The effect of the cluster randomized HIPPA intervention on childcare children’s overall physical activity
Full text
This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details. Author(s): Title: Year: Version: Copyright: Rights: Rights url: Please cite the original version: CC BY-NC-ND 4.0 https://creativecommons.org/licenses/by-nc-nd/4.0/ The effect of the cluster randomized HIPPA intervention on childcare children’s overall physical activity © the Authors, 2017. Published version Mehtälä, Anette; Sääkslahti, Arja; Soini, Anne; Tammelin, Tuija; Kulmala, Janne; Villberg, Jari; Nissinen, Kari; Poskiparta, Marita Mehtälä, A., Sääkslahti, A., Soini, A., Tammelin, T., Kulmala, J., Villberg, J., Nissinen, K., & Poskiparta, M. (2017). The effect of the cluster randomized HIPPA intervention on childcare children’s overall physical activity. Baltic Journal of Health and Physical Activity, 9(4), 89-111. https://doi.org/10.29359/BJHPA.09.4.08 2017
ORIGINAL www.balticsportscience.com doi: 10.29359/BJHPA.09.4.08 89 Baltic Journal of Health and Physical Activity 2017;9(4):89-111 Journal of Gdansk University of Physical Education and Sport in Gdansk e-ISSN 2080-9999 Authors’ Contribution: A Study Design B Data Collection C Statistical Analysis D Data Interpretation E Manuscript Preparation F Literature Search G Funds Collection article details Article statistics Word count: 6,066; Tables: 3; Figures: 2; References: 60 Received: September 2017; Accepted: November 2017; Published: December 2017 Full-text PDF: http://www.balticsportscience.com Copyright © Gdansk University of Physical Education and Sport, Poland Indexation: Celdes, Clarivate Analytics Emerging Sources Citation Index (ESCI), CNKI Scholar (China National Knowledge Infrastructure), CNPIEC, De Gruyter - IBR (International Bibliography of Reviews of Scholarly Literature in the Humanities and Social Sciences), De Gruyter - IBZ (International Bibliography of Periodical Literature in the Humanities and Social Sciences), DOAJ, EBSCO - Central & Eastern European Academic Source, EBSCO - SPORTDiscus, EBSCO Discovery Service, Google Scholar, Index Copernicus, J-Gate, Naviga (Softweco, Primo Central (ExLibris), ProQuest - Family Health, ProQuest - Health & Medical Complete, ProQuest - Illustrata: Health Sciences, ProQuest - Nursing & Allied Health Source, Summon (Serials Solutions/ProQuest, TDOne (TDNet), Ulrich’s Periodicals Directory/ulrichsweb, WorldCat (OCLC) Funding: This work was supported by the Ministry of Social Affairs and Health, Finland; the Ministry of Education and Culture, Finland and the Juho Vainio Foundation. Conflictofinterest: Authors have declared that no competing interest exists. Corresponding author: Mehtälä Marjo Anette Kristiina, Faculty of Sport and Health Sciences, Po. Box 35 (L322), 40014 University of Jyväskylä, Finland, +358 40 805 4741, [email protected] Open Access License: This is an open access article distributed under the terms of the Creative Commons Attribution-Non-commercial 4.0 International (http://creativecommons.org/licenses/by-nc/4.0/), which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non-commercial and is otherwise in compliance with the license. abstract Background TheeffectoftheclusterrandomizedHome-andchildcare-basedInterventiontoPromote Physical Activity (HIPPA) intervention on the everyday physical activity (PA) of children betweentheagesof4to5yearswasevaluated. Material/Methods Fourteenchildcarecenterswith102childrenbornin2007andtheirfamiliesparticipatedin thestudy.HIPPAwasimplementedoverasinglepreschoolyearinsevenchildcarecenters whilesevenothercenterscontinuedtheirnormalcare(controlgroup,CG).ThePAlevelsof childrenwereassessedbyaccelerometerssixtimeseverysixmonthsduringtwoandahalf yearsofresearch.ValidPAdatawereobtainedfrom69childrenatbaselineandanalyzed withalinearmixedmodel. Results ChildreninHIPPAengagedinmoreMVPA(moderate-to-vigorousPA)atpost-intervention andmoreLMVPA(light-to-vigorousPA)atthesix-monthfollow-uponweekdaysthanthe CG did (estimated net effect: 13 min/day and 15 min/day, respectively). Sex-specific analysesindicatedthatthedifferencesinweekdayMVPAandLMVPAbetweengroupswere significantatfollow-upamonggirls(estimated net effect: 15 min/day and 20 min/day, respectively),butnotamongboys. Conclusions Overall,HIPPAwaseffectiveinincreasingPAinchildcare-agedchildren,especiallyingirls. Key words physicalactivity,children,childcare,intervention,sex Theeffectoftheclusterrandomized HIPPA intervention on childcare children’s overall physical activity Marjo Anette Mehtälä1 ABCDEFG, Arja Sääkslahti1 ABE, Anne Soini2 ABE, TuijaTammelin3 BE,JanneKulmala3 BE, Jari Villberg1 BC, Kari Nissinen4 CE, Marita Poskiparta1 ABEG 1 Faculty of Sport and Health Sciences, University of Jyväskylä, Finland 2 Department of Education, University of Jyväskylä, Finland 3 LIKES – Research Centre for Physical Activity and Health, Jyväskylä, Finland 4 Finnish Institute for Educational Research, University of Jyväskylä, Finland
MehtäläM,SääkslahtiA,SoiniA,TammelinT,KulmalaJ,VillbergJ,NissinenK,PoskipartaM. Effect of HIPPA intervention on physical activity Balt J Health Phys Act 2017;9(4):89-111 90 www.balticsportscience.com introduction Physical activity (PA), especially total PA and moderate-to-vigorous PA (MVPA), appears to be associated with cardiometabolic risk factors independently of sedentary time or body composition [1, 2]. However, it is commonly known that children’s PA levels are low, and most children do not meet the current PA guidelines [3]. Participation in organized sport has increased over the decades [4], but unstructured, spontaneous everyday PA is decreasing among even the youngest children in developed countries [5, 6]. Nowadays, various indoor sedentary activities (e.g., watching TV/videos, playing electronic games while sitting, reading) compete for the interest of children against physically more active outdoor playtime [7–10]. Along with the observed low levels of PA, some children’s motor skills have declined, a trend that is possibly a reflection