Home > Strategies for enhancing the implementation of school‐based policies or practices targeting diet, physical activity, obesity, tobacco or alcohol use.

Wolfenden, Luke and McCrabb, Sam and Barnes, Courtney and O'Brien, Kate M and Ng, Kwok W and Nathan, Nicole K and Sutherland, Rachel and Hodder, Rebecca K and Tzelepis, Flora and Nolan, Erin and Williams, Christopher M and Yoong, Sze Lin (2022) Strategies for enhancing the implementation of school‐based policies or practices targeting diet, physical activity, obesity, tobacco or alcohol use. Cochrane Database of Systematic Reviews, (8), Art. no.: CD011677. DOI: 10.1002/14651858.CD011677.pub3.

External website: https://www.cochranelibrary.com/cdsr/doi/10.1002/1...

Key messages:

• Schools and their staff implement interventions to address student healthy eating, physical activity, obesity, and tobacco or alcohol use better when strategies are used to support them to do so.
• School‐based interventions whose implementation is supported may be slightly more effective in improving student healthy eating, physical activity, obesity or tobacco use.
• Most studies do not report economic evaluation of strategies to support implementation of interventions in schools or assess any potential adverse effects.

Implications for practice: 

  • The review provides evidence supporting the use of implementation strategies to improve the implementation of interventions targeting risk factors for chronic disease in schools.
  • While a range of strategies have been tested, the review does not provide evidence to guide selection of specific strategy components. Maximising the effects of implementation efforts may best be achieved through thorough formative evaluation. This includes consultation with schools and school systems to identify barriers or enablers to intervention implementation, and the codevelopment of appropriate, and contextually relevant implementation support strategies. A number of implementation frameworks are currently available to support such work. Among the most commonly used are the Theoretical Domains Framework, and the Consolidated Framework for Implementation in Research (CFIR) (Cane 2012; Damschroder 2009; French 2012).
  • Evidence regarding the effects of strategies to implement interventions in schools on student health outcomes is uncertain. Policymakers and practitioners should pay careful attention to the selection of interventions for implementation to ensure that they are sufficiently effective and amenable to implementing in the setting.
    Implications for research: 
  • Schools are one of the most valuable settings for population‐level interventions to improve child health. Despite this, there remains a surprising lack of controlled trials examining the impact of the strategies to implement initiatives to address chronic disease risks in this setting. For example, Cochrane Reviews have identified 53 randomised trials testing the efficacy of school‐based programmes to prevent alcohol misuse (Foxcroft 2011). However, we have identified just one trial of strategies to implement the alcohol prevention programmes in this setting. There is a need to reorient research investment to address this important evidence gap.
  • The review identified a need for the development and use of robust measures for the assessment of implementation outcomes. A number of the included trials included self‐report measures such as questionnaires, teacher‐completed log books and telephone interviews, of which just two were reported to have been validated. The reliability and validity of self‐reported measures of policy or practice implementation are questionable, particularly for use in trials given the potential for socially desirable responding (Greene 2008).
  • While not unique to the field of implementation (Lau 2015), of particular concern was the lack of consideration to the costs of implementing health promoting policies or practices, or their unintended adverse effects. Information regarding costs and adverse effects are particularly salient for health decision makers who must weigh the benefits of intervention with their harms and costs to community (Wolfenden 2010; Wolfenden 2015).
  • Approaches to implementation are not immune to unintended consequences (Pettigrew 2012). Future research should incorporate logic models to identify potential harms associated with implementing health promotion programmes in schools, and include measures to prospectively measure both harms and implementation costs.

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