Schools are a key setting to promote the health and well-being of children and adolescents(Reference Thompson, Leis and Davies1). Primary schools, where children attend from the ages of 5–11 years, have been highlighted as important, as this is a key time within the life course where attitudes and behaviours towards health are shaped, which are known to track into adulthood(Reference Kelder, Perry and Klepp2,Reference Montaño, Smith and Dishion3) . The role of schools in promoting child health has been emphasised by the WHO since 1986(4–6). A key aspect of this is a ‘whole-school approach to food’, a settings approach that includes consideration of the quality of all food available to children during the school day, the extent to which children are given the opportunity to learn with and about food and a school’s cultural relationship with food(5). The reach and potential impact of such an approach are substantial due to the role that schools play in supporting children who live in disadvantaged circumstances and because children consume approximately one-third of their food intake in schools during the school day(Reference Wolfenden, Nathan and Sutherland7). Although the evidence is still developing, a Cochrane systematic review and meta-analysis undertaken in 2015(Reference Langford, Bonell and Jones8) reported that whole-school approaches to food have positive effects on BMI and fruit and vegetable intake. However, in the UK, there is a lack of consistency in whole-school approaches to food adoption, both locally and nationally, resulting in inequitable access to its benefits(9).
Schools are considered unique complex systems, with multiple competing demands and a diverse range of actors including senior leadership teams, governors, teachers and parents(Reference Moore, Evans and Hawkins10). The diversity between school systems is broad, with each operating within its own context and possessing its own components, structures, rules and feedback loops(Reference Keshavarz, Nutbeam and Rowling11). Schools sit within broader political, health and food systems(Reference Moore, Evans and Hawkins10,Reference Herlitz, MacIntyre and Osborn12) . Hence, a systems-wide approach is needed to promote the wide-scale adoption of whole-school approaches to food.
The role of systems approaches in supporting the adoption and implementation of public health initiatives has been developing over the last two decades(Reference Bagnall, Radley and Jones13). To support this, a range of frameworks and models have been developed (e.g. the Intervention Level Framework(Reference Johnston, Matteson and Finegood14), Action Scales Model(Reference Nobles, Radley and Mytton15) and the Public Health 12 Framework)(Reference Bolton, Whelan and Fraser16) that involve the identification of leverage points, which are places within a system that can generate change if influenced. It has been proposed that influencing multiple leverage points across multiple parts of a system offers the greatest potential(Reference Foster-Fishman and Behrens17), as well as the meaningful involvement of stakeholders using a participatory approach (e.g. co-design), to identify leverage points and agree upon a set of actions that are most likely to result in systems-wide change(Reference Nobles, Radley and Mytton15,Reference Boyd, McKernon and Mullin18) . However, before a systems-wide approach can be developed, an understanding of how a system functions, through methods such as systems dynamic modelling, network analysis or group model building, is needed(Reference Egan, McGill and Penney19).
Currently, there is no consistent definition of what a whole-school approach to food means in practice, and school-level interventions often focus on a particular feature (e.g. school policy, food environment or fruit and vegetable provision) rather than the approach as a whole(Reference Langford, Bonell and Jones8). There is also a lack of initiatives aimed at promoting wide-scale adoption. There is, however, growing interest in the broader school system (beyond immediate school settings) and the role it plays in the adoption and implementation of public health initiatives in schools. For example, the work of Langille and Rogers(Reference Langille and Rodgers20) and McIsaac et al.(Reference McIsaac, Spencer and Stewart21) explored systems-level factors that influence the adoption of school food and physical activity initiatives in Canada, highlighting the role of national policy and the priority placed on academic achievement. But to date, this understanding has not been used to inform a systems-wide approach aimed at promoting the adoption of school food initiatives. In a previous study, we developed a map of the UK primary school food system using a group model-building approach(Reference Bryant, Burton and O’Kane22), which identified four domains of influence on children’s dietary intake during the school day: leadership, culture and curriculum; child food choice; school food offer; and home environment. This paper describes the co-design of a systems-wide action plan, using our map of the UK primary school system to promote wide-scale adoption of whole-school approaches to food, thus improving school food environments, school food provision and dietary intake in children (both within and outside of school). Specifically, our study had three aims: (1) to define what a whole-school approach to food means in practice, (2) identify leverage points from within the school food system that influence the adoption of whole-school approaches to food and (3) agree upon a set of actions to influence these leverage points.
