School Food Environment Research Articles

Poor compliance with school food environment guidelines in elementary schools in Northwest Mexico: A cross-sectional study.

In Mexico, 35.5% of school-age children were overweight or obese in 2018. The school food environment is important because children spend a significant part of their time at school and consume one-third to one-half of their daily meals there. In 2014, a Federal Government guideline for the sale and distribution of food and beverages in Mexican schools was published (the AGREEMENT) but the extent of its implementation is not known. Descriptive cross-sectional study in a representative, random sample of elementary schools, using the tools of the INFORMAS network. Data collection included: a) an interview with a school authority; b) a checklist of items available in the school canteen; c) a checklist of the school breakfast menu; and d) an evaluation of the physical environment. The main indicators were: percentage of implementation (self-report) of the AGREEMENT and percentage of compliance (researcher verified) with the AGREEMENT (based on tools b and c). 119 schools participated (response rate 87.5%), with 15.1% (95%CI 9.2-22.8) of the schools reporting having fully implemented the AGREEMENT. However, only 1% (95%CI 0-5.3) of the school canteens and 71.4% (95%CI 57.8-82.7) of the school breakfast menus fully complied with the AGREEMENT. A variety of sugar-sweetened beverages and energy-dense, nutrient poor products were found in the school canteens. Further, only 43.7% of the water fountains in schools were functional and 23.4% were clean. In only 24.4% of schools had the school authorities received formal training related to the AGREEMENT and in 28.6% of schools had the parents received information about the AGREEMENT. The AGREEMENT has been poorly implemented in elementary schools in Mexico. Actions are needed to encourage and support its full implementation to improve the food environment in Mexican schools.

Unboxing the bento box: An arts-informed inquiry into Japanese families’ experience at Canadian school lunch time

Bento, a Japanese style boxed lunch, has a distinct cultural meaning for Japanese people as a medium of affective communication between children and parents. However, in Canadian schools governed by the Anglo-Western food norms, their culinary practices may stand out. This study employed an arts-informed participatory design to explore how school-aged children (6-12 years old) of Japanese origin and their parents describe their experience bringing Japanese food to school in Canada. We conducted arts-informed workshops with 16 children who created artworks about their lunchboxes, and focus groups with 19 parents (all mothers). Children’s artworks illuminated a common aesthetics about “good” lunch that closely reflected mothers’ commitment to preparing nutritionally balanced and aesthetically appealing bento boxes. Both children and mothers reported that Canadian school food environment (e.g., short eating periods, snack times, built environment) sometimes misaligns with their food practices. Some families were compelled to modify their bento to accommodate children’s needs to fit in at school. Meantime, participants’ narratives indicate the prevalence of stigma toward “junk” food that may perpetuate food shaming at school. A more inclusive, diverse and culturally appropriate discussion on “healthy eating” at school can embrace children’s and their families’ intercultural food identities.

Vegetable intake determinants in disadvantaged adolescents: systematic review of qualitative studies

Abstract Background Evidence available on the determinants of vegetable intake in young populations is inconsistent. No review has particularly focused on this topic in disadvantaged adolescents. This systematic review aimed to investigate the determinants of vegetable intake in disadvantaged adolescents reported in qualitative studies. Methods Five electronic databases were searched until October 2020 using combinations of synonyms for vegetable intake, adolescents, and qualitative methodologies. Studies published in peer-reviewed journals were included if they used qualitative methods (e.g., interviews, focus groups, etc.), targeted disadvantaged individuals aged 12-18 years, investigated determinants, motivators and barriers to vegetable intake, and were conducted in urban settings of high-income countries. Two reviewers independently and systematically summarized the papers, assessed their quality and synthesized the findings across studies. Results Sixteen studies meeting the inclusion criteria were included. The synthesis of findings identified the following determinants for vegetable intake: sensory attributes of vegetables; psychosocial factors (nutrition knowledge, preferences/liking, self-efficacy, motivation); lifestyle factors (cost/price, time, convenience); fast food properties (taste, cost, satiety); home environment; parental influence; encouragement/support outside the household; friends' influence; school nutrition education; teachers' support; school food environment; local produce; community nutrition knowledge; and availability and accessibility of vegetables in local stores, restaurants and fast-food outlets. Conclusions Multiple determinants of vegetable intake were identified which complement those investigated in quantitative studies. Future large scale quantitative studies should attempt to examine the relative importance of these determinants in order to guide the development of successful interventions in disadvantaged adolescents. Key messages Vegetable intake is influenced by multiple factors in disadvantaged adolescents. Main determinants are vegetable attributes, personal factors, friends, family, school and community environment.

