Background
Methods
Aim and setting of the study
Case selection
General information on intervention/policy | Case selection | ||||||
---|---|---|---|---|---|---|---|
Country | Name of intervention/policy | Short description of intervention/ policy | Target group | Implementation status | Intervention/policy well-described? | Intervention/ policy evidence-based? | Intervention/ policy feasible and transferable? |
Belgium | A multi-strategy community-based intervention to promote PA in adults. A local media campaign, a website, environmental approaches, the sale and loan of pedometers, and several local PA projects were concurrently implemented. | Adults aged 18 or older | Currently implemented | Yes | Yes | Yes | |
Belgium | Tutti Frutti (intervention) [18] | Tutti Frutti is a fruit and vegetables project carried out in Flemish schools. The project aim is that schools choose one or more fixed days per week on which children can eat a piece of fruit or vegetable during the break. | Primary school children (6–12 years old) | Currently implemented | Yes | Yes | Yes |
Germany | IDEFICS is a lifestyle intervention (diet, PA, stress reduction) for the prevention of childhood obesity which was implemented in various settings (i.e., kindergarten, schools, communities) and targeted children and (grand)parents, as well as stakeholders in these settings. | Preschool and school children | Completed in 2012 | Yes | Yes | Yes | |
Germany | Federal state offices coordinating networks for the provision of healthy food options in schools (policy) [24] | The ‘Federal state offices coordinating networks for the provision of healthy food options in schools’ supports schools nationwide to develop and improve the quality of a balanced meal selection in schools. | School children | Currently implemented | Yes | Partly | Partly |
Ireland | Food Dudes Healthy Eating Programme (intervention) [21] | The aim of this intervention is to increase school children’s consumption of fruits and vegetables at school and at home. | School children | Currently implemented | Yes | Yes | Yes |
Ireland | Green Schools Programme Active travel theme (intervention) [22] | The aim of this intervention is to promote sustainable modes of transport to school (e.g., walking, cycling) and carpooling, and public transport use. | School children | Currently implemented | Yes | Partly | Yes |
Norway | Keyhole labelling (policy) [25] | The aim of this policy is to make it easier to choose healthier foods. | General population | Currently Implemented | Yes | Yes | Partly |
Norway | The aim of this policy is to make school children and adolescents consume more fruit and vegetables. | School children and adolescents | Ended in 2014 | Yes | Yes | Partly | |
Poland | European Schools for Healthy Food - Slow Food in the Canteen (intervention) [23] | The intervention promotes the consumption of fresh healthy food in canteens at primary schools. | Primary school children | Currently implemented | Yes | Yes | Yes |
Poland | Fit student (policy) [28] | The main objective of this policy is to prevent obesity among children and adolescents by identifying students at risk for obesity. | School children | Currently implemented | Yes | Yes | Yes |
Poland | Tasty, Healthy, Valuable (policy) [29] | This policy is aimed toward promoting a healthy diet through advice provided by a municipality-employed specialist (nutrition advisor) who visits the participating schools and provides detailed informational support regarding options for changing the assortment of school shops and by changing the style of cooking in canteens. | Primary school children | Currently implemented | Yes | Yes | Yes |
Poland | Fit city (policy) [30] | The main aim of this policy is to form pro-health behaviors in the local community. | General population living in Wroclaw city | Currently implemented | Yes | Yes | Yes |
Description of intervention cases
Description of policy cases
Interview participants
Case study | Interviewees | ||||
---|---|---|---|---|---|
Project coordination | Implementer (e.g., school staff) | Government | Other stakeholder | Total | |
Belgium | |||||
Intervention: 10,000 steps | 2 | 0 | 0 | 0 | 2 |
Intervention: Tutti Frutti | 1 | 0 | 1 | 0 | 2 |
Germany | |||||
Intervention: IDEFICS | 1 | 2 | 0 | 1 | 4 |
Policy: Federal state offices coordinating networks for the provision of healthy food options in schools | 0 | 3 | 0 | 0 | 3 |
Ireland | |||||
Intervention: Food Dudes Healthy Eating Programme | 2 | 3 | 1 | 1 | 7 |
Intervention: Green Schools Programme - Travel theme | 3 | 3 | 1 | 1 | 8 |
Norway | |||||
Policy: Keyhole labelling | 2 | 0 | 0 | 1 | 3 |
Policy: Free school fruit | 1 | 0 | 1 | 1 | 3 |
Poland | |||||
Intervention: European Schools for Healthy Food - Slow Food in the Canteen | 0 | 2 | 0 | 0 | 2 |
Policy: Fit Student | 2 | 0 | 0 | 0 | 2 |
Policy: Tasty, Healthy, Valuable | 1 | 1 | 0 | 0 | 2 |
Policy: Fit City | 1 | 1 | 0 | 0 | 2 |
Total | 15 | 15 | 7 | 3 | 40 |
Data collection
Interview guides
Data analysis
Results
Facilitating factors | |
Adoption | |
Staff expertise for implementation | “.. all of those decisions were very practically driven and very much…what will work on the ground, what do we do know from our experience, [name] is a former teacher as well so the two of us can be really advocating for teachers and explaining how schools operate and what would…and knowing what would work and what would not.” [Ireland, Food Dudes Healthy Eating Programme] |
Training for implementation | “… of course, we trained the employees in regard to the different modules and the structure of the intervention, as well as, certainly, regarding goals and main objectives, or target group. All of this was practiced in a four-day-workshop at the time, if I remember it correctly.” [Germany, IDEFICS] |
Communication and collaboration | “Within the Flemish Government, we have a very good collaboration for this project, which is a positive thing. […] Within the Government, we work together with different policy domains, but we also have private organisations such as VIGEZ (Flemish expertise center for health promotion and disease prevention) that are connected with the department of health, but actually it is a private organization.” [Belgium, Tutti Frutti] “…now some local authorities are brilliant, like the Road Safety Officers would have their job in schools and talk about road safety and they’ve really teamed up with us, they go into our schools and talk about road safety.” [Ireland, Food Dudes Healthy Eating Programme] |
Implementation | |
Delivery characteristics: dose & fidelity | “This means that activities or measures which had been implemented in the settings were scrutinized for completeness and that [the documentation forms] were completed together with all participants of each monthly round table meeting in order to be able to keep close track of the processes and the implementation of activities and to determine afterwards what had been implemented and what had already been part of the curriculum.” [Germany, IDEFICS] |
Adjustments and customizations | “…with special schools it’s been very much about working with the teachers in those schools to apply the principles behind the programme, em but to match them to the needs of the children and their specific need. So even within a class in a special school there might be different children who are being rewarded for doing different things…for some if they have a terrible aversion to em to bananas or yellow foods, then just to even have the banana in the same room as them might be a huge (prompt) step forward and it’s about edging them closer and closer to eating.” [Ireland, Food Dudes Healthy Eating Programme] “They have the freedom to use their own logo, house style, communication strategies and even another intervention ‘name’.” [Belgium, 10,000 steps] “We designed a system whereby the rewards would be packaged and labelled per phase and per day. So phase 1 box would arrive…it could be packed per classroom as well. So the teacher would open the box for his or her own classroom inside that would be all the phase 1 rewards, clearly packaged and labelled day 1 reward, day 2 reward, day 3 and so forth for the 16 days and that they would have if they had 28 in their class, they’d have 28 pencils or 28 sharpeners or they’d have …the number predefined. Em and then the same for phase 2 that everything was clearly labelled.” [Ireland, Food Dudes Healthy Eating Programme] “We have a few children that maybe just wouldn’t kind of like fruit and veg at all. And they actually did try it, because they really wanted the prize”. [Ireland, Food Dudes Healthy Eating Programme] |
Characteristics of the setting affecting delivery/ implementation | “I think engagement of both principals and teachers is important.” [Belgium, Tutti Frutti] “… what settings we address, what setting is probably not quite appropriate. Keywords here are e.g.: child day care centers which had a different pedagogical approach, e.g., day care centers for children with speech problems, Waldorf or Montessori kindergartens. These are day care centers which could only to a small extent identify with our concept. The selection and the tips, of course, were given to us in the round table meetings because representatives from these settings were already present.” [Germany, IDEFICS] “Internal attitude, this inner motivation, the awareness of the importance of the programme (...) You have to catch the bug yourself, even just taking the lifestyle.” [Poland, European Schools for Healthy Food – Slow Food in the Canteen] |
Implementation process evaluation | “Yes, there have been 2 evaluations already. One in 2006 and 2007. So before it became a European story. That was a process evaluation and effect evaluation.” [Belgium, Tutti Frutti] “We have a monitoring survey every 3 years in which the following is checked: how is education for physical activity taken care of? What type of methods do you adopt? What are your facilitating factors? For 10,000 Steps, we also ask about the adoption rate and the degree of anchoring.” [Belgium, 10,000 steps] |
Maintenance | |
Dissemination | “We keep on informing the schools. Every school year, we send a newsletter to the schools with information about the project. This is also available on our website. We have the Facebook-page which gives some ludic information, some nice recipes, some activities that are being carried out, or some schools who organize activities and send us the pictures of these activities. In this way, we try to pass on as much information as possible.” [Belgium, Tutti Frutti] “We managed to organize a conference, where we invited representatives from the local government. It was also attended by health and safety representatives (…) we prepared a recording of it for the TV station.” [Poland, European Schools for Healthy Food – Slow Food in the Canteen] |
