Factors influencing the adoption of a health promoting school approach in the province of Quebec, Canada

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.

Why Secondary Schools Do Not Implement Far-Reaching Smoke-Free Policies: Exploring Deep Core, Policy Core, and Secondary Beliefs of School Staff in the Netherlands

Background

Secondary schools that implement smoke-free policies are confronted with students who start smoking outside their premises. One solution is to complement smoke-free policies with prohibitions for all students to leave the school area during school hours, technically making school hours a smoke-free period. However, there are strikingly few Dutch secondary schools that implement this approach. This study explores why staff members in the Netherlands decide not to implement smoke-free school hours for all students.

Method

We interviewed 13 staff members, with different functions, from four secondary schools. The analysis was informed by the Advocacy Coalition Framework (ACF) to delve into the values, rationales, and assumptions of staff with the aim to identify deep core, policy core, and secondary beliefs.

Results

We identified six beliefs. Two deep core beliefs are that schools should provide adolescents the freedom to learn how to responsibly use their personal autonomy and that schools should only interfere if adolescents endanger or bother others. Three policy core beliefs identified included the following: that smoking is not a pressing issue for schools to deal with; that schools should demarcate their jurisdiction to intervene in adolescents’ lives in time, space, and precise risk behavior; and that implementing smoke-free school hours would interfere with maintaining positive student-staff relationships. One secondary belief identified was that smoke-free school hours would be impossible to enforce consistently.

Conclusion

This paper was the first to demonstrate the many beliefs explaining why schools refrain from voluntary implementing far-reaching smoke-free policies.

Understanding school staff members' enforcement of school tobacco policies to achieve tobacco-free school: a realist review

BACKGROUND

School tobacco policies (STPs) that aim to achieve a tobacco-free environment require consistent enforcement by school staff. However, little is known about why staff choose whether or not to enforce STPs. Therefore, we investigated staff members' responses to STPs that determine enforcement. Furthermore, we examined how these responses depend on contextual factors at the individual, interpersonal, school, implementation, and national levels.

METHODS

We performed a realist review (RR), which synthesizes existing primary evidence into a programme theory demonstrating key causal pathways through Context-Mechanism-Outcome configurations (CMOs). These CMOs link contextual factors to outcomes (i.e. staff enforcement) by explaining the underlying generative mechanisms (i.e. staff members' cognitive, psychosocial, and behavioural responses). A systematic literature search for the period 2000-2016 was performed using Academic Search Premier, PsycInfo, and MEDLINE. Forty English-language articles were identified for the synthesis.

RESULTS

Our programme theory demonstrated three CMOs: when contextual factors make staff members experience STP enforcement as part of their professional role and duties, it may lead to staff members showing responsibility for STP enforcement (CMO1); when contextual factors make staff members feel their contribution is leading to positive outcomes, it may lead to staff members showing motivation to enforce STPs (CMO2), and when contextual factors make staff members feel that they are able to deal with students' responses, it may lead to staff members showing confidence in STP enforcement (CMO3). Moreover, the programme theory provided more precise insights into what contextual factors contribute to triggering the individual mechanisms and the consequent outcomes.

CONCLUSIONS

By applying a realist approach, we have been able to detect three CMOs explaining staff members' STP enforcement. The findings provide useful insights explaining how stakeholders can support staff members' STP enforcement and consequently improve the impact of STPs on adolescent smoking.

Culture matters: a case of school health promotion in Canada

Rising concerns of poor health behaviours of children and youth have stimulated international support for a comprehensive approach to promoting the development of healthy behaviours in the early years. Health promoting schools (HPS) is increasingly adopted as an approach to guide supportive practices, but there is limited research that has reported how to effectively implement HPS at a population level. The purpose of this research was to qualitatively explore the factors preventing and facilitating implementation of HPS practices in the Canadian province of Nova Scotia. Interviews (n = 23) were conducted with school stakeholders (principals, teachers and parents) from a diverse sample of schools (n = 9) and data were analysed to develop an understanding of how school circumstances and experiences influenced HPS implementation. At a broad level, the reported barriers were structural and systemic, whereas the facilitating factors were related to organizational capacity and political leadership. It was evident that implementing and sustaining HPS required a shift in values and integration of supportive school health practices into school priorities. The results suggest that, without addressing the competing culture, which is persistently reinforced by strict academic mandates and unhealthy community norms, HPS will be vulnerable to circumstances that prevent implementation. Considering the emerging importance of mental wellbeing, it will also be important to provide schools with adequate and appropriate staff capacity and support to address this issue. Sustaining the positive effects of HPS will require continuous engagement and collaboration with multiple stakeholders to embed health promotion into school community norms.

