Advancing assessment of responsive feeding environments and practices in child care

Child care environments offer an ideal setting for feeding interventions. CELEBRATE Feeding is an approach implemented in child care environments in two Maritime Provinces in Canada to support responsive feeding (RF) to foster children's self-efficacy, self-regulation, and healthy relationships with food. This study aimed to describe RF in child care using established and enhanced scoring frameworks. The Environment and Policy Assessment and Observation (EPAO) was modified to reflect RF environments and practices, resulting in our modified EPAO and a CELEBRATE scale. Observations were conducted in 18 child care rooms. Behaviours and environments were scored on both scales, creating 21 RF scores, with a score of '3' indicating the most responsiveness. Descriptive analyses of the scores were conducted. The overall room averages were Mean (M) = 41.00, Standard Deviation (SD) = 7.07 (EPAO), and M = 37.92 SD = 6.50 (CELEBRATE). Most responsive scores among rooms within our EPAO and CELEBRATE scales, respectively, were 'educators not using food to calm or encourage behaviour' (M = 2.94, SD = 0.24; M = 2.98, SD = 0.06) and 'not requiring children to sit at the table until finished' (M = 2.89, SD = 0.47; M = 2.97, SD = 0.12). The least responsive scores within the EPAO were 'educator prompts for children to drink water' (M = 0.78, SD = 0.94) and 'children self-serving' (M = 0.83, SD = 0.38). The least responsive in the CELEBRATE scale were 'enthusiastic role modelling during mealtime' (M = 0.70, SD = 0.68) and 'praise of mealtime behaviour unrelated to food intake' (M = 0.74, SD = 0.55). The CELEBRATE scale captured unique observation information about RF to allow documenting change over time with detailed measurement to inform and support nutrition interventions within child care environments.

Looking through the lens: a photovoice study examining access to services for newcomer children

PURPOSE

Canadian new immigrant families (also known as newcomers) encounter challenges navigating systems when trying to access programmes critical for their children's healthy development. The purpose of this study is to understand how newcomer families find and use early childhood programmes and services from the perspective of families and early childhood educators (ECEs) working within a settlement organization.

METHODS

Using photovoice methodology, newcomer family members (n = 8) with young children and ECEs (n = 6) participated in a series of virtual workshops to share photos and reflect on their experiences.

RESULTS

Participants discussed the systemic barriers that obstructed newcomer families' access to services for young newcomer children. Financial challenges due to unemployment/underemployment, language and cultural differences were emphasized. Despite these barriers and challenges, participants shared how culturally responsive programmes enhanced their connections to programmes and services. Both groups of participants discussed the critical role of social networks in supporting newcomers to use programmes by helping families become aware of available services and assistance with various processes such as registration.

CONCLUSIONS

This research illustrates the lived experiences of newcomer families and identifies opportunities to address inequities, improve early childhood programmes, and enhance families' access to programmes and services.

Anti-Black racism in the early years: the experiences of Black families and early childhood educators in Nova Scotia

INTRODUCTION

Anti-Black racism is a social determinant of health that has significantly impacted Black children and families. Limited research has examined anti-Black racism during the early years-a critical period of development. In this study, we sought to understand the manifestations of anti-Black racism in early childhood and explore its impact on Black children and families.

METHODS

This qualitative research project was informed by critical race theory, Black Critical Theory and interpretive description. Early childhood educators (ECEs) and parents with Black children between the ages of 18 months and 5 years (n = 15) participated in virtual, semistructured interviews.

RESULTS

Awareness of and protection against anti-Black racism was a constant in Black families' lives. Parents felt as though they had to remain hypervigilant and overprotective of their Black children, knowing they were liable to encounter racial violence. The early learning environment was a source of heightened stress for families, given the significant amount of time young children spend in child care. Black children were often "othered" in predominately White spaces and had been objectified by White ECE staff and children. Parents worked to instill a strong sense of self-confidence in their children to counteract the negative impacts of racial discrimination.

CONCLUSION

Results from this study suggest that children as young as 18 months are experiencing racial violence and adverse childhood experiences. Findings may contribute to antiracist policy development and a focus on more inclusive early childhood education for Black children and families.

