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Estrategias para mejorar la implementación de políticas o prácticas en el lugar de trabajo orientadas al tabaco, el alcohol, la dieta, la actividad física y la obesidad
Luke Wolfenden, Sharni Goldman, Fiona G Stacey, Alice Grady, Melanie Kingsland, Christopher M Williams, John Wiggers, Andrew Milat, Chris Rissel, Adrian Bauman, Margaret M Farrell, France Légaré, Ali Ben Charif, Hervé Tchala Vignon Zomahoun, Rebecca K Hodder, Jannah Jones, Debbie Booth, Benjamin Parmenter, Tim Regan, Sze Lin Yoong | 14 November 2018

Topics

Topics

Study flow diagram.
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Figure 1

Study flow diagram.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Strategies for enhancing the implementation of school‐based policies or practices targeting risk factors for chronic disease

Patient or population: School aged children (5 ‐ <18 years)

Settings: School

Intervention: Any strategy (e.g. educational materials, educational meetings, audit and feedback, opinion leaders, education outreach visits) with the intention of improving the implementation of health promoting policies, programs or practices for physical activity, healthy eating, obesity prevention, tobacco use prevention or alcohol use prevention in schools

Comparison: No intervention or usual practice (22 trials), alternate intervention (2 trials) or minimal support comparison group (3 trials)

Outcomes

Impact

Number of Participants
(trials)

Quality of the evidence
(GRADE)d

Implementation of school‐based policies, practices or programs that aim to promote healthy or reduce unhealthy behaviours relating to child diet, physical activity, obesity, or tobacco or alcohol use

We are uncertain whether strategies improve the implementation of school‐based policies, practices or programs that aim to promote healthy or reduce unhealthy behaviours relating to child diet, physical activity, obesity, or tobacco or alcohol use.

Among 13 trials reporting dichotomous implementation outcomes—the proportion of schools or school staff (e.g. classes) implementing a targeted policy or practice—the median unadjusted (improvement) effect sizes ranged from 8.5% to 66.6%. Of seven trials reporting the percentage of a practice, program or policy that had been implemented, the median unadjusted effect (improvement), relative to the control ranged from ‐8% to 43%. The effect, relative to control, reported in two trials assessing the impact of implementation strategies on the time per week teachers spent delivering targeted policies or practices ranged from 26.6 to 54.9 minutes per week.

1599 schools

(27 trials)

Very lowa,b

Measures of student physical activity, diet, weight status, tobacco or alcohol use

We are uncertain whether strategies to improve the implementation of school‐based policies, practices or programs targeting risk factors for chronic disease impact on measures of student physical activity, diet, weight status, tobacco or alcohol use

29,181 studentsf

(21 trials)

Very lowa,b,c

Knowledge, skills or attitudes of school staff involved regarding the implementation of health promoting policies, or practices

We are uncertain whether strategies to improve the implementation of school‐based policies, practices or programs targeting risk factors for chronic disease impact on the knowledge, skills or attitudes of school staff

1347 stakeholders (3 trials)

Very lowa,b

Cost or cost‐effectiveness of strategies to improve the implementation

We are uncertain whether strategies to improve the implementation of school‐based policies, practices or programs targeting risk factors for chronic disease are cost‐effective

42 schools (1 trial)

473 students (1 trial)g

Very lowa,b,d

Unintended adverse effects of strategies to improve implementation on schools, school staff or children

We are uncertain whether strategies to improve the implementation of school‐based policies, practices or programs targeting risk factors for chronic disease result in unintended adverse effects or consequences

68 schools and 4603 studentsh (2 trials)

Very lowb,c

High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aDowngraded one level due to limitations in the design.

bDowngraded one level due to unexplained heterogeneity.

cDowngraded one level due to indirectness.

dDowngraded one level due to imprecision.

eGRADE Working Group grades of evidence

fTwo trials measured student behaviour through the use of non‐student data (e.g. purchases) and did not provide student sample sizes.

gOne trial reported on the impact of an intervention on school level revenue. One trial reported on cost‐effectiveness.

hOne trial measured adverse events through the use of non‐student data (i.e. canteen profits) and did not provide student sample sizes.

