Sustaining the implementation of alcohol management practices by community sports clubs: a randomised control trial

A systematic review to determine the effect of strategies to sustain chronic disease prevention interventions in clinical and community settings

This review assessed the effect of strategies designed to sustain the delivery of evidenced based interventions (EBIs) which target behavioural risk factors linked to leading causes of chronic disease in clinical and community settings. Seven electronic databases were searched for randomised controlled studies published from earliest record to November 2022. Studies were included if they tested a strategy to sustain the delivery of an EBI within clinical or community settings. Results were synthesised using vote counting based on direction of effect, and reported in accordance with non-meta-analytic review standards following the Synthesis Without Meta-analysis (SWiM) guidelines. Three studies met the study inclusion criteria. Two studies were community-based, with one conducted in Australian community sports clubs and the second in afterschool clubs in the United States. The single clinical-based study was conducted in community health care centres in the United States. Across the three studies, 25 strategies were employed and only two strategies were common across all studies. Synthesis using vote counting based on direction of effect indicated that two of three studies favoured the intervention as positively impacting sustainment of EBIs. Few studies have been conducted to assess the effect of strategies designed to support sustainment of EBIs for chronic disease prevention in clinical and community settings. As such, it is difficult to determine the effect of strategies designed to support sustainment. Further research with comprehensive reporting of the selection, use and testing of sustainment strategies is needed to advance understanding of how to sustain EBIs in clinical and community settings.

Interventions implemented through sporting organisations for promoting healthy behaviour or improving health outcomes

BACKGROUND

Chronic diseases are the leading cause of mortality and morbidity worldwide. Much of this burden can be prevented by adopting healthy behaviours and reducing chronic disease risk factors. Settings-based approaches to address chronic disease risk factors are recommended globally. Sporting organisations are highly prevalent, and engage many people in many countries. As such, they represent an ideal setting for public health interventions to promote health. However, there is currently limited evidence of their impact on healthy behaviour and health outcomes as previous systematic reviews are either limited in their scope (e.g. restricted to professional sporting organisations), or are out of date.

OBJECTIVES

Primary: to assess the benefits and harms of interventions implemented through sporting organisations to promote healthy behaviours (including physical activity, healthy diet) or reduce health risk behaviours (including alcohol consumption, tobacco use). Secondary: to assess the benefits and harms of these interventions to promote health outcomes (e.g. weight), other health-related behaviours (e.g. help-seeking behaviour) or health-related knowledge; to determine whether benefits and harms differ based on the characteristics of the interventions, including target population and intervention duration; to assess unintended adverse consequences of sporting organisation interventions; and to describe their cost or cost-effectiveness.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, one other database and two clinical trial registries, from inception to May 2024, to identify eligible trials. We searched Google Scholar in May 2024. We did not impose language or publication status restrictions. We also searched reference lists of included trials for other potentially eligible trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-RCTs, of any intervention conducted within or using a sporting organisation for access to a target group, that aimed to improve a health behaviour primary outcome or a secondary review outcome, and had a parallel control group (no intervention, alternative intervention). Eligible participants were any individual exposed to an intervention involving a sporting organisation, including players, members, coaches, and supporters.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We conducted random-effects meta-analyses to synthesise results where we could pool data from at least two trials. Where we could not conduct meta-analysis, we followed Cochrane guidance for synthesis using other methods and reported results according to the Synthesis Without Meta-analysis (SWiM) guidance.

