Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Physically Active Classrooms CLASSROOM_SCHOOL

Intervention Description: Given the need to find more opportunities for physical activity within the elementary school day, this study was designed to asses the impact of I-CAN!, active lessons on: 1) student physical activity (PA) outcomes via accelerometry; and 2) socioeconomic status (SES), race, sex, body mass index (BMI), or fitness as moderators of this impact.

Intervention Results: Students in treatment schools took significantly more steps than those in control schools (β = 125.267, SE = 41.327, p = .002, d = .44). I-CAN! had a significant effect on MVPA with treatment schools realizing 80% (β = 0.796, SE =0.251, p = .001; d = .38) more MVPA than the control schools. There were no significant school-level differences on sedentary behavior (β = -0.177, SE = 0.824, p = .83). SES, race, sex, BMI, and fitness level did not moderate the impact of active learning on step count and MVPA.

Conclusion: Active learning increases PA within elementary students, and does so consistently across demographic sub-groups. This is important as these sub-groups represent harder to reach populations for PA interventions. While these lessons may not be enough to help children reach daily recommendations of PA, they can supplement other opportunities for PA. This speaks to the potential of schools to adopt policy change to require active learning.

Study Design: Multilevel regression model

Setting: 28 central Texas elementary schools

Population of Focus: Fourth grade students across different schools in Texas

Data Source: Accelerometer

Sample Size: 2,493 students

Age Range: Ages 9-10 (4th grade)

Intervention Components (click on component to see a list of all articles that use that intervention): Adult-led Curricular Activities/Training Physically Active Classrooms CLASSROOM_SCHOOL

Intervention Description: Nine third- through sixth-grade classrooms (n = 292 students) in one elementary-middle school in Detroit, Michigan (49% female, 95% nonwhite; 80% qualified for free/reduced lunch) participated in this 20-week intervention where teachers implemented 5 × 4 min moderate-to-vigorous activity breaks per day. Gamification of activity breaks occurred during weeks 13-20 of the intervention and included the use of game design elements and classroom goals for activity break intensity. Moderate-to-vigorous physical activity (MVPA) during activity breaks was measured via direct observation.

Intervention Results: There was a significant effect of intervention with a 27% increase in student MVPA participation during the gamified intervention weeks compared with the standard intervention weeks (p = 0.03). Gamification of activity breaks resulted in 55% (compared with 25% during the standard intervention) of students accumulating approximately 20 min of health-enhancing physical activity per day in their classroom.

Conclusion: These findings provide preliminary evidence that gamifying activity breaks may be an important strategy for increasing student participation in classroom activity breaks.

Study Design: Cohort design

Setting: One elementary-middle school in Detroit, MI, where at least 40% of students qualified for free/reduced priced lunch

Population of Focus: Students who were able to participate in physical education classes from 9 3rd through 6th grade classrooms

Data Source: System for Observing Play and Leisure Activity in Youth (SOPLAY)

Sample Size: 292 students

Age Range: Ages 8-13

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: 116 fifth-graders were assigned to one intervention group (n = 31) participating in daily physical activity engaging the brain with Fitbit Challenge (PAEB-C), another intervention group (n = 29) wearing Fitbits only (Fitbit-O) daily, five days per week, or the comparison group (n = 56). Four-week real-time PA data were collected from the intervention students via Fitbase. Three groups were pre- and post-tested aerobic fitness.

Intervention Results: The PAEB-C students showed significantly higher steps and minutes of being very active and fairly active (F = 7.999, p = 0.014, ŋ = 0.121; F = 5.667, p = 0.021, ŋ = 0.089; F = 10.572, p = 0.002, ŋ = 0.154) and lower minutes of being sedentary daily (F = 4.639, p = 0.035, ŋ = 0.074) than the Fitbit-O group. Both Fitbit groups exhibited significantly greater increases in aerobic fitness scores than the comparison group over time (F = 21.946, p = 0.001, ŋ = 0.303). Boys were more physically active and fit than girls.

Conclusion: Technology-enhanced PA intervention was effective for improving real-time PA and aerobic fitness.

Study Design: RCT

Setting: 2 elementary schools

Population of Focus: Elementary school students

Data Source: FitBit, Fitbase, PACER test

Sample Size: 116 students

Age Range: Ages 10-11 (5th grade)

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: The intervention was performed in a sample of 47 children attending a primary school in the south of Italy and it was structured in two sessions of classroom active breaks (CABs) in three school days a week, shared with and supervised by the teachers.

