CAFÉ: a multicomponent audit and feedback intervention to improve implementation of healthy food policy in primary school canteens: a randomised controlled trial

Robust implementation of school food policy is needed to improve nutritional outcomes of children in European and Western Pacific countries: A systematic review

OBJECTIVE

The present systematic review explored compliance status with school food policies in Europe and the Western Pacific regions, challenges and facilitators of policy compliance, and its impact on children's diets and nutrient intakes.

RESEARCH METHODS

An electronic search for full-text research articles published between January 2009 and July 2023 was conducted in Science Direct and PubMed scientific databases.

RESULTS

A total of 659 titles and abstracts were screened, and final data was extracted from 34 included studies. Results showed low compliance with the school food policy in Europe and the Western Pacific regions. The European schools chad better compliance than the Western Pacific, and supportive interventions improved policy adherence. Impact assessment studies reported that the implementation of the school food policy increased fruit and vegetable consumption, thus increasing nutrient intakes (vitamin A, vitamin D, iron, calcium, folate, and dietary fibers). However, its impact on the availability and consumption of foods high in fat, sugar, and salt (HFSS) was less conclusive. The effects of the policy on the school food environment indicated no significant improvement.

CONCLUSION

Results highlighted the need for additional support and surveillance at the school level to ensure adequate policy compliance.

An audit of the dissemination strategies and plan included in international food-based dietary guidelines

OBJECTIVE

Food-based dietary guidelines (FBDG) are an important resource to improve population health; however, little is known about the types of strategies to disseminate them. This study sought to describe dissemination strategies and content of dissemination plans that were available for FBDG.

DESIGN

A cross-sectional audit of FBDG with a published English-language version sourced from the United Nations FAO repository. We searched for publicly available dissemination strategies and any corresponding plans available in English language. Two authors extracted data on strategies, which were grouped according to the Model for Dissemination Research Framework (including source, audience, channel and message). For guidelines with a dissemination plan, we described goals, audience, strategies and expertise and resources according to the Canadian Institute for Health Research guidance.

SETTING

FBDG from fifty-three countries mostly from high-income (n 28, 52·8 %), and upper-middle income (n 18, 34 %) areas were included.

PARTICIPANTS

n/a.

RESULTS

The source of guidelines was most frequently health departments (79·2 %). The message included quantities and types of foods, physical activity recommendations and 88·7 % included summarised versions of main messages. The most common channels were infographics and information booklets, and the main end-users were the public. For twelve countries (22·6 %), we were able to source an English-language dissemination plan, where none met all recommendations outlined by the Canadian Institute for Health Research.

CONCLUSIONS

The public was the most frequently identified end-user and thus most dissemination strategies and plans focused on this group. Few FBDG had formal dissemination plans and of those there was limited detailed provided.

Private school canteens: an analysis of the economic and financial aspects of the traditional and the healthy models

BACKGROUND

One of the reasons for the more prominent resistance of canteen managers to implementing healthy canteens is based on the belief in the economic infeasibility of these models. The research aimed to verify the economic and financial viability of traditional and healthy models of school canteens in a Brazilian metropolis.

METHODS

The case study was carried out with 36 companies in the school canteen sector in a Brazilian metropolis. The classification of items sold in canteens considered the extent and purpose of food processing according to the NOVA Classification. The characterization and definition of traditional canteens and healthy canteens were proposed considering the amount of in natura or minimally processed foods and culinary preparations without the presence of ultra-processed foods; the percentage of ultra-processed foods or processed foods or culinary preparations with the presence of ultra-processed foods; and the existence of prohibited foods. The economic and financial analysis was carried out mainly through the evaluation of profitability. Data were collected through an electronic self-administered questionnaire sent to canteen managers. The Mann-Whitney test was used to compare medians and the Chi-Square/Fisher's Exact Test to compare proportions.

RESULTS

The study included six companies, responsible for 36 canteen units in private schools, 30 classified in the traditional model (83.3%), and six in the healthy model (16.7%). The median percentage of natural, minimally processed foods and commercialized culinary preparations was higher among the healthy model canteens (87.9% vs. 60.0%, p < 0.001). While the median percentage of ultra-processed, processed, or preparations with the presence of ultra-processed (40.0% vs. 12.1%, p < 0.001) and prohibited foods (10.0% vs. 0%, p < 0.001) sold was higher in the traditional model canteens. The results indicated that the profitability in the healthy canteens was higher (p < 0.001) than in the traditional ones.

CONCLUSIONS

Healthy school canteens showed better financial and economic results compared to traditional canteens with emphasis on greater profitability and a shorter recovery time of the initial investment.

The impact of an e-newsletter or animated video to disseminate outdoor free-play information in relation to COVID-19 guidelines in New South Wales early childhood education and care services: a randomised controlled trial

BACKGROUND

State-based Guidelines were issued for Early Childhood Education and Care (ECEC) services (caring for children 0-6 years) recommending greater time outdoors and inclusion of indoor-outdoor programs to facilitate social distancing to reduce spread of COVID-19. The aim of this 3-arm randomised controlled trial (RCT) was to examine the impact of different dissemination strategies on increasing ECEC service intentions to adopt recommendations from the Guidelines.

METHODS

This was a post-intervention only RCT. A sample of eligible ECEC services in New South Wales (n = 1026) were randomly allocated to one of three groups; (i) e-newsletter resource; (ii) animated video resource; or (iii) control (standard email). The intervention was designed to address key determinants of guideline adoption including awareness and knowledge. Following delivery of the intervention in September 2021, services were invited to participate in an online or telephone survey from October-December 2021. The primary trial outcome was the proportion of services intending to adopt the Guidelines, defined as intention to; (i) offer an indoor-outdoor program for the full day; or (ii) offer more outdoor play time. Secondary outcomes included awareness, reach, knowledge and implementation of the Guidelines. Barriers to Guideline implementation, cost of the dissemination strategies and analytic data to measure fidelity of intervention delivery were also captured.

RESULTS

Of the 154 services that provided post-intervention data, 58 received the e-newsletter (37.7%), 50 received the animated video (32.5%), and 46 received the control (29.9%). Services who received the animated video had nearly five times the odds (OR: 4.91 [1.03, 23.34] p = 0.046) than those in the control group, to report having intentions to adopt the Guidelines. There were no statistically significant differences in awareness or knowledge of the Guidelines between either intervention or control services. Development costs were greatest for the animated video. The extent to which the dissemination strategy was viewed in full, were similar for both the e-newsletter and animated video.

CONCLUSION

This study found potential for the inclusion of interactive strategies to disseminate policy and guideline information within the ECEC setting, in the context of the need for rapid communication. Further research should explore the added benefits of embedding such strategies within a multi-strategy intervention.

