A systems approach to evaluating and improving school food environments in Aotearoa

Abstract

Aim There is global recognition that schools are important in the response to fighting the obesity epidemic among children and adolescents but the haphazard application of school-based interventions that target food system variables in isolation has led to ineffective outcomes. This thesis applied a systems approach to monitor and understand complex school food systems while, designing solutions that re-orient overall system behaviour to function in a positive and sustainable way. Method Designed to investigate the policy and practices that influence the healthiness of NZ school food environments, the School-FERST (School-Food Environment Review and Support Tool) online survey was sent to all schools across NZ in 2016. Among 819 schools that completed the survey, policies were analysed with the newly adapted WellSAT-NZ tool, while canteen and fundraising menus were evaluated for their healthiness based on Fuelled4Life. Descriptive statistics including tests for difference (school type, decile and size) and logistic regression analyses were utilized to report on the current state of NZ school food environments. Interviews with school staff (n=18) identified the best methods to translate large-scale quantitative data from monitoring initiatives back to schools in an efficient way. Group Model Building (GMB) workshops were conducted with students from two South Auckland secondary schools to understand the complex drivers of adolescent diets, and harness student capacity for identifying systems-based solutions that improve school food environments. Results Overall, School-FERST revealed that NZ policies and practices remain relatively unhealthy with limited variation by school type, decile or school size. Only 39.8% of schools reported having a written food and nutrition policy; of the policies analysed (n=145), most were not comprehensive or strongly worded. Schools continue to operate a mainly unhealthy food service, as the median score (2/5) indicated that most menus contained <40% of ‘everyday’ (healthy) items. Schools mainly fundraised using unhealthy foods and beverages (median score 1.6/2; <40% of items were ‘everyday’), but the shift to non-food/beverage fundraising activities is emerging. A large proportion of schools had an actively used garden, embedded nutrition education across the curriculum and refrained from sponsorship/marketing by food and beverage companies. Secondary schools reported student resistance as a major barrier to implementing a healthier school food environment. Interviews with change-agents in schools revealed an eagerness for feedback from monitoring initiatives to guide policy and practice but also emphasized the meaningful translation of results. iv A visual and text infographic best communicated School-FERST results and helped guide schools towards initiating positive change. GMB workshops highlighted the inextricable link between school food systems and environments external to schools (local shops, family and friends, supermarkets). Within schools, feedback loops highlighted that a mainly unhealthy canteen, unhealthy classroom rewards and a lack of nutrition education were the key drivers influencing adolescent diets. Interventions focused on re-orienting the function of these loops to operate positively by utilizing school values and goals as impetus for change. Conclusion This thesis developed a monitoring and feedback system that demonstrated the unhealthiness of NZ school food environments, and subsequently provided a blueprint to inform similar monitoring initiatives in the future. School-FERST and GMB workshops revealed the lack of strong food and nutrition policy; mainly unhealthy canteen and fundraising practices; limited nutrition education; and the use of unhealthy classroom rewards as they key drivers of unhealthy school food systems. Utilizing a systems approach to embed sustainable solutions that positively shift overall system function, creates a culture that celebrates healthy eating over time.