School-PACT: School Physical Activity Cultural Transition. A school-based physical activity intervention integrating social marketing with theories of practice

School-PACT: School Physical Activity Cultural Transition. A school-based physical activity intervention integrating social marketing with theories of practice. Conference track: Critical social marketing Introduction Epidemiological research and public health policies increasingly position physical activity as being important for population health globally. The World Health Organisation, for example, considers physical inactivity to be one of the leading causes of noncommunicable disease (NCD) (WHO, 2018a) and has recently developed a new global action plan to help countries scale-up policy actions to promote physical activity (WHO, 2018b). Ambitions to realise long-term public health goals have led to the implementation of numerous social marketing initiatives focusing on children’s physical activity (e.g. Designed To Move in the United States, Change4Life in the United Kingdom, Get set 4 life in Australia, and Eat Move Live in New Zealand). These initiatives variously involve national media campaigns, changes to Physical Education curricula, and increasing resources and opportunities for school sport. Indeed, there also exists a large body of interventionist research attempting to increase physical activity through the delivery of programmes in school settings (Dobbins et al., 2009). However, The Lancet’s latest series on physical activity raises the concern that “although more countries today have implemented physical activity surveillance systems and national strategies for promotion of physical activity, population physical activity levels have not increased” (Anderson et al., 2016). A significant body of critical scholarship exists problematizing the individualist-behavioural approaches that are predominantly adopted (Phoenix et al., 2018; Blue et al., 2016; Delormier et al., 2009; Baum and Fisher, 2014; Nettleton and Green, 2014). Current approaches often align with what Shove (2010) refers to as the dominant ‘ABC’ (attitude, behaviour, choice) paradigm in behaviour change policy which has been criticized for its inability to consider the powerful role that socio-cultural and policy contexts play in shaping the practical actions of everyday life (Cohn, 2014). Furthermore, Kelly (2018) argues that the simple causal narrative between lifestyle behaviours and disease may be accurate, but it is a mistake to assume that disease prevention strategies should simply rely on reversing the causal pathway and focus on changing behaviour. As such, there is a growing understanding that effective interventions need to go beyond ‘behaviour change’ and account for the complex social systems within which behaviour manifests (Maller and Strengers, 2015; Spotswood, 2016). We suggest that it is necessary to develop critically informed approach that eschews the problems associated with the individualist-behavioural paradigm yet is capable of meeting the challenge of improving children’s physical activity levels for which there is a strong epidemiological mandate. Approaches that account for broader social and policy contexts do, of course, already exist and they are being more widely adopted. As clear examples, the socio-ecological model has long been established (Lawson, 1992) and the ‘whole school approach’ embedded in the UKs Healthy Schools programme was intentioned to shift focus away from pupils. However, while it is encouraging to see the emphasis on a ‘systems approach’ to physical activity in the WHOs recent action plan (WHO, 2018) and the movement in behavioural change research towards ‘nudges’ – contextualised as socio-material interactions as opposed to the reliance on conscious, rational decisions making – our optimism remains guarded in a concern about the potential slippage from being systemic and socio-critical in intention to being individualist-behavioural in action. To support the systemic socio-critical intentions of public health policy, we have devised a programme of intervention for physical activity based on theories of practice, focusing on school cultural transition. We conceptualise school culture as an ecosystem of dynamically unfolding practices, which are our sites of intervention. Theoretical underpinning This study uses a practice theoretical framing, following a burgeoning suite of papers which recognise theories of practice for their potential in illuminating new ways to change socially harmful behaviours (Meier et al., 2017). Whereas traditional health research foregrounds individual action and views it as determined primarily by motives and intentions (Cohn, 2014) theories of practice, in contrast, view practices such as eating, exercising, smoking, drinking alcohol or walking not as the outcome of deliberative consideration or in relation to forms of constraint, but as emerging from the actions of people as they routinely navigate the mesh of practice templates which shape their worlds (Schatzki, 2002). Practices are the bodily-mental routines (Christensen and Ropke, 2010) that are coordinated and synchronised across space and time (Giddens, 1984; Blue et al, 2016), guiding the routinized performances of social actors (Bourdieu, 1984), which are also reconstituted by the recursive performance of those actors. Practices have an anatomy (Schau et al, 2009) made up of elements; material things, competences and meanings (Shove et al, 2012). Materiality often directly implicates the conduct of daily life (Shove and Pantzar, 2005, p.44). ‘Meanings’ refer to the unconscious forms of knowledge and shared ways the world is understood amongst practitioners (Shove et al, 2012); often embedded as an unreflective sense of the ‘right’ way to behave (Rettie et al., 2012), or of “understanding, knowing how and desiring” (Reckwitz, 2002, p.250). Competences are the “multiple forms of understanding and knowledgeability” (Shove et al, 2012, p.23) or ‘skills’ required by practices in order for a practitioner to successfully perform them. Southerton (2006) helpfully adds temporalities to this schema; the times of day, duration and temporal positioning of performances. Practices cannot be reduced to any one element (Reckwitz, 2002,) and “practices emerge, persist, shift and disappear when connections between elements of these three types are made, sustained or broken” (Shove et al. 2012, pp.14–5). Over time and through repetition, practices become entwined with others in blocks (Reckwitz, 2002) or complexes (Schatzki et al, 2001) and normalized; co-constituted through their routinized performance (Shove et al., 2012). The individual is the ‘crossing point’ or ‘carrier’ of a multitude of practices (Reckwitz, 2002). Cohn (2014), amongst others (Bell et al., 2011; Nettleton and Green, 2014; Blue et al, 2016), argues for a new paradigm of thinking about health behaviour change in which the term ‘health behaviour’ is replaced with the term “health practice”, because reifying ‘behaviour’ “fails to provide any critical insight into what people actually do and why” (p.160) and how to change it. Cohn’s gauntlet has been taken up in a burgeoning stream of research by authors using theories of practice to advance our understanding of health and intervention (Blue, 2017; Keane et al, 2017; Lindsay, 2010; Meier et al, 2017; Supski et al, 2017). For example, Blue et al. (2016) and Maller (2015) argue that labelling particular practices as 'unhealthy' or 'healthy' is unhelpful. Rather, practices such as smoking, classed as unhealthy, are small actions within larger practices like taking a tea break or celebrating a birthday (Meier et al, 2017). Examining behaviours in isolation will never provide a full picture of what is going on; for example, why problematic practices take hold and how they are resilient to efforts to persuade and support people into changing their minds. Studies using theories of practice tend to conclude that when seeking to tackle complex or ‘wicked’ problems such as physical inactivity and related obesity, policy and intervention approaches should treat practices as the sites of intervention rather than the individual (Blue et al, 2016; Meier et al, 2017). This approach allows for a helicopter view of a problem, away from an individual perspective that focuses on barriers and enablers, to a perspective focusing on the dynamics of practices (Blue, 2017; Supski et al, 2017). To influence the way practices are configured and performed, all of the elements of a practice 'as entity' should be targeted for intervention (Supski et al, 2017), which will naturally lead to an interdisciplinary perspective on how to manage social change (Spotswood et al., 2017). Secondly, intervention must consider the integration of, synchronisation and interplay between configurations of practices (Blue, 2017; Keane et al, 2017; Lindsay, 2010; Meier et al, 2017). Following from this critical position of individualist intervention approaches, including much social marketing, and given the practice-oriented theoretical basis of this project, we focus on a target set of practices rather than a target market in our intervention. The focus is children’s physical activity, but this is conceptualised as emerging from a system of practices which cluster in and through a school; which is a spatial and temporal coordinating agent. The purpose of the reported project was to identify practices from which physical activity emerges, understand how the configuration of practices enables or constrains children’s physical activity, understand how interrelationships between practices constrain or enable children’s physical activity and work with schools to design, implement and evaluate a programme of practice transition. Process of cultural transition This paper will draw on learnings from one of the pilot schools we worked with in Bristol, UK, during 2018. The process draws heavily on ideas for practice-oriented social change outlined by Vihalemm et al. (2015). The school is a state-run primary (age 4 -11) in a deprived part of the city who self-recognise as having a weak physical activity culture. Illustrated in Figure 1, the process of cultural transition blends co-creation and communication principles more traditional in social marketing with innovative practice-oriented intervention approaches. Figure 1: The process of practice-oriented physical activity cultural transition in primary schools Stage 1 involved convening the school cultural transition coalition by running workshops dedicated to discussing the value of physical activity which emerges from different practices in the school. During these workshops, held with children, teachers, parents and lunchtime supervisors, with slightly modified methodologies, the set of practices unique to the school were identified and clustered into areas of activity. For example, our pilot school focused on physical activity as emerging from PE, after school sports, whole school trips and events, active lessons, getting to and from school and breaktimes. These areas of focus will be different for other schools and are self-defined by the school. Each involves a number of different practices which bundle in unique ways. Discussions about the value of physical activity were facilitated to mobilise the school community into thinking positively about their existing school physical activity culture, to recognise and value the work already undertaken and to encourage the school to value equally the physical activity available in all areas of school life, beyond PE and traditional sports. Facilitators also invited participants to