Barriers and facilitators to the nationwide dissemination of the Dutch school-based obesity prevention programme DOiT

Abstract

Background: This article describes the barriers and facilitating factors to the adoption, implementation and continuation of the Dutch Obesity Intervention in Teenagers (DOiT) programme in the Netherlands. Methods: We evaluated the adoption, implementation and continuation of the programme at 20 voluntary prevocational schools, which adopted the programme. Interviews were conducted with DOiT coordinators and/or teachers ( n = 44) at the end of the first and second school year of the 2-year implementation period. Interviews were recorded and transcribed verbatim. Data were coded by two researchers independently. Identified barriers and facilitating factors were categorized into four groups: (i) organizational factors, (ii) individual factors, (iii) characteristics of the programme and (iv) characteristics of the implementation strategy. Results: Teachers and DOiT coordinators identified various implementation barriers (e.g. lack of planning, other urgent unforeseen priorities, no plan to cope with teacher turnover and high teacher workload) as well as facilitating factors (e.g. involvement of DOiT coordinator and support from the DOiT office, sufficient communication and collaboration between teachers, strong teacher motivation and flexibility of the programme). Conclusion: Overall, DOiT implementers were satisfied with the compatibility, layout, content and potential for tailoring the programme. Barriers for successful implementation were mainly at the school and teacher level. Findings of this study can be used for further improvement of the DOiT programme and for the development and improvement of other health promotion programmes in the school setting.

Introduction

Schools are regarded as an ideal setting to implement obesity prevention programmes, as they have access to almost all children regardless of their ethnic or socio-demographic background. ¹ Although the number of evidence-based prevention programmes in the school setting has increased in the last 20 years, ^2–5 few studies have examined factors that impede or facilitate the implementation of school-based obesity prevention programmes. ^6,7 Insight into these enhancing and undermining factors could explain why programmes’ effects were disappointing or absent and could improve dissemination and subsequent programmes implementation.

The Dutch Obesity Intervention in Teenagers (DOiT) programme is an example of a nationwide school-based obesity prevention programme in the Netherlands. DOiT targets both sides of the energy-balance equation (energy intake and energy expenditure) in order to prevent overweight and obesity in youth. DOiT consists of 12 fixed theory lessons and 4 physical education lessons (i.e. 16 lessons equally divided over 2 school years) and 3 optional lessons. To facilitate the implementation process, the programme is supported by a seven-step implementation strategy with accompanying materials to teachers on the DOiT website. ^8,9

The initial DOiT programme showed promising effects on adiposity measures and energy balance-related behaviours (EBRBs) during an RCT evaluation. ^10,11 Subsequently, the programme effectiveness was evaluated during nationwide dissemination. The programme was disseminated without strong support from a research team and, therefore, followed the natural course of adoption, implementation and maintenance. ¹² During this nationwide dissemination, the programme showed only modest effects on behaviour and no effects on adiposity measures. ¹³

Therefore, insight into factors that either facilitated or hampered dissemination is required to understand why the effects observed during the RCT were not translated into real world contexts. To answer this question, we assessed the facilitating factors and barriers to the adoption, implementation and continuation of DOiT throughout the Netherlands. Based on the results, we formulated recommendations to optimize, encourage and enhance successful implementation of DOiT and improve its effectiveness.

Methods

Intervention and implementation strategy

DOiT is a school-based obesity prevention programme for 12- to 14-year-olds, developed according to the Intervention Mapping protocol, as described in detail elsewhere. ^8,9,14 The aim of DOiT is to prevent overweight and obesity in adolescents by improving their EBRBs. The initial programme was developed and evaluated in 2002–2006. Based on the accompanying process evaluation and additional interviews with teachers, adolescents and parents in 2009, the required adaptations were made to the DOiT programme. ⁹

The adapted programme consisted of 12 fixed theory lessons and 4 physical education lessons equally divided over 2 school years, three optional lessons and a parental component. The lessons in the first year aimed at increasing awareness and knowledge of EBRBs and facilitation of healthy EBRBs. The lessons in the second year focussed on increasing awareness and acting upon the influence of the (obesogenic) environment. The parental component focussed on increasing social support of the parents and on raising awareness of the availability and accessibility of healthy products and activities in the home environment. The DOiT materials included a ‘schoolbook’ accompanied by worksheets, a student toolkit (pedometer, food/exercise diary and online computer-tailored advice) and a parental information booklet. We developed two different versions of the programme, tailored to the two higher and two lower levels of the prevocational education system in the Netherlands. ¹⁵

