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A theoretical analysis of the barriers and facilitators to the implementation of school-based physical… Weatherson, Katie A; Gainforth, Heather L; Jung, Mary E Mar 27, 2017

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SYSTEMATIC REVIEW Open AccessA theoretical analysis of the barriers andfacilitators to the implementation ofschool-based physical activity policies inCanada: a mixed methods scoping reviewKatie A. Weatherson1, Heather L. Gainforth2 and Mary E. Jung3*AbstractBackground: Given the potential impact school-based daily physical activity (DPA) policies can have on the healthoutcomes of Canadian children, it is surprising that such little research has examined the implementation and student-leveleffectiveness of these policies, and that even less have used theory to understand the barriers and facilitators affectinguptake of this policy by teachers. This review descriptively summarizes the implementation status, approaches used toimplement DPA, and the effectiveness of DPA at increasing the physical activity of children at school. In addition, theTheoretical Domains Framework (TDF) was used to explore the barriers and facilitators to DPA implementation.Methods: A scoping review of English articles using ERIC, CINAHL, and Google Scholar (2005 to 2016) was conducted.Only studies that evaluated the implementation and/or student-level effectiveness of DPA policies in Canadian elementaryschools were included. Only articles that examined DPA implementation barriers and facilitators by teachers, principals,and/or administration were eligible for the TDF analysis. Data on study characteristics and major findings regardingimplementation status, implementation approach used, and impact on student’s physical activity were extracted andwere summarized descriptively, including study quality indicators. Two coders extracted and categorizedimplementation barriers and facilitators into TDF domains.Results: The search resulted in 66 articles being retrieved and 38 being excluded for not meeting the eligibility criteria,leaving 15 eligible for review (10 of which examined barriers and facilitators to implementation from DPA deliverers’perspective). Eleven of 15 studies examined the Ontario DPA policy, and 2 studies were from both Alberta and BritishColumbia. Thirteen studies examined implementation, and only two examined effectiveness. DPA implementation status,approaches to delivery, and effectiveness on student’s PA levels are inconsistent across the three provinces. A total of 203barriers/facilitators were extracted across the ten implementation studies, most of which related to the environmentalcontext and resources (ECR; n = 86; 37.4%), beliefs about consequences (n = 41; 17.8%), and social influences (n= 36; 15.7%)TDF domains.Conclusions: With the limited research examining the DPA policy in Canada, the current status and approaches used toimplement DPA and the student-level effectiveness is not well understood; however, this review revealed that DPAdeliverers often report many barriers to DPA implementation. Most importantly, in conducting a TDF-based analysis ofthe barriers/facilitators affecting implementation, this review provides a theoretical basis by which researchers andpolicy-makers can design interventions to better target these problems in the future.(Continued on next page)* Correspondence: mary.jung@ubc.ca3School of Health and Exercise Sciences, Faculty of Health and SocialDevelopment, The University of British Columbia, Okanagan, RHS 119-3333University Way, Kelowna, BC V1V 1V7, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Weatherson et al. Implementation Science  (2017) 12:41 DOI 10.1186/s13012-017-0570-3(Continued from previous page)Registration: A protocol for this review was not registered.Keywords: Scoping review, School, Physical activity, Policy, Implementation, Barriers, Facilitators, Theoretical DomainsFrameworkBackgroundLike most children and youth worldwide [1], Canadian chil-dren are not meeting the national physical activity guide-lines for optimal health [2–4]. To address this problem, theWorld Health Organization recommends that schools de-velop policies to increase physical activity among children[5]. In an attempt to help children meet the national rec-ommendations of 60 min of moderate-to-vigorous physicalactivity (MVPA), three Canadian provinces have adopteddaily physical activity (DPA) policies aimed to increase chil-dren’s physical activity levels specifically during the schoolday [6–8]. Although the specific DPA policy requirementsfor each province varies slightly, they are comparable inthat they require elementary schools (and thus teachers,principals, and/or administration) to provide a specificamount of time each day for children to be active duringinstructional hours of the school day. For example, theMinistry of Education in Ontario mandated their DPA pol-icy in 2005, requiring elementary schools to provide at least20 min of sustained MVPA as part of the instructionalschool day for children in grades one to eight [8]. SimilarDPA policies were authorized in Alberta and BritishColumbia in 2005 and 2008, respectively, with the require-ment to provide activities that vary in form and intensityfor 30 min during the school day [6, 7]. Although DPA pol-icies ultimately aim to change and have an effect on stu-dents’ physical activity levels at school, within the contextof elementary schools, the implementation of DPA policiesrequire behavior change of the teacher to provide oppor-tunities for children to be active, and the approaches theychose to provide these opportunities is left at their personalor school’s discretion. In this way, the DPA policies poten-tially affect two different, yet interrelated behaviors (theprovision by teachers and the physical activity of students).Therefore, if DPA policies are implemented as intended,teachers, principals, and/or administration will change theirprovision/implementation behaviors, and students willchange their physical activity behaviors.While there are many examples of policies being adoptedto promote the physical activity of children [9, 10], “theadoption of policies is not sufficient to promote greaterphysical activity: policies are not self-implementing” (p.280)[11]. Implementation is the conversion of policy plans intoaction [12], and implementation evaluation examines theprogress and process of how this occurs and measures theproducts resulting from the process [13]. There are manyindividual, environmental, and social-cultural factors thatinfluence the successful implementation of policies at alocal level. This is especially true of schools, which are “dy-namic, complex, multi-level systems with numerous factorsthat can influence implementation” (p.274) [14], and thequality of implementation can affect the outcomes of thepolicy or program [15]. Therefore, studying only the adop-tion of policies while ignoring the context in which they areimplemented is detrimental to understanding how and whypolicies are or are not successful. A holistic approach thatconsiders