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School food workshop
The majority of interventions which aim to alter food choice and related behaviours have been developed using principles from health psychology and health education, with interventions largely targeted at the individual. Over time, these interventions have become more sophisticated, moving from a relatively simplistic model in which behaviour was largely determined by knowledge and attitudes, towards theories and concepts including social cognitive theory, the transtheoretical model and health literacy(1). However, it has been increasingly recognised that food choice and consumption are strongly influenced by a range of other factors operating at multiple levels of influence across domains including the environment, social context, policy and culture(2,3). In the current paper, socio-ecological and RE-AIM frameworks are used to highlight the importance of recognising intrapersonal, interpersonal, organisational/settings, community, environment and political influences, and their interactions, in developing effective and sustainable solutions to improving children's dietary intake in schools. Evidence to support this approach is presented, with a focus on selected recently published studies that highlight the importance of understanding how interactions between levels can undermine or magnify intended intervention effects.
Theoretical frameworks
Multilevel perspectives
One of the most frequently cited taxonomies of the multiple levels of influence on health is that of Whitehead, who identifies: (i) individual lifestyle factors; (ii) social and community networks; (iii) living and working conditions; and (iv) socio-economic, cultural and environmental conditions(4). In discussing actions that might be taken to tackle social inequalities in health, Whitehead largely presents actions at each level as alternatives, although she notes that causes of social inequality in health are multiple and interrelated, and that actions need to be interconnected across intervention levels.
Too often a bipolar debate
However, all too often, the potential methods to improve health, including children's dietary intake in schools, are presented as alternatives, requiring policy makers to choose between competing approaches such as: behaviour change or health determinants?, individual focus or population health?, influencing choice or legislation? Criteria that might help determine which of the alternatives to choose are also highly contested on various grounds including politics, values, ethics, strength of evidence and epistemology. For example, the Nuffield Council on Bioethics...