Multi-strategic intervention to enhance implementation of healthy canteen policy: a randomised controlled trial
Open accessAbstract
BACKGROUND: Internationally, governments have implemented school-based nutrition policies to restrict the availability of unhealthy foods from sale. The aim of the trial was to assess the effectiveness of a multi-strategic intervention to increase implementation of a state-wide healthy canteen policy. The impact of the intervention on the energy, total fat, and sodium of children's canteen purchases and on schools' canteen revenue was also assessed. METHODS: Australian primary schools with a canteen were randomised to receive a 12-14-month, multi-strategic intervention or to a no intervention control group. The intervention sought to increase implementation of a state-wide healthy canteen policy which required schools to remove unhealthy items (classified as 'red' or 'banned') from regular sale and encouraged schools to 'fill the menu' with healthy items (classified as 'green'). The intervention strategies included allocation of a support officer to assist with policy implementation, engagement of school principals and parent committees, consensus processes with canteen managers, training, provision of tools and resources, academic detailing, performance feedback, recognition and marketing initiatives. Data were collected at baseline (April to September, 2013) and at completion of the implementation period (November, 2014 to April, 2015). RESULTS: Seventy schools participated in the trial. Relative to control, at follow-up, intervention schools were significantly more likely to have menus without 'red' or 'banned' items (RR = 21.11; 95% CI 3.30 to 147.28; p ≤ 0.01) and to have at least 50% of menu items classified as 'green' (RR = 3.06; 95% CI 1.64 to 5.68; p ≤ 0.01). At follow-up, student purchases from intervention school canteens were significantly lower in total fat (difference = -1.51 g; 95% CI -2.84 to -0.18; p = 0.028) compared to controls, but not in energy (difference = -132.32 kJ; 95% CI -280.99 to 16.34; p = 0.080) or sodium (difference = -46.81 mg; 95% CI -96.97 to 3.35; p = 0.067). Canteen revenue did not differ significantly between groups. CONCLUSION: Poor implementation of evidence-based school nutrition policies is a problem experienced by governments internationally, and one with significant implications for public health. The study makes an important contribution to the limited experimental evidence regarding strategies to improve implementation of school nutrition policies and suggests that, with multi-strategic support, implementation of healthy canteen policies can be achieved in most schools. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ( ACTRN12613000311752 ).
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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 [62]
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 [62]
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 [62]
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 [62]
In Wolfenden et al., more than 80% of schools receiving multicomponent implementation support (vs. 27% in control) had more than half of all foods for sale as healthy ("green") products.
“and more than 80% (versus 27% in the control) had more than half of all foods for sale as healthy (“green”) products [62].”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [62]
In Wolfenden et al., more than 70% of schools that received multicomponent implementation support (vs. 3% in control) did not regularly sell foods restricted or banned by healthy canteen guidelines.
“In the trial by Wolfenden et al., assessing the most intensive implementation strategy—comprised of nine implementation strategies—more than 70% of schools that received multicomponent implementation support (vs. 3% in the control) did not regularly sell foods that were restricted or banned from sale by healthy canteen guidelines”
From Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review (2021) · cites this paper as [62]
Within the school setting, single or multi-component interventions that address dietary intake, and/or physical activity or sedentary behavior have shown limited effectiveness in reducing sedentary behavior and BMI.
“Within the school setting single or multi-component interventions that address dietary intake, and/or physical activity or sedentary behavior have shown limited effectiveness in reducing sedentary behavior and BMI [8–10].”
From Barriers, facilitators and capacities for childhood obesity prevention in 12 European nations: results of a policy-maker survey (2018) · cites this paper as [9]
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Cites
Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011) · Administration and Policy in Mental Health and Mental Health Services Research · doi:10.1007/s10488-010-0319-7 · Cited by 8,721 · see citing works
Cane, J., O’Connor, D., & Michie, S. (2012) · Implementation Science · doi:10.1186/1748-5908-7-37 · Cited by 4,888 · cited 1× · see citing works
“The selection of intervention components was guided by the Theoretical Domains Framework [21].”
MethodMichie, S., Johnston, M., Francis, J., Hardeman, W., & Eccles, M. (2008) · Applied Psychology · doi:10.1111/j.1464-0597.2008.00341.x · Cited by 1,789 · see citing works
Strategy for intention to treat analysis in randomised trials with missing outcome data
White, I. R., Horton, N. J., Carpenter, J. R., statistics, R. I. M. A. S., & Pocock, S. (2011) · BMJ · doi:10.1136/bmj.d40 · Cited by 849 · see citing works
Chaudoir, S. R., Dugan, A. G., & Barr, C. H. (2013) · Implementation Science · doi:10.1186/1748-5908-8-22 · Cited by 800 · see citing works
Effect of longer-term modest salt reduction on blood pressure
He, F. J., Li, J., & MacGregor, G. A. (2013) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd004937.pub2 · Cited by 737 · see citing works
Davies, P., Walker, A. E., & Grimshaw, J. M. (2010) · Implementation Science · doi:10.1186/1748-5908-5-14 · Cited by 619 · see citing works
Diffusion of a School-Based Substance Abuse Prevention Program: Predictors of Program Implementation
Rohrbach, L. A., Graham, J. A., & Hansen, W. B. (1993) · Preventive Medicine · doi:10.1006/pmed.1993.1020 · Cited by 431 · see citing works
Do school based food and nutrition policies improve diet and reduce obesity?
