ERIC ED596987: An Evaluation of the Coverage of Theoretically Based Implementation Factors in Disseminated Classroom Physical Activity Programs

2018·0.19 MB·English

by  ERIC

TBM ORIGINAL RESEARCH
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An evaluation of the coverage of theoretically based n
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implementation factors in disseminated classroom physical e
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activity programs m
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Hannah G. Calvert,1, Hannah G. Lane,2 Carolina M. Bejarano,3 Kelli Snow,4 Kate Hoppe,4 Nicole Alfonsin,5 ://a
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Lindsey Turner,1 Jordan A. Carlson4 ad
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1College of Education, Boise State Abstract p.c
University, ID 83725-1700, USA Classroom-based physical activity (CBPA) is increasingly rec- Implications om
2Department of Pediatrics, Division ommended as a method to support children’s physical activ- Practice: Numerous programs and resources are /tb
of Growth and Nutrition, University ity, health, and academic performance. Many adoption-ready available for school staff who wish to increase m
of Maryland School of Medicine, programs exist to aid in the implementation of CBPA in schools; classroom activity practices at their school, and /ad
Baltimore, MD 21201, USA yet, implementation rates remain low. The purpose of this end users should select programs/resources that va
3UCnliivneicrasli tCyh oilfd K Pasnyscahso, lLoagwy rPernocger,a KmS, study was to evaluate the extent to which resources provided fit their needs while considering the importance nce
46C6e0n4te5r ,f UorS CAhildren’s Healthy bimy paldeompetniotna-tiroena dcyo nCtBePxAtu parl ofagcratomrss taod sdurepspsoerdt itmhepolermy-ebnatsaetdio n. of school-wide implementation factors. -article
Lifestyles and Nutrition, Children’s Existing CBPA programs (N = 37) were identified through  -a
Mercy Kansas City, MO 64108, Internet searches and all materials (e.g., implementation Policy: To maximize policy effectiveness for sup- bs
USA guides) provided by each program were coded for their inclu- porting school-wide implementation, policy lan- tra
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free (yes/no), research evidence (yes/no), and targeted to 93
teacher only (vs. school). Programs covered a mean of 25.9 /tb
Chaonrrneashpcoanlvdeerntc8e9 t8o@: Hb Goi sCeaslvtaetret,. per cent (SD = 18.7 per cent) of the 14 Inner Setting imple- Rimepseleamrcehn:t aRtieosne astrrcahteergsi essh foour lsdu pdpeovretlionpg oanndgo tiensgt m/ib
mentation factors, 34.2 per cent (SD = 18.0 per cent) of the y
edu 6 Characteristics of Individuals implementation factors, and school-wide classroom physical activity, including 13
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© The Author(s) 2018. Published by more implementation factors than programs without research 947
Oxford University Press on behalf of evidence (43.7 vs. 25.9 per cent; p < .05). Although numerous b
the Society of Behavioral Medicine. adoption-ready CBPA programs are available and have many y B
strengths, their inclusion of theory-based factors that support o
This is an Open Access article distrib- increasingly common. Schools are encouraged to is
uted under the terms of the Creative or inhibit implementation is generally low. Consideration of establish a Comprehensive School Physical Activity e S
Commons Attribution Non-Commercial such factors, including organizational climate and teacher-level ta
License (http://creativecommons.org/ behavior change, is likely critical to supporting ongoing school- Program, with PA opportunities before, during, and te
licenses/by-nc/4.0/), which permits wide implementation of CBPA. Research is needed to develop after school. Along with quality physical educa- Un
navnioddne -drce otphmreom doeurircgctiiinaoaln lr ewin-u oasrnkey ,i sdm pisertodripibueumrtliy,o pncri,ot e-d. asunpdp toerstt  meffoerec twivied estsrparteeagdie Cs BfoPrA a idmdprelesmsienngt tahtieosne. factors to  tpihonys i[c2a]l aancdti vditayi ly( CreBcPeAss), iosf faenri nign tcelgarsasrl opoamrt-b aosfe da iversity
For commercial re-use, please contact Comprehensive School Physical Activity Program u
[email protected] Key words that optimizes PA during school hours [3–5]. ser o
Multiple studies have shown that CBPA can be effec- n
Consolidated Framework for Implementation 3
tive for increasing children’s PA [6–12]. Interest in 0
Research, Teacher, Dissemination, School, Behavior school-based PA and CBPA has grown rapidly over Ju
change the last two decades [13], in part due to PA’s ability ly 2
0
to improve student learning outcomes [14,15] and 19
BACKGROUND on-task behavior [7,10,16].
