Cogent Social Sciences

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Healthy living character-building strategies: A

systematic literature review

Ali Imron, Mustiningsih Mustiningsih, Rochmawati Rochmawati, Rachma

Putri Kasimbara, Zummy Anselmus Dami & Kamilatun Nisa

To cite this article: Ali Imron, Mustiningsih Mustiningsih, Rochmawati Rochmawati, Rachma
Putri Kasimbara, Zummy Anselmus Dami & Kamilatun Nisa (2023) Healthy living character-
building strategies: A systematic literature review, Cogent Social Sciences, 9:1, 2195080, DOI:
10.1080/23311886.2023.2195080

To link to this article: https://doi.org/10.1080/23311886.2023.2195080

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Imron et al., Cogent Social Sciences (2023), 9: 2195080
https://doi.org/10.1080/23311886.2023.2195080
Received: 16 September 2022
Accepted: 21 March 2023
*Corresponding author: Ali Imron,
Department of Educational
Management, Faculty of Education,
Universitas Negeri Malang, Jl.
Semarang 5, 65145, East Java,
Malang, Indonesia
E-mail: ali.imron.fip@um.ac.id
Reviewing editor:
Ana Maria Lopez Narbona, University
of Malaga: Universidad de Malaga,
Spain
Additional information is available at
the end of the article
SOCIOLOGY | REVIEW ARTICLE
Healthy living character-building strategies:
A systematic literature review
Ali Imron1*, Mustiningsih Mustiningsih1, Rochmawati Rochmawati1,
Rachma Putri Kasimbara1, Zummy Anselmus Dami2 and Kamilatun Nisa1
Abstract: The healthy living character needs to be intervened and habituated in
elementary school students because it positively impacts children’s healthy food
intake (fruits and vegetables) and several psychosocial factors (attitudes, knowl­
edge, and self-efficacy). Improving the character of a healthy life needs to be
supported by determining an accurate strategy. The study aimed to identify healthy
living character-building strategies of elementary school students. This study used
systematic review with Preferred Reporting Items for Systematic reviews and Meta-
analyses (PRISMA) guidelines. Searches for articles related to the topic used Open
Knowledge Maps, Google Scholar and Litmaps and found 60 primary articles and
supported by secondary sources such as books and proceedings. The review results
in the descriptive analysis include geographical distribution and research design.
The review results show that current research is still dominated by social cognitive
theory and social learning theory, and treatment lengths are categorized into 40
weeks, six months and six years. The findings show that eight dominant strategies
are used in shaping healthy living characters through healthy foods for the immune
formation of elementary school students. The most effective strategies to facilitate
healthy food for primary school students are the strategy of a mix of enhanced
curriculum, cross-curriculum and experiential learning and other strategies such as
ABOUT THE AUTHORS
Ali Imron is a Professor at the Department of Educational Management, Universitas Negeri Malang,
Indonesia. His research interests are Educational Management, Character Building, Educational
Administration and Educational Supervision in Primary Education.
Mustiningsih is an Associate Professor at the Department of Educational Management, Universitas
Negeri Malang, Indonesia. Her research interests are Educational Management, Educational
Leadership, and Educational Supervision.
Rochmawati is a Lecturer at the Department of Educational Administration, Universitas Negeri Malang,
Indonesia. Her research interests are Quality Management Systems, Educational Management,
Character Building, Quality Culture, Quality Assurance, Educational Administration and Supervision.
Rahma Putri Kasimbara is a lecturer at the Institute of Science Technology and Health, Dr. Soepraoen
Kesdam V/Brawijaya Hospital Malang. Her research interests are Student Health Education and
Student Health Services.
Zummy Anselmus Dami is a Doctoral candidate in Educational Management at Universitas Negeri
Malang, Indonesia. He is a lecturer at the Faculty of Education, Universitas Persatuan Guru 1945 NTT.
His research interests are Educational Leadership, Pedagogy and Christian Education.
Kamilatun Nisa is a master's student at the Department of Educational Management, Universitas
Negeri Malang, Indonesia. Her research interests are a teacher's pedagogical abilities, professionalism,
and academic supervision.
© 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribu­
tion, and reproduction in any medium, provided the original work is properly cited. The terms on
which this article has been published allow the posting of the Accepted Manuscript in
a repository by the author(s) or with their consent.
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parental involvement. This research provides insight into healthy living character-
building strategies in elementary school students and can guide policymakers,
principals, and teachers in the development of mixed strategies to improve chil­
dren’s healthy living character.

Subjects: Primary/Elementary Education; Health & Society; Health Conditions; Public

Health Policy and Practice

Keywords: strategy; healthy living character; food and nutrition; elementary school
student; systematic literature review

1. Introduction
Schools are an important arena for encouraging health promotion practices (2018; World Health
Organization WHO, 2015). Schools have become a popular place for implementing health promo­
tion and preventive interventions, as schools offer ongoing and intensive contact with children,
and lifelong health and well-being begin with promoting healthy behaviours early in life (Lee,
2009). School infrastructure, physical environment, policies, curriculum, teaching and learning, and
academic staff can positively affect a child’s health. While schools remain a popular infrastructure
for health promotion initiatives, teachers will remain the primary agents for promoting health and
nutrition in schools (United Nations Educational, Scientific and Cultural Organization, 2013). In this
context, schools are recognized as important places for action to change, not least because of
their reach and potential to influence how the younger generation engages with food (Hawkes
et al., 2015). The school provides a physical, social, and educational environment for children and
could form physical activity (PA) and eating behaviour (Butland et al., 2007).

