THE ROLE OF PARENTAL AND BUILT
ENVIRONMENT FACTORS TO EXPLAIN
PHYSICAL ACTIVITY IN 10-12 YEAR
OLD CHILDREN IN PORTUGAL.
Word count (TOTAL): 15,939
Elizaveta Fomenko
Student number: 01000021
Supervisor: Prof. Dr. Delfien Van Dyck
A dissertation submitted to Ghent University in partial fulfilment of the requirements for the degree of Master of Science in Health Education and Health Promotion
TABLE OF CONTENTS
BACKGROUND ... 2
METHODS ... 5
PARTICIPANTS ...5
MEASURES ...6
Demographic and anthropometric variables ...6
MVPA and active recreation ...6
Perceived environment ...6
Parental factors ...7
ANALYSES ...8
RESULTS ... 8
DESCRIPTIVE CHARACTERISTICS ...8
MODERATING EFFECT OF PARENTAL FACTORS IN THE RELATIONSHIP BETWEEN ENVIRONMENTAL FACTORS AND PA ...10
MODERATING EFFECT OF BMI IN THE RELATIONSHIP BETWEEN ENVIRONMENTAL FACTORS AND PARENTAL FACTORS AND PA ...11
MODERATING EFFECT OF THE PUBERTAL STAGE IN THE RELATIONSHIP BETWEEN ENVIRONMENTAL FACTORS AND PARENTAL FACTORS AND PA...12
DISCUSSION ... 13
CONCLUSION ... 16
REFERENCES ... 16
TABLES
Table 1: Content of the perceived environment factors ...7Table 2: Content of the Parental Support factor ...7
Table 3: Descriptive characteristics of the sample ...9
Table 4: Moderating effects of parental factors in the relationship between environmental factors and PA ...10
Table 5: Moderating effect of BMI in the relationship between environmental factors and PA ...11
Table 6: Moderating effect of BMI in the relationship between parental factors and PA ...12
Table 7: Moderating effect of the pubertal stage in the relationship between environmental factors and PA ...12
Table 8: Moderating effect of the pubertal stage in the relationship between parental factors and PA ...13
2
ABSTRACT
BACKGROUND: This study aims to investigate the moderating effect of parental factors in the relationship between perceived physical environmental factors and 10-12 year old Portuguese children’s physical activity (PA). Furthermore, the moderating effect of the BMI and pubertal stage in the relationship between parental and perceived physical environmental factors and PA was examined
METHODS: In total, data from 547 children and their parents were included in this cross-sectional study. An accelerometer was worn for a minimum of 4 consecutive days, children completed a questionnaire (PEACH Project, University of Bristol) concerning the perceived physical environmental factors, such as accessibility and safety, parental support and factors for active recreation, such as the frequency of active play and sport. The IPAQ-SF was
completed by the parents to asses parental modelling. Multiple moderated linear regression analyses were used to solve the research questions. The analyses were conducted in SPSS and significance was set at p<0.05. Also borderline significant results (p<0.10) were reported. RESULTS: Out of 24 investigated interactions, only 5 weak significant interactions were found. Parental support correlated significantly with more PA for everyone, independently of the children’s BMI or pubertal stage. Traffic safety was also found to correlate positively with PA. CONCLUSIONS: No convincing interacting-effects were found. Future interventions should therefore work with the whole group of 10 to 12 year old children, independently of their BMI or pubertal stage and focus on increasing parental support and the perception of traffic safety. KEYWORDS: Child, Parents, Neighborhood, Interactions, Physical activity, BMI, Pubertal stage
BACKGROUND
When talking about physical activity (PA), the WHO (2018) starts with a strong key fact stating that insufficient PA is one of the leading risk factors for death worldwide. “People who are insufficiently active have a 20% to 30% increased risk of death compared to people who are sufficiently active.” As this study will focus on children from 10 to 12 years old, the recommendation for PA is a daily 60 minutes of moderate to vigorous-intensity physical activity (MVPA). Sadly, only 36% of 10 and 11 year old Portuguese children achieve this recommendation (Baptista et al., 2011).
Previous research clearly showed that PA is important for health and quality of life in children. Many consequences of physical inactivity during childhood are only revealed when reaching adulthood, such as cardiovascular diseases, type II diabetes and skeletal health or
3 osteoporosis (Biddle, Gorely & Stensel, 2007). It is also known that physical inactivity during childhood increases the chances of being inactive during adulthood. This makes it very important to focus on PA of young children (van Sluijs, McMinn & Griffin, 2007). Another, more direct consequence of insufficient PA is even more alarming. PA helps maintaining a healthy body weight (WHO, 2018) by increasing the energy expenditure. A report from 2017 (Rito, Cruz de Sousa, Mendes & Graça) showed that there was a total of 20,7% overweight and 13,2% obese children in the Northern region of Portugal. In other words, 1/3th of the children are carrying excess weight. Such a high prevalence can only emphasise the importance of PA even more, making it a key factor to fight this currently growing health problem (Lobstein et al., 2004). Especially when knowing that insufficient PA-levels and obesity lead towards a vicious circle, as obesity makes it even more difficult to be physically active (Pietiläinen et al., 2008).
To achieve an increase in PA it is necessary to identify the right determinants that may lead to exactly that in future interventions. Children between 10 and 12 years old have many ways to be active, of which active play and sport seem to be the most common ways in Portugal. However, there is a general decreasing trend in active play and sport through time. This is one of the reasons for the higher prevalence of physical inactivity (Clements, 2004). Finding ways to stop this downward movement and increase active play and sport once again could be a good idea to improve PA-levels. Ecological models are frequently used to picture the different determinants of PA. For this study, the ecological model of the four domains of active living (Sallis et al, 2006) is used as a reference. This model explains PA through individual as well as environmental factors, and further categorizes the determinants into specific layers of the model (intrapersonal, perceived environment, behaviour, behaviour settings and policy environment). The model also takes into account the determinants that cross different layers at the same time (information environment, social cultural environment and natural environment). Up until now, many of those categories have been thoroughly investigated in relation to PA, such as the social cultural environment, with especially the parents’ role on their child’s active recreation and the effects of the neighbourhood environment concerning the children’s PA.
According to review studies it can be assumed that parents have quite some influence on their children before their puberty starts to hit in. This makes it interesting to focus on those variables for children from 10 to 12 years old, just before their puberty (McMinn, van Sluijs, Wedderkopp, Froberg & Griffin, 2008; Edwardson & Gorely, 2010; Bradley, McRitchie, Houts, Nader & O'Brien, 2011). Parental modelling and parental (motivational and instrumental) support, both associate positively with the children’s PA (Trost et al, 2003; Griffith et al., 2007; McMinn, et al., 2008; Edwardson & Gorely, 2010; Bradley et al., 2011). Parental support is the stronger
4 determinant (Yao & Rhodes, 2015) as it increases the child’s self-efficacy (Trost et al., 2003), which in turn is a strong predictor of PA (Lubans, Foster & Biddle, 2008).
There is also a growing interest for built environment factors in function of PA. Before discussing the different variables, it is important to explain the difference between the perceived or subjective environment and the objective environment. To assess the perceived environment, self-reports are used. To assess the objective environment, on the other hand, objective indicators, such as objective geographical data of a neighbourhood (Sallis et al., 2006) are used. For this study, the choice was made to focus on the perceived environment, as perceptions are easier to influence and change. According to Carroll-Scott et al. (2013) the perceived environment might even play a stronger role than the objective walkability of the neighbourhood, specifically for middle school children. One of the most frequently discussed factors is accessibility, more specifically easy access to recreational facilities (e.g. parcs, playgrounds and sport centres), and is positively correlated to PA (Roemmich et al., 2006; Wheeler, Cooper, Page & Jago, 2010; An, Shen, Yang & Yang, 2019). The same can be stated for access to public transportation, increasing the accessibility range even more (Davison & Lawson, 2006). While accessibility is crucial, its importance can be undermined by a lack of safety. There is a positive correlation between good traffic safety and the children’s PA (Davison & Lawson, 2006; Lin et al., 2017; An et al., 2019). Similar associations were found between personal safety, such as stranger danger and perceived crime rates, and PA (Carver, Timperio & Crawford, 2008; Lin et al., 2017; An et al., 2019). Both of them, traffic and personal safety, seem equally important predictors of PA (Molnar, Gortmaker, Bull & Buka, 2004).