Intervention Results: CABs showed an overall potential positive effect on the reduction of inactivity of ∼12 min and an equivalent increase in PA levels, of which 5 min were of moderate/vigorous intensity. Girls showed lower time spent in light and moderate PA and higher amount of inactivity than boys and responded better to the intervention. The satisfaction of children and teachers was high.

Conclusion: CABs program is a safe tool to reduce inactivity and increase moderate/vigorous PA. Designing structured exercise breaks adapted in a flexible way to meet the needs of the school curriculum program may increase the feasibility of such PA program in the schools.

Study Design: Non-randomized feasibility study

Setting: Elementary schools (teacher-led)

Population of Focus: 3rd grade school children

Data Source: Accelerometer data and student self-report

Sample Size: 47 students

Age Range: Ages 8-9

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Adult-led Curricular Activities/Training Physically Active Classrooms

Intervention Description: Teachers at 5 elementary schools attended training on how to implement CBPA. Data on school-day PA opportunities [physical education (PE), recess, and CBPA] were obtained via calendar and teacher-recorded CBPA logs. Daily step counts were measured via accelerometry in 1346 students across 65 classrooms in first through fifth grades.

Intervention Results: PE, recess, and CBPA contributed significantly to students' daily steps. Males accrued more steps than females over the school day, during PE, and during recess. No gender disparity was seen in the amount of additional steps accrued during CBPA. Overall step counts were lower among fifth-grade students versus first-grade students, but CBPA attenuated this difference such that grade-level differences were not significant in fifth-grade students who received CBPA.

Conclusion: Gender disparities in step totals were present on PE and recess days, but not on CBPA days. CBPA appears to provide equal PA benefits for both genders and to potentially minimize the decline in PA among older students.

Study Design: Quasi-experimental design

Setting: Public elementary schools (teacher-led)

Population of Focus: 1st through 5th grade school children

Data Source: Accelerometer data and teacher self-report

Sample Size: 1,346 students

Age Range: Ages 6-11

Intervention Components (click on component to see a list of all articles that use that intervention): Physically Active Classrooms CLASSROOM_SCHOOL Upgrade of School Facilities

Intervention Description: The aim of this study was to examine the potential impact of an environmental intervention, the addition of sit-stand desks in the classroom, on school children's sitting and physical activity during class time and after school.

Intervention Results: In total 176 children (mean age = 9.3 years) took part in the trial. At baseline, control and intervention groups spent more than 65% of class time sitting, this changed to 71.7% and 59.1% at follow-up, respectively (group effect p < 0.001). The proportion of class time spent standing and stepping, along with the proportion of time in light activity increased in the intervention group and decreased in the control group. There was no evidence of any compensatory effects from the intervention after school.

Conclusion: Incorporating sit-stand desks to change the classroom environment at primary school appears to be an acceptable strategy for reducing children's sedentary behaviour and increasing light activity especially during class time.

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: We conducted a quasi-experimental repeated measures pilot study in two primary schools in the Stirling Council area: one school with, and one without, intention to introduce the Daily Mile. Pupils at the control school followed their usual curriculum. Of the 504 children attending the schools, 391 children in primary classes 1-7 (age 4-12 years) at the baseline assessment took part. The follow-up assessment was in the same academic year. Outcomes were accelerometer-assessed average daily moderate to vigorous intensity physical activity (MVPA) and average daily sedentary behaviour, 20-m shuttle run fitness test performance and adiposity assessed by the sum of skinfolds at four sites. Valid data at both time points were collected for 118, 118, 357 and 327 children, respectively, for each outcome.

Intervention Results: After correction for age and gender, significant improvements were observed in the intervention school relative to the control school for MVPA, sedentary time, fitness and body composition. For MVPA, a relative increase of 9.1 min per day (95% confidence interval or 95%CI 5.1-13.2 min, standardised mean difference SMD = 0.407, p = 0.027) was observed. For sedentary time, there was a relative decrease of 18.2 min per day (10.7-25.7 min, SMD = 0.437, p = 0.017). For the shuttle run, there was a relative increase of 39.1 m (21.9-56.3, SMD = 0.236, p = 0.037). For the skinfolds, there was a relative decrease of 1.4 mm (0.8-2.0 mm, SMD = 0.246, p = 0.036). Similar results were obtained when a correction for socioeconomic groupings was included.

Conclusion: The findings show that in primary school children, the Daily Mile intervention is effective at increasing levels of MVPA, reducing sedentary time, increasing physical fitness and improving body composition. These findings have relevance for teachers, policymakers, public health practitioners, and health researchers.

