{'fraction_non_alphanumeric': 0.02921971922951355, 'fraction_numerical': 0.011753183153770812, 'mean_word_length': 5.2274459974587035, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Family Perceptions of a Cooking and Nutrition Program for Low-Income Children and Adolescents

Background. Flint Kids Cook, a nutrition and culinary program for children and adolescents, was created in October 2017 to address health concerns among youth and families in a low-income, urban community. In this study, researchers examined family experiences with the 6-week, chef-led program, which was taught in a farmers’ market kitchen. Methods. At the conclusion of each session, researchers used an open-ended focus group format to assess program experiences, perceived impact on youth self-efficacy for cooking and healthy eating, and caregiver support. This qualitative study was guided by thematic analysis. Results. Between November 2017 and December 2018, 72 caregivers (n = 38) and students (n = 34) participated in separate focus groups. Caregivers were primarily female (74%) and African American (71%). Most students were African American (76%) and half were female. Recurrent themes included food acceptance, dietary modifications, confidence in the kitchen, and program design. Caregivers and students agreed that location and design of the program alongside facilitation by an experienced chef were important factors for program success. Conclusions. This study demonstrated that a chef-led healthy cooking program for youth was effective in improving perceived food acceptance, dietary habits, and confidence in the kitchen. The program could be modeled in similar communities to address diet and health of children and adolescents.


Background
Children and adolescents, particularly those living in low-income households, consistently fail to meet dietary recommendations. [1][2][3][4] Given the connection between poor dietary patterns among youth and negative health outcomes, [5][6][7][8][9] there is a critical need for public health programs to address persistent barriers to healthy eating beyond basic nutrition education. Although numerous factors contribute to dietary inadequacies, a societal decline in culinary skills 10,11 and related increase in frequency of away-from-home meals 12,13 are well-recognized challenges to achieving healthy dietary habits among children and adolescents in the United States. Although some nutrition programs have responded by adding culinary skills instruction, [14][15][16] few have utilized credentialed chefs as primary instructors.
Including a chef in nutrition education programs can promote long-term health by giving young people the knowledge and skills necessary to prepare nutritionally adequate meals and snacks. [17][18][19] With the introduction of television programs and social media that involve children and adolescents cooking alongside chefs, there has been a "culinary awakening" among people of all ages, races, and socioeconomic backgrounds. 11 Recent studies have further suggested that watching television cooking shows may encourage consumption of certain foods among children. 20,21 Considering the growing popularity of cooking shows alongside their potential to change dietary behaviors of children and adolescents, healthy cooking programs facilitated by credentialed chefs could have meaningful impacts on youth, especially those at greatest risk for poor dietary behaviors. 3,22,23 Flint Kids Cook (FKC), a nutrition and culinary program for children and adolescents, was created in October 2017 to address health concerns among youth and families exposed to lead-tainted drinking water in Flint, Michigan. As the crisis unfolded, caregivers of patients at Hurley Children's Center, a large pediatric clinic in Flint, shared specific worries about child and adolescent nutrition, including limited food preparation skills in the home. 24 In direct response, a team of local chefs, registered dietitians, and researchers developed FKC. The intervention was grounded in social cognitive theory (SCT), which explains changes in behavior as the result of interactions between an individual's personal and environmental systems. [25][26][27] FKC provided interactive nutrition education and food preparation activities to improve youth knowledge, skills, and self-efficacy for cooking healthy snacks and meals at home. Environmental factors, such as caregiver support and access to healthy foods, were also addressed through the provision of take-home educational materials, recipes, and youth-friendly cooking utensils. 28 As described in an earlier publication that reported the program's impact on health-related quality of life among students, 29 FKC comprised a total of 9 hours of instruction over the course of 6 consecutive weeks. Unique to the program was its facilitation by a credentialed chef, with the assistance of a registered dietitian, who taught every class in a farmers' market commercial kitchen. Recipes and curriculum content were developed in accord with the United States Department of Agriculture's (USDA's) MyPlate. 30 During the 90-minute sessions, each dedicated to a specific food group, students (8-18 years of age) worked in groups of 3 to 4 to prepare 2 dishes that were representative of that week's food group. The children and adolescents were also encouraged to practice at home using a "homework bag" distributed to them at the end of 3 separate classes. The reusable bags each held a recipe, ingredients, and a feedback sheet for students to describe experiences with food preparation at home. The 6-week series culminated in a celebratory family dinner that the students prepared. Although caregivers did not participate in any of the classes, they were invited to observe each session from outside a window in the farmers' market kitchen.

Purpose
The current study sought to qualitatively examine family experiences with FKC through the voices of students and their caregivers.

