A summary of the key findings, grouped by the domains of the theoretical framework, is outlined in Table 2. These are presented in the sections below under three broad categories: enablers for the policy process, policy challenges, and participant suggestions to strengthen the policy. This is preceded by an overview of the relevant school food policy that applies in Samoa.
3.1 Overview of the Samoan School Food Policy Context
The Standards listed a number of commitments towards achieving their goal, including that all meals are served with vegetables and lean meat, that fruit is always available, that sandwiches and rolls include vegetables, and that food is not deep-fried. They provide menu examples aligned to the Healthy Eating Guidelines for Samoa, also recommend complementary activities that promote the guidelines.
The arrangements for school food vendor operations vary widely between schools, though most food vendors operate on school grounds as tenants, and accountability to the Standards rests with the school committee. According to policymakers some of the vendors have a registered business permit, though it is not a requirement.
3.2 Enablers for school food policy implementation in Samoa
The Standards are supported by a clear mechanism for governance and monitoring
Nearly all public schools (urban and rural) are situated inside of villages, and these villages take a central role in carrying-out government programs. In most areas, school operations and infrastructure are the responsibility of the surrounding village and school committee, while MESC adopts responsibility for teaching, learning and accountability in the public-school system. The school committee is responsible for school management, and is most often comprised of the principal, and a group of senior community members.
The Ministry of Health is the leading health promoting body in the country, and principally responsible for delivering on the Standards, which are implemented under the auspice of the HPS Committee. The Standards are continually promoted in schools during monitoring visits, during training opportunities and annual school health symposiums involving around 200 school representatives. The Government also delivers a coordinated monitoring program made of biannual visits to schools by health promotion and nutrition officers, together with representatives from MESC. Monitoring visits routinely include feedback to school principals, who are encouraged to discuss the results with the school committee. Four of the principals explained that the monitoring visits were a useful mechanism to remind them of the policy.
“So that (the monitoring visits) challenges us to make sure everything is prepared and done by the standards given to us.” (Principal, Interview 33)
Biannual reports on compliance are aggregated and submitted to policy leaders in Health and Education, as well as the HPS Committee, which is represented by sectors Health, Education, Women, and Agriculture. Reports are also presented to schools during annual HPS Symposiums, where an award system is offered as an incentive. According to health officers, schools not complying with the standards risk an official letter of reprimand or rebuke by political leaders.
The school health space is a priority of policy leaders and health officials
The document analysis revealed that MOH, as the principle driver of health policy in Samoa, has continually prioritised school health throughout their policies. MOH allocates significant resources to implementing HPS, including resourcing a team of health workers to undertake year-round monitoring.
HPS was until 2018 overseen by Samoa’s Parliamentary Advocacy Group for Healthy Lifestyles (SPAGHL), a group of parliamentarians championing public health issues. According to interviews, members of the group had in the past visited schools that were not meeting sanitation standards and threatened closure to those not meeting tobacco and sanitation standards.
Education officials recognise the importance of good nutrition
All education officials interviewed for this research indicated that they viewed nutrition as important, especially in view of the NCD crisis in Samoa. The education sector had demonstrated some commitment to improving school nutrition, including by integrating a performance indicator related to the Standards into a new set of Minimum Service Standards (2017) as an attempt to improve their enforceability.
A third of the principals we met with reported monitoring the school canteen themselves, issuing warnings to the canteen or reporting poor compliance to the school committee. One principal had successfully encouraged the committee to integrate compliance with the Standards into the canteen vendor’s contract. The contract was subsequently terminated when they were found not to comply.
“The partnership is really important, …I’m so blessed to have a very good support from not only the parents but the school committee….I raised it to the school committee…so we have made a letter to the canteen man and cancelled his contract” (Principal, Interview 34)
The policy has led to some positive changes to the school food environment
Interviewees from MESC reported that they believed that the introduction of the Standard in 2012 had led to vast improvements to the school food environment. Some schools we visited sold a large range of compliant foods, including sandwiches, eggs, popcorn, spaghetti, bags of dried cereal (e.g. rice crisps) and curry with rice. Health officers provided examples of schools delegating families in the village to supply soup on ‘healthy soup’ days, or fruits for morning tea. These were identified by participants as a revenue-earning opportunities for local families.
At least three principals discussed having complementary programs to promote healthy eating, for instance by growing fruit trees or displaying nutrition promotion materials.
