The risk of an incident hospital contact with a musculoskeletal disorder in Danish occupational fishers: a register-based study.

BACKGROUND: The prevalence of musculoskeletal disorders (MSDs) among occupational fishers is high, yet knowledge of the risk factors is scarce and inconsistent. The aim of this study was to investigate the risk from various work-related characteristics on incident hospital contact due to a musculoskeletal disorders and other pain disorders among Danish occupational fishers. METHODS: This register-based study comprised data from the Danish Occupational Cohort with eXposure (DOC*X) for all persons registered as occupational fishers between 1994 and 2017. Time-to-event analysis with Cox regression model was used with age as the time scale. RESULTS: Among the 15,739 fishers, 40% (n = 5,669 cases) had an incident hospital contact with an MSD during follow-up. Back disorders were the dominant complaint. Male fishers working less than 5 years or more than 15 years had higher risks of MSD (HR 2.40 (95% CI: 2.06, 2.80), HR: 2.04 (95% CI: 1.76, 2.35), respectively, than those working for over 20 years. Period effects confounded and reduced the risk from occupational seniority. CONCLUSION: Fishers occupational seniority vary in risk of MSDs across working life. Results showed a nonlinear relationship between the highest risk for fishers working less than 5 years and the lowest risk working more than 20 years as occupational fisher. More years in the workforce, a captain education, and primarily working part time significantly reduced the risk of experiencing a first MSDs for men. Healthy worker effect was documented.

The association between childhood motor performance and developmental trajectories of sport participation over 5 years in Danish students aged 6-16-year-old.

Sports participation has potential to promote physical activity in youth. Unfortunately, sports participation and physical activity may decline from childhood to adolescence and into adulthood. Globally, only 20% of 13-15-year-olds meet the World Health Organisation recommendations for physical activity. This study aimed to investigate the 5-year trajectories of sports participation and their association with baseline motor performance in Danish school children as part of the Childhood Health Activity and Motor Performance School Study-Denmark (CHAMPS-DK), a school-based physical activity intervention study which investigated the health benefits of increased physical education lessons. Five distinct trajectories were identified, with group 1 maintained a stable trajectory of little to no sports participation, and group 2 showing a low decreasing trend. Group 3-5, the most sports active, demonstrated increasing sport participation at different rates. Baseline motor performance score was associated with the two most active sports participation groups. Students who were more physically active during school hours participated less in organised leisure time sports. This suggest focusing on improving motor performance in youth may support future sports participation and thus health-related physical activity. But also, that it might be necessary to engage and maintain children and adolescents in leisure time sports while implementing physical activity promotion interventions.

Same, Same but Different: Comparing Program Fidelity at Early Versus Late Adopters of a Successful Long-Term School-Based Physical Activity Intervention.

Schools have been identified as a promising setting for promoting physical activity (PA). Yet, to realize changes at the population level, successful school-based PA programs need to go to scale. The Svendborgproject is an effective school-based program promoting additional physical education (PE) lessons. The aim of this study is to determine program fidelity across different school groups, representing early and late adopters of the Svendborgproject, and how these are adapting the intervention. Three different school groups were identified, covering the original intervention schools and two groups of late adopters consisting of four former control schools, and five normal schools without any previous connection to the program. A PE teacher questionnaire (n = 122) was used to determine school fidelity. The results show that, while the original intervention schools have implemented the program with the highest fidelity, all schools have implemented the program with medium to high fidelity. It is suggested that having front-runner schools achieving early success with the program both strengthens political project support and provides strategies to back late adopters' implementation of the program. Furthermore, results from the current study suggest that continual promotion of the program by school heads is less important if support is established at the structural and organizational macro level. Finally, we highlight the importance of scaling up organizational capacity when scaling up program reach to assure a workable balance between fidelity and improving the fit to specific contexts.

The metabolic syndrome is frequent in children and adolescents with type 1 diabetes compared to healthy controls.

