Healthy eating

Holiday clubs:

Thirty studies examining holiday clubs (86%) assessed the healthy eating impacts. Nine adopted a quantitative approach focusing on interventions reducing food insecurity. Child questionnaires found the food offered at the intervention was healthier when compared to at home.^{(Reference Defeyter and Stretesky67–Reference Pierce, Bowden and McCullagh69)} This was supported by staff interviews reporting that children ate more fruit and vegetables, and fewer sugary snacks.^{(Reference Graham, Crilley and Stretesky55)} Interviews with staff and parents found holiday clubs had the potential to allow children to try new foods not available at home.^{(Reference Defeyter, Graham and Russo23,Reference Defeyter and Stretesky67,Reference Kannam, Wilson and Chomitz70,Reference Round, Shinwell and Stretesky71)} Some studies suggested children increased their fruit and vegetable consumption by attending,^{(Reference Di Noia, Orr and Byrd-Bredbenner72–Reference Stretesky, Defeyter and Long75)} with one finding no impact on consumption.^{(Reference Shinwell, Finlay and Allen76)} Only two papers reported on the Eatwell Guide, with both finding clubs fell short of the recommended five portions a day.^{(Reference Crilley, Brownlee and Defeyter77,Reference Mann78)} By assessing the menus of 52 Holiday Activities and Food funded clubs, it was felt there was a need to improve the food offered by including wholegrain options and alternative sources of calcium.^{(Reference Vitale, Crossland and Shinwell79)} Although parents deemed the food healthy,^{(Reference Hill80)} there were mixed feelings regarding satisfaction over the quantity served.^{(Reference Kannam, Wilson and Chomitz70)} Staff noted disagreements regarding whether the priority was to provide healthy food or tackle food shortages,^{(Reference Holley, Mason and Haycraft81)} yet for many children, these clubs provide the only meal of the day.^{(Reference Mann, Widdison and Defeyter82)}

Breakfast clubs:

One of the main outcomes was that fewer children went hungry before the start of school.^{(Reference McKeon, Shukaitis and Cuite83,Reference Stokes, Spruance and Patten84)} Teachers viewed programmes as an important resource for children^{(Reference Young85)} with online surveys showing that 95.4% of teachers stated that children not going hungry was one of the main benefits of the club.^{(Reference Krueger, Eggett and Stokes86)} Teachers believed it was a healthy way for children to begin their day,^{(Reference Watson, Velardo and Drummond87)} with a range of evidence suggesting that the breakfasts provided were more nutritious than those provided at home.^{(Reference Chandrasekhar, Xie and Mathew88–Reference Moore, Murphy and Chaplin90)} One study found that the food consumed was less processed,^{(Reference Deavin, McMahon and Walton91)} and another reported no difference.^{(Reference Spruance, Harrison and Brady92)} Parents and teachers of children attending the universal free school breakfast scheme reported concern over the nutritional standards^{(Reference Graham, Russo and Blackledge93)} with local authority and senior school staff claiming that the breakfasts were high in sugar and fats^{(Reference Harvey-Golding, Donkin and Defeyter94)} and children described the food options as unappealing.^{(Reference Askelson, Golembiewski and Bobst95)} Parents, teachers and local authority staff had concerns over children eating breakfast at home and school, resulting in a double breakfast.^{(Reference Harvey-Golding, Donkin and Defeyter94,Reference Harvey-Golding, Donkin and Blackledge96–Reference Schanzenbach and Zaki98)} Using the National Health and Nutritional Examination Survey, a research programme assessing the health and nutrition of Americans, it was concluded that the School Breakfast Program did not meet the school meal guidelines, with there needing to be more opportunities to choose fruit and vegetables at meal time.^{(Reference Cullen and Chen99)} Schools commented on the food served with some breakfast schemes lacking quality^{(Reference Abouk and Adams100)} and variation.^{(Reference Watson, Velardo and Drummond87,Reference Fornaro, McCrossan and Hawes89)}

After-school clubs:

All interventions aimed to improve children’s and families’ healthy eating and lifestyle habits. A club focusing on children’s vegetable intake found both children and parents believed that by attending, the children increased the number of vegetables they would try.^{(Reference Overcash, Ritter and Mann101)} A longitudinal study found that after 6 months, parents still noticed an increase in their children’s willingness to consume fruits and vegetables.^{(Reference Jarpe-Ratner, Folkens and Sharma102)} Children and parents reported an increase in healthier snacks and a reduction in fats and added sugars consumed at weekends.^{(Reference Andermo, Lidin and Hellenius103–Reference Schlange, Franzen-Castle and Walther105)} Alternatively, one intervention aimed at increasing vegetable intake suggested parents found no improvement in children’s intake.^{(Reference Overcash, Vickers and Ritter106)} One observational study found that although fruit and dairy products were provided, there was a higher distribution of items full of fat and sugars such as doughnuts, muffins, crackers and cereal bars^{(Reference Baugh, Opalinski and Dyess107)} concluding that there was a greater need to feed children, and healthier options are too expensive and less inclusive.^{(Reference Baugh, Opalinski and Dyess107)}

