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

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.

A Systematic Review of the Implementation and Effectiveness of 'The Daily Mile' on Markers of Children's Health

Currently, a high percentage of children globally fail to meet the World Health Organisation's (WHO) recommended daily physical activity (PA) guidelines. The Daily Mile (TDM) is a school-based PA initiative, designed to improve primary school children's PA behaviour. The purpose of this review was to evaluate the extant TDM implementation process and identify its impact on health-related metrics. Three databases were used to search for articles from the time TDM originated in 2012 until February 2022. The identification and screening process of articles for their ability to meet this review's eligibility criteria were facilitated by use of PRISMA and Rayyan. Sixteen articles from the initial search (n = 202) were deemed eligible for inclusion. An analysis of these articles identified five common outcome categories that permeated throughout the research articles: (1) cardiorespiratory fitness (CRF); (2) anthropometry and body composition; (3) PA; (4) cognition; and (5) process evaluation. Results presented from the included articles suggests TDM positively impacts markers of a variety of health-related metrics, namely CRF and PA. However, implementation barriers including TDM's repetitive nature, time constraints associated with competing curriculum demands and inadequate facilities regularly necessitate the adaptation and development of the original TDM format by schools and teachers.

Systematic review of the barriers and facilitators to cross-sector partnerships in promoting physical activity

AIMS

To review the barriers and facilitators that cross-sector partners face in promoting physical activity.

METHODS

We searched Medline, Embase, PsychINFO, ProQuest Central, SCOPUS and SPORTDiscus to identify published records dating from 1986 to August 2021. We searched for public health interventions drawn from partnerships, where the partners worked across sectors and their shared goal was to promote or increase physical activity through partnership approaches. We used the Critical Appraisal Skills Programme UK (CASP) checklist and Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool to guide the critical appraisal of included records, and thematic analysis to summarise and synthesise the findings.

RESULTS

Findings (n = 32 articles) described public health interventions (n = 19) aiming to promote physical activity through cross-sector collaboration and/or partnerships. We identified barriers, facilitators and recommendations in relation to four broad themes: approaching and selecting partners, funding, building capacity and taking joint action.

CONCLUSION

Common challenges that partners face are related to allocating time and resources, and sustaining momentum. Identifying similarities and differences between partners early on and building good relationships, strong momentum and trust can take considerable time. However, these factors may be essential for fruitful collaboration. Boundary spanners in the physical activity system could help translate differences and consolidate common ground between cross-sector partners, accelerating joint leadership and introducing systems thinking.

PROSPERO REGISTRATION NUMBER

CRD42020226207.

A Pilot Randomised Controlled Trial to Increase the Sustainment of an Indoor-Outdoor-Free-Play Program in Early Childhood Education and Care Services: A Study Protocol for the Sustaining Play, Sustaining Health (SPSH) Trial

Early Childhood Education and Care (ECEC) settings are important environments to support children's physical activity (PA). In 2021, COVID-19 regulations recommended the provision of indoor-outdoor free-play programs in ECEC settings to reduce the transmission of COVID-19, resulting in an increased uptake of this practice. As the context has since changed, research suggests that ECEC services could cease the implementation of these practices. Therefore, this pilot randomised controlled trial (RCT) aims to examine the feasibility, acceptability, and impact of a sustainment strategy to ensure the ongoing implementation (sustainment) of ECEC-delivered indoor-outdoor free-play programs. Twenty ECEC services located in New South Wales, Australia that have implemented indoor-outdoor free-play programs since the release of COVID-19 guidelines will be recruited. The services will be randomly allocated either the sustainment strategy or usual care. The "Sustaining Play, Sustaining Health" program consists of eight strategies, developed to address key barriers against and facilitators of sustainment informed by the Integrated Sustainability Framework. The outcomes will be assessed via internal project records, staff surveys, and a self-reported measure of free play. This study will provide important data to support the performance of a fully powered trial within Australian ECEC settings and to inform the development of future sustainment strategies.

Trend Impact Analysis (TIA) of community-based futures study for pediatric obesity in Iran

BACKGROUND

Childhood obesity has been regarded as one of the main healthcare challenges in the last century, leading to critical health problems and reduced life expectancy. Many factors can play a role in its development or prevention. Using the Trend Impact Analysis (TIA), this study aimed to conduct a community-based futures study for pediatric obesity in Iran.

