Intervention Summary

An Apple A Day

An Apple A Day (AAAD) is a universal literacy-based program that helps to build and reinforce resiliency skills for substance abuse prevention and mental health promotion in children in kindergarten through 4th grade. Based on the principles of risk and resilience, AAAD focuses on the following concepts: (1) literacy; (2) personal sense of safety; (3) development of positive friendships; (4) self-esteem, self-respect, and self-efficacy; and (5) awareness of the dangers of alcohol, tobacco, and other drugs. To introduce each of these concepts, AAAD uses age-appropriate trade books, writing exercises, music, hands-on activities, role-playing, and brainstorming activities that engage the children in an interactive learning process. It also uses a curriculum that includes an instructional video, lesson plans, book summaries, student journal pages, drug fact sheets, sample letters to parents, evaluation tools, a resource guide, and book lists. In addition, participants receive incentives (e.g., stickers, pencils, erasers), which serve as reminders of the information and concepts presented, as well as three free books during the school year or two free books during the summer.

AAAD begins in kindergarten and continues through 4th grade. A trained prevention educator with a bachelor's degree in education, community psychology, or substance abuse counseling delivers the program each school year in weekly lessons for 6-8 weeks in 30-minute (kindergarten and 1st grade) or 45-minute (2nd-4th grades) sessions.

In the study reviewed for this summary, participants were in the 4th grade, and the intervention was delivered over 8 weeks.

Descriptive Information

Areas of Interest	Mental health promotion Substance use disorder prevention
Outcomes	1: Identification and use of a safe person and place 2: Reading habits and attitudes
Outcome Categories	Education
Ages	6-12 (Childhood)
Genders	Male Female
Races/Ethnicities	American Indian or Alaska Native Asian Black or African American Hispanic or Latino White Race/ethnicity unspecified
Settings	School
Geographic Locations	Urban Suburban
Implementation History	An Apple A Day has been implemented in over 20 school districts and community centers in Florida, Minnesota, Montana, New York, and Texas. Approximately 4,500 students have participated in AAAD on a yearly basis.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: No Evaluated in comparative effectiveness research studies: No
Adaptations	No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	Universal

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

O'Neill, S. An evaluation of ACCA's An Apple A Day substance abuse prevention program: Preliminary report. Unpublished manuscript.

Outcomes

Outcome 1: Identification and use of a safe person and place
Description of Measures	Identification and use of a safe person and place were measured using 4 items from a self-report survey, which was developed for the study and asked students whether they had a safe person and place to go to when feeling sad, scared, or lonely and whether they went to that safe person or place when they needed to. Students rated each item using a 4-point Likert scale ranging from "always" to "never."
Key Findings	The intervention group, which received AAAD after the pretest, was made up of 4th-grade students from schools that had administered AAAD each year, and 90% of these students had received AAAD before the 4th grade. The control group was made up of 4th-grade students from schools that had not administered AAAD. None of the students in the control group had ever received AAAD; however, they were offered the intervention after the completion of the study. Intervention and control schools were matched according to setting (i.e., urban or suburban) and student needs in relation to district resources. At posttest (8 weeks after pretest), compared with students in the control group, students in the intervention group were better able to identify and use a safe person and place (p = .01).
Studies Measuring Outcome	Study 1
Study Designs	Quasi-experimental
Quality of Research Rating	1.4 (0.0-4.0 scale)

Outcome 2: Reading habits and attitudes
Description of Measures	Reading habits and attitudes were measured using 11 items from the Elementary Reading Attitude Survey and the Motivation To Read Profile. Students responded to each item (e.g., "I tell my friends about good books I read," "How often do you read outside of school?") by using a 4-point Likert scale or selecting a multiple-choice option.
Key Findings	The intervention group, which received AAAD after the pretest, was made up of 4th-grade students from schools that had administered AAAD each year, and 90% of these students had received AAAD before the 4th grade. The control group was made up of 4th-grade students from schools that had not administered AAAD. None of the students in the control group had ever received AAAD; however, they were offered the intervention after the completion of the study. Intervention and control schools were matched according to setting (i.e., urban or suburban) and student needs in relation to district resources. At posttest (8 weeks after pretest), compared with students in the control group, students in the intervention group had more positive reading habits and attitudes (p = .03).
Studies Measuring Outcome	Study 1
Study Designs	Quasi-experimental
Quality of Research Rating	1.3 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	6-12 (Childhood)	53% Female 48% Male	33% Race/ethnicity unspecified 31% White 20% Black or African American 7% Hispanic or Latino 6% American Indian or Alaska Native 3% Asian

