Do the implementation processes of a school-based daily physical activity (DPA) program vary according to the socioeconomic context of the schools? a realist evaluation of the Active at school program

Abstract

Background

Less than half of Canadian children meet the Canadian Physical Activity (PA) Guidelines, and the proportion is even lower among children living in underprivileged neighbourhoods. Regular PA supports physical, cognitive, and psychological/social health among school-aged children. Successful implementation of school-based daily physical activity (DPA) programs is therefore important for all children and crucial for children who attend schools in lower socioeconomic settings. The purpose of this study is to uncover what worked, for whom, how, and why during the three-year implementation period of a new “flexible” DPA program, while paying particular attention to the socioeconomic setting of the participating schools.

Methods

This study is a realist evaluation using mixed methods for data generation. Longitudinal data were collected in 415 schools once a year during the three-year implementation period of the program using questionnaires. Data analysis was completed in three steps and included qualitative thematic analysis using a mixed inductive and deductive method and chi-square tests to test and refine context-mechanism-outcome (CMO) configurations.

Results

Giving the school teams autonomy in the choice of strategies appropriate to their context have allowed schools to take ownership of program implementation by activating a community empowerment process, which resulted in a cultural shift towards a sustainable DPA provision in most settings. In rural underprivileged settings, the mobilization of local resources seems to have successfully created the conditions necessary for implementing and maintaining changes in practice. In disadvantaged urban settings, implementing local leadership structures (leader, committee, and meetings) provided pivotal assistance to members of the school teams in providing new DPA opportunities. However, without continued external funding, those schools seem unable to support local leadership structures on their own, jeopardizing the sustainability of the program for children living in disadvantaged urban areas.

Conclusion

By exploring CMO configurations, we have been able to better understand what worked, for whom, how and why during the three-year implementation period of the Active at School! program. When implementing DPA policies, decision makers should consider adjusting resource allocations to meet the actual needs of schools from different backgrounds to promote equal PA opportunities for all children.

Background

Less than half of Canadian children meet the physical activity (PA) recommendation within the Canadian 24-Hour Movement Guidelines for Children and Youth [1], and the proportion is even lower for children living in underprivileged neighbourhoods [2]. Yet, regular PA supports physical, cognitive, and psychological/social health among school-aged children [3]. Schools are an ideal setting in which to increase PA among young people, as almost all children from all socioeconomic status (SES) backgrounds can be reached during critical periods of development [4]. Moreover, results of meta-analyses showed positive effects of active classrooms on academic achievement [5, 6] and positive effects on classroom behaviour [7]. Since 2005, several Canadian provinces [8] have adopted school-based daily PA (DPA) policies. These policies can be referred to as universal policies [9] because they aim to create supportive environments for PA that are universal to all children. In 2017, the province of Quebec joined these jurisdictions by launching its first policy on sports, PA and leisure, which included legislative provisions mandating the integration of 60 min of DPA within all elementary schools (K-Grade 6) by 2022 [10]. To support the schools in their DPA implementation, a specific program, Active at school! (À l’école, on bouge! [Measure 15023]) was concomitantly launched [11]. This program provides participating schools financial resources over three years to implement opportunities for students to be active 60 min every school day. It adopts a “flexible” approach to DPA, meaning that the participating schools are provided with the autonomy to develop their own custom action plan and select the new practices that are appropriate for their context and needs [11].

Given the overall rates of physical inactivity and given that socioeconomic disparities affect the activity level of children [1, 2], successful implementation of universal DPA policies is important for all children and crucial within lower-SES schools. However, a recognized limit of universal policies, including those implemented in schools, is that they are generally not effective in reducing inequalities [12,13,14,15,16]. It is possible that school-based DPA policies provide an advantage to children attending schools that are already in a favourable position or fail to proportionately improve the outcomes of those in less favourable settings. This situation would result in widening health inequalities [17].

Several factors within and outside the school environment have been found to hinder adoption, implementation, and sustainability of school-based PA programs [18,19,20] but, to our knowledge, no study has documented whether and how the implementation of school-based DPA programs might vary based on schools’ SES context. The purpose of this study is therefore to evaluate the implementation of the DPA program Active at School! while paying particular attention to the socioeconomic setting of the schools to better understand whether that setting affects implementation and, if so, how.

