Physical activity promotion in schools: which strategies
do schools (not) implement and which socioecological
factors are associated with implementation?
Greet M. Cardon
1*, Ragnar Van Acker
1, Jan Seghers
2, Kristine De Martelaer
3,
Leen L. Haerens
1and Ilse M. M. De Bourdeaudhuij
11Department of Movement and Sports Sciences, Ghent University, Watersportlaan 2, 9000 Ghent, Belgium,2Department of
Human Kinesiology, Katholieke Universiteit Leuven, Tervuursevest 10, 3001 Heverlee, Belgium and3Faculty of Physical
Education and Physical Therapy, Vrije Universiteit Brussel, Pleinlaan 2, 1050 Brussels, Belgium *Correspondence to: G. Cardon. E-mail: greet.cardon@ugent.be
Received on September 22, 2011; accepted on February 9, 2012
Abstract
We studied the implementation and associ-ated factors of strategies (e.g. sports after school and during lunch break, active school-yards, active school commuting) and organi-zational principles (e.g. safe bike racks, pupil involvement) that facilitate the physical activ-ity (PA)-promoting role of schools. Key rep-resentatives of 111 elementary and 125 secondary schools filled out an online survey. Less than half of the elementary schools organized sports during lunch-break or after school. In secondary schools the least imple-mented strategies were the promotion of active school commuting and after-school sports. In general pupil, parental and commu-nity involvement scored low. Better knowl-edge of community schools and having attended in-service training were associated with higher implementation scores in elemen-tary and secondary schools. Better implemen-tation of the strategies was found in larger schools. Participation in activities from the School Sports Association and more per-ceived interest from parents and the school board were also associated with higher imple-mentation scores. In conclusion, knowledge of community schools and in-service training next to sufficient human resources are poten-tial key factors to promote PA. Efforts are
needed to convince and help schools to increase parental and pupil involvement and to build a policy on school-community partnerships.
Introduction
While physical activity (PA) and sports participa-tion during childhood and adolescence links to better physical and mental health [1, 2] interna-tional studies show that youth PA has decreased over time [3,4]. Furthermore, the ‘Health Behav-ior in School-Aged Children’ study, conducted in 40 Western countries, revealed that only 16–26% of 11- to 15-year-old children report PA levels that meet the recommendation of daily engage-ment in 60 min or more of moderate to vigorous PA [5].
Schools are considered to be one of the preferred intervention environments for increasing daily PA in youth [6,7]. Consequently, helping schools to fulfill their PA promoting role should be a public health priority. A ‘whole-school’ approach has been recommended [6,8,9]. The Toronto Charter for Physical Activity [10] outlines a whole-school approach as one of the seven ‘best investments’ for PA, which are supported by good evidence of ef-fectiveness and that will have worldwide applica-bility. A whole-school approach to PA involves prioritizing regular, highly active physical educa-tion (PE) classes; providing suitable physical environments and resources to support structured
and unstructured PA throughout the day; support-ing walk/cycle-to school programs and enablsupport-ing all of these actions through supportive school policy and engaging staff, students, parents and the wider community ‘Community schools’ and their key feature of school-community partnerships have also been recommended for PA promotion [11]. Other key features of community schools include maxi-mizing pupils’ participation and learning opportu-nities and a child-centered approach with an integrated view on academics, services and oppor-tunities [12,13].
Recently and in line with the whole-school ap-proach, a socioecologically founded framework for PA programs within school-community partner-ships was developed [14]. This framework elabo-rates on key implementation strategies to increase PA opportunities for secondary and elementary school-aged youth and allows local tailoring. The development of the framework was commissioned by the Flemish Government (Belgium) and is part of an action plan that aims at providing practical guidelines for schools and community partners to develop extra-curricular PA promotion programs. The framework also recognizes the PA promoting role of PE classes. However, as primary objectives for PE relate not only to PA promotion and since the available PE time is limited, even the best school PE programs do not provide enough PA to meet health-related recommendations [15]. Conse-quently, the framework recommends five additional extra-curricular (outside PE) strategies to promote PA, complementary to PE: (i) providing sports and PA during lunch break, (ii) developing active schoolyards or playgrounds, (iii) promoting active commuting to school, (iv) developing a health ed-ucation policy and (v) organizing after-school sports and PA. Additionally, the framework defines organizational principles that facilitate the PA-pro-moting role of schools (e.g. cooperation with com-munity partner, parental and pupil involvement, safe and covered bike racks). The selection of some specific strategies and principles for PA promotion over others was based on a synthesis of prior evi-dence in research on health promotion. For exam-ple, the synthesis included recommendations by
several reviews on school-based PA interventions and partnerships for health promotion, process and effectiveness evaluations of PA promotion in youth, and conceptual models of health promotion. Details on the development of the framework are reported elsewhere [14].
