Effective school meal interventions: Lessons learned from Eat Well Do Well in Hull, England
Effective school meal interventions: Lessons learned from Eat Well Do Well in Hull, England
Abstract and Keywords
It is a truism to suggest that obesity has emerged as one of the most significant issues for public health policy in the last 10 years. Globally, an estimated 1.2 billion people are classified as overweight, of whom 300 million are categorized as obese. In 2004 when Eat Well Do Well was developed and introduced in the UK, around 10% of children aged 6–10 years were classified as obese. In addition, according to the Department of Health (2006) 36.6% of children in Hull were estimated to be living in poverty compared to the national average of 21.3%. This chapter presents a description and evaluation of the lessons learned from the Eat Well Do Well program, which was delivered between 2004 and 2007 by the Kingston-Upon-Hull City Council in England. This was an ambitious, innovative and exciting programme which provided all children (approximately 25,000 school children) in seventy-four primary and special schools access to free school meals which may have included healthy breakfasts, hot lunches/dinners, fruit up to Key Stage 2 (ages 11/12), and after school snack. The evaluation of Eat Well Do Well considered ‘what worked’ from the perspectives of the major stakeholders: the children, parents, caterers and schools. The chapter discusses several characteristic features of the program such as addressing health inequalities, complexity and whole of system change, and developing a spatial imagination. It presents some of the difficulties encountered including the problems associated with school meals as a political project, school meals as a service intervention, and how to relate Eat Well Do Well to other projects in schools.
It is a truism to suggest that obesity has emerged as one of the most significant issues for public health policy in the last 10 years. Globally, an estimated 1.2 billion people are classified as overweight, of whom 300 million are categorized as obese (Butland et al., 2007). In 2004 when Eat Well Do Well was developed and introduced, around 10% of children aged 6–10 years were classified as obese. In addition, according to the Department of Health (2006) 36.6% of children in Hull were estimated to be living in poverty compared to the national average of 21.3%. This chapter presents a description and evaluation of the lessons learned from the Eat Well Do Well programme, which was delivered between 2004 and 2007 by the Kingston-Upon-Hull City Council in England. This was an ambitious, innovative, and exciting programme which provided all children (approximately 25,000 school children) in 74 primary and special schools access to free school meals which may have included healthy breakfasts, hot lunches/dinners, fruit up to Key Stage 2 (ages 11/12) and after school snack. The evaluation of Eat Well Do Well considered ‘what worked’ from the perspectives of the major stakeholders: the children, parents, caterers, and schools. This chapter discusses several characteristic features of the programme such as addressing health inequalities, complexity and whole system change, and developing a spatial imagination. Finally, some of the difficulties encountered are presented and discussed including the problems associated with school meals as a political project, school meals as a service intervention, and how to relate Eat Well Do Well to other projects in schools.
The national context for school meals in England
There has been an exponential rise in the number of public health initiatives across the globe that attempt to treat and prevent childhood obesity. Most of these initiatives address lifestyle factors (mainly over-nutrition/eating and a lack of exercise). With this in mind there has been a focus specifically on what children eat at school. It would be fair to say that many issues facing schools in their attempts to provide healthy school meals have been impacted on by the challenges facing schools since the mid-1980s. At this time Margaret Thatcher and her conservative government removed nutritional standards for school food and introduced compulsory competitive tendering for school catering services. They also introduced a national curriculum, which focused on literacy, numeracy, and science, which meant that home economics as a school subject withered and became less popular with children and teachers alike. Finally, schools began to use their canteen (p.390) and kitchen for other activities leading to a removal of kitchens and kitchen equipment from most schools.
These legislative changes and challenges were introduced throughout the 1980s and 1990s (see for example, the 1980 Education Act (HMSO, 1980), 1986 Social Security Act (HMSO, 1986) which removed entitlement to free school meals and constant modifications to the national curriculum throughout the 1990s) so the recent focus on healthy school food by the present government was welcomed by many health and welfare professionals (we acknowledge the introduction of healthy school food was also challenging for many school communities, especially school caterers).
Eat Well Do Well
Between 2004 and 2007 Kingston-Upon-Hull City Council in England embarked on an ambitious, innovative, and exciting programme (called Eat Well Do Well) which provided all children (approximately 25,000 school children) in 74 primary and special schools access to free school meals which may have included healthy breakfasts, hot lunches/dinners, fruit up to Key Stage 2 (ages 11/12) and after school snack. Nationally guidance for school meals comprised minimal standards based on food groups. However, Eat Well Do Well used guidelines established by the Caroline Walker Trust (1992), which determined that school meals should be based on children’s recommended daily nutrient intake. Hull City Council was the first council in England to implement nutrient based standards. The Department of Learning and Culture within the City Council worked in partnership with the two Primary Care Trusts (PCTs) in the city to develop and implement the initiative.
