522234

research-article2014

HEJ0010.1177/0017896914522234Health Education JournalDijkman et al.

Article

Adoption of the Good Behaviour

Game: An evidence-based
intervention for the prevention
of behaviour problems

Health Education Journal

2015, Vol. 74(2) 168182
The Author(s) 2014
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DOI: 10.1177/0017896914522234
hej.sagepub.com

Marieke AM Dijkmana, Janneke Hartingb and

Marcel F van der Wala
aPublic

Health Service Amsterdam (GGD), Cluster E&G, Amsterdam, The Netherlands

of Social Medicine, Academic Medical Centre, University of Amsterdam, The Netherlands

bDepartment

Abstract
Background and objective: The Good Behaviour Game (GBG) has been shown to be effective in
preventing childhood disruptive behaviours and their long-term unfavourable health-related outcomes.
Like many other evidence-based preventive health programmes, however, its current use in Dutch primary
schools is limited, and knowledge of the factors influencing the adoption of the programme is scarce. This
study aimed to provide a theory-based description of the GBG adoption process and to examine factors
influencing this process in primary schools in Amsterdam.
Design and methods: In this mixed-methods observational study, semi-structured face-to-face interviews
with decision makers from schools that did (n=11), and did not (n=6), adopt the programme were
supplemented with structured telephone interviews with non-adopters (n=39). Based on Rogers Diffusion
Theory, the qualitative data were analysed using a deductive approach.
Results: Factors facilitating the adoption of the GBG were specific school needs and problems, formulated in
educational rather than health terms, and the visibility of the programmes positive effects. Factors impeding
adoption were competing programmes in schools and being unaware of favourable funding opportunities. In
contrast to previous studies, time investment did not play an impeding role.
Conclusion: Adoption of prevention programmes in schools may benefit from framing dissemination
strategies in educational terms, and using self-assessment procedures to reveal specific needs/problems and
to create a readiness to change. In addition, adoption may benefit from using active dissemination strategies,
including opinion leaders reporting their positive experiences with the programme, and the termination of
any ineffective programmes that schools currently use.

Keywords
Evidence-based programmes, behaviour problems, primary schools, adoption, dissemination

Corresponding author:
Marieke AM Dijkman, Cluster E&G, Public Health Service Amsterdam (GGD), P.O. Box 2200, 1000 CE Amsterdam,
The Netherlands.
Email: mdijkman@ggd.amsterdam.nl

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Introduction
Childhood aggressive and disruptive behaviours are commonly observed and well-documented
risk factors for many later unfavourable health-related outcomes (Fothergill and Ensminger, 2006;
Reef etal., 2009). As schools in Europe provide access to almost all children, they are key settings
for preventing these detrimental behaviours in children (Wilson and Lipsey, 2007). Overview studies widely endorse the positive impact of school mental health and social and emotional learning
(SEL) programmes. Beneficial effects have been found on pro-social behaviours, social-emotional
competencies, conduct and internalising problems, aggressive and disruptive behaviours, bullying,
and aspects of childrens learning behaviour and attitudes towards school (Durlak etal., 2011;
Weare and Nind, 2011; Wilson and Lipsey, 2007). In addition to these beneficial effects, there is
also a strong case for the implementation of school-based preventive health programmes from a
cost-saving perspective (Knapp etal., 2011). However, the actual use of these programmes remains
limited (Durlak etal., 2011; Hanley etal., 2010; Walker, 2004; Wilson and Lipsey, 2007).
Increased use of effective prevention programmes in schools requires a better understanding of
the dissemination and adoption processes (Adi etal., 2007; Flaspohler etal., 2008; Saul etal.,
2008). Unfortunately, few studies have specifically focused on these topics (Adi etal., 2007; Ball,
2011; Greenberg, 2004). Available studies show that factors such as strong leadership (Ballew
etal., 2010; Deschesnes etal., 2010), a good fit between the new programme and the needs of
individual schools (Noonan etal., 2009; Rohrbach etal., 2005), and the schools readiness to
change (Fixsen etal., 2013; Flaspohler etal., 2008) influence the adoption process. Sufficient time
to implement a new programme (Dusenbury etal., 2003; Fagan etal., 2009; Rohrbach etal., 2005)
and acceptable costs and sufficient funding (Ballew etal., 2010; Dusenbury etal., 2003; Kramer
etal., 2000) are also important factors for adoption. Evidence for effective strategies for the adoption of prevention programmes in schools is also limited (Backer, 2000; Fagan etal., 2009;
Johnstone etal., 2006; Rohrbach etal., 2005). Gaining a better understanding of the factors influencing the adoption process is necessary as, according to the RE-AIM model (Glasgow etal.,
1999), sufficient children should be reached by effective school mental health programmes in order
to produce significant effects in the population.
The Netherlands faces problems in the adoption of evidence-based programmes in schools.
Although effective school mental health and SEL programmes, such as Providing Alternative
Thinking Strategies (PATHS) (Greenberg etal., 1998), Friends for Life (Barrett etal., 2005), and
the Good Behaviour Game (GBG) (Barrish etal., 1969) are available, these programmes are not
widely used in Dutch primary schools (Onderwijsraad, 2006). An opportunity to gain insight into
the adoption process of an evidence-based school programme arose in the summer of 2007 when
Amsterdam local authorities decided to finance the city-wide implementation of the GBG in primary schools.
The GBG is a programme that aims to reinforce pro-social behaviour and reduce aggressive and
disruptive behaviour in the classroom, by creating a positive and predictable school environment,
by improving classroom structure, by facilitating pro-social peer interactions, and by focusing on
and systematically rewarding appropriate behaviour. The programmes primary purpose is prevention of disruptive behaviour problems, such as conduct problems or symptoms of attention deficit
hyperactivity disorder (ADHD), among primary school children. The GBG is reported to be effective in preventing and reducing behaviour problems in the classroom (Embry, 2002; Tingstrom
etal., 2006; Van Lier etal., 2004, 2005) and has positive long-term effects on, for example, smoking, drug and alcohol abuse, antisocial personality disorder, violent and criminal behaviour and
suicidal ideation (Kellam etal., 2008; Petras etal., 2008; Poduska etal., 2008; Van Lier etal.,
2009; Wilcox etal., 2008). In addition, the GBG is highly acceptable to pupils and teachers (Embry,
2002; Tingstrom etal., 2006).

