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Using a multi-stakeholder experience-based design process to co-develop the Creating Active Schools Framework

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Background: UK and global policies recommend whole-school approaches to improve childrens' inadequate physical activity (PA) levels. Yet, recent meta-analyses establish current interventions as ineffective due to suboptimal implementation rates and poor sustainability. To create effective interventions, which recognise schools as complex adaptive sub-systems, multi-stakeholder input is necessary. Further, to ensure 'systems' change, a framework is required that identifies all components of a whole-school PA approach. The study's aim was to co-develop a whole-school PA framework using the double diamond design approach (DDDA). Methodology: Fifty stakeholders engaged in a six-phase DDDA workshop undertaking tasks within same stakeholder (n = 9; UK researchers, public health specialists, active schools coordinators, headteachers, teachers, active partner schools specialists, national organisations, Sport England local delivery pilot representatives and international researchers) and mixed (n = 6) stakeholder groupings. Six draft frameworks were created before stakeholders voted for one 'initial' framework. Next, stakeholders reviewed the 'initial' framework, proposing modifications. Following the workshop, stakeholders voted on eight modifications using an online questionnaire. Results: Following voting, the Creating Active Schools Framework (CAS) was designed. At the centre, ethos and practice drive school policy and vision, creating the physical and social environments in which five key stakeholder groups operate to deliver PA through seven opportunities both within and beyond school. At the top of the model, initial and in-service teacher training foster teachers' capability, opportunity and motivation (COM-B) to deliver whole-school PA. National policy and organisations drive top-down initiatives that support or hinder whole-school PA. To the authors' knowledge, this is the first time practitioners, policymakers and researchers have co-designed a whole-school PA framework from initial conception. The novelty of CAS resides in identifying the multitude of interconnecting components of a whole-school adaptive sub-system; exposing the complexity required to create systems change. The framework can be used to shape future policy, research and practice to embed sustainable PA interventions within schools. To enact such change, CAS presents a potential paradigm shift, providing a map and method to guide future co-production by multiple experts of PA initiatives 'with' schools, while abandoning outdated traditional approaches of implementing interventions 'on' schools.
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R E S E A R C H Open Access
Using a multi-stakeholder experience-based
design process to co-develop the Creating
Active Schools Framework
Andy Daly-Smith
1,2,3*
,ThomasQuarmby
1
,VictoriaS.J.Archbold
1
, Nicola Corrigan
4
, Dan Wilson
5
, Geir K. Resaland
2
,
John B. Bartholomew
6
, Amika Singh
7,8
,HegeE.Tjomsland
2
, Lauren B. Sherar
9
,AnnaChalkley
9
,AshC.Routen
10
,
Darren Shickle
11
, Daniel D. Bingham
3
, Sally E. Barber
3
,EsthervanSluijs
12
,StuartJ.Fairclough
13
and Jim McKenna
1
Abstract
Background: UK and global policies recommend whole-school approaches to improve childrensinadequate
physical activity (PA) levels. Yet, recent meta-analyses establish current interventions as ineffective due to
suboptimal implementation rates and poor sustainability. To create effective interventions, which recognise schools
as complex adaptive sub-systems, multi-stakeholder input is necessary. Further, to ensure systemschange, a
framework is required that identifies all components of a whole-school PA approach. The studys aim was to co-
develop a whole-school PA framework using the double diamond design approach (DDDA).
Methodology: Fifty stakeholders engaged in a six-phase DDDA workshop undertaking tasks within same
stakeholder (n= 9; UK researchers, public health specialists, active schools coordinators, headteachers, teachers,
active partner schools specialists, national organisations, Sport England local delivery pilot representatives and
international researchers) and mixed (n= 6) stakeholder groupings. Six draft frameworks were created before
stakeholders voted for one initialframework. Next, stakeholders reviewed the initialframework, proposing
modifications. Following the workshop, stakeholders voted on eight modifications using an online questionnaire.
Results: Following voting, the Creating Active Schools Framework (CAS) was designed. At the centre, ethos and
practice drive school policy and vision, creating the physical and social environments in which five key stakeholder
groups operate to deliver PA through seven opportunities both within and beyond school. At the top of the
model, initial and in-service teacher training foster teacherscapability, opportunity and motivation (COM-B) to
deliver whole-school PA. National policy and organisations drive top-down initiatives that support or hinder whole-
school PA.
Summary: To the authorsknowledge, this is the first time practitioners, policymakers and researchers have co-
designed a whole-school PA framework from initial conception. The novelty of CAS resides in identifying the
multitude of interconnecting components of a whole-school adaptive sub-system; exposing the complexity
required to create systems change. The framework can be used to shape future policy, research and practice to
embed sustainable PA interventions within schools. To enact such change, CAS presents a potential paradigm shift,
providing a map and method to guide future co-production by multiple experts of PA initiatives withschools,
while abandoning outdated traditional approaches of implementing interventions onschools.
Keywords: Whole-school, Children, Whole-system, Double diamond, Co-development, Physical activity, Policy,
Physical education, Experience-based co-design
© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: a.daly-smith@leedsbeckett.ac.uk
1
School of Sport, Leeds Beckett University, Headingley Campus, Leeds LS17
7TL, UK
2
Center for Physically Active Learning, Faculty of Education, Arts and Sports,
Western Norway University of Applied Sciences, Sogndal, Norway
Full list of author information is available at the end of the article
Daly-Smith et al. International Journal of Behavioral Nutrition and Physical Activity
(2020) 17:13
https://doi.org/10.1186/s12966-020-0917-z
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Globally, 50% of children do not meet the internationally
recognised target of 60 min of moderate-to-vigorous
physical activity (MVPA) per day [1,2]. This figure rises
to 80% in higher-income countries [2] and persists into
adolescence [3]. Given these figures, it is not surprising
that the latest global physical activity report card states
childrens physical activity poses a serious level of con-
cern[4]. To effectively address such high levels of con-
cern, health promotion endeavours need to target all
levels and settings. As the majority of children have ex-
posure to school it is unsurprising that global and UK
policy recommend whole-school approaches as one of
the most promising investments for physical activity in
childhood [58]. Specifically, within the UK, the govern-
ment provide ring-fenced funding to support primary
schools (children aged 5 to 11) to provide a minimum of
30-min of physical activity per day for all pupils [9,10].
Despite these calls, it remains unclear what are the
most effective whole-school approaches to sustain
change and how they can be successfully implemented.
Concurrently, recent meta-analysesestablish that
school-based interventions have little, if any, effect on
school-time MVPA [11] or daily MVPA [12]. This may
result from the challenge of designing and delivering
feasible and sustainable approaches in schools, as evi-
denced by the many randomised controlled trials of
school-based physical activity programmes displaying
poor implementation e.g. [1315]. These findings have
been attributed to top-downapproaches where re-
searchers and external stakeholders drive intervention
design with limited input from school stakeholders [16].
Co-production of interventions by all stakeholders is
therefore essential, galvanising both bottom-up and top-
down approaches to create systems change[5,17].
The failure to establish effective physical activity inter-
ventions suggests a need to mobilise schools and align
the willing support being offered by associated stake-
holders. To do so, a whole-school physical activity
framework is required that moves beyond the conceptual
understanding of the school environment to one which
presents schools as a wider complex adaptive sub-
system[18,19]. Complex adaptive systems possess
many heterogeneous components that dynamically
interact and produce an emergent effect greater than the
individual elements, which must persist and adapt to
changing circumstances[20]. We believe the deficiency
of current conceptual models to present a map of the
many component parts likely explains why schools and
associated stakeholders fail to implement interventions
at the desired level and sustain implementation over an
extended period of time [2124]. Further, while all
frameworks (e.g. comprehensive school physical activity
programme [21]) incorporate socio-ecological theory, no
frameworks have embedded a modern understanding of
behavioural science (e.g. COM-B) [25]. This is essential
to enable all stakeholders to appreciate the magnitude of
the factors that need to be addressed and, adopt
evidence-based approaches to change the behaviours
and create system change.
New integrated approaches have emerged that enable
the identification and combination of the expertise of
multiple stakeholders in the development of systems ap-
proaches [16]. Yet, to date, these have not been applied
within the school setting, nor to design a comprehensive
whole-school physical activity framework. Importantly,
these human-centered approaches focus on outcomes
that enthuse, incentivise, and build on the strengths of
all stakeholders [26]. One common approach -
experience-based co-design - has been widely used to
create systems change in emergency medicine and men-
tal health care settings [27,28]. A specific method of
experience-based co-design is the Double Diamond De-
sign Approach (DDDA) [29] that has been used to de-
velop service improvements in health and social care
[30], patient-centered cancer treatment facilities [31],
and organisational medical care [32]. The DDDA draws
on recent discoveries on how to optimise both divergent
- creating choices- and convergent - making choices -
creative thinking processes [29,33]. With DDDA, stake-
holders progress through a four-stage reflective process
to discover, define, develop, and deliver an innovative
solution to a problem. The strength of this design ap-
proach resides in the collaboration between multiple
stakeholders within an innovative development process
to produce an understanding greater than the sum of
the individual parts [26].
