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Journal for Specialists in Pediatric Nursing

REVIEW ARTICLE

A systematic review of interventions to promote physical activity in the preschool setting Melissa Temple and Jennifer C. Robinson Melissa Temple, MSN, RN, is a PhD Candidate; and Jennifer C. Robinson, PhD, RN, FAHA, is an Associate Professor of Nursing, School of Nursing, University of Mississippi Medical Center, Jackson, Mississippi, USA

Search terms Children, environment, exercise, intervention study, motor activity, preschool, physical activity. Author contact [email protected], with a copy to the Editor: [email protected] Disclosure: The authors report no actual or potential conflicts of interest. Funding: No external or intramural funding was received. First Received November 7, 2013; Revision received February 19, 2014; Accepted for publication April 11, 2014.

Abstract Purpose. Conduct a systematic review of school-based interventions to promote physical activity in preschoolers. Design and Methods. A systematic search of literature between 2002 and 2014 in nine electronic databases and reference lists was conducted using the terms physical activity combined with environment, children, or interventions. Results. Fourteen articles were identified. Interventions were environmental, cognitive/behavioral, or a combination. Positive interventions involving preschool children included manipulation of the playground with the number of children playing at one time, markings, or equipment, and goal setting and reinforcement. Practice Implications. More research is needed to determine interventions to promote physical activity in preschool children.

doi: 10.1111/jspn.12081

One of the most serious public health problems today is obesity, and it is also one of the most difficult to eliminate. Over the past several decades, obesity rates have dramatically increased in all age groups (Centers for Disease Control and Prevention [CDC], 2013). Obesity rates among children have increased to epidemic proportions, with 32% of children being classified as overweight or obese in the United States (Institute of Medicine [IOM], 2012). Obesity rates are projected to continue to rise even though the incidence has slowed in recent years (IOM, 2012). Childhood obesity rates have more than doubled over the past 30 years among children between the ages of 2 and 5 years (National Institute of Health, 2012). The IOM’s Report on Early Childhood Obesity Policies indicated that “more than 20 percent of children between the ages of 2 and 5 are already overweight or obese” (Institute of Medicine of the National Academies, 2011, p. 1) even before they enter elementary school. Childhood obesity is a 274

strong predictor of overweight and obesity in adolescence and adulthood (CDC, 2012a). Evidence suggests that excess weight gained before 5 years of age will likely carry into later childhood. Weight at the age of 9, and then later in puberty, can be closely predicted from weight at the age of 5 (Gardner et al., 2009). Using data from a nationally represented sample of 7,738 children from the Early Childhood Longitudinal Study of the Kindergarten Class of 1998–1999 enrolled about fifteen years ago, over 12% of children were obese and almost 15% were overweight at the age of 5 (Cunningham, Kramer, & Venkat Narayan, 2014). Most disturbing was that overweight 5-year-olds were four times as likely as normal weight children to become obese by eighth grade. The impact of childhood and adult obesity on health is well documented. Obesity-related diseases, such as diabetes, heart disease, kidney failure, and cancer, can shorten life expectancy and are appearing at earlier ages (CDC, 2012a). Journal for Specialists in Pediatric Nursing 19 (2014) 274–284 © 2014, Wiley Periodicals, Inc.

M. Temple and J. C. Robinson

A Systematic Review of Interventions to Promote Physical Activity in the Preschool Setting

Long-term effects of obesity may lead to loss of productivity, increased health costs, and decrease in the quality of life (IOM, 2012). One of the major contributing factors to the increasing prevalence of obesity is insufficient physical activity for health (Cardon, Labarque, Smits, & De Bourdeaudhuij, 2009; Glickman, Parker, Sim, Cook, & Miller, 2012; Khan, 2011). Health-related behaviors, including physical activity, are learned in childhood and may persist into adulthood (Muckelbauer, Kalhoff, Mauller-Nordhorn, & Kersting, 2011). Physical activity and obesity are inversely related (Khan, 2011; Metallinos-Katsaras, Freedson, Fulton, & Sherry, 2007). Although the link between physical activity and weight is well known, preschool children may not be getting the nationally recommended amounts of, or intensity of, physical activity (Oliver, Schofield, & Kolt, 2007). Amount, intensity, and frequency are important components of determining physical activity. Activity intensity is usually categorized as sedentary, light, moderate, or vigorous. Sedentary activity is defined as extended engagement of behaviors requiring minimal movement, low energy expenditure, and rest (Tremblay, 2010), while light activity is defined as activity that does not increase the heart rate. Moderate physical activity causes the heart rate and breathing to be noticeably faster but not to the point a person cannot have a conversation, such as when walking briskly. Vigorous activity is physical activity that increases the heart rate substantially, causing hard and fast breathing to the point that it is no longer possible to have a conversation, such as when running (CDC, 2011a). There is increasing recognition that not only amounts of physical activity are important but that time spent in sedentary activity may be an important risk factor impacting health (Cardon et al., 2009; CDC, 2011a; Glickman et al., 2012; Khan, 2011). It is recommended that preschoolers should not be inactive or sedentary more than 60 min at a time unless sleeping (National Association for Sport and Physical Education [NASPE], 2009). The national recommendation by the CDC for physical activity for children and adolescents is the accumulation of 60 min or more of physical activity every day (CDC, 2011a). Providing even more guidance, the NASPE recommendation is the accumulation of at least 120 min of physical activity every day for preschool children, including 60 min of structured physical activity and 60 min of unstructured activity. During structured physical activity, bouts of moderateto-vigorous physical activity should be built in and Journal for Specialists in Pediatric Nursing 19 (2014) 274–284 © 2014, Wiley Periodicals, Inc.

