Process evaluation

Introduction

This chapter presents the qualitative findings from a detailed process evaluation conducted throughout the Stand Out in Class pilot study. The process evaluation explored key feasibility- and acceptability-related outcomes of the trial surrounding school and participant recruitment, acceptability of randomisation, acceptability of the measurement instruments and the intervention, along with the examination of any negative consequences of the intervention (such as classroom disruption). A detailed assessment of intervention fidelity was also undertaken. This chapter reports on the following study objectives:

• Objective 1 – establish and refine a recruitment strategy for schools and pupils.
• Objective 5 – assess the acceptability of randomisation to schools.
• Objective 6 – assess the acceptability of measurement instruments to teachers, children, parents and guardians, including the activPAL inclinometer as the tool for the measurement of the primary outcome.
• Objective 7 – assess the acceptability of the intervention to teachers, children, parents and guardians.
• Objective 8 – monitor any adverse effects, such as musculoskeletal discomfort and/or disruption to the classroom/learning to inform the design of a full trial and minimise or eliminate any such effects.
• Objective 9 – assess intervention fidelity over the intervention period.

Methods

Process evaluation overview

A series of interviews and focus groups with teachers, children and parents or guardians were conducted following the completion of the baseline measures and randomisation (phase 1), to explore the acceptability of the trial procedures, including randomisation (objective 5) and the acceptability of the measurement instruments (objective 6). Interviews/focus groups with teachers (n = 12 interviews), children (n = 12 focus groups) and parents/guardians (n = 7 interviews/focus groups) were conducted at each of the eight participating schools.

To help refine a recruitment strategy for a future trial, parents or guardians who did not consent their child to participate (identified by teachers who would know which parents had not consented) were asked briefly and informally by researchers visiting the schools at drop-off times or by teachers themselves if they would be willing to share their reasons for not consenting (objective 1). The acceptability of the intervention (objective 7) and children’s, teachers’, and parents and guardians’ perceptions and experiences of the intervention and outcome measures were determined at phase 1 and further explored towards the end of the intervention period (phase 2), through a further set of interviews (n = 4 with teachers from the intervention schools) and focus groups (n = 4 with children from the intervention schools) (objective 8). This included exploring any negative effects, such as discomfort from the monitoring equipment, reasons for non-compliance with the outcome measures or class disruption. Potential differences in the trial and intervention acceptability between ethnic groups were also explored as part of the analyses from the focus groups (objective 4). Towards the end of the intervention period, four interviews were conducted (with senior staff, head teachers/deputy head teachers) at each intervention school to further examine the acceptability of the intervention (objective 7). To assess intervention fidelity, intervention classrooms were observed by a member of the research team on two occasions and children’s posture during sit–stand desk use was recorded to assess any potential future risk of musculoskeletal injury.

Throughout the process evaluation, we used the conceptual framework of Hasson196 to guide the analysis of intervention fidelity and to explore adherence to the intervention (content, coverage, frequency and duration), and potential moderators of adherence to the intervention (including participant responsiveness, strategies used to facilitate implementation, quality of delivery and contextual factors).

Interview and focus group participants: acceptability and fidelity

For the interviews with participating teachers, the study co-ordinator contacted each teacher by e-mail or telephone to invite them to participate. Interviews took place at the school at a time of the teachers’ choosing. For the focus groups with children, teachers were requested by researchers to nominate three boys and three girls within their class who were confident and would want to participate in a focus group. Selected children were asked to take an information sheet and parental consent form home for their parents or guardians to read and to provide written consent for their child to participate in this phase of the research.

For the focus groups with parents and guardians, we aimed to conduct eight focus groups (one for each school) with parents and guardians who had given their consent for their child to participate in the trial. We aimed to have approximately four to six parents or guardians taking part in each focus group. The strategies employed to recruit parents/guardians to focus groups were (1) via a letter sent home from the school to parents and guardians with children who had consented to take part in the trial, detailing an exact time and date of when the focus group was going to take place (all focus groups took place in each of the schools); and (2) schools with a text message system (n = 3) sent out a reminder text on the morning of the focus group. Each of the eight teachers were asked whether or not a translator would be required before the day of the parent and guardian focus group. Only one focus group required a translator. The translator was a member of the Born in Bradford research team who had prior knowledge on the topic guides and the purpose of the focus group. All other focus groups were conducted in English.

Prior to the start of the parent and guardian focus groups, the purpose of the session was described and participants were requested to provide written informed consent. Finally, for the interviews with head teachers and senior members of staff, the study co-ordinator contacted each of the school’s head teachers and senior members of staff by e-mail or telephone to invite them to participate in an interview at the end of the study, to inform the context part of intervention fidelity.

Interview and focus group procedures: acceptability and fidelity

All of the interviews and focus groups, across both phases, used semistructured topic guides (see Report Supplementary Material 3) to ensure consistency. Questions were open ended to enable participants to raise issues important to them. Topic guides for focus groups with children were written in a language suitable for children aged 9–10 years. All interviews and focus groups were audio-recorded digitally.

Informal conversations with non-consenting parents, guardians and children: acceptability

For the informal conversations with non-consenting parents, guardians and children, teachers or researchers spoke to parents and/or children and simply asked ‘what were the reasons for not signing up to be part of the study?’. Researchers and/or school staff recorded the answer given to the question, along with the child’s sex and what relation the parent or guardian was (e.g. mother, father, grandparent, carer). This approach was taken as teachers felt that asking parents and children to a formal focus group or interview to speak about the trial in which they did not want to participate would possibly make them feel uncomfortable and less likely to speak openly.

