{"http:\/\/dx.doi.org\/10.14288\/1.0398175":{"http:\/\/vivoweb.org\/ontology\/core#departmentOrSchool":[{"value":"Medicine, Faculty of","type":"literal","lang":"en"},{"value":"Other UBC","type":"literal","lang":"en"},{"value":"Non UBC","type":"literal","lang":"en"},{"value":"Family Practice, Department of","type":"literal","lang":"en"},{"value":"Orthopaedic Surgery, Department of","type":"literal","lang":"en"}],"http:\/\/www.europeana.eu\/schemas\/edm\/dataProvider":[{"value":"DSpace","type":"literal","lang":"en"}],"https:\/\/open.library.ubc.ca\/terms#identifierCitation":[{"value":"International Journal of Environmental Research and Public Health 18 (10): 5182 (2021)","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/contributor":[{"value":"Vancouver Coastal Health Authority. Research Institute","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/creator":[{"value":"Nettlefold, Lindsay","type":"literal","lang":"en"},{"value":"Naylor, Patti-Jean","type":"literal","lang":"en"},{"value":"Macdonald, Heather M.","type":"literal","lang":"en"},{"value":"McKay, Heather Anne, 1954-","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/issued":[{"value":"2021-05-26T23:27:32Z","type":"literal","lang":"en"},{"value":"2021-05-13","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/description":[{"value":"Action Schools! BC (AS! BC) was scaled-up from an efficacy trial to province-wide delivery across 11 years (2004\u20132015). In this study we: (1) describe strategies that supported implementation and scale-up; (2) evaluate implementation (teachers\u2019 physical activity (PA) delivery) and student\u2019s PA and cardiorespiratory fitness (CRF) within a cluster randomized controlled trial during years 2 and 3 of scale-up; and (3) assess relationships between teacher-level implementation and student-level outcomes. We classified implementation strategies as process, capacity-building or scale-up strategies. Elementary schools (n = 30) were randomized to intervention (INT; 16 schools; 747 students) or usual practice (UP; 14 schools; 782 students). We measured teachers\u2019 PA delivery (n = 179) using weekly logs; students\u2019 PA by questionnaire (n = 30 schools) and accelerometry (n = 9 schools); and students\u2019 CRF by 20-m shuttle run (n = 25 schools). INT teachers delivered more PA than UP teachers in year 1 (+33.8 min\/week, 95% CI 12.7, 54.9) but not year 2 (+18.8 min\/week, 95% CI \u22120.8, 38.3). Unadjusted change in CRF was 36% and 27% higher in INT girls and boys, respectively, compared with their UP peers (year 1; effect size 0.28\u20130.48). Total PA delivered was associated with change in children\u2019s self-reported MVPA (year 1; r = 0.17, p = 0.02). Despite the \u2018voltage drop\u2019, scaling-up school-based PA models is feasible and may enhance children\u2019s health. Stakeholders must conceive of new ways to effectively sustain scaled-up health promoting interventions if we are to improve the health of students at a population level. Clinical Trials registration: NCT01412203.","type":"literal","lang":"en"}],"http:\/\/www.europeana.eu\/schemas\/edm\/aggregatedCHO":[{"value":"https:\/\/circle.library.ubc.ca\/rest\/handle\/2429\/78464?expand=metadata","type":"literal","lang":"en"}],"http:\/\/www.w3.org\/2009\/08\/skos-reference\/skos.html#note":[{"value":"International  Journal  ofEnvironmental Researchand Public HealthArticleScaling up Action Schools! BC: How Does Voltage Drop atScale Affect Student Level Outcomes? A Cluster RandomizedControlled TrialLindsay Nettlefold 1 , Patti-Jean Naylor 2 , Heather M. Macdonald 1,3 and Heather A. McKay 1,3,4,*\u0001\u0002\u0003\u0001\u0004\u0005\u0006\u0007\b\u0001\u0001\u0002\u0003\u0004\u0005\u0006\u0007Citation: Nettlefold, L.; Naylor, P.-J.;Macdonald, H.M.; McKay, H.A.Scaling up Action Schools! BC: HowDoes Voltage Drop at Scale AffectStudent Level Outcomes? A ClusterRandomized Controlled Trial. Int. J.Environ. Res. Public Health 2021, 18,5182. https:\/\/doi.org\/10.3390\/ijerph18105182Academic Editors: Sze Lin(Serene) Yoong, Nicole Nathan andRebecca GolleyReceived: 26 March 2021Accepted: 29 April 2021Published: 13 May 2021Publisher\u2019s Note: MDPI stays neutralwith regard to jurisdictional claims inpublished maps and institutional affil-iations.Copyright: \u00a9 2021 by the authors.Licensee MDPI, Basel, Switzerland.This article is an open access articledistributed under the terms andconditions of the Creative CommonsAttribution (CC BY) license (https:\/\/creativecommons.org\/licenses\/by\/4.0\/).1 Active Aging Research Team, Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute,Vancouver, BC V5Z 1M9, Canada; lindsay.nettlefold@ubc.ca (L.N.); heather.macdonald@ubc.ca (H.M.M.)2 School of Exercise Science, Physical and Health Education, University of Victoria,Victoria, BC V8P 5C2, Canada; pjnaylor@uvic.ca3 Department of Family Practice, University of British Columbia, Vancouver, BC V6T 1Z3, Canada4 Department of Orthopaedics, University of British Columbia, Vancouver, BC V5Z 1M9, Canada* Correspondence: heather.mckay@ubc.ca; Tel.: +1-604-675-2585Abstract: Action Schools! BC (AS! BC) was scaled-up from an efficacy trial to province-wide deliveryacross 11 years (2004\u20132015). In this study we: (1) describe strategies that supported implementationand scale-up; (2) evaluate implementation (teachers\u2019 physical activity (PA) delivery) and student\u2019s PAand cardiorespiratory fitness (CRF) within a cluster randomized controlled trial during years 2 and3 of scale-up; and (3) assess relationships between teacher-level implementation and student-leveloutcomes. We classified implementation strategies as process, capacity-building or scale-up strategies.Elementary schools (n = 30) were randomized to intervention (INT; 16 schools; 747 students) orusual practice (UP; 14 schools; 782 students). We measured teachers\u2019 PA delivery (n = 179) usingweekly logs; students\u2019 PA by questionnaire (n = 30 schools) and accelerometry (n = 9 schools); andstudents\u2019 CRF by 20-m shuttle run (n = 25 schools). INT teachers delivered more PA than UP teachersin year 1 (+33.8 min\/week, 95% CI 12.7, 54.9) but not year 2 (+18.8 min\/week, 95% CI \u22120.8, 38.3).Unadjusted change in CRF was 36% and 27% higher in INT girls and boys, respectively, comparedwith their UP peers (year 1; effect size 0.28\u20130.48). Total PA delivered was associated with changein children\u2019s self-reported MVPA (year 1; r = 0.17, p = 0.02). Despite the \u2018voltage drop\u2019, scaling-upschool-based PA models is feasible and may enhance children\u2019s health. Stakeholders must conceiveof new ways to effectively sustain scaled-up health promoting interventions if we are to improve thehealth of students at a population level. Clinical Trials registration: NCT01412203.Keywords: scale-up; implementation strategies; effectiveness; children; school; intervention; physicalactivity; fitness1. IntroductionPhysical activity (PA) [1] and cardiorespiratory fitness (CRF) [2] are powerful, inde-pendent [3] indicators of child and youth health. Yet, relatively few children and youthengage in recommended amounts of PA [4]; national and international data show seculardeclines in both PA [5,6] and CRF [6\u20138]. PA and CRF track across childhood [9], intoadolescence [10] and early adulthood [11,12]. High CRF in adolescence is associated withreduced risk of cardiovascular events, cancer and premature mortality in adulthood [13\u201315].Therefore, effective strategies that reach large numbers of young children are urgentlyneeded to promote PA and CRF, and to maintain behaviors across the life course.Schools are a focal setting for health promotion [16]; \u2018whole-of-school\u2019 models areone of eight best investments to enhance PA [17]. Children spend nearly half their wakinghours at school, and schools reach diverse populations of children across sociodemo-graphic and socioeconomic backgrounds [18]. However, most interventions do not extendbeyond short-term (e.g., one month to one school year in length) well-controlled efficacyInt. J. Environ. Res. Public Health 2021, 18, 5182. https:\/\/doi.org\/10.3390\/ijerph18105182 https:\/\/www.mdpi.com\/journal\/ijerphInt. J. Environ. Res. Public Health 2021, 18, 5182 1 of 23studies with relatively small cohorts [19\u201321]. Further, a recent meta-analysis found littleevidence that school-based interventions effectively enhanced daily moderate-to-vigorousPA (MVPA) [22]. Although findings could relate to implementation, relatively few studiesevaluate this link [20]. Implementation frameworks, designed to guide effective deliveryof health promoting interventions, were seldom used [20,21].