FIS EXTERNAL EVALUATION - FINAL REPORT JAN 2015 · External!Evaluation!of!Fruitin!Schools!...
Transcript of FIS EXTERNAL EVALUATION - FINAL REPORT JAN 2015 · External!Evaluation!of!Fruitin!Schools!...
External Evaluation of Fruit in Schools Final Report
January 2015
Prepared for
5+ A Day Charitable Trust
By
Judith Ball and Carolyn Watts
The 5+ A Day Charitable Trust, PO Box 66047, Beach Haven, Auckland 0749 Ph: 09 480 5057 Fax: 09 480 5058 Web: www.5aday.co.nz
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Contents Contents ....................................................................................................................................................... 2
Executive summary ...................................................................................................................................... 3
1. Introduction ............................................................................................................................................. 7
2. Fruit in Schools Programme description .................................................................................................. 9
2.1 History of Fruit in Schools .................................................................................................................. 9
2.2 International context ....................................................................................................................... 11
2.3 Findings of Previous Evaluations ...................................................................................................... 12
2.4 Current structure and operation of Fruit in Schools ........................................................................ 13
3. Findings: Benefits of Fruit in Schools ..................................................................................................... 15
3.1 Fruit in Schools feeds hungry children ............................................................................................. 15
3.2 Fruit in Schools contributes to academic outcomes ........................................................................ 16
3.3 Fruit in Schools Improves health ...................................................................................................... 18
3.4 Fruit in Schools supports a healthy school environment ................................................................. 20
3.5 Fruit in Schools supports a healthy home environment .................................................................. 24
3.6 Overall benefit of Fruit in Schools .................................................................................................... 25
4. Findings: Success Factors and Suggestions ............................................................................................ 27
4.1 Which programmes are most valued by schools and why? ............................................................. 27
4.2 Success factors for Fruit in Schools .................................................................................................. 28
4.3 How could the Fruit in Schools programme and resources be improved? ...................................... 29
5. Evaluative conclusions ........................................................................................................................... 30
References ................................................................................................................................................. 33
Appendix A: Evaluation methods ............................................................................................................... 34
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Executive summary Evaluation outline This report presents the findings of an independent evaluation of Fruit in Schools conducted by Quigley and Watts Ltd in late 2014. The primary purpose of the evaluation was to understand and document the benefits of Fruit in Schools, in particular any wider health promotion impacts, with a particular focus on nutrition and healthy eating. The evaluation drew on a range of information sources including findings from an online survey of principals of Fruit in Schools schools (n=378) with a response rate of 81%; 16 key informant interviews with school principals, Health Promoting Schools facilitators, and a Ministry of Health official; and previous Fruit in Schools evaluations.
Programme description The Fruit in Schools programme is funded by the Ministry of Health and provides a piece of fresh produce for each child each school day in low decile primary and intermediate schools. A wide range of high quality fruit and vegetables are supplied, with an emphasis on seasonal local produce. Each school has developed its own processes for storage and distribution of the fruit. As at September 2014, there were about 480 schools participating in the Fruit in Schools programme. Benefits of Fruit in Schools Principals valued Fruit in Schools highly, and believed it was very beneficial for their school and the wider community. Survey respondents were asked to rate the overall effect of Fruit in Schools on a scale from 1 (‘Has had no positive effect’) to 10 (‘Has had a very positive effect’). 87% rated it 8, 9, or 10, with 46% of principals giving Fruit in Schools the highest possible rating – 10.
Key informants advocated strongly for the continuation of the programme, and expressed concern about what would happen if Fruit in Schools ended. Findings about the specific benefits of the programme are summarised below.
Feeding hungry children
According to principals, feeding hungry children is the number one benefit of Fruit in Schools. 85% of principals surveyed reported their school had fewer hungry children as a result of Fruit in Schools. 80% reported reduced stigma as a result of Fruit in Schools, and said that children were more willing to ask for food if they were hungry. Principals said that children coming to school hungry or bringing little or no lunch was a significant issue in low decile schools.
Educational benefits
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In the survey, 72% of principals agreed or strongly agreed that ‘if Fruit in Schools was ended, academic outcomes would suffer.’ Principals explained that the main way fruit provision contributed to academic outcomes was by providing ‘brain food’ that enabled children to concentrate and stay on task, and 74% reported they had observed increased concentration in class as a result of Fruit in Schools. Many principals also observed that Fruit in Schools was contributing to learning by providing authentic learning opportunities (89%), reducing behaviour problems (46%), and improving attendance and engagement (60%).
Health benefits
Both principals and Health Promoting Schools facilitators agreed that Fruit in Schools was providing direct health benefits for children in low decile schools due to increased consumption of fresh produce, and wider dietary changes triggered by Fruit in Schools. For example, in the survey:
• 66% of principals reported they had observed an improvement in students’ general health as a result of Fruit in Schools;
• 43% had observed fewer cases of school sores and skin infections; • 35% said students had fewer sick days due to Fruit in Schools; • 91% agreed or strongly agreed that ‘the overall health of children would decline’ if Fruit in
Schools was ended; and • 97% agreed or strongly agreed that ‘if fruit in schools was ended many of our kids would eat
little or no fruit’.
Interviewees agreed that a key benefit of Fruit in Schools was the normalising of fruit eating, and the instilling of positive habits and attitudes to healthy eating.
• All principals (100%) reported that Fruit in Schools contributes to awareness among staff and pupils about the importance of healthy eating
• All principals (100%) said Fruit in Schools contributed to positive attitudes among pupils about eating fruit and vegetables
• Almost all reported that the programme contributed to awareness about the ‘5+ a day’ message (99%), and increased knowledge among pupils about nutrition and health (98%).
Supporting a healthy school environment
Key informants reported that Fruit in Schools had been part of a culture change towards addressing child health and wellbeing as a core education issue. Fruit in Schools was seen as having cultural and social benefits as well as educational and health benefits, for example 95% of principals said Fruit in School contributes to a sense of equality between pupils regardless of their family circumstances.
Almost all participating schools had broader nutrition and healthy lifestyle initiatives in place, including healthy food policies, school gardens and orchards, and healthy lunchbox initiatives for example. Health Promoting Schools facilitators commented that such changes made by schools were generally
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maintained long term. 96% of survey respondents agreed or strongly agreed that Fruit in Schools helps to keep health and wellbeing on the agenda.
Schools differed in the extent to which wider health promotion initiatives were directly attributable to Fruit in Schools. Some schools saw Fruit in Schools as the catalyst and foundation for their wider healthy lifestyle approach, whereas other schools introduced health promotion initiatives before or at the same time as Fruit in Schools and therefore saw it as a complementary programme rather than a catalyst.
Supporting a healthy home environment
Principals reported that Fruit in Schools was having a positive impact on children’s home environment and parental behaviours, at least in some families. For example 44% of principals reported that ‘many families’ were providing less sugary drinks and junk food in school lunches, and a further 40% said ‘a few families’ were doing so.
Success factors for Fruit in Schools
The majority of key informants agreed that Fruit in Schools was successful because:
• It is meeting a genuine need and making a real difference • It is very well managed, and easy for schools to participate • The fruit and vegetables provided are varied and of high quality • It has been consistent and reliable over many years
These factors, and that fact that the programme is delivered at no cost to schools or communities, have made Fruit in Schools sustainable from the schools’ perspective.
How could Fruit in Schools be improved?
Several principals and Health Promoting Schools facilitators said the programme should be expanded to higher decile schools, since food insecurity and poor nutrition are not limited to decile one and two schools. This finding was also reflected in the survey with 83% of principals agreeing or strongly agreeing that ‘Fruit in Schools should be extended and made available to all decile 3 and 4 schools.’ One Health Promoting Schools facilitator said the programme should be expanded to low decile secondary schools so that the good eating habits continue to be supported as children grow up.
Most principals were satisfied with the nutrition-‐related teaching resources available, however a lack of resources in Te Reo Māori was an issue for Māori immersion schools.
Conclusion
Based on the findings of the current evaluation, we conclude that Fruit in Schools is an effective food and nutrition programme with wide ranging benefits. It is highly valued by schools and well aligned with international evidence on how to improve nutrition and reduce obesity in children.