of the sedentary lifestyle [11, 12]. During early childhood, there is a constant need to promote PA in order to ensure that children obtain adequate motor skills and become physically active adults [13, 14]. The increase in PA, even slight, may have beneficial effects on the development of fundamental motor skills [15, 16] and executive functioning in children [17]. Most children between the ages of 2 and 6 attend childcare, so the childcare environment is of great importance to these children’s PA [6, 18]. Children’s MVPA levels have been associated with the environment and the policy of childcare centers [19] even more than they have with children’s demographic factors [20]. However, these studies have reported low levels of PA among children attending childcare, concluding that the childcare environment offers a major intervention opportunity. The importance of childcare in children’s lifelong PA has been recognized. During the past decade, interventions to promote childcare children’s PA have been implemented to an increasing extent [21, 22], but the results have been modest. Most of the studies have been short term (less than 14 weeks), and follow-up has been rare or non-existent. There have been attempts to transfer the associations shown in cross-sectional studies between children’s PA levels and outdoor time [23] to intervention programs, but these have met with mixed results [24–29]. In addition to the policies and practices of the childcare centers, the influence of teachers on children’s PA levels has been recognized [19, 30], and so teachers are often essential targets for the intervention. On the other hand, interventions have rarely been implemented by teachers themselves and the intervention program commonly comes in a top-down manner. It has been pointed out that interventions concentrating on changing the specific context to promote activity in childhood have not been sufficiently effective [31]. In attempts to change health behaviors such as PA, a wider approach may potentially be more effective [32]. Children’s families are in constant contact with their local childcare centers, a situation that provides an opportunity to intervene in the home environment as well [33]. There is currently no evidence about the effect of involving parents in childcare center interventions, but research on this topic is limited [21]. In the current study, the socio-ecological model was used as an intervention framework [34]. The Homeand childcare-based Intervention to Promote Physical Activity (HIPPA) used a three-level socio-ecological model to better target and increase the effectiveness of the intervention and to find potential
91 www.balticsportscience.com Baltic Journal of Health and Physical Activity 2017;9(4):89-111 Journal of Gdansk University of Physical Education and Sport in Gdansk e-ISSN 2080-9999 PA promotional strategies. We identified modifiable personal (preferences), behavioral (sedentary and active time) and socio-environmental (family, peers, teachers, availability of PA equipment and facilities) factors associated with children’s PA levels. The model allowed us to address the factors that affect children’s PA in childcare centers and homes, that is, in those settings where children spend a substantial part of their day [6]. The aim of this study was to evaluate the effect of the 12-month cluster randomized Homeand childcare-based Intervention to Promote Physical Activity (HIPPA) intervention designed to increase 4to 5-year-old children’s everyday PA on weekdays and at weekends both at the childcare center and at home. Six measurements of PA were conducted every six months during two and a half years of research. However, this study reports only mid-way (6 months), post-intervention (12 months) and follow-up (18 months) intervention effects. material and methods setting This cluster-randomized trial was part of a larger research project, “Dutch and Finnish 2–6-year-old children’s physical activity both at childcare and at home”. As presented in Figure 1, in spring 2010, 60 public childcare centers in the area of a city located in Central Finland were invited to participate in the HIPPA intervention. The invitation was given via a presentation to the principals of the childcare centers during a regional administrative meeting. Eleven childcare centers accepted the invitation. These childcare centers distributed the information letters and consent forms to the eligible families, who had to have a child enrolled in the participating childcare centers. The only inclusion criterion was that the child had been born in 2007. When the data collection had already begun, it was decided to expand the sample by asking four new childcare centers to participate in the study. Three of them accepted this invitation. All 14 childcare centers were located around the city and they were representative of the typical Finnish childcare system. The University of Jyväskylä Ethical Committee, along with the Social Affairs and Health officer in the city, approved the study. randomization Clusters were formed naturally from the childcare centers and they were randomized to either the intervention or the control arm. The 14 voluntary childcare centers were stratified into pairs by their districts because we hypothesized that a childcare center’s location may reflect opportunities for PA as well as indicate the socioeconomic status of families. The paired centers were randomly assigned to the intervention group (seven childcare centers) or to the control group (seven childcare centers). There were no statistically significant differences in mean indoor size, mean play area outside and availability of PA equipment between the intervention and control childcare centers. The effects of weather on the results were minimized by conducting the measurements in the paired intervention and control childcare centers at the same time. The study participants, researchers, and statisticians were blinded to the group assignment at baseline but not at the follow-up assessments.