Relative Importance of Well-Being Determinants in Atlantic Canadian Families During the Pandemic

Framed by the socio-ecological model of well-being, we examined the relative importance of factors contributing to three dimensions of well-being (child, parent, and family) during the COVID-19 pandemic. A sample of 536 participants from the Atlantic provinces of Canada answered a cross-sectional survey in 2021, covering experiences during the pandemic (eg, changes in family life and well-being). Well-being was assessed with 3 single-item measures on positive change in the life of children, parents, and families during the pandemic. This study involved 21 predictor variables (eg, change in time spent on various family activities). Using multiple regression and measures of relative importance based on the Lindeman, Merenda and Gold (lmg) method, we identified the variables most important to predicting well-being. Twenty-one predictors accounted for 21% of the variance in child well-being, 25% in parent well-being, and 36% in family well-being. Well-being at all 3 levels (child, parent, and family) shared the same top predictor (family closeness). The top 6 predictors of well-being at each level were related to leisure (eg, play) and time-use (eg, to prepare meals, engage in self-care, and rest). The effect sizes were smaller for child well-being than at the parent or family level, suggesting there may be important predictors of child well-being not accounted for in these analyses. This study may inform family-level programing and policy that seeks to promote well-being for children and their families.

Responsive Feeding Environments in Childcare Settings: A Scoping Review of the Factors Influencing Implementation and Sustainability

Children benefit from responsive feeding environments, where their internal signals of hunger and satiety are recognized and met with prompt, emotionally supportive and developmentally appropriate responses. Although there is existing research on responsive feeding environments in childcare, there is little synthesized literature on the implementation practices using a behavior change framework. This scoping review sought to explore the factors influencing the implementation and sustainability of responsive feeding interventions in the childcare environment, using the behavior change wheel (BCW). A total of 3197 articles were independently reviewed and 39 met the inclusion criteria. A thematic analysis identified the factors influencing the implementation and sustainability of responsive feeding, including the following: (1) pre-existing nutrition policies, (2) education and training, (3) provider beliefs and confidence, (4) partnership development and stakeholder engagement and (5) resource availability. The most common BCW intervention functions were education (n = 39), training (n = 38), environmental restructuring (n = 38) and enablement (n = 36). The most common policy categories included guidelines (n = 39), service provision (n = 38) and environmental/social planning (n = 38). The current literature suggests that broader policies are important for responsive feeding, along with local partnerships, training and resources, to increase confidence and efficacy among educators. Future research should consider how the use of a BCW framework may help to address the barriers to implementation and sustainability.

Responsive feeding values and practices among families across the Canadian Maritime provinces

Children benefit from responsive feeding practices where their internal signals of hunger and satiety are valued and met with prompt, emotionally supportive, and developmentally appropriate responses. Using an online survey, this study describes responsive feeding values and practices among parents of young children (0-5 years) (n = 1039) across 3 Canadian Maritime provinces. Independent-samples t-tests and 1-way ANOVA were performed to determine the differences in survey questions related to the responsive feeding practices and values. First-time parents and parents with younger children report implementing more consistently some of the challenging responsive feeding practices, such as avoiding pressuring their children to eat, compared with parents with multiple children and parents with children ages 3-5 years. Parents often have well-intended reasons to encourage their children to eat; however, these can coincide with non-responsive practices with food such as pressuring, rewarding, and restriction. These coercive practices may be ineffective and counterproductive as they reinforce reasons to eat unrelated to appetite and self-regulation. Preschool and early feeding interventions that support parents in understanding normal child development, including typical eating behaviours and self-regulation, could help to equip them for challenging feeding experiences and encourage long-term responsive feeding practices. Novelty: First-time parents and parents with younger children report more consistently avoiding pressuring their children to eat, compared with parents with multiple children and parents with children ages 3-5 years. Parents often have well-intended reasons to encourage their children to eat; however, these can coincide with non-responsive practices such as pressuring, rewarding, and restriction.

Appetite for change? Facilitators and barriers to nutrition guideline implementation in Canadian recreational facilities

