SAMRC/Wits Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
University of KwaZulu-Natal, South Africa.
Lancet Glob Health. 2023 Mar;11 Suppl 1:S19. doi: 10.1016/S2214-109X(23)00102-X.
In South Africa, overweight and obesity affects 13% of children and 17% of adolescents. School food environments play a vital role in dietary behaviours and resulting obesity rates. Interventions targeting schools can be effective if evidence-based and context relevant. There are substantial gaps in policy and implementation of government strategies to promote healthy nutrition environments. The aim of this study was to identify priority interventions to improve school food environments in urban South Africa using the Behaviour Change Wheel model.
A multiphased secondary analysis of individual interviews with 25 primary school staff was undertaken. First, we identified risk factors influencing school food environments using MAXQDA software; then deductively coded these using the Capability, Opportunity, Motivation-Behaviour model, which informs the Behaviour Change Wheel framework. To identify evidence-based interventions, we used the NOURISHING framework and matched interventions to risk factors. Last, interventions were prioritised through a Delphi survey, administered to stakeholders (n=38) representing health, education, food service, and not-for-profit sectors. Consensus for priority interventions was defined as an intervention being either somewhat or very important and feasible, with high level of agreement (quartile deviation ≤0·5).
We identified 21 interventions to improve school food environments. Of these, seven were endorsed as important and feasible to enable school stakeholders', policy makers', and children's capability, motivation, and opportunity of having healthier foods within schools. Prioritised interventions targeted a range of protective and risk factors, including issues of affordability and availability of unhealthy foods within school premises. As such, top priority interventions included (1) regulations on what kinds of foods can be sold at schools; (2) compulsory, child-friendly warning labels on unhealthy foods; and (3) training of school staff through workshops and discussions to improve school nutrition environment.
This is the first study to use the Behaviour Change Wheel and stakeholder engagement to identify intervention priorities to improve food environments in South African schools. Prioritisation of evidence-based, feasible, and important interventions that are underpinned by behaviour change theories is an important step towards enhanced policy making and resource allocation to effectively tackle South Africa's childhood obesity epidemic.
This research was funded by the National Institute for Health Research (NIHR; grant number 16/137/34) using UK Aid from the UK Government to support global health research. AE, PK, TR-P, SG, and KJH are supported by the SAMRC/Wits Centre for Health Economics and Decision Science-PRICELESS SA (grant number 23108).
在南非，超重和肥胖影响了 13%的儿童和 17%的青少年。学校食品环境对饮食行为和由此导致的肥胖率起着至关重要的作用。如果基于证据且与背景相关，针对学校的干预措施可能会很有效。在实施政府促进健康营养环境的战略方面，政策和执行方面存在着巨大的差距。本研究旨在使用行为改变车轮模型，确定改善南非城市学校食品环境的优先干预措施。
对 25 名小学工作人员的个人访谈进行了多阶段的二次分析。首先，我们使用 MAXQDA 软件确定影响学校食品环境的风险因素；然后使用能力、机会、动机-行为模型对这些因素进行演绎编码，该模型为行为改变车轮框架提供信息。为了确定基于证据的干预措施，我们使用了滋养框架，并将干预措施与风险因素相匹配。最后，通过德尔菲调查对利益相关者（n=38）进行干预措施的优先级排序，利益相关者代表卫生、教育、食品服务和非营利部门。优先干预措施的共识定义为干预措施在使学校利益相关者、决策者和儿童具备在学校内获得更健康食品的能力、动机和机会方面具有一定的重要性和可行性，且具有较高的一致性（四分位偏差≤0.5）。
我们确定了 21 项改善学校食品环境的干预措施。其中，有 7 项被认为是重要且可行的，可以使学校利益相关者、决策者和儿童有能力、有动机、有机会在学校内获得更健康的食品。优先干预措施针对一系列保护和风险因素，包括学校内出售的不健康食品的价格和可获得性问题。因此，优先干预措施包括：（1）对学校可销售的食品种类进行监管；（2）在不健康食品上贴上强制性、适合儿童的警告标签；（3）通过讲习班和讨论对学校工作人员进行培训，以改善学校营养环境。
这是第一项使用行为改变车轮和利益相关者参与来确定改善南非学校食品环境的干预措施优先事项的研究。优先考虑基于证据、可行且重要的干预措施，这些措施以行为改变理论为基础，这是加强政策制定和资源分配以有效应对南非儿童肥胖症流行的重要一步。
本研究由英国国民健康保险制度（NIHR）资助，使用英国政府的英国援助支持全球健康研究（资助号 16/137/34）。AE、PK、TR-P、SG 和 KJH 得到了 SAMRC/Wits 健康经济学和决策科学中心-PRICELSSA（资助号 23108）的支持。
