Implementation of health interventions in school. Research report

Implementation of health interventions in school Research report

Johan Jongbloet, Julie Schamp, Peer van der Kreeft, Tina van Havere, Tineke De Vriendt, Charlene Ottevaere, Lynn Steelant 20-2-2014

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Table of contents Tables and Figures ................................................................................................................................... 6 Introduction............................................................................................................................................. 7 Main objectives and Research Questions ............................................................................................... 9 Objectives ............................................................................................................................................ 9 Research questions ............................................................................................................................. 9 What is implementation? ...................................................................................................................... 10 Implementation is a process ............................................................................................................. 10 Adoption phase ............................................................................................................................. 11 Execution phase ............................................................................................................................ 12 Sustainability phase ....................................................................................................................... 12 Research Methodology ......................................................................................................................... 14 Inventory of school based interventions........................................................................................... 14 Eligible interventions ..................................................................................................................... 15 Defining categories ........................................................................................................................ 15 Intervention details and evaluation .......................................................................................... 16 Intervention target group.......................................................................................................... 16 Intervention operation .............................................................................................................. 16 Resources .................................................................................................................................. 18 Coding the interventions ............................................................................................................... 19 School Survey .................................................................................................................................... 20 Design ............................................................................................................................................ 20 Target group .................................................................................................................................. 21 Timing ............................................................................................................................................ 21 Qualitative research .......................................................................................................................... 21 Sample ........................................................................................................................................... 21 In-depth interview line .................................................................................................................. 22 Implementation guide ....................................................................................................................... 24 Drafting.......................................................................................................................................... 24 Feedback ....................................................................................................................................... 25 Results ................................................................................................................................................... 26 Inventory of school based interventions........................................................................................... 26 Excluded interventions .................................................................................................................. 26 Included interventions .................................................................................................................. 26 Evaluation .................................................................................................................................. 26

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Target group .............................................................................................................................. 26 Intervention operation .............................................................................................................. 27 Resources .................................................................................................................................. 28 Are specific interventions associated with certain target groups or necessary resources? ..... 29 Target group .......................................................................................................................... 29 Resources .............................................................................................................................. 30 Discussion ...................................................................................................................................... 30 School Survey .................................................................................................................................... 31 Respondents’ characteristics......................................................................................................... 32 Education level .......................................................................................................................... 32 Education type........................................................................................................................... 32 School associations.................................................................................................................... 33 Pupil population characteristics ................................................................................................ 33 School staff characteristics ........................................................................................................ 34 Implementation of interventions .................................................................................................. 34 Implementation activity and school characteristics.................................................................. 35 Implementation activity and intervention characteristics ........................................................ 36 Discussion ...................................................................................................................................... 37 Qualitative Research ......................................................................................................................... 38 Sample ........................................................................................................................................... 38 Interventions ............................................................................................................................. 38 Schools....................................................................................................................................... 39 In-Depth interviews and school site visits ..................................................................................... 40 Community level characteristics ............................................................................................... 40 Prevention theory and research ............................................................................................ 40 Politics ................................................................................................................................... 40 Funding .................................................................................................................................. 41 Social environment ................................................................................................................ 43 Hot topic ................................................................................................................................ 44 Characteristics of the provider .................................................................................................. 44 Perceived need for innovation .............................................................................................. 44 Perceived benefits of innovation........................................................................................... 46 Example-function .................................................................................................................. 48 Characteristics of the innovation .............................................................................................. 49 Compatibility ......................................................................................................................... 49 4

Adaptability ........................................................................................................................... 49 Educational material.............................................................................................................. 50 Evaluation .............................................................................................................................. 53 Weather ................................................................................................................................. 54 Attitude pupils ....................................................................................................................... 54 Characteristics relevant to the prevention delivery system: organizational capacity .............. 54 General organizational characteristics .................................................................................. 54 Shared vision and involvement ......................................................................................... 54 Integration of the innovation ............................................................................................ 55 Health policy ...................................................................................................................... 57 Specific practices and processes ........................................................................................... 58 Shared decision-making .................................................................................................... 58 Coordination with other agencies ..................................................................................... 59 Communication ................................................................................................................. 59 Formulation of tasks .......................................................................................................... 60 Specific staffing considerations ............................................................................................. 61 Leadership ......................................................................................................................... 61 Program champion or working group ............................................................................... 62 Managerial support ........................................................................................................... 62 Characteristics related to the prevention support system ....................................................... 63 Training .................................................................................................................................. 63 Technical assistance .............................................................................................................. 63 Summary ....................................................................................................................................... 63 Implementation guide feedback ....................................................................................................... 65 Clarity ............................................................................................................................................ 65 Legibility and design ...................................................................................................................... 65 User-friendliness ........................................................................................................................... 65 Usefulness and feasibility .............................................................................................................. 65 General comments ........................................................................................................................ 66 Final Remarks ........................................................................................................................................ 67 Attachments .......................................................................................................................................... 68 Bibliography........................................................................................................................................... 69

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Tables and Figures Table 1: inventory categories, variables and values for included interventions................................... 20 Table 2: categories and factors affecting the implementation process (Durlak & DuPre, 2008) ......... 24 Table 3: included interventions ............................................................................................................. 27 Table 4: included interventions ............................................................................................................. 27 Table 5: included interventions ............................................................................................................. 28 Table 6: included interventions ............................................................................................................. 29 Table 7: included interventions ............................................................................................................. 29 Table 8: sample by education type and education level ....................................................................... 33 Table 9: mean number of pupils per school .......................................................................................... 33 Table 10: sample of schools for explorative research ........................................................................... 39

Figure 1: levels of implementation........................................................................................................ 18

Acknowledgements We would like to thank the respondents for their contributions to the survey, the interviews and the school visits. Our gratitude also goes to the members of the project steering group for their invaluable suggestions and feedback to the research work: dr Moniek De Keyser, VCLB Regio Gent; dr Joke De Wilde, HoGent Onderzoeksaangelegenheden, Greet De Brauwere, HoGent Sociaal Werk, Prof dr Lea Maes, UGent Maatschappelijke Gezondheidskunde, Prof dr Greet Cardon, UGent Bewegings- en Sportwetenschappen, Letticia Desutter,Logo Gezond+ Gent, Marleen Roesbeke, Logo Gezond+ Gent, Olaf Moens, ViGez, Prof dr Johan vanBraak, UGent Onderwijskunde , Prof dr Inge Huybrechts, UGent Maatschappelijke Gezondheidskunde, Mia Verschraegen, HoGent Voedings- en dieetkunde, Erika Vanhauwaert, ViGez, Esther Bloch, HoGent Onderzoeksaangelegenheden, Thanks to ad interim members of the research team for their important input: Gerda De Bock and Elly Van Hyfte , HoGent Lerarenopleiding, Elke Heddebauw, HoGent Voedings- en Dieetkunde

The research team, Peer van der Kreeft, Johan Jongbloet, Julie Schamp, Tina Van Havere , Charlene Ottevaere, Lynn Steelant, Tineke De Vriendt from the departments Sociaal Werk, Orthopedagogie, Voedings- en Dieetkunde, Lerarenopleiding at Hogeschool Gent 6

Introduction In Western countries, it appears children and adolescents adopt lifestyles that have negative repercussions on their general health. Especially unhealthy nutritional habits and a lack of physical activity (often referred to as sedentary behavior) are part of a lifestyle, once a habit tending to develop further in adolescence, afterwards hard to change (De Henauw et al., 2007). This exposes them to an increased risk for several health threats later on such as diabetes and cardiovascular disorders. 10% of the European population and one of every seven children in grade 4 (9 – 10y) in Flanders suffers overweight (Seghers & Claessens, 2008). Over 60% of children who are overweight before puberty will be overweight in early adulthood. Childhood obesity is strongly associated with risk factors for cardiovascular disease, type 2 diabetes, orthopedic problems, mental disorders, underachievement in school and lower self-esteem (WHO, 2014). Overweight in youth stems from a disparity in the energy balance. Too many fat reserves are stocked inside the body when the energy intake from nutrition is bigger in proportion to the consumption of energy. These same children and youth do not exercise sufficiently and disregard recommendations for a healthy diet. This often occurs as youth have a misperception of their own lifestyle. However, not only children and youth suffer these misperceptions. Also elementary and secondary school administrations tend to believe in the school high quality health promotion is pursued, including concrete nutritional habits and physical activity facilities. In reality though a demotivating or even contra productive policy is pursued. Nevertheless, WHO states clearly that a supportive school environment is of primordial importance for implementing school interventions targeting these issues (WHO, 2008). “Many school-based interventions show consistent improvements in knowledge and attitudes, behavior and, when tested, physical and clinical outcomes (WHO, 2009; 42).” Overweight and obesity in adulthood are predicted by overweight during childhood and adolescence, indicating the importance of preventive interventions targeting a balanced diet and sufficient physical activity at an early age. Youngsters at the start of adolescence make a first important target group (Brug et al., 2010). Research indicates that intervening at that age can prevent diabetes and obesity. What is more, it can facilitate interventions and treatment at a later age. Evidently, these efforts need to be further supported at later ages and need to be tailored for every age group (Brug et al., 2010). As such, it does seem sustained to intervene from pre-school over primary into secondary school children. Here we face some problems. Even though school based interventions are often found effective during research, there exists a discrepancy between the theoretical development and testing of a program and its independent application and adoption (Haystead & Marzano, 2009). In the latter, hundred per cent loyalty to the conceptual model is impossible and not recommended as the teacher is confronted with his own concrete school- and class setting. Disseminating a prevention program, we will find a great deal of variety of program fidelity and adoption in implementation. Research shows that implementing systematically and according to plan is an important quality standard within prevention. It is found that aspects of implementation can greatly affect program outcomes (Durlak & DuPre, 2008). Between the introduction and results of an intervention, different interfering factors on the level of target group and setting can be found to influence the final results. 7

The question ‘why it works?’ is thus extremely relevant and evidence based prevention can thus not be restricted to the question if a program is effective. This is often referred to as the black box (Harachi, Abbott, Catalano, Haggerty, & Fleming, 1999; Tones & S, 1994) when we undertake an intervention and see the results, but not exactly know how this result was obtained. A research focus then must be interfering factors on the level of implementation. Limited research has been conducted/published on this topic. These factors can be evaluated through process evaluation: did implementation go according to plan; identifying facilitating and interfering factors. As such, when results do not turn out as aspired, we can distinguish between an unsuccessful intervention and an unsuccessful implementation (Harachi et al., 1999). These process data are extremely important in the working field in terms of applicability and feasibility of an intervention in a certain setting (VAD, 2010). It is exactly these data that are often missing. WHO (2007) acknowledges that implementation is often the weak link in many programs and projects.

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Main objectives and Research Questions Objectives Main objective of this research project is to develop an implementation guide for school-based interventions promoting healthy lifestyles through balanced nutritional habits and sufficient exercise. Connected to this main objective is a set of secondary objectives:   

Stock taking of existing interventions targeting nutrition and physical activity in Flanders for all three compulsory education levels, i.e. pre-school, primary and secondary school levels. Identifying facilitating and interfering factors during the implementation phase of aforementioned interventions. Developing, testing and modifying implementation guidelines for a quality adoption of those interventions on the school level.

Research questions These objectives led to the formulation of following research questions:   

Which interventions are being implemented in Flanders in school anno 2011 - 2012? Which conditions facilitate program adherence during implementation? Which conditions facilitate scaling up of interventions? Which instructions can we give intermediaries and facilitators to support them in their intervention implementation?

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What is implementation? Implementation operates at the area of tension between intervention characteristics and implementer characteristics. Implementation research is concerned with tuning the characteristics of that setting with the characteristics of the particular intervention as to maximize the potential of the health promoting or harm preventing intervention. If we succeed in doing this, we speak of good quality of implementation. For good quality of implementation, a first prerequisite is a valid choice for preventive interventions. This entails implementers are aware of institutional strengths and limitations and are able to identify an appropriate intervention. Moreover, implementers have to judge the most promising intervention in relation to their capacity and predefined goals. In our research, this entails empowering schools to recognize effective characteristics of preventive interventions focusing on physical activity and healthy food and judging their capacity as to implement those interventions. Secondly, for good quality of implementation, the intervention needs to be executed well thought out. As Durlak and DuPre (2007: 327) state: “Developing effective interventions is only the first step toward improving the health and well-being of populations.” These interventions need to be transferred from the trial setting into real world settings. This transfer however is a complex and often extensive process. Moreover, in contrast to the implementers in the effectiveness trial, DIY implementers cannot count on the same degree of support and follow-up during the implementation process. In this research project we want to assist schools and particularly teachers in the implementation process to maximize the preventive outcomes. Derzon, Sale, Springer, and Brounstein (2005) find in their meta-analysis of 46 unpublished drug prevention programs funded by SAHMSA, that for implementation of preventive programs under ideal, supported conditions, effect sizes are up to twelve times higher.

Implementation is a process Implementation refers to the realization of an innovation in a particular context. Implementation then covers the instalment, testing and prolonged use of the innovation. Good implementation quality of evidence based programs then refers to maximizing integrity. A high level of program integrity for evidence based programs should then lead to the desired outcomes just like the developers intended. However, in the whole implementation process we find intermediaries have to make their own puzzle of interventions, approaches and policy. No single setting is a tabula rasa and each intermediary has to tune an innovative approach with the existing approaches. An innovation has several consecutive phases, before being sustained in a setting. Durlak and DuPre (2008) distinguish four different phases: the dissemination phase, adoption phase, implementation phase, and consolidation or sustainability phase. During the dissemination phase information and value of a program is communicated to possible implementers. This is not the focus of this research. We focus on assisting the implementing body, schools and teachers. As a result, the dissemination phase and factors related to it will be disregarded in the rest of this research project. A second phase in the diffusion process of an innovative action is the adoption phase. This is where implementers decide to try out or decline a new program. Schools need to make it their own and introduce it in the existing structures. Thirdly, in the execution phase we are especially concerned with how well the intervention is executed. The last phase in the implementation process is called 10

the sustainability phase. After all, for good quality of implementation we want an intervention to be sustained over a longer period, but unfortunately this is often not the case (Durlak & DuPre, 2008).

Adoption phase In the adoption phase implementers try to integrate the innovative action into existing practices and structures. As such, the intervention will have to proof its fit for the particular context. The characteristics of the intervention have to be scrutinized and labelled fit for the cause and context or not. In this regard not only effectiveness of the innovation is considered. On a practical level, feasibility, duration and investment among others will be considered before given a green light. Also the institutional or cultural context will be tested on its openness for this particular innovation. In this research project we think of school climate, pedagogical mission, school support network, infrastructure, existing working groups, and so on. What is more, if adoption wants to take place, also teachers need to support the intervention in the classroom and often here is where the shoe pinches. Why prevention is not popular Even though it is widely acknowledged that prevention is generally much cheaper than treatment, we find that preventive innovations diffuse rather slowly (Rogers, 2002). This is not surprising, considering the nature of prevention. “Preventive innovations usually require an action at one point in time in order to avoid an unwanted future condition (Rogers, 2002).” For example, a first grade teacher bears the fruit of his work at the end of the school year when the children have learnt to read and write. This grants a dedicated teacher a certain amount of satisfaction. This satisfaction more often than not is absent doing prevention as the effects are only to be found on population level and they are very subtle. Rewards for the work invested in implementing preventive innovations are thus in the best case delayed, but mostly entirely absent. After one negative experience teachers are not very likely to venture again. Moreover a preventive innovation gives teachers extra work load and even requires teaching methods they are maybe not familiar with. But good prevention matters! There are several approaches for this problem. One focuses especially on activating the motivation and the sense of ‘it matters what we do’ of the implementer through different strategies. Rogers (2002) proposes five strategies for diffusing preventive innovations: 1. Change the perceived attributes of preventive innovations. As mentioned previously, the relative advantage of a preventive innovation needs to be stressed (Lock & Kaner, 2000). 2. Utilize champions to promote preventive innovations. A champion is an individual who devotes his/her personal influence to encourage adoption of an innovation. Goodman and Steckler (1989) found that champions for health ideas were often middle-level officials in an organization. 3. Change the norms of the system regarding preventive innovations through peer support. Changing norms on prevention is a gradual process over time, but can be accomplished (Kaner, Lock, McAvoy, Heather, & Gilvarry, 1999; Keller & Galanter, 1999). 4. Use entertainment–education to promote preventive innovations. Entertainment–education is the process of placing educational ideas (such as on prevention) in entertainment messages (Singhal & Rogers, 1999). 11

5. Activate peer networks to diffuse preventive innovations. Previously, we mentioned that diffusion is a social process of people talking about the new idea, giving it meaning for themselves, and then adopting. Anything that can be done to encourage peer communication about a preventive idea, such as training addiction counsellors in new addiction treatment techniques, thus encourages adoption (Martin et al., 1998). The five strategies Rogers (2002) proposes should only be applied to interventions that are proven to be successful, or are at least very promising. No prevention professional would want to stimulate bad choices, i.e. choices for ineffective interventions or interventions with iatrogenic effects. Also in this project we would not want to undermine the prevention field through promoting interventions that are not effective or promising, consuming limited funds and human resources. The last thing any prevention professional tries to accomplish is supporting schools in a choice for ineffective interventions as they certainly erode the intermediary’s experience of success, making him more reluctant in the future to engage on a new preventive innovative intervention.

Execution phase During the next phase of implementation, the intervention is executed. In this phase schools and teachers are supported, often by exterior partners towards the consolidation of the project inside the school. Especially the final implementer will be working in this phase. Related to our research this last cod in the chain from developing an intervention to delivering it, is the teacher-pupil contact. And the teacher’s resilience will be put to the test. His capabilities are challenged and shortcomings become apparent. The quality of execution of the intervention is influenced by the teacher’s skills, openness to innovation, gender, motivation, etc. In this phase the implementer is in dire need of support. Teacher support and consultation can be delivered in two forms. First, training teachers to implement the program accurately and consistently will increase implementation quality (Dusenbury et al., 2005; Peters et al., 2009). Secondly, promoting teacher motivation to implement the program (Han and Weiss, 2005). Following these authors, external consultancy is a necessary back support for quality implementation and even more, for a sustainable intervention.

Sustainability phase Finally we want an innovation to persist through time. At least until goals are attained or a new feasible intervention is more promising to reach the predefined goals. Han and Weiss (2005) focus on conditions that relate to the sustainability of mental health programs in school settings and they distil four “essential ingredients” for a sustainable program. A sustainable program must be: a) b) c) d)

Acceptable to schools and teachers Effective Feasible to implement on an on-going basis with minimal (but sufficient) resources Flexible and adaptable.

The writers realize these characteristics are necessary but insufficient conditions to make a program last. For sustaining teachers’ implementation at classroom level other conditions next to programspecific factors or school- and teacher-specific factors have to be met. They are political, bureaucratic and systemic by nature. In the case also those conditions are met, sustainability can be achieved through what they call the process model of enhanced sustainability. When a teacher implements the activities, experiences success, he will be motivated to implement the program further, acquiring 12

a better understanding of the program principles and implementation techniques, thus refining the implementer’s skills. This is translated in increase quality of implementation which translates in an increased experience of success. Teacher training and consultant feedback are vital elements during the execution phase to give this process loop a kick start, they conclude (Han and Weiss, 2005).

