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).

Is there a relationship between primary school children's enjoyment of recess physical activities and health-related quality of life? A cross-sectional exploratory study.

Issue addressed An important strategy for increasing children's physical activity is to enhance children's opportunities for school recess physical activities, yet little is known about the influence of school recess physical activities on children's health-related quality of life (HRQOL). The purpose of the present study was to explore the relationship between Australian primary school children's enjoyment of recess physical activities and HRQOL. Methods The study consisted of children at two Australian primary schools (n=105) aged 8-12 years. The Lunchtime Enjoyment Activity and Play questionnaire was used to measure school children's enjoyment of school recess physical activities. The Pediatric Quality of Life Inventory 4.0 was used to measure children's HRQOL. Researchers applied linear regression modelling in STATA (ver. 13.0) to investigate the relationship between children's enjoyment of school recess physical activities and HRQOL. Results It was discovered that primary school children's enjoyment of more vigorous-type school recess physical activities and playing in a range of weather conditions was associated with children's improved HRQOL. Conclusion The findings from this study suggest that health providers and researchers should consider providing primary school children with opportunities and facilities for more vigorous-intensity school recess physical activities as a key strategy to enhance children's HRQOL. So what? Considering a social-ecological model framework of the key predictors of children's enjoyment of school recess physical activities may provide valuable insight for school health providers into the multiple levels of influence on children's HRQOL when developing school settings and activities for school recess.

Linking secondary school physical education with community sport and recreation for girls: a process evaluation.

BACKGROUND: The purpose of this study was to undertake a process evaluation to examine the reach, adoption and implementation of a school-community linked physical activity (PA) program for girls aged 12 - 15 years (School Years 7 - 9) using the RE-AIM framework. METHODS: Various approaches were used to assess 'reach', 'adoption' and implementation: (a) a school environment survey of intervention schools (n = 6); (b) teacher feedback regarding the professional development component (91.1% response rate) and lesson implementation (60.8% response rate); and (c) post-intervention focus group interviews with physical education (PE) teachers (n = 29), students (n = 125), coaches (n = 13) and instructors (n = 8) regarding program experiences. RESULTS: Reach and Adoption: Seven schools (n = 1491 Year 7-9 female student enrolment; 70% adoption rate), five tennis clubs, eight football clubs and five leisure centres participated in the program during 2011. IMPLEMENTATION: Program design and professional development opportunities (training, resource manual and opportunities to work with coaches and instructors during PE classes) supported implementation and student engagement in PA. However, there was a lack of individual and organisational readiness to adopt program principles. For some deliverers there were deeply embedded ideologies that were not aligned with the Game Sense teaching approach upon which the program was based. Further, cognitive components of the program such as self-management were not widely adopted as other components of the program tended to be prioritised. CONCLUSION: The program design and resources supported the success of the program, however, some aspects were not implemented as intended, which may have affected the likelihood of achieving further positive outcomes. Barriers to program implementation were identified and should be considered when designing school-community linked interventions. In particular, future programs should seek to assess and adjust for organizational readiness within the study design. For example, shared commitment and abilities of program deliverers to implement the program needs to be determined to support program implementation. TRIAL REGISTRATION: ACTRN12614000446662. April 30th 2014.

Effectiveness of a school-community linked program on physical activity levels and health-related quality of life for adolescent girls.

BACKGROUND: This study evaluated the effectiveness of a school-community program on Health-Related Quality of Life (HRQoL; the primary outcome), physical activity (PA), and potential mediators of PA among adolescent girls living in low-socioeconomic rural/regional settings. METHOD: The study was a cluster-randomized controlled trial. Twelve communities with the requisite sports clubs and facilities were paired according to relevant criteria; one of each pair was randomly assigned to the intervention or control condition. Eight schools per condition were randomly selected from these communities and the intervention was conducted over one school year (2011). Female students in grades 7-9 in intervention schools participated in two 6-session PA units - a sport unit (football or tennis) and a recreational unit (leisure centre-based). These were incorporated into physical education (PE) curriculum and linked to PA opportunities for participation outside school. Students were surveyed at baseline and endpoint, self-reporting impact on primary and secondary outcome measures (HRQoL, PA) and PA mediators (e.g. self-efficacy). Linear mixed models for two-group (intervention, control) and three-group (completers, non-completers, control) analyses were conducted with baseline value, age and BMI as covariates, group as a fixed effect and school as random cluster effect. RESULTS: Participants completing baseline and endpoint measures included: 358 intervention (baseline response rate 33.7%, retention rate 61.3%) and 256 control (14.1% and 84.0%). Adjustment for age and BMI made no substantive difference to outcomes, and there were no cluster effects. For HRQoL, after adjustment for baseline scores, the intervention group showed significantly higher scores on all three PedsQL scores (physical functioning: M ± SE = 83.9 ± 0.7, p = .005; psychosocial: 79.9 ± 0.8, p = .001; total score: 81.3 ± 0.7, p = .001) than the control group (80.9 ± 0.8; 76.1 ± 0.9 and 77.8 ± 0.8). The three-group analysis found intervention non-completers had significantly higher PedsQL scores (84.0 ± 0.8, p = .021; 80.4 ± 0.9, p = .003; 81.7 ± 0.8, p = .002;) than controls (80.9 ± 0.8, 76.1 ± 0.9 and 77.8 ± 0.8). There were no significant differences for any PA measure. Intervention completers had significantly higher scores than non-completers and controls for some mediator variables (e.g. self-efficacy, behavioural control). CONCLUSION: Positive outcomes were achieved from a modest school-community linked intervention. The school component contributed to maintaining HRQoL; students who completed the community component derived a range of intra-personal and inter-personal benefits. TRIAL REGISTRATION: ACTRN12614000446662. April 30th 2014.

