Making the case for implementation fidelity: Improving outcomes for coordinated school health obesity prevention programs

Background: The HEROES Initiative is a multi-year, tri-state, school-based childhood obesity prevention intervention in K-12 schools. Based on the coordinated school health (CSH) approach and utilizing a community-university partnership, the program seeks to improve children’s nutrition and physical activity behaviors and weight status. This study describes the connection between implementation fidelity and behavioral and physiological outcomes for students participating in HEROES.

Methods: Nutrition and physical activity behavioral data were collected from students at N=18 schools in 2011-2014 using self-reported validated measures. Biometric data (e.g., height and weight) were collected by professionals and para-professionals. Implementation fidelity was assessed through observations of the school environment and interviews with key stakeholders during school site visits. Fidelity scores were determined using a quantitative scoring rubric across the CSH domains. Generalized estimating equation models were fit to determine the independent contribution of implementation fidelity on the outcomes of several eating and physical activity behaviors and students’ BMI.

Results: Schools with higher implementation fidelity were more likely to have better outcomes than schools with lower implementation fidelity for most outcomes examined. Higher implementation fidelity was associated with decreased soda consumption, increased fruit and vegetable intake, and lower BMI (ps<.05).

Conclusions: Overall, the HEROES Initiative led to improved behavior and BMI outcomes. However, there were marked differences when examining implementation fidelity, with higher implementing schools yielding better results. This study fills a gap in the literature and future school-based obesity prevention programs would benefit from focusing on implementation fidelity as an approach to establishing more effective interventions.