The aim of the current study was to co-develop a
whole-school physical activity framework with multiple
stakeholders, using the DDDA. To our knowledge, this
will be the first UK-based whole-school physical activity
framework and the first time that any framework has in-
volved experience-based co-design from conception.
Given the novelty of this approach, the following section
will present a detailed methodology of the design ap-
proach to demonstrate the iterative nature of the design
process as each phase impacts the next.
Methodology: framework development process
Participants
Purposive sampling [28], a key facet of experience-based
co-design methodology, was used to identify participants
for the six initial same stakeholder groups (1. UK re-
searcher, 2. public health specialist, 3. active schools co-
ordinator, 4. headteacher, 5. teacher and 6. active
partner schools specialist; stakeholder descriptors, see
Additional file 1). Participants (n= 50, Table 1) were re-
cruited through networks of three of the authors
Daly-Smith et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:13 Page 2 of 12
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(research, ADS; practice, DW; policy, NC). Other than
national researchers and public health representatives,
all participants were recruited from across the Yorkshire
and Humber region, one of the largest regions within
the UK (5.4 million people across 15 local authorities;
1776 primary schools). The region has the same levels of
physical (in) activity and educational outcomes than the
rest of the UK, resulting from a broad range of ethnici-
ties, socioeconomic status and rural/urban landscapes.
The stakeholders were specifically compiled to ensure
representation of the different demographics, local au-
thorities and a range of professional experiences. To en-
sure a broad national perspective (i.e. to include
opportunities and barriers beyond the experience of re-
gional schools), we invited national organisations and
representatives for the Sport England Local Delivery Pi-
lots. In addition, active schools researchers from beyond
the UK were invited to present an international perspec-
tive. No limits were placed on the number of partici-
pants in the final three stakeholder groups. Participants
were contacted via telephone and/or e-mail and were re-
quired to return consent prior to engaging in the work-
shop. Ethical clearance was granted by Leeds Beckett
University Research Ethics Committee (N
o
60271).
Overview
The initial whole-school physical activity framework de-
velopment phase took place during a two-day event in
June 2019, Leeds, UK. On day one, the stakeholders ob-
served a conference for 80 school senior leaders and
governors on whole-school approaches to physical activ-
ity. Specifically, the six initial stakeholder groups were
tasked with observing an idea generation workshop
where school leaders were tasked with identifying strat-
egies to increase MVPA by at least two minutes during
one of seven selected school-day segments. A two-
minute increase was suggested to encourage school
leaders to identify small changes that were more feasible
to implement in a packed curricular and were, therefore,
more likely to be sustainable. On day two, the stake-
holders engaged in the whole-school physical activity
framework development process using the DDDA [29]
(stage 1; Fig. 1). Following the framework development
day, an online questionnaire (stage 2) was used to mod-
ify the initialwhole-school physical activity framework
developed on day two.
Stage one: double diamond design approach
The DDDA was divided into six phases with one or
more tasks (A/B) per phase (outline; Fig. 1). Within each
phase, stakeholders worked in the same stakeholder
groups (e.g. teachers) or mixed stakeholder groups. All
discussions were recorded via dictaphones on each table.
Stakeholders were allocated to mixed stakeholder groups
using the following principles: first, one member from
each of the six initial same stakeholders groups, ensuring
a balance in the number of years of experience. Second,
stakeholders from the national organisations, local deliv-
ery pilots and international researchers were allocated to
a group, ensuring a balance in experience and group
numbers. Due to illness, only five Public Health Special-
ists were present. Therefore, stakeholders from the local
delivery pilot were allocated first and were asked to play
dual roles where they possessed the relevant expertise.
The workshop began with a summary of day one.
Next, lead researchers briefed participants on the DDDA
and the expected outcome, which was to create a whole-
school physical activity framework that would support
every child to increase their physical activity levels, work-
ing towards achieving 30 min of in-school and 60-min of
Table 1 Key stakeholder characteristics
Stakeholder Group Proportion (%)of
males/females
Years in current role
mean (range)
Years in current profession
mean (range)
Years as a qualified teacher
mean (range)
UK researchers (n= 6) 33/67 6.46 (3.012.0) 13.50 (10.018.0)
Public Health specialists
(n=5)
0/100 2.40 (0.83.0) 15.30 (8.021.5)
Active school coordinators
(n=6)
17/83 8.17 (2.016.0) 13.96 (7.820.0) 17.75 (0.032.0)
Headteachers (n= 6) 83/17 6.20 (3.89.8) 18.47 (13.730.0) 18.47 (13.730.0)
Teachers (n= 6) 50/50 4.93 (0.711.7) 13.38 (7.020.0) 11.71 (0.020.0)
Active partner school
specialists (n=6)
33/67 3.63 (0.49.8) 6.04 (0.415.0) 2.67 (0.016.0)
National organisation
representative(n=5)
40/60 5.9 (1.1716.0) 20.0 (10.041.0) 11.8 (0.041.0)
Local deliver pilot
representatives (n=5)
80/20 5.43 (0.315.0) 20.8 (10.040.0) 15.0 (0.040.0)
International researchers
(n=5)
60/40 11.62 (1.022.0) 18.73 (5.028.7) 0.40 (0.02.0)
Daly-Smith et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:13 Page 3 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
daily MVPA. Stakeholders were not introduced to exam-
ples of current school-based physical activity frameworks
[21,23,34] until the beginning of phase four. The re-
search leads took this decision as they did not want to
influence the initial designs. In addition, the UK and
international researchers were members of each mixed
stakeholder group and were aware of the different
frameworks so could refer to these within group discus-
sions if it was deemed appropriate.
The six development phases are outlined in Fig. 1.Spe-
cifically, within phase five, individuals voted for the draft
framework that best achieved the brief. Each participant
received three votes with a maximum of two votes being
allowed for any one framework. Any uncast votes were
placed on the side of the voting slip. Participants were not
allowed to vote for their own framework. Overall, mixed
stakeholder group fours draft framework received the
most votes (average number of votes per individual 1.2,
see Additional file 2). When the votes were broken down
by the same stakeholder groups, framework four was the
most popular choice in seven of the nine groupings.
Within phase six, the participants reformed into same
stakeholder groups to review framework four, the initial
frameworkdiscussing; i) what was good about the ini-
tialframework and what needed improving? ii) how the
framework may be used by their stakeholder group and
iii) the next steps? On completion of phase six, the lead
facilitators drew the workshop to a close and informed
the participants of the next whole-school physical activ-
ity framework development stage.
Stage two: online questionnaire
An additional stage - beyond the DDDA - was under-
taken to refine the initialframework (framework four)
to ensure it reflected the needs of all stakeholders. The
refinement process was undertaken remotely via an on-
line questionnaire. To develop the questionnaire, the
lead author extracted proposed modifications to the
intialframework from the audio recordings from the
nine same stakeholder groups phase six, final discus-
sions. Eight proposed modifications were suggested
(Table 2), with visual modifications being made to
framework four to demonstrate each proposed alter-
ation. Finally, the prototype frameworks that represented
each proposed modification were viewed, discussed and
approved by four authors. Once approved, an online
questionnaire was created to enable the original stake-
holders to vote (sequentially) on the suggested modifica-
tions. This was emailed two weeks after the initial
workshop and remained open for two weeks.
Results
Online questionnaire results: modification to the initial
framework
Seventy-four percent of the original stakeholders responded
totheonlinequestionnaire.Proposed modifications were
accepted when; > 50% of the participants voted to accept a
modification and > 50% of the stakeholder groups (five or
more) voted for the modification. Proposals one, two, three,
four, six and seven were accepted (Table 2). Proposals five
and eight were rejected. Finally, due to proposal five being
Fig. 1 The Double Diamond Design Approach used to develop the Creating Active Schools Framework
Daly-Smith et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:13 Page 4 of 12
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Table 2 The proportion (%) of stakeholders who agreed with the eight proposals to modify the initial whole-school physical activity framework
1. Change skills,
knowledge &
competence to
capability, opportunity
& motivation
2. Change teacher
practice & ethos
to whole-school
practice & ethos.
3. Change 5
original pillars
to 5 people-
orientated
pillars
4. Show social &
physical
environment as
interweaving
through the 5 pillars.
5. Present the five
pillars and social/
physical
environments as a
DNA helix?
6. Introduce a new part
to the model where
children are included as
the main beneficiaries?
7. Change the best-
practice physical activity
box to include 7 PA seg-
ments/ opportunities?
8. Rotate
the model
90 degrees
to the left?