Academic

Holiday clubs:

Few studies examined the academic impact of holiday programmes. All were qualitative and reported generally positive findings. Parents felt clubs provided the opportunity to engage children, preventing summer learning loss through different activities such as reading, forest schools and drama classes.^{(Reference Bruce, De La Cruz and Moreno108)} Enrichment activities, such as trips to the zoo and science classes, gave children the opportunity to learn.^{(Reference Bruce, De La Cruz and Moreno108,Reference Cox, Campbell-Jack and Blades109)} Attending school during the holidays and socialising with friends, parents and staff was felt to help with the transition through school.^{(Reference Defeyter and Stretesky67)} No studies presented quantitative data to measure objective changes in performance/attainment.

Breakfast clubs:

There was consensus among teachers that breakfast clubs helped children to focus more as they were not coming to school hungry.^{(Reference Stokes, Spruance and Patten84,Reference Young85,Reference Folta, Carmichael Djang and Halmo110)} Feeding children a nutritious breakfast yielded important gains in achievement^{(Reference Harvey-Golding, Donkin and Defeyter94)} and improved their readiness and engagement in learning.^{(Reference Hill, Byrne and Wenden111)} Teachers believed their children performed better academically after attending^{(Reference Krueger, Eggett and Stokes86,Reference Oo, Stephenson and Hege74)} . One study found an increase in children’s maths achievement by at least 23%^{(Reference Frisvold112)} with others contradicting this, suggesting little to no impact on children’s academic achievement scores.^{(Reference Schanzenbach and Zaki98,Reference Abouk and Adams100,Reference Anzman-Frasca, Djang and Halmo113–Reference Luan, Foster and Fisher115)} Evidence suggested that feeding children before school could mean that they are less likely to miss days.^{(Reference Chandrasekhar, Xie and Mathew88,Reference Hill, Byrne and Wenden111,Reference Jose, MacDonald and Vandenberg116)} By analysing student-level information on annual attendance rates, the School Breakfast Program was found to have a small to modest association with term time attendance.^{(Reference Bartfeld, Berger and Men117)}

Social

Holiday, breakfast and after-school clubs:

All three clubs had social benefits for children and parents. Children had the opportunity to meet outside school hours, allowing them to socialise with different age groups^{(Reference Defeyter and Stretesky67,Reference Hill, Byrne and Wenden111,Reference Graham, Russo and Defeyter118)} and make new friends, especially during the holidays.^{(Reference Kannam, Wilson and Chomitz70,Reference Stretesky, Defeyter and Long75,Reference Mann78,Reference Shinwell, Finlay and Allen119)} Breakfast clubs provided a relaxed social environment^{(Reference Watson, Velardo and Drummond87,Reference Ichumar, Dahlberg and Paynter120)} which parents, teachers and staff believed created a chance for social capital to develop, increasing the opportunity for social eating and interaction with peers,^{(Reference Jose, MacDonald and Vandenberg116)} enhancing their social interactions.^{(Reference Deavin, McMahon and Walton91,Reference Graham, Russo and Blackledge93,Reference Folta, Carmichael Djang and Halmo110,Reference Byrne, Hill and Wenden121)} Some holiday and after-school clubs were designed for parents to attend, allowing them to spend time with their children^{(Reference Graham, Crilley and Stretesky55,Reference Bruce, De La Cruz and Moreno108,Reference Lechuga-Peña, Brown and Mitchell122)} and meet other parents, reducing social isolation.^{(Reference Morgan, McConnon and Van Godwin68,Reference Andermo, Lidin and Hellenius103)} By attending clubs, children, parents and club staff, both quantitatively and qualitatively, felt social isolation reduced for the whole family during the holidays.^{(Reference Defeyter, Graham and Russo23,Reference Shinwell, Finlay and Allen76,Reference Long, Stretesky and Crilley123)}

Physical activity

Holiday and after-school clubs:

Sixteen holiday and four after-school clubs included a form of physical activity such as football,^{(Reference Defeyter and Stretesky67,Reference Mann78)} adventure playground^{(Reference Crilley, Brownlee and Defeyter77)} or a mix of outdoor activities.^{(Reference Defeyter, Graham and Russo23,Reference Long, Stretesky and Graham124)} Compared with being at home, children felt that attending increased their activity levels.^{(Reference Shinwell, Finlay and Allen76,Reference Mann78,Reference Cox, Campbell-Jack and Blades109)} Sixty-five children participated in focus groups, claiming they felt encouraged to go outdoors rather than stay inside and watch TV or play computer games.^{(Reference Shinwell, Finlay and Allen119)} Parents appreciated their children taking part in regular and intense activities after school^{(Reference Andermo, Lidin and Hellenius103,Reference Schlange, Franzen-Castle and Walther105)} with clubs offering more physical activity compared to at home.^{(Reference Graham, Crilley and Stretesky55,Reference Stretesky, Defeyter and Long75,Reference Shinwell, Finlay and Allen76,Reference Bruce, De La Cruz and Moreno108,Reference Cox, Campbell-Jack and Blades109)} Little quantitative data ascertained the impact of physical activity. The two that did, found children achieved the recommended 60 minutes of MVPA.^{(Reference Morgan, McConnon and Van Godwin68,Reference Pierce, Bowden and McCullagh69)} Although most studies found physical activity increased,^{(Reference Nyberg, Andermo and Nordenfelt125)} parental questionnaires found no effect on sedentary time.^{(Reference Schlange, Franzen-Castle and Walther105,Reference Shinwell, Finlay and Allen119)}

