Process evaluation results from the HEALTHY physical education intervention

Issues and Challenges in the Primary Prevention of Type 2 Diabetes Mellitus: A Systematic Review

BACKGROUND

Primary prevention of type 2 diabetes mellitus (T2DM) is possible in at-risk populations, and prevention programmes have been shown to be effective in real-world scenarios. Despite this evidence, diabetes prevalence has tripled in recent decades and is expected to reach 700 million patients by 2045, making it one of the leading causes of death globally. This review is aimed at identifying the issues and challenges in the primary prevention of T2DM.

METHODS

Scopus, Web of Science, PubMed and Ovid MEDLINE were systematically searched for published articles. Articles were screened based of inclusion and exclusion criteria. The inclusion criteria were: (1) published in 2010-2020, (2) full original article, (3) written in English, (4) qualitative, mixed-methods article, observational or interventional study. The exclusion criteria were: (1) animal study, (2) in vivo/in vitro study, (3) type 1 diabetes or gestational DM and (4) conference abstract, book chapter, report, and systematic review. Eligible articles were assessed using Mixed Methods Appraisal Tool (MMAT) by three assessors.

RESULTS

A total of 11 articles were selected for qualitative synthesis from the initial 620 articles. The issues and challenges seen in T2DM primary prevention followed three themes: healthcare program (sub-themes: lack of resources, community partnership, participation, health literacy), health provider (sub-themes: lack of implementation, health care staff, collaboration, availability), individual (sub-themes: awareness, communication, misbehaviour, family conflict).

CONCLUSION

Factors relating to healthcare programmes, health providers, and individual issues are the main challenges in T2DM primary prevention. By establishing sustainable preventative initiatives that address these issues and challenges in the primary prevention of T2DM, a reduction in T2DM prevalence could be achievable.

Start small and let it build; a mixed-method evaluation of a school-based physical activity program, Kilometre Club

BACKGROUND

Despite the benefits of physical activity, there is minimal research focusing on factors that influence real-world school-based physical activity programs. Kilometre (KM) Club is an Australian grassroots program which aims to increase physical activity in students through the completion of an outside walk or run at school. This small-scale pilot evaluation aimed to examine families, teachers and principals' perceptions of the benefits, enablers and barriers of KM Club. It also aimed to examine the effects of KM Club on student's physical activity levels during the school day.

METHODS

Four regional New South Wales (NSW) primary schools participated in this study. 26 families, four teachers, and two principals from School A, C, B and D completed semi-structured interviews to understand their perceptions of KM Club. 21 students completed emotional state-scales to understand their emotions when participating in KM Club. 141 students from Schools B, C and D participated in step-count measures using accelerometers.

RESULTS

Families, teachers and principals reported a range of benefits such as improved social connectedness, wellbeing, home and classroom behaviours, participation in sport and fitness levels. Enablers consisted of champion engagement, incentives, versatile facilities and integration with other school activities. Identified barriers included the weather and environment, program timing and health issues. Most students reported that participating in KM Club made them feel proud, confident and fantastic. School B reported a significant increase in students' daily step counts on KM Club days compared to non-KM Club days (+ 15%; p = 0.001), while School C reported no significant changes (-5%; p = 0.26). School D reported a significant increase in the number of daily steps taken by KM Club participants compared with non-KM club participants (+ 10%; p = 0.024).

CONCLUSION

There is no one-size-fits-all approach to implementing school-based physical activity initiatives. However, it appears that flexible and adaptable factors are important to the successful implementation of school-based programs, such as KM Club. This study revealed a variety of self-reported health, wellbeing and educational benefits for students, as well as an increase in student's physical activity levels at 2 of the 3 schools participating in the quantitative data collection. This pilot evaluation may help to inform future design, implementation and scale-up of KM Club and school-based health promotion programs, potentially improving child health, wellbeing and educational outcomes.

TRIAL REGISTRATION

(LNR223 - LNR/19/NCC/45).

Process evaluation of a pre-adolescent transdisciplinary health intervention for inter-generational outcomes

Background

The CIrCLE of Life Initiative was implemented to 537 grade 6 learners and their parents, in five Government-run South African primary schools. The transdisciplinary intervention was intended to increase knowledge and skills on HIV and obesity. The study aim was to assess and report on the implementation process.

Methods

Data was collected on an adapted Proctor’s taxonomy of implementation outcomes, and to assess participants’ experiences. Qualitative and quantitative data were collected through educator logbooks, researcher observations, and learner-parent workbooks.

Results

Differentiations between the various school contexts were observed. The process evaluation revealed high learner penetration (97.2%), but lower learner and parent exposure (44.3% and 55.5%, respectively). All educators thought that the intervention was a fit for both rural and urban schools, different socio-economic groups, and people of different ethnic and cultural backgrounds. The intervention was perceived to be sustainable, and there were recommendations for adoption into the school curriculum and scale-up if found to be effective.

Conclusion

The process evaluation facilitated the assessment of the implementation outcomes, described its processes, and acknowledged fundamental characteristics that could justify variability in the intervention impact and outcomes. The value of process evaluations and their benefit to the science of implementation were demonstrated.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18

BACKGROUND

Physical activity among children and adolescents is associated with lower adiposity, improved cardio-metabolic health, and improved fitness. Worldwide, fewer than 30% of children and adolescents meet global physical activity recommendations of at least 60 minutes of moderate to vigorous physical activity per day. Schools may be ideal sites for interventions given that children and adolescents in most parts of the world spend a substantial amount of time in transit to and from school or attending school.

OBJECTIVES

The purpose of this review update is to summarise the evidence on effectiveness of school-based interventions in increasing moderate to vigorous physical activity and improving fitness among children and adolescents 6 to 18 years of age. Specific objectives are: • to evaluate the effects of school-based interventions on increasing physical activity and improving fitness among children and adolescents; • to evaluate the effects of school-based interventions on improving body composition; and • to determine whether certain combinations or components (or both) of school-based interventions are more effective than others in promoting physical activity and fitness in this target population.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, BIOSIS, SPORTDiscus, and Sociological Abstracts to 1 June 2020, without language restrictions. We screened reference lists of included articles and relevant systematic reviews. We contacted primary authors of studies to ask for additional information.

SELECTION CRITERIA

Eligible interventions were relevant to public health practice (i.e. were not delivered by a clinician), were implemented in the school setting, and aimed to increase physical activity among all school-attending children and adolescents (aged 6 to 18) for at least 12 weeks. The review was limited to randomised controlled trials. For this update, we have added two new criteria: the primary aim of the study was to increase physical activity or fitness, and the study used an objective measure of physical activity or fitness. Primary outcomes included proportion of participants meeting physical activity guidelines and duration of moderate to vigorous physical activity and sedentary time (new to this update). Secondary outcomes included measured body mass index (BMI), physical fitness, health-related quality of life (new to this update), and adverse events (new to this update). Television viewing time, blood cholesterol, and blood pressure have been removed from this update.  DATA COLLECTION AND ANALYSIS: Two independent review authors used standardised forms to assess each study for relevance, to extract data, and to assess risk of bias. When discrepancies existed, discussion occurred until consensus was reached. Certainty of evidence was assessed according to GRADE. A random-effects meta-analysis based on the inverse variance method was conducted with participants stratified by age (children versus adolescents) when sufficient data were reported. Subgroup analyses explored effects by intervention type.