The formation of children’s eating behaviour involves biological, social, and environmental
factors (Ventura & Worobey, 2013). Social factors include relationships with others, and in primary
school years (ages 5 to 12), parents and teachers are very influential (Pérez-Rodrigo & Aranceta,
2001; Shloim et al., 2015). The notion that parents and teachers influence children’s eating habits
is also consistent with behavioural health theories, such as Bronfenbrenner’s ecological model
(1979) and Bandura’s Social Cognitive Theory (1986), which recognizes that significant adults, such
as parents and teachers, influence children’s behaviour through role models, normative practices,
and social support.

Through the Ministry of Education and Culture (2009), the Indonesian government has formu­
lated a character education policy to integrate it into various subjects and activities in schools.
Eighteen types of characters want to be integrated into education in schools. The Directorate of
Elementary School Development also involved researchers Directorate General of Primary
Education of the Ministry of Education and Culture (2010–2011) to compile Guidelines for
Character Education in Elementary Schools. However, that specifically pays attention to the
character of healthy living in elementary school students. On the thing, the reality on the ground
shows that elementary school learners are invaded by snacks that threaten their health.
Meanwhile, their level of assertiveness to invading unhealthy snacks is very low.

Many elementary school students do not have breakfast at home before leaving for school.
Some of them replace breakfast with snacks sold outside the school. Jawa Pos Radar Malang
(Thursday, 7 March 2013) reported that many of their students consume snacks sold outside the
canteen in elementary schools that already have canteens. Snacks consumed by students outside
the school cafeteria, based on Investigative Reportage (Trans Television), were found to contain
harmful substances such as formalin, borax, textile dyes, preservatives, and aspartame. Schools
have often made a series of efforts, but because students do not have a healthy living character,
they still risk buying snacks that endanger their health (Mariza & Kusumastuti, 2010).

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The Food and Beverage Control Agency stated that 40% of snacks were not suitable for eating.
“There are many food contents in the form of borax, and formalin still dominates the content of
harmful substances in children’s snacks in schools”, said the Director of Food Safety Surveys and
Extension, Indonesia (2022). Snacks at school are more varied and attractive than the provisions
from home. However, these attractive snacks are poor in nutrition and far from healthy.

Mariza and Kusumastuti (2010), through research in elementary schools in the sub-district of
Semarang city, found: 40.62% of the subjects in the case group and 46.87% in the control group
found unusual breakfast; 90.65% of the case group and 53.15% of the regular snack control group
and there was a relationship between snack habits and obesity. There were 43.76% of subjects
who were unusual in breakfast but ordinary snacks, and there were no subjects who were unusual
breakfast but unusual snacks. There is a meaningful relationship between breakfast habits and the
habit of not snacking. 2010) concluded, that the habit of breakfast is related to the habit of not
snacking. An unusual breakfast can increase the risk of snacks by 1.5 times. Snack habits are
related to poor nutritional status. Regular snacking increases the risk of poor nutritional status
more than sevenfold.

Based on that reality, a strategy is needed to strengthen the assertiveness and resilience of
students in resisting and resisting the temptation of snacks that invade schools and their environ­
ment. Healthy living characters need to be intervened and habituated in elementary school
students (Ulfatin et al., 2010). Therefore, it is necessary to study strategies for building healthy
living character in students, especially those at the elementary school level. The study aims to
identify elementary school students’ healthy living character-building strategies. Based on these
objectives, our SLRs seek answers to the following research questions: 1) What strategies are used
to build a healthy living character? 2) What are the theories used in researching healthy character-
building strategies? and 3). How long does treatment take in the application of healthy character-
building strategies?

2. Theoretical framework

2.1. Previous research

Research related to healthy living, activities and learning outcomes of school students has been
carried out independently and in groups. In research evaluating the national examination for
Indonesia in the Eastern region, Wiyono and Imron (2010) found that the school, in collaboration
with parents, must carry out student management focusing on the right services. The research,
sponsored by the Directorate of Primary School Development of the Ministry of National Education,
found that the provision of milk by parents in the appeal of schools when children prepare for
national exams and during the implementation of national exams further strengthens children’s
learning activities. Comparative analysis of the results of the previous year’s exam (when parents
did not provide milk) and the test results when the evaluation was carried out (parents provided
milk) showed an increase in national test scores in eastern Indonesia.

Research conducted by Ulfatin et al. (2010) also found that in primary school children in rural
areas, most (more than 70%) of the population surveyed never had breakfast, drank milk, and
were nutritionally deficient. In the rural and mountainous geographical environment with a long
distance, children come to school in a “lacklustre” state, sleepy and unable to concentrate on
studying. Interestingly, these children always carry pocket money to buy food, which is detrimental
to health from health analysis.

In previous research, 1996) found a significant association between the level of parental
involvement in educating children and their motivation and learning achievement. Research that
outlines the level of involvement in educating children based on De Roche’s theory (1985) includes
his attention to their learning, the facilitation provided, and the provision of nutritionally adequate

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foods. The study recommends that parents and schools consider aspects of the child’s diet,
nutrition and nutrition and pay attention to maintaining the child’s health.

Imron (2001) examined rural local elites in Sukolilo village, Jabung District, Malang Regency, also
found that the involvement of rural local elites such as village heads (formal elites), kyai (grass­
roots organization elites), village entrepreneurs (market sector elites), greatly determines the
success of compulsory education in rural areas. The involvement of the local rural elite, even
touching the socioeconomic aspects of the citizens, leads to the problem of direct and indirect
learning costs and concerns the nutritional factors that children should consume. The diet of
learners in the family environment, and when they are about to leave for school is recommended
to be taken seriously.

