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From policy to practice: implementation of physical activity and food policies inschools Mâsse, Louise C; Naiman, Daniel; Naylor, Patti-Jean Jun 3, 2013

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RESEARCH Open AccessFrom policy to practice: implementation ofphysical activity and food policies in schoolsLouise C Mâsse1*, Daniel Naiman1 and Patti-Jean Naylor2AbstractPurpose: Public policies targeting the school setting are increasingly being used to address childhood obesity;however, their effectiveness depends on their implementation. This study explores the factors which impeded orfacilitated the implementation of publicly mandated school-based physical activity and nutrition guidelines in theprovince of British Columbia (BC), Canada.Methods: Semi-structured interviews were conducted with 50 school informants (17 principals - 33 teacher/schoolinformants) to examine the factors associated with the implementation of the mandated Daily Physical Activity(DPA) and Food and Beverage Sales in Schools (FBSS) guidelines. Coding used a constructivist grounded theoryapproach. The first five transcripts and every fifth transcript thereafter were coded by two independent coders withdiscrepancies reconciled by a third coder. Data was coded and analysed in the NVivo 9 software. Concept mapswere developed and current theoretical perspectives were integrated in the later stages of analysis.Results: The Diffusion of Innovations Model provided an organizing framework to present emergent themes. Withthe exception of triability (not relevant in the context of mandated guidelines/policies), the key attributes of theDiffusion of Innovations Model (relative advantage, compatibility, complexity, and observability) provided a robustframework for understanding themes associated with implementation of mandated guidelines. Specifically,implementation of the DPA and FBSS guidelines was facilitated by perceptions that they: were relativelyadvantageous compared to status quo; were compatible with school mandates and teaching philosophies; hadobservable positive impacts and impeded when perceived as complex to understand and implement. In addition, anumber of contextual factors including availability of resources facilitated implementation.Conclusions: The enactment of mandated policies/guidelines for schools is considered an essential step inimproving physical activity and healthy eating. However, policy makers need to: monitor whether schools are ableto implement the guidelines, support schools struggling with implementation, and document the impact of theguidelines on students’ behaviors. To facilitate the implementation of mandated guidelines/policies, the Diffusion ofInnovations Model provides an organizational framework for planning interventions. Changing the schoolenvironment is a process which cannot be undertaken solely by passive means as we know that such approacheshave not resulted in adequate implementation.Keywords: Physical education, Physical activity, Nutrition, School policies, School guidelines, Implementation,Uptake, Barriers, Facilitators, Qualitative* Correspondence: lmasse@cfri.ubc.ca1School of Population and Public Health, University of British Columbia,F508-4480 Oak Street, Vancouver, BC V6H3V4, CanadaFull list of author information is available at the end of the article© 2013 Mâsse et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Mâsse et al. International Journal of Behavioral Nutrition and Physical Activity 2013, 10:71http://www.ijbnpa.org/content/10/1/71BackgroundSchools provide the best setting to support a population-based approach to improve physical activity (PA) andhealthy eating (HE) for all children regardless of their ethnicor socio-demographic background [1,2]. School-based pub-lic policies are increasingly being used to address childhoodobesity [2,3] and emerging evidence supports the effective-ness of such policies on positively influencing the school en-vironment. For example, school-based physical education(PE) policies have increased the amount of PE offered inschools (i.e., total minutes or days/week) [4,5] and school-based nutrition policies have resulted in less access to sugar-sweetened beverages and low nutrient energy dense foods inschools [6-8]. School-based policies also influence studentbehaviors. For example such policies have increased PAlevels, although one study documented a greater effect forgirls [4,9]; increased fitness levels [10]; and reduced studentconsumption of sugar-sweetened beverages in school[11-13]. Furthermore, evidence suggests that improvementsto both PA and HE will result in improvements in cognitivefunctioning and overall academic performance, helpingschools meet their academic mandate [14-16].While the emerging evidence suggest school-based pol-icies can positively influence the school environment andstudent behaviours, the impact on student body mass index(BMI) is less clear. Some studies have found no associationbetween school-based policies and student BMI [9,11] whileothers documented an association [17,18]. Specifically, stu-dents had lower BMIs in states with stricter PE and schoolfood policies [17] and in states with stronger competitivefood policies [18]. The effectiveness of school-based policiesagainst childhood obesity depends on their implementation,which is often less than optimal even when these policiesare publicly mandated [4,9,10]. To date, few studies have ex-amined the factors that impede or facilitate the implementa-tion of school-based obesity prevention policies. Factorsfound to impede implementation include: potential loss ofschool revenues, competing curriculum demands and prior-ities, lack of resources (staff, funding, availability of programsor teaching resources), lack of coordination, no dedicatedfunding to support the mandate, industry lobbying, and mis-conceptions about the types of food and beverages madeavailable at school [5,19-24]. In contrast implementation isenabled when there is support from key politicians, parents,physicians and school personnel as well as the provision offinancial support and having data to inform policy decisionsenabled implementation [19-22].In Canada, the Constitution Act declares education tobe under provincial jurisdiction [25], as a result anyguidelines/policies affecting the school system areenacted at the provincial level. The enactment of theDaily PA (DPA) and Food and Beverage Sales in Schools(FBSS) guidelines in the province of British Columbia(BC), Canada represented the province’s first attempt togovern the PA and food environment of schools. TheDPA guidelines set the requirements for daily physicalactivity for students. The FBSS guidelines set out mini-mum nutrition standards for food and beverages sold tostudents. In addition, both policies set out to encouragethe development of life-long healthy behaviours.Prior to the implementation of the DPA guidelines, Kto 9 grades in BC were expected to devote 10% of theirinstructional time to PE, for grade 10 students PE wasand remains a graduation requirement and for grades 11and 12 it was and remains as an elective course [26].The new DPA guidelines require schools to offer 30 mi-nutes per day of PA as part of the grade K-9 educationalcurriculum. Grade 10-12 students must document andreport a minimum of 150 minutes per week of PA,performed at a