Obstacles | |
Adoption | |
Communication and collaboration | “Often, only the sport services are implementing ‘10,000 Steps’, while the other sectors are even not aware of this. So this means that a part of the evidence-based character of the intervention is not fulfilled, as there should be strategies in all contexts in which physical activity can occur: home, work, leisure and transport. Without communication between the sectors, not all contexts are being targeted properly.” [Belgium, 10,000 steps] |
Implementation | |
Adjustments and customizations | “… the accompanying materials were in some cases considered not as very fitting [the needs of the target group] by some colleagues.” [Germany, IDEFICS] “It is not the case that we have ready-to-use materials for each and every single group: ‘OK, you work with this group? Here you have this to use’, it is not like that.” [Belgium, 10,000 steps] |
Accessibility and time issues | “It might have been wrongly judged, as the e-portal is not very easy for everyone, especially not for schools.” [Belgium, Tutti Frutti] “We have lost members of our round table meetings because the strict requirements for documentation were so time-consuming that some lost their enthusiasm at some point or another.” [Germany, IDEFICS] “We are an infant school so we have a limited number of hours every day in an already overloaded curriculum so. That was the concern that we had going into it.” [Ireland, Food Dudes Healthy Eating Programme] |
Cultural context | “…it’s not the boys are more expendable but they are expected to do slightly dangerous things. Girls are expected not to. They are expected to be on the pink bike going around the park with their pals not out on the road.” [Ireland, Green Schools Programme - Travel theme] “... changes to the norms or family values, that is a big challenge in DEIS (disadvantaged) schools, if you give people fruit and veg in a school and then they go home and their mammies give them a batter burger and chips.” [Ireland, Food Dudes Healthy Eating Programme] |
Costs and funding/ resources needed for delivery | “In small municipalities there is for example no health promotion department and therefore a lack of time and manpower to implement the intervention. Also the crisis can cause a lack of funding.” [Belgium, 10,000 steps] “The reach of the intervention decreases when there is no guaranty that the consumer will have step counters. This is the biggest threat for the intervention, especially in disadvantage groups, as there is often a need for external funding to implement step counters”. [Belgium, 10,000 steps] |
Characteristics of the settings affecting delivery/ implementation | “A switch in personnel can be ‘deadly’. If someone implementing the intervention is leaving, a lot of knowledge and networking contacts can be lost if a new staff member is not oriented soon.” [Belgium, 10,000 steps] “The internal organization of the schools, which is also a problem. That is something that we have known for a while now. But we cannot do anything about it with the Flemish Government.” [Belgium, Tutti Frutti] “Particularly academic stakeholders, such as teachers, are always more difficult. Kindergarten educators, for example, a large group, proved much more cooperative than persons higher in the social hierarchy such as teachers, who were very discerning to the point that some of them left altogether.” [Germany, IDEFICS] “If we had more money we could have a proper kitchen (...) the lady [the cook] has to finish preparing lunch and so they [students] have to meet up in the afternoon or early in the morning so that they are not interrupting their normal work. They would need a place for themselves, with equipment so that they could cook for themselves.” [Poland, European Schools for Healthy Food – Slow Food in the Canteen] “…not just in the rural environment, in some urban schools too…children have to travel right out of their estates along a main road to the school as opposed to having permeability through their local estates.” [Ireland, Green Schools Programme - Travel theme] “…because this is quite a new school, em there was em difficulties with getting the pathways and the roadways finished outside. And so everything inside the school was done, pathways and cycle lanes and cycle huts and stuff, but it was outside on the road here. So it was difficult for us to be promoting something until that really had changed.” [Ireland, Green Schools Programme - Travel theme] |
Facilitating factors | |
Adoption | |
Training for implementation | “We organized individual meetings with each group of implementers. We also conducted a content and organizational training. In terms of the implementation of the programme, we showed what the programme should look like in terms of what we require. We had further training delivered by specialists from the Medical University and the University of Life Sciences.” [Poland, Fit Student] |
