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Executive Summary

The present study is an Evaluation of Tayside Primary Schools’ Health Programmes. Particularly, it is a comparison against the core interventions of the FRESH Framework. Using stratified random sampling, 22 school personnel participated in the study. The results of the research suggest that there are differences between the perceptions of school personnel and students in terms of  the components of the FRESH framework, as well as their engagement to their school’s health services programmes. Specifically, it has been shown school personnel seem to have more favourable perceptions of the programme components compared to students. The degree of health policy development within each school is reflective of the pressures for change and its motivation to establish health tenets which will serve as guideposts for students, parents, and staff.  The management of Tayside schools ought to ensure that support and advocacy for their health policies are ingrained in both school staff and students who may synergistically work towards the success of its implementation.

An Evaluation of Tayside Primary Schools’ Health Programmes: A Comparison against the Core Interventions of the FRESH Framework

Introduction

The FRESH framework represents cooperation among different sectors to be able to “Focus Resources on Effective School Health”. It is a staunch lead in the effective promotion of health school policies.  One of its key principles is that all schools and its students deserve good health, and this thrust is possible only with the following strategies: “1) the provision of safe water and sanitation; 2) skills based health education; 3) provision of health and other services; 4) effective referral to external health service providers; and 5) links with the community” [1

The FRESH framework adequately reinforces the role of collaborative partnerships to ensure the success of school health programmes. Some sectors that may be partnered with include health and education, faculty, health personnel, students, and other parties who may help in the effort. Some of the benefits that may be yielded from an effective school health programme has direct positive implications on academic activity, encompassing improvement in enrolment rates; decrease in absenteeism; and a reduction in discriminatory practices against marginalized students [1].

The study has been carried out to determine the perceptions of school personnel on the effectiveness of their school’s health programmes. The framework against which these perceptions shall be compared is FRESH or Focusing Resources on Effective School Health. All primary schools within the Tayside area are eligible to participate in the study. However, the respondents who shall be purposively chosen, should meet the inclusion criteria of the research. In a nutshell, the core of the study would involve determining whether the school based nutrition services of the school health programme in Tayside are synchronized in letter and spirit with the parameters defined by the Focusing Resources on Effective School Health (FRESH).

The study would be limited only to an evaluation of their nutrition services; thus, other health programmes is not within the scope of the study. The research is carried out with the intention of enhancing school policy related to health services, and for drafting initiatives which may enhance the deployment of associated programmes.

Review of Related Literature

The Importance of Policies in Change Management

In the past two decades, there has been substantial research dedicated to change management amongst schools. For instance, the school improvement route has been proposed by Beare, Caldwell, & Millikan [2], Stoll & Fink [3] and Stoll [4] , which has been strongly founded on a holistic view of the school as a system; thus, human resource management interventions may then be used as a channel through which eventual school improvement may be achieved. Everard and Morris [5] have used the initial framework of Adair, prescribing management to secure objectives. This is carried out through leaders introduction of change who are equipped with the skills and competencies called for to enact change throughout the whole system. Contemporary work in 25 secondary learning institutions in the Midlands region of the United Kingdom, has accorded proof of how the change in one component of school culture has yielded various degrees of effectiveness and success. The potency of change has been assessed by demonstrating an association between change management and the results based on the perceptions of student respondents. Such empirical proof has also resulted into a consideration of qualitative data on the significance of overall school culture and particular policies in implementing change.

The root or origin of policies is reflective of the distinct management culture of a school. School staff have unique views on the need for change and in exploring their perceptions of the existing degree of anti-social behaviour among students. The more that change lends itself more easily to measurement, it is more probable that members may be convinced of the effectiveness of new policies [6].

Fullan and Hargreaves [7] purport that at the initial stage of formulating policies, the conventional reason is to provide a benchmark for acceptable behaviour within the school context. Other reasons cited for policy formulation is practically reacting to external pressures, and in such a case, initiated and lead by senior management. The required response to direct pressures compelled by legislation is prescribed by Bowe & Ball [8]. In essence, schools do not have a choice except to introduce policies to comply with legislation. Indirect pressures from legislation have caused schools to reassess their response to anti-social behaviour because they aspire to project a good image towards prospective students and their parents. The most commonly cited reason for policy formulation is to establish best practices within the school and to respond to media attention which have tackled health issues. Modifications in the management of a particular aspect of school life has been tagged thus – ‘policy’. However, in general, qualitative evidence suggests the policy makers’ acknowledgement of the contribution of behaviour in overall school improvement, as what has been documented in the Elton Report [9].

The current paper focuses on the effectiveness with which school health programmes are implemented from the introduction of related policies, provision of safe water and sanitation, skills based health education, and access to health and nutrition services. The following section discusses the FRESH framework in greater detail.

The Hungry for Success Health Promotion Framework

Hungry for Success represents Scotland’s promotion of holism in approaching both schools and children. Its dream is to optimise the servicing of meals within Scotland schools and puts forth suggestions of integration of health promotion within the curricula of these learning institutions. It is actually an initiative of the Deputy Minister for Education and Young People, Susan Deacon. The programme basically aims to enhance the “provision, presentation and nutritional content of school meals for all Scotland’s children” as a means of improving their overall well-being [10].

It is said that Scotland has one of the gravest problems of tooth decay as per 1999 to 2000 records, which signifies deprivation among its youth. In addressing the problem of poverty, the Ministry says that it aimed to make a dent by according these children with the best that life can offer – starting with the maintenance of good health. The Food in Schools Conference in 2001 has set the stage for the formulation of an encompassing strategy which targeted the nutritional content of meals offered in schools.  The call of the day was the finalisation of meal standards [10].

Setting Nutritional Standards for School Lunches

In drafting the nutritional content standards of school lunches, the programme has considered several facets. Eating for Health depicts the proportion of the child’s diet that should be sourced from each of the following five food groups: 1) bread, other cereals and potatoes, 2) fruit and vegetables,  3) milk and dairy foods, 4) meat, fish and alternatives, and 5) foods high in fat, foods and drinks high in sugar. Appendix A, B, and C have been directly quoted from http://www.scotland.gov.uk/library5/education/hfs-03.asp and these show the menu planning by food group and the nutrient standards for school lunches for pupils in primary schools [11].

On the aspect of portion sizes, it is suggested that there be bigger proportions of carbohydrate-rich food, fruits and vegetables be provide in compliance with national nutrient standards. Next, there are product specifications that shall assist in the finalisation of nutrient standards of the food offered in the market. Moreover, drinking water should likewise be made available, in the right amounts and served in sanitary cups or glasses in a hygienic room. Likewise, it emphasizes that it is the accountability of the whole learning community to advocate the apt choices of food and drink, recommending their awareness, access, availability, acceptability, and affordability. There should also be provisions for special diets, allergies, diabetes, and youth with special needs. One of their recommendations is for schools to ensure that the Scottish Nutrient Standards for School Lunches be established in “all special schools and primary schools” by December 2004. On the other hand, it has allotted two more years for secondary learning institutions [9].

