Below, the barriers and facilitators are presented according to selected proximal outcomes of the two studied components: availability (Daily provision of free FV) and accessibility and social norms (A pleasant eating environment). These proximal outcomes were selected based on the most recurrent findings. The results identify which conditions that comprise a barrier or facilitator for fidelity, dose delivered and dose received of the intervention. Furthermore, variation in implementation of the FV programme is presented.
Accessibility: food aesthetics, convenience and teachers’ timing
Pupils and teachers identified - in agreement with the programme theory of Boost (Figure
1) - high quality of FV, and large quantity and variety of the delivered FV as facilitators for pupils’ intake. These dimensions were influenced and to a large extent determined by the FV suppliers. Most pupils experienced and appreciated that abundant FV were delivered. Variety of the FV delivered enhanced the pupils’ use of the FV programme as they found it boring if they were to eat the same FV every day.
Pupils expressed that the accessibility and appearance of the FV highly influenced their intake. Most pupils preferred to eat FV cut up as snacks as they found it more appetising, easier to eat, and cosier (see for explanation of the notion cosy inserted below).
Cosy: In this article we use the term cosy to refer to the Danish phenomenon ‘
hygge’.
Hygge is a social phenomenon which in Denmark has an almost iconic status in representing a style of being together. The concept embraces a certain quality of sociality and signifies a safe, low-key, intimate form of socialisation, where the closeness is often based on sharing food or drinks.
Hygge is a ubiquitous concept in the Danish culture and hard to translate into other languages [
40]. The pleasant eating environment component was designed to promote
hygge around FV eating in class.
Girl: Well it is like cut up and so, just ready to eat, really delicious.
Girl: I never eat fruit at home because I cannot bother to take an apple and eat it. I find it boring.
Girl: You see, nobody bothers cutting FV up at home. Parents, you see, do not cut up an apple for you to eat.
Furthermore, contrary to being provided with one piece of fruit or vegetable, the cut-up FV enabled the pupils to taste different FV. Despite the fact that the same number of FV were delivered in class each day, the pupils felt they received a larger amount of FV when it was cut up compared to when they received one piece each and they liked that feeling. However, some pupils also perceived this as a drawback because it became more difficult to share the FV evenly and involved more counting of pieces and pupils arguing in class.
Several teachers also experienced that cut-up FV were popular among pupils and led to higher intake, but the practice was considered to be very time consuming.
Teacher: At the beginning I found the FV programme troublesome, I have to say. I think it took a lot of time, so I have tended to: –“if you want an apple, you take a whole apple”. I refuse to slice them all into ten pieces. It takes too long [time].
The teachers influenced dose received as they decided when the pupils could eat FV. Some teachers allowed pupils to eat FV whenever they wanted during lessons, while others were more restrictive.
According to pupils, some teachers did not allow them to eat FV during lessons because it would take time from the teaching, would leave a mess or create chaos in class.
Time was identified as the main barrier for teachers’ implementation of the two intervention components. Several of the involved had taken over a new class at the beginning of the intervention year and therefore lacked energy to engage in the different components of the Boost study. Time consuming practicalities related specifically to the FV programme included: cutting up FV (both when performed by the teacher and the pupils), restoring order after the pupils’ eating FV in class, cleaning, pupils’ food games with FV, and allocating time for eating FV.
The teachers’ control of the timing for eating FV affected not only pupils’ access to FV but also the appeal of the FV delivered: Sometimes the FV were cut up at the break prior to the class lesson, but the pupils were not allowed to eat it until the end of the lesson or after the lesson. This caused enzymatic browning of the FV.
Boy: If we have S [teacher] then it [FV] is just lying there and is slowly turning brown before we are allowed to eat it.
This timing issue limited pupils’ interest in eating the FV as they perceived it as brown, gross, unappetising, greasy or dry. According to the interviewed teachers and pupils, the lemon juice which was provided in the class kit to prevent browning was only used a few times in the beginning of the intervention period or not at all.
