From policy to practice: implementation of physical activity and food policies inschools
© Mâsse et al.; licensee BioMed Central Ltd. 2013
Received: 17 November 2012
Accepted: 17 May 2013
Published: 3 June 2013
Public policies targeting the school setting are increasingly being used toaddress childhood obesity; however, their effectiveness depends on theirimplementation. This study explores the factors which impeded or facilitatedthe implementation of publicly mandated school-based physical activity andnutrition guidelines in the province of British Columbia (BC), Canada.
Semi-structured interviews were conducted with 50 school informants (17principals - 33 teacher/school informants) to examine the factors associatedwith the implementation of the mandated Daily Physical Activity (DPA) andFood and Beverage Sales in Schools (FBSS) guidelines. Coding used aconstructivist grounded theory approach. The first five transcripts andevery fifth transcript thereafter were coded by two independent coders withdiscrepancies reconciled by a third coder. Data was coded and analysed inthe NVivo 9 software. Concept maps were developed and current theoreticalperspectives were integrated in the later stages of analysis.
The Diffusion of Innovations Model provided an organizing framework topresent emergent themes. With the exception of triability (not relevant inthe context of mandated guidelines/policies), the key attributes of theDiffusion of Innovations Model (relative advantage, compatibility,complexity, and observability) provided a robust framework for understandingthemes associated with implementation of mandated guidelines. Specifically,implementation of the DPA and FBSS guidelines was facilitated by perceptionsthat they: were relatively advantageous compared to status quo; werecompatible with school mandates and teaching philosophies; had observablepositive impacts and impeded when perceived as complex to understand andimplement. In addition, a number of contextual factors includingavailability of resources facilitated implementation.
The enactment of mandated policies/guidelines for schools is considered anessential step in improving physical activity and healthy eating. However,policy makers need to: monitor whether schools are able to implement theguidelines, support schools struggling with implementation, and document theimpact of the guidelines on students’ behaviors. To facilitate theimplementation of mandated guidelines/policies, the Diffusion of InnovationsModel provides an organizational framework for planning interventions.Changing the school environment is a process which cannot be undertakensolely by passive means as we know that such approaches have not resulted inadequate implementation.
KeywordsPhysical education Physical activity Nutrition School policies School guidelines Implementation Uptake Barriers Facilitators Qualitative
Schools provide the best setting to support a population-based approach to improvephysical activity (PA) and healthy eating (HE) for all children regardless of theirethnic or socio-demographic background [1, 2]. School-based public policies are increasingly being used to addresschildhood obesity [2, 3] and emerging evidence supports the effectiveness of such policies onpositively influencing the school environment. For example, school-based physicaleducation (PE) policies have increased the amount of PE offered in schools (i.e.,total minutes or days/week) [4, 5] and school-based nutrition policies have resulted in less access tosugar-sweetened beverages and low nutrient energy dense foods in schools [6–8]. School-based policies also influence student behaviors. For example suchpolicies have increased PA levels, although one study documented a greater effectfor girls [4, 9]; increased fitness levels ; and reduced student consumption of sugar-sweetened beverages in school [11–13]. Furthermore, evidence suggests that improvements to both PA and HE willresult in improvements in cognitive functioning and overall academic performance,helping schools meet their academic mandate [14–16].
While the emerging evidence suggest school-based policies can positively influencethe school environment and student behaviours, the impact on student body mass index(BMI) is less clear. Some studies have found no association between school-basedpolicies and student BMI [9, 11] while others documented an association [17, 18]. Specifically, students had lower BMIs in states with stricter PE andschool food policies  and in states with stronger competitive food policies . The effectiveness of school-based policies against childhood obesitydepends on their implementation, which is often less than optimal even when thesepolicies are publicly mandated [4, 9, 10]. To date, few studies have examined the factors that impede or facilitatethe implementation of school-based obesity prevention policies. Factors found toimpede implementation include: potential loss of school revenues, competingcurriculum demands and priorities, lack of resources (staff, funding, availabilityof programs or teaching resources), lack of coordination, no dedicated funding tosupport the mandate, industry lobbying, and misconceptions about the types of foodand beverages made available at school [5, 19–24]. In contrast implementation is enabled when there is support from keypoliticians, parents, physicians and school personnel as well as the provision offinancial support and having data to inform policy decisions enabled implementation [19–22].
In Canada, the Constitution Act declares education to be under provincialjurisdiction , as a result any guidelines/policies affecting the school system areenacted at the provincial level. The enactment of the Daily PA (DPA) and Food andBeverage Sales in Schools (FBSS) guidelines in the province of British Columbia(BC), Canada represented the province’s first attempt to govern the PA andfood environment of schools. The DPA guidelines set the requirements for dailyphysical activity for students. The FBSS guidelines set out minimum nutritionstandards for food and beverages sold to students. In addition, both policies setout to encourage the development of life-long healthy behaviours.
Prior to the implementation of the DPA guidelines, K to 9 grades in BC were expectedto devote 10% of their instructional time to PE, for grade 10 students PE was andremains a graduation requirement and for grades 11 and 12 it was and remains as anelective course . The new DPA guidelines require schools to offer 30 minutes per dayof PA as part of the grade K-9 educational curriculum. Grade 10-12 students mustdocument and report a minimum of 150 minutes per week of PA, performed at amoderate to vigorous intensity. While some provinces in Canada mandate that PE betaught by a PE specialist, in BC this differs by grade. At the elementary schoollevel PE is primarily taught by classroom teachers. Implementation of the guidelineswas expected by the beginning of the 2008/2009 school year.
Prior to the implementation of the FBSS guideline, schools in BC were not expected tomeet any nutritional guidelines. The FBSS guidelines were designed to maximizestudents’ access to healthier options and fully eliminate the sale ofunhealthy food and beverages in BC schools. The FBSS guidelines mandate schools toadhere to the 2007 Canada’s Food Guide  for all food and beverage sold or made available at school. Fullimplementation of the FBSS guidelines were expected by the end of the 2007/2008school year. While elementary schools in BC have fewer permanent food outlets thanin middle/high schools (45% versus 95% of schools have permanent food outlets), lesshealthy food choices were often offered in elementary schools through parents orfundraising efforts (e.g., pizza lunches or hot dog days) .