As providers of community-based physical activity programs, recreation and sports facilities serve as an important resource for health promotion. Unfortunately, the food environments within these settings often do not reflect healthy eating guidelines. This study sought to describe facilitators and barriers to implementing provincial nutrition guidelines in recreation and sports facilities in three Canadian provinces with nutrition guidelines. Semi-structured interviews were analysed thematically to identify facilitators and barriers to implementing provincial nutrition guidelines. Facilitators and barriers were then categorised using a modified "inside out" socio-ecological model that places health-related and other social environments at the centre. A total of 32 semi-structured interviews were conducted at two time-points across the three guideline provinces. Interview participants included recreation staff managers, facility committee or board members and recreation volunteers. Eight facilitators and barriers were identified across five levels of the inside out socio-ecological model. Facilitators included provincial or municipal expectations of guideline implementation, clear communication to staff around guideline directives and the presence of a champion within the community or facility who supported guideline implementation. Barriers included unhealthy food culture within community, competition from other food providers and issues within food service contracts that undermined healthy food provision. Findings reinforce the importance of top down (clear expectations regarding guideline implementation at the time of approval) and bottom up (need for buy-in from multiple stakeholders) approaches to ensure successful implementation of nutrition guidelines. The application of a modified socio-ecological model allowed for a more nuanced understanding of leverage points to support successful guideline implementation. Lay summary Healthy eating is an important behaviour for preventing chronic diseases. Supporting people to access healthy foods in places where they live, learn, work or play is a public health priority. Recreation and sports facilities are a setting where people can be physically active. Unfortunately, the food environment in these settings may not reflect nutrition guidelines. In this study, we interviewed key stakeholders from recreation and sports facilities in three Canadian provinces who had put guidelines for healthy eating in place. We used a specific framework to do this called the inside out socio-ecological model. Eight facilitators and barriers were identified using this model. Facilitators included provincial or municipal expectations of guideline implementation, clear communication to staff around guideline directives and the presence of a champion within the community or facility who supported guideline implementation. Barriers included unhealthy food culture within community, competition from other food providers and issues within food service contracts that undermined healthy food provision. Our findings can help people working in recreation and sports facilities to identify issues that may help or hinder healthy food provision in these settings.

Engaged scholarship and public policy decision-making: a scoping review

BACKGROUND

Engaged scholarship includes the coproduction and use of research by partnerships that blend research, policy and/or practice perspectives. This way of doing research attempts to bridge-the-gap between knowledge and its application. Recent reviews have described practices that support engagement and involve the community in research and patients in healthcare but there is less known about how to engage individuals working to inform public policy.

AIMS AND OBJECTIVES

The purpose of this research was to articulate the actions and context that support the coproduction and use of research to inform public policy decisions. The study focuses on partnerships between researchers and stakeholders working in public policy across different levels and sectors of government.

METHODS

A scoping review methodology was used. Relevant articles were identified from six electronic bibliographic databases of peer-reviewed literature.

FINDINGS

A total of 9904 articles were screened and 375 full-text articles were assessed for eligibility. The included 11 studies were from research partnerships internationally and described actions and contextual factors contributing to the coproduction and use of research to inform public policy. Key actions included facilitating frequent interactions with public policy stakeholders, joint planning for research, and collaboration to execute data collection and analysis. Contextual factors included clarity in responsibilities, prior relationships, and mutual respect for partner priorities and perspectives.

CONCLUSIONS

Key actions and contextual factors were identified in this review and warrant further study to strengthen research-policy partnerships and their outcomes.

Educator perceptions on the benefits and challenges of loose parts play in the outdoor environments of childcare centres

It is important to consider physical activity and movement in early life to ensure children establish and maintain healthy physical activity patterns. Recent evidence has highlighted the importance of outdoor play and the childcare environment. Active outdoor play, especially free play, supports independence, self-regulation and allows children to explore their world and make decisions. Loose parts or open-ended materials are natural or synthetic resources that can be used in more than one way, allowing children to experiment through play. Incorporating loose parts into play environments creates opportunity for new play experiences. Despite growing evidence supporting loose parts play, the perspectives of childcare providers on the benefits and challenges of this type of play have been overlooked. The purpose of this study was to identify the benefits and challenges of incorporating loose parts play into the outdoor environments of childcare centres, from the perspectives of educators who took part in the Physical Literacy in the Early Years (PLEY) project. PLEY is a larger, mixed methods intervention study with the goal of evaluating a loose parts intervention in early childcare settings. This portion of the project used qualitative description to explore educators' perspectives. Data were collected using focus groups (n = 15) with early childhood educators (n = 3–5 in each group). Thematic analysis was used to identify five themes relating to benefits, and four themes relating to challenges. Benefit themes included: loose parts enable children to take risks; loose parts spark creativity and imagination; loose parts contribute to problem-solving abilities; loose parts cultivate independence and confidence; and loose parts build relationships and leadership. Challenges included: apprehension of loose parts; loose parts as a novelty; sustainability of loose parts; and loose parts present challenges with storage. Overall, we found educators perceived outdoor loose parts play to have multiple social and cognitive benefits for preschool-aged children that are critical for optimal growth and development, and overall health and wellness.

Food in Focus: Youth Exploring Food in Schools Using Photovoice

OBJECTIVE

As part of a study exploring school food environments, this study aimed to understand youth perspectives of school food.

DESIGN

Photovoice, a qualitative visual methodology, was used to engage participants through photo-taking, with goals of enabling reflection, promoting dialogue, and facilitating change.