MAIN RESULTS

We included 20 trials (42 trial arms, 8179 participants) conducted in high-income countries, and identified four ongoing trials and four trials awaiting classification. There was considerable heterogeneity in the type of participants, interventions and outcomes assessed across trials. Included trials primarily targeted sporting organisation members (eight trials) or supporters (eight trials), males only (11 trials) and adults (14 trials). Football clubs (e.g. soccer, American football, Australian football league) were the most common intervention setting (15 trials), and interventions targeted various combinations of health behaviours, knowledge and health outcomes. Fourteen trials (10 RCTs and four cluster-RCTs) assessed the impact of a sporting organisation intervention on a primary outcome: physical activity (nine trials); diet (six trials); alcohol consumption (11 trials); and tobacco use (two trials). For RCTs, we assessed the risk of bias for primary outcomes (physical activity, diet, alcohol consumption) and unintended adverse consequences as being at low risk of bias (four outcomes), some concerns (one outcome) or high risk of bias (32 outcomes), due to outcomes being self-reported. For cluster-RCTs, we assessed the risk of bias for all primary outcomes (alcohol consumption, tobacco use) as high risk (eight outcomes), due to outcomes being self-reported. Sporting organisation interventions versus control probably have a small positive effect on the amount of physical activity per day, equivalent to approximately 7.4 minutes of moderate-to-vigorous physical activity (MVPA) per day (standardised mean difference (SMD) 0.36, 95% confidence interval (CI) 0.22 to 0.49; I2 = 3%; 4 trials, 1213 participants; moderate-certainty evidence) and may not reduce sedentary behaviour (mean difference (MD) -15.18, 95% CI -30.82 to 0.47; I2 = 0%; 2 trials, 1047 participants; low-certainty evidence). Sporting organisation interventions versus control may have a moderate positive effect on fruit and vegetable consumption, equivalent to a score increase of 1.25 points on a 12-point scale for frequency of fruit and vegetable consumption (SMD 0.50, 95% CI 0.35 to 0.65; I2 = 0%; 5 trials, 1402 participants; low-certainty evidence). Sporting organisation interventions versus control may reduce sugary drink consumption (equivalent to a reduction of sugary drink consumption by 0.8 times per day), but the evidence is very uncertain (SMD -0.37, 95% CI -0.64 to -0.10; I2 = 0%; 2 trials, 225 participants; very low-certainty evidence). Sporting organisation interventions versus control may have little to no effect on alcohol consumption (equivalent to a reduction of 0.38 units of alcohol consumed per week), but the evidence is very uncertain (MD -0.38, 95% CI -1.00 to 0.24; I2 = 78%; 7 trials, 2313 participants; very low-certainty evidence). Two trials that could not be synthesised reported equivocal findings on tobacco use (low-certainty evidence). The evidence is very uncertain about the effect of sporting club interventions on unintended adverse consequences. Five trials assessed this outcome, with two reporting that there were no adverse consequences, one reporting only non-serious adverse consequences, and two reporting that there were serious unintended adverse consequences in less than 1% of participants.

AUTHORS' CONCLUSIONS

Overall, sporting organisation interventions probably increase MVPA by 7.4 minutes per day, may result in little to no difference in sedentary behaviour, and may increase fruit and vegetable consumption. The evidence is very uncertain about whether sporting organisation interventions decrease sugary drink and alcohol consumption. Findings for tobacco use and unintended adverse consequences were equivocal in the few trials reporting these; thus, the evidence was very uncertain. These findings should be interpreted in the context of the heterogeneity of the interventions, participants and sporting organisations for some outcomes.

Improving physical activity and screen time in Australian Outside School Hours Care: Study protocol

BACKGROUND

Children's physical activity and screen time behaviours impact their physical health and well-being. In Australia, less than half of children meet daily physical activity recommendations and only one-third meet daily screen time recommendations. Nearly half a million Australian school children aged 5-12 attend Outside School Hours Care (OSHC) weekly, activities undertaken at OSHC play a key role in meeting these recommendations. Currently, physical activity and screen time practices in OSHC vary and lack policy guidance. The Activated OSHC program is a policy-based intervention that supports OSHC services to implement the physical activity and screen time guidelines.

METHODS

192 OSHC services across Australia will be recruited. 96 services will be randomly allocated to receive the Activated OSHC program. OSHC coordinators will complete online surveys examining physical activity and screen time scheduling, cost, acceptability, and feasibility. Primary outcome; changes in the proportion of intervention and control services meeting OSHC sector physical activity and screen time guidelines, and secondary outcomes; changes in children's physical activity and screen time behaviours; changes in staff behaviour will be assessed using mixed-effects regression models.

DISCUSSION

The aim of this study is to examine the impact of the Activated OSHC program on children's physical activity and screen time.

IMPACT

Recent Australian research in Outside School Hours Care (OSHC) has identified significant inconsistency in practices related to physical activity and screen time, compounded by an absence of explicit policy guidance. The Activated OSHC program is a policy-based intervention that supports OSHC services to implement the Australian OSHC physical activity and screen time guidelines. This study will assess the implementation and effectiveness of the Activated OSHC program in an effectiveness-implementation hybrid type 2 trial design. Implementation of outside school hours care sector physical activity and screen time guidelines may improve children's physical activity and screen time behaviours.

An initial typology of approaches used by policy and practice agencies to achieve sustained implementation of interventions to improve health

BACKGROUND

Scientific investigation of how to sustain the implementation of evidence-based interventions (EBI) is emerging. Sustaining the implementation of EBIs helps ensure their effects on improving health endure. External policy or practice agencies, such as government health departments, are often tasked with supporting individual organisations with sustaining their delivery of EBIs, for example, through financing, training or the provision of other supports. However, to our knowledge, the approaches taken by policy and practice agencies to support the sustainment of EBIs have not been consolidated, categorised and described as a typology.

