Adoption, implementation and sustainability of school-based physical activity and sedentary behaviour interventions in real-world settings: a systematic review

Staff motivation and schools' capacities to sustain an intervention to prevent bullying and promote wellbeing in English secondary schools: a qualitative study

Introduction

Discontinuing effective school health interventions prevents new practices from reaching wider student populations and wastes investment in implementation. While reviews have consistently identified facilitators and barriers to the sustainment of school health interventions, the social processes underlying sustainment remain unclear. We explored the post-trial sustainment of "Learning Together," a whole-school intervention, found to be effective in preventing bullying and promoting wellbeing in English secondary schools. We examined how staff and students described its sustainment in the 2 years post-trial, what factors staff referred to in explaining their motivation to sustain it, and how schools' capacities affected sustainment.

Methods and materials

Learning Together involved training staff in restorative practice (RP) and supporting schools to implement a staff-student action group and a social and emotional learning curriculum. Using a case-study design, we collected qualitative data from five schools: staff and student interviews 1-year post-trial; staff interviews 2 years post-trial; and descriptive data from the original trial's process evaluation. The General Theory of Implementation guided our thematic analysis.

Results

No school sustained the intervention in its entirety. RP was continued by some individuals in all schools and was sustained at school-level in one school. The curriculum and action groups were discontinued in all schools, although actions initiated by the groups were sustained in two schools. Staff motivation to sustain components was affected by their perceived effectiveness, and individual motivations to sustain RP differed from whole-school commitment to sustaining the approach. Schools' capacities to sustain Learning Together were affected by: the prioritization of academic learning time; the frequent implementation of new initiatives; the timeliness of interventions with school improvements plans; and leadership engagement. Schools needed support to disseminate RP knowledge and skills school-wide and ensure consistent practice, and turnover adversely impacted on knowledge transfer.

Discussion

Sustainment was an intentional, labor-intensive, social process. Intervention developers should consider whether/how interventions are designed to work alongside, replace, or can refine existing practices, and should support schools to mainstream evidence-based interventions to sustain them at school-level.

Evaluating the implementation of adult smoking cessation programs in community settings: a scoping review

Introduction

Tobacco smoking is a leading contributor to preventable morbidity and premature mortality globally. Although evidence-based smoking cessation programs have been implemented, there is limited evidence on the application of theories, models, and frameworks (TMFs), and implementation strategies to support such programs. This scoping review mapped the evidence for interventions, TMFs, and implementation strategies used for smoking cessation programs in the community.

Methods

We searched four electronic databases in addition to grey literature and conducted hand-searching between February and December 2023. Original studies of qualitative, quantitative, or mixed methods were considered for inclusion. Studies reporting prospectively planned and/or delivered implementation of smoking cessation interventions or programs, incorporating contextual factors, use of implementation TMF, implementation strategies, or other factors influencing implementation were considered for inclusion. Intervention components were categorized using the Template for Intervention Description and Replication (TIDieR) checklist. Implementation strategies were mapped to the Expert Recommendations for Implementing Change (ERIC) Strategy Clusters.

Results

A total of 31 studies were included. We identified 12 discrete interventions, commonly included as part of multicomponent interventions. Most studies reported tailoring or modifying interventions at the population or individual level. We identified 19 distinct implementation TMFs used to prospectively guide or evaluate implementation in 26 out of 31 included studies. Studies reported diverse implementation strategies. Three studies embedded culturally appropriate TMFs or local cultural guidance into the implementation process. These studies took a collaborative approach with the communities through partnership, participation, cultural tailoring, and community-directed implementation.

Discussion

Our findings highlight the methods by which the implementation of smoking cessation may be supported within the community. Whilst there is debate surrounding their necessity, there are practical benefits to applying TMFs for implementing, evaluating, and disseminating findings. We determined that whilst ERIC was well-suited as a framework for guiding the implementation of future smoking cessation programs, there was inconsistent use of implementation strategies across the ERIC domains. Our findings highlight a lack of harmonization in the literature to culturally tailor implementation processes for local communities.

Effectiveness of a multicomponent intervention to promote physical activity during the school day: rationale and methods of the MOVESCHOOL study

Background

Increasing levels of physical activity (PA) and reducing sedentary time among adolescents during the school day is a pressing need. Emerging methodologies and strategies been shown to be effective in increasing PA levels and providing additional benefits for students, such us physically active lessons (PAL), active breaks (AB) and active recesses (AR). However, evidence concerning adolescents remains limited. This manuscript presents the methods and rationale of the MOVESCHOOL study, which aims was to examine the effects of a multicomponent school-based intervention during the school day on indicators of PA, sedentary time, health, executive functions and education in adolescents.

Methods

A quasi-experimental study was conducted with the aim to involve a total of 800 students aged 12-14 years old from 11 schools (7th and 8th grade) in south-western Spain, five schools forming the intervention group and six schools forming the control group. The evaluation included two independent measurements: pre-intervention and post-intervention. The intervention lasted 29 weeks and consisted of a multi-component programme including a weekly PAL, two 5 min daily AB, and a daily AR. Primary outcomes included accelerometer-based PA and sedentary time, health-related physical fitness, academic indicators, and executive functions. For statistical analyses, descriptive, correlational, regression, and repeated measures ANOVA analyses will be applied. Additionally, qualitative data were gathered through semi-structured individual interviews and focus groups, and information will be evaluated with thematic analysis.

Discussion

The MOVESCHOOL study represents a pioneering effort in Spain, being the first of its kind to evaluate the effectiveness of a multicomponent programme in secondary schools. Furthermore, this project provides valuable insights into the effects of a multicomponent school-based PA intervention on PA levels, sedentary time, health-related, cognitive, academic indicators and psychological health markers in secondary school students. The results of this study will make a significant contribution to the educational community, providing them with innovative teaching methods and strategies that have the potential to increase PA levels during the school day. In addition, this research promises to provide a transformative experience for educators, equipping them with tools to promote the holistic development of their students, enriching their academic performance and enhancing their well-being.

Clinical trial registration

ClinicalTrials.gov, identifier NCT06254638.

School staff experiences on involvement in a co-creation process: a Health CASCADE scoping review and thematic synthesis

BACKGROUND

Implementing public health interventions in schools requires active involvement of multiple stakeholders and adaptation of interventions to fit local contexts, to account for successful design, implementation, and consequently effectiveness of these interventions. Active collaboration, preferably in a co-creation process, with school staff is needed to enhance the implementation of school-based public health interventions. However, involving them in research through a co-creation process is challenging due to competing demands on their time. Hence, there is a need for insights into the factors facilitating or impeding co-creation processes involving school staff.

METHODS

To gain in-depth knowledge of school staff's experiences a scoping review and thematic synthesis have been conducted. Peer reviewed articles written in English and published between January 2012 and November 2023 were retrieved from ERIC, Education Database, Medline (PubMed interface), Embase, Web of Science, Scopus, and Health CASCADE Co-creation Database. Considering the high amount of search results the title and abstract screening was performed using ASReview. A thematic synthesis was conducted on the included articles.

RESULTS

Ten scientific peer reviewed articles were included and thematically synthesised. Six descriptive themes described factors influencing the co-creation process, including competing work roles and responsibilities of school staff, multistakeholder collaboration, benefits of participation in the co-creation process, power imbalances between different stakeholders, and school staff's lived experiences. Additionally, four analytical themes emerged indicating that demands of the co-creation process outweigh its benefits. To tackle excessive demands school staff preferred a guided process in which high-level participation was less important. School staff joined the co-creation process to serve students and emphasised the importance of being heard and taken seriously.

CONCLUSIONS

School staff indicated that excessive demands outweigh the benefits experienced during the co-creation process. Therefore, school staff preferred less time-intensive processes. Improving students outcomes was school staff's motivation to be involved, which asks for processes with student-related goals and observable student benefits. Moreover, school staff needs to be acknowledged as an expert and valued for their involvement. These results should be considered to make co-creation processes involving school staff more feasible and satisfactory.

Factors that influence the adoption of a school-based eHealth alcohol prevention program among Spanish personnel: a mixed methods study

BACKGROUND

Evidence-based research has shown that using eHealth interventions effectively reduces risk behaviors such as alcohol consumption, a public health problem worldwide. However, despite its benefits, there has been a poor intention to adopt such innovations, and limited resources exist to understand factors influencing the uptake decision to use school-based eHealth alcohol prevention programs. This study aims to identify the factors that influence the adoption of a computer-tailored eHealth alcohol prevention program among school personnel in Spain.

METHODS

A cross-sectional study employing an exploratory sequential mixed methods research design was carried out. First, interviews were conducted with ten Spanish school counselors to assess factors influencing the adoption of the school-based eHealth program by exploring participants' awareness and salient beliefs concerning attitudes, social influences, and self-efficacy. Second, an online quantitative questionnaire was developed based on the qualitative research findings. Third, the new questionnaire was administered to Spanish school personnel (N = 100), including the school management team, school counselors, and teachers. Rogers' Diffusion of Innovations theory and the Integrated Change Model frameworks were used as theoretical bases for understanding the adoption process.

RESULTS

School personnel with a strong intention to adopt the program (intenders) perceived significantly more advantages and positive innovation attributes, than those participants with a weaker intention to adopt (non-intenders). Intenders perceived a higher personal relevance and responsibility towards using the program, more self-efficacy (e.g., ability to understand, manage time and incorporate the program) and positive social influences from their colleagues, as well as greater willingness in preparing action plans, such as monitor students' alcohol consumption and discussing the program with coworkers, than the non-intenders group. Advantages and social support were found to explain a significant portion of the variance in the adoption intention.

CONCLUSIONS

This study suggests that health intervention researchers should develop strategies to enhance educators' pro-innovation attitudes, personal relevance and responsibility, and perceived ease of use towards adopting an eHealth program. Furthermore, our results highlight that fostering school personnel's acceptance of the intervention and planning goal-oriented actions are crucial elements in optimizing adoption promotion of eHealth programs in school settings.

The FIT FIRST 10 dose-response study: evaluation of implementation outcomes

Introduction

Increasing physical activity (PA) levels among children is critical to mitigate health risks associated with physical inactivity. Schools have been highlighted as ideal setting for promoting PA. However, existing school-based PA programs often face implementation challenges. The FIT FIRST 10 (FF10) multi-sport program has been introduced in Denmark, aiming to increase PA and to enhance children's health, fitness, and well-being. This study evaluates the implementation of the FF10 program for 2nd and 3rd graders.

Materials and methods

The FF10 program was implemented in a 20-week cluster randomized controlled trial across 27 schools. Schools were assigned to a control arm or intervention arms receiving either 3 (full dose) or 1.5 (half dose) FF10 40-min lessons weekly. Teachers received a one-day training session, comprehensive manuals, and necessary equipment. Data were collected from teachers via logbooks documenting implementation fidelity, and an online questionnaire assessing program acceptability, appropriateness, and feasibility, and teachers' capability, opportunity, and motivation for implementing the FF10 program.

