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From policy to practice: implementation of physical activity and food policies inschools

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Abstract

Purpose

Public policies targeting the school setting are increasingly being used toaddress childhood obesity; however, their effectiveness depends on theirimplementation. This study explores the factors which impeded or facilitatedthe implementation of publicly mandated school-based physical activity andnutrition guidelines in the province of British Columbia (BC), Canada.

Methods

Semi-structured interviews were conducted with 50 school informants (17principals - 33 teacher/school informants) to examine the factors associatedwith the implementation of the mandated Daily Physical Activity (DPA) andFood and Beverage Sales in Schools (FBSS) guidelines. Coding used aconstructivist grounded theory approach. The first five transcripts andevery fifth transcript thereafter were coded by two independent coders withdiscrepancies reconciled by a third coder. Data was coded and analysed inthe NVivo 9 software. Concept maps were developed and current theoreticalperspectives were integrated in the later stages of analysis.

Results

The Diffusion of Innovations Model provided an organizing framework topresent emergent themes. With the exception of triability (not relevant inthe context of mandated guidelines/policies), the key attributes of theDiffusion of Innovations Model (relative advantage, compatibility,complexity, and observability) provided a robust framework for understandingthemes associated with implementation of mandated guidelines. Specifically,implementation of the DPA and FBSS guidelines was facilitated by perceptionsthat they: were relatively advantageous compared to status quo; werecompatible with school mandates and teaching philosophies; had observablepositive impacts and impeded when perceived as complex to understand andimplement. In addition, a number of contextual factors includingavailability of resources facilitated implementation.

Conclusions

The enactment of mandated policies/guidelines for schools is considered anessential step in improving physical activity and healthy eating. However,policy makers need to: monitor whether schools are able to implement theguidelines, support schools struggling with implementation, and document theimpact of the guidelines on students’ behaviors. To facilitate theimplementation of mandated guidelines/policies, the Diffusion of InnovationsModel provides an organizational framework for planning interventions.Changing the school environment is a process which cannot be undertakensolely by passive means as we know that such approaches have not resulted inadequate implementation.

Background

Schools provide the best setting to support a population-based approach to improvephysical activity (PA) and healthy eating (HE) for all children regardless of theirethnic or socio-demographic background [1, 2]. School-based public policies are increasingly being used to addresschildhood obesity [2, 3] and emerging evidence supports the effectiveness of such policies onpositively influencing the school environment. For example, school-based physicaleducation (PE) policies have increased the amount of PE offered in schools (i.e.,total minutes or days/week) [4, 5] and school-based nutrition policies have resulted in less access tosugar-sweetened beverages and low nutrient energy dense foods in schools [68]. School-based policies also influence student behaviors. For example suchpolicies have increased PA levels, although one study documented a greater effectfor girls [4, 9]; increased fitness levels [10]; and reduced student consumption of sugar-sweetened beverages in school [1113]. Furthermore, evidence suggests that improvements to both PA and HE willresult in improvements in cognitive functioning and overall academic performance,helping schools meet their academic mandate [1416].

While the emerging evidence suggest school-based policies can positively influencethe school environment and student behaviours, the impact on student body mass index(BMI) is less clear. Some studies have found no association between school-basedpolicies and student BMI [9, 11] while others documented an association [17, 18]. Specifically, students had lower BMIs in states with stricter PE andschool food policies [17] and in states with stronger competitive food policies [18]. The effectiveness of school-based policies against childhood obesitydepends on their implementation, which is often less than optimal even when thesepolicies are publicly mandated [4, 9, 10]. To date, few studies have examined the factors that impede or facilitatethe implementation of school-based obesity prevention policies. Factors found toimpede implementation include: potential loss of school revenues, competingcurriculum demands and priorities, lack of resources (staff, funding, availabilityof programs or teaching resources), lack of coordination, no dedicated funding tosupport the mandate, industry lobbying, and misconceptions about the types of foodand beverages made available at school [5, 1924]. In contrast implementation is enabled when there is support from keypoliticians, parents, physicians and school personnel as well as the provision offinancial support and having data to inform policy decisions enabled implementation [1922].

