How Children's Experiences and Perceptions of Their School Food Environment Influence Their Food-Related Decisions In-School in Urban Ghana.

School food environments play an important role in shaping children's food-related decisions, including where and what foods to acquire and consume on a school day. In Ghana, evidence indicates that food environments in and around schools may limit healthy food acquisition and consumption behaviour. This study aimed to understand how children's experiences and perceptions of their school food environment influence food acquisition and consumption decisions. Data from 18 focus group discussions with children (n = 157; aged 10-17 years) attending Public Basic Schools in the Greater Accra Region of Ghana were analysed, guided by the African urban food environment framework for creating healthy nutrition policies and interventions. Children's food decisions in school were found to be influenced by experiences and perceptions at multiple food environment levels: macro, physical and social levels in combination with individual-level factors. At the macro level, exposure to food advertisements on television emerged as an influence on food-related decisions. At the physical level, experiences and perceptions of environmental sanitation, food vendor hygiene practices, affordability, and food quality were consistently reported to influence decisions. Social-level experiences including influence from friends/peers, family (mostly caregivers/parents) and social qualities of food vendors also shaped food-related decisions. Caregiver/parental dietary advice was often linked to healthier acquisition and consumption decisions by children in school. The findings highlight the need for actions that work in synergy across multiple levels of the school food environment to create conditions that support children to acquire and consume healthier diets.