MAIN RESULTS

Based on the three new inclusion criteria, we excluded 16 of the 44 studies included in the previous version of this review. We screened an additional 9968 titles (search October 2011 to June 2020), of which 978 unique studies were potentially relevant and 61 met all criteria for this update. We included a total of 89 studies representing complete data for 66,752 study participants. Most studies included children only (n = 56), followed by adolescents only (n = 22), and both (n = 10); one study did not report student age. Multi-component interventions were most common (n = 40), followed by schooltime physical activity (n = 19), enhanced physical education (n = 15), and before and after school programmes (n = 14); one study explored both enhanced physical education and an after school programme. Lack of blinding of participants, personnel, and outcome assessors and loss to follow-up were the most common sources of bias.  Results show that school-based physical activity interventions probably result in little to no increase in time engaged in moderate to vigorous physical activity (mean difference (MD) 0.73 minutes/d, 95% confidence interval (CI) 0.16 to 1.30; 33 studies; moderate-certainty evidence) and may lead to little to no decrease in sedentary time (MD -3.78 minutes/d, 95% CI -7.80 to 0.24; 16 studies; low-certainty evidence). School-based physical activity interventions may improve physical fitness reported as maximal oxygen uptake (VO₂max) (MD 1.19 mL/kg/min, 95% CI 0.57 to 1.82; 13 studies; low-certainty evidence). School-based physical activity interventions may result in a very small decrease in BMI z-scores (MD -0.06, 95% CI -0.09 to -0.02; 21 studies; low-certainty evidence) and may not impact BMI expressed as kg/m² (MD -0.07, 95% CI -0.15 to 0.01; 50 studies; low-certainty evidence). We are very uncertain whether school-based physical activity interventions impact health-related quality of life or adverse events.

AUTHORS' CONCLUSIONS

Given the variability of results and the overall small effects, school staff and public health professionals must give the matter considerable thought before implementing school-based physical activity interventions. Given the heterogeneity of effects, the risk of bias, and findings that the magnitude of effect is generally small, results should be interpreted cautiously.

Appropriate Instructional Practice in Physical Education: A Systematic Review of Literature From 2000 to 2020

Appropriate instruction is a key component of quality physical education, which aligns student learning activities with grade-level learning outcomes. Historically, in the 1980s and late 1990s, an abundance of research was conducted to empirically link teacher effectiveness to student learning outcomes. In recent years, however, limited research has been published. Purpose: The purpose of this study was to: (a) identify research studies examining appropriate instructional practice in K-12 physical education since 2000, (b) describe the study characteristics and summarize the findings, (c) compare research to the SHAPE America's guidelines for appropriate instruction, and (d) make recommendations for future research. Methods: This study was conducted using the Preferred Reporting Items for Systematic Reviews (PRISMA) standards of quality for reporting meta-analyses. A systematic search of five electronic databases was conducted. Two reviewers retrieved articles, assessed risk of bias, and performed data extraction. The findings were synthesized using a descriptive analysis. Results: A total of 37 articles met the inclusion criteria. A thematic analysis was conducted to reduce the included articles into four themes that influenced student outcomes: (1) student engagement and participation, (2) motivation, (3) student learning, and (4) physical activity and fitness. Conclusions: This review of the literature provides evidence of the benefits of effective teaching practices and suggests that future studies in instruction should focus on teacher effectiveness and its relation to student learning outcomes. Recommendations and future directions are discussed.

A school-based, peer-led programme to increase physical activity among 13- to 14-year-old adolescents: the GoActive cluster RCT

Background

Adolescent physical activity levels are low and are associated with rising disease risk and social disadvantage. The Get Others Active (GoActive) intervention was co-designed with adolescents and teachers to increase physical activity in adolescents.

Objective

To assess the effectiveness and cost-effectiveness of the school-based GoActive programme in increasing adolescents’ moderate-to-vigorous physical activity.

Design

A cluster randomised controlled trial with an embedded mixed-methods process evaluation.

Setting

Non-fee-paying schools in Cambridgeshire and Essex, UK (n = 16). Schools were computer randomised and stratified by socioeconomic position and county.

Participants

A total of 2862 Year 9 students (aged 13–14 years; 84% of eligible students).

Intervention

The iteratively developed feasibility-tested refined 12-week intervention trained older adolescents (mentors) and in-class peer leaders to encourage classes to undertake two new weekly activities. Mentors met with classes weekly. Students and classes gained points and rewards for activity in and out of school.

Main outcome measures

The primary outcome was average daily minutes of accelerometer-assessed moderate-to-vigorous physical activity at 10 months post intervention. Secondary outcomes included accelerometer-assessed activity during school, after school and at weekends; self-reported physical activity and psychosocial outcomes; cost-effectiveness; well-being and a mixed-methods process evaluation. Measurement staff were blinded to allocation.

Results

Of 2862 recruited participants, 2167 (76%) attended 10-month follow-up measurements and we analysed the primary outcome for 1874 (65.5%) participants. At 10 months, there was a mean decrease in moderate-to-vigorous physical activity of 8.3 (standard deviation 19.3) minutes in control participants and 10.4 (standard deviation 22.7) minutes in intervention participants (baseline-adjusted difference –1.91 minutes, 95% confidence interval –5.53 to 1.70 minutes; p = 0.316). The programme cost £13 per student compared with control. Therefore, it was not cost-effective. Non-significant indications of differential impacts suggested detrimental effects among boys (boys –3.44, 95% confidence interval –7.42 to 0.54; girls –0.20, 95% confidence interval –3.56 to 3.16), but favoured adolescents from lower socioeconomic backgrounds (medium/low 4.25, 95% confidence interval –0.66 to 9.16; high –2.72, 95% confidence interval –6.33 to 0.89). Mediation analysis did not support the use of any included intervention components to increase physical activity. Some may have potential for improving well-being. Students, teachers and mentors mostly reported enjoying the GoActive intervention (56%, 87% and 50%, respectively), but struggled to conceptualise their roles. Facilitators of implementation included school support, embedding a routine, and mentor and tutor support. Challenges to implementation included having limited school space for activities, time, and uncertainty of teacher and mentor roles.

Limitations

Retention on the primary outcome at 10-month follow-up was low (65.5%), but we achieved our intended sample size, with retention comparable to similar trials.

Conclusions

A rigorously developed school-based intervention (i.e. GoActive) was not effective in countering the age-related decline in adolescent physical activity. Overall, this mixed-methods evaluation provides transferable insights for future intervention development, implementation and evaluation.

Future work

Interdisciplinary research is required to understand educational setting-specific implementation challenges. School leaders and authorities should be realistic about expectations of the effect of school-based physical activity promotion strategies implemented at scale.

Trial registration

Current Controlled Trials ISRCTN31583496.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 6. See the NIHR Journals Library website for further project information. This work was additionally supported by the Medical Research Council (London, UK) (Unit Programme number MC_UU_12015/7) and undertaken under the auspices of the Centre for Diet and Activity Research (Cambridge, UK), a UK Clinical Research Collaboration Public Health Research Centre of Excellence. Funding from the British Heart Foundation (London, UK), Cancer Research UK (London, UK), Economic and Social Research Council (Swindon, UK), Medical Research Council, the National Institute for Health Research (Southampton, UK) and the Wellcome Trust (London, UK), under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged (087636/Z/08/Z; ES/G007462/1; MR/K023187/1). GoActive facilitator costs were borne by Essex and Cambridgeshire County Councils.