Jaime, P. C., & Lock, K. (2008) · Preventive Medicine · doi:10.1016/j.ypmed.2008.10.018 · Cited by 412 · see citing works
Schwab, U., Lauritzen, L., Tholstrup, T., Halldorsson, T. I., Risérus, U., Uusitupa, M. I. J., & Becker, W. (2014) · Food & Nutrition Research · doi:10.3402/fnr.v58.25145 · Cited by 386 · see citing works
Effect of longer-term modest salt reduction on blood pressure
He, F. J., & MacGregor, G. A. (2004) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd004937 · Cited by 302 · see citing works
Prevention of the Epidemic Increase in Child Risk of Overweight in Low-Income Schools
Coleman, K. J., Tiller, C. L., Sanchez, J., Heath, E. M., Sy, O., Milliken, G. A., & Dzewaltowski, D. A. (2005) · Archives of Pediatrics and Adolescent Medicine · doi:10.1001/archpedi.159.3.217 · Cited by 245 · see citing works
What are the key food groups to target for preventing obesity and improving nutrition in schools?
Bell, C., & Swinburn, B. A. (2004) · European Journal of Clinical Nutrition · doi:10.1038/sj.ejcn.1601775 · Cited by 208 · see citing works
Self-citationFagan, A. A., & Mihalic, S. W. (2003) · Journal of Community Psychology · doi:10.1002/jcop.10045 · Cited by 197 · see citing works
Driessen, C., Cameron, A. J., Thornton, L. E., Lai, S. K., & Barnett, L. M. (2014) · Obesity Reviews · doi:10.1111/obr.12224 · Cited by 192 · see citing works
Dissemination and Implementation Research on Community-Based Cancer Prevention
Rabin, B. A., Glasgow, R. E., Kerner, J. F., Klump, M. P., & Brownson, R. C. (2010) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2009.12.035 · Cited by 172 · see citing works
Caldeira, D., Carneiro, A. V., & Costa, J. N. (2014) · PubMed · Cited by 155 · see citing works
From policy to practice: implementation of physical activity and food policies in schools
Mâsse, L. C., Naiman, D., & Naylor, P. (2013) · International Journal of Behavioral Nutrition and Physical Activity · doi:10.1186/1479-5868-10-71 · Cited by 136 · see citing works
Reaching the Healthy People Goals for Reducing Childhood Obesity
Wang, Y. C., Orleans, C. T., & Gortmaker, S. L. (2012) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2012.01.018 · Cited by 115 · see citing works
Diffusion of an effective tobacco prevention program. Part II: evaluation of the adoption phase
Parcel, G. S., O'Hara-Tompkins, N. M., Harrist, R. B., Basen-Engquist, K. M., McCormick, L. K., Gottlieb, N. H., & Eriksen, M. P. (1995) · Health Education Research · doi:10.1093/her/10.3.297 · Cited by 101 · see citing works
Hoelscher, D. M., Kelder, S. H., Murray, N., Cribb, P. W., Conroy, J., & Parcel, G. S. (2001) · Journal of Public Health Management and Practice · doi:10.1097/00124784-200107020-00012 · Cited by 90 · see citing works
Australian school canteens: menu guideline adherence or avoidance?