should last 6–10 min (NASPE, 2009). However, in two separate studies that measured physical activity via accelerometers, U.S. preschool children spent more than 60% of their active time in light activity (Metallinos-Katsaras et al., 2007), more than 6 hr each day being sedentary, and spent only 15 min per day in moderate-to-vigorous physical activity (Dolinsky, Brouwer, Evenson, Siega-Riz, & Ostbye, 2011). Average daily moderate-to-vigorous physical activity in preschool-aged children has been found to vary from 12 min to 36 min per day, and time spent in sedentary activity has been found to range from 217 min to 389 min per day, dependent on the childcare center they were attending (Sugiyama, Okely, Masters, & Moore, 2012). Increasing physical activity and decreasing sedentary time in young children have been among the major strategies in the forefront of the battle against childhood obesity. METHODS

The purpose of this article is to review interventions that have been effective in preschool-aged children that can be used to combat excess weight gain and obesity and promote healthy habits early in life. A systematic literature search was conducted to identify studies reporting preschool-based interventions to promote physical activity. The search was conducted in nine electronic databases, namely Academic Search Premier, Cumulative Index to Nursing and Allied Health Literature, PsycInfo, PubMed, Education Resources Center, Cochrane Central, Cochrane Systematic Reviews, Middle Search Plus, and Teacher Reference Center. The search was limited to research published in English from January 2002 to January 2014, and included the key terms physical activity combined with environment, or children, or interventions. Additionally, references lists from the review articles identified in the searches were reviewed, yielding additional studies. Eligible articles included interventional studies in which physical activity was the outcome. Young children and preschool-aged children enrolled in childcare settings were included. Studies that included a wider range or older upper age limit in the sample were included if preschool-aged children were also involved. Qualitative, descriptive, correlational, and study design manuscripts were excluded. Other exclusion criteria were non-English publications, review articles, studies with no physical activity interventions, or those not conducted in a 275

A Systematic Review of Interventions to Promote Physical Activity in the Preschool Setting

Electronic databases (Limits: January 2002–January 2014, English) n = 3,002

M. Temple and J. C. Robinson

Excluded: topics unrelated to school interventions, community and home interventional studies, correlation and descriptive studies, repetitive studies n = 2,907

Abstract/full-text review n = 95 Bibliography search n = 138

Figure 1 Flowchart of Selected Studies.

Excluded due to date, outcome criteria, study design, intervention, and repetitive study n = 219

Studies eligible for inclusion (n = 14) Environmental (n = 6) Behavioral (n = 4) Combination (n = 4)

school setting, such as the community-, family-, or clinic-based interventions. First, article titles were reviewed by the investigator for eligibility. Next, the abstracts of articles not excluded previously were reviewed, followed by full article review if not excluded based on the abstract. After full article review, if it was unclear whether the article met the eligibility criteria, a second investigator was consulted and consensus was reached. The search generated 3,002 articles (see Figure 1). After exclusion, 14 research articles were eligible. Studies were classified as environmental, cognitive/ behavioral, or a combination of the two. Environmental interventions are defined as strategies that manipulate the environment in some way, such as the physical design and elements, land use, or recreational facilities. Cognitive/behavioral interventions are strategies based on the cognitive ability of the target population to manipulate behavior through awareness and education. Interventions were cognitive/behavioral (n = 4), environmental (n = 6), or a combination of environmental and cognitive/behavioral (n = 4). Figure 1 depicts the search outcomes. RESULTS

Eligible article publication dates ranged from 2002 to 2014 by design, with half published in the past 4 years (n = 7). The settings included the United States 276

(n = 6) and non-United States (n = 8). Sample sizes ranged from 47 to 804, while the range of the number of schools the participants were selected from was 1–84. The age of the children ranged from preschool to 11 years old. Eight of the 14 studies were conducted outside the United States, primarily from Belgium (n = 2), the United Kingdom (n = 4), and Australia (n = 2; Cardon et al., 2009; Engelen et al., 2013; Finch et al., 2014; O’Dwyer, Ridgers, Knowles, Foweather, & Stratton, 2013; Stratton & Leonard, 2002; Stratton & Mullan, 2005; Van Cauwenberghe, De Bourdeaudhuij, Maes, & Cardon, 2012; Warren, Henry, Lightowler, Bradshaw, & Perwaiz, 2003). The majority of the studies with authors reporting significant increases in physical activity were conducted outside the United States, with only two studies in the United States resulting in significant increases. Fifty percent of the interventions used in studies outside the United States were environmental (n = 4). Of the studies conducted in the United States, the types of intervention were equally distributed. Of the studies included in the review, four environmental intervention studies resulted in increased physical activity, with all four interventions being playground-oriented. Three involved the school playground with playground markings (Stratton & Leonard, 2002; Stratton & Mullan, 2005), one Journal for Specialists in Pediatric Nursing 19 (2014) 274–284 © 2014, Wiley Periodicals, Inc.

