Describing the evidence-base for research engagement by health care providers and health care organisations: a scoping review.

BACKGROUND: Having a research-engaged health and medical workforce is associated with improvements in clinical outcomes for patients. As such, there has been significant government investment internationally to support health care organisations and services to increase staff engagement with research. OBJECTIVES: This scoping review sought to provide an overview of the literature describing strategies employed to increase research engagement by health care providers and organisations, and to undertake a qualitative analysis to generate a list of research engagement strategies. METHODS: A scoping review using systematic search strategies was undertaken to locate peer-review publications and grey literature related to research engagement by health care providers and organisations. Research engagement was defined as a 'deliberate set of intellectual and practical activities undertaken by health care staff and organisations to conduct research'. A database search of electronic records was performed with no limit on publication date. Publications were included regardless of study type (excluding systematic reviews) and categorised as either databased (presenting data or new analysis of existing data) and non-databased (no new data or analyses). Databased publications were further classified according to study type, study design and setting. A qualitative synthesis using a Framework Approach was undertaken with all studies that described a strategy to improve research engagement. RESULTS: A total of 152 publications were included in this study with 54% categorised as non-databased. Of the databased articles, the majority (72%) were descriptive studies describing prevalence of correlates of research engagement, 17 (25%) described intervention studies where only two were controlled studies. The following research engagement strategies were identified: i) dual skilled team/staff, ii) resources or physical infrastructure, iii) incentives, iv) leadership support of research, v) education/training, vi) networks, vii) forming partnerships or collaborations and viii) overall leadership structure of entity. CONCLUSIONS: The literature on research engagement is primarily opinion-based and descriptive in nature. To provide the evidence needed to inform strategies, this needs to progress beyond descriptive to more rigorous well-designed intervention research.

A randomised controlled trial of an implementation strategy delivered at scale to increase outdoor free play opportunities in early childhood education and care (ECEC) services: a study protocol for the get outside get active (GOGA) trial.

BACKGROUND: Increased outdoor play time in young children is associated with many health and developmental benefits. This study aims to evaluate the impact of a multi-strategy implementation strategy delivered at scale, to increase opportunities for outdoor free play in Early Childhood Education and Care (ECEC) services. METHODS: The study will employ a parallel-group randomised controlled trial design. One hundred ECEC services in the Hunter New England region of New South Wales, Australia, will be recruited and randomised to receive either a 6-month implementation strategy or usual care. The trial will seek to increase the implementation of an indoor-outdoor routine (whereby children are allowed to move freely between indoor and outdoor spaces during periods of free play), to increase their opportunity to engage in outdoor free play. Development of the strategy was informed by the Behaviour Change Wheel to address determinants identified in the Theoretical Domains Framework. ECEC services allocated to the control group will receive 'usual' implementation support delivered as part of state-wide obesity prevention programs. The primary trial outcome is the mean minutes/day (calculated across 5 consecutive days) of outdoor free play opportunities provided in ECEC services measured at baseline, 6-months (primary end point) and 18-months post baseline. Analyses will be performed using an intention-to-treat approach with ECEC services as the unit of analysis, using a linear mixed effects regression model to assess between-group differences. A sensitivity analysis will be undertaken, adjusting for service characteristics that appear imbalanced between groups at baseline, and a subgroup analysis examining potential intervention effect among services with the lowest baseline outdoor free play opportunities. DISCUSSION: Identifying effective strategies to support the implementation of indoor-outdoor routines in the ECEC setting at scale is essential to improve child population health. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ( ACTRN12621000987864 ). Prospectively registered 27th July 2021, ANZCTR - Registration.

A trial of a six-month sugar-sweetened beverage intervention in secondary schools from a socio-economically disadvantaged region in Australia.

