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Looking at the participation in high school physical education in the USA during the years 1999-2003.

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Participation in High School Physical Education --- United States, 1991--2003

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Physical education (PE) can increase student participation in moderate to vigorous physical activity () and help high school students gain the knowledge, attitudes, and skills they need to engage in lifelong physical activity (). Two national health objectives for 2010 are to 1) increase to >50% the proportion of adolescents who participate in daily school PE (objective no.

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Exploring reasons why some students may not participate in physical education.

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Abstract

Background

Asthma is the most common chronic illness among children and accounts for 1 in 5 of all child GP consultations. This paper reviews and discusses recent literature outlining the growing problem of physical inactivity among young people with asthma and explores the psychosocial dimensions that may explain inactivity levels and potentially relevant interventions and strategies, and the principles that should underpin them.

Methods

A narrative review based on an extensive and documented search of search of CinAHL, Embase, Medline, PsycINFO and the Cochrane Library.

Results & Discussion

Children and young people with asthma are generally less active than their non-asthmatic peers. Reduced participation may be influenced by organisational policies, family illness beliefs and behaviours, health care advice, and inaccurate symptom perception and attribution. Schools can be reluctant to encourage children to take part in physical education or normal play activity due to misunderstanding and a lack of clear corporate guidance. Families may accept a child's low level of activity if it is perceived that breathlessness or the need to take extra inhalers is harmful. Many young people themselves appear to accept sub-optimal control of symptoms and frequently misinterpret healthy shortness of breath on exercising with the symptoms of an impending asthma attack.

Conclusion

A multi-faceted approach is needed to translate the rhetoric of increasing activity levels in young people to the reality of improved fitness. Physical activity leading to improved fitness should become part of a goal orientated management strategy by schools, families, health care professionals and individuals. Exercise induced asthma should be regarded as a marker of poor control and a need to increase fitness rather as an excuse for inactivity. Individuals' perceptual accuracy deserves further research attention.

Background

Asthma in children and young people is a major health problem [-]. For reasons that are not fully understood the incidence and prevalence of asthma have increased considerably over the last thirty years, particularly for children and young people [, ]. Despite a reduction in incidence since it peaked in 1993 the UK asthma rate continues to be six times higher among children now than it was in 1976 [, ]. The prevalence rate in the 2-15 years age group is reportedly one fifth of the population (20.7%) and when compared with 56 other countries the UK has one of the highest prevalence rates of wheeze and asthma in 13-14 year old children [].

The burden on health services from asthma is extensive and increasing []. At primary care level asthma accounts for 1 in 5 of all child GP consultations [], while within secondary care in England and Wales in 1999, there were over 30,000 asthma related hospital admissions and 25 child deaths []. Asthma is thus a common condition affecting a substantial and increasing proportion of children and young people [] and as a result provides a challenge in management for the individual sufferer and for health services as a whole.

In addition to the direct effect the condition has on the wellbeing of an individual, it is increasingly recognised that the health of sufferers can be further compromised because of the impact that asthma may have on their participation in physical activity [, ]. This paper presents a narrative synthesis based on a scoping review of the literature in order to provide an overview of evidence and argument in this area, and therefore inform decisions about the future direction of empirical studies and/or more specifically focussed systematic reviews[, ]. It reviews and discusses recent literature outlining the growing problem of physical inactivity among young people with asthma and explores the psychosocial dimensions that may explain inactivity levels and potentially relevant interventions and strategies, and the principles that should underpin them.

Methods

The aim to provide an overview of evidence and argument in order to direct future research enquiry and inform potential policy indicated that a "scoping review" approach was required. Systematic reviews require a small number of highly specific questions and thus presuppose a pre-existing knowledge and understanding of the importance and priorities of key topics and issues. Scoping reviews are designed to identify and provide a rationale for these issues[], and have been used in a wide number of clinical areas [-]. They do not, therefore, claim to provide an exhaustive account of the evidence base for all specific questions.

Given the breadth of literature relating to both asthma and physical activity, and the changing characteristics of each, it was decided to initially identify relevant review articles within the recent literature, and then use these to identify other key empirical pieces. We searched the Cumulative Index of Nursing and Allied Health Literature (CinAHL); Excerpta Medica Database (Embase); Medlars Online (Medline); Psychological literature (PsycINFO); and the Cochrane Library for relevant studies published between 2001-2005 inclusive (see Table ). Abstracts were read independently by two researchers (BW and AZ - see acknowledgements) and the decision to include them compared. Disagreements were addressed through discussion of the evidence and rationale for each paper. In accordance with scoping review principles, and in order to facilitate subsequent identification of yet unknown key issues and arguments within the literature, selection criteria were purposefully broad. Papers whose central focus was not asthma were excluded at this stage as were non-empirical papers (e.g. commentaries, editorials, and discussion pieces). Sixty-one papers were identified as relevant and full papers obtained. The review articles identified by these searches allowed us to map the broad issues around which the remainder of this paper is structured. We then used the reviews, alongside key papers cited within them (which we obtained) in order to inform the narrative synthesis of arguments, issues and debates required.

Results & Discussion

The literature demonstrated empirical evidence documenting the importance of physical activity for children with asthma, reduced levels of participation, social and psychological factors influencing low participation, and principles that should underpin strategies to increase physical activity among children and young people with asthma. These are discussed in turn below.

The importance of physical activity for children and young people with asthma

Physical activity is generally accepted to be of advantage to young children in terms of bone development, motor skills, improved cardiovascular fitness, and self esteem [, ]. Physical activity is also important for children and young people with asthma. Several studies have identified significant improvements in aerobic fitness [, ] and asthma-related benefits such as reduced hospital admissions, reduced absenteeism from school, fewer consultations with health professionals, reduced medication use [], and improved ability to cope with asthma []. In addition, it remains clear that being able to participate in physical activity, particularly at school, is an important contributing factor for psychological wellbeing by, for example, reducing the body dissatisfaction that can be associated with asthma [, , ]. Furthermore, studies involving dietary alteration have shown that weight loss for obese people with asthma can improve their asthma symptoms. []. It is therefore feasible that physical activity that is conducive to weight loss might be helpful for obese children and young people with asthma.

In addition to the above benefits physical activity may also help protect against the potential increased risk of osteoporosis associated by the prolonged steroid therapy that some children and young people with asthma may experience []. Although direct evidence of such benefits is currently lacking for asthma, evidence exists to show that weight-bearing physical activity can increase bone mineral content and reduce osteoporosis risk later in life among children with acute lymphoblastic leukaemia [].

Despite these varied benefits the majority of studies of physical activity training programmes for children and young people with asthma have shown no change in actual baseline lung function [, ] or in the occurrence or degree of exercise-induced asthma []. Further RCTs and systematic reviews on the effects of physical training need are required [].

Because of this range of physical, psychological and social benefits, current evidence suggests that children and adolescents with asthma should be encouraged to participate in regular physical activity. This may improve asthma management and general health and minimise the generic risks associated with low levels of physical activity [, ].

