Evaluation of a voucher scheme to increase child physical activity in participants of a school physical activity trial in the Hunter region of Australia

The health benefits of physical activity during childhood and adolescence are well documented and include improvements in blood pressure, metabolic syndrome, adiposity, skeletal and mental health and psycho-social wellbeing [1]. Despite this, global population data suggest that physical activity levels in childhood remain unacceptably low, with between 15 and 38% of children aged 5–12 years meeting physical activity guideline recommendations in countries such as Australia [2], the United States (U.S.) [3] and the United Kingdom (U.K.) [4]. Additionally, it has been reported that 81% of adolescents (11–17 years) globally do not meet the World Health Organizations (WHO) global recommendations on physical activity [5].

Improved participation in organised sport has been recommended by the WHO ‘Global Action Plan on Physical Activity 2018–2030’ [6] as one strategy to improve population levels of physical activity, and one that may also accrue a range of other positive psychosocial outcomes for children [7]. Analysis by the Active Healthy Kids Global Alliance of data from 38 countries across six continents, for example, reported that just 40–59% of children participate in organised sport, providing considerable scope for improvement [8]. Research suggests that while there are a number of barriers to youth sports participation, cost of participation is frequently cited [9‐13].

Government policies and programs to reduce the financial burden of organized sports participation has been recommended to improve community engagement in physical activity [14]. Accordingly, governments have introduced policies and programs supporting the introduction of financial incentives and/or vouchers for organized sports participants. Rigorous assessment of the effects of such government programs, however, represents a considerable challenge [15, 16]. Programs may be introduced before baseline measures to assess impact can be undertaken and the use of control groups is often unfeasible for the population wide schemes. Evaluations of public health policies and programs are often not undertaken, and when they are, may be opportunistic, and seek to undertake the most rigorous evaluation possible given the constraints of the practice based evaluation [15, 16].

As such, reviews have identified only a handful of evaluations of financial schemes to improve physical activity [17, 18]. A review by Molema and colleagues (2016) investigating the effectiveness of financial incentives in the healthcare setting to improve physical activity levels, found only three studies, one of which provided a free sports facility membership, one provided vouchers for one leisure centre activity and the third involved a six week exercise schedule [18]. The authors suggest the identified studies are largely of poor quality/design and the outcomes suggest that the impact is small and short term [18]. Another financial incentive example is the Canadian Child Fitness Tax Credit (CFTC) [19] which was introduced to assist families with the costs of registering a child under the age of 16 years in organized physical activity programs, providing a tax credit of $75 per eligible child [19]. Evaluation of the initiative of 1004 parents with children aged 2–18 years, found just over half (55.5%) of parents were aware of the CFTC and only a quarter (26.1%) claimed the CFTC in 2007 [19]. Furthermore, approximately half of parents (54.4%) surveyed stated their child was enrolled in organized physical activity and of those who claimed the CFTC in 2007, only 15.6% agreed the CFTC had increased their child’s participation in organized physical activity [19]. The results of the study also indicated that wealthier families appeared to have benefited more from the tax credit scheme than lower income families [19].

In Australia, several states and territories have introduced voucher schemes to improve physical activity levels for various target populations including youth, women and girls and disadvantaged and remote communities [20]. Whilst uptake of such voucher schemes appears to be substantial, rigorous evaluation of impact on child physical activity is lacking [20]. A recent study (2020) [20] found Australian parents report a median annual expenditure for child physical activities of $447 (IQR $194.2–936). The median voucher value across the five out of eight Australian State and Territories who have implemented a voucher scheme was found to be AU$150 per annum (range AU$50–200 per annum) [20]. In New South Wales (NSW), a state with a geographical and socio-economical diverse population (40% of the state’s population live in regional areas) of approximately eight million people, the state government introduced the Active Kids (AK) scheme in 2018. The AK scheme is a four year investment of greater than $200 million, to help families across the entire state meet the cost of getting children into organized sport and recreation activities [21]. The AK scheme aims to reduce the financial barrier to child organized sport participation and help increase the physical activity behaviours of children 4.5 to 18 years of age. In 2018, parents/carers of school-enrolled children in NSW were able to register for one $100 AK voucher valid for redemption throughout the calendar year, which was only to be claimed through an online government platform. Vouchers can only be redeemed through an accredited provider authorised by NSW government. Physical activity providers eligible to register as an ‘accredited AK provider’ are those that provide activities including participation in moderate intensity organised sport, lasting a minimum of eight weeks. This includes sporting clubs and associations affiliated with a recognised State Sporting Organisation located in NSW, and for-profit and not-for-profit activity providers in NSW.