TRIAL REGISTRATION

Retrospectively registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on the 23/02/2023 (ACTRN 12,623,000,198,628).

Exploratory analysis of a cluster randomized controlled trial of a multi-strategy intervention delivered via online canteens on improving the nutritional quality of primary school students' pre-ordered foods & drinks at recess

School canteens are a recommended setting to deliver public health nutrition strategies given their wide reach, and frequent use by children. Online canteens, where users (i.e. students or their carers) pre-order and pay for food and drinks online, represent attractive systems to deliver strategies that encourage healthier food choices. There have been few studies exploring the efficacy of public health nutrition interventions in online food ordering environments. Therefore, this study aims to assess the efficacy of a multi-strategy intervention implemented in an online school canteen ordering system in reducing the energy, saturated fat, sugar, and sodium content of students' online recess orders (i.e. foods ordered during the mid-morning or afternoon snack period). This was an exploratory analysis of recess purchases for a cluster randomized controlled trial that initially sought to examine the efficacy of the intervention on lunch orders. A total of 314 students from 5 schools received the multi-strategy intervention (involving menu labelling, placement, prompting and availability) that was integrated into the online ordering system, and 171 students from 3 schools received the control (usual online ordering). Analysis of main outcomes found that the mean energy (difference: -269.3 kJ; P = 0.006), saturated fat (difference: -1.1 g; P = 0.011) and sodium (difference: -128.6 mg; P = 0.014) content per student recess order was significantly lower in the intervention group than the control group at 2-month follow-up. Findings suggest that embedding strategies to encourage healthier choices within online canteen ordering systems can improve the nutrient composition of student recess purchases. These results add to the current evidence base suggesting that interventions delivered via online food ordering systems represent an effective strategy for improving child public health nutrition in schools.

Strategies for enhancing the implementation of school-based policies or practices targeting diet, physical activity, obesity, tobacco or alcohol use

BACKGROUND

Several school-based interventions are effective in improving child diet and physical activity, and preventing excessive weight gain, and tobacco or harmful alcohol use. However, schools are frequently unsuccessful in implementing such evidence-based interventions.

OBJECTIVES

1. To evaluate the benefits and harms of strategies aiming to improve school implementation of interventions to address student diet, physical activity, tobacco or alcohol use, and obesity. 2. To evaluate the benefits and harms of strategies to improve intervention implementation on measures of student diet, physical activity, obesity, tobacco use or alcohol use; describe their cost or cost-effectiveness; and any harms of strategies on schools, school staff or students.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search was between 1 September 2016 and 30 April 2021 to identify any relevant trials published since the last published review.

SELECTION CRITERIA

We defined 'Implementation' as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised controlled trial (RCT) or non-randomised controlled trial (non-RCT)) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by students to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Given the large number of outcomes reported, we selected and included the effects of a single outcome measure for each trial for the primary (implementation) and secondary (student health behaviour and obesity) outcomes using a decision hierarchy. Where possible, we calculated standardised mean differences (SMDs) to account for variable outcome measures with 95% confidence intervals (CI). For RCTs, we conducted meta-analyses of primary and secondary outcomes using a random-effects model, or in instances where there were between two and five studies, a fixed-effect model. The synthesis of the effects for non-randomised studies followed the 'Synthesis without meta-analysis' (SWiM) guidelines.

MAIN RESULTS

We included an additional 11 trials in this update bringing the total number of included studies in the review to 38. Of these, 22 were conducted in the USA. Twenty-six studies used RCT designs. Seventeen trials tested strategies to implement healthy eating, 12 physical activity and six a combination of risk factors. Just one trial sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials used multiple implementation strategies, the most common being educational materials, educational outreach and educational meetings. The overall certainty of evidence was low and ranged from very low to moderate for secondary review outcomes. Pooled analyses of RCTs found, relative to a control, the use of implementation strategies may result in a large increase in the implementation of interventions in schools (SMD 1.04, 95% CI 0.74 to 1.34; 22 RCTs, 1917 participants; low-certainty evidence). For secondary outcomes we found, relative to control, the use of implementation strategies to support intervention implementation may result in a slight improvement on measures of student diet (SMD 0.08, 95% CI 0.02 to 0.15; 11 RCTs, 16,649 participants; low-certainty evidence) and physical activity (SMD 0.09, 95% CI -0.02 to 0.19; 9 RCTs, 16,389 participants; low-certainty evidence). The effects on obesity probably suggest little to no difference (SMD -0.02, 95% CI -0.05 to 0.02; 8 RCTs, 18,618 participants; moderate-certainty evidence). The effects on tobacco use are very uncertain (SMD -0.03, 95% CIs -0.23 to 0.18; 3 RCTs, 3635 participants; very low-certainty evidence). One RCT assessed measures of student alcohol use and found strategies to support implementation may result in a slight increase in use (odds ratio 1.10, 95% CI 0.77 to 1.56; P = 0.60; 2105 participants). Few trials reported the economic evaluations of implementation strategies, the methods of which were heterogeneous and evidence graded as very uncertain. A lack of consistent terminology describing implementation strategies was an important limitation of the review.

AUTHORS' CONCLUSIONS

The use of implementation strategies may result in large increases in implementation of interventions, and slight improvements in measures of student diet, and physical activity. Further research is required to assess the impact of implementation strategies on such behavioural- and obesity-related outcomes, including on measures of alcohol use, where the findings of one trial suggest it may slightly increase student risk. Given the low certainty of the available evidence for most measures further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

Outcome Evaluation on Impact of the Nutrition Intervention among Adolescents: A Feasibility, Randomised Control Study from Myheart Beat (Malaysian Health and Adolescents Longitudinal Research Team—Behavioural Epidemiology and Trial)

A healthy eating environment in the school setting is crucial to nurture the healthy eating pattern for youth. Thus, it helps to combat the obesity issue. However, the impact of healthy school environment on healthy eating habits among Asian adolescents is scarce and less clear. This clustered randomised-control study has two objectives. The first objective was to evaluate the changes in adolescents’ dietary intake after the interventions for all arms (control; healthy cooking training only; subsidization with healthy cooking training). The second objective was to compare the effect of subsidization with healthy cooking training and healthy cooking training only with the control arm on adolescents’ dietary intakes. This study consisted of 340 secondary school students aged 14 years in rural and urban Malaysia. A total of two arms of intervention and one arm of control were included. Intervention one focused on healthy cooking preparation for the canteen and convenience shop operators. Intervention two included subsidization for fruits and vegetables with a healthy cooking preparation training for the canteen and suggestions on providing healthy options to the convenience shop operators. The outcome measured was changes to dietary intake. It was measured using a three-day dietary history pre- and post-intervention. A paired-t test was used to evaluate the outcome of intervention programmes on dietary changes for all arms (control, intervention one and two). An ANCOVA test was used to investigate the effect of providing subsidization and healthy cooking preparation training to the canteen and convenience shop operators on adolescents’ dietary intakes as compared to the control arm. Overall, the reduction in energy and carbohydrates for all arms were observed. Interestingly, fat intake was significantly increased after the four-week intervention programme under healthy cooking intervention but not in the food subsidization group. When comparing between control, healthy cooking training only and subsidization with the healthy cooking training arm, there was no significant changes between arms. A robust intervention to include subsidization of healthy foods for intervention programmes at schools in a larger scale study is needed to confirm this finding.