UK Researchers (n = 5) 100 100 80 100 20 80 60 40
Public Health (n = 5) 100 80 100 100 0 80 80 80
Active Schools (n= 4) 75 100 100 100 50 100 50 50
Head Teachers (n = 5) 100 100 100 80 60 80 40 60
Teachers (n = 5) 100 80 60 100 60 100 60 20
Active Partners (n = 4) 100 100 100 75 25 100 75 50
Nat Organisations (n= 3) 33 67 100 100 67 100 100 100
LDP (n= 1) 100 100 100 100 100 100 100 100
Int Researchers (n = 5) 100 100 100 80 40 80 0 40
Total (n= 37)
Overall in agreement 92 92 92 92 41 89 57 54
Number of groups
with +ve response
8of9 9of9 9of9 9of9 4of9 9of9 6of9 4of9
Accept/ Decline
modification
Accept Accept Accept Accept Decline Accept Accept Decline
Modifications were accepted when > 50% of the total sample voted for the change and more than half of the stakeholder groups (5 or more) voted for the change. Bold text indicates proposal acceptance
Daly-Smith et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:13 Page 5 of 12
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declined, four authors designed an alternate representation
of the social and physical environment, weaving the envi-
ronments through the five people-orientated pillars.
Creating Active Schools Framework: description
Overview
The primary outcome of the study was the CAS Frame-
work (Fig. 2). The framework identifies the multiple
components required to establish schools as a complex
adaptive sub-system which, in turn, will facilitate whole-
school physical activity implementation. The bottom half
of the framework outlines the in-school factors, while
the top half identifies factors associated with teacher
training, behavioural science and the role of national
and international organisations and policy development;
the wider system beyond an individual school.
Whole school practice and ethos
The cornerstone of the CAS framework is establish-
ing whole-school practice and ethos for physical ac-
tivity - the underlying sentiment that informs the
beliefs, customs and practices around creating a
physically active school; the central box. Working
downwards, whole-school practice and ethos drives
internal school policy and vision, both essential
Fig. 2 Creating Active Schools (CAS) Framework
Daly-Smith et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:13 Page 6 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
components of creating a whole-school physical ac-
tivity approach through engaging relevant stake-
holders and creating facilitative social and physical
environments [35,36].
Key stakeholders
Five groups are included in policy and vision as essential
stakeholders; school leaders, teachers and other school
staff, children/young people, parents/guardians, and
wider stakeholders (e.g. active school coordinators, pub-
lic health specialists). School leaders (principal, wider se-
nior leadership team and governors) are responsible for
leading the development of the policy and vision state-
ments and managing associated resources. Teachers and
wider school staff are central to creating positive social
and physical environments, alongside delivering initia-
tives within the seven opportunities. Other school staff
include playground supervisors or teaching assistants,
both of whom can play an important role in whole-
school physical activity provision. Children and young
people may form pupil councils or lead opportunities for
physical activity (e.g. playground leaders). Parents/
guardians play a significant role in supporting children
to engage in extracurricular activities and may also form
parent associations. Wider stakeholders may include; ac-
tive school coordinators, active partner school specialists
or external private, charity or voluntary sector organisa-
tions who deliver initiatives within the seven opportun-
ities, or, support schools with systems-level change. All
stakeholders are essential to creating and sustaining a
whole-school physical activity approach.
The social and physical environment
The five people-orientated pillars operate within the
physical and social environment. The physical envir-
onment reflects the amount, variety (e.g. green space,
playground, school hall) and quality of school spaces
and resources available [37]. The social environment
reflects the degree to which the stakeholders engage
and support each other to provide physical activity.
For example, teachers who implement physically ac-
tive learning within supportive school social environ-
ments experience fewer implementation barriers
[3840].
Seven opportunities for physical activity
Combined, the environment and key stakeholders deter-
mine the implementation of physical activity across
seven opportunities. The opportunities are determined
by what the school can control (from the centre to the
left) and opportunities that the school can influence (to
the right of centre). The opportunities with the greatest
potential impact on whole-day physical activity reside
closest to the framework midline. Expanding physical
activity into curricular lessons (not Physical Education)
using exercise breaks or physically active learning both
enhance levels of MVPA [41,42]. Moving left, Physical
Education [4346] and break/ lunch (recess) [4648] in-
terventions that extend the duration, increase the fre-
quency and/or enhance the delivery have been shown to
be effective [49]. Finally, trips (e.g. museums) and events
(e.g. sports day, summer fair) provide one-off opportun-
ities for physical activity engagement.
Right of centre, before/ after school clubs and active
travel are opportunities that schools can influence but
cannot control, as responsibility largely resides with chil-
dren and their families. Once engaged, the school does,
however, play a central role in determining the amount
and quality of such provision (e.g. active travel plans). If
successful, both opportunities can significantly contrib-
ute to a childs whole-day physical activity levels [11,
5053]. Finally, the school can influence family and
community physical activity beyond school time. This
may involve providing active homework [54] or opening
school facilities beyond the school day to support com-
munity organisations [55]. The culmination of establish-
ing a whole-school practice and ethos that includes
physical activity focused policies and vision, positive en-
vironments, engagement with stakeholders and provision
of effective opportunities, will enhance the amount and
quality of physical activity experiences children receive
in and beyond school.
Teacher training and behavioural change theory
Working upward from whole-school practice and ethos,
wider political and policy systems - beyond the school -
strongly influence the in-school provision of physical
activity. Initial teacher training and in-service training
(CPD) are central to enhancing the capability and mo-
tivation of school staff to implement physical activity.
Currently, initial teacher training fails to provide newly
qualified teachers with sufficient capability to become
effective whole-school physical activity practitioners
[34,5658]. Until initial teacher training evolves to
meet the demands of contemporary teachers who are
tasked with delivering a curriculum focussed on phys-
ical, social and emotional development, high-quality in-
service training (CPD) is required [58]. Training should
enhance delivery skills, while also upskilling teachers
and school leaders to lead systems change for physical
activity. Behavioural science is a required component of
all training programmes (initial teacher training or in-
service training (CPD)) to enhance the capability, op-
portunity and motivation (COM-B, Michie et al., 2011)
of all stakeholders and the school system, thus maxi-
mising the likelihood of change. This, in turn, will in-
fluence the capability, motivation and opportunity of
thechildrenwithintheschools.
Daly-Smith et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:13 Page 7 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
National organisations and policy
The final part of the framework involves national organi-
sations and policies that drive the educational focus of
schools and the training needs of the key stakeholders.
While physical activity may not be front and centre of
such policies, it is essential that they align to support phys-
ical activity and avoid inadvertently promoting conflicting
behaviours (e.g. prolonged sitting in lessons). Finally, it is
essential that the framework - and approaches within - are
informed by research evidence to ensure the highest qual-
ity provision for the children whom they serve.
Discussion
To the authorsknowledge, this is the first time that
practitioners, policymakers and researchers who under-
stand the powerful driving agents of school systems and
teacher and pupil physical activity behaviour, have co-
designed a whole-school physical activity framework
from initial conception. The underlying DDDA, previ-
ously used to develop high-quality systems change in
multiple healthcare settings, was used to develop and in-
novative practice and evidence-based framework that
meets the needs of each stakeholder as well as the import-
ant constituent parts required for effective and sustainable
implementation. To achieve such an outcome, it was es-
sential for the design process to incorporate multiple
stages of divergent and convergent thinking to optimise
the final framework by challenging and refining initial
views. As a result, CAS has high face validity, and because
it has been endorsed by a range of professional groups, it
also demonstrates professional and contextual credibility.
Implications for practice
Providing greater detail than previous frameworks [2124],
CAS confirms the large number of components that must
be addressed so schools can evolve into adaptive sub-
systems with physical activity at the heart of their provision.
While little is currently known about the inter-relationship
between the different elements - and CAS does not identify
those with the greatest effect - it is the first framework to
establish whole-school ethos and practice at the heart of
whole-school physical activity provision. Importantly, and
in agreement with previous frameworks, CAS refutes the
notion of deploying single-element interventions; it rein-
forces the need to create systems change through school
leadership groups. Such change has already been identified
within current research and frameworks [21,24], yet re-
mains elusive within the school environment [34,59].
Framing every school as a unique, complex adaptive
sub-system, CAS establishes the importance of whole-
school ethos and practice. This is consistent with
Meadows[60] 12 levers of influence where value-based
leverage is central to creating sustainable change; this is
best achieved by (i) identifying systems goals, (ii)
understanding the paradigm guiding the design of the
new system and (iii) encouraging a shift in the decision-
making paradigm as new challenges arise. The dyna-
mism and complexity outlined by the potential interplay
of so many facets helps to put flesh on the bones of the
notion of compensating feedback, which explains why
powerful sub-systems, like schools, resist powerfully
[61]. To create change, CAS confirms that so much
needs to be made right. This was most evident in the in-
teractions between the five stakeholders within the social
and physical environments; these are levels that many
physical activity initiatives and previous frameworks
overlook [5].