Classroom observations: assessment of intervention fidelity and musculoskeletal discomfort

As part of the pilot assessment of intervention fidelity, intervention classrooms were observed by a trained researcher for the duration of at least half a school day (3 hours) during the spring (March, April and May) and summer (June, July and August) terms. Therefore, a total of eight observation periods, two per intervention school, took place. During the observation periods, the researcher used an adapted version of the postural observation technique developed by Benden et al.63 to observe individual children’s postures while working at a height-adjustable desk (either sitting on a stool or standing), during class time. This was to assess potential future risks of musculoskeletal injury (objectives 8 and 9). The observation of individual children lasted for 10 minutes, with the researcher first positioning themselves such that they were able to see the sagittal plane of the individual child. The researcher then started a stopwatch and used the Benden et al.63 postural observation sheet (see Report Supplementary Material 3) to identify the posture that most closely resembled the position of the child at the start of every minute for 10 minutes. During the 10 minutes, whether the child’s neck was in extension or flexion, or whether or not the child was resting their elbows and/or forearms on the workstation was also recorded.

The sex of each child was also documented by the researcher, along with the time, lesson/subject and month of the year. If a child was absent from their desk at the beginning of a minute during the 10-minute observation, the researcher marked an ‘X’ and treated it as a missing data point for analysis. Similarly, if the observed child moved during a minute of data collection, the researcher noted it in the ‘comments’ section of the data collection sheet.

The fidelity observations occurred at the same time on the same day as the posture observations. While present in the classroom, researchers had informal conversations with children during natural breaks of the day about each of the intervention components. Researchers also observed and tallied the number of boys and girls either sitting or standing while using the sit–stand desks every minute during the posture observations; this measure provided minute-by-minute data of how the sit–stand desks were being used during class time.

Two researchers conducted both posture and group (fidelity) observations. The interobserver agreement, using interval-by-interval agreement was ≥ 85% for each component of the observation tools.

Qualitative data

Audio-recordings were transcribed verbatim with anonymisation of all personal data. Interview data were then analysed using thematic analysis.197 The process involved the following steps.

Familiarisation

The researcher became immersed in the raw data by ‘repeated reading’ of the transcripts and listed key ideas for coding.

Generating initial codes

Initial codes and a coding framework were developed, informed predominantly by the objectives of this qualitative component (a deductive approach), although novel views expressed by the participants were also captured (an inductive approach).

Searching for themes

The codes were then organised into potential themes and subthemes. At this point, similarities and differences in views ‘within’ and ‘across’ participant groups (teachers, children, parents/guardians, head teachers) were explored. Owing to the similarities between the sound of boys’ and girls’ voices and all the children in general, transcribers could not distinguish between individual children. Therefore, comparisons were made between the different focus groups rather than individual children.

Reviewing themes

Coded data within each potential theme were reviewed and the themes were modified so that they formed a logical order. Each theme was then further reviewed to ensure that it fit within the entire data set.

Defining and naming themes

A short paragraph was produced for each theme and subtheme to define the ‘essence’ of the theme and subtheme and allocate a name.

Classroom observations: musculoskeletal discomfort

For both group and posture data, descriptive statistics are reported. As this is a pilot study, not powered for statistical significance, statistical tests were not performed.

Results

Some quotations in this section are reproduced with permission from Clemes et al.81 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.

Interview and focus group participants

Teachers

We recruited four male (n = 3 control, n = 1 intervention) and four female (n = 1 control, n = 3 intervention) teachers. Four teachers were of South Asian ethnicity and four were of white British ethnicity.

Children

A total of 43 children, 22 boys and 21 girls, participated in the phase 1 focus groups; and 24 children, 10 boys and 14 girls, participated in the phase 2 focus groups (intervention schools only).

Parents/guardians

A total of 18 parents and guardians (13 mothers and five fathers) from seven of the eight schools took part in the focus groups and interviews during phase 1. We were unable to recruit any participants from one school after two attempts. The teacher at this school expressed that parents and guardians struggle to find time to attend any event the school organises, including the annual parents’ evening. This was a common theme for all schools.

The findings of the focus groups and interviews from teachers, children, parents and guardians are presented, according to the key study objectives that this chapter set out to address. We include illustrative quotations to highlight key themes and indicate whether quotations came from control (C1–C4) or intervention (I1–I4) schools, and the predominant ethnicity of the school [white British (WB) or South Asian (SA)].

Objective 1: to support the refinement of a recruitment strategy for schools and pupils

The recruitment processes

Teachers

All eight teachers expressed high satisfaction with the recruitment protocol, with the study being clearly explained:

Yeah, it was very well explained and the ideas and the concept behind what you were doing, so I had no hesitation accepting really.

Teachers across both control and intervention schools also commented that the recruitment approach was appropriate and suitable for children, especially the way in which the researchers explained to the children that this was a real-life science experiment:

It worked well. I think you got quite a good uptake . . . as a class, so obviously what you were sending out and the conversations you were having with the children got them quite enthused. I think with them, with the children they’re doing something scientific because they all sort of really love science, the idea of doing something scientific with scientists is like ‘yay!’. So jumped in on that.

Children

Children across all focus groups reported that recruitment was positive for them, the study was made clear and that everyone had a choice to participate:

It was good because once I got the letter I didn’t understand what it was or not. [Researchers] told us about the letter and our teachers told us about it and told our, told us to tell our mum if we want to go or not because you first need permission off your mum, and that’s why it was a good process because you got told three times.

. . . it’s more like you get to choose to take part and if you don’t want to then it doesn’t matter.