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Identification and use of a safe person and place	1.5	1.8	0.8	2.0	1.5	1.0	1.4
2: Reading habits and attitudes	0.8	2.0	0.8	2.0	1.5	1.0	1.3

Study Strengths

Questions from standardized instruments were used, although they were modified for a 4th-grade reading level. The researchers used an appropriate, conventionally accepted measure of reliability (split-half). The items used to assess the outcomes have face validity. Pre- and posttests were matched, and data from students missing either test were excluded from analyses. Intervention and control schools were matched. By including methods that minimized the presence of educators and teachers in the classroom during survey administration, the researchers addressed possible demand characteristics and bias. Sample size was adequate.

Study Weaknesses

No information was provided about whether the modified questions were piloted to determine if 4th-grade students understood the wording. The split-half reliability estimate of the items assessing reading habits and attitudes was low. Cronbach's alpha statistics were not provided for the scales. Validity of the measures was not demonstrated (e.g., construct and criterion validity). Although it was reported that evaluators spent time with each educator in random experimental conditions to assess implementation fidelity, specific detailed information on fidelity was not provided (e.g., whether all lesson activities were conducted, how well the educators adhered to the core constructs of the curriculum, level of attendance and participation by program participants). Analyses were not conducted to determine whether there were differences between those who completed both pre- and posttests and those who did not. No information was provided regarding how items with missing responses were taken into account in the analysis of results. There were differences between the intervention and control groups at pretest; therefore selection bias could have confounded the results, especially since most students in the intervention group had received the program prior to the pretest.

Readiness for Dissemination

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

An Apple A Day, Living and Learning Through Literature: A Prevention Education Curriculum. Includes:

First Grade Journal
Fourth Grade--First Day Survey
Fourth Grade Journal
Fourth Grade--Last Day Survey
Kindergarten Journal
Living and Learning Through Literature: Curriculum Training Video
Living and Learning Through Literature: Train-the-Trainer Presentation
Principal Questionnaire
Program Evaluation
Second Grade Journal
Third Grade--First Day Survey
Third Grade Journal
Third Grade--Last Day Survey

Trade books:

Bourgeios, P., & Clark, B. Franklin fibs. New York: Scholastic.
Cannon, J. Stellaluna. New York: Scholastic.
Carlson, N. I like me. New York: Scholastic.
Freeman, D. Corduroy. New York: Scholastic.
Hoffman, M., & Binch, C. Amazing grace. New York: Scholastic.
Lionni, L. A color of his own. New York: Scholastic.
Lovell, P., & Catrow, D. Stand tall, Molly Lou Melon. New York: Scholastic.
MacDonald, A., & Fox-Davies, S. Little Beaver and the echo. New York: Scholastic.
Manus Pinkwater, D. The big orange spot. New York: Scholastic.
Willis Hudson, C., & Ford, B. G. Bright eyes, brown skin. New York: Scholastic.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
4.0	3.5	3.5	3.7

Dissemination Strengths

Program materials are of high quality and developmentally appropriate for the intended audience. The program uses easily accessible trade books that effectively represent diverse experiences and backgrounds. The training materials include clear and understandable strategies for program implementation. The quality assurance materials are straightforward and include separate questionnaires for principals, teachers, and presenters, which serve as tools for program evaluation. Pre- and postprogram survey tools are included to measure program effectiveness.

Dissemination Weaknesses

The train-the-trainer materials only provide basic information, without additional detail. Little guidance is provided on using outcome data to improve program delivery.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
An Apple A Day curriculum (includes some trade books)	$350 each	Yes
Trade books not included in the curriculum	$1.99-$3.99 each	Yes
Incentives (e.g., stickers, pencils, erasers, stamps, red ribbons)	Varies, depending on type and number of incentives	No
An Apple A Day online training	Free	No
4-hour, on- or off-site train-the-trainer workshop	$25 per individual or $250 per group (12-30 participants), plus travel expenses	No
On- or off-site consultation training	Included in cost of curriculum (travel expenses additional for sites farther than 150 miles from the developer)	No
Phone and email technical assistance	Included in cost of curriculum	No

Additional Information

Train-the-trainer workshops also are available for New York State Office of Alcoholism and Substance Abuse Services credentialing certificate hours. There is no extra cost for these workshops, which are 6 hours in length.