the complex interaction of these factors must betaken into account when considering how physical activitypolicies are implemented in various school-settings.Although it has been a decade since the first DPApolicy was mandated in Canada, evaluation of its imple-mentation and effectiveness is surprisingly limited [16,17]. Provincial school policies that have the potential topositively impact the health outcomes of so manyCanadian children warrant further investigation as totheir current implementation and effectiveness. A re-cently published review examining the adoption, diffu-sion, implementation, and impact of DPA policies acrossCanada rated the strength of each province’s policybased on the language used, the specific time and inten-sity requirements, and the inclusion of mechanisms forimplementation and monitoring [17]. This reviewhighlighted that the implementation of these policiesacross Canada is inconsistent and suboptimal. Addition-ally, only one study in BC [18] and two studies in On-tario [19, 20] have examined the effectiveness of DPApolicy implementation at increasing children’s PA levelsat school, with mixed results. It should be noted, how-ever, that the BC evaluation of DPA examined only theimpact of DPA on provision of physical education mi-nutes per week, not on overall physical activity levels atschool [18]. These mixed findings further highlight theneed to examine the factors that prevent implementationin order to understand why the policy is not having apositive impact on children’s PA levels at school. Whilethe authors of this review thoroughly examined howeach policy was conceptualized and adopted by eachprovince, they did not use theoretical principles to re-view the evaluation pertaining to the implementationand impact of these policies on students’ physical activ-ity at school, important components of understandingthe policy process [21]. Additionally, of the articles theyincluded in their review, few of the authors reportedexplicit use of behavior change theory to guide theirWeatherson et al. Implementation Science  (2017) 12:41 Page 2 of 15original research or analyze the factors affecting theimplementation process. Theory is valuable for under-standing how a policy is put into practice (i.e., imple-mentation) and in identifying the barriers (i.e., factorspreventing implementation) and the facilitators (i.e., fac-tors enhancing implementation) that influence policyimplementation, in order to explain the impact thesepolicies have on children’s physical activity levels. Thereare many factors associated with implementing interven-tions and policies in real-world settings, which requiresbehavior change at an individual, organizational, or com-munity level [22]. The implementation of the DPA policyduring the school day requires behavior change of theteacher, principals, and/or administration, and thus it isimportant to examine perceived barriers to implementa-tion from this perspective. While identifying barriers toimplementation is a common area of inquiry in imple-mentation research, theory is often not used to guideour understanding of these factors [23], which if ad-dressed would be able to increase systematic uptake andsuccess of these policies. The advantage of conducting atheory-based analysis of the barriers and facilitators af-fecting the implementation of school-based physical ac-tivity policies by teachers is that it provides a frameworkfor comprehensively understanding the relationship be-tween these factors and the mechanisms by which theyaffect teachers’ behavior. Understanding these connec-tions from a theoretical perspective better helps informand guide researchers, policy-makers and individuals re-sponsible for delivering such policies on how to developevidence-based strategies to improve uptake of the pol-icy into practice. Simply identifying barriers that are notlinked to theoretical constructs does not provide astrong foundation for intervention development.One such framework that can allow us to apply theoryand comprehensively identify the factors that need to beaddressed is the Theoretical Domains Framework (TDF)[24, 25]. The TDF is a suitable framework for retrospect-ively examining barriers and facilitators. It accounts forthe overlapping constructs that exist across behaviorchange theories and it provides categories called do-mains by which to more broadly capture the potentialrange of factors that influence implementation out-comes, thus allowing researchers to better understandpolicy implementation [25, 26]. It also provides a com-mon language for researchers to classify barriers and fa-cilitators to implementation. The 14 TDF domainsinclude knowledge, skills, memory, attention anddecision processes, behavioral regulation, social/profes-sional role and identity, beliefs about capabilities, opti-mism, beliefs about consequences, intentions, goals,reinforcement, emotion, environmental context and re-sources, and social influences [22]. The TDF has beenused in several reviews to understand barriers andfacilitators to a wide variety of behaviors (e.g., patients’exercise behavior, healthcare professionals’ behaviors inrelation to pregnancy weight management) [27, 28]. Anexamination of the barriers and facilitators to DPA im-plementation by DPA providers (i.e., teachers, principals,and/or administration) using the TDF will provide a listof the potential modifiable factors to target and allow re-searchers to create theoretically informed interventionsto improve the implementation and effectiveness of thisschool-based physical activity policy in the future.PurposeThe aim of this review was to broadly understand theimplementation and effectiveness of the DPA policy inCanadian elementary schools. Specifically, we aimed toexamine: (1) the implementation status of DPA inCanada, (2) the implementation approaches used to de-liver the DPA policy during the school day, (3) the bar-riers and facilitators to DPA policy implementation, and(4) the effectiveness of DPA policy implementation at in-creasing the physical activity of children at school.MethodsApproachDue to the variety of methods used across a small num-ber of existing evaluations, a systematic review andmeta-analysis were not possible. Instead, this mixedmethods scoping review, guided by the Arksey andO’Malley framework [29], provides a systematic descrip-tion and synthesis of data. Scoping reviews are appropri-ate for summarizing broad, understudied areas andidentifying gaps in the literature [29]. In addition, theTheoretical Domain Framework was used to code bar-riers and facilitators to DPA implementation. The Pre-ferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) criteria guided reporting ofthe methods and findings (see Additional file 1) [30]. Aprotocol for this review was not registered.Search and screeningTo retrieve research articles and governmental reportson policy evaluation of DPA in Ontario, Alberta andBritish Columbia, two databases (ERIC, CINAHL) andone search engine (Google Scholar, to identify gray lit-erature), and respective provincial government/educa-tion websites were searched in February 2015 for thetime period 2005–2015. The same search was conductedagain in May 2016 to retrieve additional articlespublished after the original search. One author executedthe searches in consultation with a librarian. The searchquery was tailored to the specific requirements of eachdatabase and broad search terms included: daily physicalactivity OR physical activity OR exercise AND polic*AND school. Additional terms were used in theWeatherson et al. Implementation Science  (2017) 12:41 Page 3 of 15advanced search option of Google Scholar, to find arti-cles with all of the words: school AND polic* ANDCanada, and with at least one of the words: daily phys-ical activity OR physical activity OR exercise ANDqualitative OR quantitative. An a priori decision wasmade to screen only the first 100 hits (as sorted by rele-vance by Google Scholar) after considering the timerequired to screen each hit and because it was believedthat further screening was unlikely to yield many morerelevant articles. Finally, reference lists of identified arti-cles were examined to retrieve additional eligible articles.One author screened titles and abstracts against eligibil-ity criteria and full texts were retrieved in situationswhere relevance was uncertain. Each eligible article wasread in its entirety to identify studies that examined thebarriers and facilitators to DPA implementation. Thescreening process to obtain the eligible studies is illus-trated in Fig. 1. Phase 1 included the search for eligiblestudies for the overall review, and phase 2 includedreviewing the implementation articles for the examin-ation of barriers and/or facilitators.Eligibility criteriaIncluded studies were those that examined any aspect ofthe implementation or impact of DPA in Canada usingqualitative and/or quantitative methods. Governmentreports were also included in the review. Inclusion cri-teria for articles and reports were (i) articles written inEnglish, (ii) publication after 2005 (after first provincialpolicy was mandated), (iii) involved some aspect of DPApolicy evaluation (implementation or impact), (iv)applicable to elementary school setting (children aged5–12 years), and (v) primary research papers. Articleswere excluded if they applied only to a secondary schoolsetting (youth aged 13–18 years), as both Alberta andOntario’s DPA policies do not apply to these students.Unless published dissertations were not included in thisreview. Articles that only addressed participants’ per-spectives or opinions of PA outcomes and did notinclude formal measurement of DPA (either subjectiveor objective; i.e., survey, interview, pedometer) were con-sidered implementation articles (not effectiveness). Toanswer the third aim of this study, implementationFig. 1 Flow chart of search results and barrier/facilitator (BF) identification. BF barrier/facilitator. Search for eligible articles was conducted in Phase1. Phase 2 involved the identification of articles that examined the barriers and facilitators to implementationWeatherson et al. Implementation Science  (2017) 12:41 Page 4 of 15articles were examined for the presence of barriers andfacilitators, operationalized as any factor, characteristic,view, or belief that either impedes or enables implemen-tation of the DPA policy. For this analysis, eligible arti-cles included those that examined barriers andfacilitators from the perspective of teachers, principals,and/or administration.Data extractionThe first author extracted the following data from eacharticle: (1) study type and design, (2) participants, (3)methods used to assess implementation and/or PA out-comes, and (4) major findings (process and/or outcomeresults). For the purposes of study type classification,only student self-reported or objectively measured phys-ical activity was considered an impact measure and clas-sified as an effectiveness article. If an article askedteachers, principals, and/or administration to report onchildren’s physical activity (based on their observation),this study was classified as an implementation article. Ifmeasured, DPA implementation status (i.e., degree towhich DPA was delivered) and approaches used to im-plement DPA (i.e., methods of DPA delivery) were ex-tracted by the same researcher. Additional informationwas extracted from each article examining the imple-mentation barriers and/or facilitators, including: (1) datacollection method and (2) behaviour change theory used,if applicable. Barrier and facilitator extraction was per-formed by one researcher, with double extraction occur-ring across 33% (n = 3) of the articles by a researchassistant. To identify barriers and facilitators, each articlewas read in its entirety by both researchers. We distin-guished between a barrier and facilitator based on howthe authors of each article reported and classified thefactor influencing DPA policy implementation. If the au-thors did not provide this distinction, we used our oper-ationalized definition stated previously. Once identified,each researcher transferred the factor to an excel spread-sheet. For qualitative studies, the barrier/facilitator wasrecorded in its original format unless only reported byauthors in a synthesized format (e.g., according to athemed code). For quantitative studies, individual bar-riers/facilitators were extracted if ≥50% of respondentsagreed that the factor influenced implementation. Inother words, a factor was not extracted if >50% of re-spondents disagreed that the barrier/facilitator was sig-nificant. Choosing to extract the barriers and facilitatorsthat were viewed by the majority of respondents as beingsignificant influences to policy implementation allowsresearchers to provide recommendations for and developinterventions that target these pertinent factors in thefuture and are hopefully relevant across multiple schoolcontexts. For questionnaire measures with an intermedi-ate category (i.e., Likert-scale questions), the barrier/facilitator was extracted if at least 50% of respondentsagreed with the intermediate category (or agreed morestrongly; see more extraction details in the commentscolumn of Table 3). If a quantitative study includedopen-ended questions about implementation barriers orfacilitators, the responses were extracted irrespective ofhow many respondents agreed they were present. Ex-tracted factors from each coder’s excel spreadsheet werecompared to assess extraction agreement across thethree studies.Quality assessmentAlthough not a requirement in Arksey and O’Malley’s[29] scoping review framework, it has been suggested byothers to include an assessment of methodological qual-ity in included studies [31]. Due to the lack of validatedquality assessment tools for process evaluations, theadapted version of the criteria described by Naylor andcolleagues [32] and originally adapted from Wierengaand colleagues [33] was used (see items and evaluationcriteria in Additional file 2). In accordance with Naylorand colleagues [32] past work, items were scored aspositive, negative, or not applicable, and studies wereclassified as strong (>75% positive), moderate (50–75%),or weak (<50%). When an item was not applicable, thatitem was excluded from the mean score of that study’srating. One reviewer conducted quality assessments forall implementation articles, with a second rater assessing33% (n = 4) of the articles. Quality assessment agreementwas based on overall global ratings not on individualitems. For the two studies examining DPA policy’s effect-iveness on children’s physical activity [19, 20], the vali-dated quality assessment tool for quantitative studiesdeveloped by the Effective Public Health Practice Project(EPHPP) [34] was used (see items and evaluation criteriain Additional file 3). The EPHPP quality assessment toolassigns a strong, moderate, or weak rating to six studycomponents to provide a global quality rating. Strongstudies have four or more strong components and noweak components. Moderate studies have fewer thanfour strong ratings and/or only one weak component.Weak studies have two or more weak components. Onlyone reviewer conducted quality assessments for thesearticles.Data synthesis/analysisImplementation status and approaches and physical ac-tivity outcomes across each eligible study were summa-rized descriptively. The TDF was used to code theimplementation barriers and facilitators reported byteachers, principals, and administration across thestudies in order to identify what needs to change forbehavior/implementation to change.Weatherson et al. Implementation Science  (2017) 12:41 Page 5 of 15Reliability of methodAgreement of barrier and facilitator extraction by coderswas assessed by percent agreement. To analyze the fac-tors that influenced the implementation of DPA acrossstudies, two researchers independently coded barriersand facilitators to the TDF domains in seven rounds. Foreach round, a percentage of the total extracted list ofbarriers and facilitators were randomly selected (acrossall papers). In the first round, the theoretical definitionsof each TDF domain were used as a framework to guidecoding. Coders met to discuss discrepancies after thefirst round (and every round thereafter), and a codingmanual was refined to the context of our research topicfor subsequent coding rounds (see 3rd column inAdditional file 4). Ongoing discussion and refinementbetween rounds ensured that recoding previous itemswas not necessary. In the first round, 9.85% of the totalidentified barriers and facilitators (n = 20) were codedusing the TDF domain and definitions [24] (seeAdditional file 4). In rounds 2 and 3, an additional 11.8%(n = 24) and 12.8% (n = 26) was coded, respectively. Inround 4, an additional 19.7% (n = 40) was coded. Inround 5, 14.8% (n = 30) more were coded, and in round6, 16.3% (n = 33) was coded. In round 7, the last 14.8%(n = 30) was coded. Where coding varied, consensus wasachieved through discussion after each round. Percentagreements, Cohen’s Kappa statistic [35] and prevalenceadjusted bias adjusted Kappa statistic (i.e., PABAK) [36]were used to show agreement between coders for newitems coded at each round. PABAK was used to accountfor the high prevalence of not assigning more than onedomain to each barrier. Intercoder agreement values of0.60–0.79 indicate “substantial” reliability, and thoseabove 0.80 are “outstanding” [37]. Finally, main themesfrom barrier/facilitator coding were identified, and illus-trative comments for each theme were selected.ResultsCharacteristics of eligible studiesSelection of eligible studies is summarized in Fig. 1. Thesearch resulted in 66 articles being retrieved and 38 be-ing excluded for not meeting the eligibility criteria.Overall, a total of 15 articles and reports met the eligibil-ity criteria for the current review [18–20, 38–49], ten ofwhich examined barriers and facilitators to implementa-tion [38, 40, 41, 43–49]. Of the 15 studies that met theinclusion criteria, 11 articles evaluated the Ontario DPApolicy [19, 20, 38–46], and 2 articles were from bothAlberta [47, 48] and British Columbia [18, 49]. Table 1summarizes each study based on province, evaluationtype, methods and data used, participants, evaluation in-dicators, and main findings. There were an equal num-ber of quantitative (n = 6), qualitative (n = 5), and mixedmethods (n = 4) studies included in this review. Themajority of the studies evaluated implementation (n =13), and two studies evaluated a combination of imple-mentation by teachers and effectiveness on student’sphysical activity levels.Study qualityDue to nature of a scoping review and the limited re-search available, articles were not excluded based ontheir quality rating (see Additional file 5 and 6). Bothraters were in complete agreement of overall global rat-ings for process evaluations. While not excluded fromthe review, we were not able to assess the quality of theAuditor General’s Office report [40] due to poor report-ing. Specifically, there was a lack of detail on themethods employed and interpretation of the results. Ofthe remaining studies evaluating the implementation ofDPA, 8 studies received moderate process scores [18,42–45, 47–49] and 4 studies received weak processscores [38, 39, 41, 46]. Based on the process that mea-sures quality assessment criteria, no studies receivedstrong process scores. This was most likely due to thelack of multiple data collection methods and the inabilityto measure data on multiple occasions. Only one studymanaged to include measurements before the DPA pol-icy was implemented to measure the change in theschool environment [18]. No studies measured policyoutcomes related to implementation dose or quality(item P8). Based on the EPHPP quality assessment tool,the two effectiveness articles received weak global rat-ings, due to poor reporting because secondary data waspresented (original articles were retrieved to assessmethods) [50, 51]. Of note is that the tool is not specificto observational studies, so some items were notapplicable.Barrier and facilitator extraction and coding reliabilityTen studies that reported factors that influence the im-plementation of DPA were included (see Fig. 1). The twoindependent coders extracted a total of 76 barriers/facili-tators from three randomly selected articles, and percentagreement for barrier and facilitator extraction was75.0%. Across each barrier and facilitator coding rounds,the average intercoder agreement was outstanding. Theinitial coding in round 1 showed substantial agreementlevels, but reliability improved following refinement ofthe coding manual (see Table 2).Implementation statusWhile one study reported 100% successful implementa-tion by principals and teachers in a sample of Calgaryelementary schools [47], most studies revealed thatschools are not meeting the implementation require-ments. In their DPA study in Ontario, Stone andcolleagues [20] categorized schools on a continuumWeatherson et al. Implementation Science  (2017) 12:41 Page 6 of 