Reimagining ways to promote and provide physical Many entities, including nonprofit organizations
activity (PA) opportunities to children and youth (e.g., American Heart Association, Let’s Move
is especially important now, considering the prev- Active Schools); businesses (e.g., Recess Rocks, Go
alence of childhood obesity in the USA [1]. Given Noodle); individuals; and organizations such as uni-
the volume of time children spend at school, efforts versities, state departments of education, and local
to provide PA opportunities in school settings are educational agencies, have developed packaged,
TBM page 1 of 11
Published online: XX XXXX 2018
ORIGINAL RESEARCH
adoption-ready programs that include structured (could also address other sources of PA during
materials to aid in CBPA delivery. Despite the wide school); and (c) targeted any grade K-6th. Programs
availability of such programs, national data suggest were excluded if they: (a) did not address class-
that less than 50 per cent of teachers offer CBPA room physical activity; (b) were created as part of a
opportunities to their students [17], and intervention research study but were not available to the public,
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studies have shown low rates of implementation after even upon request; (c) were once available, but no o
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school- or district-level adoption, with even lower longer had active websites (i.e., materials were no n
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maintenance at long-term follow-up [7,18,19]. Both longer accessible due to broken links); and (4) were ad
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classroom-level contextual factors, such as resource from a country other than the USA. All materials d
availability and teacher attitudes and perceived con- for each program, including PDFs, PowerPoints, fro
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fidence, and school-level contextual factors, such as manuals/guides, handouts, and posters, were down- h
school climate, district and school-level leadership loaded or purchased. We contacted programs that ttp
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engagement, and process monitoring, influence offered training but did not include training materi- ://a
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implementation and maintenance of CBPA [20–27]. als on their website to request these materials. Two a
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It is posited that CBPA programs will have higher contacts stated that they did not have training mate- em
rates of implementation and maintenance when the- rials because the training was more informal. Two ic.o
ory-based implementation contextual factors [28] provided a training PowerPoint, but the PowerPoint up
are addressed. did not include information that was not already .co
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To date, the breadth and depth of implementa- included in other materials. /tb
tion support provided for schools, teachers, and m
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other school stakeholders by CBPA programs has d
List of implementation factors and definitions v
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not been systematically studied. A  logical next n
CFIR was selected to guide this work due to its c
step toward supporting successful CBPA imple- wide coverage of multiple levels (i.e., individual e-a
mentation is to identify the extent to which existing and organizational) of implementation contextual rtic
adoption-ready programs address multilevel imple- le
factors [28,29], evidence of explaining variation in -a
mentation supports. b
implementation in previous work [30], relevance stra
to setting/organizational-based interventions such c
Purpose t/d
as school PA, and familiarity among the investiga- o
The primary purpose of this study was to use the tors. The CFIR includes 36 constructs that reflect i/10
Consolidated Framework for Implementation barriers and facilitators to implementation, grouped .10
Research (CFIR) [28] to investigate the inclusion 9
under five domains: Intervention Characteristics 3
of factors related to school- and classroom-level /tb
(key attributes of interventions), Outer Setting m
implementation among existing free and fee-based (factors outside the organization), Inner Setting /ib
CBPA programs. A secondary aim examined pro- (factors within the organization), Characteristics of y13
gram inclusion of implementation factors across 4
Individuals (perceptions, attitudes, and motivation /5
Intervention Characteristics of interest, including 2
of individuals), and Process (strategies to support 6
1
program cost, availability of research evidence, and 9
implementation) [31]. 4
target audience (teacher vs. school). This research 7
For the present study, 22 CFIR constructs were b
focused on adoption-ready programs accessible to selected for inclusion and one or more CBPA-specific y B
school stakeholders for use in real-world contexts. implementation factors were mapped to each CFIR ois
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construct. The identification of constructs drew on S
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METHODS the authors’ experience and knowledge of the litera- te
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ture and was conducted using an iterative approach n
Identification of programs that involved four meetings among the authors. ive
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A systematic search was conducted in mid-2017 in The primary investigator and a research assistant ity
PubMed, Google Scholar, and Google, to review first drafted the initial list of CBPA-specific imple- u
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both scientific and grey literature and identify mentation factors and definitions, mapped to CFIR. r o
adoption-ready programs directed at supporting The list was then discussed with the other study n 3
delivery of CBPA. Search terms included classroom team members over the four meetings, and refine- 0 J
physical activity + programs + interventions; active ments were made until consensus was reached. This uly
classroom; activity breaks; active lessons; classroom resulted in a list of 51 CBPA-specific implementation 20
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breaks + exercise; and classroom physical activity. factors, which is presented in Appendix A. There 9
Programs typically had their own website, were were 23 CBPA-specific implementation factors for
available for purchase on a marketplace website the Intervention Characteristics domain of CFIR,
(e.g., Amazon), or were hosted on another website 14 for the Inner Setting, 6 for the Characteristics
such as a state health department or department of of Individuals, and 8 for Process. We also catego-
education website. Included programs were as fol- rized each CBPA-specific implementation factor as
lows: (a) published in English language; (b) at least being related to the school-teacher relationship (i.e.,
partially aimed to increase PA in the classroom teacher and systems change; N = 7 implementation
page 2 of 11 TBM
ORIGINAL RESEARCH
factors) or the teacher–student relationship (i.e., descriptive statistics were calculated for all programs
student behavior change; N = 21 implementation together and then calculated only for programs that
factors), which we refer to as the “school/teacher were viewed as more comprehensive because they
grouping” (see Table  1 for factor groupings). included an implementation manual, guide, or other
Implementation factors within the Intervention material/resource beyond simple activity demon-
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Characteristics domain were not categorized using strations/instructions. Inter-rater agreement was o
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the school/teacher grouping because they were not calculated for each of the 28 double-coded imple- n
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specific to one grouping. mentation factors using percent agreement, and for ad
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index scores using intraclass correlations (ICCs). d
Coding procedures Percent agreement was evaluated with the criteria of fro
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A coding guide was created that included the ≥ 75 per cent as good to excellent, 60%–74% as mod- h
CBPA-specific implementation factor names and erate, and <60 per cent as poor [32]. ICC magnitude ttps
definitions, the related CFIR construct name and was classified using criteria of poor (≤0.40), fair ://a
