Physical activity school intervention: context matters

Physical activity school intervention: context matters Abstract School-based interventions for increasing physical activity among children are widespread, however there is still a lack of knowledge about how school context factors are linked to implementation quality and effectiveness of programmes. The aim of this paper is to examine teacher-perceived effectiveness of a Danish national classroom-based health programme ‘Active Around Denmark’ and in particular, to investigate whether perceptions vary as a function of school social context factors. After completion of the programme all teachers (N = 5.892) received an electronic questionnaire. 2.097 completed the questionnaire (response rate 36%) and 1.781 datasets could be used for analysis. The teachers were asked about their perceptions of changes in children’s attitudes towards and levels of physical activity after the competition. Our results indicated that certain contextual factors, such as schools’ prioritization of health promotion, teachers’ support by their school principal in implementation as well as teacher’s satisfaction with the school’ physical environment made a significant difference in teacher-perceived effectiveness. To conclude, teacher-perceived effectiveness of the health programme does vary as a function of school social context factors. Introduction Worldwide, low levels of physical activity cause 3.2 million deaths each year and accounted for 2.8% of Disability-Adjusted Life Years in 2010 [1]. Since physical activity habits established early in life influence adult physical activity [2], it is particularly worrying that inactivity levels among the young are increasing, a development which started in the second half of the 20th century. In Denmark, this negative trend has been stopped and even slightly reversed [3, 4]. However, in 2014 it were still only 38% of girls and 51% of boys among the 13-year olds who reached the recommended levels for physical activity of at least 1 h daily physical activity [5]. Schools have long been viewed as an important setting for promoting health and well-being [6] and interventions to support the adoption of physical activity in schools are widespread. While a review of reviews on school-based interventions aimed at promoting physical activity in children showed a positive effect on physical activity [7] inconsistencies and uncertainty about the conditions of effectiveness still exist [8–10]. Such inconsistency also characterizes school-based physical activity programmes in Denmark. While some studies have reported positive effects on physical activity [11], others did not find their programme to be effective [12]. Reasons for this heterogeneity can be many, since intervention programmes differ in terms of content, didactic approach as well as duration and intensity. Also, measurement of physical activity varies widely, further increasing difficulties in comparing results [13]. Some of the variance, however, might also be due to the fact that programmes are implemented in very different social contexts, which may enable or hinder success by affecting implementation quality. Two elements have been identified as crucial contextual factors influencing implementation quality, these are provider attributes (e.g. teachers’ skills, motivation) and delivery system characteristics (e.g. school policies, organizational norms, physical infrastructure) [14]. Successful programmes, accordingly, do not only need well-developed concepts and motivated and skilled teachers to deliver them but also wider social contexts which are consistent with and support health promoting activities. A review by Naylor, Nettlefold [15] on the implementation of school-based physical activity programmes emphasized this point by stating that ‘…we need to better understand the many factors that could be modified to advance the implementation experience’ (p. 113). A particular type of intervention, which has rarely been applied and/or studied within the realm of school-based physical activity promotion, is the competition approach, where school classes as a whole compete for prizes linked to the achievement of behavioural goals. Some studies have shown that this can be an effective tool for smoking prevention [16, 17], but as yet little is known about applicability to other health behaviours. Short-term interventions, such as competitions, may alone not be capable to consistently change complex behavioural patterns such as physical activity. However, by introducing a ‘fun element’, they may contribute to creating favourable mind-sets and attitudes towards physical activity and thereby help reduce psychological barriers in groups of children and adolescents who otherwise might tend to avoid such activities. Thus, Corder, Schiff [18] reported that class competitions may appeal specifically to inactive students who would normally not get involved in physical activity promotion interventions. In Denmark, a free 3-week-long national competition, called ‘Active Around Denmark’ (AAD; has later changed name to ‘Active All Year Round’), has been offered annually since 2006 to teachers and school children (age 5–17) in all primary and secondary schools. The programme consists of a class-based physical activity competition where the aim for each school class is to ‘be the healthiest in Denmark’. The programme mainly focuses on the fun of being physically active, but also involves aspects of healthy eating and sleeping. For more information, see Supplementary Appendix S1. The present study aimed to examine teacher-perceived change in programme-induced physical activity in school children. Teachers’ perceptions of school intervention’s success cannot replace effect evaluations but are relevant indicators in their own right, since only teachers who do perceive programs as effective will be motivated to invest ongoing efforts into using and implementing health promotion interventions and will help create a receptive climate for such programs in their schools. In particular, we intended to investigate whether teacher perceptions about change in attitudes about and levels of physical activity after completion of the competition varied as a function of specific school social context factors. The present study aims to examine whether and to which extent teachers’ perceptions of competition-related physical activity and attitude change in their classes depended on (i) perceived quality of structural-physical conditions for physical activity in the school, (ii) specific support for programme implementation by the school principal and (iii) existence of a school policy on physical activity and general prioritization of health promotion in the school. Materials and methods Study design The study was based on a cross-sectional questionnaire survey targeted at teachers who, together with their classes, had participated in the AAD competition in 2015. Data were collected from October to November 2015. All teachers (N = 5.892) filled out an electronic questionnaire between 2 and 4 weeks after completion of the AAD programme. A total of 250. 040 school children were registered for the programme by their teachers, representing 37.5% of all school children in Denmark [19]. Data collection Table I shows the questions included in the study. All information was obtained from the teacher questionnaire, developed by the research team for the present research purpose. All questions were single items, covering schools and children’s background characteristics, satisfaction with school’s physical environment, school’s prioritization of health promotion, teacher’s support from school principal and teacher’s perception of changes in children’s attitudes towards physical activity and levels of physical activity. Table I. Questionnaire variables and response categories Variable Question Original response categories Collapsed response categories School size How many students attend the school? 1-150/151-300/301-450/451-600/601-800/800 students or more Small schools (<300 children)/ Medium-sized schools (301–600 children)/ Large schools (>600 children)a School year (years 1 to 11) Which school year had you signed up for the AAD campaign this year? Year 1, year 2, year 3, year 4, year 5, year 6, year 7, year 8, year 9, year 10, year 11 Years 1–5 / years 6–8 / years 9–11 Prior participation of teachers Have you participated in AAD before? No/Yes No/Yes Immigrants in the class How many of the students in the participating class are immigrants or have parents who are immigrants? 20% or less, 21–40%, 41–60%, 61–80%, 81–100% ≤20% / >20% One or both parent(s) with higher education How many of the students in the participating class, would you estimate, have a minimum of one parent who have completed higher education (defined as an education exceeding secondary school level by at least 2 years) 20% or less, 21–40%, 41–60%, 61–80%, 81–100%, Don’t know ≤40% / 41–80% / 81% + One or both parents being unemployed How many of the students in the participating class, would you judge, have parents where one or both are unemployed? 20% or less, 21–40%, 41–60%, 61–80%, 81–100%, Don’t know ≤20% / >20% Physical activity policy Does the school have a policy for physical activity? No/Yes/Don’t know No or don’t know/Yes School’s prioritization of health promotion How high do you believe the school in general prioritizes health promotion for the students (e.g. in regards to prevention of smoking, drinking, bullying, promotion of physical activity, healthy food, etc.) 7-point scale from: –3 ‘not at all satisfied’ to +3 ‘very satisfied’ Low to medium (–3 to 0) High (+1 to +3) Satisfaction with school physical environment In general, how would you assess the structural and physical conditions in your school in relation to the possibility of exercise and physical activity for students? Playground Schoolyard Gym Hallways Classroom Equipment 7-point scale from: –3 ‘not at all satisfied’ to +3 ‘very satisfied’ Low (–3 and –2) Medium (–1, 0 and +1) High (+2 and +3) Support from school principal How satisfied have you been with the support you received for the project from your school’s principal? 7-point scale from: –3 ‘absolutely not satisfied’ to +3 ‘very satisfied’ and a separate category of ‘not relevant’b Not relevant Not satisfied with support (from –3 to 0) Satisfied with support (+1 to +3). Attitudes towards physical activity after competition Indicate if and in which way the following aspects have changed, after the students participated in the project  The students attitudes towards physical activity  The students levels of physical activity 7-point scale from: –3 ‘has become much worse’ to +3 ‘has become much better’ ‘Negative to no change’ (–3 to 0) ‘Positive change’ (+1 to +3) Positive change in level of physical activity after competition Same as above Same as above Same as above Variable Question Original response categories Collapsed response categories School size How many students attend the school? 1-150/151-300/301-450/451-600/601-800/800 students or more Small schools (<300 children)/ Medium-sized schools (301–600 children)/ Large schools (>600 children)a School year (years 1 to 11) Which school year had you signed up for the AAD campaign this year? Year 1, year 2, year 3, year 4, year 5, year 6, year 7, year 8, year 9, year 10, year 11 Years 1–5 / years 6–8 / years 9–11 Prior participation of teachers Have you participated in AAD before? No/Yes No/Yes Immigrants in the class How many of the students in the participating class are immigrants or have parents who are immigrants? 20% or less, 21–40%, 41–60%, 61–80%, 81–100% ≤20% / >20% One or both parent(s) with higher education How many of the students in the participating class, would you estimate, have a minimum of one parent who have completed higher education (defined as an education exceeding secondary school level by at least 2 years) 20% or less, 21–40%, 41–60%, 61–80%, 81–100%, Don’t know ≤40% / 41–80% / 81% + One or both parents being unemployed How many of the students in the participating class, would you judge, have parents where one or both are unemployed? 20% or less, 21–40%, 41–60%, 61–80%, 81–100%, Don’t know ≤20% / >20% Physical activity policy Does the school have a policy for physical activity? No/Yes/Don’t know No or don’t know/Yes School’s prioritization of health promotion How high do you believe the school in general prioritizes health promotion for the students (e.g. in regards to prevention of smoking, drinking, bullying, promotion of physical activity, healthy food, etc.) 7-point scale from: –3 ‘not at all satisfied’ to +3 ‘very satisfied’ Low to medium (–3 to 0) High (+1 to +3) Satisfaction with school physical environment In general, how would you assess the structural and physical conditions in your school in relation to the possibility of exercise and physical activity for students? Playground Schoolyard Gym Hallways Classroom Equipment 7-point scale from: –3 ‘not at all satisfied’ to +3 ‘very satisfied’ Low (–3 and –2) Medium (–1, 0 and +1) High (+2 and +3) Support from school principal How satisfied have you been with the support you received for the project from your school’s principal? 7-point scale from: –3 ‘absolutely not satisfied’ to +3 ‘very satisfied’ and a separate category of ‘not relevant’b Not relevant Not satisfied with support (from –3 to 0) Satisfied with support (+1 to +3). Attitudes towards physical activity after competition Indicate if and in which way the following aspects have changed, after the students participated in the project  The students attitudes towards physical activity  The students levels of physical activity 7-point scale from: –3 ‘has become much worse’ to +3 ‘has become much better’ ‘Negative to no change’ (–3 to 0) ‘Positive change’ (+1 to +3) Positive change in level of physical activity after competition Same as above Same as above Same as above a = Based on an average number of 430 students in Danish schools (19), b = the category of ‘not relevant’ was included since some teachers might have felt they did not need support from their principal in order to implement the programme. Table I. Questionnaire variables and response categories Variable Question Original response categories Collapsed response categories School size How many students attend the school? 