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

Description of interview participants

A breakdown of participants is presented in Table 1. A number of additional members of teaching staff, who were not originally invited, also agreed to participate in an interview. Twenty members of staff were interviewed at both time points of data collection for the PFS (6 catering managers, 4 head teachers, 4 PhunkyFoods programme coordinators, 6 teachers). For the FDE, only a small number of staff agreed to be interviewed in total, as many staff reported having no time to take part. No Year 2 and Year 3 teaching staff could find the time to be interviewed. One interview included three participants for the purpose of convenience, as staff were short of time.

Table 1 Description of interview participants

Factors hindering and facilitating successful implementation and sustainability of healthy lifestyle programmes

A number of factors perceived to challenge and facilitate successful implementation and sustainability of healthy lifestyle programmes, were identified by school stakeholders. Table 2 presents the perceived barriers to implementation and sustainability identified by staff, and Table 3 presents the perceived facilitators, with illustrative quotes from participants. Roman numerals (superscript) have been used to demonstrate how the themes align with the categories of factors identified for effective implementation in the implementation framework by Durlak and Dupre [26]. These factors include: I community level factors, i.e. funding; II provider characteristics, i.e. perceptions of need for and benefit of innovation and skill proficiency; III characteristics of the innovation, i.e. adaptability (flexibility) and compatibility (contextual appropriateness), availability and quality of programme activity resources; IV factors relevant to the prevention delivery System (factors related to organisational capacity), i.e. integration of new programmes, shared decision making (local input, community participation and collaboration), shared vision (commitment and staff buy-in), formulation of tasks (teams, effective human resource management), availability and quality of resources such as personnel and facilities, and leadership and programme champion; and V factors related to the prevention support system, i.e. training and technical support.

Table 2 Perceived factors hindering implementation and sustainability of healthy lifestyle programmes at the primary schools
Table 3 Perceived factors facilitating implementation and sustainability of healthy lifestyle programmes at the primary schools

Factors hindering implementation of healthy lifestyle programmes

Time constraints (IV prevention delivery system: organisational capacity)

There was a general consensus among all staff members that having limited time was perceived to be the main challenge to implementing new healthy lifestyle programmes. Competing priorities and an already congested curriculum, meant that head teachers struggled to prioritise healthy lifestyle teaching and programmes generally. Healthy lifestyle teaching occasionally had to be delivered in assembly time, rather than lesson time, due to lack of time in the curriculum.

The schools were delivering a large range of healthy eating and physical activity programmes (in lesson time and after school). Some of these programmes had overlapping content, particularly those educating around healthy food, food preparation, food waste and food sustainability (for example, Healthy School award, Food for Life partnership award, PhunkyFoods programme, Tesco Eat Happy project, Fuel for School programme and cooking clubs). These programmes compete for curriculum time, when the curriculum is already overcrowded. Implementation and acceptance of new programmes, could be hindered by over-burdening staff with too many programmes. Having sufficient time therefore, to deliver programme activities, particularly those that were not already integrated into lesson plans (in addition to the usual prescribed curriculum), was perceived to be a recurrent challenge. Catering staff also struggled to find time for additional food preparation, such as fruit and vegetable preparation for tasting activities and creative fruit displays for lunchtimes, without additional staff support and time. Although time constraints were not included as a specific factor influencing implementation in the model by Durlak and Dupre [26], the factors influencing time constraints in our study (competing priorities with a heavily congested curriculum, time to prepare and deliver programmes, and teacher overload), might reflect a resourcing issue at school level. This has thus been classified as a factor relating to the prevention delivery system [26].

Timing of programme implementation

Poor timing of healthy lifestyle programme implementation, such as receiving the programme half way through the academic year (when curriculum planning was already completed for the year), was another perceived important barrier to adoption and implementation of programmes. Timing of programme implementation was not specifically included as a factor influencing implementation in the Durlak and Dupre model [26].

