Socio-economic considerations.

No included articles reported results of socio-economic considerations relating to the Classroom SFNE element (including curriculum).

Socio-economic considerations.

No selected articles reported the results of socio-economic considerations when implementing or evaluating nutrition education programs enacted in the classroom, the Classroom (external) SFNE element.

School food and nutrition policies.

Jurisdictional differences in school food and nutrition policies were identified. An in-person school environment audit was undertaken in 2017 in two Victorian regional areas (northwestern and southeastern) and found most (55%) had some form of food/nutrition policy [33]. Conversely, a 2020 web-based audit in Greater Adelaide (SA) found no schools with publicly available nutrition policies or combined healthy eating and environmentally sustainable policies. However, in these schools, parents were encouraged to be part of a governing council, to support school activities, including children’s health and well-being development [34]. In an Australia-wide survey, almost half (47%) of parents and teachers reported their school had a food-related rule or policy in place, such as avoidance of allergy foods, prohibition of the sharing of foods between students, and promotion of healthy eating [52]. Some studies also highlighted school policies relating to lunchboxes with respect to environmental and sustainable considerations [36,52], (see Lunchboxes section).

Some teachers felt a whole-of-school approach was necessary to ensure consistent food and nutrition messages were provided to students [31]. Some stakeholders discussed that a dedicated health promotion officer or school champions, such as a HPE teacher, was necessary to gain support throughout the school and community and apply a whole-of-school-strategy [31]. Furthermore, longer term initiatives require the support of parents, local communities and business partnerships to be successful [31].

Lunchtime and other food breaks.

During school lunch breaks, many Australian schools have dedicated ‘eating’ and ‘play’ time. These eating times occur most commonly in an allocated outdoor area or in the classroom [53]. Teachers mentioned that incidental discussions sometimes occurred with students during these lunchbreaks around healthy eating practices, food waste and food culture [22], indicating this may be an important opportunity for FNE outside the curriculum. Teachers and parents recognised that teachers were an important role model to build healthy eating habits in students [36]. However, while most parents felt teachers should eat their lunch with the students, most teachers did not agree [53].

Issues were raised about the length of the lunch break [53–55] with the average time allocated being ten minutes or less [53]. More than half of parents and one-third of teachers believed this was inadequate, with longer lunchtimes associated with students consuming more food from their lunchboxes [53]. In addition to lunch breaks, many Australian primary schools provide students with a 10-minute break during class time, usually in the morning, to have a fruit and vegetable snack (usually provided by the parents). Parents and teachers felt this additional break was an important time where students learnt about these everyday foods [22,36,38], and was an effective way to increase fruit intake [36].

Canteens.

The 2017 Victorian regional school environment audit, mentioned previously, identified that 38% (n = 17) of school canteens offered a healthy canteen program [33]. Similarly, the aforementioned 2020 SA audit found some school canteen menus identified foods via the traffic light system and marketed healthy options via school newsletters [34]. Many schools have been found to deviate from government school nutrition policies by offering canteens specials for unhealthy foods during school celebrations and activities [34,40] or by not providing sufficient quantities of everyday foods [56]. Additionally, canteens menus generally offered occasional main meal items for sale cheaper than everyday main items [56]. Interventions targeting canteen managers that aimed to improve the adherence with state government policies have shown some success. Data from three randomised controlled trials were reanalysed to understand if 19 behaviour change techniques (as described by Michie, Richardson [57]) impacted school canteen’s adherence to the NSW government’s healthy canteen policy, Fresh Tastes @ School [58]. All behaviour change techniques were significantly associated with the removal of “red” foods and beverages from the menu and ensuring half the menu were “green” or everyday foods. One of these trials included a 24-month follow-up, post-implementation. It found intervention schools that met guidelines at 12 months continued to do so at 24 months and were more compliant post intervention than control schools [59].

Some teachers and parents felt that a healthy canteen menu (and therefore level of adherence to the state government policies) positively influenced food choices [36,54], while others felt that canteens contradicted the school’s healthy food messages to students by supplying unhealthy foods [36,54,60]. However, some parents also viewed the canteen as a treat for their children and were not concerned about unhealthy food options available for sale [36,52].

Edible gardens.

