Do National Nutrition Policies Relevant to Sri Lankan Adolescents Effectively Uplift Their Development and Well-Being? A Qualitative Study

Abstract

Adolescence is a crucial phase of growth and development in the life course, and healthy nutrition is essential during this period. The objective of this study was to explore the perceptions regarding the implementation of relevant nutrition policies for adolescents in Sri Lanka. The study is qualitative, employing a “phenomenology” approach. The study was conducted in the central province of Sri Lanka, with participants including adolescents (n = 18), public health inspectors (n = 3), parents (n = 12), canteen owners (n = 3), schoolteachers (n = 3), and principals (n = 3). Data were collected through interviews and analyzed using the framework analysis method. Results indicated that adolescents’ awareness of relevant policy statements is poor. Implementing nutrition policies related to adolescents in school settings and at the community level remains insufficient. In conclusion, future research should further evaluate the overall implementation of nutrition policies directed at adolescents. This will help policymakers to enhance and improve relevant policy guidelines.

Keywords

adolescents development health nutrition policies

What We Already Know

Several nutrition policies that promote the health and development of adolescents in Sri Lanka can be identified.

The prevalence of underweight, stunting, and overweight among adolescents in Sri Lanka remains considerable.

According to the current evidence, a noticeable gap exists in assessing the implementation of relevant national nutrition policies for adolescents.

What This Article Adds

Considering the inadequate implementation of nutrition policies in school settings and at the community level, immediate action is required to address the deficiencies in policy execution.

It is crucial to identify and analyze significant challenges in nutrition promotion in school settings, such as low staff awareness of nutrition, limited nutrition program availability, and inadequate administrative oversight. By highlighting these barriers, the article offers insights into the gaps that must be addressed to strengthen school-based nutrition initiatives effectively.

Introduction

Adolescence is a critical phase of growth and development in the life course, and it is the transitional period from childhood to adulthood. According to the World Health Organization (WHO), the age range for adolescence is 10 to 19 years, and this period is vital because of massive changes in functions and capacity, educational achievement, and social roles.¹ This period is crucial for building a robust foundation of good health and well-being for the rest of the life. Healthy nutrition during adolescence is one of the significant aspects that direct various preventable health issues. The current data show that about 1.3 billion adolescents live worldwide.² A significant number of adolescents live in the WHO Southeast Asia region, and it is predicted that there will be an increase in adolescents in some developing countries in the next few years.³ The Demographic Health Survey in 2006 has estimated that the 3.8 million adolescent population in Sri Lanka encompasses nearly one fifth of the country’s total population,⁴ and approximately 70% of adolescents are reported to be in schools.⁵

Nutritional health is one of the best indicators that explain the population’s overall health status.⁶ Based on the current evidence, obesity and undernutrition have become significant public health concerns among adolescents in Sri Lanka.⁷ The prevalence of underweight, stunting, and overweight among 10- to 15-years-old school children has reached considerable amounts (47.2%, 28.5%, and 2.2%, respectively).⁸ Obesity can create various negative consequences on social, physical, and emotional well-being among children.⁹

Public health policy has been recognized as one of the best approaches to addressing public health issues by changing community attitudes and behaviors. As a remedial action to address the nutrition issues among school children in Sri Lanka, the school canteen policy was introduced to the national health services in 2006. The latest revision was made to the policy in 2015. A few aspects mentioned in the revised canteen guideline for enriching nutrition among school children are providing child-friendly services, providing access to healthy food, creating a healthy canteen environment, and improving food safety.¹⁰ The Ministry of Health has introduced the national nutrition policy in Sri Lanka to achieve and maintain all Sri Lankans’ nutritional well-being. The policy emphasizes the nutritional well-being among adolescents through a separate key strategic direction: (4.6) “promote optimal nutrition and development among adolescents and youth adopting adolescent and youth-friendly approaches, while addressing the social determinants.”¹¹

A study among adolescents has concluded that policies are necessary to increase the availability and affordability of nutrient-rich foods.¹² Ensuring the quality of services provided and aligning with the current nutrition policies leads to higher health standards in school canteens and enhancing adolescent health. A recent study has shown that providing quality food and maintaining standards in school canteens has been challenging due to many gaps in the current system.¹³ According to the current evidence, there is little research assessing the implementation of national nutrition policies among adolescents in Sri Lanka, and it is essential to assess the current nutrition policies to determine their effectiveness in improving health and development among adolescents. It is also vital to identify the effectiveness of the policy guidelines for further modifications. This study is framed within a broader conceptual framework that integrates key theoretical perspectives on health behavior, sociocultural influences, and policy implementation. This framework provides a lens through which to examine nutrition-based experiences related to adolescents. Based on this background, the objective of this study was to explore the perceptions regarding the implementation of relevant nutrition policies for adolescents in Sri Lanka.

