Appendix C: The evidence

This appendix sets out the evidence statements taken from eight reviews provided by external contractors/public health collaborating centres (see appendix A) and links them to the relevant recommendations (see appendix B for the key to study types and quality assessments). The evidence statements are presented here without references – these can be found in the full review (see appendix E for details). It also sets out a brief summary of findings from the economic appraisal and the fieldwork.

The eight reviews are:

  • Review 1: 'Descriptive epidemiology'

  • Review 2: 'Correlates of physical activity in children: a review of quantitative systematic reviews'

  • Review 3: 'The views of children on the barriers and facilitators to participation in physical activity: a review of qualitative studies'

  • Review 4: 'Intervention review: under eights'

  • Review 5: 'Intervention review: children and active travel'

  • Review 6: 'Intervention review: adolescent girls'

  • Review 7: 'Intervention review: family and community'

  • Review 8: 'Review of learning from practice: children and active play'.

Evidence statement number 2.4 indicates that the linked statement is numbered 4 in review 2 'Correlates of physical activity in children: a review of quantitative systematic reviews'. Evidence statement 4.1 indicates that the linked statement is numbered 1 in review 4 'Intervention review: under eights'.

The reviews and the economic appraisal are available on the NICE website. Where a recommendation is not directly taken from the evidence statements, but is inferred from the evidence, this is indicated by IDE (inference derived from the evidence).

Recommendation 1: evidence statements 2.4, 3.1, 3.2, 3.3, 3.4, 7.1b, 7.6, 8.4

Recommendation 2: evidence statements 3.1, 3.2, 7.5

Recommendation 3: evidence statements 3.1, 3.2, 3.3, 3.4

Recommendation 4: evidence statements 2.5, 8.1

Recommendation 5: evidence statements 5.1, 5.2, 5.3, 5.4

Recommendation 6: evidence statements 3.1, 3.2, 3.4

Recommendation 7: evidence statement 3.2

Recommendation 8: evidence statements 3.1, 8.1

Recommendation 9: evidence statement 7.5

Recommendation 10: evidence statements 3.2, 4.3, 8.4

Recommendation 11: evidence statement 3.1, 6.1

Recommendation 12: evidence statements 2.4, 3.3, 5.1, 5.2, 5.3, 5.4

Recommendation 13: evidence statements 3.2, 4.3

Recommendation 14: evidence statements 3.1

Recommendation 15: evidence statements 2.4, 3.2, 7.1a, 7.5, 8.5

Evidence statements

Evidence statement 2.4

There is evidence from four systematic reviews of observational studies that: there is a large positive association between parental and social support and physical activity in young people.

Evidence statement 2.5

There is evidence from four systematic reviews of observational studies that there is a:

  • small-to-moderate positive association between access to facilities and participation in physical activity in young people

  • moderate negative association between distance from home to school and physical activity in young people

  • moderate-to-strong positive association between time spent outside and physical activity in young people

  • small negative association between local crime and physical activity in young people.

Evidence statement 3.1

There is evidence from 15 UK qualitative studies of adolescent girls (reported in 16 papers) (two [++]; six [+] and eight [-]) that the main barriers to being physically active were:

  • social pressure to conform, (for example, wanting to fit in)

  • negative experience of the school environment (for example, inappropriate school PE kit and discomfort about sharing showers, changing rooms)

  • negative experiences of sports facilities (for example, public spaces such as gyms or exercise classes were intimidating to teenage girls)

  • having to perform in public (for example, being forced to perform a skill in front of peers)

  • fear of forced competition (one study [++] reported that creating a supportive environment for the delivery of a curricula focused on participation rather than competition and empowering students led to non-active student becoming more active)

  • fear of sexual or racial harassment (for example, Asian girls described needing escorting by family member to places to participate in sports).

