Rationale and study protocol for the supporting children’s outcomes using rewards, exercise and skills (SCORES) group randomized controlled trial: A physical activity and fundamental movement skills intervention for primary schools in low-income communities

The SCORES intervention will be evaluated using a group randomized controlled trial (Figure 1). The 12-month multi-component PA and FMS intervention will target children in grades 3 and 4 (ages 7 to 10 grades) in eight primary schools. Assessments were conducted at baseline [February–March (Term 1) 2012], and will be repeated mid-program [August–September (Term 3) 2012] and at 12-months post baseline [February–March (Term 1) 2013]. The design, conduct and reporting of this group RCT will adhere to the Consolidated Standards of Reporting Trials (CONSORT) guidelines for group trials [41]. Ethics approval for this study was obtained from the Human Research Ethics Committees of the University of Newcastle, Australia and the New South Wales (NSW) Department of Education and Communities. School Principals, teachers, parents and study participants provided written informed consent.

The Socio-Economic Indexes for Areas (SEIFA) index of relative socioeconomic disadvantage was used to identify eligible primary schools. The SEIFA index (scale 1 = lowest to 10 = highest) summarizes the characteristics of people and households within an area and was developed using the following data: employment, education, financial well-being, housing stress, overcrowding, home ownership, family support, family breakdown, family type, lack of wealth (no car or telephone), low income, Indigenous status and foreign birth. Sixteen government primary schools located within 30 minutes drive from the University of Newcastle, with a SEIFA index of ≤ 5 (lowest 50%) were invited to participate in the study and eight schools consented to participate (50% consent rate). All students in grades 3 and 4 (Stage 2) at the study schools were invited to participate in the program. From the 592 eligible children at the eight schools, 460 children consented to participate (78% consent rate).

Power calculations were conducted to determine the sample size required to detect changes in the three primary outcomes [i.e., PA, cardiorespiratory fitness (CRF) and FMS] at the 12-month assessments. All calculations assumed baseline-posttest correlation scores of 0.80 and were based on 80% power with alpha levels set at p < 0.05. Using the standard deviation (SD = 33) and intraclass correlation coefficient (ICC = 0.05) values from the Kinder-Sportstudie (KISS) [42], it was calculated that a study sample of N = 440, with 8 clusters (i.e. schools) of 55 students would provide adequate power to detect an achievable between group difference of 11 moderate-to-vigorous physical activity (MVPA) minutes/day [42]. Based on data from the Action Schools BC! (SD = 13) [43] and the KISS (ICC = 0.03) [42] studies, a sample of 440 would also provide adequate power to detect a between group difference of 4 laps on the multi-stage fitness test (i.e., CFR outcome). In the absence of existing ICC values for FMS outcomes, an ICC estimate of 0.05 and a SD of 15 units [44] indicated that the study would be adequately powered to detect a between group difference of 5 units on the TGMD-II gross motor quotient.

Baseline assessments were conducted prior to randomization by trained research assistants. The intervention will be evaluated using a group RCT-design and schools were randomly allocated to the control or intervention groups for the duration of the study. Schools were match-paired based on their size and SEP (based on post-code of school) then randomly allocated to the intervention or control group using a computer-based random number producing algorithm by a researcher not involved in the current study. This method ensured that schools had an equal chance of allocation to each group.

SCORES is a 12-month multi-component PA and FMS intervention for primary schools in low-income communities (Figure 2). The socio-ecological model [45] provided a framework for the intervention components. Within this framework, behavior change strategies were guided by Self-Determination Theory (SDT) [46, 47] and Competence Motivation Theory (CMT) [48, 49]. SDT proposes that social-contextual factors (e.g., motivational strategies used by teachers and parents) can influence individuals’ motivation and subsequent behavior by satisfying three basic psychological needs: 1) Autonomy, the need to experience one’s behavior as self-endorsed or volitional; 2) Competence, the need to effectively interact with one’s environment and achieve positive outcomes; and 3) Relatedness, the need to feel supported and connected with others [46, 47]. SDT has been used extensively with adolescents in PE-based research [50‐53] and evidence suggests that students who feel self-determined are more engaged and more active in PE lessons [51, 52]. In the context of PA promotion, CMT provides a theoretical link between FMS competence and PA [48]. While CMT includes competence and a construct similar to SDT’s relatedness (social support), it differs in its focus on enjoyment and includes global self-esteem as a predictor of behavior. Our integrated model proposes that children who have high levels of perceived and actual athletic competence, receive social support from significant others and feel a sense of control over their PA experiences will enjoy PA and seek opportunities to be active in the future.