MehtäläM,SääkslahtiA,SoiniA,TammelinT,KulmalaJ,VillbergJ,NissinenK,PoskipartaM. Effect of HIPPA intervention on physical activity Balt J Health Phys Act 2017;9(4):89-111 92 www.balticsportscience.com participants In fall 2010, there were 179 children born in 2007 at the 14 childcare centers. Informed consent was provided by 102 families (57%; Fig. 1). Ninety-six children participated in the baseline measurement, with six children sick or in homecare during the measurement. PA was measured objectively by accelerometers (Actigraph GT3X) and the required amount of at least eight hours of recorded accelerometer data per day on at least two weekdays and one weekend day [35] was obtained from 81 children. The missing data were due to ten children being in homecare or sick during the measurement, and five children refused to use accelerometers at some point of the measurement. Lastly, the data of 12 children were excluded from the final analysis due to sickness or absences on two weekdays during the measurement. The final valid full baseline data were obtained from 69 children (68%; 33 boys and 36 girls; Fig. 1). Fig.1.Flowchartofstudyparticipants
93 www.balticsportscience.com Baltic Journal of Health and Physical Activity 2017;9(4):89-111 Journal of Gdansk University of Physical Education and Sport in Gdansk e-ISSN 2080-9999 intervention The HIPPA intervention was implemented during a single preschool year in childcare centers starting in August 2011. The socio-ecological model was used as a theoretical framework. To ensure the sustainability of the intervention, the program was planned to be low intensity (i.e., the intervention should create as little burden as possible for teachers and families) and easily implementable primarily by teachers. In other words, HIPPA should be able to overcome reallife demands, particularly at childcare centers. The intervention program plan was made on the basis of the baseline measurements and discussions with the teachers. On average, four teachers were present at every planning meeting in each childcare center. In these discussions, possible methods to promote, in particular, children’s spontaneous PA were presented to the teachers. It was assumed that the intervention would be implemented more intensively if the teachers decided which methods they wanted to use among the various proposals (Table 1). Table 1. HIPPA intervention strategies to promote physical activity (PA) of children in childcare centers Childcare center environment Target Methods Implementation PA knowledge and skills of principals of childcare centers interview monthly letters all seven principals were interviewed distribution 100% The Early Childhood Education and Care (ECEC) partnership monthly letters and themes* extending to the homes meetings meetings PA week calendar distribution 100% at least the content of the meetings was known by 74% of teachers used in 2/7 of the centers (29%) 62% of teachers felt that they had more tools to support parents Facilities at childcare centers facilities more inspiring for PA to children (e.g. PA equipment available for children, floor tapes and figures, obstacle courses) participating in two existing PA campaigns# 86% indoors / 59% outdoors 6/7 and 4/7 of the centers participated Outdoor playtime stressing the importance of outdoor playtime via training sessions and letters/tips organized/adult-led or adult initiated outdoor physical activities participating in two existing PA campaigns# provided average outdoor time increased 45min/day 64% of teachers carried out at least once 6/7 and 4/7 centers participated in campaigns Teachers’ knowledge of factors that influence children’s wellbeing and social support meetings with the researchers two motor skill observation training sessions monthly PA tips best practices guidelines step counters at least the content of the meetings was known by 74% of teachers 47% participated in at least one of the training sessions 55% used at least one person used in 3/7 centers 48% read and 62% felt that their knowledge increased not recorded Children’s motivation and self-efficacy Moving Pearl Box 10% of teachers tried to use Home environment Target Methods Implementation Parents’ knowledge of factors that influence children’s wellbeing monthly letters parents’ evenings distribution 100% researchers participated at least one evening/center Parents’ social support home PA tips step counters distribution 100% 13% used Family PA home PA tip cards monthly letters distribution 100% distribution 100 % Parents’ interest in the children’s childcare PA time monthly letters parents’ evenings weekly calendar of PA distribution 100% researchers participated in at least one evening/center on the wall of 2/7 centers (29%) Children’s motivation and self-efficacy PA/Screen-Free-Day cards home PA tip cards monthly letters 30% / 4% distribution 100% distribution 100% Note. *See Table 2. # VarpaatVauhtiin!andPihaseikkailu (Young Finland association “Nuori Suomi”). Correspondingly, 3/7 and 3/7 of control centers participated in these campaigns.
MehtäläM,SääkslahtiA,SoiniA,TammelinT,KulmalaJ,VillbergJ,NissinenK,PoskipartaM. Effect of HIPPA intervention on physical activity Balt J Health Phys Act 2017;9(4):89-111 94 www.balticsportscience.com Discussions with the collectively agreed intervention methods were transcribed and sent back to the childcare center so that the absent teachers would also be aware of the intervention content in the childcare centers. The intervention was to be applied throughout the whole child group. However, only the children with written research consent participated in the measurements. The teachers were encouraged to modify the childcare physical environment to be more inspiring for children’s PA. We also encouraged teachers to discuss children’s PA with the parents during the everyday encounters in the vestibule of the childcare center as well as during the child’s individual Early Childhood Education and Care (ECEC) plan discussions (see [36]). Every month (from August to May),a single health-related behavior theme was provided to the childcare centers and to homes (Fig. 2). Teachers received monthly PA tips and participated in two training sessions that focused on the motor skills of children. The control childcare centers continued their daily routines and usual care. Fig.2.MonthlythemesofHIPPA-interventionextendingtothechildcarecentersandhomes In Finland, childcare centers usually open at 6:30 a.m. and close at 5 p.m. Breakfast, a warm lunch and a snack are served every day for every child. After breakfast, there is usually structured activity time indoors and unstructured playtime outdoors. After lunch, children rest and at around 2 p.m. the snack is served. In the afternoon, children play freely indoors and/or outdoors. One indoor physical activity session and another outdoor session once a week were suggested in the Finnish early childhood physical activity recommendations [37], which were available during the implementation of this study.
95 www.balticsportscience.com Baltic Journal of Health and Physical Activity 2017;9(4):89-111 Journal of Gdansk University of Physical Education and Sport in Gdansk e-ISSN 2080-9999 We tried to strengthen the shared educational and care partnership between homes and childcare (see Table 1). Distribution of all materials, information and communication in the context of the intervention happened in the childcare center. Every month (from August to May), the same health-related behavior theme was promoted at home as well as at the childcare centers (see Fig. 2). The aim was to increase parents’ interest and awareness of the physical activities their children were participating in during childcare time so that the parents would be able to extend these activities to the home as well. To support this aim, families were offered materials that promoted a healthy lifestyle. Families received monthly letters with extra PA materials. A schedule for a sufficiently physically active day was offered to help parents make their daily routines more active. To increase their awareness of how much time they spent on physical activities as a family and how often they use it in front of the TV or computer, they were advised to complete PA and “Screen-Free Day” cards. Families also had the opportunity to borrow pedometers to motivate parents (or siblings) to be more active themselves and therefore to be more active role models for their child. Cards and pedometers were self-assessment materials and not assessed by researchers. Families also received PA tip packet, which contained the family PA tip card for every month. intervention exposure In March 2013, 105 teachers in the childcare centers participated in the HIPPA intervention. Of these, 58 (55%) responded to the questionnaire considering the extent and quality of the implementation of the HIPPA intervention (Table 1). The response rate varied from 38 percent to 100 percent between centers. Most questions, such as Did you participate in the intervention planning meeting?, had the response options of yes or no. The survey also included questions, such as Did the intervention inspire you to try to organize outdoor physical activities so that children could participate spontaneously if they wanted?, to which the response options were weekly, monthly, less often, or never. Of the respondents, 95% were going to use some of the methods of the HIPPA intervention in the future as well. The most often mentioned methods were making indoor facilities more inspiring for children to be physically active (85%) and keeping PA equipment available during free play for children (81%). measures primary outcomes Accelerometers (Actigraph GT3X) were used to assess children’s overall daily PA. The outcomes of interest were light PA, moderate-to-vigorous PA (MVPA), light-to-vigorous PA (LMVPA), and counts per minute of accelerometer wear time (cpm). The cut-points established by Van Cauwenberghe et al. [38] and a five-second epoch duration was used to count the amounts of the time children spent at the light (>1492 counts/min), moderate (>2340 counts/min), and vigorous (>3524 counts/min) intensity levels. The amounts of the time spent at different intensity levels were expressed as minutes per day. Total PA was calculated by dividing the cumulative counts by minutes of accelerometer worn, and it was expressed as mean counts per minutes (cpm).
