Active Kindergarten - Active Children
Condition: Healthy Lifestyle
Study type: Interventional

Summary: 
      The AK-AC study was designed as a two-arm, randomised by ECEC institution, evaluative
      controlled trial with the overarching aim of increasing the children's PA level and reduce
      sedentary time.
    

Detailed description: 
      Background A growing body of evidence suggests that children's physical activity (PA) level
      in childhood education and care (ECEC) settings is insufficient. Moreover, sedentary
      behaviour, defined as any waking behaviour characterized by an energy expenditure ≤ 1.5
      metabolic equivalents while in a sitting, reclining, or lying posture, is highly prevalent
      and has been identified as detrimental to children's health. Although many children have
      healthy and active lifestyles, there seems to be a relatively large group of children with a
      low PA level. This could lead to negative developmental effects such as low fitness levels,
      weak motor skills and obesity. This is especially worrying because it is known that PA level
      often tracks from childhood into adulthood. Thus, early intervention is crucial given that PA
      plays a pivotal role in children's overall health and is associated with many positive health
      outcomes, including physical fitness, cardiovascular health, bone health and psychosocial and
      cognitive development.

      PA levels have been found to be highly variable among children in ECEC settings and may
      therefore have great potential for effective interventions. Furthermore, since most children
      attend ECEC settings for many hours on most days of the week, and these institutions reach
      children across the socioeconomic spectrum, the ECEC setting may serve as an ideal avenue for
      increasing PA level, reducing sedentary time and enhancing the overall health of young
      children. However, early childhood educators identify parents rather than themselves as those
      responsible for promoting children's PA and may assume that young children receive adequate
      PA throughout the week regardless of their activities during their stay in the ECEC setting.
      Thus, intervening with children and staff in ECEC settings to equip them with the knowledge,
      abilities and motivation to promote PA in children during their ECEC time may provide
      substantial public health benefits.

      In earlier studies, PA interventions conducted in ECEC settings have shown only small to
      moderate effects and were rather inconsistent across studies. Most PA interventions that have
      been implemented in ECEC settings have been structured programmes developed by PA experts and
      delivered by staff alone or with the strong influence of trained research personnel. In some
      studies, staff-led interventions have been shown to be less effective in increasing PA than
      interventions implemented by PA experts. Similar findings have emerged regarding intervention
      effects on fundamental movement skills. The main explanation for the lower efficiency of
      staff-led interventions may be that PA experts have more knowledge and competencies regarding
      this issue. For staff-led programmes to succeed, the need for multiple staff training
      sessions and maximizing the number of trained staff has been emphasized.

      Recently, several reviews have summarized the body of knowledge regarding various aspects of
      the contexts of and prerequisites for PA in different kinds of out-of-home services for
      children of preschool age. A review including 34 studies revealed small but positive and
      significant intervention effects for children's (5 years) moderate- to vigorous-intensity PA
      (MVPA) but not for light-intensity PA. Based on their findings, the authors recommended
      interventions tailored to the target group and noted that cultural considerations, community
      needs and the provision of ongoing support should play key roles. Furthermore, they concluded
      that daily structured PA sessions, integrated into the everyday activities in the
      institutions (routines) and delivered through a hands-on approach, were most likely to
      contribute to increasing children's MVPA.

      A review of 24 PA interventions in childcare, mostly targeting children between three and
      five years of age, where staff participated in professional development either before or
      during the intervention period and provided children with opportunities for additional PA.
      Less than half of the included studies had positive effects on children's PA level. For
      further intervention studies in ECEC, the authors provided four recommendations, of which two
      were based on the papers included in the review and two were based on evidence "from broader
      ECEC literature". First, there is a need for high-quality professional development prior to
      and during the intervention, and second, there is a need for "interventions that are 'outside
      the box'" in terms of, e.g., blended professional development; the role of technology;
      targeting the health, well-being and activity levels of the educators; focusing on PA
      learning experiences, outdoor time, and energy breaks; and integrating interventions into the
      institutions' daily routines. The third, broader-based recommendation addressed the
      importance of developing meaningful and trustworthy cooperation and relationships between
      staff and researchers. The fourth and final recommendation focused on the ECEC environment as
      a key factor for providing good opportunities for PA that thus should be increasingly
      emphasized in future interventions.