Results

A total of 18 intervention schools with 36 classes participated in this study. Program fidelity was high in both intervention groups (2.8 and 2.0 session/week for full and half-dose, respectively). Confidence intervals indicated no differences between the two intervention groups for any outcomes. Teachers (n = 32) in both groups rated FF10 moderately acceptable, appropriate, and feasible (3.5-4.0 out of a potential maximum of 5). Both groups exhibited moderate physical and psychological capabilities (3.5-4.0) and high social opportunities (>4.0), but poor motivation scores (<3.5), particularly regarding the perceived benefits and automatization in delivering the FF10 program.

Conclusion

The FF10 program was almost delivered as intended, but time constraints, limited facilities, and modest teacher motivation might have hindered implementation. Reducing the program's dosage did not improve implementation outcomes, emphasizing the need for ongoing support to boost teacher motivation and integration of the program into school timetables.

Attitudes of support people: a key element when implementing technologies for people with intellectual and visual disabilities

AIM

The degree to which people with intellectual and visual disabilities can use technology relies on the level of support they receive. However, there is a lack of knowledge about the relationship between the constructs effort expectancy, attitudes, and behavioural intentions of support people (i.e. relatives and healthcare professionals) regarding the use of such technologies for people with intellectual and visual disabilities. The aim of this study was to gain insight into how these constructs are connected and to explore their relationship with support person's characteristics and the support need levels of people with intellectual and visual disabilities.

METHODS

In total, 186 support people from a Dutch healthcare organisation focusing on people with intellectual and visual disabilities participated in an online questionnaire. We used a regression analysis to explore how the constructs, the characteristics, and the level of support needs were related.

RESULTS

Both effort expectancy (β = .35; t(185) = 5.04; p < .001) and attitude (β = .75; t(185) = 15.55; p < .001) of support people were related to the intention to use technologies. The effect of effort expectancy (β = .04; t(177) = .74; p = .462) on the intention to use technologies was mediated through attitude (β = .74; t(177) = 13.28; p < .001). Younger support people scored higher on attitude than older support people.

CONCLUSIONS

Support people's effort expectancy and attitude play a significant role in their intention to use technologies when supporting people with intellectual and visual disabilities, with attitude emerging as pivotal factor.

DE-PASS Best Evidence Statement (BESt): A Systematic Review and Meta-analysis on the Effectiveness of Trials on Device-Measured Physical Activity and Sedentary Behaviour and Their Determinants in Children Aged 5-12 Years

BACKGROUND

To combat the high prevalence of physical inactivity among children, there is an urgent need to develop and implement real-world interventions and policies that promote physical activity (PA) and reduce sedentary behaviour (SB). To inform policy makers, the current body of evidence for children's PA/SB interventions needs to be translated.

OBJECTIVES

The current systematic review and meta-analysis aimed to identify modifiable determinants of device-measured PA and SB targeted in available intervention studies with randomized controlled trial (RCT) and controlled trial (CT) designs in children and early adolescents (5-12 years) and to quantify the effects of the interventions within their respective settings on the determinants of PA/SB and the outcomes PA and SB.

METHODS

A systematic search was conducted in MEDLINE, PsycINFO, Web of Science, SPORTDiscus and CENTRAL. Studies were considered if they were randomized controlled trials (RCTs) or controlled trials (CTs), included children and/or early adolescents (5-12 years; henceforth termed children), measured PA and/or SB using device-based methods and measured PA and/or SB and determinants of PA/SB at least at two timepoints. Risk of bias was assessed using the Cochrane Risk of Bias Tool for Randomised Trials (RoB2) for RCTs and Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) for CTs. The quality of the generated evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Robust Bayesian meta-analysis was conducted to quantify the effects of the interventions on the determinants of PA/SB, and the outcomes PA and SB, stratifying by study design, duration of PA/SB measurement, intervention setting and duration of follow-up measurement. Study characteristics and interventions were summarized.

RESULTS

Thirty-eight studies were included with a total sample size of n = 14,258 (67% girls). Settings identified were school, family/home, community and combinations of these. The review identified 38 modifiable determinants, spanning seven categories on individual, interpersonal and physical environmental levels, with 66% of determinants on the individual level. Overall, the results indicated trivial-to-moderate effects of the interventions on the determinants of PA and SB, with mostly trivial level of evidence for the presence of an effect (as indicated by a small Bayes factor; BF10 < 3.00). The exceptions were moderate effects on parental PA modelling in the family/home setting and SB measured during specific parts of the school day. Higher quality of evidence was found in the family/home setting compared with other settings.

DISCUSSION

Overall, the results indicated that interventions have neither been effective in modifying the determinants of PA/SB, nor changing the PA/SB outcomes in children. In general, the approach in the current review revealed the breadth of methodological variability in children's PA interventions. Research is needed to address novel approaches to children's PA research and to identify potential determinants to inform policy and future interventions.

REGISTRATION

International prospective register of systematic reviews (PROSPERO): CRD42021282874.

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.

Applying intervention mapping to develop a program for promoting short physical activity breaks during class time in upper secondary schools: the MOVE12 protocol study

Introduction

Physical inactivity is a global health challenge, exacerbated by increased screen time and sedentary behaviors. Enhancing physical activity levels at schools offers a promising approach to promote lifelong healthy habits.

Methods

This protocol paper outlines the MOVE12 pilot study, a 12-week intervention study designed to increase physical activity among Norwegian upper secondary school students through 6-7-min daily MOVE-breaks integrated into lessons. Developed using the six-phase Intervention Mapping (IM) protocol, grounded in the social-ecological model and self-determination theory, the intervention focuses on fostering motivation and creating a supportive environment. Key steps include needs assessment, performance objectives, theoretical methods, and program structuring for sustainability.

Results

Linear mixed models, t-tests, and regression analyses will evaluate quantitative outcomes, while qualitative focus groups will explore engagement and behavior change.

Discussion

MOVE12 provides insights into scalable school-based interventions addressing physical inactivity, highlighting the potential of the IM framework to establish sustainable health promotion strategies.

Co-designing a physical activity intervention for low-income mothers of preschool-aged children with community leaders: a qualitative study

BACKGROUND

Young children from low-income families experience disparities in school readiness that impact short and long-term health. Family physical activity co-participation is an interactive activity that may promote positive health and academic outcomes. The purpose of this study is to describe the process and outcomes of engaging with community leaders to co-design the Families Moving Together intervention for low-income mothers and their preschool-aged children.

METHODS

Five action planning sessions were conducted with community leaders, experts in physical activity, early learning, or engaging low-income families (i.e., families receiving housing assistance). The PRACTical planning for Implementation and Scale-up (PRACTIS) guide provided a framework for each session to address implementation and sustainability barriers and facilitators. Qualitative data were analyzed using the Framework Analysis method with inductive and deductive coding.

RESULTS

Action planning participants (N = 19) were aged 50 ± 13.4 years, mostly female (89%), and worked across several community organizations serving low-income mothers and children in an urban city in central Kentucky. Three core themes were identified from analyzing the transcripts. First, participants held shared values, such as respect and equity, that informed the intervention design process. Second, these core values provided a foundation for creating collaborative and sustainable solutions to achieve outcomes. Finally, participants described program design elements to remove barriers and increase facilitators. Through the action planning process, participants co-designed the core components of Families Moving Together, which included leading free family movement programs in the community and engaging trusted community members to deliver the intervention. The goal of this 6-month community-level intervention is to increase school readiness and health by engaging families in physical activity together.

CONCLUSIONS

Community experts and the research team used the PRACTIS guide to co-design strategies to increase physical activity and school readiness that they perceived would enhance the likelihood of implementation and sustainability in the community. Participants underscored the importance of the co-design process that centers community representation and collaborative approaches to create, implement, and sustain programs in the local community. Researchers and community leaders serving low-income mothers and children in other settings may be able to replicate the action planning process to facilitate equitable health outcomes.

Strategies for enhancing the implementation of school-based policies or practices targeting diet, physical activity, obesity, tobacco or alcohol use

BACKGROUND

A range of school-based interventions are effective in improving student diet and physical activity (e.g. school food policy interventions and classroom physical activity interventions), and reducing obesity, tobacco use and/or alcohol use (e.g. tobacco control programmes and alcohol education programmes). However, schools are frequently unsuccessful in implementing such evidence-based interventions.

OBJECTIVES

The primary review objective is to evaluate the effectiveness of strategies aiming to improve school implementation of interventions to address students' (aged 5 to 18 years) diet, physical activity, obesity, tobacco use and/or alcohol use. The secondary objectives are to: 1. determine whether the effects are different based on the characteristics of the intervention including school type and the health behaviour or risk factor targeted by the intervention; 2. describe any unintended consequences and adverse effects of strategies on schools, school staff or students; and 3. describe the cost or cost-effectiveness of strategies.

SEARCH METHODS

We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), five additional databases, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), and the US National Institutes of Health registry (clinicaltrials.gov). The latest search was between 1 May 2021 and 30 June 2023 to identify any relevant trials published since the last published review.

SELECTION CRITERIA

We defined 'implementation' as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any randomised controlled trial (RCT) or cluster-RCT conducted on any scale, in a school setting, with a parallel control group that compared a strategy to improve the implementation of policies or practices to address diet, physical activity, obesity, tobacco use and/or alcohol use by students (aged 5 to 18 years) to no active implementation strategy (i.e. no intervention, inclusive of usual practice, minimal support) or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Given the large number of outcomes reported, we selected and included the effects of a single outcome measure for each trial for the primary outcome using a decision hierarchy (i.e. continuous over dichotomous, most valid, total score over subscore). Where possible, we calculated standardised mean differences (SMDs) to account for variable outcome measures with 95% confidence intervals (CI). We conducted meta-analyses using a random-effects model. Where we could not combine data in meta-analysis, we followed recommended Cochrane methods and reported results in accordance with 'Synthesis without meta-analysis' (SWiM) guidelines. We conducted assessments of risk of bias and evaluated the certainty of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included an additional 14 trials in this update, bringing the total number of included trials in the review to 39 trials with 83 trial arms and 6489 participants. Of these, the majority were conducted in Australia and the USA (n = 15 each). Nine were RCTs and 30 were cluster-RCTs. Twelve trials tested strategies to implement healthy eating practices; 17 physical activity, two tobacco, one alcohol, and seven a combination of risk factors. All trials used multiple implementation strategies, the most common being educational materials, educational meetings, and education outreach visits, or academic detailing. Of the 39 included trials, we judged 26 as having high risks of bias, 11 as having some concerns, and two as having low risk of bias across all domains. Pooled analyses found, relative to a control (no active implementation strategy), the use of implementation strategies probably results in a large increase in the implementation of interventions in schools (SMD 0.95, 95% CI 0.71, 1.19; I2 = 78%; 30 trials, 4912 participants; moderate-certainty evidence). This is equivalent to a 0.76 increase in the implementation of seven physical activity intervention components when the SMD is re-expressed using an implementation measure from a selected included trial. Subgroup analyses by school type and targeted health behaviour or risk factor did not identify any differential effects, and only one study was included that was implemented at scale. Compared to a control (no active implementation strategy), no unintended consequences or adverse effects of interventions were identified in the 11 trials that reported assessing them (1595 participants; moderate-certainty evidence). Nine trials compared costs between groups with and without an implementation strategy and the results of these comparisons were mixed (2136 participants; low-certainty evidence). A lack of consistent terminology describing implementation strategies was an important limitation of the review.

