists contain-ing fruits and vegetables. They also moreoften expressed a need for fruits andvegetables to include in meals. Women inlater stages paid greater attention to theneeds and wants of children in relation tofood purchasing and meal preparationand made more comments about the useof fruits and vegetables for snacks.

Women in the later stages made morecomments about factors involved in mealplanning. For example, the availability offruits and vegetables in the home influ-enced meal planning and preparation.When planning meals, they were alsolikely to consider family preferences,avoiding boredom in evening meals, andquantities needed for their family. Inbaseline studies involving stage ofchange and intake of fruits and vegeta-bles by African American church mem-bers or women participating in WIC(24,25), self-efficacy and social supportwere positively associated with greaterintake in later stages. In this study, it wasshown that women in the later stages ingeneral had more skills and positive ex-periences with meal planning to includefruits and vegetables, which could con-tribute to greater self-efficacy. Women inthe later stages also seemed to havemore concerns about nutrition and spe-cific health issues such as the relation-ship between fruits and vegetables, pes-ticides, food safety issues, immunefunction, and disease prevention.

A limitation in the use of the think-aloud method is that the presence of theinvestigator could have caused partici-pants to alter their behavior or providesocially desirable responses. Precautionswere taken to minimize this bias by care-fully training investigators to be nonjudg-mental during the data collection period.

Table 1Demographic characteristics of participantsa

Age (years as mean�SD) 32�7Number of children (mean�SD) 2.4�1.4Adults in household, % (N)One 66% (45)Two 28% (19)Three or more 6% (4)Education, % (N)Up to 8th grade 2% (1)Some high school 16% (11)High school 27% (18)Some college or technical school 51% (35)College graduate 4% (3)Public assistance, % (N)WIC 42% (26)Food stamps 40% (25)Welfare 38% (24)Free or reduced-price school meals 40% (25)Used food shelves 10% (6)

aN�68 participants completing the meal prepara-tion in the home.

RESEARCH AND PROFESSIONAL BRIEFS

1644 / December 2003 Volume 103 Number 12

After the food purchasing and meal prep-aration activities, most women reportedthat the presence of the investigator wasnot influential in changing their behav-iors or verbalizations. Recruitment meth-ods resulted in a convenience sample,which limits generalizability to a largergroup of African American women.

APPLICATIONS■ The results of this study provide logicalexplanations for differences in intake offruits and vegetables by stage. There-fore, the findings could be used to matchneeds of this group to nutritional coun-seling or education to modify eating pat-terns and practices involving providingfruits and vegetables to families. Tomove individuals through the continuumof dietary behavior change, dietitianscould use specific behavioral advicebased on constructs of the Transtheo-retical model, such as skills-based pro-grams for those in preparation and actionstages and motivational counseling forthose in earlier stages.

References1. Appel L, Moore T, Obarzanek E, Vollmer W,Svetkey L, Sacks F, Bray G, Vogt T, Cutler J,Windhauser M, Lin-P-H, Karanja N, for the Dash

Collaborative Research Group. A clinical trial ofthe effects of dietary patterns on blood pressure.N Engl J Med. 1997;136:1117-1124.2. Van Duyn M, Pivonka E. Overview of the healthbenefits of fruit and vegetable consumption for thedietetics professional: Selected literature. J AmDiet Assoc. 2000;100:1511-1521.3. Steinmetz K, Potter J. Vegetables, fruit, andcancer prevention: A review. J Am Diet Assoc.1996;96:1027-1039.4. van’t Veer P, Jansen MC, Klerk M, Kok FJ.Fruits and vegetables in the prevention of cancerand cardiovascular disease. Public Health Nutr.2000;3:103-107.5. US Department of Health and Human ServicesResources. Healthy People 2010: National HealthPromotion and Disease Prevention Objectives.Available at: http://www.health.gov/healthypeople/Publications/. Accessed October 22, 2003.6. US Department of Agriculture, Agricultural Re-search Service. Data Tables: Food and NutrientIntakes by Race. 1994-1996. ARS Food SurveysResearch Group, August 1998. Available at: http://www.barc.usda.gov/bhnrc/foodsurvey/home.htm.Accessed October 22, 2003.7. US Department of Agriculture, Agricultural Re-search Service. Data Tables: Food and NutrientIntakes by Income. 1994-1996. ARS Food SurveysResearch Group, February 1999. Available at:http://www.barc.usda.gov/bhnrc/foodsurvey/home.htm. Accessed October 22, 2003.8. Prochaska J, Velicer W. The transtheoreticalmodel of health behavior change. Am J HealthPromotion. 1997;12:38-48.9. Goldberg J, Rudd R, Dietz W. Using 3 datasources and methods to shape a nutrition cam-paign. J Am Diet Assoc. 1999;99:717-722.10. Devine C, Wolfe W, Frongillo E, Bisogni C.Life-course events and experiences: Association