Study Design: QE repeated measures pilot

Setting: 2 primary schools

Population of Focus: Primary school children

Data Source: Accelerometer, bodycomposition

Sample Size: 391 students

Age Range: Ages 4-12

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Comprehensive School-Based PA Program Presentation/meeting/information Session (Classroom) Physically Active Classrooms Multicomponent School-Based Program

Intervention Description: “GiochiAmo” is an innovative randomized field trial which aims to educate children aged about nutrition, physical activity, smoking and alcohol. Each primary school class worked on a different theme. Particularly, the project is structured in two sequential phases: a lesson for each theme followed by several game sessions during the next three months.

Intervention Results: A total number of 74 and 76 children participated in the physical activity and nutrition interventions. NTs was 4.17 (SD: 2.23) before and 5.03 (SD: 2.79) after the intervention (P = 0.005). PAs was 27.4 (SD: 9.6) before and 30.5 (SD: 10.7) after the intervention (P = 0.003). No significant differences were obtained comparing males and females for all scores. Ds was 0.86 for nutrition and 3.1 for physical activity. Univariate analysis of Delta scores obtained no significant differences.

Conclusion: The present results confirm the effectiveness of 'GiochiAMO' to change nutrition and physical activity behavior.

Study Design: Single arm, cluster field trial (c-RCT)

Setting: Public primary schools

Population of Focus: Second and third grade students in primary school

Data Source: Student self-report

Sample Size: 150 students

Age Range: Ages 6-9

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: This study examined the effects of a standing desk intervention in a classroom on children's standing and sitting time at school, sedentary and physical activity levels throughout the day (waking hours), and musculoskeletal discomfort. A within-subjects crossover study design was used. Participants used either a standing desk or traditional seated desk for 21 days before swapping desks for another 21 days. Accelerometry and musculoskeletal discomfort data were collected during the last seven days of each 21-day period. Mixed models were used to analyse accelerometry data. Zero-inflated regression models and logistic regression models were used to analyse discomfort data.

Intervention Results: Forty-seven male students (aged 10⁻11 years) participated in the study. Standing time was 21 min/school day higher (p < 0.001) and sitting time was 24 min/school day lower (p = 0.003) when standing desks were used. No significant differences were found in sedentary and physical activity time during waking hours between the standing desk and seated desk conditions. Students were less likely to report musculoskeletal discomfort in the neck, shoulder, elbows and lower back when using standing desks (OR 0.52⁻0.74).

Conclusion: Standing desks significantly increased classroom standing time and decreased musculoskeletal discomfort reports but had no overall effect on daily physical activity levels. Schools should consider moving towards classrooms enabling a variety of postures to potentially improve the long-term health of children.

Study Design: Within-subjects crossover trial

Setting: 1 elementary school

Population of Focus: Male students age 10-11 years

Data Source: Accelerometry and musculoskeletal discomfort data were collected

Sample Size: 47 male students

Age Range: Ages 10-11

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: A total of 210 3rd to 5th grade (age = 9.1 ± 0.1) students from one U.S. elementary school participated in a 4-week intervention. Students’ physical activity levels were measured using pedometers, quantified by step counts pre- and post-intervention.

Intervention Results: Results from the study indicated that students’ physical activity levels increased after participation in the intervention; male students’ physical activity levels were higher than female students. Additionally, there was an increase in physical activity levels regardless of weight categories, with students of healthy weight exhibiting the most increase following participation in the intervention.

Conclusion: In view of the improvement of children’s physical activity levels following their participation in a classroom-based physical activity curriculum, it is recommended that training and resources be provided for teachers to easily implement the curriculum during the school day.

Study Design: Quasi-experimental design

Setting: Elementary schools (teacher-led)

Population of Focus: Elementary school aged children in grades 3-5

Data Source: Pedometer data, stadiometer (height), medical scale (weight)

Sample Size: 210 students

Age Range: Ages 8-11

Intervention Components (click on component to see a list of all articles that use that intervention): Physically Active Classrooms CLASSROOM_SCHOOL

Intervention Description: Classroom type (open learning spaces vs. conventional classrooms) - Components: Teachers' instructions regarding student movement (T1: restrictive, T2: free movement, T3: organized transitions, T4: organized physical activity) - Frequency and Duration: Observed during lessons over a school week - Dose/Amount: Not specified

Intervention Results: - Overall, classroom-based physical activity was not higher in open learning spaces than in conventional classrooms. - 5th grade students in open learning spaces had more sedentary time and less moderate-to-vigorous physical activity compared to those in conventional classrooms. - Both grades had more breaks from sedentary time in open learning spaces, but this did not translate to overall higher physical activity levels.

