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. Author manuscript; available in PMC: 2021 Apr 10.
Published in final edited form as: Prev Sci. 2021 Jan 16;22(3):324–333. doi: 10.1007/s11121-020-01199-z

Adapting the InPACT intervention to enhance implementation fidelity and flexibility

Rebecca E Hasson 1,2,3, Lexie R Beemer 1,2, Tiwaloluwa A Ajibewa 1,2, Andria B Eisman 4
PMCID: PMC8035283  NIHMSID: NIHMS1676050  PMID: 33453045

Abstract

BACKGROUND:

Adapting classroom-based physical activity interventions are critical for program feasibility and fidelity in low-resource elementary schools.

PURPOSE:

The purpose of this pilot study was to use Replicating Effective Programs (REP) framework to tailor the Interrupting Prolonged sitting with ACTivity (InPACT) intervention and evaluate its effectiveness on program fidelity in classrooms within a low-resource school.

METHODS:

REP was applied to adapt program packaging, teacher training and technical assistance to disseminate Tailored InPACT, a 20-week intervention where teachers implemented 5×4-minute activity breaks per day. Tailored InPACT was implemented in nine, 3rd-6th grade classrooms in one low-resource school in Detroit Michigan (80% qualified for free/reduced lunch). Intervention fidelity was measured via daily, weekly, and end-of-study self-report questionnaires and direct observation.

RESULTS:

Throughout the 20-week intervention period, 3rd-5th grade teachers achieved intervention dose (5 activity breaks per day at an average duration of 4 minutes 8 seconds). Sixth grade teachers did not achieve intervention dose as they were only able to implement 2 activity breaks per day at an average duration of 4 minutes 12 seconds.

CONCLUSIONSs:

These findings suggest 5×4-minute classroom activity breaks per day is a feasible dose of classroom activity that 3rd-5th grade teachers can implement in low-resource classroom settings. Additional adaptations are needed to maximize fidelity in 6th-grade classrooms.

Keywords: physical activity, evidence-based research, intervention study, health promotion, Replicating Effective Programs framework, implementation science

INTRODUCTION

Children living in systematically oppressed communities have high rates of inactivity (Alliance, 2016), placing them at increased risk for obesity and type 2 diabetes (Services, 2018). Evidence-based physical activity interventions implemented in elementary school classrooms hold great potential for reducing physical activity disparities at an early age by providing children with 19 minutes of in-class activity every day (Bassett et al., 2013) [approximately two-thirds of the school-based recommendations (Medicine, 2013)]. Indeed, findings from cluster randomized controlled trials of these interventions have demonstrated success in increasing in-school physical activity, improving fitness, weight status, on-task behavior and academic achievement in children (Bartholomew & Jowers, 2011; De Meij et al., 2010; Donnelly et al., 2009; Katz et al., 2010; Kibbe et al., 2011; Kriemler et al., 2010; Liu et al., 2008; Whitt-Glover, Ham, & Yancey, 2011). Classroom interventions are also helping schools achieve the physical activity goals listed in their local wellness policies (108th Congress of the United States, 2004; 111th Congress of the United States, 2010). Yet, using evidence-based in-class interventions is not enough to ensure positive health outcomes, as the success of an intervention depends on how well programs are implemented as intended (Proctor et al., 2011). For example, the Physical Activity Across the Curriculum program demonstrated that schools that implemented 75 minutes or more of the intervention per week (at least 50% of the intervention dose), showed a significantly smaller increase in body mass index over 3 years compared with the schools that implemented less than 75 minutes per week (Donnelly et al., 2009). The Texas Initiatives for Children’s Activity and Nutrition intervention was developed in three elementary schools serving ethnic minority students from low-income families. It was noted that few teachers (< 25%) implemented lessons on a daily basis as was intended and children only averaged a 3-minute increase in physical activity levels (Bartholomew & Jowers, 2011). Process evaluation also indicated that while teachers strongly supported the concept, intervention uptake and fidelity was low due to multiple competing demands and scarce resources (Bartholomew & Jowers, 2011). Evidence-based classroom interventions to date have not been sufficiently tailored to meet the needs of teachers and students (Donnelly et al., 2009), especially in low-resource schools (Bartholomew & Jowers, 2011). Hence, this lack of fit between the intervention and the context may exacerbate the very disparities interventionists are trying to mitigate.