Pupils would like to eat the FV as soon as it was brought to the classroom but their request was handled differently by teachers.
Girl: D [teacher], she is okay. When we ask for it [FV] we can have it, but T [teacher], he does not allow us to have it.
Girl: If we ask for it, he just says ’ah, but now you will not get it for sure’.
Bruised FV were rejected and described by the pupils as ‘disgusting’ and some pupils associated brown with putrefaction.
Girl: Well, I think apples and pears when they become brown then they are not… There is nothing wrong with it, but you do not really feel like eating it because it does not look that delicious.
Girl: At the end, it is getting all greasy on the surface
Interviewer: Does it mean that you do not eat the entire fruit or just not that part?
Girl: I do not eat it.
Girl: I do not eat it if it is like that all over.
Girl: The majority does not eat it.
Girl: The boys might eat it, but the girls do not.
The interviews indicated that appearance of FV was more important for girls’ intake compared to boys.
The teachers confirmed the importance of appearance for pupils’ intake.
Teacher: They do not eat it if it is the least bruised or the least something. It has to look very, very perfect otherwise…
Teacher: Well, if we cut it [FV] up and it turns brown then they will not eat it, so you have to be rather fast [distributing FV to pupils].
We also experienced pupils’ negative attitude towards browned fruit during the observations. In one class, the pupil who was FV host highlighted that it was a good idea to cut off brown areas before serving fruit to classmates.
Furthermore, if the appearance of the FV did not appeal to the pupils or did not match the pupils’ taste preferences or when the pupils were bored, they sometimes used the FV for a different purpose. In all interviewed classes, pupils, especially boys, were throwing with the FV to some extent. The FV were thus transformed into inedible objects to throw and play with.
Boy: But some of the fruit, it just make you, throwing, you can throw really well with it.
Boy: Such a tomato, it just lays well in the hand.
Boy: Or those radishes, well radishes, nobody likes radishes anyway.
Boy: We throw them. If there is something we do not like, then we throw it.
Some pupils, mostly girls, found the food games annoying as it resulted in 1) a smaller quantity of FV being available to the class, 2) threats from teachers to end the FV programme, and 3) a dirty classroom with FV all over the place.
Girl: There is hardly anyone who will eat oranges and clementines because the boys are throwing with them and you do not know if they have thrown it and put it back. And then when you open it, it is all gross.
The food games challenged the intention of creating a pleasant eating environment.
We also experienced the practice of playing and throwing with FV during observations at one school. During the observation, the FV were thrown in a game where boys and girls teased each other or flirted. The game took place so everyone could see and hear it and the involved pupils’ seemed to find it cool.
The teachers found the throwing of FV frustrating and draining.
Teacher: The children have not been able to behave properly with regards to throwing the FV. Honestly, sometimes it was so disturbing. If you saw how the classroom looked, tomato juice was running down from ceilings and walls.
According to many teachers, the FV programme required more teacher control than initially expected. Because the pupils in many classes could not administer the FV break by themselves, several teachers ended up allocating time for the FV eating during lessons.
Teacher: We have been forced to lock the classroom during breaks and to serve the fruit during lessons. It [the Boost FV programme] has become more teacher-guided than intended. That took a lot of energy.
Some teachers mentioned that they could not let the pupils do something together while eating FV during lessons, as the pupils could not control such a space.
Teacher: Sometimes you have to run the classes so strictly that the pupils are about to become suffocated. They can’t handle it if there is no structure. That is why you need to schedule it, now we do this and now we do that, the fruit is here. The prospect of a break and it is exploding.
The observations revealed rather different ways of implementing the FV break in different classes. Some teachers allowed pupils to cut up FV for themselves whenever they felt like it, both during lessons and breaks. Other teachers locked up the cutting tools and held the FV break at a prescheduled time.
Observations and interviews indicated that pupils in some classes had learned to administer the FV host responsibility of cutting up the FV without much teacher guidance. The throwing of FV also seemed to have declined by the end of the intervention period.
