The environment can exert a strong influence on people's food decisions. In order to facilitate students to make more healthy food choices and to develop healthy eating habits, it is important that the school food environment is healthy. The Healthy School Canteen programme of The Netherlands Nutrition Centre is an intervention that helps schools to make their cafeteria's offering healthier. A descriptive study was conducted by an independent research agency to survey the perceptions, experiences, and opinions of users of the programme (school directors, parents, students, and health professionals). Results show that directors and students of participating schools perceive their cafeteria's offering to be healthier after implementing the programme than prior to implementation. Next, further important results of the study are highlighted and relations with other projects, caveats, and practical recommendations are discussed. It is concluded that the Healthy School Canteen programme is a promising intervention to change the school food environment but that further research is needed to ultimately establish its effectiveness. Also, it will be a challenge to motivate all schools to enroll in the programme in order to achieve the goal of the Dutch Government of all Dutch school cafeterias being healthy by 2015.
With 14% of young people in The Netherlands being overweight [
The idea that environmental factors can be important in shaping human behaviour is not new. In the 1930s, Lewin already emphasizes in his field theory that both the person and the environment need to be taken into consideration when studying human behaviour [
Although Lewin’s equation was quite revolutionary in his days and sparked some debate among fellow scientists, his conceptualization is widely acknowledged nowadays. Also, in the domain of eating behaviour, there is ample evidence now that environmental cues can influence people’s eating decisions, both consciously and unconsciously. For example, research has demonstrated that the way food is presented, portioned, and packaged in one’s direct environment can affect the amount of food that one consumes. Specifically, larger serving portions and packages usually allure people to consume more food, which in turn leads to greater energy intake [
Interestingly, the impact of the environment on people’s food choices and eating behaviour is dependent on the way in which people make their food decisions. Specifically, decision-making and choice behaviour usually results from one of two distinct cognitive processes: reflective or impulsive processes [
A recent study indicates that most students do not consider their eating patterns important and making healthy food choices is not a top-of-mind issue for them [
At the same time, school cafeterias offer great potential to improve students’ eating behaviour. When taken into consideration that most students tend to engage in impulsive decision making, when it comes to their food, this implies that environmental cues can also “nudge” them in the direction of more healthy choices. When cafeteria offerings would be predominantly healthy and healthy food would be made more attractive (e.g., appealing presentation, putting it on display), it is to be expected that this would increase healthy choices. And indeed, a study by TNO has demonstrated that this can be a fruitful and effective means of encouraging healthy eating behaviour in students: changing the offering of vending machines into low-calorie candy, snacks, and soft drinks, resulted in students choosing these healthy products more often [
Another reason why targeting students offers great potential to improve healthy eating habits is that eating habits that are formed early in life may persist into adulthood [
Given the influence the environment can exert on students’ food choices, it is crucial to create a healthy food environment in schools that facilitates students to choose healthy food products. In this way, students are enabled to develop healthy eating habits from which they can benefit the rest of their lives. With this particular aim the Healthy School Canteen programme was developed. The Healthy School Canteen programme of The Netherlands Nutrition Centre is an environmental intervention designed to create a healthy food environment and promote healthy food choices in secondary schools and schools for vocational training in The Netherlands. This intervention entails a multicomponent strategy involving all parties: students, teachers, parents, school boards, canteen employees, Municipal Health Services, and caterers.
The programme consists of a four-step roadmap for school working groups, consisting of (1) an Inventory (what is the current state of affairs regarding cafeteria offerings, curriculum and policy?), (2) an Action Plan (setting goals and corresponding actions), (3) an Implementation Phase (implementing the action plan), and (4) an Evaluation (what has been achieved?). While completing these four steps, the school is guided towards a healthy school canteen in their own tempo. As health promoting interventions are more effective when they are structurally implemented in schools and the set up is comprehensive [
Since the pilot study in 2002, almost one third of all secondary schools in The Netherlands have worked with the programme [
In 2010, a descriptive study among users of the programme was carried out by an independent research agency to survey the perceptions, experiences, and opinions of school directors, parents, students, and health professionals with the programme [
Contacts of schools that participated in the Stimulation Award competition in 2006-2007, 2008-2009, and/or 2009-2010 were approached by e-mail to provide us with the e-mail address of their school director, student council, and parent council. A dataset with e-mail addresses of every Dutch secondary school was used to invite nonparticipating schools to participate in this study.
