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

Background: UK and global policies recommend whole-school approaches to improve childrens’ inadequate physical activity (PA) levels. Yet, recent meta-analyses establish current interventions as ineffective due to suboptimal implementation rates and poor sustainability. To create effective interventions, which recognise schools as complex adaptive sub-systems, multi-stakeholder input is necessary. Further, to ensure ‘systems’ change, a framework is required that identifies all components of a whole-school PA approach. The study’s aim was to codevelop a whole-school PA framework using the double diamond design approach (DDDA).Methodology: Fifty stakeholders engaged in a six-phase DDDA workshop undertaking tasks within same stakeholder (n = 9; UK researchers, public health specialists, active schools coordinators, headteachers, teachers, active partner schools specialists, national organisations, Sport England local delivery pilot representatives and international researchers) and mixed (n = 6) stakeholder groupings. Six draft frameworks were created before stakeholders voted for one ‘initial’ framework. Next, stakeholders reviewed the ‘initial’ framework, proposing modifications. Following the workshop, stakeholders voted on eight modifications using an online questionnaire.Results: Following voting, the Creating Active Schools Framework (CAS) was designed. At the centre, ethos and practice drive school policy and vision, creating the physical and social environments in which five key stakeholder groups operate to deliver PA through seven opportunities both within and beyond school. At the top of the model, initial and in-service teacher training foster teachers’ capability, opportunity and motivation (COM-B) to deliver whole-school PA. National policy and organisations drive top-down initiatives that support or hinder wholeschool PA.Summary: To the authors’ knowledge, this is the first time practitioners, policymakers and researchers have codesigned a whole-school PA framework from initial conception. The novelty of CAS resides in identifying the multitude of interconnecting components of a whole-school adaptive sub-system; exposing the complexity required to create systems change. The framework can be used to shape future policy, research and practice to embed sustainable PA interventions within schools. To enact such change, CAS presents a potential paradigm shift, providing a map and method to guide future co-production by multiple experts of PA initiatives ‘with’ schools, while abandoning outdated traditional approaches of implementing interventions ‘on’ schools.</div

Regresion coefficients (B) and 95% confidence intervals (95% CI) as results from the mediation analyses in the association between language spoken at home (non-native = 0, native = 1) and BMI (kg/m²)/WC (cm) in Greek simple.

*<p>Models adjusted for age and gender.</p>†<p>Models adjusted for age, gender and parental education level.</p><p>path a, b,c c’refer to the paths depicted in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0071848#pone-0071848-g001" target="_blank">Figure 1</a>.</p><p><b>Statistically significant associations are shown in bold.</b></p

Regresion coefficients (B) and 95% confidence intervals (95% CI) as results from the mediation analyses in the association between language spoken at home (non-native = 0, native = 1) and BMI (kg/m²)/WC (cm) in Dutch simple.

*<p>Models adjusted for age and gender.</p>**<p>Logistic regression coefficients.</p><p>path a, b,c c’refer to the paths depicted in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0071848#pone-0071848-g001" target="_blank">Figure 1</a>.</p><p><b>Statistically significant associations are shown in bold.</b></p

Characteristics of participants.

*<p>Student’s t-test (age, BMI, weight) and Pearson Chi-Square (% males, % parental education).</p

Means and SD for dietary, physical activity and sedentary behaviors in the Greek and Dutch samples, for native and non-native children based on language spoken at home.

*<p>P<0.05;</p>**<p>P<0.01;</p>***<p>P<0.001 native significantly lower than non-native, adjusted for age and gender.</p>∧<p>P<0.05;</p>∧∧<p>P<0.01;</p>∧∧∧<p>P<0.001 non-native significantly lower than native, adusted for age and gender.</p

Mediation mode.

<p>X: predictor variable; Y: outcome variable; M: mediator variable; a path: association between predictor (X) and potential mediator (M); b path: association between potential mediator (M) and outcome variable (Y); c: overall association between predictor variable (X) and outcome variable (Y); c’: direct effect (unmediated) of predictor variable (X) on outcome variable (Y).</p

Sample characteristics.

<p>N – total number with available data on this variable.</p>1<p>In Switzerland the first two years of education are generally not referred to as ‘school’ education. Therefore the proportion of higher educated people in Switzerland is probably an underestimation;</p>2<p>p-value for between country differences, tested with χ² in case of dichotomous variables and with ANOVA in case of a continuous variable (age).</p><p>Sample characteristics.</p

Observed proportions (%) and ranks¹ for the variables related to <b>TV watching</b> for the total sample and by country.

<p><b>Bold</b> – indicates that the observed proportion differs 10 or more percent points from the proportion in the Total sample.</p>1<p>rank orders are based on between-country comparisons by logistic regression and shown in the order of most favourable to least favourable. Countries with the same rank do not differ from each other (p>0.05).</p>2<p>potential categories are ‘fully disagree’, disagree a bit’, ‘neither disagree nor agree’, ‘agree a bit’, ‘fully agree’ or ‘always’, ‘often’, ‘sometimes’, ‘not often’, ‘never’ or ‘very good’, ‘good’, ‘neither good nor bad’, ‘bad’, ‘very bad’.</p>3<p>between brackets the estimated proportion after further adjustment for parental educational level if this differed ≥3 percent points from the unadjusted proportion.</p><p>Observed proportions (%) and ranks^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0111775#nt121" target="_blank">1</a>} for the variables related to <b>TV watching</b> for the total sample and by country.</p

Observed (%) and ranks¹ for the variables related to <b>soft drink</b> consumption for the total sample and by country.

<p><b>Bold –</b> proportions that differ ≥10 percent points from the proportion observed in the total sample.</p>1<p>rank orders are based on between-country comparisons by logistic regression analyses and shown in the order of most favourable to least favourable. Countries with the same rank do not differ from each other (p>0.05).</p>2<p>potential categories are ‘fully disagree’, disagree a bit’, ‘neither disagree nor agree’, ‘agree a bit’, ‘fully agree’ or ‘always’, ‘often’, ‘sometimes’, ‘not often’, ‘never’ or ‘very good’, ‘good’, ‘neither good nor bad’, ‘bad’, ‘very bad’.</p>3<p>between brackets the estimated proportion after further adjustment for parental educational level if this differed ≥3 percent points from the unadjusted proportion.</p><p>Observed (%) and ranks^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0111775#nt105" target="_blank">1</a>} for the variables related to <b>soft drink</b> consumption for the total sample and by country.</p

Observed proportions (%) and ranks¹ for the variables related to <b>physical activity (PA)/sport</b> for the total sample and by country.

<p><b>Bold</b> – indicates that the observed proportion differs 10 or more percent points from the proportion in the Total sample.</p>1<p>rank orders are based on between-country comparisons by logistic regression and shown in the order of most favourable to least favourable. Countries with the same rank do not differ from each other (p>0.05);</p>2<p>potential categories are ‘fully disagree’, disagree a bit’, ‘neither disagree nor agree’, ‘agree a bit’, ‘fully agree’ or ‘always’, ‘often’, ‘sometimes’, ‘not often’, ‘never’ or ‘very good’, ‘good’, ‘neither good nor bad’, ‘bad’, ‘very bad’;</p>3<p>between brackets the estimated proportion after further adjustment for parental educational level if this differed ≥3 percent points from the unadjusted proportion.</p><p>Observed proportions (%) and ranks^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0111775#nt117" target="_blank">1</a>} for the variables related to <b>physical activity (PA)/sport</b> for the total sample and by country.</p