Since the school year 2007–2008, a school policy that promotes PA and healthy foods has become mandatory in all Flemish schools as a means to prevent obesity. As a result, several health services and the Flemish School Sports As-sociation organized project-specific workshops and seminars on this topic for school boards and teachers (e.g. ‘Fit school’ project, a Flemish PA and healthy nutrition promotion project [16]). However, the Flemish Government applies a bot-tom-up strategy, so schools are free to choose which promotion program they implement. Con-sequently, some schools may organize a limited variety of PA programs (e.g. an active commuting program but no other extra-curricular programs) or solely educational interventions, which are shown to have none or limited effects in children and adolescents [17]. As a whole-school approach holds the best promise [10], it is necessary to fa-cilitate the implementation of such an approach by identifying and anticipating its contextual barriers and facilitators. The consideration of contextual barriers and facilitators within potential interven-tion settings is supported by socioecological models on health promotion, which recognize multiple influences on health behavior at personal and different environmental levels [18].
Several studies have reported policies and op-portunities for school-based PA but few studies applied a socioecological basis for analyzing potentially associated factors [19–22]. In the latter studies, PA opportunities were significantly asso-ciated with socioecological factors, including social (family support, interest and role modeling by school principals), physical (facilities avail-ability, school location) and policy factors (finan-cial and human resources). Given the limited number of studies, it is not clear if these contextual associations are generalizable and therefore, more research would advance our knowledge on this
Table I. Questionnaire items and reliability scores
Scale Kappa P Percentage of agreement
Intraclass correlation coefficients Strategies
Are PE lessons provided in all grades at least twice a week? Binarya 1.00 0.000 100 Is PA also approached in other subjects than PE? Binarya 0.55 0.000 75.0 Are sports fields and equipment for sports and play provided? Binarya 0.53 0.004 82.0
Active school commuting is promoted by your school 5-p-scaleb 0.80 Does your school (co-)organize sports
and PA during lunch break
Binarya 0.63 0.000 72.7 Does your school (co-)organize after-school sports and PA Binarya 0.63 0.000 72.7 General principles
Does your school cooperate with one or more community partners?
Binarya 0.64 0.001 82.0 Does your school have an informal or written policy
on school-community partnerships?
Binarya 0.46 0.003 72.7 Does your school have a coordinator for health or PA? 3-p-scalec 0.43 0.003 57.1 Does your school have a working group for health or PA? 3-p-scaled 0.69 0.000 81.8 Are parents involved in decision making about PA policy? Binarya 0.41 0.040 77.3 Are pupils involved in decision making about PA policy? Binarya 0.33 0.119 68.2 Specific principles
Are PE classes taught by a specialized PE teacher? Binarya 1.00 0.000 100 Do supervisors prompt for PA during recess? Binarya 0.81 0.000 90.5
The school has bike racks that are safe and covered 5-p-scaleb 0.73 The PA program during lunch
break is mainly noncompetitive
5-p-scaleb 0.87
The after-school PA program is mainly non-competitive 5-p-scaleb 0.71 How often is the PA program during lunch
break provided by qualified teachers?
5-p-scalee 0.74
How often is the after-school PA program provided by qualified teachers?
5-p-scalee 0.73
After-school sports and PA are also open for pupils from other schools
5-p-scaleb 0.99
Pupil transfer to sports clubs is promoted during lunch break PA program
5-p-scaleb 0.71
Pupil transfer to sports clubs is promoted during after-school PA program
5-p-scaleb 0.56
Is PA as a health policy integrated in all grades? Binarya 0.55 0.000 75.0 Physical environment items
Where is the school located? Binaryf 0.76 0.000 86.4 Is there a sports hall at school? Binarya 0.51 0.005 81.8
Traffic around school is safe for pupils 5-p-scaleb 0.36
School size (pupil number) Continuous 0.99
Policy items
Your school supports the criteria of the PA promotion framework
5-p-scaleb 0.50
Did you have in-service training on whole-school PA promotion?