While it is now clear that different determinants play a role in children’s PA and active recreation, the same results are not always found in every study. One of the reasons could lie in the fact that some of those determinants interact with each other. Only a few studies previously examined these moderating effects, of which only one included children. In that study from D’Haese et al. (2016) the moderating effect of psychosocial factors (including parental support) in the relationship between walkability and PA was explored. Seven of the examined interactions showed to be significant, but had a very small effect size and not all showed the same direction. The hypothesis that the walkability relates stronger to PA among children with a negative psychosocial profile could not be confirmed. Parental support and parental attitude even showed to be completely on the opposite of this hypothesis. Consequently, the first aim of this study will be to continue the search of moderating effects of parental factors on the association between perceived physical environmental factors and recreational PA. For example, it is possible that accessibility is related to higher active recreation levels, only for children with low parental support or vice versa. Finding interacting
5 effects could lead towards finding the right combination of factors for future interventions, promoting PA in children.
The second aim of this study concerns the high prevalence of overweight and obesity in children in Portugal. The importance to fight this growing health problem cannot be underlined sufficiently as being overweight is found to be an important risk factor for many diseases (van Sluijs et al, 2004). By analysing the moderating effect of the children’s BMI on the association of environmental and parental factors with recreational activity, the strongest correlates of PA for overweight and obese children might be found. This could lead towards more effective and tailored interventions targeting this growing group of overweight children.
The third and last aim of this study will be to examine the moderating effect of the children’s pubertal stage in the association between environmental and parental factors and recreational activity. Literature seems to suggest its importance for parental factors, as parental support and parental modelling start losing their positive effect on children’s PA during puberty (McMinn et al., 2008; Edwardson & Gorely, 2010; Bradley et al., 2011). The moderating effect of the children’s pubertal stage on the association between the perceived physical environmental factors and PA, however, has not been examined before.
METHODS
Middle school children (aged 10-12 years), as well as their parents, from the Porto area, Portugal, were invited to participate in the SALTA Project (Environmental Support for Leisure and Active Transport). Ethical approval for this project was obtained from the Faculty of Sports ethics committee, the Foundation for the Science and Technology and by the regional section of the ministry of Education (Santos et al., 2013). This study, being a small part of the project, uses only a section of the collected cross sectional data.
PARTICIPANTS
All 65 public middle-schools in Porto area were invited to take part in the study by letter, email or telephone. Fifty schools declined to participate and 6 others were not included due to a lack of resources and communication failure. Data were collected in 9 middle schools (school-level response rate 14%), with a total of 652 children (individual-level response rate 36%) who agreed to participate and had parental written informed consent to take part in the study. Seventeen participants were not eligible due to collecting errors and 88 participants were older than 12, leaving a total of 547 children, all included in the analyses.
6 MEASURES
Demographic and anthropometric variables
Demographic data including age and gender were obtained through a self-completed questionnaire. Anthropometric measurements were taken with the SECA 206 Bodymeter Measuring Tape (SECA, Hamburg Germany) for the height (cm) and the digital TANITA BF-522W scales (TANITA, Tokyo, Japan) for the weight (kg). Body mass index (BMI) was calculated as weight (kg) / height² (m²). Cole and Lobstein’s (2012) sex- and age-specific BMI cut points were used to define BMI categories (thinness, normal weight, overweight and obesity). To determine the pubertal stage of the participants, the children were asked to self-determine their pubertal stage using the pattern of development diagrams for pubic hair and breasts or genital development, established by Tanner. If the responses differed between pubic hair and breasts/genital development, the pubic hair stage was used.
MVPA and active recreation
MVPA and active recreation were measured differently. First of all the MVPA was objectively measured with Actigraph accelerometers, model GT1M (Actigraph, Pensacola, FL). Data were only included if the participants wore the accelerometer on at least 4 days with a minimum recording of 8 hours per day. Data were analysed using Actilife software and Evenson’s (2008) cut points defined PA intensities (sedentary, light, moderate or vigorous). MVPA per day was calculated as the total minutes of vigorous and moderate activity, divided by the number of days the accelerometer was used. Only 320 children were eligible for this variable, because of technical problems and/or insufficient wear time.
Data on active recreation were collected using a self-completed questionnaire. The questions are “How often do you normally exercise or play sport” and “How often do you normally play out?” with possible answers being “Almost never”, “1-2 times a month”, “1-2 times a week”, “3-5 times a week” and “Almost every day”. These questions are based on previous work of the PEACH project (University of Bristol). These variables were further coded to make them more continuous (with “Almost never”=0, “1-2 times a month”=0,5, “1-2 times a week”=1,5, “3-5 times a week”=4 and “Almost every day”=6,5).
Perceived environment
Data concerning the perceived environment were collected through the same self-completed questionnaire as the self-reported active recreation (PEACH Project, University of Bristol). For accessibility only three items were used, being “accessibility to park/playground or open space to play”, “accessibility to sports centre” and “accessibility to public transportation”. All three questions are 4-point-Likert scales with possible answers being “very difficult”, “difficult”, “easy”
7 and “very easy”. No scale was formed for these three items, as the internal consistency was too low (Cronbach’s Alpha = 0,388). Regarding personal safety, four items were used to form a scale (Cronbach’s Alpha = 0,643). All four items were 4-point-Likerscales with possible answers being “strongly disagree”, “disagree”, “agree” and “strongly agree”. Traffic safety was scaled the same way, using three items (Cronbach’s Alpha = 0,473) and consisted of the same answer-possibilities.
Table 1: Content of the perceived environment factors
Personal Safety I feel safe during the day; (4 items) I feel safe at night.
I am not worried about strangers on the streets. I think there are plenty of street lights.
Traffic Safety I do not think there is heavy traffic on the streets. (3 items) I do not have to cross several roads to visit friends.
I do not think there is a lot of traffic pollution.
Parental factors
The participant’s parents were also given a survey. Of those surveys, 309 were returned. Seven of those were not used, as the parents’ age was not realistic. The survey exists of several parts with one of them being the International Physical Activity Questionnaire Short Form (IPAQ-SF), which was used to assess the parents’ PA. All scores are expressed in MET-minutes/week. The total number of MET-minutes/week was used as a variable for parental modelling.
For parental support, the children’s self-completed questionnaire (PEACH Project, University of Bristol) was used once again. Seven items, each of them assessed on a 4-point-Likertscale with possible answers being “Hardly ever”, “Sometimes”, “Often” or “Always”, were joined into one scale (Cronbach’s Alpha = 0,814). All items cover questions about parental support concerning active recreation.
Table 2: Content of the Parental Support factor
Parental Support (7 items)
How often do your parents encourage you to exercise or play sport? How often do your parents exercise or play sport with you?
How often do your parents tell you that you’re doing well at exercise or sport?
How often do your parents watch you take part in exercise or play sport?
8 How often do your parents take you to exercise or play sport? (Transport)
How often do your parents like you to play out? How often do your parents play out with you?
ANALYSES
Analyses were conducted using SPSS25. Multiple linear regression analyses were used per research question and per dependent variable (MVPA, Frequency Sport and Frequency Active Play). Multicollinearity was checked through Pearson’s correlations (correlation coefficients did not exceed 0,60). To examine moderating effects, a dummy variable was made for each moderator (BMI, Pubertal stage and parental factors), based on the median. Afterwards the interaction terms were built for each possible moderating effect (crossproduct of the independent variable and the dummy variable). The multiple linear regression analyses included the main terms (independent variables) and the interaction terms. Variables with a p < 0,05 were considered as significant predictors. Interaction terms were further analysed if p < 0,10.