AUTHORS' CONCLUSIONS

We found the use of implementation strategies probably results in large increases in implementation of interventions targeting healthy eating, physical activity, tobacco and/or alcohol use. While the effectiveness of individual implementation strategies could not be determined, such examination will likely be possible in future updates as data from new trials can be synthesised. Such research will further guide efforts to facilitate the translation of evidence into practice in this setting. The review will be maintained as a living systematic review.

Intervention Mapping for Refining a Sport-Based Public Health Intervention in Rural Schools

Sport-based youth development programs, delivered through campus-community partnerships, can create impactful experiences for college students, meet university objectives, and improve the health of children in under-resourced rural communities. This study aimed to pilot test intervention mapping (IM), a systematic approach to intervention development and implementation, to refine the Hoosier Sport intervention, which is a local public health initiative that utilizes the Obesity-Related Behavioral Intervention Trials (ORBITs) model to improve physical activity in middle school children. The IM process, which included a diverse IM planning and advisory group of university representatives and local schools, was guided by self-determination theory (SDT) and social cognitive theory (SCT) and followed four steps: Logic Model of the Problem, Logic Model of Change, Program Design, and Program Production. Using SDT and SCT, we identified our personal determinants as autonomy, competence, and relatedness, while our environmental determinants were role-modeling and sports equipment access. We then created change methods and practical applications for refining and implementing our intervention and gathered pilot test data to assess the feasibility of the intervention. The IM process provided a more robust and evidence-based approach to intervention design and production, while involving stakeholders to foster meaningful collaboration and increase program success. By using IM in program development, public health interventions that promote youth development through sport will likely be more easily scaled up.

Optimizing intervention dissemination at scale: A qualitative study of multi-sector partner organization experiences

For population-wide impact of interventions, evidence-based programs must be successfully disseminated and adopted at scale. Research-practice partnerships can legitimize programs and support organizational adoption, however, ways of leveraging the contributions of partners during dissemination processes are less clear. TransformUs is a school-based physical activity and sedentary behaviour program, and since 2018, has been disseminated at scale to all primary schools in Victoria, Australia, in partnership with 16 state and national organizations. The study objective was to investigate the experiences of partner organizations disseminating TransformUs within their networks, and factors associated with awareness and adoption of the program in schools, from the perspective of partner organizations. Semi-structured interviews with representatives from 15 (out of 16) partner organizations in 2019 involved in disseminating TransformUs state-wide. An interview guide was informed by the RE-AIM framework. Interviews were audio-recorded, transcribed, and coded anonymously. Data were analysed thematically. Four themes (and 13 sub-themes) were identified: (i) organizational barriers and facilitators to dissemination; (ii) implementation support for partners; (iii) overall research experience; and (iv) dissemination strategy. Partners used multiple dissemination channels to increase adoption, and strong alignment between TransformUs and the partner organization's goals appeared to enable dissemination. Partners outlined several local, regional, and state organizations to partner with, and offered suggestions regarding preferred content and timing of dissemination activities for their networks. Researchers planning research-practice partnerships should proactively consider organizational barriers partners may face during dissemination. Regular communication and feedback on dissemination outcomes may contribute to positive research-practice experiences and allow for tailored dissemination strategies.

Relevance and quality of the Gipuzkoan extracurricular youth sports program: an evaluation from a positive youth development perspective

Physical activity and sport (PAS) programmes are an important part of organized extracurricular activities for children and young people. They appear as potentially inclusive environments where students could be provided with holistic development based on active and healthy lifestyles. The aim of this study was to evaluate and describe the Gipuzkoa School Sport Programme (GSSP) from the positive youth development (PYD). The research was carried out based on CPAR (Critical Participatory Action-Research) methodology: a "CPAR group" was created -including researchers and policymakers- to carry out the evaluation of the GSSP in which we analyzed (a) the social environment or PYD climate and (b) life skills. The evaluation and description of the GSSP confirmed that it meets most requirements for providing positive development contexts and opportunities for PYD. The choice of prioritizing multisport and deliberate play and putting early specialization aside seem key conditions to ensure PYD-promoting environments. This work could serve as a referent for decision-makers in organizations dedicated to designing, developing, implementing, and evaluating PYD-focused extracurricular youth sport programmes.

Constructs from the Consolidated Framework for Implementation Research associated with church enrollment and intervention adoption in a national implementation study of a faith-based organizational change intervention

BACKGROUND

Organizational adoption is a key but understudied step in translating evidence-based interventions into practice. The purpose of this study was to report recruitment strategies and factors associated with church enrollment and intervention adoption in a national implementation study of the Faith, Activity, and Nutrition (FAN) program.

METHODS

We worked with partners using multiple strategies to disseminate intervention availability. Interested churches completed an online form. To enroll, the church coordinator (FAN coordinator) and pastor completed baseline surveys and then received intervention online training access. We compared enrolled vs. non-enrolled churches on how they heard about the study and church characteristics. We compared intervention-adopting vs. non-adopting churches on Consolidated Framework for Implementation Research (CFIR) constructs using Fisher's exact tests, χ2, or independent sample t-tests and reported differences where p < 0.10, d≥|0.35|, or the difference in percentage points was ≥ 10.

RESULTS

We received 226 interest forms; 107 churches enrolled, and 85 churches adopted the intervention. Faith-based sources were the most, and paid media the least, effective in reaching churches, which were largely from the southeast with a Methodist or Baptist tradition (no differences by enrollment status). Enrolled churches were less likely to have 500 + worshipers and more likely to have attended a study information session than non-enrolled churches. Church (CFIR inner setting) and FAN coordinator characteristics, but not intervention characteristics, were related to intervention adoption.

CONCLUSION

Partnerships, relationships, and "face time" are important for enrolling churches in evidence-based interventions. Church and church coordinator characteristics are related to intervention adoption. Further work on adoption conceptualization and operationalization is needed.

Increasing adolescents' physical activity levels through a comprehensive school-based physical activity program: study protocol of the cluster randomized controlled trial Active School

BACKGROUND

The positive effects of regular physical activity on children and adolescents' physical and mental health are well-established. Despite these health benefits, most Swiss adolescents do not meet WHO's recommended level of physical activity, which includes a daily minimum of 60 min of moderate-to-vigorous physical activity. Due to their inclusivity, schools are identified as a key setting to promote physical activity. Recently, the comprehensive school physical activity program (CSPAP), in which teachers as physical activity leaders (PALs) play a crucial role to advance comprehensive school-based physical activity promotion, has been discussed. However, such comprehensive approaches are still lacking in Switzerland, and specific PAL trainings do not exist. Therefore, the aim of this study is to implement and evaluate Active School, a comprehensive school-based physical activity program for Swiss secondary schools with integrated PAL training.

METHODS/DESIGN

A cluster randomized controlled trial (RCT) involving 12 secondary schools (6 experimental, 6 waiting control schools) will assess baseline data and effectiveness of Active School at 12 and 24 months. Active School includes five components based on the CSPAP. Each school is encouraged to set individual physical activity goals in this regard. This process is guided by the PALs, who will participate in professional development training before and during Active School implementation. As a primary outcome, students' moderate-to-vigorous physical activity will be assessed via accelerometers. As secondary outcomes, inactivity, light physical activity, step counts, aerobic fitness and coordination will be measured, and students' general wellbeing, learning behavior, and multiple psychosocial measures related to physical activity will be assessed by questionnaires. The effectiveness evaluation is accompanied by a process evaluation that focuses on the implementation outcomes of dose of delivery, reach, feasibility, and sustainability. A mixed methods approach, including ripple effect mapping, will be employed to reconstruct and understand the implementation process.

DISCUSSION

This study will be the first to implement and evaluate a CSPAP in the Swiss school system. The specific PAL training and the simultaneous application of effectiveness and process evaluation are considered strengths of the study.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00033362). Date of registration: January 25, 2024. Retrospectively registered.

Building on Strong Foundations: Deploying Enhanced Replicating Effective Programs for evidence-based prevention curriculum adaptation

Schools frequently adopt new interventions for each new public health issue, but this is both time- and resource-intensive. Adversity exposure is an example of a pervasive public health issue that emerged during Coronavirus Disease 2019 (COVID-19) with notable consequences, including an elevated risk of developing substance use disorders and mental illnesses. Adapting existing, universal, evidence-based interventions, such as the Michigan Model for HealthTM (MMH), by incorporating trauma-sensitive content is a promising approach to meet this need. We examined critical steps in promoting MMH adaptability as part of the Enhanced REP (Replicating Effective Programs) implementation strategy during the COVID-19 pandemic. We share usability testing from the 2020 to 2021 school year and describe how we apply the results to inform the group randomized trial pilot study. We applied key steps from implementation adaptation frameworks to integrate trauma-sensitive content as COVID-19 unfolded, documenting the process through field notes. We conducted initial usability testing with two teachers via interviews and used a rapid qualitative analysis approach. We conducted member checking by sharing the information with two health coordinators to validate results and inform additional curriculum refinement. We developed an adapted MMH curriculum to include trauma-sensitive content, with adaptations primarily centered on adding content, tailoring content, substituting content, and repeating/reinforcing elements across units. We designed adaptations to retain the core functional elements of MMH. Building foundational relationships and infrastructure supports opportunities to user-test intervention materials for Enhanced REP that enhance utility and relevance for populations that would most benefit. Enhanced REP is a promising strategy to use an existing evidence-based intervention to meet better the needs of youth exposed to adversity. Building on the foundations of existing evidence-based interventions, is vital to implementation success and achieving desired public health 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.

Process Evaluation of a Scaled-Up School-Based Physical Activity Program for Adolescents: Physical Activity 4 Everyone

BACKGROUND

Physical Activity 4 Everyone (PA4E1) is a whole-school physical activity program, with demonstrated efficacy (2012-2014). PA4E1 was adapted (scaled-up) and tested in a scale-up trial (2017-2020). This process evaluation study of the scale-up trial had 2 aims. First, to describe the acceptability, appropriateness, and feasibility of PA4E1 in the scale-up trial, from the perspective of school staff involved in the program management and delivery. Second, to generate themes that may explain school staff assessments of acceptability, appropriateness, and feasibility.

