Increasing the implementation of vegetable and fruit breaks in Australian primary schools

Background and aims: Identifying strategies to increase children’s vegetable and fruit intake at a population level is a key strategy in the World Health Organization's Global Strategy on Diet, Physical Activity and Health. Schools are recommended settings in which population-wide vegetable and fruit interventions can be delivered. This thesis aimed to: 1. Review, systematic review evidence regarding the effectiveness of school-based vegetable and fruit programs in increasing children’s consumption of vegetables and fruit. ; 2. Describe school Principals’ attitudes and reported barriers to the implementation of vegetable and fruit programs in Australia; the prevalence of vegetable and fruit programs in Australian schools; and the school characteristics and implementation strategies associated with school vegetable and fruit programs. ; 3. Assess the effectiveness of a multi-strategy intervention in increasing the implementation of a vegetable and fruit program by a population of primary schools. ; 4. Describe schools’ implementation of vegetable and fruit programs and other healthy eating and physical activity practices across an eight-year period, and to determine if their implementation varies according to the size, geographic or socio-economic location of schools. ; 5. Provide recommendations for future research and practice regarding increasing the implementation of vegetable and fruit programs in primary schools. Results: A synthesis of systematic reviews found that school-based vegetable and fruit programs could have a modest impact on children’s combined vegetable and fruit intake by approximately +0.25 serves per day. A cross-sectional survey of New South Wales school Principals found that only 40% of schools in 2008 were implementing a vegetable and fruit program to the recommended level. The thesis then demonstrated in a quasi-experimental study involving 828 schools that a multi-strategy intervention can significantly increase the implementation of a vegetable and fruit program to the recommended level (intervention vs comparison (OR 2.36; 95 % CI 1.60-3.49, p<0.001). Finally, using a longitudinal cohort study with 476 New South Wales schools, the thesis found that, over an eight-year period, the implementation of vegetable and fruit programs by schools increased, as did other healthy eating practices whilst some physical activity practices did not significantly improve. Conclusion: The thesis provides new evidence and methods on how to implement vegetable and fruit programs in a population of schools. Furthermore it demonstrates a need and opportunity for public health policy makers and practitioners to adopt such strategies to enhance the implementation of vegetable and fruit programs in primary schools.