METHODS

We obtained the prevalence of overweight and obesity from the database of the Ministry of Health and Medical Education. Moreover, we reviewed 21 documents, texts, and comments from three key stakeholders in Iran and prepared a list of key experts, who were stakeholders in the field of obesity prevention of childhood in different organizations. Then, we collected the expert opinions by Delphi method. Data analysis was performed using the Excel and R software.

RESULTS

Fourteen experts participated in the first stage and nine experts in the second stage. We identified two positive drivers, including the prevalence of coronavirus disease 2019 (COVID-19) and the widespread expansion of online educational programs. Meanwhile, we identified five negative drivers as follows: (1) controlling and limiting obesogenic environments in the community, school, and family; (2) running annual compulsory anthropometry programs for students of all educational levels in health centers; (3) integrating nutrition education interventions in the curricula of all educational levels; (4) taxation of unhealthy and fast foods; and (5) preparing safe and appropriate sports environments for children and adolescents (on the streets, schools, parks, and sports clubs). Without considering the drivers, the prevalence of overweight and obesity is predicted to reach 29.10% in 2031. However, it is expected that the negative drivers can increase the prevalence trend from 23.40% in 2018 to 19.57% in 2031, the positive drivers to 32.61%, and the combination of all drivers to 23.07%.

CONCLUSION

It seems that measures such as the effective communication of policy makers, basic evaluation of the programs and policies related to the prevention of childhood obesity, and localization of the programs of international organizations for the prevention of obesity can greatly control the prevalence of childhood obesity.

Barriers and facilitators of childhood obesity prevention policies: A systematic review and meta-synthesis

Objectives

Childhood obesity is one of the worldwide considerable public health challenges and many factors can play a role in its management. Therefore, this article examined the facilitators and barriers of childhood obesity prevention (COP) policies.

Methods

This systematic review of qualitative studies was conducted via a search of the SCOPUS, PubMed, and Google Scholar databases between 1 January 2010 and 11 February 2022 and examined factors that influence the implementation of COP policies at a community approach.

Results

The parents' reluctance to engage in COP activities, lack of sufficient knowledge, and financial problems were the most reported barriers at the individual level. In addition, the beliefs about COP at the sociocultural level and limited funding and resources, time limitations in stakeholders at the implementation level, and lack of policy support at the structural level were the most frequently reported barriers. Further, effective communication between stakeholders and parents and school staff at the sociocultural level and flexibility of the intervention, delivery of healthy food programs in schools, low-cost and appropriate resources, and the availability of appropriate facilities are the most frequently reported facilitators in the structural level.

Conclusion

Individual, sociocultural, and structural level-related barriers and facilitators influence the implementation of COP policies. Most of the barriers and facilitators in this systematic review were related to the structural level.

Barriers and facilitators to the adoption of physical activity policies in elementary schools from the perspective of principals: An application of the consolidated framework for implementation research-A cross-sectional study

Background

Studies have shown that policies to promote physical activity in schools can have a positive impact on children's physical activity behavior. However, a large research gap exists as to what determinants may influence the adoption of such policies. Applying the Consolidated Framework for Implementation Research (CFIR), we investigated barriers and facilitators to the adoption of physical activity policies in elementary schools in Baden-Wuerttemberg, Germany, from the perspective of school principals.

Methods

A cross-sectional study was conducted between May and June 2021. School principals from elementary and special needs schools (n = 2,838) were invited to participate in the study. The online questionnaire used was developed based on the CFIR and included questions on school characteristics and constructs of the CFIR domains inner setting, characteristics of individuals, and process. Logistic regression analyses were performed to examine associations between policy adoption and school characteristics as well as CFIR determinants.

Results

In total, 121 schools (4%) participated in the survey, of which 49 (40.5%) reported having adopted a policy to promote physical activity. Positive associations with policy adoption were found for general willingness among teaching staff [odds ratio (OR): 5.37, 95% confidence interval (CI): 1.92-15.05], available resources (OR: 2.15, 95% CI: 1.18-3.91), access to knowledge and information (OR: 2.11, 95% CI: 1.09-4.09), and stakeholder engagement (OR: 3.47, 95% CI: 1.24-9.75).

