Factors associated with the adoption, implementation, and maintenance of a nationwide physical activity requirement in Danish public schools: A mixed methods case study

Background: Physical activity is well-known for its several health benefits among children. In 2014,the Danish Government introduced a new school reform. One element of the reform was that it became mandatory for schools to implement 45 minutes daily physical activity within the curriculum. Policies, guidelines, or initiatives targeting physical activity in schools have the potential to increase student’s physical activity levels, but solely if they are implemented effectively. Implementation of physical activity policies into a real-world context is a complex and challenging process and most schools struggle to implement such policies. Various studies have examined factors affecting the
implementation of physical activity initiatives in schools, but most studies have focused on initiatives delivered in more controlled settings. Limited research exists on the implementation of physical activity initiatives in real-world school contexts. Therefore, the aim of this thesis is to examine factors associated with the adoption, implementation, and maintenance of a nationwide physical activity requirement in Danish public schools.


Methodology: A convergent parallel mixed methods approach using quantitative and qualitative methods was applied. The overall framework behind the research was an adapted version of the socioecological model of health behavior. The adoption, implementation, and maintenance dimensions of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework were further used as an add-on to the adapted socio-ecological model, to classify in which phase of the implementation process each factor was present. The empirical data used for the examination derived from the Physical Activity in Schools After the Reform (PHASAR) study, aiming to evaluate the implementation and effects of the physical activity requirement in Danish public schools. Thirty-one public schools were included in the study. Data were collected through questionnaires with school managers and teachers, accelerometers, which students were asked to wear, and semi-structured interviews with one key respondents at eleven selected schools. Data were collected between August 2017 and October 2018. 

Results: Fifteen factors at all levels of the adapted socio-ecological model were identified to be associated with the adoption, implementation, and maintenance of the nationwide physical activity requirement. These factors were: 1) municipal support, 2) leadership), 3) time, 4) shared decisionmaking, 5) collaboration with external parties, 6) internal coordinator(s), 7) scheduling physical activity within timetables, 8) resources, 9) access to facilities, 10) school culture, 11) norms regarding change, 12) knowledge sharing, 13) a common thread for implementing the requirement, 14) motivation, and 15) competencies. Eight factors were identified to be associated with the adoption phase, ten factors were found to be associated with the implementation phase, and nine factors were associated with the maintenance phase. All levels of the adapted socio-ecological model were represented in each of the three RE-AIM phases, except for factors related to the political level, which was not identified to be associated with the implementation phase – and the physical level, which was not identified to be associated with the adoption phase. Some factors were identified in more than one of the three RE-AIM phases, but the definition of the factor differed between the phases. Several factors were further found to be linked across levels in the adapted socio-ecological model. 

Conclusion: The findings support the need for considering a combination of factors from all levels in the adapted socio-ecological model to increase the probability for successful implementation of physical activity initiatives in real-world school contexts. Especially, when implementing an PA initiative in real-world school contexts, as schools might not be interested in the initiative and thus, is it particularly important to carefully follow and support the implementation process. This also means that factors cannot be considered as isolated factors that per se will promote the implementation process. Factors seem to be interdependent, meaning that it is important to consider the relationship between factors to promote the implementation of physical activity initiatives in realworld school contexts.