Involving the headteacher in the development of school-based health interventions: A mixed-methods outcome and process evaluation using the RE-AIM framework.

Although interventions delivered in school settings have the potential to improve children's health and well-being, the implementation of effective interventions in schools presents challenges. Previous research suggests facilitating greater autonomy for schools to select interventions aligned to their needs could improve implementation and maintenance. The aim of this mixed-methods outcome and process evaluation was to explore whether involving headteachers in the developmental stages of health interventions influenced adoption, effectiveness (e.g. pupil fitness and physical activity, assessed quantitatively), implementation and maintenance (assessed quantitatively and qualitatively). Three UK primary schools were provided with a choice of five evidence-based physical activity interventions: Playground scrapstore, daily classroom refreshers, alternative afterschool clubs, parent and child afterschool activities and an 'In the Zone' playground intervention. To evaluate the impact of this autonomous approach, semi-structured interviews with headteachers (n = 3), teachers (n = 3), and a private coach, and focus groups with pupils aged 9-11 (n = 6, 31 pupils, 15 boys), were undertaken. This was alongside an outcome and process evaluation, guided by the RE-AIM framework. This study assessed the impacts on adoption, implementation and maintenance of the autonomous approach and the effect on physical activity (seven day accelerometry-GENEActiv) and aerobic fitness (20m shuttle run). All three schools adopted different intervention components; alternative afterschool clubs, parent and child afterschool activities and daily classroom refreshers. Headteachers welcomed greater autonomy in developing school-based interventions and appreciated the more collaborative approach. Mixed results were reported for the effectiveness, implementation and maintenance of the interventions adopted. Allowing pupils choice and promoting a positive school environment were key factors for enhancing engagement. Moreover, promoting inclusive physical activity projects with a consideration of existing curriculum pressures aided implementation. This mixed-methods study provides valuable insights about autonomous approaches to inform further development, implementation and maintenance for future interventions.

Introduction

Physical activity has been positively associated with both physiological and psychosocial health [1]. Current guidelines recommend that children engage in at least 60 minutes moderate-to-vigorous physical activity (MVPA) every day [2], yet few children engage in sufficient levels to meet these guidelines [3, 4]. Given that physical activity behaviours have been shown to track into adulthood [5], physical activity-promoting interventions implemented during childhood are imperative. Additionally, physical activity is known to decrease from childhood to adolescence [6, 7], with the transition from primary to secondary school marking a critical period for intervention.

Schools have been identified as an appropriate setting for such approaches [8] and many physical activity interventions have been shown to be effective in primary school settings [9-11]. However, it has been argued that only modest effects have been observed [12]. Whilst non-curricular approaches, such as playground interventions, afterschool sessions and daily classroom refreshers hold some promise under intervention conditions, the translation of effective research findings to the school in a ‘real world’ setting can be problematic [13]. Previous formative research has identified that providing headteachers with greater autonomy to select suitable interventions to align with their specific school’s needs and facilitate contextual adaptations could improve implementation and maintenance [14-16]. Guidelines for designing complex interventions suggest that permitting schools an element of local adaptation enables interventions to more closely align with their target population [17]. Moreover, the ‘Health Promoting Schools’ agenda recommends allowing schools more choice in creating their own holistic, health-centred environment that endorses their individual values and ethos [18]. Despite these guidelines and recommendations, there are few established health interventions which allow headteachers a choice of autonomy over different types of intervention. Specifically, the Action Schools! BC (AS!BC) choice-based project, implemented across Canada, has demonstrated popularity with teachers, pupils and Governmental parties alike [19], despite demonstrating little long-term effectiveness; especially for boys [20]. The AS!BC intervention is composed of six ‘Action zones’ including school environment, scheduled P.E., classroom action (mandatory), family and community, extra-curricular and school spirit. Despite designs such as the AS!BC, there remains a paucity of research where headteachers have complete autonomy over their school’s interventions, and the popularity of the choice-based approach of the AS!BC framework warrants further exploration. Therefore, the aim of the present study was to involve headteachers in the developmental stages of school-based health interventions to allow them greater autonomy and explore how this influenced adoption, effectiveness, implementation and maintenance.

Methods

Recruitment

Nine primary schools in South Wales were contacted to participate in the Community Led Active Schools Programme (CLASP). Deprivation was classified to assess the socioeconomic variability using individual free school meal entitlement [21], with free school meal eligibility (FSM) ranging from 9% to 53% (mean 37.5%). These nine schools were selected as they had participated in the formative phases of the intervention [14, 15], and three expressed an interest in continued participation. These three headteachers were provided with a project description and following an expression of interest, a further meeting was set-up to discuss participation. All children in Year 5 and 6 (aged 9–11 years) at participating schools were eligible for participation within the study. Of the 125 children eligible, informed parental consent and participant assent forms were returned by 85 children (44 boys, 41 girls, 68% response rate).

Ethical approval

Ethical approval was granted by the Swansea University Research Ethics Committee. Written informed consent was obtained from headteachers, teachers and the external coach prior to participation in the interviews. Written informed parental consent and child assent was obtained prior to participation in the research components (e.g. focus groups). Parental consent forms were also required for participation in afterschool sessions.

Intervention components

All three headteachers were presented with a choice of five evidence-based physical activity intervention components (Table 1), focusing on different school periods. Headteachers were asked to consult with key members of staff to discuss which components would best suit their school needs. The final selection regarding which components to implement (one or two) occurred during a face-to-face consultation/interview with the research team. All five were free to the schools and pupils, all costs were covered through CLASP, and teachers were provided with an overview of the how their chosen interventions should be implemented.

Table 1

Intervention components with descriptions and supporting evidence.