The programme was approved by the national Schools Standards Minister who supported the programme through his special ability and ‘Powers to Innovate’ under Section 2 of the Education Act 2002 to suspend the relevant sections of the Education Legislation (section 512 of the Education Act 1996) that prohibit councils from providing meals and refreshments free to those children who are not eligible for free meals. A major underlying principle of the programme was the relationship between healthy eating and academic attainment. However, by far the major justification of Eat Well Do Well was that it would address health inequalities across the city (Hull City Council, 2004).
In addition to the provision of free healthy school lunches, breakfasts, and after school refreshments, Hull City Council became the first council in the country to extend the provision of free fruit and vegetables under the National School Fruit and Vegetable Scheme (NSFVS) to Key Stage 2 children. The NSFVS is part of the government’s 5 A DAY programme, which is jointly funded by the Department of Health and the Big Lottery Fund and provides a free piece of fruit or a vegetable to children aged 4–6 years on each school day. The scheme was rolled out in phases across the country and was implemented locally in autumn 2004. Nationally, current provision extends only to those children in Key Stage 1. However, Hull City Council extended this provision so that all primary school children were offered a free piece of fruit or a vegetable on each school day. Typically children received bananas, pears, apples, satsumas, strawberries, cherry tomatoes, or carrots.
Schools joined Eat Well Do Well on a structured 6 weekly basis (every half term) and implemented the programme in a way phased approach that suited them so that all schools were engaged in the scheme by February 2005.
Lessons we learned from Eat Well Do Well
There are many interventions across the globe in the area of school meals. It would be fair to say that none of them possesses all the characteristics of a successful school meal intervention. (p.391) However, the Eat Well Do Well programme had many features that would be worth sharing. Later in this chapter, we also share those features, which didn’t work so well!
The evaluation of Eat Well Do Well considered ‘what worked’ from the perspectives of the major stakeholders: the children, parents, caterers, and schools. However, due to a limitation of space we will address generic features of the successful implementation of Eat Well Do Well across the city. The evaluation, which was co-ordinated through the Institute for Learning at the University of Hull, collected data from a variety of sources: children, parents, teachers, head teachers, caterers, cooks, and school staff and used a variety of methods: interviews, focus groups, surveys, experiential methods with children such as the production of DVDs of their lunchtime experiences, mapping of school dining rooms, use of modelling clay with younger children, and nutritional analysis of the food a small sample of children consumed at lunchtime.
Addressing health inequalities
The first point to make is that Eat Well Do Well was considered to be a very successful intervention by the evaluation team. As we have shown elsewhere (Colquhoun et al., 2008; Pike & Colquhoun 2009), Eat Well Do Well successfully tackled the poor nutrition of primary age children in the city. Uptake of the school meals (a measure of the impact of Eat Well Do Well), doubled from the start of the programme to its end 3 years later. Indeed, Eat Well Do Well was seen to be an important way of addressing health inequalities across the city. It did this by reducing the nutritional difference between those children who were eligible for free school meals at the start of the programme with those who were not; that is, it reduced the health gradient between these groups of children. This has been significant and an important avenue for policy development by the current Labour government. There are many other indicators of success and these are illustrated in the final evaluation report at www.hull.ac.uk-research.
Complexity and whole of system change
As we mentioned earlier, Eat Well Do Well was a highly complex intervention. The intervention itself was different in different schools (some schools implemented free healthy breakfasts initially whereas others did the free healthy lunches; others still did the free healthy after school snack – and of course any combination of these!). Of course it could be argued that this flexibility ensured that schools would implement parts of the programme that were most important and relevant to them and this was often the case. Indeed, the evaluation didn’t set out the measure the degree of ‘fidelity’ of Eat Well Do Well across the city. The evaluation team viewed this complexity as an important and necessary feature of school based interventions especially where an intervention is being implemented across whole systems such as in the case of Eat Well Do Well and where schools could tailor the intervention to suit the social, cultural, and economic characteristics of their families. There is no doubt that this degree of flexibility in the way schools engaged with Eat Well Do Well led to its eventual success.
Developing a spatial imagination
Schools that possessed what we have come to term a ‘spatial imagination’ (Pike & Colquhoun, 2009) seemed to engage more successfully with Eat Well Do Well. By spatial imagination we mean that schools were able to capture, harness, and exploit the full potential of the physical space, boundaries, and relationships in existence in the school dining room. As Pike & Colquhoun (2009) have commented, the dining room aesthetics (e.g. light, airiness, lack of noise, and little disruptive/unnecessary movement) contributed significantly to the dining experience felt by all using the dining room. This simple point cannot be overestimated. In England at least, the school dining room has often been the ‘forgotten space’ within schools while the attention of politicians, (p.392) policy makers, and educators more generally has been focused on activities within the physical boundary of the classroom.
