A Systematic Review of Multi-Component Comprehensive School Physical Activity Program (CSPAP) Interventions

Abstract

Objective:

To identify, review, and describe multicomponent physical activity (PA) interventions in terms of: (a) number and combination of Comprehensive School Physical Activity Program (CSPAP) components, (b) study characteristics, and (c) primary outcomes.

Data Source:

Five electronic databases (i.e., PubMed, PsychInfo, Physical Education Index, Sport Discus, and ERIC).

Study Inclusion and Exclusion Criteria:

Included articles were peer-reviewed, written in English language, published since 1987, and included multicomponent school-based interventions.

Data Extraction:

Data items extracted were: school level, setting, CSPAP component description, health outcomes, academic outcomes, main conclusion, and reference.

Data Synthesis:

Included articles were synthesized by: (1) CSPAP components utilized, and (2) research outcome measured (i.e., health or academic).

Results:

Across 32 studies, 11 included physical education plus 1 additional CSPAP component (PE + 1); 10 included PE + 2 additional CSPAP components; 8 included PE + 3 additional CSPAP components; and 1 included all 5 CSPAP components. Two other studies included 2 or 3 CSPAP components without PE. Most interventions targeted health outcomes (94%) rather than academic outcomes (6%).

Conclusions:

Multicomponent approaches aligned with CSPAPs are effective in promoting PA and other positive outcomes for youth in schools. Future research should seek to understand effects of CSPAP components on a variety of outcomes and settings.

Keywords

school-wide physical activity school health physical education

Introduction

A Comprehensive School Physical Activity Program (CSPAP) is a multi-component approach to providing physical activity (PA) opportunities within and beyond the school day. The goal of a CSPAP is to increase the likelihood that children and adolescents: (1) obtain the recommended 60 minutes of PA each day,¹ and (2) further develop their physical literacy skills outside of physical education.² CSPAP is recognized as the national framework for school-wide PA by the Centers for Disease Control and Prevention³ and is endorsed by many national organizations such as the Society of Health and Physical Educators of America⁴ and the Institute of Medicine.⁵

A CSPAP is comprised of 5 components with quality physical education (PE) as the foundation that provides students with the knowledge, skills, and dispositions for a lifetime of PA.⁶ According to SHAPE America, a quality PE program contains 4 essential components: (a) policy and environment (e.g., appropriate class sizes), (b) curriculum (e.g., standards-based), (c) appropriate instruction (e.g., inclusion of all students) and (d) student assessment (e.g., grading related to student learning). Quality PE is a useful starting point to increase child and adolescent health, but its potential is limited by the frequency it is offered, large class sizes, and minimal curricular time.⁷ Because of these limitations, other opportunities for PA should be offered for children and adolescents to achieve 60 minutes of moderate to vigorous PA in their day and, ultimately, understand how to be physically active for life. These opportunities include: PA during the school day (e.g., classroom PA), before and after school PA programs (e.g., intramurals), staff involvement (e.g., staff participation in PA), and family and community engagement (e.g., family members participate in school PA programs).^4,5,7,8

Multi-component PA interventions are operationally defined as initiatives that promote student, staff, or school community PA by addressing more than 1 component of CSPAP. Although similar literature reviews have been conducted on PA interventions among youth,⁹ school-based PA interventions,^10–13 and CSPAP-specific research,^7,14,15 there remains a need for a review of multicomponent PA interventions that contextualizes the variety of combinations of CSPAP components to show their impact on student health and academic outcomes in a variety of settings. There is also a need to organize combinations of CSPAP components with PE as the foundation. Therefore, the purpose of this study was to review, present, and synthesize the published research to date on multicomponent, school-based PA interventions through the lens of the CSPAP framework.

Objective

Multicomponent PA interventions were classified in terms of: (a) the number and combination of CSPAP components, (b) study characteristics, and (c) primary outcomes. The objective and unique contribution of this review is that it emphasizes multicomponent school interventions with PE as the cornerstone, makes connections to additional components of the CSPAP framework, and identifies impacts on health and academic outcomes.

Methods

Data Sources

This work was funded by a national collective impact and advocacy organization and was originally reported as a practical summary of CSPAP research.¹⁶ The current paper focuses on research implications. The systematic review protocol was prepared and reported in accordance with the Preferred Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) 2015 statement.¹⁷ Electronic databases of PubMed, Psych Info, Physical Education Index, Sport Discus, and ERIC were searched between 1987 (the beginning of the Coordinated School Health Model)¹⁸ and July 2018. These databases were chosen due to their coverage of physical health, school wellness, and education domains.¹⁹ Although the term “CSPAP” did not emerge in the literature until 2007,²⁰ multi-component approaches to school-based PA promotion align closely with a coordinated school health model; therefore 1987 was selected as an inclusive starting date.

The search strategy (see Table 1) included search terms that were created by using similar multicomponent systematic review parameters²¹ and guiding definitions (CDC, 2014). The search terms fell into one of 3 content categories (multicomponent terms; school physical health terms; academic terms). Multicomponent search terms (e.g., school-wide) were applied first to narrow the search process to find articles that assessed the implementation of a broader school intervention approach (beyond 1 CSPAP component). School physical health terms (e.g., physical education) and academic terms (e.g., class grades) were subsequently added to narrow the search to address specific outcomes related to a multicomponent approach. One term per content category was entered per search field until all combinations of terms across the categories were exhausted.

Table 1.

Search Terms by Content Categories.

Multicomponent terms (category 1)	School physical health terms (category 2)	Academic terms (category 3)
school-wide comprehensive coordinated multicomponent whole-of-school comprehensive school physical activity program	physical education physical activity physical education & physical activity	physical health mental health emotional health academic achievement academic performance class grades standardized tests graduation rates classroom behavior attendance absenteeism dropout rates behavioral problems cognition concentration memory fitness BMI

Note. Example searches:

(1) school-wide + physical education + physical health.

(2) school-wide + physical education + mental health.

(3) school-wide + physical education + emotional health.

Inclusion and Exclusion Criteria

Studies were eligible for inclusion if they were published in English-language journals, and reported on school-based multicomponent interventions that examined health and/or academic outcomes of individuals in primary and secondary schools in or outside of the U.S. Studies could be original research articles, qualitative studies, and did not have to include a control group. Studies were excluded if the intervention included only 1 component (e.g., PE only) and if they were conducted in pre-schools or post-secondary institutions.

Data Extraction

To determine the eligibility of the studies, 2 authors separately screened titles, abstracts, and full text articles in a sequential manner to determine if the articles met the inclusion criteria. Any article called into question was deliberated by 2 reviewers (e.g., whether the article met inclusion criteria) until agreement was met. If agreement was not met, questionable articles were then discussed with the 2 other authors to confirm potential article inclusion. Once all relevant articles were obtained, they were organized by number and type of CSPAP component in a Microsoft^® Excel spreadsheet (Microsoft Corporation, Redmond, VA), and the following data items were extracted: author/date, reference, source (i.e., database), search term, main conclusion, school level, setting, CSPAP components included, description of CSPAP components, utilized programs, health outcomes, and academic outcomes.

Data Synthesis

Results were organized into 2 sections by: (1) the number and combination of CSPAP components used in multicomponent interventions (e.g., PE + 1), and (2) type of outcome (i.e., academic and health outcomes). Tabulated results showed information on the article reference, number and type of CSPAP components used, study characteristics (i.e., country, school setting, school level, socioeconomic status [SES], participants), and primary outcomes (i.e., health and academic).