1-150/151-300/301-450/451-600/601-800/800 students or more Small schools (<300 children)/ Medium-sized schools (301–600 children)/ Large schools (>600 children)a School year (years 1 to 11) Which school year had you signed up for the AAD campaign this year? Year 1, year 2, year 3, year 4, year 5, year 6, year 7, year 8, year 9, year 10, year 11 Years 1–5 / years 6–8 / years 9–11 Prior participation of teachers Have you participated in AAD before? No/Yes No/Yes Immigrants in the class How many of the students in the participating class are immigrants or have parents who are immigrants? 20% or less, 21–40%, 41–60%, 61–80%, 81–100% ≤20% / >20% One or both parent(s) with higher education How many of the students in the participating class, would you estimate, have a minimum of one parent who have completed higher education (defined as an education exceeding secondary school level by at least 2 years) 20% or less, 21–40%, 41–60%, 61–80%, 81–100%, Don’t know ≤40% / 41–80% / 81% + One or both parents being unemployed How many of the students in the participating class, would you judge, have parents where one or both are unemployed? 20% or less, 21–40%, 41–60%, 61–80%, 81–100%, Don’t know ≤20% / >20% Physical activity policy Does the school have a policy for physical activity? No/Yes/Don’t know No or don’t know/Yes School’s prioritization of health promotion How high do you believe the school in general prioritizes health promotion for the students (e.g. in regards to prevention of smoking, drinking, bullying, promotion of physical activity, healthy food, etc.) 7-point scale from: –3 ‘not at all satisfied’ to +3 ‘very satisfied’ Low to medium (–3 to 0) High (+1 to +3) Satisfaction with school physical environment In general, how would you assess the structural and physical conditions in your school in relation to the possibility of exercise and physical activity for students? Playground Schoolyard Gym Hallways Classroom Equipment 7-point scale from: –3 ‘not at all satisfied’ to +3 ‘very satisfied’ Low (–3 and –2) Medium (–1, 0 and +1) High (+2 and +3) Support from school principal How satisfied have you been with the support you received for the project from your school’s principal? 7-point scale from: –3 ‘absolutely not satisfied’ to +3 ‘very satisfied’ and a separate category of ‘not relevant’b Not relevant Not satisfied with support (from –3 to 0) Satisfied with support (+1 to +3). Attitudes towards physical activity after competition Indicate if and in which way the following aspects have changed, after the students participated in the project  The students attitudes towards physical activity  The students levels of physical activity 7-point scale from: –3 ‘has become much worse’ to +3 ‘has become much better’ ‘Negative to no change’ (–3 to 0) ‘Positive change’ (+1 to +3) Positive change in level of physical activity after competition Same as above Same as above Same as above Variable Question Original response categories Collapsed response categories School size How many students attend the school? 1-150/151-300/301-450/451-600/601-800/800 students or more Small schools (<300 children)/ Medium-sized schools (301–600 children)/ Large schools (>600 children)a School year (years 1 to 11) Which school year had you signed up for the AAD campaign this year? Year 1, year 2, year 3, year 4, year 5, year 6, year 7, year 8, year 9, year 10, year 11 Years 1–5 / years 6–8 / years 9–11 Prior participation of teachers Have you participated in AAD before? No/Yes No/Yes Immigrants in the class How many of the students in the participating class are immigrants or have parents who are immigrants? 20% or less, 21–40%, 41–60%, 61–80%, 81–100% ≤20% / >20% One or both parent(s) with higher education How many of the students in the participating class, would you estimate, have a minimum of one parent who have completed higher education (defined as an education exceeding secondary school level by at least 2 years) 20% or less, 21–40%, 41–60%, 61–80%, 81–100%, Don’t know ≤40% / 41–80% / 81% + One or both parents being unemployed How many of the students in the participating class, would you judge, have parents where one or both are unemployed? 20% or less, 21–40%, 41–60%, 61–80%, 81–100%, Don’t know ≤20% / >20% Physical activity policy Does the school have a policy for physical activity? No/Yes/Don’t know No or don’t know/Yes School’s prioritization of health promotion How high do you believe the school in general prioritizes health promotion for the students (e.g. in regards to prevention of smoking, drinking, bullying, promotion of physical activity, healthy food, etc.) 7-point scale from: –3 ‘not at all satisfied’ to +3 ‘very satisfied’ Low to medium (–3 to 0) High (+1 to +3) Satisfaction with school physical environment In general, how would you assess the structural and physical conditions in your school in relation to the possibility of exercise and physical activity for students? Playground Schoolyard Gym Hallways Classroom Equipment 7-point scale from: –3 ‘not at all satisfied’ to +3 ‘very satisfied’ Low (–3 and –2) Medium (–1, 0 and +1) High (+2 and +3) Support from school principal How satisfied have you been with the support you received for the project from your school’s principal? 7-point scale from: –3 ‘absolutely not satisfied’ to +3 ‘very satisfied’ and a separate category of ‘not relevant’b Not relevant Not satisfied with support (from –3 to 0) Satisfied with support (+1 to +3). Attitudes towards physical activity after competition Indicate if and in which way the following aspects have changed, after the students participated in the project  The students attitudes towards physical activity  The students levels of physical activity 7-point scale from: –3 ‘has become much worse’ to +3 ‘has become much better’ ‘Negative to no change’ (–3 to 0) ‘Positive change’ (+1 to +3) Positive change in level of physical activity after competition Same as above Same as above Same as above a = Based on an average number of 430 students in Danish schools (19), b = the category of ‘not relevant’ was included since some teachers might have felt they did not need support from their principal in order to implement the programme. Transformations For statistical purposes, large ranges of response categories were collapsed into new categories (Table I). Parental unemployment level was dichotomized into ‘≤20%’ and ‘>20% unemployed’. While unemployment in Denmark has generally been low in recent years, it is found to be 10% and higher in socially disadvantaged areas and in deprived neighbourhoods with a high percentage of immigrants it can go up to 20–30% and higher [20, 21]. The particular cut-off was therefore chosen to enable investigating whether perceptions of effectiveness in schools located in or close to socially deprived neighbourhoods differ from those in schools situated in more average or affluent areas. Satisfaction with the school’s facilities for physical activity was split into the categories ‘low’ (–3 and –2), ‘medium’ (–1, 0 and +1) and ‘high’ (+2 and +3) satisfaction (Table I). Each level was assigned points (low = 1 point, medium = 2 points and high = 3 points) and subsequently scores on the individual aspects (i.e. playground, schoolyard etc.) were totalled, resulting in a summary score from 6 to 18 points. Overall level of satisfaction with physical environment was categorized as ‘low’ (6–12 points), ‘medium’ (13–15 points) and ‘high’ (16–18 points) with each group representing about 1/3 of the sample. The initial response format for existence of a school policy for physical activity offered three choices (yes/no/don’t know). The categories ‘no’ and ‘don’t know’ were collapsed because the main research interest pertained to the consequences of a policy teachers are aware of as compared to ‘paper policies’ which are not communicated. Statistical analysis Frequencies were used to describe the characteristics of the participating schools, classes and students’ social background (Table II). Frequencies, P-values and chi-square (χ2) tests were applied to determine the bi-variate associations between school, class and student characteristics and the two indicators for perceived programme effect. Further chi-square (χ2) tests were applied post-hoc to determine differences between sub-groups in case of more than two groups (Table III). Multi-variable analysis was performed to determine independent contributions of the different factors in explaining perceived programme change, applying hierarchical logistic regression to adjust for potential confounders. In the first step of the analysis, the variables school size, school year, teachers’ prior programme participation, student immigration background, parental educational level and parental unemployment rate were entered into the equation (Model 1 in Table IV). The second step included the main variables of interest: schools’ having a policy for physical activity, schools’ prioritization of health promotion, teachers’ satisfaction with the appropriateness of the school’s physical environment for physical activity and principals’ support of the programme (Model 2 in Table IV). Results are presented as odds ratios (OR) and 95% confidence intervals (CIs; Table IV). IBM-SPSS for Windows v. 23 was used to conduct statistical analysis. Table II. Characteristics of participating schools, classes and students’ social background (n = 1781a) Frequency (%) School size     Small: <300 students 29.7     Medium: 301–600 students 39.4     Large: >601 students 30.9 School year (age 5–17)     Year 1–5 68.8     Year 6–8 25.2     Year 9–11 6.0 Prior participation of teachers     No 29.8     Yes 70.2 Immigrants in the class     ≤20% 84.4     >20% 15.6 One or both parent(s) with higher education     ≤40% 24.7     41–80% 52.5     81% + 22.8 One or both parents unemployed     ≤20% 80.4     >20% 19.6 Physical activity school policy     No or don’t know 51.5     Yes 48.5 School’s prioritization of health promotion     Low to medium 15.4     High 84.6 Satisfaction with school physical environment     Low 33.0     Medium 38.6     High 28.4 Support from school principal     Not relevant 22.4     Not satisfied with support 50.1     Satisfied with support 27.5 Frequency (%) School size     Small: <300 students 29.7     Medium: 301–600 students 39.4     Large: >601 students 30.9 School year (age 5–17)     Year 1–5 68.8     Year 6–8 25.2     Year 9–11 6.0 Prior participation of teachers     No 29.8     Yes 70.2 Immigrants in the class     ≤20% 84.4     >20% 15.6 One or both parent(s) with higher education     ≤40% 24.7     41–80% 52.5     81% + 22.8 One or both parents unemployed     ≤20% 80.4     >20% 19.6 Physical activity school policy     No or don’t know 51.5     Yes 48.5 School’s prioritization of health promotion     Low to medium 15.4     High 84.6 Satisfaction with school physical environment     Low 33.0     Medium 38.6     High 28.4 Support from school principal     Not relevant 22.4     Not satisfied with support 50.1     Satisfied with support 27.5 a = The sample size is based on all participants with valid scores on all included predictor variables and represents number of teachers and not number of schools, i.e. some schools might be represented by several teachers. Table II. Characteristics of participating schools, classes and students’ social background (n = 1781a) Frequency (%) School size     Small: <300 students 29.7     Medium: 301–600 students 39.4     Large: >601 students 30.9 School year (age 5–17)     Year 1–5 68.8     Year 6–8 25.2     Year 9–11 6.0 Prior participation of teachers     No 29.8     Yes 70.2 Immigrants in the class     ≤20% 84.4     >20% 15.6 One or both parent(s) with higher education     ≤40% 24.7     41–80% 52.5     81% + 22.8 One or both parents unemployed     ≤20% 80.4     >20% 19.6 Physical activity school policy     No or don’t know 51.5     Yes 48.5 School’s prioritization of health promotion     Low to medium 15.4     High 84.6 Satisfaction with school physical environment     Low 33.0     Medium 38.6     High 28.4 Support from school principal     Not relevant 22.4     Not satisfied with support 50.1     Satisfied with support 27.5 Frequency (%) School size     Small: <300 students 29.7     Medium: 301–600 students 39.4     Large: >601 students 30.9 School year (age 5–17)     Year 1–5 68.8     Year 6–8 25.2     Year 9–11 6.0 Prior participation of teachers     No 29.8     Yes 70.2 Immigrants in the class     ≤20% 84.4     >20% 15.6 One or both parent(s) with higher education     ≤40% 24.7     41–80% 52.5     81% + 22.8 One or both parents unemployed     ≤20% 80.4     >20% 19.6 Physical activity school policy     No or don’t know 51.5     Yes 48.5 School’s prioritization of health promotion     Low to medium 15.4     High 84.6 Satisfaction with school physical environment     Low 33.0     Medium 38.6     High 28.4 Support from school principal     Not relevant 22.4     Not satisfied with support 50.1     Satisfied with support 27.5 a = The sample size is based on all participants with valid scores on all included predictor variables and represents number of teachers and not number of schools, i.e. some schools might be represented by several teachers. Table III. Association of school characteristics and programme effect perceived by teachers in percentages (n = 1706a) Positive change in attitudes towards physical activity after competition (n = 1706) Positive change in level of physical activity after competition (n = 1705) School size     Small: <300 students 58.7 62.3     Medium: 301–600 students 60.0 64.6     Large: >601 students 64.7 68.6  χ2; P value χ2 = 4.488 χ2 = 4.757 School year (age 5–17)     Year 1–5 64.4***b 68.1***     Year 6–8 53.8 59.1     Year 9–11 53.9 57.8  χ2; P value χ2 = 17.381*** χ2 = 13.830*** Prior participation of teachers     No 61.2 64.3     Yes 61.0 65.5  χ2; P value χ2 = 0.007 χ2 = 0.210 Immigrants in the class     ≤20% 60.4 64.4     >20% 64.5 69.1  χ2; P value χ2 = 1.571 χ2 = 2.097 One or both parent(s) with higher education     ≤40% 58.2 60.8     41–80% 64.3** 67.8**     81% + 56.8 63.8  χ2; P value χ2 = 8.311* χ2 = 6.709* One or both parents unemployed     ≤20% 62.0 65.9     >20% 57.1 62.2  χ2; P value χ2 = 2.726 χ2 = 1.614 Physical activity school policy     No or don’t know 57.3 61.6     Yes 65.1 68.9  χ2; P value χ2 = 10.673** χ2 = 10.015** Schools prioritization