To facilitate the implementation process, we developed a seven-step implementation strategy to guide teachers through the implementation process ( Table 1 ). Furthermore, DOiT was supported by an extensive teacher manual with a login for extra materials provided at the DOiT website. Appointing a DOiT coordinator was mandatory. The task of this coordinator was to support overall implementation within the school. Further, we used a personal approach by organising a ‘DOiT support office’. The contact person in this support office was available on demand for support and advice for implementers throughout the school year. The development and content of the DOiT programme is described in detail elsewhere. ^8,9

Table 1

Implementation strategy and materials for implementation of DOiT by teachers

Implementation strategy	Accompanying materials
Adoption
Step 1. Teacher reviews the DOiT programme Teachers familiarize themselves with the DOiT materials and implementation strategy. Teachers become familiar with the relative advantage and characteristics of the programme, such as information about the programme goal, materials, its flexibility and compatibility. Additional information is available on the DOiT website (e.g. stories of schools who have successfully implemented the programme and a map of the Netherlands showing schools that are currently implementing DOiT). Teachers can read about DOiT and try the DOiT materials in order to ensure that the programme is compatible with their teaching preferences.	DOiT factsheet, brochure and exemplary teaching materials
Step 2. Teacher identifies barriers for implementation, identifies solutions and gains support within the school Teachers mainly need commitment of their colleagues and management to start with DOiT. Teachers can use supporting materials that are available on the DOiT website, such as a prefab presentation, to inform relevant stakeholders within their school. Teachers need to identify barriers for implementation and find solutions. Teachers can contact the DOiT office for assistance in finding solutions to resolve their concerns.	Example presentation for colleagues and school management
Implementation
Step 3. Teacher decides to work with DOiT and develops a tailored plan for implementation During the implementation stage, teachers develop a plan for implementation. The website provides teachers with a checklist: assuring that they execute all preparatory activities.
Step 4. Teacher becomes familiar with the implementation of the programme by completing the training Teachers need to order the DOiT materials, inform colleagues and write a project plan. The key component to familiarize with the implementation of DOiT is participation in the 5-min online instruction video. The video explains the rationale of the program, shows the materials, explains how the programme should be implemented and provides practical advice. In addition, the video makes reference to the teacher manual, which provides extensive information for each lesson.	Implementation plan: a checklist Example email to inform colleagues about the start of DOiT Example time line for implementation Instruction video Teacher manual
Step 5. Teacher delivers the programme Teachers can organize a kick-off meeting for the whole school and also inviting parents. At this meeting, the school informs parents about DOiT and the importance of parental participation within the programme. In order to gain media attention, schools can send a press release, for which a template is freely available on the DOiT website. After this meeting, teachers start implementing the lessons supported by the teacher manual with a login for extra materials on the DOiT website.	Example presentation for parents Template of press release Teacher manual
Continuation
Step 6. Teacher concludes and evaluates the programme Teachers conclude the implementation of DOiT. The lessons of year one are concluded by a quiz. The second year can optionally be concluded by the organization of a parental meeting. During this meeting, students present what they have learned from DOiT, stimulating an interactive meeting. The website provides teachers with a manual for the parent meeting.	Teacher manual Manual for parent meeting
Step 7. Teacher defines impeding and facilitating factors for implementation and creates a renewed plan for implementation and embedding of DOiT It is recommended that teachers organize an evaluation and continuation meeting. Teachers define impeding and facilitating factors for implementation of DOiT at their school and create a renewed plan for continuation. This plan stimulates embedding DOiT into the regular curriculum. The website provides a guideline for evaluation.	Evaluation form Advice for continuation

Recruitment

Since August 2011, the DOiT programme was available to all schools in the Netherlands as a voluntary add-on to the mandatory curriculum. The DOiT support office employee actively recruited schools by activities such as posting news items on relevant websites, or in digital mailings and by being present at local meetings of relevant stakeholders. Additionally, a DOiT introductory package was sent to potential prevocational schools. ⁹

After ordering the DOiT materials (i.e. 7 € per student for the 2-year programme), the school was invited to participate in this study. A convenience sample of 20 schools volunteered to participate in the study. ¹² Each school was asked to appoint a contact person (‘DOiT coordinator’) for communication with both teachers and the DOiT office. ⁹

Theoretical framework

Using the innovation framework developed by Fleuren et al. ¹⁶ , we adapted the five categories of impeding and facilitating determinants to the school setting: (i) contextual factors, such as the extent to which a programme fits the existing school health policy, (ii) organizational factors, such as the decision-making process in the school, available time and budget, (iii) individual factors, such as teachers’ knowledge, skills, self-efficacy and intention to implement the programme, (iv) programme characteristics, such as compatibility and flexibility of the programme and (v) implementation strategy characteristics, such as programme training, feedback on implementation and implementation materials. Gaining insight into adoption, implementation and continuation may explain the transition of implementers from ‘non-use’ to ‘sufficient use’ through stages of innovation. ¹⁶

Data collection

The study was an observational study using semi-structured in-depth interviews to evaluate the dissemination process of DOiT at 20 prevocational education schools in the Netherlands. All other qualitative data collected or observed systematically during the study was also considered as data. ^17,18 This means that not only information from in-depth interviews with teachers and coordinators, but also all data reported during phone calls or observed during school visits was included in the analysis. The Medical Ethical Committee of the VU University Medical Center approved the study protocol. Details of the Aims, Design and Methods have been published elsewhere. ¹²

Semi-structured interviews

A semi-structured interview questioning route was used to identify the barriers and facilitators related to the dissemination of the DOiT programme experienced by teachers and DOiT coordinators at the implementing schools. At the end of each school year (around May 2012 and 2013), we invited all teachers and/or the DOiT coordinator for an in-depth interview. During these two time periods, we attempted to gain insight into facilitators and barriers for implementation, intentions and opportunities for future implementation of DOiT. Examples of interview questions were: ‘To what extent was there support within the school to initiate DOiT?’, ‘How were the methods and materials perceived?’, ‘What is the future of DOiT within the school?’ and ‘Which factors impeded or facilitated adoption, implementation and continuation of the DOiT programme at your school?’. The principal researcher led the interviews FvN (Femke van Nassau) and if necessary asked clarifying questions. A research assistant took notes and all interviews were recorded digitally.

Data analyses

Each digital interview was transcribed verbatim. Two researchers (FvN and DB (Doris Broekhuizen)) independently coded all transcripts and other data obtained during phone calls or school visits. The codes were grouped into similar concepts in order to make them more workable. Possible barriers and facilitating factors were ordered into a matrix ¹⁷ and categorized by the framework of Fleuren et al. ¹⁶ The two researchers discussed differences and agreed upon final presentation of the emerging themes. The experienced barriers and facilitators are illustrated by quotations in the ‘Results’ section. These quotations were derived from the conducted interviews and were translated into English.

Results

In total, we conducted 44 interviews with teachers and/or DOiT coordinators at the 20 implementing schools. The interviews were held with (i) the DOiT coordinator only ( n = 17), (ii) the DOiT coordinator and teachers ( n =20) and (iii) teachers only ( n = 7). The interviews took on average 43 (range 15–108) min.

Facilitators and barriers

Table 2 provides an overview of the main facilitating factors and barriers to the dissemination of the DOiT programme. We present barriers and facilitators that were mentioned by teachers and DOiT coordinators: school factors, teacher factors, programme factors and implementation strategy factors. Teachers and coordinators did not indicate influential factors at the context level.