Conclusions

This study provides a first insight into potential barriers and facilitators at the organizational level of schools that may be relevant to the adoption of physical activity policies, from the perspective of school principals. However, due to a low response rate, the results must be interpreted with caution. A strength of this study includes theoretical foundation through the use of the CFIR. The CFIR could be well-adapted to the school setting and provided valuable support for developing the questionnaire and interpreting the study results.

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.

Exploring the acceptability and feasibility of a whole school approach to physical activity in UK primary schools: a qualitative approach

Background

UK Children generally fail to meet physical activity (PA) recommendations. Whole school approaches (WSA) have the potential to impact large numbers of children due to their ubiquitous nature for school wide implementation, however there is limited knowledge regarding primary school PA WSA implementation in the UK. This study aimed to investigate the acceptability and feasibility of a PA WSA in the UK. 

Methods

Semi structured interviews explored research aims with participants. A qualitative description approach was adopted and data were analysed using thematic analysis to draw codes and themes from the data.

Results

Thirteen primary school senior leadership team (SLT) and Physical Education (PE) leads were interviewed. A PA WSA was found acceptable by all participants. Implementation, however, was questioned when other significant mechanisms were not in place. A PA WSA aided prioritisation and planning of PA provision, providing a holistic overview of all key areas of PE, school-sport and PA (PESSPA). Due to the high acceptability but dependent feasibility of a PA WSA, it is recommended that PA WSAs align with whole-school health policy and improvement plans to advance implementation. Future research, however, is needed to explore how this method is best implemented as additional interventions may also be required to promote the prioritisation of the PA agenda due to the importance of SLT backing for implementation being paramount, as results highlight.

Conclusions

PA WSAs aid awareness, understanding and planning of school wide PESSPA provision, however their implementation in complex. Having SLT support and an appropriately resourced PE lead maximised the impact and utility of a PA WSA.

Survey of South Carolina Public School Personnel Perspectives on Barriers and Facilitators to Regular Physical Activity and Healthy Eating Behaviors in Schools

BACKGROUND

In South Carolina (SC), 42% of youth are overweight or obese. Two sets of modifiable behaviors contributing to obesity are physical activity (PA) and dietary habits. School-based interventions have successfully improved these behaviors. The purpose of this study was to identify SC public school personnel perspectives on the most common barriers and facilitators to regular PA and healthy eating behaviors in schools.

METHODS

A needs assessment survey was conducted with school personnel statewide. There were 17 questions on the survey that addressed: (1) demographic information about participants' educational backgrounds, (2) barriers to regular PA and healthy eating behaviors in schools, and (3) facilitators to regular PA and healthy eating behaviors in schools. Univariate and bivariate descriptive statistical analyses were performed using IBM SPSS Statistics 27.

RESULTS

Participants (N = 1311) indicated insufficient time for regular PA (n = 514, 39.2%) and limited access to healthy foods for healthy eating (n = 271, 20.7%) as main barriers. The primary facilitators were support from administrators for regular PA (n = 264, 20.1%) and support from cafeteria staff for healthy eating (n = 234, 17.8%). Further analyses explored how factors compared based on roles in schools, academic levels, and school district classifications.

CONCLUSIONS

Results suggest that overarching barriers and facilitators to school-based interventions addressing childhood obesity exist, so common strategies to mitigate challenges and maximize supports can be used in schools. Future studies are needed to examine how decreasing barriers and enhancing facilitators affect the implementation and outcomes of these school-based interventions.

Effectiveness of a practical multi-setting lifestyle intervention on the main BMI trajectories from childhood to young adulthood: A community-based trial

Background

Preventing overweight in childhood and subsequent stages of life is still a global challenge. Despite numerous relevant lifestyle interventions, data on their impact on different BMI change pathways over time is rare. The present study aimed to investigate the effect of a multi-setting lifestyle intervention on BMI trajectories from childhood to young adulthood.

Methods

A multi-setting lifestyle intervention at the school, family, and community levels have been conducted in the Tehran Lipid and Glucose Study framework. A total of 2145 children (4–18 years, 49% boys, and 18% intervention) were recruited for the baseline assessment and were followed through five follow-up examinations during a median of 16.1 years. Using a group-based trajectory model, BMI trajectories from childhood to young adulthood were identified, and their association with the implemented intervention was assessed.

