Sleep behavioral outcomes of school-based interventions for promoting sleep health in children and adolescents aged 5 to 18 years: a systematic review.

Study Objectives: Insufficient sleep is common among children and adolescents, and can contribute to poor health. School-based interventions potentially could improve sleep behavior due to their broad reach, but their effectiveness is unclear. This systematic review focused on the effects of school-based interventions on sleep behavior among children and adolescents aged 5 to 18 years. Methods: Five electronic databases were searched for randomized controlled trials of sleep health interventions initiated or conducted in school settings and in which behavioral sleep outcomes were measured. Cochrane risk of bias tools were used to assess study quality. Results: From the 5303 database records and two papers from other sources, 21 studies (22 papers) met the inclusion criteria for this review. These studies involved 10 867 children and adolescents at baseline from 13 countries. Most studies (n = 15) were conducted in secondary schools. Sleep education was the most common intervention, either alone (n = 13 studies) or combined with other initiatives (stress management training, n = 2; bright light therapy, n = 1; health education, n = 1). Interventions were typically brief in terms of both the intervention period (median = 4 weeks) and exposure (median = 200 minutes). Behavioral outcomes included actigraphy-measured and self-reported sleep patterns, and sleep hygiene. All outcomes had high risk of bias or some concerns with bias. Sleep education interventions were typically ineffective. Later school start times promoted longer sleep duration over 1 week (1 study, high risk of bias). Conclusions: Current evidence does not provide school-based solutions for improving sleep health, perhaps highlighting a need for complex, multi-component interventions (e.g. whole-of-school approaches) to be trialed.

Effectiveness of Intervention Strategies to Increase Adolescents' Physical Activity and Reduce Sedentary Time in Secondary School Settings, Including Factors Related to Implementation: A Systematic Review and Meta-Analysis.

BACKGROUND: Globally, just one in five adolescents meet physical activity guidelines and three-quarters of the school day is spent sitting. It is unclear which types of school-based interventions strategies increase physical activity and reduce sedentary time among adolescents, or how these interventions are implemented influences their effectiveness. OBJECTIVE: The three aims of our systematic review were to (a) identify intervention strategies used within secondary school settings to improve students' movement behaviours throughout school-based initiatives, delivered at or by the school; (b) determine the overall effect of the interventions (meta-analysis) on physical activity (all intensities), sedentary time, cognitive/academic, physical health and/or psychological outcomes; and (c) describe factors related to intervention implementation. METHODS: Searches were conducted in MEDLINE complete, EMBASE, CINAHL, SPORTDiscus, APA PsycINFO, and ERIC in January 2023 for studies that (a) included high school-aged adolescents; (b) involved a school-based intervention to increase physical activity and/or decrease sedentary time; and (c) were published in English. Reported effects were pooled in meta-analyses where sufficient data were obtained. RESULTS: Eighty-five articles, representing 61 interventions, met the inclusion criteria, with 23 unique intervention strategies used. Interventions that involved whole-school approaches (i.e., physical activity sessions, environmental modifications, teacher training, peer support and/or educational resources) were favourably associated with most of the outcomes. The meta-analyses showed: (a) non-significant effects for sedentary time (Standardized mean difference [SMD] = -0.02; 95%CI, -0.14, 0.11), physical activity at all intensities (light: SMD= -0.01; 95%CI, -0.08, 0.05; moderate: SMD = 0.06; 95%CI, -0.09, 0.22; vigorous: SMD = 0.08; 95%CI, -0.02, 0.18; moderate-to-vigorous: SMD = 0.05; 95%CI, -0.01, 0.12) and waist circumference (SMD = 0.09; 95%CI, -0.03, 0.21), and (b) a small statistically significant decrease in body mass index (SMD= -0.09, 95%CI -0.16, -0.0). Factors related to intervention implementation were reported in 51% of the articles. CONCLUSION: While some intervention approaches demonstrated promise, small or null effects were found in meta-analyses. Future school-based interventions should utilize a whole-school approach designed to increase adolescents' activity across the day. Consistent reporting of implementation will increase understanding of how interventions are adopted, implemented and sustained. REGISTRATION: PROSPERO (CRD42020169988).

Extrinsic Risk Factors for Primary Noncontact Anterior Cruciate Ligament Injury in Adolescents Aged between 14 and 18 years: A Systematic Review.

