research article about physical education

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Effects of a Physical Education Program on Physical Activity and Emotional Well-Being among Primary School Children

Irina kliziene.

1 Educational Research Group, Institute of Social Science and Humanity, Kaunas University of Technology, Kaunas 44249, Lithuania

Ginas Cizauskas

2 Department of Mechanical Engineering, Faculty of Mechanical Engineering and Design, Kaunas University of Technology, Kaunas 51424, Lithuania; [email protected]

Saule Sipaviciene

3 Department of Applied Biology and Rehabilitation, Lithuanian Sports University, Kaunas 44221, Lithuania; [email protected]

Roma Aleksandraviciene

4 Department of Coaching Science, Lithuanian Sports University, Kaunas 44221, Lithuania or moc.liamg@ednargallenamor (R.A.); [email protected] (K.Z.)

5 Sports Centre, Vytautas Magnus University, Kaunas 51211, Lithuania

Kristina Zaicenkoviene

Associated data.

The data presented in this study are available on request from the corresponding author.

(1) Background: It has been identified that schools that adopt at least two hours a week of physical education and plan specific contents and activities can achieve development goals related to physical level, such as promoting health, well-being, and healthy lifestyles, on a personal level, including bodily awareness and confidence in physical skills, as well as a general sense of well-being, greater security and self-esteem, sense of responsibility, patience, courage, and mental balance. The purpose of this study was to establish the effect of physical education programs on the physical activity and emotional well-being of primary school children. (2) Methods: The experimental group comprised 45 girls and 44 boys aged 6–7 years (First Grade) and 48 girls and 46 boys aged 8–9 years (Second Grade), while the control group comprised 43 girls and 46 boys aged 6–7 years (First Grade) and 47 girls and 45 boys aged 8–9 years (Second Grade). All children attended the same school. The Children’s Physical Activity Questionnaire was used, which is based on the Children’s Leisure Activities Study Survey questionnaire, which includes activities specific to young children (e.g., “playing in a playhouse”). Emotional well-being status was explored by estimating three main dimensions: somatic anxiety, personality anxiety, and social anxiety. The Revised Children’s Manifest Anxiety Scale (RCMAS) was used. (3) Results: When analysing the pre-test results of physical activity of the 6–7- and 8–9-year-old children, it turned out that both the First Grade (92.15 MET, min/week) and Second Grade (97.50 MET, min/week) participants in the experimental group were physically active during physical education lessons. When exploring the results of somatic anxiety in EG (4.95 ± 1.10 points), both before and after the experiment, we established that somatic anxiety in EG was 4.55 ± 1.00 points after the intervention program, demonstrating lower levels of depression, seclusion, somatic complaints, aggression, and delinquent behaviours (F = 4.785, p < 0.05, P = 0.540). (4) Conclusions: We established that the properly constructed and purposefully applied eight-month physical education program had positive effects on the physical activity and emotional well-being of primary school children (6–7 and 8–9 years) in three main dimensions: somatic anxiety, personality anxiety, and social anxiety. Our findings suggest that the eight-month physical education program intervention was effective at increasing levels of physical activity. Changes in these activities may require more intensive behavioural interventions with children or upstream interventions at the family and societal levels, as well as at the school environment level. These findings have relevance for researchers, policy makers, public health practitioners, and doctors who are involved in health promotion, policy making, and commissioning services.

1. Introduction

Teaching in physical education has evolved rapidly over the last 50 years, with a spectrum of teaching styles [ 1 ], teaching models [ 2 ], curricular models [ 3 ], instruction models [ 4 ], current pedagogical models [ 5 , 6 ], and physical educational programs [ 7 ]. As schools provide benefits other than academic and conceptual skills at present, we can determine new ways to meet different goals through a variety of methodologies assessing contents from a multidisciplinary perspective. Education regarding these skills should also be engaged following a non-traditional methodology in order to overcome the lack of resources in traditional approaches and for teachers to meet their required goals [ 8 ].

Schools are considered an important setting to influence the physical activity of children, given the amount of time spent at school and the potential for schools to reach large numbers of children. Schools may be a barrier for interventions to promote physical activity (PA). Children are required to sit quietly for the majority of the day in order to receive academic lessons. A typical school day is represented by approximately 6 h, which may be extended by 30 min or longer if the child is provided motorized transportation and does not actively commute to and from school. Donnelly et al. [ 9 ] found that teachers who modelled PA by active participation in physical activity across the curriculum (i.e., promoted 90 min/week of moderate to vigorous physically active academic lessons; 3.0 to 6.0 METs, ∼10 min each) had greater SOFIT (a Likert scale from one to five, anchored with lying down for one and very active for five) scores shown by their students, compared to primary students with teachers using a lower level of modelling. Some studies have proposed the use of prediction models of METs for children, including accelerometer data. In such models, the slope and intercept of ambulatory activities (e.g., walking and running) differ from those of non-ambulatory activities, such as ball-tossing, aerobic dance, and playing with blocks [ 10 , 11 ]. Wood and Hall [ 12 ] found that children aged 8–9 years engaged in significantly higher moderate to vigorous physical activities during team games (e.g., football), compared to movement activities in PE lessons (e.g., dance).

It has been identified that schools which adopt two hours a week of PE and plan specific contents and activities to achieve development goals at the physical level can promote health, well-being, and healthy lifestyles on a personal level, including bodily awareness and confidence in one’s physical skills, as well as a general sense of well-being, greater security and self-esteem, sense of responsibility, patience, courage, and mental balance at the social level, including integration within society, a sense of solidarity, social interactions, team spirit, fair play, and respect for rules and for others, as well as wider human and environmental values [ 13 , 14 ]. Physical activity programs have been identified as potential strategies for improving social and emotional well-being in at-risk youth [ 15 ]. Emotional well-being permeates all aspects of the experience of children and has emerged as an essential element of mental health and reduction of anxiety, as well as a core component of health in general. Schools have a strong effect on children’s emotional development, and as they are an ideal environment to foster children’s emotional learning and well-being, failing to optimize the opportunity to do so could impact communities in negative ways [ 16 , 17 ]. Physical activity and exercise have positive effects on mood and anxiety, and a great number of studies have described the associations between physical activity and general well-being, mood, and anxiety [ 18 ]. Physical inactivity may also be associated with the development of mental disorders: some clinical and epidemiological studies have shown associations between physical activity and symptoms of depression and anxiety in cross-sectional and prospective longitudinal studies [ 19 ]. Low physical activity levels have also been associated with an increased prevalence of anxiety [ 20 ]. Levels of physical activity lower than those recommended by the World Health Organization are classified as a lack of physical activity or physical inactivity. Current guidelines on physical activity for children and adolescents aged 5–17 years generally recommend at least 60 min daily of moderate- to vigorous-intensity physical activities [ 21 ].

Therefore, we formulated the following research hypothesis: The application of a physical education program can have a positive impact on the physical activity and emotional well-being among primary school students.

The purpose of this study was to establish the effect of a physical education program on the physical activity and emotional well-being of primary school children.

Novelty of the work: For the first time, PE curriculum has been developed for second grade children, a new approach to physical education methodology. For the first time, anxiety is measured between first and second grades. Physical education has been a part of school curriculums for many years, but, due to childhood obesity, focus has increased on the role that schools play in physical activity and monitoring physical fitness [ 22 , 23 ].

2. Materials and Methods

2.1. participants.

The schools utilized in this study were randomly chosen from primary schools in Lithuania. Four schools were chosen from different areas of Lithuania, which are typical of the Lithuanian education system (i.e., the state system), exercising in accordance with the description of primary, basic, and secondary education programs approved by the Lithuanian Minister of Education and Science in 2015. It ought to be noted that these schools structured classes without applying selection criteria; accordingly, it very well may be said that the students in the randomly chosen classes were additionally randomly allocated to the experimental and control groups. A non-probabilistic accurate sample was utilized in the study, where subjects were incorporated relying upon the objectives of the study.

The time and place of the study, with the consent of the guardians, were settled upon ahead of time with the school administration. This study was approved by the research ethics committee of the Kaunas University of Technology, Institute of Social Science and Humanity (Protocol No V19-1253-03).

The experimental group included 45 young women and 44 young men aged 6–7 years (First Grade) and 48 young women and 46 young men aged 8–9 years (Second Grade). The control group included 43 young women and 46 young men aged 6–7 (First Grade) and 47 young women and 45 young men aged 8–9 years (Second Grade). All children went to a same school.

2.2. Instruments

2.2.1. the evaluation of physical activity.

The Children’s Physical Activity Questionnaire [ 24 ] was utilized, which is based on the Children’s Leisure Activities Study Survey (CLASS) questionnaire, which includes activities explicit to small children, such as “playing in a playhouse.” The original intent of the proxy-reported CLASS questionnaire for 6–9 year olds was to evaluate the type, recurrence, and intensity of physical activity over a standard week [ 24 ].

2.2.2. The Revised Children’s Manifest Anxiety Scale

Enthusiastic well-being status was investigated by estimating three principal dimensions: somatic anxiety, personality anxiety, and social anxiety. The Revised Children’s Manifest Anxiety Scale (RCMAS) contains 37 items with 28 items used to measure anxiety and an additional 9 items that present an index of the child’s level of defensiveness. We were only concerned with the factor analysis of anxiety; along these lines, only those 28 items used to gauge anxiety were utilized. The RCMAS comprises three factors: (1) somatic anxiety, consisting of 12 items; (2) personality anxiety, consisting of 8 items; and (3) social anxiety, consisting of 8 items [ 25 ].

The outcomes were estimated as follows: (1) physical anxiety (more than or equal to 6.0 points—high somatic level, from 5.9 to 4.5 points—typical somatic level, and from 4.4 to 1.0 points—low somatic level); (2) personality anxiety (from 2.0 to 2.5 points—low personality anxiety level, from 2.6 to 3.5 points—typical personality anxiety level, and from 3.6 to 4.5 points—high personality anxiety level); and (3) social anxiety (more than or equal to 5.5 points—high social anxiety level, from 5.4 to 4.5 points—typical social anxiety level, and from 4.4 to 3.3 points—low social anxiety level). The Cronbach’s alpha coefficient for the subscales ranged from 0.72 to 0.73.

2.3. Procedure

In this study, a pre-/mid-/post-test experimental methodology was utilized, in order to avoid any interruption of educational activities, due to the random selection of children in each group. The experimental group (First and Second Grades) was trialled for eight months. The technique for the physical education program was developed, and a model of educational factors that encourage physical activity for children was constructed.

Likewise, the methodical material for the physical education program [ 7 , 24 ] was prepared. The methodology depended on the dynamic exercise, intense motor skills repetition, differentiation, seating and parking reduction, and the physical activity distribution in the classroom (DIDSFA) model [ 26 , 27 ] ( Table 1 ).

Dynamic exercise, intense motor skills reiteration, differentiation, seating and parking reduction, and physical activity distribution in the classroom (DIDSFA) model—expanding dynamic learning time in primary physical education.

A physical education program was designed in order to advance physical activity to a significant degree, show development skills, and be agreeable. The suggested recurrence of physical education classes was three days out of the week. A typical DIDSFA First Grade model exercise lasted 30 min and had three sections: health fitness activities (10 min), ability fitness activities (15 min), and unwinding, focus, and reflection (5 min). The Second Grade model exercise lasted 45 min and comprised four sections: health fitness activities (20 min), ability fitness activities (20 min), and unwinding, focus, and reflection (5 min). Ten health-related activity units were designed, including aerobic dance, aerobic games, strolling/running, and jump-rope. The movements were developed by changing the intensity, length, and intricacy of the activities.

Although our primary focus was creating cardiovascular stamina, brief activities to develop stomach and chest strength, as well as movement skills, were incorporated. To improve motivation, children self-estimated and recorded their fitness levels from month to month. Four game units which developed ability-related fitness were incorporated (basketball, football, gymnastics, and athletics), and details of healthy lifestyles and unconventional physical activities were introduced. These sports and games had the potential for advancing cardiovascular fitness and speculation in the child’s community (e.g., fun transfers); unwinding, focus, and reflection improving with regular exercise; and valuable impacts for meditation or unwinding, namely through children’s yoga ( Table 2 ).

Physical education program (First and Second Grades).

During the study, physical education activities were taught through physical schooling, by preparing a textbook comprising two interrelated parts: (a) a textbook and (b) children’s notes. The textbooks were filled with logical tasks, self-evaluation, and activities relating to spatial perception and self-improvement. The methodological devices provide strategies for practicing with textbooks. The physical education pack considers a “natural” kind of integration and dynamic learning, building awareness, encouraging sensitivity to nature, and supporting healthy styles of living. The physical education pack takes into consideration a “natural” kind of integration and dynamic learning, building awareness, encouraging sensitivity to nature, and supporting healthy styles of living. The instructor’s manual has a unified structure, which makes it simple to utilize. Its proposals and advice are clear. The advanced version helps educators in their planning and execution activities.

The material seriously assesses intercultural mindfulness and sensitivity. The gender description is balanced; the two personalities highlighted in the textbook support this methodology. Vaquero-Solís et al. found that mixed procedures in their interventions, executed using a new methodology, greatly affected the participants [ 30 ]. Once each month, the standard methodology was applied, during which the change from hypothesis to practice was continuous. During the first exercise of the month, the material in the textbook was analysed for the future, and undertakings for the month were presented. The hypothesis was set up during practical sessions. During the hypothetical exercises, the children additionally had the chance to move around, practising the physical tasks given in the textbook. During the last exercise of the month, the tasks introduced in the textbook were performed; the activities of the month were rehashed, recalled, summed up, and assessed; and the assignment of children’s notes were performed. Children from the control group attended unmodified physical education exercises.

2.4. Data Analysis

Graphic statistics are presented for all methodical factors as the mean ± SD. The impact size of the Mann–Whitney U test was determined using the equation r = Z / N , where Z is the z-score and N is the total size of the sample (small: 0.1; medium: 0.3; large: 0.5). Statistical significance was defined as p ≤ 0.05 for all analyses. Analyses were carried out by utilizing the SPSS 23 software (SPSS Inc., Chicago, IL, USA).

3.1. Physical Activity of 6–7- and 8–9-Year-Old Children in the Experimental Group

Analysing the physical activity pre-test results of the 6–7- and 8–9-year-old children, it turned out that both the First Grade (92.15 MET, min/week) and Second Grade (97.50 MET, min/week) children in the experimental group were physically active during physical education lessons. The analysis of physical activity types, such as cycling to school, showed no differences in age, according to the MET; however, there were differences in walking to school—First Grade (15.98 MET, min/week) and Second Grade (23.50 MET, min/week)—in terms of age, according to the MET. In the context of average physical activity, a higher indicator (805.95 MET, min/week) was detected in the First Grade of the experimental group, in comparison with the Second Grade (1072.12 MET, min/week). Statistically significant differences were found in average MET for the First Grade (931.60 MET, min/week), in comparison with the Second Grade (1211.55 MET, min/week; p < 0.05, Table 3 ). The post-test of the First Grade (115.83 MET, min/week) experimental group was carried out to analyse average physical activity, in comparison with the Second Grade experimental group (130.01 MET, min/week), during physical education lessons. In the post-test, walking to school—First Grade (16.07 MET, min/week) and Second Grade (30.37 MET, min/week)—showed differences in age, according to the MET. Statistically significant differences were found during the analysis of average MET for the First Grade (1108.41 MET, min/week), in comparison with the Second Grade (1453.62 MET, min/week; p < 0.05, Table 3 ). We found a statistically significant difference between experimental and control groups ( p < 0.05) and between pre- and post-test.

Physical activity levels determined using the MET method.

Note. *, p < 0.05 (according to the Mann–Whitney U test) between physical activity types; # , p < 0.05 (according to the Mann–Whitney U test) between experimental and control groups; $ , p < 0.05 (according to the Mann–Whitney U test) between First and Second Grades; § , p < 0.05 (according to the Mann–Whitney U test) between pre-test and post-test.

3.2. Physical Activity of 6–7- and 8–9-Year-Old Children in the Control Group

Analysing the results considering the physical activity of 6–7- and 8–9-year-old children, it turned out that in the control group, both the First Grade (91.68 MET, min/week) and Second Grade (95.87 MET, min/week) children were physically active in physical education lessons during the pre-test. The analysis of physical activity types, such as cycling to school, found no differences in age, according to the MET. We found that walking to school—First Grade (0.00 MET, min/week) and Second Grade (22.15 MET, min/week—showed differences in age, according to the MET. Statistically significant differences were found during the analysis of average MET for the First Grade in the control group (906.40 MET, min/week), compared to the Second Grade (1105.71 MET, min/week; p < 0.05, Table 4 ). The post-test results for the First Grade of the control group (98.10 MET, min/week) were determined by the analysis of average physical activity, in comparison with the Second Grade children of the same group (105.70 MET, min/week), when doing physical education lessons. Statistically significant differences were found in average MET for the First Grade (995.66 MET, min/week), in comparison with the Second Grade (1211.70 MET, min/week; p < 0.05, Table 4 ).

The physical activity level using the MET method (the pre-test/post-test results of the control group).

The study performed at the beginning of the experiment showed that in the pre-test, the level of somatic anxiety of the primary school children in the CG was average (4.95 ± 1.10 points). When exploring the results of the somatic anxiety in the EG (4.95 ± 1.10 points) before and after the experiment, after the intervention programme, somatic anxiety in the EG was 4.55 ± 1.00 points, indicating lower levels of depression, seclusion, somatic complaints, aggression, and delinquent behaviours (F = 4.785, p < 0.05, P = 0.540; Figure 1 a).

Pre- and post-test levels of somatic anxiety ( a ), personality anxiety ( b ), and social anxiety ( c ) in primary school children. # , p < 0.05 between experimental and control groups; $ , p < 0.05 between First and Second Grades; *, p < 0.05 between pre- and post-test.

3.3. Anxiety of 6–7-Year-Old Children (First Grade)

When dealing with the personality anxiety results, we established that in the pre- and post-tests, the results of CG students did not statistically significantly differ (3.63 ± 0.80 points and 3.48 ± 0.50 points, respectively; F = 0.139, p > 0.05, P = 0.041). When analysing EG personality anxiety results in the pre- and post-tests, after the intervention programme, the EG personality anxiety results significantly decreased (3.55 ± 1.10 points and 2.78 ± 0.90 points, respectively; F = 5.195, p < 0.05, P = 0.549; Figure 1 b).

In the pre-test, the level of social anxiety in the CG was 6.15 ± 1.30 points. The post-test CG result was statistically significantly lower (5.18 ± 1.20 points; F = 4.75, p < 0.05, P = 0.752). When analysing the levels of the social anxiety of the EG, pre- and post-test results decreased after the intervention programme (6.32 ± 1.10 points and 4.25 ± 1.40 points, respectively) and significantly differed (F = 8.029, p < 0.05, P = 0.673; Figure 1 c).

3.4. Anxiety of 8–9-Year-Old Children (Second Grade)

The research performed at the beginning of the experiment showed that in the pre-test, the level of somatic anxiety of the adolescents in the CG was average (4.63 ± 1.10 points). When exploring the somatic anxiety results in the EG (4.50 ± 0.90 points) before the experiment and after it, a decrease in somatic anxiety in the EG was established (4.10 ± 0.75 points), indicating lower levels of depression, seclusion, somatic complaints, aggression, and delinquent behaviours (F = 4.482, p < 0.05, P = 0.610; Figure 1 a).

When dealing with the personality anxiety results, we established that in the pre- and post-test, the results of CG students were not statistically significantly different (3.10 ± 0.85 points and 2.86 ± 0.67 points, respectively; F = 0.127, p > 0.05, P = 0.057). When analysing the pre- and post-test EG personality anxiety results, after the intervention programme, the EG personality anxiety results decreased (2.93 ± 0.93 points vs. 2.51 ± 1.00 points, respectively; F = 6.498, p < 0.05, P = 0.758; Figure 1 b).

In the pre-test, the level of social anxiety in the CG was 4.55 ± 1.30 points. The post-test CG result was statistically significantly lower (3.70 ± 1.40 points; F = 4.218, p < 0.05, P = 0.652). When analysing the levels of social anxiety in the EG, pre- and post-test results decreased after the intervention programme (4.65 ± 1.15 points and 3.01 ± 1.50 points, respectively) and were significantly different (F = 8.021, p < 0.05, P = 0.798; Figure 1 c).

4. Discussion

The outcomes of this study showed that the proposed procedure for a physical education program and educational model encouraging physical activity in children had an impact on three primary dimensions—somatic anxiety, personality anxiety, and social anxiety—for children aged 6–7 and 8–9 years. The procedure depended on dynamic exercise, intense motor skills reiteration, differentiation, seating and parking reduction, and physical activity dissemination in the classroom model. Following eight months of applying this study’s physical education program, anxiety decreased in the children. Schools provide an opportune site for addressing PA promotion in children. With children spending a substantial number of their waking hours during the week at school, increased opportunities for PA are needed, especially considering trends toward decreased frequency of physical education in schools [ 31 , 32 ]. Considering physical education curricula, Chen et al. [ 29 ] described the following:

• Aerobic activities: Most daily activities should be moderate- to vigorous-intensity aerobic activities, such as bicycling, playing sports and active games, and brisk walking.
• Strength training: The program should include muscle-strengthening activities at least three days a week, such as performing calisthenics, weight-bearing activities, and weight training.
• Bone strengthening: Bone-strengthening activities should also be included at least three days a week, such as jump-rope, playing tennis or badminton, and engaging in other hopping-type activities.

School-related physical activity interventions may reduce anxiety, increase resilience, improve well-being, and increase positive mental health in children and adolescents [ 33 ]. Increasing activity levels and sports participation among the least active young people should be a target of community- and school-based interventions in order to promote well-being. Frequency of physical activity has been positively correlated with well-being and negatively correlated with both anxiety and depressive symptoms, up to a threshold of moderate frequency of activity. In a multi-level mixed effects model, more frequent physical activity and participation in sport were both found to independently contribute to greater well-being and lower levels of anxiety and depressive symptoms in both sexes [ 34 ]. There does not appear to be an additional benefit to mental health associated with meeting the WHO-recommended levels of activity [ 9 ]. Physical activity interventions have been shown to have a small beneficial effect in reducing anxiety; however, the evidence base is limited. Reviews of physical activity and cognitive functioning have provided evidence that routine physical activity can be associated with improved cognitive performance and academic achievement, but these associations are usually small and inconsistent [ 35 ]. Advances in neuroscience have resulted in substantial progress in linking physical activity to cognitive performance, as well as to brain structure and function [ 36 ]. The executive functions hypothesis proposes that exercise has the potential to induce vascularization and neural growth and alter synaptic transmission in ways that alter thinking, decision making, and behaviour in those regions of the brain tied to executive functions—in particular, the pre-frontal cortices [ 37 , 38 ]. The brain may be particularly sensitive to the effects of physical activity during pre-adolescence, as the neural circuitry of the brain is still developing [ 8 ].

During their school years, about 33% of primary and secondary school students experience the adverse effects of test anxiety [ 39 ]. Anxiety is an aversive motivational state which occurs when the degree of perceived threat is viewed as high [ 40 ]. In the concept of anxiety, a frequently made differentiation is created between trait anxiety, referring to differences in personality dimensions, and state anxiety, alluding to anxiety as a transient mindset state. These two kinds of anxiety hamper performance, particularly during complex and intentionally requested assignments [ 41 ]. Mavilidi et al. [ 42 ] presented a study investigating whether a short episode of physical activity can mitigate test anxiety and improve test execution in 6th grade children (11–12 years). The discoveries of the study by the above authors expressed that, even though test anxiety was not decreased as expected, short physical activity breaks can be utilized before assessments without blocking academic performance [ 43 ].

Physical activity has been associated with physiological, developmental, mental, cognitive, and social health benefits in young people [ 36 ]. While the health benefits of physical activity are well-established, higher levels of physical activity have also been associated with enhanced academic-related outcomes, including cognitive function, classroom behaviour, and academic achievement [ 44 ]. The evidence suggests a decline in physical activity from early childhood [ 45 ]. The physical and psychological benefits of physical activity for children and adolescents include reduced adiposity and cardiometabolic risk factors, as well as improvements in musculoskeletal health and psychological well-being [ 33 , 46 , 47 ]. However, population based-studies have reported that more than half of all children internationally are not meeting the recommended levels of physical activity, with rates of compliance declining with age from the early primary school years [ 9 ]. Therefore, it is imperative to promote physical activity and intervene early in childhood, prior to such a decline in physical activity [ 48 ]. Schools are considered ideal settings for the promotion of children’s physical activity. There are multiple opportunities for children to be physically active over the course of the school week, including during break times, sport, physical education class, and active travel to and from school [ 49 ]. There exists strong evidence of the benefits of physical activity for the mental health of children and adolescents, mainly in terms of depression, anxiety, self-esteem, and cognitive functioning [ 35 ].

Physiological adaptation (e.g., hormonal regulation) of the body during physical exercise can be applied additionally to psychosocial stressors, thus improving mental health [ 48 ]. Subsequently, it has been stated that intense physical activity which improves health-related fitness may be expected to evoke neurobiological changes affecting psychological and academic performance [ 43 ].

The results of this review contribute to knowledge about the multifaceted interactions influencing how physical activity can be enhanced within a school setting, given certain contexts. Evidence has indicated that school-based interventions can be effective in enhancing physical activity, cardiorespiratory and muscular fitness, psychosocial outcomes associated with physical activity (e.g., enjoyment), and other markers of health status in children. School- and community-based physical activity interventions, as part of an obesity prevention or treatment programme, can benefit the executive functions of children, specifically those with obesity or who are overweight [ 46 ]. Considering the positive effects of physical activity on health in general, these findings may reinforce school-based initiatives to increase physical activity [ 34 ]. This involves classroom teachers incorporating physical activity into class time, either by integrating physical activity into physically active lessons, or adding short bursts of physical activity with curriculum-focused active breaks [ 50 , 51 ]. It is widely accepted that physical inactivity is an important risk factor for chronic diseases; prevention strategies should begin as early as childhood, as the prevalence of physical inactivity increases even more in adolescence [ 52 ]. A physically active lifestyle begins to form very early in childhood and has a positive tendency to persist throughout life [ 52 ].

