Implementation of school based physical activity interventions: A systematic review

YPMED-04199; No of Pages 19 Preventive Medicine xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

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Keywords: Schools Health promotion Physical activity Child Adolescent Diffusion of innovation Implementation

School of Exercise Science, Physical and Health Education, University of Victoria, PO Box 3015 STN CSC, Victoria BC V8W 3P1, Canada Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, 2635 Laurel Street, Vancouver BC V5Z 1M9, Canada Department of Family Practice, University of British Columbia, 5950 University Boulevard, Vancouver BC V6T 1Z3, Canada d Department of Orthopaedics, University of British Columbia, 910 West 10th Avenue, Vancouver BC V5Z 1M9, Canada b c

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P.J. Naylor a,⁎, Lindsay Nettlefold b, Douglas Race b, Christa Hoy b, Maureen C. Ashe b,c, Joan Wharf Higgins a, Heather McKay b,c,d

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Objective. Implementation science is an emerging area in physical activity (PA) research. We sought to establish the current state of the evidence related to implementation of school-based PA models to explore 1) the relationship between implementation and health outcomes, and 2) factors that influence implementation. Methods. We searched 7 electronic databases (1995–2014) and included controlled studies of school-based PA programmes for healthy youth (6–18 y) measuring at least one physical health-related outcome. For objective 1, studies linked implementation level to student-level health outcome(s). For objective 2, studies reported factors associated with implementation. Results. There was substantial variability in how health outcomes and implementation were assessed. Few studies linked implementation and health outcomes (n = 15 interventions). Most (11/15) reported a positive relationship between implementation and at least one health outcome. Implementation factors were reported in 29 interventions. Of 22 unique categories, time was the most prevalent influencing factor followed by resource availability/quality and supportive school climate. Conclusions. Implementation evaluation supports scale-up of effective school-based PA interventions and thus population-level change. Our review serves as a call to action to 1) address the link between implementation and outcome within the school-based PA literature and 2) improve and standardize definitions and measurement of implementation. © 2014 Published by Elsevier Inc.

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Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Literature search and study selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Data extraction and quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Study quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Links between the level of implementation of school-based physical activity interventions and health outcomes Factors that influenced implementation of school-based physical activity models . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Links between the level of implementation of interventions and health outcomes . . . . . . . . . . . . . . Factors that influenced implementation of school-based physical activity models . . . . . . . . . . . . . . . Study limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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⁎ Corresponding author at: University of Victoria, PO Box 3015 STN CSC, Victoria, BC V8W 3P1, Canada. Fax: +1 250 721 6601. E-mail addresses: [email protected] (P.J. Naylor), [email protected] (L. Nettlefold), [email protected] (D. Race), [email protected] (C. Hoy), [email protected] (M.C. Ashe), [email protected] (J.W. Higgins), [email protected] (H. McKay).

http://dx.doi.org/10.1016/j.ypmed.2014.12.034 0091-7435/© 2014 Published by Elsevier Inc.

Please cite this article as: Naylor, P.J., et al., Implementation of school based physical activity interventions: A systematic review, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.034

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Conclusions . . . . . . . . Conflict of interest statement Authors' contributions . . . Funding . . . . . . . . . References . . . . . . . .

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Methods

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Framework

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Durlak and Dupre conducted a systematic review of more than 500 health promotion interventions targeting children and youth (including physical activity); reporting a consistent relationship between effective implementation of health interventions and positive health outcomes (Durlak and DuPre, 2008). They then conducted a secondary analysis identifying twenty-three contextual factors that they fit into a multi-level framework explaining effective implementation. Their framework categorized these factors into characteristics of the innovation and provider as well as community level factors, delivery system factors (organizational capacity) and the support system (Durlak and DuPre, 2008). We adapted Durlak and Dupre's review process to review the schoolbased physical activity literature and then integrated their framework into our discussion of the implementation factors that emerged from that literature.

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Literature search and study selection

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Our literature search occurred in two main phases, each described in further detail below. In phase 1 we conducted a search of seven electronic databases (MEDLINE, EMBASE, CINAHL, SPORTDiscus, PsycINFO, CENTRAL, and ERIC) for peer-reviewed manuscripts published between January 1st, 1995 and February 25th, 2014. One author (DR) executed the searches in consultation with coauthors. We adopted the search strategies of a previous Cochrane review of school-based physical activity programmes (Dobbins et al., 2009) and added terms related to implementation (e.g., implementation, fidelity, process evaluation). The keywords used for the MEDLINE database are provided (Fig. 1). Search strategies for the remaining databases are available from the corresponding author upon request. Where possible, we limited the search results to human studies, children and adolescents and the years 1995–2014. We exported search results to a dedicated RefWorks database. Two authors (DR, LN) independently screened titles and abstracts to ascertain relevance. Reviewers excluded records if; a) the record was deemed not relevant (e.g., not related to physical activity), b) the target population was preschool children (b6 years) or adults (N 18 years), c) the sample was a clinical population (e.g., children with asthma or cerebral palsy), d) the abstract clearly stated that the programme was delivered only after school or in the community, or e) the abstract clearly stated that the intervention was an injury prevention programme only. If there was any doubt about the relevance of a record, we retrieved the full text. Two authors (LN and CH or DR) then independently reviewed the full text of each potentially relevant publication from the electronic database search. Using consensus we included studies that; 1) assessed healthy children or adolescents aged 6–18 y, 2) evaluated a school-based physical activity programme (defined

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There is a gap between development of effective interventions and the wide-scale adoption of these interventions in real world contexts (Durlak and DuPre, 2008; Glasgow and Emmons, 2007). Generally, those adopting behaviour change initiatives are confronted with the complexity of translating interventions that were successful in optimum (controlled and monitored) conditions to real-life contexts (Glasgow and Emmons, 2007) with little information about a model's external validity (Dzewaltowski et al., 2004; Glasgow et al., 1999; Mercer et al., 2007). Details about context and how to implement interventions are typically collected through implementation evaluations — however these are rarely conducted (Durlak and DuPre, 2008). Implementation has been defined as a “specific set of activities designed to put into practice an activity or programme of known dimensions” (Fixsen et al., 2005, p.5) and encompasses all aspects of the process of programme delivery. These include; i) the extent to which a programme and its elements are implemented as planned (fidelity), ii) how much of the programme was delivered (dose delivered) or received (dose received), iii) how well different programme components are delivered (quality), iv) how responsive participants were to the programme (responsiveness), v) programme theory and practices that distinguish it from other programmes (differentiation), and vi) changes made to the programme during implementation that enhance its fit with the context (adaptation) (Durlak and DuPre, 2008, p.329). To bridge the gap between development and adoption of effective physical activity interventions on a scale broad enough to promote population level health changes, Durlak and Dupre suggest that there is a critical need to understand factors related to programme implementation. Understanding factors that influence adoption is even more challenging in school-based settings (Newland et al., 2013) due in part to the notion that schools and the education system “…sit within constantly shifting broader contexts” (Butler et al., 2010, p. 260). The need is urgent. A significant decline in the fitness of Canadian children and youth coupled with an increase in overweight/obesity since 1981 (Tremblay et al., 2010) has triggered alarm bells in the public health sector. This is not unique to Canada; children's fitness has declined around the world (Tomkinson and Olds, 2007; Knuth and Hallal, 2009). Low levels of physical activity contribute to potentially dire consequences including type II diabetes, cardiovascular disease, low self-esteem, self-efficacy and increased bullying (Janssen and Leblanc, 2010; Janssen, 2007; Biddle et al., 2004; Penedo and Dahn, 2005; Turagabeci et al., 2008; Iannotti et al., 2009). Effective physical activity interventions, delivered in settings where children learn, are likely an important part of the solution (Naylor and McKay, 2009). Apart from improved health, there are also many direct benefits to the learner and the learning environment (e.g., improved classroom management (Mahar et al., 2006; Trudeau and Shephard, 2008), enhanced cognitive function (Sibley and Etnier, 2003) and self-concept (Strong et al., 2005)). The literature is replete with systematic reviews demonstrating the efficacy of school-based approaches (Dobbins et al., 2013; van Sluijs et al., 2007; Dudley et al., 2011; Kriemler et al., 2011; Lai et al., 2014),

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“… developing effective interventions is only the first step toward improving the health and well-being of populations” (Durlak and DuPre, 2008).

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and highlighting the importance of multi-component models (van Sluijs et al., 2007; Kriemler et al., 2011). However, it seems imperative to better understand factors that support effective implementation of these programmes (Durlak and DuPre, 2008; Dzewaltowski et al., 2004; Siedentop, 2009) — but these studies are lacking. As implementation science is an emerging area in physical activity research, we sought to establish the current state of the evidence related to implementation of school-based physical activity models (including, but not specific to, ‘whole school’ models) by conducting a systematic review modelled after the approach of Durlak and Dupre (Durlak and DuPre, 2008). We addressed the following two objectives; 1) to explore the state of the evidence related to measuring and linking the level of implementation of school-based physical activity interventions and health outcomes in children (establishing dose–response), and 2) to identify factors that influenced implementation of school-based physical activity interventions.

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Please cite this article as: Naylor, P.J., et al., Implementation of school based physical activity interventions: A systematic review, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.034

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Search strategy applied to MEDLINE database (January 1st, 1995 to February 25th, 2014)

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41. sport$.tw. 42. walk$.tw. 43. cycle$.tw. 44. (("lifestyle" or life-style) adj5 acv$).tw. 45. (("lifestyle" or life-style) adj5 physical$).tw. 46. or/23-45 47. exp Schools/ 48. school.tw. 49. 47 or 48 50. exp Program Evaluaon/ 51. exp Evaluaon Studies/ 52. implementaon.mp. 53. fidelity.mp. 54. adherence.mp. 55. compliance.mp. 56. integrity.mp. 57. (faithful adj5 replicaon).mp. 58. (intervenon adj5 adopt$).mp. 59. (program adj5 adopt$).mp. 60. (intervenon adj5 uptake).mp. 61. (program adj5 uptake).mp. 62. (program adj5 delivery).mp. 63. (intervenon adj5 delivery).mp. 64. ((program or intervenon) adj5 differenaon).mp. 65. ((program or intervenon) adj5 adaptaon).mp. 66. ((program or intervenon) adj5 modif$).mp. 67. (process adj5 evaluaon).mp. 68. ((monitor$ or measur$) adj5 implementaon).mp. 69. ((program or intervenon) adj5 loyalty).mp. 70. ((program or intervenon) adj5 commitment).mp. 71. "Outcome and Process Assessment (Health Care)"/ 72. sustain$.mp. 73. or/50-72 74. 22 and 46 and 49 and 73 75. limit 74 to (yr="1995 -Current" and "all child (0 to 18 years)")

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1. Randomized controlled trials/ 2. Randomized controlled trial.pt. 3. random allocaon/ 4. double blind method/ 5. single blind method/ 6. clinical trial.pt. 7. exp Clinical Trial/ 8. or/1-7 9. (clinic$ adj trial$1).tw. 10. ((singl$ or doubl$ or treb$ or tripl$) adj (blind$3 or mask$3)).tw. 11. Placebos/ 12. Placebo$.tw. 13. Randomly allocated.tw. 14. (allocated adj2 random).tw. 15. or/9-14 16. 8 or 15 17. case report.tw. 18. Leer.pt. 19. Historical arcle.pt. 20. "review"/ 21. or/17-20 22. 16 not 21 23. exp exercise/ 24. physical inacvity.mp. 25. physical acvity.mp. 26. exp motor acvity/ 27. (physical educaon and training).mp. 28. exp "Physical Educaon and Training"/ 29. exp physical fitness/ 30. exp Sedentary Lifestyle/ 31. exp Life Style/ 32. exp leisure acvies/ 33. exp walking/ 34. exp sports/ 35. exp dancing/ 36. dancing.mp. 37. exp exercise therapy/ 38. (exercise$ adj aerobic$).tw. 39. (physical$ adj5 (fit$ or train$ or acv$ or endur$)).tw. 40. (exercis$ adj5 (train$ or physical$ or acv$)).tw.

as at least one part of the programme delivered in school and focused on physical activity), 3) included a control group, and 4) measured at least one physical health-related outcome. To address our first objective, publications must have also 5) measured physical activity and implementation (e.g., fidelity, dose delivered/received, quality) and linked the level of implementation to at least one student-level health outcome. To address our second objective, publications must have also 6) measured and reported factors (e.g., facilitators or barriers) associated with implementation. Publications that we included addressed either one or both research objectives. After review, we categorized full text records from phase 1 into one of three categories:

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188 1. Include (manuscript met all inclusion criteria for objectives 1 and/or 2); 189 Q35 2. Exclude (review article OR book chapter OR manuscript did not meet inclu190 sion criteria OR was not in English OR was not available); 191 3. Targeted search — described in further detail below (manuscript did not re192 port or link implementation to health outcomes but met all other inclusion 193 criteria OR record was a conference abstract OR record was a dissertation). 194 195 196 197 198

Phase 2 included a targeted search, a reference list review, and a forward search. A targeted search (e.g., by study name or primary authors on PubMed; general internet search for study name) was conducted individually for each manuscript that met the first four inclusion criteria (described above) but did not fulfil criteria five (report and link the level of implementation to health

outcomes) or six (report factors influencing implementation). Our rationale for these targeted searches was that a single intervention might yield multiple publications; thus, it is possible that implementation data were reported separately from other outcomes in one or more companion papers. In phase 2 we reviewed the reference lists of review papers and book chapters located in phase 1 (electronic database search) to identify any potentially relevant publications we may have missed. Finally, we reviewed the reference list and performed a forward search (using Web of Science) for included manuscripts (i.e., those that met all inclusion criteria for objectives 1 and/or 2). We reviewed the full text of all potentially relevant publications identified through these supplementary searches and categorized them as include or exclude as described above in phase 1.