Subsequently, directors of participating schools (school directors of schools that (have) participate(d) in the Healthy School Canteen Stimulation Award competition at one point in time during the years 2006–2010) and nonparticipating schools and parents and students of participating schools, were invited to participate in the study and were sent links to online questionnaires. In total, four online questionnaires were sent out; one to school directors of participating schools, one to parent councils of participating schools, one to student councils of participating schools, and one to school directors of non-participating schools (respondents of participating schools only had to answer questions that were relevant to them; respondents of schools participating in the school year 2009-2010 for instance did not have to answer questions about continuation of the programme as they had just started). Questionnaires were sent to 153 directors of participating schools, 139 parent councils, 137 student councils, and 708 nonparticipating schools.
In addition, interviews were held with ten school directors of participating schools of the Stimulation Award competition in the school year 2006-2007 and 2008-2009, who were randomly selected and approached by telephone and e-mail with the request to participate (school directors of schools participating in the Stimulation Award competition at that specific time were not approached to participate, because questions about continuation of the programme would not be relevant yet). All interviews were conducted by an independent research agency. Finally, an expert meeting was held with 12 health promoters of involved Municipal Health Services to discuss their experiences supporting schools during the process of changing the offering of their school cafeteria by implementing the Healthy School Canteen programme. For this expert meeting, all contacts of 28 Municipal Health Services were invited by e-mail to participate. The expert meeting was conducted by an independent strategy development agency.
The online questionnaire for school directors of participating schools first assessed their perception of the school’s cafeteria offerings. Specifically, the following questions were asked: “How was the ratio healthy/unhealthy offerings in the school cafeteria before start of the programme?” and “How is the ratio healthy/unhealthy offerings in the school cafeteria at this moment?”. Answers were given on 5-point Likert-type scales (1 =
Subsequently, questions about the programme, the degree of external support and continuation of the programme, and the Stimulation Award competition were presented. Specifically, the following questions were asked
“Who manages the school cafeteria?” with three response options; (1) internal management, (2) external management (professionally organized catering), or (3) otherwise, namely…. “Did your school receive support from the Municipal Health Service?” with two response options; “yes” or “no.” “How do you evaluate the support given by the Municipal Health Service?” Answers were given on 5-point Likert-type scales (1 = “Which continuation activities did your school carry out?” with response options like “structural change in canteen offerings” and “development of a school food policy”. “The Healthy School Canteen Stimulation Award competition motivated to enroll in the Healthy School Canteen programme.” Answers were given on 5-point Likert-type scales (1 =
The online questionnaire for student councils of participating schools also first assessed their perception of the school’s cafeteria offerings. The student councils were asked to represent the opinion of all students when answering the questions.
Specifically, the following questions were asked: “How was the ratio healthy/unhealthy offerings in the school cafeteria before start of the programme?” and “How is the ratio healthy/unhealthy offerings in the school cafeteria at this moment?”. Answers were given on 5-point Likert-type scales (1 =
Subsequently, questions were asked about involvement and perception of the students regarding the programme. Specifically, the following question was asked: “Were students involved at the start of the programme?”. There were three response options; (1) yes, (2) no, or (3) I do not know. In addition, students were asked to respond to the statement: “Our students acknowledge the importance of the Healthy School Canteen programme”. Answers were given on 5-point Likert-type scales (1 =
The online questionnaire for parent councils of participating schools explored involvement and perception of the parents regarding the programme. The parent councils were asked to represent the opinion of all parents when answering the questions.
