Means of Optimizing Physical Activity in the Preschool Environment: A Commentary on Coe (2019)

‘It may be that more-intensive and ongoing support to providers is needed in supporting children’s physical activity.’

Physical activity is a critical component of the young child’s development. Child care is an important settings for health promotion due in part to the large numbers of children enrolled and the many opportunities to educate and support the development of healthy behaviors. A recent review paper by Coe identified 16 intervention studies focused within the child care setting and their impact on preschool children’s physical activity. Coe examined the effectiveness of teacher training/professional development, teacher-led activity, and environmental features in supporting children’s physical activity. In this commentary, we discuss Coe’s results and identify important areas for future research. Coe found mixed results on the efficacy of these strategies to promote physical activity. Most of the interventions included multiple strategies and many targeted multiple levels of focus, including attempts to modify children’s behavior through curricula delivered to children, teacher-led activities, and modifications in the indoor and outdoor space. In addition to strategies focused on children and teachers, policy changes may be useful in promoting children’s physical activity while in child care. This could include state level policies setting standards for licensing and/or requirements for achieving quality rating standards, as well as center policies regarding physical activity. Future research should examine how best to train teachers to promote physical activity, isolate what component of the outdoor environment contribute to children’s activity, and identify how to create indoor space for movement. Addressing these research gaps can result in a better understanding of physical activity promotion in child care and contribute to improvements in children’s health.

Physical activity is an important and fundamental aspect of children’s development, promoting healthy growth of organ systems, cognitive ability, and social and emotional health. Coe’s review¹ focuses on an important issue—optimizing physical activity promotion in the preschool setting—because a large number of children from birth to 5 years of age are enrolled in child care. Child care has been identified as a primary opportunity for physical activity intervention^2-5; yet as shown in Coe’s review, there are relatively few interventions using objective monitoring to assess physical activity promotion efforts. The use of strong measures and indicators of success is necessary to understand the direct impacts of interventions on young children’s physical activity in this setting.

Among the 16 identified interventions, many were multicomponent, using multiple intervention strategies to facilitate change. Within such interventions, it is difficult to isolate specific contributions of individual components (ie, teacher training, indoor and outdoor environment, and motor skill development) to children’s physical activity. Additionally, many interventions were multilevel, meaning that they targeted more than one part of the social ecological framework within the child care environment.^6,7 For example, interventions in the review targeted children directly, their classroom teachers, and/or the physical environment of the entire center. This also precludes an understanding of the separate contributions of intervening at each level; however, multilevel interventions are needed to promote change within larger, complex systems.⁸ Future efforts should include attempts to identify contributions of the individual components as well as levels of influence in order to create the most efficacious and efficient interventions.

Coe¹ found mixed evidence regarding the effectiveness of teacher training, professional development, and teacher-led activity in supporting children’s physical activity. Within child care programs, few regulations and limited opportunities for training and professional development around physical activity exist. Training is the transfer of knowledge from an expert to the child care teacher. It is often limited in time and scope and may not ensure that providers are knowledgeable and comfortable promoting physical activity with children. Furthermore, providers are often inactive themselves and typically suffer from low health quality, high rates of obesity, depression, and other chronic conditions, which may limit their self-efficacy for promoting child physical activity.^9,10 It may be that more-intensive and ongoing support to providers is needed in supporting children’s physical activity. Training alone may be inadequate, leading to the use of “coaching” support. Training is more about the teacher than the children, with a focus on translation of knowledge about children’s physical activity, whereas coaching supports teacher’s skills in creating more children who are physically active. For instance, the SHAPES intervention conducted a series of trainings and workshops while also providing onsite technical assistance visits to individually coach and support providers in skill development.^11-14

