Analysis of foreign physical activity recommendations and guidelines for schools

Background: An adequate level of physical activity is an important part of children’s lifestyle. The school environment plays a significant role in the area of interventions and strategies aiming to increase the level of physical activity in children. Objectives: The aim of this study is to analyse foreign recommendations leading to an increased level of physical activity in children and young people in Czech schools. Methods: A systematic search of studies published between 1988 and 2012 in the English language was completed in library databases Medline, Sport Discus, ProQuest, PsychInfo, ERIC, Wiley InterScience using the following keywords: physical activity, guidelines, recommendations, school and youth. The studies were then classified based on abstract and full-text analyses. Using a content analysis the expert team formulated the final recommendations to increase the level of physical activity for schools in the Czech Republic (CR). Results: Out of the total number of 91 identified foreign studies, 25 met the predetermined criteria and were used as a basis for formulating the recommendations. These foreign studies included 15 papers published in USA, two in Australia, two in Great Britain, two in Canada, one in the European Union, one in New Zealand and one international paper (an international consensus of experts from 34 countries). Based on the interpretation of the evidence, its justification and final consensus of the expert team, the basic areas for the recommendations to increase the level of physical activity in schools in the CR were identified. Conclusions: An analysis of foreign recommendations to increase the level of physical activity designed for schools and school facilities is one of the possible methods of formulating domestic recommendations. This recommendation could contribute to deeper understanding of the issue of the deteriorating lifestyle of school-aged children in the CR and reflects the efforts for improvement.


Introduction
Overhelming evidence supports the importance of regular physical activity (PA), which has a positive effect on the health of children and young people through preventing a number of diseases, preventing overweight and obesity, decreasing high blood pressure and helping to improve mental health (Guillaume, Lapidus, Björntorp, & Lambert, 2012;Iannotti, Kogan, Janssen, & Boyce, 2009;Warburton, Charlesworth, Ivey, Nettlefold, & Bredin, 2010).
PA promotion is one of the basic intervention strategies of improving the quality of life and the effort to decrease the risk and seriousness of chronic diseases.It is also an important element in increasing the effectiveness of the educational system and has a positive A positive effect of PA on children is typically supported by targeted interventions and a change in the environment where PA takes place (De Bourdeaudhuij et al., 2010).A significant role in an effort to change the behaviour in order to increase the level of PA in children is played by the family and school (Gorman, Lackney, Rollings, & Huang, 2012;Salmon, Timperio, Telford, Carver, & Crawford, 2012;Sigmund & Sigmundová, 2011).Published studies indicate that the success rate of an intervention usually depends on the cultural and social environment of a particular school, attitude of the family and motivation invoked within the society (Kitzman-Ulrich et al., 2010;Kriemler et al., 2011).
Schools offer an optimal environment for designing, implementing, and evaluating behavioural interventions to promote PA.A school not only influences children's attitude to PA but also informs of its importance in human life (Haug, Torsheim, Sallis, & Samdal, 2010;Robertson-Wilson, Dargavel, Bryden, & Giles-Corti, 2012).One of the effective tools for increasing the level of PA in schools can be the development of evidence-based PA recommendations to promote a PA and healthy lifestyle in children (Kesäniemi, Riddoch, Reeder, Blair, & Sørensen, 2010;Warburton, Charlesworth, Ivey, Nettlefold, & Bredin, 2010).
The aim of this study was to, through foreign recommendations for PA promotion; formulate recommendations for school managers in elementary and secondary schools in the Czech Republic leading to an increase in the level of PA in children in both the school and out of school environment.

Systematic literature search
The criteria applied in the selection of suitable foreign literature included the following: • target group (children and young people aged 5 to 19 years), • type of recommendation or intervention (physical, nutrition, combined -physical + nutrition, organization), • type of school (elementary and secondary), • results (duration, areas of recommendation, application methods), • year of publishing (period from 1988 to 2012).
The keywords used were physical activity, guidelines, recommendations, school and children.We searched through six electronic databases -Medline, Sport Discus, ProQuest, PsychInfo, ERIC, Wiley InterScience using the following keywords -physical activity, guidelines, recommendations, school and youth.A prerequisite for including a study in the final content analysis was its classification as a recommendation/guideline designed for children and young people without health or other restrictions aged 5 to 19 years (Figure 1).

