Contributions to the literature
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Studies in health care settings have shown that multiple facilitators and barriers affect the sustainability of health interventions beyond effectiveness evaluations and the cessation of funding and/or other resources. This review is the first to apply this evidence-based intervention sustainability in school settings.
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Although we found many commonalities in sustainability factors between education and health care—for example, funding, the work of organisational leaders and staff turnover—we found staff lacked confidence in delivering health promotion without ongoing support and prioritised academic education over health. Perceived effectiveness through witnessing students’ engagement and wellbeing was influential; scientific evidence of effectiveness did not appear to affect sustainability.
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These findings contribute to our understanding of whether, how and why health interventions are sustained, adapted, or discontinued in schools and their ability to have a lasting impact on health outcomes.
Background
Method
Inclusion/exclusion criteria
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Focused on the (dis)continuation of a school-based public-health intervention within the set of schools originally involved in delivering it, and fieldwork was carried out after external funding and/or other resources to implement the intervention had ended
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Used qualitative or quantitative empirical methods
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Was published since 1996 (as these were judged most relevant to current policy contexts) and conducted in an Organisation for Economic Co-operation and Development (OECD) country
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The intervention:
Search strategy
Screening
Data extraction and quality appraisal
Synthesis of results
Results
Study characteristics
Study origin
Intervention characteristics and effectiveness
Study # | Intervention name; country; author(s) and year | Health outcome(s) targeted; length of intervention | Country-specific education phase; grade (age); universal or targeted approach | HPS elements | Description of components | Evaluation of effectiveness which preceded assessment of sustainability | Time between effectiveness evaluation and evaluation of sustainabilitya | |||
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Curriculum | Ethos/environment | Family/community | Study design | Evidence of effects on outcomes | ||||||
1 | Project Salsa; United States; Elder et al., 1998 [57] | Nutrition; 3 years (for school-based components) | Primary; not stated; universal | X | X | X | • Nutrition education for parents, food service staff, teachers (e.g. health fairs) • Classroom curriculum/learning activities • Links with community institutions • Student advisory committees • Changes to school menus | Non-experimental pilot evaluation. 6 intervention schools. Evaluation report was not available. | Not known. | 2–5 years |
2 | Adolescent Suicide Awareness Program (ASAP); US; Kalafat and Ryerson 1999 [53] | Suicidal feelings; flexible, minimum delivery 3 months | Secondary; grade 10 (15–16 years old); universal | X | X | X | • Classroom curriculum/learning activities • Links with community gatekeepers • Organisational consultation and policies • Educator training • Parent training | N/A—non-evaluated pilot initiative. | Not known. | 5–10 years |
3–9 | Child and Adolescent Trial for Cardiovascular Health (CATCH); US; Johnson et al. 2003 [52] Kelder et al. 2003 [49] Lytle et al. 2003 [48] McKenzie et al. 2003 [51] Osganian et al. 2003 [55] Parcel et al. 2003 [60] Hoelscher et al. 2004 [56] | Cardiovascular health; 3 years | Primary; Grades 3–5 (8–11 years old); universal | X | X | X | • Classroom curriculum/learning activities—changes to PE classes • Classroom curriculum/learning activities—health education lessons • Nutrition programme—changes to school menus, food purchasing and preparation • Family activities and event • No-smoking policy | cRCT [67] Schools unit of allocation 56 intervention schools and 40 control | Effective for primary outcomes • % of energy intake from total fat in school meals sig. Reduced in intervention schools compared with controls. • Intensity of physical activity (PA) in PE classes increased sig. More in intervention compared with controls. • Dietary knowledge and intentions, and self-reported food choice changes were sig. Greater for intervention schools. • 24-h food recall showed increased total daily energy intake among children in both intervention and control schools with ageing, but increase was greater in control schools. Fat intake was sig. Reduced among children in intervention schools. | 5 years |
10 | Project ALERT; US; St Pierre and Kaltreider 2004 [58] | Substance abuse; 2 years | Secondary; grades 7 and 8 (12–14 years old); universal | X | • Classroom curriculum/learning activities | RCT [68] 8 schools, 6 classes per school randomly assigned to 1 of 3 conditions: experimental groups × 2 and 1 control group. | No effect on primary outcome, harmful effect for one treatment condition • No evidence of beneficial effects on substance use. • Harmful effects were found for the teen-assisted intervention condition on marijuana use in the past year, and future expected marijuana use. | < 1 year | ||
