BackgroundInternationally, governments have implemented school-based nutrition policies to restrict the availability of unhealthy foods from sale. The aim of the trial was to assess the effectiveness of a multi-strategic intervention to increase implementation of a state-wide healthy canteen policy. The impact of the intervention on the energy, total fat, and sodium of children’s canteen purchases and on schools’ canteen revenue was also assessed.MethodsAustralian primary schools with a canteen were randomised to receive a 12–14-month, multi-strategic intervention or to a no intervention control group. The intervention sought to increase implementation of a state-wide healthy canteen policy which required schools to remove unhealthy items (classified as ‘red’ or ‘banned’) from regular sale and encouraged schools to ‘fill the menu’ with healthy items (classified as ‘green’). The intervention strategies included allocation of a support officer to assist with policy implementation, engagement of school principals and parent committees, consensus processes with canteen managers, training, provision of tools and resources, academic detailing, performance feedback, recognition and marketing initiatives. Data were collected at baseline (April to September, 2013) and at completion of the implementation period (November, 2014 to April, 2015).ResultsSeventy schools participated in the trial. Relative to control, at follow-up, intervention schools were significantly more likely to have menus without ‘red’ or ‘banned’ items (RR = 21.11; 95% CI 3.30 to 147.28; p ≤ 0.01) and to have at least 50% of menu items classified as ‘green’ (RR = 3.06; 95% CI 1.64 to 5.68; p ≤ 0.01). At follow-up, student purchases from intervention school canteens were significantly lower in total fat (difference = −1.51 g; 95% CI −2.84 to −0.18; p = 0.028) compared to controls, but not in energy (difference = −132.32 kJ; 95% CI −280.99 to 16.34; p = 0.080) or sodium (difference = −46.81 mg; 95% CI −96.97 to 3.35; p = 0.067). Canteen revenue did not differ significantly between groups.ConclusionPoor implementation of evidence-based school nutrition policies is a problem experienced by governments internationally, and one with significant implications for public health. The study makes an important contribution to the limited experimental evidence regarding strategies to improve implementation of school nutrition policies and suggests that, with multi-strategic support, implementation of healthy canteen policies can be achieved in most schools.Trial registrationAustralian New Zealand Clinical Trials Registry (ACTRN12613000311752)

BackgroundThe implementation of school nutrition policies, which govern the provision of food in schools, is recommended as a public health strategy to support the development of healthy dietary behaviours in school-aged children. Despite this, research internationally and in Australia indicates that few schools implement such policies. This study aims to examine whether a theoretically designed, multi-strategy intervention was effective in increasing the implementation of a healthy canteen policy in Australian primary schools.MethodsA parallel group randomised controlled trial was conducted with all government and Catholic primary schools within one region in New South Wales, Australia who had an operational canteen that provided food to primary school aged children (5–12 years) and were not currently receiving an intervention to change their canteen practices. Schools randomised to the intervention arm received a 9-month multicomponent intervention including ongoing support, provision of resources, performance monitoring and feedback, executive support and recognition. The primary outcomes were the proportion of the schools with a canteen menu that: i) did not include ‘red’ or ‘banned’ items according to the healthy canteen policy; and ii) had more than 50 % ‘green’ items. The primary outcome was assessed via menu audit at baseline and follow up by dietitians blinded to group allocation.ResultsFifty-three eligible schools were randomised to either the intervention or control group (28 intervention; 25 control). Analyses with 51 schools who returned school menus found that intervention schools were significantly more likely relative to control schools to have a menu without ‘red’ or ‘banned’ items (RR = 5.78 (1.45–23.05); p = 0.002) and have at least 50 % of menu items classified as green (RR = 2.03 (1.01–4.08); p = 0.03).ConclusionsThis study found that a multi-component intervention was effective in improving primary schools’ compliance with a healthy canteen policy. Given the lack of evidence regarding how best to support schools with implementing evidence-based policies to improve child diet, this trial for the first time provides high quality evidence to practitioners and policy makers seeking to improve nutrition policy implementation in schools.Trial registrationThis trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614001148662) 30th October 2014.

