Implementing a multicomponent school-based obesity prevention intervention: a qualitative study

Examining associations between school-level determinants and the implementation of physical activity opportunities

School-based physical activity (PA) opportunities can help students engage in greater amounts of daily PA, meet PA guidelines, and lead to improved health and educational outcomes. However, we do not completely understand the organizational challenges to implementing these opportunities successfully. This exploratory study examined associations between school-level determinants and the implementation of school-based PA opportunities. We analyzed cross-sectional survey data from schools (n = 46) participating in the Healthy Zone School Program (HZSP) (Dallas, Texas, USA) during 2019-2020. Respondents completed an electronic survey that included measures of school-level determinants (e.g. culture, leadership, priority) and the implementation of school-based PA opportunities. We used linear regression models to examine associations between determinants and implementation outcomes (number of PA opportunities delivered, perceived overall success of each PA program/activity used). After adjusting for campus type (i.e. elementary, middle, high, K-12), student race/ethnicity, and percentage of economically disadvantaged students, no constructs were associated with the number of PA opportunities implemented. Linear regression models suggest access to knowledge and information (β = 0.39, P = .012, 95% CI = 0.24-1.44) and implementation climate (β = 0.34, P = .045, 95% CI = 0.02-1.59) were positively associated with the success of school-based PA opportunities. Our findings provide suggestive evidence that access to knowledge and information and a supportive school climate may improve the overall success of PA opportunities provided to students. Future research should examine additional school-level determinants to understand their importance to implementation and inform the development of strategies to improve schools' capacity for implementing PA opportunities successfully.

Using the R = MC2 heuristic to understand barriers to and facilitators of implementing school-based physical activity opportunities: a qualitative study

BACKGROUND

Schools are a key setting for supporting youth physical activity, given their broad reach and diverse student populations. Organizational readiness is a precursor to the successful implementation of school-based physical activity opportunities. The R = MC2 heuristic (Readiness = Motivation x Innovation-Specific Capacity x General Capacity) describes readiness as a function of an organization's motivation and capacity to implement an innovation and can be applied to better understand the implementation process. The purpose of this study was to explore the barriers to and facilitators of implementing school-based physical activity opportunities in the context of organizational readiness.

METHODS

We analyzed interview data from 15 elementary school staff (principals, assistant principals, physical education teachers, and classroom teachers) from a school district in Texas. We focused on factors related to adopting, implementing, and sustaining a variety of school-based physical activity opportunities. We used the Framework Method to guide the analysis and coded data using deductive (informed by the R = MC2 heuristic) and inductive approaches. Themes were generated using the frequency, depth, and richness of participant responses.

RESULTS

Four themes emerged from the data: (1) implementation is aided by the presence of internal and external relationships; (2) physical activity opportunities compete with other school priorities; (3) seeing the benefits of physical activity opportunities motivates school staff toward implementation; and (4) staff buy-in is critical to the implementation process. Themes 1-3 aligned with subcomponents of the R = MC2 heuristic (intra- and inter-organizational relationships, priority, and observability), whereas Theme 4 (staff buy-in) related to multiple subcomponents within the Motivation component but was ultimately viewed as a distinct construct.

CONCLUSION

Our results highlight and explain how key readiness constructs impact the implementation of school-based physical activity opportunities. They also highlight the importance of obtaining staff buy-in when implementing in the school setting. This information is critical to developing readiness-building strategies that help schools improve their capacity to deliver physical activity opportunities effectively.

TRIAL REGISTRATION

Not applicable.

Applying the Integrated Sustainability Framework to explore the long-term sustainability of nutrition education programmes in schools: a systematic review

OBJECTIVE

This review aimed to identify and synthesise the enablers and barriers that influence the long-term (≥ 2 years) sustainment of school-based nutrition programmes.

DESIGN

Four databases (PubMed, Cochrane Library, Embase and Scopus) were searched to identify studies reporting on the international literature relating to food and nutrition programmes aimed at school-age (5-14 years) children that had been running for ≥ 2 years (combined intervention and follow-up period). Eligible studies were analysed using the Integrated Sustainability Framework (ISF), which involved deductive coding of programme enablers and barriers. A quality assessment was completed, using the Mixed-Methods Appraisal Tool and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

SETTING

International school-based nutrition programmes.

SUBJECTS

Individuals involved with the implementation of school-based nutrition programmes.