15Table1SummariesofdailyphysicalactivitypolicyevaluationsinCanadaAuthor,yearProvinceEvaluationtypeMethodsDatasource(s)Studyparticipants(n=samplesize)Evaluationindicators/questionsMainfindingsrelatedtoDPAPatton,2012ONImplementQUANTSurveyTeachers(n=145)%implementation,implementationapproaches,teacher’sperspectives(supportsandbarriers,attitudes)45%oftenoralwaysconductDPAondayswithnoPE;85%reportsufficientresourcesand89%reportsufficientknowledge;46%thinkDPAshouldbemorestructured;65%reportedlackofmonitoring;60%supportDPAPattonetal.2014ONImplementQUANTSurveyStudents(n=146)Implementationapproaches,barriers,attitudes46%reportedDPAeverydaythereisnotPE;barriers:studentdisruption,withholdingDPAaspunishment;majorityofstudentsagreethatthereisenoughspace/equipment/timetodoDPAeveryfdayandmajorityenjoyitAGO,2013ONImplementMIXEDSurvey,interviews,documentreviewSchoolboards(teachersandprincipals)(n=unknown)Proceduresforimplementing,monitoringandmeasurementandreportingofDPAinschoolsNeithertheMinistryorschoolboardsaremonitoringimplementation;majorityofprincipalsreportedstudentsnotgettingDPA;barriers:lackoftimeandspace,focusonliteracyStrampeletal.2014ONImplementMIXEDSurvey(withopen-endedquestions)Teachers(n=137)BarriersandpossiblesolutionstoDPAimplementationBarriers:lackoftime,resources,space,andstaffandstudentbuy-in;possiblesolutions:newgameswithminimalequipment,moreindoorDPAactivities,betterinfrastructure,moreresources,whole-schoolDPAapproach,studentleaders/DPArolemodels,school-communitylinksforDPARobertson-WilsonandLévesque,2009ONImplementQUALArchivaldocumentsN/AFrameworkusedtoexamineimplementationapproachesandchallengesDPApolicyaccountsforseveralfactors(allocationofresources,taskspecification)importantforimplementationbutnotall(sustainabilityofresources,policyvalue,evaluationplans)BrownandElliott,2015ONImplementQUALSemi-structuredinterviewsTeachers(n=14)andprincipals(n=5)DPAimplementationapproaches,facilitators,barriers,perceivedoutcomes,andsuggestionsforchangeApproaches:multiplebreaks,student-ledactivities,integrationintoothersubjects;facilitators:staffsupport,availableresources,trainingsessions;barriers:lackoftime,space,equipment,training,studentmotivation,andmonitoring;outcomes:increasedfocus,enjoyment,classroomenvironment;suggestions:whole-communityapproach,morespace,resources,andmonitoringRickwood,2015ONImplementQUALSemi-structuredinterviewsTeachers(n=5)andschooladministrators(n=4)Perceivedbarriers,associationbetweenbeliefsaboutDPApolicyandstudentPAlevelsBarriers:diminishingpriorityofDPA,usedasabehaviormanagementstrategy,lackofstudentmotivationAllisonetal.2014ONImplementQUALSemi-structuredgroupandindividualinterviewsCentralplayersindevelopmentandimplementationofDPA(n=10)Factorsinfluencingdevelopmentandimplementation,rolesofkeyplayers,barriers,andcurrentstatusofDPAIssuesofflexibilityandaccountability;severalrelationshipstoassistwithimplementation;barriersoftighttimeline,lackofsupport,insufficienttraining,lackoffacilities,spaceandequipment,poorweather,increasedteacherburden,lackofaccountability;inconsistentimplementationandlackofevaluationplanWeatherson et al. Implementation Science  (2017) 12:41 Page 7 of 15Table1SummariesofdailyphysicalactivitypolicyevaluationsinCanada(Continued)GilmoreandDonohoe,2016ONImplementQUANTSurveyTeachers(n=136)Implementationstatus;perceivedcompetence,motivationandskillstodeliverDPA46%ofteachersreportedthatDPAisnotbeingdelivered;majorityofteacherslackcompetence,motivationandskillstodeliverDPAStoneetal.2012ONCombinationQUANTAccelerometerandclassroomschedulesStudents(n=856)TotalPA,frequencyofDPAschedule,andquality,numberanddurationofsustainedboutsofMVPA(≥5min),BMILessthan50%getDPAeveryday,butforthosethatdotheyaremoreactive,morelikelytomeetguidelinesandlesslikelytobeoverweight;nochildengagedinsustainedMVPAfor≥20minHobinetal.2010ONCombinationQUANTSurveyStudents(n=2379)andschooladministrators(n=30)Student-level(sex,grade,#PEclasses/week,MVPAminutes)andschool-level(intramuralsandinterschoolprograms,DPAimplementationmodel)characteristics70%ofschoolsofferedDPAonlyondayswithoutPE;studentPAlevelswereassociatedwithPEfrequencybutnotDPAimplementationmodelKennedyetal.2010ABImplementMIXEDIntervieworsurveyPrincipals/vice-principals(n=55)andPEteachers(n=7)DPAknowledge,%implementation,approaches,barriers100%principalsandteachersreportedfullimplementation;80%ofschoolsprovideddailyPEAlbertaEducation,2008ABImplementMIXEDSurveyPrincipals(n=387)andteachers(n=638)ResourcesandsupportsforDPA,PE,DPAactivities,attitudes,challenges,monitoringstatusPositiveperceptionsofDPA,higherforprincipals;multipleapproachesforimplementationandchallenges(scheduling,lackoffacilities/space);60%ofprincipalsmonitorDPAWattsetal.2014aBCImplementQUANTSurveyPrincipals(n=351)Environmentchanges;minutesofPEperweekanddeliverymethodofPE≥150minPE/weekincreasedfrom34.1to48.1%beforeandafterimplementationMâsseetal.2013BCImplementQUALSemi-structuredInterviewsPrincipals(n=17)andteachers(n=33)Perceivedimplementation,styles/change,factorsthatimpededorfacilitatedimplementationofDPAPerceivedimplementationvariesbetweenprincipalsandteachers;prescriptivevs.non-prescriptiveapproach;majorthemes:relativeadvantage,compatibility,complexity,observability,facilitators(contextualfactors)ONOntario,ABAlberta,BCBritishColumbia,Implementimplementationevaluation,QUANTquantitative,QUALqualitative,MIXED,mixedmethods,studyusedbothquantitativeandqualitativemeasures,Combinationevaluationtypemeansstudy/reportexaminedsomeaspectofimplementationprocessandpolicyeffectiveness;AGOOfficeoftheAuditorGeneralofOntario,PEphysicaleducation,MVPAmoderate-to-vigorousphysicalactivity,BMIbodymassindexa Studyexaminednutritionalpolicyinmiddleandhighschool,onlyrelevantdatafromgrade6andDPAexaminedWeatherson et al. Implementation Science  (2017) 12:41 Page 8 of 15according to implementation schedule: according to par-ents, 16% of students were occasionally (1–2 days perweek), 34% of students were often (3–4 days per week),and 49% of students were always (5 days per week) givenopportunities to be active each day for 20 min. In oneschool district in Ontario, only 45% of teachers and 46%of students reported always or often doing DPA on dayswith no physical education [38, 39]. In BC, Watts andcolleagues [18] found that 65% of the schools theysurveyed obtained full implementation of DPA, whileanother study revealed that principals perceived greaterimplementation (90%) compared to teachers (43%) [49].Implementation approachesImplementation approaches used by DPA deliverers tofulfill DPA requirements included many differentapproaches. In BC, Mâsse, Naiman, and Naylor [49] cat-egorized implementation style taken by schools as eitherprescriptive or non-prescriptive. Prescriptive approachesrequire all children to participate during instructionaltime while non-prescriptive approaches provide childrenwith more opportunities to be active during non-instructional time. The majority of elementary schoolsacross each province adopted a prescriptive approach byincreasing physical education classes during the week[18, 43, 48] or scheduling DPA activity class into thetimetable [43, 47–49]. Ontario schools used some cre-ative methods to deliver DPA during instructional time,including integrating DPA into other curriculum sub-jects, taking multiple smaller breaks throughout the dayand allowing older students to lead DPA activities foryounger classes [43]. Non-prescriptive approaches