Understanding implementation determinants of universal school meals through an equity-driven mixed methods approach

Area of Science:

• Implementation Science
• Health Equity
• Public Health Nutrition

Background:

• Universal School Meals (USM) are vital for preventing chronic disease inequities in marginalized populations.
• Low student participation in USM limits its public health impact despite reducing food insecurity and obesity risk.
• This study investigates USM implementation determinants and challenges in a large urban school district.

Purpose of the Study:

• To identify determinants influencing Universal School Meals (USM) implementation in a major urban school district.
• To assess challenges and supports across schools with varying USM participation rates.
• To inform strategies for enhancing USM reach and impact through an Implementation Mapping process.

Main Methods:

• A convergent mixed-methods study was conducted in 8 schools (6 middle, 2 high) within the School District of Philadelphia.
• Data collection involved qualitative interviews, surveys, and mealtime observations, guided by the Consolidated Framework for Implementation Research (CFIR) and Health Equity Measurement Framework.
• Interviews were coded to identify barriers (-1, -2) and supports (+1, +2) for USM implementation, with schools grouped by participation levels (low, moderate, high).

Main Results:

• Mid-level and High-level Leaders were the strongest facilitators of USM implementation (M=1.29 and M=0.96, respectively).
• Market Pressure (competitive foods) and Relative Priority were significant barriers (M=-1.35 and M=-1.17, respectively).
• Higher participation schools reported less stigma, more equitable procedures, and greater food service manager involvement compared to lower participation schools.

Conclusions:

• Effective Universal School Meals (USM) implementation requires strong leadership at multiple levels.
• Addressing external factors like market competition and internal factors like relative priority is crucial.
• Equity-focused strategies are essential to reduce stigma and build capacity for increased USM participation and public health impact.