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Research Methodology To reach the main objective of developing an implementation guide for school-based interventions promoting healthy lifestyles through balanced nutritional habits and sufficient exercise, several research methods were used in consecutive research phases. A first phase consisted of stock taking of interventions being used at the time (academic year 2011 – 2012) in all compulsory school levels in Flanders. Since implementation operates at the tension between intervention and implementer characteristics we first want to know what type of interventions are being used in Flanders. Stock taking of existing interventions focuses the research. It is needed to define the boundaries of the implementation guide we are developing. The first research objective: “Stock taking of existing interventions targeting nutrition and physical activity in Flanders for all three compulsory education levels, i.e. pre-school, primary and secondary school levels” will be achieved here. In a second research phase we find out what interventions schools tend to implement. After this phase we are able to answer the first research question: “Which interventions are being implemented in Flanders in school anno 2011 - 2012?” Furthermore, in this research phase we focus on the other side of the tension where implementation operates: the implementer’s characteristics. We compare school characteristics with number of interventions they implement and type of interventions with times being chosen to implement. A third research phase has a qualitative nature. In this third phase we enquire through school visits and in-depth interviews what implementers indicate as facilitating and interfering factors. The second research objective: “Identifying facilitating and interfering factors during the implementation phase of aforementioned interventions” will be achieved. Also the second research question: “Which conditions facilitate program adherence during implementation?” will have its answer. In a final research phase we put the implementation guide we developed after previous research phases to the test. Several schools test the guide on different topics and give feedback. These comments are used to draft the final implementation guide. The final objective: “Developing, testing and modifying implementation guidelines for a quality adoption of those interventions on the school level.” is achieved. Also the final research question: “Which instructions can we give intermediaries and facilitators to support them in their intervention implementation?” will be answered.

Inventory of school based interventions Stock taking of school-based interventions promoting healthy nutritional habits and physical activity was carried out to achieve the first research objective: “Stock taking of existing interventions targeting nutrition and physical activity in Flanders for all three compulsory education levels, i.e. preschool, primary and secondary school levels.” This work is also preparatory work for the following research phase where we survey schools on interventions they implement. Stock taking is also a necessary exercise to focus the consecutive research phases and eventually the guide. We made an online search for interventions that are offered to schools in Flanders anno 2011 – 2012. A group of five 2nd year pupils social work explored internet and pedagogical library catalogues for school based interventions that target healthy nutrition and/or physical activity. Based on this exercise we could define our systematic search strategy.

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To limit the scope of the search we only investigated those online communication channels and supporting organizations that are generally used by the schools in Flanders. On Flemish level, these include the websites of VLOR (Vlaamse Onderwijsraad), VIGeZ (Vlaams Instituut voor Gezondheidspromotie en Ziektepreventie), National Health Services (Mutualiteiten en ziekenfondsen) and the umbrella organisations of the different Flemish school systems (GO!, OVSG, POV, VVKBaO, Federatie van Rudols Steiner scholen in Vlaanderen, FOPEM, VOOP, Raad van inrichtende machten van het Protestants-Christelijk onderwijs). On the level of the Province of EastFlanders, the websites of the CLB’s (Centre for Student Counselling) were scanned together with the homepages and newsletters of the LOGO’s (Local Health Consultation). Finally also the most prominent educational publishers were included. The Union of Flemish Publishers (VUV) has a membership group of educational and scientific publishers. In this are two expert groups of educational publishers one for primary and one for secondary education. The publishers inside this expert group were included in the search. However, for pragmatic reasons, not all publications were scrutinized. We limited the search to the website, thus only focusing on those publications that explicitly target healthy nutrition or physical activity. As such this search method disregards source books (bronnenboeken) for pre-school children and the learning and course specific manuals for primary and secondary school children (leergebied gebonden handboeken en vakgebonden handboeken).

Eligible interventions The general concept of what comprises an intervention is elusive and open to interpretation. The mere dissemination of a brochure on a new gym center could be regarded as an intervention but cannot be the scope of this research. Interesting interventions for further research thus need to be specified. Inclusion and exclusion criteria for eligible interventions were specified during a discussion meeting with experts from different related work fields (research, health sector and education). First, we concentrate on the entire spectrum of prevention: universal, selective and indicated preventive interventions. Secondly, the intervention is designed for healthy nutrition and physical activity promotion among other aims. Thirdly, as we target teachers, the intervention should have an educational component. Consequently, the teacher plays an active role in the educational component of the intervention, thus excluding those interventions where the teacher merely has a managerial function while external experts facilitate the intervention process. Also the Intervention is available for use in the school year 2011 – 2012. Finally, an intervention is regarded as such when it is a comprehensive entity contributing to the specific intervention aims. This entails that our inclusion criteria are not to be seen as quality criteria for interventions. These criteria do not state anything in regard of effectiveness of interventions. These criteria are chosen pragmatically in relation to the final objective of the project, the development of an implementation guide for school based interventions with a special focus on the teacher as principal facilitator.

Defining categories We just decided inclusion and exclusion criteria for interventions we target with the implementation guide. We are particularly interested in evidence based or – at east – promising interventions. If we want to help teachers choose and implement the most promising interventions, we need to review literature for what constitutes a promising intervention. 15

A great number of studies have been carried out on the effectiveness of school based interventions to promote a healthy lifestyle among youngsters. Since the early 1990’s there is growing consent that we need to move away from a black box- approach in prevention science, where we merely measure the overall effectiveness of interventions towards an approach where we study the mechanisms of interventions through which the actual change comes about (Harachi et al., 1999). Analysing and comparing rigid effectiveness studies enables us to shed light on the components of interventions that contribute to its effectiveness. Meta-analyses and (systematic) reviews try to grasp the characteristics that make school based interventions effective and try to identify those intervention properties that are possibly ineffective. We include and summarize results from several systematic reviews and reviews of reviews of effectiveness studies of school-based interventions promoting healthy nutrition and physical activity. Also, we include reviews that focus on interventions only targeting nutrition or only targeting physical activity. Next to effectiveness, feasibility is also an important aspect in implementation. An effective intervention requiring too much effort, time, resources will be implemented partially or not at all. We need to help teachers evaluate interventions on feasibility and effectiveness. Categorizing included interventions on variables related to feasibility and effectiveness sheds light on what type of interventions are on offer in Flanders. Taking stock, we gather relevant information divided in several categories. After literature review, the final decision on categories and variables to code interventions was made in an interdisciplinary working group consultation.

Intervention details and evaluation Concerning intervention details, we gather the name of the intervention and its homepage. We inventory the online access path to the intervention, together with the access date. Since we direct teachers towards evidence based prevention, we check for outcome and process evaluations and make inquiries for the reports.

Intervention target group A second variable category concerns the target group of the intervention. We differentiate level of education (pre-school, primary, secondary or a combination), type of education (regular education or education for children with special needs) and finally we kept track of the different forms of education (ASO, TSO, BSO, KSO). Concerning target group, one also might consider gender. It is found e.g. that sports might be more effective for boys and nutrition interventions more effective for girls (De Bourdeaudhuij et al. 2011). Because in Flanders schools are mixed by law, only selected or indicated prevention projects can specify gender. No such projects were found taking stock.

Intervention operation The variable category ‘intervention operation’ covers those variables concerned with the functioning of the intervention. A first variable concerns the aims of the intervention. Relevant interventions target or physical activity, or healthy nutrition or a combination of both, possibly completed with other aims, e.g. being safe in traffic. Brown and Summerbell (2008) suggest a combination of physical activity and dietary interventions may have positive results for children on the long term. De Meester et al. (2009) however do note that interventions aiming to affect more than one health behavior appear to be less effective in favor of physical activity. Evidence on effectiveness related to the aims of the intervention is inconclusive, but physical activity combined with healthy nutrition seems promising. 16

A second category, contributing to the functioning of an intervention is the intervention strategy. Three strategies are distinguished. Following recommendations of VIGeZ, good policy relies fundamentally on a combination of three pillars: education, regulation and agreements, and an environmental component, i.e. supply of healthy food or offer of infrastructure for physical activity (Buytaert, Moens, Tambuyzer, Wouters, & Vanhauwaert, 2010). Off course, interventions can also be constituted of a mix of intervention strategies. Literature refers to these programs as multicomponent interventions. Dobbins, De Corby, Robeson, Husson, and Tirilis (2009) found for several outcome measures the minimum effective program components to be a combination of attractive printed educational materials and changes in the school curriculum that promote physical activity. This underlines a promising combination of an educational component with an increased offer of physical activity inside the school. Also van Sluijs, McMinn, and Griffin (2007) find strong evidence for the effectiveness of interventions to promote physical activity for children and adolescents of multicomponent interventions. They also note that, taken in mind that young children’s activity is more remittent while that of adolescents is more structured, the first take more advantage of structural environmental or policy changes while the latter are more affected by traditional cognitive approaches, potentially combined with environmental approaches. Following Peters et al. (2009) we need to bear in mind the promising results that effective elements of school health promotion could be similar across several behavioral domains. For substance abuse, sexual behavior and nutrition they identified many elements that were found to be effective across two domains and found five common elements, among them multiple component programs. Most up-to-date systematic review summarizing the evidence of school-based interventions promoting healthy nutrition and physical activity habits comes from De Bourdeaudhuij et al. (2011). Also their main conclusion is a plea for programs that combine an educational and environmental component. An environmental component ideally includes increased opportunities for physical activity and healthy food together with restrictions on unhealthy food and food pricing regulations. Finally, in line with above conclusion, . Birnbaum, Lytle, Story, Perry, and Murray (2002) found that school environment alone actions (offer of healthy food) even showed a trend of decreased fruit and consumption. It is safe to conclude that a mix of strategies is more promising than singe strategy interventions. Also defining the functioning of interventions is the implementation level of the intervention. Van Sluijs, McMinn, and Griffin (2007) find strong evidence for the inclusion of a family and/or community component. De Meester, van Lenthe, Spittaels, Lien, and De Bourdeaudhuij (2009) agree including parents can enhance school-based interventions, but they note that effects are often shortterm and limited to school related physical activity with no conclusive transfer to leisure time activities. Peters et al. (2009) also find parent involvement to be effective for elementary aged children in interventions targeting nutrition. We distinguish five levels, with each following level enclosing the former one. The most basic level is targeted at the individual, the most elaborate level comprises actions within the community, involves parents, targets the whole school and has class activities. We found no school based interventions with a community component that disregard the parents. Also because of our exclusion criteria, the active educational role of the teacher, we find eligible interventions that operate on school level always have activities inside the class. Finally we did not score any of the interventions as operating solely on individual level. Based on the inclusion criteria an active/pedagogical role for the teacher in 17

the class’ automatically sets aside individually targeted interventions. Finally, there are some interventions where tailored individual feedback is included, but these interventions still have group based activities and are thus coded as such.

Figure 1: levels of implementation

Feedback, self-exploration, role playing, etc. is coded inside the category of didactical methods. We distinguish four different groups of didactical methods. Instructing, telling tales and having a demonstration falls under forms of instruction. Note that forms of instruction is a didactical method entailing only one direction of education, namely the teacher dispensing knowledge. Discussion and debating methods, together with different conversational methods in the class comprise the forms of interaction. Pupils and teacher exchange and debate ideas through these didactical methods. A third category of didactical methods are forms of playing. Examples are simulations, role play, mime and quiz. Delgado-Noguera, Tort, Martinez-Zapata, and Bonfill (2011), based on a meta-analysis of the results from 19 trials promoting fruit and vegetable intake, find that computer-based interventions are effective for that outcome in primary school children. They conclude that children probably learn best through play and computer games could provide an extra dimension of amusement further increasing motivation. A last category are forms of exercises such as homework, sub group work, selfexploration methods and lab.

Resources Also resources that need to be invested are an important aspect of an intervention. A first category concerns time that needs to be invested. Birnbaum, Lytle, Story, Perry, and Murray (2002) focus on the element of exposure to a multicomponent school-based nutrition intervention (TEENS). It results that increased exposure correlates with increased effectiveness. Also Peters et al. (2009) found a larger number of sessions had rigid positive results for nutritional interventions. We distinguish between interventions that are a one-time effort, such as a thematic day or week and interventions that comprise a succession of courses. We distinguish between series of courses in one academic year and a series of courses across several years. Finally some interventions, once started have an endurable nature. 18

A second category of resources is money-related. We distinguish between interventions that are free to use (e.g. free downloadable educative packages) and interventions that are not. Even though it seems the financial aspect is more relates to feasibility of an intervention, Delgado-Noguera, Tort, Martinez-Zapata, and Bonfill (2011) do find that free/subsidized interventions did not achieve results. It seems for effectiveness, some money needs to be invested, vene only for attractive didactical materials. Dobbins, De Corby, Robeson, Husson, and Tirilis (2009) included 26 studies with participants ranging from six to eighteen years old. For several outcome measures they found the minimum effective program components to be a combination of attractive printed educational materials and changes in the school curriculum that promote physical activity. Finally, we coded interventions along the necessity of expertise for qualitative implementation. Some interventions are to be implemented by the teacher independently, whereas in other interventions, the teacher has support from an external expert. Finally for some interventions, teacher training sessions are organized. Training is a component that certainly increases effect sizes. Following Peters et al. (2009), training of facilitators is certainly effective for interventions targeting nutrition.

Coding the interventions To categorize the interventions, a codebook was developed. Initially one reviewer coded the interventions based on the information that was available on the interventions’ homepage. The eligible interventions were divided into five equal parts and were re-coded by five other reviewers for objectivity purposes. The five reviewers were given the intervention name, its homepage and the access path and date. They each re-coded one fifth of the eligible interventions on the variable evaluation and three variable categories: target group, functioning of the intervention and necessary resources. Category Variable Intervention identification name website acces path acces date evaluation

Intervention target group

education level

education type

education forms

Intervention operation

aims

strategies

Value … … … … yes no pre-school primary secondary basic (pre-school + primary) all levels regular education education for children with special needs both general tecnical vocational artistic physical activity only healthy nutrition only physical activity + other healthy nutrition + other both both + other education regulation and agreements offer strategies

19

implementation level

learning methods

Resources

time

costs expertise

individual class school family community instruction interaction play exercise mix one off several units in one school year several units in more school years permanent character for free not for free independent in class support training

Table 1: inventory categories, variables and values for included interventions

Each of five reviewers also scrutinized one fifth of the excluded interventions. They checked if interventions were rightfully excluded based on the same inclusion and exclusion criteria mentioned above. The re-coded data was compared with the initial coding. Where differences were encountered, the first reviewer would re-analyze the available web-based information and in case this would not be decisive the concerned reviewers would discuss until consensus was reached.

School Survey After stock taking of school-based interventions promoting healthy nutrition and/or physical activity, a concise school survey was designed to answer the first research question: which interventions are being implemented in Flanders anno 2011 – 2012?

Design With this research instrument we wanted to assess which interventions schools choose to implement. The questionnaire consisted of two main parts. In a first part we provided a list with all school-based interventions promoting healthy nutrition and/ or physical activity that we encountered during our comprehensive online search. Even though we realized that a list of 186 interventions could make the completion of the questionnaire a long-winded work, we chose to include all encountered interventions in the list instead of focusing only on those interventions we included for several reasons. First of all we want to have a clear view on the overall picture of implemented interventions in schools. After this research phase we sample schools for qualitative enquiry. In this sample we need to include very active and less active schools. Schools which are very active on health promotion will provide valuable information from experience but less active schools are also valuable for providing different types of insights and exposing basic interfering factors. Secondly, surveying all interventions assesses the social relevance of the scope of our implementation guide. If we find almost no included interventions are implemented in school and we should find prohibitive objections during the qualitative research phase against implementing this type of interventions, social relevance of our product would be very low. In this case a shift in scope for the implementation guidelines would be desirable. Finally, from a practical point of view, we employed a conveniently arranged questionnaire format. Through the format of digitally ticking boxes on a word.doc, going over all interventions was only a matter of minutes, thus minimizing the 20

burden on school administrations. An extra box was left open for interventions that were not mentioned already. The second part of the questionnaire focused on the demographics of the school and respondent. The size of the school, the gender ratio among pupils and teachers, the school system, educational levels, types and forms and the amount of pupils from societal vulnerable target groups where included in the survey. Finally schools could indicate if they were interested to cooperate in further research.

Target group Logo Gezond+ is one of the partners in this research project. A Logo (local health consultation) is a regional platform under the umbrella of the Flemish Agency for Care and Health. Among their main tasks is the promotion of preventive health care for local governments, associations, enterprises, the education sector and the health care sector. Logo Gezond+ is active in 45 municipalities in the province of East-Flanders. This work terrain reflects the diversity in Flanders with urban and rural municipalities. This sample of schools also reflects the educational landscape in Flanders regarding school systems and education types, levels and forms. Cooperation with Logo Gezond+ facilitated school access and further promotion of the research project through their communication channels. What is more, Logo’s are also responsible for the promotion of preventive health in schools. As such we contacted a pool of schools that receive similar support and information on school-based preventive health. Bias from these supporting structures is thus avoided. We sent out our questionnaires to a total of 465 schools.

Timing We sent out a first wave of questionnaires by e-mail to the school administrations in October 2011, followed by two reminders (last one middle of November). We had a very low response rate of just over 40 completed questionnaires. After the Holidays, we sent another request to all schools, together with the possibility to also receive a hard copy of the questionnaire by regular mail. Two schools made use of that possibility and one of them came back to us completed.

Qualitative research After the qualitative research phase we will have reached our second research objective: “identifying facilitating and interfering factors during the implementation phase of aforementioned interventions” and we will answer the second set of research questions: “Which conditions facilitate program adherence during implementation? Which conditions facilitate scaling up of interventions?” To achieve these goals we will conduct in depth interviews and organize school site visits to a defined selection of schools.

Sample We need a sample of schools for qualitative research where we find as much information as possible on interfering and facilitating school factors for implementation of interventions promoting physical activity and healthy nutrition. We want to sample schools on two dimensions. First we want to include schools that are very active on promoting physical activity and healthy nutrition. These schools have a lot of experience with implementation. In the sample we also want to include schools that are not so active on this thematic. These schools offer a great deal of information on possible 21

interfering factors for implementation of interventions. In comparison with these types of schools facilitating factors will also be further revealed. A second dimension deals with promising interventions. We certainly want to include schools with experience in implementing promising interventions. Promising interventions might have an extra or different set of factors interfering with or facilitating implementation. Ideally our sample also reflects the education landscape in Flanders regarding education level, education type and school association. To take this sample, we first need to define what are promising interventions, based on the categories we used to code the interventions in our database. In the sheer absence of rigorously evaluated interventions in Flanders, we need to focus on promising interventions that combine several characteristics. These characteristics where elaborately described in the methodology of taking stock of interventions and are here merely summarized. First multi-component interventions seem promising in preventing unhealthy lifestyles. Also it seems a combination of targeting physical activity and healthy nutrition is promising. Further, including the whole school, parents and/or the community is more promising than an intervention restricted to the class room. Concerning didactical methods, it seems that pure instructional didactic interventions are least successful. Next, theory finds that interventions with a larger number of sessions are also promising. Finally, expertise is needed for quality implementation of interventions. Since we focus on the teachers this implies teacher training. If these interventions aren’t to be found, we will be obliged to lower standards of promising interventions, but still sample the most promising interventions from our database. In a second step of sampling, we check which schools that indicated further cooperation on the school survey, whether they are implementing such intervention(s). Inside this group of schools we check how much of our other criteria are met. If we don’t find a representation of schools by association, education level and education type, we will supplement with schools meeting the missing criteria.

