Methodological considerations and impact of school-based interventions on objectively measured physical activity in adolescents: a systematic review and meta-analysis

'Walk Buds': A walking intervention to increase physical activity, physical fitness, and emotional wellbeing, in 9-13 year old children with intellectual disabilities. Results of a clustered randomised feasibility trial

BACKGROUND

Children with intellectual disability are less physically active and more sedentary than typically developing peers. To date no studies have tested the feasibility of a school-based walking intervention for children with Intellectual Disability.

METHOD

A clustered randomised controlled trial (cRCT), with an embedded process evaluation, was used to test the feasibility of a school-based walking intervention. Eight schools (n = 161 pupils aged 9-13 years) were randomised into either an intervention arm or an 'exercise as usual' arm. Measures included physical activity, physical fitness and emotional wellbeing. Baseline and 3-month follow-up data were collected.

RESULTS

The 'Walk Buds' intervention was found to be acceptable to teaching staff and pupils, with an uptake rate of the walking sessions offered of 84%.

CONCLUSION

A number of challenges were experienced, relating to the COVID-19 pandemic, and difficulties collecting accelerometer data. Barriers, facilitators and required changes identified through the mixed methods process evaluation are discussed.

DE-PASS best evidence statement (BESt): determinants of adolescents' device-based physical activity and sedentary behaviour in settings: a systematic review and meta-analysis

BACKGROUND

Although physical activity (PA) is associated with significant health benefits, only a small percentage of adolescents meet recommended PA levels. This systematic review with meta-analysis explored the modifiable determinants of adolescents' device-based PA and/or sedentary behaviour (SB), evaluated in previous interventions and examined the associations between PA/SB and these determinants in settings.

METHODS

A search was conducted on five electronic databases, including papers published from January 2010 to July 2023. Randomized Controlled Trials (RCTs) or Controlled Trials (CTs) measuring adolescents' device-based PA/SB and their modifiable determinants at least at two time points: pre- and post-intervention were considered eligible. PA/SB and determinants were the main outcomes. Modifiable determinants were classified after data extraction adopting the social-ecological perspective. Robust Bayesian meta-analyses (RoBMA) were performed per each study setting. Outcomes identified in only one study were presented narratively. The risk of bias for each study and the certainty of the evidence for each meta-analysis were evaluated. The publication bias was also checked.

PROSPERO ID

CRD42021282874.

RESULTS

Fourteen RCTs (eight in school, three in school and family, and one in the family setting) and one CT (in the school setting) were included. Fifty-four modifiable determinants were identified and were combined into 33 broader determinants (21 individual-psychological, four individual-behavioural, seven interpersonal, and one institutional). RoBMAs revealed none or negligible pooled intervention effects on PA/SB or determinants in all settings. The certainty of the evidence of the impact of interventions on outcomes ranged from very low to low. Narratively, intervention effects in favour of the experimental group were detected in school setting for the determinants: knowledge of the environment for practicing PA, d = 1.84, 95%CI (1.48, 2.20), behaviour change techniques, d = 0.90, 95%CI (0.09, 1.70), choice provided, d = 0.70, 95%CI (0.36, 1.03), but no corresponding effects on PA or SB were found.

CONCLUSIONS

Weak to minimal evidence regarding the associations between the identified modifiable determinants and adolescents' device-based PA/SB in settings were found, probably due to intervention ineffectiveness. Well-designed and well-implemented multicomponent interventions should further explore the variety of modifiable determinants of adolescents' PA/SB, including policy and environmental variables.

Process Evaluation of a Scaled-Up School-Based Physical Activity Program for Adolescents: Physical Activity 4 Everyone

BACKGROUND

Physical Activity 4 Everyone (PA4E1) is a whole-school physical activity program, with demonstrated efficacy (2012-2014). PA4E1 was adapted (scaled-up) and tested in a scale-up trial (2017-2020). This process evaluation study of the scale-up trial had 2 aims. First, to describe the acceptability, appropriateness, and feasibility of PA4E1 in the scale-up trial, from the perspective of school staff involved in the program management and delivery. Second, to generate themes that may explain school staff assessments of acceptability, appropriateness, and feasibility.

METHODS

Data were collected at various time points throughout the 2-year implementation phase. Online surveys were collected from In-School Champions, Head Physical Education teachers, Principals, and Physical Education teachers (quantitative data). Focus groups and interviews were conducted with In-School Champions, Principals, and Physical Education teachers (qualitative data). Existing published data on website engagement, adaptations, modifications, and the scale-up trial primary outcome (implementation of physical activity practices) were triangulated with the quantitative and qualitative during analysis, to generate themes.

RESULTS

School staff delivering PA4E1 reported it was highly acceptable, appropriate, and feasible. Seven themes were generated relating to acceptability, appropriateness, and feasibility. The themes related to how the program was funded, the delivery modes of implementation support, the identification of easy-wins, the recruitment of the right in-school champion, facilitating principal buy-in, mitigating the impact of school staff turnover, and engaging the whole school.

CONCLUSIONS

Recommendations are made to inform future adaptations for PA4E1 and potentially school-based physical activity programs more generally. The findings may inform future scalability assessments of the suitability of programs for scale-up.

Patterns of Physical Activity of Adolescents With ADHD in the School Context: A Cross-Sectional Study for Clinical Practice

OBJECTIVES

To describe the daily Physical Activity (PA) patterns of adolescents with Attention-deficit/hyperactivity disorder (ADHD), to analyze the differences in terms of PA patterns between adolescents with ADHD and those without ADHD, and to study the factors associated with achieving the daily PA recommendations.

METHODS

The sample was composed of 778 adolescents who provided complete information on their PA patterns through the Physical Activity Questionnaire for Adolescents (PAQ-A). Of these, 97 had ADHD according to DSM-5 criteria.

RESULTS

The results show that being a girl or being of foreign origin and having ADHD have an impact on the achievement of the recommended amount of daily PA.

CONCLUSIONS

When promoting PA in adolescents with ADHD within the school environment, it is necessary to consider different domains and specific contexts of a school day, paying special attention to girls and adolescents with ADHD of immigrant origin.

The Health4Life e-health intervention for modifying lifestyle risk behaviours of adolescents: secondary outcomes of a cluster randomised controlled trial

OBJECTIVES

To investigate the effectiveness of a school-based multiple health behaviour change e-health intervention for modifying risk factors for chronic disease (secondary outcomes).

STUDY DESIGN

Cluster randomised controlled trial.

SETTING, PARTICIPANTS

Students (at baseline [2019]: year 7, 11-14 years old) at 71 Australian public, independent, and Catholic schools.

INTERVENTION

Health4Life: an e-health school-based multiple health behaviour change intervention for reducing increases in the six major behavioural risk factors for chronic disease: physical inactivity, poor diet, excessive recreational screen time, poor sleep, and use of alcohol and tobacco. It comprises six online video modules during health education class and a smartphone app.

MAIN OUTCOME MEASURES

Comparison of Health4Life and usual health education with respect to their impact on changes in twelve secondary outcomes related to the six behavioural risk factors, assessed in surveys at baseline, immediately after the intervention, and 12 and 24 months after the intervention: binge drinking, discretionary food consumption risk, inadequate fruit and vegetable intake, difficulty falling asleep, and light physical activity frequency (categorical); tobacco smoking frequency, alcohol drinking frequency, alcohol-related harm, daytime sleepiness, and time spent watching television and using electronic devices (continuous).

RESULTS

A total of 6640 year 7 students completed the baseline survey (Health4Life: 3610; control: 3030); 6454 (97.2%) completed at least one follow-up survey, 5698 (85.8%) two or more follow-up surveys. Health4Life was not statistically more effective than usual school health education for influencing changes in any of the twelve outcomes over 24 months; for example: fruit intake inadequate: odds ratio [OR], 1.08 (95% confidence interval [CI], 0.57-2.05); vegetable intake inadequate: OR, 0.97 (95% CI, 0.64-1.47); increased light physical activity: OR, 1.00 (95% CI, 0.72-1.38); tobacco use frequency: relative difference, 0.03 (95% CI, -0.58 to 0.64) days per 30 days; alcohol use frequency: relative difference, -0.34 (95% CI, -1.16 to 0.49) days per 30 days; device use time: relative difference, -0.07 (95% CI, -0.29 to 0.16) hours per day.

CONCLUSIONS

Health4Life was not more effective than usual school year 7 health education for modifying adolescent risk factors for chronic disease. Future e-health multiple health behaviour change intervention research should examine the timing and length of the intervention, as well as increasing the number of engagement strategies (eg, goal setting) during the intervention.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12619000431123 (prospective).

Human-centered participatory co-design with children and adults for a prototype lifestyle intervention and implementation strategy in a rural middle school

PURPOSE

The significance of regular physical activity (PA) in reducing cardiovascular disease (CVD) risk is widely acknowledged. However, children in rural areas encounter specific barriers to PA compared to their urban counterparts. This study employs human-centered participatory co-design, involving community stakeholders in developing a multi-level PA intervention named Hoosier Sport. The primary hypothesis is the co-design sessions leading to the development of a testable intervention protocol.

METHODS

Two co-design teams, each consisting of six children and six adults, were formed using human-centered participatory co-design facilitated by research faculty and graduate students. The process involved five co-design sessions addressing problem identification, solution generation, solution evaluation, operationalization, and prototype evaluation. Thematic analysis was employed to identify key themes and intervention components.

RESULTS

Child co-designers (n = 6) ranged from 6th to 8th grade, averaging 12.6 years (SD = 1.8), while adult co-designers (n = 6) averaged 43.3 years (SD = 8.08). Thematic analysis revealed children emphasizing autonomy, the freedom to choose physical and non-physical activities, and the importance of building peer relationships during PA. Adult interviews echoed the importance of autonomy and choice in activities, with a focus on relatedness through positive role modeling.

CONCLUSION

The prototype intervention and implementation strategies developed constitute a testable intervention aligned with Phase 1 of the ORBIT model. This testable prototype lays the groundwork for a collaborative campus-community partnership between the university and the local community, ensuring mutual benefits and sustainable impact.

