Do the implementation processes of a school-based daily physical activity (DPA) program vary according to the socioeconomic context of the schools? a realist evaluation of the Active at school program

Less than half of Canadian children meet the physical activity (PA) recommendation within the Canadian 24-Hour Movement Guidelines for Children and Youth [1], and the proportion is even lower for children living in underprivileged neighbourhoods [2]. Yet, regular PA supports physical, cognitive, and psychological/social health among school-aged children [3]. Schools are an ideal setting in which to increase PA among young people, as almost all children from all socioeconomic status (SES) backgrounds can be reached during critical periods of development [4]. Moreover, results of meta-analyses showed positive effects of active classrooms on academic achievement [5, 6] and positive effects on classroom behaviour [7]. Since 2005, several Canadian provinces [8] have adopted school-based daily PA (DPA) policies. These policies can be referred to as universal policies [9] because they aim to create supportive environments for PA that are universal to all children. In 2017, the province of Quebec joined these jurisdictions by launching its first policy on sports, PA and leisure, which included legislative provisions mandating the integration of 60 min of DPA within all elementary schools (K-Grade 6) by 2022 [10]. To support the schools in their DPA implementation, a specific program, Active at school! (À l’école, on bouge! [Measure 15023]) was concomitantly launched [11]. This program provides participating schools financial resources over three years to implement opportunities for students to be active 60 min every school day. It adopts a “flexible” approach to DPA, meaning that the participating schools are provided with the autonomy to develop their own custom action plan and select the new practices that are appropriate for their context and needs [11].

Given the overall rates of physical inactivity and given that socioeconomic disparities affect the activity level of children [1, 2], successful implementation of universal DPA policies is important for all children and crucial within lower-SES schools. However, a recognized limit of universal policies, including those implemented in schools, is that they are generally not effective in reducing inequalities [12‐16]. It is possible that school-based DPA policies provide an advantage to children attending schools that are already in a favourable position or fail to proportionately improve the outcomes of those in less favourable settings. This situation would result in widening health inequalities [17].

Several factors within and outside the school environment have been found to hinder adoption, implementation, and sustainability of school-based PA programs [18‐20] but, to our knowledge, no study has documented whether and how the implementation of school-based DPA programs might vary based on schools’ SES context. The purpose of this study is therefore to evaluate the implementation of the DPA program Active at School! while paying particular attention to the socioeconomic setting of the schools to better understand whether that setting affects implementation and, if so, how.

Realist evaluation [21] offers an interesting approach for achieving this objective. A realist evaluation aims at providing theory-driven explanations of how complex programs work within the context of their implementation [21, 22]. As a form of theory-driven evaluation, the realist evaluation develops tentative initial program theories about how a program works. These initial theories generally combine elements of substantive theories with stakeholders’ assumptions about how and why the program may work, derived from their research and/or professional expertise. These realist theories are used to reveal the underlying logic of programs and are then tested and refined empirically through data collection and analysis [23]. A central tenet of the realist approach is that programs work differently in different contexts. In a realist evaluation, the outcome of a program can be explained by the action of specific mechanisms in specific contexts. Realist inquiry is concerned with identifying the underlying mechanisms through which outcomes occur (or do not), and the contexts in which those mechanisms are triggered. Pawson and Tilley [21] name these configurations “context-mechanism-outcome configurations” (CMO configurations). Given that the school teams participating in the Active in School! program had the autonomy to develop action plans tailored to their needs and adapted to their context, conducting a realist evaluation is highly relevant to better understand what worked (or did not), through which mechanisms and in which socioeconomic context.

The purpose of this study was to uncover what worked (and did not work), for whom, how, and why during the three-year implementation period of the Active at School! DPA program, while paying particular attention to the socioeconomic setting of the participating schools. The program’s flexibility appears to have enabled the activation of a community empowerment process within the school teams, leading to a cultural shift towards sustained DPA provision in high-SES and middle-SES schools as well as in low-SES rural schools. Contextual factors specific to schools in an underprivileged urban setting seem to have limited the activation of mechanisms, hindering a shift towards a sustained DPA provision in those schools, which raises concerns as to the medium- and long-term effects of the program on social inequalities with respect to PA and health. To better understand the differences between urban and rural underprivileged settings, it is necessary to consider the dynamic, adaptive and nonlinear nature of program implementation [36‐38]. Our results suggest that the community empowerment process unfolded differently depending on the geographic and socioeconomic setting of schools, and that the different mechanisms do not appear to have been activated in the same way, in the same order or following a linear structure.

Firstly, our results suggest that, for all contexts, the assessment of the problem and critical awareness mechanisms played a pivotal role in program implementation and potential sustainability by creating a feedback loop [37] with the participation mechanism. The qualitative analysis shows that when school team members experienced positive changes in students, this reinforced the sense that the program was meeting a need, which encouraged staff to analyze their own practices, participate in identifying solutions, and even use the resources provided to further integrate active time. Participation, in turn, nourished a shared vision [18] of the importance of DPA routines in the school and fostered the commitment of staff to active time. The importance of observed benefits to implementation and sustainability of school-based PA programs has already been seen in previous research [18‐20], so this result is not new. Our results do, however, further the existing literature by considering the dynamic nature of this mechanism and what enables its activation.