This study explores the factors that impeded or facilitated the implementation ofpublicly mandated school-based PE and nutrition guidelines in the province of BC.Our study provides a unique opportunity to examine the implementation of the FBSSguidelines in a jurisdiction that did not previously have any guidelines or mandatedpolicies to govern the food environment of schools. In addition, it also providesthe opportunity to examine the implementation of a guideline that addresses the PAenvironment in schools while previous research conducted in other jurisdictions hasfocused on the implementation of policies directed at changing the PE environment inschools.
We examined the factors associated with the implementation of the DPA and FBSSguidelines qualitatively by conducting semi-structured interviews with 50 schoolinformants (17 principals and 33 teacher/school informants). The study protocol wasapproved by the University of British Columbia and the University of VictoriaResearch Ethics Boards and participating school districts.
Sample selection and recruitment
Schools were selected to participate in this study based on responses to a schoolsurvey administered in the 2007-2008 school year. School selection ensuredrepresentation across: self-reported levels of implementation of the guidelines,school types (elementary, middle, and high schools), and school settings (urban,suburban, and rural). Of the 513 schools that completed the 2007-2008 schoolsurvey, a total of 47 schools were invited to participate in the qualitativestudy. We targeted more middle/high schools (45% versus 21%) and more schools inneighborhoods with a higher percentage of visible minorities (32% versus 20%) inour sample. This ensured an adequate representation of these perspectives in ourdata. By including more middle/high schools, which typically have more studentsand teachers than elementary schools, our targeted sample included a higherpercentage of schools with more students and teachers.
Principals in selected schools received an invitational letter through mail andfollow-up reminders. In total, 17 schools participated in the qualitative study(36% response rate): 10 elementary schools (grades 7 or less); one junior highschool (grades 8-10), one senior high school (grades 10-12), and five highschools (grades 8-12). The socio-demographic characteristics of theparticipating schools did not differ significantly from those of thenon-participating schools, with the exception of the neighbourhoods they servedwhich had a higher percentage of visible minorities (42% versus 27%). Allprincipals (n = 17) participated in the semi-structured qualitativeinterviews as well as 33 teacher/school informants (N = 50 informantinterviews). Key informants were purposefully recruited by a delegated staffcontact. Invitation letters were distributed in mailboxes and interested keyinformants returned consent forms to the school contact who then forwarded theinformation to the research team. Key informants were predominantly classroomteachers (n = 21) but also included PE specialists(n = 9), and cafeteria staff and home economics teachers(n = 3).
Semi-structured interviews were conducted individually with principals(n = 17) and key teachers/school informants (n = 33).Interviews were conducted in the 2010-2011 school year by two-trained researchassistants. The interviews were 45 to 60 minutes long and consisted ofbroad open-ended questions with probes into emergent topics as they arose.Interviews started by asking the informants a number of background/demographicquestions including questions about their position at the school, if applicable- courses and grades taught, and years of experience overall and at the currentschool. Questions related to the DPA and FBSS guidelines asked the informant todescribe/discuss: a) their understanding and expectations of the guidelines, b)their thoughts about the guidelines, c) whether their school was implementingthe guidelines as expected, d) how they were or were not implementing theguidelines; highlighting any examples (e.g. whether their school made anychanges to implement the guidelines and if so what changes), e) the impact ofthe guidelines had on the school community (school, teachers, students, andparents), f) factors that facilitated or impeded implementation, and g) feedbackor support received from the school community about the guidelines. Interviewswere recorded digitally and researchers captured noteworthy aspects of thecontext or interview in supplementary field notes. Half of the interviewtargeted the DPA guidelines and the other half the FBSS guidelines. Allinformants provided written consent to be interviewed and received a gift cardfor participation ($15 Cdn). The designated school contact received a monetaryincentive ($50 Cdn). Substitute teachers were provided to facilitateparticipation in the interviews.
Digital recordings were transcribed verbatim and reviewed by the interviewers toensure accuracy of the data. A constructivist grounded theory approach was usedfor coding [29, 30]. It employs a less rigid application of grounded theory andexplicitly acknowledges the researchers’ expertise and biases during theanalysis process . Two independent coders initially created a set of broad codes basedupon the interview guide and research objectives. Transcripts were then codedline by line using an inductive method of open coding; whereby researchersallowed patterns and themes to emerge from the data . To ensure the trustworthiness of the coding and interpretations ofthe data, the first five transcripts and every fifth transcript thereafter werecoded in duplicate, and any discrepancies were discussed with a third researcherto reach consensus. Coding of transcripts continued until saturation. All datawere coded in the NVivo 9 software (QRS International, 2010).
Concept maps were developed to reduce the qualitative data into meaningfulconcepts. This process was initially conducted separately for understanding thebarriers and facilitators to the implementation of the guidelines. In the laterstages, this process integrated knowledge of existing theoretical perspectivesand it became apparent that the Diffusion of Innovations Model provided anorganizing framework for presenting the emerging themes . While this theoretical framework did not guide the original codingand analyses, it was used to summarize the data. Initial results were presentedto key stakeholders (staff at the Ministries of Education (n = 2)and Health (n = 3) that had firsthand knowledge of these issuesbased on their interactions with school stakeholders related to guidelineimplementation) to check the validity of the interpretations and to gain furtherinsights about our findings. This process also assessed convergence of thefindings with other data sources collected by the provincial government andconfirmed theoretical saturation as no new issues emerged in these discussions.This process served to ensure proper interpretation of our data.
Percentage of informants who perceived their schools as fullyimplementing the Daily Physical Activity (DPA) and the Food andBeverage Sales in Schools (FBSS) guidelines
Elementary schools (n = 10)
Middle & High schools (n = 7)
All schools (N = 17)
Elementary schools (n = 19)
Middle & High schools (n = 14)
All schools (N = 33)
Schools implemented the DPA guidelines by taking either:  a prescriptive approach (requiring all students to participate) asthey scheduled more PE/PA during instructional hours, added more PE classes,changed PE from a semester system to a full year class, scheduled joggingbreaks, scheduled activity class before or after school, and/or incorporatedclassroom activity breaks; or  a non-prescriptive approach (providing more opportunities but notrequiring) as they provided more PE/PA elective classes, expanded the intramuralprogram, provided lunch hour games, allowed access to facilities outside ofinstructional time, added PA clubs (walking, running, and kilometre clubs),provided guidance on how to increase PA, encouraged students to be activethrough school announcements, sent newsletters, and/or had school assemblieswith students. Higher grades were more likely to report implementing DPA in anon-prescriptive way.
