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Published: 12 April 2022

Identifying essential implementation strategies: a mixed methods process evaluation of a multi-strategy policy implementation intervention for schools

Patti-Jean Naylor⁵,
Adam Shoesmith^i,2,3,4,
Luke Wolfenden^1,2,3,four,
Alix Hall^1,2,iii,4,
Rachel Sutherland^ane,two,3,iv &
Nicole Nathan^ane,2,3,four

International Journal of Behavioral Nutrition and Physical Activity volume 19, Commodity number:44 (2022) Cite this article

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Abstract

Background

Physically Active Children in Educational activity (PACE) is composed of eight implementation strategies that improves schools' implementation of a government concrete activity policy. A greater understanding of each discrete implementation strategy could inform improvements to Footstep for delivery at-calibration. This written report aimed to: (A) measure the dose delivered, fidelity, adoption and acceptability of each strategy using quantitative data; (B) identify implementation barriers and facilitators using qualitative data; and (C) explore the importance of each strategy by integrating both data sets (mixed methods).

Methods

This study used data from a cluster randomised noninferiority trial comparing Stride with an adjusted version (Adjusted Pace) that was delivered with reduced in-person external support to reduce costs and increment scalability. Data were collected from both trials arms for between-group comparison. Descriptive statistics were produced using surveys of principals, in-school champions and teachers; and project records maintained by PACE project officers (objective A). Thematic assay was performed using in-schoolhouse champion and project officer interviews (objective B). Both data sets were integrated via a triangulation protocol and findings synthesized in the form of meta-inferences (objective C).

Results

11 in-schoolhouse champions and six project officers completed interviews; 33 principals, 51 in-school champions and 260 teachers completed surveys. Regardless of group allotment, implementation indicators were loftier for at least one component of each strategy: dose delivered =100%, fidelity ≥95%, adoption ≥83%, acceptability ≥fifty%; and several implementation barriers and facilitators were identified within 3 broad categories: external policy landscape, inner organizational structure/context of schools, and intervention characteristics and processes. All strategies were considered of import as use varied by school, however support from a school executive and in-schoolhouse champions' interest were suggested as especially of import for optimal implementation.

Conclusion

This study highlights the importance of both executive back up and in-school champions for successful implementation of schoolhouse concrete activity policies. In item, identifying and supporting an in-school champion to have loftier power and loftier involvement is recommended for future implementation strategies. This may reduce the need for intensive external support, thus improving intervention scalability.

Background

Due to the complexity of many public health interventions, it is notoriously difficult to uncover underlying mechanisms surrounding an intervention's upshot or lack thereof. Process evaluations address this 'black box' of effectiveness [1] by providing important data to help explain how and why outcomes occurred [i,two,3]. Equally such, conducting process evaluations alongside intervention effectiveness trials is recommended [1, 3, 4]. The findings may reduce inquiry waste; save valuable time and resources of health service providers; and provide conclusion makers with direction, specially for intervention scale-up and dissemination in other contexts [3, 5].

Implementation interventions aiming to enhance the uptake of testify-based policies or practices are often quite complex [vi]. Although some interventions use only one or 2 strategies to assist implementation, many consist of multiple strategies that target numerous implementation determinants [seven]. To appointment, in that location are over seventy discrete implementation strategies documented [8], each of which is multifaceted in nature [6]. For example, the unmarried strategy 'conduct educational meetings' may involve more than than ane stakeholder group, mode of delivery, setting and/or occurrence. These complexities pose a challenge determining which strategy, or combination of strategies, about likely led to the outcomes of implementation intervention studies (and how). Given that implementation science is a relatively new area of scientific discipline, little is known well-nigh the well-nigh efficient and effective approaches to reach implementation of testify-based policies or practices in various contexts [7]. Robust procedure evaluations of packaged implementation strategies hold considerable potential to contribute to this scant evidence base.

This paper describes the mixed methods process evaluation undertaken as part of a research initiative optimising a package of implementation strategies to improve schools' implementation of a government physical activeness policy. In response to poor physical activeness policy implementation by schools worldwide [9,10,11,12,13,14,15,16,17,xviii,19], and limited research almost strategies to support schools to address this, Nathan et al. developed the 'Physically Active Children in Educational activity (PACE)' intervention [xx]. Footstep consisted of eight implementation strategies, each chosen using the Theoretical Domain Framework (TDF) and the Behaviour Modify Bike (BCW) to overcome identified barriers [21], to back up school'southward compliance with an Australian state-level concrete activity policy [22]. In a series of randomised and controlled trials (RCTs), PACE consistently improved policy implementation by schools [17, 23] aslope high reports of fidelity and perceived satisfaction past stakeholders [17]. Furthermore, its meaningful impact was maintained at a lower cost to the health service provider when several implementation strategies were adapted to reduce the in-person contact fourth dimension used to support schools (i.e., Adapted PACE) [24]. Although effective, petty was known well-nigh which Footstep implementation strategies, in either their original or adapted format, were "most commonly needed, viable to deploy, and effective across implementation efforts" [25]. A greater understanding of each implementation strategy could inform further optimisation processes [26, 27] to meliorate Pace for delivery to the remaining 400+ schools in the health service region [28] and for broader calibration-upward. Additionally, this information could contribute to a scant testify base regarding detached implementation strategies employed both in schools and other settings.