Our results suggest that, in urban settings, the local leadership mechanism is critical to initiating the community empowerment process and activating a feedback loop. It seems that urban schools require strong local leadership to begin the process, since those schools are, on average, larger than rural schools, present greater resistance to program implementation and have a greater turnover of homeroom teachers (Table 3). In urban settings, therefore, formal leadership structures (leader, committee and follow-up meetings) appear to have enabled the mobilization of resources, as well as support and monitoring for members of the school team in order to ensure their participation. That participation appears to have then allowed staff to experience the benefits of active time, which reinforced their participation (feedback loop).

In underprivileged urban settings, however, our results show that the local leadership mechanism was less activated than in high- and middle-SES urban schools, which seems, in turn, to have limited activation of the feedback loop. Indeed, a smaller proportion of low-SES urban schools set up a committee and expressed their intention to maintain it, and a smaller proportion identified and publicly recognized champions in their school (Table 5). In addition, the qualitative analyses show that in the absence of ongoing external funding for the program, underprivileged urban schools are not able to sustain local leadership structures associated with the integration of active time, which makes them vulnerable to funding being cut off (Table 6).

The lack of resources in this setting and teachers’ heavy workload are contextual barriers identified by underprivileged urban schools that may explain, in part, the challenges schools face in implementing and maintaining new local leadership structures. Some schools explained that their disadvantaged context limits the reallocation of school resources towards priorities other than children’s basic needs (Table 6).

This need for additional financial support for schools in disadvantaged areas has already been underscored in the literature. Peralta et al. [39] showed that low-SES schools consistently report more barriers and fewer enablers to PA than their high-SES counterparts, while their needs are already greater. Indeed, lack of PA is usually more prevalent among lower socioeconomic groups and often passes from generation to generation [40]. To tackle social health inequities, it has therefore been suggested that public action should consider higher investment for disadvantaged schools [40]. This approach to promoting equal opportunities is called proportionate universalism [9] and consists in “offering universal interventions intended for all [environments], but with modalities or intensity that vary according to needs” ([16], p. 14, unofficial translation).

Consideration of the geographical context in our study therefore made it possible to show that in rural settings, an underprivileged context does not seem to have negatively affected implementation of the program. There, unlike the situation with urban schools in an underprivileged setting, the program seems to have initially activated the participation mechanism, triggering a feedback loop from the outset, as can be seen from the benefits (Fig. 1). This phenomenon seems to have facilitated the activation of other mechanisms, enabling the entire community empowerment process to become self-sustaining and leading to a cultural shift in favour of sustained DPA provision. This result is surprising given that a recent systematic review [41] highlighted that school-based PA interventions conducted in rural settings may pose greater challenges than in urban settings. A possible explanation for our result might be community involvement, a component that was missing from all rural intervention included in the review [41] but appeared to be a significant mechanism for the underprivileged rural schools included in our study. Indeed, our results highlighted that in underprivileged rural settings, the mobilization of nearby resources (such as strengthening links between schools and other organizations in the community and reinforcing the use of nearby infrastructure and environments) appears to have successfully modified the context (Fig. 1) in which schools evolve and created the foundations required to maintain changes in practice over the long term. This modification of the context through the mobilization of nearby resources was not observed in underprivileged urban settings (Fig. 2). Since developing partnerships have been identified several times in the literature as a factor favouring the implementation and sustainability of school-based PA programs [18, 42], additional support for schools in underprivileged urban settings aimed at enhancing community partnerships would be an avenue to explore for supporting sustainable implementations of the program. Rural underprivileged schools also demonstrated a greater involvement of students in setting up activities (Table 5). Student involvement in setting up activities has been identified in the literature as a factor favouring the implementation and sustainability of school-based PA programs [18, 19]. Hence, this could be another avenue to explore in urban underprivileged settings to drive the process of change. Nonetheless, due to the nature of their context, it remains that allocating additional financial resources in urban underprivileged settings appears necessary to enable schools to adopt and sustain the leadership structures that allow them to build or solidify partnerships in their community and/or involve more students.

The purpose of this study was to evaluate the implementation of the DPA program Active at School! using a realist approach, while paying particular attention to the socioeconomic setting of the participating schools. Our realist evaluation showed that a DPA program that gives local communities (the school teams, in this case) autonomy in the choice of strategies appropriate to their situation, while providing financial and material support, fosters the emergence of an organizational culture shift towards supporting a sustained DPA provision. The community empowerment domains constitute an insightful framework for identifying settings with greater needs and pointing to mechanisms that drive local change processes. It appears that contextual factors specific to schools located in underprivileged urban settings make the implementation of the DPA program more difficult, with the risk of accentuating existing social inequalities in health if additional resources are not deployed. Policy-makers should consider adjusting resource allocations to meet the needs of schools when implementing health-related policies in order to encourage the establishment of environments that can support all children in adopting a healthy lifestyle. [34]