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Barriers and facilitators to the implementation of a school-based physical activity policy in Canada:… Weatherson, Katie A; McKay, Rhyann; Gainforth, Heather L; Jung, Mary E Oct 23, 2017

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RESEARCH ARTICLE Open AccessBarriers and facilitators to theimplementation of a school-based physicalactivity policy in Canada: application of thetheoretical domains frameworkKatie A. Weatherson1, Rhyann McKay2, Heather L. Gainforth2 and Mary E. Jung3*AbstractBackground: In British Columbia Canada, a Daily Physical Activity (DPA) policy was mandated that requireselementary school teachers to provide students with opportunities to achieve 30 min of physical activity during theschool day. However, the implementation of school-based physical activity policies is influenced by many factors. Atheoretical examination of the factors that impede and enhance teachers’ implementation of physical activitypolicies is necessary in order to develop strategies to improve policy practice and achieve desired outcomes. Thisstudy used the Theoretical Domains Framework (TDF) to understand teachers’ barriers and facilitators to theimplementation of the DPA policy in one school district. Additionally, barriers and facilitators were examined andcompared according to how the teacher implemented the DPA policy during the instructional school day.Methods: Interviews were conducted with thirteen teachers and transcribed verbatim. One researcher performedbarrier and facilitator extraction, with double extraction occurring across a third of the interview transcripts by asecond researcher. A deductive and inductive analytical approach in a two-stage process was employed wherebybarriers and facilitators were deductively coded using TDF domains (content analysis) and analyzed for sub-themeswithin each domain. Two researchers performed coding.Results: A total of 832 items were extracted from the interview transcripts. Some items were coded into multipleTDF domains, resulting in a total of 1422 observations. The most commonly coded TDF domains accounting for75% of the total were Environmental context and resources (ECR; n = 250), Beliefs about consequences (n = 225), Socialinfluences (n = 193), Knowledge (n = 100), and Intentions (n = 88). Teachers who implemented DPA duringinstructional time differed from those who relied on non-instructional time in relation to Goals, Behaviouralregulation, Social/professional role and identity, Beliefs about Consequences. Forty-one qualitative sub-themes wereidentified across the fourteen domains and exemplary quotes were highlighted.Conclusions: Teachers identified barriers and facilitators relating to all TDF domains, with ECR, Beliefs aboutconsequences, Social influences, Knowledge and Intentions being the most often discussed influencers of DPA policyimplementation. Use of the TDF to understand the implementation factors can assist with the systematicdevelopment of future interventions to improve implementation.Keywords: School, Physical activity, Policy, Implementation, Barriers, Facilitators, Theoretical domains framework* 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. BMC Public Health  (2017) 17:835 DOI 10.1186/s12889-017-4846-yBackgroundLevels of physical activity are assiduously low among childrenand youth in Canada [1] and worldwide [2], and have in partcontributed to the increased rates of childhood overweightand obesity and associated chronic diseases (e.g., cardiovascu-lar diseases and type 2 diabetes) [3, 4]. Establishing healthylifestyle behaviours, like physical activity, is imperative duringchildhood, as these behaviours can extend across the life span[5] and have long-term health implications (e.g., preventionof weight gain/obesity, type 2 diabetes, coronary heart disease,dementia, Alzheimer’s disease) [6]. Consequently, publichealth governing bodies have prioritized strategies and inter-ventions to combat children’s physical inactivity and obesitycrisis globally [7, 8] and within Canada [9]. In Canada,schools are often the target of such initiatives as theyrepresent an environment through which to reach a largeand diverse population of youth, who spend a majority oftheir waking time in school [10, 11].Several provinces in Canada have adopted daily physicalactivity policies aimed at increasing children’s physical activityspecifically during the school day [12–14]. In BritishColumbia, the Ministry of Education mandated a DailyPhysical Activity (DPA) policy in 2008 (revised in 2011) re-quiring elementary schools to provide at least 30 min of DPAas part of the educational program for children in grades Kin-dergarten to seven [12]. Specifically, the DPA policy requireselementary students to achieve 30 min of physical activity atschool on days with no physical education.1 This requirementincludes any activities that help build endurance, strengthand flexibility (e.g., walking, running, push-ups, stretching)and that are conducted during instructional (i.e. within-class)or non-instructional (i.e. recess or lunch break) time.In order to improve the success of such policies, it is ad-vised that policy evaluation occur at the outset and continueson an ongoing basis [15]; however, minimal research inCanada has examined the process of how DPA policy plansare translated into practice (i.e., implementation) and there iscurrently no research examining the effectiveness of the DPApolicy in BC schools [16]. Central to understanding the im-plementation process is a comprehensive and theoreticalexamination of the numerous factors that can impede (i.e.,barriers) or enhance (i.e., facilitators) the successful imple-mentation of physical activity policies at a local school-level.While some research has identified barriers and facilitators toDPA implementation in Canada [17–21], theory is rarelyused to guide our understanding of these factors [22]. Behav-iour change theories postulate the psychological and environ-mental constructs that affect behaviour by specifyingmechanisms of change. Within the school context, utilizing atheoretical approach allows researchers to systematicallyidentify the potentially malleable factors affecting teacher’simplementation of the policy and to prioritize and developstrategies through which to target these key factors to im-prove policy practice and achieve desired outcomes. For thisreason, this study moves beyond the simple identification ofbarriers and facilitators to DPA policy implementation by de-scriptively linking these factors to pathways of behaviourchange in order to enhance implementation practices [23].To achieve this aim, this study uses the TheoreticalDomains Framework (TDF). The TDF, developed andvalidated by Michie and colleagues, is an integrativeframework that synthesizes over eighty constructs acrossthirty-three psychological theories in order to understandinfluences on behaviour more broadly [24, 25]. Specifically,the TDF is organized into 14 categories, called domains, tocategorize the potential range of behavioural andorganizational factors that influence implementationoutcomes [26]. Domains that address behavioural factorsinclude: Knowledge, Skills, Memory, attention and decisionprocesses, Behavioural regulation, Social/professional roleand identity, Beliefs about capabilities, Optimism, Beliefsabout consequences, Intentions, Goals, Reinforcement,and Emotion. Domains that address organizational factorsinclude: Environmental context and resources, and Socialinfluences (TDF domain definitions are provided inAdditional file 1).The TDF has been successfully applied in many settingsto identify influences on a variety of behaviours [27]. Thereare many individual, environmental and social-culturalfactors that influence the successful implementation ofpolicies in schools. For example, some of the factors shownto influence implementation include: leadership and sup-port, resource support, communication/shared decision-making, and individual self-efficacy/skills [28]. Therefore, aframework that can capture these influences operating atdifferent levels is warranted.More broadly, the TDF is a refined version of theCapability Opportunity Motivation-Behaviour (COM-B)model, an evidence-based model supporting that three keysources (i.e., capability, opportunity and motivation) inter-act to influence behaviour. The COM-B model can belinked to a practical intervention design tool called theBehaviour Change Wheel framework (BCW) [26] to guideresearchers in the selection of theory, intervention func-tions, policy categories, and behaviour change techniquesfor intervention design and delivery. As a result, the TDF isone of few frameworks linked to a comprehensive methodfor intervention design.PurposeThe purpose of this study was to use the TDF to under-stand teachers’ barriers and facilitators to the implementa-tion of the Daily Physical Activity policy in BritishColumbia elementary schools. Additionally, barriers andfacilitators were examined and compared according to howthe teacher implemented the DPA policy during the schoolday (provision of DPA during instructional time or onlynon-instructional time).Weatherson et al. BMC Public Health  (2017) 17:835 Page 2 of 16MethodsOverall designThis study used short surveys and semi-structured inter-views to explore the factors (i.e., barriers and facilitators)associated with the implementation of the Daily PhysicalActivity policy by elementary school teachers in oneschool district in British Columbia. A content analysis wasconducted using the TDF and overarching themes wereidentified within each domain. Ethical approval was ob-tained from the University of British Columbia’s Behav-ioral Research Ethics Board for research involvinghumans, and the respective school district. The Consoli-dated criteria for reporting qualitative research (COREQ)[29] guided reporting of this study (see Additional file 2).FrameworkThe first author used the TDF to construct the semi-structured interview guide [see Additional file 3], whichunderwent revision by HG who is experienced in applica-tion of the TDF and was further refined after piloting theinterview with two elementary school teachers. The TDFwas then used to categorize the implementation barriersand facilitators and explore emergent themes by domain.Sample selection and recruitmentOne school district from British Columbia representing over30 public elementary schools was chosen for convenienceand approached to participate in this study. Principals of allelementary schools were emailed an information letter torequest time to present the study to their intermediateteachers. The first investigator visited the school andconducted a presentation to the teachers, which consisted ofinformation regarding the researcher’s background and inter-ests and her study purpose and details. Teachers were eligibleto participate if they were grades 4, 5 or 6 certified schoolteachers in publicly funded elementary schools with at leastone year of experience teaching at an elementary school level,and were currently teaching in the 2015–2016 school year. Intotal, principals from 13 elementary schools (42% responserate) provided approval for their school to participate, with33 (of 40) teachers from 11 of these schools (83% responserate) providing written consent to participate in a survey andpotentially participate in the interview. The short survey in-strument consisted of questions relating to the teacher’s DPAimplementation approaches and basic demographic informa-tion and was used as a device to assist in selecting and de-scribing the interview sample. Based on survey responses,maximum variation sampling [30] was used to recruitteachers to be interviewed to ensure representation acrossteacher-reported implementation approaches, which contin-ued until data saturation was reached [31]. In total, twelve in-terviews were conducted with thirteen teachers (4 male, 9female), who were aged 30–60 years (M = 44.69, SD = 10.33)and varied in teaching experience from 5 to 34 years(M = 15.69, SD = 9.31). Of those teachers who wereinterviewed, one teacher taught grade 4, three teachers taughtgrade 4/5, two teachers taught grade 5, five teachers taughtgrade 5/6 and two teachers taught grade 6. Ten teachersreported implementing DPA by providing additionalopportunities to be active during instructional time (instruc-tional implementers), while three teachers were classified asnon-instructional implementers because they relied onstudents being active during non-instructional lunch andrecess breaks.Data collectionThe first investigator conducted twelve semi-structuredinterviews with 13 teachers between February and April2016, at a time and location convenient to each teacher(e.g., classroom, coffee shop). All interviews were con-ducted individually except for one interview, which in-cluded two grade 6 teachers from one school. The latterwas done because these teachers share a formal platooningschedule (i.e., complete curriculum together within twoclassrooms), thus reporting the same DPA implementationapproach. Each interview was between 31 and 64 min induration (M = 52.25, SD = 9.65) and consisted of a broadopen-ended question (i.e., “Are there any factors that affectif or how you implement DPA in your classroom duringclass time? If so, what?”) to elicit perceived barriers and fa-cilitators impacting the implementation of the DPA policyby teachers. Probing questions were used to clarify domain-specific content if the participant had mentioned factorsthat appeared to fit within a certain domain (see Interviewguide in Additional file 3 for more information). Thisapproach was used to minimize leading questions. Fieldnotes were taken by the interviewer during the interview toensure each relevant domain was discussed further. Verbalconsent was obtained from each participant to audio-record the interview and participants received a monetaryreimbursement ($20) for their participation.Data extraction and analysisDigital recordings were transcribed verbatim directly intoNVivo Version 11 [32] by the first author and two re-search assistants. Interview transcripts were checked foraccuracy by the interviewer; however, the transcripts werenot returned to participants for comment. We employed adeductive and inductive analytical approach in a two-stageprocess whereby extracted barriers and facilitators were 1)deductively coded using pre-existing domains (contentanalysis based on TDF), and 2) analyzed for emergentthemes within each domain. This analysis procedure waschosen because it provides a simple method for summar-izing findings in the context of focused evaluation ques-tions, while allowing exploration of unanticipated factorsassociated with implementation, and is commonly used inhealth research [33, 34] and TDF analyses [35–38].Weatherson et al. BMC Public Health  (2017) 17:835 Page 3 of 16Barrier and facilitator extractionBarrier and facilitator extraction was performed by the firstauthor, with double extraction occurring across 33% (n = 4)of the transcripts by RM to ensure the trustworthiness of thedata extraction and coding. Coders read through each inter-view transcript line-by-line, highlighting and coding the textto ‘Barrier’ or ‘Facilitator’ nodes (containers), operationalizedas any factor, characteristic, view or belief that eitherimpeded or enabled implementation of DPA by teachersduring the instructional school day, respectively. Barriers andfacilitators were extracted if the teacher being interviewedcommented that the factor affected their own personal im-plementation of DPA or if they thought it affected otherteachers’ implementation of DPA (i.e., shadowed data).Hypothetical barriers and facilitators, characterized as afactor that the teacher perceived (versus experienced/en-countered) to be a potential barrier or facilitator to them orother teachers, were not extracted (e.g., belief that specificresources or support would be helpful for implementationwithout past experience with these resources/support). If ateacher discussed the same barrier/facilitator at differenttimes within the interview, the factor was counted as separ-ate items. Therefore, the total frequency (count and percent)coded to each TDF domain represents the proportion ofinterview time spent discussing these factors within eachdomain. Discrepancies in extraction were discussed until aconsensus was reached. Agreed upon barriers and facilitatorswere transferred to an Excel spreadsheet for TDF coding.Barrier and facilitator codingTwo researchers independently coded barriers and facilitatorsfrom each interview over twelve rounds (each interview wasa new round), with the order of each round being selected atrandom. As we were attempting to understand barriers andfacilitators within the school context (and not test thereliability of the TDF), researchers coded in rounds and metto discuss discrepancies after each round. In the first round,identified barriers and facilitators were coded using the TDFdomain and definitions as a coding framework (seeAdditional file 4) [26]. Where coding varied, consensus wasachieved through discussion and the coding manual was re-fined for subsequent coding rounds to facilitate consistencyof TDF coding (see 3rd column in Additional file 4). In thecase of particularly challenging exerts, expertise was soughtfrom an expert coder who is knowledgeable and experiencedin application of the TDF. Coders also made notes andcomments on the overall meaning of each exert during eachcoding round and responses were compared across teacher-reported implementation approach type. The first coderidentified main themes from each domain and exemplaryquotations for each theme were selected, consistently cross-checking themes to original transcripts. Negative cases werehighlighted and used to refine themes that accounted for themajority of cases. To confirm that interpretations weresupported by the data, the themes were presented to the sec-ond coder and to an additional researcher who was not partof the data collection, extraction and coding for feedback.ReliabilityPercent agreement was used to show agreement on barrierand facilitator extraction. Percent agreements, Cohen’sKappa statistic [39] and prevalence-adjusted bias-adjustedKappa statistic (i.e., PABAK) [40] were used to show agree-ment between coders on categorizing the barriers and facil-itators by TDF domain, for new items coded at each roundas well as for the overall total. PABAK represents the Kappastatistic that adjusts for 1) shared bias in the coders use ofcategories, and 2) the high prevalence of negative agree-ment (i.e., when both coders agree on non-contributing do-mains) and was used to account for the high prevalence ofnot assigning more than one domain to each barrier. Inter-coder agreement values of 0.60–0.79 indicate “substantial”reliability and those above 0.80 are “outstanding” [41].ResultsReliabilityThe two independent coders extracted a total of 343barriers/facilitators from four randomly selected interviewsand percent agreement across all extraction rounds was86.3% (see Additional file 5). A total of 900 factors (417barriers, 483 facilitators) were extracted across the twelveinterviews. Upon coding, 68 (26 barriers, 42 facilitators) fac-tors were deemed ineligible (due to being hypothetical ornot affecting the targeted behaviour) and removed from thedata set (see Additional file 6), leaving a total of 832 items.All items were coded into at least one of the fourteen TDFdomains or an ‘Other’ category (for items that did notclearly fit into a pre-defined domain). Some items werecoded to multiple TDF domains, resulting in a total of 1422observations. Across all barrier and facilitator codingrounds, the average inter-coder agreement was outstanding(Percent agreement = 59.7%; Kappa = 0.73 ± 0.37;PABAK = 0.91 ± 0.13). Overall reliability improved follow-ing refinement of the coding manual (see Additional file 7)and consensus of final codes was reached through discus-sion, resulting in 1141 final barrier and facilitator codes.Implementation barriers and facilitatorsTable 1 presents the summary of TDF domains, themesand quotes organized hierarchically by percent frequencyfor all participants. Accordingly, the most commonly codedTDF domains accounting for 75% of the total barriers andfacilitators were Environmental context and resources (ECR;n = 250; 21.9%), Beliefs about consequences (n = 225; 19.7%),Social influences (n = 193; 16.9%), Knowledge (n = 100;8.8%), and Intentions (n = 88; 7.7%). Only two items wereclassified as Other (or uncodable), due to a lack of specificity.Additional file 8 outlines the frequency (total count andWeatherson et al. BMC Public Health  (2017) 17:835 Page 4 of 16Table1Summaryofthemesandsamplequotes/explanationsassignedtothetheoreticaldomainsandorganizedbyfrequencyTDFDomainFrequency(%total)ThemeSamplequotes/explanationsEnvironmentalcontextandresources21.9Lackoftimeduetocurriculardemandsandscheduleinterruptions(B)“Andhonestly,inmyworld,thedaysfly.Andjustaccomplishingthecurriculumisenoughinthosehoursthatwe’regivenwiththekids.That’swhatIfind.”(Non-implementer1)“Becauseofwhatyouhavetojamintoyourday.You’vegottodoreading,you’vegottodowriting,youhavetodo-especiallyatelementaryschool-youhavetodomath.Youhavemusic.Youhavescience,socials.Youhavelike,we’reteaching12differentsubjects,right.So,ummthere’sdayswhereya,it’shardtogetthatinthere.Ya,forsure.”(Implementer5)“Andtime,likerealistically,likeourteachingdayis-thereisalottogetthrough.Andthere’s-inelementaryschooltherearesomanyinterruptionsintheday.Soactuallylikefullinstructionaldays,sometimesyoujustfeel-likeyoualwaysfeellikeyouareracingagainsttime.Andthisterminparticular.Yougetlikepro-daysandassembliesandyou’reoutonworkshops,orwhatever.Soitjustbecomestoo-thattimeisalwaysyour–andtogiveuplike30min,that’salotoftime.Itdoesn’tseemlikeitbutinaday,likeit’salot.”