Introduction

Obesity rates for children and adults have continued to rise, especially during and after the COVID-19 pandemic (Pierce et al., (2023). Now, over 1 in 3 adults and 1 in 6 children and adolescents aged 2 to 19 are considered to have obesity (Flegal et al., (2016); Ogden et al., (2016); Pierce et al., (2023). Previous studies suggest improving dietary choices involves a social component, with the largest influence on children’s nutrition coming from their parents’ nutritional habits (Hammons, Fiese (2011)). Other research has shown that increased shared family mealtimes may improve health in children and adolescents (Patrick, Nicklas (2005)) and student-focused nutrition education programs are most effective when involving families for additional support (Camargo et al., (2020); Sahay et al., (2006); Pérez-Rodrigo et al., (2005)).

To help address these rising obesity rates and their adverse health outcomes, online and in-person “nutrition kitchens” with interactive cooking sessions have gained popularity and help to promote health, wellness, nutritional knowledge, and even nutritional behavior change for adults (Eisenberg, Imamura BEnvD (2020); Eisenberg et al., (2023), Charles et al., (2023)). A few studies have shown that experiential cooking programs may contribute to increased nutrition-based learning for children (Dougherty, Silver (2007), Robinson-O’Brien et al., (2009); Cory et al., (2021), Sweetman 2020). Many virtual nutrition education programs have influenced healthy habits including increasing vegetable acceptance, whole grain intake, and fruit intake (Policastro et al., (2023); Saxe-Custack et al., (2023)). Comparing virtual and in-person versions of the same nutrition curriculum for families has shown mixed responses in healthy eating habits depending on the format of the lesson (Saxe-Custack et al., (2023); Herman et al., (2023)). Identifying effective ways to teach children about nutrition has the downstream potential to improve population health and the functioning of the healthcare system for years to come.

During the COVID-19 pandemic, many previously in-person community partnerships had to transition to other formats to maintain relationships while following social distancing guidelines. The pandemic brought about the rise of many virtual learning platforms, which are online tools that facilitate teaching when in-person lessons cannot be conducted (Bilal et al., (2022)). Studies since the pandemic started, virtual community engagement interactions through these platforms can mitigate geographical challenges, provide convenient and portable avenues for live communication, and continue stakeholder involvement in research activities (Tamí-Maury et al., (2017); Marsh et al., (2021)).

Previous in-person initiatives in the Milwaukee community through The Food Doctors nutrition education project have shown increases in baseline nutritional knowledge for third-grade students after targeted lessons and a desire among the students to share their newfound nutritional knowledge with family members (Johnston et al., (2018)). The Food Doctors (TFD) was created in 2013 by medical students at the Medical College of Wisconsin in partnership with elementary schools throughout Milwaukee County to add an interactive, hands-on, student-lead, nutrition education intervention to the third-grade curriculum. Three culturally relevant lessons were created and received IRB approval prior to in-person lessons (Johnston et al., (2018)).

As the pandemic continued, TFD sought to implement virtual strategies to continue to support the community-academic partnership between the local academic medical center and nearby elementary schools. Virtual learning programs became popular in elementary school education during the COVID-19 pandemic, and TFD utilized this to allow for synchronous delivery of nutritional education programs. Virtual learning platforms allow both presenters and learners to engage via webcams and microphones in a private virtual classroom.

We hypothesized that quantitative and qualitative evaluation of our virtual nutrition education curriculum involving teachers, students, and families will elucidate the program format leading to the highest knowledge retention for students and identify the community and pedagogical factors that are key to the development of successful virtual nutrition-based community programs. Our target populations were teachers, students, and families to have a multidimensional evaluation of successful program factors. The objectives of this evaluation were to compare in-person and virtual program testing scores and interview teachers, families, and students to identify factors that are important for successful nutrition education in the community.

Although benefits and drawbacks of virtual education have been explored in previous research, less is known about the factors that are key to the development of successful virtual versions of nutrition-based community projects. Given pandemic challenges and inevitable future virtual learning environments, it is vital to explore and delineate the factors that promote student interaction with health topics and forge successful elementary school health education programs.

