Physical Activity & Sport Promotion in Schools Effective School-Based Interventions: What Works?

1. Denizli, Turkey, 12-14 December 2012 Physical Activity & Sport Promotion in SchoolsEffective School-Based Interventions: What Works? Stuart J. Fairclough, PhD Professor of Physical Activity Education Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, UK

2. Why schools as environments for physical activity promotion? Captive audience – school is mandatory Infra-structure – teachers, facilities, curriculum Time – 30-35 h/wk for 40+wks/yr Links to home, community, business [gyms etc] Most MVPA accrued at school (Fairclough et al., 2008; Ed 3-13, 36: 371-381)

3. School-related physical activity during the day(Trost et al., 2002, MSSE. 32, 426-431

4. But, all schools and their students are different…confounding variables • Age • Gender • Maturation • Motivation • Ethnicity • Culture • Religion • Socio-economic status • Stage of schooling • School type • Curriculum structures • Geographic location • Physical environment • School policies and ethos • Climate and weather • Class sizes Can effective intervention approaches work in all cases?

5. Schools as micro-environments for applying the socio-ecological model INTERVENTIONS TARGETING ALL LEVELS Schools • National curricula, standards, government policy • Relationships with community groups, sports clubs, commercial organisations • School departments, classes, streaming • Friends, peers, teachers, parents • Individual children and adolescents

6. School-based PA interventions...what works? It depends on the outcomes... • Context-specific PA - usually successful • Whole day PA - equivocal (possibility of compensation) • Non-school PA - seldom successful • PA-related outcomes (e.g., fitness, motor skills, BMI, etc) - equivocal • Some examples...

7. Active school travel (Cooper et al., 2012, MSSE, 44, 1890-1897) Secondary school children Primary school children

8. Travelling Green Project (McKee et al., 2007, J EpidComm Health, 1: 818-823) • Classes of 9-10 y olds from 2 schools in Scotland; • Intervention: 10 week active travel cross-curricular project comprising interactive resources: • Curriculum materials • Child and family materials • Generic and school-specific components (e.g., maps, road crossing points, etc)

9. Change in school travel mode (McKee et al., 2007, J EpidComm Health, 1: 818-823) Mean distance walked increased by 389% Mean distance travelled by car decreased by 58%

10. Active school travel Active travel is simple, free and sustainable Active travel can potentially occur 10 times each week Limited number of active travel interventions of sufficient quality Relatively small effects reported

11. PA promotion through physical education (PE) • Major goal of PE is to produce physically educated young people who have knowledge, skills, attitudes to engage in PA beyond the curriculum and throughout life • PA during class time • Influence PA out of school

12. Simple teaching intervention to increase PE class time MVPA (Fairclough & Stratton, 2005, Health Ed Res, 20: 448-457) • Aim to increase MVPA without compromising motivation and learning • 11-12 y old girls’ gymnastics lessons • Control vs. intervention classes • Intervention: MVPA included as lesson objective; modified teaching styles, organisation of pupils & equipment • HR monitoring, systematic observation and questionnaire

13. Increased PE MVPA without compromised motivation (Fairclough & Stratton, 2005, Health Ed Res, 20: 448-457) ** ** p < 0.001

14. KISS Clustered RCT (Kriemler et al., 2010, BMJ, 340 :c785) • Intervention children accumulated significantly more MVPA • in school and over whole day than Control group • But out of school MVPA was similar • Improvements in fitness, body composition, CVD risk • Compulsory and structured PA approach • No follow-up after intervention ended 1 year PE intervention in 16 classes within 15 elementary schools Multicomponent approach: daily PE, daily PA breaks, PA homework

15. Integrated curriculum approaches to PA promotion Emphasis on behaviour change through improved knowledge, understanding, behavioural skills Cross-curricular approaches allow reinforcement throughout the curriculum Lesson content commonly based around physical activity, sedentary time, plus other behaviours like healthy eating Tasks provide opportunities for content to be applied in other social contexts (e.g., home)

16. Low cost integrated curriculum approach: The CHANGE! Intervention(Mackintosh et al., 2011, Boddy et al., 2012 BMC Pub Health; Fairclough et al., in rev PLoS ONE) • Aim: Promote healthy weight through… • 1.Increased physical activity • 2. Reductions in sedentary behaviours • 3. Healthy eating • Intervention • CHANGE! curriculum:306 page teacher & pupil resource • Twilight teacher training • 5 month programme, with 10 weeks follow-up • Key results: Increased VPA, decreased waist circumference, increased breakfast consumption

17. Integrated curricular & extra-curricular intervention: Great Fun 2 Run (Gorely et al., 2009, 2011, IJBNPA) Aim: to increase physical activity and improve dietary behaviours among 7-11 year olds Parental and family involvement ‘Highlight’ events and media campaign 10 month duration, 20 months follow-up period

18. Major findings (Gorely et al., 2009, 2011, IJBNPA) • Post-intervention… • MVPA increased by ~ 9min/day • Rate of increase in % body fat, BMI, and waist circumference slowed significantly in older children • No change in fruit and vegetable intake • At 20 months follow up • Significant increases in % body fat, BMI, and waist circumference with increasing age • Post-intervention effects were not sustained

19. Non-curricular PA promotion Rationale: Content can complement formal curriculum No mandatory curriculum guidelines to follow so more flexibility Access to facilities and children

20. Play/breaktime (recess) Mandatory part of the school day Outdoors Potentially 600 playtimes per year [based on 3 x day, 5 days/wk] Largely unstructured physical activity encompassing various modes and intensities

21. Liverpool Sporting Playgrounds Project (Ridgers & Stratton, 2005, PedExercSci, 17: 281-290)

22. Sustained increases in MVPA in the painted Zoneparc playgrounds(Ridgers et al., 2007, Prev. Med, 44: 393-397)

23. Meta-analysis of effects of after-school programmes (Beets et al., 2009, Am J Prev Med, 36: 527-537) Positive effects

25. PA during different types of after-school clubs using active video games (Fairclough et al., 2012, unpublished report) Least active/fit 11-12 y old children participating in twice weekly after-school clubs Children most active doing multi-skills… & least active playing Wii Sports

27. Methodological limitations of youth PA interventions (van Sluijs et al., 2007, BMJ, 335, 703) Short duration of follow-up Lack of adjustment for potential confounders Lack of adjustment for clustering when randomisation at group level occurred Lack of precision of PA outcome measure [over-reliance on self-report]

28. So, what does work? Back to the future…?Child & Adolescent Trial for Cardiovascular Health: CATCH Why was it successful? • Size: 96 elementary schools (5000+ children) in 4 states • Duration: 3 years, with extensive follow-up • Socio-ecological approaches (individual, social, organisational, community, policy) http://www.catchinfo.org/ (Luepker et al., 1996, JAMA, 275, 768-776; McKenzie et al., 1996, Prev. Med., 25, 423-431)

29. Intervention focused on changes to: • PE curriculum, training, & support [individual,policy, organisational] • At least 90 minutes of PE spread across a minimum of three sessions per week • Food services [policy, organisational] • Family involvement [social] • Health education curriculum [individual,policy, organisational] • After-school community involvement [community, social, policy, organisational]

30. Significant improvements in… • MVPA during PE classes • Out of school vigorous PA • Dietary behaviour • Changes sustained after intervention had ended

31. 5 year maintenance effects: CATCH-ON Study(McKenzie et al., 2003, Health Ed Behav, 30: 447-462) But no evidence of maintenance in out of school PA… 5 year follow-up of CATCH in 88 schools PE MVPA maintained in Intervention schools Delayed adoption of CATCH resources plus training in Control schools

32. Based on the evidence, what works? (Kriemler et al., 2011, BJSM, 45, 923-930) • Multi-component interventions (e.g., educational, curricular, environmental) more effective than single component interventions and can broaden the reach of the population (socio-ecological model) • Family involvement (pre-adolescents?) – mediators of non-school PA and positive PA attitudes • Context-specific interventions...but long-term effects questionable • BUT…Lack of effect on out of school PA • Should intervention efforts be directed elsewhere? • Discretionary time [after-school, weekends], targeted to least active?

33. Thanks for listening! @PAEH_Group_JMU s.j.fairclough@ljmu.ac.uk http://www.ljmu.ac.uk/sps/RISES/100465.htm

34. 4 month pilot, 12 month intervention • 3 treatment arms (plus control schools): • High intensity PA (HIPA) • Fundamental movement skills (FMS) • PA signposting scheme (PASS) • 8 schools in total (2 per treatment) • Assessment of CV health, PA, fitness, FMS, body composition, self-perceptions at baseline, 6 months & post-intervention • Summary report available: http://www.sportslinx.org/index.php?option=com_content&view=category&layout=blog&id=24&Itemid=95

35. A-CLASS FMS results (Foweather et al., 2008, Percep Mot Skills, 106, 745-754)

36. Naylor et al., 2006

37. Active school model: Action Schools!: BC (Naylor et al., 2008, BJSM, 42: 338-343) Participatory model Customised 11 month programme based on schools’ perceived needs Targeted zones: environment, PE, family/community, classroom, school spirit, extra-curricular School ‘action teams’ with AS!: BC support team Prescriptive components: 15 min classroom PA/day & 2x40 min PE classes/week Aim: children get 150 minutes school-based PA/week 3 conditions: Usual practice, Liaison, Champion 4-8 week follow-up

38. Action Schools! BC...effective? (Naylor et al., 2008, BJSM, 42: 338-343) • Modest increases in whole-day pedometer counts in Intervention boys but not girls • Suggests limited non-school effects or compensation • Reflects known gender differences in PA related to discretionary time? • Significant increase in PA delivery time • 75% compliance • High teacher satisfaction • School-based intervention models should seek to maintain current PA to prevent/slow age-related decline?