OBJECTIVE: This study assessed the effectiveness of a school-based intervention in reducing adolescents' sugar-sweetened beverage (SSB) consumption and percentage of energy from SSBs. Secondary outcomes were SSB consumption within school, average daily energy intake, and body mass index z-scores. METHODS: Six secondary schools located in New South Wales, Australia were recruited to participate in a six-month pilot randomised controlled trial (1:1). The intervention included components targeting the school nutrition environment, curricula and community. Outcomes were collected via online surveys, observations, anthropometric measurements and project records. Between-group differences were assessed via linear mixed models. RESULTS: At the six-month intervention endpoint (n=862) there were no statistically significant differences between students in intervention or control schools for mean daily intake of SSBs (8.55mL; CI -26.77, 43.87; p=0.63), percentage daily energy from SSBs (0.12% kJ; CI -0.55, 0.80; p=0.72), or for secondary outcomes. Acceptability of the school-based strategies were high, however intervention fidelity varied across schools. CONCLUSION: While acceptable, improving fidelity of implementation and increasing the duration or intensity of the intervention may be required to reduce SSB intake. Implications for public health: Engaging parents and education stakeholders in the development phase to co-design interventions may prove beneficial in improving intervention fidelity and enhance behavioural outcomes.

How are frames generated? Insights from the industry lobby against the sugar tax in Ireland.

There is a causal link between the consumption of ultra-processed foods and a range of non-communicable diseases (NCDs) such as obesity, type 2 diabetes and cancers. Despite this, no country in the world has reduced its obesity levels because the factors that drive obesity continue unchanged (Swinburn et al., 2019). One systemic driver is corporate influence on the public policy process. The world's largest food and beverage manufacturers engage public relations firms to create a narrative which speaks of corporate cooperation with public health policy, while simultaneously influencing policy making in ways that are favorable to industry. We sought to examine framing as a key strategy in the corporate political activity of food industry actors attempting to resist the introduction of a public health policy. Specifically, we analyzed industry submissions for an Irish government consultation for the proposed introduction of a sugar sweetened beverage (SSB) tax in 2018. We describe how a food product like sugar is framed positively by corporate actors who rely on it as their principal ingredient. Sugar is a good focus from a framing perspective because it is currently undergoing recalibration in the public's imagination - from a benign, nourishing treat in its heyday to a dangerous 'substance' that can contribute to premature mortality. Framing is already well established as a corporate political activity (CPA) to influence public policy (Shelton et al., 2017; Nixon et al., 2015; Darmon et al., 2008). Our research expands this understanding by uncovering four underlying mechanisms used to generate frames - dichotomizing, contesting, equating and cropping. Recognizing these mechanisms could help policy makers, public health professionals and business ethicists to deconstruct any given frame that becomes dominant in corporate discourse, such as 'personal responsibility', 'inadequate exercise', 'freedom' and so on. These mechanisms may also apply to other industries such as alcohol, fossil fuels and tobacco, where hazards from interference in public health strategies are a concern.

Physical Activity Behaviors of Children Who Register for the Universal, State-Wide Active Kids Voucher: Who Did the Voucher Program Reach?

Active Kids is a government-led, universal voucher program that aims to reduce the cost of participation in structured physical activity for all school-enrolled children in New South Wales (NSW), Australia. As part of the Active Kids program evaluation, this cross-sectional study examined the Active Kids' program's reach to children in NSW and their physical activity behaviors, before voucher use. Demographic registration data from all children (4.5-18 years old) who registered for an Active Kids voucher in 2018 (n = 671,375) were compared with Census data. Binary and multinomial regression models assessed which correlates were associated with meeting physical activity guidelines and participation in the sessions of structured physical activity. The Active Kids program attracted more than half (53%) of all eligible children in NSW. Children who spoke a primary language other than English at home, were aged 15-18 years old, lived in the most disadvantaged areas, and girls, were less likely to register. Of the registered children, 70% had attended structured physical activity sessions at least once a week during the previous 12 months, whilst 19% achieved physical activity guidelines. Active Kids achieved substantial population reach and has the potential to improve children's physical activity behaviors.

Protocol for an effectiveness- implementation hybrid trial to assess the effectiveness and cost-effectiveness of an m-health intervention to decrease the consumption of discretionary foods packed in school lunchboxes: the 'SWAP IT' trial.

