Improving Children's Lifestyle and Quality of Life through Synchronous Online Education: The Nutritional Adventures School-Based Program.

The early introduction of effective nutritional educational programs is pivotal for instilling sustainable healthy behaviors. The present work aims to present a best practice example of a nutrition and overall lifestyle school-based training program, the Nutritional Adventures ("Diatrofoperipeteies"). Conducted during 2020-2022 in Greek primary schools, this synchronous, online educational initiative included two 1-school-hour activities with a nutrition instructor. Additionally, schools were randomly assigned to supplementary "at-home" supported-by-parents or "in-class" supported-by-educators educational activities. In total, n = 12,451 students of 84 primary schools participated. Parent-completed questionnaires were selected in the recruitment and post-intervention phase (40% participation rate); overall, the working sample was n = 1487 students. In the post-intervention phase, a significant increase in Mediterranean diet adherence was observed (KIDMED score: mean increment = 0.25 units; p < 0.001), particularly fruit and vegetable consumption. Time spent on physical activity increased, while screen time decreased. Students' total quality of life significantly improved (PedsQL; mean increment = 1.35 units; p < 0.001), including on all of its subscales (physical, emotional, social, and school function). Supplementary educational activities that were supported by educators rather than parents yielded a more favorable impact on students' lifestyle and quality of life. The Nutritional Adventures program can be regarded as a successful initiative in primary schools, yielding immediate advantages that extend beyond promoting healthy dietary habits.

Combating Loneliness in Older Adults during the COVID-19 Pandemic: Findings from a Volunteer-Based Program in Greece.

The COVID-19 pandemic has exacerbated the feeling of loneliness, especially among older adults. This study aims to investigate any association between COVID-19 cases in Greece and the number of Loneliness Helpline calls at the Friendship at Every Age program and to assess whether the interconnection part of the program, which interconnects older adults with volunteers, can combat loneliness/social isolation in older adults. This is a supportive, volunteer-based, social intervention program. A total of 4033 calls were collected from July 2020 to November 2022, in Greece. Older adults who participated in the interconnection part completed baseline (n = 275) and follow-up questionnaires (n = 168), including the UCLA Loneliness Scale. A time-series analysis revealed a positive association in the number of calls with COVID-19 cases (Incidence Rate Ratio per 100 new COVID-19 cases = 1.012; Confidence Interval (95% CI) [1.002, 1.022]). A significant decrease in the Loneliness Scale was observed at follow-up [difference = -0.85; 95% CI (-1.16, -0.54)], with similar results by sex, educational level, and area of living. Loneliness Helpline calls increased during COVID-19 outbreaks, while the interconnection part had a positive impact on older adults, reducing their feeling of loneliness. Similar initiatives are required to better address the needs of the ageing population during and after health crises.

Nutritional Value of Meals Designed for a School-Based Food Aid Program and Comparison with Similar Commercial Products: An Example of Good Practice from the DIATROFI Program.

Providing meals of high nutritional value should be the principal objective of large-scale school-based food aid programs. This study aimed at highlighting the nutritional value of meals distributed in the school-based food assistance DIATROFI Program by comparing them to their commercially available counterparts. For the purpose of this study, n = 13 DIATROFI meals and n = 50 commercial products from the 2016-2017 school year, and n = 12 DIATROFI meals and n = 40 commercial products from the 2022-2023 school year were selected. The protein, carbohydrate, total sugar, dietary fiber, total fat, sodium/salt content, and fatty acid methyl ester profile of DIATROFI meals were estimated through recipe simulation and national/international food databases, and verified through laboratory analyses while the relevant information was extracted from the label for commercial products. As verified by laboratory analyses and in comparison with food labels, most DIATROFI meals had lower total fat, saturated fatty acid, and sugar content, and most had higher dietary fiber content during both years. Many recipes' nutrient profiles also improved over time. DIATROFI meals present significant advantages over available commercial products. Such tailored-made school meals can prove to be advantageous in terms of nutrition profile compared to commercially available, which have yet to be impacted by food reformulation.