Training and technical support (V prevention support system)

Insufficient training was also perceived to be an important barrier to healthy eating and physical activity programme implementation. Teaching staff that were not given adequate training and preparation time to review the programme resources before implementation, were less accepting of new programmes, preferred to use more familiar programme resources and took less ownership over aspects of programmes. Furthermore, new staff appointed after a programme had started, were sometimes insufficiently trained or not given the resources to adopt a programme. A lack of sufficient communication and technical support from the programme team (providing the programme) towards schools, was also perceived to hinder implementation. For example, one school experienced difficulties with accessing timely support from the programme team to install ground beds in the garden for a growing scheme.

Availability and quality of resources (personnel and facilities) (IV prevention delivery system: organisational capacity)

Another important barrier to implementation discussed by staff was lack of adequate resources and facilities (particularly for physical activities, healthy eating education and cooking activities). Limited staff capacity to deliver after school healthy lifestyle programmes (for example cooking clubs), restricted the frequency and sustainability of delivery and number of children who could attend. Inadequate infrastructure, equipment and school space, prevented implementation of school cooking, gardening activities and sports clubs particularly. Adequate school resources and facilities to implement programmes, were thought to relate to organisational capacity, and have therefore been classified as factors relating to the prevention delivery system, from the Durlak and Dupre model [26].

Funding (I community level)

Funding was a recurrent challenge for schools. Limited funding or uncertainty about future funding, had a negative impact on access to certain healthy lifestyle programmes, such as the Food for Life or Healthy Schools programmes.

Teacher characteristics (engagement, perceived need for and benefit of innovation and skill proficiency) (II provider characteristics)

Where staff were using programmes that were perceived to be familiar and already well-established in the curriculum, such as the Physical Education curriculum, staff failed to see a need for new similar programmes, with the same key targets for behaviour change. There was therefore there some resistance to wanting to adopt these programmes initially. Fear of additional workload for staff, would also occasionally hinder programme acceptance and thus implementation initially. Lack of sufficient training and under-skilled teaching staff, was also a perceived barrier to effective implementation of physical activity or cooking activities particularly.

Effective leadership (IV prevention delivery system: organisational capacity)

Implementation of programmes was also often dependent on effective leadership from an in house programme coordinator (a designated member of staff instructing on programme delivery and facilitating access to training and resources). Lack of effective and sustained leadership from a programme coordinator, would often result in programmes not being prioritised and staff not being encouraged to use programme resources. Furthermore, little guidance and communication from programme coordinators around how a programme should be delivered, would cause large variability in level of programme delivery between teaching staff, potentially compromising programme fidelity.

Parent participation and support (IV prevention delivery system: organisational capacity)

Effective engagement of parents was universally acknowledged to be one of the most challenging and least successful elements of healthy lifestyle programme implementation. Parent attendance at meetings, activities and events in school, was generally reported to be low. Parent attitude and limited time were considered to be the main reasons. Some parents were reported to be less compliant with school food policies, packed lunch policies and healthy snack provision. Equally engaging disadvantaged pupils and parents, in school food programmes and after school sports activities, was also perceived to be challenging. There was also a perceived barrier to engaging pupils (and parents), in after school clubs, when for example they needed to attend religious studies or prayer time after school. Although not specifically included within the model by Durlak and Dupre [26], it was thought that parent involvement could be categorised alongside community involvement within ‘shared decision making’ in the model, and has therefore been classified as a factor relating to the prevention delivery system.

Factors hindering sustainability

Securing sustainable funding was perceived to be a critical barrier to long-term sustainability of nutrition and physical activity programmes. Unsustainable external support from Physical Education specialists (due to limited funding), hindered the continued delivery of physical activity programmes at schools. Having sufficient staff capacity and staff support to secure continuation of programmes at the schools, was considered to be another significant challenge, particularly for after school cooking and physical activity clubs.

Factors facilitating implementation of healthy lifestyle programmes

Contextual appropriateness and adaptability (III characteristics of the innovation)

Adaptations to programme delivery to suit the school context (timings, locations, resources, format, for example after school club or within the curriculum), were seen to facilitate more successful implementation. Programme coordinators and teaching staff, felt it important to have flexibility and autonomy over how teaching staff delivered programmes within their classrooms (with localised decision-making), as this was seen to increase likelihood of programme adoption through acceptance and ownership.