Previous literature has identified three key barriers to the implementation of classroom activity breaks in elementary schools: 1) time constraints of teachers, 2) student participation, and 3) space constraints of classrooms (Bartholomew & Jowers, 2011; Donnelly et al., 2009; McMullen, Kulinna, & Cothran, 2014; Ready, Lee, & Welner, 2004; Schanzenbach, 2014). Interrupting Prolonged Sitting with ACTivity (InPACT) is an evidence-based, in-class intervention delivered with a comprehensive set of implementation strategies to address intervention-level barriers and optimize program uptake and fidelity across a wide range of schools (Beemer et al., 2018). These enhancements included the development of: 1) exercise videos to provide additional scaffolding for teachers and help guide intensity using tempo and visual cues, as well as minimize out-of-school preparation time; 2) a printed Compendium of Physical Activities, which included 200 moderate-to-vigorous intensity physical activity (MVPA) breaks for teachers to use and adapt for their classrooms; 3) classroom management procedures and posters to help teachers efficiently transition students into beginning an activity break and return to their seats after an activity break; 4) target heart rate zone posters to enhance student participation and provide information about desired heart rate zone during the activity breaks; and 5) a series of floor plan options provided to teachers to maximize floor space for physical activity, which was particularly useful in reducing spatial conflicts between students in classrooms where space constraints were a potential barrier.

InPACT was pilot-tested in three elementary schools, one low-, mid-, and high-resource school in southeast Michigan (Beemer et al., 2018). Despite the aforementioned intervention enhancements, significant differences in implementation fidelity were observed across the three schools. InPACT teachers in the low-resource school [74% of students eligible for free and reduced-priced lunch (FRL)] implemented fewer activity breaks per day (3 breaks vs. 5 breaks) compared to children attending the mid-resource (50% FRL) and high-resource (25% FRL) schools. As a result, students accumulated fewer minutes of moderate-to-vigorous physical activity (MVPA) per day (8 minutes vs. 15 minutes). The low-resource school also reported longer transition times from a seated to standing position at the start of an activity break (101 vs 44 seconds) compared to the higher resource schools. These preliminary findings suggest teachers working in low-resource schools may face additional barriers to implementing activity breaks beyond those commonly reported by teachers across all schools.

In addition to common barrier of time constraints noted across all schools, unique barriers that reduced feasibility and, consequently, fidelity in the low-resource school implementing InPACT included: 1) competing curricular challenges and priorities, 2) limited resources for professional development time, 3) perceived student behavior and management, and 4) communication (Beemer et al., 2018). For example, 83% of the teachers in the low-resource school compared to 25% of teachers in the mid- and high- resource schools perceived their students’ behavior to be a major barrier to implementation. Implementation factors, such as support from the school principal and clear communication between the principal and teachers, were also identified as barriers experienced disproportionately by teachers in the low-resource school. These barriers limited school capacity for InPACT program delivery, which undermined program implementation and effectiveness. Adapting evidence-based interventions to balance flexibility and fidelity in program delivery and address the key barriers that are unique to low-resource schools is critical to reducing physical activity disparities and achieving public health impact in classroom settings.

Replicating Effective Programs (REP) is a theory-based implementation framework that provides a roadmap for adapting evidence-based behavioral interventions for community-based settings through a combination of intervention packaging (i.e., curriculum materials), training, and technical assistance (Kilbourne et al., 2014). REP is a multicomponent strategy designed to maximize flexibility and fidelity in program delivery and is guided by the Social Learning (Bandura, 1977) and Diffusion of Innovations Theories (Rogers, 2003). REP was developed and applied by the Centers for Disease Control and Prevention (CDC) to package and disseminate HIV behavioral and treatment interventions for implementation in community-based settings (Neumann & Sogolow, 2000). REP has been empirically evaluated and has demonstrated evidence of effectiveness in reducing risky behaviors (e.g., HIV prevention) by increasing uptake of evidence-based interventions (Tones & Green, 2004). To date, REP has not been used to tailor classroom-based physical activity interventions to address barriers and maximize fidelity and flexibility (i.e., local customizing) in low-resource schools.

