CAFÉ: a multicomponent audit and feedback intervention to improve implementation of healthy food policy in primary school canteens: A randomised controlled trial
Open accessAbstract
BACKGROUND: The implementation of nutrition policies in schools has been recommended as a strategy to improve child dietary intake. Internationally, research suggests that the majority of schools do not implement these policies. In New South Wales (NSW), Australia, the NSW Healthy School Canteen Policy requires that school canteens prohibit the sale of 'red' foods (i.e. foods that are typically nutrient poor and high in energy, such as confectionary and deep-fried foods) and 'banned'drinks (i.e. soft drinks); and that the majority of items on the menu are 'green' (i.e. foods that are good sources of nutrients, such fruits, vegetables and lean meats). This study examined the impact of a multicomponent audit and feedback intervention on schools' implementation of the NSW Healthy School Canteen Policy. A secondary aim was to assess the impact of the intervention on menu composition. METHODS: This study was a parallel group randomised controlled trial with 72 rural and remote primary schools (36 interventions, 36 controls) located in one region within NSW, Australia. Intervention schools received an initial face to face contact and up to four cycles of audit and feedback (consisting of a menu audit, written feedback report and telephone feedback) over a 12-month period. The primary trial outcomes were the proportion of schools with a canteen menu that had: i) no 'red' foods or 'banned' drinks; and ii) >50% 'green' items, as assessed via standardised menu audits undertaken by trained dietitians. For each primary outcome, between-group differences were assessed using Fisher's exact test under an intention to treat approach. RESULTS: There was insufficient evidence to conclude the intervention had a positive impact on the proportion of intervention schools with no 'red' or 'banned' items on their menu (RR = 2.8; 95% CI: 0.9 to 8.9; p = 0.0895), or on the proportion of intervention schools with more than 50% 'green' items (RR = 1.5; 95% CI: 0.7 to 3.2; p = 0.2568). These findings remained non-significant in the multiple imputation analyses. Intervention schools were significantly more likely to have a lower percentage of 'red' items (p-value: 0.007) and a higher percentage of 'green' items on the menu (p-value: 0.014). This remained statistically significant in the multiple imputation analyses for 'red items' (p-value: 0.0081) but not for 'green' items (p-value: 0.0910). CONCLUSIONS: While there was insufficient statistical evidence to suggest that this multicomponent audit and feedback intervention was effective in improving primary schools' compliance with a healthy canteen policy, the intervention demonstrated some positive impact in reducing the availability of 'red' items on the menu. TRIAL REGISTRATION: This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12613000543785 ). Registered 15th May 2013.
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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 [63]
Seven studies were assessed as low risk of detection bias.
“Seventeen of the included studies were assessed as high risk [26, 28, 37, 41, 43, 44, 46–49, 52, 54–56, 58, 66, 67] and seven studies were assessed as low risk of detection bias [27, 42, 51, 53, 60, 62, 63].”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [63]
Ten studies were assessed as low risk of selective reporting as a trial registration or a published protocol paper was identified and all a priori determined outcomes were reported.
“Ten studies were assessed as low risk of selective reporting as a trial registration or a published protocol paper was identified and all a priori determined outcomes were reported [26, 44, 51, 53, 54, 60, 62–64, 67].”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [63]
There was consistent evidence of large effects from Australian randomized trials demonstrating improvement in the availability of healthy foods at school canteens.
“There was consistent evidence of large effects from Australian randomized trials demonstrating improvement in the availability of healthy foods at school canteens [53, 62, 63].”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [63]
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“Furthermore, systematic review evidence from health care settings consistently reports that audit and feedback is an effective strategy to support guideline implementation and can maintain its effectiveness when delivered across non-face to face modalities (including telephone and written) [26, 27].”
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- Authors
- Yoong, S. L., Nathan, N., Wolfenden, L., Wiggers, J., Reilly, K., Oldmeadow, C., Wyse, R., Sutherland, R., Delaney, T., Butler, P., Janssen, L., Preece, S., & Williams, C. M.
- Affiliations
- Hunter Medical Research Institute (AU)
- Hunter New England Local Health District (AU)
- Corresponding author
- Yoong, Sze Lin
- ORCID
- Venue
- International Journal of Behavioral Nutrition and Physical Activity
- Published
- 2016-12
- Volume
- 13
- Issue
- 1
- Pages
- 126-126
- ISSN
- 1479-5868 (ISSN-L)
- PMC
- PMC5139098
- OpenAlex
- W2560500130
- Cited by
- 52
- References
- 46
- Citations by year
- 2025: 3 · 2024: 3 · 2023: 9 · 2022: 5 · 2021: 11 · 2020: 7 · 2019: 3 · 2018: 6 · 2017: 3 · 2016: 1 · 2015: 1
- FWCI
- 8.06
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- International Journal of Behavioral Nutrition and Physical Activity (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Figshare (submittedVersion, cc-by)
- Swinburne figshare (Swinburne University of Technology) (submittedVersion)
- NOVA (University of Newcastle Australia) (submittedVersion, cc-by)
- Funders
- Hunter New England Population Health
- Priority Research Centre for Health Behaviour, University of Newcastle
- Topics
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Health Professions › Speech and Hearing › School Health and Nursing Education
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
- Keywords
- policy implementation, elementary school, menu composition, soft drinks, children's food consumption, rural and remote schools, multicomponent intervention, school nutrition policy, childhood obesity prevention
- MeSH terms
- Child, Commerce, Diet, Feedback, Female, Food Services, Health Promotion, Humans, Male, New South Wales, Schools, Single-Blind Method, Nutrition Policy, Guideline Adherence
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