The CAS framework presents seven physical activity
opportunities, a greater number than observed in previ-
ous frameworks [21]. The specific positioning of each
opportunity draws on contemporary physical activity
promotion theory (expand, extend and enhance) and a
recent meta-analysis to place the most effective toward
the framework midline [11,49]. Combined, this ensures
that practitioners are being guided by the current evi-
dence base to operationalise the most effective physical
opportunities.
Of great surprise, the seven opportunities were posi-
tioned at the lowest level, suggesting not only their fra-
gility but also the importance of higher-level factors.
While previous frameworks and contemporary research
recognise the need for higher-level engagement, this is
contrary to current practice which is often characterised
by limited engagement with different levels of the school
system [62]. Consistent with previous whole-school
frameworks [21,24], the CAS framework reminds all
stakeholders to move beyond simple interventions to be-
come systems thinkers in action[17]; this reminds
practitioners to address at least three levels of their
school system; the grand system (e.g., Schools), local sys-
tem (e.g., a single school) and system parts (the mecha-
nisms of individual events/provision) [63].
The old counselling adage of the map is not the terri-
toryapplies to CAS; CAS does not identify the specifics
of any individual school. Change leaders who may act as
whole-school physical activity champions - as seen in
the comprehensive school physical activity programme
and Action Schools BC frameworks [21,24,64]can
use the framework to develop a bespoke process to fit
the unique requirements of their school. With over 20
active components, physical activity champions will re-
quire a system change plan. That plan will identify the
priorities and modify the existing structures to create
change. Perhaps this is the first framework where all of
the components have been collated. For the first time,
CAS reveals the complex challenges facing these cham-
pions, especially primary school teachers and senior
leaders with little expertise in physical education
Daly-Smith et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:13 Page 8 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
delivery, let alone systems change for whole-school
physical activity [23]. Given this complexity, as
highlighted in the CSPAP partnership framework [23], it
makes sense to address these issues in initial teacher
training programs and in-service training (CPD); in-
service teachers will need to embed the skills that estab-
lish (i) the capability, opportunity and motivation for
systems change and (ii) systems change that secures
whole-school physical activity. Importantly, the CAS
framework is the first that embeds a modern, eclectic
behaviour change framework (COM-B) [25]. The inte-
gration of the COM-B framework reflects a need for
accessible language while retaining an underlying com-
plexity of twenty-first-century behavioural decision-
making.
Unique to CAS is the practical implementation of the
framework where schools and wider stakeholders can
promote self-reflection by mapping current provision
and identifying underserved components. Maintaining
the co-production process, initiatives should be imple-
mented with, rather than on schools. At this stage, it is
essential that children, who were not engaged in our co-
development process, become equal partners in identify-
ing, developing and implementing future interventions.
To support schools, an evidence-based audit tool would
emphasise the importance of all CAS framework compo-
nents, especially whole-school ethos, practice, policy and
vision; components often neglected in previous interven-
tions. While CAS was developed within a specific UK
context, its flexible nature allows replication elsewhere.
Moreover, while secondary (high) schools may benefit
from using CAS as a guiding framework, it is important
that they establish face validity and acceptability as initial
priorities. Perhaps the first step is to identify early
adopters and seek to test and learn new/novel processes
for creating whole-school practice and ethos aligned to
physical activity.
Implications for policy
Similar to the CSPAP framework, CAS establishes the
important role of national organisations and policy. The
uniqueness of CAS resides in the graphical representa-
tion of the national organisations and policy layer as it
reinforces the importance of creating both horizontal
and vertical alignment of people, organisations and pol-
icies; this will help ensure that all changes move in the
same direction. Vertical alignment reflects the need for
key issues to be reinforced throughout all processes
down to the level of individual pupils and moments
within the school day. In contrast, horizontal alignment
requires a common shared vision within each level of
the system (e.g. national organisations and government
departments, e.g., in the UK of Health & Social Care,
Education and Digital, Culture, Media & Sport).
Misalignment between horizontal and/or vertical issues
is likely to create unhelpful friction that challenges the
creation of a clear whole-school ethos [17], weakening
any resulting interventions. To enact policy and evolve
current practice, uniquely, CAS not only provides a
checklist for change agents but also a template for the
development of a healthy schools rating scheme. Mul-
tiple schemes currently exist [65,66], yet few reflect the
full range of influential components. As a result, they
may lack the detail required to promote effective and
sustainable physical activity initiatives.
Government education, health and sports departments
that value physical activity can use the CAS framework
to drive strategic change within the education system.
Naming all departments, for the first time, promotes the
use of one central framework for whole-school physical
activity as it can be used to drive combined efforts
across all UK government departments and policies.
Such alignment, as previously stated, is central to creat-
ing a sustainable adaptive system that promotes one vi-
sion of creating an active school; CAS is unique in
graphically representing this opportunity. Furthermore,
bodies that hold schools to account for educational stan-
dards (e.g., Office for Standards in Education in the UK)
can utilise CAS as a tool to support schools to embed
physical activity throughout the school day. In addition,
national and localised sport and health organisations that
set strategies for grassroots sports and health improve-
ment can use CAS to highlight their role in whole-school
physical activity. CAS will enable organisations to align
their provision and develop more efficient and sustainable
practises in schools and their local communities.
Implications for research
The CAS framework provides researchers with an un-
derstanding of the multiple components that need to be
addressed to create and evaluate whole-school physical
activity interventions. It emphasises the need for re-
searchers to move beyond push approaches and co-
develop interventions with multiple stakeholders within
the school setting from conception [16]. The challenge
for researchers resides in creating programmes that cre-
ate systems-level change within schools. Unlike previous
frameworks, CAS highlights the need to focus on
school-level change, the role of each key stakeholder
group and the social and physical environments, not just
the interventions within the seven opportunities [62].
CAS, therefore, reveals the required components re-
searchers must be aware of when supporting schools in
the design, delivery and evaluation of future physical ac-
tivity interventions. Further, this study provides a tem-
plate for physical activity researchers in the UK and
beyond to adopt experience-based co-design approaches,
specifically using the DDDA approach.
Daly-Smith et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:13 Page 9 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Strength and limitations
A particular strength of the CAS framework is that it is,
to the authorsknowledge, the first to deploy a co-
development methodology with multiple stakeholders
holding deep and wide experience of UK school systems.
While pioneering, the final framework is based on the
vision of a specific group of stakeholders and this spe-
cific process. Involvement of further stakeholders (chil-
dren, parents, school nurses etc) or indeed alternate
expertsmay have yielded different outcomes. Yet, CAS
reflects insights from the UK and select westernised
high-income countries meaning it is likely to provide a
reasonable reflection of the components of a whole-
school physical activity framework within similar coun-
tries and education systems. In addition, the flexibility of
CAS enables contrasting school systems to prioritise dif-
ferent components with the framework to meet curricu-
lar and logistical needs. Children were not included in
the development of the CAS Framework due to the
focus on systems and processes, rather than implemen-
tation. It is envisaged that children, as key stakeholders,
will be central to creating a schools individual imple-
mentation plan and will support the implementation of
the actions needed to provide effective physical activity
opportunities.
This is the primary instance that an experience-based
co-design process - the DDDA - has been used within
the whole-school physical activity field. Recognising our
relative inexperience in design, and notwithstanding that
the paper provides a powerful template for future pro-
jects, improvements may emerge from a more refined
design process. Further, while the framework provides a
map, it does little to identify how the respective parts
interact, nor does it specify the optimal sequence(s) or
interactions that need to take place [67]. Future research
and practice collaborations will need to investigate the
implementation of the framework.
Conclusion
The CAS Framework was co-produced from initial con-
ception by multiple experts who understand the power-
ful driving agents of school systems and teacher and
student physical activity behaviour. The novelty of the
CAS framework resides in formally identifying the multi-
tude of interconnecting components of a whole-school
adaptive sub-system; this exposes the complexity re-
quired to create systems change. The iterative design
process, involving multiple stakeholders who understand
the layers of influence within and beyond schools, has
high face validity which may, for the first time, consoli-
date and direct the efforts of all stakeholders. The CAS
framework can be used to shape future policy, research
and practice to embed sustainable physical activity inter-
ventions within schools. To enact such change, the CAS
framework presents a potential paradigm shift, providing
a map and method to guide future co-production by
multiple experts of initiatives withschools, while aban-
doning outdated traditional approaches of implementing
interventions onschools. To facilitate this change, a
practical toolkit and resources are required to support
schools to implement whole-systems change that meets
the needs of their individual setting. To maximise reach,
the toolkit should be housed on a web portal with face-
to-face workshops for those schools and stakeholders
who require more specific support.
Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.
1186/s12966-020-0917-z.
