Journal of Physical Activity and Health, 2015, 12, 1536 -1542 http://dx.doi.org/10.1123/jpah.2014-0578 © 2015 Human Kinetics, Inc.
ORIGINAL RESEARCH
Effect of a Comprehensive School Physical Activity Program on School Day Step Counts in Children Ryan D. Burns, Timothy A. Brusseau, and James C. Hannon Background: Comprehensive School Physical Activity Programming (CSPAP) has the potential to increase physical activity (PA) in children over time. The purpose of this study was to examine the effect of CSPAP on school day step counts in children. Methods: Participants were 327 fourth and fifth grade children recruited from 4 elementary schools. The study was conducted within an Interrupted Time-Series Design framework. School day step counts were collected for 5 days across preintervention and postintervention time-points (10 days total) using NL-1000 piezoelectric pedometers. Robust piecewise regression examined pre- and postintervention intercepts and slopes, and the change in these parameters using postestimation statistics. Results: The slope coefficient was statistically significant across preintervention (β = –105.23, P < .001) but not postintervention time-points (β = –63.23, P = .347), suggesting decreases in steps counts across preintervention and stability of step counts across postintervention school days. Postestimation statistics yielded increases in school day step counts from the end of preintervention (day 5) to the start of postintervention (day 6; t(319) = –4.72, P < .001, Cohen’s d = 4.72). Conclusions: The CSPAP intervention increased average school day step counts and attenuated decreases in step counts throughout the school week in children. Keywords: intervention study, physical education, public health
In children, optimal levels of physical activity (PA) have been linked to decreases in the risk factors of early onset chronic disease, improved academic performance, and increases in on-task behavior in the classroom.1–5 However, the majority of children in the US do not meet the recommended daily levels set by various agencies of 60 minutes of moderate-to-vigorous physical activity (MVPA).6,7 Recently, the Centers for Disease Control (CDC) and the National Association of Sport and Physical Education (NASPE) have suggested that one solution for the lack of childhood PA is Comprehensive School Physical Activity Programming (CSPAP).8 CSPAP is a multicomponent approach by which schools use all available opportunities for students to be physically active, meet the national recommendation of 60 minutes of MVPA per day, and develop the knowledge, skills, and confidence to be physically active for a lifetime.8 CSPAP has 5 components including quality physical education, physical activity during the school day (eg, recess and classroom PA), PA before and after school, staff involvement, and family and community engagement. Indeed, many schools implementing CSPAP aim to provide quality physical education curricula, increase in the opportunities for activity during recess, and to provide physical activity breaks in the classroom in order for children to increase healthy PA behaviors during the school day. Physical education (PE) is an academic subject that is the foundation for CSPAP.8 PE allows children the opportunity to achieve significant levels of PA behaviors within a defined curriculum. Approximately 84% of states (43) mandate PE in elementary schools where children can participate in structured programs.9–11 One of the primary objectives of PE is to promote health and reduce chronic disease risk by having at least 50% of class time engaged in MVPA behaviors, which may include moderate PA such as brisk walking and vigorous PA such as running jumping, skipping, and Burns ([email protected]) and Brusseau are with the Dept of Exercise and Sport Science, University of Utah, Salt Lake City, UT. Hannon is with the College of Physical Activity and Sport Sciences, West Virginia University, Morgantown, WV. 1536
climbing.10–13 PE programs are an important vehicle in promoting PA and fitness in children for improving concurrent health and wellbeing in addition to long-term health outcomes. Therefore, increasing children’s PA levels during PE classes is of upmost importance within the public health arena. Despite the opportunities for PE to aid in student achievement of optimal daily PA, many schools in the US have had PE time reduced on a per week basis or even eliminated in favor for academic subjects.14 Additionally, many elementary PE classes are taught by paraprofessionals with a lack of sufficient training in PE pedagogy, which may lead to decreases in the odds of students achieving sufficient amounts of MVPA.15 CSPAP addresses this issue by providing PE specialists and teachers with evidence-based curriculum designs to maximize MVPA during PE and to provide pedagogical guidance to help students achieve at least 50% of PE time in MVPA. CSPAP also provides evidence-based practice to increase children’s PA during leisure times such as recess.8 Leisure time represents a minor proportion of the school day, yet it is vital to help children participate in enjoyable active play that can increase daily PA levels. Leisure time allows students a break from academic classes, allows them time to socialize with their peers, and provides opportunities to engage in enjoyable active play.16,17 Recess has been shown to account from anywhere between 11% to 21% of total daily step counts and up to 40% of daily MVPA recommendations in children.18,19 Indeed, McKenzie et al20 found that recess had the greatest proportion of children engaged in MVPA compared with all other school day leisure times. Simple modifications including incorporating semistructured activities, providing additional equipment such as balls and hula-hoops, and adding playground markings have all shown to significantly increase children’s PA at recess.21–23 These methods to increase PA during recess are implemented in CSPAP schools.8 Finally, PA breaks in the classroom is the third area where CSPAP aims to increase school day PA levels. PA breaks in the academic classroom allow students to take a mental break from academic tasks. These breaks can occur at any time during the
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school day, last anywhere from 5 to 30 minutes, and can occur once or periodically throughout the school day. Bershwinger and Brusseau24 found that 10-minute activity breaks leads to an average increase of 1000 steps/day in children. Chaddock, Hillman, Buck, and Cohen25 found that even a short break from focused concentration allows the brain to consolidate information for better retention and retrieval of memory. Studies have also found that offering PA breaks during standard classroom instruction may have favorable associations with indicators of cognitive functioning (eg, attention/ concentration), academic behaviors (eg, classroom conduct), and academic achievement (eg, test scores).26–29 CSPAP interventions have shown to decrease total sedentary behaviors during the school day in children and adolescents,30,31 however the ability for CSPAP to increase PA over time has yet to be clearly established. In addition, even though there is great potential for CSPAP to increase PA in youth, limited research has examined the effect of CSPAP specifically in a large sample of elementary school-aged children. Finally, to develop valid conclusions from displayed PA behaviors, PA must be collected at several time-points during pre- and postintervention periods, not only assess the average change in step counts, but also to assess the stability of PA measurements over time. Therefore, the purpose of this study was to examine the effect of a CSPAP on children’s school day step counts over a school week. It was hypothesized that CSPAP would significantly increase children’s school day PA measured via step counts and attenuate any decrease in PA behaviors over a school week compared with when the schools employed traditional PA programming with a single component.