Although the existence of a respiratory condition might be expected to prevent engagement in such activities the overwhelming majority of studies show that people with asthma can exercise safely if medicated appropriately and can significantly improve their cardiovascular fitness and quality of life by doing so []. Indeed, a substantial proportion of sportsmen and women who compete at the elite international level have a diagnosis of asthma [] or experience exercise-induced asthma []. The consensus of many authors is therefore that inactivity or reduced activity in the presence of an asthma diagnosis should not be accepted []. Instead, an exercise 'prescription' should be part of the management plan for all people with asthma [].

Evidence for reduced participation in physical activity among children and young people with asthma

Despite the importance of physical activity to children and young people with asthma, and although some studies have failed to demonstrate a significant difference in physical activity levels between asthmatic and non-asthmatic children[], there is growing evidence that they are in fact less active than their non-asthmatic peers. Lack of participation in physical activity by children and young people with asthma is unsurprising given that physical activity levels are known to be falling among young people in most industrialised nations [, ]. These rates fall even further as children reach adolescence [], particularly in teenage girls. At secondary school age, boys report more physical activity at 11, 13 and 15 than girls and are more likely to meet the guideline of 60 minutes moderate activity per day [].

Although the majority of evidence points to reduced physical activity among young people with asthma, conceptual and methodological problems, particularly in relation to confounding, has resulted in contradictory evidence []. These contradictions arise partly as a result of methodological and disease detection/diagnostic issues. Engagement in significant levels of physical activity can lead to improved detection; particularly exercise induced asthma (EIA). Consequently, activity rates in children and young people with asthma may appear artificially high because already-active children and young people are more likely to be diagnosed as having asthma.

Notwithstanding this methodological problem, studies in a range of countries suggest that children and young people with asthma are less active than their healthy peers and that they attribute their limited participation to their asthma. In a comparative study of 112 children with and without asthma Glazebrook et al found that children with asthma reported fewer physical activities than the non-asthma group (median 4 per day vs 6 per day). Furthermore, asthma was the strongest predictor of lower activity scores, followed by younger age[]. In addition, a study of 137 United States (US) children aged 6-12 years found that those with asthma were less active than their peers in all classifications of activity level used []. In Germany, a study of 254 teachers in 46 schools across a range of ages found that only 60% of children with asthma took part in physical education lessons on the same basis as their healthy peers: the remaining 40% did not participate, or only participated sometimes or to a limited extent []. An Australian survey also found reduced activity and a belief that asthma was responsible. Parents reported that as a result of asthma 31% did not participate in sport; 21% did not ride a bicycle; 20% did not swim; and 18% did not take part in break time play at school []. Young people with asthma also believe that their physical activity is reduced as a result. A survey of 123,000 US young people aged 12-14 found that 52% of those with a diagnosis of asthma reported that their activities were curtailed because of their asthma [].

A reduction in physical activity levels at the same time as an increase in asthma incidence and prevalence is a cause for concern and is likely to result in increasing numbers of people with asthma failing to attain their optimum health status and quality of life. The remainder of this paper explores the range of psychosocial factors that may explain low participation before briefly considering potentially relevant interventions and the principles that should underpin them.

Factors affecting participation in physical activity by children and young people with asthma

Studies suggest that three inter-connected factors affect participation in physical activity by children and young people with asthma: the illness beliefs of young people [-]; parental and family beliefs [, ]; and the knowledge and attitudes of teachers and the organisational arrangements in schools [-]. Underpinning all of these is the problem of interpretation of asthma symptoms [-]. Each of these issues is discussed in turn below. While availability of facilities might be assumed to be important as a predictor of engagement in activity the relationship is not clear cut as some studies fail to demonstrate a connection []. More detailed and focussed systematic reviews and meta-analyses of studies in this area are needed, particularly among young people with asthma.

Illness beliefs of young people with asthma

Many children and young people with asthma believe that limitations on their activity are an inevitable part of having asthma [-]. A study of 24 US teenagers with asthma showed that they perceived that despite their best efforts they were unable to participate to the level they wanted []. Consequently, there may be low levels of self-efficacy [].

Some young people may find low self-efficacy in relation to engagement in physical activity as problematic, particularly where they and their peers value such engagement. In such circumstances motivation to engage in behaviour change would otherwise have been present [, ]. In one UK study around 80% of secondary school pupils said that the resultant effect of not being able to participate in sport was the worst thing about having asthma and was potentially stigmatising, thus leading to a spoilt identity []. [].

The desire to meet socially defined forms of normality or "ordinariness", thereby maintaining membership of a valued social group and avoiding stigma or social exclusion, is known to be important for young people [-]. Maintenance of such "normality or "ordinariness", particularly in relation to gender specific definitions, appears to be a potentially important factor affecting whether young people with asthma participate in physical activities. For example, a study of 24 US 14-18 year old asthma sufferers found that for boys, being normal involved participating in physical activity, and a desire not to be last in competitive games. This meant that some boys discounted what they knew about asthma management and pushed themselves too hard. For girls this normality was less likely to include activity. However, both boys and girls recognised that there was a risk of potential stigma and labelling and many did not want to be identified as having asthma [].

Parents, teachers and coaches play important roles in providing normalising and gratifying opportunities for children with chronic illness who struggle to be competent and accepted by peers. However, many parents and teachers are concerned about the risks of physical activity in children and young people with asthma and instead deter them from activities [].

Parental and family beliefs

The influence of family factors on the activities of young people is well documented For example, a survey of around 4000 US teenagers without asthma found that a range of factors including race, educational aspirations and maternal parenting style were associated with whether girls were more likely to engage in physical activity or to have sedentary leisure habits []. Teenage girls with higher academic rank or expectation and girls whose mothers had a parenting style that balanced responsiveness and control were more likely to have higher levels of activity and lower sedentary leisure habits. Putting a high value on health, appearance and achievement was associated with higher activity levels and reduced sedentary behaviour.

Against this wider background of family influence on young people, several studies of physical activity in children and young people with asthma suggest that parental and family beliefs play a key part in both enabling children and young people to manage their asthma effectively, and sometimes hindering effective management [, ]. For example, a comparative study of exercise among asthmatic and non-asthmatic children, and their parents, found that more parents in the asthma group identified the child's health as a barrier to exercise (60.7% vs 11%)[]. Similarly, a US focus group study of 47 parents of children with asthma found that their beliefs about asthma and its treatment led many to modify the asthma treatment plan set out by a health professional, and that many unnecessarily restricted their child's physical activity because of lack of information or misinterpretation of advice given. Other parents did not restrict activity as they were concerned about the psychological consequences of such restriction, but many were concerned that they were thereby increasing their child's symptoms []. In a study of low income pre-school children in the US, children who had a history of wheezing were found to be less active than their peers. This suggested that parents may consciously or unconsciously restrict their child's activities; it is possible that these attitudes persist once the child enters school []. For example, a study of 137 US children and parents found that the strongest predictor of high activity among 6-12 year olds was parental belief that exercise could help improve the child's asthma. Children whose parents believed that the child would become ill or upset from exercise were more likely to be inactive whereas children whose parents believed that they could do as much as their peers were more likely to be active [].