Results

Four trajectory groups of BMI from childhood to young adulthood were identified, including Normal weight (41%), Young adulthood overweight (36%), Early childhood increasing overweight and adulthood obesity (19%), and Early childhood increasing obesity (4%). Only Young adulthood overweight and Early childhood increasing obesity were affected by the intervention and were concomitant with lower BMI levels than the control group, with the highest estimated effect in the latter (β=-0.52 and p = 0.018; β=-1.48 and p < 0.001, respectively).

Conclusion

The current findings indicate the highest effectiveness of a practical, healthy lifestyle intervention on those whose obesity started in the early years of life or youth. Our results could help policymakers and planners design more targeted lifestyle modification and weight control interventions.

Trial registration

This study is registered at Iran Registry for Clinical Trials, a WHO primary registry (http://irct.ir). The Iran Registry for Clinical Trials ID and date are IRCTID:IRCT138705301058N1, 29/10/2008.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14306-2.

Describing South Carolina Public School Administrators' Perceptions and Experiences Related to School-Based Interventions and Strategies to Promote Healthy Physical Activity and Eating Behaviors: A Qualitative Study

BACKGROUND

School-based interventions and strategies targeting physical activity (PA) and eating patterns have successfully addressed unhealthy behaviors contributing to excess weight in school-age children. The purpose of this study was to investigate South Carolina (SC) public school administrators' perceptions of and experiences with weight-related issues in schools and associated barriers and facilitators to awareness, selection, and implementation of school-based healthy PA and eating interventions and strategies.

METHODS

This qualitative descriptive study, guided by the Social Ecological Model and the Steps in Quality Intervention Development Model, involved semistructured interviews with SC public school administrators from all academic levels (N = 28). Data were analyzed using thematic analysis.

RESULTS

Four themes were identified from interviews (N = 28): weight-related terminology or stigma, experiences with school-based healthy PA and eating interventions and strategies, barriers to school-based healthy PA and eating interventions and strategies, and facilitators to school-based healthy PA and eating interventions and strategies.

CONCLUSIONS

Schools are well-positioned to provide interventions and strategies to improve PA and dietary habits leading to childhood obesity. School administrators, while knowledgeable and experienced with weight-related issues and school-based interventions and strategies, encounter barriers and facilitators that impact offerings and delivery. Understanding these challenges and supports is important in the development, adaptation, and implementation of school-based interventions and strategies focused on healthy PA and eating behaviors.

Children’s Participation in Free School Meals: A Qualitative Study among Pupils, Parents, and Teachers

School meals can have a key function in promoting children’s health. However, simply providing a free school meal is not a guarantee that pupils will eat the food. The purpose of this study was to explore factors influencing pupils’ participation in free school meal schemes in Oslo. The study has a qualitative research design, inspired by grounded theory. Data were collected through interviews with pupils, teachers, and parents, and participant observations in two schools participating in a pilot project funded by Oslo Municipality. Line-by-line coding, memo writing, and a constant comparative technique were used to analyze the data. One primary school and one lower-secondary school in different districts in Oslo that were implementing two different free school meal models took part in the study. In total, 39 pupils (5th–10th grade), 15 parents, and 12 school employees were included. Four main factors related to pupils’ participation in free school meals emerged from the analysis: the popularity of the food served, the attraction to the nearby shopping center, social aspects, and predictability. To promote pupils’ participation in free school meal schemes, schools need to solve the challenges of balancing between healthy food and popular but often unhealthy food. To implement school meals further, children and parents’ involvement, regularity of the meals provision, a good flow of information, and the creation of a friendly eating environment are recommended.

