Purpose: Understanding the barriers and facilitators which may be related to the sustained implementation of health promotion polices, practices or programmes in educational settings (i.e. schools and childcare services) is needed to maximise public health benefits. Despite being the fundamental building blocks for the development of any implementation support strategies, there are no reviews identifying barriers and facilitators of sustained implementation of chronic disease prevention initiatives in education settings. The primary aim of this review was to identify the factors that support or impede ongoing delivery of physical activity, nutrition, obesity, alcohol and/or tobacco prevention policies, practices or programmes in education settings.

Methods: A systematic search was undertaken in eight data bases for quantitative or qualitative studies that examined childcare, primary or secondary school teachers or administrators barriers or facilitators for maintaining or sustaining a physical activity, nutrition, obesity, alcohol and/or tobacco prevention policy, practice, or programme at least 6 months following implementation support. Following duplicate title and abstract, data from identified articles were extracted and coded against a sustainability framework. 

Results: A total of 11,487 studies were identified through database search and one additional study though reference list searching. 7,856 records were screened after removal of duplicates and 126 full tests were screened. 21 studies were included in the final analysis. Preliminary analysis suggests that most commonly reported barriers to sustaining chronic disease prevention policies, practices or programs in educational settings were; a lack of resources i.e. money, equipment, and space (25 items), as well as a lack of time (13 items). The most commonly reported facilitators included integration of the intervention into the school policy or curriculum (7 items), flexibility/adaptability of the intervention (5 items) and including fun activities in the intervention (5 items).

Conclusions: This is the first review internationally of barriers and facilitators of sustained implementation of prevention initiatives in schools and childcare, providing comprehensive evidence needed to design sustainability interventions in these settings. Strategies that target these factors may represent promising means to improve sustainability of chronic disease prevention policies in these settings.

Purpose: To evaluate the implementation of a free, evidence-based, childhood healthy weights program designed in British Columbia for children (8-12 years old) with a BMI ≥85^th percentile and their families. The 10-week program, based on the multi-process action control theory, consisted of 90-minute weekly group sessions, weekly e-sessions, plus four community-based activities. Topics included healthy eating, physical activity, physical and food literacy, sleep, screen-time, positive mental health and behavior change techniques. Eleven programs ran in seven BC communities (September 2018 - March 2019).

Methods: A mixed-methods concurrent triangulation design assessed implementation at both family and program levels. Family measures were reach, adherence, satisfaction (acceptability), facilitators and barriers. Program delivery measures were adoption, fidelity, compatibility, context, feasibility, acceptability and facilitators and barriers. Qualitative data was collected through parent and Program Facilitator interviews and quantitative data through parent and Program Facilitator surveys, attendance tracking forms and e-session analytics. Interviews were recorded, transcribed using Transcriptive software and categories identified using NVIVO. Quantitative descriptives were generated using SPSS.

Results: 132 families were eligible (n=211 enquiries), and 79 families (88 children) registered (42%). 55 families (63 children) started the program and 80% completed. Of those, 82.5% of families attended 70% of sessions. 26% of families accessed 30%+ of core e-session content. Average contact time was 17.7 hours (range 12.78-25.02 hours). Family participation facilitators were: free of cost, location, sibling inclusion, and complimentary recreation passes. Participation barriers were: other commitments, illness, transportation and scheduling. Program acceptability/satisfaction across parents and children was high, with satisfaction ratings over 4/5 for all measures.

Seven of the nine (78%) communities originally identified as pilot sites implemented the program. Fidelity was 73.5% across program components (range 42-95%). At the delivery-level, implementation facilitators were high compatibility and feasibility, context (support from recreation center, having qualified staff), and resources (room availability, manual, equipment and grant funding). Barriers to implementation were recruitment, small group size, attendance, and limited time to deliver material. Interviews showed Program Facilitator acceptability/satisfaction across all sites.

Conclusions: The FHLP was acceptable and feasible for both families and program delivery partners, but recruitment, attendance, and on-line engagement were challenges.

Purpose: Since 1975 global rates of overweight have almost tripled, increasing the risk of a variety of preventable diseases, such as cardiovascular disease, cancer, and diabetes. Proven effective interventions exist to reduce modifiable risk factors for obesity and mitigate adverse effects. Maximising the benefits of investments in overweight and obesity research requires effective interventions to be adopted and disseminated broadly across populations (scaled-up). However, interventions often need considerable adaptation to enable implementation at scale, a process that can reduce the effects of interventions.

Methods: A systematic review was undertaken for trials that sought to deliver an obesity intervention to populations on a larger scale than a preceding randomised controlled trials that established its efficacy.

Results: Ten scaled-up obesity interventions (six prevention, four treatment) were included. All trials made adaptations to interventions as part of the scale-up process, with mode of delivery adaptations being most common. Meta-analysis of BMI/zBMI from three prevention RCTs found no significant benefit of scaled-up interventions relative to control (SMD=0.03; 95% CI: -0.09, 0.15, p=0.639 – I² = 0.0%). All four treatment interventions reported significant improvement on all measures of weight status. Pooled BMI/zBMI data from prevention trials found significantly lower effects among scaled-up intervention trials than those reported in pre-scale efficacy trials (SMD=-0.11; 95% CI: -0.20, -0.02, p=0.018 – I² = 0.0%).

Across measures of weight status, physical activity/sedentary behaviour and nutrition, the effects reported in scale-up interventions were typically 75% or less of the effects reported in pre-scale-up efficacy trials.

Conclusions: The findings underscore the challenge of scaling-up obesity interventions. Results enable a more realistic appraisal of the likely effects, and reduction in effects, of interventions delivered following scale‐up—providing clearer eyes for decision making.