Binarya 0.47 0.005 72.7 Did you have in-service training on
school-community partnerships?
Binarya 0.48 0.002 72.7 There is a lack of integrated youth
policy in the municipality
issue. Moreover, no study could be located explor-ing potential factors associated with the different strategies and organizational principles as out-lined in the PA-promoting framework of Van Ackeret al.[14] and the whole-school approach [10]. Consequently, the present paper aimed at evaluating which strategies of the PA promotion framework were (not) implemented by Flemish elementary and secondary schools and which soci-oecological factors were associated with imple-mentation. As organizational principles of the framework reflect the quality of implementation, we also aimed to investigate which organizational
principles were (not) implemented and which factors were associated with implementation.
Materials and Methods
Population
From all 3438 schools in Flanders, the Dutch speak-ing part of Belgium, a randomly selected sample of 758 schools (50% elementary, 50% secondary) was invited to participate in the present study, based on statistical power analyses and a response rate of 32% in a recent school survey by the Flemish
Table I. Continued
Scale Kappa P Percentage of agreement
Intraclass correlation coefficients There is a need for a municipal coordinator
for school-community partnerships
5-p-scaleb 0.78
In how many after-school activities from the School Sports Associationg* does your school participate?
Binaryh 0.69 0.000 80.0
Sociocultural items
Your school has a partnership with a sport and PA leaderi
Binarya 0.61 0.000 86.4 PA promotion is considered important
by the school team
5-p-scaleb 0.63
The school board is Interested in school-community partnerships
5-p-scaleb 0.61
Parents are interested in PA at school 5-p-scaleb 0.50
Pupils of low socio-economic status (%) Continuous 0.98
Personal level items
Do you need more information on how to expand the PA policy at school?
Binarya 0.61 0.004 89.5 Are you aware of the Fit school project? Binarya 0.32 0.124 72.7 You are knowledgeable about the
concept of community schools
5-p-scaleb 0.93
a No/yes.
bStrongly disagree/disagree/neither agree nor disagree/agree/strongly agree. c
No coordinator/coordinator for health/coordinator for PA. dNo working group/working group for health/working group for PA. e
Never/rarely/sometimes/often/always. fUrban/rural.
g
The Flemish School Sports Association is a government-funded organization with the mission of promoting PA in all its contexts using evidence-based strategies.
h
Less than four activities/more than activities per year. i
Sports and PA leaders represent a pilot project funded by the Flemish government in which PE teachers’ teaching hours are reduced by half and are replaced by other qualified PE teachers, creating more time to facilitate extracurricular PA opportunities for pupils in an entire region [14].
government. The invitation was e-mailed to the school board in May 2009 and included a link to an online questionnaire. Within a 4-week period, three reminder mails were sent and the survey was closed in the month of June. By then, the online survey was completed by members of the school staff, knowledgeable about its school’s PA policy (59% PE teachers, 39% principals, and 4% other school administrators) and represented 243 schools (response rate 33%). The final sample with com-plete data consisted of 236 schools (111 elemen-tary, 125 secondary) from 121 different municipalities. For elementary and secondary schools, the average cluster sizes were 1.5 schools (range 1–8) and 1.7 schools (range 1–13), respec-tively. The study protocols were approved by the Ethical Committee of the Ghent University.
Procedure and instruments
The online questionnaire was pretested for item comprehension and completeness with three princi-pals and two teachers closely involved in their school PA policy. The finalized version of the questionnaire took 25–40 min to complete. Additionally, a similar convenience sample of 21 school representatives served to verify the reliability of the questionnaire, by filling out the online questionnaire twice with a 1-week interval.
In the e-mail inviting to participate in the present study, the school board was asked to have the online questionnaire filled out by a school team member, with good awareness of the PA promotion strategies at school. Questions addressed three main themes: (i) the implementation of the strategies of the PA-promoting framework (6 questions) [14], (ii) the implementation of general and specific or-ganizational principles of the PA-promoting frame-work (17 questions) [14] (e.g. cooperation with community partners, pupils involvement) and (iii) socioecological factors (18 questions) (e.g. knowl-edge about community schools, number of pupils) that may be associated with the implementation of the strategies and organizational principles of the PA-promoting framework.
The questions about the strategies of the PA promotion framework are outlined in Table I.
