|dc.description.abstract||Background: As childhood obesity becomes more prevalent around the globe, international, national and provincial bodies have called for policy makers to take action to improve the healthy eating environments where children live, learn, and play. In 2010, the Ontario Ministry of Education joined 10 other Canadian provinces/territories and introduced the Ontario School Food and Beverage Policy (P/PM 150), a set of nutrition standards for foods and beverages available to students. By September 2011, it was expected all publicly-funded elementary and secondary schools across the province would adopt P/PM 150 and apply its standards to foods offered for sale in school food venues (i.e., vending machines, cafeterias, tuck shops), through pay-for-service student nutrition programs (i.e., breakfast, snack, lunch, milk programs), and at school events. The Ministry called for a comprehensive approach to implementing P/PM 150, and left the process to be determined by regional school boards. In 2012, the Region of Peel Public Health partnered with the University of Waterloo to conduct a comprehensive process evaluation of the implementation of P/PM 150 in regional schools. The Comprehensive School Health (CSH) framework helped guide this evaluation, to investigate supports for healthy eating during the early years of implementation. The CSH framework is comprised of four inter-related pillars: Social and Physical Environments, Teaching and Learning, Healthy School Policy, and Partnerships and Services.
Purpose: This thesis focussed on the level of supports for healthy eating within school food environments during P/PM 150 implementation and the role public health has played in strengthening existing comprehensive initiatives to support healthy eating. Because policy implementation is not a static event, yet an on-going process, the three research studies conducted, captured data from two time period: Time I (2012/13) and Time II (2014). Study #1: focussed on the CSH Physical Environment and aimed to identify, describe and categorize beverages and snacks available for sale in secondary school vending machines relative to P/PM 150 standards and compare findings from Time I and Time II. Study #2: focussed on all CSH pillars and aimed to classify, compare and describe school support for healthy eating during P/PM 150 implementation and compare findings from Time I and Time II. Study #3: focussed on the role of knowledge translation reports in supporting comprehensive strategies for promoting healthy eating in all CSH pillars and aimed to evaluate school representatives’ and school public health nurses’ (PHNs) perceptions and experiences interpreting recommendations from Time I knowledge translation reports and providing recommendations for Time II feedback.
Methods: A subset of elementary and secondary schools was recruited from two school boards (i.e., Catholic and Public) in the Region of Peel. Consenting school administrators were asked to elect a school representative, described as an individual knowledgeable about the school food environment to participate in Studies #1-3 during Times I and II. Study #1: In Times I and II, the consenting school representative accompanied a researcher to complete a Food Environmental Scan (FES) checklist, a survey composed of open and close-ended questions, which also captured the availability of foods and beverages available for sale to students in food venues through photographs. For the purposes of this study, only vending machine results are presented. Photographs underwent a nutritional content analysis, which categorized beverages and into P/PM 150 subcategories and classifications (i.e., Sell Most, Sell Less, Not Permitted for Sale). Inferential statistics (i.e., paired t-tests, p<0.05) were conducted to determine changes in beverage and snack offerings between Times I and II. Study #2: In Times I and II, the consenting school representative completed a Healthy School Planner (HSP) survey, which included a series of close-ended questions regarding the current status of healthy eating promotions, practices and policies implemented in the school. Responses to close-ended questions from the HSP and the completed FES checklist were entered into a SPSS database and descriptive statistics calculated (i.e., frequencies, percentages, means, and ranges). Responses to the HSP survey were scored using an established algorithm, which categorized schools overall as Initiation, Action or Maintenance along the Healthy School Continuum, and as low/decreased support, moderate support or high/increased support for CSH pillars. Open-ended questions from the FES checklist underwent a deductive content analysis guided by the CSH pillars. Study #3: Project management prepared knowledge translation (KT) feedback reports for the larger evaluation of P/PM 150 (including surveillance of student behaviours [n=2,071 from n=45 schools], qualitative input from school stakeholders, results of the HSP and FES, and evaluation of food retail density around participating regional schools [n=45]). Draft reports were prepared following Time I, refined based on feedback from a project advisory committee, and the final reports distributed to schools (n= 19 elementary, n=26 secondary). In order to evaluate the effectiveness of the reports at informing and strengthening healthy-eating related initiatives within CSH pillars, Time II representatives and affiliated school PHNs were invited to participate in a one-on-one interview. Since the author had developed all of the original reports, an arms-length researcher was trained and conducted interviews, which were audio-recorded and transcribed verbatim. Transcripts underwent a hybrid thematic analysis, in which themes were inductively identified, categorized, entered into a codebook and then deductively confirmed by a second reviewer. All aspects of Studies #1-#3 received formal approval from the University of Waterloo Office of Research Ethics, Dufferin-Peel Catholic District School Board Ethics Review Board and the Peel District School Board Ethics Review Board.