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).

Effectiveness of the Walking in ScHools (WISH) Study, a peer-led walking intervention for adolescent girls: results of a cluster randomised controlled trial

BACKGROUND

Most adolescent girls fail to meet current physical activity guidelines. Physical activity behaviours track from childhood into adulthood and providing adolescent girls with opportunities to be physically active may have health benefits beyond childhood. The effects of walking interventions on adult cardiometabolic health are known, however less is understood about the potential of walking to promote physical activity in adolescents. Following the Walking In ScHools (WISH) feasibility study, this definitive trial aimed to evaluate the effectiveness of a novel, low-cost, school-based walking intervention at increasing physical activity levels of adolescent girls (aged 12-14 years).

METHODS

Female pupils were recruited from eighteen schools across the border region of Ireland and in Northern Ireland. In intervention schools (n = 9), girls aged 15-18 years, were trained as walk leaders, and led the younger pupils in 10-15 min walks before school, at break and lunch recess. All walks took place in school grounds and pupils were encouraged to participate in as many walks as possible each week. The primary outcome measure was accelerometer determined total physical activity (counts per minutes, cpm).

RESULTS

In total, 589 pupils were recruited to the study. At baseline, pupils engaged in a median (interquartile range (IQR)) 35.7 (21.2) mins moderate-vigorous physical activity (MVPA) per day and only 12% (n = 66) of participants met physical activity guidelines (60 min MVPA per day). The intervention was delivered for a mean (standard deviation (SD)) 19.9 ± 0.97 weeks. The mean post-intervention total physical activity for the intervention group was 676 cpm and 710 cpm in the control group. Post-intervention total physical activity did not statistically differ between groups when adjusted for age, body mass index z-scores and baseline physical activity (mean difference, -33.5, 95% CI = -21.2 to 88.1; p = 0.213).

CONCLUSIONS

'Scaling-up' physical activity interventions is challenging and despite a promising feasibility study, the results of this fully powered trial suggest that in this context, the WISH intervention did not increase device measured physical activity. Since the COVID-19 pandemic, school environments have changed and although pupils enjoyed the programme, attendance at walks was low, indicating that there is a need to better understand how to implement interventions within schools.

TRIAL REGISTRATION

ISRCTN; ISRCTN12847782; Registered 2nd July 2019.

Effects of the inclusion of physical activity in secondary education academic classes on educational indicators and health markers: rationale and methods of the ACTIVE CLASS study

Background

Increasing physical activity (PA) levels and reducing sedentary behaviors in children and adolescents is a need, especially in schools. Active breaks and physically active learning are examples of two emerging methodologies that have been shown to be effective in increasing PA levels and additionally produce improvements in children's educational markers. However, the evidence in adolescents is very limited. This paper presents the design, measurements, and interventions implemented in the ACTIVE CLASS study, whose objectives are: (i) evaluate the effects of two interventions on PA levels, sedentary time, health-related physical fitness academic indicators, cognition, and markers of psychological health among secondary education students; (ii) evaluate teachers' and students' experiences about the implementation of these the two school-based PA intervention.

Methods

A randomized controlled study is conducted with a total of 292 students aged 12-14 years old from six schools (7th and 8th grade) in Spain (three in Cadiz and three in Caceres). One school from each study provinces is randomly assigned to either the active break intervention group, the physically active learning intervention group, or the control group. The interventions have a duration of 16 weeks. Nine main measurement categories are assessed: PA and sedentary time, health-related physical fitness, academic indicators, cognition, psychological health, motivational variables, dietary patterns, sociodemographic characteristics, as well as qualitative information through semi-structured individual interviews and focus groups. Three independent measurements of evaluation are distinguished: pre-intervention, post-intervention (week 16) and retention measurement (4 weeks after the intervention). For quantitative variables, descriptive, correlational, regression and repeated measures ANOVA will be applied.

Discussion

To the best of our knowledge, the ACTIVE CLASS study is the first of its kind in Spain to evaluate the effects of incorporating active breaks and physically active learning in secondary education. In addition, this project provides important information on the effects of two school-based PA intervention arms on educational variables and health markers in adolescents. This will provide valuable and innovative training to the educational community, enabling them to implement teaching methodologies that have the potential to enhance academic performance and improve the quality of life for their students.

Clinical trial registration

clinicaltrials.gov, NCT05891054.

Psychosocial mediators and moderators of a school-based physical activity intervention among Brazilian adolescents

School-based interventions are needed due to the low levels of physical activity (PA) in adolescents. The aim is to examine the mediation effects of psychosocial factors (attitude, self-efficacy, social support from parents, friends, general teachers, and PE teachers, and environment school perception) and moderation by sex, school grade, and socioeconomic level of a school-based PA intervention on the PA practice among adolescents. The Movimente Programme is a randomised controlled trial at schools in southern Brazil (n = 921 adolescents). Strategies included teacher training, educational actions, and environmental changes. Adolescents self-reported their weekly PA. Potential psychosocial mediators and moderators were investigated through validated questionnaires in a Brazilian sample. The product of the coefficients with percentile bootstrapping 95% confidence interval was performed. The Movimente Programme was related to positive changes in adolescents' perception of the school environment and social support from general and physical education teachers. Most psychosocial variables (attitude, self-efficacy, social support from friends, and social support from teachers) were associated with PA, but none mediated the impact of the Movimente Programme on PA. Results varied according to sex and school grade. The Movimente Programme increased the adolescents' perception of the school environment and social support from teachers, but no mediators were confirmed.

School-based physical activity in relation to active travel - a cluster randomized controlled trial among adolescents enrolled in the school in motion study in Norway

BACKGROUND

Active travel and school settings are considered ideal for promoting physical activity. However, previous research suggests limited effect of school-based interventions on overall physical activity levels among adolescents. The relationship between physical activity in different domains remains inconclusive. In this study, we examined the effects of adding two weekly hours of school-based physical activity on active travel rates.

METHOD

We analyzed data from 1370 pupils in the 9th-grade participating in the cluster RCT; the School In Motion (ScIM) project. Intervention schools (n = 19) implemented 120 min of class-scheduled physical activity and physical education, in addition to the normal 2 hours of weekly physical education in the control schools (n = 9), for 9 months. Active travel was defined as pupils who reported walking or cycling to school, while motorized travel was defined as pupils who commuted by bus or car, during the spring/summer half of the year (April-September), or autumn/winter (October-February). The participants were categorized based on their travel mode from pretest to posttest as; maintained active or motorized travel ("No change"), changing to active travel (motorized-active), or changing to motorized travel (active-motorized). Multilevel logistic regression was used to analyze the intervention effect on travel mode.

RESULTS

During the intervention period, most participants maintained their travel habits. In total, 91% of pupils maintained their travel mode to school. Only 6% of pupils switched to motorized travel and 3% switched to active travel, with small variations according to season and trip direction. The intervention did not seem to influence the likelihood of changing travel mode. The odds ratios for changing travel habits in spring/summer season were from active to motorized travel 1.19 [95%CI: 0.53-2.15] and changing from motorized to active travel 1.18 [0.30-2.62], compared to the "No change" group. These findings were consistent to and from school, and for the autumn/winter season.

CONCLUSION

The extra school-based physical activity does not seem to affect rates of active travel among adolescents in the ScIM project.

TRIAL REGISTRATION

Clinicaltrials.gov ID nr: NCT03817047. Registered 01/25/2019' retrospectively registered'.

Moving beyond moderate-to-vigorous physical activity: the role of light physical activity during adolescence

Regular physical activity is an important component of a healthy lifestyle for young people. However, an estimated 80% of adolescents globally are insufficiently active. Traditionally, health benefits were attributed only to physical activity of at least moderate intensity, and recommendations focused on achieving a threshold of moderate-to-vigorous physical activity, without consideration of other aspects of movement within the 24 h cycle. Recently, the overall daily balance of active and sedentary behaviours has gained recognition as an important determinant of health. However, the relationship between light intensity physical activity and health has not been fully explored. In this perspective paper, we discuss key challenges in defining, measuring and analysing light physical activity which have hindered the advancement of knowledge in this area. Next, we suggest three ways in which light physical activity may enhance adolescent wellbeing: firstly, by replacing sedentary behaviours to increase daily movement; secondly, by supporting the accumulation of higher intensities of physical activity; and thirdly, by providing positive experiences to facilitate lifelong engagement with physical activity. In highlighting the importance of light physical activity during adolescence, we aim to encourage critical reflection and the exploration of new approaches towards physical activity within public health and beyond.

'Including us, talking to us and creating a safe environment'-Youth patient and public involvement and the Walking In ScHools (WISH) Study: Lessons learned

BACKGROUND

Young people have the right to be informed and consulted about decisions affecting their lives. Patient and public involvement (PPI) ensures that research is carried out 'with' or 'by' young people rather than 'to', 'about' or 'for' them. The aim of this paper is to outline how youth PPI can be embedded within a physical activity intervention, reflect on the impact of PPI and provide recommendations for future PPI in a similar context.

METHODS

A Youth Advisory Group (YAG) was set up within the Walking In ScHools (WISH) Study to involve adolescent girls in the delivery, implementation and dissemination of a physical activity intervention targeted at adolescents. Schools invited pupils aged 12-14 years and 15-18 years to YAG meetings (n3, from 2019 to 2023). Participative methods were used to inform recruitment strategies and data collection methods for the WISH Study.

RESULTS

Across the three YAG meetings, n51 pupils from n8 schools were involved. Pupils enjoyed the YAG meetings, felt that their feedback was valued and considered the meetings a good way to get young people involved in research. The YAG advised on specific issues and although measuring impact was not the primary aim of the YAG meetings, over the course of the study there were many examples of the impact of PPI. Recruitment targets for the WISH Study were exceeded, the attrition rate was low and pupils were engaged in data collection.

CONCLUSION

Youth PPI is a developing field and there are few physical activity studies that report the PPI work undertaken. Within the WISH Study, three YAG meetings were held successfully, and the views of adolescent girls were central to the development of the study. Considering the specific issues that the YAG advised on (study recruitment, attrition and data collection), there was evidence of a positive impact of PPI.

PATIENT OR PUBLIC CONTRIBUTION

Pupils from post-primary schools interested/participating in the WISH Study were invited to attend YAG meetings. YAG meetings were set up to consult adolescent girls on the delivery, implementation and dissemination of the WISH intervention.

Effect of an activity wristband-based intermittent teaching unit in Physical Education on students' physical activity and its psychological mediators: a cluster-randomized controlled trial. School-fit study

Objective

The main objective of the present study was to examine the effects of an intermittent teaching unit based on the use of activity wristbands and behavior modification strategies on high school students' perceptions of autonomy support, satisfaction of basic psychological needs, motivation toward Physical Education and physical activity, intention to be physically active, and habitual physical activity levels.

Materials and methods

An initial sample of 353 high school students (final sample = 175; 45.7% females; mean age = 13.3 ± 1.2 years) from two public high schools were cluster-randomly assigned into the intermittent (IG, n = 100) and control (CG, n = 75) groups. The IG performed an intermittent teaching unit twice a week for eight weeks. Specifically, the last 15 min of each lesson were used. As the main strategy to promote the practice of regular physical activity, students wore an activity wristband the whole day during the intervention period. Additionally, other behavior modification strategies were also applied (e.g., educational counseling, physical activity goals or reminders). Regarding the CG, during the intervention period (i.e,, the eight weeks that took place the intermittent teaching unit) they also performed two Physical Education sessions, but without using activity wristbands or other behavior modification strategies. Before and after the intervention, as well as at the end of the follow-up period (six weeks), students' physical activity practice mediators and physical activity levels were measured by validated questionnaires.

Results

The Multilevel Linear Model results showed that the IG students statistically significantly improved cognitive and procedural autonomy support from pre- to post-intervention (p < 0.05). They also statistically significantly improved autonomy and relatedness basic psychological needs, and autonomous motivation toward physical activity scores from post-intervention to follow-up (p < 0.05). Moreover, the results showed that the IG students statistically significantly improved habitual physical activity scores from pre- to post-intervention, and from post-intervention to follow-up (p < 0.05).

Conclusion

The intermittent teaching unit based on the use of activity wristbands and other behavior modification strategies was effective for improving students' autonomy support and habitual physical activity levels, but not the rest of physical activity practice mediators.

Clinical trial registration

https://register.clinicaltrials.gov/, ID: NCT05949463.

How to select interventions for promoting physical activity in schools? Combining preferences of stakeholders and scientists

BACKGROUND

The failure to scale-up and implement physical activity (PA) interventions in real world contexts, which were previously successful under controlled conditions, may be attributed to the different criteria of stakeholders and scientists in the selection process of available interventions. Therefore, the aim of our study was to investigate and compare the criteria applied by local stakeholders and scientists for selecting amongst suitable school-based PA interventions for implementation.

METHODS

We conducted a three-round repeated survey Delphi study with local stakeholders (n = 7; Bremen, Germany) and international scientific PA experts (n = 6). Independently for both panels, two rounds were utilized to develop a list of criteria and the definitions of criteria, followed by a prioritization of the criteria in the third round. For each panel, a narrative analysis was used to rank-order unique criteria, list the number of scorers for the unique criteria and synthesize criteria into overarching categories.

RESULTS

The stakeholders developed a list of 53 unique criteria, synthesized into 11 categories with top-ranked criteria being 'free of costs', 'longevity' and 'integration into everyday school life'. The scientists listed 35 unique criteria, synthesized into 7 categories with the top-ranked criteria being 'efficacy', 'potential for reach' and 'feasibility'. The top ranked unique criteria in the stakeholder panel were distributed over many categories, whereas four out of the top six criteria in the scientist panel were related to 'evidence'.

CONCLUSIONS

Although stakeholders and scientists identified similar criteria, major differences were disclosed in the prioritization of the criteria. We recommend an early collaboration of stakeholders and scientists in the design, implementation, and evaluation of PA interventions.

The Impact of a Challenge-Based Learning Experience in Physical Education on Students’ Motivation and Engagement

The present study investigated how challenge-based learning (CBL) in physical education (PE) may affect students’ basic psychological needs (BPNs), motivational regulations, engagement, and learning in comparison with a traditional teaching (TT) methodology. A quasiexperimental study with experimental and control groups was carried out. In total, 50 participants (16 boys and 34 girls) between 13 and 15 years old (Mage = 13.35, SD = 0.62) were involved in the experience for 6 weeks (ncontrol = 24; nexperimental = 26). Validated questionnaires were administered both before and after the intervention in both groups. Furthermore, theoretical knowledge and badminton-specific motor skill tests were carried out in both groups after the intervention. An analysis showed that after the intervention, students in the CBL condition improved their autonomy (Mbefore = 3.15 vs. Mafter = 3.39; ES = 0.26 *), competence (Mbefore = 4.01 vs. Mafter = 4.18; ES = 0.33 *), and relatedness satisfaction (Mbefore = 3.86 vs. Mafter = 4.06; ES = 0.32 *). As for behavioural engagement measures, students in the CBL condition exhibited higher scores after than those from before (Mbefore = 4.12 vs. Mafter = 4.36; ES = 0.35 *). No significant changes were observed for motivational regulations or agentic engagement. On learning outcomes, students in the experimental group achieved higher scores in both theoretical knowledge (Mcontol = 6.48 vs. Mexperimental = 6.79) and badminton-specific motor skills (Mcontol = 6.85 vs. Mexperimental = 7.65) than the control group did. The present study findings highlight that CBL might be a valid and effective methodological approach for students in PE to achieve adaptive motivational, behavioural, and learning outcomes.

Associations between organised sports participation, general health, stress, screen-time and sleep duration in adolescents

AIM

Physical activity patterns in adolescents have been associated with general health. Stress, screen-time and sleep are other factors associated with physical activity that influence health in adolescents. Physical activity accounts for several health benefits; however, the impact of organised sports participation to achieve the same health benefits are less explored. This study explored the associations of organised sports participation with general health, stress, screen-time and sleep-duration in adolescents.

METHODS

For this cross-sectional study, data from 1139 adolescents (age 13-14 years) from 34 schools were analysed. Data were collected during autumn 2019. Data collection consisted of self-reported questionnaires and standard methods for height and weight measurements.

RESULTS

Adolescents with organised sports participation ≥3 times/week were twice as likely to report better general health (OR: 2.11, CI: 1.45-3.07) and lower screen-time (OR: 1.98, CI: 1.43-2.74). Adolescents with organised sports participation ≥3 times/week were less likely to meet the recommended sleep-duration on weekdays (OR: 0.43, 95% CI: 0.29-0.65).

CONCLUSIONS

Adolescents with frequent organised sports participation had better general health, lower amounts of screen-time and shorter sleep-duration on weekdays than those with no participation. Although the causal relationships remain unknown, these results can be relevant when developing strategies promoting physical activity and health in adolescents.

Influence of pilot and small trials in meta-analyses of behavioral interventions: a meta-epidemiological study

BACKGROUND

Pilot/feasibility or studies with small sample sizes may be associated with inflated effects. This study explores the vibration of effect sizes (VoE) in meta-analyses when considering different inclusion criteria based upon sample size or pilot/feasibility status.

METHODS

Searches were to identify systematic reviews that conducted meta-analyses of behavioral interventions on topics related to the prevention/treatment of childhood obesity from January 2016 to October 2019. The computed summary effect sizes (ES) were extracted from each meta-analysis. Individual studies included in the meta-analyses were classified into one of the following four categories: self-identified pilot/feasibility studies or based upon sample size but not a pilot/feasibility study (N ≤ 100, N > 100, and N > 370 the upper 75th of sample size). The VoE was defined as the absolute difference (ABS) between the re-estimations of summary ES restricted to study classifications compared to the originally reported summary ES. Concordance (kappa) of statistical significance of summary ES between the four categories of studies was assessed. Fixed and random effects models and meta-regressions were estimated. Three case studies are presented to illustrate the impact of including pilot/feasibility and N ≤ 100 studies on the estimated summary ES.

RESULTS

A total of 1602 effect sizes, representing 145 reported summary ES, were extracted from 48 meta-analyses containing 603 unique studies (avg. 22 studies per meta-analysis, range 2-108) and included 227,217 participants. Pilot/feasibility and N ≤ 100 studies comprised 22% (0-58%) and 21% (0-83%) of studies included in the meta-analyses. Meta-regression indicated the ABS between the re-estimated and original summary ES where summary ES ranged from 0.20 to 0.46 depending on the proportion of studies comprising the original ES were either mostly small (e.g., N ≤ 100) or mostly large (N > 370). Concordance was low when removing both pilot/feasibility and N ≤ 100 studies (kappa = 0.53) and restricting analyses only to the largest studies (N > 370, kappa = 0.35), with 20% and 26% of the originally reported statistically significant ES rendered non-significant. Reanalysis of the three case study meta-analyses resulted in the re-estimated ES rendered either non-significant or half of the originally reported ES.

CONCLUSIONS

When meta-analyses of behavioral interventions include a substantial proportion of both pilot/feasibility and N ≤ 100 studies, summary ES can be affected markedly and should be interpreted with caution.

Investigating the direct and indirect effects of a school-based leadership program for primary school students: Rationale and study protocol for the 'Learning to Lead' cluster randomised controlled trial

BACKGROUND

Leadership is a valuable skill that can be taught in school, and which may have benefits within and beyond the classroom. Learning to Lead (L2L) is a student-led, primary school-based leadership program whereby older 'peer leaders' deliver a fundamental movement skills (FMS) program to younger 'peers' within their own school.

AIM

The aims of the study are to determine the efficacy of a peer-led FMS intervention on: (i) peer leaders' (aged 10 to 12 years) leadership effectiveness (primary outcome), leadership self-efficacy, well-being, and time on-task in the classroom; (ii) peers' (aged 8 to 10 years) physical activity levels, actual and perceived FMS competency, cardiorespiratory fitness, muscular power, and executive functioning; and (iii) teachers' (referred to as 'school champions') work-related stress and well-being.