RESULTS
DESCRIPTIVE CHARACTERISTICS
A total of 47,3% of the children were boys and 52,6% were girls. The independent sample t-test was used to further assess a difference between boys and girls for each variable. The mean age was 11,35 years for both genders. The difference in pubertal stage was clear between boys and girls (p<0,001), with girls tending to be in a further stage than the boys. The results for BMI showed no significant difference between boys and girls (p=0,25), with 2,4% of the children being thin, 57,2% having a normal weight, 27,4% being overweight and 13% being obese, leading to a total of 40,4% of the children carrying excess weight. When analysing accelerometer-based MVPA the scores were low with only 4,8% of the children reaching the WHO’s recommendation (of which only 1,1% being girls). There was a significant difference (p<0,001) between both genders concerning their PA. Boys tend to move more with an average 17 minutes per day or two extra hours per week more MVPA compared to girls. The same significant differences (p<0,001) were found for the frequency of active play and sport. Most perceived environmental factors, more specifically accessibility to park and playgrounds, accessibility to sport centres and personal safety, and parental factors, being parental support, showed significant differences between boys and girls (p<0,05), with girls consequently scoring
9 lower than boys. Because of the differences in descriptive characteristics between boys and girls, it was decided to run separate analyses for boys and for girls using split files.
Table 3: Descriptive characteristics of the sample
Variable All Male Female p
Gender (N=547) 259 (47,35%) 288 (52,65%)
Age (mean) (N=547) 11,35 (±0,59) 11,35 (±0,57) 11,35 (±0,61) 0,96
10 32 (5,9%) 12 20
11 290 (53,0%) 144 146
12 225 (41,1%) 103 122
Pubertal stage (mean) (N=547) 3,22 (±0,79) 2,84 (±0,64) 3,57 (±0,75) <0,001 Tanner I 1 (0,2%) 1 0 II 94 (17,2%) 72 22 III 258 (47,2%) 153 105 IV 168 (30,7%) 31 137 V 25 (4,6%) 1 24 BMI (mean) (N=547) 20,74 (±3,86) 20,69 (±3,91) 20,78 (±3,83) 0,25 Thinness Grade 1 13 (2,4%) 6 7 Normal weight 313 (57,2%) 144 169 Overweight 150 (27,4%) 69 81 Obesity 64 (11,7%) 37 27 Morbid obesity 7 (1,3%) 3 4 Accelerometer data (N=320) 152 (48,72%) 160 (51,28%)
Mean MVPA/day (min) 39,17 (±21,7) 47,88 (±23,78) 30,88 (±15,48) <0,001 >60min/day MVPA 46 (8,4%) 40 (15,4%) 6 (2,1%) Frequency Sport (N = 547) MEAN 2,57 (±2,44) 3,13 (±2,51) 2,06 (±2,24) <0,001 Almost never 160 (29,3%) 64 96 1 – 2 times a month 17 (3,1%) 2 15 1 – 2 times a week 145 (26,5%) 54 91 3 – 5 times a week 114 (20,8%) 70 44 Almost every day 111 (20,3%) 69 42 Frequency Active Play (N = 547)
MEAN 4,88 (±2,30) 5,27 (±2,00) 4,52 (±2,49) <0,001
Almost never 31 (5,7%) 6 25
1 – 2 times a month 12 (2,2%) 2 10
1 – 2 times a week 84 (15,4%) 34 50 3 – 5 times a week 78 (14,3%) 39 39 Almost every day 342 (62,5%) 178 164 Accessibility (N=547) Park or Playground* 2,95 (±0,89) 3,03 (±0,85) 2,87 (±0,91) 0,04 Sports center* 2,66 (±0,97) 2,79 (±0,95) 2,55 (±0,99) 0,004 Public transport* 3,21 (±0,86) 3,20 (±0,85) 3,22 (±0,87) 0,85 Personal Safety* (N=547) 3,06 (±0,56) 3,19 (±0,53) 2,95 (±0,56) <0,001 Traffic Safety* (N=547) 2,97 (±0,64) 3,00 (±0,62) 2,93 (±0,65) 0,19 Parental Modelling (N = 302) 137 (45,36%) 165 (54,64%)
IPAQ (mean total MET) 2994 (±3252) 3047 (±3155) 2951 (±3340) 0,62 Parental Support* (N=546) 2,85 (±0,69) 2,95 (±0,69) 2,77 (±0,69) 0,003
* All individual items and scales have a minimum value of 1 and a maximum value of 4, with 1 being a negative and 4 being a positive score.
10 MODERATING EFFECT OF PARENTAL FACTORS IN THE RELATIONSHIP BETWEEN ENVIRONMENTAL FACTORS AND PA
The parental factors showed a moderating effect in the relationship between some perceived physical environmental factors and PA. A first one concerns parental modelling in boys. Boys with high levels of parental modelling showed a positive association between the accessibility to public transport and the frequency of active play. Parental support showed another moderating effect in the relationship between the accessibility of sport centres and the frequency of sport, but only for girls. Girls with high parental support showed a positive association between the accessibility to sport centres and the frequency of sport, whereas girls with low parental support did not. Parental support showed a second moderating effect in the relation between traffic safety and frequency of sport in boys, but this could not be confirmed in further analyses (see Table 4).
Traffic safety was found to be positively related to the frequency of active play for girls and had a trend to significance in the same direction for boys’ MVPA. A last main effect was found for the girls’ frequency of sport, with good accessibility to parks and playgrounds being associated with a lower frequency of sport (see Table 4).
Table 4: Moderating effects of parental factors in the relationship between environmental factors and PA
Variables
MVPA Frequency Active Play Frequency Sport
BOYS GIRLS BOYS GIRLS BOYS GIRLS
beta p beta p beta p beta p beta p beta p MAIN EFFECTS
Accessibility Parc and Playground
-,05 ,80 -,13 ,50 ,08 ,60 ,17 ,21 ,10 ,50 -,29 ,03 Accessibility Public Transport -,28 ,14 ,13 ,43 -,15 ,30 ,03 ,77 ,10 ,49 ,02 ,88 Accessibility Sports Centre -,18 ,36 ,24 ,20 ,23 ,17 ,20 ,14 ,01 ,97 -,004 ,98 Personal Safety ,07 ,75 -,13 ,50 -,05 ,77 ,16 ,28 ,03 ,88 -,13 ,37 Traffic Safety ,41 ,10 ,02 ,93 ,09 ,64 ,27 ,05 ,07 ,69 ,09 ,53 Parental Support* -1,15 ,29 ,45 ,63 ,22 ,78 1,02 ,11 1,99 ,01 -1,21 ,06 Parental Modelling* ,62 ,56 ,34 ,72 -,88 ,22 ,11 ,87 -,09 ,90 ,15 ,82 INTERACTION EFFECTS Parental modelling by
accessibility public transport for PA
_ _ _ _ ,64 ,08 _ _ _ _ _ _
Association in low parental modelling
_ _ _ _ -,03 ,84 _ _ _ _ _ _
Association in high parental modelling
_ _ _ _ ,21 ,08 _ _ _ _ _ _
Parental support by traffic safety for PA
_ _ _ _ _ _ _ _ -,94 ,08 _ _
Association in low parental support
_ _ _ _ _ _ _ _ ,01 ,92 _ _
Association in high parental support
_ _ _ _ _ _ _ _ -,01 ,88 _ _
Parental support by accessibility sport centre for PA
_ _ _ _ _ _ _ _ _ _ ,65 ,01
Association in low parental support
_ _ _ _ _ _ _ _ _ _ ,09 ,26
Association in high parental support
_ _ _ _ _ _ _ _ _ _ ,25 ,01
11 MODERATING EFFECT OF BMI IN THE RELATIONSHIP BETWEEN ENVIRONMENTAL FACTORS AND PARENTAL FACTORS AND PA
In the relationship between perceived physical environmental factors and PA, two moderating effects of BMI were found. First of all, the accessibility to public transport was found to have a positive association to MVPA, but only in overweight and obese girls. A second effect was found in boys with normal weight. Good accessibility to sport centres is positively related to the frequency of sport for this group, while there was no significant relation found for overweight or obese boys. For girls, good accessibility to sport centres is positively correlated to the frequency of sport, independently of their weight. The same can be said for the girls’ frequency of active play and MVPA, both showing a trend to significance. Another main effect was found for the girls’ MVPA and frequency of active play, with negative personal safety being associated with more minutes of MVPA per day, but a lower frequency of active play (see Table 5).