Results

Overview

The study selection and inclusion process is outlined in Figure 1. The database search yielded 27,761 initial publications and 141 sources were gathered from a pre-existing best practice document on physical education and school physical activity.²¹ Sixty articles met inclusion criteria based on title and abstract relevance and full-text publications were screened for eligibility. Twenty-eight articles were excluded after reading the full text due to not being multicomponent school-based interventions or applicable to CSPAP.

Figure 1.

PRISMA diagram (Moher et al 2009) depicting the different phases of this review.

Study Characteristics

Of the 32 studies, 18 were conducted in the U.S., while 14 were conducted in international settings. Eight studies were conducted in urban settings,^22-29 2 in rural and urban settings,^30,31 1 in a rural setting,³² 1 in a suburban setting,³³ while 20 did not specify the setting. Twenty-three studies were conducted in elementary schools, 8 were conducted in secondary schools,^{22,23,32,34-38} and 1 was conducted in both elementary and secondary schools.³⁹ Twelve studies were conducted in schools in low-income areas,^{24-26,29,32,34,36,40-44} while 20 did not specify SES. All studies provided information on the number and age or school level of participants. In the following sections, interventions that included PE are presented first to uphold the foundational importance of this subject and component area to the CSPAP model.^6,8

PE + 1: Physical Education + 1 Additional CSPAP Component (11 Studies)

Eleven of the 32 articles reviewed (34%) included PE and 1 additional CSPAP component intervention (see Table 2).^{24,25,27,29,40,42-47} Nearly all of the 11 articles (91%) included PA during school programming as the additional component, while only 1 included before/after school PA.²⁹ PA during school initiatives included enhancing recess or integrating classroom-based PA breaks. Four of the PE + 1 multicomponent interventions were conducted in urban settings in the United States,^24,27,29,44 while 7 did not specify school locale; all occurred in elementary schools. Ten of the studies examined health outcomes, while only 1 examined an academic outcome (i.e., on-task behavior).⁴⁰ Health outcomes included PA behaviors (n = 7), motor skills (n = 2), and body mass index (BMI) (n = 1).

Table 2.

PE + 1: Physical Education + 1 Additional CSPAP Component.

Reference	CSPAP component description	Study characteristics	Primary outcomes
Brusseau & Kulinna, 2015	PE: Taught 2 days per week for 50-minutes and employed Dynamic PE curriculum PA During School: Multiple recesses (1 unstructured)	Country: United States School Setting: Not specified School Level: Elementary SES: Not specified Participants: 4 schools with 5th grade children (average age 10.0)	Children accumulated the greatest PA on days with PE and multiple recess opportunities. Children accumulated the least amount of PA on days with only 1 recess opportunity. Children accumulated an additional 1140 steps and 4.1 min of MVPA on PE days.
Brusseau et al, 2016	PE: Taught 1 day per week for 50-minutes and employed a dynamic PE curriculum PA During School: Recess led by PALs, daily classroom PA integration	Country: United States School Setting: Not specified School Level: Elementary SES: Low-income Participants: Three schools with an average student age of 8.4 years old	There were 3.02 and 2.34 greater odds that a child would achieve step count and MVPA standards and 2.26 greater odds that a child would achieve aerobic fitness standards at 12 weeks compared with baseline.
Burns et al, 2015	PE: Monthly in-service opportunities PA During School: Recess led by PALs, daily classroom PA integration	Country: United States School Setting: Not specified School Level: Elementary SES: Low-income Participants: Four schools with children aged 8-11 (grades 4-5)	School day step counts increased from the end of pre-intervention to the start of post-intervention.
Burns et al, 2016	PE: In-service trainings twice per semester on quality PE PA During School: Daily 5-minute classroom energizers using Take 10! program	Country: United States School Setting: Not specified School Level: Elementary SES: Low-income Participants: Three schools with children aged 5-12 (grades k-6)	There were 7.49 greater odds of a classroom achieving 80% on-task behavior at 6 weeks compared to baseline and 27.93 greater odds of a classroom achieving 80% on-task behavior compared to baseline.
Burns, Brusseau, et al, 2017	PE: Monthly in-service opportunities PA During School: Recess led by PALs, daily classroom PA integration	Country: United States School Setting: Urban School Level: Elementary SES: Low-income Participants: Five schools with children aged 5-12 (grades k-6)	Children enrolled in schools where PALs employed goal setting displayed greater increases in school day step counts (+665 steps) compared to control schools. In third-grade children in schools where PALs employed goal setting, there was a decrease in step counts from baseline to follow up (-832).
Burns, Fu, et al, 2017a	PE: Monthly in-service opportunities PA During School: Recess led by PALs, daily classroom PA integration	Country: United States School Setting: Not specified School Level: Elementary SES: Low-income Participants: Three schools with children aged 5-12 (grades k-6)	Motor skills improved by approx. 10% following 12-weeks of CSPAP among children. Children aged 7 to 12 years displayed greater TGMD-2 percent change from baseline compared with children who were aged 6 years.
Burns, Fu, et al, 2017b	PE: Classes focused on motor skill development PA During School: Recess led by PALs, daily classroom PA integration	Country: United States School Setting: Urban School Level: Elementary SES: Low-income Participants: Five schools with children aged 5-12 (grades 1-6)	Children scores on the overall gross motor skills scores showed statistically significant increases over the intervention period. Significant improvements were also seen for locomotor skills and ball skills sub-test scores.
Cradock et al, 2014	PE: Promotion of 150 minutes of quality PE PA During School: Integration of classroom PA and recess	Country: United States School Setting: Urban School Level: Elementary SES: Not specified Participants: Six schools with children in grades 4-5	Intervention schools demonstrated greater increases in minutes per day of MVPA and vigorous PA and greater decreases in minutes per day of sedentary time.
Jansen et al, 2011	PE: Three PE lessons per week PA Before/After School: Additional sport & play activities	Country: Netherlands School Setting: Inner-city/urban School Level: Elementary SES: Schools in low-income neighborhoods Participants: 2,622 children aged 6-12	Significant positive intervention effects were found for percentage overweight children, waist circumference, and 20 m shuttle run among those in grades 3-5. The prevalence of overweight in grades 3-5 increased by 4.3% in the control group and by 1.3% in the intervention group.
Magnusson et al, 2011	PE: One day on-site counseling PA During School: Teachers provided with PA promoting materials	Country: Iceland School Setting: Not specified School Level: Elementary SES: Not specified Participants: Six schools with children in the second grade	Children in the intervention schools were more physically active at moderate to vigorous intensities compared to those in control schools after 1 year of the intervention.
Weaver et al, 2018	PE: Teacher training on PA integration PA During School: Classroom PA integration	Country: United States School Setting: Not specified School Level: Elementary SES: Not specified Participants: 1,460 elementary aged children	Intervention boys and girls meeting the 30 min/day of MVPA increased from 18.5% to 32.2% and increased their MVPA during school hours 8.8% more than control students. During classroom time, boys and girls increased their MVPA 6.4% and 2.4% more than control students. During PE boys and girls increased their MVPA 11.5% and 8.4% more than control students and decreased in sedentary time 10.3% and 2.2% more than control students.

Note. PE = physical education; PA = physical activity; SES = socioeconomic status.