Evaluating the effects of the Lunchtime Enjoyment Activity and Play (LEAP) school playground intervention on children's quality of life, enjoyment and participation in physical activity.

BACKGROUND: An emerging public health strategy is to enhance children's opportunities to be physically active during school break periods. The aim of this study was to evaluate the effects of the Lunchtime Enjoyment Activity and Play (LEAP) school playground intervention on primary school children's quality of life (QOL), enjoyment and participation in physical activity (PA). METHODS: This study consisted of a movable/recycled materials intervention that included baseline, a 7-week post-test and an 8-month follow-up data collection phase. Children within an intervention school (n = 123) and a matched control school (n = 152) aged 5-to-12-years-old were recruited for the study. Children's PA was measured using a combination of pedometers and direct observation (SOPLAY). Quality of life, enjoyment of PA and enjoyment of lunchtime activities were assessed in the 8-12 year children. A multi-level mixed effect linear regression model was applied in STATA (version 12.0) using the xtmixed command to fit linear mixed models to each of the variables to examine whether there was a significant difference (p < 0.05) between the intervention and control school at the three time points (pre, post and follow-up). RESULTS: Significant overall interaction effects (group × time) were identified for children's mean steps and distance (pedometers) in the intervention school compared to the control school. Intervention school children also spent significantly higher proportions within specified target areas engaged in higher PA intensities in comparison to the control school at both the 7-week post-test and 8-month follow-up. A short-term treatment effect was revealed after 7-weeks for children's physical health scale QOL, enjoyment of PA and enjoyment of intra-personal play activities. CONCLUSIONS: Examining the effects of this school playground intervention over a school year suggested that the introduction of movable/recycled materials can have a significant, positive long-term intervention effect on children's PA. The implications from this simple, low-cost intervention provide impetus for schools to consider introducing the concept of a movable/recycled materials intervention on a wider scale within primary school settings. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registration Number: ACTRN12613001155785.

Children's enjoyment of play during school lunchtime breaks: an examination of intraday and interday reliability.

BACKGROUND: Enjoyment and play during school lunchtime are correlated with children's physical activity. Despite this, there is an absence of studies reporting children's enjoyment of play during school lunchtime breaks. The purpose of this study was to examine the intraday and interday reliability of children's enjoyment of school lunchtime play. METHODS: Surveys used to assess children's enjoyment of lunchtime play were distributed to and completed by 197 children (112 males, 85 females), aged 8-12 years attending an elementary school in Victoria, Australia. Children completed the surveys during class before lunch (expected enjoyment) and after lunch (actual enjoyment) for 5 days. The intra- and interday enjoyment of school lunchtime play reliability were determined using a weighted kappa. RESULTS: Intraday kappa values ranged from fair (0.31) to substantial (0.75) within each of the 5 days (median kappa = 0.41). In comparison, "expected" (0.09-0.40; median 0.30) and "actual" (0.05-0.46; median 0.28) interday enjoyment of lunchtime play displayed low reliability. CONCLUSIONS: Children's enjoyment of lunchtime play appears to be more consistent within days than across days. The findings suggest that assessment of children's enjoyment of lunchtime play once on a single day would be representative of a particular day but not necessarily that particular school week.

The development of the lunchtime enjoyment of activity and play questionnaire.