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The findings of the current evaluation reinforce and update the findings of previous evaluations and show that Fruit in Schools is still a much needed and highly valued programme. We recommend that Fruit in Schools is continued and consideration is given to the expansion of the programme to decile 3 and 4 schools, and low decile secondary schools.
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1. Introduction
The Fruit in Schools programme is funded by the Ministry of Health and supplies a piece of fresh produce for each child each school day in low decile schools. United Fresh New Zealand Incorporated delivers the fresh produce and The 5+ A Day Charitable Trust supports the programme with curriculum-‐linked resources sent free to schools.
In mid-‐2014, 5+ A Day commissioned Quigley and Watts Ltd to conduct an independent evaluation of the programme. This report presents the findings of the external evaluation.
Evaluation objectives The primary purpose of the evaluation was:
• to understand and document the benefits of Fruit in Schools, in particular any wider health promotion impacts, with a particular focus on nutrition and healthy eating.
Secondary aims were:
• to explore success factors for Fruit in Schools, and other programmes that support child health and health promotion in schools
• to gain feedback on teaching resources provided through the 5+ A Day Charitable Trust • to explore how the programme could be improved.
Evaluation methods The evaluation used both quantitative and qualitative methods and drew on a range of information including:
• Findings from an online survey of principals of Fruit in Schools schools (n=378) • 10 key informant interviews with principals at Fruit in Schools schools • 5 key informant interviews with Health Promoting Schools facilitators • 1 key informant interview with a Ministry of Health official • Previous evaluations of Fruit in Schools, and other programme documents.
The methods are described in full in Appendix A.
Structure of the evaluation report The report is organised around the evaluation objectives above. It begins with a programme description, including a brief summary of findings from previous evaluations, and international findings about similar programmes. This is followed by two sections detailing the findings of the current evaluation about the benefits of Fruit in Schools, and about success factors of the programme and suggestions for
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improvement. The concluding section brings the evaluation findings together and presents conclusions about the overall effectiveness of the programme. Appendix A provides detail about the evaluation methods and Appendix B contains the full findings of the Fruit in Schools survey of principals.
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2. Fruit in Schools Programme description
This section describes the purpose, history and current operation of Fruit in Schools. It also presents a summary of the findings of previous Fruit in Schools evaluations. It is based primarily on programme documents and evaluation reports, supplemented by key informant interviews.
2.1 History of Fruit in Schools
Origins
United Fresh became aware of Fruit in Schools type programmes in the late 1990s at an international 5 A Day symposium. After researching the Fruit Programme in the UK and visiting the Department of Health in London, United Fresh proposed a similar programme to New Zealand’s Ministry of Health in 2002 (P Dudley, personal communication, December 10, 2014). In 2004 the provision of fruit to schools was piloted in 10 low decile Auckland primary schools with 10 other low decile Auckland schools acting as control schools. In addition 5 low decile schools in Northland were included in the pilot to determine the feasibility of supplying fruit to remote schools. The pilot, evaluated by Massey University, demonstrated that schools and students accepted the fruit and that produce could be supplied to schools remote from a main centre (Ministry of Health, personal communication, December 10, 2014).
Following the success of the pilot, the Ministry developed the Fruit in Schools programme, linking fruit provision with a wider health promotion agenda. Purpose
The Fruit in Schools programme was launched in 2005 as part of the Ministry of Health’s overall strategy to improve health outcomes for New Zealanders. Fruit in Schools originally had two main objectives:
1. To promote healthy eating through offering students in low-‐decile primary schools a piece of high quality fruit for each school day.
2. To encourage schools to use a Health Promoting Schools approach to further promote healthy lifestyles in four priority areas:
healthy eating
physical activity
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Sunsmart
Smokefree
According to a Ministry of Health official, ‘The free fruit of Fruit in Schools was seen by both the government officials and the programme’s evaluators as a “carrot” or a “foot in the door” to a suite of health promotion activities, as schools had to agree to sign up to the Health Promoting Schools programme’ (Ministry of Health, personal communication, 15 October, 2014).
Roll out
Fruit in Schools was not mandatory, but the majority of schools with primary aged children (years 0-‐8) that were invited to participate agreed to take part. The programme was rolled out in phases, with the first three phases targeting mainly decile 1 schools and beginning in late 2005, early 2006 and late 2006 respectively. At the end of Phase 3 there were about 268 schools participating in the programme (Walton, 2014). Initially, each phase was funded for three years and it was envisaged the programme would end in 2009 (Boyd et al, 2009).
Following the recommendations of the Health Select Committee report on obesity and type 2 diabetes in 2007, Fruit in Schools was extended to decile 2 primary schools and decile 1 and 2 intermediate schools. The timeframe was also extended, with additional funding agreed by the Ministry of Health for 2008/09 and out years (Ministry of Health, personal communication, 15 October 2014). By the end of 2008 about 470 low decile schools and over 95,000 students were part of Fruit in Schools (Boyd et al, 2009).
Operation
A Fruit in Schools agreement was signed between each school (the Board of Trustees chair and the principal) and the manager of the local Public Health Unit, laying out the roles and commitments of each (Ministry of Health, 2006).
Support and professional development was offered to schools, and funding was provided to support teacher release for professional development and resources relating to Fruit in Schools. Fruit in Schools advisors were employed by DHB Public Health Units to provide the school support and professional development aspect of the programme.
The 5+ A Day Charitable Trust provided participating schools with equipment including buckets, chopping boards, aprons, knives, posters, teaching resources, fruit monitor certificates, stickers, and food safety and storage information. Each school then received delivery of fresh produce each week – at least enough for one piece per child per school day, with a wide variety of produce made available. United Fresh was contracted to supply the fresh produce and freight.
Health Promoting Schools
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Health Promoting Schools is a holistic, whole-‐of-‐school initiative that promotes the wellbeing of students, staff and community and removes barriers to learning, teaching and participation. It establishes a framework and a process for schools to identify priority issues and make positive changes through three building blocks:
• Curriculum, teaching and learning • School organisation and ethos • Community links and partnerships (Ministry of Health, 2006).
New Zealand policy context
Fruit in Schools was originally part of a suite of initiatives funded with the release of the Cancer Control Strategy Action Plan 2005 -‐2010 (Ministry of Health, 2005). The programme was also aligned with the goals and priorities of the Healthy Eating, Healthy Action Strategy (Ministry of Health, 2003). Its establishment did not require Cabinet decisions: the funding was agreed via Health Reports with Ministers (Ministry of Health, personal communication, 15 October 2014). As noted above the Health Select Committee Inquiry into Obesity and Type 2 Diabetes led to an expansion of Fruit in Schools, via a re-‐prioritisation of funding within the Ministry of Health.
2.2 International context Nutrition and physical activity have long been recognised as key determinants of health, and the rise of childhood obesity is of global concern. There is growing evidence internationally about what works to improve nutrition and prevent obesity in young people. International research consistently shows that teaching children about healthy eating is not, by itself, an effective strategy for changing eating habits. Rather: ‘Interventions should focus on changing elements of the physical and social environments, such as changing foods available in schools or increasing physical activity options and rewarding and incentivizing healthful choices’ (Lytle, 2013). A recent systematic review found strong evidence to support beneficial effects of child obesity prevention programmes on body mass index, particularly programmes targeting children aged six to 12 years (Waters et al, 2011). The reviewers concluded ‘our synthesis indicates the following to be promising policies and strategies:
·∙ school curriculum that includes healthy eating, physical activity and body image ·∙ increased sessions for physical activity and the development of fundamental movement
skills throughout the school week ·∙ improvements in nutritional quality of the food supply in schools ·∙ environments and cultural practices that support children eating healthier foods and
being active throughout each day ·∙ support for teachers and other staff to implement health promotion strategies and
activities (e.g. professional development, capacity building activities) ·∙ parent support and home activities that encourage children to be more active, eat more
nutritious foods and spend less time in screen based activities.’
Based on these findings, New Zealand’s Fruit in Schools programme can be seen as an evidence-‐based approach that incorporates many elements of best practice. School-‐based fruit and vegetable provision is increasingly being adopted worldwide, as outlined below.