PE + 2: Physical Education + 2 Additional CSPAP Components (10 Studies)

Ten of the 32 articles reviewed (31%) included PE and 2 additional CSPAP component interventions (see Table 3).^{28,30-33,36,38,48-50} Of the 10 articles, 5 (50%) included the additional combination of PA during school and family and community engagement programming,^30-32,36,49 3 (30%) combined PA during school and before/after school PA programming,^28,48,50 and 2 (20%) combined before/after school PA and family and community engagement.^33,38 Of the PA during school initiatives, 5 incorporated classroom PA breaks,^{28,30,32,48,49} and 3 included PA during recess or lunch.^31,36,50 Of the family and community engagement initiatives, 5 included PA homework,^{30,31,33,38,49} and 2 included take-home PA materials.^32,36 Of the before and after school PA initiatives, 2 included active transportation,^28,48 2 included self-monitoring of PA^33,38 and 1 included extracurricular PA.⁵⁰ Five of the studies did not specify the locale of the interventions,^36,38,48-50 while 2 were conducted in both rural and urban settings,³⁰ 1 was conducted in a rural setting,³² 1 was conducted in an urban setting,²⁸ and 1 was conducted in a suburban setting.³³ Seven interventions occurred in elementary schools, while 3 took place in secondary schools,^32,36,38 and all examined health outcomes as the primary outcomes. Health outcomes included PA (n = 7), muscular or aerobic fitness (n = 2), and BMI (n = 1)

Table 3.

PE + 2: Physical Education + 2 Additional CSPAP Component.

Reference	CSPAP component description	Study characteristics	Primary outcomes
Eather et al, 2013	PE: 8-Week, 60-Min PE program PA During School: Activity task cards Family & Community Engagement: Children, and family members were given an 8-week home activity program	Country: Australia School Setting: Not specified School Level: Elementary SES: Not specified Participants: 2 schools with children aged 9-11	A significant group by time effect was exhibited for the sit and reach test, the 7-stage sit-up test, and the wall squat test. Large within group effects were found for the intervention group for flexibility, muscular fitness, and the 7-stage sit up test. A medium to large effect was found for muscular fitness using the basketball throw test.
Grasten, 2015	PE: Teacher training to increase child motivation and PE enjoyment PA During School: Integration of classroom PA PA Before/After School: Active transportation to school/integration of afterschool programs	Country: Finland School Setting: Not specified School Level: Elementary SES: Not specified Participants: 2 schools with children aged 10-13	Children’s total light PA remained stable over 2 years of the program. The segments of before-school, after-school, short breaks, and girls’ class time showed declining patterns across the period.
Grydeland et al, 2013	PE: Teachers integrated SPARK program PA During School: Once a week 10-min classroom PA PA Before/After School: Active commute to school campaigns	Country: Norway School Setting: Largest towns/municipalities in SE Norway School Level: Elementary SES: Not specified Participants: 37 schools with children aged 11-12	The intervention group showed a net effect of 50 counts per minute increase from baseline to post in overall PA. The intervention affected PA among the normal weight group more positively than the overweight.
Hollis et al, 2016	PE: Teachers received 2 professional learning workshops that focused on increasing MVPA & motivation PA During School: PA breaks at least 2 days per week Family & Community Engagement: Take-home health materials distributed	Country: Australia School Setting: Rural School Level: Secondary SES: Schools in low-income neighborhoods Participants: Schools with children aged 12-13	There were group by time effects for weight and BMI in favor of the intervention group. These findings were consistent for weight and BMI at 24 months with group by time effects also found for BMI favoring the intervention group.
Kriemler et al, 2010.	PE: PE 3 times per week PA During School: Three to 5 daily PA breaks (2-5 minutes each.) Family & Community Engagement: PA homework	Country: Switzerland School Setting: Rural and urban locations School Level: Elementary SES: Not specified Participants: 95 schools with children aged 6-12	Children in the intervention group showed more negative changes in skinfolds, but improved in aerobic fitness & PA.
Meyer et al, 2014	PE: Three 45-minute PE lessons per week PA During School: Extracurricular PA for overweight & obese students during school breaks Family & Community Engagement: PA homework	Country: Switzerland School Setting: Rural and urban locations School Level: Elementary SES: Not specified Participants: 15 schools with children aged 6-12	Children in the intervention group had a significantly higher average level of aerobic fitness at follow-up while the immediate beneficial effects on the other primary outcomes were not sustained.
Sallis et al, 1997	PE: SPARK PE classes were implemented 3 times per week for 30 minutes and included health-fitness and skill-fitness activities Before/After School PA: Included self-monitoring, goal setting, stimulus control, self reinforcement, self-instruction and problem solving for PA outside of school Family & Community Engagement: Homework and monthly newsletters were intended to stimulate parent-child interaction for PA	Country: United States School setting: Suburban School level: Elementary SES: Not specified Participants: 955 elementary aged students	Students spent more minutes per week being physically active in specialist-led PE than in control classes. After 2 years, girls in the specialist-led condition had more abdominal strength and endurance and cardiorespiratory endurance than girls in the control condition. No effects were found on PA outside of school.
Sutherland et al, 2016	PE: Teacher training to maximize PA in PE PA During School: PA during school breaks (lunch/recess) twice per week Family & Community Engagement: Newsletter distributed	Country: Australia School Setting: Not specified School Level: Secondary SES: Schools in low-income neighborhoods Participants: 10 schools with children aged 12-13	The analysis revealed that the intervention group performed significantly more vigorous PA, equating to 27 min more MVPA per week.
Verstraete et al, 2007	PE: Integration of SPARK PA During School: Classroom PA breaks were provided by classroom teachers and lunch/recess equipment was provided during school breaks Before/After School PA: Extracurricular activities were provided to students and led by the PE teacher	Country: Belgium School Setting: Not specified School level: Elementary SES: Not specified Participants: 764 children; average age 11.2	Children’s moderate PA and MVPA decreased less in intervention schools. Children in intervention schools reported significantly more moderate PA in leisure time than the control group.
Young et al, 2006	PE: Classes were optimized for PA (i.e., were active in nature) and taught 5 days per week. Before/After School PA: PA students were encouraged to keep weekly exercise logs that they were provided feedback on from teachers Family & Community Engagement: Family workshop, monthly newsletters, and adult-child homework assignments	Country: United States School setting: Not specified School level: Secondary SES: Not specified Participants: 221 females in 9th grade	Intervention PE classes spent 46.9% of classes in MVPA compared with 30.5% of time for control classes. The proportion of participants who spent 3 or more hours viewing television during school days declined from 22.3% to 17% in the intervention group but stayed the same for the control group. Both groups improved cardiorespiratory fitness.

Note. PE = physical education; PA = physical activity; SES = socioeconomic status.

