Table 5.
Direction of effect sensitivity analysis for each outcome domain by study quality, study design, intervention duration, NOURISHING domains, NOURISHING action areas, stakeholder engagement, and behaviour change communication.
| Outcome Domain | Interventions, n | Positive Impact, n (%) | Negative Impact, n | No Change or Mixed Effects | Sign Test, p-Value * | 95% CI ** | |
|---|---|---|---|---|---|---|---|
| Selection of a meal component | |||||||
| Study quality | Positive rating | 8 | 5 (63%) | 0 | 3 | 0.063 | 31% to 86% |
| Neutral rating | 17 | 10 (59%) | 2 | 5 | 0.039 | 36% to 78% | |
| Study design | Pre-post assessment | 22 | 15 (68%) | 2 | 5 | 0.002 | 47% to 84% |
| Parallel arm or crossover | 3 | 0 (0%) | 0 | 3 | NA | NA | |
| Intervention duration | ≤2 months | 15 | 12 (80%) | 1 | 2 | 0.003 | 55% to 93% |
| 3+ months | 10 | 3 (30%) | 1 | 6 | 0.625 | 11% to 60% | |
| NOURISHING domains | Three domains | 15 | 10 (67%) | 1 | 4 | 0.012 | 42% to 85% |
| One or two domains | 10 | 5 (50%) | 1 | 4 | 0.219 | 24% to 76% | |
| NOURISHING action areas | Three to six action areas | 16 | 11 (69%) | 1 | 4 | 0.006 | 44% to 86% |
| One to two action areas | 9 | 4 (44%) | 1 | 4 | 0.375 | 19% to 73% | |
| Stakeholder engagement | Student engagement | 9 | 7 (78%) | 0 | 2 | 0.016 | 45% to 94% |
| Without | 16 | 8 (50%) | 2 | 6 | 0.109 | 28% to 72% | |
| Behaviour change communication | Promotion and/or training | 18 | 11 (61%) | 1 | 6 | 0.006 | 39% to 80% |
| Without | 7 | 4 (57%) | 1 | 2 | 0.375 | 25% to 84% | |
| Consumption of a meal component | |||||||
| Study quality | Positive rating | 3 | 0 (0%) | 0 | 3 | NA | NA |
| Neutral rating | 21 | 14 (67%) | 3 | 4 | 0.013 | 45% to 83% | |
| Study design | Pre-post assessment | 18 | 11 (61%) | 2 | 5 | 0.022 | 39% to 80% |
| Parallel arm or crossover | 6 | 3 (50%) | 1 | 2 | 0.625 | 19% to 81% | |
| Intervention duration | ≤2 months | 13 | 8 (62%) | 2 | 3 | 0.109 | 36% to 82% |
| 3+ months | 11 | 6 (55%) | 1 | 4 | 0.125 | 28% to 79% | |
| NOURISHING domains | Three domains | 15 | 9 (60%) | 2 | 4 | 0.065 | 36% to 80% |
| One or two domains | 9 | 5 (56%) | 1 | 3 | 0.219 | 27% to 81% | |
| NOURISHING action areas | Three to six action areas | 17 | 11 (65%) | 2 | 4 | 0.022 | 41% to 83% |
| One to two action areas | 7 | 3 (43%) | 1 | 3 | 0.625 | 16% to 75% | |
| Stakeholder engagement | Student engagement | 6 | 5 (83%) | 0 | 1 | 0.063 | 44% to 97% |
| Without | 18 | 9 (50%) | 3 | 6 | 0.146 | 29% to 71% | |
| Behaviour change communication | Promotion and/or training | 17 | 9 (53%) | 2 | 6 | 0.065 | 31% to 74% |
| Without | 7 | 5 (71%) | 1 | 1 | 0.219 | 36% to 92% | |
| Meal program participation rate | |||||||
| Study quality | Positive rating | 0 | 0 (0%) | 0 | 0 | NA | NA |
| Neutral rating | 5 | 3 (60%) | 2 | 0 | NA | 23% to 88% | |
| Study design | Pre-post assessment | 5 | 3 (60%) | 2 | 0 | NA | 23% to 88% |
| Parallel arm or crossover | 0 | 0 (0%) | 0 | 0 | NA | NA | |
| Intervention duration | ≤2 months | 1 | 1 (100%) | 0 | 0 | NA | NA |
| 3+ months | 4 | 2 (50%) | 2 | 0 | NA | 15% to 85% | |
| NOURISHING domains | Three domains | 3 | 3 (100%) | 0 | 0 | 0.250 | 44% to 100% |
| One or two domains | 2 | 0 (0%) | 2 | 0 | NA | 0% to 66% | |