Do Parental Perceptions of the Nutritional Quality of School Meals Reflect the Food Environment in Public Schools?

(1) Background: It is unknown whether parents’ perception of school meals, a determinant of student meal participation, align with the nutritional quality of meals served in schools. This study compares the healthfulness of foods offered in schools with parental perception of school meals at those same schools. (2) Method: Parents were asked to rate the healthfulness of school meals at their child’s school. Data on the types of foods offered were collected from public schools in four cities in New Jersey and matched with parent-reported data. Measures were developed to capture the presence of healthy and unhealthy items in the National School Lunch Program and the presence of a la carte offerings as well as vending machines. Multivariable analysis examined the association between parental perceptions of school meals and the school food measures after adjusting for covariates. (3) Results: Measures of the school food environment and parental perceptions were available for 890 pre-K to 12th grade students. No significant associations were observed between parental perceptions and food environment measures when examined one by one or in a comprehensive model. (4) Conclusions: Parents’ perception of the healthfulness of meals served do not align with the nutritional quality of foods offered at schools.

Characteristics of the School Food Environment Affect the Consumption of Sugar-Sweetened Beverages Among Adolescents.

Sugar-sweetened beverages are widely available and accessible in school environment, and their presence and characteristics of this environment can influence their consumption. This study examines the association of drinking fountains per 100 students, soft drink sales, soft drink advertising, and the presence of street vendors and sugar-sweetened beverages consumption among adolescents in Brazil. This cross-sectional study was carried out using data from the Study of Cardiovascular Risk in Adolescents that was conducted between March 2013 and December 2014. The sample comprised 71,475 adolescents aged 12–17 years from 1,247 public and private schools in Brazilian cities. Sugar-sweetened beverages consumption was the dependent variable. The main effect was the school food environment, which was evaluated based on drinking fountains per 100 students, soft drink sales, soft drink advertising, and the presence of street vendors. Public and private schools that sold soft drinks were associated with higher average sugar-sweetened beverages consumption among adolescents. Our study highlights the importance of creating healthy school food environments by banning sugar-sweetened beverages in schools accordingly.

Parents\u2019 and teachers\u2019 views of the promotion of healthy eating in Australian primary schools

BackgroundPrimary schools have long been identified as appropriate settings for improving the healthy eating behaviours of children and helping them develop food skills. This qualitative study explored the views of Australian primary school parents and teachers about schools’ strengths and weaknesses in promoting healthy eating and equipping children with food skills.MethodsNineteen parents and 17 teachers from Victoria participated in semi-structured interviews. Audio recordings were transcribed and underwent thematic analysis using Nvivo.ResultsThis study demonstrated that parents and teachers believed that several facilitators helped promote children’s healthy eating. These included food and nutrition education (FNE) programs, the community-based nature of schools, and teacher role modelling and the authority schools possess over children. Time scarcity, lack of teacher expertise, lack of leadership and funding were reported as barriers. School food environments such as canteens, lunch orders, fundraising events and school fairs were identified as both weaknesses and strengths by parents and teachers, which indicated inconsistent implementation of school nutrition policies across schools.ConclusionsAustralian primary schools demonstrate some useful efforts to promote healthy eating among children. However, there are numerous facilitators and barriers which impact on the promotion of healthy eating. These factors need to be addressed in order to develop healthy eating habits further among elementary students. These results provide directions for policymakers and school managers, as they point to the areas that need to be improved to assist the design of schools that better promote healthy eating among children.

The influence of the urban food environment on diet, nutrition and health outcomes in low-income and middle-income countries: a systematic review

IntroductionDiet and nutrition are leading causes of global morbidity and mortality. Our study aimed to identify and synthesise evidence on the association between food environment characteristics and diet, nutrition and...

Creating the Scratch Cooked School Food Framework: Qualitative Data Analysis of a Scratch Cooking Pilot.