visualise the culture they would like and what they would like ‘more of’ or to be ‘different’. These workshops were captured in a brief report and distributed and disseminated across the school. Stage 2 involved recruiting child and adult champions for each of the focus areas, who volunteered to collect and disseminate positive stories about the different activities which make up the school physical activity culture. These stories were disseminated using the school’s existing systems of communication, including noticeboards, Twitter, Facebook, assemblies and newsletters. These stories were collected throughout the school year and formed part of the evaluation at the end of the year. These mechanisms were also used to invite further stories through a process of iteration. Stage 3 draws on learning from the mobilisation workshops to design a programme of cultural transition, drawing on an understanding of practices. Practices across the school were interrogated to identify meanings, materials and competences (Shove et al., 2012) which can be substituted, shaped or shifted. Integrated practice bundles were interrogated to understand whether the system of practices can be reconfigured more broadly, for example thinking about temporal sequencing. These changes will be implemented by the school across the school year (stage 4). Building on the mobilisation workshops, the school will be invited to identify a goal for each practice transition activity, and how this might be evaluated. Increasing minutes of physical activity may not be the goal of all or any of the sites of practice transition. Stage 5 draws on the co-created measurement targets established throughout the programme and uses a toolkit called ‘Revaluation’ to evaluate the full and emerging value of the programme of practice transition. The Revaluation tool involves capturing stories and hard data determine ‘what has been going on’ throughout the programme. Some value can be counted, such as minutes of MVPA, but other value is based on judgements and the emergence of networks and evidence supporting cultural shift. This evidence is recorded in a simple report, which is the result of a whole school workshop involving pupils, teachers and parents in combination with evidence collected separately in the form of interviews and survey data. This forms the final ‘full value’ report of the intervention’s efficacy, against a goal of creating cultural transition. Summary: Key principles of the cultural transitions approach: - The focus is on shaping practices, not targeting or influencing people’s behaviour. - The school defines what practices are important to focus on and what elements of each practice constrain physical activity. The school also identifies how practices interrelate and the implications of these interrelationships for physical activity. - Intervention at the level of practice is based on co-created ideas from the school community, and are designed to fit with the existing system, i.e. requiring little additional resource. - Evaluation metrics are co-created by the school and measurement is supported by data collected throughout the school year in addition to a final evaluation study based on ‘full value’ report of the school cultural transition. Results The pilot study is underway. There may be results to report by June 2019. This paper is predominantly focused on exploring the principles underpinning the project. Implications for social marketing Social marketing has been critiqued as relying overly on an assumption that behaviour change is within the capacity of individuals to bring about alone (Fry, 2014; Hargreaves, 2011), and as failing to recognise the interrelationship between human behaviour and the socio-material and institutional infrastructures which shape it. This has been labelled ‘unsophisticated’ (Butler et al., 2014), and there have been numerous calls for social change programmes to expand their theoretical base and embrace ideas which avoid a dualistic interpretation of behaviour as either a result of agency, cognition and decision, or wider determinants (Butler et al., 2014; Gordon et al., 2010; Spotswood et al., 2016). Theories of practice have been heralded as having unique potential for understanding the emergence, persistence and context of problematic behaviours relating to health, wellbeing and sustainability (Shove et al., 2012) and have gained significant traction in sustainability research and intervention arenas (e.g. Wilson and Chatterton, 2011). Blue et al (2016), echoed by others (e.g. Ally et al, 2016) argue that the practice theoretical reframing of ‘behaviour change’ is “the only way out of the difficulties now facing public health policy in relation to NCDs” (p.47). Indeed, interventions and policies based on either behaviouralist or structural assumptions have failed to achieve meaningful traction against the societal problems associated with physical inactivity (Nettleton and Green, 2014; Blue et al, 2016; Blue, 2017). Blue et al (2016) call for “a major change in the theoretical foundation of public health policy and for corresponding forms of methodological inventiveness and ingenuity” (p.47). Only recently have researchers and practitioners concerned with issues of public health begun to consider the potential of theories of practice for underpinning social change programmes relating to public health issues such as physical activity. Only few social marketers have embraced theories of practice as offering potential to enhance the efficacy of their approach (although see Gordon et al.; 2018). Furthermore, within the existing published research which considers the potential of theories of practice for intervention, there are none which report their application in a community social change programme. 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