School-Level Perspectives of the Ontario Student Nutrition Program

The purpose of this study was to assess the implementation of a school snack program for children in elementary schools. School-level program volunteers’ experiences were explored using semi-structured interviews. Fieldnotes were taken during on-site school visits. Quantitative data were collected through a General Information Form and Weekly Logbooks. Seven elementary schools in Southwestern Ontario were invited and agreed to participate. Interviews (n = 27) revealed that volunteers valued the program for its universality, the excitement it created, the opportunity for students to try new foods, and the social interactions that it generated. Challenges included the burden on snack volunteers to plan, procure, and prepare foods; the competition the program posed for school priorities; limited funding; and a lack of clear purpose for the program. Suggestions for improvement included providing adequate and sustained resources and an integration of the program into the curriculum. Data obtained from 15 on-site visits, 7 General Information Forms, and 59 (out of a total of 70) Weekly Logbooks confirmed the data obtained from interviews. This research provides insights into the challenges of volunteer-led school snack programs in Canada and may guide policy makers, practitioners, and researchers in the development of a universal, nationally funded school food program.

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.

Stakeholders perspectives of barriers and facilitators of childhood obesity prevention policies in Iran: A Delphi method study

Background

The prevalence of obesity among children and adolescents is one of the most important health challenges of the present century. Many factors affect the prevention policies related to this health problem and make their implementation difficult. This study examined perceived barriers and facilitators of childhood obesity prevention policies by stakeholders.

Methods

A qualitative descriptive research design based on Delphi method was conducted. In addition, semi-structured one-to-one interviews were conducted with childhood obesity prevention policy stakeholders (n=39) and initial identification of barriers and facilitators in this area. Interviews were digitally recorded, transcribed verbatim, and finally analyzed, followed by using thematic analysis. Subsequently, two-round Delphi panel was done by sending e-mails to stakeholders (21 stakeholders participated in the first round and 15 stakeholders in the second round) for the final selection of barriers and facilitators of obesity prevention policies among children and adolescents in Iran.

Results

The identified barriers and facilitators were divided into three levels: individual, executive, and structural. Barriers and facilitators of the structural level showed a high score and priority regarding obesity prevention policies among children and adolescents.

Conclusion

The existence of significant barriers at all three levels and especially at the structural level were among the concerns of stakeholders.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12282-7.

"We've Had to Build the Plane as We Flew It.": Impacts of the COVID-19 Pandemic on School-Based Weight Management Interventions

Background: In response to the coronavirus disease 2019 (COVID-19) pandemic, elementary and secondary schools in the United States transitioned to remote learning to slow viral spread and protect students and school officials. This move interrupted academic education and school-based health interventions focused on physical activity (PA) and healthy eating behaviors to help combat childhood obesity. Little is known on how these interventions were affected by COVID-19. Methods: This concurrent multimethodological study incorporated two independent components: qualitative descriptive semistructured interviews with public school administrators and quantitative descriptive cross-sectional needs assessment survey of public school personnel. Results: Three themes were identified from interviews with school administrators (N = 28): changes in school-based interventions addressing PA and healthy eating behaviors, changes in academic delivery affecting PA and healthy eating behaviors, and needs of school administrators. From the survey (N = 1311), 635 (48.4%) participants indicated that schools' abilities to address PA and healthy eating behaviors were negatively impacted by COVID-19. The majority (n = 876, 66.8%) of participants strongly agreed or agreed that the pandemic would affect future school-based interventions related to PA and healthy eating behaviors. Conclusions: While schools are prime locations for delivering school-based weight management interventions related to childhood obesity, participants reported the pandemic had overall negative impacts on interventions addressing PA and healthy eating behaviors. Understanding these impacts is essential to adapting school-based interventions to changes from COVID-19 so students may receive health information and access health promotion interventions in remote learning environments and during social distancing.

'We know what we should eat but we don't …': a qualitative study in Irish secondary schools

Healthy eating opportunities for young people need to be provided in the school setting. Links between formal education and local policies and practices, and active involvement of students are emphasized in whole school approaches to health promotion. In many jurisdictions, schools struggle to provide nutritious food that is acceptable to students. The aim of this study was to conduct an in-depth exploration of school food and students' food choice with students, teachers and principals in six Irish secondary schools. Students conducted their own focus groups with peers, and a researcher conducted focus groups with teachers and one-to-one interviews with principals. Students, teachers and principals expressed dissatisfaction with food provision within their respective schools and reported unhealthy dietary behaviours among the student body as the norm. Divergent views, however, emerged regarding education, knowledge and the primary drivers of food choice. Teachers and principals saw a role for more education modules and students believed environmental infrastructures, practices and policies needed to be addressed to improve behaviours. This consultation with students, teachers and principals highlight that, in addition to education, the social and environmental aspects of food choice and eating at school deserve attention in future research and policy.