Realist evaluation [21] offers an interesting approach for achieving this objective. A realist evaluation aims at providing theory-driven explanations of how complex programs work within the context of their implementation [21, 22]. As a form of theory-driven evaluation, the realist evaluation develops tentative initial program theories about how a program works. These initial theories generally combine elements of substantive theories with stakeholders’ assumptions about how and why the program may work, derived from their research and/or professional expertise. These realist theories are used to reveal the underlying logic of programs and are then tested and refined empirically through data collection and analysis [23]. A central tenet of the realist approach is that programs work differently in different contexts. In a realist evaluation, the outcome of a program can be explained by the action of specific mechanisms in specific contexts. Realist inquiry is concerned with identifying the underlying mechanisms through which outcomes occur (or do not), and the contexts in which those mechanisms are triggered. Pawson and Tilley [21] name these configurations “context-mechanism-outcome configurations” (CMO configurations). Given that the school teams participating in the Active in School! program had the autonomy to develop action plans tailored to their needs and adapted to their context, conducting a realist evaluation is highly relevant to better understand what worked (or did not), through which mechanisms and in which socioeconomic context.

The purpose of this study is therefore to evaluate the implementation of the DPA program Active at School! using the realist evaluation approach. More precisely, we intend to better understand what worked (and did not work), for whom, how, and why during the three-year implementation period of the DPA program in participating schools, while paying particular attention to the socioeconomic context of the schools. Hence, this study provides a better understanding of the underlying mechanisms at play during implementation of school-based DPA and inform the development of future health-related policies in schools that might contribute to the reduction of social inequalities.

Methods

Participants and program description

The participants in this study were all the schools (415) composing the first cohort of the Active at school! program initiated in 2017 [11]. Active at school! aims to financially support schools, over a three-year period, to help them implement opportunities for the students to be active 60 min every school day, including during physical education (PE) classes. Financial resources are allocated on a degressive basis over the three-year period (during their first year of participation, schools received, in average, 15 614$ (SD = 8 114$) and this amount dropped to an average of 6 400$ (SD = 3 567$) during their third year of participation). Schools participated on a voluntary basis, and regional school boards oversaw the selection of the schools and the allocation of the financial resources provided by the Ministry. The resources allocated were to be used by selected school teams to implement new practices, both at the level of the school organization (e.g., set up a committee, appoint an in-school leader, or other) and the interventions themselves (e.g., schedule in-class active breaks or lead physical activities during recess). The participating schools were free to develop their own action plans and select the new practices that were appropriate for them. Schools nonetheless had access to supportive counselling from the academic advisor of their regional school board, as well as access to tools and ideas (e.g., brain-break videos and suggestions for classroom PA and active corridors) provided by Force 4 [24], a tool kit for schools developed by a public Foundation dedicated to the promotion of PA in Quebec. In the first year of implementation in 2017, a maximum of 450 participating schools were fixed by the Ministry, and 415 joined the program. These 415 schools reached the end of the three-year funding period in 2020.

Study design

This study is a realist evaluation [21] using mixed methods for data generation [25]. Longitudinal data were collected once a year throughout the three-year funding period of the program to document the implementation processes in the participating schools and to gather information on stakeholder perceptions of how and why the program “worked.” The use of a mixed-methods approach was deemed relevant for two main reasons. First, qualitative data were collected to explore and refine CMO configurations as they provided stakeholders’ perceptions about what worked, in their context, and why. Second, the use of quantitative data allowed a large amount of information to be collected from all participating schools throughout the three-year intervention period, which would not have been possible using only qualitative data for logistic reasons (i.e., the lack of human and financial resources to collect and analyze qualitative data from 415 schools). The mixed-methods approach can have different designs depending on how qualitative and quantitative approaches are combined [25], and we used a triangulation design to obtain different but complementary data to arrive at the best understanding of the research problem.

Ethical approval for the study was obtained from the (author’s institutional affiliation) Multifaculty Ethics Board. We followed RAMESES II standards for realist evaluations and the stages of realist evaluation including theory formulation, theory testing and refining by exploring the complex interactions of contexts, mechanisms and outcomes (CMO configurations) [26].

Theory formulation

“Realist theories typically combine elements of substantive theories with stakeholders’ theory – i.e. their ideas about how programmes may work” ([27], p. 2). These realist theories are used to reveal the underlying logic of programs and are then tested and refined using the CMO configurations [26].

The Quebec Ministry of Education’s (MEQ) ideas about how Active at school! may work is that by allocating resources and allowing the schools to develop a custom plan and implement actions tailored to their needs, the program would favour a shift in the school culture towards a sustained provision of DPA [28]. This logic is akin to bottom-up, community-based approaches to policy-making [29, 30] as the implementation of the program is based on the mobilization of a group (a school team), whose members come together to propose actions tailored to their own context to initiate a change of practices. In theory, the school team is therefore more likely to “take ownership” of the program, facilitating DPA sustainability and longer-term beneficial health and academic outcomes for the students [28].

The process by which a community can bring about cultural and structural changes eventually leading to improvement in health outcomes has been designated in the health promotion literature as community empowerment [30, 31]. Laverack and Labonté [30] argue that community empowerment can be monitored by tracking nine “domains”: how a program 1) improves participation; 2) develops local leadership; 3) builds organizational structures; 4) increases problem assessment capacities; 5) enhances critical awareness; 6) improves resource mobilization; 7) strengthens links to other organizations and people; 8) creates an equitable relationship with outside agents; and 9) increases control over program management. This robust and reliable approach has been applied in different program and cultural contexts to better understand how a group progresses towards more organized forms of social action [30].

To uncover the underlying logic of the Active at school! program, we combined the MEQ’s theory about how the program works and the community empowerment conceptual framework, using its nine domains. Each school team represents a small community comprising the principal, teachers, physical education (PE) teachers, and daycare staff. The nine domains of community empowerment are the potential mechanisms, potentially triggered differently in different contexts, by which the program would lead to the potential outcome—the intended shift in the school culture towards sustained DPA provision. Table 1 summarizes the various potential CMO configurations. Since, as far as we know, the concept of community empowerment has never been applied in a school-based PA setting, we used a recent systematic review [18] that identified factors associated with implementation of school-based PA interventions in a real-world setting to clarify how each domain could manifest itself concretely in a school setting. Furthermore, to operationalize the potential shift in the school culture, we combined the MEQ’s assumptions [28] and Schein’s definition of culture [32]. Finally, we considered two main contexts: the socioeconomic setting of the schools (high, middle or low) and the geographic setting (rural or urban). Geographic setting was selected as a primary context, together with socioeconomic setting, because of substantial differences in PA between rural and urban settings [33]. To refine the study of these main contexts, contextual factors reported in Cassar et al. [18] as influencing the implementation of school-based PA programs were also considered (Table 1). Taken together, the contextual factors, mechanisms and outcomes presented in Table 1 offer CMO configuration assumptions that potentially explain what worked, for whom, how and why during the implementation of the Active at school! program. For instance, it is possible that contextual factors such as school size, physical factors or staff turnover differ based on socioeconomic and/or geographic setting, making it easier (or harder) for a school team to use the resources allocated by the program to build organizational structures such as a committee (mechanism), which, in turn, might lead to divergent DPA routine implementation or staff engagement (outcomes). The initial buy-in to PA within a school (contextual factor) could also influence how the program improves participation (mechanism) and, eventually, the extent to which the school implements new PA practices (outcome).

Table 1 Framework of potential CMO configurations underlying the Active at school program

Data collection

Online questionnaires were sent to all participating schools through the MEQ’s accountability platform once a year throughout the program’s funding period (at the end of the school year, in May 2018, 2019 and 2020). Principals and, where appropriate, in-school appointed program leaders, were asked to jointly complete the questionnaires. In accordance with the realist evaluation methodology [21], the questionnaires were built to document the implementation processes of the program in the participating schools and to gather information on stakeholder perceptions about how and why the program “works.” The questionnaires contained an average of 40 closed-ended questions and 15 open-ended questions covering all of the configurations presented in Table 1. More specifically, the YEAR 1 questionnaire was designed to document the program’s initial implementation in terms of contextual factors, mechanisms and changes in practices. The YEAR 2 questionnaire documented modifications to the changed practices, as well as the impact of staff turnover, while the YEAR 3 version ascertained the mechanisms involved in maintaining the changed practices, in other words, the shift in school culture as funding came to an end. Two elementary school academic advisors and the program manager at the MEQ assessed the face validity of all questions and answer choices. The questionnaires were adjusted accordingly.