The introduction of AK in NSW represents the largest investment by a state government in Australia to date to improve child organized sport participation [21]. Given considerable investments by governments, there is a need for pragmatic, population-level program evaluations to assess the impact of population organized sport and physical activity population programs, like that which is underway in NSW [21]. During the first year of the AK scheme we undertook an opportunistic study to assess the potential impact of the NSW AK scheme in the Hunter region of NSW in a large group of schoolchildren who had previously participated in a child school-based physical activity randomised control trial [22]. Specifically, the research team sought to; i) describe the reach, uptake and use of AK by child demographic characteristics, previous organized sport participation and physical activity levels; ii) describe parental/carer attitudes towards the AK scheme; iii) and assess the impact of the AK scheme on organized sport participation and child physical activity in the Hunter region of NSW, Australia.

This study assessed the potential impact of the NSW AK scheme in the Hunter region of NSW among a sample of children that had previously participated in a trial of a healthy eating and physical activity intervention. The study found that voucher registration and use was ubiquitous in this sample, parents/carers were highly supportive of the scheme, and that those that redeemed the voucher had three times the odds of organized team sports participation than those that did not. Almost 90% of parents/carers indicated that they would register their child in organized sport without the voucher, an important characteristic of the sample, suggesting very high physical activity levels of children in this group. Additionally, there were no significant differences in changes in child physical activity among those that redeemed and did not redeem a voucher. Nearly three quarters of parents/carers reported their child’s physical activity had stayed the same with redemption of the voucher. These figures are similar to those reported by Spence et al. (2012) regarding the Canadian CFTC where only 15.6% agreed the CFTC has increased their child’s participation in organised physical activity [19]. Unsurprisingly, the majority of vouchers were redeemed in the first half of the year, soon after the scheme was released, a period when registrations occur for both summer and winter sports.

Previous research has suggested tailoring schemes to increase child physical activity on factors such as low family income, living regionally or remotely, having Middle-Eastern Asian cultural background and female gender [12, 31]. Our data does not substantiate all these, however there is some suggestion from our data that targeting low physically active children may be beneficial. There appears to be a positive, albeit non-significant, impact of the AK scheme on these children in our sample. Whilst a voucher scheme such as the AK may address some barriers to sports participation in identified groups, further barriers such as lack of access to facilities and sporting groups, and travel/transport may need to be addressed to increase the effectiveness of a stand-alone financial incentive.

A further unique characteristic of the study sample was the physical activity levels of children. The majority of parents/carers (89%) in this study reported their child met the physical activity guideline of a minimum of 60 min per day prior to the AK launch, suggesting a ceiling effect, where irrespective of the voucher, there was little room for improvement in child measures of physical activity. The high levels of child physical activity is likely to reflect the children’s participation in the prior successful school-based physical activity program, or selection bias. The unexpectedly high rates of reported child physical activity, coupled with high AK voucher redemption reduced study variability and power to undertake statistical analyses of associations, despite a relatively large study sample. It has also increased the risk of regression to the mean, which may explain the magnitude of the absolute reduction in measures of physical activity change over time. While such limitations are common in opportunistic and pragmatic policy evaluations [15], further research in other jurisdictions which address them is warranted to verify the study findings. Whilst children in this study were already physically active, the role of organised sport and the additional social and emotional benefits these sports can bring [7], provides opportunity for the AK scheme amongst these children.

