School physical education: effect of the Child and Adolescent Trial for Cardiovascular Health

Effects of School Nurse-Led Interventions in Collaboration with Kinesiologists in Promoting Physical Activity and Reducing Sedentary Behaviors in Children and Adolescents: A Systematic Review

The World Health Organization (WHO) recommends that schools adopt a whole-school strategy for healthy behaviors involving different health professionals. The present systematic review aimed to evaluate the efficacy of nurse-led interventions in collaboration with kinesiologists on physical activity and lifestyle behaviors' outcomes in school settings. The protocol was registered in PROSPERO (ID: CRD42022343410). The primary research study was developed through the PICOS question: children and adolescence 6-18 years (P); school nurse-led interventions in promoting physical activity (PA) and reducing sedentary behaviors (I); usual lessons, no intervention focusing on PA (C); PA levels, sedentary behaviors, and healthy lifestyle behaviors (O); experimental or observational study with original primary data and full-text studies written in English (S). Seven studies were included. Interventions were heterogeneous: besides physical activities carried out in all studies, the interventions were based on different health models and strategies (counselling, face-to-face motivation, education). Five out of seven articles investigated PA levels or their related behaviors using questionnaires, and two used ActiGraph accelerometers. Lifestyle behaviors were assessed with heterogeneous methods. Five out of seven articles showed an improvement in at least one outcome after the interventions, whereas two papers showed a statistically non-significant improvement. In conclusion, school interventions involving nurses, also in association with other professionals such as kinesiologists, can be effective in reducing sedentary behaviors and improving healthy lifestyles in children and adolescents.

Strategies for enhancing the implementation of school-based policies or practices targeting diet, physical activity, obesity, tobacco or alcohol use

BACKGROUND

Several school-based interventions are effective in improving child diet and physical activity, and preventing excessive weight gain, and tobacco or harmful alcohol use. However, schools are frequently unsuccessful in implementing such evidence-based interventions.

OBJECTIVES

1. To evaluate the benefits and harms of strategies aiming to improve school implementation of interventions to address student diet, physical activity, tobacco or alcohol use, and obesity. 2. To evaluate the benefits and harms of strategies to improve intervention implementation on measures of student diet, physical activity, obesity, tobacco use or alcohol use; describe their cost or cost-effectiveness; and any harms of strategies on schools, school staff or students.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search was between 1 September 2016 and 30 April 2021 to identify any relevant trials published since the last published review.

SELECTION CRITERIA

We defined 'Implementation' as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised controlled trial (RCT) or non-randomised controlled trial (non-RCT)) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by students to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Given the large number of outcomes reported, we selected and included the effects of a single outcome measure for each trial for the primary (implementation) and secondary (student health behaviour and obesity) outcomes using a decision hierarchy. Where possible, we calculated standardised mean differences (SMDs) to account for variable outcome measures with 95% confidence intervals (CI). For RCTs, we conducted meta-analyses of primary and secondary outcomes using a random-effects model, or in instances where there were between two and five studies, a fixed-effect model. The synthesis of the effects for non-randomised studies followed the 'Synthesis without meta-analysis' (SWiM) guidelines.

MAIN RESULTS

We included an additional 11 trials in this update bringing the total number of included studies in the review to 38. Of these, 22 were conducted in the USA. Twenty-six studies used RCT designs. Seventeen trials tested strategies to implement healthy eating, 12 physical activity and six a combination of risk factors. Just one trial sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials used multiple implementation strategies, the most common being educational materials, educational outreach and educational meetings. The overall certainty of evidence was low and ranged from very low to moderate for secondary review outcomes. Pooled analyses of RCTs found, relative to a control, the use of implementation strategies may result in a large increase in the implementation of interventions in schools (SMD 1.04, 95% CI 0.74 to 1.34; 22 RCTs, 1917 participants; low-certainty evidence). For secondary outcomes we found, relative to control, the use of implementation strategies to support intervention implementation may result in a slight improvement on measures of student diet (SMD 0.08, 95% CI 0.02 to 0.15; 11 RCTs, 16,649 participants; low-certainty evidence) and physical activity (SMD 0.09, 95% CI -0.02 to 0.19; 9 RCTs, 16,389 participants; low-certainty evidence). The effects on obesity probably suggest little to no difference (SMD -0.02, 95% CI -0.05 to 0.02; 8 RCTs, 18,618 participants; moderate-certainty evidence). The effects on tobacco use are very uncertain (SMD -0.03, 95% CIs -0.23 to 0.18; 3 RCTs, 3635 participants; very low-certainty evidence). One RCT assessed measures of student alcohol use and found strategies to support implementation may result in a slight increase in use (odds ratio 1.10, 95% CI 0.77 to 1.56; P = 0.60; 2105 participants). Few trials reported the economic evaluations of implementation strategies, the methods of which were heterogeneous and evidence graded as very uncertain. A lack of consistent terminology describing implementation strategies was an important limitation of the review.

AUTHORS' CONCLUSIONS

The use of implementation strategies may result in large increases in implementation of interventions, and slight improvements in measures of student diet, and physical activity. Further research is required to assess the impact of implementation strategies on such behavioural- and obesity-related outcomes, including on measures of alcohol use, where the findings of one trial suggest it may slightly increase student risk. Given the low certainty of the available evidence for most measures further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

Physical activity promoting teaching practices and children’s physical activity within physical education lessons underpinned by motor learning theory (SAMPLE-PE)

Purpose

Movement competence is a key outcome for primary physical education (PE) curricula. As movement development in children emerges through physical activity (PA), it is important to determine the extent of PA promotion within movement competence focused teaching pedagogies. Therefore, this study aimed to assess children’s moderate-to-vigorous PA (MVPA) and related teaching practices in primary PE within Linear pedagogy and Nonlinear pedagogy and to compare this to current practice within PE delivery in primary schools.

Methods

Participants (n = 162, 53% females, 5-6y) were recruited from 9 primary schools within the SAMPLE-PE cluster randomised controlled trial. Schools were randomly-allocated to one of three conditions: Linear pedagogy, Nonlinear pedagogy, or control. Nonlinear and Linear pedagogy intervention schools received a PE curriculum delivered by trained deliverers over 15 weeks, while control schools followed usual practice. Children’s MVPA was measured during 3 PE lessons (44 PE lessons in total) using an ActiGraph GT9X accelerometer worn on their non-dominant wrist. Differences between conditions for children’s MVPA were analysed using multilevel model analysis. Negative binomial models were used to analyse teaching practices data.

Results

No differences were found between Linear pedagogy, Nonlinear pedagogy and the control group for children’s MVPA levels during PE. Linear and Nonlinear interventions generally included higher percentages of MVPA promoting teaching practices (e.g., Motor Content) and lower MVPA reducing teaching practices (e.g., Management), compared to the control group. Teaching practices observed in Linear and Nonlinear interventions were in line with the respective pedagogical principles.

Conclusions

Linear and Nonlinear pedagogical approaches in PE do not negatively impact MVPA compared to usual practice. Nevertheless, practitioners may need to refine these pedagogical approaches to improve MVPA alongside movement competence.

Examining the Dose-Response Relationship between Outdoor Jogging and Physical Health of Youths: A Long-Term Experimental Study in Campus Green Space

Many studies have demonstrated that outdoor physical activity positively affects the physical health of young people. Here, we aimed to examine the extent to which outdoor jogging was associated with the physical health of youths, and then to decipher whether a dose–response relationship exists between them. A total of 2852 youths from a Chinese university were enrolled in a long-term experimental study between September 2018 and September 2019. We conducted two waves of physical health tests for 2852 youths (before and after the jogging interventions in 2018 and 2019, respectively) using China’s National Student Physical Health Standard (NSPHS). Paired t-tests were used to examine statistical differences. A multiple regression model was used to evaluate the associations between jogging and physical health. The results showed that: statistically significant changes in the two waves of physical health outcomes were suggested after jogging interventions; outdoor jogging in campus green space was associated with participants’ physical health after controlling for covariates; and a dose–response relationship between jogging and physical health outcomes was revealed, with 120–140 km/year (approximately 3.43–4 km/week) being the most effective intervention dose. Our findings have implications for promoting physical health in youth groups by encouraging outdoor physical activity.

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.

Deep Integration of Physical Health Education Based on Intelligent Communication Technology

In recent years, intelligent medical communication technology has developed rapidly, and the advancement of hardware technology has accelerated the development of software technology. Physical exercise breaks the limits of all aspects of the human body and requires scientific and reliable information. Industrial cameras realize collection and high-resolution image processing functions and use artificial intelligence to create conditions for collecting scientific data. With the powerful driving force of artificial intelligence, it is believed that physical education will develop to a new height. The intellectualization of physical education makes people expect that it will also bring some inevitable problems, but as long as we continue to overcome and improve, we believe that artificial intelligence will better serve physical education and benefit mankind. Artificial intelligence is the current trend of social development. This paper takes physical education as a breakthrough point to discuss the application of artificial intelligence in physical education. This paper uses the grey GM prediction model and questionnaire survey method to build an online education platform and develop an effective education model, which can integrate the country's best educational resources and reduce time and space constraints. Providing a relaxing learning environment for education, one can learn anytime, anywhere. In a typical physical education system, the average self-efficacy score is converted from 20.48 points to 68.37 points, and the average self-score of physical education in the integrated artificial intelligence environment is converted from 30.25 points to 75.54 points. The data show that the quality of education has greatly improved.

Rationale for the Essential Components of Physical Education

Purpose: This introductory article provides the context and rationale for conducting systematic literature reviews on each of the essential components of physical education, including policy and environment, curriculum, appropriate instruction, and student assessment. Methods: Four research teams from Doctoral Physical Education Teacher Education programs (D-PETE) conducted these systematic reviews using the PRISMA guidelines process. Results: This article explains the role of the national framework for increasing physical education and physical activity (i.e., Comprehensive School Physical Activity Program) in supporting the essential components of physical education. It also highlights the expectations for physical education and provides a brief history of these components. Lastly, this article highlights each of the articles presented in the special feature. Conclusion: Understanding the implementation of these components may be important for improving the physical education experience for all students and creating a foundation for lifelong physical activity and health.

