Process evaluation of the healthy primary School of the Future: the key learning points

N H M Bartelink, P van Assema, M W J Jansen, H H C M Savelberg, G F Moore, J Hawkins, S P J Kremers, N H M Bartelink, P van Assema, M W J Jansen, H H C M Savelberg, G F Moore, J Hawkins, S P J Kremers

Abstract

Background: While schools have potential to contribute to children's health and healthy behaviour, embedding health promotion within complex school systems is challenging. The 'Healthy Primary School of the Future' (HPSF) is an initiative that aims to integrate health and well-being into school systems. Central to HPSF are two top-down changes that are hypothesized as being positively disruptive to the Dutch school system: daily free healthy lunches and structured physical activity sessions. These changes are expected to create momentum for bottom-up processes leading to additional health-promoting changes. Using a programme theory, this paper explores the processes through which HPSF and the school context adapt to one another. The aim is to generate and share knowledge and experiences on how to implement changes in the complex school system to integrate school health promotion.

Methods: The current study involved a mixed methods process evaluation with a contextual action-oriented research approach. The processes of change were investigated in four Dutch primary schools during the development year (2014-2015) and the first two years of implementation (2015-2017) of HPSF. The schools (each with 15-26 teachers and 233-389 children) were in low socio-economic status areas. Measurements included interviews, questionnaires, observations, and analysis of minutes of meetings.

Results: Top-down advice, combined with bottom-up involvement and external practical support were key facilitators in embedding HPSF within the schools' contexts. Sufficient coordination and communication at the school level, team cohesion, and feedback loops enhanced implementation of the changes. Implementation of the healthy lunch appeared to be disruptive and create momentum for additional health-promoting changes.

Conclusions: Initiating highly visible positive disruptions to improve school health can act as a catalyst for wider school health promotion efforts. Conditions to create a positive disruption are enough time, and sufficient bottom-up involvement, external support, team cohesion and coordination. The focus should be on each specific school, as each school has their own starting point and process of change.

Trial registration: The study was retrospectively registered in the ClinicalTrials.gov database on 14 June 2016 (NCT02800616).

Keywords: Action research; Complex systems; Context; Implementation; Mixed methods; School health promotion.

Conflict of interest statement

GM is part of the editorial board of BMC Public Health. The other authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Programme theory