What works to improve school lunch nutritional quality - legislation or self-audit?

OBJECTIVE

Sweden updated its legislation on universal free school meals in 2011 and nutrition was explicitly mentioned. This study i) describes cross-sectional changes in school lunch nutritional quality during the following eight years, and ii) examines if repeated self-auditing, using a fully automated, online tool (School Food Sweden), based on the implementation strategy of audit and feedback, was associated with improvements.

DESIGN

Both repeated cross-sectional and longitudinal design. Factors associated with meeting nutritional criteria were examined using variance weighted least squares regression and logistic regression.

SETTING

Sweden.

PARTICIPANTS

Primary schools who self-selected to audit meal quality between March 2012 and July 2019.

RESULTS

Almost half of all (ca 4800) primary schools signed up to use the tool, and 1500 audited nutritional quality at least once. Repeated cross-sectional analyses showed the proportion meeting the nutritional criteria increased significantly between 2012/13 (11%) and 2018/19 (34%). Longitudinally, each additional audit completed increased the odds of meeting the nutritional criteria by 1.30 (CI 1.20-1.41), controlling for region and time elapsed since the legislative change. In 774 schools with repeat audits, both number of audits and frequency of accessing feedback predicted meeting the nutritional criteria (OR 2.02, CI 1.23-3.31), even after adjusting for time since the legislative change and days elapsed since previous audit.

CONCLUSIONS

Both legislation and self-audit with automatic feedback appear effective in helping schools to improve school meal quality. Self-audit with feedback may be an effective complement to legislation, or a promising alternative in settings where regulation is not an option.

Healthy and Safe School Cafeteria Program: a randomized controlled study

ABSTRACT Objective To assess the effect of an educational intervention program focused on health risk conditions, based on an assessment of the hygiene and quality of food sold in school cafeterias. Methods This is a controlled, parallel, randomized, two-arm, community study. Public and private schools with cafeterias were invited to participate. This study was conducted in 27 school cafeterias in northern and northwestern Rio Grande do Sul, a state in southern Brazil. Representatives of the school communities in the intervention group received an educational program consisting of 160-hour distance training. The most relevant outcomes were the assessment of the hygienic conditions and composition of the menus sold in school cafeterias. All outcomes were analyzed as intention-to-treat and per-protocol. For the analysis of continuous data with normal distribution, an analysis of covariance and the Generalized Linear Model were used. The level of statistical significance considered was p<0.05 for a 95% CI. Results No statistically significant difference was observed between the intervention group and the control group in the studied outcomes. There was a reduction of 76.2 points in the score for hygienic handling conditions (95% CI: -205 to 357; p=0.581). Regarding menu composition, the difference between groups was 0.48% (95% CI: -2.69 to 3.64; p=0.760) for ultra-processed foods, 0.23% (95% CI: -1.13 to 1.60; p=0.740) for processed foods, and 1.02% (95% CI: -2.59 to 4.64; p=0.581) for fresh foods. Conclusion There is not enough evidence to conclude that the intervention had a positive impact on any of the outcomes studied.

The effectiveness of canteen manager audit and feedback reports and online menu-labels in encouraging healthier food choices within students' online lunch orders: A pilot cluster randomised controlled trial in primary school canteens in New South Wales, Australia

Online school canteen lunch ordering systems may offer a unique opportunity to support the implementation of school canteen nutrition polices, while delivering behavioural interventions directly to consumers to influence healthy student purchasing. This cluster randomised controlled trial aimed to test the effectiveness of a menu audit and feedback strategy alone, and in combination with online menu labels in encouraging healthier purchasing from an online school canteen ordering system. Five intervention schools received a menu audit and feedback strategy, plus online menu labels; and five control schools received a delayed menu audit and feedback strategy. Data from 19,799 student lunch orders, containing over 40,000 items were included in the evaluation. Outcomes were assessed at baseline (pre-intervention), follow-up 1 (menu audit and feedback vs control), and follow-up 2 (menu audit and feedback plus online menu labels vs menu audit and feedback alone). From baseline to follow-up 1, the menu audit and feedback strategy alone had no significant effect on the proportion of healthy ('Everyday') and less healthy ('Occasional' or 'Should not be sold') items purchased. From baseline to follow-up 2, schools that received menu audit and feedback plus online menu labels had significantly higher odds of students purchasing 'Everyday' items (OR: 1.19; p = 0.019), and significantly lower odds of students purchasing 'Occasional' (OR: 0.86; p = 0.048) and 'Should not be sold' (OR: 0.52; p < 0.001) items. Menu audit and feedback with the addition of online menu labels was effective in increasing the proportion of healthy items purchased relative to menu audit and feedback in isolation. There may be a greater role for online menu labelling as part of a suite of strategies to improve public health nutrition in schools.

Facilitators and Barriers to Implementing Healthy School Canteen Intervention among Malaysian Adolescents: A Qualitative Study

This study evaluated implementing a school-based intervention to promote healthier dietary habits in the school environment among Malaysian adolescents using qualitative methods. This qualitative study was conducted in four secondary schools in Perak and Selangor (two urban and two rural schools) that received the intervention (either training or training and food subsidy). A total of eight focus groups (68 students aged 15 years old) and 16 in-depth interviews were conducted with canteen operators, school convenience shop operators, school teachers and school principals in each school. Thematic analysis was used to analyse the qualitative data to identify suitable themes. We found several initiatives and changes by the schools’ stakeholders to change to a healthy school canteen programme. The stakeholders also noticed the students’ food preferences that influence healthy food intake in canteens and convenience shops. The food vendors and school administrators also found that subsidising healthy meals might encourage healthy eating. Among barriers to implementing healthy school initiatives were the student’s perception of healthy food and their eating habits, which also affect the food vendors’ profit if they want to implement a healthy canteen. The school-based intervention has the potential to promotes healthier eating among school adolescents. Continuous training and monitoring of canteen operators and convenience shops are needed, including building partnerships and educating the students on healthy eating to cultivate healthy eating habits.