In national strategic research, Imron et al. (2009) found that there are (1) profiles of adolescent
mental resilience levels in the face of negative influences in their environment, (2) strategic local
wisdom values to improve adolescent mental resilience, and (3) soft skills aspects that are
prioritized to improve adolescent mental resilience. The values of local wisdom and soft skills are
recommended to be integrated into learning, because it is proven to increase the mental endur­
ance of adolescents facing current shocks from their environment. The influence of healthy snacks
from peer groups makes students tempted when their activity level is relatively low, and the
character of healthy living is still not owned.

The results of research in elementary schools found that the contribution of snacks to students’
daily consumption ranged from 10–20% (Ulya, 2003). Energy from snack foods contributed by
17.36%, protein by 12.4%, carbohydrates by 15.1%, and fat by 21.1% to daily consumption [9].
Meanwhile, Syafitri et al. (2009), while conducting a case study at the Lawanggintung 01 public
elementary school in Bogor City, found that more than half of the students allocated their pocket
money for snack food (68%). As many as 50.0% of students buy 2–3 types of main meals/week.
46.0% of students buy snacks of 6–7 types/week, and 46.0% buy drinks of 4–5 types/week. The
frequency of students’ main food snacks (3–5 times/week) was (44.0%). 66.0% of students have
a snack frequency>11 times/week, and 30.0% have a frequency of snacking drinks 6–8 times/week.
34.0% of students have energy adequacy in the weight category and normal-level deficits. The
level of adequacy of proteins and fats is in an excess category by (46.0%) and (56.0%),
respectively.

Other research results pointed out that school food programs have been identified as promising
strategies to encourage the healthy development of children (Ortega et al., 2008). In Canada
(García-Hermoso et al., 2019) and internationally (Tanaka et al., 2020), school food programs have
shown a positive impact on children’s healthy food intake (fruits and vegetables) and several
psychosocial factors (attitudes, knowledge, and self-efficacy) known to mediate healthy eating
behaviours (Chen et al., 2018). School food programs also have the potential to improve the quality
of children’s food literacy (Sandercock et al., 2010), reduce social disparities in fruit and vegetable
consumption (Zaqout et al., 2016), strengthen local food systems and can provide an effective
response to food insecurity (Emmett & Jones, 2015; Ismail et al., 2022). Research in Argentina
showed that common cafeterias play a key role in incorporating unusual foods such as certain
vegetables. Public school cafeterias have a higher potential to promote healthy food choices than
private school cafeterias (Molina-Bonetto, 2022).

Based on the research results, the rush of unhealthy snacks has surrounded students from all
situations. Their resilience in the face of the invasion of unhealthy foods and unhealthy living
habits of the environment and its peer groups must be improved. Internal reinforcement of
students to have a healthy living character should be intervened and eliminated. Kusmintardjo
(2007) pointed out that schools were established to provide learning experiences that can develop
students’ knowledge, skills, habits, attitudes, personalities and characters as expected of good

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citizens. Therefore, the child’s personal development in the broadest sense requires well-
maintained health.

2.2. Healthcare
Health services are a special type of service provided by schools to learners. As one of the
institutions responsible for educating students in schools, schools must be responsible for the
advancement of the health of their students. It depends on the principal and teachers’ knowledge
of health and school health programs, appreciation of health values, the ability to work closely
with other members of the health team, and especially on the attention to the child as well as
skills in helping to develop knowledge, attitudes, and behaviors about health.

The World Health Organization (WHO) defines health as follows: “Health is a state of complete
physical, mental and social well-being and not merely the absence of disease or infirmity”. In some
developed countries, such as the United States, as mentioned by the American Council of
Education (2005), health-related education aims to improve and maintain one’s health and take
responsibility for maintaining the health of others. In detail, the objectives of school health
services, as identified by Kusmintardjo (2007), are so that students have knowledge and under­
standing of (1) normal bodily functioning concerning good health practices,(2) the dangers of
important diseases, their prevention and control; (3) the relationship between mental and physical
processes in health; (4) reliable sources of health information; (5) scientific methods of evaluating
health concepts; (6) the influence of socioeconomic circumstances on health; (7) public health
issues, such as issues related to sanitation and industrial health.

According to Kusmintardjo (2007), in terms of skills and abilities, health services in schools are
expected to make students have: (1) the ability to manage time, including planning food, work,
recreation, rest and holidays; (2) the ability to repair and maintain nutritious food; (3) the ability to
achieve and maintain good emotional adjustment;(4) the ability to select and participate in
recreational activities, and health exercises appropriate to individual needs; (5) the ability to
avoid unnecessary diseases and infections; (6) the ability to use medical and dental services in
an intelligent manner; and (7) the ability to participate in health prevention and improvement
efforts.

2.3. Healthy living character

The term “character” comes from the Greek word “charassein”, which means to engrave or carve
on a gemstone or hard iron surface. Character means the traits-psyche, morals/ethics that
distinguish a person from others (Kamus Bahasa Indonesia, 2008). The character also means
“Distinctive trait, distinctive quality, moral strength, the pattern of behaviour found in an individual
or group” (Webster’s New World Dictionary). The character also means“. . . an individual’s pattern
of behavior. . . his moral constitution . . .”(Bohlin et al., 2001). According to Alport, “character is
personality evaluated”. Meanwhile, according to Freud, “character is a striving system which
underly behavior”. Ghozali (1995) considers character closer to akhlaq, that is, human spontaneity
in attitude or deeds that have converged in man so that when they appear, there is no need to
think about it again.