Health Literacy in Schools? A Systematic Review of Health-Related Interventions Aimed at Disadvantaged Adolescents

Socioeconomically disadvantaged populations are at greater risk of adopting unhealthy behaviours and developing chronic diseases. Adolescence has been identified as a crucial life stage to develop lifelong healthy behaviours, with schools often suggested as the ideal environment to foster healthy habits. Health literacy (HL) provides a possible solution to promote such healthy behaviours. The aim of this study was to review school-based HL-related interventions targeting socioeconomically disadvantaged adolescents and to identify effective intervention strategies for this population. Searches were performed in six databases. Inclusion criteria included age: 12–16; the implementation of a school-based intervention related to HL aimed at socioeconomically disadvantaged populations; an intervention focused on: physical activity (PA), diet, mental health, substance abuse or sleep. Forty-one articles were included, with the majority focusing on PA and diet (n = 13), PA (n = 9) or mental health (n = 7). Few interventions focused solely on substance abuse (n = 2) or sleep (n = 1), and none targeted or assessed HL as an outcome measure. There was huge heterogeneity in study design, outcomes measures and effectiveness reported. Effective intervention strategies were identified that can be used to guide future interventions, including practical learning activities, peer support and approaches targeting the school environment, the parents or that link the intervention to the community.

Reach, Recruitment, Dose, and Intervention Fidelity of the GoActive School-Based Physical Activity Intervention in the UK: A Mixed-Methods Process Evaluation

School-based multi-component physical activity (PA) promotion is advocated; however, research has indicated that a multi-component approach may not always be effective at increasing adolescent PA. Evaluation of the GoActive 12-week multi-component school-based intervention showed no effect on adolescent PA. A mixed-methods process evaluation was embedded to facilitate greater understanding of the results, to elicit subgroup perceptions, and to provide insight into contextual factors influencing intervention implementation. This paper presents the reach, recruitment, dose, and fidelity of GoActive, and identifies challenges to implementation. The process evaluation employed questionnaires (1543 Year 9s), individual interviews (16 Year 9s; 7 facilitators; 9 contact teachers), focus groups (48 Year 9s; 58 mentors), alongside GoActive website analytics and researcher observations. GoActive sessions reached 39.4% of Year 9s. Intervention satisfaction was relatively high for mentors (87.3%) and facilitators (85.7%), but lower for Year 9s (59.5%) and teachers (50%). Intervention fidelity was mixed within and between schools. Mentorship was the most implemented component. Factors potentially contributing to low implementation included ambiguity of the roles subgroups played within intervention delivery, Year 9 engagement, institutional support, and further school-level constraints. Multiple challenges and varying contextual considerations hindered the implementation of GoActive in multiple school sites. Methods to overcome contextual challenges to implementation warrant in-depth consideration and innovative approaches.

Implementation evaluation of a professional development program for comprehensive school physical activity leaders

The purpose of this study was to conduct an implementation monitoring evaluation of a yearlong comprehensive school physical activity program (CSPAP) professional development program across eight multi-state physical education (PE) teacher cohorts. Mixed-method data were collected during a three-year implementation period via workshop attendance sheets and evaluations, post-workshop implementation plans and artifacts, and follow-up phone interviews to enumerate and evaluate the program's process of recruitment, reach, dose delivered, dose received, fidelity, and context. Recruitment strategies reached a total of 234 PE teacher attendees across eight workshops, with 77 PE teachers (primarily female, elementary, public school teachers) completing all program requirements. Facilitators among full program completers were participation incentives and network opportunities, while common inhibitors were difficulty with online technology and perceptions of added workload. Completers submitted implementation plans with at least three action steps, ranging from 4 to 7 months to accomplish, that predominately commenced with securing administration approval as the first step (81%), focused on implementing student physical activity initiatives beyond PE (76%), and evidenced with mostly picture artifacts (78%). Implementation was facilitated by the presence of multilevel support at school and an elevated image of PE and PE teachers at school, and was inhibited by scheduling constraints, unrealistic planning, and conflicting perceptions of physical activity and PE. Overall, this evaluation reveals unique perspectives of PE teachers regarding schoolwide PA promotion and informs future efforts to target and effectively support CSPAP leaders.

The impact of the World Health Organization Health Promoting Schools framework approach on diet and physical activity behaviours of adolescents in secondary schools: a systematic review

OBJECTIVE

To examine the effectiveness of interventions using the World Health Organization Health Promoting Schools (HPSs) framework approach in increasing physical activity (PA) and improving the diet of 11-18-year-olds.

STUDY DESIGN

A systematic review guided by the National Health Services Centre for Reviews and Dissemination framework and reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses.

METHODS

Nine databases and trial registries were searched from 2013 to 2018 for cluster randomised controlled trials involving adolescents' aged 11-18 years. We also included relevant studies from a 2014 Cochrane Review of HPS approach on health behaviours. Data were extracted from included studies and assessed for quality.

RESULTS

Twelve eligible studies were identified from seven countries. The studies varied in outcome measures, sample size, quality and duration of intervention and follow-up. Only four of the included studies were of high to moderate quality. We found some evidence of effectiveness for physical activity only interventions and limited evidence of effectiveness for nutrition only and combined PA and nutrition interventions.

CONCLUSIONS

There were no discernible patterns across the studies to suggest effective mechanisms for the HPS approach. The family/community component was poorly developed and superficially reported in all studies. Future research should seek to understand how best to work in partnership with secondary schools, to foster and sustain a healthy eating and physical activity culture, which aligns with their core aims. More attention should be paid to the restriction of unhealthy foods in the school environment.

Impact on Physical Fitness of the Chinese CHAMPS: A Clustered Randomized Controlled Trial

BACKGROUND

School physical activity (PA) policy, physical education curriculum, teacher training, knowledge of physical fitness, and parental support are among the key issues underlying the declining trend of physical fitness in children and adolescents. The Chinese CHAMPS was a multi-faceted intervention program to maximize the opportunities for moderate and vigorous physical activity (MVPA), and increase physical fitness in middle school students. The purpose of the study was to test whether the levels of modification in school physical education policy and curriculum incrementally influenced the changes in cardiorespiratory fitness and other physical fitness outcomes.

METHODS

This 8-month study was a clustered randomized controlled trial using a 2 × 2 factorial design. The participants were 680 7th grade students (mean age = 12.66 years) enrolled in 12 middle schools that were randomly assigned to one of four treatment conditions: school physical education intervention (SPE), afterschool program intervention (ASP), SPE+ASP, and control. Targeted behaviors of the Chinese CHAMPS were the student's sedentary behavior and MVPA. The study outcomes were assessed by a test battery of physical fitness at the baseline and posttest. Sedentary behavior and MVPA were measured in randomly selected students using observations and accelerometry.

RESULTS

The terms contrasting the pooled effect of SPE, ASP, and SPE+ASP vs. Control, the pooled effect of SPE and SPE+ASP vs. ASP only, and the effect of SPE+ASP vs. ASP on CRF and other physical fitness outcomes were all significant after adjusting for covariates, supporting the study hypothesis. Process evaluation demonstrated high fidelity of the intervention in the targeted students' behaviors.

CONCLUSIONS

Chinese CHAMPS demonstrated the impact of varying the amount of MVPA and vigorous physical activity (VPA) on the physical fitness in middle school students in support of the need to increase the opportunity for PA in schools and to introduce high-intensity exercises in school-based PA programs. Modification of school policy, quality of physical education curriculum, and teacher training were important moderators of the improvement in physical fitness. (Trial registration: ChiCTR-IOR-14005388, the Childhood Health; Activity and Motor Performance Study.).