Methods

TFD transitioned from in-person lessons to virtual lessons via Zoom during the 2020–2021 school year to offer the same nutrition education curriculum as in previous years in a safe manner that aligned with the school policies surrounding the pandemic. Pre-pandemic in-person Food Doctors lessons conducted at the partner schools since 2013 consisted of three, 30–60 min, MyPlate-based nutrition lessons. MyPlate is a nutrition framework created in 2011 by the US Department of Agriculture and provides guidelines for healthy eating based on the composition of daily meals (MyPlate, 2011). Lessons were taught by volunteer medical students (referred to as student-instructors) after observing more experienced project members deliver the lessons during previous sessions. Prior to leading a lesson, student-instructors observed at least one session and were provided with detailed lesson plans explaining nutritional topics of the lessons to review before teaching. Formal nutrition education training was not required. However, through prior undergraduate education and their own medical school curriculum, student-instructors learned basic concepts of nutrition and biochemical processes surrounding nutrition. Lesson topics include identifying the differences between whole grains and enriched grains, nutritional benefits of different fruits and vegetables, nutrition labels, differences in and sources of dietary sugar, and health frameworks for considering beverage choices. Student participation was encouraged via nutrition-based questions throughout the presentation related to lesson topics and a hands-on snack activity prepared by the student-instructors and students related to foods discussed during the presentations. For example, during one lesson, students were invited to explore the health considerations of a popular snack—Flamin’ Hot Cheetos(c). The session proceeded to interactively engage students in exploring the composition of the snack, where it aligns with the MyPlate nutrition guide, and the difference between whole grains and enriched grains. Afterward, students created their own healthier alternative spicy whole grain popcorn snack applying their new conceptual understanding using spices commonly found in family pantries. Students were surveyed before and after the 3-session course to assess nutrition knowledge and gain in an IRB-approved study (Johnston et al., (2018)).

Due to the pandemic, this previous format underwent many adjustments to meet the new virtual needs of program learners. The aim of this study was to examine elements of virtual nutrition education programs that were implemented during the COVID-19 pandemic with the goal of defining the community and pedagogical factors that promote and sustain successful virtual elementary school nutrition education partnerships between academic medical centers and elementary schools. During the 2020–2021 school year we conducted two virtual nutrition programs to continue the project despite new social distancing restrictions: (1) a program during the regular school year that consisted of online nutrition lessons, quizzes, and a focus group with teachers, and (2) a summer family program featuring the same online lessons with interactive cooking sessions, focus groups with family members, and farmers market stipends.

Program descriptions

Virtual school year program

Over the 2020–2021 school year, we provided three 30-minute virtual lessons to over 100 third-grade students between five classes over Zoom, a specific virtual learning platform. During this virtual format, most students received the lessons on their computers at home. We used presentations and content from lessons that had been developed in previous years of the in-person TFD program and approved by the Institutional Review Board. Per our IRB protocol, we obtained consent from parents and assent from students prior to the students’ participation in the program. During the sessions, virtual activities aimed to mirror previous in-person lesson formatting to the greatest extent possible. Screen sharing was utilized by student-instructors so that students could view the lesson presentation in real time and follow along with the presenter. Students were encouraged to participate in periodic lesson-based questions asked by student-instructors via the “raise hand” and chat functions on Zoom in place of raising hands at school in-person. The students were also encouraged to unmute periodically and ask more detailed questions. Teachers and other program student-instructors were present virtually during the lessons and served as moderators to keep students on task and intervene on any technical difficulties. Although student-instructors were no longer able to distribute food related to the lessons, example foods that would be accessible in the home and healthy recipes were provided to students and families to continue hands-on engagement at home. A summary of our in-person and virtual lesson similarities and differences can be found in Fig. 1.

Fig. 1: Comparison of virtual and in-person school lesson curriculum delivery.
figure 1

This figure depicts a Venn Diagram showing the differences and similarities between the in-person and virtual lessons. In-person lessons included lesson-based snacks given after each lesson, student participation via hand raising, and an afternoon lesson time. Virtual lessons included no snacks due to pandemic restrictions, student participation via the Zoom chat box and “raise hand” function, and a morning lesson time. In the middle of the Venn diagram, similarities of both lesson formats included the same PowerPoint presentation, the same post-lesson quiz, and interactive questions posed to students during both lesson types.