Intervention components	Description	Supporting evidence
Daily classroom refreshers	10-minute bouts of physical activity to break up sedentary time. Physical activity card ideas issued to school staff, with teachers encouraged to allow children to take greater ownership regarding the design and delivery of their own activities.	[22–26]
Alternative activities	Alternative activities, such as street dance and skateboarding (chosen by pupils themselves), were promoted afterschool and led by an external, private coach.	[27–30]
Parent and child afterschool sessions	Combined parent and child afterschool sessions can improve enjoyment and reduce the need for child care; a barrier to physical activity for parents. This included activities such as family boxfit and was led by a private coach.	[31–35]
Playground Scrapstore	The Playground Scrapstore provided clean, safety-checked scrap equipment (e.g., cardboard boxes, tubes, cable reels) to promote imaginative free-play during playground breaks. Additional loose games equipment during break times has been shown to improve physical activity.	[36–44]
‘In The Zone’ project	‘In the Zone’ project encouraged the playground to be divided more fairly to encourage active play whilst enabling more organised, structured playtimes. An interactive DVD resource pack was provided as well as a training workshop for lunchtime supervisors.	[37, 38, 45–48]

Intervention design

Baseline quantitative measurements were taken over a two-week period (January), in addition to 1:1 interviews with headteachers (mean 18 minutes, range 15–21 minutes) to select intervention choices. All three schools then underwent their individual interventions for three months, followed by a two-week post-intervention measurement period (April). Follow-up measurements were performed three months after post-intervention (July) to assess maintenance of the project and any consequent change in health behaviours, again over a two-week period (Fig 1). For reference, the UK school structure runs from September to July. All measurements were undertaken during school time.

Fig 1

CLASP intervention timeline.

Qualitative measures

Semi-structured interviews were conducted with headteachers post-intervention (mean 22 minutes, range 14–24 minutes) and again at follow-up (mean 29 minutes, range 21–34 minutes) to ascertain views on the provision of greater autonomy with respect to school-based health interventions (Fig 1). Interviews provided the opportunity to obtain a richer, more in depth understanding regarding participants’ views of the implementation fidelity and maintenance [49]. All interviews were conducted individually in headteachers’ offices and an open-ended question-based topic guide was used throughout to facilitate discussion. Two experienced researchers (DC & CT) were present at each interview; one facilitated the interview, while the other noted key points, as well as researcher and participant interactions. The second researcher also reported back a brief summary of the interview to participants at the end of the interview, to ensure respondent validation [50]. All interviews were digitally recorded and transcribed verbatim. Following each interview, both researchers debriefed and adapted the topic guide accordingly for the next, incorporating tenets of an iterative, inductive approach to build a framework for thematic analysis; a methodology detailed elsewhere [51, 52]. At post-intervention, semi-structured interviews were also conducted individually with the Year 5/6 teachers, or deputy headteachers, at all schools (mean 13 minutes, range 11–16 minutes), and one private coach who had undertaken sessions as part of the intervention (25 minutes). This was to explore intervention implementation in greater detail. The two other coaches declined an invitation to participate in an interview due to work commitments. No additional funding was provided for their participation in interviews, so as not to incentivise their involvement.

As some of the interventions promoted pupil choice, two focus groups were undertaken with pupils from each of the three schools post-intervention, following procedures similar to that of the interviews. These focus groups took place in an empty classroom and lasted, on average, 30 minutes (range 23–40 minutes), with three to six pupils participating at any one time [53]. The focus groups all followed a semi-structured topic guide, which discussed, i) what pupils and their classmates thought about CLASP, ii) whether pupils thought anything had changed during participation, iii) if pupils would like CLASP to continue, and iv) whether or not pupils thought the school would continue with their chosen intervention components. Pupils were selected randomly to participate in focus groups following purposive allocation dependent on gender, deprivation (FSM entitlement) and participation in the interventions (identified from attendance collected through direct observations). Those pupils who did not participate in optional interventions, such as alternative activities, were included in the focus groups to understand reasons underpinning lack of engagement. For the daily classroom refresher intervention, pupils were selected at random from all those who had provided consent to participate. Engagers and non-engagers participated together in the focus groups in order to promote more organic discussions regarding facilitators and barriers. Participants were selected via stratified randomisation to ensure equal numbers.

Quantitative measures

Physical activity. Physical activity was objectively measured at 100 Hz using the GENEA © accelerometer (GENEActiv, Unilever Discover, Sharnbrook, Bedfordshire, UK), a triaxial, ± 6g seismic acceleration sensor, which has been previously validated for use in children [54]. Monitors were placed on the non-dominant wrist, to be worn 24 hours per day, for seven full days, including while sleeping and during water activities. The GENEActiv has excellent criterion validity in both adults (r = 0.86) and children (r = 0.91) when worn on the left wrist, mainly classified as the non-dominant wrist [54, 55].

Aerobic fitness. Fitness was measured through the well-validated 20m-shuttle test, using methodology described by Leger et al. [56].

Intervention dose and fidelity. Schools maintained records of the number of sessions that took place during the intervention to record dose. Coaches were asked to complete attendance records to assess engagement with sessions. Direct observations of sessions (n = 3) in all three schools were undertaken (by DC) throughout to assess fidelity and attendance at sessions.

Data analysis

Interviews and focus groups were analysed through schema analysis, fully described elsewhere [57]. Briefly, each researcher (DC & CT) developed schemas, or small sections of text detailing a common thought, from the transcripts independently. These schemas were coded by topic, such as ‘coach enthusiasm’, before the second researcher verified the schemas coded by the first researcher. No a priori hypothesis was determined and commonalities across schemas were collated to form themes, allowing the key thoughts from participants to be identified from the data. Schema analysis is an equalising method, with all researcher views pertinent and considered, that ensures validity of the working approach through group understanding [58]. Although agreement between researchers was high, any discrepancies were discussed until a consensus was reached. Qualitative and quantitative data were integrated using the triangulation protocol for mixed-methods research [59]. The data were initially analysed separately, as described above, and then combined to look for areas where similarities or discrepancies in the findings occurred. In addition to the quantitative outcome evaluation, a process evaluation was conducted, guided by the RE-AIM framework [60]; a common model used to evaluate implementation [61]. This detailed intervention fidelity, changes in pupil engagement, and qualitative views pertaining to maintenance.

The raw GENEActiv data was downloaded and the .bin files converted to 60-second epoch .csv files using GENEActiv PC software version 2.1. The 60-second epoch data files were entered into an open-source Excel macro (v2; Activinsights Ltd.) in order to eliminate sleep time [62]. Non-wear was assessed through previously described methodology [63]. KineSoft software (version 3.3.75; KineSoft, Loughborough, U.K.) was used to produce a series of standardised accelerometry outcome variables following procedures similar to those described by Esliger and Tremblay [55] and Esliger et al. [64]. To be included in the analyses, participants had to meet the wear-time criteria of 60 minutes on any three days [65]. Validated acceleration magnitude cut-points were used to classify activity intensity (min∙day-1) [54].