SETTING

Participants were recruited through 2 youth-focused community organizations in Nova Scotia, Canada.

PARTICIPANTS

Seven youths took part: 3 from a rural area and 4 from an urban center.

PHENOMENON OF INTEREST

Youth perspectives on school food environments.

ANALYSIS

The photovoice process of selecting, contextualizing (using the SHOWeD method), and codifying was used for analysis.

RESULTS

Four themes were identified. First, spaces and places were important to youth food experiences. Second, key components of food environments were identified as quality, variety, time, and price. Third, the relation between food and social influence was highlighted. Fourth, the importance of amplifying youth voice was discussed.

CONCLUSIONS AND IMPLICATIONS

Youth emphasized a desire for greater variety and quality in affordable school food options and the opportunity to be involved in decision-making regarding school food. Future research in other contexts and across larger samples is warranted to extend these findings to help inform stakeholders in school food policy and program implementation.

Eat, play, live: a randomized controlled trial within a natural experiment examining the role of nutrition policy and capacity building in improving food environments in recreation and sport facilities

Background

Recreation and sport facilities often have unhealthy food environments that may promote unhealthy dietary patterns among children. In response, some Canadian provinces have released voluntary nutrition guidelines for recreation and sport facilities, however implementation has been limited. Organizational capacity building may overcome barriers to implementing guidelines. Eat, Play, Live was a randomized controlled trial embedded within a natural experiment that tested the impact of an 18 month capacity building intervention (CBI) in enhancing implementation of provincial nutrition guidelines, and whether nutrition guidelines were associated with positive changes. Primary outcomes were facility capacity, policy development and food environment quality.

Methods

Recreation and sport facilities in three guideline provinces were randomized into a guideline + CBI (GL + CBI; n = 17) or a guideline only comparison condition (GL-ONLY; n = 15). Facilities in a province without guidelines constituted a second comparison condition (NO-GL; n = 17). Facility capacity, policy development, and food environment quality (vending and concession) were measured and compared at baseline and follow-up across conditions using repeated measures ANOVA and Chi-square statistics. Healthfulness of vending and concession items was rated as Do Not Sell (least nutritious), Sell Sometimes or Sell Most (most nutritious).

Results

There were significant time by condition effects, with significant increases in facility capacity (mean ± SD: 30.8 ± 15.6% to 62.3 ± 22.0%; p <  0.01), nutrition policy development (17.6% developed new policies; p = 0.049), overall quality of the concession food environment (14.7 ± 8.4 to 17.5 ± 7.2; p <  0.001), and in the proportion of Sell Most (3.7 ± 4.4% to 11.0 ± 9.0%; p = 0.002) and Sell Sometimes vending snacks (22.4 ± 14.4% to 43.8 ± 15.8%; p <  0.001) in GL + CBI facilities, with a significant decline in Do Not Sell vending snacks (74.0 ± 16.6% to 45.2 ± 20.1%; p <  0.001).

Conclusions

Significant improvements in facility capacity, policy development and food environment quality occurred in recreation and sport facilities that were exposed to nutrition guidelines and participated in a CBI. Outcomes did not improve in facilities that were only passively or not at all exposed to guidelines. Ongoing capacity building may enhance implementation of voluntary nutrition guidelines, however food environments remained overwhelmingly unhealthy, suggesting additional scope to enhance implementation.

Trials registration

Clinical trials registration (retrospectively registered): ISRCTN14669997 Jul 3, 2018.

Electronic supplementary material

The online version of this article (10.1186/s12966-019-0811-8) contains supplementary material, which is available to authorized users.

A translational approach to characterization and measurement of health-promoting school ethos

A health promoting schools (HPS) approach is hypothesized to influence student health and wellbeing by promoting a 'school ethos' that reflects the physical environment, social relations, organisational structure, policies and practices within schools. This complex set of factors makes health promoting school ethos (HPSE) challenging to define and measure. This work sought to theorise, develop and pilot a measure of HPSE as the context for implementation of HPS initiatives. We used a multi-method, iterative process to identify relevant HPSE concepts through triangulation of conceptual literature, existing tools and the tacit knowledge of school stakeholders. The HPSE measurement tool was administered to 18 elementary schools through a principal and teacher survey and an environmental assessment, followed by the development of HPSE scores for each school. Testing for internal consistency of items was used to examine theorized concepts, and scores for each school are summarised. HPSE included eight conceptual dimensions with internal consistency ranging from α = 0.60 to α = 0.87. Total HPSE scores across schools (N = 18) ranged from 1 to 8 (mean = 3.94, SD = 2.1), with 28-65% of schools reporting 'high' on respective HPSE dimensions. Schools included a heterogeneous mixture of HPSE scores, particularly across different dimensions. Our novel approach to tool development allowed us to conceptualize HPSE using a flexible process comprising different types and sources of evidence. The HPSE tool holds potential for identification and measurement of critical components of different school context as it relates to HPS.

