Purpose
A recent Cochrane review with 153 randomized controlled trials (RCTs) investigated the effectiveness of overweight prevention interventions. However, whether primary school-based interventions have a long-term effect on obesity-related outcomes in children, is currently largely unanswered. We aim to investigate these long-term effects on body mass index (BMI), body mass index z-scores (zBMI), waist circumference (WC), waist circumference z-scores (zWC) and weight status.
Methods
A systematic review and meta-analysis were done. Four databases were searched for RCTs and controlled studies from date of inception until June 8^th, 2021. We included articles investigating the long-term effects (≥12 months post-intervention) of primary school-based interventions containing a diet, a physical activity, or both components on outcomes of interest. Articles were assessed on their risk of bias and methodological quality. Meta-analysis was performed on eligible studies and furthermore narrative results were summarized. The quality of evidence was assessed with the GRADE tool.
Results
19 articles were included, of which 9 were pooled in meta-analysis. Follow-up post-intervention ranged between 12 and 168 months. No effects were found on BMI, zBMI and on WC in the pooled analysis. The pooled mean difference between intervention and control groups was 0.08 kg/m² (CI = -0.23, 0.39; N = 7153, Z = 0.50) for BMI, was -0.06 (CI = -0.15, 0.02; N = 3349, Z = 1.51) for zBMI, and was 0.66 cm (CI = -0.23, 1.55; N = 1653, Z = 1.46) for WC. In non-pooled studies, mixed findings were reported regarding the long-term intervention effects on the outcomes BMI, zBMI and weight status and no effects were reported on WC and zWC. Certainty of evidence was rated as either low or very low for all outcomes.
Conclusions
There is no consistent evidence for the long-term effects of primary school-based obesity prevention interventions in children on obesity-related outcomes. Based on the results we recommend policy makers and intervention developers to implement prolonged school-based interventions or additional interventions for children and adolescents for the promotion of healthy lifestyles. Finally, we emphasize the need for more high quality research in this research field.

Purpose

School is an effective venue to improve children’s diet and physical activity through health promotion programs, yet sustaining long-term, school-based program implementation can be challenging. This study aims to describe and evaluate the implementation strategies of the Coordinated Approach To Child Health (CATCH), a teacher-led coordinated school health program proven to improve dietary behaviors and prevent obesity among school children.

Methods

Brighter Bites is a 501c3 non-profit that provides sustained access to fresh produce plus nutrition education in the form of the CATCH program to low-income schools in 6 U.S. cities. CATCH implementation is evaluated annually at the end of each school year through teacher self-reported survey. Data from spring 2016 showed low CATCH implementation, hence Brighter Bites subsequently initiated several strategies to boost implementation, including: setting campus- and class-specific action plans, providing web-based access to CATCH materials and tracking system, providing monthly reports to school leadership, providing annual teacher training and ongoing technical assistance.

We used a serial cross-sectional study design to assess changes over time in implementation outcomes with teacher reported data from two timepoints - end of 2015-2016 (49 schools) and 2017-2018 (65 schools) school years. We used 22 questions to measure implementation on CATCH program activities (15 questions) and other non-CATCH nutrition and physical activity activities in the schools (7 questions). Percent implementation score was computed to standardize scores for each item in both CATCH implementation index and Overall implementation index (CATCH plus non-CATCH activities). Mann-Whitney U-test was used to compute significant changes in implementation indices scores between 2016 and 2018.

Results/Findings

We observed significant increases in %scores of various CATCH implementation activities from spring 2016 to spring 2018, including: identifying healthy foods for students (73.0-95.0, p<.001), posting CATCH/health-related work in classroom/hallways (39.3-50.8, p=.004), discussing CATCH/health-related message with parents (37.4-46.3, p=.026), and using recipes from curriculum or Brighter Bites (23.8-59.8, p<.001). We also observed significant increases in school-level Overall implementation index %mean score (35.6 to 43.6, p=.044), and non-CATCH implementation index %mean score (25.5 to 35.2, p=.002).