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Table 1. Interventions across studies

Trial

Audit and feedback

Clinical practice guidelines

Continuous quality improvements

Distribution

of supplies

External

funding

Education

games

Education

materials

Education

meeting

Education

outreach visits

Inter‐

professional

education

Length of consultation

Local consensus

process

Local opinion

leader

Managerial supervision

Monitoring performance

of delivery

Pay for performance

Tailored intervention

The use of communication

technology

Other

Alaimo 2015

X

X

X

X

X

X

Cunningham‐Sabo 2003

X

X

X

X

De Villiers 2015

X

X

X

X

Delk 2014

X

X

X

X

X

X

French 2004

X

X

X

X

Gingiss 2006

X

X

X

X

Heath 2002

X

X

X

Hoelscher 2010

X

X

X

X

X

X

X

Lytle 2006

X

X

X

X

Mathur 2016

X

X

X

X

X

McCormick 1995

X

X

X

Mobley 2012

X

X

X

X

X

X

X

X

Nathan 2012

X

X

X

X

X

X

X

Nathan 2016

X

X

X

X

X

X

X

Naylor 2006

X

X

X

X

X

X

Perry 1997

X

X

X

X

Perry 2004

X

X

X

X

X

Sallis 1997

X

X

X

X

X

Saraf 2015

X

X

X

X

X

X

X

Saunders 2006

X

X

X

X

X

X

Simons‐Morton 1988

X

X

X

X

X

X

X

Story 2000

X

X

Sutherland 2017

X

X

X

X

X

X

Whatley Blum 2007

X

X

X

X

X

X

X

X

Wolfenden 2017

X

X

X

X

X

X

X

X

X

Yoong 2016

X

X

X

X

Young 2008

X

X

X

X

X

X
Figures and Tables -
Table 1. Interventions across studies
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Table 2. Definition of EPOC subcategories utilised in the review

EPOC subcategory

Definition

Audit and feedback

A summary of health workers’ performance over a specified period of time, given to them in a written, electronic or verbal format. The summary may include recommendations for clinical action.

Clinical practice guidelines

Clinical guidelines are systematically developed statements to assist healthcare providers and patients to decide on appropriate health care for specific clinical circumstances'(US IOM).

Educational materials

Distribution to individuals, or groups, of educational materials to support clinical care, i.e. any intervention in which knowledge is distributed. For example this may be facilitated by the Internet, learning critical appraisal skills; skills for electronic retrieval of information, diagnostic formulation; question formulation.

Educational meetings

Courses, workshops, conferences or other educational meetings.

Educational outreach visits, or academic detailing

Personal visits by a trained person to health workers in their own settings, to provide information with the aim of changing practice.

External funding

Financial contributions such as donations, loans, etc. from public or private entities from outside the national or local health financing system.

Inter‐professional education

Continuing education for health professionals that involves more than one profession in joint, interactive learning.

Length of consultation

Changes in the length of consultations.

Local consensus processes

Formal or informal local consensus processes, for example agreeing a clinical protocol to manage a patient group, adapting a guideline for a local health system or promoting the implementation of guidelines.

Local opinion leaders

The identification and use of identifiable local opinion leaders to promote good clinical practice.

Managerial supervision

Routine supervision visits by health staff.

Monitoring the performance of the delivery of healthcare

Monitoring of health services by individuals or healthcare organisations, for example by comparing with an external standard.

Other

Strategies were classified as other if they did not clearly fit within the standard subcategories.

Pay for performance – target payments

Transfer of money or material goods to healthcare providers conditional on taking a measurable action or achieving a predetermined performance target, for example incentives for lay health workers.