Content analysis
The content analysis method is recommended as a simple, adaptable, systematic and objective method (Granner, Sharpe, Burroughs, Fields, & Hallenbeck, 2010;Thomas, Nelson, Silverman, & Silverman, 2010) for data analysis and extraction.Data extraction was performed by two researchers (JP and MK).The third reviewer's (ZH) role was to resolve any conflicts.The data was extracted independently for each included paper using the following keywords -physical activity, guidelines, recommendations, school and youth.We used a data collection form designed before the search.We collected information on participants and study characteristics (including age and setting), curricular activities (physical education and health education), extracurricular activities (community programmes, parents' roles), policy (school strategies), school environment and teacher education.These specific areas of interest were selected in advance by the study team on the basis of accordance with previous expert papers focused on developing PA recommendations and guidelines (Silveira, Taddei, Guerra, & Nobre, 2011;Tremblay, Boudreau-Larivière, & Cimon-Lambert, 2012).After that we contacted independent experts to check any omissions (members of the team of authors and a foreign expert), then the recommendations to increase the level of PA in schools in the Czech Republic were developed.

Results
Out of the total number of 91 potentially suitable studies published in English between 1988 and 2012, 66 were rejected.The rejected studies did not meet the specified criteria; mostly they included different age groups of children and young people, or specific groups with diseases (Figure 1).The final analysis included a total of 25 studies.The selected foreign studies included 15 studies published in the USA, two in Great Britain, two in Australia, two in Canada, one in the European Union, one in New Zealand and one was an international study (international consensus of experts from 34 countries).Despite the fact that no language filter was applied, all detected papers were published in English.All studies were conducted in non-developing countries.The general characteristics of the 25 included studies were organized by their frequency and strength of effect, see Table 1.
After the content analysis (Table 2) we identified a list of most frequently repeated recommendations in terms of content and type, and grouped them into the following areas.
Strategy development -use a coordinated approach to develop, implement, and evaluate school-based PA health promoting strategy for schools and school facilities.The aim of school strategies is to provide formal as well as informal principles that schools and local organizations respect in planning, delivering and evaluating PA programmes for young people.PA school strategies should respect national as well as regional strategies and documents and recommendations.These strategies should be in the form of a written document containing information from school managers, teachers, lecturers, sports coaches, parents, School environment -establish PA-friendly and safe environment, where PA is possible without excessive restrictions.The primary objective in an effort to increase the level of PA in children and young people in schools is to make safe areas and school facilities (gyms, playing fields) available where children and pupils can perform PA.These areas should be available not only during classes but also at weekends, special days and holidays (including summer holidays).These areas and facilities should be easily available also for non-profit organizations which organize complementary activities and physically-oriented programmes.
Physical Education (PE) lessons -implement PE curricula that appeal to the natural need of children and pupils for PA and that try to create a positive attitude to PA by developing knowledge of its health benefits.Such PE lessons should help change attitudes and behaviours and support self-confidence required to adopt and maintain a physically active lifestyle.In developing the curricula, educators should take into account particularly the age and education needs of pupils, their interests and schools conditions that are often very different.Provision of complementary programmes (clubs) that motivate pupils to active participation even after classes -cooperation with non-profit organizations, cities and local authorities where the schools are located.
Health education -implement a modification of health education curricula in order to help students develop their knowledge, skills and self-confidence, and embrace behaviours and strengthen their attitudes required to adopt and maintain a physically-active lifestyle.Creating links among the educational components of health education, school PE and other subjects in the area of PA promotion -the class teacher of the class involved should be the coordinator -an example could be links among nutrition habits, which are the domain of health education and an adequate level of PA in order to maintain or reduce body weight.
Extracurricular activities -it is important to provide a sufficient offer of extracurricular activities (clubs, programmes) that meet the needs and interests of all students.Frequently offered programmes focus on competition and team sports, which can discourage less predisposed individuals in terms of physical and health fitness from participation.Undue emphasis on performance and competitiveness in childhood contributes, especially in early and late adulthood, to a decreased level of PA.Therefore, an effort should be exerted to provide a rich offer of PA programmes attractive to a wide range of pupils and students.Non-competitive activities should include walking (hiking, Nordic walking), swimming, cycling (scooters, skateboard, etc.), or newly developing PA activities -Zumba, Frisbee, etc. Highlight effective cooperation with non-profit organizations that work with young people in the area of PA; significant support (financial, organizational, material, facilities) should be provided by the municipal or local authorities;