In Canada, the Constitution Act declares education to be under provincialjurisdiction [25], as a result any guidelines/policies affecting the school system areenacted at the provincial level. The enactment of the Daily PA (DPA) and Food andBeverage Sales in Schools (FBSS) guidelines in the province of British Columbia(BC), Canada represented the province’s first attempt to govern the PA andfood environment of schools. The DPA guidelines set the requirements for dailyphysical activity for students. The FBSS guidelines set out minimum nutritionstandards for food and beverages sold to students. In addition, both policies setout to encourage the development of life-long healthy behaviours.

Prior to the implementation of the DPA guidelines, K to 9 grades in BC were expectedto devote 10% of their instructional time to PE, for grade 10 students PE was andremains a graduation requirement and for grades 11 and 12 it was and remains as anelective course [26]. The new DPA guidelines require schools to offer 30 minutes per dayof PA as part of the grade K-9 educational curriculum. Grade 10-12 students mustdocument and report a minimum of 150 minutes per week of PA, performed at amoderate to vigorous intensity. While some provinces in Canada mandate that PE betaught by a PE specialist, in BC this differs by grade. At the elementary schoollevel PE is primarily taught by classroom teachers. Implementation of the guidelineswas expected by the beginning of the 2008/2009 school year.

Prior to the implementation of the FBSS guideline, schools in BC were not expected tomeet any nutritional guidelines. The FBSS guidelines were designed to maximizestudents’ access to healthier options and fully eliminate the sale ofunhealthy food and beverages in BC schools. The FBSS guidelines mandate schools toadhere to the 2007 Canada’s Food Guide [27] for all food and beverage sold or made available at school. Fullimplementation of the FBSS guidelines were expected by the end of the 2007/2008school year. While elementary schools in BC have fewer permanent food outlets thanin middle/high schools (45% versus 95% of schools have permanent food outlets), lesshealthy food choices were often offered in elementary schools through parents orfundraising efforts (e.g., pizza lunches or hot dog days) [28].

This study explores the factors that impeded or facilitated the implementation ofpublicly mandated school-based PE and nutrition guidelines in the province of BC.Our study provides a unique opportunity to examine the implementation of the FBSSguidelines in a jurisdiction that did not previously have any guidelines or mandatedpolicies to govern the food environment of schools. In addition, it also providesthe opportunity to examine the implementation of a guideline that addresses the PAenvironment in schools while previous research conducted in other jurisdictions hasfocused on the implementation of policies directed at changing the PE environment inschools.

Methods

We examined the factors associated with the implementation of the DPA and FBSSguidelines qualitatively by conducting semi-structured interviews with 50 schoolinformants (17 principals and 33 teacher/school informants). The study protocol wasapproved by the University of British Columbia and the University of VictoriaResearch Ethics Boards and participating school districts.

Sample selection and recruitment

Schools were selected to participate in this study based on responses to a schoolsurvey administered in the 2007-2008 school year. School selection ensuredrepresentation across: self-reported levels of implementation of the guidelines,school types (elementary, middle, and high schools), and school settings (urban,suburban, and rural). Of the 513 schools that completed the 2007-2008 schoolsurvey, a total of 47 schools were invited to participate in the qualitativestudy. We targeted more middle/high schools (45% versus 21%) and more schools inneighborhoods with a higher percentage of visible minorities (32% versus 20%) inour sample. This ensured an adequate representation of these perspectives in ourdata. By including more middle/high schools, which typically have more studentsand teachers than elementary schools, our targeted sample included a higherpercentage of schools with more students and teachers.