Voluntary nutrition guidelines to support healthy eating in recreation and sports settings are ineffective: findings from a prospective study

Interventions to support healthy eating among populations are needed to address diet-related chronic disease. Recreation and sport settings are increasingly identified as ideal settings for promoting overall health, particularly for children, through creation of environments that support positive health behaviours. These publicly funded settings typically support health through physical activity promotion. However, the food environment within them is often not reflective of nutrition guidelines. As more jurisdictions release nutrition guidelines in such settings, the purpose of this study was to assess whether voluntary nutrition guidelines, released in 2015 in the Canadian province of Nova Scotia, had any impact on food environments in these settings. Baseline and follow-up audits of food environments were conducted one year before (in 30 facilities) and one year after guideline release (in 27 facilities). Audits involved classifying all foods and beverages within vending machines and concessions as Do Not Sell, Minimum, Moderate, or Maximum nutrition, using criteria provided in the guidelines. The proportion of items within each category was calculated, and differences from pre- to post-guideline release were assessed using Chi-squared statistics. Results indicated limited change in food and beverage provision from pre- to post- guideline release. In fact, from pre- to post-guideline release, the proportion of Do Not Sell vending beverages and concession foods increased significantly, while Maximum concession beverages decreased, suggesting a worsening of the food environment post-guideline release. Findings suggest that voluntary guidelines alone are insufficient to improve food environments in recreation and sport settings. For widespread changes in the food environment of these settings to occur, more attention needs to be paid to reducing social, cultural, political and economic barriers to change (real and perceived) that have been identified in these settings, alongside developing leadership and capacity within facilities, to ensure that positive changes to food environments can be implemented and sustained.

Describing Food Availability in Schools Using Different Healthy Eating Guidelines: Moving Forward with Simpler Nutrition Recommendations

PURPOSE

Internationally, there is debate on whether a nutrient or a food-based approach to policy is more effective. This study describes the food/beverage availability in schools in Nova Scotia through a comparison of a traditional nutrient classification ("Maximum/Moderate/Minimum"), currently used in the provincial school policy and a simplified food-based system ("Core/Extra").

METHODS

School food environment audits were conducted in schools (n = 25) to record the food and beverages available. Registered dietitians categorized information using both the nutrient-based and simplified food-based classification systems. Number and percent in each category were described for items.

RESULTS

Food and beverage items consisted of breakfast, lunch, snacks, beverages, and vending of which 81% were permissible by the policy, whereas only 54% were categorized as Core. Many snacks and vending items classified as Extra fell within either Moderate (45% and 35%, respectively) or Minimum (29% and 33%, respectively) categories.

CONCLUSIONS

Dietitians have a role to support interpretation of classification systems for school nutrition policies. The nutrient-based classification used in the policy permitted some items not essential to a healthy diet as defined by the Extra food-based classification. However, the food-based Core/Extra categorization had less detail to classify nutrients.

Factors Influencing the Implementation of Nutrition Policies in Schools: A Scoping Review

BACKGROUND

Although school nutrition policies (SNPs) have been highlighted as an important intervention to support childhood nutrition, their implementation and maintenance within real-word settings is complex. There is a need to understand the factors that influence implementation by consolidating existing research and identifying commonalities and differences.

AIMS

The purpose of this review is to determine what is known about the influence of broad and local system factors on the implementation of SNPs internationally.

METHOD

This scoping review involved identifying and selecting relevant literature that related SNP implementation in primary and secondary schools. Following the search process, 2,368 articles were screened and 59 articles were synthesized and charted and emerging themes were identified.

RESULTS

Across the final studies identified, factors emerged as barriers and facilitators to the implementation of SNPs, with system implications that related to five areas to support policy action: providing macro-level support may encourage policy implementation; addressing the financial implications of healthy food access; aligning nutrition and core school priorities; developing a common purpose and responsibility among stakeholders; recognition of school and community characteristics.

DISCUSSION

While SNPs can help to support childhood nutrition, strategies to address issues related to policy implementation need to be taken to help schools overcome persistent challenges.

CONCLUSION

The results of this review provide opportunities for action across multiple system levels to ensure synergy and coordinated action toward SNP goals to foster the creation supportive nutrition environments for children.