The study results are based mainly on data collected through the YEAR 3 questionnaire. Data from the first two questionnaires were nonetheless used to better define contextual aspects in order to enhance the analyses of data collected in YEAR 3.

Data analysis

The data collection yielded a large quantity of qualitative data (answers to the open-ended questions) used in the qualitative analyses. The answers to the closed-ended questions served to create variables used in the quantitative analyses: 6 variables pertaining to potential contextual factors, 12 variables associated with potential mechanisms, and 11 variables related to potential outcomes (Table 2).

Table 2 Context- mechanism- and outcome- related variables for quantitative analysis

The data analysis was organized into three major phases and focused on realist theory testing and refinement. Phase 1 was designed to provide more specific answers to the question of what worked and how? while phases 2 and 3 looked at what worked, for whom and why?

• 1. A qualitative thematic analysis was undertaken to code the qualitative data in a mixed inductive and deductive manner [35]. The starting point for the thematic analysis was the framework concepts (Table 1), with a focus on mechanisms. First, the lead author read all data to become familiar with participant responses. Second, the qualitative data were divided according to their geographical and socioeconomic settings and analyzed separately. Sub-categories were generated inductively and deductively, using the framework concepts (Table 1), to assign meaning to portions of text within each setting. Subcategories relating to similar concepts were grouped into larger categories and compared between settings to identify similarities and differences. Subcategories and categories were reviewed by the corresponding author. This first step allowed the identification of the broad mechanisms at play (MO links) and a first exploration of CMO links.

• 2. Next, quantitative analyses were undertaken to better understand what worked, for whom, and why? Chi-square tests were used to examine differences in outcome variables based on the two main contextual variables (geographic and socioeconomic setting) to better understand what worked for whom. Interactions between geographic and socioeconomic context were examined and results are presented according to socioeconomic context for rural and urban schools separately when there was an interaction between the two contexts. Next, the same analyses were used with mechanism variables and contextual factor variables to better understand why. We used these quantitative results to refine CMO configurations identified in the previous step and explore new CMO configurations.

• 3. A last qualitative thematic analysis was undertaken to refine the CMO configurations identified in steps 1 and 2. This step involved searching for context, mechanism and outcome elements and patterns across the qualitative data collected in a mixed inductive and deductive manner.

Finally, we summarized the main results in two figures to provide visual representations of the main CMO configurations identified in Phases 1 to 3. These figures (Figs. 1 and 2) are presented in the Discussion alongside a summary of our findings and a comparison with existing literature.

Results

Participants

A total of 389 participating schools (out of 415) completed the YEAR 3 questionnaire and were included in the analyses. Of those schools, 36% are located in an underprivileged area, while 68% are in an urban setting (Table 3).

Table 3 Participating schools’ characteristics and contextual factors based on socioeconomic and geographic settings

What worked, and how?

The content analysis revealed 12 mechanism subcategories triggered by the program, leading to 3 outcomes categories. The 12 mechanism subcategories were grouped into 4 categories pertaining to 7 of the 9 community empowerment domains. These 4 mechanism categories are presented in Table 4, together with their respective subcategories, ordered from the most to the least frequently mentioned, with the proportion of participating schools reporting the mechanism (for at least one subcategory). The three outcome categories are related to the potential outcomes put forward in the framework (Table 1): implementation of new PA routines (in class, during recess, at the school and/or at the daycare services); commitment level of school team members to active time; and greater perceived value of PA for its contribution to academic success.

Table 4 Mechanisms of change and MO links

This first content analysis also revealed that the local leadership mechanism seemed relatively more triggered and/or more effective at generating outcomes in an urban context, whereas the participation and assessment of the problem and critical awareness mechanisms were more effective in the rural context (Table 4). Regarding SES differences, relatively fewer low-SES schools indicated the presence of mechanisms as a whole (Table 4), while a greater number reported negative outcomes, such as a decrease in the commitment of school team members to active time as implementation continued (9% of the low-SES participating schools, vs. 4% in middle-SES and 1% in high-SES).