      A missing perspective in recent studies focusing on PA interventions in ECEC settings might
      be that they do not fully take into account the fact that ECEC teaching professional practice
      has become increasingly complex due to increasingly diverse societies and multiple components
      related to working conditions. Thus, top-down approaches and standardized solutions
      (programmes) will possibly be difficult to implement in an ever more diverse environment in
      terms of individual, social, cultural and physical differences within and between
      institutions. Therefore, a suitable approach might be to establish organizational and
      collaborative learning processes, a community of professional learning, to improve and
      maintain staff competence. This means contextualizing pedagogical practice through continuous
      negotiation and reflection between staff members and through collective responsibility for
      improvement of practice instead of merely implementing structured programmes developed by
      external experts. While expert-delivered interventions seem to be best suited for effect
      studies, "real-world" approaches implemented by preschool teachers may have greater potential
      for developing sustainable and improved long-term practice.

      The current study therefore suggests a dialogical and bottom-up approach that takes into
      account differences within and between local ECEC settings, such as child group
      characteristics; staff competencies, personal preferences and practices for sustainable
      implementation; differences in the physical indoor and outdoor environments; and available
      equipment to promote physically active play. Interventions that can be adapted to specific
      circumstances within an organization while maintaining overall fidelity are more likely to be
      successful. Hence, the theoretical frame of the current intervention is based on Wenger's
      theory on communities of practice (COP). Crucial for this theoretical perspective is the idea
      that organizations are learning communities that share competence and experiences to develop
      new practices. Such a community involves trusting in staff professionalism and their
      knowledge about and sensitivity towards the individual child and child groups as well as
      their awareness of barriers and possibilities in terms of environment and equipment. COP
      includes three modes of belonging: engagement, imagination and alignment. Engagement is
      actively participating in practice, revealing needs for learning and change and establishing
      the collective development of the organization. Imagination connects to the staff's visions
      and experience of meaning regarding the intervention, as well as their understanding of the
      purpose. Alignment is about commitment to the entire project. To achieve positive changes
      based on COP, these types of belonging must be linked to particular processes such as the
      establishment of mutual engagement over time to promote change, self-awareness and reflection
      on institutional practices. It is also important to transfer the knowledge and purpose of a
      practice across boundaries in the institution. A further key element is to establish
      practices where multiple perspectives are heard and appreciated to ensure that staff members
      can take advantage of opportunities to develop and experience themselves as acknowledged
      contributors to the institution. The current study, "Active Kindergarten - Active Children"
      (AK-AC), aims to examine the potential of a staff-led and expert-supported intervention to
      increase children's PA level and reduce sedentary time within the ECEC setting compared to
      standard care.

      Methods Participants All children attending one of the 11 public ECEC institutions in
      Sandefjord municipality and born in 2011 (three- or four-year-olds) (n=130) were invited to
      participate in the study. Parents of a total of 116 children (89%) signed the informed
      consent form, and the children of these parents were included in the study. The intervention
      and control groups were formed at the centre level; six ECEC institutions were randomly
      assigned to the intervention group, and five institutions were assigned to the control group.
      The ECEC institutions varied in size and number of children (range 28 to 100 children). Most
      ECEC institutions follow the national recommended staff-child ratio of one staff member per
      three children under the age of three and per six children over the age of three. The
      regulations also demand one ECEC-educated teacher per nine children under the age of three
      and per 18 children over the age of three. The distribution showed a mixture of centre sizes
      in both the intervention and control group.

      Intervention Four PA experts (researchers (PhD) within the field of PA and health in children
      and physical education teachers) in collaboration with two members of the ECEC staff and two
      members of the municipal health department (paediatric physiotherapists) developed a frame
      for the intervention based on COP elements to be further developed, concretized and
      implemented by the staff. The intervention lasted for four months and contained the following
      components: pre-meetings and follow-up meetings in each ECEC institution; a start-up seminar
      and two follow-up courses with all staff members; ongoing planning and collective reflection
      practice in the ECEC institutions; a Facebook group; and an equipment package.
    

Intervention name(s): Physical activity
Intervention type(s): Behavioral
Intervention description(s): Four PA experts (researchers (PhD) within the field of PA and health in children, and physical education teachers) in collaboration with two members of the ECEC staff and two members of the municipality health department (paediatric physiotherapists) developed a frame for the intervention based on COP elements to be further developed, concretized and implemented by the staff. The intervention lasted for four months and contained the following components (Table 1): pre-meetings and follow up meetings in each ECEC institution; start up seminar and two follow up courses with all the staff members; ongoing planning and collective reflections practice in the ECEC institutions; Facebook group; and an equipment-package.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Investigator, Outcomes Assessor)
Primary purpose: Prevention