The purpose of this pilot study was to deploy REP to tailor the InPACT intervention and evaluate its effectiveness on program fidelity in one low-resource school to increase student physical activity levels in the classroom (see Figure 1). REP was applied to package and disseminate Tailored InPACT for implementation in 3rd-6th grade classrooms in one low-resource school in Detroit, Michigan. The Tailored InPACT program was informed by our previous research identifying key barriers of InPACT program implementation unique to low-resource schools and deploying the REP strategy to mitigate barriers and enhance the likelihood of successful implementation. In addition, we systematically tailored InPACT program packaging materials based on this research to suit the population and context. Finally, we worked with stakeholders which included principals and teachers to identify key areas for tailoring (e.g., adjusting intervention dose) and integrated proposed changes into the program packaging, teacher training, and technical assistance processes.

Figure 1.

Figure 1.

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Causal model for adapting the InPACT program (based on Lyon & Bruns, 2019)

METHODS

Design of REP implementation strategies.

The tailoring program packaging component of REP addressed several identified barriers (See Table 1). For competing curricular challenges and priorities, we modified the recommended daily intervention dose. Teachers noted that 10 activity breaks prescribed in the InPACT program (herein referred to as Standard InPACT) were not feasible, but suggested that increasing the duration of activity breaks from 3 to 4 minutes allowed for more activity in the classroom while minimizing the number of interruptions to the teaching curriculum (Beemer et al., 2018). Because 5 activity breaks were feasible in the mid- and high-resource schools, the intervention dose was modified from 10×3-minute breaks to 5×4-minute breaks. Previous research has demonstrated that 20 minutes of daily moderate-to-vigorous physical activity is a sufficient dose of exercise to improve cardiometabolic and mental health outcomes in children (Davis et al., 2012). As a result of this change, intervention materials including the Compendium of Physical Activities were repackaged to reflect 4-minute activity breaks. Given the increased duration of each activity break, exercises were also repackaged as circuit training activities with each movement lasting 15 seconds to reduce boredom among students.

Table 1.

Adaptations to the InPACT program packaging, teacher training, and technical assistance

Barrier REP strategy Modifications Standard InPACT Tailored InPACT
Competing curricular challenges Program packaging Daily intervention dose 10x3-minute activity breaks each day 5x4-minute activity breaks each day
Competing curricular challenges Program packaging Weekly intervention dose Up to 150 minutes of MVPA in the classroom per week Up to 100 minutes of MVPA in the classroom per week
Competing curricular challenges Program packaging Compendium of Physical Activities Included 200, 3-minute activity breaks Included 200 revamped activities to reflect 4-minute activity breaks with circuit of activities lasting 15 seconds.
Competing curricular challenges Program packaging Activity break implementation timing At least a 20-minute gap of sedentary time between implementation of breaks Could implement breaks whenever they wanted throughout the day
Ex: could do more than one break in a row
Limited resources
(professional development time)		 Teacher training Teacher Training format 2x8-hour per day in-service 3x1-hour trainings held after school over a period of three months
Disruptive students Teacher training Teacher Training Content Science-based training Skill-based training
Communication (teacher-teacher, teacher-staff) Technical assistance Teacher Support Held monthly teacher check-in meetings
Communication (teacher-staff) Technical assistance Teacher Contact Weekly InPACT newsletters via email
•Important updates for the week
•Links to activity break videos were provided
•Teacher health-promotion strategies
Communication
(principal-teacher)		 Program packaging Intervention timeframe Fall semester Winter semester
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The REP implementation strategies of adapting program packaging and teacher training were used to increase program flexibility related to implementation timing of activity breaks. Previously, when implementing Standard InPACT, teachers were instructed to maintain at least a 20-minute gap of sedentary time between implementation of breaks. In the tailored InPACT program packaging, teachers were encouraged to implement activity breaks whenever it felt most comfortable and convenient in their class schedule. In addition, teachers were permitted to complete more than one activity break in a row. Teachers also received additional training from the InPACT staff on how to effectively integrate physical activity breaks into their curriculum and received a written training manual to reinforce the in-person training they received.

The REP implementation strategy of providing teacher training was used to address the barrier of limited resources for professional development time. Specifically, teacher trainings were condensed from a 2×8-hour in-service held on back-to-back days to 3×1-hour trainings held after school over a period of three months (September-November). These teacher trainings, which were conducted once per month prior to the start of the intervention were re-designed to increase acceptability of the program and provide implementation resources in advance of the intervention start date.