MAIN BODY

To improve conceptual clarity and support both research and practice, we developed an initial working typology of the practical approaches to sustain implementation of EBIs (i.e. sustainment) in order to improve long term health from the perspective of these agencies. The working typology includes three broad approaches. The first, termed 'Self-Sustainment', is when implementation of the EBI by an organisation (e.g. hospital, clinic, school) is expected to continue (sustain) in the absence of external (agency) support. The second, termed 'Static Sustainment Support', involves the provision of pre-defined external (agency) support to assist organisations to continue implementation of an EBI. The final approach is termed 'Dynamic Sustainment Support', whereby support provided by an external agency is dynamic (continues to be adapted) overtime to assist organisations continue implementation of an intervention which may itself also evolve.

CONCLUSIONS

We describe the contexts and circumstances where each may be most appropriate in achieving sustained implementation and discuss their research and practice implications.

Do the Expert Recommendations for Implementing Change (ERIC) strategies adequately address sustainment?

Background

Sustainability science is an emerging area within implementation science. There is limited evidence regarding strategies to best support the continued delivery and sustained impact of evidence-based interventions (EBIs). To build such evidence, clear definitions, and ways to operationalize strategies specific and/or relevant to sustainment are required. Taxonomies and compilations such as the Expert Recommendations for Implementing Change (ERIC) were developed to describe and organize implementation strategies. This study aimed to adapt, refine, and extend the ERIC compilation to incorporate an explicit focus on sustainment. We also sought to classify the specific phase(s) of implementation when the ERIC strategies could be considered and applied.

Methods

We used a two-phase iterative approach to adapt the ERIC. This involved: (1) adapting through consensus (ERIC strategies were mapped against barriers to sustainment as identified via the literature to identify if existing implementation strategies were sufficient to address sustainment, needed wording changes, or if new strategies were required) and; (2) preliminary application of this sustainment-explicit ERIC glossary (strategies described in published sustainment interventions were coded against the glossary to identify if any further amendments were needed). All team members independently reviewed changes and provided feedback for subsequent iterations until consensus was reached. Following this, and utilizing the same consensus process, the Exploration, Preparation, Implementation and Sustainment (EPIS) Framework was applied to identify when each strategy may be best employed across phases.

Results

Surface level changes were made to the definitions of 41 of the 73 ERIC strategies to explicitly address sustainment. Four additional strategies received deeper changes in their definitions. One new strategy was identified: Communicate with stakeholders the continued impact of the evidence-based practice. Application of the EPIS identified that at least three-quarters of strategies should be considered during preparation and implementation phases as they are likely to impact sustainment.

Conclusion

A sustainment-explicit ERIC glossary is provided to help researchers and practitioners develop, test, or apply strategies to improve the sustainment of EBIs in real-world settings. Whilst most ERIC strategies only needed minor changes, their impact on sustainment needs to be tested empirically which may require significant refinement or additions in the future.

Increasing compliance with alcohol service laws in community sporting clubs in Australia

INTRODUCTION

Many community sporting clubs in Australia sell alcohol, but many do not comply with laws that require verification of age and forbid underage alcohol sales. This study aimed to assess the effectiveness of an intervention that incorporated sales monitoring and community awareness raising to improve compliance with alcohol service regulations in community sporting clubs.

METHODS

Non-randomised community trial in 'matched' intervention and comparison communities. A total of 50 sporting clubs from two metropolitan and two regional areas in Victoria, Australia, were selected, and baseline and follow-up purchase observations completed during 2018. Youth who looked underage were monitored as they attempted to purchase alcohol. Intervention clubs received feedback letters regarding staff sales behaviour. Other intervention actions included building awareness of underage supply of alcohol and media coverage of baseline observations.

RESULTS

Observations were completed at 46 clubs (intervention = 24; comparison = 22) at baseline and 39 (intervention = 24; comparison = 15) at follow up. Compliance was low but improved at follow up for both groups for age verification (intervention +12.5%; comparison +8.5%) and non-supply of alcohol (intervention +12.5%; comparison +10.6%); but no significant intervention effects were found.

DISCUSSION AND CONCLUSIONS

Findings indicated low compliance with age verification checks and underage alcohol sales laws at baseline. Promising improvements in compliance were observed at follow up; however, 'spillover' of intervention activities may have compromised ability to detect significant intervention effects. Further intervention effort and evaluation is recommended to encourage alcohol sales compliance in community sporting clubs.