Using the Stages of Change Model in a 5 A Day Guidebook for WIC Jean Anliker, Ph.D., M. S., R.D., * Dorothy Damron, M.S., Michael Ballesteros, M . S., Patricia Langenberg, Ph.D., Stephen Havas, M.D., M.I?H., M.S., Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Howard Hall, Room 140C, 660 W Redwood Street, Baltimore, MD 21201; El: (301) 262-5676; Fax: (301) 262-3199; E-mail: janliker@epi.umaryland.edu. Wendy Mettger, M . A . , Mettger Communications,Takoma Park, M D 20912 Robert Feldman, Ph.D., M.A., M.S., Department of Health Education, University of Maryland at College Park, College Park, MD 20742 * Author for correspondence The Get Clued in to Fruits and Vegetabla Guidebook was the pivotal educational material for the Maryland Special Sup- plemental Nutrition program for Women, Infants and Children (WIC) 5 A Day Promotion Program.The guide- book was developed based on forma- tive research with members of the tar- get audience1for the overall purpose of increasing W I C participants' fruit and vegetable consumption by helping them move through the stages of change. Previous studies had shown that low-income women consume fewer fruits and vegetables than higher- income group^.^ The WIC program provides a special educational oppor- tunity, since participants may be moti- vated to adopt healthful eating habits out of concern for their children.' Through formative research, we identified five key behaviors for increas- ing the fruit and vegetable intakes of Maryland WIC participants: (1) have fruit or 100%juice in the morning, (2) eat fruit for a snack, (3) eat a vegetable or salad at lunch, (4) have two vegetables for dinner. and (5) eat fruit for dessert. Mo- . \, tivational appeals identified for this au- dience were to be good role models for their children and to take good care of themselves during and after pregnancy1 ............................ This research was supported by the National Can- cer Institute, Grant #ROlCA59725, with supple- mental funding from the Maryland Department of Hralth and Mental Hygiene. The stages of change model devel- oped by Prochaska and DiClemente3 vrovided the theoretical framework for assisting women in improving their di- etary behaviors. According to this model, behavior change is a dynamic, nonlinear vrocess that involves a series of stages: precontemplation (not think- ing about changing behavior), con- templation (thinking about change), preparation (making definite plans to change), action (initiating change), and maintenance (continuing the changed behavior for at least 6 months). We used this model to assess participants' stages for fruit and vegetable con- sumption at the beginning and end of the inter~ention.~,' The Get Clued in to Fruits and Veg- etables Guidebook is a glossy, colorful, spi- ral-bound discussion/decision-making guide. It provides information and skill- building activities, such as self-assess- ment, goal setting, behavioral messages, decision-making exercises, and mainte- nance strategies, to help participants move to higher stages of change and ul- timatelv increased fruit and vegetable " consumption. The guidebook was dis- tributed to participants and used as the basis for a series of three bimonthly nu- trition sessions, each approximately 45 minutes in length, scheduled at WIC voucher pick-up times. Due to sched- uling constraints, participants were not grouped by stage for the sessions. How- ever, through the many group discus- sions, people at more advanced stages could share their ideas and experiences with those at earlier stages, reinforcing their own positive behaviors. While the peer educators facilitated discussions based on the guidebook during the nutrition education sessions, the guidebook was also designed to stand alone. For example, it featured a character, Ms. Newmother, who was a WIC participant with a 2-year-old child and a new baby. Busy with the new baby, Ms. Newmother was finding it difficult to eat healthful foods. To im- prove her eating habits, Ms. Newmother followed the steps described in the guidebook to move through the stages of change and find ways to eat more fruits and vegetables that were success- ful for her. Particivants who missed one or more of the nutrition sessions could read about Ms. Newmother and make their own healthy choices, using Ms. Newmother's example as a guide. The first part of the guidebook, used in the initial nutrition session, raised participants' awareness of the im- portance of eating fruits and vegeta- bles, helping the women move from precontemplation to contemplation. Participants were encouraged to think and talk about foods with special meanings for them, and the benefits of eating fruits and vegetables, both for themselves and for their children. Next, participants did a brief self-as- sessment of their fruit and vegetable in- takes and prepared themselves for ac- tion by setting a personal goal for eating more fruits and vegetables. The five key behaviors were presented, and participants were encouraged to choose the behaviors that would best help them to reach their goals. The next section of the guidebook, used in the second nutrition session. focused on action. After participants discussed their experiences working toward their goals since the first ses- sion, they used the guidebook to iden- tify barriers to reaching their goals and strategies for overcoming those barri- ers (Fig. 1). Through a guided discus- sion, the trained peer educators en- couraged the women to help each other find new and better wavs to achieve their goals. Food demonstra- tions and tip sheets were also provided to build skills and increase self-efficacy. The tip sheets were specifically de- signed to address barriers, such as con- cerns about food spoilage and cost, that other WIC participants had men- tioned during the formative research.' The last section of the guidebook, used during the third and last nutrition session,helped participants to maintain their goals and make them a habit. Par- ticivants talked about reasons for re- lapse, what to do about relapse, and ways to maintain their goal behaviors. They also discussed favorite ways to re- ward themselves for success. Two forms of evaluation showed that the guidebook was both effective and well received. First, a final survey was conducted at the end of the full- scale study, with a question asking if participants received and read the Get Clued in to Fruits and Vegetables Guide- book. Six hundred and nine participants completed this survey, for a return rate of 74%. Of the 594 people who an- swered this question, 314 (53%) said they read most of the guidebook, 178