To implement the FBSS guidelines, schools: changed content of vending machines,school store or canteen; changed vending machine supplier; made food healthier(e.g., chicken hot dogs with whole wheat buns); eliminated certain foods (hotdogs, French fries); eliminated vending machines, school stores, or canteens;required recipes be provided with bake sale items; changed portion sizes;eliminated donuts from staff meetings; cooked healthier recipes in homeeconomics; changed the educational curriculum; eliminated outside food in theschool; changed fundraising items; and eliminated classroom treats. Other lesscited changes included: eliminating carbonated beverages (purchased or broughtin from home), consulting with a nutritionist, sending newsletters to parentsabout HE and healthy recipes, having a healthy living week, asking concessionstands to close when students are on field trips, prohibiting students frombringing money on school trips to prevent purchase of food and beverages, andstarting an organic greenhouse and using the vegetables and fruits in thecafeteria.
Barriers and facilitators to implementation
Summary of the emerging themes for the Daily Physical Activity (DPA)and the Food and Beverage Sales in Schools (FBSS) guidelines
• It’s better than what we were doing
• We needed this
• We had a better way of doing this before
• It would be better if we didn’t loserevenues
• It fits our philosophy
• It fits my philosophy
• We like it versus it does not fit in my schedule
• The school community was on board
• There are favorable social norms
• There are favorable social norms
• Whose responsibility is it? We believe it is thefamily versus schools need to help those that don’thave
• Whose responsibility is it? We believe it is thefamily versus schools have a social responsibility to notprofit from selling children unhealthy food
• This takes special skills
• We (teachers) resent the top down approach taken forimplementation
• We can’t follow it all the time, we need“one-time” exceptions
• We struggled with the lack of guidance
• We found it difficult to understand the scope of theguidelines
• We’re (elementary teachers) not clear whatcounts toward DPA
• We have to figure out what to do about decreasingprofit margins
• We’re (elementary teachers) not clear thatactivities should be structured to count toward DPA
• We (teachers and Parent Advisory Council (PAC))struggle to find suitable fundraising alternatives
• Evaluating implementation of DPA is hard
• We can be perceived as overstepping our boundaries aseducators
• In higher grades it does not work as easily
• This pits the administrators against the parents
• We can’t meet all curriculum expectationsversus it helps us meet our expectations
• We struggle with food insecurity
• We have to navigate cultural relevance
• Our regional climate limits us
• Having ready-made provincial resources helped us(elementary teachers) with implementation
• Having provincial resources helped us withimplementation
• This requires schools to have the appropriateresources
• Having access to a local nutritionist is helpful
• It is easier when physical education (PE) was apriority
• Having local suppliers that comply with theguidelines is necessary
• Having a PE specialist in elementary grades helps alot
• Having mandated guidelines is useful ammunition foradministrators
• Some of us have noticed positive impacts (increasedmental alertness and focus, improved academic performance,improved classroom behaviors, students enjoy being active,positive attitude shift toward physical activity, andincreased positive student/teacher interactions)
• Some of us have noticed positive impacts(students/teachers are healthier, increased awareness abouthealthy eating, positive attitude shift toward healthyeating, and involved in more “green”initiatives)
• We lost revenues
• It decreased teachers’ autonomy
• We had to reduce curricular and/or extracurricularactivities
• It’s just more work for us (teachers &schools)
• We have noticed students selling unhealthy food
• We are encouraging students to falsify their physicalactivity data on their report cards
• More students leave school grounds at lunch –as a result they skip more classes and we are more concernedabout their safety
Sample quotes or explanations for the themes that emerged for theDaily Physical Activity (DPA) guidelines *
It’s better than what we were doing“..daily physical activity it seemed veryoverwhelming. But it didn’t take very long before itwas “you know what, this is, this is great, this issomething that should have been done a lot sooner.”(Elementary teacher)
We had a better way of doing this before“…the Ministry needs to look at ways toget more PE specialists out in the schools… If we hada PE specialist and we had it .. all the students in theschool would get a much higher level of quality out of theirphys ed.” (Elementary teacher)
It fits our philosophy “I like the philosophy,…,a healthy society is absolutely part of what weshould be encouraging and in education and setting the stagefor a person’s healthy lifestyle and a vision of beinghealthy and active all their life…it’s all good.” (Elementary principal)
We like it “I think it’s an awesomeidea.” (middle/high school teacher) versus it doesnot fit in my schedule “Teachers would love todo it. But again, …their day will not allow it.”(Elementary principal)
There are favorable social norms –Overwhelmingly, all informants talked positively aboutphysical activity.
Whose responsibility is it? We believe it is the family“I get that physical education should be partof our curriculum but I also don’t think it’sthe school’s job solely to teach healthy living, Ithink it should also come from home … but telling theschools that they need to do it, yeah, … I don’tnecessarily agree with it.” (Elementary teacher)versus schools need to help those that don’thave “…these kids really need that time… because I know a lot of them do not get outside ofschool exercise. Like they’re not in soccer,they’re not into dance; they’re not into hockeyor whatever.” (Elementary teacher)
This takes special skills “…even though,everyone to my knowledge in Canada has to take a PEmethodology course, there are very very manypeople…teaching in elementary school who areuncomfortable with PE, they’re uncomfortable withgetting the students to do activities, and gym results indodge ball for a lot of the year.” (Elementaryteacher)
We (teachers) resent the top down approach taken forimplementation “…they think the idea(DPA) is good but they’re questioning the wayit’s being implemented, yeah, more so than with thefood.” (High school teacher)
We struggled with the lack of guidance “I thinkthe schools were looking for some guidance from thedistricts, the districts dumped it back to theschool…it would be nice to have a specific guidelinesaying ‘this is what you’re doing, this is howyou do it… different schools [in this school district]are having to come up with … different models toimplement in theory the program that could be justimplemented across the board. So I would say, whyisn’t the district just coming up with a common modelthat everybody is supposed to follow and you just doit?” (Middle/high school principal)
We’re (elementary teachers) not clear what countstoward DPA – How much physical activitystudents need to accumulate? Is it 15, 20, 30, and 60minutes per day or 10 minutes in addition to PE. Can DPA beaccumulated at recess or lunch time and what aboutnon-instructional hours? Does only vigorous physicalactivity counts toward DPA but what about strength trainingactivities?
