Page 122 - ON THE WAY TO HEALTHIER SCHOOL CANTEENS - Irma Evenhuis

Chapter 7. General Discussion
Reflecting on the studies of part two
When comparing the results of our studies with others, we have to take into account that the food and drinks provided in Dutch schools differ from many other countries in that many countries provide school meals, and have formulated compulsory meal guidelines. Nevertheless, the changes in our cafeterias and vending machines as a result of the support in implementation are comparable to studies that evaluated the implementation of school food policies in other countries, such as Australia and the United States of America [51, 89, 153, 208]. Those studies also showed that several implementation tools could support schools making changes in their canteens. Examples of strategies used elsewhere include the adaptation of the tools to the schools’ own conditional factors and giving personalised feedback as well as on-going support and insight and feedback on the offered products or offering information about the guidelines [51, 182, 208]. These combined strategies were also included in our plan and adapted to the Dutch guidelines. Another strategy which is also likely to be effective in influencing students’ consumption is prescribing compulsory guidelines for offering food at school. To date, several countries have prescribed such guidelines, relating mostly to meals and vending machines standards [34]. This strategy yielded positive effects on compliance and provision, and has the potential to influence students’ consumption although offering complementary implementation support continues to be necessary [27, 152, 208].
With regard to the products offered in the vending machines, fewer changes were made compared to the offer in the cafeterias, possibly due to the fact that the machines are less easy to adapt or to the fact that external parties, like caterers or vending machine companies, determine their content. This makes schools dependent on these external parties.
Drawing on previous studies, our hypothesis was that an increase in the availability and accessibility of healthier products would encourage students to choose healthier options [25, 42, 43, 45, 49]. We observed, however, no differences in purchases. In some other studies, but not all, an increase in healthier products was seen though the quality of these studies was sometimes low [45, 49]. Our study also showed no relation between supportive implementation and student purchase behaviour. In a review about the effect of implementation of school health policy or programmes on dietary behaviour of students, eleven studies found improvements on at least one product group, while in three studies no effect was observed [51]. One difference, compared to our study, is that those studies investigated food groups separately, which, due to the low number of recorded purchases, was not possible in our study. It is possible that this may have led to being unable to detect changes in purchases, or that measurement limitations, like the moment of measuring the self-reported data, played a role. This will be discussed in the section about the methodological considerations.
The support plan consists of different implementation strategies intended to complement each other [56]. Although the contribution of each specific tool to the changes made in the canteen was not evaluated, the process evaluation evaluated the quality of each tool separately, as recommended [128]. Consistent with the literature, the personalised and tailored approach of the advisory meeting, taking schools’ specific conditions into account, was particularly evaluated as positive [182, 193]. The stakeholders also
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