Is school community readiness related to physical activity before and after the Ready for Recess intervention?

Physical Activity Interventions During the School Day: Reviewing Policies, Practices, and Benefits

BACKGROUND

There are many ways to increase physical activity (PA) during the school day as part of a Comprehensive School Physical Activity Plan. This article reviews policies and practices that can be used during the school day to increase PA for students.

METHODS

We searched systematic reviews for articles that met criteria (2010-2018, phase 1), followed by a search for individual articles addressing topics for which we did not identify a sufficiently relevant or recent review or to update an earlier review that concluded insufficient evidence (2010-2020, phase 2). We included 45 articles (45 studies, 54 interventions).

RESULTS

We grouped studies by intervention type: school-wide PA approaches to reach all students within the school setting (17), physical education (PE) interventions (13), and interventions related to recess (15). Few studies involved secondary schools or rural settings. Among 45 studies reporting PA behavior or fitness outcomes, 37 reported at least 1 improvement.

CONCLUSIONS

PA policies, PE, and recess can help improve school health by increasing the PA levels of students.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18

BACKGROUND

Physical activity among children and adolescents is associated with lower adiposity, improved cardio-metabolic health, and improved fitness. Worldwide, fewer than 30% of children and adolescents meet global physical activity recommendations of at least 60 minutes of moderate to vigorous physical activity per day. Schools may be ideal sites for interventions given that children and adolescents in most parts of the world spend a substantial amount of time in transit to and from school or attending school.

OBJECTIVES

The purpose of this review update is to summarise the evidence on effectiveness of school-based interventions in increasing moderate to vigorous physical activity and improving fitness among children and adolescents 6 to 18 years of age. Specific objectives are: • to evaluate the effects of school-based interventions on increasing physical activity and improving fitness among children and adolescents; • to evaluate the effects of school-based interventions on improving body composition; and • to determine whether certain combinations or components (or both) of school-based interventions are more effective than others in promoting physical activity and fitness in this target population.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, BIOSIS, SPORTDiscus, and Sociological Abstracts to 1 June 2020, without language restrictions. We screened reference lists of included articles and relevant systematic reviews. We contacted primary authors of studies to ask for additional information.

SELECTION CRITERIA

Eligible interventions were relevant to public health practice (i.e. were not delivered by a clinician), were implemented in the school setting, and aimed to increase physical activity among all school-attending children and adolescents (aged 6 to 18) for at least 12 weeks. The review was limited to randomised controlled trials. For this update, we have added two new criteria: the primary aim of the study was to increase physical activity or fitness, and the study used an objective measure of physical activity or fitness. Primary outcomes included proportion of participants meeting physical activity guidelines and duration of moderate to vigorous physical activity and sedentary time (new to this update). Secondary outcomes included measured body mass index (BMI), physical fitness, health-related quality of life (new to this update), and adverse events (new to this update). Television viewing time, blood cholesterol, and blood pressure have been removed from this update.  DATA COLLECTION AND ANALYSIS: Two independent review authors used standardised forms to assess each study for relevance, to extract data, and to assess risk of bias. When discrepancies existed, discussion occurred until consensus was reached. Certainty of evidence was assessed according to GRADE. A random-effects meta-analysis based on the inverse variance method was conducted with participants stratified by age (children versus adolescents) when sufficient data were reported. Subgroup analyses explored effects by intervention type.

