Building Healthy Food Environment in Schools: Evaluating Co-created Interventions in Low Resource Settings.

Project Summary:

The study aims to co-create, implement, and robustly evaluate an innovative multicomponent intervention (MI) that addresses adolescents’ current and future health**.**

The specific objectives are:

Objective 1: Community-engaged co-creation of a contextual MI to promote healthy food behaviour and environment in schools.

Objective 2: Implement and evaluate the MI in schools in India and assess effectiveness on the proportion of normal-weight adolescents as primary outcome and secondary outcomes such as global dietary recommendation score (GDRS), physical activity, and mental well-being score.

Objective 3: Evaluate the implementation of MI using the RE-AIM framework, assessing reach, adoption, implementation, and maintenance.

Objective 4: Conduct a cost-effectiveness analysis to change BMI (from overweight/obese/underweight to normal weight) and improve GDRS.

Research questions and hypotheses, theoretical approach, and methodology

The overarching research question guiding this project is: How can adolescents be supported and encouraged to adopt healthy food behaviour through co-created MI in school? Based on the state of the art, professional experience, and previous pilot project findings, our hypotheses are:

**1.**Adequate understanding of the context (stakeholders, resources, facilitators, and barriers) is needed to effectively engage communities in co-creation. (Work package (WP) 1)

**2.**MI package co-created with stakeholders will be acceptable to the end-users and foster ownership and adaptation. (WP2 and 4)

3.       Healthy food behaviour and environment in schools can reduce overweight and underweight and promote physical and mental health. (WP3)

**4.**Providing school-wide intervention will reinforce behaviours through peer support. (WP3)

**5.**Improvements in adolescent BMI occurs through multiple pathways (knowledge and supportive school environment). (WP3)

6.       Understanding of the mechanisms behind the interventions’ effects will guide future scale up. (WP4)

7.       It will be cost-effective to implement a co-created MI package in schools. (WP5)

This study will collect qualitative and quantitative data through various methods, categorized under different Work Packages (WPs):

Work Package 1 (WP1): In-depth Interviews (IDIs): Conducted with principals, teachers, school administrators, canteen staff, food vendors, and parents of 7-10 grade students. Focus Group Discussions (FGDs): Conducted with students

Work Package 3 (WP3): Anthropometric Measurements: Height and weight will be measured at baseline and follow-up to calculate BMI. The primary outcome is the difference in the proportion of normal-weight adolescents between the intervention and control groups at 12 months.

Dietary Intake & Quality: Measured using a diet quality questionnaire adapted for India (29 questions). Physical Activity Levels: Assessed using the Global Physical Activity Questionnaire (GPAQ). Mental Well-being.

Demographic & Socioeconomic Data: Includes age, gender, education, and environmental factors, collected at baseline and follow-up.

Work Package 4 (WP4):  Survey on Willingness for Healthy Dietary Choices: Adolescents will rate their likelihood of choosing specific healthy food options for lunch or snacks on a Likert scale (1–5). Focus Group Discussions (FGDs): Six FGDs will be conducted with teachers (n=3) and adolescents (n=3). Key Informant Interviews (KIIs): A total of n=16 will be conducted with key stakeholders, including public health and education officers, school principals, canteen staff, and food vendors, to assess facilitators and barriers to implementation.