Background
Methods
Study design
RQ and sub-RQ | Concepts and variables | Methods | |
---|---|---|---|
RQ1: What was the pre-existing context of the four schools prior to the introduction of HPSF? | The school context: • HP practices of teachers/parents • HP elements in school • Dominant organisational issues • Perceived barriers for HPSF • Characteristics of student population | - Interviews - Minutes - Observations - Practices_Q - Barrier_Q - Open questions in Barrier_Q | |
RQ2: How was HPSF developed and implemented and how did it interact with the context of the four schools? | 2.1: How were the two top-down changes developed and implemented in the four schools? | Two top-down changes: • Daily healthy lunch • Structured PA sessions | - Interviews - Minutes - Observations |
2.2: To which additional health promoting changes did the two top-down changes lead to in the four schools? | Changes in HP elements in school: • School routine • Policy • Education • Environment | - Interviews - Minutes - Observations | |
2.3: Which (potential) barriers for HPSF were perceived by the implementers in the four schools, and how did they change during the first two years of implementation? | Perceived (potential) barriers for HPSF: • Innovation-related • Implementers-related • Organisation-related • Socio-political context-related | - Barrier_Q | |
2.4: Which factors influenced the development and implementation of HPSF in the four schools during the first two years of implementation? | Development and implementation process of HPSF: • Coordination • Team cohesion • Bottom-up involvement • External support • Momentum | - Interviews - Minutes - Observations - Open questions in Barrier_Q | |
RQ3: After two years, to what extent was HPSF integrated and did the context of the four schools change? | 3.1: What impacts did HPSF give rise to in the four schools after the first two years of implementation? | Changes in the school context: • HP elements in school • HP practices of teachers/parents • Characteristics of student population | - Interviews - Minutes - Observations - Practices_Q |
3.2: To what extent was HPSF seen as being fully integrated into the everyday functioning of the school after the first two years of implementation? | Perceived feelings of integration | - Interviews |
Programme theory
Participating schools (S1-S4)
The Healthy Primary School of the Future
Mixed methods
Interviews
Observations
Barrier questionnaire
Practices questionnaire
Minutes of meetings
Analyses
Results
The pre-existing context of the four schools
School 1 | School 2 | School 3 | School 4 | |
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School routine | Prior to HPSF: •Lunch break time: 45 min •Children bring their own packed lunch. Implemented in Y1: vProvided healthy lunch and mid-morning snack •Structured PA and cultural sessions during lunch break •Increased lunch break time to 105 min. | Prior to HPSF: •Lunch break time: 30 min •Children bring their own packed lunch. Implemented in Y1: vProvided healthy lunch and mid-morning snack •Structured PA and cultural sessions during lunch break vIncreased lunch break time to 95 min. | Prior to HPSF: •Lunch break time 45 min •Children bring their own packed lunch. Implemented in Y1: •Structured PA and cultural sessions during lunch break. | Prior to HPSF: •Lunch break time: 1 h •Children bring their own packed lunch or go home for lunch. Implemented in Y1: •Structured PA and cultural sessions during lunch break |
Policy | Prior to HPSF: vLimited to no HP policy. Implemented in Y1: •Birthday treat policy vWater policy | Prior to HPSF: •Limited to no HP policy. Implemented in Y1: •Water policy Implemented in Y2: vBirthday treat policy | Prior to HPSF: •Birthday treat policy •Water policy | Prior to HPSF: vLimited to no HP policy. |
Education | Prior to HPSF: •Limited to no HP education. •PE classes once a week. Implemented in Y2: •Educational lunch | Prior to HPSF: •Limited to no HP education. •PE classes once a week. Implemented in Y1: •Educational lunch Development phase: •Educational programme on healthy lifestyle. | Prior to HPSF: vHealthy lifestyle education programmes. •PE classes twice a week. | Prior to HPSF: •Limited to no HP education. •PE classes once a week. |
Environ-ment | Prior to HPSF: •Once a week fruit from local supermarket. Implemented in Y1: •Providing water bottles. Implemented in Y2: •Vegetable garden in neighbourhood. | Prior to HPSF: - Implemented in Y1: •Providing water bottles. Developmental phase: vVegetable garden | Prior to HPSF: •Active Living: PA-friendly schoolyard. •JOGG: providing water bottles. •RiskCare: offered health-promoting programmes for parents and children and supported the healthy lifestyle education programme. Implemented in Y2: •Vegetables in the schoolyard. | Prior to HPSF: •EU-school-fruit: Offered fruit twice a week. |
Process of change
Development and implementation of HPSF
Two top-down HP changes
Additional HP changes
Influencing factors: interactions between HPSF and the school context
Coordination
School 1 | School 2 | School 3 | School 4 | |
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Coordination | −/+ Mainly focus on lunch break changes, modest collaboration between school coordinator and PE coordinator | ++ Overall focus, optimal collaboration between school coordinator and PE coordinator | - Limited time and focus, limited collaboration between school coordinator and PE coordinator | + Mainly focus on lunch break changes, optimal collaboration between school coordinator and PE coordinator |