BACKGROUND: Adolescents present a high incidence of ACL injury compared with other age groups. Examining the risk factors that predispose adolescents to primary noncontact ACL injury is a key strategy to decrease the number of injuries in this population. OBJECTIVE: The aim of this systematic review was to summarise the existing literature investigating extrinsic risk factors that have been linked with primary noncontact ACL injury risk (identified either using ACL injury occurrence or using screening tests measuring biomechanical mechanisms for noncontact ACL injury) in adolescents including research investigating: (1) the association between extrinsic risk factors and primary noncontact ACL injury risk; and (2) whether primary noncontact ACL injury risk was different in populations or groups exposed to different extrinsic risk factors in adolescents. METHODS: The same search strategy was used in MEDLINE, SPORTDiscus, CINAHL, PubMed and Embase. Articles were included if: written in English; published in peer-reviewed journals; investigating and discussing primary noncontact ACL injury risk associated with extrinsic risk factors; they were original research articles with an observational design; and participants presented a mean age ranging between 14 and 18 years. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (QATOCCS) was used to assess the quality and risk of bias of the articles included in this systematic review. RESULTS: The systematic review included 16 eligible articles published up to August 2022 about extrinsic risk factors for primary noncontact ACL injury including: sport (8 studies); sport exposure amount (5); sport level (3); sport season (1); environment (2); equipment (1). Differences in biomechanical risk factors predisposing to ACL injury were reported by sport in female adolescents playing basketball and soccer; however, no good evidence of differences in primary noncontact ACL injury rate by sport was reported in both male and female adolescents. There was contrasting evidence about associations between sport exposure and biomechanical and neuromuscular risk factors predisposing to ACL injury or primary noncontact ACL injury rate in both male and female adolescent players from different sports. There was weak evidence of differences in biomechanical risk factors predisposing to ACL injury by environmental condition in both male and female adolescents playing soccer and season phase in male adolescents playing basketball. Lastly, few good-quality articles suggested that higher sport level might be associated with increased primary noncontact ACL injury rate in female adolescents playing basketball and floorball and that bracing might not prevent primary noncontact ACL injuries in both male and female adolescent players from different sports. DISCUSSION: The findings emphasise the need for further research to clarify the evidence about extrinsic risk factors and primary noncontact ACL injury in adolescents to develop ACL injury prevention guidelines that would help practitioners and researchers identify adolescents at risk and design future interventions. Future epidemiological studies should collect data about extrinsic factors as well as data about primary noncontact injury separately from secondary injuries or contact injuries to better inform primary noncontact ACL injury prevention in adolescents. REGISTRATION: https://doi.org/10.17605/OSF.IO/VM82F (11/08/2021).

Playing it safe: The relationship between parent attitudes to risk and injury, and children's adventurous play and physical activity.

BACKGROUND: Children naturally seek risk in play and adventurous play outdoors confers many benefits, including the potential to increase moderate-to-vigorous physical activity (MVPA). This study aimed to investigate the relationship between parent attitudes to risk and injury, and their elementary school-aged child's daily adventurous play and MVPA. METHODS: A panel sample of 645 Australian parents/guardians completed an online survey consisting of several validated measures of risk and injury attitudes, and physical activity and play behaviour. Data were analysed via descriptive statistics, univariate and multivariable regressions using Stata 17. A series of exploratory univariate logistic regressions were conducted, followed by a series of multivariable logistic regressions fitted to test the association between parent risk and injury attitudes and (i) children's MVPA, (ii) active play and (iii) adventurous play, while adjusting for socio-demographic factors. RESULTS: Most adult participants (81%) were female. The mean age of the child participants (53% male) was 8.6 years (SD = 2.4). On average, parents were positive about children's engagement with risk, however, 78% of parents had low tolerance of risk when presented with specific play scenarios, and attitudes towards injuries varied, with mothers more concerned than fathers. After adjusting for confounders, children with parents who were tolerant of risk in play were more likely to meet the MVPA guideline of ≥60 min daily (OR 2.86, CI: 1.41, 5.82, p < 0.004) and spend more time playing adventurously (OR 3.03, CI: 1.82, 5.06, p < 0.001). Positive associations for MVPA and adventurous play were observed across all models examining parent attitudes to risk and injury. Younger children engaged in more play and physical activity, however, more positive parent attitudes appeared to moderate the age-related influences. CONCLUSIONS: We found a divergence between the outcomes parents desire for their children through engagement with risk and the play activities they are comfortable with in practice. Parent attitudes to risk and injury are potentially modifiable factors that may increase children's affordances for adventurous play and physical activity. Interventions that provide parents with practical approaches to address injury concerns and support children's risk-taking in play outdoors are recommended.