BACKGROUND: At a population level, small reductions in energy intake have the potential to contribute to a reduction in the prevalence of childhood obesity. In many school systems, there is the potential to achieve a reduction in energy intake through modest improvements in foods packed in children's school lunchboxes. This study will assess the effectiveness and cost-effectiveness of a multi-component intervention that uses an existing school-based communication application to reduce the kilojoule content from discretionary foods and drinks consumed by children from school lunchboxes whilst at school. METHODS: A Type I hybrid effectiveness-implementation cluster randomised controlled trial will be conducted in up to 36 primary schools in the Hunter New England, Central Coast and Mid North Coast regions of New South Wales, Australia. Designed using the Behaviour Change Wheel, schools will be randomly allocated to receive either a 5-month (1.5 school terms) multi-component intervention that includes: 1) school lunchbox nutrition guidelines; 2) curriculum lessons; 3) information pushed to parents via an existing school-based communication application and 4) additional parent resources to address common barriers to packing healthy lunchboxes or a control arm (standard school practices). The study will assess both child level dietary outcomes and school-level implementation outcomes. The primary trial outcome, mean energy (kJ) content of discretionary lunchbox foods packed in children's lunchboxes, will be assessed at baseline and immediately post intervention (5 months or 1.5 school terms). Analyses will be performed using intention to treat principles, assessing differences between groups via hierarchical linear regression models. DISCUSSION: This study will be the first fully powered randomised controlled trial internationally to examine the impact of an m-health intervention to reduce the mean energy from discretionary food and drinks packed in the school lunchbox. The intervention has been designed with scalability in mind and will address an important evidence gap which, if shown to be effective, has the potential to be applied at a population level. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN:12618001731280 registered on 17/10/2018. Protocol Version 1.

Two-year follow-up of a randomised controlled trial to assess the sustainability of a school intervention to improve the implementation of a school-based nutrition policy.

ISSUE ADDRESSED: School-based nutrition policies can have a positive effect on the school food environment. The primary aim of this study was to assess the primary school adherence to a mandatory state-wide healthy canteen policy 12 months after an effective multi-strategic implementation intervention concluded. METHODS: Primary schools were randomised to (a) a 12-14 months multi-strategic intervention or (b) no-intervention (control). The intervention aimed to improve implementation of a state-wide canteen policy by encouraging schools to remove unhealthy food and beverages (classified as ''red'' or ''banned'') from canteen menus and replace with healthy items (classified as ''green''). No implementation support was provided to either group by the research team between the 12 and 24 months data collection period. RESULTS: Seventy schools participated, of which 56 schools were assessed at 24-month follow-up. Intervention schools were less likely to have a menu which contained ''red/banned'' items at 24-month follow-up (RR = 2.28; 95% CI: 1.18-4.40; P = 0.01). Intervention schools, however, were not more likely than controls to have a menu which contained >50% ''green'' items at 24-month follow-up (RR = 1.29; 95% CI: 0.98-1.70; P = 0.10). Intervention schools were more likely to adhere to both policy components (no red/banned items and >50% green items on the menu) than control schools (RR = 2.61; 95% CI: 1.29-5.29; P = 0.006). Among intervention schools that were fully adherent to the policy following implementation support (12-month post baseline), all were also adherent at the 24-month follow-up. CONCLUSION: The intervention was effective in achieving long-term school adherence to a state-wide canteen policy at 24-month follow-up. SO WHAT?: The findings suggest that sustained improvements in implementation of school nutrition policies is possible following a period (12 months) of comprehensive implementation support.

Feasibility and principal acceptability of school-based mobile communication applications to disseminate healthy lunchbox messages to parents.

ISSUE ADDRESSED: This study aimed to assess the feasibility and acceptability of using an existing school-based mobile communication application to deliver messages to parents on how to pack a healthy lunchbox. METHODS: A telephone survey was conducted with 196 primary school principals within the Hunter New England region of New South Wales, Australia, in 2016. RESULTS: Almost two thirds of primary schools (59%) currently use a school-based mobile communication application to communicate with parents. Most principals (91%) agreed school lunchboxes need improving, of which 80% agree it is a school's role to provide information and guidelines to parents. However, only 50% of principals reported currently providing such information. The provision of lunchbox messages to parents by a third party appeared an acceptable model of delivery by principals. Larger schools and schools in urban and lower socio-economic localities were more likely to have used a school-based mobile communication application. CONCLUSION: The majority of principals recognise student lunchboxes need improving. The use of school-based mobile communication applications appears to be feasible and acceptable by principals as a method of communicating lunchbox messages to parents. SO WHAT?: Use of school-based mobile communication applications may be an effective method for delivering health information at a population level. Future research should assess the potential efficacy of disseminating health interventions via this modality.