Parent/guardians

Parents’ views on recruitment were also generally very positive:

Um, the impression I got was all the class were asked about it but the children decided whether they wanted to take part in it or not but we had to give consent, so she brought form home and I think give consent by a certain date and then I had to sign it and then she was given full instruction as to what to do with it.

A small number of parents mentioned that having a parents’ meeting after school to discuss the project would have been useful, as some parents did not understand what it was and that it involved sit–stand desks:

I think if the school have had had a bit of a meeting just to explain that this is what you’re doing because then you just get a sense . . . because we get loads of letters obviously . . . and like sometimes you think ah, another letter.

Equally, parents stated that this might have been difficult to attend:

I think it’s always hard because you’ve got parents that are working and things as well to invite, you know. The school do a really good job of trying to invite you to these things but always people can’t participate.

Why did parents/children choose not to participate?

Seven out of the eight schools had a minority of children whose parents did not give consent for them to take part in the trial. Reasons for non-consent were collected from children (n = 17), parents (n = 9, eight female and one male) and one grandparent via brief informal interviews conducted by either a researcher or the class teacher. Reasons given for non-consent by children included being away at the time of the study (n = 1), their parents were not happy with their child being monitored (n = 3), their parents or other caregivers were not happy to give consent (n = 3), they were not comfortable with being monitored or being part of the research (n = 5), that they, or their parents, did not receive any information about the study (n = 3) or they forgot to return the consent form (n = 2). For parents and caregivers, key reasons for non-consent were not being aware of receiving information about the study (n = 6), being away at the time of the study (n = 1), their child being ill at the time of the research (n = 2) or that their child reported not wanting to take part in the study (n = 1). Across both parents and children, the most frequent reason for not consenting to the trial was because children either lost or forgot consent forms, or information about the study was never brought home or made clear to parents. This was reported by 11 out of 27 respondents.

Objective 5: assess the acceptability of randomisation to schools

When asking teachers and children about the acceptability of randomisation, both groups expressed that there was a clear understanding of why the randomisation had occurred:

Well yeah because it makes it fair doesn’t it, it keeps everything on a level playing field and you wouldn’t necessarily want to choose your school because you are hand picking, whereas if you randomise it you make it really clear that you have got an equal chance of having desks in and going through doing those, so it just keeps everything fair doesn’t it really.

Because then you can look at the schools that have the tables and the schools that didn’t and look at the difference in health.

This was true even with teachers and children from the control schools, who were understandably disappointed not to be receiving the sit–stand desks. However, they still considered their participation in the trial to be positive and clearly understood why it was required:

Well, I completely understand why you need to have a control. You know, we teach the children, that certain investigations need a control, you need something to compare it against . . .

Well a bit sad but I felt happy at the same time because at least we’re taking part in something.

As for parents and guardians, most thought that it was a fair process:

I think it’s fair, it’s a fair process because it doesn’t . . . it’s a neutral process as well so there’s no bias towards anything and pick and choose, schools that could be biased there so this was like totally random, I think it was fair.

Objective 6: assess the acceptability of measurement instruments to teachers, children, parents and guardians, including the activPAL inclinometer as the tool for the measurement of the primary outcome

Thoughts on the activPAL

Teachers

When asked questions regarding the acceptability of the activPAL (as a primary outcome measure), the most common theme identified was the sometimes problematic issue of using the medical dressing [Hypafix^® Transparent (BSN medical, Hull, UK), also referred to as ‘stickers’ or ‘sticky pads’ by the teachers/children/parents] to attach the monitor. In some cases, this reportedly caused a minority of children to suffer from itchiness, soreness and discomfort, along with some class disruption:

Yeah, it was a bit faffy. Some of the children did complain about getting a bit of a rash, but they like to complain anyway, so it was a bit . . . I don’t want to use the word chaotic, but that was more to do with the fact that the kids were constantly, interested by them so they were focused on them . . .

However, teachers did not feel the issues associated with the medical dressing to be significant, as only a few children complained [e.g. ‘there were only a few complaints . . . ’ (Teacher, C2, WB); ‘Only a couple of them had a little reaction to it’ (Teacher, I4, WB)]. Researchers provided plenty of medical dressing so children could always replace it if required {e.g. ‘It wasn’t a big issue [monitor coming off] We had plenty of supplies . . . ’ (Teacher, C1, WB)}, and children also knew how to correctly replace the dressing, which did not cause extra burden for teachers [e.g. ‘Yeah it was absolutely fine, they, you know, they were shown how to put it on correctly, I didn’t have to do anything for them’ (Teacher, I4, WB)]. Teachers also spoke about how children had the resilience to get on with wearing the monitor and do their best to wear it for as long as possible. Teachers also noted that the activPAL monitor was not noticed by the children once they got used to wearing it, with the position of wearing it on the thigh aiding this:

I think once the children got used to wearing that it was OK for them. I think the fact that it stuck to the leg and once they had got their clothes on during the day it is something that they don’t need to worry about, they don’t fuss about, whereas sometimes if it’s out, if it’s on your arm or on your wrist then they start to play with it. So I think the positioning of where it is on the body is good.

Children

During the focus groups, 10 out of 43 children reported feeling some discomfort related to the activPAL:

When you tried to take it off it really hurt.

When I took it off I had a bit of like a little rash or a few spots, from the underneath because my leg got quite sweaty.

As with the teachers, children concluded that using medical dressing to wear the activPAL was problematic. The children explained they had to constantly replace the dressing as it became loose, mostly because of bathing or swimming:

Yeah and the stickiness was bad, it kept coming off, so then when I got a new one [sticker] I couldn’t put it on properly.

