Effectiveness of a multi-strategy intervention in increasing the implementation of vegetable and fruit breaks by Australian primary schools: A non-randomized controlled trial
Open accessAbstract
BACKGROUND: Limited evidence exists describing the effectiveness of strategies in facilitating the implementation of vegetable and fruit programs by schools on a population wide basis. The aim of this study was to examine the effectiveness of a multi-strategy intervention in increasing the population-wide implementation of vegetable and fruit breaks by primary schools and to determine if intervention effectiveness varied by school characteristics. METHODS: A quasi-experimental study was conducted in primary schools in the state of New South Wales, Australia. All primary schools in one region of the state (n = 422) received a multi-strategy intervention. A random sample of schools (n = 406) in the remainder of the state served as comparison schools. The multi-strategy intervention to increase vegetable and fruit breaks involved the development and provision of: program consensus and leadership; staff training; program materials; incentives; follow-up support; and implementation feedback. Comparison schools had access to routine information-based Government support. Data to assess the prevalence of vegetable and fruit breaks were collected by telephone from Principals of the intervention and comparison schools at baseline (2006-2007) and 11 to 15 months following the commencement of the intervention (2009-2010). GEE analysis was used to examine the change in the prevalence of vegetable and fruit breaks in intervention schools compared to comparison schools. RESULTS: At follow-up, prevalence of vegetable and fruit breaks increased significantly in both intervention (50.3% to 82.0%, p < 0.001) and comparison (45.4% to 60.9% p < 0.001) schools. The increase in prevalence in intervention schools was significantly larger than among comparison schools (OR 2.36; 95% CI 1.60-3.49, p <0.001). The effect size was similar between schools regardless of the rurality or socioeconomic status of school location, school size or government or non-government school type. CONCLUSION: The findings suggest that a multi-strategy intervention can significantly increase the implementation of vegetable and fruit breaks by a large number of Australian primary schools.
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Among 10 studies reporting the proportion of schools implementing a targeted policy, practice, or program versus a minimal or usual practice control, the median unadjusted effect size was 16.2%, ranging from -0.2% to 66.6%.
“For example, among 10 studies reporting the proportion of schools implementing a targeted policy, practice, or program versus a minimal or usual practice control, the median unadjusted effect size was 16.2%, ranging from –0.2% to 66.6%.”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [52]
Of the seven nonrandomized studies, three were considered as high risk of confounding.
“Of the seven nonrandomized studies, three were considered as high risk of confounding [26, 52, 59], while it was unclear in the remaining five studies whether confounders had been sufficiently adjusted for [39, 43, 57, 61, 67].”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [52]
An Australian study reported significant improvement relative to control (16%) in the implementation of fruit and vegetable breaks during class time.
“An Australian study also reported significant improvement relative to control (16%) in the implementation of fruit and vegetable breaks during class time [52].”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [52]
Just 5 of the 30 studies included in this review examined the impact of implementation occurring "at scale," defined as 50 or more schools.
“just 5 of the 30 studies included in this review (including three targeting implementation of nutrition interventions) examined the impact of implementation occurring “at scale,” defined as 50 or more schools [37, 43, 52, 56, 73].”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [52]
There is an accumulating body of evidence to suggest that implementation strategies have resulted in small improvements in the availability and provision of healthy foods in schools.
“While limited, there is an accumulating body of evidence to suggest that implementation strategies have resulted in small improvements in the availability and provision of healthy foods in schools [40, 44, 52].”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [52]
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Self-citationBenefits of policy support of a healthy eating initiative in schools
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Self-citationInfluenceofSchoolArchitectureandDesignonHealthy Eating:AReviewoftheEvidence
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Probability of being bullied by BMI category, children aged 11-15, OECD countries, 2013-14
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Estimates of the health expenditure associated with overweight or obesity
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Self-citationExploring long-term follow-up of effective implementation trials in schools: a secondary review
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- Authors
- Nathan, N., Wolfenden, L., Bell, A. C., Wyse, R., Morgan, P. J., Butler, M., Sutherland, R., Milat, A. J., Hector, D., & Wiggers, J.
- Affiliations
- Hunter New England Local Health District (AU)
- Hunter Medical Research Institute (AU)
- University of Newcastle Australia (AU)
- New South Wales Department of Health (AU)
- The University of Sydney (AU)
- Corresponding author
- Nathan, Nicole
- ORCID
- Venue
- BMC Public Health
- Published
- 2012-08-13
- Volume
- 12
- Issue
- 1
- Pages
- 651-651
- ISSN
- 1471-2458 (ISSN-L)
- PMC
- PMC3490882
- OpenAlex
- W1968403295
- Cited by
- 59
- References
- 42
- Citations by year
- 2026: 2 · 2025: 2 · 2024: 5 · 2023: 1 · 2022: 2 · 2021: 5 · 2020: 3 · 2019: 8 · 2018: 4 · 2017: 8 · 2016: 4 · 2015: 9 · 2014: 3 · 2013: 3
- FWCI
- 11.53
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMC Public Health (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Figshare (submittedVersion, cc-by)
- UTS ePRESS (University of Technology Sydney) (submittedVersion)
- NOVA (University of Newcastle Australia) (submittedVersion)
- Funders
- Hunter Medical Research Institute
- NSW Ministry of Health
- Topics
- Health Sciences › Health Professions › Speech and Hearing › School Health and Nursing Education
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
- Keywords
- school food programs, elementary school, school nutrition policy, program implementation, employee training, incentives, school leadership, rurality, socioeconomic status, school size, New South Wales
- MeSH terms
- Adolescent, Child, Diet, Fruit, Health Promotion, Humans, New South Wales, Schools, Vegetables, Program Evaluation, Confidence Intervals, Odds Ratio, Qualitative Research
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