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PACE: A group randomised controlled trial to increase children's break-time playground physical activity
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Original research
PACE: A group randomised controlled trial to increase children’s break-time playground physical activity Anne-Maree Parrish a,c,∗ , Anthony D. Okely a,c , Marijka Batterham b,c , Dylan Cliff a,c , Christopher Magee a,d a
Faculty of Social Sciences, University of Wollongong, Australia Mathematics and Applied Statistics, University of Wollongong, Australia c Interdisciplinary Educational Research Institute, University of Wollongong, Australia d Centre for Health Initiatives, University of Wollongong, Australia b
a r t i c l e
i n f o
Article history: Received 13 November 2014 Received in revised form 2 April 2015 Accepted 22 April 2015 Available online xxx Keywords: Schools Recess Lunch Policy Equipment Play
a b s t r a c t Objectives: To assess the effect of a school playground intervention on the physical activity levels of primary/elementary aged children. Design: Two-arm parallel group randomized controlled trial. Methods: In 2011, children aged 4–13 years from thirteen primary/elementary schools (in Illawarra, New South Wales, Australia) were invited to participate in the study. School recruitment was based on existing policies, equipment and willingness to participate. Participating schools were randomly allocated to the intervention or control using the ‘hat and draw’ method. The intervention was delivered over four months. Intervention schools introduced policy changes and portable equipment to break-time after baseline measures were collected. The primary outcome was the proportion of break-time spent in Moderate to Vigorous Physical Activity (MVPA) assessed by the System for Observing Playground Activity in Youth (SOPLAY). The analysis involved linear mixed models adjusting for the clustering effect of schools. The study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614001128684). Results: Four schools (two intervention and two control) met the inclusion criteria (1582 children: 790 males; 267 controls, total of 792 females; 248 controls). Students from the intervention schools had a greater increase at follow-up in the proportion of break-time in MVPA; (adjusted difference = 12.5 percentage points, 95% CI [−13.0%, 38.0%]; P = 0.17; r = 0.6) compared to the controls. MVPA at recess significantly increased (adjusted difference = 18.0 percentage points, 95% CI [6.9%, 29.1%]; P = 0.02; effect size = 0.7). There were no significant increases in MVPA when examining overall break times. Results were greater for girls compared to boys. Conclusions: Making environmental and policy changes are promising strategies for promoting healthenhancing physical activity during school break-time. © 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
1. Introduction Due to established health benefits,1 international recommendations specify that children should accumulate 60 min of physical activity daily.2 However, children spend large portions of their day being sedentary,3 with sedentary past-times in the home environment further jeopardizing children’s physical activity levels.4 The prevalence of sufficient physical activity in children is low in many countries, and research suggests interventions should target
∗ Corresponding author. E-mail address: [email protected] (A.-M. Parrish).
various levels of influence including the home, school and community settings.5 The school environment is ideal for the promotion of physical activity as it is a medium that reaches the majority of the population in most countries.6 Pressures to meet curricular targets can limit class time opportunities for physical activity however school break-times have the potential to contribute up to 40% of children’s recommended daily physical activity, making it an ideal setting for physical activity promotion.7 Evidence suggests an association between children’s school break time physical activity, the introduction of portable equipment (e.g. balls, ropes, hoops), and the potential for policy to influence children’s school break time physical activity levels.7–9
http://dx.doi.org/10.1016/j.jsams.2015.04.017 1440-2440/© 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Parrish A-M, et al. PACE: A group randomised controlled trial to increase children’s break-time playground physical activity. J Sci Med Sport (2015), http://dx.doi.org/10.1016/j.jsams.2015.04.017
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However few interventions have investigated the effect of environmental and policy interventions on children’s school playground physical activity levels.8 Some school break time policies, such as ‘no hat no play’ (The term ‘no hat no play’ refers to a policy in most Australian primary/elementary schools where children are required to wear a hat at school during break times for sun protection and if they forget their hat they are required to sit for the length of the break-time as punishment) and compulsory breaktime sitting periods, may negatively influence children’s break time physical activity. This study assessed the effect of an intervention which modified the physical school playground environment and implemented policy changes in order to increase break-time physical activity levels among primary/elementary school children.
2. Methods The reporting of this study is according to the CONSORT guidelines.10 It is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614001128684). It was funded by a University Faculty grant. The study was a cluster randomized trial, using a nested cohort design called Physical Activity Children and the Environment (PACE). Thirteen Catholic primary/elementary schools within the Illawarra region of New South Wales, Australia were approached to participate in the study. The study was limited to a maximum of four schools due to funding. There were no changes to the study methods after trial commencement. Permission to conduct the study was gained through the Wollongong Catholic Education office and from principals at each school. The study received ethical approval from the Human Ethics Research Committee (HE11/124). Schools were recruited based on existing policies, equipment and their willingness to be involved in the study (including to be randomized). This was established during the first contact with the school principal. To be involved in the study children at the schools had limited access to portable equipment, restricted access to larger playground areas, compulsory break sitting time and a ‘no hat no play’ policy. Recruitment of the schools occurred in June 2011. Passive consent was gained from the students at all four schools to assess observational playground physical activity data.11 Data were collected within each school setting. The intervention schools implemented a multi-component intervention: involving physical and policy changes to the school playground environment to promote break time physical activity. The intervention duration was 4 months. Baseline data were collected to accommodate school schedules at the end of Term 2 during the week commencing the 10th of June 2011 and 22nd of July 2011 at the start of Term 3. Follow-up data were collected in November 2011. The first author recruited the schools and liaised with each school principal. A school staff member was nominated as a liaison for the research staff and assisted the implementation of the intervention. The first author developed the randomisation sequence, following baseline measurements. Schools were randomized to either the intervention or control group by having an independent person draw folded pieces of paper with the schools codes on them from a hat. The research assistants were blinded but the environmental changes in the school meant they may have been aware of allocation. For ethical reasons and to minimize bias results from compensatory rivalry and resentful demoralization, the PACE intervention was offered to the control schools at the completion of post-intervention assessment (i.e., wait-list control) (supplementary Fig. 1). The intervention schools received identical sets of mixed portable equipment (valued at $800 AUD), including: 10 soccer balls, 10 rugby balls, 10 basketballs, 20 large rubber balls, 80 small bouncy balls, 35 skipping ropes, 45 hoops, two cricket sets and 18
catch cups (cup on a stick, with a long string and ball attached). It was supplied to them after baseline data collection and waitlisted to the control schools after follow up data collection. Schools decided how the equipment was distributed. One school allowed children to take equipment from a classroom tub prior to exiting for the break, the other made equipment available via access to equipment bins freely available in the playground during the break. Intervention schools were encouraged to participate in the following policy changes after baseline data was collected: a maximum 5 min sitting period at recess and 10 min at lunch, a minimum 5 min extension of each break period, a revision of each schools policies to encourage maximum access to sporting fields during break times and the introduction of a ‘no hat, play in the shade’ policy (as an alternative to ‘no hat, no play’). All of the schools in the study had large outdoor undercover play areas designed for weather protection. The fidelity of the intervention was monitored between baseline and follow-up data collection. A total of six process evaluations were conducted (at both the intervention and control schools) monitoring: the use of portable equipment, whether students had free access to the equipment, whether teachers were organising games at break-times and whether break time policy changes were being implemented. The primary outcome for the study was the proportion of time spent in MVPA (Moderate to Vigorous Physical Activity). Physical activity and area contextual characteristics (accessibility, usability, supervision, organized activities and equipment) were assessed via direct observation of school playgrounds using the validated System for Observing Play and Leisure Activity in Youth instrument (SOPLAY).11 SOPLAY is an objective momentary time sampling observational instrument, where observers scan a predetermined area of the school playground to determine the physical activity level of the children and to record playground characteristics.12 The playground was assessed, measured and segmented prior to the commencement of the scanning process. Observers agreed upon the size, area and boundaries of each area and recorded them on a school map. Each observer carried and referred to a copy of the segmented map during the break period. Two observers separately rotated around the school playground area moving to a new section every 10 min. The observers continuously scanned each area (from left to right) alternating between males and females until the break time was finished or until they moved to another section of the playground. The physical activity levels of the children are coded during each scan as either sedentary (e.g. lying down, sitting, or standing), walking or vigorous.13 MVPA was determined by summing the walking and vigorous categories.11 Student activity was recorded at a rate of approximately one child per second.13 Scanning took place on three school weekdays. Six observers were trained to use SOPLAY during an all-day training session at one school in the Illawarra region. To assess the reliability of the observer’s use of the SOPLAY instrument at the end of the training session, spearman correlation coefficients were calculated against the gold standard video. There were significant correlations between the observers scans and the gold standard ranging from r = 0.83 to r = 0.97, p < 0.001. Inter-rater reliability was assessed at baseline and follow-up (in the school environment) using Spearman’s correlations coefficients. There were significant correlations between the observers r = 0.77 and r = 0.97, p < 0.001. At the end of the study an anonymous teacher evaluation and reply paid envelope was placed in each teacher’s school internal mail box at the schools involved in the study. Teachers were asked to rank their responses using a five point Likert scale (1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, 5 = strongly disagree). The teachers were asked if they felt the research was conducted in a manner that was mindful of school activities and routines. Teachers were also asked if they believed that the following changes to policy
Please cite this article in press as: Parrish A-M, et al. PACE: A group randomised controlled trial to increase children’s break-time playground physical activity. J Sci Med Sport (2015), http://dx.doi.org/10.1016/j.jsams.2015.04.017
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Table 1 School details.
Intervention A Intervention B Control C Control D
IRSAD
IRSAD Ranking within the Illawarra
Student numbers
First break
Time in minutes
Second break
Time in minutes
Total time In minutes
943 880 988 1002
19 8 32 35
N = 576 (276 boys) N = 314 (158 boys) N = 303 (151 boys) N = 388 (205 boys)
10.30–11.00 11.20–12.10 10.30–11.00 11–11.15
30 50 30 15
1.00–1.40 1.40–2.05 1.00–1.40 12.50–1.50
40 25 40 60
70 75 70 75
Note: Australian Bureau of Statistics Index of Relative Socio-economic Advantage and Disadvantage (IRSAD) in Illawarra suburbs. The average IRSAD value is 1000. A lower score indicates that an area is relatively disadvantaged compared to an area with a higher score. Therefore, in the rankings below, the suburb with the number one ranking is considered to be the most disadvantaged.
would benefit children’s playground activity levels: a maximum 5 min of sitting time at recess, a maximum 10 min of sitting time at lunch, a minimum 5 min extension of the recess and lunch break, the introduction of a ‘no hat play in the shade’ policy and increasing access to sporting fields. When analysing children’s physical activity using SOPLAY, data is commonly reported as proportion of time spent in MVPA, as schools often have varying break time durations.11 This study was designed and analysed as a nested cross-sectional study with a pre to post-test control group design. To account for the clustered (or nested) nature of the data within each school the data was analysed using a linear mixed model (PROC MIXED in SAS V 9.2, SAS Inc Cary NC),14 where treatment group within school was modelled as a random effect. The analysis adjusted for differences between schools at baseline. Effect sizes were calculated using an adjustment of the methods proposed by Hedges (2007). The alpha level was 0.05. 3. Results Four of thirteen schools agreed to participate in the study, which included 1582 children aged 4 to 13 years (kindergarten to year 6) (M = 790; 267 controls F = 792; 248 controls). Observations did not proceed during inclement weather; if the weather prevented play, observations were rescheduled for a later date. Average daily temperatures during June and July were approximately 18 ◦ C and average monthly rainfall was 97.5 mm. Follow-up data collection was in November, average temperatures were 23 ◦ C with an average monthly rainfall of 115.6 mm. There were two breaks during each of the schools day. Three schools had a shorter break followed by a longer break. One of the intervention schools had a longer break followed by a shorter break. For the purpose of analysis and findings the shorter break will be referred to as recess and the longer breaks as lunch. The breaks totalled 70 min at schools A and C and schools B and D had 75 min of total break-time (Table 1). Neither of the intervention schools demonstrated an extension of the break times at post intervention, however Intervention school P removed the 10 min sitting time at recess so that children could play immediately and changed the lunch time policy from a compulsory 10 min sitting time to a 5 min compulsory (or when finished eating) sitting time. Intervention school J removed the 10 min sitting time at recess (it should be noted that this change
was not always consistent from anecdotal evidence in discussions with teaching staff) and had a 10 min compulsory sitting time at lunch. Both schools instigated a ‘no hat play in the shade’ policy and increased access to sporting fields. Process evaluation of the intervention schools indicated that the portable equipment was being utilised in the playground during recess and lunch. Teachers were not seen to be organising playground games, the policy changes were implemented as described. Monitoring of the control schools indicated that one of the schools provided a limited amount of their own equipment to students, students brought their own small balls at the other control school, teachers were not seen to be organising playground games nor had they made any of the policy changes proposed in this study. Whilst the ‘no hat, play in the shade’ policies were seen to be implemented, it should be noted that there were limited numbers of students without hats (one or two students). This seemed to be an average number of students at each observation of the schools in the study. There were a total of 90 teachers at the four schools involved in the study. Which included all permanent part-time and full-time staff. Twenty four teachers completed the teacher evaluation (Response rate of 0.266). Teacher responses are summarized in the supplementary table (Table 2). Tables 3 and 4 show the changes in the proportion of time spent in MVPA for the intervention and control schools at baseline and follow-up. Effect sizes indicate small to medium benefits for MVPA in both boys and girls. These were statistically significant for recess (p = 0.02) and approached statistical significance for the girls combined recess and lunch time break (p = 0.06) (Tables 3 and 4). Overall boys were more physically active than girls, a result commonly reflected in the Literature.7 For boys and girls percent MVPA increased by 13 percentage points at recess and 9.4 percentage points at lunch for the intervention schools (Table 3). MVPA decreased by 4.9 percentage points at recess and remained constant at lunch in the control schools (Table 3). 4. Discussion This study aimed to investigate the intervention effect of introducing portable equipment and policy changes to the school environment to increase children’s physical activity during recess and lunch breaks after a three or five month follow-up period. Children spent approximately 50% of their break-time in MVPA prior to
Table 2 Teacher evaluation responses (PACE data 2012).