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short description (which are broader and not CBPA- (0.41–0.60), good (0.61–0.80), and excellent (0.81– a
d
specific), and coder instructions. Coders then 1.0) [31]. Logistic regression was used to investigate em
reviewed all materials for each program, including differences in the inclusion of each of the 28 dou- ic.o
downloaded materials and website content. Coders ble-coded implementation factors (dependent varia- up
excluded program content related to a topic other ble) by three Intervention Characteristics that were .co
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than CBPA (e.g., if the construct was included but in considered key factors related to program selection /tb
relation to recess, it did not count). As part of an ini- (independent variables, entered in separate mod- m
/a
tial coder training process, all coders independently els): (i) free (yes/no), (ii) research evidence (yes/ d
v
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coded the same three programs and subsequently no), and (iii) targeted to teacher only (vs. school) n
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reconciled codes. (yes/no). Chi-square statistics are presented when e-a
The 23 CBPA-specific implementation factors an odds ratio was not able to be calculated due to rtic
within the Intervention Characteristics CFIR Domain no inclusion of the implementation factor in one of le-a
were coded as 0 = not present versus 1 = present. the groupings (e.g., free vs. cost). Index scores were bs
A single coder compiled this information, since the summarized using means and standard deviations. tra
c
implementation factors were easily identifiable and Differences in the index scores (dependent varia- t/d
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required little-to-no judgment or interpretation from bles) by the aforementioned three key Intervention i/1
0
the coder. The other 28 CBPA-specific implementa- Characteristics (independent variables) were investi- .1
0
tion factors were coded as 0 = not included in the gated using t tests. 9
3
program, 1 = included in the program but at a min- /tb
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imal level, and 2 = included more than minimally RESULTS /ib
in the program. For these implementation factors, Of the 42 programs initially identified, four were y1
3
each program was independently coded by two of excluded because they were not from the USA 4/5
the five coders, and discrepancies were reconciled and one was excluded because it was deemed to 26
1
through discussion. For the present analyses, codes be an opinion blog rather than a packaged pro- 94
were dichotomized as 0 or 1, with the 1s and 2s com- gram. A list of the 37 included programs is pro- 7 b
bined, since few implementation factors received a vided in Appendix B. Across all programs, 20 of y B
score of 2. The 2s were then used to qualitatively the 28 dichotomous implementation factors had ois
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highlight best examples. Index scores for each CFIR good-to-excellent percent agreement (75.7%–97.3%) S
Domain (except Intervention Characteristics) and between coders, and the other 8 had moderate per- tate
for implementation factors addressing the school/ cent agreement (64.9%–73%). ICCs for the index U
n
teacher relationship were created by taking a sum of scores demonstrated fair agreement for Inner Setting iv
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tohf ef ascctoorress wacitrhoisns tfhacet odrosm daivinid/gedro buyp itnhge. total number (oIfC ICnd =iv i.d5u9a2l)s, (gICooCd  =a g.6re1e4m), ePnrto cfoers s C(IhCaCra c=te r.7is6t5ic)s, rsity u
staAfff rteera cchoedde roeucto tnoc pilrioatgioranm w caos nctoamctps lveitae de,m reasile awricthh slecnhto oal-gtereaecmheern rte lafotiro ntsehaicph (eIrC–Cstu =d e.6n3t 8)r,e alantdio enxscheipl- ser on
the results of the coding for their program, and gave (ICC = .877). 30
them the opportunity to raise questions about poten- Ju
tial errors. Only one program noted an error in cod- Inclusion of implementation factors across programs ly 2
0
ing, which was related to an implementation factor 1
The least commonly included Intervention 9
within the Intervention Characteristics domain. The
Characteristics implementation factor was train the
results presented reflect the revision to this code.
trainer (individuals receive training on how to train
others; 5.4 per cent), whereas the most commonly
Statistical analyses
included was original activities (original activity ideas
The number and percent of programs receiv-
or instructions; 94.6 per cent; Table 2). Of the 15
ing a score of 1 for each implementation factor
programs that involved a fee, four (26.7 per cent) had
was reported using frequency statistics. These
research evidence. Most program fees were one time
TBM page 3 of 11
ORIGINAL RESEARCH
Table 1 | Inclusion of implementation factors related to the CFIR Inner Setting, Characteristics of Individuals, and Process Domains
CFIR Domain and CBPA-specific  Brief description No. (%) of all programs that No. (%) of programs with
Implementation Factor included factor Implementation Materials that
N = 37 programs included factorc
N = 28 programs D
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Inner Setting (14 factors) n
Communicationa Creating a network or changing the communication 7 (18.9%) 6 (21.4%) loa
structure de
d
Policy Incorporationa Incsocrhpoooral/tdinisgt rtihcet pporoligcyram into policy, or reference 9 (24.3%) 9 (32.1%) from
Marketing Materials Teachersa Post school-level adoption marketing focusing on 14 (37.8%) 14 (50.0%) h
teacher-level implementation ttp
s
Marketing Materials Students/ Post school-level adoption marketing targeting stu- 10 (27.0%) 9 (32.1%) ://a
Parentsb dents and/or parents ca
Gauging/Affecting Climatea Gauging or affecting the school climate regarding  6 (16.2%) 6 (21.4%) de
m
classroom PA ic
Leadership Initial Buy Ina Increasing administrator buy-in for program adoption 9 (24.3%) 9 (32.1%) .o
u
Student Managementb Managing student behavior in the classroom during 15 (40.5%) 13 (46.4%) p.c
PA o
m
Compatibility Adaptationsb Adapting activities based on early implementation 21 (56.8%) 19 (67.9%) /tb
and compatibility m
Incentivesa Providing incentives for teachers 7 (18.9%) 7 (25.0%) /ad
v
Goal Settinga Setting goals to support teacher implementation of 3 (8.1%) 3 (10.7%) an
classroom PA ce
MScohnoiotol rRinegaadinessa MScoanliintogr/itnagil oteriancgh tehre i mprpolegmraemn tbaatsioend oofn c tlahses srochoomo lP’sA 112 ((25.94.%7%)) 112 ((379.1.3%%)) -article
level of readiness -a
b
LeaAddeorpsthiiopn Eangagement Post Incareroausned le iamdpelresmhiepn stautpiopnort and/or involvement 6 (16.2%) 5 (17.9%) stra
c
Classroom Structureb Restructuring the physical classroom environment or 14 (37.8%) 14 (50.0%) t/d
o
tailor activities based on classroom structure i/1
Characteristics of Individuals (six factors) 0.1
Health Benefitsa Health benefits of classroom PA 28 (75.7%) 25 (89.3%) 09
3
Non-Health Benefitsa Non-health benefits of classroom PA (e.g., academics,  30 (81.1%) 26 (92.9%) /tb
behavior management) m
Teacher Motivation/Attitudes Increasing teacher motivation/attitudes to imple- 5 (13.5%) 5 (17.9%) /ib
y
Around Programa ment/support the program 13
Self-efficacya Increasing teacher confidence/self-efficacy for imple- 5 (13.5%) 4 (14.3%) 4/5
menting the program 26
1
Teacher Stage of Changea Gauging a teacher’s stage of change and/or tailoring 2 (5.4%) 2 (7.1%) 9
4
approaches on this 7
b
Teacher Attitude/Value toward Improving teacher attitudes/values about their own 6 (16.2%) 6 (21.4%) y
PAa PA Bo
Process (eight factors) ise
Scheduling Materialsb Scheduling classroom PA 17 (45.9%) 16 (57.1%) Sta
Dose/Dose Quantityb A specific number of minutes and/or frequency of  29 (78.4%) 26 (92.9%) te
activity blocks U
n
Teacher Participationb Increasing teacher participation in the activities 15 (40.5%) 14 (50.0%) ive
Implementation Leadersa Identifying/appointing champions or creating new 7 (18.9%) 7 (25.0%) rsity
leadership roles for implementation u
External Involvementa Involving parents or community members to support/ 11 (29.7%) 10 (35.7%) se
assist in the intervention r o
n
External Information Sharinga Networking or sharing implementation information 14 (37.8%) 12 (42.9%) 3
0
with external organizations or individuals? J
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Accountabilitya Enforcement or accountability 1 (2.7%) 1 (3.6%) ly
Outcomesa Assessing desired outcomes 9 (24.3%) 9 (32.1%) 20
1
aFactor affects school–teacher relationship for implementation. 9
bFactor affects teacher–student relationship for implementation.
