Background
Implementation
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The varied aspects and means by which an intervention (or programme) is integrated into one or a number of organisations. Implementation is the critical gateway between an organisational decision to adopt an intervention and the routine use of that intervention; the transition period during which individuals become increasingly skilful, consistent, and committed in their use of an intervention. |
Adapted from Damschroder et al. [41] |
Health promotion programme
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To distinguish our focus from broad, often national, policies and programmes, we defined school health promotion programmes as a designated combination of activities, learning materials, and messages which: |
• are intended to achieve specific health promotion, health education, or healthy behaviour goals in pupils |
• can be adopted and adapted within schools (e.g. whole years or classes) |
• involve the dedicated time of pupils within school in order to participate in or learn from the programme |
Such programmes may have been developed within a school or as part of a wider (e.g. research-based) initiative. They could be delivered in particular lessons or times within the school day (e.g. Personal, Social and Health Education lessons), before or after school (e.g. after-school gardening club), or have their messages and learning materials delivered within the lessons of other subjects. |
Realist review terms
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Adjudicate—To make a judgement about methodological quality or applicability in this instance and account for this judgement based on findings from the use of the critical appraisal tool or an explicit argument about why a piece of evidence was not applicable |
Consolidate—To bring together. In a realist synthesis, ‘to bring together into a more coherent whole’ |
Context—The wider configuration of factors, not necessarily connected to a programme, which may enable or constrain the operation of specific mechanisms |
Juxtapose—To place two or more things (evidence fragments) together, especially in order to suggest a link between them or emphasise the contrast between them |
Mechanism—The way in which a programme’s resources or opportunities interact with the reasoning of individuals and lead to changes in behaviour |
Programme theory—A model linking outcomes to programme activities and the underlying theoretical assumptions of a programme or intervention [20]. These models contain, even if they do not explicitly state, ideas about how a problem can be best addressed and how factors that may undermine the actions of a programme can themselves be addressed [24] |
Reconcile—To make two or more apparently conflicting things (evidence fragments) consistent or compatible |
Situate—To place something (a piece or pieces of evidence) in a context or set of circumstances and show the connections (between it/them and other evidence fragments) |
Methods
Search strategy
Screening (theory-development stage)
Screening (theory-testing stage)
‘Conceptually rich’ [29] | ‘Thicker description’ [30] but not ‘conceptually rich’ | ‘Thinner description’ [30] |
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Theoretical concepts are unambiguous and described in sufficient depth to be useful | Description of the programme theory or sufficient information to enable it to be ‘surfaced’ | Insufficient information to enable the programme theory to be ‘surfaced’ |
Relationships between and amongst concepts are clearly articulated | Consideration of the context in which the programme took place | Limited or no consideration of the context in which the programme took place |
Concepts sufficiently developed and defined to enable understanding without the reader needing to have first-hand experience of an area of practice | Discussion of the differences between programme theory (the design and orientation of a programme—what was intended) and implementation (what ‘happened in real life’) | Limited or no discussion of the differences between programme theory (the design and orientation of a programme—what was intended) and implementation (what ‘happened in real life’) |
Concepts grounded strongly in a cited body of literature | Recognition and discussion of the strengths and weaknesses of the programme as implemented | Limited or no discussion of the strengths and weaknesses of the programme as implemented |
