Schools for Health in Europe (SHE) has published a qualitative report on the barriers and facilitators to implementing a school health promotion approach in five countries. The barriers include:  Lack of understanding
about the approach, teachers having a limited focus on HP in their teaching, difficulties in the organization of the school, a lack of time from partners and limited support and involvement from government. The facilitators were the opposites of the barriers, including sufficient priority setting, support from teachers & principal, a focus on school as a healthy workplace, support from the community and support from government. The authors suggest that the implications/recommendations include:

• conducting a context-specific analysis of the barriers and facilitators in each country
• creating sufficient time and local support for schools
• improving regional and national coordination and knowledge exchange 
• creating a healthy workplace for school staff
• creating awareness that HP can be part of every lesson
• promoting the inclusion of HP as a basic element in teachers’ education 
•  promoting the explicit integration of HP as a core subject in the national curriculum 
• cooperating at a national level with a research institute and the education inspection body
• acting on the potential benefits of the Covid pandemic (increased concern for health) while addressing the problems created 

ISHN Comment. This extract from the larger study conducted by SHE researchers is a welcome addition to out growing understanding of implementation issues. Readers are encouraged to review our summary on better practices in implementing, maintaining, scaling up and sustaining (IMSS) approaches and programs. As well, we are pleased to note that the SHE recommendations are addressed in our global Fact-Finding Survey being conducted this Winter and Spring.
Read more about the SHE report ..... 

An July 2019 article in BMC Public Health underlines the need for greater clarity when we discuss scaling up programs as opposed to more effective ways to implement an effective program. "The implementation of interventions at-scale is required to maximise population health benefits. ‘Physical Activity 4 Everyone (PA4E1)’ was a multi-component school-based program targeting adolescents attending secondary schools in low socio-economic areas.An efficacy trial of the intervention demonstrated an increase in students’ mean minutes of moderate-to-vigorous physical activity (MVPA) per day and lower weight gain at low incremental cost.This study aims to assess the effectiveness and cost effectiveness of a multi-component implementation support intervention to improve implementation, at-scale, of the evidence based school physical activity (PA) practices of the PA4E1 program. Impact on student PA levels and adiposity will also be assessed, in addition to the cost of implementation." A cluster randomised controlled trial, utilising an effectiveness-implementation hybrid design, will be conducted in up to 76 secondary schools located in lower socio-economic areas across four health districts in New South Wales (NSW), Australia.Schools will be randomly allocated to a usual practice control arm or a multi-component implementation support intervention to embed the seven school PA practices of the PA4E1 program. The implementation support intervention incorporates seven strategies including executive support, in-School Champion, teacher training, resources, prompts, audit and feedback and access to an external Support Officer. The primary trial outcome will be the proportion of schools meeting at least four of the seven physical activity practices of the program, assessed via surveys with Head Physical Education teachers at 12 and 24-months. Secondary outcomes will be assessed via a nested evaluation of student PA and adiposity at 12-months (Grade 8 students) and 24 months (Grade 9 students) undertaken in 30 schools (15 per group)" . ISHN Commentary: This promises to be an excellent study but will it measure the effect and cost effect of an implementation strategy as opposed to different methods for scaling up the multi-intervention program to other schools or other regions? Read more....

(An item from the ISHN Member information service)  University-school district partnerships in the implementation of comprehensive school health programs proved to be effective in Taiwan. An article in Issue #4, 2015 of Health Education Research examined whether expanding the support for this initiative was effective in advancing HPS implementation, perceived HPS impact and perceived HPS efficacy. "In 2011, the Taiwan government expanded its support of school–district/university partnership programs that promote the implementation of the evidenced-based Health Promoting Schools (HPS) program. In 2011 and 2013, a total of 647 and 1195 schools, respectively, complemented the questionnaire. Univariate analysis results indicated that the HPS implementation levels for six components were significantly increased from 2011 to 2013. These components included school health policies, physical environment, social environment, teaching activities and school–community relationships. Participant teachers also reported significantly greater levels of perceived HPS impact and HPS efficacy after the expansion of support for school–district/university partnership programs. Multivariate analysis results indicated that after controlling for school level, HPS funding and HPS action research approach variables, the expansion had a positive impact on increasing the levels of HPS implementation, perceived HPS impact and perceived HPS efficacy." Read more>>