We’re (elementary teachers) not clear thatactivities should be structured to count toward DPA“I know that some schools feel that the recess lunchtime should be part and parcel of the DPA just formanagement reasons. But I mean you can’t guaranteethat your kids are going to be active out there at recessand lunch. Some of them might just stand there and be, youknow, bystanders.” (Elementary teacher)
Evaluating implementation of DPA is hard“We’re meeting the requirements of having iton the report card, and encouraging parents to work with thekids to meet it…but if you asked me to pull out theactual guidelines and show you step by step how we’reimplementing – no.” (Middle/high schoolprincipal)
In higher grades it does not work as easily“…it fits into an elementarytimetable… in an elementary school you can add thoseminutes in; much harder to do in a secondary where they aregoing from teacher to teacher. And every teacher is mandatedto spend so many minutes with their kids and nowyou’ve got 30 minutes added in. Elementary: okay,secondary: difficult. “ (Middle/high schoolteacher)
We can’t meet all curriculum expectations“…meeting the language arts curriculum, meetingthe math curriculum requirements, social studies, science,health education, PE, computer technology, it’s all ofit and each year the Ministry gives us one more piece. Wellthere aren’t enough minutes in a day; we’ve runout, we ran out years ago.” (Elementary principal)versus it helps us meet our expectations “Idon’t see that as taking away from other parts oftheir curriculum to do this, I see this as all onecurriculum…I would posit that by doing your 30 minutesof exercise you’ve actually helped your social studiesprogram: kids are more primed to learn, they’re moreapt to spend time on it” (Elementary principal)
We have to navigate cultural relevance“…our greatest challenges… is with ourfamilies where English is not the predominant language inthe home. And working with those families to help themunderstand that it’s really important for their kidsto get out and be active outside of school is a challengebecause they might not hold that same valueculturally…Their values might be more onacademics.” (Elementary principal)
Our regional climate limits us “I mean up herein the north it gets cold early in the season so theycan’t go outside everyday right, it’s just notnecessarily practical…I mean in the lower mainland Iguess they can go outside and do some exercises, activities,go for a walk but whatever, whatever, you know, the teachercan or wants to do with them but we have, we don’talways have outside as an option up here.”(Middle/high school teacher)
Having readymade provincial resources helped us(elementary teacher) with implementation “Ithink by way of receiving materials (from Action Schools BC)like that, and then the workshop that we got from the ActionSchools – I think that, all that kind of stuff helps,yeah.” (Elementary teacher)
This requires schools to have the appropriateresources (gymnasium, nearby park or communitycenter, large outdoor field or playground area) “Thisschool being quite small they were able to have access tothe gym a lot more than other schools – like I was atanother school… they had to share all their PE classeswith like two or three or four other classes. So they havethe benefit here of not only having the gym tothemselves…they’re able to sign up for otherextra gym periods which definitely helps.” (Elementaryprincipal)
It is easier when physical education (PE) was a priority– Meaning if the schools had more scheduled PEin place, many PE electives, or many PA classes itfacilitated implementation.
Having a PE specialist in elementary grades helps a lot“(What helps implementation?)…I thinkhaving somebody that’s a real champion when you lookat (PE Specialist name), you know, when she has the kids Imean she works them pretty hard during PE time there’sno sloughing off there. You know the kids are, they’reput to task and they seem to enjoy what they’re doingand that’s the nice thing about having one personpretty well that does all of the PE at the elementarylevel.” (Elementary principal 0936)
Some of us have noticed positive impacts (mentalalertness and focus, improved academic performance, improvedclassroom behaviors, student enjoy being active, attitudesshift toward physical activity, and increased positivestudent/teacher interactions) “I thought, I would befighting up-against a wall to get this done; and thestudents love it..they crave it. I like ‘okay, yup,yup, what are we doing for fitness today?’ they wantto be in shape and they know it’s important…andthere’s no complaint, there’s nothing”(Elementary teacher) “So it has me thinking during theschool day. How can I get my kids more active? …it’s good to have that in the back of my mind knowingthat … each day, I have to think of how can I get mykids moving.” (Elementary teacher)
It decreased teacher’s autonomy –Elementary teachers have less freedom to structure theirdaily activities.
It’s just more work for us (teachers & schools)“The videos are fun. But, uh, no, it’sjust, it’s an added stress. Yeah, I’m justcranky about the whole dumb thing [laughs].”(Elementary teacher)
We are encouraging high school students to falsify theirphysical activity data on their report cards“The kids have to write in their booklets once a weekfor 10 minutes and they write down everything they did allweek. So, they make it up it’s not worth any marks.It’s a joke. So, but it’s a good start,they’re aware. They’re forced to do it. They canreflect on it and some of them take it seriously but othersdon’t… If DPA had some teeth then those are theones that would benefit. And it’s not just studentswho are overweight…it’s the students whoare…skinny, but you know they’re just nothealthy.” (Middle/high school teacher)
Sample quotes or explanations for the themes that emerged for theFood and Beverage Sales in Schools (FBSS) guidelines
We needed this “Well I think it’s,it’s late in coming but it’s about time,yeah” (Middle/high school teacher)
It would be better if we didn’t lose revenue““I understand the meaning of itand…the students do need to eat healthier,but…it didn’t change, like the desired effectwas for students to eat healthier but the majority of themit didn’t change much, it just sent the moneyelsewhere, so. I don’t know what the answer is but, itwas a huge negative impact and it really, it really affectedus quite a bit.” (Middle/high principal)
It fits with my philosophy “I personally Ivalue what the province is doing, I understand it and Ithink they’re right minded with trying to changebehavior patterns with the young through the schools soI’m supportive to that in the philosophy that ithas.” (Elementary principal)
The school community was on board “Herethey’ve responded well. I think everybody seems to beon board.” (Elementary principal)
There are favorable social norms “Mostlystudents, all the teachers are on board with it, cause weall, you know, I think healthy eating is definitely onething that – well obesity is a problem right with, allacross north America… we’re trying to promotehealthy living, so.” (High school teacher)
Whose responsibility is it? We believe it is the family“Well personally I think that it’s thejob of parents to be properly feeding and clothing theirkids.” (Principal 1536) versus schools have asocial responsibility to not profit from sellingchildren unhealthy food “Personally Idon’t believe that we should be selling pop inschools, I don’t believe we should be sellingchocolate bars in schools. I think that those are items thatif parents choose to have their children eating themthat’s their own choice, but I don’t think thatwe should be promoting or profiting from the sales ofanything that isn’t healthy.” (Elementaryprincipal)
