The Effectiveness of Promoting a Vegetable and Fruit Consumption Behavior Program among Preschool Children in Nakhon Si Thammarat Province, Thailand

Abstract

This study aimed to design a program for promoting fruit and vegetable consumption behaviors among preschool children based on a domestic social support framework, with the goal of increasing their fruit and vegetable intake. This quasi-experimental study involved a set sample of preschool children and their caregivers who were randomly selected based on specific inclusion criteria. The study included 96 pairs of preschool-aged children and their caregivers, divided into experimental and control groups. The experimental group received the program, while the control group continued with their regular activities. The program development drew inspiration from the caregiving practices in Muang District, Nakhon Si Thammarat. The assessment tools included a preschooler’s eating behavior evaluation and a knowledge test for caregivers regarding children’s fruit and vegetable consumption and the ways to enhance it. Furthermore, experts approved the fruit and vegetable eating behavior assessment among the preschoolers, and a handbook for nurses and primary caregivers affirmed their suitability within the caregiver support framework. The developmental findings suggested that a 10-week program was appropriate and showed a promise in increasing fruit and vegetable consumption among the preschoolers. The findings, notably in the experimental group, demonstrate that caregivers should increase their knowledge of, and exhibit behavioral support in, fruit and vegetable consumption among preschoolers, and that this will eventually reflect a positive impact on preschoolers’ dietary habits.

1. Introduction

In every region of Thailand, the consumption of fruits and vegetables has decreased across all age groups and genders, particularly among children. The majority of children’s daily consumption of vegetables and fruits is less than 30% [1]. Children aged 2–5 years, both males and females, consume fewer vegetables than children aged 6–14 years [2]. Only 6.5% of children ages 2 to 5 consume the suggested amounts of fruits and vegetables. The fruit and vegetable consumption rate among younger children declines as they get older [3]. The average daily consumption of fruits and vegetables among preschoolers is approximately 150 g, which is significantly lower than the standard of the Thai daily recommendation [4]. According to a study of the eating habits of children at Aoluek School in Krabi, 60% of the vegetables prepared for lunch are left over after lunchtime [5].

The factors affecting the fruit and vegetable consumption behavior of preschool children are two-fold. (1) Environment and parental upbringing: preschool children imitate their parent’s eating habits or even the child’s own siblings [6]. In addition to parents’ personal factors, generic family characteristics such as household income influence children’s fruit and vegetable consumption. It was discovered that children from high-income households consume a greater variety of fruits and vegetables than those from low-income households [7]. Some preschoolers may have dietary restrictions or may be at an age where they are more interested in their environment than in food. If children are compelled to consume certain types of food, they will be impressed and avoid it in the future. (2) A study of the factors influencing children’s eating behavior determined that children tend to make food selections, particularly regarding vegetables and fruits. Some fruits and vegetables can be quite bitter and sour when first tried, which can discourage children from eating them the next time [8,9]. Vegetables’ odor and generally unappealing green color are also contributing factors in children’s aversion to them. When these issues increasingly arise, caregivers will naturally avoid preparing meals that involve vegetables.

This study holds significance for enhancing the dietary habits of preschool children, focusing on increasing their intake of vegetables and fruits. The caregiver assumes a pivotal role in nurturing children and serves as a role model in this context.

Therefore, it is necessary to develop guidelines for giving advice and providing excellent emotional support and knowledge-based preschool care [10]. The study of concepts and theories to support children eating fruits and vegetables revealed that the social support theory of House [11] was comprehensive in creating reinforcements for application in program construction, particularly with respect to the building of support for caregivers because caregivers are an important support force in encouraging of children to eat nutritious food through the provision of information [3]. In addition, to encourage the occurrence of physical actions related to preschool children, we must construct reinforcements both emotionally and instrumentally [10].

Attempts to develop a program that includes four types of social support and evaluates feedback on consumption during the program are rare. Moreover, most programs promote factors related to the appearance of the menu and the color of fruits and vegetables adapted into different types of food menus, creating knowledge for early childhood children [5,12]. However, there is no program that manages the environment in order to promote fruit and vegetable intake. The caregiver is a good example of eating fruits and vegetables the individual responsible for creating positive emotions for children in early childhood around fruits and vegetables. In addition, it was found that the past use of social support theory was only a study of factors related to the intake of fruits and vegetables [3,10]. However, only a small percentage of them adopted the theory of social support, which can be used in the design and development of a program to promote vegetable and fruit intake.