The main facilitators to being physically active were:

  • social and family influences (for example, social sanctioning of activities by peers provided opportunities to gain social standing and was likely to encourage continued or increased participation; having active siblings and supportive parents)

  • enjoyment (for example, enjoyment and fun during sport and physical activity; enjoyment might outweigh the impact of negative peer pressure not to participate)

  • socialisation (for example, sport provides the opportunity to socialise with friends and extend friendship networks beyond school)

  • intrinsic and extrinsic rewards (for example, wanting to participate in sport as a means to achieve a socially desirable body type; receiving praise and encouragement from PE teachers helped with self confidence and a positive self identity).

Evidence statement 3.2

There is evidence from five UK qualitative studies of children aged 8 and under (three [+] and two [-]) that: there were far fewer barriers to physical activity and sport compared to other age groups. Barriers were:

  • dislike of a focus on team sports (for example, team sport focus in primary schools)

  • gender and cultural stereotyping about appropriateness of some sports for particular genders by parents and peers for example, parent viewing boys more active than girls; some sports were more 'appropriate' for boys to play than girls; boys not allowing girls to play 'boys games')

  • costs of participation in organised sports (for example, cost in terms of time and money in participating)

  • dislike of physical activities becoming less fun and more technical and performance-orientated (for example, girls stopped participating in ballet as it became more technical and less fun-orientated).

The main facilitators for children aged 8 and under were:

  • enjoyment (for example, creative and fun activities; participating in their favourite sports or activities; older children involving younger children)

  • parental and peer support (for example, physical activity was healthy; girls and boys enjoyed playing sports more if they had started at a younger age)

  • participation in age appropriate activities (for example, fun-based dance activities at younger ages; parent seeing a progression from fun to more structured activity as children became older).

Evidence statement 3.3

There is evidence from three UK qualitative studies of children and active travel that the main barriers to active travel were:

  • children and parents' fear of traffic (for example, children feeling unsafe when playing and walking outside, particularly after school)

  • parental restrictions on independent movement (for example, parental restrictions on a child's range [distance], plus place and destinations)

  • school influence over cycling policy and storage facilities (for example, absence of any school provision of facilities reflecting a lack of support for cycling)

  • limited play destinations locally (for example, too far to travel to independently; access dangers due to traffic; play equipment unsuitable)

  • adult disapproval of children playing outside (for example, children told off for cycling or playing in streets by adults).

Only one study reported any facilitators for walking and cycling. These included:

  • providing personal freedom (for example, reported that walking and cycling increased their personal freedom and independence)

  • enjoyment and fun with friends (for example, older children enjoyed walking to school because they could mix with their friends)

  • the opportunity to explore local surroundings (for example, gave them the chance to explore local neighbourhoods with their friends and/or alone).

Evidence statement 3.4

There is evidence from two UK studies and two international qualitative studies (both Australian), of families and community that barriers to physical activity and sport were related to personal safety of children while playing outside unsupervised. Common issues were:

  • perceived stranger danger (for example, both parents and children independently reported fear of strangers)

  • risk of personal accidents (for example, both parents and children independently reported risk of accidents or getting hurt)

  • intimidation from older children (for example, both parents and children independently reported the risk of intimidation or bullying by older children; fear of rival gangs for different areas)

  • poor quality of places to play (for example, presence of drug taking equipment (like syringes) in play areas; poorly maintained toilets, shaded areas and lighting).

Facilitators were that children:

  • valued opportunities for independent outdoor play (for example, the chance to play away from adult supervision with friends; parents preferring these places for independent play to be courtyards or cul-de-sacs rather than through roads)

  • preferred activities that emphasised fun, play and enjoyment rather than skills practice (for example, older children attending athletics club liked playing with friends).

Evidence statement 4.3

There is evidence from one cluster randomised controlled trial in the UK (+), one controlled non-randomised trial in Greece (+) and one controlled before-and-after trial in the USA (-) that supervised physical activity interventions conducted in the pre-school setting can be effective in improving core physical skills such as: running, galloping, hopping, sliding, leaping, skipping and general motor agility.