Effectiveness of a dissemination strategy on the uptake of an online menu planning program: A controlled trial.

ISSUE ADDRESSED: Online systems offer opportunities to provide effective, ongoing support to childcare services to implement dietary guidelines. The study aimed to assess the effectiveness of a dissemination strategy on childcare service: (i) adoption; and (ii) use of an online menu planning program designed to increase compliance with dietary guidelines. METHODS: A nonrandomised controlled trial was conducted with long day care services across Australia. All services received an email invitation to access an online evidence-based menu planning program. Services in the intervention also received training, telephone contact and provision of a portable computer tablet to encourage program adoption and use. Outcomes were assessed at the 6-month follow-up using analytics data recorded by the online program. Outcomes included the proportion of services having accessed the program (adoption) and the proportion of services with a current menu entered in the program (use as intended). RESULTS: Twenty-seven interventions and 19 control services took part. At the 6-month follow-up, 100% vs 58% of services had adopted the online menu planning program (OR: 14.67, 95% CI: 2.43-infinity; P < 0.01) and 41% vs 5% of services had a current menu entered in the program (OR: 9.99, 95% CI: 1.01-534.57; P < 0.01) in the intervention and control arms respectively. CONCLUSIONS: This study highlights the need for strategies to support adoption and use of an online menu planning program in childcare services if the potential benefits of such a program are to be achieved. Future research should explore the effectiveness of differing strategies to increase adoption and use of online programs at scale. SO WHAT?: Strategies to support childcare service uptake and use of online programs are required in order for the potential public health benefits of such technologies to be realised.

Barriers to implementation of a healthy canteen policy: A survey using the theoretical domains framework.

ISSUE ADDRESSED: Improving implementation of school healthy canteen policies requires a comprehensive understanding of implementation barriers. Therefore, the aim of this study was to assess a range of barriers, as reported by canteen managers, using a quantitative survey instrument developed based on a theoretical framework. METHODS: A cross sectional survey of primary school canteen managers from the Hunter New England region of New South Wales was conducted of eligible schools in the study region identified as having an operational canteen. Survey items assessed canteen manager employment status, canteen characteristics and potential barriers to healthy canteen policy implementation, aligned to the 14 domains of the theoretical domains framework via a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The mean domain scores of canteen managers were calculated, less than four indicating the canteen manager considered the domain was a barrier. Canteen managers were also asked to provide the current canteen menu for audit by a dietitian. RESULTS: Of the 184 participants, 20% (n = 36) were assessed as having menus compliant with the state policy. The five most common domains identified as potential barriers to policy implementation were behavioural regulation (n = 117, 65%), skills (n = 105, 57%), beliefs about capabilities (n = 100, 55%), reinforcement (n = 95, 52%) and goals (n = 95, 52%). Canteen managers who reported optimism as a barrier had significantly lower odds of having a menu compliant with the state policy (OR = 0.39; 95% CI 0.16-0.95, P = 0.038). CONCLUSIONS: This study provides further evidence of perceived and actual barriers that canteen managers face when attempting to implement a healthy canteen policy, and highlights the need to address differences in canteen characteristics when planning implementation support. SO WHAT?: For public health benefits of nutrition policies within schools to be realised, the barriers to implementation need to be identified and used to help guide implementation support strategies.

Availability of food and beverage items on school canteen menus and association with items purchased by children of primary-school age.