Reduction of the Stigma in School Meal Settings
One other thrust of the Hunger for Success framework is the reduction if not total eradication of the stigma in the setting in which meals are consumed. This thrust incorporates the following principles: 1) positive school/whole child ethos, 2) partnership working,  3) importance of pupil consultation, 4) eliminating stigma, 5) managing the process, 6) incentives to improve uptake of school lunches, and 7) influencing choice [9].
Along these, it is recommended that all schools evaluate their present practice in forming meaningful associations between learning and teaching that are related to healthy eating. The curriculum and the manner in which the school provides food. One other recommendation is for the Scottish Health Promoting Schools Unit to integrate the suggestions of the panel when crafting their standards for health promoting schools. To encourage partnerships, it is suggested that the management of schools advocate such affiliations and supporting mechanisms for sustainability. Moreover, they should collaborate with students constantly to gain feedback about the effectiveness with which meals are provided. One other recommendation is to put high premium in ensuring the anonymity of the programme beneficiaries, through the development of an efficient ticketing or multiple use-card systems. There should be adequate, easy to access validators for the latter. Apart from these, there should also be a thorough review of seating and queuing practices. There must be sufficient importance placed on lunchtime in reviewing the structure of the school day. There should also be supervisors within the dining area. Finally, senior management is encouraged to support the “whole-child approach”.  The appropriateness of the food chosen by a child may be affected by his health knowledge; the latter may be influenced through food presentation, labelling, pricing, and effective marketing. One recommendation states that proper food labels be made for the benefit of both students and their parents. In addition, menus should be consulted with parents on a regular basis. The programme likewise suggests that the ambience of the dining room be improved to make it more conducive to healthy eating habits. Moreover, the dining room should be integrated into more encompassing state planning. The ideal set-up is one in which there is a distinct and separate area for this purpose, where facets such as furniture design and décor have been finalized with students’ input [9].

The programme has been allotted an additional £70 million support by First Minister Jack McConnell who advocates the thrusts put forth by the framework, including food education, the advocacy of school meals and the increased consumption of fruit and milk (i.e. low fat).  The 32 councils of Scotland have been partners in the programme [9].

For its part, UNISON Scotland has expressed its stance to the Communities Committee on the Schools health promotions and nutrition (Scotland) Bill; the response is noteworthy since the group has more than 150,000 members who are affiliated with the Scottish Health Service. Some of them are directly involved in the provision of meal services in schools and could help in the effective promotion of the principles of Hungry for Success. They have explicitly said in their response that there ought to be global, free school meals, which they deem as a potent way for addressing the grave problem of health and diet among Scotland’s youth. To ensure this, there ought to be adequate and competent staff, and facilities for the provision of free meals country-wide Call for evidence: Schools (health promotion and nutrition) (Scotland bill) [11].

Progress of Implementation
The following report presents the results on the progress of the implementation of Hungry for success along the following principles of the programme: 1) positive school / whole child ethos, 2) partnership working, 3) pupil consultation, 4) eliminating stigma, 5) managing the process, 6) influencing choice and 7) incentives to improve uptake of school lunches. The programme has been monitored by the HM Inspectorate of Education (HMIE) beginning September 2004. By June of 2005, there have been 33 primary schools and 6 special schools in 27 various domestic areas have undergone the exercise. It is worthy to note that the deployment in secondary schools was last month, that is, December of 2006 [13].
Briefly, the monitoring of the programme has suggested that several schools have been referring to the Hungry for Success guidelines or the food group principles in going about their menus, whilst anticipating the issuance of the H4S nutrient analysis software by the Scottish Executive which will permit them to have menus that are compliant with the Scottish Nutrient Standards. All of the schools have manifested compliance with the latter despite the absence of the software. Moreover, progress monitoring results have shown that there has been particular difficulty in achieving the expectations set for iron and sodium, but Hungry for Success has definitely helped in resolving this issue and this is expected to improve even further with the issuance of H4S software. Majority of the schools express that food quality is commendable and that there has been noteworthy efforts to improve of late. This sentiment has likewise been shared by students. There is a need to investigate issues regarding the transport of food, which includes temperature and quality, among others [13].

Food quantity was sufficient in most of the schools, but there have been issues that arose as a result of the changes proposed by Hungry for Success with regards to portion size. One reason for not feeling full is students’ choice to consume their allotment; on the other hand, there is also a risk of taking up too much especially in those schools which offered second helpings. The offering of home-baked items, crisps and beverages is not suggested as these discouraged students from consuming their food in full.  Bread of high quality has also been offered in majority of the schools. It has also been noted that table salt has been taken away by most schools, but may be availed of upon request. The increased orientation of the students with new menus was associated with the decline in the amount of food waste [13].

Some schools ensured that all related staff were informed of students who had special diets and allergies, and majority of schools had provisions for meeting the food requirements of these groups. However, the need to train catering staff on special diets needs to be focused on. There has also been staff training on Hungry for Success, which were primarily in the form of cascade sessions by their LAs on the framework.

The following are the recommendations put forth as a result of these inspections:

1)      To sustain best practices which have been pointed out and to maintain the provision of high quality food among all LAs and schools;

2)      To ensure the enhanced consumption of school meals and to guarantee healthy food choices among pupils;

3)      More collaborative partnerships with parents on school food-related issues; and

4)      Testing stringent self-evaluation on the efforts to enhance school food.

[13].

In Focus: The FRESH Framework
The FRESH framework represents collaboration among various sectors to be able to “Focus Resources on Effective School Health”. It spearheads an advocacy for effective health school policies.  The program works under the assumption that all schools and its students deserve good health, and this thrust is possible only with the following strategies: “1) the provision of safe water and sanitation; 2) skills based health education; 3) provision of health and other services; 4) effective referral to external health service providers; and 5) links with the community” [1].

The FRESH framework sufficiently emphasizes the role of collaborative partnerships to ensure the success of school health programmes. Some sectors that may be partnered with include health and education, faculty, health personnel, students, and other parties who may help in the effort. Some of the benefits that may be yielded from an effective school health programme has direct positive outcomes on academic activity, encompassing improvement in enrolment rates; decrease in absenteeism; and a reduction in discriminatory practices against marginalized students [1].

Core Interventions of FRESH

Health-related school policies. The rationale for citing health-related school policies as a core intervention for FRESH is anchored on the clear, positive advantages it may garner. These include advocacy for the general health and nutrition of children. In fact, the FRESH framework is not constrained to physical health; instead, it covers psychosocial issues as well, such as “abuse of students, sexual harassment, health-related practices of teachers and students, school violence, bullying, and guaranteeing the further education of pregnant schoolgirls and young mothers, to help promote inclusion and equity in the school environment” [14]. These policies have increased potency if deployed with extensive involved across school, national, regional, and even national levels.

Provision of safe water and sanitation. The FRESH schools website [15] expresses that amidst all the advances in technology in contemporary years, there still remains over 2 billion individuals who do not have access to sanitation facilities. The situation is as worse as not having the resources for simple washing of hands and similar primary hygiene practices. These shortcomings have far reaching implications, and may even be a cause of mortality, caused by diarrhoea, and worm infections, among others. These have the gravest impact on infants, and yet its implications extend to school age children even until the teen years [15].

The FRESH framework takes on increased importance with the acknowledgement that these diseases may be prevented through proper sanitation and hygiene. However, change does not take place with a simple structural change in the form of policies – these require attitudinal and behavioural change as well, from all parties involved in the health effort. The availability of sanitation facilities is a basic right that is critical tot eh maintenance of health and recognition of human dignity [15].

Skills based health education. The third core component of the FRESH framework is the provision of skills based health education. It is important for school personnel and students to be equipped with the skills necessary for the following: “HIV/AIDS prevention, reproductive health, early pregnancy, violence, tobacco and substance abuse” [14]. There are a host of factors that allow these diseases to proliferate, including the behaviour of the child himself, pressure from friends, cultural background, upbringing, and dysfunctional friendships.

This component also emphasizes that knowledge alone may not be sufficient in promoting health effectiveness, thus the rationale for a skills-based approach [14]. Hubley [16] asserts that disease information alone does not effectively lead to modification of behaviour. In other words, a change in cognition – that is, increased knowledge, does not immediately translate to a change in behaviour [17]. For this task, a skills approach is deemed more effectual.

Access to health and nutrition services. FRESH asserts that school health programmes are an effective means of connecting the factors of “health, education, nutrition, and sanitation.” The UK takes pride in having a highly skilled workforce within schools and which have meaningful partnerships at the local level [18]. This component of school-based health and nutrition services encompass disease screening, provision of self-administered medicine and treatments, administration of parasitic treatments, health advice, and referral to medical and community services. Ultimately, the aim is to enhance the health and nutritional state of children [19]. This component shall increase in effectiveness only when delivered alongside the other three components of school health policies, provision of water and sanitation facilities, and skills based health education [19].