(Implementer4)Resources(ideasorequipment)andadministrationortrainingworkshopsarehelpful/sufficient(F)versusnotage-appropriate/insufficient(B)Overall,teachersexplainedthattheresourcesmadeavailablewhenDPAwasfirstmandatedwerehelpfulbuthavesincegonemissingorbeenbroken.Someteachersdiscussedhowtheresourcesweresillyandnotage-appropriateforolderstudents.Teachers’autonomyisdecreased(B)versussupported(F)“Ithinkbeforeitbecameareportcardthing,Ithinkalotofuswerehavingsomesortofbreakwithinthedaybecauseweknowit’sneeded.Buttokindofhavewhereit’slikewellyouhavetodoit-tellingsomeoneyouhavetodosomething,changesit.Ithinkifyoudon’thavetodoit,sometimesyouaremorewillingtodoit.Liketoday,theconcertwasvoluntary.Wellweallshoweduptoit,right?We’renotstupid.Fiftyminutesofyouknow,takingthemoutofclassand,youknow?Theycanlistentomusicandgetsomemusicenlightenment.ButIthinkthe‘BigBrothermethod’doesn’tworkwell.”(Implementer8)“Like,Ifeelsupportedthattheygiveustheflexibilitytodoitatanypointintheday.”(Implementer1)Therearespaceconstraints(B)“Wehavespaceconstraints.Mykidsareverybigandso,youknowwhenthey’re…theyliketomoveandtheyliketomovebig!So,whenwedosomethingintheclassroomlikeaerobics,we’vegotdeskseverywhereandit’sreallydifficulttodoanythingwherethey’relyingdown.Sothat’sdefinitely…I’dsayevenmorethantime,it’sspace.”(Implementer10)“Butwedon’thavelikethecarpetareasliketheprimary’swouldhave-whereyouhaveroomthatyoucoulddoaerobictypestufforthatActionSchoolsstuff,or…becauseofthesizeofthechildren.It’ssquishy.”(Non-implementer3)Itdependsontheweather(B,F)“IdefinitelythinkthatweatherthoughisahugefactorintheamountthatpeoplegetbecauseInoticeintheSpringtimethereiswaymoreclassesoutsidedoingthingsandbeingactive.Becauseinthewintertime,whatdoyoudo?Likeit’smucky,it’ssnowy,it’scold.Sotogetdressed-especiallyifyouhaveprimarykids-andgoout,it’slike,it’sahugejob.”(Implementer4)Itisharderatanintermediatelevel(B)“WhentheDPAfirstcameout,Itried.Youknow,wehadthose,youknow,‘GetUpandMoveandDance.’AndIfoundit,honestly,IfounditeasierinprimarydoingitthenIhaveinintermediate.Becauseitseemedlikethethings,theprojectsthatwedidwereshorterprojectsandtheywereshorterchunksoftime.Andyoujusthadmorespaceintheclassroom.Andsowedidgetupanddo,youknow,impromptudancepartiesor,youknow,chairaerobics.Youknow,wedidthosekindsofthingsthattheybroughtintoteachushowtodo.ButwhenIgottointermediateandthedemandsbecamegreater,andtheydohavealongerattentionspan…soIdefinitelyinintermediatefeelthedemandsofthetimemoresothanIdidinprimary.Itwasmucheasierinprimarytodothis.”(Non-implementer2)“I’vejustfoundwiththeolderkidsthatsometimes-likethere’sdefinitelykidsintothegamesandstuffandthenthere’sotherkidsthattheyhatethat.Attheagethatthey’reat.”(Implementer3)Weatherson et al. BMC Public Health  (2017) 17:835 Page 5 of 16Table1Summaryofthemesandsamplequotes/explanationsassignedtothetheoreticaldomainsandorganizedbyfrequency(Continued)TDFDomainFrequency(%total)ThemeSamplequotes/explanationsBeliefsaboutconsequences19.7Takestimeoutofschedule(B)“IwasjustgoingtosayIcan’tthinkofanynegativeimpactotherthanthefactthatittakesawayfromteachingtime-Ifyouareincorporatingitoutsideofthelunchandtherecess.”(Implementer3)“Ithinksometeachersjustdon’tseetheimportanceofitorfeellikethey–it’sonemorethingtheyjustcan’taffordtoloseinstructionaltimeon.”(Implementer7)Requiresextraplanningandsetuptime(B)“Becausealreadyasateacheryouspendsomuchofyourowntimeduringyourlunchhour,yourpreporafterschoolpreparingforlikeyourcoresubjectareas.AndthensotopreplikeforDPA,just-it’salotasitis…”(Implementer4)NoimpactonPAlevels(B)versusincreasesPAlevelsofthosewhoneeditmost(F)“Ifyoulookatsomeofthesekidsthat’salltheydoatlunchandrecessisplay.Theycomeinexhaustedbecause,youknow…andtheonesthatdon’t,don’tdoitanyway.Likethat’stheirony.Likealotofthekidsthatdon’trunaroundatrecess,probablydon’t…they’renottheonesthatarerunningaroundatDPAeither,right?”(Implementer8)“YesIwouldsay[studentsaremoreactivewithDPAcomparedtowithout]–andwhenyouaskedthatquestion,likeIthinkofparticularstudents.UmbecauseIknowthatthoseoneswouldnotmove.LikeIwatchthemoutsidetooandtheyjustkindofhangaroundorsitoutthere.Likethey’renottheoneswhoplayeither.Soifwedon’tdoit,forthoseones,Iknowthey,theywon’tdoanythingelse.Whereasthenyouhavethosenaturallyathleticandenergeticoneswho,you’llgooutside,andyouknowthey’llstillbeplayingandrunningaroundandtheirheartratewillgetup.Soifwedon’tdoitforthem,theywillstillbefine.”(Implementer4)Studentboredom(B)“Andthat’sthethingtoo-theygetboredreallyquicklytoo.”(Implementer8)Heightensawarenessofphysicalactivityimportance(forstudentandteacher)(F)“Ithinkitsatleaststartedimportantconversationsthatneedtohappen.Ithasatleastletallofthosepeople-youknow,students,teachers,admin-knowthatthisissomethingcriticalthatneedstobeaddressedandaccountedfor.SoIthinkithasheightenedawareness.”(Implementer7)Studentenjoymentisactivitydependent(B,F)“Um,mykids…yeahImeanmykidsloveit.TheylovethatIwouldputthatinaschedule.Theylikedifferentactivities,althoughtheymoanandgroanatthedifferentonesbecausethey’renotinterested.Um,Ithinkkidsjustwanttorunaround.”(Implementer10)It’samentalbreak(forstudentandteacher)(F)“It’sgoodforthestudents,it’sgoodforme.Like,it’summeven-likeIeatmysnackthentoo.AndIactually-Iwanttosayearlierinmycareer,evenlastyear,likeIusedtogooutanddoalapwiththem,just‘causeIfoundforme,justthefreshair,thesunshine-ifit’ssunnythatday-andIwouldwalkitaswell.Iusedtorunit.Ummbutjusttogetmoving,ithelpsmeaswell.It’samentalbreakforthem,it’samentalbreakforme.”(Implementer3)Itimprovesstudents’attentionandfocuswhichimprovesthelearningenvironment(F)“Somepositiveimpactsforthestudentsandteacherswouldbewedoseemorefocusoutofthekidsaftertheyburnoffsomeenergy.Especiallythehigh-energystudents.Um,negativeeffects…Ithinktheonlynegativeeffectswewouldsay,itwouldbethatit…Idon’tknow.Idon’tthinktherewouldbeany.Somewouldcomplainaboutthatittakesuptime,right,outoftheirschedule,butIwouldarguethen,‘you’regettingthattimebackbecauseyou’regettingmorequalitytimefocustimeoutofthestudents.’”(Implementer1)“Ithinkit’sbeneficialforallteachersbecause-becauseoftheincreasedfocusand…andtheirgeneralhappiness,levelofhappinessthatjustgivesamorepositiveatmosphereintheclassroom.Andsothatpositiveatmosphere-ifyou’vegotapositiveatmosphere,kidswilllearnmore,youknow,thenifthey’restressedortiredorhungry.Ya.”(Implementer2)Weatherson et al. BMC Public Health  (2017) 17:835 Page 6 of 16Table1Summaryofthemesandsamplequotes/explanationsassignedtothetheoreticaldomainsandorganizedbyfrequency(Continued)TDFDomainFrequency(%total)ThemeSamplequotes/explanationsSocialinfluences16.9Theschoolsystemprioritizesacademics(B)versustheyprioritizeDPA(F)“Butthere’salreadysomanyotherinitiativesthatexistinschools.Umandlotsofthosefocusaroundacademics.Andittotallydependsonyourschooltooandwhatthefocusisatyourschool.UmmbecauseIknowsomeplacesthatisthefocusbecauseacademically,they’rewheretheyneedtobe.Butforus,someofthosecoreareasaremoreimportantatthispointbecausewehavekidswhocan’treadatgradelevels.Soforusthatbecomesourprimaryfocus.”(Implementer4)“SowhenIcametothiselementaryschoolthatwaskindofbuiltinwiththeirsystemandfromwhatIunderstandotherelementaryschoolsdoasimilarthing,becausethere’snomorningrecessscheduled.TheykindofbuildinanunofficialmorningrecesswhichistheDPAandsnack.Sothat’swhattheykindofdo.”(Implementer1)IimplementDPAjustlikeotherteachers(B,F)“AndI’mnotawareofanybodyintheschoolthat’sdoingitanyotherway.Sonotjustdowenothaveaschoolpolicy,I’mnotevensureifindividuals-howindividualsareapproachingitotherthanwhatI’mdoing.”(Non-implementer1)“Ya,theotherintermediateteachersIknow,likeIsaid,theyarerunningalap.Iknowthatsomeoftheprimaryteachers,theyjustgooutsideanddolikeplayontheplaygroundtime.Andthenthere’stheoneclasswhereIseetheteacherwalksaroundtheschoolwithherclass.SoIthinkthateverybody’stryingtogetinit,onewayoranother.”(Implementer4)Studentsdon’tparticipateandyoucan’tforcethemtomove(B)“Andalotoftimestheyactverysilly.Theyjustthinkit’sfunnyanditjustbecomessomethingwhereyou’relike,youknow,I’vesaidthisbefore,I’mguiltyofit,whereit’slike‘wellifyouguysaren’tgoingtodoit,ifyou’renot…thepurposeofDPAistobemovingthewholetime.Um,that…we’rejustgoingtopullitandwe’renotgoingtodoit.’”(Implementer10)“You’llseethemoutthereandyoucannotforcethem.That’sthechallengewithDPA.Icansaywearegoingtogooutanddothis.Butyoucannotforce,makethemrunorwhatever…IthinkthedilemmawithDPAisthatyeah,Ithinkit’sgreat,butyoucannotforcethechildrentophysically,todoit.Theydowhatevertheyfeellikeattheirlevel.”(Implementer8)Achampionteacherwhosharesresourcesishelpful(F)“Ifonepersoniswillingtotakeonthatorganizationalforceandreallybringpeopletogetherandcreatetheprogram,thenitwillhappen.”(Non-implementer1)“EverytimeIfindsomethinggood,Iwillsendittootherpeople.Like,‘ohhere’sthisreallycoolkidsyogathing,’or‘here’sthisreallycooldancething’andI’llsenditalongtoteachersIknow.Sometimesallofthem.Andallofthetimethefeedbackisreallygood.”(Implementer10)Studentscueteachersverballyandnon-verbally(F)“Sometimestheysay‘canwehaveabreak?’I’mlike‘OK,wecandothat.’”(Implementer8)“IguessI’mjustdrawingjudgmentuponmyexperienceandwhatIsee.Observation.Ummaremykidswigglingintheirseats,readytogo,losingfocusatthattimeoftheday?Ya,theyarereadyforabreak.Sowego,wedothatbreak.Weeatoursnack.Wecomebackinandbythetimeallthatissaidanddone,theyarerefocused,theyarereadytofocusforanotherhourand15minorwhateveritis.Ummandthat’swhy,yaIguessthat’swhyIdoit.”(Implementer3)“It’susuallybasedonthe,youknow,theyusuallycueme.Theyusually,youknow,fromtheirattention.ThatI’mlike‘Ok,weneedtodosomethingheretogetthemupandmovingandoxygen…’Liketheyjustneedtothat-youknow,aburstofoxygenintheirbrainstojustkindofwakethemup.YouknowwhatImean?Like,ya.So,it’sbasically–it’sthem.Itakemycuesfromthem.”(Implementer2)Weatherson et al. BMC Public Health  (2017) 17:835 Page 7 of 16Table1Summaryofthemesandsamplequotes/explanationsassignedtothetheoreticaldomainsandorganizedbyfrequency(Continued)TDFDomainFrequency(%total)ThemeSamplequotes/explanationsKnowledge8.8DPAisnotourexpertise(B)“Causewetendtoteachwhatweknow.AndPEanddailyphysicalactivitykindofsit-notwithallteachers,butonthebackburnerofwhatweknowreallywell.”(Implementer10)UnawareofDPApolicyrequirements(B)AlthoughallteachersknewabouttheDPApolicy,veryfewhadKnowledgeofthespecificrequirementsrelatingtoduration(i.e.,minutes),intensity(i.e.,MVPA),type(i.e.,aerobic,strength,flexibility),andtimeofday(i.e.,duringinstructionalandnon-instructional).“Ithinkteachersdon’tknowenoughaboutit–Idon’tknowenoughaboutit,andI’mprettysavvyinthatarea.ButIcouldn’t-Icouldn’ttellyouthatI’veactuallyviewedthatdocumentmyself.Andthat’swrong.”(Implementer7)Intentions7.7Teachers’prioritiesandinterestsdiffer(B,F)“Theinterestpartishardbecauseyou’reeitherinterestedoryou’renot.Andobviouslyeverybody’sinterestsvary.Soobviouslythat’saninterestofmine.Isitaninterestofotherteachers?No,theyareinterestedinotherstuff.Ummisthereawaytosupportthem?Absolutely,withstufflikethat.Ummevenjustonepersononstaffgoingtotheseworkshops,gettingeducated,gettingthatexperienceandcollectingtheresourcesandthencomingbackandpresentingthoseresourcestotherestofthestaff.Now,that’swhatIdid.Now,canIboosttheirinterestinitbydoingthosethings?No.CanIforcethemtouseit?No.It’suptothemafterthat.Soit’shard.”(Implementer3)DPAisdroppedforothersubjects(contingentintentions)(B)“It’sunfortunatethatwekindofalwayspushphysicalactivitytothe,youknow,ifwehavetimewe’lldoit.Butitistherealityofmostteachers.We’resoworriedaboutmakingsurethatourcontentcoursesarecovered,right?Sothat’sthebiggestthingisifwe’rebehindschedule-wiseinourclass,thenDPAistheonethatwe’realwayssaying,oh,wecouldmakeupanother15min,becausewealreadyhavethatscheduledin.Sowe’lltake15minandnotdoDPAtoday.”(Implementer1)Beliefsaboutcapabilities5.6DPAdeliverydependsonconfidenceandcomfort-level(B,F)“Ithinksomeofthemmightfeelthat,Imean,iftheydon’texercise,ortheydon’t,they’renotknowledgeableabouthealthyhabitsintheirownlife-‘causelotsofpeoplearen’tknowledgeable-thattheywouldn’twanttomodelitanywaysinschool.Sothosewouldprobablybetheteachers-Notthattheywouldn’tdoit,buttheywouldputonDVDsoryouknow,playgamesorsomethinglikethat.Um,Idon’tknowwhytheywouldn’tbeconfident.Ithinkthatwouldprobablybemybiggestthing.It’swhen…eveninothersubjects,ifI’mnotconfidentinteaching-Frenchisanotherone-um,thatsomebodymightnotbeconfidentin,thattheywouldn’tspendalotoftimeonFrench.”(Implementer10)“Like,ifyouaskthatquestionmaybeforsomeoneelsewhodidn’tfeelascomfortableteachingphysicalactivity,PE,theytendtonotdoasmuch.”(Implementer1)It’sdifficulttomotivatestudents(B)TeachersdiscussedthatitwasnottheprovisionofDPAopportunitiesthatwasnecessarilydifficult,butthemotivationofchildrenwhowerenotmotivatedtobeactive.“DoIwishIcouldfindsomewaytomotivatethosekidstodothat?Absolutely…it’shardasateachertomotivatethosekidsthatdon’tevenwanttoparticipate.”(Implementer3)It’seasytoimplement(F)“ButIjustdon’tthinkit’sverydifficulttoimplement.”(Implementer10)Weatherson et al. BMC Public Health  (2017) 17:835 Page 8 of 16Table1Summaryofthemesandsamplequotes/explanationsassignedtothetheoreticaldomainsandorganizedbyfrequency(Continued)TDFDomainFrequency(%total)ThemeSamplequotes/explanationsSkills4.3InitialDPA-specifictrainingwasgoodbutinsufficient/inappropriateovertime(B,F)“Whenthisallfirstcameintoplay,wedidActionSchools.Sothatwasourday.Wehadaspecialistcome.Wetriedoutabunchofthegames.Weopenedupthebins.Welookedatwhatkindofresourcestherewere.Andthenwedidsomekindofteambuilding,brainstorming,‘whatcouldthislooklikeinyourclassroom?’Itwasagreatday.Umthatwastheonlysupportthatweweregiven.”(Implementer7)Previoustrainingandexperienceishelpful(F)“IwouldsayIdo[havethenecessaryskills]becauseIdidmyentireundergradinHumanKinetics,inExerciseScience.AndobviouslywhenIwentthroughthatprogram,wediddoalot-Idon’twanttosayalot-butwediddosomePE-relatedcourses.So,didItakeasoccercourse,abasketball-Itookallthatstuffandobviouslylearntaboutthebenefitsofitall.ButIthinkjustwithmybackgroundinit,Iamprobablymorewellequippedasateacherummtojust-IcanseriouslyjusttakemykidsoutandwingagameandIjustknowhowtodoitbecauseI’vedoneitsomanytimes.”(Implementer3)Social/professionalroleandidentity3.3It’snotmyjob/responsibility(B)“Weare-Ifeltmyjobisaneducatorandweseemtobetakingonalotofsociety’sjobs.Family’sjobs.AndIthought,youknow,I’mkindofuptoherewiththeresponsibilityforeverylittlething.Thatwasmy-definitelymyfirstthought.”(Non-implementer1)“Imean,atfirstIwassortoflike,‘well,we’redoingparentaljobsnow?Likeisitnottheparentsjobtoensurethattheirchildis…’AndIstillthinkthat.Ithinkit’suptoaparenttomakesurethey’reprovidingtheirkidwithopportunitiesathome.UmmIdobelievethat.Andifthere’sadaythatwedon’tdoDPAandthekidscomplain,I’mlike‘wellrunhome.Whatdoyoudowhenyougohome?Playwithyourvideogame?’Youknow?SoIdon’treallyfeeltoobadifwedon’tgettoitorifit’sadaywhereit’sonly15min.UmmsoIdothinkthereisaresponsibilityinthehometoensurethatyourchildisgettingsomeexercise,forsure.Ya.”(Implementer5)It’smyprofessionalobligation(F)“Forme,aswithanythingelseonmyreportcard,likeIhavetoknowthatIcoveredit,thattheydiditandthatIevaluateditappropriately.Ihavetoknowthatasaneducatormyself.That’saprofessionalstandardthatIholdmyself.”(Implementer7)It’simportanttomebecauseI’mactive(F)“I’minterestedinmaintainingagoodphysicalhealthinmyownlife,itjustplaysintomyteachingbecauseofmyidentity.”