Scrutinize of healthy school canteen policy in Iran's primary schools: a mixed method study

BACKGROUND

Schools provide an opportunity for developing strategies to create healthy food environments for children. The present study aimed to analyze the Healthy School Canteen (HSC) policy and identify challenges of its implementation to improve the school food environment in Iran.

METHODS

This mixed method study included two qualitative and quantitative phases. In the qualitative phase, triangulation approach was applied by using semi-structured interviews with key informants, documents review and direct observation. Data content analysis was conducted through policy analysis triangle framework. In the quantitative phase, food items available in 64 canteens of primary schools of Tehran province were gathered. The food's nutrient data were evaluated using their nutrition facts label. The number and proportion of foods that met the criteria based on Iran's HSC guideline and the World Health Organization nutrient profile model for the Eastern Mediterranean Region (WHO-EMR) were determined.

RESULTS

The main contextual factors that affected adoption of HSC policy included health (nutritional transition, high prevalence of non-communicable diseases and unhealthy food environment in and around the schools), political (upstream supportive policies and joint memorandums about health children between the Ministry of Health and Medical Education and Ministry of Education), structural (the lack of unified stewardship, inadequate human resource capacity, poor inter-sectional cooperation), economic (school financial problems, poor fiscal supportive of food policies), and socio-cultural (mothers working outside the home, the role of children's peer group, low nutrition knowledge of school principals) factors. Assessment of the school canteens showed that a large proportion of available foods did not comply with the national guidelines (54.7 ± 2.54%) and WHO-EMR model (85.6 ± 2.34%). The main reasons identified for incomplete implementation of the policy were inadequate physical and economic infrastructure to set up standard school canteens, lack of scientific criteria for food categorization, poor monitoring, high price of healthy foods, and conflict of interest among the actors.

CONCLUSION

The majority of foods and beverages available in the school canteens did not comply with national and regional standards. Iran HSC policy needs to be improved by using an evidence-based approach and active interaction between all key actors.

Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review

Although best practice recommendations exist regarding school-based healthy eating and physical activity policies, practices, and programs, research indicates that implementation is poor. As the field of implementation science is rapidly evolving, an update of the recent review of strategies to improve the implementation of healthy eating and physical activity interventions in schools published in the Cochrane Library in 2017 was required. The primary aim of this review was to examine the effectiveness of strategies that aim to improve the implementation of school-based policies, practices, or programs to address child diet, physical activity, or obesity. A systematic review of articles published between August 31, 2016 and April 10, 2019 utilizing Cochrane methodology was conducted. In addition to the 22 studies included in the original review, eight further studies were identified as eligible. The 30 studies sought to improve the implementation of healthy eating (n = 16), physical activity (n = 11), or both healthy eating and physical activity (n = 3). The narrative synthesis indicated that effect sizes of strategies to improve implementation were highly variable across studies. For example, among 10 studies reporting the proportion of schools implementing a targeted policy, practice, or program versus a minimal or usual practice control, the median unadjusted effect size was 16.2%, ranging from -0.2% to 66.6%. Findings provide some evidence to support the effectiveness of strategies in enhancing the nutritional quality of foods served at schools, the implementation of canteen policies, and the time scheduled for physical education.

An exploratory analysis to identify behavior change techniques of implementation interventions associated with the implementation of healthy canteen policies

Empirical studies to disentangle the effects of multicomponent implementation interventions are needed to inform the development of future interventions. This study aims to examine which behavior change techniques (BCTs) primarily targeting canteen manager are associated with school's healthy canteen policy implementation. This is a secondary data analysis from three randomized controlled trials assessing the impact of a "high," "medium," and "low" intensity intervention primarily targeting canteen managers on school's implementation of a healthy canteen policy. The policy required primary schools to remove all "red" (less healthy items) or "banned" (sugar sweetened beverages) items from regular sale and ensure that "green" (healthier items) dominated the menu (>50%). The delivery of BCTs were retrospectively coded. We undertook an elastic net regularized logistic regression with all BCTs in a single model. Five k-fold cross-validation elastic net models were conducted. The percentage of times each strategy remained across 1,000 replications was calculated. For no "red" or "banned" items (n = 162), the strongest BCTs were: problem solving, goal setting (behavior), and review behavior goals. These BCTs were identified in 100% of replications as a strong predictor in the cross-validation elastic net models. For the outcome relating to >50% "green" items, the BCTs problem solving, instruction on how to perform behavior and demonstration of behavior were the strongest predictors. Two strategies were identified in 100% of replications as a strong (i.e., problem solving) or weak predictor (i.e., feedback on behavior). This study identified unique BCTs associated with the implementation of a healthy canteen policy.

Interventions to Promote Healthy Meals in Full-Service Restaurants and Canteens: A Systematic Review and Meta-Analysis

Out-of-home eating is increasing, but evidence about its healthiness is limited. The present systematic review and meta-analysis aimed to elucidate the effectiveness of full-service restaurant and canteen-based interventions in increasing the dietary intake, food availability, and food purchase of healthy meals. Studies from 2000-2020 were searched in Medline, Scopus, and Cochrane Library using the PRISMA checklist. A total of 35 randomized controlled trials (RCTs) and 6 non-RCTs were included in the systematic review and analyzed by outcome, intervention strategies, and settings (school, community, workplace). The meta-analysis included 16 RCTs (excluding non-RCTs for higher quality). For dietary intake, the included RCTs increased healthy foods (+0.20 servings/day; 0.12 to 0.29; p < 0.001) and decreased fat intake (-9.90 g/day; -12.61 to -7.19; p < 0.001), favoring the intervention group. For food availability, intervention schools reduced the risk of offering unhealthy menu items by 47% (RR 0.53; 0.34 to 0.85; p = 0.008). For food purchases, a systematic review showed that interventions could be partially effective in improving healthy foods. Lastly, restaurant- and canteen-based interventions improved the dietary intake of healthy foods, reduced fat intake, and increased the availability of healthy menus, mainly in schools. Higher-quality RCTs are needed to strengthen the results. Moreover, from our results, intervention strategy recommendations are provided.

Program for Healthier School Cafeterias in Rio Grande do Sul, Brazil: Protocol for a Community-Based Randomized Trial

Background

School cafeterias can promote poor eating habits, as these retail outlets have a variety of foods considered to be nonnutritive and unhealthy. However, despite the need for effective preventive strategies, there is still disagreement on the best approach due to the lack of evidence on interventions to prevent and treat obesity in the school settings.

Objective

We aim to verify the efficacy of an educational intervention program to improve the hygienic conditions and the composition of the menu offered in school cafeterias in the state of Rio Grande do Sul, Brazil.