Team cohesion | + External PE assigned to class, contact and collaboration improved over time, also due to annual party for whole team | ++ External PE assigned to class contact and collaboration improved over time, also due to training course for whole team and much focus and efforts from coordinators | - More classes than external PE, external PE divided by activity, limited contact between external PE and teachers, meeting helped to get to know each other. | −/+ More classes than external PE, external PE divided by activity, contact between external PE and teachers when needed, meeting helped to get to know each other. |
Bottom-up involvement: development | ++ Full year for development, teachers and parents involved, unanimous teacher support, 89% parent support | ++ Full year for development, teachers and parents involved, unanimous teacher support, 88% parent support | −/+ Full year for development, teachers and parents involved, no full teacher support, 68% parent support | - Two months for development, teachers and parents not fully involved in development process |
Bottom-up involvement: implementation | −/+ Children voice group, parental volunteers, some additional changes with involvement of parents and teachers, teachers’ assumption that HPSF consists only of the lunch break changes and does not involve teacher participation | −/+ Children voice group, parental volunteers, some additional changes with involvement of parents and teachers, teachers’ assumption that HPSF consists only of the lunch break changes and does not involve teacher participation | - Children voice group, no parental volunteers, teachers’ and parents’ involvement limited, teachers’ assumption that HPSF consists only of the lunch break changes and does not involve teacher participation | - Children voice group, parental volunteers, teachers’ assumption that HPSF consists only of the lunch break changes and does not involve teacher participation |
External support | ++ Many different external partners involved and supporting the schools in all aspects of HPSF. | ++ Many different external partners involved and supporting the schools in all aspects of HPSF. | ++ Many different external partners involved and supporting the schools in all aspects of HPSF. | ++ Many different external partners involved and supporting the schools in all aspects of HPSF. |
Team cohesion
Bottom-up involvement
External support
Momentum
Integration of HPSF in the school context and perceived impact
Discussion
How to create a disruption? | ||
1. | Creating a disruption in a school takes time and needs bottom-up involvement | This learning point shows the importance of bottom-up involvement as indicated in the programme theory. Moreover, it also relates back to the several loops of feedback arrows between HPSF and the school context. In the four participating schools was seen that creating bottom-up involvement immediately at the start of the developmental phase took time but seemed to increase people’s ownership and support. Implementation of changes also took time as the school needed to find a new way of working in the school to create for example a good collaboration between the teachers and the external PE. |
2. | Regular contact among all actors is required to get to know each other and to manage expectations. | This learning point relates back to the importance of sufficient coordination and team cohesion. In the four participating schools was seen that regular contact between the people involved, not only to discuss the content, but also to get to know each other, helped to create more understanding and feelings of mutual support. Regular contact between teachers and external PE improved team cohesion in the school, which enhanced implementation. In particular, communication about expectations of everybody’s responsibilities appeared to be important. |
3. | Top-down advice and external practical support are important for creating a disruption. | This learning point shows the importance of external support, as indicated in the programme theory. In the four participating schools was seen that top-down advice and practical support from external partners helped the schools by providing personnel, money, materials, and knowledge. |
4. | To contextualize and realize changes feedback loops are required among all involved actors. | This fourth learning point does not only relate back to the several loops of feedback arrows in the programme theory between HPSF and the school context, it also shows the importance of external support and the involvement from bottom-up. In the four participating schools was seen that feedback loops in school among staff, children, and parents made a change better fit into the school context with its specific needs and wishes. Feedback loops between school and external partners made the external support to school, to realize the changes, as efficient as possible. |
How to use a disruption? | ||
5. | A disruption is useful for implementing additional HP changes on the same topic. | This last learning point relates back to the loop in the bottom of the programme theory which indicates the momentum-effect. In this study the provided lunch disrupted the existing dynamics in the school and created momentum for nutrition-related additional HP changes, as people perceived these additional HP changes as something that came along with the provided lunch. The health promoters felt that due to the lunch in S1 and S2, additional nutrition-related HP changes were implemented with less discussion and easier acceptance, compared to other schools in the region, due to an improved health-promoting mind-set. However, the lunch did not create momentum for not nutrition-related initiatives, i.e., PA-related. |