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Health Education Journal 74(2)

The aim of the present study is to provide a theory-based description of the adoption process
relating to the GBG and the factors influencing this process. The findings will contribute to the
limited knowledge on the adoption of evidence-based school SEL and mental health
programmes.

Methods
Context
In the summer of 2007, the Amsterdam municipal authorities decided to finance city-wide implementation of the GBG. From then onwards, the Public Health Service of Amsterdam disseminated
the GBG using various strategies, e.g. sending e-mails and providing written materials to all local
primary schools and school boards. In addition, telephone calls were made to all schools, followed
by personal visits by the GBG coordinator of the Public Health Service of Amsterdam when
schools showed interest. The aim of these strategies was to inform all primary schools and school
boards in Amsterdam about the content, aims and funding opportunities of the GBG. Schools were
also given information about activities in the implementation phase in which teachers received
three afternoons of training and were coached in their classrooms during 10 60-min classroom
observations by trained advisors from the school advisory services.

Intervention
In the GBG, teachers are trained to explicitly define and systematically reward appropriate behaviour, ignore inappropriate behaviour, and facilitate interaction between disruptive and non-disruptive children. Teachers and children establish positively formulated class rules, which are
represented by pictograms. After observing children in terms of carefully pre-defined appropriate
behaviours in the classroom, teachers assign the children to small teams containing equal numbers
of disruptive and non-disruptive children. Each team receives a number of cards. During the game,
teachers take away a card when a pupil violates one of the rules. Teams are rewarded when at least
one card remains on their desk at the end of the playing time. Playing the GBG encourages children
to manage their own and their teammates behaviour through a process of group reinforcement and
mutual self-interest. At the beginning of the year, the GBG is played three times a week for 15 min
per session. During the course of the year, the amount of time spent playing the GBG is increased.
By the end of the year, when the users have institutionalised the GBG, it is played at different times
throughout the day, during different activities and in a variety of situations.

Theoretical framework
Rogers Diffusion of Innovation Theory (Rogers, 2003) provides a useful theoretical basis for
studying adoption processes (Berwick, 2003). The present study used an adapted version of a previously used diffusion of innovations framework (Harting etal., 2009). The theoretical framework
is outlined in Figure 1.
The theory distinguishes between five successive stages that innovations have to pass through
to become fully adopted, implemented and maintained. In the first stage (the knowledge stage),
people become aware of the existence of the innovation (awareness knowledge) and learn how the
innovation works (how-to knowledge). Important aspects in the second persuasion stage are general attitudes towards innovation and characteristics of the innovation such as relative advantage,
compatibility, credibility, visibility, complexity and trialability. The decision whether or not to
adopt the innovation takes place in the third decision stage, during which people often gather

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Dijkman et al.

Situational factors

previous practice
task responsibility
needs / problems

Nature of innovation decision

collective decision
authority decision

1. Knowledge stage

awareness knowledge

how-to knowledge
2. Persuasion stage

attitude

innovation characteristics
relative advantage
compatibility
credibility
visibility
complexity
trialability
3. Decision stage [adopt/reject]

gathering additional information

initial try out

skills

Communication
channels

target group
source
message
networks

Facilitators

funding
change agent
competing innovations
time investment

4. Implementation stage [actual user]

competence

experience
5. Confirmation stage [maintenance]

reinforcement

feedback

Figure 1. Theoretical framework for the diffusion process (adapted from Rogers, 2003 and Harting etal.,
2009)

further information about the innovation, start to try it out, and monitor trials by others. An estimation of the availability of the necessary skills is also made in this stage. In the fourth implementation stage, people actually start using the innovation; key factors are their competencies and
experiences. Finally, in the confirmation stage, the use of the innovation becomes part of the
routine guided by reinforcement and positive feedback. The adoption process as a whole is influenced by situational factors, for example previous practice, task responsibility and the perceived
need or problems, and by the nature of the innovation decision (collective, authority or optional).
Issues related to the communication channels used (e.g. target group, source, message and networks) and to the available facilitators (e.g. funding opportunities, the presence of a change
agent, competing innovations and time investment) are regarded as mediating factors influencing
different stages of the adoption process.