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Data extraction and quality assessment

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To address our first research objective, one of two authors (LN or CH) extracted details of the study design and population, methods used to assess implementation and health outcomes, and results related to the link between level of implementation and health outcomes. A third individual independently verified extracted data. As a preliminary indicator of study quality, we used the presence of a control group as part of our inclusion criteria. For the quantitative studies included for our first research objective we also used the validated quality assessment tool for quantitative studies (Thomas et al., 2004; Jackson et al.,

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Please cite this article as: Naylor, P.J., et al., Implementation of school based physical activity interventions: A systematic review, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.034

P.J. Naylor et al. / Preventive Medicine xxx (2015) xxx–xxx

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We illustrate the flow of papers through the subsequent screening process and reasons for exclusion in Fig. 2. The electronic database search (phase 1) identified 2078 unique records; based on title and abstract screening, we identified 486 potentially relevant publications. We added 171 potentially relevant publications from our targeted, reference list and forward searches (phase 2) for a total of 657 publications. For objective 1 (link between level of implementation and health outcomes) 18 publications from 15 interventions met our full inclusion criteria; 15 publications were identified through our primary search

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Table 1 Quality assessment for quantitative studies included for objective 1.

Of the 15 interventions (represented in 18 different publications) that met the inclusion criteria for objective 1 (Table 2), 47% were from the United States, 20% were from Canada, 20% were from Europe and 13% were from Australia. Further, of the 15 interventions, 80% were randomized controlled trials and 73% conducted assignment at the school level with 7% assignment at the student level. The majority (60%) targeted elementary school-aged children while fewer focused on youth attending middle (13%) or high school (27%). Very few studies assessed implementation of whole school, multi-strategy interventions as many focused on individual-level interventions delivered through the school setting. Of the 29 interventions (represented in 35 different publications) that met the inclusion criteria for objective 2 (Table 3), 52% were from the United States, 14% were from Australia, 7% were from Canada, 7% were from the Netherlands, 7% were from England and 3% each from Denmark, Germany, Iceland, and Pakistan. Most studies were randomized controlled trials (69%). The majority targeted elementary schoolaged children (66%); fewer focused on youth attending middle (24%) or high school (10%) students.

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We did not exclude any of the quantitative studies based on their quality rating. Of the 15 interventions, only one received strong global ratings for both the quantitative and process components (Donnelly et al., 2009; Gibson et al., 2008). Two had strong quantitative scores, but weak process scores (Haerens et al., 2006; Gentile et al., 2009). Five had moderate quantitative and strong process scores (Eather et al., 2013; Macdonald et al., 2008; Marcoux et al., 1999; Nader et al., 1996; Dishman et al., 2004, 2005; Saunders et al., 2006). There were

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A) Selection bias

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P1) Level of evaluation P2) Definition of process variables P3) Process variables P4) Data collection P5) Timing of data collection P6) Quantitative process variables P7) Qualitative process variables P8) Outcome related to implementation

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(phase 1) and 3 were identified through our supplementary searches (phase 2). For objective 2 (factors that influenced implementation), we included 35 publications from 29 interventions that met our full inclusion criteria; 18 publications were identified through our primary search (phase 1) and 17 were identified through our supplementary searches (phase 2).

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2005) developed by the Effective Public Health Practice Project (EPHPP) to assess internal and external validity and used a modified version of a quality assessment tool for process evaluations developed by Wierenga and colleagues (Wierenga et al., 2013). The EPHPP quality assessment tool assigns a strong, moderate or weak rating to six study components (Table 1). Based on these ratings, a global quality rating is assigned. Strong studies have four or more strong components and no weak components. Moderate studies have fewer than four strong ratings and/or only one weak component. Weak studies have two or more weak components. We did not assess the appropriateness of the statistical analyses within the studies. In the absence of validated quality assessment tools for process evaluations, we used a modified version of the criteria developed by Wierenga and colleagues (Wierenga et al., 2013). Eight items (Table 1) were scored as positive (+), negative (−) or not applicable (N/A). We used the same criteria as Weirenga et al. (Wierenga et al., 2013) to classify studies as strong (N75% positive), moderate (50–75%) or weak (b50%). We did not include N/A scores in the percentage calculations. To ensure we evaluated the quality of the intervention and not just the publication, we grouped those publications arising from one intervention and attempted to source missing information (e.g., about study design) from supplementary publications not included in the current review. Two reviewers conducted independent quality assessments (PJN, LN) and where ratings varied, consensus was achieved through discussion. To address our second research objective, one of five authors (CH, DR, LN, MA, PJN) extracted details of study design and population, methods used to assess implementation and factors related to programme implementation. One author (DR) reviewed the content from each co-author in conjunction with the original manuscript, compiled the list of implementation factors, and grouped the factors into categories. A second reviewer (PJN or LN) reviewed them and categories were finalized by consensus.

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Are the individuals selected to participate in the study likely to be representative of the target population? What percentage of selected individuals agreed to participate? Was the study described as randomized? If Yes, was the method of randomization described? If yes, was the method appropriate? Were there important differences between groups prior to the intervention? If yes, indicate the percentage of relevant confounders that were controlled either in the design (e.g., stratification, matching) or analysis. Was (were) the outcome assessor(s) aware of the intervention or exposure status of participants? Were the study participants aware of the research question? Were data collection tools shown to be valid? Were data collection tools shown to be reliable? Were withdrawals and drop-outs reported in terms of numbers and/or reasons per group? Indicate the percentage of participants completing the study

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Positive if implementation was evaluated on 2 or more levels (e.g., student/family, teacher) Positive if process variables were adequately described Positive if four or more process variables were reported Positive if two or more techniques were used (i.e., triangulation) Positive if process variables were measured on multiple occasions (e.g., pre, during and/or post intervention) Positive if quantitative process outcomes were assessed using methods of acceptable quality Positive if qualitative study design was adequately described (e.g., participant selection, setting, data collection) Positive if outcomes were evaluated in the context of implementation dose/quality

Quantitative quality assessment performed using the quality assessment tool for quantitative studies developed by the Effective Public Health Practice Project (EPHPP) (Thomas et al., 2004). Process measures quality assessment adapted from Wierenga et al (Wierenga et al., 2013).

Please cite this article as: Naylor, P.J., et al., Implementation of school based physical activity interventions: A systematic review, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.034

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PHASE 1 Electronic database search

PHASE 2 Targeted, reference list & forward search

2078 records idenfied from inial search of electronic databases (duplicates removed)

Targeted Search* of 276 arcles from phase 1 n=47 abstract n=16 thesis/dissertaon n=213 did not report and/or link implementaon to health outcome(s)

Reviewed tles and abstracts (n=2078)

Reference list search of 32 records from phase 1 n=31 review arcles n=1 book chapter

n=1592 excluded (not relevant)

Excluded (n=146) n=3 unable to retrieve n=18 not English n=125 did not meet inclusion criteria

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Forward search of 32 phase 1 included arcles & arcles from personal files

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Included from phase 1 (n=32) n=14 (Queson 1) n= 17 (Queson 2) n= 1 (Queson 1 & 2)

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Excluded (n=153) Did not meet all inclusion criteria

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two studies each with: moderate quantitative and moderate process scores (Ezendam et al., 2013; McNeil et al., 2009); weak quantitative and strong process scores (Slootmaker et al., 2010; Springer et al., 2012); weak quantitative and moderate process scores (Bush et al., 2010; Erwin et al., 2011). There was one study that scored weak on both aspects (Lubans et al., 2012). The question on blinding in the quality assessment tool for quantitative studies had an impact on ratings; if blinding was not mentioned, the study received a moderate score for this component but if reported as not blinded, a weak score was assigned. Only one study (Lubans et al., 2012) reported that participants were not blinded, although we assume that participants were not blinded in the other studies. We provide scores for each quality assessment component in Table 4.

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Links between the level of implementation of school-based physical activity interventions and health outcomes For the most part, studies that linked the level of implementation with outcomes reported a significant positive relationship with at least one health outcome across a broad range of those reported (11/15). Importantly, what (and how) health outcomes were assessed varied substantially between studies. For example, level of implementation positively influenced changes in fruit and vegetable consumption, physical activity participation and enjoyment, body mass index and bone strength (Table 1). There was also considerable variability in what was measured (e.g., dose delivered, dose received or fidelity) and types of scales used to assess the level of implementation. Notably, the factor most often assessed was individual participation/adherence to the intervention (dose received) by the target population (parents or children; 10/15 studies). A school or teacher level implementation measure was less often provided (e.g., dose delivered — 4 studies or fidelity — 1 study). Two intervention studies used a combination of categorical and continuous variables (Donnelly et al., 2009; Gibson et al., 2008; Nader et al.,

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Fig. 2. Flow diagram of search strategy and records considered for inclusion in the systematic review.

1996) while others used only categorical (Haerens et al., 2006; Gentile et al., 2009; Dishman et al., 2004, 2005; McNeil et al., 2009) or continuous (Slootmaker et al., 2010; Ezendam et al., 2013; Eather et al., 2013; Marcoux et al., 1999; Bush et al., 2010) variables to assess implementation. Finally, of the studies that linked implementation with outcomes, all but one were efficacy trials.

326 327 328 329 330 331

Factors that influenced implementation of school-based physical activity 332 models 333 We included 29 studies (represented by 35 different publications) that reported factors that influenced implementation of school-based physical activity models. We identified 22 categories of factors that influenced implementation of physical activity interventions in schools (Table 5). Time surfaced as the most prevalent category related to implementation. Specifically, participants most often mentioned the amount of time needed to prepare or deliver physical activity sessions or lessons, teacher overload and competing demands related to other curricular needs. Quality/availability of resources, supportive school climate, contextual appropriateness of the intervention, availability of training and teacher self-efficacy were also prominent categories that influenced implementation.

334 335

Discussion

346

336 337 338 339 340 341 342 343 344 345

Links between the level of implementation of interventions and health 347 outcomes 348 We adopted the approach of Durlak and Dupre (Durlak and DuPre, 2008) and focused on the state of the evidence related to implementation of school-based physical activity interventions. As a first step, we identified controlled trials of school-based physical activity interventions that linked the level of implementation with health outcomes. Overall, we encountered a rather meagre literature base that described

Please cite this article as: Naylor, P.J., et al., Implementation of school based physical activity interventions: A systematic review, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.034

349 350 351 352 353 354

6

Table 2 Studies reporting the association between the level of implementation (or dose) and outcomes (objective 1; 15 interventions represented by 18 publications). Studies are listed alphabetically within study design and age group categories.

t2:3 t2:4 t2:5

First author, study name, country

t2:6 t2:7 t2:8 t2:9 t2:10 t2:16 t2:11 t2:12 t2:13 t2:14 t2:15 t2:17

Randomized controlled trials Elementary Donnelly et al. n = 4905 (2009) students Gibson et al. n = 26 schools (2008) 3 school years Physical activity across the curriculum USA

t2:18 t2:19 t2:20 t2:21 t2:22

Eather et al. (2013) Fit4Fun Australia

Age group, sample size, study duration

Study details, methods

Analysis, results: relationship between implementation and outcome

U

Intervention characteristics: • 90 min/wk of physically active academic lessons (~10 min MVPA each) Outcome measures: • Primary: BMI (measured height & weight); secondary (subgroup only): daily PA (4 day accelerometry); academic achievement (WIAT-II-A); classroom PA (direct observation using SOFIT — students & teachers) Process measures: • Reach (training attendance); dose received (training evaluation survey); precision, accuracy (anthropometric reliability testing); fidelity, dose received by students (SOFIT); fidelity (student enjoyment rated by teachers); fidelity, dose received (online teacher survey); fidelity, implementation (online teacher questionnaire); fidelity, exposure (online teacher questionnaire); reach (focus group attendance); context, contamination (principal survey) Relationship between implementation and outcome: • Dose delivered (categorical & continuous) — teacher self-report Intervention characteristics: Elementary • 8 ∗ 60 min health and PE lessons, home activity programme (4 ∗ 20 min/wk) recess and lunch n = 48 time activity programme students n = 2 schools Outcome measures: • Cardiorespiratory fitness (20-m shuttle run); flexibility (sit and reach); muscular fitness (wall 8 weeks squat, seven-stage sit up, basketball throw, push ups); BMI (measured height and weight); PA (7 day pedometry); student attitudes towards intervention (questionnaire) Process measures: • Recruitment, retention, adherence (self-report), student satisfaction (questionnaire, focus groups) Relationship between implementation and outcome: • Dose received (continuous) — attendance at break time activities Intervention characteristics Elementary • Goals: ≥60 min/day PA, b2 h/day screen time, ≥5 servings F&V n = 1323 • School component (teacher resources); community component (paid advertising, unpaid media students n = 10 schools with key messages); family component (resources) Outcome measures 1 school year • PA (7 day pedometry); BMI (measured height and weight); screen time, F&V intake (questionnaire); + 6 month perceptions of change (questionnaire) follow-up Process measures: • Participation (self-reported by parents/children) Relationship between implementation and outcome • Dose received (categorical — median split) — family participation Intervention characteristics Elementary • Recreation facilitators (“connectors”) provided support and assistance to families to support their n = 360 child's engagement in activities (provided information, located programmes, registration, applied students n = 16 schools for fee assistance, advocated for additional programming where needed) Outcome measures 1 year • Primary: CAPE PA & skill-based subscales (questionnaire) • Secondary: CHQ-PF50 (questionnaire); ALCS (questionnaire); SEI (questionnaire) Process measures: • Engagement (number of phone or written contacts between family and facilitator) Relationship between implementation and outcome • Dose received (categorical — low, moderate, high) — number of contacts with facilitator Intervention characteristics Elementary • 15 min/d of PA in the classroom including a progressive jumping programme n = 514 Outcome measures students n = 10 schools • Total body BMC (DXA); proximal femur BMC (DXA); femoral neck BMC (DXA); lumbar spine BMC (DXA); femoral neck section modulus, (DXA); femoral neck cross-sectional area (DXA); 16 months subperiosteal width (DXA)