Statement of the Problem

The following problem is addressed in the paper: Are the health services and programmes of Tayside primary schools compliant with the standards prescribed by the Focusing Resources on Effective School Health (FRESH) framework?

The following subproblems were answered by the present research:

1)      What is the current level of effectiveness of Tayside primary schools’ health services based on the perceptions of its school personnel in terms of the following:

a)      Understanding the school health programme

i.)      Knowledge of the school health programme

ii.)    Extent to which the programme adapts to new requirements

iii.)  Degree to which the programme makes a difference in children’s lives

iv.)  Effect of the programme on the academic activity of the children

v.)    Social impact of the programme

b)      Basic framework

i.)      Effectiveness of health-related school policies

ii.)    State of water and sanitation facilities

iii.)  Teaching of new skills to children as part of health education

iv.)   State of health and nutrition services

c)      Supporting activities

i.)      Partnership with a local health worker through the school

ii.)    Community partnerships for the same purpose

iii.)  Pupil participation and awareness as a result of the programme

2)      What areas for improvement may be worked on to increase Tayside school’s compliance to the FRESH framework?

Methodology

In this section, the approaches and the research techniques used for the research are investigated and rationalised. The following sections are presented in the methodology: research approach, research strategy, research design decision, chosen research style, questionnaire design, and method of data analysis.

Research Approach

Cohen & Manion [20] has described deductive research methodology as a process of arriving at conclusions through an interpretation of data results or outcomes. In accordance with the research objective, the deductive approach will be used in this research. Saunders, et al [21] defines that deductive approach is use the identified theories and issues to test the obtained data. From the deductive approach researchers could develop a theoretical and conceptual framework during the process of testing the using data. In this method a concept/theory (hypothesis) is formulated before it is put to test through empirical or real world observation. The researcher has used the deductive research methodology for the purpose of this study. The researcher has drafted an instrument for data gathering based on the FRESH framework and has gathered primary data to be able to deduce valid conclusions on the degree to which Tayside’s schools comply with the prescriptions of this framework.

Research Strategy

The case study approach will be used in this research focusing on the perceptions of school personnel on the health services of their school. Robson [22] defines a case study as ‘a strategy for doing research which involves an empirical investigation of a particular contemporary phenomenon within its real life context using multiple sources of evidence’. The case study approach also has considerable ability to generate answers to the question “why?” as “how”? Questions may be addressed through survey methods. It may include questionnaires, interviews, observation, documentary analysis and questionnaires [22]. Data that have already been collected for some other purposes, perhaps processed and subsequently stored, are termed secondary data [21].

In carrying out the case study, survey questionnaire were deployed. The use of quantitative methods have a number of attractions for the inexperienced researcher. The main attraction is that they appear to be clearer cut, with more obvious boundaries around the data collection phase. However, there are also disadvantages. To meet the requirements of the underlying philosophy of this approach the research instrument must be scientifically respectable. Malhotra & Birks [23] make the point that the development of the research instrument must incorporate ‘rigorous design, administrative control and clerical accuracy’. Also, if there is to be any subtlety of analysis it will be necessary for the research to be moderately large scale. Easterby-Smith et al [24] suggest samples of 100’s or 1000’s are required if reliable results are to be produced. It is suggested by Easterby-Smith et al [24] that the quantitative philosophy leads to a preference for the use of written multiple choice questionnaires and surveys, and the statistical analysis of the results.

Research Design Decision

The quantitative method. In a quantitative study, the researcher is interested in collecting evidence so that a statement can be made about the outcomes of broadly comparable experiences. Researchers using this approach adopt an objective (or positivist) approach to the social world [20]. The philosophy of this approach is that knowledge and facts are objective and that complex problems can be best understood if they are reduced into simpler component parts, [24]. This perspective expresses itself most forcefully in a search for universal laws which explain and govern the reality which is being observed [25].

The qualitative approach. In a qualitative study the researcher is not so interested in obtaining a set of facts, but is more interested in gaining an insight into a perspective. Researchers using this approach adopt a more subjectivist approach to the social world [26-27].The philosophy of this approach is that knowledge and facts are subjective and that problems cannot be fully understood in isolation. It is important that problems are viewed as part of a complex pattern of links and relationships [24].

The main advantages of the qualitative approach is that it is intensive but flexible. Small samples, even single cases, may be sufficient, as long as they are investigated in depth and over a period of time [24]. This has obvious attractions for the under- resourced, single-handed researcher. However, there are also disadvantages to this approach. They explain that qualitative methods are slow and may create anxiety because of the lack of structure in the research design. The more participative and reflexive style of this approach means that the research is more likely to invade the researcher’s way of life.

Chosen research style. The focus of this study is to investigate the perceptions of school personnel on the effectiveness of their school’s health services, using the components of the FRESH framework as a template. The quantitative approach was used in investigating the current topic. There are some considerations in adopting a quantitative data gathering technique through the use of survey questionnaires. In addition, a semi-structured interview has been drafted to supplement the data from the survey.

Survey questionnaires that have been deployed for research have two specific objectives. One is they quantitatively depict certain facets of the group being investigated. The analysis of the questionnaires may be mainly focused on associations between variables or with making estimates in a descriptive manner to a well defined group of respondents. Next, it is also an effective means of gathering data by soliciting individual evaluations through predetermined items or questions. Their responses, which may pertain to their own views compose the data set subject for statistical analysis [27].

Questionnaire Design

The questionnaire has been self-constructed, dealing with evaluations of the different core components of the FRESH framework, as follows: 1) Health-related school policies; 2) Provision of safe water and sanitation; 3) Skills based health education; and 4) School based health and nutrition services. In addition, perceptions on supporting activities were also assessed including the following: 1) Effective partnerships between teachers and health workers and between the education and health sectors; 2) Effective community partnerships; and 3) Pupil awareness and participation.

These close-ended questions had fixed options given for each, and the respondent simply checked which option/s are applicable for him/her. Close-ended questions are questions that the researcher provides, and which may be accomplished by putting a check mark on a box or by encircling a response that corresponds to your choice. Oppenheim [28] suggests these questions are straightforward and thus easier and quicker to answer; they are very useful in testing specific hypothesis. Most probably, they shall be utilized in the beginning of the investigation, since the unrestricted responses they attract create a better picture of the survey for the researcher. The main advantage of this kind of question is its ability to obtain a summated value.

As Easterby-Smith [24] suggests that mail questionnaire is a predetermined set of questions that is sent to a predetermined sample. Its advantages over other methods include its low price, reassured anonymity, confidentiality, its large target scope and its ability to keep certain standards. Mail questionnaires are advantageous when responses have to be obtained from a sample that is geographically dispersed, or it is difficult or not possible to conduct telephone interviews to obtain the same data without much expense. Respondents can take more time to respond at convenience. However, the return rates of mail questionnaires are typically low. A 30% response rate is considered acceptable. Another disadvantage of the mail questionnaire is that any doubts the respondents might have cannot be clarified. Another disadvantage is the restriction to verbal behaviour; answers must be accepted as written without the benefit of additional explanations which interviewers could obtain by probing questions, and overall lack of control on the settings of the research. Because of these constraints, the researcher decided to personally administer the tool to the respondents.

One other option that has been considered was the self-administered questionnaire. There are some strong advantages that set out the self-administered questionnaire over other data collection techniques [29]. When compared to the mail questionnaire, the chosen method secures a higher response rate and costs less. The first of these advantages can be attributed to the fact that it is handed out in person, and that the interviewer is present. As a result, the overall atmosphere is warmer, friendlier and less impersonal. Additionally, because of the presence of the interviewer, the participants are accorded a wider scope of clarity. If anything is not clear in the questionnaire, the researcher can clarify a particular question, achieving a higher degree of accuracy and consequently more reliable responses. With regard to the second advantage, this method can be followed at a comparatively low cost, as there is no demand for trained staff but solely the cost of printing the actual questionnaire forms. It was finally decided that this type of survey questionnaire be used.