MehtäläM,SääkslahtiA,SoiniA,TammelinT,KulmalaJ,VillbergJ,NissinenK,PoskipartaM. Effect of HIPPA intervention on physical activity Balt J Health Phys Act 2017;9(4):89-111 96 www.balticsportscience.com Accelerometer data were collected for five consecutive days, three weekdays and two weekend days, per childcare center. Complete data were defined as at least eight hours of recorded accelerometer data per day for at least three days including one weekend day [35]. Parents were asked to put the accelerometers on their children’s right hip immediately after waking up and to remove them before going to bed. They were also asked to record when accelerometers were fitted and removed and why they were removed. Accelerometer data were reduced with the commonly used methods from previous PA studies among childcare-aged children [39]. Non-wearing time of accelerometers was identified as 20 minutes of consecutive zeros in the recorded data, biological implausible as 15,000 counts per minutes (cpm), and nighttime between 9 p.m. and 7 a.m. [40]. Non-wearing time, biologically implausible measurements, and nighttime were removed from the data with the self-customized software. secondary outcomes The time offered by teachers to children to be outdoors during childcare was calculated based on the measurers’ observations. The time spent outdoors was observed for at least one child group of each childcare center during the three measurement days at every measurement period. The observed child group had to contain at least one study participant. The morning outdoor time began when the children were allowed to go play outside (transition or waiting time was not included) and stopped when the whole group went back indoors. Afternoon outdoor time began in the same way as in the morning, but it mostly ended at the official closing time of the center because child groups usually play outdoors for the rest of the day. There were a few clear exceptions, such as when bad weather forced the child group to go back inside before the parents came. Morning and afternoon outdoor times during the three days were averaged separately and then summed to the total outdoor time per day. Two researchers measured children’s height and weight to the nearest 0.1 cm and to the nearest 0.1 kg using a portable stadiometer (Charder HM 200P) and a digital scale (Seca 877), respectively. The body mass index (BMI) was calculated for each child as weight (kg) divided by squared height (m2). statistical analysis In this paper we analyze the effect of the intervention (HIPPA vs. control) on the change in children’s PA (minutes of MVPA, light PA, LMVPA per day or cpm per day) over time by using a linear mixed model (LMM). We report here the results at the mid-way (6 months), post-intervention (12 months) and follow-up (18 months) stages of the study. LMM produces an appropriate analysis of correlated (clustered and repeated measures) data. In our case, the children are first clustered within centers, meaning that the outcomes of children within a center are potentially correlated (intraclass correlation ICC). Second, each child has data on several measurement occasions, which raises the need to model the correlations between the measurements. LMM allows the analysis of repeated measures even when the data are incomplete, if the missing observations can be considered missing at random [41]. The main interest lies in the effects of group and time and their interaction, which represents the effect of the intervention over time. Thus, group and
103 www.balticsportscience.com Baltic Journal of Health and Physical Activity 2017;9(4):89-111 Journal of Gdansk University of Physical Education and Sport in Gdansk e-ISSN 2080-9999 or forbidden in childcare centers. [55]. The female-domination in this study may have unintentionally led to sex differentiation of physical activities. The more pronounced influence of the social-environment for the MVPA of girls compared to that of boys is supported by the observation in the present study that the proportion of variances in the MVPA was explained by the centers only for girls, not for boys. Whether this study promoted activity in less active children or included sex-specific methods for specifically promoting PA in girls remains to be examined in future studies. Yet there has been a call to find an effective intervention targeted at girls. From that perspective, HIPPA was successful. Even though girls are commonly known to be physically less active than boys are already before school age, their PA continues declining during both childhood and adolescence [56]. Considering that health behaviors are learned already in early childhood, it is important to promote all children’s PA before the school age. Correlational studies have shown that the home environment (e.g., parent’s role-modeling and support) have a relationship to children’s PA [9, 53]. However, only a few center-based interventions with a home component have succeeded in increasing children’s PA levels [21]. In this study, although not significant, there was an increasing trend in the weekend-day PA of HIPPA girls, but not that of HIPPA boys when these groups were compared to the control group. In addition to the materials and information offered to parents in other multicomponent PA interventions conducted in nurseries [16], we also tried to increase the communication and the sense of partnership between the teachers and parents, which may be essential in promoting children’s PA [57]. It may be that this strategy better influences the parents of girls rather than those of boys, or that the girls had already assimilated habitual PA that reflected their PA behavior in the home context. Unfortunately, we do not know the extent to which parents implemented the offered material. Even though childcare centers offer a great opportunity for intervention, they also turned out to be challenging environments in which to conduct a PA intervention. Meetings and discussions with the teachers revealed many barriers to implementing the intervention in the desired way. The lack of resources and the existing safety rules were the constraints that were most often mentioned. Children were not allowed to run indoors, except in the gym. However, the gym was rarely in use by a child group more than once a week, and in some centers there may not be any gym. Increasing the amount of physical exercise sessions in an already crowded childcare curriculum was not proposed as the intervention method; the efficiency of this kind of strategy may not be enough [58] in proportion to the amount of time used and may overload teachers. It seems that in order to implement interventions successfully, the existing practices of childcare centers need to be overcome. Due to the small sample size in this study, it should be replicated with a larger sample and with an observation tool, so that information about the environment in which the PA occurs could be obtained separately for boys and girls. The small sample size also meant that no mediating analysis has been made. The factors that correlate to boys’ and girls’ PA separately remain a question for future studies. It also would be important to find out what kind of light physical activities or movements can be detected by the accelerometer. For example,