BACKGROUND: Enjoyment of physical activity is as an important determinant of children's participation in physical activity. Despite this, there is an absence of reliable measures for assessing children's enjoyment of play activities during school lunchtime. The purpose of this study was to develop and assess the reliability of the Lunchtime Enjoyment of Activity and Play (LEAP) Questionnaire. METHODS: Questionnaire items were categorized employing a social-ecological framework including intrapersonal (20 items), interpersonal (2 items), and physical environment/policy (17 items) components to identify the broader influences on children's enjoyment. An identical questionnaire was administered on 2 occasions, 10 days apart, to 176 children aged 8-12 years, attending a government elementary school in regional Victoria, Australia. RESULTS: Test-retest reliability confirmed that 35 of 39 LEAP Questionnaire items had at least moderate kappa agreement ranging from .44 to .78. Although 4 individual kappa values were low, median kappa scores for each aggregated social-ecological component reached at least moderate agreement (.44-.60). CONCLUSIONS: This study confirms the LEAP Questionnaire to be a reliable, context-specific instrument with sound content, and face validity that employs a social-ecological framework to assess children's enjoyment of school play and lunchtime activities.

Linking physical education with community sport and recreation: a program for adolescent girls.

The engagement of adolescent girls in physical activity (PA) is a persistent challenge. School-based PA programs have often met with little success because of the lack of linkages between school and community PA settings. The Triple G program aimed to improve PA levels of secondary school girls (12-15 years) in regional Victoria, Australia. The program included a school-based physical education (PE) component that uniquely incorporated student-centered teaching and behavioral skill development. The school component was conceptually and practically linked to a community component that emphasized appropriate structures for participation. The program was informed by ethnographic fieldwork to understand the contextual factors that affect girls' participation in PA. A collaborative intervention design was undertaken to align with PE curriculum and coaching and instructional approaches in community PA settings. The theoretical framework for the intervention was the socioecological model that was underpinned by both individual-level (social cognitive theory) and organizational-level (building organizational/community capacity) strategies. The program model provides an innovative conceptual framework for linking school PE with community sport and recreation and may benefit other PA programs seeking to engage adolescent girls. The objective of this article is to describe program development and the unique theoretical framework and curriculum approaches.

Do parents' and children's concerns about sports safety and injury risk relate to how much physical activity children do?

OBJECTIVE: To see whether concerns about injury risk relate to children's physical activity (PA). METHODS: Two cohorts were recruited from 19 Australian schools and assessed in 2001 (T1), 2004 (T2) and 2006 (T3). The younger (n=162) was assessed at 6, 9 and 11years old, and the older (n=259) at 11, 14 and 16 years old. At T1 and T2, parents of the younger cohort reported on fear of child being injured, and whether child would be at risk of injury if they played organised sport; the older cohort self-reported injury fear. Accelerometers assessed PA at each time point. Linear regression models examined cross-sectional associations, and also associations between T1 injury fear and risk and T2 PA, and T2 injury fear and risk and T3 PA. RESULTS: In the younger cohort at T2 (9 years), fear and risk were both negatively associated with moderate to vigorous PA (MVPA) (ß=-0.17, 95% CI -0.30 to -0.03 and ß=-0.26, 95% CI -0.41 to -0.10) and also vigorous PA (VPA). Fear was also associated with moderate PA (MPA). For the older cohort at T1, injury fear was negatively associated with MVPA (ß=-0.21, 95% CI -0.35 to -0.07) and also MPA and VPA. Parental perception of risk at T1 (6 years) was negatively associated with children's MPA at T2 (9 years) (ß=-0.17, 95% CI -0.32 to -0.02). Sex did not moderate any association. CONCLUSIONS: Younger children and their parents need to know which sports have low injury risks. Some children may need increased confidence to participate.

A longitudinal study of the family physical activity environment and physical activity among youth.

PURPOSE: Although the family environment is a potentially important influence on children's physical activity (PA), prospective data investigating these associations are lacking. This study aimed to examine the longitudinal relationship between the family environment and PA among youth. DESIGN: A 5-year prospective cohort study. SETTING: Nineteen randomly selected public schools in Melbourne, Australia. SUBJECTS: Families of 5- to 6-year-old (n  =  190) and 10- to 12-year-old (n  =  350) children. MEASURES: In 2001, parents reported their participation in PA, family-based PA, and support and reinforcement for their child's PA. In 2001, 2004, and 2006, moderate to vigorous intensity PA (MVPA) was assessed among youth using accelerometers. Weekend and "critical window" (after school until 6:00 p.m.) MVPA were examined because we hypothesized that the family environment would most likely influence these behaviors. ANALYSIS: Generalized estimating equations predicted average change in MVPA over 5 years from baseline family environment factors. RESULTS: Maternal role modeling was positively associated with boys' critical window and weekend (younger boys) MVPA. Paternal reinforcement of PA was positively associated with critical window and weekend MVPA among all boys, and paternal direct support was positively associated with weekend MVPA (older boys). Among girls, maternal coparticipation in PA predicted critical window MVPA, and sibling coparticipation in PA was directly associated with weekend MVPA (younger girls). CONCLUSIONS: Longitudinal relationships, although weak in magnitude, were observed between the family environment and MVPA among youth. Interventions promoting maternal role modeling, paternal reinforcement of and support for PA, and maternal and sibling coparticipation in PA with youth are warranted.

