Evidence-based strategies to promote physical activity among children, adolescents and young adults: review and update

This paper updates evidence reviewed in the first edition of Getting Australia Active on effective physical activity (PA) intervention strategies among children, adolescents and young adults. Intervention studies published between 1999 and September 2003 were identified using electronic databases and hand searching. A total of 28 discrete studies were identified (31 papers). Six of nine studies reported significant effects on child or youth PA in school settings. Those that incorporated whole-of-school approaches including curriculum, policy and environmental strategies appeared to be more effective than those that incorporated curriculum-only approaches. Five of 10 studies with children and two of five studies with adolescents reported increased PA or decreased sedentary behaviour in other settings. Interventions that included contact with families generally appeared to be most effective. One study with adolescents provided some evidence of the potential effectiveness of interventions based in primary care. Two of four papers reported modest short-term results among young adults, including increased PA stage of change or a higher likelihood of being adequately physically active, but none showed any evidence of sustained increases in PA. There is an urgent need for additional studies examining interventions aimed at young adults. Across the three life stages, future studies should include objective PA measures, longer-term follow-up, larger sample sizes, a specific focus on PA (rather than weight) and culturally-specific strategies that build evidence in Australian populations. Future studies should target high risk groups and a broad range of settings and strategies focusing on reducing sedentary behaviours as well as increasing PA.

How feasible are healthy eating and physical activity for young women?

Objective: This study investigated young women’s perceptions of the feasibility of physical activity and healthy eating behaviours, and how these vary by socioeconomic status, domestic characteristics and weight status. Design: This population-based study used a mailed questionnaire to investigate perceptions of the feasibility of commonly recommended healthy eating and physical activity behaviours among a sample of young women. The feasibility of 29 physical activity behaviours (e.g. relating to frequency, intensity, duration, domain/setting) and 15 healthy eating behaviours (e.g. relating to location/setting, fruit and vegetable intake, fat/sugar intake) was assessed. Height, weight and sociodemographic details were also obtained. Setting: Nation-wide community-based survey. Subjects: A total of 445 women aged 18–32 years selected randomly from the Australian electoral roll. Results: Most women reported that they either were already engaged in many of the healthy eating behaviours or saw these as highly feasible. Many physical activity behaviours, on the other hand, were perceived as less feasible, particularly among women with children and women who were overweight. Conclusions: Health promotion messages and strategies aimed at increasing physical activity and healthy eating are unlikely to succeed unless they take into account perceptions that these behaviours are not feasible. For young women, this may involve promoting more time-effective, flexible ways of achieving recommended physical activity. Messages specifically targeted to women with children, and women who are overweight, are required.

Piloting the feasibility and effectiveness of print- and telephone-mediated interventions for promoting the adoption of physical activity in Australian adults

This study examined the feasibility and effectiveness for increasing physical activity of a print-based intervention, and a print- plus telephone-mediated intervention among mid-life and older Australian adults. A randomised controlled trial study design was used. In mid-2002, 66 adults (18 men, 48 women) aged 45–78 years, who identified themselves as underactive, were recruited through advertisements and word-of-mouth at two sites (Melbourne and Brisbane), and randomised to either the print or print-plus-telephone mediated intervention group. Participants in both groups attended an initial briefing session, and over the 12-week intervention period received an instructional newsletter and use of a pedometer (both groups), and individualised telephone calls (print-plus-telephone group only). Self-reported physical activity data were collected at baseline, 12 and 16 weeks. Measures of self-reported global physical activity, moderate-vigorous intensity activity and walking all showed increases between baseline and 12 weeks for both intervention groups. These increases were generally maintained by 16 weeks, although participants in the print-plus-telephone group maintained slightly higher levels of global reported activity and walking (by approximately 30 mins/wk) than those in the print group. These interventions show potential for promoting initial increases in physical activity among mid-life and older Australian adults, and should be evaluated across more extended time periods.