PE + 3: Physical Education + 3 Additional CSPAP Components (8 Studies)

Eight of the 32 interventions reviewed (25%) included PE and 3 additional CSPAP component interventions (see Table 4).^{23,26,35,37,39,51-53} All PE + 3 multicomponent interventions included PA during school programming as one of the additional components. Four of the PE + 3 interventions included the combination of PA during school, before/after school PA, and family and community engagement as additional components to PE.^23,37,39,53 Three included the combination of PA during school, before/after school PA, and staff involvement,^26,51,52 and 1 included the combination of PA during school, staff involvement, and family and community engagement.³⁵ Of the PA during the school day initiatives, 6 included active recess or PA during other times at school (e.g., lunch),^{26,35,37,39,51,52} while 2 included classroom PA breaks.^23,53 Of the before/after school PA school initiatives, 6 included afterschool PA programs (e.g., Healthy Kids Club),^{26,37,39,51-53} and 1 included active transportation.²³ Of the staff involvement initiatives, 3 included PA information distributed by staff,^26,51,52 and 1 included staff role modeling.³⁵ Of the family and community engagement initiatives, 2 included take home information or activities for families,^23,39 1 included connecting with community partners (e.g., YMCA) to create school PA programs,³⁷ 1 included parent-led PA,⁵³ and 1 was unspecified.³⁵ One of the studies was conducted in an urban setting,²⁶ 1 was conducted in a suburban setting,²³ while 6 did not specify school locale.^{35,38,39,51-53} Four were conducted in elementary schools,^26,51-53 3 were conducted in secondary schools,^23,35,37 and 1 was conducted in both elementary and secondary schools.³⁹ Seven of the studies examined health outcomes (i.e., weight/BMI = 3; physical activity = 3; fitness = 1), while 1 study examined academic outcomes (i.e., reading and math score improvements).⁵²

Table 4.

PE + 3: Physical Education + 3 Additional CSPAP Component.

Reference	CSPAP component description	Study characteristics	Primary outcomes
Bergh et al, 2012	PE: Teachers integrated the SPARK program PA During School: Integrated classroom PA PA Before/After School: Active transportation to school Family Engagement: Fact sheets distributed among parents	Country: Norway School Setting: Towns/Municipalities School Level: Secondary SES: Not specified Participants: Schools with children aged 11-12 (grade)	At post intervention, social support was higher from intervention teachers, while a negative effect was found for self-efficacy. Weight status moderated the effect on enjoyment, with reduced enjoyment observed among overweight.
Centeio et al, 2014	PE: Teachers received evidence-based curriculum EPEC Staff Involvement: Read/distributed healthy tips of the day and healthy living newsletters, & hung health-promoting messaging PA During School: Implemented active recess and classroom PA integration PA Before/After School: Integrated the Healthy Kids Club program	Country: United States School Setting: Urban School Level: Elementary SES: Schools in low-income neighborhoods Participants: 20 schools with children aged 8-10 (grade 4)	Students increased MVPA during school an average of almost 4.5 minutes per day. Overall significant differences were found from pre to post for time spent in MVPA in PE, lunch, recess and classroom time.
Centeio et al, 2018a	PE: Evidence-based curriculum EPEC Staff Involvement: Read/distributed healthy tips of the day and healthy living newsletters, & hung health-promoting messaging PA During School: Implemented active recess and classroom PA integration PA Before/After School: Integrated the Healthy Kids Club program	Country: United States School setting: Not specified School level: Elementary SES: Not specified Participants: 628 fifth grade children	Analyses revealed a significant difference in waist to height ratio among treatment and control groups at time 2 with no significant differences based on age, sex, and race. Additionally, the analysis for BMI revealed a marginally significant lower BMI among the treatment than comparison group students.
Centeio et al, 2018b	PE: Evidence-based curriculum EPEC Staff Involvement: Read/distributed healthy tips of the day and healthy living newsletters, & hung health-promoting messaging PA During School: Implemented active recess and classroom PA integration PA Before/After School: Integrated the Healthy Kids Club program	Country: United States School setting: Not specified School level: Elementary SES: Not specified Participants: 378 fourth grade students	Program fidelity was a significant predictor of students’ reading comprehension rates of improvement, while students’ aerobic fitness level and time 2 PA levels were all significant contributors to rates of improvement in math.
Li et al, 2014	PE: Three 45-minute PE lessons per week PA During School: Extracurricular PA for overweight & obese students PA Before/After school: After school PA program Family & Community Engagement: PA homework	Country: China School Setting: Not specified School Level: Elementary & secondary SES: Not specified Participants: Schools with children aged 7 to 15 years old	The reduction of BMI was statistically significant in the intervention group compared with the increase of BMI in the control group. The decreases of triceps, subscapular, abdominal skinfold thickness and fasting glucose were also significant in the intervention group. The increase in duration of MVPA in intervention group was significantly different.
Pate et al, 2005	PE: Integrated the LEAP curriculum PA During School: PA promotion by school nurse Staff Involvement: Staff role modeling Family & Community Engagement: Not specified	Country: United States School Setting: Not specified School Level: Secondary SES: Not specified Participants: 24 schools with children aged 13-14 (grade 9)	At follow-up, 45% of girls in the intervention schools and 36% of girls in the control schools reported vigorous PA during an average of 1 or more 30-minute time blocks per day over a 3-day period.
Reed et al, 2008	PE: Two 40 min PE classes per week PA During School: Teachers delivered 15 min of moderate to intense daily PA in classrooms to achieve 75 min of extra PA per week Before/After School PA: PA clubs, such as Kilometre Club and Hip hop dance club Family & Community Engagement: Newsletters to families, parent-led walking/wheeling Wednesday and sport and motivational presentations from wheelchair basketball and the Esteem team	Country: Canada School setting: Not specified School level: Elementary SES: Not specified Participants: 268 children aged 9-11	Children in the intervention group had a 20% greater increase in fitness and a 5.7% smaller increase in blood pressure compared with the control group.
Webber et al, 2008	PE: Promoted PA for at least 50% of class time PA During School: Lunch-time Dance Dance revolution Before/After School PA: step-aerobics class, before-school open gym, basketball camp, touch football, and weekend canoe programs Family and Community Engagement: Schools were connected with community partners (e.g., YMCA) to create in-and outside of school PA programs	Country: United States School setting: Not specified School level: Secondary SES: Not specified Participants: 1721 6th graders and 3504 8th graders	Girls in intervention schools were more physically active than girls in control schools. There were no differences in fitness or body fat at either timepoint.

Note. PE = physical education; PA = physical activity; SES = socioeconomic status.

Full CSPAP: Physical Education + 4 Additional Components (1 Study)

One of the 32 articles reviewed (3%) included an intervention with all 5 CSPAP components: PE, PA during school, before/after school PA, staff involvement, and family and community engagement (see Table 5).⁴¹ A description of each of the initiatives is included in Table 5. The intervention took place in an elementary school setting and school locale was not specified. Only the health outcome of PA was examined.

Table 5.

Full CSPAP: Physical Education + 4 Additional Components.

Reference	CSPAP component description	Study characteristics	Primary outcomes
Braun et al, 2017	PE: Teachers trained to integrate more MVPA into PE lessons PA During School: Integration of classroom PA and school-wide PA morning announcements PA Before/After School: Integrated the BOKS program Family & Community Engagement: Distributed take-home health materials Staff Involvement: 30-day pedometer challenge for staff members	Country: United States School Setting: Not specified School Level: Elementary SES: Schools in low-income neighborhoods Participants: 39 schools with children in the 4th grade	The weekly estimated teacher-reported time in PA increased by 39 minutes from pre-to post-intervention: 21 minutes for recess, 17 minutes for classroom, and 1 minute for PE. The mean number of student PACER laps increased by 3 laps from pre-to post-intervention, and 1515 of 2342 (65%) students increased the number of PACER laps completed. There was a positive association between school-level changes in school-based PA time and school-level changes in PACER laps.

Note. PE = physical education; PA = physical activity; SES = socioeconomic status.

Two Multicomponent Interventions—Without PE (1 Study)

One of the 32 articles reviewed (3%) was a multicomponent intervention study that included 2 CSPAP components, PA during school and family and community involvement, and no PE component (see Table 6).²² The intervention involved the integration of classroom PA by teachers as well as assigning PA homework with parents and took place in 4 urban elementary schools. The primary health outcome studied was PA.

