# Exercise as it relates to Disease/Is the use of wearable technological devices a valid strategy to increase physical activity in Preschoolers?

This is a critique is of the article: "Feasibility and Effectiveness of a Wearable Technology-Based Physical Activity Intervention in Preschoolers: A Pilot Study" by Wonwoo Byun, Erica Y. Lau and Timothy A. Brusseau.

## What is the background to this research?

Childhood obesity is a worldwide health and economic concern with a continual rise in school-age children affected over the years. Therefore, beginning to address this issue in the years prior to starting primary school is critical. Among the many contributors to the childhood epidemic, the lack of physical activity (PA) has been shown to be a key determinant of excessive weight gains in preschool age children. Due to the association between being moderately overweight prior to puberty and the increased health risks, there is an urgency to implement effective interventions. As significant portion of time is spent by children at education institutions, schools are a prime place to promote PA. Conventional approaches to promote PA include structured programs and the modification of physical environments. If valid, the use of wearable technological devices could provide a more flexible and cost-efficiet way to increase PA in this population.

## Where is the research from?

This research was conducted collaboratively by Wonwoo Byun and Timothy A. Brusseau from the University of Utah with Eric Y. Lou from the University of British Columbia. Participants included preschoolers from five childcare centres regulated by the National Association for the Education of Young Children (NAEYC). Carer consent and approval of the University’s Institutional Review Board were obtained before commencement. The article was published in the International Journal of Environmental Research and Public Health (IJERPH) in August 2018. IJERPH is a peer-reviewed scientific journal published by Multidisciplinary Digital Publishing Institute (MDPI). No conflicts of interest were declared by the authors.

## What kind of research was this?

This was a pilot research study with a quasi-experimental, two parallel group post-test only design. The purpose of the pilot study was to determine the validity of the intervention on a smaller scale and assist in enhancing the quality and efficiency of a potential main study.

## What did the research involve?

The intervention was established using the social ecological model (SEM) and health belief model (HBM). It employed real-time PA monitoring at the childcare centres via Fitbit Flex for a week. Fitbit Flex is a validated tool for this age group. The focus was to successfully influence PA behaviours through teacher interactions and reduce the barriers teachers have in promoting PA in children. The study involved five childcare centres who were randomly assigned into two control and three intervention groups all consisting of between 16 and 21 participants. Each group was supervised by a minimum of two teachers. All data and measurements from the childcare centres were acquired in the same timeframe to minimise inaccuracy due to environmental factors.
Intervention groups:
* Participants wore activity trackers for the duration of childcare.
* Teachers were able to check the PA and sedentary behaviour (SED) levels of participants via Fitabase API to identify individuals who required more opportunity to be active.
* Teachers attended a training session prior to and were supported by research staff during the intervention.
Control groups:
* The control groups were requested to go about their day as per normal in the week and given the opportunity to participate in the same intervention program at the end.
Feedback methods:
* Carers of participants were given a 5-point Likert scale self-reported questionnaire related to their perceptions of the child’s PA. And a survey related to the wearing of activity trackers and PA monitoring at childcare.
* Teachers provided feedback via a 5-point Likert scale survey regarding the intervention. Importantly, there is debate about the validity of using a 5 point scale compared to the 7 point scale.
Limitations:
* The limitations in this study include the short intervention period, and the lack of pretest and statistical power. Thus, there is an uncertainty regarding the validity of the surveys used and the accuracy of significant results found.

## What were the basic results?

The final analysis consisted of data from 45 control-group and 48 intervention-group participants. Characteristics of both groups were similar apart from the education level of parents. The results showed the intervention group spent significantly less time in sedentary behaviour (2 min/hr) and more PA time overall (2 min/hr) compared to the control group. Teachers in the intervention group used the real-time monitoring system an average of four times a day and reported the intervention’s suitability within the classroom setting. Likewise, the parent surveys indicated a high positivity (between 3.8 and 4.7 on a 5-point scale) of the intervention and the use of Fitbit activity trackers among their children.

## What conclusions can we take from this research?

From this intervention, the use of wearable technological devices seems promising regarding feasibility and compliance of teachers, children and their carers within a childcare centre setting. This is in line with current research which suggests the use of technological wearables are effective for short-term increases in PA. An intervention on a larger scale is warranted as it could provide potential long term health benefits to participants through a decrease in SED and increase in their PA levels.

