Evaluation of a Large-Scale School Wellness Intervention Through the Consolidated Framework for Implementation Research (CFIR): Implications for Dissemination and Sustainability.

Background: Numerous studies have tested school-based interventions promoting healthy behaviors in youth, but few have integrated dissemination and implementation (D&I) frameworks. Using D&I frameworks can inform if and how an evidence-based intervention is implemented and maintained and provide strategies to address contextual barriers. Such application is necessary to understand how and why interventions are sustained over time. We evaluated a school wellness initiative called SWITCH® (School Wellness Integration Targeting Child Health) to (1) assess implementation outcomes of adoption, fidelity, and penetration, (2) discern implementation determinants through the Consolidated Framework for Implementation Research (CFIR), and (3) examine differences among inexperienced and experienced schools and influential factors to sustainment. Methods: A total of 52 schools from Iowa, United States enrolled in the 2019-2020 iteration of SWITCH (22 inexperienced; 30 experienced). The CFIR guided the adaptation of mixed methods data collection and analysis protocols for school settings. Specific attention was focused on (1) fidelity to core elements; (2) adoption of best practices; and (3) penetration of behavior change practices. Determinants were investigated through in-depth qualitative interviews and readiness surveys with implementation leaders. A systematic process was used to score CFIR domains (between -2 and +2) indicating positive or negative influence. Independent t-tests were conducted to capture differences between samples, followed by a cross-case analysis to compare determinants data. Inductive coding yielded themes related to sustainment of SWITCH beyond formal implementation support. Results: Experienced schools had higher scores on fidelity/compliance (t = -1.86 p = 0.07) and adoption (t = -2.03 p = 0.04). CFIR determinants of innovation source, culture, relative priority, and leadership engagement were positive implementation determinants, whereas tension for change and networks and communications were negative determinants. Distinguishing factors between experienced and inexperienced schools were Readiness for Implementation and Self-efficacy (experienced significantly higher; p < 0.05). Strategies to enhance sustainability were increasing student awareness/advocacy, keeping it simple, and integrating into school culture. Conclusions: Findings provide specific insights related to SWITCH implementation and sustainability but more generalized insights about the type of support needed to help schools implement and sustain school wellness programming. Tailoring implementation support to both inexperienced and experienced settings will ultimately enhance dissemination and sustainability of evidence-based interventions.

Evaluating the implementation of the SWITCH® school wellness intervention and capacity-building process through multiple methods.

BACKGROUND: School wellness programming is important for promoting healthy lifestyles and academic achievement in youth; however, research is needed on methods that can help schools implement and sustain such programs on their own. The purpose of this study was to investigate factors within and outside the school environment that influenced school capacity for implementation and potential sustainability of wellness programming. METHODS: As part of the School Wellness Integration Targeting Child Health (SWITCH®) intervention, elementary school wellness teams (N = 30) were guided through a capacity-building process focused on promoting the adoption of healthy lifestyle behaviors in students. Data on implementation were collected through three standardized surveys and interviews (pre-mid-post) and a post-implementation interview. Indicators of organizational capacity were assessed using the School Wellness Readiness Assessment (SWRA). Paired t-tests were run to assess changes in implementation (classroom, physical education, and lunchroom settings), capacity, and stakeholder engagement over time. One-way analysis of variance (ANOVA) tests were run to examine how implementation of best practices (low, moderate, high) explained differences in capacity gains. Qualitative data were analyzed through inductive and deductive analysis, following the Consolidated Framework for Implementation Research (CFIR). RESULTS: Paired t-tests showed non-significant increases in school and setting-specific capacity and implementation of SWITCH best practices over time, in addition to a consistent level of engagement from key stakeholders. ANOVA results revealed non-significant associations between implementation group and gains in school capacity (F [2, 24] = 1.63; p = .21), class capacity (F [2, 24]=0.20 p = .82), lunchroom capacity (F [2, 24]=0.29; p = .78), and physical education (F [2, 24]=1.45; p = .25). Qualitative data demonstrated that factors within the outer setting (i.e., engaging community partners) facilitated programming. Inner-setting factors (i.e., relationships with administration and staff) influenced implementation. Implementation process themes (e.g., planning, adaptation of resources to meet school capacity/needs, and engaging students as leaders) were cited as key facilitators. Schools discussed factors affecting sustainability, such as school culture and knowledge of school wellness policy. CONCLUSIONS: The results from this implementation study document the importance of allowing schools to adapt programming to meet their local needs, and highlight the strengths of measuring multiple implementation outcomes. Increased support is needed for schools regarding the formation and improvement of wellness policies as a means to enhance sustainability over time.

How Food & Fitness Community Partnerships Successfully Engaged Youth.

Authentic youth engagement was a central component of the Food & Fitness (F&F) Initiative, a 9-year community-based intervention, whose goal was to ensure that all children have equitable access to healthy food and built environments that promote safe physical activity. The youth engagement component focused on strategies and structures that would support a model framework for youth involved in F&F community partnerships. These strategies empowered youth by providing the leadership and technical skills needed in collaborative efforts to sustain change in communities with inequities, where structural racism and inequities result in poor health outcomes for children. This article describes the models that the diverse urban and rural communities across the United States employed to successfully engage youth in the vision and work of F&F and discusses overall lessons learned, challenges, and best practices/recommendations for effectively engaging youth in community-determined change.