The REP implementation strategy of providing teacher trainings was used to address the barrier of perceived disruptive student behavior. Teacher trainings were tailored to incorporate skill-building for employing classroom management techniques rather than providing the scientific rationale for the intervention. A greater emphasis was placed on the importance of establishing classroom procedures and using them consistently throughout the duration of the intervention. Similar to Standard InPACT, posters were distributed to teachers that displayed verbal cues to transition students to and from an activity break. For example, to help students transition into beginning an activity break, the cue word “MOVE” was used, which stood for Materials down, Open space, Voices quiet, and Ears listening (Beemer et al., 2018). An emphasis was also placed on children checking their heart rate immediately following an activity break, which served to help children refocus and return to task quicker. Implementation data from the Standard InPACT pilot study was also shared with the teachers implementing Tailored InPACT showing that those who utilized the program’s classroom procedures achieved higher intervention fidelity compared to teachers who did not utilize this enhancement.

The REP implementation strategies of providing technical assistance and adapting program packaging were employed to address the barrier of communication. Teacher check-in meetings were conducted once per month during the Tailored InPACT intervention (January – May) to answer questions, communicate updates, and troubleshoot problems with implementation that arose. Weekly newsletters were developed and sent to teachers providing website links to 4-minute activity break videos freely available on the internet, and health-enhancing information for teachers (e.g., how to cope with teacher stress). In terms of program packaging, the Tailored InPACT intervention timeframe was adjusted to begin implementation in the month of January vs. September to allow for more teacher-principal communication and time to address any potential organizational barriers. Taken together, these multicomponent implementation strategies informed by REP were used to systematically tailor InPACT program packaging, teacher trainings and provide technical assistance to suit the needs of teachers in this low-resource school with the goal of enhancing program feasibility, fidelity, and student physical activity levels in this context.

Pilot testing of the Tailored InPACT intervention in one low-resource school

Recruitment.

The Tailored InPACT intervention was pilot tested in one low-resource elementary school. The participating school was selected based on their participation in Project Healthy Schools, a health promotion program housed in elementary/middle schools throughout the state of Michigan (Cotts et al., 2007). The school was comprised of 1007 students in grades pre-K to 8. The racial composition of the school was as follows: 79.0% Latino, 13.1% African American, 5.5% Caucasian, 2.3% Middle Eastern, 0.2% Other Race and 0.1% Native American. The school was located in Detroit, Michigan, with 80% of students eligible for free and reduced-price lunch.

A total of nine, 3rd-6th grade classrooms (two, 3rd-grade; two, 4th-grade; two, 5th-grade; and three, 6th-grade) chosen by the school principal participated, representing a reach of approximately 300 students. All students participated in the program with the exception of one student. This study was considered Exempt Human Research by the Institutional Review Board at the University of Michigan as the study posed “no more than minimal” risk (HUM00137925).

Study design.

Tailored InPACT was a 20-week classroom-based physical activity intervention. During weeks 1–4 of the intervention, teachers followed an incremental protocol where they were asked to complete 1×4-minute activity break per day during the first week, adding an additional activity break each following week until classrooms reached a total of 5×4-minute activity breaks per day. This was carried out to allow adequate time for teacher and student familiarity with Tailored InPACT and to establish classroom procedures. During weeks 5–20 of the intervention, teachers implemented 5×4-minute activity breaks per day in their classroom. Again, teachers were given full autonomy regarding when they implemented activity breaks, allowing them to plan activity breaks at optimal times throughout the day. A full description of the study design and intervention protocol have been previously published (Beemer, Ajibewa, DellaVecchia, & Hasson, 2019).

Implementation outcome measures

Fidelity.

A daily questionnaire was sent via email at the end of each school day to assess the fidelity of the intervention (i.e. the number of activity breaks teachers implemented per day). During weeks 5–20, the question asked was, “Did you implement 5 activity breaks today?” If the teacher answered with no, the next question was “If no, how many activity breaks did you implement today?” To enhance compliance for questionnaire completion, teachers were compensated monthly in relation to how many questionnaires they completed. The payment protocol was as follows: complete 25% of questionnaires receive $25; complete 26–50% of questionnaires receive $50; complete 51–75% of questionnaires receive $75; and complete 76–100% of questionnaires receive $100. Compensation was not given for completion of activity breaks, only questionnaires.

