Barriers and facilitators to successful implementation of sustainable school meals: a qualitative study of the OPTIMAT™-intervention

Patricia Eustachio Colombo, Liselotte Schäfer Elinder, Emma Patterson, Alexandr Parlesak, Anna Karin Lindroos, Susanne Andermo, Patricia Eustachio Colombo, Liselotte Schäfer Elinder, Emma Patterson, Alexandr Parlesak, Anna Karin Lindroos, Susanne Andermo

Abstract

Background: There is an urgent need to align human diets with goals for environmental sustainability and population health. The OPTIMAT™-intervention study was developed to implement and evaluate a nutritionally adequate and climate-friendly 4-week lunch menu in Swedish primary schools. This study aimed to explore pupils' and kitchen staff's experiences of the intervention and to identify barriers and facilitators to successful implementation of sustainable school meals.

Methods: An inductive manifest qualitative method was used. Nine focus group discussions (FGDs) were conducted, six with pupils in grades 5 (ages 10-11) and 8 (ages 14-15) (n = 29) and three with kitchen staff (n = 13). Data were analyzed using qualitative content analysis.

Results: Five main categories and 11 subcategories at a manifest level emerged. The five main categories were: 1) Experiences with the new menu, unfolding variations in how the new menu was received and kitchen staff's experiences of working with it; 2) The meaning of diet sustainability, comprising pupils' and kitchen staff's perceptions about diet sustainability as a concept and part of their everyday lives; 3) Factors influencing plant-based food acceptance, covering aspects such as the influence of sensory factors, habits and peer pressure; 4) Opportunities to increase plant-based eating, including factors related to pupils' and kitchen staff's ideas for how to increase plant-based food acceptance; and 5) Need for a supportive environment to achieve dietary change, comprising pupils' and kitchen staff's thoughts on the importance of more knowledge, resources and involvement of stakeholders to eat more plant-based meals in schools.

Conclusions: Successful implementation of sustainable school meals would require more knowledge among pupils and kitchen staff. Staff also need more training in cooking of sustainable meals. Barriers among pupils could be tackled by introducing new plant-based meals more gradually and by more carefully considering the seasoning, naming and aesthetics of dishes. An increased leadership support for change and involvement of stakeholders from multiple levels within society will be key in the transition to sustainable school meals at scale.

Trial registration: The trial registration for the OPTIMAT™-intervention may be found at clinicaltrials.gov ( NCT04168632 Fostering Healthy and Sustainable Diets Through School Meals (OPTIMAT)).

Keywords: Children; Implementation research; Public health; Public sector meals; Sustainable diets.

Conflict of interest statement

The authors declare that they have no competing interests.

