Table 4 Qualitative data themes from School Wellness Teams (SWT) linked to CFIR thematic structure

 Adaptability

Adaptation of modules for school needs

“We started talking about the food groups and energy. We talked about food chains and giving the food energy for the consumer. I tie it all in that way which really helped, and we’re um, next week we’re going to be hitting the respiratory system so I’ll tie in some of the switch lessons.”

“With the food service, I think I think we’re getting more tasting foods, new foods. But you know, she’s limited on her budget to what she can do. So, we’ve had people bring things in.”

 Complexity

Perceived complexity of the intervention

“Our staff has already been trained on the benefits of movement during class. It’s more a refresher of other ways to incorporate movement while learning. It doesn’t necessarily just have to be a straight break. So, we’re going to provide a few doses of training throughout the rest of the year.”

 Cosmopolitanism

Extension support

Subtheme: Part of the team

“[Extension] has brought [SWITCH] to professional development, she has put an article in the newspaper, so she is always talking about it, she’s bringing things up um, and so I really feel like our staff in on board.”

Provision of ideas and resources

“[Extension staff], I just want to tell you that your brain breaks that you guys sent us…. Our students did ask for these about every day.”

Accountability of goal setting

“I think we were trying to go more with the flow and trying to rely on our expertise so I think the things we got from [Extension] were probably more helpful because she knew what our goals were. It was focusing on certain things that we were working on here.”

Negative Case: Lack of extension support (5 SWT reported)

“I didn’t know how available [extension staff] with the [university] extension was. You know, it said she was available but never told us to what extent. And because of that, I didn’t know how much time I could use her.”

Collaborating with community/organizations

“We’ve had a couple of try-day Fridays where the kids are introduced to three new [food] items…We were able to get the donations for that which was nice.”

“We have the farmers market come to us. In the parking lot and each kid gets so much money and they actually go out and purchase things from the farmer.”

 Peer Pressure

Positive peer pressure from other schools

“I know if like the other schools [at the conference], this is their second year that the success rate is significantly higher, because the first year is super trial and error, where you’re just like stumbling through it, and forgetting you’re doing it. It made us say, ‘Oh yeah, we’re doing this? We’ve got to do something!’”

 Networks & Communications

Greater input and implementation from those outside the SWT

“I think with SWITCH it kind of makes us more aware of our wellness policy and we’ve started working more closely with [PE Teacher] because he’s here at like a couple hours in the morning so I don’t typically see him ever and so, you know, if you don’t see somebody you don’t think about it and you never talk to them. And, so, like he’s been more a part of SWITCH this year for us and I don’t know why we didn’t think about this last year.”

“I feel like across the board teachers are realizing more and more that they need to be getting up and moving these kids around.”

Lack of staff buy-in

“We purposefully brought our food services gal to the conference, because we knew that that was a big challenge. She was kind of willing to go, but now since has not been too willing to change much.”

 Culture

SWITCH experience facilitated implementation and buy-in

“This will be our third year that we do it at the Elementary and slowly but surely I think I’m getting more teachers on board to recognize the value of wellness and increased opportunities and stuff.”

“It’s nice to have a year underneath our belt, and that, just the catchy phrase of DO, VIEW, AND CHEW, I mean, It’s easy for the kids to, uh, latch onto. I know our Try-Day Friday was probably the biggest hit.”

Lack of prior wellness involvement posed challenges

“One thing that we had talked about in our meeting the other day was um, the school that is still in our district but they had already done it are already talking about doing a fitness night with the parents…We’re not sure we’re ready to tackle that in our first year, but we have talked about maybe doing, having the 4 classrooms, and doing like a Do, View, and Chew [lesson] in each classroom, and the kids rotate.”

Overwhelming staff

“I think [5th grade teacher] probably felt overwhelmed, because she took care of all fifth graders. And she was good at her lessons. Um, an- and I think that there needs to be more... instead of just a couple people like her. Really the teachers all need to buy into it.”

“I think this year ... It seems like every year I’ve been here, we’ve just been busier and busier. I think every year they seem to throw more and more stuff at the teachers that they have to get done in class.”

 Compatibility

Tension over changing the “status quo”

“[Food service director] has been here a long time, she’s in her ways. She’s not against taste testing, as long as we do it outside of her area, and have somebody else do it, and it doesn’t interrupt her ... they’re just very set in their ways, so that’s our biggest challenge.”

“Teachers have a lot of concerns about [activity breaks]: “but [activity breaks are] just going to make them rowdy” and “that’s just gonna get them hyped up and they won’t calm down and sit down” and that might initially be true when we start them and so maybe that would be a good goal for us.”

 Relative Priority

Active promotion and priority of SWITCH

“Well for our wellness environment we’ve added, um, another block of recess time. Every day from, 2:30 to 2:40 we just added that and it’s, not saying they’re naughty but like their energy levels seems to be more focused just by, it’s like taking that ten-minute break, the afternoon goes by so much better.”

 Leadership Engagement

Administrator support

“I think just the kickoff aspect of it, and have a note going home, uh, our principal sends out a note each week to the families, what’s going on, and make sure everybody knows that, uh, next week’s the kickoff, and if they hear their child talking about it, they can expand on it.”