Table 6.

Two Multicomponent Interventions (Without PE).

Reference	CSPAP component description	Study characteristics	Primary outcomes
Barr-Anderson et al, 2012	PA During School: Peer and teacher led classroom PA integration Family & Community Engagement: PA & Healthy Eating Homework	Country: United States School Setting: Urban School Level: Secondary SES: Not specified Participants: Four schools with children in the 6th grade	The intervention was successful in increasing moderate PA in all students and moderate and vigorous PA among girls. Teachers and students reported a high level of satisfaction and receptivity with the intervention. All teachers thought the DVDs were well-received and 87% of students reported that they would recommend the enhanced program to peers.

Note. PE = physical education; PA = physical activity; SES = socioeconomic status.

Three Multicomponent Interventions—Without PE (1 Study)

One of the 32 articles reviewed (3%) included 3 CSPAP components (i.e., PA during school, staff involvement, and family involvement) without PE as an intervention (see Table 7).³⁴ The 3-component intervention involved PA integration in the classroom with a teacher-training component (i.e., staff involvement), lunchtime PA sessions led by students (i.e., PA during the school day), and newsletters distributed to parents about strategies to reduce recreational screen time (i.e., family involvement). The study was conducted in secondary schools and school locale was not specified. Primary outcomes of the study were health outcomes (i.e., student weight/BMI).

Table 7.

Three Multicomponent Interventions (Without PE).

Reference	CSPAP component description	Study characteristics	Primary outcomes
Lubans et al, 2016	Staff Involvement: Teacher professional learning PA During School: Lunchtime PA led by students and PA sessions led by teachers Family & Community Engagement: Newsletter to parents on reducing screen time	Country: Australia School Setting: Not specified School Level: Secondary SES: Schools in low-income neighborhoods Participants: 14 schools with children aged 12-14	After 18 months, there were no effects found for BMI or waist circumference. Sustained effects were found for screen-time, resistance training skill competency, and motivational regulations for school sport.

Note. PA = physical activity; SES = socioeconomic status.

Academic Outcomes (2 Studies)

Two of the 32 articles reviewed (6%) included interventions that targeted academic outcomes (see Table 8).^40,51 One article included PA during school combined with PE,⁴⁰ and 1 included PE, staff involvement, and PA during school.⁵¹ The article that included PE combined with PA during school resulted in greater odds of achieving 80% on-task behavior at 6-and 12-week follow-up compared to baseline.⁴⁰ The article that included PE, staff involvement, and PA during school found that implementing the Building Healthy Communities program significantly predicted students’ reading comprehension rates of improvement, while students’ aerobic fitness levels and PA levels were significant predictors of rates of improvement in math.⁵¹

Table 8.

Academic and Health Outcomes.