Full size image

Virtual summer program

We offered the same three 30 min lessons during the summer program that were given during the school year program. The sessions included an educational component to teach families about a nutrition concept, immediately followed by a virtual cooking session where families prepared a meal together centered around the theme from the lesson. We provided summer participants $20 in vouchers to a local farmers market to help supply nutritious foods for the cooking lesson. Funding to support the vouchers was obtained through an internal grant from the home institution. We recruited participants via e-mail from school administrative leaders and provided them with an invitation to participate and to complete the research consent forms. Student-instructors presented the virtual lessons in June and July synchronously to seven families with 15 total individuals in attendance. Participants included third-grade students (N = 7), younger siblings (N = 4), and parents (N = 4), and attendance of the sessions ranged from a minimum of 3 and a maximum of 7 students. Students and siblings who were present for lesson presentations were joined by their parents for the cooking session at the end of the lesson. Lessons occurred at 5:30 PM to encourage families to utilize the time after the presentation to enjoy a meal centered around the education session. Families received a video created by two student-instructors prior to the session providing meal preparation information. These videos were newly developed by student-instructors for this summer program. The videos outlined ingredients and showed footage of student-instructors making the meals. After the session, each family received an email that provided a session summary which included the recipe and lesson review questions to review with their children at their convenience. An example of a session summary document can be found in Fig. 7 within the Supplementary Material. After the program, families were contacted to complete a focus group to explore outcomes from their experience. A full description of the inclusion and exclusion criteria for each program can be found below in Table 1.

Table 1 shows the inclusion and exclusion criteria for study participants.
Full size table

Data collection

After the three lessons were completed, students during the school year program were given a voluntary multiple-choice post-lesson quiz via a Qualtrics link that TFD student-instructor shared in the Zoom chat box at the end of the third lesson. The multiple-choice quiz was identical to the quiz used previously during in-person lessons. Due to the COVID-19 pandemic, pre-lesson quiz scores were not able to be collected. The quiz questions given to students can be found in Fig. 6 within the Supplementary Material.

We conducted two semi-structured 30-minute focus groups with teachers from both partner schools via Zoom to assess lesson effectiveness and educator insight into lesson structure and content after lesson completion. A full list of focus group questions can be found below in Table 3 within the Supplementary Material. Focus group methods were selected because they allow researchers to delve deeply into a topic by engaging participants in open-ended discussions. They facilitate the collection of rich, detailed data through interaction among participants by encouraging engagement and discussion among participants. These dynamic exchanges can lead to insights that might not arise from individual interviews or surveys (Creswell, 2018). Teachers were encouraged to answer each question individually to identify any differences in opinion and reduce potential response bias in the group setting with colleagues and supervisors. Focus group topics included educational experience, impressions of virtual lessons, and suggestions for improvement.

Focus groups for the summer program were also conducted by TFD student-instructors. To reduce any potential participant bias due to interviewer familiarity, participants were ensured all answers were anonymous and there were no right or wrong responses. Questions for the focus groups were structured around how families felt about the farmers market incentive program and how their experience with the virtual summer program may have lasting impacts on their family habits. A full list of family focus group questions can be found in Table 4 within the Supplementary Material. School year and summer focus groups were transcribed verbatim using the Zoom transcription function with proofreading by the research team to confirm transcription accuracy.

Data analysis

Data was analyzed using a combination of statistical analysis from quiz scores prior to the pandemic (in-person) and during the pandemic (virtual) as well as identification and interpretation of themes from both school-year and summer focus groups. We used descriptive statistics to analyze the quiz scores emphasizing mean values. We also compared quiz scores in the virtual school-year program to our in-person scores collected in 2018. Two sample T-test analysis was used to compare the mean scores for the two groups.