The Fueling Learning Through Exercise Study Cluster RCT: Impact on Children's Moderate-to-Vigorous Physical Activity

INTRODUCTION

Most children do not meet the recommendations for school-time and daily moderate-to-vigorous physical activity, with significant demographic disparities and declines over the elementary school years. Investigators examined the impact of Fueling Learning through Exercise study school-based physical activity programs on school-time and total daily moderate-to-vigorous physical activity among lower-income school children.

DESIGN, PARTICIPANTS, AND INTERVENTION

Urban elementary schools (N=18) were cluster randomized to 100 Mile Club, Just Move, or control. Data collection and analyses occurred from 2015 to 2019 among third- and fourth-grade school children (N=1,008) across 2 academic years.

MAIN OUTCOME MEASURES

Student's moderate-to-vigorous physical activity was measured by 7-day accelerometry (Actigraph GT3X+) at baseline (before intervention), midpoint (6 months), and endpoint (18 months). Mixed-effects linear regression models examined program impact on school-time and daily moderate-to-vigorous physical activity, adjusting for clustering, demographics, weight status, free/reduced-price lunch eligibility, school physical activity environment, wear time, and weather. Program reach by sex, weight status, race/ethnicity, and baseline activity levels was explored.

RESULTS

Of the 979 participants analyzed (aged 8.7 [SD=0.7] years, 44% male, 60% non-White, 40% overweight/obese, 55% eligible for free/reduced-price lunch), 8.4% (18.2 [SD=7.9] minutes per day) and 19.8% (45.6 [SD=19.4] minutes per day) fulfilled the 30-minute school-time and 60-minute daily moderate-to-vigorous physical activity recommendations at baseline, respectively. Overall, daily moderate-to-vigorous physical activity decreased from baseline to 18 months (p<0.001, -5.3 minutes, 95% CI= -8.2, -2.4) with no effect of programming. However, for school-time moderate-to-vigorous physical activity, intervention schools maintained school-time moderate-to-vigorous physical activity across the 2 academic years, whereas school-time moderate-to-vigorous physical activity decreased in control schools (p=0.004, -2.3 minutes, 95% CI= -4.3, -0.4). Program reach on school-time moderate-to-vigorous physical activity appeared equitable by sex and weight status but was different by race/ethnicity (p<0.001).

CONCLUSIONS

Two different school-based physical activity programs were effective in preventing the decline in school-time moderate-to-vigorous physical activity that is typical across the elementary years, with similar reach by sex and weight status. Multiple opportunities for physical activity during school are needed to promote meeting school-time moderate-to-vigorous physical activity recommendations among diverse children.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02810834.

Y-PATHS: A Conceptual Framework for Classifying the Timing, How, and Setting of Youth Physical Activity

BACKGROUND

Multiple models and frameworks exist for the measurement and classification of physical activity in adults that are applied broadly across populations but have limitations when applied to youth. The authors propose a conceptual framework specifically designed for classifying youth physical activity.

METHODS

The Youth Physical Activity Timing, How, and Setting (Y-PATHS) framework is a conceptualization of the when (timing), how, and where (setting) of children's and adolescents' physical activity patterns. The authors developed Y-PATHS using the design thinking process, which includes 3 stages: inspiration, ideation, and implementation.

RESULTS

The Y-PATHS includes 3 major components (timing, how, and setting) and 13 subcomponents. Timing subcomponents include (1) school days: in-school, (2) school days: out-of-school, and (3) nonschool days. How subcomponents include: (1) functional, (2) transportation, (3) organized, and (4) free play. Setting subcomponents include: (1) natural areas, (2) schools, (3) home, (4) recreational facilities, (5) shops and services, and (6) travel infrastructure.

CONCLUSIONS

The Y-PATHS is a comprehensive classification framework that can help researchers, practitioners, and policymakers to better understand youth physical activity. Specifically, Y-PATHS can help to identify the domains of youth physical activity for surveillance and research and to inform the planning/evaluation of more comprehensive physical activity programming.

Impact of Weight Status on the Cardiopulmonary Fitness Outcome of a School-Based Physical Activity Program

BACKGROUND

The effectiveness of school-based physical activity interventions for improving cardiopulmonary fitness (CPF) of overweight and obese children is not well established. In this study, we evaluated whether overweight and obese children had similar changes in body mass index (BMI) and CPF as normal weight children after participating in a program for one academic year.

METHODS

Using purposive sampling at the school level, we selected 16 program and 7 control schools in a large metropolitan area in the Southeast during the 2015-2016 academic year. In these schools, 3396 fourth-graders participated with parental consent. Of these, 2332 (68.7%) participated in BMI measures and 1780 (52.4%) in Progressive Aerobic Cardiovascular Endurance Run (PACER) measures for CPF at two time points.

RESULTS

Students of all weight statuses pre-program did not show changes in BMI after program implementation. All students showed statistically significant improvements in the PACER test at follow-up, regardless of their participation in the program. However, overweight and obese children showed less improvement in CPF level than their normal weight classmates, regardless of their participation in the program.

CONCLUSION

Special attention for improving engagements of overweight and obese children may be needed to achieve improvements in their CPF level similar to that of normal weight students.

Association of Physical Education With Improvement of Health-Related Physical Fitness Outcomes and Fundamental Motor Skills Among Youths: A Systematic Review and Meta-analysis

IMPORTANCE

Whether quality- or quantity-based physical education (PE) interventions are associated with improvement of health-related physical fitness outcomes and fundamental motor skills (FMSs) in children and adolescents is unknown.

OBJECTIVE

To examine the association of interventions aimed at optimizing PE in terms of quality (teaching strategies or fitness infusion) or quantity (lessons per week) with health-related physical fitness and FMSs in children and adolescents.

DATA SOURCES

For this systematic review and meta-analysis, studies were identified through a systematic search of Ovid MEDLINE, Embase, Cochrane Controlled Trials Registry, and SPORTDiscus databases (from inception to October 10, 2019) with the keywords physical education OR PE OR P.E. AND fitness AND motor ability OR skills. Manual examination of references in selected articles was also performed.

STUDY SELECTION

Studies that assessed the association of quality- or quantity-based PE interventions with improvement in physical fitness and/or FMSs in youths (aged 3-18 years) were included.

DATA EXTRACTION AND SYNTHESIS

Data were processed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Random-effects models were used to estimate the pooled effect size (Hedges g).

MAIN OUTCOMES AND MEASURES

Health-related physical fitness outcomes and FMSs.

RESULTS

Fifty-six trials composed of 48 185 youths (48% girls) were included in the meta-analysis. Quality-based PE interventions were associated with small increases in health-related physical fitness (cardiorespiratory fitness [Hedges g = 0.24; 95% CI, 0.16-0.32] and muscular strength [Hedges g = 0.19; 95% CI, 0.09-0.29]) and FMSs (Hedges g = 0.38; 95% CI, 0.27-0.49). Subgroup analyses found stronger associations for quality-based PE interventions on body mass index (Hedges g = -0.18; 95% CI, -0.26 to -0.09), body fat (Hedges g = -0.28; 95% CI, -0.37 to -0.18), cardiorespiratory fitness (Hedges g = 0.31; 95% CI, 0.23-0.39), and muscular strength (Hedges g = 0.29; 95% CI, 0.18-0.39). Quantity-based PE interventions were associated with small increases in only cardiorespiratory fitness (Hedges g = 0.42; 95% CI, 0.30-0.55), muscular strength (Hedges g = 0.20; 95% CI, 0.08-0.31), and speed agility (Hedges g = 0.29; 95% CI, 0.07-0.51).

CONCLUSIONS AND RELEVANCE

The findings suggest that quality-based PE interventions are associated with small increases in both student health-related physical fitness components and FMSs regardless of frequency or duration of PE lessons. Because PE aims to improve more than health, high levels of active learning time may need to be balanced with opportunities for instruction, feedback, and reflection.

Identification and evaluation of risk of generalizability biases in pilot versus efficacy/effectiveness trials: a systematic review and meta-analysis

BACKGROUND

Preliminary evaluations of behavioral interventions, referred to as pilot studies, predate the conduct of many large-scale efficacy/effectiveness trial. The ability of a pilot study to inform an efficacy/effectiveness trial relies on careful considerations in the design, delivery, and interpretation of the pilot results to avoid exaggerated early discoveries that may lead to subsequent failed efficacy/effectiveness trials. "Risk of generalizability biases (RGB)" in pilot studies may reduce the probability of replicating results in a larger efficacy/effectiveness trial. We aimed to generate an operational list of potential RGBs and to evaluate their impact in pairs of published pilot studies and larger, more well-powered trial on the topic of childhood obesity.

METHODS

We conducted a systematic literature review to identify published pilot studies that had a published larger-scale trial of the same or similar intervention. Searches were updated and completed through December 31st, 2018. Eligible studies were behavioral interventions involving youth (≤18 yrs) on a topic related to childhood obesity (e.g., prevention/treatment, weight reduction, physical activity, diet, sleep, screen time/sedentary behavior). Extracted information included study characteristics and all outcomes. A list of 9 RGBs were defined and coded: intervention intensity bias, implementation support bias, delivery agent bias, target audience bias, duration bias, setting bias, measurement bias, directional conclusion bias, and outcome bias. Three reviewers independently coded for the presence of RGBs. Multi-level random effects meta-analyses were performed to investigate the association of the biases to study outcomes.

RESULTS

A total of 39 pilot and larger trial pairs were identified. The frequency of the biases varied: delivery agent bias (19/39 pairs), duration bias (15/39), implementation support bias (13/39), outcome bias (6/39), measurement bias (4/39), directional conclusion bias (3/39), target audience bias (3/39), intervention intensity bias (1/39), and setting bias (0/39). In meta-analyses, delivery agent, implementation support, duration, and measurement bias were associated with an attenuation of the effect size of - 0.325 (95CI - 0.556 to - 0.094), - 0.346 (- 0.640 to - 0.052), - 0.342 (- 0.498 to - 0.187), and - 0.360 (- 0.631 to - 0.089), respectively.