11 | School Fruit Programme and the Fruit and Vegetables Make the Marks (FVMM); Norway; Bere 2006 [61] | Fruit and vegetable consumption; 1 year | Primary; grade 6 (11 years old); universal | X | X | X | • Subscription to the national fruit and vegetable programme (free in trial phase) • Classroom curriculum/learning activities • Parent newsletters | RCT [61] 9 intervention schools, 10 control schools. | Effective for primary outcome • Strong intervention effects were observed for fruit and vegetables (F&V) eaten at school and all day. • Average F&V intake was 0.6 portions higher in the intervention group than controls at school & all day. | 1 year |
12 | Untitled - intervention focused on water consumption; Germany; Muckelbauer et al. 2009 [66] | Overweight; 2 years | Primary; grades 2 and 3 (7–9 years old); universal | X | X | • Installation of school water fountain • Classroom curriculum/learning activities | cRCT [69] City unit of allocation 17 intervention schools, 16 control schools. | Effective for some but not all primary outcomes • The risk of being overweight was sig. Reduced in the intervention group compared with controls. • No sig. Differences for BMI. There was no general weight-reducing effect. • Changes in water consumption higher in the intervention group compared with controls. No effects on juice or soft drink consumption. | < 1 year | |
13 | European Network of Health-Promoting Schools; Norway; Tjomsland et al. 2009 [43] | Healthy lifestyles; 3 years | Primary and secondary; grades 5–10 (10–16 years old); universal | X | X | X | • Health integrated into school policies • Needs assessment • A variety of activities e.g. curriculum, meals, school environment, parent-involvement (differed by school) • National, regional, and international conferences | Non-experimental pilot evaluation 10 intervention schools. Evaluation report on outcomes not available. | Not known. | 9 years |
14 | Winning with Wellness; US; Schetzina et al. 2009 [50] | Nutrition, physical activity, obesity; 1 year | Primary; grades 3 and 4 (8–10 years old) universal | X | X | • 5 min desk-side exercises • 2 x classroom curriculum—nutrition and health education • Changes to school menus and vending machines. • Snack preparation demonstrations • Walking trails • School health services • Health promotion for staff | Non-experimental pilot evaluation [50] 1 school | Effective for some but not all primary outcomes • No sig. Changes in BMI. • Students were sig. More active at school after intervention implementation than before, with an increase of approx. 886 steps per day. • Sig. fewer unhealthy foods were being offered & purchased/served to students after implementation than before. | < 1 year | |
15 | First Step to Success; US; Loman et al. 2010 [59] | Anti-social behaviour; 18 months | Primary; grades K to 2 (5–8 years old); targeted | X | X | • Universal screening • Consultant-based behavioural intervention with teacher, child and peers • Parent training | Non-randomised controlled trial [70] No. of schools not stated. | Effective for primary outcome • Sig. pre-post behavioural changes—adaptive, aggression, maladaptive, academic engaged time—for the intervention group. • No sig. Difference in teachers’ perception of how positively or negatively other children in the class viewed the target child. | 4–10 years | |
16 | GreatFun2Run; England; Gorely et al. 2011 [65] | Physical activity and fruit and vegetable consumption; 10 months | Primary; grade not stated (7–11 years old); universal | X | X | X | • Classroom curriculum/learning activities • Participation in two running events • An interactive website • A local media campaign | Non-randomised controlled trial [71] 4 intervention schools, 4 control schools | Effective for some but not all primary outcomes • Sig. increase in students’ daily steps & total time in MVPA in intervention compared to control schools. • Older participants in intervention schools showed a sig. Slowing in the rate of increase in estimated % body fat, BMI, & waistline. • No difference between groups in F&V consumption, aerobic fitness, knowledge of healthy lifestyles, perceived competence, enjoyment of PA, or intrinsic motivation. | 1 year 9 months |
17 | Fourth R program; Canada; Crooks et al. 2013 [64] | Peer and dating violence; 1 year | Secondary; grade 9 (14–15 years old); universal | X | X | • Classroom curriculum/learning activities • Parent newsletters | cRCT [72] Schools unit of allocation 10 intervention schools, 10 control schools | Effective for some but not all primary outcomes • Physical dating violence (PDV) was sig. Higher for students in control schools than for those in intervention schools. • Boys in intervention schools were less likely than boys in control schools to engage in dating violence. However, girls had similar rates of PDV in both groups. • Differences between control & intervention groups were not sig. For physical peer violence, substance use, or condom use. | 2 or more years, range not stated. | |
18 | New Moves; US; Friend et al. 2014 [47] | Obesity, physical activity, eating behaviours, body image; 1 year | Secondary; grade not stated (14–16 years old); targeted | X | X | X | • 3 x classroom curriculum/learning activities—all-girls physical education class, nutrition, and social support • Individual counselling sessions • Lunch get-togethers • Parent postcards and event | cRCT [73] Schools unit of allocation 6 intervention schools, 6 control schools | Effective for some but not all primary outcomes • Sig. differences between intervention & control students in changes in: stage of change for PA, goal setting for PA and self-efficacy to overcome barriers to PA; total non-sedentary activity; stage of change for F&V, & goal setting for healthy eating; portion control; unhealthy weight control behaviours; body satisfaction; athletic competence & self-worth. • Changes were non-significant in: body fat & BMI, total PA and MVPA, TV time, & stage of change TV, F&V intake & sugar-sweetened beverages, and breakfast, binge eating, appearance | 1–2 years |
19 | Youth@work: Talking Safety; US; Rauscher et al. 2015 [54] | Workplace safety and health; not specified—6 sessions. | Secondary; grade not stated (age not stated); universal | X | • Classroom curriculum/learning activities | Non-experimental pilot evaluation. Evaluation report was not available. | Not known | 1–9 years | ||
20 | Cognitive Behavioral Intervention for Trauma in Schools (CBITS); US; Nadeem and Ringle 2016 [46] | Post-traumatic stress disorder, anxiety and depression; 1 year | Secondary; grade 6 (11 years old); targeted | X | X | • 10 group sessions • 1–3 individual sessions • Parent and teacher education | Non-experimental pilot evaluation [74] 30 intervention schools. | Effective for primary outcome • There was a sig. Pre- to post-intervention decline in PTSD symptoms. | 2 years | |
21 | Good Behavior Game (GBG); The Netherlands; Dijkman et al. 2017 [63] | Anti-social behaviour; 1 year | Primary; grade 2 (6–7 years old); universal | X | • Behavioural approach in classroom | N/A—non-evaluated pilot initiative | Not known | 1 year 9 months | ||
22 | TAKE 10!; US; Goh et al. 2017 [44] | Physical activity and on-task behaviour; 8 weeks | Primary; grades 3–5 (8–11 years old); universal | X | • Classroom activity | Non-experimental pilot evaluation [42, 85] 1 intervention school. | Effective for some but not all primary outcomes • No sig. Effect on mean daily in-school steps. • No sig. Effect on average daily in-school moderate intensity PA levels of students. • Sig. effect on MVPA levels and vigorous intensity PA. • There was a mean % decrease of on-task behaviour by 7.7% during the baseline period & a mean percentage increase of on-task behaviour by 7.2% during the intervention period. | < 1 year | ||
23 | School outdoor smoking ban; The Netherlands; Rozema et al. 2018 [62] | Tobacco use; unspecified/continuous | Secondary; grades n/a (12–18 years old); universal | X | • Smoking ban everywhere on school grounds for everyone | N/A—non-evaluated pilot initiative | Not known | 1–40 years However, 64% of schools had implemented the ban in the last 3 years. | ||
24 | Health Optimizing PE (HOPE); US; Egan et al. 2019 [45] | Physical activity; 2 years | Secondary (middle); grades 6–7 (11–13 years old); universal | X | X | X | • Provision of technology resources • Before and after school activities • Classroom curriculum/learning activities • Family event • Parent education event | Non-experimental pilot evaluation [86] 1 intervention school. | Effective for primary outcome • Sig. difference between baseline & end of year 2 for various fitness activities & amount of PA time in class. • There was a sig. Improvement on test of knowledge of PA and healthy eating between baseline & year 1, & baseline & year 2. • The mean number of MVPA minutes (daily) declined steadily over the course of the study. | < 1 year |
Study design/methods
Study # | Intervention; author(s) and year | Study design | Methods | No. of former intervention (FI) and comparison group (CG) schools; response rates | Reporting on sustainability | W1—reliability | W2—relevance |
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1 | Project Salsa; Elder et al. 1998 [57] | • Mixed-methods. • Unknown whether data collected at single or multiple time points. • No comparison group. | Focus groups, questionnaires, oral feedback. | 6 FI schools; 100% (implied) | School-level | Low | Low |
2 | Adolescent Suicide Awareness Program (ASAP); Kalafat and Ryerson 1999 [53] | • Quantitative, cross-sectional. • Data collected at single time point. • Comparison group for survey—another suicide prevention intervention, no comparison group for interviews. | Survey of all public high schools in one county, plus structured interviews with a sub-sample of schools. | 24 FI schools; 73% 7 CG schools; 54% | School-level | Low | Med |
3 | Child and Adolescent Trial for Cardiovascular Health (CATCH) – health education curriculum; Johnson et al. 2003 [52] | • Quantitative, cross-sectional. • Data collected at single time point. • Two comparison groups—former control schools who received a low dose of the intervention at the end of the trial phase and an unexposed comparison group who received no intervention. | Questionnaires. | 56 FI schools; 100% 20 CG1a schools; 12 CG2b schools; 100%. | Staff-level | High | Low |
