The objective of the current study was to evaluate the reach, effectiveness, adoption, implementation, and maintenance of mandatory PA within curriculum at ten Danish schools. The RE-AIM evaluation tool identified central factors discussed further below.
Commitment and school culture
Generally, the results showed that both school managers and teachers were interested in the PA requirement, finding it meaningful, believing that PA witin curriculum were important, and that PA could advance student learning. This has been reflected by others as an advantage for the implementation process, since it ensures that both teachers and school managers already having an awareness of the importance of the requirement [16, 42, 51].
At four of the included schools (school 1, 2, 8, and 9) PA was already a central part of the school culture before the 2014-reform. The extent to which the requirement fits within an organization´s mission, priorities, and values has previously been pointed out as impacting the commitment towards realizing the implementation [11, 16, 50, 51]. Three of those school were the schools with highest effectiveness (school 1, 2, and 8), whereas the last school had the second lowest effetivness (school 9). Thus, existing school culture might be an important factor for the degree of implementation.
Organisation of PA within curriculum
The implementation of PA within curriculum was delivered on a daily or weekely basis by 9,5% and 53,4%, respectively. Durlak and Dupre (2008) state that positive outcome results often are obtained with implementation levels around 60% - with few studies having obtained levels greater than 80% implementation degree.
The PA requirement did not demand teachers to deliver PA within curriculum on a daily basis. The requirement did only demand students to be active at least 45 minutes daily within curriculum. This could be reached through extra PE lessons or by making a weekly PA plan with a daily responsible teacher. However, the goal of all students being active 45 minutes daily within curriculum was not achieved at any of the included schools, with effectiveness ranging from 4.5% to 82.6%, regardless of 62.9% of teachers delivering PA within curriculum on at least a weekly basis. Thus, the implementation seemed to some degree to be initiated, but not fully completed.
Results from the interviews showed two key suggestions particularly related to implementation of the mandatory PA within curriculum; scheduling PA within timetables and collaborations with external parties. Introducing a mandatory PA requirement strongly urges school staff to adhere to the requirement. At the same time, there has been an increasing pressure placed on teachers to improve academic performance, and some teachers perceive time spent on academic work to be more beneficial compared with time spent on PA . Prioritizing becomes even more strained. Scheduling PA/PE within timetables helps, thus, ensure that students achieve the mandatory amount of PA within curriculum, while teachers can be content focusing on the academic teaching in the remaining lessons. Of the six schools, that in the present study scheduled PA within timetables, three schools reached an effectiveness greater than 70% (school 1, 2, and 8) whereas the remaining three schools reached an effectiveness of 30-40% (school 4, 7, and 9). Two schools with an effectiveness greater than 70% (school 1 and 2) had tripled the amount of weekly PE, whereas the last school (school 8) had dedicated 30 minutes daily, within timetables, for PA. For some schools scheduling PA/PE within timetables, thus, seemed beneficial in order to accomplish the daily mandatory PA within curriculum. This is also reflected in previous studies, highlighting scheduling of PA within timetables as a facilitator to implementation of PA policies in schools . Moreover, well-defined program components and an extensive teacher manual to support implementation has also been regarded as important for program implementation [14, 51].
Another way to help schools accomplishing the PA requirement could be through collaborations with external parties (e.g., local or national sports clubs or consultant or instructor from the municipality). This finding is reflected in previous studies, showing that cooperation and collaboration among local agencies (e.g. partnerships, networking) are beneficial, bringing different perspectives, skills, and resources to bear on the implementation [16, 18, 47]. This is also supported by de Meij et al. (2013) indicating that involvement and support of experts in sports, health, and education was a facilitating factor for implementation at the user level.
Motivation of school staff
Most school managers had experienced teachers who, from the outset, were poorly prepared for handling PA within curriculum, highlighting the importance of competencies development. Competencies development is often defined as development of skills necessary for implementation, but to an equal extent about having a fundamental mindset about how to handle the implementation [18, 24, 50]. In addition, Durlak and Dupre (2008) state, that development of competencies also is about developing motivation and self-efficacy. Such qualities affect future performance . Thus, motivated school staff is an important factor for the implementation process and has been idenfied to affect both adoption, implementation, and maintenance [35, 51]. This is in line with Nielsen et al. (2018), highlighting the importance of training in order to ensure teachers level of skills and self-efficacy, both affecting their motivation and dedication to the innovation.
In order to ensure motivated school staff, internal coordinators were in the present study highlighted as favourable agents to include, taking care of workshops, competencies development, and ongoing training for teachers. One of five schools, stating that internal coordinators were essential for maintenance, was the school with highest effectiveness (school 2). At this school they had a team of coordinators, mostly consisting of PE teachers, responsible for making a common thread for integration of PA, ensuring that all teachers, independent of PA competencies, were able to deliver qualified PA within curriculum. The four other schools, highlighting the importance of an internal coordinator, reached an effectiveness between 30-38% (school 4, 5, 9, and 10). Those schools were, however, just in the tentative beginnings of organizing internal coordinators.