Conclusion: The study found that open learning spaces did not increase classroom-based physical activity compared to conventional classrooms, contrary to expectations.1 5th grade students in open learning spaces had more sedentary time and less moderate-to-vigorous physical activity, but both grades had more breaks from sedentary time.2 Teachers' instructions in open learning spaces were more restrictive for 5th graders, which may explain the lower physical activity levels.3 The study suggests that while open learning spaces may not increase overall physical activity, they can promote breaks from sedentary time.4 The role of teachers in promoting physical activity is highlighted, with a need to address barriers to movement integration.5 Future studies should include larger sample sizes and assess students' personal views on physical activity.6

Study Design: Observational study, multi-site, non-randomized, prospective

Setting: The study was conducted in Finland during the 2018-2019 academic year. It involved 182 3rd and 5th grade students from three schools: one with an open learning space and two with conventional classrooms. The setting included both physical environments and the social context of student-teacher interactions.

Population of Focus: 3rd and 5th grade students

Sample Size: 182

Age Range: - 3rd graders: approximately 9.3 to 9.7 years - 5th graders: approximately 11.2 to 11.5 years

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: The Israeli Health Promoting School Network (HPSN) is actively committed to enhancing a healthy lifestyle for the entire school population. This study aimed to explore the contribution of school participation in the HPSN and students' individual characteristics to healthy eating and physical activity habits among Israeli school children aged 10-12 years.

Intervention Results: Multi-level analysis indicated that student's individual characteristic was significantly associated with healthy eating and physical activity habits. The subjective self-reported health education received at school was statistically significant factor associated with students' health behaviors. The school's affiliation with the HPSN was not associated with higher healthy eating and physical activity scores after adjusting for individual factors.

Conclusion: These findings suggest that Israeli HPSN schools do not contribute to children's health behaviors more than other schools. Therefore, health promoting activities in HPSN schools need to be improved to justify their recognition as members of the HPS network and to fulfill their mission.

Study Design: Quasi-experimental design

Setting: 2 elementary schools; 5 classes

Population of Focus: 5th grade students

Data Source: Fitbit data

Sample Size: 116 5th grade students

Age Range: Ages 10-11 (5th grade)

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: We aimed to explore the feasibility and potential effectiveness of a classroom-based intervention on moderate to vigorous PA (MVPA) and total PA. The secondary aim was to assess the acceptability and sustainability of the intervention. In a mixed-methods, non-randomised, exploratory controlled before-and-after study, 152 children (10 ± 0.7 years) were recruited from five schools; two intervention (n = 72) and three control (n = 80) schools. School teachers delivered an 8-week classroom-based intervention, comprising of 10 minutes daily MVPA integrated into the curriculum. The control schools maintained their usual school routine. Mean daily MVPA (min), total PA (mean cpm), physical fitness, and health-related quality of life measurements were taken at baseline, end of intervention, and 4-weeks post-intervention (follow-up).

Intervention Results: Data were analysed using a constrained baseline longitudinal analysis model accounting for the hierarchical data structure. For the primary outcomes (MVPA and total PA) the posterior mean difference and 95% compatibility interval were derived using a semi-Bayesian approach with an explicit prior. The acceptability and sustainability of the intervention was explored via thematic content analysis of focus group discussions with teachers (n = 5) and children (n = 50). The difference in mean daily MVPA (intervention-control) was 2.8 (-12.5 to 18.0) min/day at 8 weeks and 7.0 (-8.8 to 22.8) min/day at follow-up. For total PA, the differences were -2 (-127 to 124) cpm at 8-weeks and 11 (-121 to 143) cpm at follow-up. The interval estimates indicate that meaningful mean effects (both positive and negative) as well as trivial effects are reasonably compatible with the data and design.

Conclusion: The intervention was received positively with continuation reported by the teachers and children. Classroom-based PA could hold promise for increasing average daily MVPA, but a large cluster randomised controlled trial is required.

Study Design: Mixed-methods, non-randomized, exploratory controlled before-and-after study

Setting: 5 schools; all children in years 5 & 6

Population of Focus: Year 5 & 6 students

Data Source: Hip-mounted accelerometer

Sample Size: 195 students

Age Range: Ages 9-11

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: The FIT Game is a low-cost intervention that increases fruit and vegetable consumption in elementary school children. For this study, the FIT Game was adapted into an intervention designed to increase children's physical activity at school. A total of 29 participants were recruited from a sixth-grade classroom. An ABAB reversal design was used. Participants wore an accelerometer while at school during pre/postintervention baseline (A) and intervention (B) phases. During the FIT Game intervention, daily physical activity goals encouraged the class to increase their median daily step count above the 60th percentile of the previous 10 days. When daily goals were met, game-based accomplishments were realized.

