Teams, Partners, or Champions? A Mixed-Methods Exploration of Potential Pathways of Implementation Success for Wellness Initiatives in Schools Using the Quality Implementation Framework.

Background: Local wellness policies (LWPs) promote healthy eating and physical activity practices in US schools. Achieving and sustaining quality implementation of LWPs is challenging, particularly in urban and rural schools which may lack implementation resources.

Objective: Describe implementation strategies and determinants for LWPs in "Wellness in Rural Elementary Schools" (WIRES), a national survey of US elementary schools across 4 phases using the Quality Implementation Framework.

Design: Convergent mixed-methods analysis.

Participants/setting: Five hundred fifty-nine informants (eg, principals, nurses, and teachers) from US urban and rural elementary schools completed surveys during February 2020; 50 informants (from 39 urban and rural schools) completed semistructured interviews from April to June 2020.

Main outcome measures: Surveys described implementation strategies and climate. Semistructured interviews explored implementation determinants across Quality Implementation Framework phases.

Statistical analysis performed: For surveys, we conducted descriptive statistics and Poisson logistic regression (adjusted for district clustering, stratification, and weighting). Interview data were analyzed deductively using the 4 Quality Implementation Framework phases: preparing for implementation, creating implementation structure, maintaining structure throughout implementation, and assessing future needs. Data were integrated through narrative weaving.

Results: For implementation strategies, 60% of survey respondents had "a wellness champion," 59% had a "school-level policy representative," and 37% had an "implementation team." For Quality Implementation Framework Phase 1, schools with better wellness climates had higher odds of having an implementation team (odds ratio 1.18, 95% CI 1.09 to 1.29; P < .001). In Phase 2, we identified key attributes (eg, intrinsic motivation) and recruitment strategies for wellness teams/champions and described facilitators of (eg, external partners) and threats to (eg, staff resistance) quality implementation. In Phases 3 and 4, monitoring approaches differed by implementation strategy (eg, 74% of policy representatives tracked goals compared with 43% of teams) and limited future action planning (eg, 25% integrated wellness goals into school improvement plans).

Conclusions: Findings identify how LWP implementation strategies form and are sustained and identify gap areas across implementation phases. Findings inform tailored support for urban and rural schools to initiate and carry out evidence-informed LWP implementation strategies.