There is evidence that parental concerns may stem, in part at least, from misperceptions about the nature, cause and cure of asthma itself. A study of Hong Kong parents of children with asthma identified a range of fears and misconceptions: they thought that asthma might be infectious; they were concerned that swimming and other forms of exercise would make it worse; and they believed that inhaled steroids should be avoided []. These studies underline the extent to which parental knowledge and beliefs about asthma in a range of countries may be founded on misconceptions and may hinder children's participation in physical activity. Problems may also arise when the perceptions of the young person with asthma differ markedly from those of parents or teachers. For example, a study of US teenagers found that some teenagers saw asthma as potentially dangerous but that teachers or family members often did not give credibility to their symptoms []. Another study found that carers judged asthma severity by one measure, the frequency of acute attacks, whereas for young people the impact that asthma had on their daily life and the extent to which they appeared different from their peers were more significant [].

Knowledge and attitudes of teachers and organisational arrangements in schools

Surveys of teachers in a range of countries including the US, Germany, Hong Kong and the UK have consistently found low levels of knowledge and understanding of asthma, asthma and exercise and asthma management [, , -]. Although some teachers recognise that sport is important for children with asthma [], many are unaware that medication may be taken before exercise to effectively prevent acute attacks and that children with asthma can be as competent as healthy children in sports []. Studies show that many teachers may hold outdated beliefs, for example that those with asthma should avoid PE lessons [] or that asthmatic children usually have 'overprotective mothers' []. Many teachers acknowledge that they would like more information and training []: in one UK study of primary school teachers, 93% said that they did not know enough about asthma and 94% said that they had had no training on this issue []. Similarly high levels were seen in a US survey of 291 elementary school teachers in which 78% said they did not feel adequately prepared to teach children with a chronic illness, and 77% did not feel confident to deal with asthma []. Although 95% of primary school head teachers in one UK study reported that they were 'fairly confident' or 'very confident' about the care of pupils with asthma, two-thirds expressed concern about dealing with an asthma emergency [].

Given the widespread evidence that school staff have a limited knowledge and understanding of asthma, it is likely that many are unaware of the importance and feasibility of physical activity for children and young people with asthma. Lack of knowledge about how to manage an asthma attack may lead to excessive caution and unnecessary restriction of activity. Even if individual teachers are aware that sport is important for pupils with asthma, the organisational arrangements may not support full participation by pupils with asthma. Studies in a range of countries suggest that care for children with asthma in schools is often disorganised [-]. For example, many schools do not keep adequate diagnostic registers and cannot therefore accurately identify pupils with asthma, many do not allow pupils to be responsible for their own inhalers and some require parents to administer inhalers []. Thus school policies may not facilitate appropriate asthma management around exercise and may contribute to teachers, children and parents opting for non-participation. Some reluctant exercisers may in turn take advantage of this lack of clear policies: teachers in some studies have reported that increasing numbers of children and young people are excusing themselves from activity by 'forgetting' their inhalers, bringing notes from parents or citing their doctor's advice as justification for their non-participation. This is unsurprising given that pupils' attitudes towards PE lessons are known to become less positive as children become older []. From the perspective of parents, many did not trust school staff (apart from school nurses) to supervise their child's asthma care and had more faith in the child or young person's ability to manage their own care [] - faith that may be misplaced given the tendency of many parents to over-estimate the self management skills of adolescents []. This lack of trust in school staff may have implications for parents' willingness to accept school policies on participation in routine activities by pupils with asthma.

Central to the beliefs of children, parents and school staff about the relationship between asthma and physical activity is the problem of how ambiguous physical phenomena such as breathlessness are interpreted and attributed to either physical exertion or to asthma.

Symptom perception/interpretation

The literature outlined thus far suggests that child, parental and school beliefs about asthma are likely to influence engagement in physical activity. These beliefs are likely to originate both in a socially derived stock of knowledge about asthma and through past experience of asthma itself. Leventhal's self-regulation theory has suggested that such knowledge may be embodied in abstract and archetypal form []. This is then drawn upon at times of symptom interpretation by the sufferer or observer resulting in a cognitive interpretation of the symptoms being experienced (illness representations expressed as: identity/symptoms, timeline, cause, consequences and cure/control) and a parallel emotional reaction. Both these cognitive and emotional consequences are managed by engaging in coping behaviours [, ] which are subsequently appraised and thus, potentially, used again. In the case of asthma this may be by avoiding physical activity or engaging in it depending on both underlying beliefs and past experience.

Consequently, how children, parents and teachers interpret signs such as breathlessness is likely to be at the heart of day to day management of asthma and physical activity. Misinterpretation and misattribution of signs may result in inappropriate coping strategies. For example, symptoms that may not be asthma-related (e.g. breathlessness due to physical exertion) may be misinterpreted as asthma resulting in exercise avoidance when in fact failure to engage in cardiovascular based activity is the cause. Similarly, if breathlessness is misattributed to lack of fitness when in fact it is asthma then young people may fail to use their medication appropriately and may continue exercising at levels of intensity that may prove problematic.

Although the pathophysiology underlying some asthma symptoms is characteristically distinct (e.g. wheeze) many studies show that children and parents do not find the interpretation of such symptoms to be straightforward [, ] as meanings of wheeze may vary from epidemiological definitions[]. A review of studies in paediatric asthma has revealed that children and adolescents with asthma show considerable variability in perceptual accuracy and frequently make clinically relevant errors that have the potential to affect self-management behaviour []. It is also clear from studies conducted in a range of countries that people of all ages tend to underestimate their asthma symptoms and overestimate their control [, , , ]. This tendency may lead to under-medication and erratic adherence to treatment. Indeed, it has been estimated that adherence rates for asthma treatment range from as low as 30% to, at best, only 70% []. This means that at best many children and young people with asthma may be under-medicating themselves and settling for less exercise and a poorer quality of life than they could achieve by following recommended management strategies and treatment. At worst, a tendency to over-estimate asthma control may be life-threatening for some individuals: a study of children with asthma admitted to hospital suggests that children who present to hospital with hypoxia tend to perceive themselves as less breathless than non-hypoxic children [].

The problem appears to be the interpretation of asthma symptoms. Dyspnoea (shortness of breath) is highly subjective and can occur independently of any actual constriction of the airways. Perception of dyspnoea may be influenced by asthma patho-physiology and by a range of social and psychological factors. Furthermore, there is an interrelationship between these factors as psychological factors such as stress have been shown to be sufficient to induce breathlessness in people with asthma []. In terms of patho-physiology, there is evidence to suggest that perception may vary depending on whether there is acute airway obstruction or prolonged airway obstruction. People with prolonged airway obstruction have been found to perceive symptoms less accurately than those with acute onset airway obstruction []. Greater asthma severity has been found to be associated with blunted symptom perception [].