Integrated knowledge translation in population health intervention research: a case study of implementation and outcomes from a school-based project

Background

Integrated knowledge translation (IKT) is encouraged in population health intervention research (PHIR) to ensure the co-production of policy-relevant research, yet there is little published literature that reports its implementation and outcomes. The purpose of this study was to describe and evaluate the IKT approach used in a school-based PHIR project to understand how the research informed policy and practice and identify what influenced the IKT process.

Methods

A case study approach was used to provide an in-depth description of the IKT process and understand the co-production and application of research evidence. Data were collected through document review, a survey with all elementary school principals in the school board (n = 18) following dissemination of School Reports and interviews with the IKT research team (including two researchers and three knowledge users).

Results

Approximately half of the principals reported reading their School Report (52%) and almost all of these principals attributed the partial or full adoption, or implementation, of a new practice as a result of using the information (89%). Key themes related to the IKT process emerged across the interviews, including supportive relationships, role clarity, competing priorities and the complexities of population health interventions.

Conclusions

The findings suggest that, while IKT can support policy and practice, it can be challenging to maintain engagement due to differing priorities and role ambiguity. Additional recognition, investment and research would enable better implementation of the approach, thereby bridging the gap between research, policy and practice.

Moving from Policy to Practice: A Report of School Nutrition Policy Adherence in Nova Scotia

PURPOSE

School food and nutrition policies have the potential to encourage healthier eating among children and youth to address rising concerns of poor diet quality. Despite their widespread implementation, there is little reported monitoring of policy adherence. This short report describes adherence to the provincial school food and nutrition policy in Nova Scotia (NS) that was implemented in 2006.

METHODS

An online survey was distributed to NS public schools in 2014-2015 to assess adherence to the directives and guidelines of the policy. Descriptive information was obtained for schools and indicators for policy adherence were explored.

RESULTS

A total of 242 schools completed the survey (73% response rate) and policy adherence was variable across the different components. Few schools adhered to the policy standard related to the sale of unhealthy foods and there was inconsistency in school adherence reported for other policy indicators.

CONCLUSIONS

This research suggests that further action is need to ensure "minimum nutrition" food and beverages are not available in schools and that healthy eating is reinforced through prioritizing key policy actions like pricing strategies, discontinuing fundraising with unhealthy food, and ensuring food programs are available in a nonstigmatizing manner.

At-a-glance - "A tough sell": findings from a qualitative analysis on the provision of healthy foods in recreation and sports settings

Recreation and sport settings (RSS) typically promote health in the form of physical activity, but the healthfulness of their food environment is often neglected. We explored stakeholder perspectives on barriers to healthy food provision in RSS through telephone interviews with ten representatives from RSS across Nova Scotia. Three key barriers were identified: 1) cultural norms associated with food in RSS and the broader environment, 2) the persisting notion of personal choice and responsibility, and 3) financial implications of healthy food provision. These barriers challenge healthy food provision in RSS and require multi-faceted strategies to overcome social norms that undermine health behaviours.

Culture matters: a case of school health promotion in Canada

Rising concerns of poor health behaviours of children and youth have stimulated international support for a comprehensive approach to promoting the development of healthy behaviours in the early years. Health promoting schools (HPS) is increasingly adopted as an approach to guide supportive practices, but there is limited research that has reported how to effectively implement HPS at a population level. The purpose of this research was to qualitatively explore the factors preventing and facilitating implementation of HPS practices in the Canadian province of Nova Scotia. Interviews (n = 23) were conducted with school stakeholders (principals, teachers and parents) from a diverse sample of schools (n = 9) and data were analysed to develop an understanding of how school circumstances and experiences influenced HPS implementation. At a broad level, the reported barriers were structural and systemic, whereas the facilitating factors were related to organizational capacity and political leadership. It was evident that implementing and sustaining HPS required a shift in values and integration of supportive school health practices into school priorities. The results suggest that, without addressing the competing culture, which is persistently reinforced by strict academic mandates and unhealthy community norms, HPS will be vulnerable to circumstances that prevent implementation. Considering the emerging importance of mental wellbeing, it will also be important to provide schools with adequate and appropriate staff capacity and support to address this issue. Sustaining the positive effects of HPS will require continuous engagement and collaboration with multiple stakeholders to embed health promotion into school community norms.