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Analysis Adjusted t-test and linear mixed model (BMI, descriptive data); linear mixed model (daily PA, SOFIT, academic achievement); ANOVA (influence of teacher modelling on SOFIT) + BMI change • Correlation between BMI change & average weekly minutes at school (r2 = 0.42) • Smaller BMI increase with ≥75 min of PA delivered/wk (1.8 ± 1.8 vs. 2.4 ± 2.0; p = 0.02) Classroom PA • Higher SOFIT scores with teacher modelling in classroom ? Daily PA, academic achievement • No relationship with implementation reported

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t2:23

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t2:24 t2:25 t2:26 t2:27 t2:30 t2:28 t2:29 t2:31

Gentile et al. (2009) Switch what you do, view and chew USA

t2:32 t2:33 t2:34 t2:35 t2:38 t2:36 t2:37 t2:39

McNeil et al. (2009) Activity living connections project Canada

t2:40 t2:41 t2:42 t2:45 t2:43 t2:44

Macdonald et al. (2008) Action schools! BC Canada

E

Analysis • Independent sample t-tests or chi-square tests • ANCOVA (PA, health-related fitness, attitudes) – Overall PA • No relationship between participation in break time activities and PA ? Health-related fitness, BMI, student attitudes towards intervention • No relationship with participation reported

Analysis • Baseline: ANOVA; • Longitudinal: hierarchical multilevel regression + F&V intake • Greater F&V consumption in highly involved vs. less involved children (5.3 vs. 4.1 servings/day at end of year; 4.7 vs. 4.1 servings/day after 6 months) ? PA, BMI/anthropometry, Screen time, Perceptions of change • No relationship with participation reported

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Analysis • Generalized linear model • Bivariate and multivariable modelling + CAPE — PA subscale • Greater increase in PA participation in children with highly engaged families vs. low engagement (31% vs. 8%) ? CAPE — skill-based subscale, CHQ-PF50, ALCS, SEI • No relationship with engagement reported

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Analysis • Multivariable linear regression with variance inflation factor — ITT and per protocol analyses + Femoral neck section modulus (girls) • Positive intervention effect when compliance considered Femoral neck cross-sectional area • Positive intervention effect when compliance considered

P.J. Naylor et al. / Preventive Medicine xxx (2015) xxx–xxx

Please cite this article as: Naylor, P.J., et al., Implementation of school based physical activity interventions: A systematic review, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.034

t2:1 t2:2

Marcoux et al. (1999) SPARK USA

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t2:52

t2:53 t2:54 t2:55 t2:57 t2:56

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Nader et al. (1996) CATCH USA

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E

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t2:58

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D

t2:59 t2:60 t2:61 t2:62

Haerens et al. (2006) Belgium

t2:63 t2:64 t2:65 t2:67 t2:66

Ezendam et al. (2013) FATaintPHAT The Netherlands

t2:68 t2:69 t2:70 t2:74 t2:71

Lubans et al. (2012) Physical activity

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P.J. Naylor et al. / Preventive Medicine xxx (2015) xxx–xxx

Please cite this article as: Naylor, P.J., et al., Implementation of school based physical activity interventions: A systematic review, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.034

t2:46

t2:47 t2:48 t2:49 t2:51 t2:50

Femoral neck BMC • Positive intervention effect when compliance considered – Boys • No difference between ITT and per-protocol Girls • No difference between ITT and per-protocol for subperiosteal width, proximal femur BMC, lumbar spine BMC, total body BMC Analysis Intervention characteristics Elementary • Correlation between student change scores and SPARK dollars • Health-related PE curriculum (PE specialist vs. trained classroom teacher vs. usual practice); n = 745 self-management component students + BMI (boys only) n = 7 schools Outcome measures • Negative correlation (r = −0.15) • PA (3-day accelerometry, one day recall); aerobic fitness (1 mile run); BMI (measured height and 2 years Psychosocial variables (boys only) weight); skinfold thickness; Psychosocial variables (PA attitudes, self-perception, PA intention; • PA attitudes, positive correlation (r = 0.2$) questionnaire); Parent support (questionnaire) • PA intention, positive correlation (r = 0.12) Process measures: • Self-perception, positive correlation (r = 0.13) • SPARK dollars (PA reward) earned by students during the year Parent support (boys only) Relationship between implementation and outcome • Positive correlation, (r = 0.13) • Dose received (continuous) — student participation (SPARK dollars earned) – Boys • PA, fitness, skinfolds Girls • PA, aerobic fitness, BMI, skinfolds, psychosocial variables, parent support Analysis Intervention characteristics Elementary • Mixed model regression analysis • School (classroom curricula, school food service, school PE interventions); family (take home n = 3663 curricula, family fun nights) students + Health behaviour attitudes/knowledge n = 96 schools Outcome measures • Food choice, parent reinforcement (p = 0.043) • Health behaviour attitudes/knowledge (HBQ); 24-hr dietary recall (questionnaire); PA (SAPAC); 3 years • PA positive support (p = 0.013) total cholesterol (non-fasting venipuncture) • PA self-efficacy (p = 0.04) Process measures: PA • Home curricula (percentage of related classroom activities completed by teachers; average percentage • Self-reported vigorous minutes (p = 0.022) of activity packets returned by students; percentage of students returning at least one activity packet; – Cholesterol, dietary recall (sodium, calories from fat/saturated fat, health behaviour percentage of students returning all activity packets); family fun night (Percentage of schools holding a attitudes/knowledge) (dietary knowledge, dietary intentions, usual food choice, food choice, family fun night; percentage of teachers and students attending family fun night; household teacher/friend/social reinforcement, dietary self-efficacy, PA negative support) member-to-student ratio; percentage of specified activities offered); adult participation • Not associated with adult participation (number of activity packets that an adult completed with the student) Relationship between implementation and outcome • Dose received (categorical & continuous) — adult participation Analysis Intervention characteristics Middle • Linear mixed models • PA and healthy food intervention; environmental and computer tailored component n = 2991 Outcome measures students + BMI z-score n = 15 schools • BMI and BMI z-score (measured height and weight) Greater BMI z-score increase in low implementation schools (+0.12) compared with medium 2 school years Process measures: (0.06) and high (0.09) implementation schools (p b 0.05) • Level of implementation (questionnaire) — categorized into low, medium and high levels of implementation Relationship between implementation and outcome • Dose delivered (categorical) — self-reported level by teachers Analysis Intervention characteristics • Multilevel linear and logistic regression • Internet-delivered intervention, 8 ∗ 15 min lessons addressing weight management and energy balance – • No association between process measures and any behaviour changes Outcome measures • Dietary intake (food frequency questionnaire, snack questionnaire, F&V questionnaire); PA & sedentary behaviours (questionnaire) Process measures: • Student-reported use and appreciation (questionnaire); module completion (log ins) Relationship between implementation and outcome • Dose received (continuous) — self-reported use and appreciation Analysis Intervention characteristics Secondary • Bivariate correlation between number of sessions and outcome variable • School sport sessions, PA and nutrition handbooks, seminars, n = 100 lunch-time activities, leadership sessions, pedometers for students + BMI n = 4 schools self-monitoring • Negative correlation with attendance (r = −0.38) Process measures: • Teacher compliance (teacher logs) Relationship between implementation and outcome Dose delivered (categorical) — self-reported delivery by teachers

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(continued on next page)

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First author, study name, country leaders Australia

Dishman et al. (2004) Dishman et al. (2005) Saunders et al. (2006) LEAP USA

t2:93

t2:94 t2:95 t2:96 t2:97 t2:98 t2:101 t2:99 t2:100

6 months

Outcome measures • BMI (measured height and weight); PA (5-day pedometry); PA self-efficacy, resistance training self-efficacy, Peer support for PA, PA behavioural strategies (questionnaire) Process measures: • Attendance at school sport and lunch time sessions • Relationship between implementation and outcome • Dose received (continuous) — attendance Intervention characteristics Secondary • Intervention group received a PA monitor and access to web-based tailored PA advice n = 87 Outcome measures students n = 5 schools • PA (AQuAA questionnaire); determinants of PA (questionnaire); aerobic fitness 3 months + 8 (20-m shuttle run); anthropometry & BMI (measured height & weight, waist & hip girth, skinfolds) month follow Process measures: up *student-level • Appreciation, frequency of use, PA monitor scores, login frequency randomization Relationship between implementation and outcome • Dose received (continuous) — frequency of login to website Intervention characteristics Secondary • Model included PE, school environment, health education, school health (girls) services, faculty/staff health promotion, family/community involvement. n = 2087 PE was choice-based, gender-sensitive with emphasis on self-efficacy, students n = 24 schools self-management, fun and enjoyment Outcome measures 1 year • PE enjoyment (FIPE); PA enjoyment (PACES); Self-efficacy; PA (3DPAR) Process measures: • Review of all intervention elements; observation of PE classes; staff rating of all intervention components; staff rating of PE implementation — composite fidelity score created Relationship between implementation and outcome • Fidelity (categorical) — high and low implementing schools

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Non-randomized trials Springer et al. Elementary n = 511 (2012) students Marathon n = 8 schools kids 6 months USA

Erwin et al. (2011) USA

Resistance training self-efficacy • Positive correlation with attendance (r = 0.42) PA behavioural strategies • Positive correlation with attendance (r = 0.26) PA, PA self efficacy, Peer support for PA • No relationship with attendance reported

Analysis • Multivariable linear regression – PA • Programme adherence (login frequency) not associated with PA (no data provided) ? PA determinants, Aerobic fitness, Anthropometry and BMI • No relationship with adherence reported

O

t2:102

t2:103 t2:104 t2:105 t2:106

Analysis, results: relationship between implementation and outcome

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Slootmaker et al. (2010) PAM project The Netherlands

t2:81

t2:82 t2:83 t2:90 t2:84 t2:91 t2:85 t2:92 t2:86 t2:87 t2:88 t2:89

Study details, methods

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t2:76 t2:77 t2:78 t2:80 t2:79

Age group, sample size, study duration

Elementary n = 106 students n = 2 schools Active intervention duration unclear

Analysis • Latent variable structural equation modelling + PA • Girls in high implementing schools had greater PA levels, • Changes in PA were partially mediated by self-efficacy and enjoyment Organizational factors • High implementing schools had 2 different organizational characteristics: a physical activity team and having a faculty–staff health promotion ? FIPE, PACES, Self-efficacy SEI • No relationship with implementation reported

D

Intervention characteristics • ~6 month walking, running and F&V programme where children aim to complete 26.2 miles and eat F&V 5 times/day for 26 days/month Outcome measures • PA (PAQ-C); F&V (modified from SPAN survey); athletic identity & social support (athletic identity questionnaire); outcome expectations for PA (7-item scale adapted from GEMS study); PA and F&V self-efficacy (SIP 15 Project); BMI (measured height and weight) Process measures: • Student participation & satisfaction (self-administered survey) Relationship between implementation and outcome • Dose received (continuous) — adherence/participation Intervention characteristics • Teachers asked to incorporate at least one 5–10 min bout of classroom PA/day Outcome measures • PA during the school day (4 day pedometry) Process measures: • Frequency of classroom PA breaks (teacher logs) Relationship between implementation and outcome • Dose delivered (categorical) — teacher self-report used to categorize teachers as compliant (1 break/day) or non-compliant