In-depth interview line In this research phase we conducted interviews with teachers. The interview was designed to bring to the surface interfering factors for implementation of interventions promoting a healthy diet and sufficient physical activity. The most extensive systematic review on factors influencing implementation is by the hand of Durlak and DuPre (2008). Results from over 500 studies offer strong empirical support that implementation “affects the outcomes obtained in prevention and promotion programs” (2008; 327). Next to assessing the impact of implementation on program outcomes, they sought to identify the factors affecting the very implementation process, scrutinizing the conditions interfering with implementation. Following their framework for effective implementation, we find strong connections between factors that are related to the community, the provider and the innovation. These three categories of factors determine the limits of the implementation context. Community factors relate to policy, funding, politics, etc. Provider characteristics affecting implementation are facilitators’ perceptions of need and effectiveness of the intervention, self-efficacy and skill proficiency. Under innovation characteristics we find compatibility (contextual appropriateness, fit, congruence, match) and adaptability (program modification, reinvention). For effective implementation, however, Durlak and DuPre (2008) specify two more categories. These are regarded as essential-but-not-sufficient conditions. The first set is related to the prevention 22

delivery system, i.e. everything related to the organizational capacity of the implementer’s’ institute. Organizational capacity is broken down in three categories: general organization features (work climate, openness to change, etc.), specific organizational practices and processes (shared decisionmaking, communication, etc.), and specific staffing considerations. The second set of essential conditions relates to the prevention support system, all that concerns training and technical assistance. “Under favorable circumstances, variables in all five categories interact and lead to effective implementation, that is, a process for conducting the intervention as planned (Durlak & DuPre, 2008: 335).” Out of 81 studies containing quantitative or qualitative data on factors affecting the implementation process, Durlak and DuPre (2008) identified 23 factors associated with one of the five categories. Categories

Factors affecting the implementation process

Community level factors

Prevention Theory and Research Politics Funding Policy Perceived Need for Innovation

Provider Characteristics

Perceived Benefits of Innovation Self-efficacy Skill Proficiency Compatibility (contextual appropriateness, fit, congruence, match)

Characteristics of the Innovation

Adaptability (program modification, reinvention)

Factors Relevant to the Prevention Delivery System: Organizational Capacity

General Organizational Factors

Positive Work Climate Organizational norms regarding change (a k a, openness to change, innovativeness, risk-taking) Integration of new programming Shared vision (shared mission, consensus, commitment, staff buy-in)

Specific Practices and Processes

Specific Staffing Considerations

Shared decision-making (local input, community participation or involvement, local ownership, collaboration) Coordination with other agencies (partnerships, networking, inter sector alliances, multidisciplinary linkages) Communication Formulation of tasks (workgroups, teams, formalization, internal functioning, effective human resource management Leadership Program champion (internal advocate) Managerial/supervisory/administrative support

Factors Related to the Prevention Support

Training

23

System

Technical Assistance

Table 2: categories and factors affecting the implementation process (Durlak & DuPre, 2008)

We will use this framework for analysis of interviews in the explorative research. Next to the diffusion of innovations concept and the effective characteristics of an intervention, we also use these factors to develop an in-depth interview outline. The purpose of the interview was to bring to the surface interfering factors for implementation, from the perspective of the facilitator. Based on the factors found by Durlak and DuPre (2008) we were careful for two biases. First we wanted to leave room for uncovered factors. It is possible the cultural, political, organizational context in Flanders is so characteristic uncovered factors interfere with implementation. Secondly, we really wanted to hear the teachers’ voice. We were careful not to touch on every issue by Durlak and DuPre (2008), ticking down the list. This would instigate social desired answering patterns and would bias research results. Tackling these biases we drafted an interview outline to reach the second research objective: ‘Identifying facilitating and interfering factors during the implementation phase of aforementioned interventions.’ At first we drafted an interview outline based on common sense, expert opinion and results from former research phases. Secondly we scrutinized this interview outline using the frame provided by Durlak and DuPre (2008). Using the factor categories we were sure the interview touched upon every category without being too directive or ticking down the list of factors. After the first few interviews we eliminated further two questions. These questions concerned the adoption of an intervention. However these questions were not well understood and made interviewees drop out.

Implementation guide Drafting December 2013 – January 2014 the ‘Implementation guide: better application in your class group of interventions for healthy nutrition and balanced activity’ was drafted. The drafting was based on the results of the previous research phases. Literature Review: Reviewing literature we scrutinized implementation phases and how to introduce, execute and sustain an innovation in an organization. Stock taking: In the light of the implementation guide stock taking was particularly interesting to scrutinize interventions targeting physical activity and healthy nutrition on offer to schools. We found a variety of interventions teachers can implement in their class, but also some interesting patterns and possible pitfalls. Results from this research phase especially concern the part of choice of intervention in the implementation guide. School survey: The school survey was especially helpful in determining the action items of the implementation guide. We found gaps between theory and what should be implemented and what is implemented in reality. It was also the basis for the following work exploring the interfering factors for implementation. Qualitative research: In the qualitative research phase we let teachers and school administrations, together with pupils tell us what works and what doesn’t. These often innovative ideas and perspectives were also taken on in the implementation guide. 24

Feedback This first version was distributed to a total of 15 schools. Schools would give feedback for the final version of the implementation guide. Schools would indicate how to use the guide for a two month period. Afterwards they provide feedback using a standardized form or a face to face interview or discussion group. All methods surveyed the same aspects of the guide: clarity, legibility, design, user friendliness, usefulness and feasibility.

25

Results Inventory of school based interventions Excluded interventions We identified 186 school-based interventions dealing with nutrition and/or physical activity possibly complemented by other aims. Based on the exclusion and inclusion criteria, 103 were excluded, leaving 83 included for this study. Of the excluded 103 interventions, 60 did not assign an educational role to the teacher, thus falling outside the scope of this research. Another 14 interventions no information was to be found anno 2011-2012. Another 14 interventions barely touched on the issue of exercise or healthy nutritional habits. Often the stress was on agrarian technology, solidarity and North-south relations or environmental issues. Six more were not targeted at schools or classes and one was sold out of didactical materials. The remaining interventions could not be defined as such. We found some general policy guidelines and clusters of interventions inside thematic weeks.

Included interventions In this following section we give an overview of the kind of interventions for healthy nutrition and/or physical activity we find in Flanders. First we describe the characteristics of those interventions. Have they been evaluated? Which target groups are being served? How do the interventions work? What resources are needed to implement the interventions? At the end of this section we check if some associations are to be found. We ask ourselves if certain types of interventions are associated with specific target groups. Or maybe specific types of interventions require a certain amount of resources?

Evaluation We find indications of evaluations of four out of 83 interventions. One intervention (Tutti Frutti) has an effect evaluation. However this evaluation is of low scientific value as no randomization took place, neither a pre-test was carried out in intervention and control schools (Moens, O., Stevens, V., Tambuyzer, J., Van Hoecke, L., Voorspoels, W.; 2007). Three other interventions never had a thorough effectiveness trial. The Diabetes Case (Diabeteskoffer) only indicates user friendly evaluation forms, but no results are published. ‘Schoolsnakker’ project has had a trial, but the project itself is no longer promoted. The intended pupil participation was never reached and evaluation results are no longer to be found. Finally, the game concerning the food triangle (Kwartetspel zet je tanden in de driehoek) also had a process evaluation based on teacher remarks and formed the basis for a newer version.

Target group Zooming in on target group, we find that more than 30% of interventions exclusively targets primary education. Grouping pre-school, basic education and ‘all levels’, we find that more than 75% of found interventions target children under the age of 12 years old. At the same time only one in three interventions is appropriate for secondary school-aged children. Education level

26

#

%

Basic

54

65,1

Secondary

14

16,9

Both

9

10,8

Not specified

6

7,2

Total

83

100

Table 3: included interventions by education level

Regarding type of education, we find that for the majority of interventions, specific applicability for pupils with special needs is not mentioned. Only less than 5% is explicitly designed for pupils with special needs. A little more than 8% claims appropriateness for both regular education and education for children with special needs.

Intervention operation Of included interventions we find that a majority exclusively focuses on the educational component and a small quarter of interventions only deals with an environmental component, i.e. the supply of healthy food or provision of sports infrastructure. We do not have any intervention that focuses solely on regulations and agreements. One in five interventions included do have a mix of strategies, meaning two or more strategies are combined. Intervention Strategies #

%

Education only

48

57,8

Environment only

19

22,9

Multicomponent

16

19,3

Total

83

100

Table 4: included interventions by intervention strategies

The landscape is much more diverse if we look at the intervention aims. Half of all included interventions only have eye for healthy nutrition (possibly completed with other aims but physical activity (PA)). We find a little more than a quarter of included interventions targeting only physical activity (possibly completed with other aims but healthy nutrition). Less than one in five interventions deals with both aims (possibly completed with other aims). Research indicates that the involvement of parents and/or community in a school-based intervention can reinforce intervention effects (De Meester, van Lenthe, et al; 2009). Nevertheless we find a majority of included school-based interventions limited to the level of the class (three in five interventions). Less than one fifth of included interventions also work on the level of the school and 14% have some kind of parent involvement. Only 7% of included interventions also include the wider

27

community in the intervention. One intervention (Krok Gezond) does not mention any implementation level. Implementation level #

%

Cum. %

Class

51

61,4

61,4

School

13

15,7

77,1

Family

12

14,5

91,6

Community

6

7,2

98,8

Not indicated

1

1,2

100

Total

83

100

Table 5: included interventions by implementation level

Last variable for intervention operation is the use of didactical methods. We find more than 60% of included interventions use a mix of didactical methods. Thus only less than 40% exclusively makes use of only one type of didactical methods. In line with this we only find one intervention (De actieve voedingsdriehoek) exclusively focusing on instructional methods. Eleven interventions only use interactive delivery (interaction and play methods) as a didactical method. One of every four interventions exclusively makes use of exercises. This also includes interactive formats such as computer based exercises or self-exploration methods.

Resources Feasibility of implementation depends not in the least on necessary resources. We find that for a majority of interventions, the didactical materials are completely free of royalties. Yet for 40% of interventions, there are attached costs, but often very low per pupil or per group. Another necessary resource for quality implementation of an intervention is the facilitator’s expertise. We find more than three quarter of interventions count on the expertise of the facilitator, in this case the teacher, for autonomous implementation. In less than one fifth of included interventions (note that only those interventions are included that assign an active educational task to the teacher) is the teacher supported by an external expert on site. Vast majority of those last bring costs. we only find two interventions providing some kind of teacher training (bewegingstussendoortjes op school and Fitclass). Both interventions focus on supplying physical activity possibilities and can be implemented over several years in the curriculum. Expertise #

%

Autonomous

64

77,1

On site support

15

18,1

28

Training

2

2,4

Not indicated

2

2,4

Total

83

100

Table 6: included interventions by expertise needed

Finally, interventions were scored for the time to be invested and duration of the intervention. We find a majority of interventions are one-off activities. This includes a onetime activity in the class room, such as a board game, but also the organization of a thematic day or week in the school. One third of included interventions consists of a teaching package, with several courses over an amount of time. Two thirds of those interventions have courses for several school years in the curriculum and one third have courses for only one school year. 8% of interventions have a character of permanent duration. This means that when the intervention is started, it is sustainable over a long period with a minimum of extra efforts. This type of interventions deal with offering healthy nutrition or infrastructure for physical activity. As an example, one intervention aims to engage older pupils in organizing group games with younger pupils on the playground. Time # One off

%

45 54,2

course over one year courses over several years

8

9,6

16 19,3

permanent character

7

8,4

Not indicated

7

8,4

83

100

Total Table 7: included interventions by time investment

Are specific interventions associated with certain target groups or necessary resources? Above we described the nature of the included interventions in our research design. Interesting is exploring possible association in the nature of the interventions and the target groups where they are implemented. We look for interesting association of the nature of interventions with education level and education type. We also test for association between nature of interventions and necessary resources. Target group We find no significant (X² = 24.855 and p-value = .732) association between intervention aims and education level. What is more we find a very consistent pattern. In both educational levels, most interventions focus on healthy nutrition, followed by physical activity and fewest interventions focus on both health behaviors. Also no significant differences are found for didactical methods by educational level (X² = 17.479 and p-value = .132). There is a significant association to be found for implementation levels by educational level (X² = 31.230 and p-value = .002). We find all but one of the included interventions that also include a family component (without community component) are explicitly targeted at primary education. 29

If we look at education type, a first finding is that interventions that explicitly mention exclusive applicability for the education type for children with special needs only use environmental strategies. In these four interventions there is no component of education or rules and agreements. However, when there is applicability in both education types, we do find diversity of interventions concerning intervention strategies. We also exclusively find interventions, specifically targeted at children with special needs, that are executed only on the level of the class. What is more, those four interventions only aim at increasing physical activity. In addition we also find that those school-based interventions for children with special needs exclusively make use of exercises as a didactical method. Regarding resources, what calls our attention is that the interventions for children with special needs are exclusively one-off interventions. Resources Cross tabulating for level of implementation and time investment, we find that six out of seven interventions with a permanent character are situated on the level of the entire school. The other intervention with a permanent character involves the community (Fitclass). We also find a significant association (X² = 17.743 and p-value = .007) between intervention aims and costs. Interventions exclusively promoting more physical activity are more expensive than interventions focusing on nutrition or both health behaviors. Finally, most free interventions only have an educational strategy. Often developers offer free to use teaching packages online. We find an equal share of paying interventions in the educational strategy arm, the offer strategy arm and those with a mix of strategies.

Discussion These research results reveal some important aspects for the implementation guide. First, results reveal some information on our primary beneficiaries. Secondly, we also find some indications concerning content. Thirdly, important indications for following research phases are presented. With 65% of intervention exclusively targeting children under the age of twelve, we conclude the thematic of healthy nutrition and physical activity loses importance in secondary education. Probably other issues gain importance with age such as sexuality and relationships, smoking, drinking, aggression, etc. For the implementation guide this implies especially basic education teachers will benefit. Still more than one out of four interventions target secondary schools. We should certainly not disregard this group completely. We find only a limited number of interventions specifying applicability for children with special needs. Possibly intervention designers count on the expertise of the implementer to assess applicability inside their specific intervention group. For this specific target group, and for others, the implementation guide should help teachers assess applicability in their class groups. Also content wise we find some important indications to include in the implementation guide. Since rigorous effectiveness evaluation of school based interventions promoting physical activity and healthy nutrition is clearly not a tradition in Flanders, we have to rely on international peer-reviewed literature to identify effective program components and support teachers and school administrations to choose most promising interventions. We find more than 80% are single component interventions. This is against scientific research that states multicomponent programs have better chances for effectiveness. There is an opportunity for 30

our implementation guide clarifying this and help teachers choose and implement multicomponent programs over single component programs. The majority of interventions stick to the level of the classroom, even though research indicates family and even community involvement can increase effectiveness. Also a wide school approach can increase effectiveness and increase sustainability. This could be an important recommendation for implementers’ choice of intervention. A hopeful picture we find for didactical methods with interventions adopting a lot of interaction and mixing didactical methods. Diversity of didactical methods increases the overall learning effects. The implementation guide should certainly reinforce this trend. More than three quarter of interventions count on the teacher for autonomous implementation. The intervention developers thus assume that the teachers’ expertise, together with the intervention guidelines or manual is sufficient for quality delivery of the intervention to the final target group. This implementation guide could be a welcome support for the teachers. Concerning time investment, most interventions are one off interventions. Since research indicates that higher exposure might lead to better results, the implementation guide should guide implementers towards that type of interventions. Since we find no significant difference between education level for intervention aims and didactical methods we do not need to specify between education levels in the implementation guide in that regard. We do find all but one interventions including parents are exclusively designed for primary school. It might be necessary to motivate secondary school teachers to increase parent involvement. We find strong association for the nature of interventions with type of education. Education for special needs in Flanders is organized as such that pupils with similar types of disabilities are grouped together. As such, it is not surprising to find that those interventions that exclusively target to provide physical activities are carried out exclusively on the level of the class. Teachers provide different types of exercises. The implementation guide could contribute however motivating teachers to implement booster sessions after the one shot intervention is finished. Previous research found that free interventions are not very promising towards effectiveness (Delgado-Noguera, Tort, Martinez-Zapata, and Bonfill 2011). We find free interventions mostly make use of only the educational component. Instead of directing schools to paying interventions we are rather inclined to support them to choose multi-component interventions. Finally, for following research phase, we certainly should take on costs as a possible interfering factor for implementation. Even though less than half of interventions have attached costs, since 2008, the Flanders ministry of education introduced the ‘maximum bill’. As primary and secondary education in Flanders is compulsory until the age of 18 and should be free of charge, this enactment specifies a maximum cost schools are allowed to charge for additional activities. In following research phases we need to find out if this is an interfering factor for implementation.

School Survey The stock taking and categorization of interventions for the promotion of healthy food and more physical activity in Flanders anno 2011-2012 reveals us what is on offer, but cannot shed light on 31

what happens in the schools. We do find first indications for the need of an implementation guide directed at teachers. Among other things we find that for a majority of interventions, no specific target group is mentioned. This leaves the facilitator to assess applicability in his specific class room. But do implementers choose the best fit-for-purpose intervention? Do they make a sound adaptation? What kind of interventions are implemented most often? Do teachers choose promising interventions, indicating a fair understanding of prevention theory? We need a broader understanding of what is implemented in schools. Hereunder we present findings from the school survey, connecting what is on offer, with what is used. After this research phase we are able to answer the second research question: “Which interventions are being implemented in Flanders in school anno 2011 - 2012?”

Respondents’ characteristics We received 78 completed questionnaires. On 465 schools, this is a response rate of 17%. Questionnaires were sent to school administrations. Realize that different institutional units (with unique institutional numbers) can have the same administrative board. 78 answers come from 78 administrative boards, often answering for several educational units. We find that 53 surveys have been completed by a member of the school board and in the other 25 cases the respondent is mostly involved in the decision making process on health related topics as member of a working group, level coordinator, member of executive board or direct support staff. In the qualitative research, after sampling, those respondents will be the first contact person. Underneath are the characteristics of the respondent group.

Education level We received 78 completed questionnaires from different school administrations. Looking at education levels, we find 53 of our responding administrations offering education exclusively for pupils under the age of twelve. 47 of them offer both nursery and primary education. 23 of 78 received questionnaires exclusively concern secondary education. Only two administrations have all educational levels under their wing.