MAIN RESULTS

Based on the three new inclusion criteria, we excluded 16 of the 44 studies included in the previous version of this review. We screened an additional 9968 titles (search October 2011 to June 2020), of which 978 unique studies were potentially relevant and 61 met all criteria for this update. We included a total of 89 studies representing complete data for 66,752 study participants. Most studies included children only (n = 56), followed by adolescents only (n = 22), and both (n = 10); one study did not report student age. Multi-component interventions were most common (n = 40), followed by schooltime physical activity (n = 19), enhanced physical education (n = 15), and before and after school programmes (n = 14); one study explored both enhanced physical education and an after school programme. Lack of blinding of participants, personnel, and outcome assessors and loss to follow-up were the most common sources of bias.  Results show that school-based physical activity interventions probably result in little to no increase in time engaged in moderate to vigorous physical activity (mean difference (MD) 0.73 minutes/d, 95% confidence interval (CI) 0.16 to 1.30; 33 studies; moderate-certainty evidence) and may lead to little to no decrease in sedentary time (MD -3.78 minutes/d, 95% CI -7.80 to 0.24; 16 studies; low-certainty evidence). School-based physical activity interventions may improve physical fitness reported as maximal oxygen uptake (VO₂max) (MD 1.19 mL/kg/min, 95% CI 0.57 to 1.82; 13 studies; low-certainty evidence). School-based physical activity interventions may result in a very small decrease in BMI z-scores (MD -0.06, 95% CI -0.09 to -0.02; 21 studies; low-certainty evidence) and may not impact BMI expressed as kg/m² (MD -0.07, 95% CI -0.15 to 0.01; 50 studies; low-certainty evidence). We are very uncertain whether school-based physical activity interventions impact health-related quality of life or adverse events.

AUTHORS' CONCLUSIONS

Given the variability of results and the overall small effects, school staff and public health professionals must give the matter considerable thought before implementing school-based physical activity interventions. Given the heterogeneity of effects, the risk of bias, and findings that the magnitude of effect is generally small, results should be interpreted cautiously.

Community Readiness Model for Prevention Planning: Addressing Childhood Obesity in American Indian Reservation Communities

INTRODUCTION

The community readiness model (CRM) is a stage-matched assessment protocol to assess community readiness to address a public health issue. To identify appropriate, culturally sensitive, and community-specific intervention strategies for preventing obesity in children, researchers, and community members formed a partnership to address childhood obesity within one American Indian Reservation.

METHODS

The CRM guided 30 interviews in five communities to direct the team's efforts in addressing obesity among children residing on the reservation. Interviews were scored across six dimensions on an anchored scale of one through nine; scores were then averaged to determine an overall readiness score for each community. A thematic analysis of interview responses aided in interpretation of the readiness scores and identified areas for prevention planning and intervention development.

RESULTS

The overall community readiness score for the communities was 2.9 (SD = 0.5), which falls between 2 (denial/resistance) and 3 (vague awareness) on the anchored rating scale. The thematic analysis resulted in a hierarchal classification scheme with six broad themes that corresponded to the CRM dimensions and 13 sub-themes.

DISCUSSION

The low readiness scores directed the team to implement corresponding strategies to increase awareness, while the thematic analysis suggested that action-based approaches might also be appropriate. The narrow range of scores suggest that community-wide assessments may be sufficient unless specific information is needed for each region of the community. The CRM may be an effective way to assess community readiness to address childhood obesity on an American Indian Reservation.

Differences in physical activity at recess and school-related social factors in four Finnish lower secondary schools

This study investigated the differences in physical activity (PA) at recess and school-related social factors, and described school PA promotion processes and staff experiences at four lower secondary schools from the Finnish Schools on the Move programme. Recess PA, peer relationships at school, relatedness to school, and school climate were assessed via surveys with eighth-grade students in spring 2011 (n = 385) and spring 2013 (n = 373). Local contact people in the school projects (n = 6), school staff (n = 83) and principals (n = 3) provided information on the PA promotion process via telephone interviews and surveys. Differences in student-level data in years 2011 and 2013 were analysed by gender using two-way ANOVA. Data on school processes were analysed using a combination of classification, narrative approach and content analysis.In two of the four schools, male students reported higher levels of recess PA in 2013 compared to 2011. In three schools, school-related social factors did not differ between 2011 and 2013. School cultures and routes towards a more physically active school day differed; the project was highly visible in all schools, but staff participation varied. More research is needed to determine the effective physically active strategies to promote positive social well-being and to enhance staff engagement.

Change of Community Readiness Over Time: Measurements of Reduction of Parental Support and Availability of Alcohol in Seven Communities

Aim To test the possibility of identifying community readiness changes over time. Method Key responders in seven municipalities in Stockholm County were interviewed about the availability of alcohol and parental support. The results were analyzed with paired t tests. Changes in community readiness were assessed. Ninety-three key responders from the participating communities were interviewed three times each, resulting in a total of 315 interviews. Data were collected on three occasions separated by ten months from semistructured telephone interviews based on the community readiness model. Findings Significant readiness changes were found for both issues from baseline to the first follow-up. In terms of the six dimensions of community readiness, significant differences were evident from baseline to the first follow-up for parental support and the reduction of alcohol availability. Apart from knowledge of reduced alcohol availability, there were no significant changes in overall readiness or in the dimensions from the first follow-up to the second. The findings of this study are discussed in relation to earlier studies. Conclusion In communities with an initial vague awareness of issues, a change in readiness level occurs in less than a year.