Table 5: Moderating effect of BMI in the relationship between environmental factors and PA
Variables
MVPA Frequency Active Play Frequency Sport
BOYS GIRLS BOYS GIRLS BOYS GIRLS
beta p beta beta p beta p beta p beta p MAIN EFFECTS
Accessibility Parc and Playground
-,02 ,83 ,02 ,83 ,07 ,47 ,11 ,18 -,06 ,48 -,10 ,20
Accessibility Public Transport ,05 ,62 -,07 ,51 -,002 ,98 ,07 ,33 ,02 ,86 -,03 ,70 Accessibility Sports Centre -,003 ,98 ,19 ,07 ,07 ,43 ,13 ,09 ,30 <,001 ,24 ,002
Personal Safety ,12 ,27 -,24 ,02 ,001 ,99 ,15 ,05 ,01 ,89 -,05 ,56 Traffic Safety ,29 ,006 -,03 ,79 -,08 ,38 ,09 ,27 ,10 ,27 ,02 ,78 BMI* ,58 ,40 -,34 ,58 -,46 ,35 -,07 ,88 ,83 ,09 -,90 ,05 INTERACTION EFFECTS
BMI by accessibility public transport for PA
_ _ ,64 ,06 _ _ _ _ _ _ _ _
Association in normal weight
and thinness _ _ -,03 ,79 _ _ _ _ _ _ _ _
Association in overweight and
obesity _ _ ,29 ,02 _ _ _ _ _ _ _ _
BMI by accessibility sport centre for PA
_ _ _ _ _ _ _ _ -,46 ,04 _ _
Association in normal weight
and thinness _ _ _ _ _ _ _ _ ,29 <,001 _ _
Association in overweight and obesity
_ _ _ _ _ _ _ _ -,01 ,91 _ _
* Dummy variable
No moderating effects of BMI were found in the relation between parental factors and PA. A main effect of parental support on MVPA was found in boys, and on the frequency of active play and sport for both genders. High levels of parental support are associated with more PA. Parental support has the strongest positive association to the frequency of active play and sport in both genders.
12
Table 6: Moderating effect of BMI in the relationship between parental factors and PA
Variables
MVPA Frequency Active Play Frequency Sport
BOYS GIRLS BOYS GIRLS BOYS GIRLS
beta p beta p beta p beta p beta p beta p MAIN EFFECTS
Parental Support ,23 ,10 -,03 ,81 ,33 ,004 ,27 ,008 ,45 <,001 ,46 <,001 Parental Modelling -,14 ,32 ,02 ,86 ,004 ,97 ,09 ,39 -,10 ,42 ,12 ,23
BMI* -,06 ,90 ,13 ,74 -,51 ,19 -,21 ,50 ,44 ,28 ,33 ,27
* Dummy variable
MODERATING EFFECT OF THE PUBERTAL STAGE IN THE RELATIONSHIP BETWEEN ENVIRONMENTAL FACTORS AND PARENTAL FACTORS AND PA
There was an interaction effect of the pubertal stage in the relation between traffic safety and the frequency of active play in boys. However, when further analyses were carried out, no significant results were found. Two last main effects were found, both with a trend to significance. Accessibility to parks and playgrounds was positively associated to the frequency of active play in boys and traffic safety was also found to be positively associated to the frequency of sport in girls (see Table 7).
Table 7: Moderating effect of the pubertal stage in the relationship between environmental factors and PA
Variables
MVPA Frequency Active Play Frequency Sport
BOYS GIRLS BOYS GIRLS BOYS GIRLS
beta p beta p beta p beta p beta p beta p MAIN EFFECTS
Accessibility Parc and Playground
,03 ,74 -,05 ,74 ,12 ,08 ,15 ,10 -,07 ,28 -,002 ,99 Accessibility Public Transport -,04 ,68 ,15 ,25 ,07 ,33 ,09 ,27 ,02 ,80 ,03 ,71 Accessibility Sports Centre -,07 ,41 ,11 ,41 ,11 ,12 ,11 ,21 ,16 ,03 ,21 ,02 Personal Safety ,13 ,14 -,28 ,04 -,006 ,93 ,08 ,41 -,001 ,99 ,05 ,61 Traffic Safety ,22 ,01 -,17 ,20 -,11 ,10 ,18 ,05 ,03 ,65 ,16 ,10 Pubertal Stage* ,31 ,70 -,51 ,41 -,44 ,45 ,14 ,75 -,10 ,86 ,88 ,05 INTERACTION EFFECTS
Pubertal stage by traffic safety for PA
_ _ _ _ ,74 ,02 _ _ _ _ _ _
Association in lower pubertal stage
_ _ _ _ -,09 ,19 _ _ _ _ _ _
Association in higher pubertal stage
_ _ _ _ ,25 ,17 _ _ _ _ _ _
* Dummy variable
A last moderating effect was found in the relationship between parental support and the frequency of active play in boys. Good parental support was related to more active play for boys in higher pubertal stages, while this was not the case for boys in lower pubertal stages (see Table 8).
13
Table 8: Moderating effect of the pubertal stage in the relationship between parental factors and PA
Variables
MVPA Frequency Active Play Frequency Sport
BOYS GIRLS BOYS GIRLS BOYS GIRLS
beta p beta p beta p beta p beta p beta p MAIN EFFECTS Parental Support ,23 ,05 ,04 ,81 ,44 <,001 ,27 ,03 ,39 <,001 ,42 <,001 Parental Modelling -,15 ,16 ,16 ,36 -,009 ,91 ,14 ,27 -,07 ,38 ,04 ,74 Pubertal Stage* -,16 ,71 ,18 ,65 -,19 ,58 -,13 ,67 ,16 ,66 ,08 ,78 INTERACTION EFFECTS Pubertal stage by parental modelling for PA
_ _ _ _ ,32 ,02 _ _ _ _ _ _ Association in lower pubertal stage _ _ _ _ -,002 ,98 _ _ _ _ _ _ Association in higher pubertal stage _ _ _ _ ,42 ,08 _ _ _ _ _ _ * Dummy variable
DISCUSSION
The first aim of this study was to find moderating effects of parental factors in the relationship between perceived physical environmental factors and PA. Only 2 out of 10 interactions were significant of which one only concerning girls and the other one concerning boys. Boys with positive parental modelling showed a positive association between the accessibility to public transport and the frequency of active play, whereas boys with negative parental modelling did not. The second interacting effect showed that girls with positive parental support had a positive association between the accessibility to sport centres and the frequency of sport. Both interacting effects suggest that environmental factors are only important for children enjoying positive parental factors (positive parental modelling and/or parental support), enforcing each other in this way to lead to an increase in PA. This statement, however, can not be confirmed with only those two weak interacting effects. Besides, this finding is the opposite of what was found in D’Haese et al.’s study (2016) where children with high parental support showed a negative association between the neighbourhood’s walkability and the frequency of sport. The used variables are not exactly the same, as D’Haese et al.’s study used the objective walkability while this study researches the perceived accessibility. In another study from D’Haese, Van Dyck, De Bourdeaudhuij, Deforche and Cardon (2014) no relationship was found between the walkability and PA in children from 9 to 12 years old. It could be that, whereas walkability and accessibility seem to be important factors for adults, this cannot be extended to children. As for parental factors, it can be said that they do not seem to show convincing interacting effects. This suggests that specific physical environmental factors could benefit the majority of the children, independently of the parental factors.
The second aim of the study was to examine the moderating effects of BMI in the relation between parental and perceived physical environmental factors and PA. This could potentially lead to more specific recommendations regarding how to increase the PA in children being
14 overweight or obese. Again, only 2 out of 8 interacting effects were found to be significant, of which none concerning parental factors. Girls being overweight or obese showed a positive association between the accessibility to transport and their MVPA. The second interacting effect concerned the boys’ frequency of sport. The positive association between the accessibility to sport centres and the frequency of sport was only significant in boys with normal weight, not in overweight or obese boys. This study does not prove a convincing interacting effect of the BMI and can be compared to previous findings where the same parental and perceived physical environment factors seem to play a role, independently of the weight status (Trost et al., 2001; Waters et al., 2011).
