Is level of implementation linked with intervention outcomes? Process evaluation of the TransformUs intervention to increase children’s physical activity and reduce sedentary behaviour

Abstract

Background TransformUs was a four-arm school-based intervention to increase physical activity and reduce sedentary behaviour among primary school children. Pedagogical and environmental strategies targeted the classroom, school grounds and family setting. The aims of this study were to evaluate program fidelity, dose, appropriateness, satisfaction and sustainability, and associations between implementation level and outcomes among the three intervention arms. Methods At baseline, 18-months (mid-intervention) and 30-months (post-intervention), teachers, parents and children completed surveys, and children wore GT3X ActiGraph accelerometers for 8 days at each time point to determine physical activity and sedentary time. Implementation data were pooled across the three intervention groups and teachers were categorised by level of implementation: (i) ‘Low’ (< 33% delivered); (ii) ‘Moderate’ (33–67% delivered); and (iii) ‘High’ (> 67% delivered). Linear and logistic mixed models examined between group differences in implementation, and the association with children’s physical activity and sedentary time outcomes. Qualitative survey data were analysed thematically. Results Among intervention recipients, 52% ( n = 85) of teachers, 29% ( n = 331) of parents and 92% ( n = 407) of children completed baseline evaluation surveys. At 18-months, teachers delivered on average 70% of the key messages, 65% set active/standing homework, 30% reported delivering > 1 standing lesson/day, and 56% delivered active breaks per day. The majority of teachers (96%) made activity/sports equipment available during recess and lunch, and also used this equipment in class (81%). Fidelity and dose of key messages and active homework reduced over time, whilst fidelity of standing lessons, active breaks and equipment use increased. TransformUs was deemed appropriate for the school setting and positively received. Implementation level and child behavioural outcomes were not associated. Integration of TransformUs into existing practices, children’s enjoyment, and teachers’ awareness of program benefits all facilitated delivery and sustainability. Conclusions This study demonstrated that intervention dose and fidelity increased over time, and that children’s enjoyment, senior school leadership and effective integration of interventions into school practices facilitated improved intervention delivery and sustainability. Teacher implementation level and child behavioural outcomes were unrelated, suggesting intervention efficacy was achieved irrespective of implementation variability. The potential translatability of TransformUs into practice contexts may therefore be increased. Findings have informed scale-up of TransformUs across Victoria, Australia...

Tensions and Paradoxes of Scaling Up: A Critical Reflection on Physical Activity Promotion

“…Nonetheless, the effects of adaptation on intervention effects can be mixed. For example, in school-based physical activity research, level of adaptation (fidelity) may not be associated with program efficacy [ 56 ] or lead to reduced effects [ 57 ]. This highlights the importance of enabling and integrating ways for intervention components to be adapted and monitoring the associated outcomes.…”

“…For example, in Australia, one contributing factor to the Victorian State Governments’ decision to scale the TransformUs initiative was that it coincided with the launch of a state-wide physical activity target [ 56 ]. In Canada, the scaling of Action Schools!…”

Transform-Us! cluster RCT: 18-month and 30-month effects on children’s physical activity, sedentary time and cardiometabolic risk markers

“…A recent process evaluation of the trial found that at 18 months, responding teachers (50% response rate) delivered 70% of the nine key learning messages, and almost one in five teachers provided children with active homework once a week. 49 One-third of the teachers delivered an active lesson and 56% delivered an active break every day, and almost all teachers provided access to the physical activity/sports equipment during recess and lunch breaks as well as during class lessons. The use of active pedagogy increased over time as did the use of line markings in the playground for lesson delivery.…”

Scaling up a school-based intervention to increase physical activity and reduce sedentary behaviour in children: protocol for theTransformUshybrid effectiveness–implementation trial

“…A detailed description of the programme strategies 31 and programme logic model has been published elsewhere. 20 Adaptations to the TransformUs programme for scale-up are described later in the Methods section, and online supplemental file 1 presents the evolution of TransformUs since the original RCT (2009) to date.…”

“… 20 Existing teaching practices, children’s enjoyment and teacher awareness of programme values and benefits were the main facilitators of delivery and sustainability. 20 Following the success of TransformUs , and exploration of adaptations for scaling (described in the Methods section), the Victorian Department of Education committed to partnering with the research team to support the dissemination and implementation of the programme to all primary (elementary) schools in Victoria, Australia. Given the small number of school-based interventions that are studied at scale 27 and that use implementation theories to guide this process, 28 29 scaling up of TransformUs presented a unique opportunity to investigate real-world implementation at scale.…”