As an additional measure of intervention fidelity, six trained InPACT research team members visited each classroom for approximately 4-hours per visit to directly observe activity breaks. Transition time and duration of activity breaks were calculated using direct observation via the System for Observing Play and Leisure Activity in Youth (SOPLAY) (McKenzie, Marshall, Sallis, & Conway, 2000) with researchers using a timer. Over repeated time intervals, SOPLAY uses visual scans of the classroom from left to right at a rate of about one person per second. SOPLAY was designed to record physical activity levels in open environments and has been shown to be highly reliable in youth (McKenzie et al., 2000). To calculate transition time researchers started the timer at the teacher’s initiation of doing an activity break (i.e. “class it’s time to do an activity break, please stand up”) to the onset of the activity break (i.e. pressing play on the video). Duration of activity breaks was calculated with researchers starting the timer at the start of an activity break (i.e. start of the video) and stopping the timer at the end of the activity break (i.e. end of the video). There was one observer per classroom except when inter-rater reliability occurred, wherein two observers were present in the class. The inter-rater reliability was 0.82 across all observational scans. A total of 294 observations were recorded from all classrooms combined.

Feasibility.

A weekly questionnaire was sent at the end of the school day each Friday for teachers to reflect on the previous week of implementing activity breaks. An example question was: “How much additional planning time was required for each day during the week?” An end-of-study questionnaire was given to teachers during the last week of the intervention (week 20) to assess teachers’ perceived feasibility of the Tailored InPACT program.

Data analysis

The question asked from the teacher weekly questionnaire was in multiple-choice format. This data was analyzed by dividing the number of teacher responses for each answer option by the total number of answers and the results were reported as a percentage.

Open-ended questions asked on the teacher end-of-study questionnaire related to teacher perceived feasibility of the Tailored InPACT program were used in this analysis. We used a summative qualitative content analysis approach, outlined by Hsieh and Shannon to code teacher responses into common themes (Hseih & Shannon, 2005). First, we read through all nine teacher responses for each question taking note of frequent words used. Next, we coded the answers into common themes. The final themes that emerged were reported for each question accompanied by supporting quotes from teachers in differing grades, so all perspectives were represented and given context.

Statistical analyses

All statistical analyses were performed using STATA 15.0 (Stata Corporation, TX). Linear mixed models were used to evaluate potential grade-level differences for the following outcomes: (1) activity breaks implemented per day, (2) transition time, and (3) duration of activity breaks. Grade-level (3rd vs. 4th vs. 5th vs. 6th) was included in all models as a fixed factor. To account for correlations within teachers on different days, or within days for different teachers we included crossed random effects for teacher and intervention day in the model analyzing activity breaks implemented per day. In addition, since we have multiple observations per teacher on the days we visited the school for direct observation, visits were nested within teacher in the models for duration and transition time of activity breaks. The reference for all models was 6th-grade. Additionally, pairwise comparisons were performed to further assess differences between grades for each of the three outcomes. The significance level for all analyses was p<0.05.

RESULTS

Fidelity outcomes

Table 2 displays the means and 95% confidence intervals for the following outcomes: 1) activity breaks implemented per day, 2) duration of activity breaks, and 3) transition time. Table 3 displays the fixed effect calculations for the number of activity breaks implemented per day. Teacher compliance rate of answering the daily questionnaire was 83.7% throughout the study. During weeks 5–20, the average number of activity breaks implemented per day was 3.7±0.09, or approximately 4, across all nine classrooms. When examining grade-level differences, the number of activity breaks implemented per day on average was approximately 3 breaks higher in 3rd-grade, 4th-grade, and 5th-grade compared to 6th-grade (approximately 5 vs. 2 activity breaks, all p’s= 0.01). Pairwise comparisons showed no other significant differences in the number of activity breaks implemented per day between grades (all p’s>0.05). Insert table 2–3 here.

Table 2:

Mean and 95% confidence intervals by grade-level for activity breaks implemented each day, duration of activity breaks, and transition time. AB indicated activity break and subscript letters indicate significant differences between grades (p<0.05).

Grade Mean No. AB Completed 95% confidence interval Mean Duration 95% confidence interval Mean Transition Time 95% confidence interval Total Observed AB
Third 4.5±0.2a 4.2, 4.9 223.8±34.4a 156.4, 291.2 80.9±26.7 28.6, 133.2 88
Fourth 4.6±0.2b 4.3, 5.0 211.4±34.4b,c 143.9, 278.8 104.3±27.9 49.7, 158.8 94
Fifth 4.9±0.2c 4.5, 5.3 324.7±35.9c 254.3, 395.1 74.1±27.9 19.4, 128.8 60
Sixth 1.6±0.2a,b,c 1.3, 1.9 252.1±33.9a,b 185.7, 318.6 97.9±25.8 47.3, 148.5 37
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Table 3.