The purpose of this study is to develop a novel framework that outlines the system required to implement scratch cooking in school kitchens. The data used in this study were 57 interviews with key stakeholders during the Return to Scratch Cooking Pilot that occurred in two New York City school kitchens in 2018-2019 and made significant modifications to many aspects of the existing school food system. The guiding framework for the data analysis was Meadows's Intervention Level Framework. Intervention Level Framework describes analyzing systems by examining five layers: (1) paradigm shift, (2) goals, (3) system structure (4) feedback and delays, and (5) structural elements. It also provides a framework for describing a system by defining its elements, interconnections, and purpose. Data analysis revealed four elements of the school food system: ingredients and recipes, kitchen, cooking, and the community. The interconnections that played a role in each of these elements were policies, practice, people, and promotion. Together, these four elements and four interconnections comprise the Scratch Cooked School Food framework, which has the purpose of being a tool for researchers and practitioners to utilize when planning, implementing, and evaluating scratch cooking in the school food environment.

The food environment in schools and their immediate vicinities associated with excess weight in adolescence: A systematic review and meta-analysis.

The present study systematically reviewed the characteristics of the food environment in schools and their immediate vicinities associated with excess weight in adolescents. We searched for relevant articles in seven databases. No restrictions were applied on language, publication date, and status of publication. The study selection process and data extraction were conducted by two authors independently. For meta-analyses, the random-effects model and the maximum-likelihood method were applied. A total of 9327 publications were identified from the initial search. Of these, 20 studies met the inclusion criteria and were included in the systematic review. The sale of food in school or immediate vicinity was associated with high BMI [Odds ratio (OR)= 1.14, 95% confidence interval (CI) 1.01, 2.06]. The availability of healthy food provided by school significantly decreased the odds of obesity [OR= 0.89, 95%CI 0.82, 0.96]. However, the presence of nutrition policies or programs at school was not associated with obesity (OR= 0.81, 95%CI 0.57, 1.16). This study highlights the need for improvement in school food environment, including restricting students' exposure to unhealthy foods. The quality of food (healthy vs unhealthy) provided or made available to adolescents in the school food environment influences their weight status. Therefore, promotion of healthy food programs and availability of healthy food at school would limit the prevalence of excess weight in adolescents.

The barriers and enablers to implementing the New South Wales Healthy School Canteen Strategy in secondary schools in the Illawarra and Shoalhaven regions – A qualitative study

In 2017, the New South Wales Healthy School Canteen Strategy (Strategy) was introduced into primary and secondary schools. Studies have reported that secondary schools have a lower level of compliance with healthy canteen policies compared with primary schools. This study aims to identify and describe the barriers and enablers to implementing the Strategy in Department of Education (DoE) secondary schools in the Illawarra and Shoalhaven regions. The framework underpinning the study was the systems theory. Canteen managers (CM) and principals from the 21 DoE secondary schools in the Illawarra and Shoalhaven regions were invited to participate in semi-structured interviews. The interviews were structured around the five focus areas of the Strategy, including questions on school nutrition policies and the role of the canteen. Data were collated using the interview guides as a framework and qualitative content analysis, using manual coding, was undertaken. Eight (38%) schools participated with seven CMs and six principals interviewed. Barriers to implementing the Strategy included the changing role of the canteen, the increased demands placed on CMs and inconsistencies between the school food environment and the Strategy. Enablers included monitoring implementation, and internal and external support. This study also recognised that previously identified barriers to healthy canteen strategy implementation are ongoing. The school canteen is an integral part of the school environment and therefore needs whole-of-school support if successful implementation of the Strategy is to occur. Addressing the barriers and promoting the enablers identified in this study will support better nutrition policy implementation in secondary schools.

Implementation of a regulatory food policy to reduce availability of energy-dense foods in Costa Rican high schools.

To assess the extent to which mandatory Guidelines to improve the school food environment were being implemented in Costa Rican high schools and to explore the perspectives of key policy actors towards the Guidelines. Semi-structured interviews and site observations. Interviews were recorded, transcribed verbatim and imported to NVivo 12 for analysis. Inductive and deductive themes were identified, and elements of the RE-AIM framework and the social process framework were used when classifying these themes. Sixteen public high schools in San José, Costa Rica. High school principal and kiosk concessionaires. Products that did not adhere to the Guidelines were still widely available in schools, and amongst the most prevalent challenges to implementation that emerged from our interviews, were a lack of understanding of the policy content, a lack of monitoring and accountability, and competing values amongst actors which affected their views on the role that the school must have in offering a healthy food environment. Most products offered in high schools did not meet the criteria required by the mandatory Guidelines, and several contextual factors were found to influence implementation. Strengthening the implementation of the Costa Rican Guidelines will require further actions at the governmental and school levels.