References

    1. Afshin A, Sur PJ, Fay KA, Cornaby L, Ferrara G, Salama JS, Mullany EC, Abate KH, Abbafati C, Abebe Z, Afarideh M, Aggarwal A, Agrawal S, Akinyemiju T, Alahdab F, Bacha U, Bachman VF, Badali H, Badawi A, Bensenor IM, Bernabe E, Biadgilign SKK, Biryukov SH, Cahill LE, Carrero JJ, Cercy KM, Dandona L, Dandona R, Dang AK, Degefa MG, el Sayed Zaki M, Esteghamati A, Esteghamati S, Fanzo J, Farinha CSS, Farvid MS, Farzadfar F, Feigin VL, Fernandes JC, Flor LS, Foigt NA, Forouzanfar MH, Ganji M, Geleijnse JM, Gillum RF, Goulart AC, Grosso G, Guessous I, Hamidi S, Hankey GJ, Harikrishnan S, Hassen HY, Hay SI, Hoang CL, Horino M, Ikeda N, Islami F, Jackson MD, James SL, Johansson L, Jonas JB, Kasaeian A, Khader YS, Khalil IA, Khang YH, Kimokoti RW, Kokubo Y, Kumar GA, Lallukka T, Lopez AD, Lorkowski S, Lotufo PA, Lozano R, Malekzadeh R, März W, Meier T, Melaku YA, Mendoza W, Mensink GBM, Micha R, Miller TR, Mirarefin M, Mohan V, Mokdad AH, Mozaffarian D, Nagel G, Naghavi M, Nguyen CT, Nixon MR, Ong KL, Pereira DM, Poustchi H, Qorbani M, Rai RK, Razo-García C, Rehm CD, Rivera JA, Rodríguez-Ramírez S, Roshandel G, Roth GA, Sanabria J, Sánchez-Pimienta TG, Sartorius B, Schmidhuber J, Schutte AE, Sepanlou SG, Shin MJ, Sorensen RJD, Springmann M, Szponar L, Thorne-Lyman AL, Thrift AG, Touvier M, Tran BX, Tyrovolas S, Ukwaja KN, Ullah I, Uthman OA, Vaezghasemi M, Vasankari TJ, Vollset SE, Vos T, Vu GT, Vu LG, Weiderpass E, Werdecker A, Wijeratne T, Willett WC, Wu JH, Xu G, Yonemoto N, Yu C, Murray CJL. Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the global burden of disease study 2017. Lancet. 2019;393(10184):1958–1972. doi: 10.1016/S0140-6736(19)30041-8.
    1. IPCC . Climate change and land: an IPCC special report on climate change, desertification, land degradation, sustainable land management, food security, and greenhouse gas fluxes in terrestrial ecosystems. Geneva, Switzerland: Intergovernmental Panel on Climate Change; 2019.
    1. FAO . Sustainable diets and biodiversity - directions and solutions for policy research and action proceedings of the international scientific symposium biodiversity and sustainable diets united against hunger. Rome: Food and Agriculture Organization of the United Nations; 2010.
    1. Garnett T, Finch J. What can be done to shift eating patterns in healthier, more sustainable directions? (Foodsource: chapters) [internet]: Food Climate Research Network, University of Oxford; 2016. Available from:
    1. WHO Regional Office for Europe. Food and nutrition policy for schools: a tool for the development of school nutrition programmes in the WHO European Region [Internet]. 2006. Available from:
    1. Oostindjer M, Aschemann-Witzel J, Wang Q, Skuland SE, Egelandsdal B, Amdam GV, Schjøll A, Pachucki MC, Rozin P, Stein J, Lengard Almli V, van Kleef E. Are school meals a viable and sustainable tool to improve the healthiness and sustainability of children’s diet and food consumption? A cross-national comparative perspective. Crit Rev Food Sci Nutr. 2017;57(18):3942–3958. doi: 10.1080/10408398.2016.1197180.
    1. Willett W, Rockström J, Loken B, Springmann M, Lang T, Vermeulen S, Garnett T, Tilman D, DeClerck F, Wood A, Jonell M, Clark M, Gordon LJ, Fanzo J, Hawkes C, Zurayk R, Rivera JA, de Vries W, Majele Sibanda L, Afshin A, Chaudhary A, Herrero M, Agustina R, Branca F, Lartey A, Fan S, Crona B, Fox E, Bignet V, Troell M, Lindahl T, Singh S, Cornell SE, Srinath Reddy K, Narain S, Nishtar S, Murray CJL. Food in the Anthropocene: the EAT–lancet commission on healthy diets from sustainable food systems. Lancet. 2019;393(10170):447–492. doi: 10.1016/S0140-6736(18)31788-4.