P

Analysis • Regression with student-level random intercept + PA, daily F&V intake, athletic identity, social support, PA self-efficacy, F&V self-efficacy, overweight/obesity • Significant trend (p b 0.05) • 4–8% increase in running, walking, and F&V intake for a 1 unit increase in participation – F&V at home, Competence, Outcome expectations for PA • No relationship with participation

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F

Analysis • Mixed design ANOVA with compliance as a between-subjects factor (effect of intervention on PA) + School day PA • Students with compliant teachers had greater number of steps/school day at follow up (+33%, p b 0.001) and post follow up (−32%, p b 0.001) vs. non-compliant and control

P.J. Naylor et al. / Preventive Medicine xxx (2015) xxx–xxx

Please cite this article as: Naylor, P.J., et al., Implementation of school based physical activity interventions: A systematic review, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.034

Table 2 (continued)

t2:112 t2:113 t2:114 t2:115 t2:116

t2:107 t2:108 t2:109 t2:110 t2:111

Bush et al. (2010) FunAction Canada

Middle n = 276 students n = 1 school 16 weeks

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these linkages. All of the studies were efficacy trials and most studies focused on individual-level interventions delivered through the school setting rather than on a whole school approach. This is consistent with Golden and Earp (Golden and Earp, 2012) who found that most health promotion initiatives in the last 20 years, including school-based interventions, were primarily directed towards individual level factors — despite the increased theoretical and ethical affinity with a social ecological approach. Even fewer studies linked the level of implementation to outcome across studies that adopted whole setting approaches to promoting physical activity (e.g., combined environmental, educational and other strategies) as compared with studies that adopted single focus strategies. Further, we know little about implementation after programmes are scaled up. This most likely reflects the challenges and complexity of measuring implementation of multi-level and complex strategies in real world settings (Greenhalgh et al., 2004; Sallis et al., 2006; Rowling and Samdal, 2011). Within the literature we reviewed, most studies positively linked the level of implementation to at least one targeted health outcome. This was similar to the findings from the systematic review by Durlak and Dupre (Durlak and DuPre, 2008). However, outcomes varied widely and ranged from enjoyment of physical activity to physical changes in BMI to bone strength. Importantly, some relevant outcomes like physical activity did not change or were not reported (perhaps because they were not significantly linked). For example, the Switch What You Do and Chew study, reported a linkage between dose received from the intervention and increased intake of fruit and vegetables. However, they did not report a positive effect of the intervention on physical activity, screen-time or body composition (Gentile et al., 2009). One study assessed the sustainability of a complex, whole school-based model (LEAP) and provided a notable example of how the level of implementation could be linked to outcome (Saunders et al., 2012). Specifically, the research team developed a system for scoring continued implementation of intervention activities at both teacher and school levels (Saunders et al., 2006). Given the heterogeneity of interventions, study quality, implementation and outcome measures, it was not possible to conducting a meta-analysis to determine that the magnitude of the implementation effect was premature. In terms of the quality of process evaluation dose delivered and dose received were most often reported, as would be expected based on our search criteria. However, very few studies assessed fidelity, adaptation or programme integrity. Thus, one of the key take-home messages from our review was the tremendous need to improve and standardize definitions and approaches to implementation measurement. This would allow researchers to more reliably compare results across studies and most importantly, improve the linkage of the level of implementation to outcomes. The paucity of studies linking implementation with outcomes and the lack of standardization illustrates how the science of implementation lags behind development of effective interventions and effectiveness research in our field (Fixsen et al., 2005; Glasgow, 2008; Rohrbach et al., 2006).

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+, beneficial relationship to health outcomes; −, non-significant relationship to health outcomes; and ?, relationship with health outcomes not reported. MVPA, moderate-to-vigorous physical activity; BMI, body mass index; PA, physical activity; WIAT-II-A, Wechsler Individual Achievement Test-2nd Edition; SOFIT, System for Observation of Fitness instruction Time; PE, physical education; F&V, fruit & vegetable; CAPE, Children's Assessment of Participation and Enjoyment; CHQ-PF50, Child Health Questionnaire Parent Version; ALCS, Active Living Caregiver Survey; SEI, Self-Esteem Index; BMC, bone mineral content; DXA, Dual Energy X-ray Absorptiometry; ITT, intention to treat; HBQ, Health behaviour questionnaire; SAPAC, Self-administered PA checklist; AQuAA, Activity Questionnaire for Adolescents & Adults; FIPE, Factors influencing enjoyment of PE; PACES, Physical Activity Enjoyment Scale; 3DPAR, 3 day PA recall; PAQ-C, physical activity questionnaire for older children; SPAN, school physical activity and nutrition; 7DPAR, 7 day PA recall.

Intervention characteristics • 45 min lunch time activity programme led by university students (up to 3 activity choices/day, 3–5 days/wk) Outcome measures • Leisure time PA (7 day physical activity recall, 7DPAR); PA enjoyment (physical activity enjoyment scale, PACES) Process measures: • Number of sessions offered; Participation frequency (attendance) Relationship between implementation and outcome • Dose received (continuous) — participation frequency

Analysis • ANOVA (baseline PA and participation frequency) • RM-ANOVA (effect of intervention on PA) • Correlation (change and participation frequency) – Leisure time PA • No relationship with participation (r = 0.03, p = 0.7) PA enjoyment • No relationship with participation (r = 0.00, p = 0.99)

P.J. Naylor et al. / Preventive Medicine xxx (2015) xxx–xxx

389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438

Factors that influenced implementation of school-based physical activity 439 models 440 As a second step we analysed the literature to identify factors that influenced implementation and compared these to the 23 factors described by Durlak and Dupre (Durlak and DuPre, 2008). The six most commonly cited categories in our study fit within the Durlak and Dupre model and could be classified as 1) provider characteristics (selfefficacy, skill proficiency), 2) characteristics of the innovation (compatibility/contextual appropriateness, availability and quality of resources), 3) delivery system characteristics (supportive school climate), and 4) the support system (training and support). This suggests that these are critical features to consider when designing school based physical activity interventions. Although time was not highlighted as important to implementation in the Durlak and Dupre model, it emerged in our review

Please cite this article as: Naylor, P.J., et al., Implementation of school based physical activity interventions: A systematic review, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.034

441 442 443 444 445 446 447 448 449 450 451 452

Table 3 Studies reporting factors (facilitators or barriers) that influenced implementation (objective 2; 29 interventions represented by 35 publications). Studies are listed alphabetically within study design and age group categories.

t3:3 t3:4

First author, study name, country

t3:5 t3:6 Q1 t3:7 t3:8 t3:9 t3:10

Randomized controlled trials Bartholomew et al. (2011) Initiatives for children's activities and nutrition (Texas I-CAN!) USA

Belansky et al. (2013) Adapted intervention mapping (AIM) United States

Study details, methods

Results themes (see Table 5 for description)

Elementary E1: n = 3 teachers at 3 INT schools E2: n = 3 teachers from 1 INT school, 5 days E3: n = 22 teachers at 1 INT school, 4 weeks E4: n = 25 teachers at 4 INT schools, 6 months

Intervention characteristics • Train teachers to incorporate PA into instructional time Process measures • Fidelity and implementation (teacher surveys, closed-response, n = 22; focus groups) • Implementation (teacher self-report to assess: lesson quality, self-efficacy, perceived barriers, years of teaching experience, PA level, BMI, closed-response, n = 25) • Engagement (direct observation of students, time on task) • Number of sessions offered; participation frequency (attendance); PA preferences (participant surveys); suggestions and requests (student/teacher informal consultations) Intervention characteristics • Goal to make environmental and policy changes to increase opportunities for school day PA and healthy eating • Schools to receive $3000 over 4-years Process measures • Fidelity, extent of implementation, barriers and facilitators (principals/food service managers/PE teacher semi-structured interviews) • Extent of implementation, barriers and facilitators (written products completed throughout AIM process [e.g., list of behaviour and environmental factors contributing to unhealthy eating and physical inactivity; list of possible barriers to implementation]; AIM Meeting Debriefing Forms; SHI log books) • Extent of implementation (school environmental and policy survey; direct observations of school features) Intervention characteristics • Aim to increase students' PA levels through organizational and physical environmental changes • 4 components: school's outdoor areas; playspots; active transport; club fitness Process measures • Sustainability (school leader interviews, open response)

Facilitators • Teachers highly regarded training; strong support for the concept; directions easy to understand and implement; teachers' perceptions of lesson quality and self-efficacy; teaching experience Barriers • Lessons lack integration with the curriculum; lack of planning time and resources; teachers' perceived barriers Themes • a, b, d, e, f, and g,

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Elementary Principals, food service managers and PE teachers at 5 INT schools 1-year with a 1-year follow-up

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Facilitators • Hiring a second PE teacher; salaries paid from two sources (grant and district); availability of funds; accountability; timely feedback regarding impact; external support; active involvement of leaders; involvement of all staff; communication about change Barriers • Lack of buy-in from teachers and foodservice staff; principal turnover; competing priorities Themes • a, c, g, j, n, o, and s,

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t3:15Q3 t3:16 t3:17 t3:18 t3:19 t3:20

Christiansen et al. (2013) School site, play spot, active transport, club fitness and environment (SPACE) Denmark

Elementary School leaders from 7 INT schools 2-years

t3:21Q4 t3:22 t3:23 t3:24

Elder et al. (2011) The Aventuras para Niños study United States

Elementary Principals and teachers at 6 INT schools 1-year

t3:25 t3:26 t3:27 t3:28

Gibson et al. (2008) Physical activity across the curriculum (PAAC) United States

Elementary n = 135 teachers n = 26 principals n = 14 INT schools 3 years

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Intervention characteristics • Examine the extent to which social and physical environmental changes in the school setting affect children's activity levels during recess and lunch • 3 programme components: peaceful playgrounds (game markings outlines on playgrounds); walking clubs; activity stations Process measures • Direct observations of children's PA and contextual characteristic of play areas using SOPLAY Intervention characteristics • Integrate daily PA-based academic lessons totalling 90 min/wk Process measures • Reach (training/focus group attendance) • Dose received (training evaluation survey, closed-response, n = 106) • Precision, accuracy (anthropometric reliability testing) • Fidelity (student enjoyment) • Fidelity and dose received (direct observation using SOFIT, 70% of classrooms observed) • Fidelity, dose and dose received (online weekly classroom teacher survey — form 1, closed-response, n = 80)

Facilitators • Schools plan to continue; some schools very motivated Barriers • Lack of financial support; lack of volunteer instructors; some schools lacked motivation; expensive to make environmental changes; not enough time to make environmental changes; municipality prioritizes improvements several years before implementation Themes • b, c, h, j, and n Facilitators • Dedicated principals Barriers • Staffing and attitude barriers to implementation; principals concerned about curriculum intrusions Themes • a, c

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Facilitators • Training was well organized, in-depth, relevant and helpful; materials appropriate for students; teachers confident incorporating lessons; lessons helped with behaviour management Barriers • Time constraints caused by standardized testing; need time to incorporate PA into lessons; field trips; substitute teachers; policy holds schools accountable for academic achievement; small classrooms/space constraints; teachers want more lesson demonstrations and a forum to share ideas; lessons not age appropriate (“babyish”) Themes • a, b, d, e, f, h, and k

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t3:11Q2 t3:12 t3:13 t3:14

Age group, sample size, study duration

10

Please cite this article as: Naylor, P.J., et al., Implementation of school based physical activity interventions: A systematic review, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.034

t3:1 t3:2

Hands et al. (2011) Play5 Australia

Elementary Teachers, students and parents from 27 schools 6-months

t3:32 t3:33 t3:34 t3:35 t3:36 t3:37

Helitzer et al. (1999) Helitzer et al. (1999) Steckler et al. (2003) Steckler et al. (2003)) Pathways United States

Elementary Principals, assistant principals, field coordinators, classroom and PE teachers at 21 INT school 3 years

t3:38Q6 t3:39Q7 t3:40 t3:41 t3:42 t3:43

t3:44Q8 t3:45

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Barriers • Teachers not actively engaged; time challenges Themes • a, g

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Luepker et al. (1996) McKenzie et al. (1996) Child and adolescent trial for cardiovascular health (CATCH) United States

Magnusson et al. (2011) Iceland

Elementary n = 138 teachers n = 56 INT schools 5-semesters

E

Intervention characteristics • Reduce cardiovascular disease risk factors in children via 4 components: food-service; PE; classroom curricula; family activities Process measures • Fidelity, dose, programme context and mediating factors (all measures are closed response unless otherwise stated) • External and competing programmes (School health questionnaire; food service secular trends questionnaire, structured telephone interview with food service managers) • School staff characteristics (school health questionnaire; staff tracking form) • Training and support of school staff (training attendance form; visit documentation logs; visit summary form) • Implementation (teacher weekly checklists; PA record of classes; classroom observation; teacher weekly checklists; PE observation form; SOFIT; guideline checklists; menu/recipe collection) • Student participation/exposure (daily attendance forms; family fun night forms; scorecards; teacher's weekly checklist; school meal participation worksheet) • Student characteristics (student registration form; injury monitoring form; school meal participation worksheet) Intervention characteristics • Progressively increase PA behaviour at school to a minimum of 60 min within 1-year • PA opportunities at recess, PE lessons and integrated into academic lessons Process measures • Implementation (teacher PA logbooks) • Facilitators and barriers to implementation (semi-structured focus groups with teachers, n = 11)

