A School Based Intervention for Combating Food Insecurity and Promoting Healthy Nutrition in a Developed Country Undergoing Economic Crisis: A Qualitative Study.
| Author | Dalma, A. |
Introduction
Combating food insecurity is a high priority on the agenda of the Development Cooperation Forum of the United Nations (UN 2012). Addressing food insecurity has been identified as the No. 1 Millennium Development Goal (MDG1), and it also has had great impact on MDG4 and MDG5 (reducing the under-5 mortality rate and maternal mortality rate) (UN, 2012). The prevention and treatment of child malnutrition and childhood obesity are strategic priorities both for the World Health Organization (WHO 2013) as well as the Directorate General for Health and Consumers of the E.C. (European Commission, 2010).
According to the European Directorate report on Human Rights, the number of children who are at risk of poverty and social isolation in Europe, and especially in Greece, is continuously increasing due to the economic recession (FRA 2012). In Greece, it is estimated that 686,000 children (35.4%) are facing that risk (UNICEF 2012). The ongoing economic crisis in the country has resulted in increased rates of unemployment, income reduction and economic insecurity, with more adverse consequences in socioeconomically vulnerable areas (EUROSTAT 2014).
According to WHO (2013), adverse economic conditions can lead to poor food choices and eating habits, negatively impacting the health of children and adolescents. It is important to note that, as stressed by OECD (2014), childhood obesity and child malnutrition often go hand in hand. In the past decade rates of childhood obesity have increased globally. Greece currently has one of the highest rates of childhood obesity in Europe, ranking first among the 27 member states in the EU (OECD 2014).Actions targeting both problems childhood obesity and child malnutrition are of crucial importance.
Given increasing concern for children's health, policy measures have been adopted in developed as well as developing countries that involve large-scale governmental or privately funded food aid programs that supplement children's nutritional intake at school (WFP 2013). Among them, the most effective ones were implemented for long periods of time, and included educational lectures and activities to increase diet quality and physical activity, supplied healthy food choices to the institutions, and involved participating children's family members and participating school's staff (Wang et al. 2012).
Evidence suggests that school feeding programs have multiple positive associations including weight reduction in obese children, improved eating habits of students (Doak et al. 2006; Flodmark et al. 2006), reduced school dropout rates and improved attendance (Jukes et al., 2008), improved academic performance (Belot and James 2011), and strengthened communication and trust among educational stakeholders (Rossi et al., 2008). However, research so far on school feeding programs has not included high income countries experiencing prolonged economic recession. Furthermore, there is a need for further research on the aspects of food insecurity and healthy nutrition in schools that are located in lower socioeconomic settings in these countries.
The goal of this study is to qualitatively identify the effects of a school feeding program that take place/realized in underprivileged areas across Greece on students' learning on healthy nutrition, as well as on the social and educational environment of these schools as reported by educators and school principals who experienced the program's implementation. The program was developed to reduce the rates of food insecurity and promote healthy dietary habits for children and adolescents through the daily provision of a free, healthy mid-day meal in schools located in underprivileged areas of Greece. Qualitative research that was conducted in similar interventions in the US and the EU, revealed the negative impact of social prejudice and stigmatization on students' participation, the important role of parental influence on children's eating habits as well as the learning potential and the pedagogical aspects of such programs (Bailey-Davis et al. 2013; Slusser et al. 2011; Benn and Carlsson 2014). In the present study, focus group methodology was adopted, allowing for a deeper understanding of socially shared knowledge--experiences and views--of the target population on students' food insecurity and healthy eating as well as on aspects of the implementation of a school feeding program in a developed country currently undergoing a severe economic crisis (Rabiee 2004).
Methods
The program on food aid and promotion of healthy nutrition--DIATROFI
The Program on Food Aid and Promotion of Healthy Nutrition, "DIATROFI" has been implemented since 2012; it targets students attending both elementary and secondary schools in areas of low socioeconomic status (SES). Postal codes with an average per capita income, as depicted in the taxable income database of the Greek Ministry of Finance, below specific standards were considered areas of low SES. In particular, schools were categorized in three major regions, Attica, Thessaloniki and the rest of Greece. Different conditions were set by region, so as to cover approximately 25% of Greek public schools. After establishing initial contacts with all schools in low SES areas; a total of 347 schools' principals, corresponding to 60,074 students, declared their willingness to participate for the 2012-2013 school year and completed the relevant application form.
Depending on funding availability, a set of criteria was used to prioritize the applied schools. These included (a) regional taxable income, (b) regional unemployment rate, (c) written reports by school principals providing estimates of the number of students facing food insecurity and special characteristics of schools (i.e. students from social institutions, Roma students, fainting episodes), (d) food insecurity measurements available from the previous school year, and (e) personal interviews with teachers, parents and other school personnel, conducted by an expert in qualitative methodology, to weigh the level of food insecurity in the school. During 2012-2013, 136 schools with 23,044 students were finally selected to participate. All students of participating schools were offered the opportunity to receive the free meal, irrespective of their socioeconomic status, so as to avoid stigmatization. Parents who did not wish their child to participate provided a signed statement; only 2% opted not to participate.
Each student received, on a daily basis, a meal in a box, designed by nutrition specialists so as to cover 25%-30% of children's daily requirements in terms of energy, with the exclusive use of olive oil. The meal included every day a cereal-based food item (sandwich made with cheese and either vegetables, egg or chicken; or a spinach pie), three times a week pasteurized white milk (2.5-2.8% fat content) or yogurt with honey, two times a week cheese (as a part of the sandwich or pie), and every day fresh seasonal fruit. All program participants received the same foods; however, meals distributed to children and adolescents were different in terms of quantity, in order to satisfy age-specific energy needs. Moreover, students of the participating schools are responsible for the daily distribution of the healthy meals. Two students in each class are selected each day or week to distribute the meals to their classmates. Focus groups were conducted to explore parents' attitudes towards healthy eating, their children's attitudes, the free provision of a daily school meal and other initiatives in the context of school, family and the community. In the present analysis we report the results of the focus groups conducted on both school principals and educators in Elementary and Junior High schools.
Focus group methodology
Focus groups were conducted during 2012-2013 school year with two researchers present: the moderator, who posed the questions and monitored the conversation, and the assistant moderator, who was in charge of the recording equipment and kept notes of the participants' responses. All group discussions were recorded and subsequently transcribed, using the assistant moderator's notes when needed. Before initializing the discussion, the moderator explained the nature of the study. The duration of each focus group was 60-90 minutes. Participants provided their consent for themselves. The study procedures were officially approved by the Institute of Educational Policy that operates for the benefit of public interest as an executive scientific body supporting the Ministry of Education and Religious Affairs for scientific and research issues related in primary and secondary education.
Focus groups participants
Eligible participants in the focus groups included school principals and educators in elementary and junior high schools that participated in the program in the areas of Attica (where Athens the capital of Greece is located) and Thessaloniki (the second largest city in Greece). To recruit participants initially, 24 of the participating elementary schools and 24 junior high schools in Attica as well as 12 elementary schools and 6 junior high schools in Thessaloniki were randomly selected. School principals were informed about the aims and the procedure of the study, in person and through an information letter. They were asked to inform all educators about the study aims and provide them the informative letter as well. To avoid selection bias, announcements were also posted in the educators' offices at each school, containing information about study aims and the procedure of focus groups. During recruitment many educators and few school principals reported time constraints. The focus groups were held in the school premises of one elementary and one junior high school in Attica and Thessaloniki respectively, which were randomly selected and were willing to host the specific activity.
Focus groups were conducted until saturation was reached...
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