OBJECTIVE: There is a rise in overweight and obesity among children and adolescents with type 1 diabetes (T1D) in parallel with the rise in the metabolic syndrome (MetS) among children and adolescents. The aim of the study was to describe the prevalence and characteristics of MetS in children and adolescents with T1D compared to their healthy counterparts. RESEARCH DESIGN AND METHODS: The study includes two Danish cohorts; (i) the Copenhagen cross sectional cohort 2016 of 277 children and adolescents with T1D that attend the pediatric outpatient clinic at a large hospital in greater Copenhagen and (ii) the CHAMPS-study DK which is a population-based cohort study of Danish children and adolescents (control cohort). Participants were categorized to have MetS if at least two of the following criteria were met: (i) systolic and/or diastolic blood pressure ≥ 90th percentile, (ii) waist circumference ≥90th percentile, and (iii) triglyceride ≥90th percentile and/or HDL ≤10th percentile. RESULTS: The prevalence of children with Mets in the T1D cohort was higher than in the control cohort (p = 0.002). Moreover, participants with T1D had MetS at a lower level of BMI (p < 0.001) and waist circumference (p < 0.001) than participants with MetS from the control cohort (z-scores = 0.90 and 1.51). Participants with MetS were younger than the other T1D participants (median 12.8 [9.9,14.8] vs. median 14.6 [11.2,16.9] years, p = 0.006). CONCLUSIONS: Children and adolescents with T1D have an increased risk of MetS compared to healthy controls and clinicians and caretakers should consider early prevention and health promotion strategies.

Digital Health Literacy and Information-Seeking Behavior among University College Students during the COVID-19 Pandemic: A Cross-Sectional Study from Denmark.

The COVID-19 pandemic and the concomitant infodemic have emphasized the importance of digital health literacy (DHL) to global public health research and practice. The aim of this study was to examine information-seeking behavior, the ability to find, understand and deal with health information among university college students in Denmark and/in addition we wanted to examine the impact of their close social network on students' ability to find and understand health information. This research was carried out as part of the COVID-HL university student survey by using a uniform questionnaire consisting of elaborated scales. Data were collected from a cross-sectional survey conducted at University College South during 4 weeks in April and May 2020. To capture DHL, four subscales of the DHL instrument were adapted to the pandemic context. A total of 59.9% of the students have sufficient DHL-most students find it rather easy to find information and are satisfied with the information they find on the internet. However, some (28.1%) students find it difficult to judge the quality and reliability of the information. Students with a sufficient level of DHL are more likely to seek information through search engines and websites of official institutions, while students with a limited level of DHL more often use social media for health information. Students with sufficient DHL more often share health information and less often ask for support in their network.

Recreational screen media use in Danish school-aged children and the role of parental education, family structures, and household screen media rules.

Screen media use is part of most children's everyday lives, but organisations have advised that use should be limited. The aims of this study were to describe 6-11-year-old Danish children's screen device ownership and screen media use (weekdays and weekends), including the role of parental education, family structure and household screen media rules. We conducted a cross-sectional study including 5274 Danish children aged 6-11-years sampled from ten Danish municipalities from May 2019 to November 2020. Characteristics of the sample and source population were obtained from the Danish Health Data Authority. Parent's completed the SCREENS questionnaire, which was developed to assess children's screen media habits. We used inverse probability weighted logistic and linear regression models. Smartphone and laptop ownership was higher with increasing age, and use of screen media varied across day type, age and gender. The proportion of children using screen media more than 4 h/day was 13% (95% CI 12%;14%) for weekdays and 28% (95% CI 27%;29%) for weekend days. Children of parents with medium-length or long educations had statistically significant lower odds of using screen media more than 4 h/day. We found a statistically significant graded relationship between household screen media rules and children's screen media use; the less parents reported presence of rules, the more time their children spent on screen media engagements. Our results suggest that parental educational level and family structure are related to unfavourable screen media habits, and household screen media rules may play an important role for parents to limit children's screen use.

Vigorous physical activity is important in maintaining a favourable health trajectory in active children: the CHAMPS Study-DK.

Physical activity (PA) is critical to improving health factors such as weight, adiposity, and aerobic fitness. However, children who meet PA guideline recommendations demonstrate developmental differences in health-related outcomes. To investigate prospective associations between PA behaviour (overall PA and PA intensity) and trajectories of health-related factors among physically active children. This prospective study (2.5 years) included 391 children (baseline age: 8.1 ± 1.4 years; girls 36.3%) from ten public schools. All children performed 60-min or more of moderate-to-vigorous physical activity (MVPA) per day objectively measured. Trajectories of BMI, waist circumference, and aerobic fitness were constructed with a group-based multi-trajectory model. Three trajectory subgroups were identified: 'high fitness/normal weight' (48.4% of children), 'moderate fitness /normal weight' (42.5% of children), and 'low fitness/overweight-obese' (9.1% of children). Children performing higher overall PA, were less likely of being classified as members of the 'Low Fitness/Overweight-Obese' [Relative Risk Ratio (RRR and 95% CI) = 0.56 (0.37 to 0.85) compared to 'high fitness/normal weight' subgroup. Each additional 5% in light PA time was associated with approximately twofold [RRR 2.12 (1.24-3.61)] increased risk of being in the 'low fitness/overweight-obese' trajectory relative to the 'high fitness/normal weight' trajectory. Each additional 2% in vigorous-PA time was associated with a 42% and 85% reduced risk (relative to 'high fitness/normal weight') of being in the 'moderate fitness/normal weight' [RRR 0.58 (0.38-0.96)] and 'low fitness/overweight-obesity' [RRR 0.15 (0.06-0.37)] trajectory, respectively. Overall PA and additional time in vigorous-PA was associated with improved health-related outcomes, while light PA was negatively associated with health-related outcomes among children who adhere to PA guideline recommendations. Vigorous PA was the strongest predictor of the health trajectories. All PA guidelines for children should place greater emphasis on the importance of vigorous PA.

Developmental Trajectories of Body Mass Index, Waist Circumference, and Aerobic Fitness in Youth: Implications for Physical Activity Guideline Recommendations (CHAMPS Study-DK).

OBJECTIVES: Describe the trajectories of body mass index (BMI), waist circumference, and aerobic fitness in children and identify different outcomes of guideline-recommended physical activity (PA) in a subset of active children. METHODS: We recruited students from 10 public primary schools and obtained repeated measures of BMI, waist circumference, and aerobic fitness over 30 months. Aerobic fitness was measured with the Andersen test. We objectively measured physical activity behaviour with accelerometers and classified children as 'physically active' when they achieved ≥ 60 min of moderate-to-vigorous PA per day (guideline concordance). Univariate trajectories of BMI, waist circumference, and aerobic fitness were calculated for all children, and we constructed a multi-trajectory model comprising all outcomes in the subgroup of physically active children. The construct validity of all models was investigated by examining for between-group differences in cardiovascular disease risk factors obtained from fasting blood samples. RESULTS: Data from 1208 children (53% female) with a mean (SD) age of 8.4 (1.4) years were included. The univariate trajectory models identified three distinct trajectories for BMI, waist circumference, and aerobic fitness. The multi-trajectory model classified 9.1% of physically active children as following an 'overweight/obese/low fitness' trajectory. There were moderate-to-large differences in cardiovascular risk factors between all trajectory groups (p < 0.001; d = 0.4-1.20). CONCLUSION: We identified distinct developmental trajectories of BMI, waist circumference, and aerobic fitness in children. Nearly one in 10 children who met PA guideline recommendations followed an unfavourable health trajectory. Health-related PA recommendations may be insufficient for some children.

The development of a questionnaire to assess leisure time screen-based media use and its proximal correlates in children (SCREENS-Q).

BACKGROUND: The screen-media landscape has changed drastically during the last decade with wide-scale ownership and use of new portable touchscreen-based devices plausibly causing changes in the volume of screen media use and the way children and young people entertain themselves and communicate with friends and family members. This rapid development is not sufficiently mirrored in available tools for measuring children's screen media use. The aim of this study was to develop and evaluate a parent-reported standardized questionnaire to assess 6-10-year old children's multiple screen media use and habits, their screen media environment, and its plausible proximal correlates based on a suggested socio-ecological model. METHODS: An iterative process was conducted developing the SCREENS questionnaire. Informed by the literature, media experts and end-users, a conceptual framework was made to guide the development of the questionnaire. Parents and media experts evaluated face and content validity. Pilot and field testing in the target group was conducted to assess test-retest reliability using Kappa statistics and intraclass correlation coefficients (ICC). Construct validity of relevant items was assessed using pairwise non-parametric correlations (Spearman's). The SCREENS questionnaire is based on a multidimensional and formative model. RESULTS: The SCREENS questionnaire covers six domains validated to be important factors of screen media use in children and comprises 19 questions and 92 items. Test-retest reliability (n = 37 parents) for continuous variables was moderate to substantial with ICC's ranging from 0.67 to 0.90. For relevant nominal and ordinal data, kappa values were all above 0.50 with more than 80% of the values above 0.61 indicating good test-retest reliability. Internal consistency between two different time use variables (from n = 243) showed good correlations with rho ranging from 0.59 to 0.66. Response-time was within 15 min for all participants. CONCLUSIONS: SCREENS-Q is a comprehensive tool to assess children's screen media habits, the screen media environment and possible related correlates. It is a feasible questionnaire with multiple validated constructs and moderate to substantial test-retest reliability of all evaluated items. The SCREENS-Q is a promising tool to investigate children screen media use.

