What is Needed to Improve Food Sales in Schools? Food Vendors’ Opinion from El Salvador

Save the Children International (SCI) implements a school health and nutrition program in 45 schools in El Salvador. The program’s overall goal is to increase the consumption of protein and micronutrients while reducing intake of sugar and fats among school children. Save the Children International started this program because the Latin America and Caribbean region is at the forefront of the double burden ofmalnourishment, with rocketing rates of overweight, obesity, and high rates of stunting at the same time (1). Latin Americans tend to decrease healthier foods and consume more fat and sugar when emerging from poverty (2). In the 30-year span from 1990 to 2020, Central America is projected to double its prevalence of overweight and obesity among children under five (3). School children are at a crucial age for setting eating and physical activity habits, which in turn determine their nutritional status and long term health, education, and economic productivity. Overweight and obesity have become a public health problem in El Salvador. According to a recent study in 2014 (4), 30% of 389 young adolescents (7th–11th graders) were overweight and within that group, 8% were obese, comparing to only 2% of children being underweight or very thin. In a previous study in 2012, 23% of 1st and 2nd graders were reported to be overweight or obese (5). El Salvador has a governmental recommendation regulating the sale of soft drink in schools (5, 6), which has been proposed to become a full law (7, 8). Schools stores also have a written contract, which regulates the vendor’s services, based on a model contract from the Ministry of Education. Save the Children International’s school store intervention aims to improve the quality of food that children buy at school. SCI trains and supports student brigades to enforce the current food sale regulation. Thus, monitoring and control lies in the hands of students, which fosters child participation. SCI’s program is specifically known for active child participation in design, implementation, and monitoring (9). In addition, there is great emphasis on food hygiene and safe handling, through training of the food vendors (10). The indicator of success is the proportion of schools with stores selling fruit. Of the 45 schools, we found 38 stores selling fruit in 2012 and 41 in 2013. We were intrigued to learn more about the determinants for healthy food stores on the ground. Therefore, SCI conducted key informant interviews in 2014, in six SCI supported schools, three in the Izalco municipality (Sonsonate Department), and the other three in San Pedro (La Paz Department). In each municipality, we chose one urban and two rural school food vendors. We asked open-ended questions in three thematic areas of interest: