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00005768-201003000-0001800005768_2010_42_526_ward_interventions_3report< 104_0_12_3 >Medicine & Science in Sports & Exercise©2010The American College of Sports MedicineVolume 42(3)March 2010pp 526-534Interventions for Increasing Physical Activity at Child Care[APPLIED SCIENCES: Symposium]WARD, DIANNE S.1,2; VAUGHN, AMBER2; McWILLIAMS, CHRISTINE2; HALES, DEREK1,21Department of Nutrition, University of North Carolina at Chapel Hill, NC; and 2Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, NCAddress for correspondence: Dianne S. Ward, Ed.D., Department of Nutrition, University of North Carolina, 1700 Martin L. King Jr. Blvd, Chapel Hill, NC 27599-7426; E-mail: dsward@email.unc.edu.Submitted for publication December 2008.Accepted for publication April 2009.ABSTRACTExperts agree that physical activity is critical to children's health and development. Child care is an ideal setting that could be used to increase physical activity given the large number of young children enrolled. To effectively address physical activity at child care, it is necessary to understand what strategies are most effective. This article reviews existing intervention studies targeting physical activity conducted within a child care setting (including preschools, nursery schools, and day care). Given the limited work in this setting, liberal criteria were used that allowed for inclusion of studies with diverse outcomes (physical activity, physical activity-related, motor skills) and a variety of research designs (randomized control, quasi-experimental, single group). Searching six databases, 1355 studies were located, and 19 met inclusion criteria. Half of the studies that assessed intervention impact on physical activity reported significant findings. All five studies measuring motor skills and eight assessing physical activity-related outcomes demonstrated generally positive findings. Although the variety of outcome measures and research quality made it difficult to draw conclusions, findings do provide encouragement that regularly provided, structured physical activity programs can increase the amount and intensity of physical activity that children receive and improve children's motor skills. These studies also demonstrate that the organized child care setting provides multiple targets for intervention beyond structured activity programs; however, additional studies are needed to explore such opportunities.The increased levels of obesity observed in infants, toddlers, and preschoolers have created a call to action for policy makers and public health officials (1,7). The American Academy of Pediatrics suggests increased physical activity as a strategy for preventing pediatric obesity (4). Regular physical activity not only helps young children achieve energy balance but also contributes to a variety of physical, social, and psychological developmental milestones (37).The preschool years represent a critical period for the development of young children's physical activity habits. Experts agree that during these early years, children should participate in generous amounts of physical activity through both structured and unstructured play (32). Such activities help children develop fundamental motor skills, including locomotor and object manipulation skills (44). Although research in this area is limited, associations have been observed between preschool children's gross motor abilities and their levels of physical activity (21,44). Experts agree that rich environments and knowledgeable caregivers can facilitate toddlers' and preschoolers' development of competences in movement skills (32). Recent attention has focused on the child care setting as an excellent location for intervention, including efforts to increase physical activity (28).Child care holds great potential as a point of intervention, as evidenced by a recent review of preschool children's physical activity correlates that found an association between the preschool attended and a child's physical activity (27). Several interventions have been conducted to promote physical activity in children and youth (39), but few have targeted preschool age children or the child care setting (10,12). Building on these findings, researchers have begun to explore the specific policies and environmental characteristics of child care facilities associated with increased child physical activity (8,17,18).Although cross-sectional studies are valuable for indentifying associations between children's physical activity and attributes of the child care facility, intervention studies are necessary to guide policy decisions, including resource allocation. Unfortunately, as noted by Story et al. (36), "insufficient attention" has been directed toward exploring potential child care-based obesity prevention strategies. A recent report by the New South Wales Centre for Physical Activity and Health identified only four physical activity interventions targeting the 2- to 5-yr age group, and only one of those was conducted within a child care setting (12). Although child care settings offer several behavioral and environmental opportunities for increasing the physical activity of young children, efforts to develop implementation strategies in such settings are woefully underdeveloped.This is one of few literature reviews to describe physical activity interventions at child care, primarily because of the underdeveloped state of research targeting the age group, child