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Cited by 84School Health and Nursing EducationObesity, Physical Activity, DietHealth Policy Implementation Science

Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review

Open access
Barnes, Courtney, McCrabb, Sam, Stacey, Fiona, Nathan, Nicole, Yoong, Sze Lin, Grady, Alice, Sutherland, Rachel, Hodder, Rebecca +3 more·2021·Translational Behavioral Medicine
DOI 10.1093/tbm/ibab037PMC PMC8320878
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Abstract

Although best practice recommendations exist regarding school-based healthy eating and physical activity policies, practices, and programs, research indicates that implementation is poor. As the field of implementation science is rapidly evolving, an update of the recent review of strategies to improve the implementation of healthy eating and physical activity interventions in schools published in the Cochrane Library in 2017 was required. The primary aim of this review was to examine the effectiveness of strategies that aim to improve the implementation of school-based policies, practices, or programs to address child diet, physical activity, or obesity. A systematic review of articles published between August 31, 2016 and April 10, 2019 utilizing Cochrane methodology was conducted. In addition to the 22 studies included in the original review, eight further studies were identified as eligible. The 30 studies sought to improve the implementation of healthy eating (n = 16), physical activity (n = 11), or both healthy eating and physical activity (n = 3). The narrative synthesis indicated that effect sizes of strategies to improve implementation were highly variable across studies. For example, among 10 studies reporting the proportion of schools implementing a targeted policy, practice, or program versus a minimal or usual practice control, the median unadjusted effect size was 16.2%, ranging from –0.2% to 66.6%. Findings provide some evidence to support the effectiveness of strategies in enhancing the nutritional quality of foods served at schools, the implementation of canteen policies, and the time scheduled for physical education.

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review update examined strategies to improve implementation of school-based healthy eating, physical activity, and obesity-prevention policies, practices, and programs. Across 30 studies, effects were highly variable, with some evidence supporting improvements in nutritional quality of foods served, canteen policy implementation, and time scheduled for physical education.

Key findings

  • The review included 30 studies: 22 from the original Cochrane review plus 8 newly identified studies. Sixteen targeted healthy eating, 11 targeted physical activity, and 3 targeted both; 19 used randomized designs (15 cluster randomized) and 11 were nonrandomized with a parallel control group.
  • Among 10 studies reporting the proportion of schools or school staff implementing a targeted policy, practice, or program versus minimal or usual practice control, the median unadjusted effect size was 16.2%, ranging from –0.2% to 66.6%.
  • Six studies reporting the percentage of an intervention program or program content implemented had a median unadjusted effect of 23.65% (range –8% to 43%); four studies reporting time per week for physical activity or PE lessons found improvements of 5.7 to 54.9 min per week (median 36.6 min/week).
  • Nineteen of 30 studies reported significant improvements in at least one implementation outcome, 3 reported no significant improvements, and 8 did not report significance tests; evidence supported improvements in nutritional quality of foods served at schools, canteen policy implementation, and PE time.

Methods

  • Systematic review update using Cochrane methodology and 2009 PRISMA reporting, replicating the previous review by Wolfenden et al.; searches covered August 31, 2016 to April 10, 2019 across multiple electronic databases and trial registries.
  • Eligible studies were randomized or nonrandomized with a parallel control group, set in schools with students predominantly aged 5–18 years, and tested strategies to improve implementation of healthy eating, physical activity, or obesity-prevention policies, practices, or programs by school staff; tobacco- or alcohol-only implementation studies were excluded.
  • Due to substantial heterogeneity, a narrative synthesis was conducted; effect sizes were calculated by subtracting control change from baseline from intervention change from baseline, reverse-scoring measures where needed, and using median effects when multiple primary implementation outcomes were reported.

Limitations

  • The paper states substantial variation across studies in implementation strategies, targeted policies/practices/programs, and outcome measures prevented meta-analysis and examination of specific strategies or combinations; only two studies tested the same combination of strategies.
  • The paper states 18 studies recruited fewer than 30 schools, 19 used nonvalidated self-reported implementation measures, and all but 2 studies were assessed as high risk of bias in multiple domains, so true improvements may be undetected.
  • The paper states the review did not search international implementation journals or hand-search reference lists, and extracted a limited range of trial characteristics and contextual factors; it also notes inconsistent terminology and inadequate reporting of implementation strategies across studies.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1093/tbm/ibab037

Cites

55 of 55 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 278 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    In total, 30 studies were included in this review update.

    “The 30 studies sought to improve the implementation of healthy eating (n = 16), physical activity (n = 11), or both healthy eating and physical activity (n = 3).”
    • Also stated in: § RESULTS · plain
      “In total, 30 studies were included in this review update.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Of the 27 studies included in the original Cochrane review covering multiple health risks, 22 studies examining healthy eating, physical activity, or obesity prevention policy or practice implemented were included in this review update.

    “Of the 27 studies included in the original Cochrane review covering multiple health risks, 22 studies [43–64] examining healthy eating, physical activity, or obesity prevention policy or practice implemented were included in this review update (see Fig. 1 for reasons for exclusion).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [43–64]

      Not checked in the free run.

  • Findingown data

    The narrative synthesis indicated that effect sizes of strategies to improve implementation were highly variable across studies.

    “The narrative synthesis indicated that effect sizes of strategies to improve implementation were highly variable across studies.”
    Quote in the paperSubstantial claim
  • Findingown data

    Among 10 studies reporting the proportion of schools implementing a targeted policy, practice, or program versus a minimal or usual practice control, the median unadjusted effect size was 16.2%, ranging from -0.2% to 66.6%.

    “For example, among 10 studies reporting the proportion of schools implementing a targeted policy, practice, or program versus a minimal or usual practice control, the median unadjusted effect size was 16.2%, ranging from –0.2% to 66.6%.”
    • Also stated in: § Overall effect of implementation support on policy, practice, or program implementation · plain
      “Among 10 studies reporting dichotomous implementation strategy outcomes—the proportion of schools or school staff (e.g., classes) implementing a targeted policy, practice, or program—versus a minimal or usual practice control, the median unadjusted (improvement) effect size was 16.2% and ranged from –0.2% to 66.6% [27, 41, 50–53, 60, 62–64].”
    Quote in the paperSubstantial claim0 of 10 sources checked
    • cites [27] Waters, 2017, Cluster randomised trial of a school-community child health promotion and obesity prevention intervention: Findings from the evaluation of fun ‘n healthy in Moreland!, BMC Public Health. source

      Not checked in the free run.