Nutritional education

Table 3 highlights the various types of nutritional education evidenced within the papers.

Table 3. Types of nutritional education offered

Holiday clubs:

Twenty clubs incorporated nutritional education for children and parents. e.g. food preparation.^{(Reference Shinwell, Finlay and Allen119)} Interview data across several studies highlighted a belief that children had the opportunity to learn about food and develop their confidence in the kitchen.^{(Reference Defeyter and Stretesky67,Reference Shinwell, Finlay and Allen76,Reference Bayes, Mason and Holley126)} Children felt that some clubs encouraged them to cook and try new recipes at home.^{(Reference Pierce, Bowden and McCullagh69,Reference Cotwright, Alvis and De Jesus Jimenez127,Reference Harrington, Ickes and Bradley128)} Children were familiar with the names of fruits and vegetables after taking part in cooking sessions^{(Reference Ehrenberg, Leone and Sharpe129)} and could identify where food comes from.^{(Reference Oo, Stephenson and Hege74)} However, one study reported that only 20% of children reported learning something new regarding food.^{(Reference Cox, Campbell-Jack and Blades109)}

Breakfast clubs:

Only two studies incorporated nutritional educational sessions. In one, parents and club staff believed their children were learning about the importance of breakfast in increasing energy levels and providing fuel throughout the day.^{(Reference Deavin, McMahon and Walton91)} One Australian programme incorporated fun and interactive activities to increase children’s knowledge about healthy food, with a one-year follow-up suggesting this knowledge was maintained.^{(Reference Hochfeld, Graham and Patel130)}

After-school clubs:

Families attending took part in nutritional educational opportunities such as learning about food and preparation and taking part in cooking activities. Parents believed their cooking confidence and preparation skills improved^{(Reference Overcash, Ritter and Mann101)} and they began to understand what a healthy meal should look like.^{(Reference Schlange, Franzen-Castle and Walther105)} An evaluation of The Flint Kids Cook, a club aiming to improve children’s knowledge, skills and self-efficacy for cooking healthy foods, found improvements in children’s attitudes towards cooking when comparing surveys completed at the beginning to the ones at the end of the 6-week intervention.^{(Reference Saxe-Custack, LaChance and Hanna-Attisha104)} Similar results were found regarding children’s confidence in the kitchen.^{(Reference Jarpe-Ratner, Folkens and Sharma102)} This contradicts evidence evaluating a similar intervention with no improvements in children’s attitudes towards cooking.^{(Reference Overcash, Ritter and Mann101)}

Financial

Holiday, breakfast and after-school clubs:

The benefit to parents of their children attending was a common theme throughout. As clubs were free of charge or subsidised and provided food, interviews, focus groups and questionnaires found parents felt reduced pressure to pay for children’s activities.^{(Reference Defeyter and Stretesky67,Reference Mann78)} They were able to save money, make food last longer^{(Reference Bruce, Lien and George131,Reference Defeyter, Graham and Prince132)} and manage the household budget.^{(Reference Kannam, Wilson and Chomitz70,Reference Stretesky, Defeyter and Long75,Reference Hill80,Reference Bruce, De La Cruz and Moreno108)} Through mixed method designs, parents, club staff and teachers concluded that by clubs feeding the children, financial pressure was relieved^{(Reference Graham, Crilley and Stretesky55,Reference Defeyter and Stretesky67,Reference Fornaro, McCrossan and Hawes89,Reference Harvey-Golding, Donkin and Defeyter94,Reference Jose, Vandenberg and Williams97,Reference Cox, Campbell-Jack and Blades109)} and parents’ anxiety around feeding their children was alleviated, especially during the holidays.^{(Reference Shinwell, Finlay and Allen119)} Results showed clubs were successful at reducing food insecurity for children.^{(Reference Burke, Cabili and Berman133)} There was little impact on adolescents due to the perceived stigma of attending these clubs designed for children from poor backgrounds.^{(Reference Fletcher and Frisvold134)} Teachers believed that by allowing children to take leftover food home, hunger issues decreased.^{(Reference McKeon, Shukaitis and Cuite83)} The evidence suggests that 53% of parents believed food lasted longer at home when their children were being fed at holiday clubs.^{(Reference Morgan, McConnon and Van Godwin68)} They can try new foods without the financial risk.^{(Reference Graham, Russo and Defeyter118)}