Comparison of the interventions
Regarding the forms, our results show that the forms of the intervention vary across the three departments. We see, for example, that the number and content of the intervention tools are different, as well as the number of nutrition education sessions run and the order in which the food groups are discussed by the dieticians. Many “forms” of the intervention are specific to just one of the departments (e.g. making a vegetable garden, tooth brushing sessions). In particular, we can see that department B, where dieticians only interact with teachers, differs from departments A and C where the dieticians interact directly with the pupils. Furthermore, in this department, the program is conducted over 2 years, whereas in the other two areas it lasts for just one school year. But, do these specificities of form correspond to actual differences of key functions?
Regarding the key functions, the comparison between the key functions of the “Eat and Move Well!” interventions in departments A, B and C is summarised in the following table (Table
1).
Table 1
Comparison between the key functions of the “Eat and Move Well” interventions in departments A, B and C, based on themes identified
Table
1. Comparison between the key functions of the “Eat and Move Well” interventions in departments A, B and C, based on themes identified.
In Table
1, we see that the key functions of the three interventions do not overlap. The interventions in departments A and C contain many similar or identical key functions (
n = 7 in each of these departments), while the intervention in department B contains mainly “unique” or “very different” key functions from those of the other departments’ interventions (
n = 7). The themes “Nutrition education sessions delivered to pupils by dieticians” and “Screening for and management of overweight/obesity” constitute identical key functions in departments A and C, but the department B intervention contains no such key functions.
In addition, two themes are specific to the department B intervention (“Diagnosis of needs and context” and “Comprehensive action”), as opposed to just one in the department C intervention (“Coordination with other prevention campaigns”) and none in that of department A.
The key functions identified from the interventions delivered in the three departments differ strongly in relation to the following themes:
Interaction with teachers
All the interventions described possessing key functions aimed at facilitating the implementation of all or part of the intervention by teachers, either in the form of pre-structured sessions (department A) or in a free manner (departments B and C). In department B, the dieticians interact with teachers by providing support and information throughout the 2-year program (B3). In department A, the intervention is based on a “transfer of knowledge to teachers enabling them to conduct “turnkey” nutrition education sessions using a Teacher’s Guide” (A2). This transfer of knowledge takes the form of a 2-h training session for teachers on the key nutritional messages, and of the first nutrition education session being provided by the dieticians themselves in order to show the teachers how to deliver the sessions. In department C, on the other hand, the dieticians do not interact in any formal manner with the teachers and the information required for the implementation of the program by the latter is mainly provided in written form. The purpose is essentially to provide “materials for teachers containing nutrition information and guidance on implementing the program as extensively as they would like” (C5).
Adaptation to the school context
In department C, one of the key functions consists of the “use of teaching materials adapted to the “school format”” (C3). The teaching materials for the implementation of the “Eat and Move Well!” intervention have been designed by one teacher so that they integrate fully into the general objectives of the school curriculum. In this department, as in department A, the form of the materials and the activities offered to the pupils are similar to those normally used by teachers in the school context (A5). In department B, teacher adaptation takes the form of establishing a co-constructive relationship with the latter (B5): the dieticians do not provide materials or pre-designed sessions but help them to implement the program in the manner most appropriate to their context.
In department A, one of the key functions of the intervention targeted at pupils consists of a “delivery of nutrition education session using teaching materials that encourage knowledge building and experimentation in relation to physical activity” (A4), in the same format as the sessions focusing on food. In department C, the “physical activity” dimension of the intervention is more in-depth, and the key function consists of providing “teacher support for delivering physical education sessions allowing pupils to experiment with physical activity” (C4), using information sheets produced by the French Ministry for Education’s regional adviser on physical education and sport, and in association with the latter. The approach to physical activity in department B is completely different, with “physical activity encouraged through a collective, collaborative challenge” (B4).
Program continuity
The three interventions each contain a key function aimed at the continuity of the program within schools, but to very different degrees and in very different ways. In department B, continuity is inherent in the intervention because it aims to make sustainable changes to practices and is applied comprehensively within the school rather than in a limited manner (B7). In department A, the intervention explicitly includes “Remote support offered to schools that have already completed the action” (A9) without the interaction of dieticians with pupils (A9). Lastly, in department C, the key function described within this category is summarised as the “Option for schools to implement the program independently in subsequent years” (C9), by leaving them the teaching materials used to implement it.
Regarding the context, it is important to point out that the three departments in which the “Eat and Move Well!” interventions have been described have different socio-economic and demographic characteristics. Departments B and C are particularly sparsely populated and contain many small schools, whereas department A, as well as being richer, is organised around a major city with larger educational establishments. The intervention history and institutional affiliation of the actors in question appear significant in the specificities of the key functions that we now observe in each department. As such, although it is now managed by a regional health promotion and education body (Instance régionale d’éducation et de promotion de la santé–IREPS), the “Eat and Move Well” intervention was, until 2014, delivered in department C by the Local health insurance bureau (Caisse primaire d’assurance maladie–CPAM), as in department A. This may partly explain why these two interventions seem to be more similar than department B’s intervention, managed by the IREPS from the start, and why they are more heavily based on standardised tools and contain key functions related to the screening for and management of overweight/obesity.
Context analysis also shows that changes to the national specifications and the funding terms for nutrition prevention interventions are translated differently according to the department, causing modifications of form and key functions. For example, intervention funding cuts have compelled actors in department A to rework their teaching materials to reduce printing costs, and actors in department C to reduce the attendance time of dieticians at local actor information meetings (see C7). Furthermore, the fact that the specifications mention the importance of physical activity in the approach to nutrition has led actors in department B to add a key function relating to encouraging pupils to exercise (B2).
Context, at a more local level, can also result in changes to the key functions of interventions, as we observed in department A. In 2015, the intervention was implemented in a school in a district where a cross-sectoral approach to the issue of health and a range of partnerships had already been established, enabling dieticians to introduce new key functions into their campaign (the provision of information to classroom assistants on nutrition messages, awareness-raising in canteen and out-of-hours childcare staff, and pupil-implemented changes to certain menus served in the canteen).