The range of social and psychological factors found to either influence, or be associated with asthma perception and interpretation includes age, gender, Body Mass Index (BMI), history of exercise-induced symptoms, and psychological state [-]. Perceptions of dyspnoea may be relatively precarious and easily swayed via these variables. For example, one study looked at the effect on dyspnoea reporting of giving children false feedback about their lung function (measured by peak flow) []. Children who were given a peak flow reading that was worse than the actual reading reported significantly more dyspnoea, while those who were given a reading that was considerably better than the true reading did not reduce their report of dyspnoea. In another study, children's perception of dyspnoea during resistive load breathing tasks decreased when they were shown film clips encouraging positive emotions []. No change occurred when the children were shown 'neutral' or 'negative' film clips. This suggests that psychological factors like emotional state can affect the perception of dyspnoea by children with asthma. This was borne out by another study in which children experiencing negative emotions were found to be more inclined to interpret exercise-related symptoms (e.g. fatigue, heart-pounding and sighing) as symptoms of airway obstruction []. Higher 'trait anxiety' has also been found to be associated with heightened symptom perception [].

A review of symptom perception studies in asthma concluded that although more empirical data on psychological factors are required, studies to date do suggest that the perceptual accuracy is influenced by: competition between asthma and non-asthma sensory information; negative emotions; and acquired response tendencies (e.g. habituation to symptoms, repression of symptoms, selective perception, and false interpretation of symptoms) []. These factors may favour either blunted perception or over-perception. More research is needed on factors that affect the magnitude of dyspnoea reporting.

Given the potential for misinterpretation of symptoms a proportion of those children and young people diagnosed as having exercise-induced asthma (EIA) may not be experiencing asthma-related symptoms, but instead may be breathless on exercise due to a lack of cardiovascular fitness []. There may also be social reasons encouraging such misinterpretation. Siersted et al [] have suggested that attributing breathlessness to EIA may be more acceptable to parents, coaches and children than the conclusion that the child is overweight or unfit. EIA is certainly very common [, ]; it occurs in 70-80% of patients with persistent asthma and in 12-15% of the general population [, ]. However, any over-attribution may have deleterious effects if the subsequent response of children and parents/teachers is to restrict physical activity rather than to encourage it (with or without appropriate pre-exercise asthma medication). This may mean children and young people miss out on the substantial fitness improvements that may result from appropriate exercise training, particularly in children with severe asthma [].

There is, therefore, a paradox in that while over-attribution of breathlessness to asthma may deny children sporting opportunities under-attribution (in the form of under-diagnosis) of asthma symptoms may also cause children with undiagnosed asthma to struggle with untreated symptoms and thus fail to fulfil their sporting potential []. Untangling the causes of breathlessness and deciding on appropriate action is therefore a complex but important challenge for children and young people with asthma, teachers and health professionals.

Principles and strategies to increase participation in physical activity

Addressing the multiple factors influencing participation in physical activity outlined in this paper is likely to be challenging and complex. An overview of contemporary evidence suggests that strategies must include: accurate detection, diagnosis and symptom management; acknowledge and address social and family contexts, be goal and value based and address the problem of symptom interpretation.

Detection, diagnosis and management

Increasing participation in physical activity by children and young people with asthma may require improvements in the wider field of asthma diagnosis and management. Although the health and social consequences of asthma-like symptoms in children with no diagnosis are substantial, there remains a risk of under-diagnosis of asthma, especially in girls, those with low physical activity and those with a high body mass []. For example, a survey of 123,000 US 12-14 yrs old found that 17% had asthma like symptoms but no diagnosis. Of those with no diagnosis 20% missed a half day of school or more a month because of wheeze and 25% limited their activities at least once a month []. In a study of a cohort of 7-9 year olds one in 20 children who had wheezed in the past 12 months reported a symptom profile consistent with unrecognised (and hence untreated) asthma []. Improved accuracy of initial diagnosis of asthma needs to be accompanied by appropriate ongoing management and review, not least because of the need for changes in management as the child matures. However, studies show that some children and young people with asthma are not being effectively managed: one study found that a third of children currently being treated for asthma in the UK were seen by a health professional less than once a year and that 25% had never had their lung function documented even with a peak flow meter []. The failure to perform lung function tests, coupled with the evident potential for exertional dyspnoea to be misinterpreted as asthma, suggests that it is likely that some children may be misdiagnosed as having asthma. It also suggests that studies of the prevalence of asthma that reply on self-report methods may overestimate prevalence. However, others studies have suggested that failure of parents to correctly interpret "wheeze" may lead to underestimations of prevalence within such surveys[] thereby counteracting any potential misattribution in regard to exertional dyspnoea. Further research to more clearly assess the scale of such biases is required. The introduction of the Quality Outcomes Framework and associated financial payments to UK general practice may, however, reduce misdiagnosis, as has been evidenced in other clinical areas [].

Acknowledging and addressing social and family contexts

Educating the individual with asthma about the feasibility and benefits of physical activity are unlikely to be effective if the family and school contexts are not also persuaded to encourage and facilitate participation []. A coherent asthma control strategy is likely to need to take into account the range of influences on people trying to manage their disease (e.g. family, friends, school peers, teachers) and to involve all of these stakeholders to ensure that the messages they deliver and the actions they take are mutually reinforcing []. Indeed a systematic review of interventions to promote physical activity among children and adolescents more generally found strong evidence that school based interventions with involvement of the family or community and multi-component interventions were effective in increasing physical activity []. It is likely that elements of such interventions, and the principles underlying their success, may be largely appropriate to young people with asthma as long as other more disease specific issues are simultaneously addressed. Parents, children and teachers need information about how and when those with asthma can participate in physical activity, about how to adjust medication before and during periods of extended activity and about the distinction between limitations at times of asthma exacerbation and overall limitations []. Such an approach may be both feasible and effective. For example, a US school asthma management intervention based on education for parents and children was shown at six months to reduce missed school days by two-thirds, to increase caregivers' perceptions of the amount of physical activity carried out pupils by 11% and to reduce daytime and night-time frequency of symptoms [].

Goal and value based strategies

Strategies need to draw on existing research knowledge about 'what works' in increasing activity in individuals with chronic conditions. For example, studies show that information-only interventions may have a limited effect and that programmes that teach self-management skills may be more effective [, ]. A survey of 38 children aged 8-10 years and their parents found that participation in activities increased significantly with increased asthma knowledge and the use of avoidance coping and support-seeking coping behaviours []. A study of adults with chronic illness found that a multi-component intervention model including collaborative identification of goals, identification of barriers, personally relevant problem-solving strategies and systematic follow-up and support was also effective in increasing activity []. Such programmes aim to foster 'self-competence' or self-efficacy so that the individual believes that they are capable of producing desired outcomes and avoiding negative outcomes [, ]. This means that education and asthma management must take into account the patient's own self-management goals (as opposed to purely clinical objectives) [].

