Promoting physical activity in upper elementary children using multi-theory model (MTM) of health behavior change.

BACKGROUND: Physical activity and exercise offer numerous benefits to children and Centers for Disease Control and Prevention guidelines require that school children engage in at least 60 minutes of moderate to vigorous physical activity every day. Unfortunately, up to 30% elementary students do not meet these requirements and 79% elementary schools do not provide students with physical education classes every day. The transition from elementary to secondary school is particularly deleterious for levels of physical activity. Therefore, there is a need to develop educational interventions for upper elementary school children to promote physical activity. A new theory multi-theory model (MTM) of health behavior change can be utilized to develop such interventions.
OBJECTIVES: The purpose of this article was to develop and introduce an instrument based on MTM for physical activity change in upper elementary school children and propose an approach for changing this behavior among sedentary students.
METHODS: A review of literature in MEDLINE, CINAHL, Google Scholar, and ERIC databases was conducted for physical activity in upper elementary children and multi-theory model of health behavior change to prepare this article.
RESULTS: An instrument with Flesch-Kincaid Grade level of 5.4 and the Flesch Reading Ease of 68 making it suitable for administration with upper elementary school children was developed. An approach utilizing the constructs of participatory dialogue, behavioral confidence and changes in physical environment to initiate physical activity and reifying the constructs of emotional transformation, practice for change and changes in social environment to sustain physical activity in upper elementary school children is presented.
CONCLUSIONS: MTM offers potential to augment current educational efforts to promote physical activity in upper elementary school children.

Background

Regular physical activity and exercise performed by children helps in improving their academic performance [1], managing weight, and fostering cardiovascular and musculoskeletal health thereby reducing the chances of developing chronic diseases as adults [2]. Schools provide opportunities for children to be physically active that can contribute to their meeting the 60 minutes/day moderate-to-vigorous physical activity guideline [3]. Unfortunately, many schools are not providing adequate opportunities to children for becoming physically active. A nationally representative survey of 1,831 elementary schools in United States from 2009-2012 found that only about 21% provided students with physical education classes every day [4]. A meta-analysis found that elementary children do not meet CDC guidelines for physical activity lesson time in schools [5]. Furthermore, 2009-2010 National Health and Nutrition Examination Survey in the United States based on proxy reports found that 30% children in the ages 6 to 11 years did not meet CDC recommended levels of physical activity [6].

Transition from elementary to secondary school is particularly deleterious for levels of physical activity [7]. A study with upper elementary school children revealed that total physical activity and particularly moderate to vigorous physical activity significantly declined from fifth to sixth grades [8]. There is an ardent need to develop educational interventions for upper elementary school students to enhance their physical activity levels.

In recent years various educational interventions have been tried in elementary school children to promote physical activity such as utilization of classroom instruction [9], curricular changes [10], health promotion programs consisting of educational and policy changes [11], peer-led programs [12], use of computer games [13], training of physical education teachers [14] and others. These interventions have had mixed results and many of these do not use any behavioral theory thus not aiding in evidence-based practice. The interventions in health education have progressed in four generations from knowledge-based to skill-based to theory-based to now multiple theory-based, precision interventions [15]. One such approach of utilizing multiple theories is the multi-theory model [MTM) of health behavior change [15, 16]. MTM divides the process of health behavior change into initiation and sustenance. The model advocates the constructs of participatory dialogue in which advantages of behavior change outweigh the disadvantages of making the proposed change; behavioral confidence that can come from any internal or external sources and is futuristic; and changes in physical environment that provide resources and opportunities for behavior change are instrumental in initiating the behavior change. In order to sustain the behavior change the constructs of emotional transformation in which one directs one’s feelings toward behavior change; practice for change in which one actively reflects on changing one’s behavior and devises ways of overcoming barriers; and changes in social environment in which one recruits support from family, friends, health professionals and others are reified.

The purpose of this article was twofold. First objective was to develop an instrument based on multi-theory model (MTM) of health behavior change that can gauge changes in physical activity among upper elementary school children. Second objective was to propose an approach for promoting physical activity in upper elementary school children based on MTM.

Methods

In order to prepare this article a review of literature in MEDLINE, CINAHL, Google Scholar, and ERIC databases was conducted for physical activity in upper elementary children and multi-theory model of health behavior change. Based on this review of literature, informal discussion with a group of upper elementary children in Mississippi, and a previous validated instrument with college students [15, 17] the instrument for this article was prepared by the authors (see Appendix 1).