Parents

The key themes emerging from the parent interviews and focus groups regarding the activPAL were very similar to those of the children and teachers. Four out of 18 (three mothers and one father) reported a mixture of discomfort and itchiness experienced by children when wearing the activPAL, and feelings of confusion and frustration at times around the use of the medical dressing to attach the device, particularly when bathing:

My son found it quite itchy and irritating and he couldn’t put jeans on because it was a bit annoying but otherwise.

‘The little thing when they were getting a shower, the sticky thing were coming looser and I can remember one night he couldn’t wear it because it literally wouldn’t stick.

However, the majority of parents and guardians from both control and intervention schools reported no problems regarding their children wearing the activPAL, and some reported that their children liked wearing the monitors:

It’s all right, it doesn’t hurt anyone, you know what I mean, it’s not in no-one’s way or not.

Well, my daughter, she loved it, she’s like ‘mum, I’ve got this on me thigh, I can’t get it wet, I’ve got to change it and it counts me steps’! So she were quite happy with it, I didn’t find ought wrong with it, it weren’t in way for any sort of reasons.

Thoughts on the ActiGraph

In response to questions regarding the ActiGraph, a clear theme was that the ActiGraph was much easier and more feasible for children to wear than the activPAL; this was true for all teachers (8/8), most children (38/43) and most parents (15/18):

Again, I think that was nice and, nice and easy to wear that one, wasn’t it, so it was comfortable . . . So, no problems with that one.

However, some children (n = 15) reported that wearing the ActiGraph was uncomfortable during sleep:

It was OK but when I went to sleep it annoyed be a little bit, but I just moved it somewhere else, to my other side of my hip, and it was actually a little comforting because of the elastic band.

Some children reported that it could be improved by being waterproof:

All right. This one it’s good that it goes around your waist because I had the problem for about the other one, and I think it doesn’t really hurt like the other one. But I think like everyone will say if it was waterproof it would be better because we don’t have to take it off.

A small number of parents (n = 3) mentioned that they were not sure how the ActiGraph should have been worn and what it was meant to do:

It slipped down quite a lot. There was a lot of, you know, it seems to be down here rather than up here and then there was a concern as to did it have to be in a certain place? Was it [laughs] monitoring heartbeats or anything that are less likely, you know, it was more a bit of ‘oh well it’s wobbled down and I don’t know where to put my skirt versus where that should lay’, just that kind of uncomfortable. Nothing particularly went wrong with it.

Other measures

During the focus groups, teachers, children and parents were also asked about the acceptability of the other measures (e.g. physiological, questionnaires) that were taken as part of the trial. For most teachers, there were no issues with any of the measurements taken, but one teacher commented that the Strengths and Difficulties Questionnaire added more time to an already heavy workload:

. . . the only negative would be the questionnaires that take a while to fill in [Strengths and Difficulties Questionnaire]. It’s time-consuming, that’s all it is and for a teacher who already has sort of 60 books to mark with this time of year we’re looking at reports to write, like you name it, we’ve got a massive list of things to do.

As for the children, they deemed all but one of the measures to be fun and enjoyable. The one measure a number of the children did not like was the RVIP test, which they reported to find boring and difficult.

Finally, parents felt that the health resource use questionnaire was quite burdensome:

. . . we get so many letters and stuff to read and forms to sign, I forgot about this form . . . I would off put it to one side to finish later but forgot, you know having more than one child is a full time job and they all bring, you know, so many forms to complete [from school].

Objective 7: assess the acceptability of the intervention to teachers, children and parents

Randomisation into the trial conditions occurred following baseline data collection (January 2017). The sit–stand desks (Ergotron LearnFits) were installed into the intervention classrooms at the very beginning of March 2017; the delay in desk installation was caused by shipping delays experienced by the desk manufacturer. Before the desks were installed, the researchers met with the teachers to provide them with training on the various intervention components. The teachers were provided with the Stand Out in Class training manual (see Report Supplementary Material 1) and a member of the research team met with each intervention teacher individually for approximately 1 hour, when they explained the various intervention components. During this meeting, the researcher encouraged the teacher to consider how they could rotate children in their class across the week, to ensure equal exposure to the desks. The teachers were also asked to consider how they could implement other intervention components.

Once the sit–stand desks were installed and on the first day of exposure to the desks, the researchers led a children’s workshop within each intervention class (including all children in the classroom), in which the various intervention components were described. This workshop concluded with all children, and their teacher and any teaching assistants, signing the social contract. During this visit, the researcher also discussed with the teacher their thoughts on a rotation plan for exposing children to the sit–stand desks and answered any remaining questions about the intervention.

The first phase of the qualitative work to examine the acceptability of the intervention centred around participants’ initial thoughts and experiences of using the sit–stand desks. This information was gathered from focus groups with the children and parents, and through interviews with the teachers conducted a few weeks after the installation of the sit–stand desks (phase 1). Further insights into all intervention components (the desks, training provision, nudging prompts, the social contract, researcher/practitioner support) were gathered towards the end of the intervention (phase 2) through a second set of interviews (with teachers) and focus groups (with children).

Sit–stand desks: initial thoughts before installation

Teachers

All of the teachers initially thought that the sit–stand desks, and the intervention in general, were positive:

They sounded really good, yeah, I thought they sounded like they’d suit my class really well.

However, there was some apprehension regarding the size of the desks, not knowing how large the desks would be and the issues this would have in terms of safety in the classroom:

First thought was possibly about safety and how they would work within the classroom, thinking obviously about the size of them, would they be bigger than our normal size desk, would they be smaller . . .