Evidence statement 5.1

There is evidence from five UK studies (all uncontrolled before-and-after studies [+]) that cycling promotion projects, targeting primary and secondary school children can lead to large self-reported increases in cycling both at 9–11 months and over 20–23 months. Characteristics of successful interventions included the involvement of external agencies to facilitate schools to promote and maintain cycling, with the support of parents and the local community.

There is evidence from two studies (uncontrolled before-and-after studies [+]), where cycling infrastructure was commonly part of the local transport infrastructure or children were encouraged to cycle to curriculum-related events or sports fixtures, that self-reported levels of walking declined over 20 and 23 months, implying that some of the increase in cycling may have been offset by a decrease in walking. The evidence is applicable to the UK.

Evidence statement 5.2

There is evidence from one UK study (randomised controlled trial [++]) to suggest that the introduction of school travel plans and direct support from a school travel plan adviser at primary schools did not lead to increases in self-reported levels of walking and cycling at 12 months.

There is evidence from one US and one UK study (uncontrolled before-and after-study [+]) to suggest that a mix of promotional measures including curriculum, parental and community promotions (for example, mapping safe routes to school, walk and bike to school days) can increase self-reported walking and cycling at 24 months. In the UK study, this activity was in support of a travel plan. The evidence is applicable to the UK.

Evidence statement 5.3

There is evidence from three UK studies (uncontrolled before-and-after studies [+]) to suggest that walking buses (volunteer-led walking groups supported by parents and teachers plus the involvement of the local highways or transport authority) led to increases in self-reported walking among 5–11 year olds, and reduced car use for children's' journeys to and from school at 10 weeks and 14 to 30 months.

There is evidence from one study (uncontrolled before-and-after study [-]) to suggest that the provision of a walking bus may in itself not be sufficient to stem a more general decline in walking to and from school. Retaining volunteers to act as coordinators for these schemes appears to be a key factor in the sustainability of walking buses.

Currently walking buses are found to be commonly delivered in the UK, however evidence for their applicability remains uncertain (as they may be applicable only to the specific populations or settings included in the studies).

Evidence statement 5.4

There is evidence from one UK study (controlled before-and-after study [+]), and two UK (uncontrolled before-and-after studies [+]) and one Australian studies (uncontrolled before-and-after study [+])to suggest that walking promotion schemes, involving promotional materials, incentives and rewards (such as travel diaries for children and parents and provision of 'park and walk' parking areas close to school and restriction of parking outside of schools), can lead to increases in self-reported walking to school among 4 to 11 year olds, and reduced car use for children's' journeys to and from school at 4 to 10 weeks and 41 to 48 months.

There is evidence from one UK study (controlled before-and-after study [+]) to suggest that walking campaign packs alone, including promotion materials for children and parents, did not lead to increases in walking among 4 to 11 year olds at 4 weeks.

There is evidence from two UK and one Australia study (uncontrolled before-and-after study [+]) to suggest that targeting children and parents who live a short distance to school (1 mile or less) may support interventions to encourage increase walking levels for the school journey.

The evidence mainly comes from UK studies and so is directly applicable only to populations or settings included in the studies (primary school settings). The success of broader application is uncertain.

Evidence statement 6.1

There is evidence from three cluster randomised controlled trials (one each in Australia [+], France [+], and Ireland [+]), and one controlled non-randomised trial in the USA (-), that school-based interventions outside of physical education lessons, targeting the single behaviour of physical activity, can lead to moderate-to-large increases in physical activity in adolescent girls for up to 6 months. One randomised controlled trial (++) and one cluster randomised controlled trial (+) (both from the USA), failed to show an effect. Characteristics of successful interventions were not consistent across studies, although three of the four successful trials targeted girls only. Successful interventions included self-monitoring techniques, stage-matched counselling, teacher-led extra-curricula physical activity, and multi-level programming targeting psychological, social and environmental correlates.

The evidence is drawn from non-UK studies and therefore the applicability to the UK is limited.