Methods

The philosophical stance adopted in this study was phenomenology, which asserts that reality and knowledge are constructed through individual perception and experience. It emphasizes understanding the world by delving into human experiences and perceptions, viewing knowledge as emerging from exploring lived experiences.¹⁴ This study is qualitative, and the approach is “phenomenology.” The phenomenon was the “processes” related to the purpose of the study. Adolescents aged between 10 and 19 years were the study population. Eighteen adolescents participated in this study (6 represented each sector: urban, suburban, and rural). The mean age of the participants was 16 years. Interviews were conducted among 12 school-going and 6 non–school-going adolescents (n = 18). In addition, the mothers of the interviewed adolescents (n = 12), schoolteachers (n = 3), principals (n = 3), school canteen owners (n = 3), and public health inspectors (n = 3) participated in the study. Adolescents were selected based on inclusion and exclusion criteria; selected adolescents should be aged between 10 and 19 years and without long-term illness, congenital impairment, or disabilities. In addition, they should have cafeteria facilities in their schools. Selected non–school-going children should be permanent residents in the area. Public health inspectors, principals, and teachers should have at least 6 months of working experience, and mothers should reside in the selected area.

The study settings were Ukuwela, Peradeniya, and Kothmale medical officers of health areas, and they were selected from Matale, Kandy, and Nuwara Eliya districts in the Central Province of Sri Lanka accordingly. Participants were selected based on the purposeful sampling method within the urban, suburban, and rural socioeconomic conditions. Triangulation involves using multiple data sources to validate findings and enhance the credibility and trustworthiness of the study. Therefore, different groups of participants (school-going and non–school-going adolescents, parents of the selected adolescents, schoolteachers, principals, school canteen owners, and public health Inspectors) were included in this study. The selected teachers and principals are from the same schools as the students participating in the study. Public health inspectors are frontline workers in public health, responsible for overseeing the health standards in schools and communities. The selected public health inspectors work within the medical health service areas where the selected school-age children attend schools and within the communities of non–school-going children. The selected canteen owners operate their canteens within schools located in the three selected districts. All participants either live or work within the same province, encompassing the three selected districts. In-depth interviews were conducted to collect data, and the saturation method was used as the guiding method. Each interview guide consisted of 16 to 18 semi-structured questions. Awareness about the nutrition policies for adolescents, available food in the school environment and food practices, the current role of the school administration and public health inspectors, and nutritional assessments and programs are the main areas of the data collection guides.

Ethical approval was obtained from the Faculty of Applied Sciences, Rajarata University of Sri Lanka (ERC no.: ERC/04/027). The framework approach described by Pope et al¹⁵ was applied to the data analysis. Triangulation and respondent validation methods were used to improve the validity of the data. The data collection tools in the study were pilot-tested. As the initial step, the principal investigators thoroughly immersed themselves in the interview and observation data, carefully reviewing transcripts multiple times to fully grasp the content and context. Initial codes were formulated by identifying significant data segments relevant to the research questions. This involved assigning labels to segments using descriptive codes that captured key concepts, ideas, or behaviors expressed by the study participants. Subsequently, codes were grouped based on similarities and connections to establish initial themes. Themes began to emerge through an iterative process of scrutinizing, comparing, and refining codes across the entire data set. The identified themes underwent a review and refinement process through discussion and agreement with an external analyzer to ensure the coherence, relevance, and representativeness of the data.

Results

Theme 1: Adolescents Lack Sufficient Awareness Regarding Nutrition Policies but Possess a Satisfactory Understanding of Their Own Nutrition and Health

Adolescents possess an adequate understanding of maintaining healthy dietary habits and nutrition. They acquire this knowledge primarily through the school curriculum, focusing on specific subjects, and participating in organized programs within the school environment. One critical aspect is that both school-going and non–school-going adolescents are aware of the requirement of healthy nutrition-related behaviors for their growth, development, and health. However, adolescents are unaware of nutrition policies/regulations implemented in Sri Lanka.