    • cites [41] Farmer, 2017, The effect of increasing risk and challenge in the school playground on physical activity and weight in children: A cluster randomised controlled trial (PLAY), Int J Obes (Lond). source

      Not checked in the free run.

    • cites [50] Lytle, 2006, Influencing healthful food choices in school and home environments: Results from the TEENS study, Prev Med. source

      Not checked in the free run.

    • cites [51] Mobley, 2012, Effect of nutrition changes on foods selected by students in a middle school-based diabetes prevention intervention program: The HEALTHY experience, J Sch Health. source

      Not checked in the free run.

    • cites [52] Nathan, 2012, Effectiveness of a multi-strategy intervention in increasing the implementation of vegetable and fruit breaks by Australian primary schools: A non-randomized controlled trial, BMC Public Health. source

      Not checked in the free run.

    • cites [53] Nathan, 2016, Effectiveness of a multicomponent intervention to enhance implementation of a healthy canteen policy in Australian primary schools: A randomised controlled trial, Int J Behav Nutr Phys Act. source

      Not checked in the free run.

    • cites [60] Sutherland, 2017, An RCT to facilitate implementation of school practices known to increase physical activity, Am J Prev Med. source

      Not checked in the free run.

    • cites [62] Wolfenden, 2017, Multi-strategic intervention to enhance implementation of healthy canteen policy: A randomised controlled trial, Implement Sci. source

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    • cites [63] Yoong, 2016, CAFÉ: a multicomponent audit and feedback intervention to improve implementation of healthy food policy in primary school canteens: A randomised controlled trial, Int J Behav Nutr Phys Act. source

      Not checked in the free run.

    • cites [64] Young, 2008, Process evaluation results from a school- and community-linked intervention: The Trial of Activity for Adolescent Girls (TAAG), Health Educ Res. source

      Not checked in the free run.

  • Findingown data

    In addition to the 22 studies included in the original review, eight further studies were identified as eligible.

    “In addition to the 22 studies included in the original review, eight further studies were identified as eligible.”
    • Also stated in: § RESULTS · plain
      “In this review update, seven new published studies [26–28, 38–42] and one unpublished study were identified for inclusion (see Fig. 1).”
    Quote in the paperNot a substantial claim0 of 8 sources checked
    • cites [26] Bremer, 2018, A program evaluation of an in-school daily physical activity initiative for children and youth, BMC Public Health. source

      Not checked in the free run.

    • cites [27] Waters, 2017, Cluster randomised trial of a school-community child health promotion and obesity prevention intervention: Findings from the evaluation of fun ‘n healthy in Moreland!, BMC Public Health. source

      Not checked in the free run.

    • cites [28] Egan, 2018, Two studies of partnership approaches to comprehensive school physical activity programming: A process evaluation and a case study, Diss Abstr Int Section A Humanit Soc Sci

      Not checked in the free run.

    • cites [38] Cheung, 2019, Impact of a Georgia elementary school-based intervention on physical activity opportunities: A quasi-experimental study, J Sci Med Sport. source

      Not checked in the free run.

    • cites [39] Egan, 2018, Partnerships for Active Children in Elementary Schools (PACES): First year process evaluation, Eval Program Plann. source

      Not checked in the free run.

    • cites [40] Evenhuis, 2018, Does implementation of guidelines for healthier school canteens result in changes in canteens and healthier purchase behaviour of students?, Obesity Facts

      Not checked in the free run.

    • cites [41] Farmer, 2017, The effect of increasing risk and challenge in the school playground on physical activity and weight in children: A cluster randomised controlled trial (PLAY), Int J Obes (Lond). source

      Not checked in the free run.

    • cites [42] Taylor, 2018, Impact of a multicomponent, school-based nutrition intervention on students’ lunchtime fruit and vegetable availability and intake: A pilot study evaluating the Shaping Healthy Choices Program, J Hunger Environ Nutr. source

      Not checked in the free run.

  • May combine two claims. 34
  • Classified as probably not a substantial claim. 28
  • The quote only partly states this claim. 1

  • May combine two claims.

    Findingown data

    The 30 included studies sought to improve implementation of healthy eating (n = 16), physical activity (n = 11), or both healthy eating and physical activity (n = 3).

    “The 30 studies sought to improve the implementation of healthy eating (n = 16), physical activity (n = 11), or both healthy eating and physical activity (n = 3).”
    • Also stated in: § Interventions · plain
      “Sixteen studies tested strategies to implement healthy eating policies, practices, or programs, 11 tested strategies targeting physical activity policies or practices, and 3 tested strategies targeting both healthy eating and physical activity.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Collectively from the 30 studies included from the original and updated review, 19 were conducted in the USA, 7 in Australia, 2 in Canada, and 1 each in New Zealand and the Netherlands.

    “Collectively from the 30 studies included from the original and updated review, 19 were conducted in the USA, 7 in Australia, 2 in Canada, and 1 each in New Zealand and the Netherlands.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Fifty-five records were excluded following full-text screening for reasons: wrong participants (n = 1); wrong intervention (n = 1); no comparator (n = 2); and inappropriate outcomes (n = 34).

    “Fifty-five records were excluded following full-text screening for the following reasons: wrong participants (n = 1); wrong intervention (n = 1); no comparator (n = 2); and inappropriate outcomes (n = 34).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    The largest study recruited 828 schools, whilst the smallest study recruited two schools.

    “The largest study recruited 828 schools [52], whilst the smallest study recruited two schools.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [52] Nathan, 2012, Effectiveness of a multi-strategy intervention in increasing the implementation of vegetable and fruit breaks by Australian primary schools: A non-randomized controlled trial, BMC Public Health. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    Studies were conducted between 1985 and 2018, with the duration of the studies varying from 20 weeks to 4 years.

    “Studies were conducted between 1985 [59] and 2018 [65], with the duration of the studies varying from 20 weeks [26] to 4 years [49].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [59] Simons-Morton, 1988, Implementing organizational changes to promote healthful diet and physical activity at school, Health Educ Q. source

      Not checked in the free run.

    • cites [65] Taylor, 2018, Evaluation of a pilot school-based physical activity clustered randomised controlled trial-active schools: skelmersdale, Int J Environ Res Public Health. source

      Not checked in the free run.

    • cites [26] Bremer, 2018, A program evaluation of an in-school daily physical activity initiative for children and youth, BMC Public Health. source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Twenty-six of the 30 included studies compared an implementation strategy to a control group or usual practice, whilst the remaining four studies directly compared different implementation strategies.