Protocol: Improving Access to Specialist Nephrology Care Among Rural/Remote Dwellers of Alberta: The Role of Electronic Consultation in Improving Care for Patients With Chronic Kidney Disease

Background:

As the burden of chronic kidney disease (CKD) continues to increase, many geographically dispersed Canadians have limited access to specialist nephrology care, which tends to be centralized in major urban areas. As a result, many rural/remote-dwellers in Canada experience poor quality of care and related adverse outcomes. It is imperative to develop alternative care delivery mechanisms to ensure optimal health outcomes for all Canadians.

Objective:

To investigate the feasibility and effectiveness of electronic consultation (eConsult) as a new model for interactions between specialists and primary care providers (PCPs) to improve access to care for patients with CKD.

Design:

This is a sequential, mixed methods study that will be conducted in 3 phases.

Setting:

The study will be conducted across the entire province of Alberta, supported by Alberta Kidney Care (formerly, Northern and Southern Alberta Renal Programs [NARP/SARP]).

Patients:

Patients suffering from CKD will be included in the study.

Measurements:

We will assess the barriers and enablers of implementation and adoption of an e-consultation protocol to facilitate access to care for patients with CKD in Alberta with a focus on rural/remote-dwellers with CKD. We will also evaluate the impact of the eConsult system (eg, improved access to specialist care, reduction in care gaps), assess the feasibility of province-wide implementation, and compare eConsult with practice facilitation versus eConsult alone in terms of access to specialist care, quality of care, and related outcomes.

Methods:

The study will be conducted in 3 phases. In phase 1, we will assess the perceptions of stakeholders (ie, PCPs, nephrologists, patients, policymakers, and other care providers) to improve CKD care delivery, quality, and outcomes in Alberta with focus groups and semistructured interviews. Phase 2 will engage specific family physicians for their input on key factors and logistical issues affecting the feasibility of implementing eConsult for the care of patients with CKD. Phase 3 will provide academic detailing including practice facilitation to clinics in Alberta to assess how eConsult with practice facilitation compares with eConsult alone in terms of access to specialist care, quality of care, and related outcomes.

Results:

We will assess stakeholder perceptions about potential barriers to and enablers of a new eConsult and decision support system strategy, focusing on elements that are most important for the design of a feasible and implementable intervention. We will develop, pilot test, and assess the impact of the eConsult model in improving access to specialist nephrology care and the feasibility of province-wide implementation. The final phase of the project will address key challenges for optimal care for patients with CKD living in rural, remote, and underserved areas of Alberta, particularly timely referral and disease management as well as the cost-effective benefits of eConsult.

Limitations:

Lack of high-speed Internet in many rural and remote areas of Alberta may lead to more time spent in completing the eConsult request online versus faxing a referral the traditional way. Allied health care staff (referral coordinators, administrative staff) require training to the eConsult system, and physicians at many remote sites do not have adequate staff to handle eConsult as an added task.

Conclusions:

Implementation of eConsult can favorably influence referral patterns, access to care, care quality, patient outcomes, and health care costs for people with CKD. Results of this study will inform the optimization of care for rural/remote-dwellers with CKD and will facilitate future partnerships with policymakers and provincial renal programs in Alberta to ensure optimal kidney health for all residents.

Trial registration:

Not required.

Variation in the operationalisation of dose in implementation of health promotion interventions: insights and recommendations from a scoping review

BACKGROUND

While 'dose' is broadly understood as the 'amount' of an intervention, there is considerable variation in how this concept is defined. How we conceptualise, and subsequently measure, the dose of interventions has important implications for understanding how interventions produce their effects and are subsequently resourced and scaled up. This paper aims to explore the degree to which dose is currently understood as a distinct and well-defined implementation concept outside of clinical settings.

METHODS

We searched four databases (MEDLINE, PsycINFO, EBM Reviews and Global Health) to identify original research articles published between 2000 and 2015 on health promotion interventions that contained the word 'dose' or 'dosage' in the title, abstract or keywords. We identified 130 articles meeting inclusion criteria and extracted data on how dose/dosage was defined and operationalised, which we then synthesised to reveal key themes in the use of this concept across health promotion interventions.

RESULTS

Dose was defined in a variety of ways, including in relation to the amount of intervention delivered and/or received, the level of participation in the intervention and, in some instances, the quality of intervention delivery. We also observed some conflation of concepts that are traditionally kept separate (such as fidelity) either as slippage or as part of composite measures (such as 'intervention dose').

DISCUSSION

Dose is not a well-defined or consistently applied concept in evaluations of health promotion interventions. While current approaches to conceptualisation and measurement of dose are suitable for interventions in organisational settings, they are less well suited to policies delivered at a population level. Dose often accompanies a traditional monotonic linear view of causality (e.g. dose response) which may or may not fully represent the intervention's theory of how change is brought about. Finally, we found dose and dosage to be used interchangeably. We recommend a distinction between these terms, with 'dosage' having the advantage of capturing change to amount 'dispensed' over time (in response to effects achieved). Dosage therefore acknowledges the inevitable dynamic and complexity of implementation.

Lessons learned: Evaluating the program fidelity of UNWomen Partnership for Peace domestic violence diversion program in the Eastern Caribbean

To date, there have been a plethora of punitive and diversion programs to address domestic violence around the world. However, the evaluative scholarship of such programs overwhelmingly reflects studies in developed countries while barely showcasing the realities of addressing domestic violence in developing countries. This paper features a multi-year (2008-2011) evaluation study that measured the fidelity of the United Nations Partnership for Peace (PfP) domestic violence diversion program in the Eastern Caribbean country of Grenada. Our findings illuminate organic engagement strategies that were built within existing multi-sectoral partnerships that included magistrate court judges, law enforcement officials, and social service agencies. Furthermore, we documented how the locally-devised implementation strategies ensured the program's fidelity within a resource-limited context. This paper contributes to the global evaluative scholarship, highlighting the lessons learned about implementing culturally-adapted and theoretically-driven domestic violence diversion within a developing country.

Process Evaluation of FoodMASTER Middle Grades: An Integrative Approach to Nutrition Education in the Science Classroom

OBJECTIVE

Considering current adolescent obesity rates and the lack of previous intervention effects, our purpose was to utilize process evaluation techniques to help researchers identify intervention limitations for targeted programming.

METHODS

During the 2013-2014 academic year, 9 8th grade science teachers implemented the FoodMASTER Middle Grades (FMM) science curriculum. Researchers used classroom observations, formative and summative written feedback, and structured interviews to inform the fidelity, dose received, dose delivered, and context of curricular implementation.

RESULTS

Teachers reported that class size and time restraints were primary barriers to implementation. Primary facilitators included student enjoyment, standard alignment, ease of instructions, and professional development training experience.

CONCLUSIONS

Overall, FMM was feasible for implementation in middle school science classrooms as an integrated science curriculum.

Bristol Girls Dance Project: a cluster randomised controlled trial of an after-school dance programme to increase physical activity among 11- to 12-year-old girls

Background

Many children do not meet UK physical activity (PA) guidelines. Girls are less active than boys, and the age-related decline in activity is steeper for girls. Dance is the favourite form of PA among adolescent girls in the UK. Participation in after-school dance classes could significantly contribute to girls’ PA. Therefore, after-school dance may be effective for increasing PA levels.