Evidence statement 7.1a

There is evidence from two randomised controlled trials in the USA (one [++] and one [+]) that family-based physical activity interventions targeting overweight/obese children and/or those at risk for overweight/obesity, can lead to increases in physical activity in young people. However, two randomised controlled trials in the USA (both [+]) failed to show an effect in the same target group. Characteristics of successful interventions included being located in the home and therefore not involving attendance at external sites and focused on small, specific lifestyle changes (2000 more steps per day and a single dietary target). In contrast, unsuccessful interventions required regular attendance at sites external to the home for education and/or physical activity sessions, broader physical activity and dietary behaviour change, and were with 8–9 year old African-American girls.

Evidence statement 7.1b

There is evidence from one randomised controlled trial in the USA (+), one randomised non-controlled trial in the USA (+), one controlled non-randomised trial (+) and one uncontrolled before-and-after study (-) that family-based interventions, targeting physical activity, can lead to increases in physical activity in young people. One randomised controlled trial in the USA (++) and one uncontrolled before-and-after study in the USA (-) failed to show an effect. One randomised controlled trial in the USA (-) showed a negative effect. Successful interventions were located mostly in the home and predominantly involved information packs. Two of the successful interventions involved either mothers and daughters or grandmothers, mothers, and daughters exercising together. Unsuccessful interventions all involved regular attendance at physical activity and education sessions outside of the home. Other differences between successful and unsuccessful interventions were not consistent.

Evidence statement 7.5

There is evidence from two cluster randomised controlled trials in Belgium and France (both [+]) and three controlled non-randomised trials in the Netherlands, Greece and the USA (one [+] and two [-]) that interventions involving both the school and family and/or community agencies lead to positive changes in physical activity in boys and girls aged 13 or under. These positive outcomes may include an actual increase in physical activity or less of a decline in physical activity relative to controls. Successful interventions had multiple components. At the school level this included computer-tailored advice, changes to the school environment, classroom sessions, physical activity sessions, and physical education. Family components included facilitating social support for physical activity, education on creating a supportive home environment, homework activities involving parents, and community sport information. One cluster randomised controlled trial in the USA (+) and one uncontrolled before-and-after study in the USA (-) failed to show an effect. The characteristics of these unsuccessful interventions were not consistently different from those of successful interventions.

Evidence statement 7.6

There is evidence from one controlled non-randomised trial in the USA (+) that social marketing interventions can increase levels of free-time physical activity in children and adolescents (9–15 year olds). The social marketing campaign employed engaging messages (primarily via TV advertisements) and promoted opportunities to incorporate physical activity into daily lives. The sustained nature of the campaign (2 years) was considered important to its success. Behavioural changes were seen in the activities targeted by the campaign (for example, free-time activities) and there were no effects on participation in organised sport.

Evidence statement 8.1

There is strong support for the principle of ensuring that children in the foundation stage are given the opportunity for regular outdoor play as part of the school day. Outdoor play should provide opportunities for movement and challenge, and opportunities to play safely with natural elements.

Children's play in outdoor space can be optimised through a number of practical measures such as: seeing the indoor and outdoor spaces as one environment; providing materials specifically for physically active play; making links to the curriculum; provide for diverse active activities; planning to take account of issues such as weather, light, wind direction.

The indoor environment can also be optimised for active play, through providing sufficient space; allowing freedom to move from one area to another; providing good opportunities for energetic physical movement; dividing space into active and quiet zones.

Adults can help to facilitate active play through: creating the right context for play in which children feel secure and still have the necessary freedom and autonomy to explore through free play; observing play and understanding children's interests, in order to guide the provision of resources and environments for play; interacting appropriately and intervening only when necessary; creating the right environment for play including materials and resources for play, as well as the actual place to play.

Practitioners may limit the amount of outdoor play offered to children due to a number of assumptions: that the outside is dangerous; that higher adult/child ratios are needed outside; that educators are merely supervisors outdoors, and that no learning happens outside; that the weather is a barrier; and that being outside is somehow less healthy. All of these assumptions can be tackled to increase active play outdoors.

There appears to be a strong consensus among practitioners that there should be much more out of hours use of school grounds.

