Table 3 Summary of CFIR constructs identified as barriers and facilitators
Domain | Construct | Sub-construct | Specific barriers | Specific facilitators |
|---|---|---|---|---|
Scheme characteristics | Design quality and packaging | Â | Number of articles: 15 | Number of articles: 10 |
|  |  |  | • Lack of diversity in products; repetitive menu; a single menu not considering dietary limitations or cultural diversity • No fruit and vegetables provided • Quantity of products and food not sufficient • No quality criteria for products and food served; use of low-quality food; use of agro-chemicals • Taste of healthy food described as sour and appearance not appealing • Food waste • No variety in educational activities | • Use of fresh products • Products of good quality, with good nutritional value • Homemade food • Use of local products • Less chemicals used, only organic fertilizers • Diverse snacks available • Menu-based cooking • Info provided to teachers on health damages from sugar-sweetened beverages and processed food • Use of videos in educational activities • Health education for children |
| Â | Cost | Â | Number of articles: 11 | Number of articles: 1 |
|  |  |  | • Healthy food perceived as expensive • Short shelf life of healthy food makes it more expensive • High cost of fruit and vegetables • High cost of homemade products • Higher cost of products coming from family farmers • Funds provided not sufficient for nutritional food; not sufficient to cover all children; not sufficient to cover all components of a nutritional program • No adjustment of funds provided after inflation; economic crises raised prices of food without change in funds provided | • Government and farmers invest in production |
Outer setting | Target group needs and resources | Â | Number of articles: 5 | Number of articles: 8 |
|  |  |  | • When food is not provided for free, preference to provide cheap food with low nutrition value as it is what the children can afford • Children from poor households are not familiar with the use of tap water which makes some education interventions difficult • Differences in quality, quantity, and frequency of meals when parents contribute to feeding programs; children most in need either excluded or if food was provided to all independent of parental contribution de-motivation of those parents who contributed • When children live in poverty, it is difficult to implement dietary changes, eat healthy food | • Free school meals satisfy the physiological and nutritional needs of children from poor communities • School meal may be the only meal during the day for some children, especially during economic crises • Having the school meal is a reason some parents send their children to school • Parents do not have to give children snack money, nor lunch at home when they receive it for free at school, thus saving some resources; children buy less unhealthy food as they are not given snack money • In some cases, school meals benefit families as well, as leftovers are sent home with the children • School meals provide income for local family farmers • School meals promote social integration of students • Health and nutrition-related programs in schools give access to such services to children of lower socio-economic background |
| Â | Cosmopolitanism | Â | Number of articles: 11 | Number of articles: 8 |
|  |  |  | • Lack of cooperation between principals and cooperatives providing food products to schools, with the cooperatives being perceived as not reliable, not delivering food on time, and not handling the administration of documents well by principals of schools • Lack of cooperation between teachers and caterers • When suppliers deliver food late, conflict between teachers, suppliers, and those preparing the food • Lack of cooperation between schools in regard to the design and implementation of education-related activities • Partnerships between schools, industry, and vendors on school property, where unhealthy food is made available in return for financial support by industry to schools • Lack of involvement of the health sector in schools • Lack of involvement of schools in decisions by the education sector • When nutritionists not present as an external actor, lack of cooperation between principals, parents, and teachers in monitoring feeding programs | • Cooperation between food kiosks and schools in obesity prevention programs • Cooperation between teachers and caterers • Cooperation between the community and schools in implementing school meals; raising funds for nutrition programs from the community • Cooperation between schools and nutritionists in producing menus for school feeding • Cooperation between the community, schools, parents, and health sector • Cooperation between teachers, parents, cooks, and local cooperatives • Cooperation between schools and health and education sectors in providing nutrition guidance • Cooperation between schools and farmers; produce for schools bought from local farmers • Local women prepare food for schools |
| Â | External policy and incentives | Â | Number of articles: 12 | Number of articles: 5 |
|  |  |  | • No legal sanctions for non-compliance • Schools and principals finding out about guidelines and new food policies either through a simple notice with no added information or from the news • No guidance offered on the implementation • No incentive to implement without additional funding • Industry lobbying against any policies toward sugar-sweetened beverages • Policies allowing industry to donate to schools and get tax incentives • No policies against unhealthy products as they may hurt the economy • Nutrition not a priority for policymakers compared to topics such as sexual health • Farmers facing difficulties in gaining certificates to participate in school feeding • Slow translation of international policies and guidelines into national • Schools for feeding programs chosen based on votes of the region for certain political parties | • Legislation incentivized purchases from farmers • Education government sector taking the lead in introducing nutrition-related programs for children from a poor background • Health government sector taking the lead in promoting school health • Decentralization of meal program enabled the participation of local farmers • Various legislation enabled the participation of local farmers in school feeding • When nutritional security is a priority at the national level, inter-sectoral cooperation and new legislation in this direction introduced • When international programs complementary to national programs, enabled the sustainability of national programs |
Inner setting | Structural characteristics | Â | Number of articles: 14 | Number of articles: 2 |
|  |  |  | • Lack of space for food preparation; lack of a kitchen • Lack of eating area • No food storage facilities • Problematic school structure; small schools • Lack of water and light | • Private schools have more land for planting crops • International bodies (World Food Programme) providing storage boxes • Vegetable gardens on school grounds |