Availability and quality of resources (personnel and facilities) (IV prevention delivery system: organisational capacity)

Sufficient staff capacity, resources and adequate facilities for cooking, gardening and physical activities, were considered critical for effective implementation of healthy lifestyle programmes.

Availability and quality of programme activity resources (III characteristics of the innovation)

Well-resourced programmes, with a variety of engaging, interactive and “hands on” resources were seen to facilitate delivery and increase programme acceptance. Moreover, using a variety of resources from different programmes, was thought to be beneficial by some staff. Incentives (such as rewards, stickers, certificates of achievement) that encouraged children to try new fruits and vegetables and to bring in healthy lunchboxes, were perceived to be enable more successful implementation and were perceived to improve healthy eating behaviours. The use of programme characters or role models (especially on the DVDs), were perceived to help engage pupils and drive interest in learning about healthy lifestyle. The availability of good quality programme activity resources (provided by the programme), was thought to relate to compatibility of the intervention, and was therefore classified as a factor relating to characteristics of the innovation, from the Durlak and Dupre model [26].

Integration of new programmes (in the curriculum, school structures and food policies) (IV prevention delivery system: organisational capacity and III characteristics of the innovation)

It was considered that healthy lifestyle programmes need to be integrated within the curriculum, school structure or school food policies, to ensure prioritisation and encourage implementation. This would allow teachers to incorporate programme resources and activities within their teaching plans, so that they do not have to deliver a programme in addition to their usual curriculum. Furthermore, delivering healthy eating programmes in a cross-curricular manner in a range of subject areas, rather than as a singular unit, was recommended for successful integration within the school curricula. The effective integration of new programmes was thought to be a factor relating to both organisational capacity (the extent to which the school can incorporate it into its existing practices and routines), as well as contextual appropriateness (how it fits with the school’s priorities and values) and adaptability of the intervention (to fit the schools preferences and practices). It has thus been classified as a factor relating to both the prevention delivery system and characteristics of the innovation, from the Durlak and Dupre model [26].

Teacher characteristics (perceived need for and benefit of innovation) (II provider characteristics)

Also considered important by staff was to ensure that teaching staff were confident on how new programme goals aligned with curriculum objectives. Staff that understood the value of new healthy lifestyle programmes, in enhancing children’s learning and contributing to academic achievement, were then more likely to accept and implement them.

Shared vision (commitment and staff buy-in), leadership, programme coordinator (champion) and managerial/administrative support (IV prevention delivery system: organisational capacity)

Whole-school involvement, with engagement and collaboration of all school partners (head teacher, teaching staff, catering staff, pupils and parents), were also considered key factors to successful implementation. Effective leadership from the school senior administrative team was perceived to be important to drive programmes forward and facilitate success. It was perceived that head teachers needed to champion programmes and bolster enthusiasm and support from all school staff. Furthermore, effective guidance and leadership from a designated programme coordinator, was seen to be equally important for effective implementation, through engaging staff and keeping focus on a programme.

Training and technical support (V prevention support system)

Adequate training, communication and support from programme providers to schools, were also perceived to be important enablers. It was important that staff felt confident and capable, to deliver healthy eating and physical activity messages adequately. Having access to sustained external support for healthy eating and physical activity programmes, was thought to ease implementation and sustainability of programmes. For example nutritionists to deliver healthy eating/cooking teaching, to support the new curriculum that included a focus on diet and cooking, and more support for catering staff preparing foods in the kitchen for food tasting activities. The importance of getting the right balance with support from the programme team supporting delivery in schools, was acknowledged, highlighting the need to provide a sufficient level of support, without being too invasive.

Formulation of tasks (teams, effective human resource management) (IV prevention delivery system: organisational capacity)

Ensuring adequate role delineation for delivery, with a sufficient number of suitable staff available to lead on aspects of delivery, was also thought to be a facilitator. For example, allocating staff to supervise healthy eating programme activities with pupils in the school dining room. Establishing “specialist teachers” to deliver all teaching relating to healthy lifestyle, was recommended to ease the burden on other teaching staff, who have not the time to prioritise healthy lifestyle teaching.