The development and pilot testing of a multicomponent health promotion intervention (SEHER) for secondary schools in Bihar, India

BACKGROUND

Schools can play an important role in health promotion by improving students' health literacy, attitudes, health-related behaviours, social connection and self-efficacy. These interventions can be particularly valuable in low- and middle-income countries with low health literacy and high burden of disease. However, the existing literature provides poor guidance for the implementation of school-based interventions in low-resource settings. This paper describes the development and pilot testing of a multicomponent school-based health promotion intervention for adolescents in 75 government-run secondary schools in Bihar, India.

METHOD

The intervention was developed in three stages: evidence review of the content and delivery of effective school health interventions; formative research to contextualize the proposed content and delivery, involving intervention development workshops with experts, teachers and students and content analysis of intervention manuals; and pilot testing in situ to optimize its feasibility and acceptability.

RESULTS

The three-stage process defined the intervention elements, refining their content and format of delivery. This intervention focused on promoting social skills among adolescents, engaging adolescents in school decision making, providing factual information, and enhancing their problem-solving skills. Specific intervention strategies were delivered at three levels (whole school, student group, and individual counselling) by either a trained teacher or a lay counsellor. The pilot study, in 50 schools, demonstrated generally good acceptability and feasibility of the intervention, though the coverage of intervention activities was lower in the teacher delivery schools due to competing teaching commitments, the participation of male students was lower than that of females, and one school dropped out because of concerns regarding the reproductive and sexual health content of the intervention.

CONCLUSION

This SEHER approach provides a framework for adolescent health promotion in secondary schools in low-resource settings. We are now using a cluster-randomized trial to evaluate its effectiveness and cost-effectiveness.

Implementing the health promoting school in Denmark: a case study

Purpose

– The purpose of this paper is to provide insight into teachers’ practice in implementing school-based health promotion.

Design/methodology/approach

– This qualitative research was designed as a multiple case study. The study involved five schools, 233 pupils in the age 12-16 and 23 teachers. The primary data generation method were focus groups.

Findings

– According to the national guidelines the health education in primary schools in Denmark should be based on the critical approach to health education developed within the European Network of Health Promoting Schools. However, the study showed that teachers’ implementation of the guidelines in practice was closer to traditional health education, which focuses only lifestyle change, than to critical health education which also explores the underlying conditions for health.

Research limitations/implications

– The study explored teachers’ implementation practices, and the individual and institutional factors that influence the practice. This paper restricts itself to examining teachers’ practice against the national curriculum guidelines.

Practical implications

– The teachers were not sufficiently familiar with the curriculum guidelines or the critical approach to health education. The inclusion of the national curriculum and the principles of critical health education in the initial and in-service professional development of teachers is an urgent priority if this gap is to be reduced.

Originality/value

– This paper contributes to the debate related to the potentials and barriers for implementing of health promotion interventions in a school context.

Lessons learned from the AFLY5 RCT process evaluation: implications for the design of physical activity and nutrition interventions in schools

Background

Systematic reviews have highlighted that school-based diet and physical activity (PA) interventions have had limited effects. This study used qualitative methods to examine how the effectiveness of future primary (elementary) school diet and PA interventions could be improved.

Methods

Data are from the Active For Life Year 5 (AFLY5) study, which was a cluster randomised trial conducted in 60 UK primary schools. Year 5 (8–9 years of age) pupils in the 30 intervention schools received a 12-month intervention. At the end of the intervention period, interviews were conducted with: 28 Year 5 teachers (including 8 teachers from control schools); 10 Headteachers (6 control); 31 parents (15 control). Focus groups were conducted with 70 year 5 pupils (34 control). Topics included how the AFLY5 intervention could have been improved and how school-based diet and PA interventions should optimally be delivered. All interviews and focus groups were transcribed and thematically analysed across participant groups.