Children's perceptions of their home and neighborhood environments, and their association with objectively measured physical activity: A qualitative and quantitative study

Environmental factors may have an important influence on children’s physical activity, yet children’s perspectives of their home and neighborhood environments have not been widely assessed. The aim of this study was to investigate children’s perceptions of their environments, and to examine associations between these perceptions and objectively measured physical activity. The sample consisted of 147, 10-year-old Australian children, who drew maps of their home and neighborhood environments. A subsample of children photographed places and things in these environments that were important to them. The maps were analyzed for themes, and for the frequency with which particular objects and locations appeared. Physical activity was objectively measured using accelerometers. Six themes emerged from the qualitative analysis of the maps and photographs: the family home; opportunities for physical activity and sedentary pursuits; food items and locations; green space and outside areas; the school and opportunities for social interaction. Of the 11 variables established from these themes, one home and two neighborhood factors were associated with children’s physical activity. These findings contribute to a broader understanding of children’s perceptions of their environment, and highlight the potential importance of the home and neighborhood environments for promoting physical activity behavior.

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

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

Trends in children`s physical activity and weight status in high and low socio-economic status areas of Melbourne, Victoria, 1985-2001

Objective:
To examine trends in active transport to and from school, in school sport and physical education (PE), and in weight status among children from high and low socio-economic status (SES) areas in Melbourne, Victoria, between 1985 and 2001.

Methods:
Cross-sectional survey data and measured height and weight from 1985 (n=557) and 2001 (n=926) were compared for children aged between 9–13 years within high and low SES areas.

Results:
From 1985 to 2001, the frequency of walking to or from school declined (4.38±4.3 vs. 3.61 ± 3.8 trips/wk, p<0.001), cycling to or from school also declined (1.22±2.9 vs. 0.36±1.5 trips/wk, p<0.001), and the frequency of PE lessons declined (1.64±1.1 vs. 1.18±0.9 lessons/wk, p<0.001). However, the frequency of school sport increased (0.9±1.22 vs. 1.24±0.8 sessions/wk, p<0.001). In 1985, 11.7% of children were overweight or obese compared with 28.7% in 2001 (p<0.001). Apart from walking to school and school sport, there were greater relative declines in cycling to school and PE, and increases in overweight and obesity among children attending schools in low SES areas compared with those attending schools in high SES areas.

Conclusions:
Declines in active school transport and PE have occurred at the same time as increases in overweight and obesity among Australian children.

Implications:
Promoting active school transport and maintaining school sport and PE should be important public health priorities in Australia. Current inequities in school sport and PE and in prevalence of overweight and obesity by area-level SES also need to be addressed.

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

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

Physical activity, emotional stress, sleep disturbances, and daily fluctuations in chronic fatigue symptomatology

The current study explored the relationships between physical and emotional stress and the symptomatology of chronic fatigue syndrome (CFS). Fifty-four CFS patients were studied using a longitudinal design. A self-report format was used to collect daily measures of major physical (sleep disturbance and physical activity) and emotional (subjective emotional stress level) stressors, as well as measures of levels of fatigue and secondary symptoms. The variables accounted for a moderate variance at the individual and occasion levels. Sleep disturbance and emotional stress were found to be positively associated with levels of fatigue and symptomatology, whereas physical activity was found to have a negative relationship with fatigue only. The severity of fatigue and symptoms were found to fluctuate daily in relation with the variables, indicating the complex nature of the associations.

Children's television viewing and objectively measured physical activity: associations with family circumstances

Background: The contribution of family circumstance to physical activity and television viewing has not been widely investigated in pre-adolescents, and available information is inconsistent. This study examines whether television viewing and objectively measured physical activity vary by different indicators of family circumstance.
Methods: Data from the 2001 Children's Leisure Activity Study and the 2002/3 Health, Eating and Play Study, involving Australian children in Grades Prep (mean age 6y) and 5–6 (mean age 11y), were combined. Children wore accelerometers for six consecutive 24 hour periods. Average min/day in low-intensity activity (1.0–1.9 METs) and moderate-to-vigorous-intensity activity (≥3 METs) were calculated. Parents reported children's television viewing and family circumstance. Linear regression analyses were conducted separately for young girls, young boys, older girls and older boys. Results: Complete data were available for 2458 children. Parental education and, to a lesser extent, employment level were inversely associated with television viewing. Children in single-parent families, those whose fathers were not in paid employment, and those without siblings tended to spend more time in low-intensity activity than their peers. Children with siblings spent more time in moderate-to-vigorous-intensity activity; associations were stronger for girls. Maternal education was positively associated with moderate-to-vigorous-intensity activity for younger children. Maternal employment was positively associated with moderate-to-vigorous-intensity activity for older children. Multivariable models did not demonstrate a cumulative explanatory effect.
Conclusion:  Individual measures of family circumstance were differentially associated with television, low-intensity activity and moderate-to-vigorous-intensity activity and associations were often not consistent across age-by-gender groups. Interventions may need to be tailored accordingly.

People, places...and other people? Integrating understanding of intrapersonal, social and environmental determinants of physical activity

“People or places: what should be the target?” was the provocative title of a keynote session at the fifth Australian National Physical Activity Conference held in Melbourne in 2005. This paper will argue that in fact there need not be major conflict between these views, and that couching recent debate about physical activity promotion as a polarised choice between these presents a false dichotomy. To illustrate this, the paper will consider several problems with singular approaches to understanding and promoting physical activity, and will then describe emerging empirical evidence on the nexus between people and places. To balance an increasing emphasis in the scientific literature on physical environmental determinants of physical activity, the role of intrapersonal and social factors will also be revisited. It is concluded that growing evidence supporting the multiple domains of influence on physical activity justifies calls for multi-disciplinary and multi-sectoral partnerships and approaches to the promotion of active lifestyles.

How can socio-economic differences in physical activity among women be explained? A qualitative study

This qualitative study investigated why women of low socio-economic status (SES) are less physically active than women of higher-SES. Semi-structured interviews were conducted with 19 high-, 19 mid- and 18 low-SES women. A social-ecological framework, taking into account intrapersonal, social and environmental level influences, was adopted to guide the development of interview questions and interpretation of data. Thematic analysis identified a number of key influences on physical activity that varied by SES. These included negative early life/family physical activity experiences (a consistent theme among those of low-/mid-SES); participation in a wider range of physical activities in leisure time (high-SES); greater priority given to television viewing (low-SES); lack of time due to work commitments (low-SES); lack of time due to family commitments (high-SES); and neighbourhood-level barriers (low-SES). Financial costs were not perceived as a key barrier by women in any SES group. Public health strategies aimed at reducing SES

Family structure and children's television viewing and physical activity

Objectives: This study aimed to examine how physical activity (PA) and television (TV) viewing time of children varied according to family structure.

Methods: In 2001, 5- to 6-yr-old (N = 296) and 10- to 12-yr-old (N = 919) children and their parents were recruited from 19 state elementary schools in Melbourne, Australia. Children's PA was objectively assessed using accelerometers worn for 8 d. Sociodemographic and family structure information and time spent watching TV was collected via questionnaire completed by parents.

Results: ANCOVA revealed that, after controlling for socioeconomic status and age of child, boys without any siblings spent more minutes per day watching TV (153.2 +/- 71.3) compared with those who have siblings (129.0 +/- 64.4, P < 0.05). There were also significant differences in TV viewing time between boys with one sibling (125.5 +/- 59.9), two siblings (141.9 +/- 70.1), or three or more siblings (111.6 +/- 62.6, P < 0.001). Girls from single-parent families (145.7 +/- 85.1) spent significantly more minutes per day watching TV compared with girls from two-parent families (125.1 +/- 67.7, P < 0.05). Girls with siblings spent more minutes per day in PA (148.3 +/- 67.7) compared with those who were an only child (131.0 +/- 58.9, P < 0.05). There were significant interactions between parental status and having a sibling, with PA, and also with TV viewing for girls and between parental status and having a brother with PA for boys. There were also significant interactions between having an older sibling and child's sex with PA and between number of siblings and sex with TV viewing.

Conclusions: Family structure may be an important source of influence on children's PA and TV viewing time. Aspects of family structure interact differently with PA and TV viewing, suggesting interventions may need to be tailored with consideration of the family structure of children.

Understanding environmental influences on nutrition and physical activity behaviors: where should we look and what should we count?

Research interest in the influence of environmental factors on nutrition and physical activity behaviors has surged internationally in recent years. This is evident from a rapidly expanding literature and facilitated by advances in methodological and analytical approaches to assessing multiple levels of influence on health behaviors. However, a number of conceptual challenges complicate research endeavours in this field. The purpose of this paper is to provide a 'state of the science' overview of evidence regarding environmental influences on nutrition and physical activity behaviors. We focus particularly on a number of key conceptual and methodological issues, including: a consideration of how the environment is defined; the selection and operationalization of environmental exposures; and the importance of integrating existing understanding of individual influences on behavior with the emerging data on the role of the environment. We draw on examples from the published literature including our own research studies to illustrate these issues. We conclude by proposing a research agenda to progress understanding of the influences of the environment on population nutrition and physical activity behaviors.

Development and reliability of a self-report questionnaire to examine children's perceptions of the physical activity environment at home and in the neighbourhood

Background: Environmental factors are increasingly being implicated as key influences on children's physical activity. Few studies have comprehensively examined children's perceptions of their environment, and there is a paucity of literature on acceptable and reliable scales for measuring these. This study aimed to develop and test the acceptability and reliability of a scale which examined a broad range of environmental perceptions among children.
Methods: Based on constructs from ecological models, a survey incorporating items on children's perceptions of the physical and social environment at home and in the neighbourhood was developed. This was administered on two occasions, nine days apart, to a sample of 39 children aged 11 years (54% boys), attending a metropolitan Australian elementary school. The acceptability of the survey was determined by the proportion of missing responses to each item. The test-retest reliability of individual items, scores and scales were determined using Kappa statistics and percent agreement for categorical variables, and intraclass correlation coefficients (ICC) for continuous variables.
Results: There were few missing responses to each question, with only 4% of all responses missing. Although some Kappa values were low, all categorical variables showed acceptable reliability when examined for percent agreement between test and retest (range 68%–100% agreement). Continuous variables all showed moderate to good ICC values (range 0.72–0.92).
Conclusion: Findings suggest this questionnaire is reliable and acceptable to children for assessing environmental perceptions relevant to physical activity among 11-year-old children.

Effects of a holistic health program on women's physical activity and mental and spiritual health

Intervention studies aimed at promoting increased physical activity have been trialled in many different settings including primary care, worksites and the community. Churches are also potential settings for physical activity promotion. However, little is known about the effectiveness of this setting for promoting physical activity, particularly in Australia. The purpose of this study was to evaluate the effectiveness of a mind, body and spiritually based health promotion program in increasing physical activity and promoting mental and spiritual health. Nineteen women completed the 8-week intervention, and 30 women in a non-health related 8-week program at the same church comprised a comparison group. Pre- and post-program surveys assessed outcome measures. Between-group differences over time were examined using one-way MANOVA's. Physical activity was higher in the intervention group than the comparison group. In contrast to the comparison group, both mental health (depression symptoms) and spiritual health improved significantly more among intervention participants. The data highlight the potential for a church-based setting and holistic approach to health promotion as a successful means of increasing physical activity and promoting mental and spiritual health among Australian women.