Education type Concerning education types we find 61 (more than three out of four) exclusive regular education in our sample and 13 institutions with exclusively for children with special needs. Only two administrations manage both types and we have two missing values. If we cross the education level and the education type we find following picture. Proportionally we find more schools for pupils with special needs in the pool of secondary education (almost one in three and less than one in five for basic education). Education type

Education level

Total

Regular

Special needs

Both

Basic

45

7

0

52

Secondary

16

5

1

22

All levels

0

1

1

2

32

61

Total

13

2

76

Table 8: sample by education type and education level

School associations Concerning educational networks, we find representation of all three associations in our sample, but more than half under the umbrella of free subsidized education. Other two associations (communal education and official subsidized education) each count for half of the remaining. This is a good reflection of the Flemish educational landscape.

Pupil population characteristics We anticipate that population characteristics might influence implementation of school-based prevention programs. In our sample we find a mix of schools by size. We find half of our sample consists of schools with a pupil population smaller than 500 and eight schools have a population of 700 or more (7 missing values). An interesting pattern v-concerns the mean size of schools by education level. We find a bigger mean size in secondary schools then in schools offering nursery and/or primary education. Number of pupils Education level

Mean

N

Basic

269,34

47

Secondary

484,77

22

Both

55

2

Total

330,06

71

Table 9: mean number of pupils per school by education level

We find all exclusive nursery schools have a population size under 300. Also all the schools that guarantee education for all ages are smaller schools (under 300 pupils). Furthermore above the limit of 800 pupils, we only find secondary schools. Noticeably two exclusive primary schools are rather big in size (between 500 and 600 pupils). These schools belong to a school group with different educational units in the region of the Belgian language frontier, offering both Flemish and French education. Lastly we find two schools that offer all educational levels and yet they are rather small. One of those schools is a school for children with special needs, focusing on children with physical limitations. The other one is a school connected to the University Hospital. They take care of education for youth during hospital admission, focusing on the preparation of reintegration in the normal school system. This school also attends to home education. We find diversity of educational units in our sample, but so far patterns reflect the educational landscape. As effectiveness studies of prevention programs often find gender moderated effects (Brown and Summerbell, 2008, De Bourdeaudhuij et al., 2011), we asked the number of girls and boys at school. We find a mean of 47% of boys in schools (minimum 7%, maximum 70%, sd = 11) and we find a greater gender proportion diversity in the pool of secondary schools. Since secondary education offers more specialized education, including typical male and female disciplines, this result is expected. The mean percentage of boys is slightly higher in educational units for children with special 33

needs. Still, with only a mean of 53%, even that education type counts for a rather balanced gender ratio. Not only the gender ratio of pupils can influence implementation of prevention projects in school, also other characteristics of the pupil population will affect implementation. Noticeably we believe socio economic status, ethnic background, language issues will affect proper implementation. However, since 2002 schools in Flanders can apply for extra funding when a greater percentage of so called GOK (equal education opportunities) pupils are at school. This implies that those schools have extra hours and means to work on issues the school prioritizes. GOK pupils meet (a combination of) certain criteria: non-sedentary families, mother has no certificate of higher secondary education, the child does not reside in his own family, the language at home is not Dutch, only family income is an unemployment fee or other compensation. If we look at percentages of GOK pupils, 42 schools do not indicate any GOK pupils. 15 school administrations indicate a percentage of GOK pupils lower or equal to 25% of the total population. Five schools indicate GOK pupils percentage between 26 and 50, six schools between 51 and 75, and ten more schools between 76 and 100. Eight schools even indicate their entire population consists of GOK pupils. GOK pupils percentage in our sample is not associated with school system (X² = 7,950 and p-value = ,242).

School staff characteristics For the same reasons we inquired pupil characteristics, we inquired teaching staff characteristics. Respondents indicated the number of female teachers and the number of male teachers. If we compare means of teacher staff numbers and educational levels we find the mean (M = 28, sd = 14) for education above twelve (secondary school) is much higher than for under twelve educational levels (M = 13 and sd = 7). Also a big difference exists for type of education. We find a mean of under four (sd = 3) pupils per teacher in education with special needs, whereas regular education counts 11 pupils per teacher (sd = 4) Not only the size of the body of teachers can have an influence on high quality implementation of prevention projects in school. Also other characteristics might influence implementation. Certain characteristics as motivation, personal commitment, teaching culture, age, experience, etc. will have repercussions on implementation but can hardly be scrutinized through quantitative research methods. We will try to highlight these and other issues in the following qualitative research phase. In this school survey we did ask about male-female teacher proportions. For the proportion of male teachers in our sample of Flemish schools, we find a mean of 17% (minimum 0, maximum 54, sd = 12). The picture becomes more clear if we compare means for educational levels. We find a significant (pvalue = .000) higher percentage of male teachers in secondary education (M = 28%, sd = 14) then in basic education (M = 12, sd = 7). For education type, we find similar gender proportions for regular education, education for children with special needs and schools having both on offer.

Implementation of interventions On 78 schools, we do find substantial implementation of interventions. 1243 times interventions are being implemented in schools in school year 2011 - 2012. This includes interventions we excluded from the rest of our study. We find a mean of 16 interventions per school being implemented. We do find a wide diversity regarding implementation efforts between schools. Yet, we only find one school 34

not using any of the listed interventions, but they do indicate raising consciousness with the teachers through own developed methods. On the other end, we find a school that indicates implementing 47 interventions. It is a school for pupils with special needs. They focus on pupils that need personal counseling for behavioral or emotional issues. Many interventions find a place here in the realm of personal counseling for reintegration in the mainstream school system, and meaningful participation in society.

Implementation activity and school characteristics We want to know what school factors seem to facilitate implementation of interventions and what school factors can we relate to restricting the implementation of interventions. To be sure we do not miss any important information we will do analysis on the pool of only included interventions, but where feasible and advisable we will also do analysis including excluded interventions. One way ANOVA analysis shows no mean difference for the amount of interventions schools implement in different school associations. Even if there should be differences between associations in policy regarding the amount of interventions schools should implement, we find no significant (p= .644) difference in our sample. The same holds for the intervention we a priori included (p= .900). The picture is different for education level. We find significant (p = .000) mean difference of the total number of interventions implemented between basic education and secondary education. In schools for basic education we find a mean of 19 interventions implemented. In secondary schools we find this mean is much lower. Only nine interventions are being implemented on average. This picture is sustained (p = .000) when we check for equal variances of implemented included interventions between educational levels. Between education types no significant (p = .200) difference is found in amount of implemented interventions, nor implemented included interventions. In the questionnaire we also inquired about pupil numbers and gender, teacher numbers and gender, and amount of minority pupils. We only find teacher gender seems to significantly influence the number of interventions implemented. We find a negative significant correlation of both sets of interventions with the percentage of male teachers in a school (p = .000, r = -.318 and p = .000, r = .463). Even though the correlation is weak, it is interesting gender of teaching staff seams to influence the number of interventions implemented. More female teachers in the staff lead to more interventions implemented. We find bigger schools implement less healthy nutrition and physical activity interventions than smaller schools. After all we find that a greater number of teachers is correlated negatively to the amount of interventions implemented. The same holds for the number of pupils. However, if we control for the education level, i.e. basic or secondary education, we find this correlation disappears. This implies that not the size of the school is at the basis of this effect, but the education level. Secondary schools are usually bigger schools, that also have a lower pupils per teacher rate (12 in basic education and six in secondary education). Also the correlation with the gender percentage of teachers should be interpreted in the same way. We do find significantly (p = .001) less male teachers in primary education (44%) then in secondary education (49%).

35

Implementation activity and intervention characteristics After analysis of implemented interventions and school characteristics, this dataset also sheds light on the kind of interventions that are popular in our sample schools. Based on this sample we investigate which characteristics make interventions popular. First, 32 of 78 schools indicate implementing interventions we did not come across taking stock. A closer look shows these are often educational packages developed by the school. Sometimes it is stressing a certain issue on annual basis, e.g. this year a focus on healthy food, the following on tobacco prevention. Other times there are projects that only slightly touch the issue of healthy food or physical activity e.g. sea classes or projects for mouth hygiene. In line with a growing trend of health promotion policy in Flemish schools (Buytaert, Moens, et al, 2009), we find schools are implementing a great deal of interventions for physical health or healthy nutrition promotion. More, many of those interventions are interventions we included to target with the implementation guide. Of 1243 implemented interventions in our sample in 78 schools 698 times an intervention we included is chosen versus 545 times an intervention we excluded. 56% of implementations in our sample concerns interventions we included. This is a mean of nine per school. Also seven of ten most popular interventions are interventions we target with the implementation guide, thus included interventions (De actieve voedingsdriehoek, Bewegingstussendoortjes op school, Gezond ontbijt op school, Tutti Frutti, Herfstwandeling, De verkeersslang, Rollebolle). Those seven interventions in our sample count for 312 implementations, more than 25% of all implementations. Are sports more popular than diet? We find a tendency to rather choose physical activity interventions than healthy nutrition interventions. This finding however is not significant (p = .060). The tendency is interesting however as interventions targeting physical activity are a minority in our inventory of included interventions, 22 against 41 targeting healthy nutrition. What about the use of multicomponent programs? Even though we find a majority of education only strategy interventions in our interventions inventory, we find significant less implementation of those (M = 4). We find availability only strategies are implemented significantly (p = .005, M = 14) more. Also multicomponent interventions are significantly (p = .012, M = 13) more popular than the education only interventions. What about including parents? Concerning level of implementation we cannot find any significant results on what schools tend to prefer. Even though on average schools tend to rather implement interventions that exceed the class level (M = 7 against M = 11) this is not a significant finding. Do teachers like to play or do they mainly teach? Concerning didactical methods we find no significant differences comparing means. Even though we find an indication that those interventions only adopting one type of didactical method (M = 11) are somewhat more popular than those that adopt a mix of didactical methods (M = 7), this is not found significant on the 95% confidence interval (F = 2.896, p = .093). Do teachers implement interventions that persist through time? 36

Also concerning the investment of time resources we find a non-significant pattern (F = 1.712, p = .195). It is however an interesting tendency. Interventions that are only implemented during one particular school year and one off interventions are chosen on average only seven times against 12 times interventions that persist through more school years or even have a continuous character. Schools only want free interventions? Also not significant (F = .897, p = .347) is the result when we compare the mean use of interventions for financial resources. There is a tendency in our sample that free interventions are chosen less often (M = 6) than their non-free counterparts (M = 12). Do teachers have time for training? Lastly also no significant results emerge when we compare mean implementation for expertise input required. We find no significant difference (F = .260, p = .612) whether schools in our sample would rather choose those interventions where the teacher is on his own (M = 8) or when a teacher has inclass guidance or a beforehand training session (M = 10). We do find however that schools tend to favor interventions with training sessions above others. Even though we only find two interventions that offer training sessions to teachers, we do find these interventions are being implemented 51 times.

Discussion Former research (Buytaert et al, 2010) indicates that schools in Flanders are increasingly adopting an integral health policy at school. We find many interventions are implemented. More, when we even find a mean of nine times an included intervention is being implemented in school, we conclude our implementation guide is very relevant and can certainly contribute to implementation quality. Are some schools more than others struggling to implement health projects? We are especially interested in what school characters could be at the basis. Maes and Lievens (2003) research several policy and structural variables of the school and the relationship with adolescent health and risk behavior. Only few of those variables were found to directly influence health behavior. Few direct links between structural and environmental school variables on one side and risk behavior on the other is found. This however does not entail certain school characteristics do not influence implementation of interventions inside the school. Our data show us that in basic education, more than in secondary education interventions are implemented to promote healthy nutrition and physical activity. This idea is also reflected in the offer of interventions. We find 54 interventions are exclusively designed for basic education while only 13 are exclusively designed for secondary education. Other interesting findings that require more deliberation concerns the types of interventions that are popular. Even though we find only one fourth of interventions in our included database are physical activity interventions, we do find schools prefer to implement physical activity interventions above healthy nutrition interventions. Physical activity interventions are more often one-off interventions where the teacher has onsite support from professionals. This could explain why more of those interventions are implemented. Finally, we find the schools favor interventions with mixed strategies or offer/availability strategies more than education only interventions. Also interventions that exceed the class room level seem a 37

bit more popular, even though we have less of those interventions on offer in our database. Also, against expectations, schools are inclined to use interventions that are more persistent in time. These three findings lead us to conclude schools are choosing interventions that have some characteristics already to be promising interventions. What is more, these interventions are at the same time the more complex interventions to implement. We are surprised schools choose these types of interventions. Is this a produce of Flemish health policy dedicated to more healthy schools? Is it a result of prevention work in Flanders? A next research project should repeat the school survey on a bigger scale to answer these questions. As such we will also be able to connect the characteristics of the school to the type of interventions they choose. Our sample is too small for this venture, nor was it ever the aim of this research.

Qualitative Research In the qualitative research phase we select a sample of schools for in-depth interviews and school site visits. Interfering and facilitating factors for implementation will be identified.

Sample Interventions Based on our database categories of included interventions we defined following set of intervention characteristics to be most promising: -

multi-component interventions a combination of targeting physical activity and healthy nutrition including the whole school, parents and/or the community more than pure instructional didactic methods interventions with a larger number of sessions expertise after teacher training.

We find no single intervention meeting those combined criteria among our sample of included interventions. We need to find the next best thing, doctoring the categories. Concerning expertise we can also include those interventions that provide specialized support for the teacher in the class, but still no intervention meets those combined criteria. If we seek out those interventions meeting above mentioned criteria but not necessarily targeting both health behaviors (physical activity and healthy nutrition), we still have no interventions meeting the rigid criteria for promising interventions. The next best thing is eliminating the teachers’ expertise criteria. We do find eight interventions to be multi-component interventions with an interactive delivery that are implemented on any level above class level and that are more than one-off interventions ((w)eet je alles?, 123 Aan Tafel, Beestig gezond, Moestuin in het basisonderwijs, Schoolsnakker, Speelmaatjes op school, Sportieve speelplaats, Wild van Water). We find six interventions are designed for primary education and two for secondary education (Schoolsnakker, (w)eet je alles). One intervention (Schoolsnakker) incites the implementing school to evaluate its actions. No evaluation results are published and the pupil participation as the project intended never really took off. One intervention (Sportieve Speelplaats) mentions adequacy also for 38

children with special needs and three interventions explicitly mention suitability for regular education only (Beestig Gezond, Schoolsnakker, Speelmaatjes op School).

Schools In our sample of included interventions, we identified eight possible most promising interventions: (w)eet je alles?, 123 Aan Tafel, Beestig gezond, Moestuin in het basisonderwijs, Schoolsnakker, Speelmaatjes op school, Sportieve Speelplaats, Wild van Water. 45 schools in our sample are implementing at least one of those interventions and 15 of those 45 schools showed interest for further cooperation in the research project. Nine schools offer pre-school education, one of them exclusively and eight of them in combination with primary education. Two of those eight schools exclusively offer education for children with special needs. Two schools offer exclusively primary education, both situated in the regular education type. Four schools offer exclusively secondary education. Of those four secondary schools, we find one school offering exclusively regular education and two schools with exclusive education for pupils with special needs. One secondary school offers both types of education. From the beginning we were conscious of including schools in the sample from the different school associations to be found in Flanders. This the case. Six schools in the biggest association, another six in the communal association and three in the smallest official association. We believe this sample is a solid representation of the different types; systems and levels of education in Flanders (table). Schools

preschool

primary

secondar y

regular

special needs

associatio n

# teachers

% male teachers

# pupils

% male pupils

1

n

n

y

n

y

3

85

6

243

27

2

y

y

n

n

y

2

21

14

170

44

3

n

n

y

n

y

1

48

17

118

58

4

Y

y

n

n

y

3

11

18

55

16

5

y

y

n

y

n

2

19

16

225

51

6

n

y

n

y

n

1

53

15

580

49

7

y

y

n

y

n

1

0

MISS

MISS

MISS

8

n

n

y

y

n

1

74

31

808

47

9

n

y

n

y

n

1

48

13

584

48

10

y

y

n

y

n

1

26

12

275

53

11

y

n

n

y

n

2

3

0

43

58

12

y

y

n

y

n

3

22

14

344

53

13

y

y

n

y

n

3

25

20

332

55

14

y

y

n

y

n

3

16

13

259

49

15

n

n

y

y

y

3

76

13

MISS

MISS

Table 10: sample of schools for explorative research

39

In-Depth interviews and school site visits Fifteen in-depth interviews and five school site visits are conducted as part of this research project. We report these results as a whole since they are complementary. We use the framework of Durlak and DuPre (2008) for analysis and report, as mentioned and discussed above. The five general categories are community level characteristics, characteristics of the provider, characteristics of the innovation and characteristics relevant to the prevention delivery system. While analyzing the qualitative data some more and somewhat different, but supplementary subcategories are found and defined.

