One Step Forward: Development of a Program Promoting Active School Transportation

Children's intervention participation is associated with more positive beliefs towards active school transportation among parents

Insufficient physical activity among children is a critical issue and health promoting initiatives are required to reverse this trend. In response to the current situation, a school-based intervention aiming to increase physical activity with the aid of active school transportation (AST) was implemented in one municipality in northern Sweden. By adopting the framework of the Theory of Planned Behavior, we aimed to analyse beliefs among parents whose children were or were not involved in the AST intervention. All municipality schools were included. There were 1024 responses from parents, comprising 610 who responded either 'yes' or 'no' to participating in the intervention. An adjusted linear regression analysis showed that children's intervention participation was significantly associated with more positive beliefs towards AST among parents. These results indicates that it is possible to influence beliefs that are important in the parental decision-making process by the use of an AST intervention. Therefore, to make children's active transport to school the more favorable choice for parents, it seems to be worthwhile to not only give children the opportunity to participate but also to involve parents and address their beliefs when designing interventions.

Development of a German Physical Literacy Assessment for Children in the Context of Health Promotion-An Explorative Approach

Addressing physical literacy (PL) has become increasingly relevant to counteract sedentary behaviour in children and youth. We developed an assessment tool to measure and evaluate the promotion of individual PL and its four subdomains: motivation and confidence (the affective dimension), physical competence (physical dimension), knowledge and understanding (cognitive dimension), and participation in physical activity. Within this cross-sectional study, we tested 567 children aged 6−12 years from four primary schools that differed in socioeconomic status (SES). A subsequent exploratory factor analysis conducted to examine the conformity revealed a five-factor structure. The five factors explained 39.8% of the total cumulative variance. Children with a low SES yielded lower scores in all subdomains except participation in physical activity. This effect was most pronounced in motor skills (p < 0.001, r = 0.28). Among the children with a low SES, 16.9% were overweight and 17.4% were obese, compared to 11.5% and 5.4%, respectively, for those with a high SES (p < 0.001). In conclusion, although the assessment tool was largely in line with the postulated structure, further adjustments are necessary in terms of participation and motivation. Nevertheless, this holistic view of PL, taking SES into account, should enable the focused promotion of health and health literacy.

Estimating the Health Effects of Adding Bicycle & Pedestrian Paths: Modeling At The Census Tract-Level (Preprint)

Background

Adding additional bicycle and pedestrian paths to an area can lead to improved health outcomes for residents over time. However, quantitatively determining which areas benefit more from bicycle and pedestrian paths, how many miles of bicycle and pedestrian paths are needed, and the health outcomes that may be most improved remain open questions.

Objective

Our work provides and evaluates a methodology that offers actionable insight for city-level planners, public health officials, and decision makers tasked with the question “To what extent will adding specified bicycle and pedestrian path mileage to a census tract improve residents’ health outcomes over time?”

Methods

We conducted a factor analysis of data from the American Community Survey, Center for Disease Control 500 Cities project, Strava, and bicycle and pedestrian path location and use data from two different cities (Norfolk, Virginia, and San Francisco, California). We constructed 2 city-specific factor models and used an algorithm to predict the expected mean improvement that a specified number of bicycle and pedestrian path miles contributes to the identified health outcomes.

Results

We show that given a factor model constructed from data from 2011 to 2015, the number of additional bicycle and pedestrian path miles in 2016, and a specific census tract, our models forecast health outcome improvements in 2020 more accurately than 2 alternative approaches for both Norfolk, Virginia, and San Francisco, California. Furthermore, for each city, we show that the additional accuracy is a statistically significant improvement (P<.001 in every case) when compared with the alternate approaches. For Norfolk, Virginia (n=31 census tracts), our approach estimated, on average, the percentage of individuals with high blood pressure in the census tract within 1.49% (SD 0.85%), the percentage of individuals with diabetes in the census tract within 1.63% (SD 0.59%), and the percentage of individuals who had >2 weeks of poor physical health days in the census tract within 1.83% (SD 0.57%). For San Francisco (n=49 census tracts), our approach estimates, on average, that the percentage of individuals who had a stroke in the census tract is within 1.81% (SD 0.52%), and the percentage of individuals with diabetes in the census tract is within 1.26% (SD 0.91%).