Table 2

Main facilitating factors and barriers to the nationwide adoption, implementation and continuation of the DOiT programme in the Netherlands, as mentioned by teachers and DOiT coordinators during in the interviews

Adoption	Facilitating factors	Barriers
School factors	Shared decision making; involvement teachers in decision-making process	Top-down decision making, resulting in lack of commitment of teachers
	Involvement and support from local health promotion professionals	Unclear internal communication of decision makers about expected workload for teachers
	Strong commitment of teachers and school management to start with the programme	Lack of feasibility to incorporate the ‘extra’ DOiT programme into the regular curriculum due to overload in school curriculum
	DOiT fits into existing health promotion activities in the school as part of a whole-school health promotion approach
Teacher factors	Strong motivation to start with the programme	Lack of perceived need for using a new programme, due to overlap with the current teaching materials
	Positive attitude towards the rationale of DOiT and its focus on both dietary as well as physical activity behaviour
Programme factors	Feasibility and compatibility of the programme to the regular biology, health and physical education lessons dealing with healthy nutrition and physical activity
	Perceived attractiveness of the layout and connection with the adolescents’ perception
	Perceived importance of obesity prevention in the school, need for programme that addresses both healthy nutrition as well as physical activity behaviour
Implementation strategy factors	Availability of website with a toolkit for implementation
	Face-to-face information meeting with DOiT employee
Implementation
School factors	Strong commitment of teachers and school management to implement the programme	Complexity of collaboration between teachers, different sections and teams
	Clear and short communication between teachers, sections and teams	Large teacher turnover, with lack of solutions to tackle this problem; resulting in lack of transmission of information concerning DOiT
	Clear school-wide plan for implementation	Lack of availability of materials and facilities, such as availability of computers
Teacher factors	Sufficient collaboration between teachers who implement the programme	High teacher workload; lack of time to prepare and implement the DOiT lessons
	High perceived flexibility of the programme; teacher can implement those parts of the programme that suit their teaching preference	Large variation in the amount of time teacher spent on the lessons
	Strong motivation and commitment to work with the programme	Other priorities, such as other urgent unforeseen activities and projects that suppresses the available time for implementation of DOiT
Programme factors	Compatibility of the programme to the regular biology, health education and physical education dealing with healthy nutrition and physical activity	Incorrect indication of time needed for the lessons; teachers often used the lessons as starting point for broader discussion
	Potential for tailoring the lessons with the extra online materials to the educational level and the school facilities	Programme was too complex for the vocational education level
	Satisfaction with layout and content of the materials	Lack of practical applications during the execution of the lessons
	Extensive teacher manual to support implementation	Lack of incentives for adolescents; resulting in unmotivated adolescents
	Perceived enthusiasm of adolescents	Difficulties to involve parents in programme
	Multidisciplinary character of DOiT increased collaboration between biology, health and physical education teachers	Unbundled workbook, difficulties in copying the separate worksheets
Implementation strategy factors	Overall coordination of DOiT coordinator who is highly motivated, makes a plan, distributes the materials and keeps DOiT alive in the school	DOiT coordinator who is not implementing the programme themselves
		Changes in planning for implementation
	Sufficient support from the DOiT office team
	Informative and sufficient website
Continuation
School factors	Strong commitment of teachers and school management to continue with the programme	Lack of evaluation amongst teachers, resulting in no decision making about continuation
	Available financial resources; either school budget or external funding, such as municipal grants	Shortage of financial resources
	Perceived initial implementation as pilot; continued implementation builds on lessons learned	Complexity of constant changes in the school setting, such as teacher turnover, student turnover, and replacement of DOiT in other subject, making a 2-year programme planning difficult
	High perceived fit of DOiT into existing health promotion activities in the school as part of a whole-school health promotion approach	Overload in curriculum, schools prioritize other health promotion activities then obesity prevention
Teacher factors	Strong motivation to work with the programme	High teacher workload
Programme factors	Continued implementation of perceived successful elements of the programme.	DOiT perceived as project that stops after two years
	Materials were collected and stored in schools, so that teachers could re-use them next year and continue without any extra costs	Overlap with regular teaching materials, DOiT perceived as non-complementary
		Lack of continuation due to loss of materials
Implementation strategy factors		Lack of strategy for how to continue with DOiT

School factors

In all phases, teachers expressed that the commitment of teachers and school management was a facilitator. Communication between teachers who implemented the programme was perceived as another important facilitator for implementation. A hampering factor was that schools only plan their curriculum for 1 school year. As the DOiT programme was divided over 2 schools years, this required 2-year planning. Our results indicated that the complexity of constant changes in the school setting such as teacher turnover, student turnover, and replacement of DOiT by other subjects, complicated a 2-year programme planning.