Children and young people
Children's PA guide on their way to and from school.It should increase the number of children who use active transport on the way to and from school -walking and cycling.
Step 1 -identify interest in organized commuting to school.
Step 3 -contact parents, produce a map and route of organized commuting.
Step 6 -assess, evaluate, plan for the future.

Recommendations for the development of policy documents
The main purpose of this guideline and a number of recommendations is to outline the priorities for the development of policy documents dealing with the issue of PA promotion in EU member countries.
The recommendations address several areas, an interdepartmental approach is required -sport (organized, non-organized, sport for all), health sector, education, transport, working environment, senior services, required evaluation.
(Table 2   Parents' roles -parents should be encouraged and motivated to become a positive model and to further support their children's participation in PA programmes.Joint active leisure of parents and children induces a positive family atmosphere but also allows parents to become partners of their children in acquiring knowledge and skills, shaping of behaviour and building their attitudes.School managers should actively communicate with parents through meetings and other occasions, educational materials but also by means of developing PA programmes that are based on parents-children cooperation.Parents can also act as volunteers in organizing and leading PA clubs, or supervising in gyms or on playing fields; Teacher and staff education -encourage further education of teachers and other staff members in the area of healthy lifestyle of children and young people with an emphasis on the significance of PA.School staff should actively motivate students and, throughout the whole course of study, provide them with knowledge and skills required for an effective promotion of pleasant lifelong PA.Use of evidence-based data on the level of PA and healthy lifestyle of children and young people that must be applied in teacher education programmes.Physical education and health education are the types of courses in which children and adolescents can be motivated to PA through practical demonstrations and performance of PA.
Health and PA counselling -each school should have a PA and health specialist who should be capable of providing well-founded information about suitable PA for various age groups of children and pupils, and monitoring the implementation of school programmes aimed at PA promotion and healthy lifestyle.Important is to minimise the absence of pupils in PE lessons.
Community programmes -each school should closely cooperate with local organizations on the development of PA programmes designed not only for young people but also local citizens, provision of facilities (gym, outdoor playing field, swimming pool, athletic stadium) for performing PA.Extracurricular PA constitutes a significant part of all-day PA of children and adolescents.Therefore, PA promotion must also include a more focused and closer cooperation with non-profit organizations, citizens' associations, interest groups and sports organizations in developing complementary extracurricular PA programmes.Financing of extracurricular programmes must be supported by local governments in cities and municipalities.
Evaluation -conduct regular evaluation of PA promotion activities and programmes in a school environment.The evaluation should focus primarily on the processes in short-term as well as long-term perspective in terms of both effectiveness of the developed strategies and intervention programmes and a change in and adoption of behaviours of pupils and students in order to embrace and maintain a physically active lifestyle.The most frequently used evaluation techniques for determining the level of PA include especially questionnaires and record sheets, often combined with pedometers and accelerometers or the International Physical Activity Questionnaire (IPAQ).