Intervention Results: Children met their activity goals 80% of the time during the intervention phases. Physical activity at school increased from a median of 3331 steps per day during the baseline to 4102 steps during the FIT Game phases (P<.001, Friedman test).

Conclusion: Preliminary evidence showed that playing the FIT Game could positively influence children's physical activity at school.

Study Design: Single case, reversal design pilot (ABAB)

Setting: One classroom in Cache County, UT

Population of Focus: 6th grade students

Data Source: Accelerometers

Sample Size: 29 students

Age Range: Ages 11-12

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: The purpose of the present study was to examine the effects of height-adjustable standing desks on time-series variation in sedentary behavior (SB) among primary school children. Thirty-eight children aged 11-12 years (22 boys and 16 girls) from two classes at a primary school in Nagano, Japan, participated in this study. One class was allocated as the intervention group and provided with individual standing desks for 6 months, and the other was allocated as the control group. Time spent in SB, light-intensity physical activity (LPA), and moderate-to-vigorous-intensity physical activity (MVPA) was measured using accelerometers (ActiGraph) at baseline and follow-up.

Intervention Results: Time spent in SB was significantly lower by 18.3 min/day on average in the intervention class at follow-up (interaction effects: F(1, 36) = 4.95, p = 0.035, η2 = 0.082). This was accompanied by a significant increase in time spent in MVPA (+19.9 min/day on average). Our time-series analysis showed significant decreases in SB during school time, while no change in SB was found during non-school time.

Conclusion: This result indicates that the use of standing desks promotes an overall reduction in SB with no compensatory increase during non-school time.

Study Design: Quasi-experimental design

Setting: Public primary schools

Population of Focus: 6th grade school children

Data Source: Accelerometer data and student self-report

Sample Size: 43 students

Age Range: Ages 11-12

Intervention Components (click on component to see a list of all articles that use that intervention): Physically Active Classrooms CLASSROOM_SCHOOL

Intervention Description: To assess physical activity outcomes of a pedometer-based physically active learning (PAL) intervention in primary school children. Six paired schools were randomly allocated to either a 6-week teacher-led pedometer-based physically active learning intervention or a control (n = 154, female = 60%, age = 9.9 [0.3] y). Accelerometers assessed total daily sedentary time, light physical activity (LPA), and moderate-to-vigorous physical activity (MVPA). Preintervention mean daily MVPA minutes grouped participants as Low Active (<45 min/d) and High Active (≥45 min/d).

Intervention Results: From the final sample size, the intervention (n = 52) significantly improved LPA versus control (n = 31, P = .04), by reducing sedentary time. More intervention (+10%) than control (+3%) pupils met the 60 minutes per day guidelines. In both intervention subgroups, pupils spent less time in LPA (P < .05) versus control. The greatest nonsignificant increase was found in the Low Active pupils MVPA levels.

Conclusion: Improvements in LPA were statistically significant in the intervention versus control group. In subgroup analysis, Low Active pupils in the intervention showed the greatest beneficial effects and the Most Active pupils may have replaced MVPA and sedentary time with LPA. The intervention group housed clusters of pupils showing variable responsiveness, justifying routine examination of subgroup variability in future studies.

Study Design: RCT

Setting: 6 year five classes across 6 schools

Population of Focus: Elementary school students; 9-10-year-olds

Data Source: Accelerometers

Sample Size: 154 students total; Intervention 82 & control 72

Age Range: Ages 9-10

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: Two classes (intervention students: n=22 [aged 11.8±0.4years]; control students: n=27 [11.6±0.5years]) from a public school in Lisbon were selected. The intervention involved replacing traditional seated classroom desks for standing desks, for a total duration of 16 weeks, in addition to performing teacher training and holding education/motivation sessions with students and parents. Sedentary behavior (ActivPAL inclinometer) and physical activity (Actigraph GT3X+ accelerometer) were measured for seven days immediately before and after the intervention.

Intervention Results: There were no differences in baseline behaviors between intervention and control groups (p>0.05). At follow-up (16 weeks), it was observed that the intervention group had decreased time spent sitting (total week: -6.8% and at school: -13.0% relative to baseline) and increased standing (total week: 16.5% and at school: 31.0%) based on inclinometer values (p-value for interaction group*time <0.05). No significant differences in activity outcomes were observed outside school time (week or weekend) between groups.

Conclusion: We conclude that a 16 week classroom standing desk intervention successfully reduced sitting time and increase standing time at school, with no observed compensatory effects outside of school time.