Nosotros conducted a mixed methods process evaluation aslope a cluster randomised implementation trial to explore the implementation of the eight discrete PACE implementation strategies from the perspective of school stakeholders and PACE commitment personnel. This included a comparing of Pace and Adjusted PACE, to highlight whatsoever qualitative differences when delivered with reduced in-person support. The specific objectives were:

A.
To quantitatively measure each strategy in regards to key implementation indicators including dose delivered, allegiance, adoption and acceptability (implementation outcomes [29]);
B.
To qualitatively explore factors that influenced plan implementation (barriers and facilitators); and
C.
To appraise the importance of each strategy using outcomes from both the quantitative and qualitative data sets.

Methods

Enquiry design

This procedure evaluation accompanies the Adapted Step cluster randomised noninferiority trial [24] undertaken from October 2022 – Dec 2022 (Australian New Zealand Clinical Trials Registry: ACTRN12619001229167). We used a convergent mixed methods triangulation research blueprint with quantitative and qualitative data from participants in both active trial arms collected simultaneously and weighted as (QUAN+QUAL) [30, 31]. The Medical Enquiry Council (MRC) guidance on the process evaluations of complex interventions [3], and the evaluation roadmap for physical action interventions developed past McKay et al. [29], informed study design, planning and execution.

The Adapted Footstep noninferiority trial

Total details of the Adjusted PACE cluster randomised noninferiority trial is published elsewhere [24]. Briefly, the trial was conducted in 48 main schools in NSW, Commonwealth of australia. Following consent and completion of baseline information drove, an independent statistician used a computerised random number function to cake randomise schools in a 1:i ratio to receive either Step or Adjusted PACE. Table 1 includes an overview of the eight implementation strategies (listed numerically) and their components (alphabetised), and adaptations fabricated for Adapted PACE. In short, strategy 1 (ongoing support for the in-school champion [ISC]) and 2a (principal meeting) were delivered via email/phone rather than in-person, and strategy 5 (educational outreach visit) was delivered by an ISC rather than an external project officeholder.

Table 1 Description of Stride implementation strategies and the joint display of quantitative implementation indicators (adoption and acceptability), usefulness and relevant qualitative themes for each

Full size table

Consistent with the previous PACE trials [17, 23], the primary outcome mensurate used to appraise program impact was teachers' hateful minutes of total physical activity (physical education [PE], sport, energisers or active lessons) implemented across the school week. Both groups saw improvements in the minutes of physical action teachers implemented per calendar week at follow-up, and there was a high probability of no meaningful difference between the consequence of original Pace and Adapted Footstep. A price minimisation analysis conducted from the health service provider perspective showed an estimated reduction (in AUD) of $373 (Dubiousness Interval = $178, $573) per schoolhouse to deliver Adapted Footstep compared to PACE. On the ground of these findings, we concluded that Adapted Pace is a price-efficient culling that is "every bit good equally" [32] PACE in profitable schools' implementation of a concrete activity policy.

Data collection

To ensure a full range of perspectives, we sought to obtain information from all parties involved in the commitment and implementation of strategies: PACE project officers (a PE teacher and health promotion practitioner; schools' master source of contact) and school stakeholders targeted past strategies (principals, ISC and teachers). Quantitative data were nerveless from project records maintained by project officers throughout the report period and surveys of school stakeholders conducted immediately following intervention delivery at 12-month follow-upward (October-Dec 2019). Qualitative information were collected via semi-structured interviews of project officers and a subsample of ISC too at 12-calendar month follow-up. Figure 1 provides an overview of data collection methods and corresponding analytic procedures used to address each enquiry objective.

Project records

Project officers documented the implementation of strategies using an Excel spreadsheet modified from previous trials of Stride [17, 20]. This included the expended fourth dimension and manner of delivery (in-person, electronic mail or telephone) they employed to deliver strategies, also every bit the school-level response such as staff date and attendance at training. These records enabled cess of implementation outcomes (research objective A) as defined by McKay et al. [29], including dose delivered (intended units delivered), fidelity (the extent to which strategies were implemented as prescribed) and adoption (proportion and representativeness of schoolhouse stakeholders that utilised strategies) (Additional file 1). School characteristics were also recorded to provide contextual information.

Schoolhouse stakeholder surveys

All consenting school stakeholders completed a paper survey modified from previous trials [17, 20]. In this study, these surveys were used to obtain respondent characteristics, inform implementation indicators [29] (inquiry objective A) and assess usefulness of strategies (research objective C). Additional file 1 provides an overview of the measures used to assess the different indicators for each strategy. Briefly, principal surveys included measures of adoption for schools' mandated alter (e.thou., if their schoolhouse had a physical activity policy). Teacher surveys included measures of acceptability (e.g., the extent to which respondents agreed that the staff training was acceptable in assisting them to schedule physical action); adoption (e.one thousand., whether they had used Stride resources); and usefulness (e.yard., whether the resources provided on the online portal were useful). ISC surveys were an expansion of the teacher survey, and included measures of usefulness for select strategies, inquiring the extent to which they were perceived as 'useful' for program implementation.