Specifically, the following question was asked: “Were parents involved/informed at the start of the programme?”. There were three response options; (1) yes, (2) no, or (3) I do not know. Also, the following statement was used: “Parents have a say in selection of school canteen offerings”. There were three response options; (1) yes, (2) yes, but only through the parent council, or (3) no. Next, parents were asked to respond to the following statements: “Parents know what is offered in the school cafeteria” and “Parents have a say in the cafeteria’s offering”. There were three response options; (1) yes, (2) no, or (3) I do not know. Finally, parents were asked to respond to the statement: “Parents acknowledge the importance of the Healthy School Canteen programme.” Answers were given on 5-point Likert-type scales (1 =
The online questionnaire for school directors of nonparticipating schools assessed their perceptions of the school’s cafeteria offerings. Specifically, the following question was asked: “How is the ratio healthy/unhealthy offerings in the school cafeteria at this moment?” Answers were given on 5-point Likert-type scales (1 =
The interview design was based on the online questionnaire and consisted of in-depth and additional questions about the school director’s participation, support during execution of the programme, continuation, Stimulation Award participation, and possible improvements of the programme.
The aim of this meeting was to obtain more insight in their experiences, needs and the role Municipal Health Services play within the programme. Participants were asked to indicate which components of the programme should be continued, which components should be eliminated and with which components the programme should be enriched. More specifically, one of the statements that was used was “Municipal Health Services perceive the Stimulation Award competition to be an incentive for schools.”
Response rates were as follows: 62,7% (
Differences in mean scores of participants on the questions regarding the offering before and after implementing the programme (at this moment) were compared with paired
Analyses showed that both school directors and student councils perceived the offering before and after implementation to be significantly different. Specifically, directors perceived the cafeteria offering to have shifted from relatively more unhealthy products before start of the programme (
69% of schools indicated the school cafeteria had internal management, and 31% of schools indicated the school cafeteria had external management. In addition, there appeared to be a relationship between whether the cafeteria was catered by the school or an external party: 32,7% of schools with a cafeteria managed by the school itself against 12,0% of schools with an external caterer indicated to have an almost completely healthy offering in the school cafeteria (Spearman’s
73% of participating schools indicated they were supported by a Municipal Health Service, and the majority are (very) content with this support: sufficient (32%), good (42%), and very good (17%). Only schools that started the programme during the school years 2006-2007 and/or 2008-2009 were questioned about continuation of the programme (
Three activities that have often been undertaken as continuation of the programme are structural changing the food on offer in the cafeteria (69,2%), making healthy eating a part of the regular curriculum (64,1%), and changing the school food policy (61,5%).
A majority (75,3%) of directors of participating schools (completely) agreed that the Stimulation Award competition motivated to enroll in the healthy School Canteen programme.
59,2% of the students and 47,9% of the parents say they were involved at the start of the programme. Of the parents, 15,2% reported they had a say on what is being sold in the cafeteria, and almost half of the parents indicated they know what is being sold (48,3%).
55,3% of the students and 80% of the parents (totally) agreed with the statement that the Healthy School Canteen programme is important.
Important factors for nonparticipating schools to start with the program are time and finances: 78,5% indicated enough time is (very) important, and 73,3% pointed to sufficient finances as being (very) important.
All 10 interviewed school directors were positive about the Stimulation Award competition and find it a good initiative. The interviews also revealed that schools are in need of “role model schools” and experiences of other schools for inspiration. All 10 interviewed school directors indicated support of students, teachers, and parents was created and that support of the school director was sufficient. Seven school directors indicated the school was supported during the programme by the Municipal Health Service, and 5 school directors indicated they received support from The Netherlands Nutrition Centre. All ten interviewed school directors indicated healthy food had been included in the school food policy.
During the meeting with Municipal Health Services, 12 professionals were present. Below the most important insights are discussed.