Terminologically, the character is typical-good values (knowing the value of kindness, wanting to
do good, real living well, and having a good impact on the environment) that are embedded in
oneself and manifested in behavior. Character coherently emanates from the results of thought
sports, heart sports, sports, and the sports of taste and feeling of a person or group of people.
Character is a person or group characteristic of values, abilities, moral capacities, and obstinacy in
facing difficulties and challenges (Imron, 2011).

The character has to do with moral force, connoting “positive”, not neutral (Akbar, 2012).
A person of character is a person who has positive moral qualities. Thus, character-building
education implicitly implies establishing traits or patterns of behaviour based on or related to

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a positive or good moral dimension, not a negative or bad one (Carter, 1981). Pay attention to
various definitions (etymology and terminology) (Purwadarminta, 2008). The Ministry of National
Education defines character as distinctively good values (knowing the value of good, wanting to do
good, having a good life and a good impact on the environment) that are imprinted in themselves
and implicated in behaviour (Kemendiknas, 2010). The Ministry of National Education identified 18
values in National Cultural and Character Education derived from religion, Pancasila, culture, and
national education goals. The eighteen values are religious, honest, tolerant, disciplined, hard
work, creative, independent, democratic, curiosity, national spirit, love of homeland, respect for
achievements, friendly or communicative, peace-loving, fond of reading, environmental care,
social care, and responsibility (Puskur, 2009).

There are several general strategies for building the healthy living character of students through
student management, both top-down and bottom-up and horizontal strategies. Top-down strate­
gies are offered by the perspective of behavioristic psychology, while the perspective of humanistic
psychology offers strategies of a bottom-up nature. This strategy provides a great opportunity for
students to learn a lot independently and gives them the confidence to develop a variety of
activities that lead to the formation of positive character. What is emphasized in this bottom-up
strategy is that the mentor is more aware of the urgency of the behavior that leads to good
character. The consciousness built here includes intellectual-rational, emotional-heart and spiritual
awareness. Theoretically, character education involves not only the aspects of “knowing the good”
(moral knowing) but also “desiring the good” or “loving the good” (moral feeling) and “acting the
good” (moral action) (Imron, 2011).

3. Method

3.1. Design
A systematic literature search was conducted to identify relevant previous research for inclusion in
this study review (Siangchokyoo et al., 2020). The author uses the systematic review method to
answer research questions and achieve predetermined goals. The systematic review has high
academic value because it collaborates with experts who synthesize strong evidence by reviewing
and summarizing secondary data relevant to the question under review (Amiri et al., 2020). The
systematic review was conducted according to Preferred Reporting Items for Systematic reviews
and Meta-analyses (PRISMA) guidelines (Moher et al., 2009).

3.2. Search strategy and sample

A search of the review literature includes three electronic databases: openknowledgemaps (BASE:
all disciplines), Google scholar and litmaps. Search strings are used to search for things like
“Healthy living character” AND “elementary school” OR “Primary school”, “healthy food” AND
“strategy”, “nutrition education” AND”strategy” AND elementary school OR “Primary school”,”­
healthy eating” AND”strategy” AND “elementary school”, and “food OR ‘nutrition’ AND”strategy”.
A literature search was conducted between 1973 and 2022 regarding healthy living character-
building strategies in elementary schools.

Based on the PRISMA guidelines, 486 papers were found taken in a literature search; after
duplicates and non-journals were deleted, there were still 240 articles that met the criteria.
After the screening process was carried out by removing no strategy and treatment and not
primary school level, 60 articles were found that met the inclusion criteria (Figure 1). Table 1
illustrates the list of articles included in the study.

3.3. Data analysis

In this study, the authors used content analysis—a research technique used to systematically
explain and analyze the content of writings such as books, newspapers, and journal articles to
make valid conclusions from the text to the context applied (Krippendorff, 2004; Vogt, 2005; Dami,
2021). Content analysis is related to critical and reflective studies on student management,

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Figure 1. Article selection pro­ Electronic Literature Research: openknowledgemaps (BASE: all
cess based on PRISMA. disciplines), Google scholar and litmaps

Records removed before screening:

Initial research (n = 486) Deleting duplicates (n = 29)

Identification
Not journal articles (n = 217)

Screening

Records screened & Reports excluded:

retrieved (n = 240) No strategy and treatment, and not
primary school level (n = 180)
Eligibility

Reports assessed for Inclusion criteria:

eligibility (n = 240) Selecting articles relevant for the
research questions
Article is relevant to the research's
overall aims and objectives.
Articles focus on strategies,
elementary school students and
length of treatment.
Included

Studies included in
review (n = 60)

especially strategies for building healthy living character through healthy food to strengthen
students’ immunity. This study also seeks a deeper understanding of related research (Esen
et al., 2018) based on a healthy living character to strengthen students’ immunity. The main
purpose of content analysis is to find answers to questions such as: What is the right strategy in
shaping the character of healthy living to promote healthy food to strengthen the immunity of
elementary school students?