METHOD

L2L will be evaluated using a two-arm parallel group cluster randomised controlled trial. Twenty schools located within a two-hour drive of the University of Newcastle, Australia will be recruited. We will recruit 80 students (40 peer leaders and 40 peers) from each school (N = 1,600). L2L will be implemented in three phases: Phase 1 -school champions' training via a professional learning workshop; Phase 2 -school champions' delivery of leadership lessons to the peer leaders; and Phase 3 -peer leaders' delivery of the FMS program to their younger peers. The FMS program, consisting of 12 x 30-minute lessons, will be delivered over the course of one school term (10 weeks). Study outcomes will be assessed at baseline (between mid-March to June, Terms 1 and 2), intervention end (mid-August to September, Term 3), and follow-up (November to mid-December, Term 4. This trial was prospectively registered on the Australian New Zealand Clinical Trials Registry (ANZCTR); registration number: ACTRN12621000376842.

Rethinking children's physical activity interventions at school: A new context-specific approach

Physical activity is important for children's health. However, evidence suggests that many children and adults do not meet international physical activity recommendations. Current school-based interventions have had limited effect on physical activity and alternative approaches are needed. Context, which includes school setting, ethos, staff, and sociodemographic factors, is a key and largely ignored contributing factor to school-based physical activity intervention effectiveness, impacting in several interacting ways.

Conceptualization

Current programs focus on tightly-constructed content that ignores the context in which the program will be delivered, thereby limiting effectiveness. We propose a move away from uniform interventions that maximize internal validity toward a flexible approach that enables schools to tailor content to their specific context.

Evaluation designs

Evaluation of context-specific interventions should explicitly consider context. This is challenging in cluster randomized controlled trial designs. Thus, alternative designs such as natural experiment and stepped-wedge designs warrant further consideration.

Primary outcome

A collective focus on average minutes of moderate-to-vigorous intensity physical activity may not always be the most appropriate choice. A wider range of outcomes may improve children's physical activity and health in the long-term. In this paper, we argue that greater consideration of school context is key in the design and analysis of school-based physical activity interventions and may help overcome existing limitations in the design of effective interventions and thus progress the field. While this focus on context-specific interventions and evaluation is untested, we hope to stimulate debate of the key issues to improve future physical activity intervention development and implementation.

Development and evaluation of the perceived variety-support in physical education scale (PVSPES)

The provision of variety has been posited to influence motivation in physical education. Therefore, the aim of this 3-phase study was to design and evaluate a brief scale to assess ratings of variety-support in physical education. In Phase 1, 20 experts were invited to review the developed items of the Perceived Variety-Support in Physical Education (PVSPE) scale. In Phase 2, factorial validity of item responses was assessed in a sample of adolescents aged 12-14 years (n = 265). In Phase 3, test-retest reliability was determined over a one-week period (n = 100). A one-factor model resulted in "good" fit to the data (χ2(21) = 43.265, p < 0.001, CFI = 0.968, TLI = 0.952, RMSEA = 0.089; factor loading estimates showed that indicators were highly related to the factor (range: 0.60 to 0.93); and ICC was 0.98, 95% CI [0.97 to 0.98]. Our results provide initial evidence for the validity, measurement invariance, and test-retest reliability of scores derived from the VSPE scale for use with adolescents.

Implementation evaluation of an Irish secondary-level whole school programme: a qualitative inquiry

Whole-of-school programmes (WSPs) are recommended to promote physical activity for adolescents. The Active School Flag (ASF) programme for secondary-level schools is one such WSP. Due to the difficulties of incorporating WSPs into the complex school system, there is a risk of poor implementation. The monitoring of unanticipated influences can help to understand key implementation processes prior to scale-up. The aims of this study were to identify perceived facilitators and barriers to implementing the ASF and recommend evidence-based implementation strategies. Focus groups and interviews (N = 50) were conducted in three schools with stakeholders involved in programme implementation, i.e. school management (n = 5), ASF coordinator (n = 4), student-leaders (aged 15–16 years) (n = 64) and staff committee (n = 25). Transcripts were analysed using codebook thematic analysis and were guided by the Consolidated Framework for Implementation Research. Implementation strategies were identified and were selected systematically to address contextual needs. Three themes surrounding the facilitators and barriers to implementation were generated: intervention design factors (e.g. capacity building and knowledge of implementers; and interest and buy-in for the programme), organizational factors (e.g. optimization of people and the busy school environment) and interpersonal factors (e.g. communication and collaboration). The examination of facilitators and barriers to implementation of the ASF has assisted with the identification of implementation strategies including (not limited to) a shared leadership programme for student leaders and a more flexible timeline for completion. These facilitative implementation strategies may assist in the effective implementation of the ASF.

Improving physical activity behaviors, physical fitness, cardiometabolic and mental health in adolescents - ActTeens Program: A protocol for a randomized controlled trial

This trial aims to investigate the effects of the ActTeens physical activity program, on adolescents’ physical activity level, health-related fitness, cardiometabolic and mental health. The trial will aim to recruit ~140 adolescents (aged 13–14 years). Participants will be randomized into either intervention or control groups. The intervention will be guided by social cognitive theory and self-determination theory and implemented over one school term (24-weeks). The ActTeens Program will include: (1) structured physical activity sessions delivered within physical education, including movement-based games and dynamic stretching warm-ups; resistance training skill development; high-intensity training workouts; and cool-downs; (2) self-monitoring plus goal setting for physical activity by pedometer-smart wearable; and (3) healthy lifestyle guidance (social support) by WhatsApp® messages about healthy eating and regular physical activity for the intervention and parents groups. Study outcomes will be assessed at baseline, 24-weeks from baseline, and 12-months from baseline. Physical activity (accelerometer) is the primary outcome. Secondary outcomes include muscular and cardiorespiratory fitness, cardiometabolic profile, and mental health. A process evaluation will be conducted (i.e., recruitment, retention, attendance, and program satisfaction). This project will have the potential to address many questions and debates regarding the implementation of physical activity interventions in low-and- middle-income countries.

Trial registration: ClinicalTrials.gov NCT05070377. Registered on 7 October 2021.

Cost-effectiveness of a dietary and physical activity intervention in adolescents: a prototype modelling study based on the Engaging Adolescents in Changing Behaviour (EACH-B) programme

Objective

To assess costs, health outcomes and cost-effectiveness of interventions that aim to improve quality of diet and level of physical activity in adolescents.

Design

A Markov model was developed to assess four potential benefits of healthy behaviour for adolescents: better mental health (episodes of depression and generalised anxiety disorder), higher earnings and reduced incidence of type 2 diabetes and adverse pregnancy outcomes (in terms of preterm delivery). The model parameters were informed by published literature. The analysis took a societal perspective over a 20-year period. One-way and probabilistic sensitivity analyses for 10 000 simulations were conducted.

Participants

A hypothetical cohort of 100 adolescents with a mean age of 13 years.

Interventions

An exemplar school-based, multicomponent intervention that was developed by the Engaging Adolescents for Changing Behaviour programme, compared with usual schooling.

Outcome measure

Incremental cost-effectiveness ratio (ICER) as measured by cost per quality-adjusted life-year (QALY) gained.

Results

The exemplar dietary and physical activity intervention was associated with an incremental cost of £123 per adolescent and better health outcomes with a mean QALY gain of 0.0085 compared with usual schooling, resulting in an ICER of £14 367 per QALY. The key model drivers are the intervention effect on levels of physical activity, quality-of-life gain for high levels of physical activity, the duration of the intervention effects and the period over which effects wane.

Conclusions

The results suggested that such an intervention has the potential to offer a cost-effective use of healthcare-resources for adolescents in the UK at a willingness-to-pay threshold of £20 000 per QALY. The model focused on short-term to medium-term benefits of healthy eating and physical activity exploiting the strong evidence base that exists for this age group. Other benefits in later life, such as reduced cardiovascular risk, are more sensitive to assumptions about the persistence of behavioural change and discounting.

Trail registration number

ISRCTN74109264.

Changes in physical activity across a 6-month weight loss intervention in adolescents with intellectual and developmental disabilities

BACKGROUND

Adolescents and young adults with intellectual and developmental disabilities (IDD) have high rates of obesity and low levels of physical activity. This analysis examined changes in light, moderate-to-vigorous physical activity (MVPA) and sedentary time, and the association between changes in MVPA and weight loss in adolescents and young adults with IDD and overweight and obesity participating in a 6-month multi-component weight loss intervention.

METHODS

Adolescents and young adults with IDD and overweight or obesity (body mass index ≥ 85 percentile, n = 110, age ~16 years, 52.7% female) and a parent were randomised to one of three intervention groups: face-to-face delivery/conventional reduced energy diet (n = 36), remote delivery (RD)/conventional reduced energy diet (n = 39), or RD/reduced energy enhanced stop light diet (eSLD) (n = 35.) Participants were asked to engage in 60 min/day of MVPA on 5 or more days/wk. Participants and a parent attended twice monthly education/behavioural counselling sessions with a health educator to assist participants in complying with dietary and MVPA recommendations. Education/counselling in the RD arms was delivered remotely using video conferencing, and self-monitoring of MVPA and daily steps was completed using a wireless activity tracker. Education/counselling in the face-to-face arm was delivered during home-visits and self-monitoring of MVPA and daily steps was completed by self-report using paper tracking forms designed for individuals with IDD. MVPA, light activity, and sedentary time were assessed over 7 days at baseline and 6 months using a portable accelerometer (ActiGraph wGT3x-BT).