One teacher also had concerns regarding how the rotation system would work, but these soon subsided following the training and after a short period of time of using the desks:

I thought it would be good, I also was a bit worried that it would be a pain with the whole, when we were doing that timetable like, ooh, but actually I was wrong, they’ve been fine and the way that we can use them and stuff. Like I said, now, but also as a school in the future it will be really good.

Children

One of the common themes stemming from the children’s focus groups was around what others from outside the classroom would think about the desks:

. . . I thought it was sick [having the desks] because if you came into your class and visitors come into your class, they might look at the stand-up tables and they might be thinking that this school likes to do lots of science experiments and do lots of different projects.

Other themes included the perceived positive health benefits of using a standing desk:

I thought it would be good because, like, it’ll help us to sit straight and not always limp down.

I was a bit confused because I didn’t know how sitting down was bad for you but then when you explained I was more ready.

Finally, the benefit of changing behaviour was recognised, in particular that of boys fidgeting in the class:

When I first heard about them I was like, whoa, if we have these in our class it will like really change boys’ behaviours because some boys, not me, are fidgety so it would be good for them to stand up.

Parents

The initial thoughts of parents about the sit–stand desks were mostly positive:

See I think it’s good because . . . you get up don’t you and walk about and want to walk about, kids can do this?

In addition, parents were pleasantly surprised by the size and quality of the sit–stand desks:

They’re perhaps a little bit bigger actually, you know, as in sturdier than what I imagined them to be.

Sit–stand desks: initial thoughts after installation and during the first weeks of use

Teachers

Having had the desks in the classrooms for a few weeks, teachers’ views on the desks remained positive and some of their initial anxieties about them did not materialise. One teacher was unsure whether or not the sit–stand desks would hinder their goal of improving handwriting and presentation; however, this was not found to be the case:

No, they’re better . . . the pessimistic side of me was . . . I was a bit, you know, as much as I thought ah brilliant, it will be a different way to explore teaching styles a different way to deal with these different things, the kids will enjoy it, I was thinking our big push is presentation and handwriting in school and I thought if they stood up, will that change, I thought it wouldn’t and actually I would say it certainly has not harmed handwriting and presentation?

Another teacher first thought that the children would misbehave with the sit–stand desks, but found that this generally did not happen in practice:

You know, I thought if we’re doing something and they’re . . . will they be constantly putting it up and down? But they’ve been so good with them and, you know, a few teething problems at the beginning but barely anything and they were with the kids that I thought would be fussy and they were fine. You know, no, they were fine, so better.

One teacher (I2, SA) reported many positive features of the desks, including the utility of the wheels and the design of the desks (‘Then we have got the wheels and we’ve got the locks on the wheels so we can move the children around. They can take their table and go and join another table if they need to for that work, so they are really useful to move around’); the height adjustment element (‘I also like the fact that they can stand up and they can raise the desk to the appropriate height which is a really nice thing.’); and the accessories with the desks (‘You have got pots so you’ve got places to put your pens, your paper, you’ve got places to put your whiteboards in . . . ’).

Children

Children provided much positive, as well as useful, feedback about the desks and how to improve them. Themes derived from the four focus groups were as follows.

Reduces discomfort while sitting

I think they were very helpful because whenever I’m doing my work I’m always like leaning over and it’s always hurting my back. And also whenever I’m sitting down the screen is like upwards so I’m always like this [slouching] and it’s always hurting my body and I don’t like it. But with the stand-up desks I could rather stand up so I don’t crouch like this or I can stand or I can put it up so I don’t have to like sit down on my table like this but look up to the screen like that.

Own space while using the sit–stand desks

I mean, because I’m quite a fiddler and with the tables you have your own space and I like this.

I liked it because it was only for one person to sit on, for each table. Because normally, when we have to share a table, there’s not enough space.

Disliked the design of the desk: presentation

This is quite random, like it needs to be more stylish, like . . . diamonds and fur and then purpleness.

The design of the desk (utility) positives and negatives

I think that I really like the design of the top, we have like these little holes where we can put our rulers, our pencils, our whiteboard pens and our water bottles, our purple pen, we could put anything inside and we don’t have to go to the box where we keep our stuff and get it out, where it can just be in front of us.

I dislike about it is that there’s chairs there, there’s stools there and that the brakes, because the brake sometimes can be hard to reach and they’re all at different angles, so I think if they’re both at the same place opposite each other it would be much more better.

Improvement of posture and health

. . . they help improve your body posture and each person gets like a fair chance to go on them once a week.

I prefer the like standing up on the tables because I like know that I’m doing the same amount of work and it’s like the same quality but I’m being more healthy whilst doing it.

Improvement of work and presentation

Yeah. And it also helped me in my presentation because you already know about Penny the Pencil. I think this might, if I get used to the curriculum I might even get up to gold and get about a hundred every single time because you don’t crouch and make your handwriting worse.

Like the choice to sit or stand in class

I like it because, like, every time you don’t feel comfortable while sitting down, you could just stand up and then you might feel more comfortable.

It’s like it’s a lot better than our tables because when we do our work, sometimes Miss says, sit down to do our work but then now with the stand-up-sit-down tables we can stand up more because I like working when I stand up especially when it’s stuff like art and stuff like that where you have to draw.

Parents

Parents generally considered the sit–stand desks as positive additions to the classrooms, particularly in terms of their ability to promote movement in class:

So I think that’s, I mean the break time that they get is quite limited as well. When they go home they want to have a rest and so sit down a bit more. And then, you know, my son goes to mosque for an hour so he’s sitting down again, so I think it is good for them to be standing up for a while as well.

Keep themselves active and motivated and, you know, moving about slightly more.