Reference	CSPAP component description	Study characteristics	Primary academic outcomes
Burns et al, 2016	PE: In-service trainings twice per semester on quality PE PA During School: Daily 5-minute classroom energizers using Take 10! program	Country: United States School Setting: Not specified School Level: Elementary SES: Low-income Participants: Three schools with children aged 5-12 (grades k-6)	There were 7.49 greater odds of a classroom achieving 80% on-task behavior at 6 weeks compared to baseline and 27.93 greater odds of a classroom achieving 80% on-task behavior at 12 weeks compared to baseline.
Centeio et al, 2018b	PE: Evidence-based curriculum EPEC Staff Involvement: Read/distributed healthy tips of the day and healthy living newsletters, & hung health-promoting messaging PA During School: Implemented active recess and classroom PA integration	Country: United States School setting: Not specified School level: Elementary SES: Not specified Participants: 378 fourth grade students	Fidelity of the Building Healthy Communities program significantly predicted students’ reading comprehension rates of improvement, while students’ aerobic fitness level and time 2 PA levels were all significant contributors to rates of improvement in math
Reference	CSPAP Component Description	Study Characteristics	Primary Health Outcomes
Barr-Anderson et al, 2012	PA During School: Peer and teacher led classroom PA integration Family & Community Engagement: PA & Healthy Eating Homework	Country: United States School Setting: Urban School Level: Secondary SES: Not specified Participants: Four schools with children in the 6th grade	The intervention was successful in increasing moderate PA in all students and moderate and vigorous PA among girls. Teachers and students reported a high level of satisfaction and receptivity with the intervention. All teachers thought the DVDs were well-received and 87% of students reported that they would recommend the enhanced program to peers.
Bergh et al, 2012	PE: Teachers integrated the SPARK program PA During School: Integrated classroom PA PA Before/After School: Active transportation to school Family Engagement: Fact sheets distributed among parents	Country: Norway School Setting: Towns/Municipalities School Level: Secondary SES: Not specified Participants: Schools with children aged 11-12 (grade)	At post intervention, social support was higher from intervention teachers, while a negative effect was found for self-efficacy. Weight status moderated the effect on enjoyment, with reduced enjoyment observed among overweight
Braun et al, 2017	PE: Teachers trained to integrate more MVPA into PE lessons PA During School: Integration of classroom PA and school-wide PA morning announcements PA Before/After School: Integrated the BOKS program Family & Community Engagement: Distributed take-home health materials Staff Involvement: 30-day pedometer challenge for staff members	Country: United States School Setting: Not specified School Level: Elementary SES: Schools in low-income neighborhoods Participants: 39 schools with children in the 4th grade	The weekly estimated teacher-reported time in PA increased by 39 minutes from pre-to post-intervention: 21 minutes for recess, 17 minutes for classroom, and 1 minute for PE. The mean number of student PACER laps increased by 3 laps from pre-to post-intervention, and 1515 of 2342 (65%) students increased the number of PACER laps completed. There was a positive association between school-level changes in school-based PA time and school-level changes in PACER laps.
Brusseau & Kulinna, 2015	PE: Taught 2 days per week for 50-minutes and employed Dynamic PE curriculum PA During School: Multiple recesses (1 unstructured)	Country: United States School Setting: Not specified School Level: Elementary SES: Not specified Participants: 4 schools with 5th grade children (average age 10.0)	Children accumulated the greatest PA on days with PE and multiple recess opportunities. Children accumulated the least amount of PA on days with only 1 recess opportunity. Children accumulated an additional 1140 steps and 4.1 min of MVPA on PE
Brusseau et al, 2016	PE: Taught 1 day per week for 50-minutes and employed a dynamic PE curriculum PA During School: Recess led by PALs, daily classroom PA integration	Country: United States School Setting: Not specified School Level: Elementary SES: Low-income Participants: Three schools with an average student age of 8.4 years old	There were 3.02 and 2.34 greater odds that a child would achieve step count and MVPA standards and 2.26 greater odds that a child would achieve aerobic fitness standards at 12 weeks compared with baseline.
Burns et al, 2015	PE: Monthly in-service opportunities PA During School: Recess led by PALs, daily classroom PA integration	Country: United States School Setting: Not specified School Level: Elementary SES: Low-income Participants: Four schools with children aged 8-11 (grades 4-5)	School day step counts increased from the end of pre-intervention to the start of post-intervention
Burns, Brusseau, et al, 2017	PE: Monthly in-service opportunities PA During School: Recess led by PALs, daily classroom PA integration	Country: United States School Setting: Urban School Level: Elementary SES: Low-income Participants: Five schools with children aged 5-12 (grades k-6)	Children enrolled in schools where PALs employed goal setting displayed greater increases in school day step counts (+665 steps) compared to control schools. In third-grade children in schools where PALs employed goal setting, there was a decrease in step counts from baseline to follow up (-832).
Burns, Fu, et al, 2017a	PE: Monthly in-service opportunities PA During School: Recess led by PALs, daily classroom PA integration	Country: United States School Setting: Not specified School Level: Elementary SES: Low-income Participants: Three schools with children aged 5-12 (grades k-6)	Motor skills improved by approx. 10% following 12-weeks of CSPAP among children. Children aged 7 to 12 years displayed greater TGMD-2 percent change from baseline compared with children who were aged 6 years
Burns, Fu, et al, 2017b	PE: Classes focused on motor skill development PA During School: Recess led by PALs, daily classroom PA integration	Country: United States School Setting: Urban School Level: Elementary SES: Low-income Participants: Five schools with children aged 5-12 (grades 1-6)	Children scores on the overall gross motor skills scores showed statistically significant increases over the intervention period. Significant improvements were also seen for locomotor skills and ball skills sub-test scores.
Centeio et al, 2014	PE: Teachers received evidence-based curriculum EPEC Staff Involvement: Read/distributed healthy tips of the day and healthy living newsletters, & hung health-promoting messaging PA During School: Implemented active recess and classroom PA integration PA Before/After School: Integrated the Healthy Kids Club program	Country: United States School Setting: Urban School Level: Elementary SES: Schools in low-income neighborhoods Participants: 20 schools with children aged 8-10 (grade 4)	Students increased MVPA during school an average of almost 4.5 minutes per day. Overall significant differences were found from pre to post for time spent in MVPA in PE, lunch, recess and classroom time.
Centeio et al, 2018a	PE: Evidence-based curriculum EPEC Staff Involvement: Read/distributed healthy tips of the day and healthy living newsletters, & hung health-promoting messaging PA During School: Implemented active recess and classroom PA integration PA Before/After School: Integrated the Healthy Kids Club program	Country: United States School setting: Not specified School level: Elementary SES: Not specified Participants: 628 fifth grade children	Analyses revealed a significant difference in waist to height ratio among treatment and control groups at time 2 with no significant differences based on age, sex, and race. Additionally, the analysis for BMI revealed a marginally significant lower BMI among the treatment than comparison group students.
Cradock et al, 2014	PE: Promotion of 150 minutes of quality PE PA During School: Integration of classroom PA and recess	Country: United States School Setting: Urban School Level: Elementary SES: Not specified Participants: Six schools with children in grades	Intervention schools demonstrated greater increases in minutes per day of MVPA and vigorous PA and greater decreases in minutes per day of sedentary time.
Eather et al, 2013	PE: 8-Week, 60-Min PE program PA During School: Activity task cards Family & Community Engagement: Children, and family members were given an 8-week home activity program	Country: Australia School Setting: Not specified School Level: Elementary SES: Not specified Participants: 2 schools with children aged 9-11	A significant group by time effect was exhibited for the sit and reach test, the 7-stage sit-up test, and the wall squat test. Large within group effects were found for the intervention group for flexibility, muscular fitness, and the 7-stage sit up test. A medium to large effect was found for muscular fitness using the basketball throw test.
Grasten, 2015	PE: Teacher training to increase child motivation and PE enjoyment PA During School: Integration of classroom PA PA Before/After School: Active transportation to school/integration of afterschool programs	Country: Finland School Setting: Not specified School Level: Elementary SES: Not specified Participants: 2 schools with children aged 10-13	Children’s total light PA remained stable over 2 years of the program. The segments of before-school, after-school, short breaks, and girls’ class time showed declining patterns across the period.
Grydeland et al, 2013 .	PE: Teachers integrated SPARK program PA During School: Once a week 10-min classroom PA PA Before/After School: Active commute to school campaigns	Country: Norway School Setting: Largest towns/municipalities in SE Norway School Level: Elementary SES: Not specified Participants: 37 schools with children aged 11-12	The intervention group showed a net effect of 50 counts per minute increase from baseline to post in overall PA. The intervention affected PA among the normal weight group more positively than the overweight
Hollis et al, 2016	PE: Teachers received 2 professional learning workshops that focused on increasing MVPA & motivation PA During School: PA breaks at least 2 days per week Family & Community Engagement: Take-home health materials distributed	Country: Australia School Setting: Rural School Level: Secondary SES: Schools in low-income neighborhoods Participants: Schools with children aged 12-13	There were group by time effects for weight and BMI in favor of the intervention group. These findings were consistent for weight and BMI at 24 months with group by time effects also found for BMI favoring the intervention group.
Jansen et al, 2011	PE: Three PE lessons per week PA Before/After School: Additional sport & play activities	Country: Netherlands School Setting: Inner-city/urban School Level: Elementary SES: Schools in low-income neighborhoods Participants: 2,622 children aged 6-12	Significant positive intervention effects were found for percentage overweight children, waist circumference, and 20 m shuttle run among those in grades 3-5. The prevalence of overweight in grades 3-5 increased by 4.3% in the control group and by 1.3% in the intervention group.
Kriemler et al, 2010	PE: PE 3 times per week PA During School: Three to 5 daily PA breaks (2-5 minutes each.) Family & Community Engagement: PA homework	Country: Switzerland School Setting: Rural and urban locations School Level: Elementary SES: Not specified Participants: 95 schools with children aged 6-12	Children in the intervention group showed more negative changes in skinfolds, but improved in aerobic fitness & PA.
Li et al, 2014	PE: Three 45-minute PE lessons per week PA During School: Extracurricular PA for overweight & obese students PA Before/After school: After school PA program Family & Community Engagement: PA homework	Country: China School Setting: Not specified School Level: Elementary & secondary SES: Not specified Participants: Schools with children aged 7 to 15 years old	The reduction of BMI was statistically significant in the intervention group compared with the increase of BMI in the control group. The decreases of triceps, subscapular, abdominal skinfold thickness and fasting glucose were also significant in the intervention group. The increase in duration of MVPA in intervention group was significantly different.
Lubans et al, 2016	Staff Involvement: Teacher professional learning PA During School: Lunchtime PA led by students and PA sessions led by teachers Family & Community Engagement: Newsletter to parents on reducing screen time	Country: Australia School Setting: Not specified School Level: Secondary SES: Schools in low-income neighborhoods Participants: 14 schools with children aged 12-14	After 18 months, there were no effects found for BMI or waist circumference. Sustained effects were found for screen-time, resistance training skill competency, and motivational regulations for school sport.
Magnusson et al, 2011	PE: One day on-site counseling PA During School: Teachers provided with PA promoting materials	Country: Iceland School Setting: Not specified School Level: Elementary SES: Not specified Participants: Six schools with children in the second grade	Children in the intervention schools were more physically active at moderate to vigorous intensities compared to those in control schools after 1 year of the intervention.
Meyer et al, 2014	PE: Three 45-minute PE lessons per week PA During School: Extracurricular PA for overweight & obese students during school breaks Family & Community Engagement: PA homework	Country: Switzerland School Setting: Rural and urban locations School Level: Elementary SES: Not specified Participants: 15 schools with children aged 6-12	Children in the intervention group had a significantly higher average level of aerobic fitness at follow-up while the immediate beneficial effects on the other primary outcomes were not sustained.
Pate et al, 2005	PE: Integrated the LEAP curriculum PA During School: PA promotion by school nurse Staff Involvement: Staff role modeling Family & Community Engagement: Not specified	Country: United States School Setting: Not specified School Level: Secondary SES: Not specified Participants: 24 schools with children aged 13-14 (grade 9)	At follow-up, 45% of girls in the intervention schools and 36% of girls in the control schools reported vigorous PA during an average of 1 or more 30-minute time blocks per day over a 3-day period.
Reed et al, 2008	PE: Two 40 min PE classes per week PA During School: Teachers delivered 15 min of moderate to intense daily PA in classrooms to achieve 75 min of extra PA per week Before/After School PA: PA clubs, such as Kilometre Club and Hip hop dance club Family & Community Engagement: Newsletters to families, parent-led walking/wheeling Wednesday and sport and motivational presentations from wheelchair basketball and the Esteem team	Country: Canada School setting: Not specified School level: Elementary SES: Not specified Participants: 268 children aged 9-11	Children in the intervention group had a 20% greater increase in fitness and a 5.7% smaller increase in blood pressure compared with the control group.
Sallis et al, 1997	PE: SPARK PE classes were implemented 3 times per week for 30 minutes and included health-fitness and skill-fitness activities Before/After School PA: Included self-monitoring, goal setting, stimulus control, self reinforcement, self-instruction and problem solving for PA outside of school Family & Community Engagement: Homework and monthly newsletters were intended to stimulate parent-child interaction for PA	Country: United States School setting: Suburban School level: Elementary SES: Not specified Participants: 955 elementary aged students	Students spent more minutes per week being physically active in specialist-led PE than in control classes. After 2 years, girls in the specialist-led condition had more abdominal strength and endurance and cardiorespiratory endurance than girls in the control condition. No effects were found on PA outside of school.
Sutherland et al, 2016	PE: Teacher training to maximize PA in PE PA During School: PA during school breaks (lunch/recess) twice per week Family & Community Engagement: Newsletter distributed	Country: Australia School Setting: Not specified School Level: Secondary SES: Schools in low-income neighborhoods Participants: 10 schools with children aged 12-13	The analysis revealed that the intervention group performed significantly more vigorous PA, equating to 27 min more MVPA per week.
Verstraete et al, 2007	PE: Integration of SPARK PA During School: Classroom PA breaks were provided by classroom teachers and lunch/recess equipment was provided during school breaks Before/After School PA: Extracurricular activities were provided to students and led by the PE teacher	Country: Belgium School Setting: Not specified School level: Elementary SES: Not specified Participants: 764 children; average age 11.2	Children’s moderate PA and MVPA decreased less in intervention schools. Children in intervention schools reported significantly more moderate PA in leisure time than the control group.
Weaver et al, 2018	PE: Teacher training on PA integration PA During School: Classroom PA integration	Country: United States School Setting: Not specified School Level: Elementary SES: Not specified Participants: 1,460 elementary aged children	Intervention boys and girls meeting the 30 min/day of MVPA increased from 18.5% to 32.2% and increased their MVPA during school hours 8.8% more than control students. During classroom time, boys and girls increased their MVPA 6.4% and 2.4% more than control students. During PE boys and girls increased their MVPA 11.5% and 8.4% more than control students and decreased in sedentary time 10.3% and 2.2% more than control students.
Webber et al, 2008	PE: Promoted PA for at least 50% of class time PA During School: lunch-time Dance Dance revolution Before/After School PA: step-aerobics class, before-school open gym, basketball camp, touch football, and weekend canoe programs Family and Community Engagement: Schools were connected with community partners (e.g., YMCA) to create in-and outside of school PA programs	Country: United States School setting: Not specified School level: Secondary SES: Not specified Participants: 1721 6th graders and 3504 8th graders	Girls in intervention schools were more physically active than girls in control schools. There were no differences in fitness or body fat at either timepoint.
Young et al, 2006	PE: Classes were optimized for PA (i.e., were active in nature) and taught 5 days per week. Before/After School PA: PA students were encouraged to keep weekly exercise logs that they were provided feedback on from teachers Family & Community Engagement: Family workshop, monthly newsletters, and adult-child homework assignments	Country: United States School setting: Not specified School level: Secondary SES: Not specified Participants: 221 females in 9th grade	Intervention PE classes spent 46.9% of classes in MVPA compared with 30.5% of time for control classes. The proportion of participants who spent 3 or more hours viewing television during school days declined from 22.3% to 17% in the intervention group but stayed the same for the control group. Both groups improved cardiorespiratory fitness.