After analyzing the focus group data separately between the school year program and the summer program, we also investigated commonalities between the teacher and family focus groups. For these groups, we used content analysis as our methodology to classify data into identified categories of similar meanings and to identify patterns within the data. Two coders were trained by a qualitative researcher at our institution. The coders reviewed the focus group transcripts and created independent coding schemes using open coding techniques and descriptive content analysis (Glaser, 2001, Strauss, Corbin (1998), Walker, Myrick (2006)). To reduce coding bias, coders independently reviewed transcripts. After, coders met to discuss the initial code lists and agreed on a consensus for a final coding scheme. Disagreements in codes were resolved through discussion between coders. Additionally, once the final coding scheme was implemented, members of the coding team were still able to suggest new codes throughout the coding process. If the coding members agreed on the significance of the new code, it was then added to the coding scheme. Axial coding was conducted between primary themes to develop a multifactorial model that represented the dynamics of virtual learning from the teacher and family perspective. After coding was complete, we calculated inter-rater reliability using percent agreement. This was calculated by an additional member of the research team that independently coded a random selection of the transcripts and compared codes to the coding outcomes of the original coding team. For the school year program, percent agreement was calculated at 84%. For the summer program, percent agreement was calculated at 75%. Themes from the school-year program and student quiz scores from the virtual program were shared with teachers from each school at two learning sessions after the data was finalized.

Results

We collected quiz data from 109 students across our two partnering schools. Of the 109 quiz submissions, 29 students did not elect to participate (N = 80). Scores ranged from 0 to 8 points out of 10 total points. The mean, median, and mode of quiz scores were calculated and compared to 2018 data (N = 116) collected by TFD team during in-person lessons with the same partnering schools and quiz questions. Average quiz scores with standard deviation error bars can be seen in Fig. 2. When comparing in-person data to virtual data, we found that post-lesson quiz mean score decreased from 6.79 (2018) to 4.39 (2021). Two sample T-test comparison shown in Table 2 yielded a t value of 8.36 as compared to 2018 in-person post-test data, indicating a significant difference between the two groups with different lesson formats (p < 0.0001). Virtual quiz scores from the 2020–2021 school year more closely resembled pre-lesson quiz scores from 2018, representing reduced post-lesson knowledge as compared to in-person curriculum in previous years.

Fig. 2: Score comparisons between in-person and virtual lesson quizzes.
figure 2

This figure shows the test scores for students during the 3 observation periods: 2018 in-person pre-lesson data, 2018 in-person post-lesson data, and 2021 in-person post-lesson data. The average score for 2018 in-person pre-lesson data was 4.84. The average score for 2018 in-person post-lesson data was 6.79. The average score for 2021 in-person post-lesson data was 4.39.

Full size image
Table 2 Post-Lesson Quiz Score Quantitative Analysis.
Full size table

For the school year program, focus group invitations were extended to all third-grade teachers (N = 5) and the educational support staff (N = 2) present in their classrooms for TFD lessons. All teachers and educational support staff invited consented to interview (N = 7). Key themes of the teacher focus groups included the importance of support systems, the need for further program integration into the school community, and the benefit of engagement strategies for virtual learning.

In the summer program, focus group invitations were extended to all 15 participants who joined the program, with 8 individuals consenting to participate (N = 8). Participant breakdown included adults (N = 4), third-grade children (N = 3), and siblings (N = 1). Interview topics included perceptions on the virtual nutrition program, interaction with farmers markets, and the impact of the program on nutritional behaviors. Qualitative analysis yielded three primary themes: satisfaction with the virtual summer program, benefits and barriers to utilizing farmers markets, and family interactions with nutrition material after the program.

Analysis of the teacher and family focus groups together revealed three larger umbrella themes felt to be important in enabling successful nutrition education programming: support, community, and engagement. Example quotes from both school-year and the summer virtual program focus group that reflect on what support, community, and engagement represent from the participants are included below. A full list of themes is included in Table 5 within the Supplementary Material.

In the teacher focus groups, support was represented by several sub-themes that we labeled teacher-teacher support, teacher-student support, teacher-parent support, Food Doctors-parent support, and providing material pick-up for virtual lessons. During the summer program, parents described support through positive outcomes associated with program participation. One parent highlighted their favorite parts of the program and said:

“In a more family-oriented way, we get to sit down as a family and try [new foods] or put a twist on something we might already know. Then we could go to the farmers market and try to either pick substitutes for things, or just try new things.”