Essential Skills for Health Communication, Barriers, Facilitators and the Need for Training: Perceptions of Healthcare Professionals from Seven European Countries.

Many healthcare professionals are unaware of the necessary skills and barriers hindering interpersonal health communication. This study aimed to evaluate the healthcare professional's perception regarding health communication training's necessity, barriers, facilitators and critical skills in health communication. Data from a cross-sectional online survey in the framework of the H-Com project were utilized. The study included 691 healthcare professionals (physicians, nurses, students and allied health professionals) from seven European countries. Only 57% of participants had participated in health communication training, while 88.1% of them indicated a willingness to be trained in health communication. Nurses were more likely (OR = 1.84; 95% CI 1.16, 2.91) to have received such training, compared to physicians. Most examined communication skills, barriers and facilitators of effective communication, and perceived outcomes of successful communication were considered crucial for most participants, although physicians overall seemed to be less concerned. Most agreed perceived outcomes were improved professional-patient relations, patient and professional satisfaction, physical and psychological health amelioration and patients' trust. Nurses evaluated the importance of these communication skills and communication barriers, facilitators and outcomes higher than physicians. Physicians may underestimate the importance of communication skills more than nurses. Health communication should become an integral part of training for all health professionals.

Health-Related Quality of Life in Childhood and Adolescence: The Interrelation with Level of Adherence to Mediterranean Diet and Dietary Trajectories: Highlights from the DIATROFI Program (2021-2022).

Children's dietary habits can have a key role in contributing to an improvement in their Health-Related Quality of Life (HRQoL). This study aims to assess the connection between Mediterranean diet adherence and HRQoL in a sample of Greek students, utilizing data from the DIATROFI program. The parents of 3774 students (mean age 7.8 (2.6) years) reported their children's HRQoL and level of adherence to the Mediterranean dietary pattern at the beginning and end of the 2021-2022 school year. At baseline, most students' adherence was characterized as moderate (55.2%) or high (25.1%). Students with moderate or high adherence tο the Mediterranean diet were less likely to report a total HRQoL below the median at baseline (OR = 0.56, 95%CI = 0.44, 0.70), along with all its dimensions (physical, emotional, social, and school functions). A one-unit improvement in KIDMED score (beginning-end of schoolyear) was associated with the likelihood of an improvement in total HRQoL (beginning-end of schoolyear) (OR = 1.09, 95%CI = 1.02, 1.17), emotional (OR = 1.09, 95%CI = 1.02, 1.17), and social functions (OR = 1.13, 95%CI = 1.05, 1.22), but not with physical and school functions. The health benefits of the Mediterranean diet in children may not be limited to disease prevention but also extend to their overall wellbeing.

Older People in Emergencies; Addressing Food Insecurity, Health Status and Quality of Life: Evaluating the "365+ Days of Care" Program.

During emergencies, older adults stand among the most vulnerable, facing long-lasting food insecurity and overall health issues. The "365+ Days of Care" food aid program addressed food insecurity and poor quality of life among vulnerable older adults following a devastating wildfire in Greece. Our aim was to evaluate the program's efficiency, using a process evaluation framework and a partial cost-utility analysis. In total, n = 133 wildfire-hit residents (≥65 years) received daily tailored, pre-cooked meals and/or weekly food packages. The study outcomes were assessed from baseline to 12 months later. Focus groups and interviews (n = 30), researcher observations, and questionnaires were used to assess the beneficiaries' perception of the initiative. Within the 12-month follow-up period, food insecurity and malnutrition risk decreased, whereas Mediterranean diet adherence; quality of life; and physical, social, and mental health were improved (p < 0.05). A one-point increase in food insecurity was positively associated with improved quality of life, general health, limitation in activities, body pain, vitality, and pain/discomfort (p's < 0.05), and it was marginally associated with mobility, anxiety/depression, and self-evaluated health status (p's < 0.1). Quantitative and qualitative data characterized it as successful, acceptable, beneficial, and of high quality. The partial cost-utility ratio was one QALY gained per EUR 22.608. The utilization of well-designed food aid programs during emergencies can alleviate food insecurity and improve quality of life in older adults.