Purpose: To describe the process of optimising and scaling-up an evidence-based intervention targeting the implementation of dietary guidelines in early childhood and education care (ECEC) centres. To our knowledge, this is the first attempt to describe a systematic process of optimising and scaling-up a nutrition program in ECEC.

Methods: This presentation will provide an overview of the steps we have undertaken to optimise and scale up an implementation intervention in ECEC. As part of this, we undertook a three arm randomised controlled trial in one region in Australia (Hunter New England). The interventions included a high-intensity intervention primarily delivered face-to-face and a low intensity telephone intervention, targeting childcare centre implementation of dietary guidelines on their menus. We undertook a prioritisation process, based on both quantitative and qualitative data to assess suitability of each of the interventions for scale up and which implementation strategies to retain. Finally, we embedded these strategies into an online program and sought to assess the impact of the program on childcare centre menus and child consumption in one state (New South Wales) and centre adoption of the program nationally.

Results/findings: The high intensity intervention resulted in a large effect on improving childcare menus, while the lower intensity was not effective in changing provision of food. We describe the process of translating these interventions into an online program aimed at supporting ECEC centres to plan healthier menus. The online program was highly acceptable among ECEC staff, and effective in increasing child consumption of fruit and reducing consumption of discretionary foods in care. The program was also significantly cost-beneficial relative to usual care in NSW. The intervention has been scaled up and adopted by over 3000 ECEC centres in Australia.

Conclusions: This study describes an innovative process of optimising intensive face-to-face implementation interventions in ECEC for scale up to improve child health, and produce population wide adoption. Such systematic processes are crucial to develop as the health benefits of effective nutrition interventions can only be achieved if they are widely adopted by end-users.

Purpose: Factors within and outside the school environment can affect the degree to which wellness programs are implemented. The Cooperative Extension system in the U.S. provides a way to disseminate evidence-based programs within and across states, but little is known about its impact on school programming. The study addresses this gap by evaluating the influence of Extension on school wellness programming guided by the SWITCH (School Wellness Integration Targeting Child Health) process.

Methods: The study adopts a mixed-methods approach, informed by the Consolidated Framework for Implementation Research (CFIR), to study the facilitators and barriers of school wellness programming. Following the SWITCH capacity-building framework, elementary school (N= 30) wellness teams (SWT) were provided with training, resources, and a web-based platform designed to enhance health behavior change for obesity prevention in youth. The 2019 iteration of SWITCH intentionally promoted support from state Extension staff during implementation, but the SWTs had autonomy over how programming was implemented. Data on school programming efforts were collected from SWTs through 3 standardized surveys (pre-mid-post) and a post-implementation interview. Indicators of school wellness capacity and school wellness environment were assessed using the validated School Wellness Environment Profile (SWEP) and changes (pre-post) analyzed using 2-Way (Time*Extension Support) ANOVA models. Interview data were analyzed using a constant comparison approach, followed by deductive analysis grounded in CFIR concepts, with particular emphasis on the outer setting, inner setting, and process domains.

Results: Quantitative data revealed no significant main or interaction effects for Extension support. Significant main effects of time (p=0.02) for school wellness environment were observed, but not for capacity (p=0.29). Qualitative data demonstrated that factors within the outer setting (e.g., engaging Extension and community partners) facilitated programming. Inner setting factors (high/low support from administration and school staff) significantly affected implementation. Process construct themes (SWT planning, communication, and engaging students) were found to have a positive influence on implementation.

Conclusions: Results highlight the facilitators and barriers of school wellness programming and the supportive influence from Extension and community partners. The mixed-methods framework identified other factors in inner setting and process domains that also explain variability in outcomes of school wellness programming.

Purpose: Incentive-based programs are popular among health insurers to encourage health behaviours. However, little is known about the economic credentials of such programs. This study aimed to determine the cost-effectiveness of the ACHIEVE (Active CHoices IncEntiVE) incentive-based program designed to encourage increased physical activity and reduced sedentary behaviour in middle-aged adults.
Methods: A within-trial cost-efficacy analysis was undertaken and results expressed as the cost per minute reduction in sitting time, cost per Body Mass Index (BMI) unit reduction, and the cost per MET minute increase resulting from the intervention. An additional analysis of the long-term cost-effectiveness of the intervention scaled up to the Australian population was modelled from the health sector perspective. Pathway analysis was used to determine the resource use associated with the intervention. In the scale up scenario, the 16-week intervention was modelled for roll-out across Australia over a 1-year time horizon for people with private health insurance who are insufficiently active. Health-adjusted life years (HALY) gained (based on calculated effects on BMI and MET minutes) and cost-offsets (resulting from reductions in obesity-related diseases) were tracked until the cohort reached age 100 years or death. A 3% discount rate was used and all outcomes are expressed in 2010 values. Simulation modelling techniques were used to present a 95% uncertainty interval around the incremental cost-effectiveness ratio (ICER).
Results: The ACHIEVE intervention cost AUD$110,419 (95% CI: 103,833;114,503), which equates to AUD$1,051 per BMI unit loss, AUD$594 per mean sitting minute reduced per week and AUD$70 per MET minute gained per week. If scaled-up to all eligible Australians, a total of 265,096 participants would be recruited. The mean net cost of the scale-up was AUD$89.9 million (95% CI: AUD$37.6 million; $AUD165 million). Health care cost savings were AUD$17 million (95% CI: AUD$30.5 million; AUD$4.1 million). Total HALYs gained were 4,976 (95% CI: 3,283 to 6,933). The mean ICER was estimated at AUD$18,949 (95% CI: 6,727; 39,271) per HALY gained which is considered cost-effective in the Australian setting.
Conclusion: The study findings suggest that financial incentives are cost-effective in promoting healthy behaviours related to physical activity and sedentary behaviour.