Semi-structured interviews of project officers

All project officers involved in the delivery of Pace (Northward = 6) were interviewed using a semi-structured interview guide developed post-obit guidelines [31]. Open up-ended questions explored project officer's perspectives of plan implementation by schools, including any barriers and facilitators to doing then (research objective B). Project officers were also asked to rank the elevation 3 strategies that they perceived as essential for successful programme implementation and provide a rationale for these choices (enquiry objective C). The facilitator used prompts to explore differences between PACE and Adapted Pace.

Semi-structured interviews of ISC

We purposively sampled ISC using a maximum variation arroyo [33] with a minimum target sample size of eight ISC: four from Stride schools and four from Adapted Stride schools with at least one in each grouping representing low and high levels of program date. Following recommendations for qualitative sampling [33, 34], project officers carried out recruitment by email invitation until we reached data saturation (i.e., sampling to the betoken of back-up) to ensure sufficient depth of data for a robust analysis. Interviews offered in-person or by phone were scheduled in advance with consenting ISC. They were conducted using a semi-structured interview guide developed following guidelines [31]. Open-ended questions explored participant'south experiences with PACE and factors that influenced implementation by schools (research objective B). Each participant received a $xxx grocery souvenir card as a token of appreciation for their fourth dimension.

Information analysis

Quantitative and qualitative information were analysed separately and and so merged for estimation equally per Creswell et al. [30] (Fig. 1).

Quantitative data assay

An independent statistician used projection records and survey information to produce descriptive statistics (mean, SD and proportions) to accost each inquiry objective.

Qualitative data assay

Interviews were audio-recorded and transcribed verbatim. Interview facilitators checked transcripts for accurateness, corrected equally necessary and anonymised any identifiable comments. The concluding copies were entered into QSR NVivo [35] for inductive thematic analysis using the standard approach reported past Braun and Clarke [36]. First, 2 experienced members of the enquiry team (i) independently coded a subset of transcripts, (ii) checked for agreeance and resolved discrepancies with a third researcher, and (iii) developed a combined code scheme. Ane of the researchers then applied the code scheme to the remaining transcripts, discussing new codes with the other researcher and updating where necessary. The assay pair then looked for patterns within the final codes and generated a listing of themes that emerged in relation to research objective B. The proposed list of themes was reviewed, modified where required and finalised with names and definitions for each. This process was guided by a consensual qualitative inquiry process [37] inclusive of ongoing discourse and confirmation with other members of the PACE evaluation and delivery team. In improver, 1 member of the research squad searched project officeholder transcripts and recorded for each, the pinnacle three strategies reported as essential for successful programme implementation (research objective C).

Mixed methods analysis

Quantitative and qualitative data were weighted equally due to their shared contribution in addressing evaluation objectives. Each data set up were integrated [30, 38] using common methods for information integration. In the first method, known every bit 'following a thread' [38], nosotros used preliminary findings from each data set to course hypothesis warranting farther exploration, identify key themes, and/or translate the other information set. In the 2d method of information integration, nosotros compared and integrated the findings from each data set according to 'triangulation protocol' [38]. Specifically, we developed a side-by-side joint display table [39] with quantitative and qualitative findings juxtaposed in relation to each implementation strategy, facilitating cross-data comparing and convergence including areas of agreement, dissonance, or silence (when a theme from 1 data set is not found in another) [38]. We reported an integrative review of results derived from this process in the form of theoretical statements referred to equally meta-inferences [40].

Results

At 12-calendar month follow-up, a full of 33 principals (33/48; response rate = 69%), 51 ISC (51/57 from 41 schools [some schools had > i ISC]; response charge per unit = 89%) and 260 teachers (across all 48 schools) completed surveys; and 11 ISC took part in an interview (Fig. 2). Table ii provides an overview of the characteristics of schools, principals and teachers, including a breakdown between groups.

Table 2 Overview of school, principal and teacher characteristics at 12-month follow-up

Full size table

Research objective A: implementation indicators

Dose delivered and fidelity

Project officers delivered each strategy to all schools (dose delivered = 100%). Fig. 2 details allegiance of each implementation strategy. At that place was at least 95% allegiance for at least one component of each strategy at all schools with the exception of 71% allegiance of the educational outreach visit at Adjusted Footstep schools.

Adoption and acceptability

Table 1 includes a comprehensive description of the adoption and acceptability of strategies past targeted stakeholders. Overall the PACE implementation strategies were highly adopted, with no less than 83% adoption by schools and/or stakeholders to at least one component of each strategy. Some strategy components had low adoption (≤50%), in particular strategy 2b (school executives develop a schoolhouse physical activeness policy) with 39% of principals indicating an existing physical activity policy at their school. Other components with low adoption were those related to the online portal. For case, 50% of schools had at least i teacher view the professional learning videos available on the online portal and 43% of surveyed teachers reported accessing the online portal resources. In that location was piddling variation between Pace and Adapted PACE in regards to strategy adoption. Adjusted Stride had 25% lower adoption to strategy v (staff grooming session) although 3 schools were 'unknown', and 49% lower adoption to strategy 8b (ISC develop further equipment packs).