Note. PE = physical education; PA = physical activity; SES = socioeconomic status.

Health Outcomes (30 Studies)

Thirty of the 32 articles (94%) included interventions targeting health outcomes (see Table 8). Interventions including PE and 1 additional component (n = 11) resulted in: (1) increased time spent in PA,^27,42,45-47 (2) increased steps,^24,42,43,45 (3) greater odds of achieving aerobic fitness standards,⁴² (4) improved motor skills,^25,44 (5) decreases in sedentary time,²⁷ and (6) improvements in weight, waist circumference and the 20 meter shuttle run.²⁹ Interventions including PE and 2 additional components (n = 10) resulted in: (1) increased time spent in physical activity,^{28,30,33,36,38,48,50} (2) improved flexibility and muscular fitness,⁴⁹ (3) unhealthy weight gain prevention,³² (4) improved fitness,^30,31 and (5) improved muscular strength and endurance.³³ Interventions including PE and 3 additional components (n = 7) resulted in: (1) increased time spent in PA,^26,35,37 (2) a moderating effect of weight status on PA enjoyment,²³ (3) reduced BMI,^39,51 and (4) improved fitness and blood pressure.⁵³ One intervention that included PE and 4 additional components resulted in increased time spent in PA and number of PACER laps.⁴¹ One multicomponent intervention including 2 components without PE resulted in increased time spent in PA.²² One multicomponent intervention including 3 components without PE resulted in reduced screen time, improvements in resistance training skill competencies, and increased motivation for sport.³⁴

Discussion

The purpose of this study was to identify, review, and describe multicomponent PA interventions in terms of: (a) the number and combination of CSPAP components, (b) study characteristics, and (c) primary outcomes. In all, 32 studies were found that examined multicomponent, school-based PA interventions through the lens of the CSPAP framework. Results of the review indicated that: (1) most interventions included PE as a component, (2) PE combined with PA during the school day was the most frequently used combination of CSPAP components, (3) many studies did not report demographic characteristics such as locale or SES, and (4) health outcomes were examined more than academic outcomes. The following sections will discuss what these findings mean for current and future CSPAP-related research and provide a practical summary for practitioners implementing CSPAPs.

Physical Education as CSPAP Cornerstone

Results of this review indicated that the majority of evidence (94%) related to multicomponent interventions included PE. The most common PE interventions included the implementation of evidence-based PE curriculums,^{23,24,26,28,33,43-45,51,52} training PE teachers to provide more moderate to vigorous PA (MVPA) during PE lessons,^39,46,47,50 and increasing the weekly amount of time allocated for PE.^31,36,54 Implementing an evidence-based curriculum is known as a key element of quality PE that facilitates the development of the knowledge, skills, and attitudes necessary for PA participation.⁵⁵ Additionally, increasing the amount of time students spend in MVPA during PE class is important since the national recommendation is for students to be moderately to vigorously active for at least 50 percent of class time.⁴ Together, an evidence-based PE curriculum and more time spent in MVPA during PE support the goal of a CSPAP, which is to develop physical literacy that promotes lifelong PA. Finally, it is important to note that interventions that increased the weekly amount of time for PE rarely achieved the 150 minutes of PE recommended at the elementary level or 225 at the secondary level.^31,36,54 Although elements of quality PE are present in these interventions, there is still a need to understand how policies can be enforced that hold states, districts, and schools accountable to implement all elements of quality PE, the cornerstone of a CSPAP.