A last aim was to examine the moderating effect of the children’s pubertal stage in the relationship between parental and perceived physical environmental factors and PA. It is said that parental factors lose their effect when children enter adolescence (McMinn et al., 2008; Edwardson & Gorely, 2010; Bradley et al., 2011) and no literature was found concerning the perceived environment. Once again, results did not show to be very convincing. Only 1 out of 8 interacting effects showed to be significant and this only for boys. Boys being in higher pubertal stages showed a positive correlation between high levels of parental support and the frequency of active play, while boys being less developed showed no correlation at all. This finding is the opposite of what was found in the literature, where puberty seems to diminish the association between parental factors and PA (McMinn et al., 2008; Edwardson & Gorely, 2010; Bradley et al., 2011). Only Bradley et al. (2011) seemed to find a comparable result for girls. Girls who experienced puberty early found to have a positive and increased association between parental support and MVPA. To experience puberty between the age of 10 and 12 years old is seen as early puberty. It seems that not only the presence or absence of puberty plays a role, but also the age at which it starts, showing differences between early and late puberty (McMinn et al., 2008; Bradley et al., 2011). It is difficult to confirm the interacting effect of puberty on parental factors with these study’s results.
According to these results, there is no clear evidence for interacting effects of parental factors, BMI or the pubertal stage. This suggests that the right parental and perceived physical environmental factors could benefit the majority of the children, independently of the parental factors, weight status and pubertal development. It is therefore interesting to now look at the main effects in this study. Parental support showed a positive association to PA for both boys and girls. For boys, 8,4% of the variance in the frequency of active play and 6,9% of the variance in the frequency of sport could be explained by parental support. For girls it was 6,9% and 10,2% respectively. Future interventions should therefore especially focus on increasing parental support, as it shows to be the strongest factor, independent of weight status. Besides,
15 parental support further increases the self-efficacy of the children (Trost et al., 2003) which seems to be the biggest problem for overweight and obese children (Trost et al., 2001). Traffic safety was also found to have a positive association to PA, especially concerning the boys’ MVPA, with an explained variance of 4,3%, and girls’ frequency of active play, with an explained variance of 2,2%. The variance is way smaller than for parental support. However, this finding does confirm previous research stating the importance of traffic safety concerning children’s PA (Krahnstoever-Davison & Lawson, 2006; Carver et al., 2008; Loprinzi et al., 2012). A majority of the children between 9 and 11 years old called the main road “scary and dangerous”, while 11 to 16 year old children would not want to play or go out in their streets if there was too much traffic (Molnar et al., 2004). In the current study a three-item-scale with a weak internal consistency was used to assess traffic safety. It is possible that a stronger association would have been found in this study if the scale had a better internal consistency. It could be a good idea to not only increase the child’s perceived traffic safety, but also the parents’. When parents have a safe feeling about traffic safety in their neighbourhood it increases the safety feeling of their children (Molnar et al., 2004; Carver et al., 2008). Another advantage is an increase in granted mobility licences. If traffic safety is perceived as safe by the parents, they will more easily authorize their children to play and go outside, leading to an increase in PA-levels (Weir, Etelson, & Brand, 2006; Carver et al., 2008; Jago et al., 2009). In addition to parental support and traffic safety it could still be a good idea to also focus on the accessibility to sport centres. Even though there was no significant association found between the accessibility to sport centres and the frequency of sport in girls with low parental support and overweight or obese boys, it still shows associations with MVPA, the frequency of active play and the frequency of sports. For boys, 1,4% of the variance in the frequency of active play and 2,2% of the variance in the frequency of sport could be explained by the accessibility to sport centres. For girls it was 4,2% and 3,3% respectively. The reason that the effect sizes are so small could lie in the fact that this factor only consists of one 4-point-Likert-item. It is possible that the associations would have been more convincing if this determinant was assessed differently. It is also possible that this determinant is just not as important as some other factors. The same can be said for the other variables of this study that were not further discussed, such as the accessibility to park and playgrounds, the accessibility to public transport and personal safety. Personal safety even showed some contradicting results with a negative association with an explained variance of 3,2% found for the girls’ MVPA, while at the same time a positive association with an explained variance of 4,1% was found for the girls’ frequency of active play. It could be that the rest of the variance might be found in other factors, not included in this study. Future studies should therefor focus on other determinants than these perceived physical environmental and parental factors to predict active recreation. Other
16 active domains, such as active transport, school-bound and household activities, might also be interesting to research to find the remaining variance for MVPA.
The strength of this study lies in the relatively large sample. Another strength is the combination of self-reported and objective assessment of the children’s PA. The first limitation of this study is the cross-sectional design, making it impossible to talk about effects and leading to statements about associations. The second limitation concerns the self-reported questionnaires. There were a lot of missing data, some questions were not sufficiently clear and the internal consistency was not always satisfactory, especially concerning the accessibility. It is possible that different results would have been found if another, more complete, measurement tool was used. Validated instruments to assess the perceived accessibility, such as the AIMFREE (Accessibility Instruments Measuring Fitness and Recreation Environments) or NEWS-Y (Neighborhood Environment Walkability Scale for Youth), could have shown more reliable results (Rimmer, Riley, Wang & Rauworth, 2009; Rosenberg et al., 2009). A last limitation lies in the use of the IPAQ-SF assessment tool. Parental modelling showed little to no results in this study, while at the same time the parents’ PA was overestimated largely. According to a systematic review by Lee, Macfarlane, Lam and Stewart (2011) it seems that the IPAQ-SF continually overestimates the PA-level. Besides it also seemed to be difficult to use, as many parents made mistakes, leading to missing data.
CONCLUSION
No convincing moderating effects were found, which could suggest that future interventions targeting the PA of 10 to 12 year old children should focus on the whole group instead of dividing them by weight status or pubertal stage. Based on the results of this study, it seems that parental support is a satisfying factor to focus on in future interventions, followed by traffic safety. More research is needed to confirm the effect of the perceived accessibility on PA in children.
REFERENCES
An, R., Shen, J., Yang, Q., & Yang, Y. (2019). Impact of built environment on physical activity and obesity among children and adolescents in China: A narrative systematic review. Journal of Sport and Health Science, 8(2), 153-169.
Baptista, F., Santos, D., Silva, A., Mota, J., Santos, R., Vale, S., Ferreira, J., Raimundo, A., Helena, M., & Sardinha, L. (2011). Prevalence of the Portuguese Population Attaining Sufficient Physical Activity. Medicine and science in sports and exercise, 44(3), 466-73.
17 Biddle, S.J.H., Gorely, T., & Stensel, D.J. (2007). Health-enhancing physical activity and sedentary behaviour in children and adolescents. Journal of Sports Sciences, 22(8), 679-701. Bradley, R.H., McRitchie, S., Houts, R.M., Nader, P., O'Brien, M., & NICHD Early Child Care Research Network. (2011). Parenting and the decline of physical activity from age 9 to 15. The international journal of behavioral nutrition and physical activity, 8(33). Retrieved 24 March, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3095990/
Brown, H.E., Pearson, N., Braithwaite, R.E., Brown, W.J., & Biddle S.J.H. (2013). Physical Activity Interventions and Depression in Children and Adolescents: A Systematic Review and Meta-Analysis. Sports Medicine, 43(3), 195–206.
Carroll-Scott, A., Gilstad-Hayden, K., Rosenthal, L., Peters, S.M., McCaslin, C., Joyce, R., & Ickovics, J.R. (2013). Disentangling neighborhood contextual associations with child body mass index, diet, and physical activity: The role of built, socioeconomic, and social environments. Social Science & Medicine, 95, 106-114.
Carver, A., Timperio, A., & Crawford, D. (2008). Playing it safe: The influence of neighbourhood safety on children's physical activity—A review. Health & Place, 14(2), 217-227.
Carver, A., Timperio, A., & Crawford, D. (2012). Young and free? A study of independent mobility among urban and rural dwelling Australian children. Journal of Science and Medicine in Sport, 15(6), 505-510.
Cole, T.J., & Lobstein, T. (2012). Extended international (IOTF) body mass index cut-offs for thinness, overweight and obesity. Pediatric Obesity, 7(4), 284-294.
Cordovil, R., Lopes, F., & Neto, C. (2015). Children's (in)dependent mobility in Portugal. Journal of Science and Medicine in Sport, 18(3), 299-303.
Davison, K. K., & Lawson, C.T. (2006). Do attributes in the physical environment influence children's physical activity? A review of the literature. International Journal of Behavioral Nutrition and Physical Activity, 3(19). Retrieved 6 April, 2019, from
https://ijbnpa.biomedcentral.com/track/pdf/10.1186/1479-5868-3-19
D’Haese, S., Gheysen, F., De Bourdeaudhuij, I., Deforche, B., Van Dyck, D., & Cardon, G. (2016). The moderating effect of psychosocial factors in the relation between neighborhood walkability and children’s physical activity. International Journal of Behavioral Nutrition and Physical Activity, 13(128). Retrieved 17 May, 2019, from
https://biblio.ugent.be/publication/8500421/file/8500422.pdf
Edwardson C.L., & Gorely, T. (2010). Parental influences on different types and intensities of physical activity in youth: A systematic review. Psychology of Sport and Exercise, 11(6), 522-535.