METHODS

Data were collected at various time points throughout the 2-year implementation phase. Online surveys were collected from In-School Champions, Head Physical Education teachers, Principals, and Physical Education teachers (quantitative data). Focus groups and interviews were conducted with In-School Champions, Principals, and Physical Education teachers (qualitative data). Existing published data on website engagement, adaptations, modifications, and the scale-up trial primary outcome (implementation of physical activity practices) were triangulated with the quantitative and qualitative during analysis, to generate themes.

RESULTS

School staff delivering PA4E1 reported it was highly acceptable, appropriate, and feasible. Seven themes were generated relating to acceptability, appropriateness, and feasibility. The themes related to how the program was funded, the delivery modes of implementation support, the identification of easy-wins, the recruitment of the right in-school champion, facilitating principal buy-in, mitigating the impact of school staff turnover, and engaging the whole school.

CONCLUSIONS

Recommendations are made to inform future adaptations for PA4E1 and potentially school-based physical activity programs more generally. The findings may inform future scalability assessments of the suitability of programs for scale-up.

How long does it take to scale-up obesity prevention interventions?

OBJECTIVE

The scale-up of evidence-based interventions is necessary to reverse high rates of obesity. However, scale-up doesn't occur frequently nor in a timely manner. While it has been estimated that takes 14-17 years for research translation to occur, the time taken to scale-up prevention interventions is largely unknown. This study examined the time taken to scale-up obesity prevention interventions across four scale-up pathways.

METHODS

A sample of obesity prevention interventions that had been scaled-up or implemented at scale were found using a structured search strategy. Included interventions were mapped against four scale-up pathways and timeframes associated with each stage of the scale-up pathway were identified to determine the time taken to scale-up.

RESULTS

Of the 90 interventions found that were scaled-up to at least a city-wide level, less than half reported a comprehensive research pathway to scale-up and a third did not report any evidence of efficacy or effectiveness prior to scale-up. The time taken to scale-up ranged from 0 to 5 years depending on the pathway taken. Those following a comprehensive pathway took approximately 5 years to scale-up, while interventions that had only one evidence generating step took between 1 and 1.5 years to scale-up. For the remaining interventions, scale-up occurred immediately post-development without evidence generation.

CONCLUSIONS

Our findings indicate that the scale-up of obesity prevention interventions can occur more quickly than previous estimates of 14-17 years. Our findings support previous research that scale-up of interventions occurs through a variety of pathways and often scale-up occurs in absence of prior evidence of effectiveness.

The Secret Sauce? Taking the Mystery Out of Scaling-Up School-Based Physical Activity Interventions

Over the last 4 decades, physical activity researchers have invested heavily in determining "what works" to promote healthy behaviors in schools. Single and multicomponent school-based interventions that target physical education, active transportation, and/or classroom activity breaks effectively increased physical activity among children and youth. Yet, few of these interventions are ever scaled-up and implemented under real-world conditions and in diverse populations. To achieve population-level health benefits, there is a need to design school-based health-promoting interventions for scalability and to consider key aspects of the scale-up process. In this opinion piece, we aim to identify challenges and advance knowledge and action toward scaling-up school-based physical activity interventions. We highlight the key roles of planning for scale-up at the outset, scale-up pathways, trust among partners and program support, program adaptation, evaluation of scale-up, and barriers and facilitators to scaling-up. We draw upon our experience scaling-up effective school-based interventions and provide a solid foundation from which others can work toward bridging the implementation-to-scale-up gap.

Effect of a pragmatic lifestyle modification intervention on physical activity levels and body mass index among obese and overweight adolescents in Udupi, India: a cluster randomized trial

Background

Determine the effects of a multifactorial lifestyle intervention on physical activity (PA), BMI and health-related quality of life (QoL) in obese and overweight adolescents.

Methods

Nine schools in India were clustered randomly in a 12-month study with students allocated to a multifactorial intervention (MFI), or exercise only (EX) or control (CON) group. Participants were adolescents aged 11-16 years (n=671). In the MFI group, adolescents and their parents received lifestyle education using a validated booklet combined with a PA intervention for school students. The EX group received school-based PA only; the CON group continued regular activities. Primary outcomes were PA levels measured with the PAQ-A, and BMI; the secondary outcome was health-related QoL. A linear regression statistical model was used to analyse time, group effects and interactions, with Bonferroni correction for within-group differences at baseline (T0) and at 12-weeks (T1) (post-intervention), 6-month (T2) and 12-month (T3) follow-ups.

Results

Significant time and group effects observed for all groups with PA scores (p<0.001), with MFI group having largest increase in PA; with BMI (p<0.001) and MFI showing the least gain in BMI; and HRQOL (p<0.001), with MFI group showing greatest improvement in scores. There were significant increases in PA at T1 and T3 time-points with the EX group, and at T3 time-point only for MFI and CON, with MFI group showing largest increase in HRQOL scores. BMI increased significantly for all groups at T2 (MFI p=0.001, EX p<0.001) and T3 (p<0.001), while HRQOL increased significantly for both MFI and EX at both follow-ups (p<0.001).

Conclusions

School-based lifestyle MFI was more effective for improving PA, lifestyle behaviours and HRQOL than exercise alone for adolescents, although BMI was not reduced. MFI with PA could be an effective school-based approach for behaviour modification but BMI has limitations for measuring body composition changes.

Registration

CTRI/2019/04/018834 (30/04/2019).

Evaluating the Perceived Health-Related Effectiveness of 'The Daily Mile' Initiative in Irish Primary Schools

Many Irish primary school children do not meet recommended physical activity (PA) guidelines. The Daily Mile (TDM) is a primary school initiative designed to increase children's PA output. This study evaluates TDM's perceived effect on Irish primary school children's health-related metrics. A mixed-methods study, comprising two data collection phases, used the RE-AIM framework to evaluate TDM. Phase One involved teachers, principals and classroom assistants (n = 191) from TDM-registered schools completing a questionnaire. Two TDM-registered schools participated in Phase Two, where (i) interviews were conducted with each principal, (ii) a teacher sub-sample (n = 4) participated in a focus group, and (iii) a child sub-sample (n = 14) participated in separate focus groups. TDM was perceived to positively impact the markers of children's health, including their PA behaviour, physical fitness and social well-being. Inclement weather (66.5%) and a lack of time (56.5%) were reported as the top-ranked implementation barriers. Moreover, TDM's repetitive nature often left children feeling disinterested and resulted in some teachers modifying the initiative to maintain engagement levels. Maintaining the long-term implementation of TDM and its health benefits in primary schools may require bespoke amendments to the original format to preserve children's engagement.

Integrated Measure of PRogram Element SuStainability in Childcare Settings (IMPRESS-C): development and psychometric evaluation of a measure of sustainability determinants in the early childhood education and care setting

BACKGROUND

There is a need for valid and reliable measures of determinants of sustainability of public health interventions in early childhood education and care (ECEC) settings. This study aimed to develop and evaluate the psychometric and pragmatic properties of such a measure - the Integrated Measure of PRogram Element SuStainability in Childcare Settings (IMPRESS-C).

METHODS

We undertook a two-phase process guided by the COnsensus-based Standards for the selection of health status Measurement INstruments checklist (COSMIN) and Psychometric and Pragmatic Evidence Rating Scale (PAPERS). Phase 1 involved measure development; i.e., determining items and scales through an iterative process and assessment of face and content validity. Phase 2 involved the evaluation of psychometric and pragmatic properties. The 29-item measure completed by service executives (directors and nominated supervisors) was embedded in a larger survey from a national sample of Australian ECEC services assessing their implementation of nutrition and physical activity programs. Structural validity, concurrent validity, known groups validity, internal consistency, floor and ceiling effects, norms, and pragmatic qualities of the measure were assessed according to the PAPERS criteria.

RESULTS

The final measure contained 26 items, with respondents reporting how strongly they agreed or disagreed on a five-point Likert scale. Phase 1 assessments confirmed the relevance, and face and content validity of the scale. In Phase 2, we obtained 482 completed surveys, of which 84% (n = 405) completed the entire measure across 405 ECEC settings (one executive per service). Three of the four fit indices for the confirmatory factor analysis met the pre-specified criteria (SRMR = 0.056, CFI = 0.993, RMSEA = 0.067) indicating 'good' structural validity. The IMPRESS-C illustrated: 'good' internal consistency, with Cronbach's alpha values from 0.53 to 0.92; 'emerging' concurrent validity; 'poor' known groups validity; 'good' norms; and 'good' overall pragmatic qualities (cost, readability, length, and assessor burden).

CONCLUSIONS

The IMPRESS-C possesses strong psychometric and pragmatic qualities for assessing service executive-level perceptions of determinants influencing sustainment of public health interventions within ECEC settings. To achieve a full range of perspectives in this setting, future work should be directed to also develop and test measures of sustainability determinants at the implementer level (e.g., among individual educators and staff).

The Effectiveness of Physical Activity Policies in Center-Based Childcare: A Systematic Review and Meta-Analysis

Purpose: Many young children spend a significant portion of time in center-based childcare settings; however, these children are often not sufficiently active during care. Promoting physical activity through policy implementation is one mechanism which has the potential to increase physical activity. The purpose of this systematic review and meta-analysis was to provide an overview of physical activity policies implemented in childcare centers and determine their effect on children's physical activity. Methods: Electronic searches were conducted in CINAHL, Medline, PsycINFO, EMBASE, Scopus, SPORTDiscus, and Sports Medicine and Education Database. Two reviewers independently examined 3,286 articles to find peer-reviewed, original studies that assessed the impact of physical activity policies on children's physical activity. Random effects meta-analyses were used to determine the impact of policies. Results: A total of 13 articles met the inclusion criteria; in which 12 unique policies were implemented. Results of the meta-analyses suggest that introducing new physical activity policies did not increase children's moderate-to-vigorous physical activity (MVPA); however, compared to centers without a formalized physical activity policy, children in centers with a formalized policy engaged in significantly more MVPA and total physical activity. Conclusions: Introducing new physical activity policies alone may not be sufficient to increase children's engagement in physical activity, and it may be important to combine with capacity-building initiatives for childcare staff and early childhood educators. Results reinforce the value of childcare centers implementing their own formalized physical activity policies to support children's physical activity, which highlights the importance of regulating physical activity practices in childcare. Registration: CRD42022326037.

Sustainable effects of a motor skill programme on physical activity levels in 7-8 years old children, in the Eastern Cape Province of South Africa

BACKGROUND

Deteriorating global physical activity (PA) levels among children warrants new and sustainable approaches to increase PA levels. This study aimed to determine the immediate and sustainable influences of a 9-week movement program on the PA levels in 7 to 8-year-old school children in the Raymond Mhlaba Municipality in the Eastern Cape Province of South Africa.