Teachers acknowledged that the pandemic restructured their classrooms dramatically, and they noticed significant difficulties with changing educational formats. Despite these challenges, teachers described gratitude for the continuation of lessons and the support they received from TFD in formulating holistic educational experiences through health topics. Teachers described efforts to bring nutritional topics to class themselves but found that having additional support from the program increased health-based discussions among their students. Teachers also expressed an interest in learning how the program would translate to the home environment, and they were eager to keep parents involved in teaching topics. To improve parental involvement, teachers recommended sending more materials home with parents, such as recipe books, video links, or summary sheets. For example, one teacher said:

“Moving forward, I think it would be cool, I don’t know how realistic it is, but if you know there was like the recipe, or just some of the food items that parents could come pick up at the school.”

Community was represented in the ways that TFD programs could be mutually supportive of and by existing programs. From the teacher perspective, community was emphasized in the sub-theme of program integration into the school campus, which discussed school programs that coincided with the goals of TFD. There were several preexisting school programs that could benefit the goals of TFD, such as a school fruit and vegetable program mentioned by one teacher:

“There is a fruit and vegetable program that provides fruits and vegetables for snacks for students in schools. And that does expose them to some fruits and vegetables that they probably have never heard of. And so, if we can somehow incorporate that with what you guys are doing, I think that would be beneficial.”

Teachers encouraged increased program engagement in school life, such as cafeteria lunch time and art class, to promote further student immersion into the TFD programs. During the summer lessons, parents discussed community in terms of using the local farmers market as a way to support small businesses rather than supermarkets. The addition of a community resource increased participants’ knowledge of local sources for fresh, quality ingredients. By holding the nutrition sessions virtually, families went to the market on their own to search for the ingredients needed for the meal. One of the family participants highlighted the differences between the farmers market and traditional grocery store experience by saying:

“I think the quality of the produce is better [at the farmers market] because you could tell that it was homegrown… It might not be as big as a store bought. But there is a flavor difference.”

For two of the three interviewed families, the program was their first experience shopping at a farmers market. Participants described benefits such as better produce selection and drawbacks like higher prices and limited hours.

The engagement theme was represented through challenges and successes with lesson retention and healthy behavior changes. We define engagement from the Glossary of Education Reform as, “the degree of attention, curiosity, interest, optimism, and passion that students show when they are learning or being taught, which extends to the level of motivation they have to learn and progress in their education,” and this definition was used to examine student engagement behaviors after the lessons (“Student Engagement” 2016). Increased engagement during the lessons garnered additional student interactivity and teacher approval throughout this project. One teacher highlighted the uniqueness of having outside presenters from TFD come to campus and said:

“We try our best as educators to help [students] and develop the whole child but it’s really nice having like an outside source come in, so it’s like a little in-class field trip fun.”

Areas for improvement with lesson engagement were noted as teachers described challenges with virtual learning and students’ fading interest in virtual learning platforms. During the virtual summer program, engagement was highlighted in the live cooking sessions and post-session materials that allowed families to share in nutrition education together. Increased nutrition-based discussions within families enhanced engagement in the summer lessons. One parent mentioned that her family had more conversations about lesson topics and said:

“I think that when shopping in the grocery store or even when we’re eating, we’ll frequently have conversations about some of the concepts, such as [is this food] whole grain or is it enriched.”

Families expressed their recurrent use of healthy lesson recipes as well as their children wanting to eat new foods that were introduced through the recipes. The relationship between themes from the focus groups are summarized in Fig. 3.

Fig. 3: Key factors for successful nutrition education.
figure 3

This figure depicts a map of the themes from qualitative interviews from both teachers and families. In the center of the map, there are three larger dark circles connected by lines containing the main themes of support, community, and engagement in a triangular connection. Sprouting off of the community circle are lines to two smaller circles with the themes of program integration into the school campus (from the teacher interviews) and benefits and barriers to utilizing the farmers markets (from the family interviews). Sprouting from the engagement circle are lines to five smaller circles of family interactions with nutrition material after the program (from the family interviews) and four additional themes from the teacher interviews: Food Doctors as role models, fading interest in online learning platforms, lesson engagement, and TFD as a change in topics and educators. Finally, sprouting from the support circle are lines to six smaller circles of satisfaction with the virtual summer program (from the family interviews) and five additional themes from the teacher interviews: teacher-teacher support, teacher-student support, TFD-parent support, providing material pickup, and teacher-parent support.