Paired t-tests were conducted to assess changes in MVPA, sedentary time and fitness from baseline to post-intervention and follow-up. Paired t-tests were used due to unequal numbers of observations between time-points and the low sample size that would have resulted from requiring observations at all three time-points. Additionally, in this instance, the assumption that compound variance would not differ could not be guaranteed. Preliminary analyses to ensure normal distribution of data were completed prior to all further analyses. STATA V.12.1 (STATA, Texas, USA) was used for all statistical analyses and statistical significance was set at p<0.05 throughout.

Results

The results section will firstly outline the choices of intervention components by school and the reasons for this selection. The outcome and process evaluation results will then be formatted in accordance with the RE-AIM framework; reach, effectiveness, adoption, implementation and maintenance. In this instance, adoption will be presented prior to effectiveness to provide clarity due to the nature of the intervention.

Intervention component choice and reasons for selection

The intervention components chosen per school were; School A–Alternative activities (Street dance and basketball), School B–Alternative activities (Street dance) and Parent and Child afterschool sessions (Family Boxfit), and School C–Daily Classroom Refreshers (Fig 2).

Fig 2

CLASP implementation schematic.

Legend: The down arrow shows where the headteacher, teacher and children had a choice in the intervention, whereas for the school C, the headteacher made the choice (SD = Street Dance, B = Basketball, FB = Family Boxfit).

Although all three schools were provided with autonomy over intervention choice, the three headteachers exercised their autonomy in very different ways, and opted for different approaches to tackle their school's physical activity needs (Fig 2). During the initial interviews, headteachers from two schools (A and B) mentioned that they strived to be democratic in their approach and discussed the options with respective deputies or P.E. co-ordinators. However, Headteacher C took a more autocratic approach.

School A chose alternative activities, as the headteacher believed these were something they could not offer themselves as a school, though expressed a preference for allowing pupils to choose which specific activities were implemented. School B also chose alternative activities, in addition to parent and child activity sessions, as the headteacher wanted to address and improve parental engagement. School B was also keen to honour student and parental choice in the selection of activities. Pupils were administered surveys by researchers prompting selection of varying types of sports or activities, and parents were invited to a coffee morning at the school to discuss different activity types. Leaflets notifying the days and times of the sessions taking place were sent out to parents and pupils.

The headteacher from school C decided on a curriculum-based approach. In this instance, the pupils had no choice over the intervention component. Indeed, school C chose daily classroom refreshers as the headteacher believed this approach was advantageous for concentration, behaviour and academic achievement and would ‘capture all children as opposed to a haphazard few that would attend an out of school activity’. School ground constraints, previous unsuccessful experiences, litigation risk and high numbers of existing afterschool activities meant other options were less attractive across all three schools.

Reach

The reach of the interventions differed greatly between schools. School C, which had daily classroom refreshers, engaged 100% of pupils as this was undertaken during usual classroom sessions. For schools A and B, attendance fluctuated greatly between voluntary afterschool sessions. Attendance records were completed sporadically, leading to insufficient data capture, and therefore this data could not be quantified with any certainty.

Adoption

Nine schools were contacted initially with three expressing an interest. These three schools (FSM 9%-53%, mean 34%) demonstrated a 33% adoption; slightly lower than the 47% adoption of a recent similar physical activity intervention study [66]. Reasons for non-participation from the other six schools included a new headteacher who was not involved in the first phase of CLASP [14, 15], and a headteacher who was currently undergoing health issues. No information was provided as to why the other four schools did not respond.

Effectiveness (physical activity, sedentary time and fitness)

Of the 85 individuals who participated in the study, 72 pupils across the three schools met the accelerometer wear-time criteria and were included in the analyses. Due to the paired t-test analysis, if results were present for only one time point the data was removed from the analysis.

When MVPA was stratified by school, all three schools showed a positive trend between baseline and post-intervention (Table 2), though this was only significant for school C. There were significant increases in MVPA from baseline and follow-up for all three schools. Similarly, sedentary time reduced in all three schools at post-intervention, with schools A and C demonstrating a significant decrease. At follow-up, significant decreases in sedentary time of 118, 118 and 100 min.day-1 were observed for schools A, B and C, respectively.

Table 2

Changes in MVPA, sedentary time and fitness per school between baseline, post-intervention and follow-up.

		School A	School B	School C
MVPA		n = 20	n = 11	n = 23
	Baseline	99.0 (31.4)	105.2 (48.0)	99.9 (30.7)
	Post-intervention	107.2 (39.4)	114.2 (43.4)	117.0 (36.3)
	Difference	8.3 (24.6)	9.0 (50.5)	17.0 (25.9)
	(95%CI)	-19.8 to 3.3	-42 to 25.0	5.8 to 28.2
		n = 18	n = 11	n = 19
	Baseline	97.3 (32.6)	103.6 (42.2)	97.1 (31.2)
	Follow-up	144.8 (60.8)	147.9 (33.6)	135.3 (49.4)
	Difference	47.5 (54.5)	44.3 (41.8)	38.3 (30.5)
	(95%CI)	20.4 to 74.6	16.2 to 72.4	23.6 to 53.0
Sedentary Time		n = 20	n = 11	n = 23
	Baseline	687.5 (96.9)	706.1 (123.0)	707.7 (50.4)
	Post-intervention	616.7 (72.7)	677.2 (71.1)	643.1 (103.0)
	Difference	70.8 (78.8)	28.9 (83.9)	64.7 (106.2)
	(95%CI)	33.9 to 107.7	-27.5 to 85.2	18.7 to 110.6
		n = 18	n = 11	n = 19
	Baseline	692.5 (100.5)	701.5 (118.1)	706.3 (53.0)
	Follow-up	573.6 (148.4)	582.8 (75.4)	606.2 (99.4)
	Difference	118.9 (145.5)	118.7 (99.1)	100.1 (83.7)
	(95%CI)	46.5 to 191.3	52.2 to 185.3	59.7 to 140.4
Fitness		n = 20	n = 16	n = 24
	Baseline	31.1 (13.5)	25.9 (13.7)	38.6 (14.6)
	Post-intervention	39.8 (17.6)	27.3 (12.5)	43.2 (15.8)
	Difference	8.7 (14.6)	1.4 (12.7)	4.6 (8.4)
	(95%CI)	1.9 to 15.5	-8.2 to 5.3	1.0 to 8.1
		n = 18	n = 15	n = 25
	Baseline	28.8 (14.0)	25.9 (13.7)	39.2 (13.3)
	Follow-up	39.1 (18.7)	29.2 (10.0)	38.7 (14.7)
	Difference	10.3 (15.9)	3.3 (7.6)	-0.5 (8.9)
	(95%CI)	2.4 to 18.2	-7.5 to 0.9	-3.2 to 4.2

Data represented as Mean (SD), unless otherwise stated. Post-intervention refers to three months post-baseline (April) and follow-up refers to six months post-baseline (July). Bold = achieves significance (p<0.05).