We all have an important role to play in increasing children’s physical activity. Schools must promote and influence a healthy environment for children. Most primary school children spend an average of 6–7 h a day at school, which is most of their daytime. A balanced and adapted physical education lesson provides cognitive content and training for developing motor skills and knowledge in the field of physical activity. Our 8-month physical education program can give children the opportunity to increase physical activity and improve emotional well-being, which can encourage children to be physically active throughout life.

5. Conclusions

Low physical activity in children is a major societal problem. The growing number of children with obesity is a concern for doctors and scientists. The focus of our study was to improve emotional well-being and physical activity in children. Since elementary school children spend most of their day at school, physical education lessons are a great tool to increase physical activity. A balanced and adapted physical education lesson can help to draw children’s attention to the health benefits of physical activity. It was established that the properly constructed and purposefully applied 8-month physical education program had an impact on the physical activity and emotional well-being of primary school children (i.e., 6–7 and 8–9 year olds) in three main dimensions: somatic anxiety, personality anxiety, and social anxiety. Our findings suggest that the 8-month physical education program intervention is effective for increasing levels of physical activity. Changes in these activities may require more intensive behavioural interventions in children or upstream interventions at the family and societal level, as well as at the school environment level. These findings have relevance for researchers, policy makers, public health practitioners, and doctors who are involved in health promotion, policy making, and commissioning services.

Author Contributions

Conceptualization, I.K. and S.S.; methodology, I.K.; software, R.A.; validation, G.C.; formal analysis, K.Z.; investigation, K.Z.; resources, I.K.; data curation, G.C.; writing—original draft preparation, I.K.; writing—review and editing, S.S.; visualization, G.C.; supervision, R.A.; project administration, R.A.; funding acquisition, K.Z. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki. The time and place of the study, with the consent of the parents of the participants, were agreed upon in advance with the school administration. This study was approved by the research ethics committee of Kaunas University of Technology, Institute of Social Science and Humanity (Protocol No V19-1253-03).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Article Contents

Introduction.

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‘Physical education makes you fit and healthy’. Physical education's contribution to young people's physical activity levels

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S. Fairclough, G. Stratton, ‘Physical education makes you fit and healthy’. Physical education's contribution to young people's physical activity levels, Health Education Research , Volume 20, Issue 1, February 2005, Pages 14–23, https://doi.org/10.1093/her/cyg101

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The purpose of this study was to assess physical activity levels during high school physical education lessons. The data were considered in relation to recommended levels of physical activity to ascertain whether or not physical education can be effective in helping young people meet health-related goals. Sixty-two boys and 60 girls (aged 11–14 years) wore heart rate telemeters during physical education lessons. Percentages of lesson time spent in moderate-and-vigorous (MVPA) and vigorous intensity physical activity (VPA) were recorded for each student. Students engaged in MVPA and VPA for 34.3 ± 21.8 and 8.3 ± 11.1% of lesson time, respectively. This equated to 17.5 ± 12.9 (MVPA) and 3.9 ± 5.3 (VPA) min. Boys participated in MVPA for 39.4 ± 19.1% of lesson time compared to the girls (29.1 ± 23.4%; P < 0.01). High-ability students were more active than the average- and low-ability students. Students participated in most MVPA during team games (43.2 ± 19.5%; P < 0.01), while the least MVPA was observed during movement activities (22.2 ± 20.0%). Physical education may make a more significant contribution to young people's regular physical activity participation if lessons are planned and delivered with MVPA goals in mind.

Regular physical activity participation throughout childhood provides immediate health benefits, by positively effecting body composition and musculo-skeletal development ( Malina and Bouchard, 1991 ), and reducing the presence of coronary heart disease risk factors ( Gutin et al. , 1994 ). In recognition of these health benefits, physical activity guidelines for children and youth have been developed by the Health Education Authority [now Health Development Agency (HDA)] ( Biddle et al. , 1998 ). The primary recommendation advocates the accumulation of 1 hour's physical activity per day of at least moderate intensity (i.e. the equivalent of brisk walking), through lifestyle, recreational and structured activity forms. A secondary recommendation is that children take part in activities that help develop and maintain musculo-skeletal health, on at least two occasions per week ( Biddle et al. , 1998 ). This target may be addressed through weight-bearing activities that focus on developing muscular strength, endurance and flexibility, and bone health.

School physical education (PE) provides a context for regular and structured physical activity participation. To this end a common justification for PE's place in the school curriculum is that it contributes to children's health and fitness ( Physical Education Association of the United Kingdom, 2004 ; Zeigler, 1994 ). The extent to which this rationale is accurate is arguable ( Koslow, 1988 ; Michaud and Andres, 1990 ) and has seldom been tested. However, there would appear to be some truth in the supposition because PE is commonly highlighted as a significant contributor to help young people achieve their daily volume of physical activity ( Biddle et al. , 1998 ; Corbin and Pangrazi, 1998 ). The important role that PE has in promoting health-enhancing physical activity is exemplified in the US ‘Health of the Nation’ targets. These include three PE-associated objectives, two of which relate to increasing the number of schools providing and students participating in daily PE classes. The third objective is to improve the number of students who are engaged in beneficial physical activity for at least 50% of lesson time ( US Department of Health and Human Services, 2000 ). However, research evidence suggests that this criterion is somewhat ambitious and, as a consequence, is rarely achieved during regular PE lessons ( Stratton, 1997 ; US Department of Health and Human Services, 2000 ; Levin et al. , 2001 ; Fairclough, 2003a ).

The potential difficulties of achieving such a target are associated with the diverse aims of PE. These aims are commonly accepted by physical educators throughout the world ( International Council of Sport Science and Physical Education, 1999 ), although their interpretation, emphasis and evaluation may differ between countries. According to Simons-Morton ( Simons-Morton, 1994 ), PE's overarching goals should be (1) for students to take part in appropriate amounts of physical activity during lessons, and (2) become educated with the knowledge and skills to be physically active outside school and throughout life. The emphasis of learning during PE might legitimately focus on motor, cognitive, social, spiritual, cultural or moral development ( Sallis and McKenzie, 1991 ; Department for Education and Employment/Qualifications and Curriculum Authority, 1999 ). These aspects may help cultivate students' behavioural and personal skills to enable them to become lifelong physical activity participants [(thus meeting PE goal number 2 ( Simons-Morton, 1994 )]. However, to achieve this, these aspects should be delivered within a curriculum which provides a diverse range of physical activity experiences so students can make informed decisions about which ones they enjoy and feel competent at. However, evidence suggests that team sports dominate English PE curricula, yet bear limited relation to the activities that young people participate in, out of school and after compulsory education ( Sport England, 2001 ; Fairclough et al. , 2002 ). In order to promote life-long physical activity a broader base of PE activities needs to be offered to reinforce the fact that it is not necessary for young people to be talented sportspeople to be active and healthy.

While motor, cognitive, social, spiritual, cultural and moral development are valid areas of learning, they can be inconsistent with maximizing participation in health-enhancing physical activity [i.e. PE goal number 1 ( Simons-Morton, 1994 )]. There is no guidance within the English National Curriculum for PE [NCPE ( Department for Education and Employment/Qualifications and Curriculum Authority, 1999 )] to inform teachers how they might best work towards achieving this goal. Moreover, it is possible that the lack of policy, curriculum development or teacher expertise in this area contributes to the considerable variation in physical activity levels during PE ( Stratton, 1996a ). However, objective research evidence suggests that this is mainly due to differences in pedagogical variables [i.e. class size, available space, organizational strategies, teaching approaches, lesson content, etc. ( Borys, 1983 ; Stratton, 1996a )]. Furthermore, PE activity participation may be influenced by inter-individual factors. For example, activity has been reported to be lower among students with greater body mass and body fat ( Brooke et al. , 1975 ; Fairclough, 2003c ), and higher as students get older ( Seliger et al. , 1980 ). In addition, highly skilled students are generally more active than their lesser skilled peers ( Li and Dunham, 1993 ; Stratton, 1996b ) and boys tend to engage in more PE activity than girls ( Stratton, 1996b ; McKenzie et al. , 2000 ). Such inter-individual factors are likely to have significant implications for pedagogical practice and therefore warrant further investigation.

In accordance with Simons-Morton's ( Simons-Morton, 1994 ) first proposed aim of PE, the purpose of this study was to assess English students' physical activity levels during high school PE. The data were considered in relation to recommended levels of physical activity ( Biddle et al. , 1998 ) to ascertain whether or not PE can be effective in helping children be ‘fit and healthy’. Specific attention was paid to differences between sex and ability groups, as well as during different PE activities.

Subjects and settings

One hundred and twenty-two students (62 boys and 60 girls) from five state high schools in Merseyside, England participated in this study. Stage sampling was used in each school to randomly select one boys' and one girls' PE class, in each of Years 7 (11–12 years), 8 (12–13 years) and 9 (13–14 years). Three students per class were randomly selected to take part. These students were categorized as ‘high’, ‘average’ and ‘low’ ability, based on their PE teachers' evaluation of their competence in specific PE activities. Written informed consent was completed prior to the study commencing. The schools taught the statutory programmes of study detailed in the NCPE, which is organized into six activity areas (i.e. athletic activities, dance, games, gymnastic activities, outdoor activities and swimming). The focus of learning is through four distinct aspects of knowledge, skills and understanding, which relate to; skill acquisition, skill application, evaluation of performance, and knowledge and understanding of fitness and health ( Department for Education and Employment/Qualifications and Curriculum Authority, 1999 ). The students attended two weekly PE classes in mixed ability, single-sex groups. Girls and boys were taught by male and female specialist physical educators, respectively.

Instruments and procedures

The investigation received ethical approval from the Liverpool John Moores Research Degrees Ethics Committee. The study involved the monitoring of heart rates (HRs) during PE using short-range radio telemetry (Vantage XL; Polar Electro, Kempele, Finland). Such systems measure the physiological load on the participants' cardiorespiratory systems, and allow analysis of the frequency, duration and intensity of physical activity. HR telemetry has been shown to be a valid and reliable measure of young people's physical activity ( Freedson and Miller, 2000 ) and has been used extensively in PE settings ( Stratton, 1996a ).

The students were fitted with the HR telemeters while changing into their PE uniforms. HR was recorded once every 5 s for the duration of the lessons. Telemeters were set to record when the teachers officially began the lessons, and stopped at the end of lessons. Total lesson ‘activity’ time was the equivalent of the total recorded time on the HR receiver. At the end of the lessons the telemeters were removed and data were downloaded for analyses. Resting HRs were obtained on non-PE days while the students lay in a supine position for a period of 10 min. The lowest mean value obtained over 1 min represented resting HR. Students achieved maximum HR values following completion of the Balke treadmill test to assess cardiorespiratory fitness ( Rowland, 1993 ). This data was not used in the present study, but was collated for another investigation assessing children's health and fitness status. Using the resting and maximum HR values, HR reserve (HRR, i.e. the difference between resting and maximum HR) at the 50% threshold was calculated for each student. HRR accounts for age and gender HR differences, and is recommended when using HR to assess physical activity in children ( Stratton, 1996a ). The 50% HRR threshold represents moderate intensity physical activity ( Stratton, 1996a ), which is the minimal intensity required to contribute to the recommended volume of health-related activity ( Biddle et al. , 1998 ). Percentage of lesson time spent in health enhancing moderate-and-vigorous physical activity (MVPA) was calculated for each student by summing the time spent ≥50% HRR threshold. HRR values ≥75% corresponded to vigorous intensity physical activity (VPA). This threshold represents the intensity that may stimulate improvements in cardiorespiratory fitness ( Morrow and Freedson, 1994 ) and was used to indicate the proportion of lesson time that students were active at this higher level.

Sixty-six lessons were monitored over a 12-week period, covering a variety of group and individual activities ( Table I ). In order to allow statistically meaningful comparisons between different types of activities, students were classified as participants in activities that shared similar characteristics. These were, team games [i.e. invasion (e.g. football and hockey) and striking games (e.g. cricket and softball)], individual games (e.g. badminton, tennis and table tennis), movement activities (e.g. dance and gymnastics) and individual activities [e.g. athletics, fitness (circuit training and running activities) and swimming]. The intention was to monitor equal numbers of students during lessons in each of the four designated PE activity categories. However, timetable constraints and student absence meant that true equity was not possible, and so the number of boys and girls monitored in the different activities was unequal.

Number and type of monitored PE lessons

Student sex, ability level and PE activity category were the independent variables, with percent of lesson time spent in MVPA and VPA set as the dependent variables. Exploratory analyses were conducted to establish whether data met parametric assumptions. Shapiro–Wilk tests revealed that only boys' MVPA were normally distributed. Subsequent Levene's tests confirmed the data's homogeneity of variance, with the exception of VPA between the PE activities. Though much of the data violated the assumption of normality, the ANOVA is considered to be robust enough to produce valid results in this situation ( Vincent, 1999 ). Considering this, alongside the fact that the data had homogenous variability, it was decided to proceed with ANOVA for all analyses, with the exception of VPA between different PE activities.

Sex × ability level factorial ANOVAs compared the physical activity of boys and girls who differed in PE competence. A one-way ANOVA was used to identify differences in MVPA during the PE activities. Post-hoc analyses were performed using Hochberg's GT2 correction procedure, which is recommended when sample sizes are unequal ( Field, 2000 ). A non-parametric Kruskal–Wallis ANOVA calculated differences in VPA during the different activities. Post-hoc Mann–Whitney U -tests determined where identified differences occurred. To control for type 1 error the Bonferroni correction procedure was applied to these tests, which resulted in an acceptable α level of 0.008. Although these data were ranked for the purposes of the statistical analysis, they were presented as means ± SD to allow comparison with the other results. All data were analyzed using SPSS version 11.0 (SPSS, Chicago, IL).

The average duration of PE lessons was 50.6 ± 20.8 min, although girls' (52.6 ± 25.4 min) lessons generally lasted longer than boys' (48.7 ± 15.1 min). When all PE activities were considered together, students engaged in MVPA and VPA for 34.3 ± 21.8 and 8.3 ± 11.1% of PE time, respectively. This equated to 17.5 ± 12.9 (MVPA) and 3.9 ± 5.3 (VPA) min. The high-ability students were more active than the average- and low-ability students, who took part in similar amounts of activity. These trends were apparent in boys and girls ( Table II ).

Mean (±SD) MVPA and VPA of boys and girls of differing abilities

Boys > girls, P < 0.01.

Boys > girls, P < 0.05.

Boys engaged in MVPA for 39.4% ± 19.1 of lesson time compared to the girls' value of 29.1 ± 23.4 [ F (1, 122) = 7.2, P < 0.01]. When expressed as absolute units of time, these data were the equivalent of 18.9 ± 10.5 (boys) and 16.1 ± 14.9 (girls) min. Furthermore, a 4% difference in VPA was observed between the two sexes [ Table II ; F (1, 122) = 4.6, P < 0.05]. There were no significant sex × ability interactions for either MVPA or VPA.

Students participated in most MVPA during team games [43.2 ± 19.5%; F (3, 121) = 6.0, P < 0.01]. Individual games and individual activities provided a similar stimulus for activity, while the least MVPA was observed during movement activities (22.2 ± 20.0%; Figure 1 ). A smaller proportion of PE time was spent in VPA during all activities. Once more, team games (13.6 ± 11.3%) and individual activities (11.8 ± 14.0%) were best suited to promoting this higher intensity activity (χ 2 (3) =30.0, P < 0.01). Students produced small amounts of VPA during individual and movement activities, although this varied considerably in the latter activity ( Figure 2 ).

Mean (±SD) MVPA during different PE activities. ** Team games > movement activities ( P < 0.01). * Individual activities > movement activities ( P < 0.05).

Mean (±SD) VPA during different PE activities. ** Team games > movement activities ( Z (3) = −4.9, P < 0.008) and individual games ( Z (3) = −3.8, P < 0.008). † Individual activities > movement activities ( Z (3) = −3.3, P < 0.008). ‡ Individual game > movement activities ( Z (3) = −2.7, P < 0.008).

This study used HR telemetry to assess physical activity levels during a range of high school PE lessons. The data were considered in relation to recommended levels of physical activity ( Biddle et al. , 1998 ) to investigate whether or not PE can be effective in helping children be ‘fit and healthy’. Levels of MVPA were similar to those reported in previous studies ( Klausen et al. , 1986 ; Strand and Reeder, 1993 ; Fairclough, 2003b ) and did not meet the US Department of Health and Human Services ( US Department of Health and Human Services, 2000 ) 50% of lesson time criterion. Furthermore, the data were subject to considerable variance, which was exemplified by high standard deviation values ( Table II , and Figures 1 and 2 ). Such variation in activity levels reflects the influence of PE-specific contextual and pedagogical factors [i.e. lesson objectives, content, environment, teaching styles, etc. ( Stratton, 1996a )]. The superior physical activity levels of the high-ability students concurred with previous findings ( Li and Dunham, 1993 ; Stratton, 1996b ). However, the low-ability students engaged in more MVPA and VPA than the average-ability group. While it is possible that the teachers may have inaccurately assessed the low and average students' competence, it could have been that the low-ability group displayed more effort, either because they were being monitored or because they associated effort with perceived ability ( Lintunen, 1999 ). However, these suggestions are speculative and are not supported by the data. The differences in activity levels between the ability groups lend some support to the criticism that PE teachers sometimes teach the class as one and the same rather than planning for individual differences ( Metzler, 1989 ). If this were the case then undifferentiated activities may have been beyond the capability of the lesser skilled students. This highlights the importance of motor competence as an enabling factor for physical activity participation. If a student is unable to perform the requisite motor skills to competently engage in a given task or activity, then their opportunities for meaningful participation become compromised ( Rink, 1994 ). Over time this has serious consequences for the likelihood of a young person being able or motivated enough to get involved in physical activity which is dependent on a degree of fundamental motor competence.

Boys spent a greater proportion of lesson time involved in MVPA and VPA than girls. These differences are supported by other HR studies in PE ( Mota, 1994 ; Stratton, 1997 ). Boys' activity levels equated to 18.9 min of MVPA, compared to 16.1 min for the girls. It is possible that the characteristics and aims of some of the PE activities that the girls took part in did not predispose them to engage in whole body movement as much as the boys. Specifically, the girls participated in 10 more movement lessons and eight less team games lessons than the boys. The natures of these two activities are diverse, with whole body movement at differing speeds being the emphasis during team games, compared to aesthetic awareness and control during movement activities. The monitored lessons reflected typical boys' and girls' PE curricula, and the fact that girls do more dance and gymnastics than boys inevitably restricts their MVPA engagement. Although unrecorded contextual factors may have contributed to this difference, it is also possible that the girls were less motivated than the boys to physically exert themselves. This view is supported by negative correlations reported between girls' PE enjoyment and MVPA ( Fairclough, 2003b ). Moreover, there is evidence ( Dickenson and Sparkes, 1988 ; Goudas and Biddle, 1993 ) to suggest that some pupils, and girls in particular ( Cockburn, 2001 ), may dislike overly exerting themselves during PE. Although physical activity is what makes PE unique from other school subjects, some girls may not see it as such an integral part of their PE experience. It is important that this perception is clearly recognized if lessons are to be seen as enjoyable and relevant, whilst at the same time contributing meaningfully to physical activity levels. Girls tend to be habitually less active than boys and their levels of activity participation start to decline at an earlier age ( Armstrong and Welsman, 1997 ). Therefore, the importance of PE for girls as a means of them experiencing regular health-enhancing physical activity cannot be understated.

Team games promoted the highest levels of MVPA and VPA. This concurs with data from previous investigations ( Strand and Reeder, 1993 ; Stratton, 1996a , 1997 ; Fairclough, 2003a ). Because these activities require the use of a significant proportion of muscle mass, the heart must maintain the oxygen demand by beating faster and increasing stroke volume. Moreover, as team games account for the majority of PE curriculum time ( Fairclough and Stratton, 1997 ; Sport England, 2001 ), teachers may actually be more experienced and skilled at delivering quality lessons with minimal stationary waiting and instruction time. Similarly high levels of activity were observed during individual activities. With the exception of throwing and jumping themes during athletics lessons, the other individual activities (i.e. swimming, running, circuit/station work) involved simultaneous movement of the arms and legs over variable durations. MVPA and VPA were lowest during movement activities, which mirrored previous research involving dance and gymnastics ( Stratton, 1997 ; Fairclough, 2003a ). Furthermore, individual games provided less opportunity for activity than team games. The characteristics of movement activities and individual games respectively emphasize aesthetic appreciation and motor skill development. This can mean that opportunities to promote cardiorespiratory health may be less than in other activities. However, dance and gymnastics can develop flexibility, and muscular strength and endurance. Thus, these activities may be valuable to assist young people in meeting the HDA's secondary physical activity recommendation, which relates to musculo-skeletal health ( Biddle et al. , 1998 ).

The question of whether PE can solely contribute to young people's cardiorespiratory fitness was clearly answered. The students engaged in small amounts of VPA (4.5 and 3.3 min per lesson for boys and girls, respectively). Combined with the limited frequency of curricular PE, these were insufficient durations for gains in cardiorespiratory fitness to occur ( Armstrong and Welsman, 1997 ). Teachers who aim to increase students' cardiorespiratory fitness may deliver lessons focused exclusively on high intensity exercise, which can effectively increase HR ( Baquet et al. , 2002 ), but can sometimes be mundane and have questionable educational value. Such lessons may undermine other efforts to promote physical activity participation if they are not delivered within an enjoyable, educational and developmental context. It is clear that high intensity activity is not appropriate for all pupils, and so opportunities should be provided for them to be able to work at developmentally appropriate levels.

Students engaged in MVPA for around 18 min during the monitored PE lessons. This approximates a third of the recommended daily hour ( Biddle et al. , 1998 ). When PE activity is combined with other forms of physical activity support is lent to the premise that PE lessons can directly benefit young people's health status. Furthermore, for the very least active children who should initially aim to achieve 30 min of activity per day ( Biddle et al. , 1998 ), PE can provide the majority of this volume. However, a major limitation to PE's utility as a vehicle for physical activity participation is the limited time allocated to it. The government's aspiration is for all students to receive 2 hours of PE per week ( Department for Education and Employment/Qualifications and Curriculum Authority, 1999 ), through curricular and extra-curricular activities. While some schools provide this volume of weekly PE, others are unable to achieve it ( Sport England, 2001 ). The HDA recommend that young people strive to achieve 1 hour's physical activity each day through many forms, a prominent one of which is PE. The apparent disparity between recommended physical activity levels and limited curriculum PE time serves to highlight the complementary role that education, along with other agencies and voluntary organizations must play in providing young people with physical activity opportunities. Notwithstanding this, increasing the amount of PE curriculum time in schools would be a positive step in enabling the subject to meet its health-related goals. Furthermore, increased PE at the expense of time in more ‘academic’ subjects has been shown not to negatively affect academic performance ( Shephard, 1997 ; Sallis et al. , 1999 ; Dwyer et al. , 2001 ).

Physical educators are key personnel to help young people achieve physical activity goals. As well as their teaching role they are well placed to encourage out of school physical activity, help students become independent participants and inform them about initiatives in the community ( McKenzie et al. , 2000 ). Also, they can have a direct impact by promoting increased opportunities for physical activity within the school context. These could include activities before school ( Strand et al. , 1994 ), during recess ( Scruggs et al. , 2003 ), as well as more organized extra-curricular activities at lunchtime and after school. Using time in this way would complement PE's role by providing physical activity opportunities in a less structured and pedagogically constrained manner.

This research measured student activity levels during ‘typical’, non-intensified PE lessons. In this sense it provided a representative picture of the frequency, intensity and duration of students' physical activity engagement during curricular PE. However, some factors should be considered when interpreting the findings. First, the data were cross-sectional and collected over a relatively short time frame. Tracking students' activity levels over a number of PE activities may have allowed a more accurate account of how physical activity varies in different aspects of the curriculum. Second, monitoring a larger sample of students over more lessons may have enabled PE activities to be categorized into more homogenous groups. Third, monitoring lessons in schools from a wider geographical area may have enabled stronger generalization of the results. Fourth, it is possible that the PE lessons were taught differently, and that the students acted differently as a result of being monitored and having the researchers present during lessons. As this is impossible to determine, it is unknown how this might have affected the results. Fifth, HR telemetry does not provide any contextual information about the monitored lessons. Also, HR is subject to emotional and environmental factors when no physical activity is occurring. Future work should combine objective physical activity measurement with qualitative or quantitative methods of observation.

During PE, students took part in health-enhancing activity for around one third of the recommended 1-hour target ( Biddle et al. , 1998 ). PE obviously has potential to help meet this goal. However, on the basis of these data, combined with the weekly frequency of PE lessons, it is clear that PE can only do so much in supplementing young people's daily volume of physical activity. Students need to be taught appropriate skills, knowledge and understanding if they are to optimize their physical activity opportunities in PE. For improved MVPA levels to occur, health-enhancing activity needs to be recognized as an important element of lessons. PE may make a more significant contribution to young people's regular physical activity participation if lessons are planned and delivered with MVPA goals in mind.

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Author notes

1REACH Group and School of Physical Education, Sport and Dance, Liverpool John Moores University, Liverpool L17 6BD and 2REACH Group and Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool L3 2ET, UK

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• Published: 17 December 2020

Physical education class participation is associated with physical activity among adolescents in 65 countries

• Riaz Uddin 1 , 2 , 3 ,
• Jo Salmon 1 ,
• Sheikh Mohammed Shariful Islam 1 , 3 &
• Asaduzzaman Khan 2 , 3  

Scientific Reports volume  10 , Article number:  22128 ( 2020 ) Cite this article

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In this study we examined the associations of physical education class participation with physical activity among adolescents. We analysed the Global School-based Student Health Survey data from 65 countries (N = 206,417; 11–17 years; 49% girls) collected between 2007 and 2016. We defined sufficient physical activity as achieving physical activities ≥ 60 min/day, and grouped physical education classes as ‘0 day/week’, ‘1–2 days/week’, and ‘ ≥ 3 days/week’ participation. We used multivariable logistic regression to obtain country-level estimates, and meta-analysis to obtain pooled estimates. Compared to those who did not take any physical education classes, those who took classes ≥ 3 days/week had double the odds of being sufficiently active (OR 2.05, 95% CI 1.84–2.28) with no apparent gender/age group differences. The association estimates decreased with higher levels of country’s income with OR 2.37 (1.51–3.73) for low-income and OR 1.85 (1.52–2.37) for high-income countries. Adolescents who participated in physical education classes 1–2 days/week had 26% higher odds of being sufficiently active with relatively higher odds for boys (30%) than girls (15%). Attending physical education classes was positively associated with physical activity among adolescents regardless of sex or age group. Quality physical education should be encouraged to promote physical activity of children and adolescents.

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Introduction.

Physical activity is essential for health and wellbeing of children and adolescents 1 . Physical activity improves musculoskeletal, cardiac, metabolic, psychosocial, and cognitive health, and enhances cardiorespiratory and muscular fitness of children and adolescents 1 , 2 , 3 , 4 . Regular participation also decreases adiposity in those who are overweight 3 . For optimal health benefits, the current international guidelines (i.e., the World Health Organization [WHO]) recommends that those aged 5–17-years accumulate at least 60 min of moderate-to-vigorous physical activity daily 5 . Globally, four out of five (81%) adolescents aged 11–17 years do not meet this recommendation and are insufficiently active 6 . Such inactive behaviours during adolescence have both current and future ramifications on health and wellbeing as behaviours such as physical activity established during adolescence can carry over to adulthood 7 , 8 . Therefore, pragmatic strategies to promote physical activity during adolescence around the globe are of critical importance 9 .

Adolescent physical activity occurs in different settings and domains including at home, in the community, for transportation, and at school. Opportunities for physical activity at school include during recess and lunch breaks, school sport and physical education lessons. Physical education classes may provide resources and opportunities for students to accumulate the daily physical activity level and can contribute to daily energy expenditure 10 , 11 . Recent meta-analyses found that 41% of secondary school 12 and 45% of elementary school 13 physical education lessons comprised moderate-to-vigorous physical activity. In many countries, physical education provides children and adolescents the understanding and motivation for an active lifestyle and also creates an environment to acquire knowledge and skills for physical activity throughout life 14 , 15 . In addition, adolescents who may have limited access to space and equipment outside of school can benefit from attending physical education classes at school 10 , 11 . School-based physical education, therefore, can be an accessible source of physical activity for many adolescents and can help develop an active healthy lifestyle 16 . In addition to the number of physical education classes, access to high-quality physical education experience (e.g., teacher behaviours, learning outcomes), which forms the foundation for lifelong engagement in physical activity, is also important for children and adolescents 17 , 18 , 19 .

Available evidence suggest that participation in physical education classes are positively associated with higher levels of physical activity 20 , 21 , 22 , 23 , 24 . However, the evidence is mostly based on single-country studies from high-income countries with limited multi-country study and lack of representation of low- and lower-middle-income countries 25 . A recent multi-country study reported country- and regional-level differences in physical education class participation, which was also differed by sex, age, and country-income classification 26 . In addition, delivery, content and quality of physical education also vary within and between countries 27 , 28 . It is often provided infrequently in schools across countries, and therefore the potential impact on total moderate-to-vigorous physical activity among boys and girls may be limited 29 . In order to obtain a comprehensive global perspective on the relationship between physical education and physical activity, large multi-country studies with representative samples are essential. Given the context and the opportunities that exist in schools for physical activity promotion, in this study, we aimed to examine whether participation in physical education classes (i.e., number of physical education class attendance) is associated with sufficient level of physical activity among adolescents (overall, and by sex and age-group) from 65 countries around the globe. We hypothesised that higher number of physical education class participation would be positively associated with sufficient level of physical activity among adolescents.

Data source

Data for this study were from the Global School-based Student Health Survey (GSHS), a population-based survey of school-going children and adolescents around the world 30 . In all participating countries, the GSHS uses the same standardised sampling technique and study methodology. All participants completed a standardised self-administered anonymous questionnaire, which included, but was not limited to, questions on demographics (e.g., age, sex), participation in physical education classes and physical activity. GSHS adopted questionnaire items, including items to measure physical activity and physical education from the Youth Risk Behavior Survey of American Adolescents. Countries, where GSHS were implemented, were encouraged to use culturally appropriate examples, words, and phrases to ensure sociocultural adaptability of the items. Furthermore, using a rigorous translation and back-translation process with the assistance of WHO and US CDC, countries were allowed to translate the questionnaire into their local language 31 .

As of 8 December 2019, 98 countries/territories around the globe had at least one GSHS dataset publicly available with the surveys being conducted between 2007 and 2016. For countries with more than one GSHS dataset, we used the most recent one available. Of the 98 countries, 84 countries had data on PA, while 67 countries had data on physical education. Two countries (Niue and Tokelau) were excluded from the analyses due to their small sample size (n < 140). The analytical sample consists of 206,417 adolescents aged 11 or younger to 17 years from 65 countries. Only a small proportion of students (1.05%) were in the age group “11 years old or younger”, and for modelling purposes, they were considered as 11 years old for this analysis, as it was not possible to determine what proportion of 1.05% students were younger than 11 years old. All countries provided nationally representative samples.

The GSHS received ethics approval from the Ministry of Education or a relevant Institutional Ethics Review Committee, or both in each of the participating countries. Only those adolescents and their parents who provided written or verbal consent participated. As the current study used retrospective, de-identified, publicly available data, ethics approval was not required for this secondary analysis. Detailed methods of the GSHS have been described on both the US CDC and the WHO websites 30 , 32 .

Outcome measure—physical activity participation

Physical activity was assessed with one item: ‘During the past 7 days, on how many days were you physically active for a total of at least 60 min per day?’ The response options were 0–7 days. Consistent with the WHO recommendations 5 , we defined participants as ‘sufficiently active’ who did ≥ 60 min/day of physical activity on seven days of the week.

Study factor—physical education participation

Physical education class attendance was assessed with one item: ‘During this school year, on how many days did you go to physical education (PE) class each week?’ The responses were classified into three groups: ‘0 day/week’, ‘1–2 days/week’, and ‘≥ 3 days/week’ as used elsewhere 25 , 33 .

Adolescents self-reported age, sex, and daily hours of sitting (when not in school or doing homework) in the survey. Food insecurity was assessed by asking: ‘During the past 30 days, how often did you go hungry because there was not enough food in your home?’ with response options being never, rarely, sometimes, most of the time, and always. As the GSHS did not include any direct measure of socioeconomic status, this variable was used as a proxy measure of socioeconomic status 34 , 35 . Self-reported height and weight were used to compute body mass index (BMI), which was categorised as underweight (BMI < −2SD), overweight (BMI >  + 1SD), and obese (BMI >  + 2SD), relative to median BMI, by age and sex based on the WHO Child Growth Standards 36 .

Statistical analyses

Of the 65 countries with data on physical activity and physical education, nine countries were from Africa, 20 from the Americas, 15 from Eastern Mediterranean, five from South East Asia, and 16 from the Western Pacific region. Using the World Bank country classification, collected at the time of the survey for the respective countries, seven countries were classified as low‐income, 21 lower‐middle‐income, 18 upper‐middle‐income, and 18 high-income. Income classification information was not available for Cook Island. The prevalence estimates of physical activity and physical education were obtained by using a Stata command ‘svyset’ to take into account sampling weights and the clustered sampling design of the surveys.

In examining the country-level association of physical education with physical activity, a set of covariates was considered including age, sex, weight status (i.e., BMI), food insecurity, and sitting time. Sitting time was considered as an adjusting factor given its demonstrated association with physical activity in adolescents 37 . Given the binary nature of physical activity outcome, logistic regression analysis with robust standard errors was used to examine the association at the country level, by taking into account the sampling weight that was applied to each participant record to adjust for non-response and the varying probability of selection. This GSHS weighting factor was applied in an identical way to estimate the association in each participating country. Within the GSHS protocol, weighting accounted for the probability of selection of schools and classrooms, non-responding schools and students, and distribution of the population by sex and grade.

Random effects meta-analysis was used to generate pooled estimates of the association between physical education and physical activity for the overall sample, by country income category (e.g., low-income, lower-middle income, upper-middle income, and high-income), and by WHO region, stratified by sex and age groups (11–14 years vs 15–17 years). Two age groups (11–14 years [early adolescence] and 15–17 years [middle adolescence]) 38 were considered to stratify the analysis in order to examine whether the association estimates vary across phases of adolescence. This analysis used DerSimonian and Laird method 39 with the estimate of heterogeneity being taken from the Mantel–Haenszel model. As the GSHS were conducted across different cultural settings in 65 countries around the world over a long period of time (2007–2016), it was reasonable to assume that the association estimates across countries were likely to vary from survey to survey, which supports the use of random effects meta-analysis that can adjust heterogeneity among studies 40 . The percentage of variability in estimates across studies that is attributable to between study heterogeneity (I 2 ) in our analysis ranges from 54.3 to 80.2%, which suggests a strong presence of heterogeneity in the association estimates, and further supports the use of random effects meta-analysis. All adjusted estimates of the association parameters are presented in the form of odds ratio (OR) and 95% confidence interval (CI). All analyses were conducted by StataSE V14.0.

Ethics approval and consent to participate

The GSHS received ethics approval from both a national government administration and an institutional review board or ethics committee. Only adolescents and their parents who provided written/verbal consent participated. As the current study used retrospective publicly available data, we did not require ethics approval from any Institutional Ethics Review Committee for this secondary analysis.

The mean age of the participating adolescents (n = 206,417) was 14.35 (SD = 1.45) years, 54.4% aged 11–14 years, and 49.2% were girls. The prevalence of sufficient physical activity was 15.0%, with boys having higher prevalence (18.3%) than girls (11.5%). Over half (56.5%) of adolescents participated in physical education classes 1–2 days/week (boys 54.7%; girls 58.3%) and about a quarter (24.2%) participated in physical education classes ≥ 3 days/week (boys 26.8%; girls 21.6%). As shown in Fig.  1 , the overall percentage of adolescents being sufficiently active was greater for those who attended more physical education classes in both sexes.

Proportion of adolescents sufficiently physically active by participation in physical education classes, Global School-based Student Health Survey, 2007–2016.

Estimates of associations of physical education class participation with sufficient physical activity by country are shown in Table 1 . The country-level analysis shows that 50 out of 65 participating countries (77%) demonstrated significant and positive associations between attending physical education classes ≥ 3 days/week and being sufficiently active with 33 countries (51%) revealing at least double the odds (OR ≥ 2.0) of meeting physical activity guidelines. For example, Bolivian adolescents who attended physical education classes ≥ 3 days/week had threefold odds of reporting sufficient physical activity compared with their counterparts who attended no physical education class (OR 3.00, 95% CI 1.93–4.67). In examining the association between attending physical education classes 1–2 days/week and being sufficiently active, 20 countries (31%) demonstrated significant positive associations. For example, Thai adolescents who attended physical education classes 1–2 days/week had double the odds to reporting sufficient physical activity compared with their counterparts who attended no physical education class (OR 2.11, 95% CI 1.39–3.19). As shown in Table 1 , attending physical education classes ≥ 3 days/week was positively and strongly associated with physical activity in all WHO regions with South East Asia region showing the strongest association (OR 2.89, 2.11–3.97), followed by Africa (OR 2.45, 1.72–3.48) and Western Pacific region (OR 2.40, 1.92–3.00). The analysis also showed evidence of positive and moderate association between attending physical education classes 1–2 days/week and being sufficiently active in all WHO regions with the pooled association estimates ranging from OR 1.19 (1.01–1.41) in the Americas region to OR 1.86 (1.03–3.36) in South East Asia.

Overall, adolescents who took physical education classes ≥ 3 days/week, compared to those who did not take any physical education classes, had double the odds of being sufficiently active (OR 2.05, 95% CI 1.84–2.28) with no apparent gender (OR 2.09, 1.88–2.33 for boys; and OR 1.95, 1.69–2.25 for girls) or age (OR 2.19, 1.93–2.48 for 11–14-year-old; and OR 2.03, 1.80–2.28 for 15–17-year-old adolescents) differences (Table 2 ). Adolescents who participated in physical education classes 1–2 days/week had 26% higher odds of being sufficiently active (OR 1.26, 1.15–1.37) with relatively higher odds for boys (OR 1.30, 1.17–1.46) than girls (OR 1.15, 1.03–1.29) and younger adolescents aged 11–14 years (OR 1.28, 1.16–1.42) that older adolescents aged 15–17 years (OR 1.19, 1.08–1.32).

The odds of attending physical education classes ≥ 3 days/week and being sufficiently active were lower in country with higher income (Table 2 ). In low-income countries, adolescents who participated in physical education classes ≥ 3 days/week had 137% higher odds of being sufficiently active (OR 2.37, 1.51–3.73) with comparable odds for boys (OR 2.51, 1.70–3.70) and girls (OR 2.36, 1.31–4.26) and slightly higher odds for younger (OR 2.94, 1.92–4.51) than older adolescents (OR 2.32, 1.36–3.96). In high-income countries, the odds of being sufficiently active was 85% higher for adolescents who attended physical education classes ≥ 3 days/week (OR 1.85; 1.52–2.25) with no apparent gender (boys OR 1.89, 1.50–2.37; girls OR 1.69, 1.36–2.10) or age (younger OR 1.83, 1.47–2.28; older OR 1.80 (1.48–2.19) differences. In lower-middle income countries, adolescents who attended physical education classes 1–2 days/week had 39% higher odds of being sufficiently active (OR 1.39, 1.19–1.62) compared to their counterparts who did not take any physical education classes, with relatively higher odds for boys (OR 1.46, 1.21–1.76) than girls (OR 1.30, 1.03–1.65), and similar odds for younger (OR 1.36, 1.09–1.68) and older adolescents (OR 1.33, 1.16–1.51).

Boys of South East Asian region who participated in physical education classes ≥ 3 days/week had the highest odds of being sufficiently active (OR 3.29, 1.97–5.47), followed by the boys of Africa region (OR 2.41, 1.74–3.33) (Supplementary Table S1 ). Girls of Western Pacific and Africa region who participated in physical education classes ≥ 3 days/week had the highest odds of being sufficiently active (OR 2.68, 1.89–3.77, and OR 2.63, 1.63–4.26, respectively). Even by attending physical education classes 1–2 days/week, boys of the Americas region and girls of Africa region can increase their odds, though not considerably, of being sufficiently active (OR 1.29, 1.06–1.58, and OR 1.41, 1.15–1.73, respectively).

Both younger and older adolescents in all WHO regions demonstrated positive association between ≥ 3 days/week physical education class attendance and meeting the physical activity recommendations (Supplementary Table S1 ). Younger adolescents in South East Asia (OR 3.03, 2.42–3.79) and Africa (OR 2.95, 2.07–4.20), and older adolescents in South East Asia (OR 3.24, 1.57–6.67) who participated in physical education classes ≥ 3 days/week had over three times higher odds of being sufficiently active. There were moderate positive associations between physical education class attendance for 1–2 days/week and meeting the physical activity recommendations for younger adolescents in Africa (OR 1.38, 1.03–1.84), the Americas (OR 1.29, 1.07–1.56), and Eastern Mediterranean regions (OR 1.24, 1.06–1.44), and for older adolescents in Africa (OR 1.24, 1.03–1.48), Eastern Mediterranean (OR 1.26, 1.07–1.49), and Western Pacific region (OR 1.19, 1.01–1.41).

To our knowledge, this is the most extensive global study to assess the association of physical education class attendance with physical activity of adolescents, based on nationally representative samples from 65 countries around the globe. The key finding of our study is that adolescents, irrespective of sex or age, who had a higher frequency (≥ 3 days/week) of physical education class attendance had significantly higher odds of meeting the WHO’s physical activity recommendations. The estimates of association between the frequency of attending physical education and meeting physical activity recommendations were lower among countries with higher income. We observed some regional differences with South East Asia having the highest associations and the Americas having the lowest. Our findings suggest that adolescents, especially girls and those aged 15–17 years, are mostly benefited from a higher frequency (i.e., ≥ 3 days/week) of physical education participation. Our study also found some benefits of less frequent participation in physical education classes (1–2 days/week) in meeting the physical activity guidelines, which is encouraging. About one-third of the countries demonstrated positive association between less frequent participation in physical education classes and meeting the physical activity recommendations, and such association was prominent in boys and younger adolescents in all but low-income countries. Our study thus argues that even less frequent participation in physical education classes can bring some benefits for some adolescents.

Our finding that a higher frequency of physical education class attendance was positively associated with meeting the physical activity recommendations is consistent with other studies in children and adolescents 20 , 21 , 24 , 25 . It has been argued that participation in physical education classes acts as a positive reinforcement to “keep young people going” by being more physically active with less time in sedentary behaviour throughout the day 25 . Physical education classes provide children with an opportunity to familiarise themselves with different types of physical activity, motivates them to be active within the school environment, and potentially also encourages more out-of-school physical activity 41 . Physical activity during physical education classes may reduce fatigue and improve mood by changing neurophysiological stimulation and the brain’s information processing function (i.e., cerebral cortex), which may improve children’s preparedness to move more throughout the day 25 . While the frequency of physical education class is important, it is also critical that children have access to quality physical education 18 , 19 . Previously, researchers have suggested that in spite of the traditional class-based and sports-centred physical education curriculum, physical education ought to be a health-centred dynamic learning experience for children 19 , 42 . Quality physical education is important for age-appropriate cognitive learning and to acquire fitness, develop motor skills and psychosocial and emotional skills, which can help children to lead an active lifestyle, inside and outside of the school environment, throughout their life course 18 , 19 , 42 . Given the role of physical education for active and healthy lifestyle, different stakeholders, including United Nations agencies (i.e., UNESCO) 19 , European Commission 17 , have recommended to ensure quality physical education for children and adolescents, and called for political commitments and actions from Governments and supports from the international communities.

In our study, adolescents boys and girls in low-income countries with ≥ 3 days/week physical education class attendance had the highest odds of meeting the physical activity recommendations, and the associations became smaller (yet significant) with a higher country income classification for both sexes. A previous 12-country study 25 reported similar findings for boys, but not for girls. Unlike our study that is based on self-reported data, the earlier study used a device-based physical activity measure and included Australia and other high-income countries of Europe and North America. In addition to high-income countries, our study included adolescents from low- and lower-middle-income countries. It is possible that for many children, regardless of sex or country income, schools provide the most pragmatic and readily accessible opportunities for various physical activity, while out-of-school physical activity options, logistics, and environments might be variable 10 , 11 . The environments, in general, may be more supportive of out of school physical activity for children in high-income countries than their counterparts in low-income countries; however, high-income countries may have other challenges including gender and socioeconomic disparities in physical activity. For example, children from high-poverty neighbourhood may have fewer opportunities for out of school physical activity in many high-income countries 43 , 44 . Appreciating the heterogeneity in resources for physical education within- and across countries, all governments should consider schools as the primary focus to promote an active and healthy lifestyle among children and adolescents, which is likely to be a cost-effective and opportunistic initiative to get them moving. Our findings also show that physical education is potentially more important in South East Asia than the Americas in promoting physical activity. In addition to environmental support, such variations could be a sign of the quality of the respective physical education programs, including time allocated for physical education across the countries. There is a large heterogeneity in weekly time allocated for physical education in countries around the globe. For example, weekly time for physical education of secondary school students in Bangladesh (180 min) is reportedly higher than in Peru (90 min) 28 . Research is needed to understand whether physical education classes are designed to facilitate physical activity and/or how much time students actually spend in physical activity during physical education classes. It is also important to understand how physical education lessons can help the students to develop skills so that they can be more active both inside and outside of school. This information can help in designing a physical education curriculum with balanced components of physical activity and physical education lessons on other health and wellbeing so that the students can develop a healthy lifestyle. Opportunities for quality physical education should be equitable and inclusive, and available for all children regardless their gender, disability status, socio-economic position, and cultural or religious backgrounds, and the delivery of physical education should be ensured for marginalised and vulnerable groups 19 .

The strengths of our study are the inclusion of a large number of countries around the globe, representing different world regions and income groups. All countries included in our study provided nationally representative data. We used the GSHS sample weighting to account for distribution of the population by age and sex in countries for whose data were analysed. Any potential skewness, by sex or age, in the observed data is unlikely to impact the weighted analysis results. All countries where GSHS was implemented, used a standardised data collection procedure. In all countries, a standardised questionnaire with the same survey items to assess physical activity and physical education class attendance was used, which facilitated our regional comparisons. We adjusted our estimates for several potential covariates to avoid possible confounding effects of these factors.

The findings of our study should be interpreted in light of its limitations. Data for our study were collected using self-reported questionnaire; these data are vulnerable to social desirability and recall bias. Unavailability of GSHS data from European and North American countries, some of the Latin/Central American and Asia and Pacific countries, limits the generalisability of the findings only to the GSHS participating countries. Although a standardised questionnaire was used in all participating countries, there is a lack of information on the reliability and validity of GSHS measures across different countries or cultures. Physical education classes can have different meanings and can constitute different components, including a knowledge-based curriculum component (i.e., lessons and discussions) and/or skill-based physical activity session, in different settings. We did not have any information on components of physical education classes across the participating countries. The cross‐sectional design of the study limits our ability to make any causal inferences from the association estimates. Some adolescents in our study may have had difficulties with understanding the questionnaire because of poor reading skills. In this study, we used data collected between 2007 and 2016, which may have biased the results because of the period effect.

Conclusions

Our study suggests a positive association between regular participation in physical education classes and meeting the physical activity guidelines among children and adolescents around the globe regardless of sex or age group. The odds were lower in high- than low-income countries. The benefits of regular participation in physical education classes to enhance physical activity are universal across all WHO regions, with the highest being observed among adolescents from South East Asian countries. Even less frequent participation in physical education classes (i.e., 1–2 days a week) was related to higher odds of being sufficiently active in all but low-income countries, especially in boys. Thus, the findings support the importance of physical education for ensuring sufficient physical activity among school-going children and adolescents around the globe. Countries must not miss the opportunity to ensure schools deliver a daily or at least 3 days per week of well-designed physical education classes, which can play a vital role in creating active nations around the world.

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Acknowledgements

The authors would like to thank the US Centers for Disease Control and Prevention and the World Health Organization for making the Global School-based Student Health Survey (GSHS) data publicly available for analysis. The authors thank the GSHS country coordinators and other staff members. R.U. is supported by Alfred Deakin Postdoctoral Research Fellowship. J.S. is supported by a National Health and Medical Research Council Leadership Level 2 Fellowship (APP 1176885). S.M.S.I. is supported by the Institute for Physical Activity and Nutrition, Deakin University and a post doctorate fellowship from the National Heart Foundation of Australia (Award #102112).

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Uddin, R., Salmon, J., Islam, S.M.S. et al. Physical education class participation is associated with physical activity among adolescents in 65 countries. Sci Rep 10 , 22128 (2020). https://doi.org/10.1038/s41598-020-79100-9

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Articles on Physical education

Displaying 1 - 20 of 36 articles.

New government guidance for PE lets teachers and pupils down

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Is exercise really good for the brain? Here’s what the science says

Matthieu P. Boisgontier , L’Université d’Ottawa/University of Ottawa and Boris Cheval , Université de Genève

Girls should get the chance to play football at school – but PE needs a major rehaul for all students

Shrehan Lynch , University of East London

School playgrounds are getting squeezed: here are 8 ways to keep students active in small spaces

Brendon Hyndman , Charles Sturt University ; Jessica Amy Sears , Charles Sturt University , and Vaughan Cruickshank , University of Tasmania

Outdoor education has psychological, cognitive and physical health benefits for children

Jean-Philippe Ayotte-Beaudet , Université de Sherbrooke and Felix Berrigan , Université de Sherbrooke

London’s Olympic legacy: research reveals why £2.2 billion investment in primary school PE has failed teachers

Vicky Randall , University of Winchester and Gerald Griggs

How sport can help young people to become better citizens

Vaughan Cruickshank , University of Tasmania and Casey Peter Mainsbridge , University of Tasmania

Missing out on PE during lockdowns means students will be playing  catch-up

Jora Broerse , Victoria University ; Cameron Van der Smee , Federation University Australia , and Jaimie-Lee Maple , Victoria University

Disabled children still face exclusion in PE – here’s what needs to change

Tom Gibbons , Teesside University and Kevin Dixon , Northumbria University, Newcastle

Taking the circus to school: How kids benefit from learning trapeze, juggling and unicycle in gym class

Marion Cossin , Université de Montréal

Thinking of choosing a health or PE subject in years 11 and 12? Here’s what you need to know

Brendon Hyndman , Charles Sturt University and Vaughan Cruickshank , University of Tasmania

Aussie kids are some of the least active in the world. We developed a cheap school program that gets results

Taren Sanders , Australian Catholic University ; Chris Lonsdale , Australian Catholic University ; David Lubans , University of Newcastle ; Michael Noetel , The University of Queensland , and Philip D Parker , Australian Catholic University

When men started to obsess over  six-packs

Conor Heffernan , The University of Texas at Austin

PE can do much more than keep children fit – but its many benefits are often overlooked

David Grecic , University of Central Lancashire ; Andrew Sprake , University of Central Lancashire , and Robin Taylor , University of Central Lancashire

Distance learning makes it harder for kids to exercise, especially in low-income communities

Katelyn Esmonde , Johns Hopkins University and Keshia Pollack Porter , Johns Hopkins University

Kids need physical education – even when they can’t get it at school

Collin A. Webster , University of South Carolina

Learning through adventure: the many skills that can be taught outside the classroom

Gary Stidder , University of Brighton

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Julie McCleery , University of Washington

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How children who dread PE lessons at school can be given a sporting chance

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New Research Examines Physical Education in America

By Morgan Clennin, PhD, MPH, Kaiser Permanente of Colorado, University of South Carolina, and National Physical Activity Plan

School-based physical education (PE) is recommended by the Community Guide as an effective strategy to promote physical activity among youth. Unfortunately, many have speculated that PE exposure has declined precipitously among U.S. students in the past decade. Limited resources and budgets, prioritization of core academic subjects, and several other barriers have been cited as potential drivers of these claims. However, few large-scale studies have explored the merit of these claims – leaving the answers following questions unknown:

Has PE attendance decreased among U.S. students in the past decades?

What policies and practices are in place to support quality PE?

To answer these questions, the President’s Council on Sports, Fitness & Nutrition tasked the National Physical Activity Plan Alliance (NPAPA) to review the available evidence and summarize their findings. The primary objective of this effort was to better understand PE exposure over time to inform national recommendations and strategies for PE.