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All primary schools in

Amsterdam
(n=186 schools)

Schools adopting the GBG

(n=18 schools)

(n=11 schools; 15
respondents)

Schools not adopting the GBG

(n=168 schools)

(n=6 schools; 6
respondents)

Face-to face interviews

(n=39 respondents)
Telephone interviews

Figure 2. Schools adopting and not adopting the Good Behaviour Game (GBG) and participating in
interviews

Design and sample

This mixed-methods observational study began after the dissemination strategies were implemented by the Public Health Service of Amsterdam. During the 20082009 school year, of the 186
primary schools in Amsterdam 18 decided to adopt the GBG (Figure 2). Our intention was to
interview a sample of decision makers (school administrators or internal school advisors) from 10
adopting and 10 non-adopting schools. As a convenience sample, decision makers were asked to
participate in a face-to-face interview as soon as they had decided to adopt or reject the GBG. Of
the 18 adopting schools, decision makers in 11 were interviewed. After that, no additional information was obtained (theoretical saturation).
Recruiting respondents from non-adopting schools proved much more difficult. After 6
months of recruiting using e-mail and telephone, respondents from only six non-adopting
schools were willing to participate in a face-to-face interview. Since the point of theoretical
saturation for this group had not been reached, we decided to use short quantitative structured
telephone interviews as an additional research method. For that, we took a random sample of
40 of the 162 non-adopting schools in Amsterdam. This sample was expected to be sufficiently
representative to collect generalisable quantitative data on the topics previously raised in the
face-to-face interviews.
The study was reviewed and approved by the Medical Ethical Committee of the VU Medical
Centre Amsterdam.

Measures
In accordance with the study objective, our measurement instruments aimed to develop an inventory specifically of the adoption process: that is, of the first three stages in the theoretical framework depicted in Figure 1.

Semi-structured interview (face-to-face)

A semi-structured interview, covering all constructs of the adoption process (Figure 1) was used
to gain information about the factors that might influence the GBG adoption process. All the

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Dijkman et al.

constructs from the theoretical framework were included in the interview. Examples of questions are: Were you aware of the existence of the GBG? (knowledge stage); What is your
attitude towards the GBG?(persuasion stage), How and where did you search for additional
information about the GBG? (decision stage); How do you feel about the schools responsibility in preventing behaviour problems? (situational factors); Who was involved in the decision
about adopting or rejecting the GBG in your school? (nature of the innovation decision); How
were you informed about the GBG? (communication channels) and In what way did the funding of the GBG influence the adoption decision?(facilitators). After their initial answers to
these questions, the respondents were invited to further elaborate on the subjects raised in relation to the various theoretical constructs. The interviews lasted about 60 min, took place in
school, and were conducted by two members of the research team (10 interviews by MD and
seven by a research assistant)

Structured interview (telephone)

The structured telephone interviews were organised around the same theoretical concepts as the
semi-structured face-to-face interviews. Based on the results of these interviews, we included a
selection of the most salient items in the structured telephone interviews (Table 1). Topics included:
familiarity with the funding opportunities of the GBG, knowledge about the content and the aims
of the GBG, expectations about the GBG, and reasons for not adopting the GBG. Response categories were close-ended, meaning that the researcher asked the questions and ticked the best fit for
respondents answers on the form. The interviews lasted about 10 min and were conducted by a
research assistant.

Data analysis
The audio-taped semi-structured face-to-face interviews were transcribed verbatim and imported
as text documents in a software programme for qualitative analysis (MAXQDA version 10). For
the qualitative content analysis, we used a deductive approach (Ritchie and Spencer, 1994), which
included a systematic analysis of the data based on an analytic framework featuring key concepts
and variables as initial coding categories (Pope etal., 2000; Ritchie and Spencer, 1994). Data were
coded using the framework variables as the main codes (e.g. situational factors, knowledge stage)
and their further specifications as sub-codes (e.g. previous practice, awareness knowledge ), while
leaving room for the identification of new concepts and variables as a means to further specify and
refine the initial analytical framework (Pope etal., 2000).
The initial coding was carried out by the first author (MD), who was familiar with adoption/
implementation processes, and experienced in qualitative content analysis. The preliminary data
categorisation was then checked by and discussed with the second author (JH), who is experienced in the use of a deductive framework approach to analysis and its application to adoption/
implementation studies in particular. This resulted in a further specification of the definitions of
some of the sub-codes and rearrangement of some of the text fragments into different theoretical
constructs and variables. This categorisation was followed by a process of constant comparison
(Pope etal., 2000), during which the content of the codes and sub-codes was systematically compared for adopting and non-adopting schools to identify the factors that had specific influence on
the adoption process.
Descriptive analyses of data derived from the structured telephone interviews were analysed
with SPSS version 17.