Principals in selected schools received an invitational letter through mail andfollow-up reminders. In total, 17 schools participated in the qualitative study(36% response rate): 10 elementary schools (grades 7 or less); one junior highschool (grades 8-10), one senior high school (grades 10-12), and five highschools (grades 8-12). The socio-demographic characteristics of theparticipating schools did not differ significantly from those of thenon-participating schools, with the exception of the neighbourhoods they servedwhich had a higher percentage of visible minorities (42% versus 27%). Allprincipals (n = 17) participated in the semi-structured qualitativeinterviews as well as 33 teacher/school informants (N = 50 informantinterviews). Key informants were purposefully recruited by a delegated staffcontact. Invitation letters were distributed in mailboxes and interested keyinformants returned consent forms to the school contact who then forwarded theinformation to the research team. Key informants were predominantly classroomteachers (n = 21) but also included PE specialists(n = 9), and cafeteria staff and home economics teachers(n = 3).

Data collection

Semi-structured interviews were conducted individually with principals(n = 17) and key teachers/school informants (n = 33).Interviews were conducted in the 2010-2011 school year by two-trained researchassistants. The interviews were 45 to 60 minutes long and consisted ofbroad open-ended questions with probes into emergent topics as they arose.Interviews started by asking the informants a number of background/demographicquestions including questions about their position at the school, if applicable- courses and grades taught, and years of experience overall and at the currentschool. Questions related to the DPA and FBSS guidelines asked the informant todescribe/discuss: a) their understanding and expectations of the guidelines, b)their thoughts about the guidelines, c) whether their school was implementingthe guidelines as expected, d) how they were or were not implementing theguidelines; highlighting any examples (e.g. whether their school made anychanges to implement the guidelines and if so what changes), e) the impact ofthe guidelines had on the school community (school, teachers, students, andparents), f) factors that facilitated or impeded implementation, and g) feedbackor support received from the school community about the guidelines. Interviewswere recorded digitally and researchers captured noteworthy aspects of thecontext or interview in supplementary field notes. Half of the interviewtargeted the DPA guidelines and the other half the FBSS guidelines. Allinformants provided written consent to be interviewed and received a gift cardfor participation ($15 Cdn). The designated school contact received a monetaryincentive ($50 Cdn). Substitute teachers were provided to facilitateparticipation in the interviews.

Data analysis

Digital recordings were transcribed verbatim and reviewed by the interviewers toensure accuracy of the data. A constructivist grounded theory approach was usedfor coding [29, 30]. It employs a less rigid application of grounded theory andexplicitly acknowledges the researchers’ expertise and biases during theanalysis process [30]. Two independent coders initially created a set of broad codes basedupon the interview guide and research objectives. Transcripts were then codedline by line using an inductive method of open coding; whereby researchersallowed patterns and themes to emerge from the data [31]. To ensure the trustworthiness of the coding and interpretations ofthe data, the first five transcripts and every fifth transcript thereafter werecoded in duplicate, and any discrepancies were discussed with a third researcherto reach consensus. Coding of transcripts continued until saturation. All datawere coded in the NVivo 9 software (QRS International, 2010).

Concept maps were developed to reduce the qualitative data into meaningfulconcepts. This process was initially conducted separately for understanding thebarriers and facilitators to the implementation of the guidelines. In the laterstages, this process integrated knowledge of existing theoretical perspectivesand it became apparent that the Diffusion of Innovations Model provided anorganizing framework for presenting the emerging themes [32]. While this theoretical framework did not guide the original codingand analyses, it was used to summarize the data. Initial results were presentedto key stakeholders (staff at the Ministries of Education (n = 2)and Health (n = 3) that had firsthand knowledge of these issuesbased on their interactions with school stakeholders related to guidelineimplementation) to check the validity of the interpretations and to gain furtherinsights about our findings. This process also assessed convergence of thefindings with other data sources collected by the provincial government andconfirmed theoretical saturation as no new issues emerged in these discussions.This process served to ensure proper interpretation of our data.

Results

Perceived implementation

Implementation of the DPA and FBSS guidelines was reported by all schools butpercentage of full implementation varied by guidelines (Table 1). Overall, the percentage of schools that perceived a fullimplementation of the DPA guidelines was higher in elementary schools than inmiddle/high schools; however elementary teacher/school informants reported muchlower implementation than principals. In contrast, the percentage of schoolsthat perceived full implementation of the FBSS guidelines was lower amongelementary teacher/school informants than among middle/high schoolteacher/school informants. In middle/high schools, fewer principals thought theywere meeting the FBSS guidelines than teacher/school informants (28.6% versus42.8%); however, many indicated being close to complying with theguidelines.