    1. The Swedish National Agency for Education. Statistik om förskola, skola och vuxenutbildning. Swedish. (Statistics on preschool, school and adult education) [Internet]. Available from: . [cited 2020 May 27].
    1. The Swedish Food Agency. School Lunches [Internet]. Available from: . [cited 2020 Jan 22].
    1. Eustachio Colombo P, Patterson E, Elinder LS, Lindroos AK. The importance of school lunches to the overall dietary intake of children in Sweden: a nationally representative study. Public Health Nutr. 2020:1–11.
    1. Eustachio Colombo P, Elinder LS, Parlesak A, Lindroos AK, Patterson E. Fostering sustainable dietary habits through optimized school meals in Sweden – OPTIMAT. Public Health Panor. 2017;3:557–560.
    1. Eustachio Colombo P, Patterson E, Lindroos AK, Parlesak A, Elinder LS. Sustainable and acceptable school meals through optimization analysis: an intervention study. Nutr J. 2020;19(1):61. doi: 10.1186/s12937-020-00579-z.
    1. Landsverk J, Brown CH, Chamberlain P, Palinkas LA, Ogihara M, Czaja S, Goldhaver-Fiebert JD, Rolls Reutz JA, Horwitz SM. In: Design and analysis in dissemination and implementation research. Brownson RC, Colditz GA, Proctor EK, editors. New York: Oxford University Press; 2012. pp. 225–260.
    1. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50. doi: 10.1186/1748-5908-4-50.
    1. Durlak JA, DuPre EP. Implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation. Am J Community Psychol. 2008;41(3-4):327–350. doi: 10.1007/s10464-008-9165-0.
    1. Fischer-Møller MF, Persson M, Skylare E. In: Halloran A, editor. Solutions Menu - A Nordic guide to sustainable food policy. Copenhagen: Nordic Council of Ministers; 2018.
    1. Johnston JL, Fanzo JC, Cogill B. Understanding sustainable diets: a descriptive analysis of the determinants and processes that influence diets and their impact on health, food security, and environmental sustainability. Adv Nutr Int Rev J. 2014;5(4):418–429. doi: 10.3945/an.113.005553.
    1. UNFCCC. Climate-Efficient School Kitchens and Plant-Powered Pupils | Germany | UNFCCC [Internet]. Available from: . [cited 2019 Sep 11].
    1. Lombardini C, Lankoski L. Forced choice restriction in promoting sustainable food consumption: intended and unintended effects of the mandatory vegetarian day in Helsinki schools. J Consum Policy. 2013;36(2):159–178. doi: 10.1007/s10603-013-9221-5.
    1. Patton MQ. Qualitative research & evaluation methods: integrating theory and practice. Fourth. Thousand Oaks, California: SAGE Publications, Inc; 2015.
    1. Kitzinger J. Qualitative research: introducing focus groups. BMJ. 1995;311(7000):299–302. doi: 10.1136/bmj.311.7000.299.
    1. Krueger RA, Casey MA. Focus groups: a practical guide for applied research. 5. SAGE: Thousand Oaks, California; 2015.
    1. Hoppe MJ, Wells EA, Morrison DM, Gillmore MR, Wilsdon A. Using focus groups to discuss sensitive topics with children. Eval Rev. 1995;19(1):102–114. doi: 10.1177/0193841X9501900105.
    1. Powell RA, Single HM. Focus groups. Int J Qual Health Care. 1996;8(5):499–504. doi: 10.1093/intqhc/8.5.499.
    1. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–112. doi: 10.1016/j.nedt.2003.10.001.
    1. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107–115. doi: 10.1111/j.1365-2648.2007.04569.x.
    1. Rogers EM. Diffusion of innovations. 5. New York: Free Press; 2003.
    1. MacDonald MA, Green LW. Reconciling concept and context: the dilemma of implementation in school-based health promotion. Health Educ Behav. 2001;28(6):749–768. doi: 10.1177/109019810102800607.
    1. Mytton J, Ingram J, Manns S, Thomas J. Facilitators and barriers to engagement in parenting programs: a qualitative systematic review. Health Educ Behav Off Publ Soc Public Health Educ. 2014;41:127–137.