| NOURISHING action areas | Three to six action areas | 4 | 3 (75%) | 1 | 0 | 0.625 | 30% to 95% |
| One to two action areas | 1 | 0 (0%) | 1 | 0 | NA | NA | |
| Stakeholder engagement | Student engagement | 2 | 2 (100%) | 0 | 0 | 0.500 | 34% to 100% |
| Without | 3 | 1 (33%) | 2 | 0 | NA | 6% to 79% | |
| Behaviour change communication | Promotion and/or training | 5 | 3 (60%) | 2 | 0 | NA | 23% to 88% |
| Without | 0 | 0 (0%) | 0 | 0 | NA | NA | |
| Attitudes and perceptions related to changes to the meal service | |||||||
| Study quality | Positive rating | 3 | 3 (100%) | 0 | 0 | 0.250 | 44% to 100% |
| Neutral rating | 10 | 6 (60%) | 4 | 0 | 0.754 | 31% to 83% | |
| Study design | Pre-post assessment | 9 | 8 (89%) | 1 | 0 | 0.039 | 57% to 98% |
| Parallel arm or crossover | 4 | 1 (25%) | 3 | 0 | 0.625 | 5% to 70% | |
| Intervention duration | ≤2 months | 4 | 4 (100%) | 0 | 0 | 0.125 | 51% to 100% |
| 3+ months | 9 | 5 (56%) | 4 | 0 | NA | 27% to 81% | |
| NOURISHING domains | Three domains | 8 | 6 (75%) | 2 | 0 | 0.289 | 41% to 93% |
| One or two domains | 5 | 3 (60%) | 2 | 0 | NA | 23% to 88% | |
| NOURISHING action areas | Three to six action areas | 9 | 7 (78%) | 2 | 0 | 0.180 | 45% to 94% |
| One to two action areas | 4 | 2 (50%) | 2 | 0 | NA | 15% to 85% | |
| Stakeholder engagement | Student engagement | 3 | 3 (100%) | 0 | 0 | 0.250 | 44% to 100% |
| Without | 10 | 6 (60%) | 4 | 0 | 0.754 | 31% to 83% | |
| Behaviour change communication | Promotion and/or training | 9 | 7 (78%) | 2 | 0 | 0.180 | 45% to 94% |
| Without | 4 | 2 (50%) | 2 | 0 | NA | 15% to 85% | |
LEGEND: Study quality: variables apportioned per risk of bias assessment results as either, (1) positive rating, or (2) neutral rating; Study design: variables apportioned according to measurement scores used for analysis as either, (1) pre-post measurements = intervention arm before and after scores, or (2) parallel arm or crossover = comparison of post-intervention scores; Intervention duration: variables apportioned according to duration of intervention implementation as either, (1) ≤2 months, or (2) 3+ months; NOURISHING domains: variables apportioned according to number of NOURISHING framework domains as either, (1) interventions targeting 3 domains, or (2) interventions targeting 1–2 domains. NOURISHING action areas: variables apportioned according to number of NOURISHING framework action areas as either, (1) interventions targeting 3–6 action areas, or (2) interventions targeting 1–2 action areas; Stakeholder engagement: variables apportioned according to presence of stakeholder engagement during intervention development and/or implementation as either, (1) with students, or (2) without students; Behaviour change communication: variables apportioned for interventions as either, (1) including promotion and/or training, or (2) without promotion and/or training. TABLE NOTES: * Sign test excludes studies with no change/mixed effects direction as they cannot be said to represent either a positive or a negative effect direction [86]; NA denotes unstable point estimate due to low number of studies. ** 95% Confidence interval (CI) estimation for binomial proportions using the Wilson interval method [85,87].