Assessing Quality of Life in First- and Second-Generation Immigrant Children and Adolescents; Highlights from the DIATROFI Food Aid and Healthy Nutrition Promotion Program.

To compare first- and second-immigrant pediatric populations with a non-immigrant pediatric population in terms of quality-of-life metrics, a cross-sectional analysis using data from the DIATROFI Program was implemented. In total, n = 2277 students (mean age: 9(4) years) from public schools in Greece participating in the 2020-2021 school year were analyzed. The students' immigration status (first-generation/second-generation) was defined as per the standard definition. The students' health related-quality of life (HRQoL) was assessed using a parental-perceived quality of life questionnaire. The sample included 4.8% first-generation and 21.2% second-generation immigrant students. Compared with non-immigrants, the first-generation immigrant students were more likely to have poor HRQoL (odds ratio (OR) = 2.82; 95% confidence interval (95%CI) = 11.75, 4.53), physical (OR = 1.91; 95%CI = 1.18, 3.10), social (OR = 1.94; 95%CI = 1.16, 3.22) and school function (OR = 2.52; 95%CI = 1.54, 4.13). Similar results were observed for second-generation immigrant students regarding HRQoL (OR = 1.68; 95%CI = 1.28, 2.21), physical (OR = 1.60; 95%CI = 1.23, 2.10) and school function (OR = 2.09; 95%CI = 1.58, 2.77). Children with one parent having a country of origin different that the country of residence had elevated odds of having poor emotional health (OR = 1.19; 95%CI = 0.87, 1.64). The family's affluency level was interrelated with the connection of poor HRQoL and immigration status. The immigrant students have a poorer quality of life depending on their immigration generation and irrespective of their socioeconomic background.

Using an IT-Based Algorithm for Health Promotion in Temporary Settlements to Improve Migrant and Refugee Health.

The application of the electronic algorithm developed by the Mig-Healthcare project was pilot tested in a sample of migrants and refugees in 2 Reception and Identification Centres (RICs), temporary settlements, in Greece using portable devices. The questions relate to health literacy issues, to mental health, to vaccination history, to lifestyle habits such as smoking, alcohol intake, diet, to the presence of diseases such as heart disease or diabetes, to the use of prevention services and to dental care. A total of 82 adults, 50 women and 32 men, participated. Data analysis showed that 67.1% (55) of the respondents had difficulty in understanding medical information and 57.3% (47) did not know where to seek medical help for a specific health problem. Four main areas of health problems were identified and further action is required: (A) mental health concerns, (B) vaccinations, (C) obesity, and (D) dental hygiene. Direct linkage with the "Roadmap and Toolbox" section of the project's website gave the respondents access to many sources and tools, while through the use of the interactive map, specific referral points of healthcare delivery in their area were identified. IT-based intervention in migrant and refugee populations in Greece are effective in increasing health literacy levels and identifying areas for health promotion interventions in these groups. Through linkage with the project's database, access to healthcare provision points and action to seek appropriate healthcare when necessary are encouraged. Given the attenuated vulnerability profile of people living in temporary settlements, this algorithm can be easily used in primary care settings to improve migrant and refugee health.

Access to Healthcare for Migrant Patients in Europe: Healthcare Discrimination and Translation Services.