Table 1 Percentage of informants who perceived their schools as fullyimplementing the Daily Physical Activity (DPA) and the Food andBeverage Sales in Schools (FBSS) guidelines

Implementation styles/change

Schools implemented the DPA guidelines by taking either: [1] a prescriptive approach (requiring all students to participate) asthey scheduled more PE/PA during instructional hours, added more PE classes,changed PE from a semester system to a full year class, scheduled joggingbreaks, scheduled activity class before or after school, and/or incorporatedclassroom activity breaks; or [2] a non-prescriptive approach (providing more opportunities but notrequiring) as they provided more PE/PA elective classes, expanded the intramuralprogram, provided lunch hour games, allowed access to facilities outside ofinstructional time, added PA clubs (walking, running, and kilometre clubs),provided guidance on how to increase PA, encouraged students to be activethrough school announcements, sent newsletters, and/or had school assemblieswith students. Higher grades were more likely to report implementing DPA in anon-prescriptive way.

To implement the FBSS guidelines, schools: changed content of vending machines,school store or canteen; changed vending machine supplier; made food healthier(e.g., chicken hot dogs with whole wheat buns); eliminated certain foods (hotdogs, French fries); eliminated vending machines, school stores, or canteens;required recipes be provided with bake sale items; changed portion sizes;eliminated donuts from staff meetings; cooked healthier recipes in homeeconomics; changed the educational curriculum; eliminated outside food in theschool; changed fundraising items; and eliminated classroom treats. Other lesscited changes included: eliminating carbonated beverages (purchased or broughtin from home), consulting with a nutritionist, sending newsletters to parentsabout HE and healthy recipes, having a healthy living week, asking concessionstands to close when students are on field trips, prohibiting students frombringing money on school trips to prevent purchase of food and beverages, andstarting an organic greenhouse and using the vegetables and fruits in thecafeteria.

Barriers and facilitators to implementation

The emergent themes associated with the implementation of the DPA and FBSSguidelines are presented in Table 2 with illustrativequotes in Tables 3 and 4. Withthe exception of triability (e.g., the extent the which the innovation can betried before deciding whether it is adopted/implemented), the themes werecategorized by the characteristics of the Diffusion of Innovations Model [32]. The key innovation attributes described in the model (relativeadvantage compatibility, complexity, and observability) provide a relevant androbust framework to organize emergent themes for both the DPA and FBSSguidelines. The guidelines were mandated and thus triability did not emerge as apredominant theme. Contextual facilitators did emerge as a key theme which wasadded.

Table 2 Summary of the emerging themes for the Daily Physical Activity (DPA)and the Food and Beverage Sales in Schools (FBSS) guidelines
Table 3 Sample quotes or explanations for the themes that emerged for theDaily Physical Activity (DPA) guidelines *
Table 4 Sample quotes or explanations for the themes that emerged for theFood and Beverage Sales in Schools (FBSS) guidelines

Relative advantage

In general, informants had a positive opinion of both guidelines relative tothe status quo (“it’s better than what we were doing” forthe DPA guidelines and “we needed this” for FBSS). However, someelementary school informants, who were in the school system prior to budgetcuts that eliminated PE specialists in elementary schools in the late1980’s and early 90’s thought they “had a better way ofdoing this before” when they had PE specialists. The irony of this wasdiscussed in the context of the DPA guidelines. In contrast, while the FBSSguidelines were perceived as positive from a ‘health’perspective, their advantage were often tempered by their potential negativeimpact on school revenues.

