DISCUSIÓN

Translational research is fundamental for improving health status (43, 258). Translational science requires simplification and better communication of the evidence to make it easier for non-academics to decipher research outcomes (258). This can be achieved by translating the outcomes into practical tools (258), such as a model that can guide practitioners working with communities. Summarising the findings into a simple model that highlights the main research concepts makes it easier to incorporate the concepts into health promotion planning, policy development and further research in the area.

The model developed from this research emphasises that health promotion interventions require consideration of the individual embedded in their environment. The bottom section of the framework (Figure 6.2) summarises established concepts from the literature, which recognise the role of environments as supported by many health promotion models and theories, such as Ottawa charter (55) and SEM (53). The model acknowledges that supportive environments are a crucial part of the process to change eating habits. This section also highlights that strengthening school community action is an essential element of creating a supportive environment.

The research supports earlier statements that individual behaviour models, such as The Theory of Planned Behaviour, are not effective for guiding public health research with children as the environmental concepts are neglected. The top section of Figure 6.2 shows that this model has embedded key stakeholders, the children, within their environment by connecting children’s decision-making criteria with the food available within the school food environment. While the results of qualitative research are not generalisable, a cohesive and shared narrative emerged to inform the results of this research. This shared understanding led to the model. Theoretically, the model will support the change of behaviours within a broader environmental context, improve the outcomes of healthy eating programs in schools and move closer to the ideal (described in section 1.3).

Theoretical models can assist planning for healthy public policy (246). There has been support for the development of healthy public policy globally since Ottawa charter (55) and more recently the Helsinki declaration on health in all policies and the Shanghai declaration (43, 50, 51). Policies can shape opportunities for people to make healthier choices (181, 182). The model developed from this research provides an opportunity to guide policy across states and territories where various strategies are implemented within the school to promote healthy eating. Most importantly, the model can be used as a checkpoint to ensure all concepts are considered collectively before embarking on a health promotion initiative in schools. When a model can translate across a range of different state and territory school- based programs, such that there is one model used nationally, the consistency and strength of action is increased (246).

Policies that influence food and nutrition are vital (43). Although policy formation is presented as a linear process, it has been acknowledged that in reality, policy formation and

implementation is an iterative process driven by values and dependent on the social environment (43, 182). It has been recognised that policy is not always driven by research, evidence or the best possible approach (182). Policy makers use a range of information but academic research is not often one of them (258). Improving the communication of the evidence to policy makers by translating research outcomes into practical tools can improve the potential of evidence being translated to policy (258). This must be done in a way that it incorporates the views and experiences of the community (258). Developing a model, which summarises the main research findings, is an important step to integrate evidence into policy.

More specifically, with respect to National public health policy, the results support a review of current eating guidelines as this research shows children make food choices from a

collection of concepts that do not align with the current ADGs. In addition, the research supports that an understanding about healthy foods and having healthy foods available is important but it does not necessarily translate into children choosing and eating healthy food (172, 248, 249). More effort is required to offer food that meets children’s decision-making criteria. Concerning national curriculum (259), there is an opportunity to revamp the health and physical activity learning area and connect healthy messages taught in class to other areas of the school environment to maintain consistency of messages across the whole school setting. This research shows that children are able to articulate collectively five shared decision-making concepts and the process of exploring children’s views on factors that influence food choice incorporated into the national curriculum can result in child participation to strengthen the food environment becoming the norm in all schools.

Alternatively, the idea of using the model to assist with the evaluation of national policy is worth considering. Current nutrition-related policies for offering food to children may benefit from an appraisal in light of the decision-making criteria that children use and other aspects of the model. The appraisal could highlight specific areas from the model that are missing in a policy, or areas that need strengthening in a policy. The model also provides a practical tool to support the translation of formative research to nutrition-related health policy. At a local level, an implication of the research could be that Education Departments make school nutrition policies mandatory using the model to help guide the policy development. Part of the policy can include a process to consider children’s decision-making criteria for making food choices. The concepts in the model developed from the research are broad enough that schools can adapt them for their specific context. The concepts can also inform guidelines that contain ideas how canteens can work with healthy options that align with the ADGs and adjust the healthy foods to make them more desirable for children.

For public health and health promotion, using a gold standard Randomised Control Trial (RCT) is not seen to accommodate the real-life variables that inevitably occur outside of the laboratory (43, 182, 258). As such, the type of research described here is an appropriate way of approaching the research is PAR, rather than the gold standard RCT. This research provides a consistent way of working in schools using research approaches that are appropriate for public health and health promotion research. PAR is an example of an approach suitable for interventions with children in schools (217, 235) and this model could be used to guide such a process. Furthermore, the Discovery Day is a suitable data

collection method to access the views of children during school. The Discovery Day also aligns with the appropriate stage of cognitive development. Children at primary school need a physical object to relate to when discussing their thoughts and feelings as they are not able to think in an abstract way at this age (141). This would include using the children’s school canteen as a proxy to give them the context they need for exploring their views.

Summary

In summary, the concepts uncovered in this research have added to the established concepts that support healthy eating behaviours to form a theoretical model. The new knowledge gained from this research adds to known factors that influence children’s eating behaviours in the school setting. The model recognises what is currently known (current state of play) and adds new concepts to support movement towards the ideal. This new paradigm can take health promotion in the school setting one-step further and can have an impact on eating behaviours at a broader level. The framework supports the SEM, can guide policy development and is suitable for the cognitive development stage for primary school children. While the theoretical model could be translated across a range of policies, strategies and accreditation systems, it is acknowledged that more research is required to refine the model. Stemming from the results is a recommendation to conduct the research on a larger scale among a range of demographics and food environments to see if similar