title: Process evaluation of a sport-for-health intervention to prevent smoking amongst primary school children: SmokeFree Sports.
abstract: BACKGROUND
  SmokeFree Sports (SFS) was a multi-component sport-for-health intervention aiming at preventing smoking among nine to ten year old primary school children from North West England. The purpose of this study was to evaluate the process and implementation of SFS, examining intervention reach, dose, fidelity, acceptability and sustainability, in order to understand the feasibility and challenges of delivering such interventions and inform interpretations of intervention effectiveness.
  
  
  METHODS
  Process measures included: booking logs, 18 focus groups with children (n = 95), semi-structured interviews with teachers (n = 20) and SFS coaches (n = 7), intervention evaluation questionnaires (completed by children, n = 1097; teachers, n = 50), as well direct observations (by researchers, n = 50 observations) and self-evaluations (completed by teachers, n = 125) of intervention delivery (e.g. length of sessions, implementation of activities as intended, children's engagement and barriers). Descriptive statistics and thematic analysis were applied to quantitative and qualitative data, respectively.
  
  
  RESULTS
  Overall, SFS reached 30.8% of eligible schools, with 1073 children participating in the intervention (across 32 schools). Thirty-one schools completed the intervention in full. Thirty-three teachers (55% female) and 11 SFS coaches (82% male) attended a bespoke SFS training workshop. Disparities in intervention duration (range = 126 to 201 days), uptake (only 25% of classes received optional intervention components in full), and the extent to which core (mean fidelity score of coaching sessions = 58%) and optional components (no adaptions made = 51% of sessions) were delivered as intended, were apparent. Barriers to intervention delivery included the school setting and children's behaviour and knowledge. SFS was viewed positively (85% and 82% of children and teachers, respectively, rated SFS five out of five) and recommendations to increase school engagement were provided.
  
  
  CONCLUSIONS
  SFS was considered acceptable to children, teachers and coaches. Nevertheless, efforts to enhance intervention reach (at the school level), teachers' engagement and sustainability must be considered. Variations in dose and fidelity likely reflect challenges associated with complex intervention delivery within school settings and thus a flexible design may be necessary. This study adds to the limited scientific evidence base surrounding sport-for-health interventions and their implementation, and suggests that such interventions offer a promising tool for engaging children in activities which promote their health.
authors.affiliation: Centre for Health Promotion Research, Leeds Beckett University, Calverley Building, City Campus, Leeds, LS1 3HE, UK. j.trigwell@leedsbeckett.ac.uk.
authors.forename: Joanne
authors.initials: J
authors.lastname: Trigwell
authors.affiliation: Centre for Public Health, Liverpool John Moores University, Henry Cotton Campus, 15-21 Webster St., Liverpool, L3 2AT, UK. C.E.McGee@ljmu.ac.uk.
authors.forename: Ciara E
authors.initials: CE
authors.lastname: McGee
authors.affiliation: Physical Activity Exchange, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, 62 Great Crosshall Street, Liverpool, L3 2AT, UK. R.C.Murphy@ljmu.ac.uk.
authors.forename: Rebecca C
authors.initials: RC
authors.lastname: Murphy
authors.affiliation: Centre for Public Health, Liverpool John Moores University, Henry Cotton Campus, 15-21 Webster St., Liverpool, L3 2AT, UK. L.A.Porcellato@ljmu.ac.uk.
authors.forename: Lorna A
authors.initials: LA
authors.lastname: Porcellato
authors.affiliation: Institution of Population Health Research, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK. mussher@sgul.ac.uk.
authors.forename: Michael
authors.initials: M
authors.lastname: Ussher
authors.affiliation: School of Sport, Exercise and Health Sciences, Loughborough University, Leicestershire, LE11 3TU, UK. K.Garnham-Lee@lboro.ac.uk.
authors.forename: Katy
authors.initials: K
authors.lastname: Garnham-Lee
authors.affiliation: Physical Activity Exchange, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, 62 Great Crosshall Street, Liverpool, L3 2AT, UK. Z.R.Knowles@ljmu.ac.uk.
authors.forename: Zoe R
authors.initials: ZR
authors.lastname: Knowles
authors.affiliation: Department of Sport and Physical Activity, Edge Hill University, St. Helens Road, Ormskirk, Lancashire, L39 4QP, UK. lawrence.foweather@edgehill.ac.uk.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Foweather
mesh_terms: D002648:Child; D002652:Child Behavior; D004739:England; D005260:Female; D017144:Focus Groups; D006266:Health Education / Q000458:organization & administration; D006293:Health Promotion / Q000458:organization & administration; D006801:Humans; D008297:Male; D015397:Program Evaluation; D012572:School Health Services / Q000458:organization & administration*; D012574:Schools / Q000458:organization & administration*; D000074606:Smoking Prevention; D013177:Sports