Page 107 - ON THE WAY TO HEALTHIER SCHOOL CANTEENS - Irma Evenhuis

affecting implementation from different perspectives. We were therefore able to develop tools that were broadly supported, engaged different stakeholders, and could be easily integrated into existing school routines. We evaluated the tools using a combination of qualitative and quantitative data collected through questionnaires, an evaluation meeting, and online registered data. This combination resulted in reliable and broad insight into both the effects of the tools on perceived factors affecting implementation and the quality of implementation and also provided indications for improvement.
The limitations of this work include first, that we only had data from twenty schools
and a relatively small number of stakeholders per school. Included stakeholders, like representatives of caterers and school canteen advisors, represent or visit a large number
of schools, thus extending the range of schools affected. Within our study, four caterer employees were involved in multiple schools, of which one was involved in intervention
and control schools. This could have biased the results as the received intervention could
have influenced the control schools. It is possible that this made the differences between intervention and control schools smaller. Hence, as it was only one person, the bias will
be negligible. Second, as mentioned, the Canteen Scan was still in development during
data collection. Consequently, school canteen advisors of the Dutch Nutrition Centre
could fill in the scan, but for many stakeholders, this was still too difficult. This resulted in
low uptake. Stakeholders responded positively to the score and advice generated by the
Canteen Scan after being filled out by school canteen advisors. This resulted in the Canteen
Scan being improved after this research study. Reasonably, this would improve the use
for stakeholders. Third, as all included schools were already motivated to implement the 6 guidelines, stakeholders may have been more positive about their perceived individual
and environmental factors regarding implementation of school canteen guidelines than non-included schools. This may have resulted in an underestimation of the tools’ effect. Finally, as fidelity is an important concept to measure the quality of implementation [101, 122, 201], we measured it using a combination of dose delivered, dose received, and satisfaction. However, previous studies show that measuring fidelity in multi- component, tailored interventions is difficult and yet, there is no consensus about how to measure it [201]. To be able to compare the quality of implementation across studies, it is recommended to clearly define and use one consistent method to assess fidelity and other process evaluation concepts [201].
Implications
As also recognized in a previous study [71], creating support and involvement of students, colleagues, and stakeholders within and outside the school and keeping the healthier school canteen on the agenda are both essential and a challenge. Regular reminders such as newsletters, regular contacts with the school canteen advisors, and prompts to fill in the Canteen Scan helped schools to continue paying attention to a healthier food environment. To support sustainable implementation, a healthier school canteen should be aligned with other school health policy, combined with environmental policy to influence the surroundings of the school. To keep stakeholders involved, regular monitoring and feedback of the food environment by measuring the availability and accessibility of healthier food and drink products in canteens and also of students’ wishes and needs are recommended. However, in the Netherlands, schools are not obliged to offer and promote healthier foods or drinks at schools. For this reason, our implementation plan will only
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