Parent-focused online intervention to promote parents’ physical literacy and support children’s physical activity: results from a quasi-experimental trial

The promotion of physical literacy (PL) offers a potentially promising approach for childhood PA interventions [8]. The concept of PL is emphasized as an important ideology and defined as “the motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities for life” [9]. There are still some debates in terms of how PL should be defined, but the notion of moving from a unidimensional construct of PA to a more holistic one is agreed upon by many researchers [10]. Even though there might be different clear-cut definitions of PL, Whitehead’s framework [9] is broadly used (i.e., 70% of papers adopted the concept) and widely accepted by most people. Moreover, compared with other PL concepts, Whitehead’s concept of PL is based on the premise of a holistic, individualized journey [10]. Cairney et al. [8] proposed a PL conceptual model and stated that the development of PL early in life may influence their subsequent PA participation and consequent health benefits across the life course [8, 10]. PL is considered a dynamic concept, which consists of four domains: affective domain (motivation and competence), physical domain (physical competence), cognitive domain (knowledge and understanding), and behavioral domain (engagement in physical activities for life) [11]. Taken together, these four domains represent a holistic approach to lifelong PA participation [12]. PL may offer a more holistic and reflexive approach to incorporating PA promotion into the behavioral change and healthcare setting, where context, psychosocial aspects, individual competence, and understanding and knowledge may be concerned [13].

Being primary caregivers, parents typically play an essential role in children's growth and development and in shaping their PA behaviors [14]. Parents can influence their children’s PA in a range of ways, including the provision of logistical and social support (e.g., transportation to training and encouragement), co-participation (i.e., participating together), and role modeling an active lifestyle [15‐17]. A synthesis of results from 39 high-quality reviews [18] provided strong evidence that parents play a crucial role in promoting PA for children across various community settings (i.e., family and home, childcare, school). Given the role parents play in their children's PA engagement, parent direct involvement was a key element in designing the family-based intervention [19].

In response, researchers have designed and evaluated a range of PA interventions to improve PA and related physical and mental health development in the family context [19‐21]. A systematic review reaffirms the crucial role that parents play in supporting and controlling children’s PA levels and found that both physical and social environmental factors operating within the home environment are important influences on school primary children’s PA patterns [22]. As such, changing the home physical environment and parenting behaviors are crucial in shaping and promoting children’s PA [23]. Lloyd et al. [23] conducted a randomized controlled trial to examine potential parenting behaviors of children’s PA change in the community program, and the findings indicated that the program positively impacts fathers' modeling of PA and parent–child co-PA.

However, family-based interventions showed mixed effects; some of them showed small-to-moderate effects or no effects [24, 25]. Findings from a systematic review and meta-analysis suggest that interventions with the involvement of parents to promote PA in children are effective, with 66% demonstrating a positive effect on PA [19]. Especially, parent-focused interventions involving the education of parents have previously been used to improve children’s PA behaviors. However, the level of parent involvement varied among previous research, and intervention design in which parents were targeted, while children were only involved in the data collection stage was still lacking in existing studies [26]. Accordingly, there is a need to provide more novel, effective, and feasible parent-focused interventions, especially in the current pandemic context. A negative consequence of stay-at-home orders and social distancing regulations was decreased opportunities for both parents and children to be physically active under the influence of COVID-19 [27, 28]. Particularly, schools and many workplaces were closed, and organized PA sessions were canceled in schools, resulting in transitioning activities that once took place outside of the home to online implementation in the home environment [29].

Parental involvement with children’s PL journey is considered crucial and meaningful, which is essential in supporting their child and their own PL development [30]. Lane et al. [30] designed a non-randomized, one-arm concurrent nested study to explore the feasibility of a PL program designed to build parental self-efficacy to support their child’s PL. The program shows promise as a PL intervention is feasible to influence parenting practices with regard to PL to develop children’s PL and PA. However, the study only included a small group of participants (35 parents of young children) and lack of a control group. Thereby, there is insufficient evidence to support the feasibility and effectiveness of delivery in an online format for interventions based on the PL framework.