Procurement and distribution of supplies

Systems for procuring and distributing drugs or other supplies.

Tailored interventions

Interventions to change practice that are selected based on an assessment of barriers to change, for example through interviews or surveys.

The use of information and communication technology

Technology based methods to transfer healthcare information and support the delivery of care.

Figures and Tables -
Table 2. Definition of EPOC subcategories utilised in the review
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Table 3. Summary of intervention, measures and absolute intervention effect size in included studies

Trial

Trial name

Targeted risk factor

Implementation strategies

Comparison

Primary Implementation outcome

and measures

Effect size

P < 0.05

Alaimo 2015

School Nutrition Advances Kids (SNAK)

Nutrition

Clinical practice guidelines, educational materials, educational outreach visits, external funding, local consensus processes, tailored interventions

Usual practice or waiting‐list control

Continuous:

i) Nutrition policy score and

ii) Nutrition education and/or practice score (2 measures)

Median (range)

0.65 (0.2 to 1.1)

0/2

Cunningham‐Sabo 2003

Pathways

Nutritionc

Clinical practice guidelines, educational materials, educational meetings, educational outreach visits

Usual practice

Continuous:

Nutrient content of school meals % of calories from fat breakfast/lunch

(2 measures)

Median (range)

‐3% (‐3.3% to ‐2.7%)

1/2

De Villiers 2015

HealthKick

Nutritionc

Local opinion leaders, educational materials, educational outreach visits, education meetings

Minimal support control

Dichotomous:

% implementing a variety of policies and practices (3 measures)

Median (range)

25% (12.5% to 29.5%)

Not reported

Delk 2014

No trial name

Physical activity

Local consensus process, educational meetings, clinical practice guidelines, educational outreach visits, tailored interventions, other

Different implementation strategy

Continuous:

% of teachers that conducted activity breaks weekly (1 measure 2 comparisons)

Dichotomous:

% implementing a variety of policies and practices (2 measures 4 comparisons)

Median (range)

13.3% (11.1% to 15.4%)

Median (range)

26.5% (19.4% to 31.9%)

6/6

French 2004

Trying Alternative Cafeteria Options in Schools (TACOS)

Nutrition

Local consensus processes, tailored intervention, educational meetings, pay for performance

Usual practice or waiting‐list control

Continuous

% of program implementation (5 measures)

Median (range)

33% (11% to 41%)

5/5

Gingiss 2006

Texas Tobacco Prevention Initiative

Tobacco

Educational meetings, educational outreach visits, external funding, local consensus processes

Usual practice

Dichotomous:

% implementing a variety of policies and practices (10 measures)

Median (range) 18.5% (‐1% to 59%)

7/10

Heath 2002

El Paso Coordinated Approach to Child Health (El Paso CATCH)

Nutritionc

Educational materials, educational meetings, educational outreach visits

Usual practice

Continuous:

% fat in school meal

(2 measures)

Sodium of school meals

(2 measures)

Effect size

Median (range)

‐1.7% (‐4.4% to 1%)

Median (range)

‐29.5 (‐48 to ‐11)

1/4

Hoelscher 2010

Travis County Coordinated Approach To Child Health (CATCH) Trial

Nutrition and physical activity

Educational materials, educational meetings, educational outreach visits, pay for performance, other, the use of information and communication technology, local consensus process

Different implementation strategy

Continuous:

Mean number of lessons/or activities (5 measures)

Dichotomous:

% implementing a variety of policies and practices (2 measures)

Median (range)

0.8 (‐0.4 to 1.2)

Median (range)

4.4% (3.6% to 5.2%)

4/7

Lytle 2006

Teens Eating for Energy and Nutrition at School (TEENS)

Nutrition

Educational materials, educational meetings, local opinion leaders, local consensus processes

Usual practice or waitling‐list control

Dichotomous:

% of schools offering or selling targeted foods (4 measures)

Median (range)

8.5% (4% to 12%)