    “Twenty-six of the 30 included studies compared an implementation strategy to a control group or usual practice, whilst the remaining four studies directly compared different implementation strategies [39, 40, 46, 49].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [39] Egan, 2018, Partnerships for Active Children in Elementary Schools (PACES): First year process evaluation, Eval Program Plann. source

      Not checked in the free run.

    • cites [40] Evenhuis, 2018, Does implementation of guidelines for healthier school canteens result in changes in canteens and healthier purchase behaviour of students?, Obesity Facts

      Not checked in the free run.

    • cites [46] Delk, 2014, Promoting teacher adoption of physical activity breaks in the classroom: findings of the Central Texas CATCH Middle School Project, J Sch Health. source

      Not checked in the free run.

    • cites [49] Hoelscher, 2010, Reductions in child obesity among disadvantaged school children with community involvement: The Travis County CATCH Trial, Obesity (Silver Spring). source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    The number of implementation strategies, as characterized by the EPOC Taxonomy, ranged from two to nine (mean number of strategies = 6.5).

    “The number of implementation strategies, as characterized by the EPOC Taxonomy [32] (see Appendix III), ranged from two to nine (mean number of strategies = 6.5).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [32] Effective Practice and Organisation of Care, 2016

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The updated search identified 3,815 unique records, of which 62 full-text records and one unpublished study were assessed for eligibility.

    “The updated search (August 31, 2016 to April 10, 2019) identified 3,815 unique records of which 62 full-text records and one unpublished study (identified via the trial registry search, findings have since been published [37]) were assessed for eligibility (see Fig. 1).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [37] Nathan, 2020, Implementation of a school physical activity policy improves student physical activity levels: Outcomes of a cluster-randomized controlled trial, J Phys Act Health. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The majority of studies (n = 22) were conducted within primary (or elementary) schools, which cater for children aged 5-12 years.

    “The majority of studies (n = 22) were conducted within primary (or elementary) schools, which cater for children aged 5–12 years.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Nineteen included studies employed randomized designs (including 15 cluster randomized) and the remaining 11 studies were nonrandomized with a parallel control group.

    “Nineteen included studies employed randomized designs (including 15 cluster randomized) and the remaining 11 studies were nonrandomized with a parallel control group.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The remaining studies were conducted in middle schools (n = 5) catering for children aged 11-14 years and secondary schools (n = 3) catering for children aged 13-18 years.

    “The remaining studies were conducted in middle schools (n = 5) catering for children aged 11–14 years and secondary schools (n = 3) catering for children aged 13–18 years.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    No study tested the effectiveness of just one implementation strategy and only two studies tested the same combination of strategies.

    “No study tested the effectiveness of just one implementation strategy and only two studies [26, 38] tested the same combination of strategies.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [26] Bremer, 2018, A program evaluation of an in-school daily physical activity initiative for children and youth, BMC Public Health. source

      Not checked in the free run.

    • cites [38] Cheung, 2019, Impact of a Georgia elementary school-based intervention on physical activity opportunities: A quasi-experimental study, J Sci Med Sport. source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Six studies reported the percentage of an intervention program or program content that had been implemented; the unadjusted median effect, relative to the control, in the proportion of program or program content implemented was 23.65% (range -8% to 43%).

    “Six studies reported the percentage of an intervention program or program content that had been implemented, the effects of which were mixed [47, 55, 56, 58, 60, 61]. The unadjusted median effect, relative to the control in the proportion of program or program content implemented, was 23.65% (range –8% to 43%) [47, 55, 56, 58, 60, 61].”
    Quote in the paperSubstantial claim0 of 6 sources checked
    • cites [47] French, 2004, An environmental intervention to promote lower-fat food choices in secondary schools: Outcomes of the TACOS Study, Am J Public Health. source

      Not checked in the free run.

    • cites [55] Perry, 2004, A randomized school trial of environmental strategies to encourage fruit and vegetable consumption among children, Health Educ Behav. source

      Not checked in the free run.

    • cites [56] Perry, 1997, The Child and Adolescent Trial for Cardiovascular Health (CATCH): Intervention, implementation, and feasibility for elementary schools in the United States, Health Educ Behav. source

      Not checked in the free run.

    • cites [58] Story, 2000, 5-a-day Power Plus: process evaluation of a multicomponent elementary school program to increase fruit and vegetable consumption, Health Educ Behav. source

      Not checked in the free run.

    • cites [60] Sutherland, 2017, An RCT to facilitate implementation of school practices known to increase physical activity, Am J Prev Med. source

      Not checked in the free run.

    • cites [61] Whatley Blum, 2007, Implementation of low-fat, low-sugar, and portion-controlled nutrition guidelines in competitive food venues of Maine public high schools, J Sch Health. source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Of the 30 included studies, 19 reported significant improvements in at least one implementation outcome; 3 studies did not report any significant improvements in implementation; and 8 did not report any significance tests on such outcomes.

    “Of the 30 included studies, 19 reported significant improvements in at least one implementation outcome (including the one unpublished study) [44, 46–50, 52–58, 60–62, 64, 68]; 3 studies did not report any significant improvements in implementation [26, 43, 63] and 8 did not report any significance tests on such outcomes [27, 38, 39, 42, 51, 59, 66, 67].”
    Quote in the paperSubstantial claim0 of 10 sources checked
    • cites [44] Cunningham-Sabo, 2016, Fuel for Fun: A cluster-randomized controlled study of cooking skills, eating behaviors, and physical activity of 4th graders and their families, BMC Public Health. source

      Not checked in the free run.

    • cites [46] Delk, 2014, Promoting teacher adoption of physical activity breaks in the classroom: findings of the Central Texas CATCH Middle School Project, J Sch Health. source

      Not checked in the free run.

    • cites [47] French, 2004, An environmental intervention to promote lower-fat food choices in secondary schools: Outcomes of the TACOS Study, Am J Public Health. source

      Not checked in the free run.

    • cites [48] Heath, 2002, Evaluation of the institutionalization of the coordinated approach to child health (CATCH) in a U.S./Mexico border community, Health Educ Behav. source

      Not checked in the free run.

    • cites [49] Hoelscher, 2010, Reductions in child obesity among disadvantaged school children with community involvement: The Travis County CATCH Trial, Obesity (Silver Spring). source

      Not checked in the free run.