(An item from the ISHN Member information service)  The implementation, scaling up, maintenance and sustainability of individual programs as well as multi-intervention approaches such as comprehensive school health promotion requires new frameworks and better ways to understand the complex interactions at multiple levels in several systems. An article in Issue #5, 2015 of Prevention Science helps us toward that goal, as it describes the implementation and sustainability of a Social-Emotional Learning program in four schools in Wales. "his paper draws upon Rogers (2003) Diffusion of Innovations Theory to explain the adoption, implementation and discontinuance of a SEL intervention. A pragmatic, formative process evaluation was conducted in alignment with phase 1 of the UK Medical Research Council’s framework for Developing and Evaluating Complex Interventions. Employing case-study methodology, qualitative data were generated with four socio-economically and academically contrasting secondary schools in Wales implementing the Student Assistance Programme. Semi-structured interviews were conducted with 15 programme stakeholders. Data suggested that variation in implementation activity could be largely attributed to four key intervention reinvention points, which contributed to the transformation of the programme as it interacted with contextual features and individual needs. These reinvention points comprise the following: intervention training, which captures the process through which adopters acquire knowledge about a programme and delivery expertise; intervention assessment, which reflects adopters’ evaluation of an intervention in relation to contextual needs; intervention clarification, which comprises the cascading of knowledge through an organisation in order to secure support in delivery; and intervention responsibility, which refers to the process of assigning accountability for sustainable delivery." Read more>>

(An item from the ISHN Member information service)  An article in Volume 76, 2015 of Preventive Medicine reports on a review of studies using the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate physical activity interventions aimed at youth. "A systematic search for controlled interventions conducted within the last ten years identified 50 studies that met the selection criteria. Based on Reach, Efficacy/Effectiveness, Adoption, Implementation and Maintenance criteria, most of these studies focused on statistically significant findings and internal validity rather than on issues of external validity. Due to this lack of information, it is difficult to determine whether or not reportedly successful interventions are feasible and sustainable in an uncontrolled, real-world setting. Areas requiring further research include costs associated with recruitment and implementation, adoption rate, and representativeness of participants and settings. This review adds data to support recommendations that interventions promoting physical activity in youth should include assessment of adoption and implementation issues". Read more>>

(An item from the ISHN Member information service)  A traditional approach to evaluating the effectiveness of school health promotion programs was used in a small scale study reported in Issue #4, 2015 of Health Promotion Practice. The authors report that "SH interventions are evidence based and integrated into the curriculum, while embedded in complementary healthy school policies and environment. This study evaluates the effects of such an intervention on Dutch high schools. Methods. Two Dutch high schools and two controls were followed to evaluate the intervention’s effects on health behaviors, body mass index, and psychosocial problems after 1 year (N = 969) and 2 years (N = 605). Outcomes were measured via self-report surveys and analyzed with mixed methods regression analyses. To complement information on intervention effects, structured interviews were held with a representative sample of teachers per intervention school to map their respective whole school approach implementation success. Results. After 2 years, one intervention school showed significant improvements: Body mass index and excessive screen time use were reduced. In the other intervention school, priority targets did not improve. These findings reflected their respective success in intervention implementation, for example, differences in intervention integration and tailoring." The challenges associated with this type of study, beyond the short term measurement of behavioural effects, is that we are no informed about why implementation worked in one school but not the other. Read more>>

(An item from the ISHN Member information service)  A special issue (Issue 2-3, 2015) of Journal of Educational and Psychological Consultation examines the use of school psychologists as systems-level consultants as a strategy to deal with the complexities of the multi-level changes required to introduce and sustain comprehensive approaches to school mental health promotion. An interdisciplinary perspective is used to select the articles which cover topics such as Interdisciplinary Collaboration Supporting Social-Emotional Learning, Ecologically Based Organizational Consultations, the Competencies for Systems-Level Consultants, Multi-Tiered Systems of Support, Collaboration Between School Psychologists and Administrators and Critical Features and Lessons Learned for Implementation. Read more>> Readers may also be interested in a similar ISHN description of a systems-based approach to SMH that is based on capacity and capacity-building at this web page.