At present, the consumption of fruits and vegetables among preschoolers is declining. Through an examination of past initiatives, it was identified that the target population encompasses children aged 1 to 3 years, school-aged children, and students, all of whom were subjects of study in the effort to promote programs encouraging fruit and vegetable consumption. For preschool children group, factors associated with fruit and vegetable consumption were investigated, as well as strategies for promoting fruit and vegetable consumption in child development centers through education and menu modification. However, such studies do not promote family environment management or the involvement of primary caregivers at home. Therefore, this research develops a program and tool with which to assess the fruit and vegetable consumption habits of preschool-aged children living with their primary caregivers. This is due to the fact that the primary caregiver is an essential model for preschoolers to imitate [13,14,15].

This study aimed to develop a program with which to promote fruit and vegetable consumption among preschool children and a tool with witch to assess their fruit and vegetable consumption. In addition, we set out to compare the knowledge and behavior of caregivers in promoting fruit and vegetable eating behavior between the control group and the experimental group, as well as to compare preschool fruit and vegetable consumption behaviors before and after intervention.

2. Conceptual Framework

House’s concept of social support [11] has been applied to the study of promoting fruit and vegetable intake in preschool children, and it has been discovered that parents play a crucial role in fostering social support for children to consume healthy food (Figure 1). Parents are responsible for establishing boundaries regarding the consumption of fruits and vegetables. Emotional support, including being a positive model in terms of food consumption, is statistically significantly associated with children’s fruit and vegetable eating behavior [10], as is parental encouragement of fruit and vegetable consumption [16].

To evaluate the effectiveness of a promoting a fruit and vegetable consumption behavior program among preschool children and primary caregivers in Nakhon Si Thammarat Province, the conceptual framework of social support is applied for 10 weeks. The literature review revealed that the caregiver is an important factor in introducing nutritious diets such as fruits and vegetables to children [17], is a model for children’s consumption [18], and is an important factor in creating an environment for reinforcing healthy eating [3,10,18]. According to House’s conceptual framework of social support, social support can be divided into four categories:

• Emotional Support—acceptance, attention, and respectfulness with respect to thoughts and behavior;
• Appraisal Support—feedback and demonstrating value;
• Information Support—providing knowledge and information as a guide for problem-solving;
• Instrumental Support—demonstrating support through the use of equipment and appropriate items or services.

3. Materials and Methods

3.1. Study Design

This study had a quasi-experimental two-group research design, with a pre-test and post-test design. This research aims to develop programs and research instruments for primary caregivers to use to promote fruit and vegetable consumption among preschool children. According to the conceptual framework of House’s (1988) social support theory, 96 pairs of preschool-aged children and their primary caregivers in Nakhon Si Thammarat Province were used to test the instruments designed by the researchers.

The researchers selected a sample using random sampling as follows:

Purposive sampling: According to a random selection, a child development center in Muang District, Nakhon Si Thammarat, was selected. In every household, the primary caregivers in the Muang District experience a similar urban lifestyle. There are 19 child development centers in Muang District, Nakhon Si Thammarat Province.

Simple random sampling: This is sampling without replacement and requires a list of child development centers under the Sub-District Administrative Organization, Nakhon Si Thammarat Province, with a total of 1 center.

Names of children from student records were used to select the sample based on inclusion and exclusion criteria.

3.2. Research Instruments

The researcher developed the following research instruments.

The data collection instruments for this study were divided into 4 sections.

Section 1: General information on preschool and primary caregiver’s preschool;

Section 2: A questionnaire investigating the behavior of children taking care of family meals.

This section of the questionnaire was adapted from the Child Eating Behavior Questionnaire (CEBQ) ([14]) into a total of 20 questions, consisting of 14 positive questions and 6 negative questions, regarding the behaviors of primary caregivers in encouraging children to consume fruits and vegetables. The performance grading criteria were categorized into 5 levels as follows in

Table 1. Grading of performance in encouraging children to consume fruits and vegetables in a week.