Municipal Health Services feel that the Stimulation Award competition is a relevant part of the Healthy School Canteen programme, and according to them, the programme is a good way to highlight the importance of healthy nutrition in secondary schools. However, they indicate that there should be more time to execute the programme when participating in the Stimulation Award competition, partly because they need enough time to recruit schools.
It appears that schools participating in the Healthy School Canteen programme have been successful in creating improvements in their school cafeteria offerings due to implementing the programme, as they report to have healthier offerings compared to nonparticipating schools. Also, the Stimulation Award competition is seen as a motivator to enroll in the programme both by schools and Municipal Health Services. It is encouraging that both school management and students perceive that their cafeteria’s offering has positively shifted into the direction of more healthy than unhealthy food products. A recent study on overweight prevention in secondary schools in The Netherlands in 2010-2011 supports this finding and states that, for a large number of schools, improvements in their cafeteria were realized (at least in part) by participating in the Healthy School Canteen programme [
The Healthy School Canteen programme and the present findings are also relevant in light of the overall aim of the Dutch government to realize healthy school canteens in all schools in The Netherlands by 2015. The present findings provide a first indication that the Healthy School Canteen programme could be a powerful contributor in achieving this goal. This goal was also adopted by the Dutch Covenant on Healthy Weight. This Covenant is a collaboration of a total of 27 actors from (national and local) governments, industry and civil society organizations, which are collectively committed to fight against the rising trend of overweight and obesity. The main goals of the Covenant are increasing awareness of health risks related to overweight and obesity and achieving an arrest in the evolution of overweight and obesity in children and adults. Within this Covenant a Manifest on Healthier Food in schools was realised in 2011 in which parties agree to work together towards schools where the food offered in the school cafeteria is healthy to a minimum of 75% according to the Dutch guidelines for healthy food.
Across Europe, many countries take action to positively change the school food environment. For example, English chef Jamie Oliver has striven to improve unhealthy diets and poor cooking habits in schools in the United Kingdom since 2005 when he launched his “Feed Me Better” campaign. Since 2006, junk food is banned in British schools, and new legal food-based standards for school food were brought in. Next to the UK, also Portugal has compulsory regulations on the provision of school lunches [
Results indicate that support from a Municipal Health Service is highly appreciated. As mentioned before, Municipal Health Services do not always have enough time and manpower to assist all schools in need of support in their region. Therefore, it is to be recommended to keep the Canteen Brigade as an important component of the programme. The Brigade provides schools with tailored advice, so schools know where to start, which products are suitable for a healthy offering, and how to create a healthy school canteen. And indeed, the Brigade is increasingly being called upon by schools to help them change the cafeteria offerings. Another advantage of deploying a Brigade is that it reinforces the efforts of the Municipal Health Services, for example, by acting as interlocutor when talking with an extern caterer.
Another recommendation to ensure continuation of the programme that follows from the present findings is that schools should always be advised to include healthy nutrition in their school food policy. In addition, schools should strive for structural changes in the school cafeteria offerings and incorporate healthy eating in the regular curriculum. These factors should increase potential success. Also, schools can be informed about the “Healthy School Method” of the Centre for Healthy Living. This method promotes an integrated and structured approach to create a healthy school, including healthy cafeteria offerings.
A last recommendation concerns the Municipal Health services. To be better able to meet their need, it is advisable to allocate more time to them to recruit schools for the Stimulation Award competition.