Compatibility

Both guidelines were perceived to be compatible with schools’ orteachers’ expectations of what the school learning environment shouldprovide (“it fits our philosophy” and “we like it”for DPA guidelines and “it fits my philosophy” and “theschool community was on board” for FBSS guidelines). Most statementsabout the DPA guidelines focused on how this fits with “us”, the“school” or “teachers”, while the responses aboutthe FBSS guidelines focussed more on how they affect “us” as“individuals”. Informants talked positively about the importanceof PA and HE suggesting strong favorable social norms about these behaviourswhich in some cases translated into positive feelings toward the guidelinesbut not always. For both guidelines, some informants questioned whetherschools or parents should be responsible or solely responsible for providingPA and HE opportunities. Others felt schools had a social responsibility toaddress these issues (“schools need to help those that don’thave” for the DPA guidelines and “schools have a socialresponsibility to not profit from selling children unhealthy food” forthe FBSS guidelines). Finally, compatibility issues specific to DPA includedthe difficulty in fitting DPA into the schedule, lacking skills to providemore PA and resenting the top down approach taken in mandating the DPAguidelines. For the FBSS guidelines, some informants felt strongly about theneed to allow for “one-time exceptions” to ensure it fits withhow schools function.

Complexity

Many of the complexity issues revolved around understanding of theguidelines. For the DPA guidelines, many struggled with the lack ofdirection provided in the guidelines; what counted toward DPA and howactivities should be structured to count toward DPA. For the FBSSguidelines, many were not sure about the scope of the guidelines; whetherthey applied only to vending machines or to all food and beverages and alsowhen (within school hours) and where (outside school events) the guidelinesapplied.

Other complexity issues revolved around the barriers teachers or schoolsencountered when they tried to fully implement the guidelines. For the DPAguidelines, informants from higher grades (where reporting on DPA bystudents was required) struggled to report how students met their PArequirements on report cards. In contrast, informants from lower gradesstruggled with meeting all curriculum expectations. Schools with a largeimmigrant population talked about the need to address the value of PA toensure implementation of the DPA guidelines in this population. Schoolswhere the weather tended to be more extreme talked about their struggle toimplement the DPA guidelines in inclement weather.

For the FBSS guidelines, schools struggled with maintaining profit marginsand finding suitable fundraising alternatives. In addition, some schools hadencountered problems when their teachers eagerly embraced the guidelines butparents perceived that they had overstepped educational boundaries bytalking to the children about or forbidding some food. Finally, indisadvantaged schools, where food security was a widespread concern,administrators struggled to implement the guidelines while also trying tofeed their disadvantaged students.

Facilitators

Appropriate resources and support were considered key facilitators to theimplementation of both guidelines. For the DPA guidelines, this includedhaving ready-made provincially available resources (Action Schools! BC),school resources (gymnasium, nearby park or community center, large outdoorfield or playground area), and a PE specialist in their school (elementarygrades). Implementation was also easier in schools where PE was a priorityprior to the implementation of the guidelines. In the context of the FBSSguidelines, having provincial resources that were developed to supportimplementation (e.g. Brand Name Foodlist) as well as existing programsavailable were seen as facilitative. In addition, having a nutritionistavailable for consultation (a resource added with the launch of the FBSSguidelines through Dietitians Services) and having local suppliers thatcomplied with the guidelines facilitated implementation. Interestingly, thetop-down approach to enact the school guidelines, which was seen asproblematic by some, was perceived by one administrator as helpful; ithelped to create positive changes in the school without the administratortaking personal blame.

Observability

Positive impacts were observed as a result of implementing the guidelines(see Table 2). Unintended consequences were alsonoted for the DPA guidelines, including teachers feeling they had lessautonomy over their schedules and increased workload through direct deliveryat the elementary school level and through the responsibility of trackingand documenting student DPA at the high school level. Unintended observableconsequences of the FBSS guidelines implementation included: loss of revenuefrom food/beverage sales, fundraising activities and bake sales; reducedfunds for curricular and/or extracurricular activities (field trips, musicprogram, social assistance program, athletic program, sporting events, andothers); selling of unhealthy food and beverages by “entrepreneurialstudents”; and more students leaving school grounds at lunch timewhich then resulted in students being late to class after their lunch break,skipping classes, or increased concerns about student safety.