Fitness improved significantly for schools A and C between baseline and post-intervention, whereas only small increases in fitness were reported in school B. Interestingly, only school A continued to demonstrate an increase at follow-up. Fitness measures in schools B and C at follow-up were comparable to baseline.

Implementation

The implementation type, levels of autonomy and the dose of sessions delivered for all three schools is presented in Fig 2, in addition to implementation facilitators and barriers expressed by headteachers, teachers and pupils.

Dose and fidelity

School A (alternative activities–street dance and basketball). The street dance group completed 8 out of 11 sessions, including an assembly performance, and 6 of 11 basketball sessions were delivered. Basketball sessions were mainly cancelled as a result of inconsistent attendance by the coach (four sessions) and a clash with school parents’ evening. Cancellation of street dance was also due to a clash with parents’ evening and school transition periods to high school. The headteacher noted attendance started high for street dance, but decreased with time, whereas participation in basketball was lower at the outset but increased steadily throughout, due to word of mouth.

School B (alternative activity & parent and child activity). Street dance completed 8 out of 11 sessions but did not manage to undertake the performance. Reasons for cancellations included a clash with parent’s evenings, school strikes and availability of coach. Again, the headteacher reported attendance started high for street dance but decreased steadily throughout. Parent and child afterschool boxfit sessions started 2 weeks after the other sessions due to initial lack of interest (8 out of 11 delivered). A few parents participated in the first sessions, but direct observations of sessions found these quickly became pupil-only sessions. However, these sessions still promoted family engagement as siblings attended together and parents verbally interacted during sessions.

School C (daily classroom refresher). Daily activity energisers were reported by the teacher as being completed an average of 4/5 times a week (less on busier weeks). When used at times that were least disruptive, it was felt they aided pupils’ concentration and helped break up monotonous periods during the school day.

Factors affecting intervention implementation

Headteachers and teachers reported a number of factors which influenced the delivery of the chosen interventions, and pupils reported factors which influenced their engagement or disengagement. These qualitative insights provide further understanding of the difficulties these schools faced when implementing new interventions, including; coach consistency, enthusiasm and session delivery, alignment with existing curriculum, competition for time, the need for a school lead to champion the project, inclusivity, parental attitudes and autonomy.

Coach consistency, enthusiasm and session delivery. The impact of the specific coach, and their approach to the sessions, was highlighted as influential, with enthusiasm, confidence and consistency all key factors in both engaging the pupils and maintaining delivery of the sessions. Basketball sessions were less structured, as the coach was unable to attend every session. The headteacher (school A) believed these inconsistencies caused the children to lose interest and believed, ‘the take up wasn’t as good with the basketball but I think that was more to do with sometimes the coach was letting them down and I think, you know what children are like…if things are not completely consistent they just give up don’t they?’.

The headteacher of school A felt that ‘the street dance was more successful than the basketball, but that was more to do with I think the enthusiasm of the coach really, so… we’re going to continue to use them as a coach into September’. This headteacher perceived the enthusiasm from both the street dance coach, coupled with support from the Head of Physical Education (P.E.), to be a key driver to effective implementation. The pupils from school C also mentioned the enthusiasm of the teacher as a factor, stating that daily classroom refreshers at the start were much better. Pupils stated that initially the daily classroom activities varied considerably, but after a while, the same activities, mainly running, were repeatedly used, causing some repetition and reluctance to participate. ‘At the beginning we were doing it with balls and everything and then like every day we’d just do running’. This was predominantly reasoned by pupils to result from a lack of teacher time to plan activities.

Bad behaviour was detailed by the external coach as having a distinct influence in school B, which became more of an issue as sessions progressed, especially with the girls. This had a knock-on effect on attendance as the focus was taken away from the activity itself, making it less enjoyable for all. One pupil stated, ‘I think everyone quit, I think everyone quit because it was just like a lot of arguments wasn’t there?’. Moreover, the coach reportedly found it difficult to differentiate for all abilities and engagement levels, and reported it was hard to teach sometimes because some pupils attended predominantly because ‘their friends had come along’, which led to ‘some being engaged, some not’. The accumulation of these issues meant unfortunately school B could not proceed with the street dance performance as the pupils were not prepared enough. However, the headteacher from school A believed the performance helped ‘create an event’ and amplified enthusiasm.

Alignment with existing curriculum. Initial motivating factors for headteachers selecting intervention components (schools B and C) included the perception that the project provided a great opportunity for pupils to participate in new activities whilst contributing towards health and well-being elements accountable to the schools’ inspectorate body. Conversely, one teacher from school B thought street dance and boxfit had managed to engage those disinterested with P.E., mainly because it was so different from the current prescriptive P.E. curriculum. This teacher commented, ‘they know what sort of thing they’re gonna [sic] be doing as they go through school in PE, but it was so different, so it got their attention’.

Further positives include the fact that daily classroom refreshers did not require any special equipment and were not particularly time-consuming, thus not taking time away from core curriculum components. However, the teacher delivering the classroom refreshers (school C) found the project difficult to consistently implement on a day-to-day basis due to curriculum time pressures. This teacher stated the activity sessions were, ‘just another project to fit into the day'.

Competition for in-school and afterschool sessions. The headteacher from school A believed that, ‘if we were running this [street dance] as part of an enrichment activity when they were all in school, they’d be fighting to get onto it’. Whereas, afterschool sessions rely on children to be motivated enough to stay behind after school. Some children from this school (A) expressed a desire to join as many clubs as possible to alleviate the usual boredom experienced after school in the house. However, others who didn’t engage alluded to the competitiveness for time post-school due to clashes with other activities or wanting to spend time with their friends, thus they were influenced by who else attended afterschool sessions.