Methods

We will conduct a randomized, parallel, two-arm, community-based controlled study. Elementary and high schools, both public and private, in the State of Rio Grande do Sul, Brazil, that have a cafeteria will be eligible. Schools will be recruited and randomly assigned to the intervention (n=27) or control (n=27) group. The intervention group will receive an educational intervention program based on the guidelines issued by the Ministry of Health of Brazil, consisting of a 160-hour distance-learning qualification course, for 10 weeks, and using the Moodle platform and WhatsApp app. The intervention targets the owners and people in charge of the cafeterias, food handlers, principals, vice principals, teachers, pedagogical coordinators, dietitians, representatives of students' parents, and students over 16 years old. Meanwhile, the control group will receive only a printed copy of the book containing the guidelines used. The efficacy of the intervention will be determined by the hygienic conditions of the cafeteria and the composition of the menu offered, also considering the levels of processing of food sold. All outcomes will be analyzed as intention-to-treat and per-protocol. We will use covariance analysis or a generalized linear model for continuous data and ordinal logistic regression for ordinal categorical data. The level of statistical significance considered will be P<.05 for a 95% CI.

Results

This project was funded in early 2018. We administered the intervention program in 2019. All data have already been collected, and we are analyzing the data. The results are expected in 2021.

Conclusions

To our knowledge, this may be the first randomized controlled study in school cafeterias held in Brazil. The results will provide evidence for the formulation of public food and nutritional security policies and for the development of effective strategies to provide safe and healthy school meals.

Trial Registration

Brazilian Clinical Trials Registry RBR-9rrqhk; https://ensaiosclinicos.gov.br/rg/RBR-9rrqhk

International Registered Report Identifier (IRRID)

DERR1-10.2196/22680

Dissemination and implementation of a policy on school health in public schools: A systematic review

BACKGROUND

The need to achieve school health and promote well-being that would transcend children's school life has been highlighted in several studies. Promotion of health and well-being of children has not been achieved despite the prescripts of the World Health Organization and national mandates.

OBJECTIVES

The purpose of this systematic review was to explore and describe the current evidence on the dissemination and implementation of a policy on school health in public schools.

METHODS

Five steps of a systematic review were used to achieve the purpose of the study. The steps include framing a clear review question, developing a search approach through gathering and classifying evidence, conducting a critical appraisal, evidence summary as well as the results. Ebscohost, SAE publications, Web of Science and JSTOR databases were used to identify articles written between 2013 and 2018 and to enable access to current studies on the promotion of school health. Keywords included the following: dissemination; implementation; school health policy; and public schools. The search yielded n = 1995 articles. From this figure, 1976 articles were ineligible and only 19 articles met the inclusion criteria.

RESULTS

Seven themes emerged from the findings of this systematic review as follows: shared information, training and development of key role-players, programme development and research, commitment from key role-players, monitoring activities, executive support and collaborative partnerships.

CONCLUSION

The findings show that it is possible for a policy on school health to be disseminated and implemented effectively in public schools.

Adolescents' views on high school food environments

ISSUE ADDRESSED

This study explored adolescents' views on high school food environments and potential strategies to help them to make informed food choices.

METHODS

Fifteen focus groups were conducted with 131 adolescents aged 12-17 years from three high schools in South East Queensland, Australia. Adolescents were asked how their school food environment (dis)encouraged them to eat healthy and what schools could do to help them eat healthier. All focus groups were audio recorded. Data were analysed using content and thematic data analysis methods.

RESULTS

Four major themes emerged: food availability and affordability; food related policy and regulations; nutrition education; and attitudes, preferences and practices. Adolescents stated that nutrition education within the school curriculum and positive role modelling by peers and school staff in healthy eating were the major factors in helping them to make informed food choices. In contrast, high availability, affordability, fundraising, peer pressure, positive attitudes and negative role modelling towards unhealthy foods impacted unhealthy dietary behaviours.

CONCLUSIONS

Emerging results indicate that adolescents do not perceive the current high school food environments as helping them to make healthy food choices. Adolescents suggested limiting unhealthy foods in high schools by implementing strict food and beverage policies, compulsory nutrition education classes and changing attitudes towards healthy foods as strategies to improve high school food environments. SO WHAT?: This study highlights the importance of high school food environments in impacting adolescents' food choices. Strategies identified by adolescents inform public health practitioners and school authorities on how high school food environments could be tailored to help them in making better food choices.

The Effect of Supportive Implementation of Healthier Canteen Guidelines on Changes in Dutch School Canteens and Student Purchase Behaviour

We developed an implementation plan including several components to support implementation of the "Guidelines for Healthier Canteens" in Dutch secondary schools. This study evaluated the effect of this plan on changes in the school canteen and on food and drink purchases of students. In a 6 month quasi-experimental study, ten intervention schools (IS) received support implementing the guidelines, and ten control schools (CS) received only the guidelines. Changes in the health level of the cafeteria and vending machines were assessed and described. Effects on self-reported purchase behaviour of students were analysed using mixed logistic regression analyses. IS scored higher on healthier availability in the cafeteria (77.2%) and accessibility (59.0%) compared to CS (60.1%, resp. 50.0%) after the intervention. IS also showed more changes in healthier offers in the cafeteria (range -3 to 57%, mean change 31.4%) and accessibility (range 0 to 50%, mean change 15%) compared to CS (range -9 to 46%, mean change 9.7%; range -30 to 20% mean change 7% resp.). Multi-level logistic regression analyses on the intervention/control and health level of the canteen in relation to purchase behaviour showed no relevant relations. In conclusion, the offered support resulted in healthier canteens. However, there was no direct effect on students' purchase behaviour during the intervention.

What Is Dissemination and Implementation Science?: An Introduction and Opportunities to Advance Behavioral Medicine and Public Health Globally

There has been a well-documented gap between research (e.g., evidence-based programs, interventions, practices, policies, guidelines) and practice (e.g., what is routinely delivered in real-world community and clinical settings). Dissemination and implementation (D&I) science has emerged to address this research-to-practice gap and accelerate the speed with which translation and real-world uptake and impact occur. In recent years, there has been tremendous development in the field and a growing global interest, but much of the introductory literature has been U.S.-centric. This piece provides an introduction to D&I science and summarizes key concepts and progress of the field for a global audience, provides two case studies that highlight examples of D&I research globally, and identifies opportunities and innovations for advancing the field of D&I research globally.