BACKGROUND: Discrimination based on ethnicity and the lack of translation services in healthcare have been identified as main barriers to healthcare access. However, the actual experiences of migrant patients in Europe are rarely present in the literature. OBJECTIVES: The aim of this study was to assess healthcare discrimination as perceived by migrants themselves and the availability of translation services in the healthcare systems of Europe. METHODS: A total of 1407 migrants in 10 European Union countries (consortium members of the Mig-HealthCare project) were surveyed concerning healthcare discrimination, access to healthcare services, and need of translation services using an interviewer-administered questionnaire. Migrants in three countries were excluded from the analysis, due to small sample size, and the new sample consisted of N = 1294 migrants. Descriptive statistics and multivariable regression analyses were conducted to investigate the risk factors on perceived healthcare discrimination for migrants and refugees in the EU. RESULTS: Mean age was 32 (±11) years and 816 (63.26%) participants were males. The majority came from Syria, Afghanistan, Iraq, Nigeria, and Iran. Older migrants reported better treatment experience. Migrants in Italy (0.191; 95% CI [0.029, 0.352]) and Austria (0.167; 95% CI [0.012, 0.323]) scored higher in the Discrimination Scale to Medical Settings (DMS) compared with Spain. Additionally, migrants with better mental health scored lower in the DMS scale (0.994; 95% CI [0.993, 0.996]), while those with no legal permission in Greece tended to perceive more healthcare discrimination compared with migrants with some kind of permission (1.384; 95% CI [1.189, 1.611]), as opposed to Austria (0.763; 95% CI [0.632, 0.922]). Female migrants had higher odds of needing healthcare assistance but not being able to access them compared with males (1.613; 95% CI [1.183, 2.199]). Finally, migrants with chronic problems had the highest odds of needing and not having access to healthcare services compared with migrants who had other health problems (3.292; 95% CI [1.585, 6.837]). CONCLUSIONS: Development of culturally sensitive and linguistically diverse healthcare services should be one of the main aims of relevant health policies and strategies at the European level in order to respond to the unmet needs of the migrant population.

Dietary patterns and food insecurity of students participating in a food aid programme: the Mediterranean perspective.

BACKGROUND: To explore the effect of household food insecurity on dietary patterns of children and adolescents participating in a school food-aid programme in regions of Greece with low socioeconomic status. METHODS: A cross-sectional study was conducted during the school year 2013-14, among 406 schools in low socioeconomic status regions of Greece. Dietary habits and sociodemographic characteristics of students and their families were recorded. Factor analysis was used in order to derive children's and adolescents' dietary patterns and analysis of covariance was performed to examine the effect of households' food insecurity level on those patterns. A total of 31 399 students participated in the study; 16 652 children (5-11 years) and 14 747 adolescents (12-18 years). RESULTS: Factor analysis identified five dietary patterns in both age groups, explaining the 49.1% (children) and 53.0% (adolescents) of the total variation in intake. After adjusting for various factors, the household's food insecurity was significantly associated with the majority of the derived patterns in both age groups, with most pronounced differences being observed for the consumption of red meat, poultry and fish, fruits, as well as red processed meat, cereals and dairy products, which was lower among children and adolescents with food insecurity. Children with food insecurity consumed significantly more unhealthy food, such as chips, fast food, sugared drinks, sweets, French fries and mayonnaise sauce. CONCLUSIONS: Promotion of healthy eating to households facing food insecurity is of crucial importance, giving emphasis in the design of low cost, yet highly nutritious programmes.

Determinants of Refugee and Migrant Health Status in 10 European Countries: The Mig-HealthCare Project.

In this study, we collect and synthesize information on the health status of the refugee/migrant population in ten European countries in order to map refugee/migrant health needs. With this information, we identify areas of intervention and healthcare system strengthening to provide the basis for future health planning and effective healthcare provision to migrants, asylum-seekers and refugees in the European Union (EU). METHODS: 1407 migrants in ten European Union countries (consortium members of the Mig-HealthCare project) were surveyed on general health, mental health, and specific diseases using an interviewer-administered questionnaire. Descriptive statistics and multivariable linear regression analyses were conducted to investigate the risk factors on general quality of life for migrants and refugees in the EU. RESULTS: Mean age was 31.9 (±11.05) years and 889 (63.1%) participants were males. The majority came from Syria, Afghanistan, Iraq, Nigeria, and Iran. Having a mental health disorder or a chronic disease such as a heart or respiratory disease was associated with worse general health. On the other hand, having permission to stay in the country of interview and being interviewed in the country of final destination was associated with better general health. Access to health care services was fragmented or unavailable for some interviewees because of linguistic, cultural, or administrative barriers. CONCLUSIONS: The management of chronic diseases and mental health conditions in European migrants and refugees is a key priority for health service provision. Further efforts should be made to guarantee healthcare access for migrant and refugee populations.