M. Temple and J. C. Robinson

A Systematic Review of Interventions to Promote Physical Activity in the Preschool Setting

involved the addition of play equipment (Hannon & Brown, 2008), and one study decreased playground density (Van Cauwenberghe et al., 2012). One combination cognitive/behavioral and environmental intervention resulted in increased physical activity. The intervention was the addition of loose recycled material to the playground area, as well as parent and staff education (Engelen et al., 2013). One behavioral intervention study resulted in increased physical activity. The intervention was described as the addition of 30 min of structured activity daily consisting of a mixture of light, moderate-to-vigorous, and vigorous physical activity with long- and short-term goal setting using a chart with stickers. Lesson plans incorporated reminders to promote self-efficacy and selfregulation (Annesi, Smith, & Tennant, 2013). All six intervention studies that resulted in increased physical activity measured physical activity objectively using accelerometers (Annesi et al., 2013; Engelen et al., 2013; Hannon & Brown, 2008; Van Cauwenberghe et al., 2012) or heart rate monitors (Stratton & Leonard, 2002; Stratton & Mullan, 2005). In the studies with no significant change in physical activity postintervention, physical activity was measured by pedometer (Bellows, Davies, Anderson, & Kennedy, 2013), questionnaire (Fitzgibbon et al., 2005; Warren et al., 2003), or using an observation tool (Cosco, Moore, & Smith, 2014; Finch et al., 2014; Ward et al., 2008). There was no measure that was used consistently based on the type of intervention being implemented. The cognitive/behavioral studies each reported using pedometers, accelerometers, and questionnaires. The studies implementing combination interventions used accelerometers, pedometers, questionnaires, and observation to measure physical activity. Accelerometers, observation, and heart rate monitors were used with the environmental intervention studies (see Table 1). COGNITIVE/BEHAVIORAL INTERVENTIONS

Four studies utilizing cognitive/behavioral interventions were identified (see Table 1). The interventions were specific curriculum programs designed to incorporate activity into the curriculum while educating children about healthy lifestyles. Only one behavioral intervention resulted in positive increases in physical activity. The sample was made up of 92% African American children, and the intervention was a curriculum intervention modifying the 30 min of structured physical activity each day by combining with behavioral skills training that was preschool age-appropriate. The 30-min strucJournal for Specialists in Pediatric Nursing 19 (2014) 274–284 © 2014, Wiley Periodicals, Inc.

tured physical activity included bouts of light, moderate-to-vigorous, and vigorous physical activity. The behavioral component, which comprised goal setting, monitoring progress, and acknowledgment of achievement, was intermingled with the physical activity. In the control group, 30 min of structured physical activity was varied based on teacher discretion, with no specific durations of times for intensities of physical activity. Statistical analysis revealed significant increases in vigorous and moderate-to-vigorous physical activity (p < .001, p < .001, respectively). This represented an increase of 9.3% of vigorous physical activity and 8.7% of moderate-to-vigorous physical activity in the treatment group when compared with the control group (Annesi et al., 2013). In another cognitive/behavioral study, schooland family-based interventions were used to promote physical activity in children 5–7 years old. Children were randomly assigned to a control group, nutrition group, physical activity group, or a combination nutrition and physical activity group. Physical activity patterns were assessed by asking children about their school day via a questionnaire completed by parents, with only a 45% completion rate at the final stage. No change was noted in the physical activity patterns of the children at the end of the study (Warren et al., 2003). A third study implemented in Head Start centers in the United States involved a curriculum-designed intervention focused on motor skills and nutrition. The curriculum intervention was taught 4 days a week for 18 weeks for 15–20 min. It was led by the teacher and consisted of multiple activities. Both the intervention and control group also received a 12-week nutritional program. In another interventional component in the study, educational materials were sent home to parents. Parents recorded the number of steps their children took each day, measured by pedometer. No intervention effect was found on physical activity levels (Bellows et al., 2013). Finally, an active curriculum aimed at increasing physical activity and decreasing sedentary time was implemented in the fourth study. Accelerometers were used to measure sedentary time, light physical activity, and moderate-to-vigorous physical activity. No intervention effect was found for sedentary time or physical activity (O’Dwyer et al., 2013). ENVIRONMENTAL INTERVENTIONS

Six publications were categorized as environmental interventions (see Table 1). Studies that focused on 277

278

Setting

United States Salt Lake City, Utah University-based preschool England urban area schools Northwest Wales schools in deprivation areas Belgium Preschool

Hannon and Brown (2008)

Bellows and colleagues (2013)

United States Head Start centers in rural and urban setting

Van Cauwenberghe and colleagues (2012) Behavioral interventions United States Annesi and colleagues YMCA preschools Metropolitan (2013) Atlanta

Stratton and Leonard (2002) Stratton and Mullan (2005)

United States North Carolina licensed childcare centers

Cosco and colleagues (2014)

Environmental interventions Cardon and Belgium public colleagues preschools (2009)

References

Table 1. Literature Review

3–5 years, primarily African American

Preschool

238 (7)

201 (4)

Replaced regular 30 min structured physical activity with sessions of activity which included bouts of Vig and MVPA combined with goal setting, self-monitoring, and achievement acknowledgment; control continued regular 30 min structured time Intervention group: 15–20 min teacher-led activities 4 days/week for 18 weeks and 12-week nutrition program; control: 12-week nutrition program

4–6 years

4–11 years

99 (4)

128 (4)

5–7 years

3–5 years

Preschool

4–5 years

Age

47 (2)

64 (1)

804 (27)

583 (40)

No. of children (schools)

Lowering playground density during recess

Fluorescent colored playground markings Multicolor playground markings

Adding play equipment to the playground

4 conditions: (1) play equipment, (2) markings, (3) play equipment plus markings, (4) control Changing the playground by outdoor renovation and garden installation

Intervention strategy

Pedometers

Accelerometers

Accelerometer

Heart rate monitors

Heart rate monitors

Accelerometers

Observation—CARS

Accelerometers

Measures

Steps

Vig MVPA ST

PA levels (min)

MVPA, VPA, and MVPA

EE

Stationary, stationary with limb or trunk movement, slow-easy, moderate, fast Sedentary, light, moderate, and vigorous PA

Sedentary, light, moderate, or vigorous PA

Outcome

None identified

Behavior change theory

+Light-moderate PA; +MVPA at recess; −Sed time; effect stronger in girls

+Vig; +MVPA; -Sed time

None identified

None identified

+MVPA +VPA

No significant difference between intervention and control group

None identified

None identified

None identified

Theory

No significant findings, although children were found to be 22% more likely engaged in nonsedentary activities post-renovation −Sedentary +Light +Moderate +Vigorous + EE

No change in activity levels detected

Results

A Systematic Review of Interventions to Promote Physical Activity in the Preschool Setting M. Temple and J. C. Robinson

Journal for Specialists in Pediatric Nursing 19 (2014) 274–284 © 2014, Wiley Periodicals, Inc.

Journal for Specialists in Pediatric Nursing 19 (2014) 274–284 © 2014, Wiley Periodicals, Inc. Preschool

Primary school 5–7 years

5–7 years old

3–5 years

Preschool

Preschool

156 (12)

213 (3)

226 (12)

459 (20)

289 Year 1; 300 Year 2 (12)

34 case workers (84 childcare centers)

EPAO

Questionnaire

Pedometers EPAO

Accelerometers

Questionnaire

Accelerometers

Nutrition and PA Environment and policies

BMI, freq and duration PA, TV viewing, food intake

Steps

Sedentary, light PA, MVPA

Knowledge and PA frequency and duration

LPA, MVPA, Sed

None identified

SCT SEC

No change in PA or TV viewing

Nonsignificant improvement

SEC

None identified

+Total PA +MVPA

Nonsignificant change in mean child step counts

None identified

SEC

No change in PA patterns

No intervention effect detected at 6 weeks or 6 months

Notes: BMI, body mass index; CARS, Children Activity Rating Scale; EE, energy expenditure; EPAO, Environment and Policy Assessment and Observation; LPA, light physical activity; LTPA, leisure physical activity; mod and MPA, moderate physical activity; MVPA, moderate-to-vigorous physical activity; PA, physical activity; SCT, social cognitive theory; SEC, social ecological theory; sed, sedentary; vig or VPA, vigorous physical activity.

England 6-week educational program for Preschools in staff and children and activity disadvantaged cards; control received areas resource pack no guidance Warren and United Kingdom 4 conditions: (1) “Eat Smart,” (2) colleagues Oxford “Play Smart,” (3) “Eat Smart & (2003) Primary schools in Play Smart,” (4) “Be Smart” close proximity to the university Combination environmental and cognitive/behavioral interventions Engelen and Australia Addition of loose recycled colleagues Catholic co-ed materials to school playground (2013) primary schools in and group education Sidney intervention for teachers, staff, and parents Finch and New South Wales, 20 min daily structured colleagues Australia movement sessions, increase (2014) Childcare centers opportunities for activity, staff role modeling, limiting screen time, more readily available portable play equipment Fitzgibbon and United States Weekly newsletters and colleagues Chicago assignments for parents, (2005) Head Start centers 40 min education session for children combined with physical activity; control received a general health intervention Self-assessment, action planning, United States Ward and continuing education colleagues North Carolina childcare centers workshops, technical (2008) assistance, and reassessment of childcare setting

O’Dwyer and colleagues (2013)

M. Temple and J. C. Robinson A Systematic Review of Interventions to Promote Physical Activity in the Preschool Setting

279

A Systematic Review of Interventions to Promote Physical Activity in the Preschool Setting

playground changes demonstrated the most promise in promoting physical activity in young children, including preschool children (Hannon & Brown, 2008; Stratton & Leonard, 2002; Stratton & Mullan, 2005; Van Cauwenberghe et al., 2012). Two separate studies with interventions described as adding playground markings and painting playgrounds produced significant increases in energy expenditure among 5- to 7-year-old children (p ≤ .02; Stratton & Leonard, 2002), and significant increases in moderate-to-vigorous physical activity among 4- to 11-year-old children (p < .01; Stratton & Mullan, 2005). Lowering of playground density by decreasing the number of preschool children on the playground at one time caused small but positive (p < .001) increases in light-to-vigorous and moderateto-vigorous physical activity in children 4–6 years old (Van Cauwenberghe et al., 2012). The approach used by Hannon and Brown (2008) to increase physical activity in preschool children involved adding equipment to the playground. Although children spent almost half of their outdoor playtime sedentary, there was a decrease from baseline in sedentary activity and an increase in light, moderate, and vigorous physical activity (p < .001 for all four measures; Hannon & Brown, 2008). Two other studies that modified playgrounds did not demonstrate significant changes, however. One environmental study utilizing playground markings, plus the addition of playground equipment, did not detect any significant changes in physical activity (Cardon et al., 2009). The last study renovated preschool playgrounds, and while children were more likely to be nonsedentary moderate-to-vigorous physical activity did not significantly increase (Cosco et al., 2014). COMBINED ENVIRONMENTAL AND COGNITIVE/BEHAVIORAL INTERVENTIONS

A total of four studies with combined cognitive/ behavioral and environmental interventions were identified (see Table 1). The predominant cognitive/ behavioral interventions utilized included education and training for staff, children, and/or parents. There were three studies with no significant results (Finch et al., 2014; Fitzgibbon et al., 2005; Ward et al., 2008). Two interventions were not specifically focused on physical activity but also included nutrition and had multiple outcome measures, including body mass index (Fitzgibbon et al., 2005; Ward et al., 2008). The third study introduced a multilevel intervention specifically focused on physical activity, 280

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with no change in step counts (p = .12) measured by pedometers (Finch et al., 2014). The combination study that did detect an intervention effect reported only physical activity as the outcome measure. In this study, loose materials, such as crash mats, weighted boxes, milk crates, and Styrofoam boxes filled with newspaper and taped shut, were introduced on the playgrounds. In the cognitively focused part of the intervention, parents, teachers, and staff participated in large group discussions related to benefits of free play and health risk taking. Results revealed small but significant increases in break time total physical activity (p = .002) and the number of minutes children spent in moderate-tovigorous physical activity (p = .006), as well as a decrease in sedentary time (p = .01; Engelen et al., 2013). DISCUSSION

Our results indicate that very few physical activity interventions have been tested specifically in preschool-aged children. Further, we found only 14 original articles that described school-based physical activity interventions with varying success. Of those 14 articles, six reported significant findings (four environmental, one behavioral, and one combination of behavioral/cognitive and environmental) and eight articles reported no significant findings (two environmental, three behavioral, and three combination behavioral/cognitive and environmental). Interventions with significant effects were predominately environmental and consisted mainly of playground interventions. The positive effects of making changes in the environment to increase physical activity are similar to findings in other studies with school-aged children (Howe, Freedson, Alhassan, Feldman, & Osganian, 2012; Lanningham-Foster et al., 2008; Loucaides, Jago, & Charalambous, 2009; Ridgers, Fairclough, & Stratton, 2010; Verstraete, Cardon, De Clereq, & De Bourdeaudhuij, 2006). The environment is increasingly being recognized as influential on health behaviors, such as physical activity. Effective interventions with preschool children, such as decreasing playground density, may make more space available for running and chasing, and appear to be a feasible intervention (Van Cauwenberghe et al., 2012). Altering playground space by adding equipment or markings (Hannon & Brown, 2008; Stratton & Leonard, 2002; Stratton & Mullan, 2005) may stimulate physical activity and energy expenditure. Fluorescent colors were used to paint Journal for Specialists in Pediatric Nursing 19 (2014) 274–284 © 2014, Wiley Periodicals, Inc.

M. Temple and J. C. Robinson

A Systematic Review of Interventions to Promote Physical Activity in the Preschool Setting

markings, in two studies reviewed, and included a clock face, a castle, dragon mazes, hopscotch, and a pirate ship on playground surfaces (Stratton & Leonard, 2002; Stratton & Mullan, 2005). In addition, adding small pieces of sports equipment, such as balls, or recycled materials that children can play with may be effective. Many parents comment that often children prefer to play with a big box used to package a toy, rather than the toy itself. Perhaps inexpensive, recycled materials provide children with an opportunity for creative, active play. In adults and communities, changes in the built environment have resulted in increased physical activity in a number of studies (CDC, 2011b; Frost et al., 2010; Schuz et al., 2012), consistent with many of the environmental interventions reviewed. School playgrounds offer a sustainable context for promoting physical activity. Only one cognitive/behavioral interventional study produced an interventional effect (Annesi et al., 2013), while the other three produced no interventional effects (Bellows et al., 2013; O’Dwyer et al., 2013; Warren et al., 2003). The same was true of the combination cognitive/behavioral and environmental intervention studies. One produced a positive interventional effect (Engelen et al., 2013), while the other three did not (Finch et al., 2014; Fitzgibbon et al., 2005; Ward et al., 2008). There may be several reasons for these findings, such as reliance on parent reporting, low response rate at follow-up, short duration of the intervention, and/or insufficient staff training. The behavioral components included education for staff, parent, and/or children. The environmental components consisted of physical activity promotion initiated by staff, such as integrating physical activities with the lessons. Depending on the age and cognitive development of the child, cognitive/behavioral interventions likely will have varying success, especially if used as the only intervention. In the preschool years, developmental milestones in play, learning, speaking, behavior, and movement are still being met. Children in this age group become more independent and explore things around them. Interactions with family and other individuals around them shape their personality and ways of thinking and moving (CDC, 2012b). In this review, only two studies utilizing a cognitive/behavioral intervention resulted in significant increase in physical activity. One was combined with an environmental intervention where the cognitive portion was aimed at adult caretakers (Engelen et al., 2013), and the other (Annesi et al., 2013) was combined with Journal for Specialists in Pediatric Nursing 19 (2014) 274–284 © 2014, Wiley Periodicals, Inc.

structured physical activity sessions with bouts of moderate-to-vigorous and vigorous physical activity built into the sessions. Of note, only the studies that measured physical activity using accelerometers and heart rate monitors were able to detect an increase related to the intervention, indicating that measurement issues may be very important in studies involving young children. Measurement of physical activity in the preschool-aged group is problematic due to the lack of valid and acceptable measures (Pate, Almeida, McIver, Pfeiffer, & Dowda, 2006). Varying methods of measuring physical activity in preschoolers have included measuring physical activity in time, frequency, step counts, energy expenditure based on heart rate, direct observation via tools, and questionnaires answered by parents and/or teachers (Bellows et al., 2013; Cosco et al., 2014; Fitzgibbon et al., 2005; Hannon & Brown, 2008; Stratton & Mullan, 2005). Subjective measures of physical activity include direct observation, which relies on human observation of physical activity by interpretation and recording. There are multiple observation tools available with differing protocols on categories of physical activity. Physical activity is not measured continuously with direct observation; therefore, the inability to adequately assess intermittent physical activity may exist. A second subjective measure of physical activity is via questionnaires (Oliver et al., 2007); however, self-report is not recommended for children under the age of 10. For this reason, teachers and/or parents must be relied on to report physical activity of preschool children on questionnaires (Pfeiffer, Dowda, McIver, & Pate, 2009). Multiple questionnaires are available and have been used in older children and adults, but a standardized questionnaire has not been sufficiently evaluated for physical activity assessment in preschoolers. Pedometers are considered an objective measure of physical activity and are frequently used because of the low cost. Correlational studies have demonstrated moderate associations between pedometers and direct observation. A value of 13,874 steps per day in preschool-aged children is comparable to 60 min of moderate-to-vigorous physical activity per day in children 4–5.9 years old (Oliver et al., 2007). However, in the studies reviewed, there was no increase in physical activity when measured by pedometers, making it unclear if the issue is related to the intervention or to measurement error. The most accepted measure of physical activity in preschool children is accelerometry. Because this age group tends to participate in short bursts of 281

A Systematic Review of Interventions to Promote Physical Activity in the Preschool Setting

high-intensity physical activity, accelerometers are recommended (Beets, Bornstein, Dowda, & Pate, 2011). Accelerometers measure movement in planes or axes, either vertically, or in a combination of vertical, horizontal, and diagonal planes, depending on type. Accelerometers are limited in detecting upper body movement (Oliver et al., 2007); however, with children, much of their activity is running, jumping, walking, or climbing, all movements are likely captured by accelerometers. Most research using accelerometers and converting activity counts into categories or levels of physical activity have been done in adults (Pate et al., 2006). Differences in cut points affect estimates of physical activity, operationalized to categorize activity into sedentary, light, moderate, or vigorous physical activity (Beets et al., 2011). Cut points developed especially for preschool children vary, but one commonly used criteria was developed by Pate and colleagues (2006). These cut points operationalize activity counts as sedentary (≤37.5 counts/15 s), light (38–419 counts/15 s), moderateto-vigorous (≥420 counts/15 s), or vigorous physical activity (≥842 counts/15 s; Pfeiffer et al., 2009). Heart rate response is another measure of physical activity that was used in two reviewed studies to estimate energy expenditure and was able to detect differences. Further research using heart rate monitors in this age group is warranted, especially because heart rate response may vary by weight status and is dependent on a number of things, including emotional stress, body position, medications, and digestion. There are several limitations associated with this review. Only articles published in the English language were included in the review, and the gray literature was not searched, potentially missing important, effective interventions that might increase physical activity in preschool-aged and older children. In the articles identified, inconsistent measures of physical activity make comparisons and conclusions challenging. In addition, many of the studies had small sample sizes, which limited the confidence in results. CONCLUSION

Involvement in physical activity in early childhood is beneficial in promoting children’s social, emotional, and psychological development, as well as establishing physical activity habits that may carry into adolescence and adulthood. Many children do not accumulate 60 min of moderate-to-vigorous phy282

M. Temple and J. C. Robinson

sical activity daily as recommended. There is a large variability of physical activity levels of preschool children attending preschools. While low levels of physical activity have been identified in preschool children in the United States (Hannon & Brown, 2008), there is a dearth of research testing interventions to increase physical activity in preschool children. With an estimated 20–27% (Cunningham et al., 2014; Institute of Medicine of the National Academies, 2011) of children between the ages of 2 and 5 already overweight or obese, more research is needed. There are many areas of opportunity for nurses to provide education and work collaboratively among healthcare providers, parents, schools, and communities. By understanding what type of interventions work best with preschool children, policy changes can be implemented resulting in greater opportunity to increase physical activity, which has been identified as a significant factor in the rise of overweight and obesity in this age group.

How might this information affect nursing practice?

Obesity and insufficient physical activity are causing a major health crisis. Many school-aged and preschool-aged children are not sufficiently active for health. There is longitudinal evidence that intervening to prevent and combat obesity early in life is imperative (Cunningham et al., 2014). The childcare setting or preschool offers numerous influences on enrolled children, such as time for physical activity, outdoor space and equipment, indoor space and equipment, staff behavior, education, and policies (Larson, Ward, Neelon, & Story, 2011). Childcare staff determine daily schedules, such as time outdoors and when and how long to use playground equipment (Brown, Googe, McIver, & Rathel, 2009; Copeland, Kendeigh, Saelens, Kalkwarf, & Sherman, 2012). Nurses and school personnel who are designing strategies to promote physical activity in preschool children need to know what interventions are most effective. Environmental changes appear to show promise in increasing physical activity in this age group; however, research with this age group is limited. It is encouraging that the environmental changes do not necessarily involve great expense. Playground markings and the introduction of small play equipment or recycled materials may be feasible for preschools with limited budgets. Nurses practicing in the school setting can use this information to promote health polices and efforts to

Journal for Specialists in Pediatric Nursing 19 (2014) 274–284 © 2014, Wiley Periodicals, Inc.

M. Temple and J. C. Robinson

A Systematic Review of Interventions to Promote Physical Activity in the Preschool Setting

enhance the play environments of preschool children, and stress the importance of active play in an environment that supports physical activity. The need for more research is evident to give nurses the tools to implement health-promoting behaviors. References Annesi, J., Smith, A., & Tennant, G. (2013). Effects of the start for life treatment on physical activity in primarily African American children of ages 3–5 years. Psychology, Health & Medicine, 18(3), 300–309. doi:10.1080/ 13548506.2012.712704 Beets, M. W., Bornstein, D., Dowda, M., & Pate, R. R. (2011). Compliance with national guidelines for physical activity in U.S. preschoolers: Measurement and interpretation. Pediatrics, 127(4), 658–664. Bellows, L. L., Davies, P. L., Anderson, J., & Kennedy, C. (2013). Effectiveness of a physical activity intervention for Head Start preschoolers: A randomized intervention study. American Journal of Occupational Therapy, 67(1), 28–36. Brown, W. H., Googe, H. S., McIver, K. L., & Rathel, J. M. (2009). Effects of teacher-encouraged physical activity on preschool playgrounds. Journal of Early Intervention, 31(2), 126–145. doi:10.1177/1053815109331858 Cardon, G., Labarque, V., Smits, D., & De Bourdeaudhuij, I. (2009). Promoting physical activity at the preschool playground: The effects of providing markings and play equipment. Preventive Medicine, 48(4), 335– 340. Centers for Disease Control and Prevention. (2011a). How much physical activity do children need? Retrieved from http://www.cdc.gov/physicalactivity/everyone/ guidelines/children.html/ Centers for Disease Control and Prevention. (2011b). Strategies to prevent obesity and other chronic diseases. Retrieved from http://www.cdc.gov/obesity/ downloads/PA_2011_WEB.pdf Centers for Disease Control and Prevention. (2012a). Basics about childhood obesity. Retrieved from http://www.cdc .gov/obesity/childhood/basics.html Centers for Disease Control and Prevention. (2012b). Preschoolers (3 to 5 years of age). Retrieved from http://www.cdc.gov/ncbddd/childdevelopment/ positiveparenting/preschoolers.html Centers for Disease Control and Prevention. (2013). Winnable battles. Retrieved from http://www.cdc.gov/winnablebattles/ Copeland, K. A., Kendeigh, C. A., Saelens, B. E., Kalkwarf, H. J., & Sherman, S. N. (2012). Physical activity in child-care centers: Do teachers hold the key to the playground? Health Education Research, 27(1), 81–100. doi:10.1093/her/cyr038

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Cosco, N. G., Moore, R. C., & Smith, W. R. (2014). Childcare outdoor renovation as a built environment health promotion strategy: Evaluating the preventing obesity by design intervention. American Journal of Health Promotion, 28(3), S27–S32. Cunningham, S. A., Kramer, M. R., & Venkat Narayan, K. M. (2014). Incidence of childhood obesity in the United States. New England Journal of Medicine, 370(5), 403–411. doi:10.1056/NEJMoa1309753 Dolinsky, D. H., Brouwer, R. J., Evenson, K. R., Siega-Riz, A. M., & Ostbye, T. (2011). Correlates of sedentary time and physical activity among preschool-aged children. Preventing Chronic Disease: Public Health Research, Practice, and Policy, 8(6), 1–14. Engelen, L., Bundy, A. C., Naughton, G., Simpson, J. M., Bauman, A., Ragen, J., . . . van der Ploeg, H. P. (2013). Increasing physical activity in young primary school children—It’s child’s play: A cluster randomised controlled trial. Preventive Medicine, 56(5), 319–325. Finch, M., Wolfenden, L., Morgan, P. J., Freund, M., Jones, J., & Wiggers, J. (2014). A cluster randomized trial of a multi-level intervention, delivered by service staff, to increase physical activity of children attending center-based childcare. Preventive Medicine, 58, 9–16. Fitzgibbon, M., Stolley, M., Schiffer, L., Van Horn, L., KauferChristoffel, K., & Dyer, A. (2005). Two-year follow-up results for Hip-Hop to Health Jr.: A randomized controlled trial for overweight prevention in preschool minority children. Journal of Pediatrics, 146(5), 618–625. Frost, S. S., Goins, R. T., Hunter, R. H., Hooker, S. P., Bryant, L. L., Kruger, J., & Pluto, D. (2010). Literature review: Health-promoting community design. Effects of the built environment on physical activity of adults living in rural settings. American Journal of Health Promotion, 24(4), 267–283. doi:10.4278/ajhp.08040532 Gardner, D. S., Hosking, J., Metcalf, B. S., Jeffery, A. N., Voss, L. D., & Wilkin, T. J. (2009). Contribution of early weight gain to childhood overweight and metabolic health: A longitudinal study. Pediatrics, 123(1), e67–e73. Glickman, D., Parker, L., Sim, L. J., Cook, H. D., & Miller, E. A. (2012). Accelerating progress in obesity prevention: Solving the weight of the nation. Washington, DC: The National Academies Press. Hannon, J. C., & Brown, B. B. (2008). Increasing preschoolers’ physical activity intensities: An activity-friendly preschool playground intervention. Preventive Medicine, 46(6), 532–536. Howe, C. A., Freedson, P. S., Alhassan, S., Feldman, H. A., & Osganian, S. K. (2012). A recess intervention to promote moderate-to-vigorous physical activity. Pediatric Obesity, 7(1), 82–88. doi:10.1111/j.204 7-6310.2011.00007.x Institute of Medicine. (2012). Accelerating progress in obesity prevention: Solving the weight of the nation. Retrieved from