Short-term efficacy of reducing screen media use on physical activity, sleep, and physiological stress in families with children aged 4-14: study protocol for the SCREENS randomized controlled trial.

BACKGROUND: During the recent decade presence of digital media, especially handheld devices, in everyday life, has been increasing. Survey data suggests that children and adults spend much of their leisure on screen media, including use of social media and video services. Despite much public debate on possible harmful effects of such behavioral shifts, evidence from rigorously conducted randomized controlled trials in free-living settings, investigating the efficacy of reducing screen media use on physical activity, sleep, and physiological stress, is still lacking. Therefore, a family and home-based randomized controlled trial - the SCREENS trial - is being conducted. Here we describe in detail the rationale and protocol of this study. METHODS: The SCREENS pilot trial was conducted during the fall of 2018 and spring of 2019. Based on experiences from the pilot study, we developed a protocol for a parallel group randomized controlled trial. The trial is being conducted from May 2019 to ultimo 2020 in 95 families with children 4-14 years recruited from a population-based survey. As part of the intervention family members must handover most portable devices for a 2-week time frame, in exchange for classic mobile phones (not smartphones). Also, entertainment-based screen media use during leisure must be limited to no more than 3 hours/week/person. At baseline and follow-up, 7-day 24-h physical activity will be assessed using two triaxial accelerometers; one at the right hip and one the middle of the right thigh. Sleep duration will be assessed using a single channel EEG-based sleep monitor system. Also, to assess physiological stress (only assessed in adults), parameters of 24-h heart rate variability, the cortisol awakening response and diurnal cortisol slope will be quantified using data sampled over three consecutive days. During the study we will objectively monitor the families' screen media use via different software and hardware monitoring systems. DISCUSSION: Using a rigorous study design with state-of-the-art methodology to assess outcomes and intervention compliance, analyses of data from the SCREENS trial will help answer important causal questions of leisure screen media habits and its short-term influence on physical activity, sleep, and other health related outcomes among children and adults. TRIAL REGISTRATION: NCT04098913 at https://clinicaltrials.gov [20-09-2019, retrospectively registered].

Three times as much physical education reduced the risk of children being overweight or obese after 5 years.

AIM: We evaluated the effect that increasing physical education lessons from 1.5 to 4.5 hours per week for 5 years had on the body mass index (BMI) and waist circumferences of children aged 5-11 years at inclusion. METHODS: From 2008 to 2013, six intervention schools in Svendborg, Denmark, delivered 4.5 hours of physical education lessons per week to 750 children. Meanwhile, four matched control schools gave 549 children the standard 1.5 hours of physical education lessons per week. Measurements were taken at baseline and yearly for 5 years. Of the 1299 children, 81 joined the schools after 2008. RESULTS: At baseline, the percentage of overweight children was 12% in the intervention schools and 13% in the control schools, whereas 15% and 19% were abdominal obese, respectively. After 5 years, the respective risks of remaining abdominal obese or overweight were 43% and 51% in the intervention schools and 78% and 84% in the control schools. Mean BMI increased 0.450 kg/m2 more in the control group over the five-year period. The intervention was not effective in decreasing the average waist circumference. CONCLUSION: Three times as much physical education lessons per week, for 5 years, effectively decreased BMI and the likelihood of remaining overweight or obese.

Childhood motor performance is increased by participation in organized sport: the CHAMPS Study-DK.

Evidence suggests that motor performance in children is declining globally. We tested whether participation in organized sport is associated with motor performance, and estimate the effect of 30 months participation in organized sport on motor performance. Study participants were 1067 primary school students, enrolled in the Danish Childhood Health, Activity, and Motor Performance School study. Participation in organized sport was reported via text messaging. Coordination-related motor performance composite, fitness-related motor performance composite, and total motor performance composite were calculated. Data were analyzed using Generalized Estimating Equations. Participation in organized sport was positively associated with motor performance (all composites) in models that did and did not control for baseline motor performance. For models that did not control for baseline motor performance, this equated to 2-6% increases in motor performance per weekly sport session; for models that did control for baseline motor performance, this equated to 1-5% increases in motor performance per weekly sport session. Positive associations between participation in organized sport and motor performance identify participation in organized sport as a way to improve motor performance in children. These results might provide the basis to determine whether participation in organized sport could be beneficial for children with developmental movement disorders.