(An item from the ISHN Member information service) ISHN has been critical of the "training then hoping" strategies that are often the default option for improving practice and introducing new health and social programs in schools. This blog article pulls together three recent articles on how health professionals use knowledge (or not) when modifying their practice. The first article, published in the May 2015 Issue of the International Journal for Equity & Health,  "was to identify existing knowledge to action models or frameworks and critically examine their utility for promoting or supporting health equity. Forty-eight knowledge to action models or frameworks were identified. All of the models were then assessed across six characteristics relevant for supporting health equity. While no models scored full marks, the highest scoring models were found to have features relevant to advancing health equity. In the assessment, we propose six characteristics that could be important markers: 1) an explicit mention of equity, justice or similar concept; 2) the involvement of various stakeholders; 3) an explicit focus on engagement across multiple sectors or disciplines; 4) the use of an inclusive conceptualization of knowledge; 5) the recognition of the importance of contextual factors; and, 6) a proactive or problem-solving focus. Specific populations, topics and solutions are marginalized, ignored, or not acted upon when, for example, only certain knowledge is considered valuable, when we don’t have a specific focus on equity or justice, and when we don’t work across sectors or consider contextual determinants of health." The authors concluded that "Each could be strengthened in some way to make them more useful in supporting health equity by considering the six characteristics used in this review. Of particular interest is knowledge brokering as well as the use of holistic and cross-sector models of knowledge to action that consider environmental and contextual determinants. These are specific future avenues identified in this project." In other words, using "knowledge to action" frameworks, even if they are adapted to suit equity purposes, was not sufficient to improve efforts related to equity.
The second article, published in Issue #1, 2015 of Health Technology Assessment, was to identify the impacts and likely impacts on health care, patient outcomes and value for money of Cochrane Reviews published by 20 NIHR-funded CRGs during the years 2007–11. The authors note that "we found 40 examples where reviews appeared to have influenced primary research and reviews had contributed to the creation of new knowledge and stimulated debate. Twenty-seven of the 60 reviews had 100 or more citations in Google Scholar™ (Google, CA, USA). Overall, 483 systematic reviews had been cited in 247 sets of guidance. This included 62 sets of international guidance, 175 sets of national guidance (87 from the UK) and 10 examples of local guidance. Evidence from the interviews suggested that Cochrane Reviews often play an instrumental role in informing guidance, although reviews being a poor fit with guideline scope or methods, reviews being out of date and a lack of communication between CRGs and GDs were barriers to their use. Cochrane Reviews appeared to have led to a number of benefits to the health service including safer or more appropriate use of medication or other health technologies or the identification of new effective drugs or treatments. However, whether or not these changes were directly as a result of the Cochrane Review and not the result of subsequent clinical guidance was difficult to judge." The authors of this second article concluded that " The clearest impacts of Cochrane Reviews are on research targeting and health-care policy, with less evidence of a direct impact on clinical practice and the organisation and delivery of NHS services". In other words, systematic reviews and possibly even the practice guidelines that try to use such Cochrane Reviews as their basis, may or may not affect practice.
The third article, published in the April 2015 Issue of the Cochrane Database of Systematic Reviews, examined "whether tailored intervention strategies are effective in improving professional practice and healthcare outcomes. We compared interventions tailored to address the identified determinants of practice with either no intervention or interventions not tailored to the determinants...Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers, obstacles, or factors (which we collectively refer to as determinants of practice). Change may be more likely if implementation strategies are specifically chosen to address these determinants." The authors conclude that "The findings continue to indicate that tailored interventions can change professional practice, although they are not always effective and, when they are, the effect is small to moderate. There is insufficient evidence on the most effective approaches to tailoring, including how determinants should be identified, how decisions should be made on which determinants are most important to address, and how interventions should be selected to account for the important determinants. In addition, there is no evidence about the cost-effectiveness of tailored interventions compared to other interventions to change professional practice."
Our take away from these three and other studies we have been reading is that knowledge about better practices or better programs is insufficient to implement or sustain improvements in professional or organizational practices. The answers lie within the organizational or community context, likely based on their current core mandates, perceived and real constraints, traditions and routines and current system-level and adopter concerns at various levels. In other words, we may need to make a significant shift away from "evidence-based practice" towards auch better understanding of "practice-based experience".  

(From the ISHN Member information service)  As we learn more about the sustainability of multi-intervention approaches and programs, we are seeing the development of various techniques to measure and monitor such sustainability. An article in Issue #2, 2014 of School Psychology Quarterly reports o the development of "the School-Wide Universal Behavior Sustainability Index: School Teams (SUBSIST; McIntosh, Doolittle, Vincent, Horner, & Ervin, 2009) a measure of school and district contextual factors that promote the sustainability of school practices, demonstrated measurement invariance across groups of schools that differed in length of time implementing school-wide Positive Behavioral Interventions and Supports (PBIS; Sugai & Horner, 2009), student ethnic composition, and student socioeconomic status (SES). School PBIS team members and district coaches representing 860 schools in 14 U.S. states completed the SUBSIST. Findings supported strong measurement invariance, for all items except 1, of a model with two school-level factors (School Priority and Team Use of Data) and 2 district-level factors (District Priority and Capacity Building) across groups of schools at initial implementation, institutionalization, and sustainability phases of PBIS implementation. Schools in the sustainability phase were rated significantly higher on School Priority and Team Use of Data than schools in initial implementation." Read more>>