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The idea of Fruit in Schools had been talked about internationally since the late 1990s. The UK government introduced a nationwide School Fruit and Vegetable Scheme in 20041, targeting children aged 4 -‐7 years, and providing a piece of fresh produce for each child each school day. Evaluation showed that attitudes to and consumption of fruit and vegetables improved while children were part of the programme, but this did not lead to sustained changes in consumption as children got older and left the scheme (European Commission, 2012).
In 2009 The European Commission launched a European School Fruit Scheme, providing a 50% subsidy to encourage member states to introduce fruit provision in schools. The key elements of the Scheme were as follows:
(a) distribution of products in educational establishments, ranging from nurseries to secondary schools.
(b) accompanying measures to raise awareness about the importance of fruit and vegetable consumption as well as healthy eating habits, and to strengthen the link with agriculture through for example farms visits or gardening sessions.
(c) networking, monitoring and evaluation of the implementation of Schemes in individual Member States (European Commission, 2012).
An evaluation of the first three years of the scheme concludes: ‘National evaluations indicate that the Scheme has strong potential and is an appropriate tool to exercise a positive influence on the eating habits of children and parents alike, encouraging them towards consuming more fruit and vegetables in the future, provided that the Scheme’s long-‐term continuation is ensured’ (European Commission, 2012).
2.3 Findings of Previous Evaluations The Ministry of Health commissioned a comprehensive process and outcome evaluation of Fruit in Schools, which was carried out by the New Zealand Council for Educational Research (NZCER) from 2005-‐2009 using both quantitative and qualitative methods. The final report was published in 2009 and concluded ‘FiS has had a positive impact on schools’ and students’ approaches to healthy lifestyles, is starting to impact on home behaviours, and is strengthening public health infrastructure’ (Boyd et al, 2009, p viii). Quantitative findings showed that Fruit in Schools students were more likely than comparison students to have either maintained their initial positive health related practices (which generally decline as children get older) or made small positive improvements. This pattern was evident across all four health areas: nutrition, physical activity, Smokefree and Sunsmart. Other positive changes identified in the evaluation included: School level
1 Prior to this national programme funded by the NHS, there was a pilot of 500 schools in 2000-‐2001, and the programme operated regionally, funded through a Lotteries Grant, until 2004 when it was nationalised. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publichealth/Healthimprovement/FiveADay/FiveADaygeneralinformation/DH_4002149
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• higher priority placed on health and wellbeing • strengthened healthy eating and sunsmart policies • increased opportunities given to students for physical activity • increased engagement with other health initiatives and agencies • students given more health-‐related leadership opportunities
Individual student level
• maintained positive attitudes towards, and awareness of, healthy behaviours • increased consumption of fruit and vegetables • increased physical activity • had positive attitudes toward school
Internal surveys carried out by 5+ A Day in 2008 and 2009 supported the finding that Fruit in Schools was starting to impact on home behaviours. In both years about 80% of schools reported that teachers had noticed a difference in lunchboxes. In 2009, 40% reported more fruit in lunchboxes, and 77% reported healthier lunches (5+ A Day, n.d.).
Subsequently Colmar Brunton was commissioned by 5+ A Day to conduct two surveys in 2010: one gauging public opinion of the Fruit in Schools initiative, and the other measuring the impact of the programme according to school principals. The public opinion survey found that 38% of New Zealanders were aware of Fruit in Schools; 9 out of 10 believed the programme should be government funded, and 87% wanted to see Fruit in Schools funded beyond 2010 (Colmar Brunton, 2010a).
In the survey of 200 principals (about 45% of participating schools), all reported that Fruit in Schools had helped reinforce healthy eating messages in their school, and all had seen an increase in pupil consumption of fruit and vegetables as a result of participating in the programme. 89% of principals reported increased concentration in class as a result of Fruit in Schools; 84% said pupils were generally healthier; and 67% said pupils had fewer sick days. Other programme benefits reported by over 85% of principals were: pupils gaining more knowledge about fruit and vegetables; pupils taking more interest in fruit and vegetables; pupils eating a wider variety of fruit; pupils eating healthier lunches; and pupils encouraging each other to eat more fruit and vegetables. Principals valued the programme very highly, and when asked to rate its impact on a scale of 1 to 10, 90% rated it 8, 9, or 10 (Colamr Brunton, 2010b).
The current evaluation updates and extends this previous work.
2.4 Current structure and operation of Fruit in Schools As at September 2014, there were about 480 schools participating in the Fruit in Schools programme.
In 2009, the new Government reviewed the programme and decided to continue fruit provision for all qualifying low-‐decile schools but cut the ‘administrative component’. The Minister of Health announced
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‘We will no longer pay for DHB provider staff to oversee the programme nor will the programme fund teacher release time’ (Ryall, 2009).
The Fruit in Schools programme continues to be funded by the Ministry of Health. United Fresh New Zealand Incorporated manages the freight and delivery of the fresh produce and The 5+ A Day Charitable Trust supports the programme with curriculum-‐linked resources sent free to schools. A wide variety of quality fresh produce is delivered nationwide to participating schools. Priority is given to provide locally grown, seasonal, New Zealand produce whenever possible. The 5+ A Day Charitable Trust continue to develop and provide participating schools with curriculum-‐linked teaching resources to support the fresh produce provision. 5+ A Day also engage in ongoing communication with principals, teachers and school-‐appointed Fruit in Schools coordinators through newsletters and phone calls for example.
Schools have developed their own systems for storing, managing and distributing the fruit, often with student leaders playing a key role. In many schools the class teacher chooses when the class will have a fruit break, and the class all eat together; at other schools the whole school eats the fruit at a particular time (at the beginning of morning break for example); and a few schools opt for a ‘grazing’ option where children help themselves to fruit as and when they want. Schools reported they received an ample supply, and that fruit was never wasted: any surplus was used in cooking projects, distributed to nearby preschools or kohanga reo, or sent home with children for example.
Since the announcement of changes to the Fruit in Schools programme in 2009, the Ministry of Health has not released any policies or plans about addressing nutrition and physical activity. That being the case, the current purpose of the programme has not been made explicit, nor where it sits in the current policy environment.
In this context, there is some ambiguity about the relationship between Health Promoting Schools and Fruit in Schools. According to a Ministry of Health official: ‘When the Minister cut funding for Fruit in Schools advisors his decision was… that that work would be picked up by existing Health Promoting Schools staff.’ However in practice there appear to be regional differences: in some regions the relationship between Fruit in Schools and Health Promoting Schools has continued much as it did pre-‐2009 albeit with fewer DHB staff providing support, while in other regions Health Promoting Schools staff do not see themselves as having any role in relation to Fruit in Schools. It should be noted that the structure and delivery of Health Promoting Schools has itself undergone major changes in recent years.
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3. Findings: Benefits of Fruit in Schools
The findings in this section are drawn from an online survey of principals of Fruit in Schools schools, and interviews with 15 key informants – 10 principals and 5 regional Health Promoting Schools facilitators.
The survey was conducted in October 2014 and all 467 principals of Fruit in Schools schools were invited to participate. The response rate was 81%; a very high response rate for this type of survey.
Ten principals were randomly selected from the 186 who were willing to be contacted for a follow up interview, and were interviewed over the phone in November 2014. There was a good geographical spread, and a range of different school types represented. Four were in a main urban centre, four in provincial towns, and two in rural settings. School size ranged from two classes to over 470 children, and school types included Kura Kaupapa Māori , an area school (Years 0-‐13), contributing schools (Year 0-‐6) and full primary schools (Year 0-‐8).
Five Health Promoting Schools facilitators were interviewed to inform the evaluation. Health Promoting Schools facilitators work with schools across their region to support the implementation of the Health Promoting Schools programme. They are generally employed by the District Health Board in each region.
3.1 Fruit in Schools feeds hungry children According to principals, feeding hungry children is the number one benefit of Fruit in Schools. 85% of principals surveyed reported their school had fewer hungry children as a result of Fruit in Schools. 80% reported reduced stigma as a result of Fruit in Schools, and said that children are more willing to ask for food if they were hungry.
The importance of Fruit in Schools as a food security initiative was also reflected in the interviews with principals, who reported that children coming to school hungry and/or bringing little or no lunch was a major issue.
‘Our children have pathetic lunches, or none at all... so Fruit in Schools and other programmes we have, like the milk and other things, offset that and give these children maybe the only fruit-‐slash-‐vegetable that they might have that day’ (Principal).