D

P

Elementary n = 8 teachers n = 3 PE teachers n = 3 INT schools 2-years

Facilitators • Teachers enjoyed and understood the need/purpose of the lessons and believed students benefit from the curriculum; classroom teachers knew how to use materials and arrange lessons; classroom teachers gained skill and confidence; lessons integrated with other subjects; curriculum was well organized; parents found events worthwhile Barriers • School administrators not aware of all programme components; field coordinators lacked understanding of their responsibilities; amount/type of communication varied from site to site; teachers did not follow lessons plans/omitted parts of lessons; teachers wanted more flexibility with lessons — frustrated with the need to teach the whole curriculum; insufficient teacher training; new teaching styles required more student participation and created management problems; lessons took longer than planned, did not challenge the students; later lessons were considered to be “less meaty”; family members did not understand programme objectives; lack of lead-time in notifying parents about family events Themes • a, b, d, e, f, i, k, o, p, and q Facilitators • High satisfaction with CATCH PE components; quality of training; annual/biannual training; teaching resources; ease of implementation; perceived benefits to students Barriers • Classroom teachers found activities significantly more difficult to implement than PE teachers; costs; staff time; competing classroom requirements; training time limited by budgets; did not coordinate with other agencies Themes • a, b, d, e, f, j, and k

R O

P.J. Naylor et al. / Preventive Medicine xxx (2015) xxx–xxx

O

F

Facilitators • Improved student productivity; calmness in class after lessons; improved teacher and student PA attitudes; training and on-site counselling satisfaction; extra PE lesson; student readiness to participate; principal and teachers positive attitudes; good collaboration with teachers Barriers • Steep learning curve; competing curriculum demands; winter weather; teachers' openness to change; tightly booked gymnasium; quality of school property (continued on next page)

11

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t3:29Q5 t3:30 t3:31

• Fidelity, implementation (online weekly classroom teacher survey — form 2, closed response, n = 75) • Fidelity, exposure (online classroom teacher questionnaire, closed response, 84% response rate) • Context, contamination (competing factors survey, closed-response, n = 22); semi-structured focus groups (n = 79) Intervention characteristics • Increase PA by encouraging children to take ownership of their PA behaviour Process measures • Parent observations (questionnaire) • Implementation (teacher daily checklist; student diaries) Intervention characteristics • Four components: culturally appropriate PA/nutrition curriculum and daily 5 min activity breaks; maximizing PA during PE; improved food service; family programme Process measures • Reach (classroom/PE/Food service personnel teacher training attendance log; family registration form; family fun night attendance) • Extent and fidelity (training evaluation form; family pack challenge return log; classroom teacher/curriculum checklist and structured interview; food service kitchen contact form) • Extent (PE calendar; student exposure questionnaire) • Fidelity (PE mentor visit summary form; PE and recess teacher checklists and structured interview; food service manager structured interview; student evaluation form; adult evaluation form; field notes form) • Additional measures (classroom/PE/recess/food service observations, school reports, family advisory group minutes)

12

First author, study name, country

Age group, sample size, study duration

Study details, methods

Results themes (see Table 5 for description)

Marcoux et al. (1998) Sport, play, and active recreation for kids (SPARK) United States

Elementary n = 2 PE specialists n = 24 teachers n = 549 students n = 391 parents n = 7 INT schools 2 years

Intervention characteristics • Designed to promote sport and motor skill development and PA • Two components: PE curriculum and self-management curricula • Self-management curricula includes: goal setting, behavioural skills training, reward system and parent involvement Process measures • Fidelity: lesson content, duration, frequency and interactiveness (direct observation checklists, n = 148 observations) • Ease of implementation and teacher satisfaction (questionnaire, closed response, n = 24) • Parent evaluation (questionnaire, closed response; 52% response) • Student participation (total SPARK dollars earned during the year) • Predictors of student participation (accelerometry; anthropometry; self-reported PA attitudes, self-perception and intention, questionnaires, closed response; parent support survey, closed response) Intervention characteristics • Promote PA and healthy eating in elementary schools • 6 components: environment; extracurricular; classroom; PE; school spirit; family and community Process measures • Characteristics of schools: organizational climate, level of institutionalization, environmental influences and minutes of PE (survey, closed response) • Characteristics of teachers: self-efficacy, outcome expectations, behavioural capacity (survey, closed response) • Attributes of the innovation: adoption and implementation (survey, closed response) • Fidelity (examine actual vs. prescribed PA delivered; actual vs. potential weeks logged; planned vs. implemented activities) • Feasibility: satisfaction; facilitators; barriers [workshop evaluation; feedback surveys; semi-structured telephone interviews with: school facilitators (n = 2) and school administrators (n = 7); semi-structured focus groups with teachers (n = 28), students (n = 26), and parents (n = 16)] Intervention characteristics • Increase PA and decrease sedentary behaviour • 6 lessons targeting TV viewing; computer use; PA; mediators of behaviour change Process measures • Fidelity, feasibility (teacher interviews, open response, n = 22; student surveys, closed response, n = 429)

Facilitators • Parents participation and opinion Barriers • Some teachers considered tasks irrelevant, had insufficient time to cover lesson material, found the material difficult to teach, rejected the philosophy of the reward system, were unaccustomed to group discussions and problem solving and were frustrated with the programme's emphasis on behaviour change rather than knowledge-oriented content Facilitators and barriers • Acceptance of the programme varied between participating schools Themes • a, d, f, and i

t3:51Q10 Masse et al. (2012) and t3:52Q11 Naylor et al. (2006) t3:53 Action schools! t3:54 BC (AS! BC) t3:55 Canada

U

N

C

O

Elementary Masse et al. n = 122 principals n = 599 teachers n = 10 INT schools Naylor et al. n = 2 school facilitators n = 7 school administrators n = 28 teachers n = 26 students n = 16 parents n = 10 INT schools 16-months

R

R

Facilitators • Higher level of teacher education; fewer than 20 years of teaching experience; school's level of institutionalizing the programme; training attendance; participating in N1 training session; resources; class time devoted to PA; positive student response; flexible model; teacher and parent support; communication; starting small; weather Barriers • Teacher constraints; unsupportive school environment; physical barriers; scheduling and coordination; time constraints; negative teacher attitudes; space limitations; language and culture; government support; weather; communication Themes • a, b, c, e, g, h, i, l, m, o, p, r, t, and v

E

C

T

E

D

t3:56Q12 Salmon et al. (2011) t3:57 Switch-2-activity t3:58 Australia

Elementary n = 33 teachers n = 436 students 8 INT schools 7-weeks

t3:59Q13 Gortmaker et al. (2011) t3:60 Planet health t3:61 United States

Middle School n = 99 teachers n = 9 PE teachers n = 5 INT schools 2-years

t3:62Q14 Hall et al. (2012) t3:63 HEALTHY PE t3:64 United States

Middle school n = 7 PA coordinators n = 21 INT schools n = 7 field centres across the United States 5 semesters

P

Facilitators • Materials easy to follow and deliver Barriers • Teachers modified and integrating lessons into other aspects of the curriculum; lack of time to deliver lessons; lack of additional training; crowded school curriculum Themes • a, d, e, f, and p Facilitators Intervention characteristics • Experience with interdisciplinary curricula • Reduce obesity by increasing PA and promoting a healthy diet • 4 components: reduce screen time; increase MVPA; decrease high-fat foods intake; Facilitators and barriers • When the units were started during the school year; teacher motivation; fewer PE increase fruit and vegetable intake classes offered; ease of implementation Process measures Themes • Implementation (teacher self-report checklists) • f, g, and h Intervention characteristics Facilitators • Goal to reduce risk-factors for Type 2 diabetes by promoting PA and a healthy diet • PA coordinator in-person interactions with teachers; high level of intervention • 4 integrated components: behaviour; communications; nutrition; PE fidelity; teacher buy-in Process measures Barriers • Fidelity, dose delivered, dose received, implementer participation; barriers • Classroom management/disruptive student behaviour; veteran PE teachers resist (PE class observations, n = 1101 observations; PA coordinator interviews, change; school-wide interruptions; shortened PE classes; student confusion over open-response, n = 77) instructions; adverse weather; large student to teacher ratios; limited PE facility space; lack of institutional support for PE; non-study trainings; covering classes Facilitators and barriers

R O

O

F

P.J. Naylor et al. / Preventive Medicine xxx (2015) xxx–xxx

Please cite this article as: Naylor, P.J., et al., Implementation of school based physical activity interventions: A systematic review, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.034

t3:46Q9 t3:47 t3:48 t3:49 t3:50

Table 3 (continued)

t3:68Q16 Peralta et al. (2009) t3:69 The fitness improvement t3:70 and lifestyle awareness t3:71 programme (FILA) t3:72 Australia

t3:73Q17 Singh et al., 2009 t3:74 DOiT t3:75 Netherlands

t3:76Q18 Webber et al. (2008) and t3:77Q19 Young et al. (2008) t3:78 Trial of activity for t3:79 adolescent girls (TAAG) t3:80 United States

Middle school n = 8 science teachers n = 562 students n = 5 INT schools 10-weeks

U

N

Intervention characteristics • Reduce obesity risk through the promotion of positive PA and dietary behaviours • 24 lessons based on social cognitive theory and self-determination theory Process measures • Workshop 1 (evaluation form, closed response) • Workshop 2 (online survey, closed response) • Teacher support (online survey, 1 open response question) • Implementation faithfulness (classroom observation form, closed response), completion (lesson completion form) and barriers (on-line survey, one open response question) • Student engagement (classroom observation form, closed response and field notes) and satisfaction (student survey, closed response) • Classroom management (classroom observation form, closed response and field notes) • Competing programmes (student survey, closed response) • External factors/school context (state school statistics) •Teacher characteristics, satisfaction and curriculum evaluation (online survey, closed response) Intervention characteristics • Assess the feasibility, acceptability and potential efficacy of a lifestyle awareness programme with low cardiorespiratory fitness boys Process measures • Fidelity, dose, reach, exposure, acceptability (enjoyment scales, closed response; semi-structured interviews with programme champion, n = 1; parent survey, n = 11)

C

O

R

R

Middle school (boys) n = 1 programme champion at 1 INT school 6-months

E

C

T

E

D

Middle School School board members, site staff, teachers and students from 10 INT schools 20-months

P

Intervention characteristics • Aim to prevent excessive weight gain among adolescents • Reduce consumption of high fat foods and sugar sweetened beverages; reduce screen time; increase active transportation Process measures • RE-AIM model: reach, effectiveness, adoption, implementation, maintenance (questionnaires, closed response)

Intervention characteristics Middle school (girls) Teachers from 36 middle schools • Increase support, incentive and opportunities for girls' PA • 4 components: linking school/community agencies; PE; health education; social 2-years marketing Process measures • Reach (semi-structured teacher interviews; student participation) • Fidelity (workshop observations; completion logs) • Dose, reach (PE/health education workshop attendance logs; student surveys; TAAG process evaluator forms) • Dose, fidelity, acceptability (structured observations; teacher surveys) • Acceptability (student survey) • Coordination with agencies (semi-structured principal interviews)

Facilitators • Programme should include a variety of non-curricular PA sessions; school-based rewards for participants; allocation of adequate time, support and funding from PE faculty; parent support and perceived impact on their child; age-appropriate activities; promoting group support and participation; positive feedback to parents and participants Barriers • Unplanned public holiday; wet weather; peer facilitator's lack of motivation; lack of participant motivation/confidence Themes • a, b, c, d, h, i, l, m, n, and s Facilitators • Intervention content; motivated teachers and school board members; intervention manual and materials; embedding the intervention in policy Barriers • Time constraints; low student motivation; insufficient funding; lack of PE teachers; lack of facilities; lack of teacher buy-in; existing contracts with agencies Facilitators and barriers • Perceived difficulty of lesson material; programme intensity Themes • a, b, c, d, g, j, l, n, and r Facilitators • Tailoring the programme to the needs of the school, community and participants; highly accepted and enjoyed by students; collaboration with outside agencies; reaching students during the school day (fewer competing time priorities) Barriers • Competing priorities; limited interest in research activities; decreased control over students can reduce teacher's motivation Themes • a, d, g, j, l, and q

R O

P.J. Naylor et al. / Preventive Medicine xxx (2015) xxx–xxx

O

F

(continued on next page)

13

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t3:65Q15 Lee et al. (2013) t3:66 Choice, control & change t3:67 United States

• Some teachers found workshops to be of value others found them to be ‘overkill’; mix of motivated and disengaged teachers; variable PE class time; teachers' structuring of classroom activities Themes • b, c, e, g, h, m, q, and t Facilitators • Support from implementation coordinators; student participation and engagement; relevance and applicability of activities to the students' lives; science-based lessons were more familiar to teachers; student satisfaction; teacher satisfaction/enthusiasm Barriers • Student misbehaviour; conflicting school priorities; language barrier; teacher's perceptions of activities and workload; student misbehaviour/discipline issues; student language barriers Facilitators and barriers • Student ethnicity Themes • a, c, d, e, f, g, l, and q