Regarding intervention components, researchers have focused on different parts of PL to design and implement the intervention. Ha et al. [20] delivered ten face-to-face workshops and activity sessions to parents and children in a 6-month period in primary schools in Hong Kong to enhance children’s fundamental movement skill (FMS) competence and PA. For improving children’s PA participation and parents’ perceived motor competence, motivation, and knowledge about PA, Morgan et al. [21, 31] invited parents and children to attend seven face-to-face group sessions (90 min each) in a 3-month program in Australian school halls. Similarly, these two studies targeted different elements of PL framework to conduct the interventions through a series of organized face-to-face initiatives. Nevertheless, a recent systematic review reported that only 38.6% of the interventions formulated intervention components to cover all the core PL domains [32], and only a few researchers have explored the feasibility of interventions designed to improve PA in both children and parents with the mixed results, leading to insufficient understanding of “what PL-supportive programs look like in practice” [33]. Therefore, interventions are needed on committing to systematically address all domains of PL simultaneously [32].

In Hong Kong, the rate of inactivity in children is high, and also in parents [34]. Referring to the conceptual framework proposed by Morgan and colleagues, which is an approach to the design and delivery of health behavior interventions targeting PA promotion, consists of four core intervention components: content, format, facilitator, and pedagogy. In terms of the content, reciprocal reinforcement was proposed, in which can be found when parents and children are independently encouraged to role model healthy behaviors at home [35]. Thus, increasing the activity levels of children and their parents may result in sustained changes in both parties, increasing the long-term effectiveness of the intervention. In light of the research gaps in the extant studies, in the current study, we examined the feasibility and effectiveness of a parent-led intervention that was designed to increase parent self-efficacy on PL and PA participation of primary school children and their parents. Our intervention was guided by the Whitehead's PL framework [9], which is considered a holistic and dynamic framework and is described as the motivation, confidence, physical competence, knowledge, and understanding that provides individuals with the movement foundation for lifelong participation in PA across multiple levels of the program design.

In this study, we conducted a non-randomized controlled trial to examine the feasibility and effectiveness of the intervention. In terms of feasibility, we used Bowen's framework [36], which is a conceptual framework that guides investigators on how to design a feasibility intervention. We focused on three areas to examine the intervention’s feasibility: acceptability, fidelity, and implementation. Concerning the effectiveness of the intervention, we hypothesized that participants in the experimental group, compared to those in the comparison group, would demonstrate larger improvements in PA, parent–child co-activity, family PA routines, and parent PL after receiving the 3-month intervention. To examine the effect of the intervention, all outcomes were measured at baseline and after the intervention.

We conducted a non-randomized controlled trial with one experimental and one comparison group. The protocol of the study was reviewed and approved by the university ethical review committee and prospectively registered at the Chinese Clinical Trial Registry (registration number: ChiCTR2100041903) on 09 January 2021. All methods were carried out in relevance with relevant guidelines.

A power calculation was conducted to estimate the required sample size and the number of families based on the research questions. Calculations were conducted using G*Power 3.1.9.4, with an alpha level set to 0.05 and power to 0.8. Based on previous findings, the expected effect size was set at 0.5 [20]. The total required sample size was calculated to be 128 parent–child pairs. Conservatively, a 20% drop-out rate was estimated from baseline to post-intervention; a total of 160 parents and children was calculated to target as the recruitment sample size. To ensure the representativeness of the sample, we recruited participants from different districts in Hong Kong.

Participants in the study were a subsample of families who have consented to take part in the Fun to Move@JC project [34]. Fun to Move@JC is a school-based multi-component project launched in 2017 with the aim of enhancing the PA of primary school students and their parents. Participants of this project received a pair (one for the student and one for a parent) of wrist-worn PA trackers free of charge. They could also sign up for the project’s extra-curricular activity classes for free. Project schools received support from the project team to create or modify activity-friendly environments for students. Teachers from participating schools also received regular professional development training led by the project team.

We contacted teachers in the project schools (a total of 35 primary schools), asked them to help publicize the recruitment information for the current program. We also posted relevant information on the online platform to recruit participants. In January 2021, participants from 33 local primary schools in Hong Kong responded to our invitation. Parents and children who were from all three districts in Hong Kong (New Territories, Hong Kong Island, and Kowloon) volunteered to sign up to participate in our program.

In the current study, primary school children (i.e., Grade 1 to 6, typically aged 7–12 years) and their father or mother (grandparents or caretakers were excluded) were included. Children and parents with physical or mental disabilities that may influence their PA behaviors and those who are unable to understand and speak Cantonese and/or Mandarin were excluded from the study. Eligible parents received an invitation letter, which introduced the purpose of the study and the intervention components. An online briefing session was conducted to introduce the study design. Parents who agreed to take part in the program returned signed consent forms prior to baseline data collection. In order to establish whether the intervention was feasible and any changes in the outcome could be attributed to intervention components of the sub-study, but not to the parent project, data from families who did not enroll in the current study but participated in the Fun to Move@JC project were used for comparison purposes. These families were invited to complete surveys sent to them via a mobile application developed by the Fun to Move@JC project. Families who provided matching responses at the corresponding time periods as the intervention group was considered the comparison sample.