cMaterials provided by these programs were considered more comprehensive because they included guides or other content that supported implementation rather than solely activity instructions.
CFIR Consolidated Framework for Implementation Research; CBPA classroom-based physical activity.
fees ranging between US$10 and US$100, though implementation factors were included in <50 per
some program fees were higher, for example, US$10 cent of programs (Table 1). The least commonly
per month. Across the Inner Setting, Characteristics included implementation factor from these domains
of Individuals, and Process domains, 24 of the 28 was accountability (enforcement or accountability; 2.7
page 4 of 11 TBM
ORIGINAL RESEARCH
Table 2 | Inclusion of implementation factors related to the CFIR Intervention Characteristics Domain
CFIR Domain and CBPA-specific  Brief description No. of (%) programs including
Implementation Factor factor (N = 37 programs)
Intervention Characteristics D
o
Research Evidence Published research on the classroom PA part of the 9 (24.3%) w
n
program lo
a
Grade Specific Separate activities targeted at different/specific  9 (24.3%) d
e
Original Activities Orgigriandael alecvtievlisty ideas or instructions 35 (94.6%) d from
Short Activities Activities of 5 min or less 14 (37.8%) http
Long Activities Activities of 6–10 min 12 (32.4%) s
Extra-long Activities Activities of more than 10 min 7 (18.9%) ://ac
a
Flexible Activity Duration/No Duration Listed Activity duration is flexible 22 (59.5%) de
m
Curriculum Integration Activities that are integrated into the academic 15 (40.5%) ic
curriculum .o
u
p
Activity Video(s) Videos to use during classroom PA 15 (40.5%) .c
o
Music Music to use during activities 8 (21.6%) m
Educational Handout(s) Brief materials/resources detailing the program or 14 (37.8%) /tbm
school PA /a
d
Educational Booklet(s) More extensive resource guides or manuals 15 (40.5%) va
n
Educational Powerpoint(s) Visual slide show for training 8 (21.6%) ce
Visiting Training Trainer(s) come to the school/district 6 (16.2%) -artic
Send for Training Teachers/staff are sent to program’s facility for  2 (5.4%) le
training -a
b
s
Online Training Teachers/staff complete online training 5 (13.5%) tra
Train the Trainer Individuals receive training on how to train others 2 (5.4%) ct/d
Advanced Implementation Support Person/consultant that provides tailored/custom 3 (8.1%) oi/1
support 0
.1
Targeted to School Material that targets school-level adoption 20 (54.1%) 0
9
3
Implementation Material(s) Material that facilitates implementation of program 28 (75.7%) /tb
(e.g., manual, guide, detailed website content) m
Funding Materials/resources addressing how/where to apply 4 (10.8%) /iby
1
for funds to support implementation 3
4
Program Fee Fee to obtain program (excluding cost for training) 15 (40.5%) /5
2
6
Training Fee Fee-based training offered 8 (21.6%) 1
9
4
CFIR Consolidated Framework for Implementation Research; CBPA classroom-based physical activity. 7
b
y
B
per cent), whereas the most commonly included was included across programs, when compared with o
is
nonhealth benefits (nonhealth benefits of classroom factors related to the teacher–student relationship e
S
PA [e.g., academics and behavior management]; (index score of 3.3 out of 7; 46.7 per cent inclusion; ta
92.9 per cent). The inclusion of implementation fac- p < .05). te U
tors was slightly higher when only considering the n
iv
subset of programs that included any implementa- Implementation factor inclusion by key Intervention ers
tion materials (N = 28). However, 20 of the 28 imple- Characteristics ity
u
mentation factors were included in <50 per cent of There were no significant differences in the inclu- s
e
programs. sion of individual implementation factors between r o
n
The index scores, representing the number of fac- programs that were free (N = 22) versus fee-based 3
0
tors included, differed by CFIR domain and school/ (N = 15) (Table 3). For programs that had no J
u
teacher grouping. Fewer Inner Setting implementa- research evidence (N = 28) versus programs with ly
2
tion factors (index score of 3.6 out of 14; 25.9 per research evidence (N = 9), four implementation fac- 0
1
9
cent inclusion) were included across programs, tors had significantly higher odds of being included
when compared with implementation factors related in research-based programs. These included policy