We can’t follow it all the time; we need “onetime exceptions” “So what was at thegrad barbecue? Well, there was regular coke and stuff likethat. They wouldn’t fall under the guidelines, so. Wejust kind of ignore the guidelines and because, if webrought in juices and stuff like that, probablywouldn’t be drank at an event like that.”(Middle/high school principal) and“There are timeswhen we do fundraising, obviously a pizza sale one day for atrip…it’s not following the Guidelines, butit’s for fundraising for the school.”(Elementary principal)
We found it difficult to understand the scope of theguidelines (just vending or all food served) andwhere they apply (fundraising activities, activitiesorganized by Parent Advisory Council, bake sale items,classroom treats, outside school hours activities,advertizing in school, accepting sponsorship from companies,and accepting incentives from vending machines company)
We have to figure out what to do about decreasing profitmargins “Well it’d be revenue from thevending machines, but also the cafeteria. Cause theycan’t sell – cause like a lot of the junk foodwere good money makers… Higher margin of profit,whereas quality food, the profit margin is not there.”(Middle/high school principal)
We (teachers and Parent Advisory Council (PAC) struggleto find suitable fundraising alternatives “ Soas I said, for our PAC (Parent AdvisoryCouncil)…certainly they’ve communicated theyfind it somewhat…restricted in what they can sell (forfundraising).” (Elementary principal)
We can be perceived as overstepping our boundaries aseducators “Looking at kids’ lunches andrecognizing the things that are healthy and commenting onit, … that gets the ire of some parents up becauseyou’re embarrassing my children when you’retalking about their lunch. You shouldn’t be doingthat. If you want to talk to me as the parent about it,that’s one thing, but don’t talk to thekid.” (Elementary teacher)
This pits the administrators against the parents“And we were greeted by a big cheer…the parentsthought “yeah, great”. And so… we stillhave parents who come every day and drop offMcDonald’s lunches and stuff, you know, we weresaying, we can’t stop them from doing that, butwe’d say “you can’t bring pop, you have tobring something else for them to drink.” And mostparents would go “Oh, OK, I didn’t know. Yeah,fine.” “And it was going OK for awhile, untilone of our PAC executive members…took exception to thepop-free rule, saying that it…infringed upon parentalrights, because it was the parent’s right to decidewhat the children ate, what they put in their child’slunches… we were now putting a child in a compromisedposition… the parent might be in a…situationwhere they have nothing else at home to feed theirchild….so we had to [sigh] for the sake of, Idon’t know, relationships…repeal that policy,and we sat down together – administration and PAC tocome up with a statement that we all agreed upon and thensent it out to the community” (Elementaryprincipal)
We struggled with food insecurity “We’rean inner city school…in some cases feeding kids ismore important.” (Elementary principal)
Having provincial resources helped us withimplementation (e.g., booklet provided by theMinistry of Education, website, and the Fruit and Vegetableprogram)
Having access to a local nutritionist is helpful“I mean, we’re lucky in the sense thatfood and beverage is with the cafeteria program. Thedistrict does have a director that’s in charge of allprograms, so she (district nutritionist) oversees, evenschool stores, what’s being purchased … I meanthat’s beneficial so we have to follow thoseguidelines, just like the chef has to order specific things,sometimes not happy about it, but to follow thoseguidelines, she does.” (Middle/high schoolprincipal)
Having local suppliers that comply with the guidelines isnecessary “Finding a vendor, like this vendoris now out of XXX,… we get a new delivery person everymonth …they know what they’re supposed to put in[the vending machine], but they’re visiting, Idon’t know how many sites a day, and “Oh, Idon’t have any of this stuff left, so I just want tofill the hole, so I put in Coke Zero” orwhatever…We probably had to phone 10 times during theyear…“Get that guy back here and tell him topull out that Coke.” You know, that’s the lastthing I wanna have to waste time on… So, we’vehad some problems in that general area.“ (High schoolprincipal)
Having mandated guidelines is a useful ammunition foradministrators “Having the (FBSS) guidelinesis helpful because it gives you sort of that ammunitionbehind you to say ‘well there’s a provincialguideline and it’s expected.” (Middle/highschool principal)
Some of us have noticed positive impacts(students/teachers are healthier, increased awareness abouthealthy eating, positive attitude shift toward healtheating, and involved in more “green”initiatives) “Oh definitely so, yeah. I foundthis (the FBSS guidelines) made a difference to kid’sattitudes and especially their behaviour, you know,especially with a lot less sugar.” (Elementaryprincipal)
We lost revenues – without being prompted manymiddle/high school principals noted a revenue loss of$10,000 to $45,000.
We had to reduce curricular and/or extracurricularactivities “…it’s great to bepromoting healthy food, on the one hand it’s, youknow, our athletic program half the funding we used to havefor running our athletic program was coming from theprofits.” (High school principal)
We have noticed students selling unhealthy food– entrepreneurial student took upon themselves to“illegally” sell less healthy food items.
More students leave school grounds at lunch – asresult they skip more classes and we are more concernedabout their safety “If I had the vendingmachines capability, I bet I would keep another 50, 60, 100kids on site, which I would prefer because it’s whenthey go off site that I lose them, that’s where theyskip, or get into trouble, or decide to buy something theyshouldn’t be buying. And if I can keep them on-site Ihave more, for lack of a better word, control of whatthey’re doing with their lunch breaks.”(Middle/high school principal)
In general, informants had a positive opinion of both guidelines relative tothe status quo (“it’s better than what we were doing” forthe DPA guidelines and “we needed this” for FBSS). However, someelementary school informants, who were in the school system prior to budgetcuts that eliminated PE specialists in elementary schools in the late1980’s and early 90’s thought they “had a better way ofdoing this before” when they had PE specialists. The irony of this wasdiscussed in the context of the DPA guidelines. In contrast, while the FBSSguidelines were perceived as positive from a ‘health’perspective, their advantage were often tempered by their potential negativeimpact on school revenues.
Both guidelines were perceived to be compatible with schools’ orteachers’ expectations of what the school learning environment shouldprovide (“it fits our philosophy” and “we like it”for DPA guidelines and “it fits my philosophy” and “theschool community was on board” for FBSS guidelines). Most statementsabout the DPA guidelines focused on how this fits with “us”, the“school” or “teachers”, while the responses aboutthe FBSS guidelines focussed more on how they affect “us” as“individuals”. Informants talked positively about the importanceof PA and HE suggesting strong favorable social norms about these behaviourswhich in some cases translated into positive feelings toward the guidelinesbut not always. For both guidelines, some informants questioned whetherschools or parents should be responsible or solely responsible for providingPA and HE opportunities. Others felt schools had a social responsibility toaddress these issues (“schools need to help those that don’thave” for the DPA guidelines and “schools have a socialresponsibility to not profit from selling children unhealthy food” forthe FBSS guidelines). Finally, compatibility issues specific to DPA includedthe difficulty in fitting DPA into the schedule, lacking skills to providemore PA and resenting the top down approach taken in mandating the DPAguidelines. For the FBSS guidelines, some informants felt strongly about theneed to allow for “one-time exceptions” to ensure it fits withhow schools function.
