Priority setting for school nutrition research: developing a collaborative research agenda

Abstract

Priority setting in health research can assist stakeholders to identify research and policies that have the greatest potential for benefits to public health. Priority setting has been utilized by researchers to identify barriers, facilitators, and recommendations for future public health research. This commentary describes how a priority-setting approach was used as part of a workshop activity on the school nutrition environment in Ontario, Canada, to facilitate brainstorming, sorting, and rating of concepts related to the school nutrition environment. This work demonstrates an interesting and concrete case of priority setting, of interest for various planning activities (both programming and research), particularly those around school-based healthy eating programs or a related research agenda.

Introduction

In 1991, New Brunswick adopted the first school nutrition policy in Canada. Now, each province has its own policy that, at a minimum, aims to improve the nutritional quality of food available to students (Province of British Columbia 2013; Alberta Government 2012, Ontario Ministry of Education 2010; etc.). Beyond that, however, policies vary widely in their content, departmental oversight, mandate, and accountability. While some positive health outcomes are attributed to these policies (e.g., increased consumption of milk products, reduced consumption of sugar-sweetened beverages, increased odds of meeting fruit and vegetable recommendations, increased energy expenditure, increase in rates of active transportation) (e.g., Mayne et al. 2015; Fung et al. 2013), barriers also exist. For example, challenges associated with implementing the Ontario School Food and Beverage Policy (P/PM 150) include interpretation of the policy (Vine et al. 2017), forming funding partnerships, lack of volunteers, scheduling and workload (Valaitis et al. 2014), limited designated eating spaces at school, and proximity to external non-policy-compliant food (Vine et al. 2014). Ontario is not alone in identifying these types of challenges, they exist in other parts of Canada as well (Downs et al. 2012; Taylor et al. 2011; McKenna 2010).

Given the many health concerns related to poor eating habits of school students in Canada (Fung et al. 2013), there is need for a more concerted effort across the country to enable students to achieve the benefits associated with healthy eating. Fortunately, a model exists to inform future action. In 2017, we used a priority-setting approach to engage stakeholders in facilitated brainstorming, sorting, and rating of concepts related to research on school nutrition policy. Priority setting in health research can assist stakeholders to identify research and policies that have the greatest potential for benefits to public health (Manns et al. 2014). Face-to-face encounters have emerged as the most efficient way to facilitate collaboration among those working in policy, practice, and research to identify gaps in knowledge and to improve public health (Jansen et al. 2010). The literature on priority setting reveals its many methodological forms, including online surveys (Rosala-Hallas et al. 2018), semi-structured interviews with stakeholders (Cooke et al. 2015), or structured approaches including the nominal group technique (Rankin et al. 2016), the James Lind Alliance Priority Setting Partnership (The James Lind Alliance Guidebook 2018), and the Delphi method (Hsu and Sandford 2007).

In health services delivery and research, priority-setting opportunities have proven effective in identifying what evidence is relevant to implement, how best to implement it, and where the greatest gains can be made in changing clinical practice (Buckley et al. 2013). Less work has been done in priority setting for public health research and policies.

Integrated knowledge translation (IKT) involves the co-production of knowledge through an ongoing relationship between decision-makers (managers, policy-makers) and researchers in order to engage in mutually beneficial research to support decision-making (Kothari and Wathen 2013). An IKT approach was used by Kothari and others (Kothari et al. 2014) to build a public health research agenda in Public Health Systems Research. In doing so, they were successful in bringing together public health researchers, practitioners and policy-makers to identify six top priorities for research in Ontario (Kothari et al. 2014).

We used the priority-setting approach as part of a workshop activity within a research project on the school nutrition environment in Ontario, guided by the challenges of implementing P/PM 150 in Ontario. The school nutrition environment, including the food available in cafeterias, vending machines, and tuck shops, and the policies that shape these offerings play a key role in the dietary behaviours of children and youth (Vine et al. 2017; Vine et al. 2014). This was a collaborative project led by Vine and Leatherdale at the University of Waterloo, with the Ontario Ministry of Education, Dietitians of Canada, and the Ontario Physical Health and Education Association (Ophea) as partners.

The workshop focused on P/PM 150, which sets nutrition standards for all food and beverages sold in public elementary and secondary schools across Ontario (Ontario Ministry of Education 2010). The nutrition standards apply to all food and beverages sold in venues (e.g., vending machines, cafeterias), within all programs (e.g., lunch programs), and during all events (e.g., sports events, bake sales) (Ontario Ministry of Education 2010). Overall, 31 attendees participated in the 2-day workshop in Waterloo, Ontario. Attendees represented researchers, other stakeholders, and trainees (PhD and Master’s level) interested in nutrition. We had representation from six universities across Canada (Brock University, Laurentian University, University of Alberta, University of New Brunswick, University of Waterloo, and York University), four Ontario public health units, two Ontario school boards, and four not-for-profit organizations that focus on nutrition and physical activity. We also had the support of an external facilitator to guide us through the 2 days.