Most of the interviewed teachers referred to year 7 pupils as a special age group challenging implementation. According to the teachers many things are going on in this age group due to psychological, physical and social developmental changes and the pupils need a lot of structure.
Teacher: Ah well it is just that, well it is year 7 and everything is running around their heads.
Teacher: Well you know, there is really nothing getting through to them, they are “under reconstruction” those boys at year 7. They are simply all gone.
In summary, high quality, quantity and variety of FV were facilitators for dose received. As expected according to our programme theory, accessibility and appearance acted as both facilitators and barriers for dose received and were influenced by the teachers’ timing of the FV break. Teachers’ lack of time was a barrier for dose delivered and fidelity. The throwing of FV had an impact on the implementation by affecting 1) fidelity and dose delivered of the pleasant eating environment component as some teachers made more restrictions resulting in less pupil involvement and 2) dose received of the free FV as the pupils rejected the thrown FV. The teachers perceived the pupils’ age and social dynamics in the pupil group as barriers to teacher dose delivered and pupils’ dose received of the intervention.
Social norms: eating together
The interviews illustrated that pupils who shared and ate the same FV together formed a sense of community around the FV programme.
Interviewer: What makes it cosy, do you think?
Girl: Maybe the fact that we do the same thing and that it is something we do together.
Girl: Also we can sit and talk.
Girl: Yes, so we are a bit united in what we are doing.
Interviewer: Would it be different if you ate fruit that you had brought from home?
Girls: Yes.
Interviewer: How is it different?
Girl: Ah well, it is not served, you have to take it out of your bag yourself and things like that.
Girl: And then we do not bring the same fruit.
Interviewer: So it makes a difference that everyone has the same fruit.
Girl: And the same fruit, so you can talk about it.
The pupils appreciated that the FV programme was for everyone and some pupils expressed that it became a habit to eat FV in class and that they affected each other’s eating habits. Especially girls highlighted the cosiness of sharing the FV and being allowed to chat with each other while eating. Some girls perceived the implementation of the FV programme as getting an extra break, making school work in class less boring.
Girl: Well, we eat it together and then sometimes we are allowed to talk a bit when we are not working on something. It is almost like free time or freedom when we eat it.
The importance of having this free time, a specific time that belonged to the pupils, was also illustrated in an interview with a group of girls expressing their strong discontent with being forced to use their break to cut up the FV.
Contrary to the girls, the boys did not experience the FV eating as a shared activity.
Interviewer: How do you like eating FV together with your classmates?
Boy: It is okay. I do not really think about that we are eating it together as you just take some and then eat it by yourself.
Interviewer: So you do not experience it as a shared activity as such?
Boy: No, not at all.
These boys’ intake was not motivated by eating FV at the same time as classmates. Some boys felt that the girls appreciated the social aspects of eating FV together to a greater extent than them. Our interview questions prompted some boys to reflect on the eating situation and they concluded that they actually talked more with each other while eating the FV than while eating their packed lunch. During our observations we experienced that boys left the classroom as soon as the break began e.g. to go outside to play football while several girls stayed in the classroom and ate FV. In some interviews boys expressed their discontent with not getting FV when they returned from playing football as it had already been eaten.
The teachers reported that pupils enjoyed having FV in class during lessons and/or breaks. The teachers were unsure whether the pupils experienced the FV programme as creating a sense of community. According to some teachers, their pupils distinguished themselves from pupils from other classes by having the privilege of free FV. They liked to point out that the FV belonged to them. In some classes, our observations showed that pupils were eating the FV during breaks in smaller groups while talking. In other classes little social interaction took place as the pupils ate FV in the lesson while working.
In summary, eating FV as a shared activity acted as a facilitator for dose received by the pupils, especially among girls. The interviews indicated a gender differential appeal and reach of the social aspects of the pleasant eating environment component. The pupils’ sense of being unique because they were chosen to get a FV programme might also act as a facilitator for dose received. Lack of time served as a barrier for teachers’ delivery of A pleasant eating environment and their fidelity to this component.