Results

Analysis yielded four themes.

Child engagement: Data suggested that programme success is likely to be enhanced if children feel that they have a sense of autonomy over their own behaviour and if the activities are practical.

School: Finding a project champion within the school would enhance intervention effectiveness. Embedding diet and physical activity content across the curriculum and encouraging teachers to role model good diet and physical activity behaviours were seen as important.

Parents and community: Encouraging parents and community members into the school was deemed likely to enhance the connection between schools, families and communities, and “create a buzz” that was likely to enhance behaviour change.

Government/Policy: Data suggested that there was a need to adequately resource health promotion activity in schools and to increase the infrastructure to facilitate diet and physical activity knowledge and practice.

Discussion and Conclusions

Future primary school diet and PA programmes should find ways to increase child engagement in the programme content, identify programme champions, encourage teachers to work as role models, engage parents and embed diet and PA behaviour change across the curriculum. However, this will require adequate funding and cost-effectiveness will need to be established.

Trial registration

ISRCTN50133740

“Change in schools it’s more like sort of turning an oil tanker”

Purpose

– The purpose of this paper is to add to the evidence of best practice in the implementation of the Health Promoting Schools (HPS) framework by examining the process of creating readiness for change in a large international school in South-East Asia. Using a settings-based approach and guided by readiness for change theory the data collected reflects which factors were most influential in the decision of the leadership team (LT) to adopt a comprehensive HPS model. It follows the process of creating readiness in the early stages of adopting a HPS approach and captures the critical factors effecting leader’s beliefs and support for the program.

Design/methodology/approach

– This research is a case study of a large pre-K-12 international school in South-East Asia with over 1,800 students. A mixed methods qualitative approach is used including semi-structured interviews and document analysis. The participants are the 12 members of the LT.

Findings

– Readiness for change was established in the LT who adopted a HPS approach. That is, they adopted a comprehensive model to address health-related priorities in the school and changed the school’s mission and accountability processes to specifically include health. Uncovering the reasons why the LT supported this change was the primary focus of this research. Building the motivation to change involved establishing a number of key beliefs three of which were influential in bringing about readiness for change in this case study. These included the belief that leadership support existed for the proposed change, a belief that there was a need for change with a clear discrepancy in the present and preferred operations in relation to addressing the health issues of the school and the belief that HPS was the appropriate solution to address this discrepancy.

Research limitations/implications

– Adopting a HPS approach is the first phase of implementation. Long-term research may show if the integrity of the chosen model is maintained as implementation continues. The belief construct of valence, that is, the belief that the change will benefit the change recipient, was not reliably assessed in this research. Further research needs to be conducted to understand how this construct is interpreted in the school setting. The belief construct of valence was not reliably assessed in this research. Further research needs to be done to understand how this construct fits in the school setting.

Practical implications

– This paper provides a promising example of how health can be integrated into the school’s Mission and Strategic Learning Plan. The example presented here may provide strategies for others working in the field of HPS.

Originality/value

– Creating readiness is an often over-looked stage of building sustainable change. International schools cater to more than three million students are a rarely researched in regards to health education. It is predicted that the numbers of students in international schools will grow to more than six million in the next ten years.

Data for action: the use of formative research to design a school-based intervention programme to increase physical activity in adolescents

Formative research is a critical step for the development of interventions aimed at changing behaviours, as is the case of physical activity. This process permits obtaining detailed information about the programme application context. 'Follow the Footstep' is a quasi-experimental and longitudinal study in secondary schools, the aim of which is to increase levels of physical activity among adolescents. To inform the design of the intervention programme, formative research has been carried out to analyse the perceptions of parents, teachers and students, through six focus groups.The social-ecological model was used both to carry out the formative research and then to design the programme, including five levels of influence on behaviour (individual, interpersonal, organizational, community and political), which are important when it comes to adopting a comprehensive intervention approach. The authors describe how the results of formative research were transferred to guide the design and development of the intervention. As results indicate, parents, teachers and students agreed on a need to intervene by engaging adolescents and their close social environment. The school centre is the key organizational structure to implement this intervention, supported by professionals and the community.