The 2017 Victorian regional school audit found nearly all schools (90%) in regional Victoria had a school vegetable garden [33]. The edible garden in a rural Tasmanian school was found to be a substantial aspect of the SFNE that fostered food literacy and potentially improved food security amount students and families [61]. Edible gardens enhanced student’s knowledge and skills that led to improved behaviors around food production, nutrition and meal preparation, and ultimately better health and wellbeing [46,61]. For example, in regional Queensland, it was found students attending schools with a vegetable garden were more likely to know and recall the Australian Dietary Guidelines vegetable serves than students in schools without a vegetable garden [46]. One study reported that most Victorian schools were using the program developed by the Stephanie Alexander Kitchen Garden Foundation (SAKGF) [38]. This program was initially established to address childhood obesity by integrating health with the growing and preparing of foods in a school garden and then cooking and eating those foods [62]. It has since been adapted to align with the school curriculum potentially serving multiple purposes regarding specific curriculum areas, the promotion of healthy eating, and the enjoyment of new foods [38,62].

Socio-economic considerations.

One study observed student purchases at the canteen and found students generally chose unhealthy options irrespective of school characteristics (e.g., school size, socio-economic status, remoteness) [63]. Another study found there were no difference in the price of cheapest main food item for sale at canteens across socio-economic advantage [56]. No other selected articles discussed the impact of socio-economic factors for any of the school SFNE elements.

School Breakfast Programs (SBP).

The 2017 Victorian regional school audit [33] found 46% of schools in regional Victoria had a SBP for students (since this article SBP have been made universal in Victoria [64]). Although these programs are often established to address food insecurity [65], practically, students often chose to attend for many reasons, including time constraints of their parents (juggling family and work commitments), having to leave home early or travel on the bus to school, and having access to different food options than at home [66]. Staff, volunteers, parents, and student attendees felt the benefits of a SBP went beyond providing additional food to alleviate hunger. For example, social interactions and relationship-building between students and with staff and volunteers was mentioned positively by all involved in these programs [65–67]. SBPs were also seen to improve student engagement in the school system; facilitated monitoring of well-being leading to early intervention when required, contributed to the development of manners, personal skills, and positive learning behaviours, provided adult role models, and improved academic performance [66,67]. Strengths of SBPs were strong community partnerships, and the satisfaction and pleasure gained by involved staff and key stakeholders who valued the program [65,66]. Challenges to providing a SBP included insufficient support and funding from government, schools, community partners and other key stakeholders, difficulties finding staff and volunteers to run the program, insufficient supplies (donated/rescued food) to support child preferences and the rapid expansion of the program as it moves beyond supporting food insecurity, and overreliance of key personal (often volunteers) to advocate for the program [66,67].

Lunchboxes.

Schools attempted to manage lunchbox contents through methods such as lunchbox audits or supervisors [34,54], providing parents feedback on appropriate lunchbox foods, and lunchbox guidelines [54,68] to promote healthy eating among students. Information around food guidelines were communicated to parents through school websites, newsletters, enrolment packs, information sessions and school communication applications [34,54]. Parents in two surveys felt confident they had sufficient nutrition knowledge to pack a healthy lunchbox but faced many barriers [55,69]. This included the financial burden of purchasing healthier foods [55,69], especially foods which aligned to their children’s food preferences (and therefore would be eaten and not wasted), which was of particular importance for students with special needs [69]. Additionally, some parents also faced issues around time for lunchbox preparation [55,69], particularly for parents who were employed [69]. Teachers felt that it was important to disseminate food and nutrition information to parents to ensure healthy foods were consumed by students [31].

Parents and teachers discussed the potential effects of lunchbox policies and guidelines on family households. Some parents felt environmental and sustainable lunchbox policies, such as “nude foods” policies, may have promoted healthy eating among students [36]. However, parents also discussed that lunchboxes can be a source of stress, anxiety and shame. Parents around Australia have reported teachers taking photos of student lunchboxes in order to communicate their beliefs around specific food items being ‘good’ or ‘bad’ [70]. This surveillance elicited great shame among the parents, particularly for those who prepared the lunchboxes photographed [54,70]. Other mothers who had not personally received feedback about their children’s lunchboxes also felt lunchboxes were used to judge the quality of their parenting, including perceived judgement from teachers, other parents and self-judgement for not instilling healthy eating ideologies in their children [69]. Students were also negatively impacted, as they felt worry, embarrassment, fear and shame, and were exposed to social repercussions and reprimands from teachers and other students [54,70]. Lunchboxes were a key source of tension and potential conflict between teachers and parents [69,70].

Canteen online order system.