Discussion
The aim of the study is, through an analysis of foreign recommendations, to formulate recommendations for elementary and secondary school managers in the Czech Republic leading to an increase in the level of PA in pupils in both school and out of school environments.
Increasing the level of PA in school-aged children as well as preventing a further increase in overweight and obesity requires cooperation between parents, teachers, schools and school facility managers and children.In spite of the fact that partial physical interventions are effective in dealing with an insufficient level of PA and overweight and obesity reduction in children (Jansen et al., 2011;Sigmund, El Ansari, & Sigmundová, 2012), a more systematic and general approach must be implemented (Story, Kaphingst, Robinson-O'Brien, & Glanz, 2008).Regarding the fact that the school environment presents one of the key locations for various interventions, particularly of a physical nature, this setting must be focused on (Jansen et al., 2011;Khambalia, Dickinson, Hardy, Gill, & Baur, 2012;Lavelle, Mackay, & Pell, 2012;Waters, de Silva-Sanigorski, et al., 2011).
A series of recommendations based on the presented analysis of foreign studies (Table 2) are designed to promote PA in schoolchildren and young people aged 5 to 19 by increasing its level.The defined recommendations are intended especially for schools and school facility managers.We based the development of this guide on 25 foreign papers supported by research results in the area of PA.A significant part of the overall concept leading to a sustainable improvement of individual determinants of schoolchildren's healthy lifestyle is the quality of school environment and the promotion of teacher education as well as other staff (60% of all recommendations is focused on the impact of school environment and 32% on teacher education).School employees (teaching as well as non-teaching) should actively motivate students and provide them with sufficient knowledge and skills required for an effective promotion of pleasant lifelong PA.These recommendations are in accordance with foreign recommendations (Baranowski et al., 1997;Michigan Department of Community Health, 2002;NASPE, 2001NASPE, , 2009aNASPE, , 2009bNASPE, , 2009cNASPE, , 2010;;USDHHS & USDA, 2011).The role of the teacher and educator is perceived as one of the most significant areas in the process of increasing the level of PA (Cothran, Kulinna, & Garn, 2010;McDavid, Cox, & Amorose, 2012).One of the key elements to achieve this is a systematic process of teacher education in the areas of active lifestyle and PA (Schwarz, 2011;Tessier, Sarrazin, & Ntoumanis, 2010).
The performed analyses also show that one of the possibilities of systematically addressing the insufficient level of PA in schools may be the development of school-based strategies that provide formal and informal principles governing school-based planning, implementation and assessment of PA promotion programmes (40% of recommendations) (Kropski, Keckley, & Jensen, 2012) and at the same time should comply with applicable national and regional strategies, documents and recommendations (Simovska, Dadaczynski, & Woynarowska, 2012).These strategies should be in the form of a written document that contains information provided by school managers, teachers, lecturers, sports coaches, parents, students, but also health care providers, public health, other schools and community workers (ACSM, 1988;Baranowski et al., 1997;EC, 2008;Kolt et al., 2006;NASPE, 2009aNASPE, , 2009bNASPE, , 2009c;;USDHHS & USDA, 2003, 2011).The development of school strategies and action plans to promote and increase the level of PA in children and young people is considered one of the basic elements in an effective approach to address the issue (Brennan, Castro, Brownson, Claus, & Orleans, 2011;Evenson, Ballard, Lee, & Ammerman, 2009;Harris, Kuramoto, Schulzer, & Retallack, 2009).In the Czech Republic, however, such strategies and recommendations do not exist at the moment or are not comprehensive (Kalman, Hamřík, & Pavelka, 2009).
The school environment is suitable for the implementation of PA programmes (Dobbins, De Corby, Robeson, Husson, & Tirilis, 2009;Teufel-Shone, Fitzgerald, Teufel-Shone, & Gamber, 2009) through which PE (56% of recommendations) and health education curricula (20% of recommendations) can be implemented that appeal to the natural need for PA in children and young people and become a basis for an active lifelong learning (Donnelly et al., 2009).A significant element is also the blending of "school life" and "out of school life" and active development of the knowledge of PA and its significance for health, helping to change attitudes and behaviours and support self-confidence required for adopting and maintaining a physically active lifestyle (ACSM, 1988;Bagby & Adams, 2007;Baranowski et al., 1997;Michigan Department of Community Health, 2002;NASPE, 2009aNASPE, , 2009bNASPE, , 2009cNASPE, , 2010;;Sallis & Patrick, 1994;USDHHS & USDA, 2011).
PA, which is an inseparable and cross-section part of school curricula also in the Czech Republic (Sigmund, Sigmundová, Frömel, & Vašíčková, 2010), can result in an increase in the natural need for PA and improved study results in schoolchildren (Donnelly et al., 2009;Kibbe et al., 2011).An important educative aspect that can have a positive influence on the level of PA in children includes school facilities and equipment, particularly the learning environment and material equipment that should be appropriate in terms of purpose, hygiene and aesthetics (Gorman, Lackney, Rollings, & Huang, 2012;Gronberg, Jansen, & Taylor, 2011).The provision of a safe and appropriate environment for performing PA can be achieved by making school facilities accessible (gym, outdoor field), making sports facilities available outside school lessons (weekends, holidays), promoting active transport (bicycle stands, lockers), during school lessons and breaks -providing opportunities to stretch on the carpet, do exercise, relax, PA should not be used as a form of punishment (ACSM, 1988;Baranowski et al., 1997;Department of Health andAgeing, 2004a, 2004b;Michigan Department of Community Health, 2002;NASPE, 2001NASPE, , 2010;;USD-HHS, 2011;USDHHS & USDA, 2011).The results of the foreign studies indicate (60% of analysed recommendations) that the quality of the environment and school surroundings plays an important role in promoting PA in school-aged children (Colabianchi, Kinsella, Coulton, & Moore, 2009;Haug, Torsheim, Sallis, & Samdal, 2010;Lanningham-Foster et al., 2008).Based on the comparison with the results of studies dealing with school conditions and background suitable for PA promotion in the Czech Republic, it is clear that this area must be addressed in a systematic way.This primarily includes insufficient material equipment, unsuitable conditions for the promotion of active transport and related safety around schools (Pavelka, Sigmundová, Hamřík, & Kalman, 2012).
In an effort to increase the level of PA in schools, not only students and teachers must be involved.At least 24% of analysed recommendations emphasize also parents' roles.In this context, parents' participation in extracurricular activities of PA nature is of utmost importance (Zecevic, Tremblay, Lovsin, & Michel, 2010).Parents should also be involved in the process of increasing the overall level of PA in children (Kitzman-Ulrich et al., 2010).An important part of the process is an effort to encourage and motivate them to become models for their children and to promote their children's participation in additional activities of a PA nature (ACSM, 1988;Baranowski et al., 1997;NASPE, 2010;USDHHS & USDA, 2011).Irrespective of gender and age, the correlations between parents' and their children's PA are positive, they are primarily found in the duration of everyday walking, followed by overall weekly PA and moderate-to-vigorous PA.It can be concluded that "more active parents, both fathers and mothers, bring up more physically active children" (Sigmund, Sigmundová, Frömel, & Vašíčková, 2010).

