Table 1.

Barriers to and facilitators of HEALTHY

Barrier or facilitator	Frequency	Illustrative quotes
Barriers to the behavior intervention component
Teacher frustration that FLASH took time away from regular course content and standardized test preparation	21	School administrator: “Teachers are reluctant to give up their instructional time. No matter how great or fun or what the benefits are, they feel so pressured to get in all of their standard curriculum.”
Student misbehavior during FLASH	16
Teachers who poorly prepared for FLASH or lacked classroom management	12
Lack of student interest and participation	9	HPC: “[As some students became older,] they act like they're too cool for school and don't participate.”
Students who developed negative attitudes toward FLASH over time	7
FLASH was not a good fit in certain classes (e.g., English and social studies)	4
Facilitators of the behavior intervention component
Teacher interest and engagement in preparing for and implementing FLASH	17	HPC: “[These FLASH teachers were] always excited to be involved and to learn about what they will be doing and how they can enhance the lessons we provide them to make the best experience possible for the kids. They're excited about it—their enthusiasm is definitely infectious. The kids pay attention and get what we're trying to teach them and really absorb the material.”
Teachers effectively managing their FLASH classes	14
Student interest and engagement in FLASH activities	11
Teachers delivering FLASH according to protocol	7
Barriers to the communications intervention component
PA announcements that were “garbled” and “hard to hear” or students simply did not pay attention to the announcements	17	HPC: “We have limited time where we can meet with the SPCs outside of their classes to train them and fully utilize them in the activities. Trainings were often rushed, and sometimes the teachers would not allow them to come down for trainings due to their behavior.”
Students who defaced or tore down HEALTHY posters	8
HEALTHY posters falling down due to adhesion problems	6
Lack of time during the school day to prepare and effectively use SPCs for HEALTHY events and activities	6
Facilitators of the communications intervention component
Student interest in student generated media (i.e., creating HEALTHY posters using images and messages from real students in intervention schools)	11	HPC: “Students were very willing to participate and enjoyed seeing themselves on the posters.”
Positive attitudes and social skills of SPCs	9
Support from school administrators and staff in hanging communications materials and coordinating HEALTHY events	4	HPC: “The SPCs are a really good group of kids. They are really outgoing and are willing to do whatever we ask them to do. They are always willing to help us.”
Barriers to the nutrition intervention component
Lack of availability of high fiber and low fat foods to bring into schools	53	Student: “They changed our lunches—took away the good stuff!”
Student resistance to food and beverage changes	46
Resistance to changing menus because of budgetary concerns	40	School food service manager: “The hardest thing at our school was just trying to get the kids used to new items.”
Rising costs of healthful and nutritious foods	32
Vending machines operated by outside parties who would not comply with HEALTHY requirements	22
Lack of cooperation from school food service personnel in implementing nutrition changes	19	RD: “Healthier items are at a higher cost and it's difficult to get those items within the school nutrition budget.”
Limited variety of nutritious, healthful products in order to vary menus	17
Lengthy and difficult process to add new healthful items to food service department bids and to change recipes	17	RD: “Pizza was very difficult to replace—difficult to find a healthy pizza that the kids liked at a price the district was willing to pay.”
Healthful meals that were time- and labor-intensive to prepare	13
Small or noisy cafeterias that were not conducive to Taste Tests and Cafeteria Learning Labs	13
State policies that were counter to HEALTHY goals (e.g., serving 2 % milk or serving meals with high calorie requirements)	11	RD: “It just takes a while for the district to want to actually make all of the changes and work with you to make the changes. It takes time to build those relationships and for them to buy into it.”
Facilitators of the nutrition intervention component
School food service managers who accepted and supported the nutrition intervention, were open to food service changes, collaborated with the RDs, and took the initiative in making changes	24	RD: “[This food service manager and her staff] are a lot more open to recommendations, new products, new recipes, new ways of cooking, new ways of presenting items, new ways of preparing food.”
School district food service directors who encouraged and supported food service managers in making changes, were responsive to RD requests to change recipes, and added more healthful products to bids	18
Schools that had already made some changes to their food and beverage service prior to the study	18	RD: “Having a nutrition supervisor and food service manager that were 200 % on board, who went above and beyond was so helpful.”
Students who were open and receptive to nutrition changes	14
Food service managers who had authority and direct control over what products were ordered and what got on school menus	7
District- or state-level policies prohibiting certain unhealthful foods and beverages being served (e.g., candy or whole milk)	7	Teacher: “There were a lot of kids who were trying to do what they were supposed to do and actually interested in making those changes.”
Availability of healthful products to replace unhealthful items	6
Barriers to the physical education intervention component
Lack of teacher preparation for and engagement in implementing HEALTHY PE lessons and activities	29	Teacher: “You're gonna have the same ones that never want to participate and always just want to be in their little social group.”
Students who do not want to participate in PE activities	14
Teachers with poor classroom management skills	12
Inadequate gym space for HEALTHY PE activities	12	Teacher: “It was just difficult sometimes to get things done or keep the kids real active cause the space was so limited.”
PE classes with too many students	11
Teachers who were resistant to the HEALTHY PE intervention	10
Poor use and management of PE equipment	10	Teacher: “[Some of my colleagues] would not really take to it because they don't want to change their old techniques and their old lesson plans.”
School administrators who did not value or support PE compared to other courses	9
PE teachers who were “burned out” and “don't care anymore”	8
Students who is behaved during PE	8	PAC: “Some of the teachers had bad attitudes or apathy. It's hard to change. And those attitudes tend to translate to bad results in the classroom.”
Students who became bored with repetitive PE activities	4
Lack of coordination and teamwork of team-taught PE classes	4
Facilitators of the physical education intervention component
Teachers who prepared for and were engaged in implementing the HEALTHY PE lessons	42	PAC: “[Two teachers at this school] are very engaged in implementing the units. They take their jobs very seriously and they read over each lesson plan ahead of time.”
PE teachers who were “highly skilled” in classroom management, content areas, and classroom instruction	20
Teachers who modified the HEALTHY PE lessons and activities to better fit their students and settings	20
PE teachers who were receptive to constructive feedback from the PACs	16	PAC: “One of the teachers was very creative with making adjustments to the lessons. She would often make them better. She came up with very creative ways to use the space so that the students would keep up with MVPA.”
Schools with ample PE equipment and adequate PE facilities (i.e., gym space or outdoor fields)	13
Students who were willing to participate in the HEALTHY PE activities	9
Schools with mandated in-service days for PE teachers aided in training HEALTHY PE teachers	9	Teacher: “Students usually want to engage in the games—they want to play and be active so they participate.”
Barriers to the HEALTHY intervention program overall
Resistance from students and teachers to HEALTHY changes	15	School district food service director: “I think it's resistance to change on the student level or with the adults that work with us—when you come in with any new concept, you are going to have some resistance.”
Lack of support for and acceptance of the program by teachers and school administrators	11
Decrease in student motivation for HEALTHY due to an attitude change during the latter part of the study	9
Facilitators of the HEALTHY intervention program overall
Students being interested in and liking HEALTHY	30	HPC: “This school is much less difficult than our other schools. The principal is easygoing. She lets us do what we need to do. We are actually appreciated at this school.”
Support for the HEALTHY program from teachers	17
Support for the program from school administrators	16
Teachers collaborating with one another	3