The implementation strategies were considered highly adequate past stakeholders. More than fifty% of teachers agreed or strongly agreed that all only i strategy were adequate in profitable them to schedule physical activity. The data on the online portal was considered acceptable by 43% of surveyed teachers. There was little variation between PACE and Adapted Pace schools in regards to strategy acceptability, with the exception of strategy 5 (staff training session), with nearly twenty% fewer teachers at Adjusted Step schools indicating acceptability for both the overall session and content.

Inquiry objective B: influences of implementation

Thematic analysis revealed several influential factors of implementation (facilitators and barriers). Each theme fell within i of three identified categories: external policy landscape, inner organisational context/structure (schools) or Stride characteristics and processes. This fits within three of the five wide domains of the Consolidated Framework for Implementation Research (CFIR): outer setting, inner setting, and intervention characteristics [41]. Figure 3 provides an overview of themes and subthemes that emerged within each category, and Table S3 describes each and includes sample quotes.

External policy landscape

The external policy landscape consisted of the NSW Department of Pedagogy Sport and Concrete Activeness Policy [22], and the Personal Development, Health and Concrete Educational activity (PDHPE) syllabus released by NSW Educational activity Standards Authority (NESA) in 2022 [42]. For the nearly office, these government mandates appeared to facilitate program implementation past necessitating that schools provided concrete activity. The new syllabus was a bulwark for staff that perceived accommodating further scheduling changes as burdensome.

Inner organisational context/structure (schools)

Several themes emerged related to the inner organisational context/structure of schools. Facilitators included instructor's positive physical activity values and beliefs; executives' back up of Pace and appropriately, teachers' provision of school twenty-four hours physical activity; and schools with a culture conducive to physical action that perceived PACE as a useful improver. Barriers included the limited time and competing demands of staff; staff turnover; instructor's negative physical activity values and beliefs; schools with a culture conducive to concrete activity that perceived PACE as unnecessary; and schools without a physical action civilisation that did not assign value to information technology.

The nearly prominent inner setting theme was "ISC ability-interest" whereby the level of program implementation at each schoolhouse was proportional to the power and interest of the ISC. This corresponds to stakeholder assay theory from the organizational strategic management literature, in which stakeholders with loftier power (power to influence others due to their position within an organization or devolution) and high interest are considered well-nigh salient to attain objectives. Using pre-defined stakeholder classifications [43], our data showed that ISC 'Players' (high ability and high interest) were consistently associated with greater implementation of PACE strategies. Conversely, schools with ISC that had low power and/or low interest ('Subjects', 'Context Setters', and 'Crowd Members') were challenged to implement some PACE strategies (Fig. four).

Pace characteristics and processes

The final themes relating to PACE characteristics and processes were implementation facilitators: (i) the adaptable and flexible model providing a variety of physical action options for teachers; (ii) the observable benefits of the program on students; and (3) the engaging nature of the intervention via practical hands-on preparation sessions, expertise and energetic back up from project officers, and the provision of quality resource.

Research objective C: importance of strategies

Table 1 is the joint-brandish used to accost research objective C, with quantitative and qualitative findings juxtaposed in relation to each strategy.

Strategy 1: external, ongoing back up

This was non considered within the summit three for 'well-nigh important strategy' by whatever project officer, although the project officeholder characteristics (e.chiliad., energetic expertise) contributing to an engaging innovation, was a theme for facilitating implementation:

Footstep ISC 62: And we likewise were lucky enough to take [PO] to come up in, and he showed how you could practise information technology easily linked to maths and easily get information technology inside your classrooms for other things as well, which was really good. He was really inspirational. His free energy was amazing and the staff really liked having him there … when [PO] came with his energy and fabricated it expect and then simple, a lot of people instantly started doing information technology.

Those schools with ISC 'Players' appeared to rely less on this strategy, especially Adapted PACE ISC that successfully delivered the staff training themselves:

Adjusted PACE ISC 107: … nosotros don't need micro-managing but we also don't need onerous stuff. Every now so is great and that's fine and email conversation is perfect … then we have a chat and then we [ISC] keep that alive in our schoolhouse.

This strategy had high rates of adoption (all but one school engaged in correspondence with project officers) and reported acceptability past ISC (87%). Qualitative data revealed that limited time and competing demands of staff was a central implementation barrier; suggesting that strategies such as this 1 which demands little of stakeholders' time and energy (with responsibility falling on the health service provider) may be highly adopted and acceptable by stakeholders.

Metainferences: This strategy is hands executed and assists with successful program implementation. It is highly important for schools without ISC 'Players'.

Strategy 2: mandate modify

This was considered the virtually important strategy (ranked start) by 5/half dozen projection officers and all interviewed ISC referred to the importance of executive back up, except those who were an executive themselves. As such, the presence of a supportive executive within schools was a theme for facilitating implementation:

Footstep ISC 121: … considering if you're doing the whole school stuff, and so anybody needs to be on board and the all-time way for this is the executive to atomic number 82 the mode. So whoever'due south in charge, similar ane of your deputies or your [banana principal] are involved and leading information technology, information technology's much more likely to be implemented in the classrooms. Aye, they need to be on board from the start.

Executive support also equipped ISC with the 'ability' necessary to successfully implement strategies:

Project officer 06: The [ISC] who had those executive support or were executives, they were a lot more than positive about the program … at that place was definitely more change in the school and more successful with the entire program.