What worked for whom, and why?

The results of the quantitative analyses used to contextualize outcomes (what worked for whom?) and mechanisms (why?) as a function of the two main contextual variables (geographic and socioeconomic setting) are found in Table 5.

Table 5 What worked, for whom, and why? Outcome and mechanism variables in function of participating schools’ socioeconomic and geographic setting

From an overall perspective, the vast majority of participating schools reported having implemented new PA routines in class, during recess, at the school and at the daycare services (between 74 and 95%, depending on the means) over the three years of program implementation. A majority (85%) of schools also saw their school team place greater value on PA for its contribution to academic achievement and observed an increase in commitment to active time on the part of homeroom teachers (69%), PE teachers (62%) and daycare educators (57%) over the three-year implementation period, despite the progressive decrease in funding.

Schools located in a rural setting integrated more outdoor field trips than did urban schools (87% vs. 76%, p < 0.05) but fewer new PA routines at daycare services (75% vs. 92%, p < 0.001). For all other outcomes, the quantitative analyses did not reveal any difference between urban and rural settings. Regarding variations in SES, the quantitative analyses support what was observed qualitatively: the commitment of school team members to daily active time is, on average, lower in underprivileged settings than at more privileged schools. In the former, fewer PE teachers became more engaged over the implementation period (55% vs. 71%, p < 0.05), while more homeroom teachers became less engaged (7% vs. 1%, p < 0.05). Despite the foregoing, rural schools in an underprivileged setting performed better than other rural schools by integrating more active recesses (96% vs. 86% and 83% for high and middle SES, p < 0.05) and by a greater increase in the value placed on PA by the school team for its contribution to academic success (94% vs. 86% and 81% for high and middle SES, p < 0.05). However, urban schools in an underprivileged setting performed negatively compared with other urban schools. They integrated fewer new PA routines at their daycare services (87% vs. 97% and 94% high and middle SES, p < 0.05), and a lower proportion of those schools reported an increase in the value placed on PA for its contribution to academic success (79% vs. 92% and 85%, for high and middle SES, p < 0.05).Regarding the mechanism variables, on the one hand, underprivileged rural schools outperformed middle- and high-SES rural schools for variables related to the local leadership and participation mechanisms, which may explain the relatively stronger outcomes in that setting (Table 5).

On the other hand, urban schools in an underprivileged setting performed more poorly than other urban schools for variables associated with the local leadership and resource mobilization mechanisms. A lower proportion of low-SES urban schools appointed and confirmed their intention to maintain a committee in charge of the program (51% vs. 76% and 67% for high and middle SES, p < 0.01), and a lower proportion of those schools identified and publicly acknowledged program champions in their school (38% vs. 57% and 51% for high and middle SES, p < 0.05). Compared with middle-SES schools, they were also fewer to have implemented strategies for updating the activities offered to students (46% vs. 67%, p < 0.05).

Finally, urban schools in general presented certain contextual factors that may limit the activation of mechanisms and affect the scope of the culture shift. On average, urban schools received less funding to implement the program ($53/student, SD = $25 vs. $73/student, SD = $39; p < 0.001; Table 3), while a larger proportion of urban schools reported experiencing resistance within the school team towards implementing daily active time (53% vs. 34%, p < 0.001, Table 3). Although not statistically significant, a higher proportion also reported a large turnover in homeroom teachers during implementation (22% vs. 14%, Table 3). The final qualitative analysis once again shows that in urban schools (context), local leadership (mechanism) appears to be relatively more important for generating outcomes than is the case in rural settings:

The fact that the principal made physical activity a priority in our educational plan was a very important factor in implementing change. Setting up a committee to act on that priority was also a factor. UH-68.

In underprivileged urban settings, several schools explained that a lack of resources (contextual factor) made it difficult to free up staff to lead the program and form a committee (local leadership mechanism) and, as a result, limited student and staff participation (participation mechanism), which appears to have compromised the sustainability of changes in practice (outcomes) in those settings (Table 6). A lack of time, heavy teacher workloads and managing students with special needs are other contextual factors identified by schools in an underprivileged setting that seem to have limited the activation of mechanisms (Table 6).