Study Design
This was a qualitative study of FKC, a healthy cooking program at a local farmers' market for children and adolescents in a low-income, urban area. Researchers purposively sampled students who had completed FKC and their caregivers to assess family experiences with the program.

Study Setting and Recruitment
An estimated 60% of youth live below the poverty line in Flint, Michigan, 31 and the community continues to struggle with a limited number of full-service grocery stores operating within city limits. 32 A lead-in-water crisis that negatively impacted the health and well-being of children and adolescents in Flint has further exacerbated challenges with food access and affordability. 33,34 In response to caregiver concerns about child nutrition, a team of local chefs, registered dietitians, and researchers developed FKC. Posters and flyers were displayed in local pediatric offices and partnering community sites in Flint to recruit students into the program. Children and adolescents who were 8 to 18 years old, spoke English, and had not participated in a prior session of FKC were eligible to participate. Although Flint residency was not required, most students reported living at a Flint address. Caregivers and students were not charged for enrollment or cooking incentives.

Qualitative Assessment
Following the tenets of qualitative methodology, the research team developed an open-ended focus group format to assess program experiences; impact on youth self-efficacy for cooking and healthy eating; and caregiver support. Two members of the research team, trained in qualitative research methods, facilitated focus groups. The focus group guide (Table 1) was developed using literature, [14][15][16] SCT, and researchers' experiences with the topic and population. Questions were exploratory with a focus on FKC and related relationships with dietary behaviors and meal preparation at home.
Researchers collected data via 11 separate semistructured focus groups with caregivers (6 total groups) and students (5 total groups) between November 2017 and December 2018. All focus groups took place during the final class in the 6-week series; therefore, only caregivers and students in attendance on the final day were eligible. Caregiver focus groups occurred while students were preparing a meal for their families. Students participated in the focus groups immediately following meal preparation. Individuals participated in only 1 focus group, lasting 45 to 65 minutes. Mean number of participants was 7 for student focus groups (range 5-8) and 6 for caregiver focus groups (range 3-10). No incentive was provided for focus group participation. After a total of 72 caregivers and students participated in a focus group, researchers terminated data collection based on a joint conclusion that data related to the primary research questions were repetitive, and no additional concepts were being observed. 35

Data Analysis
Focus group audio recordings were transcribed verbatim for textual data analysis. Researchers used a multistep coding process, guided by thematic analysis, [36][37][38] to uncover and analyze patterns across transcripts and formulate illustrative themes. 39 Three researchers completed an initial coding process, independently highlighting, labeling and developing potential categories for thematic purposes. Less reflective themes were then eliminated, and similar themes collapsed. Finally, explanatory quotations were selected to support the final themes and sub-themes. Descriptive data were recorded and analyzed using SPSS statistical software (version 23, IBM Corp., Armonk, NY, 2015).

Ethical Approval and Informed Consent
The current study received exempt status from the Michigan State University Institutional Review Board (IRB exemption number: x17-820e) for research conducted in commonly accepted educational settings that involves normal educational practices. Written consent was obtained from caregivers and assent was obtained from children and adolescents. The study was carried out in accordance with the ethical principles established by the Declaration of Helsinki.