The Association Between Classroom Food Habits, Perceived Personal Health and Nutrition Beliefs in Elementary Teachers and Pre-Service Teachers

Understand how teachers’ perceived health and nutrition beliefs and impact the classroom food environment. Compare in-service and pre-service teachers’ (PCTs) attitudes toward personal health and nutrition on their classroom food habits Design: In this cross-sectional design participants completed validated questionnaires to assess nutrition knowledge, nutrition self-efficacy, attitudes toward the school food environment, classroom food practices, personal health beliefs and BMI. Teachers (n=24) were recruited from a southeast U.S. public elementary school and PCTs (n=85) were recruited from a local university. Participants were predominately Hispanic (70%) and female (90%); average age and BMI (teachers: 33-40 yrs, 29.9; PCTs: 18-24 yrs, 26.2) Statistical Analysis: One-way ANOVA, regressions and descriptive analyses conducted using SPSSv.26 Teachers had significantly higher nutrition knowledge (F=13.173,p=.0004) and lower attitudes toward the school food environment (F=8.100,p=.005) compared to PCTs. PCTs’ personal health beliefs were positively associated with nutrition self-efficacy (r=.416,p<.001), classroom food practices were positively associated with attitudes toward unhealthy foods in school (r=.331,p=.002); and BMI was inversely associated with attitudes toward the school food environment (r=-.292,p=.009) and personal health beliefs (r=-.270,p=.014). Teachers’ BMI was positively associated with attitudes toward unhealthy foods in school (r=.511,p=.021) and inversely associated with nutrition self-efficacy (r=-.572,p=.008) and personal health beliefs (r=-.611,p=.004). This study identified personal health views which impact teachers’ beliefs on nutrition and classroom food practices. Teachers were more knowledgeable about nutrition yet viewed the school food environment as less influential on children compared to PCTs. Both groups had low confidence in their personal health. Additional research is needed to improve teachers’ health beliefs and classroom food environments.

Scrutinize of healthy school canteen policy in Iran\u2019s primary schools: a mixed method study

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.

Middle School Stakeholder Perceptions of School Nutrition Reform Since the Healthy, Hunger-Free Kids Act of 2010

ABSTRACT Background School nutrition reform continues to be of interest to many due to the potential for widespread benefits for students who eat at school. however, disparities still exist in implementing the mandates resulting from the 2010 Healthy, Hunger-Free Kids Act. Purpose The purpose of this study was to investigate middle school stakeholders’ perspectives on the school food environment since the initiation of school nutrition reform. Methods Stakeholders from 14 public middle schools participated in interviews on topics related to school nutrition reform. Results Major themes included benefits, barriers and recommendations to improve the food environment. reciprocal determinism provided a framework for understanding the interactions of behavior, the environment and personal factors affecting the implementation of school nutrition reform. Discussion Key informants felt that if schools had more flexibility and decision-making power in what school nutrition reform looked like for their particular community, the program would be more successful. Translation to Health Education Practice Insights from this investigation emphasize the interaction of the home and school environment, on personal and behavioral factors of students. for reform to be successful, schools must involve stakeholders, use local resources, and conduct periodic needs assessment to determine the appropriate strategies to improve the school food environment. A AJHE Self-Study quiz is online for this article via the SHAPE America Online Institute (SAOI) http://portal.shapeamerica.org/trn-Webinars

Understanding the need for a whole-of-society approach in school nutrition policy implementation: a qualitative analysis