L’appropriation par les primo-adoptants de l’Approche École en santé au Quebec

L’ Approche École en santé (AÉS) est une approche globale de promotion de la santé inspirée des principes des « Health Promoting Schools » (écoles promotrices de santé). L’AÉS est associée à un dispositif d’accompagnement des écoles volontaires pour l’implanter qui comporte des ressources professionnelles d’accompagnement et divers outils. Le présent article rend compte des résultats d’une recherche qualitative portant sur l’appropriation locale de cette approche par des écoles ayant participé à la première vague d’implantation au Québec. Après avoir exposé le contexte, la méthodologie et le cadre théorique de l’étude, nous présenterons les appropriations locales observées, et ce qui semble les avoir conditionnées, du point de vue des acteurs.

Barriers and facilitators to the promotion of healthy eating lifestyles among adolescents at school: the views of school health coordinators

This study evaluates the perceptions of teachers in charge of coordinating health education in schools: the School Health Coordinators (SHCs). It addresses the success and barriers of the development and implementation regarding the first year of healthy eating programmes in their schools. This research is based on 16 face-to-face semi-structured interviews with SHCs from Portuguese public schools offering from fifth to ninth grades. A thematic analysis was performed and themes were identified, taking into consideration similarities and differences among the participants' opinions. The results showed that the schools in this study often involved a set of separate healthy diet promotion activities with a low level of joint effort from all members of the school. Nevertheless, in Portugal, health education is based on the broad concept that school health promotion is compulsory for all schools. Two main barriers were identified in order to explain this divergence: structural and political idiosyncrasies among schools and the food environment inside and outside the schools. The results are discussed considering the wide range of factors influencing young people's eating behaviours and recommendations are made for the different agents interacting with them in order to promote appropriate eating habits.

Schools' absorptive capacity to innovate in health promotion

PURPOSE

A comprehensive "health promoting schools" (HPS) approach is advocated by the World Health Organization to foster the health of students. To date, few studies have evaluated schools' capacity to implement it in an optimal way. The purpose of this paper is to present a conceptual framework that identifies core features likely to facilitate the incorporation of innovation, such as HPS, into school functioning.

DESIGN/METHODOLOGY/APPROACH

The framework was built by combining dimensions derived from two major strands of literature, i.e. management and HPS. It has taken root in Zahra and George's model of organisation absorptive capacity (AC) for new knowledge but has been adapted to better explore AC in a school context. The contrasting cases of two secondary schools that adopted a HPS approach in Quebec, Canada, for at least three years were used to illustrate the value of the framework.

FINDINGS

The framework proposed is a multidimensional model that considers components such as modulators, antecedents, integration mechanisms and strategic levers as potential determinants of AC, i.e. acquisition, assimilation, transformation and exploitation. The conceptual framework helped to qualify and compare AC regarding HPS in the two cases and holds promise to appreciate mechanisms having the greatest influence on it.

ORIGINALITY/VALUE

The framework can serve as a conceptual guide to facilitate the absorption of innovation in schools and to design future empirical research to better understand the underlying process by which schools strengthen their capacities to become settings conducive to the health of youth.

Professional development in the context of Healthy Schools in Quebec

This article reports preliminary research results on a professional development (PD) model as a mechanism for supporting absorption of the Healthy School (HS) approach into school functioning. The purpose of our study was to document the model implementation process and understand whether it influenced, or not, the accompanied actors' knowledge and practices about HS. The theoretical basis of the model and a description of its implementation, its appreciation by actors and its influence on their knowledge and confidence are presented. The research was conducted in three Quebec schools that had adopted this approach for at least 2 years. Multiple case study methodology, with pre- (T0) and post- (T1) intervention comparison, was adopted. The results disclose that the PD model implemented, which involves socio-constructivist accompaniment, has several assets that support the acquisition and application of new knowledge related to HS in order to promote its absorption within schools. Our findings indicate that PD likely reinforced the actors' knowledge and understanding as well as their confidence. The lessons drawn from the evaluation of this PD model could serve to enhance accompaniment methods implemented to promote the absorption of such initiatives in schools. Our data highlight the relevance and effectiveness of accompaniment anchored in action, calling for practice based on reflection and expert recommendations to meet the objectives of health and academic success.