A comprehensive overview and qualitative analysis of government-led nutrition policies in Australian institutions

Background

Institutions are a recommended setting for dietary interventions and nutrition policies as these provide an opportunity to improve health by creating healthy food environments. In Australia, state and territory governments encourage or mandate institutions in their jurisdiction to adopt nutrition policies. However, no work has analysed the policy design across settings and jurisdictions. This study aimed to compare the design and components of government-led institutional nutrition policies between Australian states and territories, determine gaps in existing policies, and assess the potential for developing stronger, more comprehensive policies.

Methods

Government-led institutional nutrition policies, in schools, workplaces, health facilities and other public settings, were identified by searching health and education department websites for each Australian state and territory government. This was supplemented by data from other relevant stakeholder websites and from the Food Policy Index Australia website. A framework for monitoring and evaluating nutrition policies in publicly-funded institutions was used to extract data and a qualitative analysis of the design and content of institutional nutrition policies was performed. Comparative analyses between the jurisdictions and institution types were conducted, and policies were assessed for comprehensiveness.

Results

Twenty-seven institutional nutrition policies were identified across eight states and territories in Australia. Most policies in health facilities and public schools were mandatory, though most workplace policies were voluntary. Twenty-four included nutrient criteria, and 22 included guidelines for catering/fundraising/advertising. While most included implementation guides or tools and additional supporting resources, less than half included tools/timelines for monitoring and evaluation. The policy design, components and nutrient criteria varied between jurisdictions and institution types, though all were based on the Australian Dietary Guidelines.

Conclusions

Nutrition policies in institutions present an opportunity to create healthy eating environments and improve population health in Australia. However, the design of these policies, including lack of key components such as accountability mechanisms, and jurisdictional differences, may be a barrier to implementation and prevent the policies having their intended impact.

A Three-Arm Randomised Controlled Trial of High- and Low-Intensity Implementation Strategies to Support Centre-Based Childcare Service Implementation of Nutrition Guidelines: 12-Month Follow-Up

The study aimed to compare the effectiveness of a suite of implementation strategies of varying intensities on centre-based childcare service implementation of nutrition guideline recommendations at 12-month follow-up. A six-month three-arm parallel group randomised controlled trial was undertaken with 69 services, randomised to one of three arms: high-intensity strategies (executive support; group face-to-face training; provision of resources; multiple rounds of audit and feedback; ongoing face-to-face and phone support); low-intensity strategies (group face-to-face training; provision of resources; single round of audit and feedback); or usual care control. Across all study arms, only three high-intensity services were compliant with overall nutrition guidelines. A significant group interaction was found between the three arms for compliance with individual food groups. Relative to control, a significantly greater proportion of low-intensity services were compliant with dairy, and a significantly greater proportion of high-intensity services were compliant with fruit, vegetables, dairy, breads and cereals, and discretionary foods. No significant differences between the high- and low-intensity for individual food group compliance were found. High-intensity implementation strategies may be effective in supporting childcare service implementation of individual food group recommendations. Further research is warranted to identify strategies effective in increasing overall nutrition compliance.

Secondary school implementation of a healthy eating policy

ISSUE ADDRESSED

Healthy canteen policies regulating the sales of food and beverages are available across all the states and territories in Australia. The aim of this study was to assess the compliance with a newly updated healthy school canteen policy in New South Wales (NSW) among a sample of secondary schools.

METHODS

A cross-sectional study of secondary school canteen menus was undertaken in selected regions across NSW (September 2017-November 2017). Government and Catholic secondary schools with a canteen menu publicly available on school websites were eligible for inclusion. Menus were classified according to the NSW Healthy School Canteen Strategy using a Quick Menu Audit tool, previously validated in primary schools.

RESULTS

Of 62 Catholic and 128 Government secondary schools located in the study region, 53 secondary schools (25 Catholic and 28 Government) were eligible to participate. The average percentage of "everyday" (healthy) items on secondary school menus was 54% (strategy criteria is >75%). Twenty-eight per cent of menus had no "sugary drinks" (should not be sold). None of the 53 menus assessed met all strategy criteria regarding the availability of foods and beverages. There was no statistically significant difference in meeting; (a) 75% minimum "everyday" items and (b) no "sugary drinks," by socio-economic region, remoteness, school enrolments or school type.

CONCLUSIONS

If public health benefits of healthy eating policies are to be realised, secondary schools need to be supported to implement such policies. SO WHAT?: Future research assessing the impact of intervention strategies to support policy implementation in secondary schools is recommended.

Adapting implementation strategies: a case study of how to support implementation of healthy canteen policies

OBJECTIVES

Although evidence-based interventions (EBIs) and effective strategies to implement them exist, they cannot be used by policy makers and practitioners if they do not align with end users' needs. As such, adaptations to EBIs and implementation approaches are likely to occur to increase 'fit' with end users' capacity. This article describes an approach undertaken by a population health service delivery unit in one Australian state to develop an adapted implementation strategy to support the implementation of the mandatory healthy canteen policy (EBI) to all schools located in the service delivery region.

STUDY DESIGN

This is a case study of adapting an intervention to improve implementation of the healthy canteen policy.

METHODS AND RESULTS

This is a six-step pragmatic, empirically driven approach. The steps include (i) adapt, where appropriate, the EBI to facilitate implementation; (ii) identify end users' capacity for implementation; (iii) identify opportunities to adapt the implementation interventions while preserving meaningful intervention impact; (iv) undertake program adaptation; (v) develop training and resources to support delivery of implementation strategies and; (vi) evaluate the adapted intervention. This article describes the application of these steps by the authors to develop an adapted support strategy consistent with end users' needs.

CONCLUSIONS

This study provides some guidance on how to adapt implementation support approaches particularly when EBIs cannot be adapted. Future empirical research providing guidance on making practical adaptation decisions are needed.

Ultra-processed food consumption by Brazilian adolescents in cafeterias and school meals

This cross-sectional study utilized the National School Health Survey 2015 database to assess the association between school cafeterias; the meals offered by the Brazilian School Food Program (PNAE); and the consumption of industrialized/ultra-processed salty foods, sweets, and soft drinks among Brazilian adolescents. A sample of 102,072 adolescents, aged 11-19 years, who were enrolled in the 9th grade completed the survey. The evaluated outcome was the consumption of industrialized/ultra-processed salty foods, sweets, and soft drinks. A Poisson regression model-based multivariate analysis was performed. The effect measure was the prevalence ratio (PR) with its respective 95% confidence intervals (CIs). The results indicated that Brazilian adolescents who attended schools without meals offered through the PNAE had a higher probability of regularly (≥5 times/week) consuming ultra-processed salty foods [PR = 1.06, CI = 1.01-1.11] and soft drinks [PR = 1.08, CI = 1.03-1.14] compared to those who attended schools that offered PNAE meals. Moreover, the presence of a school cafeteria was associated with a higher probability to consume industrialized/ultra-processed salty foods [PR = 1.05, CI = 1.02-1.08], sweets [PR = 1.09, CI = 1.07-1.11], and soft drinks [PR = 1.10, CI = 1.07-1.13]. School meals appear to be associated with the consumption of ultra-processed foods by Brazilian adolescents, indicating areas for health promotion programs.

