Table 3 The “intensity” of work involved in implementing the healthy children’s initiative, themes and exemplars from ethnographic fieldnotes

 Multi-component practices

They [this HCI Team] don’t invest money in this [practice] because it is so hard to achieve all three parts, and they don’t get credit for only achieving a portion of it. –Team I

 Practice achievement is influenced by broader factors outside of an individual’s control

[The health promotion officer] gives an example of a rural area where their local business– a general store/bakery – provides the canteen 1 day a week. The school doesn’t have any other resources - parents, volunteers, facilities etc. - to provide the canteen so working with the local business is the only way to get food into the school. So they don’t have a choice or much control over what’s served, even though they know it doesn’t [meet the criteria for a healthy canteen]. (Name) says this is why the notes in PHIMS is important to help people understand the context of the area... She can’t work with the businesses, instead, she just talks to the principal and tries to provide some resources. She says, “You can’t work with them, you can’t do anything about that, and most of the time [the canteen practice] the only thing they’re not achieving due to circumstance.” – Team G

 Site-level: Local community context

(Name) explained that the strategies that work for Sydney Metro are going to be hard to promote here. For instance, there are no footpaths in the rural areas and the children have to travel a long way to school.

-Team F

 Site-level: More pressing needs or different priorities

(This team) talks about how they try to align with schools health framework, and emphasize this. But schools have other issues to deal with. These issues include truancy. And “social welfare issues” that are rooted in history between place and Aboriginal communities. She tells a story of how she went to speak with a school about [the HCI program] and the principal told her that that day, he was dealing with 8 “displaced students who didn’t have housing.” – Team I

 Site-level: Alignment between program aims and sites’ needs and/or priorities

[The Early Childhood Services program] is a totally different program from [the primary schools program], because the setting is so different. [The early childhood program] sits more easily in the child care services, it aligns more with what the child care centres already do, and [the practitioners] have something relevant to offer because the practices correspond to the requirements in their service agreements. The school environment is different and there is so much else going on. – Team J

“I think ultimately, it’s about supporting each service in what they want to do. I think we’ve come into a little bit too much with a government perspective and pushing what we want them to do. Some of these, especially child cares, they’re private businesses, they don’t have to do what we say. So if we’re not supporting them to achieve their goals, we’re not going to get anywhere with them. It’s the same with the schools. The education used to be a 50–50 partnership between health and education and education just isn’t engaged. So, we’re trying to push something on them that doesn’t really fit into what they do. We’re not recognizing their capacity and their skills by doing that.” Interview in Team G

 HCI-team level: Proximity of sites to Team offices

(This team) doesn’t often travel, the limit that they put on travel time is about 3.5 h (one way). 2 h is not considered a far drive for them. However, sometimes they will go out to schools but they must be strategic and maximize their travel as much as possible. – Team I

 HCI-team level: Ratio of sites to practitioner

She questions how other teams can do it. Explains that their newest staff member came from (Team name) where she was responsible for > 300 sites. Here, they each have 50 sites per 1 FTE. With 300 sites, there is no way that they can do more than just focus on the practices. So to the new staff, coming here was a “health promotion dream.”

– Team A

 HCI-team level: Access to additional financial resources beyond HCI funding

[They have] no time to develop resources. “We get jealous when we see what other [teams] produce.” But they just don’t have time. Or money.

Team G

 Accumulation of activities over a long period of time

(Name) was happy that he got the principal's permission to go directly to the educator, because the principal is too busy to make things happen, she just needs to agree and then he needs someone else to do the job. At this centre they have had so many changes a couple of years ago that they were not ready, so he just circled around and built a relationship, now they are getting there. 'That is just patience, just being there for when they are ready’. This is what the implementation plans from the ministry do not always get, it is about what our centre’s needs are, not what the program’s needs are. – Team L

 Extensive time and effort to build relationships provide the foundation for HCI

I ask (name) how important the personal stuff is for her day-to-day work? (Name) thinks it is probably the most important because that relationship and having that communication between them and their job and what we’re trying to get them to do, they’re not going to listen to you at all if there’s no … if you haven’t built that relationship there’s no way they’re going to make any changes so being able to build that relationship and have conversations with them is probably the most important thing in terms of getting them to actually make changes …