The content analysis method used in this study involves two steps. First, the authors selected
texts relevant to the objectives of the study, based on a literature review that sought to obtain
representative texts related to the prescriptive part (“what should be”)—the application of appro­
priate strategies in shaping the character of healthy living through promoting healthy foods (“what
exists”)—in this case, strengthening the immunity of elementary school students through healthy
food. At this stage, the author uses open Knowledge maps, Google scholar and Litmaps to conduct
a literature review to obtain representative texts on strategies to form healthy living characters
and healthy food for elementary school students. To determine the publications related to the
topic of this study, then a combination of keywords and phrases is investigated. By searching with
the keywords ‘healthy eatingʹ, ‘elementary school studentʹ, ‘strategies to promote healthy eatingʹ,
nutrition education, and ‘food and nutrition. The search results found 60 primary articles related to
the study topic, supported by articles, books, and proceedings.

The second step involves coding messages embedded in the text according to the concept of the
student’s healthy living character. At this stage, the authors first unite or identify the right units of
a message to code, using the technique suggested by Krippendorff (2004), which identifies the
number of main books and articles that discuss healthy living character-building strategies through

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Table 1. Healthy living character-building strategies through healthy food for elementary
school students
Authors Dominant Theory Length of Treatment Strategy
Framework &
Research design
Francis et al. (2010), RCT 32 Weeks Curriculum approach
Trinidad & Tobago, Self-
funded.
Auld et al. (1998) USA, QE/SCT, CDT 4 Years Cross-curricular &
Kraft Food experiential learning
Bell & Lamb (1973) USA, QE 6 Weeks Popham Instruction
Dairy Council, Inc. Model
Edwards & Hermann QE 3 Weeks Literary abstraction
(2011), USA
Fahlman et al. (2008), QE 4 Weeks Curriculum approach
USA
Friel et al. (1999) Ireland, QE/SLT 10 Weeks Cross-curricular
Dept of Health
Gortmaker et al. (1999) QE/SCT/BCT 2 Years Cross-curricular & Social
USA, Walton Family Marketing Approach
Foundation
Govula et al. (2007) USA QE 6 Weeks Curriculum approach
Horne et al. (2004) UK, QE/SLT 16 Weeks Animation abstraction &
Horticultural contingent reinforcement
Development Council, foF & V consumption
Fresh Produce
Consortium,
ASDA, Co-operative
Group, Safeway,
Sainsbury, Somerfield,
Tesco, Bird’s Eye
Liquori et al. (1998), USA QE/SCT 1 Year Experiential learning
Manios et al. (2002), QE 6 Years Curriculum approach &
Greece, Kellogg’s, Greek Literary abstraction
Ministry of Sport, Greek
Ministry of Education
McAleese & Rankin QE 12 Weeks Curriculum approach &
(2007), USA. Experiential learning
(School Garden)
Morgan et al. (2010) QE/SCT 10 Weeks Curriculum approach &
Australia, Hunter Medical Modified Experiential
Research, Coles learning (School Garden)
Simmons-Morton et al. QE/SCT 40 Weeks Curriculum approach
(1991), USA, HHLBI Grant
Agozzino et al. (2007), CT/CogT 40 Weeks Curriculum approach
Italy
Amaro et al. (2006), Italy, CT 24 Weeks Kalèdo Board Game (15-
Amici di Raoul Follereau 30mins play time p/w)
(AIFO)
Anderson et al. (2005), CT/TPB 36 Weeks Curriculum approach,
UK, Food Standards experiential learning,
Agency video & literary
abstraction, Marketing
and canteen provisions
Baronowski et al. (2000), CT/SCT 12 Weeks Curriculum approach,
USA Experiential learning, goal
setting, problem solving,
& contingent
reinforcement

(Continued)

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Authors Dominant Theory Length of Treatment Strategy

Framework &
Research design
Bere et al. (2006), CT/SCT 28 Weeks Curriculum approach &
Norway, Norwegian Experiential learning
Research Council
Bere et al. (2011), UK, CT/mixed 2 Weeks Contingent reinforcement
Medical Research Council
National Prevention
Research Initiative
Day et al. (2008), Canada CT 12 Weeks Integrates classroom
learning, environmental
change strategies, &
a family/community
component
Domel et al. (1993), USA, CT/SCT 6 Weeks “5 a Day - for Better
The International Apple Health”
Institute
Duncan et al. (Duncan CT 6 Weeks Curriculum approach &
et al. (2011), New Experiential learning
Zealand, Health Research
Council
Foster et al. (2008), USA, CT 2 Years School self-assessment,
CDC, US Department of nutrition education,
Agriculture/Food and nutrition policy, social
nutrition Service marketing & Cross-
curricular/Integrated
learning
Gorely et al. (2009), UK, CT/SCT 40 Weeks Curriculum approach,
Great Run, Coca-Cola Physical education
Company lessons & homework
tasks Fun run event
Head (1974), USA, CT 20 Weeks Cross Curriculum
Emergency food and approach
Medical Services
Hendy et al. (2011), USA, CT/SCT 12 Weeks Kid’s Choice Program
grants from Penn State SDT (KCP), contingent
University reinforcement & parental
involvement.
Hoffman et al. (2010), CT/SLT 2 Years Cross-Curricular program,
USA, National Institute of school-wide, lunchroom
Child Health and Human & family components
Development
James et al. (2005), UK, CT/NR 40 Weeks Cross curricular
GlaxoSmithKline, Aventis,
Pfizer Florence
Nightingale Foundation
Kipping (2010), UK, CT/SCT 20 Weeks Curriculum approach
Department of Health
Kristjansdottir et al. CT 2 Years Curriculum approach to
(2010), Iceland, The developed with teachers
University of Iceland, The and supported by
Icelandic Centre homework, letters to
for Research, Brim parents and meetings
Seafood with parents
Luepker et al. (1996), CT 3 Years Curriculum Approach &
USA, National Heart, family education.
Lung, and Blood Institute