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.

Implementation of a Dutch school-based integrated approach targeting education, health and poverty-a process evaluation

This study provides an evaluation of the implementation of a school-based integrated approach to improve academic outcomes by targeting children’s education, health, and poverty. A two-year municipal subsidy program was provided to four primary schools in a deprived urban neighborhood in Amsterdam. Schools were put in charge of the implementation and coordination of the program. The municipality and district authorities provided assistance. This study evaluated whether the program functioned as integrated approach, i.e., whether it targeted multiple domains and environments by involving various agencies and actors, and what factors facilitated or hampered this. It also yielded an overview of the initiatives implemented and the facilitators and barriers of successful implementation of initiatives. Principals’ perceptions served as the main input for this study. We thematically analyzed seven written customized plans for spending the subsidy (one to two per school), 15 transcripts of interviews with the principals (three to four per school) and the minutes of 16 meetings between principals, policy officers, and researchers. According to the principals, the schools had made great progress in the education domain and in improving the school’s pedagogical climate, but in the health and poverty domains less progress had been made. Apart from the municipality, relatively few external agencies and actors had been actively involved in the program, and progress in other environments than the school was hardly achieved. This study shows that functioning of the program as integrated approach was facilitated by connections between initiatives, and that hired, well-trusted third parties may be crucial to establish these connections.

Lay summary

This study evaluated whether a two-year municipal program to improve academic outcomes by targeting children’s education, health, and poverty, provided to primary schools in a deprived urban neighborhood, functioned as intended, and if so why, or if not, why not. The program was intended to function as integrated approach. This means that it was supposed to target the mentioned domains, the school, home, and neighborhood environment, and to involve various agencies and actors, such as school staff, policy officers, parents, children, and external organizations. The school principals could implement multiple, self-chosen, initiatives. According to the principals, on whose perceptions this evaluation study was primarily based, both teaching and the school climate improved during the program. However, improvements in children’s health and poverty levels, and outside the school environment in general, were more difficult to achieve. In addition, the program involved mainly school staff and policy officers. The program thus functioned as an integrated approach, but only to a limited extent. The functioning of the program as integrated approach was facilitated by involving hired third parties to stimulate interconnection of initiatives, i.e., initiatives serving the same goals, involving multiple agencies and actors, and/or being implemented in the same location.

Process evaluation of fruit and vegetables distribution interventions in school-based settings: A systematic review

•

Assesses how school fruit & vegetable distribution interventions are implemented.

•

Child fruit & vegetable intake is influenced by how intervention is implemented.

•

Recommendations for implementing fruit & vegetable interventions in schools.

•

Studies should also consider sustainability, cost-effectiveness and implementation.

Despite the importance of process evaluation in program evaluations, research has focused primarily on the effectiveness of fruit and vegetables (FVs) distribution interventions on children’s consumption, with little attention given to how these interventions achieve their outcomes. Five bibliographic databases (Embase, PubMed, ProQuest, Scopus, and Web of Science Core Collection) were searched in June 2019 for studies of interventions where the main focus was the implementation of distributed FVs to school-aged children as a snack. The Critical Appraisal Skills Programme (CASP) tool was used to appraise the risk of bias within included studies. Data were extracted based on study characteristics and findings. Results identified 24 studies reporting on 11 interventions and 1 policy. The findings of this systematic review indicate that the majority of the studies included limited references to implementation research. Recurring limitations include an absence of an evaluation theoretical framework and the data collection methods used. Also, several factors were identified as informing the success of snack-based FVs distribution programs, including participation of the school community, school characteristics, background knowledge, and parental engagement. Lack of timely FVs delivery, limited funding, inadequate awareness about the program, insufficient teachers’ time, and food waste were identified as challenges to successful programming. Findings indicate that distributing FVs to school-aged children as a snack can increase their consumption, but only with proper implementation. Further evaluative research is required to better inform future implementation of snack-based FV distribution interventions in school settings.

School Staff's Perspectives on the Adoption of Elementary-School Physical Activity Approaches: A Qualitative Study

Background

There is a need to understand how schools adopt physical activity approaches (curricula, programs and practices), but few studies report on this process.