A pilot study has been conducted with 2 students and 2 faculty to countercheck the comprehension of the interviewees of the research topic and the interpretation of its items. The respondents are asked to answer and comment on the questions. Based on their feedback, some changes are made to the questionnaire to improve the questions considered to be biased so that they would generate more honest and accurate answers. This piloting reveals that the duration necessary for accomplishing the survey shall not be over 10 minutes for each respondent.

Respondents and Sampling Plan

All primary schools within the Tayside area are eligible to participate. Parent-and-community committees, as well as school principles, received a letter explaining the aim of the study and asking permission to evaluate their health programs. For this exploratory study, only year 6 students were asked to participate.

A parental consent form was issued to all students, and those who return their forms were able to take part. The consent form will provide contact details of the primary researcher. Also, the form outlined participant rights, such as voluntary participation, withdrawal without penalty, and anonymity through the use of participant numbers. Participants were assured of secure storage of all data relevant to this study, and that after 5 years the data will be shredded. These ethical precautions are necessary because some student demographics need to be collected as control variables, including, socio-economic status, ethnicity, gender and age.

No incentives were provided for participation in this study. All results were shared with the students, their parents and the schools, to contribute to their policy reviews.

Procedure

Primary data and secondary data will used in this research. Collecting the primary data the researcher will be able to gather updated and relevant information [30]. The researcher can gather primary data by distributing a self-constructed questionnaire and conducting interviews. Questionnaires are an inexpensive way to gather data from a potentially large number of respondents. Often they are the only feasible way to reach a number of reviewers large enough to allow statistically analysis of the results [31].

Secondary data were gathered from text books, online sources, magazines and journals. Primary data were gathered through the use of a self-constructed Tayside Health Services Evaluation Questionnaire (see Appendix A and B). This will have multiple items, pertaining to the components of the FRESH framework. The tool shall undergo content validation and pilot testing prior to deployment.

Stratified random sampling shall be used to select school personnel and students who shall be eligible to participate in the study. Overall, there were 22 teachers and school personnel who served as sample. The following are the inclusion criteria for school personnel: 1) Tenure of at least 3 years in the school; and 2) willingness to participate in the study.

The researcher has called prospective respondents and have given them a copy of the self-administered questionnaire once they have expressed willingness to participate in the study. They were informed that the results of the study shall strictly be used for academic / research purposes. Due to time constraints, the time frame for deploying the instrument and collating the data through phone interviews is limited to 2 weeks. On completion of the study the respondents were thanked. They were informed that results may be made available to all of them following submission of the paper. The accomplished surveys were collated, tabulated and statistically analyzed.

The following schedule has been followed in undertaking this research:

Literature review

Primary data gathering

Documentation

Write up of results and discussion

Method for Data Analysis

The researcher used SPSS (Statistical Package for Social Sciences) software to process and analyse the data gathered from questionnaire. Frequency distributions were presented to show the demographic characteristics of the respondents. The t-test for two independent samples shall be used to compare the averages of school personnel and students. These prospective differences in perceptions may have important policy implications [27]. Recommendations on how the schools may be able to improve their level of health services have been put forth.

Results and Discussion

The following results were culled from the survey questionnaires deployed to the various schools at Tayside.

Table 1. Knowledge about the school health programme.

Response
Frequency
Percentage
Mean
Very Good
9
40.91%
3.41
Good
13
59.09%
Fair
0
0.00%
Unsatisfactory
0
0.00%
Total
22
100.00%

Table 1 shows that 41% of the respondents say that they have very good knowledge of the school health programme; while the remaining 59% state that they rate the school health programme as good. The mean for knowledge on the school health programme is 3.41, which is substantively interpreted as good.

Table 2. Extent to which the programme adapts to new requirements.

Response
Frequency
Percentage
Mean
Very Good
5
22.73%
3.00
Good
12
54.55%
Fair
5
22.73%
Unsatisfactory
0
0.00%
Total
22
100.00%

On the extent to which the programme adapts to new requirements, majority of the respondents at 55% say that their school programme is good in this aspect, while equal percentages of 23% say that their programmes are either very good or fair in this facet. The average for the extent to which the programme adapts to new requirements is 3.00 which indicates that overall, Tayside schools are able to adapt to new requirements.

Table 3. Degree to which the programme makes a difference in children’s lives.

Response
Frequency
Percentage
Mean
Very Good
0
0.00%
2.86
Good
19
86.36%
Fair
3
13.64%
Unsatisfactory
0
0.00%
Total
22
100.00%

On the degree to which the programme makes a difference in children’s lives, most of the respondents (86%) say that their school programme is good in making such a difference among its pupil’s lives. The remaining 14% say that their programme is fair in this facet. The mean of the item is 2.86, which indicates that in general, Tayside school health programmes are good in making a difference in children’s lives.

Table 4. Effect of the programme on the academic activity of the children.

Response
Frequency
Percentage
Mean
Very Good
5
22.73%
3.14
Good
15
68.18%
Fair
2
9.09%
Unsatisfactory
0
0.00%
Total
22
100.00%

When gauging the effect of the school health programme on the academic activity of the children, majority of the respondents at 68% say that their school health programme had good impact on this aspect, while 23% expressed that it had very good impact. The remainder 9% said that their programme had fair effect on the students’ academic activity. The mean of 3.14 suggests that overall, Tayside school health programmes were good in terms of its positive effect on the academic activity of students.

Table 5. Social impact of the programme.

Response
Frequency
Percentage
Mean
Very Good
7
33.33%
3.10
Good
10
47.62%
Fair
3
14.29%
Unsatisfactory
1
4.76%
Total
21
100.00%

On the assessment of the social impact of the programme, the majority of respondents (48%) said that their school health programme had good social impact, while a substantial 33% expressed that these had very good social impact. 14% evaluated the programmes as having fair impact while a minority 5% said that these had unsatisfactory social impact. The mean for the item is 3.10, which indicates that overall, Tayside schools’ health programmes were good in terms of their impact to society.

Table 6. Effectiveness of health-related school policies.

Response
Frequency
Percentage
Mean
Very Good
4
22.22%
2.89
Good
8
44.44%
Fair
6
33.33%
Unsatisfactory
0
0.00%
Total
18
100.00%

The next item was on the effectiveness of health-related policies, which was rated as food by 44% of the respondents. 33% rated their policies as fair, while 22% said that these were very good. Overall, the rating for this item is 2.89, which suggests that overall, Tayside schools’ health-related school policies are good.

Table 7. State of water and sanitation facilities.

Response
Frequency
Percentage
Mean
Very Good
1
4.76%
2.24
Good
9
42.86%
Fair
5
23.81%
Unsatisfactory
6
28.57%
Total
21
100.00%

On the presence of water and sanitation facilities, majority of the respondents at 43% assessed these as good, while a significant percentage at 28% rated this as unsatisfactory. 24% evaluated water and sanitation facilities as fair, while there is a small minority at 4% who rated these as very good. On the whole, the mean rating of 2.24 indicates that overall, the water and sanitation facilities of Tayside schools have a fair status.

Table 8. Teaching of new skills to children as part of health education.

Response
Frequency
Percentage
Mean
Very Good
1
5.00%
2.40
Good
9
45.00%
Fair
7
35.00%
Unsatisfactory
3
15.00%
Total
20
100.00%

Table 9. State of health and nutrition services.

Response
Frequency
Percentage
Mean
Very Good
0
0.00%
2.52
Good
11
52.38%
Fair
10
47.62%
Unsatisfactory
0
0.00%
Total
21
100.00%

When the respondents were asked to rate the state of their health and nutrition services, majority of them at 52% said that their health and nutrition services were good, while 48% said that such services were fair. The mean of 2.52 (when rounded off) suggests that the state of health and nutrition services at the Tayside region is good.