RESULTS

From the 7366 articles identified, thirteen studies (seven qualitative, five mixed methods and one quantitative descriptive) were included, from which the enablers and barriers of eleven different nutrition-related programmes were analysed. Thirty-four factors across the five domains of the ISF were identified that influenced the sustained implementation of programmes. The most common barrier was a lack of organisational readiness and resources, whereas the most common enabler was having adequate external partnerships and a supportive environment.

CONCLUSIONS

These findings have application during the initiation and implementation phases of school-based nutrition programmes. Paying attention to the 'outer contextual factors' of the ISF including the establishment and maintenance of robust relationships across whole of government systems, local institutions and funding bodies are crucial for programme sustainment.

Application of an Implementation Framework Using Mixed Methods in Preschool Settings

Research Findings. Application of mixed methods in a dissemination and implementation framework can give researchers a better understanding of the reach and delivery of early childhood obesity prevention programs in preschool settings, as well as potential facilitators and barriers related to implementation and sustainability. This study utilized a simultaneous, exploratory, mixed-methods design to investigate individual-, organizational-, and intervention-level factors that were related to the implementation and sustainability of policy, system, and environment (PSE) changes as part of a larger obesity prevention program in a randomly selected sample of preschool centers (n = 20). Individual-level factors, and specifically the attitudes and skills of preschool providers, were identified in both the qualitative and quantitative data as important factors related to the sustainability of PSE changes (r = .56, p < .01). Staff and leadership engagement and adaptability of the program were also identified as important factors related to the implementation and sustainability of PSE changes. Practice or Policy. These findings highlight the complexity of implementation success and suggest PSE obesity prevention interventions in preschool centers require the consideration of numerous, multilevel factors to ensure programming is impactful and sustained over time.

Barriers and enablers to the implementation of school-based obesity prevention strategies in Jeddah, KSA

Introduction

Despite schools' recognised role in mitigating childhood overweight, many schools fail to implement physical activity or nutrition strategies. The current study explored the enablers and barriers to implementing obesity prevention strategies in Jeddah, KSA.

Methods

This research is based on 14 semi-structured interviews with intermediate school principals and sports teachers to gain insight into their perception of barriers and enablers to implementing obesity prevention strategies. Themes were deductively generated from the data.

Results

Participants estimated the prevalence of overweight and obesity among their students to be between 3 and 15% with an increasing trend, particularly among female students. Participants identified five categories of barriers to implementation of obesity prevention intervention: curriculum; schools strategies promoting healthy weight; lack of resources; student’s lifstyle; and a lack of teachers in nutrition and sports. School regulations, staff and sufficient resources were the most frequently reported enablers. Participants also identified food services, awareness, and partnerships as barriers and enablers.

Conclusion

There is a need for better infrastructure and financial support for schools and professional development opportunities for teachers from the Saudi Ministry of Education. The Ministry also needs to support the development of multilevel health promotion strategies at school and home and reach out to the broader community.

Domains of Capacity Building in Whole-Systems Approaches to Prevent Obesity-A "Systematized" Review

Despite increased awareness of its risks, for the most part, contemporary efforts for obesity prevention have been patchy at best. As such, the burgeoning interest in whole-systems approaches (WSAs) that acknowledge the complex, dynamic nature of overweight and obesity and operate across multiple levels of society is particularly timely. Many components of "community capacity building" (CB), an essential but often neglected aspect of obesity prevention, overlap with "best practice principles" in effective/optimal community-based obesity-prevention initiatives. Rhetoric urging WSAs and community CB in public health abounds although operative and efficacious contemporary examples of these approaches to reducing obesity levels are scarce. The aim of this investigation was to undertake a systematized review of the level of capacity building incorporated in published literature on WSAs targeting obesity to better understand how domains of CB have been incorporated. A PubMed search and a recently published systematic review were utilized to identify WSAs to obesity prevention between 1995-2020. A team-based approach to qualitative thematic data analysis was used to systematically assess and describe each intervention regarding explicit capacity-building practice. Despite not being specifically designed for building capacity, a significant proportion of the WSAs studied in the current report had implemented several CB domains.