Several interviewed project officers and ISC indicated that executives drove the physical activity culture of schools; some other theme that facilitated program implementation. In the quantitative findings, 84% of ISC reported that primary support to schedule physical action was useful/extremely useful. This strategy was also associated with several positive implementation indicators: 100% of schools had a schoolhouse executive provide verbal delivery to the plan during an initial meeting; 80% of surveyed school principals reported a school-level physical activeness policy either existing or in the procedure of being adult; 84% communicated their support for the plan to the broader school community; and 72% indicated that Step was a school priority. Even so over ane quarter (xxx%) of surveyed teachers did not feel that they had support from their school executive. Farther exploration of the qualitative information showed agreeance with these quantitative findings. Whilst executive support was reportedly provided at well-nigh schools, there were select schools where information technology was considerably less prevalent or non-existent:

Project officeholder 03: You accept some [executives] that'll just go past their desk and they just flick it to, "oh this will get to our sports person" and they don't even look at information technology again. They don't even come to the staff meeting … We had a mix of schools where that would happen, where we get that kind of high adoption or depression adoption.

Poor executive support was associated with low ISC power, making them a 'Crowd Member' or 'Subject' and thus hindering their power to perform responsibilities and implement the programme. Information technology was also associated with a school culture that was non-conducive to physical activeness in which PACE was bereft to instigate change. Both of these were identified as fundamental barriers to programme implementation.

Metainferences: This strategy is highly important for successful implementation and is too linked to other of import strategies. It may be poorly adopted by some schools.

Strategy 3: identify and set up ISC

This was considered an of import strategy by all projection officers; ranked starting time by i project officer and within the top three by the other five projection officers. This strategy was strongly related to the qualitative theme of ISC power-interest; identifying an ISC 'Histrion' with a high level of power and interest from the onset appeared to be benign, if not essential, for program implementation:

Project Officeholder 02: It really depends on who the school champion is and who you connected with as to how the school takes information technology on board … And then if the school champion is completely on board and can evoke change and tin can deliver, get the staff on board.

The one-day workshop was as well considered an important piece contributing to successful program implementation, as it presented an opportunity to heighten ISC interest in the programme and ability (via self-efficacy) to evangelize within their respective school. It as well contributed to the engaging innovation via experiential learning and outlined the adaptable/flexible choice-based model – both of which emerged as themes for facilitating implementation. Importantly, the workshop appeared to prepare Adapted PACE ISC to evangelize the staff training themselves:

Adjusted PACE ISC 66: Yeah, at that place was so much in that [workshop] and information technology was really practical and me, at that fourth dimension, I wasn't probably an overly sports person at that stage, but I did feel confident that when I left I could teach information technology because y'all came abroad and it was an actual practical workshop.

Of the surveyed ISC, 78% indicated that having an ISC was useful/extremely useful. From the instructor perspective, 73% indicated that the assistance from their ISC to implement Step was acceptable. These indicators evidence that some ISC may non have been engaged in their function. This is consistent with the qualitative findings – although most ISC were 'Players', there were select cases with depression ability and/or involvement ('Context Setters', 'Crowd Members' or 'Subjects') which hindered plan implementation:

Adjusted Step ISC 83: [I] could have been delivering it amend...It's been probably half a year since I've kind of checked in about that. Things just arrive the way. We've got one [executive] … and then they ship me to a hundred other things and I'm only spread so thin.

Metainferences: This strategy is highly of import for successful program implementation. Information technology may exist poorly implemented by some schools.

Strategy 4: develop a formal implementation blueprint

This was not considered 1 of the peak three most important strategies; however project officers noted that it was incorporated into the full mean solar day ISC workshop. This strategy contributed to the engaging innovation via quality resources (qualitative theme and sub-theme) that facilitated implementation. A few interviewed project officers also mentioned that such school documents may exist used to "handover" information to new staff, thus addressing the bulwark of staff turnover (qualitative theme). Of the surveyed stakeholders, 77% of ISC indicated that developing guiding documents such as this was useful/extremely useful and 66% of teachers indicated that it was acceptable in assisting them to schedule physical activeness.

Metainferences: This strategy is very easy to execute (included in strategy 3b) and may help some schools with plan implementation.

Strategy 5: educational outreach visits

This was considered an important strategy (top three) by four/6 projection officers. It corresponded to several identified implementation facilitators: strategies to heighten teachers' attitudes, beliefs and level of support; an caption of the option-based model; and an engaging innovation via experimental learning to engage staff:

Pace ISC 62: At first, [staff] were similar, "No, there's no way nosotros can fit this in." Merely then they started realizing that you tin can comprise it into other things. And nosotros practice information technology a lot of the fourth dimension without even thinking about it. Then yeah, they were really receptive … I recollect the staff felt that they had a better grip and handle on what they were doing with the hours.