Additional file 1. Table S1. Stakeholder role descriptions
Additional file 2. Stage 1, phase 5 voting results; mean votes awarded
to each draft framework by stakeholder grouping
Abbreviations
CAS Framework: Creating Active Schools Framework; DDDA: Double-
diamond design approach; MVPA: Moderate-to-vigorous physical activity;
PA: Physical activity; UK: United Kingdom
Acknowledgements
We would like to acknowledge all of the participants who engaged in the
workshop and contributed to the development of the Creating Active
Schools Framework. In addition, we would like to thank Dr. Laurie Patterson
and Luke Norris who provided research support on the workshop day.
Authorscontributions
ADS, TQ, VSJA, NC, DW & JM created the study concept. ADS led the design
of the study with all authors contributing to the study design and ethics
submission. ADS, NC and DW recruited study participants. ADS and TQ led
the co-design workshop. ADS, DW, NC, JM and DS reviewed the initial frame-
work and suggested visual representations for the proposals. ADS and DW
designed the final CAS framework. ADS and JM drafted the manuscript and
had the overall responsibility for the final content. All authors contributed to
sections of the draft manuscript and have critically read, reviewed, and ap-
proved the final manuscript.
Funding
The conference and workshop were jointly funded through an internal
Leeds Beckett Research grant, the Yorkshire Sport Foundation and Public
Health England (Yorkshire and Humber). Twinkl Educational Publishing kindly
sponsored the conference and workshop event. ADS (partially), DDB and
SEBs involvement was supported by Sport Englands Local Delivery Pilot
Bradford; weblink: https://www.sportengland.org/our-work/local-delivery-
pilots-community-of-learning/. In additional DDB and SEB invovlement was
also funded by the National Institute for Health Research Yorkshire and
Humber ARC (reference: NIHR20016), and the UK Prevention Research
Partnership, an initiative funded by UK Research and Innovation Councils, the
Department of Health and Social Care (England) and the UK devolved
administrations, and leading health research charities; weblink: https://mrc.
ukri.org/research/initiatives/prevention-research/ukprp/. The views expressed
in this publication are those of the author(s) and not necessarily those of
Sport England, the National Institute for Health Research or the Department
of Health and Social Care. ACR is funded by the National Institute for Health
Research (NIHR) Applied Research Collaboration East Midlands (ARC EM). The
views expressed are those of the author(s) and not necessarily those of the
NIHR or the Department of Health and Social Care. Yorkshire Sport
Foundation (author, DW) and Public Health England (author, NC) were
involved in the design of the study, interpretation of the online voting
results and creation of the final Creating Active Schools Framework.
Daly-Smith et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:13 Page 10 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Availability of data and materials
Data sharing not applicable to this article as no datasets were generated or
analysed during the current study.
Ethics approval and consent to participate
The protocol and informed consent were approved by Leeds Beckett
University Research Ethics Committee (No 60271).
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
School of Sport, Leeds Beckett University, Headingley Campus, Leeds LS17
7TL, UK.
2
Center for Physically Active Learning, Faculty of Education, Arts and
Sports, Western Norway University of Applied Sciences, Sogndal, Norway.
3
Born in Bradford, Bradford Institute for Health Research, Bradford Teaching
Hospitals Foundation Trust, Bradford, UK.
4
Public Health England (Yorkshire
and Humber Centre), London, UK.
5
Yorkshire Sport Foundation, Gildersome,
UK.
6
Department of Kinesiology and Health Education, The University of
Texas at Austin, Austin, TX, USA.
7
Department of Public and Occupational
Health, Amsterdam UMC, Amsterdam Public Health, Amsterdam, The
Netherlands.
8
Mulier Institute, Utrecht, the Netherlands.
9
School of Sport,
Exercise and Health Sciences, Loughborough University, Loughborough, UK.
10
NIHR Applied Research Collaboration East Midlands (ARC EM), Diabetes
Research Centre, University of Leicester, Leicester, UK.
11
Leeds Institute of
Health Sciences, University of Leeds, Leeds, UK.
12
Centre for Diet and Activity
Research, MRC Epidemiology Unit, University of Cambridge, Cambridge, UK.
13
Dept. Sport and Physical Activity, Edge Hill University, Ormskirk, UK.
Received: 9 December 2019 Accepted: 23 January 2020
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67. Lewis MA, Fitzgerald TM, Zulkiewicz B, Peinado S, Williams PA. Identifying
Synergies in Multilevel Interventions: The Convergence Strategy. Health
Educ Behav. 2017;44:23644.
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... The CAS framework is the first whole-school approach to integrate multi-stakeholder perspectives with behaviour change theory (BCT) and implementation science to ensure it is informed by research and practice [19]. The framework underpinned the development of the CAS programme that focuses on transforming organisational culture to promote physical activity in schools across four domains: policy, environments, stakeholders, and opportunities. ...
... The framework incorporates both the COM-B model of behaviour change identifies three factors that must be present for behaviour change to occur [17], and the Consolidated Framework for Implementation Research (CFIR) to identify physical activity determinants across multiple levels of the organisation [20] (Supplementary File Figure S1). For more detail on the CAS framework and its theoretical underpinnings, please see Daly-Smith et al., 2020 [19]. This study aims to evaluate the effectiveness of the CAS programme on organisational culture for physical activity in schools. ...
... The research team sought to ensure questions aligned with the COM-B and CAS frameworks. First, the paper authors who have expertise in school-based physical activity, behaviour change, and implementation science reviewed the previously validated school wellness questionnaire (SWQ) [24], CAS framework [19], CAS profiling tool, COM-B model [21], and six-item COM-B questionnaire assessing the effectiveness of interventions [25]. From this, a set of questions were developed that focused on school readiness and organisational capacity to promote physical activity. ...
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Background: National and international guidance recommends whole-school approaches to physical activity, but there are few studies assessing their effectiveness, especially at an organisational level. This study assesses the impact of the Creating Active School's (CAS) programme on organisational changes to physical activity provision. Methods: In-school CAS leads completed a 77-item questionnaire assessing school-level organisational change. The questionnaire comprised 19 domains aligned with the CAS framework and COM-B model of behaviour change. Wilcoxon Signed Rank Tests assessed the pre-to-nine-month change. Results: >70% of schools (n = 53) pre-CAS had inadequate whole-school physical activity provision. After nine months (n = 32), CAS had a significant positive effect on organisational physical activity. The positive change was observed for: whole-school culture and ethos, teachers and wider school staff, academic lessons, physical education (PE) lessons, commute to/from school and stakeholder behaviour. Conclusions: This study provides preliminary evidence that CAS is a viable model to facilitate system-level change for physical activity in schools located within deprived areas of a multi-ethnic city. To confirm the results, future studies are required which adopt controlled designs combined with a holistic understanding of implementation determinants and underlying mechanisms.
... The purpose of education must be focusing on and developing the talents and potentials of each stakeholder in the school, instead of merely focusing on the students (Daly-Smith et al. 2020). When contemplating any implementation related to school improvement and effectiveness, teachers should be given priority as the second-largest group in educational settings after students because teachers are the primary agents of change in schools (MacGilchrist et al. 2004). ...
... This term refers to quality level and character feature of a school life (Coulombe et al. 2020). The research demonstrated that the self-efficacy of teachers is positively influenced by a supportive environment at school (Daly-Smith et al. 2020;Meristo and Eisenschmidt 2014). Finally, the last layer within EIS is the policy and societal values. ...
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There is a shifting paradigm in gifted education from person-based approaches (i.e., identifying giftedness) to process-based approaches (i.e., transacting giftedness). This new framework is centered on enriching educational opportunities that will make the process meaningful (i.e., gifted) to everyone in a setting. However, little is known about how this renewed perspective can be applied in teacher professional development. In line with the socio-ecological models, our study aims to identify the best appropriate model to describe teacher self-efficacy (i.e., the dependent variable in the study) as professional development from an ecological perspective and to propose an ecologically intelligent school (EIS) for the advancement of self-efficacy. Structural equation modeling (SEM) was performed to create a model using TALIS 2018 dataset. Afterward, indices of goodness-of-fit criteria were examined for each model. The results indicate that there is a complex ecological background, in that various factors affect the dependent variable. Model 3 was determined as the most suitable model that can be proposed as an ecologically intelligent school (EIS) for the advancement of self-efficacy. The factors within the three layers of the socio-ecological model-communication with teachers, communication with students, school climate, and feeling valued by the national level-altogether created an appropriate model explaining teacher professional development, regarding self-efficacy.
... Taken together, these findings support a whole school approach to PA premotions as has been demonstrated by the Crating Active Schools and CSPAS in the United Kingdom and United States respectively [43,44]. The whole school approach strives to create a physical and social environment that supports PA and increase opportunities for PA before, during and after school. ...