Fixed effect calculations for number, duration, and transition time of activity breaks implemented per day, by grade-level.

Outcome Fixed Effects Coefficient Standard error p-value 95% confidence interval
Number Third Grade 2.86 0.23 0.001 2.40, 3.32
Fourth Grade 3.00 0.24 0.001 2.52, 3.48
Fifth Grade 3.26 0.24 0.001 2.80, 3.72
Sixth Grade (reference grade) 1.64 0.15 -- 1.35, 1.94
Duration Third Grade −28.33 48.29 0.56 −122.98, 66.32
Fourth Grade −40.78 48.32 0.40 −135.50, 53.93
Fifth Grade 72.56 49.39 0.14 −24.24, 169.36
Sixth Grade (reference grade) 252.13 33.91 -- 185.67, 318.60
Transition time Third Grade −17.04 37.14 0.65 −89.82, 55.74
Fourth Grade 6.33 37.98 0.89 −68.10, 80.77
Fifth Grade −23.80 38.02 0.53 −98.33, 50.72
Sixth Grade (reference grade) 97.93 25.82 -- 47.33, 148.54
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Dose delivered.

Of the activity breaks observed by research staff, 98% were video led while 2% were teacher led. The exercise videos, used by all nine teachers, averaged 247.8±9.2 seconds (i.e., 4 minutes 8 seconds) in duration with students exercising throughout the entire break. There were no significant differences in the duration of activity breaks in 3rd-, 4th-, and 5th-grade compared to 6th-grade (all p’s>0.05). However, activity break videos implemented by 5th-grade teachers were significantly longer compared to 3rd-grade teachers (p=0.04) and 4th-grade teachers (p=0.02).

Quality of delivery.

The average transition time from seated instruction to activity break onset, across all nine classrooms, was 83.17±6.05 seconds (i.e., 1 minute 23 seconds). Transition time of activity breaks did not significantly differ between grades (p>0.05). Pairwise comparisons showed no other significant differences in transition time between grades (all p’s>0.05).

Feasibility.

Overall, the teacher compliance rate of answering the weekly questionnaire was 78.1% during the study. When asked each week: “How much additional planning time was required for each day?” approximately 94% of responses were 0–15 minutes, 6% of responses were 15–30 minutes, and less than 1% of responses were more than 30 minutes.

Teacher compliance rate of answering the end-of-study questionnaire was 100%. When asked the question: “How did your students respond to the activity breaks?” the top two responses were (1) “loved them” and (2) “enjoyed them.” When asked the question: “Please share one success story related to InPACT from your classroom.” Themes were: (1) student’s desired to be active, (2) students increased their participation during activity breaks, and (3) activity breaks increased cohesion among peers. The following are comments from teachers supporting these findings: (1) 3rd-grade teacher: “Students know when a break is necessary and voice it,” (2) 5th-grade teacher: “Two students who didn’t like participating ended up doing it and loved the workout videos,” and (3) 6th-grade teacher: “A student in my class got along better with classmates because of participating in the activity breaks with them.”

Post intervention, teachers were asked: “Did you feel supported by your school administration during your participation in InPACT?” In response, 100% of teachers reported “yes”. Example answers included: (1) 3rd-grade teacher: “Yes, we all know kids need to move and have breaks. The fact that we could miss staff meetings for InPACT meetings speaks to that.” (2) 5th-grade teacher: “Yes, the principal wanted to participate and encouraged the program.” When asked the question “Did you feel supported by the InPACT team during your participation in InPACT?” 100% of teachers reported “yes”. Example answers included: (1) 3rd-grade teacher: “Yes, the newsletters and suggestions were helpful” and (2) 6th-grade teacher: “Yes, they stopped by often and gave hints and suggestions.”