Both principals and Health Promoting Schools facilitators stressed that Fruit in Schools was valuable not only because it was filling children’s tummies, but because it was doing so with nutritious food:
‘For some of our kids, coming to school hungry is a big issue…The key thing is ensuring that the kids get quality nutrition during the day…so for us it has established really good eating patterns for our kids; our kids aren’t hungry, and everyone benefits’ (Principal).
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The health and nutritional benefits of Fruit in School are discussed further in 3.3 below.
Principals generally framed hunger primarily as an educational issue, rather than (or as well as) a health or social issue. For example:
‘It makes a huge difference. Some of our children don’t come to school with adequate food, particularly on benefit days, and therefore the Fruit in Schools allows those children to be fed and to nurture their brain ready for learning’ (Principal).
One Health Promoting Schools facilitator (who had been a high school teacher prior to her current role), commented that before Fruit in Schools, the issue of hunger had not really been on the radar as an education issue. She said:
‘(Fruit in Schools) was really the core, the beginning of really looking at ‘how hungry are our young people?’ It was the foundation (for addressing hunger and lack of food security)’ (Health Promoting Schools facilitator).
Another said that feeding hungry children is now part of the culture of primary schools:
‘It’s part and parcel of the ethos and the culture of the school now. It’s not a priority area, it’s just normal. “If we’ve got hungry kids we just feed them”’(Health Promoting Schools facilitator).
A Health Promoting Schools facilitator explained that this culture change came about largely because teachers and principals saw for themselves, through Fruit in Schools, what a difference nutrition made to learning and classroom management. Another Health Promoting Schools facilitator had a different view, and said most schools were already aware of the link between nutrition and learning prior to Fruit in Schools.
3.2 Fruit in Schools contributes to academic outcomes Many principals believed Fruit in Schools was making a valuable contribution to academic outcomes. For example, one principal of a Kura Kaupapa Māori felt Fruit in Schools had played a key role in lifting achievement at her school:
‘We know in the long run the fruit is good for achievement, for Māori achievement, and it’s happening at this school because of Fruit in Schools’(Principal).
Another principal noted that a range of factors come together to support achievement, and Fruit in Schools was one of those factors:
‘In our school these kids enter our school with low levels of literacy and numeracy, and they very quickly accelerate. We don’t attribute that necessarily to Fruit in Schools, but it helps. The kids are able to concentrate through the day, their energy levels are maintained through the day, so that’s definitely a factor’ (Principal).
In the survey, 72% of principals agreed or strongly agreed that ‘if Fruit in Schools was ended, academic outcomes would suffer.’ Principals explained that the main way fruit provision contributed to academic
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outcomes was by providing ‘brain food’ that enabled children to concentrate and stay on task. Some also felt Fruit in Schools was contributing to learning by providing authentic learning opportunities, reducing behaviour problems, and improving attendance and engagement. These four pathways to improved academic outcomes are described in more detail below.
Concentration
In the survey 74% of Principals reported that they had observed increased concentration in class as a result of Fruit in Schools. Furthermore, 82% agreed or strongly agreed that ‘if Fruit in Schools was ended, concentration would suffer.’ The principals who were interviewed saw a direct relationship between nutrition and children’s ability to concentrate and learn. For example:
‘You can’t learn if you’re hungry’ (Principal).
‘(The children have a fruit break), and they return to their learning and they’re focused and ready to go again’ (Principal)
‘We believe that healthy food supports a healthy brain, which therefore is better energised to support learning opportunities…that’s good logic, and we certainly observe that food in a child’s stomach early in the day at least it takes away that distracter from learning which otherwise would be there’ (Principal).
Learning opportunities
89% of the principals surveyed agreed or strongly agreed that ‘Fruit in Schools provides a range of authentic learning opportunities.’ The principals who were interviewed described some of these, for example:
• linking the fruit provision with mathematics: counting, fractions and so on • learning about cooking and food preparation by making cakes, smoothies etc with the fruit • triggering inquiry learning e.g. about grafting fruit trees • linking with the health curriculum • leadership opportunities e.g. fruit monitors • learning to recognise and name a wide range of fruit and vegetables.
One principal commented:
‘There’s been maths links made at times, there’s obviously been health links made at other times, and sometimes even – I mean, when we first started (Fruit in Schools) there were children who didn’t even know what a pear was, they’d never seen one, and so…there have been times when our children have been introduced to fruit that they’ve never tasted or seen before’ (Principal).
Both principals and Health Promoting Schools facilitators commented that basic knowledge (e.g. knowing what a pear or a pineapple was) could not necessarily be taken for granted in low decile
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schools. Eating a range of fruit was seen as a valuable experiential learning opportunity in itself, and helped to build both knowledge and appreciation:
‘We’ve had to teach them how to love fruit because they haven’t had it. Sometimes you get a bit of a lump in your throat when they see (a fruit they haven’t seen before) and say “What’s that whaea? What’s it taste like?”’(Principal).
Behaviour
Many principals observed a relationship between nutrition and behaviour, with 46% reporting fewer behaviour problems as a result of Fruit in Schools. One survey respondent commented:
‘The nutritious fruit available on demand -‐ Year 0-‐6 are able to help themselves to as much as they want during play and lunch times -‐ has had, I believe, a noticeable effect on behaviour. The whole school is more settled, kids feel good’ (Principal).
Three out of ten of the principals interviewed also mentioned that improved behaviour was a key benefit of Fruit in Schools. For example:
‘If you’re hungry you’re going to be cross, you’re going to be unhappy, so children need food – it’s not rocket science – and for children in some families, they rely on the fruit in schools (Principal).
‘The key benefits are – it feeds the hungry. And when you’re hungry, that can produce behavioural issues, so it’s helped to diminish that’ (Principal).
Attendance and engagement
One principal noted that attendance had improved because of Fruit in Schools, since parents were no longer keeping children at home because of inability to provide a school lunch:
‘Over the time that we’ve had Fruit in Schools, we certainly don’t have a problem with absence any more at all…Parents at one time were not sending their child because they didn’t have any money (to provide food), but now all our parents, our community knows “send the kids to school”. It’s huge’ (Principal).
This comment was supported by the survey findings: 54% of principals agreed or strongly agreed that ‘if Fruit in Schools was ended absenteeism would increase’ and 60% of principals observed that children were more engaged with school as a result of Fruit in Schools.
3.3 Fruit in Schools Improves health
Impacts of increased fruit consumption
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Both principals and Health Promoting Schools facilitators agreed that Fruit in Schools was providing direct health benefits for children in low decile schools due to increased consumption of fresh produce, and wider dietary changes triggered by Fruit in Schools. For example, in the survey:
• 66% of principals reported they had observed an improvement in students’ general health as a result of Fruit in Schools;
• 43% had observed fewer cases of school sores and skin infections; • 35% said students had fewer sick days due to Fruit in Schools; and • 91% agreed or strongly agreed that ‘the overall health of children would decline’ if Fruit in
Schools was ended.
These findings were backed up in the key informant interviews, for example one principal said:
‘It’s been a huge benefit in terms of raising the health outcomes of our children, keeping them healthy, particularly through the winter months. [So you’ve noticed quite a difference?] Oh, absolutely. I don’t have data in front of me but there certainly have been times when there have been outbreaks of colds and things like that in different schools… and we’ve noticed, anecdotally, that our children survive those (outbreaks) much better than they have in the past. We’re less likely to have children away than we’ve had in the past’ (Principal).
Several principals and one Health Promoting Schools facilitator also noted the impact on emotional and mental health, saying that the kids ‘felt good’ because of the fruit provision. One said:
‘I think it’s the best thing they ever did…Because when you see how that one piece of fruit a day has changed the outlook of all these young people, you cannot be anything but eternally grateful for that to have happened’ (Health Promoting Schools facilitator).
Principals said that fruit was unaffordable for many families. One commented:
‘For many children that’s the one piece of fruit they will get for that day, which they will get five days a week. They won’t get it on Saturday and Sunday, and they so look forward to it. It’s not because the whānau expect it to be there, it’s just the reality that fruit is a luxury in a low decile area’ (Principal).
In the survey almost all principals (97%) agreed or strongly agreed that ‘if fruit in schools was ended many of our kids would eat little or no fruit’.
