Abstract
BackgroundSchools provide an opportunity for developing strategies to create healthy food environments for children. The present study aimed to analyze the Healthy School Canteen (HSC) policy and identify challenges of its implementation to improve the school food environment in Iran.MethodsThis mixed method study included two qualitative and quantitative phases. In the qualitative phase, triangulation approach was applied by using semi-structured interviews with key informants, documents review and direct observation. Data content analysis was conducted through policy analysis triangle framework. In the quantitative phase, food items available in 64 canteens of primary schools of Tehran province were gathered. The food’s nutrient data were evaluated using their nutrition facts label. The number and proportion of foods that met the criteria based on Iran’s HSC guideline and the World Health Organization nutrient profile model for the Eastern Mediterranean Region (WHO-EMR) were determined.ResultsThe main contextual factors that affected adoption of HSC policy included health (nutritional transition, high prevalence of non-communicable diseases and unhealthy food environment in and around the schools), political (upstream supportive policies and joint memorandums about health children between the Ministry of Health and Medical Education and Ministry of Education), structural (the lack of unified stewardship, inadequate human resource capacity, poor inter-sectional cooperation), economic (school financial problems, poor fiscal supportive of food policies), and socio-cultural (mothers working outside the home, the role of children’s peer group, low nutrition knowledge of school principals) factors. Assessment of the school canteens showed that a large proportion of available foods did not comply with the national guidelines (54.7 ± 2.54%) and WHO-EMR model (85.6 ± 2.34%). The main reasons identified for incomplete implementation of the policy were inadequate physical and economic infrastructure to set up standard school canteens, lack of scientific criteria for food categorization, poor monitoring, high price of healthy foods, and conflict of interest among the actors.ConclusionThe majority of foods and beverages available in the school canteens did not comply with national and regional standards. Iran HSC policy needs to be improved by using an evidence-based approach and active interaction between all key actors.
Highlights
Schools provide an opportunity for developing strategies to create healthy food environments for children
The findings of the qualitative part of the study are categorized based on the policy analysis triangle framework, i.e., policy content, context, policy-making process, and actors, as follows: Policy content This bylaw addresses the school canteens, and reflects policymakers’ attention to the importance of school food environment
The findings of the current study revealed that four years after implementation of the policy of healthy school canteens in Iran, more than 54% of available foods in school canteens of Tehran did not comply with the list of permitted foods of the national guideline
Summary
Schools provide an opportunity for developing strategies to create healthy food environments for children. Childhood is a critical period to form lifelong dietary behaviors which influence future risk of obesity and dietrelated non-communicable diseases (NCDs) [1, 2]. Despite this fact, the prevalence of obesity and NCDs in children and adolescents are increasing in both developed and developing countries and has become a major health challenge [3]. Prevalence of overweight or obesity was estimated 20% in school age-children of European countries [5]. The prevalence of overweight and obesity in Iranian population aged less than 18 years was estimated 5.5% (95% CI,5.1–6.0) and 15.1% (95% CI, 13.5–17), respectively from 2000 to 2013. A nationwide study in 2015, showed that over 20% of students aged 7–18 years had excess weight and abdominal obesity [9]
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