Internal coordinators or program champions has been pointed out by others as an advantage in ensuring an successful implementation process [11, 16, 19]. Program champions, particular those who are highly placed in an organization and have the respect of other staff, can do much to help orchestrate an innovation through the entire diffusion process from adoption to maintenance .
School management support and priority
School management support was found to be of vital importance for developing a school culture supporting the delivery of PA within curriculum. This is supported by others, reporting that leader support is a clear enhancement in securing motivation to PA programs [14, 16, 51]. Moreover, in a school-based mental health program Kam et al. (2003) showed a significant association between principal support and teacher´s fidelity of the implementation on student outcomes. Students improved significantly on all outcomes when both principal support and teacher´s fidelity of the implementation were high. Several negative changes were, however, found when principal support was low. This underlines the importance of school management support of the innovation .
Results from the interviews showed that school managers experienced some teachers were skeptical towards the mandatory PA components, which could be due to the additional workload following the requirement. Previous research show that, when introducing new innovations, teachers are concerned about potential additional workload, challenging them to priorities possibilities and obligations [1, 42, 45]. In order to oblige this, the present study showed the importance of shared decision-making, as teacher involvement heightened commitment to the innovation. Involvement of teachers in decision-making processes (e.g. development of a PA implementation strategy) has previously been shown to facilitate motivation innovations, uniting organizational members regarding the value and purpose of the innovation [10, 16, 51]. This further clarify the importance of school management support, taking responsibility for leading the implementation process through teacher involvement and dialogue in order to ensure motivation and ownership for the implementation.
School management priority was in the present study highlighted as a central factor for maintenance. Results further showed, that the two schools searching for teachers interested in PA when hiring reached an effectiveness greater than 70% (school 2 and 8). The importance of school management priority is also shown in previous research in respect of creating coherence and prioritize in situations where consensus about what exactly should be done many time is only partial [16, 18, 35, 48]. A review by Cassar et al. (2019), among others, also found that active involvement of leaders, supporting and prioritizing the PA program, was a key determinant for both implementation and maintenance [6, 31, 32, 51].
Results from the interviews showed that schools felt a lack of support from the municipality in order to maintain PA initiatives. One school highlighting this was the school with lowest effectiveness (school 3). Schools felt that, at times, the sheer volume of new initiatives made it difficult to dedicate adequate resources for one area like, for instance, PA. Schools and the educational system are busy with the core business of learning. This premise affects specific agendas on, for instance, increasing the volume of curriculum based PA . The need for continued municipal support is frequently highlighted – stressing that allocation of resources to schools (e.g., time for schools to develop an PA strategy or support regarding facilities) is needed [16, 30, 39]. Moreover, a study by Skovgaard & Johansen (2020) highlighted the importance of managers (both school and district managers), employees, and other core stakeholders developing a shared strategy for the area and set ambitious goals, which are realistic to achieve. Such strategy could help both schools and municipalities, reaching a common understanding of the implementation process – that it takes times and that schools are not able to implement new startegies every second month.
In the present study, the two schools reaching the highest effectiveness (school 1 and 2 ) were located in the same municipality. Results from the interviews revealed that all schools in that municipality were economically supported by the municipality if the schools chose to become part of their municipal PA programme, tripling the amount of weekly PE. This case is a great example of a successful implementation process, with active involvement of both schools and municipalities, developing a shared strategy .
A strength of this study was the use of multiple data sources including accelerometer, questionnaire, and interviews, as it provided a more comprehensive understanding of the RE-AIM dimensions and strengthened the external validity, credibility, and transferability of the study [5, 23]. We recognize, however, that this study has some limitations. Generally, eight of the included schools were located in the region of Southern Denmark and two schools were located in the Capital region. Inclusion of schools from other regions would have been beneficial, ensuring greater national representativeness. Due to the study design of the PHASAR study, this was not a possibility, though .
Another general limitation was the inclusion of students from different grades, which made it difficult to compare schools. Consequently, the results indicates that students in lower grades are more active than students in upper grades. Ideally, students from same grades were included at all of the participating schools. Unfortunately, this was not at possibility due to the study design. Exclusion of grade 1 to grade 4 students were chosen, though, as the PA level among the youngest student vary a lot from the older students. Some steps were, thus, taken in order to reach a comparable sample, but age still seem to be of considerable importance.
Another limitation is that recall bias may have emerged, since the interviews were conducted three-four years after introduction of the school reform.
Finally, it is important to acknowledge that the present study only represents teachers through questionnaire. The teachers were unfortunately not able to take part in the interviews due to limited time allocated for taking part in the study.