Improving awareness, attitudes and knowledge about healthy eating
The key benefit of Fruit in Schools from the perspective of Health Promoting Schools facilitators was the normalising of fruit eating and creation of healthy habits. Some considered that, from a health perspective, the potential life-‐long impact of the programme on the young participants may be even more valuable than any immediate impacts observed. This point was also raised by several principals who said for example:
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‘It’s getting to children and helping them see the importance of eating fruit, and making sure they get into the habit of eating it regularly’ (Principal).
‘I think for a school like ours it’s a really key thing, and it not only has health benefits but introduces children to the idea that fruit should be part of your diet’ (Principal).
In the survey, all principals (100%) reported that Fruit in Schools contributes to awareness among staff and pupils about the importance of healthy eating, and 92% said the programme contributed ‘a lot’ to this outcome. Similarly all (100%) said Fruit in Schools contributed to positive attitudes among pupils about eating fruit and vegetables, with 91% saying it contributed ‘a lot’. Almost all reported that the programme contributed to awareness about the ‘5+ a day’ message (99%), and increased knowledge among pupils about nutrition and health (98%).
3.4 Fruit in Schools supports a healthy school environment Nutrition and healthy eating
86% of principals agreed or strongly agreed that ‘nurturing the health and wellbeing of pupils is core business for primary schools,’ and evaluation findings indicate that almost all Fruit in Schools schools have broader nutrition and healthy lifestyle initiatives in place. Examples include a school garden (82% of schools), cooking at school (72%), initiatives to encourage parents/whānau to pack healthy lunches (63%), and changes to what is sold in the tuck shop (37%). School orchards were a widespread new initiative, with four out of ten principals interviewed reporting their school had planted fruit trees in recent years. Other measures mentioned by principals were a healthy food policy, inclusion of food and nutrition goals in the school charter and/or strategic plan, a decision not to sell chocolate as a fundraiser, and a ‘water-‐only’ policy at school.
Health Promoting Schools facilitators commented that environmental and policy changes made by schools were generally sustained long term, and almost all Health Promoting Schools continue to include a focus on nutrition:
‘They’ve looked at various things around the whole nutrition aspect…Nearly every one of our schools have got something around nutrition. Some have done it through nutrition policies, some have looked at canteen practices, there’s been a wide range of different approaches’ (Health Promoting Schools facilitator).
The extent to which these wider nutrition and healthy eating initiatives were attributed to Fruit in Schools varied from school to school. In the survey 84% of principals agreed or strongly agreed that ‘Fruit in schools has been a catalyst for action on other issues in our school.’ When Fruit in Schools was first rolled out, schools were required to become a Health Promoting School in order to receive the fruit and there was professional development for teachers attached to the programme, and so for some schools Fruit in Schools was definitely a trigger for wider consideration of health issues. As one Health Promoting Schools facilitator explained, once schools were engaged with Health Promoting Schools they could see the value in it for its own sake, and it became self-‐sustaining:
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‘(Fruit in Schools) was a carrot to get people to engage with us [Health Promoting Schools] and to look at health as an issue within the school or kura. And it was quite a good carrot for getting schools on board. And some schools then realised that actually they didn’t need the carrot, that actually it is something that’s good to do’ (Health Promoting Schools facilitator).
To be clear: this did not mean that schools no longer wanted the fruit provision – quite the opposite. Some schools still see Fruit in Schools as the foundation of their wider food and nutrition approach, as demonstrated in the following quotes:
‘Fruit in Schools has actually pushed us to push other things out that weren’t so good like sweets in lunchboxes and replacing them with fruit. We’re a water drinking school now…and that’s part of the Fruit in Schools, it’s like salt and pepper -‐ they go together. It sits in the middle, the fruit, and then around that we build all the other things’ (Principal).
‘We’ve taken deliberate steps to be a Health Promoting School, and with that (we encourage) healthy food choices, so… we don’t allow sugar sweetened drinks on site, we save any fatty or fried food for one day a week, and our staff are aware that if we have any kind of promotion on site – like today is pet day -‐ that there are only healthy options out there. So there has been a link to that, and really that did stem out of that initial work with Fruit in Schools and the four pillars of health’ (Principal).
However some schools were already active Health Promoting Schools at the time Fruit in Schools was rolled out and some introduced a range of health and wellbeing initiatives (including Fruit in Schools) at around the same time. These schools tended to view Fruit in Schools and other health initiatives as complimentary to one another, and did not attribute wider changes to Fruit in Schools specifically. For example, principals commented:
‘It works together with other initiatives. It works together with our healthy food policy, and it works together with our kaupapa it takes a village to raise a child. It all fits nicely together. We’re a project Energise school, so it works in with that too, and it fits into our charter, our vision of what our community sees as important, which is our kids being healthy’ (Principal).
‘It is hard to attribute changes to one particular component, however Fruit in Schools is a big part of our healthy lifestyles push’ (Principal).
‘We had a healthy eating policy before Fruit in Schools. This programme compliments what we do in our kura’ (Principal).
Interviewees said Fruit in Schools supported other initiatives by providing a tangible daily reminder about healthy eating. Almost all survey respondents (96%) agreed or strongly agreed that ‘Fruit in Schools helps to keep health and wellbeing on the agenda.’ 93% of principals reported that Fruit in Schools contributes a lot to staff and student awareness about healthy eating (with the remaining 7% reporting that it contributes ‘a little’ to this outcome). 75% said Fruit in Schools contributes a lot (and a further 24% said it contributes a little) to staff and student awareness about the ‘5+ a Day’ message.
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Physical Activity, Sunsmart & Smokefree
Some interviewees observed that there was a continuing focus on the ‘four pillars of health’ that were promoted at the outset of Fruit in Schools: healthy eating, physical activity, sun protection and Smokefree. For example one Health Promoting Schools facilitator said:
It’s ongoing. I mean the Cancer Society says that in (this region) nearly all the schools are Sunsmart accredited and re-‐accredited, the National Heart Foundation are there, all the schools are actively involved in Smokefree initiatives, and physical activity. It’s ongoing, it’s become sustainable, and I think that is also because of Health Promoting Schools’(Health Promoting Schools facilitator).
However, this did not seem to be the case in all regions. Another Health Promoting Schools facilitator said that, of the four issues originally introduced with Fruit in Schools, the one that schools were still focused on as a priority in his area was food and nutrition, and also physical activity to a degree. ‘Sunsmart yes, but it’s not a priority, and Smokefree is not a priority’ (Health Promoting Schools facilitator).
Physical activity certainly seemed to be a focus in many schools nationwide with 59% of principals reporting that Fruit in Schools has triggered or supported increased opportunities/encouragement for kids to be physically active during breaks, and 41% reporting increased physical activity during class time. Half said that a local sports trust had supported health promotion initiatives in the school in the past year, and a number of schools mentioned that they were part of Project Energize.
Oral Health
Although it was not initially a focus-‐area for Fruit in Schools, 40% of schools mentioned that Fruit in Schools had triggered or supported oral health initiatives, such as provision of toothbrushes to children and/or tooth-‐brushing promotion. Principals also mentioned that initiatives like a water-‐only policy, and banning fizzy drinks and lollies from lunches and tuck shops had a positive knock-‐on effect on oral health. One principal commented:
‘Our teeth are not good in this area, because many of the kids don’t own a toothbrush, but she (the dental nurse) had to admit a big improvement since Fruit in Schools was introduced so there’s got to be a connection’ (Principal).
Overall 30% of principals said they had observed improved dental health/hygiene as a result of Fruit in Schools.
Overall school environment
One Health Promoting Schools facilitator said that the whole environment in schools has become healthier -‐ mentally, physically and emotionally -‐ and that Fruit in Schools has played a key part, because it demonstrated – even to those initially sceptical or opposed to the programme -‐ that children learn better if their physical and emotional needs are met. Other Health Promoting Schools facilitators and
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principals agreed that addressing child health and wellbeing was now part of the ethos of many schools: ‘It’s just who we are’ (Principal).
Comments suggested that Fruit in Schools also contributed to cultural wellbeing by supporting Māori values and practices such as manaakitanga, for example:
‘(Fruit in Schools supports) manaakitanga -‐ taking school fruit to share with others when attending school events/trips and sharing with manuhiri when and if we can’ (Principal).
