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Table 4 Qualitative results table detailing themes, supportive quotes and potential implications on cost or uptake of the intervention

From: Exploring the economics of public health intervention scale-up: a case study of the Supporting Healthy Image, Nutrition and Exercise (SHINE) cluster randomised controlled trial

Theme and sub-theme Example supporting quote Potent implications for
Theme: Benefit of the intervention
 Universal delivery Researcher 03: “If schools were delivering the HPE curriculum to the level that it needs to be, there probably wouldn’t be much difference because the message is that foundation message of: what is healthy behaviour? But I feel that where SHINE has the advantage, it’s delivering the same message to everyone rather than getting perhaps a diluted message from various teachers of varying knowledge bases.” Uptake of the intervention – potential enabler
 Targeted intervention with universal delivery Researcher 05: “I think that the students are able to get targeted messages in a way that doesn't appear targeted at all is probably the best aspect of it. So that way, they can work through the program at their own pace and pick what's interesting for them, but then also get some additional information that may help with some underlying problems.” Uptake of the intervention – potential enabler
Theme: Economies of scale
 Economies of scale Researcher 05: “I think that the students are able to get targeted messages in a way that doesn't appear targeted at all is probably the best aspect of it. So that way, they can work through the program at their own pace and pick what's interesting for them, but then also get some additional information that may help with some underlying problems.” Cost – potential for cost-savings through economies of scale
Theme: Acceptability, accessibility
 Aligns with curriculum Researcher 04: “…we contracted a health and physical education curriculum expert to review the program content to make sure that it did align with the junior years … Basically, the curriculum’s done for the teachers, all they have to do is just monitor.” Uptake of the intervention – potential enabler
 Busy nature of the school environment, need to integrate into existing work practices Policy personnel 06: “I think, in terms—if schools don’t see it as an added extra, you’ve got greater leverage. Schools are asked to do a lot of things. Schools are asked to do respectful relationship program. They’re asked to do—they’ve got to track kids against their activity levels, their resilience levels, are they happy, healthy and well. The government ask them to do a lot of things. If you can show that it’s not an add on, I think you’ve got a feasible program. If it can be done with limited resourcing within the school, then you’ve probably got a feasible program.” Uptake of the intervention – potential barrier
 Sensitive content Researcher 01: “…you can’t go in to Catholic schools because they felt that Year 7 was too young to be addressing the eating disorder issue. Despite the fact being that the most common age for the onset of eating disorder is twelve, which is exactly the age that Year 7 students are, they were very risk averse about that concern, that we were going to raise problems.” Uptake of the intervention – potential barrier
Access to technology Teacher 602: “The program was probably harder for us to administer this semester due to the 'public works' building going on at school. This meant we were constantly shifting venues, kids didn't always have access to the internet and they stopped bringing devices to class because of this. No devices made it stressful because then you were constantly reverting to 'plan B's' all the time and this creates stress.” Uptake of the intervention – potential barrier
Policy personnel 06: “There’s nothing worse for a teacher than thinking they’re doing this once a week for eight weeks, and then losing a lesson because oh, the technology’s working, it’s not working. That’s a huge barrier, especially in remote areas.”
 Heterogeneity of technology Researcher 02: “So, problem is different schools have different IT setups, and so if we design an app, it may not all work smoothly on every application, especially when you talk about deployment within a scale, enlarged number of schools. I think that would require pretty much a review of what we have built this for. What we have built, this right now, probably it only would be more like a prototype. So there would be definitely much heavier investment in terms of IT to make it work in that scale.” Uptake of the intervention – potential barrier
 Inclusivity Researcher 04: “The cultural inclusivity was a bit of an issue, as well as just the level of literacy. So, it’s a bit of a passion of mine of making it accessible to a range of intellectual levels or so, with kids with say hearing issues, sight issues and just intellectual disabilities.” Uptake of the intervention – potential barrier
Theme: Teacher champions
 Teacher champions Teacher 1103: “We were fortunate that I could take over the overseeing of this program and therefor make it easier for the class teachers. I felt that the program was not taken as seriously by class teachers as it could have been BUT they are very busy in their own day to day teaching and other responsibilities so honestly they didn't have time. And it’s the old adage 'if you don't have ownership the delivery/teaching is sometime impeded'.” Uptake of the intervention – potential enabler
Theme: Sustainability
 Staff resources Researcher 01: “To be sustainable in the long term, it would need people who are—it would need a couple of staff dedicated to it, but a couple of staff could manage it across every school in the country.” Cost – potential increase in cost in provision of human resources
 Funding Researcher 02: “And we have some other mass programs, has been very successful when they were funded, during the funding period. Of course, when the funds dried up, essentially, they no longer can maintain the program, and either they just go to a commercial company, or they just become zombie programs.” Cost – sustainability of funding required
Theme: Potential changes to the intervention for delivery at scale
 Engagement Teacher 704: “Students felt that as the platform for the program was online, more of the activities could have been interactive or conducive to a computer rather than slabs of writing they were required to read, and often skip ahead. Their suggestion was even a video of someone reading this information as a starting point for improvement, which a preventative skip ahead button, forcing them to listen and learn all the information.” Cost – potential increase in cost to further facilitate student engagement with the program
Researcher 01: “Okay, so we’ve learnt a lot in doing the intervention and I can see that we—and it’s what I would like to do to it, is add an audio track behind the whole program.”
Researcher 02: “Just like any software that involves lots of users, there will be different human factors there as well. Like, we didn’t expect students to skip through the content without reading them, so we try to establish how to make the program more effective and use technology in a way to actually guide students to read more carefully, to obtain the knowledge better.”
 Enhanced integration of teacher tracking and assessment tools Researcher 04: “The feedback also that we received to what teachers from the teaching perspective was, that they didn’t know what their students were answering, they didn’t know how much their students were engaging with the program and considering the program asks the students to consider their daily lives and consider their personal goals and things like that, and ask them to create change around some of those issues, some of the content that the students are answering can be confidential which is why we couldn’t give teachers access to what the students were answering, but we do realise that the teachers—because it is covering some of, I think it was eighty hours of the curriculum, the teachers do need to report and assess on that, so that was something that we had overlooked or perhaps hadn’t addressed as well as we would have liked to initially.” Cost – potential increase in cost to further integrate teacher tracking and assessment tools into the program
Researcher 05: “So throughout the main program, I would put in more activities that the teachers can actually get responses to. So some of it might be that the students can still do it as they do it now, so that’s helping them reflect on their behaviours and stuff like that, which teachers won’t have access to. So it encourages students to still do it honestly. But then yeah, have other aspects where teachers can actually use it for marking.”  
 Additional student and teacher resources Researcher 01: “We’ve got a teacher manual that they get. Again, I would say it might be more valuable to develop a video for teachers rather than send them a manual but, give them the manual as well because they can check, go back and look at things. But give them an instruction video would be probably something that, if you were trying to go to scale, I’d definitely do.” Cost- potential increase in cost to develop such resources