Purpose

To obtain elementary school staff's perspectives regarding how their schools are currently adopting physical activity approaches.

Methods

We recruited 15 participants from four job types in an urban Texas school district to participate in semi-structured interviews. We coded and analyzed interviews using directed content analysis and iterative categorization.

Results

We identified four themes pertaining to how the district, schools, and teachers contribute to the adoption of approaches. Themes included: (1) Staff identify new approaches through numerous channels; (2) Adoption occurs at multiple organizational levels; (3) District staff fulfilled a supporting role in the adoption process; and (4) School staff's perceptions of approach characteristics influence adoption.

Discussion

We found that schools adopt physical activity approaches at both the district- and school-level. Additionally, multiple stakeholders played a role in the adoption process and those roles varied across approaches.

Translation to Health Education Practice

Time, money, space, staff, competing priorities, limited information, the school's mission, and the benefits an approach provides to children are factors that researches and practitioners should consider when starting a new physical activity approach.

Global PRoMiSe (Perioperative Recommendations for Medication Safety): protocol for a mixed-methods study

INTRODUCTION

Medication errors (MEs), which occur commonly in the perioperative period, have the potential to cause patient harm or death. Many published recommendations exist for preventing perioperative MEs; however, many of these recommendations conflict and are often not applicable to middle-income and low-income countries. The goal of this study is to develop and disseminate consensus-based recommendations for perioperative medication safety that are tailored to country income level.

METHODS AND ANALYSIS

The primary site of this mixed-methods study is Massachusetts General Hospital/Harvard Medical School. Participants include a minimum of 108 international medication safety experts, 27 from each of the World Bank's four country income groups (high, upper-middle, lower-middle and low-income). Using the Delphi method, participants will rate the appropriateness of candidate medication safety recommendations by completing online surveys using RedCAP. We will use Condorcet ranking methods to prioritise the final recommendations for each country income group. We will execute a comprehensive dissemination strategy for the recommendations across each country income group. Finally, we will conduct semistructured interviews with our participants to evaluate the initial adoption and implementation of the recommendations in each country income group.

ETHICS AND DISSEMINATION

This study was approved by the Human Research Committee/Institutional Review Board at Partners Healthcare (2019P003567). Findings will be published in peer-reviewed journals and presented at local and international conferences.

TRIAL REGISTRATION NUMBER

NCT04240301.

Engaging stakeholders in the adaptation of the Connect for Health pediatric weight management program for national implementation

Background

Connect for Health is an evidence-based weight management program with clinical- and family-facing components for delivery in pediatric primary care for families of children ages 2 to 12 years. We used the Consolidated Framework for Implementation Research (CFIR) to guide formative work prior to national implementation. The purpose of this study was to describe the process and results of stakeholder engagement and program adaptation.

Methods

We used mixed qualitative and quantitative methods to iteratively adapt and optimize the program by assessing needs and perspectives of clinicians and parents, as well as contextual barriers, facilitators, and organizational readiness for the uptake of the proposed program tools and implementation strategies. We conducted interviews with primary care clinicians from four health care organizations in Boston, MA; Denver, CO; and Greenville, SC, and used principles of immersion-crystallization for qualitative analyses. We also conducted surveys of parents of children with a body mass index ≥ 85th percentile.

Results

We reached thematic saturation after 52 clinician interviews. Emergent themes representing the CFIR domains of intervention characteristics, outer and inner setting, and process included (1) importance of evidence-based clinical decision support tools that integrate into the workflow and do not extend visit time, (2) developing resources that respond to family’s needs, (3) using multimodal delivery options for family resources, (4) addressing childhood obesity while balancing competing demands, (5) emphasizing patient care rather than documentation and establishing sustainability plans, and (6) offering multiple training methods that incorporate performance feedback. Of the parents surveyed (n = 400), approximately 50% were Spanish-speaking and over 75% reported an annual income < $50,000. Parents affirmed the importance of addressing weight management during well-child visits, being provided with referrals and resources, and offering multiple methods for resource delivery. Decisions about program modifications were made at the program and healthcare-system level and based on stakeholder engagement findings. Modifications included cultural, geographic, and target audience adaptations, as well as varied resource delivery options.