Schools were asked if they implemented the dif-ferent strategies during the ongoing school year. To obtain a better insight into the quality of strat-egy implementation, schools were also asked if they implemented the organizational principles of the framework. A distinction was made between general (i.e. governance and stakeholder related) principles of the PA promotion framework and specific principles linked to the different strategies (Table I).
The socioecological factors can be found in
Table I. Each single question or item represented one socioecological factor. Selected factors in-cluded relevant significant barriers and facilitators of school-based PA opportunities in other studies [19,22–25] and additional potentially influencing factors (e.g. partnership with sport and PA leaders) agreed on by a panel of four experts. In total, the survey included 18 items representing factors po-tentially associated with the implementation of strategies and organizational principles of the PA promotion framework. Consistent with socioeco-logical models of health promotion [18] factors covered the socioecological levels and categorized accordingly into four physical environmental, six policy related, five sociocultural and three personal factors.
Data analysis
Test–retest reliability of the questionnaire was established by calculating intraclass correlation coefficients and values of Kappa and following Landis and Koch’s benchmarks of 0–0.20 poor, 0.21–0.40 fair, 0.41–0.60 moderate, 0.61–0.80 sub-stantial, and 0.81–1.0 almost perfect [26].
Descriptive statistics were analyzed using SPSS 16.0. Independent samples t-tests and chi-square tests were performed to explore representativeness of responding schools for school size, location and educational type.
Each strategy of the PA promotion framework was represented by one questionnaire item and awarded one point if implemented. Consequently, all six strategies reflected their composite imple-mentation score on 6 (sum score). Similarly, each organizational principle of the PA promotion
framework was represented by one item and awarded one point if implemented. The 6 general and 11 specific organizational principles therefore reflected their composite implementation score on 17 (sum score). Binary measures were awarded a score of 0 (no) or 1 (yes) and each item with three-and five-point measures was recoded to a 0/1 score (Tables IIandIII).
Differences in composite implementation scores between elementary and secondary schools were analyzed with independent samplest-tests. In addi-tion, multivariate regression analyses were con-ducted for elementary and secondary schools separately using MLwiN version 2.20. Multilevel modeling (two-level: school-municipality) was ap-plied to take into account clustering of schools within municipalities.
Four models, one for each socioecological level, were constructed to examine associations between the independent variables (personal, physical, policy and sociocultural factors) and the implementation of strategies and principles of the PA promotion framework. Non-significant factors were excluded from the models one at a time. For all analyses, significance was set at
P<0.05.
Results
Reliability of questionnaire items
Results of the reliability analyses are shown in
Table I. All items representing the different strategies and general principles of the PA promo-tion framework had moderate to perfect reliability. For the specific principles linked to the frame-work’s strategies and the socioecological factors, all items had moderate to almost perfect reliability, except for three items: (i) pupil involvement, (ii) traffic safety of the school environment and (iii) awareness of an ongoing national PA project that promotes a whole-school approach. However, based on Landis and Koch [26], the reliability of these items was fair and as these items deemed of interest and were not overlapping with other items it was decided to keep them in the analyses.
Representativeness
Participating elementary schools had a similar pro-portion of schools in rural areas, compared with all elementary school in Flanders (35.1% versus 40.5%, respectively;P= 0.26), but a higher mean number of pupils (218 versus 133 pupils,
respec-Table II. Percentages of elementary and secondary schools implementing the strategies of the PA promotion framework
Elementary schools Secondary schools
Strategies Percentage Strategies Percentage
Are PE lessons provided at least twice a week? (% yes)a
100 Are PE lessons provided at least twice a week? (% yes)a
100 Is PA also approached in other subjects than
PE? (% yes)a
87 Is PA also approached in other subjects than PE? (% yes)a
84 Are sports fields and equipment for sports and
play provided? (% yes)a
81 Does your school (co-)organization sports and PA during lunch break? (% yes)a
72 Active school commuting is promoted by
your school. (% agree/strongly agree)b
76 Are sports fields and equipment for sports and play provided? (% yes)a
64 Does your school (co-)organize sports and PA
during lunch break? (% yes)a
41 Active school commuting is promoted by your school. (% agree/strongly agree)b
43 Does your school (co-)organize after-school
sports and PA? (% yes)a
26 Does your school (co-)organize after-school sports and PA? (% yes)a
35
Scoring for the composite implementation score: a0=no; 1=yes.
b
Table III. Percentages of elementary and secondary schools implementing the general and specific organizational principles of the PA promotion framework
Elementary schools Secondary schools
General principles Percentage General principles Percentage
Does your school have a coordinator for health or PA?