(Continued)

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Table 1. (Continued)
Authors Dominant Theory
Framework &
Research design
Mangunkusumo et al.
(2007) The Netherlands,
Organisation for Health
Research and
Development
Muth (2008), USA,
American Medical
Association
Panunzio et al. (2007),
Italy
Parcel et al. (1989), USA,
National Heart, Lung, and
Blood Institute
Parmer (2009), USA
Perry et al. (1998), USA,
National Cancer Institute
Perry et al. (1985), USA
Powers et al. (2005), USA.
State Cooperative
Extension System and
State Department of
Human Resources
Quinn et al. (2003), USA,
Kappa Omicron Nu, Food
Bank of Central New York
Resnicow et al. (1998),
USA, National Heart, Lung
and Blood Institute
Reynolds et al. (2000),
USA, National Cancer
Institute Grant
Sahota et al. (2001), UK,
Northern and Yorkshire
Region Research and
Development Unit
Shannon and Chen
(1988), USA, Pennsylvania
State Department of
Education
Smolak et al. (1998), USA,
Ohio Dept of Education
Length of Treatment Strategy
CT 12 Weeks Internet-tailored advice &
dietary counselling
CT/SCT 12 Weeks Curriculum approach &
Train-the-trainer model
CT 36 Weeks Curriculum approach
CT/SLT 14 Weeks Curriculum approach: The
New School Lunch,
Children’s Active Physical
Education (CAPE), and Go
For Health classroom
instruction.
CT/ELT 28 Weeks Curriculum approach &
Experiential Learning
CT/SLT 40 Weeks The 5-a-Day Power Plus
Program, curricula
parental involvement &
Changes industry
involvement and support.
CT/SLT/PBT 10 Weeks Curriculum approach &
Friends program
CT/SCT 6 Weeks Pizza Please Board Game
& Nutrition education
CT 40 Weeks Experiential learning &
the support of parents
CT/SCT 6 Weeks Curriculum approach &
the teacher wellness
program
CT/SCT 2 Years High 5 intervention on FV
consumption based
around 3 interventions:
classroom component,
Parent component, Food
Service component.
CT 40 Weeks Active programme
promoting lifestyle in
schools (APPLES
program),
Multidisciplinary,
multiagency programme,
and physical activity &
Cross Curricular.
CT 3 Years Curriculum approach
CT 24 Weeks Curriculum approach
(Continued)
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Authors Dominant Theory Length of Treatment Strategy

Framework &
Research design
Spiegel & Foulk (2006), CT/TRA 24 Weeks Wellness, Academics &
USA, Institute for You (WAY) Program &
America’s Health Cross-curricular
Taylor et al. (2007), New CT 2 Years APPLE Project, physical
Zealand activity initiative, Cross
curricular school, & GoTri
card game
Velde et al. (2008), The CT/SCT 52 Weeks Pro-children intervention,
Netherlands, Norway, Curriculum approach &
Spain, Commission of Family web-based
European Communities feedback tool
(RTD) programme
Cohen et al. (2014), USA NR 1 Year Food Service Intervention
Purwani & Muwakhidah NR 3 Months Education through the
(2016), Indonesia media of Illustrated
storybooks and
demonstrations of
hazardous substance
tests on snacks
Emerson et al. (2017), NR 6 Months Power Plate Program
Norwood City School (PPP)
District, Ohio, USA.
Solikah (2018), Indonesia NR 1 Weeks Clean and Healthy
Behavior (PHBS)
Garden et al. (2020), the NR 4 Years Fruit and vegetable
West Midlands, UK. intake, physical activity
energy expenditure &
Dietary intake
Verdonschot et al. (2020), NR 6 Months FV provision + education
Netherlands and FV provision program
only
Ronitawati et al., (2020), NR 3 Weeks Educational counseling
Indonesia on balanced nutrition
guidelines, food ranger
games on balanced
nutrition and the
provision of “Isi Bekalku”
media which was
followed up with each
student bringing
provisions from home.
Verdonschot et al. (2021), NR 2 Years Cross-curricular
Netherlands and
Australia
Ibnu et al. (2021), NR 2 Months Emotional demonstration
Indonesia using the reference
module “EMO DEMO”.
Aydin et al. (2022), ST 1 Year The cooperation of
Australia parents and teachers
Magurno & Fenton SCT 6 Weeks Nutrition education
(2022). The Town of intervention
Webb Union Free School
District, New York, USA.
Notes: TPB = Theory of Planned Behaviour; SCT = Social Cognitive Theory; CDT = Cognitive Development Theory; SLT =
Social Learning Theory; BCT = Behavioural Choice Theory; CogT = Cognitive Theory; SDT = Self Determination Theory;
GST = Group Socialization Theory; ELT = Experiential Learning Theory; PBT = Problem Behaviour Theory; TRA = Theory
of Reasoned Action; ST: Stakeholder Theory; RCT = Randomised controlled trial; QE = Quasi experimental; CT = Cluster-
controlled trial; FV = Fruit and vegetable; NR= Not reported

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Figure 2. Geographic 35 31
distribution. 30
Notes: USA = United States of 25
America; UK: United Kingdom
20
15
10 8
5 3 3 4 4
1 1 2 1 2 1 1
1
0

Figure 3. Research design.

