Page 128 - ON THE WAY TO HEALTHIER SCHOOL CANTEENS - Irma Evenhuis

Chapter 7. General Discussion
longer period; b) in a diversity of schools; c) to its cost-effectiveness, and d) to its financial
sustainability for practice.
First, whether the current tools are sufficient to maintain healthier school cafeterias and vending machines over longer periods of time needs to be investigated. Since the implementation tools were developed on the basis of the needs of stakeholders starting to work with the Guidelines for Healthier Canteens, the next step is to gain insight into the needs of stakeholders who have been working with the guidelines for a while. It is possible that their needs change due to their experience, or that they need recurrent stimuli to remain active. With regard to these needs, whether the current tools are sufficient to maintain healthier school canteens should be investigated. School are rewarded with an annual healthier school canteen award, which they receive when they meet the Guidelines for Healthier Canteens. The Netherlands Nutrition Centre found that up to 2019, a total of 731 schools have had such an award, of which 407 (56%) received one for two or more years [215]. This indicates that maintaining a healthier canteen for multiple years is possible. However, more insight into why a school was (not) able to maintain their healthy canteen is recommended [216]. Besides, the effect of this annual reward might not be sustainable, and its value in addition to the other supportive tools should be investigated.
Second, it is of interest to explore if the support is appropriate for a diversity of schools: schools that differ in context with regard to for example, differences in the stage of implementation of the guidelines, educational levels offered, management of the canteen (with and without a caterer), location (inside a city, and more rural). Additionally, as we recognized that the included schools in our study were already motivated to start working towards a healthier canteen, investigations are recommended into the impact of the support on schools who are less motivated is recommended. This will reveal whether additional tools are needed for certain schools.
Third, future investigations should look at sustainable possibilities for finance and delivery the (personal) approach to all schools. It is known that the costs of scaling up such approaches can be challenging [89]. Nevertheless, in Australia a high and medium intensity programme has been evaluated as more positive on cost-effectiveness compared to a low intensity programme, so the relative costs (effects per euro) may be affordable [217]. It is therefore of interest to investigate the cost-effectiveness and the ideal intensity of the developed support.
Finally, the financial sustainability for schools and caterers should be investigated. For example: included stakeholders had already reported their concerns about the profitability of the canteen. Research showed that a healthier offer in vending machines did not result to negative financial consequences [43]. Experiences from practice appear to indicate a minor financial drop in income that is only temporary, although this has yet to be investigated. Available systems like telemetric data from vending machines or electronic cash desk systems can be used to measure these financial consequences.
Achieving insight into food choices of students due to a healthier school canteen
In our study, the food purchases of students inside the school were investigated. Future research should evaluate the effects of a healthier canteen on students’ dietary behaviour
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