Parallel to different subjects we learn about nutrition; i.e., Nutrition components like carbohydrates, protein, vitamins, . . . sometimes our school arrange nutrition programs to make aware us. . . (Adolescent [A]-5)

As my knowledge . . . we should take nutritious food always to be healthy and to reduce diseases. . . (A-4)

Nutritious food should take to be healthy and good food makes us energetic. . . (A-2)

Nutrients help to maintain a healthy range in the weight for height. . . (A-13)

Theme 2: Adolescents Have Favorable Attitudes Toward Food Selection and Nutrition

Adolescents have positive behavioral intentions about healthy food choices. A few participants mentioned that they selected food based on ingredients mentioned on the food labels. In addition, some of them believe that nutritious food can prevent certain diseases.

We should eat nutritious food, . . . nutrition helps to maintain weight for height . . . Nutritious food should take to be healthy, and good food gives us energy. (A-1)

It should contain good nutrition components . . . (A-15)

When we are doing more activities, we need energy. if not, we cannot do whatsoever for a longer period. (A-8)

Theme 3: Unhealthy Practices Related to Nutrition Are Prominent Among Adolescents

Several determinants affect adolescents’ unhealthy food practices: peer pressure, availability of unhealthy food, accessibility, poor parents’ attention, personal preferences, media influences, and poor implementation of nutrition policies. Nutrition practices were mainly supported by unhealthy food availability in the school canteens and other community places that provide food. These venues predominantly offer food items rich in sugars, oils, and starches, contributing to the perpetuation of unhealthy eating habits among adolescents. Despite this awareness, adolescents frequently opt for these less nutritious choices, highlighting the complex interplay between environmental influences and personal decision-making in shaping dietary behaviors during adolescence.

Generally, they sell wade, rolls, those, string hoppers, pastries, porridge, milk, tea, fruits, juices, lavariya, pancake, cutlets, noodles, peak. (A-3)

. . . oily food, sweets, food made from flour . . . bread, buns available in the canteen . . . (A-7)

Sometimes I buy food, according to friend suggestions . . . affordability is high . . . (A-9)

. . . children more like to instant food . . . this could be influenced their friends and media promotions. (Mother [M]-3)

I know. . . we use more oil and salt for meals. (M-2)

Theme 4: Poor Implementation of the Nutrition Policies in the School and Community Settings Is Obvious

Programs implemented by the health sector in schools helped to some extent to change unhealthy nutritional practices. However, these programs are limited to health education and do not attempt to empower the school community to change unhealthy practices. Continuing scheduled nutrition assessments (ie, body mass index, waist-hip ratio) among adolescents in the school setting are rare.

Public Health Inspector comes to the school and assesses our weight and height. He helps us to know our BMI . . . (A-6), . . . provide Vitamins . . . (A-12)

Instant food are banded for our canteen . . . but it is not continuously implemented . . . (A-12)

. . . no idea because there was not any program in our school . . . (A-1)

Principal suggests students eat nutritious food in the assembly. (A-12)

I do not become aware of any special nutrition programs in our village . . . (A-18)

Theme 5: Navigating Challenges in School Canteens: Awareness Gaps, Limited Training, and Promoting Healthy Choices

Two out of 3 canteen owners who participated in the study were unaware of the canteen policy. They do not have any special training on implementing the policy guidelines. The main thing these owners follow is food safety and hygiene. They do not highly consider the ingredients of the food. Generally, they sell high-fat, high-sugar, and starchy food. However, they do provide healthy food as well. The canteen owners are well aware of unhealthy food and its impacts on health and development. Healthy food-promoting practices are limited, and some health messages are displayed. Regular monitoring by the canteen committee or the responsible external persons is scarce.

As Informed by the public health inspector, we know which food can sell, the price of the food, food storage, cleanness of the food and the place. (Canteen owner [C]-1)

. . . need to sell traditional food, less oily food, cannot sell instant food, less price, cannot rap by using newspapers, cleanliness of the food, place . . . (C-3)

. . . Usually we use a mask, glouse, handle, and head covers while delivering food . . . we daily clean the environment . . . school management advised us to do this. . . (C-2)

Theme 6: Challenges in School Nutrition Oversight: Staff Awareness, Limited Programs, and Administrative Oversight

The school staff does not have satisfactory awareness of the nutrition policies they must implement at the school level. Some teachers have advised the canteen owners on unhealthy food items, the environment, and unhealthy practices while preparing and delivering food. According to the staff members, there are no unique healthy food promotion programs except 1 or 2 health education events annually. The school administration mentioned that the school development committee’s poor attention to the canteen is prominent.

