Implementation of Ontario’s School Food and Beverage Policy (P/PM 150) in Peel Region: A Qualitative Evaluation

摘要

INTRODUCTION: With obesity rates rising in Canada, schools have been identified as an ideal setting for health promotion interventions. Across the world, school nutrition policies have been implemented to try and improve the diets and food behaviours of youth; however, policies differ greatly in their design and implementation. While some policies are considered voluntary (where schools are given a guideline with which to create their own policies), the Ontario Ministry of Education’s School Food and Beverage Policy (P/PM 150) was mandated as of September 2011 for all schools in Ontario. Many factors have been identified as facilitators and barriers to school nutrition policy implementation across settings. Additionally, recommendations have been provided in terms of ‘best practices’ for school nutrition policy implementation. It is important to understand why school nutrition policy implementation works better in some contexts compared to others. PURPOSE: The purpose of the research was to: i) describe the school food context (including student food behaviours and influences on those behaviours) in Region of Peel schools; ii) examine, from the perspectives of multiple stakeholders, the process of P/PM 150 implementation; including perceived challenges / successes with policy implementation, and its impacts; iii) analyze the results in relation to the constructs of Damschroder’s Consolidated Framework for Implementation Research.METHODS: This qualitative study consisted of 5 food service provider interviews, 15 school stakeholder interviews (3 elementary, 12 secondary); 5 elementary school parent focus groups; and 11 student focus groups (7 elementary, 4 secondary). Two surveys were conducted that provided responses to open-ended questions from 46 secondary school parent surveys, and 1,251 Grade 6-10 students. Focus group, interview and open-ended survey data were analyzed using NVivo 10 qualitative analysis software. An interpretive description approach was used. Common themes were coded and patterns were found. Comparisons between participant groups were also analyzed by conducting matrix queries in NVivo 10. A second-coder analyzed a sample of transcripts and high level codes to ensure inter-rater reliability.RESULTS: In relation to the context in which the policy was introduced, participants most frequently expressed negative opinions related to food quality, low variety, and high cost of school food. The most commonly reported student behaviour was bringing their own food from home. Many factors potentially influenced students’ food behaviours, at the individual level (e.g., age, SES), social factors (e.g., parent/peer influence), and macro-level factors (e.g., weather, and community SES). Additionally, school, home and outside (of school) environments were an important factor influencing students’ food choices, as they determined what foods were available and either promoted (e.g., school health promotion activities) or discouraged healthy eating behaviours (e.g., negative role models for healthy eating). In regards to P/PM 150, participants felt that the policy promoted healthy eating, provided students’ access to healthy options, and provided a safety net for students with bad eating habits. They reported concerns regarding freedom of choice, policy content (e.g., ignored portion control, balance), and negative effects on food quality (taste, variety, affordability) and food behaviours. Some adult participants engaged in various activities (e.g. attending workshops, appointing champions) to support implementation, although activities varied widely by school. Some felt the transition was relatively easy while others described it as a larger adjustment. Participants reported a variety of resources and supports for policy implementation, such as policy booklets, workshops/ training events, P/PM 150-specific committees, and support from Public Health; while a variety of resources/supports were mentioned, not all were considered helpful. Lastly, participants described their perceived successes and challenges with implementation which related to outcomes and impacts. In terms of successes, the ability to find popular compliant choices led to positive outcomes on school food quality. That, in addition to school health promotion activities, led to positive impacts on students’ food behaviours. Regarding perceived challenges, participants felt that P/PM 150 significantly limited food choices leading to negative impacts on school food quality, variety, prices/affordability and portions. These changes led to student rebellion, and leaving school grounds to buy unhealthier options from the outside competition that were not bound by the policy. Challenges were also linked to school food revenue loss. Participants provided recommendations to the Ontario Ministry of Education that related to: a) the process of implementation (e.g., follow-up with schools, monitor compliance); b) changing the policy direction (e.g., reducing policy restrictions); and c) increasing clarity/consistency of policy messages (e.g., explaining why the policy is in place). DISCUSSION: The contextual factors found to influence school food behaviours in Peel Region schools corroborates much of what has been reported in the literature. Factors influencing P/PM 150 policy implementation were closely aligned to the constructs described in Damschroder’s Consolidated Framework for Implementation Research. Two additional constructs were identified that were not reflected in the framework: ‘implementation climate outside the school’ and ‘adaptability of the inner setting’. Study results indicated that these were significant factors influencing implementation in Peel Region schools. Therefore, these factors should be a considered in further revisions of the framework, in particular where it is being used to support policy implementation. CONCLUSION: Understanding the context of the real world setting including the social cultural, physical and economic environment in which a new intervention is being implemented is critically important. This thesis explored the school context in one region in Ontario from the perspective of multiple stakeholders ranging from students to the staff in the food industry. Implementation of a new school food policy (P/PM 150) was found to be complex with many factors influencing its successful uptake by school stakeholders. While participants discussed many challenges and negative outcomes and impacts resulting from P/PM 150, positive impacts on school food and food behaviours were also reported. While P/PM 150 successes were identified, results related to typical food behaviours showed that the home environment still had a significant impact on student food behaviours. Therefore, impacts of the policy could be limited without addressing other environments. Those planning to implement school food policies in the future need to consider comprehensive approaches that address potential influencing factors and environments outside of the school that impact student food behaviours.