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Background Like many countries in sub-Saharan Africa, Kenya has experienced rapid urbanization in recent years. Despite the distinct socioeconomic and environmental differences, few studies have examined the adherence to movement guidelines in urban and rural areas. This cross-sectional study aimed at examining compliance to the 24-hour movement guidelines and their correlates among children from urban and rural Kenya.Method Children (n = 539) aged 11.1 ± 0.8 years (52% female) were recruited from 8 urban and 8 rural private and public schools in Kenya. Physical activity (PA) and sleep duration were estimated using 24-h raw data from wrist-worn accelerometers. Screen time (ST) and potential correlates were self- reported. Multi-level logistic regression was applied to identify correlates of adherence to combined and individual movement guidelines.ResultsCompliance with the combined movement guidelines was low overall (7%), and higher among rural (10%) than urban (5%) children. Seventy-six percent of rural children met the individual PA guidelines compared to 60% urban children while more rural children also met sleep guidelines (27% vs 14%). The odds of meeting the combined movement guidelines reduced with age (OR = 0.55, 95% CI = 0.35-0.87, p = 0.01), was greater among those who could swim (OR = 3.27, 95% CI = 1.09-9.83, p = 0.04), and among those who did not engage in ST before school (OR = 4.40, 95% CI = 1.81-10.68, p
... The concept of co-creation has a diverse heritage from psychotherapy, management science, innovation and open innovation, design, literary theory, and creativity practice (Ind & Coates, 2013). We can also find recent relevant explorative studies with the public health domain, where co-creation is a multi-dimensional construct starting out from the very start of a research design (Darlington & Masson, 2021, Daly-Smith, et al., 2020. Based on the findings of Darlington and Masson (2021), co-creation is a voluntary-based process of bottom-up collaboration informed by values of diversity, mutual trust, openness, autonomy, freedom, respect and shared expertise, responsibility, and decision-making. ...
Chapter
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This project was aimed at taking on the challenge of developing a didaktik for preschool, through empirical and theoretical work. The design was built on teachers’ own video observations of play activities in preschool, where they themselves were participants. Teachers, their principals, and researchers met regularly at the university to collaboratively discuss the video recordings. On these occasions the researchers also provided further education on theoretical concepts useful for analysing play activities in preschool, such as metacommunication and intersubjectivity. The outcome was the theorisation of Play-Responsive Early Childhood Education and Care (PRECEC), consisting of a coherent conceptualisation of teaching, as a responsive activity, and play, as something participants signal to each other through shifts between communicating and acting as is and as if. A challenge we discuss in this chapter is how to deal with the ‘unknown’ in a practice-based research project, i.e. not only reproducing knowledge (further education) but also, critically and at the same time, developing new knowledge (research).
... The concept of co-creation has a diverse heritage from psychotherapy, management science, innovation and open innovation, design, literary theory, and creativity practice (Ind & Coates, 2013). We can also find recent relevant explorative studies with the public health domain, where co-creation is a multi-dimensional construct starting out from the very start of a research design (Darlington & Masson, 2021, Daly-Smith, et al., 2020. Based on the findings of Darlington and Masson (2021), co-creation is a voluntary-based process of bottom-up collaboration informed by values of diversity, mutual trust, openness, autonomy, freedom, respect and shared expertise, responsibility, and decision-making. ...
Chapter
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In this commentary concluding this volume (Wallerstedt, Brooks, Ødegaard & Pramling, this volume), we discuss three principal matters: (i) what constitutes problems in research carried out in collaboration between researchers and ECEC personnel, (ii) limitations and ethical dilemmas that we find particular to such research, and finally (iii) the very terminology employed for this kind of research and its participating groups of collaborators.
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In 2014, the Danish government introduced a wide-ranging reform of primary and lower secondary education that applied to all public schools. A distinctive feature was that it became mandatory for schools to provide an average of 45 min of daily physical activity (PA). The capacity for change of local school heads and the schools overall are considered key to fulfilling such a policy-driven requirement. The aim of this study is therefore to explore local school heads’ ability to implement the stated requirement of 45 min of daily PA within their local organizational capacity for change. Eleven semi-structured interviews were conducted across 11 schools. Respondents were school staff with management responsibilities (leading teachers with school management responsibilities, deputy heads and school heads). Results indicate that local school heads are central agents in converting the Danish school requirement of 45 min of daily PA into local action. This includes their ability to advance broad aims into concrete goals, secure supportive structures and organize the implementation strategy. Heads also need to support the staff in building sufficient knowledge capacity on how to arrange and incorporate PA into their daily practice, support the widespread dissemination of this knowledge across the school and reserve work hours for such activities. Assigning local PA ambassadors was particularly highlighted as important implementation support, as they can help build and disseminate knowledge while also broadcasting the school head’s strategy and focus on integrating and upholding students’ PA levels.
Preprint
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Background Few whole-school physical activity programmes integrate implementation science frameworks within the design, delivery, and evaluation. As a result, knowledge of the key factors that support implementation at scale is lacking. The Creating Active School programme was co-designed and is underpinned by the COM-B model and the Consolidated Framework for Implementation Research. The study aims to understand the initial impact and implementation of CAS in Bradford over 9 months using McKay’s implementation evaluation roadmap. Methods Focus groups and interviews were conducted with school staff (n = 30, schools = 25) CAS Champions (n = 9) and the CAS strategic lead (n = 1). Qualitative data were analysed both inductively and deductively. The deductive analysis involved coding data into a priori themes based on McKay et al’s implementation evaluation roadmap, using a codebook approach to thematic analysis. The inductive analysis included producing initial codes and reviewing themes before finalising. Results Identified themes aligned into three categories: (i) key ingredients for successful adoption and implementation of CAS, (ii) CAS implementation: challenges and solutions, and (iv) the perceived effectiveness of CAS at the school level. This included the willingness of schools to adopt and implement whole-school approaches when they are perceived as high quality and aligned with current school values. The programme implementation processes were seen as supportive; schools identified and valued the step-change approach to implementing CAS long-term. Formal and informal communities of practice provided “safe spaces” for cross-school support. Conversely, challenges persisted with gaining broader reach within schools, school staff's self-competence and shifting school culture around physical activity. This resulted in varied uptake between and within schools. Conclusions This study provides novel insights into the implementation of CAS, with outcomes aligning to the adoption, reach, and sustainability. Successful implementation of CAS was underpinned by determinants including acceptability, intervention complexity, school culture and school stakeholders’ perceived self-efficacy. The combination of McKay’s evaluation roadmap and CFIR establishes a rigorous approach for evaluating activity promotion programmes underpinned by behavioural and implementation science. Resultantly this study offers originality and progression in understanding the implementation and effectiveness of whole-school approaches to physical activity.
Preprint
Full-text available
Background Few whole-school physical activity programmes integrate implementation science frameworks within the design, delivery, and evaluation. As a result, knowledge of the key factors that support implementation at scale is lacking. The Creating Active School programme was co-designed and is underpinned by the COM-B model and the Consolidated Framework for Implementation Research. The study aims to understand the initial impact and implementation of CAS in Bradford over 9 months using McKay’s implementation evaluation roadmap. Methods Focus groups and interviews were conducted with school staff (n = 30, schools = 25) CAS Champions (n = 9) and the CAS strategic lead (n = 1). Qualitative data were analysed both inductively and deductively. The deductive analysis involved coding data into a priori themes based on McKay et al’s implementation evaluation roadmap, using a codebook approach to thematic analysis. The inductive analysis included producing initial codes and reviewing themes before finalising. Results Identified themes aligned into three categories: (i) key ingredients for successful adoption and implementation of CAS, (ii) CAS implementation: challenges and solutions, and (iv) the perceived effectiveness of CAS at the school level. This included the willingness of schools to adopt and implement whole-school approaches when they are perceived as high quality and aligned with current school values. The programme implementation processes were seen as supportive; schools identified and valued the step-change approach to implementing CAS long-term. Formal and informal communities of practice provided “safe spaces” for cross-school support. Conversely, challenges persisted with gaining broader reach within schools, school staff's self-competence and shifting school culture around physical activity. This resulted in varied uptake between and within schools. Conclusions This study provides novel insights into the implementation of CAS, with outcomes aligning to the adoption, reach, and sustainability. Successful implementation of CAS was underpinned by determinants including acceptability, intervention complexity, school culture and school stakeholders’ perceived self-efficacy. The combination of McKay’s evaluation roadmap and CFIR establishes a rigorous approach for evaluating activity promotion programmes underpinned by behavioural and implementation science. Resultantly this study offers originality and progression in understanding the implementation and effectiveness of whole-school approaches to physical activity.