Conclusions

We propose and evaluate a methodology to enable decision makers to weigh the extent to which 2 bicycle and pedestrian paths of equal cost, which were proposed in different census tracts, improve residents’ health outcomes; identify areas where bicycle and pedestrian paths are unlikely to be effective interventions and other strategies should be used; and quantify the minimum amount of additional bicycle path miles needed to maximize health outcome improvements. Our methodology shows statistically significant improvements, compared with alternative approaches, in historical accuracy for 2 large cities (for 2016) within different geographic areas and with different demographics.

A Reusable Multiplayer Game for Promoting Active School Transport: Development Study

Background

Most children and adolescents in Sweden do not meet the recommended daily physical activity levels of the World Health Organization. Active school transport (AST) and gamification are potential methods for increasing children’s daily physical activity. We previously developed a game named Tic-Tac-Training for promoting active transport at workplaces; however, the game has not been applied to AST.

Objective

The objectives of this study are to investigate how Tic-Tac-Training functions to promote AST among schoolchildren in northern Sweden, improve the game to be more suitable for schoolchildren, and construct a road map for future development based on children’s ideas.

Methods

First, we developed Tic-Tac-Training using the Scrum agile software development method. Second, we conducted a questionnaire-based formative evaluation of the game with schoolchildren (n=16; 9/16, 56% male; 6/16, 38% female; and 1/16, 6% other aged 11-12 years) in Luleå, Sweden. Third, we conducted focus group interviews with 33 children (13/33, 39% male and 20/33, 61% female aged 12-13 years) to gather ideas for gamifying AST. We mapped the interview results to the Octalysis gamification framework and established a road map for future development.

Results

The formative evaluation revealed several issues, including a lack of interesting game features, lack of support for continuous engagement, disliked competitive features, and lack of incentives for discourse and participation. New features such as rewards, collectibles, and levels were implemented based on the results. The focus group interviews revealed additional ideas for gamifying AST, such as using avatars, in-game currency and trading, and context-sensitive tasks.

Conclusions

The results have several potential impacts on how reusable, gamified AST interventions can be developed and what kind of gamification elements schoolchildren in northern Sweden wish to see. These results can interest game researchers and teachers who wish to apply gamification in school contexts. Finally, we aim to continue developing the game based on the road map.

Initial Design and Testing of Multiplayer Cooperative Game to Support Physical Activity in Schools

Recent studies have shown that children are not adequately physically active and there is a need to increase children’s physical activity. This study describes new opportunities and solutions for using existing games and gamification to increase physical activity among children in Sweden. We adopted the principles of Tic-Tac-Training to redesign, build, and test a classical multiplayer cooperative game, Battleship, to create a PA game that children experience as fun and engaging. The low fidelity prototype of the game was developed using an iterative game development life cycle and tested with 13 young male children aged 8–11 in a real-world informal setting. A mixed-method research approach was used to understand the users’ experiences and the impact of the Battleship-PA game on behavior change regarding physical activity. Research data were collected through audio recordings of interactions, direct observation, and a user experience questionnaire. The results of this study indicate both positive and negative feedback that can be used to improve the game and user experiences. The results from the unfiltered recordings revealed that both teams were competitive, cooperated within their team, and became excited whenever they destroyed opponent’s ships or were close to winning. However, the children felt bored and exhausted when many gamification tasks were repeated several times in a game session. Direct observation indicated that the children enjoyed the physical activities resulting from playing the game. However, participants who had not previously played the classical version of Battleship were confused about the objectives and concept of the game. The analysis of the user experience questionnaire indicated that most children found the game easy to play, motivating, engaging, interactive, fun, cooperative, competitive, and visually appealing. Furthermore, most children agreed that the game helped them to be physically active and strongly agreed that they enjoyed performing the physical activities in the game. Future work is needed to improve the game user interface, gamification elements, and prepare additional physical activity tasks for a rewarding experience.