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Table 1. Results of telephone interviews with non-participators

Are you familiar with the fact that the GBG is offered for free?
No
Yes
Channel
E-mail sent to school
Network of internal advisors
School boards
Colleagues at other schools
Other channels
Do you have knowledge about the content and the
aims/effects of the GBG?
No
Yes
Content
Game with cards
Clear rules
Rewards
Teams
Positive feedback
Other
Aims and effects
Increasing on-task behaviour
Reducing problem behaviour
Reducing ADHD-like behaviour
More structure in classroom
More silence in classroom
Positive classroom climate
Learning social skills
Improving learning achievements
Improving teachers skills
Improving class management
Other
What are your expectations of the GBG?
No expectations
Expectations
Interesting
Positive/good
Other
What is the most important reason for not
participating in the GBG?
Not aware of the available funding
No knowledge about content of the GBG
No priority
Teachers are overburdened
Does not correspond to schools views

18
21

46
54

8
3
2
3
5

38
14
10
14
24

24
15

62
38

5
7
5
2
6

33

47
33
13
40

5
3
3
1

33
20
20
7

6
2

4
30
9
1
6
3

10
1
3
1
5

40
13

27

77
23
11
67
33

26
3
8
3
13
(Continued)

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Dijkman et al.
Table 1. (Continued)

What is the most important reason for not

participating in the GBG?
Does not correspond to schools long-term plan
No need
School uses other programme/methods to address problem
behaviour
School is busy implementing quality programme
School is under supervision of inspection
Busy implementing other programmes
Dont know
Wanted to adopt the GBG but registration failed

1
7
16

3
18
41

4
2
5
3
2

10
5
13
8
5

Results
Respondent characteristics
Semi-structured face-to-face interviews were held with 15 decision makers from 11 of the 18
schools that adopted the GBG, and with six decision makers from six of the non-adopting schools
(Figure 2). Both sub-samples covered a wide but largely comparable range in terms of the respondents number of years of work experience in the school (318 years for adopting versus 619 years
for non-adopting), the number of pupils per school (149500 for adopting versus 73339 pupils for
non-adopting) and the percentage of pupils with a low socio-economic status (SES) and non-Dutch
ethnic background (1683% for adopting versus 073% for non-adopting schools).
The telephone interviews were held with decision makers from 39 schools (response rate 98%);
one school could not be contacted even after several attempts. The 39 respondents came from a
diverse range of schools in terms of numbers of pupils (range 62848) and the percentage of pupils
with a low SES and non-Dutch ethnic background (081%).

Semi-structured and structured interviews

The results of the semi-structured and structured interviews are described below according to the
theoretical framework and are reported in an integrated form.

Knowledge stage
The semi-structured interviews showed that decision makers from both adopting and non-adopting
schools were aware of the existence of the GBG and the available funding. This awareness knowledge was less evident in respondents from non-adopting schools who were interviewed by telephone. Of this latter group, almost 50% were not familiar with the availability of funding for the
GBG, and about 25% mentioned lack of knowledge about funding opportunities as the main reason
for not adopting.
Only a few of the respondents in the semi-structured interviews had how-to knowledge concerning the aims/content of the GBG. There were no differences in how-to knowledge themes
mentioned by adopting and non-adopting schools. Similar results were found in the structured
telephone interviews: these showed that about 35% of the decision makers in non-adopting
schools did not know about the aims/content of the GBG and about 75% had no outcome expectations for the GBG.
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Persuasion stage
Respondents from adopting schools more often expected specific relative advantages from the
GBG. Positive effects were expected (in particular) for group atmosphere, tranquillity and structure in the classroom, on-task behaviour and for teachers pedagogical skills. All these advantages
were formulated in educational terms.
Most of the respondents from adopting schools mentioned that the GBG was compatible with
existing methods and other school programmes. They also said that the GBG was compatible with
the schools views about pedagogical climate.
I think that the most important reason for participation is that you can easily make the GBG fit in with
whatever you do, or whatever way you do it [respondent 10]

Opinions on the importance of the credibility of the GBG were mixed. Some respondents regarded
the fact that the GBG is evidence based as a very strong influencing factor in the adoption
decision.
I think thats quite important. Because if you start something and you want to make it work in the school,
in the long run as well, you have to know for sure that its good. [respondent 11]

Other decision makers did not consider this to be important at all, and considered positive experience from their own practice to be much more important.
If its advantageous to your school, its positive. Then its not important if there is research evidence or not.
It should offer us something. Thats what counts for us. [respondent 14]

Others regarded both scientific evidence and practical experience as equally important for the
adoption decision.
During the initial try-out of the programme, almost all actual users became very enthusiastic
about the effects of the GBG; these were noticeable directly in the classrooms (visibility).
Thanks to the GBG, one of the teachers was finally capable of doing what she had to do, namely teaching
children [respondent 17].

The respondents did not mention the complexity or trialability aspects of the GBG. There were no
differences between adopters and non-adopters regarding their opinions on any of the factors in the
persuasion stage, except for compatibility and visibility. Regarding compatibility, particularly the
non-adopters strongly believed that the GBG was not fully compatible with existing methods and
views.