283

A Systematic Review of Interventions to Promote Physical Activity in the Preschool Setting

http://iom.edu/Reports/2012/Accelerating-Progress -in-Obesity-Prevention/Report-Brief.aspx?page=1 Institute of Medicine of the National Academies. (2011). Early childhood obesity prevention policies committee on obesity prevention policies for young children (L. L. Birch, L. Parker, & A. Burns, Eds.). Washington, DC: National Academies Press. Khan, F. (2011). Combating obesity through the built environment: Is there a clear path to success? Journal of Law, Medicine & Ethics, 39(3), 387–393. doi:10.1111/ j.1748-720X.2011.00608.x Lanningham-Foster, L., Foster, R. C., McCrady, S. K., Manohar, C., Jensen, T. B., Mitre, N. G., . . . Levine, J. A. (2008). Changing the school environment to increase physical activity in children. Obesity (Silver Spring, Md.), 16(8), 1849–1853. Larson, N., Ward, D., Neelon, S., & Story, M. (2011). What role can child-care settings play in obesity prevention? A review of the evidence and call for research efforts. Journal of the American Dietetic Association, 111(9), 1343–1362. Loucaides, C., Jago, R., & Charalambous, I. (2009). Promoting physical activity during school break times: Piloting a simple, low cost intervention. Preventive Medicine, 48(4), 332–334. Metallinos-Katsaras, E. S., Freedson, P. S., Fulton, J. E., & Sherry, B. (2007). The association between an objective measure of physical activity and weight status in preschoolers. Obesity (Silver Spring, Md.), 15(2), 686– 694. Muckelbauer, R., Kalhoff, H., Mauller-Nordhorn, J., & Kersting, M. (2011). Childhood overweight and obesity: Introduction into epidemiology and prevention strategies. Current Nutrition & Food Science, 7(3), 191–199. National Association for Sport and Physical Education. (2009). Active start: A statement of physical activity guidelines for children from birth to age 5 (2nd ed.). Sewickley, PA: American Alliance for Health, Physical Education, & Dance. National Institute of Health. (2012). Why obesity is a health problem? Retrieved from http://www.nhlbi.nih.gov/ health/public/heart/obesity/wecan/healthy-weight -basics/obesity.htm O’Dwyer, M. V., Ridgers, N. D., Knowles, Z. R., Foweather, L., & Stratton, G. (2013). Effect of a school-based active play intervention on sedentary time and physical activity in preschool children. Health Education Research, 28(6), 931–942. doi:10.1093/her/cyt097 Oliver, M., Schofield, G. M., & Kolt, G. S. (2007). Physical activity in preschoolers: Understanding prevalence and measurement issues. Sports Medicine, 37(12), 1045–1070. Retrieved from http://www.cdc.gov/nchs/data/nhsr/ nhsr025.pdf Pate, R. R., Almeida, M. J., McIver, K. L., Pfeiffer, K. A., & Dowda, M. (2006). Validation and calibration of an

284

M. Temple and J. C. Robinson

accelerometer in preschool children. Obesity (Silver Spring, Md.), 14(11), 2000–2006. Pfeiffer, K. A., Dowda, M., McIver, K. L., & Pate, R. R. (2009). Factors related to objectively measured physical activity in preschool children. Pediatric Exercise Science, 21(2), 196–208. Ridgers, N. D., Fairclough, S. J., & Stratton, G. (2010). Twelve-month effects of a playground intervention on children’s morning and lunchtime recess physical activity levels. Journal of Physical Activity and Health, 7(2), 167–175. Schuz, B., Wurm, S., Ziegelmann, J. P., Wolff, J. K., Warner, L. M., Schawarzer, R., & Tesch-Romer, C. (2012). Contextual and individual predictors of physical activity: Interactions between environmental factors and health cognitions. Health Psychology, 31(6), 714–723. Stratton, G., & Leonard, J. (2002). The effects of playground markings on the energy expenditure of 5- to 7-year-old children. Pediatric Exercise Science, 14(2), 170–180. Stratton, G., & Mullan, E. (2005). The effect of multicolor playground markings on children’s physical activity level during recess. Preventive Medicine, 41(5–6), 828–833. Sugiyama, T., Okely, A. D., Masters, J. M., & Moore, G. T. (2012). Attributes of childcare centers and outdoor play areas associated with preschoolers’ physical activity and sedentary behavior. Environment and Behavior, 44(3), 334–349. Tremblay, M. S. (2010). Assessing the level of sedentarism. In C. Bouchard & P. Katzmarzyk (Eds.), Physical activity and obesity (2nd ed., pp. 13–25). Baton Rouge, LA: Human Kinetics. Van Cauwenberghe, E., De Bourdeaudhuij, I., Maes, L., & Cardon, G. (2012). Efficacy and feasibility of lowering playground density to promote physical activity and to discourage sedentary time during recess at preschool: A pilot study. Preventive Medicine, 55(4), 319–321. doi:10.1016/j.ypmed.2012.07.014 Verstraete, S., Cardon, G., De Clereq, D., & De Bourdeaudhuij, I. (2006). Increasing children’s physical activity levels during recess periods in elementary schools: The effects of providing game equipment. European Journal of Public Health, 16(4), 415–419. Ward, D. S., Benjamin, S. E., Ammerman, A. S., Ball, S. C., Neelon, B. H., & Bangdiwala, S. I. (2008). Nutrition and physical activity in childcare results from an environmental intervention. American Journal of Preventive Medicine, 35(4), 352–356. doi:10.1016/j.amepre.2008.06.030 Warren, J., Henry, C., Lightowler, H., Bradshaw, S., & Perwaiz, S. (2003). Evaluation of a pilot school programme aimed at the prevention of obesity in children. Health Promotion International, 18(4), 287–296.

Journal for Specialists in Pediatric Nursing 19 (2014) 274–284 © 2014, Wiley Periodicals, Inc.

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