18 Evenson, K.R., Catellier, D.J., Gill, K., Ondrak, K.S., & McMurray, R.G. Calibration of two objective measures of physical activity for children. Journal of Sports Sciences, 26(14), 1557– 1565.
Gordon-Larsen, P., Nelson, M.C., Page, P., & Popkin, B.M. (2006). Inequality in the Built Environment Underlies Key Health Disparities in Physical Activity and Obesity. Pediatrics, 117(2), 417-424.
Griew, P., Page, A., Thomas, S., Hillsdon, M., & Cooper, A.R. (2010). The school effect on children's school time physical activity: The PEACH Project. Preventive Medicine, 51(3-4), 282-286.
Griffith, J.R., Clasey, J.L., King, J.T., Gantz, S., Kryscio, R.J., & Bada, H.S. (2007). Role of parents in determining children's physical activity. World Journal of Pediatrics, 3(4). Retrieved 25 March, 2019, from http://wjpch.com/UploadFile/20074004.pdf
Hoehner, C.M., Soares, J., Perez, D.P., Ribeiro, I.S., Joshu, C.E., Pratt, M., Legetic, B.D., Carvalho Malta, D., Matsudo, V.R., Roberto Ramos, L., Simões, E.J., & Brownson, R.C. (2008). Physical Activity Interventions in Latin America: A Systematic Review. American Journal of Preventive Medicine, 24(3), 224-233.
Jago, R., Thompson, J.L., Page, A.S., Brockman, R., Cartwright, K., & Fox, K.R. (2009). Licence to be active: parental concerns and 10–11-year-old children's ability to be independently physically active. Journal of Public Health, 31(4), 472–477.
Lee, P.H., Macfarlane, D.J., Lam, T.H., & Stewart S.M. (2011). Validity of the International Physical Activity Questionnaire Short Form (IPAQ-SF): a systematic review. The International Journal of Behavioral Nutrition and Physical Activity, 8(115). Retrieved 17 June, 2019, from
https://doi.org/10.1186/1479-5868-8-115
Lin, E.Y., Witten, K., Oliver, M., Carroll, P., Asiasiga, L., Badland, H., & Parker, K. (2017). Social and built-environment factors related to children's independent mobility: The importance of neighbourhood cohesion and connectedness. Health & Place, 46, 107-113.
Lobstein, T. , Baur, L., & Uauy, R. (2004). Obesity in children and young people: a crisis in public health. Obesity Reviews, 5, 4-85.
Lopes, V.P., Rodrigues, L.P., Maia, J.A.R., & Malina, R.M. (2011). Motor coordination as predictor of physical activity in childhood. Scandinavian Journal of Medicine & Science in Sports, 21(5), 663-669.
Loprinzi, P.D., Cardinal, B.J., Loprinzi, K.L., & Lee, H. (2012). Benefits and Environmental Determinants of Physical Activity in Children and Adolescents. Obesity Facts, 5, 597-610. Lubans, D.R., Foster, C., & Biddle, S.J.H. (2008). A review of mediators of behavior in interventions to promote physical activity among children and adolescents. Preventive Medicine, 47(5), 463-470.
19 Molnar, B.E., Gortmaker, S.L., Bull, F.C., & Buka, S.L. (2004). Unsafe to Play? Neighborhood Disorder and Lack of Safety Predict Reduced Physical Activity among Urban Children and Adolescents. American Journal of Health Promotion, 18(5), 378–386.
McMinn, A.M., van Sluijs, E.M.F., Wedderkopp, N., Froberg, K., & Griffin, S.J. (2008). Sociocultural Correlates of Physical Activity in Children and Adolescents: Findings from the Danish Arm of the European Youth Heart Study. Pediatric Exercise Science, 20(3), 319-332. Nader, P.R., Bradley, R.H., Houts, R.M., McRitchie, S.L., & O’Brien, M. (2008). Moderate-to-Vigorous Physical Activity From Ages 9 to 15 Years. JAMA, 300(3), 295–305.
Padez, C., Mourão, I., Moreira, P., & Rosado, V. (2009). Prevalence and risk factors for overweight and obesity in Portuguese children. Acta Paediatrica, 94(11), 1550-1557.
Pietiläinen, K.H., Kaprio, J., Borg, P., Plasqui, G., Yki-Järvinen, H., Kujala, U.M., Rose, R.J., Westerterp, K.R., & Rissanen, A. (2008). Physical inactivity and obesity: A vicious circle. Obesity (Silver Spring), 16(2), 409–414.
Riddoch, C., Andersen, L.B., Wedderkopp, N., Harro, M., Klasson-Heggebø, L., Sardinha, L., Cooper, A., & Ekelund, U. (2004). Physical Activity Levels and Patterns of 9- and 15-yr-Old European Children. Medicine & Science in Sports & Exercise, 36(1), 86-92.
Rimmer, J.H., Riley, B., Wang, E., & Rauworth, A. (2009). Development and validation of AIMFREE: Accessibility Instruments Measuring Fitness and Recreation Environments. Disability and Rehabilitation, 26(18), 1087-1095.
Rito, A., Cruz de Sousa, R., Mendes, S., & Graça, P. (2017). Childhood Obesity Surveillance Initiative (Report COSI Portugal 2016). Retrieved from Instituto Nacional de Saúde website:
http://repositorio.insa.pt/bitstream/10400.18/4857/8/COSI%202016_V2_fev2018.pdf
Roemmich, J.N., Epstein, L.H., Raja, S., Yin, L., Robinson, J., & Winiewicza, D. (2006). Association of access to parks and recreational facilities with the physical activity of young children. Preventive Medicine, 43(6), 437-441.
Rosenberg, D., Ding, D., Sallis, J.F., Kerr, J., Norman, G.J., Durant, N., Harris, S.K., & Saelens, B.E. (2009). Neighborhood Environment Walkability Scale for Youth (NEWS-Y): reliability and relationship with physical activity. Preventive Medicine, 49(2-3), 213-218. Sallis, J.F., Prochaska, J.J., & Taylor, W.C. (2000). A review of correlates of physical activity of children and adolescents. Medicine & Science in Sports & Exercise, 32(5), 963-975. Sallis, J.F., Taylor, W.C., Dowda, M., Freedson, P.S., & Pate, R.R. (2002). Correlates of Vigorous Physical Activity for Children in Grades 1 through 12: Comparing Parent-Reported and Objectively Measured Physical Activity. Pediatric Exercise Science, 14(1), 30-44.
Sallis, J.F., Cervero, R.B., Ascher, W., Henderson, K.A., Kraft, M.K., & Kerr, J. (2006). An ecological approach to creating active living communities. Annual Review of Public Health, 27(1), 297-322.
20 Sallis, J.F., & Glanz, K. (2006). The Role of Built Environments in Physical Activity, Eating, and Obesity in Childhood. The Future of Children, 16(1), 89-108.
Sallis, J.F., Floyd, M.F., Rodríguez, D.A., & Saelens, B.E. (2012). Role of Built Environments in Physical Activity, Obesity, and Cardiovascular Disease. Circulation, 125(5), 729–737. Santos, M.P., Pizarro, A.N., Mota J. & Marques, E.A. (2013). Parental physical activity, safety perceptions and children’s independent mobility. BMC Public Health, 13(584). Retrieved 25 April, 2019, from https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/1471-2458-13-584
Schoeppe, S, Duncan, M.J., Badland, H.M., Oliver, M., & Browne, M. (2014). Associations between children’s independent mobility and physical activity. BMC Public Health, 14(91).
Retrieved 7 April, 2019, from
https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/1471-2458-14-91
Taylor, R. W., Williams, S. M., Farmer, V. L., & Taylor, B. J. (2013). Changes in physical activity over time in young children: a longitudinal study using accelerometers. PloS one, 8(11). Retrieved 24 March, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3839894/
Troiano, R.P., Berrigan, D, Dodd, K.W., Mâsse, L.C., Tilert, T., & McDowell, M. (2008). Physical activity in the United States measured by accelerometer. Medicine & Science in Sports & Exercise, 40(1), 181-188.