Allied to the spatial imagination in relation to the dining room we also need to consider the physical use of space and how it was and wasn’t used for other features of a successful dining experience. Queuing for instance, has been a major concern for many schools. Often it’s in the queue where a lot of disruption, noise, and behaviour problems often occur. Successful schools have recognized this and now have in place a shortened queuing system, pictures of the meals/food for children to choose from as they queue, different year levels queuing at different times on a rotation basis, and even children acting as monitors/buddies to ‘police’ the queue freeing the adult supervisors to assist children eating their dinners.
The food counter has often been a source of frustration, particularly for younger/smaller children. Because of the physical layout of the food server and the food warmers often these younger and smaller children can’t see the food on offer. Some schools have recognized this and created a ‘ramp’ for the younger children to be able to see what food is available. This small change in parallel with the pictures of the food and menus visible from the queue has meant that children arrive at the food counter much more able to make an informed decision about the food they would like to eat.
The active involvement of children in these features was an important aspect of a successful programme. As Colquhoun et al. (2008: 94) have commented about the children at Langley Primary School1 in the city:
In order to overcome this problem (of slow queues) the school developed a menu display board. This was done during ICT lessons with a year 6 group (10–11 year olds). The children were asked to design the menu display using written words and pictures. The menus were then laminated and displayed on a flipboard outside the dining room where children pick up their dinner plates. Consequently, children were able to think about what they wanted for lunch while waiting in the queue and this resulted in less time spent queuing and less congestion in the dining room. Pictures of menu items were also displayed above the counter and changed on a daily basis by breakfast club attendees. This further informed children about their lunch options providing an image of the food to ensure that access to menu information was not dependent on reading ability. Children felt that there was a sense of ownership in the dining room. They had renamed their dining room ‘Langley Cool Café’ and a sign was displayed on the door. Children in year 5 (9–10 year olds) commented that this helped to deliver an important message that the dining room was ‘their’ space.
Other schools according to Colquhoun et al. (2008: 97) also involved children creatively in their dining experience, often through their school council:
This school encouraged children to try new foods, often tasters would be available for children to try something new … The school council often discussed the food options available and, following a suggestion by the council, the school made available vegetable soup as a starter in winter. This school purchased colourful dishes on which to serve the food instead of using large institutional trays.
A significant feature of successful schools is that they have adults eating with the children in the dining rooms. Usually these adults are teaching related staff (teachers and/or classroom assistants) and it is clear they have more positive perceptions of the impact of healthier eating on children if they do eat in the dining room with the children. Middlebank primary school in Hull introduced an important innovation to Eat Well Do Well that encouraged what we called ‘seamless provision’ (p.393) of school meals, which meant the transition from curriculum time to dinner time was effortless and caused little disruption, especially at this school as the following except from Colquhoun et al. (2008: 97) illustrates:
In the early stages of the project evaluation observations revealed that there were considerable problems with discipline in this school dining room. This was already acknowledged by the head teacher and by lunchtime staff including dinner ladies and cooks. The school embarked on a process of lunchtime reorganisation, whereby teachers were encouraged to eat with the children in the dining room to maintain discipline and to socialise with children around the table. In order to achieve this the lunchtime period was included as part of the school day so that teachers did not have to give up their own time to sit and eat with the children. Teachers still had an equivalent lunch break, but this was staggered so that their break might come before or after the children’s lunchtime. This ensured that over the lunch period in the dining room teachers were available to supervise children. This supervision started in the classroom where children were encouraged to wash their hands and to line up in the class. The whole class then walked down to the dining room together. The class lined up outside the dining room and the lunchtime supervisors would allocate six children to each table. Once seated, children remained at the table until they were told to approach the counter. Bread and water were provided on the table so that children could help themselves when they wished. Tables were also laid with plates and cutlery and this helped to add to a restaurant style atmosphere.
Crucial to this was the incorporation of the lunchtime into the school day so that lunchtime practices began in the classroom and carried through into the dining room. (Colquhoun et al., 2008: 97)
The other significant adults in the dining room – the lunchtime supervisors (sometimes and inaccurately called ‘dinner ladies’), played an important role in encouraging the children to eat their lunches. The role of the lunchtime supervisor was to assist the children with their lunches (cutting up difficult pieces of food for the younger children), tidying the dining room, and ensuring a safe environment for the children to eat their meal. The evaluation team recognized the importance of these adults to children’s healthier eating and recommended to Hull City Council that they develop a training programme covering the role of the lunchtime supervisor, healthier eating, behaviour management and creating a supportive dining room experience (see Pike, 2008; Pike & Colquhoun, 2010). Of course, it was important to link this training to developments in school improvement and in particular in England to the new Ofsted inspection framework, which included qualitative and quantitative indicators of children’s well-being (see http://ofsted.gov.uk/).