moderate to vigorous intensity. Whilesome provinces in Canada mandate that PE be taught bya PE specialist, in BC this differs by grade. At the elem-entary school level PE is primarily taught by classroomteachers. Implementation of the guidelines was expectedby the beginning of the 2008/2009 school year.Prior to the implementation of the FBSS guideline,schools in BC were not expected to meet any nutritionalguidelines. The FBSS guidelines were designed tomaximize students’ access to healthier options and fullyeliminate the sale of unhealthy food and beverages in BCschools. The FBSS guidelines mandate schools to adhereto the 2007 Canada’s Food Guide [27] for all food andbeverage sold or made available at school. Full imple-mentation of the FBSS guidelines were expected by theend of the 2007/2008 school year. While elementaryschools in BC have fewer permanent food outlets thanin middle/high schools (45% versus 95% of schools havepermanent food outlets), less healthy food choices wereoften offered in elementary schools through parentsor fundraising efforts (e.g., pizza lunches or hot dogdays) [28].This study explores the factors that impeded or facili-tated the implementation of publicly mandated school-based PE and nutrition guidelines in the province of BC.Our study provides a unique opportunity to examine theimplementation of the FBSS guidelines in a jurisdictionthat did not previously have any guidelines or mandatedpolicies to govern the food environment of schools. Inaddition, it also provides the opportunity to examine theimplementation of a guideline that addresses the PA en-vironment in schools while previous research conductedin other jurisdictions has focused on the implementationof policies directed at changing the PE environment inschools.MethodsWe examined the factors associated with the implemen-tation of the DPA and FBSS guidelines qualitatively byMâsse et al. International Journal of Behavioral Nutrition and Physical Activity 2013, 10:71 Page 2 of 12http://www.ijbnpa.org/content/10/1/71conducting semi-structured interviews with 50 schoolinformants (17 principals and 33 teacher/school infor-mants). The study protocol was approved by the Univer-sity of British Columbia and the University of VictoriaResearch Ethics Boards and participating schooldistricts.Sample selection and recruitmentSchools were selected to participate in this study basedon responses to a school survey administered in the2007-2008 school year. School selection ensured repre-sentation across: self-reported levels of implementationof the guidelines, school types (elementary, middle, andhigh schools), and school settings (urban, suburban, andrural). Of the 513 schools that completed the 2007-2008school survey, a total of 47 schools were invited to par-ticipate in the qualitative study. We targeted moremiddle/high schools (45% versus 21%) and more schoolsin neighborhoods with a higher percentage of visible mi-norities (32% versus 20%) in our sample. This ensuredan adequate representation of these perspectives in ourdata. By including more middle/high schools, which typ-ically have more students and teachers than elementaryschools, our targeted sample included a higher percent-age of schools with more students and teachers.Principals in selected schools received an invitationalletter through mail and follow-up reminders. In total, 17schools participated in the qualitative study (36% re-sponse rate): 10 elementary schools (grades 7 or less);one junior high school (grades 8-10), one senior highschool (grades 10-12), and five high schools (grades 8-12).The socio-demographic characteristics of the partici-pating schools did not differ significantly from those ofthe non-participating schools, with the exception of theneighbourhoods they served which had a higher percent-age of visible minorities (42% versus 27%). All principals(n = 17) participated in the semi-structured qualitativeinterviews as well as 33 teacher/school informants(N = 50 informant interviews). Key informants were pur-posefully recruited by a delegated staff contact. Invita-tion letters were distributed in mailboxes and interestedkey informants returned consent forms to the schoolcontact who then forwarded the information to theresearch team. Key informants were predominantlyclassroom teachers (n = 21) but also included PE special-ists (n = 9), and cafeteria staff and home economicsteachers (n = 3).Data collectionSemi-structured interviews were conducted individuallywith principals (n = 17) and key teachers/school infor-mants (n = 33). Interviews were conducted in the 2010-2011 school year by two-trained research assistants. Theinterviews were 45 to 60 minutes long and consisted ofbroad open-ended questions with probes into emergenttopics as they arose. Interviews started by asking the in-formants a number of background/demographic ques-tions including questions about their position at theschool, if applicable - courses and grades taught, andyears of experience overall and at the current school.Questions related to the DPA and FBSS guidelines askedthe informant to describe/discuss: a) their understandingand expectations of the guidelines, b) their thoughtsabout the guidelines, c) whether their school wasimplementing the guidelines as expected, d) how theywere or were not implementing the guidelines; highlight-ing any examples (e.g. whether their school made anychanges to implement the guidelines and if so whatchanges), e) the impact of the guidelines had on theschool community (school, teachers, students, and par-ents), f ) factors that facilitated or impeded implementa-tion, and g) feedback or support received from theschool community about the guidelines. Interviews wererecorded digitally and researchers captured noteworthyaspects of the context or interview in supplementaryfield notes. Half of the interview targeted the DPAguidelines and the other half the FBSS guidelines. All in-formants provided written consent to be interviewedand received a gift card for participation ($15 Cdn). Thedesignated school contact received a monetary incentive($50 Cdn). Substitute teachers were provided to facilitateparticipation in the interviews.Data analysisDigital recordings were transcribed verbatim andreviewed by the interviewers to ensure accuracy of thedata. A constructivist grounded theory approach wasused for coding [29,30]. It employs a less rigid applica-tion of grounded theory and explicitly acknowledges theresearchers’ expertise and biases during the analysisprocess [30]. Two independent coders initially created aset of broad codes based upon the interview guide andresearch objectives. Transcripts were then coded line byline using an inductive method of open coding; wherebyresearchers allowed patterns and themes to emerge fromthe data [31]. To ensure the trustworthiness of the cod-ing and interpretations of the data, the first five tran-scripts and every fifth transcript thereafter were codedin duplicate, and any discrepancies were discussed witha third researcher to reach consensus. Coding of tran-scripts continued until saturation. All data were codedin the NVivo 9 software (QRS International, 2010).Concept maps were developed to reduce the qualita-tive data into meaningful concepts. This process was ini-tially conducted separately for understanding thebarriers and facilitators to the implementation of theguidelines. In the later stages, this