9th Biennial ACSPRI Social Science Methodology Conference

Introduction
Effective chronic disease prevention initiatives (policies, programs, and practices) need to be implemented and sustained in key settings to achieve long-term public health impacts. While progress has been made in understanding how to implement initiatives, their sustainment, especially after external support ends, remains understudied. Systematic reviews indicated that only around 20% of initiatives sustain after the initial implementation period (1). However, some programs do continue without ongoing support. This approach, termed ‘self-sustaining’, has been defined as: “when implementation of the EBI by an organization (e.g., hospital, clinic, school) is expected to continue (sustain) in the absence of external (agency) support”(2).

Sustaining initiatives offers numerous advantages including efficient resource allocation within no ongoing costs, maximising benefits for the target settings, and achieving a broader public health impact. With many initiatives implemented with short-term, non-recurrent funding, understanding how to sustain after the funding period is critical. This requires understanding the conditions that lead to self-sustainment, information that can be translated to the program design phase to facilitate long-term sustainment.

Novel methods are warranted to advance this evidence base, given the lengthy timelines required for longitudinal sustainment research. One such method - increasingly recognised for its ability to explore program mediators while accounting for the variability present in complex settings - is Qualitative Comparative Analysis (QCA) (3). QCA allows for the configuration of necessary and/or sufficient conditions that lead to an outcome of interest, offering insights into program sustainment. This study aims to identify the conditions associated with the self-sustainment of chronic disease prevention initiatives, specifically focusing on those in the school setting (i.e., school-based programs which have sustained after the cessation of external support).

Methods
This study will use a crisp-set QCA (csQCA) methodology, as outlined by Kane et al (3). Comprehensive case studies of self-sustaining initiatives will be developed using various data sources, including research staff insights, systematic reviews, published data, grey literature and publicly available websites. Definitions and thresholds for both cases and conditions of interest will be ascertained through an in-depth literature review; expert consultations; and ongoing discourse within the research team inclusive of sustainability experts, implementation scientists, school-setting practitioners, and a qualitative research expert trained in QCA.

Conclusion:
This study will be the first to rigorously explore the conditions that are necessary and/or sufficient for initiatives to self-sustain in the school setting. Specifically, this will isolate the key factors that operationalise self-sustainment which, translated into practice, may support the design of programs with the best chance to sustain without ongoing support. This is particularly valuable for settings with limited resources and/or multiple competing interests, such as schools. Additionally, this study will contribute to the growing public health research applying QCA methods and set precedence for future applications of QCA.

References
1. Wiltsey Stirman S, Kimberly, John., Cook, Natasha., Calloway, Amber., Castro, Frank., and, Charns M. The sustainability of new programs and innovations: a review of the empirical literature
and recommendations for future research. Implementation Science. 2012;7(17).
2. Wolfenden L, Shoesmith A, Hall A, Bauman A, Nathan N. An initial typology of approaches used by policy and practice agencies to achieve sustained implementation of interventions to improve health. Implement Sci Commun. 2024;5(1):21.
3. Kane H, Lewis MA, Williams PA, Kahwati LC. Using qualitative comparative analysis to understand and quantify translation and implementation. Transl Behav Med. 2014;4(2):201-8.

Introduction: Schools have been identified as a key setting to deliver public health programs. To fully understand the value of school-based public health programs, it is essential to explore not only the primary health impacts but also any additional benefits they may offer for children. Additionally, exploring how these programs affect different subgroups of children can help to address health inequities. This information is attainable through qualitative research methods, however school-based research rarely includes children. We used novel qualitative methods with students, supplemented with interviews of teachers, to explore the impacts of a daily sport uniform policy aimed to improve student physical activity.

Methods: We purposively sampled schools from urban and rural areas in NSW, Australia that had implemented a daily sport uniform policy. Consenting schools facilitated recruitment of teachers and student participants. Semi-structured focus groups of students and interviews of teachers were conducted during school break time. For student focus groups, we used creative, age-appropriate techniques such as visual and written responses on post-it notes and physical movement to ensure student comfort while enhancing their engagement and contribution. Inductive thematic analysis was then used for both data sets (students and teachers), with triangulation of findings across data sets.

Results: Focus groups and interviews involved 13 students and two teachers across different schools. Students were highly engaged with the focus group activities, eliciting rich verbal and written/visual data for analysis. Analysis revealed several key findings: sport uniforms not only enhanced student physical activity during and outside schools hours (as intended), but they also had numerous other positive impacts on student wellbeing including reduced stress, and increased comfort. The daily sport uniform was especially important for girls, allowing them to move freely and feel more confident every day of the school week.

Conclusion: The use of innovative and pragmatic qualitative methods in this study allowed for an in-depth exploration of the impacts of a daily sport uniform policy, capturing both anticipated and unexpected effects on students and teachers. The method we used ensured high engagement and comfort among student participants, yielding rich, multi-dimensional data. The triangulation of findings from both students and teachers strengthened the robustness of the results. These methodological approaches underscore the value of qualitative research in school settings, particularly when working with children, and demonstrate the importance of using intentional qualitative methods to fully capture the diverse impacts of public health interventions.