    • cites [50] Lytle, 2006, Influencing healthful food choices in school and home environments: Results from the TEENS study, Prev Med. source

      Not checked in the free run.

    • cites [52] Nathan, 2012, Effectiveness of a multi-strategy intervention in increasing the implementation of vegetable and fruit breaks by Australian primary schools: A non-randomized controlled trial, BMC Public Health. source

      Not checked in the free run.

    • cites [53] Nathan, 2016, Effectiveness of a multicomponent intervention to enhance implementation of a healthy canteen policy in Australian primary schools: A randomised controlled trial, Int J Behav Nutr Phys Act. source

      Not checked in the free run.

    • cites [54] Naylor, 2006, Action Schools! BC: A socioecological approach to modifying chronic disease risk factors in elementary school children, Prev Chronic Dis.

      Not checked in the free run.

    • cites [55] Perry, 2004, A randomized school trial of environmental strategies to encourage fruit and vegetable consumption among children, Health Educ Behav. source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Studies tested a range of multicomponent implementation strategies, with only two studies testing the same combination.

    “Studies tested a range of multicomponent implementation strategies, with only two studies testing the same combination [26, 38].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [26] Bremer, 2018, A program evaluation of an in-school daily physical activity initiative for children and youth, BMC Public Health. source

      Not checked in the free run.

    • cites [38] Cheung, 2019, Impact of a Georgia elementary school-based intervention on physical activity opportunities: A quasi-experimental study, J Sci Med Sport. source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Large changes were reported in a small randomized trial (12 schools per group), in the presence of a written school nutrition or policy, but not canteen policy, in a trial by Waters et al.

    “Large changes were also reported in a small randomized trial (12 schools per group), in the presence of a written school nutrition or policy, but not canteen policy, in a trial by Waters et al. [27].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [27] Waters, 2017, Cluster randomised trial of a school-community child health promotion and obesity prevention intervention: Findings from the evaluation of fun ‘n healthy in Moreland!, BMC Public Health. source

      Not checked in the free run.

  • The quote only partly states this claim.

    Findingcitation

    Several studies within the review found significant reductions in energy from fat provided by lunch meals, in magnitudes exceeding 200 kJ.

    “Several studies within the review found significant reductions in energy from fat [44, 48, 56]”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [44] Cunningham-Sabo, 2016, Fuel for Fun: A cluster-randomized controlled study of cooking skills, eating behaviors, and physical activity of 4th graders and their families, BMC Public Health. source

      Not checked in the free run.

    • cites [48] Heath, 2002, Evaluation of the institutionalization of the coordinated approach to child health (CATCH) in a U.S./Mexico border community, Health Educ Behav. source

      Not checked in the free run.

    • cites [56] Perry, 1997, The Child and Adolescent Trial for Cardiovascular Health (CATCH): Intervention, implementation, and feasibility for elementary schools in the United States, Health Educ Behav. source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Effects were mixed among the at-scale studies, with three reporting significant improvements in the majority of implementation outcomes and the remaining two studies reporting no improvement.

    “Effects were mixed among these studies, with three reporting significant improvements in the majority of implementation outcomes [37, 52, 56], whilst the remaining two studies reporting no improvement [38, 43].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [37] Nathan, 2020, Implementation of a school physical activity policy improves student physical activity levels: Outcomes of a cluster-randomized controlled trial, J Phys Act Health. source

      Not checked in the free run.

    • cites [52] Nathan, 2012, Effectiveness of a multi-strategy intervention in increasing the implementation of vegetable and fruit breaks by Australian primary schools: A non-randomized controlled trial, BMC Public Health. source

      Not checked in the free run.

    • cites [56] Perry, 1997, The Child and Adolescent Trial for Cardiovascular Health (CATCH): Intervention, implementation, and feasibility for elementary schools in the United States, Health Educ Behav. source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    In contrast to a similar review conducted within the childcare setting where a number of studies used similar score-based measures of implementation, enabling the pooling of studies for meta-analysis, such homogeneity in outcomes and measures was not evident within this review.

    “In contrast to a similar review conducted within the childcare setting [35] where a number of studies used similar score-based measures of implementation, enabling the pooling of studies for meta-analysis, such homogeneity in outcomes and measures was not evident within this review.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [35] Wolfenden, 2020, Strategies to improve the implementation of healthy eating, physical activity and obesity prevention policies, practices or programmes within childcare services, Cochrane Database Syst Rev

      Not checked in the free run.

  • May combine two claims.

    Findingnone given

    A lack of consistent terminology and inadequate reporting of employed implementation strategies across studies is an important limitation of this review.

    “Finally, a lack of consistent terminology and inadequate reporting of employed implementation strategies across studies is an important limitation of this review.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In childhood and adolescence, a healthy diet, physical activity, and healthy weight are independently associated with immediate positive health outcomes, including improved mental health and academic performance.

    “In childhood and adolescents, a healthy diet [2, 3], physical activity [4–6], and healthy weight [7] have also been found to be independently associated with immediate positive health outcomes, including improved mental health and academic performance.”
    Quote in the paperSubstantial claim0 of 6 sources checked
    • cites [2] Burrows, 2017, Associations between dietary intake and academic achievement in college students: A systematic review, Healthcare (Basel) source

      Not checked in the free run.

    • cites [3] O’Neil, 2014, Relationship between diet and mental health in children and adolescents: A systematic review, Am J Public Health. source

      Not checked in the free run.

    • cites [4] Lubans, 2016, Physical activity for cognitive and mental health in youth: A systematic review of mechanisms, Pediatrics source

      Not checked in the free run.

    • cites [5] Singh, 2012, Physical activity and performance at school: A systematic review of the literature including a methodological quality assessment, Arch Pediatr Adolesc Med. source

      Not checked in the free run.

    • cites [6] Donnelly, 2016, Physical Activity, fitness, cognitive function, and academic achievement in children: A systematic review, Med Sci Sports Exerc. source

      Not checked in the free run.

    • cites [7] OECD, 2019 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Schools provide continual access to children during a critical period of their development, making them an attractive and important setting for health promotion initiatives.

    “Schools represent an attractive and important setting for health promotion initiatives as they provide continual access to children during a critical period of their development [10, 11].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [10] World Health Organization, 2012

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    • cites [11] World Health Organization, 2017

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    Premisecitation

    Systematic reviews have identified well over 100 randomized trials of school-based interventions targeting student diet, physical activity, or obesity and have demonstrated that such interventions can be effective in reducing associated health risks.