Conclusions

To ensure the fit between the Connect for Health program and national implementation settings, adaptations were systematically made through engagement of clinician and parent stakeholders to support adoption, sustainability, and health outcomes.

Trial registration

NCT04042493

Effective implementation of primary school-based healthy lifestyle programmes: a qualitative study of views of school staff

Background

Primary schools are valuable settings to implement healthy lifestyle (healthy eating and physical activity) interventions, aimed at targeting childhood obesity. This study explored school staff perceptions of factors that hinder and enable successful implementation and sustainability of healthy lifestyle interventions in primary schools. Qualitative data was pooled and analysed from two evaluations carried out in primary schools in North England: a feasibility study of a nutrition and physical activity educational programme (PhunkyFoods Feasibility Study), and an evaluation of a healthy eating programme (The Food Dudes Evaluation).

Methods

Sixty-five qualitative semi-structured interviews were conducted with head teachers, teachers, catering managers, designated school-based programme coordinators and programme staff supporting schools with programme delivery, at 14 schools involved in both evaluations. Thematic analysis was undertaken and emergent themes categorised using a framework for successful implementation by Durlak and Dupre (2008).

Results

Overall, all schools were delivering a range of healthy lifestyle programmes, often with overlapping content. Perceived challenges to implementation of individual programmes included: limited time, timing of implementation, limited training and support, insufficient resources, capacity and facilities, staff perceptions of intervention and perceived skill-proficiency (for cooking and physical activities). Short-term funding, lack of external and internal support were perceived to hinder sustainability. Staff recommendations for successful implementation of future programmes included: extended training and planning time, sufficient capacity, external support for delivery, good resources (interactive, practical and adaptable), and facilities for cooking, healthy eating, gardening and physical activities. Head teachers need to prioritise delivery of a few key healthy lifestyle programmes, in an overcrowded curriculum. Schools need to employ strategies to engage participation of staff, pupils and parents long term.

Conclusions

Effective implementation of school-based healthy lifestyle programmes was thought to be aided by flexible and adaptable programmes, enabling good contextual fit, well-resourced programmes and effective leadership at multiple levels, pupil (pupils support delivery) and parent involvement. To facilitate sustainability, it was perceived that programmes need to be integrated within the curriculum and school policies long term, with sustained support from head teachers and staff. These findings are relevant to programme developers, policy makers and those involved in delivering interventions.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7550-2) contains supplementary material, which is available to authorized users.

How Can Physical Activity Be Promoted Among Children and Adolescents? A Systematic Review of Reviews Across Settings

Introduction: A vast majority of children and adolescents are physically inactive. As a result, high obesity rates and related diseases have made physical activity promotion a politically relevant topic. In order to form the basis for political decision making, evidence is required regarding the efficacy and effectiveness of interventions for physical activity promotion. In contrast to previous research, this systematic review of reviews targets three key settings (family and home, childcare, school), and is among the largest to have been conducted.

Methods: A systematic review of reviews was conducted as part of a large-scale project to develop national recommendations for physical activity promotion in Germany. Six electronic databases were searched and inclusion criteria were defined. Two independent reviewers screened the titles and abstracts of potentially relevant literature. 213 reviews were identified and categorised by target group. A total of 74 reviews were identified dealing with children and adolescents. Each review underwent a quality assessment.

Results: 39 reviews with the highest quality and relevance were analysed. Three reviews focused on the family and home setting, 4 on the childcare setting, 28 on the school setting and 4 on other settings. Evidence revealed the key role played by parents in promoting physical activity in children within each setting. Furthermore, evidence pointed toward the efficacy of multi-component interventions in the childcare and school setting. Several evidence-based intervention strategies were identified for childcare facilities and schools.

Discussion: The review of reviews identified a number of promising strategies for PA promotion among children and adolescents. Among reviews, multi-component interventions in childcare facilities and schools stand out prominently. At the same time, the review of reviews indicated that there is still a lack of studies on the efficacy of interventions that go beyond the individual level. We recommend that future research should also target community and policy level interventions and interventions other than the school setting. In order to make more specific recommendations regarding the scale-up of promising intervention strategies, further knowledge about the effectiveness, health equity and cost effectiveness of interventions is needed.