Facilitating the implementation and efficacy of health-promoting schools via an action-research approach in Taiwan

Taiwan launched its evidence-based health-promoting school (HPS) program via an action-research approach in 2010. The program featured a collaborative partnership between schools, local education authorities and university support networks. This study was focused on examining whether an HPS action-research approach was effective in advancing HPS implementation, perceived HPS impact and perceived HPS efficacy in Taiwan. In 2011, questionnaires were sent to 900 sample schools in Taiwan. A total of 621 schools returned the questionnaire, including 488 primary schools and 133 middle schools. The response rate was 69%. This study compared the difference in HPS implementation status, perceived HPS impact and perceived HPS efficacy between those schools that had implemented action-research HPS (138 schools) and those that had not (483 schools). The univariate analysis results indicated that the HPS implementation levels for components that included school health policies, physical environment, social environment, teaching activities and school-community relations were significantly higher in action-research schools than in non-action-research schools. Teachers in action-research schools reported significantly higher levels of HPS impact and HPS efficacy than non-action-research schools. The multivariate analysis results indicated that after controlling for school level and HPS funding, the HPS action-research approach was significantly positively related to greater levels of HPS implementation, perceived HPS impact and perceived HPS efficacy.

The association between socio-ecological factors and having an after-school physical activity program

BACKGROUND

After-school physical activity (PA) programs promote PA among youth. Few studies have used socio-ecological health models to identify barriers and facilitators of after-school PA programs. This study examined which socio-ecological factors are associated with having an after-school PA program.

METHODS

A questionnaire was administered to key representatives of 114 elementary and 129 secondary schools. The association between socio-ecological factors and having an after-school PA program was analyzed at school level.

RESULTS

In both types of schools more knowledge about community schools was positively associated with having an after-school PA program (odds ratio [OR] = 1.96; 95% confidence interval [CI] = 1.18-3.27; OR = 1.88; 95% CI = 1.27-2.80, respectively). In elementary schools, environmental factors associated with having an after-school PA program included PA facilities (OR = 4.98; 95% CI = 1.08-23.05), a PA working group (OR = 3.37; 95% CI = 1.02-11.10), agreements with the community (OR = 1.60; 95% CI = 1.05-2.43), shortage of human resources (OR = 0.57; 95% CI = 0.37-0.89) and lack of support from teachers (OR = 0.51; 95% CI = 0.33-0.80). In secondary schools, environmental factors included the presence of a remunerated coordinator (OR = 5.12; 95% CI = 1.38-19.10) and partnerships with "sport and PA leaders" (OR = 3.54; 95% CI = 1.01-12.41).

CONCLUSION

Having an after-school PA program was associated with personal and environmental factors, which supports the use of socio-ecological frameworks for explorative and intervention studies aiming to increase after-school PA programs.

How divergent conceptions among health and education stakeholders influence the dissemination of healthy schools in Quebec

This paper focuses on dissemination of the healthy schools (HS) approach in the province of Quebec, Canada. Dissemination aims at raising awareness about HS and promoting its adhesion among actors concerned with youth health in school. As HS is a joint initiative based on agreement and collaboration between health and educational sectors, the positions of stakeholders that foster cooperation between these sectors were considered to be critical to optimize its dissemination. The study's objectives were to: (i) examine and contrast the stakeholders' conceptions of HS and (ii) understand how converging and diverging stakeholders' positions on HS favourably or negatively influence its dissemination in Quebec. Gray's analytical approach to collaboration and its focus on stakeholders' mindframe about a domain served as a conceptual lens to examine stakeholders' positions regarding HS. Collection methods included documentary analysis and semi-structured interviews of 34 key internal and external informants at the provincial, regional and local levels. The results showed consensual adhesion to fundamental principles of the HS approach. However, differences in conceptualization between provincial authorities of the two sectors concerning the way to disseminate HS have been observed. These differences represented a significant barrier to HS optimal dissemination. A dialogue between the two authorities appears to be essential to arrive at a negotiated and shared conceptualization of this issue in the Quebec context, thus allowing agreements for adequate support. The results may serve as the basis for a more fruitful dialogue between actors from the two sectors, at different administrative levels.