About the project
The overarching aim of this project was to identify effective strategies and tools to increase the implementation of the Norwegian national guideline on food and meals in school (“school meal guideline”) in primary schools and after-school services. Toward this end, three interlinked studies on guideline implementation were conducted, the first two of which had a formative purpose for the third. The first study concerned development of questionnaires to measure guideline adherence, the second examined practice determinants for guideline implementation, and the third tested strategies for strengthened implementation. More specific objectives are described below.
The knowledge generated from this project will be used to strengthen the future work on country-wide implementation of the guideline in question, and be applied in the Directorate of Health’s additional work on guidelines and other guidance.
Objectives
- Develop self-administered, web-based questionnaires to measure adherence to the national school meal guideline in primary schools and after-school services and assess their validity and reliability.
- Examine barriers to and enablers of implementation of the national school meal guideline in primary school and after-school services by applying an implementation science determinant framework for data collection and analysis.
- Test whether an intervention to provide schools with implementation support could increase schools’ adherence to the national guideline, and identify important implementation dimensions linked with intervention effects
Background
The responsibility of Norwegian municipalities to work systematically to promote and protect the health of their population is embodied in the Public Health Law. The national guideline for food and meals in schools is mandated by this legislation and aims to ensure favorable eating conditions and high nutritional quality of the food and drinks on offer. National surveys have shown that implementation is weak in some areas and that guideline awareness is low among principals and leaders of the after-school service. Tools to measure guideline adherence have not been developed. Evidence gaps remain as to what hinders and enables implementation and which strategies are effective for increasing implementation.
Implementation science constitutes the main theoretical underpinning of the project, supported by the socioecological model to understand practice determinants. The work applies both quantitative and qualitative methods, both of which are fundamental for studying the many aspects and complexities of implementation.
Results
- The cognitive interviews led to improved relevance, wording, and user friendliness of the questionnaires to measure adherence to the national school meal guideline. In the subsequent test–retest study, most items obtained Cohen’s kappa values for reliability rated as “substantial” or “almost perfect”; >80% of items showed a percentage agreement of ≥70%, and both of the questionnaires’ adherence index scores obtained an intraclass correlation coefficient (for absolute agreement) (ICCA) >0.80.
- Guided by the Multilevel Quality Implementation Framework (MQIF), the qualitative study identified several factors affecting guideline implementation at macro, school, and individual levels, some of which were interdependent. Important barriers included a weak mandate from national authorities to prioritize work on school meals, weak leadership for school meals by principals, and lack of a school culture among teachers around meal practices. Whole-school discussions about meal practices enabled improvement work at the school level.
- Evaluation of the 6-month implementation intervention showed a significant difference of 4 percentage points in change scores between the groups (P = 0.003) after adjusting for baseline adherence. The effect was not associated with school-level socioeconomic status. Implementation was assessed as high across most of the dimensions, with school-level fidelity correlating the highest with the change score.
Financing
Research Council of Norway and the Norwegian Directorate of Health
Cooperation
Norwegian Directorate of Health, Norwegian Center for Child Behavioral Development and Østfold County Authority.
Start and Finnish
2016-2022