2/4

Mathur 2016

Bihar School Teachers Study (BSTS)

Tobacco

Local opinion leader, continuous quality improvement, education materials, education meeting, local consensus process

Usual practice or waiting‐list control

Dichotomous:

% implementing a variety of policies and practices (2 measures)

Median (range)

56.9% (36.3% to 77.5%)

2/2

McCormick 1995

The North Carolina School Health and Tobacco Education Project (SHTEP)/ Skills Management
and Resistance Training (SMART)

Tobacco

Educational meetings, local consensus processes, educational materials

Minimal support control

Dichotomous:

% later implementation of curriculum for school district (1 measure)

Continuous:

Mean extent later implementation for school district (% of total curriculum activities taught) (1 measure)

Effect Size (95%CI)

16.7% (‐37.7% to 64.1%)

Mean differencea

0.56%

0/2

Mobley 2012

HEALTHY study

Nutritionc

Educational games, educational meetings, external funding, tailored intervention, educational materials, educational outreach, other, the use of information and communication technology

Usual practice or waiting‐list control

Dichotomous:

% schools meeting various nutrition goals (12 measures)

Median (range)

15.5% (0% to 88%)

Not reported

Nathan 2012

Good for Kids. Good for Life

Nutrition

Educational materials, educational meetings, local consensus processes, local opinion leaders, other, monitoring the performance of the delivery of the healthcare, tailored interventions

Minimal support control

Dichotomous:

% Schools implementing a vegetable and fruit break (1 measure)

Mean difference (95%CI)

16.2% (5.6% to 26.8%)

1/1

Nathan 2016

No trial name

Nutrition

Audit and feedback, continuous quality improvement, education materials, education meeting, local consensus process, local opinion leader, tailored intervention, other

Usual practice

Dichotomous:

% implementing a variety of policies and practices (2 measures)

Median (range)

35.5% (30.0% to 41.1%)

2/2

Naylor 2006

Action Schools! British Columbia (BC)

Physical activity

Educational materials, educational meetings, educational outreach meetings, local consensus process, other, tailored Interventions

Usual practice or waiting‐list control

Continuous:

Minutes per week of physical activity implemented in the classroom (1 measure 2 comparisons)

Median (range)

54.9 minutes (46.4 to 63.4)

2/2

Perry 1997

Child and Adolescent Trial for Cardiovascular Health (CATCH)

Nutrition and physical activityd

Educational materials, educational meetings, educational outreach visits, other

Usual practice or waiting‐list control

Continuous:

% of kilocalories from fat in school lunch (1 measure)

Mean milligrams of sodium in lunches (1 measure)

Cholesterol milligrams in lunches (1 measure)

Quality of PE lesson % of 7 activities observed (1 measure)

Effect size

Mean difference (95%CI)

‐4.3% (‐5.8% to ‐2.8%)

Mean difference (95%CI)

‐100.5 (‐167.6 to ‐33.4)

Mean difference (95%CI)

‐8.3 (‐16.7 to 0.1)

Mean difference (95%CI)

14.3% (11.6% to 17.0%)

3/4

Perry 2004

The Cafeteria Power Plus project

Nutrition

Educational meetings, educational outreach visits, educational materials,

local consensus processes, other

Usual practice or waiting‐list control

Continuous:

% of program implementation (2 measures)

Mean number of fruit and vegetables available (2 measures)

Median (range)

14% (‐2% to 30%)

Median (range)

0.64 (0.48 to 0.80)

2/4

Sallis 1997

Sports, Play, and Active Recreation for Kids (SPARK)

Physical activity

Educational materials, educational meetings, educational outreach visits, length of consultation, other

Usual practice or waiting‐list control

Continuous:

Duration (minutes) per week of physical education lessons (1 measure)

Frequency (per week) of physical education lessons (1 measures)

Mean difference (95%CI)

26.6 (15.3 to 37.9)

Mean difference (95%CI)

0.8 (0.3 to 1.3)