Results
Between October 2017 and December 2018, 71 students (mean age 10.9 ± 2.3) participated in FKC. The majority of students were African American (85%) and residents of Flint (78%), and approximately half were female (51%). A total of 72 caregivers (n = 38) and students (n = 34) participated in focus groups to examine family perceptions of the program. As shown in Table  2, caregivers were primarily female (74%) and African American (71%). Most of the students who participated in focus group discussions (mean age 10.6 ± 2.2) were African American (76%) and residents of Flint (88%), and half were female (50%). Presented below are the findings of the following recurrent themes that emerged during focus group discussions: (i) food acceptance; (ii) dietary modifications; (iii) confidence in the kitchen; and (iv) program design. These themes are organized in Table 3 according to associated sub-themes.
Food acceptance. Student engagement in food preparation during the program was credited with improving overall food acceptance. Many caregivers, who described their own children as "picky eaters," shared how participation in the program improved willingness to try new foods at home (Table 3, sub-theme 1.1). Some said unfamiliar foods that were introduced during the program were later requested at home. Others recalled their surprise when watching their own children taste foods during class that had been previously refused at home. Similarly, students discussed experimentation with a variety of foods during FKC classes as well as increased acceptance of new foods at home. Many caregivers discussed their children's newfound desire to participate not only in food preparation, but also in food shopping (Table 3, sub-theme 1.2). In addition to receiving requests for foods that were introduced during the program, some caregivers said that children and adolescents started to talk more about food, particularly during trips to the grocery store. Several caregivers further described how their daughter or son began to purchase these foods with their own money. She (daughter) will tell me, "Mom, I need you to pick up this and that from the store." And if I come home from work without it, she will say, "Well, come on. We better put our coats on, so we can go to the store." I say I'm tired, and she says, "It's okay, I'll get everything. You just walk in and pay." (African American female caregiver, 1C) Since the class, he (son) is constantly reminding the family that we should eat more of this or shouldn't have too much of that. So, he is conscious of it. And when we take him to the grocery store with us, he always runs and brings stuff to us and says, "We need this! We need this!" (African American male caregiver, 1C) Dietary modifications. Caregivers and students recognized that the program included not only culinary education and shopping My daughter swore she hated sweet potatoes, but the second she made the [recipe from class], she came home and said, "Buy sweet potatoes!" I looked at her like she was crazy, and she said, "I like them now." (Caucasian female caregiver, 1C) When we go to the grocery store, she (daughter) is like, "Buy this. Buy this." [She] gets a weekly allowance, so she also buys stuff on her own and brings it home and says, "I bought this, and I learned this (in class), and we had this (in class 2. At-home meals He (son) would rather stay in and eat. After school he used to say, "I'm hungry." And I would say, "Okay, wait until we get home, and we will make something." And he would say, "No, stop somewhere." Now, we just pull everything out of the cupboards, and he will go at it. He says, "We will have this. We will have this. 3. Take-home recipes What I liked the most about the program was that the children were given ingredients to take home and prepare those items at home. (African American female caregiver, 1C) When we are driving home (from FKC), she's always excited about cooking stuff for the family, and she wants to surprise us. It's easy (take-home) recipes that they can make themselves, so she is really proud of that. This cooking will make her independent too. (Caucasian female caregiver, 1C) Abbreviations: FKC, Flint Kids Cook; #C, number of children in the household who participated in FKC.

Table 3. (continued)
cooking, but also instruction related to the importance of proper nutrition. Most credited FKC with encouraging healthy eating habits at home (Table 3; sub-theme 2.1). Some caregivers described an increased awareness of foods during the program, noting that their daughter or son made requests for more variety in meals and snacks prepared at home, particularly in relation to fruits and vegetables. Similarly, students talked about a desire to eat healthier as their food preparation skills improved.
[ Many caregivers discussed a decrease in consumption of meals and snacks away from home as interest in food preparation grew (Table 3; sub-theme 2.2). Some shared that children and adolescents were less likely to request fast food and pre-packaged foods while participating in the program. Others discussed how their children became more interested in preparing fresh foods at home. Confidence in the kitchen. Caregivers and students described a new feeling of confidence that resulted from participation in FKC. Caregivers specifically noted the influence of the program on youth interest in cooking (Table 3; sub-theme 3.1). Nearly every caregiver talked about their student's strong desire to attend class every week, sharing stories of notes left throughout their homes to remind caregivers of the cooking classes or wearing FKC aprons when they returned home from school. Caregivers who watched the classes from outside the kitchen also commented on student engagement during the sessions. Many caregivers talked about feeling more comfortable with their child or adolescent cooking at home because of noticeable improvements in cooking skills during the program (Table 3; sub-theme 3.2). Some caregivers were reluctant to allow their daughter or son to cook independently prior to participation in FKC. However, after learning proper food preparation techniques from an experienced chef, caregivers expressed a willingness to support students in practicing these skills at home. Similarly, students credited the class for facilitating improvements in cooking skills. Caregivers discussed the importance of FKC in teaching life-skills (Table 3; sub-theme 3.3). Many highlighted the importance of cooking at home in contrast to purchasing prepared meals or fast foods and, as a result, shared intentions to continue to support their children's growing interest in food preparation. Some caregivers, whose daughter or son enrolled in the class with an interest in a career in culinary arts, acknowledged how the program reinforced this as a career option. Similarly, students recognized the importance of learning to prepare foods as they grow older to support a healthy lifestyle. Program design. Caregivers and students agreed that location and design of the program were important for success. FKC was facilitated inside of a farmers' market kitchen where students worked at large tables in teams of 3 to 4. It was necessary for students and families to walk through the farmers' market to reach the kitchen. Students talked extensively about the classroom structure and setting that encouraged hands-on learning and teamwork (Table 3; subtheme 4.1). Most preferred the farmers' market kitchen to their school kitchens, which were often regarded as either too small to support the program or entirely absent within their schools. Caregivers appreciated the large kitchen as well as the exposure to a variety of fresh foods available within the farmers' market. Nearly every caregiver and student pointed to the importance of the experienced chef who facilitated the classes ( Take-home recipes with necessary ingredients were supplied to students at the end of 3 of 6 class sessions (