Fostering self-efficacy will entail taking account of psychological factors and of differences between individuals (e.g. high self-regulators or low self-regulators). This suggests that physical activity may also need to be promoted in different ways to boys and girls. Strategies should probably take account of gender differences in regard to the relationship between self/social identity and physical activity, and the differing motivating factors underpinning involvement in sports and exercise []. However, while such targeting appears theoretically appropriate a recent review for children and young people more generally cast doubt on the evidence base to support the effectiveness for such differentiation []. Further research in this area is required. Despite this uncertainty, it continues to appear sensible to target individuals' key motivators irrespective of how they are socially patterned. Bailis et al [] have suggested that some individuals may be more likely to participate if emphasis is placed on the availability of support while others may be motivated more by external challenges and targets. Similarly, arguments framed in terms of the health benefits of performing a behaviour have been shown to be more persuasive for some individuals than those framed in terms of the costs of non-performance [].

Addressing symptom interpretation

Difficulties in interpreting asthma symptoms may be a major contributor to the beliefs held by young people with asthma, their parents and teachers. More research is needed to identify distinct types of perceptual errors, to identify factors related to perceptual inaccuracy, to examine the relationship between perceptual accuracy and relevant outcomes, and to identify effective interventions [, ]. It is not yet possible to reliably predict which individuals are most at risk of making clinically serious errors. Health professionals need to adopt an individualized approach to symptoms to guide patient education and management; identify patients prone to making clinically relevant errors; and develop and implement interventions to improve accuracy of symptom perception, both for those who under-perceive their symptoms and those who over-perceive them []. Individuals who are prone to under-estimate their symptoms may benefit from training and feedback using peak flow meters in order to improve perceptual accuracy. Individuals who tend to make symptom magnification errors can be informed of which symptoms accurately predict their functioning and which do not, and can be helped to differentiate asthma-related sensations from those that are unrelated [, ].

Strengths and limitations of the review

This breadth of topic and associated searching permitted within scoping reviews and associated narratives means that, as in this case, it is possible to "map" out the range of key contemporary issues on a given topic, and the linkages between them. It also provides the basis for decision making about areas which may be important to target for future primary research as well as those where more specifically defined systematic reviews may be needed. However, in achieving this there are unavoidable limitations. The breadth of topic and associated searches means that we cannot claim to have identified all relevant papers on each issue and have been forced to make judgments as to how deep and detailed investigations should be in relation to each topic area. Identification of one study and finding necessarily leads to a host of other underlying issues which could also be investigated and reported. However, we believe that we have successfully provided sufficient depth without sacrificing the breadth and interconnection of issues which are at the heart of a scoping type review. A scoping review cannot include a full quality appraise, weight or "pool" data[], as in more meta-analysis procedures. However, we believe that these limitations do not interfere with the broader purposes and value of the scoping review and indeed provide the foundation for future systematic reviews in these areas.

Conclusion

Asthma is a common problem which impacts on individuals, their families and society. The literature from many countries over several decades shows a clear pattern of short term barriers to increased activity preventing children and young people with asthma attaining long term physical fitness with all its consequent benefits to lung health, general health, social and psychological well-being. Activity and physical fitness deserve a place in goal setting for generic and individual asthma management plans. The way young people perceive and respond to physiological signals such as shortness of breath on exercise requires attention.

Declarations

Acknowledgements

We would like to thank Ali Zohoor (AZ) for contributing to the selection of abstracts.

Competing interests

Authors' contributions

BW conceived the review, collated the papers, reviewed and synthesised the findings and drafted the paper. AP, RN and GH reviewed the findings and contributed to the writing of the paper.

The authors declare that they have no competing interests.

Authors' Affiliations

Social Dimensions of Health Institute, University of Dundee, Dundee, UK

General Practice Section, Division of Community Health Sciences, University of Edinburgh, UK

Division of Community Health Sciences, University of Dundee, Dundee, UK

Division of Community Health Sciences, University of Edinburgh, Edinburgh, UK

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Exploring and explaining low participation in physical activity among children and young people with asthma: a review

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Asthma is the most common chronic illness among children and accounts for 1 in 5 of all child GP consultations. This paper reviews and discusses recent literature outlining the growing problem of physical inactivity among young people with asthma and explores the psychosocial dimensions that may explain inactivity levels and potentially relevant interventions and strategies, and the principles that should underpin them.

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The article is based on a study done to investigate student motivation in physical education by examining self-discipling, motivation, and engagment.

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Press Reference: A-Be, Be-Co, Co-Fa, Fa-Gu, Gu-Ku, Ky-Ma, Ma-No, No-Sa, Sa-Sw, Sw-Ur, and Uz-Z

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This article looks at the participation in high school physical education in Canada during the years 1999-2003.

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Participation in High School Physical Education-Ontario, Canada, 1999-2005

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MMWR. 2007;56:52-54 1 table omitted School-based physical education (PE) programs provide regular and structured opportunities for youths to participate in moderate or vigorous physical activities that help meet the Canadian public health recommendation for 90 minutes of daily physical activity.1 To...

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The article discusses how physical education can help a students mind and body to be successful in other subjects.

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Education.com | #1 Educational Site for Pre-K through 5

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A study to assess the levels of physical activity competence and enjoyment for scondary students.

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Physical activity, perceived competence and enjoyment during secondary school physical education

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This study aimed to assess the levels of physical activity, perceived competence and enjoyment of English secondary school children. Seventy three students (mean age 13.1 years) from 5 schools took part. Physical activity was assessed during Physical Education (PE) lessons using heart rate telemetry. Perceived competence and enjoyment were measured by a post lesson questionnaire.

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Article discusses how children's attitudes could be a big element of why students do not participate in physical education.

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Attitudes of high school students toward physical education and their sport activity preferences.

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Attitudes of high school students toward physical education and their sport activity preferences.

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The article discusses factors that could motivate children to become more physically active.

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Personal Health

Instead of focusing on patients' unexplained symptoms, cognitive behavioral therapy encourages patients to replace unrealistic or unhelpful thoughts with more rational ideas.

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Instead of focusing on patients' unexplained symptoms, cognitive behavioral therapy encourages patients to replace unrealistic or unhelpful thoughts with more rational ideas.

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Researching the assoication of gender, athletic competence, and enjoyment of physical education.

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International Journal of Behavioral Nutrition and Physical Activity

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Abstract

Background

The current study examined associations between gender, perceived athletic competence, and enjoyment of physical education (PE) class over time in a cohort of children enrolled in grade four (ages 9 or 10) at baseline (n = 2262).

Methods

We assessed each student 5 times over a period of 2 years. We used mixed effects modeling to examine change over time in enjoyment of PE.