Guided by the evidence-based behavior change technique that was proposed by Michie et al. [37], the intervention included a series of interactive workshops for parents with activity sessions and PL homework with an informative take-home message. The intervention period lasted three months (between March and June 2021).

The intervention consisted of six 60-min parent workshops that were delivered online. The key topics and descriptions of the workshops are also shown in Table 1, and the workshops were delivered in the same order as they are presented in the table. The aims of the workshops were to 1) provide the informative message to enhance parents’ awareness of PA participation, self-efficacy on PA, and knowledge of PL; and 2) deliver playful activities, resources and instruct FMS that could increase parents’ motivation and competence in supporting their children's PL development and align with co-engagement in PA with children. Based on the elements of the behavior change technique, this was an example of how we operationalized it. For instance, one of the workshops is focusing on time management, the role of parents, and reducing screen time. We used the four behavioral change techniques. With regard to goals and planning, we suggest parents set a goal defined in terms of the behavior to be achieved and with a detailed action plan. We encourage parents to manage family PA time and establish a regular PA routine. To emphasize the role of parents, we used feedback and monitoring techniques to encourage parents' monitoring of behavior and provide informative feedback. We informed parents of the WHO PA guidelines and encouraged them to limit their children’s screen time. For the natural consequences, we provided information about health consequences of the behavior and emphasized the consequences of the behavior with the aim of making them more memorable. In terms of repetition and substitution, we focused on behavior substitution (e.g., suggesting that the person go for exercise rather than watching television in their leisure time) and habit formation (e.g., prompt repetition of the PA behavior on a regular basis until they form a regular PA pattern and a lifelong PL journey).

Furthermore, the intervention design was based on the holistic physical literacy framework focusing on systematically employ four domains of PL. Namely, affective domain (motivation and competence), physical domain (physical competence), cognitive domain (knowledge and understanding), and behavioral domain (engagement in physical activities for life). By combining theory with practice, parents can not only understand the knowledge and information related to physical literacy but also deepen their understanding of activities and transfer the knowledge to their future daily lives.

Workshops were delivered in real-time online due to the COVID-19 pandemic and to reach participants scattered in various districts in Hong Kong simultaneously. Parents who were in the experimental group attended the workshops biweekly via Zoom, a video conferencing service. Some parents reviewed the full workshop content with recorded videos if they were not able to attend the workshop through the live streams. The recorded videos were shared with parents after each workshop via WhatsApp (the most popular social networking application in Hong Kong). Each parent workshop was divided into two sections, a 20-min knowledge sharing and education session and a 40-min activity session. At the end of each workshop, parents were invited to share their insights and suggestions. The knowledge sharing and education sections in the workshops were delivered by the lead researcher, who had both theoretical knowledge and practice experience in the development of PL and PA interventions [20, 38, 39], parent education techniques [20], and community-based PA promotion [34]. Activity sessions were embedded in the workshops to enable learning and sharing in a more relaxed manner. Activity sessions for each topic were led by the coaches who held degrees in sports science or physical education. All the coaches have the basic knowledge and experience of PE teaching who led the interactive activity sessions to enable parents to understand the knowledge in practice. Parents learned movement patterns and exercises under the instruction and monitoring of the coach. Similar to in-person instruction, coaches provided key points to complete motor skill and encouraged parents to participate in the activity session. The workshop content was designed and developed by the lead researcher and research team using evidence-based behavior change techniques [37] and recommendations from previous literature in PL development [30, 40]. Furthermore, parents' preferences, suggestions, and other real needs were received via an online survey prior to the program's implementation. The workshops were tailored and developed to cater to the needs of parents.

Apart from intervention delivery via workshops, parents were given electronic worksheets after each workshop. The worksheets echoed the theme of the workshops and were designed for two objectives, namely self-learning and self-monitoring. Specifically, the worksheet covered the essence of each workshop for parents to review as a take-home message and encouraged parent–child PA, setting daily/weekly goals and reporting and reflecting on the relevant PA and/or FMS performed each day/week. Parents were asked to complete worksheets and submit them via WhatsApp.