14

First author, study name, country

t3:81 Neumark-Sztainer et al. t3:82Q20 (2003) New moves t3:83 United States

t3:84Q21 Ward et al. (2006) t3:85 Lifestyle education for t3:86 activity programme t3:87 (LEAP) t3:88 United States

t3:89 Non-randomized trials t3:90 t3:91Q22 Almas et al. (2013) t3:92 Pakistan

t3:93Q23 Crawford et al. (2013) t3:94 Ride2School t3:95 Australia

t3:96Q24 De Meij et al. (2010) and t3:97Q25 De Meij et al. (2012) t3:98Q26 Jurg et al. (2008); t3:99 JUMP-in Netherlands

Age group, sample size, study duration

Study details, methods

Results themes (see Table 5 for description)

High school (girls) n = 3 principals n = 3 teachers n = 89 students n = 96 parents n = 3 INT schools 16 weeks + 8 month follow-up

Intervention characteristics • Alternative PE programme for girls targeting socio-environmental, personal and behavioural factors • PA (4 days/wk), nutrition and social support sessions (every other wk) Process measures • Programme satisfaction and sustainability (teacher and principal open-response interviews, parent (n = 67) and participant (n = 79) closed and open-response surveys) • Programme impact (participant semi-structured interviews, n = 30) Intervention characteristics • Promote high school girls' PA • 6 components: PE; health education; healthy school environment; school health services, faculty/staff health promotion; family/community involvement Process measures • Dose, reach, participant feedback, implementation feedback, fidelity, completeness, implementation, barriers (assessed using: record reviews [closed response]; direct observation checklist [closed response]; LEAP criteria/EAP PE criteria [assessed the 16 essential elements of LEAP, closed response]; organizational assessment interview [closed-response]; LEAP champion and teacher survey)

Facilitators • All-girls class composition; guest instructor units; integration of nutrition and social support; student manuals and exercise logs; various incentives; field trips; principals thought of ways to fund the programme Barriers • Finding time to discuss key concepts without taking away from activity time Themes • a, b, c, d, and j

U

N

High school (girls) n = 23 LEAP champion and key teachers n = 12 INT schools 2-years

C

O

Facilitators • Increased acceptance and ownership of changes Barriers • Lack of personnel; lack of time; scheduling and time challenges; readiness to change; difficult understanding and implementing behaviour skills concepts; reaching/motivating parents Themes • a, b, c, f, h, i, and s

R

R

Elementary (girls) n = 131 girls from 1INT school 20 weeks

Elementary Principals, coordinators and teachers n = 3 schools, Phase 1 n = 13 schools, Phase 2 13-months, Phase 1 9-months, Phase 2

Elementary Students, parents, school directors, school staff, PE teachers, policy makers and sports coordinators 2-years

E

Intervention characteristics • Assess a PA programme with preadolescent girls to determine feasibility and influence on blood pressure and body mass index Process measures • Feasibility (participant recruitment and retention rates; treatment fidelity, %PA sessions implemented) • Acceptability (questionnaire, 1-item, closed response) Intervention characteristics • Increase active transport to school through behaviour change • Phase 1 (programme activities and infrastructure improvements) • Phase 2 (customized advice, support and resources) Process measures Phase 1 • Extent of implementation, facilitators, barriers (monthly face-to-face or telephone interviews with the coordinator, open response) Phase 2 • Extent of implementation, implementation feedback, facilitators, barriers (semi-structured telephone interviews with the principal (n = 11); semi-structured interviews with the coordinator (n = 2); semi-structured focus groups with teachers (n = 21)) • Participant feedback (semi-structured focus groups with students (n = 70) Intervention characteristics • Designed to promote PA among primary school children • 6 components: school sports activity; pupil follow-up; in-class exercise; awareness and self-efficacy; parental information service; an activity week Process measures • Implementation (teacher questionnaire, closed response, n = 20) • Extent of implementation (semi-structured interviews with PE teachers, steering group members, sports coordinators, one district A and B sports and recreation staff member) • Intervention quality and programme components (document analysis: project plan; meeting minutes) • Dose and reach (questionnaires; structured in-depth interviews; document analysis) • Determinants of the innovation process (school and environmental scan; questionnaires; structured in-depth interviews; SWOT analysis; document analysis)

C

Barriers • Winter vacations; legal matters in the city; heavy rains Themes • a, b, c, e, f, g, h, k, l, and m

T

E

D

P

Facilitators • School and community support; utilizing programme resources; easier to implement in smaller more established schools with a more accepting school culture; higher density neighbourhood with lower car use; greater use of infrastructure improvements; coordinator assistance; highly motivated schools and parents in supportive physical and sociocultural environments; pre-existing supportive infrastructure Barriers • Competing priorities required attention, resources and staff time; schools had different levels of commitment; differing expectations between schools Themes • a, b, c, e, i, o, and t

R O

O

Facilitators • Admin support; committed and motivated project members; existing local networks; effective cooperation between schools and local networks; parent recruitment; trained instructors; instructional presentations consistent with teachers' terminology, goals and needs; experience with exercise activities; project targets aligned with those involved; use of pupil-follow-up system to detect and motivate inactive children; compatibility of JUMP-in tasks with PE teachers and sports coordinators day-to-day work; perceived fit with policies; financial resources; clear communication of strategies; perceived importance within the school; teachers' willingness to collaborate; tailoring the programme to the school Barriers • Fully booked school year; teacher workload; delayed development of programme components; encouraging school staff to implement programme components; compatibility with the curriculum; absence of clear guidelines; differences in

F

P.J. Naylor et al. / Preventive Medicine xxx (2015) xxx–xxx

Please cite this article as: Naylor, P.J., et al., Implementation of school based physical activity interventions: A systematic review, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.034

Table 3 (continued)

t3:100 Q27 Gorely et al. (2011) t3:101 GreatFun2Run t3:102 United Kingdom

Elementary n = 8 teachers from 4 INT schools 10-months with 18–20 month follow-up

U

N

C

t3:103 Q28 Holt et al. (2013) t3:104 United States

Elementary n = 68 teachers n = 142 students n = 4 INT schools 6-months

O

R

R

E

C

t3:105 Q29 Honer et al. (2012) t3:106 Germany

Elementary Teachers from 1 school 8-weeks

T

E

D

t3:107 Q30 Morris et al. (2013) t3:108 Great activity programme t3:109 United Kingdom

Elementary n = 4 teachers from 2 INT schools 8-months

t3:110 Q31 Webster et al. (2013) t3:111 Physical activity t3:112 promotion in the t3:113 academic classroom t3:114 (PAPAC) t3:115 United States

Elementary n = 201 teachers at 79 schools Descriptive/ cross-sectional

t3:116 t3:117 t3:118

Middle school n = 24 teachers n = 745 students n = 391 parents 16 weeks

Bush et al. (2010) FunAction Canada

P

E, Evaluation; INT, intervention; MVPA, moderate to vigorous PA; SOFIT, system for observing fitness; PA, physical activity; and PE, physical education.

R O

O

F

15

t3:119

expectations and responsibilities; low attendance at parent meetings; decreased steering committee support; cooperation between local agencies; lack of formalized contracts; lack of: space, teacher buy-in/motivation, PE teacher authority, coordination and control, training skills, communication, preparation time and admin support Themes • a, b, c, d, e, f, g, h, i, j, l, n, and o Facilitators Intervention characteristics • Resources useful for generating ideas; school leadership; continued professional • Aim to increase children's PA levels through PE development • 5 components (CD-rom learning and teaching resource; 2 highlighted events; Barriers interactive website; media campaign; summer activity wall planner and record) • Time issues; competing resources and curriculum demands; some teachers do not Process measures teach PE; staffing changes; limited ability to follow through the intervention with • Attitudes towards programme and programme impact (semi-structured the same students interviews with teachers, n = 8) Facilitators and barriers • Follow-up support for teachers; family support Themes • a, b, c, e, h, i, and u Facilitators Intervention characteristics • Professional development attendance; ease of integration and use of • Determine the extent of implementation of a 20-minute PA policy curriculum-based lessons; receiving proper resources and professional Process measures • Classroom PA tracking sheets (self-report; closed response with one area provided development prior to implementation; Training lead to increased knowledge and confidence; positive classroom behaviour changes for subjective comments; n = 54 in Sept, n = 45 in Feb) Barriers • Weather; time issues; lack of ongoing professional development; decreased administrator and teacher support; not knowing how to provide students with activity; academic priorities Themes • a, b, c, d, e, f, k, and m Facilitators Intervention characteristics • Adapting lesson content to class size • Goal to increase PA and motor performance in elementary children Barriers • 8 sport-based health promoting PE lessons of 90 min • Altering lessons due to lack of time; need more ball games for boys Process measures Themes • Implementation (observation of PE lessons) • a, d, and p • Quality of content, barriers, student behaviour (guideline-based interviews, open response) • Evaluation of health promotion PE lessons (student questionnaires, closed response) Facilitators Intervention characteristics • Teachers felt programme benefited children; strong leadership for providing a • Increase children's PA levels through PE supportive environment • Materials based on GreatFun2Run programme (3 highlighted events; 12 Great Barriers Goals; interactive website; media campaign; vacation activity planner) • Lack of time to become familiar with resources Process measures Facilitators and barriers • Attitudes towards programme; programme improvements; programme impact • Parent support and role modelling of healthy behaviours; formal training might (12 semi-structured focus groups with students; semi-structured classroom teacher encouraged greater implementation interviews, n = 4; semi-structured telephone interviews with parents, n = 12) Themes • a, c, e, i, and k, Facilitators Intervention characteristics • Policy awareness; supportive school environment; perceived attributes; • Examine a theoretical model based in diffusion of innovations theory and social domain-specific innovativeness; sufficient classroom space and resources; ecological perspective on elementary classroom teachers' adoption of PAPAC compatibility with current educational practice; easy to implement; rewarding Process measures teachers for trying new ideas • Policy awareness, perceived school support, perceived attributes of PAPAC; domain-specific innovativeness, self-reported PAPAC (5 closed response questionnaires) Themes • b, c, d, f, k, and r Intervention characteristics Barriers • Increase PA among multi-ethnic underserved adolescents • Students unavailable or disinterested in activities; shyness; friends not • 45 min lunch-time PA sessions offered 3 to 5 days/wk participating; no school showers; hot/humid weather; part-time work; Process measures familial/scholastic obligations • Number of sessions offered; participation frequency (attendance); PA preferences Themes (participant surveys); suggestions/requests (student and teacher informal consultations) • a, b, l, and m

P.J. Naylor et al. / Preventive Medicine xxx (2015) xxx–xxx

Please cite this article as: Naylor, P.J., et al., Implementation of school based physical activity interventions: A systematic review, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.034

• RE-AIM model: reach, effectiveness, adoption, implementation, maintenance

470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492

F

O

468 469

C

466 467

E

464 465

R

462 463

R

460 461

O

459

R O

Table 4 Quality assessment of 15 studies (18 publications) included for objective 1.