process integratedknowledge of existing theoretical perspectives and itMâsse et al. International Journal of Behavioral Nutrition and Physical Activity 2013, 10:71 Page 3 of 12http://www.ijbnpa.org/content/10/1/71became apparent that the Diffusion of InnovationsModel provided an organizing framework for presentingthe emerging themes [32]. While this theoretical frame-work did not guide the original coding and analyses, itwas used to summarize the data. Initial results werepresented to key stakeholders (staff at the Ministries ofEducation (n = 2) and Health (n = 3) that had firsthandknowledge of these issues based on their interactionswith school stakeholders related to guideline implemen-tation) to check the validity of the interpretations and togain further insights about our findings. This processalso assessed convergence of the findings with other datasources collected by the provincial government and con-firmed theoretical saturation as no new issues emergedin these discussions. This process served to ensureproper interpretation of our data.ResultsPerceived implementationImplementation of the DPA and FBSS guidelines wasreported by all schools but percentage of full implemen-tation varied by guidelines (Table 1). Overall, the per-centage of schools that perceived a full implementationof the DPA guidelines was higher in elementary schoolsthan in middle/high schools; however elementaryteacher/school informants reported much lower imple-mentation than principals. In contrast, the percentage ofschools that perceived full implementation of the FBSSguidelines was lower among elementary teacher/schoolinformants than among middle/high school teacher/school informants. In middle/high schools, fewer princi-pals thought they were meeting the FBSS guidelines thanteacher/school informants (28.6% versus 42.8%); how-ever, many indicated being close to complying with theguidelines.Implementation styles/changeSchools implemented the DPA guidelines by taking ei-ther: [1] a prescriptive approach (requiring all studentsto participate) as they scheduled more PE/PA during in-structional hours, added more PE classes, changed PEfrom a semester system to a full year class, scheduledjogging breaks, scheduled activity class before or afterschool, and/or incorporated classroom activity breaks; or[2] a non-prescriptive approach (providing more oppor-tunities but not requiring) as they provided more PE/PAelective classes, expanded the intramural program, pro-vided lunch hour games, allowed access to facilities out-side of instructional time, added PA clubs (walking,running, and kilometre clubs), provided guidance onhow to increase PA, encouraged students to be activethrough school announcements, sent newsletters, and/orhad school assemblies with students. Higher grades weremore likely to report implementing DPA in a non-prescriptive way.To implement the FBSS guidelines, schools: changedcontent of vending machines, school store or canteen;changed vending machine supplier; made food healthier(e.g., chicken hot dogs with whole wheat buns); elimi-nated certain foods (hot dogs, French fries); eliminatedvending machines, school stores, or canteens; requiredrecipes be provided with bake sale items; changed por-tion sizes; eliminated donuts from staff meetings; cookedhealthier recipes in home economics; changed the edu-cational curriculum; eliminated outside food in theschool; changed fundraising items; and eliminated class-room treats. Other less cited changes included: eliminat-ing carbonated beverages (purchased or brought in fromhome), consulting with a nutritionist, sending newslet-ters to parents about HE and healthy recipes, having ahealthy living week, asking concession stands to closewhen students are on field trips, prohibiting studentsfrom bringing money on school trips to prevent pur-chase of food and beverages, and starting an organicgreenhouse and using the vegetables and fruits in thecafeteria.Barriers and facilitators to implementationThe emergent themes associated with the implementa-tion of the DPA and FBSS guidelines are presented inTable 2 with illustrative quotes in Tables 3 and 4. Withthe exception of triability (e.g., the extent the which theinnovation can be tried before deciding whether it isadopted/implemented), the themes were categorized byTable 1 Percentage of informants who perceived their schools as fully implementing the Daily Physical Activity (DPA)and the Food and Beverage Sales in Schools (FBSS) guidelinesDPA guidelines FBSS guidelinesPrincipals Elementary schools (n = 10) 90.0% 50.0%Middle & High schools (n = 7) 14.3% 28.6%All schools (N = 17) 58.8% 41.1%Teacher/school informants Elementary schools (n = 19) 42.9% 36.8%Middle & High schools (n = 14) 28.6% 42.8%All schools (N = 33) 36.4% 39.4%(N = 50).Mâsse et al. International Journal of Behavioral Nutrition and Physical Activity 2013, 10:71 Page 4 of 12http://www.ijbnpa.org/content/10/1/71the characteristics of the Diffusion of Innovations Model[32]. The key innovation attributes described in themodel (relative advantage compatibility, complexity, andobservability) provide a relevant and robust frameworkto organize emergent themes for both the DPA andFBSS guidelines. The guidelines were mandated and thustriability did not emerge as a predominant theme.Contextual facilitators did emerge as a key theme whichwas added.Relative advantageIn general, informants had a positive opinion of bothguidelines relative to the status quo (“it’s better thanwhat we were doing” for the DPA guidelines and “weTable 2 Summary of the emerging themes for the Daily Physical Activity (DPA) and the Food and Beverage Sales inSchools (FBSS) guidelinesDPA themes FBSS themesRelative advantage• It’s better than what we were doing • We needed this• We had a better way of doing this before • It would be better if we didn’t lose revenuesCompatibility• It fits our philosophy • It fits my philosophy• We like it versus it does not fit in my schedule • The school community was on board• There are favorable social norms • There are favorable social norms• Whose responsibility is it? We believe it is the family versus schoolsneed to help those that don’t have• Whose responsibility is it? We believe it is the family versus schools havea social responsibility to not profit from selling children unhealthy food• This takes special skills• We (teachers) resent the top down approach taken for implementation • We can’t follow it all the time, we need “one-time” exceptionsComplexity• We struggled with the lack of guidance • We found it difficult to understand the scope of the guidelines• We’re (elementary teachers) not clear what counts toward DPA • We have to figure out what to do about decreasing profit margins• We’re (elementary teachers) not clear that activities should be structuredto count toward DPA• We (teachers and Parent Advisory Council (PAC)) struggle to findsuitable fundraising alternatives• Evaluating implementation of DPA is hard • We can be perceived as overstepping our boundaries as educators• In higher grades it does not work as easily • This pits the administrators against the parents• We can’t meet all curriculum expectations versus it helps us meet ourexpectations• We struggle with food insecurity• We have to navigate cultural relevance• Our regional climate limits usFacilitator• Having ready-made provincial resources helped us (elementaryteachers) with