Results: Study #1 recruited 19 secondary schools to participate in an audit of school vending machines in both Time I and Time II. FES checklists recorded 75 beverages (59 varieties across schools in Time I, 45 varieties in Time II), mostly water, juices and milk-based beverages and 132 snacks (87 varieties across schools inTime I, 103 varieties in Time II), mostly grain-based snacks, vegetable/fruit chips and baked goods. A majority of schools offered one or more Not Permitted for Sale beverage (47% of schools in Time I, 58% of schools in Time II) or snack (74% of schools in Time I, 53% of schools Time II). Significantly more schools met P/PM 150 standards for snacks but not beverages in Time II. In Study #2, 25 school representatives (n=8 elementary, n=17 secondary) completed a HSP survey and FES checklist in both Times I and II. Most schools kept a rating of Action (n=20) along the Healthy School Continuum from Time I to Time II. The Physical Environment was the most supportive (100% of schools had high/increased support) due to adequate provision of spaces and time to eat and socialize with friends. The Social Environment was the least supportive (56% low/decreased support) due to limited consultation with school community members (24% of schools consulted parent organizations, 16% consulted parents/families, 16% consulted staff) and few healthy eating events run by students (e.g., 40% of schools had a student nutrition council). Only two schools achieved the highest overall rating (Maintenance) in Time II. In Study #3, 32 school representatives and 11 school PHNs (71% response rate) participated in a one-on-one interview. Most participants liked the knowledge translation report’s format and presentation of data; however, not all information presented was found to be relevant. A third of schools (31%) used the report to increase awareness, focus planning or inform new healthy eating initiatives. Although PHNs were available to support uptake of the reports’ recommendations, only 19% of schools shared their report with the PHN. PHNs identified six key steps to improve uptake of the evaluation findings: take a strengths-based approach; focus on what can be accomplished at school; make prescriptive, individualized recommendations; distribute feedback reports during school planning Times; present information through multiple avenues; and form an inclusive and effective dissemination strategy.
Discussion: Variable supports for healthy eating were identified within each CSH pillar among the three studies. Supports can also help facilitate the implementation and sustainability of P/PM 150; however, more work is required to address issues of policy non-adherence. In the Healthy School Policy pillar, schools have self-governing policies to help support healthy eating in schools; however, more consideration is needed to help clarify the government-mandated P/PM 150 standards and reduce the possibility of misinterpretation and misuse. More consideration is needed on the categorization of beverages based upon sugar content and it should be made explicit that P/PM 150 standards apply to beverage container size not labels’ serving size. By improving the comprehensiveness and clarity of policy standards, there will be less room for misinterpretation and improved application. The Physical Environment The presence of Not Permitted for Sale beverages and snacks in secondary school vending machines provided further evidence for the need for a formal monitoring system of P/PM 150 as requested by the Ontario Auditor General. Audit and feedback systems would provide a structured approach to consistent monitoring procedures; reporting results to the school board or Ministry of Education would enhance accountability of schools to meeting P/PM 150 regulations; and school board feedback could act as a means of enhancing the awareness of school stakeholders (i.e., staff, students, food service workers, PHNs) regarding healthy eating. The Social Environment was the least supported as it required voluntary dedication of time provided by school healthy eating champions. These individuals, who are personally passionate about supporting the health and development of students, are described as leverage points within the policy implementation process, possessing the ability to both oversee top-down implementation and gather bottom-up support. Champions are repeatedly identified as agents of change in the facilitation of comprehensive approaches to school health and should be highly valued and frequently acknowledged by the school community. The Teaching and Learning pillar had variable support for healthy eating provided through existing curriculum and extracurricular activities. Previous research has documented that teachers and administrators perceive school nutrition policies to be of low importance, thus limiting the ability for a school to reach full policy adherence. Findings from Study #3 highlight that educators must perceive an initiative to be meaningful in order for it to be implemented; therefore, more work is needed to increase the perceived value of P/PM 150 by linking policy outcomes to academic achievements. The Ontario Ministry of Education can help reduce the burden on teachers to embed healthy eating messaging into daily classroom lessons by providing curriculum supports that increase the perceived value of P/PM 150 held by teachers and reinforce students’ positive health behaviours. The Partnerships and Services pillar had variable levels of support for healthy eating, and Study #3 emphasized a need for schools to seek involvement from a broad array of school stakeholders in supporting healthy eating and sustaining P/PM 150. Implementation science explains policy adherence is more likely to be achieved when stakeholder groups are supportive of the organizational change. This requires garnering buy-in from all groups by showcasing the value of the policy and promoting active collaboration, which can enhance a sense of ownership and helps the policy reach its intended impact. School PHNs can function as knowledge brokers and play a role in gathering support from school stakeholders, although more work is required to promote uptake of their services by school administrators.
Conclusion: This research was one of the first to use the CSH framework to examine the extent to which healthy eating was supported during the early years of the implementation of the Ontario School Food and Beverage Policy (P/PM 150). Lessons from dissemination and implementation science added to the existing knowledge of how supports for healthy eating within each CSH pillar can further support P/PM 150 implementation and sustainability. The Ontario Ministry of Education should consider working with regional public health units, regional school boards, a representative sample of Ontario elementary and secondary schools and food service providers to work collaboratively to identify the best ways to ensure: P/PM 150 standards are comprehensive, clear and audits and feedback are conducted (Healthy School Policy); school health eating champions are identified and valued (Social Environment); foods in schools adhere to P/PM 150 (Physical Environment); P/PM 150 curriculum supports are developed for multiple classroom subjects and aligned with various school health concerns (Teaching and Learning); and processes are set in place to garner support from stakeholder groups and develop a sense of shared ownership for policy success (Partnerships and Services).||en