Understanding implementation determinants of universal school meals through an equity-driven mixed methods approach.

Background: Policies, such as Universal School Meals (USM), are essential for preventing inequities in chronic disease risk among socially and economically marginalized populations. Implementing USM reduces food insecurity and obesity risk, among other academic/health outcomes; unfortunately, across the nation student participation (i.e., reach) is lower than expected, limiting its public health impact. Grounded in implementation science and health equity frameworks, this study aimed to: 1) investigate the determinants of implementing USM in a large, urban school district and 2) assess key challenges and supports across schools with varying levels of participation in USM.

Methods: A needs and assets assessment was undertaken in the 2023-2024 academic year with the School District of Philadelphia to address implementation-related challenges for USM as part of a broader Implementation Mapping process. Overall, 8 schools (6 middle; 2 high) participated in a convergent mixed methods study comprising qualitative interviews, surveys, and mealtime observations. Data collection was grounded in the Consolidated Framework for Implementation Research (CFIR) and Health Equity Measurement Framework. Interviews were deductively coded through the CFIR; barriers were coded negatively (either -1 or -2), supports coded positively (+ 1 or + 2), and neutral determinants coded as 0. Schools were grouped into low, moderate, and high meal participation for disaggregated analysis and comparison of determinants across reach.

Results: 193 participants included teachers (29%), parents (26%), students (middle 14%; high school 10%), administrators (13.5%), and food service personnel (11%). Participants identified as Black/African American (43%), White (26%), Hispanic/Latino (20%), Asian (5%), Middle Eastern (1.8%), and other (3.8%). The strongest facilitators of USM implementation were Mid-level Leaders (i.e., climate leaders; M = 1.29[-1,2]) and High-level Leaders (i.e., administrators; M = 0.96[-1,2]); strongest negative USM determinants were Market Pressure (i.e., competitive foods; M = -1.35[-2,0]), and Relative Priority (M = -1.17[-2,-1]). Emerging differences between low and moderate/high participation groups were found in Culture, Assessing Needs of Recipients, Access to Knowledge/Information, Human Equality-Centeredness, and Implementation Leads. Overall, higher participation schools reported less stigma, more equitable implementation procedures, and more involvement from food service managers than lower participation schools.

Conclusions: Equity-focused strategies targeting key issues within and outside the school setting are needed to reduce stigma and increase capacity for implementation.