Methods
Theoretical approach
Action Scales Model
The Action Scales Model (ASM)(Reference Nobles, Radley and Mytton15) was used as a guide to develop the action plan, which conceptualises potential leverage points within a system as weights and a set of scales; the largest of the weight depicts the ‘beliefs’ or paradigm underpinning a system, which, if influenced, offer the greatest opportunity to reshape the ways in which that system functions. In contrast, the smallest of the weights depicts ‘events’ within a system (e.g. one-off training events), which offer a quick fix and are often the easiest to implement but generate little leverage for systems change. The practical use of the ASM includes convening a team of stakeholders to identify leverage points within a system and then categorising them by weight category. Actions to influence each leverage point are then agreed upon, with the aim of including a range of actions across each weight category. The agreed-upon actions are represented in an action plan (see Table 1, for example).
Table 1. Example leverage points and actions according to each weight category of the Action Scales Model(Reference Nobles, Radley and Mytton15)
DfE, UK Government Department for Education; Ofsted, Office for Standards in Education, Children’s Services and Skills.
CONNECTS-Food action plan development process
A co-design method was used to develop the CONNECTS-Food action plan. The process involved six steps (Figure 1): (1) gaining an understanding of how the school food system operates (mapping the school food system); (2) convening a co-design team of school stakeholders; (3) defining a whole-school approach to food; (4) identifying leverage points within the school food system, which, if influenced, could support adoption of whole-school approaches to food; (5) identifying and agreeing upon actions to influence those leverage points; and (6) development of two work packages to support schools to implement the approach. Step 1 was undertaken in a previous study(Reference Bryant, Burton and O’Kane22). Steps 2–6 are part of the present study. Our work was supported by a partnership board comprising decision-makers and advocates of the whole-school approach to food in England and Northern Ireland. The content of co-design workshops and partnership board meetings is summarised here, with full details provided in Additional File 1.
Figure 1. Co-design process.
Partnership board
The partnership board (n 10) met four times during the study and included representatives from Public Health England, the Public Health Agency in Northern Ireland, the UK Government Department for Education (DfE), the Education Authority in Northern Ireland, GENIUS network (network of school food advocates), UK-based organisations aiming to promote children’s access to healthy food at school (School Food Matters(23) and Sustain)(24) and representatives from three local government authorities in England.
Step 1: Understanding how the school food system operates
We have previously reported on how we developed a map of the school food system using a group model-building approach to understand how the system operates(Reference Bryant, Burton and O’Kane22); therefore, the process is only described briefly here.
Journey mapping workshops with children
Eight in-person ‘journey mapping’(Reference Trebble, Hansi and Hydes25) workshops were held with primary school children (n 80) aged 5–11 years in eight schools across four regions of the UK (Belfast, Bradford, Leeds and Newcastle) to understand factors within the school food system that influence a child’s food intake during the school day. During workshops, researchers performed an activity where each child picked a card denoting a particular moment in the day (e.g. morning break) and the child described what normally happened at that time. During the activity, researchers mapped out the children’s school day ‘journey’ against an image of a timeline on a white board, which was reviewed at the end to facilitate further discussion.
Systems mapping workshops with adult school stakeholders
A series of systems mapping workshops with adult school stakeholders was held online via Zoom in conjunction with the journey mapping workshops. Systems mapping workshops were attended by eighty-one school stakeholders (headteachers, governors, parents, teachers, caterers and representatives of national school food organisations) who each attended one workshop. Some stakeholders were based in the same four regions of the UK as the journey mapping workshops, while others, representing national organisations, came from other parts of the UK. The journey maps produced by the children were presented during the workshops to facilitate discussions around the factors that influence child food intake throughout the school day. The series of workshops resulted in an initial map of the school food system.