Negative case: Poor administrator support (6 SWT reported)

“I think it’s getting some of those messages at the forefront. I know that for me it’s a struggle to get my administration on board and so I feel like I’m ... I just feel like it’s a struggle all the time to really have to fight to get in the classrooms and get time.”

“We just don’t have the time right now with no school, I mean you know…And our administrators don’t want to sound certain lessons.”

 Available Resources

Lack of resources

Time

“The thing that I find the most challenging is, we don’t have time to teach what we’re supposed to teach. And this is now on top of that. That’s the biggest challenge I have.”

Facilities/Personnel

“And I’ve also been talking with our PE teacher and the nurse, and I brought it to the school leadership team’s attention that we want to try and do something like the walking program in the mornings, but we’re very limited in our new space. We have no playground, per se.”

“It’s a part time school, [lunchroom staff] are employed by the school, but they’re part time. So, they’re on from this time to this time, so they don’t want to be anything extra because they don’t get paid for that. So, having them on, you know on a committee, on this ... you know it doesn’t work very well.”

 Access to Knowledge & Information

Online platform usability

“Fourth graders did not do any tracking [online]. The very first time, um, [teacher] said he did it, it took him 45 min of class time. And he says he just couldn’t do it again.”

“To record their information in and... it’s hard for them to get on the computers every single day to log in. So, we did a paper form last year and then once a week they would log in.”

“I was a little bit when it first started…we share chrome books and sometimes their Internet wasn’t up and powerful as it needed to be and now that we had to share it.”

 Individual Identification with Organization

Core team - school communication and perceived support

“Yesterday during PE, [food service] brought in the lunch trays. As I’m having PE! They just wheel them in and stick them and leave them in the gym. I’m like, “Class is in session.” So yeah, some logistics...”

 Other Personal Attributes

School wellness team (SWT) motivation

“My kids were with us, so, um, I sent [newsletter] out to all the teachers today and said “I would love to bring my speaker in to every classroom and show your kids this.” And so, I’ve already got [an activity break]. I’ve got a schedule already started working on. So, I’m going to take that ... and I mean, it’s a fun song, and if you play it loud, I think they’ll love it, so. These little tiny things that take two seconds ... I mean, it takes three minutes total. It’ll be fun to integrate not only our fourth and fifth graders, but actually our [whole] school.”

“We are- we’re trying very, very hard, I just want you to know. We are trying to do this on top of all of our regular responsibilities. So, school counselor, school nurse, and PE teacher for the district. Um... so we’re trying to make it as easy as we can on ourselves. So, if what we’re doing is not meeting the requirements, tell us. Otherwise, we want to do the very bare minimum.”

 Planning

SWT weekly meetings

“I think the other thing that’s a challenge that for us is that two of us on our, on our team are part-time, so [teacher] and I are part-time… and then [assistant] does before-school activities, and then after school, he’s busy too… a challenge we’ve had, is trying to figure out when’s the best time for us to meet and making sure that we don’t forget those. We don’t think it’s feasible for us to be able to meet on a weekly basis, but we’re going to try to meet every other week and see how that goes.”

Striking a balance- avoiding burdening staff

“I think [PE teacher] has his information, he’s ready to go, he’s used to doing all this kind of stuff. I think our biggest challenge is in the classroom. Trying to get one person to try to help the other two teachers put it together and, as being a school nurse, I just don’t feel comfortable with it. I’m an educator, too, but I don’t know where I can help because I feel that a lot of SWITCH is really being put on the classroom teacher.”

“I think the lessons are pretty well laid out um, Jen took the time to go through and, each lesson has a folder that the teachers can come in, grab, and are welcome to use whenever they can get that in.”

Importance of training conference

“It helped having our students [at the conference]. I was able to understand it more because I went this year because I didn’t go last year. It really helps the new people. It helps to listen to people’s ideas that they shared what worked at their schools.”

 Opinion Leaders

Changing students’ perceptions of health behavior

“I can speak for my class with what they’ve done. I’ve got a lot more that are open minded when it comes to trying things, whether it’s, you know activities, or whether it’s the foods. When we talk about, when we do our nutrition lessons and we talk about things I don’t hear as many, grunts and groans as the things, as lessons went on about, you know, food choices.”

“I watched them! Like never before have they eaten red peppers at lunch, but they ate ‘em yesterday! Isn’t it crazy when you introduce it like, at a certain time, you know, then it like, it does. I brought, um, grapefruits to [another school] yesterday, and the kids were all like, “No, we’re not eating them.” Then they were like, “We want more!”

Making parents aware of SWITCH

“I think things are happening, because I saw [a parent] at teachers’ night, she was like, ‘Oh, my daughter just asked me to buy different fruits and vegetables at the store.’”

“I actually had a mom that emailed me today saying how her son has talked about the smoothies so she wanted to know if I could give up the recipe.”

“It’s very hard. You know, we have the language barrier and a lot of our parents work… we have a large number of parents that are not engaged in what’s going on here at school.”