CONCLUSIONS

Pre-emptive avoidance of RGBs during the initial testing of an intervention may diminish the voltage drop between pilot and larger efficacy/effectiveness trials and enhance the odds of successful translation.

Assessing the Wider Implementation of the SHARP Principles: Increasing Physical Activity in Primary Physical Education

To assess the wider application of the SHARP (Stretching whilst moving, High repetition of skills, Accessibility, Reducing sitting and standing, and Promotion of physical activity) Principles intervention on children’s moderate to vigorous physical activity (MVPA) in physical education (PE), when applied by teachers and coaches. A quasi-experimental intervention was employed in nine primary schools (experimental, n = 6: control, n = 3) including teachers (n = 10), coaches (n = 4), and children (aged 5 to 11 years, n = 84) in the West Midlands, UK. Practitioners applied the SHARP Principles to PE lessons, guided by an innovative behaviour change model. The System for Observing Fitness and Instruction Time (SOFIT) was used to measure children’s MVPA in 111 lessons at pre- (n = 60) and post-intervention (n = 51). Seven interviews were conducted post-intervention to explore practitioners’ perceptions. Two-way ANOVA (Analysis of Variance) revealed that teachers increased children’s MVPA by 27.7%. No statistically significant change in children’s MVPA was observed when taught by the coaches. The qualitative results for teachers were ‘children’s engagement’, a ‘pedagogical paradigm shift’, and ‘relatedness’; and for coaches ‘organisational culture’ and ‘insufficient support and motivation’. The SHARP Principles intervention is the most effective teaching strategy at increasing MVPA in primary PE when taught by school based staff (rather than outsourced coaches), evidencing increases almost double that of any previously published study internationally and demonstrating the capacity to influence educational policy and practice internationally.

Longitudinal Trajectories of Children's Physical Activity and Sedentary Behaviors on Weekdays and Weekends

BACKGROUND

The objective was to examine changes of children's time spent in sedentary, light physical activity, moderate to vigorous physical activity (MVPA), and estimated energy expenditure (EE) rates during weekdays and weekends across 3 years.

METHODS

An initial sample of 261 children's (mean age = 7.81 y) 5-day physical activity and EE were assessed annually via accelerometry across 3 years using repeated-measures multivariate analysis of variance. The outcome variables were time spent in sedentary, light physical activity, MVPA, and kilocalories per day for weekdays and weekends.

RESULTS

A significant decrease in MVPA and EE occurred during weekdays across the 3 years (P = .01). Only the second-year data demonstrated an increase (+2.49 min) in weekend MVPA (P = .04). Children's sedentary time during weekdays increased significantly in years 1 and 2 (P = .01), yet significantly decreased in the third year (-44.31 min). Children's sedentary time during weekends significantly decreased in the first year (-27.31 min), but increased in the following 2 years (P = .01). Children's light physical activity demonstrated a statistically significant increase in year 2 (+3.75 min) during weekdays (P = .05).

CONCLUSIONS

Children's MVPA and EE generally declined during weekdays but were maintained during weekends across a 3-year time span. Children may benefit most from weekday intervention strategies.

The impact of a park refurbishment in a low socioeconomic area on physical activity: a cost-effectiveness study

Background

Physical inactivity is the fourth highest cause of death globally and is a major contributor to increases in healthcare expenditure. Improving public open spaces such as parks in areas of low socio-economic position (SEP) may increase recreational physical activity in disadvantaged populations. We assessed the cost-effectiveness of the installation of a play-space in a large metropolitan park in a low socioeconomic area based on changes in physical activity.

Methods

Observational data of visitor counts and activities undertaken in the park before the installation of the new play-scape (T1), at two months (T2) and 14 months post-installation (T3) were obtained for the intervention and a control park (with no refurbishment) located in a high SEP metropolitan area. Observed sitting, standing, and moderate and vigorous-intensity physical activity were converted to yearly MET-h according to age. Costs of the play-scape and ongoing maintenance were obtained from the organisation managing the refurbishment. The incremental cost-effectiveness ratio (ICER) (ratio of incremental cost to incremental effect) was calculated based on the incremental increase in MET-h from T1 to T3 assuming a 20-year lifetime of the play-scape. Observation counts combining moderate and vigorous activity were used in the sensitivity analysis.

Results

When compared with T1, at T3 the new play-scape resulted in an overall incremental net gain of 114,114 MET-h (95% UI: 80,476 − 146,096) compared with the control park and an incremental cost effectiveness ratio (or cost per MET-h gained per park visitor) of AUD $0.58 (95% UI: $0.44–$0.80).

The sensitivity analysis combining moderate and vigorous activity into one category showed an increase in estimated incremental MET-h of 118,190 (95% CI: 83,528 − 149,583) and a lower incremental cost per MET-h gained of AUD $0.56 (95% UI: $0.43–$0.77).

Conclusions

Using a benchmark of cost-effectiveness for physical activity interventions of AUD $0.60–$1.30, this study suggests that the installation of a play-scape located in a low SEP area is cost-effective based on its potential to facilitate increases in MET-h. It provides much needed preliminary evidence and requires replication elsewhere.

Electronic supplementary material

The online version of this article (10.1186/s12966-019-0786-5) contains supplementary material, which is available to authorized users.

Effects of Generalization of Engagement in Parkour from Physical Education to Recess on Physical Activity

PURPOSE

To investigate the effect of generalization of engagement in parkour from physical education (PE) to organized and supervised recess on voluntary participation and moderate-to-vigorous physical activity (MVPA).

METHOD

Children received a 6-day parkour unit in PE and every two lessons they could voluntarily participate in 20-min parkour recess. Fourteen elementary school classes constituting 281 children (8-10 years old) and 16 PE teachers were randomized to either three supervised or three organized parkour recess sessions. During supervised recess, PE teachers supervised to ensure safety, and children could play freely on the parkour landscape. During organized recess, PE teachers provided instructional tasks as well as supervision for safety on the parkour landscape. The parkour landscape in the gymnasium was identical in both recess conditions and similar to previous parkour landscape in PE. Participation and MVPA were measured using systematic observation.

RESULTS

Significantly more children from organized compared to supervised recess participated in all three sessions (60% vs. 43%, p = .008, V = .16). Children showed significantly less sedentary behavior (24% vs. 30%, p = .013, η² = .063) and more MVPA (76% vs. 70%, p = .012, η² = .066) during organized compared to supervised recess. The proportion of total MVPA spent doing parkour was significantly higher in organized compared to supervised recess for low- (36% vs. 24%, p = .005, η² = .082) and high-skilled children (33% vs. 26%, p = .034, η² = .048).

CONCLUSION

Generalization of engagement in parkour was higher in organized compared to supervised recess.

Individual-, family-, and school-level interventions targeting multiple risk behaviours in young people

BACKGROUND

Engagement in multiple risk behaviours can have adverse consequences for health during childhood, during adolescence, and later in life, yet little is known about the impact of different types of interventions that target multiple risk behaviours in children and young people, or the differential impact of universal versus targeted approaches. Findings from systematic reviews have been mixed, and effects of these interventions have not been quantitatively estimated.

OBJECTIVES

To examine the effects of interventions implemented up to 18 years of age for the primary or secondary prevention of multiple risk behaviours among young people.

SEARCH METHODS

We searched 11 databases (Australian Education Index; British Education Index; Campbell Library; Cumulative Index to Nursing and Allied Health Literature (CINAHL); Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; Embase; Education Resource Information Center (ERIC); International Bibliography of the Social Sciences; MEDLINE; PsycINFO; and Sociological Abstracts) on three occasions (2012, 2015, and 14 November 2016)). We conducted handsearches of reference lists, contacted experts in the field, conducted citation searches, and searched websites of relevant organisations.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster RCTs, which aimed to address at least two risk behaviours. Participants were children and young people up to 18 years of age and/or parents, guardians, or carers, as long as the intervention aimed to address involvement in multiple risk behaviours among children and young people up to 18 years of age. However, studies could include outcome data on children > 18 years of age at the time of follow-up. Specifically,we included studies with outcomes collected from those eight to 25 years of age. Further, we included only studies with a combined intervention and follow-up period of six months or longer. We excluded interventions aimed at individuals with clinically diagnosed disorders along with clinical interventions. We categorised interventions according to whether they were conducted at the individual level; the family level; or the school level.