Family physical activity and sedentary environments and weight change in children.

OBJECTIVE: To examine associations between family physical activity and sedentary environment and changes in body mass index (BMI) z-scores among 10-12-year-old children over three years. METHOD: Design. Longitudinal (three-year follow-up). Subjects. In total, 152 boys and 192 girls aged 10-12 years at baseline. MEASUREMENTS: Measured height and weight at baseline and follow-up (weight status, BMI z-scores); aspects of the family physical activity and sedentary environment (parental and sibling modelling, reinforcement, social support, family-related barriers, rules/restrictions, home physical environment) measured with a questionnaire completed by parents at baseline. RESULTS: At baseline, 29.6% of boys and 21.9% of girls were overweight or obese, and mean (standard deviation, SD) BMI z-scores were 0.44 (0.99) and 0.28 (0.89), respectively. There was a significant change in BMI z-score among girls (mean change = 0.19, SD = 0.55, p < 0.001), but not boys. Among boys, the number of items at home able to be used for sedentary behaviour (B = 0.11, p = 0.037) was associated with relatively greater increases in BMI z-score. Among girls, sibling engagement in physical activity at least three times/wk (B = -0.17, p = 0.010) and the number of physical activity equipment items at home (B = -0.05, p = 0.018) were associated with relatively greater decreases in BMI z-score. CONCLUSION: Sibling physical activity and environmental stimuli for sedentary behaviours and physical activity within the home may be important targets for prevention of weight gain during the transition from childhood to adolescence.

Does weight status influence associations between children's fundamental movement skills and physical activity?

This study sought to determine whether weight status influences the association among children's fundamental movement skills (FMS) and physical activity (PA). Two hundred forty-eight children ages 9-12 years participated. Proficiency in three object-control skills and two locomotor skills was examined. Accelerometers objectively assessed physical activity. Body mass index was calculated to determine weight status. Correlations between physical activity and FMS proficiency were evident among boys and girls. No significant interaction was apparent when examining FMS proficiency scores, PA variables, and weight status. Future studies should examine a broader range of skills and types of activities to better characterize this relationship and to inform the promotion of movement skill proficiency and PA.

Parental concerns about childhood obesity and the strategies employed to prevent unhealthy weight gain in children.

OBJECTIVES: To describe parental concerns about their child's weight, to determine the proportion of parents taking preventive action to avoid obesity in their children and the predictors of taking preventive action, and to describe the strategies adopted by parents. DESIGN: A cross-sectional survey was conducted. Children's heights and weights were measured, and parents completed a questionnaire that included measures of their own weight status, perceptions of their child's weight, concerns about their child's current weight and future weight as an adolescent and adult, and the strategies used to prevent obesity. SETTING: The study was conducted in Melbourne, Australia. SUBJECTS: A total of 291 families of children aged 5-6 years and 919 families of children aged 10-12 years participated. RESULTS: Eighty-nine per cent of parents of overweight 5-6-year-olds and 63% of parents of overweight 10-12-year-olds were unaware their child was overweight. Seventy-one per cent of parents of overweight 5-6-year-olds and 43% of parents of overweight 10-12-year-olds were not concerned about their child's current weight. Although 31% of parents of 5-6-year-olds and 43% of parents of 10-12-year-olds were taking action to prevent unhealthy weight gain in their children, less-educated parents were less likely to do so. CONCLUSIONS: Public health programmes are required to raise parental recognition of childhood overweight and of related risk behaviours, and to provide parents with practical strategies to prevent unhealthy weight gain in their children.

Association of family environment with children's television viewing and with low level of physical activity.

