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

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

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

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

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

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

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