4.1.1. Promote the Implementation of School Food and Health Policies and Guidelines
In 2004, the World Health Assembly endorsed the “WHO Global Strategy on Diet, Physical Activity and Health” (DPAS) due to an increase in non-communicable diseases (NCDs) and to counteract its major risk factors. This strategy encourages governments to develop and implement “school policies and programs that promote healthy diets and increase levels of physical activity” [
21]. The DPAS School Policy Framework builds on existing WHO initiatives (of which the NFSI is one) and aims to guide policy-makers in the development and implementation of these policies [
21]. However, research has shown that most schools have failed to implement these nutrition policies at the school level [
11]. In our study, the majority of the interviewed school administrators were not aware of national or regional health policies for schools. Further, only seven out of the 19 school administrators knew that a health policy was implemented at their school.
The WHO policy framework recommends implementing a school curriculum on healthy foods and beverages, a food service environment that includes quality standards, an environment for physical activity, and the promotion of health services by school staff [
21]. Although six of the seven schools included health and nutrition services, these were inadequate and did not include basic services such as a school feeding program, WASH infrastructure, dietary guidelines, medical check-ups, or screening services. Further, only six of the school administrators were aware of food vendor guidelines. Food vendor guidelines address the kind of foods that should be sold as well as the hygiene conditions. The WHO also encourages governments to promote the use of nutritional standards by food vendors who are present on or near the school premises [
21].
Studies have found that school food and nutrition policies can change the school food environment and influence better food choices for the entire student population, as opposed to only an individual [
22]. A systematic review and meta-analysis on the effectiveness of school food environment policies identified that meal standardization, which included fruits and vegetables, increased their consumption and improved the dietary behaviors of school children. However, evidence is still scarce as the majority of studies were conducted in industrialized countries [
6]. In one study from Burkina Faso, no schools had a written nutrition policy in place and access to clean water, or hygienic food, and toilet facilities were inadequate in three out of the six schools [
17,
23]. A study conducted in South Africa found that after the implementation of school policies various school-based interventions were put in place such as increasing the availability of healthier foods at school canteens or among food vendors or such as providing nutrition education to the students [
24]. These interventions were identified to have contributed to at least minor improvements in health outcomes. Similar findings were made in Mexico [
25] and Brazil [
26]. Without policies in place, the implementation of various nutrition interventions is a challenge. The integration of such policies should be promoted and guaranteed in the school environment.
4.1.2. Improve the Availability of Health, Nutrition and WASH Services in Schools
Based on our study findings, we encourage to improve the school environment as set out in the WHO NFSI [
16]. One potential intervention point is through qualified school teachers. Well-trained teachers can change adolescents’ food choices and attitudes by providing nutrition education and sharing knowledge about healthy eating and practices [
27,
28]. However, one challenge is that the proportion of qualified teachers in sub-Saharan Africa is low, representing 64% of primary and 50% of secondary school teachers. This proportion has constantly declined since 2000 as schools increasingly hire less qualified contract teachers at lower costs [
8]. Out of 19 schools in our study, only two had a designated health and/or nutrition teacher and three schools had a designated staff member to deliver health and nutrition services over the last two years. In addition, the majority of schools did not have a health and nutrition curriculum. Hence, 16 out of 19 schools did not provide lessons on healthy eating and 18 schools did not provide lessons on unhealthy foods or beverages.
A study similar to ours was conducted among 16 secondary schools in South Africa to evaluate the food and nutrition environment linked to government policy programs, school health packages and services, which included health assessment and screening, health and nutrition education and promotion and on-site services by school nurses, and foods sold [
29]. The authors reported that the South African government introduced an Integrated School Health Program (ISHP) in 2012 to improve the general health of in-school adolescence and promote their food and nutrition environment. Most of the teachers were trained by the Department of Education, others through workshops, self-study or as part of the teaching training. The curriculum included teaching on healthy eating, a balanced diet, ill health, harmful substances in food production and physical education/exercise on a weekly or bi-weekly basis [
29]. Despite this initiative, they found not only a lack of designated school staff, but also that the majority of teachers who taught nutrition had no formal nutrition training and showed poor knowledge on questions related to healthy diets. Thus, even though nutrition was included in the curriculum and considered a success of the ISHP, the quality of nutrition training and knowledge on healthy diets of school administrators also in Burkina Faso should receive closer attention and further investigation.
Our findings show that there was an inadequate level of health services provided by the schools. Specifically, there was no provision of micronutrient supplementation and screening services for vision, hearing, and oral health. Only two of the 19 schools screened for common illnesses or infections. The implementation of WASH practices was low, with under one-quarter of schools providing soap and water at the handwashing stations. Numerous health benefits have been associated with cleaning hands with both soap and water, which can reduce one-third of diarrhea cases among school children [
30]. Further, only 5% of schools had gender-specific dressing rooms and just under two-thirds of schools had gender-separated toilets. A lack of (unisex) toilets was also recognized in a study conducted in rural Burkina Faso [
10].
