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

Abstract

BackgroundNumerous 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.MethodsA 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.ResultsExperienced 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.ConclusionsFindings 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.

Assessing the Impacts of Creating Active Schools on Organisational Culture for Physical Activity

“…Consequently, the results from this study indicate that the CAS programme is broadly successful in guiding the development of opportunities for physical activity in schools. These findings contribute to the growing evidence base surrounding whole-school approaches to physical activity, reinforcing the use of CFIR and other implementation frameworks and strategies to create organisational change in schools for physical activity provision [ 31 ]. In alignment with the SWITCH programme—a whole-school approach designed to support school wellness and reduce youth obesity levels—the results showed significant changes to the provision of opportunities for physical activity at an organisational level [ 24 , 31 ].…”

“…These findings contribute to the growing evidence base surrounding whole-school approaches to physical activity, reinforcing the use of CFIR and other implementation frameworks and strategies to create organisational change in schools for physical activity provision [ 31 ]. In alignment with the SWITCH programme—a whole-school approach designed to support school wellness and reduce youth obesity levels—the results showed significant changes to the provision of opportunities for physical activity at an organisational level [ 24 , 31 ]. Results may be similar due to the SWITCH measure of organisational capacity underpinning the current questionnaire [ 24 ].…”

“…Such approaches aim to support longer-term behaviour engagement as teachers can flex programme delivery to meet their unique needs and the dynamic nature of the school environment. Similar to the SWITCH intervention [ 31 ], parents’ behaviour scored lowest pre-intervention and did not improve over the initial nine-month period, suggesting that CAS did not engage parents within the early stages of the intervention. These findings are consistent with the SWITCH programme where parents had low levels of engagement due to reduced representation within the programme [ 24 ].…”

A Health Equity Implementation Approach to Child Health Literacy Interventions

“…The three health equity domains have been integrated into the Consolidated Framework for Implementation Research (CFIR) [ 20 ]. The CFIR is a widely used implementation determinant framework to facilitate design, implementation and evaluation of evidence-based interventions in child health in multiple healthcare [ 30 , 31 ] and non-healthcare (e.g., schools [ 32 , 33 ]) settings. CFIR has five domains—Intervention characteristics, Inner Context, Outer Context, Recipients, and Process—that allow the comprehensive identification and understanding of factors that many determine or predict implementation success.…”

Individual and Contextual Factors Associated with Classroom Teachers’ Intentions to Implement Classroom Physical Activity

“…Given the literature documenting the influence of organizational culture and leadership on teachers’ behaviors, determinants of implementation [ 31 ] are best conceptualized with a systems perspective that considers various levels (e.g., individual, organizational), and interactions across levels. Common determinants include organizational support, social relations, and leadership [ 32 , 33 , 34 ]. Although teachers within a school share a similar context, their perceptions of those environments may differ.…”