MehtäläM,SääkslahtiA,SoiniA,TammelinT,KulmalaJ,VillbergJ,NissinenK,PoskipartaM. Effect of HIPPA intervention on physical activity Balt J Health Phys Act 2017;9(4):89-111 104 www.balticsportscience.com how much light PA measured by the accelerometer contains movement such as balancing on the trunk of a tree or on top of a beam or hanging on a jungle gym, in other words, those activities that promote development of motor skills [59]? strengths and limitations This study has several strengths. It widens the limited research area of childcare children’s PA interventions, and responds to the previously stated need for long-term follow-up and multicomponent studies [60]. The total activity during the day was assessed excluding the possibility that children replace activity that would have otherwise occurred at other times of the day [31]. The feasibility of the HIPPA intervention for the childcare environment was ensured by its low-burden, participatory, real-life context approach. This study is, of course, not without limitations. The sample was rather small and gathered from one Finnish city only, so generalizing the study results should be done with caution. In this kind of longitudinal study, it is a challenge to keep the same participants throughout the whole study. Generally, there is a high churn rate among the clients in childcare centers due to factors such as unemployment or having a newborn in the family. Furthermore, we accounted for the risk that there would be some children absent during the measurement periods due, for example, to sickness. Although the growth curves (i.e., slopes) differed between the treatment and control groups, there was large variability among children. Explanations for this variability (e.g., teacher and parent variables) were not explored. Seasonal differences may also affect the levels of PA. In the current study, the baseline and post-intervention measurements were conducted in the fall, but the follow-up measurements came during the winter. However, the PA levels of the intervention group were compared to the control group and the measurements in the intervention and control groups were always made at the same time. In this study, the time spent at childcare on weekdays was not separated from the time after the childcare, so it is not possible to differentiate if, during the weekdays, the HIPPA intervention affected childcare PA or home PA. The children, however, spend most of the day (over 7 hours/day) at the childcare center, so the effect of childcare on children’s overall weekday activity levels is relatively large. Furthermore, the context in which and with whom children spent their time on weekends (home, grandparents) were not adjusted for in the models, so the results of weekends should be interpreted carefully. conclusions The HIPPA intervention, conducted in a real-life context, was found to be effective in increasing childcare-aged children’s PA, especially that of girls. Moreover, teachers found it was feasible to implement in childcare centers. This study provides support for the sparse evidence of the effect of multicomponent PA interventions, additional knowledge about the PA of childcare-aged children, and resources to increase children’s habitual PA. In the future, we need more intensive interventions or ones targeted at the specific needs
105 www.balticsportscience.com Baltic Journal of Health and Physical Activity 2017;9(4):89-111 Journal of Gdansk University of Physical Education and Sport in Gdansk e-ISSN 2080-9999 of individual children to reach current PA recommendations for children. Future interventions should also try to modify factors at the community and/ or policy levels (e.g., through cooperation between childcare centers and different organizations, and teachers’ PA education). Such modifications could lower the barriers (e.g., in policies and practices, attitudes, and the physical environment) that children face in being physically active enough in their immediate surroundings. acknowledgements We are grateful to the teachers and other staff in the childcare centers as well as the children and their parents for their collaboration in this study. references [1] Ekelund U, Luan J, Sherar LB, et al. Moderate to vigorous physical activity and sedentary time and cardiometabolic risk factors in children and adolescents. JAMA. 2012;307(7):704-712. doi:10.1001/ jama.2012.156. [2] Remmers T, Sleddens EFC, Gubbels JS, et al. Relationship between physical activity and the development of body mass index in children. Med Sci Sports Exerc. 2014;46(1):177-184. doi:10.1249/ MSS.0b013e3182a36709. [3] Hinkley T, Salmon J, Okely AD, Crawford D, Hesketh K. Preschoolers’ physical activity, screen time, and compliance with recommendations. Med Sci Sports Exerc. 2012;44(3):458-465. doi:10.1249/ MSS.0b013e318233763b. [4] Tremblay MS, Barnes JD, González SA, et al. Global Matrix 2.0: Report Card grades on the physical activity of children and youth comparing 38 countries. J Phys Act Health. 2016;13(Suppl 2):S343-S366. doi:10.1123/jpah.2016-0594. [5] Dollman J, Norton K, Norton L. Evidence for secular trends in children’s physical activity behaviour. Bri J Sports Med. 2005;39(12):892-897. doi:10.1136/bjsm.2004.016675. [6] Sturm R. Childhood obesity – What we can learn from existing data on societal trends, Part 1. Prev Chronic Dis. 2005;2(1):A12. [Available at: http://www.cdc.gov/pcd/issues/2005/jan/04_0038.htm]. [7] Clements R. An investigation of the status of outdoor play. Contemp Iss Early Childhood. 2004;5(1):6880. [8] Cui Z, Hardy LL, Dibley MJ, Bauman A. Temporal trends and recent correlates in sedentary behaviours in Chinese children. Int J BehavNutr Phys Act. 2011;8(93). doi:10.1186/1479-5868-8-93. [9] Hinkley T, Salmon J, Okely AD, Hesketh K, Crawford D. Correlates of preschool children’s physical activity. Am J Prev Med 2012;43(2):159-167. doi:10.1016/j.amepre.2012.04.020 [10] Sääkslahti A, Numminen P, Salo P, Tuominen J, Helenius H, Välimäki I. Effects of a three-year intervention on children’s physical activity from age 4 to 7. Pediatr Exerc Sci. 2004;16(2):167-180. [11] Roth K, Ruf K, Obinger M, et al. Is there a secular decline in motor skills in preschool children? Scand J Med Sci Sports. 2010;20(4):670-678. doi:10.1111/j.1600-0838.2009.00982.x [12] Hardy LL, King L, Espinel P, Cosgrove C, Bauman A. NSW Schools Physical Activity and Nutrition Survey (SPANS) 2010: Full Report. Sydney: NSW Ministry of Health; 2011. [Available at: http://www. health.nsw.gov.au/heal/Pages/spans-2010-full-report.aspx] [Accessed April 10, 2016]. [13] Barnett LM, Van Beurden E, Morgan PJ, Brooks LO, Beard JR. Childhood motor skill proficiency as a predictor of adolescent physical activity. J Adolesc Health. 2009;44(3):252-259. doi:10.1016/j. jadohealth.2008.07.004. [14] Bürgi F, Meyer U, Granacher U, et al. Relationship of physical activity with motor skills, aerobic fitness and body fat in preschool children: a cross-sectional and longitudinal study (Ballabeina). Int J Obes. 2011;35:937-944. doi:10.1038/ijo.2011.54 [15] Laukkanen A, Finni T, Pesola A, Sääkslahti A. Brisk physical activity ensures the development of fundamental motor skills in children – but light is also needed! Liikunta & Tiede. 2013;50(6):47-52. [16] Reilly JJ, Kelly L, Montgomery C, et al. Physical activity to prevent obesity in young children: cluster randomised controlled trial. Br Med J. 2006;333(7577):1041-1043. doi:10.1136/bmj.38979.623773.55. [17] van der Niet AG, Smith J, Scherdera EJA, Oosterlaanb J, Hartmana E, Visschera C. Associations between daily physical activity and executive functioning in primary school-aged children. J Sci Med Sport. 2015;18(6):673-677. doi:10.1016/j.jsams.2014.09.006. [18] OECD Family Database. 2015. [Available at: http://www.oecd.org/els/family/database.htm.] [Accessed April 8, 2016]. [19] Trost SG, Ward DS, Senso M. Effects of child care policy and environment on physical activity. Med Sci Sports Exerc. 2010;42(3):520-525. doi:10.1249/MSS.0b013e3181cea3ef.
MehtäläM,SääkslahtiA,SoiniA,TammelinT,KulmalaJ,VillbergJ,NissinenK,PoskipartaM. Effect of HIPPA intervention on physical activity Balt J Health Phys Act 2017;9(4):89-111 106 www.balticsportscience.com [20] Grøntved A, Pedersen GS, Andersen LB, Kristensen PL, Møller NC, Froberg K. Personal characteristics and demographic factors associated with objectively measured physical activity in children attending preschool. Pediatr Exerc Sci. 2009;21(2):209-219. [21] MehtäläMAK, Sääkslahti AK, Inkinen ME, Poskiparta MEH. A socio-ecological approach to physical activity interventions in childcare: a systematic review. Int J BehavNutr Phys Act. 2014;11(22). doi:10.1186/1479-5868-11-22. [22] Ward DS, Vaughn A, McWilliams C, Hales D. Interventions for increasing physical activity at child care. Med Sci Sports Exerc. 2010;42(3):526-534. doi:10.1249/MSS.0b013e3181cea406. [23] Sallis JF, Prochaska JJ, Taylor WC. A review of correlates of physical activity of children and adolescents. Med Sci Sports Exerc. 2000;32(5):963-975. [24] Alhassan S, Sirard JR, Robinson TN. The effects of increasing outdoor play time on physical activity in Latino preschool children. Int J Pediatr Obes. 2007;2(3):153-158. doi:10.1080/17477160701520108 [25] Alhassan S, Nwaokelemeh O, Ghazarian M, Roberts J, Mendoza A, Shitole S. Effects of locomotor skill program on minority preschoolers’ physical activity levels. Pediatr Exerc Sci. 2012;24(3):435-449. [26] Alhassan S, Nwaokelemeh O, Lyden K, Goldsby T, Mendoza A. A pilot study to examine the effect of additional structured outdoor playtime on preschoolers’ physical activity levels. Child Care Pract. 2013;19(1):23-35. doi:10.1080/13575279.2012.712034. [27] Cardon G, Labarque V, Smits D, de Bourdeaudhuij I. Promoting physical activity at the pre-school playground: The effects of providing markings and play equipment. Prev Med. 2009;48(4):335-340. doi:10.1016/j.ypmed.2009.02.013. [28] Nicaise V, Kahan D, Reuben K, Sallis JF. Evaluation of a redesigned outdoor space on preschool children’s physical activity during recess. Pediatr Exerc Sci. 2012;24(4):507-518. [29] Van Cauwenberghe E, de Bourdeaudhuij I, Maes L, Cardon G. Efficacy and feasibility of lowering playground density to promote physical activity and to discourage sedentary time during recess at preschool: A pilot study. Prev Med. 2012;55(4):319-321. doi:10.1016/j.ypmed.2012.07.014. [30] Pate RR, Brown WH, Pfeiffer KA, et al. An intervention to increase physical activity in children: A randomized controlled trial with 4-year-olds in preschools. Am J Prev Med. 2016;51(1):12-22. doi:10.1016/j.amepre.2015.12.003. [31] Metcalf B, Henley W, Wilkin T. Effectiveness of intervention on physical activity of children: systematic review and meta-analysis of controlled trials with objectively measured outcomes (EarlyBird 54). BMJ. 2012;345(e5888). doi: https://doi.org/10.1136/bmj.e5888. [32] Welk G. The youth physical activity promotion model: A conceptual bridge between theory and practice. Quest. 1999;51(1):5-23. doi:10.1080/00336297.1999.10484297. [33] Verbestel V, van Cauwenberghe E, De Coen V, Maes L, de Bourdeaudhuij I, Cardon G. Withinand between-day variability of objectively measured physical activity in preschoolers. Pediatr Exerc Sci. 2011;23(3):366-378. [34] McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health EducQuart. 1988;15:351-377. [35] Mattocks C, Tilling K, Riddoch C. Improvements in the measurement of physical activity in childhood obesity research; lessons from large studies of accelerometers. Clin Med Insights Pediatr. 2008;2:2736. [36] Heikkilä M, Ihalainen S, Välimäki A. National curriculum guidelines on early childhood education and care in Finland. Helsinki: Stakes; 2004. [Available at: https://www.julkari.fi/bitstream/ handle/10024/75535/267671cb-0ec0-4039-b97b-7ac6ce6b9c10.pdf?sequence=1] [Accessed May 15, 2016]. [37] Recommendations for physical activity in early childhood education. Helsinki: Ministry of Social Affairs and Health; 2005. [Available at: https://julkaisut.valtioneuvosto.fi/bitstream/handle/10024/72925/ URN%3ANBN%3Afi-fe201504225286.pdf?sequence=1] [Accessed November 23, 2011]. [38] van Cauwenberghe V, Labarque V, Trost SG, de Bourdeaudhuij I, Cardon G. Calibration and comparison of accelerometer cut points in preschool children. Int J Pediatr Obes. 2011;6:e582-589. doi:10.310 9/17477166.2010.526223. [39] Cain KL, Sallis JF, Conway TL, van Dyck D, Calhoon L. Using accelerometers in youth physical activity studies: A review of methods. J Phys Act Health. 2013;10(3):437-450. [40] Esliger DW, Copeland JL, Barnes JD, Tremblay MS. Standardizing and optimizing the use of accelerometer data for free-living physical activity monitoring. J Phys Act Health. 2005;2(3):366. doi:10.1123/jpah.2.3.366. [41] West B, Welch KB, Galecki AT. Linear mixed models: a practical guide using statistical software. Boca Raton (FL): Chapman & Hall/CRC; 2007. [42] Timmons BW, Naylor P, Pfeiffer KA. Physical activity for preschool children– how much and how? App Physiol Nutr Metab. 2007;32:S122-S134. [43] Templeton GF. A two-step approach for transforming continuous variables to normal: Implications and recommendations for IS research. Commun Assoc Inform Sys. 2011;28(4). [Available at: http:// aisel.aisnet.org/cais/vol28/iss1/4]. [44] Howell DC. Statistical methods for psychology (7th ed.). Belmont, CA: Wadsworth; 2010. [45] Gordon ES, Tucker P, Burke SM, Carron AV. Effectiveness of physical activity interventions for preschoolers: A meta-analysis. Res Q Exerc Sport. 2013;84(3):287-294. doi:10.1080/02701367.201 3.813894.
