Addressing the double burden of malnutrition among Thai school-aged children with a complex school nutrition intervention: A process evaluation

Abstract Background The Dekthai Kamsai programme, a complex school nutrition intervention implemented in Thailand, demonstrated favourable outcomes in reducing the risk of developing obesity and stunting. This article aims to describe the intervention, contextual factors, and their interactions influencing the outcomes. Methods We conducted a process evaluation using data obtained from 14 focus group discussions held with 69 school staff from 14 intervention schools and 4 control schools, from January to February 2022, and a document analysis. Results Perceived strengths of the programme included: 1) its multi-component design targeting both diet and physical activity using food and physical activity guidelines for children, close monitoring of students’ anthropometric outcomes for ongoing nutrition improvements, and complementary components that synergistically enhanced and sustained its outcomes; and 2) a multi-sectoral support system to build schools’ capacity and facilitate programme implementation. Perceived limitations were no adequate effort to address wasting and suboptimal fidelity. Regarding contextual factors, child nutrition and well-being were not a priority for the education sector, which resulted in limited resources and the willingness of school staff to adopt and implement the programme. Schools in higher socio-economic urban neighbourhoods tended to receive greater external support and benefit more from better infrastructure of urban areas. The programme’s impact in urban schools tended to be offset by urban obesogenic environments. School staff having interest in children’s well-being tended to adopt and implement the programme intensively. A healthier food culture tended to enhance the intervention success. Conclusions These findings highlight the importance of 1) providing multifaceted interventions; 2) making child nutrition and well-being a priority of the education sector; and 3) improving school contexts notably policy, leadership, capacity, social capital, social and physical environments.