    “Systematic reviews have identified well over 100 randomized trials of school-based interventions targeting student diet, physical activity, or obesity and have demonstrated that such interventions can be effective in reducing associated health risks [12–14].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [12] Demetriou, 2012, Physical activity interventions in the school setting: A systematic review, Psychol Sport Exerc source

      Not checked in the free run.

    • cites [13] Brown, 2009, Systematic review of school-based interventions that focus on changing dietary intake and physical activity levels to prevent childhood obesity: An update to the obesity guidance produced by the National Institute for Health and Clinical Excellence, Obes Rev. source

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    • cites [14] Liu, 2019, A systematic review and meta-analysis of the overall effects of school-based obesity prevention interventions and effect differences by intervention components, Int J Behav Nutr Phys Act. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    An unhealthy diet, inadequate physical activity, and excessive weight gain are independent risk factors for the leading causes of death and disability globally, including cancer and cardiovascular disease.

    “An unhealthy diet, inadequate physical activity, and excessive weight gain are independent risk factors for the leading causes of death and disability globally, including cancer and cardiovascular disease [1].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] Global Disease Collaborators, 2019, Health effects of dietary risks in 195 countries, 19902017: A systematic analysis for the Global Burden of Disease Study 2017

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Full texts of potentially eligible studies were examined for eligibility by a pair of review authors independently.

    “For potentially eligible studies, full texts of manuscripts were examined for eligibility by a pair of review authors independently.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Overall, the impact of strategies on the implementation of physical activity and healthy eating policies, practices, and programs was unclear, and the certainty of the evidence was low in the 2017 review.

    “Overall, the impact of strategies on the implementation of physical activity and healthy eating policies, practices, and programs was unclear, and the certainty of the evidence was low [25].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [25] Wolfenden, 2017, Strategies for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease, Cochrane Database Syst Rev

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The 2017 Cochrane review identified 27 studies, 15 of which aimed to improve the implementation of healthy eating practices, and 6 studies targeted physical activity.

    “The review identified 27 studies, 15 of which aimed to improve the implementation of healthy eating practices, and 6 studies targeted physical activity (the remaining studies pertained to alcohol and tobacco prevention) [25].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [25] Wolfenden, 2017, Strategies for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease, Cochrane Database Syst Rev

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Authors were not blind to author or journal information during screening.

    “Authors were not blind to author or journal information.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Title and abstract screening for eligible studies was performed independently by review authors in pairs.

    “Title and abstract screening for eligible studies was performed independently by review authors in pairs.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The field of implementation science is rapidly evolving and a number of implementation studies targeting healthy eating and physical activity policies, practices, and programs have been published in recent years.

    “The field of implementation science, however, is rapidly evolving and a number of implementation studies targeting healthy eating and physical activity policies, practices, and programs have been published in recent years [26–28].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [26] Bremer, 2018, A program evaluation of an in-school daily physical activity initiative for children and youth, BMC Public Health. source

      Not checked in the free run.

    • cites [27] Waters, 2017, Cluster randomised trial of a school-community child health promotion and obesity prevention intervention: Findings from the evaluation of fun ‘n healthy in Moreland!, BMC Public Health. source

      Not checked in the free run.

    • cites [28] Egan, 2018, Two studies of partnership approaches to comprehensive school physical activity programming: A process evaluation and a case study, Diss Abstr Int Section A Humanit Soc Sci

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Disagreements between review authors were resolved via consensus or, when required, by a third author.

    “Disagreements between review authors were resolved via consensus or, when required, by a third author.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    The inclusion of effect sizes is for descriptive purposes and should not be considered as pooled estimates of effect.

    “The inclusion of such effect sizes is for descriptive purposes and should not be considered as pooled estimates of effect as they do not weigh study effects by the inverse of their variance, nor do they consider study issues of study quality or design.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Discrepancies between review authors during data extraction were resolved via consensus or by a third author when required.

    “Discrepancies between review authors were resolved via consensus or by a third author when required.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Disagreements between review authors on risk of bias were resolved via consensus or, when required, by a third author.

    “Disagreements between review authors were resolved via consensus or, when required, by a third author.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    This review aligns with the 2009 PRISMA checklist and utilized Cochrane methodology to replicate the previous review by Wolfenden et al.

    “This review aligns with the reporting guidelines specified within the 2009 PRISMA checklist for systematic reviews [29] (Supplementary File I) and utilized Cochrane methodology to replicate the previous review by Wolfenden et al. [25].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [29] Liberati, 2009, The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: Explanation and elaboration, BMJ. source

      Not checked in the free run.

    • cites [25] Wolfenden, 2017, Strategies for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease, Cochrane Database Syst Rev

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Two authors independently assessed risk of bias within each included study using the Cochrane Handbook Risk of Bias tool.

    “Two authors independently assessed risk of bias within each included study using the “Risk of Bias” tool described within the Cochrane Handbook for Systematic Reviews of Interventions [33].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [33] Higgins, 2011

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Evidence-based guidelines recommend schools adopt a range of policies, practices, and programs, such as scheduling and provision of physical activity and active play opportunities, reducing the availability of unhealthy foods for sale at schools, and alignment of food services with national dietary guidelines.

    “These evidence-based guidelines recommend schools adopt a range of policies, practices, and programs, such as the scheduling and provision of physical activity and active play opportunities, reducing the availability of unhealthy foods for sale at schools and alignment of foods services with national dietary guidelines [15, 18, 19].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [15] Australian Government Department of Health and Ageing, 2013

      Not checked in the free run.

    • cites [18] Government of Canada

      Not checked in the free run.

    • cites [19] NSW Government

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Data extraction was completed independently by two authors unblinded to author and journal information.

    “Data extraction was completed independently by two authors unblinded to author and journal information.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Two studies were assessed as low risk for both sequence generation and allocation concealment.

    “Two studies were assessed as low risk for both sequence generation and allocation concealment [27, 37].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [27] Waters, 2017, Cluster randomised trial of a school-community child health promotion and obesity prevention intervention: Findings from the evaluation of fun ‘n healthy in Moreland!, BMC Public Health. source

      Not checked in the free run.

    • cites [37] Nathan, 2020, Implementation of a school physical activity policy improves student physical activity levels: Outcomes of a cluster-randomized controlled trial, J Phys Act Health. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The remaining five studies were assessed as unclear risk of detection bias due to insufficient information regarding the blinding of data collection staff.