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The complexities of including students with autism in schools throughout Australia has resulted in the increased necessity for collaboration between stakeholders. For included students with autism, secondary school presents a variety of subjects, teachers and peers that have the potential to increase anxiety levels compared to their primary experience. Communication between important stakeholders is critical in alleviating issues for students with autism before they escalate. In this paper, researchers report and reflect on the implementation of a co-design process as a rigorous practice-based research methodology that provided an empathy focussed platform to explore possibilities in designing a prototype digital solution to support students with autism. The project was designed to identify communication issues associated with the secondary experience of students with autism and to create solutions via the development of a rapid prototype communication app. Findings from this project suggest that involving diverse stakeholders in co-designing and exploring possibilities in complex school environments had two benefits: stakeholders had the opportunity to see the challenge from other parties’ perspectives, and the process promoted creativity and flexibility in generating people-based solutions.
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Background: Physical activity has many health benefits for young people. In 2018, WHO launched More Active People for a Healthier World, a new global action on physical activity, including new targets of a 15% relative reduction of global prevalence of insufficient physical activity by 2030 among adolescents and adults. We describe current prevalence and trends of insufficient physical activity among school-going adolescents aged 11-17 years by country, region, and globally. Methods: We did a pooled analysis of cross-sectional survey data that were collected through random sampling with a sample size of at least 100 individuals, were representative of a national or defined subnational population, and reported prevalence of of insufficient physical activity by sex in adolescents. Prevalence had to be reported for at least three of the years of age within the 10-19-year age range. We estimated the prevalence of insufficient physical activity in school-going adolescents aged 11-17 years (combined and by sex) for individual countries, for four World Bank income groups, nine regions, and globally for the years 2001-16. To derive a standard definition of insufficient physical activity and to adjust for urban-only survey coverage, we used regression models. We estimated time trends using multilevel mixed-effects modelling. Findings: We used data from 298 school-based surveys from 146 countries, territories, and areas including 1·6 million students aged 11-17 years. Globally, in 2016, 81·0% (95% uncertainty interval 77·8-87·7) of students aged 11-17 years were insufficiently physically active (77·6% [76·1-80·4] of boys and 84·7% [83·0-88·2] of girls). Although prevalence of insufficient physical activity significantly decreased between 2001 and 2016 for boys (from 80·1% [78·3-81·6] in 2001), there was no significant change for girls (from 85·1% [83·1-88·0] in 2001). There was no clear pattern according to country income group: insufficient activity prevalence in 2016 was 84·9% (82·6-88·2) in low-income countries, 79·3% (77·2-87·5) in lower-middle-income countries, 83·9% (79·5-89·2) in upper-middle-income countries, and 79·4% (74·0-86·2) in high-income countries. The region with the highest prevalence of insufficient activity in 2016 was high-income Asia Pacific for both boys (89·0%, 62·8-92·2) and girls (95·6%, 73·7-97·9). The regions with the lowest prevalence were high-income western countries for boys (72·1%, 71·1-73·6), and south Asia for girls (77·5%, 72·8-89·3). In 2016, 27 countries had a prevalence of insufficient activity of 90% or more for girls, whereas this was the case for two countries for boys. Interpretation: The majority of adolescents do not meet current physical activity guidelines. Urgent scaling up of implementation of known effective policies and programmes is needed to increase activity in adolescents. Investment and leadership at all levels to intervene on the multiple causes and inequities that might perpetuate the low participation in physical activity and sex differences, as well as engagement of youth themselves, will be vital to strengthen the opportunities for physical activity in all communities. Such action will improve the health of this and future young generations and support achieving the 2030 Sustainable Development Goals. Funding: WHO.
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Purpose: Low levels of physical activity and high levels of sedentary behaviour are pervasive, especially in schools. Pre-service teacher education is pivotal to school and educational reform but is an under-studied setting for physical activity and sedentary behaviour intervention research. The objective of this pilot study was to test the feasibility and potential impact of embedding evidence-based active pedagogy based on an adapted version of Transform-Us!, Transform-Ed! in one core unit of an undergraduate teacher education degree. Methods: Baseline and follow-up measures (i.e. surveys) were conducted with Bachelor of Education (Primary) pre-service teachers who received the Transform-Ed! intervention and academic educators who delivered the intervention. Focus groups of senior academics and telephone interviews with primary school principals examined perceptions of intervention feasibility and explored potential real-world relevance and impact of pre-service teachers training in active pedagogy. Results: After 12 weeks, pre-service teachers (n = 218) were significantly more willing (pre-post change Δ = 0.54, 95% CI [0.16, 0.91]), confident (Δ = 1.40, 95% CI [0.89, 1.91]) and competent (Δ = 2.39, 95% CI [1.85, 2.92]) to deliver Transform-Ed!, had more positive feelings about the impact of physical activity on student outcomes (Δ = 2.05, 95% CI [1.58, 2.52]), and perceived fewer barriers to integrating Transform-Ed! into current and future teaching (Δ = - 7.26, 95% CI [- 8.88, - 5.64]). Four major themes emerged from the focus groups (n = 9) and interviews (n = 5) around participant perceptions of Transform-Ed!: (i) acceptability and appropriateness, (ii) need (tertiary level), (iii) need (primary level) and (iv) overcoming challenges. Conclusion: The Transform-Ed! pilot study demonstrated promising results across multiple participant levels, as it was perceived to be feasible, acceptable and appropriate by pre-service teachers, academics and school principals. The findings have direct implications for the progression of Transform-Ed! from pilot to a future definitive trial.
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Background: Most physical activity interventions in children focus on the school setting; however, children typically engage in more sedentary activities and spend more time eating when at home. The primary aim of this cluster randomised controlled trial was to investigate the effects of a compulsory, health-related homework programme on physical activity, dietary patterns, and body size in primary school-aged children. Methods: A total of 675 children aged 7-10 years from 16 New Zealand primary schools participated in the Healthy Homework study. Schools were randomised into intervention and control groups (1:1 allocation). Intervention schools implemented an 8-week applied homework and in-class teaching module designed to increase physical activity and improve dietary patterns. Physical activity was the primary outcome measure, and was assessed using two sealed pedometers that monitored school- and home-based activity separately. Secondary outcome measures included screen-based sedentary time and selected dietary patterns assessed via parental proxy questionnaire. In addition, height, weight, and waist circumference were measured to obtain body mass index (BMI) and waist-to-height ratio (WHtR). All measurements were taken at baseline (T0), immediately post-intervention (T1), and 6-months post-intervention (T2). Changes in outcome measures over time were estimated using generalised linear mixed models (GLMMs) that adjusted for fixed (group, age, sex, group x time) and random (subjects nested within schools) effects. Intervention effects were also quantified using GLMMs adjusted for baseline values. Results: Significant intervention effects were observed for weekday physical activity at home (T1 [P < 0.001] and T2 [P = 0.019]), weekend physical activity (T1 [P < 0.001] and T2 [P < 0.001]), BMI (T2 only [P = 0.020]) and fruit consumption (T1 only [P = 0.036]). Additional analyses revealed that the greatest improvements in physical activity occurred in children from the most socioeconomically deprived schools. No consistent effects on sedentary time, WHtR, or other dietary patterns were observed. Conclusions: A compulsory health-related homework programme resulted in substantial and consistent increases in children's physical activity - particularly outside of school and on weekends - with limited effects on body size and fruit consumption. Overall, our findings support the integration of compulsory home-focused strategies for improving health behaviours into primary education curricula. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12618000590268 . Registered 17 April 2018.
Article
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Background: Girls Active is a physical activity programme, delivered in UK secondary schools, with the aim of increasing moderate-to-vigorous physical activity (MVPA) in girls aged 11-14 years. This study presents the process evaluation as part of a 14-month cluster randomised controlled trial designed to evaluate the effectiveness of the Girls Active programme and which showed no difference in the primary outcome (MVPA at 14 months) between intervention and control arms. Methods: Quantitative and qualitative data were collected from intervention schools over the course of the 14 month trial. Feedback forms and attendance records were completed at the end of all teacher and peer leader training and review days. At 7- and 14-months, semi-structured interviews were conducted with the lead Girls Active teacher in all intervention schools (n = 10) and staff from the intervention provider (n = 4) and hub school (n = 1). At 14 months, separate focus groups with peer leaders (n = 8 schools), girls who participated in the evaluation component of the trial (n = 8 schools), and a sample of boys (n = 6 schools) were conducted. All participants in the intervention schools were asked to complete an exit survey at 14 months. Teachers (intervention and control) completed a school environment questionnaire at baseline, 7- and 14-months. Results: The Girls Active programme, i.e., the training and resources, appeared to be well received by teachers and pupils. Factors that may have contributed to the lack of effectiveness include: some initial uncertainty by teachers as to what to do following the initial training, a predominant focus on support activities (e.g., gathering opinions) rather than actual physical activity provision, and school-level constraints that impeded implementation. Conclusions: Girls Active and what it was trying to achieve was valued by schools. The programme could be improved by providing greater guidance to teachers throughout, the setting of timelines, and providing formal training to peer leaders. Trial registration: ISRCTN, ISRCTN10688342 . Registered 12 January 2015.