Community level characteristics In our qualitative research we found that some characteristics on community level affect the implementation of health interventions in the participating schools. Prevention theory and research Firstly we found that prevention theory and research finds its way to schools primarily via e-mail and is addressed to the principal or the person responsible for health policy at schools. They report an overload of information about health interventions and initiatives, and a lack of structure and inventory of this information. Teachers on the contrary report not having access that easily to what new and existing material there is available for health promotion in schools. They have to take the initiative and talk to the principal, the person responsible for health policy or the center for student support for more information. Once that is done, they are being referred to a specific organization or health intervention package were they can consult the possibilities and options. “Rond gezondheid krijgen we enorm veel mails. Heel veel mails en pakketten. […] Eigenlijk te veel. Op de duur zie je niet meer het bos door de bomen. Op de duur is het teveel. Je geraakt oververzadigd. Kunnen die initiatieven niet geïnventariseerd worden, maar onderverdeeld in voeding, beweging, verkeer, zodat al die initiatieven bij elkaar zitten, en onderverdeeld in kleuter, onderbouw en bovenbouw. Dat zou duidelijker en overzichtelijker zijn voor ons.” (Sint-Antonius, lager onderwijs, directrice, 01:01:00 – 01:06:08) “Als er een vraag is van de leerkrachten, dan toon ik hen waar ze die informatie kunnen vinden in het CLB. Ik heb zelf ook zo eens naar de Kankerstichting gebeld en dan hebben zij mij een quiz en een DVD opgestuurd, maar dat is altijd puur eigen initiatief.” (Koninklijk Atheneum, secundair onderwijs, leerkracht, 19:58 – 20:42) “Interventies zoals Tutti frutti in het kleuteronderwijs en lager onderwijs verlopen allemaal heel goed, maar een hip, naar tieners gericht, niet-commercieel pakket rond voeding voor het secundair onderwijs, ik weet niet of dat bestaat.” (Koninklijk Atheneum, secundair onderwijs, leerkracht, 40:26 – 43:05) Politics Further we note that most participating schools report the obligation from larger educational structures to define some key themes each year. These themes must be given special care and attention during that year by organizing interventions and actions in regard to the chosen theme. The inquired schools state that this is a helpful way for the head of the school, teachers and pupils to 40

think about and work towards more awareness of certain topics. However, they think it’s important that the regulation goes as far as it goes and doesn’t oblige them to implement a certain intervention or a series of interventions. They are given a large amount of freedom on how they elaborate the key themes, which intervention(s) they implement, how they implement these and who is involved. A dictation of more rigid and directive rules would have the opposite effect and be considered as more likely to fail. The fact that they can freely decide the realization of this policy according to their own school culture and capacity is much appreciated. “We zijn verplicht om een matrix te kiezen vanuit Brussel, de hoofdzetel van het gemeenschapsonderwijs. Dat is veeleer om de scholen die niet werken rond gezondheid, want er zijn scholen die niet werken rond gezondheid, op een spoor te zetten dat ze er aan moeten werken.” (Dr. Ovide Decroly-school, lager onderwijs, directeur, 01:03:02 – 01:03:27) “Wij moeten een keuze maken voor Brussel, de hoofdzetel van het gemeenschapsonderwijs, om in regel te zijn met het gezondheidsbeleid. […] Zoals ze zegt, die matrices, wij volgen dat niet altijd. We geven twee thema’s aan omdat er twee moeten aangegeven worden, maar het mag niet dwangmatig opgelegd worden, want dan is dat ook verkeerd. Iets dat opgelegd wordt, is gedoemd om te mislukken.” (Dr. Ovide Decroly-school, lager onderwijs, directeur, 01:04:02 – 01:03:40) “De school wordt vanuit het onderwijs opgelegd om een gezondheidsbeleid uit te bouwen. Ik heb die documenten doorgenomen die ons werden toegestuurd en van daaruit zijn we vertrokken met onze doelstellingen.” (Instituut Sint-Lutgardis, secundair onderwijs, leerkracht, 07:15 – 07:27) One school reports to have experienced a negative influence of the broader educational structures, more specifically the inspection. In regard to healthy food they had implemented a daily offer of fresh homemade soup for pupils and school personnel. An educator of the school made this soup every morning and pupils and school personnel could buy a cup during the morning break for a very reasonable price. This initiative was very successful and was implemented for over two years before the school inspection decided that making the soup during school hours wasn’t part of the educators assignment. Due to this, they were forced to stop this activity. Funding The third finding is that most schools report very few to no difficulty regarding funds for healthy food education and physical activities at schools. Although they recognize that working with pupils and school personnel on these topics has some financial implications, they state that money is not an interfering factor. It’s remarkable that these schools are very creative and innovative in raising necessary resources. Some schools choose health interventions where most material is included and look for cheap alternatives to aspects that are not included, for example a sticker or an extra 10minutes-break as a reward for the pupils. Another school entered into a competition and won 1000€ to execute their winning health initiative. Other schools install a beverage vending machine or organize a cake sale or a festive dinner of which the benefit goes to the work group health or environment. Finally, some schools look for sponsors to supply them with for example yoghurt or bread for a healthy breakfast.

41

“Enkel de beloningen voor de kinderen zijn ten laste van de school, de rest zit allemaal in de interventie. Dat houdt niets in en maakt het zeker de moeite waard. Een extra speeltijd kost u niets. 240 ijsjes in de Aldi heeft me 35€ gekost, dat is de kost niet he. Ik probeer dan ook te zoeken naar iets dat leuk is voor de kinderen, dat moet niet kostelijk zijn, maar het is de bedoeling dat het aangenaam is.” (Sint-Antonius, lager onderwijs, directrice, 24:35 – 25:34) “Van Sam de Verkeersslang krijgen we altijd gratis fluojassen. Je moet het wel aanvragen en bij de eerste zijn om te reageren, dus ik ben altijd bij de pinken en snel om te reageren zodat we erbij zijn. […] Waar ik gratis fluojassen kan bestellen, doe ik dat. Stad Eeklo heeft ook al eens gratis fluojassen gegeven, één of andere bank heeft al eens gratis fluojassen uitgedeeld. […] Al wat ik kan aanvragen, ook bijvoorbeeld via Klasse, bekijk ik. Alles wat ik vind, steek ik in mijn map gezondheidsbeleid. Want het komt misschien ooit wel eens van pas.” (Sint-Antonius, lager onderwijs, directrice, 32:02 – 32:55 en 01:02:15 – 01:02:53) “We hebben ooit meegedaan aan een wedstrijd. Honderd scholen kregen 1000€ als ze met een goed initiatief rond gezondheid kwamen. Met dat geld en dan ook in samenwerking met de groene school hier in de buurt hebben we achteraan een bos ingericht en afgebakend met een Finse piste. Daarnaast zijn er ook tropische toestellen gekocht om een fit-o-meter te maken. […] Zo hebben ze aan heel dat domein een sportieve look gegeven.” (Koninklijk Atheneum, secundair onderwijs, leerkracht, 06:40 – 07:33) “Op die aantal jaar hebben we wel wat budget. We hebben een drankenautomaat laten komen enkele jaren geleden. En dan berekend hoeveel die per maand verbruikt aan elektriciteit. Dat bedrag wordt afgetrokken van de winst die we daarop hebben en de overschot wordt in de kas gestoken van de werkgroep milieu en gezondheid. Ondertussen hebben we wel een redelijk bedrag en daar kunnen we wel al iets mee doen.” (Instituut Sint-Lutgardis, secundair onderwijs, leerkracht, 10:44 – 11:09) “We moeten kijken dat we het binnen ons budget gedaan krijgen. […] Af en toe zoeken we ook naar sponsoring, zoals Zespri van de kiwi’s heeft al een aantal acties gedaan.” (Reynaertschool, buitengewoon secundair onderwijs, directrice, 10:47 – 11:19) “Het is natuurlijk een belasting voor de school, aangezien we geen geld vragen aan de ouders voor dat ontbijt. We zoeken altijd of er een beetje sponsoring kan zijn, zoals voor yoghurt is dat soms mogelijk of voor brood gaan we altijd bij dezelfde bakker en die geeft dan één of twee broden gratis. Daarnaast worden er ook een aantal keer activiteiten gedaan, bijvoorbeeld een stoverij-avond, een koekenverkoop, en daar kan ook een deel van gebruikt worden om dat te financieren.” (De Octopus, buitengewoon lager onderwijs, directrice, 09:10 – 09:53) Some schools however report finding it financially hard to set up health interventions. These schools consequently look for interventions and opportunities that are for free. They indicate that this factor is not only a reason to choose for this particular intervention, but is also a facilitating factor for its implementation. 42

“Het materiaal is volledig gratis en ook de fluojasjes werden gratis geleverd. […] Dit is zeker een belangrijke factor, of het gratis aangeboden wordt of er een prijskaartje aan hangt, aangezien alle budgetten inkrimpen.” (De Rijdtmeersen, lager onderwijs, zorgcoördinator, 09:22 – 09:50) “Als school is het altijd leuk als je gratis materiaal kan verkrijgen. Bij Sam de Verkeersslang bijvoorbeeld. Bij de kiwi’s krijgen we gratis ballen, dus daar doen we zeker ook aan mee. Van het VCOV krijg je placemats enzo. Van de CM krijg je brooddozen. Dat zijn natuurlijk ook wel lokkers.” (Sint-Antonius, lager onderwijs, directrice, 01:01:41 – 01:02:15) Most schools report that collaboration between schools, especially within the school community, is a good way to meet these financial challenges. The larger the organization, the more possibilities and opportunities there are to work on healthy nutritional and physical habits with children and adolescents at schools. “Er zijn wel een aantal financiële aspecten die meespelen he. Rond voeding hebben we dat nu niet gevoeld, maar rond beweging hebben we toch wel een aantal materialen tekort. […] En daarom is het ook belangrijk en gemakkelijk dat je samenwerkt met de scholengemeenschap. Als je het op je eigen school alleen doet, is het soms moeilijk.” (Gesubsidieerde Vrije Basisschool, lager onderwijs, directrice, 26:21 – 27:01) Social environment Another factor on community level that, according to some schools, affects the implementation of an intervention is the social environment and home situation of pupils. Some schools report that for healthy food as much as for physical activity parents play an important role when it comes to the implementation and the success of an intervention. Working parents do not spare time to bring children to school by bike of they have to go to work by car e.g. In regard to healthy food habits, some pupils come from less prosperous families where healthy food, as this is quite expensive, is the first thing they save on. These children have no reference of a healthy lifestyle at home, which makes it hard for schools to work on that topic. Similar to this, schools notice that when they try to implement healthy nutritional or physical habits, or linked to this the wearing of a helmet while riding a bike, it’s hard to get it done by everyone as some children and teenagers don’t get the example from their parents at home. “Ik denk niet dat kinderen hierdoor meer worden aangezet om de fiets te nemen voor verplaatsingen niet gerelateerd aan de school. Dat is nog altijd bepalend door de ouders. Eigenlijk zouden we een campagne moeten oprichten “welke ouders komen met de fiets naar school?”. Kinderen willen soms wel fietsen, maar ouders, zeker van jongeren kinderen, zeggen gemakkelijker “Hup, auto binnen en we zijn weg”. De stress in onze maatschappij zorgt ervoor dat ouders bepalen hoe zij naar school komen. […] Ouders doen wel moeite tijdens de weken van Sam De Verkeersslang, maar na een aantal weken als die actie gepasseerd is, is het toch gemakkelijk om terug de auto in te vliegen.” (SintAntonius, lager onderwijs, directrice, 34:38 – 36:05)

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“Naar gezonde voeding en gezondheidsbeleid toe hebben wij een heel moeilijk publiek omdat het buitengewoon onderwijs is. Voor veel van onze leerlingen is eten enerzijds een vorm van compensatie voor zaken die zij missen en anderzijds is het ook zo dat zij uit milieus komen waar eten een primaire behoefte is alleszins en waar het zeker niet gemakkelijk is om gezond te eten. Waarom niet? Wel, budgettair, de zaken die gezond zijn, zijn meestal ook vrij duur, dan denk ik aan fruit, groenten, vis, zodat dat het eerste is dat bij hen verdwijnt.” (Reynaertschool, buitengewoon secundair onderwijs, directrice, 00:06 – 00:50) Hot topic Finally, the last community level characteristic we extracted from the interviews and school site visits that whether or not facilitates the implementation of a health intervention, is to what extent healthy food and/or physical activity is a hot topic at the moment of implementation. When pupils think it’s ‘cool’ and ‘young’ to pursue a healthy lifestyle, this will moderate the implementation of a health intervention at school. In extension, the involvement of a well-known media-figure in an intervention also facilitates its implementation. “Er wordt heel veel gedaan rond gezondheidsbeleid, alhoewel ik nu de indruk heb dat het een beetje aan het verwateren is. Er is zoveel waar rond moet gewerkt worden en de hype van het gezondheidsbeleid is een beetje weg. (Reynaertschool, buitengewoon secundair onderwijs, directrice, 24:14 – 24:25) “We hebben ook eens een project gedaan met Kim Gevaert. Dat was een wedstrijd. Je moest zes momenten per jaar effectief bewegen met de leerlingen, de bewegingsmomenten die je gedaan had omschrijven en doorsturen naar de vereniging waar Kim Gevaert meter van was. Zij is dan op het einde van het schooljaar met onze leerlingen effectief een uur komen bewegen. Dat was dan wel heel leuk voor hen uiteraard.” (Reynaertschool, buitengewoon secundair onderwijs, directrice, 24:14 – 24:25) “Gezondheid is nu iets dat hip is. Vroeger zou iedereen in een hoekje een slaatje eten, maar nu is dat net hip als je zegt “ik eet gezond”, gezond eten is toch alleszins niet meer ouderwets. Plus dat de commerce daar op springt. Dat is misschien niet zo tof, maar die buiten die gezonde producten dan uit.” (Koninklijk Atheneum, secundair onderwijs, leerkracht, 25:24 – 26:45)

Characteristics of the provider A couple of significant characteristics of the provider, in our research defined as teachers, educators and other school staff involved, are found to be relevant for the implementation of health interventions in schools. Perceived need for innovation All schools define a certain need for the innovation. This perceived need contains several factors depending on the kind of intervention being implemented and the particular school culture and school context. The recognition of this need for innovation by the provider facilitates the implementation of the chosen intervention. 44

Firstly mentioned, the home situation where some children and adolescents are being raised in demands further and more specific education on healthy lifestyle. The schools see themselves as the ideal opportunity to meet this lack of knowledge and awareness. “We hebben leerlingen die beperkt zijn en die uit kansarme gezinnen komen of het minder goed hebben thuis. Via het gezond ontbijt op school proberen we dan toch ook aan hen te tonen wat kan en wat niet kan. We hebben een aantal leerlingen die niet meer naar huis gaan, die afgesloten zijn voor thuis, en dan is de school een soort thuis voor hen.” (Sint-Lodewijk, buitengewoon secundair onderwijs, leerkracht, 29:13 – 30:01) “Gezondheidsbeleid is heel belangrijk op school, zeker voor onze leerlingen. Gezonde voeding en zo, daar moet de nadruk op worden gelegd, anders gebeurt dat niet. Ik denk dat ze thuis ook niet altijd even gezond eten en leven. (Binnenhof, buitengewoon secundair onderwijs, leerkracht, 28:45 – 29:06) “Wat betreft ons gezond ontbijt op school, hebben we toch wel verschillende kinderen die qua thuissituatie nood hebben aan ook op dat gebied onderwijs te krijgen.” (De Octopus, buitengewoon lager onderwijs, leerkracht, 00:50 – 01:02) “De tweede schooldag is er voor de derdejaars kennismaking met gezond ontbijt. Dat was met boterkoeken, appels, bananen, fruitsap, enzovoort. Er is heel veel fruit teruggekomen. Je ziet dat de leerlingen dat niet van thuis uit meegekregen hebben. […] Ondanks dat het gratis is.” (Kunstinstituut, secundair onderwijs, studiemeesteres, 25:07 – 26:11) “De leerkracht heeft een voorbeeldfunctie, maar je mag niet onderschatten wat ze van thuis hebben meegekregen. Als ik zie wat die gasten hier eten over de middag… Zeer weinig leerlingen eten gezond over de middag en hebben een potje mee van thuis. Ze hebben nochtans een frigo en een microgolfoven ter beschikking om klaargemaakt eten te bewaren en op te warmen, maar het is de minderheid die dat doet.” (Kunstinstituut, secundair onderwijs, studiemeesteres, 21:17 – 22:04) “Er zijn altijd kinderen die ’s morgens naar school komen zonder dat ze iets gegeten hebben. Onze hoofddoelstelling is ervoor zorgen dat kinderen hebben ontbeten voor ze naar school komen, want we stellen soms vast dat kinderen een flauwte krijgen of dat de aandacht en concentratie vermindert omdat ze met een lege maag naar school komen. Ook betrappen ze zo rapper een ziekte van iemand anders. (Dr.Ovide Decroly-school, lager onderwijs, directeur, 34:00 – 34:26) “We moeten kijken naar hoe we bij onze kinderen ertoe kunnen bijdragen dat ze gezond eten en gezond leven. Dat is een belangrijke taak van de school omdat we voelen dat bij heel wat gezinnen daar minder aandacht aan besteed wordt en dat men vooral eet om te eten en dat men er niet bij stilstaat hoeveel vet chips en hoeveel suiker suikerrijke dranken hebben.” (Dr.Ovide Decroly-school, lager onderwijs, directeur, 1:44:42 – 1:45:16)

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Secondly, informing children in pre-school and raising awareness about healthy nutritional habits and physical activity is seen as providing the essential foundation of a healthy lifestyle for the rest of their lives. “Sam de Verkeersslang is eigenlijk voor de lagere school bedoeld, maar wij hebben een rups gemaakt op kleuterniveau om dat ook een beetje te integreren bij de kleuters. […] Want we vinden promoten van het gezond en het veilig naar school komen daar toch ook heel belangrijk.” (Sint-Antonius, lager onderwijs, directrice, 02:29 – 03:05) “We proberen gezonde voeding zo breed mogelijk door te trekken in de werking van de school, omdat we vinden dat we toch wel de basis leggen bij kleuters wat betreft hun eetgewoonten. Dus als ze het hier al kunnen correct aanleren, hopen we dat ze dat toch wel meedragen later. Meer kunnen we niet doen. Het is alleszins een goede start voor de kleuters.” (’t Kapoentje, kleuteronderwijs, directrice en leerkracht, 21:17 – 21:38) The third aspect of the need for implementation of health interventions is two-sided. In our qualitative research the general tendency was that schools for regular education note that it’s necessary to implement several health interventions and repeat the message actively throughout the whole year, whereas schools for special education report the absolute need for innovation, but warn for an overload of interventions. A constant repeat of the health message among pupils in schools for special education might have an effect opposite to the intended one. “Je moet daar gedurende het hele jaar door aandacht aan schenken, want dat verwatert bij veel leerlingen. Je moet dat altijd maar terug opnemen. Daarom onderneemt de werkgroep verkeer verschillende acties, zoals bijvoorbeeld controles aan de schoolpoorten, en zorgden we ook voor een extra dimensie, namelijk Sam de Verkeersslang.” (Sint-Antonius, lager onderwijs, directrice, 06:40 – 07:10) “Wij merken toch wel dat je met het gezondheidsbeleid moet bezig zijn, maar dat je daar niet constant op mag hameren, omdat je dan een aversie krijgt. Op de duur krijg je reacties zoals “Ze zijn daar weer, het zal weer gezond zijn.” en d’office is het dan slecht in hun ogen. Ze gaan het op de duur associëren met smakeloos en kleurloos. Ik spreek uiteraard enkel voor onze doelgroep, maar je moet daar echt heel voorzichtig mee zijn.” (Reynaertschool, buitengewoon secundair onderwijs, directrice, 38:07 – 38:37) Perceived benefits of innovation Next to a certain need for innovation, schools report that the perceived benefit of innovation by the provider is an important facilitating factor when implementing an intervention. Most schools report a realistic perspective on the possible benefit of health interventions. They believe they can inform pupils, raise awareness and make a difference up until a certain point, and for one pupil more than for another. However, they remain rather down-to-earth and are aware of the persisting influence of the home situation and environment on pupils and their lifestyle. These schools don’t see this realistic perspective as an interfering factor, nor indicate it as a major facilitating factor.