Aim: To assess the impact of a multistrategy intervention designed to improve teachers’ implementation of a school physical activity (PA) policy on student PA levels. Methods: A cluster-randomized controlled trial was conducted in 12 elementary schools. Policy implementation required schools to deliver 150 minutes of organized PA for students each week via physical education, sport, or class-based activities such as energizers. Schools received implementation support designed using the theoretical domains framework to help them implement the current policy. Results: A total of 1,502 children in kindergarten to grade 6 participated. At follow-up compared with control, students attending intervention schools had, measured via accelerometer, significantly greater increases in school day counts per minute (97.5; 95% confidence interval [CI], 64.5 to 130.4; P < .001) and moderate to vigorous physical activity (MVPA) (3.0; 95% CI, 2.2–3.8, P < .001) and a greater decrease in sedentary time (−2.1; 95% CI, −3.9 to −0.4, P = .02) per school day. Teachers in intervention schools delivered significantly more minutes (36.6 min) of PA to their students at follow-up (95% CI, 2.7–70.5, P = .04). Conclusions: Supporting teachers to implement a PA policy improves student PA. Additional strategies may be needed to support teachers to implement activities that result in larger gains in student MVPA.

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Background The effectiveness of digital health interventions is commonly assumed to be related to the level of user engagement with the digital health intervention, including measures of both digital health intervention use and users’ subjective experience. However, little is known about the relationships between the measures of digital health intervention engagement and physical activity or sedentary behavior. Objective This study aims to describe the direction and strength of the association between engagement with digital health interventions and physical activity or sedentary behavior in adults and explore whether the direction of association of digital health intervention engagement with physical activity or sedentary behavior varies with the type of engagement with the digital health intervention (ie, subjective experience, activities completed, time, and logins). Methods Four databases were searched from inception to December 2019. Grey literature and reference lists of key systematic reviews and journals were also searched. Studies were eligible for inclusion if they examined a quantitative association between a measure of engagement with a digital health intervention targeting physical activity and a measure of physical activity or sedentary behavior in adults (aged ≥18 years). Studies that purposely sampled or recruited individuals on the basis of pre-existing health-related conditions were excluded. In addition, studies were excluded if the individual engaging with the digital health intervention was not the target of the physical activity intervention, the study had a non–digital health intervention component, or the digital health interventions targeted multiple health behaviors. A random effects meta-analysis and direction of association vote counting (for studies not included in meta-analysis) were used to address objective 1. Objective 2 used vote counting on the direction of the association. Results Overall, 10,653 unique citations were identified and 375 full texts were reviewed. Of these, 19 studies (26 associations) were included in the review, with no studies reporting a measure of sedentary behavior. A meta-analysis of 11 studies indicated a small statistically significant positive association between digital health engagement (based on all usage measures) and physical activity (0.08, 95% CI 0.01-0.14, SD 0.11). Heterogeneity was high, with 77% of the variation in the point estimates explained by the between-study heterogeneity. Vote counting indicated that the relationship between physical activity and digital health intervention engagement was consistently positive for three measures: subjective experience measures (2 of 3 associations), activities completed (5 of 8 associations), and logins (6 of 10 associations). However, the direction of associations between physical activity and time-based measures of usage (time spent using the intervention) were mixed (2 of 5 associations supported the hypothesis, 2 were inconclusive, and 1 rejected the hypothesis). Conclusions The findings indicate a weak but consistent positive association between engagement with a physical activity digital health intervention and physical activity outcomes. No studies have targeted sedentary behavior outcomes. The findings were consistent across most constructs of engagement; however, the associations were weak.