Full size image

In many instances, the three main themes of support, community, and engagement also showed significant overlap in comments from teachers and parents. For example, one teacher suggested the following improvement to lesson plans:

“Even if it was just like a short little like couple minute to minute video of just like a recap of things that kids learn that parents could kind of review with their kids, I think that’d be helpful too, then the parents won’t feel like I have to know all of this information.”

In this quote, support from TFD and parents and increasing student engagement through supplemental videos was thought to synergistically impact lesson effectiveness from the educator perspective. A representation of the dynamics of the three main themes of support, community, and engagement interacting with the learner can be found below in Fig. 4. While the three main themes synergize (blue arrows), they each also individually impact the learner and learning environment (green arrows).

Fig. 4: Learner relationships with key factors of virtual nutrition education.
figure 4

This figure depicts the connections between the three main themes of support, community, and engagement with the learner. The three main themes of support, community, and engagement within circles are arranged in a triangular pattern with blue bidirectional arrows connecting each circle. This bidirectionality represents the reliance and collaboration of each of the main themes upon each other during the lessons. In the center of the triangle is a circle labeled “learner.” Three green unidirectional arrows pointing toward the learner sprout from each of the three main themes of support, community, and engagement to represent the impact of the three main themes on the learner.

Full size image

Discussion

While previous literature has described aspects of virtual programs that increase participation, there is a lack of research that examines virtual nutrition programs at the elementary level with input from teachers and family. Our study explored differences in student knowledge of nutritional topics between in-person and virtual programs and also identified elements that can make virtual nutrition education programs most effective from teacher and family perspectives by leveraging strengths related to support, community, and engagement.

Some previous comparisons between virtual and in-person nutrition education programs have suggested virtual programs can lead to higher intake of whole grains and fruits (Saxe-Custack et al., (2023), Prowse, Carsley (2021), Sharma et al., (2021)). Studies of graduate-level nutrition learners also suggest virtual learning arenas are preferred due to perceived improved interactivity, connectedness, and improved accommodation of various learning styles (Heuberger, Clark (2019)). On the contrary, other suggest in-person curriculum can also lead to improved dietary intake (Jeans et al., (2023), Metcalfe et al., (2022)). Additional studies have suggested that there are actually minimal differences between virtual learning modalities when compared directly to their in-person counterparts (Watts et al., (2022)). Because of these inconsistencies between direct comparisons between in-person and virtual learning, it can be difficult to determine the ideal modality to provide vital nutrition curriculum to students.

When comparing post-lesson scores between 2021 to 2018, we saw a decrease in student performance. However, teachers unanimously endorsed TFD as a beneficial part of their classroom activities with a preference to continue lessons in-person and suggestions to increase student engagement and participation.

Potential factors that could have contributed to the decrease in quiz scores may stem from technological barriers of the virtual format including student burnout, reduced interaction among students, diminished experiential learning due to inability to participate in hands-on nutrition activities, virtual or home distractions, and differences in lesson timing. Our findings also align with previous studies that have noted the limitations of virtual learning formats (Stelitano et al., (2020)). All teachers interviewed highlighted the effects of virtual learning during COVID-19 on their students. The decrease in quiz scores were consistent with teachers’ concerns during interviews about global knowledge deficits induced by the pandemic virtual learning structure. Based on their feedback, students experienced widespread decreases in knowledge for all third-grade topics, and new incoming third graders the following year showed lower baseline knowledge when starting third-grade than expected from the teachers based on previous in-person years. The interviewed teachers attribute this student decrease in knowledge and retention to virtual learning and pandemic challenges. Although nutritional knowledge was less than prior years by the end of the program, we acknowledge this finding was located in the setting of structural factors limiting knowledge beyond our program. We believe students deserve enrichment in nutrition in the best and most appropriate format that is available. In a pandemic or other circumstance in which virtual formats are the best option, we believe effective nutrition education may be offered utilizing some of the key strategies illustrated here.