METHODS

A randomized control trial including two groups (control group (CG) and intervention group (IG)), pre-post-retest (after six months of no intervention) design was used. Seventy school children, mean age 7.12 years (± 0.71) (n = 35 IG; n = 35 CG) participated in the study. A 9-week movement program was followed twice a week for 30 min during school hours. PA was measured for 7 consecutive days using a hip-mounted wGT3X-BT Actigraph accelerometer. The Test of Gross Motor Development-Third Edition (TGMD-3) was used to assess motor skills. Hierarchical Linear Modelling (HLM) was applied to analyze the data with time, sex, and group as predictors. Effect sizes were computed using Cohen's d-cut points to assess the practical significance of changes over time. Estimated regression coefficients were also computed to determine the strength of the relationship between moderate-to-vigorous physical activity (MVPA) and fundamental movement skills (FMS).

RESULTS

Before the intervention, 60% of the IG met the 60 min of daily MVPA guideline, while light physical activity (LPA) per day was also higher than sedentary behavior (SB) in both groups. No immediate (p < 0.01) or sustainable (p < 0.01) increases in MVPA levels were found and no positive associations emerged between FMS and MVPA levels.

CONCLUSIONS

This intervention had little to no effect on children's MVPA. More understanding of the activity behavior and interests of children is needed to improve their PA behavior through the content of movement programs. Strategies are also needed to communicate clear messages at a personalized but also parental level, focusing on enhancing health through regular PA, especially to promote PA in young children.

Effect of capacity building interventions on classroom teacher and early childhood educator perceived capabilities, knowledge, and attitudes relating to physical activity and fundamental movement skills: a systematic review and meta-analysis

BACKGROUND

Capacity building may play an important role in improving classroom teachers' and early childhood educators' (ECE) capacity to implement physical activity and FMS interventions. Capacity building is the development of knowledge, skills, and structures to improve the capability of individuals and organisations to achieve effective health promotion. This review aimed to determine the efficacy of capacity building interventions on teachers' and ECEs' perceived capabilities, knowledge, and attitudes relating to physical activity and fundamental movement skills.

METHODS

An exhaustive literature search of six electronic databases was conducted. Controlled, single-group pre-post studies were included if they measured the effect of a capacity building intervention on in-service or pre-service classroom teachers' (primary or secondary) or ECEs' physical activity or fundamental skills related perceived capabilities, knowledge, or attitudes. The effects of interventions were synthesised using random effects meta-analysis. Subgroup analysis and meta-regression was conducted to determine if the effects differed based on study design, type of teacher (ECE vs. primary school), or teacher level (pre-service vs. in-service).

RESULTS

A total of 22 studies reporting on 25 unique samples were included in the meta-analyses. Only studies reporting on ECEs and primary school teachers were identified. Interventions most commonly included training/professional development, resources and toolkits, communities of practice, mentorships, and ongoing support. Results showed that capacity building interventions significantly improved teachers' and ECEs' perceived capabilities (g = 0.614, 95% CI = 0.442, 0.786), knowledge (g = 0.792 95% CI = 0.459, 1.125), and attitudes (g = 0.376 95% CI = 0.181, 0.571). The effects did not differ significantly as a function of any of the moderators examined.

CONCLUSION

Findings from this review provide strong support that capacity building interventions are efficacious at improving teachers' and ECEs' perceived capabilities, knowledge, and attitudes related to promoting physical activity and teaching fundamental movement skills. Pre-service teachers and ECEs should be provided training in physical activity and fundamental movement skills as part of their degrees, and continual professional development and capacity building should be offered to in-service teachers and ECEs to promote physical activity and fundamental movement skills in children.

Qualitative multi-stakeholder evaluation of the adoption, implementation and sustainment of the school-based dietary intervention "Jump-in"

BACKGROUND

Comprehensive school-based programs applying the WHO Health Promoting School Model have the potential to initiate and sustain behavior change and impact health. However, since they often include intervention efforts on a school's policies, physical environment, curriculum, health care and involving parents and communities, they significantly 'intrude' on a complex system that is aimed primarily at education, not health promotion. More insights into and concrete strategies are therefore needed regarding their adoption, implementation, and sustainment processes to address the challenge to sustainable implementation of HPS initiatives in a primarily educational setting. This study consequently evaluates adoption, implementation and sustainment processes of Amsterdam's Jump-in healthy nutrition HPS intervention from a multi-stakeholder perspective.

METHODS

We conducted semi-structured interviews and focus groups with all involved stakeholders (n = 131), i.e., Jump-in health promotion professionals (n = 5), school principals (n = 7), at-school Jump-in coordinators (n = 7), teachers (n = 20), parents (n = 50, 9 groups) and children (n = 42, 7 groups) from 10 primary schools that enrolled in Jump-in in the school year 2016-2017. Included schools had a higher prevalence of overweight and/or obesity than the Dutch average and they were all located in Amsterdam's low-SEP neighborhoods. Data were analyzed using a directed content analysis, in which the Determinants of Innovation Model was used for obtaining theory-based predetermined codes, supplemented with new codes emerging from the data.

RESULTS

During intervention adoption, all stakeholders emphasized the importance of parental support, and accompanying workshops and promotional materials. Additionally, parents and teachers indicated that a shared responsibility for children's health and nuanced framing of health messages were important. During implementation, all stakeholders needed clear guidelines and support structures. Teachers and children highlighted the importance of peer influence, social norms, and uniform application of guidelines. School staff also found further tailoring of the intervention and dealing with financial constraints important. For long-term intervention sustainment, incorporating the intervention policies into the school statutes was crucial according to health promotion professionals.

CONCLUSIONS

This qualitative evaluation provides valuable insights into factors influencing the adoption, implementation, and sustainment processes of dietary interventions, such as the importance of transparent and consistent intervention guidelines, clear communication regarding the rationale behind intervention guidelines, and, stakeholders' involvement in decision-making.

The impact of the world's first regulatory, multi-setting intervention on sedentary behaviour among children and adolescents (ENERGISE): a natural experiment evaluation

BACKGROUND

Regulatory actions are increasingly used to tackle issues such as excessive alcohol or sugar intake, but such actions to reduce sedentary behaviour remain scarce. World Health Organization (WHO) guidelines on sedentary behaviour call for system-wide policies. The Chinese government introduced the world's first nation-wide multi-setting regulation on multiple types of sedentary behaviour in children and adolescents in July 2021. This regulation restricts when (and for how long) online gaming businesses can provide access to pupils; the amount of homework teachers can assign to pupils according to their year groups; and when tutoring businesses can provide lessons to pupils. We evaluated the effect of this regulation on sedentary behaviour safeguarding pupils.

METHODS

With a natural experiment evaluation design, we used representative surveillance data from 9- to 18-year-old pupils before and after the introduction of the regulation, for longitudinal (n = 7,054, matched individuals, primary analysis) and repeated cross-sectional (n = 99,947, exploratory analysis) analyses. We analysed pre-post differences for self-reported sedentary behaviour outcomes (total sedentary behaviour time, screen viewing time, electronic device use time, homework time, and out-of-campus learning time) using multilevel models, and explored differences by sex, education stage, residency, and baseline weight status.

RESULTS

Longitudinal analyses indicated that pupils had reduced their mean total daily sedentary behaviour time by 13.8% (95% confidence interval [CI]: -15.9 to -11.7%, approximately 46 min) and were 1.20 times as likely to meet international daily screen time recommendations (95% CI: 1.01 to 1.32) one month after the introduction of the regulation compared to the reference group (before its introduction). They were on average 2.79 times as likely to meet the regulatory requirement on homework time (95% CI: 2.47 to 3.14) than the reference group and reduced their daily total screen-viewing time by 6.4% (95% CI: -9.6 to -3.3%, approximately 10 min). The positive effects were more pronounced among high-risk groups (secondary school and urban pupils who generally spend more time in sedentary behaviour) than in low-risk groups (primary school and rural pupils who generally spend less time in sedentary behaviour). The exploratory analyses showed comparable findings.

CONCLUSIONS

This regulatory intervention has been effective in reducing total and specific types of sedentary behaviour among Chinese children and adolescents, with the potential to reduce health inequalities. International researchers and policy makers may explore the feasibility and acceptability of implementing regulatory interventions on sedentary behaviour elsewhere.

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

BACKGROUND

The primary purpose of this review is to synthesise the effect of strategies aiming to sustain the implementation of evidenced-based interventions (EBIs) targeting key health behaviours associated with chronic disease (i.e. physical inactivity, poor diet, harmful alcohol use, and tobacco smoking) in clinical and community settings. The field of implementation science is bereft of an evidence base of effective sustainment strategies, and as such, this review will provide important evidence to advance the field of sustainability research.

METHODS

This systematic review protocol is reported in accordance with the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) checklist. Methods will follow Cochrane gold-standard review methodology. The search will be undertaken across multiple databases, adapting filters previously developed by the research team, data screening and extraction will be performed in duplicate, strategies will be coded using an adapted sustainability-explicit taxonomy, and evidence will be synthesised using appropriate methods (i.e. meta-analytic following Cochrane or non-meta-analytic following SWiM guidelines). We will include any randomised controlled study that targets any staff or volunteers delivering interventions in clinical or community settings. Studies which report on any objective or subjective measure of the sustainment of a health prevention policy, practice, or programme within any of the eligible settings will be included. Article screening, data extraction, risk of bias, and quality assessment will be performed independently by two review authors. Risk of bias will be assessed using Version 2 of the Cochrane risk-of-bias tool for randomised trials (RoB 2). A random-effect meta-analysis will be conducted to estimate the pooled effect of sustainment strategies separately by setting (i.e. clinical and community). Sub-group analyses will be undertaken to explore possible causes of statistical heterogeneity and may include the following: time period, single or multi-strategy, type of setting, and type of intervention. Differences between sub-groups will be statistically compared.

DISCUSSION/CONCLUSION

This will be the first systematic review to determine the effect of strategies designed to support sustainment on sustaining the implementation of EBIs in clinical and community settings. The findings of this review will directly inform the design of future sustainability-focused implementation trials. Further, these findings will inform the development of a sustainability practice guide for public health practitioners.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022352333.

Was it a HIIT? A process evaluation of a school-based high-intensity interval training intervention

BACKGROUND

Despite a growing body of research investigating high-intensity interval training (HIIT) in schools, there are limited process evaluations investigating their implementation. This is concerning because process evaluations are important for appropriately interpreting outcome findings and augmenting intervention design. This manuscript presents a process evaluation of Making a HIIT, a school-based HIIT intervention.

METHODS

The Making a HIIT intervention spanned 8 weeks and was completed at three schools in Greater Brisbane, Australia. Ten classes (intervention group) completed 10-min teacher-led HIIT workouts at the beginning of health and physical education (HPE) lessons, and five classes (control group) continued with regular HPE lessons. The mixed methods evaluation was guided by the Framework for Effective Implementation by Durlak and DuPre.