Decision stage
Decision makers at three adopting schools had searched for additional information, especially on
the Internet. Two had contacted other schools that had already implemented the GBG to ask for
further information (trial by others); respondents from non-adopting schools did not mention this.
In general, respondents from both adopting and non-adopting schools thought that teachers from
their school had sufficient skills to be able to implement the GBG.

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Situational factors
None of the respondents mentioned anything about previous practice with the GBG.
Both adopting and non-adopting schools felt that they had a task responsibility in terms of preventing problem behaviour in children.
Thats definitely our job, 100%, even more than 100%. If we didnt work on that, how would the children
be able to learn? [resp. 15]

Respondents from almost every adopting school perceived specific needs and problems that could be
met and solved by implementing the GBG. Problems mentioned by respondents were: children with
poor on-task behaviour, showing lack of attention and not obeying rules, noisy classrooms, and teachers poor pedagogical skills. These needs and problems were presented in educational terminology.
There were a lot of discipline problems in the classroom and the playground. Children did not obey
rules and had trouble concentrating. We also wanted to create a tranquil atmosphere in the school.
[respondent 14]

The respondents from non-adopting schools either did not mention these problems and needs, or said
that they already used other programmes to overcome these problems (see also facilitators below).

Nature of innovation decision

Several schools perceived the decision by the Amsterdam municipal authorities to finance city-wide
implementation of the GBG as an authoritarian decision. Although schools were not obliged to participate in the GBG, they felt that adopting and implementing the GBG had been forced upon them.
I think its good that schools have the freedom to participate or not, because I think the municipal
authorities cant tell Amsterdam schools how to work. That affects your autonomy. I think its great that the
offer is there, because its an opportunity for schools to work with it, but there should be no obligation for
all schools to do this. [respondent 8]

Within almost every school, the nature of the adoption decision was more or less collective, meaning that teachers were involved somewhere along the process of decision making.
There were no differences in the way that adopting and non-adopting schools described this
decision.

Communication channels
Respondents from adopting and non-adopting schools mentioned many different channels by
which information about the GBG had reached them, for example e-mails from the Amsterdam
Public Health Service, through networks of internal advisors, and via contact with other schools,
parents, the school advisory service, and professional literature. Schools explicitly appreciated
having received information about the GBG by e-mail from the Amsterdam Public Health Service.

Facilitators
The fact that GBG was funded by the Amsterdam municipal authorities influenced the adoption
decision in various ways. Some respondents stated that the main reason for adopting the GBG was

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that it was offered for free, that is, because implementing the GBG would be costly they could not
have done this without the funding. Some regarded municipal funding as important but not decisive (i.e. it gave an extra push), whereas others said the funding had not influenced their
decision.
Its a lot of money, but if wed thought it had to be done, we would have done it anyway. [respondent 15]

In this respect, the adopting and non-adopting schools equally endorsed these various points of
view.
Time investment was not important in the adoption decision; in the semi-structured interview
only two school representatives mentioned its influence on their decision.
The presence of competing programmes was particularly important for respondents from nonadopting schools. Because many of them were implementing other programmes with the same or
different objectives, they chose not to adopt the GBG.
Were already heavily engaged in cooperative learning and are working hard to improve pupil behaviour,
so we thought it would be superfluous to do the GBG as well. [respondent 3]

However, most of these competing programmes were in fact not evidence based.

Discussion
This study identified factors influencing the adoption of the GBG, as an example of an evidencebased school prevention programme. An important finding was that the schools specific needs and
problems were a strong facilitating factor in the adoption process and decision. Of special note was
the fact that these perceived needs and problems were explicitly formulated in educational terms
and not in terms of health or health promotion. This finding confirms earlier suggestions that health
promotion dissemination strategies for programmes like the GBG should be tightly tailored to the
attainment of educational goals, such that effective programmes provide solutions to needs (e.g.
concerns about academic performance) identified as being important by the schools (Butler etal.,
2010; Deschesnes etal., 2010; Jourdan etal., 2011; Weare and Nind, 2011).
At the non-adopting schools, needs and problems were either perceived as not existing or as
already having been addressed by other competing programmes (that were not supported by as
strong an evidence base). First, this finding suggests that some kind of assessment could be useful
to identify the schools current needs and problems (Jourdan etal., 2011; Stormont etal., 2011).
Such an assessment could function as a tool to increase the receptiveness and readiness to change
towards innovations, both of which have been described as important facilitators for adoption
(Fixsen etal., 2013; Flaspohler etal., 2008). According to Fixsen etal. (2013), readiness should be
assessed, developed and sustained to create the required awareness that a problem is actually there,
as a first step towards taking action to solve it. Such an assessment should preferably include all
levels, from top management to the classroom teachers and assistants. Second, our finding indicates that non-adopting schools may think that they are solving their problems by implementing
programmes that do not have proven effectiveness, while in fact they are not. In view of the absence
of intended effects and the limited time available for various learning areas in the school setting
(Deschesnes etal., 2010) it is undesirable for schools to invest time and money implementing programs that are not evidence based. This may indicate that future adoption strategies should also
address the termination of ineffective programmes, an aspect that has received little attention thus
far (Greenberg etal., 2003; Philliber and Nolte, 2008).

