Page 13 - ON THE WAY TO HEALTHIER SCHOOL CANTEENS - Irma Evenhuis

healthier products in school canteens is likely to stimulate students to choose these products [26, 38]. This effect can be further enhanced by making these healthier products 1 more accessible through attractive presentation and promotion [25, 42-45]. Examples of strategies applied in schools include increasing the offering of water and making it more
easily accessible; offering more (ready-to-eat) fruit or vegetables; promoting healthy products with reduced prices or advertisements; and reducing the number of less healthy
snacks [42, 46-48], However, as the quality of some of the performed studies is low, and
since they have conflicting results [45, 49], more evaluations are needed on the effects of adaptations on the availability and accessibility of healthier food products in the school
setting [49].
Although increasing attention is being paid to healthy food environments at schools, involved stakeholders experience difficulties in implementing such policies/guidelines [34, 39]. Implementation challenges experienced include costs, waste, kitchen equipment, support and other programmes interfering with the school food environment [36]. Previous research has shown that proper implementation support can improve the uptake, implementation, maintenance and effectiveness of school-based interventions, including school canteen regulations [50-52].
Implementation of healthier school canteens
Implementation is the process in which settings integrate or start using innovations such as policies or evidence-based interventions [53]. In this process, implementation tools support stakeholders to perform the intervention as intended [54, 55]. These tools are (tailored) activities or materials offered to involved stakeholders, such as an information brochure, training, or providing a helpdesk. Since multiple needs will be identified to implement an intervention, there is a need to develop a mixture of supportive tools which together form a single implementation plan [56]. The process of creating such a balanced implementation plan is not merely a practice or evidence-based trajectory: on the one hand, to be able to align the tools to the needs of practice, involvement of future stakeholders is important [57, 58]; and, on the other hand, a structured theory-based development is likely to increase the sustained effect of the intervention [59]. Consequently, a combined approach with input from practice and the use of theory during the complete process of developing and evaluating the implementation plan increases the likelihood that the plan will be used in practice, that the intervention is performed as intended and, consequently, that the intervention has the assumed effect [60].
In the last decade, implementation science has recognised the need for theories, models and frameworks as the basis for the development and evaluation of implementation interventions. This resulted in several theories and frameworks to guide the development of implementation tools [59, 61]. Although the steps involved differ, the overall concept is to start by establishing the (expected) needs of the involved stakeholders during implementation. It is therefore important to first gain insight into the barriers and facilitators with regard to the implementation of the innovation, as experienced by involved stakeholders [60]. Next, the most important identified barriers or facilitators, also known as factors to change, need to be connected to behaviour change methods [58]. Using behavioural change taxonomies increases the likelihood that the tools really change the targeted factors [62-64]. For example (Figure 1.1), in order to improve knowledge as a factor
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