Assessing community readiness online: a concurrent validation study

Background

Community readiness for facilitation and uptake of interventions can impact the success of community-based prevention efforts. As currently practiced, measuring community readiness can be a resource intensive process, compromising its use in evaluating multisite community-based prevention efforts. The purpose of this study was to develop, test and validate a more efficient online version of an existing community readiness tool and identify potential problems in completing assessments. This study was conducted in the context of a complex community-based childhood obesity prevention program in South Australia.

Methods

Following pre-testing, an online version of the community readiness tool was created, wherein respondents, with detailed knowledge of their community and prevention efforts, rated their communities on five anchored rating scales (Knowledge of Efforts, Leadership, Knowledge of the Issue, Community Climate, and Resources). Respondents completed the standard, over-the-phone community readiness interview (“gold standard”) and the new online survey. Paired t-test, St. Laurent’s correlation coefficient and intra-class correlation (ICC) were used to determine the validity of the online tool. Contact summary forms were completed after each interview to capture interview quality.

Results

Twenty-five respondents completed both assessments. There was a statistically significant difference in the overall community readiness scores between the two methods (paired t-test p = 0.03); online scores were consistently higher than interview scores. St. Laurent’s correlation of 0.58 (95 % CI 0.42–0.73) was moderate; the ICC of 0.65 (95 % CI 0.35–0.83) was good. Only for the leadership and resources dimensions was there no statistically significant difference between the scores from the two methods (p = 0.61, p = 0.08 respectively). St Laurent’s correlation (r = 0.83, 95 % CI 0.71–0.92) and the ICC (0.78, 95 % CI 0.57–0.90) were excellent for leadership. Qualitative results from the standard interview method suggest that some respondents felt reluctant to answer questions on behalf of other community members. This may have impacted their self-selected ratings and/or responses to questions during the interview.

Conclusions

Concurrent validity for the online method was supported for the Leadership dimension only. However, the online method holds promise as it reduces time and resource burden, allowing for a quicker return of results to the community to inform program planning, implementation and evaluations to improve community health.

A critical discussion of the Community Readiness Model using a case study of childhood obesity prevention in England

Recent reforms to the public health system in England aim to generate co-ordinated action between local authorities, healthcare systems and communities to target local health priorities. To support this effort, researchers must contribute and evaluate appropriate strategies for designing interventions tailored to community-specific needs. One strategy is to apply the Community Readiness Model (CRM), which uses key informant interviews to assess a community's readiness to address local issues. This article presents a critical discussion of the CRM developed from a case study of obesity prevention in pre-adolescent girls within a community in the United Kingdom. Data were collected between February and November 2011. We offer lessons learnt and recommendations relating to (i) modifications to the interview guide; (ii) key informant identification; (iii) conducting interviews to theoretical saturation; (iv) using key informants to define their community; (v) key informant's ability to respond on behalf of the community; (vi) using a qualitative model with a quantitative scoring system; and (vii) the optimum application of transcript scoring. In conclusion, the CRM can help researchers, health professionals and local authorities identify the priorities of a community. It is recommended that users of the model be careful to identify and recruit suitable key informants with the help of the community under study, select an appropriate 'community' and utilise the qualitative findings to strengthen the interpretation of the readiness score.

Adolescents' physical activity at recess and actions to promote a physically active school day in four Finnish schools

The national Finnish Schools on the Move programme support schools with their individual plans to promote school-based physical activity (PA). We examined the changes in adolescents' recess and overall PA in four lower secondary schools and described the school actions to promote students' PA and the local contact persons' perceptions of the effects. Recess and overall PA were assessed four times by anonymous questionnaires from students in grades 7-9 (n = 789) in 2010-12, and local contact persons (n = 7) provided information on school actions with diaries, interviews and surveys. Student data were analysed with descriptive statistics and chi-square tests, and school actions data were analysed with quantitative content analysis. The proportion of students who participated in physical activities at recess at least sometimes increased from 30% to 49% in physically active play and from 33% to 42% in ball games, mostly due to improvements in males' participation. Females' participation in recess activities increased in two schools with gender-specific physical activities or facilities. Overall PA levels declined slightly. Organized recess activities, student recess activators and equipment provision and sports facilities development were considered to have affected students' PA positively. Solutions for getting females more physically active in the school setting are needed.

