title: Implementing a free school-based fruit and vegetable programme: barriers and facilitators experienced by pupils, teachers and produce suppliers in the Boost study.
abstract: BACKGROUND
  Multi-component interventions which combine educational and environmental strategies appear to be most effective in increasing fruit and vegetable (FV) intake in adolescents. However, multi-component interventions are complex to implement and often poorly implemented. Identification of barriers and facilitators for implementation is warranted to improve future interventions.This study aimed to explore implementation of two intervention components which addressed availability and accessibility of FV in the multi-component, school-based Boost study which targeted FV intake among Danish 13-year-olds and to identify barriers and facilitators for implementation among pupils, teachers and FV suppliers.
  
  
  METHODS
  We conducted focus group interviews with 111 13-year-olds and 13 teachers, completed class observations at six schools, and conducted telephone interviews with all involved FV suppliers. Interviews were transcribed, coded and analysed using qualitative analytical procedures.
  
  
  RESULTS
  FV suppliers affected the implementation of the FV programme at schools and thereby pupils' intake through their timing of delivery and through the quality, quantity and variety of the delivered FV. Teachers influenced the accessibility and appearance of FV by deciding if and when the pupils could eat FV and whether FV were cut up. Different aspects of time acted as barriers for teachers' implementation of the FV programme: time spent on having a FV break during lessons, time needed to prepare FV and time spent on pupils' misbehaviour and not being able to handle getting FV. Teacher timing of cutting up and serving FV could turn into a barrier for pupils FV intake due to enzymatic browning. The appearance of FV was important for pupils' intake, especially for girls. FV that did not appeal to the pupils e.g. had turned brown after being cut up were thrown around as a part of a game by the pupils, especially boys. Girls appreciated the social dimension of eating FV together to a larger extent than boys.
  
  
  CONCLUSIONS
  Limited time and pupils' misbehaviour were barriers for teachers' implementation. Establishing FV delivery to schools as a new routine challenged FV suppliers' implementation. Food aesthetics were important for most pupils' FV intake while the social dimension of eating FV together seemed more important to girls than boys.
  
  
  BACKGROUND
  Current Controlled Trials ISRCTN11666034.
authors: Centre for Intervention Research in Health Promotion and Disease Prevention, National Institute of Public Health, University of Southern Denmark, Øster Farimagsgade 5A 2nd floor, 1353 Copenhagen K, Denmark. aka@niph.dk.
authors: Anne Kristine
authors: AK
authors: Aarestrup
authors: Rikke
authors: R
authors: Krølner
authors: Thea Suldrup
authors: TS
authors: Jørgensen
authors: Alexandra
authors: A
authors: Evans
authors: Pernille
authors: P
authors: Due
authors: Tine
authors: T
authors: Tjørnhøj-Thomsen
mesh_terms: D000293:Adolescent; D003718:Denmark; D005178:Faculty; D005247:Feeding Behavior / Q000523:psychology*; D005260:Female; D017144:Focus Groups; D005522:Food Services / Q000458:organization & administration*; D005638:Fruit; D006293:Health Promotion / Q000379:methods; D006801:Humans; D008297:Male; D036301:Qualitative Research; D012572:School Health Services / Q000458:organization & administration*; D013334:Students; D014675:Vegetables