RESULTS

Mixed modelling analysis completed using participants with valid accelerometer data (i.e. ≥4-10 h days) at baseline (n = 68) and 6 months (n = 30) revealed no significant changes in light, moderate- MVPA, or sedentary time across the 6-month intervention (all P > 0.05). Participants obtained 15.2 ± 21.5 min/day of MVPA at baseline and 19.7 ± 19.7 min/day at 6 months (P = 0.119). Mixed modelling indicated no significant effects of group (P = 0.79), time (P = 0.10), or group-by-time interaction (P = 0.21) on changes in MVPA from baseline to 6 months. Correlational analysis conducted on participants with valid accelerometer data at both baseline and 6 months (n = 24) revealed no significant associations between baseline sedentary time (r = 0.10, P = 0.40) and baseline MVPA (r = -0.22, P = 0.30) and change in MVPA across the 6-month intervention. Additionally, attendance at education/counselling sessions (r = 0.26, P = 0.22) and frequency of self-monitoring of MVPA were not significantly associated with change in MVPA from baseline to 6 months (r = 0.26, P = 0.44). Baseline MVPA (r = 0.02, P = 0.92) and change in MVPA from baseline to 6 months (r = 0.13, P = 0.30) were not associated with changes in body weight across the 6-month intervention.

CONCLUSION

We observed a non-significant increase in MVPA (30%), which was not associated with the magnitude of weight loss in a sample of adolescents and young adults with IDD who participated in a 6-month multi-component weight loss intervention. Additional strategies to increase MVPA in adolescents and young adults with IDD participating in weight loss interventions need to be developed and evaluated.

Do adolescents' experiences of the barriers to and facilitators of physical activity differ by socioeconomic position? A systematic review of qualitative evidence

This review aims to systematically identify and synthesize qualitative data on adolescents' experiences of the barriers to and facilitators of physical activity to understand whether these differ by socioeconomic position. Multiple databases (MEDLINE, Web of Science Core Collection, PsycINFO, and ERIC) were searched in August 2020. Duplicate title/abstract and full text screening was conducted. Studies were included if they reported qualitative data collected from adolescents (aged 10-19), a measure of socioeconomic position and focused on physical activity. Studies not published in English or published before 2000 were excluded. Relevant data were extracted and methodological quality assessed (in duplicate). Data were analyzed using Thomas and Harden's methods for the thematic synthesis. Four analytical themes emerged from the 25 included studies: (1) social support, (2) accessibility and the environment, (3) other behaviors and health, and (4) gendered experiences. These themes appeared across socioeconomic groups; however, their narratives varied significantly. For example, provision and access to local facilities was discussed as a facilitator to middle and high socioeconomic adolescents, but was a barrier to low socioeconomic adolescents. These findings can be used to inform how different socioeconomic groups may benefit from, or be disadvantaged by, current interventions.

Peer-led physical activity intervention for girls aged 13 to 14 years: PLAN-A cluster RCT

Background

Increasing physical activity among girls is a public health priority. Peers play a central role in influencing adolescent behaviour. Peer-led interventions may increase physical activity in adolescent girls, and a feasibility trial had shown that PLAN-A (Peer-led physical Activity iNtervention for Adolescent girls) had evidence of promise to increase physical activity in adolescent girls.

Objective

The objective was to test whether or not PLAN-A can increase adolescent girls’ physical activity, relative to usual practice, and be cost-effective.

Design

This was a two-arm, cluster-randomised controlled trial, including an economic evaluation and a process evaluation.

Participants

State-funded secondary schools in the UK with girls in Year 9 (aged 13–14 years) participated in the trial. All Year 9 girls in participating schools were eligible.

Randomisation

Schools were the unit of allocation. They were randomised by an independent statistician, who was blinded to school identities, to the control or intervention arm, stratified by region and the England Index of Multiple Deprivation score.

Intervention

The intervention comprised peer nomination (i.e. identification of influential girls), train the trainers (i.e. training the instructors who delivered the intervention), peer supporter training (i.e. training the peer-nominated girls in techniques and strategies underpinned by motivational theory to support peer physical activity increases) and a 10-week diffusion period.

Outcomes

The primary outcome was accelerometer-assessed mean weekday minutes of moderate to vigorous physical activity among Year 9 girls. The follow-up measures were conducted 5–6 months after the 10-week intervention, when the girls were in Year 10 (which was also 12 months after the baseline measures). Analysis used a multivariable, mixed-effects, linear regression model on an intention-to-treat basis. Secondary outcomes included weekend moderate to vigorous physical activity, and weekday and weekend sedentary time. Intervention delivery costs were calculated for the economic evaluation.

Results

A total of 33 schools were approached; 20 schools and 1558 pupils consented. Pupils in the intervention arm had higher Index of Multiple Deprivation scores than pupils in the control arm. The numbers randomised were as follows: 10 schools (n = 758 pupils) were randomised to the intervention arm and 10 schools (n = 800 pupils) were randomised to the control arm. For analysis, a total of 1219 pupils provided valid weekday accelerometer data at both time points (intervention, n = 602; control, n = 617). The mean weekday moderate to vigorous physical activity was similar between groups at follow-up. The central estimate of time spent engaging in moderate to vigorous physical activity was 2.84 minutes lower in the intervention arm than in the control arm, after adjustment for baseline mean weekday moderate to vigorous physical activity, the number of valid days of data and the stratification variables; however, this difference was not statistically significant (95% confidence interval –5.94 to 0.25; p = 0.071). There were no between-arm differences in the secondary outcomes. The intervention costs ranged from £20.85 to £48.86 per pupil, with an average cost of £31.16.

Harms

None.

Limitations

The trial was limited to south-west England.

Conclusions

There was no evidence that PLAN-A increased physical activity in Year 9 girls compared with usual practice and, consequently, it was not cost-effective.

Future work

Future work should evaluate the utility of whole-school approaches to promote physical activity in schools.

Trial registration

This trial is registered as ISRCTN14539759.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 6. See the NIHR Journals Library website for further project information. This trial was designed and delivered in collaboration with the Bristol Randomised Trials Collaboration (BRTC), a United Kingdom Clinical Research Commission (UKCRC)-registered Clinical Trials Unit that, as part of the Bristol Trials Centre, is in receipt of NIHR Clinical Trials Unit support funding. The sponsor of this trial was University of Bristol, Research and Enterprise Development www.bristol.ac.uk/red/. The costs of delivering the intervention were funded by Sport England.

Scale-up of the Physical Activity 4 Everyone (PA4E1) intervention in secondary schools: 24-month implementation and cost outcomes from a cluster randomised controlled trial

Background

Physical Activity 4 Everyone (PA4E1) is an evidence-based program effective at increasing adolescent physical activity (PA) and improving weight status. This study aimed to determine a) the effectiveness of an adapted implementation intervention to scale-up PA4E1 at 24-month follow-up, b) fidelity and reach, and c) the cost and cost-effectiveness of the implementation support intervention.

Methods

A cluster randomised controlled trial using a type III hybrid implementation-effectiveness design in 49 lower socio-economic secondary schools, randomised to a program (n = 24) or control group (n = 25). An adapted implementation intervention consisting of seven strategies was developed to support schools to implement PA4E1 over 24-months. The primary outcome was the proportion of schools implementing at least four of the 7 PA practices, assessed via computer assisted telephone interviews (CATI) with Head Physical Education Teachers. Secondary outcomes included the mean number of PA practices implemented, fidelity and reach, cost and cost-effectiveness. Logistic regression models assessed program effects.

Results

At baseline, no schools implemented four of the 7 PA practices. At 24-months, significantly more schools in the program group (16/23, 69.6%) implemented at least four of the 7 PA practices than the control group (0/25, 0%) (p < 0.001). At 24-months, program schools were implementing an average of 3.6 more practices than control schools (4.1 (1.7) vs. 0.5 (0.8), respectively) (P < 0.001). Fidelity and reach of the implementation intervention were high (> 75%). The total cost of the program was $415,112 AUD (2018) ($17,296 per school; $117.30 per student).

Conclusions

The adapted implementation intervention provides policy makers and researchers with an effective and potentially cost-effective model for scaling-up the delivery of PA4E1 in secondary schools. Further assessment of sustainability is warranted.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12617000681358 prospectively registered 12th May 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01206-8.

Physical Activity through a Classroom-Based Intervention: A Pragmatic Non-Randomized Trial among Swedish Adolescents in an Upper Secondary School

Schools are an important arena to curb the decline in physical activity (PA) in youth. School-based interventions with accelerometer-measured PA are warranted. This study aimed to increase accelerometer-measured PA in adolescents following a 12-month school-based intervention. Two school-classes of 16–18-year-old Swedish students were allocated to intervention group and control group. Accelerometer-measured PA was gathered at baseline, 6- and 12-month follow-up. Mixed-effects linear regression was used to investigate between-group and within-group differences in mean minutes per day (min/day) of moderate to vigorous PA (MVPA), light PA (LPA) and sedentary time (ST). Fifty-seven students participated (intervention group = 31, control group = 26). At 12-month follow-up, the intervention group performed 5.9 (95% CI: −4.3, 16.2) min/day more in MVPA, 1.8 (95% CI: −17.9, 14.2) min/day less in LPA, and 4.1 (95% CI: −27.3, 19.2) min/day less in ST compared to the control group. Within the intervention group, there was no significant change in PA. Within the control group, LPA decreased (95% CI: −19.6, −0.2; p = 0.044) and ST increased (95% CI: 1.8, 30.8; p = 0.028). Although no between-group differences in PA were statistically significant, the within-group changes may suggest a preventive impact on the decline in PA during adolescence.

Psychometrics of three Swedish physical pediatric item banks from the Patient-Reported Outcomes Measurement Information System (PROMIS)®: pain interference, fatigue, and physical activity

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS®) aims to provide self-reported item banks for several dimensions of physical, mental and social health. Here we investigate the psychometric properties of the Swedish pediatric versions of the Physical Health item banks for pain interference, fatigue and physical activity which can be used in school health care and other clinical pediatric settings. Physical health has been shown to be more important for teenagers' well-being than ever because of the link to several somatic and mental conditions. The item banks are not yet available in Sweden.

METHODS

12- to 19-year-old participants (n = 681) were recruited in public school settings, and at a child- and psychiatric outpatient clinic. Three one-factor models using CFA were performed to evaluate scale dimensionality. We analyzed monotonicity and local independence. The items were calibrated by fitting the graded response model. Differential Item analyses (DIF) for age, gender and language were calculated.