Many of the complexity issues revolved around understanding of theguidelines. For the DPA guidelines, many struggled with the lack ofdirection provided in the guidelines; what counted toward DPA and howactivities should be structured to count toward DPA. For the FBSSguidelines, many were not sure about the scope of the guidelines; whetherthey applied only to vending machines or to all food and beverages and alsowhen (within school hours) and where (outside school events) the guidelinesapplied.
Other complexity issues revolved around the barriers teachers or schoolsencountered when they tried to fully implement the guidelines. For the DPAguidelines, informants from higher grades (where reporting on DPA bystudents was required) struggled to report how students met their PArequirements on report cards. In contrast, informants from lower gradesstruggled with meeting all curriculum expectations. Schools with a largeimmigrant population talked about the need to address the value of PA toensure implementation of the DPA guidelines in this population. Schoolswhere the weather tended to be more extreme talked about their struggle toimplement the DPA guidelines in inclement weather.
For the FBSS guidelines, schools struggled with maintaining profit marginsand finding suitable fundraising alternatives. In addition, some schools hadencountered problems when their teachers eagerly embraced the guidelines butparents perceived that they had overstepped educational boundaries bytalking to the children about or forbidding some food. Finally, indisadvantaged schools, where food security was a widespread concern,administrators struggled to implement the guidelines while also trying tofeed their disadvantaged students.
Appropriate resources and support were considered key facilitators to theimplementation of both guidelines. For the DPA guidelines, this includedhaving ready-made provincially available resources (Action Schools! BC),school resources (gymnasium, nearby park or community center, large outdoorfield or playground area), and a PE specialist in their school (elementarygrades). Implementation was also easier in schools where PE was a priorityprior to the implementation of the guidelines. In the context of the FBSSguidelines, having provincial resources that were developed to supportimplementation (e.g. Brand Name Foodlist) as well as existing programsavailable were seen as facilitative. In addition, having a nutritionistavailable for consultation (a resource added with the launch of the FBSSguidelines through Dietitians Services) and having local suppliers thatcomplied with the guidelines facilitated implementation. Interestingly, thetop-down approach to enact the school guidelines, which was seen asproblematic by some, was perceived by one administrator as helpful; ithelped to create positive changes in the school without the administratortaking personal blame.
Positive impacts were observed as a result of implementing the guidelines(see Table 2). Unintended consequences were alsonoted for the DPA guidelines, including teachers feeling they had lessautonomy over their schedules and increased workload through direct deliveryat the elementary school level and through the responsibility of trackingand documenting student DPA at the high school level. Unintended observableconsequences of the FBSS guidelines implementation included: loss of revenuefrom food/beverage sales, fundraising activities and bake sales; reducedfunds for curricular and/or extracurricular activities (field trips, musicprogram, social assistance program, athletic program, sporting events, andothers); selling of unhealthy food and beverages by “entrepreneurialstudents”; and more students leaving school grounds at lunch timewhich then resulted in students being late to class after their lunch break,skipping classes, or increased concerns about student safety.
Our study provided an in-depth analysis of the factors that influenced implementationof school-based PA and nutrition guidelines in BC, Canada. Implementation of the DPAand FBSS guidelines was influenced by perceptions that the guidelines: wererelatively advantageous compared to status quo, were compatible with school mandatesand teaching philosophies, were complex to understand and implement, and hadobservable positive impacts. A number of contextual factors including availabilityof resources facilitated implementation; however, tremendous variability wasobserved across schools in terms of the factors identified as influencingimplementation. Interestingly, the target of the guidelines also contributed to thevariability reported in the effectiveness of implementation between guidelines andschools. The FBSS guidelines targeted the school environment and thus itspredominant impact was at the school level, including the Parent Advisory Council(PAC) in some cases. In contrast, the DPA guidelines targeted both teachers andschools; as teachers were responsible for the delivery of PA in the context of theclassroom in lower grades and schools were responsible for documenting how studentsmet the DPA requirements in higher grades.
Our findings support the findings of similar studies of the U.S. school wellnesspolicy. These studies found similar barriers to implementation such as: revenueloss, competing demands, lack of resources, support from the school community,difficulty in finding fundraising alternatives, and decreased resources forcurricular or extracurricular activities [5, 19, 22, 24]. Some of our findings are perhaps unique to the Canadian context andother countries that do not have subsidized federal school meal/breakfast programs . For example, addressing food insecurity is more complex when schools arenot provided with infrastructure support or funds to subsidize school meals. Inaddition, schools cannot count on the subsidized school meal to maintain cafeteriarevenues when modifying their “A La Carte” offerings. This has beenfound to offset anticipated revenue loss in some U.S. schools, where school mealsare subsidized . Our findings may also be unique because other countries have focused onPE- rather than PA-related school policies. For example, understanding how the DPAguidelines are implemented outside of PE and dealing with increased elementaryteacher workloads are highly relevant themes in the context of DPA but not PE.Finally, some findings of the current study have not been documented in previousstudies but may apply to similar policies and contexts, including statements about:needing one-time exceptions for HE policies, shifting the responsibility fromschools to parents, navigating cultural relevance, having more students leave schoolgrounds (high schools only), and having more green initiatives integrated infundraising activities.
Our study is one of the first qualitative studies to use the key attributes of theDiffusion of Innovations Model to organize the factors associated withimplementation of school-based PA and nutrition policies/guidelines . With the exception of triability, the key innovation attributesdescribed in the model (relative advantage, compatibility, complexity, andobservability) provide a relevant and robust framework to organize emergent themesfor both the DPA and FBSS guidelines. Most importantly, this framework provides auseful structure for planning and developing strategies to improve theimplementation of school-based policies/guidelines.