Migrants' and refugees' health status and healthcare in Europe: a scoping literature review.

BACKGROUND: There is increasing attention paid to the arrival of migrants from outwith the EU region to the European countries. Healthcare that is universally and equably accessible needs to be provided for these migrants throughout the range of national contexts and in response to complex and evolving individual needs. It is important to look at the evidence available on provision and access to healthcare for migrants to identify barriers to accessing healthcare and better plan necessary changes. METHODS: This review scoped 77 papers from nine European countries (Austria, Cyprus, France, Germany, Greece, Italy, Malta, Spain, and Sweden) in English and in country-specific languages in order to provide an overview of migrants' access to healthcare. The review aims at identifying what is known about access to healthcare as well as healthcare use of migrants and refugees in the EU member states. The evidence included documents from 2011 onwards. RESULTS: The literature reviewed confirms that despite the aspiration to ensure equality of access to healthcare, there is evidence of persistent inequalities between migrants and non-migrants in access to healthcare services. The evidence shows unmet healthcare needs, especially when it comes to mental and dental health as well as the existence of legal barriers in accessing healthcare. Language and communication barriers, overuse of emergency services and underuse of primary healthcare services as well as discrimination are described. CONCLUSIONS: The European situation concerning migrants' and refugees' health status and access to healthcare is heterogeneous and it is difficult to compare and draw any firm conclusions due to the scant evidence. Different diseases are prioritised by different countries, although these priorities do not always correspond to the expressed needs or priorities of the migrants. Mental healthcare, preventive care (immunization) and long-term care in the presence of a growing migrant older population are identified as priorities that deserve greater attention. There is a need to improve the existing data on migrants' health status, needs and access to healthcare to be able to tailor care to the needs of migrants. To conduct research that highlights migrants' own views on their health and barriers to access to healthcare is key.

Community-Based Healthcare for Migrants and Refugees: A Scoping Literature Review of Best Practices.

BACKGROUND: Strengthening community-based healthcare is a valuable strategy to reduce health inequalities and improve the integration of migrants and refugees into local communities in the European Union. However, little is known about how to effectively develop and run community-based healthcare models for migrants and refugees. Aiming at identifying the most-promising best practices, we performed a scoping review of the international academic literature into effective community-based healthcare models and interventions for migrants and refugees as part of the Mig-HealthCare project. METHODS: A systematic search in PubMed, EMBASE, and Scopus databases was conducted in March 2018 following the PRISMA methodology. Data extraction from eligible publications included information on general study characteristics, a brief description of the intervention/model, and reported outcomes in terms of effectiveness and challenges. Subsequently, we critically assessed the available evidence per type of healthcare service according to specific criteria to establish a shortlist of the most promising best practices. RESULTS: In total, 118 academic publications were critically reviewed and categorized in the thematic areas of mental health (n = 53), general health services (n = 36), noncommunicable diseases (n = 13), primary healthcare (n = 9), and women's maternal and child health (n = 7). CONCLUSION: A set of 15 of the most-promising best practices and tools in community-based healthcare for migrants and refugees were identified that include several intervention approaches per thematic category. The elements of good communication, the linguistic barriers and the cultural differences, played crucial roles in the effective application of the interventions. The close collaboration of the various stakeholders, the local communities, the migrant/refugee communities, and the partnerships is a key element in the successful implementation of primary healthcare provision.