of health promotion     Low to medium 55.7 60.2     High 64.3 68.1  χ2; P value χ2 = 36.487*** χ2 = 11.107*** Satisfaction with school physical environment     Low 58.2 60.6     Medium 59.7 64.7     High 66.3** 71.0**  χ2; P value χ2 = 7.964* χ2 = 12.446** Support from school principal     Not relevant 56.6 61.7     Not satisfied with support 57.7 62.2     Satisfied with support 70.8*** 73.4***  χ2; P value χ2 = 26.283*** χ2 = 19.417*** Positive change in attitudes towards physical activity after competition (n = 1706) Positive change in level of physical activity after competition (n = 1705) School size     Small: <300 students 58.7 62.3     Medium: 301–600 students 60.0 64.6     Large: >601 students 64.7 68.6  χ2; P value χ2 = 4.488 χ2 = 4.757 School year (age 5–17)     Year 1–5 64.4***b 68.1***     Year 6–8 53.8 59.1     Year 9–11 53.9 57.8  χ2; P value χ2 = 17.381*** χ2 = 13.830*** Prior participation of teachers     No 61.2 64.3     Yes 61.0 65.5  χ2; P value χ2 = 0.007 χ2 = 0.210 Immigrants in the class     ≤20% 60.4 64.4     >20% 64.5 69.1  χ2; P value χ2 = 1.571 χ2 = 2.097 One or both parent(s) with higher education     ≤40% 58.2 60.8     41–80% 64.3** 67.8**     81% + 56.8 63.8  χ2; P value χ2 = 8.311* χ2 = 6.709* One or both parents unemployed     ≤20% 62.0 65.9     >20% 57.1 62.2  χ2; P value χ2 = 2.726 χ2 = 1.614 Physical activity school policy     No or don’t know 57.3 61.6     Yes 65.1 68.9  χ2; P value χ2 = 10.673** χ2 = 10.015** Schools prioritization of health promotion     Low to medium 55.7 60.2     High 64.3 68.1  χ2; P value χ2 = 36.487*** χ2 = 11.107*** Satisfaction with school physical environment     Low 58.2 60.6     Medium 59.7 64.7     High 66.3** 71.0**  χ2; P value χ2 = 7.964* χ2 = 12.446** Support from school principal     Not relevant 56.6 61.7     Not satisfied with support 57.7 62.2     Satisfied with support 70.8*** 73.4***  χ2; P value χ2 = 26.283*** χ2 = 19.417*** * P < 0.05, **P < 0.01, ***P < 0.001. a = Sample size for the different analyses diverges due to varying numbers of valid answers for the change assessments and b = *behind the percentages indicates significant differences of rates between the respective sub-group and both other groups. Table III. Association of school characteristics and programme effect perceived by teachers in percentages (n = 1706a) Positive change in attitudes towards physical activity after competition (n = 1706) Positive change in level of physical activity after competition (n = 1705) School size     Small: <300 students 58.7 62.3     Medium: 301–600 students 60.0 64.6     Large: >601 students 64.7 68.6  χ2; P value χ2 = 4.488 χ2 = 4.757 School year (age 5–17)     Year 1–5 64.4***b 68.1***     Year 6–8 53.8 59.1     Year 9–11 53.9 57.8  χ2; P value χ2 = 17.381*** χ2 = 13.830*** Prior participation of teachers     No 61.2 64.3     Yes 61.0 65.5  χ2; P value χ2 = 0.007 χ2 = 0.210 Immigrants in the class     ≤20% 60.4 64.4     >20% 64.5 69.1  χ2; P value χ2 = 1.571 χ2 = 2.097 One or both parent(s) with higher education     ≤40% 58.2 60.8     41–80% 64.3** 67.8**     81% + 56.8 63.8  χ2; P value χ2 = 8.311* χ2 = 6.709* One or both parents unemployed     ≤20% 62.0 65.9     >20% 57.1 62.2  χ2; P value χ2 = 2.726 χ2 = 1.614 Physical activity school policy     No or don’t know 57.3 61.6     Yes 65.1 68.9  χ2; P value χ2 = 10.673** χ2 = 10.015** Schools prioritization of health promotion     Low to medium 55.7 60.2     High 64.3 68.1  χ2; P value χ2 = 36.487*** χ2 = 11.107*** Satisfaction with school physical environment     Low 58.2 60.6     Medium 59.7 64.7     High 66.3** 71.0**  χ2; P value χ2 = 7.964* χ2 = 12.446** Support from school principal     Not relevant 56.6 61.7     Not satisfied with support 57.7 62.2     Satisfied with support 70.8*** 73.4***  χ2; P value χ2 = 26.283*** χ2 = 19.417*** Positive change in attitudes towards physical activity after competition (n = 1706) Positive change in level of physical activity after competition (n = 1705) School size     Small: <300 students 58.7 62.3     Medium: 301–600 students 60.0 64.6     Large: >601 students 64.7 68.6  χ2; P value χ2 = 4.488 χ2 = 4.757 School year (age 5–17)     Year 1–5 64.4***b 68.1***     Year 6–8 53.8 59.1     Year 9–11 53.9 57.8  χ2; P value χ2 = 17.381*** χ2 = 13.830*** Prior participation of teachers     No 61.2 64.3     Yes 61.0 65.5  χ2; P value χ2 = 0.007 χ2 = 0.210 Immigrants in the class     ≤20% 60.4 64.4     >20% 64.5 69.1  χ2; P value χ2 = 1.571 χ2 = 2.097 One or both parent(s) with higher education     ≤40% 58.2 60.8     41–80% 64.3** 67.8**     81% + 56.8 63.8  χ2; P value χ2 = 8.311* χ2 = 6.709* One or both parents unemployed     ≤20% 62.0 65.9     >20% 57.1 62.2  χ2; P value χ2 = 2.726 χ2 = 1.614 Physical activity school policy     No or don’t know 57.3 61.6     Yes 65.1 68.9  χ2; P value χ2 = 10.673** χ2 = 10.015** Schools prioritization of health promotion     Low to medium 55.7 60.2     High 64.3 68.1  χ2; P value χ2 = 36.487*** χ2 = 11.107*** Satisfaction with school physical environment     Low 58.2 60.6     Medium 59.7 64.7     High 66.3** 71.0**  χ2; P value χ2 = 7.964* χ2 = 12.446** Support from school principal     Not relevant 56.6 61.7     Not satisfied with support 57.7 62.2     Satisfied with support 70.8*** 73.4***  χ2; P value χ2 = 26.283*** χ2 = 19.417*** * P < 0.05, **P < 0.01, ***P < 0.001. a = Sample size for the different analyses diverges due to varying numbers of valid answers for the change assessments and b = *behind the percentages indicates significant differences of rates between the respective sub-group and both other groups. Table IV. Multi-variable association between school characteristics and teachers’ perceived changes in children’s physical activity levels and physical activity attitudes (n = 1706) Positive change in attitudes towards physical activity after competition (n = 1706) Positive change in level of physical activity after competition (n = 1705) Model 1 OR 95% CI OR 95% CI School size     Small: <300 students 0.825 0.635–1.072 0.823 0.630–1.075     Medium: 301–600 students 0.819 0.644–1.042 0.853 0.667–1.092     Large: >601 students 1.00 1.00 School year (age 5–17)     Year 1–5 1.523* 1.007–2.303 1.504 0.991–2.285     Year 6–8 0.985 0.636–1.527 1.037 0.667–1.614     Year 9–11 1.00 1.00 Prior participation of teachers     No 1.00 1.00     Yes 0.955 0.769–1.186 0.981 0.786–1.223 Immigrants in the class     ≤20% 1.00 1.00     >20% 1.248 0.922–1.689 1.312 0.961–1.791 One or both parent(s) with higher education     ≤40% 1.203 0.881–1.642 0.935 0.681–1.284     41–80% 1.458* 1.135–1.873 1.237 0.957–1.600     81% + 1.00 1.00 One or both parents unemployed     ≤20% 1.00 1.00     >20% 0.783 0.594–1.032 0.871 0.657–1.155 Model 2a Physical activity school policy     No or don’t know 1.00 1.00     Yes 1.209 0.985–1.484 1.209 0.981–1.491 Schools prioritization of health promotion     Low to medium 1.00 1.00     High 1.978*** 1.481–2.640 1.843*** 1.382–2.460 Satisfaction with school physical environment     Low 0.869 0.662–1.013 0.740* 0.560–0.978     Medium 0.785 0.609–1.013 0.774 0.595–1.005     High 1.00 1.00 Support from school principal     Not relevant 0.542*** 0.401–0.732 0.592** 0.436–0.806     Not satisfied with support 0.599*** 0.460–0.780 0.655** 0.500–0.857     Satisfied with support 1.00 1.00 Positive change in attitudes towards physical activity after competition (n = 1706) Positive change in level of physical activity after competition (n = 1705) Model 1 OR 95% CI OR 95% CI School size     Small: <300 students 0.825 0.635–1.072 0.823 0.630–1.075     Medium: 301–600 students 0.819 0.644–1.042 0.853 0.667–1.092     Large: >601 students 1.00 1.00 School year (age 5–17)     Year 1–5 1.523* 1.007–2.303 1.504 0.991–2.285     Year 6–8 0.985 0.636–1.527 1.037 0.667–1.614     Year 9–11 1.00 1.00 Prior participation of teachers     No 1.00 1.00     Yes 0.955 0.769–1.186 0.981 0.786–1.223 Immigrants in the class     ≤20% 1.00 1.00     >20% 1.248 0.922–1.689 1.312 0.961–1.791 One or both parent(s) with higher education     ≤40% 1.203 0.881–1.642 0.935 0.681–1.284     41–80% 1.458* 1.135–1.873 1.237 0.957–1.600     81% + 1.00 1.00 One or both parents unemployed     ≤20% 1.00 1.00     >20% 0.783 0.594–1.032 0.871 0.657–1.155 Model 2a Physical activity school policy     No or don’t know 1.00 1.00     Yes 1.209 0.985–1.484 1.209 0.981–1.491 Schools prioritization of health promotion     Low to medium 1.00 1.00     High 1.978*** 1.481–2.640 1.843*** 1.382–2.460 Satisfaction with school physical environment     Low 0.869 0.662–1.013 0.740* 0.560–0.978     Medium 0.785 0.609–1.013 0.774 0.595–1.005     High 1.00 1.00 Support from school principal     Not relevant 0.542*** 0.401–0.732 0.592** 0.436–0.806     Not satisfied with support 0.599*** 0.460–0.780 0.655** 0.500–0.857     Satisfied with support 1.00 1.00 * P < 0.05, **P < 0.01, ***P < 0.001. a = The variables in Model 2 are adjusted for all the covariates in Model 1. Table IV. Multi-variable association between school characteristics and teachers’ perceived changes in children’s physical activity levels and physical activity attitudes (n = 1706) Positive change in attitudes towards physical activity after competition (n = 1706) Positive change in level of physical activity after competition (n = 1705) Model 1 OR 95% CI OR 95% CI School size     Small: <300 students 0.825 0.635–1.072 0.823 0.630–1.075     Medium: 301–600 students 0.819 0.644–1.042 0.853 0.667–1.092     Large: >601 students 1.00 1.00 School year (age 5–17)     Year 1–5 1.523* 1.007–2.303 1.504 0.991–2.285     Year 6–8 0.985 0.636–1.527 1.037 0.667–1.614     Year 9–11 1.00 1.00 Prior participation of teachers     No 1.00 1.00     Yes 0.955 0.769–1.186 0.981 0.786–1.223 Immigrants in the class     ≤20% 1.00 1.00     >20% 1.248 0.922–1.689 1.312 0.961–1.791 One or both parent(s) with higher education     ≤40% 1.203 0.881–1.642 0.935 0.681–1.284     41–80% 1.458* 1.135–1.873 1.237 0.957–1.600     81% + 1.00 1.00 One or both parents unemployed     ≤20% 1.00 1.00     >20% 0.783 0.594–1.032 0.871 0.657–1.155 Model 2a Physical activity school policy     No or don’t know 1.00 1.00     Yes 1.209 0.985–1.484 1.209 0.981–1.491 Schools prioritization of health promotion     Low to medium 1.00 1.00     High 1.978*** 1.481–2.640 1.843*** 1.382–2.460 Satisfaction with school physical environment     Low 0.869 0.662–1.013 0.740* 0.560–0.978     Medium 0.785 0.609–1.013 0.774 0.595–1.005     High 1.00 1.00 Support from school principal     Not relevant 0.542*** 0.401–0.732 0.592** 0.436–0.806     Not satisfied with support 0.599*** 0.460–0.780 0.655** 0.500–0.857     Satisfied with support 1.00 1.00 Positive change in attitudes towards physical activity after competition (n = 1706) Positive change in level of physical activity after competition (n = 1705) Model 1 OR 95% CI OR 95% CI School size     Small: <300 students 0.825 0.635–1.072 0.823 0.630–1.075     Medium: 301–600 students 0.819 0.644–1.042 0.853 0.667–1.092     Large: >601 students 1.00 1.00 School year (age 5–17)     Year 1–5 1.523* 1.007–2.303 1.504 0.991–2.285     Year 6–8 0.985 0.636–1.527 1.037 0.667–1.614     Year 9–11 1.00 1.00 Prior participation of teachers     No 1.00 1.00     Yes 0.955 0.769–1.186 0.981 0.786–1.223 Immigrants in the class     ≤20% 1.00 1.00     >20% 1.248 0.922–1.689 1.312 0.961–1.791 One or both parent(s) with higher education     ≤40% 1.203 0.881–1.642 0.935 0.681–1.284     41–80% 1.458* 1.135–1.873 1.237 0.957–1.600     81% + 1.00 1.00 One or both parents unemployed     ≤20% 1.00 1.00     >20% 0.783 0.594–1.032 0.871 0.657–1.155 Model 2a Physical activity school policy     No or don’t know 1.00 1.00     Yes 1.209 0.985–1.484 1.209 0.981–1.491 Schools prioritization of health promotion     Low to medium 1.00 1.00     High 1.978*** 1.481–2.640 1.843*** 1.382–2.460 Satisfaction with school physical environment     Low 0.869 0.662–1.013 0.740* 0.560–0.978     Medium 0.785 0.609–1.013 0.774 0.595–1.005     High 1.00 1.00 Support from school principal     Not relevant 0.542*** 0.401–0.732 0.592** 0.436–0.806     Not satisfied with support 0.599*** 0.460–0.780 0.655** 0.500–0.857     Satisfied with support 1.00 1.00 * P < 0.05, **P < 0.01, ***P < 0.001. a = The variables in Model 2 are adjusted for all the covariates in Model 1. Ethics According to the Act on a Biomedical Research Ethics Committee System in Denmark, the project was not a biomedical research project and therefore did not need the ethic committee’s approval. All teachers were informed that their participation in the study was voluntary and that their responses would be anonymized. Results The questionnaire was completed by 2.097 teachers, resulting in a response rate of 36%. This percentage is based on completed questionnaires of all teachers who had initially registered a school class for the programme. However, it is unknown how many of the 5.892 teachers, after initial registration, failed to actually implement the programme, for instance due to time problems, illness etc. The response rate to the questionnaire is therefore likely to underestimate true response, since the true reference number of eligible teachers is bound to be lower than the number of 5.892 who initially registered. Questionnaires of 64 were excluded retrospectively, since teachers had only answered between one and nine of the initial background questions. Further, to achieve a homogeneous sample size across the different analyses 252 questionnaires were excluded since teachers had felt unable to answer one or more of the questions about children’s socio-economic background (parental unemployment and educational background) by choosing the ‘don’t know’-answer option. The final sample used for data analysis thus included N = 1.781 respondents. For information about the characteristics of the participating schools and students, see Table II. As shown in Table II, the initial descriptive analysis showed that a total of 61.1% and 65.2%, respectively, of the teachers reported a positive change in children’s attitudes towards and levels of physical activity as a result of the programme. Sample size for the different analyses diverges due to varying numbers of valid answers for the change assessments. Bi-variate results As for socio-demographic characteristics of the participating students there was a consistent difference in change of perceived