(% coordinator for health or PA)a
78 Does your school have a coordinator for health or PA?
(% coordinator for health or PA)a
68
Does your school cooperate with community partners? (% yes)b
60 Does your school have a working group for health
or PA? (% working group for health or PA)c
66
Does your school have a working group for health or PA? (% working group for health or PA)c
43 Are pupils involved in decision making about PA policy? (% yes)b
48
Are pupils involved in decision making about PA policy? (% yes)b
38 Does your school cooperate with community partners? (% yes)b
38 Does your school have a policy on
school-community partnerships? (% yes)b
31 Does your school have a policy on school-community partnerships? (% yes)b
25
Are parents involved in decision making about PA policy? (% yes)b
14 Are parents involved in decision making about PA policy? (% yes)b
10
Specific principles Percentage Specific principles Percentage
Are PE classes taught by a specialized PE teacher? (% yes)b
96 Are PE classes taught by a specialized PE teacher? (% yes)b
99
The after-school sports and PA are mainly non-competitive. (% agree/strongly agree)d
90 How often is the PA program during lunch break provided by qualified teachers? (% often/always)e
84
How often is the PA program during lunch break provided by
qualified teachers? (% often/always)e
87 The school has safe and covered bike racks. (% yes)b
74
How often is the after-school PA program provided by qualified teachers?
(% often/always)e
83 The PA program during lunch break is mainly non-competitive.
(% agree/strongly agree)d
72
The PA program during lunch break is mainly non-competitive.
(% agree/strongly agree)d
78 How often is the after-school PA program provided by qualified teachers?
(% often/always)e
68
The school has safe and covered bike racks. (% yes)b
69 The after-school sports and PA are mainly non-competitive. (% agree/strongly agree)d
52
Do supervisors prompt for PA during recess? (% yes)b
57 Do supervisors prompt for PA during recess? (% yes)b
39 Pupil transfer to sports clubs is promoted
during after-school PA program (% agree/strongly agree)d
35 Pupil transfer to sports clubs is promoted during after-school PA program (%a gree/strongly agree)d
34
Is PA as a health policy integrated in all grades? (% yes)b
27 Pupil transfer to sports clubs is promoted during lunch break PA program (% agree/strongly agree)d
20
After-school sports and PA are open for pupils from other schools.
(% agree/strongly agree)d
21 After-school sports and PA are open for pupils from other schools.
(% agree/strongly agree)d
tively,P< 0.001). Participating secondary schools had a similar mean number of pupils compared with secondary schools in Flanders (425 versus 380 pupils, respectively, P = 0.23) and a similar pro-portion of schools in rural areas (21.6% versus 21.8%, respectively; P= 0.95). Representation of secondary school educational types was similar to the situation in Flanders (32.0% versus 30.8% tech-nical or vocational, 29.6% versus 25.2% general, 25.6% versus 34.1% mixed and 12.8% versus 9.9% special;P= 0.23).
Implementation of the PA promotion
framework
Descriptives on implementation are shown in
Tables IIandIII. All schools had PE lessons at least twice a week and almost all schools approached PA also in other subjects than PE. Sports fields and equipment for sports and play were provided in 81% of the elementary schools and 64% of the secondary schools. Less than half of the elementary schools organized sports and PA during lunch breaks and only 26% organized after-school sports. For secondary schools, the least implemented strat-egies were the promotion of active school commut-ing (43%) and the organization of after-school sports and PA (35%). As for the strategies, the composite or total implementation score (on 6) did not differ between elementary (4.11 6 1.18) and secondary schools (3.99 6 1.20) (t(234) = 0.75,P= 0.46).
The large majority of elementary (78%) and sec-ondary (68%) schools had a coordinator for health and PA. In 60% of the elementary schools, there
was cooperation with partners in the community, while this cooperation was only reported in 38% of the secondary schools. Having a policy on school-community partnerships and involving the parents were the least implemented general princi-ples in both elementary and secondary schools.