Table 2: Summary of findings grouped by theoretical domains
Contextual factors
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Unhealthy and banned foods are very affordable to children when compared to healthy alternatives
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Local food vendors significantly influence food consumption by school children
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Political leaders are very supportive of school-based food policy
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The Standards are supported by a clear mechanism for governance and monitoring
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Nutrition is included in the school curriculum, but not at all levels of schooling
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The local community has oversight of the school environment and infrastructure
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Policy Content
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The Standards comprehensively outline allowable and banned foods
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The Standards have no meaningful repercussions for non-compliance
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Process
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The health agency dedicates adequate resources to promote and monitor the policy
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Training was provided to school-level actors at inception
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The policy is routinely monitored
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The policy has not been formally evaluated
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Actors
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Political leaders and health officials are very committed to regulating foods in schools
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Cross-sectorally, there is a varied perception of responsibility for ensuring the Standards are effectively implemented
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Education actors face a number of competing priorities which prevent them from prioritising implementation of the Standards
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All actors demonstrate interest in the health and wellbeing of children
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School-level actors report that they know about and understand the policy
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School and community level actors exercise discretion and agency in implementing the Standards
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Nutrition literacy and financial resources were key barriers to the effective implementation of the Standards
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Outcomes
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The policy has led to some positive outcomes in the school food environment
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A large proportion of schools are still selling unhealthy foods and beverages to children, including sugar-sweetened beverages, ice-blocks, dried noodles and highly processed meats
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3.3 Policy challenges facing improvements to the school food environment
Unhealthy foods and beverages are still widely available in schools
Interviewees from both MOH and MESC indicated that there were a large proportion of school food vendors still selling unhealthy foods. Biannual program reports show consistently low compliance year-on-year (62, 63), lingering between 32% and 36% between 2014 and 2018. The compliance report for 2016 found that over 55% of schools still sold ice blocks and sweetened beverages, despite widespread recognition that they were a banned product for schools (63). Conclusions from the Government’s own reports acknowledge the lack of progress in improving compliance, and call on stakeholders to make greater efforts to ensure that standards are adhered to.
We were invited by a number of schools to visually inspect their canteens during the interview process. Foods and beverages that were commonly available included cakes, doughnuts, packaged sweet biscuits, chips and extruded snacks, milo and other sugar-sweetened beverages, hot dogs and other processed meat franks, noodles, chop suey (noodles with soy sauce), ice-cups and white-bread sandwiches. One canteen manager stated that she was trying to convert her canteen into a healthy canteen, but she was currently selling fries, doughnuts, cream buns, packaged biscuits, chocolate, packaged savoury snacks, dried noodles and a range of sugar-sweetened beverages.
The School Nutrition Standards are not enforceable
The Standards have no clear implications for non-compliance, and policymakers and principals consistently noted that the lack of enforceability was a significant barrier to policy implementation and effectiveness. Policy officers explained that they could only provide warnings to non-compliant schools. It was evident through these interviews that the existing accountability mechanisms were exerting little pressure to food vendors operating in and around schools. Other health policies that apply to schools and are protected by legislation (for example The Tobacco Act and Food Safety Act) are all enforceable, risking school closure for non-compliance.
“If they sell the food in unhygienic environments, they would be warned or a closure…School nutrition Standards, there's nothing in the law [to enforce it]…They don't take it seriously unless we regulate the food to be sold in schools.” (Health Official, Interview 15)
The challenge of cross-sectoral collaboration and perceptions of responsibility
Despite significant efforts to address the contribution of poor nutrition to NCDs, health officials believed nutrition was a low-priority for other key actors, specifically villages and MESC. MOH indicated that the Standards would be more effective should the Education department take over their responsibility. Conversely, the education officials we met with indicated they believed nutrition promotion to be the responsibility of health officials.
“As I see, because the Education ministry, they are not encouraging because they said their goal is just teaching. They are there to teach, not to do anything else about nutrition” (Senior Health Official, Interview 15)
“(School) nutrition should sit with MOH and they should be driving it as well. Collaborating of course with us, when they do go into schools” (Education Official, Interview 12)
Four health officials noted that the interests of partnering sectors in HPS had dwindled over time, and that officers representing them at committee meetings often rotated between meetings, affecting continuity and the likelihood of recommendations being taken to (or actioned by) senior leaders.
One senior official from Education explained that that the ability of the Education sector to dedicate more ‘space’ to nutrition in the curriculum would require a mandate from senior policy leaders, and that this would be in direct competition with other priorities (e.g. sexual health).
“(Samoan) people are dying everywhere, getting sick [from NCDs]. The only way to enforce it is to have it as a policy decision from the high level. And it’s the only way to turn things around and say the focus on health must be made compulsory.... in terms of NCDs... It’s important, but it’s packed together with PE [physical education], you know?” (Senior Education Official, Interview 38)
According to policy officers in health and education, the personal motivation of individual principals to administer and enforce the Standards is a critical aspect of success.
“It really depends on the school principal ‘cause there are principals that are really supportive, and also we’ve come across principals that just don't want to do anything with the Standards.” (Health Official, Interview 17)
School-level actors are exercising ‘agency’
We found that canteen vendors were exercising a high-degree of agency in running their canteens, and that the accountability mechanisms were not adequately influencing school committees to prioritise nutrition. In at least five of the schools we visited, we noted a large disconnect between the principal’s statements of commitment to the policy, and the foods being sold.