Discussion

Our study provided an in-depth analysis of the factors that influenced implementationof school-based PA and nutrition guidelines in BC, Canada. Implementation of the DPAand FBSS guidelines was influenced by perceptions that the guidelines: wererelatively advantageous compared to status quo, were compatible with school mandatesand teaching philosophies, were complex to understand and implement, and hadobservable positive impacts. A number of contextual factors including availabilityof resources facilitated implementation; however, tremendous variability wasobserved across schools in terms of the factors identified as influencingimplementation. Interestingly, the target of the guidelines also contributed to thevariability reported in the effectiveness of implementation between guidelines andschools. The FBSS guidelines targeted the school environment and thus itspredominant impact was at the school level, including the Parent Advisory Council(PAC) in some cases. In contrast, the DPA guidelines targeted both teachers andschools; as teachers were responsible for the delivery of PA in the context of theclassroom in lower grades and schools were responsible for documenting how studentsmet the DPA requirements in higher grades.

Our findings support the findings of similar studies of the U.S. school wellnesspolicy. These studies found similar barriers to implementation such as: revenueloss, competing demands, lack of resources, support from the school community,difficulty in finding fundraising alternatives, and decreased resources forcurricular or extracurricular activities [5, 19, 22, 24]. Some of our findings are perhaps unique to the Canadian context andother countries that do not have subsidized federal school meal/breakfast programs [33]. For example, addressing food insecurity is more complex when schools arenot provided with infrastructure support or funds to subsidize school meals. Inaddition, schools cannot count on the subsidized school meal to maintain cafeteriarevenues when modifying their “A La Carte” offerings. This has beenfound to offset anticipated revenue loss in some U.S. schools, where school mealsare subsidized [34]. Our findings may also be unique because other countries have focused onPE- rather than PA-related school policies. For example, understanding how the DPAguidelines are implemented outside of PE and dealing with increased elementaryteacher workloads are highly relevant themes in the context of DPA but not PE.Finally, some findings of the current study have not been documented in previousstudies but may apply to similar policies and contexts, including statements about:needing one-time exceptions for HE policies, shifting the responsibility fromschools to parents, navigating cultural relevance, having more students leave schoolgrounds (high schools only), and having more green initiatives integrated infundraising activities.

Our study is one of the first qualitative studies to use the key attributes of theDiffusion of Innovations Model to organize the factors associated withimplementation of school-based PA and nutrition policies/guidelines [32]. With the exception of triability, the key innovation attributesdescribed in the model (relative advantage, compatibility, complexity, andobservability) provide a relevant and robust framework to organize emergent themesfor both the DPA and FBSS guidelines. Most importantly, this framework provides auseful structure for planning and developing strategies to improve theimplementation of school-based policies/guidelines.

Strengthening the relative advantage of DPA guidelines may require:increasing access to PE specialists at the school or district level, providingtraining, and sharing the evidence linking PA to improved cognitive functioning andacademic performance in schools [14]. In addition, sharing the evidence may also enhance their perceivedcompatibility as some informants felt parents rather than schoolsshould take responsibility for PA. Addressing complexity may require:providing more direction to schools on how to meet the guidelines, sharing models ofsuccessful implementation, supporting ethnically diverse schools that lack parentalsupport for the guidelines, and developing an infrastructure to facilitate trackingand documentation in higher grades. Observability is an interestingcharacteristic to address as teachers can observe the positive impact of DPA onstudents’ health or academic performance; however, enhancing the benefits toteachers also seems important given concerns of increased workload and schoolexpectations.

Communicating the health related evdence [68, 1113, 17, 18] in support of the FBSS guidelines appears important for bolstering theirrelative advantage and offsetting mixed feelings associated with theirpotential impact on school revenues. Similar to the DPA guidelines, perceivedcompatibility may also be improved by communicating the evidencelinking HE with academic performance [15, 16]. Issues raised under complexity highlighted the need to: educateteachers on how to talk sensitively about HE without usurping parental authority,find suitable fundraising alternatives to minimize conflicts with PAC, minimizerevenue loss, and ensure disadvantaged students are not negatively impacted by theguidelines. Observability can be strengthened by implementing strategiesto: prevent or subsidize loss of revenues, reduce the number of students leavingschool grounds at lunch time, and prevent the entrepreneurial students from sellingunhealthy food.