physical activity as well as attitudes depending on school year (Table III). Also, teachers’ perceptions of children’s attitude changes and perceived level of physical activity depended on the educational background of the parents of the participating children. Further, there was a significant difference for both outcomes depending on whether schools had a policy for physical activity and whether they prioritized health promotion. Finally, significant differences in teachers’ perceptions of change were found for teacher’s satisfaction with the school’s physical environment and teacher’s satisfaction with their principal’s support. Multi-variable results The multi-variable analysis showed that the odds of teachers reporting positive change in children’s attitudes towards physical activity were 52% higher for teachers who had participated with classes from lower school years (year 1–5) and 46% higher for teachers of classes where 41–80% children came from a higher-education background. Teachers with low satisfaction with the schools’ physical environment were 26% less likely to report positive changes in children’s levels of physical activity than those with high levels of satisfaction (Table IV). As further indicated by the results shown in Table IV, principal support was independently associated with all change indicators. Teachers not satisfied with support from their school principal for implementing the programme were 40% less likely to report favourable change in attitudes and 35% less likely to report increased levels of physical activity than those satisfied with such support. Finally, existence of a school policy for physical activity did not make a difference in perceived change on any of the parameters after adjusting for all other variables, while teachers who reported a high prioritization of health promotion by the school were 98% more likely to report positive change in children’s attitudes and 84% more likely to report increased activity levels. Discussion Findings from this cross-sectional study clearly indicated that certain aspects of the school social context can make a significant difference when it comes to teachers’ view of the effectiveness of a class-based physical activity competition intervention. The physical environment in particular seems relevant for teachers’ evaluations. Those who did not perceive the physical setting of their school as providing a favourable setting for implementing physical activity tended to also report less change in children’s physical activity. It is easily conceivable that physical activity interventions are harder to implement in schools lacking adequate or attractive sports facilities, recess grounds or classroom space which allows for playing games and conducting the exercises involved in the programme. These results are in line with other studies, which have also reported positive associations between school outdoor physical environment and physical activity level in children [22, 23]. Furthermore studies has found associations between neighbourhood environment (such as walking/biking facilities, walkability, pedestrian safety structures, vegetation, traffic speed or volume, access or proximity to recreational facilities, land-use mix and residential density) and physical activity among children [24]. Further, the present study suggests a particular relevance of the school principal’s support for physical activity interventions. To our knowledge, no other studies within the area of physical activity have investigated this relation between support of the principal and successful implementation. In a broader perspective, however, principal support has been shown to be one of the most important factors for successful implementation of interventions in schools in general [25], and more particular it has been reported that principal support can positively influence the sustainability of usage of an elementary school health-related physical education programme [26]. Also, intervention studies in the area of mental health and drug use prevention have provided evidence for the important role of school principals. Thus in implementation studies regarding anti-bullying lessons in school [27] as well as substance use prevention [28] it was found that lack of support from the principal may directly impede or weaken teachers’ efforts to implement a programme. Further, from an intervention study regarding emotional competence and aggression management it was reported that adequate support from the school principal together with a high level of classroom program implementation predicted program effectiveness [29]. Specifically, school heads can facilitate health promotion programmes by assigning special time, space or material resources for such efforts and thereby improve implementation quality, but also by providing special incentives, benefits and recognition for teachers’ engagement in such activities. Seen from the perspective of health promotion frameworks, such as the PRECEDE-PROCEED model [30] both availability of an appropriate physical infrastructure as well as support from the principal can be conceived of as enabling factors which provide essential pre-requisites for successfully conducting a health promotion intervention. Support from the principal may in addition have reinforcing features, for instance when it provides teachers and students with encouragement and positive feedback for their activities. Interestingly, having a school policy on physical activity, while being significantly related to both variables of perceived change on the bi-variate level, lost its significance in the multi-variable model. This is in contrast with other findings that school physical activity policies do influence behavioural change [31] but may be explained by the present study’s simultaneous inclusion of the school’s prioritization of health promotion into the model. Actual prioritization of health promotion may reflect more specific actions than a general policy and thus may be more relevant, and therefore may have superseded an effect of school health policy. In a similar vein, organizational policies are likely to be reflected in specific positive or negative actions by key actors, such as school principals providing encouragement and support or they result in concrete investments into the built environment, such as gyms, playgrounds, etc. Thus, principal support and physical environment may act as a mediator between explicit official policies on physical activity and behaviour change and thereby eliminate direct effects of policies. It should also be noted that while a large majority of over 80% of teachers stated that their school prioritized health promotion, and 50% were aware of a physical activity policy, only 28% were satisfied with the support from their principal for programme implementation (with another 22% considering this type of support as not relevant). This suggests that it may be important to investigate concrete conditions and actions in practice rather than exclusively focusing on general visions and policies. Compared to the findings about socio-structural school context there were only few indications that the competition programme might be more or less effective in different groups of students. The only consistent difference indicated that teachers more often perceived effectiveness in groups of younger as compared to older students. This is in line with the results from a systematic review, where the most effective physical activity interventions were summarized and where it was suggested that for children, school-based physical activity programmes were the most effective intervention type, whereas for adolescents other settings were more appropriate [32]. Beyond such a setting effect, the age difference in the present study may further be explained by the specific content of the AAD intervention programme, which was largely relying on elements involving games and play. In combination with the competition format this might have been particularly appealing to younger students. Limitations The main limitation lies in the cross-sectional character of the study where, perceived change in attitudes and behaviour was assessed only retrospectively and not with a before-after measurement. In general, subjective direct assessment of change is considered problematic because of cognitive and motivational biases (e.g. due to implicit theory of change, response shifts) may affect validity [33, 34]. As for motivational bias, teachers who have implemented a competition programme certainly have a vested interest in its success and may therefore be expected to overestimate change. However, it was not absolute estimates of programme effects, which were the main focus of the present study but relative differences between teachers conducting the same programme in different social contexts. Yet, it may still be argued that teachers with a generally positive or optimistic outlook may have been more likely to have a positive view about the social context of their schools as well as about the effectiveness of the competition in terms of creating behavioural change. Further, a response rate of 36%, while common for this type of survey, may suggest selection effects. In 2015, the competition was running for the 11th time, and for the last nine of these occasions a questionnaire had been sent out to the teachers. Non-participation may therefore not have been primarily biased due to the variables of interest in this study, i.e. social context factors or positive/negative experiences with the program but may have been mostly due to prior participation. Since the large majority of participants had taken part more than once in the campaign many from this group might have considered it unnecessary to provide feedback every time. As for measurement it could be argued, that for some variables more complex multi-item measures may have been preferable over single items in order to strengthen reliability as well as validity. This issue is probably most relevant in case of principal support assessment, since this definitely is a multi-dimensional construct. Due to the considerable length of the questionnaire, which for instance also required detailed evaluative responses regarding different aspects of the intervention programme (which were not covered here), this did not seem a feasible option. Finally, results, while being suggestive, should be interpreted with caution since they reflect short-term teacher-perceived effectiveness only. The teachers’ view is certainly crucial, since they are the ones who in most cases implement health programs and only positive evaluations of such efforts will ensure continuous motivation. Whether, however, actual and longer-term behaviour change is achievable with a classroom competition program needs to be tested by controlled intervention studies and by using more objectifiable assessment methods of physical activity change, such as accelerometers. Nevertheless, our study offers a new perspective on the different contextual factors that can influence the effects of a health promotion programme, which can be built upon in future studies. Future practices can utilize these findings by ensuring the support of the principals before implementing school health programmes and by enhancing the physical environment at the schools, with the purpose of increasing programme effectiveness. Conclusion Our findings suggest that teacher-perceived effects of a national classroom-based health programme ‘AAD’ do vary as a function of certain areas of schools’ social context. Based on the findings, it may be recommended to invest in the physical-structural setting as well as ensuring and/or mobilizing support from the principal for physical activity programmes to enhance effectiveness. In general, what is needed but what is still too often lacking, are health promotion initiatives based on ‘whole-school approaches’ [35], which create coordinated and integrated settings and can provide favourable environments for successful implementation of specific programme initiatives. Future studies can build upon and expand the present findings by including not only the teachers’ perspectives on the schools’ social context, but by also incorporating the view of school principals, as well as children’s and parents’ beliefs and expectations about such programmes. Further, more detailed investigations are needed about the mechanisms by which social context factors have an influence on teachers’ perceptions, for example studies which focus on whether effects are mediated via specific aspects of programme implementation such as dose delivered and dose received. Supplementary data Supplementary data are available at HEAL online. Acknowledgements The AAD programme is conducted by University College South Denmark under project manager lector Anders Flaskager (afla@ucsyd.dk). The authors would like to show our gratitude to Anders Flaskager for his support, and the teachers for their participation in the study. Conflict of interest statement None declared. References 1 Lim SS , Vos T , Flaxman AD et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010 . Lancet 2012 ; 380 : 2224 – 60 . Google Scholar CrossRef Search ADS PubMed 2 Telama R , Yang X , Viikari J et al. Physical activity from childhood to adulthood: a 21-year tracking study . Am J Prev Med 2005 ; 28 : 267 – 73 . Google Scholar CrossRef Search ADS PubMed 3 Rasmussen M , Due P. Skolebørnsundersøgelsen 2010 [Health Behaviour in School-Aged Children (HBSC) 2010]. Copenhagen : National institute of public health, University of Southern Denmark , 2011 . 4 Due P , Holstein B. Skolebørnsundersøgelsen 2002 [Health Behaviour in School-Aged Children (HBSC) 2002]. Copenhagen : Institute of public health, University of Copenhagen , 2003 . 5 Rasmussen M , Pedersen TP , Due P. Skolebørnsundersøgelsen 2014 [Health Behaviour in School-Aged Children (HBSC) 2014]. Copenhagen : National institute of public health, University of Southern Denmark , 2015 . 6 Mullen PD , Evans D , Forster J et al. Settings as an important dimension in health education/promotion policy, programs, and research . 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Relations between the school physical environment and school social capital with student physical activity levels . BMC Public Health 2013 ; 13 : 1 – 8 . Google Scholar CrossRef Search ADS PubMed 24 Ding D , Sallis JF , Kerr J et al. Neighborhood environment and physical activity among youth: a review. Am J Prev Med 2011 ; 41 : 442 – 55 . Google Scholar CrossRef Search ADS 25 Forman SG , Olin SS , Hoagwood KE et al. Evidence-based interventions in schools: developers’ views of implementation barriers and facilitators . School Mental Health 2009 ; 1 : 26 – 36 . Google Scholar CrossRef Search ADS 26 Dowda M , Sallis JF , McKenzie TL et al. Evaluating the sustainability of SPARK physical education . Res Q Exerc Sport 2005 ; 76 : 11 – 9 . Google Scholar PubMed 27 Ahtola A , Haataja A , Kärnä A et al. Implementation of anti-bullying lessons in primary classrooms: how important is head teacher support? Educ Res 2013 ; 55 : 376 – 92 . 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For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health Education Research Oxford University Press