Table 10. Partnership with a local health worker through the school.

Response
Frequency
Percentage
Mean
Very Good
5
31.25%
3.00
Good
7
43.75%
Fair
3
18.75%
Unsatisfactory
1
6.25%
Total
16
100.00%

44% of the respondents said that the partnership of the school with a local health worker was good, while 31% assessed it as very good. 19% of them said that it was fair, while a minority 6% evaluated it as unsatisfactory. Overall, the average of the item is 3.00 which indicates that this facet of Tayside schools’ health programmes was gauged as good.

Table 11. Community partnerships for the same purpose.

Response
Frequency
Percentage
Mean
Very Good
0
0.00%
2.33
Good
9
42.86%
Fair
10
47.62%
Unsatisfactory
2
9.52%
Total
21
100.00%

The extent to which they formed community partnerships was rated as fair by majority of the respondents at 48%, while a substantial percentage of 43% have a rating of ‘good’. The remainder 9% assert that this facet was unsatisfactory. The average for this item is 2.33, which indicates only a fair rating in terms of building community partnerships for their schools’ health programmes.

Table 12. Pupil participation and awareness as a result of the programme.

Response
Frequency
Percentage
Mean
Very Good
8
38.10%
3.14
Good
8
38.10%
Fair
5
23.81%
Unsatisfactory
0
0.00%
Total
21
100.00%

On pupil participation and awareness as a result of the programme, equal percentages of respondents at 38% expressed that their school programme was either very good or good on this aspect. The remainder 24% evaluated their programmes as fair. The average rating for pupil participation and awareness was 3.14, which indicates that in general, Tayside school health programmes were good at eliciting pupil participation and awareness.

Discussion

Management and Staff Support as Determinants of Success

The results of the present study show that teacher and management support are critical to the success of the school’s health services programme. In fact, all of the teachers surveyed expressed that they needed the support of other pertinent parties, including parents, the Council, and the NHS to be able to implement a health programme successfully. When teachers are strongly engaged in the formulation and implementation of school health policies, it is more likely that they will be deemed or evaluated more effective. Management style is a critical factor in the introduction of change within a school. For instance, Bush [32] purports that for the authoritarian leader, such change may simply be part of the bureaucratic structure of the school. In contrast, for more open and affable senior managers, the approach may engage all staff in the decision making process. In some other instances, change is brought forth ambivalently, seemingly as an outcome of micropolitical pressures brought to bear with staffroom negotiations. In such an instance, power play or some other form of transaction transpires [33-34].

Evidence suggests that while there is strong and broad ownership of policy with the staff feeling that they were actively engaged in the process, there is a need to sustain the momentum, lest it be overtaken by more pressing and seemingly more urgent issues. Wallace [35] demonstrates that having numerous objectives may result in a weakening or even loss of drive. In addition, Fullan [6] emphasizes the significance of the beginning stage, where ideas for change become adequately integrated into staff thinking or in organisational practice to allow successful implementation. Some of the respondents did express some level of difficulty in sustaining momentum in health policy implementation.

The critical role of a leader in policy implementation is also stressed. Crawford, Kydd, & Riches [36] presents an array of leadership approaches which might be determined by the context of managerial action. Naturally, if health services are not among the priorities of the leader and chances are not provided for strong staff engagement and participation, the atmosphere conducive for such a change may not be created.

Changing Practices: Policies and Culture

There is a need to review the school health policies of Tayside primary schools, and to identify the concrete means with which improvement areas may be addressed. These policies ought to be supported by the proper strategies and programs that target both school personnel and students. The approach cannot be lopsided, with exclusive focus on only one party. A policy is a structural change – which aims to elicit desirable cognition, affect and behaviour from amongst those involved in whole school system.

The significance behind the drafting of a policy, apart from being organisational development initiatives of the school, is a three-prong approach. First, a policy makes it transparent to everyone about what the school is undertaking in a specific area and the rationale behind such an activity. Moreover, it disseminates information on the practice expected within the school and permits progress tracking. This is certainly one improvement area for Tayside schools, since information dissemination on the FRESH framework seems to be wanting. Based from the survey, all teachers have not heard of the FRESH framework yet, much less about the policies that are supportive of it. When an analysis between basic philosophy and policy and practice is undergone, one will realize that this is distinct from one school to another, and may be practically related to the goals of the learning institution. These, in effect, somehow serve as indicators of how the school translates its objectives into tangible realities [37].The more profound goals are intrinsic or inherent into the culture of the organisation, represented by policies utilized to guide how relationships ought to managed and daily practice [38].

If the culture advocates the changed practices, it is probable that policies will be developed from a rationale integrated into the goals of the school and will accord the detail of practice in everyday school life. These may be regularly assessed by institutional self-evaluation [4]. Several authors indicate that policies ought to be associated to the overall goals and strategies of the school; moreover, it should also provide details of curricular practice, referral systems, and the role of participating staff. Several schools have cited indispensable elements such as ‘respect for each other, working together and using lines of communication for all – not just the pupils’ and ‘acknowledge the rights of access of each individual to all opportunities’ [39].

Decision makers in Tayside primary schools ought to be aware of the distinction between improving culture and drafting health policy. For real change in health policy to occur, this entails more than a change in policy. This is a basic tenet to the management of educational effectiveness purported by Hargreaves [40]. While the more authoritarian school leader is bent towards social control and drafting policies, those who tend towards social cohesion were more comfortable with engaging staff, parents and pupils, before proceeding to formal policy formulation. This holds true for the current situation at Tayside – suggesting that stronger engagement in a health programme is possible only if all these parties are involved in the process each step of the way.

Publication of Health Policies

Where the objectives are explicitly expressed, the Tayside schools have exerted effort in the advertisement and publication of their health programme policies. In almost all schools, there is a reference to a benchmark of student-created posters in school corridors and rooms, serving as a reminder to all students to comply with the standards of the school’s health programme. “Wash hands thoroughly before eating”. “Cleanliness is next to Godliness.” “Health is wealth.”

These tenets have been openly developed in Tayside schools, where senior governors, school staff, and parents were encouraged to be engaged in health policy development and formulation process. However, not all Tayside schools demonstrated such openness. A parent of one Tayside school says, ‘health policy is not always clear because principles are not defined’ and one year head from one school further comments, ‘the health policy is not owned by enough staff to affect the culture of the school because not everyone is involved’.

All the Schools have the tuck shop, the healthy tuck shop sells fresh fruit, fruit juice, low-fat crisps, raisins, cereal bars and yogurts, (two primary 7 pupils sell the items from the tuck shop. And it is very popular with the pupils). Moreover, all the schools provide healthy lunches. These are clear indicators of health programme support; however, it has also been noted that not all parents are supportive of their children in terms of healthy food intake. In other words, some of them still condone eating junk food. If policies are in place at school but are not reinforced at home, Tayside schools will have greater difficulty in instilling authentic health beliefs and habits among their students.

Strengthening Advocacy during the Implementation Phase

Whether through an attempt to enhance school effectiveness or through more direct managerial action, the pragmatic tenets of health policy implementation need to be assessed and implemented by all staff. Some teachers have expressed some lack of advocacy or support, ‘we are having some difficulty in implementation because not all staff are clear about the purpose, implementation details, and ultimate objective of our health services policy. Our role as stewards is not clearly defined.’ At its most sophisticated level, this leads to some forms of contract, the usage of health checklists to ensure that health policies are complied with, and a monitoring system which intends to ensure sustenance and continued effectiveness. The t-tests of the current study shows that there was higher engagement among school personnel than with students, since school administration were more actively engaged in and aware of the benefits of the health policy and were involved as decision makers along the process. Such evidence suggests that Tayside schools which have health policies which have well-defined goals, explained in a language understood by students, advertised as principles of good and peaceful community life by staff, and exercised consistently in action, have a higher probability of attaining their goals [6] under the overarching FRESH health framework.

