Context matters-the phased development of an adaptable food literacy intervention: Up for Cooking.

Adapting interventions to the context increases the impact and sustainability of interventions. Literature acknowledges the need to adapt existing interventions and that these adaptations should be clearly reported. However, little is known about how to incorporate adaptation from the beginning. This paper argues that interventions should be developed and adaptations should be made using an ongoing non-linear approach. An action-oriented research approach with feedback loops is proposed. We illustrate this with the development of a food literacy intervention 'Up for Cooking' (Dutch: Zin in Koken) and present lessons learned in developing, implementing and studying such adaptable interventions. Interventions should clearly define and differentiate the intervention function and form. Implementers, in turn, should be encouraged to tailor interventions within a form that fits with a specific context. Sufficient time, continuous adaptation based on co-creation, feedback loops and interdisciplinary collaboration are important prerequisites for the development of adaptable interventions.

Co-Creation Approach with Action-Oriented Research Methods to Strengthen "Krachtvoer"; A School-Based Programme to Enhance Healthy Nutrition in Adolescents.

In recent years, the nutritional pattern of the Dutch adolescent has cautiously improved. However, progress can be gained if more Dutch adolescents adhere to the nutritional guidelines. School-based initiatives offer opportunities to deal with the unhealthy eating behaviours of adolescents via nutrition educational interventions. In designing and/or re-designing school-based interventions, it is important to enhance optimal context-oriented implementation adaptation by involving the complex adaptive school system. This paper elaborates on the way of dealing with the dynamic implementation context of the educational programme "Krachtvoer" (ENG: "Power food") for prevocational schools, how the programme can be adapted to each unique implementation context, and how the programme can be progressively kept up to date. Following a co-creation-guided approach with various intersectoral stakeholders within and outside the school setting, action-oriented mixed research methods (i.e., observations, semi-structured interviews, focus group interviews, programme usage monitoring, and questionnaires) constantly provide input to develop the programme and its implementation strategy via continuous micro-process cycles. Successful co-creation of school-based health promotion seems to be dependent on proper intersectoral cooperation between research and practice communities, a national partner network that can provide project-relevant insights and establish capacity building aimed at improving contextual fit, and a time-investment balance in and between sectors.

Involving Parents in Promoting Healthy Energy Balance-Related Behaviors in Preschoolers: A Mixed Methods Impact and Process Evaluation of SuperFIT.

Parental involvement is an essential component of obesity prevention interventions for children. The present study provides a process and impact evaluation of the family component of SuperFIT. SuperFIT is a comprehensive, integrated intervention approach aiming to improve energy balance-related behaviors (EBRBs) of young children (2-4 years). A mixed methods design combined in-depth interviews with parents (n = 15) and implementers (n = 3) with questionnaire data on nutritional and physical activity-related parenting practices (CFPQ and PPAPP), the physical home environment (EPAO_SR) (n = 41), and intervention appreciation (n = 19). Results were structured using the concepts of reach, adoption, implementation, and perceived impact. Findings indicated that the families reached were mostly those that were already interested in the topic. Participants of the intervention appreciated the information received and the on-the-spot guidance on their child's behavior. Having fun was considered a success factor within the intervention. Parents expressed the additional need for peer-to-peer discussion. SuperFIT increased awareness and understanding of parents' own behavior. Parents made no changes in daily life routines or the physical home environment. Translating knowledge and learned strategies into behavior at home has yet to be achieved. To optimize impact, intervention developers should find the right balance between accessibility, content, and intensity of interventions for parents.

The Effectiveness of the Good Affordable Food Intervention for Adults with Low Socioeconomic Status and Small Incomes.

