The Cochrane database of systematic reviewsAug 29, 2022

Ways to improve putting school policies into practice for diet, exercise, obesity, smoking, or alcohol use

GLP-1 Therapies Weekly Brief ↗PubMed ↗DOI ↗

Updated Apr 3, 2026

Abstract

The use of implementation strategies may result in a large increase in the implementation of interventions in schools (SMD 1.04, 95% CI 0.74 to 1.34).

Implementation strategies are associated with a slight improvement in student diet (SMD 0.08, 95% CI 0.02 to 0.15) and physical activity (SMD 0.09, 95% CI -0.02 to 0.19).
The evidence suggests little to no difference in obesity outcomes (SMD -0.02, 95% CI -0.05 to 0.02).
Effects on tobacco use are very uncertain (SMD -0.03, 95% CI -0.23 to 0.18).
One trial indicates that implementation strategies may slightly increase student alcohol use (odds ratio 1.10, 95% CI 0.77 to 1.56).
Few trials reported economic evaluations of implementation strategies, with evidence graded as very uncertain.
A lack of consistent terminology for implementation strategies was identified as a limitation.

Simplified

BACKGROUND: Several school-based interventions are effective in improving child diet and physical activity, and preventing excessive weight gain, and tobacco or harmful alcohol use. However, schools are frequently unsuccessful in implementing such evidence-based interventions.

OBJECTIVES: 1. To evaluate the benefits and harms of strategies aiming to improve school implementation of interventions to address student diet, physical activity, tobacco or alcohol use, and obesity. 2. To evaluate the benefits and harms of strategies to improve intervention implementation on measures of student diet, physical activity, obesity, tobacco use or alcohol use; describe their cost or cost-effectiveness; and any harms of strategies on schools, school staff or students.

SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search was between 1 September 2016 and 30 April 2021 to identify any relevant trials published since the last published review.

SELECTION CRITERIA: We defined 'Implementation' as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised controlled trial (RCT) or non-randomised controlled trial (non-RCT)) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by students to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Given the large number of outcomes reported, we selected and included the effects of a single outcome measure for each trial for the primary (implementation) and secondary (student health behaviour and obesity) outcomes using a decision hierarchy. Where possible, we calculated standardised mean differences (SMDs) to account for variable outcome measures with 95% confidence intervals (CI). For RCTs, we conducted meta-analyses of primary and secondary outcomes using a random-effects model, or in instances where there were between two and five studies, a fixed-effect model. The synthesis of the effects for non-randomised studies followed the 'Synthesis without meta-analysis' (SWiM) guidelines.

MAIN RESULTS: We included an additional 11 trials in this update bringing the total number of included studies in the review to 38. Of these, 22 were conducted in the USA. Twenty-six studies used RCT designs. Seventeen trials tested strategies to implement healthy eating, 12 physical activity and six a combination of risk factors. Just one trial sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials used multiple implementation strategies, the most common being educational materials, educational outreach and educational meetings. The overall certainty of evidence was low and ranged from very low to moderate for secondary review outcomes. Pooled analyses of RCTs found, relative to a control, the use of implementation strategies may result in a large increase in the implementation of interventions in schools (SMD 1.04, 95% CI 0.74 to 1.34; 22 RCTs, 1917 participants; low-certainty evidence). For secondary outcomes we found, relative to control, the use of implementation strategies to support intervention implementation may result in a slight improvement on measures of student diet (SMD 0.08, 95% CI 0.02 to 0.15; 11 RCTs, 16,649 participants; low-certainty evidence) and physical activity (SMD 0.09, 95% CI -0.02 to 0.19; 9 RCTs, 16,389 participants; low-certainty evidence). The effects on obesity probably suggest little to no difference (SMD -0.02, 95% CI -0.05 to 0.02; 8 RCTs, 18,618 participants; moderate-certainty evidence). The effects on tobacco use are very uncertain (SMD -0.03, 95% CIs -0.23 to 0.18; 3 RCTs, 3635 participants; very low-certainty evidence). One RCT assessed measures of student alcohol use and found strategies to support implementation may result in a slight increase in use (odds ratio 1.10, 95% CI 0.77 to 1.56; P = 0.60; 2105 participants). Few trials reported the economic evaluations of implementation strategies, the methods of which were heterogeneous and evidence graded as very uncertain. A lack of consistent terminology describing implementation strategies was an important limitation of the review.

AUTHORS' CONCLUSIONS: The use of implementation strategies may result in large increases in implementation of interventions, and slight improvements in measures of student diet, and physical activity. Further research is required to assess the impact of implementation strategies on such behavioural- and obesity-related outcomes, including on measures of alcohol use, where the findings of one trial suggest it may slightly increase student risk. Given the low certainty of the available evidence for most measures further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

Funding

Competing interests

Some members of the review team are currently undertaking a series of randomised trials aiming to facilitate the implementation of healthy eating and physical activity policies and practices by schools (LW, CB, KO, NN, RS, RH, CW, SLY). Authors LW, NN, RS, SLY, RH, and CMW are authors on one or more of the trials conducted in Australia. For such trials, eligibility, data extraction, risk of bias assessment and GRADE assessment were carried out by review authors who were not directly involved in these studies, this is in line with the Cochrane Conflict of Interests Policy. The authors have not received any benefit, in cash or kind, any hospitality, or any subsidy derived from any source perceived to have an interest in the outcome of the review. All authors have contributed to the development of evaluation of trials examining the impact of implementation strategies in community settings, including those conducted in schools. LW is Co‐ordinating Editor, SMc is Assistant Managing Editor and Method Editor, and KO is a Method Editor for Cochrane Public Health. LW, SMc and KO were not involved in any stage of the editorial management or assessment of this review. LW: no other conflicts of interest. SMc: no other conflicts of interest. CB: no other conflicts of interest. KO: no other conflicts of interest. KN: no other conflicts of interest. NN: no other conflicts of interest. RS: no other conflicts of interest. RH: no other conflicts of interest. FT: no other conflicts of interest. EN: no other conflicts of interest. CMW: no other conflicts of interest. SLY: no other conflicts of interest.

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Ways to improve putting school policies into practice for diet, exercise, obesity, smoking, or alcohol use

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