\u201cDeveloping effective interventions is only the first step toward improving the healthand well-being of populations\u201d [23]. Effective interventions must be moved out of theresearch setting, delivered broadly, and sustained within supportive systems to effectchange at a population level [19]. Few school-based PA interventions have been scaled-up [19,24]; school-based interventions implemented at scale over longer time periods (e.g.,>2 years) are even more scarce [25]. We define scale-up as \u201cthe process by which healthinterventions shown to be efficacious on a small scale and or under controlled conditionsare expanded under real world conditions into broader policy or practice\u201d [26].In 2003, we developed, implemented and evaluated Action Schools! BC (AS! BC) [27]in a randomized controlled efficacy trial involving 10 elementary schools in British Columbia(BC), Canada. We showed that AS! BC was feasible for teachers to deliver, and effectivelyenhanced delivery of classroom-based PA [28]. AS! BC improved children\u2019s PA [29],CRF [30] and bone health [31]\u2014likely mediated by increased PA delivery by teachers [28].Importantly, academic performance was not compromised despite children in interventionschools spending more time engaged in PA [32]. More than 90% of teachers were satisfiedwith AS! BC training workshops, classroom resources and the Support Team. Importantly,70% of teachers were confident in their ability to deliver AS! BC activities in their class-room following the training workshop [28]. Based on these promising outcomes the BCgovernment supported phased, province-wide scale-up beginning in 2004; AS! BC wassustained\u2014defined here as sustained delivery and stakeholder support\u2014through 2015.Here we describe AS! BC scale-up across 11 years, and provide results from the two-year randomized controlled effectiveness trial we conducted beginning in the second yearof scale-up. We aimed to assess whether the AS! BC model could be delivered at broad scaleto schools in a more diverse range of communities and geographies, while maintaining thestudent-level health benefits we observed in our previous trial [29,30]. While we previouslydescribed the \u2018comprehensive pathway\u2019 [33] by which we scaled up AS! BC [34], herewe heed the call to more clearly describe implementation strategies [35] we adopted toscale-up AS! BC and support implementation at scale for 11 years.Our objectives are three-fold: (1) to describe strategies that supported implementationof AS! BC across 11 years of scale-up (2004\u20132015); (2) to evaluate implementation (teachers\u2019PA delivery) and impact (children\u2019s PA and CRF) within our cluster randomized controlledtrial during years two and three of province-wide scale-up; and (3) to assess relationshipsbetween teacher-level implementation and student-level outcomes.2. Action Schools! BCWe developed AS! BC in partnership with BC Ministries of Health and Educationand describe the model in detail elsewhere [27,34]. Briefly, AS! BC was a flexible, wholeof school model that provided elementary schools and generalist teachers with tools andsupport to create customized action plans. Action plans enabled schools and teachersto provide more opportunities for more children to make healthy choices more often.Overall, AS! BC aimed to increase children\u2019s PA (to 150 min\/week) across six ActionZones (School Environment, Scheduled Physical Education (PE), Classroom Action, Familyand Community, Extra-curricular, School Spirit). The model was not curriculum based;instead, teachers and schools chose Action Zone(s) they wished to target to enhance PAopportunities for students. \u2018Classroom Action\u2019 was the only prescriptive component ofAS! BC; teachers were asked to provide an additional 15 min\/day of PA during class time(75 min\/week) in addition to the weekly schedule of physical education. We describe keycomponents of AS! BC in Table 1.Int. J. Environ. Res. Public Health 2021, 18, 5182 2 of 23Table 1. Key components of the Action Schools! BC (AS! BC) model. Reprinted from Journal of Science and Medicinein Sport 9(5), Naylor et al [28], Lessons learned from Action Schools! BC\u2014An \u2018active school\u2019 model to promote physicalactivity in elementary schools, p413-423 (2006), with permission from Elsevier.Component DescriptionAction ZonesSix areas in which opportunities for physical activity could be provided tostudents. The six Zones were: (1) School Environment, (2) School Spirit,(3) Physical Education, (4) Extra-curricular, (5) Family and Community and(6) Classroom Action.AS! BC Support TeamA central technical support unit that developed and provided AS! BC resources(training workshops, written materials, Classroom Action Bins, school newsletterinserts for families) and ongoing consultation (on-site and telephone) toadministrators, teachers and the School Action Team.AS! BC School FacilitatorsTwo elementary school teachers seconded by the AS! BC Support Team toprovide training, support and advice to the schools and liaise between theSupport Team and the School Action Team.School Action TeamA committee of school stakeholders (e.g., interested intermediate grade teachers,administrators, parents, health, sport\/recreation practitioners) that created andsupported implementation of the Action Plan.Planning Guide for Schools and Teachers A set of inventories and worksheets that guided teachers and the School ActionTeam to identify school priorities and create their Action Plan.Action Pages! A resource directory using curriculum organizers to link teachers, coaches orcommunity instructors with recommended and available resources.Classroom Action BinA storage bin for the classroom filled with playground balls, videos, skippingropes, exercise bands, strength grippers and teaching resources that supportedthe Action Plan.As per models that describe \u2018essential\u2019 elements of implementation and scale-up [36,37],the AS! BC Support Team (JW Sporta; Support Team) was crucial to AS! BC implementationand scale-up success [28]. JW Sporta included experts in healthy living and educationwho had worked within the BC elementary school system for > 20 years to develop anddeliver sport education resources. As the cornerstone of implementation, they established\u2018resource teams\u2019 [37] who guided all aspects of implementation and evaluation of AS! BCin schools province-wide. That is, they worked closely with a host of school communitypartners at regional and provincial levels to develop AS! BC materials, tools and prod-ucts, and systematically built capacity within schools to deliver the intervention [28]. TheSupport Team widely promoted AS! BC, worked to build and maintain partnerships withschools and a broad range of local, provincial, national and international stakeholders, andcollaborated with the research team to design and conduct the evaluation. During scale-up,the Support Team was comprised annually of 5\u20138 full and part-time staff and various con-tractors who worked with ~75 teacher\/facilitator trainers annually. Teachers\/facilitatorswho delivered AS! BC workshops had travel and training expenses covered and receivedeither an honorarium or were bought out of teaching time (Teacher on Call) at their ownschool as needed to deliver training.We provide a detailed overview of AS! BC\u2019s \u2018comprehensive pathway\u2019 [33] to scale-up elsewhere [34] and provide a timeline in Figure 1. With continued support fromBC Ministry of Health, we built on the success of AS! BC, demonstrated in our efficacystudy [27,29,30], and initiated provincial scale-up in 2004. AS! BC began as a PA initiativefor grade 4\u20137 students; however, the program was continually enhanced to include HealthyEating (2006 [38]), PA for kindergarten\u2014grade 3 (2006), PA Student Leadership (2006), andHealthy Eating Student Leadership (2011).Int. J. Environ. Res. Public Health 2021, 18, 5182 3 of 23Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 4 of 25   Eating (2006 [38]), PA for kindergarten\u2014grade 3 (2006), PA Student Leadership (2006), and Healthy Eating Student Leadership (2011).  Figure 1. Timeline of Action Schools! BC (AS! BC) scale-up and the randomized controlled effectiveness trial. Open triangles indicate dates where we report implementation strategies and scale-up data (end of first, second, third and final year of scale-up; objective 1). Circles indicate the start of each data collection period within the randomized controlled effectiveness trial (objectives 2 and 3); closed circles represent the beginning (T1) and end (T2) of year 1, open circles represent the beginning (T3) and end (T4) of year 2. 3. Materials and Methods 3.1. Objective 1: Implementation Strategies across 11 Years of Province-Wide Scale up (2004\u20132015) To address our first objective, we retrospectively reviewed the Support Team\u2019s detailed annual reports and monthly statistical summaries. We first generated a list of implementation strategies, defined as \u201cmethods or techniques used to enhance adoption, implementation, and sustainability of evidence-based interventions (EBIs)\u201d [39]. We grouped implementation strategies into three broad categories [40]: (a) implementation process; (b) capacity-building and; (c) scale-up. Implementation process strategies are \u201cprocesses or activities that implementation or quality improvement (resource) teams perform to plan, select, and integrate an EBI into practice\u201d [40]. Capacity-building strategies targeted individuals\u2019 general capacity (motivation, self-efficacy) to execute implementation process strategies (e.g., training and technical assistance) [40]. Scale-up strategies enacted by the support system targeted implementing a specific EBI in multiple settings [40]. We map our strategies to standardized language [39] and follow reporting guidelines [41] to describe each strategy. We extracted data on reach of AS! BC at scale-up (e.g., number of schools registered), and implementation strategies at scale-up (e.g., number of workshops delivered, number of participants attending) from the Support Team\u2019s reports. 3.2. Objectives 2 & 3: Randomized Control Effectiveness Trial (2005\u20132007) We conducted a cluster randomized controlled trial of AS! BC, that incorporated aspects of a hybrid type I effectiveness-implementation study design [42] in a subset of schools (Clinical Trials Registry NCT01412203) beginning in year 2 of provincial scale-up. A school cluster design was used given the whole-school nature of AS! BC. Evaluation took place over two school years (2005\u20132007) with measurement scheduled for the beginning and end of each school year (T1\u2013T4; Figure 1). 3.2.1. Study Design and Participants The research team introduced AS! BC and the research study at the annual province-wide principals and vice principal\u2019s meeting in Vancouver, Canada (2005). A formal letter inviting principals to participate was sent to all BC schools. Administrators from eighty-seven schools from across BC expressed interest; we contacted them and 30 schools that met our inclusion criteria (not currently participating in AS! BC or any other PA or healthy Figure 1. Timeline of Action Schools! BC (AS! BC) scale-up and the randomized controlled effectiveness trial. Open trianglesindicate dates where we report implementation strategies and scale-up data (end of first, second, third and final year ofscal -up; objective 1). Circles indicate the start of each d ta colle tion peri d within the randomized controlled effectivenesstrial (objectives 2 nd 3); closed circles represent the beginning (T1) and e d (T2) of year 1, open circl s repres t thebeginning (T3) and end (T4) of year 2.3. Materials and Methods3.1. Objective 1: Implementation Strategies across 11 Years of Province-Wide Scale up (2004\u20132015)To address our first objective, we retrospectively reviewed the Support Team\u2019s de-tailed annual r ports and monthly statistical summaries. We first generated a list ofimplement tion strategies, defined as \u201cmethods or techniques used to enh nce dop-tion, implementation, and sustainability of evidence-based interventions (EBIs)\u201d [39]. Wegrou ed implementation strategies into three broad categories [40]: (a) implementationprocess; (b) capacity-building and; (c) scale-up. Implementation process strategies are\u201cprocesses or activities that implementation or quality improvement (resource) teams per-form to plan, select, and integrate an EBI into practice\u201d [40]. Capacity-building strategiestargeted individuals\u2019 general capacity (motivation, self-efficacy) to execute implementationprocess strategies (e.g., training and technical assistance) [40]. Scale-up strategies enactedby the support system targeted implementing a specific EBI in multiple settings [40]. Wemap our strategies to standardized language [39] and follow reporting guidelines [41] todescribe each strategy. We extracted data on reach of AS! BC at scale-up (e.g., number ofschools registered), and implementation strategies at scale-up (e.g., number of workshopsdelivered, number of participants attending) from the Support Team\u2019s reports.3.2. Objectives 2 & 3: Randomized Control Effectiveness Trial (2005\u20132007)We conducted a cluster randomized controlled trial of AS! BC, that incorporatedaspects of a hybrid type I effectiveness-implementation study design [42] in a subset ofschools (Clinical Trials Registry NCT01412203) beginning in year 2 of provincial scale-up.A school cluster design was used given the whole-school nature of AS! BC. Evaluation tookplace over two school years (2005\u20132007) with measurement scheduled for the beginningand end of each school year (T1\u2013T4; Figure 1).3.2.1. Study Design and ParticipantsThe research team introduced AS! BC and the research study at the annual province-wide principals and vice principal\u2019s meeting in Vancouver, Canada (2005). A formal letterinviting principals to participate was sent to all BC schools. Administrators from eighty-seven sc ool from across BC expressed interest; we conta ted them and 30 schools thatmet our inclusion criteria (not currently participating in AS! B or any other P r healthyeating program beyond hysical educatio (PE)) volunteered to partic pate (Figure 2). Weinvit d all grade 4 and 5 teachers in volunte chools to participate in the evaluation.Schools were stratified by size (\u2265300 or <300 students) and geographic location (5 healthregions) and randomly assigned to intervention (INT; n = 16 schools) or usual practice(UP; n = 14 schools) conditions by an external research group using a computer generatedsequence. Schools randomized to the UP group maintained their regular activities.Int. J. Environ. Res. Public Health 2021, 18, 5182 4 of 23Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 5 of 25   eating program beyond physical education (PE)) volunteered to participate (Figure 2). We invited all grade 4 and 5 teachers in volunteer schools to participate in the evaluation. Schools were stratified by size (\u2265300 or <300 students) and geographic location (5 health regions) and randomly assigned to intervention (INT; n = 16 schools) or usual practice (UP; n = 14 schools) conditions by an external research group using a computer generated sequence. Schools randomized to the UP group maintained their regular activities.   Figure 2. CONSORT diagram illustrating flow of schools through study. * 3 girls at UP schools consented to accelerometry only. \u2020 Details on follow-up and analysis at the student-level are described in text and tables for each outcome. Figure 2. CONSORT diagram illustrating flow of schools through study. * 3 girls at UP schoolsconsented to accelerometry only. \u2020 Details on follow-up and analysis at the student-level are describedin text and tables for each outcome.All grade 4 and 5 students (of participating teachers) who participated in regularPE and provided written informed consent from a parent or guardian, were eligible forthe evaluation. Schools incorporated AS! BC into regular programming; all students tookpart in the intervention, regardless of whether they consented to be evaluated. Researchethics boards at the University of British Columbia (B05-0505) and University of Victoria(07-05-149f) approved this investigation.3.2.2. Implementation Measures (Physical Activity Delivery by Teachers)All teachers were asked to complete weekly PA logs to record the PA that their classengaged in; this included PE and additional PA such as Classroom Action (INT schoolsonly) and PA-related field trips. For each teacher, we calculated the percentage of weeklylogs returned and average weekly PA delivered (min\/week). For teachers at INT schools,we also calculated average weekly Classroom Action PA (min\/week) as an indicator offidelity to the model.3.2.3. Impact Measures (Student-Level Outcomes)Trained research staff collected all data; it was not possible to blind research staff togroup assignment. Children were excused from their classroom in small groups for mea-surement (~6\/group), which took place in school gymnasia, common spaces, or outdoorsSelf-reported physical activity: We measured moderate-to-vigorous PA (MVPA) overthe previous 7 days in the whole cohort (n = 30 schools) using the valid and reliableInt. J. Environ. Res. Public Health 2021, 18, 5182 5 of 23Physical Activity Questionnaire for Children (PAQ-C) [43], which we modified to includean estimate of time spent in various leisure-time activities in question 1 [44]. Researchassistants administered the questionnaire in small groups of 4\u20136 students. We averagedPAQ-C items to create a general PA score ranging from 1 (low active) to 5 (high active)and obtained an estimate of time (min\/day; MVPAPAQ) spent in MVPA from question 1.Estimated time in MVPA (min\/day) was positively skewed; 42 participants (3% of totalobservations) self-reported MVPAPAQ \u2265 500 min\/day. We limited the maximum possiblevalue to 500 min\/day (approximately 3 SD from mean). We included participants who haddata for both PA score and MVPAPAQ.Objectively measured physical activity: In a subgroup of participants at schoolsin proximity to our research centre (n = 9 schools), we measured PA objectively usingActiGraph GT1M accelerometers (Pensacola, FL, USA) with 15-s epochs. Accelerometerswere attached to an elastic belt and positioned at the iliac crest. Children were asked towear the accelerometer during waking hours for five consecutive days (includes weekdaysand weekends), only removing it for water-based activities (e.g., swimming, showering).We excluded data from the day of distribution to eliminate between-school differences indistribution time and any initial reactivity to wearing the monitor.Prior to processing, each accelerometer file was individually screened for spuriousdata points and patterns. We used custom software (KineSoft Version 3.3.76, Loughbor-ough, UK) and recommended cutpoints [45,46] to classify activity intensity and included allparticipants with at least 10 h of data on three or more days (no restrictions on weekday vs.weekend days). We considered periods of continuous zeroes \u2265 60 min biologically implau-sible and excluded them from our analysis. For analysis we used counts\/min as an estimateof total PA, and MVPA (MVPAAccel), defined using a cutpoint of \u22652296 counts\/min [45,46].We also dichotomized children into those that achieved\/did not achieve an average of\u226560 min\/day of MVPA to estimate compliance to recommended PA guidelines [47].Cardiovascular fitness: To assess CRF we used a multistage 20 m shuttle run [48] ad-ministered in small groups. We recorded the total number of laps each child completed andcalculated age- and sex-specific z-scores [49]\u2014we use both the number of laps completedand the z-scores in the analyses. Five schools (two INT, three UP) in northern BC did notcomplete CRF measurement due to resource constraints.Anthropometry and demographics: We assessed participants\u2019 height without shoestwice to the nearest millimeter using a portable stadiometer (Seca Model 214, Hanover,MD) and body mass twice to the nearest 0.1 kg using an electronic scale (Seca Model 840,Hanover, MD). If measures of height or weight differed by more than 0.4 cm or 0.2 kg,respectively, we obtained a third measure. We used the mean of the two closest valuesor the median of three equidistant values in our analyses. Body mass index (BMI) wascalculated as weight divided by height squared (kg\/m2). We estimated maturity offset(years from age at peak height velocity, APHV) using validated equations that includemeasures of age and height [50]. We determined ethnicity based on parental report ofparent and\/or grandparents birth place. Most children were white (57%) while remainingchildren were Asian (25%), North American Aboriginal (10%), and other or mixed ethnicity(9%); this approximates the diversity of the BC population [51].3.2.4. Sample Size CalculationAS! BC was powered at the level of teacher implementation (PA delivery) to detecta medium effect size [52] of 0.25 between groups. With a power of 0.80 and \u03b1 = 0.05we required a minimum of 64 teachers per condition (128 total; based on a minimum of3 teachers per school representing 22 schools per condition).3.3. Statistical AnalysisObjective 1\u2014Implementation strategies: We describe the number of implementationstrategies and where relevant, the number of activities\/events within each implementa-tion strategy.Int. J. Environ. Res. Public Health 2021, 18, 5182 6 of 23Objective 2\u2014Implementation measures: At the teacher level, we assessed differ-ences in PA logs completed by study year (year 1 vs. year 2) and group (INT vs. UP) usingWilcoxon rank-sum tests. We fit linear regression models and adjusted for school cluster(Stata command: vce (cluster)) to compare average PA delivery (min\/week) for each yearbetween INT and UP groups. At INT schools, we also compared average Classroom ActionPA delivery (min\/week) between years 1 and 2.Objective 2\u2014Impact measures: At the student level, we compared baseline charac-teristics of students attending UP and INT schools (separately for boys and girls) usingunpaired t-tests, ANOVA or Chi-square as required. A month long, provincial teach-ers\u2019 strike (with subsequent student dismissal from school) prevented data collection at15 schools (9 INT, 6 UP) at the end of year 1. We compared baseline descriptive characteris-tics of students attending schools that were (n = 15 schools) and were not (n = 15 schools)measured at the end of year 1 using unpaired t-tests.We compared student-level outcomes between INT and UP schools at the end of years1 (T2) and 2 (T4) of the randomized controlled trial. For all PA measures and CRF (numberof laps completed) we fit sex-specific linear regression models, adjusted for baseline (T1)value, age, BMI, ethnicity and school cluster (Stata command: vce (cluster)). We alsoreplaced baseline BMI with maturity offset [50] in all models to account for potentialdifferences in maturity between groups. The model for CRF age and sex specific z-scoresincluded both girls and boys and did not include age as a covariate but was otherwisesimilar. For MVPAaccel, we included wear time, but it did not improve model fit andwas removed from the final model. We assessed model fit visually using model residuals(normality, linearity and homoscedascity) and identified influential data points usingCook\u2019s D statistics. We report the adjusted mean difference with 95% CI (INT-UP) andeffect size of the regression coefficient for the \u2018group\u2019 variable (Cohen\u2019s d; stata command:esizereg [53]) as an indicator of the magnitude of the between-group difference [54]. Wedescribe effect sizes of 0.2, 0.5 and 0.8 as small, medium and large, respectively [52]. Fordescriptive purposes, we also report unadjusted percent change where appropriate. Finally,we examined between-group differences in the percentage of girls and boys achievingPA guidelines at the end of year 1 and 2 using Chi-square tests; we use Cramer\u2019s V as anestimate of the magnitude of the difference and apply the same thresholds as for Cohen\u2019s dabove. We analyzed student data as per each school\u2019s initial random assignment (intentionto treat; ITT). However, the largest school in the study (UP; n = 163 students at baseline)spontaneously adopted the AS! BC intervention at the start of year 2. Thus, for the year2 (T4) analysis we also conducted a sensitivity analysis excluding this school.Objective 3\u2014Link between implementation and outcomes: We investigated theassociation between PA delivered (dose) and student outcomes in two ways. First, we usedPearson correlations to describe the association between PA delivered (Total or ClassroomAction) and student outcomes at INT schools (no adjustment for school cluster). Second,we dichotomized delivery of Classroom Action PA (the only prescriptive component ofAS! BC) into \u2018high\u2019 (\u226545 min\/week; \u226560% of target [23]) and \u2018low\u2019 (<45 min\/week). Wethen compared change in student-level outcomes between the two groups using linearregression models, adjusted for school cluster as above. All statistical analyses wereperformed using Stata version 13 (StataCorp, College Station, TX, USA).4. Results4.1. Objective 1: Implementation Strategies across 11 Years of Province-Wide Scale up (2004\u20132015)We used a variety of strategies across three broad categories (implementation process,capacity-building, scale-up [40]) to support implementation and province wide scale-upof AS! BC across 11 years. We specify implementation strategies in Table 2 and providerelevant data below.Int. J. Environ. Res. Public Health 2021, 18, 5182 7 of 23Table 2. Scale-up and implementation strategies fell into three categories: implementation process, capacity-building, and scale-up [40].Strategy Description Specification Alignment with Taxonomy [39]Implementation Process Strategies: The Support Team worked with schools to support implementation of AS! BC4 Steps to Becoming an Action SchoolThe Support Team worked with schools on the \u201c4Steps to Becoming an Action School\u201d:(1) registration(2) taking stock (needs assessment covering 5areas\u2014equipment, human resources,community resources, teaching resources andschool health)(3) taking action (action planning; schools createan Action Team, develop an Action Plan andschedule a workshop)(4) reporting (schools reflect on their Action Planand progress over the school year)Actor: AS! BC Support TeamAction: Once a school indicated interest the SupportTeam sent materials (detailed below) to assist theschool. Each school completed a needs assessment(see \u2018Taking Stock\u2019, in adjacent column) and createdan Action Plan that supported the school\u2019s goalsand aligned with available resources. The flexibilityof the AS! BC model made it adaptable to schoolsneeds and available resources. Schools completedyear-end reporting related to progress on the ActionPlan. Action plans and annual reports werereceived and reviewed by the Support Team.Target: Participating schoolsTemporality: Needs assessment and actionplanning were done after registration. Reportingoccurred annually at the end of the school year.Provide ongoing consultationProvide local technical assistanceConduct local needs assessmentAssess for readiness and identify barriersand facilitatorsPromote adaptabilityTeacher on Call Provincial release timeThe BC Government provided funding for a TeacherOn Call to allow at least one teacher perintervention school to attend an AS! BC workshop,or participate in another activity to supportimplementation of AS! BC at their school.Actor: AS! BC Support TeamAction: Release timeTarget: Participating schools\/teachersTemporality: Once after registration and again asnew training opportunities were offered (e.g., as AS!BC expanded to include Healthy Eating, releasetime was available to schools again)Access fundingAS! BC Classroom Action BinParticipating schools received a Classroom ActionBin (1\/grade). Bins included equipment andbest-practice resources teachers could use tosupport their Action Plan (e.g., playground balls,DVDs\/videos, skipping ropes, posterspromoting movement).Actor: AS! BC Support TeamAction: The Support Team provided ClassroomAction Bins to support schools implementingAS! BC.Target: Classroom teachersTemporality: Resources were available on thewebsite. The Support Team regularly updatedmaterials based on feedback from participatingschools, administrators and teachers. Action binswere provided (1\/grade) once schools created anaction plan.Provide equipmentInt. J. Environ. Res. Public Health 2021, 18, 5182 8 of 23Table 2. Cont.Strategy Description Specification Alignment with Taxonomy [39]AS! BC support and communication materialsThe Support Team developed materials to helpschools promote healthy living (including PA andhealthy eating) within the school community.Key resources included: AS! BC planning guide(\u2018how to\u2019 manual that guided schools and teachersthrough the steps to become an \u2018Action School\u2019);Classroom Action resource (support delivery ofClassroom Action\u2014additional 15 min PA\/day);Introduction to Classroom Action Zone DVD(1\/school); Action Pages! (Nationwide inventory ofPA, PE and healthy eating resources); AS! BCplayground circuits (customized for schools andmade available on the website); Weekly activity logsto track PA delivered to students; E-news deliveredto administrators and teachers; Success storiesshared on website and through outreach channels.Actor: AS! BC Support TeamAction: The Support Team developed, updated(e.g., revisions, new materials) and distributedsupport and communication materials to supportschools implementing AS! BC.Target: Schools and teachersTemporality: Resources were available on thewebsite. The Support Team regularly updatedmaterials based on feedback from participatingschools, administrators and teachers. E-news wasdelivered monthly.Provide equipmentDevelop and distribute educational materialsObtain and use feedbackCapture and share local knowledgeBranded incentives Additional resources and equipment to support PAand healthy eating in the school.Actor: AS! BC Support TeamAction: The Support Team offered incentives toschools to encourage them to complete annualreports.Target: Participating schoolsTemporality: Annually to support reporting andalso periodically throughout the yearProvide incentivesAdvisory committeesThe provincial advisory committee had community,school and government representatives. The schooladvisory committee had teacher and principalrepresentativesActor: Principal investigators and AS! BC SupportTeamAction: After receipt of funding, the committeeswere formed to provide input on design andimplementation of AS! BCTarget: Key stakeholdersTemporality: Advisory groups met regularlythroughout deliveryUse advisory boards and workgroupsCreate an implementation blueprintTeacher Mentorship Additional support for schools and teachersActor: AS! BC Support TeamAction: Trainers were available to provideadditional support including classroom visits,action planning, planning for healthy eating,organizing equipment and resources, etc.Target: Participating schools and teachersTemporality: As requested throughout deliveryProvide ongoing consultationInt. J. Environ. Res. Public Health 2021, 18, 5182 9 of 23Table 2. Cont.Strategy Description Specification Alignment with Taxonomy [39]Capacity-building Strategies: involve the management and implementation of a process to deliver AS! BC workshops, build capacity across the province, and maintain interest and momentum within registered schools.AS! BC workshops and ongoing