Conclusions

Our result suggests developing a comprehensive implementation toolkit was especially successful to sustain CATCH implementation efforts.

Purpose: The multi-strategy Physically Active Children in Education (PACE) intervention effectively increases schools' implementation of physical activity policies. However, PACE may be improved by enhancing its capacity to reach a larger portion of the population (scale-up) while reducing its relative cost. Our aim is to describe the optimisation process we are using to improve PACE for scale-up.

Methods: Optimisation is an emerging field within implementation science involving a cyclical and data-driven process to improve health interventions to achieve pre-specified objectives. The intent is to identify an intervention that is as effective as possible within the resource constraints of end-users (delivery providers and/or target setting). The optimisation of PACE involves sequential stages of research inclusive of randomised controlled trials (RCTs) conducted in NSW, Australia. Within each stage, quantitative and qualitative data from assessments of intervention effectiveness, costs and processes (e.g., acceptability, implementation and mechanisms of action) are used to identify opportunities to incrementally improve PACE for delivery at scale.

Results: Optimisation stage I comprised two randomised and controlled trials of PACE: (i) a 2017 pilot trial in 12 primary schools showed the feasibility and preliminary effectiveness of PACE for improving both schools' policy compliance and students participation in physical activity; (ii) a 2018 implementation trial in 62 primary schools established the effectiveness and cost-effectiveness of PACE as it was originally designed, for improving schools' implementation of a mandatory physical activity policy. Optimisation stage II involved a 2019 randomised and controlled noninferiority trial in 48 primary schools, exploring an adapted PACE model with reduced in-person contact from external support personnel. Findings showed that adapted PACE minimized the relative cost of delivery without adversely impacting on the effect.

Conclusion: The resultant 'optimised' PACE intervention is an effective, cost-effective and scalable model for service delivery. It may set precedence for other jurisdictions where physical activity policy implementation by schools remains an issue. Moreover, the optimisation of PACE is the first of its kind to apply an optimisation process to improve an implementation strategy; thus, providing important information for researchers and policy makers seeking to improve the impact of health interventions. 

Purpose: Many effective public health implementation interventions employ multiple strategies however little is known about the relative contribution of each discrete strategy in achieving desired effects. A mixed methods process evaluation was conducted alongside a cluster randomized noninferiority trial to explore eight discrete implementation strategies used in a multi-strategy intervention (PACE) that increases schools' implementation of a physical activity policy. The objectives were to evaluate: (A) quantitatively, strategy dose, adherence, adoption and acceptability; (B) qualitatively, implementation barriers and facilitators; and (C) integrating both data sets, the importance of each discrete PACE strategy.

Methods: Participating schools were randomly assigned to receive PACE or an adapted model with reduced in-person contact from external support personnel. Data were collected from both active trials arms for between-group comparison. Descriptive statistics were produced using surveys of principals, in-school champions and teachers; and project records maintained by PACE project officers. Thematic analysis was performed using in-school champion and project officer interviews. Both data sets were integrated ('mixed methods') via a triangulation protocol.

Results/findings: Eleven in-school champions and six project officers completed interviews; 33 principals, 51 in-school champions and 260 teachers completed surveys. Regardless of group allocation, each strategy had high outcomes for dose (100%); adherence (≥95%); adoption (≥83%); acceptability (≥50%); and several implementation barriers and facilitators were identified within three broad categories: external policy landscape, inner organizational structure/context of schools, and intervention characteristics and processes. All strategies were considered important as use varied by school; however support from a school executive and in-school champions' interest were suggested as especially important for optimal implementation. 

Conclusions: This study highlights the importance of both executive support and in-school champions for schools' successful implementation of physical activity policies. In particular, identifying and supporting an in-school champion with high power and high interest is recommended. This may reduce the need for intensive external support, thus improving intervention scalability. The PACE implementation strategies are commonly employed to improve the implementation of policies and practices in community settings, therefore the findings may contribute to improving implementation of health interventions broadly.