Trost, S.G., Kerr, L.M., Ward, D.S., & Pate, R.R. (2001). Physical activity and determinants of physical activity in obese and non-obese children. International Journal of Obesity, 25, 822– 829.
Trost, S.G., Sallis, J.F., Pate, R.R., Freedson, P.S., Taylor, W.C., & Dowda, M. (2003). Evaluating a model of parental influence on youth physical activity. American Journal of Preventive Medicine, 25(4), 277-282.
van Sluijs, E.M.F., McMinn, A.M., & Griffin, S.J. (2007). Effectiveness of interventions to promote physical activity in children and adolescents: systematic review of controlled trials. BMJ, 335, 703. Retrieved 20 March, 2019, from https://www.bmj.com/content/335/7622/703
Waters, E., de Silva‐Sanigorski, A., Burford, B.J., Brown, T., Campbell, K.J., Gao, Y., Armstrong, R., Prosser, L., & Summerbell, C.D. (2011) Interventions for preventing obesity in children. Cochrane Database of Systematic Reviews, 12. Retrieved 17 June, 2019, from
https://doi.org/10.1002/14651858.CD001871.pub3
Weir, L.A., Etelson, D., & Brand, D.A. (2006). Parents' perceptions of neighborhood safety and children's physical activity. Preventive Medicine, 43(3), 212-217.
Wheeler, B.W., Cooper, A.R., Page, A.S., & Jago, R. (2010). Greenspace and children's physical activity: A GPS/GIS analysis of the PEACH project. Preventive Medicine, 51(2), 148-152.
21 World Health Organization. (2018). Physical Activity. Retrieved 20 march, 2019, from
https://www.who.int/news-room/fact-sheets/detail/physical-activity
Yao, C.A., & Rhodes, R.E. (2015). Parental correlates in child and adolescent physical activity: a meta-analysis. International Journal of Behavioral Nutrition and Physical Activity,
12(10). Retrieved 7 April, 2019, from
DE ROL VAN OUDERLIJKE EN
OMGEVINGSFACTOREN OM
FYSIEKE ACTIVITEIT VAN 10-12
JAAR OUDE KINDEREN IN
PORTUGAL TE VERKLAREN.
Aantal woorden (TOTAAL): 15.939Elizaveta Fomenko
Stamnummer: 01000021
Promotor: Prof. dr. Delfien Van Dyck Copromotor: Prof. dr. Maria Paula Santos
Masterproef voorgelegd voor het behalen van de Master in de Gezondheidsvoorlichting en - bevordering
ABSTRACT
BACKGROUND: This study aims to investigate the moderating effect of parental factors in the relationship between perceived physical environmental factors and 10-12 year old Portuguese children’s physical activity (PA). Furthermore, the moderating effect of the BMI and pubertal stage in the relationship between parental and perceived physical environmental factors and PA was examined. The main effects of the parental and perceived physical environmental factors were also observed.
METHODS: In total, data from 547 children and their parents were included in this cross-sectional study. An accelerometer was used for the MVPA, children completed a questionnaire concerning the perceived physical environmental factors, such as accessibility and safety, parental support and factors for active recreation, such as the frequency of active play and sport. The IPAQ-SF was completed by the parents to
asses parental modelling. Multiple moderated linear regression analyses were used to solve the research questions.
RESULTS: Only 5 out of 24 investigated interactions were found to be significant. Two of them suggesting that accessibility has a positive association to PA only for children with positive parental factors. The other three moderating effects concern BMI and pubertal stage and were contradicting each other or evidence from literature. Parental support correlated significantly with more PA for everyone, independently of the BMI or pubertal stage. Traffic safety was also found to correlate positively with PA.
CONCLUSIONS: No convincing interacting-effects were found. Future interventions should therefore work with the whole group of children, independently of their BMI or pubertal stage and focus on increasing parental support and the perception of traffic safety.
KEYWORDS: Child, Parents, Neighborhood, Interactions, Physical activity, BMI, Pubertal stage
2 ACHTERGROND: Deze studie heeft als doel het modererend effect na te gaan van ouderlijke factoren in de relatie tussen gepercipieerde fysieke omgevingsfactoren en fysieke activiteit (FA) van 10-12 jaar oude Portugese kinderen. Verder werd het modererende effect van de BMI en de puberale ontwikkeling in de relatie tussen ouderlijke en waargenomen fysieke omgevingsfactoren en FA onderzocht. De hoofdeffecten van ouderlijke en waargenomen fysieke omgevingsfactoren werden ook geobserveerd.
METHODOLOGIE: In totaal werden de gegevens van 547 kinderen en hun ouders opgenomen in deze cross-sectionele studie. Een accelerometer werd gebruikt voor de MVPA, kinderen vulden een vragenlijk in over de waargenomen fysieke omgevingsfactoren, zoals toegankelijkheid en veiligheid, ouderlijke steun en factoren voor actieve recreatie, zoals de frequentie van actief spelen en sport. De IPAQ-SF werd door de ouders ingevuld om ouderlijke modelling na te gaan. Meerdere gemodereerde lineaire regressieanalyses werden uitgevoerd om de onderzoeksvragen op te lossen.
RESULTATEN: Slechts 5 van de 24 onderzochte interacties bleken significant te zijn. Twee van hen suggereren dat toegankelijkheid een positieve associatie heeft met FA enkel voor kinderen met positieve ouderlijke factoren. De andere drie interactie-effecten betreffen BMI en het puberale ontwikkeling en waren tegenstrijdig met elkaar of met de literatuur. Ouderlijke steun correleert significant met meer FA voor iedereen, ongeacht de BMI of puberale ontwikkeling. Verkeersveiligheid bleek ook positief te correleren met PA.
CONCLUSIE: Er zijn geen overtuigende interactie-effecten gevonden. Toekomstige interventies focussen daarom best op de hele groep kinderen, onafhankelijk van hun BMI of puberale ontwikkeling en richten zich op het stimuleren van ouderlijke en de perceptie van verkeersveiligheid.