- Team E

 Some practitioners were conservative in assigning a ‘tick’ in PHIMS

(Name) walks through each performance indicator and is surprisingly (the ethnographer’s estimation) quite conservative with her “ticking” of the boxes. From (the ethnographer’s) impression of the (Director of the childcare service), she was quite insistent that they do physical activity and that they are “reporting” on a weekly basis to the families. I may have given them more ticks. But (name) explains that the physical activity is not “structured,” the food interactions aren’t “intentional,” and although they are reporting, they don’t have a quality improvement mechanism in place which (name) sees as the purpose of the Practice #15: Site monitors and reports achievements of healthy eating and physical activity objectives annually. Therefore, she does not give them full scores in these areas, and indicates the site could improve upon these areas. – Team H

 Some practitioners took a more “liberal” approach

“I think that conversations around healthy food or sometimes a bit everyday food that happens over lunch time, I value that, and I would say that’s happening every day. Where some officers think that it needs to be very structured and it needs to be an activity. Where I think – and this is sort of where my issue with PHIMS is because if you were compliant with all the minimum adoption standards, you'd have a horrible report. You would have services not meeting, and it would be a really poor indicator of what services are actually doing, just because of the gaps in how you collect the data.” – Team F

 When to tick a box and comparing interpretations amongst teams was common

(Name) says that their program adoption has gone up for the first time in a long time, and it is now (above 70%). She says that other teams are higher, but “we are harsher” on the selection criteria. She tells the team, “we can decide as a team if we want to relax on the criteria cause we have it on the hardest setting.” – Team F

A problem with PHIMS is that they have to rely on teacher report for the practices. She thinks that, compared to other teams, they are quite “accurate” in their interpretation of what is going on in the schools. What this means is that they don’t necessarily rely on the teacher report, and they are strict in their interpretation of practice achievement. To her, this is reflected in the fact that their practice achievement on the canteen strategy is at 22%, while the state’s average is 50%. - Team M

 Partial progress towards practice achievements is not accounted for in PHIMS

They say the problem with PHIMS is that all practices are considered to be equal to each other in the PHIMS system. But the “canteen KPI is massive”; a massive amount of work to achieve, while other practices aren’t as hard to obtain. Because of the implementation targets, they are unable to focus their work on the practices that are going to make the “most difference” in terms of health outcomes. This changes the way they make decisions regarding how they spend their money – Team I

 Practitioners were concerned about the difficulties of capturing incremental progress over a long period of time

(Name) says, “there’s a massive disconnect between what comes up on PHIMS and what you’ve done to get that data. And it’s really hard to translate what you do when you go out and you have a conversation with someone face-to-face, and you talk to them about what they do day to day, and come back to the office and you just type into a computer.”

– Team E

(The practitioner) says you have to be a “pragmatist” and that it’s a long-term/organic process to get things done … (it’s an) incremental approach- get a new principal, you get her onboard, now she’s onboard, you get the Parents and Citizens to chip in money, a new canteen person comes on board.

Researcher: And then years later you tick a box in PHIMS and it gets counted?

Practitioner: Exactly, do you see what I’m saying? The tick in PHIMS is like the tip of an iceberg. It’s that tiny bit above the surface. And behind it is years of chatting, visits, gently urging, suggesting they go in this direction rather than that direction. - Team G

 PHIMS does not document the particular activities taken to achieve an outcome

(Name) told me about the fact that what is captured in PHIMS is essentially a tick in a box, but leading up to that there has been fact sheets, conversations, a whole lot of other stuff, so PHIMS is “not a true reflection” of the work they do.

– Team E

(Name) told me about one particular tick to demonstrate how PHIMS falls short; to look into the kids lunchboxes is one simple activity and one tick, but to bring himself into the position where he has the trust and the position to get to look at the kids’ lunchboxes took him 15 visits - Team L

“But [our activities] need to be recorded because … we have to justify our roles. When they were talking about the funding, they were trying to work out how many hours we spent supporting each school and I didn’t have any data to be able to say that. I can say that we do a site visit every year, but I have no idea how many emails we do at this school. So unless it’s all in there, we need to be able to say to support 100 schools, it takes us 1200 phone calls, 1300 emails and just be able to actually quantify that. There’s no way of doing that at the moment”.

– Interview in Team G