Exploring facilitating factors and barriers to the nationwide dissemination of a Dutch school-based obesity prevention program “DOiT”: a study protocol

The program was developed according to the Intervention Mapping protocol [7] using input from representatives of the target group (adolescents), implementers (teachers) and parents. DOiT is a school-based obesity prevention program for 12 to 14-year olds. DOiT focuses on five EBRBs: (1) reducing intake of sugar-containing beverages; (2) reducing intake of high-energy snacks; (3) reducing screen time; (4) increasing levels of physical activity (i.e. active transport and sports participation) and (5) daily and healthy breakfast consumption [11]. The program consists of a classroom component, an environmental component and a parental component. The program covers 12 fixed theory lessons, four physical education (PE) lessons, equally divided over two school years, and three optional additional lessons. The classroom lessons in the first year aim to increase awareness and knowledge of EBRBs. The lessons in the second year focus on the influence of the (obesogenic) environment. The environmental component aims to raise awareness of the school environment, finding solutions to reduce negative influences within the environment and setting a plan for improvement. The parental component focuses on stimulating social support of the parents and raising awareness of the availability and accessibility of healthy products and activities in the home environment. As part of the DOiT program, all parents receive an information booklet in which the topics of the DOiT lessons are described. During the program, students receive homework assignments to complete with their parents. Optionally, at the end of the program schools can organize a meeting for parents, where students present what they learned.

The DOiT materials include a ’schoolbook’ accompanied by worksheets, a student toolkit (pedometer, food/exercise diary and an online computer-tailored advice) and a parental information booklet. DOiT is supported by an extensive teacher manual with a login for extra materials provided at the DOiT website. Table 1 provides an overview of the DOiT program.

Using the IM protocol, we developed the implementation strategy with the input of different implementation stakeholders. Teachers are the main implementers of DOiT. For that reason, teachers are supported by the DOiT implementation strategy. The strategy consists of seven steps to support adoption, implementation and continuation of DOiT within the school (see Table 2 for an overview). To facilitate the implementation process, a relatively low-profile implementation strategy with accompanying materials are available to teachers on the DOiT website [15]. The website provides general background information about the DOiT project, i.e. contact information, news items, information video, testimonials of schools who have successfully implemented DOiT, and a map of the Netherlands showing schools that currently implement DOiT. Teachers can read about DOiT and try the DOiT exemplary teaching materials in order to ensure that the program is compatible with their own context. The website has four domains targeting the different stakeholders i.e. 1) schools, 2) employees at supporting organisations, 3) parents and 4) students. In the parental domain, parents can read the information booklet online. Students have their own domain, containing a computer-tailored test and health-related videos. All domains are accessible free of charge.

Due to the ’real life’ condition of the study, there was no teacher training, interference or guidance by the research team.

We aimed to include 20 DOiT implementation schools in the process evaluation. This number was based on feasibility and also a similar study, conducted in the Netherlands, evaluating the dissemination process of a Dutch healthy diet program, the Krachtvoer evaluation study [20].

After a school ordered the DOiT materials, the school was invited to participate in the study. The school was then informed about the study protocol by telephone and written information. If the school agreed to participate, the researcher visited the school in order to explain the procedures. Participating schools needed to meet the following criteria: (1) willing to implement DOiT during two subsequent school years; (2) a signed agreement of participation in the study during that period (2011–2013); (3) willingness to appoint a DOiT coordinator who was the linking agent between the research team and the school; (4) being able to participate with at least three classes of the first two years of their prevocational education, and (5) willingness to provide space and time for measurements. All teachers involved in the implementation of DOiT were asked to participate in the process evaluation. If schools participated in the study, they received free materials for three classes and a short report of the research results upon completion.

Regarding the process indicator effectiveness, 510 students per group were needed to detect a relevant difference in body mass index (BMI) between the intervention and control groups. Therefore, ten control schools were needed. Taking into account the clustered design, missing data and dropout (25%), a sample size of 1274 students were required to conduct multi-level analyses with an estimated power of 90% and an alpha level of significance set at 0.05 (see Table 4).

