Optimising a multi-strategy implementation intervention to improve the delivery of a school physical activity policy at scale: findings from a randomised noninferiority trial

Abstract

Background To maximise their potential health benefits, school-based physical activity policies need to be implemented at scale. This paper describes the third in a sequence of trials that sought to optimise an effective strategy (PACE) to assist schools’ implementation of a physical activity policy. Specifically, it aimed to determine the probability that a multi-strategy intervention adapted to reduce in-person contact (Adapted PACE) was “as good as” the original intervention (PACE) in increasing the weekly minutes of structured physical activity implemented by classroom teachers. Methods A noninferiority cluster randomised controlled trial was undertaken with 48 primary schools in New South Wales, Australia. Schools were randomised to receive PACE or a model with adaptations made to the delivery modes (Adapted PACE). Teachers’ scheduled minutes of weekly physical activity was assessed at baseline (Oct 2018-Feb 2019) and 12-month follow-up (Oct-Dec 2019). The noninferiority margin was set at − 16.4 minutes based on previous data and decision panel consensus. A linear mixed model analysed within a Bayesian framework was used to explore noninferiority between the two PACE models. A cost minimisation analysis was conducted from the health service provider perspective, using the Australian dollar (AUD). Results The posterior estimate for the between group difference at follow-up was − 2.3 minutes (95% credible interval = − 18.02, 14.45 minutes). There was an estimated 96% probability of Adapted PACE being considered noninferior (only 4% of the posterior samples crossed the noninferiority margin of − 16.4 minutes). That is, the minutes of physical activity implemented by teachers at Adapted PACE schools was not meaningfully less than the minutes of physical activity implemented by teachers at PACE schools. The mean total cost was AUD$25,375 (95% uncertainty interval = $21,499, $29,106) for PACE and AUD$16,421 (95% uncertainty interval = $13,974, $19,656) for Adapted PACE; an estimated reduction of AUD$373 (95% uncertainty interval = $173, $560) per school. Conclusions It is highly probable that Adapted PACE is noninferior to the original model. It is a cost-efficient alternative also likely to be a more suitable approach to supporting large scale implementation of school physical activity policies. Trial registration Retrospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619001229167).

A systematic review of economic evaluations of interventions targeting childhood overweight and obesity

“…114 Thirty-eight studies evaluated interventions with the main components cutting across multiple intervention categories. 31,38,[52][53][54]60,61,[63][64][65][66][67][68]70,73,75,76,79,80,83,94,[99][100][101][102][107][108][109][110][111]123,125,130,131,134,137,139,140 All but three of these multi-category interventions involved behavioral components: Of the three that did not, one intervention targeted food standards across English schools, 83 while two others sought to change the school drinking water environment in the United States. 73,76 One study considered hypothetical scenarios of reduction in the prevalence of obesity, and no intervention was specified.…”

“…As suggested by some of the studies we reviewed, there might be an opportunity to cost-effectively translate existing lifestyle interventions to online and mobile app-based versions. 79,140 However, the complexities associated with costing these interventions present a knowledge gap for the assessment of cost-effectiveness. 227 We advocate for transparency in reporting any difficulties associated with estimating the cost components of these interventions.…”

“…Of all the included studies, 18 reported variations of non-anthropometric measures as the primary outcome. 53,[57][58][59]66,72,85,92,113,114,132,133,135,[139][140][141]179,180 In two studies, consequences were measured primarily as a change in the proportion of schools that adhered to a canteen policy, 108 [33][34][35][66][67][68][69][70][71][72][73][74][75][76][77][78][79][84][85][86][87][88][89][90][91][92][93][94][95][96]…”

“…135 Without an explicit cost-effectiveness threshold, decision-making may prove complicated if an intervention is more effective and costlier than a comparator. One of the included studies 140 met the criteria for classification as a CMA. 18,19 In CBAs, a ratio of benefits to costs exceeding one indicated value for money.…”

Scale-up of the Internet-based Professional Learning to help teachers promote Activity in Youth (iPLAY) intervention: a hybrid type 3 implementation-effectiveness trial

“…Bridging this gap is vital, as scaling up effective interventions is the only means to enhance the health of children and adolescents at a population level. Our trial represents one of the largest and most comprehensive type 3 hybrid implementation-effectiveness studies of a whole-of-school physical activity intervention published to date [ 9 , 37 , 38 ]. The iPLAY program reach more than 30,000 students and implementation fidelity was relatively high and consistent with what was observed in our cluster RCT.…”