(Implementer10)“Butlike,I’mpassionateaboutsports.I’vedonesportsmywholelifeandI’malwayscoaching.LikeI’mthecoachhere…andIprobablydoourDPAmoreconsistentlythanothers.”(Implementer1)Weatherson et al. BMC Public Health  (2017) 17:835 Page 9 of 16Table1Summaryofthemesandsamplequotes/explanationsassignedtothetheoreticaldomainsandorganizedbyfrequency(Continued)TDFDomainFrequency(%total)ThemeSamplequotes/explanationsReinforcement2.8Lackofmonitoring(B)NoteacherssaidthattheywereassessedonwhetherornottheyimplementDPA.Whiletheyarerequiredtoreportchildren’sfulfillmentofDPAonthereportcards(i.e.,‘meeting’,or‘notmeeting’),mostteachersbelievedthissystemhadnoeffectontheimplementationofthepolicy.“It’skindoflikehavingalaw,right?Ifyouhavealawinplaceonpaper,that’sallgood.Butifit’sneverenforcedfromyourlawofficials,right?Thennoone’severgoingtotake…they’renotgoingtoputanystockintoit.Sothat’showIfeelrightnow.It’snotreally…‘enforce’isabadwayofputtingit,but,yeah.It’snevermonitoredIguess.”(Implementer1)Optimism2.8Optimismdependsonstudent’smotivationtobeactive(B,F)TeachershadmixedfeelingsaboutthesuccessoftheDPApolicy,linkingtheiroptimismtostudent’smotivationtobeactive.“You’regoingtohavesomeoneinthatgroupthatdoesnotwanttodothat.Thatdoesn’tlikeit.Andso,youcan’tforcethem,youknow?Ourhandsaretied.SothewholeDPAisanawesomeidea,butit’snotpracticalifthekiddoesn’twanttodoit.They’renotgoingtodoit.Soyoujusttrytodoitasmuchasyoucanandgetthemtoparticipateasmuchasthey’rewillingto.”(Implementer8)“…thekidsthataregoingtobeactive,aregoingtobeactive.Andthekidsthataren’t,aren’t.”(Non-implementer3)Emotion2.4It’sfrustrating(B)“Idon’tthinkitsjustfrustrationaroundDPA,butit’sfrustrationaroundfindingthetimetoaccomplishalltheexpectations.Andit’snothorriblebecauseImean,IabsolutelylovemyjobandIwouldn’twanttodoanythingelse.…SoIdon’tthinkit’sjustDPA,Ithinkit’sjusttherigorsofitall.”(Non-implementer2)I’mworriedthatstudentswillgethurt(B)“ButImeanbecauseI’mnottrainedinthatkindofstuff,itdoesworrymesometimesthatI’mdoingtheactivitiesthatarebytrainedpeopleandthen,youknowI’masmartperson,soIknowaboutinjuryandIknowaboutwarmingupandthatkindofstuffbutI’mnotanexpert.Sowhatwouldhappenifakidpulledamusclereallybadlyorsomethingandtheirparents…theirparentsprobablycouldgetangryandIcouldgetinsomesortoftrouble.Sothat’saworryofmine.Iguessit’sa,itwouldbearestriction.”(Implementer10)It’sajoke(B)“WhenyoubroughtitupofcourseIwassmilingorifnotasmirk,causeit’sjoke-like.Howdoyoufititinadayalreadythat’soverscheduled.”(Implementer6)Ienjoyittoo(F)“Andit’sfunny–you’dthinkthatit’sforthekidsbutIuseitalotformyselftoo.IfIcangetastretchinthere,I’mfeelingbetterfortherestoftheday.”(Implementer6)“AndIlovedoingit.Ilookforwardtothatmovementbreak.”(Implementer7)Goals1.9PlanningforandschedulingDPAintothetimetable(F)“Ithinkitdefinitelyhastodowithhavingasetschedulethat’sworkingnow,andthisisnowthethirdyearofkindofthistypeofschedulethatI’vebeenusing.SolikeIsaid,firstyearwasmyfirstyearinelementaryschoolhereandthensecondyearwaskindof,IdidasimilarscheduleandthenIchangedeverythingaroundandactuallybuiltinDPAintheseblocks.SoIthinkthat’sthemajordrivebehindit.”(Implementer1)Weatherson et al. BMC Public Health  (2017) 17:835 Page 10 of 16Table1Summaryofthemesandsamplequotes/explanationsassignedtothetheoreticaldomainsandorganizedbyfrequency(Continued)TDFDomainFrequency(%total)ThemeSamplequotes/explanationsMemory,attentionanddecisionprocesses0.01ForgettingaboutDPA(B)Overall,almostallteachersdiscussednotrememberingorforgettingtoimplementDPAduringtheschoolday.Idon’tthinkaboutit,it’saroutine(F)“Ithinkinitiallywhenwefirststartedit,IwasveryconscientiousaboutthatbutnowIthinkIdon’treallythinkaboutit,wejustkinda,incorporateit.”(Implementer5)“Iwanttosayit’sjustroutine.LikeIwriteoutadayplaneverysingleday.AndeverysingledayIjustwriteitinthere.Andactually,IplantheblocksIhavebeforeandIplantheblocksafterforthatummit’s–andIknowit’snotaspecifictimeinhere.But-andinmymindI’malwayslikeit’s15min.Butit’snot.Itturnsinto20–25minprettymucheveryday.ButIplanaccordingly.Andit’saroutine,it’ssomethingwedoeveryday.”(Implementer3)Behaviouralregulation0.007Writingitdown(ontimetable,board)helpsusremember(F)TeacherswhoimplementedDPAregularlydiscussedtheimportanceofwritingitontheirtimetableortheboardinordertoremindthemselvestoconductDPA.“Idothat[scheduleitin]becausethat’sjust-well,thatshowsmythinkingandit’smyplan.Andthenugh,itremindsmetodoit,orthatkindofthing.Umm,andthenIalsoputitontheboard,right?Becauseeverydaytheagendasup.”(Implementer5)B,barrier;F,facilitatorAllquotesareinparenthesesandclarifyingtextisnotNote:Inthistable,implementerreferstoinstructionalimplementerandnon-implementerreferstonon-instructionalimplementerWeatherson et al. BMC Public Health  (2017) 17:835 Page 11 of 16percent) of barriers/facilitators that were identified acrosseach TDF domain by implementation approach group.Across all participants, more facilitators than barriers werediscussed in relation to Knowledge, Behavioural regulation,Beliefs about consequences, Goals, and Social influencesdomains. Barriers and facilitators were equally discussed inBeliefs about capabilities, Optimism, and Intentionsdomains. Non-instructional implementers discussed rarelyor not at all factors related to Memory, attention and deci-sion processes, Behavioural regulation, and Goals. These dif-ferences are explored more descriptively in the next section.Comparison of barriers and facilitators by teacherimplementation approachTeachers, irrespective of implementation approach (i.e.,whether or not they provided DPA during the instructionalschool day) experienced similar barriers and facilitatorswith regards to Skills (e.g., DPA-specific training, previoustraining/experience), Knowledge (e.g., lack of knowledgeabout DPA requirements), Environmental context and re-sources (e.g., poor, inappropriate or lack of DPA-specifictraining; lack of time due to curricular demands and sched-ule interruptions; weather and space constraints),Reinforcement (e.g., lack of monitoring), Social influences(e.g., school-level priorities, support from other teachers,student participation), and Optimism (e.g., mixed feelingsabout success of policy).Where teachers who implemented DPA during instruc-tional time differed from those who relied on non-instructional time was in their Goals and Behaviouralregulation (e.g., planning for and scheduling DPA in time-table; providing schedule to students), Social/professionalrole and identity (e.g., strong personal physical activityidentity and belief in responsibility to get children activeat school), experience of the Consequences (e.g., linkingphysical activity to improvements in attention and focusfor a better classroom learning environment) and Socialinfluences (e.g., recognizing and responding to children’sverbal and non-verbal cues to move throughout the day).DiscussionSimilar to the review examining the barriers and facilita-tors to DPA policy implementation in Canada [42], thisstudy highlights teachers’ implementation of the DPApolicy may be impacted by factors relating to ECR, Beliefsabout consequences, and Social influences, as well asKnowledge and Intentions. The identified themes in thisstudy have been reported in other DPA studies [17–21,43–47], as well as studies examining the implementationof other school-based PA initiatives [48–52]. For example,similar themes in the ECR domain include lack of time inthe schedule due to