Case Studies On Health Promotion Initiatives From The Nordic Countries

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Contents
	Introduction
1	Promoting healthy school meals for Norwegian children
2	From control policy to comprehensive family planning: success stories from Finland
3	Everybody is needed - Södra Skaraborg, Sweden
4	The promotion of oral health among Danes
5	Interventions for smoke-free schools. From information deficit to social influence
6	The prevention of night blindness in Bangladesh
7	Health policy development in Costa Rica

Case study #1: Promoting healthy school meals for Norwegian children

Name of the person reporting:	Knut-Inge Klepp
Address:	Institute for Nutrition Research University of Oslo P.O.Box 1046 Blindern N-0316 Oslo Norway
Telephone:	+ 47 - 22 85 13 78
Fax No.	+ 47 - 22 85 15 12
E-mail:	K.I.Klepp@basalmed.uio.no

Rationale for Initative

In Norway, school meals for most pupils (grades 1 - 9) consist of lunch-bags (open-faced sandwiches) brought from home. Milk is usually offered at school (at subsidized prizes), while typically, no food is offered for students to purchase at school.

Surveys conducted in the late 1980s and early 1990s indicated that a substantial group of pupils did not bring food from home. This was particularly true for secondary school pupils, and it was estimated that almost 20% of these pupils (grades 7 - 9) did not bring lunch-bags. Furthermore, it was observed that the time allocated to the school meal was very short (< 15 minutes in more than a third of the schools), and more than 90% of the pupils were left unattended to eat in their classrooms.

In 1993, a national survey of eating patterns among Norwegian 7th and 11th graders clearly demonstrated that students who did not eat lunch regularly, reported to have a diet higher in fat and sugar than did students who ate lunch every day.

Objectives of Initiative

Based on these findings, the Norwegian National Nutrition Council decided upon a set of National guidelines for school meals (in Norway, virtually all schools are public schools):

All pupils should be allowed to eat at regular times, not exceeding 3 - 4 hours between meals.
These meals should consist of open-faced sandwiches (lunch bag), skimmed or low-fat milk, fruit and/or vegetables.
All schools should offer skimmed or low-fat milk, fruit and/or vegetables.
All schools should offer sandwiches (bread) to pupils with no lunch-bag.
Secondary schools and high schools should have a cafeteria/dining area.
All pupils should have sufficient time for eating, i.e. a minimum of 20 minutes.
Younger pupils (grades 1 - 3) should be attended (by an adult) while eating.
An effort should be made to create a positive and enjoyable atmosphere during the meal-time.
As part of the extended "open school" program, pupils should have the opportunity of eating breakfast and one meal in the afternoon (in addition to the school lunch).
The funds and resources needed to organize the school meals should be made available by the local municipalities.

Description of Initiative

In order to promote these environmental changes within Norwegian schools, the National Nutrition Council has, since 1991, focused on:

Nation-wide distribution of the new recommendations and promotional material suggesting how cafeterias and the school meal can be organized.
Providing economic incentives for schools to develop new models for how to organize the school meal.
Supporting a national campaign to promote lunch-bags among school-children. This campaign was initiated and promoted by a number of non-governmental organizations in close collaboration with the National Nutrition Council.
Promoting legislation that would make it obligatory for local municipalities to ensure well-organized school meals for all pupils in the grades 1 through 10.

Evaluation and Evidence of Success

To date, the following results have been observed as a direct result of the school meal initiative:

Policy change

On December 1, 1995 the following Governmental policy was passed as an amendment to the Law on Health Services in the Municipalities (No. 66; Nov. 19, 1992):

§ 11. Meal: Appropriate facilities for eating which also promote the social functions of the meal should be available.

As an additional explanation to this amendment, the following paragraph was included in the legal text:

Comments to § 11. Meal: The National Nutrition Councils guidelines for school meals apply in order to secure the nutritional standard and social function of the meal.

Behavior change

Using Norwegian data from the international WHO Health Behaviour in School Children surveys, we investigated changes in reported meal patterns among 5th, 7th and 9th graders from 1983 to 1993.

From 1983 to 1989 we saw a significant trend indicating that fewer students were eating lunch every day (from 74% to 64%). This trend was, however, reversed from 1989 to 1993 as the proportion of students reporting to eat lunch every day increased to 73%. This pattern, including a statistically significant increase in the proportion of students reporting to eat lunch every day from 1989 to 1993, was seen for both boys and girls and for students in all three age groups.

Reflections

Based on available data and our experience to date, we can conclude that:

As of 1996, the Norwegian Government has made it obligatory to ensure well-organized school meals for all pupils in the 10 first grades of the Norwegian public schools.
Available survey data indicate that the negative trend of declining proportion of pupils eating school-lunch every day has been reversed since 1990.

In order to investigate the extent to which schools have started to offer food and opened school cafeterias, a nationwide survey (similar to the one conducted in 1991) is scheduled for Spring 1997. Furthermore, local investigations are currently being conducted in order to study what impact an organized school meal might have on the overall dietary habits of students, and how the meals are perceived by students and school staff.

Finally, the Norwegian school meal initiative was a national effort. Nation-wide dissemination of the intervention efforts was secured by working through the public school system and through the national legislative system. The apparent success, so far, in putting school meals on the agenda, mobilizing schools to organize their school meals according to the national guidelines, and increasing the proportion of students reporting to eat lunch, is believed to be a result of the combined effort of a "top-down" healthy policy initiative and a

"bottom-up" mobilization of students and school personnel to increase the proportion of students bringing lunch-bags from home and schools offering food for those students not bringing their own lunch-bags. While the first strategy was promoted by a governmental agency, the National Nutrition Council, the latter strategy was mainly promoted by non-governmental organizations and their local chapters. The National Nutrition Council continues its efforts to promote healthy school meals and to investigate potential intended and unintended outcomes of this initiative.

References:

Klepp,K.I., Halvorsen,M., Bjørneboe,G.E.Aa. & Wold,B. (1996). Evaluating "Food on the Schools" - Changes over time in reported meal frequency among Norwegian school children. Scandinavian Journal of Nutrition, 40(3), 113-116.

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