Most student meals were ordered online where an online ordering system was available [71]. Foods sold via these online platforms were found to lack vegetables [72]. There were also differences in the cost of foods, with less healthy foods (assessed using the traffic light system) being generally cheaper than healthier foods [73]. However, when comparing between online and paper bag orders, no real difference in nutrition quality or content was identified [71].

Five cluster randomised controlled trials [74–79] and one randomised controlled trial [80] were implemented in online canteen ordering systems in NSW to improve the healthiness of lunch orders. These studies tested a variety of interventions, including providing tailored feedback into the order [74], menu labelling, repositioning of healthier items, prompting, feedback, and incentives to encourage healthier ordering [75–77], labelling foods according to the State’s healthy canteen policy [78], adjusting menu item ingredients to include more vegetables [80], and incorporating consumer behaviour strategies into the display of the order [79].

Three of these studies found minimal or no changes to the purchases of everyday or “green” foods when comparing intervention and control schools [74,77,79]. However, two trials found significant improvements. In one intervention, schools reported increased vegetables purchases (77% increase) [80]. In the pilot of the second intervention, use of choice architecture strategies embedded in the on-line systems appeared to sustain the proportion of foods purchased by students in the intervention school categorised as everyday (<1% change) into the following term (compared to a 3% reduction in control schools) [78]. During the upscaled implementation, students attending the intervention schools had 7% more proportion of everyday food purchases (compared to a 3% reduction in control schools, i.e., 10% accumulated difference between groups) after 12 months [75], which increased to 10% at 18 months (compared to 6% increase in control schools, i.e., 4% accumulated difference between groups) [76]. These results show a narrowing of the differences between intervention and control group purchases of everyday foods overtime, which appear to be due to the control schools enacting changes in the absence of an intervention (potentially because of an observation effect), rather than the intervention schools losing ground. These changes also did not equate to large effects on energy density of lunch orders. During the pilot, there were no significant differences to total energy [78], while during the upscaled implementation, there were small but statistically significant differences in total energy (less than 300kJ) of the orders [75,76].

OSHC and education programs in the OSHC setting.

During an audit of OSHC facilities in two health districts in NSW (n = 89), it was found that most (59%) had a nutrition policy in place, including 37% that were part of an umbrella organisation that had a nutrition policy [81]. OSHC facilities that were part of a larger organisation, were more likely to be using menu planning templates and checklists, and providing more vegetables, whole grains, and occasional (i.e., discretionary items) foods to the students than those that were smaller or independent [81].

Observations of OSHC food practices found that meals offered to students were generally in the form of fruit platters, sandwiches (with confectionary fillings such as jam, honey, cinnamon sugar, sprinkles/hundreds-and-thousand), and cooked meals (everyday and occasional foods) [81]. Foods mostly consisted of fruit, occasional foods, grains and dairy products [81,82]. Positive mealtime factors included staff sitting down with students, foods provided on platters, and the absence of sugar sweetened beverages [82]. Negative mealtime features were the occasional modelling of unhealthy food practices by staff (e.g., consuming occasional items) [82].

Many OSHC staff had never received formal food and nutrition training but nonetheless often felt confident to plan menus, locate nutritious meals and foods, and perform other nutrition related activities [83]. There were mixed outcomes on the effectiveness of nutrition related training provided to OSHC staff. One study [81] found training of staff made no impact to the foods offered to students, and another [83] reported staff felt improved confidence in menu planning, accessing food ideas, and delivering nutrition-based activities for children and this led to increased fruit and vegetable consumption among students. Additionally, this study specifically developed a Facebook™ group and a user-friendly website that created motivation among members and a supportive environment to share ideas, try out new health promotion activities and recipes which encouraged students to try new foods [83].

Food and nutrition communication with parents.

In the web-based 2020 SA audit, over three-quarters (77%) of primary schools had healthy eating promotional resources in their curriculum, newsletters, or websites [234]. One school had also implemented a health advocacy group to address “junk food” concerns on school premises and which involved parents, teachers and students [34]. Other studies found schools communicated with parents about food and nutrition mainly through newsletters, but also through school apps, emails, brochures, face-to-face meetings, and workshops [35,51].

Online platforms were commonly used by schools as means for communicating about food and nutrition to parents [37,68]. Principals in one study felt that it was appropriate to provide healthy lunchbox messages to parents through digital communication methods at least monthly, and that it was suitable for these messages to come from a reputable third party [68]. The type of information provided to parents matters. One study found that while parents felt nutrition resources received from their school were not informative or useful, they were still interested in receiving more information from the school about nutrition [37].