implementation• Having provincial resources helped us with implementation• This requires schools to have the appropriate resources • Having access to a local nutritionist is helpful• It is easier when physical education (PE) was a priority • Having local suppliers that comply with the guidelines is necessary• Having a PE specialist in elementary grades helps a lot • Having mandated guidelines is useful ammunition for administratorsObservability• Some of us have noticed positive impacts (increased mental alertnessand focus, improved academic performance, improved classroombehaviors, students enjoy being active, positive attitude shift towardphysical activity, and increased positive student/teacher interactions)• Some of us have noticed positive impacts (students/teachers arehealthier, increased awareness about healthy eating, positive attitude shifttoward healthy eating, and involved in more “green” initiatives)• We lost revenues• It decreased teachers’ autonomy • We had to reduce curricular and/or extracurricular activities• It’s just more work for us (teachers & schools) • We have noticed students selling unhealthy food• We are encouraging students to falsify their physical activity data ontheir report cards• More students leave school grounds at lunch – as a result they skipmore classes and we are more concerned about their safetyMâsse et al. International Journal of Behavioral Nutrition and Physical Activity 2013, 10:71 Page 5 of 12http://www.ijbnpa.org/content/10/1/71Table 3 Sample quotes or explanations for the themes that emerged for the Daily Physical Activity (DPA) guidelines*Themes Sample quotesRelativeadvantageIt’s better than what we were doing “..daily physical activity it seemed very overwhelming. But it didn’t take very long before itwas “you know what, this is, this is great, this is something that should have been done a lot sooner.” (Elementary teacher)We had a better way of doing this before “…the Ministry needs to look at ways to get more PE specialists out in theschools… If we had a PE specialist and we had it .. all the students in the school would get a much higher level of quality out oftheir phys ed.” (Elementary teacher)CompatibilityIt fits our philosophy “I like the philosophy, …,a healthy society is absolutely part of what we should be encouraging and ineducation and setting the stage for a person’s healthy lifestyle and a vision of being healthy and active all their life…it’s all good.” (Elementary principal)We like it “I think it’s an awesome idea.” (middle/high school teacher) versus it does not fit in my schedule “Teachers wouldlove to do it. But again, …their day will not allow it.” (Elementary principal)There are favorable social norms – Overwhelmingly, all informants talked positively about physical activity.Whose responsibility is it? We believe it is the family “I get that physical education should be part of our curriculum but Ialso don’t think it’s the school’s job solely to teach healthy living, I think it should also come from home … but telling theschools that they need to do it, yeah, … I don’t necessarily agree with it.” (Elementary teacher) versus schools need to helpthose that don’t have “…these kids really need that time … because I know a lot of them do not get outside of schoolexercise. Like they’re not in soccer, they’re not into dance; they’re not into hockey or whatever.” (Elementary teacher)This takes special skills “…even though, everyone to my knowledge in Canada has to take a PE methodology course, there arevery very many people…teaching in elementary school who are uncomfortable with PE, they’re uncomfortable with getting thestudents to do activities, and gym results in dodge ball for a lot of the year.” (Elementary teacher)We (teachers) resent the top down approach taken for implementation “…they think the idea (DPA) is good but they’requestioning the way it’s being implemented, yeah, more so than with the food.” (High school teacher)ComplexityWe struggled with the lack of guidance “I think the schools were looking for some guidance from the districts, the districtsdumped it back to the school…it would be nice to have a specific guideline saying ‘this is what you’re doing, this is how you doit… different schools [in this school district] are having to come up with … different models to implement in theory theprogram that could be just implemented across the board. So I would say, why isn’t the district just coming up with a commonmodel that everybody is supposed to follow and you just do it?” (Middle/high school principal)We’re (elementary teachers) not clear what counts toward DPA – How much physical activity students need to accumulate?Is it 15, 20, 30, and 60 minutes per day or 10 minutes in addition to PE. Can DPA be accumulated at recess or lunch time andwhat about non-instructional hours? Does only vigorous physical activity counts toward DPA but what about strength trainingactivities?We’re (elementary teachers) not clear that activities should be structured to count toward DPA “I know that some schoolsfeel that the recess lunch time should be part and parcel of the DPA just for management reasons. But I mean you can’tguarantee that your kids are going to be active out there at recess and lunch. Some of them might just stand there and be, youknow, bystanders.” (Elementary teacher)Evaluating implementation of DPA is hard “We’re meeting the requirements of having it on the report card, and encouragingparents to work with the kids to meet it…but if you asked me to pull out the actual guidelines and show you step by step howwe’re implementing – no.” (Middle/high school principal)In higher grades it does not work as easily “…it fits into an elementary timetable… in an elementary school you can addthose minutes in; much harder to do in a secondary where they are going from teacher to teacher. And every teacher ismandated to spend so many minutes with their kids and now you’ve got 30 minutes added in. Elementary: okay, secondary:difficult. “ (Middle/high school teacher)We can’t meet all curriculum expectations “…meeting the language arts curriculum, meeting the math curriculumrequirements, social studies, science, health education, PE, computer technology, it’s all of it and each year the Ministry gives usone more piece. Well there aren’t enough minutes in a day; we’ve run out, we ran out years ago.” (Elementary principal) versus ithelps us meet our expectations “I don’t see that as taking away from other parts of their curriculum to do this, I see this as allone curriculum…I would posit that by doing your 30 minutes of exercise you’ve actually helped your social studies program: kidsare more primed to learn, they’re more apt to spend time on it” (Elementary principal)We have to navigate cultural relevance “…our greatest challenges… is with our families where English is not thepredominant language in the home. And working with those families to help them understand that it’s really important for theirkids to get out and be active outside of school is a challenge because they might not hold that same value culturally…Theirvalues might be more on academics.” (Elementary principal)Our regional climate limits us “I mean up here in the north it gets cold early in the season so they can’t go outside everydayright, it’s just not necessarily practical…I mean in the lower mainland I guess they can go outside and do