RESULTS

Program reach: Ten schools were contacted to successfully recruit three schools, from which 79% of eligible students (n = 308, x ¯ age: 13.0 ± 0.6 years, 148 girls) provided consent. Dosage: The average number of HIIT workouts provided was 10 ± 3 and the average number attended by students was 6 ± 2. Fidelity: During HIIT workouts, the percentage of time students spent at ≥ 80% of maximum heart rate (HRmax) was 55% (interquartile range (IQR): 29%-76%). Monitoring of the control group: During lessons, the intervention and control groups spent 32% (IQR: 12%-54%) and 28% (IQR: 13%-46%) of their HPE lesson at ≥ 80% of HRmax, respectively. Responsiveness: On average, students rated their enjoyment of HIIT workouts as 3.3 ± 1.1 (neutral) on a 5-point scale. Quality: Teachers found the HIIT workouts simple to implement but provided insights into the time implications of integrating them into their lessons; elements that helped facilitate their implementation; and their use within the classroom. Differentiation: Making a HIIT involved students and teachers in the co-design of HIIT workouts. Adaption: Workouts were modified due to location and weather, the complexity of exercises, and time constraints.

CONCLUSION

The comprehensive evaluation of Making a HIIT provides important insights into the implementation of school-based HIIT, including encouragings findings for student enjoyment and fidelity and recommendations for improving dosage that should be considered when developing future interventions.

TRIAL REGISTRATION

ACTRN, ACTRN12622000534785 , Registered 5 April 2022 - Retrospectively registered.

Acceptability and perceived feasibility of the KaziKidz health promotion intervention among educators and caregivers in schools from South Africa: a qualitative descriptive study

BACKGROUND

Despite the uncontested benefits of physical activity, its promotion lags behind in the public health agenda of low- and middle-income countries (LMICs). School-based interventions are promising strategies to foster health during childhood, but evidence of their effectiveness is limited and inconclusive for LMICs. Thus, further investigation is needed on contextual factors associated with intervention implementation in low-resource settings. We studied the acceptability and feasibility of the KaziKidz health promotion intervention and its implementation and make recommendations to improve future adoption and sustainability.

METHODS

KaziKidz was implemented in four primary schools from low-income communities in South Africa in 2019. Semi-structured interviews with four school principals, three focus group interviews with 16 educators, and another three with 16 caregivers were conducted between October and November 2021. Participants were purposively recruited. Interview transcripts were analyzed via thematic analysis using a deductive and reflexive approach.

RESULTS

Three main themes influencing intervention implementation and adoption were identified: (1) prioritizing teachers' needs (2), integrating the program into the school structure, and (3) creating opportunities in the community. Supporting recommendations included: (theme 1) adopting intervention approaches that are inclusive of educators' health and providing them with capacity development and external support; (theme 2) fostering a feeling of ownership and belonging among school stakeholders to adapt interventions to specific resources and needs; and (theme 3) raising community awareness to encourage individuals to claim power over and actively engage with the program.

CONCLUSIONS

Comprehensive interventions comprising health support, adequate training, and ongoing assistance for educators combined with school-wide and community outreach actions seeking to strengthen program ownership, accountability, and engagement can enhance uptake of school-based interventions and long-term maintenance.

TRIAL REGISTRATION

ISRCTN15648510, registered on 17/04/2020.

Promoting hEalthy Diet and Active Lifestyle (PEDAL): a protocol for the development and feasibility study of a multicomponent intervention among primary school children in Singapore

BACKGROUND

Setting healthy lifestyle habits during the formative years of childhood is critical as habits can track to adulthood and help prevent obesity and chronic disease risks in later life. While multicomponent interventions have been shown to be effective in changing the lifestyle behaviours of children, there is a limited understanding of the feasibility of such interventions in primary schools in Singapore. A multiphase mixed method study was conducted to develop and examine the feasibility of a theory-based multicomponent school-based intervention-Promoting hEatlthy Eating and Active Lifestyle (PEDAL).

METHODS

Underpinned by Kincaid's ideation model, the PEDAL intervention was developed to increase fruit and vegetable consumption and decrease sedentary behaviours among children. This study consists of three phases. Phase 1 details the development of PEDAL, which consists of four components: (A) a series of interactive health education lessons, (B) actionable home activities to support habit formation, (C) parental/guardian engagement, and (D) optimising the school environment. In Phase 2, components A and B of PEDAL were implemented in two public, co-educational primary schools among Primary 5 students (aged 10-12 years) in Singapore. Data was collected quantitatively using questionnaires and qualitatively using focus group discussions (FGDs) with students and teachers. The feasibility dimensions of components A and B, including recruitment capability, data collection, social validity, and practicality were examined, and ideation on healthy eating and physical activity was explored. In Phase 3, the full PEDAL intervention was pilot-tested in two other public, co-education primary schools with the same target population, using a concurrent mixed method quasi-experimental study design. Feasibility dimensions and potential effectiveness of the intervention will be assessed.

DISCUSSION

This study will provide insights into the feasibility of PEDAL and inform its refinement. Findings from the pilot test will guide the planning of a larger-scale definitive trial.

TRIAL REGISTRATION

Registered with ISRCTN registry (ISRCTN16114046) on 16 October 2022.

Effectiveness of Intervention Strategies to Increase Adolescents' Physical Activity and Reduce Sedentary Time in Secondary School Settings, Including Factors Related to Implementation: A Systematic Review and Meta-Analysis

BACKGROUND

Globally, just one in five adolescents meet physical activity guidelines and three-quarters of the school day is spent sitting. It is unclear which types of school-based interventions strategies increase physical activity and reduce sedentary time among adolescents, or how these interventions are implemented influences their effectiveness.

OBJECTIVE

The three aims of our systematic review were to (a) identify intervention strategies used within secondary school settings to improve students' movement behaviours throughout school-based initiatives, delivered at or by the school; (b) determine the overall effect of the interventions (meta-analysis) on physical activity (all intensities), sedentary time, cognitive/academic, physical health and/or psychological outcomes; and (c) describe factors related to intervention implementation.

METHODS

Searches were conducted in MEDLINE complete, EMBASE, CINAHL, SPORTDiscus, APA PsycINFO, and ERIC in January 2023 for studies that (a) included high school-aged adolescents; (b) involved a school-based intervention to increase physical activity and/or decrease sedentary time; and (c) were published in English. Reported effects were pooled in meta-analyses where sufficient data were obtained.

RESULTS

Eighty-five articles, representing 61 interventions, met the inclusion criteria, with 23 unique intervention strategies used. Interventions that involved whole-school approaches (i.e., physical activity sessions, environmental modifications, teacher training, peer support and/or educational resources) were favourably associated with most of the outcomes. The meta-analyses showed: (a) non-significant effects for sedentary time (Standardized mean difference [SMD] = -0.02; 95%CI, -0.14, 0.11), physical activity at all intensities (light: SMD= -0.01; 95%CI, -0.08, 0.05; moderate: SMD = 0.06; 95%CI, -0.09, 0.22; vigorous: SMD = 0.08; 95%CI, -0.02, 0.18; moderate-to-vigorous: SMD = 0.05; 95%CI, -0.01, 0.12) and waist circumference (SMD = 0.09; 95%CI, -0.03, 0.21), and (b) a small statistically significant decrease in body mass index (SMD= -0.09, 95%CI -0.16, -0.0). Factors related to intervention implementation were reported in 51% of the articles.

CONCLUSION

While some intervention approaches demonstrated promise, small or null effects were found in meta-analyses. Future school-based interventions should utilize a whole-school approach designed to increase adolescents' activity across the day. Consistent reporting of implementation will increase understanding of how interventions are adopted, implemented and sustained.

REGISTRATION

PROSPERO (CRD42020169988).

Academic Stress Interventions in High Schools: A Systematic Literature Review

The experience of academic stress is common during high school and can have significant negative consequences for students' educational achievement and wellbeing. High school students frequently report heightened levels of school-related distress, particularly as they approach high-stakes assessments. Programs designed to reduce or prevent academic stress are needed, and their delivery in school settings is ideal to improve treatment access. The current review aimed to examine the effectiveness of high school-based programs in reducing or preventing academic stress. A systematic search returned 31 eligible studies across 13 countries. Programs were categorised according to intervention type, format, and facilitator. Results showed that the methodological quality of most studies was poor, and many used an inactive control group. As predicted by theories of academic stress, the strongest evidence was for programs grounded in cognitive-behavioural therapy (CBT). There was evidence that both universal and targeted approaches can be beneficial. The unique implementation issues for these two formats are discussed. Most programs were delivered by psychologists and were generally effective, but almost all of these were CBT programs. A smaller proportion of programs delivered by teachers were effective. Therefore, future studies should evaluate the implementation success of programs to improve the rate of effective delivery by school staff. Overall, the field will benefit from more randomised controlled trials with comparisons to active control groups, larger sample sizes and longer-term follow-ups.

Influencing factors for the implementation of school-based interventions promoting obesity prevention behaviors in children with low socioeconomic status: a systematic review

BACKGROUND

Health inequity (HI) remains a major challenge in public health. Improving the health of children with low socioeconomic status (SES) can help to reduce overall HI in children. Childhood obesity is a global problem, entailing several adverse health effects. It is crucial to assess the influencing factors for adoption, implementation, and sustainment of interventions. This review aims to identify articles reporting about influencing factors for the implementation of school-based interventions promoting obesity prevention behaviors in children with low SES. It aims to critically appraise the articles' quality, assess influencing factors, categorize and evaluate them, and to discuss possible implications.

METHODS

A systematic search was conducted in 7 databases with the following main inclusion criteria: (1) school-based interventions and (2) target group aged 5-14 years. The Consolidated Framework for Implementation Research, its five domains (intervention characteristics, inner setting, outer setting, characteristics of individuals, process) along with 39 categories within these domains were used as deductive category system for data analysis. We grouped the articles with regard to the characteristics of the interventions in simple and complex interventions. For each domain, and for the groups of simple and complex interventions, the most commonly reported influencing factors are identified.

RESULTS

In total, 8111 articles were screened, and 17 met all eligibility criteria. Included articles applied mixed methods (n=11), qualitative (n=5), and quantitative design (n=1). Of these, six were considered to report simple interventions and eleven were considered to report complex interventions. In total, 301 influencing factors were assessed. Aspects of the inner setting were reported in every study, aspects of the outer setting were the least reported domain. In the inner setting, most reported influencing factors were time (n=8), scheduling (n=6), and communication (n=6).

CONCLUSION

This review found a wide range of influencing factors for implementation and contributes to existing literature regarding health equity as well as implementation science. Including all stakeholders involved in the implementation process and assessing the most important influencing factors in the specific setting, could enhance implementation and intervention effectiveness. More empirical research and practical guidance are needed to promote obesity prevention behaviors among children with low SES.

REGISTRATION

CRD42021281209 (PROSPERO).