to the Characteristics of Individuals (index score of incorporation (incorporating the program into policy,
2.1 out of 6; 34.2 per cent inclusion) and Process or reference school/district policy), school readiness
(index score of 2.8 out of 8; 34.8 per cent inclusion) (scaling/tailoring the program based on the school’s
domains (p < .05). Fewer implementation factors level of readiness), teacher attitude/value of PA (improv-
related to the school-teacher relationship (index ing teacher attitudes/values about their own PA),
score of 5.2 out of 21; 24.7 per cent inclusion) were and implementation leaders (identifying/appointing
TBM page 5 of 11
ORIGINAL RESEARCH
er only (0) vs. targeted chool (1) 17; School: N = 20 2χOR (CI) or 2.50 (0.42, 14.96) 2.00 (0.42, 9.63) 3.25 (0.78, 13.48) 5.00 (0.89, 28.08) 5.33 (0.56, 51.09) 10.67 (1.17, 97.19)* 0.95 (0.26, 3.55) 1.33 (0.36, 4.93) 2.50 (0.42, 14.96) c2.78 16.00 (1.77, 144.72)* c1.80 5.33 (0.56, 51.09) 1.96 (0.50, 7.69) 3.09 (0.64, 15.00) 3.75 (0.62, 22.58) 1.32 (0.19, 9.02) 0.17 (0.02, 1.71) c2.49 1.88 (0.30, 11.78) 10.89 (2.26, 52.42)* 2.36 (0.47, 11.82) Download
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Odds Ratios (0 is the reference category for each gro No Research Evidence (0) vs. Research Evidence (1) No research: N = 28; Research: N = 9 2χ%(0)%(1)OR (CI) or 17.922.21.31 (0.21,8.32) 14.355.67.50 (1.39, 40.56)* 32.155.62.64 (0.59, 12.25) 25.033.31.50 (0.29, 7.65) 14.322.21.71 (0.29, 11.40) 17.944.43.68 (0.72, 18.82) 35.755.62.25 (0.49, 10.34) 53.666.71.73 (0.36, 8.35) 14.333.33.00 (0.53, 17.16) 7.111.11.63 (0.13, 20.36) 21.455.64.58 (0.93, 22.59) c0.022.26.58 * 14.322.21.71 (0.29, 11.40) 28.666.75.00 (0.99, 25.02) c67.90100.03.82 78.688.92.18 (0.23, 21.04) 10.722.22.38 (0.33, 17.17) 10.722.22.38 (0.33, 17.17) c7.10.00.68 7.144.410.4 (1.48, 72.99)* 39.366.73.09 (0.64, 15.00) 75.088.92.67 (0.28, 25.25) .oup.com/tbm/advance-article-abstract/doi/10.10
9
3
/tb
Characteristics Cost (1) ost: N = 15 2χOR (CI) or 0.19 (0.02, 1.78) 1.24 (0.27, 5.64) 1.17 (0.30, 4.50) 0.97 (0.22, 4.26) 0.24 (0.03, 2.33) 0.67 (0.14, 3.22) 0.96 (0.25, 3.67) 0.31 (0.08, 1.22) 0.52 (0.09, 3.14) 0.71 (0.06, 8.67) 1.33 (0.32, 5.55) 1.50 (0.09, 26.01) 0.24 (0.03, 2.33) 0.72 (0.18, 2.84) 0.81 (0.18, 3.69) 5.25 (0.56, 49.08) 0.97 (0.14, 6.69) 2.50 (0.36, 17.17) 1.50 (0.09, 26.01) 1.58 (0.27, 9.17) 1.65 (0.44, 6.20) 1.18 (0.24, 5.89) m/iby134/5261947
ss key Intervention  Free (0) vs. Free: N = 22; C %(1) 6.7 26.7 40.0 26.7 6.7 20.0 40.0 40.0 13.3 6.7 33.3 6.7 6.7 33.3 73.3 93.3 13.3 20.0 6.7 20.0 53.3 80.0 by Boise State U
ctors acro %(0) 27.3 22.6 36.4 27.3 22.7 27.3 40.9 68.2 22.7 9.1 27.3 4.5 22.7 40.9 77.3 72.7 13.6 9.1 4.5 13.6 40.9 77.3 niversity
n fa us
mentatio aogram er on 3
Differences in inclusion of impleTable 3 | Inner SettingaCommunicationaPolicy IncorporationaMarketing Materials TeachersbMarketing Materials Students/ParentsaGauging/Affecting ClimateaLeadership Initial Buy InbStudent ManagementbCompatibility AdaptationsaIncentivesaGoal SettingaMonitoringaSchool ReadinessaLeadership Engagement Post AdoptionbClassroom Structure Characteristics of IndividualsaHealth BenefitsaNon-Health Benefits Teacher Motivation/Attitudes Around PraSelf-efficacyaTeacher Stage of ChangeaTeacher Attitude/Value toward PA ProcessbScheduling MaterialsbDose/Dose Quantity 0 July 2019
page 6 of 11 TBM
ORIGINAL RESEARCH
*
er only (0) vs. targeted chool (1) 17; School: N = 20 2χOR (CI) or 1.50 (0.38, 5.66) 6.86 (0.73, 64.10) 3.11 (0.67, 14.44) 1.96 (0.50, 7.69) c0.87 10.67 (1.17, 97.19) Download
eted to teachto s Teacher: N = %(1) 45.0 30.0 40.0 45.0 5.0 40.0 ed from http
Targ %(0) 35.3 5.9 17.6 29.4 0.0 5.9 s://aca
d
e
up) mic
Odds Ratios (0 is the reference category for each gro No Research Evidence (0) vs. Research Evidence (1) No research: N = 28; Research: N = 9 2χ%(0)%(1)OR (CI) or 39.344.41.24 (0.27, 5.64) 7.155.616.25 (2.32, 114.06)* 28.633.31.25 (0.25, 6.26) 39.333.30.77 (0.16, 3.75) c 0.011.13.20 17.944.42.68 (0.72, 18.82) .oup.com/tbm/advance-article-abstract/doi/10.10
9
3
/tb
Cost (1) ost: N = 15 2χOR (CI) or 2.45 (0.63, 9.49) 1.13 (0.21, 5.95) 1.33 (0.32, 5.55) 0.44 (0.12, 1.80) 1.51c 4.22 (0.86, 20.85) m/iby134/5261947