Results

Enjoyment of PE declined among girls but remained constant among boys. Higher levels of perceived competence were associated with higher PE enjoyment. A 3-way interaction between gender, competence, and time revealed that PE enjoyment was lowest and declined most markedly among girls with low perceived athletic competence. Among boys with low competence, enjoyment remained at a consistently low level.

Conclusions

Our results indicate that lower perceived athletic competence is associated with low enjoyment of PE, and, among girls, with declining enjoyment. Findings suggest that interventions in a PE context that target perceived competence should be considered in future work.

Keywords

Prospective cohort study Athletic competence Physical education

Introduction

Regular engagement in physical activity is associated with a variety of psychological, social and physical benefits for children and youth [, ]. Unfortunately, previous research has consistently demonstrated that physical activity decreases during the transition from childhood to adolescence, with girls in particular showing significant declines in participation [-]. There is no widely accepted explanation for this phenomenon; however, several authors have suggested that negative experiences in, and perceptions of, school-based physical education (PE) class may be an important factor in the decline in physical activity, particularly among girls []. This decline occurs at the same time PE becomes an optional part of the curriculum in most school systems in North America [].

School-based PE programs are often touted as an effective means of positively affecting health and physical activity behaviours during childhood [] and later life []. School programs reach the vast majority of children [], and can affect physical activity both directly and indirectly. PE classes can provide children with activity that directly fosters motor skill development and fitness, and can also stimulate positive perceptions of physical activity - thereby influencing motivation to engage in physical activity [-]. Unfortunately, declining physical activity participation during adolescence suggests that there are deficiencies in the current PE programs being implemented. Moreover, it remains unclear whether students' experiences, or perceptions of those experiences, in school PE truly facilitate physical activity over the long term.

One important determinant of physical activity is simply youths' perceived enjoyment of such activity. Data from several studies show that motivation to participate in physical activity in children is influenced by perceptions of physical activity as fun, interesting, and challenging [, ]. Enjoyment of physical activity is positively correlated with physical activity participation levels for children and adolescents [-]. Enjoyment of PE class specifically has also been identified as a predictor of physical activity []. Sallis and colleagues [] investigated 22 potential correlates of physical activity in school children and found that students' enjoyment of PE class was a robust predictor of physical activity at both younger (grades 4-6) and older (grades 7-12) ages. Given its strong link to physical activity in children and youth, further investigation of enjoyment within the context of PE classes is warranted.

Numerous theories of motivated behavior that have been applied to understanding and predicting physical activity participation (e.g., social cognitive theory, competence motivation theory, self-determination theory) highlight positive affect (e.g., fun, enjoyment) as a proximal motivator of physical activity. Positive affect, in turn, is influenced by more distal perceptions such as self-efficacy or competence, outcome expectations, autonomy, and relatedness. In the literature on children's physical activity, perceptions of competence, autonomy, and perceived success have been shown to predict physical activity enjoyment, as well as to reduce negative perceptions, such as boredom [, ]. In the school environment, self-efficacy with respect to leisure-time physical activity was the strongest predictor of PE class enjoyment in a sample of middle school girls []. Together, these findings suggest that perceived competence may be an important factor affecting students' enjoyment of their experiences in PE.

The objective of the present study was to investigate associations between perceived athletic competence, PE class enjoyment, and gender in a sample of school-aged children across grades 4 to 6. We conducted a 3-year prospective study, allowing us to extend existing research in this field, which, with one exception [], has relied exclusively on cross-sectional data [, , -]. Importantly, we were able to examine trends in perceptions of athletic competence and PE enjoyment over time. Based on cognitive theories of motivation and previous research in children's physical activity [e.g., 6-12], we hypothesized that perceived athletic competence would be a significant predictor of children's PE enjoyment.

Although the major objective of the study was to investigate the relationship between perceived competence and enjoyment of PE, we also set out to extend previous work investigating gender differences as they relate to PE enjoyment. In previous studies, girls have been found to enjoy PE less than boys [, , ]. It is possible that determinants of PE enjoyment vary by gender; however, our understanding of why girls differ from boys in their enjoyment of PE remains limited, primarily because studies have either simply established the presence of gender differences with no further elaboration or test of possible mechanisms [], or have limited their sample to girls []. For example, the study by Barr-Anderson and colleagues [] identified a number of individual and contextual factors associated with PE enjoyment; but, by excluding boys, the design precluded an examination of the sources of gender differences. In line with previous research, we hypothesized that girls would report lower PE enjoyment than boys. As an exploratory step, gender was examined as a potential moderator of the relationship between perceived athletic competence and PE enjoyment over time.

Methods

Study sample and data collection

The data for this study come from the Physical Health and Activity Study Team (PHAST), a longitudinal cohort study of the health, physical activity, and development of children. The target population for this study included all children enrolled in Grade 4 in the public school system of a large region in southern Ontario, Canada. In Year One (2004-05) of the study, we obtained ethics approval from the regional district school board and from Brock University. We received permission from 75 of 92 possible school principals (83%) and informed consent from the parents of 2262 of 2378 children (95.4%) in these schools. We established testing and training protocols, and completed pilot testing in the fall of 2004. Data collection began in May 2005, with follow-ups in the September 2005, May and September 2006, and May of 2007. We have data, therefore, on a cohort of children from the end of grade 4 through to the end of grade 6 (5 time points over three years). Sample sizes and descriptive statistics for key measures for each wave are shown in Table .

Teams of three to four trained research assistants tested children during regular school hours. Only those who demonstrated competence in the administration of all measurements, as assessed by the core research team, were allowed to take part in the study. Research assistants were randomly observed by the core research team to ensure that anthropometric procedures were being followed. Questionnaires were administered in the classroom under supervision of the team. On completion, team members escorted children to the gymnasium, where fitness and anthropometric assessments were completed. Steps were taken to ensure privacy during assessment of weight. All equipment was calibrated daily.

Measures

Enjoyment of physical education

The dependent variable is a measure of perceived enjoyment of PE class []. Unlike previous work [-], we used a multi-item measure of perceived enjoyment of PE. Each item requires the child to decide which of two descriptions best describes him or her. This is accomplished by selecting one of a pair of sentences that present mutually exclusive descriptions. For example, " Some children have fun in physical education class", and " Other kids would rather miss physical education class". The child then indicates whether the sentence he or she selected was " sort of true for me" or " really true for me". There were three items tapping into enjoyment, fun, and perceived difficulty of games in PE. The enjoyment of PE class scale has good to excellent test-retest reliability ( r = 0.70-0.89) as well as strong predictive and construct validity for children and adolescents 9 to 16 years of age []. Higher scores indicate greater enjoyment of PE class.