OBJECTIVE: To (i) describe the proportion of foods and beverages available on school canteen menus classified as having high ('green'), moderate ('amber') or low ('red') nutritional value; (ii) describe the proportion of these items purchased by students; and (iii) examine the association between food and beverage availability on school canteen menus and food and beverage purchasing by students. DESIGN: A cross-sectional study was conducted as part of a larger randomised controlled trial (RCT). SETTING: A nested sample of fifty randomly selected government schools from the Hunter New England region of New South Wales, Australia, who had participated in an RCT of an intervention to improve the availability of healthy foods sold from school canteens, was approached to participate. SUBJECTS: School principals, canteen managers and students. RESULTS: The average proportion of green, amber and red items available on menus was 47·9, 47·4 and 4·7 %, respectively. The average proportion of green, amber and red items purchased by students was 30·1, 61·8 and 8·1 %, respectively. There was a significant positive relationship between the availability and purchasing of green (R 2=0·66), amber (R 2=0·57) and red menu items (R 2=0·61). In each case, a 1 % increase in the availability of items in these categories was associated with a 1·21, 1·35 and 1·67 % increase in purchasing of items of high, moderate and low nutritional value, respectively. CONCLUSIONS: The findings provide support for school-based policies to improve the relative availability of healthy foods for sale in these settings.

Scale up of a multi-strategic intervention to increase implementation of a school healthy canteen policy: findings of an intervention trial.

BACKGROUND: Implementation interventions delivered in schools to improve food provision have been found to improve student diet and reduce child obesity risk. If the health benefits of food availability policies are to be realised, interventions that are effective need to be implemented at scale, across an entire population of schools. This study aims to assess the potential effectiveness of an intervention in increasing the implementation, at scale, of a healthy canteen policy by Australian primary schools. METHODS: A non-controlled before and after study was conducted in primary schools located in the Hunter New England region of New South Wales, Australia. Schools received a multi-component intervention adapted from a previous efficacious and cost-effective randomised control trial. The primary trial outcome was the proportion of canteen menus compliant with the state healthy canteen policy, assessed via menu audit at baseline and follow-up by dietitians. Secondary outcomes included policy reach and adoption and maintenance policy implementation. RESULTS: Of the 173 schools eligible for inclusion in the trial, 168 provided menus at baseline and 157 menus were collected at follow-up. At follow-up, multiple imputation analysis found 35% (55/157) of schools compared to 17% (29/168) at baseline (OR = 2.8 (1.6-4.7), p = < 0.001) had menus compliant with the state healthy canteen policy. As an assessment of the impact of the intervention on policy reach, canteen manager and principal knowledge of the policy increased from 64% (n = 76) and 38% (n = 44) respectively at baseline to 69% (n = 89) and 60% (n = 70) at follow-up (p = 0.393, p = 0.026). Adoption of the policy increased from 80% (n = 93) at baseline to 90% (n = 104) at follow-up (p = 0.005) for principals, and from 86% (n = 105) to 96% (n = 124) (p = 0.0001) for canteen managers. Multiple imputation analysis showed intervention effects were maintained six-months post intervention (33% of menus compliant OR = 2.6 (1.5-4.5), p = < 0.001 compared to baseline). CONCLUSIONS: This study found school canteen compliance with a healthy food policy increased in association with a multi-strategy intervention delivered at scale. The study provides evidence for public health policy makers and practitioners regarding strategies and modes of support required to support improvement in nutrition policy implementation across entire populations of schools.

Economic analysis of three interventions of different intensity in improving school implementation of a government healthy canteen policy in Australia: costs, incremental and relative cost effectiveness.

BACKGROUND: No evaluations of the cost or cost effectiveness of interventions to increase school implementation of food availability policies have been reported. Government and non-government agency decisions regarding the extent of investment required to enhance school implementation of such policies are unsupported by such evidence. This study sought to i) Determine cost and cost-effectiveness of three interventions in improving school implementation of an Australian government healthy canteen policy and; ii) Determine the relative cost-effectiveness of the interventions in improving school implementation of such a policy. METHODS: An analysis of the cost and cost-effectiveness of three implementation interventions of varying support intensity, relative to usual implementation support conducted during 2013-2015 was undertaken. Secondly, an indirect comparison of the trials was undertaken to determine the most cost-effective of the three strategies. The economic analysis was based on the cost of delivering the interventions by health service delivery staff to increase the proportion of schools 'adherent' with the policy. RESULTS: The total costs per school were $166,971, $70,926 and $75,682 for the high, medium and low intensity interventions respectively. Compared to usual support, the cost effectiveness ratios for each of the three interventions were: A$2982 (high intensity), A$2627 (medium intensity) and A$4730 (low intensity) per percent increase in proportion of schools reporting 'adherence'). Indirect comparison between the 'high' and 'medium intensity' interventions showed no statistically significant difference in cost-effectiveness. CONCLUSIONS: The results indicate that while the cost profiles of the interventions varied substantially, the cost-effectiveness did not. This result is valuable to policy makers seeking cost-effective solutions that can be delivered within budget.