Discussion
Previous research reported significant improvements in cooking skills, attitude toward cooking, and healthrelated quality of life among children and adolescents who participated in FKC. 29 The current study further illustrates that caregivers and students perceive the program to have a positive influence on food acceptance, dietary habits, food preparation at home, and interest in cooking among students. Central to our findings was the importance of a credentialed chef facilitator who was acknowledged by caregivers and students for skillfully teaching food preparation and recipe modification. Students agreed that the inclusion of the chef was critical to their enjoyment and learning throughout the program. In addition, many caregivers, who watched outside the kitchen during the classes, credited the chef with capturing the attention of young students during the program. This finding supports limited research that has suggested experiential cooking and nutrition programs facilitated by chefs may be effective in increasing learning and enjoyment among children and adolescents. 19 The site of the program was also considered important to success. Although a recent review suggested that integration of culinary programs within the academic curricula may improve their effectiveness, 11 limitations of schools that are located in low-income areas should be acknowledged. Most children and adolescents who participated in focus group discussions felt strongly about facilitation of the class within a kitchen but indicated that kitchens within their schools were either too small to accommodate the class or altogether absent. Most felt that changing the location of FKC to their respective schools would lessen both impact and enjoyment. Caregivers further appreciated that the location of FKC exposed their daughter or son to fresh, locally grown foods, as well as farmers in the community. With previous evidence suggesting that farmers' market nutrition programs are associated with increases in child consumption of fruits and vegetables, 40 healthy cooking programs that simultaneously expose youth to farmers' market kitchens and fresh, local foods have strong potential to enhance learning and behavior.
Research suggests that Americans are increasingly eating meals away from home, a behavior that has consistently been associated with adverse nutritional consequences. 12,41,42 Although not specifically measured in the current study, caregivers talked extensively about the impact of FKC on fast foods purchasing. When presented with options, most caregivers indicated that children and adolescents preferred experimenting with foods at home rather than purchasing prepared or fast foods while they were participating in the program. Caregivers credited FKC with this specific change in child and adolescent dietary behaviors. Given the association between eating meals and snacks away from home and health of youth, 12,13,41 this particular finding is notable.
Finally, the current study supports previous literature demonstrating that early experiences with food have a formative impact on dietary behaviors. 22 Interestingly, the impact of the current program reached beyond the home and into grocery stores. Many caregivers shared specific experiences related to youth interest in food shopping while participating in FKC. This finding is particularly important considering recent evidence that suggests child involvement in food purchasing helps direct food choices to unfamiliar foods that are healthy. 43 Future research will investigate the influence of FKC on household food shopping and household food environment using validated assessments.
Limitations of the current study should be acknowledged. The sample was small and specific to 1 program that targeted children and adolescents residing in a lowincome, urban area. Therefore, results may not be generalizable to a broader population. However, FKC could certainly be modeled in areas confronted with similar challenges related to youth dietary patterns and access to innovative nutrition and health programs. Although such areas may face challenges securing funding and access for similar programs, limitations of alternative designs must be considered, as caregivers and students alike identified the program's facilitation by a chef and location inside a farmers' market commercial kitchen as key components of its success. Lastly, there may have been selection bias if feedback from families who chose not to participate in focus groups or were absent from the final session differed from those who agreed to share their experiences. It is important to note, however, that every student and nearly every caregiver asked to participate in the focus groups agreed to do so.

Conclusions
Although research suggests that cooking programs may positively influence food-related preferences and behaviors among children and adolescents, 14-16 multiple knowledge gaps related to youth experiences, ideal program length, and intervention components remain. 14 The current study demonstrated that a chef-led healthy cooking program designed to engage and educate children and adolescents was perceived as effective in improving student food acceptance, dietary habits, and confidence in the kitchen. Given recent challenges related to COVID-19, future research will investigate feasibility and preliminary effectiveness of a virtual version of FKC.

Author Contributions
AS-C conceived the study, study design and analysis; collected data; led analysis of the data; and led all writing and drafting of the manuscript. MG recruited participants into the study, collected data, and participated in data analysis and drafting of the manuscript. HCL contributed significantly to interpretation of results and drafting of the manuscript. MH-A assisted in conceptualization of the study and the drafting and revising of the manuscript. ON participated in data collection and drafting and revising of the manuscript.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by Michigan Health Endowment Fund (R-1710-141906); and Flint H2O project (The Michigan Health Endowment Fund and Flint H2O project had no role in the design, analysis or writing of this article.)