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“Ze nemen dat wel mee naar huis, ze weten dat wel hoor, maar of ze zich daar allemaal even bewust van natuurlijk, dat denk ik niet.” (Sint-Pietersinstituut, secundair onderwijs, directeur, 16:02 – 16:09) “Het brengt sowieso een gezondere leefstijl mee, de leerlingen bewegen meer. Maar ik denk niet dat kinderen hierdoor meer worden aangezet om de fiets te nemen voor verplaatsingen buiten het schoolverkeer. Dat is nog altijd bepalend door de ouders.” (Sint-Antonius, lager onderwijs, directrice, 34:22 – 34:49) “We kunnen alleen maar, en dat is eigenlijk ook ons doel, een aanzet geven tot en hopen dat ze het verder zetten. Dat is het enige.” (Instituut Sint-Lutgardis, secundair onderwijs, leerkracht, 18:24 – 18:32) Some schools report a very distinctive positive evolution and enthusiasm among children and teenagers about the health intervention. This is a strong motivating and encouraging factor for the provider and all school personnel involved, and hence facilitates the implementation of health interventions. “Elke woensdag krijgen ze bij ons fruit. […] En ik merk wel dat moest er nu geen fruit zijn vandaag, ze mij wel zouden aanspreken met “Waar is dat fruit? Of “Hoe komt het dat er vandaag geen fruit is?”. Sinds het eerste leerjaar krijgen ze elke week fruit […] en ik merk wel dat ze als ze dat niet krijgen er naar vragen. Tijdens de examens is dat zo bijvoorbeeld.” (Sint-Lodewijk, buitengewoon secundair onderwijs, leerkracht, 45:47 – 46:26) “Hier en daar is er eens eentje dat geen fruit mee heeft, maar 99% heeft wel ook op andere dagen fruit mee. Ze eten sowieso wel veel fruit en drinken veel water. Qua gezondheidsbeleid hameren we daar wel op.” (’t Kapoentje, kleuteronderwijs, directrice en leerkracht, 03:05 – 03:18) “We merkten dat het aansloeg bij de leerlingen, die waren enthousiast. Dat was sowieso een pro om voor die interventie te kiezen en te implementeren.” (Instituut Sint-Lutgardis, secundair onderwijs, leerkracht, 04:07 – 04:15) “Vooral die motivatie van de leerlingen en eventueel collega’s die bijspringen. Of leerlingen die enthousiast gemaakt worden. Of als een leerling je passeert en zegt “Mevrouw, ik ben een appel aan het eten he”. Voor mij persoonlijk is dat zeer stimulerend en motiverend.” (Instituut Sint-Lutgardis, secundair onderwijs, leerkracht, 19:28) “Wat maakt de interventie voor ons geslaagd? De dynamiek die wordt gecreëerd onder het korps, leerkrachten en leerlingen uiteraard. Als je voelt die laatste dag dat is het, iedereen doet mee, er is ambiance, er is sfeer, er is muziek, enzovoort. Wanneer leerlingen erover praten. Dat vinden we fantastisch. En als je dan merkt dat leerlingen hun flesjes staan te vullen aan waterfonteintjes, of als je leerlingen ziet die fruit meebrengen, dan is het goed.” (Instituut Sint-Lutgardis, secundair onderwijs, leerkracht, 25:47 – 26:18)

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One school explains the choice for a weekly fruitday at school where children have to take their own fruit in comparison to the health intervention Tutti frutti where the school provides in fruit for the pupils. They hope that in doing so the parents will become motivated to eat fruit themselves and to more integrate healthy food habits in the home environment and the lifestyle of parents and child(ren). This assumption encourages the provider and facilitates the implementation of this kind of intervention. “Als ouders voor hun kleuter fruit moeten kopen, zullen ze misschien zelf dan ook wat meer fruit eten. Eén appel voor de fruitdag op woensdag, koop je niet, je koopt direct een heel pak appels. Dus op die manier is de kans groot dat ze thuis misschien meer fruit eten.” (’t Kapoentje, kleuteronderwijs, directrice en leerkracht, 22:42 – 22:56) Few teachers and school personnel note that social desirability in the healthy behavior of pupils must be taken into account when benefits or effects are looked for. Children and teenagers might display more healthy behavior when teachers are around, but they might not do so outside school context. “Op het moment dat de leerkracht erbij is, zullen ze wel hun best doen om op een goed blaadje te staan bij de leerkracht, maar ik weet niet of het daarbuiten effect heeft.” (Reynaertschool, buitengewoon secundair onderwijs, directrice, 14:25 – 14:37) One school reports that they don’t organize a health intervention such as for example a weekly fruit day, because they have the impression that the pupils don’t want to eat fruit but instead prefer a biscuit for a snack. Furthermore the school doesn’t believe it can make a difference and change this kind of preference in behavior of their pupils. “Fruitdag wordt niet georganiseerd omdat de leerlingen niet kiezen voor fruit. Ze voelen zich daar waarschijnlijk niet mee gevuld. Dat is natuurlijk ook een eetgewoonte die van thuis uit wordt meegegeven, dus als ze thuis al niet gewoon zijn van veel fruit te eten, dan gaan ze dat zeker hier ook niet doen.” (Kunstinstituut, secundair onderwijs, studiemeesteres, 02:22 – 02:43) Example-function Most schools stress the importance of practicing what you preach with regard to health interventions in schools. Teachers, educators and other school staff act as an example. Hence it is an inevitable requirement that they put into practice the message of the health intervention in front of pupils to achieve an as optimal implementation and result as possible. “De juffen drinken geen cola, geen frisdrank op school, geen koeken met chocolade. Wij moeten natuurlijk het goede voorbeeld geven, anders kan je dat niet maken.” (’t Kapoentje, kleuteronderwijs, directrice en leerkracht, 06:00 – 06:19) Op de speelplaats staan twee juffen, één ervan eet een appel, de andere eet niets. “Ik had vroeger een koek mee, hoewel fruit al verplicht was voor de leerlingen. De leerlingen en zij [de collega-juffrouw ernaast] hebben me daar op gewezen en ze hadden gelijk. Ik kon dat eigenlijk niet maken. Sindsdien doe ik dat niet meer.” (Klaverdries, lager onderwijs, opvoeder en leerkracht, observatie en gesprek school site visit)

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Characteristics of the innovation Compatibility Most schools indicate the importance of choosing the right health intervention as a condition for a successful implementation. An intervention must fit into the specific school culture and must be adapted to the diversity within the school. “We hebben het niet helemaal uitgewerkt zoals het ons werd voorgesteld. Het is ook niet de bedoeling dat je dat slaafs volgt. We hebben het op ons eigen niveau verwerkt en bekeken wat we er zelf van kunnen meepikken. […] We hebben het dus uitgewerkt volgens de regels van het spel, maar zodat het geënt was op onze schoolcultuur. We hebben gekeken welke elementen op welke manier konden worden naar voor gebracht en hoe we dat hier concreet konden naar voor brengen, want elke school heeft een andere schoolcultuur.” (Dr. Ovide Decroly-school, lager onderwijs, directeur, 22:16 – 23:32) Adaptability An important remark often made by schools is that teachers like to add to a personal touch and some creativity to the standardized intervention. In that regard an ideal intervention is flexible to allow small changes or leaves room to add a certain aspect, i.e. to determine the price of merchandise or what to give as a reward for the pupils. That personal input helps a facilitator to ‘own’ the intervention, which leads to more confidence and greater satisfaction. "De keuze voor Sam De Verkeersslang is er gekomen omwille van de mails die daarover binnenkwamen, maar ook omwille van de vrijheid die je nog hebt. Je kan echt op de stops waar er een beloning aan vasthangt, kiezen. Dat wordt echt niet vastgelegd. Wij kunnen dus zelf met onze werkgroep bepalen om dit jaar bijvoorbeeld te kiezen voor een banaan of een sticker. Vorig jaar hadden we fluo armbandjes en een fluo sleutelhanger voor aan de schooltas aan iedereen gegeven. We kunnen er creatief mee omgaan en we hebben nog een beetje de vrijheid.” (Sint-Antonius, lager onderwijs, directrice, 08:45 – 09:28) “Inhoudelijk laten ze ons als school voldoende vrijheid en dat is goed. We zijn zelf bijvoorbeeld ook vrij om de prijs te vragen voor de producten die we willen. Het is niet dat ze ons iets leveren aan één euro en ons opleggen het maximum aan één euro en tien cent te verkopen.” (Sint-Pietersinstituut, secundair onderwijs, directeur, 03:40 – 04:05) Some schools push it even further and note that they prefer to work with material and interventions that they develop themselves. Some of these schools take a formal health intervention as a starting point and make their own educational material, sources and/or time schedule. Other schools take their own experience and common sense to set up and develop a health intervention from scratch. We notice that schools using this working method are all secondary schools and mostly schools for children with special needs. “Zo’n pakket is heel flexibel en aanpasbaar. Soms is er geen map voor buitengewoon onderwijs. We nemen dan gewoon een map van lager onderwijs en dan lukt dat wel. Het is niet omdat er geen map is voor buitengewoon onderwijs dat wij niets vinden om daar 49

rond te werken. We nemen dan gewoon de map van het lager onderwijs en passen dat aan.” (Binnenhof, buitengewoon secundair onderwijs, leerkracht, 51:50 – 52:13) “Pakketten, ja, maar het meeste is uit onszelf gekomen. Dat bewegingsmoment is gegeven door een Zumba-leraar. Dat is de man van de dokter van onze school, die is dansleraar. Hij is het gewoon om aan jongeren met een beperking beweegmogelijkheden te geven. We proberen dus zoveel mogelijk met dingen die we zelf maken of organiseren te werken in de plaats van met didactisch materiaal van een interventie.” (Sint-Lodewijk, buitengewoon secundair onderwijs, leerkracht, 31:44 – 32:14) “We doen geen beroep op klaargemaakte pakketten, maar ontwerpen de acties op school zelf en werken die uit. Enkel de quiz van de Stichting voor Kanker en de antitabaksdag van de Wereld Gezondheidsorganisatie. We proberen wel iets aan te nemen, maar zo een pakket…[gebruiken we liever niet]” (Koninklijk Atheneum, secundair onderwijs, leerkracht, 37:25 – 38:02) The enthusiasm and commitment of school personnel affects the importance of ready-to-go or selfmade health interventions in the process of implementation. From the interviews, but mostly from the overall atmosphere and working and team spirit observed during school site visits we can conclude that the more enthusiastic and engaged the school staff is, the more they are willing to invest time and energy into branching out the health intervention(s) and even broader, the health policy, at school. Educational material A much quoted facilitating characteristic in the interviews and school site visits was a high degree of user-friendliness of the intervention. This is described as the intervention being highly elaborated and containing a very detailed and to-the-point manual. Most participating schools report that clear instructions and directions for school board, teachers and other school personnel included in the intervention make the implementation of the intervention easier. After all, this saves the provider and organization a fair amount of energy, effort and time, all of which are considered to be very valuable and limited for school personnel. “Ervoor hadden we een winkeltje met louter bio-producten, maar die producten zijn zeer duur om ergens te vinden, dus dat was zeer moeilijk om dat te combineren, want wij moesten daar dan zelf om ofwel naar de Colruyt ofwel naar andere winkels. Op de duur heb ik gezegd dat doe ik niet meer. […] Terwijl nu brengen ze dat van dat programma zelf naar hier en dat is een groot verschil. Het komt hier allemaal tezamen toe.” (SintPietersinstituut, secundair onderwijs, directeur, 30:18 -31:00) In order to facilitate the implementation, the educational material needs to be found attractive to work with for teachers as well as for pupils, next to the user-friendliness. Attractive educational material contains a strong visual component that reoccurs throughout the whole intervention, i.e. a symbol, an animal, an icon. Other material of the intervention such as posters, letters or flyers ideally have a colorful, neat and fit-for-purpose presentation adapted and accessible to the target group. Especially pre-schools and primary schools indicate the importance of the visual aspects of health interventions.

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“Het huis van Alijn is heel interessant met al die kamertjes en alles wat in de kamertjes staat. […] Het echt visualiseren helpt de kinderen om het te begrijpen.” (Gesubsidieerde Vrije Basisschool, lager onderwijs, directrice, 31:57 – 32:27) “Voor elke hap een stap was ludiek voorgesteld met een konijn en dat konijn sprak de kinderen ook heel sterk aan. Het was heel mooi voorgesteld. […] Het konijn zag er heel fit uit. Het was een vinnig konijn. Dat sprak de kinderen, zeker het eerste en het tweede, de laatstejaars keken daar niet meer zo naar, heel erg aan. En er was ook een onderlegger waar dat konijn op stond met spelletjes. Dus als zij klaar waren met eten en mama en papa waren nog aan het eten, konden zij spelletjes doen. Dat konijn moesten we ook als symbool gebruiken op onze briefwisseling.” (Dr. Ovide Decroly-school, lager onderwijs, directeur, 34:38 – 36:40) “De lay out van de slang is doorslaggevend en heel belangrijk naar kinderen toe. In de kleuterschool hing die in de polyvalente zaal, dus waar de kinderen binnenkomen. En hier in de lagere school was het in de inkomhal, dus een plaats waar ouders en kinderen regelmatig passeren. Ook het feit dat je een spandoek kan ophangen in de klas is belangrijk in deze interventie. […] Sowieso kan je afleiden dat als het visueel voor de kinderen aantrekkelijk is, er meer aandacht aan zal besteed worden dan wanneer het een actie is die niet ondersteund is door opvallend materiaal.” (De Rijdtmeersen, lager onderwijs, zorgcoördinator, 04:50 – 05:06 en 11:28 – 11:44) Next to the visual component, the educational material needs to comprise different educational working methods to pass the message of the health intervention, especially activating learning methods. This means that next to instructing pupils, pupils need to be activated through for example role-playing or group discussions. “Met die workshop schouder- en nek-massage willen we de leerlingen zelf laten ervaren hoe ze twee minuutjes kunnen ontspannen tijdens een lange les of wanneer ze aan het blokken zijn. Door ze zelf actief de hen voor getoonde technieken te laten proberen, hopen we dat ze er meer van zullen opsteken en het langer zullen onthouden.” (Koninklijk Atheneum, secundair onderwijs, leerkracht, observatie en gesprek school site visit) “Ervaringsgericht leren komt bij ons zeer sterk aan bod omdat we de leerlingen zelf laten koken in de workshops. Teamwork komt ook sterk naar voor, samen met leren van leerlingen, omdat ze in groepjes de gerechten moeten klaarmaken. We gebruiken ook veel videomateriaal om de infosessies te ondersteunen.” (Sint-Gertrudiscollege, secundair onderwijs, zorgcoördinator, 35:00 – 35:40) Another characteristic of the innovation that facilitates implementation of a health intervention is group competition and some kind of reward. These two aspects motivate pupils to look positively at the intervention, accept it in the school environment and cooperate if that particular intervention demands teamwork.

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“Ook het feit dat ze beloond worden, speelt natuurlijk mee. Een beetje competitie. Het feit dat ze toch wel de winnende klas willen zijn, dat speelt ook wel een grote rol.” (De Rijdtmeersen, lager onderwijs, zorgcoördinator, 11:45 – 11:59) “Wat voor onze leerlingen een grote motivatie was, was een voetbal bij een actie van Zespri. We kregen een poster van Zespri en ze moesten zoveel mogelijk stickertjes van kiwi’s sparen en dan kregen ze een bal. Ze voetballen graag en voor hen was dat dan een extra stimulans om ’s middags als dessert een kiwi te eten omdat ze dan weer een stickertje kregen. Dat zijn zaken die helpen.” (Reynaertschool, buitengewoon secundair onderwijs, directrice, 39:37 – 39:57) Some schools in our research emphasize the importance of ‘no obligations’ attached to the intervention when implementing health interventions in secondary schools. Teenagers need to be given the freedom of choice. If not, they will not support and appreciate the intervention which can harm the implementation. “Vrijblijvendheid is heel belangrijk, want als je iets gaat verplichten, gaat het niet werken. […] Leerlingen kunnen zelf bepalen of ze een fairtrade-product kopen. En ook wat betreft de wekelijkse veggie-dag op donderdag kunnen kinderen kiezen, want er wordt altijd een niet-vegetarisch alternatief aangeboden.” (Sint-Pietersinstituut, secundair onderwijs, directeur, 25:08 – 26:) Health interventions that are linked to official educational curricula and objectives are found to be more valuable to choose in the first place and manageable whilst their implementation in a following stage of the process. When objectives are not specifically defined in the intervention, most schools prefer to define them themselves previous to the start of the implementation. It makes the intervention accessible for teachers and easier and clearer to work with in the class context. Even more importantly, it makes sure that official educational objectives are to be found in the lessons and that teachers can prove this. It’s remarkable how some schools also involve the general educational project of the broader educational structure into the formulation of objectives related to the health intervention. Like that the health intervention becomes more than its primary goal of teaching pupils healthier nutritional and physical habits, focusing on more general and moral aims as well. “We gaan meestal op de dingen in die praktisch, goed uitgewerkt zijn, niet teveel kosten en gekoppeld zijn aan de leerplannen. Die koppeling is zeer belangrijk.” (Sint-Antonius, lager onderwijs, directrice, 01:11:39 – 01:11:50) “Dan gaan we eigenlijk niet kijken naar wat de doelstelling is van de producten, maar we gaan kijken naar onze eindtermen en naar onze leerplannen, naar wat wij moeten kunnen bereiken? Dat is eigenlijk altijd ons uitgangspunt en heel gericht gaan we dat gaan bepalen.” (Gesubsidieerde Vrije Basisschool, lager onderwijs, directrice, 03:24 – 03:50) “We vinden het belangrijk om aan gezondheid en promotie van gezonde leefstijl te werken op onze school. Zeker met de voeten die op de voorgrond treden. […] En vooral ook te kijken naar de voeten die minder aan bod komen in de lessen. We hebben ook een 52

aparte werkgroep voor de voeten en die bekijken waar er te weinig en te veel aandacht aan wordt besteed.” (Sint-Lodewijk, buitengewoon secundair onderwijs, leerkracht, 24:00 – 28:37) “De gezelligheid benadrukken van samen ontbijten, het gezondheidsaspect, dat driehoek aspect met het zoeken van een evenwicht daarin en het gevoel van samenhorigheid voor de school.” (De Octopus, buitengewoon lager onderwijs, leerkracht, 03:06 – 03:28) Evaluation Most schools indicate that evaluating a health intervention is not easy. They point out that there is no evaluation instrument available. Moreover, the concerning behavior doesn’t easily allow an official evaluation, since it’s not easily captured in facts and figures, and teachers can’t evaluate the behavior outside the school context. Therefore these schools report evaluating the health intervention in an informal way by observing general impressions of teachers and school staff among pupils. “De leerkrachten hebben aanwijzingen, maar wij praten daar eigenlijk bitterweinig over, want… Het is niet dat daar geen opvolging van is, want de leerkrachten volgen dat elk afzonderlijk in hun klas op, maar we gaan daar ook geen analyse van maken ten aanzien van de hele school, omdat er al zodanig veel bevraagd wordt.” (Dr. Ovide Decroly-school, lager onderwijs, directeur, 01:15:52 – 01:16:35) “Ik zie wel enkele effecten, denk ik. Eerst en vooral de prijs die we gewonnen hebben dit jaar omdat we de hoogste deelname altijd hebben aan SVS1-activiteiten, op dat vlak scoren we dan toch al goed. De school is ook aantrekkelijk geworden door dat bos met Finse piste errond. […] Wat betreft drinken en voeding zullen er op lange termijn wel zichtbare effecten zijn. We meten dat niet. Als we ons daar ook moeten mee bezighouden… […] Alle leerkrachten zien de effecten van die acties wel.” (Koninklijk Atheneum, secundair onderwijs, leerkracht, 21:22 – 24:38) Some schools however point out the importance of some kind of evaluation to weigh out the costs and the benefits of the intervention in order to decide a repetition of the intervention the next week, month or year. Also, they state that an indication of the rate of success of the intervention is a motivating factor for teachers and other school staff involved. This in turn is a facilitating factor for the implementation of the health intervention. These schools show different ways of such kind of evaluation, involving teachers, parents and/or pupils. “We hebben al een paar jaar een inventaris opgemaakt voor de interventie begon hoeveel komen er met de fiets, hoeveel dragen een fluojas en een helm, tijdens de interventie en een paar weken erna. Dit jaar hebben we dat niet gedaan omdat het zodanig druk was. Maar daarin zagen we wel een groei.” (Sint-Antonius, lager onderwijs, directrice, 30:35 – 31:07) “We hebben de laatste keer de leerlingen een strookje laten invullen met enkele vraagjes zoals wat vond je leuk, wat vond je minder leuk, hoe heb je dat ervaren, wat kon beter, 1

Stichting Vlaamse Schoolsport.