The picture of health: examining school-based health environments through photographs

Health-promoting schools (HPS) is an effective approach to enhance the health and well-being of children and youth, but its measurement remains a challenge considering contextual differences across school environments. The purpose of this study was to qualitatively explore the physical features of the school environment through photographs of schools that had implemented an HPS approach compared with schools that had not. This study used a descriptive approach, wherein physical features of the school environment were distilled through visual images and qualitatively analyzed. School environment data were collected from 18 elementary schools (10 HPS, 8 comparison schools) from a school board in rural Nova Scotia (Canada). Evaluation assistants captured photographs of the physical school environment as part of a broader environment audit. Overarching themes included the promotion, access and availability of opportunities for healthy eating and physical activity, healthy school climate and safety and accessibility of the school. The photographs characterized diverse aspects of the school environment and revealed differences between schools that had implemented an HPS approach compared with schools that had not. There were increased visual cues to support healthy eating, physical activity and mental well-being, and indications of a holistic approach to health among schools that implemented an HPS approach. This research adds to understanding the environmental elements of HPS. The use of photographic data to understand school environments provided an innovative method to explore the physical features of schools that had implemented an HPS approach.

Evaluation of a health promoting schools program in a school board in Nova Scotia, Canada

A Health promoting schools (HPS) approach aims to make schools a healthy place through a holistic approach that promotes a supportive 'school ethos' and emphasizes improvements in physical, social, and emotional well-being and educational outcomes. A HPS initiative in rural Nova Scotia (Canada) provided an opportunity for a population-level natural experiment. This study investigated student well-being and health behaviours between schools with and without HPS implementation and schools with high and low school ethos scores. Student well-being, nutrition, and physical activity were examined in a cross-sectional survey of elementary students in Nova Scotia, Canada in 2014. Multiple regression was used to assess the relationship with student well-being using the Quality of Life in School (QoLS) instrument and health behaviours. The main exposure was attending one of the 10 HPS schools; secondary exposure was the school ethos score. The overall QoLS score and its subdomain scores in the adjusted models were higher in students attending HPS schools compared to those in non-HPS schools, but the differences were not statistically significant and the effect sizes were small. Students in schools that scored high on school ethos score had higher scores for the QoLS and its subdomains, but the difference was only significant for the teacher-student relationship domain. Although this study did not find significant differences between HPS and non-HPS schools, our results highlight the complexity of evaluating HPS effects in the real world. The findings suggest a potential role of a supportive school ethos for student well-being in school.

Interventions to Support System-level Implementation of Health Promoting Schools: A Scoping Review

Health promoting schools (HPS) is recognized globally as a multifaceted approach that can support health behaviours. There is increasing clarity around factors that influence HPS at a school level but limited synthesized knowledge on the broader system-level elements that may impact local implementation barriers and support uptake of a HPS approach. This study comprised a scoping review to identify, summarise and disseminate the range of research to support the uptake of a HPS approach across school systems. Two reviewers screened and extracted data according to inclusion/exclusion criteria. Relevant studies were identified using a multi-phased approach including searching electronic bibliographic databases of peer reviewed literature, hand-searching reference lists and article recommendations from experts. In total, 41 articles met the inclusion criteria for the review, representing studies across nine international school systems. Overall, studies described policies that provided high-level direction and resources within school jurisdictions to support implementation of a HPS approach. Various multifaceted organizational and professional interventions were identified, including strategies to enable and restructure school environments through education, training, modelling and incentives. A systematic realist review of the literature may be warranted to identify the types of intervention that work best for whom, in what circumstance to create healthier schools and students.

Validation of the "Quality of Life in School" instrument in Canadian elementary school students

Background. School is an integral component of the life of a child, and thus quality of school life is an important part of the overall quality of life experienced by a child. There are a few instruments available to measure the quality of school life but they are often not available in English, or they are not appropriate for use alongside other instruments in a survey of young children. The Quality of Life in School (QoLS) instrument is a short, self-report measure to assess elementary school students’ perception of their quality of school life in four domains. The instrument was developed in Israel and has been validated among Hebrew-speaking children. The aim of the current study was to evaluate the psychometric properties of the QoLS measure in Canadian elementary school children.

Methods. A total of 629 children attending grades 4–6 were recruited in a population-based cross-sectional study. The QoLS measure was administered to participating children by trained research assistants. In addition, their socio-demographic details and academic data were also obtained. The psychometric testing included exploratory factor analysis and reliability estimation using internal consistency (Cronbach’s Alpha). Construct validity was investigated using the known groups comparisons for discriminative validity and via convergent validity.

Results. A four-factor structure was generated explaining 39% of the total variance in the model. The results showed good internal consistency and acceptable floor and ceiling effects. Cronbach’s Alpha ranged from 0.75 to 0.93. Known groups comparisons showed that the QoLS measure discriminated well between subgroups on the basis of gender, grade, and academic achievement, thus providing evidence of construct validity. The convergent validity was also appropriate with all the four domains demonstrating moderate to strong correlations to each other and to the total QoLS score.