Implementation indicators for this strategy were high for the overall sample (> 80% adoption and > 70% acceptability) however compared to Pace schools, Adjusted PACE schools had lower adoption (96% vs 71%) and acceptability (81% vs 64%). The employ of an ISC to evangelize this strategy in Adapted Step may impede implementation in some schools. Although the majority of ISC felt adequately prepared to deliver this strategy themselves, eighteen% did not. This is in agreeance with both information sets showing select cases of Adapted PACE ISC that did not proceed to deliver this strategy. This may be due to their limited time/competing demands or leaving the school before delivering the strategy (ISC turnover) – both identified barriers of program implementation. However, qualitative data positioned ISC power-interest as the primary gene that influenced implementation of this strategy at Adapted PACE schools. ISC 'Players' successfully delivered this strategy whereas those with low power and low involvement struggled or failed to do so:

Project officer 01: … say in [Adjusted Step] the schoolhouse champion has been able to become back to the school, organise a time to have the whole schoolhouse meeting on the agenda, then provide the presentation [educational outreach] the whole school and teachers have a lot more than of an thought … and definitely I think if you've got the support of the executive team. So I know in some of those [Adapted PACE] schools at that place was an executive that was a schoolhouse champion, they were able to plainly assistance become it on the agenda, push it into a staff meeting, organise it.

Step used energetic and knowledgeable, external projection officers to deliver this strategy which was identified every bit an implementation facilitator. Regardless, 12% of ISC at PACE schools did not report this strategy as being useful and 18% of teachers did not study information technology every bit acceptable. This may be due to several of the identified implementation barriers that are applicative to both intervention groups (Footstep and Adapted Step) such as low executive support, negative attitudes/behavior of staff, or schools that already prioritised physical activity and felt Pace was unnecessary:

Adjusted PACE ISC 114: I implemented daily fitness prior to even going away to the [ISC workshop] so we're still currently doing that … information technology hasn't really enriched what we're doing.

Metainferences: This strategy is important for successful programme implementation. ISC 'Players' (influenced past strategy ii and three) are well positioned to deliver this strategy themselves. Delivery by a project officeholder may be needed for schools with an ISC 'Subject', 'Context Setter' or 'Crowd Member'.

Strategies half dozen, 7 and viii: educational materials, success stories and equipment pack

The resources were considered of import (top three) by ii/6 project officers. The quality resources contributing to an engaging innovation emerged as an implementation facilitator, with several interviewed ISC and project officers referring to their usefulness for teachers:

PACE ISC 122: Aye, I think the resource is perfect … We can go to them if we e'er really need something … information technology gave usa a lot more tools to be able to do it and just physically not having to go and find the resources.

Quantitative data showed partial implementation for each resources: 65% of surveyed teachers found the online portal useful (43% personally accessed it) and 57% considered the equipment pack acceptable in profitable them to schedule concrete action. The qualitative data expanded on this, showing that the utilize of resources differed by school depending what they needed and/or found most useful. For case, some schools plant the online portal almost useful whereas others emphasised the equipment pack and did not use the online portal at all.

Metainferences: The resources are easily executed and may assist schools with program implementation. The importance of each resources varied by school; a range of options permit schools to select and access those that are most useful for them.

Summary of metainferences

A synthesis of metainferences for the importance of each strategy led to the conceptual model displayed in Fig. 5. No strategies appeared to exist discretionary every bit they differed in adoption, acceptability and usefulness on a school-by-school ground. What worked best and was needed in one school was not necessarily the same for another. However, a few strategies may be considered extremely important as they resulted in improved implementation of the overall program, in add-on to remaining strategies. Specifically, nominating an ISC 'Thespian' (via strategy 3a) and reinforcing this by providing them with the power (via strategy 2) and enhanced interest (via strategy 3b) to engage in responsibilities. Schools with an ISC 'Player' were more likely to successfully implement PACE whereas schools with an ISC 'Crowd Member' faced implementation challenges and required greater support from the other strategies.

Discussion

Studies exploring, comparison and contrasting implementation strategies for school-based concrete activity interventions are rare. Nosotros had a novel opportunity to assess the implementation of 8 detached implementation strategies, previously examined through a series of randomised controlled, and noninferiority trials, which collectively improved schools' compliance with a state-level physical activity policy. The results corroborated the noninferiority trial findings of Adapted Stride being considered "every bit good as" PACE for increasing teachers' scheduled minutes of physical activity [24]. The quantitative implementation indicators were generally high for schools in both groups and the barriers and facilitators identified qualitatively were impartial to group resource allotment. Using state-of-the art mixed methods data integration techniques, we developed meta-inferences for the importance of each discrete implementation strategy and from that, an emergent conceptual model suggesting a path for successful implementation. Although the majority of strategies were of import (4/6), two (mandating modify and identifying and preparing an ISC) and a related contextual cistron (ISC power-interest) emerged as critical to implementation. The findings and related recommendations to optimise PACE are discussed in the context of the literature following.

Our meta-inferences highlighted the importance of the ISC power-interest as a cardinal component to successful implementation. Specifically, we constitute that schools with an ISC 'Histrion' had college levels of implementation strategy implementation compared to those with an ISC 'Crowd Member'. This is supported past stakeholder analysis theory [43] and recommendations to ensure that champions of schoolhouse-based concrete activity programs have the skills, knowledge and disposition to assume the responsibilities expected of them [44]. Further, a 2022 review of champions in healthcare-related implementation identified specific, like characteristics associated with champions' effectiveness, including enthusiasm and energy to bulldoze the program, strong educator and presentation skills, having political acumen, a personal belief in the initiative, and beingness respected and well-liked [45]. Champion attributes may profoundly touch on implementation of health interventions, and also the likelihood of their successful scale-up [46, 47]. In the 2007 World Health System (WHO) framework for scaling up public health interventions, Simmons and Shiffman [47] country that successful scale-upwards is more than likely with "effective and motivated leaders who command say-so and accept credibility". Identifying an ISC 'Player' should be a priority of PACE and where this is non possible, every effort should be taken to improve the nominee's depression ability and/or interest via the ISC workshop and executive support. Frameworks and measures to place and classify stakeholders [48, 49] may be a useful starting point for developing guidelines to systematically identify platonic ISC candidates at schools.