Good Affordable Food (GAF) is a small-group nutrition education intervention for adults with low socioeconomic status and small incomes. It aims to empower participants to save money on groceries and consume healthier diets. This paper reports the short-term and longer-term effects on behavioural determinants and self-reported behavioural changes. A quasi-experimental control group design was applied with a baseline measurement, a post-test immediately after the intervention, and a follow-up measurement after six months. The study included 237 participants (intervention group: n = 131; control group: n = 106) at baseline, 197 at post-test, and 152 at follow-up. Data were collected by telephone, mostly using closed interview questions. Positive short-term and longer-term effects were found for attitude towards the costs of healthy foods, food label use, and the use of liquid butter or oil to prepare hot meals. Short-term intervention effects related to knowledge towards saving money on groceries, self-efficacy towards healthy eating, portion size awareness, and mindful eating. GAF was effective in changing some determinants and behaviours related to cost and food consumption, however, mostly in the short term. Thereby, it is an example of combining pricing and health information in nutrition education that developers of effective nutrition education for low-income groups can build on.

Restrictive rules of Dutch mothers regarding their children's dietary intake between meals.

The use of restrictive food rules by parents has been found to be associated with dietary intake in their children. The aim of this study was to explore the use of restrictive rules of Dutch mothers regarding their child's food intake between main meals in detail, to generate necessary input for setting priorities for further research and intervention development. A cross-sectional questionnaire study on nine restrictive rules was completed by 359 mothers of primary school children aged 4-12years. Mothers reported to use an average of 4.1 (SD 2.1) out of nine restrictive food rules and all rules measured in this study were used. The rules mother's reported to use most were not eating shortly before meals, not eating certain foods too often and not eating too much of certain foods. The rules varied according to different foods, but particularly applied to the intake of potato chips, nuts and savory snacks, candy and chocolate. Mothers of a younger age, lower educated mothers and mothers with a higher BMI were less likely to use (certain) restrictive rules. This study showed that mothers use a large variety of rules, particularly to restrict the intake of unhealthy foods and reported on several subgroups that were less likely to use (certain) rules. Our results direct further research and inform the development of interventions.

Examining the relationship between completeness of teachers' implementation of the Krachtvoer healthy diet programme and changes in students' dietary intakes.

OBJECTIVE: The goal of the current study was to examine if the completeness of programme implementation and the completeness of implementation of specific programme elements of the Dutch school-based healthy diet promotion programme Krachtvoer are related to short- and longer-term changes in students' fruit, sweets and breakfast intakes. DESIGN: Data on students' dietary intakes were collected 1­4 weeks and 6 months after programme implementation. Teachers filled in a logbook on programme implementation after each lesson. The relationships between changes in students' dietary intakes and completeness of implementation of the programme and of specific programme elements were tested using mixed linear regression analyses. SETTING: Thirteen Dutch prevocational schools. SUBJECTS: Eight hundred and seventy-six of the 1117 participating students and eighteen of the twenty-two participating teachers. RESULTS: Completeness of programme implementation was positively related to an increase in fruit consumption in the short term. Completeness of implementation of food exposure activities and a practical lesson on advertisements were related to an increase in fruit consumption in the short as well as the longer term. No such relationships were found for sweets and breakfast consumption. CONCLUSIONS: Our results indicate that efforts should be made to help teachers implement the programme as fully as possible.

Healthier food choices as a result of the revised healthy diet programme Krachtvoer for students of prevocational schools.

BACKGROUND: Krachtvoer is a Dutch healthy diet programme for prevocational schools, developed in 2001 and revised for a broader target group in 2007, based on the findings of an evaluation of the first version. The goal of this study was to report on the short- and longer-term total and subgroup effects of the revised programme on students' fruit, fruit juice, breakfast, and snack consumption. METHODS: Schools were randomized to the experimental condition, teaching the Krachtvoer programme, or to the control condition teaching the regular nutrition lessons. Self-reported consumption of fruit, fruit juice, breakfast and snacks was measured at baseline directly before programme implementation, one to four weeks after finishing programme implementation, and after six months. Mixed linear and logistic regression analyses were conducted. RESULTS: In total 1117 students of 13 experimental schools and 758 students of 11 control schools participated in the study. Short- and longer-term favourable intervention effects were found on fruit consumption (mean difference between experimental and control group 0.15 servings at both posttests). Regarding fruit juice consumption, only short-term favourable effects were revealed (mean difference between experimental and control group 0.05 glasses). Intervention effects on breakfast intakes were limited. No changes in snack frequency were reported, but students made healthier snack choices as a result of the programme. Some favourable as well as unfavourable effects occurred in subgroups of students. CONCLUSIONS: The effects on fruit consumption and snack choices justify the current nationwide dissemination of the programme. Achieving changes in breakfast consumption may, however, require other strategies.