    “The remaining five studies were assessed as unclear risk of detection bias due to insufficient information regarding the blinding of data collection staff provided [38, 50, 57, 59, 61].”
    Quote in the paperNot a substantial claim0 of 5 sources checked
    • cites [38] Cheung, 2019, Impact of a Georgia elementary school-based intervention on physical activity opportunities: A quasi-experimental study, J Sci Med Sport. source

      Not checked in the free run.

    • cites [50] Lytle, 2006, Influencing healthful food choices in school and home environments: Results from the TEENS study, Prev Med. source

      Not checked in the free run.

    • cites [57] Sallis, 1997, The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students. Sports, Play and Active Recreation for Kids, Am J Public Health. source

      Not checked in the free run.

    • cites [59] Simons-Morton, 1988, Implementing organizational changes to promote healthful diet and physical activity at school, Health Educ Q. source

      Not checked in the free run.

    • cites [61] Whatley Blum, 2007, Implementation of low-fat, low-sugar, and portion-controlled nutrition guidelines in competitive food venues of Maine public high schools, J Sch Health. source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    Four studies were assessed as low risk of bias for random sequence generation, but the method of allocation concealment was unclear.

    “While four studies were assessed as low risk of bias for random sequence generation, the method of allocation concealment was unclear [53, 60, 62, 63].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [53] Nathan, 2016, Effectiveness of a multicomponent intervention to enhance implementation of a healthy canteen policy in Australian primary schools: A randomised controlled trial, Int J Behav Nutr Phys Act. source

      Not checked in the free run.

    • cites [60] Sutherland, 2017, An RCT to facilitate implementation of school practices known to increase physical activity, Am J Prev Med. source

      Not checked in the free run.

    • cites [62] Wolfenden, 2017, Multi-strategic intervention to enhance implementation of healthy canteen policy: A randomised controlled trial, Implement Sci. source

      Not checked in the free run.

    • cites [63] Yoong, 2016, CAFÉ: a multicomponent audit and feedback intervention to improve implementation of healthy food policy in primary school canteens: A randomised controlled trial, Int J Behav Nutr Phys Act. source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    Nine studies, including eight with nonrandomized designs, were assessed as high risk of selection bias.

    “Nine studies, including eight with nonrandomized designs, were assessed as high risk of selection bias [26, 39, 43, 48, 49, 51, 52, 57, 61].”
    Quote in the paperNot a substantial claim0 of 9 sources checked
    • cites [26] Bremer, 2018, A program evaluation of an in-school daily physical activity initiative for children and youth, BMC Public Health. source

      Not checked in the free run.

    • cites [39] Egan, 2018, Partnerships for Active Children in Elementary Schools (PACES): First year process evaluation, Eval Program Plann. source

      Not checked in the free run.

    • cites [43] Alaimo, 2015, Project FIT: A school, community and social marketing intervention improves healthy eating among low-income elementary school children, J Community Health. source

      Not checked in the free run.

    • cites [48] Heath, 2002, Evaluation of the institutionalization of the coordinated approach to child health (CATCH) in a U.S./Mexico border community, Health Educ Behav. source

      Not checked in the free run.

    • cites [49] Hoelscher, 2010, Reductions in child obesity among disadvantaged school children with community involvement: The Travis County CATCH Trial, Obesity (Silver Spring). source

      Not checked in the free run.

    • cites [51] Mobley, 2012, Effect of nutrition changes on foods selected by students in a middle school-based diabetes prevention intervention program: The HEALTHY experience, J Sch Health. source

      Not checked in the free run.

    • cites [52] Nathan, 2012, Effectiveness of a multi-strategy intervention in increasing the implementation of vegetable and fruit breaks by Australian primary schools: A non-randomized controlled trial, BMC Public Health. source

      Not checked in the free run.

    • cites [57] Sallis, 1997, The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students. Sports, Play and Active Recreation for Kids, Am J Public Health. source

      Not checked in the free run.

    • cites [61] Whatley Blum, 2007, Implementation of low-fat, low-sugar, and portion-controlled nutrition guidelines in competitive food venues of Maine public high schools, J Sch Health. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Four studies were assessed as high risk for loss of clusters.

    “Four studies were assessed as high risk for loss of clusters [27, 38, 46, 60].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [27] Waters, 2017, Cluster randomised trial of a school-community child health promotion and obesity prevention intervention: Findings from the evaluation of fun ‘n healthy in Moreland!, BMC Public Health. source

      Not checked in the free run.

    • cites [38] Cheung, 2019, Impact of a Georgia elementary school-based intervention on physical activity opportunities: A quasi-experimental study, J Sci Med Sport. source

      Not checked in the free run.

    • cites [46] Delk, 2014, Promoting teacher adoption of physical activity breaks in the classroom: findings of the Central Texas CATCH Middle School Project, J Sch Health. source

      Not checked in the free run.

    • cites [60] Sutherland, 2017, An RCT to facilitate implementation of school practices known to increase physical activity, Am J Prev Med. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Study design and conductnone given

    The remaining four studies were at unclear risk of bias due to incorrect analysis.

    “Three studies were high risk of bias due to incorrect analysis [42, 46, 58], while eight studies were assessed as low risk [27, 37, 38, 41, 54, 56, 64, 67] and the remaining studies (n = 4) at unclear risk [26, 47, 55, 60].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [26] Bremer, 2018, A program evaluation of an in-school daily physical activity initiative for children and youth, BMC Public Health. source

      Not checked in the free run.

    • cites [47] French, 2004, An environmental intervention to promote lower-fat food choices in secondary schools: Outcomes of the TACOS Study, Am J Public Health. source

      Not checked in the free run.

    • cites [55] Perry, 2004, A randomized school trial of environmental strategies to encourage fruit and vegetable consumption among children, Health Educ Behav. source

      Not checked in the free run.

    • cites [60] Sutherland, 2017, An RCT to facilitate implementation of school practices known to increase physical activity, Am J Prev Med. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    One study was at unclear risk of bias due to baseline imbalance.

    “Three studies were assessed as high risk [26, 27, 42], while the remaining study [54] was at unclear risk of bias due to baseline imbalance.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [54] Naylor, 2006, Action Schools! BC: A socioecological approach to modifying chronic disease risk factors in elementary school children, Prev Chronic Dis.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Study design and conductnone given

    Eight studies were assessed as low risk of bias due to incorrect analysis.