DISCUSSION

The purpose of this pilot study was to test the feasibility of the Tailored InPACT program and evaluate its effectiveness on program fidelity in a low-resource school. On average, 3rd-through 5th-grade teachers achieved intervention dose by implementing 5 activity breaks per day. The average duration of activity breaks was 4 minutes and 8 seconds, thereby allowing 3rd-5th grade students to accumulate approximately 20 minutes of classroom activity per day (100 minutes of classroom activity per week). Sixth-grade teachers did not achieve intervention dose with only 2 activity breaks implemented per day, providing 6th-grade students with only 8 minutes of classroom activity per day (40 minutes of classroom activity per week). These findings suggest tailoring the InPACT intervention enhanced the feasibility and fidelity of classroom-based physical activity interventions for 3rd-5th grade teachers in a low resourced school. Additional adaptations are needed to increase feasibility and fidelity among 6th-grade teachers.

In the absence of tailored program packaging, low intervention fidelity has been observed in classroom-based physical activity interventions implemented in low-resource schools (Bartholomew & Jowers, 2011; Weaver et al., 2018). Partnerships for Active Children in Elementary Schools, a comprehensive school-based physical activity intervention, which included classroom activity, was implemented in one low-resource elementary school district in South Carolina (Weaver et al., 2018). This intervention provided teacher trainings but no mention of intervention tailoring was included. Study findings suggested students accumulated a modest 3-minute increase in physical activity throughout the school day. Texas Initiatives for Children’s Activity and Nutrition (I-CAN) was implemented in three elementary schools with students who were disproportionately minority and of low socioeconomic status (Bartholomew & Jowers, 2011). This intervention included an approach of training teachers to modify their lesson plans to incorporate physical activity during academic time, however program packaging was not tailored to context. Few teachers (< 25%) implemented lessons on a daily basis as was intended. Process evaluation suggested that while teachers strongly supported the concept, they experienced notable barriers to implementation including lack of planning time and available resources. As a result, students accumulated less than 5 minutes of classroom activity per day. TAKE 10! is one of the most widely used and disseminated classroom-based physical activity programs with high fidelity (Stewart, Dennison, Kohl, & Doyle, 2004). Yet, costs associated with purchasing the curriculum and competing curricular demands and priorities noted in low-resource schools make this program less feasible. Taken together, these findings reiterate that evidence-based physical activity interventions implemented in low-resource schools must be adapted to maximize program fidelity. Third- through 5th-grade teachers in the present study who implemented Tailored InPACT achieved the intervention dose of 5 activity breaks per day. This dose was similar to the dose achieved in the mid-resource and high-resource schools, and substantially higher than the dose achieved in the low-resource school that implemented Standard InPACT (Beemer et al., 2018). Hence, these findings provide preliminary evidence that adapting the InPACT intervention to maximize fidelity may reduce disparities in program delivery and student classroom physical activity participation.

The vast majority of classroom-based physical activity interventions have been conducted at the elementary grade level with fewer programs implemented at the middle school grade level (Prevention, 2018). The Standard InPACT intervention was previously implemented in one 6th-grade classroom in a mid-resource school where slightly fewer activity breaks were implemented per day in that classroom compared to 4th- and 5th-grade teachers (4 vs. 5 activity breaks per day) (Beemer et al., 2018). In the present study, Tailored InPACT implementation rates were significantly lower with 6th-grade teachers implementing on average 2 activity breaks per day compared to 5 activity breaks in the other classrooms. Process evaluation suggested that rotating classroom structures were a unique barrier to full implementation for 6th-grade teachers. At the elementary grade level, students remain with their teacher throughout the school day whereas middle school students (i.e., 6th-grade) rotate classrooms as teachers provide instruction on specific content areas (e.g. science, math, and language arts). Despite using the floor plans, space issues continued to be of concern for 6th-grade teachers as some classrooms had up to 44 students per class. Previous research has also identified student reluctance to participate in classroom activity as a barrier among middle school students (Dinkel, Schaffer, Snyder, & Lee, 2017).