Development and Initial Validation of the PILCAST Questionnaire: Understanding Parents' Intentions to Let Their Child Cycle or Walk to School

Children generally do not meet the recommendation of 60 min of daily physical activity (PA); therefore, active school transportation (AST) is an opportunity to increase PA. To promote AST, the involvement of parents seems essential. Using the theory of planned behavior (TPB), the aim was to develop and validate the PILCAST questionnaire to understand parents’ intentions to let their child cycle or walk to school. Cross-sectional sampling was performed, where 1024 responses were collected from parents. Confirmatory factor analysis indicated acceptable fit indices for the factorial structure according to the TPB, comprising 32 items grouped in 11 latent constructs. All constructs showed satisfying reliability. The regression analysis showed that the TPB explained 55.3% of parents’ intentions to let the child cycle to school and 20.6% regarding walking, increasing by a further 18.3% and 16.6%, respectively, when past behavior was added. The most influential factors regarding cycling were facilitating perceived behavioral control, positive attitudes, subjective and descriptive norms, and for walking, subjective and descriptive norms. The PILCAST questionnaire contributes to a better understanding of the psychological antecedents involving parents’ decisions to let their child cycle or walk to school, and may therefore provide guidance when designing, implementing and evaluating interventions aiming to promote AST.

Conceptual Ambiguity Surrounding Gamification and Serious Games in Health Care: Literature Review and Development of Game-Based Intervention Reporting Guidelines (GAMING)

BACKGROUND

In health care, the use of game-based interventions to increase motivation, engagement, and overall sustainability of health behaviors is steadily becoming more common. The most prevalent types of game-based interventions in health care research are gamification and serious games. Various researchers have discussed substantial conceptual differences between these 2 concepts, supported by empirical studies showing differences in the effects on specific health behaviors. However, researchers also frequently report cases in which terms related to these 2 concepts are used ambiguously or even interchangeably. It remains unclear to what extent existing health care research explicitly distinguishes between gamification and serious games and whether it draws on existing conceptual considerations to do so.

OBJECTIVE

This study aims to address this lack of knowledge by capturing the current state of conceptualizations of gamification and serious games in health care research. Furthermore, we aim to provide tools for researchers to disambiguate the reporting of game-based interventions.

METHODS

We used a 2-step research approach. First, we conducted a systematic literature review of 206 studies, published in the Journal of Medical Internet Research and its sister journals, containing terms related to gamification, serious games, or both. We analyzed their conceptualizations of gamification and serious games, as well as the distinctions between the two concepts. Second, based on the literature review findings, we developed a set of guidelines for researchers reporting on game-based interventions and evaluated them with a group of 9 experts from the field.

RESULTS

Our results show that less than half of the concept mentions are accompanied by an explicit definition. To distinguish between the 2 concepts, we identified four common approaches: implicit distinction, synonymous use of terms, serious games as a type of gamified system, and distinction based on the full game dimension. Our Game-Based Intervention Reporting Guidelines (GAMING) consist of 25 items grouped into four topics: conceptual focus, contribution, mindfulness about related concepts, and individual concept definitions.

CONCLUSIONS

Conceptualizations of gamification and serious games in health care literature are strongly heterogeneous, leading to conceptual ambiguity. Following the GAMING can support authors in rigorous reporting on study results of game-based interventions.

Possibilities and challenges in developing and implementing an empowerment-based school-intervention in a Swedish disadvantaged community

In this paper, we describe and critically reflect on the possibilities and challenges of developing and implementing an empowerment-based school intervention regarding healthy food and physical activity (PA), involving participants from a Swedish multicultural area characterized by low socioeconomic status. The 2-year intervention was continually developed and implemented, as a result of cooperation and shared decision making among researchers and the participants. All 54 participants were seventh graders, and the intervention comprised health coaching, health promotion sessions and a Facebook group. We experienced that participants valued collaborating with peers, and that they took responsibility in codeveloping and implementing the intervention. Participants expressed feeling listened to, being treated with respect and taken seriously. However, we also experienced a number of barriers that challenged our initial intentions of aiding participation and ambition to support empowerment. Moreover, it was challenging to use structured group health coaching and to work with goal-setting in groups of participants with shared, and sometimes competing, goals, wishes and needs related to food and PA. Successful experiences from this intervention was the importance of acquiring a broad and deep understanding of the context and participants, being open to negotiating, as well as adjusting the intervention.