Acute effect of physical activity on academic outcomes in school-aged youth: A systematic review and multivariate meta-analysis

BACKGROUND

There has been an increase in the number of studies examining the effect of acute and chronic physical activity on academic outcomes in children and adolescents in the last two decades. We aimed to systematically determine the acute effects of physical activity on academic outcomes in school-aged youth and to examine possible moderators.

METHODS

We conducted a systematic search using PubMed, Web of Science, SPORTDiscus, and PsycINFO databases (from inception to 11th January 2023) for studies assessing the acute effects of physical activity on academic performance-related outcomes in school-aged youth. A univariate and multivariate meta-analysis was conducted based on a random-effects model with restricted maximum likelihood used to pool the academic outcomes results (Hedge's g).

RESULTS

We included 11 articles (803 children and adolescents [range: 6-16 years]) in the systematic review. Overall, acute physical activity increased academic outcomes (Hedge's g = 0.35, 95% CI: 0.20-0.50). Multivariate meta-analyses revealed that physical activity increased academic performance in mathematics (Hedge's g = 0.29, 95% CI: 0.16-0.42) and language (Hedge's g = 0.28, 95% CI: 0.09-0.47). Only behavior change techniques (Hedge's g = 0.54, 95% CI, 0.18-0.90, p < 0.001) played a significant role in this relationship.

CONCLUSIONS

A single bout of physical activity can improve academic outcomes in school-aged youth, which may serve as a complementary tool for the educational field. However, the observed heterogeneity in the results indicates that we should interpret the findings obtained with caution.

Outer-context determinants on the implementation of school-based interventions for LGBTQ+ adolescents

Background

Schools are critical venues for supporting LGBTQ+ youth well-being. Implementing LGBTQ-supportive practices can decrease experiences of stigmatization, discrimination, and victimization that lead to adverse mental health outcomes like anxiety, depression, and suicidality. However, schools are also subject to a wide range of outer-context pressures that may influence their priorities and implementation of LGBTQ-supportive practices. We assessed the role of emergent outer-context determinants in the context of a 5-year cluster randomized controlled trial to study the implementation of LGBTQ-supportive evidence-informed practices (EIPs) in New Mexico high schools.

Method

Using an iterative coding approach, we analyzed qualitative data from annual interviews with school professionals involved in EIP implementation efforts.

Results

The analysis yielded three categories of outer-context determinants that created challenges and opportunities for implementation: (a) social barriers related to heterocentrism, cisgenderism, and religious conservatism; (b) local, state, and national policy and political discourse; and (c) crisis events.

Conclusions

By exploring the implications of outer-context determinants for the uptake of LGBTQ-supportive practices, we demonstrate that these elements are dynamic-not simply reducible to barriers or facilitators-and that assessing outer-context determinants shaping implementation environments is crucial for addressing LGBTQ health equity.

Scaling up a school-based intervention to increase physical activity and reduce sedentary behaviour in children: protocol for the TransformUs hybrid effectiveness-implementation trial

INTRODUCTION

Efficacious programmes require implementation at scale to maximise their public health impact. TransformUs is an efficacious behavioural and environmental intervention for increasing primary (elementary) school children's (5-12 years) physical activity and reducing their sedentary behaviour within school and home settings. This paper describes the study protocol of a 5-year effectiveness-implementation trial to assess the scalability and effectiveness of the TransformUs programme.

METHODS AND ANALYSIS

A type II hybrid implementation-effectiveness trial, TransformUs is being disseminated to all primary schools in the state of Victoria, Australia (n=1786). Data are being collected using mixed methods at the system (state government, partner organisations), organisation (school) and individual (teacher, parent and child) levels. Evaluation is based on programme Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. RE-AIM domains are being measured using a quasi-experimental, pre/post, non-equivalent group design, at baseline, 12 and 24 months. Effectiveness will be determined in a subsample of 20 intervention schools (in Victoria) and 20 control schools (in New South Wales (NSW), Australia), at baseline, 12 and 24 months. Primary outcomes include TransformUs Reach, Adoption, Implementation and organisational Maintenance (implementation trial), and children's physical activity and sedentary time assessed using accelerometers (effectiveness trial). Secondary outcomes include average sedentary time and moderate to vigorous-intensity physical activity on weekdays and during school hours, body mass index z-scores and waist circumference (effectiveness trial). Linear mixed-effects models will be fitted to compare outcomes between intervention and control participants accounting for clustering of children within schools, confounding and random effects.

ETHICS AND DISSEMINATION

The trial was approved by the Deakin University Human Research Ethics Committee (HEAG-H 28_2017), Victorian Department of Education, the NSW Department of Education, Australian Catholic University (2017-145R), Melbourne Archdiocese Catholic Schools and Catholic Schools NSW. Partners, schools/teachers and parents will provide an informed signed consent form prior to participating. Parents will provide consent for their child to participate in the effectiveness trial. Findings will be disseminated via peer-reviewed publications, scientific conferences, summary reports to schools and our partner organisations, and will inform education policy and practice on effective and sustainable ways to promote physical activity and reduce sedentary behaviours population-wide.

TRIAL REGISTRATION NUMBER

Australian Clinical Trials Registration Registry (ACTRN12617000204347).

A cluster randomised controlled trial to assess the effectiveness of a multi-strategy sustainability intervention on teachers' sustained implementation of classroom physical activity breaks (energisers): study protocol

BACKGROUND

Governments internationally have invested hugely in the implementation and scale-up of school-based physical activity interventions, but have little evidence of how to best sustain these interventions once active implementation support ceases. This study will assess the effectiveness of a multi-strategy sustainability intervention on classroom teachers' sustainment of energisers (short 3-5 min physical activity breaks during class-time) scheduled across the school day from baseline to 12 and 24-month follow-up.

METHODS

A cluster randomised controlled trial will be conducted in 50 primary schools within the Hunter New England, Illawarra Shoalhaven, Murrumbidgee and Northern New South Wales (NSW) Local Health Districts of NSW Australia. Schools will be randomly allocated to receive either usual support or the multi-strategy sustainability intervention that includes: centralised technical assistance from a trained project officer; formal commitment and mandated change obtained from school principals; training in-school champions; reminders for teachers; educational materials provided to teachers; capturing and sharing local knowledge; and engagement of parents, carers and the wider school community. The primary trial outcome will be measured via a teacher logbook to determine the between-group difference in the change in mean minutes of energisers scheduled across the school day at 12 and 24-month follow-up compared to baseline. Analyses will be performed using an intention to treat framework. Linear mixed models will be used to assess intervention effects on the primary outcome at both follow-up periods.

DISCUSSION

This study will be one of the first randomised controlled trials to examine the impact of a multi-strategy sustainability intervention to support schools' sustainment of a physical activity intervention. The proposed research will generate new evidence needed for the partnering organisations to protect their considerable investments to date in physical activity promotion in this setting and will provide seminal evidence for the field globally.

TRIAL REGISTRATION

ACTRN12620000372987 version 1 registered 17th March 2020. Version 3 (current version) updated 4th August 2023.

Efficiency of an Alternative Physical Education Program for the Lower Grades of Elementary School Children

(1) Introduction: This research was conducted with the aim of assessing whether an alternative physical education (PE) program could effectively substitute for the traditional PE curriculum and aid in accomplishing the essential goals and objectives of PE among younger elementary school children. (2) Materials and Methods: This longitudinal 6-month study included third-grade elementary school children of both genders, who were healthy, lived in urban areas, and were involved in an alternative PE program, as well as the regular PE classes. The sample of participants comprised 214 students, with 105 participants in the experimental group and 109 participants in the control group, who underwent pre- and post-intervention measurements. For the purposes of this study, 11 variables were applied to assess the parameters of growth and development, motor abilities, and physical and health education. MANCOVA and ANCOVA methods were used to determine the effects resulting from the alternative and regular PE programs, and differences between the groups, respectively. The data are reported as the mean and standard deviations, and were analyzed using the statistical package SPSS version 20.0 (SPSS Inc., Armonk, NY, USA). (3) Results: Based on the research results obtained for motor abilities and physical and health education, it was concluded that both the alternative and regular PE programs had positive effects in achieving the goals and objectives of PE, but without statistical significance at the multivariate and univariate levels. The differences between the two groups were found to be negligible (effect size, ES < 0.2). (4) Discussion: Sports and PE have distinct objectives and approaches. While sports emphasize competition and winning, PE aims to impart fundamental skills and knowledge, prioritizing inclusivity among younger students. Success in PE is measured by the number of students meeting these goals, potentially affecting both talented and struggling learners. (5) Conclusions: The results obtained from the conducted research indicate that both the alternative PE program and the regular PE program influence changes in motor abilities and physical and health education to a limited extent. The alternative PE program proposed in this study, with its modifications to the structure of existing, regular PE program, can fully replace the latter in schools that do not meet the required spatial and material standards.

Applying the Integrated Sustainability Framework to explore the long-term sustainability of nutrition education programmes in schools: a systematic review

OBJECTIVE

This review aimed to identify and synthesise the enablers and barriers that influence the long-term (≥ 2 years) sustainment of school-based nutrition programmes.

DESIGN

Four databases (PubMed, Cochrane Library, Embase and Scopus) were searched to identify studies reporting on the international literature relating to food and nutrition programmes aimed at school-age (5-14 years) children that had been running for ≥ 2 years (combined intervention and follow-up period). Eligible studies were analysed using the Integrated Sustainability Framework (ISF), which involved deductive coding of programme enablers and barriers. A quality assessment was completed, using the Mixed-Methods Appraisal Tool and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

SETTING

International school-based nutrition programmes.

SUBJECTS

Individuals involved with the implementation of school-based nutrition programmes.

RESULTS

From the 7366 articles identified, thirteen studies (seven qualitative, five mixed methods and one quantitative descriptive) were included, from which the enablers and barriers of eleven different nutrition-related programmes were analysed. Thirty-four factors across the five domains of the ISF were identified that influenced the sustained implementation of programmes. The most common barrier was a lack of organisational readiness and resources, whereas the most common enabler was having adequate external partnerships and a supportive environment.

CONCLUSIONS

These findings have application during the initiation and implementation phases of school-based nutrition programmes. Paying attention to the 'outer contextual factors' of the ISF including the establishment and maintenance of robust relationships across whole of government systems, local institutions and funding bodies are crucial for programme sustainment.

Implementation models and frameworks used to guide community-based physical activity programs for children: a scoping review

BACKGROUND

The implementation of community-based programs is key to effective, sustainable initiatives that can support population-level changes in children's physical activity. The purpose of this scoping review was to explore the implementation models and frameworks used to develop (process models), explore (determinant frameworks), and/or evaluate (evaluation frameworks) community-based physical activity programs for children. Also, the foundational components of the implementation models and frameworks and practical application in real-world settings were described.