Adoption in physical environment | “The fact that there was a type of subscription scheme maybe also was a factor that supported the implementation of free school fruit.” [Norway, Free school fruit program] “This programme functions well because there is a range of other already-existing programmes that accompany it, e.g. ‘The Health-promoting Schools’.” [Poland, Fit Student] “It is like this, in [name of city] we served as vanguard for the expansion of full-time schools in Germany. In the course of the expansion the issue of school meals entered the discussion at an early stage. The idea of implementing a central point of contact for these issues came up even before this federal and federal state project.” [Germany, Federal state offices coordinating networks for the provision of healthy food options in schools] |
Governmental and legal involvement | “In the elections 2005 in the campaign some focus on school meals. One party wanted free hot school meals and two other parties wanted a free school meal. When the three parties formed a coalition I think free school fruit came. Because they didn’t get free school meals they had to come with something.” [Norway, Free school fruit program] “The development and expansion of full-time schools in the federal state is, of course, a big influential component.” [Germany, Federal state offices coordinating networks for the provision of healthy food options in schools] |
Collaboration and communication | “Ähm, clearly, it is beneficial that we are not primarily ecotrophologists. We have one colleague and she comes from ecotrophology, another one is a teacher and I am originally a teacher and a trained cook myself. This combination helps us getting perceived as partners by kitchen staff, caterers, and meal service providers.” [Germany, Federal state offices coordinating networks for the provision of healthy food options in schools] “The topic ‘school meals’ is so multi-layered that it is necessary to cooperate with other professions and other partners or else you will not make any progress.” [Germany, Federal state offices coordinating networks for the provision of healthy food options in schools] “We invited representatives of the Medical University, the University of Natural Sciences, health-promoters, school nurses and behavioural nurses, nutritionists. Together we designed the programme and planned activities. So there was a multi-sectoral collaboration: scientific, academic, educational and it all helped in developing a more realistic delivery of the programme.” [Poland, Fit Student] |
Implementation | |
Delivery characteristics | “... when the Nordic countries meet there is a certain instinct for competition, so it’s like If they can do it, so can we.” [Norway, Keyhole] “The participants who regularly took part in the workshop received different prizes from our partners: tickets to sport halls, cultural and pro-health places as well as some gadgets. We notice that the mere fact of rewarding is very important (...) it is a good motivational system for them.” [Poland, Fit City] |
Simplicity of the policy | “For both the industry and the government, because we knew that the Keyhole, sort of, worked more or less in Sweden. It was 20 years old or something.” [Norway, Keyhole] “We know from the last consumer research that one in two people say that the labelling makes it easier to choose healthy [products].” [Norway, Keyhole] |
Costs and funding/ resources needed for delivery | “I think it had not been this successful had we not had long term funding of 5 years then and now three additional years. This is crucial in attempting to motivate people to cooperate and to commit themselves to this kind of quality. Long-term funding definitely was a good thing.” [Germany, Federal state offices coordinating networks for the provision of healthy food options in schools] “We did our [evaluation] with such [consumer] inquiries. Lots of questions on what it means and so on ... But in other ways ...? Yes, they follow the product development, I think.” [Norway, Keyhole] |
Maintenance | |
Long-term funding and political support | “There has been control campaigns with the other Nordic countries, and now it is a part of the control [made by The Norwegian Food Safety Authority] ... It is necessary that we [The Norwegian food Safety Authority] prioritise the labelling.” [Norway, Keyhole] “From the Federation we get the message that the VNS is the most successful of the entire INFORM campaign and that there are several ministers stating that – depending on election cycles – they would like to pursue this project in some fashion.” [Germany, Federal state offices coordinating networks for the provision of healthy food options in schools] |
Obstacles | |
Adoption | |
Adoption in physical environment | “The fact that the education system is public and not private [was the obstacle] because it meant that the financing was very limited. Wanting to equip the kitchen, the management of a particular [educational] institution will not ask the parents for the money to get a new oven, they can only inform the parents about it.” [Poland, Tasty, Healthy, Valuable] “There is no room in the canteen, the capacities are not sufficient. Plus, it is political, too. When children wish to seize a full-time school program and the head of school has to admit that they do not have the capacities. Or if you find out that children having been accepted into full-time school programs have to eat their meals in the classrooms.” [Germany, Federal state offices coordinating networks for the provision of healthy food options in schools] |