Mandating change also emerged as the nigh of import strategy. Specifically, executive support facilitated the implementation of not merely the overall programme, simply besides the adoption of other strategies. Equally the authoritative leader inside schools, executives have the potential to influence implementation of health programs via endorsement, providing oversight and accountability, and/or enacting formal requirements [50]. In a 2022 evaluation of a school-based participatory health intervention, the level of leadership engagement by school administrators strongly distinguished between high and low implementation schools [51]. Similarly, an evaluation of a multi-strategy schoolhouse smoking prevention program found that loftier- and medium- implementation schools had higher levels of authoritative leadership than depression implementation schools (77.3 and 83.3% vs 42.ix%) [52]. The link between executive support and implementation in schools underpins that efforts are needed to address the occasional poor adoption of Footstep past some school executives, although this may be naturally addressed under the external policy landscape in NSW (the Department of Education policy and the new PE syllabus). Such "macro-systemic sources of influence" create authoritative force per unit area for schools to implement health programs [50] and may increase executive support of Footstep over fourth dimension. In Canada for case, the Every bit! BC intervention was rolled out in primary schools in the context of a Provincial Daily Concrete Activity policy existence implemented. Over three quarters of primary schoolhouse principals (76%) reported an increased priority assigned to physical activity over a 3 year menstruum due to a combination of Equally! BC and the Provincial policy [53].

During intervention blueprint, each Pace strategy was chosen using a robust, theory-based procedure to overcome identified barriers of the target behaviour [xx]. Our findings endorse the final multi-strategy arroyo, showing that the majority of Step strategies were important and fifty-fifty those considered less important remained considerably useful for implementation past some schools. This is likely due to the broad variation in factors that influence implementation of physical activeness programs in schools [54] including those in the electric current written report. In a serial of RCTs undertaken to meliorate a multi-strategy intervention to assist schools to implement a government nutrition policy, the research squad establish that removing perceptibly nonessential strategies (to reduce delivery costs) forfeited the intervention event [55]. From the electric current findings no Step strategy appears dispensable; thus those identified as virtually of import should be emphasised in efforts made to amend implementation. It is too important to note that many "less important" strategies were easily implemented within existing infrastructure and represent little opportunity price to the wellness service provider and/or schools.

Although at that place were relatively few implementation barriers to PACE, 'bachelor time/competing demands of staff' was prominent, with overt mention in nearly every interview and impacting each of principals, ISC and teachers. Accordingly, Step strategies with the highest adoption and acceptability were those requiring the to the lowest degree amount of time and effort from targeted stakeholders. In a 2022 systematic review of factors influencing the implementation of school-based physical activity interventions, the most prevalent barrier was fourth dimension (e.g., competing instructional requirements) [54]. Strategies to assist schools to implement school day physical activity should business relationship for the express time of staff, although this may be challenging in the context of scale-up which often relies more on organizations for implementation support [47]. This underscores the importance of using ISC 'Players', equally school staff are more likely to prioritise and deliver a plan that they value despite fourth dimension constraints [54].

This written report has several notable limitations. Commencement, stakeholder surveys were finalised prior to our deciding to use a mixed methods approach, which resulted in less congruency between the qualitative and quantitative information collection methods than nosotros would have liked. A prospectively designed mixed methods process evaluation would meliorate on this in the future. 2nd, in that location is a take chances of positive response bias from ISC who may have perceived interviewers as associated with Pace commitment personnel, despite clear indication of their separation from the delivery squad. Third, although our inductive, data-driven qualitative approach allowed a rich description of the information without constraint to any pre-existing framework [33, 36], future qualitative inquiry in the implementation science field could adopt a more businesslike arroyo such as incorporating a framework-driven analysis [56]. Fourth, an essential ingredient within the conceptual model is ISC ability-interest. This is based on a comprehensive integration of multiple data sources and rigorous analyses, even so a formal comparison of quantitative intervention implementation scores and assignment to a ability-interest category for each school is necessary to substantiate our findings. Lastly, although we purposefully sampled for interviews to ensure we had perspectives from a range of schools, we interviewed fewer ISC from the 'low engagement school' category due to recruitment challenges. Regardless, we met our total target sample and we were able to triangulate findings beyond school sites and supplement with project officeholder's insight as 'key informants' [33, 34], thus achieving sufficient depth and breadth of data for schools of all implementation levels.

Decision

Adapted Pace is the preferred model for delivery at-scale due to its ability to reach a greater proportion of the population at a lower cost to the health service provider, and with an acceptable consequence on policy implementation [24]. This study reinforces this and shows that identification and pick of ISC who are 'Players' and demonstration of executive support are very important (if non essential) for successful policy implementation and consequential bear on. These findings expose opportune ways to optimise Step with minimal adaptations and at no additional cost to the health service provider. Given these strategies are commonly employed to improve the implementation of policies and practices in the schoolhouse setting [57], our findings may contribute to improving implementation of school health interventions broadly.