Teacher: ‘The problem is that you can’t plan two years ahead. Planning a year in advance works just fine, you can say “Okay, here are the classes, we’ve got this number of students, this number of teachers, who’s going to lead the programme?”. But you just can't do that two years in advance; schools are continuously changing, so you can’t plan that far ahead.’

Involvement and support from local health promotion professionals (i.e. intermediaries at municipalities, municipal health services or sport organizations) was perceived as a facilitator to programme implementation. These health promotion professionals can support schools and provide financial resources to adopt and continue to work with DOiT. Continued implementation after 1 year often depended on the flexibility in the curriculum and the persistence of the DOiT coordinator. Finally, lack of financial resources impeded continuation with the programme.

Teacher factors

Teachers considered overweight and obesity as an important health problem. Furthermore, they regarded the DOiT programme, with its focus on dietary as well as physical activity behaviour, as a feasible school intervention programme. In general, there was strong motivation to start with DOiT among teachers. There was a large variation in the amount of time teachers had spent on the DOiT lessons. Teachers perceived the flexibility of the programme as a facilitating factor.

Teacher: ‘For me, that’s the added value of DOiT: you can pick and choose the elements you want.’

The opportunity to tailor the programme to their teaching preferences and available teaching time was much appreciated, but also meant extra efforts and preparation. At the start of the school year, teachers had the intention to implement the programme, but during the school year the available time for implementation of DOiT was often reduced, due to cancelation of classes and other urgent unforeseen priorities, such as other activities and projects.

DOiT coordinator: 'You've got a lot of different things all going on at the same time, so it's a real organizational challenge to get certain things off the ground.'

Programme factors

Overall, teachers were satisfied with the layout and content of the DOiT programme and intended to continue or use programme elements in the future. Furthermore, the extensive teacher manual was regarded as a workable manual for programme implementation. However, the programme was regarded as too complicated for the lower vocational education level. Teachers reported that the teaching materials would benefit from the inclusion of more practical applications, such as online videos. Although teachers found it important to involve parents in the programme, in practice parental involvement appeared difficult.

DOiT coordinator: 'You see relatively little; I think that needs to happen at home. But because you've already got so much on your plate it's difficult to find time for this. In my view, parents are the ones who are best positioned to influence their children and make this a success.'

Implementation strategy factors

Lack of planning was experienced as hampering implementation and continuation of the programme.

Teachers regarded the DOiT coordinator as the most critical component for school-wide implementation. Facilitating tasks of the coordinator were responsibility for overall coordination, planning of programme, distribution of materials and keeping the enthusiasm towards DOiT alive.

Teacher: 'Keeping DOiT alive and sending us reminder mails, that really worked for us.'

Besides support from the DOiT coordinator, support from the DOiT office employee was also regarded as a facilitating factor for successful adoption and continuation. Teachers were satisfied with the DOiT website and supporting implementation materials.

Discussion

Because schools are an ideal setting for implementation of childhood obesity prevention programmes, this study explored factors that may facilitate or hinder the adoption, implementation and continuation of such programmes in the school setting. We found various important implementation barriers (e.g. lack of planning, other urgent unforeseen priorities, no plan to cope with teacher turnover and high teacher workload) as well as facilitating factors (e.g. involvement of DOiT coordinator and support from the DOiT office, sufficient communication and collaboration between teachers, strong teacher motivation and flexibility of the programme). These insights from schools implementing the DOiT programme echo themes that have been highlighted in previous studies that evaluated barriers and facilitators in the school setting. ^6,7,19,20

Given that teachers were overall satisfied with the compatibility, layout, content and potential for tailoring the programme, programme factors seem less impeding for the delivery of the DOiT programme. Rather, barriers for successful implementation appeared to be at the school and teacher level, such as complexity of the school setting and teacher turnover. The strongest barriers to sustained implementation of the programme were the complexity of constant changes in the school setting such as other urgent unforeseen priorities, high workload and lack of communication and collaboration between teachers. Furthermore, large teacher turnover was perceived as a problem for implementation and sustainability—as was expected from extant literature. ^16,21,22 We extended and spread the initial programme over 2 school years to account for the fact that effects dissipated once the programme stopped. ¹¹ In practice, it seemed difficult to plan a 2-year programme, due to constant changes in the school setting. Schools that successfully overcame such barriers had more flexibility in the curricula, strongly motivated and committed teachers and a devoted DOiT coordinator, in comparison to their unsuccessful counterparts.