    “Three studies were high risk of bias due to incorrect analysis [42, 46, 58], while eight studies were assessed as low risk [27, 37, 38, 41, 54, 56, 64, 67] and the remaining studies (n = 4) at unclear risk [26, 47, 55, 60].”
    Quote in the paperNot a substantial claim0 of 8 sources checked
    • cites [27] Waters, 2017, Cluster randomised trial of a school-community child health promotion and obesity prevention intervention: Findings from the evaluation of fun ‘n healthy in Moreland!, BMC Public Health. source

      Not checked in the free run.

    • cites [37] Nathan, 2020, Implementation of a school physical activity policy improves student physical activity levels: Outcomes of a cluster-randomized controlled trial, J Phys Act Health. source

      Not checked in the free run.

    • cites [38] Cheung, 2019, Impact of a Georgia elementary school-based intervention on physical activity opportunities: A quasi-experimental study, J Sci Med Sport. source

      Not checked in the free run.

    • cites [41] Farmer, 2017, The effect of increasing risk and challenge in the school playground on physical activity and weight in children: A cluster randomised controlled trial (PLAY), Int J Obes (Lond). source

      Not checked in the free run.

    • cites [54] Naylor, 2006, Action Schools! BC: A socioecological approach to modifying chronic disease risk factors in elementary school children, Prev Chronic Dis.

      Not checked in the free run.

    • cites [56] Perry, 1997, The Child and Adolescent Trial for Cardiovascular Health (CATCH): Intervention, implementation, and feasibility for elementary schools in the United States, Health Educ Behav. source

      Not checked in the free run.

    • cites [64] Young, 2008, Process evaluation results from a school- and community-linked intervention: The Trial of Activity for Adolescent Girls (TAAG), Health Educ Res. source

      Not checked in the free run.

    • cites [67] Evenhuis, 2020, The effect of supportive implementation of healthier canteen guidelines on changes in Dutch school canteens and student purchase behaviour, Nutrients source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    For the remaining studies (n = 18), the risk of reporting bias was deemed unclear as a published protocol or trial registration was not identified.

    “For the remaining studies (n = 18), the risk of reporting bias was deemed unclear as a published protocol or trial registration was not identified.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    Risk of contamination was assessed as low for the majority of clustered studies (n = 11), with only two studies assessed as high and the remaining two studies unclear.

    “Risk of contamination was assessed as low for the majority of clustered studies (n = 11), with only two studies assessed as high [42, 55] and the remaining two studies unclear [26, 37].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [42] Taylor, 2018, Impact of a multicomponent, school-based nutrition intervention on students’ lunchtime fruit and vegetable availability and intake: A pilot study evaluating the Shaping Healthy Choices Program, J Hunger Environ Nutr. source

      Not checked in the free run.

    • cites [55] Perry, 2004, A randomized school trial of environmental strategies to encourage fruit and vegetable consumption among children, Health Educ Behav. source

      Not checked in the free run.

    • cites [26] Bremer, 2018, A program evaluation of an in-school daily physical activity initiative for children and youth, BMC Public Health. source

      Not checked in the free run.

    • cites [37] Nathan, 2020, Implementation of a school physical activity policy improves student physical activity levels: Outcomes of a cluster-randomized controlled trial, J Phys Act Health. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    Despite considerable heterogeneity in the effects of implementation strategies, the findings provide some evidence to support the effectiveness of strategies in enhancing the nutritional quality of foods served at schools, implementation of canteen nutrition policies, improvements in the time scheduled for PE, and the quality of PE lessons.

    “Despite considerable heterogeneity in the effects of implementation strategies, the findings provide some evidence to support the effectiveness of strategies in enhancing the nutritional quality of foods served at schools [61], implementation of canteen nutrition policies [62], improvements in the time scheduled for PE [57], and the quality of PE lessons [54].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [61] Whatley Blum, 2007, Implementation of low-fat, low-sugar, and portion-controlled nutrition guidelines in competitive food venues of Maine public high schools, J Sch Health. source

      Not checked in the free run.

    • cites [62] Wolfenden, 2017, Multi-strategic intervention to enhance implementation of healthy canteen policy: A randomised controlled trial, Implement Sci. source

      Not checked in the free run.

    • cites [57] Sallis, 1997, The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students. Sports, Play and Active Recreation for Kids, Am J Public Health. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    As the effects of interventions may attenuate when delivered on a larger scale, the potential benefit of strategies to improve population-wide implementation of school health initiatives remains uncertain.

    “As the effects of interventions may attenuate when delivered on a larger scale, the potential benefit of strategies to improve population-wide implementation of school health initiatives remains uncertain.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    While it is possible to result in large improvements (up to 66.6%) in the implementation of policies and practices, the effects of implementation strategies are likely dependent on context, the factors impeding implementation, and the extent to which the selected implementation strategies adequately address these.

    “Such findings indicate that while it is possible to result in large improvements (up to 66.6% in this instance) in the implementation of policies and practices, the effects of implementation strategies are likely dependent on context, the factors impeding implementation, and the extent to which the selected implementation strategies adequately address these.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The median effect size across heterogeneous implementation outcomes is a meaningful summary of the effectiveness of implementation strategies.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The review extracted a limited range of the many trial characteristics, outcomes, and other structural or contextual factors that may influence implementation.

    “the review extracted a limited range of the many trial characteristics, outcomes, and other structural or contextual factors that may influence implementation.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    A search of international implementation journals and a hand search of reference lists of included studies was not conducted, which may have identified additional eligible studies to contribute to the findings of this review.

    “A search of international implementation journals and a hand search of reference lists of included studies was not conducted, which may have identified additional eligible studies to contribute to the findings of this review.”
    Quote in the paperNot a substantial claim
53 of 53

  • The authors state this as an assumption.

    No review of school-based implementation interventions has been undertaken since the 2017 Cochrane review.

    “We are not aware of any review of school-based implementation interventions undertaken since that review.”

  • The authors state this as an assumption.

    For randomized trial designs with follow-up-only implementation outcome data, baseline values are equivalent or differ only by chance.

    “Studies collecting outcome data at follow-up only for an implementation outcome were included for randomized trial designs only (i.e., equivalent baseline values assumed or differ only by chance) or if baseline values were assumed to be zero (i.e., a school policy did not exist at baseline).”

  • The authors state this as an assumption.

    For studies where a school policy did not exist at baseline, baseline values are assumed to be zero.