Implementation of a successful long-term school based physical education intervention: Exploring provider and programme characteristics.

There is an ongoing need for research focusing on how to implement physical activity programmes into a school setting. This includes documentation of the extent to which programmes are compatible with the basic views of providers and their local practices. The present study explores the Svendborgproject - a programme tripling the amount of physical education in six public schools, sustaining it for 10-years and documenting a decreased incidence of overweight, obesity and cardiovascular risk factors. The aim was to analyse provider and programme characteristics of the Svendborgproject to gain insights into providers motives for adopting, implementing, and maintaining the programme. Six school heads and six teachers were interviewed to explore how they perceived programme compatibility to their school's practice and their own role as providers. Both teachers and school heads found the additional lessons a valuable asset that fitted existing school values and priorities. Additionally, physical education teachers participated in a course providing new perspectives and teaching methods that aided the implementation of the programme. Lastly, school heads stressed that implementation fidelity was heavily dependent on the dedication of physical education teachers and on having simple programme requirements that made it clear what could be expected of the programme.

Spinal pain is prospectively associated with cardiovascular risk factors in girls but not boys (CHAMPS study-DK).

PURPOSE: To examine the prospective associations between spinal pain exposures and risk factors for cardiovascular disease in children and explore the mediating role of health-related physical activity. METHODS: Students were recruited from ten public primary schools. Each week from November 2008 to October 2010, parents reported spinal pain occurrences in their children via text messaging. Clustered cardiovascular risk was estimated with a composite score comprising fasting serum triglycerides, homeostasis assessment model-estimated insulin resistance (HOMA-IR), total to high-density lipoprotein cholesterol ratio, and systolic blood pressure. Additional outcomes were fasting serum insulin and glucose concentrations and body mass index categories. Associations were explored with multilevel mixed regression models and reported with beta coefficients (ß) and percent difference scores. All models were adjusted for potential confounders. RESULTS: Data from 1022 children (53% female) with mean ± SD age of 8.4 ± 1.4 years were included. Girls with spinal pain had greater clustered cardiovascular risk (ß [95% CI]; percent difference [95% CI] = .41 [.02-.80]; 3.3% [.2-6.4%]) than those without spinal pain. Similar outcomes were observed for log insulin (percent difference [95% CI] = 3.4% [.6-6.2%]) and log HOMA-IR = (percent difference [95% CI] = 3.8% [.4-7.3%]). Remaining associations between spinal pain and cardiovascular risk in girls were nonsignificant. There were no associations between spinal pain and cardiovascular risk in boys. Moderate-to-vigorous-intensity physical activity did not appear to mediate this relationship. CONCLUSION: These findings suggest a potentially important link between spinal pain and cardiovascular risk in girls that may be independent of health-related physical activity. These slides can be retrieved under Electronic Supplementary Material.

Physical education and leisure-time sport reduce overweight and obesity: a number needed to treat analysis.

BACKGROUND: School-based physical education (PE) and organised leisure-time sports participation (LTSP) represent important physical activity opportunities for children. We examined the preventive effect of increased PE as well as LTSP on overweight and obesity (OW/OB) in school children. METHODS: Longitudinal data from children attending 10 primary schools in the Danish municipality of Svendborg, comprising 6 intensive PE (270 min/week) and 4 control (90 min/week) schools were assessed. Age- and sex-specific cut-offs for body mass index (BMI) determined OW/OB status. Associations between OW/OB status and school type (intensive PE or control) or LTSP were investigated using mixed, multilevel logistic regression models. Significant parameter estimates were converted into number needed to treat statistics (NNT). RESULTS: In total, 1009 children (53.3% female; mean age 8.4 ± 1.4 years) were included in the analysis, with 892 children (52% female) being normal weight (NW) at baseline. Eighteen (NNT = 17.1; 95% CI [11.0, 226.1]) children attending an intensive PE school for 2 years, resulted in one fewer case of OW/OB compared with attendance at a normal PE school. For NW children, prevention of one case of OW/OB requires 36 (NNT = 35.8; 95% CI [25.1, 596.3]) children to participate in intensive PE for 2 years in comparison with normal PE. LTSP over 2 years may prevent OW/OB if 15 children participate in one LTSP session/week, 9 in two LTSP sessions/week and 8 in three LTSP sessions/week; for normal weight children, 25 children had to participate in one LTSP session/week, 16 in two LTSP sessions/week and 14 in three LTSP sessions/week. CONCLUSION: We provide the first NNT estimates of school-based PE and LTSP to prevent the onset of OW/OB. PE, and separately, LTSP seem to have both a protective and a treatment effect against OW/OB in children.

