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A mixed-methods exploration of implementation of a comprehensive school healthy eating model one year after scale-up

  • Patti-Jean Naylor (a1), Heather A McKay (a2), Maria Valente (a3) and Louise C Mâsse (a3)
Abstract Objective

To study the implementation of a school-based healthy eating (HE) model one year after scale-up in British Columbia (BC). Specifically, to examine implementation of Action Schools! BC (AS! BC) and its influence on implementation of classroom HE activities, and to explore factors associated with implementation.


Diffusion of Innovations, Social Cognitive and Organizational Change theories guided our approach. We used a mixed-methods research design including focus group interviews (seven schools, sixty-two implementers) and a cross-sectional multistage survey to principals (n 36, 92 % response rate) and teachers of grades 4 to 7 (n 168, 70 % response rate). Self-reported implementation of classroom HE activities and reported use of specific AS! BC HE activities were primary implementation measures. Thematic analysis of focus group data and multilevel mixed-effect logistic regression analyses of survey data were conducted.


Elementary schools across BC, Canada.


Thirty-nine school districts, thirty-six principals, 168 grade 4 to 7 teachers.


Forty-two per cent of teachers in registered schools were implementing AS! BC HE in their classrooms. Users were 6·25 times more likely to have delivered a HE lesson in the past week. Implementation facilitators were school champions, technical support and access to resources; barriers were lack of time, loss of leadership or momentum. Implementation predictors were teacher training, self-efficacy, experience with the physical activity component of AS! BC, supportive school climate and parental post-secondary education.


Our findings reinforce that continued teacher training and support are important public health investments that contribute to successful implementation of school-based HE models after scale-up.