Strengthening the relative advantage of DPA guidelines may require:increasing access to PE specialists at the school or district level, providingtraining, and sharing the evidence linking PA to improved cognitive functioning andacademic performance in schools . In addition, sharing the evidence may also enhance their perceivedcompatibility as some informants felt parents rather than schoolsshould take responsibility for PA. Addressing complexity may require:providing more direction to schools on how to meet the guidelines, sharing models ofsuccessful implementation, supporting ethnically diverse schools that lack parentalsupport for the guidelines, and developing an infrastructure to facilitate trackingand documentation in higher grades. Observability is an interestingcharacteristic to address as teachers can observe the positive impact of DPA onstudents’ health or academic performance; however, enhancing the benefits toteachers also seems important given concerns of increased workload and schoolexpectations.
Communicating the health related evdence [6–8, 11–13, 17, 18] in support of the FBSS guidelines appears important for bolstering theirrelative advantage and offsetting mixed feelings associated with theirpotential impact on school revenues. Similar to the DPA guidelines, perceivedcompatibility may also be improved by communicating the evidencelinking HE with academic performance [15, 16]. Issues raised under complexity highlighted the need to: educateteachers on how to talk sensitively about HE without usurping parental authority,find suitable fundraising alternatives to minimize conflicts with PAC, minimizerevenue loss, and ensure disadvantaged students are not negatively impacted by theguidelines. Observability can be strengthened by implementing strategiesto: prevent or subsidize loss of revenues, reduce the number of students leavingschool grounds at lunch time, and prevent the entrepreneurial students from sellingunhealthy food.
Our findings also uncovered the contextual factors that facilitated implementation ofmandated guidelines and highlighted the importance of available resources as acommon facilitator. The implementation of the DPA guidelines in BC was preceded bythe large scale dissemination of Action Schools! BC, a comprehensive whole schoolapproach to increasing PA opportunities across six school action zones (including PEand the classroom) . The dissemination of the initiative began four years before the DPAguidelines were implemented and provided schools and teachers with planning tools,equipment, training, on-going technical support and a suite of better practiceresources that were developed for the school setting and ready to use . Participants specifically highlighted this as a facilitator. In theabsence of such infrastructure, it is likely that other jurisdictions attempting toimplement similar guidelines may be faced with more barriers than we observed.Action Schools! BC integrated HE in 2008 which once again provided the same supportsto schools and teachers to modify their school food environment.
Finally, considerable variability was observed in terms of the strategies employed toimplement these guidelines. The extent to which some strategies (e.g., using aprescriptive or non-prescriptive approach to implement the DPA guideline) are moreeffective than other ones remain unknown and deserves further investigation. Inaddition, we do not know whether the DPA and FBSS guidelines significantly improvedthe school environment. Many informants indicated the school PA and food environmentimproved with the implementation of these guidelines; however, much more work needsto be done to uncover whether policy strategies alone or combined with otherapproaches will help reverse the current childhood obesity epidemic.
In conclusion, emerging evidence suggests school-based policies targeting the schoolPA and food environment can influence student behaviors [4, 9–13]. The enactment of mandated guidelines/policies is considered an essentialstep in changing the school PA and food environment. However, effectiveimplementation is critical to success. Policy makers need to: monitor whetherschools are able to implement the guidelines, provide support to schools strugglingwith implementation, and document whether the guidelines are influencingstudents’ behaviors as intended. The Diffusion of Innovations model provides auseful framework for understanding the factors that impede or facilitateimplementation of guidelines in schools.
Daily physical activity
Food and beverage sales in schools
Parent advisory council
This study was funded by the Canadian Institutes of Health Research, Institute ofNutrition, Metabolism and Diabetes (funding reference number GIR-99715). Dr.Mâsse received salary support from the Michael Smith Foundation for HealthResearch (senior scholarship), the Child and Family Research Institute locatedat the Children’s and Women’s Health Centre of British Columbia(level 2 scientist award), and the Sunny Hill Foundation to complete thiswork.
The authors would like to thank Eric Lorenz for coordinating the data collectionand contributing to the development of the data collection tools. Finally, theauthors would like to thank Whitney Moser for collecting the data and coding thedata.
- Institute of Medicine (IOM): Preventing childhood obesity: Health in the balance. 2005, Washington, DC: The National Academies PressGoogle Scholar
- Institute of Medicine (IOM): Accelerating Progress in Obesity Prevention: Solving the Weight of theNation. 2012, Washington, DC: The National Academies Press.Google Scholar
- Institute of Medicine (IOM): Nutrition standards for foods in schools: leading the way toward healthieryouth. 2007, http://books.nap.edu/openbook.php?isbn=0309103835.Google Scholar
- Kelder SH, Springer AS, Barroso CS, Smith CL, Sanchez E, Ranjit N, Hoelscher DM: Implementation of Texas Senate Bill 19 to increase physical activity inelementary schools. J Public Health Policy. 2009, 30 (Suppl 1): S221-S247.View ArticleGoogle Scholar
- Slater SJ, Nicholson L, Chriqui J, Turner L, Chaloupka F: The impact of state laws and district policies on physical education andrecess practices in a nationally representative sample of US publicelementary schools. Arch Pediatr Adolesc Med. 2012, 166 (4): 311-316. 10.1001/archpediatrics.2011.1133.View ArticleGoogle Scholar
- Boles M, Dilley JA, Dent C, Elman MR, Duncan SC, Johnson DB: Changes in local school policies and practices in Washington State after anunfunded physical activity and nutrition mandate. Prev Chronic Dis. 2011, 8 (6): A129.Google Scholar