Objectives

To determine the effectiveness and cost-effectiveness of a dance-based intervention to increase the objectively assessed mean weekday minutes of moderate- to vigorous-intensity physical activity (MVPA) of Year 7 girls (11- and 12-year olds) 1 year after baseline measurement.

Design

Two-arm cluster randomised controlled trial and economic evaluation. Year 7 girls in participant schools received a ‘taster’ session and were invited to participate. Up to 33 girls per school were able to participate. Schools were randomly assigned (equal numbers) to intervention or control arms.

Setting

A total of 18 mainstream secondary schools across greater Bristol.

Participants

Year 7 girls in participating schools who could participate in physical education.

Intervention

Nine intervention schools received an after-school dance intervention (40 × 75-minute sessions) underpinned by self-determination theory, which attempts to improve intrinsic motivation for being active, and delivered by external dance instructors. Control schools continued as normal.

Main outcome measures

The main outcome was accelerometer-assessed mean minutes of MVPA at T2. Measures were assessed at baseline (T0), the end of the intervention (T1) and at T0 + 52 weeks (T2).

Results

Baseline MVPA levels were high. A total of 508 girls were included in the primary analysis, which found no difference in weekday MVPA between trial arms. There was no effect on secondary accelerometer outcomes. Data were subjected to a per-protocol analysis and no effect was found. However, at T1, girls who attended dance classes had 4.61 minutes more of MVPA and 14.27 minutes more of light-intensity activity between 15.00 and 17.00 on the days on which they attended intervention sessions. The intervention was inexpensive at £73 per participant (£63 when excluding dance instructor travel) but was not cost-effective owing to the ineffectiveness of the intervention. The European Quality of Life-5 Dimensions Youth survey data were unresponsive to changes in the sample. The process evaluation reported that girls in attendance enjoyed the sessions, that exertion levels were low during sessions and that attendance was low and declined. Fidelity to the session-plan manual was low but theoretical fidelity (to self-determination theory) was good. Qualitative information provides information for improving future interventions.

Conclusions

The intervention was enjoyed by participants. However, there was no difference in the MVPA levels (which were high at baseline) of girls allocated to receive dance compared with girls receiving the control. High baseline MVPA levels indicate that the study appealed to an already active cohort and, therefore, may not have targeted those most in need of an intervention. Dance is an enjoyable activity for adolescent girls and could be further trialled as a means by which to increase PA. Research might consider the impact of dividing the intervention period into smaller blocks.

Trial Registration

Current Controlled Trials ISRCTN52882523.

Funding

The National Institute for Health Research Public Health Research programme. The work was also undertaken with the support of the Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), a UK Clinical Research Collaboration (UKCRC) PHR Centre of Excellence. Joint funding (MR/KO232331/1) from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the Welsh Government and the Wellcome Trust, under the auspices of the UKCRC, is gratefully acknowledged. This study was designed and delivered in collaboration with the Bristol Randomised Trials Collaboration, a UKCRC Registered Clinical Trials Unit in receipt of NIHR Clinical Trials Unit support funding. All intervention costs were funded by the respective councils to which the participant schools were affiliated, namely North Somerset Council, Bristol City Council, and Bath and North East Somerset Council.

Process evaluation of the Bristol girls dance project

Background

The Bristol Girls Dance Project was a cluster randomised controlled trial that aimed to increase objectively measured moderate-to-vigorous physical activity (MVPA) levels of Year 7 (age 11–12) girls through a dance-based after-school intervention. The intervention was delivered in nine schools and consisted of up to forty after-school dance sessions. This paper reports on the main findings from the detailed process evaluation that was conducted.

Methods

Quantitative and qualitative data were collected from intervention schools. Dose and fidelity were reported by dance instructors at every session. Intervention dose was defined as attending two thirds of sessions and was measured by attendance registers. Fidelity to the intervention manual was reported by dance instructors. On four randomly-selected occasions, participants reported their perceived level of exertion and enjoyment. Reasons for non-attendance were self-reported at the end of the intervention. Semi-structured interviews were conducted with all dance instructors who delivered the intervention (n = 10) and school contacts (n = 9) in intervention schools. A focus group was conducted with girls who participated in each intervention school (n = 9).

Results

The study did not affect girls’ MVPA. An average of 31.7 girls participated in each school, with 9.1 per school receiving the intervention dose. Mean attendance and instructors’ fidelity to the intervention manual decreased over time. The decline in attendance was largely attributed to extraneous factors common to after-school activities. Qualitative data suggest that the training and intervention manual were helpful to most instructors. Participant ratings of session enjoyment were high but perceived exertion was low, however, girls found parts of the intervention challenging.

Conclusions

The intervention was enjoyed by participants. Attendance at the intervention sessions was low but typical of after-school activities. Participants reported that the intervention brought about numerous health and social benefits and improved their dance-based knowledge and skills. The intervention could be improved by reducing the number of girls allowed to participate in each school and providing longer and more in-depth training to those delivering the intervention.

Trial registration

ISRCTN52882523 Registered 25th April 2013.

Intervention fidelity in a school-based diet and physical activity intervention in the UK: Active for Life Year 5

BACKGROUND

Active for Life Year 5 (AFLY5) is an educational programme for Year 5 children (aged 9-10) designed to increase children's physical activity, decrease sedentary behaviour and increase fruit and vegetable intake. This paper reports findings from a process evaluation embedded within a randomised controlled trial evaluating the programme's effectiveness. It considers the fidelity of implementation of AFLY5 with a focus on three research questions: 1. To what extent was the intervention delivered as planned? 2. In what ways, if any, did the teachers amend the programme? and 3. What were the reasons for any amendments?

METHODS

Mixed methods were used including data collection via observation of the intervention delivery, questionnaire, teacher's intervention delivery log and semi-structured interviews with teachers and parents. Qualitative data were analysed thematically and quantitative data were summarised using descriptive statistics.

RESULTS

Following training, 42 of the 43 intervention school teachers/teaching staff (98%) were confident they could deliver the nutrition and physical activity lessons according to plan. The mean number of lessons taught was 12.3 (s.d. 3.7), equating to 77% of the intervention. Reach was high with 95% of children in intervention schools receiving lessons. A mean of 6.2 (s.d. 2.6) out of 10 homeworks were delivered. Median lesson preparation time was 10 min (IQR 10-20) and 28% of lessons were reported as having been amended. Qualitative findings revealed that those who amended the lessons did so to differentiate for student ability, update them for use with new technologies and to enhance teacher and student engagement. Teachers endorsed the aims of the intervention, but some were frustrated with having to adapt the lesson materials. Teachers also a reported tendency to delegate the physical activity lessons to other staff not trained in the intervention.

CONCLUSIONS

Fidelity of intervention implementation was good but teachers' enthusiasm for the AFLY5 programme was mixed despite them believing that the messages behind the lessons were important. This may have meant that the intervention messages were not delivered as anticipated and explain why the intervention was found not to be effective.

TRIAL REGISTRATION

ISRCTN50133740.

Implementing health promotion programmes in schools: a realist systematic review of research and experience in the United Kingdom

Background

Schools have long been viewed as a good setting in which to encourage healthy lifestyles amongst children, and schools in many countries aspire to more comprehensive, integrated approaches to health promotion. Recent reviews have identified evidence of the effects of school health promotion on children’s and young people’s health. However, understanding of how such programmes can be implemented in schools is more limited.