Partnership board meeting 1: Following the development of the initial systems map, a partnership board meeting was held. An image of the initial systems map was presented to the board, and the partnership board was invited to ask questions and suggest if any nodes or connections were missing.
Step 2: Convening of co-design team
We convened a co-design team of twelve school stakeholders to develop the CONNECTS-Food action plan alongside a team of researchers with expertise in school food, systems thinking and intervention development. All stakeholders invited to be part of the co-design team (n 81) had attended a systems mapping workshop that was held in step 1, whereby stakeholders were informed of the opportunity to join the co-design team at the end of each workshop, with an email sent around after the workshop to provide further details of what would be involved(Reference Bryant, Burton and O’Kane22). There was no limit on the number of stakeholders permitted to join the group and no eligibility criteria, although we aimed to include a range of stakeholders to represent a variety of perspectives. Co-design workshops lasted 2 h and were held online using Zoom, as favoured by the co-design team. All workshops were recorded so that discussions could be revisited afterwards to ensure nothing was missed. Six workshops were held over 6 months between September 2021 and February 2022.
Step 3: Defining a whole-school approach to food (study aim 1)
Co-design workshop 1
In the first co-design meeting, the team provided feedback on the initial systems map developed in step 1 to enable the final version to be developed. In the second half of the workshop, the co-design team was asked to define what a whole-school approach to food means in practice by listing objectives of the approach (e.g. to make lunchtimes a vital element of school life), as well as detailing who was expected to adopt each objective (e.g. headteachers). After the meeting, three members of the research team (WB, JW, NOK) further expanded the list of objectives by reviewing publicly available resources designed to support schools in implementing a whole-school approach to food. Listed objectives were thematically grouped (by WB and NOK) to set out key themes/principles that underpin the approach.
Co-design workshop 2
In workshop 2, each key principle, as proposed by the research team, was presented to the co-design team. Co-design team members were asked to refine concepts and reach agreement on the final set of principles.
Step 4: Identifying leverage points within the school food system (study aim 2)
Co-design workshop 3
Prior to workshop 3, a member of the research team considered each key principle within the context of the school food system map and proposed which factors within the system would influence the adoption of each principle. A series of sub-systems maps was then developed using Kumu systems mapping software(26), one for each principle (Figures 2–8). During the workshop, the group considered each sub-system in turn to identify potential leverage points to influence the adoption of each key principle.
Figure 2. Sub-system 1: Priorities of school leadership teams.
Figure 3. Sub-system 2: Food on the curriculum.
Figure 4. Sub-system 3: School food provision.
Figure 5. Sub-system 4: School food policy and culture.
Figure 6. Sub-system 5: School dining experience.
Figure 7. Sub-system 6: Stakeholder involvement.
Figure 8. Sub-system 7: Pastoral care.
Co-design workshop 4
During workshop 4, leverage points to influence as part of the CONNECTS-Food action plan were agreed by considering their feasibility to influence and potential systems-wide impact (as guided by ASM weight categories). This was achieved by undertaking a ranking activity as described in Additional File 1.
Step 5: Development of the action plan (study aim 3)
Partnership board meeting 2
Following agreement by the co-design team on which leverage points to influence, a meeting was convened with the partnership board for feedback and guidance. Specifically, the partnership board members were asked to draw on their experience and expertise from a regional and national perspective to generate ideas on how they thought the leverage points could be influenced. During the meeting, an initial draft of the action plan was developed.
Co-design workshop 5
Co-design team members were asked to develop the initial action plan further by building upon the actions proposed by the partnership board, as well as considering additional actions. The team was also asked to consider whether they were aware of work being undertaken locally to influence the adoption of whole-school approaches to food to avoid replication or consider whether CONNECTS-Food actions might support this work.