Effects of a structural intervention and implementation on physical activity among youth in residential children's homes

This study reports the effects of a structural intervention, ENRICH (Environmental Interventions in Children's Homes) which targeted the physical and social environment within residential children's homes (RCHs) to increase physical activity (PA) among residents (n=799). Participating RCHs (n=29) were randomized to Early (n=17) or Delayed (n=12) groups from 2004 to 2006 and 2006 to 2008, respectively. Children's PA was measured at three time periods (2004, 2006, 2008). Intent-to-treat analysis revealed no intervention impact on PA. Subsequent analyses used process evaluation data to group organizations into high and low PA-promoting RCHs to compare PA level, controlling for assignment to condition. Organizations with high PA-promoting environments were found to have more active youth. Utility of a comprehensive implementation monitoring plan and the need for formative assessment of organizational capacity is discussed.

Assessing community readiness for overweight and obesity prevention in pre-adolescent girls: a case study

BACKGROUND

Childhood overweight and obesity is a global public health concern. For girls in particular, being overweight or obese during pre-adolescence (aged 7-11 years) has intergenerational implications for both the mother and her future offspring. In the United Kingdom (UK) there is increasing interest in community targeted interventions but less is known about how to tailor these approaches to the needs of the community. This study applied the Community Readiness Model (CRM), for the first time in the UK, to demonstrate its applicability in designing tailored interventions.

METHODS

Community readiness assessment was conducted using semi-structured key informant interviews. The community's key informants were identified through focus groups with pre-adolescent girls. The interviews addressed the community's efforts; community knowledge of the efforts; leadership; community climate; community knowledge of the issue and resources available to support the issue. Interviews were conducted until the point of theoretical saturation and questions were asked separately regarding physical activity (PA) and healthy eating and drinking (HED) behaviours. The interviews were transcribed verbatim and were firstly analysed thematically and then scored using the assessment guidelines produced by the CRM authors.

RESULTS

Readiness in this community was higher for PA than for HED behaviours. The lowest scores related to the community's 'resources' and the 'community knowledge of the issue'; affirming these two issues as the most appropriate initial targets for intervention. In terms of resources, there is also a need for resources to support the development of HED efforts beyond the school. Investment in greater physical education training for primary school teachers was also identified as an intervention priority. To address the community's knowledge of the issue, raising the awareness of the prevalence of pre-adolescent girls' health behaviours is a priority at the local community level. Inconsistent school approaches contributed to tensions between schools and parents regarding school food policies.

CONCLUSIONS

This study has identified the readiness level within a UK community to address the behaviours related to overweight and obesity prevention in pre-adolescent girls. The focus of an intervention in this community should initially be resources and raising awareness of the issue within the community.

Changes in community readiness among key school stakeholders after Ready for Recess

School community readiness (CR) for health promotion efforts may be critical to the effectiveness of school-based interventions aimed at promoting youth physical activity and reducing childhood obesity. The purpose of this study was to: (i) identify key informants who scored highest on school CR at baseline and (ii) determine the effects of Ready for Recess on changes in CR among school key informants from baseline to post-intervention. Key informants (N = 98) across 17 schools participated in CR interviews. Interview questions focused on school CR for physical activity and childhood obesity efforts across six dimensions. At baseline, principals scored higher than teachers in overall readiness and knowledge of the issue and higher than recess staff and nurses in leadership. Leadership readiness decreased across key informants at post-intervention and principals demonstrated greater decreases when compared with recess staff. Baseline disparities between principals and other key informants suggest principals may have overestimated the readiness of staff implementing the intervention. Declines among principals indicate that they may not have been prepared to deliver adequate support to successfully implement the intervention. These results illuminate the importance of assessing/improving school readiness prior to interventions. The CR model may provide an opportunity to improve school-based physical activity interventions.