some exercises,activities, go for a walk but whatever, whatever, you know, the teacher can or wants to do with them but we have, we don’talways have outside as an option up here.” (Middle/high school teacher)Mâsse et al. International Journal of Behavioral Nutrition and Physical Activity 2013, 10:71 Page 6 of 12http://www.ijbnpa.org/content/10/1/71needed this” for FBSS). However, some elementaryschool informants, who were in the school system priorto budget cuts that eliminated PE specialists in elemen-tary schools in the late 1980’s and early 90’s thought they“had a better way of doing this before” when they hadPE specialists. The irony of this was discussed in thecontext of the DPA guidelines. In contrast, while theFBSS guidelines were perceived as positive from a‘health’ perspective, their advantage were often temperedby their potential negative impact on school revenues.CompatibilityBoth guidelines were perceived to be compatible withschools’ or teachers’ expectations of what the schoollearning environment should provide (“it fits our phil-osophy” and “we like it” for DPA guidelines and “it fitsmy philosophy” and “the school community was onboard” for FBSS guidelines). Most statements about theDPA guidelines focused on how this fits with “us”, the“school” or “teachers”, while the responses about theFBSS guidelines focussed more on how they affect “us”as “individuals”. Informants talked positively about theimportance of PA and HE suggesting strong favorablesocial norms about these behaviours which in somecases translated into positive feelings toward the guide-lines but not always. For both guidelines, someinformants questioned whether schools or parentsshould be responsible or solely responsible for providingPA and HE opportunities. Others felt schools had a so-cial responsibility to address these issues (“schools needto help those that don’t have” for the DPA guidelinesand “schools have a social responsibility to not profitfrom selling children unhealthy food” for the FBSSguidelines). Finally, compatibility issues specific to DPAincluded the difficulty in fitting DPA into the schedule,lacking skills to provide more PA and resenting the topdown approach taken in mandating the DPA guidelines.For the FBSS guidelines, some informants felt stronglyabout the need to allow for “one-time exceptions” to en-sure it fits with how schools function.ComplexityMany of the complexity issues revolved around under-standing of the guidelines. For the DPA guidelines, manystruggled with the lack of direction provided in theguidelines; what counted toward DPA and how activitiesshould be structured to count toward DPA. For the FBSSguidelines, many were not sure about the scope of theguidelines; whether they applied only to vending ma-chines or to all food and beverages and also when(within school hours) and where (outside school events)the guidelines applied.Table 3 Sample quotes or explanations for the themes that emerged for the Daily Physical Activity (DPA) guidelines*(Continued)FacilitatorHaving readymade provincial resources helped us (elementary teacher) with implementation “I think by way of receivingmaterials (from Action Schools BC) like that, and then the workshop that we got from the Action Schools – I think that, all thatkind of stuff helps, yeah.” (Elementary teacher)This requires schools to have the appropriate resources (gymnasium, nearby park or community center, large outdoor fieldor playground area) “This school being quite small they were able to have access to the gym a lot more than other schools – likeI was at another school… they had to share all their PE classes with like two or three or four other classes. So they have thebenefit here of not only having the gym to themselves…they’re able to sign up for other extra gym periods which definitelyhelps.” (Elementary principal)It is easier when physical education (PE) was a priority – Meaning if the schools had more scheduled PE in place, many PEelectives, or many PA classes it facilitated implementation.Having a PE specialist in elementary grades helps a lot “(What helps implementation?)…I think having somebody that’s areal champion when you look at (PE Specialist name), you know, when she has the kids I mean she works them pretty hard during PEtime there’s no sloughing off there. You know the kids are, they’re put to task and they seem to enjoy what they’re doing and that’sthe nice thing about having one person pretty well that does all of the PE at the elementary level.” (Elementary principal 0936)ObservabilitySome of us have noticed positive impacts (mental alertness and focus, improved academic performance, improved classroombehaviors, student enjoy being active, attitudes shift toward physical activity, and increased positive student/teacher interactions)“I thought, I would be fighting up-against a wall to get this done; and the students love it..they crave it. I like ‘okay, yup, yup,what are we doing for fitness today?’ they want to be in shape and they know it’s important…and there’s no complaint, there’snothing” (Elementary teacher) “So it has me thinking during the school day. How can I get my kids more active? … it’s good to havethat in the back of my mind knowing that … each day, I have to think of how can I get my kids moving.” (Elementary teacher)It decreased teacher’s autonomy – Elementary teachers have less freedom to structure their daily activities.It’s just more work for us (teachers & schools) “The videos are fun. But, uh, no, it’s just, it’s an added stress. Yeah, I’m justcranky about the whole dumb thing [laughs].” (Elementary teacher)We are encouraging high school students to falsify their physical activity data on their report cards “The kids have towrite in their booklets once a week for 10 minutes and they write down everything they did all week. So, they make it up it’s notworth any marks. It’s a joke. So, but it’s a good start, they’re aware. They’re forced to do it. They can reflect on it and some ofthem take it seriously but others don’t… If DPA had some teeth then those are the ones that would benefit. And it’s not juststudents who are overweight…it’s the students who are…skinny, but you know they’re just not healthy.” (Middle/high school teacher)* All quotes are in parentheses and clarifying text is not.Mâsse et al. International Journal of Behavioral Nutrition and Physical Activity 2013, 10:71 Page 7 of 12http://www.ijbnpa.org/content/10/1/71Table 4 Sample quotes or explanations for the themes that emerged for the Food and Beverage Sales in Schools(FBSS) guidelinesThemes Sample quotesRelativeadvantageWe needed this “Well I think it’s, it’s late in coming but it’s about time, yeah” (Middle/high school teacher)It would be better if we didn’t lose revenue ““I understand the meaning of it and…the students do need to eat healthier,but…it didn’t change, like the desired effect was for students to eat healthier but the majority of them it didn’t change much, itjust sent the money elsewhere, so. I don’t know what the answer is but, it was a huge negative impact and it really, it reallyaffected us quite a bit.” (Middle/high principal)CompatibilityIt fits with my philosophy “I personally I value what the province is doing, I understand it and I think they’re right minded withtrying to change behavior patterns with the young through the schools so I’m supportive to that in the philosophy that it has.”