This competitiveness for afterschool time was reinforced in school B, as some boys who did not attend mentioned family boxfit clashed with their running club. One pupil even asked, ‘can we get, change the box fit on Wednesday? Because loads of people need to go to…athletics’. Nonetheless, the headteacher explained that afterschool sessions ran every day so would have clashed regardless of day of the week.

School lead. Assigning a designated teacher to promote activities, and chase up children who did not attend, was suggested by both the deputy headteacher and class teacher from school B as one improvement to further enhance attendance. The class teacher remarked that, ‘pupils often attend sessions more to appease the teacher than actually wanting to do the activity’, so this approach may help raise attendance initially, but it is unclear what effect this would have on maintenance. The deputy headteacher remarked that it was imperative the ‘right kind’ of teacher was assigned to street dance or boxfit sessions, otherwise this would negate the intended effect. This was evidenced further in school C, as the class teacher had a high level of expertise regarding physical activity, which the pupils saw as a positive. Furthermore, the intervention in school A was led directly from the headteacher, who fully embraced a whole school engagement approach to implementation by including key members of staff in the initial discussions, with the enthusiasm for the project then disseminating throughout the whole school.

Inclusivity. When interviewed at follow-up, the Head of P.E. and headteacher from school A favoured street dance’s non-competitive nature and the focus on teamwork, meaning it was more inclusive and attracted those normally disengaged with physical activity. This was further endorsed by the Year 5 teacher from school B, who commented that, ‘there were some children who took part that I didn’t think would…on the yard they don’t join in with football, basketball, anything like that, they just sort of keep to themselves, so for them to be included in a group exercise was a big deal’. Conversely, one headteacher reported the competitiveness of basketball was viewed as off-putting by pupils in school A. Pupils from school C discussed in focus groups that daily classroom refreshers engaged the whole class, though did note that during periods of extended writing, the sessions could be disruptive. However, the teacher stated that the daily energisers would be best used, ‘more for concentration I think …especially in primary school they have break time in a morning, they have a break time in the afternoon, and they’re always up on their feet moving about the class, so I don’t feel that it makes a lot of difference to their healthy lifestyle’.

Parental attitudes/time. Parents’ attitudes were perceived as a barrier to afterschool attendance for parent and child afterschool sessions in school B, and this headteacher said that, ‘getting our parents to engage sometimes can be quite difficult’. Parents’ own experiences were perceived to have an impact as some, ‘didn’t have a particularly good experience of school, so even to just get some of the parents in [to school] is a huge thing’. Pupils from school B listed logistical issues why parents were unable to attend, such as, ‘mum and dad are at work’, or, ‘mum works nights so she has to sleep in the days’. Though others referred to more generic attitudinal factors towards physical activity such as, ‘my dad doesn’t like to exercise’, or, ‘my mother would think it’s a bit ridiculous to pay to get fit whereas we can just like do it on the streets ourselves’. Pupils preferred the idea of taking part during school time to remove these attitudinal barriers of parents influencing what they chose to do.

Autonomy. Initially, all three headteachers were positive about this novel approach, stating, ‘It was nice that there was a partnership and exciting that there was something that could be talked about and agreed upon’. One headteacher (school C) said in an ideal world, schools would be presented with a choice of options then schools would find it easier to adopt a programme suitable for their needs, as ‘everyone can maybe choose something then’. Conversely, when interventions offer only one project, some schools would say, ‘No that’s not going to work for us, no thank you’; limiting rates of intervention adoption. With all schools having differing agendas, the headteacher from school A believed they were best placed to understand the individual needs of their school and how to most effectively address these by choosing an intervention that best suits them.

Whilst school staff enjoyed the opportunity to select their own interventions, in some instances there was discordance between pupils’ and headteachers’ tastes. Interestingly, all schools noted that if they were to participate in the CLASP intervention again, they would provide pupils with greater autonomy and allow them greater ownership, rather than just the school leadership team. The deputy headteacher from school A reported that permitting pupils choice over the types of activities implemented within CLASP was definitely valuable and helped those pupils usually disengaged with P.E. to engage with physical activity. The school was able to align this approach with its existing policies for promoting pupil voice. This increased the ownership for pupils, which generated an element of accountability for missed sessions and helped maintain attendance levels. Additionally, due to existing practices in schools, pupils opined that it would be unfair if they had no choice in the matter. The general consensus from these pupils was that, ‘children like choosing’, and that asking children what they wanted to do was the best option to increase physical activity, as opposed to headteachers pre-selecting sports or activities at random for pupils to try.

Maintenance

Assessing the maintenance of these projects was a key focus of this study. As reported earlier in the effectiveness section, favourable changes in MVPA, sedentary time and fitness were observed, most of which were sustained at the three-month follow-up (Table 2). Only one of the three schools, school A, maintained sessions after the mandatory intervention period of three months. The key difference was a whole school enthusiasm for the intervention, from the headteacher and head of P.E., all the way down to the pupils. Direct observations found this headteacher was present at the majority of afterschool sessions, demonstrating full engagement and enthusiasm for the project. Additionally, the enthusiasm of the street dance coach and the enjoyment of the performance element played a role in sustaining these sessions. Observations in schools B and C found the headteachers rarely attended sessions. The headteacher in school C went as far as to say, ‘I haven’t seen an awful lot of it…I’ve pretty much left it to (the teacher)’. Although there was class integration in school C, there was only limited maintenance of the daily classroom refreshers intervention at follow-up. The teacher suggested this was mainly due to the class management benefits, as opposed to health benefits, and stated, ‘if I see that they’re finding a task difficult where they really have to focus, or they’re finding it hard to concentrate, that’s when I’d take them out’. Therefore, the daily classroom refreshers were implemented on an ad hoc basis and much less often than the once-a-day employed during the intervention.

Discussion

This study aimed to involve headteachers in the developmental stages of school-based health interventions to allow them greater autonomy and explore how this influenced adoption, effectiveness, implementation and maintenance. The CLASP intervention demonstrated that providing headteachers with a choice of physical activity projects was a positive approach to the adoption of a school-based intervention as this was viewed as a more collaborative approach to working. Mixed results were reported for the effectiveness, implementation and maintenance of an autonomous model. However, contributing influential factors were similar to those reported in more traditional school-based health interventions, such as a lack of time and existing curriculum pressures.