4 | CATCH – PE component; Kelder et al. 2003 [49] | • Mixed-methods, cross-sectional. • Data collected at single time point. • Two comparison groups—former control schools who received a low dose of the intervention at the end of the trial phase and an unexposed comparison group who received no intervention. | Questionnaires, observation of PE lessons, in-depth interviews. | 56 FI schools; 100% 20 CG1 schools; 12 CG2 schools; 100% | Staff-level | Med | Med |
5 | CATCH – all components; Lytle et al. 2003 [48] | • Qualitative, cross-sectional. • Data collected at a single time point. • One comparison group—former control schools. | Interviews. | 56 FI schools; 100% 20 CG1 schools; 100% | Staff-level | Med | High |
6 | CATCH – PE component; McKenzie et al. 2003 [51] | • Quantitative, cross-sectional. • Data collected at a single time point. • One comparison group—former control schools. | Observation of PE lessons, questionnaires. | 56 FI schools; 100% 20 CG1 schools; 100% | Staff-level | Low | Low |
7 | CATCH – food service component; Osganian et al. 2003 [55] | • Mixed-methods, cross-sectional. • Data collected at a single time point. • One comparison group— former control schools. | Monitoring data, interviews and questionnaires. | 56 FI schools; 100% 20 CG1 schools; 100% | School-level and staff-level | High | Med |
8 | CATCH – school climate; Parcel et al. 2003 [60] | • Quantitative, cross-sectional. • Data collected at single time point. • No comparison group. | Questionnaires, observation of PE lessons, monitoring data. | 56 FI schools; 100% | School-level | High | Low |
9 | CATCH – all components; Hoelscher et al. 2004 [56] | • Quantitative, cross-sectional. • Data collected at single time point. • Two comparison groups—former control schools who received a low dose of the intervention at the end of the trial phase and an unexposed comparison group who received no intervention. | Questionnaires, observation of PE lessons, monitoring data. | 56 FI schools; 100% 20 CG1 schools; 12 CG2 schools; 100% | School-level and staff-level | High | Low |
10 | Project ALERT; St Pierre and Kaltreider 2004 [58] | • Qualitative. • Data collected at single time point. • No comparison group. | Interviews. | 8 FI schools; 100% | School-level | Low | Low |
11 | School Fruit Programme and the Fruit and Vegetables Make the Marks (FVMM); Bere 2006 [61] | • Quantitative, longitudinal. • Data collected over multiple time points, following the students’ outcomes over time (same individuals). • Comparison group. | Questionnaires. | 9 FI schools; 100% 10 CG schools; 100% | School-level | High | Low |
12 | Untitled - intervention focused on water consumption; Muckelbauer et al. [66] | • Quantitative, cross-sectional. • Data collected at multiple time points (not necessarily the same individuals). • No comparison group. | Questionnaire, (structured) telephone interview, measure water flow of fountains. | 17 FI schools; 100% | School-level | Med | Low |
13 | European Network of Health-Promoting Schools; Tjomsland et al. 2009 [43] | • Qualitative. • Data collected at single time point. • No comparison group. | Telephone interviews and document analysis. | 7 FI schools; 70% | School-level | Med | High |
14 | Winning with Wellness; Schetzina et al. 2009 [50] | • Quantitative, cross-sectional. • Data collected at multiple time points (not necessarily the same individuals). • No comparison group. | Survey. | 1 FI school; 100% | Staff-level | Med | Low |
15 | First Step to Success (FSS); Loman et al. 2010 [59] | • Quantitative, cross-sectional. • Data collected at a single time point. • No comparison group. | Structured interview by telephone or in-person and website process evaluation tool. | 29 FI schools; 13/29 school districts (45%) had continued to use the intervention. District administrators nominated schools. | School-district level and school-level | Low | Low |
16 | GreatFun2Run; Gorely et al. 2011 [65] | • Mixed-methods, cross-sectional and longitudinal. • Data on students’ outcomes collected over multiple time points (same individuals). • Data on teachers and students’ views of the intervention collected at a single time point. • Comparison group used for student outcomes | Observation, anthropometric measures, focus groups, interviews. | 4 FI schools; 100% | Staff-level | High | Med |
17 | Fourth R program; Crooks et al. 2013 [64] | • Quantitative cross-sectional. • Study sample were teachers trained in the intervention two or more years ago. • Data collected at single time point. • No comparison group. | Online survey. | Not known | Staff-level | Low | Med |
18 | New Moves; Friend et al. 2014 [47] | • Mixed-methods, cross-sectional. • Data collected at single time point. • Comparison group—teachers received a lower dose of New Moves at the end of the trial. | Questionnaire, interviews and PE lesson observation. | 6 FI schools; 100% 6 CG schools; 100% | School-level | Med | Med |
19 | Youth@work: Talking Safety; Rauscher et al. 2015 [54] | • Quantitative, cross-sectional. • Study sample were teachers that were trained in the intervention between 2004 and 2012. • Data collected at single time point. • No comparison group. | Telephone survey. | Not known | Staff-level (sustainability score) | Low | Low |