    1. Van Cauwenberghe E, Maes L, Spittaels H, van Lenthe FJ, Brug J, Oppert J-M, et al. Effectiveness of school-based interventions in Europe to promote healthy nutrition in children and adolescents: systematic review of published and “grey” literature. Br J Nutr. 2010;103(6):781–797. doi: 10.1017/S0007114509993370.
    1. Thomas J, Sutcliffe K, Harden A, Oakley A, Oliver S, Rees R, et al. Children and healthy eating: a systematic review of barriers and facilitators. Centre for Reviews and Dissemination (UK); 2003.
    1. Thaker S, Steckler A, Sanchez V, Khatapoush S, Rose J, Hallfors DD. Program characteristics and organizational factors affecting the implementation of a school-based indicated prevention program. Health Educ Res. 2007;23(2):238–248. doi: 10.1093/her/cym025.
    1. Jourdan D, Christensen JH, Darlington E, Bonde AH, Bloch P, Jensen BB, Bentsen P. The involvement of young people in school- and community-based noncommunicable disease prevention interventions: a scoping review of designs and outcomes. BMC Public Health. 2016;16(1):1123. doi: 10.1186/s12889-016-3779-1.
    1. Griebler U, Rojatz D, Simovska V, Forster R. Effects of student participation in school health promotion: a systematic review. Health Promot Int. 2017;32(2):195–206. doi: 10.1093/heapro/dat090.
    1. Payán DD, Sloane DC, Illum J, Farris T, Lewis LB. Perceived barriers and facilitators to healthy eating and school lunch meals among adolescents: a qualitative study. Am J Health Behav. 2017;41(5):661–669. doi: 10.5993/AJHB.41.5.15.
    1. Aarestrup AK, Krølner R, Jørgensen TS, Evans A, Due P, Tjørnhøj-Thomsen T. Implementing a free school-based fruit and vegetable programme: barriers and facilitators experienced by pupils, teachers and produce suppliers in the boost study. BMC Public Health. 2014;14(1). 10.1186/1471-2458-14-146.
    1. Birch L, Savage JS, Ventura A. Influences on the development of Children’s eating Behaviours: from infancy to adolescence. Can J Diet Pract Res Publ Dietit Can Rev Can Prat Rech En Diet Une Publ Diet Can. 2007;68:s1–56.
    1. Goldthorpe J, Epton T, Keyworth C, Calam R, Brooks J, Armitage C. What do children, parents and staff think about a healthy lifestyles intervention delivered in primary schools? a qualitative study. BMJ Open. 2020;10:e038625. doi: 10.1136/bmjopen-2020-038625.
    1. Appleton KM, Hemingway A, Rajska J, Hartwell H. Repeated exposure and conditioning strategies for increasing vegetable liking and intake: systematic review and meta-analyses of the published literature. Am J Clin Nutr Oxford Academic. 2018;108(4):842–856. doi: 10.1093/ajcn/nqy143.
    1. Micha R, Karageorgou D, Bakogianni I, Trichia E, Whitsel LP, Story M, Peñalvo JL, Mozaffarian D. Effectiveness of school food environment policies on children’s dietary behaviors: a systematic review and meta-analysis. PLoS One. 2018;13(3):e0194555. doi: 10.1371/journal.pone.0194555.
    1. Elinder LS, Eustachio Colombo P, Patterson E, Parlesak A, Lindroos AK. Successful implementation of climate-friendly, nutritious, and acceptable school meals in practice: the OPTIMAT™ intervention study. Sustainability. 2020;12(20):8475. doi: 10.3390/su12208475.
    1. UN General Assembly. Transforming our world: the 2030 Agenda for Sustainable Development. UN General Assembly; 2015 Oct. Report No.: A/RES/70/1.
    1. Korstjens I, Moser A. Series: practical guidance to qualitative research. Part 4: trustworthiness and publishing. Eur J Gen Pract. 2018;24(1):120–124. doi: 10.1080/13814788.2017.1375092.
    1. Lincoln YS, Guba EG. Naturalistic inquiry. Beverly Hills, Calif: Sage Publications; 1985. Naturalistic inquiry.
    1. Carcary M. The research audit trial – enhancing trustworthiness in qualitative inquiry. Electron J Bus Res Methods. 2009;7:11–24.

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