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Introduction: To encourage healthier food/drink choices, the “Guidelines for Healthier Canteens” were developed by the Netherlands Nutrition Centre. This paper describes (1) how we developed a plan to support implementation of the “Guidelines for Healthier Canteens” in Dutch secondary schools, and (2) how we will evaluate this plan on process and effect level.
Materials and Methods: The implementation plan (consisting of several tools) was developed in cooperation with stakeholders. Barriers/facilitators to implement the guidelines were identified by 14 interviews and prioritized during one expert meeting. Thereafter, these barriers were translated into implementation tools using behavioral change methods and implementation strategies. The implementation plan consists of the tools: tailored advice provided via an advisory meeting and report, based on a questionnaire about the stakeholders'/school's context and the “Canteen Scan,” an online tool to assess the product availability and accessibility; communication materials; an online community; newsletters; a factsheet with students' wishes/needs. This implementation plan will be evaluated on process and effect in a 6-month quasi-experimental controlled design with 10 intervention and 10 matched control schools. Process outcomes will be measured: (1) factors affecting implementation and (2) the quality of implementation, both collected via a questionnaire among involved stakeholders. Effect outcomes will be collected pre/post-intervention with: (1) self-reported purchase behavior among around 100 students per school; (2) the “health level” of the school canteen. Linear and linear/logistic two-level regression analyses will be performed.
Discussion: The implementation tools are developed by combining a theory and practice-based approach, with input from different stakeholders. If these tools are evaluated positive, it will support schools/stakeholders to create a healthier school canteen.
Trial Registration: Dutch Trial register no.: NTR5922, date of registration June 20, 2016; METC no.: 2015.331; EMGO+ project number: WC2015-008.
Keywords: schools, nutrition, canteen, adolescents, implementationPrevention of overweight and obesity during childhood is important because of the high prevalence worldwide and associated short and long-term physical, social and mental health problems (1–4). Although prevention should start in early life, adolescence is also a critical period for prevention, because adolescents start to deal with more responsibilities, and develop their own identity and habits in eating behavior, which may persist in later life (5, 6). To promote healthy dietary behavior, it is important to change the food environment to stimulate individuals toward healthier food choices (7–10). For adolescents, schools are a key setting to encourage healthy eating as schools have a pedagogical task and a large reach, and adolescents spend a lot of time there (10, 11). Although schools are increasingly aware of their role in obesity prevention and the need for a healthier school canteen, there is room for improvement (12–14). Schools often experience barriers to implement a healthier school canteen and need support to implement and continue actions regarding a healthier school canteen (14, 15). Hence, improvements in the canteen like removing the marketing of less healthy products and increasing the offer of healthier food and drinks in vending machines remain difficult (12, 13).
Decreasing the availability of low-nutrient, energy-dense foods/beverages in comparison to high-nutrient, low energy foods/beverages in the school canteen and vending machines, and formulating relevant school food policy, are examples of promising strategies to change the food environment and reduce consumption of low nutritious foods, and increase purchases of favorable foods/beverages (16–19). The Dutch Ministry of Health, Welfare and Sport has set a policy target to increase the number of schools with a healthier canteen (20). The Netherlands, has around 1,500 secondary schools, which offer different educational levels for youth between the ages of 11 to approximately 18 years. Most schools offer food or drinks for sale as substitute to the food/drinks students bring from home. In 2014, the Netherlands Nutrition Centre developed the “Guidelines for Healthier Canteens” in consultation with future users and experts in the field of food and behavior change (21). These guidelines are based on studies which investigated influences on making choices, the Dutch Nutritional guidelines “The Wheel of Five,” and experiences with the “Healthy School Canteen” programme (22, 23). According to the “Guidelines for Healthier Canteens” school canteens should offer a majority of healthier products. Healthier products are defined as foods and drinks that are included in the Dutch “Wheel of Five,” such as whole wheat bread, fruit and vegetables, and products that are not included, but contain a limited amount of calories, saturated fat, and sodium (22). In addition, the canteen should promote healthier products by applying “accessibility criteria,” such as placing the healthier products at the most eye-catching spots and attractive presentation of fruit and vegetables. Further, drinking water should be encouraged and in its written policy, the school should state that their canteen meets the guidelines (21).
Stakeholders need support to implement the guidelines in their school (15, 26, 27). Such an implementation support plan will be better aligned to the needs of practice, and thereby more feasible, if the needs and wishes of stakeholders are taken into account (9, 28, 29). Therefore, during the development and evaluation stage, collaboration with these stakeholders is recommended (28, 29). It is also recommended to apply theory, such as the use of a structural framework for the development and evaluation of the implementation plan, the use of behavior change models to translate the need of practice into implementation strategies and the use of a combination of implementation tools (30, 31). The collaboration with practice in combination with the use of theory will increase the likelihood of a feasible and effective implementation. To succeed over time, implementation of new guidelines should allow adaptations to local circumstances but, nonetheless, be conducted with rigor and consistency. This article describes: (1) how we developed a plan to support implementation of canteen guidelines in Dutch secondary schools; and (2) how we will evaluate this implementation plan on process and effect level. The process will be evaluated on factors affecting implementation perceived by stakeholders and the quality of implementation. The effect will be evaluated by determining changes in the health level of canteens and in the self-reported purchase behavior of adolescents.
The input of practice during the development and evaluation of our implementation plan will give insights to researchers about working elements. We hypothesize that this approach will increase future uptake and effect of the implementation plan. With our implementation plan we aim to facilitate the process to create a healthier school canteen, and thereby to stimulate Dutch adolescents to purchase healthier foods and beverages during school time.
Many approaches to support the development and evaluation of implementation interventions exist and have corresponding steps (30–32). In this study the “Grol and Wensing Implementation of Change Model” (2006, updated in 2016) was used to develop and evaluate the implementation plan to disseminate the Guidelines for Healthier Canteens in secondary schools (30). A strength of this model is that it combines several approaches and has been improved over time. It consists of six steps from developing a proposal for change when new guidelines are developed to continuous evaluation and adaptation of the implementation plan. The first two steps are not applicable as the guidelines already exist. The last step falls outside the scope of this research but will be aimed to perform in the future. Hence, this paper describes the application of the three middle steps: (3) the need assessment of the target group and setting, (4) the selection of corresponding implementation strategies, and (5) the development, testing, and executing of the implementation plan. In the selection of implementation strategies, characteristics of the Intervention Mapping approach are used (31). We divided our study into two phases: first the development, which has already been performed and second the evaluation of the implementation plan. These phases and a timeline are presented in Figure 1 and explained below. To report this study design, the SPIRIT 2013 Statement was used, if applicable (33). As a full description of an implementation plan makes it possible to use it in practice, to compare results and to enhance reproducibility (34), this article explains how we developed and will evaluate the implementation plan, while a separate article will describe the content of the implementation plan. Namely, by describing the factors aimed to change with the plan, the behavioral change methods, implementation strategies and an explanation of the implementation tools.