(From the ISHN Member information service) An article in the June 21, 2014 issue of The Lancet calls for systems thinking from governments and Un agencies when they decide on the set of goals to replace the existing MDG goals. The authors assert that "Global priorities have progressed from the Millennium Development Goals (MDG) that will expire in 2015 to global sustainable development. Although there is not yet a consensus on the specific goals for the post-MDG era, the post-2015 investment agenda for health will probably emphasise social determinants of health, sustainable development, non-communicable diseases, health systems strengthening, universal health coverage, the health of women and children, and ageing."  They then go on to make the case for "systems thinking". " The MDGs were undoubtedly successful in focusing international donor financing and domestic investments to achieve the targets set in these goals. Yet, undue emphasis on financing narrow disease programmes used to achieve disease-specific targets in the MDGs often missed opportunities to effectively strengthen health systems.1 Consequently, several low-income countries with weak health systems have struggled to reach the targets set in health-related MDGs and will not achieve them by 2015.2 An important lesson from the MDGs is that current and emerging global health challenges require action that embraces interdisciplinary and intersectoral approaches to development,3 which acknowledge the path-dependence and context-dependence of implementation." 
A table in the article underlines the differences between "selective approaches" (linear thinking) focused on preventing specific problems and "systems thinking" In linear thinking, the program is developed from a blueprint, developed by trials in controlled circumstances, that are top-down in nature, often without considering local contexts or potential unintended consequences. In systems-based approaches, learning and context drive the action and selection of issues to be addressed as well as the programs. In linear thinking, the programs target disease-specific, quick-wins. Planners develop a specific program for a specific population and assess its ability to produce specific short-term outcomes. In systems-based approaches, the action is across various sectors, with key stakeholders involved from the beginning to develop and implement approaches across the relevant sectors. In selective thinking, there is a reliance on isolated, quantitative measures. Single snap shot data points are used by specialized experts to assess if the programs are meeting their objectives. In systems thinking, multiple interative measurements and synthesis as well as relationships are used to assess progress. Longitudinal, real-world data from multiple qualitative and quantitative sources are used to monitor relevant effects.  Read more>>      

(From the ISHN Member information service)     An article in Issue #3, 2014 of Health Promotion Practice illustrates the challenges of working in loosely-coupled education and health systems. This Canadian study examined policy documents on school nutrition and education in Canada at the federal, provincial and regional or local authority levels. The researchers note that "Results reveal distinct differences across federal, provincial, and regional levels. The availability of nutritious food in schools and having nutrition education as part of the curriculum were key components of the physical environment across federal and provincial levels. Federal and provincial priorities are guided by a health promotion framework and adopting a partnership approach to policy implementation. Gaps in regional-level policy include incorporating nutrition education in the curriculum and making the link between nutrition and obesity."  Read more>>

(An item from the ISHN Member information service) The research supporting multi-intervention approaches and programs in school health promotion is abundant and long standing. Recent research is underlining the need for long-term, systemic planning and investments in capacity-building in areas such as coordination, work force development, inter-agency agreements, coordinated policy development and joint issue management. However, experience in the real world suggests that local health authorities (LHA) do not follow that research and instead, constantly try to implement short-term, project-style interventions based on a "training, then hoping" strategy. Four articles in Issue #6, 2013 of American Journal of Preventive Medicine examine evidence-based decision-making in LHA's and provide clues for this cognitive dissonance.  One article examines the factors that affect evidence-based decision-making (EBDM) and found that "Although most people understood the concept, a relatively small number had substantial expertise and experience with its practice. Many indicated that they applied EBDM unevenly. Factors associated with use of EBDM included strong leadership; workforce capacity (number and skills); resources; funding and program mandates; political support; and access to data and program models suitable to community conditions." A second article found that "Local decision-making authority was perceived as greatly restricted by what public health activities were legally mandated and the categoric nature of funding sources, even as some leaders exercised deliberate strategic approaches. One’s workforce and board of health were also influential in making decisions regarding resource allocations. Programmatic mandates, funding restrictions, local stakeholders, and workforce capacity appear to trump factors such as research evidence and perceived community need in public health resource allocation." A third article suggested that LHA participation in a "Practice-based Research Network" will help in the implementation of research. A fourth article introduced the idea that LHA's could make use of local taxation revenue.  Read More>> 

(An item from the ISHN Member information service) "Going beyond training and hoping" is a colourful way to describe the paradigm shift now underway in research, practice and policy-making in school health promotion and social development. The words in the titles of the articles the October 2013 Issue of implementation Science are indicative of the new concepts that must be among the new, fundamentally different way that we approach our work and careers in the future. Although these concepts are applied to non-school settings and practices, their resonance should be self-evident. They include: transfer and implementation, scale-up, spread, and sustainability, making change last, leadership in complex networks, multifaceted, multilevel continuous quality improvement programs, dynamic sustainability frameworks and Social network diagnostics. Read more>>