Study Design: Cluster non-randomized controlled trial

Setting: Public elementary school

Population of Focus: 6th grade students

Data Source: Micro inclinometer and accelerometers

Sample Size: 49 students

Age Range: Ages 11-13

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: Physically Active Learning (PAL) program called Cogni-Actif - Duration: 8 weeks - Frequency: Three sessions per week - Dose: 15-minute video clips per session - Components: Integration of physical activity with academic learning, specific physical movements, and academic content

Intervention Results: - The PAL program was effective in increasing students' physical activity levels by adding movements during class time. - The integration of learning with movement improved student attention and focus, leading to better learning outcomes. - The program improved students' sleep quality and reduced screen time outside of school.

Conclusion: - The PAL program is a potentially effective tool for promoting physical activity in elementary school classrooms.1 - Co-designing programs with practitioners is crucial for maximizing effectiveness. - Integrating physical activity with academic learning is beneficial for both physical and academic outcomes.2 - Technology can support PAL practices,3 with potential for future development of digital tools like exergames.4 - Further research is needed to explore broader societal implications, including public health contributions and reducing health disparities.5 - Future studies should consider different settings and populations,6 and obtain quantitative measures to confirm results.7

Study Design: Embedded experimental design; Mixed-method approach; Crossover design

Setting: - Physical setting: Elementary classrooms in three different schools - Geographical location: Quebec, Canada - Time period: During the COVID-19 pandemic - Population: 82 students and 7 teachers - Environmental factors: Adherence to public health guidelines related to COVID-19

Population of Focus: - Students: 82 fourth-grade students (37 boys, 45 girls; aged 9.8±0.4 years) - Teachers: 7 teachers (4 fourth-grade teachers, 3 health and physical education teachers)

Sample Size: - Total students: 82 - Total teachers: 7 - Boys: 37 - Girls: 45

Age Range: 9.8±0.4 years

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: The purpose of this pilot study was to examine the feasibility, acceptability, and preliminary efficacy on fitness and cognition of a recess intervention in elementary school children. Two schools were randomized to either a 3-month cardiorespiratory and muscular fitness intervention (15 minutes/weekday during recess) or control condition (standard recess activities). Process evaluation (feasibility and acceptability) measures were recorded daily (research staff questionnaire), weekly (accelerometer and heart rate monitors), and post-intervention (participant and school-staff questionnaires). Preliminary efficacy measures included pre- and post-intervention inhibition/attention, working memory, and cardiorespiratory and muscular fitness scores.

Intervention Results: Some feasibility and acceptability measures were favorable (88% of the lessons were implemented, 78% of the lessons were implemented as planned, and the majority of students and school staff were satisfied with most aspects of the intervention). However, intensity adherence during the intervention sessions based on accelerometry (% of time spent in moderate-to-vigorous activity: 41.7 ± 14.5) and participation (19.4% attendance rate) were lower than expected. Preliminary efficacy of the intervention on cognitive and fitness outcomes was not demonstrated.

Conclusion: This study provided evidence that some aspects of the fitness intervention were acceptable during school recess. However, important implementation factors (i.e., intervention exposure) should be targeted to improve youth fitness programs offered during this school setting.

Study Design: Feasibility RCT Pilot

Setting: 2 elementary schools

Population of Focus: Elementary school students

Data Source: Accelerometer, questionnaire

Sample Size: 53 students

Age Range: Ages 8-9

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: The primary aim of this study was to explore the acceptability and feasibility of three brief single-component primary school PA interventions targeting 9⁻10-year-old children. The secondary aim was to examine the effectiveness of the interventions on increasing PA levels and reducing sedentary time. The single-component interventions included active classroom breaks (AB; 3 schools; n = 119 children) Born to Move (BTM) exercise videos (2 schools; n = 50 children), and playground supervisory staff training (2 schools; n = 56 children). Qualitative data from participating children (n = 211), class teachers (n = 6), and playground supervisory staff (n = 8) explored the experiences, acceptability, and feasibility of each intervention component. Accelerometers were worn by 225 children during the last week of implementation.

Intervention Results: Playground staff reported difficulties in implementing activities due to children's age and competing responsibilities on the staffs' time. Children reported that the ABs and BTM videos were enjoyable. During half hour time windows, including the ABs and BTM videos, children engaged in 4.8 min and 8.6 min of moderate to vigorous PA (MVPA) on average, respectively. ABs and BTM videos positively affected MVPA. ABs were feasible to implement; however, teachers faced some barriers in implementing the BTM videos.

Conclusion: Feasibility of playground interventions may be dependent on staff responsibilities and age of the children.