Implementation Factors and Teacher Experience of the Integrated Nutrition Education Program: A Mixed Methods Program Evaluation

BACKGROUND

School-based programs are widely implemented to address childhood obesity. Despite the promise of these programs, evidence on their effectiveness is mixed. Adopting a dissemination and implementation (D&I) science focus utilizing mixed methods can provide a broader understanding and more robust details about these programs. The goal of this evaluation is to understand how implementation factors and teacher experience influence implementation success and outcomes of the Integrated Nutrition Education Program (INEP), an elementary school-based nutrition program, using a mixed-methods design.

METHODS

Reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework guided the development of the evaluation and multiple methods were deployed. Hierarchical linear regression was used to assess the association between D&I construct variables within levels of influence and teacher perception of INEP impact from a quantitative end-of-year teacher survey. Follow-up qualitative interviews with teachers were analyzed using constant comparison analysis.

RESULTS

Workload and burden emerged as significant factors related to implementation in the quantitative analysis. The follow-up qualitative data collection identified other factors teachers found important to the adoption, implementation, and maintenance of INEP.

CONCLUSION

Results of this evaluation can be used to inform program improvement efforts for INEP and provide information on ways to promote reach, effectiveness, adoption, implementation, and maintenance of similar school-based health promotion programs.

Understanding the experience of the implementer: teachers' perspectives on implementing a classroom-based nutrition education program

School-based programs are widely implemented to combat childhood obesity, but these programs have mixed results. Dissemination and implementation science approaches to evaluation using qualitative methods can provide more robust details about program functioning that may be able to help explain the variation in the impact of these programs. Fourteen in-depth interviews were conducted with classroom teachers implementing a school-based program, the Integrated Nutrition Education Program (INEP), to explore their experience. Factors related to organization, individual and intervention levels emerged as facilitators and barriers to program implementation. Key factors were school culture at the organization level, individual perception and belief in the intervention at the individual level and program content, perceived complexity and adaptability at the intervention level. Socioeconomic status of the community and family involvement were contextual factors identified across all levels. Findings from this qualitative evaluation can be used for the quality improvement of INEP, but beyond this these can also be informative for other school-based programs to promote adoption, implementation and maintenance.

Process evaluation of the Centrally Procured School Food Program (CPSFP) in Ontario, Canada: school-level perspectives

This study explored the implementation of the Centrally Procured School Food Program (CPSFP)-a free, universal, volunteer-led snack program for elementary school children. To assess participants' perceptions and experiences with the CPSFP, interviews were conducted in school-level participants (n = 33) using a semi-structured interview guide. Fifteen on-site visits also were conducted at each school to observe implementation practices. Quantitative data were obtained through a general information form where participants provided school characteristics and weekly logbooks where they described program operations and food quality. Most participants expressed positive perceptions of the CPSFP, identifying it as a valuable program for their students. Successful program implementation was associated with an appreciation for the CPSFP and the participation of the school community. Challenges to program implementation included concerns with the volume and types of food provided, issues with classroom food delivery and distribution and communication challenges. Suggestions for improvement included building capacities and enhancing student engagement in the program. Participants provided an in-depth assessment of the implementation of the CPSFP. The lessons learned and suggestions provided may help not only enhance the reach, feasibility and fidelity of the CPSFP, but inform the best practices for similar programs.

Implementation Leadership in School Nutrition: A Qualitative Study

OBJECTIVE

This paper identifies implementation leadership characteristics in the school nutrition setting and places findings in the context of implementation leadership literature.

METHODS

Fourteen interviews were conducted with school district leadership/staff in an urban school district. Modified grounded theory was employed.

RESULTS

Four themes emerged: (1) understanding of technical/operational intervention details; (2) ability to proactively develop and communicate plans; (3) supervisory oversight; and (4) intervention framing. Themes were consistent with 4 of the 5 dimensions comprising the Implementation Leadership Scale: knowledgeable, proactive, perseverant, and distributed leadership. The supportive domain was not a major finding. An additional domain, how leaders message the intervention to staff, was identified.

CONCLUSIONS AND IMPLICATIONS

Implementation leadership in school nutrition appears similar, but not identical, to leader behaviors present in the Implementation Leadership Scale. School nutrition leaders might consider involving staff early in implementation planning, incorporating technical expertise, and clearly communicating the intervention purpose to support successful implementation. Future research might explore the interplay between leadership and implementation outcomes.