Methods Participants Students were recruited from 4 elementary schools located in the Southwestern United States. Each school implemented the comprehensive school-based PA intervention (CSPAP); therefore the study was quasi-experimental in its methodology. Participants included 327 students (n = 162 girls, n = 165 boys) from the fourth and fifth grades, having a mean age of 9.60 ± 1.75 years and were characterized by the following ethnic backgrounds: Caucasian (43%), Hispanic (44%), African-American (7%), Native American (4%), and Asian/Pacific Islander (2%). Approximately 56% of the sample received Free & Reduced Lunch. Written assent was obtained from the students and written consent was obtained from the parents before data collection. The University Institutional Review Board approved the protocols used in this study.
Instrumentation The NL-1000 piezoelectric pedometer (New-Lifestyles INC, Lee’s Summit, MO, USA) was used to measure PA by monitoring school day step counts. This pedometer has been validated for measuring PA (both step counts and MVPA) in the pediatric population.32,33 The NL-1000 detects step counts as well as the cumulative daily time (displayed in hours, minutes, and seconds) detected within the selected MVPA range, with a detailed description of MVPA function given in Hart et al.32 The NL-1000 allows for setting preferred intensity thresholds at any 1 of 9 levels. The pedometers were all worn on the right side of the body at the level of the iliac crest above the right knee. All pedometers were given an identification number and assigned to a student participant with the corresponding identifier. Students were instructed not to look at the pedometer’s
display monitor throughout the school day to avoid the potential for behavioral reactivity.
CSPAP Intervention The program’s primary focus was to provide training and assistance to improve PE. Specifically, regular in-service opportunities and teacher trainings were provided monthly to ensure that PE was guided by national PE/PA standards, was student-centered and developmentally appropriate, had a core focus on physical activity and motor skill development, taught management skills and promoted self-discipline, included all students, emphasized proper learning over outcome, promoted lifetime personal wellness, and taught responsibility and cooperation and promote diversity.34 The 2 major outcomes goals for physical education were physical activity and health. Furthermore, goals were set for teachers to get children to be active at least 50% of class time. PE in these schools was taught 2 days per week for 30 minutes per day and used a Dynamic Physical Education for Elementary School Children curriculum.35 Lessons typically included a short warm-up or instant activity followed by fitness time, skill practice, and game play. In addition to PE, schools offered PA opportunities at recess and integrated into lessons or classroom activity breaks. Recess offers an excellent opportunity for children to engage in free play or semistructured physical activity during the school day, and allows them to apply skills learned in PE. For this study, schools provided activity stations and recess staff strongly encouraged students to play in one of many semistructured activities or use the walking trails set up to “walk and talk” with friends. “No Parking Zones” were established to limit the number of students that would often sit or stand in certain playground locations. These schools offered a 20-minute recess immediately following lunch as well as a 15-minute afternoon recess. Lunch recess was semistructured with a series of games and activities. Afternoon recess was more informal and led by the classroom teacher, and equipment was available for teachers to use. Classroom teachers were encouraged to implement at least 2 or 3 5-minute activity breaks throughout the day. Examples of physical activity breaks in the classroom included: stretching or relaxation break, walking around the classroom or hallway, jumping with an invisible jump rope, doing squats, push-up, or sit-ups, and/ or passing a ball around the classroom.
Procedures Pedometer data collection took place on 5 consecutive school days (Monday through Friday) across preintervention and postintervention time-points (10 days total). Preintervention data collection took place in late September and postintervention data collection took place in early April, 6 months after the cessation of the CSPAP intervention. The participants’ parents completed a background questionnaire used to collect sample demographic information (ie, age, sex, race/ethnicity). Height (to the nearest 0.5 cm) and weight (to the nearest 0.1 kg) were directly measured on each student using a digital scale (Seca 882 Digital BMI Scale; Chino, CA, USA) and portable stadiometer (Seca 214; Chino, CA, USA). Across the 10 days (pre- and postintervention) of pedometer data collection, the research team was present to prompt students and provide instructions that complied with study protocol. Every morning at the beginning of the school day, students were prompted to place their monitor on the proper body location. At the end of each school day, students were prompted to remove their pedometers and hand them to their homeroom teachers. In addition, research team members actively provided prompts about correctly wearing the
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instrument. At the end of each school day, research team members recorded daily step count totals for each student. Research team members also scanned student responses each day and questioned children if data appeared unusual or if the student displayed extreme step count scores. Data were entered into an EXCEL spreadsheet daily to ensure data completeness and quality. If pedometers were lost, broken, or tampered with by a student participant, the respective student was not given another pedometer and was omitted from the study (< 1% of the sample). Finally, students participated in daily validation checks by completing a brief survey about their previous day’s PA. Survey question items required a yes or no response regarding if they wore their pedometer the entire day and if they removed the pedometer for any reason. The pedometer data collection process was repeated daily at each of the 4 schools. The aforementioned procedures supported the quality of the data collected in this sample of school-aged children.
Piecewise regression analysis was employed to examine the intercepts and slopes pre- and postintervention, separated by a breakpoint after day 5. Because of the clustering at the individual level (ie, times within each individual), the parameters from piecewise regression were estimated using a cluster option and the HuberWhite robust sandwich standard error estimator. This approach ensures the precision of the parameter estimates by adjusting for nonindependent data at the individual level. To test whether there were statistically significant differences between intercepts and slopes from piecewise regression from pre- to postintervention, postestimation analysis was employed using a linear combination of estimator test (lincom). Alpha level was set at P ≤ .05 and all analyses were carried out using STATA v13.0 statistical software package (College Station, TX, USA).
Statistical Analyses
Initial screening of the data showed several potential outliers based on z-scores (+3.0z) and moderate positive skewness using k-density plots. After removal of the outliers, the k-density plots approximated a Gaussian distribution for preintervention and postintervention daily step counts. Figure 1 and Figure 2 visually show the distribution pre- and postintervention average daily step counts across age cohorts and between sexes, respectively. Factorial ANOVA with repeated measures showed statistically significant main effects for sex [F(1, 318) = 14.44, P < .001] and time [F(319) = 39.69, P < .001], with boys, on average, displaying greater step counts than girls (Mean Δ Boys – Girls = 1144.79, Cohen’s d = 0.56) and postintervention, on average, displaying greater daily step counts than preintervention (Mean Δ Post – Pre = 1126.32, Cohen’s d = 0.58). There was no statistically significant main effect for age [F(2, 317) = 0.26, P = .77] and no interaction between any of the factors. Table 1 shows the results from piecewise regression analysis displaying the pre- and postintervention coefficient estimates for the intercepts and slopes. Figure 3 is a scatterplot with lines of best fit across pre- and postintervention time-points separated by a breakpoint after day 5. Intercept coefficients across both pre- and
Data were initially screened for outliers using boxplots and z-scores and normality was checked on daily pre- and postintervention step counts using k-density plots and the Shapiro-Wilk test for normality. Preliminary analysis included a 2×2×2 Factorial ANOVA test with repeated measures to examine the effect of age, sex, and time on daily averaged step counts. Age and sex were between-subject factors and time (preintervention, postintervention) was the within subject factor. Effect sizes were calculated using Cohen’s d with 0.2 interpreted as a small, 0.5 as a medium, and 0.8 as a large effect size.36 The primary analysis was conducted within an Interrupted Time Series Design (ITSD) quasi-experimental framework with the time-series disturbance being the intervention implemented after day 5. Preintervention time points were days 1–5 and postintervention time-points were days 6–10. Within ITSD designs, the stability of the outcome variable can be assessed pre- and postintervention via the slope of the time coefficient, and the averaged change in the outcome can be assessed via the change in the intercept coefficients from the end of preintervention to the start of postintervention.
Results
Figure 1 — Average daily step counts pre- and postintervention across age cohorts (Mean ± Standard Deviation). JPAH Vol. 12, No. 12, 2015
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Figure 2 — Average daily step counts pre- and postintervention for girls and boys (Mean ± Standard Deviation).
Table 1 Piecewise Regression Intercepts and Slope Parameter Estimates Pre- and Postintervention Using the Robust Sandwich Estimator (Dependent Variable = Daily Step Counts) β coefficient
Huber-White Standard Error
95% CI
P-valuea
Intercept preintervention
3263.02
100.60
3065.75, 3460.29
< 0.001
Intercept postintervention
4424.08
224.49
3983.87, 4864.28
< 0.001
Time slope preintervention
–105.23
41.44
–186.51, –23.96
0.011
Time slope postintervention
–63.23
67.29
–195.18, 68.72
0.347
Abbreviations: 95% CI, 95% Confidence Interval. a Alpha level set at P ≤ .05.
Figure 3 — Scatterplot with predicted linear fit lines pre- and postintervention separated by a breakpoint after day 5. JPAH Vol. 12, No. 12, 2015
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postintervention time-points were statistically significant (P < .001). The slope coefficient was statistically significant across preintervention time-points (P = .011) but not statistically significant across postintervention time-points (P = .347). Postestimation lincom tests yielded statistically significant differences between the end of preintervention and the start of postintervention (t(319) = –4.72, P < .001, Cohen’s d = 4.72), but no statistically significant differences were found between the preintervention and postintervention slope coefficients (t(319) = –0.53, P = .595, Cohen’s d = 0.53).
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Discussion The purpose of this study was to examine the effect of CSPAP on school day steps counts in elementary school-aged children from the forth and fifth grades. The results indicate that CSPAP increased averaged daily step counts from the end of preintervention to the start of postintervention, increased overall average daily step counts, and attenuated decreases in steps counts as children progressed through the school week. This is the first study examining the efficacy of CSPAP in a large sample of elementary school-aged children and the first study examining the effect of CSPAP on PA trends over a school week using pedometer step counts. It is evident that CSPAP increased PA levels, however the efficacy of the intervention in sustaining elevated PA behaviors over longer periods of time needs to be supported with additional research. As stated previously, optimizing PA behaviors is important in children not only to decrease the risk factors for early onset chronic disease but to also optimize learning and to improve on-task behaviors in the classroom.1–3,27–29 There have been several schoolbased PA interventions developed to increase PA in children. These interventions include the Sports, Play, and Active Recreation for Kids (SPARK), TAKE 10!, Promoting Lifetime Activity for Youth (PLAY), and the Coordinated Approach to Child Heath (CATCH) among others.36–40 Many of these interventions are limited in scope to specific time periods such as during PE, leisure times, classroom breaks, or during after school programs. CSPAP is unique in that it uses a multicomponent approach that aims to improve PA during all the aforementioned time periods using trained PA Leaders (PALS) to lead and organize school PA, staff involvement, in addition to family and community engagement.8 Because there is an abundance of research showing the potential benefits of optimal PA,1–3,27–29 agencies including the CDC and NASPE, developed the concept of CSPAP to achieve 3 primary goals: 1) Increase opportunities during the school day to increase MVPA for students, 2) Increase the number of minutes that students are required to participate in PE, and 3) Increase the number of students that participate in at least 60 minutes of PA daily.8 These goals were set to increase the health and well-being of children using a multifaceted approach during school PE, before and after school, and PA during school leisure times such as at lunch and at recess. Using CSPAP, physical activity breaks are also integrated into the classroom by taking several 5-minute breaks incorporating MVPA behaviors such as marching in place, jumping with an invisible rope, or taking walking laps around the classroom.8 Because of its relatively novel conceptual framework, there has been limited research specifically examining CSPAP thus far in the literature. Carson et al30 reported that a CSPAP intervention using trained PA leaders increased the number of PA offerings per school and, using accelerometers, showed that CSPAP schools had students spend significantly less time in sedentary behaviors during compared with schools that did not employ CSPAP. However, it was unclear whether CSPAP significantly increased PA over time
to improve heath outcomes. It was concluded that CSPAP blunted declines in MVPA and increases in sedentary behavior during school time. Another study was conducted by Vander Ploeg et al31 examining the effect of a Comprehensive School Health Program on pedometer-measured PA during and after school in a large cohort of 5th graders from Canada. The results from Vander Ploeg et al31 showed that the Comprehensive School Health program significantly increased average steps per day over a 2-year period after adjusting for gender and overweight status. The current study support these findings from Carson et al30 and Vander Ploeg et al31 using a younger sample of US students exclusively during school hours within an ITSD design. The results of this study clearly indicate that CSPAP intervention increased school day step counts and attenuated the decrease in step counts throughout the school week that were previously seen across preintervention time-points. An average increase of 1126 steps per school day was seen postintervention. This increase significantly increases the odds for a student achieving 12,000 steps per day recommended by various agencies and may roughly equate to an additional 10 minutes of MVPA per day if the additional activity was at least 100 steps per minute.41,42 The increase in steps is also similar to the average difference in step increases seen between the Comprehensive School Health and control schools found by Vander Ploeg et al31 where a mean difference of 1221 steps was displayed after adjusting for gender and overweight status. Although this increase was statistically significant, it is well below the proposed 2500 steps per day increase needed to manifest health benefits.42 Therefore, it is uncertain whether CSPAP can increase PA enough to improve health benefits over time. Because data collection took place only over a 1-week period during pre- and post intervention, it is inconclusive whether the increase seen in this study is adequately representative of all school day step counts during CSPAP. Despite this, an increase of approximately 1126 steps per day over time may still yield positive health benefits, but this needs to be supported by future research using clinical cardio-metabolic health markers. The slope of the postintervention time trend was not statistically significant, meaning on average, step counts were relatively stable throughout the week. However across preintervention time-points, there was a statistically significant time slope, therefore steps during preintervention tended to decrease per day across the school week. This is a novel finding in that not only can CSPAP increase average PA behaviors, but also attenuate the decline in PA seen over time. The decrease in step counts across preintervention time-points equate to an approximate decrease of 500 steps on Friday compared with Monday. If the trend consistently holds, this decrease over time may yield significant reductions in PA behaviors over the school year in the absence of effective school PA programming. There are limitations to this study that must be considered before the results can be generalized. First, PA was measured using step counts via pedometers. Despite being an objective measure of PA behaviors validated against heart rate monitoring and accelerometers, pedometer step counts do not provide any accurate information regarding the intensity of PA behaviors. Second, even though time trends were established across pre- and postintervention time-points for 1 school week, the long term efficacy of CSPAP needs to be further examined using prospective studies of longer duration. Third, there was no control group to compare the CSPAP intervention to. It was decided to be unethical to withhold CSPAP from some schools and not others; therefore having a true experimental design with clustered randomization was compromised. To address this, an ITSD design was implemented which is considered a valid research design
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to establish casual inference due to its prospective characteristics and multiple measurements across pre- and postintervention timepoints. Forth, preintervention and postintervention data collection was separated by several months. This was done to ensure time to fully implement the CSPAP intervention at each school, however PA behaviors between preintervention and postintervention time periods were not measured and may have provided additional time trend information. Finally, this study was conducted in 4 elementary school located in the southwest region of the US and was conducted in forth and fifth grade students; therefore the external validity of the results is questionable compared with schools in other regions of the US with different cultures and climates and compared with younger or older age cohorts. In conclusion, the CSPAP intervention increased average daily step counts and attenuated decreases in step counts as children progressed through the school week. The results support the efficacy of the CSPAP in increasing ambulatory PA behaviors in school-aged children. Future research needs to further examine CSPAP interventions using valid measures of PA intensity such as accelerometers and over longer time periods to establish the sustainability of CSPAP in children. Increasing PA behaviors in children is paramount to decrease the incidence of chronic disease as children track through youth and into adulthood. Interventions such as CSPAP show great potential to increase the health and wellbeing of children by increasing daily PA levels. Acknowledgments The authors would like the administrators, parents, teachers, and students who participated in this study.
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28. Taras H. Physical activity and student performance at school. J Sch Health. 2005;75:214–218. PubMed doi:10.1111/j.17461561.2005.00026.x 29. McNaughten D, Gabbard C. Physical exertion and immediate mental performance of sixth-grade children. Percept Mot Skills. 1993;77:1155–1159. PubMed doi:10.2466/pms.1993.77.3f.1155 30. Carson RL, Castelli DM, Pulling Kuhn AC, et al. Impact of trained champions of comprehensive school and sedentary behaviors. Prev Med. 2014;69(Suppl 1):S12–9. doi:10.1016/j.ypmed.2014.08.025. PubMed 31. Vander Ploeg KA, McGavock J, Maximova K, Veugelers PJ. Schoolbased health promotion and physical activity during and after school hours. Pediatrics. 2014;133:e371–e378. PubMed doi:10.1542/ peds.2013-2383 32. Hart TL, Brusseau T, Kulina PH, McClain JJ, Tudor-Locke C. Evaluation of low-cost objective instruments for assessing physical activity in 10-11 year old children. Res Q Exerc Sport. 2011;82:600–609. PubMed doi:10.1080/02701367.2011.10599796 33. McMinn D, Rowe D, Stark M, Nicol L. Validity of the new lifestyles NL-1000 accelerometer for measuring time spent in moderate-tovigorous physical activity in school settings. Meas Phys Educ Exerc Sci. 2012;14:67–78. doi:10.1080/10913671003715516 34. Darst PW, Pangrazi RP, Brusseau TA, Erwin H. Dynamic physical education for secondary school students. 8th ed. San Francisco, CA: Benjamin Cummings; 2015.
35. Pangrazi RP, Beighle A. Dynamic physical education for elementary school students. 17th ed. San Francisco, CA: Benjamin Cummings; 2012. 36. Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale, NJ: L. Erlbaum Associates; 1988. 37. Sallis JF, McKenzie TL, Alcaraz JE, Kolody B, Faucette N, Howell MF. Effects of a two-year health related physical education program (SPARK) on physical activity and fitness in elementary school children. Sports, Play, and Active Recreation for Kids. Am J Public Health. 1997;87:1328–1334. PubMed doi:10.2105/AJPH.87.8.1328 38. Stewart JA, Dennison DA, Kohl HW, III, Doyle JA. Exercise level and energy expenditure in the TAKE 10! in-class physical activity program. J Sch Health. 2004;74:397–400. PubMed doi:10.1111/j.1746-1561.2004.tb06605.x 39. Ernst MP, Pangrazi RP. Effects of physical activity program on children’s physical activity levels and attraction to physical activity. Pediatr Exerc Sci. 1999;11:393–405. 40. Luepker RV, Perry CL, McKinley SM, et al. Outcomes of a field trial to improve children’s dietary patterns and physical activity. The Child and Adolescent Trial for Cardiovascular Health. JAMA. 1996;275:768– 776. PubMed doi:10.1001/jama.1996.03530340032026 41. Colley RC, Janssen I, Tremblay MS. Daily step target to measure adherence to physical activity guidelines in children. Med Sci Sports Exerc. 2012;44:977–982. PubMed doi:10.1249/MSS.0b013e31823f23b1 42. Tudor-Locke C, Hatano Y, Pangrazi RP. Revisiting “How many Steps are Enough?”. Med Sci Sports Exerc. 2008;40(7, Suppl):S537–S543. PubMed doi:10.1249/MSS.0b013e31817c7133
JPAH Vol. 12, No. 12, 2015
ORIGINAL RESEARCH
Effect of a Comprehensive School Physical Activity Program on School Day Step Counts in Children Ryan D. Burns, Timothy A. Brusseau, and James C. Hannon Background: Comprehensive School Physical Activity Programming (CSPAP) has the potential to increase physical activity (PA) in children over time. The purpose of this study was to examine the effect of CSPAP on school day step counts in children. Methods: Participants were 327 fourth and fifth grade children recruited from 4 elementary schools. The study was conducted within an Interrupted Time-Series Design framework. School day step counts were collected for 5 days across preintervention and postintervention time-points (10 days total) using NL-1000 piezoelectric pedometers. Robust piecewise regression examined pre- and postintervention intercepts and slopes, and the change in these parameters using postestimation statistics. Results: The slope coefficient was statistically significant across preintervention (β = –105.23, P < .001) but not postintervention time-points (β = –63.23, P = .347), suggesting decreases in steps counts across preintervention and stability of step counts across postintervention school days. Postestimation statistics yielded increases in school day step counts from the end of preintervention (day 5) to the start of postintervention (day 6; t(319) = –4.72, P < .001, Cohen’s d = 4.72). Conclusions: The CSPAP intervention increased average school day step counts and attenuated decreases in step counts throughout the school week in children. Keywords: intervention study, physical education, public health
In children, optimal levels of physical activity (PA) have been linked to decreases in the risk factors of early onset chronic disease, improved academic performance, and increases in on-task behavior in the classroom.1–5 However, the majority of children in the US do not meet the recommended daily levels set by various agencies of 60 minutes of moderate-to-vigorous physical activity (MVPA).6,7 Recently, the Centers for Disease Control (CDC) and the National Association of Sport and Physical Education (NASPE) have suggested that one solution for the lack of childhood PA is Comprehensive School Physical Activity Programming (CSPAP).8 CSPAP is a multicomponent approach by which schools use all available opportunities for students to be physically active, meet the national recommendation of 60 minutes of MVPA per day, and develop the knowledge, skills, and confidence to be physically active for a lifetime.8 CSPAP has 5 components including quality physical education, physical activity during the school day (eg, recess and classroom PA), PA before and after school, staff involvement, and family and community engagement. Indeed, many schools implementing CSPAP aim to provide quality physical education curricula, increase in the opportunities for activity during recess, and to provide physical activity breaks in the classroom in order for children to increase healthy PA behaviors during the school day. Physical education (PE) is an academic subject that is the foundation for CSPAP.8 PE allows children the opportunity to achieve significant levels of PA behaviors within a defined curriculum. Approximately 84% of states (43) mandate PE in elementary schools where children can participate in structured programs.9–11 One of the primary objectives of PE is to promote health and reduce chronic disease risk by having at least 50% of class time engaged in MVPA behaviors, which may include moderate PA such as brisk walking and vigorous PA such as running jumping, skipping, and Burns ([email protected]) and Brusseau are with the Dept of Exercise and Sport Science, University of Utah, Salt Lake City, UT. Hannon is with the College of Physical Activity and Sport Sciences, West Virginia University, Morgantown, WV. 1536
climbing.10–13 PE programs are an important vehicle in promoting PA and fitness in children for improving concurrent health and wellbeing in addition to long-term health outcomes. Therefore, increasing children’s PA levels during PE classes is of upmost importance within the public health arena. Despite the opportunities for PE to aid in student achievement of optimal daily PA, many schools in the US have had PE time reduced on a per week basis or even eliminated in favor for academic subjects.14 Additionally, many elementary PE classes are taught by paraprofessionals with a lack of sufficient training in PE pedagogy, which may lead to decreases in the odds of students achieving sufficient amounts of MVPA.15 CSPAP addresses this issue by providing PE specialists and teachers with evidence-based curriculum designs to maximize MVPA during PE and to provide pedagogical guidance to help students achieve at least 50% of PE time in MVPA. CSPAP also provides evidence-based practice to increase children’s PA during leisure times such as recess.8 Leisure time represents a minor proportion of the school day, yet it is vital to help children participate in enjoyable active play that can increase daily PA levels. Leisure time allows students a break from academic classes, allows them time to socialize with their peers, and provides opportunities to engage in enjoyable active play.16,17 Recess has been shown to account from anywhere between 11% to 21% of total daily step counts and up to 40% of daily MVPA recommendations in children.18,19 Indeed, McKenzie et al20 found that recess had the greatest proportion of children engaged in MVPA compared with all other school day leisure times. Simple modifications including incorporating semistructured activities, providing additional equipment such as balls and hula-hoops, and adding playground markings have all shown to significantly increase children’s PA at recess.21–23 These methods to increase PA during recess are implemented in CSPAP schools.8 Finally, PA breaks in the classroom is the third area where CSPAP aims to increase school day PA levels. PA breaks in the academic classroom allow students to take a mental break from academic tasks. These breaks can occur at any time during the
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school day, last anywhere from 5 to 30 minutes, and can occur once or periodically throughout the school day. Bershwinger and Brusseau24 found that 10-minute activity breaks leads to an average increase of 1000 steps/day in children. Chaddock, Hillman, Buck, and Cohen25 found that even a short break from focused concentration allows the brain to consolidate information for better retention and retrieval of memory. Studies have also found that offering PA breaks during standard classroom instruction may have favorable associations with indicators of cognitive functioning (eg, attention/ concentration), academic behaviors (eg, classroom conduct), and academic achievement (eg, test scores).26–29 CSPAP interventions have shown to decrease total sedentary behaviors during the school day in children and adolescents,30,31 however the ability for CSPAP to increase PA over time has yet to be clearly established. In addition, even though there is great potential for CSPAP to increase PA in youth, limited research has examined the effect of CSPAP specifically in a large sample of elementary school-aged children. Finally, to develop valid conclusions from displayed PA behaviors, PA must be collected at several time-points during pre- and postintervention periods, not only assess the average change in step counts, but also to assess the stability of PA measurements over time. Therefore, the purpose of this study was to examine the effect of a CSPAP on children’s school day step counts over a school week. It was hypothesized that CSPAP would significantly increase children’s school day PA measured via step counts and attenuate any decrease in PA behaviors over a school week compared with when the schools employed traditional PA programming with a single component.
Methods Participants Students were recruited from 4 elementary schools located in the Southwestern United States. Each school implemented the comprehensive school-based PA intervention (CSPAP); therefore the study was quasi-experimental in its methodology. Participants included 327 students (n = 162 girls, n = 165 boys) from the fourth and fifth grades, having a mean age of 9.60 ± 1.75 years and were characterized by the following ethnic backgrounds: Caucasian (43%), Hispanic (44%), African-American (7%), Native American (4%), and Asian/Pacific Islander (2%). Approximately 56% of the sample received Free & Reduced Lunch. Written assent was obtained from the students and written consent was obtained from the parents before data collection. The University Institutional Review Board approved the protocols used in this study.
Instrumentation The NL-1000 piezoelectric pedometer (New-Lifestyles INC, Lee’s Summit, MO, USA) was used to measure PA by monitoring school day step counts. This pedometer has been validated for measuring PA (both step counts and MVPA) in the pediatric population.32,33 The NL-1000 detects step counts as well as the cumulative daily time (displayed in hours, minutes, and seconds) detected within the selected MVPA range, with a detailed description of MVPA function given in Hart et al.32 The NL-1000 allows for setting preferred intensity thresholds at any 1 of 9 levels. The pedometers were all worn on the right side of the body at the level of the iliac crest above the right knee. All pedometers were given an identification number and assigned to a student participant with the corresponding identifier. Students were instructed not to look at the pedometer’s
display monitor throughout the school day to avoid the potential for behavioral reactivity.
CSPAP Intervention The program’s primary focus was to provide training and assistance to improve PE. Specifically, regular in-service opportunities and teacher trainings were provided monthly to ensure that PE was guided by national PE/PA standards, was student-centered and developmentally appropriate, had a core focus on physical activity and motor skill development, taught management skills and promoted self-discipline, included all students, emphasized proper learning over outcome, promoted lifetime personal wellness, and taught responsibility and cooperation and promote diversity.34 The 2 major outcomes goals for physical education were physical activity and health. Furthermore, goals were set for teachers to get children to be active at least 50% of class time. PE in these schools was taught 2 days per week for 30 minutes per day and used a Dynamic Physical Education for Elementary School Children curriculum.35 Lessons typically included a short warm-up or instant activity followed by fitness time, skill practice, and game play. In addition to PE, schools offered PA opportunities at recess and integrated into lessons or classroom activity breaks. Recess offers an excellent opportunity for children to engage in free play or semistructured physical activity during the school day, and allows them to apply skills learned in PE. For this study, schools provided activity stations and recess staff strongly encouraged students to play in one of many semistructured activities or use the walking trails set up to “walk and talk” with friends. “No Parking Zones” were established to limit the number of students that would often sit or stand in certain playground locations. These schools offered a 20-minute recess immediately following lunch as well as a 15-minute afternoon recess. Lunch recess was semistructured with a series of games and activities. Afternoon recess was more informal and led by the classroom teacher, and equipment was available for teachers to use. Classroom teachers were encouraged to implement at least 2 or 3 5-minute activity breaks throughout the day. Examples of physical activity breaks in the classroom included: stretching or relaxation break, walking around the classroom or hallway, jumping with an invisible jump rope, doing squats, push-up, or sit-ups, and/ or passing a ball around the classroom.
Procedures Pedometer data collection took place on 5 consecutive school days (Monday through Friday) across preintervention and postintervention time-points (10 days total). Preintervention data collection took place in late September and postintervention data collection took place in early April, 6 months after the cessation of the CSPAP intervention. The participants’ parents completed a background questionnaire used to collect sample demographic information (ie, age, sex, race/ethnicity). Height (to the nearest 0.5 cm) and weight (to the nearest 0.1 kg) were directly measured on each student using a digital scale (Seca 882 Digital BMI Scale; Chino, CA, USA) and portable stadiometer (Seca 214; Chino, CA, USA). Across the 10 days (pre- and postintervention) of pedometer data collection, the research team was present to prompt students and provide instructions that complied with study protocol. Every morning at the beginning of the school day, students were prompted to place their monitor on the proper body location. At the end of each school day, students were prompted to remove their pedometers and hand them to their homeroom teachers. In addition, research team members actively provided prompts about correctly wearing the
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instrument. At the end of each school day, research team members recorded daily step count totals for each student. Research team members also scanned student responses each day and questioned children if data appeared unusual or if the student displayed extreme step count scores. Data were entered into an EXCEL spreadsheet daily to ensure data completeness and quality. If pedometers were lost, broken, or tampered with by a student participant, the respective student was not given another pedometer and was omitted from the study (< 1% of the sample). Finally, students participated in daily validation checks by completing a brief survey about their previous day’s PA. Survey question items required a yes or no response regarding if they wore their pedometer the entire day and if they removed the pedometer for any reason. The pedometer data collection process was repeated daily at each of the 4 schools. The aforementioned procedures supported the quality of the data collected in this sample of school-aged children.
Piecewise regression analysis was employed to examine the intercepts and slopes pre- and postintervention, separated by a breakpoint after day 5. Because of the clustering at the individual level (ie, times within each individual), the parameters from piecewise regression were estimated using a cluster option and the HuberWhite robust sandwich standard error estimator. This approach ensures the precision of the parameter estimates by adjusting for nonindependent data at the individual level. To test whether there were statistically significant differences between intercepts and slopes from piecewise regression from pre- to postintervention, postestimation analysis was employed using a linear combination of estimator test (lincom). Alpha level was set at P ≤ .05 and all analyses were carried out using STATA v13.0 statistical software package (College Station, TX, USA).
Statistical Analyses
Initial screening of the data showed several potential outliers based on z-scores (+3.0z) and moderate positive skewness using k-density plots. After removal of the outliers, the k-density plots approximated a Gaussian distribution for preintervention and postintervention daily step counts. Figure 1 and Figure 2 visually show the distribution pre- and postintervention average daily step counts across age cohorts and between sexes, respectively. Factorial ANOVA with repeated measures showed statistically significant main effects for sex [F(1, 318) = 14.44, P < .001] and time [F(319) = 39.69, P < .001], with boys, on average, displaying greater step counts than girls (Mean Δ Boys – Girls = 1144.79, Cohen’s d = 0.56) and postintervention, on average, displaying greater daily step counts than preintervention (Mean Δ Post – Pre = 1126.32, Cohen’s d = 0.58). There was no statistically significant main effect for age [F(2, 317) = 0.26, P = .77] and no interaction between any of the factors. Table 1 shows the results from piecewise regression analysis displaying the pre- and postintervention coefficient estimates for the intercepts and slopes. Figure 3 is a scatterplot with lines of best fit across pre- and postintervention time-points separated by a breakpoint after day 5. Intercept coefficients across both pre- and
Data were initially screened for outliers using boxplots and z-scores and normality was checked on daily pre- and postintervention step counts using k-density plots and the Shapiro-Wilk test for normality. Preliminary analysis included a 2×2×2 Factorial ANOVA test with repeated measures to examine the effect of age, sex, and time on daily averaged step counts. Age and sex were between-subject factors and time (preintervention, postintervention) was the within subject factor. Effect sizes were calculated using Cohen’s d with 0.2 interpreted as a small, 0.5 as a medium, and 0.8 as a large effect size.36 The primary analysis was conducted within an Interrupted Time Series Design (ITSD) quasi-experimental framework with the time-series disturbance being the intervention implemented after day 5. Preintervention time points were days 1–5 and postintervention time-points were days 6–10. Within ITSD designs, the stability of the outcome variable can be assessed pre- and postintervention via the slope of the time coefficient, and the averaged change in the outcome can be assessed via the change in the intercept coefficients from the end of preintervention to the start of postintervention.
Results
Figure 1 — Average daily step counts pre- and postintervention across age cohorts (Mean ± Standard Deviation). JPAH Vol. 12, No. 12, 2015
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Figure 2 — Average daily step counts pre- and postintervention for girls and boys (Mean ± Standard Deviation).
Table 1 Piecewise Regression Intercepts and Slope Parameter Estimates Pre- and Postintervention Using the Robust Sandwich Estimator (Dependent Variable = Daily Step Counts) β coefficient
Huber-White Standard Error
95% CI
P-valuea
Intercept preintervention
3263.02
100.60
3065.75, 3460.29
< 0.001
Intercept postintervention
4424.08
224.49
3983.87, 4864.28
< 0.001
Time slope preintervention
–105.23
41.44
–186.51, –23.96
0.011
Time slope postintervention
–63.23
67.29
–195.18, 68.72
0.347
Abbreviations: 95% CI, 95% Confidence Interval. a Alpha level set at P ≤ .05.
Figure 3 — Scatterplot with predicted linear fit lines pre- and postintervention separated by a breakpoint after day 5. JPAH Vol. 12, No. 12, 2015
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postintervention time-points were statistically significant (P < .001). The slope coefficient was statistically significant across preintervention time-points (P = .011) but not statistically significant across postintervention time-points (P = .347). Postestimation lincom tests yielded statistically significant differences between the end of preintervention and the start of postintervention (t(319) = –4.72, P < .001, Cohen’s d = 4.72), but no statistically significant differences were found between the preintervention and postintervention slope coefficients (t(319) = –0.53, P = .595, Cohen’s d = 0.53).
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Discussion The purpose of this study was to examine the effect of CSPAP on school day steps counts in elementary school-aged children from the forth and fifth grades. The results indicate that CSPAP increased averaged daily step counts from the end of preintervention to the start of postintervention, increased overall average daily step counts, and attenuated decreases in steps counts as children progressed through the school week. This is the first study examining the efficacy of CSPAP in a large sample of elementary school-aged children and the first study examining the effect of CSPAP on PA trends over a school week using pedometer step counts. It is evident that CSPAP increased PA levels, however the efficacy of the intervention in sustaining elevated PA behaviors over longer periods of time needs to be supported with additional research. As stated previously, optimizing PA behaviors is important in children not only to decrease the risk factors for early onset chronic disease but to also optimize learning and to improve on-task behaviors in the classroom.1–3,27–29 There have been several schoolbased PA interventions developed to increase PA in children. These interventions include the Sports, Play, and Active Recreation for Kids (SPARK), TAKE 10!, Promoting Lifetime Activity for Youth (PLAY), and the Coordinated Approach to Child Heath (CATCH) among others.36–40 Many of these interventions are limited in scope to specific time periods such as during PE, leisure times, classroom breaks, or during after school programs. CSPAP is unique in that it uses a multicomponent approach that aims to improve PA during all the aforementioned time periods using trained PA Leaders (PALS) to lead and organize school PA, staff involvement, in addition to family and community engagement.8 Because there is an abundance of research showing the potential benefits of optimal PA,1–3,27–29 agencies including the CDC and NASPE, developed the concept of CSPAP to achieve 3 primary goals: 1) Increase opportunities during the school day to increase MVPA for students, 2) Increase the number of minutes that students are required to participate in PE, and 3) Increase the number of students that participate in at least 60 minutes of PA daily.8 These goals were set to increase the health and well-being of children using a multifaceted approach during school PE, before and after school, and PA during school leisure times such as at lunch and at recess. Using CSPAP, physical activity breaks are also integrated into the classroom by taking several 5-minute breaks incorporating MVPA behaviors such as marching in place, jumping with an invisible rope, or taking walking laps around the classroom.8 Because of its relatively novel conceptual framework, there has been limited research specifically examining CSPAP thus far in the literature. Carson et al30 reported that a CSPAP intervention using trained PA leaders increased the number of PA offerings per school and, using accelerometers, showed that CSPAP schools had students spend significantly less time in sedentary behaviors during compared with schools that did not employ CSPAP. However, it was unclear whether CSPAP significantly increased PA over time
to improve heath outcomes. It was concluded that CSPAP blunted declines in MVPA and increases in sedentary behavior during school time. Another study was conducted by Vander Ploeg et al31 examining the effect of a Comprehensive School Health Program on pedometer-measured PA during and after school in a large cohort of 5th graders from Canada. The results from Vander Ploeg et al31 showed that the Comprehensive School Health program significantly increased average steps per day over a 2-year period after adjusting for gender and overweight status. The current study support these findings from Carson et al30 and Vander Ploeg et al31 using a younger sample of US students exclusively during school hours within an ITSD design. The results of this study clearly indicate that CSPAP intervention increased school day step counts and attenuated the decrease in step counts throughout the school week that were previously seen across preintervention time-points. An average increase of 1126 steps per school day was seen postintervention. This increase significantly increases the odds for a student achieving 12,000 steps per day recommended by various agencies and may roughly equate to an additional 10 minutes of MVPA per day if the additional activity was at least 100 steps per minute.41,42 The increase in steps is also similar to the average difference in step increases seen between the Comprehensive School Health and control schools found by Vander Ploeg et al31 where a mean difference of 1221 steps was displayed after adjusting for gender and overweight status. Although this increase was statistically significant, it is well below the proposed 2500 steps per day increase needed to manifest health benefits.42 Therefore, it is uncertain whether CSPAP can increase PA enough to improve health benefits over time. Because data collection took place only over a 1-week period during pre- and post intervention, it is inconclusive whether the increase seen in this study is adequately representative of all school day step counts during CSPAP. Despite this, an increase of approximately 1126 steps per day over time may still yield positive health benefits, but this needs to be supported by future research using clinical cardio-metabolic health markers. The slope of the postintervention time trend was not statistically significant, meaning on average, step counts were relatively stable throughout the week. However across preintervention time-points, there was a statistically significant time slope, therefore steps during preintervention tended to decrease per day across the school week. This is a novel finding in that not only can CSPAP increase average PA behaviors, but also attenuate the decline in PA seen over time. The decrease in step counts across preintervention time-points equate to an approximate decrease of 500 steps on Friday compared with Monday. If the trend consistently holds, this decrease over time may yield significant reductions in PA behaviors over the school year in the absence of effective school PA programming. There are limitations to this study that must be considered before the results can be generalized. First, PA was measured using step counts via pedometers. Despite being an objective measure of PA behaviors validated against heart rate monitoring and accelerometers, pedometer step counts do not provide any accurate information regarding the intensity of PA behaviors. Second, even though time trends were established across pre- and postintervention time-points for 1 school week, the long term efficacy of CSPAP needs to be further examined using prospective studies of longer duration. Third, there was no control group to compare the CSPAP intervention to. It was decided to be unethical to withhold CSPAP from some schools and not others; therefore having a true experimental design with clustered randomization was compromised. To address this, an ITSD design was implemented which is considered a valid research design
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to establish casual inference due to its prospective characteristics and multiple measurements across pre- and postintervention timepoints. Forth, preintervention and postintervention data collection was separated by several months. This was done to ensure time to fully implement the CSPAP intervention at each school, however PA behaviors between preintervention and postintervention time periods were not measured and may have provided additional time trend information. Finally, this study was conducted in 4 elementary school located in the southwest region of the US and was conducted in forth and fifth grade students; therefore the external validity of the results is questionable compared with schools in other regions of the US with different cultures and climates and compared with younger or older age cohorts. In conclusion, the CSPAP intervention increased average daily step counts and attenuated decreases in step counts as children progressed through the school week. The results support the efficacy of the CSPAP in increasing ambulatory PA behaviors in school-aged children. Future research needs to further examine CSPAP interventions using valid measures of PA intensity such as accelerometers and over longer time periods to establish the sustainability of CSPAP in children. Increasing PA behaviors in children is paramount to decrease the incidence of chronic disease as children track through youth and into adulthood. Interventions such as CSPAP show great potential to increase the health and wellbeing of children by increasing daily PA levels. Acknowledgments The authors would like the administrators, parents, teachers, and students who participated in this study.
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