It's about being the good parent: exploring attitudes and beliefs towards active school transportation

In recent decades, there has been a decline in active school transportation (AST). Parents play an important role as the key decision-makers of children’s AST, and there is a need of more knowledge about the decision-making process and parents’ beliefs towards AST. The overall aim of this study was to explore parents’ attitudes and beliefs towards AST in the northern part of Sweden. Twenty parents participated in semi-structured interviews, which was based on the theory of planned behaviour. Qualitative content analysis was used to analyse the interviews. The analysis yielded one main theme, “Parenting and active school transportation – making route choices in a changed landscape” and four subthemes, “Knowing that it is beneficial while struggling with daily life”, “Considering barriers and solutions to enable AST”, “Parenting is challenging and about balancing”, and “Reflecting and contemplating about what we and others do”. Winter conditions affect parents’ decisions, and this needs to be considered when facilitating AST in these regions. Overall better health, increased physical activity, time spent outdoors, and free play were revealed as positive outcomes of AST. Decisions were also influenced by social norms and how the idea of parenting has changed through generations. The findings of this study are likely to be important when promoting AST.

Long-Term Perspectives of a School-Based Intervention to Promote Active School Transportation

There is a global need for sustainable interventions that increase physical activity among children, and active school transportation (AST) can promote physical activity among schoolchildren. Therefore, an intervention based on gamification, empowerment, and social cognitive theory was initiated in 2016 to promote AST. The aim of this study was to follow up on participants' experiences one and two years after the AST intervention was initiated. Data were collected through focus groups and individual interviews which were analyzed using qualitative content analysis. Thirty-one pupils (2017), and forty pupils (2018) aged 9-10 years, two teachers (2017, 2018) and one principal (2018) participated in the study. The result is presented as one main theme; "Unity for an active community-An intervention towards making the active choice the easy choice" and three sub-themes; "Well begun is half done-Engagement sparks motivation", "It takes two to tango-Keep moving with gamifications and togetherness" and "Jumping on the bandwagon-From project to everyday use." The results show that the concept of the intervention was attractive to re-use and that it created a habit to use AST among the children. Interventions to promote AST can benefit from the use of engagement, togetherness, and gamification.

Grit as Perseverance in Physical Activity Participation

Childhood is a critical period for the acquisition of healthy behaviors, and the promotion of sustainable healthy behavior among children is greatly important. Therefore, an increased understanding of the relationship between grit and physical activity in a school context is needed. The purpose of this study is to describe and develop an understanding of students' and teachers' awareness and experiences concerning grit as a health-promoting factor. Fifty-five students and three teachers participated in the study. Data were collected through the Short Grit Scale and focus group interviews. There were weak to non-significant correlations between the three teachers' ratings of their students' grit and the children's own ratings. The qualitative results show that children and teachers understood the construct of grit but had slightly different perceptions of it and that grit is not considered to be set in stone. The participants made an association between grit, motivation, meaningfulness, and setting goals. The findings indicate that grit might be an ideal target for making physical activity interventions sustainable.

Children's motivation overcame parental hesitation: active school transportation in Sweden

To meet the recommendation of 60 min of daily physical activity, children can be encouraged to walk or bike to school, which is known as active school transportation (AST). The aim of this study was to describe parents' attitudes to AST and to explore their experience when implementing interventions to promote it. To explore parent's experiences, we collected pre- and post-intervention data via three questionnaires, using both closed and open questioning techniques. The pre-intervention questionnaire informed development of the intervention. Open-ended questions (pre- and post-) were analyzed with qualitative content analysis. In the intervention, there were 42 children, with 63 parents answering pre-intervention questionnaires and 44 answering a post-intervention questionnaire. The analysis resulted in one main theme: children's motivation and active travel reduces parents' perception of problems, along with three subthemes: parental concerns and suggestions for solutions, children's motivation guides parental choice of transport mode, and trying it changes attitudes. In conclusion, it is beneficial to use the enthusiasm and motivation of children to overcome parental hesitation with AST. In addition, it is critical to acknowledge their concerns, as they are the gatekeepers to the children's use of AST and it is valuable to empower parents when designing relevant interventions. Interventions to increase AST could preferably target changed behavior, and parents' confidence in their children's ability to use active transport in a safe and effective way, vs focusing on changing parental attitudes.