Partnership board meeting 3
After the co-design team had developed the action plan further, the partnership board convened again to provide further feedback and guidance. The partnership board was also asked if they were involved in or aware of work at a national level aimed at influencing the adoption of whole-school approaches to food to understand whether the CONNECTS-Food action plan could complement or support this work (and to avoid replication).
Following partnership board meeting 3, the final draft of the action plan was emailed to all members of the co-design team and partnership board for final comments or suggestions. The research team also explored the recent literature on whole-school approaches to food to scope out relevant work being undertaken by other research groups to identify potential collaborators. Once all comments had been received, two members of the research team (WB and MB) updated the action plan, consolidating all ideas and discussions that had been provided by the co-design team, research team and partnership board up to that point. It was decided that the final set of actions would need to be conceived within two separate work packages to streamline activities: one to support schools directly in implementing key principles of the approach and the second to influence change within the wider system (e.g. policy level).
Co-design workshop 6
The aim of workshop 6 was to agree on how each action would be delivered within the two work packages. During the workshop, it was agreed that actions in work package 1 would be delivered via an online resource for schools, as this would be the most accessible and acceptable mode of delivery for schools. It was agreed that actions in work package 2 (wider systems changes) would be delivered by collaborating with other organisations (e.g. school food organisations, local government authority, academic institutions and the UK Government DfE) who were already advocating for systems-wide change.
Step 6: Development of work packages 1 and 2
CONNECTS-Food resource (work package 1)
The CONNECTS-Food online resource was designed by members of the research team in collaboration with the co-design team and a website designer. Before the online resource was launched to the public, a draft was presented to the partnership board and academics in the field for review and feedback. The final resource (www.CONNECTS-Food.com) was made available to schools and promoted through press release and social media.
Development of impact and collaboration work package (work package 2)
The development of work package 2 was facilitated by members of the research team (MB and WB) who initiated a series of meetings with potential collaborators to develop a strategy for influencing change in the wider system. A dissemination plan was developed to promote the impact of the work, and further research was planned.
Results
Step 1: Understanding how the school food system operates
Our systems map has previously been published(Reference Bryant, Burton and O’Kane22), which enabled us to understand how the school food system operates (Additional File 2).
Step 2: Convening the co-design team
Our co-design team is described in Table 2.
Table 2. Co-design team members
Step 3: Defining a whole-school approach to food (study aim 1)
We identified seven key principles of a whole-school approach to food: (1) The ‘priorities of headteachers and senior leadership team’, which include objectives aimed at encouraging headteachers to provide leadership in setting a positive food culture. (2) ‘Food on the curriculum’, which includes objectives that encourage headteachers and teachers to ensure that learning with and about food is incorporated into lessons. (3) ‘School food provision’, which includes objectives to encourage the headteacher and catering teams to improve the school food offer. (4) ‘School food policy and culture’, which includes objectives for headteachers and other stakeholders to ensure that children receive consistent messages about food, which is reflected in policy and overall culture. (5) The ‘dining experience’, which includes objectives to encourage the headteacher and catering teams to improve the lunchtime environment. (6) ‘Stakeholder engagement’, which includes objectives for senior leadership teams to actively engage with children, their families and the wider community in school food activities. (7) ‘Pastoral care’, which includes objectives for senior leadership teams to support families to access nutritious food. Our full list of whole-school approaches to food objectives is provided in Additional File 3.
Step 4: Identifying leverage points within the school food system (study aim 2)
Leverage points identified through discussion with the co-design team are detailed in Table 3 and summarised below according to each key principle.
Table 3. Leverage points identified for each key principle
Priorities of school leadership teams
The expectations of schools as set out by the UK Government DfE and the inspection framework used by the Office for Standards in Education, Children’s Services and Skills (Ofsted) were perceived by the co-design team as being highly influential over whether headteachers and other members of the senior leadership team in schools would be willing to commit to adopting a whole-school approach to food (beliefs/goals). State schools, which sit within and are funded by local governments, were also perceived to require the support of their local government bodies (goals). Knowledge of how to deliver a whole-school approach to food was described as important (events), as was the headteacher’s confidence to adopt the approach. It was also recognised that the key to influencing adoption was alleviating concerns that the approach would require substantial time, money and staff capacity (structures).