Healthiness of Food and Beverages for Sale at Two Public Hospitals in New South Wales, Australia.

(1) Background: Our aim was to conduct objective, baseline food environment audits of two major western Sydney public hospitals and compare them to recently revised state nutritional guidelines. (2) Methods: A cross-sectional assessment was conducted (June-July2017) across 14 fixed food outlets and 70 vending machines in two hospitals using an audit tool designed to assess the guideline's key food environment parameters of availability, placement, and promotion of 'Everyday' (healthy) and 'Occasional' (less healthy) products. (3) Results: Availability: Overall, Everyday products made up 51% and 44% of all products available at the two hospitals. Only 1/14(7%) fixed outlets and 16/70(23%) vending machines met the guideline's availability benchmarks of ≥75% Everyday food and beverages. Proportion of Everyday products differed among different types of food outlets (café, cafeteria, convenience stores). Placement: On average, food outlets did not meet recommendations of limiting Occasional products in prominent positions, with checkout areas and countertops displaying over 60% Occasional items. Promotion: Over two-thirds of meal deals at both hospitals included Occasional products. (4) Conclusion: Baseline audit results show that substantial improvements in availability, placement, and promotion can be made at these public hospitals to meet the nutrition guidelines. Audits of other NSW hospitals using the developed tool are needed to investigate similarities and differences in food environment between sites. These findings highlight the need for ongoing tracking to inform whether the revised guidelines are leading to improved food environments in health facilities.

Assessing the potential impact of a front-of-pack nutritional rating system on food availability in school canteens: A randomised controlled trial.

BACKGROUND: Front-of-pack graphical nutritional rating of products is becoming an important strategy in many countries to improve healthy food purchases by consumers. Evidence of the effectiveness of such on facilitating healthy food choices by school food service providers has not been reported. The primary aim of the study was to assess the impact of providing front-of-pack nutritional rating information on school canteen managers' likely food selections. Secondary outcomes were canteen manager awareness, attitudes and reported barriers to using the front-of-pack information. METHODS: A randomised controlled trial involving primary school canteen managers was conducted in a single region in New South Wales, Australia. Eligible participants were randomised to an intervention or control group and asked in a telephone interview which of 12 common food products sold in school canteens they would sell. Both groups received product name and brand information. The intervention group also received information regarding the nutritional rating of products. RESULTS: Canteen managers in the intervention group were significantly more likely than those in the control group to indicate they would sell three of the six 'healthier' products (p = 0.036, 0.005, 0.009). There was no difference between groups in the likelihood of making available for sale any of the six 'less healthy' products. The majority of canteen managers who had heard of a product nutritional rating system agreed that it was helpful in identifying 'healthier' foods (88%, n = 31). CONCLUSIONS: The inclusion of product nutritional rating information has the potential to improve the availability of some 'healthier' items on canteen menus and contribute to improving child dietary intake. Further research is required to determine whether the use of product nutritional rating information actually makes a difference to canteen manager choices.

Multi-strategic intervention to enhance implementation of healthy canteen policy: a randomised controlled trial.

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 ).

Online canteens: awareness, use, barriers to use, and the acceptability of potential online strategies to improve public health nutrition in primary schools.