DATA COLLECTION AND ANALYSIS

We identified a total of 34,680 titles, screened 27,691 articles and assessed 424 full-text articles for eligibility. Two or more review authors independently assessed studies for inclusion in the review, extracted data, and assessed risk of bias.We pooled data in meta-analyses using a random-effects (DerSimonian and Laird) model in RevMan 5.3. For each outcome, we included subgroups related to study type (individual, family, or school level, and universal or targeted approach) and examined effectiveness at up to 12 months' follow-up and over the longer term (> 12 months). We assessed the quality and certainty of evidence using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We included in the review a total of 70 eligible studies, of which a substantial proportion were universal school-based studies (n = 28; 40%). Most studies were conducted in the USA (n = 55; 79%). On average, studies aimed to prevent four of the primary behaviours. Behaviours that were most frequently addressed included alcohol use (n = 55), drug use (n = 53), and/or antisocial behaviour (n = 53), followed by tobacco use (n = 42). No studies aimed to prevent self-harm or gambling alongside other behaviours.Evidence suggests that for multiple risk behaviours, universal school-based interventions were beneficial in relation to tobacco use (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.60 to 0.97; n = 9 studies; 15,354 participants) and alcohol use (OR 0.72, 95% CI 0.56 to 0.92; n = 8 studies; 8751 participants; both moderate-quality evidence) compared to a comparator, and that such interventions may be effective in preventing illicit drug use (OR 0.74, 95% CI 0.55 to 1.00; n = 5 studies; 11,058 participants; low-quality evidence) and engagement in any antisocial behaviour (OR 0.81, 95% CI 0.66 to 0.98; n = 13 studies; 20,756 participants; very low-quality evidence) at up to 12 months' follow-up, although there was evidence of moderate to substantial heterogeneity (I² = 49% to 69%). Moderate-quality evidence also showed that multiple risk behaviour universal school-based interventions improved the odds of physical activity (OR 1.32, 95% CI 1.16 to 1.50; I² = 0%; n = 4 studies; 6441 participants). We considered observed effects to be of public health importance when applied at the population level. Evidence was less certain for the effects of such multiple risk behaviour interventions for cannabis use (OR 0.79, 95% CI 0.62 to 1.01; P = 0.06; n = 5 studies; 4140 participants; I² = 0%; moderate-quality evidence), sexual risk behaviours (OR 0.83, 95% CI 0.61 to 1.12; P = 0.22; n = 6 studies; 12,633 participants; I² = 77%; low-quality evidence), and unhealthy diet (OR 0.82, 95% CI 0.64 to 1.06; P = 0.13; n = 3 studies; 6441 participants; I² = 49%; moderate-quality evidence). It is important to note that some evidence supported the positive effects of universal school-level interventions on three or more risk behaviours.For most outcomes of individual- and family-level targeted and universal interventions, moderate- or low-quality evidence suggests little or no effect, although caution is warranted in interpretation because few of these studies were available for comparison (n ≤ 4 studies for each outcome).Seven studies reported adverse effects, which involved evidence suggestive of increased involvement in a risk behaviour among participants receiving the intervention compared to participants given control interventions.We judged the quality of evidence to be moderate or low for most outcomes, primarily owing to concerns around selection, performance, and detection bias and heterogeneity between studies.

AUTHORS' CONCLUSIONS

Available evidence is strongest for universal school-based interventions that target multiple- risk behaviours, demonstrating that they may be effective in preventing engagement in tobacco use, alcohol use, illicit drug use, and antisocial behaviour, and in improving physical activity among young people, but not in preventing other risk behaviours. Results of this review do not provide strong evidence of benefit for family- or individual-level interventions across the risk behaviours studied. However, poor reporting and concerns around the quality of evidence highlight the need for high-quality multiple- risk behaviour intervention studies to further strengthen the evidence base in this field.

Identifying and Quantifying the Unintended Variability in Common Systematic Observation Instruments to Measure Youth Physical Activity

BACKGROUND

Direct observation protocols may introduce variability in physical activity estimates.

METHODS

Thirty-five physical education lessons were video recorded and coded using the System for Observing Fitness Instruction Time (SOFIT). A multistep process examined variability in moderate to vigorous physical activity (MVPA%; walking + vigorous/total scans). Initially, per-SOFIT protocol MVPA% (MVPA%SOFIT) estimates were produced for each lesson. Second, true MVPA% (mean MVPA% of all students using all observations, MVPA%true) estimates were calculated. Third, MVPA% (MVPA%perm) was calculated based on all permutations of students and observation order. Fourth, physical education lessons were divided into 2 groups with 5 lessons from each group randomly selected 10,000 times. Group MVPA%perm differences between the 10 selected lessons were compared with the MVPA%true difference between group 1 and group 2.

RESULTS

Across all lessons, 10,212,600 permutations were possible (average 291,789 combinations per lesson; range = 73,440-570,024). Across lessons, the average absolute difference between MVPA%true and MVPA%SOFIT estimates was ±4.8% (range = 0.1%-17.5%). Permutations, based on students selected and observation order, indicated that the mean range of MVPA%perm estimates was 41.6% within a lesson (range = 29.8%-55.9%). Differences in MVPA% estimates between the randomly selected groups of lessons varied by 32.0%.

CONCLUSION

MVPA% estimates from focal child observation should be interpreted with caution.

Moderators of School-Based Physical Activity Interventions on Cardiorespiratory Endurance in Primary School-Aged Children: A Meta-Regression

The purpose of this study was to examine potential moderators of school-based physical activity interventions on cardiorespiratory endurance in primary school-aged children using meta-regression. An Internet search with several databases was employed, extracting school-based pediatric physical activity intervention studies published within the past 30 years. Studies were included if there was a control or comparison group, if the study sample included primary school-aged children, if the targeted outcome of cardiorespiratory endurance was objectively assessed, if the intervention was at least partially school-based, and if the effect estimate's variability was reported. An inverse-variance random effects meta-regression was employed using the primary predictors of component number (single component or multi-component) and intervention length using 20 extracted studies with 23 total effects. The overall pooled effect on cardiorespiratory endurance was statistically significant (Hedges' g = 0.30, 95% C.I.: 0.19⁻0.40; p < 0.001). Using random effects meta-regression, neither component number (b = ⁻0.09, 95% C.I.: ⁻0.40⁻0.23; p = 0.560) or intervention length (b = 0.001, 95% C.I.: ⁻0.002⁻0.004; p = 0.427) yielded a significant modifying effect on cardiorespiratory endurance. School-based physical activity interventions have a significant pooled effect on cardiorespiratory endurance in primary school-aged children. Component number and intervention length does not modify this effect, suggesting other sources for between-study heterogeneity.

An Intervention to Increase Students' Physical Activity: A 2-Year Pilot Study

INTRODUCTION

Schools are called upon to provide children with 30 minutes/day of moderate to vigorous physical activity (MVPA). Most school-based physical activity interventions have not targeted schools that serve children from low-income families. This study evaluated the effects of a pilot, competency-building professional development program on the school day MVPA and total activity (light- to vigorous-intensity activity) of students from schools that serve low-income families.

STUDY DESIGN

Single group intervention with multiple follow-up repeated cross-sectional measures.

SETTING/PARTICIPANTS

Students attending eight elementary schools in one low-income school district serving 3,719 students.

INTERVENTION

Participatory-based, experiential, competency-building professional development workshop for physical education and classroom teachers. Baseline was fall 2015, and the intervention was delivered during spring 2016 through spring 2017.

MAIN OUTCOME MEASURES

Hip-placed accelerometers were used to derive the percentage of children accumulating 30 minutes of MVPA during the school day, minutes of MVPA, and time spent sedentary. Analyses were conducted during July 2017.

RESULTS

A total of 1,570 first- and fourth-grade students (49.8% girls, 87.0% African American, 88% free and reduced-price lunch) were measured across the project. Primary analyses indicated that the percentage of girls and boys meeting the 30-minutes/day guideline increased by 9.3% (95% CI=4.7%, 13.9%) and 10.4% (95% CI=5.5%, 15.3%), respectively. A corresponding increase of 1.7 (95% CI=0.5, 2.8) and 2.5 (95% CI=1.1, 3.8) MVPA minutes accumulated during the school day were observed for both girls and boys, respectively. Primary analyses indicated that statistically significant increases in MVPA and total activity for boys and girls were observed across the school day, during classroom time, and during physical education.

CONCLUSIONS

Participatory-based, experiential, competency-building professional development is an effective strategy for increasing students' MVPA and total activity in low-income schools. However, data from this study indicate that targeting settings outside of the school day may be more appropriate given that schools were providing more than two thirds of the recommended 30 minutes/day of MVPA prior to intervention.

Characteristics of Teacher Training in School-Based Physical Education Interventions to Improve Fundamental Movement Skills and/or Physical Activity: A Systematic Review

BACKGROUND

Fundamental movement skill (FMS) competence is positively associated with physical activity (PA). However, levels of both FMS and PA are lower than expected. Current reviews of interventions to improve FMS and PA have shown that many school-based programs have achieved positive outcomes, yet the maintenance of these interventions is variable. Teachers play a central role in the success and longevity of school-based interventions. Despite the importance of teacher engagement, research into the nature and quality of teacher training in school-based PA and FMS interventions has received little attention.

OBJECTIVE

The aim of this systematic review was to investigate the type and quantity of teacher training in school-based physical education PA and/or FMS interventions, and to identify what role teacher training had on the intervention outcome.

METHODS

A systematic search of eight electronic databases was conducted. Publication date restrictions were not implemented in any database, and the last search was performed on 1 March 2015. School physical education-based interventions facilitated by a school teacher, and that included a quantitative assessment of FMS competence and/or PA levels were included in the review.

RESULTS

The search identified 39 articles. Eleven of the studies measured FMS, 25 studies measured PA and three measured both FMS and PA. Nine of the studies did not report on any aspect of the teacher training conducted. Of the 30 studies that reported on teacher training, 25 reported statistically significant intervention results for FMS and/or PA. It appears that teacher training programs: are ≥ 1 day; provide comprehensive subject and pedagogy content; are framed by a theory or model; provide follow-up or ongoing support; and measure teacher satisfaction of the training, are more effective at improving student outcomes in FMS and/or PA. However, the provision of information regarding the characteristics of the teacher training was largely inadequate. Therefore, it was difficult to ascertain which teacher training characteristics were most important in relation to intervention effectiveness.

CONCLUSION

It is clear that whilst teachers are capable of making substantial improvements in student outcomes in PA and FMS, the findings of this review suggest the teacher training component of school-based PA and/or FMS interventions is not only under-reported but is under-studied, and, perhaps as a result, the value of teacher training is not widely understood. What remains unclear, due to poor reporting, is what role teacher training is having on these outcomes.