- Kubik MY, Wall M, Shen L, Nanney MS, Nelson TF, Laska MN, Story M: State but not district nutrition policies are associated with less junk foodin vending machines and school stores in US public schools. J Am Diet Assoc. 2010, 110 (7): 1043-1048. 10.1016/j.jada.2010.04.008.View ArticleGoogle Scholar
- Kubik MY, Farbakhsh K, Lytle LA: Two years later: wellness councils and healthier vending in a cohort ofmiddle and high schools. J Adolesc Health. 2011, 49 (5): 550-552. 10.1016/j.jadohealth.2011.03.011.View ArticleGoogle Scholar
- Kim J: Are physical education-related state policies and schools’ physicaleducation requirement related to children’s physical activity andobesity?. J Sch Health. 2012, 82 (6): 268-276. 10.1111/j.1746-1561.2012.00697.x.View ArticleGoogle Scholar
- Sanchez-Vaznaugh EV, Sanchez BN, Rosas LG, Baek J, Egerter S: Physical education policy compliance and children’s physicalfitness. Am J Prev Med. 2012, 42 (5): 452-459. 10.1016/j.amepre.2012.01.008.View ArticleGoogle Scholar
- Taber DR, Stevens J, Evenson KR, Ward DS, Poole C, Maciejewski ML, Murray DM, Brownson RC: State policies targeting junk food in schools: racial/ethnic differences inthe effect of policy change on soda consumption. Am J Public Health. 2011, 101 (9): 1769-1775.View ArticleGoogle Scholar
- Levy DT, Mabry PL, Wang YC, Gortmaker S, Huang TT, Marsh T, Moodie M, Swinburn B: Simulation models of obesity: a review of the literature and implications forresearch and policy. Obes Rev. 2011, 12 (5): 378-394. 10.1111/j.1467-789X.2010.00804.x.View ArticleGoogle Scholar
- Cradock AL, McHugh A, Mont-Ferguson H, Grant L, Barrett JL, Wang YC, Gortmaker SL: Effect of school district policy change on consumption of sugar-sweetenedbeverages among high school students, Boston, Massachusetts, 2004-2006. Prev Chronic Dis. 2011, 8 (4): A74.Google Scholar
- Singh A, Uijtdewilligen L, Twisk JW, van MW, Chinapaw MJ: Physical activity and performance at school: a systematic review of theliterature including a methodological quality assessment. Arch Pediatr Adolesc Med. 2012, 166 (1): 49-55. 10.1001/archpediatrics.2011.716.View ArticleGoogle Scholar
- Florence MD, Asbridge M, Veugelers PJ: Diet quality and academic performance. J Sch Health. 2008, 78 (4): 209-215. 10.1111/j.1746-1561.2008.00288.x.View ArticleGoogle Scholar
- Hoyland A, Dye L, Lawton CL: A systematic review of the effect of breakfast on the cognitive performanceof children and adolescents. Nutr Res Rev. 2009, 22 (2): 220-243. 10.1017/S0954422409990175.View ArticleGoogle Scholar
- Riis J, Grason H, Strobino D, Ahmed S, Minkovitz C: State school policies and youth obesity. Matern Child Health J. 2012, 16 (Suppl 1): S111-S118.View ArticleGoogle Scholar
- Taber DR, Chriqui JF, Perna FM, Powell LM, Chaloupka FJ: Weight status among adolescents in States that govern competitive foodnutrition content. Pediatrics. 2012, 130 (3): 437-444. 10.1542/peds.2011-3353.View ArticleGoogle Scholar
- Agron P, Berends V, Ellis K, Gonzalez M: School wellness policies: perceptions, barriers, and needs among schoolleaders and wellness advocates. J Sch Health. 2010, 80 (11): 527-535. 10.1111/j.1746-1561.2010.00538.x.View ArticleGoogle Scholar
- McKenna ML: Issues in implementing school nutrition policies. Can J Diet Pract Res. 2003, 64 (4): 208-213. 10.3148/64.4.2003.208.View ArticleGoogle Scholar
- Johnston LD, Delva J, O’Malley PM: Soft drink availability, contracts, and revenues in american secondaryschools. Am J Prev Med. 2007, 33 (4, Supplement 1): S209-S225. 10.1016/j.amepre.2007.07.006.View ArticleGoogle Scholar
- Dodson EA, Fleming C, Boehmer TK, Haire-Joshu D, Luke DA, Brownson RC: Preventing childhood obesity through state policy: qualitative assessment ofenablers and barriers. J Public Health Policy. 2009, 30 (Suppl 1): S161-S176.View ArticleGoogle Scholar
- Pan Canadian Joint Consortium for School Health: Stakeholder engagement for improved school policy: development andimplementation. Can J Public Health. 2010, 101 (Suppl 2): S20-S23.Google Scholar
- Schwartz MB, Henderson KE, Falbe J, Novak SA, Wharton CM, Long MW, O’Connell ML, Fiore SS: Strength and comprehensiveness of district school wellness policies predictpolicy implementation at the school level. J Sch Health. 2012, 82 (6): 262-267. 10.1111/j.1746-1561.2012.00696.x.View ArticleGoogle Scholar
- Constitution Act, 1867, 30 & 31 Victoria, c. 3. (U.K.), R.S.C. 1985,App. II, No.11. [Cited 13 A.D. Apr 6]. 1867, http://www.canlii.org/en/ca/const/const1867.html.
- Active Healthy Kids Canada: Don’t Let This Be The Most Physical Activity Our Kids Get AfterSchool. The Active Healthy Kids Canada 2011 Report Card on Physical Activity forChildren and Youth. 2011, [cited 13 A.D. Apr 6];http://dvqdas9jty7g6.cloudfront.net/reportcard2011/ahkcreportcard20110429final.pdf.Google Scholar
- Health Canada: Canada’s Food Guide - Main Page. http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php 2008October 7 [cited 2009 Apr 21];http://www.hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/pdf/food-guide-aliment/view_eatwell_vue_bienmang-eng.pdf.
- Rideout K, Levy-Milne R, Martin C, Ostry AS: Food sales outlets, food availability, and the extent of nutrition policyimplementation in schools in British Columbia. Can J Public Health. 2007, 98 (4): 246-250.Google Scholar
- Glaser BG, Strauss AL: The discovery of grounded theory. 1967, Chicago, IL: AldineGoogle Scholar
- Charmaz K: Constructing grounded theory: A practical guide through qualitativeanalysis. 2003, London, England: Sage Publications.Google Scholar
- Miles MB, Huberman AM: An expanded sourcebook: Qualitative data analysis. 1994, Thousand Oaks, CA: SageGoogle Scholar
- Rogers EM: Diffusion of Innovations. 2003, New York: Free Press, 5Google Scholar
- McKenna ML: Policy options to support healthy eating in schools. Can J Public Health. 2010, 101 (Suppl 2): S14-S17.Google Scholar
- Woodward-Lopez G, Gosliner W, Samuels SE, Craypo L, Kao J, Crawford PB: Lessons learned from evaluations of California’s statewide schoolnutrition standards. Am J Public Health. 2010, 100 (11): 2137-2145. 10.2105/AJPH.2010.193490.View ArticleGoogle Scholar
- Naylor PJ, Macdonald HM, Reed KE, McKay HA: Action schools! BC: a socioecological approach to modifying chronic diseaserisk factors in elementary school children. Prev Chronic Dis. 2006, 3 (2): A60.Google Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), whichpermits unrestricted use, distribution, and reproduction in any medium, provided theoriginal work is properly cited.