While it may seem counterintuitive given the low fidelity rate, one strategy to enhance program fidelity could be to scale-up implementation to include all 6th-grade classrooms in the school building as it would provide a more consistent schedule to implement activity breaks. By encouraging all 6th-grade teachers to implement one activity break with each set of students they teach, this could create a more structured routine and sense of community among 6th-grade teachers and their students. It is important to note that providing more support to teachers in the form of developing additional classroom management strategies will also be needed as it may be more challenging to implement one activity break with different groups of students compared to implementing five activity breaks with one group of students. Based on the work of Kilbourne et al, intervention supports in the form of internal facilitation, can serve as a tool to increase InPACT fidelity and student participation (Kilbourne et al., 2014). Internal facilitators work within the school building and have protected time to support teachers in implementing evidence-based programs by helping them align program activities with the priorities of the school administration. Physical education teachers and mental health professionals including social workers could take on this facilitation role given their experience and expertise in promoting student health. Another potential strategy could include adding game design elements to enhance teacher motivation and student participation in classroom activity breaks. We previously demonstrated that adding daily, weekly, and end-of-program prizes as a reward helped students meet their classroom physical activity goals and resulted in a 27% increase in physical activity participation (Beemer et al., 2019). Developing a reward system and promoting friendly competition among 6th-grade teachers and students may help to reduce barriers to implementation and promote social cohesion across the entire grade level. Finally, qualitative data should also be collected to identify and develop intervention enhancements that can enable 6th-grade teachers to overcome structural as well as student barriers to program delivery to more effectively maximize intervention fidelity in low-resource schools.

Strengths and limitations

Strengths of this study included: (1) obtaining stakeholder input to optimize the dose of physical activity delivered in classrooms, (2) high teacher compliance in completing questionnaires allowing for a reliable account of teacher’s daily participation in the intervention, and (3) use of the REP framework to guide the tailoring of the InPACT intervention. Limitations of this study should also be noted. Teachers were aware when observation days were taking place, potentially influencing teacher implementation of activity breaks. Teachers were also compensated for daily and weekly questionnaire completion (not implementation of activity breaks) therefore, we recognize that social desirability may have influenced teacher responses. End-of-study questionnaires were also answered retrospectively. Finally, this school was selected based on their participation in Project Healthy Schools and thus may have been more motivated to participate than a different low-resource school that does not have a health initiative already in place.

Conclusions

When designing and implementing interventions, previous research has demonstrated that a “one-size fits all” approach does not provide the necessary support that leads to successful implementation in low-resource schools (Barr-Anderson et al., 2017). Yet, most classroom-based physical activity interventions use an equality-based approach to increase physical activity participation among students (Bartholomew & Jowers, 2011; De Meij et al., 2010; Donnelly et al., 2009; Katz et al., 2010; Kibbe et al., 2011; Kriemler et al., 2010; Liu et al., 2008). In essence, equality-based interventions provide similar resources and support to diverse community schools, irrespective of the available resources and needs of each school in achieving the recommended 30 minutes of school-based activity (Hasson, 2017). Findings from the Standard and Tailored InPACT intervention highlight the need for an equity-based approach in classroom-based physical activity programming. Equity in this case refers to adapting intervention program packaging, teacher training, and technical assistance to maximize program fit and fidelity to increase and maintain physical activity participation in diverse pediatric populations (Hasson, 2017).

Tailored InPACT is designed to meet the specific needs of low-resourced schools to motivate physical activity behavior change in elementary school-age students. Future research should continue to apply principles from implementation science to identify additional facilitators and barriers to intervention implementation in low-resource elementary schools. By enhancing opportunities for low-income children to engage in health-enhancing physical activity in classrooms, opportunities arise to eliminate physical activity disparities in this context.

Acknowledgements:

The authors thank collaborators from the University of Michigan School of Education, College of Architecture and Urban Planning, Project Healthy Schools, and Michigan Consulting for Statistics, Computing and Analytics Research staff for their contributions to this project. In addition, the authors are grateful for the principal, teachers, and students for their involvement in this study. The results are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation.

Funding sources: This study was funded by the University of Michigan Mcubed Seed Funding Program. A.B. Eisman was supported during this project by a National Institute of Health training award (1K01DA044279-01A1). The study sponsors had no involvement in the study design; collection, analysis and interpretation of the data; the writing of the manuscript; or the decision to submit the manuscript for publication.

Footnotes

Ethics approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was considered Exempt Human Research by the Institutional Review Board at the University of Michigan (HUM00137925) due to the following reason: “research conducted in established or commonly accepted educational settings, involving normal educational practice, such as (i) research on regular and special education instructional strategies, or (ii) research on the effectiveness of or the comparison among instructional techniques, curricula, or classroom management methods”.

Conflicts of interest: Hasson, Beemer, Ajibewa and Eisman declare that they have no conflicts of interest.

Consent to participate: Because this study was deemed exempt and de-identified data was collected, informed consent was not obtained from study participants.

AVAILABILITY STATEMENT

The dataset generated during and/or analyzed during the current study are not publicly available because individual privacy could be compromised, but are available upon written request to the corresponding author.

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