Governmental and legal involvement/ collaboration and communication | “Regulations - we had to get EU’s approval, and that took three to 4 months. But that was probably not the worst part. The worst part was reaching an agreement between Norway and Sweden on the criteria.” [Norway, Keyhole] “And that is, yeah, yeah, I said it in the beginning, the range of consultations offered is very broad. But there are quite a lot of people, many stakeholders who have their word in this, as well, and who have the authority to make decisions in other places.” [Germany, Federal state offices coordinating networks for the provision of healthy food options in schools] “Of course, the success of the VNS [Federal state offices coordinating networks for the provision of healthy food options in schools] or the gaining of sponsorship/financial carriers depends on the political atmosphere in the federal state. Considering [name of city], where one financial carrier is very committed, the impact and significance of the VNS is quite different. This is one factor sometimes impeding work in some federal states.” [Germany, Federal state offices coordinating networks for the provision of healthy food options in schools] “To me it was a little bit puzzling that it was so little thought through the implementation and that it was not planned more collaboration and involvement from all partners.” [Norway, Free school fruit program] |
Community use | “In schools there are no contact persons for this topic, and too few people are responsible. This makes it difficult to address the proper persons who may be able to put something into action.” [Germany, Federal state offices coordinating networks for the provision of healthy food options in schools] “After 5 years, we indeed have schools where neither the school principal nor the parents have an interest in the topic.” [Germany, Federal state offices coordinating networks for the provision of healthy food options in schools] |
Implementation | |
Costs and funding/ resources needed for delivery | “The amount allocated by a ministry, particularly at the federal state level, does not increase. One is somehow dependent on good will from the ministries and that they will put money into this project and not into another measure.” [Germany, Federal state offices coordinating networks for the provision of healthy food options in schools] “There were really some misunderstandings. Some municipalities believed that they didn’t get funding anymore. They thought that they had to have free school fruit but that they didn’t get any money from the State anymore. They misunderstood.” [Norway, Free school fruit program] “With three full time positions in charge of 3300 schools we are unable to provide counselling to every single school.” [Germany, Federal state offices coordinating networks for the provision of healthy food options in schools] |
Implementation process evaluation | “There are no financial means for any type of evaluation. Of course, evaluation of our work is mandatory. We keep documentation of our counselling activities and events. It is possible for participants to evaluate our events, but these are issues that we were left alone with.” [Germany, Federal state offices coordinating networks for the provision of healthy food options in schools] |
Other factors | “... no real opportunity to sanction, other than making complaints and then you were on the blacklist and there were some in the media.” [Norway, Free school fruit program] |
Results of the intervention case studies
Facilitating factors concerning the adoption of interventions
Facilitating factors concerning the implementation of interventions
Facilitating factors concerning the maintenance of interventions
Obstacles to the adoption, implementation, and maintenance of interventions
Results of the policy case studies
Facilitating factors concerning the adoption of policies
Facilitating factors concerning the implementation of policies
Facilitating factors concerning the maintenance of policies
Obstacles to the adoption of policies
Obstacles to policy implementation
Obstacles to policy maintenance
Discussion
Facilitating factors | Barriers | |||
---|---|---|---|---|
Interventions | Policies | Interventions | Policies | |
Adoption | ||||
Training for implementation | ✓ | ✓ | – | – |
Staff expertise for implementationb
| ✓ | – | – | – |
Adoption in physical environmentc
| – | ✓ | ✓ | ✓ |
Governmental and legal involvementc
| – | ✓ | – | ✓ |
Community use | – | – | – | ✓ |
Collaboration and communication | ✓ | ✓ | ✓ | – |
Implementation | ||||
Theory useb
| – | – | – | – |
Delivery characteristics: dose and fidelity | ✓ | ✓ | – | – |
Adjustments and customizations | ✓ | - | ✓ | – |
Simplicity | – | ✓ | – | – |
Accessibility | – | – | ✓ | – |
Time issues | – | – | ✓ | – |
Cultural context | – | – | ✓ | – |
Costs and funding/resources needed for delivery | – | ✓ | ✓ | ✓ |
Characteristics of the setting affecting delivery/implementationb
| ✓ | – | ✓ | – |
Implementers’ characteristics affecting implementationb
| – | – | – | – |
Implementations process evaluation | ✓ | – | – | ✓ |
Other factors | – | – | – | ✓ |
Maintenance | ||||
Dissemination | ✓ | – | – | – |
Staff and stakeholders: Training for transferb
| – | – | – | – |
Differences in healthcare systems across countriesb
| – | – | – | – |
Long-term funding and political supportc
| – | ✓ | – | – |