with fruit and vegetable consumption in 3 ethnicgroups. J Am Diet Assoc. 1999;99:309-314.11. Treiman K, Freimuth V, Damron D, Lasswell A,Anliker J, Havas S, Langenberg P, Feldman R.Attitudes and behaviors related to fruit and vege-tables among low-income women in the WIC pro-gram. J Nutr Educ. 1996;28:149-156.12. Campbell M, Demark-Wahnefried W, SymonsM, Kalsbeek W, Dodds J, Cowan A, Jackson B,Motsinger B, Hoben K, Lashley J, Demissie S,McClelland J. Fruit and vegetable consumptionand prevention of cancer: The Black ChurchesUnited for Better Health Project. Am J PublicHealth. 1999;89:1390-1396.13. Havas S, Anliker J, Damron D, Langenberg P,Ballesteros M, Feldman R. Final results of theMaryland WIC 5 A Day promotion program. Am JPublic Health. 1998;88:1161-1167.14. Ericsson K. Protocol Analysis: Verbal Reportsas Data. Cambridge, MA: MIT Press; 1993.15. Fredelius G, Sandell R, Linqvist C. Who shouldreceive subsidized psychotherapy? Analysis ofdecision-makers’ think-aloud protocols. QualHealth Res. 2002;12:640-656.16. Fonteyn M, Fisher A. Use of think-aloudmethod to study nurses’ reasoning and decisionmaking in clinical practice settings. J NeurosciNurs. 1995;27:124-128.17. Cooke B. Mental Processes and StructuresUnderlying Expertise in Problem Solving. Minne-apolis, MN: University of Minnesota; 1988. PhDdissertation.18. Anderson KL. A Comparison of Structure ofKnowledge and Thinking Processes in Relation toPerformance Differences Among Experts, Interme-diates, and Novices in Solving Housing SelectionProblems. Minneapolis, MN: University of Minne-sota; 1989. PhD dissertation.19. Thompson F, Subar A, Brown C, Smith A,

Table 2Major factors influencing decision making according to stages of changea

Factorb General themes: later stages comparedwith earlier stagesc

Representative quotes

Preferences Greater consideration of quantity neededGreater consideration of varieties and use of

colorLiking fruits or vegetables that were healthy

“I like broccoli a lot. I am a vegetable person. I think broccoli is so healthy . . . broccoli,cauliflower.”

“I love cabbage. It’s a very good nutritious source of food too.”“They eat a lot of fruit. I just didn’t get any today. I have to go somewhere to get it

cause that was too high. Cause they will go through a bag of apples a day.”“The mustard greens. I am going to get a couple of those. That will be enough for me

and my son.”“I like the Gala apples cause they’re—they’re a lot fresher than the rest and they look a

lot better. So, I get about four of them. We eat about one to one and a half per day.”Specific

needsGreater use of lists containing fruits and

vegetablesMore often expressed a need for fruits and

vegetables to include in mealsMore consideration of the needs and wants

of children

“I always have vegetables or something to go with that, always.”“I love fish sticks with mashed potatoes. And I love cucumbers and I wanted to make

that a side dish.”“We do need a bag of celery sticks. It’s on the list so I’m getting it.”“They have fruits in their lunch for every lunch.”“I promised. I’ve got to get carrots for my son.”

Health andnutrition

Greater concern about nutrition issues andother more specific health issues

“I have high blood pressure and I’m on high blood pressure medication and they makeit a demand for me that I eat a lot of fruit.

So, I try to do that.”“I have to get a lot of green leafy vegetables because being anemic I need them. I

really need them.”“I am really looking at buying healthier foods for them because my girl, my infant is so

chunky right now.”“We try to stick with something that at least has vitamin C in it so we can get

nutrients.”

aRefers to decision-making involved in fruit and vegetable purchasing and preparation.bMajor factors influenced by stage of change.cSubjects in the later stages of change (preparation, action, maintenance) were more likely to express these attitudes and behaviors when selecting andpreparing fruits and vegetables.

RESEARCH AND PROFESSIONAL BRIEFS

Journal of THE AMERICAN DIETETIC ASSOCIATION / 1645

Sharbaugh C, Jobe J, Mittl B, Gibson J, Ziegler R.Cognitive research enhances accuracy of food fre-quency questionnaire reports: Results of an exper-imental validation study. J Am Diet Assoc. 2002;102:212-225.20. National Cancer Institute Risk Factor Monitor-ing and Methods Branch, Division of Cancer Con-trol and Population Sciences. National Institutes ofHealth Eating at America’s Table Study QuickFood Scan. Available at: http://riskfactor.cancer.gov/diet/screeners/fruitveg/allday.pdf. AccessedOctober 24, 2003.21. National Institutes of Health BehaviorChange Consortium. Stages of Change (5 ADay). Available at: http://www1.od.nih.gov/behaviorchange/measures/PDF/5daystg.pdf.Accessed October 24, 2003.22. Miles MB, Huberman AM. Qualitative DataAnalysis. 2nd ed. Thousand Oaks, CA: Sage;1994.