Whilst AK has achieved population reach across NSW substantially supporting the financial costs towards organized sport and physical activity participation, inequalities exist within program reach and voucher use. Such findings reflect a substantial proportion of children living in disadvantaged areas have not engaged with the program, with parents/carers in the most disadvantaged quartile twice as likely to have never heard of the AK scheme and more than twice as likely to have registered for a voucher but not redeemed a voucher compared to the least disadvantaged quartile [32]. These results compare to those from the Canadian CFTC study which found 28.2% of parents in the lowest income quartile claimed the CFTC compared to 55% in the highest income quartile [19]. The findings from the current study demonstrate the high levels of population wide awareness and uptake of the AK scheme, however, further targeted work is required to increase the awareness and engagement in AK amongst socially disadvantaged groups.

Additionally, all participants in this study were previously recruited to a study involving school based physical activity strategies to increase child physical activity whilst at school [22]. This pre-existing trial may have already induced changes to child physical activity and sport participation during school. Parents/carers appeared to participate in the scheme for economic reasons, as a cost subsidy, in this already active group of children. These differences raise the issue of external validity across the state (NSW) as a whole and highlights the challenges in undertaking opportunistic regional evaluations of large-scale initiatives to improve population levels of physical activity. On a positive note, parents/carers reported it was easy to access a sporting group and redeem the voucher and perhaps unsurprisingly, supported the continuation of the voucher. Almost no parents/carers however reported registering for a voucher to encourage their child to be more physically active (n = 5, 1.2%).

The study findings need to be considered and interpreted in the context of methodological shortcomings. Potentially most profound was the opportunistic use of a research panel. The boutique nature of the research panel limits the external validity of the study findings and may explain, in part, a number of unexpected findings. The study sample comprised participants who had previously participated in a physical activity intervention [22], and whose parents/carers were far more educated (52% with a University degree/Advanced education) than the study region (Hunter region) (11%), and NSW more broadly (23%) [33]. Children in this sample were also reportedly more physically active with 89.0% meeting guidelines compared to 31.7% of those in the study region and 24.2% in NSW [34]. More than half (54%) of the eligible NSW population registered for an AK voucher in 2018, with a state redemption rate of 81.9% [35]. Once again the redemption rate in this sample is higher than the state at 96.0% (407 out of 424 participants who registered for an AK voucher).

There are a number of limitations alongside lack of generalisability that are worth noting. This sample included only primary school age children, as research suggests that adolescent’s physical activity participation is likely to be lower, the impact of AK may also be different in this age group. Child physical activity levels were parental-reported, not objectively measured. Further, we did not split analyses of physical activity levels into in-school and out-of-school activity, limiting the identification of when children are choosing to be active. Therefore, to gain a better understanding of the impact of AK on child and adolescent physical activity levels, further research across all age groups, with the inclusion of objectively measured physical activity, such as the use of accelerometers, separating in-school and out-of-school activity is recommended. Strengths of the study include its relatively low rate of attrition and the use of a longitudinal study design, including pre-AK scheme data collection, capturing comprehensive information to assess a range of aspects of the AK scheme.

This study aimed to understand the sport and physical activity behaviours of children in the Hunter region, including their awareness and uptake of the NSW government AK scheme. Whilst most of the sample of children within this study already achieved recommended levels of physical activity, those who redeemed a voucher were slightly more likely to participate in organised individual and team based activities. AK also provides a unique platform to learn more about the participation behaviours of children and adolescents and through the consistent standard metrics of the program evaluation, comparisons can be made across the state. Given the already active nature of this sample, no significant improvements in physical activity levels were noted, but the positive contribution community sport can have on the health and wellbeing outcomes amongst children and young people is reinforced. Whilst voucher schemes can help address financial barriers, and are highly supported by parents/carers, future direction should address targeting these vouchers to populations that are culturally diverse, inactive, and disadvantaged to better promote health and physical wellbeing.