Canteen government policies.

Two studies [84,85] were conducted in WA and assessed school canteen compliance and motivation for compliance with the state government’s canteen policy, WA Healthy Food and Drink Policy (WA Canteen Policy), ten years after its implementation. An audit of school canteen menus (n = 101 primary schools) found that, on average, menus included 72% “green items”, 27% “amber items” and 1% “red items”. This equated to 59% of primary schools meeting all traffic light targets (≥60% green items, ≤ 40% amber items and zero red items) [84]. Additionally, 89% of primary school menus met the green target, however, only 62% met the red target (details of amber compliance were not provided for primary schools). Most primary school menus also incorporated additional WA Canteen Policy requirements (e.g., fruit, plain water, and milk available, and the sale of amber savoury items restricted to ≥2 days per week) and almost half (47%) had colour-coded their menus [84]. No significant differences were found between schools located in metropolitan versus regional areas. In the second study, a survey among WA public school stakeholders (n = 307) – principals, teachers, canteen managers and Parent and Citizens (P&C) Committee presidents – a majority from primary schools (76%) found most stakeholders (84%) were motivated to meet the WA Canteen Policy and most desired (65%) to exceed policy requirements, particularly canteen managers (76%) [86]. Stakeholders were also asked their opinions on proposed policy extensions. The majority of respondents agreed with: a menu consistent with classroom health curriculum (83%); preservative/additive-free foods (78%); foods priced by healthiness (72%); healthy eating information included in school newsletters (70%); prioritising local foods/produce (68%) and seating areas for children (65%). Finally, most respondents were interested in additional resources to support policy implementation, such as information for parents, student assignments on the topic, healthy lunchbox, etc. [86].

The NSW Fresh Tastes @ School (NSW Canteen Policy) was assessed in one regional area of NSW in two studies [59,85]. The first study included a canteen intervention and found compliance with the NSW Canteen Policy increased in the control group from zero in 2013 to 24% in 2016 [59]. The second study found similar compliance levels (20%) with the NSW Canteen Policy in 2017 [85]. Canteen managers identified reasons for low compliance as the inability to influence student behaviour, inadequate skills, low self-confidence, lack of reinforcement, and poor ability to set/meet goals for the canteen [85].

Socio-economic considerations.

Two studies considered the socio-economic impacts of school lunchbox contents and costs. One study (reported in two articles) [87,88] found that students attending schools located in disadvantaged areas were significantly more likely to have lunchboxes containing more serves of everyday foods (average 0.21 serves), more serves of occasional foods (average 0.4 serves), and total higher total energy (average 306kJ) [87], than students going to schools in advantaged areas. The energy sourced from everyday foods were similar regardless of living in advantage/disadvantage areas [87]. Additionally, the cost of foods contained within these lunchboxes (of students attending schools in disadvantaged areas) tended to be more expensive [88]. The second study supported these findings. A parent survey found there was no difference between level of disadvantage of the school and time spent by parents preparing lunchboxes or the cost of lunchbox foods [55]. However, parents with lower socio-economic status were significantly more likely to pack occasional foods (based on a scoring system) than parents with higher socio-economic status, but there was no difference in the amount of everyday foods [55].

Two studies [72,73] considered socio-economic factors when assessing online canteen ordering systems. One study found schools located in more advantaged areas offered more vegetables with hot meals (but not any other meal type) than schools in more disadvantaged areas [72]. Another study reported that schools in most disadvantaged areas tended to sell less healthy foods cheaper than healthy items [73].

Finally, one study reported that online platforms were less likely to be used in schools located in more disadvantaged areas as means for communicating about food and nutrition to parents [68].

Education programs (beyond the classroom).

Three lunchbox interventions aimed to improve the types of food included in children’s lunchboxes [89–92]. These interventions used behaviour change models, such as the Behaviour Change Wheel [91,92] and the Health Belief Model [89], to target parents’ behaviour through improved nutrition knowledge. One intervention also included strategies to improve the school food environment (e.g., by supporting the development of nutrition policies) and children’s knowledge (e.g., by providing curriculum resources) [91,92]. These programs were found to have positive impacts, including: establishment of lunchbox nutrition guidelines at intervention schools [92]; parents having more confidence and able to make healthier lunchbox choices after the intervention [90,92]; and significant improvements to parents’ knowledge of dietary guidelines regarding fruits and vegetables [90].