TREFWOORDEN: Kind, Ouders, Omgeving, Omgeving, Interactions, Fysieke activiteit, BMI, Puberteit
3
INHOUDSTAFEL
1. INLEIDING ... 5 2. UITGEBREIDE LITERATUURSTUDIE ... 7 2.1. FYSIEKE ACTIVITEIT: DEFINITIE, RICHTLIJNEN EN PREVALENTIE ... 7 2.2. IMPACT VAN FYSIEKE (IN)ACTIVITEIT OP DE GEZONDHEID ... 8 2.3. ECOLOGISCH MODEL VAN DE VIER DOMEINEN VAN ACTIEF LEVEN ... 9 2.3.1. Intrapersoonlijk: Demografische en biologische factoren ... 12 2.3.2. Gedrag: Domeinen van actief leven ... 13 2.3.3. Omgeving: Toegankelijkheid en veiligheid ... 15 2.3.4. Sociaal-culturele omgeving: de rol van ouders ... 16 2.4. CONCLUSIE EN ONDERZOEKSVRAGEN ... 18 3. AANVULLENDE ANALYSES EN RESULTATEN ... 21 3.1. Databewerking in SPSS ... 21 3.1.1. Demografische en biologische variabelen ... 21 3.1.2. Factoren van fysieke activiteit... 22 3.1.3. Gepercipieerde fysieke omgevingsfactoren ... 23 3.1.4. Ouderlijke factoren ... 23 3.2. Vergelijking van gemiddelden tussen verschillende subgroepen ... 24 3.2.1. Een vergelijking van gemiddelden tussen jongens en meisjes ... 25 3.2.2. Een vergelijking van gemiddelden tussen de verschillende leeftijden ... 26 3.2.3. Een vergelijking van gemiddelden tussen lage en hogere puberale ontwikkeling ... 27 3.2.4. Een vergelijking van de gemiddelden tussen de categorieën van BMI .... 28 3.2.5. Een vergelijking van de gemiddelden tussen kinderen met negatieve versus positieve ouderlijke steun ... 29 3.2.6. Een vergelijking van de gemiddelden tussen kinderen met negatieve versus positieve ouderlijke modelling ... 30 3.3. Het profiel van een kind dat de richtlijn voor FA haalt ... 31 4. UITGEBREIDE DISCUSSIE ... 32 5. UITGEBREIDE CONCLUSIE ... 36 BIBLIOGRAFIE ... 37 BIJLAGE 1: Logboek ... 43
4
LIJST MET TABELLEN
Tabel 1: Frequenties per leeftijd ... 21 Tabel 2: Frequenties per BMI categorie... 21 Tabel 3: Frequenties dummy-variabele BMI ... 22 Tabel 4: Frequenties dummy-variabele puberteit ... 22 Tabel 5: Een vergelijking van gemiddelden tussen jongens en meisjes ... 25 Tabel 6: Een vergelijking van gemiddelden tussen de verschillende leeftijden... 26 Tabel 7: Een vergelijking van gemiddelden tussen lage en hogere puberale ontwikkeling ... 27 Tabel 8: Een vergelijking van de gemiddelden tussen de categorieën van BMI ... 28 Tabel 9: . Een vergelijking van de gemiddelden tussen kinderen met negatieve versus positieve ouderlijke steun ... 29 Tabel 10: Een vergelijking van de gemiddelden tussen kinderen met negatieve versus positieve ouderlijke modelling ... 30 Tabel 11: Een vergelijking van de gemiddelden tussen kinderen die de richtlijn voor FA halen versus kinderen die de richtlijn voor FA niet halen ... 31
5
1. INLEIDING
Fysieke activiteit (FA), of eerder het gebrek eraan, loopt parallel met verschillende fysieke gezondheidsklachten, alsook een negatief psychologisch welbevinden. Hierdoor is er een FA-richtlijn ontstaan. Jammer genoeg bereikt een meerderheid van de 10 tot 12 jaar oude kinderen die niet. Het is zelfs zo dat veel van hen op die leeftijd een sterkere daling van FA ervaren. Dat zou al dan niet te maken hebben met de start van de puberteit. Naast de negatieve tendens voor FA is er bijkomend een verhoging in het aantal kinderen met overgewicht of obesitas. Het lijkt dus interessant en nodig om interventies te creëren die focussen op die complexe leeftijdsgroep. Om efficiënte interventies te kunnen doen, dienen de juiste determinanten te worden gekozen. Het is al langer geweten dat FA niet enkel afhangt van eigen beslissingen. Dat is zeker het geval bij jonge kinderen, die nog zeer afhankelijk zijn van hun ouders. Omgevingsfactoren en psychosociale factoren dienen daarom onderzocht te worden. Ondanks de vele hypothesen dat die factoren een invloed hebben op de FA, werden ze zelden overtuigend bewezen. Een van de mogelijke verklaringen kan liggen aan bepaalde interactie-effecten. Er werd slechts één studie gevonden die interactie-effecten onderzocht voor kinderen; een bijkomende studie hierover lijkt daarom niet overbodig.
Deze studie gaat na of ouderlijke factoren en gepercipieerde fysieke omgevingsfactoren een rol hebben op de FA van 10 tot 12 jaar oude kinderen uit de omgeving van Porto, Portugal. Er wordt hierbij dieper ingegaan op het interactie-effect van ouderlijke factoren in de relatie tussen gepercipieerde fysieke omgevingsfactoren en FA. Door de hoge prevalentie aan overgewicht en obesitas in de leeftijdsgroep werd er gekozen om ook het interactie-effect van BMI te onderzoeken in de relatie tussen ouderlijke factoren en gepercipieerde fysieke omgevingsfactoren en FA. Bijkomend werd een derde interactie-effect van de puberteit in de relatie tussen ouderlijke factoren en gepercipieerde fysieke omgevingsfactoren en FA onderzocht, wegens een vermoeden dat het niet de leeftijd, maar de puberteit is die zorgt voor een plotse vermindering in FA.
Deze thesis bestaat uit twee delen waarvan 1) het Engelstalige artikel en 2) het Nederlandstalige verslag. Het artikel is het hoofdelement, waarvoor het verslag slechts ondersteuning biedt. Het verslag legt als het ware uit waarom bepaalde keuzes (bijvoorbeeld van de gebruikte determinanten) werden gemaakt, legt de
6 methodologie meer gedetailleerd uit en graaft dieper in de bespreking van de resultaten aan de hand van bijkomende analyses. Het verslag start dus met een meer diepgaande bespreking van de literatuur. In de literatuurstudie wordt FA besproken (definitie, richtlijnen, prevalentie, enzovoort) en het effect op de gezondheid van de kinderen. Daarna volgt een bespreking van de determinanten. In het artikel ligt de focus op de gebruikte determinanten, zijnde FA, gepercipieerde bereikbaarheid en veiligheid, ouderlijke steun en ouderlijke modelling. In het verslag komen nog meer relevante determinanten aan bod. Daarnaast wordt de keuze voor de gebruikte factoren beter uitgelegd. Dit leidt tot slot tot de drie onderzoeksvragen. Het tweede deel van de thesis bestaat uit de methode, de resultaten en de bespreking van de resultaten. Hierbij bevat het artikel de belangrijkste analyses en is het verslag slechts een uitbreiding daarvan. De discussie van het verslag bevat nieuwe aandachtspunten met betrekking tot de resultaten. De link met de literatuur wordt hierbij verder uitgediept. Ten slotte bevat de conclusie een samenvatting van de belangrijkste bevindingen, alsook specifieke suggesties voor toekomstige interventies.
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2. UITGEBREIDE LITERATUURSTUDIE
2.1. FYSIEKE ACTIVITEIT: DEFINITIE, RICHTLIJNEN EN PREVALENTIE
“People who are insufficiently active have a 20% to 30% increased risk of death compared to people who are sufficiently active.” (WHO, 2018)
Het belang van fysieke activiteit (FA) kan niet genoeg onderlijnd worden, zo blijkt uit het uitgebreide onderzoek rond dit thema. Deze studie focust op kinderen tussen de 10 en 12 jaar oud. Waarom het belangrijk is om die specifieke groep te bestuderen, wordt later verduidelijkt.
Voordat er dieper wordt ingegaan op het belang van FA, is het tevens belangrijk om te begrijpen wat dit betekent voor die leeftijdsgroep. FA is niet enkel sporten of naar school fietsen: het omvat alle vormen van beweging, zijnde spelen, sport, transport, huishoudelijke taken, hobby’s, lessen LO op school, enzovoort (Sallis et al, 2006). De WHO (2018) beschrijft het als elke lichaamsbeweging geproduceerd door de lichaamsspieren en leidende tot energieverbruik. Het kan dus overal plaatsvinden, zoals bijvoorbeeld op school, thuis of zelfs op straat. Omdat de manier waarop en de locatie geen belang hebben, zijn de richtlijnen van de WHO (2018) zeer flexibel. Kinderen tussen de 5 en 17 jaar oud zouden dagelijks 60 minuten aan matige tot intensieve FA moeten doen. Matige intensiteit komt overeen met een MET-waarde tussen de 3 en 6. Hierbij kan de persoon nog spreken tijdens de FA, maar is de hartslag al verhoogd. Voorbeelden van zulke activiteiten zijn wandelen, fietsen, maar bijvoorbeeld ook huishoudelijke taken zoals poetsen. Indien de MET-waarde hoger ligt dan 6, dan spreken we over een hoge intensiteit. Voorbeelden hiervan zijn hardlopen en voetballen (Ainsworth, Haskell, & White, 2000). WHO’s richtlijn overschrijden zou daarnaast leiden tot extra gezondheidsvoordelen. De manier waarop de richtlijn wordt behaald is vrij te kiezen, met een voorkeur voor aerobe activiteit. Aerobe activiteit is vaak langdurig en de ademhaling en hartslag zijn verhoogd. Hierdoor wordt er meer zuurstof verbruikt door het lichaam. Die vorm van activiteit versterkt de algehele conditie en het cardiovasculair systeem. Voorbeelden van zulke activiteiten zijn lopen, fietsen, zwemmen, snelwandelen, dansen, enzovoort. Daarnaast is het ook aangeraden om minstens drie keer per week aan hoge intensiteit te bewegen met een focus op kracht en flexibiliteit. Dit kan aan de