Physical activity school intervention: context matters

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Abstract

Abstract School-based interventions for increasing physical activity among children are widespread, however there is still a lack of knowledge about how school context factors are linked to implementation quality and effectiveness of programmes. The aim of this paper is to examine teacher-perceived effectiveness of a Danish national classroom-based health programme ‘Active Around Denmark’ and in particular, to investigate whether perceptions vary as a function of school social context factors. After completion of the programme all teachers (N = 5.892) received an electronic questionnaire. 2.097 completed the questionnaire (response rate 36%) and 1.781 datasets could be used for analysis. The teachers were asked about their perceptions of changes in children’s attitudes towards and levels of physical activity after the competition. Our results indicated that certain contextual factors, such as schools’ prioritization of health promotion, teachers’ support by their school principal in implementation as well as teacher’s satisfaction with the school’ physical environment made a significant difference in teacher-perceived effectiveness. To conclude, teacher-perceived effectiveness of the health programme does vary as a function of school social context factors. Introduction Worldwide, low levels of physical activity cause 3.2 million deaths each year and accounted for 2.8% of Disability-Adjusted Life Years in 2010 [1]. Since physical activity habits established early in life influence adult physical activity [2], it is particularly worrying that inactivity levels among the young are increasing, a development which started in the second half of the 20th century. In Denmark, this negative trend has been stopped and even slightly reversed [3, 4]. However, in 2014 it were still only 38% of girls and 51% of boys among the 13-year olds who reached the recommended levels for physical activity of at least 1 h daily physical activity [5]. Schools have long been viewed as an important setting for promoting health and well-being [6] and interventions to support the adoption of physical activity in schools are widespread. While a review of reviews on school-based interventions aimed at promoting physical activity in children showed a positive effect on physical activity [7] inconsistencies and uncertainty about the conditions of effectiveness still exist [8–10]. Such inconsistency also characterizes school-based physical activity programmes in Denmark. While some studies have reported positive effects on physical activity [11], others did not find their programme to be effective [12]. Reasons for this heterogeneity can be many, since intervention programmes differ in terms of content, didactic approach as well as duration and intensity. Also, measurement of physical activity varies widely, further increasing difficulties in comparing results [13]. Some of the variance, however, might also be due to the fact that programmes are implemented in very different social contexts, which may enable or hinder success by affecting implementation quality. Two elements have been identified as crucial contextual factors influencing implementation quality, these are provider attributes (e.g. teachers’ skills, motivation) and delivery system characteristics (e.g. school policies, organizational norms, physical infrastructure) [14]. Successful programmes, accordingly, do not only need well-developed concepts and motivated and skilled teachers to deliver them but also wider social contexts which are consistent with and support health promoting activities. A review by Naylor, Nettlefold [15] on the implementation of school-based physical activity programmes emphasized this point by stating that ‘…we need to better understand the many factors that could be modified to advance the implementation experience’ (p. 113). A particular type of intervention, which has rarely been applied and/or studied within the realm of school-based physical activity promotion, is the competition approach, where school classes as a whole compete for prizes linked to the achievement of behavioural goals. Some studies have shown that this can be an effective tool for smoking prevention [16, 17], but as yet little is known about applicability to other health behaviours. Short-term interventions, such as competitions, may alone not be capable to consistently change complex behavioural patterns such as physical activity. However, by introducing a ‘fun element’, they may contribute to creating favourable mind-sets and attitudes towards physical activity and thereby help reduce psychological barriers in groups of children and adolescents who otherwise might tend to avoid such activities. Thus, Corder, Schiff [18] reported that class competitions may appeal specifically to inactive students who would normally not get involved in physical activity promotion interventions. In Denmark, a free 3-week-long national competition, called ‘Active Around Denmark’ (AAD; has later changed name to ‘Active All Year Round’), has been offered annually since 2006 to teachers and school children (age 5–17) in all primary and secondary schools. The programme consists of a class-based physical activity competition where the aim for each school class is to ‘be the healthiest in Denmark’. The programme mainly focuses on the fun of being physically active, but also involves aspects of healthy eating and sleeping. For more information, see Supplementary Appendix S1. The present study aimed to examine teacher-perceived change in programme-induced physical activity in school children. Teachers’ perceptions of school intervention’s success cannot replace effect evaluations but are relevant indicators in their own right, since only teachers who do perceive programs as effective will be motivated to invest ongoing efforts into using and implementing health promotion interventions and will help create a receptive climate for such programs in their schools. In particular, we intended to investigate whether teacher perceptions about change in attitudes about and levels of physical activity after completion of the competition varied as a function of specific school social context factors. The present study aims to examine whether and to which extent teachers’ perceptions of competition-related physical activity and attitude change in their classes depended on (i) perceived quality of structural-physical conditions for physical activity in the school, (ii) specific support for programme implementation by the school principal and (iii) existence of a school policy on physical activity and general prioritization of health promotion in the school. Materials and methods Study design The study was based on a cross-sectional questionnaire survey targeted at teachers who, together with their classes, had participated in the AAD competition in 2015. Data were collected from October to November 2015. All teachers (N = 5.892) filled out an electronic questionnaire between 2 and 4 weeks after completion of the AAD programme. A total of 250. 040 school children were registered for the programme by their teachers, representing 37.5% of all school children in Denmark [19]. Data collection Table I shows the questions included in the study. All information was obtained from the teacher questionnaire, developed by the research team for the present research purpose. All questions were single items, covering schools and children’s background characteristics, satisfaction with school’s physical environment, school’s prioritization of health promotion, teacher’s support from school principal and teacher’s perception of changes in children’s attitudes towards physical activity and levels of physical activity. Table I. Questionnaire variables and response categories Variable Question Original response categories Collapsed response categories School size How many students attend the school? 1-150/151-300/301-450/451-600/601-800/800 students or more Small schools (<300 children)/ Medium-sized schools (301–600 children)/ Large schools (>600 children)a School year (years 1 to 11) Which school year had you signed up for the AAD campaign this year? Year 1, year 2, year 3, year 4, year 5, year 6, year 7, year 8, year 9, year 10, year 11 Years 1–5 / years 6–8 / years 9–11 Prior participation of teachers Have you participated in AAD before? No/Yes No/Yes Immigrants in the class How many of the students in the participating class are immigrants or have parents who are immigrants? 20% or less, 21–40%, 41–60%, 61–80%, 81–100% ≤20% / >20% One or both parent(s) with higher education How many of the students in the participating class, would you estimate, have a minimum of one parent who have completed higher education (defined as an education exceeding secondary school level by at least 2 years) 20% or less, 21–40%, 41–60%, 61–80%, 81–100%, Don’t know ≤40% / 41–80% / 81% + One or both parents being unemployed How many of the students in the participating class, would you judge, have parents where one or both are unemployed? 20% or less, 21–40%, 41–60%, 61–80%, 81–100%, Don’t know ≤20% / >20% Physical activity policy Does the school have a policy for physical activity? No/Yes/Don’t know No or don’t know/Yes School’s prioritization of health promotion How high do you believe the school in general prioritizes health promotion for the students (e.g. in regards to prevention of smoking, drinking, bullying, promotion of physical activity, healthy food, etc.) 7-point scale from: –3 ‘not at all satisfied’ to +3 ‘very satisfied’ Low to medium (–3 to 0) High (+1 to +3) Satisfaction with school physical environment In general, how would you assess the structural and physical conditions in your school in relation to the possibility of exercise and physical activity for students? Playground Schoolyard Gym Hallways Classroom Equipment 7-point scale from: –3 ‘not at all satisfied’ to +3 ‘very satisfied’ Low (–3 and –2) Medium (–1, 0 and +1) High (+2 and +3) Support from school principal How satisfied have you been with the support you received for the project from your school’s principal? 7-point scale from: –3 ‘absolutely not satisfied’ to +3 ‘very satisfied’ and a separate category of ‘not relevant’b Not relevant Not satisfied with support (from –3 to 0) Satisfied with support (+1 to +3). Attitudes towards physical activity after competition Indicate if and in which way the following aspects have changed, after the students participated in the project  The students attitudes towards physical activity  The students levels of physical activity 7-point scale from: –3 ‘has become much worse’ to +3 ‘has become much better’ ‘Negative to no change’ (–3 to 0) ‘Positive change’ (+1 to +3) Positive change in level of physical activity after competition Same as above Same as above Same as above Variable Question Original response categories Collapsed response categories School size How many students attend the school? 1-150/151-300/301-450/451-600/601-800/800 students or more Small schools (<300 children)/ Medium-sized schools (301–600 children)/ Large schools (>600 children)a School year (years 1 to 11) Which school year had you signed up for the AAD campaign this year? Year 1, year 2, year 3, year 4, year 5, year 6, year 7, year 8, year 9, year 10, year 11 Years 1–5 / years 6–8 / years 9–11 Prior participation of teachers Have you participated in AAD before? No/Yes No/Yes Immigrants in the class How many of the students in the participating class are immigrants or have parents who are immigrants? 20% or less, 21–40%, 41–60%, 61–80%, 81–100% ≤20% / >20% One or both parent(s) with higher education How many of the students in the participating class, would you estimate, have a minimum of one parent who have completed higher education (defined as an education exceeding secondary school level by at least 2 years) 20% or less, 21–40%, 41–60%, 61–80%, 81–100%, Don’t know ≤40% / 41–80% / 81% + One or both parents being unemployed How many of the students in the participating class, would you judge, have parents where one or both are unemployed? 20% or less, 21–40%, 41–60%, 61–80%, 81–100%, Don’t know ≤20% / >20% Physical activity policy Does the school have a policy for physical activity? No/Yes/Don’t know No or don’t know/Yes School’s prioritization of health promotion How high do you believe the school in general prioritizes health promotion for the students (e.g. in regards to prevention of smoking, drinking, bullying, promotion of physical activity, healthy food, etc.) 7-point scale from: –3 ‘not at all satisfied’ to +3 ‘very satisfied’ Low to medium (–3 to 0) High (+1 to +3) Satisfaction with school physical environment In general, how would you assess the structural and physical conditions in your school in relation to the possibility of exercise and physical activity for students? Playground Schoolyard Gym Hallways Classroom Equipment 7-point scale from: –3 ‘not at all satisfied’ to +3 ‘very satisfied’ Low (–3 and –2) Medium (–1, 0 and +1) High (+2 and +3) Support from school principal How satisfied have you been with the support you received for the project from your school’s principal? 