2/2

Saraf 2015

No trial name

Nutrition, physical activity and tobacco

Educational games, educational materials, educational meetings, local consensus processes, local opinion leaders, tailored Interventions, other

Usual practice

Dichotomous:

% implementing a variety of policies and practices (6 measures)

Median (range)

36.9% (‐5.3% to 79.5%)

5/6

Saunders 2006

Lifestyle Education for Activity Program (LEAP)

Physical activity

Educational materials, educational meetings, educational outreach visits, local consensus processes, local opinion leaders, other

Usual practice or waiting‐list control

Continuous:

School level policy and practice related to physical activity from the school administrators perspective (9 measures)

N/Ab

Not reported

Simons‐Morton 1988

Go for Health

Nutritionc

Educational materials, educational outreach visits, local consensus processes, local opinion leaders, managerial supervision, monitoring of performance, other

Usual practice

Continuous:

Macronutrient content of school meals (2 measures)

N/Ab

Not reported

Story 2000

5‐a‐Day Power Plus

Nutrition

Educational meetings, other

Usual practice

Continuous:

Mean number of fruit and vegetables available (2 measures)

% of guidelines implemented and % of promotions held (4 measures)

Median (range)

1.15 (1 to 1.3)

Median (range)

38.4% (28.5% to 43.8%)

6/6

Sutherland 2017

Supporting Children’s Outcomes using Rewards, Exercise and Skills (SCORES)

Physical activity

Audit and feedback, education materials, education meeting, education outreach visits, local opinion leader, other

Usual practice or waiting‐list control

Dichotomous:

% implementing a variety of policies and practices (2 measures)

Continuous:

Physical education lesson quality score

(1 measures)

% of program implementation (4 measures)

Median (range)

19% (16% to 22%)

Mean difference

21.5a

Median (range)

‐8% (‐18% to 2%)

0/2

1/1

0/4

Whatley Blum 2007

No trial name

Nutrition

Clinical practice guidelines, educational materials, educational meetings, educational outreach visits, external funding, distribution of supplies, local consensus process, other

Usual practice or waiting‐list control

Continuous:

% of food and beverage items meeting guideline nutrient and portion criteria (6 measures)

Median (range)

42.95% (15.7% to 60.6%)

5/6

Wolfenden 2017

No trial name

Nutrition

Audit and feedback, continuous quality improvement, external funding, education materials, education meeting, education outreach visits, local consensus process, local opinion leader, tailored intervention, other

Usual practice

Dichotomous:

% implementing a variety of policies and practices (2 measures)

Median (range)

66.6% (60.5% to 72.6%)

2/2

Yoong 2016

CAFÉ

Nutrition

Audit and feedback, continuous quality improvement, education materials, tailored intervention

Usual practice

Dichotomous:

% implementing a variety of policies and practices (2 measures)

Median (range)

21.6% (15.6% to 27.5%)

0/2

Young 2008

Trial of Activity for Adolescent Girls (TAAG)

Physical activity

Education materials, education meetings, educational outreach visits, inter‐professional education, local consensus processes, local opinion leaders

Usual practice

Dichotomous:

% implementing a variety of policies and practices (7 measures)

Continuous:

Average number of physical activity programs taught (1 measure)

Median (range)

9.3% (‐6.8% to 55.5%)

Effect Size (95%CI)

5.1 (‐0.4 to10.6)

1/8

aNo measure of variability.

bDid not report aggregate results by group.

cPhysical activity was also a targeted risk factor however, this component did not meet our inclusion criteria (e.g. implementation outcomes unavailable, study staff implemented physical activity component etc.) and was therefore, not considered in our review.

dTobacco use was also a targeted risk factor however, this component did not meet our inclusion criteria (e.g. implementation outcomes unavailable) and was therefore, not considered in our review.

Figures and Tables -
Table 3. Summary of intervention, measures and absolute intervention effect size in included studies
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