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enzovoort. Ze moeten natuurlijk wel heel concreet zijn. En nu is het de bedoeling om op basis van die informatie verder te gaan. We doen dat bijvoorbeeld met de welzijnsdag ook. Vorig jaar is dat geëvalueerd geweest door de leerlingen. Toen zijn een aantal werkpunten aan het licht gekomen en daar gaan we nu vanmiddag op de werkvergadering mee rekening houden bij de organisatie van de welzijnsdag van dit schooljaar.” (Instituut Sint-Lutgardis, secundair onderwijs, leerkracht, 23:49 – 24:31) “We hebben een enquête opgesteld voor de ouders. Die gaat volgende week mee met de leerlingen. Daar staat onder andere in weten ouders waar we mee bezig zijn, voel je thuis een effect van wat er op de school gebeurt, welk effect heb je dan gevoeld, of heb je er geen gevoeld. Het is heel kort, maar we proberen toch te zoeken naar of we hier een aantal zaken hebben bereikt.” (Gesubsidieerde Vrije Basisschool, lager onderwijs, directrice, 09:50 – 10:33) Weather Other factors that could facilitate or interfere in the implementation of the health intervention are mentioned, such as the weather. When activities outside are part or core of the intervention, schools report the weather as a determining factor of succession. “De leerkrachten hebben beslist om dat dit jaar opnieuw te doen omdat dat vorig jaar wel een leuke actie was. We hadden ook goed weer vorig jaar, terwijl dat nu wel heel wat minder was. Als het regent zijn mensen al minder gemotiveerd natuurlijk om met de kinderen per fiets naar school te gaan.” (De Rijdtmeersen, lager onderwijs, zorgcoördinator, 02:52 – 03:08) Attitude pupils Some schools report that when things are given to pupils for free, they don’t always appreciate and respect that. “Donderdag Gezonderdag doen we niet meer, daar zijn we mee gestopt. Elke eerste donderdag van de maand gaven we iets gezond gratis, bijvoorbeeld een wortel of een stukje appel. Maar het gratis geven, wat werkt niet, ze smeten daarmee in het rond. 7080% van de leerlingen gaat daar netjes mee om, de rest gooit ermee op de speelplaats. Gratis wordt niet altijd geapprecieerd door iedereen.” (Sint-Pietersinstituut, secundair onderwijs, directeur, 28:23 – 29:53)

Characteristics relevant to the prevention delivery system: organizational capacity General organizational characteristics Shared vision and involvement A positive attitude towards the health intervention and involvement of teachers in a healthy lifestyle facilitates its implementation. Even more, teachers and educators, as well as pupils and school principal value when everyone involved shows interest in the health program and the pupils efforts in joining the program. “Als ik zie dat iemand [een leerling] een potje van thuis klaargemaakt aan tafel zit op te eten, dan ga ik eens gaan kijken en zeg ik “Mmmm, dat ziet er lekker uit”, en dan zijn ze 54

[de leerlingen] wel content.” (Kunstinstituut, secundair onderwijs, studiemeesteres, 22:30 – 22:44) “Wij zeggen ook wel tegen de kleutertjes “Wie heeft er lekker fruit mee?” en “Wat zit er in uw doos vandaag?” Ja, het wordt wel opgevolgd en nageleefd door zowel onze kleuters als onze juffen.” (’t Kapoentje, kleuteronderwijs, directrice en leerkracht, 14:50 – 15:01) Most interviews and school site visits show that whether or not the school staff shares the same vision according to the health intervention, affects the motivation of the foremen and the implementation of the intervention. Negative comments or attitudes are clearly interfering characteristics. “Als we voor iets gaan, dan is dat op het spoor zetten en dan wordt iedereen in dezelfde richting, ik ga niet zeggen geduwd, maar de hoofden allemaal in dezelfde richting en wordt er volledig voor gegaan. Het is een integrale activiteit en iedereen wordt erbij betrokken, van opvoeders en leerkrachten tot keukenpersoneel en directeur.” (Dr. Ovide Decroly-school, lager onderwijs, directeur, 01:13:00 – 01:13:21) “Als collega’s onterechte commentaar hebben, zoals “Ben je daar nu weer met je bananen?” of “Denk je nu echt dat je daar iets mee bereikt?”, zo die dingen, dat moet voor mij niet. Dat werkt dat zeer demotiverend. Of bijvoorbeeld ook als er tijdens de gezonde week op vrijdag, de climax-dag, activiteiten waren buiten op de speelplaats, iedereen is buiten en dan ga je nog rap iets halen in de leraarskamer en zitten er daar vier leerkrachten hun boterhammen op te eten. Daar word ik misselijk van. Dat kan niet. Het gezondheidsbeleid wordt veel gedragen op onze school, maar niet voor 100%.” (Instituut Sint-Lutgardis, secundair onderwijs, leerkracht, 19:50 – 20:29) Integration of the innovation Most schools indicate the value of integrating the health intervention in the general health policy of the school. They are convinced that the implementation of a health intervention is being facilitated when the intervention is not a one-off and isolated activity, but is combined with similar activities and embedded in a generally promoted healthy lifestyle. “Als er minder vanuit een beleid wordt gewerkt, dan zijn het losse flodders en dan weet ik niet of het eenzelfde effect kan hebben.” (Gesubsidieerde Vrije Basisschool, lager onderwijs, directrice, 25:45 – 25:53) “Gezondheidsinterventies zijn bij ons niet iets dat los staat van de rest. Het moet ook ergens gekaderd zijn binnen het brede schoolbeleid. Wij dulden geen chips en geen frisdrank. Het is ook goed voor ouders en kinderen dat ze op die manier zien dat we daarin blijven volharden. Het heeft geen zin om een losse actie te voeren, een losse flodder, en dan de week erna met chips en frisdrank op school toe te komen. Dat gaat niet.” Zowel binnen school (hele jaar door vakoverschrijdend) als inbreng en samenwerking van buitenaf.” (Dr. Ovide Decroly-school, lager onderwijs, directeur, 40:01 – 40:44)

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“In aanvulling met de gezondheidsacties die we hier houden op school, wordt er al tien jaar geen frisdrank meer verkocht. Er is ondertussen ook een drankenautomaat met de nadruk op de iets gezondere dranken. Plat water zit daarin, spuitwater, chocomelk, fruitsap, en koude thee. Je kan daar moeilijk alleen maar water in steken. Maar dus geen cola, fanta, sprite, enzovoort.” (Instituut Sint-Lutgardis, secundair onderwijs, leerkracht, 08:34 – 08:54) Cooperation between different working groups in schools, such as environmental working groups and health working groups, or safety working groups and health working groups, resulting in interventions concentrating on both values, for example. “Wij hebben hier ook een MOS-project, Milieu op school. Die mensen hebben eind augustus de beslissing genomen om iets te doen rond het klimaat. In het kader van 16 oktober de Wereld Voedsel Dag, hebben alle vierdes activiteiten gedaan rond het klimaat en gezonde voeding hebben we erbij genomen. We hebben dus de zorg voor gezonde voeding gecombineerd met de zorg voor het klimaat en het milieu.” (SintGertrudiscollege, secundair onderwijs, zorgcoördinator, 02:10 – 03:23) “We proberen dat ook met bijvoorbeeld Dikke Truien-dag. We maken met de hele school soep. Dat zijn werkelijk emmers soep, honderd liter bijna. Met de kinderen in de klas worden er groenten gesneden. Beneden in de keuken werd de soep dan gemaakt. […] En die soep werd dan gratis aangeboden aan de ouders die op bezoek kwamen tijdens het bewegingsmoment, dit jaar was dat de dans the move tegen pesten. Ondertussen leren de ouders ook dat soep gezonder is dan andere tussendoortjes.” (Dr. Ovide Decrolyschool, lager onderwijs, directeur, 30:30 – 31:31) Also, introducing health issues in existing activities with (grand)parents, or demanding healthy efforts from parents for birthday treats. “Wij maken ook eens fruitsla met de kinderen. Wanneer er rond oma en opa gewerkt wordt, tijdens de grootouderdag, komen er grootouders in de klas om activiteiten te doen en toen is er met de kinderen fruitsla gemaakt.” (’t Kapoentje, kleuteronderwijs, directrice en leerkracht, 21:50 – 22:06) “Wat we ook doen, als er bijvoorbeeld een verjaardag is van een kind, vragen we aan de ouders om geen snoep mee te geven, maar bij voorkeur cake. Als ze drankjes willen geven, dan liefst gezonde.” (Dr. Ovide Decroly-school, lager onderwijs, directeur, 14:55 – 15:09) Likewise, connecting health issues to very specific educational curricula and objectives of pupils in secondary schools. “De richtingen van sociaal-technische die veel rond koken doen duwen het effect van de interventie wel wat, door het maken van bijvoorbeeld gezonde hapjes, soep, gezonde broodjes, enzovoort.” (Koninklijk Atheneum, secundair onderwijs, leerkracht, 25:00 – 25:20)

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“De vrijwilligers voor de winkel worden in het derde jaar gezocht. We nemen leerlingen uit de richting economie om producten te verkopen omdat ze dan iets kunnen koppelen aan hun lesgebeuren.” (Sint-Pietersinstituut, secundair onderwijs, directeur, 06:45 – 06:58) “We hebben hier ook een kantoorrichting en in het vijfde en het zesde jaar van die richting hebben ze dat in hun lessen verwerkt en hebben de leerlingen zelf de brieven voor de buurtwinkels en bakkers opgesteld en geschreven. We hebben daar leuke reacties op gekregen en veel sponsormateriaal gekregen.” (Sint-Lodewijk, buitengewoon secundair onderwijs, leerkracht, 20:21 – 20:44) One primary school even has the explicit intention to incorporate the health intervention in a project week the following year instead of organizing one day only, and to involve the pupils of the secondary school as well. “Volgend jaar willen we het in een projectweek steken rond gezondheid, bewegen en milieu zodat je dan een groter project hebt, dat misschien ook door het middelbaar kan gedragen worden en waarbij er meer mogelijkheden zullen ontstaan.” (De Rijdtmeersen, lager onderwijs, zorgcoördinator, 15:05 – 15:23) Closely related to the fact that health interventions need to be integrated in schools, all schools indicate the importance of repetition of the health intervention. Repeating the content and message of the health intervention is a condition for pupils to learn, remember and live up to it. The more pupils get confronted with health issues, the more they develop an open mind for those actions which facilitates the implementation of health interventions. “Herhaling blijft nodig voor de leerlingen. Voor kinderen wordt het dan herkenbaar. Het is goed om dat gezondheidsverhaal regelmatig te hernemen, niet enkel één week per schooljaar.” (Gesubsidieerde Vrije Basisschool, lager onderwijs, directrice, 31:49 – 32:07) “We organiseren eenmalig een gezond ontbijt op een woensdagmorgen. Daar zien we dat sommige kinderen vanuit die keuze naar een aantal dingen willen grijpen waaraan je ziet dat die kinderen het niet gewoon zijn om gezonde dingen te eten. Dan weten wij dat daar aan moet gewerkt worden en dat zet zich door in de klas waar ze er nog verder rond werken. Dat trekt zich ook door naar de tutti frutti dat we ingevoerd hebben. Op die manier leggen ze de link en worden ze er aan herinnerd zoals “Weet je nog dat ontbijt?” en “Dat was gezond”, en ze leren dan eens een ander stuk fruit eten.” (De Octopus, buitengewoon lager onderwijs, leerkracht, 01:23 – 01:54) Health policy Almost every school stresses the facilitating effect of a clear and structured vision and policy in which health interventions can be situated. This is experienced by teachers as a meaningful support for the setup, implementation and execution of a health intervention. This plan ideally is a working document that is available for all school staff and can be adapted, altered and completed over the years. “Ik denk dat wat het gemakkelijk maakt is dat je die visie hebt en dat je om de zes jaar die zaken gaat belichten. Je moet er niet teveel over nadenken, want het staat in die 57

visietekst die gebaseerd is op de eindtermen en leerplannen. Dat is altijd het uitgangspunt. Dat maakt het gemakkelijker om iets te organiseren, om iets erdoor te krijgen en om iedereen er achter te scharen.” (Gesubsidieerde Vrije Basisschool, lager onderwijs, directrice, 24:30 – 24:46) “Ik heb het gezondheidsbeleid uitgewerkt op basis van teksten en documenten. Wat deze visie goed maakt, is het feit dat er naar teruggekoppeld wordt door de directie. Als die bijvoorbeeld een vraag krijgt van een collega “Mogen wij dit of mogen wij dat?” dat hij zegt “Dat staat niet in ons gezondheidsbeleid, we kunnen dat niet maken”. We kunnen daar wel aanpassingen aan doen, maar er zijn ook grenzen.” (Instituut Sint-Lutgardis, secundair onderwijs, leerkracht,21:10 – 21:40) “Ons gezondheidsplan is onze visietekst. Dit is een zeer uitgebreid document met eerst een algemeen stuk over waarden, normen, verwachtingen en afspraken. Vervolgens wordt heel concreet opgelijst voor bewegen enerzijds en voor voeding anderzijds wat er allemaal gedaan wordt. Elk jaar worden daar dingen aan toegevoegd of geschrapt, telkens in een ander kleurtje. Het is dus een echt werkdocument voor ons waar we gemakkelijk naar terug kunnen grijpen.” (Klaverdries, lager onderwijs, zorgcoördinator, gesprek en document school site visit) Specific practices and processes Shared decision-making Next to input coming from teachers, educators and school principal in the choice of health program and the way it is being implemented, all schools indicate that community participation and involvement in the intervention are important for an adequate implementation. First of all parents need to be informed and where possible given the chance to take initiative and/or take part in the intervention. “Het is belangrijk om de betrokkenheid van de ouders hoog te houden. Er worden telkens veel foto’s getrokken en op de schoolwebsite gezet zodat de ouders weten en zien wat er aan de hand is en het goed kunnen opvolgen.” (Sint-Antonius, lager onderwijs, directrice, 19:35 – 19:57) “We proberen de ouders te betrekken door het meegeven van gezondheidskaarten met de leerlingen. De mini-enquête op het einde van het jaar waarbij er gepeild wordt naar de effecten ook thuis. Bij infovergaderingen vragen we om bij verjaardagen gezond cadeaus mee te brengen. En dat lukt eigenlijk voor 60%. De ouders gaan dus mee in gezonde cadeaus, ook bewegingscadeaus. De gezondheidsbrief wordt ook in de maandbrief gecommuniceerd. De ouders worden hier maandelijks geïnformeerd over de gezondheidsinitiatieven. Op het schoolfeest was het centrale thema ook gezondheid. Ik denk dat we op die manier wel ver gaan in onze betrokkenheid van de ouders.” (Gesubsidieerde Vrije Basisschool, lager onderwijs, directrice, 17:30 – 20:13) Some schools stipulate that the role of pupils themselves in the implementation is not to be underestimated.

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“De menu wordt besproken met de kinderen en de catering.” (Gesubsidieerde Vrije Basisschool, lager onderwijs, directrice, 41:03 – 41:11) “De leerlingenraad hebben we hier wel. Sinds vorig jaar loopt dat terug goed. Ze spreken ervan om de leerlingen te laten meehelpen met die projecten. Vorig jaar hebben ze eens soep en chocomelk uitgedeeld in het kader van de Warme Truiendag. Want wij ondervinden dat als de leerlingen het zelf doen, bijvoorbeeld bedeling doen, reclame rond maken, enzovoort, dat het meer aanspreekt naar de anderen toe.” (SintGertrudiscollege, secundair onderwijs, zorgcoördinator, 35:45 – 37:19) “Wij hebben twee leerlingenraden, één voor de onderbouw en één voor de bovenbouw. In de leerlingenraad kan ik zeggen “Het valt mij op dat de fluojassen minder en minder gedragen worden, kan je het meenemen naar je klas en het nog eens zeggen?” Of ik kan hen nog eens herinneren aan dat ze voor gezonde tussendoortjes moeten kiezen.” (SintAntonius, lager onderwijs, directrice, 51:00 – 51:14) Coordination with other agencies Most schools report that partnership with other agencies has an added value to the implementation of the health intervention. This for several reasons. First of all, because of the possibility to receive certain material or gadgets for free. Secondly, because it offers more opportunities to enter into bigger and well-organized initiatives, and thirdly, because it enhances an integrated approach on the health policy. “Ik heb verschillende mutualiteiten aangeschreven en hen gevraagd of ze bereid waren mee in te stappen in ons gezondheidsbeleid. Dankzij dit initiatief hebben wij een nauwe samenwerking met de CM en de Bond Moyson. Kinderen die geen brooddoos hebben, krijgen er één van de CM of de Bond Moyson. […] En in het kader van de voedingsdriehoek worden er door Sodexo in het begin van het schooljaar lessen gegeven aan de kinderen in verband met ‘wat is gezonde voeding?’.” (Dr. Ovide Decroly-school, lager onderwijs, directeur, 18:45 – 19:29) “Stad Gent organiseerde donderdag veggie-dag en deed een oproep naar zoveel mogelijk scholen, openbare diensten en mensen die een bedrijfsrestaurant hebben om mee te doen, en wij dachten “we doen mee”.” (Sint-Pietersinstituut, secundair onderwijs, directeur, 24:06 – 24:28) “We hadden een hele dag georganiseerd en dat begon met een gezond ontbijt voor alle leerlingen gevolgd door een bewegingsmoment voor alle leerlingen op de speelplaats. Daarna hadden we vier workshops van Onafhankelijk ziekenfonds. Die kwamen spreken rond seksualiteit, middelengebruik, veilig fuiven (o.a. gehoor), goede rug- en zithouding.” (Sint-Lodewijk, buitengewoon secundair onderwijs, leerkracht, 09:45 – 10:49) Communication A lot of schools report the facilitating effect of the opportunity and possibility to communicate and share knowledge on health interventions with colleagues within the school, but also within the broader school community. This dissemination of information and experiences informs school staff about what’s available on the market, motivates them to choose an intervention and helps them 59

implement the intervention. Some schools put all the information at the school staff’s disposal in the center for pupils support or the teacher’s room. Other schools have a digital platform that is accessible to all teachers. One school remarks that the first way is a rather difficult way of spreading the information among teachers, since it demands more initiative, time and effort of teachers, and the location doesn’t allow all the teachers consulting those maps and books. “Hier [in de kast in de leraarskamer] in deze mappen staat alle informatie over alle gezondheidsacties die bij ons op school gedaan worden. Ze zijn dus vrij te consulteren voor alle leerkrachten.” (Klaverdries, lager onderwijs, vier leerkrachten, observatie en groepsgesprek school site visit) “Wij hebben een elektronische leeromgeving waar alle gezondheidsmaterialen van alle scholen verzameld worden, bijvoorbeeld concrete lesvoorbereidingen, werkblaadjes, werkmethoden, wat dan ook. Met succes zetten we dat daar op en dat is door alle leerkrachten te raadplegen.” (Gesubsidieerde Vrije Basisschool, lager onderwijs, directrice, 24:48 – 25:06) “De basismappen staan bij het CLB met voldoende informatie, daar zit echt alles in, maar dat is niet toegankelijk. Allez, dat is wel toegankelijk, maar of ze dat gaan doen… En stel u voor dat alle zeventig leraars daar voor dit of dat binnengaan…” (Koninklijk Atheneum, secundair onderwijs, leerkracht,19:39 – 19:55) Formulation of tasks Most schools describe the formulation of tasks, and more specifically the dividing of workload that comes with implementing health interventions as a crucial characteristic. This doesn’t necessarily imply that all school staff needs to be involved just as much and needs to be assigned an equally fair task. It implies on the contrary the feeling whether or not the intervention is hold to be attainable by the school staff member(s) involved, since this feeling strongly affects the enthusiasm and motivation of the school staff. Depending on that feeling, it is important that more or less people need to be involved and/or that tasks need to be reappointed. The attainability of the intervention depends on several things, such as time within the assignment of the particular teacher or educator, support from other teachers, educators or pupils, reachable resources, financial opportunities, etc. “De bedenking bij leerkrachten is wel telkens, niet zozeer dat de lessen wegvallen, want daar zien ze het belang wel van in, maar kwestie van organisatie, voorbereiden, aankopen, organisatie van de zaal, opruimen achteraf, is het toch iedere keer weer kijken hoe we het gaan aanpakken en eraan werken dat iedereen betrokken is.” (De Octopus, buitengewoon lager onderwijs, leerkracht, 06:24 – 06:49) “Vijf of zes jaar geleden zijn we daar mee begonnen, vorig jaar en het jaar ervoor is het niet geweest en dit jaar gaan we het nog eens opnieuw doen. De reden waarom het twee jaar niet geweest is, is dat we de jaren ervoor ervaren hebben dat we dat met twee mensen moesten dragen voor een volledige school. Dat was een succes, maar zeer zwaar belastend voor ons. Dit jaar ga ik het opnieuw doen omdat ik vijf leerlingen mee in mijn groepje krijg en die leerlingen gaan dat doen in het kader van een sociaal project in het vijfde middelbaar. We gaan sowieso met zes mensen zijn die het gaan doen en dat lijkt