Identifying modifiable risk factors and screening strategies associated with anterior cruciate ligament injury risk in children aged 6 to 13 years: A systematic review.

Growing anterior cruciate ligament (ACL) injury incidence is reported in countries across Europe, North America and in Australia for 5-14-year-olds, yet research on injury risk reduction predominantly focuses on populations aged > 13 years. For injury risk reduction, it is crucial to understand (i) which modifiable risk factors are associated with ACL injury in children (6-13 years) and (ii) how these risk factors are assessed. Articles were grouped according to sex/gender and/or maturational/age differences and examined modifiable risk factors during different physical screening tasks. The included articles (n = 40) predominantly examined intrinsic risk factors in girls aged 10-13 years. Factors mechanically linked to increased ACL loading at this age included increased peak knee adductor moments, knee valgus angles, hip and knee extension, and ground reaction forces. Assessment focused on laboratory-based assessments (e.g., motion capture, force plates). This review concluded that modifiable risk factors are present in children aged 6-13 years and that injury risk reduction strategies should be implemented as early as possible regardless of sex/gender. Further, screening strategies need updating to be childhood specific and feasible for the wide community. Additional research on extrinsic risk factors, norm values and children aged 6-9 years could allow for more targeted risk reduction strategies.

Increasing rates of ACL injuries in children aged 5 to 14 years are reported in countries across Europe, North America and in AustraliaResearch on modifiable risk factors focuses on internal risk factors in children aged 10-13 years and neglects external risk factors as well as younger children (6-10 years)Screening strategies to determine risk of ACL injury risk in children are laboratory based as opposed to cost-effective and quicker-to-analyse in-field assessmentResearch is warranted to examine external risk factors and in-field screening strategies in childhood.

Scaling up a school-based intervention to increase physical activity and reduce sedentary behaviour in children: protocol for the TransformUs hybrid effectiveness-implementation trial.

INTRODUCTION: Efficacious programmes require implementation at scale to maximise their public health impact. TransformUs is an efficacious behavioural and environmental intervention for increasing primary (elementary) school children's (5-12 years) physical activity and reducing their sedentary behaviour within school and home settings. This paper describes the study protocol of a 5-year effectiveness-implementation trial to assess the scalability and effectiveness of the TransformUs programme. METHODS AND ANALYSIS: A type II hybrid implementation-effectiveness trial, TransformUs is being disseminated to all primary schools in the state of Victoria, Australia (n=1786). Data are being collected using mixed methods at the system (state government, partner organisations), organisation (school) and individual (teacher, parent and child) levels. Evaluation is based on programme Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. RE-AIM domains are being measured using a quasi-experimental, pre/post, non-equivalent group design, at baseline, 12 and 24 months. Effectiveness will be determined in a subsample of 20 intervention schools (in Victoria) and 20 control schools (in New South Wales (NSW), Australia), at baseline, 12 and 24 months. Primary outcomes include TransformUs Reach, Adoption, Implementation and organisational Maintenance (implementation trial), and children's physical activity and sedentary time assessed using accelerometers (effectiveness trial). Secondary outcomes include average sedentary time and moderate to vigorous-intensity physical activity on weekdays and during school hours, body mass index z-scores and waist circumference (effectiveness trial). Linear mixed-effects models will be fitted to compare outcomes between intervention and control participants accounting for clustering of children within schools, confounding and random effects. ETHICS AND DISSEMINATION: The trial was approved by the Deakin University Human Research Ethics Committee (HEAG-H 28_2017), Victorian Department of Education, the NSW Department of Education, Australian Catholic University (2017-145R), Melbourne Archdiocese Catholic Schools and Catholic Schools NSW. Partners, schools/teachers and parents will provide an informed signed consent form prior to participating. Parents will provide consent for their child to participate in the effectiveness trial. Findings will be disseminated via peer-reviewed publications, scientific conferences, summary reports to schools and our partner organisations, and will inform education policy and practice on effective and sustainable ways to promote physical activity and reduce sedentary behaviours population-wide. TRIAL REGISTRATION NUMBER: Australian Clinical Trials Registration Registry (ACTRN12617000204347).