Regarding interaction during the summer program, we found that participants enjoyed interacting with their family members and the student-instructor through the meal preparation. Past studies have shown that interactions such as student-teacher and student-content increase overall achievement and student engagement (Liao et al., (2021), Murimi et al., (2018)). Focus groups with families from the summer program yielded positive participant feedback with the virtual delivery method, particularly because the families had a scheduled time to create a family meal together centered around the nutrition topic. Shopping at the farmers market yielded mixed feedback related to produce selection, prices, and limited hours. Overall, families were satisfied with the knowledge and experiences their children gained during the program.

The themes of support, community, and engagement work together synergistically, but they also have noted individual contributions to the virtual learning environment.

Support

Throughout both the summer and school year virtual projects, a triangulated support system was evident between teachers, parents, and students to promote improved nutritional knowledge and healthy eating. The established relationship between parents, teachers, and students previously developed is modified with TFD program for additional avenues of support (“Triangle of Support”, 2022). TFD received support from teachers, students, and parents through program feedback and participation, while TFD provided support by increasing nutrition program availability and educational aids available to students and parents (Fig. 5). It must also be noted that students experiencing food insecurity may not have had access to in-person school nutrition programs, such as subsidized school lunches, during the pandemic that supported their overall health in previous years, placing a greater emphasis on the importance of continuing in-person nutrition programs with shared food elements.

Fig. 5: Support systems during lessons.
figure 5

This figure depicts the support systems that were present during lessons that should be leveraged by current and future educational programs. Three circles containing “parents,” “students,” and “teachers” are arranged in a triangular pattern connected by bidirectional arrows to represent the bidirectional support from each of these groups towards each other. In the center of the triangle is an additional circle labeled “TFD” representing The Food Doctors. This circle is also connected to the “parents,” “students,” and “teachers” circles through additional bidirectional arrows to show the support systems that can be accessed and optimized with educational programs from outside the school system such as TFD (“Triangle of Support”, 2022).

Full size image

Students played a major role in relationships with parents and teachers. Students would discuss information from TFD lessons with both parents and teachers, providing further exposure to lesson topics (Cory et al., (2021)). Parents noted that their children would teach them concepts from the lessons as they prepared meals afterwards. After the summer program, families reported further conversations about the lessons both when shopping for meals and eating dinner, illustrating the continuing conversation between family members. These conversations after lesson delivery were examples of how leveraging the relationship between students and their supporting adults can promote further reinforcement of content.

For programs interested in implementing similar nutritional programs in schools and the community, we recommend optimizing support channels by sending home summary sheets or videos after sessions to strengthen topics seen during the sessions and increase participant and family connection to the program, eliciting feedback from research participants to improve a program’s reach and impact during and after a program is implemented, and maximizing connections between parents, teachers, students, and the curriculum in the grade school environment to support further interaction and familiarity with topics. Utilizing elements of support that simultaneously incorporate student engagement and the local community can provide further synergy within this framework.

Community

Continuing the partnership between the medical community and local schools to support students remained the primary goal of TFD project. When pandemic restrictions challenged the continuation of the program, discovering a new path for the lessons in a timely manner while also supporting students, parents, and staff became the updated objective of the program. Adaptation of curriculum and close partnerships with the schools bolstered the commitment to the health of the students. Because the relationship between the schools and the program had already been established for many years, there was an element of trust with school stakeholders that enhanced the ability of the program to continue virtually and recruit families during the summer sessions. Previous studies in nutrition education and support have also shown that community relationships can take years to develop (Tanumihardjo et al., (2023)). Even though the new learning programs were based in a virtual context outside of the community (mostly in students’ individual homes) we found that leveraging the community dynamic improved the virtual learning environment.

Although the program joined the school community as an external partner coming into each classroom, there were noted benefits to this dynamic. Teachers discussed that students were more engaged with lesson topics due to the novelty of having outside guests facilitate the program. The presence of guests from the medical school also prompted further classroom conversations about continuing education through graduate school and the role of doctors in the community, topics which received positive reviews from teachers. Integrating into the school campus and gathering benefits and barriers to utilizing the farmers markets provided valuable suggestions from participants to further improve the program.