The NPAPA began by establishing a collaborative partnership with experts in the federal government, industry, and academia. The group analyzed existing national data sources that could be used to examine changes in PE attendance and current implementation of PE policies and practices. These efforts culminated in a final report and two peer-reviewed manuscripts. A summary of the group’s findings are outlined below.

Key Findings:

• 1/2 of U.S. high school students did not attend PE classes—which is consistent over the 24-year period studied (1991-2015).
• The percentage of U.S. high school students reporting PE attendance did not change significantly between 1991 and 2015 for the overall sample or across sex and race/ethnicity subgroup.
• Daily PE attendance did decrease 16% from 1991 to 1995 then attendance rates remained stable through 2015.
• > 65% of schools implemented 2-4 of the 7 essential PE policies
• Implementation of PE policies varied by region, metropolitan status, and school level.
• Data indicates minority students have been disproportionately affected by cuts to school PE programs during the past two decades.

Recommendations Based on Key Findings:

• Prioritize efforts to expand collection of surveillance data examining trends in PE attendance among elementary and middle school students.
• Develop policies to improve PE access for all students in order for PE to contribute to increased physical activity among youth.
• Adopt policies and programs that prioritize PE to maximize the benefits of PE.
• Utilize the findings of these efforts to target professional development and technical assistance for PE practitioners.

The Education sector of the NPAP provides evidence-based strategies and tactics that can guide efforts to support the provision of quality PE to all students. More information, and links to the respective manuscripts, can be found on the NPAPA website: http://physicalactivityplan.org/projects/physicaleducation.html

The Office of Disease Prevention and Health Promotion (ODPHP) cannot attest to the accuracy of a non-federal website.

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Journal of Physical Education Research (JOPER) is a scientific publication. It is a peer reviewed and referred journal, officially publishes original research articles on Physical Education and its allied sciences. The JOPER is an open access international journal has four annual issues (March, June, September and December), with its own issue number and supplements if necessary for each issue. JOPER publishes in both printed and online version. It is devoted to the promotion of physical education and allied sciences. The experiences of different countries are very important to share on a platform like this. Therefore, this international journal serves to bring scholars from diver's background interns of their domain of specialization and scholarships and will enrich our understanding of various issues related to the physical education and sports. It also provides an International forum for the communication and evaluation of data, methods and findings in physical education and allied sciences. Based on the international character of the Journal, the articles/research papers can be published by authors from all over the world. The journal is under the indexing phase in several international bodies and organizations. The journal publishes scientific publications according to the criteria listed in the Guidelines for the Authors. Everyone who has met the requirements of the journal and who takes full responsibility for all that is written in the publication has the right to publish their article with us. The review and the corrections made by the editorial board and its associates do not dismiss the author (the co-authors) from the responsibility for his/her publication, and they also do not change its originality.

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Peer-reviewed

Research Article

An experimental study on the influence of healthy physical education curriculum model on sports ability of Chinese senior high school students

Contributed equally to this work with: Shengting Dai, Qian Qiu, Yuancai Zhang, Jingfei Yan, Rongbin Yin

Roles Conceptualization, Data curation, Funding acquisition, Writing – original draft

Affiliation School of Sports Science and Engineering, East China University of Science and Technology, Shanghai, China

Roles Data curation, Investigation, Methodology, Software, Writing – review & editing

Affiliation Physical Education College, Xuchang University, Xuchang, China

Roles Methodology, Resources, Supervision, Validation

Affiliation College of Physical Education and Health, East China Normal University, Shanghai, China

Roles Conceptualization, Project administration, Resources, Supervision, Validation, Visualization, Writing – review & editing

* E-mail: [email protected] (JY); [email protected] (RY)

Affiliation Ministry of Physical Education, Shanghai Institute of Technology, Shanghai, China

Roles Methodology, Supervision, Validation, Writing – review & editing

Affiliation School of Physical Education, Soochow University, Suzhou, China

• Shengting Dai, 
• Qian Qiu, 
• Yuancai Zhang, 
• Jingfei Yan, 
• Rongbin Yin

• Published: May 14, 2024
• https://doi.org/10.1371/journal.pone.0298858
• Reader Comments

In recent years, the growing incidence of health issues among Chinese students, including obesity, diabetes, and other chronic diseases, has been attributed to a sedentary lifestyle, lack of physical activity, and unhealthy eating habits. Physical education (PE) classes play a crucial role in promoting physical activity and fostering healthy lifestyles among Chinese students. The purpose of this study was to investigate the influence of the healthy PE curriculum model on the sports ability of senior high school students in China. The trial adopted a quasi-experimental design with equivalent groups. The experimental group followed the healthy PE curriculum model in their PE classes, while the control group received traditional technical instruction. During the 12-week intervention, 149 senior high school students completed the sports ability test as both the pre-test and post-test measurements for this experimental study. The results indicated that the experimental group showed significant improvements in sports ability compared to the control group, highlighting the positive effects of the healthy PE curriculum model. The structural characteristics of the healthy PE curriculum model provided essential support for students’ learning and proved to be an effective way to promote physical literacy among senior high school students in China.

Citation: Dai S, Qiu Q, Zhang Y, Yan J, Yin R (2024) An experimental study on the influence of healthy physical education curriculum model on sports ability of Chinese senior high school students. PLoS ONE 19(5): e0298858. https://doi.org/10.1371/journal.pone.0298858

Editor: Preeti Kanawjia, GSVM Medical College, INDIA

Received: June 8, 2023; Accepted: February 1, 2024; Published: May 14, 2024

Copyright: © 2024 Dai et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data files are available from the DRYAD database: https://datadryad.org/stash/share/tP5af3E1HsllsF8bjCxfVtemLPPGNzDQBM0Orgn56c4 .

Funding: The funding for this research was made possible through the generous support of several grants: [East China University of Science and Technology Exploratory Research Fund Project]: This grant, awarded by [East China University of Science and Technology], grant number [JKL02222201], played a pivotal role in funding the initial stages of our research, including data collection and preliminary analyses. [Shanghai Educational Science Research Project]: We also received support from [Shanghai Municipal Commission of Education], grant number [C2023025], which significantly contributed to the development of our experimental design and the execution of specific research protocols. [contribution to study design, data curation, funding acquisition, decision to publish, and preparation of the manuscript, etc.]

Competing interests: The authors have declared that no competing interests exist.

1. Introduction

Physical education plays a crucial role in the development and well-being of students, especially during their formative years in senior high school [ 1 , 2 ]. With the growing concern for the sedentary lifestyles and poor health habits of today’s youth, there is a need for innovative physical education models that can help promote healthy lifestyles and enhance sports abilities [ 3 ]. In recent years, China has witnessed a dramatic increase in the number of students who suffer from health issues due to lack of physical activity [ 4 , 5 ]. The traditional physical education curriculum model in China is exam-oriented, which means that students focus mainly on achieving good grades rather than improving their physical fitness [ 6 ]. Therefore, there is a need to evaluate the effectiveness of physical education curricula in promoting physical activity and improving sports ability among Chinese senior high school students [ 7 ].

To effectively advance the implementation of China’s new primary and secondary school curriculum standards and foster the development of students’ core competencies in physical education and health, Professor Ji Liu, who led the 2015 National Primary and Secondary School Physical Education and Health Curriculum Standards Development and Revision Group and is associated with East China Normal University, drew inspiration from the” National Medium and Long-term Education Reform and Development Plan (2010–2020).”Guided by the fundamental principles outlined in the national “Physical Education and Health Curriculum Standards” for primary and secondary schools, Professor Ji Liu amalgamated international insights from physical education curriculum models and domestic best practices. This culminated in the proposal of a comprehensive physical education and health curriculum model, aptly named “The Healthy Physical Education Curriculum Model(HPECM),which harmoniously blends an international perspective with distinctively Chinese characteristics [ 8 ]. HPECM ( Table 1 ) plays a pivotal role in driving the implementation of the national”Curriculum Standards” in the domain of physical education and health. It not only aligns with the principles and ethos of the “Curriculum Standards” but also offers clear guidance and methodologies to address critical issues in curriculum development, as articulated by Professor Ji Liu in 2015.

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https://doi.org/10.1371/journal.pone.0298858.t001

This model adopts a comprehensive curriculum perspective, operating within the framework of curriculum discourse. It encompasses the holistic design of the curriculum, ranging from modules to individual units, with a strong emphasis on effective curriculum implementation. This approach outlines overarching requirements and specific implementation strategies."

The main purpose of the Healthy Physical Education Curriculum Model is to solve the problem of the continuous decline in the physical health level of Chinese teenagers in the past 30 years. The implementation of the Healthy Physical Education Curriculum Model requires grasping three key points: sports skills, physical fitness, and exercise load. In terms of sports skills, structured skill learning and practice are emphasized. Whether it is a new teaching or a review class, attention should be paid to activities and competitions, and single-skill teaching should be rejected, with time maintained at around 20 minutes (a 40-minute class as an example). In terms of physical fitness, diversified, interesting, and compensatory physical fitness design is emphasized, with time maintained at around 10 minutes. In terms of exercise load, it is emphasized that the average heart rate of students in the classroom should reach 140–160 times per minute, and the continuous exercise time of students should account for about 75% of the total class time. It should be noted that the exercise time of each student does not need to reach 75% of the total class time, but the teacher should arrange the entire activity time to not exceed 25% of the total class time in a static state. The structural characteristics of the Healthy Physical Education Curriculum Model not only help improve students’ sports ability but also contribute to the cultivation of students’ physical literacy [ 9 ].

Physical education curriculum models have been developed to address this issue and improve the quality of PE programs. Several studies have examined the effectiveness of the HPECM in improving sports ability outcomes among youth [ 10 , 11 ]. However, most of these studies have focused on elementary and middle school students. There is a need for research on the influence of the HPECM on sports ability among senior high school students. Therefore, the aim of this experimental study is to investigate the influence of HPECM on the sports ability of Chinese senior high school students. The study seeks to evaluate whether a curriculum model that emphasizes healthy physical activity can improve the sports ability of students and promote a more active lifestyle.

2. Materials and methods

2.1 study design.

Before the experimental research, the teacher of the experimental group was trained in the theory and practice of the healthy physical education curriculum model and achieved satisfactory training results. According to the school facilities, teachers’ characteristics, and students’ learning experience, the teaching experiment theme is basketball. Basketball teaching lasts for 12 weeks, two classes per week, for a total of 24 classes, each class lasting 80 minutes.

The experimental group firmly grasped the three key points of the healthy physical education curriculum model, and the teaching plan was jointly written between researcher and teacher after discussion. The control group implements routine teaching [ 12 ], that is, technical-traditional teaching, which has the following remarkable characteristics: The average heart rate of students in the whole class is less than 140 beats/min; Mainly adopts single movement skill teaching; There is no special physical exercise in the class. During the 12-week intervention period, all students completed the test of sports ability variables two times as the pre-test and post-test of this experimental study.

During the experiment, it is important to minimize the influence of irrelevant factors on the results. The control process mainly involves the following aspects: using identical teaching materials for both groups; ensuring that the teaching time is the same for both groups; adjusting the amount of teaching based on the weather and various school activities that may affect the experiment; to reduce experimental errors caused by differences in teaching styles and abilities among different teachers, the experimental and control groups are taught by the same teacher, and the experimental teacher is instructed to strictly follow the experimental plan while the control group should not intentionally imitate the experimental group’s teaching. Both the experimental and control groups were the students’ usual teachers. The principal investigator is present to assist and correct any problems that arise to ensure the effectiveness of the experimental teaching in the experimental group.

Inclusion/exclusion criteria :

Inclusion Criteria :

Educational Level: Participants must be currently enrolled high school students attending physical education classes.

Grade Range: Participants must specifically be high school sophomores.

Prior Physical Education Experience: Eligible participants should have successfully completed at least one year of physical education coursework.

Consent: Prior to participation, written informed consent is mandatory from both the students and their legal guardians.

Exclusion Criteria :

Medical Conditions: Participants with documented cardiovascular or respiratory conditions that may be adversely affected by physical activity will be excluded from the study.

Advanced Knowledge of Experimental Methods: Students possessing prior exposure or training in the experimental teaching methods under investigation will be excluded from participation.

These criteria aim to ensure a clear definition of the study’s target population, emphasizing the requisite educational level, grade, and prior experience in physical education. The inclusion of specific exclusion criteria serves to safeguard participant safety and maintain the integrity of the experimental design. Obtaining written informed consent further underscores the ethical considerations of the study.

Intervention condition and the control condition :

Intervention Condition: The intervention condition centers on the application of The Healthy Physical Education Curriculum Model (HPECM). Grounded in contemporary pedagogical theories, HPECM seamlessly integrates cutting-edge teaching strategies tailored to elevate student engagement, facilitate skill acquisition, and optimize overall outcomes in physical education. This intervention marks a departure from conventional didactic methods, introducing a student-centric paradigm. HPECM adopts an innovative approach by incorporating technology-assisted learning tools, personalized feedback mechanisms, and collaborative learning experiences. The overarching objective is to create an enriched educational environment that transcends traditional instructional practices.

Control Condition: To mitigate potential experimental errors arising from variations in physical education teaching methods, basketball is consistently chosen as the focal subject for this study. In addressing potential confounding factors linked to diverse teaching styles and instructor capabilities, a meticulous control strategy is implemented. Specifically, both the experimental and control classes within the same academic period are instructed by the same teacher. To ensure consistency, explicit instructions are provided to the experimental teachers, mandating adherence to the experimental plan. Conversely, the control class is advised against intentionally mimicking the experimental conditions. Throughout the teaching sessions, the experimental instructor actively engages in problem-solving, offering assistance and corrections promptly.

2.2 Participants

The research study selected second-year students from a high school in Shanghai as research objects. Class selection was conducted through a randomization procedure. A random number generator was employed to allocate classes to either the experimental or control group. This approach aimed to ensure an unbiased selection process and create comparable groups at the study’s outset. Two classes from the second grade of high school were randomly selected as Experimental Group 1 (girls class) and Experimental Group 2 (boys class) due to the influence of class division teaching. Additionally, two classes were randomly selected as Control Group 1 (girls class) and Control Group 2 (boys class). Students were asked about their past medical history, family genetics, cardiovascular disease status, etc., to rule out potential risks in sports. There were 76 students in the experimental group (36 boys and 40 girls), and 73 students in the control group (35 boys and 38 girls). Please refer to Table 2 for the mean and standard deviation of the age, height, and weight of students in each experimental class and control class. During the process of recruiting subjects, there were no refusals to participate, and all subjects participated fully in the teaching experiment.

https://doi.org/10.1371/journal.pone.0298858.t002

2.3 Ethics statement

Prior to conducting the study, ethical approval was granted by the University Committee on Human Research Protection (UCHRP) of East China Normal University. The research protocol, including the participant consent process, was reviewed and approved by the UCHRP under protocol number [Approval Number: HR 095–2019].

All participants in this study were voluntary respondents selected by the research panel. They were provided with detailed information about the study’s purpose, procedures, potential risks, and benefits. Participants were assured that their responses would be treated as strictly confidential and anonymous. The confidentiality of their data was maintained throughout the research process. Participants provided written informed consent to participate in this study. In accordance with the approved protocol, each participant confirmed their willingness to participate by endorsing the following statement on a paper questionnaire: "I voluntarily consent to participate in this research project. I understand that my participation is entirely voluntary and that I have the right to withdraw from the study at any point without any negative consequences."

2.4 Data collection

Data were collected over a period of 3 months (From October 2020 to December 2020), incorporating pre-test and post-test measurements. The data collection process comprised the following steps:

Pre-Test Assessment: Prior to the intervention, baseline measurements were obtained to assess the initial sports ability level of the participants.

Post-Test Assessment: Following the intervention period, post-test measurements were conducted to evaluate the impact of the healthy physical education curriculum model. The same assessment components used in the pre-test were administered to both the control and intervention groups. The post-test assessments use the same standardized protocols and equipment as the pre-test.

2.5 Experimental intervention program

2.5.1 motor skill intervention program..

The motor skill exercises for both the experimental and control groups were standardized to focus on basketball. This design was implemented to eliminate potential interference from varying motor skill exercises on the experimental results [ 13 – 16 ]. The design of motor skill instruction in the experimental group adhered to the guidelines set forth by the HPECM for motor skill teaching. Structured basketball skill instruction was employed to empower students to master a comprehensive set of motor skills. The approach advocated against the exclusive teaching of isolated techniques, instead emphasizing theintegration of basketball learning within practical activities and competetive scenarios. During basketball instruction, a priority was placed on minimizeing breaks, optimizing group dynamics, and enabling students to engage in supplementary exercises during idle moments. Teachers also reinforced precise movement techniques, encouraged cooperative practice, and instilled a sense of courage and initiative.

2.5.2 Physical fitness intervention program.

The principles governing physical fitness program design were aligned with the requirments of the HPECM. These princples were thougfully talored to suit the unique physical and psychological characteristics of high school students:

• Emphasis was placed on diversification and enjoyment in the methods and approaches employed for physical fitness exercises. This approach aimed to counteract the monotony often associated with endurance focused activities like running laps, repetitive exercises such as sit-ups for core strength, and sprinting for speed.
• Special attention was given to the concept of "compensatory" physical fitness exercises. Considering the distinctive demands of basketball within this study, students were encouraged to participate in supplementary exercises targeting core abdominal strength, cardiovascular endurance, and agility. This approach was integrated into the basketball curriculum, fostering a holistic and balanced approach to physical fitness development among students.
• Efforts were made to avoid transforming physical education classes into mere physical fitness testing sessions.

2.5.3 Motor cognitive ability intervention program.

The intervention principles of the motor cognitive ability intervention plan were formulated in accordance with the spirit of the HPECM and the contemporary teaching philosophy. These principles were strategically designed to accommodate the physical and psychological development characteristics inherent to high school students. Within the classroom setting, students were introduced to motor cognitive ability related knowledge through engaging PowerPoint presentations. Experimental teachers placed a strong emphasis on cultivating student’s motor cognitive ability throughout the teaching process. For instance, during warm-up exercises, teachers underscored the critical role of preparation activities in injury prevention and highlighted the benefits of relaxation in alleviating exercise-related fatigue.

2.6 Test variables

The assessment of sports ability includes three aspects: motor skills, physical fitness, and motor cognitive ability. Motor skills mainly include single skill assessment, combination skill assessment, and performance assessment in competition. Physical fitness tests mainly include indicators such as body composition, muscle strength, muscle endurance, Cardiopulmonary function, speed, flexibility, and agility. Motor cognitive ability is mainly assessed using scale tests. See Table 3 for specific details.

https://doi.org/10.1371/journal.pone.0298858.t003

2.6.1 Motor skill test.

Testing Protocol:

Single Techniques: Participants are assessed on fundamental basketball skills, including shooting. Each participant is given a specific task, and their execution is observed and rated based on established criteria.

Combination Techniques: This segment evaluates participants’ ability to seamlessly integrate various basketball skills. The task is passing and shooting, assessing the fluidity and effectiveness of their execution.

Match Performance: Participants engage in a simulated basketball game, applying their skills in a dynamic and competitive context. This allows for the assessment of strategic decision-making, teamwork, and adaptability during actual gameplay.

Evaluation Method:

Three experienced teachers serve as evaluators for each test, ensuring a comprehensive and reliable assessment. Each teacher scores participants independently based on predefined criteria for each skill and performance aspect. The final score for each participant is derived by calculating the average of the three individual scores.

Scoring Criteria:

1.Single Techniques

[85 points—100 points] Standard Attainment (70%): 6 males, 4 females; Technical Evaluation (30%): Demonstrates accurate posture and distinct finger flicking motion.

[75 points—84 points] Standard Attainment (70%): 4 males, 3 females; Technical Evaluation (30%): Exhibits relatively accurate posture with noticeable finger flicking motion.

[60 points—74 points] Standard Attainment (70%): 3 males, 2 females; Technical Evaluation (30%): Displays accurate posture with no discernible finger flicking motion.

[59 points and below] Standard Attainment (70%): 2 males, 1 female; Technical Evaluation (30%): Features inaccurate posture with no discernible finger flicking motion.

2.Combination Techniques

[85 points—100 points] Exceptional proficiency in passing and dribbling, demonstrating accurate passing, a correct and effortless shooting motion, and seamless coordination in passing, receiving, and shooting. Males complete the task within 45 seconds, and females within 56 seconds, with a successful shot count of 3 or more.

[75 points—84 points] Competent in passing and dribbling, showcasing correct shooting form and excellent coordination. Males complete the task within 50 seconds, and females within 60 seconds, with a successful shot count of 2 or more.

[60 points—74 points] Adequate execution of passing and shooting, albeit with slightly weaker coordination. Males complete the task within 55 seconds, and females within 65 seconds, with a successful shot count of 1 or more.

[59 points and below] Notable errors and significant mistakes in passing and shooting. Males complete the task in 55 seconds or more, and females in 65 seconds or more, with a successful shot count of 0.

3. Match Performance

[85 points—100 points]Personal Attack Ability: Proficient utilization of offensive skills (shooting, penetration, break, pass, and catch the ball) with a rational and skilled approach.Defensive Ability: Demonstrates strength in individual defense and cooperative defense skills.Tactical Awareness: Exhibits a robust individual tactical action ability, quick transition between attack and defense, and a keen sense of fast attack throughout the entire game.

[75 points—84 points]Personal Attack Ability: Displays a reasonable and skilled application of offensive techniques (throwing, sudden moves, passing).Defensive Ability: Strong performance in individual defense and cooperative defense. Tactical Awareness: Possesses a strong individual tactical action ability, fast attack and defense transition speed, and a heightened consciousness of fast attacks throughout the game.

[60 points—74 points]Personal Attack Ability: Demonstrates a general level of rationality and proficiency in utilizing offensive techniques (throwing, leaping, passing).Defensive Ability: Displays average individual defense and coordination defense skills. Tactical Awareness: Possesses a moderate individual tactical action ability, with a general speed in attack and defense transition, and a reasonable awareness of fast attacks throughout the game.

[59 points and below]Personal Attack Ability: Shows poor and unskilled use of offensive techniques (throwing, sudden moves, passing).Defensive Ability: Exhibits poor individual defense and cooperative defense skills. Tactical Awareness: Displays weak individual tactical action ability, slow offensive and defensive transition speed, and a poor consciousness of fast attacks throughout the entire game.

2.6.2 Physical fitness test.

The body composition test includes two indexes: Percentage of Body Fat (PBF) and Waist-Hip Ratio (WHR). PBF is measured primarily by the Jawon body composition analyzer [ 17 ]. WHR is calculated by measuring the waist and hip circumference using a soft ruler, with measurements taken twice on each side and then averaged [ 18 ].

The cardiopulmonary function test includes two indicators: vital capacity [ 19 ] and a 20-meter shuttle run test [ 20 ]. Vital capacity is measured using an electronic spirometer. The 20-meter shuttle run test requires students to run back and forth between two lines that are 20 meters apart in time with the music. As the test progresses, the music speed increases. If a student cannot reach the endpoint within the required time twice in a row, the test is stopped, and the score is recorded as the number of completed 20-meter shuttles, with the unit being "times."

The muscle strength test includes two indicators: upper limb muscle strength, measured by grip strength [ 21 ], and lower limb muscle strength, measured by standing long jump [ 22 ]. For the grip strength test, the subject stands upright with their feet shoulder-width apart, arms hanging down, and palms facing inward. They then squeeze the inner and outer handles of a dynamometer with maximum effort, and the score is recorded in "kg" units. Each subject is measured twice, and the best score is taken. For the standing long jump test, the subject stands behind the take-off line with their feet together and jumps forward as far as possible without stepping or jumping in place. The distance from the take-off line to the nearest landing point is measured vertically, and the score is recorded in "m" units. Again, two measurements are taken, and the best score is taken.

The muscle endurance test measures a student’s ability to complete as many sit-ups as possible within one minute [ 23 ]. To start, the student lies down on a soft pad with their knees bent at a 90-degree angle and their hands interlaced behind their head. The examiner holds the student’s ankles on both sides, fixing their feet to the ground. Upon hearing the ’start’ command, the student completes the sit-up motion by pulling in their stomach and touching or crossing their elbows over their knees before returning to the starting position. One point is awarded for each successful sit-up completed. The examiner records the number of completed sit-ups in one minute, using "times" as the unit of measurement.

The indicator for the flexibility test is the sit-and-reach test [ 24 ]. Firstly, the teacher explains the test requirements and demonstrates. During the test, the subject sits with their feet flat against the vertical board of the measuring device, with their legs straight and not bent, and their arms straight and extended forward, pushing the cursor with their fingertips until they can no longer reach forward. Each subject is tested twice, and the best score is recorded in "cm" units.

The indicator for the speed test is the 50-meter run [ 25 ]. Firstly, the teacher explains the test requirements and organizes the students to conduct sufficient warm-up exercises. During the test, two people are tested in each group. The subjects stand at the starting line and begin to run when they hear the "run" command. The starter waves the flag at the same time as the command is given, and the timer starts timing when the flag moves. The stopwatch stops when the subject’s chest reaches the vertical plane of the finish line, and the score is recorded in "S (seconds)." The test requires the subjects not to false start, and any false starters will be called back for a restart.

The agility test is measured by the 20-second shuttle run [ 26 ], as illustrated in Fig 1 . The subject assumes a squatting position with legs straddling the center. Upon hearing the start signal, they swiftly move to the right side and repeatedly shuttle back and forth in the order of "center→right→center→left→center…". Each time the subject crosses a line, it is counted as one, and the number of crossings completed within 20 seconds is recorded. The test is performed twice, and the best score is recorded in "times" units.

https://doi.org/10.1371/journal.pone.0298858.g001

2.6.3 Motor cognitive ability test.

This study used a Motor Cognitive Ability Scale, which was targeted at senior high school students and included two dimensions: motor cognition and physical fitness awareness, with a total of 9 items. The "motor cognition" dimension reflected senior high school students’ knowledge and methods of sports activities, appreciation of sports, and information about sports events. The "physical fitness awareness" dimension reflected information about senior high school students’ physical development. The scale used a 5-level Likert rating, where scores from 1 to 5 were calculated based on the degree of understanding of the theme, ranging from low to high, such as "I understand the competition rules of the sports I have learned." To assess internal consistency, we calculated Cronbach’s alpha for the scale. The standardized Cronbach’s α coefficient values of the two dimensions of sports cognition and physical fitness awareness of the scale are 0.897 and 0.865 respectively, and the standardized Cronbach’s of the scale is 0.918. To assess construct validity, we conducted exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).The χ2 /df for the scale is 2.839. The goodness-of-fit indces, GFI, CFI, NFI, TLI, and IFI, are 0.977, 0.987,0.980, 0.978, and 0.987, respectively. The RMSEA is 0.058, and the RMR is 0.029. All the fitting indexes met the standard of good fit and met the statistical requirements.