(Elementary principal)The school community was on board “Here they’ve responded well. I think everybody seems to be on board.” (Elementaryprincipal)There are favorable social norms “Mostly students, all the teachers are on board with it, cause we all, you know, I think healthyeating is definitely one thing that – well obesity is a problem right with, all across north America… we’re trying to promotehealthy living, so.” (High school teacher)Whose responsibility is it? We believe it is the family “Well personally I think that it’s the job of parents to be properlyfeeding and clothing their kids.” (Principal 1536) versus schools have a social responsibility to not profit from sellingchildren unhealthy food “Personally I don’t believe that we should be selling pop in schools, I don’t believe we should beselling chocolate bars in schools. I think that those are items that if parents choose to have their children eating them that’s theirown choice, but I don’t think that we should be promoting or profiting from the sales of anything that isn’t healthy.” (Elementaryprincipal)We can’t follow it all the time; we need “one time exceptions” “So what was at the grad barbecue? Well, there was regularcoke and stuff like that. They wouldn’t fall under the guidelines, so. We just kind of ignore the guidelines and because, if webrought in juices and stuff like that, probably wouldn’t be drank at an event like that.” (Middle/high school principal) and“Thereare times when we do fundraising, obviously a pizza sale one day for a trip…it’s not following the Guidelines, but it’s forfundraising for the school.” (Elementary principal)ComplexityWe found it difficult to understand the scope of the guidelines (just vending or all food served) and where they apply(fundraising activities, activities organized by Parent Advisory Council, bake sale items, classroom treats, outside school hoursactivities, advertizing in school, accepting sponsorship from companies, and accepting incentives from vending machinescompany)We have to figure out what to do about decreasing profit margins “Well it’d be revenue from the vending machines, butalso the cafeteria. Cause they can’t sell – cause like a lot of the junk food were good money makers… Higher margin of profit,whereas quality food, the profit margin is not there.” (Middle/high school principal)We (teachers and Parent Advisory Council (PAC) struggle to find suitable fundraising alternatives “ So as I said, for ourPAC (Parent Advisory Council)…certainly they’ve communicated they find it somewhat…restricted in what they can sell (forfundraising).” (Elementary principal)We can be perceived as overstepping our boundaries as educators “Looking at kids’ lunches and recognizing the things thatare healthy and commenting on it, … that gets the ire of some parents up because you’re embarrassing my children whenyou’re talking about their lunch. You shouldn’t be doing that. If you want to talk to me as the parent about it, that’s one thing,but don’t talk to the kid.” (Elementary teacher)This pits the administrators against the parents “And we were greeted by a big cheer…the parents thought “yeah, great”.And so… we still have parents who come every day and drop off McDonald’s lunches and stuff, you know, we were saying, wecan’t stop them from doing that, but we’d say “you can’t bring pop, you have to bring something else for them to drink.” Andmost parents would go “Oh, OK, I didn’t know. Yeah, fine.” “And it was going OK for awhile, until one of our PAC executivemembers…took exception to the pop-free rule, saying that it…infringed upon parental rights, because it was the parent’s rightto decide what the children ate, what they put in their child’s lunches… we were now putting a child in a compromisedposition… the parent might be in a…situation where they have nothing else at home to feed their child….so we had to [sigh]for the sake of, I don’t know, relationships…repeal that policy, and we sat down together – administration and PAC to come upwith a statement that we all agreed upon and then sent it out to the community” (Elementary principal)We struggled with food insecurity “We’re an inner city school…in some cases feeding kids is more important.” (Elementaryprincipal)FacilitatorHaving provincial resources helped us with implementation (e.g., booklet provided by the Ministry of Education, website,and the Fruit and Vegetable program)Having access to a local nutritionist is helpful “I mean, we’re lucky in the sense that food and beverage is with the cafeteriaprogram. The district does have a director that’s in charge of all programs, so she (district nutritionist) oversees, even schoolstores, what’s being purchased … I mean that’s beneficial so we have to follow those guidelines, just like the chef has to orderspecific things, sometimes not happy about it, but to follow those guidelines, she does.” (Middle/high school principal)Having local suppliers that comply with the guidelines is necessary “Finding a vendor, like this vendor is now out of XXX,…we get a new delivery person every month …they know what they’re supposed to put in [the vending machine], but they’revisiting, I don’t know how many sites a day, and “Oh, I don’t have any of this stuff left, so I just want to fill the hole, so I put inCoke Zero” or whatever…We probably had to phone 10 times during the year…“Get that guy back here and tell him to pull outMâsse et al. International Journal of Behavioral Nutrition and Physical Activity 2013, 10:71 Page 8 of 12http://www.ijbnpa.org/content/10/1/71Other complexity issues revolved around the barriersteachers or schools encountered when they tried to fullyimplement the guidelines. For the DPA guidelines, infor-mants from higher grades (where reporting on DPA bystudents was required) struggled to report how studentsmet their PA requirements on report cards. In contrast,informants from lower grades struggled with meeting allcurriculum expectations. Schools with a large immigrantpopulation talked about the need to address the value ofPA to ensure implementation of the DPA guidelines inthis population. Schools where the weather tended to bemore extreme talked about their struggle to implementthe DPA guidelines in inclement weather.For the FBSS guidelines, schools struggled with main-taining profit margins and finding suitable fundraisingalternatives. In addition, some schools had encounteredproblems when their teachers eagerly embraced theguidelines but parents perceived that they had over-stepped educational boundaries by talking to the childrenabout or forbidding some food. Finally, in disadvan-taged schools, where food security was a widespreadconcern, administrators struggled to implement theguidelines while also trying to feed their disadvantagedstudents.FacilitatorsAppropriate resources and support were considered keyfacilitators to the implementation of both guidelines. Forthe DPA guidelines, this included having ready-madeprovincially available resources (Action Schools! BC),school resources (gymnasium, nearby park or commu-nity center, large outdoor field or playground area), anda PE specialist in their school (elementary grades). Im-plementation was also easier in schools where PE was apriority prior to the implementation of the guidelines. Inthe context of the FBSS guidelines, having provincial re-sources that were developed to support implementation(e.g. Brand