in-cluded providing more opportunities and access tofacilities at recess and lunch breaks, without providingadditional times to be active during instructional time[40, 47–49]. For example, in Alberta, 57% of schools re-ported increasing resources through the purchasing ofequipment for gym and recess [48].Identified barriers and facilitatorsA total of 203 barriers/facilitators were extracted acrossthe ten studies. Table 3 outlines the number of bar-riers/facilitators that were identified across DPA studiesbased on the TDF domains. Some of these barriers werecoded under multiple domains, resulting in a total of230 coded barriers/facilitators. The most commonlycoded TDF domains were environmental context andresources (ECR; n = 86; 37.4%), beliefs about conse-quences (n = 41; 17.8%), and social influences (n = 36;15.7%). No barriers/facilitators were coded in memory,attention and decision processes, goals, or optimismdomains. Only four of the ten articles that examinedimplementation used theory to guide the study. Identi-fied themes from the TDF domains are listed inAdditional file 7.Effectiveness of DPA policy implementation on children’sphysical activityOnly 2 of the 15 articles examined the impact ofDPA on student’s physical activity behavior [18, 19].Hobin and colleagues [19] examined associations be-tween student self-reported MVPA and schools’ DPAimplementation model and found that student phys-ical activity was associated with PE frequency perweek but not the DPA implementation model (i.e.,DPA only on days without PE, in addition to dailyPE or as part of daily PE). Stone and colleagues [20]used accelerometers and classroom schedules tocompare total physical activity and sustained boutsof MVPA to frequency of DPA schedule. They foundthat less than 50% of students received DPA everyday, and no child engaged in sustained MVPA for20 min as required by the DPA guidelines. However,for children who did receive DPA every day, theywere more active overall, more likely to meet PAguidelines, and less likely to be overweight comparedto students who did not receive DPA.Table 2 Intercoder agreement statistics including percent agreement, Kappa and PABAK and the number of observations usedduring each coding roundRound % total (n observations) Mean percent positive agreement(n observationsa)Mean Kappa (±SD) Mean PABAK (±SD)Round 1 9.85 (20) 70.0 (20) 0.66 ± 0.50 0.90 ± 0.15Round 2 11.8 (24) 88.5 (26) 0.90 ± 0.25 0.97 ± 0.08Round 3 12.8 (26) 71.0 (31) 0.79 ± 0.41 0.94 ± 0.12Round 4 19.7 (40) 76.2 (42) 0.74 ± 0.44 0.92 ± 0.12Round 5 14.8 (30) 84.2 (38) 0.85 ± 0.35 0.94 ± 0.12Round 6 16.3 (33) 77.5 (40) 0.83 ± 0.34 0.94 ± 0.11Round 7 14.8 (30) 84.8 (33) 0.90 ± 0.29 0.97 ± 0.09Kappa Cohen’s Kappa statistic [35], PABAK prevalence adjusted bias adjusted Kappa statistic [36]aSome barriers were coded under multiple domains if applicable. Mean percent was calculated based on each code the BF was givenWeatherson et al. Implementation Science  (2017) 12:41 Page 9 of 15Table3TDFidentifiedbarriersandfacilitatorsofDPAPaper(author,year)ProvinceParticipantsMethodScaleTheoryTotalBFsidentified(n)TDFbarriers(n)CommentsMâsseetal.2013BCPrincipalsandteachersInterviewsN/ADOI24ECR(9)Beliefsaboutconsequences(4)SPRI(3)Socialinfluences(2)Skills(2)Beliefsaboutcapabilities(2)Knowledge(2)Theorywasusedtoarrangestudyfindings,butdidnotguideinterview.Kennedyetal.2010ABPrincipals,vice-principals,andPEteachersSurveyCheckallthatapplyN/A12ECR(8)Socialinfluences(4)Skills(1)Knowledge(1)Thesurveycontainedpresetanswers;participantswereallowedtogivemorethanoneanswer.Frequencies(%)werereported,andfactorswereextractedifatleast50%oftherespondentscheckedthatthebarrierwaspresent.Strampeletal.2014ONTeachersSurveyLikertscale(1=stronglydisagreeto5=stronglyagree)N/A13ECR(8)Socialinfluences(3)Beliefsaboutcapabilities(1)SPRI(1)Skills(1)Knowledge(1)Frequencies,meansandstandarddeviationswerereported.Extractionandcodingwasbasedofffrequencies.Themiddleanchorwas“neitheragreenordisagree”andanyresponsesforthisoptionwerenotincludedindeterminingifthefactorwasextracted.Someitemswerereversescored,andtherefore,thesewereaccountedforinitemextraction.Allopen-endedresponseswereextracted.Patton,2012ONTeachersSurveyLikertscale(1=neverto5=always)N/A14Beliefsaboutconsequences(6)ECR(4)SocialInfluences(2)Emotion(1)Reinforcement(1)Intentions(1)Onlyextractedbarriersthatatleast50%ofrespondentsbelievedsometimes,often,oralwaysinfluenceddeliveryofDPA.Allisonetal.2014ONKeyinformants(involvedininitialdevelopmentandimplementationofDPA)InterviewsN/AN/A24ECR(13)Beliefsaboutconsequences(3)Skills(3)Knowledge(3)Reinforcement(3)SPRI(2)SocialInfluences(2)Intentions(1)Beliefsaboutcapabilities(1)BrownandElliot,2015ONTeachersandprincipalsInterviewsN/ASETandANGELO61ECR(22)Beliefsaboutconsequences(13)SocialInfluences(13)Skills(6)Reinforcement(5)Intentions(3)Beliefsaboutcapabilities(3)Knowledge(3)SPRI(1)Behavioralregulation(1)Rickwood,2015ONTeachersandadministratorsInterviewsN/ACST15ECR(5)Beliefsaboutconsequences(4)Socialinfluences(3)Intentions(1)Beliefsaboutcapabilities(1)SPRI(1)ParticipantsdiscussedbarriersmoreinrelationtoPE,coaching,andoverallgeneralPA;notalwaysDPA-specific.However,DPApoliciesdoincludePEasamethodtomeetDPAguidelines,andtherefore,allreportedbarriersandfacilitatorswereextracted.Weatherson et al. Implementation Science  (2017) 12:41 Page 10 of 15Table3TDFidentifiedbarriersandfacilitatorsofDPA(Continued)AlbertaEducation,2008ABPrincipalsandteachersSurveyLikertscale(1=stronglyagreeto5=stronglydisagree)N/A33ECR(13)Beliefsaboutconsequences(11)Socialinfluences(7)Beliefsaboutcapabilities(2)Skills(1)Knowledge(2)SPRI(1)Onlyextractedbarriersthatreceivedatleast50%agreement(somewhatagree,stronglyagree).Themiddleanchorwas“neitheragreenordisagree”andanyresponsesforthisoptionwerenotincludedindeterminingifthefactorwasextracted.PrincipalsreportedlesschallengesassociatedwithDPAimplementationandperceivedmorepositiveoutcomesthanteachers.Despitethisdifference,thesameextractioncriteriaappliedirrespectiveofwhetheritwastheteachersorprincipalsagreeing/disagreeingthatthefactorwaspresent.AuditorGeneral’sOffice,2013ONSchoolboards(principalsandteachers)Surveys,interviews,documentreviewNotreportedN/A3ECR(3)Surveyquestiontypewasnotreported.Descriptiveresultswerepresentedonthemostinfluentialbarriers.Thesefactorswereextracted.GilmoreandDonohoe,2016ONTeachersSurveyLikertscale(7-ptscalefromstronglydisagreetostronglyagree;anchorsnotprovided)FMST4Skills(2)ECR(1)Knowledge(1)Beliefsaboutcapabilities(1)Intentions(1)Onlyextractedbarriersthatreceivedatleast50%agreement(agree,stronglyagree).Themiddleanchorwas“neitheragreenordisagree”andanyresponsesforthisoptionwerenotincludedindeterminingifthefactorwasextracted.BCBritishColumbia,ABAlberta,ONOntario,PEphysicaleducation,DPAdailyphysicalactivitypolicy,PAphysicalactivity,DOIdiffusionofinnovations,SETSocialEcologicalTheory,ANGELOAnalysisGridforEnvironmentsLinkedtoObesityFramework,CSTCulturalSystemsTheory,FMSTFord’sMotivationSystemsTheory,TDFTheoreticalDomainsFramework,ECRenvironmentalcontextandresources,SPRIsocial/professionalroleandidentity,N/AnotapplicableWeatherson et al. Implementation Science  (2017) 12:41 Page 11 of 15DiscussionWith the limited research examining the DPA policy inCanada, the current status and approaches used to im-plement DPA, and the impact on student’s physical ac-tivity levels is not well understood; however, this reviewrevealed that DPA deliverers (i.e., teachers, principals,administration) often report many barriers to DPA im-plementation, most of which relate to the environmentalcontext and resources (i.e., lack of training, time, and re-sources), beliefs about consequences (i.e., burden onteacher, classroom influences), and social influences (i.e.,lack of student/parent interest) domains of the TDF. Un-derstanding these implementation barriers from a theor-etical perspective is the key to creating solutions toovercoming them in the future. Our review adds thistheoretical analysis to the existing literature and is rele-vant to other studies examining the implementation ofschool-based interventions and polices that commonlyreport similar barriers and facilitators to uptake [32].Barriers and facilitators and theoretically informedsolutions to DPA implementationNearly all implementation evaluations reviewed for thisarticle examined staff member’s perspectives regardingthe barriers and facilitators to DPA policy implementa-tion. Common themes emerged irrespective of province,context/scheduling requirement (i.e., instructional ornon-instructional), or data collection methodology (i.e.,quantitative or qualitative), and the majority of barriersreported by teachers and principals related to the TDFtheoretical domains of ECR, social influences, and beliefsabout consequences. These implementation barriers ex-perienced by DPA deliverers are similar to those re-ported by others implementing similar school-based PApolicies [52–56], highlighting that school policy imple-menters experience similar barriers and challenges whenimplementing PA initiatives in a school context.A primary strength of this study as compared to previ-ous reviews is that in using a theoretical framework tounderstand policy implementation, researchers can de-velop theoretically informed solutions to the identifiedbarriers and design interventions that can better targetthese problems in the future [57]. A TDF analysis pro-vides the behavioral diagnosis of what needs to changein a specific context in order for a target behavior tooccur and can be linked to intervention functions andtechniques to change behavior through guidance of theBehaviour Change Wheel framework (BCW) [22]. Thisreview highlights the need to create interventions thattarget barriers relating to the (1) ECR, (2) beliefs aboutconsequences, and (3) social influences domains. Inter-vention functions that have been linked to these do-mains include: (1) training, restriction, environmentalrestructuring and enablement. (2) Education, persuasion,and modeling, and (3) restriction, environmental re-structuring, modeling and enablement, respectively [22].Therefore, DPA implementation may improve if some orall of these intervention functions are directed at theDPA deliverers through interventions. For example, onestrategy to overcome the commonly reported barrier oflack of training (coded in the TDF domains ECR, skills,and knowledge) would be for Ministries of Educationand/or school boards to provide additional and ongoingtraining to teachers on how to conduct DPA during theinstructional and non-instructional school day. Similarly,to target teachers’ perception of a lack of time (i.e., ECR)and to minimize the burden that they feel about fittingDPA during the busy school day (i.e., beliefs about con-sequences), school boards can emphasize how DPA posi-tively benefits children’s focus and concentration (i.e.,education) or require that DPA is a part of the overallcurriculum and monitor it more readily (i.e., environ-mental restructuring). Focusing specifically on teacher’sreported implementation barriers and perceptions willassist with policy implementation, considering that theyexpress less support, perceive less effectiveness of, andreport more barriers for DPA implementation than prin-cipals [38, 43, 48].Low adoption of DPA implementationThe level of perceived implementation adoption is in-consistent across the three provinces. Overall, it appearsthat only about half of the elementary schools studiedare meeting their respective DPA time requirement, asself-reported by teachers and principals. However “[the]self-reported findings may reflect what is scheduled ver-sus actual policy implementation” (p.S75) as made evi-dent by direct observations in a school-based PA policyevaluation in Alabama [58]. Moreover, scheduling DPAinto the school day provides children with the opportun-ity to be active, but does not guarantee that students areactive during this time.Implementation approachesImplementation approaches across Canada have varied,with the majority of schools adopting prescriptive (e.g.,additional PE and scheduling DPA into timetable, inte-grating DPA into other curriculum subjects, taking mul-tiple smaller breaks throughout the day) approaches,and some schools are using non-prescriptive (e.g., intra-murals, lunch hour games and open access to facilitiesand equipment) approaches (defined by Mâsse and col-leagues [49]). Non-prescriptive approaches would allowschools and teachers to take a more hands-off approachand possibly minimize the two major perceived barriersrelating to ECR, including a lack of time in schedule [38,40, 41, 43, 47–49] and conflicting with other curriculardemands [38, 40, 41, 43, 45, 49]. Unfortunately, theWeatherson et al. Implementation Science  (2017) 12:41 Page 12 of 15implementation delivery methods currently used are notlinked to PA outcomes, and as such, it is unknown howeffective these specific approaches are at increasingchildren’s physical activity levels at school. A more spe-cific examination of the behavior change techniques [59]that teachers, principals, and administrative staff use todeliver DPA would be beneficial for linking implementa-tion approaches to identified barriers, and ultimately, PAoutcomes.Future researchThere is an obvious need for future evaluation to exam-ine DPA policy implementation and effectiveness acrossall three provinces. Few studies have evaluated the ef-fectiveness of the various DPA implementation ap-proaches employed by elementary schools on student’sPA levels. To understand the impact of these policies,further research that uses objective measures of PA inchildren is needed. Even though DPA policy implemen-tation barriers and facilitators have been examined indepth, it is unclear whether or not these findings havebeen utilized to change implementation practices. Inparticular, it is unclear if and what strategies have beenprovided to or used by schools to overcome barriers andfacilitate implementation of the policy. In order for theDPA policy to meet prescribed outcomes, it is essentialthat current evaluation research findings be translatedinto usable forms to allow for schools to adopt imple-mentation procedures according to research-basedevidence. The use of the TDF to analyze barriers