Muscle Fitness Changes During Childhood Associates With Improvements in Cardiometabolic Risk Factors: A Prospective Study.

BACKGROUND: The role of muscle fitness in controlling cardiometabolic risk factors during childhood is incompletely understood. METHODS: A prospective observational design including 6- to 11-year-old children (n = 512) was used to study associations between 1.5-year changes in handgrip strength, standing vertical jump displacement, the short shuttle run, and a composite of these with changes in composite and single cardiometabolic risk markers. The authors modeled sequential mixed linear regressions controlling for changes in cardiorespiratory fitness, waist circumference, and other putative confounding variables. RESULTS: Statistically significant associations, standardized beta (95% confidence intervals), were observed between changes in composite muscle fitness -0.19 (-0.30 to -0.07), muscular strength -0.15 (-0.25 to -0.06), and agility 0.14 (0.04 to 0.23), but not muscular power -0.06 (-0.14 to 0.03) with changes in the composite risk score. In sex-stratified analysis, associations were robust in girls, but not in boys. Control for changes in cardiorespiratory fitness and waist circumference greatly attenuated associations. Changes in muscle fitness were strongly associated with changes in waist circumference in both girls -0.21 (-0.37 to -0.05) and boys -0.23 (-0.35 to -0.11) after controlling for cardiorespiratory fitness. CONCLUSIONS: Our data support a unique role of muscle fitness in the promotion of metabolic health and prevention of excess adipose tissue accumulation in children.

Symptoms of depression in young adulthood is associated with unfavorable clinical- and behavioral cardiovascular disease risk factors.

Depression in young adults is a growing concern to public health. This study aims to investigate if depression status in young adults is related to clinical and behavioral cardiovascular disease (CVD) risk factors. Cross-sectional data from a population-based sample of young Danish adults participating in the European Youth Heart Study 2009-2010 were used to examine this (n = 644, mean age 24.3 years 47% male). Measures of cardiorespiratory fitness (CRF), body composition, blood pressure, fasting levels of high and low density lipids (HDL, LDL), insulin, and glucose were obtained. Symptoms of depression were obtained using the Major Depression Inventory scale. Information on sleep disorders; drinking and smoking habits were obtained by questionnaires. Associations of depression with CVD risk factors were examined using logistic and linear regression adjusted for age and sex. Prevalence of mild-moderate-severe depression was 8.7% (5.6% males, 11.5% females). Significant sex differences were found in the association between several CVD risk factors and depression status. Women with depression had higher odds of overweight (OR = 2.2, 95%CI: 1.01-4.0), abdominal adiposity (OR = 2.5, 95%CI: 1.2-4.8), low CRF (OR = 2.5, 95%CI: 1.2-5.5), insulin resistance (OR = 2.3, 95%CI: 1.1-4.6), low HDL (OR = 2.0, 95%CI: 1.01-4.1) and high LDL (OR = 2.2, 95%CI: 1.04-4.5) compared to women without depression. Men with depression had significantly increased odds of having high blood pressure and being smokers compared to men without depression (OR: 3.1, 95%CI: 1.1-8.8 and OR: 3.0, 95%CI: 1.1-8.4, respectively). Depression symptoms in young adulthood were related to unfavorable clinical- and behavioral CVD risk factors, particularly in women.

Using the RE-AIM framework to evaluate a school-based municipal programme tripling time spent on PE.

Documenting the implementation of effective real-world programmes is considered an important step to support the translation of evidence into practice. Thus, the aim of this study was to identify factors influencing the adoption, implementation and maintenance of the Svendborgproject (SP) - an effective real-world programme comprising schools to implement triple the amount of physical education (PE) in pre-school to sixth grade in six primary schools in the municipality of Svendborg, Denmark. SP has been maintained for ten years and scaled up to all municipal schools since it was initiated in 2008. The Reach, Effectiveness, Adoption, Implementation and Maintenance framework (RE-AIM) was applied as an analytic tool through a convergent mixed method triangulation design. Results show that SP has been implemented with high fidelity and become an established part of the municipality and school identity. The successful implementation and dissemination of the programme has been enabled through the introduction of a predominantly bottom-up approach combined with simple non-negotiable requirements. The results show that this combination has led to a better fit of programmes to the individual school context while still obtaining high implementation fidelity. Finally, the early integration of research has legitimated and benefitted the programme.