11

13

35

QE CT RCT mixed

healthy food to strengthen the immunity of elementary school students. These other sources come
from other references used to support primary data and identify words, sentences, statements, and
arguments related to this topic of study, thus finding the dominant strategy used to shape the
character of healthy living of students through healthy food to strengthen students’ immunity.

4. Results

4.1. Descriptive analysis

This review provides a descriptive analysis of the study. This includes geographical distribution, and
research design (Figure 2).

Most research on healthy living character-building strategies through healthy food for elemen­
tary school students was found in the United States of America, with 31 articles (Figure 2).
The second largest research concentration was found in the United Kingdom, with eight articles.
These findings indicate that the topic of this study is mostly limited to countries other than the
United States of America and the United Kingdom, including Indonesia, which is only four articles.
This suggests that this topic still needs to be developed in research.

Most of the research conducted in the literature is quantitative with a cluster-controlled trial
research design, contributing about 35 articles (Figure 3). A total of 13 articles from the research

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Figure 4. Strategy.

design were quasi-experimental, and one article each used a randomised controlled trial and
mixed. This indicates the need for further qualitative studies to be carried out.

4.2. Healthy living character building strategies

Eight dominant strategies for character-shaping healthy living address the predetermined areas of
healthy food for primary school students (food consumption/energy intake, consumption or pre­
ference of fruits and vegetables, consumption or preference of sugar, and nutritional knowledge).
Some studies include more than one of these teaching strategies in their intervention groups
(Figure 4).

Strategies for shaping the healthy living character of primary school students that are dominant
are: 1) An enhanced curriculum approach (i.e. a special nutrition education program outside the

Figure 5. Theory. 18 17

Notes: SCT = Social Cognitive 16

Theory; CDT = Cognitive
Development Theory; SLT = 14
Social Learning Theory; BCT =
12
Behavioural Choice Theory;
CogT = Cognitive Theory; TPB = 10 9
Theory of Planned Behaviour;
SDT = Self Determination 8 7
Theory; NR= Not reported; ELT
6
= Experiential Learning Theory;
PBT = Problem Behaviour 4
Theory; TRA = Theory of
Reasoned Action; ST: 2 1 1 1 1 1 1 1 1 1 1
Stakeholder Theory
0
SCT CDT SLT BCT CogT TPB SDT NR ELT PBT TRA ST n/a

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Figure 6. Length of treatment. 60

52

50 40

36
40
32
28
30 24
20
20 16 12
14
6 10 12
6 2
10 7 7 4 6
3 4 5 3 7 3
3 3 2 2 2 2 2 2 2 1
1 2 1 1 1 1 1 1 3 1 2
1 1 1 1
0
Weeks Months Years

existing health curriculum delivered by teachers or specialists); 2) a cross-curricular approach (i.e.

a nutrition education program delivered in two or more traditional primary school subjects); 3)
parental involvement (i.e. programs that require active participation or assistance from parents
inside or outside the school environment); 4) experiential learning approaches (i.e. school or
community garden activities, cooking and preparing meals); 5) a contingent reinforcement
approach (an award or incentive given to a student in response to a desired behavior); 6) an
approach to literary abstraction (i.e. literature read by/for children in which the character promotes
or exemplifies positive behavior); 7) a game-based approach (a board or card game played by
students at school designed to promote positive behavior and the learning of new knowledge);
and 8) a web-based approach (i.e. an internet-based resource or feedback mechanism accessible
to students at home or school).

4.3. Theory used in research on healthy character-building strategies

Figure 5 provides an overview of the theoretical perspective on healthy character-building strate­
gies through healthy living for healthy food for elementary school students.

In all, 16 theories were identified. The two theories commonly used in the literature include
social cognitive theory and social learning theory, while the ten theories are still little used in the
literature, including the theory of planned behaviour; cognitive development theory; behavioural
choice theory; cognitive theory; self-determination theory; group socialization theory; experiential
learning theory; problem behaviour theory; theory of reasoned action and stakeholder theory, and
nine studies do not use the theory dominated by Indonesia. The results of this review indicate that
many theories still need to be used for future research. The findings of this review also prove that
one of the dominant strategies used is experiential learning, but it is not supported by experiential
learning theory.

4.4. Duration of treatment in the implementation of a healthy character-building strategy

Based on Figure 6, it was found that the length of treatment was 40 weeks (curriculum approach,
cross-curricular, parental involvement, and experiential learning), six months (Power Plate Program
and fruit and vegetable provision), and six years (curriculum approach & literary abstraction).

5. Discussion
This study aims to identify and describe various intervention strategies for the healthy living
character of learners in promoting healthy food to strengthen students’ immunity. Based on the
content analysis approach, it was found that the application of the strategy cannot be done in
a single piece but must be mixed because it supports and complements each other. First,

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curriculum-based strategies are the most popular or better that can reduce food consumption or
energy intake results. In addition, other studies using experiential learning approaches (school/
community gardens, cooking lessons, and food preparation) reported results related to reducing
food consumption and energy intake. The study of first-graders aged 6–7 at three public elemen­
tary schools in Tokyo found that energy from healthy eating correlated with motor fitness in
children and their physical activity. These findings suggest that consuming a healthy diet that
includes whole grains, vegetables, fruits, dairy, fish and meat, and exercise habits is essential for
childhood motor fitness (Hatta et al., 2022).

