Measuring implementation fidelity of school-based obesity prevention programmes: a systematic review

Abstract

BackgroundUntil now, there is no clear overview of how fidelity is assessed in school-based obesity prevention programmes. In order to move the field of obesity prevention programmes forward, the current review aimed to 1) identify which fidelity components have been measured in school-based obesity prevention programmes; 2) identify how fidelity components have been measured; and 3) score the quality of these methods.MethodsStudies published between January 2001–October 2017 were selected from searches in PubMed, EMBASE, PsycINFO, CINAHL, Cochrane Library and ERIC. We included studies examining the fidelity of obesity prevention programmes (nutrition and/or physical activity and/or sitting) at school (children aged 4–18 year) measuring at least one component of implementation fidelity. A data extraction was performed to identify which and how fidelity components were measured. Thereafter, a quality assessment was performed to score the quality of these methods. We scored each fidelity component on 7 quality criteria. Each fidelity component was rated high (> 75% positive), moderate (50–75%) or low (< 50%).ResultsOf the 26,294 retrieved articles, 73 articles reporting on 63 different studies were included in this review. In 17 studies a process evaluation was based on a theoretical framework. In total, 120 fidelity components were measured across studies: dose was measured most often (N = 50), followed by responsiveness (N = 36), adherence (N = 26) and quality of delivery (N = 8). There was substantial variability in how fidelity components were defined as well as how they were measured. Most common methods were observations, logbooks and questionnaires targeting teachers. The quality assessment scores ranged from 0 to 86%; most fidelity components scored low quality (n = 77).ConclusionsThere is no consensus on the operationalisation of concepts and methods used for assessing fidelity in school-based obesity prevention programmes and the quality of methods used is weak. As a result, we call for more consensus on the concepts and clear reporting on the methods employed for measurements of fidelity to increase the quality of fidelity measurements. Moreover, researchers should focus on the relation between fidelity and programme outcomes and determine to what extent adaptations to programmes have been made, whilst still being effective.Electronic supplementary materialThe online version of this article (10.1186/s12966-018-0709-x) contains supplementary material, which is available to authorized users.

Evaluating health promotion in complex adaptive school systems

“…Since HPSF was quite comparable between S1 and S2, and between S3 and S4, we saw an opportunity to explore the moderating role of the school context on the intervention effects of the HPSF. However, a limitation is that we could not determine whether differences in effects between schools were due to differences in the implementation of the HPSF [20,30,88]. Furthermore, two comparisons are still limited; however, we were able to combine the results of both comparisons and form stronger conclusions about the moderating role of the school context.…”

“…A strength of the study is that due to using mixed methods, we were able to employ the principle of data triangulation and combine the accuracy of quantitative questionnaires with in-depth insights afforded by interviews, observations, minutes, and open questions. Triangulation is a strategy that facilitates validation of data through crossverification from different sources [103], and is stimulated by other researchers to employ in process evaluations [88]. Using CARA meant that the researchers in this pilot were not external observers, but actively participating partners in the initiative.…”

“…The Health Promoting School framework as defined by the World Health Organization aims for a whole-school approach, and focuses on reorienting school systems toward health promotion through embedding health and well-being in the curriculum, creating healthy social and physical environments and engaging with parents and the wider community [21]. This concept has shown promise, though several studies (including the Netherlands) indicate that effects are often hampered by underestimation of the challenges associated with implementing meaningful wholesystem changes [20,32,42,88].…”

“…To better understand implementation processes [88], we conducted a process evaluation. In line with recent debates in this research area [47][48][49]52], the focus in this process evaluation was not on the fidelity of intervention components in purely compositional terms, but on adaptation of the intervention and system to one another, and factors crucial for sustained change [88,92]. The aim of the current study was to generate knowledge and experiences on how to implement changes in the complex school system to integrate school health promotion and to share key learning points.…”

“…The Health Promoting School framework, as defined by the World Health Organization, aims for a whole-school approach and it focuses on embedding health and well-being in the curriculum, creating healthy social and physical environments, and engaging with parents and the wider community [21]. However, even though this strategy to integrate health promotion into the whole school system is promising, suboptimal results are often observed, due to, among other things, challenges regarding the implementation of specific health-promoting (HP) changes as part of this school-wide change and how to create a meaningful impact [20,30,32,42,63,88]. To understand these challenges, the suggestion has been made to consider schools as complex adaptive systems [11,153].…”