Also, some critical remarks seem in place. First, it is noteworthy that, with respect to the near future, the atmosphere seems to be somewhat less favorable compared to five years ago. During the school year 2006-2007, 59% of the secondary schools expected to pay more attention to the issue of overweight in the near future, compared to 31% in 2011 [
In addition, some barriers concerning the content of the programme have to be tackled, as not all school directors report a shift from mostly unhealthy offerings before the programme to mostly healthy offerings currently. Unfortunately, we do not have full insight in completion of the programme: schools who participated in the Stimulation Award competition were included in the study. This implies they started with the programme, but sometimes it takes several months or even years to completely change the food on offer in the school canteen. As a result, it was not known whether the schools had successfully implemented the programme. Also, intractability of practice might play a role in this matter. There can always be crucial factors in some schools that negatively impact the process. From experience, we know most of the time these factors are lack of time or lack of support from other important parties within the school. Therefore, more has to be done to involve other important parties like students and parents. As a first step, The Netherlands Nutrition Centre has started using inspirational examples of other schools to motivate schools to organize activities for students, for instance, giving them an active role in composing and preparing the cafeteria offerings. This might actually work as a double-edged sword, as these actively engaged students might be perceived as role models by other students hereby creating a positive social norm that could encourage other students to pay more attention to their eating behaviour. Another matter that has room for improvement is information about time and finances that are needed for implementing the programme. Specifically, directors of nonparticipating schools indicate that time and finances are factors that play a role in deciding whether to participate or not. More information needs to be given about these factors so that schools can make well-informed decisions. In order to meet this need, a factsheet will be composed that provides directors with the information they need.
Also, schools have to be stimulated to only remove and not add unhealthy products. The School Canteen Brigade of The Netherlands Nutrition Centre will play an important role in this, educating schools how to execute to programme effectively and how to compose a healthy offering. Moreover, in the present study, it was found that school directors of schools with a caterer managed by the school itself perceived their cafeterias to have a healthier offering than schools directors of schools with an external caterer. This is a finding that needs attention. The Manifest on Healthier Food can play an important role in changing this situation, by committing different parties—including external caterers—to achieve a minimum of 75% healthy products according to the Dutch guidelines for healthy food.
At this point, we would like to stress that, in the present descriptive study, only user perceptions have been measured and no quantitative data of food supplies in the school canteens of participating and nonparticipating schools were measured. Moreover, the programme’s effect on students’ actual eating behaviour has not been measured in this study. Whether the programme will prove to be effective in changing students’ eating behaviour has yet to be demonstrated. However, previous research has established that changing aspects in the food environment can indeed affect eating behaviour. For example, aforementioned research in The Netherlands by TNO has clearly demonstrated that making offerings healthier can change students’ choices in a positive way and that changes in assortment can lead to changes in consumption [
More research is also needed to get more insight in effects and barriers that might operate in each of the four different steps of the programme. The current research has not taken this into account. In addition, it might be interesting to examine whether there are differences between participating schools and nonparticipating schools in domains like health issues and neighbourhood socioeconomic status. Future research should give more insight in these differences as this might provide new starting points to recruiting and stimulate schools to enroll in the programme.
The environment can exert a strong influence on people’s food decisions. In order to facilitate students to make more healthy food choices and to develop healthy eating habits, it is therefore important that the school food environment is healthy. The Healthy School Canteen programme is an intervention that helps schools to make their cafeteria’s offering healthier. The present study shows that this intervention is promising, as directors and students of participating schools perceive their cafeteria’s offering to be healthier after implementing the programme than prior to implementation, and participating schools perceive their cafeteria’s offering to be healthier than nonparticipating schools.
It will be a challenge to motivate schools to enroll in the programme in order to achieve the goal of all school cafeterias in The Netherlands being healthy by 2015. While it is promising that one-third of schools are (or have been) participating in the programme, still two-thirds of schools have not participated yet. And as a lower percentage of secondary schools consider themselves to be coresponsible for the prevention of overweight among their students, it may be necessary and fruitful to explore other ways to attain this goal. Possibly, we could take France and Spain as an example and use legislation to create healthy school cafeterias in every school in The Netherlands.
With the present obesity epidemic and the number of young people in The Netherlands being overweight continuing to grow, any measures that may help in facilitating healthy food choices deserve to be put into consideration. In light of the Dutch government’s preference for stimulating individuals to make their own health decisions, interventions that are aimed at creating a healthier environment that enables and facilitates people to make healthy decisions are a particularly fruitful venue to be further explored.