Action330: Promoting children's physical activity via enhanced after-school leadership

Context
Many children do not meet the Chief Medical Officer's target of an hour of physical activity every day. Adults who are physically active are less likely to develop heart disease, diabetes and obesity. These diseases result in large healthcare costs, reduced work productivity work and adversely impact quality of life. Ensuring everyone is physically active is therefore important for the nation's physical and economic health.

The end of primary school is a critical period for the establishment of children's physical activity patterns. Developing children's skills and interest in physical activity at this age is likely to help the children to be more active in adolescence and onto adulthood.

The after-school period that has been recognised as a time when children could engage in physical activity. Data from the USA and Spain indicates that programmes delivered after-school can increase children's physical activity. Although many UK schools provide after-school physical activity interventions none of these programmes has been rigorously evaluated.

Teaching Assistants (TAs) are a resource in all primary schools and our experience indicates that many TAs would welcome an opportunity to deliver after-school activities but lack the skills and confidence to do so. Head-teachers are keen to allow their TAs to deliver after-school activities because it shows that the school is developing the skills of its work-force. An after-school physical activity intervention delivered by TAs could therefore be a cost-effective, sustainable intervention.

Aims and objectives
The overall aim of the study is to design and then evaluate a new physical activity programme for Year 5 & 6 (9-11 year old) students which will be delivered by TAs. There will be two elements to the work. First we will conduct qualitative work with TAs, national experts, children and parents on how best to deliver an after-school physical activity programme. We will then use this information to develop a new Teaching Assistant training programme and physical activity session plans that TAs will deliver.

Once the intervention has been developed we will conduct a pilot evaluation of the intervention. This will involve randomly assigning ten schools to take part in the new programme for two school terms with students in ten further schools randomly assigned to a control (non-intervention) group. We will collect physical activity and related questionnaire data on the children's preferences for physical activity and perceived ability to be active from both groups before the new programme starts, during the programme and 6 months after the programme has ended. These data will be compared to indicate whether participation in the intervention led to increases in physical activity or related perceived ability to be active, and if changes are maintained six months later.

Applications and benefits
The research is designed to indicate whether the new after-school programme is likely to increase children's physical activity and if any positive effect is likely to be maintained 6 months later when half of the students are in secondary school. The information obtained will tell us whether the intervention is of sufficient merit to warrant a full randomised controlled trial evaluation and if so what size the trial is likely to be and what data need to be collected. The pilot evaluation will also tell us what cost data will need to be collected so that we determine the potential "value for money" of the project. The information will also be of use to agencies such as the Youth Sport Trust who design and disseminate physical activity programmes for children. The study will also be of interest to schools as it will provide evidence of the potential utility of training TAs to deliver physical activity programmes and how physical activity training could contribute towards the contributing professional development of TAs.

The project includes both formative research and then a feasibility trial. A summary of the research methods that will be used in each phase is outlined below.

Formative research: Phases 1 and 2 will involve interviews with Teaching Assistants, teacher trainers and parents along with focus groups with Year 5/6 students. All interviews and focus groups will be digitally recorded, transcribed verbatim and the transcripts verified. All transcripts will be thematically analysed.

Feasibility trial: Phase 4 of the project will be a feasibility trial in which 600, Year 5 and 6 students are recruited from 20 primary schools. Half of the schools will be randomly allocated to the intervention arm with the remaining schools allocated to the control arm. Schools will be stratified according to school district and the school tax credit information.

Two Teaching Assistants in each intervention school will attend a 5-day training programme that will focus on developing their physical activity management skills. Teaching Assistants will also be provided with 36 session plans. Teaching Assistants will deliver the new programme for 18-weeks in intervention schools. Children in control schools will participate in data collection only.

Students in intervention and control schools will provide data at baseline (time 0), in the middle of the intervention (time 0+9 weeks), at the end of the intervention period (time 0 + 18 weeks) and 4-months after the intervention has ended (time 0+36 weeks). The primary outcome will be accelerometer determined minutes of MVPA per day. Participants will also complete questionnaires to assess change in scores on psychosocial constructs.

Analyses will mainly be descriptive in nature and will include means (SD) or N (%) as appropriate. Between group comparisons will be made using appropriate regression models, but with the focus on 95% confidence intervals in order to estimate possible effect sizes. P-values will not be considered.

The proposed research has the potential to benefit: 1) Children and families; 2) schools and local education authorities; 3) Teaching Assistants; 4) Policy makers; 5) researchers; and 6) Society. The way in which each group could benefit and the timescales for benefits are summarised below.
1. Children and their families: It is intended that children in the intervention schools will find the programme to be enjoyable and that the programme will result in improved physical activity and positive attitudes towards physical activity. Parents of children in intervention schools will also benefit from the provision of a safe environment in which their child can be active immediately after-school. In previous research we have found that many children like to be part of research and find wearing accelerometers and answering questionnaires enjoyable. We therefore feel that both intervention and control school children will receive an immediate benefit from the project. Over the long-term, if the feasibility trial indicates that the intervention warrants further examination via a full RCT and the RCT indicates that intervention is effective the programme could positively affect the physical activity patterns and attitudes of a large number of children.

2. Schools and local education authorities: Intervention schools will benefit from a new programme that will run immediately after-school. Intervention schools will also immediately benefit from the training of the Teaching Assistants which fulfils workforce development requirements. More broadly control schools and the two local education authorities with whom we are collaborating will benefit from an understanding of the potential utility of using Teaching Assistants to deliver physical activity programmes after-school. These benefits will be evident at the end of the study (Spring 2014).

3. Teaching Assistants: It is intended that the training programme will increase the skills of Teaching Assistants. Many Teaching Assistants are looking to develop their skills as a means of either getting promoted to a "Higher Level Teaching Assistant", securing acceptance onto a Teacher Training Course or as part of their general career development. As such, Teaching Assistants will receive an immediate benefit from being in an intervention school.

4. Policy makers: The information obtained from the study will provide policy makers with information about the potential utility of the intervention. This information will help policy makers form future public health policy over the next 5-10 years.

5. Researchers: All aspects of the research will be of great interest to fellow researchers. Data from phases 1 and 2 will provide information about means of delivering physical after-activity programmes after-school and how best to work with Teaching Assistants to deliver these programmes. The data from the feasibility trial will provide information about the likely effect of the intervention, the school-associated intra-class correlation and how that may affect future sample sizes. Each of these aspects of the study will help researchers who are designing interventions that focus on changing physical activity or related health behaviours in the after-school period. As we will communicate findings at the end of each phase of the project via peer-reviewed papers and conference presentations we would envisage that all necessary information will be available to fellow researchers within 12-months of the end of the project (i.e. Spring 2015).

6. Society: In the longer-term (i.e. 5-10 years) it is envisaged that the data obtained from this project will inform new physical activity interventions which in turn will positively affect the physical activity patterns of children and adolescents. If the interventions increase physical activity there will be associated improvements in the health of UK children and adolescents.