107 www.balticsportscience.com Baltic Journal of Health and Physical Activity 2017;9(4):89-111 Journal of Gdansk University of Physical Education and Sport in Gdansk e-ISSN 2080-9999 [46] Joy, play and doing together – Recommendations for physical activity in early childhood. 21st ed. Helsinki: Ministry of Education and Culture; 2016. [Available at: http://urn.fi/URN:ISBN:978-952-263-413-9]. [47] Global recommendations on physical activity for health. Geneva: World Health Organization; 2010. [Available at: http://apps.who.int/iris/bitstream/10665/44399/1/9789241599979_eng.pdf]. [48] Sanford DeRousie RM. Making changes that last: Examining the sustainability of an evidence-based preschool curriculum.Ann Arbor: The Pennsylvania State University; 2008. [49] Jepson RG, Harris FM, Platt S, Tannahill C. The effectiveness of interventions to change six health behaviours: a review of reviews. BMC Public Health. 2010;10:538. doi:10.1186/1471-2458-10-538. [50] Janssen I, LeBlanc AG. Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. Int J Behav Nutr Phys Act. 2010;7(40). doi: 10.1186/1479-5868-7-40. [51] Stodden DF, Goodway JD, Langendorfer SJ, et al. A developmental perspective on the role of motor skill competence in physical activity: An emergent relationship. Quest. (00336297) 2008;60(2):290306. doi:10.1080/00336297.2008.10483582. [52] Robinson L, Stodden D, Barnett L, et al. Motor competence and its effect on positive developmental trajectories of health. Sports Med. 2015;45(9):1273-1284. doi:10.1007/s40279-015-0351-6. [53] Crespo NC, Corder K, Marshall S, et al. An examination of multilevel factors that may explain gender differences in children’s physical activity. J Phys Activ Health. 2013;10(7):982-992. [54] Yamamoto S, Becker S, Fischer J, De Bock F. Sex differences in the variables associated with objectively measured moderate-to-vigorous physical activity in preschoolers. Prev Med. 2011;52(2):126-129. doi:10.1016/j.ypmed.2010.11.014. [55] Storli R, Sandseter EBH. Preschool teachers’ perceptions of children’s rough-and-tumble play (R&T) in indoor and outdoor environments. Early Child Dev Care. 2015;185(11-12):1995-2009. doi:10.10 80/03004430.2015.1028394. [56] Reilly JJ. When does it all go wrong? Longitudinal studies of changes in moderate-to-vigorous-intensity physical activity across childhood andadolescence. J Exerc Sci Fit. 2016;14(1):1-6. doi:10.1016/j. jesf.2016.05.002. [57] Tucker P, van Zandvoort MM, Burke SM, Irwin JD. The influence of parents and the home environment on preschoolers’ physical activity behaviours: A qualitative investigation of childcare providers’ perspectives. BMC Public Health. 2011;11(168). doi:10.1186/1471-2458-11-168. [58] Van Cauwenberghe E, Labarque V, Gubbels J, de Bourdeaudhuij I, Cardon G. Preschooler’s physical activity levels and associations with lesson context, teacher’s behavior, and environment during preschool physical education. Early Child Res Q. 2012;27(2):221-230. doi:10.1016/j. ecresq.2011.09.007. [59] Laukkanen A. Physical activity and motor competence in 4-8-year old children: results of a familybased cluster-randomized controlled physical activity trial. University of Jyväskylä. Studies in Sport, Physical Education and Health 238; 2016. [60] van Sluijs EMF, McMinn AM, Griffin SJ. Effectiveness of interventions to promote physical activity in children and adolescents: Systematic review of controlled trials. BMJ Brit Med J. 2007;335(7622):703. doi:10.1136/bmj.39320.843947.BE.