Given the feedback from parents and teachers, we recommend similar programs to integrate into the school or local community and include community resources, such as farmers markets, to promote the role of the educational program within preexisting frameworks.

Engagement

The program received the greatest number of opportunities for positive changes within the engagement arena. Feedback from teachers and families suggested engagement through hands-on activities (like snacks that had been made in the classroom in previous years during in-person lessons) and resources sent home could help bridge the gap between the post-lesson quiz scores seen this year as compared to previous in-person years. Many of the support systems identified by teachers to improve the school year lessons and increase parental involvement (such as lesson materials available at home) were also mentioned by parents during the summer program as lesson highlights. The student-instructors’ roles as role models and TFD as a unique learning experience helped promote engagement, while fading interest in online learning platforms and limited opportunities for hands-on activities and at-home activities decreased engagement.

It is important for programs seeking to update curricula to hold feedback sessions to reinforce the connection and cooperation between involved parties. These focus group sessions ultimately propelled the program to develop a stronger framework to continue the goal of effective and sustained nutrition education for students while also supporting local school partners.

Limitations

Limitations of the school year program included no virtual pre-lesson quiz data from the 2020–2021 school year for comparison to post-lesson quiz data and a 26.6% reduction in potential sample size due to students opting not to elect to complete the quiz virtually. Limitations to the summer program include limited sample size and potential participant bias. There was possible response bias due to group teacher focus groups conducted with all the teachers and educational support staff from the third-grade team, although participants were included to answer independently from others on their teaching team. Potential volunteer bias may alter the group demographics as they may have different motives than the general public for joining the program. Since the family interviewer also taught the summer lessons, a respondent bias may be present. These limitations could have decreased the diversity in teacher, student, and parent responses, therefore effectively reducing variability in the data. To limit these biases, future research could involve larger sample sizes or use interviewers outside of the research team. The percent agreement for focus group coding was 84% for the virtual school year program and 75% for the virtual summer program.

Conclusions

Though this study, we sought to define the community and pedagogical factors that promote and sustain successful virtual nutrition education partnerships and discovered support, community, and engagement as key pillars to optimize interactions between students, parents, teachers, and academic medical centers. This study represents an innovative approach to community nutrition partnerships by analyzing not only student participant knowledge gain and qualitative feedback with modern virtual learning platforms but also engaging key support systems through parents and siblings in addition to educational partners in teachers and educational support staff.

When support, community, and engagement are optimized in nutrition education lessons, there is further interaction with lesson material. Through analysis of the focus group themes, it becomes clear that the three main lesson themes rely on each other. Engagement was optimized through strategies to make the lessons more interactive, but increased lesson engagement was made possible through the support of participants and community resources. Families endorsed a feeling of support that was tied to having engaging lessons and having community resources to reinforce lesson topics. Teachers had a similar feeling through student engagement with the novelty of the nutritional curriculum and potential for further integration into the school system. Community resources were successfully integrated into the program due to parents’ relationship with the program, and future opportunities for involvement within the school community were developed based on teacher feedback during focus groups and subsequent learning sessions. Emphasizing all three main themes is important for programs looking to integrate these nutrition education programs into their schools successfully for learners.

When bringing health topics to the elementary school setting, it is beneficial for similar programs to incorporate the framework of support, community, and engagement as imperative tenets to guide curriculum implementation. For new programs looking to get started within the school system, efforts to deliver curriculum can be organized and built out using the themes as a guiding structure. If these avenues are not able to be optimized in a virtual setting for a particular program, conducting sessions in-person may be more useful. Based on the wide sample size across schools, results have the potential to be adapted to school and family settings in a variety of circumstances.

Looking into the future, education and child health are certain to face additional challenges due to factors such as changing technologies, climate change, the wealth gap, rising mental health concerns, and the obesity epidemic. The COVID-19 pandemic provided a unique opportunity for the exploration of strategies to improve childhood health during a shifting virtual education landscape and development of the framework of support, community, and engagement to benefit students now and in future unprecedented times.