Teams, partners, or champions? A mixed methods exploration of potential pathways of implementation success for wellness initiatives in schools using the Quality Implementation Framework.

Abstract

Background: Local wellness policies (LWPs) promote healthy eating and physical activity practices in U.S. schools. Achieving and sustaining quality implementation of LWPs is challenging, particularly in urban and rural schools (which may lack implementation resources).

Objective: Describe implementation strategies and determinants for LWPs in "Wellness in Rural Schools" (WIRES), a national survey of U.S. elementary schools across 4 phases using the Quality Implementation Framework (QIF).

Design: Convergent mixed method analysis.

Participants: /Setting: 559 informants (e.g., principals, nurses, teachers) from U.S. urban and rural elementary schools completed surveys in February 2020; 50 informants (from 39 urban and rural schools) completed semi-structured interviews from April - June 2020.

Main outcome measures: Surveys described implementation strategies and climate. Semi-structured interviews explored implementation determinants across QIF phases.

Statistical analysis performed: For surveys, we conducted descriptive statistics and Poisson logistic regression (adjusted for district clustering, stratification, weighting). Interview data were analyzed deductively using 4 QIF phases: (1) preparing for implementation; (2) creating implementation structure; (3) maintaining structure throughout implementation; (4) assessing future needs. Data were integrated through narrative weaving.

Results: For implementation strategies: 60% percent of survey respondents had "a wellness champion", 59% had a "school-level policy representative", and 37% had an "implementation team." For QIF phase 1, schools with better wellness climates had higher odds of having an implementation team (OR=1.18; CI [1.09,1.29]; p<0.001). In Phase 2, we identified key attributes (e.g., intrinsic motivation) and recruitment strategies for wellness teams/champions, and described facilitators of (e.g., external partners) and threats to (e.g., staff resistance) quality implementation. In Phases 3-4, monitoring approaches differed by implementation strategy (e.g., 74% of policy representatives tracked goals compared to 43% of teams) and limited future action planning (e.g., 25% integrated wellness goals into school improvement plans).

Conclusions: Findings identify how LWP implementation strategies form and are sustained, and identify gap areas across implementation phases. Findings inform tailored support for urban and rural schools to initiate and carry out evidence-informed LWP implementation strategies.