23. Ma J, Betts NM, Horacek T, Georgiou C, WhiteA, Nitzke S. The importance of decisional balanceand self-efficacy in relation to stages of change forfruit and vegetable intakes by young adults. Am JHealth Promotion. 2002;16:157-166.24. Campbell M, Symons M, Demark-WahnefriedW, Polhamus B, Bernhardt J, McClelland J, Wash-ington C. Stages of change and psychologicalcorrelates of fruit and vegetable consumptionamong rural African-American church members.Am J Health Promotion. 1998;12:185-191.25. Havas S, Treiman K, Langenberg P, Balles-teros M, Anliker J, Damron D, Feldman R. Factorsassociated with fruit and vegetable consumptionamong women participating gin WIC. J Am DietAssoc. 1998;98:1141-1148.

Funded by USDA-CSREES 00-35200-

9064.

Food handling behaviors of specialimportance for pregnant women, infantsand young children, the elderly, andimmune-compromised peoplePATRICIA KENDALL, PhD, RD; LYDIA C. MEDEIROS, PhD, RD;

VIRGINIA HILLERS, PhD, RD; GANG CHEN, PhD; STEVE DIMASCOLA

ABSTRACT

This study used a Web-based Delphi process with a group of nationally recognized foodsafety experts to identify food-handling behaviors of special importance in reducing therisk of foodborne illness among pregnant women, infants and young children, elderlypeople, and people with compromised immune systems because of disease or pharma-cologic therapy. Behaviors were related to 13 pathogens. Top-rated behaviors for preg-nant women were associated with Listeria monocytogenes, Toxoplasma gondii, andSalmonella species. Top-rated behaviors for infants and young children, elderly peo-ple, and immune-compromised people were associated with a number of differentpathogens. The results should help dietetics professionals and community health edu-cators focus their efforts on those behaviors of special importance to the populationbeing targeted. J Am Diet Assoc. 2003;103:1646-1649.

A ll population groups widely knownfor being at high risk for foodborneillness are collectively character-

ized by suppressed immune function,whether because of age (the very youngor very old), reproductive status (preg-nancy), pharmacologic therapy (chemo-therapy, organ transplantation), or dis-ease (human immunodeficiency virusinfection) (1). Together, these groupsrepresent approximately 20% of theAmerican population (1,2).

Although each of these high-riskgroups is immune suppressed or com-promised, they differ in the length oftime that immune function is affectedand in the source of the physiologic in-sult on the immune system. During preg-nancy, alteration of cellular immunefunction leads to increased susceptibilityto intracellular infections, most notablytoxoplasmosis and listeriosis (3). Amongelderly people, age-associated decreasesin humoral and cellular immunity, age-related changes in the gastrointestinaltract, malnutrition, lack of exercise, en-try into nursing homes, and excessiveuse of antibiotics are all factors that maycontribute to increased morbidity andmortality from foodborne-induced gas-troenteritis (4). Long-term immunesuppression may also occur because ofdiseases such as acquired immunodefi-ciency syndrome (AIDS) or from drugtherapies used to treat disease or to pre-vent tissue rejection (5). Further com-promise is associated with poor nutri-tional status that is either primary to thetissue wasting associated with diseasestates, as in AIDS or late-stage cancer, orsecondary to anorexia caused by thera-peutic agent action (6,7).

Education is essential in reducingcases and outbreaks of foodborne ill-nesses that continue to occur among allconsumers, but is of particular impor-tance for those at greatest risk of food-borne illness. Although all food safetyguidelines are important, there may besome that have special importance fortargeted audiences, either because offood consumption practices or greatervulnerability to specific pathogens (8).The objective of this study was to de-velop consensus among experts con-cerning behaviors of special importancein reducing the risk of foodborne illnessamong four high-risk groups: pregnantwomen, infants and young children, el-derly people, and people with compro-mised immune systems because of dis-ease or pharmacologic therapy.

P. Kendall is a professor and extension specialist, Department of Food Sci-

ence and Human Nutrition, Colorado State University, Fort Collins, CO. L. C.

Medeiros is an associate professor, The Ohio State University, Columbus, OH.

V. Hillers is an extension food specialist, Department of Food Science and Hu-

man Nutrition, Washington State University, Pullman, WA. G. Chen is a re-

search associate, Social Science, and S. DiMascola is an instructional de-

signer, The Ohio State University, Columbus, OH.

Address correspondence to: Patricia Kendall, PhD, RD, Department of Food

Science and Human Nutrition, Colorado State University, Fort Collins, CO

80523-1571. E-mail: kendall@cahs.colostate.edu

Copyright © 2003 by the American Dietetic Association.

0002-8223/03/10312-0009$30.00/0

doi: 10.1016/j.jada.2003.09.027

RESEARCH AND PROFESSIONAL BRIEFS

1646 / December 2003 Volume 103 Number 12