For older children, play facilities are most valued when they are close at hand. If a facility is more than a few hundred metres away, regular use declines dramatically.

Evidence statement 8.4

It is well acknowledged that physical education contributes to the development of core skills. However, there appears to be much less consensus on the role of play in developing core skills.

Core skills can be developed through natural active play, especially when the play is determined by the children themselves.

The role of the play practitioner may be less about planning complex programmes to focus on core skill development, but instead facilitating active play.

Evidence statement 8.5

There is often reluctance by parents and professional carers to also go outside and supervise children playing outdoors in poor weather.

It appears that practitioners are put off by the weather more than children.

There are many examples of ways that this has been tackled, through encouraging children to spend time outside independently or under supervision in all weathers; encouraging parents and carers to allow their children to be outside; and encouraging nursery and teaching staff to spend time outside with children as part of their formal and informal activities.

There is a great deal of experience of a positive approach to bad weather, much of which has been incorporated into the UK Forest Schools movement, building on its origins in Sweden.

Cost-effectiveness evidence

For this guidance the economic appraisal consisted of a review of economic evaluations and a cost-effectiveness analysis.

  • 'A rapid review of economic literature related to the promotion of physical activity, play and sport for pre-school and school age children in family, pre-school, school and community settings'.

  • 'A cost-effectiveness scenario analysis of four interventions to increase child and adolescent physical activity: the case of walking buses, free swimming, dance classes and community sports'.

Review of economic evaluations

Overall, the rapid review found that there was very limited economic evidence with respect to the promotion of physical activity, play and sport in the four core areas identified. Only two economic evaluations were appraised on the strength of their evidence, both were from the USA and considered interventions to modify the behaviour of obese children, while one study also considered the behaviour of their obese parents. However, these studies were considered not to be relevant to the development of the guidance due their targeting of only obese children.

Cost-effectiveness analysis

A case study or scenario analysis approach was taken to model four different physical activity programmes and consider the cost effectiveness of each as far as was practical with the available data. The programmes considered were:

  • walking buses

  • free swimming

  • dance classes

  • community sports.

The analysis sought to estimate the additional minutes of physical exercise derived from the interventions, and these minutes of exercise per year were used to derive the short-term quality of life improvements for children.

However, there was uncertainty associated with the cost-effectiveness results as, due to the limitations of the evidence, it was necessary to make a number of unverified assumptions within the analyses. The results were also shown to be sensitive to changes in these assumptions.

Only walking buses were estimated to be cost effective. This was assuming a cost-effectiveness threshold of £20,000 per QALY and because of their relatively low cost and that children benefited by being engaged in the activity on a regular basis over time. However, due to the number of assumptions made producing the cost-effectiveness estimates, the PDG was cautious in drawing conclusions.

Fieldwork findings

Fieldwork aimed to test the relevance, usefulness and feasibility of putting the recommendations into practice. The PDG considered the findings when developing the final recommendations. For details, go to the fieldwork section in appendix B and online.

Participants with a direct or indirect role in promoting physical activity, play and sport with children were very positive about the recommendations and their potential to help promote physical activity.

Many participants stated that the recommendations would be both useful and relevant and that, if successfully implemented, would have a significant impact on policy and service provision. Potentially, they could address inconsistencies in the provision and quality of physical activity initiatives.

For service providers and practitioners who are not doing much work in this area, the recommendations were seen to provide useful guidance to help develop new policies. For those already heavily involved in physical activity work, they served to provide reassurance and weight to that work. They were also seen to reinforce aspects of the 'Early years' foundation stage framework, particularly in relation to the provision of safe, secure and challenging environments for physical activity.

Practitioners said the recommendations did not offer a new approach but agreed that the measures had not been implemented universally.

Feedback suggests that many of the stakeholders who should be involved in implementing the recommendations may not be aware that guidance published by NICE would directly impact on their work. They believed wider and more systematic implementation would be achieved if there was an awareness-raising campaign.

  • National Institute for Health and Care Excellence (NICE)