Appreciation and implementation of the Krachtvoer healthy diet promotion programme for 12- to 14- year-old students of prevocational schools.

BACKGROUND: Krachtvoer is a school-based healthy diet programme, developed in 2001 and revised in 2007 to meet the needs of particular segments of the target population as well as a wider target group. The main aims of the present process evaluation of the revised programme were to examine student and teacher appreciation of the programme, completeness of and adherence to its implementation, and relations between appreciation and completeness of implementation. METHODS: Data were collected among 22 teachers and 1117 students of 13 schools, using student evaluation forms, teacher logbooks, telephone interviews, and classroom observations. RESULTS: Results indicate favourable levels of teacher and student appreciation for the programme in general and the revised elements. Girls, first-year students and students with more favourable dietary intakes particularly appreciated individual programme elements. Levels of completeness of implementation were high, but several teachers did not adhere to the intended implementation period. Some moderately strong relations were found between teacher appreciation and completeness of implementation scores. CONCLUSION: We conclude that the revisions have resulted in a programme that was appreciated well, also by the extended target group, and was implemented with a high degree of completeness. Teacher appreciation proved potentially important for completeness of implementation. We identified several aspects requiring improvement, indicating the importance of continued programme updates and repeated evaluation.

Evaluation of an adoption strategy for a healthy diet programme for lower vocational schools.

This paper describes the evaluation of an adoption strategy for the school-based healthy diet programme Krachtvoer. Health promotion (HP) professionals from five Regional Public Health Services (RPHSs) in The Netherlands were asked to recruit a total of 25 schools to adopt the Krachtvoer programme in accordance with this strategy. Afterwards, they were interviewed about their adherence to and subjective evaluation of the strategy. The adoption rate of the programme was calculated and 10 adopting and 9 rejecting teachers were interviewed about the reasons for their decision. The HP professionals' adherence to the strategy was good, as well as their appreciation and the perceived feasibility of the strategy. The person-to-person approach that characterized this strategy was considered important. The strategy led to an adoption rate of 53.2%. On average, adopters mentioned 4.4 reasons and rejecters mentioned 5.4 reasons for their decision. Most reasons were school related and programme related and in case of the adopters also teacher related. The diversity of reasons revealed the complexity of teachers' decision making. Although there is some room for improvement of the adoption strategy and the programme itself, especially socio-political conditions in schools and in RPHSs need change for a further increase in programme adoption.

Breakfast consumption among children and adolescents in the Netherlands.

BACKGROUND: The Netherlands Nutrition Centre (NNC) recommends eating a daily breakfast preferably including products from five food groups. The aims of this study were to examine to what extent breakfast consumption among Dutch youngsters attending primary and secondary education (aged 10-19 years) is in accordance with these recommendations and whether breakfast habits differ among demographic subgroups. METHODS: A cross-sectional study was conducted among 2404 youngsters at 71 schools in the Netherlands. All Dutch schools were stratified by educational level and province, and randomly ordered within the strata. Participants completed an online questionnaire at school including food frequency items and a 24-h recall. RESULTS: The percentage of participants reporting to consume breakfast every day varied between 62.9 and 95.5 in different subgroups. Skipping breakfast was associated with being older, being a girl, attending vocational or senior general education and being of non-Dutch origin. Of the participants, <9% consumed products from five food groups as recommended. Participants especially ate products from the 'grain group', followed by the 'dairy group', the 'fats group', 'the liquids group' and the 'fruit/fruit juice group'. Bread, butter and milk were the most frequently consumed products and the majority chose healthy (i.e. low-fat) variants within food groups (i.e. wholemeal bread). CONCLUSION: Health promotion efforts should aim to stimulate breakfast consumption, particularly among vocational school students and adolescents of non-Dutch origin. Special attention should be given to breakfast quality. Future research should investigate whether better adherence to the recommendations of the NNC results in enhanced nutrient intake at breakfast.