Sit–stand desks: thoughts and reflections towards the end of the intervention (phase 2 data collection)

Teachers

Towards the end of the intervention, all the teachers expressed that the desks had become part of the classroom. They had thus overcome some of their original worries, which included whether or not the desks would cause a distraction:

Yeah, it, well for me I’m now used to them so before, I think for the first month or so, I was kind of looking at them as to how would they work, how well would they work with the children, would it just be a distraction for them, but now it’s, it’s kind of just the norm for the children, and we’re kind of, we’re used to them and every week when we rotate round we, we just do it steadily.

Children

The children felt that having the desks in their classroom had been very positive, with key themes including changing behaviour for the better, having the option to stand and increases in personal space available:

I think of it as really good, because it changes your behaviour as well, so if you stand up and having a test, then you can move them around, rather than three people sitting on each table. It’s good that they have wheels and you can move around with them, and also it helps because when you’re standing up it makes less noise than pulling chairs, or then I go grab things, so it’s much more better than a normal table and chairs.

When I first saw the desks, I thought it was all plain and boring, but now, 5 months later, now it’s really helpful because people who don’t like sitting down, the desk is really useful for them.

Teachers’ training

The teachers reported that they were very pleased with the intervention training that they had received prior to the start of the study. One teacher reflected that having examples of desk use from previous schools had been really informative and that if it was not for the teachers’ training they would not have thought thoroughly about the groups and the fair rotation of the children:

Yeah, I think the fact that the things that you and [other researcher] already had in place from maybe previous schools or already set up was really good [examples of how other schools in previous studies have rotated children]. It gave us time to thrash out how we would do it fairly, how we would get all the children to have a go on the desks because that is something perhaps if you hadn’t of spoken to me about, I may have kept the same children on the desks for 4, 5 or 6 weeks without rotating round. It just meant that we were really structured in the way that we were using the desks and who was on them and everybody getting a turn.

Professional development/project manual

The teachers reported that they generally found the professional development manual (intervention guide) helpful and informative. However, three of the four teachers thought that the document was lengthy and that they struggled to have the time to read it thoroughly. It was also generally felt that the training provided alone was sufficient for them to understand the intervention:

Yeah, it’s quite, ah, lengthy . . . I think that was literally on that thing, I did skim it but I did think it was quite lengthy, I think it’s just because those types of things, you can get quite a lot of those throughout the day for different things and it’s always this, you just don’t have time to read it all so I skimmed it.

Nudging prompts

Teachers

Reactions to the nudge prompts were mixed. Three of the teachers reported not using the prompts, one teacher felt that the cards were not needed because the children were very engaged with the sit–stand desks and waited to use the cards should children’s interest and engagement decline:

I’ve not had to use them because I am saving them for when they need to get a bit motivated by it all.

Another teacher reported that the cards were not used because they were seen as not necessary and a possible distraction:

No we haven’t . . . I felt they haven’t been needed and that they might have been a bit of a distraction. I feel like the children have a lot to remember in the day anyway. I just thought it would be another thing to be checking on and another thing that might get kind of lost, so we didn’t.

Other reasons for not using the nudge cards included the perception that they were too childish and not suitable for children this age. However, one teacher felt that the cards were a good addition and gave ownership of the use of these to the standing leader/captain to encourage children to take ownership of the intervention:

We use those cards [nudge cards] and rotate those everyday which means that the children who are on the desk [standing desk], who have standing leader every day they can take ownership rather of it all rather than myself because it’s there for their desk really, it’s there for them.

Children

None of the children initially knew what the nudging prompts were until reminded by the researcher. Children from two schools stated that they remembered the nudge prompts, but that these were used only for the first few weeks of having the desks:

. . . oh yeah! We had them at first it was right at the beginning, no one really liked them though [chorus of agreement] . . .

The desk rotation plan

Teachers

The rotation system adopted by each teacher is discussed in detail Objective 9: assess intervention fidelity over the intervention period. Regarding acceptability of the rotation plan, all teachers ensured that their pupils were rotated around the class and that desk exposure was fair across all pupils. The teachers commented that sitting down with a researcher and gaining their help in devising a rotation plan was extremely useful, given their busy workload:

We did it about five or six times [rotation plan during training] in the different groups and then we got the groups that are the main groups but like I say then there’s that ability to then edit it in terms of what I’m teaching but still making sure that everyone gets what they’ve got. But I thought the actual sat down, because it’s one of those things that if I didn’t do it then, I just . . . not that I wouldn’t have done it, because I would have had to, but it’s just one of those things that if you do it there and then and sat down with researchers and just actually working out and making sure I’ve got it in there and then on Monday it was stuck up and they knew straightaway and it could start straightaway, it’s just one of those things that would have got further and further down the list. So, I found that really useful, just sat down talking with you guys and working out the school timetable and just getting that done, so that was probably the most use for me and the most use for the kids as well because they know where they are then.

Children

In all schools, the children confirmed that rotation took place consistently throughout the duration of the study. The issues raised by the children centred around how teachers rotated children differently and how two teachers changed the rotation plan during the study. This theme will be discussed in more detail in Objective 9: assess intervention fidelity over the intervention period.

Fortnightly support with researchers/practitioners

Although fortnightly support from the researchers via either telephone or e-mail was planned, this rarely happened in practice. The teachers reported busy workloads, that they seldom checked their e-mails and/or did not have access to a telephone in their classrooms, making contact difficult. Importantly, though, the teachers did not consider that they needed regular contact during the intervention because they felt confident delivering it following the training received:

. . . its really tough to do, it would be like really hard for teachers to do. We are so busy I never really check my e-mails and a telephone conversation is tough because its teaching or its marking or its reports, but if you are getting in touch to come into school I and most teachers will follow up any messages left with reception.