What we learned that didn’t work so well
School meals as a political project
There were three inter-related features of Eat Well Do Well that in our view could have been improved. The first is that there was a significant political imperative for the Labour Council in the city to address the many social, health, economic, and educational issues facing residents across the city. In 2004 when Eat Well Do Well was introduced Hull City Council faced many issues (as outlined in its Comprehensive Performance Assessment – see www.hull.gov.uk) and the timeline from programme conception by councillors and council officials to implementation by school communities and caterers was very short. Indeed, this undue haste was responsible for many schools not implementing the full programme of breakfast, mid-morning fruit, lunch, and after school snack for at least a year. The capacity of schools to cater for more children eating healthier lunches in school was challenged (e.g. physical capacity such as ovens, machines, and pleasant dining rooms) as were the skills of cooks who, for the previous 20 years, had been de-skilled. This capacity problem will be faced by many schools if the government introduces free healthy lunch to all primary age children in the country.
The second major issue facing the successful implementation of Eat Well Do Well was that the programme was seen by many as simply a ‘service intervention’ with little integration across the curriculum or indeed even located within a whole school approach. Even though the whole school approach was adopted by many schools for their Healthy School activities, but possibly as a result of the undue haste mentioned earlier, there was little sense that schools could go beyond seeing Eat Well Do Well as something more than the provision of a service at lunchtime. As a result, between 2004 and 2007 council officials were almost permanently in a state of ‘catch up’ trying to encourage schools to include healthier eating within their curriculum, support parents to take up the healthier eating ‘message’, and involve children in decision-making, menu design, and meal composition. Of course, healthy eating was part of the personal, social, and health education curriculum but our point is that there was little special emphasis on curriculum links with Eat Well Do Well.
Relating Eat Well Do Well to other projects in schools
The third and final feature of Eat Well Do Well that didn’t work as well as it could have is that it wasn’t really related to other healthier eating projects such as the National Healthy Schools Programme or ‘Shape Up’ (see www.hull.ac.uk/Ifl-research). Schools in Hull have been very successful adopting Healthy Schools and many schools have also been engaged in other projects designed to address the structural determinants of obesity. However, because of the two problems outlined earlier – that Eat Well Do Well was seen as a ‘service intervention’ and that it wasn’t integrated across the curriculum and whole school communities – the third problem – the lack of any formal (or even informal relationship) with other projects was problematic (we are conscious that this may be seen as ‘teacher bashing’ but that is not our intention!). Clearly, with hindsight, if Eat Well Do Well were to be re-introduced now or in the future it would be a very different programme. We need to remind ourselves that Hull City Council was the first council anywhere in the UK to introduce such a programme across the whole city and as such encountered (and solved) many pioneering issues.
Eat Well Do Well in many ways was a project ahead of its time. Introducing a whole of system change across an entire city in a short time frame was an incredible challenge. Unfortunately, because Eat Well Do Well stopped after 3 years it is difficult to comment on the long-term impact of Eat Well Do Well on health measures such as obesity. However, because of the flexibility inherent in working across a whole system, school communities managed to introduce Eat Well Do Well in a way that was meaningful to them. Because of this they were able to reap the benefits of the city council’s pioneering and innovative approach to helping families across the city and reducing the disadvantage gap experienced by many children. Significantly, by doing so they also created a more supportive learning environment for all primary age children in the city.
Butland, B., Jebb, S., Kopelman, P., et al. (2007) Foresight tackling obesities: future choices project report. HMSO, London.
Caroline Walker Trust. (1992) Nutritional guidelines for school meals: report of an expert working group, The Caroline Walker Trust, London.
Colquhoun, D., Wright, N., Pike, J., & Gatenby, L. (2008) Evaluation of Eat Well Do Well, Kingston upon Hull’s school meal initiative, University of Hull, Kingston Upon Hull.
(p.395) Department of Health (2006) Community health profile for city of Kingston Upon Hull. Available at http://www.communityhealthprofiles.info/profiles/hp2006/lo_res/00FA-HP2006.pdf, [Date accessed 1 December 2009].
Hull City Council (2004) Report to Cabinet, 20th July, Kingston Upon Hull City Council, Kingston Upon Hull.
HMSO (1980) The Education Act, 1980, HMSO, London.
HMSO (1986) The Social Security Act, 1986, HMSO, London.
Pike, J. (2008) Foucault, space and primary school dining rooms, Children’s Geographies 6(4), 413–422.
Pike, J. & Colquhoun, D. (2009) The relationship between policy and place: the role of school meals in addressing health inequalities. Health Sociology Review 18(1), 50–60.
Pike, J. & Colquhoun, D. (2010) Embodied childhood in the health promoting school. In K. H˝orschelmann & R. Colls, R. (Ed.) Contested bodies of childhood and youth, Basingstoke: Palgrave Macmillan.
(1) The name of the schools cited in this chapter have been changed for anonymity.