Concepts are parsimonious (i.e. provide the simplest, but not over-simplified, explanation) | Some attempt to explain anomalous results and findings with reference to context and data | No attempt to explain anomalous results and findings with reference to context and data |
- | Description of the factors affecting implementation | Limited or no description of the factors affecting implementation |
- | Typified by | Typified by |
Terms—‘model’, ‘process’, or ‘function’ | Mentioning only an ‘association’ between variables | |
Verbs—‘investigate’, ‘describes’, or ‘explains’ | ||
Topics—‘experiences’ |
Development of programme theories
Programme details | Study type | How implementation assessed |
---|---|---|
Active primary school (pilot) | ||
Co-ordinators worked with schools to provide opportunities for physical activity within and outside of the curriculum. | ||
Physical activity | ||
Delivered to: pupils (5–11 years) (primary) | ||
Delivered by: co-ordinators | ||
Lowden et al. [42] | BA | Available resources |
Process evaluation | Adaptation | |
APPLES—the Active Programme Promoting Lifestyle Education in Schools | ||
Multi-disciplinary health promotion team worked with schools to develop school action plans tailored to each school’s perception of needs. | ||
Obesity | ||
Delivered to: pupils (8–10 years) (primary) | ||
Delivered by: health promotion team | ||
Sahota et al. [43] | CRCT | Engagement |
Process evaluation | ||
ASSIST—A Stop Smoking in Schools Trial | ||
Pupils nominated ‘influential peers’ who received training to become ‘peer supporters’ who aimed to reduce/stop smoking amongst their peers. | ||
Substance use (tobacco) | ||
Delivered to: pupils (12–13 years) (secondary) | ||
Delivered by: peers (12–13 years) | ||
Audrey et al. [44] | NA | Researchers’ reflections on programme implementation |
Audrey et al. [45] | NA | NA |
Audrey et al. [46] | Process evaluation | Adolescents’ perspectives |
Audrey et al. [43] | Process evaluation | Teachers perceptions |
Holliday et al. [47] | Process evaluation | Fidelity of delivery |
Blueprint | ||
15 lessons (‘normative’ focus) delivered over 2 years; parenting skill workshops; local media coverage, managed by media relations agency; education and training for local retailers; involvement of wider community of drug professionals and organisations. | ||
Substance use (legal and illegal substances) | ||
Delivered to: pupils (11–13 years) (secondary) | ||
Delivered by: teachers | ||
Stead et al. [48] | CBA | Teacher training |
Process evaluation | Curriculum | |
School drug advisor support for delivery in schools | ||
Stead et al. [49] | Process evaluation | Fidelity |
Adaptation of content | ||
Teaching confidence | ||
Training | ||
Blueprint Evaluation Team [50] | Evaluation | Materials |
Student participation | ||
Citizenship Safety Project | ||
Secondary school pupils trained to teach aspects of accident prevention and risk awareness | ||
Injury prevention | ||
Delivered to: pupils (6–7 years) (primary) | ||
Delivered by: peers (14–15 years) | ||
Frederick, Barlow [51] | CBA | Perceptions of project (teacher/year 10 students) |
(pilot study) | ||
Eat Smart Play Smart | ||
Behaviourally focused ‘lunchtime clubs’ of 25 min/week (for 20 weeks) to raise value of desired behaviour, tasting opportunities, incentives, and practical skills. | ||
Obesity | ||
Delivered to: pupils (5–7 years) (primary) | ||
Delivered by: researchers | ||
Warren et al. [52] | RCT | Practical tasks/participation |
Incorporation of materials into curriculum | ||
Family Smoking Education (Health Education Authority) | ||
Teachers’ guide, parents’ leaflet, and pupils’ booklet were provided and delivered within the curriculum in the way that teachers judged to be most suitable. | ||
Substance use (tobacco) | ||
Delivered to: pupils (11–13 years) (secondary) | ||
Delivered by: teachers | ||
Newman, Nutbeam [53] | CBA | Teachers’ feedback on programme delivery |
GGHB Sexual Health Education | ||
One lesson per week (5-week duration, as part of PSE curriculum), emphasising pupils’ ownership of the issues and challenging misconceptions with factual information. Mainly single sex groups. Included whole group, small group, and individual work and video, reading material, and quizzes. | ||
SRE | ||
Delivered to: pupils (11–16 years) (secondary) | ||
Delivered by: teachers | ||
Lowden, Powney [54] | Process evaluation | Student engagement |
Teachers’ experiences | ||
HeLP—Healthy Lifestyle Programme | ||
Over three terms (18 months), a range of activities intended to change behaviour at individual, family, and institutional levels—competitions, workshops, parents’ evening, PSHE lessons, drama activities, 1:1 goal-setting and assessment, newsletters. | ||
Obesity | ||
Delivered to: pupils (8–11 years) (primary) | ||
Delivered by: teachers, drama group, researchers | ||
Wyatt et al. [55] | CRCT (pilot) | Delivery |
Process evaluation | Resources | |
KAT—Kids, Adults Together | ||
Classroom activities, ‘fun evening’ for families, DVD for pupils to watch with parents. | ||
Substance use (alcohol) | ||
Delivered to: pupils (9–11 years) (primary) | ||
Delivered by: teachers | ||
Rothwell, Segrott [56] | Process evaluation | Engagement |
NE Choices | ||
Drama workshop, ‘youth work projects’, outdoor activity programme for ‘high-risk’ youth, and drugs awareness sessions for parents, training for teachers, youth workers, and school governors. | ||
Substance use (legal and illegal drugs) | ||
Delivered to: pupils (13–16 years) (secondary) | ||
Delivered by: various (theatre company, teachers, youth workers) | ||
Stead et al. [57] | CBA | Project aims versus youth work aims |
Process evaluation | Concordance/adaptation to participants needs | |
PhunkyFoods Programme | ||
Lesson plans (1-h duration) to support delivery through art, drama, music, and play activities. Schools can adapt lesson plans. DVDs, books, and games provided. | ||
Healthy eating and physical activity | ||
Delivered to: pupils (5–11 years) (primary) | ||
Delivered by: school staff | ||
Teeman et al. [58] | BA | Teachers’ experiences |
Process evaluation | ||
Project Tomato | ||
Manual and 12 curriculum-related lesson plans formed ‘core elements’; other elements were ‘customisable’—cooking lessons, growing club information, team set-up information. Support materials (kit bags, newsletters, parent handouts) provided. | ||
Obesity | ||
Delivered to: pupils (8–9 years) (primary) | ||
Delivered by: teachers | ||
Christian [59] | CRCT | Fidelity |
Process evaluation | ‘Appreciation’ of programme | |
RIPPLE—Randomised Intervention of Pupil Peer Led Sex Education | ||
Peer educators trained by an external team to prepare classroom sessions (3 × 1 h), which were delivered without teacher supervision. Sessions used participatory learning methods and activities, covering relationships, STIs, and contraception. | ||
SRE | ||
Delivered to: pupils (13–14 years) (secondary) | ||
Delivered by: peers (16–17 years) | ||
Forrest et al. [60] | Process evaluation | Participation in programme |
Student engagement | ||
Sex educator characteristics | ||
Strange et al. [61] | Process evaluation | Engagement with the programme |
Perceived benefits beyond health promotion | ||
Strange et al. [62] | Process evaluation | Engagement with the programme |
Oakley et al. [63] | Process evaluation | Engagement with the programme |
Stephenson et al. [64] | CRCT | Programme participation |
Process evaluation | Student satisfaction with programme | |
Fidelity | ||
Strange et al. [65] | CRCT | Student engagement |
Schools on the Move | ||
Teacher training covering embedding physical activity into the curriculum; distribution of pedometers to pupils, with instructions on how to use and record their activity levels on a website. | ||
Physical activity | ||
Delivered to: pupils (4–11 years) (primary and secondary) | ||
Delivered by: teachers | ||
Stathi et al. [66] | BA | Programme participation |
Process evaluation | Schools ethos | |
Resources | ||
Programme support | ||
Rewards | ||
SHARE—Sexual Health and Relationships: Safe, Happy and Responsible | ||
5-day teacher training, to deliver 20 classroom sessions (piloted and developed over 2 years). Sessions included small group work and games, information leaflets, and skill development through interactive video and role play. | ||
SRE | ||
Delivered to: pupils (13–15 years) (secondary) | ||
Delivered by: teachers | ||
Wight et al. [67] | CRCT | School attitudes (PSE, context) |
Process evaluation | Teachers’ attitudes/teaching styles | |
(preliminary baseline) | Teachers’ relations to pupils | |
Teaching elements | ||
Wight, Abraham [68] | Programme development | NA |
Buston, Hart [69] | Process evaluation | Student attitudes |
Teacher confidence | ||
Buston et al. [70] | Process evaluation | ‘Fit’ with school organisation |
Teachers’ explanations and reflections | ||
Buston et al. [71] | CRCT | Fidelity |
Process evaluation | ||
Buston et al. [72] | Process evaluation | Student engagement (discomfort, gender, teacher, trust, fun) |
Buston, Wight [73] | Process evaluation | Young women |
Group discussions | ||
Timing, skill-based lessons | ||
Wight et al. [74] | CRCT | Organisational factors (i.e. timetabling) |
Process evaluation | Skill-based delivery | |
Wight, Buston [75] | Process evaluation | Teacher training, |
Developing confidence | ||
Familiarisation of programme | ||
Collegiality | ||
Buston, Wight [76] | Process evaluation | Student engagement (understanding variation between classes) |
Teachers’ explanations and reflections | ||
Smoking and Me | ||
1-day teacher training and teachers’ guide—five lesson outlines and guidance for choosing group leaders and managing groups. Lessons predominantly small group work—discussion, role play, and decision-making activities. | ||
Substance use (tobacco) | ||
Delivered to: pupils (12–13 years) (secondary) | ||
Delivered by: teachers, peers | ||
Newman et al. [77] | CBA | Pupil engagement |
Fidelity | ||
SPICED—Schools Partnership in Children’s Education on Drugs | ||
2-day training for professionals delivering programme. Seven classroom sessions, using participative learning, role play, and group discussion—covering facts about legal and illegal drugs, develop understanding of risk, and promote confidence and decision-making skills. | ||
Substance use (legal and illegal drugs) | ||
Delivered to: pupils (9–11 years) (primary) | ||
Delivered by: teacher, police officer, school nurse | ||
Crosswaite et al. [78] | Process evaluation | Classroom setting |
Training provided | ||
Issues around involvement of professional groups | ||
UK Resilience Programme | ||
Professionals delivering the programme attended 10-day training course in USA. Manualised intervention (18 × 1 h workshops) teaching cognitive behavioural and social problem-solving skills. | ||
Well-being | ||
Delivered to: pupils (11–12 years) (secondary) | ||
Delivered by: trained facilitators | ||
Challen et al. [79] | CBA | Pupils’ and teachers’ experiences |
Challen et al. [80] | Process evaluation | |
Y-Active | ||
Various physical activities—breakfast club, physical education, lunchtime fitness classes, after-school play club, after-school sports. A ‘small fee’ was charged for breakfast and after-school activities (opt-in only). | ||
Physical activity and well-being | ||
Delivered to: pupils (9–11 years) (primary) | ||
Delivered by: YMCA sports coaches/play workers | ||
Stathi, Sebire [81] | Process evaluation | Project staff’s experiences |
Testing of programme theories
Theme | Context-mechanism-outcome | Area and sources | Full synth.a |
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Programme theory 1—preparing for implementation
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Preparation for the introduction of a health promotion programme to a school is more likely to be successful when systematically planned in conjunction with other school responsibilities. This involves | |||
Pre-delivery consultation | Well-established, uncontentious programmes are perceived as credible and ‘workable’ by teachers and require only basic pre-delivery consultation to be viewed as acceptable; However If a programme contains novel topic or delivery components, then staff’s unfamiliarity with these elements risks them being viewed as unacceptable. In these cases, more extensive pre-delivery consultation is required. Also If a programme’s topic or approach is contentious for some stakeholders, then consultation needs to be inclusive of these stakeholders. | p.1–4; 8–11 | |
Pupil engagement | Whatever the topic of a programme, pupils are engaged if the relevance and multiple benefits (personal, social, academic) of a programme are made clear. Also Novelty can be a strong way of initially engaging pupils’ attention, but novelty alone is insufficient for maintaining engagement. | p.5–6 | |
Reciprocity | For all programmes, successful preparation for delivery hinges on teachers’ and pupils’ judgement that they will receive the support they deem to be necessary to achieve multiple goals. | p.5–10 | |
Current practice and interests | Programmes can ‘work with’ current practice and interests in a number of ways (e.g. by meeting an unmet need, by complementing, or by driving change), but the contexts in which these processes occur remains unclear. | p.9–10 | |
Identifying clear aims and priorities, including intended outcomes | None identified | Not applicable | |
Programme theory 2—introducing a programme within a school
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The introduction of a health promotion programme to a school is more likely to be successful when it is incorporated into school activities through | |||
