How best to measure implementation of school health curricula: a comparison of three measures

The impact of school health education programs is often attenuated by inadequate teacher implementation. Using data from a school-based nutrition education program delivered in a sample of fifth graders, this study examines the discriminant and predictive validity of three measures of curriculum implementation: class-room observation of fidelity, and two measures of completeness, teacher self-report questionnaire and post-implementation interview. A fourth measure, obtained during teacher observations, that assessed student and teacher interaction and student receptivity to the curriculum (labeled Rapport) was also obtained. Predictive validity was determined by examining the association of implementation measures with three study outcomes; health knowledge, asking behaviors related to fruit and vegetables, and fruit and vegetable intake, assessed by 7-day diary. Of the 37 teachers observed, 21 were observed for two sessions and 16 were observed once. Implementation measures were moderately correlated, an indication of discriminant validity. Predictive validity analyses indicated that the observed fidelity, Rapport and interview measures were significantly correlated with post-test student knowledge. The association between health knowledge and observed fidelity (based on dual observation only), Rapport and interview measures remained significant after adjustment for pre-test knowledge values. None of the implementation variables were significantly associated with student fruit and vegetable intake or asking behaviors controlling for pre-test values. These results indicate that the teacher self-report questionnaire was not a valid measure of implementation completeness in this study. Post-implementation completeness interviews and dual observations of fidelity and Rapport appear to be more valid, and largely independent methods of implementation assessment.