    “Studies collecting outcome data at follow-up only for an implementation outcome were included for randomized trial designs only (i.e., equivalent baseline values assumed or differ only by chance) or if baseline values were assumed to be zero (i.e., a school policy did not exist at baseline).”

  • The paper relies on this without support.

    The median effect size across heterogeneous implementation outcomes is a meaningful summary of the effectiveness of implementation strategies.

    “The median effect size of the primary implementation outcomes reported in this review (16.5%, range 0.2% to 66.6%) are comparable with implementation efforts in other community settings.”

  • The paper relies on this without support.

    The original review's 22 studies and the 8 newly included studies are comparable enough to combine for synthesis.

    “Collectively, from the newly included studies and the 22 studies included in the original review by Wolfenden et al. [25], most studies employed randomized controlled trial designs to test multicomponent implementation support strategies.”
5 of 5

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Much of the evidence for individual or groups of ERIC strategies remains narrowly focused, with prior systematic reviews and meta-analyses generally focusing on a specific strategy, subpopulation, disease, outcome, service setting, or geography.

    “However, much of the evidence for individual or groups of ERIC strategies remains narrowly focused. Prior systematic reviews and meta-analyses have assessed strategy effectiveness, but have generally focused on a specific strategy, (e.g., Audit and Provide Feedback) [14–16], subpopulation, disease (e.g., individuals living with dementia) [16], outcome [15], service setting (e.g., primary care Clin”

    From A systematic review of experimentally tested implementation strategies across health and human service settings: evidence from 2010-2022 (2024) · cites this paper as [17]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Detection-bias categories cover only 29 studies

    Minor

    The stated high-, low-, and unclear-risk counts sum to 29, although the review includes 30 studies.

    Reported 30 · recomputed 29

  • Study 51 is assigned both high and unclear selection risk

    Minor

    Reference 51 appears in both the high-risk and unclear-risk selection-bias lists.

  • The number of nonrandomized studies changes from 11 to seven

    Minor

    The study-design summary identifies 11 nonrandomized studies, but the confounding assessment says there were seven.

  • Discussion changes the reported median effect and range

    Minor

    The discussion reports a median of 16.5% and a minimum of positive 0.2%, whereas the results report 16.2% and a minimum of negative 0.2% for the proportion implementing a policy, practice, or program.

  • Confounding-risk groups total eight, not seven

    Minor

    The confounding assessment describes three studies at high risk and the remaining five at unclear risk. That is eight studies, not the seven stated in the same sentence.

    Reported 7 · recomputed 8

  • Reasons for exclusion account for only 38 of 55 records

    Minor

    The four stated reasons account for 38 exclusions, leaving 17 of the 55 excluded records unexplained.

    Reported 55 · recomputed 38

6 of 6

Cites

Flagged first, then by citations

Research works printed but not linked: 13

  1. Singh, 2012, Physical activity and performance at school: A systematic review of the literature including a methodological quality assessment, Arch Pediatr Adolesc Med., 166, 49, 10.1001/archpediatrics.2011.716 · DOI · Paper page
  2. OECD, 2019, The Heavy Burden of Obesity: The Economics of Prevention, 10.1787/67450d67-en · DOI
  3. World Health Organization, 2017, Report of the Commission on Ending Childhood Obesity. Implementation Plan: Executive Summary
  4. Australian Government Department of Health and Ageing, 2013, National Healthy School Canteens Pocket Guide
  5. Chriqui, 2013, School District Wellness Policies: Evaluating Progress and Potential for Improving Children’s Health Five Years After the Federal Mandate
  6. Egan, 2018, Two studies of partnership approaches to comprehensive school physical activity programming: A process evaluation and a case study, Diss Abstr Int Section A Humanit Soc Sci, 78, 64
  7. Schillinger, 2010, An Introduction to Effectiveness, Dissemination and Implementation Research. UCSF Clinical and Translational Science Institute (CTSI) Resource Manuals and Guides to Community-Engaged Research
  8. Australian Institute of Health Welfare, 2020, Australia’s Children
  9. Effective Practice and Organisation of Care, 2016, The EPOC Taxonomy of Health Systems Interventions. EPOC Resources for Review Authors
  10. Higgins, 2011, Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0
  11. Wolfenden, 2020, Strategies to improve the implementation of healthy eating, physical activity and obesity prevention policies, practices or programmes within childcare services, Cochrane Database Syst Rev, 2, CD011779
  12. Evenhuis, 2018, Does implementation of guidelines for healthier school canteens result in changes in canteens and healthier purchase behaviour of students?, Obesity Facts, 11, 119
  13. Bell, 2018, Grandparents Raising Grandchildren in the 21st Century [PhD dissertation]

Cited by

Sorted by citations

Authors
Barnes, C., McCrabb, S., Stacey, F., Nathan, N., Yoong, S. L., Grady, A., Sutherland, R., Hodder, R., Innes-Hughes, C., Davies, M., & Wolfenden, L.
Affiliations
  • Hunter Medical Research Institute (AU)
  • New South Wales Office of Preventive Health, Sydney, New South Wales, Australia
Corresponding author
Barnes, Courtney
ORCID
Venue
Translational Behavioral Medicine
Publisher
Oxford University Press (OUP)
Published
2021-06-03
Volume
11
Issue
7
Pages
1365-1410
ISSN
  • 1613-9860 (ISSN-L)
  • 1869-6716
DOI
10.1093/tbm/ibab037
PMC
PMC8320878
OpenAlex
W3164426215
Cited by
84
References
55
Citations by year
2026: 17 · 2025: 20 · 2024: 31 · 2023: 7 · 2022: 9
FWCI
2.66
Type
journal article
Language
en
Open access
Licence
Locations
  • Translational Behavioral Medicine (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Figshare (submittedVersion, cc-by)
  • NOVA (University of Newcastle Australia) (submittedVersion, cc-by)
Funders
  • New South Wales Office Preventive Health
  • Hunter New England Population Health
  • University of Newcastle
  • Hunter New England
  • Australian Research Council (DE170100382)
  • National Health and Medical Research Council (APP1150661, APP1128348)
  • Heart Foundation (101175)
Topics
  • Health Sciences › Health Professions › Speech and Hearing › School Health and Nursing Education
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
Keywords
healthy eating, physical activity, implementation strategies, implementation science, childhood obesity, school food quality, physical education, school-based intervention
MeSH terms
Diet, Healthy, Child, Health Policy, Health Promotion, Humans, Schools, Exercise

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-06.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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