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1. Condon C (2006) The fat bomb exploded but no one heard the bang. Eur J Cardiovasc Nurs 5, 99101.
2. Hill JO & Melanson EL (1999) Overview of the determinants of overweight and obesity: current evidence and research issues. Med Sci Sports Exerc 31, 11 Suppl. S515S521.
3. Institute of Medicine (2005) Preventing Childhood Obesity: Health in the Balance. Washington, DC: The National Acadamies Press.
4. Macdonald HM, Kontulainen SA, Petit MA et al. (2008) Does a novel school-based physical activity model benefit femoral neck bone strength in pre- and early pubertal children? Osteoporos Int 19, 14451456.
5. Wu XY, Ohinmaa A & Veugelers PJ (2012) Diet quality, physical activity, body weight and health-related quality of life among grade 5 students in Canada. Public Health Nutr 15, 7581.
6. Shields M (2006) Overweight and obesity among children and youth. Health Rep 17, issue 3, 2742.
7. Plotnikoff RC, Karunamuni N, Spence JC et al. (2009) Chronic disease-related lifestyle risk factors in a sample of Canadian adolescents. J Adolesc Health 44, 606609.
8. Lazarou C, Panagiotakos DB & Matalas AL (2009) Lifestyle factors are determinants of children's blood pressure levels: the CYKIDS study. J Hum Hypertens 23, 456463.
9. Moriarty-Kelsey M & Daniels SR (2010) Childhood obesity is the fuel that fires adult metabolic abnormalities and cardio-vascular disease. Child Obes 6, 250256.
10. Harding S, Maynard MJ, Cruickshank K et al. (2008) Overweight, obesity and high blood pressure in an ethnically diverse sample of adolescents in Britain: the Medical Research Council DASH study. Int J Obes (Lond) 32, 8290.
11. Wechsler H, Devereaux RS, Davis M et al. (2000) Using the school environment to promote physical activity and healthy eating. Prev Med 31, Suppl. 2, S121S137.
12. Institute of Medicine (2012) Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. Washington, DC: The National Academies Press.
13. Carter MA & Swinburn B (2004) Measuring the ‘obesogenic’ food environment in New Zealand primary schools. Health Promot Int 19, 1520.
14. de Sa J & Lock K (2008) Will European agricultural policy for school fruit and vegetables improve public health? A review of school fruit and vegetable programmes. Eur J Public Health 18, 558568.
15. Knai C, Pomerleau J, Lock K et al. (2006) Getting children to eat more fruit and vegetables: a systematic review. Prev Med 42, 8595.
16. Flynn MA, McNeil DA, Maloff B et al. (2006) Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with ’best practice’ recommendations. Obes Rev 7, Suppl. 1, 766.
17. Sharma M (2006) School-based interventions for childhood and adolescent obesity. Obes Rev 7, 261269.
18. French SA & Stables G (2003) Environmental interventions to promote vegetable and fruit consumption among youth in school settings. Prev Med 37, 593610.
19. Glasgow RE (2008) What types of evidence are most needed to advance behavioral medicine? Ann Behav Med 35, 1925.
20. Klesges LM, Dzewaltowski DA & Glasgow RE (2008) Review of external validity reporting in childhood obesity prevention research. Am J Prev Med 34, 216223.
21. Durlak JA & DuPre EP (2008) Implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation. Am J Community Psychol 41, 327350.
22. Milat AJ, King L, Bauman AE et al. (2012) The concept of scalability: increasing the scale and potential adoption of health promotion interventions into policy and practice. Health Promot Int 28, 285298.
23. Gugglberger L & Dur W (2011) Capacity building in and for health promoting schools: results from a qualitative study. Health Policy 101, 3743.
24. Rohrbach LA, Grana R, Sussman S et al. (2006) Type II translation: transporting prevention interventions from research to real-world settings. Eval Health Prof 29, 302333.
25. Owen N, Glanz K, Sallis JF et al. (2006) Evidence-based approaches to dissemination and diffusion of physical activity interventions. Am J Prev Med 31, 4 Suppl. S35S44.
26. Dunn AL & Bettinghaus EP (2006) Diffusion and dissemination for increasing physical activity in world populations. Am J Prev Med 31, 4 Suppl. S94S96.
27. Buller DB (2006) Diffusion and dissemination of physical activity recommendations and programs to world populations. Am J Prev Med 31, 4 Suppl. S1S4.
28. Oldenburg B & Parcel GGS (2002) Diffusion of innovations. In Health Behavior and Health Education, 2nd ed., pp. 312334 [K Glanz, BK Rimer and BM Lewis, editors]. San Francisco, CA: Jossey-Bass.
29. Hoelscher DM, Kelder SH, Murray N et al. (2001) Dissemination and adoption of the Child and Adolescent Trial for Cardiovascular Health (CATCH): a case study in Texas. J Public Health Manag Pract 7, 90100.
30. Naylor PJ, Macdonald HM, Reed KE et al. (2006) Action Schools! BC: a socioecological approach to modifying chronic disease risk factors in elementary school children. Prev Chronic Dis 3, A60.