Effects of a Three-Tiered Intervention Model on Physical Activity and Fitness Levels of Elementary School Children

Response to intervention (RtI) models are frequently used in schools to tailor academic instruction to the needs of students. The purpose of this study was to examine the effects of using RtI to promote physical activity (PA) and fitness in one urban elementary school. Ninety-nine students in grades 2-5 participated in up to three tiers of intervention throughout the course of one school year. Tier one included 150 min/week of physical education (increased from 90 min/week the previous year) and coordinated efforts to improve school health. Tier two consisted of 30 min/week of small group instruction based on goal setting and social support. Tier three included an after-school program for parents and children focused on healthy living. PA, cardiovascular fitness, and body composition were assessed before and after the interventions using pedometers, a 20-m shuttle run, and height/weight measurements. From pre- to post-testing, PA remained relatively stable in tier one and increased by 2349 steps/day in tier two. Cardiovascular fitness increased in tiers one and two by 1.17 and 1.35 ml/kg/min, respectively. Although body mass index did not change, 17 of the 99 students improved their weight status over the course of the school year, resulting in an overall decline in the prevalence of overweight/obesity from 59.6 to 53.5 %. Preliminary results suggest that the RtI model can be an effective way to structure PA/health interventions in an elementary school setting.

Studies of Physical Education in the United States Using SOFIT: A Review

PURPOSE

An objective database for physical education (PE) is important for policy and practice decisions, and the System for Observing Fitness Instruction Time (SOFIT) has been identified as an appropriate surveillance tool for PE across the nation. The purpose of this review was to assess peer-reviewed studies using SOFIT to study K-12 PE in U.S. schools.

METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses informed the review, and 10 databases were searched for English-language articles published through 2016. A total of 704 records identifying SOFIT were located, and 137 full texts were read. Two authors reviewed full-text articles, and a data extraction tool was developed to select studies and main topics for synthesis.

RESULTS

Twenty-nine studies that included direct observations of 12,256 PE lessons met inclusion criteria; 17 were conducted in elementary schools, 9 in secondary schools, and 3 in combined-level schools. Inconsistent reporting among studies was evident, including not all identifying the number of classes and teachers involved. All studies reported student physical activity, but fewer reported observer reliabilities (88%), lesson context (76%), teacher behavior (38%), and PE dosage (34%). The most frequently analyzed independent variables were teacher preparation (48%), lesson location (38%), and student gender (31%).

CONCLUSIONS

SOFIT can be used reliably in diverse settings. Inconsistent reporting about study procedures and variables analyzed, however, limited comparisons among studies. Adherence to an established protocol and more consistent reporting would more fully enable the development of a viable database for PE in U.S. schools.

Strategies for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease

BACKGROUND

A number of school-based policies or practices have been found to be effective in improving child diet and physical activity, and preventing excessive weight gain, tobacco or harmful alcohol use. Schools, however, frequently fail to implement such evidence-based interventions.

OBJECTIVES

The primary aims of the review are to examine the effectiveness of strategies aiming to improve the implementation of school-based policies, programs or practices to address child diet, physical activity, obesity, tobacco or alcohol use.Secondary objectives of the review are to: Examine the effectiveness of implementation strategies on health behaviour (e.g. fruit and vegetable consumption) and anthropometric outcomes (e.g. BMI, weight); describe the impact of such strategies on the knowledge, skills or attitudes of school staff involved in implementing health-promoting policies, programs or practices; describe the cost or cost-effectiveness of such strategies; and describe any unintended adverse effects of strategies on schools, school staff or children.

SEARCH METHODS

All electronic databases were searched on 16 July 2017 for studies published up to 31 August 2016. We searched the following electronic databases: Cochrane Library including the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; Embase Classic and Embase; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); Dissertations and Theses; and SCOPUS. We screened reference lists of all included trials for citations of other potentially relevant trials. We handsearched all publications between 2011 and 2016 in two specialty journals (Implementation Science and Journal of Translational Behavioral Medicine) and conducted searches of the WHO International Clinical Trials Registry Platform (ICTRP) (http://apps.who.int/trialsearch/) as well as the US National Institutes of Health registry (https://clinicaltrials.gov). We consulted with experts in the field to identify other relevant research.

SELECTION CRITERIA

'Implementation' was defined as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised or non-randomised) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by school staff to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

Citation screening, data extraction and assessment of risk of bias was performed by review authors in pairs. Disagreements between review authors were resolved via consensus, or if required, by a third author. Considerable trial heterogeneity precluded meta-analysis. We narratively synthesised trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated).

MAIN RESULTS

We included 27 trials, 18 of which were conducted in the USA. Nineteen studies employed randomised controlled trial (RCT) designs. Fifteen trials tested strategies to implement healthy eating policies, practice or programs; six trials tested strategies targeting physical activity policies or practices; and three trials targeted tobacco policies or practices. Three trials targeted a combination of risk factors. None of the included trials sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials examined multi-strategic implementation strategies and no two trials examined the same combinations of implementation strategies. The most common implementation strategies included educational materials, educational outreach and educational meetings. For all outcomes, the overall quality of evidence was very low and the risk of bias was high for the majority of trials for detection and performance bias.Among 13 trials reporting dichotomous implementation outcomes-the proportion of schools or school staff (e.g. classes) implementing a targeted policy or practice-the median unadjusted (improvement) effect sizes ranged from 8.5% to 66.6%. Of seven trials reporting the percentage of a practice, program or policy that had been implemented, the median unadjusted effect (improvement), relative to the control ranged from -8% to 43%. The effect, relative to control, reported in two trials assessing the impact of implementation strategies on the time per week teachers spent delivering targeted policies or practices ranged from 26.6 to 54.9 minutes per week. Among trials reporting other continuous implementation outcomes, findings were mixed. Four trials were conducted of strategies that sought to achieve implementation 'at scale', that is, across samples of at least 50 schools, of which improvements in implementation were reported in three trials.The impact of interventions on student health behaviour or weight status were mixed. Three of the eight trials with physical activity outcomes reported no significant improvements. Two trials reported reductions in tobacco use among intervention relative to control. Seven of nine trials reported no between-group differences on student overweight, obesity or adiposity. Positive improvements in child dietary intake were generally reported among trials reporting these outcomes. Three trials assessed the impact of implementation strategies on the attitudes of school staff and found mixed effects. Two trials specified in the study methods an assessment of potential unintended adverse effects, of which, they reported none. One trial reported implementation support did not significantly increase school revenue or expenses and another, conducted a formal economic evaluation, reporting the intervention to be cost-effective. Trial heterogeneity, and the lack of consistent terminology describing implementation strategies, were important limitations of the review.

AUTHORS' CONCLUSIONS

Given the very low quality of the available evidence, it is uncertain whether the strategies tested improve implementation of the targeted school-based policies or practices, student health behaviours, or the knowledge or attitudes of school staff. It is also uncertain if strategies to improve implementation are cost-effective or if they result in unintended adverse consequences. Further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

Initial Outcomes of a Participatory-Based, Competency-Building Approach to Increasing Physical Education Teachers' Physical Activity Promotion and Students' Physical Activity: A Pilot Study

This study examined the initial effects of a participatory-based, competency-/skill-building professional development workshop for physical education (PE) teachers on the use of physical activity (PA) promotion practices (e.g., eliminating lines, small-sided games) and students' moderate-to-vigorous physical activity (MVPA). A total of 823 students (52.8% boys) wore accelerometers at baseline (fall 2015) and outcome (spring 2016) on PE and non-PE days. The System for Observing Fitness Instruction Time+ measured changes in PA promotion practices. Teachers ( n = 9) attended a 90-minute workshop prior to outcome data collection. Mixed-model linear regressions estimated changes in teacher practices and students' MVPA. Three of the nine targeted PA promotion practices changed in the desired direction (i.e., p < .05; increased motor content and lessons taught outdoors, reduced activities with lines), with three more teacher practices trending in the desired direction (i.e., reduced management time and activities with elimination, increased small-sided games). During PE, boys and girls increased MVPA by 2.0 (95% confidence interval [1.1, 3.0]), and 1.3 (95% confidence interval [0.5-2.0]) minutes, respectively. However, there were no statistically significant changes in boys' or girls' MVPA during the school day. Greater implementation of promotion practices by the PE teachers was associated with boys', but not girls', MVPA during PE. Girls in high- and low-implementing teachers' lessons experienced increases in MVPA, suggesting that even small changes in PA promotion practices can increase girls' MVPA during PE. Overall, the workshops were effective at increasing teachers' PA promotion and students' MVPA in PE. Other school-based strategies that complement and extend efforts targeting PE are recommended to increase children's total daily PA.

Examining the impact of a province-wide physical education policy on secondary students' physical activity as a natural experiment

Background

The purpose of this paper is to examine the impact of a province-wide physical education (PE) policy on secondary school students’ moderate to vigorous physical activity (MVPA).

Methods

Policy: In fall 2008, Manitoba expanded a policy requiring a PE credit for students in grades 11 and 12 for the first time in Canada. The PE curriculum requires grades 11 and 12 students to complete a minimum of 55 h (50% of course hours) of MVPA (e.g., ≥30 min/day of MVPA on ≥5 days a week) during a 5-month semester to achieve the course credit.

Study Designs: A natural experimental study was designed using two sub-studies: 1) quasi-experimental controlled pre-post analysis of self-reported MVPA data obtained from census data in intervention and comparison [Prince Edward Island (PEI)] provinces in 2008 (n = 33,619 in Manitoba and n = 2258 in PEI) and 2012 (n = 41,169 in Manitoba and n = 4942 in PEI); and, 2) annual objectively measured MVPA in cohorts of secondary students in intervention (n = 447) and comparison (Alberta; n = 224) provinces over 4 years (2008 to 2012).

Analysis: In Study 1, two logistic regressions were conducted to model the odds that students accumulated: i) ≥30 min/day of MVPA, and ii) met Canada's national recommendation of ≥60 min/day of MVPA, in Manitoba versus PEI after adjusting for grade, sex, and BMI. In Study 2, a mixed effects model was used to assess students’ minutes of MVPA per day per semester in Manitoba and Alberta, adjusting for age, sex, BMI, school location and school SES.

Results

In Study 1, no significant differences were observed in students achieving ≥30 (OR:1.13, 95% CI:0.92, 1.39) or ≥60 min/day of MVPA (OR:0.92, 95% CI: 0.78, 1.07) from baseline to follow-up between Manitoba and PEI. In Study 2, no significant policy effect on students’ MVPA trajectories from baseline to last follow-up were observed between Manitoba and Alberta overall (−1.52, 95% CI:-3.47, 0.42), or by covariates.