The study was conducted in a way that was mindful of school activities and routines A maximum of 5 min sitting at recess would benefit children’s activity levels A maximum of 10 min sitting at lunch would benefit children’s activity levels A minimum 5 min extension of the recess and lunch break would benefit children’s activity levels Introducing ‘no hat, play in the shade’ would benefit children’s activity levels Increasing access to sporting fields would benefit children’s activity levels
% Agree/strongly agree
% Neutral
% Disagree or strongly disagree
% No response
100 (N = 24)
0
0
0
62.5 (N = 15) 95.8 (N = 23) 45.8 (N = 11)
16.7 (N = 4) 0 8.3 (N = 2)
16.7 (N = 4) 0 41.7 (N = 10)
4.2 (N = 1) 4.2 (N = 1) 4.2 (N = 1)
66.7 (N = 16) 75 (N = 18)
4.2 (N = 1) 16.7 (N = 4)
25 (N = 6) 4.2 (N = 1)
4.2 (N = 1) 4.2 (N = 1)
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Table 3 Changes in the percentage of time spent in MVPA for recess (morning break) and lunch.
% MVPA recess
% Sedentary recess
% MVPA lunch
% Sedentary lunch
Gender
Baseline intervention mean (+SD)
Control mean (+SD)
Follow-up intervention mean(+SD)
Control mean (+SD)
Adjusted difference 95%CI
Padj
Effect size
Boys Girls Boys and Girls Boys Girls Boys and Girls Boys Girls Boys and Girls Boys Girls Boys and Girls
66.2(0.033) 49.4(0.056) 55.4(0.026) 33.8(0.033) 50.6(0.056) 44.6(0.026) 61.4(0.041) 41.0(0.071) 48.9(0.055) 38.6(0.041) 59.0(0.071) 51.1(0.055)
52.0(0.034) 42.7(0.056) 45.7(0.027) 48.0(0.034) 57.3(0.056) 54.3(0.027) 52.0(0.041) 44.2(0.071) 49.2(0.055) 48.0(0.041) 55.8(0.071) 50.8(0.055)
73.6(0.033) 62.1(0.055) 68.5(0.026) 26.4(0.033) 37.9(0.055) 31.5(0.026) 73.1(0.041) 50.4(0.071) 62.5(0.055) 26.9(0.041) 49.6(0.071) 37.5(0.055)
45.8(0.032) 37.8(0.055) 40.8(0.026) 54.2(0.032) 62.2(0.055) 59.2(0.026) 56.8(0.040) 44.6(0.070) 53.8(0.054) 43.2(0.040) 55.4(0.070) 46.2(0.054)
0.136(−0.070,0.341) 0.177(−0.156,0.509) 0.180(0.069,0.291) −0.136(−0.341,0.070) −0.177(−0.509,0.156) −0.180(0.069,0.291) 0.068(−0.413,0.550) 0.091(−0.100,0.281) 0.090(−0.255,0.436) −0.068(−0.550,0.413) −0.091(−0.281,0.100) −0.090(−0.436,0.255)
0.105 0.150 0.020 0.105 0.150 0.020 0.604 0.177 0.378 0.604 0.177 0.378
0.407 0.581 0.716 −0.407 −0.581 −0.716 0.212 0.432 0.499 −0.212 −0.432 −0.499
MVPA, moderate-to-vigorous physical activity (% walking plus % vigorous).
the intervention, indicating a potential to make realistic changes to school environments to increase children’s physical activity levels. While few interventions assess the introduction of portable equipment to promote school break time MVPA, Verstrate9 found a significant increase in children’s MVPA during recess as a result of introducing games equipment. Loucaides15 found a significant increase in children’s steps after court rotation, playground markings and jump ropes were introduced. Ridger’s et al16,17 used two mixed methods interventions to investigate the effect of playground markings, colour coded areas and portable equipment on children’s break time MVPA with small but non-significant increases. In the current study, children in the intervention and control groups spent 52% and 48% of their break time in MVPA at baseline respectively, increasing by 13.6 percentage points at the intervention schools and one percentage point at the control schools (see Table 4). Introducing portable equipment and policy changes appears to be a potentially efficacious approach for increasing children’s school break time MVPA. The results from the intervention were surprising as a nonsignificant but large effect size was observed for girls at recess. Possibly changes introduced as part of this intervention could benefit girls. Boys often dominate open spaces in the playground and are involved in ball play, whilst girls remain on the outer edge socializing.18 Policy changes such as the removal of forced sitting time at the start of recess may promote activity from the outset for girls, removing the inclination to sit and talk for the entire recess period. In addition, possibly the type of portable equipment (e.g., ropes, catch cups, hoops) introduced as part of the intervention appealed more to girls than boys. There was not a significant change in boy’s physical activity during the lunch break, which may reflect the way that boys normally play when they have access to larger sporting fields during the lunch break period (e.g. providing opportunities for activities such as football). The use of portable equipment is the most frequently reported variable which has positively impacting break-time physical activity.7,8 If schools chose to introduce portable equipment to the
playground setting, policies affecting the way that it is introduced could potentially impact break-time physical activity. Free access to portable equipment during the entire break may be more likely to promote activity than restricted access (where students must chose a piece of equipment at the start of lunch from a classroom box without the opportunity to revisit the box during the break time).19 Ongoing maintenance of portable equipment can also promote long term problems for schools as equipment can be lost or broken. It is recommended that schools are given budgets to not only provide for the purchase of physical education equipment but the availability and maintenance of portable equipment for break time use. Whilst the findings in this study and the broader literature indicate that the introduction of portable equipment shows potential for increasing students school break time MVPA, few studies have investigated changes to school policy as a means of increasing break time physical activity7 . It is possible that small feasible changes to policies during the school day have the potential to increase children’s physical activity levels. To date primary schools in Australia have been reasonably successful at implementing sun safe policies which encourage the use of hats while outdoors.20 Unfortunately these policies have often involved a ‘no hat no play’ rule as a disincentive for children who forget their hats.21 Such a measure may be counterintuitive for children’s overall health. While reducing sun exposure through the use of hats may decrease the potential for skin cancer; punishing children by stopping them from playing impacts physical activity and ironically increases the risk of other forms of cancer.22 Feasible changes to policy such as ‘no hat, play in the shade’ instead of ‘no hat, no play’ may still act as a punishment whilst preventing children from being sedentary. One third of teachers responding to the evaluation believed allowing children to play in the shade would not increase children’s activity levels. This is a little surprising, however the teachers may believe leniency around policies requiring children to wear hats may result in more children forgetting to bring their hats, as the ‘no hat no play’ policy can be very effective in encouraging hat wearing.23 If schools
Table 4 Changes in the percentage of time spent in MVPA at recess and lunch combined. Activity
Gender
Baseline intervention mean (+SD)
Control mean (+SD)
Follow-up intervention mean (+SD)
Control mean (+SD)
Adjusted difference 95%CI
Padj
Effect size
% MVPA
Boys Girls Boys and Girls Boys Girls Boys and Girls
63.2(0.017) 44.4(0.048) 52.0(0.035) 36.8(0.017) 55.6(0.048) 48.0(0.035)
52.8(0.017) 43.4(0.049) 48.0(0.035) 48.2(0.017) 56.6(0.049) 52.0(0.035)
72.7(0.017) 56.0(0.048) 65.6(0.035) 27.3(0.017) 44.0(0.048) 34.4(0.035)
53.0(0.015) 42.1(0.049) 49.1(0.034) 47.0(0.015) 57.9(0.048) 50.9(0.034)
0.085(−0.059,0.228) 0.129(−0.021,0.279) 0.125(−0.130,0.380) −0.085(−0.226,0.059) −0.129(−0.279,0.021) −0.125(−0.380,0.130)
0.128 0.066 0.170 0.128 0.066 0.170
0.298 0.482 0.584 −0.298 −0.482 −0.584
% Sedentary
MVPA, moderate-to-vigorous physical activity (% walking plus % vigorous).
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ensure students wear hats for sun protection, playing in the shade is a suitable alternative to ‘no hat no play’. Further feasible policy changes may impact the amount of time children have to play. In some schools students are required to sit for lengthy periods of time to eat their recess and lunch. Schools should resist employing compulsory sitting time policies during the shorter recess break in particular. Often snack foods eaten at recess, such as apples or bananas, can be easily consumed whilst walking around and children can still sit if they choose. In addition, in many Australian Primary schools children are allowed to drink water and eat fruit and vegetables (known as ‘Munch and Crunch’)24 during class times prior to the recess break. If children have the opportunity to eat whilst in class, this could allow more time for activity during break times’. This type of practice not only benefits children’s nutrition, but could allow for uninterrupted play at recess. Whilst there may be some concern about children properly consuming their lunch, often older children finish their lunch quickly and are required to sit waiting until the elicited time frame or until those in younger years have finished. Reductions or reassessment of compulsory sitting time could potentially impact children’s physical activity levels and allow them to be properly nourished. Conklin et al25 found that on average children take seven to 10 min to eat their lunch. Using evidence to guide policy could result in appropriately timed compulsory sitting time. Revising the length of compulsory sitting time for all children, may allow many children to finish their lunch and have the potential for a greater period of time to be active. Ensuring children have access to larger sporting fields offers the potential to encourage more opportunities for physical activity, particularly for children who prefer ball games.26 In some instances schools limit access to sporting fields because of the time it takes to get to them. Reducing compulsory sitting time may also provide the extra time needed to get to the fields. In all the teacher evaluations, the intervention procedures were acceptable for all respondents, an encouraging response supporting the intervention changes. However, only half of the teachers believed restricting students recess to 5 min sitting time would benefit children’s physical activity levels. These findings were indicative of some inconsistencies in the implementation of the intervention policy changes at intervention school J during recess sitting time, however most teachers supported the maximum 10 min sitting time at lunch. Teachers may be concerned children will not eat all of their recess or lunch if they are not required to sit to eat. Dr Golley suggests parents provide more portable snacks allowing them to eat and move27 . In all this study demonstrates the potential for small changes to school policy and feasible additions of portable equipment to contribute to children’s overall physical activity levels at a population level. There were, however, some limitations associated with this study. The study findings may have been limited by the modest response to the teacher survey and could reflect the findings of those interested in the study. Whilst the study findings indicate the introduction of portable equipment and policy changes increases children’s school break time MVPA the study is limited by the number of schools involved in the study, the findings would be more generalizable in a larger randomized controlled trial. There is a potential for observer bias when using the SOPLAY instrument. In an effort to avoid bias only one observer knew which schools were the intervention schools and which were the controls. However, the observers may have noticed more equipment in the playground of the intervention schools during the recess break. The SOPLAY instrument labels sedentary time as sedentary (e.g. lying down, sitting, or standing). More current definitions of sedentary behaviour do not include standing and refer to any behaviour where the individual is sitting or reclining (<1.5 metabolic equivalents).28 Caution should be taken when comparing
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sedentary behaviour in this study to studies using more recent versions of this definition to explain sedentary time. It should be acknowledged that differences in seasons may affect children’s physical activity levels in the school playground. Whilst temperatures were several degrees higher during the follow-up data collection, data was collected at one intervention and one control school at the same time to account for seasonal variation. Notably physical activity levels in the control schools remained fairly constant at baseline and follow-up, however they increased at the intervention schools. 5. Conclusion This study observed small to medium effects in children’s school break-time physical activity as a result of the introduction of portable equipment and policy changes within the school environment. Small changes to school policy and feasible additions of portable equipment have the potential to contribute to children’s overall physical activity levels at a population level. 6. Practical implications • Providing portable equipment to primary school playground environments has the potential to increase children’s physical activity levels. • Changes to school break-time policy have the potential to increase primary school children’s physical activity levels. • The changes introduced as part of this study have the potential to particularly impact the physical activity levels of girls during school break times. Acknowledgements We would like to acknowledge the students and staff from the schools involved in this study. We would also like to thank the research assistants involved in the data collection. This project was supported by an internal Faculty Research Committee grant. ADO is supported by a National Heart Foundation of Australia Career Development Fellowship (CR11S 6099). DC is funded by a National Heart Foundation of Australia Postdoctoral Research Fellowship (PH 11S 6025). Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jsams.2015.04.017 References 1. Janssen I, LeBlanc A. Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. IJBNPA 2010; 7(1):1–16. 2. World Health Organisation. Global Strategy on Diet. Phys Act Health 2013. http:// www.who.int/dietphysicalactivity/pa/en/ 3. Pate RR, Mitchell JA, Byun W et al. Sedentary behaviour in youth. Br J Sports Med 2011; 45(11):906–913. 4. Salmon J, Ball K, Crawford D et al. Reducing sedentary behaviour and increasing physical activity among 10-year-old children: overview and process evaluation of the ‘Switch-Play’ intervention. Health Promot Int 2005; 20(1):7–17. 5. Colley RC, Garriguet D, Janssen I et al. Physical activity of Canadian children and youth: accelerometer results from the 2007–2009 Canadian Health Measures Survey. Health Rep 2011; 22(1). 6. Council on School Health. The crucial role of recess in school. Pediatrics 2013; 131(1):183–188. 7. Ridgers ND, Salmon J, Parrish AM et al. Physical activity during school recess: a systematic review. Am J Prev Med 2012; 43(3):320–328. 8. Parrish AM, Okely AD, Stanley RM et al. The effect of school recess interventions on physical activity. Sports Med 2013; 43(4):287–299. 9. Verstraete SJ, Cardon GM, De Clercq DL et al. Increasing children’s physical activity levels during recess periods in elementary schools: the effects of providing game equipment. Eur J Public Health 2006; 16(4):415–419.
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10. Okely AD, Salmon J, Trost SG et al. Discussion paper for the development of physical activity recommendations for children under 5 years, Canberra, Australia, Australian Department of Health and Ageing, 2008. 11. McKenzie TL, Marshall SJ, Sallis JF et al. Leisure-time physical activity in school environments: an observational study using SOPLAY. Prev Med 2000; 30(1):70–77. 12. McKenzie TL. SOPLAY system for observing play and leisure activity in youth; description and procedures manual D.o.E.a.N. sciences editor, San Diego, San Diego State University, 2006. 13. Mc Kenzie TL. System for observing play and leisure activity in youth, description and procedures manual, San Diego, Department of Exercise and Nutritional Sciences, San Diego State University, 2006. 14. Bocarro JN, Kanters MA, Cerin E et al. School sport policy and school-based physical activity environments and their association with observed physical activity in middle school children. Health Place 2012; 18(1):31–38. 15. Warburton DER, Charlesworth S, Ivey A et al. A systematic review of the evidence for Canada’s physical activity guidelines for adults. Int J Behav Nutr Phys Act 2010; 7:39. 16. Ridgers ND, Stratton G, Fairclough SJ et al. Children’s physical activity levels during school recess: a quasi-experimental intervention study. IJBNPA 2007; 4:19. 17. Ridgers ND, Fairclough SJ, Stratton G. Twelve-month effects of a playground intervention on children’s morning and lunchtime recess physical activity levels. J Phys Act Health 2010; 7(2):167–175. 18. Evans J. In search of peaceful playgrounds. Educ Res Perspect 2001; 28(1):45–56.
19. Parrish AM, Yeatman H, Iverson D et al. Using interviews and peer pairs to better understand how school environments affect young children’s playground physical activity levels: a qualitative study. Health Educ Res 2012; 27(2):269–280. 20. Jones S, Beckmann K, Rayner J. Australian primary schools’ sun protection policy and practice: evaluating the impact of the national sunsmart schools program. Health Promot J Aust 2008; 19(2):86–90. 21. Masso M. Policy and practice for preventing skin cancer in children. Public Health Nurs 2006; 23(4):361–365. 22. Janssen I, LeBlanc A. Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. Int J Behav Nutr Phys Act 2010; 7:40. 23. Giles-Corti B, English DR, Costa C et al. Creating sunsmart schools. Health Educ Res 2004; 19(1):98–109. 24. Garden-Robinson J. Crunch & munch program improves food preparation and gardening knowledge and skills. J Nutr Educ Behav 2011; 43(4 (Suppl. 1)):S25. 25. Conklin M, Lambert L, Anderson J. How long does it take students to eat lunch? A summary of three studies. J Child Nutr Manag 2002; 26:1–6. 26. Parrish A, Russell KG, Yeatman H et al. What factors influence children’s activity? BJSN 2009; 4(1):6–10. 27. Tremblay MS, Warburton DE, Janssen I et al. New Canadian physical activity guidelines. Appl Physiol Nutr Metab 2011; 36:36–46. 28. Tremblay MS, LeBlanc AG, Kho ME et al. Systematic review of sedentary behaviour and health indicators in school-aged children and youth. Int J Behav Nutr Phys Act 2011; 8(1):98.
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Contents lists available at ScienceDirect
Journal of Science and Medicine in Sport journal homepage: www.elsevier.com/locate/jsams
Original research
PACE: A group randomised controlled trial to increase children’s break-time playground physical activity Anne-Maree Parrish a,c,∗ , Anthony D. Okely a,c , Marijka Batterham b,c , Dylan Cliff a,c , Christopher Magee a,d a
Faculty of Social Sciences, University of Wollongong, Australia Mathematics and Applied Statistics, University of Wollongong, Australia c Interdisciplinary Educational Research Institute, University of Wollongong, Australia d Centre for Health Initiatives, University of Wollongong, Australia b
a r t i c l e
i n f o
Article history: Received 13 November 2014 Received in revised form 2 April 2015 Accepted 22 April 2015 Available online xxx Keywords: Schools Recess Lunch Policy Equipment Play
a b s t r a c t Objectives: To assess the effect of a school playground intervention on the physical activity levels of primary/elementary aged children. Design: Two-arm parallel group randomized controlled trial. Methods: In 2011, children aged 4–13 years from thirteen primary/elementary schools (in Illawarra, New South Wales, Australia) were invited to participate in the study. School recruitment was based on existing policies, equipment and willingness to participate. Participating schools were randomly allocated to the intervention or control using the ‘hat and draw’ method. The intervention was delivered over four months. Intervention schools introduced policy changes and portable equipment to break-time after baseline measures were collected. The primary outcome was the proportion of break-time spent in Moderate to Vigorous Physical Activity (MVPA) assessed by the System for Observing Playground Activity in Youth (SOPLAY). The analysis involved linear mixed models adjusting for the clustering effect of schools. The study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614001128684). Results: Four schools (two intervention and two control) met the inclusion criteria (1582 children: 790 males; 267 controls, total of 792 females; 248 controls). Students from the intervention schools had a greater increase at follow-up in the proportion of break-time in MVPA; (adjusted difference = 12.5 percentage points, 95% CI [−13.0%, 38.0%]; P = 0.17; r = 0.6) compared to the controls. MVPA at recess significantly increased (adjusted difference = 18.0 percentage points, 95% CI [6.9%, 29.1%]; P = 0.02; effect size = 0.7). There were no significant increases in MVPA when examining overall break times. Results were greater for girls compared to boys. Conclusions: Making environmental and policy changes are promising strategies for promoting healthenhancing physical activity during school break-time. © 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
1. Introduction Due to established health benefits,1 international recommendations specify that children should accumulate 60 min of physical activity daily.2 However, children spend large portions of their day being sedentary,3 with sedentary past-times in the home environment further jeopardizing children’s physical activity levels.4 The prevalence of sufficient physical activity in children is low in many countries, and research suggests interventions should target
∗ Corresponding author. E-mail address: [email protected] (A.-M. Parrish).
various levels of influence including the home, school and community settings.5 The school environment is ideal for the promotion of physical activity as it is a medium that reaches the majority of the population in most countries.6 Pressures to meet curricular targets can limit class time opportunities for physical activity however school break-times have the potential to contribute up to 40% of children’s recommended daily physical activity, making it an ideal setting for physical activity promotion.7 Evidence suggests an association between children’s school break time physical activity, the introduction of portable equipment (e.g. balls, ropes, hoops), and the potential for policy to influence children’s school break time physical activity levels.7–9
http://dx.doi.org/10.1016/j.jsams.2015.04.017 1440-2440/© 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
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However few interventions have investigated the effect of environmental and policy interventions on children’s school playground physical activity levels.8 Some school break time policies, such as ‘no hat no play’ (The term ‘no hat no play’ refers to a policy in most Australian primary/elementary schools where children are required to wear a hat at school during break times for sun protection and if they forget their hat they are required to sit for the length of the break-time as punishment) and compulsory breaktime sitting periods, may negatively influence children’s break time physical activity. This study assessed the effect of an intervention which modified the physical school playground environment and implemented policy changes in order to increase break-time physical activity levels among primary/elementary school children.
2. Methods The reporting of this study is according to the CONSORT guidelines.10 It is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614001128684). It was funded by a University Faculty grant. The study was a cluster randomized trial, using a nested cohort design called Physical Activity Children and the Environment (PACE). Thirteen Catholic primary/elementary schools within the Illawarra region of New South Wales, Australia were approached to participate in the study. The study was limited to a maximum of four schools due to funding. There were no changes to the study methods after trial commencement. Permission to conduct the study was gained through the Wollongong Catholic Education office and from principals at each school. The study received ethical approval from the Human Ethics Research Committee (HE11/124). Schools were recruited based on existing policies, equipment and their willingness to be involved in the study (including to be randomized). This was established during the first contact with the school principal. To be involved in the study children at the schools had limited access to portable equipment, restricted access to larger playground areas, compulsory break sitting time and a ‘no hat no play’ policy. Recruitment of the schools occurred in June 2011. Passive consent was gained from the students at all four schools to assess observational playground physical activity data.11 Data were collected within each school setting. The intervention schools implemented a multi-component intervention: involving physical and policy changes to the school playground environment to promote break time physical activity. The intervention duration was 4 months. Baseline data were collected to accommodate school schedules at the end of Term 2 during the week commencing the 10th of June 2011 and 22nd of July 2011 at the start of Term 3. Follow-up data were collected in November 2011. The first author recruited the schools and liaised with each school principal. A school staff member was nominated as a liaison for the research staff and assisted the implementation of the intervention. The first author developed the randomisation sequence, following baseline measurements. Schools were randomized to either the intervention or control group by having an independent person draw folded pieces of paper with the schools codes on them from a hat. The research assistants were blinded but the environmental changes in the school meant they may have been aware of allocation. For ethical reasons and to minimize bias results from compensatory rivalry and resentful demoralization, the PACE intervention was offered to the control schools at the completion of post-intervention assessment (i.e., wait-list control) (supplementary Fig. 1). The intervention schools received identical sets of mixed portable equipment (valued at $800 AUD), including: 10 soccer balls, 10 rugby balls, 10 basketballs, 20 large rubber balls, 80 small bouncy balls, 35 skipping ropes, 45 hoops, two cricket sets and 18
catch cups (cup on a stick, with a long string and ball attached). It was supplied to them after baseline data collection and waitlisted to the control schools after follow up data collection. Schools decided how the equipment was distributed. One school allowed children to take equipment from a classroom tub prior to exiting for the break, the other made equipment available via access to equipment bins freely available in the playground during the break. Intervention schools were encouraged to participate in the following policy changes after baseline data was collected: a maximum 5 min sitting period at recess and 10 min at lunch, a minimum 5 min extension of each break period, a revision of each schools policies to encourage maximum access to sporting fields during break times and the introduction of a ‘no hat, play in the shade’ policy (as an alternative to ‘no hat, no play’). All of the schools in the study had large outdoor undercover play areas designed for weather protection. The fidelity of the intervention was monitored between baseline and follow-up data collection. A total of six process evaluations were conducted (at both the intervention and control schools) monitoring: the use of portable equipment, whether students had free access to the equipment, whether teachers were organising games at break-times and whether break time policy changes were being implemented. The primary outcome for the study was the proportion of time spent in MVPA (Moderate to Vigorous Physical Activity). Physical activity and area contextual characteristics (accessibility, usability, supervision, organized activities and equipment) were assessed via direct observation of school playgrounds using the validated System for Observing Play and Leisure Activity in Youth instrument (SOPLAY).11 SOPLAY is an objective momentary time sampling observational instrument, where observers scan a predetermined area of the school playground to determine the physical activity level of the children and to record playground characteristics.12 The playground was assessed, measured and segmented prior to the commencement of the scanning process. Observers agreed upon the size, area and boundaries of each area and recorded them on a school map. Each observer carried and referred to a copy of the segmented map during the break period. Two observers separately rotated around the school playground area moving to a new section every 10 min. The observers continuously scanned each area (from left to right) alternating between males and females until the break time was finished or until they moved to another section of the playground. The physical activity levels of the children are coded during each scan as either sedentary (e.g. lying down, sitting, or standing), walking or vigorous.13 MVPA was determined by summing the walking and vigorous categories.11 Student activity was recorded at a rate of approximately one child per second.13 Scanning took place on three school weekdays. Six observers were trained to use SOPLAY during an all-day training session at one school in the Illawarra region. To assess the reliability of the observer’s use of the SOPLAY instrument at the end of the training session, spearman correlation coefficients were calculated against the gold standard video. There were significant correlations between the observers scans and the gold standard ranging from r = 0.83 to r = 0.97, p < 0.001. Inter-rater reliability was assessed at baseline and follow-up (in the school environment) using Spearman’s correlations coefficients. There were significant correlations between the observers r = 0.77 and r = 0.97, p < 0.001. At the end of the study an anonymous teacher evaluation and reply paid envelope was placed in each teacher’s school internal mail box at the schools involved in the study. Teachers were asked to rank their responses using a five point Likert scale (1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, 5 = strongly disagree). The teachers were asked if they felt the research was conducted in a manner that was mindful of school activities and routines. Teachers were also asked if they believed that the following changes to policy
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Table 1 School details.
Intervention A Intervention B Control C Control D
IRSAD
IRSAD Ranking within the Illawarra
Student numbers
First break
Time in minutes
Second break
Time in minutes
Total time In minutes
943 880 988 1002
19 8 32 35
N = 576 (276 boys) N = 314 (158 boys) N = 303 (151 boys) N = 388 (205 boys)
10.30–11.00 11.20–12.10 10.30–11.00 11–11.15
30 50 30 15
1.00–1.40 1.40–2.05 1.00–1.40 12.50–1.50
40 25 40 60
70 75 70 75
Note: Australian Bureau of Statistics Index of Relative Socio-economic Advantage and Disadvantage (IRSAD) in Illawarra suburbs. The average IRSAD value is 1000. A lower score indicates that an area is relatively disadvantaged compared to an area with a higher score. Therefore, in the rankings below, the suburb with the number one ranking is considered to be the most disadvantaged.
would benefit children’s playground activity levels: a maximum 5 min of sitting time at recess, a maximum 10 min of sitting time at lunch, a minimum 5 min extension of the recess and lunch break, the introduction of a ‘no hat play in the shade’ policy and increasing access to sporting fields. When analysing children’s physical activity using SOPLAY, data is commonly reported as proportion of time spent in MVPA, as schools often have varying break time durations.11 This study was designed and analysed as a nested cross-sectional study with a pre to post-test control group design. To account for the clustered (or nested) nature of the data within each school the data was analysed using a linear mixed model (PROC MIXED in SAS V 9.2, SAS Inc Cary NC),14 where treatment group within school was modelled as a random effect. The analysis adjusted for differences between schools at baseline. Effect sizes were calculated using an adjustment of the methods proposed by Hedges (2007). The alpha level was 0.05. 3. Results Four of thirteen schools agreed to participate in the study, which included 1582 children aged 4 to 13 years (kindergarten to year 6) (M = 790; 267 controls F = 792; 248 controls). Observations did not proceed during inclement weather; if the weather prevented play, observations were rescheduled for a later date. Average daily temperatures during June and July were approximately 18 ◦ C and average monthly rainfall was 97.5 mm. Follow-up data collection was in November, average temperatures were 23 ◦ C with an average monthly rainfall of 115.6 mm. There were two breaks during each of the schools day. Three schools had a shorter break followed by a longer break. One of the intervention schools had a longer break followed by a shorter break. For the purpose of analysis and findings the shorter break will be referred to as recess and the longer breaks as lunch. The breaks totalled 70 min at schools A and C and schools B and D had 75 min of total break-time (Table 1). Neither of the intervention schools demonstrated an extension of the break times at post intervention, however Intervention school P removed the 10 min sitting time at recess so that children could play immediately and changed the lunch time policy from a compulsory 10 min sitting time to a 5 min compulsory (or when finished eating) sitting time. Intervention school J removed the 10 min sitting time at recess (it should be noted that this change
was not always consistent from anecdotal evidence in discussions with teaching staff) and had a 10 min compulsory sitting time at lunch. Both schools instigated a ‘no hat play in the shade’ policy and increased access to sporting fields. Process evaluation of the intervention schools indicated that the portable equipment was being utilised in the playground during recess and lunch. Teachers were not seen to be organising playground games, the policy changes were implemented as described. Monitoring of the control schools indicated that one of the schools provided a limited amount of their own equipment to students, students brought their own small balls at the other control school, teachers were not seen to be organising playground games nor had they made any of the policy changes proposed in this study. Whilst the ‘no hat, play in the shade’ policies were seen to be implemented, it should be noted that there were limited numbers of students without hats (one or two students). This seemed to be an average number of students at each observation of the schools in the study. There were a total of 90 teachers at the four schools involved in the study. Which included all permanent part-time and full-time staff. Twenty four teachers completed the teacher evaluation (Response rate of 0.266). Teacher responses are summarized in the supplementary table (Table 2). Tables 3 and 4 show the changes in the proportion of time spent in MVPA for the intervention and control schools at baseline and follow-up. Effect sizes indicate small to medium benefits for MVPA in both boys and girls. These were statistically significant for recess (p = 0.02) and approached statistical significance for the girls combined recess and lunch time break (p = 0.06) (Tables 3 and 4). Overall boys were more physically active than girls, a result commonly reflected in the Literature.7 For boys and girls percent MVPA increased by 13 percentage points at recess and 9.4 percentage points at lunch for the intervention schools (Table 3). MVPA decreased by 4.9 percentage points at recess and remained constant at lunch in the control schools (Table 3). 4. Discussion This study aimed to investigate the intervention effect of introducing portable equipment and policy changes to the school environment to increase children’s physical activity during recess and lunch breaks after a three or five month follow-up period. Children spent approximately 50% of their break-time in MVPA prior to
Table 2 Teacher evaluation responses (PACE data 2012).
The study was conducted in a way that was mindful of school activities and routines A maximum of 5 min sitting at recess would benefit children’s activity levels A maximum of 10 min sitting at lunch would benefit children’s activity levels A minimum 5 min extension of the recess and lunch break would benefit children’s activity levels Introducing ‘no hat, play in the shade’ would benefit children’s activity levels Increasing access to sporting fields would benefit children’s activity levels
% Agree/strongly agree
% Neutral
% Disagree or strongly disagree
% No response
100 (N = 24)
0
0
0
62.5 (N = 15) 95.8 (N = 23) 45.8 (N = 11)
16.7 (N = 4) 0 8.3 (N = 2)
16.7 (N = 4) 0 41.7 (N = 10)
4.2 (N = 1) 4.2 (N = 1) 4.2 (N = 1)
66.7 (N = 16) 75 (N = 18)
4.2 (N = 1) 16.7 (N = 4)
25 (N = 6) 4.2 (N = 1)
4.2 (N = 1) 4.2 (N = 1)
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Table 3 Changes in the percentage of time spent in MVPA for recess (morning break) and lunch.
% MVPA recess
% Sedentary recess
% MVPA lunch
% Sedentary lunch
Gender
Baseline intervention mean (+SD)
Control mean (+SD)
Follow-up intervention mean(+SD)
Control mean (+SD)
Adjusted difference 95%CI
Padj
Effect size
Boys Girls Boys and Girls Boys Girls Boys and Girls Boys Girls Boys and Girls Boys Girls Boys and Girls
66.2(0.033) 49.4(0.056) 55.4(0.026) 33.8(0.033) 50.6(0.056) 44.6(0.026) 61.4(0.041) 41.0(0.071) 48.9(0.055) 38.6(0.041) 59.0(0.071) 51.1(0.055)
52.0(0.034) 42.7(0.056) 45.7(0.027) 48.0(0.034) 57.3(0.056) 54.3(0.027) 52.0(0.041) 44.2(0.071) 49.2(0.055) 48.0(0.041) 55.8(0.071) 50.8(0.055)
73.6(0.033) 62.1(0.055) 68.5(0.026) 26.4(0.033) 37.9(0.055) 31.5(0.026) 73.1(0.041) 50.4(0.071) 62.5(0.055) 26.9(0.041) 49.6(0.071) 37.5(0.055)
45.8(0.032) 37.8(0.055) 40.8(0.026) 54.2(0.032) 62.2(0.055) 59.2(0.026) 56.8(0.040) 44.6(0.070) 53.8(0.054) 43.2(0.040) 55.4(0.070) 46.2(0.054)
0.136(−0.070,0.341) 0.177(−0.156,0.509) 0.180(0.069,0.291) −0.136(−0.341,0.070) −0.177(−0.509,0.156) −0.180(0.069,0.291) 0.068(−0.413,0.550) 0.091(−0.100,0.281) 0.090(−0.255,0.436) −0.068(−0.550,0.413) −0.091(−0.281,0.100) −0.090(−0.436,0.255)
0.105 0.150 0.020 0.105 0.150 0.020 0.604 0.177 0.378 0.604 0.177 0.378
0.407 0.581 0.716 −0.407 −0.581 −0.716 0.212 0.432 0.499 −0.212 −0.432 −0.499
MVPA, moderate-to-vigorous physical activity (% walking plus % vigorous).
the intervention, indicating a potential to make realistic changes to school environments to increase children’s physical activity levels. While few interventions assess the introduction of portable equipment to promote school break time MVPA, Verstrate9 found a significant increase in children’s MVPA during recess as a result of introducing games equipment. Loucaides15 found a significant increase in children’s steps after court rotation, playground markings and jump ropes were introduced. Ridger’s et al16,17 used two mixed methods interventions to investigate the effect of playground markings, colour coded areas and portable equipment on children’s break time MVPA with small but non-significant increases. In the current study, children in the intervention and control groups spent 52% and 48% of their break time in MVPA at baseline respectively, increasing by 13.6 percentage points at the intervention schools and one percentage point at the control schools (see Table 4). Introducing portable equipment and policy changes appears to be a potentially efficacious approach for increasing children’s school break time MVPA. The results from the intervention were surprising as a nonsignificant but large effect size was observed for girls at recess. Possibly changes introduced as part of this intervention could benefit girls. Boys often dominate open spaces in the playground and are involved in ball play, whilst girls remain on the outer edge socializing.18 Policy changes such as the removal of forced sitting time at the start of recess may promote activity from the outset for girls, removing the inclination to sit and talk for the entire recess period. In addition, possibly the type of portable equipment (e.g., ropes, catch cups, hoops) introduced as part of the intervention appealed more to girls than boys. There was not a significant change in boy’s physical activity during the lunch break, which may reflect the way that boys normally play when they have access to larger sporting fields during the lunch break period (e.g. providing opportunities for activities such as football). The use of portable equipment is the most frequently reported variable which has positively impacting break-time physical activity.7,8 If schools chose to introduce portable equipment to the
playground setting, policies affecting the way that it is introduced could potentially impact break-time physical activity. Free access to portable equipment during the entire break may be more likely to promote activity than restricted access (where students must chose a piece of equipment at the start of lunch from a classroom box without the opportunity to revisit the box during the break time).19 Ongoing maintenance of portable equipment can also promote long term problems for schools as equipment can be lost or broken. It is recommended that schools are given budgets to not only provide for the purchase of physical education equipment but the availability and maintenance of portable equipment for break time use. Whilst the findings in this study and the broader literature indicate that the introduction of portable equipment shows potential for increasing students school break time MVPA, few studies have investigated changes to school policy as a means of increasing break time physical activity7 . It is possible that small feasible changes to policies during the school day have the potential to increase children’s physical activity levels. To date primary schools in Australia have been reasonably successful at implementing sun safe policies which encourage the use of hats while outdoors.20 Unfortunately these policies have often involved a ‘no hat no play’ rule as a disincentive for children who forget their hats.21 Such a measure may be counterintuitive for children’s overall health. While reducing sun exposure through the use of hats may decrease the potential for skin cancer; punishing children by stopping them from playing impacts physical activity and ironically increases the risk of other forms of cancer.22 Feasible changes to policy such as ‘no hat, play in the shade’ instead of ‘no hat, no play’ may still act as a punishment whilst preventing children from being sedentary. One third of teachers responding to the evaluation believed allowing children to play in the shade would not increase children’s activity levels. This is a little surprising, however the teachers may believe leniency around policies requiring children to wear hats may result in more children forgetting to bring their hats, as the ‘no hat no play’ policy can be very effective in encouraging hat wearing.23 If schools
Table 4 Changes in the percentage of time spent in MVPA at recess and lunch combined. Activity
Gender
Baseline intervention mean (+SD)
Control mean (+SD)
Follow-up intervention mean (+SD)
Control mean (+SD)
Adjusted difference 95%CI
Padj
Effect size
% MVPA
Boys Girls Boys and Girls Boys Girls Boys and Girls
63.2(0.017) 44.4(0.048) 52.0(0.035) 36.8(0.017) 55.6(0.048) 48.0(0.035)
52.8(0.017) 43.4(0.049) 48.0(0.035) 48.2(0.017) 56.6(0.049) 52.0(0.035)
72.7(0.017) 56.0(0.048) 65.6(0.035) 27.3(0.017) 44.0(0.048) 34.4(0.035)
53.0(0.015) 42.1(0.049) 49.1(0.034) 47.0(0.015) 57.9(0.048) 50.9(0.034)
0.085(−0.059,0.228) 0.129(−0.021,0.279) 0.125(−0.130,0.380) −0.085(−0.226,0.059) −0.129(−0.279,0.021) −0.125(−0.380,0.130)
0.128 0.066 0.170 0.128 0.066 0.170
0.298 0.482 0.584 −0.298 −0.482 −0.584
% Sedentary
MVPA, moderate-to-vigorous physical activity (% walking plus % vigorous).
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ensure students wear hats for sun protection, playing in the shade is a suitable alternative to ‘no hat no play’. Further feasible policy changes may impact the amount of time children have to play. In some schools students are required to sit for lengthy periods of time to eat their recess and lunch. Schools should resist employing compulsory sitting time policies during the shorter recess break in particular. Often snack foods eaten at recess, such as apples or bananas, can be easily consumed whilst walking around and children can still sit if they choose. In addition, in many Australian Primary schools children are allowed to drink water and eat fruit and vegetables (known as ‘Munch and Crunch’)24 during class times prior to the recess break. If children have the opportunity to eat whilst in class, this could allow more time for activity during break times’. This type of practice not only benefits children’s nutrition, but could allow for uninterrupted play at recess. Whilst there may be some concern about children properly consuming their lunch, often older children finish their lunch quickly and are required to sit waiting until the elicited time frame or until those in younger years have finished. Reductions or reassessment of compulsory sitting time could potentially impact children’s physical activity levels and allow them to be properly nourished. Conklin et al25 found that on average children take seven to 10 min to eat their lunch. Using evidence to guide policy could result in appropriately timed compulsory sitting time. Revising the length of compulsory sitting time for all children, may allow many children to finish their lunch and have the potential for a greater period of time to be active. Ensuring children have access to larger sporting fields offers the potential to encourage more opportunities for physical activity, particularly for children who prefer ball games.26 In some instances schools limit access to sporting fields because of the time it takes to get to them. Reducing compulsory sitting time may also provide the extra time needed to get to the fields. In all the teacher evaluations, the intervention procedures were acceptable for all respondents, an encouraging response supporting the intervention changes. However, only half of the teachers believed restricting students recess to 5 min sitting time would benefit children’s physical activity levels. These findings were indicative of some inconsistencies in the implementation of the intervention policy changes at intervention school J during recess sitting time, however most teachers supported the maximum 10 min sitting time at lunch. Teachers may be concerned children will not eat all of their recess or lunch if they are not required to sit to eat. Dr Golley suggests parents provide more portable snacks allowing them to eat and move27 . In all this study demonstrates the potential for small changes to school policy and feasible additions of portable equipment to contribute to children’s overall physical activity levels at a population level. There were, however, some limitations associated with this study. The study findings may have been limited by the modest response to the teacher survey and could reflect the findings of those interested in the study. Whilst the study findings indicate the introduction of portable equipment and policy changes increases children’s school break time MVPA the study is limited by the number of schools involved in the study, the findings would be more generalizable in a larger randomized controlled trial. There is a potential for observer bias when using the SOPLAY instrument. In an effort to avoid bias only one observer knew which schools were the intervention schools and which were the controls. However, the observers may have noticed more equipment in the playground of the intervention schools during the recess break. The SOPLAY instrument labels sedentary time as sedentary (e.g. lying down, sitting, or standing). More current definitions of sedentary behaviour do not include standing and refer to any behaviour where the individual is sitting or reclining (<1.5 metabolic equivalents).28 Caution should be taken when comparing
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sedentary behaviour in this study to studies using more recent versions of this definition to explain sedentary time. It should be acknowledged that differences in seasons may affect children’s physical activity levels in the school playground. Whilst temperatures were several degrees higher during the follow-up data collection, data was collected at one intervention and one control school at the same time to account for seasonal variation. Notably physical activity levels in the control schools remained fairly constant at baseline and follow-up, however they increased at the intervention schools. 5. Conclusion This study observed small to medium effects in children’s school break-time physical activity as a result of the introduction of portable equipment and policy changes within the school environment. Small changes to school policy and feasible additions of portable equipment have the potential to contribute to children’s overall physical activity levels at a population level. 6. Practical implications • Providing portable equipment to primary school playground environments has the potential to increase children’s physical activity levels. • Changes to school break-time policy have the potential to increase primary school children’s physical activity levels. • The changes introduced as part of this study have the potential to particularly impact the physical activity levels of girls during school break times. Acknowledgements We would like to acknowledge the students and staff from the schools involved in this study. We would also like to thank the research assistants involved in the data collection. This project was supported by an internal Faculty Research Committee grant. ADO is supported by a National Heart Foundation of Australia Career Development Fellowship (CR11S 6099). DC is funded by a National Heart Foundation of Australia Postdoctoral Research Fellowship (PH 11S 6025). Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jsams.2015.04.017 References 1. Janssen I, LeBlanc A. Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. IJBNPA 2010; 7(1):1–16. 2. World Health Organisation. Global Strategy on Diet. Phys Act Health 2013. http:// www.who.int/dietphysicalactivity/pa/en/ 3. Pate RR, Mitchell JA, Byun W et al. Sedentary behaviour in youth. Br J Sports Med 2011; 45(11):906–913. 4. Salmon J, Ball K, Crawford D et al. Reducing sedentary behaviour and increasing physical activity among 10-year-old children: overview and process evaluation of the ‘Switch-Play’ intervention. Health Promot Int 2005; 20(1):7–17. 5. Colley RC, Garriguet D, Janssen I et al. Physical activity of Canadian children and youth: accelerometer results from the 2007–2009 Canadian Health Measures Survey. Health Rep 2011; 22(1). 6. Council on School Health. The crucial role of recess in school. Pediatrics 2013; 131(1):183–188. 7. Ridgers ND, Salmon J, Parrish AM et al. Physical activity during school recess: a systematic review. Am J Prev Med 2012; 43(3):320–328. 8. Parrish AM, Okely AD, Stanley RM et al. The effect of school recess interventions on physical activity. Sports Med 2013; 43(4):287–299. 9. Verstraete SJ, Cardon GM, De Clercq DL et al. Increasing children’s physical activity levels during recess periods in elementary schools: the effects of providing game equipment. Eur J Public Health 2006; 16(4):415–419.
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Please cite this article in press as: Parrish A-M, et al. PACE: A group randomised controlled trial to increase children’s break-time playground physical activity. J Sci Med Sport (2015), http://dx.doi.org/10.1016/j.jsams.2015.04.017