2.7 Statistical analysis

The experiment utilizes a single-factor two-group pretest-posttest design, with covariance analysis applied to process the experimental data. The pretest scores of the test indicators are treated as covariates, and the group (consisting of an experimental class and a control class) is treated as the independent variable. The posttest scores of the test indicators are used as the dependent variables. By analyzing the changes in the physical literacy-related indicators of sports and health subjects in both the experimental and control classes, the effectiveness of the experimental intervention can be determined. If there is no significant difference in the changes of the related test indicators between the two classes, a paired sample t-test is conducted to examine whether there is a significant improvement in the post-test results of each class’s related indicators.

This section may be divided by subheadings. It should provide a concise and precise description of the experimental results, their interpretation, as well as the experimental conclusions that can be drawn.

3.1 Motor skill results

Table 4 provides descriptive statistics for the motor skill results of the experimental and control groups. The results are presented separately for each variable and by gender.

https://doi.org/10.1371/journal.pone.0298858.t004

For the 1-minute shooting task, the mean scores for both girls and boys in the experimental groups increased from pre-test to post-test. The girls in the experimental group improved their mean score by 8.17 points ( SD = 4.94), while the boys in the experimental group improved by 3.85 points ( SD = 11.10). The control groups also saw an increase in mean scores from pre-test to post-test, with girls improving by 5.65 points ( SD = 6.34) and boys improving by 2.06 points ( SD = 12.09). However, the experimental group showed a larger improvement in mean scores compared to the control group. For the passing and cutting coordination task, the mean scores for both girls and boys in the experimental groups increased from pre-test to post-test. The girls in the experimental group improved their mean score by 4.89 points ( SD = 4.92), while the boys in the experimental group improved by 5.39 points ( SD = 8.96). The control groups also showed an increase in mean scores from pre-test to post-test, but the improvement was smaller compared to the experimental group. The girls in the control group improved their mean score by 2.26 points ( SD = 3.43), while the boys in the control group improved by 3.85 points ( SD = 8.08). For the game performance task, the mean scores for both girls and boys in the experimental groups increased from pre-test to post-test. The girls in the experimental group improved their mean score by 5.71 points ( SD = 6.21), while the boys in the experimental group improved by 5.30 points ( SD = 4.47). The control groups also showed an increase in mean scores from pre-test to post-test, but the improvement was smaller compared to the experimental group. The girls in the control group improved their mean score by 4.132 points ( SD = 5.02), while the boys in the control group improved by 3.28 points ( SD = 5.72).

Overall, the experimental groups showed greater improvement in mean scores from pre-test to post-test compared to the control groups across all three tasks. The results suggest that the intervention had a positive impact on the motor skills of both girls and boys.

The results of the covariance analysis are shown in Table 5 . After controlling for the pre-test scores of male and female students in each class during the second year of high school, the post-test scores of the experimental group were significantly higher than those of the control group. Specifically, in terms of passing and cutting coordination, male and female students in the experimental group showed significantly higher scores than those in the control group. Moreover, in basketball games, the post-test scores of male and female students in the experimental group were also significantly higher than those in the control group after controlling for their pre-test scores. These findings suggest that adopting the Chinese Healthy Physical Education Curriculum model can effectively enhance the sports skills of second-year high school students, in comparison with traditional physical education teaching methods.

https://doi.org/10.1371/journal.pone.0298858.t005

3.2 Physical fitness results

Table 6 presents the descriptive statistics of the physical fitness results, including the pre-test and post-test mean scores and standard deviations for each dimension, variable, gender, and group.

https://doi.org/10.1371/journal.pone.0298858.t006

In terms of body composition, the experimental class 1 for girls and boys’ experimental class 2 had a slightly lower post-test mean score for percent body fat (PBF) compared to their respective control classes, although the difference was minimal. A similar trend was observed in waist-to-hip ratio (WHR), where the girls’ experimental class 1 and boys’ experimental class 2 had slightly lower post-test mean scores compared to their respective control classes. Regarding cardiopulmonary function, both the girls’ experimental class 1 and boys’ experimental class 2 had higher post-test mean scores for vital capacity compared to their respective control classes. For the 20-meter shuttle run, both girls’ and boys’ experimental classes had higher post-test mean scores compared to their respective control classes. In terms of muscle strength, the girls’ experimental class 1 and boys’ experimental class 2 had higher post-test mean scores for grip strength compared to their respective control classes. However, for standing long jump, there was no significant difference observed between the experimental and control classes. For muscle endurance, the girls’ experimental class 1 and boys’ experimental class 2 had higher post-test mean scores for 1-minute crunches compared to their respective control classes. Regarding flexibility, the girls’ experimental class 1 and boys’ experimental class 2 had higher post-test mean scores for seated forward bend compared to their respective control classes. Finally, in speed and agility, the experimental classes had slightly better post-test mean scores compared to their respective control classes.

In summary, the experimental classes showed an overall improvement in physical fitness in most dimensions, variables, genders, and groups compared to the control classes. However, the differences were sometimes minimal and not significant, indicating a need for further investigation and analysis of the results to determine the effectiveness of the physical fitness intervention.

The results of the covariance analysis are shown in Table 7 . Using pre-test scores as covariates, the study found that the post-test scores of male students in the experimental class were significantly lower than those of male students in the control class in terms of percent body fat (PBF), while there was no significant difference in PBF between female students in the experimental and control classes. The study also found that the experimental class had significantly lower waist-to-hip ratio (WHR) and significantly higher lung capacity, 20-meter shuttle run, grip strength, and standing long jump scores compared to the control class for both male and female students. Additionally, the experimental group had significantly higher scores on one-minute sit-ups and the 20-second shuttle run compared to the control group for both male and female students. However, the experimental group had significantly lower scores on the 50-meter run compared to the control group for both male and female students. The study concluded that using the Chinese Health and Physical Education Curriculum model can significantly improve physical fitness outcomes among male and female students in the second year of high school.

https://doi.org/10.1371/journal.pone.0298858.t007

3.3 Motor cognitive ability results

Table 8 presents the descriptive statistics for the motor cognitive ability results, specifically for the variables of motor cognition and physical fitness awareness.

https://doi.org/10.1371/journal.pone.0298858.t008

For the variable of motor cognition, the experimental class 1 for girls had a lower pre-test mean score compared to the control class 1, but this difference was not statistically significant. However, the experimental class 1 had a higher post-test mean score compared to the control class 1, and this difference was statistically significant. For boys, the experimental class 2 had a lower pre-test mean score compared to the control class 2, but this difference was not statistically significant. The experimental class 2 had a higher post-test mean score compared to the control class 2, and this difference was statistically significant.

For the variable of physical fitness awareness, the experimental class 1 for girls had a slightly higher pre-test mean score compared to the control class 1, but this difference was not statistically significant. The experimental class 1 had a significantly higher post-test mean score compared to the control class 1. For boys, the experimental class 2 had a lower pre-test mean score compared to the control class 2, but this difference was not statistically significant. The experimental class 2 had a significantly higher post-test mean score compared to the control class 2.

In summary, the experimental classes showed improvement in motor cognitive ability in terms of motor cognition and physical fitness awareness compared to the control classes. The differences were statistically significant for most comparisons, except for the pre-test mean scores in some cases. These results suggest that the physical fitness intervention had a positive impact on the motor cognition of the students. However, further research is needed to fully evaluate the effectiveness of the intervention.

Table 9 presents the results of a covariance analysis investigating the impact of gender and group membership on motor cognition and physical fitness awareness in experimental and control groups. The analysis revealed significant differences between the two groups in both variables. Girls in the experimental group scored higher in motor cognition and physical fitness awareness compared to girls in the control group. The same trend was observed for boys in the experimental group, who outperformed boys in the control group in both variables.

https://doi.org/10.1371/journal.pone.0298858.t009

These results suggest that incorporating motor activities into the curriculum can positively affect motor cognition in students, particularly in motor cognition and physical fitness awareness. Gender differences were also observed, emphasizing the importance of considering gender when designing interventions to enhance motor cognition in school settings. These findings can inform future instructional approaches to promote motor cognitive abilities among students.

4 Discussion

4.1 motor skill.

The study measured motor skills using three tasks: 1-minute shooting, passing and cutting coordination, and game performance. The results show that both girls and boys in the experimental groups improved their mean scores from pre-test to post-test in all three tasks, and their improvements were greater than those in the control groups.

In the 1-minute shooting task, both the experimental and control groups showed improvement from pre-test to post-test. However, the experimental group had a larger improvement in mean scores compared to the control group. This suggests that the intervention program was effective in improving shooting accuracy for both girls and boys. It is important to note that while the girls in the experimental group had a higher mean score at post-test than the boys, the boys had a higher mean score at pre-test, indicating potential gender differences in initial motor skill levels. Similarly, in the passing and cutting coordination task, both the experimental and control groups showed improvement from pre-test to post-test, but the experimental group had a larger improvement in mean scores compared to the control group. This suggests that the intervention program was effective in improving passing and cutting coordination for both girls and boys. In the game performance task, both the experimental and control groups showed improvement from pre-test to post-test, with the experimental group showing a larger improvement in mean scores compared to the control group. This suggests that the intervention program was effective in improving game performance for both girls and boys [ 27 , 28 ].

Overall, the study’s results suggest that the intervention program was effective in improving the motor skills of both girls and boys across all three tasks. The results align with previous research that has demonstrated the positive impact of intervention programs on motor skill development in children [ 29 ]. However, it is important to note that the study’s results are limited by the small sample size and the potential influence of other factors, such as natural maturation and practice effects.

4.2 Physical fitness

The findings of this study revealed that the experimental classes had an overall improvement in most variables of physical fitness compared to the control classes. The experimental classes demonstrated a slightly lower post-test mean score for PBF and WHR, indicating a trend towards healthier body composition. Moreover, the experimental classes exhibited higher post-test mean scores for vital capacity, shuttle run, grip strength, crunches, and seated forward bend, indicating improvement in cardiopulmonary function, muscle strength, muscle endurance, and flexibility, respectively. In terms of speed and agility, the experimental classes also showed a slight improvement in post-test mean scores.

The observed gender differences in initial motor skill levels in the 1-minute shooting task suggest that there may be a need to provide targeted intervention strategies for girls and boys to achieve optimal outcomes. Moreover, although the experimental classes showed an improvement in most dimensions of physical fitness, the differences were sometimes minimal and not significant, indicating a need for further investigation and analysis of the results. Therefore, it may be necessary to incorporate additional strategies or activities to enhance the effectiveness of physical fitness interventions for school-aged children [ 30 , 31 ].

These findings are consistent with previous research that has shown the positive effects of physical fitness interventions on children’s physical fitness and health outcomes [ 32 – 34 ]. The results of this study can be used to inform the development of future physical fitness interventions that can be implemented in schools or community settings.

4.3 Motor cognitive ability

The study examined the impact of HPECM intervention on motor cognition and physical fitness awareness among students in two experimental classes compared to two control classes. The results of the study indicated that the experimental groups showed improvement in both motor cognition and physical fitness awareness compared to the control groups. The differences were statistically significant for most comparisons, except for the pre-test mean scores in some cases. These findings suggest that incorporating physical activity into the curriculum can positively impact motor cognition in students, particularly in motor cognition and physical fitness awareness.

The results of the study are consistent with previous research that has shown a positive relationship between physical activity and cognitive functioning. For instance, a study by Hillman found that regular physical activity can improve cognitive performance and brain function in children [ 35 ]. Similarly, a study by Diamond and Lee reported that physical activity can enhance cognitive control and working memory in children [ 36 ].

The study also highlighted the importance of considering gender when designing interventions to enhance motor cognition in school settings. The results showed that girls in the experimental group scored higher in motor cognition and physical fitness awareness compared to girls in the control group, and the same trend was observed for boys. These findings are consistent with previous research indicating that gender differences exist in physical activity levels and that girls tend to be less physically active than boys [ 37 – 39 ].

The study has some limitations. Firstly, the sample size was relatively small, and the study was conducted in a specific cultural and geographic context. Therefore, caution should be exercised when generalizing the results to other populations. Secondly, the research exclusively focused on basketball, lacking a comparative analysis with other activities or sports projects. Future research endeavors will include comparative studies across various projects. Additionally, the study did not investigate the long-term effects of the HPECM intervention on sports ability. Future research could address these limitations by conducting larger-scale studies in diverse populations and exploring the long-term effects of HPECM intervention on sports ability.

5. Conclusions

In conclusion, this study provides evidence that healthy physical education curriculum model can effectively promote sports ability in senior high school students. The structural characteristics of a healthy physical education curriculum model provide needed support for students learning, improve students’ sports ability, and can be an effective way to promote physical literacy in senior high school students. Further research is needed to explore the long-term effects of the healthy physical education curriculum model on sports ability in students.

Acknowledgments

We would like to thank the physical education teachers, students and parents who participated in this experimental study. Without your cooperation, we could not complete this experiment.

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Artificial intelligence (AI) has increasingly found its way into more and more areas of our lives, including education. This focused collection aims to address opportunities, challenges, and issues around the use of a broad variety of AI tools in physics education and physics education research.

Editorial: Call for Papers for Focused Collection of Physical Review Physics Education Research : Investigating and Improving Quantum Education through Research

December 4, 2023.

In the year 2025, we will be celebrating the 100th anniversary of the formulation and development of quantum theory. The United Nations is working toward a declaration of 2025 as the International Year of Quantum Science and Technology (IYQST). In the spring of 2025, Physical Review Physics Education Research (PRPER) will join the celebration by rolling out a special issue of the journal focused on investigating and improving quantum education.

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Investigating students’ insight after attending a planetarium presentation about the apparent motion of the Sun and stars

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Hans Bekaert, Mieke De Cock, Wim Van Dooren, and Hans Van Winckel Phys. Rev. Phys. Educ. Res. 20 , 010141 (2024)

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In the following special collection from Physical Review Physics Education Research , authors examine and highlight racial diversity, specifically how Black physicists and people of color navigate within the physics community at large.

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November 22, 2022.

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November 17, 2021.

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Trends of physical activity and recreational screen time among Chinese children and adolescents: a national study from 2017 to 2019

• Ming Ming Guo 1 ,
• Koon Teck Koh 2 &
• Xiao Zan Wang 1  

BMC Public Health volume  24 , Article number:  1305 ( 2024 ) Cite this article

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Metrics details

The prevalence of physical inactivity and sedentary behavior among children and adolescents is a growing public health concern. This study aims to examine the trends in Physical Activity (PA) and Recreational Screen Time (RST) amongst children and adolescents in China, considering variations in genders, school levels, areas (urban versus rural), and regions (north versus south). The findings provide a foundation to guide policy and strategy making for future health promotion and development.

An annual national cross-sectional survey was conducted in China from 2017 to 2019 cumulatively involving 52,503 (48% female) children and adolescents from grades 4 to 12 (aged 12.72 ± 2.12). Data on PA and RST were collected through self-administered questionnaires. Weighted least squares regression was used to analyze the trends and differences in PA and RST among the participants’ profiles.

There was an annual decreased in PA compliance rate of approximately 3.43% (95% CI: 0.79-6.08%) for primary school students, primarily among males residing in rural areas, and in northern regions. Middle school students experienced a yearly decrease of about 5.23% (95% CI: 2.55-7.92%) in PA compliance across all genders, regions, and urban areas. Similarly, the RST compliance rates for primary school students declined by approximately 3.18% (95% CI: 1.57-4.78%) annually for all genders and areas, but only in the northern regions.

Conclusions

This research highlights a downward trend in PA and RST compliance amongst Chinese children and adolescents, with variations based on school level, gender, area, and region. Urgent policies and interventions are imperative to promote PA while mitigating excessive RST within these populations.

Peer Review reports

Introduction

Physical activity (PA) refers to any bodily movement that causes energy expenditure in skeletal muscles [ 1 ]. Recreational Screen Time (RST) includes all discretionary screen time (e.g., nonemployment or non-school related) taken while sedentary, typically encompassing activities such as television viewing, video gaming, and computer use [ 2 ]. Previous studies have demonstrated that insufficient PA and excessive RST can significantly affect the physiological and psychological health of children and adolescents, thereby affecting their quality of life and daily performance. These health impacts include an increased incidence of myopia, obesity, type 2 diabetes, anxiety, depression, and cardiovascular diseases [ 3 ]. Additionally, these conditions are associated with reduced sleep quality, diminished levels of physical fitness, and impaired cognitive abilities and academic performance [ 3 ]. Children and adolescents who fail to achieve 60 min of Moderate-to-Vigorous Physical Activity (MVPA) per day as advised by the World Health Organization’s (WHO) guidelines are considered physically inactive [ 3 ]. Furthermore, Canada’s 24-hour movement guidelines suggest that children and adolescents should restrict their RST to under 2 h per day [ 2 ]. Despite these guidelines, studies have shown that worldwide compliance rates amongst children and adolescents are low – only 19% of children and adolescents meet WHO’s PA recommendations, while a mere 34–39% comply with Canada’s RST guidelines [ 4 , 5 ]. Given the alarming levels of PA and RST amongst children and adolescents worldwide, the WHO aims decrease global physical inactivity by 15% by 2030 [ 3 ].

Compared to other countries around the world, Chinese children and adolescents have lower levels of PA and longer RST. According to the Global Report Card on Physical Activity for Children and Youth, China is one of the lowest ranked countries in terms of PA and RST indicators [ 6 ]. This has led to an increase in obesity rates among Chinese children and adolescents in recent years, as well as healthcare expenditures [ 7 ]. More importantly, if this trend persists, it is likely to cause a decline in China’s future human resources [ 8 ]. Cui and Zhang suggested that the low levels of PA and high RST amongst Chinese children and adolescents may be associated with China’s economic development and the rapid proliferation of electronic devices. Specifically, China’s rapid economic growth has reduced the likelihood of children and adolescents assisting with agricultural or industrial production in their families, altered their modes of commuting, thereby decreasing their levels of PA. Furthermore, the wide spread of electronic devices has attracted significant number of the children and adolescents to spend substantial amounts of time on smartphones or tablets. This not only increases their RST but also further diminishes the possibility of them engaging in outdoor PA [ 9 , 10 ]. This was especially so in the early 21st century, where China’s economic growth surpassed the annual Gross Domestic Product (GDP) growth rate of 9%, and the prevalence of smartphone usage amongst children and adolescents increased by more than 10% annually [ 11 , 12 ]. However, there is a lack of research examining the current trends in PA and RST amongst Chinese children and adolescents, which presents a gap in the literature.

Previous studies have pointed out that there are significant disparities in children and adolescents’ PA levels based on their school levels, areas (urban versus rural), and regions. Male students also tend to display more PA and RST than females, primarily due to societal cultural factors and gender role expectations that restrict opportunities and reduce social support for PA among females, and also because males are more predisposed towards screen-based entertainment activities, such as video games [ 3 ]. Additionally, changes in academic pressure and living conditions result in lower school-level students engaging in more PA and less RST than their higher school-level counterparts [ 13 ]. Children and adolescents residing in urban regions also display more PA and less RST compared to those living in rural areas because there are more opportunities and accessibilities for PA [ 9 ]. Regional factors such as favorable temperature, better air quality, and higher level of economic development also provide a conducive environment for children and adolescents to participate in PA [ 14 , 15 , 16 ]. However, findings from these cross-sectional studies are unable to adequately predict current trends in PA and RST, and hence, have limited contribution to guiding policy formulation and designing health promotion programs.

Previous literature has explored the changing trends in PA and RST amongst children and adolescents. On one hand, studies by Ng et al. and Knuth et al. found due to lifestyle changes, PA amongst children and adolescents over the last few decades have decreased significantly [ 17 , 18 ]. Moreover, research conducted in the United States and China showed a global increasing trend in RST amongst children and adolescents due to widespread screen consumption [ 19 , 20 ]. On the other hand, Guthold et al. and Kalman et al. argued that the PA of children and adolescents worldwide is slowly increasing due to the implementation of various health promotion interventions in different countries [ 4 , 21 ]. For instance, based on the reports by the Active Healthy Kids Global Alliance, there appears to be a decreasing trend in RST amongst children and adolescents globally over the past decade. A reason for this could be due to changes in the rating method adopted by such reports. In 2018, these reports subdivided the D grade into D-, D, and D+ (representing 20-26%, 27-33%, and 34–39% of children and adolescents meeting the RST guidelines, respectively), which resulted in the global percentage rating of children and adolescents meeting the RST guidelines to subsequently shift from D to D+ [ 5 , 6 , 22 ]. Consequently, it may not be meaningful to compare trends in RST amongst children and adolescents solely based on grades.

These conflicting results, combined with the lack of previous research investigating the changing trends in PA and RST amongst children and adolescents of different genders, school levels, areas, and regions thereby limit our understanding. This is especially so for highly digitalized countries with rapid economic development such as China. To close this gap, a large-scale cross-sectional survey over 3 consecutive years (2017–2019) was conducted. Specifically, two research questions guide the present study: (1) what are the changing trends in PA and RST amongst children and adolescents in China? And (2) how do these trends differ between genders, school levels, areas (urban versus rural), and regions (north versus south)?

Materials and methods

Study design and participants.

This research was conducted as part of the “Construction of a Big Data Platform for Children and Adolescents’ Sports and Fitness in China (CBDPCASF)” project. The CBDPCASF project, funded by the National Social Science Foundation of China (Grant No. 16ZDA228), aims to establish a comprehensive platform for collating health and fitness-related data for Chinese children and adolescents. Between 2017 and 2019, the research team sent research invitations to schools involved in the project from September to December annually. Schools that accepted the invitation randomly selected students (two classes in each grade) from 4 to 12 grades (aged 10 to 18 years old) to participate in the study. Students below grade 4 were not invited to participate in the study because they might not understand the questionnaire content well, potentially leading to invalid responses.

During the period from 2017 to 2019, a total of 52,503 Chinese children and adolescents from 150 schools across 45 cities ranging from grades 4 to 12 participated in this study. The average age of these participants was 12.72 ± 2.12 years, and among these participants, 25,322 were female, accounting for 48% of the total. The annual number of participants from 2017 to 2019 was 22,820, 16,061, and 13,622 respectively.

Informed consent from participants and their guardians were obtained before initiating the survey each year. Subsequently, participants received a web link to a questionnaire from their teachers, which was hosted on the Questionnaire Star platform [ 23 ]. The questionnaire comprised a total of 20 questions, including participants’ demographic details (school names, grades, genders), and their PA and RST for the previous week. The survey required approximately 15 min to complete. Participants were asked to complete the questionnaire either in the computer classroom in school or at home using their parents’ mobile phones. For geographic and regional analysis of PA and RST, the areas (urban/rural) and regions (north/south) were determined based on the name of the school that the participants attended, using the Baidu Map Open Platform [ 24 ]. Privacy protection protocols were adhered to by de-identifying or removing all personal identifiers, thereby ensuring the confidentiality and rigor of this study. Data regarding the corresponding Chinese population, categorized by year, gender, school level, area, and region were procured from the China Statistical Yearbook to calculate weighted average compliance rates [ 11 , 25 , 26 ]. Finally, participants with incomplete information, incorrect responses, abnormal results, outliers (based on Tukey’s method) [ 27 ], and those unable to engage in PA due to exceptional circumstances or pre-existing medical conditions (such as disabilities or fractures) during the survey period were excluded.

Instruments

The Chinese adaptation of the Physical Activity Questionnaire for Older Children (PAQ-C) was employed to evaluate the participants’ PA [ 28 ]. The PAQ-C is a self-report tool used to assess PA level based on a 7-day recall period. Its reliability and validity have been established in previous studies, with a Cronbach’s alpha coefficient of 0.821, demonstrating its suitability for assessing PA amongst Chinese children and adolescents [ 29 , 30 ]. The PAQ-C comprises of 10 items, starting with a question on the frequency of engagement in various PA such as swimming, martial arts, and basketball. Items 2 to 8 focus on the PA status during specific intervals, such as during physical education classes, recess, after school, evenings, and weekends. The penultimate item asks about the frequency of engaging in PA for more than thirty minutes daily in the past week. The final item focuses on special circumstances that might have impeded PA in the past week. The first 9 questions employ a five-point Likert scale, with 1 indicating the lowest level or frequency of PA participation, while 5 represents the highest level or frequency of PA participation. The final question offers 2 options, “Yes” and “No”, for participants to indicate whether they were restricted from engaging in PA in the past week due to any special circumstances. The final PA score was s calculated as the average of scores from questions 1 to 9, reflecting the participants’ level of PA over the past 7 days [ 28 ]. Furthermore, based on the comparative study of PAQ-C and accelerometer data by Voss et al., a PAQ-C score above 2.87 essentially equates to a daily MVPA time of more than 60 min. Therefore, the present study considered a PAQ-C score above 2.87 to be in compliance with the PA guidelines [ 29 ].

Participants’ RST was assessed using the Chinese adaptation of the Adolescent Sedentary Activity Questionnaire (ASAQ) [ 31 ]. This self-administered instrument uses a 7-day recall period to assess children and adolescents’ sedentary time. Its reliability and validity in studying sedentary time amongst Chinese children and adolescents have been previously established by several studies, with a Cronbach’s alpha coefficient of 0.729 [ 31 , 32 ]. The ASAQ contains 6 items that investigate participants’ RST over the past 7 days. These items encompass the daily time spent watching TV or movies, and using smartphones, computers, or tablets (excluding time spent for study and work purposes). The calculation of participants’ weekly RST is achieved by the total sum of the 6 items. The average daily RST is obtained by dividing the weekly RST by 7 [ 31 ]. According to the Canadian 24-hour Movement Guidelines and the Chinese Children and Adolescents’ Physical Activity Guidelines [ 2 , 33 ], participants with less than 2 h of daily RST are considered to have met the RST guidelines.

