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Abstract Background To maximise their potential health benefits, school-based physical activity policies need to be implemented at scale. This paper describes the third in a sequence of trials that sought to optimise an effective strategy (PACE) to assist schools’ implementation of a physical activity policy. Specifically, it aimed to determine the probability that a multi-strategy intervention adapted to reduce in-person contact (Adapted PACE) was “as good as” the original intervention (PACE) in increasing the weekly minutes of structured physical activity implemented by classroom teachers. Methods A noninferiority cluster randomised controlled trial was undertaken with 48 primary schools in New South Wales, Australia. Schools were randomised to receive PACE or a model with adaptations made to the delivery modes (Adapted PACE). Teachers’ scheduled minutes of weekly physical activity was assessed at baseline (Oct 2018-Feb 2019) and 12-month follow-up (Oct-Dec 2019). The noninferiority margin was set at − 16.4 minutes based on previous data and decision panel consensus. A linear mixed model analysed within a Bayesian framework was used to explore noninferiority between the two PACE models. A cost minimisation analysis was conducted from the health service provider perspective, using the Australian dollar (AUD). Results The posterior estimate for the between group difference at follow-up was − 2.3 minutes (95% credible interval = − 18.02, 14.45 minutes). There was an estimated 96% probability of Adapted PACE being considered noninferior (only 4% of the posterior samples crossed the noninferiority margin of − 16.4 minutes). That is, the minutes of physical activity implemented by teachers at Adapted PACE schools was not meaningfully less than the minutes of physical activity implemented by teachers at PACE schools. The mean total cost was AUD$25,375 (95% uncertainty interval = $21,499, $29,106) for PACE and AUD$16,421 (95% uncertainty interval = $13,974, $19,656) for Adapted PACE; an estimated reduction of AUD$373 (95% uncertainty interval = $173, $560) per school. Conclusions It is highly probable that Adapted PACE is noninferior to the original model. It is a cost-efficient alternative also likely to be a more suitable approach to supporting large scale implementation of school physical activity policies. Trial registration Retrospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619001229167).

Abstract Background Physically Active Children in Education (PACE) is composed of eight implementation strategies that improves schools’ implementation of a government physical activity policy. A greater understanding of each discrete implementation strategy could inform improvements to PACE for delivery at-scale. This study aimed to: (A) measure the dose delivered, fidelity, adoption and acceptability of each strategy using quantitative data; (B) identify implementation barriers and facilitators using qualitative data; and (C) explore the importance of each strategy by integrating both data sets (mixed methods). Methods This study used data from a cluster randomised noninferiority trial comparing PACE with an adapted version (Adapted PACE) that was delivered with reduced in-person external support to reduce costs and increase scalability. Data were collected from both trials arms for between-group comparison. Descriptive statistics were produced using surveys of principals, in-school champions and teachers; and project records maintained by PACE project officers (objective A). Thematic analysis was performed using in-school champion and project officer interviews (objective B). Both data sets were integrated via a triangulation protocol and findings synthesized in the form of meta-inferences (objective C). Results Eleven in-school champions and six project officers completed interviews; 33 principals, 51 in-school champions and 260 teachers completed surveys. Regardless of group allocation, implementation indicators were high for at least one component of each strategy: dose delivered =100%, fidelity ≥95%, adoption ≥83%, acceptability ≥50%; and several implementation barriers and facilitators were identified within three broad categories: external policy landscape, inner organizational structure/context of schools, and intervention characteristics and processes. All strategies were considered important as use varied by school, however support from a school executive and in-school champions’ interest were suggested as especially important for optimal implementation. Conclusion This study highlights the importance of both executive support and in-school champions for successful implementation of school physical activity policies. In particular, identifying and supporting an in-school champion to have high power and high interest is recommended for future implementation strategies. This may reduce the need for intensive external support, thus improving intervention scalability.

Abstract Background The ‘scale-up’ of effective physical activity interventions is required if they are to yield improvements in population health. The purpose of this study was to systematically review the effectiveness of community-based physical activity interventions that have been scaled-up. We also sought to explore differences in the effect size of these interventions compared with prior evaluations of their efficacy in more controlled contexts, and describe adaptations that were made to interventions as part of the scale-up process. Methods We performed a search of empirical research using six electronic databases, hand searched reference lists and contacted field experts. An intervention was considered ‘scaled-up’ if it had been intentionally delivered on a larger scale (to a greater number of participants, new populations, and/or by means of different delivery systems) than a preceding randomised control trial (‘pre-scale’) in which a significant intervention effect (p