What is needed to reduce the risk of anterior cruciate ligament injuries in children? - Hearing from experts.

OBJECTIVE: Anterior cruciate ligament (ACL) injuries are an emerging health problem in children. Acknowledging considerable gaps in knowledge, the aim of this study was to examine the current knowledge on childhood ACL injury, and to explore risk assessment and reduction strategies, with experts in the research community. DESIGN: Qualitative study; semi-structured expert interviews. METHODS: Interviews with seven international, multidisciplinary academic experts were conducted from February until June 2022. A thematic analysis approach organized verbatim quotes into themes using Nvivo Software. RESULTS: Gaps in knowledge on the actual injury mechanism, and influence of physical activity behaviours, constrain targeted risk assessment and reduction strategies in childhood ACL injuries. Strategies to examine and reduce the risk of ACL injury included: examining an athletes' whole-body performance, moving from constraint (e.g., squat) to less constraint (e.g., single-leg) tasks, making assessments into children's context, building a movement repertoire at young age, performing risk reduction programs, multiple sports, and prioritising rest. CONCLUSION: Research is urgently warranted on the actual injury mechanism, reasons for ACL injuries in children, and potential risk factors to update risk assessment and reduction strategies. Further, educating stakeholders on risk reduction strategies could be essential to address the increasing occurrence of childhood ACL injuries.

"Children are precious cargo; we don't let them take any risks!": Hearing from adults on safety and risk in children's active play in schools: a systematic review.

BACKGROUND: Understanding determinants of children's outdoor play is important for improving low physical activity levels, and schools are a key setting for both. Safety concerns shape children's opportunity to play actively outdoors, therefore, this qualitative evidence synthesis aimed to i) examine adult (e.g., parent, teacher, yard supervisor, principal) perspectives on safety and risk in children's active play during recess in elementary and/or middle schools, and ii) identify how safety and risk influence playground supervision and decision making in this setting. METHODS: Six electronic databases were systematically searched in March 2021, with an updated search in June 2022. Records were screened against eligibility criteria using Covidence software, and data extraction and synthesis were performed using predesigned coding forms in Microsoft Excel and NVivo. Framework synthesis methodology was employed, guided by a conceptual framework structured on the socio-ecological model (SEM) and affordance theory. RESULTS: From 10,370 records, 25 studies were included that represented 608 adults across 89 schools from nine countries. The synthesis identified 10 constraining and four affording factors that influenced whether school staff were risk-averse or risk tolerant during recess, and, in turn, the degree to which children's play was managed. Constraining factors stemmed from fears for children's physical safety, and fear of blame and liability in the event of playground injury, which shaped parent, school staff and institutional responses to risk. Interrelated factors across SEM levels combined to drive risk-averse decision making and constraining supervision. Emerging evidence suggests children's active play in schools can be promoted by fostering a risk tolerant and play friendly culture in schools through play facilitation training (e.g., risk-reframing, conflict resolution) and engaging stakeholders in the development of school policies and rules that balance benefits of play against potential risks. CONCLUSIONS: Findings show several socio-cultural factors limited the ability of school staff to genuinely promote active play. Future work should seek to foster risk tolerance in schools, challenge the cultural norms that shape parent attitudes and institutional responses to risk in children's play, and explore novel methods for overcoming policy barriers and fear of liability in schools. TRIAL REGISTRATION: PROSPERO registration: CRD42021238719.

Accuracy vs. Practicality of Inertial Measurement Unit Sensors to Evaluate Motor Competence in Children.

The TGMD (i.e., Test of Gross Motor Development) has been considered as one of the gold standards of assessment tools for analysis of motor competence in children. However, it is rarely used by teachers in schools because the time, resources, and expertise required for one teacher to assess a class of students is prohibitive in most cases. A potential solution may be to automate the testing protocol using objective measures and inertial measurement unit sensors. An accurate method using 17 sensors to capture full body motion profiles and machine learning methods to objectively assess proficiency has been developed; however, feasibility of this method was low. Subsequently, a simplified method using four sensors (i.e., attached to wrists and ankles) was found to be effective, efficient, and potentially highly feasible for use in school settings. For some skills, however, not all skill criteria could be assessed. Additionally, misclassification on occasion, marred results. In the present paper we consider a previous experiment that used wireless motion capture to assess criteria from the TGMD-3. We discuss the advantages alongside the disadvantages of testing motor competence in children using sensors and consider the question-Can a compromise be struck between accuracy and feasibility?