BackgroundOnly three of twenty Caribbean Community (CARCICOM) countries have mandatory school nutrition policies despite one third of the region’s children being overweight or obese. In Barbados, there are nutrition guidelines which lack the legal mandate of a formal policy. We aim to assess the comprehensiveness of current national nutrition guidelines and to understand the factors operating in the inner and outer school setting that may influence the implementation of a mandatory school nutrition policy from the perspectives of school administrators.MethodsA documentary analysis of existing nutritional guidelines was conducted along with qualitative semi-structured interviews in primary (elementary) and secondary (high) schools in Barbados. We purposively sampled six primary and four secondary school administrators (principals, deputy principals or senior teachers) to explore their knowledge and views on the National School Nutrition Guidelines. The deterministic implementation paradigm, Consolidated Framework for Implementation (CFIR), was used to explore the complexities within the inner and outer settings of schools. Documentary analysis used a theory-based framework informed by the Wellness School Assessment Tool—school policy analysis questionnaire. Interview transcripts were team coded using thematic analysis with constant comparison facilitated by NVIVO software version12.ResultsSchool administrators were unaware of the existing National School Nutrition Guidelines which documentary analysis found to be restrictive and weak for implementation. Administrators envisioned a government-led (outer setting), whole of society approach as the most effective strategy for the development and implementation of a proposed mandatory school nutrition policy. School administrators identified lack of financial and human resources as barriers to nutrition policy implementation. Formal and informal food vendors are institutionalized in schools and are influential determinants of the school food environment. Schools have individually reached into the outer setting to work with civil society organizations and private individuals to provide financial support and nutrition expertise to their institutions. Mass media campaigns in the outer setting may influence child and parental food choices.ConclusionSchool administrators describe that government-led, CSO supported policy development using a whole-of-society approach has implications for improving nutrition policy implementation. Our findings demonstrate the use of a deterministic implementation framework in the pre-implementation phase of school nutrition policy development.

Personal, proxy, and collective food agency among early adolescents

Early adolescence is a critical time for health behavior development because agency increases during the transition from childhood to adolescence. This qualitative study sought to identify how early adolescent participants described food-related agency. One-on-one interviews were conducted with 30 early adolescents (10–13 years). Data analysis was guided by Bandura's three modes of agency: personal, proxy, and collective. Results suggest participants' food behaviors were informed by a growing knowledge about nutrition, household food rules, and school food environments. Participants described different modes of agency in four areas – grocery shopping, cooking, consumption decisions, and nutrition information seeking – with varying degrees of agency in each area. Understanding how each of the three modes operate and the interplay between them can information future research aimed at improving the nutrition behaviors of early adolescents.

The Food Environment of Primary School Learners in a Low-to-Middle-Income Area in Cape Town, South Africa.

Rapid changes in food environments, where less nutritious foods have become cheaper and more accessible, have led to the double burden of malnutrition (DBM). The role food environments have played in shaping the DBM has attained global interest. There is a paucity of food environment research in low-to-middle-income countries. We conducted a case study of the food environments of school aged learners. A primary school in Cape Town was recruited. A multi-method design was used: a home food and eating behaviours questionnaire completed by 102 household respondents and four questions completed by 152 learners; learner participatory photography; a semi-structured school principal interview; a tuckshop inventory; observation of three-day tuckshop purchases. Foods that were commonly present in households: refined carbohydrates, fats/oils, chicken, processed meats, vegetables, fruit, legumes, snacks/drinks. Two thirds of households had rules about unhealthy drinks/snacks, ate supper together and in front of the TV, ate a home cooked meal five–seven times/week and ate breakfast together under two times/week. Vegetables were eaten under two times/week in 45% of households. A majority of learners (84%) took a lunchbox to school. Twenty-five learners photographed their food environment and 15 participated in semi-structured interviews. Six themes emerged: where to buy; what is available in the home; meal composition; family dynamics; peer engagement; food preparation. Items bought at informal food outlets included snacks, drinks and grocery staples. The principal interview revealed the establishment of a healthy school food environment, including a vegetable garden, although unhealthy snacks were sold at the tuckshop. Key dimensions of the food environment that require further investigation in disadvantaged urban and informal settlement areas include the home availability of unhealthy foods, eating behaviours in households and healthfulness of foods sold by informal food outlets.

Development of the Food Related Environments at School and Home Questionnaire (FRESH-Q)