and fa-cilitators to implementation assists with this process forfuture research interventions.Strengths and limitationsWhile the strength of this review is the utilization of atheoretical framework to categorize the factors that in-fluence the implementation of the DPA policy acrossthree Canadian provinces, it is important to recognizeits limitations. A limited number of databases weresearched and therefore our search for articles was notexhaustive. It is possible that the search terms did notresult in the complete retrieval of DPA policy articles inthis context. The exclusion of dissertation data may alsohave limited relevant research from this review. Futureresearch should consider a formal systematic review thatincludes similar DPA policies from international jurisdic-tions to provide more comprehensive and moregeneralizable findings.Only one author screened articles for eligibility andextracted data from all studies. Of the studies that wereincluded, it is difficult to compare findings and thereforedraw conclusions from this review, due to the nature ofheterogeneity in policy implementation and evaluation.Barriers and facilitators were not always explicitlydiscussed, and the authors did not have access to theraw data from each eligible article. Therefore only bar-riers and facilitators that were reported by the originalauthors could be extracted and coded, and findings maynot encompass the full range of factors that influenceDPA implementation. Given the heterogeneity of report-ing barriers and facilitators across studies, we found ituseful to code the barriers and facilitators in rounds,using the TDF domain definitions. After each round,consensus discussion allowed us to refine the codingmanual to the context of the research topic, and thisstrengthened our agreement.Our parameters for barrier and facilitator extractionexcluded factors that may have a significant role on im-plementation. Even if most respondents did not agreethat a barrier or facilitator influenced implementation, itstill represents a factor that should be considered in tai-loring interventions. However, while some factors maynot have been extracted from one study, they may havebeen extracted from other studies and therefore werestill captured in our findings. In the future, it would behelpful for authors to use consistent methods for meas-uring and reporting barriers and facilitators (e.g., using atheoretical framework like the TDF). Finally, the level atwhich the barrier/facilitator was being discussed in theoriginal research was not always clear (i.e., does thefactor affect the teacher implementing DPA or thestudent engaging in physical activity?). The use of theTDF allowed us to accomplish this by categorizing thebarriers/facilitators according to the DPA deliverer (i.e.,teacher, principal, administration); however, it is possiblethat the level at which the barrier/facilitator was workingwas incorrectly interpreted by the researchers.ConclusionsOverall, the research evaluating the daily physical activ-ity policies in Ontario, Alberta, and British Columbiahas many shortcomings. Of particular concern is thelack of evaluation in British Columbia and Alberta.While the majority of studies have examined the processof DPA policy implementation in elementary schools, alack of implementation adoption undermines futureevaluation of the policy’s effectiveness on student PAlevels. Only when schools report greater adherence toimplementation, will there be value in measuring thepolicy’s effectiveness. Also, “[b]ecause policy and pro-gram implementation are evolving processes thattypically entail extensive adaptation, evaluation effortsmust continue to attend to process issues” (p. 56) [12].Important process issues include addressing the barriersto implementation. While research evidence is limitedand the use of theory to guide our understanding of pol-icy evaluation has been scarcely utilized, this review pro-vides a theoretical lens in which to understand theWeatherson et al. Implementation Science  (2017) 12:41 Page 13 of 15barriers and facilitators to DPA policy implementation.It is our hope that this analysis will assist researchers increating interventions to overcome implementation bar-riers and more successfully fulfill policy guidelines to beable to evaluate the effectiveness of these policies on stu-dent’s PA levels in the future.Additional filesAdditional file 1: PRISMA Checklist. Completed PRISMA checklistindicating page number in manuscript of relevant content. (DOC 58 kb)Additional file 2: Process measures quality assessment. Qualityassessment criteria for process evaluations, adapted from Wierenga andcolleagues [33]. (DOCX 73 kb)Additional file 3: Impact measures quality assessment. Qualityassessment criteria for effectiveness evaluations, adapted from Thomasand colleagues [34]. (DOCX 81 kb)Additional file 4: TDF coding manual. TDF domains and definitionsused to code barriers and facilitators. (DOCX 127 kb)Additional file 5: Quality assessment of implementation studies. Qualityratings for each implementation study using Wierenga and colleagues[33] quality assessment criteria. (DOCX 86 kb)Additional file 6: Quality assessment of effectiveness studies. Qualityratings for each effectiveness study using Thomas and colleagues [34]quality assessment criteria. (DOCX 53 kb)Additional file 7: Themed barriers and facilitators to DPAimplementation by theoretical domain. Identified themes toimplementation barriers and facilitators arranged by TDF domains.(DOCX 132 kb)AcknowledgementsA research assistant assisted with double extraction and coding ofimplementation barriers and facilitators.FundingThis study was undertaken with no funding.Availability of data and materialsAll data generated or analyzed during this study are included in thispublished article (and its supplementary information files).Authors’ contributionsKW envisioned and planned the study, collected the data, and drafted themanuscript. KW and HG analyzed the data. All authors read and approvedthe final manuscript.Competing interestsThe authors declare that they have no competing interests.Consent for publicationNot applicable.Ethics approval and consent to participateNot applicable.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1School of Health and Exercise Sciences, Faculty of Health and SocialDevelopment, University of British Columbia, Okanagan, ART 360-1147Research Road, Kelowna, BC V1V 1V7, Canada. 2School of Health and ExerciseSciences, Faculty of Health and Social Development, University of BritishColumbia, Okanagan, ART 129-1147 Research Road, Kelowna, BC V1V 1V7,Canada. 3School of Health and Exercise Sciences, Faculty of Health and SocialDevelopment, The University of British Columbia, Okanagan, RHS 119-3333University Way, Kelowna, BC V1V 1V7, Canada.Received: 22 July 2016 Accepted: 13 March 2017References1. 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Ann BehavMed. 2013;46:81–95.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Weatherson et al. Implementation Science  (2017) 12:41 Page 15 of 15


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