In almost all schools, PE was taught by a special-ized PE teacher. The least implemented specific organizational principles (less than 50%) in elemen-tary school were: the promotion of transfer to a sports club (during after-school PA: 35%; during lunch break: 20%), integration of PA as a health policy in all grades (27%) and opening after-school sports for pupils from other schools (21%). In sec-ondary schools, the least implemented organiza-tional principles were supervisors prompting during recess (39%), the promotion of transfer to a sports club (during after-school PA: 34%; during lunch break: 20%), opening after-school sports for pupils from other schools (16%) and integration of PA as a health policy in all grades (15%).
Also for the organizational principles, the total implementation score (on 17) did not differ between elementary (8.79 6 2.92) and secondary schools (8.2362.75) (t(234) = 1.53,P= 0.13).
Multi-level analyses showed that there was no significant between-municipality variation for the composite implementation scores for the strategies and the organizational principles.
As shown inTables IVandV, significant associ-ations with the composite implementation scores for the strategies and the organizational principles were found at all socioecological levels. Having better knowledge of community schools and having
Table III.Continued
Elementary schools Secondary schools
Pupil transfer to sports clubs is promoted during lunch break PA program (% agree/strongly agree)d
20 Is PA as a health policy integrated in all grades? (% yes)b 15
Scoring for the composite implementation score:
a0=No coordinator; 1=coordinator for health/coordinator for PA. b
0=No; 1=yes.
c0=No working group; 1=working group for health/working group for PA. d
0=Strongly disagree/disagree/neither agree nor disagree; 1=agree/strongly agree. e0=Never/rarely/sometimes; 1=often/always.
attended in-service training on building school-community partnerships were the only factors that were positively associated with implementation scores for the strategies and organizational principles in both elementary and secondary schools. Having attended in-service training on whole-school PA promotion also was positively associated with imple-mentation scores in elementary and secondary schools except for the implementation of organiza-tional principles in secondary schools. In elementary schools, awareness of a national PA project with a whole-school strategy (Fit school) was positively related to the implementation score for the strategies. A rural location was positively associated with the implementation scores for strategies and orga-nizational principles in secondary schools only. Safer traffic in the neighborhood was positively associated with the implementation scores for the strategies in elementary school and of the
organizational principles in secondary schools. Higher numbers of pupils were related to a higher implementation score for the strategies in both elementary and secondary schools.
In elementary schools, a higher perceived need for a municipal coordinator for school-community partnerships to promote PA was associated with a lower implementation score for the strategies, while in secondary schools, support for the PA-promoting framework was positively associated with a higher implementation score.
Participation in after-school activities from the School Sports Association was positively associ-ated with implementation of the organizational principles in elementary and secondary schools and with implementation of the strategies in secondary schools.
In secondary schools, support for the PA promo-tion framework was positively associated with
Table IV. Multivariate regression analyses on the contribution of socioecological factors to the implementation score of the strategies of the PA promotion framework
Elementary schools Secondary schools
Level Item/factor b(SE) b(SE)
Personal Knowledge about community schools 0.368 (0.108)**** 0.356 (0.097)**** Awareness of the ‘Fit school’ project 0.485 (0.289)**
Physical Rural location 0.743 (0.213)****
Number of pupils 0.617 (0.216)**** 0.322 (0.206)* Traffic safety around school 0.220 (0.107)**
Policy Perceived need for a municipal coordinator for school-community partnerships
0.253 (0.102)***
Participation in after-school activities from the School Sports Association
0.566 (0.220)*** School supports the criteria of
the PA promotion framework
0.280 (0.147)** In-service training on building
school-community partnerships
0.589 (0.225)*** 0.324 (0.237)* In-service training on whole-school
PA promotion
0.445 (0.223)** 0.567 (0.226)*** Sociocultural Interest from the school board in
school-community partnerships
0.256 (0.112)*** Interest from parents in PA at school 0.221 (0.127)** 0.161 (0.114)* Relative priority of other themes
than PA within the school
0.212 (0.121)** Partnership with a sport
and PA leader
0.608 (0.339)**
implementation of the organizational principles. More perceived interest from parents in PA at school was associated with higher implementation scores for the strategies in elementary and secondary schools and for the organizational principles in ele-mentary schools. A partnership with a ‘sport and PA leader’ was positively associated with implementa-tion of the strategies in elementary schools. More interest from the school board in school-community partnerships associated with higher implementation scores for the strategies in secondary schools and for the organizational principles in both elementary and secondary schools. In secondary schools, a higher priority of other themes than PA was negatively associated with implementation of the strategies.