supportTraining workshops were coordinated by theSupport Team and delivered by the Support Team,Master or Regional Trainers. Ongoing support (viaemail, phone) was available as needed.Actor: AS! BC Support TeamAction: The Support Team worked with schools tosecure a date for workshops. Classroom ActionTraining workshops were 3 h long. Refreshertraining workshops were 1 h long. Training wasdelivered face-to-face to groups of teachers inschools (gymnasia, multi-purpose rooms, emptyclassrooms) and followed principles of experientiallearning and self-efficacy theory. Trainingworkshops included positive modelling, verbalpersuasion and opportunities for teachers to besuccessful and recognized. The Support Team andTrainers provided ongoing support during theschool year via email and telephone, and over timeteachers\/schools could register for a selection ofadditional in-person workshops throughout theyear (e.g., student playground leadership).Workshop participants completed evaluation forms,which were returned to the Support Team and usedto improve future workshops.Target: Participating teachers and schoolsTemporality: Ongoing throughout the yearConduct ongoing trainingMake training dynamicObtain and use feedbackAS! BC Master and Regional TrainersThe Support Team used a network of MasterTrainers and Regional Trainers to deliver workshopsacross the province. Regional trainers self-identifiedas interested and submitted a resume. If accepted,they participated in training during a SummerInstitute, offered annually.Actor: AS! BC Support TeamAction: The network of Master and RegionalTrainers supported the delivery of workshopsprovince-wide.Target: Participating teachers and schoolsTemporality: Ongoing throughout the yearIdentify and prepare championsTrain the trainerSummer Institute The Summer Institute served as a trainingopportunity for Master and Regional trainers.Actor: AS! BC Support TeamAction: Individuals selected as Master or RegionalTrainers attended the Summer Institute led by theSupport Team. The Summer Institute used a trainthe trainer approach to build training capacityacross the province.Target: Future Master and Regional trainersTemporality: The Summer Institute was 2 days induration held in August prior to the start of theschool academic year.Identify and prepare championsMake training dynamicTrain the trainerInt. J. Environ. Res. Public Health 2021, 18, 5182 10 of 23Table 2. Cont.Strategy Description Specification Alignment with Taxonomy [39]Regional Trainer Support MaterialsA number of resources supported the Master andRegional trainers. Key resources included: RegionalTrainer Guides (workshop templates, presentationtips, checklists, evaluation forms and handouts forschools); Regional Trainer bags (teaching resourcesand equipment for leading workshops); AS! BCbranded materials (e.g., clothing, clipboard, waterbottle, pens); E-newsActor: AS! BC Support TeamAction: The Support Team provided Master andRegional Trainers with materials to supportworkshop delivery around the provinceTarget: AS! BC Master and Regional TrainersTemporality: Master and Regional Trainersreceived support materials prior to deliveringworkshops. E-news was delivered monthly.Provide equipmentAS! BC websiteThe AS! BC website was updated regularly withregistration numbers and contained resources forteachers and schools including: playground circuits,and the latest versions of all support materials andteaching resources.Actor: AS! BC Support TeamAction: The Support Team kept the website up todate with the latest registration data (by schooldistrict and school) and resources.Target: Teachers, schools, communitiesTemporality: Updates and additions to websitewere ongoingDevelop and distribute educational materialsScale-up Strategies: The AS! BC Support Team used a comprehensive marketing and promotion strategy to achieve full school district representation and strategically inform community stakeholders to increase supportand build sustainable, far-reaching networks for the initiative.Build partnershipsTo build partnerships with schools and stakeholdersthe Support Team participated in a number ofevents. This was an opportunity to promote AS! BC,network with relevant stakeholders. Stakeholdersspanned the following sectors: government (e.g.,ministries of health, education), education (e.g.,teachers\u2019 associations, parent advisory council,universities), health (e.g., health authorities,regional health units), sport (e.g., sport associations,parks and recreation) and community (e.g.,neighbourhood houses, youth organizations).Actor: AS! BC Support TeamAction: Coordinated and\/or deliveredpresentations, displays or promotional materials atevents to support networking, relationship building,and ongoing collaboration with key stakeholdersTarget: Community and provincial organizationswithin BC, across Canada, and internationallyTemporality: Ongoing during scale-upPromote network weavingWork with educational institutionsInt. J. Environ. Res. Public Health 2021, 18, 5182 11 of 23Table 2. Cont.Strategy Description Specification Alignment with Taxonomy [39]Recruitment strategiesA range of marketing and promotion strategieswere used to recruit teachers, school administratorsand other members of the school community to beinvolved with AS! BC.Actor: AS! BC Support TeamAction: Prepared and shared one-pagers, rack cards,brochures, promotional posters, AS! BC displays,media profiles, mailouts to schools and managedthe AS! BC website. The Support Team respondedto requests for information (from website) and usedtargeted approaches (e.g., contacting schoolsdirectly) to engage schools.Target: Teachers, school administrators and othermembers of the school communityTemporality: Mail-outs occurred twice a year (Sept,Jan). Other activities as needed and ongoingduring scale-up.Develop and distribute educational materialsIncrease demandPromotional StrategiesThe Support Team used a variety of promotionalstrategies to inform schools and communitystakeholders about AS! BC.Actor: AS! BC Support TeamAction: The Support team made presentations toprincipals and administrators at school districtmeetings, and to teachers at school staff meetings.At these meetings, the Support Team provided anoverview of AS! BC including requirements andbenefits of enrolling. Other promotional strategiesincluded maintaining an AS! BC website andsemi-annual mailouts to all BC elementary andmiddle schools.Target: Principals, administrators, teachers, schoolsTemporality: Ongoing during scale-upConduct educational meetingsIncrease demandInt. J. Environ. Res. Public Health 2021, 18, 5182 12 of 234.1.1. Implementation Process StrategiesThe Support Team helped schools complete the \u201c4 Steps to Becoming an ActionSchool\u201d: register, take stock (needs assessment), take action (action planning), and report.The Support Team set the following targets for initial provincial scale-up in elementaryschools: 160\/1568 schools (~10%) registered in AS! BC by the end of year 1 (June 2005),640 schools (~40%) registered by the end of year 2 (June 2006), and 1120 schools (~70%)registered by the end of year 3 (June 2007). The number of registered schools exceededtargets; by the end of the first year of scale-up (June 2005), 617 schools (39%) across BCwere registered (involving 3,236 teachers and administrators, and 85,110 students). By theend of the second year of scale-up (June 2006), 935 schools (60%) were registered (involving6,693 teachers and administrators, and 170,700 students) with representation across allBC school districts; 75% of school districts had more than 50% of schools registered. Bythe end of year 3 of scale-up (June 2007), 1,316 schools (84%) across BC were registered(involving 12,971 teachers and administrators, and 331,200 students). By the end of the11-year implementation (2015), >1400 schools (>90%) across BC were registered (involving>87,500 teachers and administrators and reaching approximately 500,000 students).4.1.2. Capacity-Building StrategiesCapacity-building activities included workshops delivered by the Support Team totrain new teachers and maintain interest and momentum within registered schools (e.g.,refresher training or workshops on new topics). During scale-up, the Support Teamincluded 5 full-time staff and 75 volunteer teacher trainers annually. Over 11 years ofscale-up, more than 225 AS! BC Trainers were trained.By the end of the second year of scale-up, the Support Team had delivered 608 work-shops with 9593 teachers and administrators participating. By the end of the third yearof scale-up, 1212 workshops had been delivered with 18,825 teachers and administratorsparticipating. From 2004\u20132015 the Support Team delivered 5034 workshops (2591 PA;1572 Student Leadership; 871 Healthy Eating) to 87,631 teachers and administrators (75,341for PA workshops) representing 1408 (1395 schools did PA workshops; 89%) or 90% of BCelementary schools.4.1.3. Scale-up StrategiesScale-up strategies aimed to increase the number of schools delivering AS! BC. TheSupport Team used a comprehensive marketing and promotion strategy to achieve fullschool district representation and strategically inform community stakeholders to increasesupport and build sustainable, far-reaching networks. The Support Team made presen-tations to principals and administrators in 40% of school districts during the first year ofscale-up; presentations were made to the remaining 60% of districts in the second year.The Support Team also coordinated and\/or delivered presentations, displays, and\/orpromotional materials at events supported by n = 51 organizations in year two of scale-up and n = 64 organizations in year three. Organizations spanned the following sectors:government (e.g., ministries of health, education), education (e.g., teachers\u2019 associations,parent advisory council, universities), health (e.g., health authorities, regional health units),sport (e.g., sport associations, parks and recreation) and community (e.g., neighbourhoodhouses, youth organizations).4.2. Randomized Control Effectiveness Trial (2005\u20132007)4.2.1. ParticipantsOver the 2-year study 179 teachers (90 INT, 89 UP) and 1529 children (394 INT girls,353 INT boys; 397 UP girls, 385 UP boys; 64% of eligible students) from 30 schools consentedto participate in the evaluation (Figure 2). Due to teacher and student movement betweenclasses after year 1, 128 teachers (72%) participated during 1 year only (59 in year 1 only,69 in year 2 only); 51 teachers (28%) participated across both years. Therefore, 110 teachersparticipated in year 1, and 120 teachers participated in year 2.Int. J. Environ. Res. Public Health 2021, 18, 5182 13 of 23We provide baseline student characteristics in Table 3. Age, BMI, maturity offset, PAscore and CRF were similar between INT and UP girls at baseline. Girls attending INTschools had higher MVPA (self-reported and accelerometer-measured) and total PA andwere more likely to achieve PA guidelines than UP girls. Boys attending INT schools wereyounger, further from APHV (less mature), and less fit than UP boys. However, MVPAPAQwas lower among UP boys. BMI, PA score, MVPAAccel and the proportion meeting PAguidelines was similar between INT and UP boys. In both girls and boys there was a higherproportion of white vs. Asian students at INT schools compared with UP schools.Baseline BMI, PA score and CRF were similar between girls who were measured atthe end of year 1 and those who were not (due to the provincial teachers\u2019 strike). However,girls not measured at the end of year 1 were younger (\u22120.1 year, p = 0.007) and reportedhigher MVPAPAQ (+20.8 min\/day, p = 0.009) at baseline than girls that were measured.Age, BMI, and CRF were similar between boys who were measured at the end of year 1and those who were not. However, boys not measured at the end of year 1 had higher PAscores (+0.1 units, p = 0.03) and MVPAPAQ (+32.2 min\/day, p = 0.001) at baseline than boysat measured schools. Finally, there were more Asian students, and fewer white students atmeasured schools compared with non-measured schools (% Asian\/white\/other: 38\/45\/17vs. 7\/75\/18, p < 0.001). This was a function of focusing our limited T2 measurement (dueto teachers\u2019 strike) on schools in proximity to our research centre in Metro Vancouver.4.2.2. Physical Activity Delivery by TeachersTwenty-three teachers in year 1 and 11 teachers in year 2 did not return any activitylogs. A further 20 teachers (1 in year 1 and 19 in year 2) completed their logs retrospectivelyand 11 teachers (all year 2) completed a mix of on-time and retrospective activity logs thatwe could not disentangle. On average, teachers with one or more retrospective logs re-ported delivering more weekly PA than those completing all logs on time (+17.1 min\/week;95% CI 4.2, 30.0). As a result, we include only those with exclusively \u2018on time\u2019 logs in theseanalysis (n = 86 in year 1 and n = 79 in year 2). These teachers returned a median of 81%activity logs (IQR 57\u201390%) in year 1 and 77% activity logs (IQR 54\u201394%) in year 2. Teachersat INT schools returned more logs than did teachers at UP schools (median 86% vs. 70%for INT and UP, respectively).Table 4 summarizes total PA delivery by year and group assignment for teachers withat least one \u2018on time\u2019 PA log (year 1: 78%, year 2: 66%). In year 1, INT teachers deliveredmore PA as compared with UP schools. In year 2, PA delivery was similar between INTand UP schools. Within the ITT analysis, PA delivery did not differ by year within UP orINT schools. However, when we excluded 5 influential data points (PA delivery well above(178\u2013278 min\/week) or below (22.5 min\/week) the average (122.5 min\/wk)) PA deliveryat INT schools decreased from year 1 to year 2 (year 1 vs. year 2: \u221216.7 min\/day; 95%CI \u221232.0, \u22121.4). Teachers at intervention schools who participated across both years ofthe study provided +25.4 min\/week more PA during year 2 than teachers who were newin year 2. Overall findings did not change with the sensitivity analysis (data not shown).Within INT schools, teachers delivered a similar amount of Classroom Action PA betweenyears 1 (33.1 min\/week; 95% CI 25.3, 41.0) and 2 (25.9 min\/week; 95% CI 13.7, 38.1).Int. J. Environ. Res. Public Health 2021, 18, 5182 14 of 23Table 3. Baseline values for girls and boys at usual practice (UP) and intervention (INT) schools. Only participants with complete data for the covariates age, BMI and ethnicity areincluded (see note). Values are mean (SD) or number (%).Girls BoysTotal(n = 694)UP(n = 340)INT(n = 354)Difference(95% CI)Total(n = 660)UP(n = 336)INT(n = 324)Difference(95% CI)Age (years) 9.9 (0.6) 9.9 (0.6) 9.9 (0.6) 0.05 (\u22120.03, 0.1) 9.9 (0.6) 10.0 (0.6) 9.9 (0.6) 0.1 (0.03, 0.2)BMI (kg\/m2) 18.2 (3.3) 18.3 (3.2) 18.1 (3.5) 0.2 (\u22120.3, 0.7) 18.8 (3.7) \u2020 18.8 (3.8) 18.9 (3.6) \u22120.2 (\u22120.7, 0.4)Maturity offset (years fromAPHV) \u22121.8 (0.6) \u22121.8 (0.6) \u22121.9 (0.5) 0.05 (\u22120.03, 0.1) \u22122.9 (0.5) \u2020 \u22122.9 (0.5) \u22123.0 (0.5) \u22120.8 (0.004, 0.1)Ethnicity, #Asian\/white\/other(% Asian\/white\/other)165\/394\/135(24\/57\/19)110\/163\/67(32\/48\/20)55\/231\/68(16\/65\/19) -173\/386\/101(26\/58\/15)119\/165\/52(35\/49\/15)54\/221\/49(17\/68\/15) -PA score (range 1\u20135) 3.0 (0.6)n = 6313.0 (0.6)n = 3283.1 (0.6)n = 303 \u22120.1 (\u22120.2, 0.02)3.3 (0.7) \u2020n = 6053.2 (0.6)n = 3263.3 (0.7)n = 279 \u22120.1 (\u22120.2, 0.03)MVPAPAQ (min\/day)101.1 (92.7)n = 63191.4 (81.3)n = 328111.5 (102.8)n = 303 \u221220.1 (\u221234.7,\u22125.5)131.8 (112.1) \u2020n = 605120.8 (101.9)n = 326144.6 (121.8)n = 279 \u221223.8 (\u221241.9,\u22125.6)Cardiorespiratory fitness(laps)22.6 (11.3)n = 57123.4 (12.0)n = 27521.9 (10.5)n = 296 1.4 (\u22120.4, 3.3)26.6 (14.6) \u2020n = 54828.9 (15.2)n = 28624.1 (13.5)n = 262 4.8 (2.4, 7.2)Cardiorespiratory fitness(z-score)\u22120.1 (0.8)n = 571\u22120.1 (0.8)n = 275\u22120.1 (0.7)n = 296 0.1 (\u22120.04, 0.2)\u22120.3 (0.8) \u2020n = 548\u22120.2 (0.8)n = 286\u22120.4 (0.7)n = 262 0.2 (0.1, 0.3)Accelerometry n = 203 n = 114 n = 89 n = 191 n = 117 n = 74Total PA (counts\/min) 439.4 (126.1) 414.6 (111.7) 471.2 (136.7) \u221256.6 (\u221291.9,\u221221.4) 502.4 (134.6)\u2020 513.5 (133.9) 484.9 (134.7) 28.5 (\u221210.9, 68.0)MVPAAccel (min\/day) 42.3 (17.0) 38.6 (14.8) 47.2 (18.5) \u22128.6 (\u221213.4,\u22123.9) 54.3 (20.1) \u2020 55.6 (20.3) 52.2 (19.8) 3.3 (\u22122..5, 9.2)60 min MVPA\/day,# (%) meeting\/not meeting30\/173(15\/85)9\/105(8\/92)21\/68(24\/76)16%(\u22126,\u221226)66\/125 \u2020(35\/65)44\/73(38\/62)22\/52(30\/70)\u22128%(\u221222, 6)UP, Usual practice; INT, intervention; BMI, body mass index; APHV, age at peak height velocity; PA, physical activity; MVPAPAQ, Moderate-to-vigorous PA from question 1 of the Physical Activity Questionnaire-Child; MVPAAccel, Moderate-to-vigorous PA from accelerometer. Difference calculated as UP-INT; values in bold indicates significant difference between UP and INT within sex; \u2020 Significantly different fromgirls. Note: We excluded 13 students (4 INT girls, 5 INT boys; 1 UP girl, 3 UP boys) from analysis who had medical conditions that interfered with participation in regular PA or cardiovascular health (e.g.,cerebral palsy, diabetes, juvenile arthritis, cardiac anomalies, spina bifida). We also excluded 175 participants missing data for one or more covariates: age (6 INT girls, 1 INT boy; 2 UP girls, 3 UP boys), baselineBMI (19 INT girls, 20 INT boys; 42 UP girls, 38 UP boys) or ethnicity (15 INT girls, 7 INT boys; 17 UP girls, 12 UP boys).Int. J. Environ. Res. Public Health 2021, 18, 5182 15 of 23Table 4. Physical activity delivery (min\/week) by teachers at usual practice (UP) and intervention (INT) schools duringyear 1 and year 2 as determined using weekly activity logs. Values are mean (95% CI).UP INT Difference (INT\u2212UP) p-ValueYear 1 (n = 86) 104.9 (89.2, 120.5) 138.7 (124.5, 152.9) 33.8 (12.7, 54.9) <0.01Year 2 (n = 79) 110.5 (95.9, 125.1) 124.4 (111.7, 137.1) 13.9 (\u22125.5, 33.3) 0.2Difference(Year 2\u2212Year 1)5.6 (\u221210.1, 21.3)p = 0.5\u221214.2 (\u221229.5, 1.1)p = 0.07UP, usual practice; INT, intervention.4.2.3. Student\u2019s Physical Activity and FitnessSelf-reported PA (PAQ-C): PA score was similar (effect sizes <0.1), between INT andUP girls at the end of years 1 and 2 (Table 5). PA score was lower among INT boys ascompared with UP boys at the end of year 1, but not year 2 (Table 5); however, effectsizes were small (~0.2). Sensitivity analysis did not change girls\u2019 results; however, boysat INT schools had lower PA score at the end of year 2 than boys at UP schools withinthe sensitivity analysis (\u22120.2; 95% CI \u22120.3, \u22120.02; (Supplementary Table S1)). For girlsand boys, MVPAPAQ did not differ between INT and UP groups at the end of year 1or 2 within ITT or sensitivity analyses (effect sizes all <0.2). We provide the intraclasscorrelation coefficient (ICC) for baseline, change from T1\u2013T2, and change from T1\u2013T4 inSupplementary Table S2. Replacing baseline BMI with maturity offset at baseline did notchange results.Objectively measured PA (accelerometer): For girls and boys, total PA and MVPAAccelwere similar (effect sizes range from \u22120.16 to 0.05) between INT and UP groups at the endof years 1 and 2 (Table 5). Sensitivity analysis did not change boys\u2019 results; however, girlsat INT schools had lower total PA and MVPAAccel at the end of year 2 compared with UPgirls (Supplementary Table S1). More INT girls than UP girls met PA guidelines at the endof year 1 (40% vs. 22%, p < 0.001, effect size = 0.19); however, achievement of PA guidelineswas similar at the end of year 2 (33% vs. 22%, p = 0.06, effect size = 0.13). Achievementof PA guidelines did not differ between INT and UP boys at the end of year 1 (48% vs.55%, p = 0.3) or year 2 (48% vs. 51%, p = 0.7) (effect sizes < 0.1 for both). We provide theintraclass correlation coefficient (ICC) for baseline, change from T1\u2013T2, and change fromT1\u2013T4 in Supplementary Table S2. Replacing baseline BMI with maturity offset at baselinedid not change results.Cardiorespiratory fitness: On average, girls at INT schools completed 7.5 more laps(95% CI \u22120.5, 