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A second important facilitating factor that we found was the visibility of the effects of the programme. The positive effects of the GBG, that only became directly observable during the initial
try-out of the programme, considerably eased the adoption process in other schools. This indicates
that, for future dissemination strategies, the visibility of effects can be capitalised by making use
of opinion leaders and peers reporting their own positive experiences with the prevention programmes (Ballew etal., 2010; Buller etal., 2007).
An important impeding factor for the adoption of the GBG was the lack of awareness about the
existence of the programme (Stormont etal., 2011) and its funding opportunities. Higher levels of
awareness about the latter aspect may be beneficial, as about one-third of the schools in our samples reported that the costless availability of the programme was the strongest argument to adopt
the GBG. As recommended (Grol and Grimshaw, 2003), the Amsterdam Public Health Service
used several communication channels to inform every primary school in Amsterdam about the
existence and funding of the GBG programme; however, they were not fully effective in raising the
awareness required to adopt the GBG. A reason for this limited reach may be that the mixed dissemination approach was dominated by passive strategies. Active strategies, for instance those
involving enthusiastic users of the programme (Ballew etal., 2010; Buller etal., 2007), as well as
the use of additional channels, (Rohrbach etal., 2005) such as websites, conference presentations
and networking activities, might further increase the decision makers awareness level (Foster and
Tickle, 2012). A second reason may be the widely acknowledged fact that schools tend to get
flooded with information on all kinds of programmes (Butler etal., 2010).
In contrast to previous studies (Fagan and Mihalic 2003; Fagan etal., 2009), time investment
did not appear to be an inhibiting factor in the decision to adopt the GBG. A possible explanation
for this is that playing the GBG simply parallels the teaching of normal school subjects, such as
language skills. Therefore, adopting the GBG may be seen as not requiring additional time investments in an already busy school schedule. A second explanation could be that schools expect the
initial time investment required to adopt and implement the GBG to have its pay off in the longer
term. That is, the GBG reduces behavioural problems that impede the learning process and positively influences on-task behaviour, both of which are expected to improve school performance.

Limitations
First, it is important to recognise that the study was somewhat limited in its scope and impact. This
was due to the intention of the Amsterdam municipal authorities to use the findings of the present
study to improve their dissemination strategy in order to actually achieve the city-wide adoption of
the GBG. This meant that the time frame for the study was rather limited and that the study scope
was determined by the adoption process as it actually progressed in municipal practice. Our current
understanding of the adoption process could therefore additionally benefit from studies with a
longer time frame including larger numbers of schools.
Second, the convenience sample, with substantial differences in inclusion rates between adopting and non-adopting schools, may have caused some selection bias. We aimed to address this bias
by collecting additional data from (in particular) non-adopting schools via interviews by telephone.
However, differences in the type of interview (e.g. interview length and question format) hindered
adequate comparisons between subgroups of schools.
Third, the qualitative data were initially coded and analysed by one researcher [MD], which
may have influenced the reliability and validity of the results. However, we tried to optimise this
reliability by intensively discussing the data analysis (the coding and comparison process) with a
second researcher [JH], and to enhance the validity of our findings by using and integrating two
data sources as a means of triangulation (Polit and Beck, 2004).

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Fourth, the funding of the GBG by the Amsterdam authorities appeared to be an influential factor in the adoption process of the programme. However, the city-wide character of this funding
hampers the generalisability of our results; that is, other factors may become more prominent in the
adoption process in situations in which school-based prevention programmes are not fully funded.
Finally, although Rogers Diffusion Theory served as a useful framework to address our research
question, supplementing this theory with more recent work, such as Fixsens implementation
framework (Fixsen etal., 2013), could have provided additional value in exploring facilitating factors and barriers to the adoption of the GBG.

Implications
This study offers some insight into how to improve the adoption of evidence-based school SEL and
mental health programmes. First, framing dissemination strategies in educational terms may help
school staff to more easily accept the programme, because it is recognisable and fits their own professional priorities and language. Second, disseminators could use assessment procedures to reveal
the schools specific needs and problems, and increase the schools readiness for change. Third,
implementers should preferably make use of active strategies in which enthusiastic users of SEL and
school mental health programmes report their positive experiences. Fourth, researchers should study
how the use of ineffective programmes can be terminated. Finally, policymakers should be aware
that funding the implementation of evidence-based SEL and school mental health programmes can
significantly improve social and emotional health of children and is often cost-saving for society.
Funding
Financial support of this study came from the Netherlands Organisation for Health Research and Development
(ZonMw, nr 120710001).