Our findings also uncovered the contextual factors that facilitated implementation ofmandated guidelines and highlighted the importance of available resources as acommon facilitator. The implementation of the DPA guidelines in BC was preceded bythe large scale dissemination of Action Schools! BC, a comprehensive whole schoolapproach to increasing PA opportunities across six school action zones (including PEand the classroom) [35]. The dissemination of the initiative began four years before the DPAguidelines were implemented and provided schools and teachers with planning tools,equipment, training, on-going technical support and a suite of better practiceresources that were developed for the school setting and ready to use [35]. Participants specifically highlighted this as a facilitator. In theabsence of such infrastructure, it is likely that other jurisdictions attempting toimplement similar guidelines may be faced with more barriers than we observed.Action Schools! BC integrated HE in 2008 which once again provided the same supportsto schools and teachers to modify their school food environment.

Finally, considerable variability was observed in terms of the strategies employed toimplement these guidelines. The extent to which some strategies (e.g., using aprescriptive or non-prescriptive approach to implement the DPA guideline) are moreeffective than other ones remain unknown and deserves further investigation. Inaddition, we do not know whether the DPA and FBSS guidelines significantly improvedthe school environment. Many informants indicated the school PA and food environmentimproved with the implementation of these guidelines; however, much more work needsto be done to uncover whether policy strategies alone or combined with otherapproaches will help reverse the current childhood obesity epidemic.

Conclusions

In conclusion, emerging evidence suggests school-based policies targeting the schoolPA and food environment can influence student behaviors [4, 913]. The enactment of mandated guidelines/policies is considered an essentialstep in changing the school PA and food environment. However, effectiveimplementation is critical to success. Policy makers need to: monitor whetherschools are able to implement the guidelines, provide support to schools strugglingwith implementation, and document whether the guidelines are influencingstudents’ behaviors as intended. The Diffusion of Innovations model provides auseful framework for understanding the factors that impede or facilitateimplementation of guidelines in schools.

Abbreviations

DPA:

Daily physical activity

FBSS:

Food and beverage sales in schools

HE:

Healthyeating

PA:

Physical activity

PAC:

Parent advisory council

PE:

Physicaleducation.

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Acknowledgements

This study was funded by the Canadian Institutes of Health Research, Institute ofNutrition, Metabolism and Diabetes (funding reference number GIR-99715). Dr.Mâsse received salary support from the Michael Smith Foundation for HealthResearch (senior scholarship), the Child and Family Research Institute locatedat the Children’s and Women’s Health Centre of British Columbia(level 2 scientist award), and the Sunny Hill Foundation to complete thiswork.

The authors would like to thank Eric Lorenz for coordinating the data collectionand contributing to the development of the data collection tools. Finally, theauthors would like to thank Whitney Moser for collecting the data and coding thedata.

Author information

Correspondence to Louise C Mâsse.

Additional information

Competing interests

We the authors, have no financial or non-financial competing interests with thecontent of this manuscript.

Authors’ contributions

LM is the principal investigator on a Canadian Institutes of Health Research grant,wrote the grant, supervised and trained all research staff, developed the datacollection and analysis protocols, analyzed the data, drafted the manuscript, andfinalized the manuscript. DN was a research assistant on the grant, collected data,managed the coding of the qualitative data, drafted sections of the manuscript, andcritically reviewed the manuscript, and approved the manuscript. PJN is aco-investigator on the grant, provided input in the grant and development of thedata collection and analysis protocols, critically reviewed the manuscript, andapproved the manuscript. All authors read and approved the final manuscript.

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Mâsse, L.C., Naiman, D. & Naylor, P. From policy to practice: implementation of physical activity and food policies inschools. Int J Behav Nutr Phys Act 10, 71 (2013) doi:10.1186/1479-5868-10-71

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Keywords

  • Physical education
  • Physical activity
  • Nutrition
  • School policies
  • School guidelines
  • Implementation
  • Uptake
  • Barriers
  • Facilitators
  • Qualitative