Option Details	Positive (Score)	Negative (Score)
Every day	5	1
5–6 times	4	2
3–4 times	3	3
1–2 times	2	4
Never	1	5

.

Section 3: An evaluation of caregivers’ knowledge of their children’s fruit and vegetable consumption and how to encourage their child’s fruit and vegetable eating behavior. It consisted of 4 multiple-choice questions, totaling 8 items, with the following criteria for scoring:

If the caregiver gave a correct answer, the score was given 1;

If the caregiver gave a wrong answer, the score was given 0.

Section 4: The 24-h consumption of fruits and vegetables among preschool children was modified from the 24-h eating behavior record form, and it required the primary caregiver to record the children’s consumption of fruits and vegetables over the previous 3 days.

The caregiver estimated the proportion of vegetables consumed at each meal using a tablespoon to measure and record the results. The researcher then calculated the quantity recorded by the primary caregiver, using the unit as a portion.

The caregiver estimated the proportion of fruits consumed at each meal by counting the number of fruits or pieces of fruit to measure and record the results. The researcher then calculated the quantity recorded by the primary caregiver using the unit as a portion.

3.3. Experimental Instruments

The promoting fruit and vegetable consumption behavior program among preschool children employed the social support theory proposed by House (1988) as a framework. The experimental period was 10 weeks, and the instruments used to implement the program were as follows:

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A handbook for nurses consisted of the implementation of a 10-week program to promote fruit and vegetable eating behavior in preschool children, steps and activities to support the primary caregivers of preschool children, and a follow-up concerning the fruit and vegetable eating behavior in preschool children;

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Online-based LINE application was used to publish a handbook for primary caregivers to use in encouraging preschool children to consume more fruits and vegetables.

3.4. Data Collection

The duration of the intervention was 10 weeks. From the control group, on the 1st week, we collected pre-test data. In the 2nd–10th weeks come the assessment of the 24-h recording of preschool fruit and vegetable eating habits, recorded every 3 weeks. On the 10th week, we collected the post-test data and gave the E-book to the caregiver, as well as advice on how to improve preschoolers’ fruit and vegetable consumption behaviors. The difference between the control and experiment groups is that, during the 2nd–10th week, the researcher gave the information to the caregiver via the official LINE application, and the caregiver group shared their experience about how to promote fruit and vegetable consumption in preschool using the social support framework.

3.5. Ethical Statement

All activities involving the participation of human subjects in this research were conducted in accordance with institutional ethical guidelines and considerations. This research was considered for approval by the Ethics Committee in Human Research Walailak University, certificate number WUEC-22-110-01 (certified as of 4 April 2022). The researchers conducted the study following the Declaration of Helsinki.

The researchers provided comprehensive information to the participants regarding the study’s procedure, significance, purpose, and their voluntary participation in adherence to the principle of unaffected withdrawal. Prior to commencement, caregivers granted written informed consent. All procedures involving human participants in these studies adhered to ethical institutional standards. Participant information was solely used for academic purposes and was not disclosed to anyone other than the relevant researchers.

3.6. Statistical Analysis

Statistical analyses were conducted using IBM SPSS Statistics 26.0.0.1 (Armonk, NY, USA). Descriptive statistics were employed to compare general information between the control and experimental groups. The Fisher’s exact test, Chi-square, and independent t-test statistics were utilized to assess differences among these groups.

The differences in mean scores—comparing the data on the feeding behaviors of caregivers and their knowledge about methods of modifying preschoolers’ fruit and vegetables consumption behaviors—between the control and experimental group were analyzed by the researcher via the t-test. The differences in mean scores suggest a further comparison between fruit and vegetable consumption behaviors before and after intervention within the control and experimental groups using t-test statistics.

4. Results

For the characteristics of the preschool children, it was found that 55.21% of the children in the sample group were male and 44.79% were female. Overall, children’s growth was in the normal range, with 51.04% meeting the weight-for-length criteria. When comparing the differences in the preschool children’s general information between the control group and experimental group, no statistically significant differences (p > 0.05) were found, as shown in

Table 2. General information on preschool children.