Difficulties in Sustenance

Staff in both public and private schools acknowledge that in attaining the goals of any policy because of certain concerns such as lack of time, manpower, and other resources. The more difficult concerns are the lack of interest and enthusiasm among those who should be actively involved. The outcome of all of these difficulties is some basic philosophical hardships in health policy development that focuses on relationships. Eraut [41] expresses how professional education necessitates that the staff in both public and private schools to analyze and breed the required knowhow, skills, and attitudes to manage change and address the need to develop effective health policies.

Assessment of Tayside Schools Based on the FRESH Framework

Health-related school policies. The presence of clear policies seem to be present in Tayside primary schools, at least from the perspective of school administrators. More than students, school personnel see the clear rationale for practicing the standards prescribed by the FRESH framework. They understand that the health programme shall help in promoting the general health and nutrition of children. When asked about the kind of health programmes that their schools are implementing currently, these seem to be in conformance with the FRESH framework, which expresses that health programmes in schools must encompass not only the physical health of children, but also psychosocial health as well. Among the responses in the semi-structured interview include various physical health programmes, and a number of psychosocial health policies, including school violence, bullying, treatment towards pregnant schoolgirls and young mothers.

Provision of safe water and sanitation. For this item, school personnel have given hig ratings. The relatively low rating on this item show that the standards which they currently see in practice in their schools do not conform or is not consistent with those prescribed by their health programme. There needs to be a physical check of these water and sanitation facilities. If they do comply with the standards prescribed by FRESH, these results ought to be publicized among the students who seem to have a negative impression of the school on this item.

All the school personnel interviewed said they had resources for simple washing of hands and similar primary hygiene practices. On the other hand, one of the two school children interviewed say that they sometimes have non-potable water. According to the Provision of safe water and sanitation article in the freshschools.org website, these shortcomings have far reaching implications, and may even be a cause of mortality, caused by diarrhoea, and worm infections, among others [13].

The children are cognizant of their schools’ health programmes, and yet seem to be dissatisfied with the various facets prescribed by FRESH. The FRESH framework takes on increased importance with the acknowledgement that these diseases may be prevented through proper sanitation and hygiene. However, change does not take place with a simple structural change in the form of policies – these require attitudinal and behavioural change as well, from all parties involved in the health effort. The availability of sanitation facilities is a basic right that is critical tot eh maintenance of health and a recognition of human dignity [15].

Skills based health education. On the third component of skills-based health education, the interview suggests that teachers have been taught skills on HIV/AIDS prevention, reproductive health, early pregnancy, violence, tobacco and substance abuse [14]. However, not all of these programs were cascaded to all students. The two children interviewed said that only reproductive health has been covered in their formal classes. There is also a need to explain to students the host of factors that allow these diseases to proliferate, including the behaviour of the child himself, pressure from friends, cultural background, upbringing, and dysfunctional friendships. Upon probing, the researcher has realized that skills based education is still not fully developed and standardized across all Tayside schools.

The results suggest that knowledge of the health programme may not be enough to promote advocacy among both school personnel and students. This is consistent with the idea espoused by the freshschools.org website, which expresses that knowledge alone may not be sufficient in promoting health effectiveness. This justifies the need for a skills-based approach. In addition, Hubley asserts that disease information alone does not effectively lead to modification of behaviour. In other words, a change in cognition – that is, increased knowledge, does not immediately translate to a change in behaviour [11]. For this task, a skills approach is deemed more effectual.  This is an area that needs to be improved in Tayside schools, specially in the manner in which this component is advertised among students.

Access to health and nutrition services. On the access to health and nutrition services, teachers seem to have given high ratings on this factor. In the interview responses, both school personnel and students suggest that these school services are in place. However, the lower ratings of the students may speak about the lack of effectiveness or drafting a more systematic manner for implementation. FRESH asserts that school health programmes are an effective means of connecting the factors of “health, education, nutrition, and sanitation.” All respondents do say that they have most of the following services: disease screening, provision of self-administered medicine and treatments, administration of parasitic treatments, health advice, and referral to medical and community services. Similar to the other components of the framework, this needs to be enhanced and publicized further among the students to solicit greater commitment and advocacy to health goals.

The outcomes on engagement suggest that both school personnel and students are willing to give their commitment to their schools’ health programmes and goals. There must be a systematic and strategic way of capitalizing on such engagement.

Conclusion

The present study shows that significant differences do exist between the perceptions of school personnel and students in terms of  the components of the FRESH framework, as well as their engagement to their school’s health services programmes. In particular, it has been shown school personnel seem to have given more favourable feedback across most factors compared to students who were interviewed. The degree of health policy development within each school is reflective of the pressures for change and its motivation to establish health tenets which will serve as guideposts for students, parents, and staff.

From the study, it is clear that the level of health policy development may be depicted in some sort of continuum. Successful policy implementation, as asserted by Glover and colleagues [39], seemed to have two elements: 1) clear documentation, and 2) consistent application. The consistency of application also suggested some degree of monitoring and assessment as a characteristic. Policies which were not documented will be less successful and effective. On the other hand, documented and undocumented policies become equally ineffective when they are not consistently applied, when no policy exists, or when staff enact such policy pragmatically [39]. The management of Tayside schools ought to ensure that support and advocacy for their health policies are ingrained in both school staff and students who may synergistically work towards the success of its implementation.

References

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Appendix A: Menu planning by food group

Group 1
(Bread, other Cereals and Potatoes)
Guidance for Primary and Secondary Schools
Supplementary Guidance for Secondary Schools
Rationale
Bread, other Cereals and Potatoes
Every school lunch should contain a portion or portions of food from this group.

Starchy foods are usually inexpensive and provide energy, fibre, vitamins and minerals. Children should be encouraged to fill up on these foods. Portions should be large enough to satisfy young appetites.
Bread
A variety of extra bread, including brown and wholemeal, should be available daily as a meal accompaniment for all pupils, at no additional charge. Crusty bread, quarters of bread rolls and buns are popular and can be offered in baskets at the counter.

Garlic bread should be served a maximum of twice a week.

Bread can be provided in a variety of forms to replace fried products including naan, pitta and crusty bread.

The maximum sodium content of bread will be specified in the product specifications.

Provides for the varying appetites and energy requirements within this wide age group.

Limiting high fat options will help to reduce the total amount of fat in the menu.

This is to provide variety and alternatives to fried potatoes.

Bread contributes significant amounts of sodium to the diet. Setting this sodium restriction will contribute to UK-wide reduction of sodium in bread.
Rice, Pasta and Noodles
Rice and pasta should each be offered a minimum of once a week. Noodles should be offered where appropriate, e.g. with stir-fry or sweet and sour dishes.

This is to provide variety and alternatives to fried potatoes.
Potatoes
The following products should be served a maximum of twice a week in primary (and ideally in secondary) schools: roasts, chips, smiley faces and other shaped products, e.g. Alphabites, croquettes and waffles.

Local Authority Purchasing Officers should be encouraged to buy chips with as low fat content as possible.

The maximum fat content of potato products will be specified in the product specifications. If possible, all potato products should be oven baked rather than fried.

Where a fried item is offered, a non-fried alternative should also be offered.
We recognise that chips will continue to be available each day in some secondary schools, but encourage these schools to work towards the primary school standards. However, non- fried alternatives to chips, e.g. mashed, boiled and baked potatoes should be available daily and actively promoted.
Limiting fried and high fat options helps to reduce the total amount of fat in the menu. While trying to influence choice, with the prevalence of the cash cafeteria system in many secondary schools, we recognise that limiting the availability of chips in some secondary schools to twice a week may be unrealistic at present.

Children selecting fried options from the menu more than twice a week are likely to exceed the nutrient standard for total fat. Menu planners may therefore find fried food, including chips, can appear in the menu no more than twice per week.