care settings, and physical activity. Thus, the aim of this article was to provide a comprehensive review of existing studies that report physical activity outcomes for interventions at child care (preschool, nursery school, or day care) among children in the age group birth to 5 yr. On the basis of this review, common factors in the success or failure of an intervention will be identified, and recommendations will be made for future research investigations.METHODSA systematic review of the published English-language literature was performed, searching for intervention studies that focused on promoting physical activity in young children at center-based child care settings (including preschool, nursery school, and day care, but excluding after school). Six databases, including ERIC, PsycINFO, Physical Education Index, PubMed, SportDiscus, and ISI Web of Science, were searched in March 2008 and updated in March 2009. No limits were placed on date of publication. The PubMed search used a combination of MeSH terms and text words including preschool child, childhood, child welfare, child care, day care, nursery schools, motor activity, physical activity, movement, motor skills, exercise, intervention studies, health promotion, and health education. Terms used when searching other databases were exercise, physical activity, preschool, nursery school, and child care. Also, literature reviews identified during the search were explored for additional studies of interest. After the initial searches, titles and abstracts were independently screened for relevance by two authors. Discrepancies were resolved through discussion with a third reviewer. The remaining papers were obtained and reviewed against the following inclusion criteria: 1) use of a child care setting; 2) implementation of an intervention trial; 3) targeting toward young children (birth to 5 yr); 4) inclusion of a primary or secondary focus on physical activity-broadly defined as physical activity, physical fitness, motor skills, sedentary time, or policies that affect physical activity; and 5) publication within a peer-reviewed journal. Because the literature in this area is limited, multiple study designs were allowed including the following: randomized control trials, quasi-experimental studies, pre-post designs, and nonrandomized designs.RESULTSThe initial (March 2008) and follow-up (March 2009) searches of all six databases generated 1355 unique articles, books, abstracts, dissertations, and conference proceedings. Screening of titles and abstracts for relevance and elimination of all non-peer-reviewed papers and books reduced that list to 191 articles. All articles were reviewed, including their reference lists, from which 19 intervention studies that met the criteria for inclusion were identified. These studies were then categorized into three groups: 1) studies with a physical activity outcome; 2) studies with a physical activity-related outcome (e.g., reduced TV time, changes in physical activity policies); and 3) studies with a motor skills outcome. Descriptive information about each of these studies is in Tables 1-3. Within each table, interventions were further categorized as either curricular or environment/policy. Two studies (20,34) included assessment of both physical activity and motor skills and therefore appear in two different tables.TABLE 1. Intervention studies at child care with a physical activity outcome.TABLE 2. Intervention studies at child care with a physical activity-related outcome.TABLE 3. Intervention studies at child care with a motor development-related outcome.Studies with a physical activity outcome.Eight studies included a specific measure of physical activity, assessed by either accelerometer (n = 5) (2,6,26,34,38), parent self-report (n = 2) (22,23), or pedometer (n = 1) (20). Five of these studies implemented some type of curriculum (6,20,22,23,34), whereas three used environmental/policy strategies (2,26,38). Although all five curricular studies included a physical activity component, the primary focus in four of these studies was obesity prevention (20,22,23,34), whereas the last focused primarily on bone health (6). In comparison, the primary focus of all three of the environment/policy interventions was physical activity (2,26,38).All five curricular studies had average-to-strong research designs (one within-center randomization [6], one between center randomization [20], and three cluster-randomized [22,23,34]); however, only two were able to demonstrate significant increases in children's physical activity-Binkley and Specker (6) and Eliakim et al. (20). Binkley and Specker (6) evaluated the impact of physical activity and calcium supplementation on children's bone mineral content using a factorial design (calcium-yes/no; physical activity-gross motor/fine motor). The physical activity component was delivered in 30-min sessions, 5 d·wk−1, for 12 months. The gross motor group participated in bone-loading activities such as jumping, hopping, and skipping, whereas the fine motor group was given an equivalent amount of time for activities that kept children sitting quietly, such as arts and crafts. In the second study, Eliakim et al. (20) evaluated the impact of a health promotion intervention on child weight outcomes. The program included structured physical activity sessions and nutrition education. This intervention was delivered in 45-min sessions, 6 d·wk−1, for 14 wk, using a circuit training approach with a large