We encourage nutritious food, but other foods are sold continuously. (Teacher [T]-2)

Most of the time they try to sell healthy food items . . . (Principal [P]-2)

Students and the staff can use the canteen during school time . . . no allocated period . . . (P-3)

Evaluation of nutrition program is a good method but needs to implement correctly, and it should monitor regular basis . . . (P-1)

Monitors by the public health inspector, but not regularly . . . (T-1)

Theme 7: Public Health Inspectors’ Role: Awareness, Oversight, and Challenges in Promoting Nutrition at School and Community Levels

Public health inspectors are aware of the canteen policy and some aspects of the national nutrition policy. They conduct health education programs in schools and examine the school canteen operations (ie, especially the canteen staff’s hygienic practices and physical environment). However, they do not consider the food types offered. Furthermore, regular visits and assessments of the canteen are limited. Nutrition-related programs in communities are lacking, and there is a notable absence of routine nutrition assessments at the community level.

We conduct health education programs in schools and measure students’ health status. (Public Health Inspectors [PHI]-1)

. . . . assess canteen environment and hygiene practices of canteen staff, but it is not a regular assessment . . . (PHI-2)

. . . we engage with some screening programs in communities; however, we do not conduct any special nutrition program. (PHI-1)

Discussion

This study explored perceptions of the current situation of implementing nutrition policies for adolescents in Sri Lanka. The results of this study revealed that the nutrition policies related to adolescents should be strengthened as these policies are not successfully applied within community settings. Healthy nutrition directs the low-risk level of noncommunicable diseases. As nutrition is related to sustainable development goals, nutrition-based policies are prominent globally.¹⁶ Various successful examples of enacting effective nutrition policies can be identified.¹⁷

Although nutrition policies have been considered globally, there is still a gap in effective policies for adolescents in countries.¹⁸ Because of this, development during adolescence reached a more perilous situation. Lancet reports provide evidence emphasizing the significance of nutrition policies among adolescents and the importance of a novel global-level policy framework for adolescent nutrition.^19,20 In addition, effective school-based health and nutrition programs have been prioritized and are cost-effective and low-cost solutions.²¹ However, we can identify specific gaps in the current nutrition policies, including poor coordination, less community involvement, and poor advocacy. Therefore, policymakers should focus on the nutrition guidelines that the relevant international bodies provide to integrate the relevant nutritional aspects into the current policies.^22,23

Similar results have been shown in a recent Indonesian study; adolescent nutrition is not a priority in the national development agenda in Indonesia.¹⁸ Furthermore, a recent review of the national-level health policies among countries has shown that nutrition among adolescents does not firmly adhere to policy development.²⁴ A cross-sectional study conducted in Rathnapura district, Sri Lanka, has shown that the nonavailability of canteens in schools is a prominent factor that leads to a missed opportunity to have healthy food. Furthermore, the school canteen policy has not been successfully implemented, and the contribution of the health and education sectors is very poor.²⁵ The absence of canteens in certain schools poses a significant challenge to addressing nutrition among adolescents as students may resort to purchasing food from outside shops. This obstacle underscores the need to reconsider existing policies to accommodate alternative food sources for students in schools without canteens.

The phenomenology approach is a popular method in qualitative inquiries, and it is well-suited for exploring the lived experiences of individuals.²⁶ By centering on the lived experiences of adolescents, phenomenology allows for a deep exploration of their subjective perspectives and meanings attributed to their experiences. This paradigm assisted in delving deeply into the subjective experiences, perceptions, and meanings individuals attributed to their experiences during the study. Adolescents’ nutrition policies focus on underweight, stunting, and overweight issues to ensure holistic support for their growth and development. Improving awareness of nutritional policies among the general public is essential because it can enhance policy enactment. Based on the current evidence, adolescent nutrition remains an emerging priority to strengthen because unhealthy behavior practices have been increased.²⁷ Schools should be the focal setting to address nutritional problems of adolescents and policy development and implementation in collaboration with the Ministry of Health and Education to address nutritional-based issues.

Conclusion

Future research should focus on assessing the overall implementation of nutrition policies targeting adolescents. This would assist policymakers in refining and advancing relevant policy guidelines. In addition, this study revealed that key personnel perceive a need for improved evaluation structures, suggesting this as a potential area for future research to support effective policy implementation.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Prabhath Pallewaththa

Supun Prakash

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