Participants’ area (urban/rural) was determined using the geographical location of their schools and the Application Programming Interface (API) provided by Baidu Maps’ open platform [ 24 ]. This platform is created by Baidu, China’s largest map service provider. It offers services like maps, location search, route planning, and positioning. This platform allows users to extract information such as administrative regions and urban-rural classifications for specific locations published by the Chinese government [ 24 ]. Given China’s policy that requires students to attend schools near their residence, the school’s location is therefore considered representative of the student’s geographical location [ 34 ]. Based on the names of the schools that participants attended, we were able to obtain their provinces, cities, and areas (rural versus urban) classification using the Baidu Maps Open Platform. Based on participants’ provinces and cities information, we categorized their regions as either “North” or “South”. Participants located north of the Qinling-Huaihe Line were classified under the “North” region, while those located south of the Qinling-Huaihe Line was classified under the “South” region. The Qinling-Huaihe Line was used as it serves as a natural geographical dividing line in China. The south region of this line generally experience higher temperatures, humidity, and better air quality as compared to those in the north region [ 35 ].

The total population data for each participant group was extracted from the Chinese Statistical Yearbook [ 11 , 25 , 26 ] and was subsequently used as weighting information during data analysis. The Chinese Statistical Yearbook is an annual publication that comprehensively reflects the economic and social development of China. It systematically includes data – the number of students in each region, province, area, school level, and gender – at the national level, as well as across various provinces in China [ 11 ].

Statistical analyses

All samples were grouped based on the year, region, province, area, school level, and gender categories. The PA and RST compliance rates for each group were computed. To enhance the representativeness of the data, Mixed Linear Regression (MLR) [ 4 ] was used to estimate the missing rural or urban compliance rates for provinces that included only urban or rural participants. This estimation was carried out by leveraging on data from provinces with both urban and rural participation. The total population of each group previously obtained from the Chinese Statistical Yearbook was incorporated into the dataset as a weighting variable for subsequent analyses [ 20 ].

Following this, the weighted average PA and RST compliance rates and the 95% Confidence Intervals (95% CI) were calculated based on participants’ region, area, school level, and gender. The Weighted Least Squares Regression (WLS) was used to evaluate linear trends in PA and RST compliance rates from 2017 to 2019. Absolute differences in the PA and RST compliance rates by year, region, area, school level, and gender were also determined using WLS based on the data collected during this period (i.e., from 2017 to 2019). For ease of data visualization, the trends of PA and RST compliance amongst children and adolescents of different regions, areas, school levels, and genders were presented using line graphs. All data processing and analyses were conducted using Python (Python 3.10, Python Software Foundation, Wilmington, DE, USA) with the statsmodels, scipy, seaborn, and matplotlib extension libraries [ 36 ]. A two-sided significance level was set at 0.05.

Participant characteristics

Following data cleaning processes, a total of 11,353 participants (21.62%) were excluded from the analysis. The exclusion was due to several reasons: 24 participants (0.05%) lacked the necessary grade information; 3,147 participants (5.99%) could not participate in PA during the survey period due to various circumstances, such as illness or menstrual cycles for female participants; 4,746 participants (9.04%) submitted incorrect responses; 1,491 participants (2.84%) reported total sitting times that exceeded 24 h per day; 80 participants (0.15%) had a sample size smaller than 10 after being grouped by year, province, school level, gender, area, and region; 1,865 (3.55%) of participants’ PA scores or overall sitting time were considered as outliers. As a result, the final analysis was conducted using a dataset of 41,150 individuals, including 20,262 females (49%). This sample comprised of 22,143 primary school students, 13,320 middle school students, and 5,687 high school students. Notably, the annual sample size varied: for primary school students, it ranged from 4,458 to 12,282; for middle school students, it was between 2,973 and 5,484; and for high school students, it fell between 1,755 and 2,053. Unweighted and weighted sample sizes for each year, school level, gender, area, and region are respectively provided in Table  1 and sTable  1 .

• Physical activity

Results from the present study showed that in 2019, only a handful of children and adolescents met the recommended PA level set by WHO – 25.33% (95% CI: 21.05-29.61%) of primary school students, 17.61% (95% CI:14.68-20.55%) of middle school students, and 12.56% (95% CI: 4.37-20.75%) of high school students met the guidelines (Table  2 ).

From 2017 to 2019, the average annual decrease in PA compliance rates was 3.43% (95% CI: 0.79-6.08%) for primary school students, 5.23% (95% CI: 2.55-7.92%) for middle school students, and 5.35% (95% CI: 2.67-8.03%) for male students. For rural and urban students, the average annual decrease in PA compliance rates was 2.89% (95% CI: 1.03-4.75%) and 4.37% (95% CI: 1.43-7.31%), respectively. For students in the northern and southern regions, the average annual decrease in PA compliance rate was 4.82% (95% CI: 1.97-7.66%) and 3.6% (95% CI: 0.37-6.84%), respectively. However, PA compliance rates remained constant during this period for high school students, and for female students. The downward trend in PA compliance amongst primary school students was primarily driven by a reduction in PA compliance amongst male students, students in rural areas, and students in northern regions. The decline in PA compliance rates amongst middle school students was observed across all genders, regions, and urban areas, but was not among rural areas. Analysis of compliance rate trends for PA by genders, areas, and regions, categorized according to school levels can be found in sTable  2 . For overall prevalence estimates, please refer to Table  2 ; Fig.  1 .

Upon aggregating data from 2017 to 2019, we found that during the primary school stage, PA compliance consistently decreased with each increase in grade level (Odds Ratio [OR] = 0.98, 95% CI:0.97–0.99 for each grade increment compared to the previous grade). However, during the high school, PA compliance increased consistently with each increase grade level (OR = 1.13, 95% CI:1.11–1.14 for each grade increment compared to the previous grade). We also found that across all school levels, the PA compliance of females was significantly lower than that of males, and this gender gap widens as the educational stage progresses. The OR of PA compliance for females, compared to males in the primary school, middle school, and high school stages were 0.92, 0.88, and 0.83 respectively. Furthermore, during the high school stage, the odds of PA compliance amongst children and adolescents in the southern region were significantly lower than those in the northern region (OR = 0.88 95% CI:0.85–0.89; refer to Table  3 ).

• Recreational screen time

The analysis of compliance rate, trends for RST compliance rates by genders, areas, and regions, segregated by school levels are shown in sTable  2 . In 2019, more than 80% of children and adolescents recorded less than 2 h of RST per day. Specifically, 80.76% (95% CI:77.93-83.58%) from primary schools, 82.86% (95% CI:78.99-86.72%) from middle schools, and 90.52% (95% CI:85.43-95.60%) from high schools (refer to Table  2 ).

From 2017 to 2019, the average annual decrease in RST compliance rates was 3.18% (95% CI: 1.57-4.78%) for primary school students, and 4.17% (95% CI: 2.63-5.71%) for students in the northern regions. For male and female students, the average annual decrease in RST compliance rates was 2.42% (95% CI: 0.53-4.32%) and 3.08% (95% CI: 1.77-4.39%), respectively. For rural and urban students, the average annual decrease was 2.21% (95% CI: 1.04-3.38%) and 2.89% (95% CI: 1.16-4.62%), respectively. However, RST compliance rates remained constant for middle school and high school students, as well as for students from the southern region. The decline in RST compliance rates amongst primary school students was observed across genders, areas, and northern regions, but not for students from the southern regions. Although there was no significant overall decline in RST compliance rates amongst middle school students, there was a significant decline observed amongst middle school students that were female, from rural areas, and from northern regions between 2017 and 2019. Analysis of compliance rate trends for RST by genders, areas, and regions, categorized according to school levels can be found in sTable  2 . For overall prevalence estimates, please refer to Table  2 ; Fig.  2 .

When comparing the data collected between 2017 and 2019, we found that during the high school stage, RST compliance rates consistently decreases with each grade level increases (OR = 0.97, 95% CI:0.96–0.98 for each grade increment compared to the previous grade). We also found that across primary school and middle school stages, the RST compliance rates of females was significantly higher than males. The OR of RST compliance rates for females, compared to males, was 1.06 in primary and middle schools. Furthermore, during the primary school and middle school stages, the odds of RST compliance among children and adolescents in the southern region were significantly lower than those in the northern region, with ORs for primary and middle schools being 0.98 and 0.96 respectively (refer to Table  3 ).

Crude weighted trends in physical activity from 20,017 − 2019. Data were weighted to be nationally representative. Error bars indicate 95% CIs

Crude weighted trends in recreational screen time from 20,017 − 2019. Data were weighted to be nationally representative. Error bars indicate 95% CIs

This study explored the current trends in PA and RST among Chinese children and adolescents and examined how these trends vary by genders, school levels, areas (urban versus rural), and regions (north versus south) in China – a country that is experiencing rapid economic development and high levels of digitalization in Asia. Using 3 consecutive large-scale surveys conducted from 2017 to 2019, a significant decline in both PA and RST compliance rates amongst children and adolescents was observed. Notably, the decrease in PA compliance rate was mainly due to primary and middle school students, while the decline in RST compliance rate arose mainly from primary school students.

As emphasized in the policy guidelines from the “Physical Activity Guidelines for Americans”, understanding the trends of PA and RST is a crucial prerequisite for devising and implementing strategies to enhance PA and reduce RST [ 37 ]. However, according to the “Expert Consensus Statement on Physical Activity and Health in Chinese Children and Adolescents (2020)”, the unclear trends of PA and RST pose a myriad of challenges to launching effective health promotion initiatives aimed at increasing PA and reducing RST amongst Chinese children and adolescents [ 8 ]. Although global reviews [ 4 , 5 ] and previous studies from Europe [ 38 ] and the United States [ 39 ] have identified the evolving trends and patterns of PA and RST amongst children and adolescents in their respective countries, these results are largely inconsistent. Additionally, results from previous studies lack precise depiction of the trends in PA and RST across different genders, school levels, regions, and areas in an Asian context. Furthermore, there is limited research examining the PA and RST trends of children and adolescents situated in highly digitalized countries with rapid economic development, such as China. China is characterized by gender-based expectations, academic pressure across different schooling stages, urban-rural dichotomy, a geographical range from tropics to temperate zones, along with swift socioeconomic changes since the 21st century. Hence, the present study offers substantial opportunities to bridge the research gap by providing a timely and contemporary understanding of current PA and RST trends amongst children and adolescents of different genders, school levels, areas, and regions from the lens of a rapid growing Asian country.

Contrary to previous studies that reported a gradual decline in the PA levels of children and adolescents with increasing grade levels [ 14 , 40 , 41 ], findings from the present study indicated that during the high school phase, students’ PA compliance rates actually increased with each advancing grade. This discrepancy may be attributed to the intense academic pressure endured by high school students in China – the National College Entrance Examination (Gaokao) taken by high school students is the solitary path to higher education and a brighter career path. Given that the number of students taking the national examination typically exceeds the total number of places offered by each university, the results of this two-day examination significantly influences students’ future academic trajectories [ 42 ]. As such, academic pressure increases significantly and high school students may participate in PA as a stress-relief outlet.

We also observed that students from the affluent southern region demonstrated lower levels of PA than their counterparts in the comparatively poorer northern regions. In the wealthier southern region, parents have more financial resources to support their children’s participation in various tuition classes to improve their examination results. This could explain the lower levels of PA participation amongst high school students in the southern region compared to their northern counterparts – more time is devoted to academics while reducing the amount of time available to engage in PA.

Our study also found a notable decline in PA compliance amongst primary and middle school students. This result contradicts the findings of Guthold et al. and Bucksch et al. which previously suggested that there was a slight increase in children and adolescents’ PA compliance in the early 20th century [ 4 , 21 ]. However, Silva et al.’s study on Brazilian children and adolescents showed similar results to the present study – there was a significant downward trend in PA compliance in this age group [ 43 ]. As posited by Ng et al., the levels of PA is closely related to the economic development of a country [ 17 ]. Given that China and Brazil have undergone rapid economic development and social transformation during the past few decades, this could perhaps explain the rapid decline in PA amongst children and adolescents in these 2 countries. Interestingly, our study showed that the decline was more prominent in males (particularly in the primary schools) and not females unlike what was observed in Silvia et al.’s study on Brazilian children and adolescents. This difference in findings could be associated with social safety environments. In China, safety issues, such as theft or harassment, rarely affect females from engaging in PA, whereas in Brazil, safety is a major concern that hugely influences girls’ participation in outdoor PA [ 43 ].

Another interesting finding from our study is that in rural areas, the decline in PA compliance was most significant among primary school students, whereas in urban areas, it was the middle school students who experienced a more pronounced decrease in PA compliance. This could be attributed to academic pressure between primary and middle schools, as well as the urban-rural division. In China, unlike middle school and high school students who face pressures from important examinations such as the ‘Zhongkao’ (middle school graduation examination) or ‘Gaokao’ (college entrance examination), primary school students generally face less academic pressure. Thus, providing sufficient PA opportunities at this stage of their development may be able to curb the downward trend of their PA involvement. However, compared to urban parents who enroll their children in various extracurricular interest tutoring classes (such as basketball, martial arts, taekwondo) and take them to various PA venues (such as parks, gymnasiums etc.), rural areas in China often lag behind urban area in terms of availability of spaces, facilities, and opportunities for PA [ 44 ], resulting in the difference in PA habits among urban and rural primary school students. At middle schools, students start to feel the pressure of the high school entrance examination. This pressure tends to be more pronounced among urban students due to disparities in parental educational beliefs and levels of economic development between urban and rural areas. Compared to urban parents who invest more in academic tutoring for their children [ 45 ], rural parents often place less emphasis on the quality of their children’s education [ 46 ]. Some rural parents may even have their middle school-aged children assist with household or agricultural tasks. This might explain why rural middle school students have more opportunities for PA. This explains the difference in PA trends between urban and rural middle school students.

Another crucial finding from our study is the changing trends of PA amongst primary school students. We found that the downward trend is more pronounced in students residing in the northern compared to the south region. This could be due to the differences in economic development level and environmental factors between the 2 regions. In the past decade, economic development in southern China has surpassed that of the north, with statistical data from 2019 indicating that the GDP of the northern region accounted for only 35% of China’s total GDP [ 47 ]. As a result, the southern region has more fund and resources to invest in public sports facilities such as stadiums and parks, which could delay the decline in PA rates. Conversely, people in the northern region may lack these facilities to engage in PA. Furthermore, unfavorable weather conditions and increasing air pollution in the north may severely limit outdoor PA opportunities, leading to a significant decline in PA in this region [ 35 ].

In light of the key findings from the present study, as well as the impact of lower PA on the physical and mental health of children and adolescents [ 3 ], future interventions should aim to mitigate the negative impacts of economic development by directing more economic growth income towards the construction of public sports facilities. Consequently, this provides more opportunities for the public to engage in outdoor PA. The formulation and implementation of fun and engaging programs to encourage more Chinese children and adolescents to increase their PA levels in and outside school is also imperative. One example is to gather feedback from the students on the types of new sports and games that excite them, and incorporate them in the physical education curriculum. Future policies could also aim to address and reduce the amount of academic pressure placed on middle and high school students, for example, by requiring schools to reduce the assignment of homework and limiting the establishment of academic tutoring classes may provide more times children and adolescents to engage in PA.

Our result indicates that the RST compliance among children and adolescents in the southern region is significantly lower than of the northern region. This disparity might stem from the varying economic conditions across northern and southern regions of China. From 2008 to 2019, southern China experienced a per capita GDP growth rate of 9.42%, outpaced northern China with a growth rate of 8.32% [ 47 ]. This accelerated economic development in the south has resulted in a higher proliferation of electronic devices (such as computers, tablets, or mobile phones) among children and adolescents. Consequently, contributing to a decrease in RST compliance in the southern region.

Our study’s results also indicated a substantial decrease in RST compliance among primary school children and adolescents from 2017 to 2019. This aligns with global trends, which shown a significant worldwide increase in RST during the first 20 years of the 21st century [ 20 , 48 ]. The primary cause of this trend is the rapid proliferation of televisions, computers, mobile phones, and tablets since the beginning of the 21st century [ 9 , 10 ]. Interestingly, the drop in RST compliance was not significant among primary and middle school students in the southern region, but it was significant in the north, rural area, and among female middle school students. We attribute this trend to the increased availability of electronic devices in the northern and rural regions during 2017–2019 [ 12 ]. In the more affluent southern and urban regions, most students already had the necessary electronic devices before 2017 [ 12 ], which could explain the insignificant changes in their RST compliance rate. Furthermore, the significant decrease in RST compliance amongst female middle school students may be attributed to lifestyle changes associated with puberty. As Hardy suggested, interpersonal issues and socializing become central aspects of girls’ lives as they enter adolescence, leading them to allocate more time for online chatting with friends, which contributed to an increased in their RST [ 49 ].

Given the detrimental effects of extended RST on the physical and mental health of children and adolescents [ 48 ], findings from the present study suggest that the government should consider implementing policies to mitigate children and adolescents’ electronic device usage time. Schools should offer interesting PA programs (e.g. orienteering, hip hop dancing etc.) for female middle school students beyond running or walking with their friends to enhance their motivation in PA participation.

To the best of our knowledge, this is the first study to explore current trends in PA and RST amongst children and adolescents of different genders, school levels, areas, and regions in a rapid development and digitalized country. The strengths of this study include the use of a national representative sample, consistent data collection over 3 consecutive years using the same instruments, and a detailed analysis of varying trends in PA and RST amongst children and adolescents.

Although this study makes notable contributions to the literature, there are several limitations that are worth noting. First, the self-report survey tools may not accurately represent the actual PA and RST of children and adolescents. Therefore, there may be slight deviations in the calculation of compliance rates for PA and RST. Although these errors do not affect our estimation of the trend changes in PA and RST for children and adolescents, future studies should employ objective measures such as triaxial accelerometer to enhance the study design. Second, the PA questionnaire does not provide information regarding the duration and frequency of PA. Therefore, in this study, the calculation of PA compliance is based on the research results of Voss rather than the guidelines from WHO. This reduces the comparability of this study with other studies. Future research should consider tools that include intensity, frequency, and duration of PA. Lastly, our study solely focused on RST, and did not include time spent using computers or other electronic devices for educational purposes. Our study also did not consider other types of sedentary behavior, such as educational, social, and transportation time. Future research should examine the different types of SB to obtain a more accurate distribution of sedentary time amongst children and adolescents.

The present study found significant decline in PA compliance rates of primary and middle school students, and in RST compliance rates of primary school students in China from 2017 to 2019. This downward trend varies by school levels, genders, areas, and regions. From a public health and health education perspective, this study underscores the urgency of increasing PA and reducing RST among middle school and primary school students. Future policies and research should pay closer attention to the impact of rapid economic development and digitization on the PA and RST behaviors of children and adolescents, and provide specific and targeted programs to promote the development of an active and healthy youthful citizen.

Data availability

The datasets analyzed in the current study are available from the corresponding author on reasonable request.

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Acknowledgements

We acknowledge and appreciate the following individuals for their invaluable contributions to this research: Yangming Zhu for coordination with the CBDPCASF School, and Jinwang Zhang for verification of schools’ data.

This research was funded by the National Social Science Foundation of China (Grant No. 20CTY011) and the Institute of Curriculum and Textbook Research of the Ministry of Education, China (Grant No. JCSZDXM2022002).

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X.Z. Wang conceived and designed the study, additionally taking responsibility for data collection. K.T. Koh was instrumental in the manuscript’s conception and design, further contributing to its intellectual content. M.M. Guo, aside from his involvement in the study’s conception and design, carried out the data analysis, engaged in data collection, drafted the initial manuscript, and provided intellectual contributions to the manuscript. All authors have meticulously reviewed and given their approval to the final version of the manuscript.

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Guo, M.M., Koh, K.T. & Wang, X.Z. Trends of physical activity and recreational screen time among Chinese children and adolescents: a national study from 2017 to 2019. BMC Public Health 24 , 1305 (2024). https://doi.org/10.1186/s12889-024-18822-1

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Evaluation of the digital teacher professional development TARGET-tool for optimizing the motivational climate in secondary school physical education

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• Gwen Weeldenburg   ORCID: orcid.org/0000-0002-9707-1352 1 , 2 ,
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Given the complexity of teaching, continuing teacher professional development (CPD) is essential for maintaining and enhancing teaching effectiveness, and bridging the gap between ever-evolving theory and practice. Technological advancements have opened new opportunities for digital tools to support CPD. However, the successful integration of such digital tools into practice poses challenges. It requires adherence to CPD prerequisites and acknowledgment of the complexity of the professional development process. This study explored the applicability of the developed digital PE teacher professional development TARGET-tool in a secondary school PE context. We examined the perceived usability of this tool and gained insights into the process of teachers’ professional development as a result of using the tool. Ten PE teachers from different schools implemented the TARGET-tool within their PE context for a period of 4 to 6 weeks. Individual semi-structured interviews and the System Usability Scale provided insights into the perceived usability and the process of teacher professional development. The TARGET-tool demonstrated its potential as an effective tool for supporting teachers’ professional development. Future tool improvements were identified to further optimize the perceived usability, such as simplifying complex features, providing additional support and resources, and improving (data) presentations. Using the Interconnected Model of Professional Growth as a theoretical basis, it was demonstrated how the use of the TARGET-tool engages teachers as active and reflective participants in their professional development and induces changes within the external domain, the domain of practice, the domain of consequences, and the personal domain.

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Introduction

Teaching is considered complex given the dynamic context and constantly evolving practice confronting teachers with relational, emotional, and intellectual challenges on a daily basis (Day, 2017 ). Effective teaching involves understanding students’ individual needs and using teaching strategies to meet these needs. Due to the substantial heterogeneity in the psychomotor, social, and affective domains present among secondary school students, physical education (PE) teachers in particular, are confronted with a wide range of abilities and needs in class (Komar et al., 2019 ; Moen et al., 2020 ; Warburton et al., 2019 ). For students to adopt a physically active lifestyle (i.e., objective of PE; WHO, 2018 ), it is crucial to build inclusive PE learning environments in which students’ differential needs are met, and positive student experiences are ensured (Cox & Williams, 2008 ; Haerens et al., 2010 ; Hagger et al., 2005 ). The TARGET framework (Ames, 1992 ; Epstein, 1989 ) is a valuable theoretical framework to support PE teachers in achieving this goal. By manipulating the classroom dimensions task , authority , recognition , grouping , evaluation, and time , a favorable PE learning climate (i.e., mastery climate) can be created (Braithwaite et al., 2011 ; Harwood et al., 2015 ; Urdan & Kaplan, 2020 ). By employing several teaching strategies, the teacher can modify the (learning) tasks assigned to students, the authority provided to complete them, the manner students are recognized , grouped, and evaluated , and the amount of time available for instruction. Examples of these teaching strategies include providing variety and alternation within the learning tasks (task dimension) of empowering students to take responsibility for their learning through choice and opportunities for self-regulation (authority dimension). The implementation of these research-based insights, however, is not self-evident (Hastie et al., 2014 ; Weeldenburg et al., 2021 ). Transforming content knowledge of the TARGET framework into the unique and individual PE context is a complex and challenging process for many PE teachers (Velija et al., 2008 ). Continuing teacher professional development (CPD) is vital to update teachers’ knowledge, enhance teaching effectiveness, and address the complexity of teaching (Atencio et al., 2012 ; Lander et al., 2022 ; Parker & Patton, 2017 ; Yoon et al., 2007 ). CPD can involve various formal and informal activities, such as attending workshops, participating in peer-to-peer discussions on online PE forums, and pursuing an advanced teaching degree. To ensure the effectiveness of CPD activities, teachers need support in bridging the gap between theory and practice (Armour et al., 2017 ), and tools that facilitate the access and use of scientific insights in their professional practice should be developed (Grimshaw et al., 2012 ).

Technological advancements have led to new opportunities for developing digital tools for CPD (An, 2021 ; Hennessy et al., 2022 ; Philipsen et al., 2019 ; Walker et al., 2012 ). With the development of online environments, such as social media platforms, online forums, virtual learning environments, and collaborative workspaces, for example, promising CPD opportunities for teachers to enhance their professional development more flexibly and responsively appeared. Online professional learning communities (PLCs) have become increasingly popular in education as a way for teachers to connect with peers, share ideas, and improve their practice. Research showed that participation in online PLCs can be beneficial and could lead to increased teacher efficacy, improved student achievement, and greater job satisfaction (Ekici, 2018 ; Parsons et al., 2019 ; Trust et al., 2016 ; Xue et al., 2021 ). The application of technological tools within the teaching practice itself provides opportunities for teachers as well. In the context of PE, a variety of technologies have been developed and are currently used, such as tablets, mobile applications, video, wearables (e.g., accelerometers), and exergames (Phelps et al., 2021 ). However, most of these types of technology focus on enhancing student learning, rather than supporting teachers in performing the fundamental teaching tasks (i.e., lesson planning, instructing, and assessing) and their professional development. For example, Goto et al. ( 2020 ) developed a visualization and evaluation system for human movement trajectories, providing students with objective feedback on their performance, whereas Mast et al. ( 2017 ) reported on the tool ‘BalanSAR’ which visually projects animations to allow students to conduct balancing exercises. In contrast, some studies are reporting on types of technology that primarily focus on the process of teachers’ learning and enhancing skills, knowledge, and expertise (i.e., CPD), rather than improving student learning. Calderón and Tannehill ( 2021 ), for example, used the ‘Phyz app’ to support and empower teachers to enact a new curriculum models-based framework, while Penney et al. ( 2012 ) developed and implemented a digital assessment tool for secondary school PE. Yang et al. ( 2020 ) developed the ‘Voice Interactive Artificial Intelligence Educational Robot’ to assist teachers in individualizing PE and responding to students’ interests, and the ‘V-observer’, an online environment developed at Ghent University, allows PE teachers to identify and optimize their motivating teaching style (Bouten et al., 2023 ).