Headteachers appreciated the opportunity for greater autonomy regarding interventions during the developmental, adoption and implementation stages; concurring with previous research suggesting that engaging key stakeholders during initial stages improves intervention implementation [67]. The increased autonomy given to headteachers during this study allowed them to select intervention components that best aligned with their current priorities and personal values; an important guideline for developing complex interventions [17] and a key recommendation of the ‘Health Promoting Schools’ agenda [18]. The choice of five research-informed physical activity interventions provided greater adaptability, enabling each headteacher to select a project that best suited their school’s needs, as opposed to traditional, standardised intervention styles. The selection of different intervention components amongst the three schools demonstrates choice is both desired and warranted.

Curriculum pressure and the need to prioritise core subjects, such as literacy and numeracy, were influential factors in headteachers’ decisions regarding intervention choice. Afterschool sessions proved popular from a headteacher perspective, as they were less burdensome on schools in terms of implementation. Time and curriculum pressures have regularly been identified as a barrier to the implementation of traditional school-based physical activity initiatives [15, 68] and this does not appear to be specific to an autonomous approach. Interestingly, the only school not to select an afterschool session implemented daily classroom refreshers that were designed to engage the whole class, even though this was during curriculum time. This was due to the headteacher’s understanding of the positive impacts of physical activity breaks on concentration, learning and behaviour; concurrent with beliefs widely reported in the literature [22, 23, 69]. This was believed to be a more inclusive approach that would engage all pupils, as opposed to only those motivated and able to stay behind for afterschool sessions. This is consistent with previous research detailing that afterschool sessions would need to be very attractive in order to have high engagement [36]. Attendance at afterschool sessions is known to be influenced by enjoyment [70] and the provision of transportation home after the session [71]. Therefore, the headteacher believed they would be improving health and academic achievement for the class as a whole, rather than only the few; a universal approach consistent with the population strategy detailed by Geoffrey Rose [72]. This difference in approaches suggests that when offered a choice, headteachers may prioritise interventions which fit best around existing pressures, such as curriculum pressure, as opposed to those which demonstrate greater effectiveness but are more burdensome for schools to implement. Therefore, it is advisable to offer whole school, evidence-based choices which have shown potential for effectiveness, ideally in partnership with capacity-building for schools to aid delivery.

It is noteworthy that only one school (A) opted to fully maintain their intervention, and the headteacher identified whole school support as an important facilitator in this maintenance. This is in accordance with the ‘Health Promoting Schools’ agenda which promotes whole school or class integration of an intervention [18]. Class integration was also evident in the partial maintenance of the inclusive daily classroom refreshers in school C.

One headteacher believed a second key facilitator for maintenance was the street dance performance, as this promoted street dance to non-participating pupils and helped increase excitement about the sessions; a known facilitator for school-based interventions identified by headteachers [15]. Headteachers also reported that the member of staff chosen to promote the activity needed to be an appropriate teacher who could motivate pupils to participate. Social support from teachers has previously been identified as a significant mediator in improving physical activity levels in children [73]. The importance of this teacher-pupil interaction highlighted throughout CLASP warrants further research to fully understand the effects on both motivation and physical activity engagement.

The key concept explored through this study was increased autonomy of schools, and this proved influential during the implementation stage of the intervention through promoting more of a partnership approach between the headteacher and researchers. Interestingly, only one headteacher fully discussed the intervention option with their teachers before implementation. Whilst it is important to engage the headteachers initially, buy-in is also required across the whole school. Previous research has discussed the discordance between administrators’ and teachers’ views on health-based interventions and the impacts on implementation [74]. Moreover, a supportive school climate has been identified as a key factor for effective implementation [68].

Another key recommendation from headteachers and pupils, for improved implementation of school-based interventions, was the inclusion of pupils in the consultation process. Schools that utilised this approach noted multiple benefits, such as improved engagement and the promotion of pupil voices, and planned to introduce this aspect at an earlier stage for future projects. At follow-up, the only school who did not incorporate the views of pupils, expressed an interest in exploring this in the future. Previous research demonstrated children are rarely included in the design and implementation of projects [75]. The recommendations from headteachers in this study demonstrated the approach works well within a primary school setting, in the context of physical activity, and would benefit from further exploration in future school-based interventions.

Strengths and limitations

The mixed-methods approach used throughout the CLASP project was a key strength. The quantitative outcomes allowed an insight into the effects of the interventions on changes in physical activity, sedentary time and fitness. Furthermore, the extensive qualitative work, with multiple recipients of the intervention, provided a rich, contextual understanding of the acceptability and fidelity of the intervention and the mediators underpinning the quantitative changes seen in pupil health behaviours [49]. Whilst all three intervention choices reported favourable changes to MVPA, sedentary time and fitness, these results should be interpreted with caution. Given the timing of the intervention (January through to July), the influence of seasonal variation (Winter to Summer) cannot be precluded [76]. Additionally, school A mentioned that participating in this study increased awareness of pupils’ physical activity levels, and the impact of additional school interventions cannot be separated out. The lack of feedback from all the coaches at follow-up was also a limitation. Moreover, the sporadic recording of attendance of afterschool sessions prevented reach being calculated with any certainty. Future studies would benefit from the use of age- and sex-matched comparison schools to provide additional insights into the results reported here. Finally, the utilisation of the RE-AIM framework helped guide a more rigorous outcome and process evaluation [60], allowing greater insights from a proof-of-concept perspective. Furthermore, the focus on adoption and maintenance, in addition to implementation, was innovative as these aspects have been identified as under-researched areas within this field [61].

Conclusions

Headteachers perceived that being provided greater autonomy resulted in much more of a partnership approach to school-based interventions and welcomed the idea for future interventions. However, mixed results were reported for the effectiveness, implementation and maintenance of the interventions. Nonetheless, headteachers highlight that involving pupils in the decision-making process and promoting a positive school environment were key factors for enhancing engagement. Promoting inclusive physical activity projects, with a consideration of existing curriculum pressures, aided implementation for headteachers. Overall, this mixed-methods study provides valuable insights about autonomous approaches that could inform further development, implementation and maintenance for future interventions.

9 Jan 2020

PONE-D-19-31826

Involving the headteacher in the development of school-based health interventions: A mixed-method outcome and process evaluation using the RE-AIM framework.