competing curricular demands [17–19, 21, 43–46, 50–52], access to resources (space, facilities,equipment and ideas) [17–19, 21, 43–50], and inclementweather [43–46]. Related Beliefs about consequencesthemes include an increase in teacher workload, burdenand stress [18, 44, 46], improved student focus, attentionand/or academic performance [17, 18, 44, 46, 49, 51], im-proved classroom learning environment [17–19, 46], andoverall student enjoyment and interest in physical activity[17, 44, 46]. Similar themes within the Social influencesdomain include level of support from staff, administrationand other school champions [18, 20, 21, 44, 48, 49], andstudent participation/preferences [18, 20, 21, 45, 48]. Dueto these similarities, it is possible that intervention designsbased on this study may be effective within other schoolcontexts (e.g., different provinces/countries).Addressing barriers to implementation is important be-cause these factors affect implementation fidelity, which inturn has implications on the policy meeting its desiredoutcomes. Very little research has examined the impact ofthese policies on children’s physical activity levels at school[16, 42]. Considering the different approaches to implemen-tation by teachers in this study, it is possible the differentapproaches result in different outcomes. This studycompares similarities and differences in perceived barriersand facilitators to DPA implementation by teacher-reportedimplementation approach, suggesting that a targetedintervention approach is necessary for different contexts.Future studies should examine effectiveness of these ap-proaches on physical activity levels of children at schoolthrough objective measurement. This study’s findings can beused to provide context for and interpret why different DPApolicy implementation approaches succeed or fail to meetintended outcomes at the student level [53].While there are added challenges to the provision of DPAopportunities during instructional time (as opposed to rely-ing on non-instructional time for children to be active), theinstructional implementers were able to overcome thesechallenges. Common challenges reported by both instruc-tional and non-instructional implementers included issuesrelating to ECR (e.g., lack of time, resources and space) andSocial influences (e.g., lack of school-level priority). It may bethat teachers who implement DPA during instructional timeare better able to overcome these underlying organizationalbarriers to DPA delivery. Accordingly, instructional teachersdiffered from non-instructional teachers on a number of be-havioural domains, particularly those in which they couldexert a degree of individual control, such as planning, sched-uling and having strong personal beliefs in the importance ofphysical activity. For example, instructional implementersdiscussed facilitators with regards to Goals and Behaviouralregulation (e.g., planning for and scheduling DPA in thetimetable), and in their Social/professional role and identity(e.g., strong personal PA identity and belief in their responsi-bility to get children active at school). Non-instructionalteachers did not plan for (i.e., set goals) or schedule DPA intotheir timetables (i.e., regulate their provision of DPA), bothWeatherson et al. BMC Public Health  (2017) 17:835 Page 12 of 16of which helped to facilitate instructional implementersprovision of DPA opportunities during the instructionalschool day. Therefore, while it may seem that targeting bar-riers to DPA implementation may provide an effective meansto improve implementation, an important distinction may bethe factors that assist the instructional teachers in providingmore DPA opportunities during instructional time. Re-searchers may want to consider these variations for interven-tion design and delivery in specific contexts.ImplicationsThe current study builds on previous research examiningthe factors influencing the implementation of DPA inCanada through the inclusion of an evidence-based deter-minant framework by which to provide a theory-basedanalysis of the implementation barriers and facilitators.Embedding these factors within the TDF domains enablesresearchers to develop interventions aimed at targetingthe constructs shown to have the most salient influenceon behaviour. This behavioural diagnosis is also relevantto policy makers who wish to better support teachers intheir implementation efforts. In this study, teachers mostoften discussed factors within the ECR, Beliefs about con-sequences, Social influences, Knowledge and Intentions do-mains. When organized heuristically, these domains arerepresentative of all sources of behaviour in the COM-Bmodel, namely capability (Knowledge), opportunity (ECR,Social influences) and motivation (Beliefs about conse-quences, Intentions) components, and have important im-plications for theory selection in intervention design.These findings suggest that all components are interactingto influence teachers’ DPA implementation behaviours,and therefore selecting a theory that broadly encompassesall determinants of behaviour may be more successful atpromoting behavior change. Alternatively, reflective mo-tivation theories may not be the most effective option forintervention design because they fail to consider thebroader physical and social-environmental influences onbehaviour. Findings from other DPA studies in Canadahave found that both individual- and organizational-levelfactors influence DPA implementation. In Ontario, for ex-ample, Allison and colleagues [43] found that policyawareness, teacher self-efficacy, scheduling and monitor-ing are significant predictors of implementation fidelity.Efforts to improve implementation must target these indi-vidual- and system-level factors.To create interventions, the relevant theoretical do-mains can be mapped onto intervention functions (e.g.,via the Behaviour Change Wheel framework [BCW]) [26]and behaviour change techniques [23]. For example, pos-sible intervention functions to target ECR include Train-ing, Restriction, Environmental restructuring andEnablement. To minimize teachers’ perception of a lack oftime (due to curricular demands), an intervention couldbe designed to train teachers how to incorporate physicalactivity into other lessons. Likewise, consideration of com-peting behaviours, namely other school curriculum sub-jects, may be another means by which to minimize theburden of a lack of time. As another example, the educa-tion intervention function could be used to target theteachers’ lack of knowledge of DPA policy guidelines, andcould be delivered by improving policy guideline dissem-ination and providing clear recommendations to teacherson how to achieve these guidelines.After using the TDF to understand the behaviour, inter-vention designers can select the behaviour change tech-niques (BCTs), or active intervention components, aimedat targeting the relevant domains. For instance, BCTs thathave been mapped to the ECR domain include: restructur-ing the physical or social environment, discriminative(learned) cue, prompts/cues, or avoidance/changing ex-posure to cues for the behaviour [54]. To address the lackof time example provided above, schools could restructurethe environment by creating policies whereby teachersmust schedule opportunities for their students to be activeinto their timetables. However, adoption of individualschool policy