Discussion
This study provides more insights in the implemen-tation of evidence-based strategies and principles set out by a PA promotion framework. Several evidence-based strategies defined in the PA promo-tion framework were implemented in most Flemish
elementary and secondary schools. PE was delivered in all grades of all schools, which was expected because PE delivery of 2 hours week–1is mandatory in Flemish schools. However, there was substantial room for improvement on several other PA promo-tion strategies.
School-based PA and sports during lunch break and after school were organized in less than half of the Flemish elementary schools, which is similar to findings in the United States [21]. As these ex-tracurricular strategies can contribute to reaching adequate levels of PA [27,28], efforts are needed to further increase implementation of these strate-gies. PA programs during lunch break can be coordinated and organized by the teacher team or by older peers under teacher supervision. The or-ganization of after-school PA programs may be more difficult due to human resource problems and the challenge of finding professional sport and PA teachers willing to guide the after-school activities [29]. Therefore, partnerships with PA and sport providers in the community [14, 27] and modest registration fees for participating pupils may be required [29].
Table V. Multivariate regression analyses on the contribution of socioecological factors to the implementation score of organizational principles of the PA promotion framework
Elementary schools Secondary schools
Level Item/factor b(SE) b(SE)
Personal Knowledge about community schools 0.602 (0.156)**** 0.444 (0.130)****
Physical Rural location 0.409 (0.293)*
Number of pupils
Traffic safety around school 0.428 (0.139)***
Policy Participation in after-school activities from the School Sports Association
0.647 (0.314)*** 0.538 (0.305)** Perceived lack of integrated youth
policy in the municipality
0.294 (0.180)* School support the criteria of
the PA promotion framework
0.345 (0.204)** In-service training on building
school-community partnerships
1.039 (0.323)**** 0.727 (0.305)*** In-service training on whole-school
PA promotion
0.508 (0.314)* Sociocultural Interest from the school board in
school-community partnerships
0.323 (0.167)** 0.480 (0.143)**** Interest from parents in PA at school 0.282 (0.184)*
It was promising to find that the large majority of Flemish elementary and secondary schools approached PA also in other school subjects (out-side PE) and provided sports fields and materials during breaks. Apparently the schools foster PA promotion, however, the organization of after-school programs seems more difficult.
In secondary schools, active commuting to school was promoted in only 43% of schools. The lower percentage compared with elementary schools (76%) could be explained by the fact that active school commuting is more common in sec-ondary school children, compared with elementary school children [30]. However, as it is such an im-portant source of PA [31] and taking into account that still half of the teenagers does not actively commute to school [30] despite Flanders’ walker and cyclist friendly environment, there is still ample room for improvement.
Focusing on the implementation of general orga-nizational principles of the PA promotion frame-work, we can define some areas of concern. A first concern relates to the strategies for involve-ment of pupils and parents in the school’s PA policy that were implemented by only a minority of Flem-ish elementary and secondary schools, while such strategies have been increasingly recommended [17, 32, 33]. The finding that 38% of secondary schools cooperated with community partners is a second concern as local partners in the community have the potential to improve the effectiveness of health promotion at school [34]. In the present study, only about 30% of schools had a policy on school-community partnerships for PA promotion. To improve the success of potential partnerships such a policy is needed, including an action plan with clearly defined goals and organizational inputs of the partners [35–37]. Furthermore, a working group was established in only four of 10 elementary schools. A working group, with the participation of the school principal, teachers, parents and pupils, and community partners needs to be further pro-moted as an essential instrument for the develop-ment of a health and PA policy at school [14,24]. The scores for the implementation of the specific organizational principles were relatively low.
Nonetheless, it was promising that most Flemish schools involved qualified teachers in the PA pro-grams organized during lunch break and after school. This involvement may contribute to the quality of the extra-curricular programs and to the objective of leading pupils to more leisure time opportunities for PA in the community. In the same line, after-school opportunities for PA could be in-creased by partnerships with other schools in the neighborhood, which have shown to facilitate the provision of more extensive programs and a more efficient use of resources [29]. It is promis-ing that 21% of the elementary schools and 16% of the secondary schools already implemented this progressive principle of cooperation by opening up their after-school program for pupils from other schools. However, it still leaves lots of room for improvement. The findings also show that further efforts are needed to convince secondary schools to offer non-competitive activities during after-school hours. Other studies also reported that after-school PA programs with an emphasis on competition are more commonly available [21, 38], which is less beneficial for groups at risk for PA deprivation [38]. Furthermore, only a minority of elementary and secondary schools integrated PA as a health policy theme in all grades. Consequently, schools ought to develop their PA promotion plan within a working group that exceeds the PE teachers and that includes a whole curriculum approach.