Conclusions

The Manitoba policy mandating PE in grades 11 and 12 had no effect on student MVPA overall or by key student or school characteristics. However, the effect of the PE policy may be underestimated due to the use of a nonrandomized research design and lack of data assessing the extent of policy implementation across schools. Nevertheless, findings can provide evidence about policy features that may improve the PE policy in Manitoba and inform future PE policies in other jurisdictions.

Examination of motor skill competency in students: evidence-based physical education curriculum

BACKGROUND

Researchers found that children with a competent level of motor skill performance are more likely to be physically active. This study examined how well K-1 students demonstrated motor skill competency in relation to Physical Education Content Standard 1.

METHODS

Participants were K-1 grade students (N = 1,223-1,588; boys = 568-857; girls = 526-695; Mean age = 5.5 yrs old) who were enrolled in nine elementary schools. The K-1 students' motor skill competency in running, weight transferring, hand dribbling, and underhand catching skills was assessed using four PE Metrics skill assessment rubrics in the intervention year 1 and year 2, respectively. Data were analyzed by means of descriptive statistics and independent sample t-tests.

RESULTS

The students in the intervention year 1 and year 2 cohorts performed at the Competent Level or higher in the four skill assessments. The prevalence of the students' demonstration of skill competency across the four skills was high in the two intervention years. The intervention year 2 cohort scored significantly higher than the intervention year 1 cohort in the four skill assessments. The boys significantly outperformed than the girls in the two manipulative skills in the intervention year 1 and in the two manipulative skills and the weight transferring skill in the intervention year 2. No gender differences in the running skill in either year were found.

CONCLUSIONS

The evidence-based CATCH PE play a critical role in developing and building K-1 students' ability to demonstrate motor skill competency in four fundamental skills.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03015337 , registered date: 1/09/2017, as "retrospectively registered".

Using cost-effectiveness analysis to prioritize policy and programmatic approaches to physical activity promotion and obesity prevention in childhood

Participation in recommended levels of physical activity promotes a healthy body weight and reduced chronic disease risk. To inform investment in prevention initiatives, we simulate the national implementation, impact on physical activity and childhood obesity and associated cost-effectiveness (versus the status quo) of six recommended strategies that can be applied throughout childhood to increase physical activity in US school, afterschool and childcare settings. In 2016, the Childhood Obesity Intervention Cost Effectiveness Study (CHOICES) systematic review process identified six interventions for study. A microsimulation model estimated intervention outcomes 2015-2025 including changes in mean MET-hours/day, intervention reach and cost per person, cost per MET-hour change, ten-year net costs to society and cases of childhood obesity prevented. First year reach of the interventions ranged from 90,000 youth attending a Healthy Afterschool Program to 31.3 million youth reached by Active School Day policies. Mean MET-hour/day/person increases ranged from 0.05 MET-hour/day/person for Active PE and Healthy Afterschool to 1.29 MET-hour/day/person for the implementation of New Afterschool Programs. Cost per MET-hour change ranged from cost saving to $3.14. Approximately 2500 to 110,000 cases of children with obesity could be prevented depending on the intervention implemented. All of the six interventions are estimated to increase physical activity levels among children and adolescents in the US population and prevent cases of childhood obesity. Results do not include other impacts of increased physical activity, including cognitive and behavioral effects. Decision-makers can use these methods to inform prioritization of physical activity promotion and obesity prevention on policy agendas.

Does physical education influence eye-hand coordination? The Lifestyles of our Kids intervention study

In Australian government-funded primary schools, the responsibility for physical education (PE) falls mainly on general classroom teachers, many of whom possess limited PE training. This study sought to examine the impact of specialist-taught PE on eye-hand coordination (EHC) development. In this 4-year cluster-randomized intervention, participants were 187 boys and 172 girls initially in grade 2 in 29 primary schools, where no school employed university-trained specialist PE teachers. In 13 (intervention) schools, specialist PE teachers conducted 268 PE classes (two 45-minute sessions/wk) from grade 2 to grade 6. The intervention was based on traditional PE educational objectives, including fundamental motor skills, but did not specifically focus on EHC. The remaining 16 (control) schools continued with common-practice PE taught by general classroom teachers (30-60 min/wk). EHC was measured by a ball throw and wall-rebound catch test and recorded at ages 8, 10, and 12 (SD 0.3) at ends of grades 2, 4, and 6, respectively. There was steady yearly improvement of EHC in both groups, but no evidence of any intervention effect in boys (P=.88) or girls (P=.20). The introduction of specialist-taught PE during 4 years of primary school did not influence EHC development. Considering evidence that classroom teachers make little contribution to PE in this jurisdiction, together with the steady progression of EHC over the 4 years, other influences such as organized sport, after-school activities, natural development, and parental instruction are conceivably more influential factors in EHC development during primary school years.

The theory of expanded, extended, and enhanced opportunities for youth physical activity promotion

BACKGROUND

Physical activity interventions targeting children and adolescents (≤18 years) often focus on complex intra- and inter-personal behavioral constructs, social-ecological frameworks, or some combination of both. Recently published meta-analytical reviews and large-scale randomized controlled trials have demonstrated that these intervention approaches have largely produced minimal or no improvements in young people's physical activity levels.

DISCUSSION

In this paper, we propose that the main reason for previous studies' limited effects is that fundamental mechanisms that lead to change in youth physical activity have often been overlooked or misunderstood. Evidence from observational and experimental studies is presented to support the development of a new theory positing that the primary mechanisms of change in many youth physical activity interventions are approaches that fall into one of the following three categories: (a) the expansion of opportunities for youth to be active by the inclusion of a new occasion to be active, (b) the extension of an existing physical activity opportunity by increasing the amount of time allocated for that opportunity, and/or (c) the enhancement of existing physical activity opportunities through strategies designed to increase physical activity above routine practice. Their application and considerations for intervention design and interpretation are presented. The utility of these mechanisms, referred to as the Theory of Expanded, Extended, and Enhanced Opportunities (TEO), is demonstrated in their parsimony, logical appeal, support with empirical evidence, and the direct and immediate application to numerous settings and contexts. The TEO offers a new way to understand youth physical activity behaviors and provides a common taxonomy by which interventionists can identify appropriate targets for interventions across different settings and contexts. We believe the formalization of the TEO concepts will propel them to the forefront in the design of future intervention studies and through their use, lead to a greater impact on youth activity behaviors than what has been demonstrated in previous studies.

A systematic review of children's dietary interventions with parents as change agents: Application of the RE-AIM framework

INTRODUCTION

Interventions targeting children's dietary behavior often include strategies that target parents as implementation agents of change, though parent involvement on intervention effectiveness is unclear. The present study systematically assessed (1) reporting of reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of child dietary intervention studies with parents as change agents and (2) evaluated within these studies the comparative effectiveness of interventions with and without a parent component.

METHODS

The search was conducted in PubMed, PsycINFO, and Cochrane Library. Eligible studies were required to include a condition with a parental component, a comparison/control group, and target a child dietary behavior outcome. Forty-nine articles met criteria. Raters extracted RE-AIM and parent implementation information for each study.

RESULTS

Effectiveness (72.5%) was the highest reported RE-AIM element, followed by reach (27.5%), adoption (12.5%), implementation (10%), and maintenance (2.5%). Median reporting of parent implementation was highest for adoption and enactment (20%), followed by receipt (7.5%), and maintenance (2.5%). Six studies tested comparative effectiveness of parental involvement on child dietary outcomes.

CONCLUSION

Current RE-AIM reporting among children's dietary interventions is inchoate. The contribution of parental involvement on intervention effectiveness remains unclear. Increased focus should be placed on reporting of external validity information, to enable better translation of research to practical applications.

School-Based and PRECEDE-PROCEED-Model Intervention to Promote Physical Activity in the High School Students: Case Study of Iran

OBJECTIVES

Students attend sedentary life style and less like vigorous physical activity. This study investigated the effects of School-based intervention on increasing physical activity for decreasing obesity among high-school obese and overweight boys, based on the components of PRECEDE PROCEED Model, to participate in median - vigorous physical activity among the first Period of high school boys in the city of Urmia, Iran.

METHODS

This study was an experimental intervention that conducted at 4 high schools that were divided into 2 groups of intervention (40) and the control (40) male students, schools in junior high schools in Urmia.

RESULTS

Three and six months after the intervention, significant differences were found between the experimental and control groups of schools, in the amount of students' participation in vigorous physical activity (p<0.01).

CONCLUSIONS

According to the results, the school-based intervention and components of PRECEDE PROCEED Model had a positive impact on the improvement of physical activity and decrease in physical inactivity among the students.

Assessing Barriers and Enhancers to Increasing Physical Activity during the School Day in Children on an American Indian Reservation: A Qualitative Research Study

Objective

We attempted to determine factors that enhance or limit physical activity (PA) in children living on an American Indian (AI) reservation.

Methods

Six audio-recorded focus groups (FGs) were conducted. Each group included 6 - 8 participants (N = 42) with 3 grade specific FGs (4^th - 6^th grade students) and 3 adult FGs.

Results

FG analysis identified 4 main barriers to PA: school environment; community and school resources; electronic devices; and the role of parents and family. Analysis revealed 3 main strategies to increase PA: structured/non-competitive activities; structured/competitive activities; and increasing school and community-wide capacity.

Conclusion

The results from this study provide a school health perspective on the 4-day school week.