“I think they just pick the food that sells fast…. … they only look at income [of the canteen]…they don't see the benefits of children eating those foods” (Health Official, Interview 15)
Several principals indicated that they personally had little influence over canteen sales. In two instances, the principals reported that their canteen vendor was in the family of a leading school committee member, an arrangement that reduced the power of the principal to enforce change. One principal appeared visibly disappointed when she took us to the canteen and saw what was being sold.
“We always talk to them about the food they bring and they sell to the pupils in school, but they don’t admire what we say” (Principal, Interview 28)
Although every vendor we interviewed was aware of the Standards, we noted that those retailing non-compliant foods discussed so without hesitation. For instance, one vendor told us he knew of the guidelines, but had on display only cakes, cookies, sugar-sweetened beverages. Another vendor knew of the guidelines but sold only icey poles and doughnuts. None of the vendors raised with us any concerns regarding implications for non-compliance.
Capacity and resources of implementing actors
Vendors in both urban and rural schools discussed that the relative cost of healthy food would make it difficult to run a successful business whilst being compliant with the Standards. One canteen manager indicated that she wasn’t committed to the Standards because the foods advocated in them were cost-prohibitive and non-competitive, lamenting that they should have been costed for feasibility.
“Cause we don't care. We’re business people, right?.…It's very expensive for the food that is required” (School Food Vendor, Interview 29)
Reportedly, the majority of school committees rely on revenue generated by the canteen to maintain school grounds and infrastructure, an arrangement that creates a conflict for principals attempting to enforce Standards.
Vendors we met appeared to have a very limited understanding of nutrition principles. Though the Standards provide an extensive list of compliant foods, examples given by vendors of compliant foods indicated they were misinterpreting the guidelines. Policymakers from both health and education indicated that lack of understanding around nutrition was a systemic problem.
“But now we've realised that sometimes the community find it hard to follow or to understand what constitutes healthy food” (Education Official, Interview 12)
For instance, one canteen manager discussed how she only sold cooked noodles instead of dry noodles because they were a healthier alternative, and told us she was ‘dry frying’ commercial chicken nuggets and French fries to improve their healthfulness. Another canteen manager explained that she sold chicken franks (highly processed sausages) because they were a healthier alternative to hot dogs. Many schools listed ‘chop suey’ (noodles cooked in soya sauce, with or without canned beef) or white bread as examples of healthier alternatives. While many of these are allowed on the Standards, they are to be accompanied by “a generous amount of vegetables” (page 9 of the Standards)(64).
The food environment negatively influences policy implementation
The broader food environment in Samoa was a principle problem identified by interviewees throughout this research. The poor nutritional quality of food being sold by informal food vendors surrounding the school settings was noted by all nine of the principals we interviewed, and by half of the canteen vendors.
According to interviewees, children were commonly leaving school grounds during school hours, and returning with cheap processed foods. This was affecting canteen viability, as well as canteen vendor commitment to implementing the Standards.
“There’s a lot of vendors now…that’s how they want to make unhealthy food because the vendor is selling this food and the kids go and buy from them instead of buying the food that they are carrying in the canteen” (Policy Official, Interview 16)
For children and their families, the affordability of healthier foods and beverages, compared with less-healthy alternatives, was consistently reported as a key barrier to the implementation of the Standards by school principals, vendors and policymakers.
“I think despite all that we’ve been trying to do, it comes down to costs. Because a can of Coke costs sometimes go down as far as 1.50 tala [USD0.65]. And a meal, you don’t get a meal for one tala.” (Politician from the Samoa Parliamentary Advocacy Group for Healthy Lifestyles, Interview 20)
Children’s preference for unhealthy foods, and their unwillingness to purchase healthy foods at a higher cost was perceived by both policymakers and policy implementers to be a key challenge.
Policy effectiveness has not been evaluated
The Standards had not undergone evaluation to examine its impact on policy objectives since their launch in 2012. Monitoring reports are routinely discussed at HPS Committee meetings, though the level of representation at these meetings reportedly limits the degree to which these are used to generate high-level policy discussion across agencies, and policy officers we talked to were unclear if compliance reports were used by policy leaders (e.g. heads of agencies and parliamentarians).
3.4 Participant recommendations for addressing challenges
Interviewees identified a number of opportunities to strengthen policy action. One school had requested a more nuanced approach to monitoring, to better reflect some of the positive changes and to incentivise improvements made overtime.
One principal suggested others should work to engage the interest and support of community leaders and the school committee to pressure vendors operating in and around school grounds, and ban unhealthy food vendors from operating nearby. Three principals had pinned compliance to the opportunity to operate a food outlet on school grounds.
Others felt the issue of school nutrition and nutrition literacy should once again be brought to the attention of political leaders in the context of Samoa’s concerns around the rise of diet-related NCDs. They recommended that the policy should become fully enforceable, that children should be banned from leaving school grounds during school hours, and that nutrition curriculum should become a mandatory subject throughout a child’s education.
“And if Cabinet were to see numbers, patterns of NCDs escalating, then propose best options to do this, through education system, through the community…things can happen.” (Senior Education Official, Interview 33)