The effectiveness of different types of information provided to parents was also assessed. Messages in the ‘benefits’, ‘susceptibility’, and ‘severity’ constructs of the Health Belief Model and those discussing health benefits (compared to discussing food groups) had a greater influence on a parent’s intention to pack a healthy lunchbox, while personalisation of messages (e.g., by including the child’s name) had no impact on parent’s intentions [89]. Parents’ acceptance of push notifications also diminished over time, reducing the effectiveness of ongoing intervention messaging [92]. Furthermore, these programs had minimal or no long-term impact on actual lunchbox contents [90–92].

Another article discussed the importance of relationships between schools and communities to ensure health promotion programs, such as obesity prevention, were effective [60]. School stakeholders (principals, canteen managers, school council committee members and teachers) interviewed felt that some parents were actively involved and supported these programs, but ultimately there was minimal action for health promotion by the community, for example, from local health departments, parents and schools [60].

Government policies and initiatives.

An overarching review of state government nutrition policies across Australia published in 2020 found school nutrition policies for each state and territory, were mandatory for all public schools except in Tasmania [93]. All policies contained essential components for success, but some lacked monitoring and accountability components. For example, all school nutrition policies had implementation guides and tools, extras resources to support implementation, and except for SA, a guide for catering, fundraising, and advertising. They also had nutrition standards based on the Australian Dietary Guidelines. All state and territory nutrition policies, except Queensland and Tasmania, included roles and responsibilities for policy implementation and adherence. The ACT and NSW school nutrition policies included an outline of a monitoring and evaluation plan, and NSW, Queensland, and Tasmania included monitoring and evaluation tools. Tasmania, Victoria, and WA school nutrition policies also had an accreditation program [93].

In 2015, the NSW Healthy Children Initiative (HCI) was established to reduce childhood overweight and obesity by 5% by 2025 [94,95]. This included investing in an embedded health promotion workforce within regional health districts and upscaling several trialled programs to achieve this target. Within a suite of programs, the Live Life Well @ School (LLW@S) program was established in the primary school setting [94]. The LLW@S program included ten ‘desirable school practices’ across the areas of the curriculum, food and physical activity environment, professional development, and included extensive monitoring and reporting mechanisms [95]. By 2017, 83% of all primary schools in NSW were trained and participating in this program [94], and of those participating, most had achieved the progressively higher program targets in 2016 (79% of school had achieved 70% of the desirable practices, n = 1639) and 2017 (73% of schools had achieved 80% of desirable practices, n = 1495) [95].

One of the aspects of the HCI which supported success, were using programs with setting-based approaches that fostered relationships between policymakers, the local health promotion workforce and the schools in their district [94]. This approach created flexibility in the programs to meet the needs of the local community. It also upskilled partner organisations to incorporate health promotion activities into their daily practices. Furthermore, central monitoring of the programs ensured accountability and provided an avenue for feedback to program managers. Finally, it contributed to dialogue around childhood obesity and encouraged investment in health promotion [94].

In Victoria, the local government in Geelong had been supporting the local implementation of The Achievement Program since 2012, which was then scaled-up to a state-wide service. This program is similar to the LLW@S initiative, except that program implementation is carried out by a not-for-profit organisation. The Achievement Program used a whole-of-setting approach to reduce childhood obesity and related chronic diseases in three settings, schools, childcare, and workplaces [31]. By 2015, 70% of primary schools in the City of Greater Geelong had registered for the program, of which 15% had achieved a “Health Promoting Setting” status [96]. Government-led initiatives were also supported by stakeholders who felt that state-based nutrition policies were important for fostering relationships between the health and education settings and provided leverage for funding school initiatives [31].

Resources (including digital materials).

Teacher and staff accessed a variety of nutrition resources and platforms online, including from evidence-based websites, other websites, and Facebook™ groups [22,31,35,39,83]. These sites were mainly discovered through word-of-mouth and internet searches [31]. They also reported using Government resources, such as the Australian Guide to Healthy Eating [22], purchasing teaching resources from teaching suppliers, such as MAPPEN, Twinkl and Teach Starter [22], utilising resources provided through professional development courses, [17], and accessing resources from other places, such as food retailers [22]. Teachers also utilised nutrition program materials, such as resources provided through the Stephanie Alexander Kitchen Garden Program and Cultivating Community Program, and physical materials such as food and gardens during their lessons [35]. Teachers were reported to be continually interested in accessing credible new and updated resources [39] and felt that their personal beliefs around nutrition should not be relied upon [31].