Name Foodlist) as well as existing programsavailable were seen as facilitative. In addition, having anutritionist available for consultation (a resource addedwith the launch of the FBSS guidelines through Dieti-tians Services) and having local suppliers that compliedwith the guidelines facilitated implementation. Interest-ingly, the top-down approach to enact the school guide-lines, which was seen as problematic by some, wasperceived by one administrator as helpful; it helped tocreate positive changes in the school without the admin-istrator taking personal blame.ObservabilityPositive impacts were observed as a result ofimplementing the guidelines (see Table 2). Unintendedconsequences were also noted for the DPA guidelines,including teachers feeling they had less autonomy overtheir schedules and increased workload through directdelivery at the elementary school level and through theresponsibility of tracking and documenting student DPAat the high school level. Unintended observable conse-quences of the FBSS guidelines implementation in-cluded: loss of revenue from food/beverage sales,fundraising activities and bake sales; reduced funds forcurricular and/or extracurricular activities (field trips,music program, social assistance program, athletic pro-gram, sporting events, and others); selling of unhealthyTable 4 Sample quotes or explanations for the themes that emerged for the Food and Beverage Sales in Schools(FBSS) guidelines (Continued)that Coke.” You know, that’s the last thing I wanna have to waste time on… So, we’ve had some problems in that general area.“(High school principal)Having mandated guidelines is a useful ammunition for administrators “Having the (FBSS) guidelines is helpful because itgives you sort of that ammunition behind you to say ‘well there’s a provincial guideline and it’s expected.” (Middle/high schoolprincipal)ObservabilitySome of us have noticed positive impacts (students/teachers are healthier, increased awareness about healthy eating, positiveattitude shift toward health eating, and involved in more “green” initiatives) “Oh definitely so, yeah. I found this (the FBSSguidelines) made a difference to kid’s attitudes and especially their behaviour, you know, especially with a lot less sugar.”(Elementary principal)We lost revenues – without being prompted many middle/high school principals noted a revenue loss of $10,000 to $45,000.We had to reduce curricular and/or extracurricular activities “…it’s great to be promoting healthy food, on the one hand it’s,you know, our athletic program half the funding we used to have for running our athletic program was coming from the profits.”(High school principal)We have noticed students selling unhealthy food – entrepreneurial student took upon themselves to “illegally” sell lesshealthy food items.More students leave school grounds at lunch – as result they skip more classes and we are more concerned about theirsafety “If I had the vending machines capability, I bet I would keep another 50, 60, 100 kids on site, which I would preferbecause it’s when they go off site that I lose them, that’s where they skip, or get into trouble, or decide to buy something theyshouldn’t be buying. And if I can keep them on-site I have more, for lack of a better word, control of what they’re doing withtheir lunch breaks.” (Middle/high school principal)* All quotes are in parentheses and clarifying text is not.Mâsse et al. International Journal of Behavioral Nutrition and Physical Activity 2013, 10:71 Page 9 of 12http://www.ijbnpa.org/content/10/1/71food and beverages by “entrepreneurial students”; andmore students leaving school grounds at lunch timewhich then resulted in students being late to class aftertheir lunch break, skipping classes, or increased con-cerns about student safety.DiscussionOur study provided an in-depth analysis of the factorsthat influenced implementation of school-based PA andnutrition guidelines in BC, Canada. Implementation ofthe DPA and FBSS guidelines was influenced by percep-tions that the guidelines: were relatively advantageouscompared to status quo, were compatible with schoolmandates and teaching philosophies, were complex tounderstand and implement, and had observable positiveimpacts. A number of contextual factors including avail-ability of resources facilitated implementation; however,tremendous variability was observed across schools interms of the factors identified as influencing implemen-tation. Interestingly, the target of the guidelines alsocontributed to the variability reported in the effective-ness of implementation between guidelines and schools.The FBSS guidelines targeted the school environmentand thus its predominant impact was at the school level,including the Parent Advisory Council (PAC) in somecases. In contrast, the DPA guidelines targeted bothteachers and schools; as teachers were responsible forthe delivery of PA in the context of the classroom inlower grades and schools were responsible fordocumenting how students met the DPA requirementsin higher grades.Our findings support the findings of similar studies ofthe U.S. school wellness policy. These studies foundsimilar barriers to implementation such as: revenue loss,competing demands, lack of resources, support from theschool community, difficulty in finding fundraising alter-natives, and decreased resources for curricular or extra-curricular activities [5,19,22,24]. Some of our findingsare perhaps unique to the Canadian context and othercountries that do not have subsidized federal schoolmeal/breakfast programs [33]. For example, addressingfood insecurity is more complex when schools are notprovided with infrastructure support or funds tosubsidize school meals. In addition, schools cannotcount on the subsidized school meal to maintain cafe-teria revenues when modifying their “A La Carte” offer-ings. This has been found to offset anticipated revenueloss in some U.S. schools, where school meals are subsi-dized [34]. Our findings may also be unique becauseother countries have focused on PE- rather than PA-related school policies. For example, understanding howthe DPA guidelines are implemented outside of PE anddealing with increased elementary teacher workloads arehighly relevant themes in the context of DPA but notPE. Finally, some findings of the current study have notbeen documented in previous studies but may apply tosimilar policies and contexts, including statementsabout: needing one-time exceptions for HE policies,shifting the responsibility from schools to parents, navi-gating cultural relevance, having more students leaveschool grounds (high schools only), and having moregreen initiatives integrated in fundraising activities.Our study is one of the first qualitative studies to use thekey attributes of the Diffusion of Innovations Model toorganize the factors associated with implementation ofschool-based PA and nutrition policies/guidelines [32]. Withthe exception of triability, the key innovation attributes de-scribed in the model (relative advantage, compatibility, com-plexity, and observability) provide a relevant and robustframework to organize emergent themes for both the DPAand FBSS guidelines. Most importantly, this framework pro-vides a useful structure for planning and developing strat-egies to improve the implementation of school-basedpolicies/guidelines.Strengthening the relative advantage of DPA