PLOS ONE

Dear Dr. Christian,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

We would appreciate receiving your revised manuscript by Feb 23 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Lawrence Palinkas

Academic Editor

PLOS ONE

Journal requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Lines 72-74 – The Action Schools! BC framework is cited as the example intervention but would be helpful to clarify at first citation or in Table 1 (line 106) if any of the intervention components described in this intervention overlap with or were a featured component from Action Schools! BC. Asked slightly differently, I don't see any of the Action Schools! BC journal citations in the supporting evidence column. Does this mean the components from that intervention are not included in the intervention options for this research project?

Line 85 “Deprivation was classified…” – is this phrase referring to exclusion or inclusion criteria?

Line 106 – there are a number of peer-reviewed journal articles that highlight the impact of classroom-based physical activity. The first reference below would likely inform this article; it is more current than reference 24.:

• Watson A et al. Effect of classroom-based physical activity interventions on academic and physical activity outcomes: a systematic review and meta-analysis. Int J Behav Nutr Phys Act. (2017)

• Carlson JA et al. Contextual factors related to implementation of classroom physical activity breaks. Transl Behav Med. (2017)

• Donnelly JE et al. Classroom-based physical activity, cognition, and academic achievement. Prev Med. (2011)

Line 106 - Question – In Table 1, “In The Zone” project, it was noted there was a “training workshop for lunchtime supervisors.” Was teacher training provided for the other 4 interventions? Or, were there "overviews" for teachers regarding how the other 4 interventions should be implemented with fidelity (even if they were led by a coach) to help with sustainability?

Line 112 – are the UK sites operating in a year-round school setting? (Follow-up in July would be almost impossible in the U.S. school systems so indicating the schools operate year-round would help a reader).

Lines 134-135 – RE: “The two other coaches declined invitation to participate in an interview due to work commitments.” Questions: Were these coaches paid by the study to participate as physical activity (PA) leaders only? Were they employed by the school (e.g. as physical education teachers) or external PA leaders/coaches, for example, from a local fitness or recreation center? Was the interview a condition of engagement as a coach at the front end of the study? Did they receive a stipend for “coaching” and providing feedback on the intervention?

Line 144- 147 – notes pupils were selected randomly and then “Those pupils who did not participate in optional interventions, such as alternative activities, were included in the focus groups to understand reasons underpinning lack of engagement.” Questions: 1) Were those pupils who did not participate in the interventions in the same focus groups as those who did participate? 2) Did those pupils who did not participate have consent to participate and chose not to, that is, was participation optional by the teacher?

Line 233 – Is it possible to include the range of pupils / parents that were reached for the after school activities (even if attendance records were sporadic)? Given intervention strength is often determined by dose x reach this seems to be a disclosure gap.

Line 298 - Coach consistency, enthusiasm and session delivery: It would be helpful for a reader to have one or two opening statements that basically summarize what supported implementation and what deterred implementation and or pupil participation.

Lines 378-379 - it would be helpful to have a sample testimonial statement for this text: "the idea of using

daily energisers as an active break when concentration waned appealed as a future approach"

Line 380 - Parental recruitment strategies are not outlined in the paper. Understanding what techniques were used would be great. Were paper notices sent home? Were intervention details (time commitment) sent via email or in a voice mail? Were there reminder notices to parents?

Line 392 - Clarity is needed early in the manuscript re: teacher and pupil input on selection of intervention activities. To what extent did the headteachers consult with / get the opinion of other teachers and pupils when they selected the interventions or did they make the decision on their own? Was the same selection process employed at School A, B and C? Line 403 says "Whilst school staff enjoyed the opportunity to select their own interventions, in some instances there was discordance between pupils’ and headteachers’ tastes." This sentence makes it sound like teachers could pick their own strategy but earlier descriptive text seemed to suggest the headteachers selected the interventions.

Line 439 - Encouraging "impact on ...maintenance" seems to be an overstatement given the results reported in the previous section.

Line 502 - Strengths and Limitations: The lack of feedback from coaches at follow-up would seem to be a limitation. The ability of a school to sustain an intervention that requires an external coach would seem to be challenging for schools unless the coach is employed by the school system and paid for his/her time.

Figure 2 - Level of choice - does the down arrow indicate that all levels between the headteacher and the children had a choice of the intervention? There should be an acronym abbreviation in column School A Intervention chosen to define (Street Dance & Basketball [SD/B])

Reviewer #2: Review

With choice-based/autonomous participatory models recommended by the Health Promoting Schools literature this research presents an interesting and relevant implementation evaluation of an approach where schools choose relevant evidence-based PA interventions to implement. The analysis uses a well-accepted public health evaluation framework to explore implementation and outcomes and the research is very comprehensive. The manuscript is well written although the complexity of the evaluation and the amount of data makes the discussion challenging. Following are some revisions that I believe will enhance the manuscript. The discussion is a key area for revision.

Introduction

The discussion includes some reference to the health promoting schools framework and approach however the introduction doesn’t. On page four in the introduction where there is discussion about the “increasing autonomy design of AS! BC” and where a lack of research on autonomous designs is highlighted, the section could be strengthened with the evidence about health promoting schools approaches which, at their most pure, are meant to enhance school level autonomy. The evidence on HPS approaches tends to support focused ‘choice-based’ approaches where schools are constrained to issues like physical activity, healthy eating or mental health. I am not suggesting how to approach this but that the section should be enhanced related to the broader literature on autonomous HPS designed interventions in schools. (Lines 444-445 from discussion could be moved into this section).

Methods

Page 7 Lines 148-151. The approach to talking to engaged and non-engaged students sounds purposive but you state that pupils were randomly selected. How did you ensure that both types of students were present and represented if you used random selection? (perhaps a detail about how balanced randomized selection ended up being in terms of engaging and non-engaging students). I don’t understand randomly selecting in this situation but at least showing the actual situation that occurred through the process to result in both voices being heard and perhaps highlighting in the results how the comments were similar or different across the two types of students?

Results

Page 11 Line 252 – do you mean across all schools (overall when all three schools were analysed together? As on the previous line you said only School C was significant? These two statements seem to contradict.

Discussion

Overall I like the comprehensive approach to the study but the discussion is the component of the manuscript that is in need of quite a bit of work. It needs to be tightened and focused on the actual aims and results of the study. As it is currently written it is suggesting findings and conclusions that aren’t supported by the data.