Integrating a programme into the life of a school (senior support) | Across a wide range of programmes, it is necessary for the actions of seniors to be tangible so that teachers feel confident in playing their role in programme delivery. However The extent of senior support is less important where pupil groups are more stable (e.g. in primary schools) and less contentious health issues are addressed. | p.12–13 | |
Integrating a programme into the life of a school (leadership skills) | If a named co-ordinator is willing, able, and has the support and capacity to take responsibility, then programme delivery is improved. The success of this role depends on a person’s credibility and influence rather than his/her level of seniority. | p.13–14 | |
Engaging those who deliver and participate in health promotion programmes (training and professional development) | If teachers perceive that training for a programme addresses relevant skill or knowledge deficits, then they are more likely to be motivated to engage with that training. However If a programme’s approach is discordant with teachers’ personal values, then engagement can be problematic. | p.15–17 | |
Engaging those who deliver and participate in health promotion programmes (pupils) | At both primary and secondary school levels, programme flexibility to accommodate pupils’ different rates of physical, psychological, and social development facilitates engagement. At primary school, pupils experiencing a programme as fun is the main way to engage pupils. At secondary school, pupils’ engagement pivots on a perception that a programme is both fun to take part in and addresses a perceived knowledge or skill deficit. Also Where a programme addresses controversial behaviours, teacher-pupil confidentiality is key to pupil engagement. | p.17–22 | |
Programme theory 3—embedding a programme into routine practice
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The routine delivery (‘embedding’) of a programme takes time and motivation. It is likely to involve changes in the school environment and the development of new relationships between stakeholders that require pro-active management so that | |||
Different stakeholders’ goals are reconciled | None identified | Not applicable | |
Organisational decisions in other areas of school life are made taking into account how they impact onprogramme delivery | No additional insight to that in programme theory 2 (‘integrating a programme’) | p.22 | |
School staff’s existing relationships with pupils are built upon | None identified | Not applicable | |
Stakeholders’ enthusiasm, knowledge, and experience are harnessed | None identified | Not applicable | |
Knowledge of ‘core’ and ‘peripheral’ elements and minimum resources, skills, and informational content is retained | None identified | Not applicable | |
Responsibility for programme delivery becomes rooted in the school | Insufficient evidence to express context-mechanism-outcome | p.23 | |
Expectations about implementation are fed back | No additional insight to that in programme theory 2 (‘integrating a programme’) | p.23–24 | |
Programme theory 4—fidelity of implementation and programme adaptation
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The preparation for, introduction, initial delivery, and ongoing sustainability of a health promotion programme in a school is more likely to be successful when there is | |||
Specificity about essential, optional, and adaptable programme elements | Insufficient evidence to express context-mechanism-outcome | p.24–26 | |
Scope for ‘mutual adaptation’ between the programme and the people delivering it | Insufficient evidence to express context-mechanism-outcome | p.24–26 |
Critical appraisal
Data extraction
Synthesis
Findings
Programme theory 1: preparing for implementation
Pre-delivery consultation
Pupil engagement
Reciprocity
Negotiation (about SRE programme delivery)
Concordance of the programme with current practice and interests
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Meeting an unmet need in a school in a way that is consistent with other school activities (i.e. ‘meshing’)
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‘Working with’ and therefore contributing to the development of a particular school ethos (i.e. ‘complementing’)
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Co-ordinating other school activities to fit with programme components (i.e. ‘driving’)