Barriers and facilitators influencing the sustainment of health behaviour interventions in schools and childcare services: a systematic review

Background

Sustainment has been defined as the sustained use or delivery of an intervention in practice following cessation of external implementation support. This review aimed to identify and synthesise factors (barriers and facilitators) that influence the sustainment of interventions (policies, practices, or programmes) in schools and childcare services that address the leading risk factors of chronic disease.

Methods

Seven electronic databases and relevant reference lists were searched for articles, of any design, published in English, from inception to March 2020. Articles were included if they qualitatively and/or quantitatively reported on school or childcare stakeholders’ (including teachers, principals, administrators, or managers) perceived barriers or facilitators to the sustainment of interventions addressing poor diet/nutrition, physical inactivity, obesity, tobacco smoking, or harmful alcohol use. Two independent reviewers screened texts, and extracted and coded data guided by the Integrated Sustainability Framework, an existing multi-level sustainability-specific framework that assesses factors of sustainment.

Results

Of the 13,158 articles identified, 31 articles met the inclusion criteria (8 quantitative, 12 qualitative, 10 mixed-methods, and 1 summary article). Overall, 29 articles were undertaken in schools (elementary n=17, middle n=3, secondary n=4, or a combination n=5) and two in childcare settings. The main health behaviours targeted included physical activity (n=9), diet (n=3), both diet and physical activity (n=15), and smoking (n=4), either independently (n=1) or combined with other health behaviours (n=3). Findings suggest that the majority of the 59 barriers and 74 facilitators identified to impact on intervention sustainment were similar across school and childcare settings. Factors predominantly relating to the ‘inner contextual factors’ of the organisation including: availability of facilities or equipment, continued executive or leadership support present, and team cohesion, support, or teamwork were perceived by stakeholders as influential to intervention sustainment.

Conclusions

Identifying strategies to improve the sustainment of health behaviour interventions in these settings requires a comprehensive understanding of factors that may impede or promote their ongoing delivery. This review identified multi-level factors that can be addressed by strategies to improve the sustainment of such interventions, and suggests how future research might address gaps in the evidence base.

Trial registration

This review was prospectively registered on PROSPERO: CRD42020127869, Jan. 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01134-y.

An exploration of constructs related to dissemination and implementation of an early childhood systems-level intervention

Obesity and overweight in early childhood have detrimental impacts on children's health and development. Changing policy, system and environmental features focused on physical activity and healthy eating behaviors as part of health promotion interventions can play a key role in prevention strategies in early childhood education settings. These types of changes can have broad reach and are often sustained over time, which allows for impact on children who enter the early childhood education setting year after year. However, there is currently a gap between the generation of evidence for health promotion programs and their application into practice. This study used qualitative methods to evaluate intervention-, organizational- and individual-level factors within a dissemination and implementation framework that may be related to the implementation of a health-promoting intervention in early childhood education settings. Intervention-level factors, including feasibility and adaptability, organizational-level factors, including staff and leadership engagement, and individual-level factors, including attitudes, skills and knowledge, were identified as constructs that impacted the successful implementation of the intervention. These findings provide insight into core dissemination and implementation constructs that should be targeted by obesity prevention interventions in early childhood education settings to ensure maximum impact on sustainable behavior change.

Recommendations for Administrators' Involvement in School-Based Health Promotion: A Scoping Review

School administrator involvement is recognized as a key factor in the extent to which school health promotion programs and initiatives are successfully implemented. The aims of this scoping review are to: (a) Identify existing documents that contain recommendations regarding the involvement of school administrators in school-based health promotion; (b) distill and summarize the recommendations; (c) examine differences in the recommendations by targeted professional level, professional group, health promotion content focus, and by whether the recommendations are evidence-based or opinion-based; and (d) evaluate the research informing the recommendations. We drew upon the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines to conduct the review. Our team conducted a comprehensive literature search with no date or geographic restrictions from January 2018 through April 2018 using four electronic databases: Academic Search Complete, Google Scholar, Physical Education Index, and PubMed. Eligibility criteria included any online documents, in English, that contained recommendations targeting school administrators’ (e.g., principals, assistant principals, superintendents) involvement (e.g., support, endorsement, advocacy) in school health programming (e.g., physical activity, nutrition, wellness). The search yielded a total of 1225 records, which we screened by title, then by abstract, and finally by full text, resulting in 61 records that met inclusion criteria. Data (e.g., recommendations, targeted contexts, targeted administrators) from these records were extracted for a content analysis. Included records contained 80 distinct recommendations, which we summarized into three themes (Collaboration, Advocacy, and Support) using a content analysis. Separate content analyses revealed no qualitative differences in the recommendations by professional level, professional group, or content focus, or by whether the recommendations were evidence-based or opinion-based. Twenty-one of the included records were peer-reviewed research articles. Using the Mixed Methods Appraisal Tool (MMAT), we appraised qualitative research articles the highest and mixed methods research articles the lowest. This review provides a basis for future research and professional practice aiming to increase school administrators’ involvement in school-based health promotion.