The principal at one school where students were allowed to help themselves to fruit at any time said:
‘The food is available to them ‘just like being at home’. It contributes to the ‘whānau’ learning environment which we put a lot of energy into creating’ (Principal).
Social benefits
According to 80% of principals, Fruit in Schools contributes ‘a lot’ to a sense of equality between pupils, regardless of their family circumstances. A further 15% thought Fruit in Schools contributed ‘a little’ to that outcome. Principals explained:
‘We call the ‘read and feed’ time (when children eat their fruit) ‘social time’, and because it’s social time there isn’t any child that stands out more than anyone else’ (Principal).
‘It takes the stigma away, and that’s huge…When you’re giving someone fruit, you’re not giving them rubbish, you’re giving them quality, and it’s a very even, equal thing to be giving out. It doesn’t create a divide and it doesn’t create judgement’ (Principal).
Environmental benefits
Several principals saw links between Fruit in Schools and environmental initiatives such as composting, waste management and Enviroschools.
Community and health sector engagement
47% of principals said Fruit in Schools contributes ‘a lot’ to engagement between school and families/whānau, and a further 41% said it contributes ‘a little’ to this outcome. Interviewees explained that families were appreciative and supportive of Fruit in Schools, it raised awareness about the importance of fruit and vegetables with whānau, and also said that fruit was often sent home to families when there were leftovers. However principals reported it was the wider Health Promoting Schools approach that had really made a difference to this outcome. One principal said:
‘Fruit in Schools has helped indirectly by raising awareness, but linkage with the community hasn’t been a direct result of Fruit in Schools. It was certainly part of the discussions we were having with the community, but it was more due to Health Promoting Schools and the general approach, not Fruit in Schools specifically’ (Principal).
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One Health Promoting Schools facilitator commented that initiatives like school gardens had helped to enhance community spirit and broken down barriers:
‘Parents of the lower social and economic strata, and in particular young Māori parents, felt very intimidated coming into a school, where now those barriers are dropping away and they are actively becoming involved’ (Health Promoting Schools Facilitator).
The same facilitator commented that Fruit in Schools had strengthened pre-‐existing relationships between schools and health promotion agencies, and helped to forge new ones. Although Fruit in Schools no longer ‘officially’ has a focus on physical activity, Sunsmart or Smokefree, schools reported ongoing linkages with a range of health promotion agencies. For example, 67% reported getting support from a DHB Health Promoting Schools facilitator in the past year, 51% had recieved support from a sports trust, 43% from the Heart Foundation, 35% from the Cancer Society, and 25% from Smokefree.
3.5 Fruit in Schools supports a healthy home environment
Principals reported that Fruit in Schools was having a positive impact on children’s home environment and parental behaviours, at least in some families. For example 44% of principals reported that ‘many families’ were providing less sugary drinks and junk food in school lunches, and a further 40% said ‘a few families’ were doing so. Table 1 below presents findings from the survey:
Table 1: Based on feedback from parents, pupils and staff, has Fruit in Schools contributed to any of the following changes at home?
Yes, many families
Yes, a few families
No Don’t know
Less sugary drinks and junk food in school lunches
44% 40% 8% 7%
More fruit in kids’ lunchboxes 25% 47% 18% 11% Families grow more fruit and veges at home
8% 34% 12% 45%
Positive changes to food shopping habits 11% 35% 5% 49% Children are more involved in preparing meals
10% 31% 5% 54%
Kids eat more fruit and veges at family meals
15% 27% 4% 53%
Although many principals had limited knowledge about what was happening in pupils’ homes, the general picture was one of positive change. Participants explained that families were influenced by children bringing ideas and attitudes home from school, for example:
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‘Our school gardeners report that some of them have started family gardens at home’ (Principal).
However, as the following quote illustrates, financial barriers may limit the extent that children can influence their parents:
‘It’s also feeding through into the community as well, because the kids are used to eating fruit and they’re encouraging their parents to buy it. But I still don’t believe that parents have the financial ability to be able to buy fresh fruit all the time for their kids’ (Health Promoting Schools facilitator).
Families were also potentially influenced through school policies (e.g. bans of certain items from lunchboxes) and initiatives such as nutrition tips and recipes in the school newsletter. One principal explained:
‘It’s not just a hand out. It’s got to have an associated message with it, and we certainly emphasise that both with the children…and also in our fortnightly school newsletters that go out to parents. We do have a ‘healthy tip’ and we often allude to the importance of healthy food, fruit and so on, and recommended foods to allow for in the home’ (Principal).
According to some principals, particularly those in urban areas, their school went to considerable lengths to try to influence, educate and support parents in relation to healthy food and nutrition, sometimes with rather limited success. For example one principal said his school had provided parent workshops about nutrition and healthy lunchboxes, but these had been poorly attended. Another had partnered with a local NGO to offer a fruit and vegetable co-‐op enabling families to receive a box of produce for $10 per week. However there was little up-‐take from parents, which the principal was at a loss to explain. She said:
‘The thing I worry about is whether or not we are actually shifting attitudes. And I think with this generation, the kids may grow up with this because they’ve lived with it for so long, which is a good reason for continuing it, but I’m not sure that we’ve shifted their parents and their thinking’ (Principal).
This concern was also shared by other principals, who talked about the ‘uphill battle’ against ‘rubbish’ in lunchboxes.
3.6 Overall benefit of Fruit in Schools
Principals valued Fruit in Schools highly, and believed it was very beneficial for their school and the wider community. Survey respondents were asked to rate the overall effect of Fruit in Schools on a scale from 1 (‘Has had no positive effect’) to 10 (‘Has had a very positive effect’). 87% rated it 8, 9, or 10, with 46% of principals giving Fruit in Schools the highest possible rating – 10.
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Interviewees all talked about Fruit in Schools in very positive terms, for example:
‘I’m one happy principal, I wouldn’t change it for the world, and I’d be devastated if it stopped’ (Principal).
‘I think it’s one of the best initiatives that’s ever come out to schools’. […]I believe it does have an impact on our children – on their health, on their wellbeing, on their behaviour, on their effort in class – and those are the types of things that we’re really keen on when we’re looking at how we can support children. And because we see it as such a gap in our community -‐ fruit and vegetables, healthy lunches, and actually having food (at all) -‐ this is a way that our children are provided with those things that we might call basics, but they’re not for them, sometimes they’re luxuries’ (Principal).
Almost all of the principals interviewed expressed concern about the possibility of the programme being cut, even though the interview did not include specific questions on this issue. Principals’ unsolicited comments included:
‘I just ask myself – how could we sustain this if the government turned around and said “we’re not paying for this anymore”? How could we sustain it? Because we would have to. And that’s my big question – I don’t know. What would we do?’ (Principal).
‘I’ve always thought it could happen, but I’d be devastated if Fruit in Schools stopped, I really would. I think I’d honestly cry for a few days’ (Principal).
Health Promoting Schools facilitators were also strong advocates of the programme, due to its wide reaching benefits. One had the following message:
‘Please don’t stop the fruit. That is our biggest fear up here: that it’ll stop’ (Health Promoting Schools facilitator).
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4. Findings: Success Factors and Suggestions
4.1 Which programmes are most valued by schools and why?
A range of programmes and agencies that support child health in schools were highly valued by principals. These included Regional Sports Trusts, Fruit in Schools, Milk in Schools, other food provision programmes, the Heart Foundation, social services providers, public health nurses and school health clinics. Schools also valued local support for food and nutrition initiatives from local businesses, church groups, voluntary organisations and parents/whānau.
Such support was valued because principals saw a clear need in low decile communities to address the impacts of poverty so that children’s health and educational achievement did not suffer. They also appreciated the specialist skills and knowledge that external agencies were able to bring.
Most principals saw the various programmes as mutually supportive, each making a valued contribution to the school’s overall goals. For example one South Auckland school said their environmental and health promotion initiatives worked together:
‘It’s all a complete package. The other thing we’ve got now is a health clinic at school with a focus on rheumatic fever and skin conditions– that’s making a huge difference. Now any child with a sore throat is swabbed, and in the winter we were coming up with 11 positive throat swabs a week’ (Principal).