would first require considerable changes toovercome factors working at the social- and structural-level. Ultimately, final decisions about intervention func-tions, BCTs and modes of delivery can only be selected ac-cording to what can be feasibly and acceptably deliveredwithin the specific school context [23].Strengths and limitationsThe main strength of this study was the use of the Theoret-ical Domains Framework to categorize and comprehendimplementation barriers and facilitators. However, the TDFis not a theory, and therefore it cannot provide an explan-ation as to how these domains are connected and influenceone another [53], limiting our understanding of how thesefactors interact in complex contexts. While the TDFshowed good utility for categorizing barriers and facilitatorswithin this context, it was difficult to differentiate betweensome domains (e.g., Beliefs about consequences and Opti-mism), noted too by other researchers [35, 37]. Addition-ally, using the TDF framework to guide the interviewschedule and deductively code barriers and facilitatorsmeans that the researchers approached the data with an in-formed, yet potentially strong bias. However, the interviewprotocol was designed to minimize leading questions andextracting barriers and facilitators prior to coding into spe-cific domains was done to minimize bias of identification ofrelevant text and increase trustworthiness. Although theinterviewer asked participants to provide examples of bar-riers/facilitators that they had experienced versus perceivedto impact DPA implementation, and efforts were made tominimize hypothetical barrier/facilitator extraction, it ispossible that this distinction was not clearly discernable forWeatherson et al. BMC Public Health  (2017) 17:835 Page 13 of 16participants. According to Sparkes and Smith [55], a gen-eral weakness of content analyses is that they suggest thatthe more themes or categories that are counted reflect themeaningfulness or significance of that category. In thisstudy, the total count (n) coded to each TDF domain in-cluded repeated barriers/facilitators and each count reflectthe proportion of time that the teachers dedicated to dis-cuss the respective factor. Therefore, frequency of barriers/facilitators coded to domains should not be a proxy for im-portance or significance. Some domains or themes that oc-curred only a few times may be highly meaningful to ateachers’ implementation of DPA and thus be areas ofpotential interest (and future research) for those creatinginterventions to target these factors in the future. Finally,this study aimed to include teachers with diverse DPAimplementation approaches. Unfortunately, it was difficultto identify and recruit teachers who did not provide DPAopportunities during instructional time, most likely due tosocial desirability bias.ConclusionGiven that the effectiveness of school-based physical activitypolicies depends on their implementation, it is important tounderstand the challenges that teachers face in providingphysical activity opportunities at school and to identify thelevers that increase implementation. This study theoreticallyidentified the barriers and facilitators impacting the imple-mentation of the DPA policy in British Columbia and thisinformation can be used to explain how the context influ-ences the success or failure of the policy. The advantage ofusing a theoretical framework to understand the barriers isthat it can assist researchers in the systematic developmentof future interventions to target the factors shown to impedeimplementation.Endnotes1Over the course of the planning for and data collectionof this study, the BC Ministry of Education revised theDPA policy statement multiple times. As such, there is nolonger any division between PE and non-PE days. TheDPA requirements of 30 min of physical activity are nowrequired irrespective of school days with or without PE.Additional filesAdditional file 1: TDF domain definitions. TDF with domain definitions(DOCX 117 kb)Additional file 2: Consolidated criteria for reporting qualitative research(COREQ). 32-item reporting checklist for qualitative research (DOCX 20 kb)Additional file 3: Interview guide. Interview guide organized by TDFdomain (DOCX 120 kb)Additional file 4: TDF coding manual. TDF domain definitions andcoding notes used to code barriers and facilitators (DOCX 100 kb)Additional file 5: Double extraction agreement. Inter-coder percent agree-ment across four barrier and facilitator extraction rounds (DOCX 40 kb)Additional file 6: Ineligible extracted barriers and facilitators. Totalcounts of extracted barriers and facilitators that were ineligible oruncodable (DOCX 49 kb)Additional file 7: Inter-coder agreement statistics. Inter-coder agreementstatistics including percent agreement, Kappa and PABAK and the numberof observations used during each coding round (DOCX 72 kb)Additional file 8: Barriers and facilitators by TDF domain andimplementation approach. Frequency counts of barriers and facilitatorscoded to each TDF domain by teacher implementation approach(DOCX 77 kb)AbbreviationsDPA: Daily Physical Activity policy; ECR: Environmental context and resources(TDF domain); PABAK: Prevalence adjusted bias adjusted Kappa statistic;TDF: Theoretical Domains FrameworkAcknowledgementsWe would like to thank the school district and participants for their time andresponses provided in the interviews.FundingKW received funding from the Canadian Institutes of Health Research - CanadaGraduate Scholarship to conduct this research and the project was funded by aMichael Smith Foundation for Health Research grant (#5917) to MJ.Availability of data and materialsThe datasets generated and/or analysed during the current study are notpublicly available in order to maintain participant privacy.Authors’ contributionsKW conceptualized the study, and MJ/HG provided intellectual input into themethodological design. KW conducted the interviews, transcribed andanalyzed the interview data and drafted the manuscript. RM provideddouble extraction and coding of implementation barriers and facilitators. Allauthors reviewed and approved the final manuscript.Ethics approval and consent to participateThis research was performed in accordance with the Declaration of Helsinkiand ethical approval was obtained from the Canadian University’sBehavioural Research Ethics Board for research involving humans, and therespective school district. All participants provided written informed consent.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.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, The 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, The 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.Weatherson et al. BMC Public Health  (2017) 17:835 Page 14 of 16Received: 15 March 2017 Accepted: 13 October 2017References1. 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Cane J, Richardson M, Johnston M, Ladha R, Michie S. From lists ofbehaviour change techniques (BCTs) to structured hierarchies: comparisonof two methods of developing a hierarchy of BCTs. Br J Health Psychol.2015;20:130–150.55. Sparkes AC, Smith B. Qualitative research methods in sport, exercise &health: from process to product. New York, NY: Routledge; 2014.•  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. BMC Public Health  (2017) 17:835 Page 16 of 16


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