Providing alternatives to fried potatoes is the first step to achieving the nutrient standard for fat.
Group 2 (Fruits and Vegetables)
Fresh, Frozen, Canned and Dried Varieties and Fruit Juice
Every school lunch whether hot, cold, or a packed lunch should contain two portions of food from this group.

The menu as a whole should provide a choice of at least two vegetables and two fruits in addition to fruit juice every day and throughout the lunch service. At least one of these vegetables should be served free of added fat including salad dressings.

Fruit, vegetables and salads provide vitamins, minerals and fibre and experts recommend five portions of fruit and vegetables a day.

Habitually low consumption of fruit and vegetables remains one of the most damaging features of the Scottish diet.
Vegetables
Fruit and vegetable choices should be actively promoted and consideration given to providing vegetables inclusively in the price of every meal. They should also be served in an appealing and easy to eat way.

Vegetable-based soup should contain a minimum of one portion of vegetables per serving and can then count as one portion.
Maximum sodium content of soup will be specified in product specifications.

Baked beans should be served as a vegetable a maximum of twice a week. Canned spaghetti and similar products should not be served in place of a vegetable.

If beans or pulses form the protein part of a main course, a vegetable that is not beans or pulses should also be available.

A child may be put off choosing vegetables if they have to pay extra for them.

Children often enjoy cold and raw vegetables best and salad and fruit bars are also popular.

Soup is a good vehicle for vegetables, popular with many children. We found that some schools had prohibited the serving of soup because of concerns about scalding. We recommend that practical solutions to operational issues arising from health and safety concerns should be found so that children are not denied this route to increasing their vegetable intakes.

Unlike most vegetables, baked beans do not contain Vitamin C. Processed tomato sauce should not be counted as a vegetable portion.

This increases the variety for the vegetarian option.
Fruit
Where there is choice, a dessert which provides at least one portion of fruit should be offered every day. Where there is no choice, a fruit-based dessert such as fresh fruit, fruit tinned in juice, fruit salads, fruit crumble, fruit jelly or fruit pie should appear on the menu a minimum of three times a week.

Pies, crumbles and other composite fruit dishes should contain a minimum of one portion of fruit per serving.

This increases the fruit content of the lunch.
Group 3 (Milk and Milk Products)
Milk and Milk Products, Yoghurts and Milk-based Desserts
Most school lunches should contain a portion or portions of food from this group.

Milk and milk products are an excellent source of several nutrients including protein, vitamins and calcium, important for good bone development.
Milk
Plain or flavoured drinking milk should be available as an option every day. Semi-skimmed and skimmed milks have the same amount of calcium as whole milk and should be provided for drinking as well as for cooking.

Milk is a good alternative to sugary fizzy drinks and semi-skimmed milk provides less fat. The use of semi-skimmed milk is in line with existing recommendations, e.g. the Scottish Diet Action Plan.
Cheese
Cheese should be served as the main protein item instead of meat or fish a maximum of twice a week.

Cheese to be served as cheese and biscuits, as part of a salad or as a filling for sandwiches and baked potatoes should have as low a fat and sodium content as possible. The maximum fat and sodium content of cheese will be specified in the product specifications.

Vegetarian alternatives to cheese should be available a minimum of three times a week.

Where there is no choice, cheese as a sandwich filler should be offered a maximum of three times a week.

Where a portion of cheese is served as the main protein item, it also counts as a portion of food from the meat, fish and alternative sources of protein food group, but can be higher in fat than other products in this group.

Cheese is a high fat food and the product specification will help to reduce the total amount of fat in the menu

This provides variety for vegetarians.

This provides variety and reduces fat intake.
Group 4 (Meat, Fish and Alternatives)
Meat, Fish and Alternatives, e.g. Eggs, Peas, Beans and Lentils
Every school lunch should contain a portion or portions of food from this group. of protein.

Meat, fish and alternatives such as eggs, beans and pulses are a major source
Beef, Pork, Lamb and Poultry
Red meat (beef, pork and lamb) based meals should be served a minimum of twice a week.

Lean meat should be used in dishes containing meat and this will have a fat content of about 10%.
Caterers should take steps to reduce the fat content of their meat dishes as much as possible.

The maximum fat and sodium content of stews, casseroles, meatballs and curries will be specified in the product specifications.

Red meat is a good source of iron.

This will help to improve the quality of meat used in recipes whilst reducing the overall fat intake.

The product specifications will help meet nutritional standards.
Processed Meat Products and Pies
Processed meat products, i.e. hot dogs, frankfurters, sausages, beef burgers, meatballs, haggis and shaped poultry products(e.g. nuggets), pastry topped pies and other pastry products (e.g. bridies, sausage rolls, Cornish pasties, Scotch Pies) should be served a maximum of once a week.

The vegetable content of composite dishes such as pies should be increased where possible. Potato-topped pies will have a lower fat content and should be encouraged in preference to pastry-topped pies.

Overall, meals should provide no more than 35% total energy from fat therefore inclusion of high fat dishes should be limited.

Processed meat products are likely to be high in fat.
If manufacturers can produce a suitable range of lower fat products this recommendation may be reviewed as part of the ongoing process of establishing product specifications.
Composite Dishes
The maximum fat and sodium content of lasagne, moussaka, macaroni cheese, spaghetti bolognese, tuna pasta bake, ravioli and other composite dishes will be specified in the product specifications. Vegetable content should be increased where possible.

Product specifications will help meet nutritional standards.
Fish
Fish, in addition to tuna fish, should appear on the menu a minimum of once a week.

Oil-rich fish (sild, sardines, kippers, salmon, mackerel and herring) should be served once a week. Mackerel salads and pâtés are often popular.

This will provide variety in the menu.

Oil-rich fish contain valuable, protective fatty acids that are deficient in the Scottish diet and their use should be encouraged.
Many children are unfamiliar with these foods and should be encouraged to try them through the use of tasters.
Processed Fish Products
The maximum fat and sodium content of fish portions, fish fingers and shaped fish products will be specified in the product specifications. Any fish products that do not meet these specifications should be served a maximum of once a week.

Overall, meals should provide no more than 35% total energy from fat therefore inclusion of high fat dishes should be limited. Fish should be presented in a form that children will eat.
Pizza
Maximum fat and sodium content for pizza will be specified in the product specifications and its frequency on the menu determined by its ultimate specification. Vegetable toppings should be encouraged and used wherever possible.

Pizza is often higher in fat than many other composite dishes.
Vegetarian Products
Vegetarian products resembling meat products, e.g. sausages and burgers made from textured vegetable protein (TVP) should have a similar protein content to meat products. Maximum fat and sodium content will be specified in the product specifications.

These products will be the main source of protein for vegetarians and it must therefore be available in a sufficient quantity in any meat replacements. Vegetarian products should meet the same specifications for fat as processed meat products.
Stir-in Sauce
Maximum fat and sodium content will be specified in the product specifications for stir-in sauces for bolognese, stews, curries and other ethnic dishes.

Limiting the fat and sodium content of these products will help in achieving the nutrient standards.
Group 5 (Foods containing Fat and Foods and Drinks containing Sugar
Foods containing Fat and Foods containing Sugar
The use of foods from this group should be limited. There should be no active promotion or advertising of full fat crisps, confectionery or fizzy, sugary soft drinks within the dining room.

Foods from this category are consumed to excess by Scottish children, providing excess fat, sugar and salt in the diet.
Sweetened Soft Drinks
Fizzy, sugary soft drinks should not be served as part of school lunch in primary schools and should not be encouraged in secondary schools. Carbonated water, plain water, milk and fruit juices are considered appropriate drinks. Flavoured waters are popular with children and low sugar versions are acceptable. We note the desirability to gradually wean Scottish children away from a predilection for sweet flavours. There is a popular movement amongst children to drinking plain water and this should be encouraged.
We recognise that sweetened soft drinks will be available each day in some secondary schools. However, they should not be served as part of a combination meal or meal deal or packed lunch. These schools may find that a staged progression from sugary fizzy drinks to diet versions and the promotion of lower sugar squashes and flavoured waters is helpful.
The promotion of chilled bottled water as well as the adequate provision of freely available drinking water is considered very important.
To achieve the nutrient standard for sugar and for the protection of dental health, we consider that there is no place for sugary, carbonated (fizzy) drinks as part of school lunches.
Confectionery, e.g. Chocolate, Sweets
Where confectionery is still being sold, it should be set away from the food service points.
A working distinction is made between manufactured confectionery and home baking.