7-point scale from: –3 ‘absolutely not satisfied’ to +3 ‘very satisfied’ and a separate category of ‘not relevant’b Not relevant Not satisfied with support (from –3 to 0) Satisfied with support (+1 to +3). Attitudes towards physical activity after competition Indicate if and in which way the following aspects have changed, after the students participated in the project  The students attitudes towards physical activity  The students levels of physical activity 7-point scale from: –3 ‘has become much worse’ to +3 ‘has become much better’ ‘Negative to no change’ (–3 to 0) ‘Positive change’ (+1 to +3) Positive change in level of physical activity after competition Same as above Same as above Same as above a = Based on an average number of 430 students in Danish schools (19), b = the category of ‘not relevant’ was included since some teachers might have felt they did not need support from their principal in order to implement the programme. Table I. Questionnaire variables and response categories Variable Question Original response categories Collapsed response categories School size How many students attend the school? 1-150/151-300/301-450/451-600/601-800/800 students or more Small schools (<300 children)/ Medium-sized schools (301–600 children)/ Large schools (>600 children)a School year (years 1 to 11) Which school year had you signed up for the AAD campaign this year? Year 1, year 2, year 3, year 4, year 5, year 6, year 7, year 8, year 9, year 10, year 11 Years 1–5 / years 6–8 / years 9–11 Prior participation of teachers Have you participated in AAD before? No/Yes No/Yes Immigrants in the class How many of the students in the participating class are immigrants or have parents who are immigrants? 20% or less, 21–40%, 41–60%, 61–80%, 81–100% ≤20% / >20% One or both parent(s) with higher education How many of the students in the participating class, would you estimate, have a minimum of one parent who have completed higher education (defined as an education exceeding secondary school level by at least 2 years) 20% or less, 21–40%, 41–60%, 61–80%, 81–100%, Don’t know ≤40% / 41–80% / 81% + One or both parents being unemployed How many of the students in the participating class, would you judge, have parents where one or both are unemployed? 20% or less, 21–40%, 41–60%, 61–80%, 81–100%, Don’t know ≤20% / >20% Physical activity policy Does the school have a policy for physical activity? No/Yes/Don’t know No or don’t know/Yes School’s prioritization of health promotion How high do you believe the school in general prioritizes health promotion for the students (e.g. in regards to prevention of smoking, drinking, bullying, promotion of physical activity, healthy food, etc.) 7-point scale from: –3 ‘not at all satisfied’ to +3 ‘very satisfied’ Low to medium (–3 to 0) High (+1 to +3) Satisfaction with school physical environment In general, how would you assess the structural and physical conditions in your school in relation to the possibility of exercise and physical activity for students? Playground Schoolyard Gym Hallways Classroom Equipment 7-point scale from: –3 ‘not at all satisfied’ to +3 ‘very satisfied’ Low (–3 and –2) Medium (–1, 0 and +1) High (+2 and +3) Support from school principal How satisfied have you been with the support you received for the project from your school’s principal? 7-point scale from: –3 ‘absolutely not satisfied’ to +3 ‘very satisfied’ and a separate category of ‘not relevant’b Not relevant Not satisfied with support (from –3 to 0) Satisfied with support (+1 to +3). Attitudes towards physical activity after competition Indicate if and in which way the following aspects have changed, after the students participated in the project  The students attitudes towards physical activity  The students levels of physical activity 7-point scale from: –3 ‘has become much worse’ to +3 ‘has become much better’ ‘Negative to no change’ (–3 to 0) ‘Positive change’ (+1 to +3) Positive change in level of physical activity after competition Same as above Same as above Same as above Variable Question Original response categories Collapsed response categories School size How many students attend the school? 1-150/151-300/301-450/451-600/601-800/800 students or more Small schools (<300 children)/ Medium-sized schools (301–600 children)/ Large schools (>600 children)a School year (years 1 to 11) Which school year had you signed up for the AAD campaign this year? Year 1, year 2, year 3, year 4, year 5, year 6, year 7, year 8, year 9, year 10, year 11 Years 1–5 / years 6–8 / years 9–11 Prior participation of teachers Have you participated in AAD before? No/Yes No/Yes Immigrants in the class How many of the students in the participating class are immigrants or have parents who are immigrants? 20% or less, 21–40%, 41–60%, 61–80%, 81–100% ≤20% / >20% One or both parent(s) with higher education How many of the students in the participating class, would you estimate, have a minimum of one parent who have completed higher education (defined as an education exceeding secondary school level by at least 2 years) 20% or less, 21–40%, 41–60%, 61–80%, 81–100%, Don’t know ≤40% / 41–80% / 81% + One or both parents being unemployed How many of the students in the participating class, would you judge, have parents where one or both are unemployed? 20% or less, 21–40%, 41–60%, 61–80%, 81–100%, Don’t know ≤20% / >20% Physical activity policy Does the school have a policy for physical activity? No/Yes/Don’t know No or don’t know/Yes School’s prioritization of health promotion How high do you believe the school in general prioritizes health promotion for the students (e.g. in regards to prevention of smoking, drinking, bullying, promotion of physical activity, healthy food, etc.) 7-point scale from: –3 ‘not at all satisfied’ to +3 ‘very satisfied’ Low to medium (–3 to 0) High (+1 to +3) Satisfaction with school physical environment In general, how would you assess the structural and physical conditions in your school in relation to the possibility of exercise and physical activity for students? Playground Schoolyard Gym Hallways Classroom Equipment 7-point scale from: –3 ‘not at all satisfied’ to +3 ‘very satisfied’ Low (–3 and –2) Medium (–1, 0 and +1) High (+2 and +3) Support from school principal How satisfied have you been with the support you received for the project from your school’s principal? 7-point scale from: –3 ‘absolutely not satisfied’ to +3 ‘very satisfied’ and a separate category of ‘not relevant’b Not relevant Not satisfied with support (from –3 to 0) Satisfied with support (+1 to +3). Attitudes towards physical activity after competition Indicate if and in which way the following aspects have changed, after the students participated in the project  The students attitudes towards physical activity  The students levels of physical activity 7-point scale from: –3 ‘has become much worse’ to +3 ‘has become much better’ ‘Negative to no change’ (–3 to 0) ‘Positive change’ (+1 to +3) Positive change in level of physical activity after competition Same as above Same as above Same as above a = Based on an average number of 430 students in Danish schools (19), b = the category of ‘not relevant’ was included since some teachers might have felt they did not need support from their principal in order to implement the programme. Transformations For statistical purposes, large ranges of response categories were collapsed into new categories (Table I). Parental unemployment level was dichotomized into ‘≤20%’ and ‘>20% unemployed’. While unemployment in Denmark has generally been low in recent years, it is found to be 10% and higher in socially disadvantaged areas and in deprived neighbourhoods with a high percentage of immigrants it can go up to 20–30% and higher [20, 21]. The particular cut-off was therefore chosen to enable investigating whether perceptions of effectiveness in schools located in or close to socially deprived neighbourhoods differ from those in schools situated in more average or affluent areas. Satisfaction with the school’s facilities for physical activity was split into the categories ‘low’ (–3 and –2), ‘medium’ (–1, 0 and +1) and ‘high’ (+2 and +3) satisfaction (Table I). Each level was assigned points (low = 1 point, medium = 2 points and high = 3 points) and subsequently scores on the individual aspects (i.e. playground, schoolyard etc.) were totalled, resulting in a summary score from 6 to 18 points. Overall level of satisfaction with physical environment was categorized as ‘low’ (6–12 points), ‘medium’ (13–15 points) and ‘high’ (16–18 points) with each group representing about 1/3 of the sample. The initial response format for existence of a school policy for physical activity offered three choices (yes/no/don’t know). The categories ‘no’ and ‘don’t know’ were collapsed because the main research interest pertained to the consequences of a policy teachers are aware of as compared to ‘paper policies’ which are not communicated. Statistical analysis Frequencies were used to describe the characteristics of the participating schools, classes and students’ social background (Table II). Frequencies, P-values and chi-square (χ2) tests were applied to determine the bi-variate associations between school, class and student characteristics and the two indicators for perceived programme effect. Further chi-square (χ2) tests were applied post-hoc to determine differences between sub-groups in case of more than two groups (Table III). Multi-variable analysis was performed to determine independent contributions of the different factors in explaining perceived programme change, applying hierarchical logistic regression to adjust for potential confounders. In the first step of the analysis, the variables school size, school year, teachers’ prior programme participation, student immigration background, parental educational level and parental unemployment rate were entered into the equation (Model 1 in Table IV). The second step included the main variables of interest: schools’ having a policy for physical activity, schools’ prioritization of health promotion, teachers’ satisfaction with the appropriateness of the school’s physical environment for physical activity and principals’ support of the programme (Model 2 in Table IV). Results are presented as odds ratios (OR) and 95% confidence intervals (CIs; Table IV). IBM-SPSS for Windows v. 23 was used to conduct statistical analysis. Table II. Characteristics of participating schools, classes and students’ social background (n = 1781a) Frequency (%) School size     Small: <300 students 29.7     Medium: 301–600 students 39.4     Large: >601 students 30.9 School year (age 5–17)     Year 1–5 68.8     Year 6–8 25.2     Year 9–11 6.0 Prior participation of teachers     No 29.8     Yes 70.2 Immigrants in the class     ≤20% 84.4     >20% 15.6 One or both parent(s) with higher education     ≤40% 24.7     41–80% 52.5     81% + 22.8 One or both parents unemployed     ≤20% 80.4     >20% 19.6 Physical activity school policy     No or don’t know 51.5     Yes 48.5 School’s prioritization of health promotion     Low to medium 15.4     High 84.6 Satisfaction with school physical environment     Low 33.0     Medium 38.6     High 28.4 Support from school principal     Not relevant 22.4     Not satisfied with support 50.1     Satisfied with support 27.5 Frequency (%) School size     Small: <300 students 29.7     Medium: 301–600 students 39.4     Large: >601 students 30.9 School year (age 5–17)     Year 1–5 68.8     Year 6–8 25.2     Year 9–11 6.0 Prior participation of teachers     No 29.8     Yes 70.2 Immigrants in the class     ≤20% 84.4     >20% 15.6 One or both parent(s) with higher education     ≤40% 24.7     41–80% 52.5     81% + 22.8 One or both parents unemployed     ≤20% 80.4     >20% 19.6 Physical activity school policy     No or don’t know 51.5     Yes 48.5 School’s prioritization of health promotion     Low to medium 15.4     High 84.6 Satisfaction with school physical environment     Low 33.0     Medium 38.6     High 28.4 Support from school principal     Not relevant 22.4     Not satisfied with support 50.1     Satisfied with support 27.5 a = The sample size is based on all participants with valid scores on all included predictor variables and represents number of teachers and not number of schools, i.e. some schools might be represented by several teachers. Table II. Characteristics of participating schools, classes and students’ social background (n = 1781a) Frequency (%) School size     Small: <300 students 29.7     Medium: 301–600 students 39.4     Large: >601 students 30.9 School year (age 5–17)     Year 1–5 68.8     Year 6–8 25.2     Year 9–11 6.0 Prior participation of teachers     No 29.8     Yes 70.2 Immigrants in the class     ≤20% 84.4     >20% 15.6 One or both parent(s) with higher education     ≤40% 24.7     41–80% 52.5     81% + 22.8 One or both parents unemployed     ≤20% 80.4     >20% 19.6 Physical activity school policy     No or don’t know 51.5     Yes 48.5 School’s prioritization of health promotion     Low to medium 15.4     High 84.6 Satisfaction with school physical environment     Low 33.0     Medium 38.6     High 28.4 Support from school principal     Not relevant 22.4     Not satisfied with support 50.1     Satisfied with support 27.5 Frequency (%) School size     Small: <300 students 29.7     Medium: 301–600 students 39.4     Large: >601 students 30.9 School year (age 5–17)     Year 1–5 68.8     Year 6–8 25.2     Year 9–11 6.0 Prior participation of teachers     No 29.8     Yes 70.2 Immigrants in the class     ≤20% 84.4     >20% 15.6 One or both parent(s) with higher education     ≤40% 24.7     41–80% 52.5     81% + 22.8 One or both parents unemployed     ≤20% 80.4     >20% 19.6 Physical activity school policy     No or don’t know 51.5     Yes 48.5 School’s prioritization of health promotion     Low to medium 15.4     High 84.6 Satisfaction with school physical environment     Low 33.0     Medium 38.6     High 28.4 Support from school principal     Not relevant 22.4     Not satisfied with support 50.1     Satisfied with support 27.5 a = The sample size is based on all participants with valid scores on all included predictor variables and represents number of teachers and not number of schools, i.e. some schools might be represented by several teachers. Table III. Association of school characteristics and programme effect perceived by teachers in percentages (n = 1706a) Positive change in attitudes towards physical activity after competition (n = 1706) Positive change in level of physical activity after competition (n = 1705) School size     Small: <300 students 58.7 62.3     Medium: 301–600 students 60.0 64.6     Large: >601 students 64.7 68.6  χ2; P value χ2 = 4.488 χ2 = 4.757 School year (age 5–17)     Year 1–5 64.4***b 68.1***     Year 6–8 53.8 59.1     Year 9–11 53.9 57.8  χ2; P value χ2 = 17.381*** χ2 = 13.830*** Prior participation of teachers     No 61.2 64.3     Yes 61.0 65.5  χ2; P value χ2 = 0.007 χ2 = 0.210 Immigrants in the class     ≤20% 60.4 64.4     >20% 64.5 69.1  χ2; P value χ2 = 1.571 χ2 = 2.097 One or both parent(s) with higher education     ≤40% 58.2 60.8     41–80% 64.3** 67.8**     81% + 56.8 63.8  χ2; P value χ2 = 8.311* χ2 = 6.709* One or both parents unemployed     ≤20% 62.0 65.9     >20% 57.1 62.2  χ2; P value χ2 = 2.726 χ2 = 1.614 Physical activity school policy     No or don’t know 57.3 61.6     Yes 65.1 68.9  χ2; P value χ2 = 10.673** χ2 = 10.015** Schools prioritization of health promotion     Low to medium 55.7 60.2     High 64.3 68.1  χ2; P value χ2 = 36.487*** χ2 = 11.107*** Satisfaction with school physical environment     Low 58.2 60.6     Medium 59.7 64.7     High 66.3** 71.0**  χ2; P value χ2 = 7.964* χ2 = 12.446** Support from school principal     Not relevant 56.6 61.7     Not satisfied with support 57.7 62.2     Satisfied with support 70.8*** 73.4***  χ2; P value χ2 = 26.283*** χ2 = 19.417*** Positive change in attitudes towards physical activity after competition (n = 1706) Positive change in level of physical activity after competition (n = 1705) School size     Small: <300 students 58.7 62.3     Medium: 301–600 students 60.0 64.6     Large: >601 students 64.7 68.6  χ2; P value χ2 = 4.488 χ2 = 4.757 School year (age 5–17)     Year 1–5 64.4***b 68.1***     Year 6–8 53.8 59.1     Year 9–11 53.9 57.8  χ2; P value χ2 = 17.381*** χ2 = 13.830*** Prior participation of teachers     No 61.2 64.3     Yes 61.0 65.5  χ2; P value χ2 = 0.007 χ2 = 0.210 Immigrants in the class     ≤20% 60.4 64.4     >20% 64.5 69.1  χ2; P value χ2 = 1.571 χ2 = 2.097 One or both parent(s) with higher education     ≤40% 58.2 60.8     41–80% 64.3** 67.8**     81% + 56.8 63.8  χ2; P value χ2 = 8.311* χ2 = 6.709* One or both parents unemployed     ≤20% 62.0 65.9     >20% 57.1 62.2  χ2; P value χ2 = 2.726 χ2 = 1.614 Physical activity school policy     No or don’t know 57.3 61.6     Yes 65.1 68.9  χ2; P value χ2 = 10.673** χ2 = 10.015** Schools prioritization of health promotion     Low to medium 55.7 60.2     High 64.3 68.1  χ2; P value χ2 = 36.487*** χ2 = 11.107*** Satisfaction with school physical environment     Low 58.2 60.6     Medium 59.7 64.7     High 66.3** 71.0**  χ2; P value χ2 = 7.964* χ2 = 12.446** Support from school principal     Not relevant 56.6 61.7     Not satisfied with support 57.7 62.2     Satisfied with support 70.8*** 73.4***  χ2; P value χ2 = 26.283*** χ2 = 19.417*** * P < 0.05, **P < 0.01, ***P < 0.001. a = Sample size for the different analyses diverges due to varying numbers of valid answers for the change assessments and b = *behind the percentages indicates significant differences of rates between the respective sub-group and both other groups. Table III. Association of school characteristics and programme effect perceived by teachers in percentages (n = 1706a) Positive change in attitudes towards physical activity after competition (n = 1706) Positive change in level of physical activity after competition (n = 1705) School size     Small: <300 students 58.7 62.3     Medium: 301–600 students 60.0 64.6     Large: >601 students 64.7 68.6  χ2; P value χ2 = 4.488 χ2 = 4.757 School year (age 5–17)     Year 1–5 64.4***b 68.1***     Year 6–8 53.8 59.1     Year 9–11 53.9 57.8  χ2; P value χ2 = 17.381*** χ2 = 13.830*** Prior participation of teachers     No 61.2 64.3     Yes 61.0 65.5  χ2; P value χ2 = 0.007 χ2 = 0.210 Immigrants in the class     ≤20% 60.4 64.4     >20% 64.5 69.1  χ2; P value χ2 = 1.571 χ2 = 2.097 One or both parent(s) with higher education     ≤40% 58.2 60.8     41–80% 64.3** 67.8**     81% + 56.8 63.8  χ2; P value χ2 = 8.311* χ2 = 6.709* One or both parents unemployed     ≤20% 62.0 65.9     >20% 57.1 62.2  χ2; P value χ2 = 2.726 χ2 = 1.614 Physical activity school policy     No or don’t know 57.3 61.6     Yes 65.1 68.9  χ2; P value χ2 = 10.673** χ2 = 10.015** Schools prioritization of health promotion     Low to medium 55.7 60.2     High 64.3 68.1  χ2; P value χ2 = 36.487*** χ2 = 11.107*** Satisfaction with school physical environment     Low 58.2 60.6     Medium 59.7 64.7     High 66.3** 71.0**  χ2; P value χ2 = 7.964* χ2 = 12.446** Support from school principal     Not relevant 56.6 61.7     Not satisfied with support 57.7 62.2     Satisfied with support 70.8*** 73.4***  χ2; P value χ2 = 26.283*** χ2 = 19.417*** Positive change in attitudes towards physical activity after competition (n = 1706) Positive change in level of physical activity after competition (n = 1705) School size     Small: <300 students 58.7 62.3     Medium: 301–600 students 60.0 64.6     Large: >601 students 64.7 68.6  χ2; P value χ2 = 4.488 χ2 = 4.757 School year (age 5–17)     Year 1–5 64.4***b 68.1***     Year 6–8 53.8 59.1     Year 9–11 53.9 57.8  χ2; P value χ2 = 17.381*** χ2 = 13.830*** Prior participation of teachers     No 61.2 64.3     Yes 61.0 65.5  χ2; P value χ2 = 0.007 χ2 = 0.210 Immigrants in the class     ≤20% 60.4 64.4     >20% 64.5 69.1  χ2; P value χ2 = 1.571 χ2 = 2.097 One or both parent(s) with higher education     ≤40% 58.2 60.8     41–80% 64.3** 67.8**     81% + 56.8 63.8  χ2; P value χ2 = 8.311* χ2 = 6.709* One or both parents unemployed     ≤20% 62.0 65.9     >20% 57.1 62.2  χ2; P value χ2 = 2.726 χ2 = 1.614 Physical activity school policy     No or don’t know 57.3 61.6     Yes 65.1 68.9  χ2; P value χ2 = 10.673** χ2 = 10.015** Schools prioritization of health promotion     Low to medium 55.7 60.2     High 64.3 68.1  χ2; P value χ2 = 36.487*** χ2 = 11.107*** Satisfaction with school physical environment     Low 58.2 60.6     Medium 59.7 64.7     High 66.3** 71.0**  χ2; P value χ2 = 7.964* χ2 = 12.446** Support from school principal     Not relevant 56.6 61.7     Not satisfied with support 57.7 62.2     Satisfied with support 70.8*** 73.4***  χ2; P value χ2 = 26.283*** χ2 = 19.417*** * P < 0.05, **P < 0.01, ***P < 0.001. a = Sample size for the different analyses diverges due to varying numbers of valid answers for the change assessments and b = *behind the percentages indicates significant differences of rates between the respective sub-group and both other groups. Table IV. Multi-variable association between school characteristics and teachers’ perceived changes in children’s physical activity levels and physical activity attitudes (n = 1706) Positive change in attitudes towards physical activity after competition (n = 1706) Positive change in level of physical activity after competition (n = 1705) Model 1 OR 95% CI OR 95% CI School size     Small: <300 students 0.825 0.635–1.072 0.823 0.630–1.075     Medium: 301–600 students 0.819 0.644–1.042 0.853 0.667–1.092     Large: >601 students 1.00 1.00 School year (age 5–17)     Year 1–5 1.523* 1.007–2.303 1.504 0.991–2.285     Year 6–8 0.985 0.636–1.527 1.037 0.667–1.614     Year 9–11 1.00 1.00 Prior participation of teachers     No 1.00 1.00     Yes 0.955 0.769–1.186 0.981 0.786–1.223 Immigrants in the class     ≤20% 1.00 1.00     >20% 1.248 0.922–1.689 1.312 0.961–1.791 One or both parent(s) with higher education     ≤40% 1.203 0.881–1.642 0.935 0.681–1.284     41–80% 1.458* 1.135–1.873 1.237 0.957–1.600     81% + 1.00 1.00 One or both parents unemployed     ≤20% 1.00 1.00     >20% 0.783 0.594–1.032 0.871 0.657–1.155 Model 2a Physical activity school policy     No or don’t know 1.00 1.00     Yes 1.209 0.985–1.484 1.209 0.981–1.491 Schools prioritization of health promotion     Low to medium 1.00 1.00     High 1.978*** 1.481–2.640 1.843*** 1.382–2.460 Satisfaction with school physical environment     Low 0.869 0.662–1.013 0.740* 0.560–0.978     Medium 0.785 0.609–1.013 0.774 0.595–1.005     High 1.00 1.00 Support from school principal     Not relevant 0.542*** 0.401–0.732 0.592** 0.436–0.806     Not satisfied with support 0.599*** 0.460–0.780 0.655** 0.500–0.857     Satisfied with support 1.00 1.00 Positive change in attitudes towards physical activity after competition (n = 1706) Positive change in level of physical activity after competition (n = 1705) Model 1 OR 95% CI OR 95% CI School size     Small: <300 students 0.825 0.635–1.072 0.823 0.630–1.075     Medium: 301–600 students 0.819 0.644–1.042 0.853 0.667–1.092     Large: >601 students 1.00 1.00 School year (age 5–17)     Year 1–5 1.523* 1.007–2.303 1.504 0.991–2.285     Year 6–8 0.985 0.636–1.527 1.037 0.667–1.614     Year 9–11 1.00 1.00 Prior participation of teachers     No 1.00 1.00     Yes 0.955 0.769–1.186 0.981 0.786–1.223 Immigrants in the class     ≤20% 1.00 1.00     >20% 1.248 0.922–1.689 1.312 0.961–1.791 One or both parent(s) with higher education     ≤40% 1.203 0.881–1.642 0.935 0.681–1.284     41–80% 1.458* 1.135–1.873 1.237 0.957–1.600     81% + 1.00 1.00 One or both parents unemployed     ≤20% 1.00 1.00     >20% 0.783 0.594–1.032 0.871 0.657–1.155 Model 2a Physical activity school policy     No or don’t know 1.00 1.00     Yes 1.209 0.985–1.484 1.209 0.981–1.491 Schools prioritization of health promotion     Low to medium 1.00 1.00     High 1.978*** 1.481–2.640 1.843*** 1.382–2.460 Satisfaction with school physical environment     Low 0.869 0.662–1.013 0.740* 0.560–0.978     Medium 0.785 0.609–1.013 0.774 0.595–1.005     High 1.00 1.00 Support from school principal     Not relevant 0.542*** 0.401–0.732 0.592** 0.436–0.806     Not satisfied with support 0.599*** 0.460–0.780 0.655** 0.500–0.857     Satisfied with support 1.00 1.00 * P < 0.05, **P < 0.01, ***P < 0.001. a = The variables in Model 2 are adjusted for all the covariates in Model 1. Table IV. Multi-variable association between school characteristics and teachers’ perceived changes in children’s physical activity levels and physical activity attitudes (n = 1706) Positive change in attitudes towards physical activity after competition (n = 1706) Positive change in level of physical activity after competition (n = 1705) Model 1 OR 95% CI OR 95% CI School size     Small: <300 students 0.825 0.635–1.072 0.823 0.630–1.075     Medium: 301–600 students 0.819 0.644–1.042 0.853 0.667–1.092     Large: >601 students 1.00 1.00 School year (age 5–17)     Year 1–5 1.523* 1.007–2.303 1.504 0.991–2.285     Year 6–8 0.985 0.636–1.527 1.037 0.667–1.614     Year 9–11 1.00 1.00 Prior participation of teachers     No 1.00 1.00     Yes 0.955 0.769–1.186 0.981 0.786–1.223 Immigrants in the class     ≤20% 1.00 1.00     >20% 1.248 0.922–1.689 1.312 0.961–1.791 One or both parent(s) with higher education     ≤40% 1.203 0.881–1.642 0.935 0.681–1.284     41–80% 1.458* 1.135–1.873 1.237 0.957–1.600     81% + 1.00 1.00 One or both parents unemployed     ≤20% 1.00 1.00     >20% 0.783 0.594–1.032 0.871 0.657–1.155 Model 2a Physical activity school policy     No or don’t know 1.00 1.00     Yes 1.209 0.985–1.484 1.209 0.981–1.491 Schools prioritization of health promotion     Low to medium 1.00 1.00     High 1.978*** 1.481–2.640 1.843*** 1.382–2.460 Satisfaction with school physical environment     Low 0.869 0.662–1.013 0.740* 0.560–0.978     Medium 0.785 0.609–1.013 0.774 0.595–1.005     High 1.00 1.00 Support from school principal     Not relevant 0.542*** 0.401–0.732 0.592** 0.436–0.806     Not satisfied with support 0.599*** 0.460–0.780 0.655** 0.500–0.857     Satisfied with support 1.00 1.00 Positive change in attitudes towards physical activity after competition (n = 1706) Positive change in level of physical activity after competition (n = 1705) Model 1 OR 95% CI OR 95% CI School size     Small: <300 students 0.825 0.635–1.072 0.823 0.630–1.075     Medium: 301–600 students 0.819 0.644–1.042 0.853 0.667–1.092     Large: >601 students 1.00 1.00 School year (age 5–17)     Year 1–5 1.523* 1.007–2.303 1.504 0.991–2.285     Year 6–8 0.985 0.636–1.527 1.037 0.667–1.614     Year 9–11 1.00 1.00 Prior participation of teachers     No 1.00 1.00     Yes 0.955 0.769–1.186 0.981 0.786–1.223 Immigrants in the class     ≤20% 1.00 1.00     >20% 1.248 0.922–1.689 1.312 0.961–1.791 One or both parent(s) with higher education     ≤40% 1.203 0.881–1.642 0.935 0.681–1.284     41–80% 1.458* 1.135–1.873 1.237 0.957–1.600     81% + 1.00 1.00 One or both parents unemployed     ≤20% 1.00 1.00     >20% 0.783 0.594–1.032 0.871 0.657–1.155 Model 2a Physical activity school policy     No or don’t know 1.00 1.00     Yes 1.209 0.985–1.484 1.209 0.981–1.491 Schools prioritization of health promotion     Low to medium 1.00 1.00     High 1.978*** 1.481–2.640 1.843*** 1.382–2.460 Satisfaction with school physical environment     Low 0.869 0.662–1.013 0.740* 0.560–0.978     Medium 0.785 0.609–1.013 0.774 0.595–1.005     High 1.00 1.00 Support from school principal     Not relevant 0.542*** 0.401–0.732 0.592** 0.436–0.806     Not satisfied with support 0.599*** 0.460–0.780 0.655** 0.500–0.857     Satisfied with support 1.00 1.00 * P < 0.05, **P < 0.01, ***P < 0.001. a = The variables in Model 2 are adjusted for all the covariates in Model 1. Ethics According to the Act on a Biomedical Research Ethics Committee System in Denmark, the project was not a biomedical research project and therefore did not need the ethic committee’s approval. All teachers were informed that their participation in the study was voluntary and that their responses would be anonymized. Results The questionnaire was completed by 2.097 teachers, resulting in a response rate of 36%. This percentage is based on completed questionnaires of all teachers who had initially registered a school class for the programme. However, it is unknown how many of the 5.892 teachers, after initial registration, failed to actually implement the programme, for instance due to time problems, illness etc. The response rate to the questionnaire is therefore likely to underestimate true response, since the true reference number of eligible teachers is bound to be lower than the number of 5.892 who initially registered. Questionnaires of 64 were excluded retrospectively, since teachers had only answered between one and nine of the initial background questions. Further, to achieve a homogeneous