 Formally Appointed Internal Implementation Leaders

Shared versus sole leadership

“Just so it’s not just the two of us always making the decisions for everybody, because that’s when where we felt like we would do something, and then it would just be like, well. It didn’t seem to be well received, and I think if we get everybody involved it would be a little bit more well received.”

 Champions

Within SWT coordination

“I think what hurts us is me being here just half a day. Um because then it’s hard to follow up with Angie and get together with her because it’s just, you know, if I were here all day, then there’d be before school and after school that her and I could cross paths um so I think that’s been kind of a barrier. But overall I think it’s been successful.”

“I’m trying to keep it going, but it’s, it feels like some days it’s dying a slow death…Well, it’s because it’s so hard, um, you know. I keep thinking, “Gosh, if we had a nurse here, that was here all the time, that could kind of help spearhead [programming]. I mean [nurse] been great about, you know, willing to, to help out and everything, but busy with all her hats that she wears and it’s hard when you don’t have that dedicated person that can really just take it and run with it.”

Student leadership in programming

“We’ve gotten our youth ambassadors more involved since the last time we talked. They’ve made another video. They’ve really gotten on board with being part of our SWITCH booth at parent teacher conferences. They’re planning to do some activities, and um they made the flyer to give to the kids and that was their idea.”

“And I think we’ll see that kids leading the teachers then. Because if you give a wellness coach of the week title, they will not neglect their duties. They will remember that.”

 External Change Agents

Collaborations with community

We did a meeting with [dietician] from [local grocery store]. It went really well. She’s going to come visit the school and she gave us some ideas for our tastings and we were gonna do a demonstration at parent-teacher conferences…. She’ll just have some food out there for them to try. We did that last year and it went pretty well.”

“Our AmeriCorps person will be in the classroom next week doing nutrition and then our school nurse, she and I are going to do a little blurb on dentistry, oral health, things like that. And that’s because we had some data come up in our district after we had hygienists in the building.”

County extension leaders running programs

“She made us stickers to go in the assignment books that we had for the students. They could document how many hours of screen time they had, how many fruits and vegetables they had and how many hours of activity. We also documented how many steps, we have pedometers and so we also documented how many steps we had and we used those stickers for that.”

“[Extension staff] actually came and talked to our staff about what we had been doing and how we were working together. She came and participated in parent-teacher conferences. Her and the guidance counselor set up a station together downstairs for the parents as they were coming in.”

 Executing

Module implementation

“We don’t have much PE time. Our kids have one PE class a week usually of 40 min… So, for [PE teacher] to do these activities plus regular PE is, I would think, a challenge.”

Posters and student incentives

“Having the posters and stuff up in the gym, or in the, you know, lunch room is very easy to do. That’s easy to maintain, the kids see it all the time”

Adaptive implementation strategies

“I was pretty enthused about it because I thought it kind of brought all three things together with the do, chew, and view. So many times, it seems like people want to concentrate on just one of those, but it’s a combination of all those that really makes a difference. As a PE teacher with the lessons, those weren’t any problem to implement. I modified most of them to fit our situation.”

New wellness programs and structural changes

“In the mornings, in the winter time, we’re doing yoga, before school starts.”

“[Before SWITCH] The milk was just worded in the same, you know, usually the chocolate and the white are both up sort of in front not really separate. White in the front, chocolate in the back. Um, so that week it was probably about 65% were choosing the white over the chocolate. So then [lunchroom staff] showed the amount of sugar that’s in the white versus the chocolate and what’s the better choice and what’s the healthier choice…. and after the lesson, it went up to 85%.”

Environmental barriers/weather issues

I think we might want to, at least push it off just because we’ve had so few days of school that I think, I mean teachers are already freaking out about not having their kids in class.”

“As far as any classroom time, I have not been in the classroom because every time I’m supposed to be in the classroom, it’s a snow day.”

Staff wellness initiatives

“I had a chart by my office that if they did sixty minutes of exercise during the week, at least minimum, then they could put their name up on the chart, and it was kind of a challenge. The kids saw it when they went out for recess to see if their teacher was doing it. And we had one faculty staff member that did it all twelve weeks, so we gave her a salad cutting bowl.”

 Reflecting & Evaluating

High potential for sustainability

“It really helps and then we incorporate more brain breaks in the afternoon, I think that’s even better. Because they get up and move, you know, every few minutes and for the sustainability, this isn’t going to be too difficult to sustain at all.”

Practice to policy- Wellness policy improvement

“Last year we had our nutrition audit and I’m the Food Service Director as well as the School Nurse, and um, we added the Switch program to our Wellness Policy, and that fit in perfectly and they were very impressed that we were doing that. So, that was really nice to have that on board and in place when they came to do our audit.”

Lack of policy change, awareness

“Part of it that I struggle with and so does [colleague] is the school policy because administration and they say it was reviewed and approved at board and [colleague] didn’t even know it was reviewed. And we’re like well, we don’t do this. Does it follow? So, I think to them it’s just a document on paper but I also know their focus since last year was getting the referendum to pass, so they weren’t listening to anything that we were suggesting. So now that it’s done and in progress, perhaps we can approach them about it.”