This will discourage purchase as part of a meal and help to achieve the nutrient standard for sugar and for the protection of dental health.
Puddings, Cakes, Biscuits, Jam, Jelly and Ice Cream
Where there is no choice, all desserts on offer should be fruit and/or milk-based(including yoghurt). Caterers are, however, encouraged to review home-baking recipes to lower fats and sugars and include nutrient-rich, whole- food ingredients.

Desserts and puddings are a useful way of boosting the total energy in children’s diets while providing important nutrients. They can also help to increase fruit intake. Specifications will help to lower fat intake.
Butter and Spreads
Only polyunsaturated and monounsaturated fats, spreads and oils and low fat spreads should be used.

This will contribute to a reduction in the fat intake in line with the Scottish Diet Action Plan targets. As part of a healthy diet, it is also important to reduce the amount of saturated fats eaten, by replacing them with unsaturated fats(with an emphasis on monounsaturates).
Cooking Fats and Oils
Only polyunsaturated and monounsaturated fats, spreads and oils should be used.

Savoury Potato Snacks, Crisps and Corn Snacks
Crisps should be offered as part of a combination meal option/meal deal or packed lunch a maximum of twice a week.
We believe that many pack sizes are too large and the fat content per 100g is excessive. The maximum pack size, fat and sodium content will be specified in the product specifications.

Crisps are commonly consumed throughout the day, e.g. at break times and eating multiple packets should not be encouraged.
Source: http://www.scotland.gov.uk/library5/education/hfs-03.asp [3]

Appendix B: Nutrient standards for school lunches for pupils in primary schools.

Unit
Infants 5-6 years
Junior 7-10 years
Energy
30% of EAR 1
Mean of girl and boy

MJ/Kcal
2.04 MJ
489 Kcal
2.33 MJ
557 Kcal
Fat
Not more than 35% of food energy
Max
g
19
21.7
Saturated Fatty Acids
Not more than 11% of food energy
Max
g
6
6.8
Carbohydrates
Not less than 50% of food energy
Min
g
65.2
74.3
NME (non-milk extrinsic) Sugars 2
Not more than 11% of food energy
Max
g
14.3
16.3
Fibre/NSP (non-starch polysaccharides) 3
Not less than 30% of calculated reference value
Min
g
3.9
4.5
Protein
Not less than 30% of RNI 4
Min
g
5.9
8.5
Iron
Not less than 40% of RNI
Min
mg
2.4
3.5
Calcium
Not less than 35% of RNI
Min
mg
158
193
Vitamin A (retinol equivalents)
Not less than 30% of RNI
Min
g
150
150
Folate
Not less than 40% of RNI
Min
g
40
60
Vitamin C
Not less than 35% of RNI
Min
mg
11
11
Sodium
Not more than 30% of RNI
Max
mg
393
655
Fruit and Vegetables
1/3 of five portions per day

Portions
2
2
1

Estimated average requirement
2 These are added sugars rather than the sugar that is integrally present in the food (e.g. table sugar, honey, sugar in fruit juice and soft drinks)
3 Here calculated as 8g per 1,000 kcal
4 Reference nutrient intake

Source: http://www.scotland.gov.uk/library5/education/hfs-03.asp [3]

Table 3: Nutrient standards for school lunches for pupils in secondary schools.

Unit
All secondary11-18 years
Energy
30% of EAR 1
Mean of girl and boy

MJ/Kcal
2.70 MJ
646 Kcal
Fat
Not more than 35% of food energy
Max
g
25.1
Saturated
Not more than 11% of food energy
Max
g
7.9
Fatty Acids

Carbohydrates
Not less than 50% of food energy
Min
g
86.1
NME (non-milk extrinsic) Sugars 2
Not more than 11% of food energy
Max
g
18.0
Fibre/NSP (non-starch polysaccharides) 3
Not less than 30% of calculated reference value
Min
g
5.2
Protein
Not less than 30% of RNI 4
Min
g
13.3
Iron
Not less than 40% of RNI
Min
mg
5.9
Calcium
Not less than 35% of RNI
Min
mg
350
Vitamin A (retinol equivalents)
Not less than 30% of RNI
Min
g
185
Folate
Not less than 40% of RNI
Min
g
80
Vitamin C
Not less than 35% of RNI
Min
mg
13
Sodium
Not more than 30% of RNI
Max
mg
786
Fruit and Vegetables
1/3 of five portions per day

Portions
2
1 Estimated average requirement
2 These are added sugars rather than the sugar that is integrally present in food (e.g. table sugar, honey, sugar in fruit juice and soft drinks)
3 Here calculated as 8g per 1,000 kcal
4 Reference nutrient intake

Source: http://www.scotland.gov.uk/library5/education/hfs-03.asp [3]

Appendix D – School Student Questionnaire

Name of school ________________________

Q1       About you

1.1       Grade
___________________

1.2 (This part can be left blank if you prefer)

Name……………………………………… Email…………………………………………………
Address………………………………………………………………………………………………

Based on your knowledge and experience, please give your opinion to the following questions:-

Q2       Understanding the school health programme

2.1       I have a comprehensive understanding of my school’s health programme

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

2.2       The school’s health program informs me of significant changes and developments.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

2.3       The school’s health programme has positive effects on academic activity.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

2.5       The school’s health programme has positive social impact.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

2.6       The school’s health programme is cost efficient is not a financial burden to me.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

Q3       Basic Framework

3.1       Health-related school policies have significantly changed since the programme has been introduced.
5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

3.2       Our water and sanitation facilities are well maintained.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

3.3       Since the introduction of the program, I have been taught new skills as part of health education.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

3.4       The overall state of health services in our school is exemplary.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

Q4       Supporting Activities

3.1       Our school has an effective partnership with a local health worker.
5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

3.2       Our school has an effective community partnership established for the same purpose.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

3.3       There is strong pupil participation and awareness on the school’s health programme.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

Appendix E – School Employee Questionnaire

Name of school ________________________

Q1       About you

1.1       Please mark the boxes next to the categories that apply to you
(you may need to mark more than one)

I am a…

Principal                                                                     Teacher (Grade _____ )

Librarian                                                                    Gym Coach

Cafeteria Supervisor                                                  Administrative Personnel

Helper / Runner                                                         Security In charge

                                                                                          Lab In charge

other (please specify)………………………………….

1.2 (This part can be left blank if you prefer)
Name……………………………………… Email…………………………………………………
Address………………………………………………………………………………………………

Based on your knowledge and experience, please give your opinion to the following questions:-

Q2       Understanding the school health programme

2.1       I have a comprehensive understanding of my school’s health programme

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

2.2       The school’s health program informs me of significant changes and developments.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

2.3       The school’s health programme has positive effects on academic activity.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

2.5       The school’s health programme has positive social impact.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

2.6       The school’s health programme is cost efficient is not a financial burden to me.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

Q3       Basic Framework

3.1       Health-related school policies have significantly changed since the programme has been introduced.
5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

3.2       Our water and sanitation facilities are well maintained.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

3.3       Since the introduction of the program, I have been taught new skills as part of health education.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

3.4       The overall state of health services in our school is exemplary.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

Q4       Supporting Activities

3.1       Our school has an effective partnership with a local health worker.
5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

3.2       Our school has an effective community partnership established for the same purpose.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

3.3       There is strong pupil participation and awareness on the school’s health programme.

5 – Strongly Agree       4 – Agree      3- Neutral     2- Disagree      1- Strongly Disagree

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