Research MethodsBarriers and Facilitators for Teachers' Implementation of the Curricular Component of the Boost Intervention Targeting Adolescents' Fruit and Vegetable Intake
Introduction
A high intake of fruit and vegetables (FV) may prevent cardiovascular diseases, obesity, and certain cancers.1, 2, 3 Like children in most Western countries, Danish schoolchildren do not meet the national recommendations of eating at least 600 g (2.5 cups) FV daily4 and their intake decreases as they enter the teen years.5 Eating habits in adult life including intake of FV are established in childhood and early youth.6, 7 Thus it is important to promote increased FV intake among schoolchildren. Multicomponent school-based interventions combining educational and environmental strategies seem effective for this purpose6, 8 but are often poorly implemented.9, 10 Studying barriers and facilitators to implementing intervention components is an important part of process evaluation and may contribute to the interpretation of outcome findings and guide the development of future interventions.11, 12 Many studies have focused on barriers and facilitators to implementing health promotion programs in schools and some address healthy eating and FV programs.13, 14, 15, 16 However, little is known about factors influencing implementation of curricular activities as part of school-based FV interventions targeting adolescents. Most implementation studies have used quantitative methods and assessed implementation level and fidelity.9, 10, 17 Qualitative studies may provide a richer insight into how teachers handle the implementation process, their acceptability of the intervention, and perceived barriers to implementation.11
This study was inspired by Rogers' Diffusion of Innovations Theory.18 According to Rogers (2003), factors essential for implementing an innovation include characteristics of (1) the implementers, including their perceptions of the innovation; and (2) the innovation, including flexibility and contextual appropriateness of the innovation. In accordance with this theory, previous studies of school-based curricular interventions have identified teachers' acceptability of the intervention, commitment to the intervention, and engagement of change agents as facilitating implementation.12, 19, 20 Moreover, teacher training, easily accessible curricular activities, and administrative support facilitate implementation and motivate implementers to use the curriculum.12, 19, 21
Guided by the concepts of Diffusion of Innovations Theory and the findings of previous implementation studies described above, the aim of this study was to identify barriers and facilitators to teachers' implementation of curricular activities in the Danish multicomponent, school-based Boost intervention targeting adolescents' FV intake.
Section snippets
The Boost Study
The Boost intervention combined educational and environmental strategies within the school, home, and local community including curricular activities, free daily delivery of FV at school, parental newsletters, and fact sheets for sports and youth clubs.22 The intervention was implemented for 9 months (September, 2010 to May, 2011) and evaluated in a cluster-randomized controlled trial including 2,289 students in seventh grade (approximately 13-year-olds) from 20 intervention- and 20 control
Results
The majority of the 22 teachers interviewed were women (68%), 50% were Boost coordinators, and 35% were class teachers in seventh grade. The teachers participating represented a wide range of subjects. Most teachers taught Danish classes (61%) whereas equal proportions (26%) taught mathematics and home economics classes. Data collection was ended when new interviews did not add new information, indicating that point of data saturation was reached.30
The presentation of barriers and facilitators
Times Issues
Several studies6, 16, 34 highlight time issues as crucial barriers to implementing school-based interventions. Such interventions are time-consuming and burden teachers. This study emphasizes the importance of accounting for time aspects other than preparation time and intervention duration; time related to contextual factors, such as external ministerial demands and competing interests, must also be considered. However, most teachers who were interviewed reported using the Boost curriculum to
Implications for Research and Practice
The visual maps of Situational Analysis provided this study with different views on how teachers' implementation of the Boost curriculum was framed and influenced by circumstances and contextual problems. This cartographic approach might be useful in future implementation studies to clarify complex data and strengthen the analytical reflectivity. The use of theoretical concepts and existing empirical knowledge on implementation enabled conceptualization and discussion of the findings.
Acknowledgments
The Boost study is part of the Centre for Intervention Research in Health Promotion and Disease Prevention, National Institute of Public Health, University of Southern Denmark. The Centre is funded by TrygFonden and the Danish Cancer Society. Copenhagen Food House contributed financially to the development of the teaching material. The authors thank participating teachers and co-moderators Anne Hjøllund Christiansen and Ida Monrad. They also thank Henriette Langstrup, Associate Professor,
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2021, Preventive Medicine ReportsCitation Excerpt :In addition, teachers’ implementation was also challenged by intervention duration (e.g., 1-year) (Jorgensen et al., 2014). Deterioration in implementation over time was a noted challenge demonstrated previously in similar interventions (Wind et al., 2008; Aarestrup et al., 2014, 2015; Jorgensen et al., 2014) despite evidence that longer interventions (i.e., adequate time and duration) are more effective at promoting health and dietary behavior change than those with only one or a few sessions (Wang and Stewart, 2013; Ciliska et al., 2000; Hoelscher et al., 2002). Health promoters often encounter the problem of motivating schools to participate in such programs because of time constraints.
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2019, Journal of Nutrition Education and BehaviorCurricular activities and change in determinants of fruit and vegetable intake among adolescents: Results from the Boost intervention
2017, Preventive Medicine ReportsCitation Excerpt :It was tested in a school-randomized controlled trial among all seventh grade students (≈ 13-year-olds) from a random sample of 20 intervention and 20 control schools from 10 randomly selected municipalities in Denmark. Implementation of intervention components was monitored by a thorough quantitative and qualitative process evaluation (Aarestrup et al., 2014a; Jørgensen et al., 2014; Aarestrup et al., 2014b; Aarestrup et al., 2015). The Boost intervention is described in details elsewhere (Krølner et al., 2012).
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