METHODS

The methodological framework developed by Arksey and O'Malley (2005) and the updated recommendations from Levac, Colquhoun and O'Brien (2010) were used to search, identify, and summarize applicable studies. This review also met the requirements in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Reviews Checklist (PRISMA-ScR). A detailed search of six databases and three academic journals was conducted. Information about the article, the program, and the implementation model/framework were extracted and summarized.

RESULTS

The search retrieved 42,202 articles, of which 27 met the inclusion criteria. Eleven process models, one determinant framework, and two evaluation frameworks were identified. Nineteen components were developed from the models and frameworks. Tailoring, situational analysis, and element identification were common components among the identified models and frameworks.

CONCLUSIONS

Since the execution of interventions is vital for creating successful health-promoting initiatives, researchers and program developers should consider using implementation models and frameworks to guide their community-based physical activity programs. Further research examining the application of new and existing implementation models and frameworks in developing, exploring, and evaluating community-level programs is warranted.

Initial insights into the impact and implementation of Creating Active Schools in Bradford, UK

BACKGROUND

Few whole-school physical activity programmes integrate implementation science frameworks within the design, delivery, and evaluation. As a result, knowledge of the key factors that support implementation at scale is lacking. The Creating Active Schools (CAS) programme was co-designed and is underpinned by the Capability, Opportunity, Motivation and Behaviour (COM-B) model and the Consolidated Framework for Implementation Research (CFIR). The study aims to understand the initial impact and implementation of CAS in Bradford over 9 months using McKay's et al.'s (2019) implementation evaluation roadmap.

METHODS

Focus groups and interviews were conducted with school staff (n = 30, schools = 25), CAS Champions (n = 9), and the CAS strategic lead (n = 1). Qualitative data were analysed both inductively and deductively. The deductive analysis involved coding data into a priori themes based on McKay et al's implementation evaluation roadmap, using a codebook approach to thematic analysis. The inductive analysis included producing initial codes and reviewing themes before finalising.

RESULTS

Identified themes aligned into three categories: (i) key ingredients for successful adoption and implementation of CAS, (ii) CAS implementation: challenges and solutions, and (iv) the perceived effectiveness of CAS at the school level. This included the willingness of schools to adopt and implement whole-school approaches when they are perceived as high quality and aligned with current school values. The programme implementation processes were seen as supportive; schools identified and valued the step-change approach to implementing CAS long-term. Formal and informal communities of practice provided "safe spaces" for cross-school support. Conversely, challenges persisted with gaining broader reach within schools, school staff's self-competence and shifting school culture around physical activity. This resulted in varied uptake between and within schools.

CONCLUSIONS

This study provides novel insights into the implementation of CAS, with outcomes aligning to the adoption, reach, and sustainability. Successful implementation of CAS was underpinned by determinants including acceptability, intervention complexity, school culture and school stakeholders' perceived self-efficacy. The combination of McKay's evaluation roadmap and CFIR establishes a rigorous approach for evaluating activity promotion programmes underpinned by behavioural and implementation science. Resultantly this study offers originality and progression in understanding the implementation and effectiveness of whole-school approaches to physical activity.

What happens when a whole-school health promotion research trial ends? a case study of the SEHER program in India

Background

Health promotion interventions that are developed and evaluated by researchers and other external providers are at risk of not being sustained beyond the initial implementation period. When delivered by a lay school health worker, the SEHER study of a whole-school health promotion intervention in Bihar, India was found to be feasible, acceptable and effective in improving school climate and student health behaviors. The objective of this case study is to describe the decision-making processes, barriers, and enablers to continuing the SEHER intervention following its official closure.

Methods

For this exploratory qualitative case study, data were collected from four government-run secondary schools, two of which continued SEHER and two of which discontinued it after official closure. Thirteen school staff were interviewed, and 100 girls and boys (aged 15-18  years old) participated in eight focus groups discussing their experiences of the process of continuing the intervention (or discontinuing) following its official closure. Thematic analysis was conducted in NVivo 12 using grounded theory.

Results

No school sustained the intervention as originally delivered in the research trial. In two schools, the intervention was adapted by selecting sustainable components, whereas in two others it was discontinued altogether. We identified four interrelated themes that explained the complex decision-making process, barriers, and enablers related to program continuation: (1) understanding of the intervention philosophy among school staff; (2) school capabilities to continue with intervention activities; (3) school attitudes and motivation about implementing the intervention, and; (4) the education policy environment and governance structures. Suggestions for overcoming barriers included adequate resource allocation; training, supervision, and support from external providers and the Ministry of Education; and formal government approval to continue the intervention.

Conclusion

Sustaining this whole-school health promotion intervention in low-resource school settings in India depended on individual, school and government factors as well as external support. These findings suggest that health interventions will not necessarily become embedded in a school's operations merely because they are designed as a whole-school approach or because they are effective. Research should identify the resources and processes required to balance planning for future sustainability while awaiting trial results about an intervention's effectiveness.

A Systematic Review of the Implementation and Effectiveness of 'The Daily Mile' on Markers of Children's Health

Currently, a high percentage of children globally fail to meet the World Health Organisation's (WHO) recommended daily physical activity (PA) guidelines. The Daily Mile (TDM) is a school-based PA initiative, designed to improve primary school children's PA behaviour. The purpose of this review was to evaluate the extant TDM implementation process and identify its impact on health-related metrics. Three databases were used to search for articles from the time TDM originated in 2012 until February 2022. The identification and screening process of articles for their ability to meet this review's eligibility criteria were facilitated by use of PRISMA and Rayyan. Sixteen articles from the initial search (n = 202) were deemed eligible for inclusion. An analysis of these articles identified five common outcome categories that permeated throughout the research articles: (1) cardiorespiratory fitness (CRF); (2) anthropometry and body composition; (3) PA; (4) cognition; and (5) process evaluation. Results presented from the included articles suggests TDM positively impacts markers of a variety of health-related metrics, namely CRF and PA. However, implementation barriers including TDM's repetitive nature, time constraints associated with competing curriculum demands and inadequate facilities regularly necessitate the adaptation and development of the original TDM format by schools and teachers.

Aligning Organizational Priorities and System Policies to Support Implementation Scale-Up of a Tailored Classroom-Based Physical Activity Intervention in Low-Resource Schools

BACKGROUND

A mismatch between organizational priorities and system-level policies can negatively impact implementation and sustainment of classroom-based physical activity (PA) interventions. The purpose of this study was twofold: (1) present methods to systematically identify organization- and system-level implementation barriers, and (2) align organizational priorities and system policies by designing multi-level implementation strategies. This alignment will support implementation scale-up of a tailored PA intervention in one low-resource intermediate school district (ISD; 16 districts, 32 schools) in central Michigan.

METHODS

Multi-level assessments of organizational readiness were conducted using the Hexagon Discussion and Analysis Tool to assess intervention-context fit, the Wellness School Assessment Tool 3.0 to evaluate district PA policy strength and comprehensiveness, and semi-structured interviews were conducted to assess administrative support and priorities related to PA programming.

RESULTS

Our assessments revealed three implementation barriers: limited structural capacity to sustain teacher training, limited resources across districts and school buildings to support teachers, and misalignment of ISD and district PA policies and priorities.

CONCLUSIONS

Greater attention to organizational capacity and existing infrastructure should be considered a priori to support effective implementation and sustainment of PA interventions in low-resource schools.

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

Background

The primary purpose of this review is to synthesise the effect of strategies aiming to sustain the implementation of evidenced based interventions (EBIs) targeting key health behaviours associated with chronic disease (i.e., physical inactivity, poor diet, harmful alcohol use and tobacco smoking) in clinical and community settings. The field of implementation science is bereft of an evidence base of effective sustainment strategies, and as such this review will provide important evidence to advance the field of sustainability research.

Methods

This systematic review protocol is reported in accordance with the Preferred Reporting Items for Systematic review and Meta-Analysis Protocol (PRISMA-P) checklist (Additional file 1). Methods will follow Cochrane gold-standard review methodology. The search will be undertaken across multiple databases, adapting filters previously developed by the research team; data screening and extraction will be performed in duplicate; strategies will be coded using an adapted sustainability-explicit taxonomy; evidence will be synthesised using appropriate methods (i.e. meta-analytic following Cochrane or non-meta-analytic following SWiM guidelines). We will include any randomised controlled study that targets any staff or volunteers delivering interventions in clinical or community settings. Studies which report on any objective or subjective measure of the sustainment of a health prevention policy, practice, or program within any of the eligible settings will be included. Article screening, data extraction, risk of bias and quality assessment will be performed independently by two review authors. Risk of bias will be assessed using Version 2 of the Cochrane risk-of-bias tool for randomised trials (RoB 2). A random effect meta-analysis will be conducted to estimate the pooled effect of sustainment strategies separately by setting (i.e. clinical and community). Sub-group analyses will be undertaken to explore possible causes of statistical heterogeneity and may include: time period, single or multi strategy, type of setting and type of intervention. Differences between sub-groups will be statistically compared.

Discussion/Conclusion

This will be the first systematic review to determine the effect of strategies designed to support sustainment on sustaining the implementation of EBIs in clinical and community settings. The findings of this review will directly inform the design of future sustainability-focused implementation trials. Further, these findings will inform the development of a sustainability practice guide for public health practitioners.

Registration

This review was prospectively registered with PROSPERO (registration ID: CRD42022352333).

How to select interventions for promoting physical activity in schools? Combining preferences of stakeholders and scientists

BACKGROUND

The failure to scale-up and implement physical activity (PA) interventions in real world contexts, which were previously successful under controlled conditions, may be attributed to the different criteria of stakeholders and scientists in the selection process of available interventions. Therefore, the aim of our study was to investigate and compare the criteria applied by local stakeholders and scientists for selecting amongst suitable school-based PA interventions for implementation.

METHODS

We conducted a three-round repeated survey Delphi study with local stakeholders (n = 7; Bremen, Germany) and international scientific PA experts (n = 6). Independently for both panels, two rounds were utilized to develop a list of criteria and the definitions of criteria, followed by a prioritization of the criteria in the third round. For each panel, a narrative analysis was used to rank-order unique criteria, list the number of scorers for the unique criteria and synthesize criteria into overarching categories.

RESULTS

The stakeholders developed a list of 53 unique criteria, synthesized into 11 categories with top-ranked criteria being 'free of costs', 'longevity' and 'integration into everyday school life'. The scientists listed 35 unique criteria, synthesized into 7 categories with the top-ranked criteria being 'efficacy', 'potential for reach' and 'feasibility'. The top ranked unique criteria in the stakeholder panel were distributed over many categories, whereas four out of the top six criteria in the scientist panel were related to 'evidence'.

CONCLUSIONS

Although stakeholders and scientists identified similar criteria, major differences were disclosed in the prioritization of the criteria. We recommend an early collaboration of stakeholders and scientists in the design, implementation, and evaluation of PA interventions.