Second, curriculum-based strategies are once again the most popular regarding fruit and
vegetable consumption or preference. The curriculum-based approach was statistically significant
in increasing fruit and vegetable consumption or preferences among children of primary school
age (Dudley et al., 2015). However, it is important to note that many studies that use a curriculum-
based approach also combine their interventions with secondary approaches (experience-learning
and parental involvement). The involvement of the person referred to in this study is communica­
tion between parents and teachers about lunch boxes, communication barriers and ways of
improving the communication of parent and teacher engagement, and parents’ expectations of
teachers, and especially schools need to prepare time allocations for children to have lunch (Aydin
et al., 2022). The results of previous studies showed that parents should supervise and teach
children about the dangers of consuming food carelessly so that children can distinguish foods
that are good for consumption at school (Nasution et al., 2021). Thus, at this stage, it is difficult to
determine the extent to which one’s curriculum-based approach contributes to forming a healthy
living character to strengthen the immunity of elementary school students.

Third, in primary school, enhanced curriculum strategies (based mainly on behavioral or social
cognitive theories) are required by students to reduce sugar consumption or sugar-laden drinks,
fruit juices or carbohydrate consumption. Furthermore, Taylor et al. (2007) found that cross-
curricular strategies by reducing the consumption of sugar or fruit juices can improve the healthy
living behaviors of elementary school students. Fourth, previous research also adopted
a curriculum approach that needs improvement to develop primary school children’s nutritional
knowledge. This suggests that quality curriculum interventions (largely based on behavioral or
social cognitive learning theory) can improve primary school students’ nutritional knowledge with
desired zones of effect (Hattie, 2009). In line with other studies (Reynolds et al., 2000; De Villiers
et al., 2016), another study showed that receiving an education led to a significant increase in
nutritional knowledge in primary school children. This increase in knowledge in children remains
significant over the long term and is in line with previous studies, which identified a significant
increase in the nutritional knowledge of primary school children after education. Increasing knowl­
edge can be done through fruit and vegetable advertisements—which effectively increase fruit and
vegetable consumption among children (Oke & Tan, 2022). The results of previous studies showed
that whether school food policy is implemented or not can affect the potential of fruit and
vegetable provision programs to affect the fruit and vegetable intake of primary school children.
The effectiveness of healthy living character programs through healthy food will increase if school
food policies are implemented (Verdonschot et al., 2020).

6. Conclusion
The results of this study show that many strategies can be used to shape the healthy living
character of primary school children that lead to positive changes in the nutritional knowledge
and behaviour of primary school children, especially healthy foods, to strengthen the immunity of
elementary school students. The most effective strategies to facilitate healthy eating in children’s
primary schools are improved curricula, cross-curricula, and experiential learning approaches.
These strategies must be mixed with other strategies, such as parental involvement.

The dominant theories used include social cognitive theory and social learning theory, while still
little used in the literature, namely the theory of planned behaviour; cognitive development theory;

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behavioural choice theory; cognitive theory; self-determination theory; group socialization theory;
experiential learning theory; problem behaviour theory; theory of reasoned action and stakeholder
theory. Finally, treatment lengths are categorized into 40 weeks, six months and six years.

The study’s results significantly contribute to policymakers, principals and teachers developing
a curriculum and integrating appropriate mixed strategies in improving students’ healthy life
character behaviour because it can strive for the quality of education and student outcomes.
This mixed strategy is made into a national program, created guidelines, disseminated, implemen­
ted, and evaluated gradually.

7. Agenda for future research

In a systematic review on healthy living character-building strategies of elementary school stu­
dents, we found that implementing strategies to improve the healthy living character of elemen­
tary school students cannot only use one strategy but must be a mix of strategies. The curriculum-
based approach is integrated with cross-curricular, experience-learning, and parental involvement.
Building a healthy living character in elementary schools needs to be supported by a mixed
strategy because each strategy complements the other. Future research needs to consider
mixed strategies so that there is a significant increase in healthy living character. Current research
is still dominated by social cognitive theory and social learning theory.

In contrast to that, other studies do not use theory. Future research needs to adopt theories that
are still rarely used, including behavioural choice theory, cognitive theory, theory of planned
behaviour, self-determination theory, problem behaviour theory, theory of reasoned action, and
stakeholder theory. Regarding the length of treatment, each strategy has its time duration. The
literature review found that the most widely used strategy, the curriculum approach, had two
different durations of time, 40 weeks, and six years. Thus, future research must use cultural
variables to measure timing based on context. Based on this, the research methods that can be
used are qualitative with case study approaches, phenomenology, site studies and ethnography.
This qualitative research method is still scarce in this research topic. Future research will be
interesting if studies examine comparisons between public and private schools to identify strategy
implementation effectiveness. Finally, geographical research in Indonesia related to this topic
needs to be followed up because it still needs to be improved.

Funding Correction
The work was supported by the KEMENTERIAN This article has been corrected with minor changes. These
PENDIDIKAN, KEBUDAYAAN, RISET, DAN TEKNOLOGI changes do not impact the academic content of the
DIREKTORAT JENDERAL PENDIDIKAN TINGGI, RISET, DAN article
TEKNOLOGI [0267/E5/AK.04/2022].
Citation information
Author details Cite this article as: Healthy living character-building stra­
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E-mail: ali.imron.fip@um.ac.id Mustiningsih Mustiningsih, Rochmawati Rochmawati,
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Mustiningsih Mustiningsih1 Kamilatun Nisa, Cogent Social Sciences (2023), 9:
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Rochmawati Rochmawati1
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