| Â | Readiness for implementation | Available resources | Number of articles: 23 | Number of articles: 4 |
|  |  |  | • Not enough teachers, canteen workers, and external professionals to help with nutrition-related interventions/programs/policies • Capacity building, training needed for various activities (e.g., using school meal planner tools, training for teachers on the management of nutrition program, training for cooks) • No financial resources for some actions (e.g., educational activities) • Rent paid by kiosks (serving unhealthy food) on school property used for different school needs; profit from canteens used for school financial needs (e.g., teacher salaries); school resources coming from industry • Lack of time of the school staff and children (e.g., teachers and children cleaning up, teachers having to attend after-school meetings, monitoring by principals, teaching and nutrition coordination by teachers, eating time for fruit and vegetables) • No training materials • Lack of equipment such as scales and blenders | • Workshops and training provided (e.g., for lunch ladies, cooks, nutrition education for teachers with no such background, instruction on how to incorporate nutrition in the curriculum) • Materials for teachers easing integration of interventions in the curriculum |
Characteristics of individuals | Knowledge and beliefs about the scheme | Â | Number of articles: 8 | Number of articles: 14 |
|  |  |  | • Principals’ and teachers’ belief that children do not like healthy food, fruit, and vegetables • Teachers’ belief that children do not have an understanding about healthy eating • Principals’ belief that family habits shape what children eat, and it is the family’s responsibility to make sure they eat healthy • Teachers belief that parents do not provide nutrition-rich food and lack knowledge of the topic • Lack of knowledge among the school staff (principals, kiosks workers) on existing policies, guidelines as well as nutrition more generally | • School staff’s (principals, pedagogical coordinators) belief that it is possible to change child eating habits in the school setting and that it is the responsibility of the school to do so • School staff’s belief that nutrition food is good for the children and school meal programs are good for the entire community • School staff’s belief that school feeding programs increase attendance and improve grades and discipline • Principals’ and teachers’ belief that school programs can positively change eating habits at home and children may carry them into adulthood • Teachers’ belief that school feeding is a basic human right • Nutrition intervention motivating teachers to improve their own health |
Process | Engaging | External change agents | Number of articles: 16 | Number of articles: 8 |
|  |  |  | • Funds given to cooperatives regardless of work done or problematic documentation submitted • Training to cooperatives limited and without follow-up • No training for family farmers, volunteer cooks, and community members; not informed of the intervention/policy/program properly • When community members involved in feeding programs on a voluntary basis, lack of participation due to challenges with transportation, training, and time • Lack of nutritionists (with the role of monitoring planning execution of school feeding programs); work overload for those nutritionists that were available • National government-level actors (e.g., supervisors from the Ministry of Education) not aware of the roles and responsibilities • Lack of cooperation between government bodies (e.g., health and education) in implementing interventions/policies/programs; each passing the responsibility to the other • Strong industry lobby against any action toward limiting unhealthy food access for children | • When nutritionists available, their role was important in the implementation • Intersectorality (cooperation between different government bodies—e.g., health, education) and cooperation with family farmers • Training for family farmers, cooperatives; family farmers organizing in cooperatives; lobbying for participation in school feeding programs • Advocacy groups with a focus on healthy lifestyles important to bring policy changes • Prioritization of nutrition by government bodies (e.g., education) • Volunteering by community members to contribute to school feeding programs (e.g., members of women’s association preparing meals, village leaders, and midwives monitoring implementation) |
| Â | Â | Innovation participants | Number of articles: 10 | Number of articles: 17 |
|  |  |  | • Children expressed views that healthy food was unappealing and lacked variety • Low participation by children in activities taking place after school hours • Parents informed of interventions/policies/programs through notes, their participation in turn low • Parents not informed of the interventions/policies/programs; not involved in decision-making at the national level and in some cases school level • Generally lack of involvement of parents; when activities available, challenges to participate due to work obligations • Parents perceived vegetables as something you eat when you are poor | • Encouragement, guidance, and motivation of children by teachers during meals; discussing food waste • Children looking forward to school due to the meal; children coming to school early due to breakfast being served • Children with a positive impression of healthy food; belief it is good for health, mood, weight control, and concentration • Educational, group activities and lectures for children and parents (food and nutrition fairs for parents and children) • Child involvement in developing materials; children as change agents for the program; promoting hygiene practices • Parents given a chance to participate in mid-day meal program; invited to cooking competitions; invited to taste the school meal food • Parents’ outreach through social media • Nutritionists speaking to parents seen as helpful • Health experts invited to parent meetings • Positive views toward interventions/policies/programs in particular by parents of a poor background • Improvements in hygiene perceived as a result of intervention/policy/program • Improvement of eating practices at home |
| Â | Executing | Â | Number of articles: 11 | Number of articles: 2 |
|  |  |  | • Late, irregular payment by the government to cooperatives, suppliers, caterers, and farmers • Delayed submission of documentation by principals, delaying payments to suppliers • Various difficulties with the delivery of products, including insufficient quantities • Late deliveries of cooking gas • No enforcement of food policy by principals, so as not to decrease the profit of on-site sellers • No visits by nutritionists implemented • Food committee members responsible for monitoring did not implement visits • Some funds embezzlement by food committee members | • Some positive changes in schools in regard to selling unhealthy foods following food policy at the national level • Hygiene practices implemented as a result of home-grown school feeding program |