Co-design of a sustainable and acceptable implementation intervention to maximise the impact of whole school approaches to food within primary schools

Background: Children consume a third of their food at school, providing an opportunity to promote healthy diets and reduce levels of obesity. The World Health Organisation and UK government recommend that schools adopt approaches across the whole school day that support children to make healthy food choices, offering consistency in the quality of foods provided, eating culture, education about diet, and use of food to learn. In reality, uptake is poor, partly due to lack of direction on how to use such an approach, but also because schools work in highly complex environments with multiple competing demands, and influences from wider factors like national policy, cultural beliefs, population characteristics, costs and catering requirements.

Methods: We will design a practical and acceptable intervention to help primary schools adopt whole school approaches to food. This will be done in partnership with key people (stakeholders) including head teachers, teachers, staff, children, parents, school governors, local businesses, and local and national government, by:

1. Hosting stakeholders workshops in Bradford, Leeds, Newcastle and Belfast to discuss factors influencing what children eat during the school day. We will ask people to consider potential influencing factors at school (e.g. space needed to provide lunch), in the community (e.g. cultural influences on eating practices) and from wider society (e.g. government policies on free-school meals). We will encourage discussion on how these factors relate to each other and use this information to build a picture called a 'systems map', providing a richer understanding of the local and wider influences on children's food choice. The map may also help to identify parts of the system most likely to respond to intervention and whether adding an intervention in one part (e.g. a packed lunch policy) is likely to cause positive or negative adaptations in others (food eaten at home).

2. Inviting stakeholders to take part in designing an intervention. This will involve consideration of the factors identified in our system maps. Based on existing discussion with people who work in schools, we do not expect the intervention to involve excess paperwork or expense for schools. Instead, it might include visual resources (like websites or videos) to support schools to include children in decision making, and to improve the food environment. It could also consider changes to catering decisions or specific activities such as embedding catering staff more across the school, growing food in schools, teaching with food, avoiding using food as reward/or punishment, and consistent food messages. To ensure the intervention supports schools without excessive burden, acceptability and potential barriers will be a key consideration during development. Importantly, we will focus on developing an intervention that has the best chance of supporting those in greatest need.

3. Seeking feedback about our draft intervention ideas from our wider stakeholder group. We will share the draft with stakeholders and ask them to rate its acceptability and how easily they can be used by schools. A form will also be used for stakeholders to consider which parts of the intervention they feel can be applied across all schools and which may be less transferable. We will then make any required improvements before fully developing the intervention and its resources.

Impact and dissemination: The intervention has the potential to improve dietary options extending beyond the school day. It is important that it is evaluated so that, if successful, it can become standard practice. We will therefore engage with key decision makers and advocates, including Public Health England, School Food Matters (a national organisation supporting schools) and the Department of Education. We will share our findings widely, including with schools, children and parents, and will develop plans to test its impact on food choice.

A third of primary school children are overweight or obese in the UK and nutrition recommendations are consistently not met. Inequalities in these areas in the UK are the highest amongst all OECD countries and this disparity increases between 5-11 years. Primary schools provide an opportunity to support children to make healthy food choices, with 30% of a child's diet consumed at school. This is also an excellent setting to form behaviours and social/cultural norms; providing an opportunity to improve diet within and outside of school. WHO and UK government advocate 'whole school approaches to food', promoting consistency in food availability, culture, policy and education. However, implementation is poor against the backdrop of multiple competing priorities. Hence, we plan to better understand school food systems in order to co-design an implementation intervention to support them to implement whole school approaches to food via 4 work packages(WP): WP1: Engagement and recruitment of key stakeholders in Leeds, Bradford, Belfast and Newcastle (teachers, staff, caterers, governors, children, parents, local businesses and local authority representatives); WP2: Workshops with stakeholders to develop system maps highlighting factors influencing food choice and uptake of whole school approaches to foods; WP3: Co-design of a sustainable, equitable and acceptable intervention, including compilation of a draft (extended) intervention logic model and theory of change, which incorporates consideration of context, external influences (i.e. wider system), and unintended outcomes (e.g. inequitable impact); WP4: Seeking feedback on the draft intervention from stakeholders, considering implementation within a broader socio-ecological system and transferability for optimal spread and impact. Throughout the project, we will engage with partners in local authorities, PHE, DfE and School Food Matters to develop a dissemination strategy to optimise impact and enable a future evaluation

Primary schools and the children and families they serve will benefit most from this research. In the UK, children consistently fail to meet nutritional recommendations and levels of obesity continue to rise. And, those living in the highest levels of deprivation suffer most. The World Health Organisation and the UK government recommend that schools adopt approaches across the whole school day to support children to make healthy choices as one solution to this problem; however, schools are complex systems and there are many other competing priorities that mean that this is often not achieved.

We have already engaged with stakeholders, including schools, teachers, children and governors in the preparation of this bid; all of whom agreed that this was a priority area. Importantly, head teachers supported the notion of 'whole school approaches to food', though they recognised barriers and told us that further support was required. These PPI activities also enabled us to explore the acceptability of our methodological approach so that we are able to demonstrate impact through ensuring 'Design, conduct and analysis robust and appropriate' as a key area within the NIHR Adding Value in Research framework. For example, we tested WP2 methods with 10 children, who demonstrated active participation and gave suggestions about how to gain trust of children.

Our research will continue to engage with our PPI groups in addition to working with a wider stakeholder group of teachers, school staff, caterers, school governors, children, families, local businesses and local authorities to co-design an intervention to support schools to adopt 'whole school approaches to food'. This will consider not only the foods that are provided, but also the school ethos about food across the day. This has the potential to improve dietary choice in children which extends beyond the school day (supporting positive decisions outside of school too).

Partners including, Departments for Education (DfE and DE Ireland) and School Food Matters and local authorities support the work and will help develop the intervention and publicise its findings using a dissemination strategy that is developed in partnership with these agencies. We also have a confirmed Advisory group, including representation from Public Health England, CRN public health, Fuse Centre for Translational Research in Public Health, School of Public Health Research and expertise from implementation science (Foy).

By bringing together our partners, advisors and other key stakeholders to consider the complexity of schools and acceptability of adopting whole school approaches to food, the research has potential to contribute to increased awareness of the importance of the school food environment by public and professionals. It will also prompt activities and investment by our partners/advisors and will support future research activity to test its impact on diet and obesity in children.