20 | Cognitive Behavioral Intervention for Trauma in Schools (CBITS); Nadeem and Ringle 2016 [46] | • Qualitative. • Study sample were clinicians who had worked in former intervention schools. • Data collected at single time point. • No comparison group. | Interviews. | Not known | Staff-level | High | High |
21 | Good Behavior Game (GBG); Dijkman et al. 2017 [63] | • Mixed-methods, cross-sectional. • Data collected at single time point. • No comparison group. | Questionnaire and interviews. | 16 FI schools; 94% | School-level (sustainability score) | Med | High |
22 | TAKE 10!; Goh et al. 2017 [44] | • Qualitative. • Data collected at single time point. • No comparison group. | Interviews. | 2 FI schools; opportunity sample. | Staff-level | Med | Med |
23 | School outdoor smoking ban; Rozema et al. 2018 [62] | • Mixed-methods, cross-sectional. • No comparison group. | Questionnaire for all secondary schools enquiring about use of outdoor smoking ban. Additional questionnaire for those with ban. Qualitative interviews with sub-sample of schools conducted 6 months later. | 438 schools; response rate not known—schools currently with the intervention. | School-level (sustainability score) | Low | Med |
24 | Health Optimizing PE (HOPE); Egan et al. 2019 [45] | • Qualitative single case study. • Data collected at multiple time points from the research team—interviewed twice during the trial phase, and once 1 year post-trial phase. • Data collected at single time point from teachers and students. • No comparison group. | Document analysis, interviews, focus group. | 1 FI school; 100% | School-level | High | Med |
Timeframe examined
Study participants
Study quality
Explicit use of conceptual framework
Reporting of sustainability
Study # | Intervention; author(s) and year | Sustainability of the intervention (FI = former intervention, CG = comparison group) | ||
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Curriculum | Ethos/environment | Family/community | ||
1 | Project Salsa; Elder et al. 1998 [57] | One school (17%) continued nutrition-related activities for students and parents. | No schools continued student advisory committees and changes to school menus. Nutrition education classes for adults continued, unknown if this occurred in all schools. | The nutrition information provided by a community institution was discontinued and replaced with a different intervention, delivered by parent volunteers. |
2 | Adolescent Suicide Awareness Program (ASAP); Kalafat and Ryerson 1999 [53] | 96% of FI schools continued student training, although at a lesser dosage, compared to 100% of CG schools. | 67% of schools had written policies and procedures for responding to at-risk students, compared to 86% of CG schools. 8% of schools continued educator training, compared to 0% of CG schools. | All schools retained links with community agencies. 13% of schools continued parent training compared to 0% of CG schools. |
3 | Child and Adolescent Trial for Cardiovascular Health (CATCH) – health education curriculum; Johnson et al. 2003 [52] | 19% of teachers in FI schools used CATCH health education activities, compared to 5% in CG1a schools and 0% in CG2b schools. 23% of teachers in FI schools used CATCH health education materials, compared to 11% in CG1 schools and 0% in CG2 schools. 69% of teachers in FI schools taught zero hours of CATCH in the current school year, compared to 84% in CG1 schools, and 99% in CG2 schools. | ||
4 | CATCH – PE component; Kelder et al. 2003 [49] | 35% of teachers in FI schools had CATCH PE materials available, compared to 19% in CG1a schools. 32% of teachers in FI schools had used CATCH PE materials, compared to 22% in CG1 schools. There were no sig. differences between study groups (FI, CG1, or CG2b) in the amount of physical activity. | ||
5 | CATCH – all components; Lytle et al. 2003 [48] | 34% of staff from FI schools said they were partially implementing the health education curriculum, compared to 23% of staff from CG1a schools. 66% said it was not implemented their school, compared to 62% in CG1 schools. 24% of staff from FI schools said they were still implementing CATCH PE. 70% of staff from FI schools said they used elements of it, compared to 93% from CG1 schools. 6% of staff from FI schools said they had discontinued CATCH PE, compared to 7% of staff from CG1 schools. | None of the food service staff from FI schools said they were fully implementing the food service component ‘Eat Smart (ES)’. 27% of the respondents from CG1 schools said ES was not being used at their school. Most district-level respondents said that some of the ES guidelines were being followed. Sustainability of the no-smoking policy not reported. | 4% of staff from FI schools said they carried out some parts of the family component. All other staff indicated it had been discontinued. |
6 | CATCH – PE component; McKenzie et al. 2003 [51] | 70% of teachers from FI schools who had had CATCH PE training reported using the CATCH PE curriculum, compared to 57% from CG1a schools. There were no sig. differences between FI and CG1 schools in the amount of physical activity in PE lessons and class energy expenditure. | ||
