Assessment of the obesogenic environment in primary schools:
All six schools contacted agreed to participate in the study. Two schools were located in an area with very high socioeconomic status, two were at the high level, and the other two were at the moderate level. There are no school located in the low socioeconomic area in Jakarta. The number of students ranged from 111 to 541 per school. In general, the schools had no or only one teacher trained in nutrition and health education, usually the PE teacher or the teacher in charge at the school health post. Both of the schools located in the moderate socioeconomic status (SES) have one teacher trained in nutrition and health education, however only one of the two schools located in the high and very high SES have such teacher. Two of the four public schools observed in this study shared buildings, sports fields and canteens with other schools. Another school shared the building/area with an orphanage. Table 1 describes the characteristics of the schools.
Food access and availability
Table 2 presents the food access and availability of each school based on components 2 and 3 of the PSEA tool. All schools have a school canteen within their premises, which is open in accordance with the school operation time. No healthy canteen guidelines existed in any of the schools. All of the canteens served a breakfast menu, and the most popular food choices were rice-based meals (e.g., fried rice, coconut rice, turmeric rice), fried/instant noodles/vermicelli, sweet breads/buns, spaghetti, and various deep-fried snacks. One public school canteen had vegetable soup on their menu. Sugar-sweetened beverages and instant (sachet) drinks were the most favorite drinks among the students in all schools.
Almost all canteens had fruits or vegetables on their menu. However, the canteen staff in all schools remarked that fruits or vegetables were not popular among the students. One canteen in a private school never offered healthy meal options to the students because of the thought that no one is going to buy them. When the canteen staff was asked about healthy diet promotion in the menu, two canteens of the four public schools mentioned that they provided a healthy meal as a special menu of the day that is promoted occasionally. None of the two private school’s canteens ever promoted a healthy diet. The two schools in moderate SES area admitted promoting healthy meal in daily basis, while those in higher SES level only occasionally or never had promotion.
“There are vegetables every day, such as bean sprouts, mustard greens and tofu, and sometimes spinach. The children’s favorite meal is crispy chicken”
Canteen staff (school 5).
The canteen staff perceived healthy food as those without high content of sugar and salt, but still preferred by children. This would be difficult as children love sugary and savory food. We found that sugar-sweetened beverages and fried foods were highly popular.
“What is taken into consideration is that the snacks sold in the canteen, the food and drink itself, must be healthy, not high in sugar and salt, children like it, but should take into account the spices and the containers used.”
Canteen staff (school 6).
The food prices in this study are reported in United States (US) dollars and cents. Rice-based meals usually cost less than one dollar, whereas the cost for snacks (e.g., chips, crackers, variety of deep-fried snacks, sweets, and chocolate) was even lower (< 15 cents). Fruit costs approximately 7 cents, and fruit juices (with added sugar) costs higher (approximately 70 cents). The bottled (600 mL) mineral water costs 15 cents, whereas the costs for sugar-sweetened beverages and instant drinks were slightly higher, approximately 20 cents.
School canteens were regularly inspected by the local public health centers (Puskesmas). Some (2/6) were also inspected by the Indonesian Food and Drug Agency. Inspections also included the street food vendors in the surrounding area. All the canteen staff considered that routine inspection by the Puskesmas was sufficient to maintain the hygiene and quality of the canteen. None of the inspections took notice of the food variation and nutrition quality, as their main concern was to examine food hygiene and cleanliness. Catering services from external sources were also optional in some schools (3/6), especially in the private schools. These services were usually organized by parents or a former teacher. This external food source was provided at an additional charge to the students. The catering service provided a complete lunch box consists of rice, meat/chicken, vegetables, fruit, and dessert (e.g., ice cream/probiotic drinks).
Almost all schools had easy access to street vendors. Only one school did not have access to street vendors because it is located in a narrow alley, which limited the vendors’ access to the school environment. Most schools (5/6) did not have strict regulation that forbade their students to buy food from street vendors, but one private school banned their students’ access to street vendors.
“We do not know if the food outside the school is healthy or not; we never ask. We only know about the food inside the fence. “
Deep-fried foods, ice cream, and sugar-sweetened beverages were the most common foods offered by the street vendors. The price for these foods was even lower than the foods sold in the school canteen. Because street vendors usually sell food in carts or a bicycle, they can easily come and go and thus are able to avoid inspection from authorities.
School policies and environment in healthy eating
School policies and environment in healthy eating is presented in Table 3 based on components 4 to 8 of the PSEA tool. All school headmasters claimed to have a written policy that actively promotes healthy eating to students, which mainly integrated topics about healthy eating within the national school curriculum, such as in a natural science lesson. Two of the public schools and one of the private schools had additional program, such as having a weekly fruit day or weekly healthy breakfast and offering eating breakfast together with all students and teachers. Some schools (3/6) also claimed to regulate the type of foods that should be available in the canteen or in the student’s lunch box and provided information on healthy food and eating. Teachers delivered the messages through announcement in the class. Nevertheless, almost all schools admitted that they do not strictly monitor the implementation of these regulations.
The headmasters and PE teachers used the number of students who brought lunch box from home as a parameter to measure the effectiveness of the policy on nutrition, hence five schools claimed that the policy had been effective. One public school headmaster admitted that the regulations were ineffective because the canteen is typically fully occupied with parents who wait for their children; thus the children get food from the street vendors instead. However, he stated that the schools already planned to implement a new strategy the following school year.
“Starting next school year, the children are required to bring food from home, so their food is clean, they learn to be calm, and they wouldn’t want to buy food from the street vendors as often.”
Headmaster of the four public-schools located in moderate and high SES area claimed that they placed a high or very high priority on the promotion of healthy eating. These priorities were shown by the presence of healthy diet posters around school and the implementation of healthy eating practices at certain events. Two other schools also provided health education in collaboration with the local public health center. Nevertheless, both private schools in the very high SES area assumed healthy eating was a low priority.
All headmasters and PE teachers considered teachers to be a good role model in healthy eating for students. Teachers usually brought their own lunchbox, chose healthier food from the canteen menu, promoted a healthy lunchbox to students, and reminded students to not buy food from the street vendors. They were also in agreement that parents are important factors and very supportive toward promoting healthy eating, especially for motivating students to bring lunch from home.
Physical activities policy and environment
Physical activity was promoted through PE as a compulsory subject in the national school curriculum. However, only two schools (1 public and 1 private) had a written regulation about physical activity (Table 3). Duration of physical education in public schools was longer than in private schools. All schools had sports fields and provided sports equipment for the students. However, some schools (2/6) acknowledged the need of sports field for the students as the schools are surrounded by streets in which many vehicles passing by.
“The play area outside the building or school is very inadequate because it is full of traders selling, even if there are no traders the place is also not suitable as a play area considering that many vehicles pass by”
They also encouraged students to participate in sports competition and physical activities. One public school motivated its students to walk or use bicycles to school. All PE teachers asserted that the physical activity policy had been quite effective in their schools, as shown by the attainment of awards in some sports competitions as well as a large number of students who walk from home to school. Five schools rated their teachers as being a very good role model in physical activities through their frequent involvement in the students’ physical activities. One of the private schools held monthly events for teacher–student physical activities.