Food in the curriculum
The expectations set by DfE and Ofsted were perceived by the co-design team to be highly influential over whether schools would be willing to adopt changes to their wider curriculum to incorporate learning with and about food (beliefs). As this is not currently mandatory within UK primary schools, the co-design team felt that teachers would need to be motivated to adopt the changes themselves and perceive that they have the relevant skills, training, confidence and budget (beliefs).
School food provision
Members of the co-design team explained that the decision to adopt changes to school food provision would sometimes be made at the local authority level but other times by an in-house catering team (structures). The priorities of the headteacher were again highlighted, who were perceived to have the power to seek out new and better contracts with caterers if they wanted to (beliefs), as well as the skills of the individuals within school catering teams (structures).
School food policy and culture
The extent to which the DfE and Ofsted prioritised a whole-school approach and the perceived beliefs and values of other school stakeholders (e.g. teachers, pupils and parents) was felt to be influential over whether headteachers would choose to adopt changes to policy and culture (beliefs). High staff turnover was mentioned as making it difficult to sustain the implementation of a whole-school approach to food policies, which could also influence decisions around whether to adopt new policies and initiatives (structures).
Dining experience
Some practical barriers were believed to influence whether a headteacher would choose to adopt changes in their school to ensure a pleasant dining experience for children. For example, a lack of time in the day to accommodate long lunch breaks, along with the availability of funds and physical space to facilitate changes to the dining area (structures). Gaining the support of teachers and caterers was also described as important (beliefs).
Stakeholder engagement
The co-design team explained that it was the role of the headteacher to instigate involvement of stakeholders from within and outside of the school. However, it was acknowledged that other stakeholders from within the school could also support the adoption of this principle by leading engagement with others. For example, caterers could engage with children regarding menu design, and teachers could involve parents in school events that incorporated food.
Pastoral care
The co-design team agreed that challenges within school budgets could be a barrier to adopting this principle, for example, potential restrictions on the number of families that can access free school meals (structures/goals). Establishing a good relationship between families and the school was described as important for facilitating the adoption of this principle so that potential issues in accessing healthy food could be identified (structures). Knowledge levels among staff around eating behaviours of concern (e.g. children being hungry) were also described as being influential over whether schools felt confident to support children and their families to access good food (structures).
Based on these discussions, a list of thirty-eight potential leverage points to influence within the action plan was produced, which was shortened to twenty during the scoring exercise (Table 4).
Table 4. CONNECTS-Food action plan
Step 5: Development of the action plan (study aim 3)
The action plan is detailed in Table 4. In brief, actions to promote the commitment of headteachers to adopt a whole-school approach to food included collaborating with the DfE to monitor school-level adoption of the approach. Other actions included signposting headteachers and teachers to relevant training and resources to support them to adopt key principles, as well as providing examples of other schools that have successfully adopted the principles.
Step 6: CONNECTS-Food action plan delivery
Work package 1 (online resource for schools)
The delivery of actions in this work package aimed to offer implementation support to schools as a mechanism to promote motivation, knowledge and confidence to adopt the approach via an online resource. The resource includes the provision of a self-review tool to help schools determine to what degree they are already delivering the approach, highlight areas for improvement and support them in developing their whole-school approach to food public statement (to be displayed on their website).
Work package 2 (impact and collaboration)
The delivery of actions within this work package is ongoing. To date, they have included being involved in an ongoing collaboration with DfE to support and monitor the adoption of whole-school approaches to food. Four local authorities in the UK have agreed to use the CONNECTS-Food resource to support their local evaluations of whole-school approach adoption. A research collaboration is underway with the Fix Our Food in Schools project(27) in which the CONNECTS-Food key principles are used as a framework to measure the current adoption of a whole-school approach to food in schools in the UK.