BackgroundThe implementation of nutrition policies in schools has been recommended as a strategy to improve child dietary intake. Internationally, research suggests that the majority of schools do not implement these policies. In New South Wales (NSW), Australia, the NSW Healthy School Canteen Policy requires that school canteens prohibit the sale of ‘red’ foods (i.e. foods that are typically nutrient poor and high in energy, such as confectionary and deep-fried foods) and ‘banned’drinks (i.e. soft drinks); and that the majority of items on the menu are ‘green’ (i.e. foods that are good sources of nutrients, such fruits, vegetables and lean meats). This study examined the impact of a multicomponent audit and feedback intervention on schools’ implementation of the NSW Healthy School Canteen Policy. A secondary aim was to assess the impact of the intervention on menu composition.MethodsThis study was a parallel group randomised controlled trial with 72 rural and remote primary schools (36 interventions, 36 controls) located in one region within NSW, Australia. Intervention schools received an initial face to face contact and up to four cycles of audit and feedback (consisting of a menu audit, written feedback report and telephone feedback) over a 12-month period. The primary trial outcomes were the proportion of schools with a canteen menu that had: i) no ‘red’ foods or ‘banned’ drinks; and ii) >50% ‘green’ items, as assessed via standardised menu audits undertaken by trained dietitians. For each primary outcome, between-group differences were assessed using Fisher’s exact test under an intention to treat approach.ResultsThere was insufficient evidence to conclude the intervention had a positive impact on the proportion of intervention schools with no ‘red’ or ‘banned’ items on their menu (RR = 2.8; 95% CI: 0.9 to 8.9; p = 0.0895), or on the proportion of intervention schools with more than 50% ‘green’ items (RR = 1.5; 95% CI: 0.7 to 3.2; p = 0.2568). These findings remained non-significant in the multiple imputation analyses. Intervention schools were significantly more likely to have a lower percentage of ‘red’ items (p-value: 0.007) and a higher percentage of ‘green’ items on the menu (p-value: 0.014). This remained statistically significant in the multiple imputation analyses for ‘red items’ (p-value: 0.0081) but not for ‘green’ items (p-value: 0.0910).ConclusionsWhile there was insufficient statistical evidence to suggest that this multicomponent audit and feedback intervention was effective in improving primary schools’ compliance with a healthy canteen policy, the intervention demonstrated some positive impact in reducing the availability of ‘red’ items on the menu.Trial registrationThis trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12613000543785). Registered 15th May 2013.

BackgroundNo evaluations of the cost or cost effectiveness of interventions to increase school implementation of food availability policies have been reported. Government and non-government agency decisions regarding the extent of investment required to enhance school implementation of such policies are unsupported by such evidence. This study sought to i) Determine cost and cost-effectiveness of three interventions in improving school implementation of an Australian government healthy canteen policy and; ii) Determine the relative cost-effectiveness of the interventions in improving school implementation of such a policy.MethodsAn analysis of the cost and cost-effectiveness of three implementation interventions of varying support intensity, relative to usual implementation support conducted during 2013–2015 was undertaken. Secondly, an indirect comparison of the trials was undertaken to determine the most cost-effective of the three strategies. The economic analysis was based on the cost of delivering the interventions by health service delivery staff to increase the proportion of schools ‘adherent’ with the policy.ResultsThe total costs per school were $166,971, $70,926 and $75,682 for the high, medium and low intensity interventions respectively. Compared to usual support, the cost effectiveness ratios for each of the three interventions were: A$2982 (high intensity), A$2627 (medium intensity) and A$4730 (low intensity) per percent increase in proportion of schools reporting ‘adherence’). Indirect comparison between the ‘high’ and ‘medium intensity’ interventions showed no statistically significant difference in cost-effectiveness.ConclusionsThe results indicate that while the cost profiles of the interventions varied substantially, the cost-effectiveness did not. This result is valuable to policy makers seeking cost-effective solutions that can be delivered within budget.

Objective To assess the effectiveness of lunchbox interventions aiming to improve the foods and beverages packed and consumed by children at centre-based care or school; and subsequent impact on children’s adiposity. Methods Systematic search of nine databases for controlled trials published in English between 1995-January 2017. Where appropriate, data were pooled in a random effects meta-analysis. Results Of the 1601 articles identified, ten studies (centre-based care n = 4, school n = 6) were included of which eight were RCTs. The impact of interventions on the packing of discretionary foods, sugar-sweetened drinks and other core foods was inconsistent. Meta-analysis of four RCTs trials found a moderate increase in provision of vegetables (SMD = 0.40 95% CI 0.16 to 0.64, p = 0.001, I 2 = 82%; equivalent to a mean difference of 0.28 serves) but not fruit. Four studies reported impact on children’s dietary intake, one reported no significant effect on consumption of discretionary foods, one reported improvements in the consumption of sugar-sweetened drinks and water, and two reported improvements in consumption of vegetables and fruit. Two studies, that were broader obesity prevention interventions, reported no significant impact on adiposity. Conclusions There is some evidence that lunchbox interventions are effective in improving the packing of vegetables in children’s lunchboxes, however more robust research is required to determine the impact on children’s dietary intake and adiposity. Trial registration PROSPERO 2016: CRD42016035646 . Electronic supplementary material The online version of this article (10.1186/s12966-019-0798-1) contains supplementary material, which is available to authorized users.