Perceived athletic competence

We used the Perceived Athletic Competence (PAC) subscale of the Harter Self-Perception Profile for Children (SPPC) [] to measure children's views about their abilities with respect to physical activity. The SPPC employs a structured alternative choice format. Children are asked to choose one of a pair of sentences (e.g., " some kids wish they could be a lot better at sports" and " other kids feel they are good enough at sports") and to then indicate whether the selected sentence was "sort of true for me" or "really true for me". The PAC subscale is comprised of six items scored from 0 to 4, yielding a range of possible scores from 6 to 24. Test-retest reliability and internal consistency of the PAC subscale have been shown to be satisfactory, and existing work has supported the hypothesized factor structure of the scale as a whole [, ]. The PAC subscale was included in the models as a continuous variable. To aid in the interpretation of results, values one standard deviation above and below the observed mean were used to calculate expected levels of enjoyment at "high" and "low" levels of PAC.

Individual and demographic characteristics

We selected several covariates found to be associated with enjoyment of PE in children in existing work []. The child's height was measured without footwear using a SECA™ portable stadiometer. Weight was measured and recorded to the nearest 0.1 kg using a Tanita™ electronic medical scale. Measured height and weight were used to calculate body mass index (BMI; kg/m ²) for each participant.

Participation in organized activities was derived from a 63-item measure that assesses past-year participation in free and active play called the Participation Questionnaire (PQ) []. Six items provide an inventory of participation in organized athletic and recreational pursuits and sport and dance lessons. The PQ has consistently demonstrated strong construct validity and significant correlations with body fat, aerobic capacity, motoric competence, and other health outcomes [, ]. Criterion validity has been established using correlations with teacher evaluations of activity ( r = 0.62); and test-retest reliability of the PQ in a sample of school children in grades 4-6 was measured as 0.81 [].

Parental education was assessed using a brief questionnaire administered at study baseline. Approximately 63% (n = 1496) of respondents provided information on education. However, as this survey was conducted before the beginning of formal data collection on children, subsequent changes in the composition of the sample and difficulties in matching records meant that this measure was available for only 45.7% (n = 982) of the final sample. We elected to retain the measure in the analysis, including an indicator variable signifying missing values (n = 1168; 54.3%).

Statistical analysis

We used mixed effects modeling to measure change within individuals over time while adjusting for correlation of measures within children (repeated measures) and within schools. We included random intercepts at the school and student levels, as well as a random slope for time. Analysis of the data revealed possible seasonal effects, so we chose to use an unstructured covariance matrix. We specified three models. The first examines the effects of gender and time on perceived enjoyment of PE, adjusting for baseline age. To identify potential differences between boys and girls in change in reported enjoyment of PE over time, we included a time by gender interaction (Model 1). Next, we added PAC scores, as well as other covariates known to be associated with enjoyment of PE (Model 2). In the final model, we tested for a moderating effect of gender by adding three interaction terms: time by PAC, gender by PAC, and gender by time by PAC (Model 3). This procedure allows for the possibility that the effect of PAC may not be the same between genders across time. All analyses were conducted using SAS version 9.1.

Results

The average age of children at baseline was 9.6 years (SD = 0.34). Slightly more than half of the students were male (50.9%). Table contains descriptive data for enjoyment of PE and all other time-varying measures included in the analysis. Model 1 (see Table ) shows the effect of time and gender on reported enjoyment of PE. The presence of a significant effect for gender by time (b = 6.50 × 10⁻⁴, p < 0.001) indicates that there is a divergence of boys' and girls' enjoyment scores. In order to facilitate the interpretation of this result, we have graphed the association between gender, time, and PE using the equation from model 1, illustrated in Figure . The Y-axis of this chart, representing predicted values of enjoyment, shows the range from 1 SD below to 1 SD above the total mean. For boys, there is a slight increase (0.18 SDs) in reported enjoyment from grade 4 to grade 6. For girls, however, reported enjoyment of PE slightly decreased (0.08 SDs) over that same period.

In Model 2, the effect of PAC on reported enjoyment was assessed in concert with other potential covariates. Consistent with the hypothesis, there was a significant effect for PAC, with higher scores associated with greater PE enjoyment, net of the other factors (see Model 2 in Table ). The coefficient for the interaction between time and gender remained largely unchanged after adjusting for BMI, participation in organized sports, parental education, and PAC. After adjusting for age, gender and time, however, these variables did exert independent effects on enjoyment. Higher BMIs were associated with lower levels of reported PE enjoyment (b = -0.03, p < 0.001), whereas greater participation in sports and organized activities was associated with higher levels of reported enjoyment (b = 0.02, p < 0.001). There was also a weak effect of parental education, with children of parents who hold undergraduate university degrees reporting lower levels of enjoyment of PE than other groups (b = -0.21, p < 0.001).

As shown in Table , the introduction of PAC and the other covariates to the equation in Model 2 had very little effect on the coefficient for time by gender (b = 6.30 × 10⁻⁴, p < 0.001 compared with b = 6.50 × 10⁻⁴, p < 0.001 from Model 1). This suggests that the effect of PAC on enjoyment over time may differ by gender. In order to test for this, a set of 2-way and 3-way interactions with PAC, time, and gender were added to the model. Complete results from this analysis are shown in Model 3 in Table . Most interestingly, a significant 3-way interaction emerged between gender, time, and PAC (b = -1.00 × 10⁻⁴, p < 0.001). Again, to facilitate the interpretation of this result, we used the full equation in Model 3 to graph the association between PAC, time, and perceived enjoyment for both boys and girls (see Figure ). In Figure , "lower" PAC is represented by a score 1 SD below the mean, and "higher" PAC by a score 1 SD above the mean. The results indicate that gender has no effect on enjoyment of PE for children who perceived themselves as having higher competence with regard to sports and athletics. In fact, over time, there is a slight trend in both boys and girls in this group toward increasing levels of enjoyment. Gender difference did, however, emerge among children with lower perceived competence. Specifically, although children with lower perceived competence persistently had lower levels of enjoyment of PE compared to those with higher perceived competence, the enjoyment levels among boys remained relatively stable over time. Among girls, however, lower perceived competence was marked by decreases in enjoyment of PE over time.

Discussion

The purpose of the present study was to investigate the association between perceived athletic competence and enjoyment of PE. Drawing on cognitive theories of motivation [, ], we hypothesized that perceived athletic competence would be positively associated with PE class enjoyment. Generally, the results of this study supported this hypothesis, but the relationship between perceived competence and PE enjoyment was qualified by a 3-way interaction with gender and time. Consistent with previous cross-sectional research [, , -, ], we found that girls reported lower levels of PE enjoyment than boys. Importantly, however, our results indicate that these differences increased over time. Although previous research has found significant associations between PAC and enjoyment of PE [], this was the first study to test the association using longitudinal data.

The current findings support previous calls for the targeting of perceived competence in intervention work aimed at increasing PE enjoyment among school-aged children [, ]. Although the hypothesized PAC and PE enjoyment relationship was supported in this study, it is important to acknowledge that the relationship was complicated by an interaction with gender and time. Specifically, the interaction showed that children of both genders who had higher levels of perceived competence reported higher and increasing levels of PE enjoyment. However, differences emerged among children with lower levels of perceived competence, where boys reported low but stable levels of PE enjoyment over time, while girls began with lower levels of PE enjoyment that continued to decline further over time. These findings offer evidence that gender differences in PE enjoyment are effectively non-existent among children with high levels of perceived competence, and suggest greater efforts should be made to understand why some children have lower perceptions of athletic competence. Improving children's views of their physical abilities may be an important goal, particularly among girls with low perceived competence. The interaction between gender, competence and enjoyment should be a key consideration in planning the content and delivery of PE.

