Benefits of physical activity
Physical activity is associated with a reduced risk of heart disease, stroke, type 2 diabetes mellitus, obesity and some cancers.1 Physical activity is also associated with improved profiles for a number of risk factors, including insulin, glucose, blood pressure, body composition2 and emotional well-being in young people3 and adults.1
Children’s physical activity levels
Despite the widely demonstrated benefits associated with being regularly physically active, data from the UK Millennium cohort study4 show that only 51% of 7- to 8-year-olds meet the recommendation of 1 hour of moderate to vigorous physical activity (MVPA) per day. Primary school is a key time for developing motor co-ordination and sport-related skills and for building children’s confidence and interest in physical activity. Physical activity levels in children have been shown to decline during primary school.5,6 Making the most of these ‘skill-hungry’ years could be essential to the development of positive physical activity skills and attitudes. There is moderate evidence of physical activity behaviours tracking from childhood to adulthood;7 therefore, finding ways to foster physical skills and positive attitudes during these early years may help children engage in regular physical activity at secondary school and on into adulthood.
Previous school-based physical activity interventions
The primary school setting provides opportunities to reach large numbers of children in order to implement public health interventions.8 Systematically reviewed evidence9 has indicated that the effectiveness of school-based physical activity interventions delivered during the curriculum is limited. The review concluded that where there was an effect this was mainly in studies of poor methodological quality.9 Identified limitations included short follow-up, inadequate adjustment for potential confounders, lack of adjustment for children clustered in schools and the use of self-report measures of physical activity.9 A 2012 review10 of physical activity interventions for children and adolescents, which included an objective assessment of physical activity, reported an average improvement of 4 minutes of MVPA per day in intervention participants compared with control participants. Of the 30 studies included in the review, only 16 were deemed to be of high methodological quality. Contributory factors to low-quality scores included high attrition, lack of intention-to-treat (ITT) analyses and no adjustment for the clustered nature of the data.
There is an absence of child physical activity programmes that have been shown to be effective and that are ready to be implemented by local public health teams.11 The RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework was developed to translate research into practice.12 The RE-AIM framework strikes a balance between public health-focused interventions that have good internal validity (as examined in effectiveness trials) and public health-focused interventions that have good external validity (can be nationally implemented).12 Numerous physical activity interventions have shown promise at the pilot/feasibility stage, but either they failed to achieve an impact in a definitive trial10 or, if an impact was achieved throughout a trial, this was not sustained during implementation.13 As such, it is important to design physical activity interventions with future implementation in mind. A feasibility study can be used to identify changes to the study/intervention design that can enhance the external validity of the definitive trial evaluation.14 One way to achieve this is to identify whether or not all elements of the RE-AIM framework can be assessed and then use the information to guide changes to the design.11
Rationale for extracurricular interventions
The primary school curriculum is limited to 2 hours of physical education (PE) per week, making it challenging to implement curriculum-based physical activity interventions and providing little opportunity for children to meet public health guidelines or to develop their physical literacy.15 Time immediately after school is discretionary time for children16 and could be utilised to promote physical activity.17 Evidence shows that children who are inactive after school are less likely to meet physical activity guidelines;16 therefore, organised after-school programmes that maximise the opportunities for physical activity could be an effective means of engaging primary school children in more physical activity.8,18 Owing to a lack of capacity among teaching staff, the current provision of extracurricular physical activity in primary schools is dominated by expensive external practitioners, such as football coaches,19 which is costly to the school or to parents, and caters primarily to children who are already active. Provision may have been enhanced since the UK government doubled the primary school PE Premium to £320M for all primary schools in England, which was available from September 2017;20 however, the external provider model remains expensive for schools.
Use of teaching assistants
Teaching assistants (TAs) are an important part of the school system. TAs support teachers in class management and teaching. The number of TAs has significantly increased in the UK since 2000 and they now constitute one-third of the workforce in UK schools.18 Streamlined staff numbers in schools highlight the importance of utilising existing staff to deliver extracurricular programmes. Therefore, training TAs to deliver after-school programmes could be a low-cost means of helping children to be active. An aim of the study is to assess the feasibility, potential sustainability and cost-effectiveness of an after-school physical activity intervention delivered by TAs.
Use of self-determination theory
Interventions have been more successful when they are based on psychological theory than when they are not.21 Psychological theory can be used to inform intervention design and facilitate the identification (ID) of key mediators of behaviour change.21 Self-determination theory (SDT)22 may be particularly appropriate for understanding children’s physical activity. SDT focuses on motivation for behaviour and argues that those with autonomous motivation (i.e. doing physical activity because it is fun or personally valued) have more positive behavioural, cognitive and affective outcomes than those with controlled motivation (i.e. doing physical activity because of feelings of guilt or pressure from others). Evidence from the PE and sport psychology literature demonstrates that autonomous motivation is associated with positive physical activity outcomes in children and adolescents.23 Previous research into UK primary school children shows that having intrinsic motivation is associated with higher levels of objectively measured physical activity.24 Autonomous motivation and psychological well-being can be achieved when three innate needs are met: (1) autonomy (i.e. having choice about and ownership over one’s behaviour), (2) competence (i.e. feeling able and effective in one’s environment) and (3) relatedness (i.e. feeling a mutual sense of connectedness with others). Cross-sectional evidence supports the positive relationship between psychological need satisfaction and autonomous motivation in primary school children.24 Thus, programmes that help children feel part of the decision-making process, confident and competent in their physical ability and part of a supportive team will increase their motivation to be and remain active.
Another feature of SDT is that it suggests that motivational quality is determined partly by the motivational climate created by leaders.25 This is particularly appropriate for Action 3:30R (hitherto referred to as Action 3:30 for simplicity), as previous research has shown that TAs can be trained to provide curricular content in a safe environment, using a delivery style that fosters optimal motivation and development.26 For example, TAs can enhance autonomous motivation by (1) being autonomy-supportive (e.g. involving children in decision-making), (2) providing structure (e.g. giving clear expectations, reasoning and guidelines) and (3) being interpersonally involved (e.g. showing empathy and interest). By doing this, TAs can have a positive effect on pupils’ motivation, behavioural engagement and psychological well-being.25
Summary of formative work
An evaluation was recently completed of an after-school intervention, Action 3:30.18 The original feasibility study was conducted in 20 schools and participants were Year 5 and 6 pupils (aged 9–11 years). Ten schools were allocated to the intervention arm and 10 schools were allocated to the control arm (normal practice). The intervention consisted of training TAs to deliver 60-minute after-school physical activity sessions twice per week for 20 weeks. The intervention was based on SDT. TAs were trained to facilitate sessions that covered a range of activities and provided support for pupils’ autonomy, competence and relatedness.27 The results showed that the Action 3:30 intervention holds promise as a scalable physical activity approach.26,28 The adjusted difference in weekday MVPA was 4.3 minutes higher [95% confidence interval (CI) –2.6 to 11.3 minutes higher] at the end of the intervention in the intervention arm. Sex-stratified analyses indicated that the intervention may hold more promise for boys (8.6 more minutes of weekday MVPA than control, 95% CI 2.8 to 14.5 more minutes) than for girls (0.15 more minutes of weekday MVPA than control, 95% CI –9.7 to 10.0 more minutes). The results from the process evaluation suggested that the intervention was implemented as planned and well received by schools, TAs and pupils.26,28 Although the effect on mean levels of MVPA among boys was among the best that has been shown for physical activity interventions in children,21 more work is needed to improve the content for girls. In addition, findings from the process evaluation showed that improvements are required to improve attendance, recruit less active pupils and increase TAs’ ability to manage disruptive behaviour.
Rationale for the trial
The evaluation of the original Action 3:30 programme showed that training TAs to deliver after-school physical activity sessions holds promise. The issues raised from the original programme have been addressed in a revised intervention. The aim of the study is to test, in a feasibility study, whether or not the revised intervention leads to increases in the physical activity of both boys and girls, as well as whether or not it results in the recruitment of less active children and in higher attendance levels. In addition, the study aims to test whether or not it is possible to use the RE-AIM framework to assess the implementation potential of the intervention.