Results

The instrument developed by the authors is presented in Appendix 1. The Flesch-Kincaid Grade level of this instrument was found to be 5.4 thus making it suitable for administration with upper elementary school children and the Flesch Reading Ease of this instrument was found to be 68 once again making it readily comprehensible in this age group. The construct of participatory dialogue is derived from a subtractive score of advantages minus disadvantages of being physically active for 60 minutes daily. Both advantages and disadvantages are measured on a scale of never (0), almost never (1), sometimes (2), fairly often (3), and very often (4). Some of the advantages that the instrument taps into include being healthy, being relaxed, getting sick less often, having more energy, and enjoying life more. Some of the disadvantages included in the instrument are getting tired, not having enough time for school or other activities, not having enough time for friends and getting injuries. The construct of behavioral confidence is based on a response to five items on a scale of not at all sure (0), slightly sure (1), moderately sure (2), very sure (3), and completely sure (4). The behavioral confidence entails being physically active despite having school work, despite finding time for rest, without getting tired and without sustaining any injuries. The construct of changes in physical environment is also measured on a scale of not at all sure (0), slightly sure (1), moderately sure (2), very sure (3), completely sure (4) and taps into having a place for being physically active, being able to afford it and be able to use tools to exercise. The construct of emotional transformation also uses the same scale of not at all sure (0), slightly sure (1), moderately sure (2), very sure (3), completely sure (4) and gauges surety about directing feelings toward the goal of physical activity, inspiring oneself toward the goal and defying self-doubt. The construct of practice for change also utilizes the same scale of surety and measures ability to monitor, being active despite barriers and changing plans when faced with difficulties. The construct of changes in social environment also uses the same scale of surety and asks about getting help from a family member, friend or health worker. Finally, the intention to initiate and sustain physical activity are measured on scales of not at all likely (0), somewhat likely (1), moderately likely (2), very likely (3), and completely likely (4).

Discussion

The purpose of this article was to develop and introduce an instrument based on multi-theory model (MTM) for physical activity change in upper elementary school children and propose an approach for changing this behavior among sedentary students. The instrument that has been presented can be validated for face and content validity by a panel of experts that include a mix of experts on this theory, upper elementary school children and instrumentation. The instrument can further be subjected to construct validation by administering it to a sample of upper elementary school children and doing confirmatory factor analysis on the subscales using structure equation modeling or an extension of exploratory factor analysis (Sharma & Petosa, 2014). Internal consistency reliability of subscales can be established by computing Cronbach’s alpha and test retest reliability assessment can also be done [18].

The proposed approach for promoting physical activity in upper elementary school children based on MTM is depicted in a logic diagram in Figure 1. While MTM has not been tested with school-aged children it has been tested with college students and found to be useful [17]. In order to facilitate participatory dialogue it is important to have personalized discussion with the kids about advantages and disadvantages of at least 60 minutes per day of physical activity and exercise. For building behavioral confidence demonstration and re-demonstration of skills by students will be helpful. This can also be complemented with a discussion on sources of behavioral confidence for being physically active and how to build it. Regarding changes in physical environment the educators must ensure that children have access to playgrounds in the premises of the school and that they utilize these. For bringing about emotional transformation interactive affective exercises (such as role play, psychodrama or simulation) can be deployed to explore feelings in children and how to direct them toward goals for being physically active. In order to foster practice for change cell phone apps or computer journaling should be encouraged for the students to monitor their daily physical activity. A growing number of upper elementary children are having access to these gadgets and spending greater time on these [19]. There is a potential to employ these measures in educational interventions to promote physical activity. Finally for building changes in social environment peer-to-peer social support is indispensable and must be utilized. Previous interventions have also found this approach to be beneficial [12] (Fig. 1).

Fig. 1.

Using Multi-theory model (MTM) of health behavior change to promote physical activity in upper elementary children.

In summary, it can be appreciated that MTM offers potential to augment current educational efforts to promote physical activity in upper elementary school children. MTM based interventions have an advantage of being brief and precise in fostering behavior change thus making them replicable. Careful and concerted operationalization of this model to this target group has the potential to help sedentary school children become more physically active.