15.5) than girls at UP schools at the end of year 1 (effect size = 0.48; Table 5).The increase in number of laps corresponded to a 26% increase in girls at UP schools, anda 62% increase in girls at INT schools (unadjusted percent change). On average, boys atINT schools completed 4.7 more laps (95% CI 1.4, 8.0) than boys at UP schools at the endof year 1 (effect size = 0.28; Table 5). The increase in number of laps corresponded to a23% increase in boys at UP schools, and a 50% increase in boys at INT schools (unadjustedpercent change). The between-group difference was <1 lap (effect sizes < 0.1) at the end ofyear 2 for both girls and boys (Table 5). On average, age- and sex-specific z-scores were0.33 greater (95% CI 0.2, 0.5) in children at INT schools compared with UP children atthe end of year 1 (effect size = 0.36); there was no between-group difference at the endof year 2 (\u22120.03; 95% CI \u22120.3, 0.2; effect size < 0.1). Sensitivity analysis did not changethe findings (Supplementary Table S1). We provide the intraclass correlation coefficient(ICC) for baseline, change from T1\u2013T2, and change from T1\u2013T4 in Supplementary Table S2.Replacing baseline BMI with maturity offset at baseline did not change results.Int. J. Environ. Res. Public Health 2021, 18, 5182 16 of 23Table 5. Physical activity (PA) and cardiorespiratory fitness (CRF) at the end of year 1 (T2) and 2 (T4) in girls and boys attending usual practice (UP) compared with intervention (INT)schools. Values are means (SD) or adjusted mean difference (95% CI) using an intention to treat analysis. We include effect size (ES; Cohen\u2019s d) as an indicator of the magnitude of thebetween-group difference.Girls BoysUP INT Adjusted Difference(INT-UP) * ES UP INTAdjusted Difference(INT-UP) * ESPA ScoreT2 3.1 (0.6)n = 2143.2 (0.6)n = 126 0.05 (\u22120.1, 0.2) 0.083.5 (0.6)n = 2073.3 (0.6)n = 99 \u22120.1 (\u22120.2, \u22120.03) \u22120.16T4 3.0 (0.6)n = 2563.1 (0.6)n = 236 0.02 (\u22120.1, 0.2) 0.033.4 (0.6)n = 2633.3 (0.6)n = 193 \u22120.1 (\u22120.3, 0.02) \u22120.23MVPAPAQ (min\/day)T2 103.1 (87.7)n = 214124.6 (101.3)n = 126 4.8 (\u221221.5, 31.2) 0.05150.5 (100.4)n = 207141.8 (101.3)n = 99 \u221210.8 (\u221235.4, 13.7) \u22120.1T4 77.7 (51.8)n = 25696.9 (72.4)n = 236 10.9 (\u22123.8, 25.6) 0.17108.1 (67.1)n = 263115.2 (77.9)n = 193 2.2 (\u221216.6, 21.1) 0.04Total PA (counts\/min)T2 498.2 (181.0)n = 84566.7 (248.3)n = 67 1.2 (\u221273.0, 75.4) 0.01615.1 (191.9)n = 77588.5 (275.8)n = 55 11.1 (\u2212152.4, 174.5) 0.05T4 471.5 (174.3)n = 77500.7 (185.3)n = 56 \u221238.1 (\u2212108.6, 32.3) \u22120.2567.4 (190.3)n = 76535.6 (169.8)n = 44\u22126.9 (\u2212109.1, 95.3) \u22120.04MVPAAccel (min\/day)T2 47.3 (19.4)n = 8456.2 (23.1)n = 67 \u22120.05 (\u22126.1, 6.0) 0.070.2 (26.0)n = 7760.2 (26.1)n = 55 \u22124.2 (\u221218.7, 10.3) \u22120.16T4 46.0 (18.5)n = 7751.9 (22.0)n = 56 \u22121.9 (\u22128.5, 4.7) \u22120.164.9 (25.6)n = 7659.8 (23.6)n = 44 \u22121.5 (\u221217.3, 14.4) \u22120.06CRF (# laps)T2 27.4 (13.6)n = 18333.8 (18.8)n = 98 7.5 (\u22120.5, 15.5) 0.4833.8 (16.8)n = 17235.4 (17.6)n = 92 4.7 (\u22121.2, 10.6) 0.28T4 30.4 (14.2)n = 21528.8 (14.1)n = 221 \u22120.8 (\u22125.8, 4.1) \u22120.0638.3 (18.0)n = 22634.2 (16.2)n = 180 0.5 (\u22123.9, 5.0) 0.03MVPA, Moderate to vigorous physical activity; PAQ, Physical Activity Questionnaire for Children; Accel, accelerometer; CRF, cardiorespiratory fitness. * Adjusted difference at follow up (T2 or T4) between UPand INT groups; adjusted for baseline (T1) score, age, BMI, ethnicity and school cluster.Int. J. Environ. Res. Public Health 2021, 18, 5182 17 of 234.2.4. Link with ImplementationDose of Total PA delivered was positively associated with change in MVPAPAQ duringyear 1 (r = 0.17, p = 0.02). Dose (Total or Classroom Action PA) did not correlate with changein any other student-level outcome (Supplementary Table S3). Change in student outcomesdid not differ between children in classes that received at least 60% delivery of ClassroomAction PA compared with classes exposed to <60% in years 1 or 2 (Supplementary Table S4).5. DiscussionResearchers advocate for whole-of-school [55] and scaled up approaches [19], yet adearth of effective whole school PA interventions were scaled-up [24]. There are myriadreasons why scale-up does not occur. Not least of which is the considerable support,knowledge and sustained resources needed to do so. Thus, we felt it important to chroniclethe phased approach we adopted to implement and scale-up Action Schools! BC across11 years, with committed support from BC government ministries and a host of schoolcommunity partners (Figure 1). We also describe implementation and scale-up strategiesthat facilitated implementation and sustained AS! BC delivery, as this may aid other teamsworking in this important field of study.Schools are complex and dynamic systems [56], and present many challenges toscaling-up effective interventions. The rapid uptake of AS! BC in the first three yearsof scale-up illustrated the need and appetite for the intervention, a window of opportu-nity [57] afforded by the political climate and the success of our scale-up and implementa-tion strategies. It was not possible to formally evaluate the influence of individual strategies.However, we note that our implementation and scale-up approach incorporated many\u2018essential elements\u2019 of comprehensive school health implementation models [58]. Ourapproach also aligned with implementation and scale-up frameworks [23,36,37], and whatpolicy-makers deemed the drivers of successful scale-up and sustainability [57]. Gover-nance, leadership, resources, outsourcing delivery, accountability structures and committedstakeholder engagement all played a key role to support scale-up and sustainability ofAS! BC.Much has been written about the key role of central support teams to build capacityand provide ongoing support to increase deliverers awareness, knowledge, skills, self-efficacy, and motivation to adopt and implement effective interventions [36,59]. Capacity-building studies in public health and community-based practice identified technical assis-tance, training and tools as central strategies to support effective implementation [23,36,60].These were all focal points of AS! BC, and received sustained investment from BC govern-ment ministries. For example, grants to support scale-up funded the Support Team (5\u20138 fulland part-time staff and various contractors; their office space; travel; communications, etc.),covered costs for teachers and facilitators who delivered AS! BC workshops (travel, train-ing, release time or honoraria as needed), AS! BC resources such as equipment (ClassroomAction) bins, resource manuals and other printed materials required for day-to-day deliveryof the model, and release time for classroom teachers to attend training workshops.Unique features of AS! BC also likely played a role in successful scale-up. The multi-component model provided schools flexibility to create their own Action Plans, based onteachers\u2019 and schools\u2019 available resources and self-identified needs. This provided schoolsautonomy to adapt the model to context\u2014a core condition for successful implementationof a comprehensive school health approach [58]. New implementation strategies andprogram materials were added over time to address the changing needs of schools, andsustain interest. For example, after the effectiveness trial, the Support Team added newworkshops on healthy eating and PA across all grades, arranged teacher mentorship,provided refresher and student leadership training and offered additional resources suchas e-newsletters, posters and instructional manuals. The Support Team tracked delivery ofeach of these; we did not assess outcomes related to these additional activities.Below, we delve further into the unique aspects of AS! BC scale-up, and present keystrengths, limitations and implications of our findings.Int. J. Environ. Res. Public Health 2021, 18, 5182 18 of 23Findings from the subset of schools that participated in the two-year randomized,controlled effectiveness trial showed that teachers at intervention schools delivered morePA during year 1 of the study as compared with teachers at usual practice schools. However,teacher compliance with activity logs was a challenge. Others noted this previously andattributed poor compliance to the substantial demands on teachers across a broad range ofadministrative and instructional tasks [61]. Despite greater PA delivery by teachers in year1, students\u2019 PA did not increase significantly. This is consistent with some [22,62], but notall [63,64], systematic reviews published in the last 10 years. Even when improvementsin students\u2019 PA were observed in other trials, the effect was modest. For example, across20 controlled trials students\u2019 PA (moderate and vigorous) increased by approximatelyone min\/day [63].Nevertheless, in the current study, for intervention schools we observed a 36% and 27%(unadjusted percent change) greater increase in girls\u2019 and boys\u2019 fitness, respectively, comparedwith peers attending usual practice schools during year one. While this was not statisticallysignificant after controlling for the relatively small number of variably sized clusters, werecognize the limitations of relying solely on p values [54]. This between-group differencecorresponds to approximately 30\u201360 s additional running or a difference in peak oxygenconsumption of approximately 1.0 mL\/kg\/min for boys and 1.9 mL\/kg\/min for girls at theend of year one\u2013two to four times greater than that observed in a recent pooled analysis of20 controlled trials [63]. We consider the magnitude of change indicated by the meaningfuleffect sizes, particularly in girls, an important finding. On average, girls are less fit comparedwith boys\u2014a difference which increases with age and maturation [65]\u2014and, tend to benefitless from interventions than boys [63]. We also consider this result promising in light of thesuggested secular decline in children\u2019s fitness of 7.3% between 1981 and 