Table 6 Contextual factors (barriers and enablers) and CMO links in underprivileged rural and urban settings

In rural settings (context), the participation mechanism appears to have been relatively more effective in generating outcomes. Changes in practice seem to have been initiated less by formal leadership (mechanism) and more by informal participation in various activities: “In our small school, all the staff got involved and participated actively” (RL-123). “The fact that teachers had informal discussions in the hallway motivated them to try new things” (RM-71). Access to infrastructure and quality outdoor environments, as well as the presence of partnerships, were also mentioned by underprivileged rural schools as contextual factors that enabled outcomes to be achieved. It is interesting to note that some contextual factors (such as partnerships and the presence of a committee) were previously identified as mechanisms (Table 4), which indicates that the community empowerment process appears to have modified, over the course of implementation, the context in which schools evolve.

Discussion

The purpose of this study was to uncover what worked (and did not work), for whom, how, and why during the three-year implementation period of the Active at School! DPA program, while paying particular attention to the socioeconomic setting of the participating schools. The program’s flexibility appears to have enabled the activation of a community empowerment process within the school teams, leading to a cultural shift towards sustained DPA provision in high-SES and middle-SES schools as well as in low-SES rural schools. Contextual factors specific to schools in an underprivileged urban setting seem to have limited the activation of mechanisms, hindering a shift towards a sustained DPA provision in those schools, which raises concerns as to the medium- and long-term effects of the program on social inequalities with respect to PA and health. To better understand the differences between urban and rural underprivileged settings, it is necessary to consider the dynamic, adaptive and nonlinear nature of program implementation [36,37,38]. Our results suggest that the community empowerment process unfolded differently depending on the geographic and socioeconomic setting of schools, and that the different mechanisms do not appear to have been activated in the same way, in the same order or following a linear structure.

Firstly, our results suggest that, for all contexts, the assessment of the problem and critical awareness mechanisms played a pivotal role in program implementation and potential sustainability by creating a feedback loop [37] with the participation mechanism. The qualitative analysis shows that when school team members experienced positive changes in students, this reinforced the sense that the program was meeting a need, which encouraged staff to analyze their own practices, participate in identifying solutions, and even use the resources provided to further integrate active time. Participation, in turn, nourished a shared vision [18] of the importance of DPA routines in the school and fostered the commitment of staff to active time. The importance of observed benefits to implementation and sustainability of school-based PA programs has already been seen in previous research [18,19,20], so this result is not new. Our results do, however, further the existing literature by considering the dynamic nature of this mechanism and what enables its activation.

Our results suggest that, in urban settings, the local leadership mechanism is critical to initiating the community empowerment process and activating a feedback loop. It seems that urban schools require strong local leadership to begin the process, since those schools are, on average, larger than rural schools, present greater resistance to program implementation and have a greater turnover of homeroom teachers (Table 3). In urban settings, therefore, formal leadership structures (leader, committee and follow-up meetings) appear to have enabled the mobilization of resources, as well as support and monitoring for members of the school team in order to ensure their participation. That participation appears to have then allowed staff to experience the benefits of active time, which reinforced their participation (feedback loop).

In underprivileged urban settings, however, our results show that the local leadership mechanism was less activated than in high- and middle-SES urban schools, which seems, in turn, to have limited activation of the feedback loop. Indeed, a smaller proportion of low-SES urban schools set up a committee and expressed their intention to maintain it, and a smaller proportion identified and publicly recognized champions in their school (Table 5). In addition, the qualitative analyses show that in the absence of ongoing external funding for the program, underprivileged urban schools are not able to sustain local leadership structures associated with the integration of active time, which makes them vulnerable to funding being cut off (Table 6).

The lack of resources in this setting and teachers’ heavy workload are contextual barriers identified by underprivileged urban schools that may explain, in part, the challenges schools face in implementing and maintaining new local leadership structures. Some schools explained that their disadvantaged context limits the reallocation of school resources towards priorities other than children’s basic needs (Table 6).