Woods, J., Bressan, A., Langelaan, C., Mallon, A. L., & Palermo, C. E. (2014) · Health Promotion Journal of Australia · doi:10.1071/he14009 · Cited by 86 · see citing works
From Paper to Practice: Barriers to Adopting Nutrition Guidelines in Schools
Downs, S., Farmer, A. P., Quintanilha, M., Berry, T. R., Mager, D. R., Willows, N. D., & McCargar, L. J. (2011) · Journal of Nutrition Education and Behavior · doi:10.1016/j.jneb.2011.04.005 · Cited by 78 · see citing works
Government food service policies and guidelines do not create healthy school canteens
de Silva, A. M., Breheny, T., Jones, L. V., Lacy, K. E., Kremer, P. J., Carpenter, L. M., Bolton, K. A., Prosser, L., Gibbs, L. F., Waters, E., et al. (2011) · Australian and New Zealand Journal of Public Health · doi:10.1111/j.1753-6405.2010.00694.x · Cited by 71 · see citing works
Ardzejewska, K., Tadros, R., & Baxter, D. G. (2012) · Health Education Journal · doi:10.1177/0017896912437288 · Cited by 66 · see citing works
Chriqui, J. F., Resnick, E. A., Schneider, L., et al. (2013) · Cited by 64 · see citing works
Bell, C., Davies, L. J., Finch, M., Wolfenden, L., Francis, J. L., Sutherland, R., & Wiggers, J. H. (2014) · Public Health Nutrition · doi:10.1017/s1368980013003364 · Cited by 64 · see citing works
Self-citationAssessment of the School Nutrition Environment
Yoong, S. L., Nathan, N. K., Wyse, R. J., Preece, S. J., Williams, C. M., Sutherland, R. L., Wiggers, J. H., Delaney, T. M., & Wolfenden, L. (2015) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2015.02.002 · Cited by 63 · see citing works
Self-citationNathan, N., Wolfenden, L., Bell, A. C., Wyse, R., Morgan, P. J., Butler, M., Sutherland, R., Milat, A. J., Hector, D., & Wiggers, J. (2012) · BMC Public Health · doi:10.1186/1471-2458-12-651 · Cited by 59 · see citing works
Self-citationFirst Law regulating school canteens in Brazil: evaluation after seven years of implementation
Gabriel, C. G., de Vasconcelos, F. D. A. G., de Andrade, D. F., et al. (2026) · Archivos Latinoamericanos de Nutrición · doi:10.37527/2009.59.2.003 · Cited by 54 · see citing works
Drummond, C., & Sheppard, L. A. (2011) · Health Education Research · doi:10.1093/her/cyr036 · Cited by 44 · see citing works
Improvement in primary school adherence to the NSW Healthy School Canteen Strategy in 2007 and 2010
Hills, A., Nathan, N., Robinson, K., Fox, D., & Wolfenden, L. (2015) · Health Promotion Journal of Australia · doi:10.1071/he14098 · Cited by 43 · see citing works
Self-citationSchofield, M. J., Edwards, K., & Pearce, R. (1997) · Australian and New Zealand Journal of Public Health · doi:10.1111/j.1467-842x.1997.tb01791.x · Cited by 38 · see citing works
Wolfenden, L., Nathan, N., Williams, C. M., Delaney, T. M., Reilly, K., Freund, M., Gillham, K. E., Sutherland, R., Bell, A. C., Campbell, L., et al. (2014) · Implementation Science · doi:10.1186/s13012-014-0147-3 · Cited by 33 · see citing works
Self-citationHealth Behavior Research: The Quality of the Evidence Base
Oldenburg, B. F., Ffrench, M., & Sallis, J. F. (2000) · American Journal of Health Promotion · doi:10.4278/0890-1171-14.4.253 · Cited by 31 · see citing works
Outcomes of the West Australian school healthy food and drink policy
Pettigrew, S., Pescud, M., & Donovan, R. J. (2012) · Nutrition & Dietetics · doi:10.1111/j.1747-0080.2011.01564.x · Cited by 27 · see citing works
Kolehmainen, N., & Francis, J. J. (2012) · Implementation Science · doi:10.1186/1748-5908-7-100 · Cited by 24 · see citing works
Nutrition-Friendly Schools Initiative (NFSI)
Jackson, A., & Ashworth, A. (2006) · Public Health Nutrition · doi:10.1079/phn2006968 · Cited by 8 · see citing works
Drummond, C. (2008) · Flinders Academic Commons (Flinders University) · Cited by 5 · see citing works
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Barnes, C., McCrabb, S., Stacey, F., Nathan, N., Yoong, S. L., Grady, A., Sutherland, R., Hodder, R., Innes-Hughes, C., Davies, M., et al. (2021) · Translational Behavioral Medicine · doi:10.1093/tbm/ibab037 · Cited by 84 · see citing works
Self-citationAbu-Omar (2018) · doi:10.1186/s12889-018-6368-7 · Cited by 67 · see citing works
- Authors
- Wolfenden, L., Nathan, N., Janssen, L. M., Wiggers, J., Reilly, K., Delaney, T., Williams, C. M., Bell, C., Wyse, R., Sutherland, R., Campbell, L., Lecathelinais, C., Oldmeadow, C., Freund, M., & Yoong, S. L.
- Affiliations
- Hunter New England Local Health District (AU)
- Deakin University (AU)
- University of Newcastle Australia (AU)
- Corresponding author
- Wolfenden, Luke
- ORCID
- Venue
- Implementation Science
- Published
- 2017-01-11
- Volume
- 12
- Issue
- 1
- Pages
- 6-6
- ISSN
- 1748-5908 (ISSN-L)
- PMC
- PMC5225642
- OpenAlex
- W2577846984
- Cited by
- 93
- References
- 39
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 10 · 2023: 12 · 2022: 11 · 2021: 16 · 2020: 11 · 2019: 15 · 2018: 9 · 2017: 5
- FWCI
- 21.50
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- Implementation Science (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
- Australian Research Council (Linking Project Scheme (LP130101008))
- 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
- elementary school students, energy intake, dietary fat intake, sodium intake, academic detailing, performance feedback, school principals, parent committees, Australian primary schools
- MeSH terms
- Diet, Healthy, Child, Child, Preschool, Health Policy, Health Promotion, Humans, Income, Menu Planning, New South Wales, Personal Satisfaction, Restaurants, Schools, Social Support
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