2014 [7]. Whilelong-term implications and clinical relevance of small improvements in children\u2019s CRFare difficult to discern, evidence in adults suggests that even small improvements in CRFyield clinically important outcomes [66]. For example, in adult men, a 1-minute increase intreadmill test duration over approximately 5 years was associated with a 7.9% reductionin all-cause mortality and an 8.6% reduction in cardiovascular disease mortality [66]. AsCRF tracks through childhood [10] and adolescence [11] there is a potential for these smallchanges to influence adult health.Our previous efficacy trial improved PA [29] and CRF [30] among students whoattended AS! BC schools. This pattern, wherein benefits decrease with the move fromefficacy to real world trials, is not unique to our work [67]. Scale-up requires adaptation tofit new contexts and delivery systems, and to accommodate resource constraints. This maylead to an attenuation of the intervention effect\u2014known as the \u201cscale-up penalty\u201d [68,69]or an intervention \u201cvoltage drop\u201d [70] of 25\u201350% [67]. In the effectiveness trial, interventionteachers delivered ~14\u201333 min\/week more PA than teachers at usual practice schools;the difference in PA dose between teachers at intervention compared with usual practiceschools was higher (45\u201355 min\/week) in our efficacy trial [34]. In the Classroom Actionzone, teachers in the effectiveness trial delivered ~47% of the target PA in Year 1, and ~35%of the target in Year 2. An estimated 60% of program delivery is required to elicit beneficialchange [23]. Therefore, at AS! BC scale-up, dose of PA delivered may have been insufficientto elicit similar improvements in children\u2019s PA and fitness, as compared with the efficacytrial. Our findings highlight the challenge of implementing an \u2018effective\u2019 interventionto accommodate scale-up. This \u2018tug-of war\u2019 [71] to retain implementation fidelity whileadapting school-based interventions to achieve \u2018best fit\u2019 for diverse geographic regions andschool populations, is a topic that deserves further attention.A number of factors may have contributed to voltage drop at scale-up in our study.First, due to a provincial teacher strike, we were unable to collect data in some schoolsat the end of year 1. This reduced our sample size for key outcomes and impacted ouranalyses. Second, we decreased the amount of support provided to teachers during theeffectiveness trial (as compared with the efficacy trial), as the Support Team sought toreduce intervention delivery costs during scale-up. Third, intervention teachers deliveredInt. J. Environ. Res. Public Health 2021, 18, 5182 19 of 23less PA in year 2 compared with year 1. This might reflect that training sessions in year 2were \u2018refresher\u2019 workshops (~1 h duration) compared with full workshops in year 1 (~3 hduration). Thus, new teachers in year 2 may not have been as well-trained or committed todeliver the AS! BC intervention as teachers in year 1. Teachers at intervention schools whoparticipated across both years of the study provided +25.4 min\/week more PA during year2 than teachers who were new in year 2. We [20] and others [23] have shown a positiverelationship between dose and at least one health outcome. We noted a positive associationbetween total PA delivered by teachers and change in students\u2019 PA score over the firstyear of the study. This highlights that engaged, motivated, and trained teachers are key tosuccessful outcomes at the student level. Thus, as a means to continually build capacity,teacher training through ongoing (new and refresher) courses each year is a worthwhileinvestment. Fourth, unlike the efficacy trial, there were no self-identified champions atschools during scale-up. Scale-up models [72] identify the key role that local championsplay in scale-up success.Strengths and LimitationsWe highlight several strengths of our study that address gaps in the current literature.Specifically, (i) we describe the chronology of AS! BC scale-up, and implementation strate-gies that supported its translation into a \u201creal-world\u201d setting. Across school-based healthpromoting interventions more broadly, only 5 examined sustainability more than 5 yearslater [25]. To our knowledge, AS! BC is one of only two other whole-school PA models(CATCH [73] and Take10! [74]) to be implemented at scale with continuous stakeholdersupport over more than a decade; (ii) we evaluated the impact of AS! BC across two yearsof scale-up in a large and diverse cohort of children (~1500 children across the province);and (iii) we investigated the link between program implementation and student-levelhealth outcomes.There are many challenges associated with conducting pragmatic, real-world trialsin schools. Therefore, we acknowledge several limitations of our study. First, due tovariability in the number of children per school (cluster), and a teacher strike that renderedus unable to measure 50% of participating schools at the end of year 1, we could not applymultilevel modeling techniques to account for our clustered study design [75]. However,we adjusted the standard errors to account for the non-independence of individuals fromthe same school cluster [76]. This approach may have limited our ability to detect statisti-cally significant intervention effects, despite large changes in CRF (Type 2 error). Second,due to poor compliance with activity logs we could not determine the extent to whichteachers participated in all aspects of intervention delivery (i.e., across all Action Zones).Third, without direct observation of classroom teachers, and subsequent student partic-ipation (not feasible in scale-up studies), we do not know the intensity of PA delivered(dose delivered), or the degree to which students responded to, and were engaged in,the activities (dose received). We recognize the distinction between \u2018dose delivered\u2019 byteachers and \u2018dose received\u2019 by students and aspects of implementation that influencethese implementation indicators (e.g., fidelity, quality and participant responsiveness) [23],that we did not measure.6. ConclusionsIt is possible to scale-up and sustain whole of school PA interventions over the longerterm (>10 years), with the ongoing support of government and school-community stake-holders. Despite many challenges to doing so, there is a need for implementation resourceteams to conceive of new ways to sustain benefits of scaled-up school-based health pro-moting interventions to improve students\u2019 health at a population level. Support units withestablished connections to schools and comprised of researchers, government stakehold-ers and school community-based practitioners are a critical element of scale-up success.Greater PA delivery by trained teachers and the magnitude of change in fitness we ob-served in AS! BC intervention schools, suggests that scaled-up school-based PA modelsInt. J. Environ. Res. Public Health 2021, 18, 5182 20 of 23may enhance children\u2019s health. Notably, implementation and capacity-building throughongoing teacher training, support and compliance are key factors to realize and sustainbenefits. Future school-based interventions guided by rigorous implementation processmodels that support program delivery, and evaluation frameworks that assess key im-plementation, scale-up and sustainability indicators would be a welcome addition to thecurrent literature.Supplementary Materials: The following are available online at https:\/\/www.mdpi.com\/article\/10.3390\/ijerph18105182\/s1.Author Contributions: Conceptualization, P.-J.N. and H.A.M.; Data curation, L.N. and H.M.M.;Formal analysis, L.N. and H.M.M.; Funding acquisition, P.-J.N. and H.A.M.; Investigation, L.N.;Methodology, P.-J.N. and H.A.M.; Resources, P.-J.N. and H.A.M.; Supervision, P.-J.N.; Visualization,L.N.; Writing\u2014original draft, L.N. and H.A.M.; Writing\u2014review and editing, L.N., P.-J.N., H.M.M.and H.A.M. All authors have read and agreed to the published version of the manuscript.Funding: We gratefully acknowledge funding support from the BC Ministry of Health, 2010 LegaciesNow, the BC Ministry of Education, BC Ministry of Tourism, Sport, and the Arts, the ProvincialHealth Services Authority, the Heart and Stroke Foundation of Canada (BC Heart PG05-0327) andthe Canadian Institutes of Health Research (OCO 74248).Institutional Review Board Statement: The study was conducted according to the guidelines of theDeclaration of Helsinki, and approved by the Research Ethics Boards of the University of BritishColumbia (protocol code B05-0505, 2005) and University of Victoria (protocol code 07-05-149f, 2005).Informed Consent Statement: Informed consent was obtained from all participants (parents\/guardiansas needed) involved in the study.Data Availability Statement: The datasets used during the current study are not publicly available asstipulated in our participant consent forms but are available from the authors on reasonable request.Acknowledgments: We are grateful to all of the students, parents, teachers, administrators, commu-nity and government stakeholders for their support of Action Schools! BC and participation in thestudy. We thank Bryna Kopelow and Jennifer Fenton (JW Sporta)\u2014leaders of the Action Schools!BC Support Team\u2014for their tireless commitment to AS! BC and unwavering support of schools andteachers. We also thank the research staff and all trainees for their contributions over the years.Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the designof the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, orin the decision to publish the results.References1. Chaput, J.P.; Willumsen, J.; Bull, F.; Chou, R.; Ekelund, U.; Firth, J.; Jago, R.; Ortega, F.B.; Katzmarzyk, P.T. 2020 WHO guidelineson physical activity and sedentary behaviour for children and adolescents aged 5\u201317 years: Summary of the evidence. Int. J.Behav. Nutr. Phys. Act. 2020, 17, 141. [CrossRef]2. Ortega, F.B.; Ruiz, J.R.; Castillo, M.J.; Sjostrom, M. 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