The SCORES intervention will be implemented in three phases. Phase 1 will focus on teacher professional learning, student workshops, provision of equipment and the establishment of a school committee. In Phase 2, the research team will work with the school committees to advocate for relevant policy change to promote PA and FMS. In addition, the research team will employ a range of strategies to engage parents and encourage them to support their children’s PA. Phase 3 will address strategies to improve school-community links (e.g., inviting local sporting organizations to assist with school sport programs). The focus of this phase will be program consolidation and the research team will work with schools to establish sustainability. The intervention components are detailed in Table 1 and a description of how the socio-ecological framed intervention will facilitate behavior change at the individual, interpersonal, organizational and community levels is provided below:

Interpersonal: The SCORES intervention will target teachers, parents and the students themselves as facilitators of behavior change. The teacher professional learning workshops will provide opportunities for non-specialist PE (i.e., classroom teachers) to improve their teaching skills and knowledge in regards to PA promotion and FMS development. The workshops were guided by SDT and CMT and will be used to reinforce the SAAFE (Supportive, Active, Autonomous, Fair and Enjoyable) teaching principles, which were developed for the study and are described in Table 2.

Parents will be engaged using the following strategies: a) newsletters describing intervention progress and encouraging PA and FMS practice, b) weekly FMS homework (using FMS activity cards to be completed by children at home under parental supervision), and c) a parent information evening focusing on parental strategies to promote PA and FMS development outside of school setting. Finally, students who have gained SCORES accreditation will be responsible for organizing recess and lunch-time physical activities for other students in the study schools.

Organizational: The research team will work with the schools to implement evidence-based policy and practice that is supportive of all students’ PA. The specific PA policies are provided in Table 1. A school committee will be established to guide a review of existing school policy and the implementation of new policies. The research team conducted an audit of each school’s equipment and resources. Intervention schools will be provided with PA equipment (e.g. bats, balls etc.) to support PA promotion, based on their individual requirements.

Control group: To prevent potential compensatory rivalry and resentful demoralization [54], the control schools will be provided with a condensed version of the program following the 12-month assessments. The condensed version of the program will include the professional learning workshops for teachers and students, strategies to engage parents and a review of school PA policy will be conducted. A PA equipment pack valued at approximately $1000 AUD (including pedometers, bats, balls, cones, goals etc.) will also be provided based on individual school requirements.

Baseline assessments were conducted by trained research assistants at the study schools. Mid-intervention (6-months) and post-intervention (12-months) assessments will also be conducted at the study schools. For consistency and accuracy, a protocol manual, which includes specific instructions for conducting all assessments, was developed and will be used by research assistants. Questionnaires were completed before the physical assessments in exam-like conditions and physical assessments were conducted in a sensitive manner (e.g., weight measured in a discreet, private setting). Demographic information including age, gender, ethnicity, language spoken at home and mother/father’s highest level of school was collected at baseline. A range of primary and secondary outcomes and hypothesized mechanisms of behavior change will be measured.

A poor understanding of the mechanisms of behavior change in PA interventions has been noted in the literature [65, 66]. Students, parents and teachers will complete a range of scales assessing individual and socio-environmental level mediators of PA behavior change.

A range of process data will be collected to complement the outcome data. Process measures will include i) teacher and student attendance at workshops (i.e., percentage attendance), ii) student leadership accreditation (i.e., number of students who complete the workshop and satisfy the accreditation guidelines), iii) teacher satisfaction with professional learning workshops (using workshop evaluation questionnaires at the end of Phase 1), iv) parental involvement will be determined using a process evaluation questionnaire (e.g. reading newsletters and completion of home-based FMS tasks) and attendance at the parent evening, v) teacher, student and parent satisfaction with all intervention components (using process evaluation questionnaires at the completion of the study), vi) compliance with PA policies will be determined through interviews with school Principals, vii) PE intervention fidelity will be determined (using SOFIT observations). PE lessons will be observed at baseline, 6- and 12-months using the System for Observing Fitness Instruction Time (SOFIT) tool [72]. Percentage of lesson time spent in MVPA and time dedicated to skill development will be assessed. All teachers of Stage 2 students (both intervention and control groups) will be observed at each time point.

The study will be adequately powered to detect clinically important changes in the three primary outcomes at the 12-month assessments. Statistical analyses of the primary and secondary outcomes will be conducted using linear mixed models with PROC MIXED in SAS V 9.1 (SAS Institute Inc, Cary, NC) and alpha levels will be set at p < 0.05. The mixed models will be specified to adjust for the clustered nature of the data and will follow the intention to treat principle. Potential moderators of the intervention effects (e.g., ethnicity, socio-economic status and type of school) will be explored using linear mixed models. Differences between participants in the intervention and groups at baseline and differences between completers and those who drop out of the study will be examined using Chi square and independent samples t-tests in PASW Statistics 17 (SPSS Inc. Chicago, IL) software. Hypothesized mediators of PA behavior change will be examined using multilevel linear analysis and a product-of-coefficients test that is appropriate for cluster randomized controlled trials [73].