"All the fun stuff, the teachers say, 'that's dangerous!'" Hearing from children on safety and risk in active play in schools: a systematic review.

BACKGROUND: Active play is vital for healthy child development, and schools are a valuable setting to promote this behaviour. Understanding the determinants of children's physical activity behaviour during recess, particularly the role of risk-taking and the influence safety concerns have on active play, is required. This systematic review aimed to 1) synthesise qualitative research with children that explored their perceptions of safety and risk in active play during recess in elementary and/or middle school, and 2) develop a model from the findings to guide efforts in schools to optimise children's active play opportunities during recess. METHODS: Six online databases were systematically searched for articles published between January 2000 and March 2021. Following PRISMA guidelines, records were screened against eligibility criteria using Covidence software, and data extraction and synthesis was conducted using customised forms in Excel and NVivo software. Framework synthesis methodology was employed, conceptually guided by Bronfenbrenner's socio-ecological model and Gibson's affordance theory. RESULTS: Of 9664 records, 31 studies met inclusion criteria, representing 1408 children across 140 schools from 11 countries. An emergent conceptual framework was developed encompassing 23 risk and safety themes and 10 risky play types that children desired in schools. Individual characteristics (age, gender, physical literacy) influenced children's engagement with risk and how they kept themselves safe. Across outer SEM levels, factors interacted to constrain or afford children's active play. Socio-cultural factors (supervision practices, rules, equipment restrictions) constrained active play, which children perceived were driven by adults' concern with physical safety. These factors contributed to a cycle of risk-averse decision making and diminished play affordances, which could inadvertently exacerbate safety issues. A model for risk tolerance in children's active play has been proposed. CONCLUSIONS: The findings show a disparity between the active play children want in schools and what they are able to do. Future work should balance the concerns of adults against the active play children want, involve children in decisions about playground policy, and foster a risk-tolerant culture in schools.

Validity evidence for the Pictorial Scale of Perceived Water Competence short form (PSPWC-4).

Promoting swimming and water safety is an important public health issue. The Pictorial Scale of Perceived Water Competence (PSPWC) requires children to indicate their perceived competence using three difficulty levels for 17 swimming scenarios. The aim was to purposefully select four critical scenarios of the PSPWC to create the PSPWC-short form and test for associations with actual swim competence. Four of 17 scenarios were selected and extended to a four-point response scale by adding an extra difficulty level. Parents whose children had participated in at least 1-week swim-intensive programme in 2021 were invited to participate in the study, and perceptions of 139 children (mean age 6.9 years, SD = 1.9) were matched with certificate data of actual swim competence pre- (n = 139) and post-programme (n = 29). Moderate positive correlations were found between swim level at programme start and perception of: retrieving an object in deep water (rho = 0.57), swimming on front (rho = 0.60), swimming on back (rho = 0.69), treading water (rho = 0.63) and the summed score of all four (rho = 0.71). After adjusting for sex and age, higher perceived skill was still significantly associated with increasing achieved skill levels. The PSPWC-short form appears to provide a valid measure to be used as a brief screening assessment.

Enhancing the implementation and sustainability of fundamental movement skill interventions in the UK and Ireland: lessons from collective intelligence engagement with stakeholders.

BACKGROUND: To have population-level impact, physical activity (PA) interventions must be effectively implemented and sustained under real-world conditions. Adequate Fundamental Movement Skills (FMS) is integral to children being able to actively participate in play, games, and sports. Yet, few FMS interventions have been implemented at scale, nor sustained in routine practice, and thus it is important to understand the influences on sustained implementation. The study's aim was to use Collective Intelligence (CI)-an applied systems science approach-with stakeholder groups to understand barriers to the implementation of FMS interventions, interdependencies between these barriers, and options to overcome the system of barriers identified. METHODS: Three CI sessions were conducted with three separate groups of experienced FMS intervention researchers/practitioners (N = 22) in the United Kingdom and Ireland. Participants generated and ranked barriers they perceive most critical in implementing FMS interventions. Each group developed a structural model describing how highly ranked barriers are interrelated in a system. Participants then conducted action mapping to solve the problem based on the logical relations between barriers reflected in the model. RESULTS: The top ranked barriers (of 76) are those related to policy, physical education curriculum, and stakeholders' knowledge and appreciation. As reflected in the structural model, these barriers have influences over stakeholders' efficacy in delivering and evaluating interventions. According to this logical structure, 38 solutions were created as a roadmap to inform policy, practice, and research. Collectively, solutions suggest that efforts in implementation and sustainability need to be coordinated (i.e., building interrelationship with multiple stakeholders), and a policy or local infrastructure that supports these efforts is needed. CONCLUSIONS: The current study is the first to describe the complexity of barriers to implementing and sustaining FMS interventions and provide a roadmap of actions that help navigate through the complexity. By directing attention to the ecological context of FMS intervention research and participation, the study provides researchers, policy makers, and practitioners with a framework of critical components and players that need to be considered when designing and operationalising future projects in more systemic and relational terms.

A systematic review of tools designed for teacher proxy-report of children's physical literacy or constituting elements.

BACKGROUND: Physical literacy (PL) in childhood is essential for a healthy active lifestyle, with teachers playing a critical role in guiding its development. Teachers can assist children to acquire the skills, confidence, and creativity required to perform diverse movements and physical activities. However, to detect and directly intervene on the aspects of children's PL that are suboptimal, teachers require valid and reliable measures. This systematic review critically evaluates the psychometric properties of teacher proxy-report instruments for assessing one or more of the 30 elements within the four domains (physical, psychological, cognitive, social) of the Australian Physical Literacy Framework (APLF), in children aged 5-12 years. Secondary aims were to: examine alignment of each measure (and relevant items) with the APLF and provide recommendations for teachers in assessing PL. METHODS: Seven electronic databases (Academic Search Complete, CINAHL Complete, Education Source, Global Health, MEDLINE Complete, PsycINFO, and SPORTDiscus) were systematically searched originally in October 2019, with an updated search in April 2021. Eligible studies were peer-reviewed English language publications that sampled a population of children with mean age between 5 and 12 years and focused on developing and evaluating at least one psychometric property of a teacher proxy-report instrument for assessing one or more of the 30 APLF elements. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance was followed for the conduct and reporting of this review. The methodological quality of included studies and quality of psychometric properties of identified tools were evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidance. Alignment of each measure (and relevant items) with the APLF domains and 30 elements was appraised. RESULTS: Database searches generated 61,412 citations; reduced to 41 studies that evaluated the psychometric properties of 24 teacher proxy-report tools. Six tools were classified as single domain measures (i.e. assessing a single domain of the APLF), eleven as dual-domain measures, and seven as tri-domain measures. No single tool captured all four domains and 30 elements of the APLF. Tools contained items that aligned with all physical, psychological, and social elements; however, four cognitive elements were not addressed by any measure. No tool was assessed for all nine psychometric properties outlined by COSMIN. Included studies reported a median of 3 out of nine psychometric properties. Most reported psychometric properties were construct validity (n = 32; 78% of studies), structural validity (n = 26; 63% of studies), and internal consistency (n = 25; 61% of studies). There was underreporting of content validity, cross-cultural validity, measurement error, and responsiveness. Psychometric data across tools were mostly indeterminate for construct validity, structural validity, and internal consistency. CONCLUSIONS: There is limited evidence to fully support the use of a specific teacher proxy-report tool in practice. Further psychometric testing and detailed reporting of methodological aspects in future validity and reliability studies is needed. Tools have been designed to assess some elements of the framework. However, no comprehensive teacher proxy-report tool exists to assess all 30 elements of the APLF, demonstrating the need for a new tool. It is our recommendation that such tools be developed and psychometrically tested. TRIAL REGISTRATION: This systematic review was registered in the PROSPERO international prospective register of systematic reviews, with registration number CRD42019130936 .

It's Not Just What You Do but the Way You Do It: A Systematic Review of Process Evaluation of Interventions to Improve Gross Motor Competence.