Voices from Pupil Participation in the Health Promotion Intervention "Pulse for Learning and Health [PuLH]" in Primary and Middle School

In order to improve the learning conditions and health of schoolchildren, the Pulse for Learning and Health [PuLH] program in Sweden has introduced additional mandatory moderate to vigorous physical activity [MVPA] that lasts for 30 min three times a week. The PE teachers used a child-centered coaching approach to support all pupils. The aim of this study was to explore pupils’ perception and experience of PuLH that has been implemented in primary and middle schools in Sweden. We have taken into account children’s rights perspectives and adopted an exploratory and interpretive approach. In total, 73 pupils (34 girls, 39 boys, grades 4–9) were recruited through purposive sampling. 13 focus group interviews (n = 71) and individual interviews (n = 2) were carried out. All interviews were analyzed using qualitative content analysis. The analysis resulted in three major themes: ‘promotes academic performance and a learning school environment’, ‘promotes health and well-being’, and ‘individual and structural barriers’. From children’s perspective, the results highlight the importance of teachers and principals taking into account the interests and needs of all pupils, to have a well-planned MVPA intervention and to deal with issues regarding body ideals.

Physical Activity and Mobile Phone Apps in the Preschool Age: Perceptions of Teachers and Parents

BACKGROUND

Physical activity (PA) is already beneficial at the preschool age. In many countries, young children spend most of their days in the preschool setting, making it a common arena for PA interventions. Mobile health tools are becoming increasingly popular to promote PA in different populations; however, little is known about the interest for and how the preschool setting could incorporate such a tool.

OBJECTIVE

This study aimed to examine how teachers and parents perceive PA in preschool-aged children in general and their perceptions of how a mobile phone app could be used to promote PA in the preschool setting.

METHODS

Semistructured interviews were conducted with 15 teachers (93%, [14/15] women, mean age 43.5 years, 47%, [7/15] with a university degree and 10 parents [91%, 9/10] women, mean age 38.9 years, all with a university degree) recruited from 2 urban preschools in central Sweden. The interviews were recorded, fully transcribed, coded, and analyzed using thematic analysis by means of an inductive approach.

RESULTS

The analysis revealed 4 themes: (1) children are physically active by nature, (2) the environment as a facilitator or a barrier, (3) prerequisites of the adult world, and (4) an app in the preschool setting-challenges and possibilities. Parents and teachers perceived preschoolers as being spontaneously physically active; however, high-intensity PA was perceived as low. The PA was specifically performed during the day in the preschool. Identified facilitators of PA were access to safe and engaging outdoor environments such as forests, spacious indoor areas, and adult involvement. Adult involvement was considered especially important for children preferring sedentary activities. Identified barriers for PA were restricted indoor and outdoor space, rules for indoor activities, and lack of adult involvement because of time constraints. The teachers perceived that they had limited skills and experiences using apps in general, although they also acknowledged the increasing role of technological tools in the curriculum. Thus, the teachers expressed an interest for an app designed as a support tool for them, especially for situations when PA was limited because of perceived barriers. They suggested the app to include accessible information regarding the health benefits of PA in children linked to a library of activities for different settings and seasons. Parents suggested interactive app features including problem-solving tasks and music and dance, but not video clips as they made children passive.

CONCLUSIONS

Vigorous PA was perceived as low in preschool-aged children. Future tailoring of interventions in the preschool setting should work around barriers and support facilitators to PA, especially PA of high intensity. In such work, an app could serve as a source of inspiration for PA in different ages, settings, and seasons and thus reduce environmental and structural inequalities in the preschool setting.

Active School Transportation in Winter Conditions: Biking Together is Warmer

There has been a decline in children's use of active school transportation (AST) while there is also limited research concerning AST in winter conditions. This study aimed to explore the prerequisites and experiences of schoolchildren and parents participating in an empowerment- and gamification-inspired intervention to promote students' AST in winter conditions. Methods: Thirty-five students, who were aged 12⁻13 years, and 34 parents from the north of Sweden participated in the study. Data were collected using photovoice and open questions in a questionnaire and analyzed using qualitative content analysis. Results: The results show that involvement and togetherness motivated the students to use AST. In addition, during the project, the parents changed to have more positive attitudes towards their children's use of AST. The students reported that using AST during wintertime is strenuous but rewarding and imparts a sense of pride. Conclusion: Interventions for increasing students' AST in winter conditions should focus on the motivational aspects for both children and parents. For overcoming parental hesitation with regards to AST during winter, addressing their concerns and empowering the students are key factors. To increase the use of AST all year around, targeting the challenges perceived during the winter is especially beneficial.