1. I think the discussion needs to start out with an introduction that re-highlights the aim, lays out an order to the discussion based on the aim of the study highlighted on Page 4 and also is ordered based on the presentation of the results which were ordered based on RE-AIM. This will help with clarity and focus on the results.

2. Ultimately the introduction should also highlight the big messages (conclusions) that you will provide details about in the discussion e.g. this mixed methods study showed mixed results related to the adoption and implementation of autonomous models and highlighted that autonomous models may be influenced by school factors highlighted previously in the literature. (and reiterate in the conclusions) A key introductory message is about mixed results but that the study provides valuable insights about autonomous approaches that could inform further development and implementation of such approaches. You suggest something like this in the limitations when you highlight that the RE_AIM framework allowed for insights from a ‘proof-of-concept’ perspective.

3. The discussion and conclusions need to be more measured and based on the data. I suggest this because the first sentence 437-438 says it was a positive approach but the adoption rates were similar to, or worse than, choice-constrained studies in the literature (so choice didn’t appear to influence adoption), you didn’t really show effectiveness but potential effectiveness (maybe… those results were very difficult to interpret given the lack of information about participating in the interventions so what caused the effect??). However, during the implementation evaluation the principals told you they liked the choice but 2/3 didn’t sustain. These are very mixed results and need to be discussed far more cautiously.

4. You talk about local adaptation in the discussion (Lines 445-449) but you have no evidence that adaptation went on – you didn’t set out to study it, you didn’t collect data about adaptation and you haven’t looked into the adaptation literature. I suggest removing any comments about adaptation and how the approach demonstrates adaptation is both desired and warranted. You provided autonomy/choice. That is the focus of the article.

5. Overall I would suggest that the discussion needs to be cut back a bit ensuring that you aren’t re-presenting results but discussing the results in the context of the literature. For instance you go school by school discussing individual reasons for adoption where this could be a global statement about the different rationales for adoption and how they are similar or different – then compare this to adoption factors outlined in the literature. I believe Story et al have presented data on administrators perspectives to implementing HPS that might prove useful to compare to.

6. I think both the introduction and conclusion should talk about the key messages – e.g. use of mixed methods and the strength in elucidating the complexity of adoption and implementation. I believe that what you have really started to show is that adoption and implementation autonomous or non-autonomous models may be constrained by similar factors that influence adoption and implementation and are common to the broader school context. This is a very important finding, not yet discussed in the literature.

7. Effectiveness results need to be discussed in light of reach. If you have a completely voluntary intervention in two schools but see increases in physical activity across a set of children that volunteer with no control group are you seeing an intervention effect? If it is cross-site comparison it is no surprise that the universal strategy showed a significant outcome in terms of MVPA but the sedentary results are very hard to explain. How are these children less sedentary when no intervention focused on this and only one showed differences in MVPA (did your LPA show changes?)? Is this seasonality? These data have significant limitations that are not even discussed in the limitations section. They need to be.

Limitations

There is a body of implementation literature that shows Principal support is important and choice is important but a head teacher is one individual that works with a number of other professionals in a school to implement. In some jurisdictions the equivalent of the Head teacher doesn’t adopt anything without asking the teachers if they are willing. The limitations of the administrators choosing need to be discussed. There was a theme where one school did take a ‘consultative approach with their staff’.

Page 20 and 21 Lines 460-461 – this head teacher’s opinion is supported by Geoffrey Rose and the population health concept that universal strategies that create small changes in behavior are more beneficial at the population health outcome level than interventions targeted at those at highest risk. You could add a comment to this effect. However, above I have recommended talking more succinctly and globally about the different rationale for adoption and how interventions may need to offer multiple reasons to Principals to encourage adoption depending on their context and beliefs and that other factors such as staff transitions, illness etc. influenced adoption.

Line 452 –systematic reviews on PA implementation in schools show that curriculum pressure and competing demands are key barriers to school PA implementation. When you are discussing the factors that guided what intervention was adopted it should be placed in the context of that literature. The fact that two of three strategies selected were based on avoiding these barriers and required an external coach is critical. Thus… it may be that when there are no policy drivers a majority of school administrators will select an option that is potentially not as effective nor guaranteed to reach the whole school body, negating the power of the universal school-based approach. In fact your evidence further convinces me of the need for policy interventions accompanied by constrained autonomy interventions and capacity-building to ensure school PA delivery. I don’t expect you to go out on a limb and say this but I am just providing an alternative interpretation of your data to perhaps highlight the need for a more measured interpretation.

Page 23 Lines 518 – involving pupils in the decision-making process, etc. were not (based on your data) key factors in improving adoption and maintenance. They were key factors suggested by stakeholders as potentially contributing to adoption and maintenance. As well, do you actually mean contributing to implementation and maintenance in this sentence? Adoption is the school adopting the autonomous approach (participating) or the head teacher adopting a certain strategy. It is important to be consistent with your language across the document.

Conclusions

I feel that the conclusions currently misrepresent your findings. These need re-writing once the discussion is re-focused and the new approach to the discussing the results is adopted. These should mirror key statements made in the introduction to the discussion and key rationale from the introduction/aims but perhaps offer a recommendation as well (more research needed comparing two approaches etc.)

Perhaps the second sentence on line 517 “However, whilst this aspect engaged headteachers (did it? 30% of those asked participated – How about “whilst headteachers in this study supported the approach”) it was not solely sufficient to support maintenance of the PA strategy chosen nor did it guarantee effective implementation. This may be because teachers who largely are responsible for implementation were not engaged? or… because larger drivers influence adoption and implementation. It appears that autonomous and non-autonomous models may be influenced by similar implementation factors.

I leave it to you to decide on what the key messages are but I do believe that the reframing I suggest makes this a very nice addition to the literature.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

21 Feb 2020

A response to reviewers has been uploaded as a separate Word document.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

9 Mar 2020

Involving the headteacher in the development of school-based health interventions: A mixed-method outcome and process evaluation using the RE-AIM framework.

PONE-D-19-31826R1

Dear Dr. Christian,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

With kind regards,

Lawrence Palinkas

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

20 Mar 2020

PONE-D-19-31826R1

Involving the headteacher in the development of school-based health interventions: A mixed-methods outcome and process evaluation using the RE-AIM framework.

Dear Dr. Christian:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

For any other questions or concerns, please email plosone@plos.org.

Thank you for submitting your work to PLOS ONE.

With kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Lawrence Palinkas

Academic Editor

PLOS ONE