31. Naylor PJ, Macdonald HM, Warburton DE et al. (2008) An active school model to promote physical activity in elementary schools: Action Schools! BC. Br J Sports Med 42, 338343.
32. Reed KE, Warburton DE, Macdonald HM et al. (2008) Action Schools! BC: a school-based physical activity intervention designed to decrease cardiovascular disease risk factors in children. Prev Med 46, 525531.
33. Kumanyika S (2012) Raising the bar for research to lower the weight of the population. Health Educ Behav 39, 383385.
34. Wiecha JL, El Ayadi AM, Fuemmeler BF et al. (2004) Diffusion of an integrated health education program in an urban school system: planet health. J Pediatr Psychol 29, 467474.
35. Gittelsohn J, Merkle S, Story M et al. (2003) School climate and implementation of the Pathways study. Prev Med 37, 6 Pt 2, S97S106.
36. Johnson CC, Li D, Galati T et al. (2003) Maintenance of the classroom health education curricula: results from the CATCH-ON study. Health Educ Behav 30, 476488.
37. Lytle LA, Ward JL, Nader PR et al. (2003) Maintenance of a health promotion program in elementary schools: results from the Catch-on study key informant interviews. Health Educ Behav 30, 503518.
38. Macdonald HM, Kontulainen SA, Khan KM et al. (2007) Is a school-based physical activity intervention effective for increasing tibial bone strength in boys and girls? J Bone Miner Res 22, 434446.
39. Day ME, Strange KS, McKay HA et al. (2008) Action Schools! BC–Healthy Eating: effects of a whole-school model to modifying eating behaviours of elementary school children. Can J Public Health 99, 328331.
40. Mâsse LC, McKay H, Valente M et al. (2012) Physical activity implementation in schools: a 4-year follow-up. Am J Prev Med 43, 369377.
41. Ryan F, Coughlan M & Cronin P (2007) Step-by-step guide to critiquing research. Part 2: Qualitative research. Br J Nurs 16, 738744.
42. Rimer BK, Glanz K & Rasband G (2001) Searching for evidence about health education and health behavior interventions. Health Educ Behav 28, 231248.
43. McKenzie TL, Li D, Derby CA et al. (2003) Maintenance of effects of the CATCH physical education program: results from the Catch-on Study. Health Educ Behav 30, 447462.
44. Rogers EM (2003) Diffusion of Innovations, 5th ed. New York: Free Press.
45. Steckler A, Goodman RM & Kegler MC (2002) Mobilizing organizations for health enhancement: theories of organizational change. In Health Behavior and Health Education, 2nd ed., pp. 335360 [K Glanz, BK Rimer and BM Lewis, editors]. San Francisco, CA: Jossey-Bass.
46. Hanson WE, Creswell JW, Clark VLP et al. (2005) Mixed methods research designs in counseling psychology. J Couns Psychol 52, 224235.
47. Steckler A, Goodman RM, McLeroy KR et al. (1992) Measuring the diffusion of innovative health promotion programs. Am J Health Promot 6, 214224.
48. Goodman RM, McLeroy KR, Steckler AB et al. (1993) Development of level of institutionalization scales for health promotion programs. Health Educ Q 20, 161178.
49. Brenowitz N & Tuttle CR (2003) Development and testing of a nutrition-teaching self-efficacy scale for elementary school teachers. J Nutr Educ Behav 35, 308311.
50. Corbin J & Strauss A (2008) Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory, 3rd ed. Thousand Oaks, CA: SAGE Publications.
51. Dollahite J, Hosig KW, Adeletti White K et al. (1998) Impact of a school-based community intervention program on nutrition knowledge and food choices in elementary school children in rural Arkansas Delta. Health Educ Behav 30, 463475.
52. Kelder SH, Mitchell PD, McKenzie TL et al. (2003) Long-term implementation of the CATCH physical education program. Health Educ Behav 30, 463475.
53. Osganian SK, Parcel GS & Stone EJ (2003) Institutionalization of a school health promotion program: background and rationale of the CATCH-ON study. Health Educ Behav 30, 410417.
54. Story M, Mays RW, Bishop DB et al. (2000) 5-a-day Power Plus: process evaluation of a multicomponent elementary school program to increase fruit and vegetable consumption. Health Educ Behav 27, 187200.
55. Weiss EH & Kien CL (1987) A synthesis of research on nutrition education at the elementary school level. J Sch Health 57, 813.
56. Singh AS, Chinapaw MJ, Brug J et al. (2009) Process evaluation of a school-based weight gain prevention program: the Dutch Obesity Intervention in Teenagers (DOiT). Health Educ Res 24, 772777.
57. Hoelscher DM, Feldman HA, Johnson CC et al. (2004) School-based health education programs can be maintained over time: results from the CATCH Institutionalization study. Prev Med 38, 594606.
58. Riis J, Grason H, Strobino D et al. (2012) State school policies and youth obesity. Matern Child Health J 16, Suppl. 1, S111S118.
59. Damschroder LJ, Aron DC, Keith RE et al. (2009) Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 4, 50.
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