Priority-setting process

Priority setting was utilized to systematically integrate input from workshop participants into statements that describe perceived needs or issues related to school nutrition policy implementation and evaluation within and outside Ontario. Brainstorming, sorting of statements, and rating were undertaken to produce a set of results-based concepts to inform the development of a research agenda.

Its specific objectives included to:

1. Provide an opportunity for health researchers and knowledge users working in the areas of school-based nutrition, food policy, food security, and comprehensive school health to develop partnerships;

2. Provide an opportunity to review, reflect on, and discuss current research and evidence on provincial- and local-level school nutrition policies across Canada and within Ontario (through structured presentations from researchers, the policy-maker, public health personnel, and school board administration); and,

3. Brainstorm and discuss research gaps and opportunities, as well as emerging opportunities for evaluation (e.g., facilitators and barriers to policy implementation, local-level school culture, partnership opportunities) and future research.

The priority-setting process followed three steps:

• Step 1:

  Preparation (i.e., participant selection and development of focus for conceptualization; this occurred prior to the workshop)

Focus prompt: Generate statements that describe the issues or needs related to school nutrition policy implementation within and outside of Ontario.

• Step 2:

  Group brainstorming and generation of statements (i.e., priorities, suggestions, solutions) based on a focal statement. Each group was asked to write their statements on flip chart paper. When satisfied with their statements, these were transferred to individual cue cards and numbered (1, 2, 3...).

• Step 3:

  Step 3 involved a sense-making exercise in order to move forward. As such, statements were sorted and rated:

1. Sorting of statements: each group sorted the statements their group identified during step 2 into piles that represented unique concepts for the group. Each statement fit into a (concept) pile that made the most sense to the group.

2. Rating of statements: each statement was rated to indicate its importance to the participants using a 7-point scale, where “1” meant “Lowest priority”, “4” meant “Moderate priority”, and “7” meant “Highest priority”.

Results

The results from participants included reflections on the policy itself as well as suggestions for research, listed in order of frequency of response. Participants indicated that a lack of understanding about the role of food in schools was a challenge to policy implementation (e.g., is it primarily revenue-generating or is it to provide students with healthy food?). Participants indicated a need to evaluate the compliance and enforcement of P/PM 150 in Ontario schools, including identifying appropriate measures for evaluation. Participants alluded to difficulties associated with policy interpretation at the school level (i.e., applying the nutrition standards). The group identified a number of research opportunities, such as conducting case studies with teachers to better understand perceptions of their roles and responsibilities for policy implementation, and the support (or lack thereof) they receive for implementation. A scan of what and when students are eating at school, including food purchasing behaviours and revenue, would provide a glimpse into broader policy compliance. Results also identified the need to assess whether a regional-level rather than a provincial-level policy would be more appropriate for Ontario.

After the workshop, organizers summarized and synthesized the results and prepared a report for the Ministry of Education (Fall 2018). In late 2019, organizers submitted an evidencea-informed research agenda including policy objectives, the identification of measures and outcomes, and promising practices to the Ontario Ministry of Education to inform the Ministry’s update of P/PM 150. As well, Vine and Leatherdale were invited to be expert advisors in the update of P/PM 150.

Key strengths of the approach

Priority setting is a structured participatory approach to data collection, integrating input from multiple sources. The inclusion of a range of stakeholders (e.g., policy-makers, public health professionals, school board administrators, researchers) invested in school nutrition research and policy was instrumental in developing a research agenda that was reflective of the experiences and needs of participants. The 2-day workshop provided an opportunity for a diverse group of individuals to get acquainted, collaborate, and develop research partnerships that may extend beyond this work. Participants were enthusiastic, engaged, and invested in influencing research, policy, and practice related to the school nutrition environment. Our close partnership with and involvement of the policy-maker allowed us to work together to ensure we had selected the appropriate focus prompt, to ensure we were inviting the right stakeholders, and to garner input on the needs of the policy-maker in developing the agenda, all of which are important for increased likelihood of uptake.

Key limitations of the approach

While priority setting allowed workshop participants to share their experiences working with school nutrition policies within and/or outside of Ontario, it is important to note that the results do not reflect the voice of students, teachers, or parents, nor all the priorities of researchers and policy stakeholders. However, results may reflect some of their experiences with P/PM 150, either through participants’ research or through observations of policy implementation by school board personnel. A future engagement opportunity to include student, teacher, and parent voices is needed.

Conclusions

Almost two generations of students have completed their education in Canadian schools since the first school nutrition policy. Challenges associated with implementing the first policy continue to be challenges today (McKenna 2003). Ontario took this important step to involve practitioners, researchers, and policy-makers to set research priorities for school nutrition policy. This model could inform future priority setting on both research and action that could be coordinated, comprehensive, and impactful. It is time for key stakeholders from across Canada to come together to set research and action priorities and make the changes required to improve school nutrition. This work demonstrates an interesting and concrete case of and approach to priority setting, of interest for various planning activities (both programming and research), particularly those planning school-based healthy eating programs or a related research agenda.

Funding information

We received financial support from a CIHR Planning and Dissemination Grant (No. 51771).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.