This need for additional financial support for schools in disadvantaged areas has already been underscored in the literature. Peralta et al. [39] showed that low-SES schools consistently report more barriers and fewer enablers to PA than their high-SES counterparts, while their needs are already greater. Indeed, lack of PA is usually more prevalent among lower socioeconomic groups and often passes from generation to generation [40]. To tackle social health inequities, it has therefore been suggested that public action should consider higher investment for disadvantaged schools [40]. This approach to promoting equal opportunities is called proportionate universalism [9] and consists in “offering universal interventions intended for all [environments], but with modalities or intensity that vary according to needs” ([16], p. 14, unofficial translation).

Consideration of the geographical context in our study therefore made it possible to show that in rural settings, an underprivileged context does not seem to have negatively affected implementation of the program. There, unlike the situation with urban schools in an underprivileged setting, the program seems to have initially activated the participation mechanism, triggering a feedback loop from the outset, as can be seen from the benefits (Fig. 1). This phenomenon seems to have facilitated the activation of other mechanisms, enabling the entire community empowerment process to become self-sustaining and leading to a cultural shift in favour of sustained DPA provision. This result is surprising given that a recent systematic review [41] highlighted that school-based PA interventions conducted in rural settings may pose greater challenges than in urban settings. A possible explanation for our result might be community involvement, a component that was missing from all rural intervention included in the review [41] but appeared to be a significant mechanism for the underprivileged rural schools included in our study. Indeed, our results highlighted that in underprivileged rural settings, the mobilization of nearby resources (such as strengthening links between schools and other organizations in the community and reinforcing the use of nearby infrastructure and environments) appears to have successfully modified the context (Fig. 1) in which schools evolve and created the foundations required to maintain changes in practice over the long term. This modification of the context through the mobilization of nearby resources was not observed in underprivileged urban settings (Fig. 2). Since developing partnerships have been identified several times in the literature as a factor favouring the implementation and sustainability of school-based PA programs [18, 42], additional support for schools in underprivileged urban settings aimed at enhancing community partnerships would be an avenue to explore for supporting sustainable implementations of the program. Rural underprivileged schools also demonstrated a greater involvement of students in setting up activities (Table 5). Student involvement in setting up activities has been identified in the literature as a factor favouring the implementation and sustainability of school-based PA programs [18, 19]. Hence, this could be another avenue to explore in urban underprivileged settings to drive the process of change. Nonetheless, due to the nature of their context, it remains that allocating additional financial resources in urban underprivileged settings appears necessary to enable schools to adopt and sustain the leadership structures that allow them to build or solidify partnerships in their community and/or involve more students.

Fig. 1

Interaction between CMOs in low SES rural setting

Fig. 2

Interaction between CMOs in low SES urban setting

Limitations

These findings enrich the understanding of the underlying mechanisms at play during the implementation of school-based DPA, but it is important to acknowledge limitations. First, the participating schools were self-selected to enroll in the program and were not representative of all schools in the province, limiting the generalizability of the findings. Second, the surveys provided self-reported implementation data and may be subject to bias on behalf of schools. Finally, we were not able to interview participants, which may have deprived us of some nuances that in-person interviews could have offered. Nonetheless, using questionnaires to collect large amounts of qualitative and quantitative data allowed for both an overall and a refined analysis of the implementation processes.

Conclusion

The purpose of this study was to evaluate the implementation of the DPA program Active at School! using a realist approach, while paying particular attention to the socioeconomic setting of the participating schools. Our realist evaluation showed that a DPA program that gives local communities (the school teams, in this case) autonomy in the choice of strategies appropriate to their situation, while providing financial and material support, fosters the emergence of an organizational culture shift towards supporting a sustained DPA provision. The community empowerment domains constitute an insightful framework for identifying settings with greater needs and pointing to mechanisms that drive local change processes. It appears that contextual factors specific to schools located in underprivileged urban settings make the implementation of the DPA program more difficult, with the risk of accentuating existing social inequalities in health if additional resources are not deployed. Policy-makers should consider adjusting resource allocations to meet the needs of schools when implementing health-related policies in order to encourage the establishment of environments that can support all children in adopting a healthy lifestyle. [34]