In this study, we found that involvement in physical activity in schools was high and common sports such as running and soccer were provided. However, only eight out of 19 schools had a playground or track-field. Further, three of the schools offered common sports such as football, netball, and volleyball to only the boys. These results suggest that more needs to be done to address the low participation of girls in school-based physical activities. The WHO recommends that children and adolescents should be involved in at least 60 min of physical activity daily for optimum health outcomes [
31]. Research has shown that low physical activity in early adolescence carries major health implications into adulthood [
32]. The availability of sports facilities can increase student participation in physical activities and school lessons [
33].
4.1.3. Strengthen the School Food Environment
We suggest that more progress needs to be made to strengthen the availability of nutritious foods in the school environment in Burkina Faso. These findings were also emphasized by Pacific et al. [
18], who conducted a systematic literature review on the contribution of home and school environment on children’s weight and food choices in Africa. They found ten Africa-based studies, which confirmed that the perception and availability of healthy foods provided at home and in schools positively impacted the children’s food choices [
18], while equally healthy foods provided by school food vendors may decrease the odds of obesity among the schoolchildren [
34]. Subsequently, an integrated approach should be applied. We recommend strengthening the school food environment through the provision of school feeding programs, food vendor regulations and the integration of gardens at the school and community level.
Our study revealed that approximately only one-quarter of schools had a school feeding program in place. School feeding programs can alleviate hunger and reduce micronutrient deficiency, anemia and obesity, and may equally positively impact school attendance, academic performance and gender equality [
35,
36,
37]. In 2018, a presidential initiative was launched to strengthen school feeding programs in Burkina Faso through domestic financing and a multi-sectoral approach [
38]. School feeding programs such as those initiated by the FAO focus on supporting the infrastructure and capacity for food provision to increase the availability and diversity of foods provided in schools [
39]. In the schools of our study, only six out of 19 schools had a kitchen or food storage and three schools had a designated cafeteria or canteen. Likely because of the lack of school canteens, students have to look for other food sources from food vendors or meals provided by their parents. In order to make good and healthy food choices, schools should encourage teachers and school health nurses to integrate healthy eating into their curriculum and provide nutrition guidelines or even regulations for food vendors.
A study by Okeyo et al. [
29] among 16 secondary schools in South Africa also assessed the food environment through food vendors. Accordingly, most of the South African students (59%) bought their food from vendors. The main food items purchased by the students were unhealthy energy-dense foods such as chips, cakes/donuts, and chocolates. Fruits were bought by only 11% of the students. Our survey confirmed these findings as food vendors mostly sold unhealthy snacks and processed foods when compared to fruits, which were the least sold (14 versus three out of 18 food vendors) and consumed by the in-school adolescents. Food vendors play a critical role in the school environment, as 69% of students in our study bought snacks from food vendors. It may be convenient for students to buy snacks from food vendors especially in schools without a formal feeding program; however, they can be unhealthy and high in fat and sugar [
40,
41]. Hence, food vendors should be encouraged to sell fruits and vegetables as snacks rather than energy-dense alternatives [
42]. Studies in Burkina Faso and El Salvador were able to address this issue by training the vendors in healthy preparation of their foods and convinced some of them of the benefits of selling healthier drinks and fruits to students [
17,
43].
Our results also show that most schools (90%) did not cultivate their own vegetable gardens. School gardens may allow students to learn about healthy eating and the production of fresh vegetables [
29]. Previous research has reported that increased fruit and vegetable consumption is positively associated with academic performance [
44] and reduces the risk for micronutrient deficiencies and non-communicable diseases [
45]. Further, a Burkina Faso study found that community engagement played an important role in the promotion of school vegetable gardens as both community members and parents helped with preparing the land and finding water for the gardens, especially during the dry season [
46]. The authors of the study reported that successful community engagement in school garden projects significantly increased the student’s knowledge of good nutrition intake [
46]. However, school gardens also have their challenges such as due to their seasonality, required time commitment, and small output [
29]. An alternative may be the enhancement of community or home gardens as over half of the students in our study received their meals from their parents. Parents were found to act as role models, shape positive behavior change and modify available foods at home [
47]. Campaigns should therefore also target the parents and community through the promotion of healthy eating behavior and attitudes [
16,
18].
Overall, our study is in line with other research on school-based programs, which continue to reveal many challenges for implementing school-based interventions, including non-existing school nutrition policies, unregulated food environments, inadequate sanitary facilities, and limited financial resources [
6,
29,
36,
48].