Many teachers felt there were insufficient nutrition education materials, and those available often required updating [35,36,39]. Teachers and stakeholders (government, non-government organisations and academia) also discussed the usefulness of available resources. They felt the most useful nutrition resources were those which did not need a stable internet connection, were free or cheap and from a credible source, were fit-for-purpose, adaptable, aligned to curriculum, and were co-designed with education experts [31]. Lack of easy access to free online resources, concerns around cyber safety, insufficient classroom devices, unstable internet, and insufficient time to maintain digital devices/programs were reported as barriers to using nutrition resources in the classroom [31,39]. Furthermore, teachers discussed that a lack of reliable resources reduced their confidence to teach FNE to their students [36], and therefore may have contributed to less FNE being taught in primary schools.

Home food environment.

The home environment can impact on the effectiveness of school programs. For example, school stakeholders (principals, canteen managers, school council committee members and teachers) in one school felt that the promotion of healthy eating (in the context of obesity prevention) by schools was less effective on students’ food choices when parents had opinions or modelled behaviours which contradicted the program’s messages [60]. The school environment may also influence the home environment. Some studies reported parents and students perceived children attempted to influence food choices in the home after learning about food and nutrition at school [38,40]. However, another study found that when the home environment is at odds with health eating messages taught to children by schools (particularly around a healthy lunchbox) parents may feel frustrated, concerned, worried, upset, and angry, and children can feel embarrassed, fearful, and ashamed [70].

Billboards and advertisements.

Food and beverage advertising near schools was found to be widespread, including at food and non-food shops retailers, at the roadside, and on government infrastructure such as train stations and bus shelters [97–99]. Trapp and Hopper [99] found there were, on average, 25 (range: 0–190) food advertisements surrounding primary schools, and the presence of a shopping area near a school increased the presence of food advertisements by seven-fold. Furthermore, of these advertisements, the marketing power (assessed using an adolescent informed tool) of occasional food advertisements contained significantly more influential features compared to everyday food advertisements [100]. Richmond and Watson [98] found students were exposed to between two and ten food advertisements when travelling on train, bus or walking to school. Foods advertised were predominantly for occasional foods [97–99].

Fast-food outlets.

One study investigated the occurrence of fast-food outlets surrounding schools located in metropolitan Perth [101]. They found almost half of primary schools (44%) had at least one fast-food outlet within 400 metres of the school grounds, over three quarters (77%) had one within 800 metres and most (86%) had one within one kilometre [101].

Socio-economic considerations.

Government initiatives may have a good reach for specific “at risk” populations. Two studies assessed the uptake of government policies and initiatives in less disadvantaged areas. In the NSW LLW@S initiative, 71% (n = 432) of participating schools with a higher proportion of First Nations students, 72% (n = 769) of participating schools located in more disadvantaged area, and 65% (n = 28) of participating schools in remote areas had met 80% of the desirable practices in 2017 [95]. In Geelong (Victoria), there was a greater participation in The Achievement Program by schools located in the most disadvantaged quartile compared with those in the least disadvantaged quartile (78% v 52%), and this was also seen for completion of program objectives (22% vs 17%) [96]. However, it should be noted these rates were not linear across the socio-economic disadvantage quartiles [96]. Desirable practices in the areas of curriculum and food and physical activity environment were well adopted particularly when supported by other programs, such as Crunch&Sip. Professional development, monitoring and reporting practices were less adopted, particularly in areas where it may be difficult for schools to access appropriate training (e.g., remote locations) [95,96]. These findings suggest that schools in less disadvantaged areas may find these programs more beneficial for improving the SFNE for their students.Students attending schools located in lower socio-economic areas were exposed to significantly more unhealthy food and alcohol advertisements (within 250 metres of the school) [99] and which were more likely to contain more influential features aimed at children and adolescents [100], compared to schools located in higher socio-economic areas.

Finally, schools (primary, secondary and K-12 combined) located in low socio-economic areas were more likely to have a higher incidence of fast-food outlets within 400 metres of the school grounds compared to schools located in high socio-economic areas [101].

No other papers discussed the impact of socio-economic factors associated with external elements.