However one principal of the ten interviewed valued Fruit in Schools above other initiatives:
‘It’s a clear winner because 1) the easy access to it; 2) the nutrition and health benefits to the child; 3) keeping them focused and on-‐task, and also the learning spin offs from it’ (Principal).
Interestingly, two of the principals interviewed (both at large urban schools) said they had chosen not to have a breakfast programme at school. One explained that he did not believe in breakfast programmes because they took away responsibility from parents, and he objected to schools becoming a ‘welfare state extension’ loaded with ever-‐growing expectations on top of their core role. Both schools took the approach of monitoring if children were coming to school hungry or without lunch and approaching the parents:
‘Then we say “right, we’ve got a social worker in the school who’s going to work with you and assist you to contact the right agencies and get that support”’ (Principal).
Another principal said they had tried to link with a particular health promotion agency ‘but there was just too much work involved…to move through all these levels, it was just too much to do’ (Principal).
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4.2 Success factors for Fruit in Schools
The majority of principals and Health Promoting Schools facilitators were in agreement about a number of success factors for Fruit in Schools:
• It is meeting a genuine need and making a real difference • It is very well managed, and easy for schools to participate • The fruit and vegetables provided are varied and of high quality • It has been consistent and reliable over many years
These factors, and that fact that the programme is delivered at no cost to schools or communities, have made Fruit in Schools sustainable from the schools’ perspective.
Easy
5+ A Day was praised by several key informants for the smooth running of the programme, good communication with schools, and their quick response on the rare occasions that something went wrong with the delivery or the quality of the produce. A couple of principals mentioned that the lack of paperwork and the ‘no strings attached’ nature of the programme also made it easy for schools:
‘Fruit in Schools is great because it arrives, the kids need the food, we know that fruit’s healthy for them…and we’re not having to prove ourselves all the time or fill out forms’ (Principal).
Principals commented that because they had set up good internal processes and the delivery of fruit was so reliable, the programme worked ‘like clockwork’ and took very little day to day effort.
Universal
The fact that the fruit is provided to all the children in the school was seen as important by two of the interviewed principals. One said:
‘I think the best thing about it is that…there’s no baggage around its delivery – it’s for everybody. I think if you actually targeted it to ‘at risk’ families there would be issues around it’ (Principal).
Tangible
Two principals commented that the fruit provision set Fruit in Schools apart from many other programmes because it provided a tangible and experiential daily reminder for schools and communities:
‘It’s visual, you know. Not just talking about it, but you can see it, it’s visual, it’s here. It’s in all our classrooms and our whānau know about it, and our community’ (Principal).
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4.3 How could the Fruit in Schools programme and resources be improved?
All of the principals interviewed were happy with the way Fruit in Schools was being delivered and most could not think of any way in which the programme could be improved. However there were a few suggestions made by key informants which are outlined below.
Expand the programme
Several principals and Health Promoting Schools facilitators said the programme should be expanded to higher decile schools, since food insecurity and poor nutrition are not limited to decile one and two schools:
‘I think it should go to every school...Even in high decile schools there are still pockets of poverty we see in those areas. That would be my biggest thing’ (Health Promoting Schools facilitator).
This finding was also reflected in the survey in which 83% of principals agreed or strongly agreed that ‘Fruit in Schools should be extended and made available to all decile 3 and 4 schools.’ One Health Promoting Schools facilitator said the programme should be expanded to low decile secondary schools so that the good eating habits continue to be supported as children grow up.
Opportunities to engage and say thank you
Several principals wanted to ensure that students did not take the fruit provision for granted, and were concerned about young people becoming dependent on handouts. Ideas included putting a face to the programme, and providing opportunities for students to write thank you letters:
‘It would be really good to have someone from Fruit in Schools...to come in when we do our PB4L2 assemblies, and introduce themselves and have a wee chat...I’d like the children to understand that this is fantastic and maybe have a relationship with the Fruit in Schools person, even if they just see that person once a year, then they’re able to send a thank you card or an email... “Look we made a recipe from your fruit!”’ (Principal).
Connecting with other schools
One principle said it would be valuable to have some way of schools being about to connect with each other around how they use Fruit in Schools, for example sharing what they have done to capitalise on learning opportunities and the way they’ve linked with other programmes.
Teaching resources
2 PB4L stands for ‘Positive Behaviour for Learning’. This is a Ministry of Education initiative that provides a range of evidence-‐based programmes and frameworks to support schools to improve the behaviour of young people. PB4L is aimed at improving learner engagement and achievement by improving behaviour.
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95% of principals agreed or strongly agreed that ‘The 5+ A Day teaching resources help to reinforce healthy eating messages’. The principals who were interviewed were in broad agreement that the resources available for teaching about food and nutrition were plentiful and of good quality. In practice, they did not differentiate between resources provided by 5+ A Day and other resources in this topic area, so feedback is general rather than specific to the 5+ A Day resources. Principals either said they could not comment, or were positive about the resources, e.g.
‘I think they’re very cool, they’re very neat and engaging as far as younger people are concerned, and I know the junior teachers manage them really well’ (Principal).
The only gap mentioned was a lack of resources in Te Reo Māori . One principal explained that her Māori medium school only uses classroom resources that are in the Māori language, so Māori translations (e.g. on a website, if not hard copy) would be valued. Another teacher in a predominantly Māori school mentioned the importance of using pictures and stories that rural Māori children could identify with:
‘Our kids find it hard to relate to some of the pictures because they’re quite town-‐orientated. We live next to a mountain, surrounded by the natural forest and farms so when we see the books, we can’t relate to it because…it’s not what they see (in their daily life)’ (Principal).
She also suggested the idea of incorporating health and nutrition messages into reading books, or a theatre production that visits schools, similar to the Books in Homes3 initiative, or linked to that programme.
Principals said that teachers and pupils are increasingly using the internet for teaching resources and inquiry learning, so provision of electronic resources should be a priority. One commented:
‘The times of having a big resource room with all sorts of different (hard copy) resources are coming to an end…So I think that organisations like 5 + A Day and others need to be looking at what they’re providing around e-‐learning, because I think that’s the future for schools’ (Principals).
5. Evaluative conclusions
Based on the findings of the current evaluation, we conclude that Fruit in Schools is an effective food and nutrition programme with wide ranging benefits. It is highly valued by schools and well aligned with international evidence on how to improve nutrition and reduce obesity in children. Demonstrated benefits in the New Zealand context include:
Educational benefits
• Improved concentration in class
3 See http://www.booksinhomes.org.nz/Page/AboutUs/WhatWeDo.aspx
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• Provision of authentic learning opportunities • Fewer behaviour problems • Improved attendance • Improved engagement with school
Health benefits
• Improved awareness, attitudes and knowledge about healthy eating • Increased consumption of fruit and vegetables • improved general health and resistance to illness • Fewer cases of school sores and other skin infections • Fewer sick days • Improved oral health
Social benefits
• feeds hungry children • reduces stigma associated with hunger and poverty • contributes to a sense of equality amongst pupils • supports Māori values and practices such as manaakitanga
Wider health promotion benefits
• keeps health and wellbeing on the agenda in schools • acts as a catalyst for other food and nutrition initiatives • complements and supports other health and sustainability initiatives such as school gardens and
orchards, healthy food policies, Project Energize and other physical activity programmes, Enviroschools etc
• has some impact on children’s home environment and parents’ behaviour
Principals and Health Promoting Schools facilitators viewed Fruit in Schools as a successful and sustainable programme within schools and identified the following key success factors:
• It is meeting a genuine need and making a real difference • It is very well managed, and easy for schools to participate • The fresh produce provided is varied and of high quality • It has been consistent and reliable over many years.
The only suggestion for improvement that was widely voiced was an expansion of Fruit in Schools beyond decile one and two primary schools. Other suggestions were to make resources available in Te Reo Māori , and ensure that they appeal to young Māori including those in rural areas.
The findings of the current evaluation reinforce and update the findings of previous evaluations and show that Fruit in Schools is still a much needed and highly valued programme. We recommend that
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Fruit in Schools is continued and consideration is given to the expansion of the programme to decile 3 and 4 schools, and low decile secondary schools.
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References
5+ A Day (n.d.) Fruit in Schools Telephone Survey Comparison-‐ 2008 and 2009. Unpublished report.