Various Combinations of CSPAP Components

A majority of evidence (34%) reviewed was related to multicomponent interventions that included PE and only 1 additional component. This finding is not surprising, since it may be more difficult to implement and evaluate the impact of extensive multi-component interventions. Beyond PE, the second most common CSPAP component implemented was PA during the school day. This finding is in line with a process evaluation of a CSPAP professional development program that also found that PA during the school day was the most commonly implemented component in a CSPAP.⁵⁶ These results suggest that PA during the school day may be the most feasible intervention other than PE to integrate. This review also found that the number of studies decreased as the number of CSPAP components implemented increased. Only 1 study included all 5 CSPAP components as the model is conceptualized,⁴¹ suggesting a need for more research on full CSPAP model implementation. Understanding which CSPAP components positively effect short-term PA levels and which enable sustained commitment to lifelong PA could help determine which components are the most important to emphasize.

Study Characteristics

This review found that most multicomponent PA interventions were conducted in elementary schools, while 8 were conducted in secondary schools,^{22,23,32,34-38} and 1 was conducted in both elementary and secondary schools.³⁹ This finding is not surprising, given the challenges with implementing PA opportunities with secondary students, including academically prioritized schedules.⁵ Future research should develop tailored interventions to meet the unique needs of secondary students. The current review also found that most studies did not specify the locale in which the study was conducted, while 8 were conducted in urban locales,^{22-24,26-29,44} 1 in a suburban locale,³³ 1 in a rural locale,³² and 2 in both rural and urban locales.^30,31 Urban settings typically have built environments that are supportive of PA (i.e., sidewalks, recreational facilities) and access to resources (e.g., community agencies) that can support CSPAPs⁵⁷ while rural settings tend to have insufficient resources for providing CSPAPs and are understudied.⁵⁸ More research is needed, particularly in rural settings, to determine how to overcome barriers to CSPAP implementation across diverse settings.⁵⁸ Finally, most studies did not specify socio-economic status (SES), while 12 were conducted in low-income settings. The focus on lower SES schools is not surprising given that they are known for providing fewer school-wide PA opportunities and thus represent a high-need population.^59,60 Given the extent of missing demographic data in the current review, future research should prioritize reporting demographic characteristics such as locale and SES for comparisons to be drawn and to inform future tailored interventions.

Study Outcomes

This review found that most multicomponent PA interventions examined health outcomes as the primary outcome compared to only 2 studies that examined academic outcomes (i.e., on-task behavior, improved math and language arts performance).^40,52 Nearly all studies that examined health outcomes positively impacted student PA levels and fitness, as well as motor skills,^25,44 and sedentariness.^27,34 This finding adds to existing literature showing that most evaluations of multicomponent PA interventions focus on PA levels and fitness.⁶¹ Of the studies focused on health outcomes, only 1 study examined and found positive effects on student motivation and competencies related to PA as secondary outcomes.³⁴ A previous review found similar findings and suggested a need for additional CSPAP research on PA correlates since facilitators of individual-level PA behavior (e.g., skills, dispositions) are needed for successful CSPAP implementation.^14,62 With only 2 studies that targeted academic outcomes, there is a need for future research to examine the effects of multicomponent PA interventions on what are traditionally considered high-priority outcomes for schools. Understanding how CSPAPs affect student learning and academic outcomes could enhance advocacy efforts for CSPAPs among administration and school staff who prioritize academics, leading to positive changes in school culture and policies for PA.⁶¹

Practical Significance

Practitioners implementing CSPAPs should ensure that the PE component is supported by an evidence-based curriculum and well-defined policies. Given its prevalence, PA during the school day may be the most feasible intervention other than PE to integrate and can include classroom PA integration, enhanced/extended recess, among other interventions. Before and after school PA programs such as Healthy Kids Club or Build Our Kids Success (BOKS)^41,63 are not constrained by an emphasis on academic outcomes, and therefore have great potential to increase student PA levels.⁶⁴ Collaborating with families and communities is essential to the success of a CSPAP since involving the family (e.g., parents) in PA can lead to the adoption and maintenance of PA in children.⁶⁵ Finally, school employee wellness programs (including PA initiatives) can positively impact employees’ physical,⁶⁶ mental,⁶⁷ and work-related health,⁶⁸ as well as have a positive role-modeling effect on student health behaviors,⁶⁹ therefore there is a need for further integration of the staff involvement component. A more detailed practical summary of CSPAP research is publicly available.¹⁶

Limitations

This current review is not free from limitations. The sample was limited to studies integrating school-based multicomponent PA interventions related to CSPAP and not any other PA-related intervention framework, including ones with nutrition-related components. The exclusion of non-peer-reviewed articles, dissertation abstracts, studies not in English, studies without interventions, and studies conducted outside of the school setting may have excluded potentially relevant research. Due to the heterogeneity of studies in terms of intervention, sample size, measurement, and outcomes examined, it was not possible to conduct a meta-analysis. Furthermore, the method for study extraction would have been enhanced with calculation of inter-rater reliability of the researchers.

Conclusions

From searches of more than 27,761 studies, 32 articles were reviewed that utilized more than 1 CSPAP component in a variety of school settings. This review provided a unique contribution to the literature by its primary emphasis on examining multicomponent school interventions guided by the CSPAP framework and classification of interventions by type of outcome. Overall, the results suggest multi-component approaches aligned with CSPAPs are effective in promoting PA in schools and can result in a variety of other positive outcomes for youth.

So What?

What is already known on this topic?

Comprehensive School Physical Activity Programs (CSPAP) should be offered in schools to help children and adolescents achieve 60 minutes of moderate to vigorous physical activity (PA) each day. Although similar literature reviews on school PA interventions exist, there remains a need for a review of multicomponent PA interventions that contextualizes the variety of combinations of CSPAP components to show their impact on student health and academic outcomes at different grade levels.

What does this article add?

This review places emphasis on multicomponent school PA interventions guided by the CSPAP framework and identifies impacts on health and academic outcomes.

What are the implications for health promotion practice or research?

Overall, results suggest that multicomponent PA interventions can be effective at promoting PA in schools and can result in positive health and academic outcomes for youth. Continued implementation and evaluation of multicomponent PA interventions guided by the CSPAP framework are warranted for a variety of settings and outcomes.

Supplemental Material

Supplemental Material, sj-doc-1-ahp-10.1177_08901171211013281 - A Systematic Review of Multi-Component Comprehensive School Physical Activity Program (CSPAP) Interventions

Supplemental Material, sj-doc-1-ahp-10.1177_08901171211013281 for A Systematic Review of Multi-Component Comprehensive School Physical Activity Program (CSPAP) Interventions by Ann Pulling Kuhn, Peter Stoepker, Brian Dauenhauer and Russell L. Carson in American Journal of Health Promotion

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by Active Schools U.S.

ORCID iD

Ann Pulling Kuhn, PhD, MS

Supplemental Material

Supplemental material for this article is available online.

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