References
Adi Y, Kiloran A, Janmohamed K, etal. (2007) Systematic review of the effectiveness of interventions to
promote mental wellbeing in primary schools Report 1: Universal approaches which do not focus on
violence or bullying. Coventry: University of Warwick.
Backer TB (2000) The failure of success: Challenges of disseminating effective substance abuse prevention
programs. Journal of Community Psychology 28(3): 363373.
Ball A (2011) Educator readiness to adopt expanded school mental health: Findings and implications for
cross-system approaches. Advances in School Mental Health Promotion 4(2): 3950.
Ballew P, Brownson RC, Haire-Joshu D, etal. (2010) Dissemination of effective physical activity interventions: are we applying the evidence? Health Education Research 25(2): 185198.
Barrett PM, Lock S and Farrell LJ (2005) Developmental differences in universal preventive intervention for
child anxiety. Clinical Child Psychology and Psychiatry 10: 539.
Barrish HH, Saunders M and Wolf MM (1969) Good behavior game: Effects of individual contingencies for
group consequences on disruptive behavior in a classroom. Journal of Applied Behavioral Analysis 2(2):
119124.
Berwick DM (2003) Disseminating innovations in health care. Journal of the American Medical Association
289(15): 19691975.
Buller DB, Young WF, Fisher KH, etal. (2007) The effect of endorsement by local opinion leaders and
testimonials from teachers on the dissemination of a web-based smoking prevention program. Health
Education Research 22(5): 609618.
Butler H, Bowes G, Drew S, etal. (2010) Harnessing complexity: Taking advantage of context and relationships in dissemination of school-based interventions. Health Promotion Practice 11(2): 259267.
Deschesnes M, Trudeau F and Kebe M (2010) Factors influencing the adoption of a health promoting school
approach in the province of Quebec, Canada. Health Education Research 25(3): 438450.

Downloaded from hej.sagepub.com at THE AGA KHAN UNIV on June 4, 2015

181

Dijkman et al.

Durlak JA, Weissberg RP, Dymnicki AB, etal. (2011) The impact of enhancing students social and emotional
learning: A meta-analysis of school-based universal interventions. Child Development 82(1): 405432.
Dusenbury L, Brannigan R, Falco M, etal. (2003) A review of research on fidelity of implementation:
Implications for drug abuse prevention in school settings. Health Education Research 18(2): 237256.
Embry DD (2002) The Good Behavior Game: A best practice candidate as a universal behavioral vaccine.
Clinical Child and Family Psychology Review 5(4): 273297.
Fagan AA and Mihalic S (2003) Strategies for enhancing the adoption of school-based prevention programs:
Lessons learned from the blueprints for violence prevention replications of the life skills training program. Journal of Community Psychology 31(3): 235253.
Fagan AA, Brooke-Weiss B, Cady R, etal. (2009) If at first you dont succeedkeep trying: Strategies to
enhance coalition/school partnerships to implement school-based prevention programming. Australian
& New Zealand Journal of Criminology 42(3): 387405.
Fixsen D, Blase K, Horner R, etal. (2013) Scaling-up Brief; Readiness for Change. Available at: http://sisep.
fpg.unc.edu/resources/scaling-brief-3-readiness-change (accessed 21 October 2013).
Flaspohler P, Anderson-Butcher D, Bean J, etal. (2008) Readiness and school improvement: Strategies for
enhancing dissemination and implementation of expanded school mental health practices. Advances in
School Mental Health Promotion 1(1): 1627.
Foster GRK and Tickle M (2012) Optimizing school-based health-promotion programmes: Lessons from
a qualitative study of fluoridated milk schemes in the UK. Health Education Journal 72(2): 163171.
Fothergill KE and Ensminger ME (2006) Childhood and adolescent antecedents of drug and alcohol problems: A longitudinal study. Drug and Alcohol Dependence 82(1): 6176.
Glasgow RE, Vogt TM and Boles SM (1999) Evaluating the public health impact of health promotion interventions: The RE-AIM framework. American Journal of Public Health 89(9): 13221327.
Greenberg MT (2004) Current and future challenges in school-based prevention: The researcher perspective.
Prevention Science 5(1): 513.
Greenberg MT, Kusche C and Mihalic SF (1998) Blueprints for Violence Prevention, Book Ten: Promoting
Alternative Thinking Strategies. Boulder County: University of Colorado Institute for Behavioral
Science.
Greenberg MT, Weissberg RP, OBrien MU, etal. (2003) Enhancing school-based prevention and youth
development through coordinated social, emotional, and academic learning. American Psychologist
58(67): 466474.
Grol R and Grimshaw J (2003) From best evidence to best practice: Effective implementation of change in
patients care. The Lancet 362(9391): 12251230.
Hanley S, Ringwalt CL, Ennett S, etal. (2010) The prevalence of evidence-based substance use prevention
curricula in the nations elementary schools. Journal of Drug Education 40(1): 5160.
Harting J, Rutten GM, Rutten ST, etal. (2009) A qualitative application of the diffusion of innovations theory
to examine determinants of guideline adherence among physical therapists. Physical Therapy 89(3):
221232.
Johnstone E, Knight J, Gillham K, etal. (2006) System-wide adoption of health promotion practices by
schools: Evaluation of a telephone and mail-based dissemination strategy in Australia. Health Promotion
International 21(3): 209218.
Jourdan D, Stirling J, Mannix MP, etal. (2011) The influence of professional factors in determining primary
school teachers commitment to health promotion. Health Promotion International 26(3): 302310.
Kellam SG, Brown CH, Poduska JM, etal. (2008) Effects of a universal classroom behavior management
program in first and second grades on young adult behavioral, psychiatric, and social outcomes. Drug
and Alcohol Dependence 95(Suppl 1): S5-S28.
Knapp M, McDaid D and Parsonage M (2011), Mental Health Promotion and Mental Illness Prevention: The
Economic Case. London: LSE.
Kramer L, Laumann G and Brunson L (2000) Implementation and diffusion of the Rainbows Program in
rural communities: Implications for school-based prevention programming. Journal of Educational and
Psychological Consultation 11(1): 3764.