ObjectivesDelineating determinants of food choice within the school and home environments of adolescents might help to translate advocacy efforts to effective interventions. However, this will require the development of valid instruments that measure school and home food environmental factors systematically. We conducted a cross-sectional study to develop a valid questionnaire that evaluates the food-related environments at schools and homes (FRESH- Q) of adolescents aged 10–15 years in Mumbai, India. MethodsA preliminary draft was developed based on a review of literature, eleven focus group discussions (FGDs) with adolescents (n = 36) and parents (n = 27), and eight in-depth interviews (IDIs) with school supervisors followed by the identification of school food (SFE) and home food environment (HFE) constructs and an item pool generation. The content validity was evaluated by an expert panel and the item-wise content validity indices (I-CVI) for clarity and relevance were calculated. The questionnaire was pretested in 42 adolescents for face validity and further administered among 315 adolescents (mean age 13.2 (2.1) years) for psychometric evaluation. The principal axis method of exploratory factor analysis (EFA) established the construct validity and the internal consistency was determined using Cronbach alpha values > 0.7. A sub-sample (n = 108) completed FRESH-Q twice to estimate test-retest reliability. ResultsContent analysis of FGDs and IDIs revealed six SFE and eleven HFE constructs. The I-CVI for the majority of items were satisfactory (0.72–0.96) and the Cronbach alpha values were 0.88 for SFE and 0.92 for HFE items. The intra-class correlation coefficients ranged from 0.78–0.96 indicating good to excellent reliability. Four factors – availability, and affordability of school foods, adolescents’ perceptions of SFE, and cafeteria policies explained 76.2% of the variance in SFE items. The EFA model identified five underlying constructs for HFE items – availability, accessibility and visibility of foods at home, family dietary habits, food purchasing behaviors, parents’ perceptions and consumption patterns. ConclusionsA valid 36 item self-reported questionnaire was developed to evaluate the school and home food environments of urban adolescents in India. Further investigations in different settings are recommended. Funding SourcesNone.

Promoting healthy foods among urban school children in Bangladesh: a qualitative inquiry of the challenges and opportunities

BackgroundIn Bangladesh overweight and obesity among urban school children are on the rise. Urban school children tend to consume foods dense in calories and few fruits and vegetables which is associated with overweight and obesity. The current study explored the barriers and opportunities for promoting healthy diets among school children from the perspective of teachers and parents in Dhaka, Bangladesh.MethodsWe conducted 14 key informant interviews with teachers and principals, six focus group discussions with 31 mothers of school children (5 to 15 year old) and 14 structured observations of the school food environment. Inductive thematic analysis was performed manually.ResultsSchools were important for development of food preferences of children, however, most school cafeterias provided foods based on profit rather than health considerations. A shift in food culture resulted in making eating out acquire many meanings beyond convenience. Mothers, especially those who were employed, struggled to prepare healthy foods due to time pressure. Mothers were generally concerned about chemicals added to raw foods in markets which led to limited fruit and vegetable consumption.ConclusionsThere were many challenges to promoting healthy foods to school children within and outside the school. It is important to formulate policies and guidance to create a supportive environment for healthy foods in and in the proximity of schools. It is also important to educate consumers about identifying and choosing healthy foods. Laws related to food safety should be adequately implemented to boost the population’s confidence in safety of available healthy foods in the food system.

Barriers and facilitators to the implementation of nutrition standards for school food: a mixed-methods systematic review protocol.

Background: The importance of nutrition during childhood and the high prevalence of child and adolescent obesity has resulted in several countries implementing nutritional standards for school food as a way of providing healthy school food environments. Yet, there has been less focus on the barriers and facilitators influencing the process of implementing school food standards. This mixed-methods systematic review aims to address this evidence gap by synthesising the empirical evidence on the factors that may influence the implementation of school food standards. Methods: This mixed-methods systematic review will use qualitative, quantitative and mixed-methods evidence from peer-reviewed publications retrieved from the following databases; PubMed, CINAHL, Scopus, EMBASE, Medline, PsycINFO and Web of Science. Grey literature will be accessed through Google Scholar, Open Access Theses and Dissertations, OpenGrey, RIAN, EThOS, ProQuest, WorldCat, Networked Digital Library of Theses and Dissertations, and public health organisation websites will also be accessed. Screening reference lists and citation chaining of all included studies will also be undertaken. No restrictions on publication date or language will be applied, however, only primary research studies relevant to supply-side stakeholders will be eligible for inclusion. Study quality will be assessed using the Mixed Methods Appraisal Tool. Study titles and abstracts will be screened to decide whether the full-text manuscript should be retrieved. For screening reliability, a second review author will assess a random sample of 20%. Kappa statistics will be used to assess inter-rater reliability, with values of 0.75 and higher representing high agreement. Two authors will independently extract data and factors reported to influence implementation. This will be synthesized using the Theoretical Domains Framework. Discussion: A comprehensive understanding of these factors can provide guidance to relevant stakeholders to enhance the adoption, implementation and sustainability of nutrition standards for school meals. Systematic review registration: PROSPERO CRD42019117904.