Designing, implementing and evaluating an educational intervention targeting weight bias and fat stereotyping

Weight bias directed at individuals at a higher weight leaves them feeling victimised and judged. When possessed by health professionals, stigmatising attitudes may compromise professionalism and quality of care or education provided. An intervention study was conducted in the higher education setting (n = 124), through tailored course design and delivery. The intervention was embedded into a health elective that pre-service health professionals were enrolled in. Attitudes to weight and knowledge of nutrition were targeted simultaneously. Surveys conducted pre- and post-intervention revealed moderate success in achieving study aims of improving nutrition knowledge and decreasing bias. Focus group analyses supported the quantitative findings.

Randomised study demonstrates sustained benefits of a pre-school intervention designed to improve nutrition and physical activity practices

BACKGROUND

Health-promoting programmes must demonstrate sustained efficacy in order to make a true impact on public health. This study aimed to determine the effect of the Healthy Incentive for Pre-schools project on health-promoting practices in full-day-care pre-schools 18 months after a training intervention.

METHODS

Thirty-seven pre-schools completed the initial study and were included in this follow-up study. The intervention consisted of one training session with either the pre-school 'manager-only' or 'manager and staff' using a specifically developed needs-based training resource pack comprised of written educational material and a validated health-promoting practice evaluation tool. Direct observation data of health-promoting practices were collected and allocated a score using the evaluation tool by a research dietitian at three time points; pre-intervention, between 6 and 9 months post-intervention and at 18-month follow-up. An award system was used to incentivise pre-schools to improve their scores.

RESULTS

Health-promoting practice scores improved significantly (P < 0.001) from the 6-9 month post-intervention to the 18-month follow-up evaluation. No significant differences were observed between 'manager-only' and 'manager and staff' trained pre-schools.

CONCLUSIONS

The introduction of a pre-school evaluation tool supported by a training resource was successfully used to incentivise pre-schools to sustain and improve health-promoting practices 18 months after intervention training.

Implementation Science and Nutrition Education and Behavior: Opportunities for Integration

Implementation science (IS) is the study of approaches designed to increase adoption and sustainability of research evidence into routine practice. This article provides an overview of IS and ideas for its integration with nutrition education and behavior practice and research. Implementation science application in nutrition education and behavior practice can inform real-word implementation efforts. Research opportunities include advancing common approaches to implementation measurement. In addition, the article provides suggestions for future studies (eg, comparative effectiveness trials comparing implementation strategies) to advance the knowledge base of both fields. An example from ongoing research is included to illustrate concepts and methods of IS.

Barriers and facilitators to adoption, implementation and sustainment of obesity prevention interventions in schoolchildren- a DEDIPAC case study

BACKGROUND

The aim of the study was to explore the implementation of school based diet and physical activity interventions with respect to the barriers and facilitators to adoption, implementation and sustainability; supportive actions required for implementation and recommendations to overcome identified barriers. Two interventions rolled out nationally in Ireland were chosen; Food Dudes, a programme to encourage primary school children to consume more fruit and vegetables and Green Schools Travel (GST), an active travel to school programme in primary and secondary schools. Trained school coordinators (teachers) cascade the programmes to other teaching staff.

METHODS

Multiple case study design using qualitative semi-structured interviews with key stakeholders: primary and secondary school teachers, school coordinators, project coordinators/managers, funders and intermediaries. Fifteen interviews were conducted. Data were coded using a common categorization matrix. Thematic analysis was undertaken using the Adoption, Implementation and Maintenance elements of the RE-AIM implementation framework.