The present study found that the two most im-portant socioecological factors associated with implementation scores were knowledge of commu-nity schools and in-service training. In-service training on school-community partnerships and whole-school PA promotion were broadly associ-ated with more and better implementation. Logi-cally, knowledge of community schools, of which school-community partnerships are a key feature [39] and awareness of the ‘Fit school’ project, which offers multiple PA promotion components were also associated with higher implementation scores. Based on these findings, in-service training on school-community partnerships and whole-school PA promotion, combined with the dissemi-nation of ready-to-use PA projects, may encourage
the implementation of school-based PA promotion. However, the cross-sectional study design does not exclude the possibility that participation in in-service training may have resulted from schools encountering implementation issues. Nonetheless, results of this study support reviews reporting that in-service training is a core component of successful implementation of evidence-based health promotion programs [40]. Another policy factor, which related to higher implementation scores in both school groups, was participation in after-school activities from the Flemish School Sports Association. As this association strongly promotes the whole-school PA promotion concept, this find-ing was expected. Furthermore, reports of a higher need for a municipal coordinator for school-community partnerships were related to lower strat-egy implementation scores in elementary schools. Possibly, these schools lack the capacity to estab-lish community links as they express the need for an external coordinator. In the same line, larger schools showed higher implementation scores. A larger (PE) teacher team may explain this finding. Based on the above findings, it can be concluded that sufficient human resources is a key factor to promote PA. This may be countered by higher parent involvement and school-community partnerships.
Other significant factors included rural location and safer traffic. A rural school location was asso-ciated with higher implementation scores in sec-ondary schools, which is consistent with a study on PA opportunities in middle schools [22]. It is argued that in urban secondary schools limited space and overcrowding may impede the organiza-tion of PA during recess/lunch break [22]. In future efforts, specific attention may be needed to support inner-city secondary schools and to maximize use of space within and around the school area. As safer traffic around elementary and secondary schools was also associated with higher implementation scores, environmental changes to enhance traffic safety are recommendable, including speed restric-tions, sidewalk and bicycle lane improvements and walking school buses or bike pooling [40].
Finally, interest from the school board in school-community partnerships and perceived parental
interest in PA related to higher implementation scores in elementary and secondary schools. Interna-tional studies support this finding and underpin the importance of participation of the school board and parents for a more effective school policy on PA and health [19,32,41]. Consequently, regular commu-nication and initiatives tuned to school boards and parents (e.g. participation in working group on school health policies, family-centered PA events) are of interest.
Limitations of the present study include the lim-ited response rate, which makes it difficult to gen-eralize findings and urges cautious interpretation. However, the response rate was comparable with the average of 37% among other online surveys [42]. Moreover, social desirability of the respond-ents could not be excluded and the cross-sectional design did not allow drawing conclusions on cau-sality. Although the school sample was represen-tative on several variables, schools with less interest in PA promotion may have declined to participate Consequently, it is unknown if some factors are the result or the predictor of higher implementation scores. Future research could further develop socioecological measures of the school environment and study the longitudinal relationship with school-based PA promotion by using a combination of self-report and more objective observations.
Strengths of the present study are the inclusion of a relatively large sample of schools. Moreover, in our opinion, the present study advances previ-ous research on PA promotion through the school by focusing on implementation issues. The find-ings contribute to schools’ and community’s common objective of providing youth with more PA opportunities.
To conclude, in Flanders elementary schools should increase efforts to organize sports and PA during lunch break and afterschool, while in sec-ondary schools, active school commuting and after-school sports need more promotion. Knowledge on community schools and in-service training next to sufficient human resources are potential key factors to promote PA. Furthermore, efforts are needed to convince and help schools to increase parental and
pupil involvement and to build a policy on school-community partnerships.
Funding
This work was supported by the Policy Research Center Culture, Youth and Sport funded by the Flemish Government.
Conflict of interest statement
None declared.References
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