Methods

We conducted a realist review to identify the conditions and actions which lead to the successful implementation of health promotion programmes in schools. We used the international literature to develop programme theories which were then tested using evaluations of school health promotion programmes conducted in the United Kingdom (UK). Iterative searching and screening was conducted to identify sources and clear criteria applied for appraisal of included sources. A review advisory group comprising educational and public health practitioners, commissioners, and academics was established at the outset.

Results

In consultation with the review advisory group, we developed four programme theories (preparing for implementation, initial implementation, embedding into routine practice, adaptation and evolution); these were then refined using the UK evaluations in the review. This enabled us to identify transferable mechanisms and enabling and constraining contexts and investigate how the operation of mechanisms differed in different contexts. We also identified steps that should be taken at a senior level in relation to preparing for implementation (which revolved around negotiation about programme delivery) and initial implementation (which centred on facilitation, support, and reciprocity—the latter for both programme deliverers and pupils). However, the depth and rigour of evidence concerning embedding into routine practice and adaptation and evolution was limited.

Conclusions

Our findings provide guidance for the design, implementation, and evaluation of health promotion in schools and identify the areas where further research is needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0338-6) contains supplementary material, which is available to authorized users.

Implementing health promotion programmes in schools: a realist systematic review of research and experience in the United Kingdom

BACKGROUND

Schools have long been viewed as a good setting in which to encourage healthy lifestyles amongst children, and schools in many countries aspire to more comprehensive, integrated approaches to health promotion. Recent reviews have identified evidence of the effects of school health promotion on children's and young people's health. However, understanding of how such programmes can be implemented in schools is more limited.

METHODS

We conducted a realist review to identify the conditions and actions which lead to the successful implementation of health promotion programmes in schools. We used the international literature to develop programme theories which were then tested using evaluations of school health promotion programmes conducted in the United Kingdom (UK). Iterative searching and screening was conducted to identify sources and clear criteria applied for appraisal of included sources. A review advisory group comprising educational and public health practitioners, commissioners, and academics was established at the outset.

RESULTS

In consultation with the review advisory group, we developed four programme theories (preparing for implementation, initial implementation, embedding into routine practice, adaptation and evolution); these were then refined using the UK evaluations in the review. This enabled us to identify transferable mechanisms and enabling and constraining contexts and investigate how the operation of mechanisms differed in different contexts. We also identified steps that should be taken at a senior level in relation to preparing for implementation (which revolved around negotiation about programme delivery) and initial implementation (which centred on facilitation, support, and reciprocity-the latter for both programme deliverers and pupils). However, the depth and rigour of evidence concerning embedding into routine practice and adaptation and evolution was limited.

CONCLUSIONS

Our findings provide guidance for the design, implementation, and evaluation of health promotion in schools and identify the areas where further research is needed.

Implementation of school based physical activity interventions: a systematic review

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.

Increasing children's physical activity through a teaching-assistant led extracurricular intervention: process evaluation of the action 3:30 randomised feasibility trial

BACKGROUND

Many children do not engage in recommended levels of physical activity (PA), highlighting the need to find ways to increase children's PA. Process evaluations play an important role in improving the science of randomised controlled trials. We recently reported the results of the Action 3:30 cluster randomised feasibility trial illustrating higher levels of moderate to vigorous intensity PA among boys but not girls. The aim of this paper is to report the process evaluation results including intervention fidelity, implementation, context and how intervention components and trial design could be improved before proceeding to a definitive RCT.

METHODS

Children's session enjoyment was assessed every two weeks. Reasons for non-attendance were provided by questionnaire at the end of the intervention. Post intervention interviews were held with participating teaching assistants (TAs) and school key contacts (KCs), and focus groups were conducted with children in all 10 intervention schools. Interviews and focus groups examined how recruitment and session attendance might be improved and established which elements of the programme that were and were not well received.

RESULTS

Data indicated good intervention fidelity with TA's adopting enjoyment-focussed teaching styles and the sessions improving children's skills and self-esteem. Several positive aspects of implementation were identified, including high session variety, the opportunity to work in teams, the child-led sessions and the engaging leader style. In terms of context there was evidence that TA's faced difficulties managing challenging behaviour and that further training in this area was needed. TAs and KCs felt that recruitment could be improved by providing taster sessions during PE lessons and clarifying the days that the clubs would run at the point of recruitment. The programme could be improved to enhance interest for girls, by including training for managing disruptive behaviour and making some activities more age-group appropriate.

CONCLUSIONS

Action 3.30 showed promise but could be improved by ensuring age appropriate activities, providing more appeal to girls and improving recruitment through taster sessions and early establishment of days of the week it is to be offered on.

TRIAL REGISTRATION

ISRCTN58502739.

Obesity prevention and the Health promoting Schools framework: essential components and barriers to success

Background

Obesity is an important public health issue. Finding ways to increase physical activity and improve nutrition, particularly in children, is a clear priority. Our Cochrane review of the World Health Organization’s Health Promoting Schools (HPS) framework found this approach improved students’ physical activity and fitness, and increased fruit and vegetable intake. However, there was considerable heterogeneity in reported impacts. This paper synthesises process evaluation data from these studies to identify factors that might explain this variability.

Methods

We searched 20 health, education and social-science databases, and trials registries and relevant websites in 2011 and 2013. No language or date restrictions were applied. We included cluster randomised controlled trials. Participants were school students aged 4-18 years. Studies were included if they: took an HPS approach (targeting curriculum, environment and family/community); focused on physical activity and/or nutrition; and presented process evaluation data. A framework approach was used to facilitate thematic analysis and synthesis of process data.

Results

Twenty-six studies met the inclusion criteria. Most were conducted in America or Europe, with children aged 12 years or younger.

Although interventions were acceptable to students and teachers, fidelity varied considerably across trials. Involving families, while an intrinsic element of the HPS approach, was viewed as highly challenging. Several themes emerged regarding which elements of interventions were critical for success: tailoring programmes to individual schools’ needs; aligning interventions with schools’ core aims; working with teachers to develop programmes; and providing on-going training and support. An emphasis on academic subjects and lack of institutional support were barriers to implementation.

Conclusions

Stronger alliances between health and education appear essential to intervention success. Researchers must work with schools to develop and implement interventions, and to evaluate their impact on both health and educational outcomes as this may be a key determinant of scalability. If family engagement is attempted, better ways to achieve this must be developed and evaluated. Further evaluations of interventions to promote physical activity and nutrition during adolescence are needed. Finally, process evaluations must move beyond simple measures of acceptability/fidelity to include detailed contextual information to illuminate exactly what works, for whom, in what contexts and why.

Childhood Obesity Research Demonstration project: cross-site evaluation methods

INTRODUCTION

The Childhood Obesity Research Demonstration (CORD) project links public health and primary care interventions in three projects described in detail in accompanying articles in this issue of Childhood Obesity. This article describes a comprehensive evaluation plan to determine the extent to which the CORD model is associated with changes in behavior, body weight, BMI, quality of life, and healthcare satisfaction in children 2-12 years of age.

DESIGN/METHODS

The CORD Evaluation Center (EC-CORD) will analyze the pooled data from three independent demonstration projects that each integrate public health and primary care childhood obesity interventions. An extensive set of common measures at the family, facility, and community levels were defined by consensus among the CORD projects and EC-CORD. Process evaluation will assess reach, dose delivered, and fidelity of intervention components. Impact evaluation will use a mixed linear models approach to account for heterogeneity among project-site populations and interventions. Sustainability evaluation will assess the potential for replicability, continuation of benefits beyond the funding period, institutionalization of the intervention activities, and community capacity to support ongoing program delivery. Finally, cost analyses will assess how much benefit can potentially be gained per dollar invested in programs based on the CORD model.