BACKGROUND: Motor competence is an important predictor of health behaviours. However, levels of motor competence are low in children and adolescents. Many interventions have improved motor competence, yet intervention effects were highly variable. Potential causes of such variations are not fully understood. Process evaluation can assist with the understanding of why an intervention worked or not, but its application and reporting in motor competence interventions has received little attention. OBJECTIVES: The primary aim of this review was to investigate whether process evaluations have been reported in interventions to improve motor competence and, if reported, which process evaluation measures have been used. A secondary aim was to explore the association of intervention characteristics and process evaluation findings (outcomes of process evaluation measures) with intervention outcomes, in a search for what process evaluation measures may impact on intervention functioning and outcomes. METHODS: The process of conducting and reporting this review adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review protocol was registered with PROSPERO (CRD42019124412). A systematic search of seven electronic databases (i.e. MEDLINE [via EBSCOhost], Cochrane Central Register of Controlled Trials [CENTRAL], CINAHL, Academic Search Complete, Education Database, SPORTDiscus and Scopus) was conducted with no date restrictions. Eligibility criteria included the following: (1) a study sample of typically developing children and adolescents aged 5-18 years, (2) an intervention aimed to improve motor competence, (3) an intervention included a control group, (4) a report of motor competence outcome at both pre- and post-intervention. Only original articles published in English in peer-reviewed journals were considered. Process evaluation measures and findings were extracted using the UK Medical Research Council's process evaluation framework in order to provide overarching descriptions on the implementation, mechanism of change and context of interventions. Univariable meta-regressions were performed to ascertain whether selected study-level covariates moderated the improvement in motor competence outcomes in interventions. RESULTS: The search identified 60 intervention studies. Only 30 studies (50%) reported process evaluation measures. No studies reported (or employed) theoretical frameworks to guide process evaluation. Process evaluation measures relating to implementation were most commonly reported, with the most prevalent aspect being fidelity. This was followed by reporting on measures relating to mechanism of change and context of the intervention. Meta-analysis results suggested intervention duration, dose, inclusion of process evaluation aim, provision of lesson plans, sample size and sex as potential moderators. CONCLUSIONS: Reporting of process evaluation measures may help build our understanding of the optimal characteristics of motor competence interventions. However, process evaluation is under-used and/or under-reported. This review serves as a call for more process evaluations and better reporting in motor competence interventions.

Using Collective Intelligence to identify barriers to implementing and sustaining effective Fundamental Movement Skill interventions: A rationale and application example.

To have population-level impact, interventions must be effectively implemented and sustained under real-world conditions. Few Fundamental Movement Skill (FMS) interventions are implemented at scale, and even fewer are sustained in a way that allows for ongoing evaluation. There has been increasing recognition of applying systems thinking to investigate the multitude of influences on interventions. To improve research-practice translations, investigations need to incorporate synthesised perspective and collective input from intervention stakeholders. This study trials Collective Intelligence (CI) - an applied systems science approach - to understand barriers to the adoption, implementation and institutionalisation of effective FMS interventions for children and adolescents. A total of 58 barriers were generated and organised into 13 barrier categories. Participants voted to select 10 critical barriers and generated a structural map among the barriers to guide future action mapping. Barriers related to Government and Institutional factors and Curricular Conflicts were structured as fundamental drivers of the system of barriers. By presenting this application example, we aim to underline the considerations and alleviate barriers to conducting much needed implementation and sustainability studies in FMS interventions. CI also adds to the "tool box" to understand the complexity and functioning of public health interventions, such as those targeting physical activity behaviours.

Embedding Active Pedagogies within Pre-Service Teacher Education: Implementation Considerations and Recommendations.

The physical activity levels of children in Australia are critically low and correlate with reduced academic achievement and poor health outcomes. Schools provide an ideal setting for physical activity interventions to help children move more. Instead of targeting in-service teachers, this study embedded an evidence-based active pedagogy program called Transform-Ed! into pre-service teacher education. Pre/post surveys and post-program interviews and focus group discussions were conducted with key stakeholders (n = 5), lecturers (n = 6), and pre-service teachers (n = 274) involved with the 12-week program. The design, implementation, and evaluation of the study were systematically guided by all five dimensions of Glasgow and colleagues' RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. Linear mixed models, descriptive analysis and a framework approach were used to analyse the data. Significant improvements were observed in pre-service teachers' willingness, confidence, and competence to implement physically active pedagogic strategies following the intervention. Pre-service teacher perceived effectiveness of such strategies on student outcomes also significantly increased and perceived barriers decreased. High adherence was consistently reported and the program was maintained after completion of the implementation trial by all lecturers. Four key themes spanning multiple dimensions and participant levels informed recommendations for program scalability: an "inter-systemic approach", a "co-design" approach, "embedded in professional practice", and "evidence of impact" on teacher practice. Anchored in real-world settings and tethered by implementation science, Transform-Ed! could have the potential to advance the teaching capability of teachers, and transform the learning experience and physical and academic outcomes of primary school students.