A Community-Based Physical Education and Activity Intervention for African American Preadolescent Girls: A Strategy to Reduce Racial Disparities in Health

Physical activity habits fostered and developed early in life tend to persist into adulthood, reducing the incidence of chronic diseases associated with a sedentary lifestyle in later life. This is of particular importance for racial and ethnic minority populations who experience significant disparities in rates of chronic disease. Thus, promoting physical activity in minority children is an effective strategy for reducing these health disparities. Unfortunately, however, recommendations for effective implementation of such programs are sorely lacking. This article describes the development and implementation of Lively Ladies, a physical education and activity intervention targeted to low-income, preadolescent, African American girls in a community-based youth services organization. Low-income, minority girls face the catch-22 situation of being at higher risk for physical inactivity while having limited or no access to physical fitness programs. This article demonstrates that community-based youth organizations can play an important role in changing this situation. The authors’ experience with Lively Ladies indicates the effectiveness of a theory-based program addressing modifiable psychosocial and environmental determinants of behavior. They provide recommendations to guide future design and implementation of community-based physical education and activity interventions for a population group that tends to have increased risk for physical inactivity and limited access to fitness programs and facilities.

Adoption and Institutionalization of the Child and Adolescent Trial for Cardiovascular Health (CATCH) in El Paso, Texas

One goal of national health-promotion research is to disseminate and institutionalize experimentally tested programs in local communities. In 1997, the national Child and Adolescent Trial for Cardiovascular Health (CATCH) was chosen by the Paso del Norte Health Foundation as their first community-wide preventive health initiative for the El Paso, Texas/Juárez, México border region. With help from researchers at the University of Texas at Houston, evaluators from the University of Texas at El Paso, and the Region 19 Educational Services Center, CATCH was implemented in 18 Title I pilot schools. Known as the Coordinated Approach to Child Health 5 years later, the El Paso CATCH program has been embraced by the border community and reaches 108 elementary schools from New Mexico to West Central Texas. There are also plans to implement CATCH in Juárez. This article describes the institutionalization of CATCH in a predominately Hispanic, low income border region.

Increasing physical activity levels in primary school physical education: The SHARP Principles Model

Objectives: To evaluate the effectiveness of a one-year teaching intervention to increase moderate to vigorous physical activity (MVPA) during primary school physical education (PE). Methods: A quasi-experimental, non-equivalent group design involving four classes from two primary schools in the West Midlands, UK. In March 2014 schools were selected through purposive sampling to match schools in terms of size and demographics (baseline, n = 111: post-intervention, n = 95); data were collected from children in school years 3 and 4 (aged 7 to 9 years). The intervention involved developing teacher effectiveness through the SHARP Principles Model which was grounded in the Self Determination Theory (SDT), the Social Ecological Model (SEM) and three key ingredients from the Behaviour Change Taxonomy (BCT). MVPA was assessed at baseline and four weeks post-intervention using the System for Observing Fitness and Instruction Time (SOFIT). Four individual teacher interviews were conducted with the intervention school, to explore teachers' perceptions of the intervention. Results: A two-way ANOVA (Analysis of Variance) indicated large interaction effect sizes for time spent in MVPA (F(1, 27) = 11.07, p = 0.003, η_p² = .316) and vigorous activity (VPA) (F = (1,27) = 8.557, p = .007, η_p² = .263). PA in the intervention school increased significantly whereas in the control school MVPA remained relatively constant and VPA decreased. The qualitative findings revealed two main emergent themes: a paradigm shift and teacher's developing pedagogy. Conclusions: The intervention was effective in increasing MVPA in PE. Recommendations based on this evaluation would be for the SHARP Principles Model to be replicated and evaluated on a wider scale across a variety of contexts.

•

We designed and evaluated a primary PE teaching strategy intervention.

•

The intervention yielded a large effect size, and increased children's MVPA by 30%.

•

The SHARP Principles Model re-directed the school's approach to primary PE.

•

Qualitative data suggested a paradigm shift in the teacher's thinking towards PE.

•

Mixed methods assisted in understanding the effectiveness of the intervention.

Public Disclosure to Improve Physical Education in an Urban School District: Results From a 2-Year Quasi-Experimental Study

BACKGROUND

Many elementary schools have policies requiring a minimum amount of physical education (PE). However, few schools comply with local/state PE policy and little is known about how to improve adherence. We evaluated changes in PE among fifth-grade classes, following participatory action research efforts to improve PE quantity and policy compliance that focused on publically disclosing PE data.

METHODS

Data were collected in 20 San Francisco public elementary schools in spring 2011 and 2013. PE schedules were collected and PE classes were directly observed (2011, N = 30 teachers; 2013, N = 33 teachers). Data on the proportion of schools meeting state PE mandates in 2011 were shared within the school district and disclosed to the general public in 2012.

RESULTS

From 2011 to 2013, PE increased by 11 minutes/week based on teachers' schedules (95% CI: 3.0, 19.6) and by 14 minutes/week (95% CI: 1.9, 26.0) based on observations. The proportion of schools meeting the state PE mandate increased from 20% to 30% (p = .27).

CONCLUSIONS

Positive changes in PE were seen over a 2-year period following the public disclosure of data that highlighted poor PE policy compliance. Public disclosure could be a method for ensuring greater PE policy adherence.

Variability and Stability in Daily Moderate-to-Vigorous Physical Activity among 10 Year Old Children

Day-to-day variability and stability of children's physical activity levels across days of the week are not well understood. Our aims were to examine the day-to-day variability of moderate-to-vigorous physical activity (MVPA), to determine factors influencing the day-to-day variability of MVPA and to estimate stability of MVPA in children. The sample comprises 686 Portuguese children (10 years of age). MVPA was assessed with an accelerometer, and BMI was computed from measured height and weight. Daily changes in MVPA and their correlates (gender, BMI, and maturity) were modeled with a multilevel approach, and tracking was calculated using Foulkes &amp; Davies γ. A total of 51.3% of boys and 26.2% of girls achieved 60 min/day of MVPA on average. Daily MVPA was lower during the weekend (23.6% of boys and 13.6% of girls comply with the recommended 60 min/day of MVPA) compared to weekdays (60.8% and 35.4%, boys and girls, respectively). Normal weight children were more active than obese children and no effect was found for biological maturation. Tracking is low in both boys (γ = 0.59 ± 0.01) and girls (γ = 0.56 ± 0.01). Children's MVPA levels during a week are highly unstable. In summary, boys are more active than girls, maturation does not affect their MVPA, and obese children are less likely to meet 60 min/day of MVPA. These results highlight the importance of providing opportunities for increasing children's daily MVPA on all days of week, especially on the weekend.

Cost Effectiveness of an Elementary School Active Physical Education Policy

INTRODUCTION

Many American children do not meet recommendations for moderate to vigorous physical activity (MVPA). Although school-based physical education (PE) provides children with opportunities for MVPA, less than half of PE minutes are typically active. The purpose of this study is to estimate the cost effectiveness of a state "active PE" policy implemented nationally requiring that at least 50% of elementary school PE time is spent in MVPA.

METHODS

A cohort model was used to simulate the impact of an active PE policy on physical activity, BMI, and healthcare costs over 10 years for a simulated cohort of the 2015 U.S. population aged 6-11 years. Data were analyzed in 2014.

RESULTS

An elementary school active PE policy would increase MVPA per 30-minute PE class by 1.87 minutes (95% uncertainty interval [UI]=1.23, 2.51) and cost $70.7 million (95% UI=$51.1, $95.9 million) in the first year to implement nationally. Physical activity gains would cost $0.34 per MET-hour/day (95% UI=$0.15, $2.15), and BMI could be reduced after 2 years at a cost of $401 per BMI unit (95% UI=$148, $3,100). From 2015 to 2025, the policy would cost $235 million (95% UI=$170 million, $319 million) and reduce healthcare costs by $60.5 million (95% UI=$7.93 million, $153 million).

CONCLUSIONS

Implementing an active PE policy at the elementary school level could have a small impact on physical activity levels in the population and potentially lead to reductions in BMI and obesity-related healthcare expenditures over 10 years.

A cluster randomised controlled trial to investigate the effectiveness and cost effectiveness of the 'Girls Active' intervention: a study protocol

BACKGROUND

Despite the health benefits of physical activity, data from the UK suggest that a large proportion of adolescents do not meet the recommended levels of moderate-to-vigorous physical activity (MVPA). This is particularly evident in girls, who are less active than boys across all ages and may display a faster rate of decline in physical activity throughout adolescence. The 'Girls Active' intervention has been designed by the Youth Sport Trust to target the lower participation rates observed in adolescent girls. 'Girls Active' uses peer leadership and marketing to empower girls to influence decision making in their school, develop as role models and promote physical activity to other girls. Schools are provided with training and resources to review their physical activity, sport and PE provision, culture and practices to ensure they are relevant and attractive to adolescent girls.

METHODS/DESIGN

This study is a two-arm cluster randomised controlled trial (RCT) aiming to recruit 20 secondary schools. Clusters will be randomised at the school level (stratified by school size and proportion of Black and Minority Ethnic (BME) pupils) to receive either the 'Girls Active' intervention or carry on with usual practice (1:1). The 20 secondary schools will be recruited from state secondary schools within the Midlands area. We aim to recruit 80 girls aged 11-14 years in each school. Data will be collected at three time points; baseline and seven and 14 months after baseline. Our primary aim is to investigate whether 'Girls Active' leads to higher objectively measured (GENEActiv) moderate-to-vigorous physical activity in adolescent girls at 14 months after baseline assessment compared to the control group. Secondary outcomes include other objectively measured physical activity variables, adiposity, physical activity-related psychological factors and the cost-effectiveness of the 'Girls Active' intervention. A thorough process evaluation will be conducted during the course of the intervention delivery.

DISCUSSION

The findings of this study will provide valuable information on whether this type of school-based approach to increasing physical activity in adolescent girls is both effective and cost-effective in the UK.

TRIAL REGISTRATION

ISRCTN10688342. Registered 12 January 2015.

A national school-based health lifestyles interventions among Chinese children and adolescents against obesity: rationale, design and methodology of a randomized controlled trial in China

BACKGROUND

The prevalence of obesity among children and adolescents has been rapidly rising in Mainland China in recent decades, both in urban and rural areas. There is an urgent need to develop effective interventions to prevent childhood obesity. Limited rigid data regarding children and adolescent overweight prevention in China are available. A national random controlled school-based obesity intervention program was developed in the mainland of China.