7 | CATCH – food service component; Osganian et al. 2003 [55] | 25% of cooks in FI schools said the ES manual was present in the school kitchen compared to 15% in CG1a schools. 15% of cooks in FI schools said they used it compared to 3% in CG1 schools. 34% of cooks in FI schools said the recipe box was present in the kitchen compared to 20% in CG1 schools 32% of cooks in FI schools said they used it compared to 12% in CG1 schools. | ||
8 | CATCH – school climate; Parcel et al. 2003 [60] | Schools in which principals and teachers were more open were sig. more likely to be teaching more hours of CATCH. ‘Open’ principals were supportive, low on rigid monitoring/control and low on restrictiveness. ‘Open’ teachers were highly collegial, had a network of social support and were engaged with school. Schools in which principals and teacher were more open, and schools higher in organisational health, were sig. more likely to have a greater percentage of calories from saturated fat in school lunches. | ||
9 | CATCH – all components; Hoelscher et al. 2004 [56] | No differences between study groups (FI, CG1a, CG2b) and % of class time spent in moderate to vigorous physical activity or vigorous physical activity. All study groups exceeded the CATCH goal of 90 min of PE/week. Teachers reported teaching only about two CATCH lessons during the previous school year, a much lower dosage than the original intervention. Over 88% of PE teachers and 60% of classroom teachers reported using the CATCH PE activity box in the previous school year. | 30% of FI schools achieved the total fat goal of < 30%, compared to 10% of CG1 schools and 17% CG2 schools. 45% of FI schools achieved the saturated fat goal of < 10%, compared to 30% of CG1 schools and 17% of CG2 schools. Most ES guidelines implemented consistently across all study conditions. No schools met the ES guidelines for sodium. Sustainability of the no-smoking policy was not reported. | The family component was taught infrequently. |
10 | Project ALERT; St Pierre and Kaltreider 2004 [58] | 38% of schools continued the curriculum. | ||
11 | School Fruit Programme and the Fruit and Vegetables Make the Marks (FVMM); Bere 2006 [61] | Sustainability of the classroom curriculum/learning activities was not reported. | 44% of schools continued to participate in the School Fruit Programme (SFP) (paying for it), compared to 30% of CG schools (n = 3). 66% of students subscribed to the School Fruit Programme, compared to 21% of students in CG schools. Students from FI schools who continued to participate in the SFP ate 0.4 portions more FV at school than students from FI schools that discontinued participation. | Sustainability of the parent newsletters was not reported. |
12 | Untitled - intervention focused on water consumption; Muckelbauer et al. [66] | Sustainability of the classroom curriculum/learning activities was not reported. | 65% of schools retained the water fountain. The mean water flow was highest in the first 3 months of implementation. Afterwards, it decreased by about 35% until the end of the intervention, and remained stable between implementation and sustainability phases. | |
13 | European Network of Health-Promoting Schools; Tjomsland et al. 2009 [43] | Sustainability of specific classroom curriculum/learning activities was not reported. | 86% of schools had sustained and developed health promotion practices—specific activities and policies were not reported. 71% of schools referred to aspects of health promotion in their vision statements/priority areas. Sustainability of the needs assessment and national, regional and international conferences were not reported. | Sustainability of specific family/community activities was not reported. |
14 | Winning with Wellness; Schetzina et al. 2009 [50] | 50% of teachers reported teaching students the nutrition curriculum. Sustainability of the health education curriculum was not reported. | 100% of teachers reported using the 5 min desk-side exercises. Sustainability of the changes to school menus and vending machines, snack preparation demonstrations, use of walking trails, school health services and health promotion activities for staff was not reported. | |
15 | First Step to Success (FSS); Loman et al. 2010 [59] | 8/13 school districts (62%) reported at least one school was continuing to use the behavioural intervention. 72% of the schools nominated by district administrators reported sustainment (mean duration was 7.1 years). 28% of the schools had discontinued implementation (mean duration was 2.4 years). | Sustainability of the parent-training component was not reported. | |
16 | GreatFun2Run; Gorely et al. 2011 [65] | 25% of teachers were currently using any of the intervention resources. There were no sig. differences between students from FI and CG schools in steps per day or moderate to vigorous physical activity at the time of the sustainability study (in contrast to trial phase). | The sustainability of the use of the summer activity wall planner and website was not reported. | The sustainability of the running events was not reported. |