Parent and community participation (shared decision-making) (IV prevention delivery system: organisational capacity)

Working in partnership with parents on healthy initiatives was considered important to successful implementation, particularly in relation to the provision of healthier packed lunches and encouraging school meals. Involvement with the local community was also thought to be a strong programme attribute. Initiatives such as: community allotments, market stalls selling fruit and vegetables (past sell by date), for the Fuel for School Programme, school shop selling meals to the community, and school meals for local pensioners, were thought to have been successful for fostering community engagement in healthy eating initiatives. Furthermore, the importance of embedding programmes in the local community was highlighted, although it was acknowledged that schools would need additional staff support with this.

Pupil characteristics, engagement and motivation

Programmes and initiatives were deemed most successful when pupils were given a central role in delivery. It was reported that pupils who were given leadership roles in the Food Dudes programme (coordinating the completion of level cards and receipt of rewards), valued the responsibility and encouraged their peers to participate. The Food Ambassador programme and School Nutrition Action Group/ School Food Council at several schools, gave pupils a voice over school food policies and healthy eating initiatives, and pupils modelled healthy eating behaviours to their peers. They were considered important strategies for successfully engaging other pupils and fostering ownership. Pupils leading on aspects of programme delivery was not specifically discussed in the Durlak and Dupre model [26].

Factors facilitating sustainability

Continuous engagement in healthy lifestyle programmes and initiatives, was considered critical to successful sustainability of programmes. It was considered that programmes need to be sufficiently long in duration to be effective in changing pupil behaviours and need to be therefore institutionally embedded. Furthermore, regular communication about programmes (assemblies, meetings) between staff and between staff and pupils and reflecting on programme delivery, was considered important to encourage staff and pupil engagement. Developing the expertise to deliver programmes in house, was viewed as equally important for sustainability, to foster autonomy and programme ownership. Sustained commitment and support from head teachers and the senior leadership team towards programmes, was considered important to sustain staff engagement and build capacity. For example, establishing a team of dedicated staff to deliver aspects of programmes long term, for example cooking and gardening clubs after school. Whether ongoing funding was secured was also considered critical for programme sustainability.

Recommendations for overcoming barriers and effective future implementation of healthy lifestyle programmes

Training and support

An important recommendation was to provide all members of staff with adequate training and planning time, to review programme resources and incorporate resources into lesson plans. Training and support should be provided through training workshops (whole-school and one-to-one where necessary), visits, phone calls, emails. Training needs to be interactive and practical, with written materials and sharing of success stories between schools. Staff also need to be given sufficient time to pass on training messages to other members of staff that cannot attend, or new staff. If a programme is to be implemented in September at the start of the next academic year, it was recommended that staff receive the training and resources in May of the previous academic year.

Resources

Staff also recommended easily accessible programme resources, that can be easily adapted, such as online resources. These were thought to save staff time and could be made more appropriate for pupils with different learning abilities. Interactive resources, relating to cooking and growing foods, online activities on tablets (for example interactive quizzes at the end of topics with certificates for completion), online videos and DVDs for pupils of all ages were also recommended. Also considered important were: physical activity resources for after school clubs; programmes that offer sports that appeal to girls, such as girls only football teams; resources with clear and simple learning objectives, cross-referenced to the national curriculum; and more group work resources. Furthermore, it was perceived that growing resources need to factor in time to grow vegetables, and programmes need more age appropriate resources (videos), and culturally appropriate programme messages. For more effective implementation of healthy eating initiatives, there were recommendations for more volunteers to deliver cooking activities after school, improved cooking facilities, and pre-prepared fruit and vegetables for food tasting initiatives, so that catering staff could spend their time on the presentation of fruit and vegetable displays. Furthermore, sufficient storage facilities for fresh produce, would allow programmes such as the Food Dudes and Fuel for School programme to be more easily implemented.

Parent participation and support

Recommended strategies for engaging parents more effectively in programmes included: inviting parents in for school meal taster sessions; healthy food workshops; attendance at School Nutrition Action Group/School Food Council meetings; and after school cooking, gardening and physical activities for parents and pupils to learn together. It was recommended that cooking clubs need to be delivered by a familiar member of staff, rather than somebody external, to appeal to parents. Improved communication about healthy lifestyle programmes between schools and parents (school website, newsletters, meetings), was also recommended.

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