Boyd S, Dingle, R & Hodgen E (2009) The changing face of Fruit in Schools: 2009 overview report. Final Health Futures evalution report prepared for the Ministry of Health. Wellington: New Zealand Council for Educational Research.
Colmar Brunton (May 2010a) Fruit in Schools research: Gauging public opinion of Fruit in Schools initiative [Presentation]. Auckland: Colmar Brunton.
Colmar Brunton (July 2010) Fruit in Schools [Presentation]. Auckland: Colmar Brunton.
European Commission (2012a) Annex 5: Overview of the British School Fruit and Vegetable Scheme. Retrieved from http://ec.europa.eu/agriculture/evaluation/market-‐and-‐income-‐reports/2012/school-‐fruit-‐scheme/annex5_en.pdf
European Commission (2012b) Report from the Commission to the European Parliament and the Council in accordance with Article 184(5) of Council Regulation (EC) No 1234/2007 on the implementation of the European School Fruit Scheme. Brussels: European Commission.
Lytle l (2012) Dealing with the childhood obesity epidemic: a public health approach. Abdom Imaging 37(5):719-‐24.
Ministry of Health (2003) Healthy Eating, Healthy Action Strategy. Wellington: Ministry of Health.
Ministry of Health (2003) New Zealand Cancer Control Strategy. Wellington: Ministry of Health.
Ministry of Health (2005) New Zealand Cancer Control Strategy: Action Plan 2005-‐2010. Wellington: Ministry of Health.
Ministry of Health (2006) Fruit in Schools loose-‐leaf kit May 2006. Wellington: Ministry of Health.
Ryall T (2009, October 29) Fruit in schools future confirmed [Press release]. Retrieved from http://www.beehive.govt.nz/release/fruit-‐schools-‐future-‐confirmed
Walton, M (2014) Applying a complexity lens to health policy and evaluation, unpublished manuscript, Wellington, Massey University.
Waters E, de Silva-‐Sanigorski A, Hall BJ, Brown T, Campbell KJ, Gao Y, Armstrong R, Prosser L, Summerbell CD. (2011) Interventions for preventing obesity in children. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD001871. DOI: 10.1002/14651858.CD001871.pub3.
Appendix A: Evaluation methods
Project Plan A project plan, outlining the scope and methods for the evaluation, was developed by Quigley and Watts in collaboration with 5+ A Day Charitable Trust, and signed off on October 2nd 2014. Minor adjustments, for clarification, were made as the project progressed.
Evaluation objectives The primary purpose of the evaluation was:
• to understand and document the benefits of Fruit in Schools, in particular any wider health promotion impacts, with a particular focus on nutrition and healthy eating.
Secondary aims were to:
• explore success factors for Fruit in Schools, and other programmes that support child health and health promotion in schools.
• gain feedback on teaching resources provided through the 5+ A Day Charitable Trust • explore how the programme could be improved
Research Questions The data collection and analysis were guided by the following overarching research questions:
1. What are the impacts that FIS is having on children/families/schools? Impacts may include: a. Knowledge, awareness and attitudes about nutrition and other health issues
(staff/students/parents) b. Health promoting behaviour (e.g. changes in eating habits, contents of lunchboxes,
physical activity etc) c. Health promoting school activities (e.g. gardening, cooking, physical activity initiatives,
smokefree initiatives , sunsmart initiatives) d. Health outcomes (e.g. general health, sick days, dental health, skin health) e. Education (e.g. concentration, behaviour) f. School-‐community linkage (e.g. new or better links with parents/whānau, community
groups, health promotion organisations)
2. What is the value of FIS to schools, and what is it about FIS that makes it effective (particularly in comparison to other programmes that provide food in schools)?
3. What are stakeholders’ perceptions about teaching resources provided by 5+ a Day Charitable Trust?
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4. How could FIS be improved?
Document and Literature Scan This phase of the work involved a review of programme documents and a relevant New Zealand and international literature. Based on this review a programme description was developed, including background information on the history and purpose of Fruit in Schools, and the current context and operation of the programme. Evaluation findings to date about New Zealand’s Fruit in Schools programme were also summarised, along with findings about similar programmes internationally.
Fruit in Schools Survey A brief online survey was prepared using Survey Monkey. The questions were developed in collaboration with 5+ A Day, based on previous evaluations and the aims of the current evaluation. The survey was pre-‐tested internally before being finalised.
Quigley and Watts Ltd emailed a link to the survey to all 467 participating schools for whom email addresses were available (provided by 5+ A Day) on October 20th. Where possible, the survey was sent directly to the principal, but for some schools only an ‘office’ or general email address was available. The subject line and brief cover message made it clear that the survey was to be completed by the principal.
Only one person opted out of the survey. Eight emails ‘bounced’ and 5+ A Day followed up with these schools to obtain the correct email address, where possible. Subsequently Quigley and Watts re-‐sent the survey link to four schools. Two reminder emails were sent out to principals who had not yet responded, and the survey closed on October 31st.
378 responses were received, a response rate of 81%. The results of the survey are provided in full in Appendix B.
Key informant interviews Data collection also included 16 key informant interviews with 10 school principals, 5 Health Promoting Schools facilitators and 1 Ministry of Health official.
Principals
The survey included a question asking principals if they would be willing to participate in a follow up interview; 186 responded ‘yes’. These records were numbered and an online random number generator was used to randomly select 10 principals to be interviewed. Principals were contacted in the order that they were selected, and in all 14 principals were contacted since four were unavailable or declined to be interviewed.
There was a good geographical spread, and a range of different school types represented. Four were principals of a school in a main urban centre, four in provincial towns, and two in rural settings. School size ranged from two classes to over 470 children, and school types included Kura Kaupapa Māori , an area school (Years 0-‐13), contributing schools (Year 0-‐6) and full primary schools (Year 0-‐8).
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Health Promoting Schools facilitators
Health Promoting Schools facilitators work with schools across their region to support the implementation of the Health Promoting Schools programme. They are generally employed by the District Health Board in each region. 5+ A Day provided contact details for Health Promoting Schools facilitators around the country. The evaluators made a purposive selection to ensure a wide geographical spread.
Ministry of Health
The Ministry of Health official contacted had been involved in the Fruit in Schools programme from its outset, and provided a funder’s perspective.
Materials An information sheet was prepared for potential key informants explaining the purpose of the evaluation, the interview procedure, and explaining that their name would not be used in the final report.
Three semi-‐structured interview schedules were prepared to guide the interviews with principals, Health Promoting Schools facilitators and the Ministry of Health official. The questions were based on the aims of the evaluation, and sought add depth to the survey findings.
Procedure In most cases potential participants were invited to be interviewed by email, which included the information sheet about the evaluation. This was followed up by a phone call to establish willingness to be involved, and arrange an interview time. In a few cases the initial contact was by phone (because an email address was unavailable), but in either case, all participants received an information sheet by email. Each interview began with a brief discussion about the purpose of the interview, confidentiality and anonymity, and each interviewee had an opportunity to ask questions. Participants gave verbal consent for the interview to be recorded. They were recorded using a digital voice recorder.
All the interviews were conducted by telephone. The interviews follow a semi-‐structured format based on a pre-‐prepared interview schedule. The questions differed depending on the interviewee’s role in relation to Fruit in Schools, and sought both factual information and key informant perceptions about the programme.
Notes were written up immediately after each interview with reference to the interview recording. Verbatim quotes were marked as such in the notes, and other sections paraphrased.
Analysis The evaluation objectives and research questions formed the framework for analysis. Material relevant to each objective and question was identified in each data source. Material from each data source was analysed and summarised separately, and then brought together and overall findings identified.
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Reporting The evaluation report was organised according to the evaluation objectives. The draft report was internally peer reviewed by a senior Quigley and Watts staff member before being submitted to the client.
Strengths and limitations There was an excellent response rate of to the survey (81%), so we can be confident that the findings accurately reflect the majority views of principals. The use of both qualitative and quantitative methods adds depth to the findings, and triangulation of data sources further adds to the validity of the findings.
A limitation of the evaluation is that it is based on the perceptions and observations of school principals and Health Promoting Schools facilitators. Objective measurement of outcomes was beyond the scope of the current evaluation, as was inclusion of whānau or pupil perspectives.