RESULTS

As part of the three one-factor models, we found support that each item bank measures a unidimensional construct. No monotonicity or local dependence were found. We found that 11 items had significant lack of fit in the item response theory (IRT) analyses. The result also showed DIF for age (seven items) and language (nine items). However, the differences on item fits and effect sizes of McFadden were negligible. After considering the analytic results, graphical illustration, item content and clinical relevance we decided to keep all items in the item banks.

CONCLUSIONS

We translated and validated the U.S. PROMIS item banks pain interference, fatigue and physical activity into Swedish by applying CFA, IRT and DIF analyses. The results suggest adequacy of the translations in terms of their psychometrics. The questionnaires can be used in school health and other pediatric care. Future studies can be to use Computerized Adaptive Testing (CAT), which provide fewer but reliable items to the test person compared to classical testing.

Adaptation, Student Participation and Gradual Withdrawal by Researchers as Sustainability Strategies in the High School-Based Young and Active Intervention: School Coordinators' Perspectives

Ensuring the sustainability of school-based public health intervention activities remains a challenge. The Young and Active (Y&A) intervention used peer-led workshops to promote movement and strengthen students' sense of community in 16 Danish high schools. Peer mentors inspired first-year students to implement movement activities. To support sustainability, we applied a three-year stepwise implementation strategy using university students as peer mentors in year 1 and senior high school students in the following two years. This study explores the sustainability potential of Y&A, focusing on school coordinators' reflections on the intervention's fit to their schools and the student-driven approach, and we assess the three-step implementation strategy. The study is based on telephone interviews with coordinators (n = 7) from schools that participated in all three years and participant observations of four workshops (a total of approximately 250 participating students). Results were generated through an abductive analysis. Seven schools continued the intervention throughout the three years and adapted it to fit their priorities. The student-driven approach was perceived to be valuable, but few student-driven activities were initiated. Teacher support seemed crucial to support students in starting up activities and acting as peer mentors in workshops. The three-step implementation strategy proved valuable due to the peer-approach and the possibility of gradual adaptation. In future similar initiatives, it is important to address how the adequate staff support of students can be facilitated.

An online family-based self-monitoring and goal-setting intervention to improve children’s physical activity: the FRESH feasibility trial and three-arm pilot RCT

Background

Family-based physical activity promotion presents a promising avenue for promoting whole-family physical activity, but high-quality research is lacking.

Objectives

To assess the feasibility, acceptability and preliminary effectiveness of FRESH (Families Reporting Every Step to Health), a child-led online family-based physical activity intervention; and to identify effective and resource-efficient family recruitment strategies.

Design

The project consisted of (1) a randomised feasibility trial, (2) a randomised controlled pilot trial and (3) a systematic review and Delphi study.

Setting

Norfolk/Suffolk counties, UK.

Participants

Families, recruited from schools, workplaces and community settings, were eligible to participate if one child aged 7–11 years and one adult responsible for their care provided written consent; all family members could participate.

Interventions

The FRESH intervention, guided by self-determination theory, targeted whole families and was delivered via an online platform. All family members received pedometers and were given website access to select family step challenges to ‘travel’ to target cities around the world, log steps, and track progress as they virtually globetrotted. Families were randomised to FRESH intervention, pedometer-only or control arm.

Main outcome measures

Physical (e.g. blood pressure), psychosocial (e.g. family functioning) and behavioural (e.g. device-measured family physical activity) measures were collected at baseline and at 8- and 52-week follow-up. A mixed-methods process evaluation assessed the acceptability of the intervention and evaluation.

Data sources review

Systematic search of four databases (Cochrane Library, PubMed, PsycINFO and SCOPUS).

Review methods

Articles were screened in duplicate, and data extraction was fully checked. Academic experts participated in the three-round Delphi study. Data were combined to identify effective and resource-efficient family recruitment strategies.

Inclusion criteria

Included generally healthy school-aged children and at least one adult; intervention attempted to change physical activity, sedentary behaviour, screen use, diet, or prevent overweight/obesity in multiple family members; presented relevant measure of effect in children and adults.

Results

The feasibility study (12 families, 32 participants; 100% retention at 8 weeks) demonstrated the feasibility and acceptability of FRESH, but highlighted that adaptations were required. Of 41 families recruited in the pilot study (149 participants), 98% and 88% were retained at the 8-week and 52-week follow-up, respectively. More children in the FRESH arm self-reported doing more family physical activity, and they thought that FRESH was fun. There were no notable between-group differences in children’s outcomes. Change in moderate to vigorous physical activity at 8 weeks favoured FRESH intervention adults [vs. control: 9.4 minutes/week (95% confidence interval 0.4 to 18.4) vs. pedometer only: 15.3 (95% confidence interval 6.0 to 24.5)], and was stronger in fathers, but this was not maintained. In 49 included studies, apart from recruitment settings and strategies used (reported in 84% and 73% of the studies, respectively), recruitment details were scarce. School-based recruitment was predominant. The Delphi study identified a wide range of recruitment settings and strategies.

Limitations

Recruitment was the main limitation of the FRESH studies; generalisability of the proposed recruitment strategies may be limited.

Conclusions

This study has demonstrated the feasibility and acceptability of the FRESH intervention. However, we failed to recruit the target sample size and were unable to demonstrate a signal of effectiveness. Future research should employ a multifaceted recruitment approach.

Future work

Further refinements to intervention delivery and recruitment methods should be investigated.

Study registration

Current Controlled Trials ISRCTN12789422 and PROSPERO CRD42019140042.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.

Physical activity behaviours in adolescence: current evidence and opportunities for intervention

Young people aged 10-24 years constitute 24% of the world's population; investing in their health could yield a triple benefit-eg, today, into adulthood, and for the next generation. However, in physical activity research, this life stage is poorly understood, with the evidence dominated by research in younger adolescents (aged 10-14 years), school settings, and high-income countries. Globally, 80% of adolescents are insufficiently active, and many adolescents engage in 2 h or more daily recreational screen time. In this Series paper, we present the most up-to-date global evidence on adolescent physical activity and discuss directions for identifying potential solutions to enhance physical activity in the adolescent population. Adolescent physical inactivity probably contributes to key global health problems, including cardiometabolic and mental health disorders, but the evidence is methodologically weak. Evidence-based solutions focus on three key components of the adolescent physical activity system: supportive schools, the social and digital environment, and multipurpose urban environments. Despite an increasing volume of research focused on adolescents, there are still important knowledge gaps, and efforts to improve adolescent physical activity surveillance, research, intervention implementation, and policy development are urgently needed.

Improving children's fundamental movement skills through a family-based physical activity program: results from the "Active 1 + FUN" randomized controlled trial

Background

Physical activity is related to many positive health outcomes, yet activity levels of many children are low. Researchers have suggested that family-based interventions may improve physical activity behaviors of both children and their parents. In this study, we evaluated the “Active 1 + FUN” program, which was designed based on tenets of self-determination theory. Intervention components included free sporting equipment, ten coach-led workshops and activity sessions, and one booster session.

Methods

We evaluated the intervention program using a randomized controlled trial. One hundred seventy-one families were randomly allocated to either an experimental group or a wait-list control group. Participants were exposed to program contents over a nine-month period, while families in the control did not receive any form of intervention. Measured constructs included moderate-to-vigorous physical activity, co-physical activity behaviors, fundamental movement skills, BMI, and several self-reported questionnaire outcomes. Hierarchical linear modeling was used to compare changes in measured outcomes across the two groups.

Results

No significant intervention effects were found for children’s and parents’ accelerometer-measured moderate-to-vigorous physical activity, or their co-physical activity. However, in terms of children’s fundamental movement skills, a significant Time*Group interaction (B = 0.52, 95% CI [0.07, 0.96] for Times 1 to 2; B = 0.24, 95% CI [0.01, 0.48] for Times 1 to 3) in favor of the experimental group was found.

Conclusions

Results suggested that the “Active 1 + FUN” program was effective in improving children’s fundamental movement skills. Additional research is needed to examine how family-based initiatives could effectively improve physical activity behaviors too.

Trial registration

ANZCTR, ACTRN12618001524280. Registered 11 September 2018, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375660.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01160-5.

A school-based, peer-led programme to increase physical activity among 13- to 14-year-old adolescents: the GoActive cluster RCT

Background

Adolescent physical activity levels are low and are associated with rising disease risk and social disadvantage. The Get Others Active (GoActive) intervention was co-designed with adolescents and teachers to increase physical activity in adolescents.

Objective

To assess the effectiveness and cost-effectiveness of the school-based GoActive programme in increasing adolescents’ moderate-to-vigorous physical activity.

Design

A cluster randomised controlled trial with an embedded mixed-methods process evaluation.

Setting

Non-fee-paying schools in Cambridgeshire and Essex, UK (n = 16). Schools were computer randomised and stratified by socioeconomic position and county.

Participants

A total of 2862 Year 9 students (aged 13–14 years; 84% of eligible students).

Intervention

The iteratively developed feasibility-tested refined 12-week intervention trained older adolescents (mentors) and in-class peer leaders to encourage classes to undertake two new weekly activities. Mentors met with classes weekly. Students and classes gained points and rewards for activity in and out of school.

Main outcome measures

The primary outcome was average daily minutes of accelerometer-assessed moderate-to-vigorous physical activity at 10 months post intervention. Secondary outcomes included accelerometer-assessed activity during school, after school and at weekends; self-reported physical activity and psychosocial outcomes; cost-effectiveness; well-being and a mixed-methods process evaluation. Measurement staff were blinded to allocation.

Results

Of 2862 recruited participants, 2167 (76%) attended 10-month follow-up measurements and we analysed the primary outcome for 1874 (65.5%) participants. At 10 months, there was a mean decrease in moderate-to-vigorous physical activity of 8.3 (standard deviation 19.3) minutes in control participants and 10.4 (standard deviation 22.7) minutes in intervention participants (baseline-adjusted difference –1.91 minutes, 95% confidence interval –5.53 to 1.70 minutes; p = 0.316). The programme cost £13 per student compared with control. Therefore, it was not cost-effective. Non-significant indications of differential impacts suggested detrimental effects among boys (boys –3.44, 95% confidence interval –7.42 to 0.54; girls –0.20, 95% confidence interval –3.56 to 3.16), but favoured adolescents from lower socioeconomic backgrounds (medium/low 4.25, 95% confidence interval –0.66 to 9.16; high –2.72, 95% confidence interval –6.33 to 0.89). Mediation analysis did not support the use of any included intervention components to increase physical activity. Some may have potential for improving well-being. Students, teachers and mentors mostly reported enjoying the GoActive intervention (56%, 87% and 50%, respectively), but struggled to conceptualise their roles. Facilitators of implementation included school support, embedding a routine, and mentor and tutor support. Challenges to implementation included having limited school space for activities, time, and uncertainty of teacher and mentor roles.

Limitations

Retention on the primary outcome at 10-month follow-up was low (65.5%), but we achieved our intended sample size, with retention comparable to similar trials.

Conclusions

A rigorously developed school-based intervention (i.e. GoActive) was not effective in countering the age-related decline in adolescent physical activity. Overall, this mixed-methods evaluation provides transferable insights for future intervention development, implementation and evaluation.

Future work

Interdisciplinary research is required to understand educational setting-specific implementation challenges. School leaders and authorities should be realistic about expectations of the effect of school-based physical activity promotion strategies implemented at scale.

Trial registration

Current Controlled Trials ISRCTN31583496.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 6. See the NIHR Journals Library website for further project information. This work was additionally supported by the Medical Research Council (London, UK) (Unit Programme number MC_UU_12015/7) and undertaken under the auspices of the Centre for Diet and Activity Research (Cambridge, UK), a UK Clinical Research Collaboration Public Health Research Centre of Excellence. Funding from the British Heart Foundation (London, UK), Cancer Research UK (London, UK), Economic and Social Research Council (Swindon, UK), Medical Research Council, the National Institute for Health Research (Southampton, UK) and the Wellcome Trust (London, UK), under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged (087636/Z/08/Z; ES/G007462/1; MR/K023187/1). GoActive facilitator costs were borne by Essex and Cambridgeshire County Councils.

Weight Loss and Improvement of Metabolic Alterations in Overweight and Obese Children Through the I2AO2 Family Program: A Randomized Controlled Clinical Trial

Childhood obesity is a major public health concern. We wanted to evaluate the effectiveness of a multidisciplinary program based on healthy eating, exercise, cognitive-behavioral therapy, and health education to achieve weight loss and improve metabolic parameters in overweight and obese children. A randomized, controlled clinical trial with long-term follow-up (24 months) was conducted at a community care center in overweight and obese individuals aged 6-12 years. A sample of 108 children was divided into an experimental and a control group receiving a standard care program. The experimental groups received a 12-month interdisciplinary program; the results were evaluated at 4 months, the end of the intervention, and at follow-up 12 months later. Anthropometric and biological marker measurements related to metabolic alterations, dyslipidemia (based on total cholesterol), hyperglycemia, fasting glycaemia, triglycerides, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol in blood were recorded. The intervention had a significant effect (p < 0.001) in terms of decreased body mass index, skinfolds, and waist and arm circumferences. These changes were accompanied by biochemical changes underlying an improvement in metabolic parameters, such as a significant reduction in total cholesterol, low-density lipoprotein-cholesterol, triglycerides, and hyperglycemia and a significant increase in high-density lipoprotein-cholesterol. These effects were still significant for markers of excess weight or obesity in the experimental group 12 months after the end of the intervention, suggesting that an enduring change in healthy lifestyles had been maintained period. This interdisciplinary, nurse-led program helped to reduce childhood and adolescent excess weight and obesity and had long-lasting effects.

School-based interventions modestly increase physical activity and cardiorespiratory fitness but are least effective for youth who need them most: an individual participant pooled analysis of 20 controlled trials

OBJECTIVES

To determine if subpopulations of students benefit equally from school-based physical activity interventions in terms of cardiorespiratory fitness and physical activity. To examine if physical activity intensity mediates improvements in cardiorespiratory fitness.

DESIGN

Pooled analysis of individual participant data from controlled trials that assessed the impact of school-based physical activity interventions on cardiorespiratory fitness and device-measured physical activity.

PARTICIPANTS

Data for 6621 children and adolescents aged 4-18 years from 20 trials were included.

MAIN OUTCOME MEASURES

Peak oxygen consumption (VO2Peak mL/kg/min) and minutes of moderate and vigorous physical activity.

RESULTS

Interventions modestly improved students' cardiorespiratory fitness by 0.47 mL/kg/min (95% CI 0.33 to 0.61), but the effects were not distributed equally across subpopulations. Girls and older students benefited less than boys and younger students, respectively. Students with lower levels of initial fitness, and those with higher levels of baseline physical activity benefitted more than those who were initially fitter and less active, respectively. Interventions had a modest positive effect on physical activity with approximately one additional minute per day of both moderate and vigorous physical activity. Changes in vigorous, but not moderate intensity, physical activity explained a small amount (~5%) of the intervention effect on cardiorespiratory fitness.

CONCLUSIONS

Future interventions should include targeted strategies to address the needs of girls and older students. Interventions may also be improved by promoting more vigorous intensity physical activity. Interventions could mitigate declining youth cardiorespiratory fitness, increase physical activity and promote cardiovascular health if they can be delivered equitably and their effects sustained at the population level.

Time-efficient intervention to improve older adolescents' cardiorespiratory fitness: findings from the 'Burn 2 Learn' cluster randomised controlled trial

BACKGROUND

Cardiorespiratory fitness (CRF) is an important marker of current and future health status. The primary aim of our study was to evaluate the impact of a time-efficient school-based intervention on older adolescents' CRF.

METHODS

Two-arm cluster randomised controlled trial conducted in two cohorts (February 2018 to February 2019 and February 2019 to February 2020) in New South Wales, Australia. Participants (N=670, 44.6% women, 16.0±0.43 years) from 20 secondary schools: 10 schools (337 participants) were randomised to the Burn 2 Learn (B2L) intervention and 10 schools (333 participants) to the control. Teachers in schools allocated to the B2L intervention were provided with training, resources, and support to facilitate the delivery of high-intensity interval training (HIIT) activity breaks during curriculum time. Teachers and students in the control group continued their usual practice. The primary outcome was CRF (20 m multi-stage fitness test). Secondary outcomes were muscular fitness, physical activity, hair cortisol concentrations, mental health and cognitive function. Outcomes were assessed at baseline, 6 months (primary end-point) and 12 months. Effects were estimated using mixed models accounting for clustering.

RESULTS

We observed a group-by-time effect for CRF (difference=4.1 laps, 95% CI 1.8 to 6.4) at the primary end-point (6 months), but not at 12 months. At 6 months, group-by-time effects were found for muscular fitness, steps during school hours and cortisol.

CONCLUSIONS

Implementing HIIT during curricular time improved adolescents' CRF and several secondary outcomes. Our findings suggest B2L is unlikely to be an effective approach unless teachers embed sessions within the school day.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12618000293268).

Process Evaluation of a School-Based High-Intensity Interval Training Program for Older Adolescents: The Burn 2 Learn Cluster Randomised Controlled Trial

Process evaluations can help to optimise the implementation of school-based physical activity interventions. The purpose of this paper is to describe the process evaluation of a school-based high-intensity interval training (HIIT) program for older adolescent students, known as Burn 2 Learn (B2L). B2L was evaluated via a cluster randomised controlled trial in 20 secondary schools (10 intervention, 10 control) in New South Wales, Australia. Teachers (n = 22 (55% female)) from the 10 intervention schools, delivered the program over three phases (Phases 1 and 2, 6 months; Phase 3, 6 months) to older adolescent students (n = 337 (50% female); mean ± standard deviation (SD) age = 16.0 ± 0.4 years). Process evaluation data were collected across the 12-month study period. Teachers delivered 2.0 ± 0.8 and 1.7 ± 0.6 sessions/week in Phases 1 and 2 respectively (mean total 25.9 ± 5.2), but only 0.6 ± 0.7 sessions/week in Phase 3. Observational data showed that session quality was high, however heart rate (HR) data indicated that only half of the students reached the prescribed threshold of ≥85% predicted HRmax during sessions. Over 80% of teachers reported they intended to deliver the B2L program to future student cohorts. Almost 70% of students indicated they intended to participate in HIIT in the future. Teachers considered the program to be adaptable, and both students and teachers were satisfied with the intervention. B2L was implemented with moderate-to-high fidelity in Phases 1 and 2, but low in Phase 3. Our findings add to the relatively scant process evaluation literature focused on the delivery of school-based physical activity programs.

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.

Primary prevention of overweight and obesity in adolescents: An overview of systematic reviews

The aim of this overview of systematic reviews was to summarize evidence from up-to-date reviews of the effectiveness of interventions aimed at preventing overweight and obesity in adolescents aged 10 to 19 years. We searched nine databases for systematic reviews published between January 2008 and November 2019. We used A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 to assess the quality of reviews, excluding those of critically low quality, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool to grade the certainty of included evidence. We included 13 reviews. Three reviews focused on dietary behaviour, six on physical activity, and four on both types of behaviours. Individual-oriented and school-based interventions dominated. Results across reviews showed little or no effect on body mass index, or physical activity levels of adolescents, whereas results from a couple of reviews suggest possibly beneficial effects of public health interventions on dietary behaviours (i.e., consumption of sugar-sweetened beverages). The certainty of evidence was low to very low for all outcomes. Overall, the evidence base for the effect of primary interventions to prevent overweight and obesity in adolescents is weak. In particular, there is a lack of reviews assessing the impact of environmental interventions targeting adolescents, and reviews addressing social inequality are virtually absent from this body of literature.

Individual and Environmental Factors Associated with Participation in Physical Activity as Adolescents Transition to Secondary School: A Qualitative Inquiry

The transition from elementary to secondary school is an emotionally and socially complex time when adverse behaviors appear, such as decreased levels of physical activity (PA). Behavioral and environmental factors that influence PA during this time are poorly understood. Therefore, we aimed to identify factors that influence PA as adolescents transition to secondary school. Qualitative interviews were conducted with a sample of 27 ethnically diverse child–parent dyads within the public-school system in British Columbia, Canada (50% boys, 68% mothers, 25% White). The interviews probed for environmental and behavioral factors in school, family, and social contexts that potentially initiated changes in PA, specifically related to the adolescents’ transitions. Interviews were recorded and transcribed verbatim. Thematic analyses identified factors at the individual, social, familial, and school levels that may trigger adolescents to change their participation in PA as they transition from elementary to secondary school. Twenty-two factors emerged from the qualitative analysis including school factors (8), household factors (3), social factors (4), and intrapersonal factors (7). These findings contribute to a better understanding of adolescents’ PA behaviors and highlight the influence of changing environments as they transition from elementary school to secondary school.

Organised physical activity during leisure time is associated with more objectively measured physical activity among Swedish adolescents

AIM

The aim of this study was to investigate associations between participation in organised physical activity (PA), such as sport and exercise during leisure time, and objectively measured PA and sedentary time in a large representative sample of Swedish adolescents.

METHODS

This study was part of the school-based cross-sectional Swedish national dietary survey Riksmaten Adolescents 2016-17. Data from 3477 adolescents aged 11-12, 14-15 and 17-18 years were used in the analyses. Participation in organised PA and parental education were reported in questionnaires. PA and sedentary time were objectively measured through accelerometry during seven consecutive days.

RESULTS

Adolescents who participated in organised PA had significantly higher total PA (14%, P < .001), more time spent on moderate-to-vigorous PA (MVPA) (8 minutes, P < .001) and had less sedentary time (15 minutes, P < .001). Those who participated in organised PA were more likely to reach recommended PA levels. Total PA and MVPA did not differ by parental education among those who participated in organised PA.

CONCLUSION

Adolescents who participated in organised PA were more physically active, less sedentary and more likely to reach PA recommendations than those who did not.

Scale-up of the Physical Activity 4 Everyone (PA4E1) intervention in secondary schools: 12-month implementation outcomes from a cluster randomized controlled trial

BACKGROUND

'Physical Activity 4 Everyone' (PA4E1) was an efficacious multi-component school-based physical activity (PA) program targeting adolescents. PA4E1 has seven PA practices. It is essential to scale-up, evaluate effectiveness and assess implementation of such programs. Therefore, the aim is to assess the impact of implementation support on school practice uptake of the PA4E1 program at 12 and 24 months.

METHODS

A cluster randomised controlled trial, utilising a type III hybrid implementation-effectiveness design, was conducted in 49 randomly selected disadvantaged Australian Government and Catholic secondary schools. A blinded statistician randomly allocated schools to a usual practice control (n = 25) or the PA4E1 program group (n = 24), with the latter receiving seven implementation support strategies to support school PA practice uptake of the seven practices retained from the efficacy trial. The primary outcome was the proportion of schools adopting at least four of the seven practices, assessed via telephone surveys with Head Physical Education Teachers and analysed using exact logistic regression modelling. This paper reports the 12-month outcomes.

RESULTS

Schools were recruited from May to November 2017. At baseline, no schools implemented four of the seven practices. At 12 months significantly more schools in the program group had implemented four of the seven practices (16/24, 66.7%) than the control group (1/25, 4%) (OR = 33.0[4.15-1556.4], p < 0.001). The program group implemented on average 3.2 (2.5-3.9) more practices than the control group (p < 0.001, mean 3.9 (SD 1.5) vs 0.7 (1.0)). Fidelity and reach of the implementation support intervention were high (both > 80%).

CONCLUSIONS

Through the application of multiple implementation support strategies, secondary schools were able to overcome commonly known barriers to implement evidence based school PA practices. As such practices have been shown to result in an increase in adolescent PA and improvements in weight status, policy makers and practitioners responsible for advocating PA in schools should consider this implementation approach more broadly when working with schools. Follow-up is required to determine whether practice implementation is sustained.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12617000681358 registered 12th May 2017.

A Web-Based Intervention to Prevent Multiple Chronic Disease Risk Factors Among Adolescents: Co-Design and User Testing of the Health4Life School-Based Program

BACKGROUND

Chronic diseases are the leading cause of death worldwide. Addressing key lifestyle risk factors during adolescence is critical for improving physical and mental health outcomes and reducing chronic disease risk. Schools are ideal intervention settings, and electronic health (eHealth) interventions afford several advantages, including increased student engagement, scalability, and sustainability. Although lifestyle risk behaviors tend to co-occur, few school-based eHealth interventions have targeted multiple behaviors concurrently.

OBJECTIVE

This study aims to summarize the co-design and user testing of the Health4Life school-based program, a web-based cartoon intervention developed to concurrently prevent 6 key lifestyle risk factors for chronic disease among secondary school students: alcohol use, smoking, poor diet, physical inactivity, sedentary recreational screen time, and poor sleep (the Big 6).

METHODS

The development of the Health4Life program was conducted over 18 months in collaboration with students, teachers, and researchers with expertise relevant to the Big 6. The iterative process involved (1) scoping of evidence and systematic literature review; (2) consultation with adolescents (N=815) via a cross-sectional web-based survey to identify knowledge gaps, attitudes, barriers, and facilitators in relation to the Big 6; (3) content and web development; and (4) user testing of the web-based program with students (n=41) and teachers (n=8) to evaluate its acceptability, relevance, and appeal to the target audience.

RESULTS

The co-design process resulted in a six-module, evidence-informed program that uses interactive cartoon storylines and web-based delivery to engage students. Student and teacher feedback collected during user testing was positive in terms of acceptability and relevance. Commonly identified areas for improvement concerned the length of modules, age appropriateness of language and alcohol storyline, the need for character backstories and links to syllabus information, and feasibility of implementation. Modifications were made to address these issues.

CONCLUSIONS

The Health4Life school-based program is the first universal, web-based program to concurrently address 6 important chronic disease risk factors among secondary school students. By adopting a multiple health behavior change approach, it has the potential to efficiently modify the Big 6 risk factors within one program and to equip young people with the skills and knowledge needed to achieve and maintain good physical and mental health throughout adolescence and into adulthood.

Isotemporal substitution of sedentary behavior for physical activity on cardiorespiratory fitness in children and adolescents

Both sedentary behavior (SB) and physical activity (PA) are associated with cardiorespiratory fitness (CRF) and independent of each other. Due to the limited time during school for children and adolescents, it is necessary to explore the isotemporal substitution of SB for PA on CRF.A total 536 eligible participants selected from the 7 traditional administrative regions of China were included in this study. The outcome was CRF, determined using a 20-meter shuttle run test, and exposures were SB, light physical activity (LPA), and moderate-to-vigorous physical activity (MVPA) measured with accelerometers. We analyzed the cross-sectional associations of substituting SB with LPA, MVPA, and combinations of LPA and MVPA with CRF, using an isotemporal substitution model.Reallocating SB into MVPA was associated with higher CRF for male (P < .01) and female (P < .01) children and female adolescents (P < .05). In the mixed redistribution, the ratio of LPA to MVPA for male children and female adolescents started from 16:4 and 14:6, respectively, tended toward improvements in CRF. For female children, regardless of the ratio of LPA to MVPA, it was always associated with higher CRF.Reallocating SB into MVPA isotemporally was positively associated with CRF for male and female children and female adolescents but not for male adolescents. MVPA is the key factor to improve CRF when combinations of LPA and MVPA replace SB. The combined approach can provide basis for the selection of target and monitoring variables in intervention studies, and has more flexible choices for improving CRF that are more consistent with the daily PA habits of children and adolescents.

Effectiveness and cost-effectiveness of the GoActive intervention to increase physical activity among UK adolescents: A cluster randomised controlled trial

BACKGROUND

Less than 20% of adolescents globally meet recommended levels of physical activity, and not meeting these recommended levels is associated with social disadvantage and rising disease risk. The determinants of physical activity in adolescents are multilevel and poorly understood, but the school's social environment likely plays an important role. We conducted a cluster randomised controlled trial to assess the effectiveness of a school-based programme (GoActive) to increase moderate-to-vigorous physical activity (MVPA) among adolescents.

METHODS AND FINDINGS

Non-fee-paying, co-educational schools including Year 9 students in the UK counties of Cambridgeshire and Essex were eligible for inclusion. Within participating schools (n = 16), all Year 9 students were eligible and invited to participate. Participants were 2,862 13- to 14-year-olds (84% of eligible students). After baseline assessment, schools were computer-randomised, stratified by school-level pupil premium funding (below/above county-specific median) and county (control: 8 schools, 1,319 participants, mean [SD] participants per school n = 165 [62]; intervention: 8 schools, 1,543 participants, n = 193 [43]). Measurement staff were blinded to allocation. The iteratively developed, feasibility-tested 12-week intervention, aligned with self-determination theory, trained older adolescent mentors and in-class peer-leaders to encourage classes to conduct 2 new weekly activities. Students and classes gained points and rewards for engaging in any activity in or out of school. The primary outcome was average daily minutes of accelerometer-assessed MVPA at 10-month follow-up; a mixed-methods process evaluation evaluated implementation. Of 2,862 recruited participants (52.1% male), 2,167 (76%) attended 10-month follow-up measurements; we analysed the primary outcome for 1,874 participants (65.5%). At 10 months, there was a mean (SD) decrease in MVPA of 8.3 (19.3) minutes in the control group and 10.4 (22.7) minutes in the intervention group (baseline-adjusted difference [95% confidence interval] -1.91 minutes [-5.53 to 1.70], p = 0.316). The programme cost £13 per student compared with control; it was not cost-effective. Overall, 62.9% of students and 87.3% of mentors reported that GoActive was fun. Teachers and mentors commented that their roles in programme delivery were unclear. Implementation fidelity was low. The main methodological limitation of this study was the relatively affluent and ethnically homogeneous sample.

CONCLUSIONS

In this study, we observed that a rigorously developed school-based intervention was no more effective than standard school practice at preventing declines in adolescent physical activity. Interdisciplinary research is required to understand educational-setting-specific implementation challenges. School leaders and authorities should be realistic about expectations of the effect of school-based physical activity promotion strategies implemented at scale.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN31583496.