Validity and reliability evidence for motor competence assessments in children and adolescents: A systematic review.

Valid and reliable tests of motor competence are necessary to allow researchers and practitioners to quantify levels of motor competence, identify skill deficiencies, and determine the effectiveness of motor skill interventions. The primary study aim was to systematically review the validity and reliability of scores derived from gross motor competence tests for typically developing child and adolescent populations. The secondary aim of this review was to identify the most prevalent motor skills assessed across all instruments. A search of seven electronic databases identified 57 different skill assessment tools from 107 studies. Construct validity was the most common measurement property examined (60 studies; 56%). Content validity (21 studies; 20%) was the least commonly explored measurement property. Scores derived from the Test of Gross Motor Development - second and third edition had the most support for validity and reliability. The most common skills included in these skill batteries were the overhand throw (n = 33), catch (n = 32), jump (n = 31) and hop (n = 26). Research efforts should focus on: (1) further investigation of measurement properties of existing tools rather than developing new assessments and (2) further investigation of existing tools and their measurement properties in adolescent populations.

Conceptualising and testing the relationship between actual and perceived motor performance: A cross-cultural comparison in children from Australia and Germany.

Previous studies investigating the relationship between motor skill, physical activity and fitness in children have not thoroughly considered the role of self-perception. Therefore, the study aim was to test a theoretical framework, which considered both actual and perceived motor skill as well as actual and perceived fitness. Potential moderating effects of sex and country were considered. Data on motor skill, fitness, as well as self-perception of motor skill and fitness were collected from 145 Australian children and 214 German children (age range 7 to 10 years). For actual motor skill and fitness, mean differences for sex, age and country were found. For perceived motor performance (perceived motor skill and perceived fitness) no mean differences were found for age. Path analyses were performed. The final model showed significant relations between actual performance (object control skill, fitness) and perceived performance (object control skill, fitness). All model paths had low to moderate regression weights with the lowest relationship reported between actual and perceived fitness. Sex and country showed no effects. This integrated approach has led to a better understanding of the relationship between children's perceived and objective performance, and cultural differences within them.

Three-year maintenance of a teacher-led programme targeting motor competence in early adolescent girls.

Motor competence (MC) in youth is associated with positive health outcomes, yet few achieve their developmental capability. Although numerous MC studies address initial intervention effectiveness, fewer consider intervention sustainability. This study aimed to investigate whether teachers continued to implement an effective MC programme targeting girls (mean age 12.4 ± 0.3 years), three years post-intervention. Ongoing implementation was examined using three domains of the UK Medical Research Council's framework: (i) implementation, (ii) mechanisms of impact, and (iii) context. Teachers (n = 18) completed self-report questionnaires and participated in focus group discussions (FGs). Descriptive statistics analysed questionnaires. FGs were audio recorded, transcribed verbatim and analysed in NVivo 11 using a framework approach. All teachers had continued to implement the programme, or elements thereof, three years post-intervention. The intervention structure, in particular alignment to the physical education context and curriculum, most notably influenced ongoing programme implementation. Improvement, both teacher practice and student performance, emerged as a driver of sustained impact. The programme demand appeared to be the most important facilitator of programme sustainability. Adaptations made to enhance contextual fit of the programme, post-intervention, extended the programme reach. Framed by implementation science, these findings provide valuable insight into programme sustainability and potential scalability.

Bringing objectivity to motor skill assessment in children.

The study purpose was to use Inertial Measurement Units (IMUs) to objectively assess children's motor competence in seven movement skills. Fourteen children aged from seven to 12 years (M = 9.64) participated. Children were asked to perform up to 10 trials of each skill. Children performed the skills, which were captured by XSENS MVN Awinda wireless motion capture, and video. Skills were assessed from video as per the criteria from the Test of Gross Motor Development 3. Initially, 17 IMU sensors were used for signal processing, but this was restricted to four sensors (wrists and ankles) to be more feasible for field assessment. Results of the signal testing against its modelled "Good" signal, showed the skip was classified correctly each time, as was the sidestep. Accuracy % rates for each skill were: kick (95.2), catch (95.0), throw (80.5), jump (78.9), and hop (76.9). Using signal processing-based methods via four sensors was a reliable and feasible way to assess seven motor skills in children. This approach means monitoring and assessment of children's skills can be objective, which will potentially reduce the time involved in motor skill assessment and analysis for research, clinical, sport and education purposes.