ContinuedTable 3 | Free (0) vs. Free: N = 22; C %(0)%(1) bTeacher Participation31.853.3aImplementation Leaders18.220.0 a27.333.3External InvolvementaExternal Information Sharing45.526.7aAccountability 0.06.7aOutcomes13.640.0aConstruct affects school–teacher relationship for implementation. bConstruct affects teacher–student relationship for implementation. c2χOR not calculable, value provided. *Indicates significant difference, p < .05. CFIR Consolidated Framework for Implementation Research; CBPA classroom-based physical activity. by Boise State University user on 30 July 2019
TBM page 7 of 11
ORIGINAL RESEARCH
champions or creating new leadership roles for c
sti 7* 8 4* 3* 6*
itsmecahpcolhoeeml r (eNonn tla=yt  io2(Nn0 )).,= A fo1mu7r)o nvimegr ppsulreosm gterhanomtsaest ittoaanrrg gfeeattceetddo rttsoo httahhdee geted T-stati −3.3 −0.5 −3.2 −3.1 −2.0
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sgii(PnsmiArgtcarno)lamu,nit fodssiitcc reoh atderanbdi rntuulgleglyyeai n-tdihtigenne ir gasgmhhcf aoihetptrhere r eriionp adiirlstmsocdi ahg(psls ro lcoaebohmfmul e-ybl dee-ienaunvidt elnai(long itpni gaoict nunicrocde lnlaiaoues)sf,dsni rneccomgdeloa o. msnaisnTidr t oohmPproeAirinsmno)eg,-- eacher only (0) vs. tto school (1) (1) %(SD) 34.29 (17.28) 35.83 (14.58) 45.00 (27.02) 31.90 (17.28) 55.00 (27.92) Downloaded from
atCghnrFeoTdI u -Rttopoeu isttntacD oglc moson,me musr aem(paivnasbes raeeilsraseo nsdoindn fs t g hf oeadafacte c tisotnhihrrd eese odrxeif n o swcutclhteuocerdroe eem ssdn,ce ohrsw e)od.piotirhfle/fietsnere eanecntahicnceehgrs Targeted to t (0) %(SD) 5.97 (15.47) 2.35 (21.63) 2.79 (13.43) 6.25 (12.15) 6.97 (24.77) https://academ
between programs that were free versus those that 1 3 2 1 3 ic.o
were fee-based (Table 4). Programs that had research up
ewdvoeimrdeea nimnc)oe rfheoa rl ditk hseeilg ynI nitfonic eairnn Sctlleyut dthienig gch o(etnr  s=itn r−due2cxt.s9 s7wc, oiptrh e<isn .( 0it.5he).e,, dence (1) T-statistic −2.97* −2.47* −1.82 −3.02* −1.74 .com/tbm/a
Process (t = −1.82, p < .05), and school–teacher rela- vi d
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ssPtntitssnihhhhceoorodnaeiioEtnppt r tecxt sie xehen(h(at ta tsaago ims sp=cvrc f= hg 6 ( peo (−ttee .lr tw−7e 3te=rpe=.2 sos. up 1d  −. f0−b3oeo o36,rl3nftr. i hp,2 s. tc0 hpteh4p<eh2 e r,e n .<eo,ds p0 tI cgp 5ni.<h or0nr)<n aoe,f5i. e tm0soa.)iar0e5 anl l v a5Sl)ld ,ecrh)e 0s c orsttact–sechtnhdoui2ha ntar sce oeegn cshnovts i o(hegt,pilt dd–ro nra=–tteiosirenh sfneeg−iacga cc rhctt 3paea hhso.n.mrc3ra eoetae7trPlsls lcy , eetrrr tep aonee,hi hrll<vgtaraageie ertg.tted a0pdiidhtoo m5re eiinnedd)nars,--- No Research Evidence (0) vs. Research (0) %(SD)(1) %(SD) 21.17 (17.44)40.48 (15.15) 30.36 (17.60)46.30 (13.89) 30.80 (22.17)47.22 (27.80) 20.41 (14.48)38.10 (17.66) 42.35 (29.22)60.32 (17.17) ance-article-abstract/doi/10.1093/tbm
Appendix C. /ib
y
1
3
DTIhSiCsU rSeSseIOarNch identified a large number of packaged, statistic 1.05 −0.99 −0.90 −0.02 0.01 4/5261
adoption-ready programs for supporting CBPA T- 947
b
in schools. Programs ranged in their adaptability, y
intended audience, and PA delivery mode (e.g., 1) 7) 3) 9) 1) 9) Bo
tinoictAminnneelroilacgggaymt hcn h-pebhfnauooinraetmiauoreqdsrl geg,-psu d ah,durel cfeea t sasthlsmme,icioc vevrioameslisyeit n nn rtyweweaedtt eaxtdied pitxttne rheiervteovgl ouns iana .mvgas l,toielrup ev oarnalaessymefltcuatli ity hnnchscoo eteghofrooart rve-dfrpplafsineaded rr v osoorrer reeefmgeoe ldsliro l samo maabpetdttmedpeiteoenidh/rd odtgio ama nnut vivosctllsaiiee.o clno isuds hnHkgr)d to, is o seleuocplunws-dphlbrcpa- oeaplhupnetvvnooihvoceligroddeeerrtetll,.---- across key Intervention Characteristics Free (0) vs. Cost ( (0) %(SD)(1) %(SD) 28.57 (18.18)21.90 (19.3 31.82 (17.75)37.78 (18.3 31.82 (22.07)39.17 (27.4 24.68 (15.10)24.76 (19.8 46.75 (27.94)46.67 (28.2 ise State University user on 30 Ju
program adoption. It is likely that more extensive s  ly
iaateoavmidngfafof WriddepnniCc erl igioeetndFt imfshvd oI sCiReli fenavw nnB,r ai eagdttPnsawyheuAsdtsleh aiy oo, tli o-ofcaInla pnehr s coeutvt risev ecoogunrehlnsevpe rbs sneecpp a neodprowrrotmerrriaioigdtoteleshgrln ,r yta irts on mah pCt mrieoastmeh h.rosmpatp.enir rac reTagpounscohevrlytiaoinee nsrog rt gltierryihs gsida tme aim ctp nrhptso,ehi olztaefedseaelm eo-ntawi pmtoteiuotannaharrcltaelialkadnlyst--- Differences in index scoreTable 4 | Groupings CFIR Domains Inner Setting Characteristics of Individuals Process School/Teacher Grouping School–Teacher Relationship Teacher–Student Relationship *Indicates significant difference, p < .05. 2019
page 8 of 11 TBM
ORIGINAL RESEARCH
beneficial for teachers, since many value the ability school–teacher relationship implementation factors.