Effectiveness of a school food aid programme in improving household food insecurity; a cluster randomized trial.

BACKGROUND: Aim of this cluster randomized trial was to examine the impact of a school feeding programme combining healthy meals provision and educational activities to reduce food insecurity. METHODS: Schools participating in the DIATROFI Program in Greece during the 2014-2015 school year were randomly allocated between a multicomponent intervention (MI: each student received a daily healthy meal along with educational actions; 28 schools) and an educational intervention (EI; 23 schools). A linear-mixed model was used to examine intervention effect on change from baseline in the food insecurity score, as measured via the Food Security Survey Module (FSSM). The analysis was based on 1442 pre-post intervention questionnaire pairs in the MI group and 986 in the EI group. RESULTS: The reduction in food insecurity score in the MI group was statistically significantly greater compared to the EI group, by 9.8% or -0.31 [95% confidence interval (CI) -0.61 to -0.01] FSSM units after adjusting for potential confounders. MI intervention was significantly more effective compared to EI, among students in food insecure households (mean -0.44, 95% CI -0.84 to -0.04), students in households facing hunger (mean -1.04, 95% CI -1.91 to -0.17) and overweight/obese students (mean -0.36, 95% CI -0.72 to -0.01). CONCLUSION: For interventions aiming to address childhood food insecurity, public health focus should be oriented towards school-based programmes combining food assistance with activities that promote healthy nutrition.

Lifestyle E-Coaching for Physical Activity Level Improvement: Short-Term and Long-Term Effectivity in Low Socioeconomic Status Groups.

E-coaching applications can improve people's lifestyles; however, their impact on people from a lower socioeconomic status (low SES) is unknown. This study investigated the effectiveness of a lifestyle e-coaching application in encouraging people facing low SES disadvantages to engage in a more active lifestyle over a course of 19 weeks. In this bicountry study, 95 people with low activity level (GR: 50, NL: 45) used a mobile application linked to a wearable activity tracker. At the start and after 6 and 19 weeks, self-reported physical activity levels, attitudes, and intention towards increasing activity levels, perceived behavioral control, and wellbeing were measured. Results indicated that participants using the lifestyle e-coaching application reported significantly more often an increase in activity levels than a parallel control group. Additionally, the people using the application also more often reported increased levels of wellbeing and perceived behavioral control. Therefore, lifestyle e-coaching applications could be a cost-effective solution for promoting healthier lifestyles in low-SES populations.

Immunization related behaviour among healthcare workers in Europe: Results of the HProImmune survey.

OBJECTIVES: Vaccine preventable diseases (VPDs) continue to pose a significant threat to healthcare workers (HCWs) while immunization among this group remains low. HCWs' behaviours as well as facilitators and barriers towards their vaccination for a number of VPDs were explored through an EU-wide survey. METHODS: HCWs across the EU answered online survey that explored attitudes and behaviours towards vaccination for a number of VPDs. Response data were adjusted based on weights estimated by HCWs' country and working profession according to WHO statistics. The survey was delivered between October 2012 and April 2014. RESULTS: Analysis was based on responses from 5,424 HCWs from 14 European countries. The majority (86.7%) had a positive attitude regarding immunizations. HCWs considered influenza (86.4%), viral hepatitis type B (71.9%) and tuberculosis (59.1%) as higher risk diseases for occupational exposure in the workplace. However, 43.8% reported not receiving a seasonal influenza vaccine in the last 10 years and 65.6% reported not receiving the pandemic influenza vaccine in 2009. Main enablers towards immunizations included believing in vaccine protection and easy, free of charge access to vaccines in the workplace. Barriers to up-to-date immunizations differed according to disease but included concerns about short- and long-term effects. CONCLUSION: Although the concept of mandatory vaccination seems to be favoured by many health professionals in Europe, it remains a controversial subject both among HCWs' profession categories and also among different countries. Interventions to increase vaccination among HCWs would benefit by tailoring their approach according to disease and target group.