Scale up of a multi-strategic intervention to increase implementation of a school healthy canteen policy: findings of an intervention trial

Background

Implementation interventions delivered in schools to improve food provision have been found to improve student diet and reduce child obesity risk. If the health benefits of food availability policies are to be realised, interventions that are effective need to be implemented at scale, across an entire population of schools. This study aims to assess the potential effectiveness of an intervention in increasing the implementation, at scale, of a healthy canteen policy by Australian primary schools.

Methods

A non-controlled before and after study was conducted in primary schools located in the Hunter New England region of New South Wales, Australia. Schools received a multi-component intervention adapted from a previous efficacious and cost-effective randomised control trial. The primary trial outcome was the proportion of canteen menus compliant with the state healthy canteen policy, assessed via menu audit at baseline and follow-up by dietitians. Secondary outcomes included policy reach and adoption and maintenance policy implementation.

Results

Of the 173 schools eligible for inclusion in the trial, 168 provided menus at baseline and 157 menus were collected at follow-up. At follow-up, multiple imputation analysis found 35% (55/157) of schools compared to 17% (29/168) at baseline (OR = 2.8 (1.6–4.7), p = < 0.001) had menus compliant with the state healthy canteen policy. As an assessment of the impact of the intervention on policy reach, canteen manager and principal knowledge of the policy increased from 64% (n = 76) and 38% (n = 44) respectively at baseline to 69% (n = 89) and 60% (n = 70) at follow-up (p = 0.393, p = 0.026). Adoption of the policy increased from 80% (n = 93) at baseline to 90% (n = 104) at follow-up (p = 0.005) for principals, and from 86% (n = 105) to 96% (n = 124) (p = 0.0001) for canteen managers. Multiple imputation analysis showed intervention effects were maintained six-months post intervention (33% of menus compliant OR = 2.6 (1.5–4.5), p = < 0.001 compared to baseline).

Conclusions

This study found school canteen compliance with a healthy food policy increased in association with a multi-strategy intervention delivered at scale. The study provides evidence for public health policy makers and practitioners regarding strategies and modes of support required to support improvement in nutrition policy implementation across entire populations of schools.

Economic analysis of three interventions of different intensity in improving school implementation of a government healthy canteen policy in Australia: costs, incremental and relative cost effectiveness

Background

No evaluations of the cost or cost effectiveness of interventions to increase school implementation of food availability policies have been reported. Government and non-government agency decisions regarding the extent of investment required to enhance school implementation of such policies are unsupported by such evidence. This study sought to i) Determine cost and cost-effectiveness of three interventions in improving school implementation of an Australian government healthy canteen policy and; ii) Determine the relative cost-effectiveness of the interventions in improving school implementation of such a policy.

Methods

An analysis of the cost and cost-effectiveness of three implementation interventions of varying support intensity, relative to usual implementation support conducted during 2013–2015 was undertaken. Secondly, an indirect comparison of the trials was undertaken to determine the most cost-effective of the three strategies. The economic analysis was based on the cost of delivering the interventions by health service delivery staff to increase the proportion of schools ‘adherent’ with the policy.

Results

The total costs per school were $166,971, $70,926 and $75,682 for the high, medium and low intensity interventions respectively. Compared to usual support, the cost effectiveness ratios for each of the three interventions were: A$2982 (high intensity), A$2627 (medium intensity) and A$4730 (low intensity) per percent increase in proportion of schools reporting ‘adherence’). Indirect comparison between the ‘high’ and ‘medium intensity’ interventions showed no statistically significant difference in cost-effectiveness.

Conclusions

The results indicate that while the cost profiles of the interventions varied substantially, the cost-effectiveness did not. This result is valuable to policy makers seeking cost-effective solutions that can be delivered within budget.

Mechanisms of implementing public health interventions: a pooled causal mediation analysis of randomised trials

BACKGROUND

The World Health Organization recommends that nations implement evidence-based nutritional guidelines and policies in settings such as schools and childcare services to improve public health nutrition. Understanding the causal mechanism by which implementation strategies exert their effects could enhance guideline implementation. The aim of this study was to assess the mechanisms by which implementation strategies improved schools and childcare services' adherence to nutrition guidelines.

METHODS

We conducted a mechanism evaluation of an aggregated dataset generated from three randomised controlled trials conducted in schools and childcare services in New South Wales, Australia. Each trial examined the impact of implementation strategies that targeted Theoretical Domains Framework constructs including knowledge, skills, professional role and identity, environmental context and resources. We pooled aggregated organisation level data from each trial, including quantitative assessments of the Theoretical Domains Framework constructs, as well as measures of school or childcare nutrition guideline compliance, the primary implementation outcome. We used causal mediation analysis to estimate the average indirect and direct effects of the implementation strategies and assessed the robustness of our findings to varying levels of unmeasured and unknown confounding.

RESULTS

We included 121 schools or childcare services in the pooled analysis: 79 allocated to receive guideline and policy implementation strategies and 42 to usual practice. Overall, the interventions improved compliance (odds ratio = 6.64; 95% CI [2.58 to 19.09]); however, the intervention effect was not mediated by any of the four targeted Theoretical Domains Framework constructs (average causal mediation effects through knowledge = - 0.00 [- 0.05 to 0.04], skills = 0.01 [- 0.02 to 0.07], professional role and identity = 0.00 [- 0.03 to 0.03] and environmental context and resources = 0.00 [- 0.02 to 0.06]). The intervention had no significant effect on the four targeted Theoretical Domains Framework constructs, and the constructs were not associated with school or childcare nutrition guideline compliance. Potentially, this lack of effect could be explained by imprecise measurement of the mediators. Alternatively, it is likely that that the interventions were operating via alternative mechanisms that were not captured by the four Theoretical Domains Framework constructs we explored.

CONCLUSIONS

Even though public health implementation strategies led to meaningful improvements in school or childcare nutrition guideline compliance, these effects were not mediated by key targeted constructs of the Theoretical Domains Framework. Future research should explore the mechanistic role of other Theoretical Domains Framework constructs and evaluate system-level mechanisms informed by an ecological framework.

TRIAL REGISTRATION

All trials were prospectively registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12613000543785 . Registered 15/05/2013; ACTRN12614001148662 . Registered 30/10/2014; ACTRN12615001032549 . Registered 1/10/2015).