Study Design: Mixed methods pilot

Setting: 7 Primary schools in low-income district (Skelmersdale, West Lancashire, UK)

Population of Focus: Year 5 students

Data Source: Group interviews with students, individual interviews with teachers and playground supervisory staff, accelerometer, teacher recording sheet

Sample Size: 211 students, 6 teachers, 8 playground supervisory staff

Age Range: Ages 9-10

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: The AS:Sk intervention was implemented for eight weeks in four schools with three control schools continuing normal practice. It consisted of eight components: active breaks, bounce at the bell, 'Born To Move' videos, Daily Mile or 100 Mile Club, playground activity challenge cards, physical education teacher training, newsletters, and activity homework. Child-level measures were collected at baseline and follow-up, including objectively measured PA.

Intervention Results: After accounting for confounding variables, the intervention had a significant effect on school day ST which was significantly less for the intervention children by 9 min per day compared to the control group. The AS:Sk pilot intervention was effective in reducing school day ST but significant changes in PA were negligible.

Conclusion: To increase the efficacy of the current and future school-based interventions, authors should focus on implementation and process evaluations to better understand how schools are implementing intervention components.

Study Design: Cluster RCT

Setting: 7 Primary schools in low-income district (Skelmersdale, West Lancashire, UK)

Population of Focus: Year 5 students

Data Source: Accelerometers, shuttle run test, anthropometrics, questionnaire

Sample Size: 232 students, 3 control schools, 4 intervention

Age Range: Ages 9-10

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: This study investigated whether children engaged in more physical activity (PA) on school days that included Forest School (FS) sessions than a regular school day or a school day with a Physical Education (PE) lesson. How FS sessions influenced children's general levels of PA and wellbeing was also explored across gender. A mixed-methods study followed a sample of 59 child participants aged 7 to 9 years old, from four primary schools, whilst taking part in twelve weekly FS sessions.

Intervention Results: Children had significantly greater levels of light PA on a FS day and a PE school day compared to a regular school day and children reported feeling both happier and relaxed as a consequence of the intervention. From the qualitative data, boys and girls reported different likes of the FS interventions, whereas their dislikes of FS were comparable.

Conclusion: Findings from this research provide evidence for such outdoor, nature-based learning within the school curriculum contributing to daily PA in children.

Study Design: Mixed-methods study

Setting: 4 primary schools in NW England

Population of Focus: Primary school students

Data Source: Accelerometer (primary), also questionnaire

Sample Size: 59 students

Age Range: Ages 7-9

Intervention Components (click on component to see a list of all articles that use that intervention): Physically Active Classrooms CLASSROOM_SCHOOL

Intervention Description: Seventy-seven 4th grade students (41 males) were included in an intervention (Move for Thought program: M4T) group (n = 46) that utilized PA integrated with mathematics or a control group (n = 31). Accelerometer data from each student were collected during five complete school days. M4T and control classroom sessions were identified using teachers' logs. Accelerometer data were extracted, processed separately, and aggregated into a single data set. Minutes and percent time at different PA intensities were obtained using accelerometer minute-by-minute predicted METs.

Intervention Results: One-way ANOVAs on PA levels showed a significant group effect (F = 5.33, p < 0.05) on moderate-to-vigorous PA (MVPA) in favor of the M4T group, but not on sedentary and light PA. The most active integrated PA provided 10.88 min of MVPA (SD = 11.87; 21.38 ± 24.38%) in a 50 min class period.

Conclusion: Integrating PA with mathematics in the classroom can contribute to increasing MVPA levels in children.

Study Design: Intervention and control classrooms

Setting: 1 elementary school in a rural Midwestern state

Population of Focus: 4th grade students

Data Source: Accelerometers

Sample Size: 77 students (41 males; 36 females)

Age Range: Ages 9-10 (4th grade)

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: Year 3 students (n=172, mean age 8.4±0.3 years, 48% male) were recruited from 10 classes across two urban primary schools. Participants were randomly assigned to a seated classroom (Classroom) group or physically-active lessons in the playground (Playground) and crossed over to the alternative condition in the subsequent school term. The 6-week intervention comprised 3×30min sessions/week. Multiplication-tables (teacher-designed test) and general maths (standardised test) were assessed pre- and post-intervention. Aerobic fitness was assessed via the shuttle-run. Pre- to post-intervention change scores were compared for analysis and effect sizes (ES) calculated. Total PA and MVPA were assessed with accelerometers in a subset of participants.

Intervention Results: Multiplication scores improved significantly more in Playground than Classroom groups (ES=0.23; p=0.045), while no significant differences were observed in general numeracy (ES=0.05; p=0.66). Total PA and MVPA were substantially higher during Playground than Classroom lessons (ES: total PA=7.4, MVPA=6.5; p<0.001) but there were no differences in PA/MVPA between the groups throughout the rest of the school day. Aerobic fitness improved more in Playground than Classroom groups (ES=0.3; p<0.001) while the change in BMI was not different between groups (p=0.39).