focus on endurance activities but incorporating coordination and flexibility activities as well. Two days a week, sessions were led by a professional youth coach, whereas on other days, they were led by a preschool teacher (or assistant).Two of the three null studies were conducted by Fitzgibbon et al., both testing the Hip-Hop to Health, Jr. intervention. One implemented the intervention in a predominantly African American population (22), whereas the other used a predominantly Latino population (23). This program had an obesity focus and was delivered in 45-min sessions, three times per week, for 14 wk, with equal time dedicated to nutrition and physical activity topics. The physical activity sessions included a 5-min warm-up, a 10-min aerobic activity, and a 5-min cool-down led by the teacher. Multiple games and strategies, such as "trips to the zoo," were used. Although a significant reduction in weight gain (the primary outcome) was observed in the African American sample, no differences were found in the Latino sample. It should be noted, however, that a relatively weak physical activity measure (parental report of physical activity time and intensity) was used in both these studies. The third null study was conducted in Scotland and evaluated the Movement and Activity Glasgow Intervention in Children (MAGIC), a program designed to prevent obesity by promoting increased physical activity (34). The program consisted of 30-min sessions, 3 d·wk−1, for 24 wk, and provided physical activity programming delivered by trained school staff members. Activities were designed to increase children's physical activity and fundamental movement skills. Failure of the MAGIC intervention was puzzling on the basis of positive results observed in the initial pilot (35).The other three studies with physical activity outcomes were classified as environment/policy interventions. Unlike the curricular studies noted above, impact on physical activity was assessed during the program rather than after intervention. The strategies used within these three environment/policy studies varied; one provided additional outdoor free play time (2), one added special portable equipment to the playground (26), and one provided training to classroom teachers about integrating physical activity into their usual classroom lessons (38). None of these studies had robust research designs and could, in most cases, be described as pilot or feasibility studies. Both the provision of playground equipment and teacher training demonstrated significant results, but additional recess time had no effect.Studies targeting a physical activity-related outcome.Eight studies included a physical activity-related outcome; five of these were curriculum-based (14,15,20,31,33) and three were environment/policy interventions (5,42,43). Outcomes assessed in these studies ranged widely and included HR (14,33), physical fitness (20,31), sedentary time (15), child care physical activity environment (5,42), and physical activity programming (43). Within the five curricular interventions, physical activity was the primary focus for two (14,33), one focused on TV viewing (15), and the remaining two focused on obesity (20,31). Within the three environmental/policy interventions, only one focused primarily on physical activity (43), while the remaining two focused on obesity (5,42).All five of the curriculum-based studies demonstrated significant impact on their physical activity-related measures. The two physical activity-focused curricular studies used HR monitoring to assess program impact, comparing HR during the intervention with usual child care conditions (14,33). Deal (14) provided children with a single session of a 2-h movement program. Children were guided, one-on-one by a university student, through a series of 10-min lessons in locomotor, manipulative, stability or gymnastics, large muscle or climbing, fitness, and swimming (20 min) skills. The study by Parish et al. (33), which also assessed HR, implemented a "mastery motivational play" program delivered in 30-min sessions, 2 d·wk−1, for 3 wk. These play sessions were designed to promote mastery of key gross and fine motor skills and foster child motivation to participate in physical activities. Changes in children's triceps skinfolds were used to assess the impact of the obesity-focused intervention by Mo-suwan et al. (31). For this study, the intervention involved adding a 15-min walk before morning class and a 20-min aerobic dance session after the afternoon nap. The obesity-focused curricular program used by Eliakim et al. (20) (described earlier) was able to show a significant improvement in children's physical fitness (600-m run time) in addition to increasing their physical activity. The final curricular intervention study focused on reducing TV viewing using an interactive, educational program delivered by research staff through seven weekly 20-min sessions (15). Although all curriculum-based studies with physical activity-related outcomes demonstrated positive intervention effects, they varied greatly in terms of design quality, study length, and purpose.The three remaining studies with a physical activity-related outcome assessed the child care environment or teacher-reported behavior. Two of these studies, a pilot and a main trial, implemented the Nutrition and Physical Activity Self-assessment for Child Care (NAP SACC) intervention (5,42). The NAP SACC intervention was implemented by Child Care Health Consultants-individuals employed by counties and municipalities to improve health and safety at child care. During a 6-month period, centers are led through five core steps: 1) self-assessment, 2) action planning, 3) educational workshops delivered by consultants, 4) technical assistance from consultants, and 5) repeat of self-assessment. Consultants were encouraged to maintain frequent contact with centers throughout to provide technical assistance. The Environment and Policy Assessment and Observation (EPAO) instrument, developed specifically for the study (41), was used to assess changes in centers' environmental characteristics. In both pilot and main trial, findings were modest but encouraging. The third environment/policy intervention study piloted the utility of incorporating Animal Trackers into the preschool curriculum (43). The program provided several 10-min activities designed to integrate structured movement and motor skills practice with preschool learning concepts. During this 10-wk intervention, teachers were encouraged to incorporate one 10-min activity each day. Although results demonstrated program adoption, the single-group posttest-only design provided no information about how much structured physical activity took place before the implementation.Studies targeting a motor skills outcome.Five intervention studies were found that included a focus on motor skill outcome; four were curricular (13,25,34,40) and one was classified as environment/policy (24). All of these intervention studies demonstrated positive impact on some aspect of children's motor skills. Only one of them used a strong research design with a large number of participants (34), because it was powered for its primary outcome, accelerometer-measured physical activity. All of the other studies had weak research designs (e.g., within-center randomization [40], parallel group design [25], and no control group [13]) and/or enrolled fewer than 100 children (13,24,25,40).Most of the four curriculum-based interventions resembled physical education programs. The MAGIC study (described earlier) (34), implemented for 24 wk, addressed fundamental motor skills and was designed to meet Scottish Curricular standards for "physical development and movement." Both Connor-Kuntz and Dummer (13) and Goodway and Branta (25) used a motor skill intervention developed from a preschool physical education curriculum (19). Lessons addressed physical fitness, body management, fundamental motor skills, games, and dance objectives and were designed to introduce children to a variety of skills rather than teaching one or two to a mastery level. Connor-Kuntz and Dummer (13) delivered the program using 30-min sessions, 3 d·wk−1, for 8 wk, and compared it against a similar program supplemented with a language enrichment component. Because this study's focus was language development, the motor skills group was considered a control; increased motor skill performance was observed in both groups, with no significant difference between groups. Goodway and Branta (25) used the same curriculum, delivered through 45-min sessions, 2 d·wk−1, for 12 wk, and compared it against a control group receiving the typical preschool program. Large significant changes in locomotor and object manipulation skills were observed in the intervention group compared with the control. Finally, Greek dancing intervention (with music and movement elements, singing games, and dances) was evaluated for its ability to develop coordination skills (kinesthetic, differentiation, balance ability, orientation in space, rhythmic ability, and response ability) (40). Intervention children had significantly higher postintervention scores, although the groups were equivalent at baseline.Of the studies with a motor skills focus, only one located through this review process was classified as an environment/policy study. Gabbard (24) assessed the impact of adding climbing and overhead apparatus to a child care play area and their effect on upper body muscular endurance. Both intervention and control children had access to a play area for 30 min·d−1, 5 d·wk−1, for 10 wk; however, additional climbing and overhead apparatus were available to children in the intervention group. It is unclear, however, whether randomization occurred within one child care center or whether this was a two-group design. Results showed that intervention children had significantly higher strength (straight arm hand) scores after intervention.DISCUSSIONSummary and future research directions.Through this review, we located 19 unique studies that met inclusion criteria: eight that assessed intervention impact on the basis of a measure of physical activity, eight that assessed a physical activity-related outcome, and five studies with a motor skill outcome. Two studies had multiple outcomes that fit two categories (20,34). The limited number of articles found and recent dates of publication for most of the articles (15 of the 19 studies published since 2004) highlight this research's nascent stage of development.Of these 19 studies, only three failed to produce at least some positive outcome: the two Hip-Hop to Health, Jr. studies (22,23) that used a very poor measure of physical activity and the study of Alhassan et al. (2) that was a small pilot in a single Head Start Center where additional free play time was added for 2 d. One additional study, MAGIC (34), scored both a positive and negative outcome-it failed to create an increase in physical activity among the intervention centers, but it did result in a significant improvement in motor skills. Of these studies with a null outcome, three of the four had strong research designs and included many children (22,23,34). Although all the studies with a physical activity-related outcome (HR, body composition, run time, environmental characteristics) and motor skill outcome had positive intervention effects, findings should be interpreted carefully because of the limitations in research design (e.g., nonrandom assignment, no control group, or pilot/feasibility nature). Thus, "cautious optimism" about their conclusions is suggested.Many (n = 12) of the interventions used a formal curriculum to implement structured physical activity that would increase total daily physical activity (6,20,22,23,34), improve motor skill development (13,25,29,34,40), or produce some other activity-related outcome (14,15,20,31,33). Of this grouping, the TV reduction study by Dennison et al. (15) differs considerably from the others in that its purpose is to reduce sedentary behavior, not to increase activity. Deal's (14) use of the single session of a movement program also differs dramatically from the others in that it did not attempt to institute a regular, ongoing program. The 10 studies remaining were all implemented during multiple weeks, providing regular physical activity programming, and hence providing some insight about the ideal amount of structured physical activity useful for the child care setting. Time provided in these curricular interventions ranged between 1.0 and 4.5 h·wk−1. The motor skill development-focused programs, all of which demonstrated positive results, provided 1.5 h weekly of structured activity. None of these studies included sessions longer that 45 min (range = 30-45 min), and none were implemented more than 3 d·wk−1 (range = 2-3 d). In comparison, only two of the five curricular programs targeting total daily physical activity were successful. Programs that succeeded in increasing physical activity provided more structured activity, 2.5-4.5 h·wk−1 (delivered in 30- to 45-min sessions, on 4-6 d·wk−1) versus 1.0-1.5 h·wk−1 (delivered in 20- to 30-min sessions, 3 d·wk−1) provided by the unsuccessful programs. Although 1.5 h·wk−1 of structured physical activity seems sufficient to achieve improvements in motor skills, a greater amount, or dose, may be required to increase children's total physical activity. The higher amount of structured activity required to produce a successful physical activity outcome, 30-45 min·d−1 for 5-6 d·wk−1, is still less than the 1-h (60 min) per day (5 d·wk−1) recommended by National Association for Sport and Physical Education (NASPE) for preschool children (32).Another question that must be addressed in future research is the appropriate balance between structured and unstructured activity. Experts suggest that preschool children be provided with generous amounts of free play time (9), so programs to increase structured physical activity should not be implemented at the expense of children's free play. Existing emphasis on academic preparation already threatens activity time, even in preschool, as was recently noted in a report from the Alliance for Childhood (3). If time during the preschool or nursery school day is highly structured with academic preparation, programs requiring teacher-led physical activity might unintentionally reduce the time children are provided for free or self-directed play. As noted by Burdette and Whitaker (9) and endorsed by the American Academy of Pediatrics (4), children should be allowed more free play because it contributes substantially to the enjoyment of play, creativity, and friendship.In this review, three studies altered the free play environment at preschool either through the provision of more time (2) or additional equipment (24,26). No additional activity was observed when children were provided with 30 additional minutes of outdoor free play time in the morning and afternoon. However, this small study was conducted in one Head Start Center, with predominately Latino children, and only for 2 d. Perhaps a longer period of adjustment, or testing in more centers, is necessary. It has been observed that children are most active during the first 10-15 min of time outdoors (11,30). Perhaps an additional activity session of 30 min would be more effective than extending a single session to 1 h.Although the extension of time was ineffective, both studies that added equipment resulted in improved physical activity (26) or improved physical fitness (24). Both these studies were small in scope but consistent with findings from cross-sectional observations. Play equipment, when present, has also been shown to prompt children's participation in more physically challenging activities; conversely, when such equipment is absent, children engage in more sedentary and inactive games (16). Bower et al. (8) found that portable equipment was associated with greater amounts of physical activity, a finding supported in a recent study by Dowda et al. (17).In addition to the studies that provided extra time and equipment, four other interventions targeted environment and/or policy at the child care center. Two studies trained teachers to provide structured physical activity using brief 10-min lessons that could be easily integrated into their preschool curriculum (38,43). Increased activity time was noted in both studies, but the study of Trost et al. (38) used an objective assessment (accelerometers), whereas in the study of Williams et al. (43), teachers reported the time of activity provided. Instead of integrating movement into academic time as in the studies of Trost et al. and Williams et al., Connor-Kuntz and Dummer (13) integrated language development into activity time, demonstrating that this reverse integration did not diminish the motor skills' impact. Policies that promote integration of physical activity with existing preschool curriculum may be a feasible approach to balancing the many demands on time during the preschool day.Policies promoting structured physical activity should also consider the need for teacher training. Among the studies that provided structured physical activity programs, most used specialized, well-trained staff to implement at least part of the intervention. The importance of sufficient training is further illustrated by studies that have attempted to use existing child care staff for program delivery. The MAGIC intervention (34), which used "nursery staff," failed to produce increases in children's physical activity. Investigators suggested that insufficient teacher training was a possible cause. Although process data showed "good" implementation of the physical activity program during the full trial, investigators perceived that quality of delivery in the pilot (which had a significant finding) was higher. The "move and learn" intervention (38) also depended on existing preschool teachers for incorporating these new lessons into their regular curriculum. Although teachers received a 3-h training session and a video demonstration of activities, investigators noted that teachers experienced difficulty implementing the lessons and required additional training midway through implementation. This additional training did seem to rectify the issue. These two studies call attention to the challenges associated with adequately training teachers or staff to implement structured activity programs and highlight the need for policies to address this issue (17,18).The majority of studies included in this review used targeted strategies to influence physical activity at child care by focusing on specific aspects, such as structured or unstructured physical activity time, additional equipment, or teacher training. The NAP SACC intervention (5,42) was quite different, taking a more comprehensive approach to environment and policy. Although the NAP SACC intervention itself had modest results, it did provide a method for addressing the array of child care environment and policy characteristics that could be leveraged to increase children's physical activity. The project created a set of "best practice guidelines" identifying eight target areas within the child care setting: active opportunities, portable and fixed play equipment, sedentary opportunities, sedentary environment, staff behaviors, physical activity training/education, and physical activity policies. Although these guidelines were created on the basis of the best available evidence, more research is required to understand how each of the factors, individually and collectively, influences child activity.Intervention research designed to increase physical activity in young children through child care settings is in its infancy. Such studies are indispensable for developing policies and practices concerning the amount and type of physical activity that should be provided at child care. Also, studies such as these will identify approaches that not only increase physical activity during a child's day at a care facility but also lay a foundation for an active, healthy life. The studies reviewed in this article not only provide valuable insight into existing physical activity interventions conducted at child care settings but also highlight the many gaps in knowledge that still remain. Although the differences in research design, intervention focus, and outcomes measured make it difficult to draw solid conclusions or offer specific recommendations, the findings do provide encouragement that regularly provided, structured physical activity programs can increase the amount and intensity of physical activity that children receive and improve children's motor skills. Because of the varied nature of outcomes measured and the small number of existing studies, no conclusions can be drawn regarding improving fitness level or weight status, reducing TV viewing time, or increasing overall physical activity. Modifications to the child care environment, such as additional equipment, teacher training, and altered physical activity policies/practices, have the potential to improve child physical activity outcomes but require additional investigation. Only through increased quantity and quality of research in this area will we be able to understand how the child care setting affects physical activity of young children and what intervention strategies are most appropriate to produce active, healthy children.Disclosure of funding: None.Special thanks to Rachel Tabak for her contribution to the review process and in editing the manuscript.Results presented in this article do not constitute endorsement by the American College of Sports Medicine.REFERENCES1. Alderman J, Smith JA, Fried EJ, Daynard RA. Application of law to the childhood obesity epidemic. J Law Med Ethics. 2007;35(1):90-112. [CrossRef] [Medline Link] [Context Link]2. Alhassan S, Sirard JR, Robinson TN. 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