Availability of data and materials

The datasets used for the current study are available from the respective author upon reasonable asking.

Abbreviations

Footstep:: Physically Active Children in Instruction
TDF:: Theoretical Domain Framework (TDF)
BCW:: Behaviour Change Wheel
RCT:: Randomised controlled trial
MRC:: Medical Inquiry Quango
NSW:: New South Wales
ISC:: In-school champion
PE:: Physical Education
PDHPE:: Personal Evolution, Health and Physical Education
NESA:: NSW Teaching Standards Authority
WHO:: Globe Health Arrangement

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Acknowledgements

The authors would similar to thank all of the participating schools and projection officers involved in the delivery of PACE. Nosotros would like to thank Christophe Lecathelinais for his statistical help with quantitative data.

Funding

No funding to declare. Infrastructure back up was provided from Hunter New England Local Health Commune Population Health.

Author information

Affiliations

School of Medicine and Public Health, The Academy of Newcastle, ane University Drive, Callaghan, NSW, 2308, Australia

Cassandra Lane, Adam Shoesmith, Luke Wolfenden, Alix Hall, Rachel Sutherland & Nicole Nathan
Hunter New England Population Health, Hunter New England Expanse Health Service, Newcastle, NSW, Australia

Cassandra Lane, Adam Shoesmith, Luke Wolfenden, Alix Hall, Rachel Sutherland & Nicole Nathan
Priority Research Centre for Wellness Behaviour, The University of Newcastle, Newcastle, NSW, Commonwealth of australia

Cassandra Lane, Adam Shoesmith, Luke Wolfenden, Alix Hall, Rachel Sutherland & Nicole Nathan
Hunter Medical Research Institute, New Lambton Heights, NSW, Commonwealth of australia

Cassandra Lane, Adam Shoesmith, Luke Wolfenden, Alix Hall, Rachel Sutherland & Nicole Nathan
School of Do Scientific discipline, Physical and Health Education, University of Victoria, Victoria, BC, Canada

Patti-Jean Naylor

Contributions

First writer CL led the development of this manuscript. LW and NN conceived the intervention concept. CL and PJN adult the research design. All authors advised on, and oversaw, implementation of the intervention and data collection. CL and As conducted interviews. CL, PJN and Equally conducted data cleaning and analyses. All authors contributed to and canonical the final version of the manuscript.

Corresponding author

Correspondence to Cassandra Lane.

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Ethics approval and consent to participate

Ethics approval was obtained from the Hunter New England Human Enquiry Ideals Committee (2019/ETH12353), The University of Newcastle Human Research Ethics Committee (H-2008-0343), as well as the NSW Section of Education and the relevant Catholic Schools Offices. All study participants provided informed consent.

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Not applicable.

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The authors declare that they have no competing interests.

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Supplementary Information

Additional file 1.

Additional file two:

Tabular array S3. Results from thematic analysis - Main influences of implementation with instance quotes from interviews of in-school champions and project officers.

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Lane, C., Naylor, PJ., Shoesmith, A. et al. Identifying essential implementation strategies: a mixed methods process evaluation of a multi-strategy policy implementation intervention for schools. Int J Behav Nutr Phys Act nineteen, 44 (2022). https://doi.org/ten.1186/s12966-022-01281-v

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Received: 04 Nov 2021
Accustomed: 21 March 2022
Published: 12 April 2022
DOI : https://doi.org/10.1186/s12966-022-01281-5

Keywords

Physical activeness
Policy
Implementation
Adaptations
Mixed methods
Scale-up
School
Children
Champions

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Pathways to Art Appreciation a Source Book for Media Methods

Identifying essential implementation strategies: a mixed methods process evaluation of a multi-strategy policy implementation intervention for schools

Abstract

Background

Methods

Results

Conclusion

Background

Methods

Enquiry design

The Adapted Footstep noninferiority trial

Data collection

Project records

Schoolhouse stakeholder surveys

Semi-structured interviews of project officers

Semi-structured interviews of ISC

Information analysis

Quantitative data assay

Qualitative data assay

Mixed methods analysis

Results

Research objective A: implementation indicators

Dose delivered and fidelity

Adoption and acceptability

Inquiry objective B: influences of implementation

External policy landscape

Inner organisational context/structure (schools)

Pace characteristics and processes

Research objective C: importance of strategies

Strategy 1: external, ongoing back up

Strategy 2: mandate modify

Strategy 3: identify and set up ISC

Strategy 4: develop a formal implementation blueprint

Strategy 5: educational outreach visits

Strategies half dozen, 7 and viii: educational materials, success stories and equipment pack

Summary of metainferences

Discussion

Decision

Availability of data and materials

Abbreviations

References

Acknowledgements

Funding

Author information

Affiliations

Contributions

Corresponding author

Ethics declarations

Ethics approval and consent to participate

Consent for publication

Competing interests

Additional information

Publisher's Note

Supplementary Information

Additional file 1.

Additional file two:

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Cite this article

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