to tailor programs to meet the specific needs of their This corroborates previous evidence showing that
classroom [20, 22]. A majority of programs included many school-based PA programs have focused on
structured PA that was flexible in duration, which developing teachers’ skills and knowledge, with less
also provides flexibility to teachers. Most programs attention paid to behavior change, organizational
D
did not include formal training to implement CBPA factors, and other implementation drivers [39]. With o
w
and more often included an educational handout or so many programs addressing teacher-level factors, n
lo
resource guide/booklet. Although the provision of it seems that many programs put the responsibility ad
e
booklet/handout-type resources has value for ongo- for student behavior change solely in the hands of d
ing implementation support, structured training in teachers, which is not supported by recent literature fro
m
the form of professional development or preservice on effective implementation of PA programs [26]. h
learning—provided in conjunction with ongoing In accordance with systems approaches, multiple ttp
s
coaching—is likely to be a more effective approach stakeholders within a school, not just teachers, play ://a
c
for supporting ongoing implementation when com- a critical role in the success of CBPA program imple- a
d
pared with receiving materials alone [33]. Thus, mentation. Successful implementation efforts are em
many of the adoption-ready programs identified in likely to be those that create school-level changes, ic.o
this review may be more appropriate for stakehold- including changes in norms and culture around PA up
ers who have been introduced to CBPA previously, during the school day, through key features such .co
m
rather than first-time adopters. as administrative buy-in/support, goal setting, and /tb
The most commonly included implementation monitoring of progress. Among programs reviewed m
/a
factors within the Inner Setting, Characteristics of here, few included these implementation factors, d
v
a
Individuals, and Process domains of CFIR, were with 24.3, 8.1, and 29.7 per cent including gain- n
c
related to highlighting the physical and mental ben- ing initial administrative buy-in, setting goals for e-a
efits of CBPA, and supporting adaptations to the teacher implementation of CBPA, and monitoring rtic
delivery of CBPA. The consensus across programs, progress, respectively. Interestingly, even programs le
-a
with regard to increasing teachers’ knowledge of that were targeted to the school (vs. to teacher only) b
s
the benefits of CBPA, suggests that this is an essen- more adequately included implementation factors tra
c
tial core component of CBPA programs. However, related to both the school–teacher relationship and t/d
o
research shows that knowledge is typically not suf- the teacher–student relationship, further highlight- i/1
0
ficient for supporting sustainable behavior change ing the necessity of the whole-of-school approach for .1
0
[34]. Adaptability is critical for successful implemen- increased implementation support. 9
3
tation, as contextual factors can vary widely across Regarding teacher factors, although monitor- /tb
m
settings and “one size fits all” programs are generally ing was included in over a third of programs with /ib
not well received or sustainable [35, 36]. Although implementation materials, it was evident that goal y
1
3
many programs are being adapted in local contexts setting, teacher stage of change, teacher attitudes, 4
/5
[7], guidance on adaptations can be beneficial for and other teacher-level behavior change tech- 2
6
maintaining fidelity to the most critical aspects of niques were rarely included. Since goal setting 19
4
the program while permitting flexibility to other and monitoring in particular have been among 7
b
aspects. the most consistently effective tools in behavior y B
The lack of significant differences in implemen- change interventions [40, 41], future CBPA efforts o
is
tation factor inclusion between free and fee-based should aim to better incorporate and test these e S
programs suggests that both have similar potential tools. Regarding school-level implementation fac- ta
te
for supporting successful implementation. Although tors, over one-third of programs included external U
n
intervention cost is often a consideration in program involvement and information sharing, but leader- iv
e
adoption [37], school- or district-level leaders should ship engagement and school climate were seldom rs
consider whether programs have been empirically included. Previous research shows that leadership ity u
tested before making decisions regarding program characteristics (specific to CBPA) and school cli- se
uptake [38]. Indeed, programs with published mate around CBPA are important predictors of r o
n
research evidence had higher inclusion of imple- implementation [20, 21, 23, 24, 42]. Future CBPA 3
0
mentation factors with organizational-level implica- research should aim to develop (or utilize previ- J
u
tions (e.g., incorporating policy and assessing school ously developed) theoretically based tools that both ly 2
readiness) than programs without an evidence base. support school stakeholders’ ability to implement 01
9
Thus, programs created in research settings should the program and address the contextual factors
be highlighted when disseminating CBPA programs that serve as barriers or facilitators to implemen-
and resources. tation. Improving attitudes toward implementation
An individual teacher-directed approach was of CBPA would also likely benefit climate around
common among programs, illustrated by the PA in general and could further aid in implementa-
higher index scores among the student–teacher tion of a Comprehensive School Physical Activity
relationship implementation factors versus the Program [3, 4].
TBM page 9 of 11
ORIGINAL RESEARCH
In general, CBPA programs are readily available, SUPPLEMENTARY MATERIAL
but likely do not provide enough supporting mate- Supplementary material is available at Translational
rials alone to enable broad adoption and imple- Behavioral Medicine online.