Data	Total (n = 96)		Experimental Group (n = 48)		Control Group (n = 48)		p-Value
	Number	%	Number	%	Number	%
Gender
Male	53	55.21	29	60.42	24	50	0.305 a
Female	43	44.79	19	39.58	24	50
Ages
3 years old	20	20.83	10	20.83	10	20.83	1.00 a
4 years old	40	41.67	20	41.67	20	41.67
5 years old	36	37.50	18	37.50	18	37.50
Child growth by height and weight
Thin	14	14.50	9	18.75	5	10.42	0.164 b
Quite thin	7	7.29	3	6.25	4	8.33
Slim	49	51.04	19	39.58	30	62.50
Plump	8	8.33	4	8.33	4	8.33
Risk to obesity	8	8.33	5	10.42	3	6.25
Obesity	10	10.42	8	16.67	2	4.17

p > 0.05, ^a = chi-square, ^b = Fisher’s exact test.

.

The caregivers consisted of 96 subjects (79.2% female). The average age was 37.5 years (SD = 11.48), with 77.1% being parents and 16.7% being grandparents. When comparing the differences in the general data of caregivers between the control group and the experimental group, no statistically significant differences (p > 0.05) were found, as shown in

Table 3. General information about caregivers.

Data	Total (n = 96)		Control Group (n = 48)		Experimental Group (n = 48)		p-Value
	Number	%	Number	%	Number	%
Gender
Male	20	20.80	13	27.08	7	14.58	0.208 a
Female	76	79.20	35	72.92	41	85.42
Age (min–max = 20–76, Mean = 37.52)
Mean (SD)	37.52 (11.48)		37.08 (10.54)		37.96 (12.44)		0.711 c
Relationship between caregiver and preschool
Father/Mother	74	77.10	39	81.25	35	72.92	0.611 b
Grandparent	16	16.70	6	12.50	10	20.83
Uncle/Aunt	6	6.30	3	6.25	3	6.25

p > 0.05, ^a = chi-square; ^b = Fisher’s exact test; ^c = independent t-test.

.

A comparison was performed on the differences in mean scores of the caring behaviors of the main caregivers in encouraging preschool children to eat fruits and vegetables before participating in the program in both the experimental and the control group. There was no statistically significant difference between the control and experimental group (p > 0.05), as

Table 4. Compared data on feeding behavior and knowledge of methods with which to promote fruit and vegetable eating behavior modification in caregivers pre-intervention.

Data	Experimental Group (n = 48)		Control Group (n = 48)		Mean Difference	df	t	p-Value
	M	SD	M	SD
Feeding behavior of the caregiver	72.67	7.72	71.69	9.09	−0.98	94	−0.57	0.571
Knowledge about methods to promote fruit and vegetable eating behaviors	3.42	1.46	3.35	1.38	−0.06	94	−0.22	0.829

p > 0.05. df = degree of freedom.

shows.

The behaviors of the caregivers in encouraging preschool children to eat fruits and vegetables after participating in the program (M = 79.52, SD = 4.40) were higher than before participating in the program (M = 72.67, SD = 7.72). It was found that there was a statistically significant difference between the control and the experimental group (p < 0.001). The caregivers of the experimental group (M = 79.52, SD = 4.40) had a higher mean knowledge score than the control group (M = 71.06, SD = 6.97). The mean difference for early preschool children’s consumption of fruits and vegetables in the experimental group (M = 5.92, SD = 1.4) was significantly (p < 0.001) higher than that in the control group (M = 4.33, SD = 1.53), as shown in

Table 5. Compared data on feeding behavior and knowledge of methods with which to promote fruit and vegetable eating behavior modification in caregivers post-intervention.

Data	Experimental Group (n = 48)		Control Group (n = 48)		Mean Difference	df	t	p-Value
	M	SD	M	SD
Feeding behavior of the caregiver	79.52	4.40	71.06	6.97	−8.46	94	−7.1	0.00 ***
Knowledge about methods to promote fruit and vegetable eating behaviors	5.92	1.4	4.33	1.53	−1.58	94	−5.3	0.00 ***

p < 0.001 ***. df = degree of freedom.

.