CONCLUSIONS

The keys to combining and analyzing data across multiple projects include the CORD model framework and common measures for the behavioral and health outcomes along with important covariates at the individual, setting, and community levels. The overall objective of the comprehensive evaluation will develop evidence-based recommendations for replicating and disseminating community-wide, integrated public health and primary care programs based on the CORD model.

Intervention fidelity in a teacher-led program to promote physical activity in preschool-age children

OBJECTIVE

To examine protocol fidelity among teachers involved in a six-month cluster-randomized physical activity (PA) intervention.

METHODS

In 2011, preschools in Springfield, MA were randomized to short bouts of structured PA (SBS-PA, n=5) or unstructured playtime (UPA, n=5). SBS-PA provided structured PA in the classroom during the first 10 min of gross-motor playtime followed by 20 min of unstructured playtime. UPA consisted of 30 min of unstructured playtime. All teachers (SBS-PA and UPA) received a written study protocol and 1.5h of training. SBS-PA also received videos to use to lead structured PA and 1.5 additional hours of training. Study fidelity and process evaluation were assessed twice weekly via semi-structured questionnaire.

RESULTS

Only 56.6% of SBS-PA and 75.2% of UPA free playtimes lasted for 30 min; 86.3% of SBS-PA teachers implemented structured PA during the first 10 min of gross-motor playtime but only 67.2% delivered the intervention as instructed. Only 68.5% of SBS-PA teachers implemented the 20-minute unstructured playtime. SBS-PA teachers reported that time limitations was a major barrier in implementing the designed intervention. Pre-post changes in PA did not differ between groups.

CONCLUSION

Limited fidelity to intervention protocol likely impacted study findings. Future studies should focus on strategies to improve adherence among intervention leaders.

The impact of web-based HOT (Healthy Outcomes for Teens) Project on risk for type 2 diabetes: a randomized controlled trial

BACKGROUND

The HOT (Healthy Outcome for Teens) Project is an innovative online educational intervention for middle school children for prevention of diabetes and obesity by balancing food intake with physical activity. The objective was to improve knowledge, outcome expectations, self-efficacy, and self-reported food intake and skills and to compare a passive online learning (POL) control group with an active online learning (AOL) treatment group by implementing a social cognitive theory (SCT)-grounded online intervention.

SUBJECTS AND METHODS

In total, 214 participants were recruited from three middle schools. Full data were secured for 181 students. Six valid, reliable questionnaires were administered online, pre/post, to both the AOL and POL groups to assess knowledge gain, self-reported intake, and meal planning skills, as well as change in SCT constructs.

RESULTS

Subjects in the AOL group improved significantly for all five categories of planning a meal questionnaire (P=0.001) and also for outcome expectations for exercise (P=0.001). At postintervention, no significant differences were found for composite scores of exercise self-efficacy, weight efficacy lifestyle, and rapid eating assessment plan questionnaires between AOL versus POL (by Mann-Whitney test).

CONCLUSIONS

We conclude that teens participating in the AOL version of the HOT Project intervention acquired skills for planning a meal and improved outcome expectations for exercise.

Implementing a multicomponent school-based obesity prevention intervention: a qualitative study

OBJECTIVE

To explore barriers and facilitators to implementing and sustaining Healthy Choices, a 3-year multicomponent obesity prevention intervention implemented in middle schools in Massachusetts.

METHODS

Using purposive sampling, 56 in-depth interviews were conducted with middle school employees representing different positions (administrators, teachers, food service personnel, and employees serving as intervention coordinators). Interviews were recorded and transcribed. Emergent themes were identified using thematic analyses.

RESULTS

State-mandated testing, budget limitations, and time constraints were viewed as implementation barriers, whereas staff buy-in, external support, and technical assistance were seen as facilitating implementation. Respondents thought that intervention sustainability depended on external funding and expert assistance.

CONCLUSIONS AND IMPLICATIONS

Results confirm the importance of gaining faculty and staff support. Schools implementing large-scale interventions should consider developing sustainable partnerships with organizations that can provide resources and ongoing training. Sustainability of complex interventions may depend on state-level strategies that provide resources for implementation and technical assistance.

Linking secondary school physical education with community sport and recreation for girls: a process evaluation

BACKGROUND

The purpose of this study was to undertake a process evaluation to examine the reach, adoption and implementation of a school-community linked physical activity (PA) program for girls aged 12 - 15 years (School Years 7 - 9) using the RE-AIM framework.

METHODS

Various approaches were used to assess 'reach', 'adoption' and implementation: (a) a school environment survey of intervention schools (n = 6); (b) teacher feedback regarding the professional development component (91.1% response rate) and lesson implementation (60.8% response rate); and (c) post-intervention focus group interviews with physical education (PE) teachers (n = 29), students (n = 125), coaches (n = 13) and instructors (n = 8) regarding program experiences.

RESULTS

Reach and Adoption: Seven schools (n = 1491 Year 7-9 female student enrolment; 70% adoption rate), five tennis clubs, eight football clubs and five leisure centres participated in the program during 2011.

IMPLEMENTATION

Program design and professional development opportunities (training, resource manual and opportunities to work with coaches and instructors during PE classes) supported implementation and student engagement in PA. However, there was a lack of individual and organisational readiness to adopt program principles. For some deliverers there were deeply embedded ideologies that were not aligned with the Game Sense teaching approach upon which the program was based. Further, cognitive components of the program such as self-management were not widely adopted as other components of the program tended to be prioritised.

CONCLUSION

The program design and resources supported the success of the program, however, some aspects were not implemented as intended, which may have affected the likelihood of achieving further positive outcomes. Barriers to program implementation were identified and should be considered when designing school-community linked interventions. In particular, future programs should seek to assess and adjust for organizational readiness within the study design. For example, shared commitment and abilities of program deliverers to implement the program needs to be determined to support program implementation.

TRIAL REGISTRATION

ACTRN12614000446662. April 30th 2014.

School factors as barriers to and facilitators of a preventive intervention for pediatric type 2 diabetes

School-based interventions are essential to prevent pediatric obesity and type 2 diabetes. School environmental factors influence implementation of these interventions. This article examines how school factors acted as barriers to and facilitators of the HEALTHY intervention. The HEALTHY study was a cluster-randomized trial of a multicomponent intervention implemented in 21 schools. Interview data were analyzed to identify barriers and facilitators. Barriers included teacher frustration that intervention activities detracted from tested subjects, student resistance and misbehavior, classroom management problems, communication equipment problems, lack of teacher/staff engagement, high cost and limited availability of nutritious products, inadequate facility space, and large class sizes. Facilitators included teacher/staff engagement, effective classroom management, student engagement, schools with direct control over food service, support from school leaders, and adequate facilities and equipment. Contextual barriers and facilitators must be taken into account in the design and implementation of school-based health interventions.

