Page 126 - ON THE WAY TO HEALTHIER SCHOOL CANTEENS - Irma Evenhuis

Chapter 7. General Discussion
and tools that our plan consists of. By doing so, our process evaluation measured if these determinants changed due to the support in implementation. Although this alignment seems obvious, the impact of implementation strategies on stakeholders’ determinants like knowledge and attitude have rarely been assessed in school health promotion supportive programmes [51].
Another strength was that we measured the quality of each implementation tool separately with multiple measures like satisfaction, dose delivered and dose received. We selected only the most important process evaluation concepts used in implementation research as it was not feasible to measure all recommended concepts [122]. While using only a selection of concepts is a limitation, it is a strength that we assessed both self-reported and objective data (for example dose received concerning the newsletter). These objective data were generated automatically during the intervention, for example, whether participants opened the received digital newsletter, and which part they clicked to read more, was recorded.
Implications
This thesis focuses on support to facilitate schools and involved stakeholders to create a healthier availability and accessibility of food and drinks inside schools. The knowledge gained has implications for future actions. In this discussion, it is important to emphasise that (changing) healthy eating of students is complex, and is subject to multiple influences related to the school food environment. In advance, it is therefore of interest to use the social ecological model of Story, et al. (2008), Figure 7.1, to review the different influences involved in this complex interplay [15].
This model includes four levels: 1) individual factors, like demographics, and personal behavioural determinants; 2) social environment, including the support and experienced norms of family and friends; 3) physical environment, not only the environment inside schools, including the canteen, but also the environment around school; and 4) macro- level environment, including regulations and policy support with regard to the canteen as well as the societal and cultural norms.
Offering support aiming to facilitate creating a healthier school canteen includes both individual factors of students and stakeholders (like behavioural determinants of students and canteen employees), the social environment (the support of friends, and the reaction of students on the healthier offer in the canteen), and the physical environment inside school (making changes in the school canteen). However, this support is also related to other physical environments inside school (like attention for nutritional education and the healthiness of food and drinks offered at schools’ activities) and outside school (like shops around school, but also the home, sports and worksite environment) and the macro-level environment (the norms about healthy eating in the society and the efforts of the national and local government). Consequently, when considering the implications for future research, practice and policy, attention will be paid to how these different levels of the ecological model can contribute to successful implementation of healthier school canteen guidelines, thus stimulating adolescents’ healthy dietary habits in school.
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