Issue addressed This study of primary school principals assessed the awareness, use, barriers to use and acceptability of online canteens. Methods A telephone survey of 123 primary school principals within the Hunter New England Region of New South Wales, Australia was conducted from September 2014 to November 2014. Results Fifty-six percent of principals were aware of the existence of online canteens, with 8% having implemented such a system, and 38% likely to do so in the future. Medium/large schools were more likely to be aware of or to use online canteens, however there were no differences in awareness or use in relation to school rurality or socioeconomic advantage. Principals cited parent internet access as the most commonly identified perceived barrier to online canteen use, and the majority of principals (71-93%) agreed that it would be acceptable to implement a range of consumer behaviour strategies via an online canteen. Conclusions Study findings suggest that despite relatively low levels of current use, online canteens have the potential to reach a large proportion of school communities in the future, across geographical and socioeconomic divides, and that the nutrition interventions which they have the capacity to deliver are considered acceptable to school principals. So what? Online canteens may represent an opportunity to deliver nutrition interventions to school communities. Future research should examine the feasibility and potential effectiveness of interventions delivered via this modality.

Effectiveness of a multicomponent intervention to enhance implementation of a healthy canteen policy in Australian primary schools: a randomised controlled trial.

BACKGROUND: The implementation of school nutrition policies, which govern the provision of food in schools, is recommended as a public health strategy to support the development of healthy dietary behaviours in school-aged children. Despite this, research internationally and in Australia indicates that few schools implement such policies. This study aims to examine whether a theoretically designed, multi-strategy intervention was effective in increasing the implementation of a healthy canteen policy in Australian primary schools. METHODS: A parallel group randomised controlled trial was conducted with all government and Catholic primary schools within one region in New South Wales, Australia who had an operational canteen that provided food to primary school aged children (5-12 years) and were not currently receiving an intervention to change their canteen practices. Schools randomised to the intervention arm received a 9-month multicomponent intervention including ongoing support, provision of resources, performance monitoring and feedback, executive support and recognition. The primary outcomes were the proportion of the schools with a canteen menu that: i) did not include 'red' or 'banned' items according to the healthy canteen policy; and ii) had more than 50 % 'green' items. The primary outcome was assessed via menu audit at baseline and follow up by dietitians blinded to group allocation. RESULTS: Fifty-three eligible schools were randomised to either the intervention or control group (28 intervention; 25 control). Analyses with 51 schools who returned school menus found that intervention schools were significantly more likely relative to control schools to have a menu without 'red' or 'banned' items (RR = 5.78 (1.45-23.05); p = 0.002) and have at least 50 % of menu items classified as green (RR = 2.03 (1.01-4.08); p = 0.03). CONCLUSIONS: This study found that a multi-component intervention was effective in improving primary schools' compliance with a healthy canteen policy. Given the lack of evidence regarding how best to support schools with implementing evidence-based policies to improve child diet, this trial for the first time provides high quality evidence to practitioners and policy makers seeking to improve nutrition policy implementation in schools. TRIAL REGISTRATION: This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12614001148662 ) 30th October 2014.

Validity of four measures in assessing school canteen menu compliance with state-based healthy canteen policy.

Issue addressed In order to assess the impact of healthy school canteen policies on food availability for students, valid methods of measuring compliance are needed that can be applied at scale. The aim of this study is to assess the validity and direct cost of four methods to assess policy compliance: 1) principal and 2) canteen manager self-report via a computer-assisted telephone interview; and 3) comprehensive and 4) quick menu audits by dietitians, compared with observations. Methods A cross-sectional study took place in the Hunter region of NSW, Australia, in a sample of 38 primary schools that had previously participated in a randomised controlled trial to improve healthy canteen policy compliance. Policy compliance was assessed using the four methods specified above. Percentage agreement, kappa, sensitivity and specificity compared with observations was calculated together with the direct time taken and costs of each method. Indirect costs (including set-up costs) for all measures have not been included. Results Agreement with observations was substantial for the quick menu audit (kappa=0.68), and moderate for the comprehensive menu audit (kappa=0.42). Principal and canteen manager self-report resulted in poor agreement and low specificity with the gold standard. The self-reported measures had the lowest cost, followed by the quick menu audit and lastly the comprehensive menu audit. Conclusion The quick menu audit represents a valid and potentially low-cost method of supporting policy implementation at scale. So what? This study demonstrates that a quick menu audit represents a valid measure of undertaking assessment of school canteen policy compliance at a population level.