The behavioral score in terms of the average fruit and vegetable eating of preschool children in the experimental group (M = 3.42, SD = 2.00) was found to increase compared to before joining the program (M = 2.52, SD = 2.04), and the mean score of fruit consumption in early childhood in the experimental group (M = 4.17, SD = 3.83) was revealed to increase compared to that before enrolling the program (M = 5.61, SD = 3.1). The fruit-eating behavior score of preschool children in the experimental group (M = 3.42, SD = 3.38) was higher than that of the control group (M = 1.81, SD = 2.07). SD = 3.1), as shown in

Table 6. Compared data of vegetable and fruit consumption of preschool children pre- and post-intervention between the experimental and the control group.

Vegetable and Fruit Consumption Proportion	Before		After		t	p-Value
	M	SD	M	SD
Vegetable consumption
Experimental (n = 48)	2.52	2.04	3.42	2.00	−8.176	0.000 ***
Control group (n = 48)	1.80	2.06	1.81	2.07	−0.144	0.886
Fruit consumption
Experimental (n = 48)	4.17	3.83	5.61	3.1	−5.392	0.000 ***
Control (n = 48)	3.43	3.38	2.98	2.65	2.08	0.643

p < 0.001 ***.

.

5. Discussion

After receiving a program with which to promote vegetable and fruit consumption behaviors among preschool children, it was found that in the experimental group, when comparing the before and after behaviors of caregivers with respect to taking care of preschool children’s consumption habits, the caregiver had knowledge of the child’s fruit and vegetable intake and how to modify the child’s fruit and vegetable eating behaviors. The consumption of vegetables and fruits among preschool children tends to be higher after the experiment than before the experiment. The results indicate that receiving the program, along with social support across all four aspects (emotional support, information support, instrumental support, and appraisal support), can be discussed as follows.

Through emotional support throughout the entire operation, the researchers assured that caregivers were able to encourage preschoolers’ fruit and vegetable consumption in an upward direction, opening inquiry channels to reduce stress during practices [19]. When caregivers reduced stress and pressure, children consumed more fruits and vegetables and felt happier during meals [20]. In addition, the sharing of ideas and encouragement among caregiver groups was essential to bolstering caregivers’ confidence in carrying out appropriate fruit and vegetable consumption guidelines for children.

For information support, we encourage educating caregivers about children’s nutritional status, caring behaviors with which to encourage children to eat their meals, the appropriate amount of fruit and vegetable consumption among preschool children, the impact of not consuming vegetables and fruits, and how to make food look appetizing—all of these will provide primary caregivers with appropriate guidance in meal planning for children [21] and how to improve food’s visual appeal [22], as well as guidelines for teaching children to eat correctly and properly [23].

For instrumental support in preparing the caregiver application, it was determined that creating materials with knowledge-based content and additional inquiry channels will help caregivers gain confidence. They can ask questions to get additional information about how to encourage children to eat more fruits and vegetables, such as by making food more visually appealing.

Appraisal support was conducted by monitoring the consumption behavior of preschool children and providing the primary caregiver with feedback in promoting an appropriate caregiving style.

The House [11] social support theory was adopted so that primary caregivers could receive adequate and comprehensive social support. The preschool children care guidelines provided to primary caregivers included social support across all four aspects, namely, emotional support, informational support, instrumental support, and appraisal support, which parents could apply according to the context of each family in order to encourage preschool children to eat fruits and vegetables.

The limitation of this study lies in the fact that the sample, consisting of 96 attendees, was only representative of a specific community in Nakhon Si Thammarat; it does not accurately represent the entirety of Thailand. Additionally, the sample of preschool children included a slightly higher number of males than females in each group prior to program participation, although this gender distribution difference did not reach statistical significance.

6. Conclusions

This research emphasized the necessity of including caregivers in the promotion of fruit and vegetable consumption among preschool children. The better growth and development of the children included in this study has suggested the future application of the approach on a larger scale to produce a healthy generation; however, this study was conducted for only 10 weeks, which is inadequate, and further study with larger sample sizes and longer study periods is warranted. Additionally, it is advisable for researchers to conduct an extensive investigation into how the program impacts dietary behaviors, particularly in relation to vegetable and fruit consumption, among preschool children.