MehtäläM,SääkslahtiA,SoiniA,TammelinT,KulmalaJ,VillbergJ,NissinenK,PoskipartaM. Effect of HIPPA intervention on physical activity Balt J Health Phys Act 2017;9(4):89-111 108 www.balticsportscience.com appendix Table A1. Final model of weekday MVPA of whole sample Source Numerator df Denominator df F Sig. Intercept 1 91.7 9573.50 .000 Time_lin 1 183.6 40.77 .000 Time_qd 1 176.6 1.21 .273 Time_cub 1 173.4 3.09 .080 Group 1 63.2 0.55 .460 Sex 1 60.4 11.89 .001 Age 1 59.4 1.40 .242 BMI 1 60.1 4.43 .040 Season 1 174.6 3.25 .073 Group * Time_lin 1 181.8 6.73 .010 Group * Time_qd 1 176.1 0.98 .324 Group * Time_cub 1 174.0 5.60 .019 Table A2. Final model of weekday LMVPA of whole sample Source Numerator df Denominator df F Sig. Intercept 1 93.5 706.60 .000 Time_lin 1 186.7 30.19 .000 Time_qd 1 179.5 1.12 .292 Time_cub 1 176.5 5.22 .023 Group 1 63.8 2.32 .132 Sex 1 61.7 17.06 .000 Age 1 60.4 0.88 .352 BMI 1 61.4 3.68 .060 Season 1 177.6 1.82 .179 Group * Time_lin 1 185.1 5.92 .016 Table A3. Final model of weekday light PA of whole sample Source Numerator df Denominator df F Sig. Intercept 1 99.2 1223.26 .000 Time_lin 1 188.9 1.28 .260 Time_qd 1 181.6 1.47 .227 Time_cub 1 174.2 0.03 .867 Group 1 64.0 4.02 .049 Sex 1 64.9 25.61 .000 Age 1 61.1 0.01 .937 BMI 1 62.0 2.36 .130 Season 1 177.2 0.04 .848 Group * Time_lin 1 185.4 3.62 .059 Time_lin * Sex 1 184.2 0.06 .812 Time_qd * Sex 1 178.4 4.82 .029 Time_cub * Sex 1 177.2 4.27 .040
109 www.balticsportscience.com Baltic Journal of Health and Physical Activity 2017;9(4):89-111 Journal of Gdansk University of Physical Education and Sport in Gdansk e-ISSN 2080-9999 Table A4. Final model of weekday cpm of whole sample Source Numerator df Denominator df F Sig. Intercept 1 84.4 43281.49 .000 Time_lin 1 187.2 41.76 .000 Group 1 59.3 1.05 .310 Sex 1 57.4 12.63 .001 Age 1 56.1 1.15 .288 BMI 1 57.1 3.14 .082 Season 1 177.2 24.38 .000 Group * Time_lin 1 185.4 4.03 .046 Table A5. Final model of weekday MVPA of girls Source Numeratordf Denominatordf F Sig. Intercept 1 2.3 408.42 .001 Time_lin 1 104.4 28.33 .000 Group 1 13.8 3.41 .086 Age 1 31.0 2.05 .162 BMI 1 41.1 16.14 .000 Season 1 99.0 12.09 .001 Group * Time_lin 1 103.6 4.56 .035 Group * Age 1 31.4 6.37 .017 Group * BMI 1 37.6 6.97 .012 Table A6. Final model of weekday LMVPA of girls Source Numerator df Denominator df F Sig. Intercept 1 3.0 617.45 .000 Time_lin 1 102.6 18.85 .000 Group 1 13.5 2.72 .122 Age 1 25.6 1.03 .320 BMI 1 35.8 12.70 .001 Season 1 96.5 8.47 .004 Group * Time_lin 1 101.4 4.56 .035 Group * BMI 1 32.3 5.65 .024 Group * Age 1 28.0 6.59 .016 Table A7. Final model of weekday light PA of girls Source Numerator df Denominator df F Sig. Intercept 1 20.3 1028.32 .000 Time_lin 1 100.7 1.41 .238 Group 1 10.8 2.05 .180 Age 1 22.3 0.70 .411 BMI 1 21.4 3.99 .059 Season 1 93.3 0.72 .398 Group * Time_lin 1 99.1 3.56 .062
MehtäläM,SääkslahtiA,SoiniA,TammelinT,KulmalaJ,VillbergJ,NissinenK,PoskipartaM. Effect of HIPPA intervention on physical activity Balt J Health Phys Act 2017;9(4):89-111 110 www.balticsportscience.com Table A8. Final model of weekday cpm of girls Source Numerator df Denominator df F Sig. Intercept 1 4.4 654.59 .000 Time_lin 1 100.8 17.57 .000 Group 1 28.1 4.34 .046 Age 1 29.5 1.43 .241 BMI 1 35.1 8.81 .005 Season 1 94.1 16.73 .000 Group * Time_lin 1 101.0 0.34 .559 Group * Age 1 27.6 3.09 .090 Group * BMI 1 35.4 5.11 .030 Group * Season 1 94.0 3.89 .052 Table A9. Final model of weekday MVPA of boys Source Numeratordf Denominatordf F Sig. Intercept 1 51.2 419.64 .000 Time_lin 1 82.7 15.63 .000 Time_qd 1 79.6 4.81 .031 Time_cub 1 81.4 6.31 .014 Group 1 30.2 0.00 .983 Age 1 29.1 0.03 .856 BMI 1 27.9 0.01 .928 Season 1 81.3 0.01 .907 Group * Time_lin 1 81.6 1.69 .198 Group * Time_qd 1 79.3 0.02 .900 Group * Time_cub 1 80.3 4.76 .032 Table A10. Final model of weekday LMVPA of boys Source Numeratordf Denominatordf F Sig. Intercept 1 48.6 624.53 .000 Time_lin 1 83.0 13.33 .000 Time_qd 1 80.4 4.74 .032 Time_cub 1 81.9 9.95 .002 Time_qn 1 80.9 3.86 .053 Group 1 30.1 0.12 .735 Age 1 29.4 0.00 .986 BMI 1 28.3 0.03 .870 Season 1 81.8 0.00 .970 Group * Time_lin 1 82.4 0.72 .399 Table A11. Final model of weekday light PA of boys Source Numeratordf Denominatordf F Sig. Intercept 1 53.8 1151.03 .000 Time_lin 1 85.8 1.33 .252 Time_qd 1 82.5 3.57 .062 Time_cub 1 84.4 8.15 .005 Group 1 30.6 1.15 .292 Age 1 29.8 0.52 .475 BMI 1 28.3 0.17 .682 Season 1 84.4 0.20 .658 Group * Time_lin 1 84.9 0.36 .548
111 www.balticsportscience.com Baltic Journal of Health and Physical Activity 2017;9(4):89-111 Journal of Gdansk University of Physical Education and Sport in Gdansk e-ISSN 2080-9999 Table A12. Final model of weekday cpm of boys Source Numeratordf Denominatordf F Sig. Intercept 1 45.4 28820.60 .000 Time_lin 1 79.8 26.34 .000 Time_qd 1 76.3 4.40 .039 Time_cub 1 78.8 1.58 .213 Group 1 45.3 0.93 .340 Age 1 27.8 0.04 .848 BMI 1 26.7 0.10 .750 Season 1 79.6 6.54 .012 Group * Time_lin 1 80.0 0.07 .791 Group * Time_qd 1 76.3 0.28 .596 Group * Time_cub 1 78.9 8.84 .004 Group * Season 1 79.6 4.35 .040 Cite this article as: MehtäläM,SääkslahtiA,SoiniA,TammelinT,KulmalaJ,VillbergJ,NissinenK,PoskipartaM.The effect of the cluster randomized HIPPA intervention on childcare children’s overall physical activity. Balt J Health Phys Act. 2017;9(4):89-111. doi: 10.29359/BJHPA.09.4.08