References

    1. Dooris Mark, Poland Blake, Kolbe Lloyd, de Leeuw Evelyne, McCall Douglas S., Wharf-Higgins Joan. Global Perspectives on Health Promotion Effectiveness. New York, NY: Springer New York; 2007. Healthy Settings; pp. 327–352.
    1. Langford R, Campbell R, Magnus D, Bonell CP, Murphy SM, Waters E, et al. The WHO health promoting school framework for improving the health and well-being of students and staff. Cochrane Database Syst Rev. 2011;1.
    1. Bonell C, Parry W, Wells H, Jamal F, Fletcher A, Harden A, et al. The effects of the school environment on student health: a systematic review of multi-level studies. Health Place. 2013;21:180–191.
    1. Suhrcke M, de Paz Nieves C. The impact of health and health behaviours on educational outcomes in high-income countries: a review of the evidence: World Health Organization. Denmark: Regional Office for Europe Copenhagen; 2011.
    1. Fiscella K., Kitzman H. Disparities in Academic Achievement and Health: The Intersection of Child Education and Health Policy. PEDIATRICS. 2009;123(3):1073–1080.
    1. Leurs MT, Schaalma HP, Jansen MW, Mur-Veeman IM, St. Leger LH, De Vries N. Development of a collaborative model to improve school health promotion in the Netherlands. Health Promot Int. 2005;20(3):296–305.
    1. WHO. Promoting health through schools: report of a WHO expert committee on comprehensive school health education and promotion. 1997.
    1. WHO. Health promoting schools: A framework for action. Manila, Philippines: World Health Organization Western Pacific Region. 2009.
    1. Deschesnes M, Martin C, Hill AJ. Comprehensive approaches to school health promotion: how to achieve broader implementation? Health Promot Int. 2003;18(4):387–396.
    1. Darlington EJ, Violon N, Jourdan D. Implementation of health promotion programmes in schools: an approach to understand the influence of contextual factors on the process? BMC Public Health. 2018;18(1):163.
    1. Keshavarz N, Nutbeam D, Rowling L, Khavarpour F. Schools as social complex adaptive systems: a new way to understand the challenges of introducing the health promoting schools concept. Soc Sci Med. 2010;70(10):1467–1474.
    1. Schaap R, Bessems K, Otten R, Kremers S, van Nassau F. Measuring implementation fidelity of school-based obesity prevention programmes: a systematic review. Int J Behav Nutr Phys Act. 2018;15(1):75.
    1. Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350:h1258.
    1. Owen B, Brown AD, Kuhlberg J, Millar L, Nichols M, Economos C, et al. Understanding a successful obesity prevention initiative in children under 5 from a systems perspective. PLoS One. 2018;13(3):e0195141.
    1. Hawe P, Shiell A, Riley T. Theorising interventions as events in systems. Am J Commun Psychol. 2009;43(3–4):267–276.
    1. Mason M. What is complexity theory and what are its implications for educational change? Educ Philos Theory. 2008;40(1):35–49.
    1. Gubbels JS, Van Kann DH, de Vries NK, Thijs C, Kremers SP. The next step in health behavior research: the need for ecological moderation analyses-an application to diet and physical activity at childcare. Int J Behav Nutr Phys Act. 2014;11(1):52.
    1. Young I, St Leger L, Buijs G. School health promotion: evidence for effective action. Background paper SHE factsheet. 2013;2.
    1. Willeboordse M, Jansen M, van den Heijkant S, Simons A, Winkens B, de Groot R, et al. The healthy primary School of the Future: study protocol of a quasi-experimental study. BMC Public Health. 2016;16(1):1.
    1. Hawe P. Lessons from complex interventions to improve health. Annu Rev Public Health. 2015;36:307–323.
    1. Patton MQ. Developmental evaluation: applying complexity concepts to enhance innovation and use. New York: Guilford Press; 2011.
    1. Rutter H, Savona N, Glonti K, Bibby J, Cummins S, Finegood DT, et al. The need for a complex systems model of evidence for public health. Lancet 2017.
    1. Bartelink NH, van Assema P, Jansen MW, Savelberg HH, Willeboordse M, Kremers SP. The healthy primary School of the Future: a contextual action-oriented research approach. Int J Environ Res Public Health. 2018;15(10):2243.
    1. Poland B, Krupa G, McCall D. Settings for health promotion: an analytic framework to guide intervention design and implementation. Health Promot Pract. 2009;10(4):505–516.
    1. Fleuren MA, Paulussen TG, Van Dommelen P, Van Buuren S. Towards a measurement instrument for determinants of innovations. Int J Qual Health C. 2014;26(5):501–510.
    1. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322–1327.
    1. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):1.
    1. Durlak JA, DuPre EP. Implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation. Am J Community Psychol. 2008;41(3–4):327–350.
    1. Pearson M, Chilton R, Wyatt K, Abraham C, Ford T, Woods HB, et al. Implementing health promotion programmes in schools: a realist systematic review of research and experience in the United Kingdom. Implement Sci. 2015;10(1):149.
    1. Moore GF, Evans RE, Hawkins J, Littlecott H, Melendez-Torres G, Bonell C, et al. From complex social interventions to interventions in complex social systems: future directions and unresolved questions for intervention development and evaluation. Evaluation. 2019;25(1):23–45.
    1. Van Kann DH, Jansen M, De Vries S, De Vries N, Kremers S. Active living: development and quasi-experimental evaluation of a school-centered physical activity intervention for primary school children. BMC Public Health. 2015;15(1):1315.
    1. Schils T. Leerlingen in het voortgezet onderwijs: wie zitten daar? Hoe zitten ze in hun vel? Hoe slim zijn ze? [Pupils in secondary education: who are they? What is their sense of self-worth? How smart are they?] Kaans reports K04201102-K04201104. Maastricht: Kaans/Maastricht University School of business and economics; 2011.
    1. Vermeer AJMBN, Hesdahl MH, Janssen-Goffin MJH, Linssen ECAJ, Rutten N, Hajema KJ. Lokale rapporten Volksgezondheid Toekomst Verkenning: Een nieuwe kijk op gezondheid in Heerlen, Kerkrade, Landgraaf en Brunssum; [Local reports on Public Health Development: A new perspective on health in Heerlen, Kerkrade, Landgraaf and Brunssum] GGD Zuid Limburg: Geleen; 2014.
    1. Gevers Dorus, Kremers Stef, de Vries Nanne, van Assema Patricia. The Comprehensive Snack Parenting Questionnaire (CSPQ): Development and Test-Retest Reliability. International Journal of Environmental Research and Public Health. 2018;15(5):862.
    1. O’Connor TM, Cerin E, Hughes SO, Robles J, Thompson DI, Mendoza JA, et al. Psychometrics of the preschooler physical activity parenting practices instrument among a Latino sample. Int J Behav Nutr Phys Act. 2014;11(1):3.
    1. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.
    1. Lipsey MW. Design sensitivity: statistical power for experimental research. Pugey: Sage, 1990.
    1. Shinde S, Weiss HA, Varghese B, Khandeparkar P, Pereira B, Sharma A, et al. Promoting school climate and health outcomes with the SEHER multi-component secondary school intervention in Bihar, India: a cluster-randomised controlled trial. Lancet. 2018;392(10163):2465–2477.
    1. Gubbels JS, Gerards SM, Kremers SP. Use of food practices by childcare staff and the association with dietary intake of children at childcare. Nutrients. 2015;7(4):2161–2175.
    1. Boonen A, de Vries N, de Ruiter S, Bowker S, Buijs G. HEPS Guidelines. NIGZ, Woerden, The Netherlands: Guidelines on Promoting Healthy Eating and Physical Activity in Schools; 2009.
    1. Rogers EM. Diffusion of preventive innovations. Addict Behav. 2002;27(6):989–993.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj