Physical activity for children and young people

Evidence statement 2.4

There is evidence from four systematic reviews of observational studies that: there is a large positive association between parental and social support and physical activity in young people.

Evidence statement 2.5

There is evidence from four systematic reviews of observational studies that there is a:

Evidence statement 3.1

There is evidence from 15 UK qualitative studies of adolescent girls (reported in 16 papers) (two [++]; six [+] and eight [-]) that the main barriers to being physically active were:

The main facilitators to being physically active were:

Evidence statement 3.2

There is evidence from five UK qualitative studies of children aged 8 and under (three [+] and two [-]) that: there were far fewer barriers to physical activity and sport compared with other age groups. Barriers were:

The main facilitators for children aged 8 and under were:

Evidence statement 3.3

There is evidence from three UK qualitative studies of children and active travel that the main barriers to active travel were:

Only one study reported any facilitators for walking and cycling. These included:

Evidence statement 3.4

There is evidence from two UK studies and two international qualitative studies (both Australian), of families and community that barriers to physical activity and sport were related to personal safety of children while playing outside unsupervised. Common issues were:

Facilitators were that children:

Evidence statement 4.3

There is evidence from one cluster randomised controlled trial in the UK (+), one controlled non-randomised trial in Greece (+) and one controlled before-and-after trial in the USA (-) that supervised physical activity interventions conducted in the pre-school setting can be effective in improving core physical skills such as: running, galloping, hopping, sliding, leaping, skipping and general motor agility.

Evidence statement 5.1

There is evidence from five UK studies (all uncontrolled before-and-after studies [+]) that cycling promotion projects, targeting primary and secondary school children can lead to large self-reported increases in cycling both at 9 to 11 months and over 20 to 23 months. Characteristics of successful interventions included the involvement of external agencies to facilitate schools to promote and maintain cycling, with the support of parents and the local community.

There is evidence from two studies (uncontrolled before-and-after studies [+]), where cycling infrastructure was commonly part of the local transport infrastructure or children were encouraged to cycle to curriculum-related events or sports fixtures, that self-reported levels of walking declined over 20 and 23 months, implying that some of the increase in cycling may have been offset by a decrease in walking. The evidence is applicable to the UK.

Evidence statement 5.2

There is evidence from one UK study (randomised controlled trial [++]) to suggest that the introduction of school travel plans and direct support from a school travel plan adviser at primary schools did not lead to increases in self-reported levels of walking and cycling at 12 months.

There is evidence from one US and one UK study (uncontrolled before-and after-study [+]) to suggest that a mix of promotional measures including curriculum, parental and community promotions (for example, mapping safe routes to school, walk and bike to school days) can increase self-reported walking and cycling at 24 months. In the UK study, this activity was in support of a travel plan. The evidence is applicable to the UK.

Evidence statement 5.3

There is evidence from three UK studies (uncontrolled before-and-after studies [+]) to suggest that walking buses (volunteer-led walking groups supported by parents and teachers plus the involvement of the local highways or transport authority) led to increases in self-reported walking among 5 to 11 year olds, and reduced car use for children's' journeys to and from school at 10 weeks and 14 to 30 months.

There is evidence from one study (uncontrolled before-and-after study [-]) to suggest that the provision of a walking bus may in itself not be sufficient to stem a more general decline in walking to and from school. Retaining volunteers to act as coordinators for these schemes appears to be a key factor in the sustainability of walking buses.

Currently walking buses are found to be commonly delivered in the UK, however evidence for their applicability remains uncertain (as they may be applicable only to the specific populations or settings included in the studies).

Evidence statement 5.4

There is evidence from one UK study (controlled before-and-after study [+]), and two UK (uncontrolled before-and-after studies [+]) and one Australian studies (uncontrolled before-and-after study [+])to suggest that walking promotion schemes, involving promotional materials, incentives and rewards (such as travel diaries for children and parents and provision of 'park and walk' parking areas close to school and restriction of parking outside of schools), can lead to increases in self-reported walking to school among 4 to 11 year olds, and reduced car use for children's' journeys to and from school at 4 to 10 weeks and 41 to 48 months.

There is evidence from one UK study (controlled before-and-after study [+]) to suggest that walking campaign packs alone, including promotion materials for children and parents, did not lead to increases in walking among 4 to 11 year olds at 4 weeks.

There is evidence from two UK and one Australia study (uncontrolled before-and-after study [+]) to suggest that targeting children and parents who live a short distance to school (1 mile or less) may support interventions to encourage increase walking levels for the school journey.

The evidence mainly comes from UK studies and so is directly applicable only to populations or settings included in the studies (primary school settings). The success of broader application is uncertain.

Evidence statement 6.1

There is evidence from three cluster randomised controlled trials (one each in Australia [+], France [+], and Ireland [+]), and one controlled non-randomised trial in the USA (-), that school-based interventions outside of physical education lessons, targeting the single behaviour of physical activity, can lead to moderate-to-large increases in physical activity in adolescent girls for up to 6 months. One randomised controlled trial (++) and one cluster randomised controlled trial (+) (both from the USA), failed to show an effect. Characteristics of successful interventions were not consistent across studies, although three of the four successful trials targeted girls only. Successful interventions included self-monitoring techniques, stage-matched counselling, teacher-led extra-curricular physical activity, and multi-level programming targeting psychological, social and environmental correlates.

The evidence is drawn from non-UK studies and therefore the applicability to the UK is limited.

Evidence statement 7.1a

There is evidence from two randomised controlled trials in the USA (one [++] and one [+]) that family-based physical activity interventions targeting overweight/obese children and/or those at risk for overweight/obesity, can lead to increases in physical activity in young people. However, two randomised controlled trials in the USA (both [+]) failed to show an effect in the same target group. Characteristics of successful interventions included being located in the home and therefore not involving attendance at external sites and focused on small, specific lifestyle changes (2000 more steps per day and a single dietary target). In contrast, unsuccessful interventions required regular attendance at sites external to the home for education and/or physical activity sessions, broader physical activity and dietary behaviour change, and were with 8 to 9 year old African-American girls.

Evidence statement 7.1b

There is evidence from one randomised controlled trial in the USA (+), one randomised non-controlled trial in the USA (+), one controlled non-randomised trial (+) and one uncontrolled before-and-after study (-) that family-based interventions, targeting physical activity, can lead to increases in physical activity in young people. One randomised controlled trial in the USA (++) and one uncontrolled before-and-after study in the USA (-) failed to show an effect. One randomised controlled trial in the USA (-) showed a negative effect. Successful interventions were located mostly in the home and predominantly involved information packs. Two of the successful interventions involved either mothers and daughters or grandmothers, mothers, and daughters exercising together. Unsuccessful interventions all involved regular attendance at physical activity and education sessions outside of the home. Other differences between successful and unsuccessful interventions were not consistent.

Evidence statement 7.5

There is evidence from two cluster randomised controlled trials in Belgium and France (both [+]) and three controlled non-randomised trials in the Netherlands, Greece and the USA (one [+] and two [-]) that interventions involving both the school and family and/or community agencies lead to positive changes in physical activity in boys and girls aged 13 or under. These positive outcomes may include an actual increase in physical activity or less of a decline in physical activity relative to controls. Successful interventions had multiple components. At the school level this included computer-tailored advice, changes to the school environment, classroom sessions, physical activity sessions, and physical education. Family components included facilitating social support for physical activity, education on creating a supportive home environment, homework activities involving parents, and community sport information. One cluster randomised controlled trial in the USA (+) and one uncontrolled before-and-after study in the USA (-) failed to show an effect. The characteristics of these unsuccessful interventions were not consistently different from those of successful interventions.