In contrast with previous studies, financial and school management support were not perceived as main barriers. Financial support is often mentioned as a major barrier to the adoption of a programme in other studies. ^19,23,24 This was not the case in our study. Possible explanations expressed by coordinators are that the DOiT programme and materials were offered at a relatively low cost and that schools often had sufficient budget (such as general school budget, the school sports budget or external municipal funding) for health promotion projects like DOiT. Further, the website, with additional materials such as the implementation strategy, was freely accessible to all school in the Netherlands. Although some schools mentioned that lack of financial resources was a barrier for continuation, this was not the case for most schools, who planned to re-use the materials or elements of the programme.

School management support and commitment was experienced as an important facilitator. This is in line with previous studies that found good management skills and support for the programme to be beneficial for implementation success. ^20,24 In our study, it appeared that the school management was mainly involved in the DOiT adoption and continuation decision, but they did not interfere with the implementation process; teachers coordinated, planned and organized the DOiT programme. However, commitment was regarded as facilitator throughout all phases.

Strengths and limitations

A major strength of this study is that we examined barriers and facilitating factors that schools experienced during 2 subsequent years of implementation of DOiT. Another strength of this study is that we also conducted interviews with teachers and/or coordinators at schools that stopped implementing DOiT; this gives a rather complete and real-world view. The final strength of this study is that we structured the data according to the theoretical framework of Fleuren et al. ¹⁶ previously used in comparable studies ⁶ , making comparison with other studies possible.

This study also has some limitations. Bias may have occurred because the principal researcher and a research assistant conducted the interviews. Interviewed teachers knew the principal researcher; which may have led to more socially desirable answers. Recall bias may also have emerged, since the interviews were conducted at the end of each school year. Furthermore, analyses of qualitative data rely on the subjective interpretation of researchers. To reduce this bias, two researchers independently analysed all data.

Implications for future implementation of DOiT

Based on the results of this study, we formulated three recommendations at the programme level as well as the support level, to optimise, encourage and enhance successful implementation of the DOiT programme and improve programme effectiveness:

(i) Inclusion of more practical applications during the execution of the lessons, such as online videos or social media usage;

(ii) Stronger involvement of parents. In practice, the parental component was poorly implemented. Since other studies also report difficulties in reaching and involving parents, ^25,26 additional interviews with parents and teachers or participatory research with involvement of parents would be needed to reconsider if a parental component is feasible and what adaptations should be made in order to improve parent participation in DOiT;

(iii) Addition of a face-to-face instruction for coordinators and preferably also teachers instead of only a 5-min instructional video. Earlier studies showed that pre-intervention training is a common method to provide implementers with the required knowledge and skills for implementing a programme. ^22,27 This training can promote understanding of the theoretical and practical principles that underlie the evidence-based programme.

Conclusion

In conclusion, the interviewed teachers and coordinators expressed that lack of planning, urgent unforeseen priorities, inability to cope with high teacher turnover and workload were important barriers for adoption, implementation and continuation of the DOiT programme. In contrast, involvement of a DOiT coordinator and support from the DOiT office, adequate communication and collaboration between teachers, strong teacher motivation and flexibility of the programme were mentioned as facilitators for dissemination of the DOiT programme. Findings of this study can be used for further improvement of the DOiT programme and for the development and improvement of other health promotion programmes in the school setting.

Acknowledgements

We would like to thank all schools and teachers for their participation in the research.

Funding

This study was financially supported by the SNS REAAL Fonds (20109966) and the Dutch Heart Foundation (2010036).

Conflicts of interest : None declared.

Key points

• The interviewed teachers and coordinators expressed that lack of planning, urgent unforeseen priorities, inability to cope with high teacher turnover and workload were important barriers for adoption, implementation and continuation of the Dutch Obesity Intervention in Teenagers (DOiT) programme.

• Involvement of a DOiT coordinator and support from the DOiT office, adequate communication and collaboration between teachers, strong teacher motivation and flexibility of the programme were mentioned as facilitators for dissemination of the DOiT programme.

• Findings of this study can be used for further improvement of the DOiT programme and for the development and improvement of other health promotion programmes in the school setting.