Conclusion: Physically-active lessons may benefit the learning of maths multiplication-tables while favourably contributing to school-day PA/MVPA.

Study Design: Randomized controlled cross-over trial

Setting: 10 classes across 2 urban primary schools

Population of Focus: Year 3 students age

Data Source: Accelerometers

Sample Size: 172 students

Age Range: Average age 8.4

Intervention Components (click on component to see a list of all articles that use that intervention): Physically Active Classrooms CLASSROOM_SCHOOL

Intervention Description: 374 children in Year 3 and 4 (74% response) were recruited from six schools across Melbourne, Australia. Schools were randomised to the ACTI-BREAK intervention or usual teaching practice. The intervention involved teachers incorporating 3×5min active breaks into their classroom routine daily. Academic achievement was assessed using 1-min tests in reading and mathematics; classroom behaviour at the individual and whole class level was observed by teachers; and physical activity levels were assessed using accelerometers. Multilevel mixed effects linear regression models were conducted using intention to treat (ITT) and per protocol (PP) analyses.

Intervention Results: Significant intervention effects were found for classroom behaviour at the individual level (ITT B=16.17; 95% CI: 6.58, 25.76); effects were stronger for boys (B=21.42; 95% CI: 10.34, 32.49) than girls (B=12.23; 95% CI: 1.52, 22.92). No effect was found for classroom behaviour at the whole class level, reading, math or physical activity. PP findings were similar.

Conclusion: Implementing active breaks during class time may improve classroom behaviour, particularly for boys. There was no evidence to suggest that implementing active breaks had any adverse effect on academic achievement or classroom behaviour, which may encourage classroom teachers to incorporate active breaks into their routine.

Study Design: Pilot cluster RCT

Setting: 6 Elementary Schools in Melbourne, Australia

Population of Focus: Year 3 & 4 students

Data Source: Accelerometers

Sample Size: 374 students

Age Range: Ages 8-10

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL Physically Active Classrooms

Intervention Description: The Daily Physical Activity (DPA) policy in British Columbia requires elementary schools to help students achieve 30 min of physical activity during instructional and noninstructional time on school days. The purpose of this study was to determine how elementary teachers implement the DPA policy, and examine differences in children's light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA) at school, based on how the teacher implemented the DPA policy during the school day (provision of DPA during instructional time or only noninstructional time). In this observational mixed-methods study, 12 teachers were interviewed on their implementation approaches. Teachers provided DPA opportunities during instructional time (i.e., prescriptive implementers, n = 9) or relied on students to be active during noninstructional times (i.e., nonprescriptive, n = 3). Next, 10 students from each interviewed teacher's classroom were randomly selected to wear accelerometers for one school week.

Intervention Results: Teacher's DPA implementation strategy accounted for a significant proportion of variance in student's activity throughout the school day (p's < .05). The prescriptive group (n = 88) was more active (LPA and MVPA) and spent a greater proportion of their school days in MVPA during instructional time than the nonprescriptive group (n = 23). Heterogeneity in policy implementation creates variations in policy effectiveness.

Conclusion: Students provided with opportunities to be active during instructional time may accumulate more MVPA compared with those who are not given these opportunities.

Study Design: Observational mixedmethod study

Setting: 13 public elementary schools

Population of Focus: Elementary school students

Data Source: Accelerometers

Sample Size: 111 students

Age Range: Ages 9-12

Intervention Components (click on component to see a list of all articles that use that intervention): Physically Active Classrooms CLASSROOM_SCHOOL

Intervention Description: Active breaks at primary school are feasible, may increase daily moderate to vigorous physical activity (MVPA) and decrease off-task behaviour without adversely affecting cognitive function and learning.

Intervention Results: Children in the intervention group engaged in 15.4 and 10.9 minutes more MVPA per day at 3 and 6 weeks respectively (P < .001). Participation significantly increased the proportion of children who met the Australian 24-Hour Movement Guidelines (P < .001). At pre, middle and end of intervention, 44.4%, 60.8% and 55.1% of intervention children and 46.5%, 45.9% and 45.8% of controls met the guidelines. Significantly fewer students engaged in off-task behaviour in the intervention classes at mid and final weeks of intervention (-1.4 students, P = .003). No significant intervention effects were found for wellbeing, cognitive and maths performance.

Conclusion: Active classroom breaks are an effective way to increase physical activity among primary school children while reducing off-task classroom behaviour. SO WHAT?: Primary school students' health would benefit from active breaks with no detrimental effects on wellbeing, maths and cognitive performance.