RESULTS

Good working relationships within and across government departments, intermediaries and schools were critical for intervention adoption, successful implementation and sustainability. Organisational and leadership ability of coordinators were essential. Provision of participation incentives acted as motivators to engage children's interest. A deep understanding of the lives of the target children was an important contextual factor. The importance of adaptation without compromising core components in enhancing intervention sustainability emerged. Successful implementation was hindered by: funding insecurity, school timetable constraints, broad rather than specific intervention core components, and lack of agreement on conduct of programme evaluation. Supportive actions for maintenance included ongoing political support, secure funding and pre-existing healthy lifestyle policies.

CONCLUSIONS

Successful implementation and scale up of public health anti-obesity interventions in schools is dependent on good contextual fit, engagement and leadership at multiple levels and secure funding. Recommendations to overcome barriers include: capacity to deliver within an already overcrowded curriculum and clear specification of intervention components within a conceptual framework to facilitate evaluation. Our findings are generalisable across different contexts and are highly relevant to those involved in the development or adaptation, organisation or execution of national public health interventions: policy makers, guidelines developers, and staff involved in local organisation and delivery.

Behavior change is not one size fits all: psychosocial phenotypes of childhood obesity prevention intervention participants

Variability in individuals' responses to interventions may contribute to small average treatment effects of childhood obesity prevention interventions. But, neither the causes of this individual variability nor the mechanism by which it influences behavior are clear. We used qualitative methods to characterize variability in students' responses to participating in a childhood obesity prevention intervention and psychosocial characteristics related to the behavior change process. We interviewed 18 students participating in a school-based curriculum and policy behavior change intervention. Descriptive coding, summary, and case-ordered descriptive meta-matrices were used to group participants by their psychosocial responses to the intervention and associated behavior changes. Four psychosocial phenotypes of responses emerged: (a) Activated-successful behavior-changers with strong internal supports; (b) Inspired-motivated, but not fully successful behavior-changers with some internal supports, whose taste preferences and food environment overwhelmed their motivation; (c) Reinforced-already practiced target behaviors, were motivated, and had strong family support; and (d) Indifferent-uninterested in behavior change and only did target behaviors if family insisted. Our findings contribute to the field of behavioral medicine by suggesting the presence of specific subgroups of participants who respond differently to behavior change interventions and salient psychosocial characteristics that differentiate among these phenotypes. Future research should examine the utility of prospectively identifying psychosocial phenotypes for improving the tailoring of nutrition behavior change interventions.

Sustaining obesity prevention in communities: a systematic narrative synthesis review

Obesity is a global problem for which sustainable solutions are yet to be realized. Community-based interventions have improved obesity-related behaviours and obesity in the short term. Few papers have explored how to make the interventions and their intended outcomes sustainable. The aim of this paper is to identify factors that contribute to the sustainability of community-based obesity prevention interventions and their intended outcomes. A systematic narrative synthesis review was conducted of published community-based obesity prevention interventions to identify factors contributing to intervention sustainability. Data extracted were included study authors' perspectives of intervention success and sustainability. Eighty-one papers met the inclusion criteria, and from these we identified ten factors that contribute to sustainability: resourcing, leadership, workforce development, community engagement, partnerships, policy, communications, adaptability, evaluation and governance. This review of community-based obesity prevention interventions gives rise to optimism that sustainable change is possible. We propose a framework to help practitioners build sustainability into their interventions and report on them so that others can also benefit.

The Influence of Organizational Culture on School-Based Obesity Prevention Interventions: A Systematic Review of the Literature

BACKGROUND

Although the influence of organizational culture has been examined on a variety of student outcomes, few studies consider the influence that culture may have on school-based obesity prevention interventions. We present a systematic review of the literature to examine how elements of organizational culture may affect the adoption, implementation, and sustainability of school-based obesity prevention interventions.

METHODS

Fourteen studies examining the impact of organizational-level characteristics on school-based obesity prevention interventions were identified through the online databases EBSCO (CINAHL, ERIC, Agricola), Web of Science, Medline (PubMed), and Scopus.

RESULTS

Five themes were identified as elements of organizational culture that influence the adoption, implementation, and sustainability of school-based obesity prevention interventions: organizational response to limited resources, value placed on staff training and professional development, internal support, organizational values, and school climate.

CONCLUSIONS

Organizational culture can greatly influence the success of school-based obesity interventions. The collection of data related to organizational-level factors may be used to identify strategies for creating and sustaining a supportive environment for obesity prevention interventions in the school setting.