sample size across the different analyses 252 questionnaires were excluded since teachers had felt unable to answer one or more of the questions about children’s socio-economic background (parental unemployment and educational background) by choosing the ‘don’t know’-answer option. The final sample used for data analysis thus included N = 1.781 respondents. For information about the characteristics of the participating schools and students, see Table II. As shown in Table II, the initial descriptive analysis showed that a total of 61.1% and 65.2%, respectively, of the teachers reported a positive change in children’s attitudes towards and levels of physical activity as a result of the programme. Sample size for the different analyses diverges due to varying numbers of valid answers for the change assessments. Bi-variate results As for socio-demographic characteristics of the participating students there was a consistent difference in change of perceived physical activity as well as attitudes depending on school year (Table III). Also, teachers’ perceptions of children’s attitude changes and perceived level of physical activity depended on the educational background of the parents of the participating children. Further, there was a significant difference for both outcomes depending on whether schools had a policy for physical activity and whether they prioritized health promotion. Finally, significant differences in teachers’ perceptions of change were found for teacher’s satisfaction with the school’s physical environment and teacher’s satisfaction with their principal’s support. Multi-variable results The multi-variable analysis showed that the odds of teachers reporting positive change in children’s attitudes towards physical activity were 52% higher for teachers who had participated with classes from lower school years (year 1–5) and 46% higher for teachers of classes where 41–80% children came from a higher-education background. Teachers with low satisfaction with the schools’ physical environment were 26% less likely to report positive changes in children’s levels of physical activity than those with high levels of satisfaction (Table IV). As further indicated by the results shown in Table IV, principal support was independently associated with all change indicators. Teachers not satisfied with support from their school principal for implementing the programme were 40% less likely to report favourable change in attitudes and 35% less likely to report increased levels of physical activity than those satisfied with such support. Finally, existence of a school policy for physical activity did not make a difference in perceived change on any of the parameters after adjusting for all other variables, while teachers who reported a high prioritization of health promotion by the school were 98% more likely to report positive change in children’s attitudes and 84% more likely to report increased activity levels. Discussion Findings from this cross-sectional study clearly indicated that certain aspects of the school social context can make a significant difference when it comes to teachers’ view of the effectiveness of a class-based physical activity competition intervention. The physical environment in particular seems relevant for teachers’ evaluations. Those who did not perceive the physical setting of their school as providing a favourable setting for implementing physical activity tended to also report less change in children’s physical activity. It is easily conceivable that physical activity interventions are harder to implement in schools lacking adequate or attractive sports facilities, recess grounds or classroom space which allows for playing games and conducting the exercises involved in the programme. These results are in line with other studies, which have also reported positive associations between school outdoor physical environment and physical activity level in children [22, 23]. Furthermore studies has found associations between neighbourhood environment (such as walking/biking facilities, walkability, pedestrian safety structures, vegetation, traffic speed or volume, access or proximity to recreational facilities, land-use mix and residential density) and physical activity among children [24]. Further, the present study suggests a particular relevance of the school principal’s support for physical activity interventions. To our knowledge, no other studies within the area of physical activity have investigated this relation between support of the principal and successful implementation. In a broader perspective, however, principal support has been shown to be one of the most important factors for successful implementation of interventions in schools in general [25], and more particular it has been reported that principal support can positively influence the sustainability of usage of an elementary school health-related physical education programme [26]. Also, intervention studies in the area of mental health and drug use prevention have provided evidence for the important role of school principals. Thus in implementation studies regarding anti-bullying lessons in school [27] as well as substance use prevention [28] it was found that lack of support from the principal may directly impede or weaken teachers’ efforts to implement a programme. Further, from an intervention study regarding emotional competence and aggression management it was reported that adequate support from the school principal together with a high level of classroom program implementation predicted program effectiveness [29]. Specifically, school heads can facilitate health promotion programmes by assigning special time, space or material resources for such efforts and thereby improve implementation quality, but also by providing special incentives, benefits and recognition for teachers’ engagement in such activities. Seen from the perspective of health promotion frameworks, such as the PRECEDE-PROCEED model [30] both availability of an appropriate physical infrastructure as well as support from the principal can be conceived of as enabling factors which provide essential pre-requisites for successfully conducting a health promotion intervention. Support from the principal may in addition have reinforcing features, for instance when it provides teachers and students with encouragement and positive feedback for their activities. Interestingly, having a school policy on physical activity, while being significantly related to both variables of perceived change on the bi-variate level, lost its significance in the multi-variable model. This is in contrast with other findings that school physical activity policies do influence behavioural change [31] but may be explained by the present study’s simultaneous inclusion of the school’s prioritization of health promotion into the model. Actual prioritization of health promotion may reflect more specific actions than a general policy and thus may be more relevant, and therefore may have superseded an effect of school health policy. In a similar vein, organizational policies are likely to be reflected in specific positive or negative actions by key actors, such as school principals providing encouragement and support or they result in concrete investments into the built environment, such as gyms, playgrounds, etc. Thus, principal support and physical environment may act as a mediator between explicit official policies on physical activity and behaviour change and thereby eliminate direct effects of policies. It should also be noted that while a large majority of over 80% of teachers stated that their school prioritized health promotion, and 50% were aware of a physical activity policy, only 28% were satisfied with the support from their principal for programme implementation (with another 22% considering this type of support as not relevant). This suggests that it may be important to investigate concrete conditions and actions in practice rather than exclusively focusing on general visions and policies. Compared to the findings about socio-structural school context there were only few indications that the competition programme might be more or less effective in different groups of students. The only consistent difference indicated that teachers more often perceived effectiveness in groups of younger as compared to older students. This is in line with the results from a systematic review, where the most effective physical activity interventions were summarized and where it was suggested that for children, school-based physical activity programmes were the most effective intervention type, whereas for adolescents other settings were more appropriate [32]. Beyond such a setting effect, the age difference in the present study may further be explained by the specific content of the AAD intervention programme, which was largely relying on elements involving games and play. In combination with the competition format this might have been particularly appealing to younger students. Limitations The main limitation lies in the cross-sectional character of the study where, perceived change in attitudes and behaviour was assessed only retrospectively and not with a before-after measurement. In general, subjective direct assessment of change is considered problematic because of cognitive and motivational biases (e.g. due to implicit theory of change, response shifts) may affect validity [33, 34]. As for motivational bias, teachers who have implemented a competition programme certainly have a vested interest in its success and may therefore be expected to overestimate change. However, it was not absolute estimates of programme effects, which were the main focus of the present study but relative differences between teachers conducting the same programme in different social contexts. Yet, it may still be argued that teachers with a generally positive or optimistic outlook may have been more likely to have a positive view about the social context of their schools as well as about the effectiveness of the competition in terms of creating behavioural change. Further, a response rate of 36%, while common for this type of survey, may suggest selection effects. In 2015, the competition was running for the 11th time, and for the last nine of these occasions a questionnaire had been sent out to the teachers. Non-participation may therefore not have been primarily biased due to the variables of interest in this study, i.e. social context factors or positive/negative experiences with the program but may have been mostly due to prior participation. Since the large majority of participants had taken part more than once in the campaign many from this group might have considered it unnecessary to provide feedback every time. As for measurement it could be argued, that for some variables more complex multi-item measures may have been preferable over single items in order to strengthen reliability as well as validity. This issue is probably most relevant in case of principal support assessment, since this definitely is a multi-dimensional construct. Due to the considerable length of the questionnaire, which for instance also required detailed evaluative responses regarding different aspects of the intervention programme (which were not covered here), this did not seem a feasible option. Finally, results, while being suggestive, should be interpreted with caution since they reflect short-term teacher-perceived effectiveness only. The teachers’ view is certainly crucial, since they are the ones who in most cases implement health programs and only positive evaluations of such efforts will ensure continuous motivation. Whether, however, actual and longer-term behaviour change is achievable with a classroom competition program needs to be tested by controlled intervention studies and by using more objectifiable assessment methods of physical activity change, such as accelerometers. Nevertheless, our study offers a new perspective on the different contextual factors that can influence the effects of a health promotion programme, which can be built upon in future studies. Future practices can utilize these findings by ensuring the support of the principals before implementing school health programmes and by enhancing the physical environment at the schools, with the purpose of increasing programme effectiveness. Conclusion Our findings suggest that teacher-perceived effects of a national classroom-based health programme ‘AAD’ do vary as a function of certain areas of schools’ social context. Based on the findings, it may be recommended to invest in the physical-structural setting as well as ensuring and/or mobilizing support from the principal for physical activity programmes to enhance effectiveness. In general, what is needed but what is still too often lacking, are health promotion initiatives based on ‘whole-school approaches’ [35], which create coordinated and integrated settings and can provide favourable environments for successful implementation of specific programme initiatives. Future studies can build upon and expand the present findings by including not only the teachers’ perspectives on the schools’ social context, but by also incorporating the view of school principals, as well as children’s and parents’ beliefs and expectations about such programmes. Further, more detailed investigations are needed about the mechanisms by which social context factors have an influence on teachers’ perceptions, for example studies which focus on whether effects are mediated via specific aspects of programme implementation such as dose delivered and dose received. Supplementary data Supplementary data are available at HEAL online. Acknowledgements The AAD programme is conducted by University College South Denmark under project manager lector Anders Flaskager (afla@ucsyd.dk). The authors would like to show our gratitude to Anders Flaskager for his support, and the teachers for their participation in the study. Conflict of interest statement None declared. References 1 Lim SS , Vos T , Flaxman AD et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010 . Lancet 2012 ; 380 : 2224 – 60 . 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Health Education ResearchOxford University Press

Published: May 5, 2018

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