## Practical advice

Considerations:
* Wearable technology can be a useful tool not just for teachers but for parents at home.
* It is important for wearable devices to be easy to use and perceived by children to be enjoyable to achieve adherence. They were generally found easy to use in this study.
* A holistic approach is required to make positive change, in particular utilising the parents and teachers of children. Parents in particular can positively aid their child’s view and participation in PA through modelling encouraging and active behaviour.
Recommendations for future trials:
* Future trials need to be implemented for a longer duration with a larger population size. This study while limited due to time and resources was an initial step towards more extensive research of the validity of potential strategies to increase PA in preschool age children.
* Provide different options of software operating systems to cater for personal preferences of teachers.
* Offer teachers a more customisable Fitabase API user interface for tracking specific data targets with the option to access children’s activity data via a picture instead of their name.
* Provide relevant resources to teachers such as lesson plans and activity ideas to help them be more effective and better equipped in promoting PA within the class setting.
* Integrate family involvement in the intervention during out of care hours. For example, providing parents with the opportunity to monitor and actively promote PA during those times.

## Further information/resources

* Childhood obesity:
** https://www.healthdirect.gov.au/obesity-in-children
** https://www.aihw.gov.au/reports/overweight-obesity/overweight-obesity-australian-children-adolescents/summary
** https://www.obesityaction.org/get-educated/understanding-childhood-obesity/what-is-childhood-obesity/
* Fitabase API: https://www.fitabase.com/resources/knowledge-base/fitabase-api/what-is-the-fitabase-api/
* Fitbit Flex: https://www.fitbit.com/pl/shop/flex
* Health belief model (HBM): https://www.verywellmind.com/health-belief-model-3132721
* Likert scale: https://www.simplypsychology.org/likert-scale.html
* Social ecological model (SEM): https://www.simplypsychology.org/Bronfenbrenner.html
* WHO guidelines on physical activity and sedentary behaviour: https://www.who.int/publications/i/item/9789240015128

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 Byun W, Lau EY, Brusseau TA. Feasibility and effectiveness of a wearable technology-based physical activity intervention in preschoolers: A pilot study. International journal of environmental research and public health. 2018;15(9):1821.
* ↑ Organization WH. Taking action on childhood obesity World Health Organization; 2018.
* ↑ Leppänen M, Nyström CD, Henriksson P, Pomeroy J, Ruiz J, Ortega F, et al. Physical activity intensity, sedentary behavior, body composition and physical fitness in 4-year-old children: results from the ministop trial. International Journal of Obesity. 2016;40(7):1126-33.
* ↑ Pate R, O'neill J, Liese A, Janz K, Granberg E, Colabianchi N, et al. Factors associated with development of excessive fatness in children and adolescents: a review of prospective studies. Obesity reviews. 2013;14(8):645-58.
* ↑ Leppänen M, Henriksson P, Nyström CD, Henriksson H, Ortega FB, Pomeroy J, et al. Longitudinal physical activity, body composition, and physical fitness in preschoolers. Medicine and Science in Sports and Exercise. 2017;49(10).
* ↑ Weihrauch-Blüher S, Wiegand S. Risk factors and implications of childhood obesity. Current obesity reports. 2018;7(4):254-9.
* ↑ Díaz-Quesada G, Bahamonde-Pérez C, Giménez-Egido JM, Torres-Luque G. Use of Wearable Devices to Study Physical Activity in Early Childhood Education. Sustainability. 2021;13(24):13998.
* ↑ In J. Introduction of a pilot study. Korean journal of anesthesiology. 2017;70(6):601-5.
* ↑ Byun W, Lee J-M, Kim Y, Brusseau TA. Classification accuracy of a wearable activity tracker for assessing sedentary behavior and physical activity in 3–5-year-old children. International Journal of Environmental Research and Public Health. 2018;15(4):594.
* ↑ Joshi A, Kale S, Chandel S, Pal DK. Likert scale: Explored and explained. British journal of applied science & technology. 2015;7(4):396.
* ↑ Lam C, Milne-Ives M, Harrington R, Jani A, Helena van Velthoven M, Harding T, et al. Internet of things–Enabled technologies as an intervention for childhood obesity: A systematic review. PLOS Digital Health. 2022;1(4):e0000024.
* ↑ Hesketh KR, Lakshman R, van Sluijs EM. Barriers and facilitators to young children's physical activity and sedentary behaviour: a systematic review and synthesis of qualitative literature. Obesity Reviews. 2017;18(9):987-1017.