School health promotion is advocated. Implementation studies on school health promotion are less often conducted as effectiveness studies and are mainly conducted conventionally by assessing fidelity of “one size fits all” interventions. However, interventions that allow for local adaptation are more appropriate and require a different evaluation approach. We evaluated a mutual adaptation physical activity and nutrition intervention implemented in eight primary schools located in low socioeconomic neighborhoods in the Netherlands, namely the KEIGAAF intervention. A qualitative, multiple-case study design was used to evaluate implementation and contextual factors affecting implementation. We used several qualitative data collection tools and applied inductive content analysis for coding the transcribed data. Codes were linked to the domains of the Consolidated Framework for Implementation Research. NVivo was used to support data analysis. The implementation process varied greatly across schools. This was due to the high level of bottom-up design of the intervention and differing contextual factors influencing implementation, such as differing starting situations. The mutual adaptation between top-down and bottom-up influences was a key element of the intervention. Feedback loops and the health promotion advisors played a crucial role by navigating between top-down and bottom-up. Implementing a mutual adaptation intervention is time-consuming but feasible.

Background: The Early Care and Education (ECE) setting plays an important role in the promotion of a healthy lifestyle in young children. SuperFIT is a comprehensive, integrated intervention approach designed to promote healthy energy balance-related behaviours in preschoolers. Insight in the process of implementation and the context in which SuperFIT was implemented supports the understanding of how the intervention works in practice. This process evaluation examined factors that influenced the implementation and maintenance, as well as the (perceived) changes in the ECE setting. Methods: A mixed-methods study was conducted. SuperFIT was implemented at twelve preschools in the south of the Netherlands. The process evaluation was performed among preschool teachers, managers of the preschool organisation, and implementers. Semi-structured in-depth (group) interviews, quantitative process questionnaires, the Child-care Food and Activity Practices Questionnaire (CFAPQ) and the Environmental and Policy Assessment and Observation (EPAO) were used to evaluate the implementation and maintenance of SuperFIT and the changes in the preschool setting. The interviews were analysed using a theoretical framework based on the Implementation Framework of Fleuren and Damschröder’s Consolidated Framework for Implementation Research. Descriptive analyses were performed on the quantitative data. Results: Various intervention activities were implemented in the preschool setting. Although the intention to maintain SuperFIT was present, this was hindered by time constraints and lack of financial resources. Important factors that influenced implementation and maintenance were incongruence with current practice, limited perceived capabilities to integrate SuperFIT in daily practice, group composition at the preschools, and the perceived top-down implementation. Organizational vision and societal attention regarding healthy behaviour in general were perceived to be supportive for implementation and maintenance. Predominantly, favourable changes were seen in the nutrition- and physical activity-related practices of preschool teachers and other aspects of the social preschool environment such as the use of play materials. Limited changes were observed in the physical preschool environment. Conclusions: Several factors influenced the implementation and maintenance of SuperFIT in the preschool setting. Some factors evolved over time from hindering to facilitating, emphasising the importance of allowing sufficient time for intervention implementation. SuperFIT changed mainly the social preschool environment. Trial registration: Clinicaltrials.gov, NCT03021980, date registered: January 16, 2017, prospectively registered

The Challenge Me intervention aimed to indirectly involve parents in a school-based intervention, by challenging primary school children to perform physical activity (PA) and nutrition-related activities with their parents. The aim of this study is to gain insight in whether this was a feasible strategy to engage children and parents, especially those of vulnerable populations. An exploratory cross-sectional study design was applied. Four primary schools implemented the intervention. Data consisted of challenges completed (intervention posters) and child and family characteristics (questionnaires and anthropometric measurements). Associations between challenges performed and child and family characteristics were assessed using linear regression analysis. Of the 226 study participants, 100% performed at least one challenge, and 93% performed at least one challenge involving parents. Children who performed more PA challenges were often younger, a sports club member, lived in higher socioeconomic status neighbourhoods, of Western ethnicity and from larger families. Regarding nutrition challenges involving parents, younger children performed more challenges. There was no difference in intervention engagement regarding gender, weight status, PA preference, healthy nutrition preference, or the Family PA and Family Nutrition Climate. Challenge Me has potential in involving parents in a school-based intervention. However, certain characteristics were associated with higher involvement.