OBJECTIVE: This study examined associations between the family environment and children's television (TV) viewing and likelihood of being low-active. RESEARCH METHODS AND PROCEDURES: In 2001, children were recruited from 19 primary schools in Melbourne, Australia. Parents completed a questionnaire about their child's TV viewing and the family environment. Children also completed a questionnaire and wore an accelerometer for 8 days. Movement counts were used to identify low-active children (lowest quartile). Data were analyzed in May 2004. RESULTS: The sample consisted of 878 children (mean age = 11.5 +/- 0.6 yrs). Multiple logistic regression revealed that socioeconomic status [adjusted odds ratios (AOR) = 0.4 boys], frequency families watched TV together (AOR = 2.0 boys), mothers' (AOR = 1.8 boys; AOR = 2.5 girls) and fathers' (AOR = 2.6 boys; AOR = 2.8 girls) TV viewing, and rules prohibiting TV during mealtimes (AOR = 0.6 boys; AOR = 0.6 girls) related to children watching TV >or=2 h/d. Variables associated with low-level physical activity included self-reported enjoyment of Internet use (AOR = 1.7 boys) and preference for watching TV (AOR = 2.3 girls), perception that mother uses computer a lot (AOR = 1.9 boys) and likes using the computer (AOR = 0.6 girls), fathers' reported computer/electronic games use (AOR = 1.7 girls), frequency families used computer together (AOR = 0.4 girls), rules that TV viewing must be supervised (AOR = 1.9 boys; AOR = 0.6 girls), and having pay TV (AOR = 0.6 boys) and electronic games at home (AOR = 2.6 boys). DISCUSSION: These findings suggest that the relationships between the family environment and TV viewing and low-level activity are complex and that these behaviors are distinct.

Reducing sedentary behaviour and increasing physical activity among 10-year-old children: overview and process evaluation of the 'Switch-Play' intervention.

Overweight and obesity has doubled among children in Australia. There is an urgent need to develop primary prevention strategies to prevent current and future unhealthy weight gain. The aims of this paper are to describe a randomized controlled trial ('Switch-Play') developed to prevent unhealthy weight gain among 10-year-old children and to report the findings of the process evaluation. Children from three government primary schools were randomized by class to one of four conditions: a behavioural modification group (BM; n = 69); a fundamental motor skills group (FMS; n = 73); a combined BM and FMS group (n = 90); or a control (usual classroom lessons) group (n = 61). Children in the BM group participated in 19 sessions that encouraged them to reduce screen-based behaviours, and identified physical activity alternatives. The FMS group participated in 19 lessons that focused on mastery of six skills: run, throw, dodge, strike, vertical jump and kick. The combined group participated in all the BM and FMS activities. The intervention specialist teacher reported that the children showed high enjoyment and engagement (88% lessons attended) in most aspects of the programme. At-home tasks were completed by 57-62% of the children, and 92% completed the in-class tasks. Two-thirds of the children in the BM group participated in the behavioural contracting to switch off the TV. Most of the children reported high enjoyment of the programmes, and only a small proportion (7-17%) reported difficulties in switching off their nominated TV shows. More than half the children reported reducing their TV viewing; however, less than half reported increasing their physical activity. It was found that most aspects of the intervention arms of the programme were successfully delivered to the majority of children participating in 'Switch-Play'; that the programmes were delivered as intended; and that the programmes were favourably evaluated by participating children and their parents.

Perceptions about the local neighborhood and walking and cycling among children.

BACKGROUND: This study examined associations between perceptions of the local neighborhood and walking and cycling among children. METHODS: Children aged 5-6 years (n=291) and 10-12 years (n=919) were recruited from 19 Australian primary schools. Parents reported their child's usual walking or cycling to local destinations and their perceptions of their neighborhood. Ten- to twelve-year-olds were asked their perceptions of traffic, strangers, road safety and sporting venues, and their perceptions of their parent's views on these issues. RESULTS: Five- to six-year-old boys whose parents believed there was heavy traffic in their area were 2.8 times more likely (95%CI=1.1-6.8), and 5- to 6-year-old girls whose parents owned more than one car were 70% less likely (95%CI=0.1-0.8), and whose parents believed that public transport was limited in their area were 60% less likely (95%CI=0.2-0.9) than other children to walk or cycle at least three times per week. Parental belief that there were no lights or crossings was associated with walking or cycling among 10- to 12-year-old boys (OR=0.4, 95%CI=0.2-0.7). Among older girls, parent's belief that their child needed to cross several roads to reach play areas (OR=0.4, 95%CI=0.2-0.8) and that there is limited public transport in their area (OR=0.7, 95%CI=0.4-0.97), and child's belief that there were no parks or sports grounds near home (OR=0.5, 95%CI=0.3-0.8) were associated with a lower likelihood of walking or cycling. CONCLUSION: Perceptions of the local neighborhood may influence children's physical activity.