17 | Fourth R program; Crooks et al. 2013 [64] | 72% of teachers said they had implemented the intervention in the most recent school year. During the most recent year of implementation: 40% said they had implemented 81% or more of the programme; 25% said 61–80% of the programme; 18% said 41–60% of the programme; 13% said 21–40% of the programme; 5% said less than 20% of the programme | The sustainability of the parent newsletters was not reported. | |
18 | New Moves; Friend et al. 2014 [47] | 83% of schools continued the intervention to some degree. One school closed; one discontinued the intervention. Of schools that remained open (n = 11): • 91% offered an all-girls PE class 4 times a week. In 9/10 observed classes, most girls met the goal for being active at least 50% of the class. • 45% of schools continued to implement nutrition and social support classes. | 27% of schools offered individual coaching sessions, though less frequently than the intervention specified. 0% of schools continued lunch get-togethers. | Sustainability of the parent postcards and event were not reported. |
19 | Youth@work: Talking Safety; Rauscher et al. 2015 [54] | 81% of teachers had taught the curriculum more than once since being trained in it, with a mean sustainability score of 10.1 (SD = 6.6, maximum score 18). The mean fidelity score was 2.1 (SD 2.2, maximum score 6). | ||
20 | Cognitive Behavioral Intervention for Trauma in Schools (CBITS); Nadeem and Ringle 2016 [46] | 50% of clinicians implemented the counselling intervention 1 year after the trial phase. 0% of clinicians implemented the intervention 2 years after the trial phase. | Sustainability of parent outreach activities not reported. | |
21 | Good Behavior Game (GBG); Dijkman et al. 2017 [63] | The mean sustainability score was 8.7 (range 2–14, maximum score 20). | ||
22 | TAKE 10!; Goh et al. 2017 [44] | 20% of teachers implemented the activities regularly (2 or more times a week; during the trial phase, teachers implemented the intervention on average once a day). Some teachers (numbers not given) implemented it less regularly (once a week or less). A few teachers (numbers not given) discontinued the intervention. | ||
23 | School outdoor smoking ban; Rozema et al. 2018 [62] | The mean sustainability score was 5.70 (SD 0.9, maximum score 7). | ||
24 | Health Optimizing PE (HOPE); Egan et al. 2019 [45] | Teachers (numbers not given) were still using the technology resources. The classroom curriculum was discontinued. | One element of the before and after school activities—‘Intramurals’ was discontinued and then reinstated 2 months later. Another before and after school activity was discontinued. | The family fun run event continued (the event had existed pre-trial phase). The parent education event was discontinued. |
Sustainability of the interventions
Study # | Intervention name; author(s) and year | Effects on outcome(s) summarised | % of schools/staff that sustained the curriculum component | % of schools/staff that sustained the ethos/environment component | % of schools/staff that sustained the family component |
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3–9 | Effective for primary outcomes | 23% of teachers had used health education materials 32% of teachers had used PE materials 88% of PE specialists had used PE materials | 15% of cooks said they used the intervention manual. 32% of cooks said they used the intervention recipe box. | 4% of staff | |
11 | School Fruit Programme and the Fruit and Vegetables Make the Marks (FVMM); Bere 2006 [61] | Effective for primary outcomes | Not reported | 44% of schools | Not reported |
15 | First Step to Success; Loman et al. 2010 [59] | Effective for primary outcomes | n/a | Not reported | Not reported |
20 | Cognitive Behavioral Intervention for Trauma in Schools (CBITS); Nadeem and Ringle 2016 [46] | Effective for primary outcomes | n/a | 0% of clinicians | 0% of teachers |
24 | Health Optimizing PE (HOPE); Egan et al 2019 [45] | Effective for primary outcomes | 0% of schools (NB one school in study) | One activity continued, one activity discontinued | 0% of teachers |
12 | Untitled - intervention focused on water consumption; Muckelbauer et al. 2009 [66] | Effective for some but not all primary outcomes | Not reported | 65% of schools | n/a |
14 | Winning with Wellness; Schetzina et al. 2009 [50] | Effective for some but not all primary outcomes | 50% of teachers (not all classroom activities reported) | Not reported | n/a |
16 | GreatFun2Run; Gorely et al. 2011 [65] | Effective for some but not all primary outcomes | 25% of teachers | Not reported | Not reported |
17 | Fourth R program; Crooks et al. 2013 [64] | Effective for some but not all primary outcomes | 72% of teachers | n/a | Not reported |
18 | New Moves; Friend et al. 2014 [47] | Effective for some but not all primary outcomes | 91% of schools continued PE; 45% continued health education | 27% of schools continued individual staff-student coaching sessions; 0% of schools staff-student lunch get-togethers | Not reported |
22 | TAKE 10!; Goh et al. 2017 [44] | Effective for some but not all primary outcomes | n/a | 20% of teachers | n/a |
10 | Project ALERT; St Pierre and Kaltreider 2004 [58] | No effect on primary outcome, harmful effect for one treatment condition | 38% of schools | n/a | n/a |