Strengths and limitations
An important strength is that we collected relevantly developed, research-based recommendations to identify any gaps in existing knowledge and to establish the priorities for future research.The research recommendations were formulated by experts for future iterative reviews and modifications.Our study also has several limitations.Firstly, because we did not include unpublished studies and studies that were published in a different language than English, and because we did not perform extensive cross-referencing of the reference lists in the papers that were retrieved from electronic databases, several relevant papers may have been excluded.Secondly, the review was limited to 10 main outcomes and did not include several other outcomes that may be relevant for children and youth (risky and aggressive behaviours and measures of mental health and well-being).Generally, these limitations may have biased the results and recommendations that were developed.

Conclusions and recommendations
The presented recommendations are intended for schools and school facility managers.They should facilitate the formulation and application of their own PA recommendations in schools and school facilities towards a sustainable increase in the level of PA in school-aged children.The proposed recommendations reflect the need for a systematic approach to the unsatisfactory lifestyle of school-aged children in the Czech Republic.The formulated recommendations encourage further scientific discussions and constructive comments in order to develop recommendations acceptable on a national scale.

Table 1
General characteristic of the included studies, organized by frequency and strength of effect a International consensus of experts from 34 countries.

Table 2
Analysis of foreign recommendations to increase PA in order to promote health in children and young people -ordered by year of issue (Table2 continues)