457 458

P

t4:1 t4:2

455 456

district decision-makers would have highlighted broader community level factors as important. Researchers most often assessed student level behaviour change (dose received) to represent school and teacher level implementation. This focus may reflect i) a lack of familiarity with the range of factors associated with implementation across different models (e.g., fidelity, quality), ii) barriers to the assessment of these factors, or iii) simply a lack of focus on, or understanding of, implementation science itself. Importantly, to better understand the relation of factors such as quality and type of activity and responsiveness of the target audience to implementation (Greenberg et al., 2005) these factors must be more routinely assessed. Further, localized decision-making and adaptation to different contexts by school stakeholders are the foundation of a comprehensive school health approach (Samdal and Rowling, 2011; Deschesnes et al., 2003). This speaks to the ‘dynamic’ (ever-changing) nature of whole school-based physical activity models, which inherently presents another challenge for measurement (Samdal and Rowling, 2011). The adaptable nature of schools supports the need to conduct ‘real-world’ based implementation research to identify varied ‘real-world’ solutions to challenging implementation problems. There were more recently published studies related to school-based physical activity intervention implementation. This likely reflects increased recognition and acceptance that process evaluations provide a foundation upon which outcomes can be interpreted (Durlak and DuPre, 2008; Greenberg et al., 2005) and that they support translation of interventions into real world settings (Glasgow, 2008). However, as most were efficacy trials that are commonly delivered by motivated research volunteers they may not be generalizable to a more ‘real-world’ classroom setting where teachers struggle with competing demands on their time and may deal with a more diverse and indifferent student body (Glasgow and Emmons, 2007). Finally, many of the factors that emerged as important were consistent with the broader literature on implementation (Durlak and DuPre, 2008; Fixsen et al., 2005; Greenberg et al., 2005) and fuel the argument that “having a multi-level ecological framework for understanding implementation” is the best way forward (Durlak and DuPre, 2008). Sallis and colleagues also supported this multi-level ecological framework for school physical activity promotion (Sallis et al., 2003). Indeed, there is general agreement among researchers regarding the need for more layered, coordinated, and multi-pronged health promotion strategies (Naylor and McKay, 2009; Sallis et al., 1998, 2006; Bauman et al.,

T

493

as the factor most consistently identified as a barrier to implementation of school-based physical activity initiatives. Most of the other factors that fell within the categories we identified aligned with the Durlak and Dupre model. Specific factors like lesson scheduling, weather and classroom disruption appear to be specific to school physical activity promotion. Community level (e.g., politics and theory) and general factors within the prevention delivery system (in this case the school, e.g., organizational norms, shared decision-making) were not reported and fewer studies identified factors within these categories overall. We discuss these findings in light of the literature, below. Time constraints were noted as a key factor that influenced implementation in most studies (23/29). However, time factors did not emerge as important in the Durlak and Dupre model or in any of the models we reviewed (Damschroder et al., 2009). Others (Greenberg et al., 2005) developed implementation models specifically for schools but these models also did not delineate time constraints as an influential factor. Greenberg et al. (Greenberg et al., 2005) identified allocation of time as a school level resourcing issue. Time constraints (time to prepare and deliver the physical activity intervention, competing demands and teacher overload) might also reflect school level resourcing in our study — described as a delivery system factor in the Durlak and Dupre model. It may be that although every teacher experiences limited time as a barrier, some teachers prioritize a programme and deliver it despite these constraints, perhaps based on the value they place on it. There is some evidence to support this in the behavioural medicine literature (Rhodes et al., 2009; Rhodes and Blanchard, 2007, 2011; Brawley et al., 1998). However, the school physical activity literature has yet to explore this line of inquiry. Thus, our review suggests that as the science of implementation evolves in the field of school-based physical activity interventions, a standardized measure of time constraints should be utilized. The importance of the contextual appropriateness of the intervention, delivery agent efficacy, supportive organizational climate and training and technical support all emerged as important factors in our review. These findings align with previous reviews (Durlak and DuPre, 2008; Fixsen et al., 2005; Damschroder et al., 2009; Greenberg et al., 2005). The importance of teacher perceptions of benefit, adaptability of the resources, funding, multi-agency coordination, school scheduling, communications, policy and leadership were cited less often. This may reflect that teachers most often participated in the studies. It is possible that interviews or focus groups with school administrators or school

D

453 454

P.J. Naylor et al. / Preventive Medicine xxx (2015) xxx–xxx

E

16

t4:3

Quantitative quality assessment a

t4:4 t4:5

Selection bias

t4:24 t4:25

a b

Confounders

Blinding

Data collection methods

Withdrawals/ dropouts

Global quantitative rating

P1

P2

P3

P4

P5

P6

P7

P8

Global process rating

C

N

Donnelly 2009 Gibson 2008 Eather 2013 Gentile 2009 McNeil 2009 Macdonald 2008 Marcoux 1999 Nader 1996 Haerens 2006 Ezendam 2012 Lubans 2012 Slootmaker 2010 Dishman 2004 Dishman 2005 Saunders 2006 Springer 2012 Erwin 2011 Bush 2010

Moderate

Strong

Strong

Moderate

Strong

Strong

Strong

+

+

+

+

+

+

+

+

Strong

Weak Moderate Weak Weak Moderate Moderate Strong Weak Weak Weak Weak

Strong Strong Strong Strong Strong Strong Strong Strong Strong Strong Strong

Strong Strong Strong Strong Weak Strong Strong Strong Strong Weak Strong

Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate Weak Moderate Moderate

Strong Strong Strong Strong Strong Strong Strong Strong Strong Strong Strong

Strong Strong Strong Strong Moderate Moderate Moderate Strong Strong Strong Moderate

Moderate Strong Moderate Moderate Moderate Moderate Strong Moderate Weak Weak Moderate

+ − − + + + − − − + +

+ + + + + + + + + + +

+ − − + + + − − − + +

+ − − + + + − + − + +

+ − + + + + − − − + +

+ + + + + + + + + + +

+ N/A N/A + N/A N/A N/A N/A N/A N/A +

+ + + + + + + + + + +

Strong Weak Moderate Strong Strong Strong Weak Moderate Weak Strong Strong

Weak Weak Weak

Weak Weak Weak

Strong Weak Weak

Moderate Moderate Moderate

Strong Strong Strong

Strong Weak Moderate

Weak Weak Weak

+ − +

+ + +

+ − −

+ − −

+ + +

+ + +

N/A N/A N/A

+ + +

Strong Moderate Moderate

U

t4:6 t4:7 t4:8 t4:9 t4:10 t4:11 t4:12 t4:13 t4:14 t4:15 t4:16 t4:17 t4:18 t4:19 t4:20 t4:21 t4:22 t4:23

Study design

Process measures quality assessment b

Quantitative quality assessment performed using the quality assessment tool for quantitative studies developed by the Effective Public Health Practice Project (EPHPP) (Thomas et al., 2004). Process measures quality assessment adapted from Wierenga et al (Wierenga et al., 2013). See Table 1 for definitions of P1–P8.

Please cite this article as: Naylor, P.J., et al., Implementation of school based physical activity interventions: A systematic review, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.034

494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534

P.J. Naylor et al. / Preventive Medicine xxx (2015) xxx–xxx Table 5 Number of studies reporting each factor that influenced implementation of school-based interventions (objective 2; 29 studies represented by 35 publications).

t5:28 t5:29 t5:30 t5:31 t5:32

Facilitator

Barrier

Both

Time (e.g., competing instructional requirements, teacher overload)IV Availability/quality of resources (e.g., activity resources, personnel, facilities)III Supportive school climate (e.g., shared vision/administrative support)IV Contextual appropriateness (e.g., programme/resource acceptability)III Training/workshops and technical support from programme staff V Self-efficacy (e.g., ease of implementation, teacher's skill proficiency)II Teacher characteristics, engagement and motivationII Lesson scheduling and programme coordination (e.g., inability to follow students over time, field trips, vacation breaks) Parent support and perceptions Coordination with other agenciesIV Perceived/observed benefits of innovationII Student characteristics, engagement and motivation Weather FundingI CommunicationIV Adaptability (e.g., flexibility of the programme)III Classroom management/disruptive student behaviour PolicyI Accountability and feedbackII Characteristics of the school (e.g., school size, language barriers, student ethnicity, built environment) Staff turnover/changing roles Physical factors (e.g., appropriate footwear/clothing)

1 6 9 6 6 6 2 1 5 3 7 3 0 3 1 3 0 2 3 1 0 0

22 7 2 2 2 3 4 7 1 3 0 2 6 3 2 1 4 2 0 2 2 1

1 4 6 7 6 4 5 2 3 1 0 2 1 0 2 0 0 0 0 0 0 0

O

Lower case letters refer to themes identified in Table 3. Superscript roman numerals refer to categories within the Durlak and Dupre model (Durlak and DuPre, 2008): I II III IV V

Community level Provider characteristics Characteristics of the intervention Organizational capacity Prevention support system.

540

Study limitations

541 542

557

We acknowledge that our systematic review had a number of limitations. First, our findings are limited by the search terms and definitions we used to conduct the searches. Specifically, use of the search term programme or intervention excluded papers on state level policy implementation. Thus, there is an emerging body of literature on policy implementation that we do not reference in our review (e.g., SanchezVaznaugh et al., 2012). Neither did our definitions and thus our review represent the many subtleties related to implementation highlighted by Fixsen et al. (2005). Second, we deliberately cast a broad net and in doing so captured many interventions that did not utilize a whole setting, multi-level, comprehensive school health approach. We excluded studies that did not meet our minimum standard of having a control group but did not make further exclusions based on the quality assessment. Finally, we recognize that the results of the review may be influenced by publication bias whereby the literature includes studies with positive findings and where process evaluation data for trials with no effect may not be of interest.

558

Conclusions

559

The study of implementation of school-based physical activity interventions is in its infancy. We view our findings as a call to action to address the urgent need for more school-based physical activity studies that; i) assess implementation through comprehensive process evaluation, ii) link implementation with health outcomes, and iii) focus on implementation after scale up. We urge researchers to also consider the valuable role that process evaluation data may play in understanding, and learning from, negative findings. To compare across studies

547 548 549 550 551 552 553 554 555 556

560 561 562 563 564 565 566

C

E

R

R

545 546

N C O

543 544

U

536 537

T

538 539

2009). A number of reviews over the past five years (van Sluijs et al., 2007; Kriemler et al., 2011) and our own work (Naylor and McKay, 2009) support this notion. Specifically, there is now convincing evidence that comprehensive whole school models that incorporate both teacher and school level activities, are the most effective (Saunders et al., 2012).

535

F

Factors affecting implementation

P

t5:26 t5:27

a b c d e f g h i j k l m n o p q r s t u v

D

t5:4 t5:5 t5:6 t5:7 t5:8 t5:9 t5:10 t5:11 t5:12 t5:13 t5:14 t5:15 t5:16 t5:17 t5:18 t5:19 t5:20 t5:21 t5:22 t5:23 t5:24 t5:25

R O

t5:3

E

t5:1 t5:2

17

there is also a dire need to improve and standardize definitions and measurement of implementation. This presents its own set of challenges, given the contextual differences in education systems regionally, nationally and internationally. Our ultimate goal should be to scale-up effective interventions as a means to improve health at the population level. To do so we need to better understand the many factors that could be modified to advance the implementation experience (Butler et al., 2010). In closing, we heed the caution of Berliner (2002) related to challenges inherent to school-based research “…the power of contexts, the ubiquity of interactions and the short half-life of our findings” (p. 20).

567

Conflict of interest statement The authors declare that there are no conflicts of interest.

578 579

Authors' contributions

580

PJN conceived of the study, participated in study design and coordination, contributed to data analysis, and drafted, edited and wrote the manuscript. LN participated in design and coordination, contributed to data analysis and helped to draft, write and edit the manuscript. DR performed the systematic searches, contributed to data analysis and critically revised the manuscript. CH contributed to data analysis and critically revised the manuscript. MCA participated in study design and critically revised the manuscript. JWH participated in study design and critically revised the manuscript. HAM conceived of the study, participated in its design and coordination and helped to draft, write and edit the manuscript.

581 582

Funding

592

This research was supported in part through a grant from the Canadian Institutes of Health Research (MHA-90871), Dr. McKay's Knowledge Translation award and the Centre for Hip Health and Mobility.

593

Please cite this article as: Naylor, P.J., et al., Implementation of school based physical activity interventions: A systematic review, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.034