In order to recruit control schools, we asked all intervention schools to provide the name of comparable schools in that area. As a result, we aimed to include control schools, matched on level of education, location (rural/urban area) and school size. Control schools did not implement DOiT during the study period. Regular contact with the management and teachers of control schools was ensured in order to promote their continued participation. Also the control schools received a short report of the research results upon completion.

Process data were collected by teachers, DOiT coordinators, DOiT support office, students and parents throughout the whole research period.

At baseline (T0), after eight (T1) and 20 months (T2), all teachers involved in the implementation of DOiT were asked to complete an online questionnaire about the impeding and facilitating factors of the implementation of DOiT. Completing the questionnaire took approximately 30 minutes. The majority of the questionnaire consisted of structured questions, measured on a bipolar five-point Likert scale. A few open-ended questions were added. The questionnaire was based on existing questionnaires, used in the previous DOiT evaluation [14, 21] and the Krachtvoer evaluation study [22]. The questionnaire contained questions regarding the context, recruitment, satisfaction, maintenance, and potential relevant implementation-related determinants of the program. Additionally, the questionnaire contained items on other on-going studies and other innovations or school health-promotion programs. After each lesson teachers were requested to complete an online log. Completing the log took approximately 5 minutes per lesson. Using this log, we aimed to administer completeness of implementation by having teachers indicate if the lesson was taught, when it was taught and how the lesson was prepared and implemented. Teachers could tick off what activities were executed in preparation of the lesson on a list of proposed activities according to the teacher manual and how much time they spent on these activities. Teachers ticked off what materials were used during the lesson, what lesson activities were implemented and if the implementation complied with the prescription in the teacher manual. Finally, teachers reported how much time they spent in the classroom and rated their satisfaction with the lesson on a ten-point rating scale. Additionally to the questionnaires and logbooks, we aimed to visit each school at least once during the research period for a structured observation of a DOiT lesson.

At the end of each school year (T1 and T2), i.e. in total twice during the research period, a sub-group of teachers and the coordinator were invited for an in-depth interview to gain more insight into the implementation of the DOiT program, its content, recruitment, fidelity and satisfaction with the dissemination strategy, and overall satisfaction with DOiT. Furthermore, facilitators and barriers for implementation, intentions and opportunities for future implementation of DOiT were discussed.

During the recruitment period and the implementation period, the DOiT support office employee was requested to complete a log regarding all meetings, recruitment activities and communication with teachers and schools.

After the recruitment phase, teachers that had not ordered the DOiT program were invited to complete a web-based questionnaire in order to gain insight into reasons for not implementing DOiT. The questionnaire contained questions regarding context and recruitment. Participants were invited by email to complete the questionnaire. Completing the questions took approximately 10 minutes.

Before the start of DOiT (T0) and after 20 months (T2), parents were invited to complete an online questionnaire. Parents were reached via the school. Schools were asked to email the web link directly to parents. The questionnaire was based on the ENERGY parent questionnaire [26] and contained items on the physical home environmental, i.e. availability and accessibility of sugar-containing beverages and high sugar/high fat snacks, options for physical activity (sports and active transport), rules for screen time (TV viewing and computer use), availability and accessibility of breakfast products and availability of pocket money for food and drinks. The questionnaire mainly consisted of structured questions, measured on a bipolar five-point Likert scale. At T2, ten additional questions were asked about their satisfaction with DOiT (i.e. parental information booklet, homework assignments and parent meeting). Completing the questions took approximately 5 minutes.

Partly based on the audit instruments used in the ENERGY study [27] and the ENDORSE study [28], a DOiT audit instrument was developed to assess the availability and accessibility of foods and physical activity facilities in and around the school. Before the start of DOiT (T0) and after 20 months (T2), two researchers independently completed the audit instrument at each school. The audit instrument consisted of five parts: (1) food/drink available in the canteen; (2) food/drink available in vending machines; (3) physical activity facilities; (4) bicycle parking; and (5) available food retail outlets around school. For the majority of the items, the audit instrument had a ‘tick box’ answering format. The instrument assesses characteristics of the school environment in an objective manner. When subjective characteristics such as ‘state of baseball field’, or ‘space in the bicycle parking’ were present, photographs were taken. The DOiT audit instrument was pretested for its reliability at two schools.