Downloaded from hej.sagepub.com at THE AGA KHAN UNIV on June 4, 2015

182

Health Education Journal 74(2)

Noonan RK, Emshoff JG, Mooss A, etal. (2009) Adoption, adaptation, and fidelity of implementation of
sexual violence prevention programs. Health Promotion Practice 10(1 Suppl): 59S-70S.
Onderwijsraad (2006) Naar meer evidence-based onderwijs. Den Haag: Onderwijsraad.
Petras H, Kellam SG, Brown CH, etal. (2008) Developmental epidemiological courses leading to antisocial
personality disorder and violent and criminal behavior: Effects by young adulthood of a universal preventive intervention in first- and second-grade classrooms. Drug and Alcohol Dependence 95(Suppl 1):
S45-S59.
Philliber S and Nolte K (2008) Implementation science: Promoting science-based approaches to prevent teen
pregnancy Prevention Science 9(3): 166177.
Poduska JM, Kellam SG, Wang W, etal. (2008) Impact of the Good Behavior Game, a universal classroombased behavior intervention, on young adult service use for problems with emotions, behavior, or drugs
or alcohol. Drug and Alcohol Dependence 95(Suppl 1): S29-S44.
Polit DF and Beck CT (2004) Nursing Research, Principles and Methods, 7th ed. Philadelphia: JB Lippincott
Co.
Pope C, Ziebland S and Mays N (2000) Qualitative research in health care. Analysing qualitative data. British
Medical Journal 320(7227): 114116.
Reef J, Diamantopoulou S, van Meurs I, etal. (2009) Child to adult continuities of psychopathology: A
24-year follow-up. Acta Psychiatrica Scandinavica 120(3): 230238.
Ritchie J and Spencer L (1994) Qualitative data analysis for applied policy research. In: Bryman A and
Burgess R (eds) Analyzing qualitative data. London: Routledge, pp.173194.
Rogers EM (2003) Diffusion of Innovations, 5th edition. New York, NY: Free Press.
Rohrbach LA, Ringwalt CL, Ennett ST, etal. (2005) Factors associated with adoption of evidence-based
substance use prevention curricula in US school districts. Health Education Research 20(5): 514526.
Saul J, Duffy J, Noonan R, etal. (2008) Bridging science and practice in violence prevention: Addressing ten
key challenges American Journal of Community Psychology 41(34): 197205.
Stormont M, Reinke W and Herman K (2011) Teachers knowledge of evidence-based interventions and
available school resources for children with emotional and behavioral problems. Journal of Behavioral
Education 20, 138147.
Tingstrom DH, Sterling-Turner HE and Wilczynski SM (2006) The good behavior game: 19692002.
Behavioral Modification 30(2): 225253.
Van Lier PA, Huizink A and Crijnen A (2009) Impact of a preventive intervention targeting childhood disruptive behavior problems on tobacco and alcohol initiation from age 10 to 13 years. Drug and Alcohol
Dependence 100(3): 228233.
Van Lier PA, Muthen BO, van der Sar RM, etal. (2004) Preventing disruptive behavior in elementary
schoolchildren: Impact of a universal classroom-based intervention. Journal of Consulting and Clinical
Psychology 72(3): 467478.
van Lier PA, Vuijk P and Crijnen AA (2005) Understanding mechanisms of change in the development
of antisocial behavior: The impact of a universal intervention. Journal of Abnormal Child Psychology
33(5): 521535.
Walker HM (2004) Commentary: Use of evidence-based interventions in schools: Where weve been, where
we are, and where we need to go. Worldviews Evidence Based Nursing 33(3): 398407.
Weare K and Nind M (2011) Mental health promotion and problem prevention in schools: What does the
evidence say? Health Promotion International 26(Suppl 1): i29-i69.
Wilcox HC, Kellam SG, Brown CH, etal. (2008) The impact of two universal randomized first- and second-grade classroom interventions on young adult suicide ideation and attempts. Drug and Alcohol
Dependence 95(Suppl 1): S60-S73.
Wilson SJ and Lipsey MW (2007) School-based interventions for aggressive and disruptive behavior: Update
of a meta-analysis. American Journal of Preventive Medicine 33(2 Suppl): S130-S143.

Downloaded from hej.sagepub.com at THE AGA KHAN UNIV on June 4, 2015