National Dietary Guidelines of Greece for children and adolescents: a tool for promoting healthy eating habits.

OBJECTIVE: Dietary guidelines are an essential policy tool for facilitating optimal dietary patterns and healthy eating behaviours. We report: (i) the methodological approach adopted for developing the National Dietary Guidelines of Greece (NDGGr) for Infants, Children and Adolescents; and (ii) the guidelines for children aged 1-18 years. DESIGN: An evidence-based approach was employed to develop food-based recommendations according to the methodologies of the WHO, FAO and European Food Safety Authority. Physical activity recommendations were also compiled. Food education, healthy eating tips and suggestions were also provided. SETTING: The NDGGr encompass food-based nutritional and physical activity recommendations for promoting healthy dietary patterns and eating behaviours and secondarily to serve as a helpful tool for the prevention of childhood overweight and obesity. RESULTS: The NDGGr include food-based recommendations, food education and health promotion messages regarding: (i) fruits; (ii) vegetables; (iii) milk and dairy products; (iv) cereals; (v) red and white meat; (vi) fish and seafood; (vii) eggs; (viii) legumes; (ix) added lipids, olives, and nuts; (x) added sugars and salt; (xi) water and beverages, and (xii) physical activity. A Nutrition Wheel, consisting of the ten most pivotal key messages, was developed to enhance the adoption of optimal dietary patterns and a healthy lifestyle. The NDGGr additionally provide recommendations regarding the optimal frequency and serving sizes of main meals, based on the traditional Greek diet. CONCLUSIONS: As a policy tool for promoting healthy eating, the NDGGr have been disseminated in public schools across Greece.

Promotion of Immunizations for Health Professionals in Europe: A Qualitative Study in Seven European Member States.

Health Care Workers (HCWs) are a high-risk group for contracting Vaccine-Preventable Diseases who, despite legislation and guidance, remain undervaccinated. In order to understand their barriers and needs, focus groups were formed with 278 physicians, nurses, infection-control personnel, and policy-makers in 7 EU MS. Several implications for the development of promotional initiatives were identified including the need to overcome organizational barriers, to sensitize HCWs about the importance of immunization and to provide specific up-to-date information about vaccinations covering prevalence of diseases, protection years, side effects, administration times, antibody examinations, costs and immunization settings.

Daily distribution of free healthy school meals or food-voucher intervention? Perceptions and attitudes of parents and educators.

AIMS: To qualitatively evaluate the optimal intervention (food-voucher approach vs. free daily meal distribution), aimed at reducing food insecurity and promoting healthy eating among students attending public schools in socioeconomically disadvantaged areas. METHODS: We randomly assigned 34 schools to one of the two interventions: students in 17 schools received a daily lunch-box and parents in the other 17 schools received a food voucher of equal value once a month. All students were offered the opportunity to participate. We conducted 30 focus groups in all participating schools (17 in the meal distribution and 13 in the food voucher schools). Eligible participants included parents (n = 106), educators (n = 66) and school principals (n = 34). We qualitatively evaluated their perceptions and attitudes towards the program. RESULTS: Important differences were observed between the two approaches, with more favourable perceptions being reported for the meal distribution approach. More specifically, social stigmatization was minimized in the meal distribution approach, through the participation of all students, compared with the food-voucher participants who reported feelings of embarrassment and fear of stigmatization. Secondly, the meal distribution approach alleviated child food insecurity through the provision of the daily meal, while the food-voucher intervention helped manage household food insecurity, as vouchers were mainly used for purchasing food for family meals. Furthermore, the educational and experiential nature of the meal distribution approach intensified healthy eating promotion, while the food-voucher intervention was efficient mainly for conscious parents regarding healthy eating. CONCLUSIONS: The meal distribution intervention was considered more effective than the food-voucher one. Hence, for interventions aiming at tackling food insecurity of children and adolescents, public health focus could be oriented towards school-based in kind food assistance.