A Mixed-Methods Comparison of Classroom Context During Food, Health & Choices, a Childhood Obesity Prevention Intervention

BACKGROUND

Schools are frequent settings for childhood obesity prevention; however, intervention results are mixed. Classroom context may hold important clues to improving these interventions.

METHODS

We used mixed methods to examine classroom context during a curriculum intervention taught by trained instructors in fifth grade classrooms. We identified classrooms with high and low buy-in using cluster analysis and compared intervention delivery and reception, student energy balance-related behavior, and student perceptions about supports and barriers to energy balance.

RESULTS

Delivery and reception did not differ between the groups. Between-group differences in unhealthy behaviors were smaller at posttest, due to improvement in low buy-in classes. Although student perceptions of supports and barriers to energy balance were similar across groups, students in high buy-in classes indicated food preferences as a support while students in low buy-in classes indicated food preferences as a barrier. Neighborhood environment emerged as a universal barrier.

CONCLUSIONS

Trained instructors may improve intervention delivery and reception regardless of classroom context. Social norms could explain high levels of unhealthy behavior in low buy-in classes at baseline; improvement at posttest suggests that the curriculum may have motivated change. All children need more strategies and supportive policies to overcome a challenging food environment.

Factors That Impact the Success of Interorganizational Health Promotion Collaborations: A Scoping Review

OBJECTIVE

To explore published empirical literature in order to identify factors that facilitate or inhibit collaborative approaches for health promotion using a scoping review methodology.

DATA SOURCE

A comprehensive search of MEDLINE, CINAHL, ScienceDirect, PsycINFO, and Academic Search Complete for articles published between January 2001 and October 2015 was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

STUDY INCLUSION AND EXCLUSION CRITERIA

To be included studies had to: be an original research article, published in English, involve at least 2 organizations in a health promotion partnership, and identify factors contributing to or constraining the success of an established (or prior) partnership. Studies were excluded if they focused on primary care collaboration or organizations jointly lobbying for a cause.

DATA EXTRACTION

Data extraction was completed by 2 members of the author team using a summary chart to extract information relevant to the factors that facilitated or constrained collaboration success.

DATA SYNTHESIS

NVivo 10 was used to code article content into the thematic categories identified in the data extraction.

RESULTS

Twenty-five studies across 8 countries were identified. Several key factors contributed to collaborative effectiveness, including a shared vision, leadership, member characteristics, organizational commitment, available resources, clear roles/responsibilities, trust/clear communication, and engagement of the target population.

CONCLUSION

In general, the findings were consistent with previous reviews; however, additional novel themes did emerge.

Assessing the sustainability of daily chlorhexidine bathing in the intensive care unit of a Veteran's Hospital by examining nurses' perspectives and experiences

BACKGROUND

Daily bathing with chlorhexidine gluconate (CHG) of intensive care unit (ICU) patients has been shown to reduce healthcare-associated infections and colonization by multidrug resistant organisms. The objective of this project was to describe the process of daily CHG bathing and identify the barriers and facilitators that can influence its successful adoption and sustainability in an ICU of a Veterans Administration Hospital.

METHODS

We conducted 26 semi-structured interviews with a convenience sample of 4 nurse managers (NMs), 13 registered nurses (RNs) and 9 health care technicians (HCTs) working in the ICU. We used qualitative content analysis to code and analyze the data. Dedoose software was used to facilitate data management and coding. Trustworthiness and scientific integrity of the data were ensured by having two authors corroborate the coding process, conducting member checks and keeping an audit trail of all the decisions made.

RESULTS

Duration of the interviews was 15 to 39 min (average = 26 min). Five steps of bathing were identified: 1) decision to give a bath; 2) ability to give a bath; 3) decision about which soap to use; 4) delegation of a bath; and 5) getting assistance to do a bath. The bathing process resulted in one of the following three outcomes: 1) complete bath; 2) interrupted bath; and 3) bath not done. The outcome was influenced by a combination of barriers and facilitators at each step. Most barriers were related to perceived workload, patient factors, and scheduling. Facilitators were mainly organizational factors such as the policy of daily CHG bathing, the consistent supply of CHG soap, and support such as reminders to conduct CHG baths by nurse managers.