The 30-minute workshop with children

Both teachers and children felt that the workshops were useful and acceptable:

Yeah, I thought the talk with the children was fantastic, like honestly, because I said that. ‘I think you [researcher] should be a teacher’, like I thought they were all really engaged, I thought they understood well, I thought all the questions they asked were answered, it was pitched right at their level . . . I loved the examples of how they should use it and the examples given of good posture, bad posture, how the desks should be.

I thought it helped, because if we just had them without anyone talking to us we’d be like, how do you get them up?

A small number of children commented that they wanted an actual desk to practise with during the workshop. This applied to one class in which, due to timetabling restrictions, the workshop took place just before the desks were installed:

You could bring in one of them tables to show them how it works so it makes it a lot easier to understand for little children.

Standing champion/leader

Teachers

The standing champion was employed in each of the schools differently, with one teacher forgetting that there should have been a standing champion to motivate children to stand while using the sit–stand desks:

. . . completely forgot about the standing captain!

Another teacher rarely used this strategy because it was felt that it was not needed and would have been a distraction:

No we haven’t . . . I felt they haven’t been needed and that they might have been a bit of a distraction. I feel like the children have a lot to remember in the day anyway. I just thought it would be another thing to be checking on and another thing that might get kind or lost, so we didn’t.

One teacher drew on the standing champion to encourage children to take ownership and lead the group’s use of the sit–stand desks:

I wanted the children to think I am in charge today everyone using the desks should be using them to stand not to sit down all day, and also to ensure that everyone’s behaviour is good while on the desks. Like I have said I wanted the children to have ownership of this and the standing champion was part of this.

The fourth teacher incorporated the standing champion role at the beginning, but expressed that the incentive award proposed for this role was against the school policy:

You know and it just kind of fell a little bit and we’re not really supposed to like offer prizes and things at school . . . That’s sort of the school policy so there was no prize for it so they weren’t as bothered by it.

Children

Children’s perspectives of the standing champion element of the intervention differed across schools and, interestingly, differed from the perspectives of the teachers. Children from one school explained that the standing champion would be someone who would inform the teacher about the behaviour of the other children and the use of the sit–stand desks, which was deemed to be positive, as the champion/leader would receive a prize. However, this occurred only during the first few weeks:

A standing champion was actually so good, it was tempting for you to keep your behaviour good because when it was the end of the day and Miss makes a decision who was the champion leader, she gives a prize out to them, so I think it’s really good . . . little gifts, we have a box which she buys toys and then you go and then pick whichever you want . . . It kind of stopped like a couple of months ago.

As for the other class, one child again explained how the teacher implemented the standing champion role, which was awarded daily, instead of weekly, and how it was documented on the class display who had used the desks that day or not. However, as in the other class, this was not sustained:

No, he was like told that he was like in charge of it. There was a different captain every day . . . We had like this sheet of paper next to the window where at the end of the day we have to take it to say who has been on it and if a person hasn’t been on it we just write their name down . . . it stopped a long time probably near the beginning.

Group contract

The group social contract applied by the researchers at the end of the children’s workshop was an aspect that all four teachers praised, enjoyed and used. The teachers reported laminating the contract and displaying it in the classroom as a reminder to the children that they had agreed to use the desks appropriately:

. . . simple and yet great idea, laminated and put it up on the wall. Children this age like these kind of things, and it was great that those who did not take part in the measurement aspects had the chance to have a go at this and they themselves felt they were part of the study even though they did not participate in the measurements.

Overview of the trial: positives, negatives and things to change for the future

At the end of the phase 2 interviews and focus groups, the teachers and children were asked for their thoughts about the positive and negative features of the trial and what they would like to change in the future. Themes and example quotations are reported online in Report Supplementary Material 3. Reported in Table 21 are the ratings of acceptability for the trial’s procedures, measures and intervention components. There were no overall differences in the acceptability of the trial or intervention between different ethnic groups.

Objective 8: monitor any adverse effects, such as musculoskeletal discomfort and/or disruption to the classroom or learning, to inform the design of a full trial and minimise or eliminate any such effects

Musculoskeletal discomfort

There were no reports of any musculoskeletal discomfort when using the sit–stand desks in the focus groups with the children. Similarly, the results from the child-reported Body Comfort Survey (see Table 13) revealed an increase in the proportion of pupils (from both groups) reporting that they felt better at their desks at follow-up.

Posture

The researchers observed each of the four intervention classes twice, once in the spring term and once in the summer term. A total of 76 10-miunte observations occurred during the observation periods and posture was recorded every minute during each 10-minute observation. Of the 76 observations, 46 (60.5%) were of boys and 30 (39.5%) were of girls. A total of 56 observations (73.7%) took place in the spring and 20 (26.3%) took place in the summer. A complete set of observation data was not achieved for 28 (36.8%) children, due to their movement away from their desk during the observation period. Participants’ postures at 1-minute intervals were therefore examined; this led to 661 data points [boys n = 390 (59%); girls n = 231 (41%)].

Thirty-six per cent of the classroom observations recorded children standing and 64% recorded children sitting at the sit–stand desks. Children were more likely to exhibit unfavourable postures of neck flexion (> 20°) and neck extension (> 20°) when seated at the desks than when standing. A high proportion of children rested their elbows on the desks while working (48%) and there were no apparent differences in this posture between those seated and those standing.

Classroom disruption and pupil behaviour

The teachers reported minimal disruption to classroom and pupil behaviour resulting from the introduction of the desks. Any disruptions that did occur happened during the first few days of using the desks, but quickly settled down. One teacher explained:

Only really the first group for the first day or so and then once they had realised obviously to not to just play with them, I think more often than not it wasn’t necessarily the standing up, it was more lifting of the desk, putting it down, lifting it up.