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me wel oké en beter haalbaar dan de voorbije jaren.” (Instituut Sint-Lutgardis, secundair onderwijs, leerkracht, 01:40 – 02:24) “Het zou moeten opgenomen worden in ons takenpakket. Dat zou helpen om het te implementeren, dat het deel uitmaakt van ons takenpakket.” (Kunstinstituut, secundair onderwijs, studiemeesteres, 12:34-12:59) Specific staffing considerations Leadership Most schools involved in this research consider support and approval from the school principal as an essential term to the implementation of health interventions. What this support consists of or should consist of, is not the same for all schools. Some school staff members note that all they need is approval for an intervention. They emphasize that they don’t ask for or miss more contribution of any kind from the school principal. A couple of these school staff members state that they prefer that kind of freedom instead of other people intervening in their actions. Other school staff members report that the reason why they don’t expect or need more involvement from the head of the school is because they realize that the head of the school has other more important things to do. Another significant group of schools think it’s very motivating and facilitating when the head of the school is actively involved in choosing, implementing and/or executing a health intervention. They appreciate every kind of investment of time and/or energy. “We hebben nog een werkgroep gezonde voeding gehad met een viertal ouders, mezelf als personeelslid en een leerkracht. Dat is wel al een aantal jaar geleden, maar die zijn daar mee gestopt. De ouders ondervonden dat ze niet voldoende gesteund werden door het schoolbestuur in de zaken die ze wilden doen. Ze waren bijvoorbeeld heel sterk tegen de automaten. Ze ondervonden dat ze niet veel konden doen. […] De directie is van mening dat de leerlingen moeten leren keuzes maken. En door dergelijke gezondheidsacties dat we hen moeten sensibiliseren en laten kiezen voor wat het meest gezonde is. Want wij zijn een kleine maatschappij in een grote maatschappij en als ze hier buiten komen, moeten ze ook keuzes maken. Dat is hun visie. En dat is een beetje waar de werkgroep gezonde voeding een andere mening over had. En op de duur zeiden die mensen ‘we kunnen in feite niet veel meer doen dan hier samen zitten en zeggen hoe het moet, maar als er het schoolbestuur dat tegenhoudt…’.” (Sint-Gertrudiscollege, secundair onderwijs, zorgcoördinator, 39:05 – 40:13 en 57:24 – 58:12) “Voor ons is de steun van de directie die wij nodig hebben om een gezondheidsinterventie in te voeren het feit dat ze het initiatief toestaan. Wij werken zelf alles uit en geven alles vorm, maar moesten we materiaal of iets dergelijk vragen aan de directie, dan zouden we dat wel krijgen.” (Klaverdries, lager onderwijs, leerkracht, gesprek school site visit) “Van de directeur hadden we dan wel ondersteuning. Die had bijvoorbeeld op een bepaald moment de weddenschap aangegaan met ons als wij stuks fruit op die periode kunnen verkopen, dan ga ik verkleed als banaan een half uur toezicht doen op de speelplaats. We hebben het gehaald, mits een beetje zeuren, maar we hebben het gehaald. En dat was wel leuk. Het was voor een groot stuk een stimulans. De leerlingen 61

vonden dat ook super. [… ] We waren dansinitiatie aan het geven en hij stond mee te dansen. Allez, ik bedoel, hij is wel hoofd van onze school hier en die staat gewoon mee te dansen. Hij is er echt wel bij betrokken.” (Instituut Sint-Lutgardis, secundair onderwijs, leerkracht, 05:17 – 05:50 en 20:39 – 20:54) “Onze adjunct-directeur zit mee in de stuurgroep en is een heel belangrijke trekker van alles wat te maken heeft met gezondheidsbeleid bij ons. Dat vergemakkelijkt de werking en organisatie van gezondheidsinterventies enorm.” (Koninklijk Atheneum, secundair onderwijs, leerkracht, gesprek school site visit) Program champion or working group Most schools indicate the importance of leadership in the implementation of health interventions, and more generally, in the health policy at schools. Some schools define this kind of leadership as one person, a program champion, taking the lead and the initiative. Other schools note that a working group for health and/or environment is sufficient to fulfill this task. “Er was een leerkracht die dat organiseerde, maar die geeft niet elke dag les. Dan gebeurde het dat ze er niet was op het moment dat er fruit moest verkocht worden en de leerlingen deden dat dan ook niet, hoewel het hun taak was. Zij sprong dikwijls in als er niemand was, maar als ze hier niet is, dan gaat dat niet he. Nee, je hebt echt iemand nodig die dat consequent kan organiseren en er achter zitten.” (Kunstinstituut, secundair onderwijs, studiemeesteres, 27:30 – 28:34) “Ik maak soms al een voorselectie van zaken die eventueel bruikbaar zijn binnen onze doelgroep en dat bekijken we dan samen in de vakwerkgroep. Dan wordt er overlegd wat de hoofdleidraad is en wat we gaan gebruiken. De werkgroep hangt samen met het milieu op school en bestaat uit enkele leerkrachten.” (Reynaertschool, buitengewoon secundair onderwijs, directrice, 03:57 – 04:43) Managerial support The encouragement of the head of the school during and after the implementation of health interventions is found to be very motivating by some schools. In a few schools the head of the school and the school staff closely involved in the organization of the intervention, try to motivate all school staff to live up to the health intervention. “De directie is wel altijd heel enthousiast. Ze komt dan daarna nog eens bij u om te zeggen dat het een leuke week en een leuke dag was. Op de dag zelf kwam ze ook een hapje eten en dat is ook wel leuk. Ze motiveert ons ook wel om het volgend schooljaar opnieuw te doen.” (Binnenhof, buitengewoon secundair onderwijs, leerkracht, 21:41 – 22:01) “Gezondheidsbeleid is ook één van mijn stokpaardjes. We doen daar toch heel veel rond. Ook naar de leerkrachten toe. De stappentellers voor de leerkrachten hebben we ook dit jaar. Dat is ook zeer leuk. Een beetje competitie er in steken. ‘Hoeveel stappen heb jij al?’ en na het weekend is het nagaan hoeveel stappen iedereen al heeft. Het gaat hem ook een beetje om het plezier erin hebben, teambuilding en ondertussen toch wel gezond bezig zijn.” (Sint-Antonius, lager onderwijs, directrice, 01:00:17 - 01:00:52) 62

Characteristics related to the prevention support system Training None of the schools that participated in our qualitative research report having received some kind of training or education on the health intervention by the prevention support system. They also state that they don’t need any schooling about the intervention. “De betrokken leerkrachten hebben geen training gekregen, maar ze hebben wel op de website van Eva recepten gehaald.” (Sint-Gertrudiscollege, secundair onderwijs, zorgcoördinator, 25:45 – 26:05) “We verwachten geen training of andere ondersteuning, want dat lukt vrij goed. Dat is nu ook niet iets dat ons wereldvreemd is, gezonde voeding. Over fruit en groenten weten we zelf wel voldoende.” (’t Kapoentje, kleuteronderwijs, directrice en leerkracht, 20:53 – 21:05) Technical assistance The same accounts for the technical assistance offered by the prevention support system. Most schools note that they know of the possibility to contact the organization, but inform that they don’t need assistance of any kind during the implementation. “Wij hebben nooit moeten terugvallen op Eva. We hebben enkel die map daar aangekocht, maar daarna geen contact meer gehad.” (Binnenhof, buitengewoon secundair onderwijs, leerkracht, 31:02 – 31:21) “Ondersteuning vanuit het de organisatoren van het project zelf is niet nodig, wel vanuit campusniveau. Ik denk dat we daar de hoofden eens bij elkaar moeten steken en kijken wat de mogelijkheden zijn.” (De Rijdtmeersen, lager onderwijs, zorgcoördinator, 17:22 – 17:45) “We hadden geen vragen, alles was duidelijk en we hebben dus nooit beroep moeten doen op de technische ondersteuning.” (Gesubsidieerde Vrije Basisschool, lager onderwijs, directrice, 53:18 – 35:25)

Summary Our qualitative research shows some characteristics that affect the implementation of health interventions in the participating schools. As proved above, it also rises some questions and issues about health interventions in general. Concerning community related factors, we find that prevention theory and research does find its way to schools, but in an non-structured way. This overload of information results in a lack of overview, something many schools struggle with. The influence and obligations of larger educational structures and policy is found to be just the right amount. As regards funding, most schools recognize the financial challenge that comes with working on a healthy lifestyle at schools. However, they report few to no difficulties and show a high degree of creativity and initiative to make it work. The two most often named ways to reduce the costs are looking for free material and sponsoring, and collaboration within the school community. 63

We find two more community related characteristics in addition to the characteristics that Durlak and DuPre (2008) put forward. For one, the social environment and home situation of children and teenagers has an impact on the implementation of health interventions. When pupils don’t learn a healthy lifestyle at home, that makes it hard for schools to work on that topic. The second additional factor is the degree to which health is a hot topic among children and teenagers and whether or not media-attention is given to the topic. In regard to the provider, some characteristics are found to be facilitating to the implementation. When there is perceived a certain need for the innovation and benefits of the innovation, the implementation tends to be made easier. Educators and teachers serving as an example also helps implementing a health program. Next to characteristics of the community and of the provider, several characteristics of the innovation are found to be facilitating or interfering the implementation. Choosing the right health intervention for example is a condition for successful implementation. User-friendliness and freedom for some creativity are two other factors that matter. Next to that, the educational material must be found attractive, as in containing a strong visual component and activating learning methods. Competition and rewards for pupils in interventions also facilitate the implementation. Health interventions that are linked to official curricula and objectives give teachers something to hold on to and hence facilitates the implementation. The opinions of the effect of evaluation of the intervention on implementation is found to be not clear-cut. Some schools identify it as facilitating, others don’t do it in the first place because they don’t have the means to do so. Finally, two factors are determined that cannot be altered by schools, but do can be of significant importance for implementing an intervention, namely the weather and the attitude of pupils. With respect the prevention delivery system, some general organizational characteristics are reported. A positive attitude, involvement and sharing the same vision among school staff is important, as well as setting up a general school health policy. The health intervention needs to be integrated in a clear vision and throughout the whole functioning of the school. This automatically implies multidisciplinary linkages, introducing health issues in existing activities, connecting the health program to educational curricula and objectives, and repetition of the health message. As far as specific practices and processes of the prevention delivery system are concerned, shared decision-making with all parties (i.e. school personnel, pupils and parents) and cooperation with other agencies is considered to be of great facilitating value. Furthermore, communication and the possibility to share knowledge and experiences among teachers is not easy to organize in practice, but can facilitate the implementation. Also, the formulation of tasks is crucial in the implementation of the intervention, although what this formulation is precisely is different for each school. The main aspect is that the implementation of the intervention must be found attainable for teachers and other school staff. Two specific staffing considerations were defined. Firstly, support and approval from the school principal is essential for implementation of health programs. Secondly, there must be some kind of leadership (i.e. a program champion of working group) when implementing health interventions, and finally, support and encouragement of the head of the school motivates school staff members.

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Last but not least, the characteristics related to the prevention support system that Durlak and DuPre (2008) identified as factors that can affect the implementation of health interventions in schools, are recognized, but not given any meaning to. None of the schools has had some kind of training or education, and none of the schools has needed technical assistance. They didn’t find this facilitating, nor interfering.

Implementation guide feedback As from November 15th teachers/school teams/administrations demonstrated interest to review the implementation guide. A draft version was printed and distributed accordingly. Teachers reviewed the guide and members of health project groups discussed it with colleagues. A feedback sheet was distributed as from January 2014 to gather feedback. In the closed section a 3 point Likert scale was used to score on different categories as user-friendliness, lay out, applicability etc. An open section enquired about their expectations, strengths and room for improvement.

Clarity Teachers clearly indicate a lack of practical examples. With the statement ‘I would have loved to have more practical examples’, all with no exceptions agree. This feedback we also gathered in informal communication with teachers who did not complete an evaluation sheet. For the final version of the implementation guide more examples will be introduced. We have many examples of interventions from the inventory and school survey. From the qualitative research we find many innovative ideas of implementation we like to share. What is concerned structure of the guide, not a single reviewer scores it to be below expectations. All are satisfied or neutral about the formulation of objectives, coherence of different chapters and distinction of essentials and side issues.

Legibility and design Legibility and design is clearly one of the best scored categories. Only one teacher is neutral about the stimulating effect of the lay out. All teachers endorse a right choice of language and jargon.

User-friendliness Less consensus we find on user-friendliness. Yet no single one scores it below average. We could spend more time on structure however to make it easier to navigate to the information the particular user concerns.

Usefulness and feasibility The most important evaluation category is usefulness and feasibility. A first problem to tackle is the innovative character of the implementation guide. It is clear teachers expected a more hands-on approach in the guide and were disappointed not to find any practical materials to use immediately in the class room. As such, usefulness is scored rather low. One comment from a young teacher: “I recently graduated five years ago and this guide does not provide new information I did not already got from my schooling.” For the same reason teachers are afraid this guide will not help them save time in health promotion. For these reasons they are very wary to actually use the guide in class. In contrast, more teachers do indicate they would share and promote the guide with other teachers.

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General comments We enquired teachers about the expectations they had before reading and using this guide. Teachers indicate they had high hopes for an instrument applicable in the class room. An instrument that contains fresh materials they can use in the class room. Finished content for practical applicability in the class room. In this regard teachers were somewhat disappointed. We learn two main things from the review phase of this project. First of all, when introducing the guide it should be much clearer what is the focus. This guide is not an inventory on ready to use materials, nor is it a new allencompassing ready to use intervention to promote healthy food and physical activity in the class room. We should make clear from the beginning that we acknowledge that every class room is a reality on its own and therefore no ‘one size fits all’ interventions are desirable. Secondly, if we do want to help teachers choose and implement projects effectively, we realize we need to be more hands-on. Beforehand we were reluctant to introduce existing interventions as examples under different headings in the guide. We did want to promote some projects over other projects. Merely, we wanted to point out the components one should be looking for in an intervention and assess applicability in his class group. Now we realize we do need to provide practical examples of those components in existing interventions. As such, if a school wants to include parents, they find a theoretical part that is supported by a hands-on example. Moreover we will include ideas and quotes from teachers we interviewed for motivational purposes. Finally, one of the strongholds of this guide is the applicability in different education forms and levels. Even though one teacher indicates limited applicability in secondary education, this is not supported by other teachers. Also, different sets in implementation are mentioned as a stronghold. Sometimes steps are disregarded because of being obvious. This guide clearly shows that every component or step fulfills a role in the bigger picture.

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Final Remarks From the research results we still believe teachers can use any support for quality implementation of interventions promoting healthy nutrition and physical activity in the class room. However teachers do indicate being somewhat reluctant to training. At least for this thematic, in line with this, we found training is not established in Flanders. Only two interventions offer training for teachers. We regret this situation as it is well known training increases interventions’ potential. On the other hand we do believe teachers in Flanders receive a good training for didactical methods, class management, etc. With this implementation guide we hope to raise awareness on the possibilities of extra training for prevention among teachers. At the same time we hope to support teachers in implementation with this paper guide. At the very beginning of the project, we had to determine the main focus of the research project in one brainstorm session. We decided to focus on the last cod in the chain of prevention, namely the contact between the teacher and the pupil. We felt that teachers do a great deal of ‘last minute’ adaptation to make an intervention work in their class room, with their specific group of pupils. We wanted to have a clear view of what exactly happens in the class room when one such prevention program is delivered. How do teachers adapt a standardized program to their pupils? And are these adaptations advisable? Soon we found teachers rely greatly on the adaptation coordination of a working group. Concerned teachers join together to pioneer the thematic in school. We found for adaptation of implementation in school they fulfill a key role and should also be targeted with this implementation guide. They translate the year objectives from the administration in activities. This working group is thus the key for the last cod in the chain of prevention. Moreover, in the feedback forms for the draft implementation guide we asked teachers who would be the target group for this implementation guide. Without exception, members of the health working group are mentioned, next to form masters and members of the school administration.

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Attachments to be achieved at the contact address -

Codeboek inventaris Vragenlijst scholenbevraging Interviewlijn half open interviews Samenvatting Wegwijzer – Hoe gebruik je pakketten voor gezonde voeding en beweging in je klas?

Contact Peer van der Kreeft, promotor, Hogeschool Gent Vakgroep Sociaal Werk, Valentin Vaerwyckweg 1, 9000 Gent, Belgium, +32 9 2432651, [email protected] Download documents on pure.hogent.be

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