568 569 570 571 572 573 574 575 576 577

583 584 585 586 587 588 589 590 591

594 595 596

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Bauman, A., Murphy, N., Lane, A., 2009. The role of community programmes and mass events in promoting physical activity to patients. Br. J. Sports Med. 43 (1), 44–46. Berliner, D.C., 2002. Educational research: the hardest science of all. Educ. Res. 31 (8), 18–20. Biddle, S.J., Gorely, T., Stensel, D.J., 2004. Health-enhancing physical activity and sedentary behaviour in children and adolescents. J. Sports Sci. 22 (8), 679–701. Brawley, L.R., Martin, K.A., Gyurcsik, N.C., 1998. Problems in assessing perceived barriers to exercise: confusing obstacles with attributions and excuses. In: Duda, J.L. (Ed.), Advances in sport and exercise psychology measurement. Fitness Information, Morgantown, WV, pp. 337–350. Bush, P.L., Laberge, S., Laforest, S., 2010. Physical activity promotion among underserved adolescents: “make it fun, easy, and popular”. Health Promot. Pract. 11 (3 Suppl.), 79S–87S. Butler, H., Bowes, G., Drew, S., et al., 2010. Harnessing complexity: taking advantage of context and relationships in dissemination of school-based interventions. Health Promot. Pract. 11 (2), 259–267. Damschroder, L.J., Aron, D.C., Keith, R.E., Kirsh, S.R., Alexander, J.A., Lowery, J.C., 2009. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement. Sci. 4 (pp. 50-5908-4-50). Deschesnes, M., Martin, C., Hill, A.J., 2003. Comprehensive approaches to school health promotion: how to achieve broader implementation? Health Promot. Int. 18 (4), 387–396. Dishman, R.K., Motl, R.W., Saunders, R., et al., 2004. Self-efficacy partially mediates the effect of a school-based physical-activity intervention among adolescent girls. Prev. Med. 38 (5), 628–636. Dishman, R.K., Motl, R.W., Saunders, R., et al., 2005. Enjoyment mediates effects of a school-based physical-activity intervention. Med. Sci. Sports Exerc. 37 (3), 478–487. Dobbins, M., De Corby, K., Robeson, P., Husson, H., Tirilis, D., 2009. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6–18. Cochrane Database Syst. Rev. (Online) 1 (1), CD007651. Dobbins, M., Husson, H., DeCorby, K., LaRocca, R.L., 2013. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18. Cochrane Database Syst. Rev. 2, CD007651. Donnelly, J.E., Greene, J.L., Gibson, C.A., et al., 2009. Physical Activity Across the Curriculum (PAAC): a randomized controlled trial to promote physical activity and diminish overweight and obesity in elementary school children. Prev. Med. 49 (4), 336–341. Dudley, D., Okely, A., Pearson, P., Cotton, W., 2011. A systematic review of the effectiveness of physical education and school sport interventions targeting physical activity, movement skills and enjoyment of physical activity. Eur. Phys. Educ. Rev. 17, 353. Durlak, J.A., DuPre, E.P., 2008. Implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation. Am. J. Community Psychol. 41 (3–4), 327–350. Dzewaltowski, D.A., Estabrooks, P.A., Klesges, L.M., Bull, S., Glasgow, R.E., 2004. Behavior change intervention research in community settings: how generalizable are the results? Health Promot. Int. 19 (2), 235–245. Eather, N., Morgan, P.J., Lubans, D.R., 2013. Feasibility and preliminary efficacy of the Fit4Fun intervention for improving physical fitness in a sample of primary school children: a pilot study. Phys. Educ. Sport Pedagog. 18 (4), 389–411. Erwin, H.E., Beighle, A., Morgan, C.F., Noland, M., 2011. Effect of a low-cost, teacherdirected classroom intervention on elementary students' physical activity. J. Sch. Health 81 (8), 455–461. Ezendam, N.P., Noordegraaf, V.S., Kroeze, W., Brug, J., Oenema, A., 2013. Process evaluation of FATaintPHAT, a computer-tailored intervention to prevent excessive weight gain among Dutch adolescents. Health Promot. Int. 28 (1), 26–35. Fixsen, D.L., Naoom, S.F., Blase, K.A., Friedman, R.M., Wallace, F., 2005. Implementation Research: A Synthesis of the Literature. University of South Florida, Louis de la Parte Mental Health Institute, The National Implementation Research Network, Tampa, FL. Gentile, D.A., Welk, G., Eisenmann, J.C., et al., 2009. Evaluation of a multiple ecological level child obesity prevention program: switch what you do, view, and chew. BMC Med. 7, 49. Gibson, C.A., Smith, B.K., DuBose, K.D., et al., 2008. Physical activity across the curriculum: year one process evaluation results. Int. J. Behav. Nutr. Phys. Act. 5 (36). Glasgow, R.E., 2008. What types of evidence are most needed to advance behavioral medicine? Ann. Behav. Med. 35 (1), 19–25. Glasgow, R.E., Emmons, K.M., 2007. How can we increase translation of research into practice? Types of evidence needed. Annu. Rev. Public Health 28, 413–433. Glasgow, R.E., Vogt, T.M., Boles, S.M., 1999. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am. J. Public Health 89 (9), 1322–1327. Golden, S.D., Earp, J.A., 2012. Social ecological approaches to individuals and their contexts: twenty years of health education & behavior health promotion interventions. Health Educ. Behav. 39 (3), 364–372. Greenberg, M.T., Domitrovich, C.E., Graczyk, P.A., Zins, J.E., 2005. The Study of Implementation in School-Based Preventive Interventions: Theory, Research, and Practice. Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, MD. Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., Kyriakidou, O., 2004. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 82 (4), 581–629. Haerens, L., Deforche, B., Maes, L., Stevens, V., Cardon, G., De Bourdeaudhuij, I., 2006. Body mass effects of a physical activity and healthy food intervention in middle schools. Obesity 14 (5), 847–854.

P

598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681

Helitzer, D.L., Davis, S.M., Gittelsohn, J., et al., 1999. Process evaluation in a multisite, primary obesity-prevention trial in American Indian schoolchildren. Am. J. Clin. Nutr. 69 (4 Suppl.), 816S–824S. Iannotti, R.J., Kogan, M.D., Janssen, I., Boyce, W.F., 2009. Patterns of adolescent physical activity, screen-based media use, and positive and negative health indicators in the U.S. and Canada. J. Adolesc. Health 44 (5), 493–499. Jackson, N., Waters, E., Guidelines for Systematic Reviews in Health Promotion and Public Health Taskforce, 2005. Criteria for the systematic review of health promotion and public health interventions. Health Promot. Int. 20 (4), 367–374. Janssen, I., 2007. Physical activity guidelines for children and youth. Appl. Physiol. Nutr. Metab. 32 (Suppl. 2E), S109–S121. Janssen, I., Leblanc, A.G., 2010. Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. Int. J. Behav. Nutr. Phys. Act. 7, 40. Knuth, A.G., Hallal, P.C., 2009. Temporal trends in physical activity: a systematic review. J. Phys. Act. Health 6 (5), 548–559. Kriemler, S., Meyer, U., Martin, E., van Sluijs, E.M., Andersen, L.B., Martin, B.W., 2011. Effect of school-based interventions on physical activity and fitness in children and adolescents: a review of reviews and systematic update. Br. J. Sports Med. 45 (11), 923–930. Lai, S.K., Costigan, S.A., Morgan, P.J., et al., 2014. Do school-based interventions focusing on physical activity, fitness, or fundamental movement skill competency produce a sustained impact in these outcomes in children and adolescents? A systematic review of follow-up studies. Sports Med. 44, 67–79. Lubans, D.R., Morgan, P.J., Callister, R., 2012. Potential moderators and mediators of intervention effects in an obesity prevention program for adolescent boys from disadvantaged schools. J. Sci. Med. Sport 15 (6), 519–525. Macdonald, H.M., Kontulainen, S.A., Petit, M.A., Beck, T.J., Khan, K.M., McKay, H.A., 2008. Does a novel school-based physical activity model benefit femoral neck bone strength in pre- and early pubertal children? Osteoporos. Int. 19, 1445–1456. Mahar, M.T., Murphy, S.K., Rowe, D.A., Golden, J., Shields, A.T., Raedeke, T.D., 2006. Effects of a classroom-based program on physical activity and on-task behavior. Med. Sci. Sports Exerc. 38 (12), 2086–2094. Marcoux, M.F., Sallis, J.F., McKenzie, T.L., Marshall, S., Armstrong, C.A., Goggin, K.J., 1999. Process evaluation of a physical activity self-management program for children: spark. Psychol. Health 14 (4), 659–677. McNeil, D.A., Wilson, B.N., Siever, J.E., Ronca, M., Mah, J.K., 2009. Connecting children to recreational activities: results of a cluster randomized trial. Am. J. Health Promot. 23 (6), 376–387. Mercer, S.L., DeVinney, B.J., Fine, L.J., Green, L.W., Dougherty, D., 2007. Study designs for effectiveness and translation research: identifying trade-offs. Am. J. Prev. Med. 33 (2), 139–154. Nader, P.R., Sellers, D.E., Johnson, C.C., et al., 1996. The effect of adult participation in a school-based family intervention to improve children's diet and physical activity: the child and adolescent trial for cardiovascular health. Prev. Med. 25 (4), 455–464. Naylor, P.J., McKay, H.A., 2009. Prevention in the first place: schools a setting for action on physical inactivity. Br. J. Sports Med. 43 (1), 10–13. Neumark-Sztainer, D., Story, M., Hannan, P.J., Rex, J., 2003. New moves: a school-based obesity prevention program for adolescent girls. Prev. Med. 37 (1), 41–51. Newland, B., Dixon, M.A., Green, B.C., 2013. Engaging children through sport: examining the disconnect between program vision and implementation. J. Phys. Act. Health 10 (6), 805–812. Penedo, F.J., Dahn, J.R., 2005. Exercise and well-being: a review of mental and physical health benefits associated with physical activity. Curr. Opin. Psychiatry 18 (2), 189–193. Rhodes, R.E., Blanchard, C.M., 2007. What do confidence items measure in the physical activity domain? J. Appl. Soc. Psychol. 37, 753–768. Rhodes, R.E., Blanchard, C.M., 2011. Time displacement and confidence to participate in physical activity. Int. J. Behav. Med. 18 (3), 229–234. Rhodes, R.E., Blanchard, C.M., Courneya, K.S., Plotnikoff, R.C., 2009. Identifying beliefbased targets for the promotion of leisure-time walking. Health Educ. Behav. 36 (2), 381–393. Rohrbach, L.A., Grana, R., Sussman, S., Valente, T.W., 2006. Type II translation: transporting prevention interventions from research to real-world settings. Eval. Health Prof. 29 (3), 302–333. Rowling, L., Samdal, O., 2011. Filling the black box of implementation for healthpromoting schools. Health Educ. 111 (5), 347–362. Sallis, J.F., Bauman, A., Pratt, M., 1998. Environmental and policy interventions to promote physical activity. Am. J. Prev. Med. 15 (4), 379–397. Sallis, J.F., McKenzie, T.L., Conway, T.L., et al., 2003. Environmental interventions for eating and physical activity: a randomized controlled trial in middle schools. Am. J. Prev. Med. 24 (3), 209–217. Sallis, J.F., Cervero, R.B., Ascher, W., Henderson, K.A., Kraft, M.K., Kerr, J., 2006. An ecological approach to creating active living communities. Annu. Rev. Public Health 27, 297–322. Samdal, O., Rowling, L., 2011. Theoretical and empirical base for implementation components of health-promoting schools. Health Educ. 111 (5), 367–390. Sanchez-Vaznaugh, E.V., Sanchez, B.N., Rosas, L.G., Baek, J., Egerter, S., 2012. Physical education policy compliance and children's physical fitness. Am. J. Prev. Med. 42 (5), 452–459. Saunders, R.P., Ward, D., Felton, G.M., Dowda, M., Pate, R.P., 2006. Examining the link between program implementation and behavior outcomes in the lifestyle education for activity program (LEAP). Eval. Program Plann. 29, 352–364. Saunders, R.P., Pate, R.R., Dowda, M., Ward, D.S., Epping, J.N., Dishman, R.K., 2012. Assessing sustainability of Lifestyle Education for Activity Program (LEAP). Health Educ. Res. 27 (2), 319–330. Sibley, B.A., Etnier, J.L., 2003. The relationship between physical activity and cognition in children: a meta-analysis. Pediatr. Exerc. Sci. 15, 243–256.

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References

U

N

C

O

R

R

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P.J. Naylor et al. / Preventive Medicine xxx (2015) xxx–xxx

Tomkinson, G.R., Olds, T.S., 2007. Secular changes in pediatric aerobic fitness test performance: the global picture. Med. Sport Sci. 50, 46–66. Tremblay, M.S., Shields, M., Laviolette, M., Craig, C.L., Janssen, I., Gorber, S.C., 2010. Fitness of Canadian children and youth: results from the 2007–2009 Canadian health measures survey. Health Rep. 21 (1), 7–20. Trudeau, F., Shephard, R.J., 2008. Physical education, school physical activity, school sports and academic performance. Int. J. Behav. Nutr. Phys. Act. 5 (pp. 10-5868-5-10). Turagabeci, A.R., Nakamura, K., Takano, T., 2008. Healthy lifestyle behaviour decreasing risks of being bullied, violence and injury. PLoS One 3 (2), e1585. van Sluijs, E.M., McMinn, A.M., Griffin, S.J., 2007. Effectiveness of interventions to promote physical activity in children and adolescents: systematic review of controlled trials. BMJ 335 (7622), 703. Wierenga, D., Engbers, L.H., Van Empelen, P., Duijts, S., Hildebrandt, V.H., Van Mechelen, W., 2013. What is actually measured in process evaluations for worksite health promotion programs: a systematic review. BMC Public Health 13 (pp. 1190-2458-13-1190).

N C O

R

R

E

C

T

E

D

P

R O

O

F

Siedentop, D.L., 2009. National plan for physical activity: education sector. J. Phys. Act. Health 6 (Suppl. 2), S168–S180 (2009. Date of Publication). Slootmaker, S.M., Chinapaw, M., Seidell, J.C., van Mechelen, W., Schuit, A.J., 2010. Accelerometers and Internet for physical activity promotion in youth? Feasibility and effectiveness of a minimal intervention [ISRCTN93896459]. Prev. Med. 51 (1), 31–36. Springer, A.E., Kelder, S.H., Ranjit, N., Hochberg-Garrett, H., Crow, S., Delk, J., 2012. Promoting physical activity and fruit and vegetable consumption through a community– school partnership: the effects of marathon kids on low-income elementary school children in Texas. J. Phys. Act. Health 9 (5), 739–753. Steckler, A., Ethelbah, B., Martin, C.J., et al., 2003. Pathways process evaluation results: a school-based prevention trial to promote healthful diet and physical activity in American Indian third, fourth, and fifth grade students. Prev. Med. 37 (6 Pt 2), S80–S90. Strong, W.B., Malina, R.M., Blimkie, C.J., et al., 2005. Evidence based physical activity for school-age youth.[see comment]. J. Pediatr. 146 (6), 732–737. Thomas, B.H., Ciliska, D., Dobbins, M., Micucci, S., 2004. A process for systematically reviewing the literature: providing the research evidence for public health nursing interventions. Worldviews Evid. Based Nurs. 1 (3), 176–184.

U

768 769 770 771 772 773 774 775 776 777 778 779 780 781 782 783 784 785

19

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