Nutritional Quality of School Meals in France: Impact of Guidelines and the Role of Protein Dishes

In France, school meals must comply with 15 frequency criteria (FC) expressed as nutritional requirements (e.g., “starters containing more than 15% fat served no more than four times out of 20”) in a series of 20 consecutive meals. The objective was to assess, for the first time, the nutritional impact of complying with French school food FC. Based on 40 series of meals actually served in primary schools (“observed series”), several scenarios (1600 series per scenario) of compliance or non-compliance with FC were simulated, and nutritional quality was assessed via the mean adequacy ratio (MAR/2000 kcal). In the observed series, only 9.7 FC on average (range 4–14) were fulfilled. In the simulated series: (i) MAR was positively associated with FC compliance level, with the highest MAR obtained with complete compliance; (ii) MAR decreased when meat or fish-based dishes were replaced by dishes without meat or fish; and (iii) removing the protein dish without replacement led to the lowest MAR. This study demonstrates that French school food guidelines ensure good nutritional quality of food services. It also shows that generalizing the service of meals without meat or fish would deteriorate overall nutritional quality, highlighting the need to define the composition of vegetarian dishes and their frequency of service to children.

Strategies for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease

BACKGROUND

A number of school-based policies or practices have been found to be effective in improving child diet and physical activity, and preventing excessive weight gain, tobacco or harmful alcohol use. Schools, however, frequently fail to implement such evidence-based interventions.

OBJECTIVES

The primary aims of the review are to examine the effectiveness of strategies aiming to improve the implementation of school-based policies, programs or practices to address child diet, physical activity, obesity, tobacco or alcohol use.Secondary objectives of the review are to: Examine the effectiveness of implementation strategies on health behaviour (e.g. fruit and vegetable consumption) and anthropometric outcomes (e.g. BMI, weight); describe the impact of such strategies on the knowledge, skills or attitudes of school staff involved in implementing health-promoting policies, programs or practices; describe the cost or cost-effectiveness of such strategies; and describe any unintended adverse effects of strategies on schools, school staff or children.

SEARCH METHODS

All electronic databases were searched on 16 July 2017 for studies published up to 31 August 2016. We searched the following electronic databases: Cochrane Library including the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; Embase Classic and Embase; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); Dissertations and Theses; and SCOPUS. We screened reference lists of all included trials for citations of other potentially relevant trials. We handsearched all publications between 2011 and 2016 in two specialty journals (Implementation Science and Journal of Translational Behavioral Medicine) and conducted searches of the WHO International Clinical Trials Registry Platform (ICTRP) (http://apps.who.int/trialsearch/) as well as the US National Institutes of Health registry (https://clinicaltrials.gov). We consulted with experts in the field to identify other relevant research.

SELECTION CRITERIA

'Implementation' was defined as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised or non-randomised) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by school staff to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

Citation screening, data extraction and assessment of risk of bias was performed by review authors in pairs. Disagreements between review authors were resolved via consensus, or if required, by a third author. Considerable trial heterogeneity precluded meta-analysis. We narratively synthesised trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated).

MAIN RESULTS

We included 27 trials, 18 of which were conducted in the USA. Nineteen studies employed randomised controlled trial (RCT) designs. Fifteen trials tested strategies to implement healthy eating policies, practice or programs; six trials tested strategies targeting physical activity policies or practices; and three trials targeted tobacco policies or practices. Three trials targeted a combination of risk factors. None of the included trials sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials examined multi-strategic implementation strategies and no two trials examined the same combinations of implementation strategies. The most common implementation strategies included educational materials, educational outreach and educational meetings. For all outcomes, the overall quality of evidence was very low and the risk of bias was high for the majority of trials for detection and performance bias.Among 13 trials reporting dichotomous implementation outcomes-the proportion of schools or school staff (e.g. classes) implementing a targeted policy or practice-the median unadjusted (improvement) effect sizes ranged from 8.5% to 66.6%. Of seven trials reporting the percentage of a practice, program or policy that had been implemented, the median unadjusted effect (improvement), relative to the control ranged from -8% to 43%. The effect, relative to control, reported in two trials assessing the impact of implementation strategies on the time per week teachers spent delivering targeted policies or practices ranged from 26.6 to 54.9 minutes per week. Among trials reporting other continuous implementation outcomes, findings were mixed. Four trials were conducted of strategies that sought to achieve implementation 'at scale', that is, across samples of at least 50 schools, of which improvements in implementation were reported in three trials.The impact of interventions on student health behaviour or weight status were mixed. Three of the eight trials with physical activity outcomes reported no significant improvements. Two trials reported reductions in tobacco use among intervention relative to control. Seven of nine trials reported no between-group differences on student overweight, obesity or adiposity. Positive improvements in child dietary intake were generally reported among trials reporting these outcomes. Three trials assessed the impact of implementation strategies on the attitudes of school staff and found mixed effects. Two trials specified in the study methods an assessment of potential unintended adverse effects, of which, they reported none. One trial reported implementation support did not significantly increase school revenue or expenses and another, conducted a formal economic evaluation, reporting the intervention to be cost-effective. Trial heterogeneity, and the lack of consistent terminology describing implementation strategies, were important limitations of the review.

AUTHORS' CONCLUSIONS

Given the very low quality of the available evidence, it is uncertain whether the strategies tested improve implementation of the targeted school-based policies or practices, student health behaviours, or the knowledge or attitudes of school staff. It is also uncertain if strategies to improve implementation are cost-effective or if they result in unintended adverse consequences. Further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

Preschool and School Meal Policies: An Overview of What We Know about Regulation, Implementation, and Impact on Diet in the UK, Sweden, and Australia

School meals make significant contributions to healthy dietary behaviour, at a time when eating habits and food preferences are being formed. We provide an overview of the approaches to the provision, regulation, and improvement of preschool and primary school meals in the UK, Sweden, and Australia, three countries which vary in their degree of centralisation and regulation of school meals. Sweden has a centralised approach; all children receive free meals, and a pedagogical approach to meals is encouraged. Legislation demands that meals are nutritious. The UK system is varied and decentralised. Meals in most primary schools are regulated by food-based standards, but preschool-specific meal standards only exist in Scotland. The UK uses food groups (starchy foods, fruit and vegetables, proteins and dairy) in a healthy plate approach. Australian States and Territories all employ guidelines for school canteen food, predominantly using a "traffic light" approach outlining recommended and discouraged foods; however, most children bring food from home and are not covered by this guidance. The preschool standards state that food provided should be nutritious. We find that action is often lacking in the preschool years, and suggest that consistent policies, strong incentives for compliance, systematic monitoring, and an acknowledgement of the broader school eating environment (including home provided food) would be beneficial.