1 | Project Salsa; Elder et al., 1998 [57] | n/k | 17% of schools | 0% of schools | Not reported |
2 | Adolescent Suicide Awareness Program (ASAP); Kalafat and Ryerson 1999 [53] | n/k | 96% of schools | 67% of schools | 13% of schools |
13 | European Network of Health-Promoting Schools; Tjomsland et al. 2009 [43] | n/k | Not reported | 71% of schools | Not reported |
19 | Youth@work: Talking Safety; Rauscher et al. 2015 [54] | n/k | Not reported | n/a | n/a |
21 | Good Behavior Game (GBG); Dijkman et al. 2017 [63] | n/k | n/a | Not reported | n/a |
23 | School outdoor smoking ban; Rozema et al. 2018 [62] | n/k | n/a | Not reported | n/a |
Thematic synthesis of barriers and facilitators of sustainability
Theme | Sub-themes | Sub-sub-themes | Reports that identified (sub)theme |
---|---|---|---|
Schools’ capacity to sustain health intervention—the social norms, roles and resources that affected whether schools could sustain an interventions | Educational outcomes took precedence over health promotion | N/A | |
Staff roles in sustainability—how the professional roles of different staff contributed to sustainability processes. | The importance of the principal and school administration | ||
Teachers’ autonomy in the classroom | |||
Funding and material resources—the availability of funding, materials and space for sustaining an intervention. | N/A | ||
Cognitive resources—schools’ access to staff with the knowledge and skills to continue to promote, co-ordinate and/or deliver the intervention. | Staff turnover—the need to train new staff and retain experienced and trained staff. | ||
The importance of training | |||
Social resources—the resources that came from schools’ connections with other schools and organisations | N/A | ||
Staff motivation and commitment—factors influencing the intentions of staff to sustain an intervention | Observing and evaluating effectiveness | N/A | |
Staff confidence in delivering health promotion | N/A | ||
Parent support for the intervention | N/A | ||
Believing in the importance of the intervention | N/A | ||
The impact of school climate | N/A | ||
Intervention adaptation and integration—factors influencing whether it was operationally possible to sustain an intervention | The workability of the intervention—the work carried out to fit the intervention into existing school practices and routines. | Fitting the intervention into the time available | |
Matching the intervention to students’ needs | |||
The need for up-to-date materials | |||
The integration of the intervention into school policies and plans. | N/A | ||
Wider policy context for health promotion—whether policies supported school health promotion | N/A | N/A |
Theme 1: Schools’ capacity to sustain health interventions
…if you’re going to prioritize, you’re going to prioritize on academics. ...You always concentrate on academics but there was more room for PE and health and those kinds of things before the state kicked in the really extremely rigorous academic standards. ([48], p. 515)
It is an individual decision. The state has a framework of what we are supposed to teach. We are asked to teach the things that the district recommends, but if you have more time, you can teach other things as well. No one has asked us to use the CATCH curriculum since the program ended in our school so it was up to us. ([48], p. 509)
Lack of finances was mentioned as a reason that teachers did not offer guest instructors or hold weekly lunch bunches. Whereas some teachers asked for volunteers to teach yoga or dance, others used videos or asked students to pay a $5 activities fee at the beginning of the class to use for guest instructors’ fees. ([47], p. 5)
We’ve lost a major senior administrator that is proactive and advocated for the kids’ needs, across the board, regular education and special education. Things have changed. Within the last year, they’re just looking at all the academics right now. ([46], p. 138)
The staff development was interesting and motivated teachers. They learned about nutrition and fitness. They got excited about it and therefore implemented it. And that made it difficult to implement in schools that had not had the training. They missed a real motivational surge and missed looking at the importance and hearing from experts. ([48], p. 515)
Theme 2: Staff motivation and commitment
It gives the team power. And, especially now, with more children with behavioral problems in the classroom. When you stay on the positive side, almost all children will get along. ([63], p. 85)
Taylor said, ‘We started these warmups, and then they stopped. I don’t know why, but I wish we had them. It is hard to run the CV day with no warmup.’ ([65], p. 114)
Among classroom teachers, feeling inadequately prepared to implement PE was frequently reported; and in many cases, teachers had little interest in gaining the skill. ([49], p. 471)
I think a lot of it is home life, if the parents don’t push them towards sporting activities then you’re fighting a battle straight away in school. ([65], p. 8)
School satisfaction and safety are at the bottom of this school. It is under the teachers’ skin and in our walls. We work with this no matter what is on our agenda. ([43], p. 59)