Discussion
This paper describes the co-design of a systems-wide action plan devised to promote the adoption of whole-school approaches to food. We defined key principles of the approach and considered how the school food system works towards or against the adoption of each principle. We applied the ASM(Reference Nobles, Radley and Mytton15) to identify leverage points and develop our action plan, seeking guidance from our partnership board, consisting of regional and national school stakeholders. The resulting list of actions forms two work packages: one to support schools in implementing a whole-school approach to food and the other to influence change in the wider system.
Stage one of the ASM process involved developing an understanding of the school food system. Group model building is widely used to understand complex problems in public health, such as the causes of obesity(Reference Savona, Brown and Macauley28) and inadequate fruit and vegetable intake in children(Reference Zolfaghari, Meshkovska and Banik29), but there are few examples of using this as a starting point to design a systems-wide action plan. One such example, however, is the work of Pinzon et al.(Reference Pinzon, Waterlander and de Pooter30), who used group model building and ASM guidance to develop a systems approach to tackle obesity-related behaviours in adolescents. In line with our systems-wide approach, their action plan included setting up collaborations with local authorities to improve the food environment as well as undertaking further research. Authors say that their actions were only the starting point for change, with measurable change only likely after several years, although through ongoing monitoring, they identified that the most sustainable actions were those that were incorporated into existing initiatives, such as working with local authorities who were already committed to updating local food policies(Reference de Pooter, Luna Pinzon and den Hertog31).
Our action plan predominantly aimed to influence the beliefs of headteachers along with system goals as set by the DfE and local authorities. Others have also identified these as priority areas for change. For example, Schliemann et al.(Reference Schliemann, Spence and O’Kane32), who undertook a priority setting activity in the UK to understand where future research efforts need to focus to improve the school food system, highlighted the importance of securing the buy-in of headteachers and policymakers so that school food policies are valued and prioritised. In another priority setting study, Johnson et al.(Reference Johnson, Zarnowiecki and Hutchinson33) explored barriers and facilitators to changing the school food system in Australia, identifying the need for governments to lead on changing the school food agenda to promote change at the local level.
Our systems approach offers direct support to schools through tools and guidance. The need to offer this support is surprising given the volume of previous initiatives that have been designed to support a whole-school approach to food delivery (e.g. Food for Life(34) and the School Food Plan)(Reference Dimbleby and Vincent35). A systematic review undertaken in 2020(Reference Ronto, Rathi and Worsley36) also highlighted the need for a two-pronged approach to support compliance with school food policy, including direct support for schools alongside wider systems change.
Strengths and limitations
Our systems-wide approach was developed in collaboration with school-level and national stakeholders who were geographically and organisationally diverse. Our co-design team defined a whole-school approach to food by identifying key principles, which our findings suggest are still not well understood. These key principles are already being used in research and by local authorities to measure the implementation of the approach and can be used by others.
We invited eighty-one school stakeholders to be part of our co-design team. Of these, only twelve opted to participate. However, we ensured that we achieved representation from a range of school stakeholders, including headteachers, school food improvement officers and catering leads, in order to provide a ‘bottom-up’ perspective(Reference Fals-Borda and Rahman37). We acknowledge, however, that our co-design team did not involve school children. A recognised challenge in developing a systems approach with children is striking a good balance between systems theory and participant engagement, although this challenge could have been alleviated by using tailored methods such as drawing, storytelling and discussion(Reference Sevón, Marleena and Anna38). We also strived to engage parents within our co-design team, but uptake was low. This could have altered the direction of our action plan, as we know from our systems mapping work and the wider literature that family engagement is a key component of a whole-school approach to food implementation(Reference Langford, Bonell and Jones8). The expertise of our research team and partnership board may have unintentionally influenced the objectives and scope of the CONNECTS-Food action plan, for example, the ongoing commitment of DfE to monitor the implementation of a whole-school approach to food and the advocacy work of school food organisations on our partnership board. However, a strength of this paper is that we clearly set out our methods for developing our approach, which is known to be lacking in some co-design studies(Reference Slattery, Saeri and Bragge39).