Although the added value of such tools has become apparent (Lupton, 2013 ; Roth, 2014 ; Williamson, 2014 ), successful implementation is complex and not evident (Hilvoorde & Koekoek, 2018 ). To be effective, digital tools should preferably meet the prerequisites for CPD as described in the literature, such as being evidence-informed (Hennessy et al., 2021 ; Osborne et al., 2013 ), facilitating active teacher involvement, addressing teachers’ needs and interests (Anamuah-Mensah et al., 2012 ; Power, 2019 ), being aligned with and applicable in teachers’ professional practice (Bødker, 2015 ; Seely et al., 2000 ), stimulating critical reflection on current teaching practice (Sargent & Calderón, 2021 ), supporting iterative cycles of experimentation and reflection within a safe environment (Bakkenes et al., 2010 ; DeLuca et al., 2015 ; Korthagen, 2017 ; Polly & Hannafin, 2010 ), and focusing on student outcomes (Armour et al., 2017 ; O’Sullivan & Deglau, 2006 ).

A widely accepted theoretical framework that acknowledges this complexity of CPD is the Interconnected Model of Professional Growth (IMPG; Clarke & Hollingsworth, 2002 ). This model (see Fig.  1 ) is useful for understanding how teachers develop their skills and knowledge over time. It proposes the perspective of teachers as active learners who shape their professional development by actively engaging in reflective participation in both professional development programs and in their day-to-day teaching practice. According to the IMPG, professional development results from the reflection and enactment in the various domains that encompass the teacher’s world: (1) the external domain , which refers to external sources of new information, stimulus, or support emerging from outside the teacher’s daily practice; (2) the domain of practice , which refers to all kinds of professional experimentation, including the enactment of developed learning materials in class; (3) the domain of consequences , which refers to salient outcomes such as student learning or student motivation; (4) the personal domain , which refers to teacher’s knowledge, beliefs, and attitudes.

The interconnected model of professional growth (Clarke & Hollingsworth, 2002 )

In a previous publication (Weeldenburg et al., 2023 ) we described the development of a digital teacher professional development tool that acknowledges these domains. This so-called ‘TARGET-tool’ aims to support PE teachers in building and optimizing an inclusive and motivating learning climate in secondary school PE. It consists of an online teacher dashboard and mobile device student scans. By using the tool, the teachers will go through several process steps to gain insights into students’ motivational experiences within PE class, receive practical suggestions to improve the PE motivational learning climate, experiment with the selected motivating strategies within PE practice, reflect on their teaching performance and monitor changes in student motivational experiences over time.

Although PE teachers were actively involved in the design process as targeted end-users and conducted several user tests, real-life implementation of the finalized TARGET-tool is needed to investigate its applicability in the secondary school PE context. Therefore, the first aim of the present study was to examine the perceived usability of the TARGET-tool within a real-life secondary school PE context. Perceived usability refers to the subjective feelings toward products from the perspective of usage and encompasses various factors such as ease of use, learnability, efficiency, error frequency, and satisfaction (Yang et al., 2012 ). Secondly, using the IMPG as a framework, we aimed to gain insights into the process of teacher professional development as a result of using the digital tool. To provide a comprehensive view we first describe the main function and functionalities of the TARGET-tool, and of some technical components and processes that enable the TARGET-tool to perform its intended function, followed by the results of the evaluation study.

Description of the developed TARGET-tool

The TARGET-tool was developed using a participatory design approach (Sanders, 2008 ), involving researchers, designers, and PE teachers. The collaborative process spanned 14 months and consisted of seven phases, incorporating interactive and iterative research and design activities. Throughout this process, the challenges and needs of PE teachers regarding a motivational PE climate were identified. Ideas for the TARGET-tool were then explored, prototyped, designed, developed, validated, tested, and critically reviewed. A full description of this design and development process can be found in our previous paper (Weeldenburg et al., 2023 ). In the following section, we provide a short description of the TARGET-tool's function, content, and functionalities.

Function and content of the TARGET-tool

The digital TARGET-tool was developed to support PE teachers in building an optimal motivational learning climate in secondary school PE and enhancing their knowledge and skills. It comprises an online teacher dashboard and student scans (see Fig.  2 ). Drawing from research on the evidence-based theoretical TARGET framework (e.g., Bortoli et al., 2017 ; Cecchini et al., 2020 ; Urdan & Kaplan, 2020 ; Weeldenburg et al., 2021 ), several potential motivating teaching strategies and matching teacher actions within the task , authority , recognition , grouping , evaluation, and time dimension were identified and embedded in the tool. Within the authority dimension, for example, the tool provides the teachers with the suggestion to enhance students’ involvement in decision-making processes (i.e., teaching strategy) through the following teacher action options: the application of questioning; creating moments for students to discuss (e.g., time outs); providing opportunities for choice and promoting personal goal setting. These teaching strategies and actions are made accessible for teachers by printable cards and provided by the tool after finishing the previous user process steps (see Fig.  3 ).

TARGET-tool interfaces existing of a teacher dashboard (left and center, desktop) and student scans (right, mobile device)

The process involved predefined steps

The TARGET-tool user process

The TARGET-tool supports teachers in going through a specific process (see Fig.  3 ), enabling them to gain insights into students’ motivational PE experiences and optimize the motivational climate. This process involves several predefined steps implemented in the desktop interface and visualized in a teacher dashboard (see Fig.  2 ). Even though the tool was designed to be as self-explanatory as possible, the availability of high-quality support materials can be expected to enhance its uptake. Therefore, upon the teacher’s first login to the TARGET-tool, they are directed to a dedicated landing page that introduces the tool’s functionalities. This page provides supportive information about the importance of fostering a motivating PE learning climate and how the tool can assist teachers in optimizing it. Included on this landing page is an introductory video (in Dutch) accessible by the following link: https://vimeo.com/764468446 .

The following user steps are predefined and implemented in the dashboard of the TARGET-tool:

Enter general information into the user profile and select the classes for experimentation.

Select one or two relevant TARGET dimensions after reviewing detailed information about all TARGET dimensions and optionally completing the SELF-scan. The SELF-scan assesses the teacher’s perceived abilities in applying motivating teaching strategies across all TARGET dimensions by responding to 62 items (e.g., ‘In general, I provide plenty of variety and alternation in the PE lessons’) using a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). This results in scores on all TARGET dimensions providing the teacher with insights to identify their strengths and opportunities for professional development.

Schedule the TARGET-scan for students and generate student scan passwords .

Conduct a TARGET-scan at the beginning of PE class to retrieve information on students’ overall perceptions of the motivational climate regarding the selected TARGET dimension(s) (i.e., baseline measurement). The TARGET-scan involves a short questionnaire (10–13 items; e.g., ‘In general, there is plenty of variety and alternation in the PE lessons’) that students administer on their mobile device by using a five-point Likert scale ranging from 1 to 5. Students’ answers are logged in the TARGET-tool database and form the baseline measurement.

Review the TARGET-scan results to identify professional development opportunities and gain insights for the next step in the process.

Select relevant and applicable potential motivating teaching strategies based on the results within the selected dimension(s). These strategies are presented as printable cards.

Experiment for a substantial period with the selected motivating strategies by implementing them in PE practice.

Conduct a QUICK-scan (optional) at the end of an experimental PE lesson to gain information on students’ experiences and make adjustments if needed. This scan consists of a two-item questionnaire related to how interesting and enjoyable (i.e., intrinsic motivation; (Ryan & Deci, 2017 ) the students found the current PE lesson.

Review the QUICK-scan results (optional) and identify potential improvements regarding the implemented teaching strategies. The data collected from students is processed and presented to the teacher. This provides the teacher with insights to make interim adjustments if needed.

Conduct a second TARGET-scan at the end of the experimental phase to gain insight into the effect of the interventions. Based on these results it can be decided to (a) continue experimenting within the selected TARGET dimension(s), (b) continue experimenting within the selected TARGET dimension(s) involving other classes, (c) finalize the experiment and shift the focus to another TARGET dimension, or (d) pause.

For more detailed information concerning the functionalities, technical specifications of the teacher dashboard, student scans, data visualization, and privacy concerns, we refer to Supplementary Information.

Evaluation of the TARGET-tool

To identify potential flaws in the design, uncover opportunities to improve, and learn about the target users, several usability tests were conducted on prototypes of the TARGET-tool in the previous development phases. The perceived usability of the completed TARGET-tool, however, has not yet been examined. Therefore, this study aimed to examine the perceived usability of the completed TARGET-tool within a real-life secondary school PE context. As the tool is intended to support and stimulate teachers in their professional development, we also aimed to gain insights into the process of teacher professional development as a result of using the digital tool.

Participants and settings

After ethical approval was granted by the university’s research ethics committee, participants were recruited by inviting PE teachers from the university’s network to participate in this study. The convenience sample consisted of 10 PE teachers (9 male; 1 female) and their 18 PE classes (i.e., 399 students) from 10 different secondary schools in the Netherlands. The mean age of the PE teachers was 39.5 years (SD = 9.9) and an average of 16.9 years (SD = 9.3) of teaching experience. PE in these schools was mixed-gender grouped and mandatory for two lessons (of 50–60 min each) per week throughout the school year. In the Netherlands, all PE teachers in secondary education are specialist teachers who obtained their teacher qualifications through a 4-year physical education teacher education bachelor’s program. For all participants written informed consent was obtained after they had received information in which the purpose of the research project and its methods were explained, and voluntary participation and confidentiality were emphasized.

Study design

To test and evaluate the TARGET-tool within the PE context participants were asked to experiment with the TARGET-tool for a period of 4 to 6 weeks within their PE practice. Leading up to the experimental phase the participants received login details and instructions to set up their individual TARGET-tool accounts. Based on the idea that teachers should be able to work with the tool individually and independently, no further instructions on how to use the tool were provided to the participants.

Data collection

Individual semi-structured interviews.

Individual online interviews were conducted to explore PE teachers’ perceptions of the usability of the TARGET-tool and gain insights into the process of teacher professional development. A semi-structured approach was used to ensure data comparability and coverage of relevant topics while allowing for follow-up questions (Fontana & Frey, 2005 ). Each participating teacher was interviewed individually for approximately 30–40 min using the Microsoft Teams platform. The interviews consisted of a series of questions that focused (i) on the perceived usability (e.g., ‘How did you use the TARGET-tool in your PE practice and what were your findings?’), and (ii) on the process of professional development (e.g., ‘What did you do differently in your PE lessons and what did that look like?’). The interview guide was constructed based on the concepts of usability and professional development to identify relevant variables and provide a basis for data interpretation. All interviews were recorded and transcribed verbatim.

System Usability Scale

The System Usability Scale (SUS; Brooke, 1996 , 2013 ; Lewis, 2018 ) was used to collect quantitative data regarding the perceived usability of the TARGET-tool. The SUS is a standardized and validated questionnaire designed to assess the perceived usability of a wide range of systems, products, and services (Brooke, 1996 , 2013 ; Sauro, 2011 ). The instrument consists of 10 items (e.g., ‘I thought the tool was easy to use’), each scored on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The questionnaire was administered online by using Microsoft Forms. To examine potential changes in the perceived usability over time, the SUS was carried out at the mid-term and the end of the experimental phase.

Data analysis

The data were analyzed using the Framework Method (Gale et al., 2013 ). This method organizes and analyzes teachers’ interview data systematically, identifying overlaps and inconsistencies in their perceptions (Gale et al., 2013 ; Nowell et al., 2017 ). While themes were pre-defined based on specific areas of interest and existing theory (deductive approach), the method also allows for the emergence of new themes from the data (i.e., inductive approach; (Gale et al., 2013 ; Nowell et al., 2017 ). After the audio recordings were transcribed verbatim, the coding process commenced. To minimize bias throughout the coding process and optimize the trustworthiness (Nowell et al., 2017 ) of the data analysis, several sequential and interconnected steps were taken. The first author checked each transcript with the audio recordings for accuracy and with that became familiar with the data. Thereafter the coding process took place using ATLAS.ti Mac version 22.0.0 software. With the pre-defined themes from the interviews, the first and second authors of this study first generated a code set independently and subsequently discussed this to reach a consensus about an initial working version of the code set. Next, two transcripts were independently coded by both researchers. The coded transcripts, including notes containing suggestions for new or adapted themes or codes, were compared and discussed before agreement on the final set of codes applicable to all transcripts (see Table  1 ). All transcripts were then coded, and following the Framework Method, quotes were lifted from the transcripts and charted into a framework matrix. Each quote was summarized and placed within a specific row (participant) and column (code) which allowed us to compare the views of all participants concerning each theme. This matrix structure was then employed for interpreting the data.

Although the SUS evaluates perceived elements of effectiveness, efficiency, and user satisfaction, the instrument yields a single number representing a composite measure of the overall perceived usability of the system or product. To compute the overall SUS score, the following calculation methodology is used: For the positively worded items (odd numbers), the score contribution is the scale position minus 1. For negatively worded items (even numbers), the score contribution is 5 minus the scale position. Ultimately, to calculate the final SUS score, the sum of the item score contributions was multiplied by 2.5. This generates a score that ranges from 0 (very poor perceived usability) to 100 (excellent perceived usability) in 2.5-point increments (Bangor et al., 2009 ). To analyze the differences between the SUS scores at the mid-term and the end of the experimental phase, a paired sample t-test was conducted after examining the assumptions of normality. In addition, the effect size was calculated using Hedges’ g , which is appropriate for relatively small sample sizes (Hedges, 1981 ). Cohen’s criteria were used for interpretation as follows: ≤ 0.20 as small, 0.50 as medium, ≥ 0.80 as large (Cohen, 2013 ).

The results will be presented along two main themes, i.e., perceived usability and professional development, and the underlying subthemes. These findings will be illustrated by quotes to support the narrative.

• Perceived usability

Learnability

Regarding the learnability of the TARGET-tool, which refers to how easy it is for users to learn to perform basic tasks effectively the first time they are dealing with the tool, the teachers valued and pointed out the importance of the ‘progressive’ dashboard. This dashboard seems to contribute to the learnability of the tool. It optimizes the navigability of the user interface and supports teachers going through the whole process independently:

" Well, I like the dashboard, and the different steps were easy to go through, so it went pretty smoothly" [R7].

Overall, the different functionalities of the tool (e.g., conduct a self-scan, select TARGET dimensions, and perform student scans) are experienced as being relatively easy to learn and understand:

" The tool is very handy in use, and very simple. Clear symbols, I really like that" [R2].

To generate passwords for conducting the student scans the teacher first needs to schedule the student scans. Most teachers, however, experienced this functionality in the tool as highly complex. It frustrated teachers and impeded their ability to perform the task efficiently for the first time:

" But, uh, I find the schedule feature a bit confusing" [R5].

Lastly, the teachers indicated that despite the introduction video on the home page in which the function and functionalities of the TARGET tool are explained, the effective use of the tool in the initial stage could increase if they were provided with an overview and some more explanation of the tool before the implementation:

" What I found difficult at the beginning of the process was the lack of an overview of all functionalities of the tool. The introduction clip was helpful, but not enough to get a good picture" [R2].

Concerning how quickly and accurately users can perform the intended tasks within the tool (i.e., efficiency), the teachers were particularly positive about the self-scan and student scans. They described how simply they could perform the self-scan by which they gained information on their strengths and opportunities within the different TARGET teaching dimensions. The teachers noted how easily they could perform the student scan within PE practice and efficiently gain information on students’ PE experience and identify opportunities to optimize the motivational climate:

" Well, it’s nice that the scans can be conducted on students’ mobile phones. Students could complete them very quickly at the beginning or end of the lesson" [R10].

In addition, some teachers reported on the complexity of locating and analyzing the student scan results per class. They seem to overlook the functionality within the tool by which the results can be presented per class, gender, and period, and that enables comparison between groups and over time as well. After the teacher has critically reviewed the TARGET-scan results and identified professional development opportunities, the tool prompts the teacher to select relevant and applicable potential motivating strategies to experiment with in their PE practice. The number of potential motivating strategies provided by the tool, however, is perceived by some teachers as overwhelming and therefore dysfunctional:

" Then I ended up with the motivational strategies. And, to be honest, I kind of dropped out. I found all those motivational strategies so extensive that I found it difficult to select a few" [R1].

Error frequency

With respect to the error frequency which refers to how many errors the users make while interacting with the tool, and how easily they can recover from them, it was notable that the (dis)functionality of scheduling student scans emerged from the data once more. Aside from the complexity of this functionality impacting the learnability of the tool, it was reported that once the teachers discovered what went wrong, they could recover from it:

" Those passwords didn’t work. So that was a bit of a hassle with my students. But I soon realized what the problem was, so I rescheduled the scan" [R7].

No further references were made regarding the error frequency of the tool.

Satisfaction

Satisfaction refers to the level of comfort the user experiences when using the tool and involves the user’s attitude toward the tool. In general, the teachers in the present study expressed a positive attitude towards the TARGET-tool and valued the intention of the tool by which they were encouraged to examine student PE experiences more objectively, and critically reflect on their existing teaching practice and improve it:

" I think it’s an interesting instrument. It stimulates you to take a critical look at teaching practice and routines" [R2].

The emphasis of the tool is placed on the supportive, individualized, and private character. Nevertheless, it is conceivable that teachers would find it stressful to collect data among students concerning their teaching practice. The teachers stated that they were aware that asking for student feedback put them in a vulnerable position, yet, they considered this feedback very useful and noticed that students appreciated the opportunity to provide the teachers with information about their PE experiences:

" On the one hand, it [i.e., student feedback] makes you vulnerable, but at the same time, children appreciate it very much if you ask for their opinion and respect their opinion. And especially if you say, that you would like to learn from this feedback and do better" [R10].

System usability scale

In addition to the qualitative data, the SUS was used to collect quantitative data regarding the perceived usability of the TARGET-tool. The total mean SUS score at mid-term was 57.3 (SD = 20.7) and at the end of the experimental phase 67.0 (SD = 21.2) out of 100. These scores indicate that the perceived usability of the tool can be considered ‘OK’ (Bangor et al., 2009 ). The mean increase represents a medium effect size ( g  = 0.47). However, the change was not statistically significant (p = 0.38).

Tool improvements

The results highlighted several key areas for tool improvement. Firstly, many teachers found the feature for scheduling student scans and generating passwords too complex and in need of improvement. Additionally, it was suggested that the tool could assist teachers in the selection process of motivating strategies by providing a curated list of strategies. The visibility and accessibility of the function that allows results to be presented per class, gender, and period, enabling comparisons over time and between groups, should also be enhanced. Some specific suggestions were made for tool improvements and expansion, such as including an option to generate QR codes alongside passwords. To provide teachers with just-in-time information and assistance, adding a FAQ feature with video tutorials was recommended. Furthermore, it was suggested to include additional theoretical background information and offer practical suggestions at different levels to cater to variations in teachers’ knowledge, skills, and abilities:

" Well, I think I already know quite a bit, maybe more than some colleagues. So perhaps it is interesting to refer to literature based on the suggestions that are given or to offer these suggestions at different levels" [R10].

Although the motivating teaching strategies are printable, it was proposed to also deliver a tangible card set of these strategies along with the digital TARGET-tool to keep drawing attention to these teaching strategies and stimulate the discussion within the PE department:

" Because the tool is digital, the focus on the strategies and their implementation into PE practice may move into the background. By using physical cards and placing them on a wall or other visible locations, for example, the strategies are kept in the teacher’s attention. This could also encourage PE colleagues to consider the strategies as well" [R7].

Lastly, the idea of building a learning community by connecting a forum feature to the tool, for example, was proposed. Some teachers described their need for a supportive environment where TARGET-tool users can collaborate, learn from each other, and expand their knowledge and skills. Especially when the teacher is the only member of the PE department using the tool:

" It would be very nice if you could exchange ideas with someone who is also using the tool and wants to improve their PE practice. Preferably this happens among teachers from the same PE department. However, if you are the only one in the team then it would be nice to share ideas with other users from other schools" [R10].

Professional development

Individual online interviews were conducted to gain insights into the complex process of teacher professional development as a result of using the TARGET-tool. This process involves ongoing reflection and enactment in four interrelated domains.

External domain

With regard to the external domain, the teachers described how the tool provided them with new knowledge, and how the tool encouraged them to start thinking about and discussing student motivation and motivating teaching strategies within PE:

" As I said, with the TARGET-tool you are getting informed about student motivation and provided with tools to get started in your lessons. […] It is also a stimulus to start conversations with your colleagues about this topic" [R5].

By performing the student scans, the teachers noted that they were provided with new information and insights into students’ perceptions and experiences within PE, and how this information increased their self-awareness and formed a stimulus for potential change:

" I think I am quite well informed and doing well in PE, but it was interesting to find out that students experience things differently than I intended" [R6].

Domain of practice

The teachers explained how they experimented with the motivating teaching strategies recommended by the TARGET-tool (i.e., domain of practice). Some teachers, for example, selected the grouping dimension and implemented strategies that focused on working with smaller and more flexible groups and involving students in the grouping process:

“In the last 10 minutes of the two versus two basketball game, the students were allowed to change and determine new pairs” [R1]. “So, I varied in the student groups. Sometimes I let the students choose themselves, at times I made the groups myself, and we varied between heterogeneous and homogeneous groups” [R2].

Further, a teacher described how experimenting with motivating teaching strategies within the evaluation dimension also led to the development of new educational materials, such as an assessment rubric. And how this assessment tool subsequently aided the teacher in providing students with feed-up, feedback, and feed-forward information to scaffold the learning process:

" Based on this rubric I first let the students perform a self-assessment, and I did a formative assessment in the second lesson. Based on the scores the students knew exactly how they performed on the task [i.e., somersault] and could see what they could do to perform better. According to the motivating strategy, this information is important for student motivation" [R4].

Another example of how teachers experimented within their own PE practice, is related to the authority dimension. Teachers translated the suggestion to enhance students’ involvement in decision-making processes (i.e., teaching strategy) by providing opportunities for choice and self-regulation:

" With korfball, for example, the students were allowed to change or develop new playing rules to improve the game" [R6].

Domain of consequence

Concerning the domain of consequence, which refers to the salient outcomes and impact of teachers’ new teaching practice, they noted that their experiments generally worked out well and that students appreciated the changes:

" I also asked some students how they experienced it. They told me that they found it very motivating because they now know what is expected from them and how to improve" [R4].

Although the teaching strategies within the different TARGET dimensions provided by the tool can be considered as motivating for all students, the teachers in the present study pointed out the potential differential outcomes or impact on different (groups of) students:

" The changes have been well received by most students, however less so by some other students. I don’t think that it is possible to please all students and ensure enjoyment with all students in PE" [R7].

Personal domain

As a result of working with the TARGET-tool there were some changes reported regarding the personal domain. The teachers described how they gained new knowledge and insights:

" Well, I noticed that students have a need for autonomy and that they can bear the associated responsibility as well" [R3].

Teachers also reflected on how their personal experiences when implementing new teaching practices have led to changes in their thoughts or convictions and attitudes toward specific teaching strategies:

" I have become convinced that I can provide my students with more opportunities for self-regulation and that I sometimes have to change my teaching habits to ensure more enjoyable experiences for my students" [R2].

Constraints for professional development

The teachers pointed out some (potential) barriers that could limit their professional development opportunities. All teachers referred to the time aspect and how hectic situations in schools often demand immediate attention and consume a significant amount of time and resources:

" I just didn’t get around to it due to lack of time" [R1]. " I actually worked with the tool less than I had planned. Because we just have a new sports hall and you can’t imagine how much extra work that takes" [R9].

While teachers emphasized the importance of consultation and collaboration among PE teachers in the school for professional development, there were limited moments or opportunities created for meaningful discussions:

" Increasing the debate on this in the team would be beneficial and necessary" [R7].

One teacher also reflected on how resistance or reluctance towards adopting new PE practices among certain colleagues can frustrate professional development:

" We still practice some outdated methods which I want to change. But it is challenging to bring my older colleagues on board and embrace other practices" [R2].

Concerning the digital TARGET-tool specifically, another potential barrier was highlighted in the interviews. It was noted that the implementation of stricter policies regarding mobile device use in schools could jeopardize the use of student scans to gain objective data on students’ perceptions within PE:

" I wanted to perform quick scans as well, but in our new school policies, the use of mobile phones in the classroom will become prohibited. So, therefore I restricted myself to the target scans [R10].

Discussion and conclusion

CPD is crucial for enhancing effective teaching, bridging the theory–practice gap, and addressing the complexity of teaching (Armour et al., 2017 ; Atencio et al., 2012 ; Lander et al., 2022 ; Parker & Patton, 2017 ; Yoon et al., 2007 ). Digital tools offer new opportunities for supporting CPD (An, 2021 ; Hennessy et al., 2022 ; Philipsen et al., 2019 ; Walker et al., 2012 ). However, integrating these tools successfully in educational practice requires adhering to CPD prerequisites and recognizing the complexity of the professional development process. In this study, we examined the perceived applicability of the TARGET-tool in real-life secondary school PE contexts and gained insights into the complex process of teachers’ professional development as a result of using the digital tool. The most salient outcomes and implications will be discussed.

Perceived usability plays a crucial role in determining the effectiveness and user acceptance of a product (Yang et al., 2012 ). The present study provides valuable insights into aspects of the usability of the TARGET-tool, including perceived learnability, efficiency, error frequency, and satisfaction. Overall, teachers indicated that the usability of the TARGET-tool can be considered satisfactory. The teachers valued, for example, the ‘progressive’ dashboard which improved the learnability of the tool by enhancing user interface navigability. It enabled them to become familiar with the tool’s functionalities gradually and perform tasks independently and effectively. When user interfaces are easy to understand and navigate, and the technology is relatively simple to learn, users are more likely to adopt and integrate it into their work routines (Carroll et al., 2003 ; Roldán-Álvarez et al., 2016 ). Some teachers, however, expressed the need for a more comprehensive overview and explanation of the TARGET-tool before implementation to improve its effectiveness in the initial stages. This finding highlights the importance of providing teachers with additional information and instruction prior to the TARGET-tool usage. This is in line with the findings of Havard et al. ( 2018 ) and O’Neal et al. ( 2017 ) who emphasized the value of supporting teachers in integrating technology effectively into their educational practice. Accordingly, the TPACK model (Koehler et al., 2013 ; Mishra & Koehler, 2006 ), which focuses on incorporating technology effectively into teaching, stresses the importance of teachers’ technological content knowledge (TCK) and technological pedagogical knowledge (TPK). Therefore, equipping PE teachers with information on how the TARGET-tool can enhance or transform specific PE content areas (TCK) and providing insights on its use and integration in PE teaching practice (TPK) would be beneficial.