Evidence statement 7.6

There is evidence from one controlled non-randomised trial in the USA (+) that social marketing interventions can increase levels of free-time physical activity in children and adolescents (9 to 15 year olds). The social marketing campaign employed engaging messages (primarily via TV advertisements) and promoted opportunities to incorporate physical activity into daily lives. The sustained nature of the campaign (2 years) was considered important to its success. Behavioural changes were seen in the activities targeted by the campaign (for example, free-time activities) and there were no effects on participation in organised sport.

Evidence statement 8.1

There is strong support for the principle of ensuring that children in the foundation stage are given the opportunity for regular outdoor play as part of the school day. Outdoor play should provide opportunities for movement and challenge, and opportunities to play safely with natural elements.

Children's play in outdoor space can be optimised through a number of practical measures such as: seeing the indoor and outdoor spaces as one environment; providing materials specifically for physically active play; making links to the curriculum; provide for diverse active activities; planning to take account of issues such as weather, light, wind direction.

The indoor environment can also be optimised for active play, through providing sufficient space; allowing freedom to move from one area to another; providing good opportunities for energetic physical movement; dividing space into active and quiet zones.

Adults can help to facilitate active play through: creating the right context for play in which children feel secure and still have the necessary freedom and autonomy to explore through free play; observing play and understanding children's interests, in order to guide the provision of resources and environments for play; interacting appropriately and intervening only when necessary; creating the right environment for play including materials and resources for play, as well as the actual place to play.

Practitioners may limit the amount of outdoor play offered to children due to a number of assumptions: that the outside is dangerous; that higher adult/child ratios are needed outside; that educators are merely supervisors outdoors, and that no learning happens outside; that the weather is a barrier; and that being outside is somehow less healthy. All of these assumptions can be tackled to increase active play outdoors.

There appears to be a strong consensus among practitioners that there should be much more out of hours use of school grounds.

For older children, play facilities are most valued when they are close at hand. If a facility is more than a few hundred metres away, regular use declines dramatically.

Evidence statement 8.4

It is well acknowledged that physical education contributes to the development of core skills. However, there appears to be much less consensus on the role of play in developing core skills.

Core skills can be developed through natural active play, especially when the play is determined by the children themselves.

The role of the play practitioner may be less about planning complex programmes to focus on core skill development, but instead facilitating active play.

Evidence statement 8.5

There is often reluctance by parents and professional carers to also go outside and supervise children playing outdoors in poor weather.

It appears that practitioners are put off by the weather more than children.

There are many examples of ways that this has been tackled, through encouraging children to spend time outside independently or under supervision in all weathers; encouraging parents and carers to allow their children to be outside; and encouraging nursery and teaching staff to spend time outside with children as part of their formal and informal activities.

There is a great deal of experience of a positive approach to bad weather, much of which has been incorporated into the UK Forest Schools movement, building on its origins in Sweden.

Review of economic evaluations

Overall, the rapid review found that there was very limited economic evidence with respect to the promotion of physical activity, play and sport in the four core areas identified. Only two economic evaluations were appraised on the strength of their evidence, both were from the USA and considered interventions to modify the behaviour of obese children, while one study also considered the behaviour of their obese parents. However, these studies were considered not to be relevant to the development of the guidance due their targeting of only obese children.

Cost-effectiveness analysis

A case study or scenario analysis approach was taken to model four different physical activity programmes and consider the cost effectiveness of each as far as was practical with the available data. The programmes considered were:

The analysis sought to estimate the additional minutes of physical exercise derived from the interventions, and these minutes of exercise per year were used to derive the short-term quality of life improvements for children.

However, there was uncertainty associated with the cost-effectiveness results as, due to the limitations of the evidence, it was necessary to make a number of unverified assumptions within the analyses. The results were also shown to be sensitive to changes in these assumptions.

Only walking buses were estimated to be cost effective. This was assuming a cost-effectiveness threshold of £20,000 per QALY and because of their relatively low cost and that children benefited by being engaged in the activity on a regular basis over time. However, due to the number of assumptions made producing the cost-effectiveness estimates, the PDG was cautious in drawing conclusions.