Article
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Abstract Purpose The aim of this mixed-studies systematic review was to ascertain the effectiveness of school-based interventions at increasing physical activity (PA) and/or reducing sedentary time (ST) in children aged 5 to 11 years, as well as to explore effectiveness in relation to categories of the theory of expanded, extended and enhanced opportunity (TEO). Methods Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 5 databases were searched using pre-defined search terms. Following title and abstract screening of 1115 records, the removal of duplicates (n = 584) and articles that did not meet the inclusion criteria agreed to a priori (n = 419) resulted in 112 records that were full-text screened. Two independent reviewers subsequently used the mixed-methods appraisal tool to assess the methodological quality of 57 full-text studies that met the inclusion criteria after full-text screening. The interventions were summarised using the TIDierR checklist and TEO. The strength of evidence was determined using a five-level rating system utilising a published decision tree. Results Overall evidence ratings for interventions implemented within school settings were no evidence on moderate-to-vigorous physical activity and inconclusive evidence on sedentary time. In relation to the TEO, expansion of PA appeared to be the most promising intervention type for MVPA, with moderate evidence of effect, whereas extension and enhancement of PA opportunity demonstrated no evidence of effect. A critical issue of possible compensatory behavior was identified by analysis of intervention effect in relation to PA measurement duration; when studies measured changes in PA during the actual intervention there was moderate evidence of effect, whereas those that measured changes in PA during the school day presented inconclusive evidence of effect and those that measured changes in PA over a whole day yielded no evidence of effect. Two meta-analysis of those studies using a whole-day accelerometer measure for MVPA or ST showed a significant but moderate effect for MVPA (effect size (ES) = 0.51; 95% Confidence Interval (CI): 0.02–0.99) and a large but non-significant effect for ST 1.15 (95%CI: –1.03 to 3.33); both meta-analysis demonstrated low precision, considerable inconsistency, and high heterogeneity. Conclusion The findings have important implications for future intervention research in terms of intervention design, implementation, and evaluation.
Article
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Purpose: To identify co-produced multi-stakeholder perspectives important for successful widespread physically active learning (PAL) adoption and implementation. Methods: A total of 35 stakeholders (policymakers n = 9; commercial education sector, n = 8; teachers, n = 3; researchers, n = 15) attended a design thinking PAL workshop. Participants formed 5 multi-disciplinary groups with at least 1 representative from each stakeholder group. Each group, facilitated by a researcher, undertook 2 tasks: (1) using Post-it Notes, the following question was answered: within the school day, what are the opportunities for learning combined with movement? and (2) structured as a washing-line task, the following question was answered: how can we establish PAL as the norm? All discussions were audio-recorded and transcribed. Inductive analyses were conducted by 4 authors. After the analyses were complete, the main themes and subthemes were assigned to 4 predetermined categories: (1) PAL design and implementation, (2) priorities for practice, (3) priorities for policy, and (4) priorities for research. Results: The following were the main themes for PAL implementation: opportunities for PAL within the school day, delivery environments, learning approaches, and the intensity of PAL. The main themes for the priorities for practice included teacher confidence and competence, resources to support delivery, and community of practice. The main themes for the policy for priorities included self-governance, the Office for Standards in Education, Children's Services, and Skill, policy investment in initial teacher training, and curriculum reform. The main themes for the research priorities included establishing a strong evidence base, school-based PAL implementation, and a whole-systems approach. Conclusion: The present study is the first to identify PAL implementation factors using a combined multi-stakeholder perspective. To achieve wider PAL adoption and implementation, future interventions should be evidence based and address implementation factors at the classroom level (e.g., approaches and delivery environments), school level (e.g., communities of practice), and policy level (e.g., initial teacher training).
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Objectives Assess feasibility, acceptability and costs of delivering a physically active lessons (PAL) training programme to secondary school teachers and explore preliminary effectiveness for reducing pupils’ sedentary time. Design and setting Secondary schools in East England; one school participated in a pre-post feasibility study, two in a pilot cluster-randomised controlled trial. In the pilot trial, blinding to group assignment was not possible. Participants Across studies, 321 randomly selected students (51% male; mean age: 12.9 years), 78 teachers (35% male) and 2 assistant head teachers enrolled; 296 (92%) students, 69 (88%) teachers and 2 assistant head teachers completed the studies. Intervention PAL training was delivered to teachers over two after-school sessions. Teachers were made aware of how to integrate movement into lessons; strategies included students collecting data from the environment for class activities and completing activities posted on classroom walls, instead of sitting at desks. Primary and secondary outcomes Quantitative and qualitative data were collected to assess feasibility and acceptability of PAL training and delivery. Outcomes were assessed at baseline and ~8 weeks post-training; measures included accelerometer-assessed activity, self-reported well-being and observations of time-on-task. Process evaluation was conducted at follow-up. Results In the feasibility study, teachers reported good acceptability of PAL training and mixed experiences of delivering PAL. In the pilot study, teachers’ acceptability of training was lower and teachers identified aspects of the training in need of review, including the outdoor PAL training and learning challenge of PAL strategies. In both studies, students and assistant head teachers reported good acceptability of the intervention. Preliminary effectiveness for reducing students’ sedentary time was not demonstrated in either study. Conclusions No evidence of preliminary effectiveness on the primary outcome and mixed reports of teachers’ acceptability of PAL training suggest the need to review the training. The results do not support continuation of research with the current intervention. Trial registration number ISRCTN38409550 .
Article
Objective This review provides the frst meta-analysis of the impact of physically active lessons on lesson-time and overall physical activity (PA), as well as health, cognition and educational outcomes. Design Systematic review and meta-analysis of controlled studies. Six meta-analyses pooled effects on lesson-time PA, overall PA, in-class educational and overall educational outcomes, cognition and health outcomes. Meta-analyses were conducted using the metafor package in R. Risk of bias was assessed using the Cochrane tool for risk of bias. Data sources PubMed, Embase, PsycINFO, ERIC and Web of Science, grey literature and reference lists were searched in December 2017 and April 2019. studies eligibility criteria Physically active lessons compared with a control group in a randomised or non-randomised design, within single component interventions in general school populations. Results 42 studies (39 in preschool or elementary school settings, 27 randomised controlled trials) were eligible to be included in the systematic review and 37 of them were included across the six meta-analyses (n=12 663). Physically active lessons were found to produce large, signifcant increases in lesson-time PA (d=2.33; 95% CI 1.42 to 3.25: k=16) and small, increases on overall PA (d=0.32; 95% CI 0.18 to 0.46: k=8), large, improvement in lesson-time educational outcomes (d=0.81; 95% CI 0.47 to 1.14: k=7) and a small improvement in overall educational outcomes (d=0.36; 95% CI 0.09 to 0.63: k=25). No effects were seen on cognitive (k=3) or health outcomes (k=3). 25/42 studies had high risk of bias in at least two domains. Conclusion In elementary and preschool settings, when physically active lessons were added into the curriculum they had positive impact on both physical activity and educational outcomes. These fndings support policy initiatives encouraging the incorporation of physically active lessons into teaching in elementary and preschool setting.
Article
Background Increasing awareness of the complexity of public health problems, including obesity, has led to growing interest in whole systems approaches (WSAs). We carried out a systematic review of WSAs targeting obesity and other complex public health and societal issues. Methods Seven electronic databases were searched from 1995 to 2018. Studies were included if there had been an effort to implement a WSA. Study selection was conducted by one reviewer with a random 20% double checked. Data extraction and validity assessment were undertaken by one reviewer and checked by a second reviewer. Narrative synthesis was undertaken. Results 65 articles were included; 33 about obesity. Most examined multicomponent community approaches, and there was substantial clinical and methodological heterogeneity. Nevertheless, a range of positive health outcomes were reported, with some evidence of whole systems thinking. Positive effects were seen on health behaviours, body mass index (BMI), parental and community awareness, community capacity building, nutrition and physical activity environments, underage drinking behaviour and health, safety and wellbeing of community members, self-efficacy, smoking and tobacco-related disease outcomes. Features of successful approaches reported in process evaluations included: full engagement of relevant partners and community; time to build relationships, trust and capacity; good governance; embedding within a broader policy context; local evaluation; finance. Conclusions Systems approaches to tackle obesity can have some benefit, but evidence of how to operationalise a WSA to address public health problems is still in its infancy. Future research should: (a) develop an agreed definition of a WSA in relation to obesity, (b) look across multiple sectors to ensure consistency of language and definition, (c) include detailed descriptions of the approaches, and (d) include process and economic evaluations. Key messages Interventions working towards systems approaches are associated with a range of positive health outcomes. Evidence of systems science and systems thinking was less clear, even in the most “joined up” approaches.