CONCLUSIONS

Patient bathing in ICUs is a complex process that can be hindered and interrupted by numerous factors. The decision to use CHG soap for bathing was only one of 5 steps of bathing and was largely influenced by scheduling/workload and patient factors such as clinical stability, hypersensitivity to CHG, patient refusal, presence of IV lines and general hygiene. Interventions that address the organizational, provider, and patient barriers to bathing could improve adherence to a daily CHG bathing protocol.

Testing an Integrated Model of Program Implementation: the Food, Health & Choices School-Based Childhood Obesity Prevention Intervention Process Evaluation

Childhood obesity is a complex, worldwide problem. Significant resources are invested in its prevention, and high-quality evaluations of these efforts are important. Conducting trials in school settings is complicated, making process evaluations useful for explaining results. Intervention fidelity has been demonstrated to influence outcomes, but others have suggested that other aspects of implementation, including participant responsiveness, should be examined more systematically. During Food, Health & Choices (FHC), a school-based childhood obesity prevention trial designed to test a curriculum and wellness policy taught by trained FHC instructors to fifth grade students in 20 schools during 2012-2013, we assessed relationships among facilitator behaviors (i.e., fidelity and teacher interest); participant behaviors (i.e., student satisfaction and recall); and program outcomes (i.e., energy balance-related behaviors) using hierarchical linear models, controlling for student, class, and school characteristics. We found positive relationships between student satisfaction and recall and program outcomes, but not fidelity and program outcomes. We also found relationships between teacher interest and fidelity when teachers participated in implementation. Finally, we found a significant interaction between fidelity and satisfaction on behavioral outcomes. These findings suggest that individual students in the same class responded differently to the same intervention. They also suggest the importance of teacher buy-in for successful intervention implementation. Future studies should examine how facilitator and participant behaviors together are related to both outcomes and implementation. Assessing multiple aspects of implementation using models that account for contextual influences on behavioral outcomes is an important step forward for prevention intervention process evaluations.

A Qualitative Exploration of Implementation Factors in a School-Based Mindfulness and Yoga Program: Lessons Learned from Students and Teachers

Identifying factors relevant for successful implementation of school-based interventions is essential to ensure that programs are provided in an effective and engaging manner. The perspectives of two key stakeholders critical for identifying implementation barriers and facilitators - students and their classroom teachers - merit attention in this context and have rarely been explored using qualitative methods. This study reports qualitative perspectives of fifth and sixth grade participants and their teachers of a 16-week school-based mindfulness and yoga program in three public schools serving low-income urban communities. Four themes related to program implementation barriers and facilitators emerged: program delivery factors, program buy-in, implementer communication with teachers, and instructor qualities. Feedback from students and teachers is discussed in the context of informing implementation, adaptation, and future development of school-based mindfulness and yoga programming in urban settings.

One size does not fit all-qualitative process evaluation of the Healthy School Start parental support programme to prevent overweight and obesity among children in disadvantaged areas in Sweden

Background

Parental support interventions have shown some effectiveness in improving children’s dietary and physical activity habits and preventing overweight and obesity. To date, there is limited research on barriers and facilitators of school-based parental support interventions targeting overweight and obesity. This study aimed to describe barriers and facilitators influencing implementation of the Healthy School Start (HSS) intervention in disadvantaged areas in Stockholm, Sweden, from the perspective of parents and teachers.

Methods

Focus groups and individual interviews with teachers (n = 10) and focus groups with parents (n = 14) in the intervention group of the HSS were undertaken, guided by the Consolidated Framework for Implementation Research (CFIR). Transcriptions were analysed using qualitative content analysis in two steps: deductive sorting in two domains of the CFIR (intervention characteristics and process), and subsequent inductive analysis.

Results

The overarching theme “tailoring the intervention to increase participant engagement” was found. Among teachers, barriers and facilitators were related to how the intervention was introduced, perceptions of the usefulness of the classroom material, preparation ahead of the start of the intervention, cooperation between home and school and children’s and parents’ active engagement in the intervention activities.

For parents, barriers and facilitators were related to the perceived relevance of the intervention, usefulness of the material, experiences of the Motivational Interviewing (MI) sessions, the family member targeted by the intervention, cooperation between home and school and parents’ ability to act as good role models.

Conclusion

It seems important to tailor the intervention to the abilities of the target group in order to increase participant engagement. Including activities that focus on parents as role models and cooperation between parents seems important to bring about changes in the home environment. It also appears important to include activities that target cooperation between home and school.