mentation across schools. CBPA programs should
prioritize the inclusion of these materials to maxi- Compliance with Ethical Standards
D
mize usability. Resources that have been developed o
w
and curated by the Centers for Disease Control and Conflict of Interest: Authors Hannah G. Calvert, Hannah G. Lane, Carolina n
M. Bejarano, Kelli Snow, Kate Hoppe, Nicole Alfonsin, Lindsey Turner, and lo
Prevention to support school-wide implementation Jordan A. Carlson declare that they have no conflicts of interest. ad
e
of health interventions [43] and particularly CBPA d
implementation [44] can provide guidance in this Ethical Approval: This article does not contain any studies with human par- fro
m
area. Importantly, Leeman and colleagues noted that ticipants and animals performed by any of the authors. h
the complexity of tools was a barrier for school-level ttp
uptake; thus, there is a give and take between the Fmuencdhianngi:s mTh iast sCtuhdildyr ewna’ss Mfuenrdceyd K bayn stahse CKiatyth. aTrhinise rBeseerrayr cRhi cwhaarsd saolsno gsruapn-t s://a
c
complexity of a resource and its utility for facilitat- ported by the Institute of Education Sciences, U.S. Department of Education, a
d
ing school-wide change [43]. Stakeholders who are through grant R305A150277 to Boise State University, and by the em
disseminating programmatic resources for schools NNaattiioonnaall IInnssttiittuuttee so fo fD iHaebaelttehs uanndde rD iAgwesatrivde Naunmd bKeird nFe3y2 DDiKs1e1a5se14s 6o.f Tthhee ic.o
should consider this balance between resource com- opinions expressed are those of the authors and do not represent views up
plexity (including the number of implementation of the Institute of Education Sciences, U.S. Department of Education, or the .co
National Institutes of Health. m
factors addressed) and pragmatic usability to ensure /tb
that the resource will best fit the needs of a particu- m
Informed Consent: This study does not involve human participants and is /a
lar school context. therefore not required. d
v
a
n
c
e
Strengths and limitations References -a
This study was among the first to systematically rtic
le
investigate adoption-ready CBPA programs for their -a
inclusion of theory-based implementation contex- 1. SPkreinvnaelern cAeC o, fR oabveasnitbya aknhdt sSeNv,e rSek oeblteosni tyJA in, UPSer crihni ldErMen, , 1A9rm9s9t–ro2n0g1 S6C. J. bstra
tual factors. Our coding process yielded acceptable Pediatr. 2018;141(3):e20173459. c
inter-rater agreement, which supports the validity of 2. Society of Health and Physical Educators (SHAPE) America. The Essential t/do
the data. However, some content could have been 3. CCoemntpeorsn efnotrs Dofis Pehayssei cCaol Endtruocl atainodn . PRreesvtoennt, iVoAn:. SCHoAmPpEr eAhmeenrsiicvae; 2s0ch1o5o.l i/10
missed, which could have led to measurement error, physical activity programs: a guide for schools. 2013. Available at http:// .1
0
www.cdc.gov/healthyschools/physicalactivity/cspap.htm. Accessibility 9
bcount twacet sm toad oeb etaffionr mts attoe rcioamls mexucnluicsaivtee lyw iatvha pilraobgler abmy 4. vSeorciifieetdy  Deocfe mHbeearl t1h7 , 2an0d1 8.Physical Educators (SHAPE) America. 3/tbm
request and allow them to point out potential inaccu- CLoogm p6r0e hMeninsiuvtee sS cohfo oPlh Pyhsyicsailc aAl cAtcivtiivtyit yE Pacrohg Draamy s:[ pHoeslpitiinogn Asltla Stteumdeenntt]s. /iby
racies in our coding. The list of implementation fac- Reston, VA: SHAPE America; 2013. 13
tors was created using the investigators’ knowledge 5. AIncsttivitiutyte aondf MPheydsicicinael . EEdduuccaatitoinng toth Se chSotuodl.e nWt asBhoidnyg:t oTna, kDinCg: PNhaytisoincaall 4/52
of the literature and experience in CBPA research, Academies Press; 2013. 61
but the list may not contain all factors that are impor- 6. Calvert HG, Mahar MT, Flay B, Turner L. Classroom-based physical activ- 94
ity: minimizing disparities in school-day physical activity among elemen- 7
tant for implementation. Future studies should use tary school students. J Phys Act Health. 2018;15(3):161–168. by
other methods to identify and rank the importance 7. Carlson JA, Engelberg JK, Cain KL, et al. Implementing classroom physical B
of various implementation factors and strategies for activity breaks: associations with student physical activity and class- ois
room behavior. Prev Med. 2015;81:67–72. e
supporting CBPA implementation, such as concept 8. Donnelly JE, Greene JL, Gibson CA, et al. Physical activity across the cur- S
riculum (PAAC): a randomized controlled trial to promote physical activ- ta
mapping or the Delphi method [45, 46]. ity and diminish overweight and obesity in elementary school children. te U
Prev Med. 2009;49(4):336–341. n
9. Kelder S, Hoelscher DM, Barroso CS, Walker JL, Cribb P, Hu S. The CATCH iv
CONCLUSIONS Kids Club: a pilot after-school study for improving elementary students’ ers
Although many CBPA programs and resources nutrition and physical activity. Public Health Nutr. 2005;8(2):133–140. ity
10. Mahar MT, Murphy SK, Rowe DA, Golden J, Shields AT, Raedeke TD. u
exist, more work is needed to overcome the numer- Effects of a classroom-based program on physical activity and on-task se
ous barriers to widespread and ongoing implemen- behavior. Med Sci Sports Exerc. 2006;38(12):2086–2094. r o
11. Stewart JA, Dennison DA, Kohl HW, Doyle JA. Exercise level and energy n
tation of CBPA, as simply training teachers to deliver expenditure in the TAKE 10! in-class physical activity program. J Sch 30
CBPA is often not sufficient. Existing programs Health. 2004;74(10):397–400. J
should be supplemented with efforts to deliver 12. Whitt-Glover MC, Ham SA, Yancey AK. Instant Recess®: a practical tool uly
for increasing physical activity during the school day. Prog Community 2
implementation strategies that address the unique Health Partnersh. 2011;5(3):289–297. 01
contextual factors faced by each school. These 13. Castelli DM, Centeio EE, Hwang J, et al. VII. The history of physical activ- 9
ity and academic performance research: informing the future. Monogr
efforts likely need to address systems’ changes at the Soc Res Child Dev. 2014;79(4):119–148.
organizational and individual levels and should be 14. Rasberry CN, Lee SM, Robin L, et al. The association between school-
based physical activity, including physical education, and academic
prioritized in future research. This work can benefit
performance: a systematic review of the literature. Prev Med. 2011;52
from the use of implementation science frameworks (Suppl 1):S10–S20.
15. Donnelly JE, Hillman CH, Castelli D, et al. Physical activity, fitness, cog-
and methods, which is becoming more common in
nitive function, and academic achievement in children: a systematic
community-based research. review. Med Sci Sports Exerc. 2016;48(6):1197–1222.
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