title: CAFÉ: a multicomponent audit and feedback intervention to improve implementation of healthy food policy in primary school canteens: a randomised controlled trial.
abstract: BACKGROUND
  The implementation of nutrition policies in schools has been recommended as a strategy to improve child dietary intake. Internationally, research suggests that the majority of schools do not implement these policies. In New South Wales (NSW), Australia, the NSW Healthy School Canteen Policy requires that school canteens prohibit the sale of 'red' foods (i.e. foods that are typically nutrient poor and high in energy, such as confectionary and deep-fried foods) and 'banned'drinks (i.e. soft drinks); and that the majority of items on the menu are 'green' (i.e. foods that are good sources of nutrients, such fruits, vegetables and lean meats). This study examined the impact of a multicomponent audit and feedback intervention on schools' implementation of the NSW Healthy School Canteen Policy. A secondary aim was to assess the impact of the intervention on menu composition.
  
  
  METHODS
  This study was a parallel group randomised controlled trial with 72 rural and remote primary schools (36 interventions, 36 controls) located in one region within NSW, Australia. Intervention schools received an initial face to face contact and up to four cycles of audit and feedback (consisting of a menu audit, written feedback report and telephone feedback) over a 12-month period. The primary trial outcomes were the proportion of schools with a canteen menu that had: i) no 'red' foods or 'banned' drinks; and ii) >50% 'green' items, as assessed via standardised menu audits undertaken by trained dietitians. For each primary outcome, between-group differences were assessed using Fisher's exact test under an intention to treat approach.
  
  
  RESULTS
  There was insufficient evidence to conclude the intervention had a positive impact on the proportion of intervention schools with no 'red' or 'banned' items on their menu (RR = 2.8; 95% CI: 0.9 to 8.9; p = 0.0895), or on the proportion of intervention schools with more than 50% 'green' items (RR = 1.5; 95% CI: 0.7 to 3.2; p = 0.2568). These findings remained non-significant in the multiple imputation analyses. Intervention schools were significantly more likely to have a lower percentage of 'red' items (p-value: 0.007) and a higher percentage of 'green' items on the menu (p-value: 0.014). This remained statistically significant in the multiple imputation analyses for 'red items' (p-value: 0.0081) but not for 'green' items (p-value: 0.0910).
  
  
  CONCLUSIONS
  While there was insufficient statistical evidence to suggest that this multicomponent audit and feedback intervention was effective in improving primary schools' compliance with a healthy canteen policy, the intervention demonstrated some positive impact in reducing the availability of 'red' items on the menu.
  
  
  BACKGROUND
  This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12613000543785 ). Registered 15th May 2013.
authors.affiliation: School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia. Serene.Yoong@hnehealth.nsw.gov.au.|Hunter Medical Research Institute, New Lambton, NSW, 2305, Australia. Serene.Yoong@hnehealth.nsw.gov.au.|Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia. Serene.Yoong@hnehealth.nsw.gov.au.|Hunter New England Population Health, Locked Bag 10, Wallsend, NSW, 2287, Australia. Serene.Yoong@hnehealth.nsw.gov.au.
authors.forename: Sze Lin
authors.initials: SL
authors.lastname: Yoong
authors.affiliation: School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, New Lambton, NSW, 2305, Australia.|Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter New England Population Health, Locked Bag 10, Wallsend, NSW, 2287, Australia.
authors.forename: Nicole
authors.initials: N
authors.lastname: Nathan
authors.affiliation: School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, New Lambton, NSW, 2305, Australia.|Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter New England Population Health, Locked Bag 10, Wallsend, NSW, 2287, Australia.
authors.forename: Luke
authors.initials: L
authors.lastname: Wolfenden
authors.affiliation: School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, New Lambton, NSW, 2305, Australia.|Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter New England Population Health, Locked Bag 10, Wallsend, NSW, 2287, Australia.
authors.forename: John
authors.initials: J
authors.lastname: Wiggers
authors.affiliation: School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, New Lambton, NSW, 2305, Australia.|Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter New England Population Health, Locked Bag 10, Wallsend, NSW, 2287, Australia.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Reilly
authors.affiliation: School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, New Lambton, NSW, 2305, Australia.
authors.forename: Christopher
authors.initials: C
authors.lastname: Oldmeadow
authors.affiliation: School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, New Lambton, NSW, 2305, Australia.|Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter New England Population Health, Locked Bag 10, Wallsend, NSW, 2287, Australia.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Wyse
authors.affiliation: School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, New Lambton, NSW, 2305, Australia.|Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter New England Population Health, Locked Bag 10, Wallsend, NSW, 2287, Australia.
authors.forename: Rachel
authors.initials: R
authors.lastname: Sutherland
authors.affiliation: School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, New Lambton, NSW, 2305, Australia.|Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter New England Population Health, Locked Bag 10, Wallsend, NSW, 2287, Australia.
authors.forename: Tessa
authors.initials: T
authors.lastname: Delaney
authors.affiliation: School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, New Lambton, NSW, 2305, Australia.|Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter New England Population Health, Locked Bag 10, Wallsend, NSW, 2287, Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: Butler
authors.affiliation: School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, New Lambton, NSW, 2305, Australia.|Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter New England Population Health, Locked Bag 10, Wallsend, NSW, 2287, Australia.
authors.forename: Lisa
authors.initials: L
authors.lastname: Janssen
authors.affiliation: Hunter New England Population Health, Locked Bag 10, Wallsend, NSW, 2287, Australia.
authors.forename: Sarah
authors.initials: S
authors.lastname: Preece
authors.affiliation: School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, New Lambton, NSW, 2305, Australia.|Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia.|Hunter New England Population Health, Locked Bag 10, Wallsend, NSW, 2287, Australia.
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Williams
mesh_terms: D002648:Child; D003132:Commerce; D004032:Diet / Q000592:standards; D005246:Feedback; D005260:Female; D005522:Food Services / Q000592:standards; D019983:Guideline Adherence; D006293:Health Promotion; D006801:Humans; D008297:Male; D009517:New South Wales; D018673:Nutrition Policy; D012574:Schools; D016037:Single-Blind Method
keywords: Audit and feedback; Implementation; Nutrition; Nutrition policies; Primary schools