Process evaluation and proximal impact of an affect-based exercise intervention among adolescents

The objective of this study was to evaluate the implementation and proximal impact of an intervention designed to enhance adolescents' affective experience during Physical Education (PE). Healthy adolescents (N = 74) were randomly assigned to an affect-based or a traditional exercise prescription. Intervention logs, observations and interviews documented the implementation of the intervention. Participants completed a 30-min exercise task at an intensity that felt "good" to them before and after the intervention. Study procedures were implemented successfully and students enjoyed study participation. The intervention had no impact on exercise intensity during PE or during the "feels-good" exercise task. Among adolescents who manifested a negative affective response to moderate-intensity exercise at baseline, the selected intensity during the "feels-good" task increased over time. The intervention may have been too weak to impact behavior over and above a high-quality PE program. The results do suggest, however, that reluctant exercisers may choose to exercise at a higher intensity after experiencing a high-quality PE program in combination with heart rate monitoring.

The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement

BACKGROUND

The World Health Organization's (WHO's) Health Promoting Schools (HPS) framework is an holistic, settings-based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed.

OBJECTIVES

To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well-being of students and their academic achievement.

SEARCH METHODS

We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland, ClinicalTrials.gov, Current controlled trials, and WHO International Clinical Trials Registry Platform. We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles.

SELECTION CRITERIA

We included cluster-randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school's ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements.

DATA COLLECTION AND ANALYSIS

At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random-effects meta-analyses to provide a summary of results across studies.

MAIN RESULTS

We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand-washing (2), multiple risk behaviours (7), cycle-helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self-reported data and high attrition rates for some studies. In addition, there was a lack of long-term follow-up data for most studies.We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta-analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school-related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement.

AUTHORS' CONCLUSIONS

The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well-designed research is required to establish the effectiveness of this approach for other health topics and academic achievement.

Implementation of The World Starts With Me, a comprehensive rights-based sex education programme in Uganda

This article presents a process evaluation of the implementation of the sex education programme the World Starts With Me (WSWM) for secondary school students in Uganda. The purpose of this mixed-methods study was to examine factors associated with dose delivered (number of lessons implemented) and fidelity of implementation (implementation according to the manual), as well as to identify the main barriers and facilitators of implementation. Teachers' confidence in teaching WSWM was negatively associated with dose delivered. Confidence in educating and discussing sexuality issues in class was positively associated with fidelity of implementation, whereas the importance teachers attached to open sex education showed a negative association with fidelity. Main barriers for implementing WSWM were lack of time, unavailability of computers, lack of student manuals and lack of financial support and rewards. Other barriers for successful implementation were related to high turnover of staff and insufficient training and guidance of teachers. Teachers' beliefs/attitudes towards sexuality of adolescents, condom use and sex education were found to be important socio-cognitive factors intervening with full fidelity of implementation. These findings can be used to improve the intervention implementation and to better plan for large-scale dissemination of school-based sex education programmes in sub-Saharan Africa.

Lessons learned from the HEALTHY primary prevention trial of risk factors for type 2 diabetes in middle school youth

The HEALTHY trial was designed to take a primary prevention approach to risk factors for type 2 diabetes in youth, primarily obesity. The study involved over 6,000 students at 42 middle schools across the U.S. Half received an integrated intervention program of components addressing the school food environment, physical education, lifestyle behaviors, and promotional messaging. The intervention was designed to be more comprehensive than previous efforts, and the research was amply funded. Although the primary objective of reducing the percentage of overweight and obesity in schools that received the intervention program, as compared with control schools, was not obtained, key secondary outcomes indicated an intervention effect. In retrospect, senior investigators involved in the study's design, conduct, and analysis discuss weaknesses and strengths and offer recommendations for future research efforts that address prevention of childhood obesity from a public health perspective.

Assessment of the knowledge of diabetes mellitus among school teachers within the scope of the managing diabetes at school program

OBJECTIVE

Training teachers and education professionals on diabetes is crucial for full-time monitoring of diabetic children in schools. The objective of this study was to assess the knowledge on diabetes in a group of school teachers in Turkey.

METHODS

Between November 2010 and November 2011, 1054 teachers from three regions of Ankara were given a questionnaire to assess their knowledge on diabetes. The mean age of the group (27% males, 73% females) was 38.8±8 years. 61.7% of the participants were class teachers, 23.3% were school counselors, and the rest were physical education teachers and administrators.

RESULTS

A fair percentage (47.6%) of the participants had a moderate knowledge level on diabetes and 32.4% expressed a lower level of knowledge. A large proportion (94%) gave an accurate definition of diabetes. Of the total group of 1054 teachers, 625 were aware that blood glucose level might decrease in diabetic children during follow-up. Also, 75% believed that diabetic children were eligible for physical education classes. 52.8% of these teachers had no diabetic child in their classes and teachers with a diabetic patient in their family had better knowledge of diabetes compared to their counterparts.

CONCLUSIONS

Our study results indicate that school teachers have limited knowledge on diabetes. We believe that their knowledge levels can be improved by widespread training programs.

Intervention dose estimation in health promotion programmes: a framework and a tool. Application to the diet and physical activity promotion PRALIMAP trial

Background

Although the outcomes of health promotion and prevention programmes may depend on the level of intervention, studies and trials often fail to take it into account. The objective of this work was to develop a framework within which to consider the implementation of interventions, and to propose a tool with which to measure the quantity and the quality of activities, whether planned or not, relevant to the intervention under investigation. The framework and the tool were applied to data from the diet and physical activity promotion PRALIMAP trial.

Methods

A framework allowing for calculation of an intervention dose in any health promotion programme was developed. A literature reviews revealed several relevant concepts that were considered in greater detail by a multidisciplinary working group. A method was devised with which to calculate the dose of intervention planned and that is actually received (programme-driven activities dose), as well as the amount of non-planned intervention (non-programme-driven activities dose).

Results

Indicators cover the roles of all those involved (supervisors, anchor personnel as receivers and providers, targets), in each intervention-related groups (IRG: basic setting in which a given intervention is planned by the programme and may differ in implementation level) and for every intervention period. All indicators are described according to two domains (delivery, participation) in two declensions (quantity and quality). Application to PRALIMAP data revealed important inter- and intra-IRG variability in intervention dose.

Conclusions

A literature analysis shows that the terminology in this area is not yet consolidated and that research is ongoing. The present work provides a methodological framework by specifying concepts, by defining new constructs and by developing multiple information synthesis methods which must be introduced from the programme's conception. Application to PRALIMAP underlined the feasibility of measuring the implementation level. The framework and the tool can be used in any complex programme evaluation. The intervention doses obtained could be particularly useful in comparative trials.

Trial registration

PRALIMAP is registered at ClinicalTrials.gov under NCT00814554

Feasibility Analysis of Standing Desks for Sixth Graders

Background. In this pilot study, the authors aimed to examine the implementation of standing desks on classroom performance and behavior. They also examined how the standing desks affected in-class physical activity and body mass index. Methods. Eight sixth graders from Hope Lutheran elementary school participated in the study (age 11.3 ± 0.5 years). Baseline and 8-month postintervention measures were step counts using (W4L Classic pedometers), height, weight, and behavioral markers. Results. Data showed that there were no statistically significant changes in the participants’ body mass index (19.4 kg/m2 vs 19.3 kg/m2), step counts (1886 steps vs 2248 steps), and behavioral markers including classroom management, concentration, and discomfort. Height and weight changes were significant and are attributed to the normal growth rate associated with the age of the participants (146.8 cm vs 151.8 cm, P < .0001; 41.4 kg vs 44.5 kg, P > .0007). Conclusions. It is feasible to integrate standing desks into a classroom without negative effects. Although the authors observed over a 19% increase in pedometer activity, it was not statistically significant. This highlights the importance for larger experimental groups and the use of more advanced physical activity tracking and body composition technologies.