METHODS/DESIGN

The study was designed as a national multi-centered cluster randomized controlled trial involving more than 70,000 children and adolescents aged 7-18 years from 7 provinces in China. In each center, about 12-16 primary and secondary schools, with totally at least 10000 participants were randomly selected (Primary: Secondary = 1:1). All of the selected schools were randomly allocated to either intervention or control group (Intervention: Control = 1:1).The multi-components school-based and family-involved scheme was conducted within the intervention group for 9 month, while students in the control group followed their usual health practice. The intervention consisted of four components: a) Create supportive school and family environment, b) Health lifestyles education and related compulsory physical activities, c) Instruct and promote school physical education, d) Self-monitor obesity related behaviors. Four types of outcomes including anthropometric, behavioral, blood chemical and physical fitness were measured to assess the effectiveness of the intervention program.

DISCUSSION

This is the first and largest multi-centered school-based obesity intervention program with the consideration of geographical and social-demographic characteristics of the rapidly increased obesity prevalence of Chinese children and adolescent. The intervention is based on Social Cognitive Theory and Social-Ecological Model of Health, and follows a stepwise approach guided by PRECEDE-PROCEED (P-P) Model and Intervention Map. The results of and lesson learned from this study will help guide future school-based national childhood obesity prevention programs in Mainland China.

TRIAL REGISTRATION

January 22, 2015;

REGISTRATION NUMBER

NCT02343588.

A systematic review of public health-aligned recommendations for preparing physical education teacher candidates

PURPOSE

Since Sallis and McKenzie's seminal article in 1991 outlining physical education's role in public health, increased attention has been given to promoting youth physical activity in schools. The present study systematically reviewed the literature from 1991 to 2013 to identify recommendations for the preparation of physical education teacher candidates (PETCs) from a public health perspective.

METHOD

Eight online databases (e.g., Educational Resources Information Center, Google Scholar) served as data sources for the study. Multiple combinations of key terms (e.g., physical education teacher education [PETE], public health, health-oriented) were used to identify relevant literature meeting search criteria. A content analysis was used to identify 47 distinct recommendations from 25 included articles and to synthesize these recommendations into major areas of focus.

RESULTS

Three major areas of focus were identified: (a) candidate profile (e.g., PETCs should be physically active and fit role models), (b) candidate knowledge (e.g., PETCs should know about behavior change theories), and (c) candidate skills (e.g., PETCs should be able to advocate for school-based physical activity).

CONCLUSION

This review can serve as a blueprint for PETE programs seeking to align professional preparation with public health goals.

Implementation of school based physical activity interventions: a systematic review

OBJECTIVE

Implementation science is an emerging area in physical activity (PA) research. We sought to establish the current state of the evidence related to implementation of school-based PA models to explore 1) the relationship between implementation and health outcomes, and 2) factors that influence implementation.

METHODS

We searched 7 electronic databases (1995-2014) and included controlled studies of school-based PA programmes for healthy youth (6-18 y) measuring at least one physical health-related outcome. For objective 1, studies linked implementation level to student-level health outcome(s). For objective 2, studies reported factors associated with implementation.

RESULTS

There was substantial variability in how health outcomes and implementation were assessed. Few studies linked implementation and health outcomes (n=15 interventions). Most (11/15) reported a positive relationship between implementation and at least one health outcome. Implementation factors were reported in 29 interventions. Of 22 unique categories, time was the most prevalent influencing factor followed by resource availability/quality and supportive school climate.

CONCLUSIONS

Implementation evaluation supports scale-up of effective school-based PA interventions and thus population-level change. Our review serves as a call to action to 1) address the link between implementation and outcome within the school-based PA literature and 2) improve and standardize definitions and measurement of implementation.

Incorporating primary and secondary prevention approaches to address childhood obesity prevention and treatment in a low-income, ethnically diverse population: study design and demographic data from the Texas Childhood Obesity Research Demonstration (TX CORD) study

BACKGROUND

There is consensus that development and evaluation of a systems-oriented approach for child obesity prevention and treatment that includes both primary and secondary prevention efforts is needed. This article describes the study design and baseline data from the Texas Childhood Obesity Research Demonstration (TX CORD) project, which addresses child obesity among low-income, ethnically diverse overweight and obese children, ages 2-12 years; a two-tiered systems-oriented approach is hypothesized to reduce BMI z-scores, compared to primary prevention alone.

METHODS

Our study aims are to: (1) implement and evaluate a primary obesity prevention program; (2) implement and evaluate efficacy of a 12-month family-centered secondary obesity prevention program embedded within primary prevention; and (3) quantify the incremental cost-effectiveness of the secondary prevention program. Baseline demographic and behavioral data for the primary prevention community areas are presented.

RESULTS

Baseline data from preschool centers, elementary schools, and clinics indicate that most demographic variables are similar between intervention and comparison communities. Most families are low income (≤$25,000) and Hispanic/Latino (73.3-83.8%). The majority of parents were born outside of the United States. Child obesity rates exceed national values, ranging from 19.0% in preschool to 35.2% in fifth-grade children. Most parents report that their children consume sugary beverages, have a television in the bedroom, and do not consume adequate amounts of fruits and vegetables.

CONCLUSIONS

Interventions to address childhood obesity are warranted in low-income, ethnically diverse communities. Integrating primary and secondary approaches is anticipated to provide sufficient exposure that will lead to significant decreases in childhood obesity.

How can schools help youth increase physical activity? An economic analysis comparing school-based programs

OBJECTIVE

For optimal health, physical activity should be an integral and routine part of daily life. Youth spend a significant amount of time at school yet rarely achieve the recommended 60 min of moderate and vigorous physical activity in physical education (PE) classes or recess. This study assessed the following types of school-based opportunities to improve physical activity for youth: after-school programs, before-school programs, PE classes, extended-day PE, and short physical activity breaks during the school day.

METHOD

An economic analysis conducted in 2013 compared school-based approaches to increasing physical activity. Analysis factors included costs, reach, effects on physical activity gains, cost-effectiveness, and other potentially augmenting benefits.

RESULTS

Two programs were significantly superior in terms of reach and cost per student: (1) extending the school day with mandatory PE participation and (2) offering short (10-minute) physical activity breaks during regular classroom hours. After-school program costs per student are high and the programs have a smaller reach, but they offer benefits (such as childcare) that may justify their higher costs. Before-school programs did not appear feasible.

CONCLUSION

Incorporating short physical activity breaks into the existing school day would be a cost-effective way to increase school-based activity. This type of program is inexpensive and has broad reach. Inserting activity breaks throughout the day is appropriate, especially when youth are otherwise largely sedentary.

Cost-Effectiveness of Population-Level Physical Activity Interventions: A Systematic Review

Objective.

This systematic review synthesizes the evidence on the cost-effectiveness of population-level interventions to promote physical activity.

Data Source.

A systematic literature search was conducted between May and August 2013 in four databases: PubMed, Scopus, Web of Science, and SPORTDiscus.

Study Inclusion and Exclusion Criteria.

Only primary and preventive interventions aimed at promoting and maintaining physical activity in wide population groups were included. An economic evaluation of both effectiveness and cost was required. Secondary interventions and interventions targeting selected population groups or focusing on single individuals were excluded.

Data Extraction.

Interventions were searched for in six different categories: (1) environment, (2) built environment, (3) sports clubs and enhanced access, (4) schools, (5) mass media and community-based, and (6) workplace.

Data Synthesis.

The systematic search yielded 2058 articles, of which 10 articles met the selection criteria. The costs of interventions were converted to costs per person per day in 2012 U.S. dollars. The physical activity results were calculated as metabolic equivalent of task hours (MET-hours, or MET-h) gained per person per day. Cost-effectiveness ratios were presented as dollars per MET-hours gained. The intervention scale and the budget impact of interventions were taken into account.

Results.

The most efficient interventions to increase physical activity were community rail-trails ($.006/MET-h), pedometers ($.014/MET-h), and school health education programs ($.056/MET-h).

Conclusion.

Improving opportunities for walking and biking seems to increase physical activity cost-effectively. However, it is necessary to be careful in generalizing the results because of the small number of studies. This review provides important information for decision makers.

Action Schools! BC implementation: from efficacy to effectiveness to scale-up

OBJECTIVES

To describe Action Schools! BC (AS! BC) from efficacy to scale-up.

PARTICIPANTS/SETTING

Education and health system stakeholders and children in grades 4-6 from elementary schools in British Columbia, Canada.

INTERVENTION

At the provincial level, the AS! BC model reflected socioecological theory and a partnership approach to social change. Knowledge translation and exchange were embedded as a foundational element. At the school level, AS! BC is a comprehensive school health-based model providing teachers and schools with training and resources to integrate physical activity (PA) and healthy eating (HE) into the school environment. Our research team partnered with key community and government stakeholders to deliver and evaluate AS! BC over efficacy, effectiveness and implementation trials.

RESULTS

On the basis of significant increases in PA, cardiovascular fitness, bone and HE in AS! BC schools during efficacy trials, the BC government supported a provincial scale-up. Since its inception, the AS! BC Support Team and >225 trained regional trainers have delivered 4677 teacher-focused workshops (training approximately 81,000 teachers), reaching approximately 500,000 students. After scale-up, PA delivery was replicated but the magnitude of change appeared less. One (HE) and 4 (PA) years after scale-up, trained AS! BC teachers provided more PA and HE opportunities for students even in the context of supportive provincial policies.

CONCLUSIONS

Whole school models like AS! BC can enhance children's PA and health when implemented in partnership with key stakeholders. At the school level, adequately trained and resourced teachers and supportive school policies promoted successful scale-up and sustained implementation. At the provincial level, multisectoral partnerships and embedded knowledge exchange mechanisms influenced the context for action at the provincial and school level, and were core elements of successful implementation.

TRIAL REGISTRATION NUMBER

Clinical Trials Registry NCT01412203.