Similar to findings in many intervention and observational studies, the current review highlights the importance of having a quality outdoor space for stimulating children’s physical activity. A quality outdoor space includes various landscape features (eg, large open spaces, shaded areas, small hills) and a variety of fixed and portable play equipment in good working condition. Additionally, providing time for children to go outside is critical because it has been linked to increased activity in children.^15,16 Coe¹ and others have raised the idea of optimizing children’s physical activity levels while outdoors by offering more frequent, shorter sessions as opposed to extending outdoor play sessions,¹⁷ which is a promising strategy considering that children’s physical activity levels decrease across a session of outdoor play.^18,19 In fact, an intervention testing more-frequent, shorter outdoor periods found a significant increase in children’s physical activity.²⁰ However, changing the classroom schedule may be difficult for some centers; as such, it is important to work with classroom teachers, so they can effectively prompt children to be more active when their physical activity levels begin to decline. Helping teachers identify and implement effective prompts or to facilitate unstructured (ie, child directed) play opportunities is critical because there is some evidence suggesting that teachers interacting with or attempting to create structured physical activity opportunities for children may unintentionally decrease children’s physical activity levels.^21,22

Less attention has been placed on the role of indoor spaces in promoting physical activity, even though children spend the majority of their child care day indoors. Research has shown that when providers have more suitable indoor space, physical activity of children increases.²³ However, many child care facilities, particularly family child care homes, which are small businesses where children are cared for in the provider’s own home, have inadequate indoor space. Improving indoor spaces for active play opportunities may be particularly important because providers frequently cite poor weather as a barrier to going outside where children are most active. Furthermore, little is known about the types of indoor portable play equipment and how it affects children’s physical activity. Additionally, more work is needed to improve how teachers can provide opportunities for indoor physical activity without compromising other learning objectives. Some studies have focused on the integration or pairing of physical activity with existing curricular activities, offering teachers the ability to meet multiple education and health objectives at once.^14,24,25 Future research and practice efforts should teach strategies to help classroom teachers capitalize on available indoor space, equipment, and integration opportunities to facilitate indoor play.

Coe¹ highlighted a number of interventions designed to promote motor skill development, but few assessed the impact of these interventions on children’s physical activity. Children’s motor skill development is enhanced through various learning experiences, either formal (eg, focused lessons) or informal (eg, teacher-led activities or games) and exposure to stimulating and challenging environments. Similar to overall physical activity level, supportive teachers and a quality physical environment are key to improving motor development. Furthermore, because of the potential for advanced motor skill development to contribute to increased physical activity, it will be important for future interventions to measure both these outcomes.

Coe¹ concludes that polices are needed to support the factors identified in this review associated with the young child’s physical activity. It should be noted that there are state-level policies that regulate the child care setting—for example, those around licensure, quality rating, and teacher credentialing. Experts describe a “spectrum” of opportunities that include policies, practices, and environments that can be leveraged in support of obesity prevention, which includes physical activity promotion.²⁶ Rules and regulations can be effective, but they may also threaten a vulnerable and poorly financed industry such as child care if the costs of implementing these rules and regulations are not accounted for. Although some level of regulatory policies can be effective,²⁷ adherence is necessary. Use of national recommendations and identification of best practices can be helpful in creating standards that ultimately become common practice.²⁸ Policies can also be created and implemented at the individual program level. Having written policies at the center level can communicate clearly to staff, families, and the community what practices and environmental supports are in place to support children’s physical activity. Although not a guarantee of adherence, having articulated policies can guide practice.

Overall, Coe’s review¹ highlights several important research and practice gaps for future work. First, “What are the best ways to train and coach child care workers to promote physical activity?” To have the greatest public health impact, these strategies should be developed and refined with an emphasis on real-world applicability. That is, evidence-based training and coaching initiatives must have a potential for implementation through existing delivery network (eg, training and technical assistance via child care resource and referral agencies). Second, “What specifically about the outdoor environment is needed to facilitate physical activity?” With the focus on multicomponent interventions, research is needed on the individual contribution of the landscape features, fixed and portable play equipment, and teacher practices. This information can inform effective, parsimonious multicomponent interventions and programs in the future. Third, “How can indoor spaces be capitalized on to promote physical activity?” To date, indoor spaces have received less attention relative to physical activity compared with outdoor spaces, yet the indoor environment offers many opportunities to promote physical activity through integrated learning activities. Future efforts dedicated to these gaps have the potential to advance our understanding of physical activity promotion in child care settings, improve public health practice, and ultimately foster the development of healthy physical activity behaviors in the many young children attending child care.