These findings support perceived competence as a focus for interventions designed to increase enjoyment of PE. It is important, however, to understand that competence is just one of many determinants of enjoyment of and participation in physical activity. Cognitive theories of intrinsic motivation, for example, emphasize not only competence, but also perceptions of choice or autonomy [, ]--constructs that were not measured in this study. A PE program that not only targets positive perceptions of competence, but that also provides a variety of different activities--allowing participants to choose those most of interest to them--is likely to produce greater levels of intrinsic motivation and enjoyment [, ].

Recent work has also emphasized the importance of understanding sport ability beliefs [], which underlie feelings of competence because they reflect children's perceptions of the modifiability of their performance []. If children perceive their physical abilities to be fixed and not amenable to improvement though practice, it is unlikely that perceptions of enjoyment will be increased in PE settings, where the emphasis is often on raw skill acquisition. One way to improve engagement and perceived competence would be to expose children to a wider spectrum of activities. This would create more opportunities for individuals to discover activities for which they have a particular aptitude or that they find appealing, interesting, and challenging. In fact, this is consistent with the stated policy of PE in the jurisdiction in which this study was conducted. The Ontario Ministry of Education, the governmental body responsible for education curriculums for the schools included in this study, outlines that a major learning goal to be helping students achieve a greater understanding of achieving lifelong health through the promotion of physical and health literacy. Physical literacy, defined as the ability to move, with confidence, across a wide array of physical activities that benefit the whole person (mind and body), being particularly relevant []. A caveat, however, was that schools (and teachers) in our study were ultimately responsible for designing and implementing PE classes; which could have varied considerably across school districts depending on available resources (e.g., some schools had state of the art gymnasiums, while other schools did not even have on-site facilities). The idea is to expose children to a greater range of activities, enabling all children to find confidence in different movements suited to individual athletic abilities. Therefore, it was not particularly surprising that higher levels of organized physical activity, as measured by the PQ, were associated with greater reported enjoyment of PE. Overall, focusing on developing competence may not be enough, and understanding and changing negative core beliefs with regard to abilities may also need to be part of the strategy. For example, focusing on individual goal setting, striving for self-set or negotiated standards of performance, and providing greater autonomy and choices in physical activity may be necessary.

Although not a focus of the present study, many of the control variables included in the models were also significantly related to perceived enjoyment of PE. In particular, higher BMI scores were associated with lower level of enjoyment throughout this time period. BMI is of particular interest, as other work has shown that conditions that influence motoric competence are also associated with lower perceived enjoyment of PE [, ]. Unpacking the temporal associations between these factors and PE enjoyment remains to be done.

The present study has a number of limitations. Although our analysis took correlation within and variation among schools into account with the use of random effects, we were unable to also consider class or school-level factors associated with the delivery of PE (e.g., teacher competence) or the perceived climate in PE class (e.g., supportive, competitive, etc.). While our focus was on individual-level factors, the inclusion of contextual effects would provide a more complete picture; this remains an area for future research. In particular, intervention studies that manipulate teaching environment could shed light on the importance of context in perceived enjoyment.

Conclusion

Enjoyment of PE makes continued engagement in physical activity more likely; if children do not enjoy PE, they may be less likely to lead an active lifestyle, and to realize the associated health benefits. The results of our study show that girls, in particular, are less likely to enjoy physical education when compared to boys and that this gap in enjoyment grows over time. This may be due to the fact that girls have, on average, lower perceived physical ability. Of course, other factors, not measured in this study (e.g., maturation) may also contribute to observed gender differences. This is the first study to show that the association between perceived enjoyment of PE and PAC is contingent upon gender as well as time. If enjoyment of PE is to be increased, physical educators should attend not only to the development of skills, but also to increasing feelings of competence, particularly competence in PA that the child is able to perceive with relevance to activities inside and outside of the school. In this sense, the mind, as well as the body, must be the focus of instruction in PE class, and should be part of the broader curriculum in physical education for all children; which may be especially the case for young girls.

Declarations

Acknowledgements

Financial support for this study was provided by the Canadian Institute for Health Research (grant no. 66959). JC is supported by an endowed professorship in child health through the Department of Family Medicine at McMaster University.

Authors' original submitted files for images

Competing interests

Authors' contributions

JC, JH, and BF are all principle investigators on the PHAST project, and contributed to the design and execution of the study. MYK, SV, and SRB made significant contributions towards the analytic and the intellectual content being presented. All authors read and approved the final manuscript.

The authors declare that they have no competing interests.

Below are the links to the authors' original submitted files for images.

Authors' Affiliations

Department of Family Medicine, McMaster University, Hamilton, Canada

Centre for Addiction & Mental Health, Toronto, Canada

Department of Community Health Sciences, Brock University, Catharines, Canada

Department of Kinesiology, McMaster University, Hamilton, USA

References

Whitehead J: Physical activity and intrinsic motivation. Research Digest. 1993, 23: 1-22. Retrieved Retrieved August 24, 2008 form http://www.fitness.gov/intrinsic.pdf Cited in Prochaska et al (2003)

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Gender, perceived competence and the enjoyment of physical education in children: a longitudinal examination

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The current study examined associations between gender, perceived athletic competence, and enjoyment of physical education (PE) class over time in a cohort of children enrolled in grade four (ages 9 or 10) at baseline (n = 2262). We assessed each student 5 times over a period of 2 years.

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The barriers the students have when it comes to the participation and enjoyment in P.E.

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I plan to study how to increase participation and enjoyment for my basketball unit in my 9th grade physical education class because I want to find out why some students do not participate or why they don’t enjoy physical education. I want to show the reasons why some students do not want to participate so I may better understand which methods would help improve participation and enjoyment.

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“Action research is largely about developing the professional disposition of teachers, that is, encouraging teachers to be continuous learner—in their classroom and in their practice” (Mills 2014, p. 13)

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It is also important to gain informed consent from your participants.  In this case, it is important, in my opinion, for the teacher to understand that the students have now become part of the research, and are no longer just students in the classroom. (L. Tremblay, personal communication, May 9th 2013)
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“The key issue for teacher researchers studying their own practices, and hence, collecting data primarily based on student outcomes, relates to the fact that they are acting not only as the researchers, but also as the change agents who have the power and authority to bring about change in their classrooms” (Mills, 2014, p. 37).

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“Action research is any systematic inquiry conducted by teacher researchers, principals, school counselors, or other stakeholders in the teaching/learning environment to gather information about how their particular schools operate, how they teach, and how well their students learn”(Mills 2014, p.8)