Objective 9: assess intervention fidelity over the intervention period

We report intervention fidelity against the framework of Hasson,196 and fidelity (whether or not the intervention was implemented as planned), dose (frequency and duration of the intervention), reach and contextual factors are reported below. Participant responsiveness to the intervention (e.g. acceptability) is discussed in detail above (see Objective 7: assess the acceptability of the intervention to teachers, children and parents).

Fidelity: whether or not the intervention was implemented as planned

During the observation visits, the researchers documented whether or not the different intervention components (sit–stand desks being used, rotation plan in place, grouping of children as planned, standing champion, social contract, nudge cards) were taking place. A summary of the fidelity results are reported in Table 22.

Sit–stand desk use in the classroom

During the spring and summer terms, it was clear from the classroom observations, conversations with children, and from the phase 1 interviews and focus groups that all sit–stand desks were being used across all intervention classes. However, the use of the desks did change during the trial for intervention schools 1 and 3. In intervention school 1, the teacher decided to remove the stools from the sit–stand desks, and did so before the start of every school day and again before lessons began after lunch. Stools were stacked up in the corner of the classroom. The children had the option of using the stools should they so choose, but they were required to collect them. The teacher removed the stools to encourage children to stand:

I noticed they were sitting more and more, you know, I just moved um, put them in the corner, because after all it’s easy it’s just take them away [remove stools, place in the corner] because if there’s a chair there, you’re going to sit down. If there’s not, then you don’t so.

The children viewed this to be acceptable, with one explaining:

I think it’s better if the chairs are in the corner, because when we got them at first we stood up a lot but after a while everyone just sat down, now Miss has moved them we forget to even sit down spend all lesson standing and no one cares . . . well I don’t care!

In intervention school 3, the teacher who was originally recruited to the trial was absent for the first 3 months of the intervention and was absent for the original training. On their return from leave, this teacher observed how the stools were being used and decided to remove them completely:

When I first arrived in the class I noticed that they were using the desks, but mostly sitting, they were on a rota basis, and some children wanted to use a desk to stand but would have to wait a week to have a go, so I removed the stools and reminded the children that if they wanted to sit down, they already had a place in class to sit, the standing desks were there to stand-up on.

Rotation plan and grouping of children (intervention dose)

Only one school implemented the rotation system recommended during the initial training and outlined in the intervention protocol (i.e. of two groups of six children using the sit–stand desks every day). Despite this, all schools devised a rotation plan and had it clearly displayed. The two predominantly white British schools had one group of six children use the sit–stand desks daily. The final school opted to have one group of six children use the sit–stand desks per week. Reasons given for not following the protocol included that the twice-a-day rotation was not suited to the dynamics of the particular classroom and a preference for children to manage the rotation themselves:

I don’t think rotating them twice in a day is really feasible within my class the way we run things, with different sets for different classes.

. . . they knew where the rota was, they knew when to check it, they knew when they were changing and it’s been absolutely fine for my class to do that themselves and independently, it’s what I promote.

One teacher who did follow the twice-daily rotation protocol reported that she had no issues in doing this, but was thankful for the intervention training:

Yeah, it’s not a problem at all, it’s really easy, quick, simple to do rotate . . . But I thought the actual sat down [training], because it’s one of those things that if I didn’t do it then, I just . . . not that I wouldn’t have done it, because I would have had to, but it’s just one of those things that if you do it there and then and sat down with researchers and just actually working out and making sure I’ve got it in there and then on Monday it was stuck up and they knew straightaway and it could start straightaway.

Standing champion

Three schools reported to implement a standing champion in the first term, but during the final term only one school had maintained this role. The standing champion role was sometimes used as a reward for children who had been using desks well and/or who had been well behaved. Standing champions were employed to ensure that the rotation plan and groups were correct and that children were using the sit–stand desks correctly and safely.

Social contract

Three of the four classes clearly displayed the social contract signed by all children, with this tending to be displayed alongside the rotation plan and groups. However, during the focus groups, four children expressed that they had no memory of the teachers referring to the social contract:

I thought that it never existed [response to discussion of social contracts], I think we all forgot that it did exist, though.

Nudge cards

Nudge cards were inconsistently used in the intervention. All schools tried using the cards but reports from both the teachers and children indicated that they were of limited value and were thus discontinued. None of the schools used the nudge cards on the days of the observations, in either the spring or summer terms.

Reach

It was clear from the classroom observations and qualitative research that all children had access to the sit–stand desks throughout the trial and that teachers tried to fairly expose children to the desks.

Contextual influences

From the interviews with the teachers and senior members of staff towards the end of the intervention, it was evident that the political, organisational and economic context of the school had no impact on the fidelity of the intervention. The participating teachers were not negatively affected by an increased workload relating to the trial and from the head teachers’ perspectives; two of the head teachers had deliberately selected teachers to participate who were efficient in managing their workloads:

. . . [teacher] is super at managing her time and hence why I agreed it would work with [teacher], other members of staff I would have said no it wouldn’t have been and I think then it would have been a problem.

All schools were fully committed to the study and had no internal organisational or political constraints or issues that had an impact on the fidelity of the intervention. One potential barrier to the use of the desks was seen to be cost had schools had to purchase them themselves:

No there’s been no economical consequences, obviously because we’ve not paid for anything. If we did, then looking at the budget, that wouldn’t be a possibility.

In conclusion, the four intervention schools and head teachers welcomed their involvement in the trial and ensured that the teachers and pupils had full support to participate fully in the intervention.