The present study highlighted the tool’s effectiveness in providing PE teachers with valuable information about their teaching practices. Teachers highly appreciated the simplicity and ease of use of the self-scan feature, which allowed them to quickly identify their strengths and areas for improvement across TARGET dimensions. The student scan feature was found efficient in gathering information about students’ PE experience and identifying opportunities to enhance the motivational climate. However, some teachers felt overwhelmed by the abundance of motivating strategies provided by the tool. This perception of overload may hinder the tool’s usability, as the efficiency of digital tools impacts teachers’ adoption and integration of technology into their teaching practices (Kearney et al., 2018 ). Therefore, it is important to address this issue by refining the tool’s design and presentation of motivating strategies to enhance usability.

Despite areas identified for improvement, such as simplifying complex features and providing additional support and resources, this study indicates that teachers had a positive attitude towards the TARGET-tool. They expressed satisfaction with its intention and purpose, seeing it as potentially beneficial for objectively examining students’ PE experiences, critical reflection on their teaching practice, and making improvements. This positive attitude highlights the tool’s potential to foster self-reflection and professional growth among teachers.

Teachers need to be recognized as active learners who shape their professional development through reflection and enactment in various domains, including the external domain, the domain of practice, the domain of consequence, and the personal domain (Clarke & Hollingsworth, 2002 ). The results of this study provided insights into the various aspects of these domains and their impact on PE teachers’ professional development.

The IMPG perspective suggests that learning and growth occur when changes in one domain lead to changes in another through the mediating process of reflection and enactment (Clarke & Hollingsworth, 2002 ). Our study revealed the impact of working with the TARGET-tool on teachers’ knowledge and understanding of student motivation and motivating teaching strategies in PE. For example, the tool introduced them to the theoretical TARGET framework (Ames, 1992 ; Epstein, 1989 ) which was previously unknown to them, expanding their insights into student motivation. Moreover, the TARGET-tool prompted teachers to critically reflect on student motivation and their teaching strategies. By conducting student scans, teachers gained a deeper understanding of how students perceive PE and their own instructional approaches. The tool seemed to increase teachers’ self-awareness and stimulate reflection, potentially leading to changes in their teaching practices. These findings indicate that the TARGET-tool effectively supports teachers in acquiring new knowledge and encourages reflection, aligned with the intended goals of the tool.

The results of our study showed how the teachers experimented with motivating teaching strategies recommended by the TARGET-tool within the domain of practice. According to the IMPG, professional experimentation is key to CPD, and professional development should be deliberately designed to offer teachers the opportunity to enact change in a variety of forms (Clarke & Hollingsworth, 2002 ). The TARGET-tool allowed teachers to select and try out teaching strategies that they considered suitable in their specific context. An example of this put forward by the teachers involved the authority dimension in which they explored the suggestion to enhance students’ involvement in decision-making processes, aiming to foster autonomy and self-regulation. These teachers saw this as fitting because the data collected with the TARGET-tool suggested this was an area for improvement. Furthermore, it was described how the experimentation within the evaluation dimension, led to the development of new educational materials to support student learning. Coenders and colleagues ( 2015 , 2019 ) demonstrated how the development of educational material substantially contributed to teacher growth. Therefore, they revised the IMPG to the ‘Extended Interconnected Model of Teacher Professional Growth’ (Coenders & Terlouw, 2015 ; Coenders & Verhoef, 2019 ) by adding the ‘developed material domain’. The examples of teachers’ experimentation with motivating teaching strategies, as well as evidence of changes in the domains, showcased the potential impact of the TARGET-tool on teachers’ professional development.

Within the domain of consequence, the findings of this study indicated that the experiments conducted by teachers generally yielded positive results. The teachers’ reflections on the consequences of their new teaching practices revealed a sense of satisfaction. They expressed, for example, that seeing their experiments work out well was a rewarding experience. The positive outcomes experienced by teachers in our study can therefore be considered important for reinforcing their confidence and beliefs in the applied teaching strategies and for encouraging them to further explore alternative teaching strategies.

Our study suggests that using the TARGET-tool can impact teachers’ personal domain. They reported gaining new knowledge and insights which suggest that the TARGET-tool is supportive in bridging the gap between theory and practice and thereby meeting a significant prerequisite of effective professional development tools (Armour et al., 2017 ; Grimshaw et al., 2012 ). Moreover, our study revealed that the teachers’ personal experiences in using the tool and implementing new teaching strategies played a role in shaping their thoughts, convictions, and attitudes toward specific teaching strategies. As teachers experimented with different instructional approaches, they encountered evidence of the impact these strategies had on student outcomes. According to the seminal work by Guskey ( 1986 ) and Guskey and Yoon ( 2009 ) teachers’ attitudes and beliefs about effective teaching strategies, will change only after they have personally experienced positive changes in students’ learning outcomes. This ‘proven’ added value is deemed to be important for teachers’ willingness to innovate their teaching practice and ensure professional growth (Clarke & Hollingsworth, 2002 ; Parker & Patton, 2017 ). The TARGET-tool motivates teachers to implement and experiment with motivating teaching strategies. Our findings suggest that this experiential learning process prompted a reflection on their existing beliefs and practices, leading to a reconsideration and, in some cases, a modification of it. The willingness to re-evaluate beliefs and embrace new teaching strategies suggests an openness to change and a commitment to continuous improvement. Indeed, active involvement and conducting iterative cycles of experimentation and reflection are considered crucial for effective CPD (Korthagen, 2017 ; Sargent & Calderón, 2021 ; Tannehill et al., 2021 ).

Despite the positive aspects of the TARGET-tool, several potential barriers to professional development were identified by the teachers. Time constraints emerged as a major challenge, with teachers expressing the difficulty of allocating sufficient time and resources for professional development due to the demanding nature of their work. This problem was already highlighted prior to the commencement of the current study when nine PE teachers withdrew due to time constraints and excessive workload. These teachers indicated they were engaged in a demanding period at school, which left them unable to participate in this study despite their initial commitments. Consistent with previous studies related to teacher professional development (e.g., Khalid et al., 2014 ; Parker et al., 2012 ; Slingerland et al., 2021 ; Taylor, 2020 ; Xue et al., 2021 ) our findings emphasize the importance of providing teachers with sufficient time and opportunities for professional development activities.

The limited opportunities for meaningful discussions and collaboration among PE teachers within and between schools were also pointed out by the teachers in this study. This implies there is a need for opportunities to exchange ideas, experiences, and expertise among teachers. Indeed, several studies (e.g., Hunuk et al., 2013 ; Parker et al., 2012 ; Tannehill & MacPhail, 2017 ; Trust et al., 2016 ; vanOostveen et al., 2019 ) stress the importance of building learning communities to impact the professional development of teachers positively. Research has shown that participation in (online or in-person) learning communities leads to, for example, the enhancement of teachers’ content knowledge and the improvement of their teaching practice (Makopoulou & Armour, 2011 ; Yu & Chao, 2022 ). In addition, participation in learning communities can support teacher empowerment (Parker et al., 2010 ; Tannehill & MacPhail, 2017 ), increase their willingness to jointly solve problems (Yu & Chao, 2022 ) and enhance their confidence in implementing digital technologies into their practice (OECD, 2014 ; Sheffield et al., 2018 ). Hence, we strongly advocate for facilitating collaborative opportunities among users of the TARGET-tool to optimize its potential and ensure the effective professional development of PE teachers.

Contribution and implications

We presented a comprehensive case study detailing the implementation and evaluation of the TARGET-tool, a unique teacher professional development tool designed to support PE teachers in creating an inclusive and motivating learning environment within secondary school PE settings. Our study contributes to various academic domains, including educational technology, human–computer interaction (HCI), teacher professional development, and physical education.

The theoretical contributions of our research are twofold. Firstly, we advance pedagogical knowledge by showcasing how technology, such as the TARGET-tool, could effectively bridge the theory–practice gap in teacher professional development. In doing so, we respond to the call made by a substantial group of international HCI experts, to gain insights into how technologies can be effectively integrated into the complex educational context and better tailored to the specific needs of teachers (Stephanidis et al., 2019 ). Secondly, we add to the theoretical foundations of technology integration in pedagogy, emphasizing the importance of aligning technology with pedagogical objectives, as put forward in the Technological Pedagogical Content Knowledge (TPACK) model (Koehler et al., 2013 ; Mishra & Koehler, 2006 ).

On the practical front, our study provides valuable insights into the importance of the perceived usability of technology in educational settings. We explored factors such as learnability, efficiency, error frequency, and satisfaction, underlining the potential for successful integration of technology such as the TARGET-tool into teachers’ work routines. Moreover, since our study has established the potential effectiveness of the TARGET-tool for enhancing motivating teaching practices, it offers PE teachers a tangible instrument for critical reflection and professional development. Our research illustrates how a technological tool could impact various domains of teachers’ professional growth, including changes in knowledge, teaching strategies, and personal beliefs. However, this study has also uncovered practical challenges, such as time constraints and limited collaboration opportunities as barriers to professional development. This emphasizes the importance of providing teachers with conditions for effective use of digital tools in the educational context (e.g., adequate time and establishing collaborative learning communities). Despite acknowledging the positive aspects of the use of the TARGET-tool, our study shows the importance of ongoing support, refinement, and collaborative opportunities for sustaining the long-term impact of professional development tools. Overall, our study not only highlights the practical applicability of the TARGET-tool but also makes substantive contributions to the broader discourse on optimizing educational technology for enhanced teaching practices and student engagement in the field of PE.

Strengths and limitations

To the best of our knowledge, this is the first study in the context of PE in which a digital tool for teacher professional development is presented and evaluated. We did not only evaluate the perceived usability of the tool in the authentic PE setting, we also explored its intended function of supporting the process of teachers’ professional development. With that, the tool was reviewed from a broader perspective in which the interrelationship between technology and pedagogy was acknowledged. We believe our research contributes to the understanding of how digital tools can effectively be embedded in the educational process and enhance teaching practices. However, there are limitations to consider. The findings are based on the subjective perspectives of a small, convenience sample of teachers, potentially leading to sampling bias. Future research with a larger and more diverse sample would provide a more comprehensive understanding of the process of professional development as a result of using the TARGET-tool. Additionally, studying the tool’s usability and impact over a longer period would be valuable.

Conclusion and recommendations

The TARGET-tool has demonstrated its potential as an effective tool for supporting teachers’ professional development in a secondary school context. Furthermore, it has been shown how the use of the TARGET-tool engages teachers as active and reflective participants in their professional development and induces changes across all domains of professional growth.

Future opportunities for TARGET-tool development and improvement have been identified. Based on the findings of the present study, it is recommended to enhance the perceived usability of the TARGET-tool by simplifying complex features such as scheduling student scans, generating scan passwords, analyzing student scan results, and selecting motivating teaching strategies. To enhance the tool’s effectiveness in the initial stages, it is suggested to provide PE teachers with a more comprehensive overview and insights on its use and integration in teaching practice before using the tool. For instance, organizing a brief online introduction meeting for new users could be beneficial. Moreover, facilitating learning communities among TARGET-tool users is recommended to optimize its effective implementation. Utilizing platforms like Microsoft Teams can facilitate the creation of such a learning community, connecting users and enabling them to discuss, learn from one another, collaboratively resolve issues, and enhance their teaching practices. Additionally, these communities could offer teachers support, empowering them to build confidence in integrating the TARGET-tool into their unique teaching practices.

Data availability

The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.

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Weeldenburg, G., Slingerland, M., Borghouts, L.B. et al. Evaluation of the digital teacher professional development TARGET-tool for optimizing the motivational climate in secondary school physical education. Education Tech Research Dev (2024). https://doi.org/10.1007/s11423-024-10379-5

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Cultural Relativity and Acceptance of Embryonic Stem Cell Research

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There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities.

INTRODUCTION

Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve.

Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes. [1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research. [2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.” [3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops. [4]  Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture.

I.     Global Cultural Perspective of Embryonic Stem Cells

Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense, [5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research. [6] Consequently, global engagement in ESC research depends on social-cultural acceptability.

a.     US and Rights-Based Cultures

In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism, [7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.” [8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed. [9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field. [10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture. [11]

b.     Ubuntu and Collective Cultures

African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama , which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,” [12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth. [13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole . Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value. [14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society.

Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.” [15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail.

Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable. [16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus. [17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines. [18]

Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim. [19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research. [20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF.  Their use is conditioned on consent, and available only to married couples. [21] The community's receptiveness to stem cell research depends on including communitarian African ethics.

c.     Asia

Some Asian countries also have a collective model of ethics and decision making. [22] In China, the ethics model promotes a sincere respect for life or human dignity, [23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life. [25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research. [26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions. [27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency. [28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021. [29] However, issues still need to be addressed in implementing effective IRB review and approval procedures.

The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy, [30] research ethics should also adapt to ensure respect for the values of its represented peoples.

Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies. [31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells. [32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval, [33] and in another instance, the oocyte source was unclear and possibly violated ethical standards. [34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust.

d.     Middle East

Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells, [35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research. [36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors. [37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so. [38]

Jordan has a positive research ethics culture. [39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial. [40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation. [41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.” [42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes.

e.     Europe

In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected. [43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44]

For example, in Germany, Lebenzusammenhang , or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.” [45]  Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount. [46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007. [47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization. [48] Spain’s approach differs still, with a comprehensive regulatory framework. [49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility. [50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices. [51]

II.     Religious Perspectives on ESC

Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives.

The Qur'an states:

“And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.” [52]

Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception. [53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible. [54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research. [55]

In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided. [56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden. [57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all. [58] Acceptance varies on applied beliefs and interpretations.

Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero, [59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all. [60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime. [61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit. [62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets. [63]

Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life. [64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception: [65]

“If she is found pregnant, until the fortieth day it is mere fluid,” [66]

Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation. [67] Stem cell research is accepted due to application of these religious laws.

We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory , which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions. [68] We only wish to show that the interaction with morality varies between cultures and countries.

III.     A Flexible Ethical Approach

The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities.

While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe. [69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation.

For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent. [70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context, [71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders.  This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research.

Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values. [72]

An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions. [73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion.

IV.     Concerns

Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values. [74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions.

Other concerns include medical tourism, which may promote health inequities. [75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments. [76]

For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.” [77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices. [78]

The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.” [79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds. [80]

While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research.

For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society.

This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model.

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[7] Socially, at its core, the Western approach to ethics is widely principle-based, autonomy being one of the key factors to ensure a fundamental respect for persons within research. For information regarding autonomy in research, see: Department of Health, Education, and Welfare, & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research.; For a more in-depth review of autonomy within the US, see: Beauchamp, T. L., & Childress, J. F. (1994). Principles of Biomedical Ethics . Oxford University Press.

[8] Sherley v. Sebelius , 644 F.3d 388 (D.C. Cir. 2011), citing 45 C.F.R. 46.204(b) and [42 U.S.C. § 289g(b)]. https://www.cadc.uscourts.gov/internet/opinions.nsf/6c690438a9b43dd685257a64004ebf99/$file/11-5241-1391178.pdf

[9] Stem Cell Research Enhancement Act of 2005, H. R. 810, 109 th Cong. (2001). https://www.govtrack.us/congress/bills/109/hr810/text ; Bush, G. W. (2006, July 19). Message to the House of Representatives . National Archives and Records Administration. https://georgewbush-whitehouse.archives.gov/news/releases/2006/07/20060719-5.html

[10] National Archives and Records Administration. (2009, March 9). Executive order 13505 -- removing barriers to responsible scientific research involving human stem cells . National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/removing-barriers-responsible-scientific-research-involving-human-stem-cells

[11] Hurlbut, W. B. (2006). Science, Religion, and the Politics of Stem Cells.  Social Research ,  73 (3), 819–834. http://www.jstor.org/stable/40971854

[12] Akpa-Inyang, Francis & Chima, Sylvester. (2021). South African traditional values and beliefs regarding informed consent and limitations of the principle of respect for autonomy in African communities: a cross-cultural qualitative study. BMC Medical Ethics . 22. 10.1186/s12910-021-00678-4.

[13] Source for further reading: Tangwa G. B. (2007). Moral status of embryonic stem cells: perspective of an African villager. Bioethics , 21(8), 449–457. https://doi.org/10.1111/j.1467-8519.2007.00582.x , see also Mnisi, F. M. (2020). An African analysis based on ethics of Ubuntu - are human embryonic stem cell patents morally justifiable? African Insight , 49 (4).

[14] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics , 22 (2), 112–122. https://doi.org/10.1111/dewb.12324

[15] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324

[16] Jackson, C.S., Pepper, M.S. Opportunities and barriers to establishing a cell therapy programme in South Africa.  Stem Cell Res Ther   4 , 54 (2013). https://doi.org/10.1186/scrt204 ; Pew Research Center. (2014, May 1). Public health a major priority in African nations . Pew Research Center’s Global Attitudes Project. https://www.pewresearch.org/global/2014/05/01/public-health-a-major-priority-in-african-nations/

[17] Department of Health Republic of South Africa. (2021). Health Research Priorities (revised) for South Africa 2021-2024 . National Health Research Strategy. https://www.health.gov.za/wp-content/uploads/2022/05/National-Health-Research-Priorities-2021-2024.pdf

[18] Oosthuizen, H. (2013). Legal and Ethical Issues in Stem Cell Research in South Africa. In: Beran, R. (eds) Legal and Forensic Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-32338-6_80 , see also: Gaobotse G (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[19] United States Bureau of Citizenship and Immigration Services. (1998). Tunisia: Information on the status of Christian conversions in Tunisia . UNHCR Web Archive. https://webarchive.archive.unhcr.org/20230522142618/https://www.refworld.org/docid/3df0be9a2.html

[20] Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[21] Kooli, C. Review of assisted reproduction techniques, laws, and regulations in Muslim countries.  Middle East Fertil Soc J   24 , 8 (2020). https://doi.org/10.1186/s43043-019-0011-0 ; Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[22] Pang M. C. (1999). Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions. Journal of medical ethics , 25(3), 247–253. https://doi.org/10.1136/jme.25.3.247

[23] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[24] Wang, Y., Xue, Y., & Guo, H. D. (2022). Intervention effects of traditional Chinese medicine on stem cell therapy of myocardial infarction.  Frontiers in pharmacology ,  13 , 1013740. https://doi.org/10.3389/fphar.2022.1013740

[25] Li, X.-T., & Zhao, J. (2012). Chapter 4: An Approach to the Nature of Qi in TCM- Qi and Bioenergy. In Recent Advances in Theories and Practice of Chinese Medicine (p. 79). InTech.

[26] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students.  Stem cells international ,  2021 , 6667743. https://doi.org/10.1155/2021/6667743

[27] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students.  Stem cells international ,  2021 , 6667743. https://doi.org/10.1155/2021/6667743

[28] Zhang, J. Y. (2017). Lost in translation? accountability and governance of Clinical Stem Cell Research in China. Regenerative Medicine , 12 (6), 647–656. https://doi.org/10.2217/rme-2017-0035

[29] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[30] Chen, H., Wei, T., Wang, H.  et al.  Association of China’s two-child policy with changes in number of births and birth defects rate, 2008–2017.  BMC Public Health   22 , 434 (2022). https://doi.org/10.1186/s12889-022-12839-0

[31] Azuma, K. Regulatory Landscape of Regenerative Medicine in Japan.  Curr Stem Cell Rep   1 , 118–128 (2015). https://doi.org/10.1007/s40778-015-0012-6

[32] Harris, R. (2005, May 19). Researchers Report Advance in Stem Cell Production . NPR. https://www.npr.org/2005/05/19/4658967/researchers-report-advance-in-stem-cell-production

[33] Park, S. (2012). South Korea steps up stem-cell work.  Nature . https://doi.org/10.1038/nature.2012.10565

[34] Resnik, D. B., Shamoo, A. E., & Krimsky, S. (2006). Fraudulent human embryonic stem cell research in South Korea: lessons learned.  Accountability in research ,  13 (1), 101–109. https://doi.org/10.1080/08989620600634193 .

[35] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

[36] Association for the Advancement of Blood and Biotherapies.  https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia

[37] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia.  BMC medical ethics ,  21 (1), 35. https://doi.org/10.1186/s12910-020-00482-6

[38] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics , 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics , 23 (3), 260–268. https://doi.org/10.1111/dewb.12355 ; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know . Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know

[39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[41] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[42] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France.  Biotechnology Law Report ,  32 (6), 349–356. https://doi.org/10.1089/blr.2013.9865

[45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[46] Tomuschat, C., Currie, D. P., Kommers, D. P., & Kerr, R. (Trans.). (1949, May 23). Basic law for the Federal Republic of Germany. https://www.btg-bestellservice.de/pdf/80201000.pdf

[47] Regulation of Stem Cell Research in Germany . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany

[48] Regulation of Stem Cell Research in Finland . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland

[49] Regulation of Stem Cell Research in Spain . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain

[50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered:

Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110.

Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ...  Revista do Colegio Brasileiro de Cirurgioes ,  41 (5), 374–377. https://doi.org/10.1590/0100-69912014005013

Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India . Routledge.

For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe   

[51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights.  Cultura (Iasi, Romania) ,  14 (2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent?  Research Ethics ,  13 (1), 23-41.  https://doi.org/10.1177/1747016116650235

[52] The Qur'an  (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23

[53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life . Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/

[54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics , 31: 399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386

[55] Rashid, R. (2022). When does Ensoulment occur in the Human Foetus. Journal of the British Islamic Medical Association , 12 (4). ISSN 2634 8071. https://www.jbima.com/wp-content/uploads/2023/01/2-Ethics-3_-Ensoulment_Rafaqat.pdf.

[56] Sivaraman, M. & Noor, S. (2017). Ethics of embryonic stem cell research according to Buddhist, Hindu, Catholic, and Islamic religions: perspective from Malaysia. Asian Biomedicine,8(1) 43-52.  https://doi.org/10.5372/1905-7415.0801.260

[57] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[58] Lecso, P. A. (1991). The Bodhisattva Ideal and Organ Transplantation.  Journal of Religion and Health ,  30 (1), 35–41. http://www.jstor.org/stable/27510629 ; Bodhisattva, S. (n.d.). The Key of Becoming a Bodhisattva . A Guide to the Bodhisattva Way of Life. http://www.buddhism.org/Sutras/2/BodhisattvaWay.htm

[59] There is no explicit religious reference to when life begins or how to conduct research that interacts with the concept of life. However, these are relevant verses pertaining to how the fetus is viewed. (( King James Bible . (1999). Oxford University Press. (original work published 1769))

Jerimiah 1: 5 “Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee…”

In prophet Jerimiah’s insight, God set him apart as a person known before childbirth, a theme carried within the Psalm of David.

Psalm 139: 13-14 “…Thou hast covered me in my mother's womb. I will praise thee; for I am fearfully and wonderfully made…”

These verses demonstrate David’s respect for God as an entity that would know of all man’s thoughts and doings even before birth.

[60] It should be noted that abortion is not supported as well.

[61] The Vatican. (1987, February 22). Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day . Congregation For the Doctrine of the Faith. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html

[62] The Vatican. (2000, August 25). Declaration On the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells . Pontifical Academy for Life. https://www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pa_acdlife_doc_20000824_cellule-staminali_en.html ; Ohara, N. (2003). Ethical Consideration of Experimentation Using Living Human Embryos: The Catholic Church’s Position on Human Embryonic Stem Cell Research and Human Cloning. Department of Obstetrics and Gynecology . Retrieved from https://article.imrpress.com/journal/CEOG/30/2-3/pii/2003018/77-81.pdf.

[63] Smith, G. A. (2022, May 23). Like Americans overall, Catholics vary in their abortion views, with regular mass attenders most opposed . Pew Research Center. https://www.pewresearch.org/short-reads/2022/05/23/like-americans-overall-catholics-vary-in-their-abortion-views-with-regular-mass-attenders-most-opposed/

[64] Rosner, F., & Reichman, E. (2002). Embryonic stem cell research in Jewish law. Journal of halacha and contemporary society , (43), 49–68.; Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[65] Schenker J. G. (2008). The beginning of human life: status of embryo. Perspectives in Halakha (Jewish Religious Law).  Journal of assisted reproduction and genetics ,  25 (6), 271–276. https://doi.org/10.1007/s10815-008-9221-6

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[67] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[68] Gert, B. (2007). Common morality: Deciding what to do . Oxford Univ. Press.

[69] World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA , 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Declaration of Helsinki – WMA – The World Medical Association .; see also: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979).  The Belmont report: Ethical principles and guidelines for the protection of human subjects of research . U.S. Department of Health and Human Services.  https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html

[70] Zakarin Safier, L., Gumer, A., Kline, M., Egli, D., & Sauer, M. V. (2018). Compensating human subjects providing oocytes for stem cell research: 9-year experience and outcomes.  Journal of assisted reproduction and genetics ,  35 (7), 1219–1225. https://doi.org/10.1007/s10815-018-1171-z https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6063839/ see also: Riordan, N. H., & Paz Rodríguez, J. (2021). Addressing concerns regarding associated costs, transparency, and integrity of research in recent stem cell trial. Stem Cells Translational Medicine , 10 (12), 1715–1716. https://doi.org/10.1002/sctm.21-0234

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[75] Pirzada, N. (2022). The Expansion of Turkey’s Medical Tourism Industry.  Voices in Bioethics ,  8 . https://doi.org/10.52214/vib.v8i.9894

[76] Stem Cell Tourism: False Hope for Real Money . Harvard Stem Cell Institute (HSCI). (2023). https://hsci.harvard.edu/stem-cell-tourism , See also: Bissassar, M. (2017). Transnational Stem Cell Tourism: An ethical analysis.  Voices in Bioethics ,  3 . https://doi.org/10.7916/vib.v3i.6027

[77] Song, P. (2011) The proliferation of stem cell therapies in post-Mao China: problematizing ethical regulation,  New Genetics and Society , 30:2, 141-153, DOI:  10.1080/14636778.2011.574375

[78] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[79] International Society for Stem Cell Research. (2024). Standards in stem cell research . International Society for Stem Cell Research. https://www.isscr.org/guidelines/5-standards-in-stem-cell-research

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Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

MS Bioethics Columbia University (Disclosure: affiliated with Voices in Bioethics)

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