In this project, co-design team members were asked to solve the complex problem of promoting the adoption of a whole-school approach to food by prioritising leverage points to influence and developing an action plan. Ideally, in co-design projects, the problem-solution cycle is iterative, and interventions are tested and then adapted accordingly(Reference Dorst and Cross40). The scope of the current study did not extend to monitoring the implementation and impact of our systems-wide approach to enable ongoing adaptation of our action plan, although future funding will be sought to explore these aspects. The method used to develop the CONNECTS-Food action plan involved drawing upon the experiences and expertise of our co-design team and partnership board, which was an iterative process. We chose to undertake meetings with our co-design team and partnership board separately; however, encouraging greater collaboration between the stakeholder groups could have supported the development of relationships between those stakeholders ‘working on the ground’ and those with greater input into national decision-making.
A limitation of the ASM framework is the lack of focused guidance on consolidating systems thinking with other disciplines such as implementation and behavioural science, which could strengthen the development of systems approaches by applying appropriate theory when considering leverage points and actions.
Recommendations for future research
We recommend the use of co-design methods to develop systems approaches that address public health challenges such as poor adoption of initiatives that are known to be effective. Engaging implementation and beneficiary stakeholders ensures a good understanding and feasibility of leverage points and actions. Seeking engagement from key decision-makers including policymakers through collaboration, partnership and co-design has the power to support policy and environmental-level actions. Evaluation of systems-based studies is also strongly recommended, although not included in this study. Adequate time and resources are needed to monitor implementation and enable understanding of the impact and adaptation of actions. Assigning actions to smaller working groups with responsibility for delivery and regular reporting on progress and impact is key(Reference Pinzon, Waterlander and de Pooter30,Reference de Pooter, Luna Pinzon and den Hertog31) . A comprehensive review of available systems frameworks is advised to identify which best fit the needs of the project, for example, use of relevant language, clear processes for transparent reporting and appropriate consideration to applicable theory and models from other disciplines (such as implementation science and behavioural theory) to promote successful outcomes.
Conclusion
We identified that the beliefs and priorities of headteachers, along with the system’s goals set by the Department for Education, were the greatest leverage points for change in the UK primary school food system. Our co-design team was successful in supporting our understanding of how the school food system operates, identifying leverage points and agreeing upon actions. The methods described here can be replicated by others to understand leverage points for change within other school contexts and contribute to the growing literature on developing systems-wide approaches to support public health implementation.
Supplementary material
For supplementary material accompanying this paper, visit https://doi.org/10.1017/S1368980025101353.
Acknowledgements
The authors would like to acknowledge the members of the co-design team who worked on the co-design of the CONNECTS-Food study: Ian Thomson-Smith, Jason O’Rourke, Sara Rawnsley, Gillian Boundy, Deborah David, Kim Smith, Myles Bremner, Christine Boyle, Jayne Jones, Sophie Aherne, Emily Fieldhouse, Linda Keiller and our partnership board, who provided oversight and guidance.
Financial support
This research was funded by the Medical Research Council through the Public Health Intervention Development Fund (MRV003860/1) and the University of York Internally Distributed Fund. The funders had no role in the conceptualisation, design, data collection, analysis, decision to publish or preparation of the manuscript.
Competing interests
All authors declare that they have no competing interests.
Authorship
M.B. led the overall CONNECTS-Food research. W.B. managed the CONNECTS-Food project and led recruitment, data collection and analysis. J.V.W., S.A., C.E.L.E., T.B., H.R., S.S. and A.M.S. contributed to the CONNECTS-Food study design. All authors were involved in the co-design of the CONNECTS-Food intervention. W.B. designed and led the qualitative components of the pilot study. All authors contributed to writing the paper.
Ethics human subject participation
This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures were approved by the University of York Health Sciences Research Governance Committee (HSRGC/20210/428/A). This manuscript describes the co-design of a systems-based approach and did not involve research participants. Co-design team members were deemed part of the research team and not ‘research participants’; therefore, obtaining written or verbal informed consent was not required.
Open access