In addition, to attract parents to attend the workshops, each workshop session was titled to a topic that is of interest to parents of primary school students. To avoid parents dropping out due to workshop contents being over technical or theoretical, workshop contents focused on practical tips on how parents can help children and themselves improve FMS and fitness, sustain PA behaviors, and, more generally in improve health and well-being. Besides, to enhance parent engagement and adherence, digital notifications and reminders were sent on a regular basis. After the intervention, in order to encourage and reinforce the knowledge and activities that parents have learned throughout the intervention and to apply and sustain the active routines in the future life, each participating family received a certificate, parent–child sports T-shirts, and portable exercise equipment to maintain active lifestyles and develop PL.

IBM SPSS 24.0 (SPSS Inc, Illinois, USA) was used for all statistical analyses. To evaluate the intervention effects on measured outcomes, we followed the intention-to-treat principle for the participants. To deal with missing data, the last observation carried forward approach was used to combine the observed and imputed data then to analyze in order to conform to an intention to treat analysis [45]. We used random intercept, random slope linear mixed models to evaluate the effectiveness of the intervention between time, group, and groups over time. Specifically, the significance of the Time*Group terms in the regression models was examined. A significant Time*Group term would imply the existence of an intervention effect. The analyses were conducted for changes from baseline to post-intervention.

We found no Time*Group interaction effects for parents’ daily steps (B = -334.46, 95% confidence interval (CI) [-1096.00, 427.08], p = 0.39) and time spent in MVPA (B = -2.95, 95% CI [-7.54, 1.64], p = 0.21). Moreover, children’s daily steps (B = 316.33, 95% CI [-943.30, 1575.96], p = 0.62) and MVPA (B = -1.13, 95% CI [-5.65, 3.40], p = 0.62) suggested no Time*Group interaction effects from Times 1 to 2.

A significant Time*Group effect in favor of the experimental group was found for parent–child co-activity from Times 1 to 2 (B = 0.17, 95% CI [0.08, 0.27], p < 0.001). In terms of family routines, no Time*Group interaction effects were found for PA routine (B = -0.01, 95% CI [-0.09, 0.08], p = 0.90) or Co-PA routine (B = 0.03, 95% CI [-0.05, 0.11], p = 0.44) from Times 1 to 2. With regards to parent perceived PL, the Time*Group interaction effect was significant in favor of the experimental group from Times 1 to 2 (B = 0.16, 95% CI [0.08, 0.24], p < 0.001).

The participating parents expressed relatively high satisfaction after they attended the workshops. Each question in each session scored more than 4 out of a total of 5 (Table 4). The average score for the acceptability of the workshop was 4.33. Parents were most satisfied with the speaker’s sharing, while they were least satisfied with the overall arrangement of the workshop.

For the fidelity of the intervention, parents in the experimental group averaged an attendance rate of 73% for workshops and activity sessions. The parents who did not attend gave reasons for their absence including working overtime, staying home to care for younger children, illness, and time conflict. Parents who were absent from the workshops were provided with video clips of the workshops recorded. An average of 81% of parents reviewed the recordings after the workshops. In terms of the learning materials, we received 149 copies (i.e., 66.5% of parents submitted the worksheets) from the parents and provided individual feedback and encouragement to parents. Parents also shared photos and videos about home-based/outdoor activities via WhatsApp.

With regard to the acceptability of the program, participants provided positive feedback (i.e., score of above 3.5) on all intervention components (Table 5). One hundred fifty-two participants responded to questions about intervention acceptability. Their satisfaction with the whole program was evaluated from the arrangement, schedule, contents, information, learning materials, and mode. Moreover, 152 parents responded to the psychological and behavioral change after the intervention. Namely, knowledge of PA and PL, proficiency of FMS, motivation to participate PA, and frequency of co-participation in PA with their children. Of these, the worksheet was the most feasible as one component of the intervention.

Moreover, participants responded to two open-ended questions regarding their experience and suggestions to the program. With regard to the question of “which part of the workshop you are most satisfied with”, the majority of parents (64.47%, 98 out of 152) were most satisfied with the coaches. Besides, parents expressed their satisfaction with the interactive activities (59.87%, 91 out of 152), the speaker's sharing (54.61%, 83 out of 152), and the online delivery mode (47.37%, 72 out of 152). Furthermore, 70 parents provided feedback regarding the suggestions for program improvements. Among them, 27 parents suggested that the workshops could be arranged on weekends and longer in the duration of each workshop. In addition, parents also expressed that although online workshops were flexible, they expected to attend face-to-face workshops, outdoor activities, and parent–child interactive activity sessions. Besides, parents commended that the learning materials could be shared through online platforms, which would be more interactive and convenient.