Conclusions. QoLS appears to be a valid and reliable measure for quality of school life assessment in young Canadian children.

Providing context to the implementation of health promoting schools: A case study

PURPOSE

Issues related to program context are important components of population health interventions and particularly among complex, adaptive initiatives in schools. Health Promoting Schools (HPS) is a global approach to support early development of healthy behaviors among children and youth. The purpose of this study was to explicate the practical and contextual processes that influenced implementation of HPS in schools in Nova Scotia (Canada).

METHODS

Using a case-study approach, data was collected using interviews (n=14) with principals, teachers and parents, observations collected during school visits and document review in five diverse schools.

RESULTS

Case study schools reported a variety of HPS practices and three key themes emerged that provided context to the processes that facilitated their implementation. The results suggest that although school characteristics (theme 1), like staff allocation, physical location and resources, are important, these barriers can be mitigated by building organizational capacity (theme 2) and establishing a supportive school community culture (theme 3).

CONCLUSIONS

The study provided insight to the variability in implementation by describing how contextual barriers were experienced and mitigated by schools. Establishing a broad system to support HPS, with collaboration across health and education sectors, could help to progress adoption, implementation and sustainability of HPS.

Moving Forward with School Nutrition Policies: A Case Study of Policy Adherence in Nova Scotia

Many Canadian school jurisdictions have developed nutrition policies to promote health and improve the nutritional status of children, but research is needed to clarify adherence, guide practice-related decisions, and move policy action forward. The purpose of this research was to evaluate policy adherence with a review of online lunch menus of elementary schools in Nova Scotia (NS) while also providing transferable evidence for other jurisdictions. School menus in NS were scanned and a list of commonly offered items were categorized, according to minimum, moderate, or maximum nutrition categories in the NS policy. The results of the menu review showed variability in policy adherence that depended on food preparation practices by schools. Although further research is needed to clarify preparation practices, the previously reported challenges of healthy food preparations (e.g., cost, social norms) suggest that many schools in NS are likely not able to use these healthy preparations, signifying potential noncompliance to the policy. Leadership and partnerships are needed among researchers, policy makers, and nutrition practitioners to address the complexity of issues related to food marketing and social norms that influence school food environments to inspire a culture where healthy and nutritious food is available and accessible to children.

The impact of school policies and practices on students' diets, physical activity levels and body weights: A province-wide practice-based evaluation

OBJECTIVES

To assess what health promotion policies and practices were adopted by schools in Nova Scotia and the extent that these policies and practices affected the diet quality, physical activity (PA) and weight status of students.

METHODS

We developed and administered a 'school practice assessment tool' to assess the presence of 72 different school-based health promotion policies and practices. Surveys were conducted in 2003 and 2011 to assess diet, PA and weight status in approximately 10,000 grade 5 students. We used multilevel regression methods to examine changes in these outcomes across schools with varying levels of health promotion policies and practices between the two time-points.

RESULTS

Between 2003 and 2011 the diet quality of students improved, PA decreased and the prevalence of childhood obesity increased. Although we did not find consistent or significant favourable benefits resulting from higher implementation levels, we did observe fewer negative trends among schools at higher levels of implementation.

CONCLUSION

Our results build on the current gap in knowledge on the impact of Health Promoting Schools (HPS) implementation through population health interventions, but there is a continued need for further evaluation and monitoring of school policies to understand how HPS practices are supporting healthier eating and PA for students.

The impact of a population-level school food and nutrition policy on dietary intake and body weights of Canadian children

OBJECTIVE

The objective of this study is to assess population-level trends in children's dietary intake and weight status before and after the implementation of a provincial school nutrition policy in the province of Nova Scotia, Canada.

METHOD

Self-reported dietary behavior and nutrient intake and measured body mass index were collected as part of a population-level study with grade 5 students in 2003 (n=5215) and 2011 (5508), prior to and following implementation of the policy. We applied random effects regression methods to assess the effect of the policy on dietary and health outcomes.

RESULTS

In 2011, students reported consuming more milk products, while there was no difference in mean consumption of vegetables and fruits in adjusted models. Adjusted regression analysis revealed a statistically significant decrease in sugar-sweetened beverage consumption. Despite significant temporal decreases in dietary energy intake and increases in diet quality, prevalence rates of overweight and obesity continued to increase.

CONCLUSION

This population-level intervention research suggests a positive influence of school nutrition policies on diet quality, energy intake and healthy beverage consumption, and that more action beyond schools is needed to curb the increases in the prevalence of childhood obesity.