guidelinesmay require: increasing access to PE specialists at the schoolor district level, providing training, and sharing the evidencelinking PA to improved cognitive functioning and academicperformance in schools [14]. In addition, sharing the evi-dence may also enhance their perceived compatibility assome informants felt parents rather than schools shouldtake responsibility for PA. Addressing complexity may re-quire: providing more direction to schools on how to meetthe guidelines, sharing models of successful implementation,supporting ethnically diverse schools that lack parental sup-port for the guidelines, and developing an infrastructure tofacilitate tracking and documentation in higher grades. Ob-servability is an interesting characteristic to address asteachers can observe the positive impact of DPA onstudents’ health or academic performance; however, enhan-cing the benefits to teachers also seems important givenconcerns of increased workload and school expectations.Communicating the health related evdence[6-8,11-13,17,18] in support of the FBSS guidelinesappears important for bolstering their relative advan-tage and offsetting mixed feelings associated withtheir potential impact on school revenues. Similar tothe DPA guidelines, perceived compatibility may alsobe improved by communicating the evidence linkingHE with academic performance [15,16]. Issues raisedunder complexity highlighted the need to: educateteachers on how to talk sensitively about HE withoutusurping parental authority, find suitable fundraisingalternatives to minimize conflicts with PAC, minimizerevenue loss, and ensure disadvantaged students arenot negatively impacted by the guidelines. Observabil-ity can be strengthened by implementing strategies to:prevent or subsidize loss of revenues, reduce theMâsse et al. International Journal of Behavioral Nutrition and Physical Activity 2013, 10:71 Page 10 of 12http://www.ijbnpa.org/content/10/1/71number of students leaving school grounds at lunchtime, and prevent the entrepreneurial students fromselling unhealthy food.Our findings also uncovered the contextual factors thatfacilitated implementation of mandated guidelines andhighlighted the importance of available resources as a com-mon facilitator. The implementation of the DPA guidelinesin BC was preceded by the large scale dissemination of Ac-tion Schools! BC, a comprehensive whole school approachto increasing PA opportunities across six school actionzones (including PE and the classroom) [35]. The dissemin-ation of the initiative began four years before the DPAguidelines were implemented and provided schools andteachers with planning tools, equipment, training, on-goingtechnical support and a suite of better practice resourcesthat were developed for the school setting and ready to use[35]. Participants specifically highlighted this as a facilitator.In the absence of such infrastructure, it is likely that otherjurisdictions attempting to implement similar guidelinesmay be faced with more barriers than we observed. ActionSchools! BC integrated HE in 2008 which once again pro-vided the same supports to schools and teachers to modifytheir school food environment.Finally, considerable variability was observed in termsof the strategies employed to implement these guide-lines. The extent to which some strategies (e.g., using aprescriptive or non-prescriptive approach to implementthe DPA guideline) are more effective than other onesremain unknown and deserves further investigation. Inaddition, we do not know whether the DPA and FBSSguidelines significantly improved the school environ-ment. Many informants indicated the school PA andfood environment improved with the implementation ofthese guidelines; however, much more work needs to bedone to uncover whether policy strategies alone or com-bined with other approaches will help reverse thecurrent childhood obesity epidemic.ConclusionsIn conclusion, emerging evidence suggests school-basedpolicies targeting the school PA and food environmentcan influence student behaviors [4,9-13]. The enactmentof mandated guidelines/policies is considered an essen-tial step in changing the school PA and food environ-ment. However, effective implementation is critical tosuccess. Policy makers need to: monitor whether schoolsare able to implement the guidelines, provide support toschools struggling with implementation, and documentwhether the guidelines are influencing students’ behav-iors as intended. The Diffusion of Innovations modelprovides a useful framework for understanding the fac-tors that impede or facilitate implementation of guide-lines in schools.AbbreviationsDPA: Daily physical activity; FBSS: Food and beverage sales in schools;HE: Healthy eating; PA: Physical activity; PAC: Parent advisory council;PE: Physical education.Competing interestsWe the authors, have no financial or non-financial competing interests withthe content of this manuscript.Authors’ contributionsLM is the principal investigator on a Canadian Institutes of Health Researchgrant, wrote the grant, supervised and trained all research staff, developedthe data collection and analysis protocols, analyzed the data, drafted themanuscript, and finalized the manuscript. DN was a research assistant on thegrant, collected data, managed the coding of the qualitative data, draftedsections of the manuscript, and critically reviewed the manuscript, andapproved the manuscript. PJN is a co-investigator on the grant, providedinput in the grant and development of the data collection and analysisprotocols, critically reviewed the manuscript, and approved the manuscript.All authors read and approved the final manuscript.AcknowledgementsThis study was funded by the Canadian Institutes of Health Research,Institute of Nutrition, Metabolism and Diabetes (funding reference numberGIR-99715). Dr. Mâsse received salary support from the Michael SmithFoundation for Health Research (senior scholarship), the Child and FamilyResearch Institute located at the Children’s and Women’s Health Centre ofBritish Columbia (level 2 scientist award), and the Sunny Hill Foundation tocomplete this work.The authors would like to thank Eric Lorenz for coordinating the datacollection and contributing to the development of the data collection tools.Finally, the authors would like to thank Whitney Moser for collecting thedata and coding the data.Author details1School of Population and Public Health, University of British Columbia,F508-4480 Oak Street, Vancouver, BC V6H3V4, Canada. 2School of ExerciseScience, Physical and Health Education, University of Victoria, Vancouver, BC,Canada.Received: 17 November 2012 Accepted: 17 May 2013Published: 3 June 2013References1. Institute of Medicine (IOM): Preventing childhood obesity: Health in thebalance. Washington, DC: The National Academies Press; 2005.2. 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Prev Chronic Dis 2006, 3(2):A60.doi:10.1186/1479-5868-10-71Cite this article as: Mâsse et al.: From policy to practice: implementationof physical activity and food policies in schools. International Journal ofBehavioral Nutrition and Physical Activity 2013 10:71.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitMâsse et al. International Journal of Behavioral Nutrition and Physical Activity 2013, 10:71 Page 12 of 12http://www.ijbnpa.org/content/10/1/71


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